prep ak ischial direct form l5580 prep ak ischial thermo mold by 9pDQ63

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									                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price            Effective Date
00102       ANESTH REPAIR OF CLEFT LIP                                               $20.78        20120901
00103       ANESTH BLEPHAROPLASTY                                                    $20.78        20120901
00104       ANESTH ELECTROSHOCK                                                      $20.78        20120901
00120       ANESTH EAR SURGERY                                                       $20.78        20120901
00124       ANESTH EAR EXAM                                                          $20.78        20120901
00126       ANESTH TYMPANOTOMY                                                       $20.78        20120901
00140       ANESTH PROCEDURES ON EYE                                                 $20.78        20120901
00142       ANESTH LENS SURGERY                                                      $20.78        20120901
00144       ANESTH CORNEAL TRANSPLANT                                                $20.78        20120901
00145       ANESTH VITREORETINAL SURG                                                $20.78        20120901
00147       ANESTH IRIDECTOMY                                                        $20.78        20120901
00148       ANESTH EYE EXAM                                                          $20.78        20120901
00160       ANESTH NOSE/SINUS SURGERY                                                $20.78        20120901
00162       ANESTH NOSE/SINUS SURGERY                                                $20.78        20120901
00164       ANESTH BIOPSY OF NOSE                                                    $20.78        20120901
00170       ANESTH PROCEDURE ON MOUTH                                                $20.78        20120901
00172       ANESTH CLEFT PALATE REPAIR                                               $20.78        20120901
00174       ANESTH PHARYNGEAL SURGERY                                                $20.78        20120901
00176       ANESTH PHARYNGEAL SURGERY                                                $20.78        20120901
00190       ANESTH FACE/SKULL BONE SURG                                              $20.78        20120901
00192       ANESTH FACIAL BONE SURGERY                                               $20.78        20120901
00210       ANESTH CRANIAL SURG NOS                                                  $20.78        20120901
00211       ANESTH CRAN SURG HEMOTOMA                                                $20.78        20120901
00212       ANESTH SKULL DRAINAGE                                                    $20.78        20120901
00214       ANESTH SKULL DRAINAGE                                                    $20.78        20120901
00215       ANESTH SKULL REPAIR/FRACT                                                $20.78        20120901
00216       ANESTH HEAD VESSEL SURGERY                                               $20.78        20120901
00218       ANESTH SPECIAL HEAD SURGERY                                              $20.78        20120901
00220       ANESTH INTRCRN NERVE                                                     $20.78        20120901
00222       ANESTH HEAD NERVE SURGERY                                                $20.78        20120901
00300       ANESTH HEAD/NECK/PTRUNK                                                  $20.78        20120901
00320       ANESTH NECK ORGAN 1YR/                                                   $20.78        20120901
00322       ANESTH BIOPSY OF THYROID                                                 $20.78        20120901
00326       ANESTH LARYNX/TRACH 1 YR                                                 $20.78        20120901
00350       ANESTH NECK VESSEL SURGERY                                               $20.78        20120901
00352       ANESTH NECK VESSEL SURGERY                                               $20.78        20120901
00400       ANESTH SKIN EXT/PER/ATRUNK                                               $20.78        20120901
00402       ANESTH SURGERY OF BREAST                                                 $20.78        20120901
00404       ANESTH SURGERY OF BREAST                                                 $20.78        20120901
00406       ANESTH SURGERY OF BREAST                                                 $20.78        20120901
00410       ANESTH CORRECT HEART RHYTHM                                              $20.78        20120901
00450       ANESTH SURGERY OF SHOULDER                                               $20.78        20120901
00452       ANESTH SURGERY OF SHOULDER                                               $20.78        20120901
00454       ANESTH COLLAR BONE BIOPSY                                                $20.78        20120901
00470       ANESTH REMOVAL OF RIB                                                    $20.78        20120901
00472       ANESTH CHEST WALL REPAIR                                                 $20.78        20120901
00474       ANESTH SURGERY OF RIB                                                    $20.78        20120901
00500       ANESTH ESOPHAGEAL SURGERY                                                $20.78        20120901
00520       ANESTH CHEST PROCEDURE                                                   $20.78        20120901
00522       ANESTH CHEST LINING BIOPSY                                               $20.78        20120901
00524       ANESTH CHEST DRAINAGE                                                    $20.78        20120901
00528       ANES MEDIASCPY DX THORSCPY                                               $20.78        20120901
00529       ANES MEDSCPYTHORSCPY 1 LUNG                                              $20.78        20120901
00530       ANESTH PACEMAKER INSERTION                                               $20.78        20120901
00532       ANESTH VASCULAR ACCESS                                                   $20.78        20120901
00534       ANESTH CARDIOVERTER/DEFIB                                                $20.78        20120901
00537       ANESTH CARDIAC ELECTROPHYS                                               $20.78        20120901
00539       ANESTH TRACH-BRONCH RECONST                                              $20.78        20120901
00540       ANESTH CHEST SURGERY                                                     $20.78        20120901



                                              Page 1
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price            Effective Date
00541       ANESTH ONE LUNG VENTILATION                                               $20.78        20120901
00542       ANESTH REMVL PLEURA                                                       $20.78        20120901
00546       ANESTH LUNG CHEST WALL SURG                                               $20.78        20120901
00548       ANESTH TRACHEA BRONCHI SURG                                               $20.78        20120901
00550       ANESTH STERNAL DEBRIDEMENT                                                $20.78        20120901
00560       ANESTH HEART SURG W/O PUMP                                                $20.78        20120901
00561       ANESTH HEART SURG 1 YR                                                    $20.78        20120901
00562       ANESTH HRT SURG W/PMP AGE 1                                               $20.78        20120901
00563       ANESTH HEART SURG W/ARREST                                                $20.78        20120901
00566       ANESTH CABG W/O PUMP                                                      $20.78        20120901
00567       ANESTH CABG W/PUMP                                                        $20.78        20120901
00580       ANESTH HEART/LUNG TRANSPLNT                                               $20.78        20120901
00600       ANESTH SPINE CORD SURGERY                                                 $20.78        20120901
00604       ANESTH SITTING PROCEDURE                                                  $20.78        20120901
00620       ANESTH SPINE CORD SURGERY                                                 $20.78        20120901
00622       ANESTH REMOVAL OF NERVES                                                  $20.78        20120901
00625       ANES SPINE TRANTHOR W/O VENT                                              $20.78        20120901
00626       ANES SPINE TRANSTHOR W/VENT                                               $20.78        20120901
00630       ANESTH SPINE CORD SURGERY                                                 $20.78        20120901
00632       ANESTH REMOVAL OF NERVES                                                  $20.78        20120901
00634       ANESTH FOR CHEMONUCLEOLYSIS                                               $20.78        20120901
00635       ANESTH LUMBAR PUNCTURE                                                    $20.78        20120901
00640       ANESTH SPINE MANIPULATION                                                 $20.78        20120901
00670       ANESTH SPINE CORD SURGERY                                                 $20.78        20120901
00700       ANESTH ABDOMINAL WALL SURG                                                $20.78        20120901
00702       ANESTH FOR LIVER BIOPSY                                                   $20.78        20120901
00730       ANESTH ABDOMINAL WALL SURG                                                $20.78        20120901
00740       ANESTH UPPER GI VISUALIZE                                                 $20.78        20120901
00750       ANESTH REPAIR OF HERNIA                                                   $20.78        20120901
00752       ANESTH REPAIR OF HERNIA                                                   $20.78        20120901
00754       ANESTH REPAIR OF HERNIA                                                   $20.78        20120901
00756       ANESTH REPAIR OF HERNIA                                                   $20.78        20120901
00770       ANESTH BLOOD VESSEL REPAIR                                                $20.78        20120901
00790       ANESTH SURG UPPER ABDOMEN                                                 $20.78        20120901
00792       ANESTH HEMORR/EXCISE LIVER                                                $20.78        20120901
00794       ANESTH PANCREAS REMOVAL                                                   $20.78        20120901
00796       ANESTH FOR LIVER TRANSPLANT                                               $20.78        20120901
00797       ANESTH SURGERY FOR OBESITY                                                $20.78        20120901
00800       ANESTH ABDOMINAL WALL SURG                                                $20.78        20120901
00802       ANESTH FAT LAYER REMOVAL                                                  $20.78        20120901
00810       ANESTH LOW INTESTINE SCOPE                                                $20.78        20120901
00820       ANESTH ABDOMINAL WALL SURG                                                $20.78        20120901
00830       ANESTH REPAIR OF HERNIA                                                   $20.78        20120901
00832       ANESTH REPAIR OF HERNIA                                                   $20.78        20120901
00834       ANESTH HERNIA REPAIR 1 YR                                                 $20.78        20120901
00836       ANESTH HERNIA REPAIR PREEMIE                                              $20.78        20120901
00840       ANESTH SURG LOWER ABDOMEN                                                 $20.78        20120901
00842       ANESTH AMNIOCENTESIS                                                      $20.78        20120901
00844       ANESTH PELVIS SURGERY                                                     $20.78        20120901
00846       ANESTH HYSTERECTOMY                                                       $20.78        20120901
00848       ANESTH PELVIC ORGAN SURG                                                  $20.78        20120901
00851       ANESTH TUBAL LIGATION                                                     $20.78        20120901
00860       ANESTH SURGERY OF ABDOMEN                                                 $20.78        20120901
00862       ANESTH KIDNEY/URETER SURG                                                 $20.78        20120901
00864       ANESTH REMOVAL OF BLADDER                                                 $20.78        20120901
00865       ANESTH REMOVAL OF PROSTATE                                                $20.78        20120901
00866       ANESTH REMOVAL OF ADRENAL                                                 $20.78        20120901
00868       ANESTH KIDNEY TRANSPLANT                                                  $20.78        20120901
00870       ANESTH BLADDER STONE SURG                                                 $20.78        20120901



                                               Page 2
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price            Effective Date
00872       ANESTH KIDNEY STONE DESTRUCT                                             $20.78        20120901
00873       ANESTH KIDNEY STONE DESTRUCT                                             $20.78        20120901
00880       ANESTH ABDOMEN VESSEL SURG                                               $20.78        20120901
00882       ANESTH MAJOR VEIN LIGATION                                               $20.78        20120901
00902       ANESTH ANORECTAL SURGERY                                                 $20.78        20120901
00904       ANESTH PERINEAL SURGERY                                                  $20.78        20120901
00906       ANESTH REMOVAL OF VULVA                                                  $20.78        20120901
00908       ANESTH REMOVAL OF PROSTATE                                               $20.78        20120901
00910       ANESTH BLADDER SURGERY                                                   $20.78        20120901
00912       ANESTH BLADDER TUMOR SURG                                                $20.78        20120901
00914       ANESTH REMOVAL OF PROSTATE                                               $20.78        20120901
00916       ANESTH BLEEDING CONTROL                                                  $20.78        20120901
00918       ANESTH STONE REMOVAL                                                     $20.78        20120901
00920       ANESTH GENITALIA SURGERY                                                 $20.78        20120901
00921       ANESTH VASECTOMY                                                         $20.78        20120901
00922       ANESTH SPERM DUCT SURGERY                                                $20.78        20120901
00924       ANESTH TESTIS EXPLORATION                                                $20.78        20120901
00926       ANESTH REMOVAL OF TESTIS                                                 $20.78        20120901
00928       ANESTH REMOVAL OF TESTIS                                                 $20.78        20120901
00930       ANESTH TESTIS SUSPENSION                                                 $20.78        20120901
00932       ANESTH AMPUTATION OF PENIS                                               $20.78        20120901
00934       ANESTH PENIS NODES REMOVAL                                               $20.78        20120901
00936       ANESTH PENIS NODES REMOVAL                                               $20.78        20120901
00938       ANESTH INSERT PENIS DEVICE                                               $20.78        20120901
00940       ANESTH VAGINAL PROCEDURES                                                $20.78        20120901
00942       ANESTH SURG ON VAG/URETHRAL                                              $20.78        20120901
00944       ANESTH VAGINAL HYSTERECTOMY                                              $20.78        20120901
00948       ANESTH REPAIR OF CERVIX                                                  $20.78        20120901
00950       ANESTH VAGINAL ENDOSCOPY                                                 $20.78        20120901
00952       ANESTH HYSTEROSCOPE/GRAPH                                                $20.78        20120901
01112       ANESTH BONE ASPIRATE/BX                                                  $20.78        20120901
01120       ANESTH PELVIS SURGERY                                                    $20.78        20120901
01130       ANESTH BODY CAST PROCEDURE                                               $20.78        20120901
01140       ANESTH AMPUTATION AT PELVIS                                              $20.78        20120901
01150       ANESTH PELVIC TUMOR SURGERY                                              $20.78        20120901
01160       ANESTH PELVIS PROCEDURE                                                  $20.78        20120901
01170       ANESTH PELVIS SURGERY                                                    $20.78        20120901
01173       ANESTH FX REPAIR PELVIS                                                  $20.78        20120901
01180       ANESTH PELVIS NERVE REMOVAL                                              $20.78        20120901
01190       ANESTH PELVIS NERVE REMOVAL                                              $20.78        20120901
01200       ANESTH HIP JOINT PROCEDURE                                               $20.78        20120901
01202       ANESTH ARTHROSCOPY OF HIP                                                $20.78        20120901
01210       ANESTH HIP JOINT SURGERY                                                 $20.78        20120901
01212       ANESTH HIP DISARTICULATION                                               $20.78        20120901
01214       ANESTH HIP ARTHROPLASTY                                                  $20.78        20120901
01215       ANESTH REVISE HIP REPAIR                                                 $20.78        20120901
01220       ANESTH PROCEDURE ON FEMUR                                                $20.78        20120901
01230       ANESTH SURGERY OF FEMUR                                                  $20.78        20120901
01232       ANESTH AMPUTATION OF FEMUR                                               $20.78        20120901
01234       ANESTH RADICAL FEMUR SURG                                                $20.78        20120901
01250       ANESTH UPPER LEG SURGERY                                                 $20.78        20120901
01260       ANESTH UPPER LEG VEINS SURG                                              $20.78        20120901
01270       ANESTH THIGH ARTERIES SURG                                               $20.78        20120901
01272       ANESTH FEMORAL ARTERY SURG                                               $20.78        20120901
01274       ANESTH FEMORAL EMBOLECTOMY                                               $20.78        20120901
01320       ANESTH KNEE AREA SURGERY                                                 $20.78        20120901
01340       ANESTH KNEE AREA PROCEDURE                                               $20.78        20120901
01360       ANESTH KNEE AREA SURGERY                                                 $20.78        20120901
01380       ANESTH KNEE JOINT PROCEDURE                                              $20.78        20120901



                                              Page 3
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                  Mod 1         Mod 2     Rate Type   Price            Effective Date
01382       ANESTH DX KNEE ARTHROSCOPY                                               $20.78        20120901
01390       ANESTH KNEE AREA PROCEDURE                                               $20.78        20120901
01392       ANESTH KNEE AREA SURGERY                                                 $20.78        20120901
01400       ANESTH KNEE JOINT SURGERY                                                $20.78        20120901
01402       ANESTH KNEE ARTHROPLASTY                                                 $20.78        20120901
01404       ANESTH AMPUTATION AT KNEE                                                $20.78        20120901
01420       ANESTH KNEE JOINT CASTING                                                $20.78        20120901
01430       ANESTH KNEE VEINS SURGERY                                                $20.78        20120901
01432       ANESTH KNEE VESSEL SURG                                                  $20.78        20120901
01440       ANESTH KNEE ARTERIES SURG                                                $20.78        20120901
01442       ANESTH KNEE ARTERY SURG                                                  $20.78        20120901
01444       ANESTH KNEE ARTERY REPAIR                                                $20.78        20120901
01462       ANESTH LOWER LEG PROCEDURE                                               $20.78        20120901
01464       ANESTH ANKLE/FT ARTHROSCOPY                                              $20.78        20120901
01470       ANESTH LOWER LEG SURGERY                                                 $20.78        20120901
01472       ANESTH ACHILLES TENDON SURG                                              $20.78        20120901
01474       ANESTH LOWER LEG SURGERY                                                 $20.78        20120901
01480       ANESTH LOWER LEG BONE SURG                                               $20.78        20120901
01482       ANESTH RADICAL LEG SURGERY                                               $20.78        20120901
01484       ANESTH LOWER LEG REVISION                                                $20.78        20120901
01486       ANESTH ANKLE REPLACEMENT                                                 $20.78        20120901
01490       ANESTH LOWER LEG CASTING                                                 $20.78        20120901
01500       ANESTH LEG ARTERIES SURG                                                 $20.78        20120901
01502       ANESTH LWR LEG EMBOLECTOMY                                               $20.78        20120901
01520       ANESTH LOWER LEG VEIN SURG                                               $20.78        20120901
01522       ANESTH LOWER LEG VEIN SURG                                               $20.78        20120901
01610       ANESTH SURGERY OF SHOULDER                                               $20.78        20120901
01620       ANESTH SHOULDER PROCEDURE                                                $20.78        20120901
01622       ANES DX SHOULDER ARTHROSCOPY                                             $20.78        20120901
01630       ANESTH SURGERY OF SHOULDER                                               $20.78        20120901
01634       ANESTH SHOULDER JOINT AMPUT                                              $20.78        20120901
01636       ANESTH FOREQUARTER AMPUT                                                 $20.78        20120901
01638       ANESTH SHOULDER REPLACEMENT                                              $20.78        20120901
01650       ANESTH SHOULDER ARTERY SURG                                              $20.78        20120901
01652       ANESTH SHOULDER VESSEL SURG                                              $20.78        20120901
01654       ANESTH SHOULDER VESSEL SURG                                              $20.78        20120901
01656       ANESTH ARM-LEG VESSEL SURG                                               $20.78        20120901
01670       ANESTH SHOULDER VEIN SURG                                                $20.78        20120901
01680       ANESTH SHOULDER CASTING                                                  $20.78        20120901
01682       ANESTH AIRPLANE CAST                                                     $20.78        20120901
01710       ANESTH ELBOW AREA SURGERY                                                $20.78        20120901
01712       ANESTH UPPR ARM TENDON SURG                                              $20.78        20120901
01714       ANESTH UPPR ARM TENDON SURG                                              $20.78        20120901
01716       ANESTH BICEPS TENDON REPAIR                                              $20.78        20120901
01730       ANESTH UPPR ARM PROCEDURE                                                $20.78        20120901
01732       ANESTH DX ELBOW ARTHROSCOPY                                              $20.78        20120901
01740       ANESTH UPPER ARM SURGERY                                                 $20.78        20120901
01742       ANESTH HUMERUS SURGERY                                                   $20.78        20120901
01744       ANESTH HUMERUS REPAIR                                                    $20.78        20120901
01756       ANESTH RADICAL HUMERUS SURG                                              $20.78        20120901
01758       ANESTH HUMERAL LESION SURG                                               $20.78        20120901
01760       ANESTH ELBOW REPLACEMENT                                                 $20.78        20120901
01770       ANESTH UPPR ARM ARTERY SURG                                              $20.78        20120901
01772       ANESTH UPPR ARM EMBOLECTOMY                                              $20.78        20120901
01780       ANESTH UPPER ARM VEIN SURG                                               $20.78        20120901
01782       ANESTH UPPR ARM VEIN REPAIR                                              $20.78        20120901
01810       ANESTH LOWER ARM SURGERY                                                 $20.78        20120901
01820       ANESTH LOWER ARM PROCEDURE                                               $20.78        20120901
01829       ANESTH DX WRIST ARTHROSCOPY                                              $20.78        20120901



                                              Page 4
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1         Mod 2   Rate Type   Price         Effective Date
01830       ANESTH LOWER ARM SURGERY                                               $20.78        20120901
01832       ANESTH WRIST REPLACEMENT                                               $20.78        20120901
01840       ANESTH LWR ARM ARTERY SURG                                             $20.78        20120901
01842       ANESTH LWR ARM EMBOLECTOMY                                             $20.78        20120901
01844       ANESTH VASCULAR SHUNT SURG                                             $20.78        20120901
01850       ANESTH LOWER ARM VEIN SURG                                             $20.78        20120901
01852       ANESTH LWR ARM VEIN REPAIR                                             $20.78        20120901
01860       ANESTH LOWER ARM CASTING                                               $20.78        20120901
01916       ANESTH DX ARTERIOGRAPHY                                                $20.78        20120901
01920       ANESTH CATHETERIZE HEART                                               $20.78        20120901
01922       ANESTH CAT OR MRI SCAN                                                 $20.78        20120901
01924       ANES THER INTERVEN RAD ART                                             $20.78        20120901
01925       ANES THER INTERVEN RAD CAR                                             $20.78        20120901
01926       ANES TX INTERV RAD HRT/CRAN                                            $20.78        20120901
01930       ANES THER INTERVEN RAD VEI                                             $20.78        20120901
01931       ANES THER INTERVEN RAD TIP                                             $20.78        20120901
01932       ANES TX INTERV RAD TH VEIN                                             $20.78        20120901
01933       ANES TX INTERV RAD CRAN VEIN                                           $20.78        20120901
01935       ANESTH PERC IMG DX SP PROC                                             $20.78        20120901
01936       ANESTH PERC IMG TX SP PROC                                             $20.78        20120901
01951       ANESTH BURN LESS 4 PERCENT                                             $20.78        20120901
01952       ANESTH BURN 4-9 PERCENT                                                $20.78        20120901
01953       ANESTH BURN EACH 9 PERCENT                                             $20.78        20120901
01958       ANESTH ANTEPARTUM MANIPUL                                              $20.78        20120901
01960       ANESTH VAGINAL DELIVERY                                                $20.78        20120901
01961       ANESTH CS DELIVERY                                                     $20.78        20120901
01962       ANESTH EMER HYSTERECTOMY                                               $20.78        20120901
01963       ANESTH CS HYSTERECTOMY                                                 $20.78        20120901
01965       ANESTH INC/MISSED AB PROC                                              $20.78        20120901
01966       ANESTH INDUCED AB PROCEDURE                                            $20.78        20120901
01967       ANESTH/ANALG VAG DELIVERY                                             $331.90        20120901
01968       ANES/ANALG CS DELIVER ADD-ON                                           $20.78        20120901
01969       ANESTH/ANALG CS HYST ADD-ON                                            $20.78        20120901
01990       SUPPORT FOR ORGAN DONOR                                                $20.78        20120901
01991       ANESTH NERVE BLOCK/INJ                                                 $20.78        20120901
01992       ANESTH N BLOCK/INJ PRONE                                               $20.78        20120901
01996       HOSP MANAGE CONT DRUG ADMIN                                            $62.33        20120901
10021       FNA W/O IMAGE                                                          $93.00        20120901
10022       FNA W/IMAGE                                                            $91.98        20120901
10040       ACNE SURGERY                                                           $67.27        20120901
10060       DRAINAGE OF SKIN ABSCESS                                               $71.60        20120901
10061       DRAINAGE OF SKIN ABSCESS                                              $121.54        20120901
10080       DRAINAGE OF PILONIDAL CYST                                            $107.53        20120901
10081       DRAINAGE OF PILONIDAL CYST                                            $169.19        20120901
10120       REMOVE FOREIGN BODY                                                    $87.91        20120901
10121       REMOVE FOREIGN BODY                                                   $170.21        20120901
10121       REMOVE FOREIGN BODY                                   A               $505.90        20110101
10140       DRAINAGE OF HEMATOMA/FLUID                                            $100.65        20120901
10160       PUNCTURE DRAINAGE OF LESION                                            $82.05        20120901
10180       COMPLEX DRAINAGE WOUND                                                $152.88        20120901
10180       COMPLEX DRAINAGE WOUND                                A               $551.78        20110101
11000       DEBRIDE INFECTED SKIN                                                  $34.40        20120901
11001       DEBRIDE INFECTED SKIN ADD-ON                                           $14.27        20120901
11004       DEBRIDE GENITALIA PERINEUM                                            $404.88        20120901
11005       DEBRIDE ABDOM WALL              80                                    $107.78        20120901
11005       DEBRIDE ABDOM WALL              81                                    $107.78        20120901
11005       DEBRIDE ABDOM WALL              82                                    $107.78        20120901
11005       DEBRIDE ABDOM WALL              AS                                    $107.78        20120901
11005       DEBRIDE ABDOM WALL                                                    $538.90        20120901



                                                 Page 5
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1         Mod 2   Rate Type   Price          Effective Date
11006       DEBRIDE GENIT/PER/ABDOM WALL                                          $493.04         20120901
11008       REMOVE MESH FROM ABD WALL       80                                      $37.86        20120901
11008       REMOVE MESH FROM ABD WALL       81                                      $37.86        20120901
11008       REMOVE MESH FROM ABD WALL       82                                      $37.86        20120901
11008       REMOVE MESH FROM ABD WALL       AS                                      $37.86        20120901
11008       REMOVE MESH FROM ABD WALL                                             $189.32         20120901
11010       DEBRIDE SKIN AT FX SITE                                               $304.74         20120901
11010       DEBRIDE SKIN AT FX SITE                               A               $152.98         20110101
11011       DEBRIDE SKIN MUSC AT FX SITE                                          $338.88         20120901
11011       DEBRIDE SKIN MUSC AT FX SITE                          A               $152.98         20110101
11012       DEB SKIN BONE AT FX SITE                                              $457.37         20120901
11012       DEB SKIN BONE AT FX SITE                              A               $152.98         20110101
11042       DEB SUBQ TISSUE 20 SQ CM/                                               $47.39        20120901
11042       DEB SUBQ TISSUE 20 SQ CM/                             A                 $98.72        20110101
11043       DEB MUSC/FASCIA 20 SQ CM/                                             $182.44         20120901
11043       DEB MUSC/FASCIA 20 SQ CM/                             A                 $98.72        20110101
11044       DEB BONE 20 SQ CM/                                                    $250.98         20120901
11044       DEB BONE 20 SQ CM/                                    A               $278.12         20110101
11045       DEB SUBQ TISSUE ADD-ON                                                  $23.19        20120901
11045       DEB SUBQ TISSUE ADD-ON                                A                 $84.67        20110101
11046       DEB MUSC/FASCIA ADD-ON                                                  $40.51        20120901
11046       DEB MUSC/FASCIA ADD-ON                                A                 $84.67        20110101
11047       DEB BONE ADD-ON                                                         $66.50        20120901
11047       DEB BONE ADD-ON                                       A               $263.23         20110101
11055       TRIM SKIN LESION                                                        $31.09        20120901
11056       TRIM SKIN LESIONS 2 TO 4                                                $37.71        20120901
11057       TRIM SKIN LESIONS OVER 4                                                $45.10        20120901
11100       BIOPSY SKIN LESION                                                      $67.01        20120901
11101       BIOPSY SKIN ADD-ON                                                      $21.91        20120901
11300       SHAVE SKIN LESION                                                       $44.08        20120901
11301       SHAVE SKIN LESION                                                       $60.39        20120901
11302       SHAVE SKIN LESION                                                       $72.11        20120901
11303       SHAVE SKIN LESION                                                       $84.85        20120901
11305       SHAVE SKIN LESION                                                       $44.59        20120901
11306       SHAVE SKIN LESION                                                       $62.17        20120901
11307       SHAVE SKIN LESION                                                       $73.64        20120901
11308       SHAVE SKIN LESION                                                       $81.54        20120901
11310       SHAVE SKIN LESION                                                       $54.78        20120901
11311       SHAVE SKIN LESION                                                       $69.56        20120901
11312       SHAVE SKIN LESION                                                       $80.77        20120901
11313       SHAVE SKIN LESION                                                     $100.90         20120901
11400       EXC TR-EXT B9MARG 0.5 CM                                                $75.68        20120901
11401       EXC TR-EXT B9MARG 0.6-1 CM                                              $93.26        20120901
11402       EXC TR-EXT B9MARG 1.1-2 CM                                            $103.96         20120901
11403       EXC TR-EXT B9MARG 2.1-3 CM                                            $120.01         20120901
11404       EXC TR-EXT B9MARG 3.1-4 CM                                            $136.32         20120901
11404       EXC TR-EXT B9MARG 3.1-4 CM                            A               $484.29         20110101
11406       EXC TR-EXT B9MARG 4.0 CM                                              $195.43         20120901
11406       EXC TR-EXT B9MARG 4.0 CM                              A               $505.90         20110101
11420       EXC H-F-NK-SP B9MARG 0.5                                                $76.19        20120901
11421       EXC H-F-NK-SP B9MARG 0.6-1                                              $99.12        20120901
11422       EXC H-F-NK-SP B9MARG 1.1-2                                            $110.58         20120901
11423       EXC H-F-NK-SP B9MARG 2.1-3                                            $128.67         20120901
11424       EXC H-F-NK-SP B9MARG 3.1-4                                            $148.55         20120901
11424       EXC H-F-NK-SP B9MARG 3.1-4                            A               $505.90         20110101
11426       EXC H-F-NK-SP B9MARG 4 CM                                             $213.78         20120901
11426       EXC H-F-NK-SP B9MARG 4 CM                             A               $647.50         20110101
11440       EXC FACE-MM B9MARG 0.5 CM                                               $83.83        20120901
11441       EXC FACE-MM B9MARG 0.6-1 CM                                           $106.25         20120901



                                                 Page 6
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
11442       EXC FACE-MM B9MARG 1.1-2 CM                                           $119.50         20120901
11443       EXC FACE-MM B9MARG 2.1-3 CM                                           $143.45         20120901
11444       EXC FACE-MM B9MARG 3.1-4 CM                                           $181.16         20120901
11444       EXC FACE-MM B9MARG 3.1-4 CM                           A               $260.88         20110101
11446       EXC FACE-MM B9MARG 4 CM                                               $248.94         20120901
11446       EXC FACE-MM B9MARG 4 CM                               A               $647.50         20110101
11450       REMOVAL SWEAT GLAND LESION                                            $231.36         20120901
11450       REMOVAL SWEAT GLAND LESION                            A               $647.50         20110101
11451       REMOVAL SWEAT GLAND LESION                                            $299.39         20120901
11451       REMOVAL SWEAT GLAND LESION                            A               $647.50         20110101
11462       REMOVAL SWEAT GLAND LESION                                            $228.05         20120901
11462       REMOVAL SWEAT GLAND LESION                            A               $647.50         20110101
11463       REMOVAL SWEAT GLAND LESION                                            $306.78         20120901
11463       REMOVAL SWEAT GLAND LESION                            A               $647.50         20110101
11470       REMOVAL SWEAT GLAND LESION                                            $253.02         20120901
11470       REMOVAL SWEAT GLAND LESION                            A               $647.50         20110101
11471       REMOVAL SWEAT GLAND LESION                                            $315.19         20120901
11471       REMOVAL SWEAT GLAND LESION                            A               $647.50         20110101
11600       EXC TR-EXT MALMARG 0.5 CM                                             $118.23         20120901
11601       EXC TR-EXT MALMARG 0.6-1 CM                                           $144.73         20120901
11602       EXC TR-EXT MALMARG 1.1-2 CM                                           $158.74         20120901
11603       EXC TR-EXT MALMARG 2.1-3 CM                                           $180.65         20120901
11604       EXC TR-EXT MALMARG 3.1-4 CM                                           $200.02         20120901
11604       EXC TR-EXT MALMARG 3.1-4 CM                           A               $277.24         20110101
11606       EXC TR-EXT MALMARG 4 CM                                               $284.10         20120901
11606       EXC TR-EXT MALMARG 4 CM                               A               $505.90         20110101
11620       EXC H-F-NK-SP MALMARG 0.5                                             $120.52         20120901
11621       EXC S/N/H/F/G MALMRG 0.6-1                                            $146.00         20120901
11622       EXC S/N/H/F/G MALMRG 1.1-2                                            $164.86         20120901
11623       EXC S/N/H/F/G MALMRG 2.1-3                                            $193.14         20120901
11624       EXC S/N/H/F/G MALMRG 3.1-4                                            $217.34         20120901
11624       EXC S/N/H/F/G MALMRG 3.1-4                            A               $505.90         20110101
11626       EXC S/N/H/F/G MALMRG 4 CM                                             $263.46         20120901
11626       EXC S/N/H/F/G MALMRG 4 CM                             A               $647.50         20110101
11640       EXC F/E/E/N/L MALMRG 0.5CM                                            $125.36         20120901
11641       EXC F/E/E/N/L MALMRG 0.6-1                                            $152.63         20120901
11642       EXC F/E/E/N/L MALMRG 1.1-2                                            $175.81         20120901
11643       EXC F/E/E/N/L MALMRG 2.1-3                                            $207.66         20120901
11644       EXC F/E/E/N/L MALMRG 3.1-4                                            $255.82         20120901
11644       EXC F/E/E/N/L MALMRG 3.1-4                            A               $505.90         20110101
11646       EXC F/E/E/N/L MALMRG 4 CM                                             $336.85         20120901
11646       EXC F/E/E/N/L MALMRG 4 CM                             A               $647.50         20110101
11719       TRIM NAILS                                                              $13.76        20120901
11720       DEBRIDE NAIL 1-5                                                        $19.87        20120901
11721       DEBRIDE NAIL 6 OR MORE                                                  $28.03        20120901
11730       REMOVAL OF NAIL PLATE                                                   $62.43        20120901
11732       REMOVE NAIL PLATE ADD-ON                                                $28.79        20120901
11740       DRAIN BLOOD FROM UNDER NAIL                                             $29.05        20120901
11750       REMOVAL OF NAIL BED                                                   $140.39         20120901
11752       REMOVE NAIL BED/FINGER TIP                                            $201.29         20120901
11755       BIOPSY NAIL UNIT                                                        $85.36        20120901
11760       REPAIR OF NAIL BED                                                    $133.77         20120901
11762       RECONSTRUCTION OF NAIL BED                                            $174.28         20120901
11765       EXCISION OF NAIL FOLD TOE                                               $84.34        20120901
11770       REMOVAL OF PILONIDAL LESION                                           $170.46         20120901
11770       REMOVAL OF PILONIDAL LESION                           A               $659.74         20110101
11771       REMOVAL OF PILONIDAL LESION                                           $354.43         20120901
11771       REMOVAL OF PILONIDAL LESION                           A               $659.74         20110101
11772       REMOVAL OF PILONIDAL LESION                                           $428.32         20120901



                                               Page 7
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1         Mod 2   Rate Type   Price          Effective Date
11772       REMOVAL OF PILONIDAL LESION                          A                $659.74        20110101
11900       INJECTION INTO SKIN LESIONS                                            $36.69        20120901
11900       INJECTION INTO SKIN LESIONS                          A                 $19.76        20110101
11901       ADDED SKIN LESIONS INJECTION                                           $46.88        20120901
11960       INSERT TISSUE EXPANDERS                                               $609.23        20120901
11960       INSERT TISSUE EXPANDERS                              A                $660.56        20110101
11970       REPLACE TISSUE EXPANDER                                               $402.07        20120901
11970       REPLACE TISSUE EXPANDER                              A              $1,217.14        20110101
11971       REMOVE TISSUE EXPANDERS                                               $300.66        20120901
11971       REMOVE TISSUE EXPANDERS                              A                $625.87        20110101
11976       REMOVAL OF CONTRACEPTIVE CAP                                           $97.33        20120901
11980       IMPLANT HORMONE PELLETS                                                $70.07        20120901
11981       INSERT DRUG IMPLANT DEVICE                                             $89.69        20120901
11982       REMOVE DRUG IMPLANT DEVICE                                            $100.90        20120901
11983       REMOVE/INSERT DRUG IMPLANT                                            $155.17        20120901
12001       REPAIR SUPERFICIAL WOUNDS                                              $98.10        20120901
12002       REPAIR SUPERFICIAL WOUNDS                                             $104.21        20120901
12004       REPAIR SUPERFICIAL WOUNDS                                             $122.81        20120901
12005       REPAIR SUPERFICIAL WOUNDS                                             $152.63        20120901
12005       REPAIR SUPERFICIAL WOUNDS                            A                 $50.00        20110101
12006       REPAIR SUPERFICIAL WOUNDS                                             $189.32        20120901
12006       REPAIR SUPERFICIAL WOUNDS                            A                 $50.00        20110101
12007       REPAIR SUPERFICIAL WOUNDS                                             $212.50        20120901
12007       REPAIR SUPERFICIAL WOUNDS                            A                 $50.00        20110101
12011       REPAIR SUPERFICIAL WOUNDS                                             $104.21        20120901
12013       REPAIR SUPERFICIAL WOUNDS                                             $114.66        20120901
12014       REPAIR SUPERFICIAL WOUNDS                                             $134.79        20120901
12015       REPAIR SUPERFICIAL WOUNDS                                             $169.19        20120901
12016       REPAIR SUPERFICIAL WOUNDS                                             $201.80        20120901
12016       REPAIR SUPERFICIAL WOUNDS                            A                 $50.00        20110101
12017       REPAIR SUPERFICIAL WOUNDS                                             $176.83        20120901
12017       REPAIR SUPERFICIAL WOUNDS                            A                 $50.00        20110101
12018       REPAIR SUPERFICIAL WOUNDS      80                                      $42.86        20120901
12018       REPAIR SUPERFICIAL WOUNDS      81                                      $42.86        20120901
12018       REPAIR SUPERFICIAL WOUNDS      82                                      $42.86        20120901
12018       REPAIR SUPERFICIAL WOUNDS      AS                                      $42.86        20120901
12018       REPAIR SUPERFICIAL WOUNDS                                             $214.29        20120901
12018       REPAIR SUPERFICIAL WOUNDS                            A                 $50.00        20110101
12020       CLOSURE OF SPLIT WOUND                                                $174.03        20120901
12020       CLOSURE OF SPLIT WOUND                               A                $124.14        20110101
12021       CLOSURE OF SPLIT WOUND                                                $103.45        20120901
12021       CLOSURE OF SPLIT WOUND                               A                 $93.19        20110101
12031       INTMD WND REPAIR S/A/T/EXT                                            $155.94        20120901
12032       INTMD WND REPAIR S/A/T/EXT                                            $197.98        20120901
12034       INTMD WND REPAIR S/TR/EXT                                             $197.47        20120901
12034       INTMD WND REPAIR S/TR/EXT                            A                 $50.00        20110101
12035       INTMD WND REPAIR S/A/T/EXT                                            $239.51        20120901
12035       INTMD WND REPAIR S/A/T/EXT                           A                 $50.00        20110101
12036       INTMD WND REPAIR S/A/T/EXT                                            $262.19        20120901
12036       INTMD WND REPAIR S/A/T/EXT                           A                 $93.19        20110101
12037       INTMD WND REPAIR S/TR/EXT                                             $294.80        20120901
12037       INTMD WND REPAIR S/TR/EXT                            A                $137.59        20110101
12041       INTMD WND REPAIR N-HF/GENIT                                           $163.07        20120901
12042       INTMD WND REPAIR N-HF/GENIT                                           $188.55        20120901
12044       INTMD WND REPAIR N-HF/GENIT                                           $220.40        20120901
12044       INTMD WND REPAIR N-HF/GENIT                          A                 $50.00        20110101
12045       INTMD WND REPAIR N-HF/GENIT                                           $240.53        20120901
12045       INTMD WND REPAIR N-HF/GENIT                          A                 $93.19        20110101
12046       INTMD WND REPAIR N-HF/GENIT                                           $294.29        20120901



                                                Page 8
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1         Mod 2   Rate Type   Price         Effective Date
12046       INTMD WND REPAIR N-HF/GENIT                            A                $93.19        20110101
12047       INTMD WND REPAIR N-HF/GENIT      80                                     $62.78        20120901
12047       INTMD WND REPAIR N-HF/GENIT      81                                     $62.78        20120901
12047       INTMD WND REPAIR N-HF/GENIT      82                                     $62.78        20120901
12047       INTMD WND REPAIR N-HF/GENIT      AS                                     $62.78        20120901
12047       INTMD WND REPAIR N-HF/GENIT                                            $313.91        20120901
12047       INTMD WND REPAIR N-HF/GENIT                            A               $137.59        20110101
12051       INTMD WND REPAIR FACE/MM                                               $173.77        20120901
12052       INTMD WND REPAIR FACE/MM                                               $198.23        20120901
12053       INTMD WND REPAIR FACE/MM                                               $218.11        20120901
12054       INTMD WND REPAIR FACE/MM                                               $231.36        20120901
12054       INTMD WND REPAIR FACE/MM                               A                $50.00        20110101
12055       INTMD WND REPAIR FACE/MM                                               $277.48        20120901
12055       INTMD WND REPAIR FACE/MM                               A                $93.19        20110101
12056       INTMD WND REPAIR FACE/MM                                               $324.11        20120901
12056       INTMD WND REPAIR FACE/MM                               A                $93.19        20110101
12057       INTMD WND REPAIR FACE/MM         80                                     $71.85        20120901
12057       INTMD WND REPAIR FACE/MM         81                                     $71.85        20120901
12057       INTMD WND REPAIR FACE/MM         82                                     $71.85        20120901
12057       INTMD WND REPAIR FACE/MM         AS                                     $71.85        20120901
12057       INTMD WND REPAIR FACE/MM                                               $359.27        20120901
12057       INTMD WND REPAIR FACE/MM                               A               $137.59        20110101
13100       REPAIR OF WOUND OR LESION                                              $205.11        20120901
13100       REPAIR OF WOUND OR LESION                              A               $168.54        20110101
13101       REPAIR OF WOUND OR LESION                                              $259.64        20120901
13101       REPAIR OF WOUND OR LESION                              A               $168.54        20110101
13102       REPAIR WOUND/LESION ADD-ON                                              $70.83        20120901
13120       REPAIR OF WOUND OR LESION                                              $213.01        20120901
13120       REPAIR OF WOUND OR LESION                              A                $93.19        20110101
13121       REPAIR OF WOUND OR LESION                                              $289.20        20120901
13121       REPAIR OF WOUND OR LESION                              A                $93.19        20110101
13122       REPAIR WOUND/LESION ADD-ON                                              $78.73        20120901
13131       REPAIR OF WOUND OR LESION                                              $235.69        20120901
13131       REPAIR OF WOUND OR LESION                              A                $93.19        20110101
13132       REPAIR OF WOUND OR LESION                                              $381.95        20120901
13132       REPAIR OF WOUND OR LESION                              A               $124.14        20110101
13133       REPAIR WOUND/LESION ADD-ON                                             $111.35        20120901
13150       REPAIR OF WOUND OR LESION                                              $234.42        20120901
13150       REPAIR OF WOUND OR LESION                              A               $168.54        20110101
13151       REPAIR OF WOUND OR LESION                                              $267.29        20120901
13151       REPAIR OF WOUND OR LESION                              A               $168.54        20110101
13152       REPAIR OF WOUND OR LESION                                              $369.71        20120901
13152       REPAIR OF WOUND OR LESION                              A               $168.54        20110101
13153       REPAIR WOUND/LESION ADD-ON                                             $122.05        20120901
13160       LATE CLOSURE OF WOUND                                                  $541.70        20120901
13160       LATE CLOSURE OF WOUND                                  A               $660.56        20110101
14000       SKIN TISSUE REARRANGEMENT                                              $405.90        20120901
14000       SKIN TISSUE REARRANGEMENT                              A               $471.22        20110101
14001       SKIN TISSUE REARRANGEMENT                                              $526.16        20120901
14001       SKIN TISSUE REARRANGEMENT                              A               $483.46        20110101
14020       SKIN TISSUE REARRANGEMENT                                              $455.84        20120901
14020       SKIN TISSUE REARRANGEMENT                              A               $483.46        20110101
14021       SKIN TISSUE REARRANGEMENT                                              $575.34        20120901
14021       SKIN TISSUE REARRANGEMENT                              A               $483.46        20110101
14040       SKIN TISSUE REARRANGEMENT                                              $505.27        20120901
14040       SKIN TISSUE REARRANGEMENT                              A               $471.22        20110101
14041       SKIN TISSUE REARRANGEMENT                                              $627.83        20120901
14041       SKIN TISSUE REARRANGEMENT                              A               $483.46        20110101
14060       SKIN TISSUE REARRANGEMENT                                              $514.44        20120901



                                                  Page 9
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
14060       SKIN TISSUE REARRANGEMENT                             A               $483.46         20110101
14061       SKIN TISSUE REARRANGEMENT                                             $673.18         20120901
14061       SKIN TISSUE REARRANGEMENT                             A               $483.46         20110101
14301       SKIN TISSUE REARRANGEMENT                                             $727.71         20120901
14302       SKIN TISSUE REARRANGE ADD-ON    80                                      $32.00        20120901
14302       SKIN TISSUE REARRANGE ADD-ON    81                                      $32.00        20120901
14302       SKIN TISSUE REARRANGE ADD-ON    82                                      $32.00        20120901
14302       SKIN TISSUE REARRANGE ADD-ON    AS                                      $32.00        20120901
14302       SKIN TISSUE REARRANGE ADD-ON                                          $160.01         20120901
14350       SKIN TISSUE REARRANGEMENT                                             $495.08         20120901
14350       SKIN TISSUE REARRANGEMENT                             A               $672.80         20110101
15002       WOUND PREP TRK/ARM/LEG                                                $217.85         20120901
15002       WOUND PREP TRK/ARM/LEG                                A               $168.54         20110101
15003       WOUND PREP ADDL 100 CM                                                  $47.65        20120901
15003       WOUND PREP ADDL 100 CM                                A               $168.54         20110101
15004       WOUND PREP F/N/HF/G                                                   $259.39         20120901
15004       WOUND PREP F/N/HF/G                                   A               $168.54         20110101
15005       WND PREP F/N/HF/G ADDL CM                                               $80.01        20120901
15005       WND PREP F/N/HF/G ADDL CM                             A               $168.54         20110101
15040       HARVEST CULTURED SKIN GRAFT                                           $164.35         20120901
15040       HARVEST CULTURED SKIN GRAFT                           A                 $93.19        20110101
15050       SKIN PINCH GRAFT                                                      $357.74         20120901
15050       SKIN PINCH GRAFT                                      A               $168.54         20110101
15100       SKIN SPLT GRFT TRNK/ARM/LEG                                           $566.17         20120901
15100       SKIN SPLT GRFT TRNK/ARM/LEG                           A               $660.56         20110101
15101       SKIN SPLT GRFT T/A/L ADD-ON                                           $122.05         20120901
15101       SKIN SPLT GRFT T/A/L ADD-ON                           A               $672.80         20110101
15110       EPIDRM AUTOGRFT TRNK/ARM/LEG                                          $562.09         20120901
15110       EPIDRM AUTOGRFT TRNK/ARM/LEG                          A               $192.02         20110101
15111       EPIDRM AUTOGRFT T/A/L ADD-ON                                            $80.77        20120901
15111       EPIDRM AUTOGRFT T/A/L ADD-ON                          A               $170.40         20110101
15115       EPIDRM A-GRFT FACE/NCK/HF/G                                           $566.42         20120901
15115       EPIDRM A-GRFT FACE/NCK/HF/G                           A               $192.02         20110101
15116       EPIDRM A-GRFT F/N/HF/G ADDL                                           $111.86         20120901
15116       EPIDRM A-GRFT F/N/HF/G ADDL                           A               $170.40         20110101
15120       SKN SPLT A-GRFT FAC/NCK/HF/G                                          $621.20         20120901
15120       SKN SPLT A-GRFT FAC/NCK/HF/G                          A               $660.56         20110101
15121       SKN SPLT A-GRFT F/N/HF/G ADD                                          $173.52         20120901
15121       SKN SPLT A-GRFT F/N/HF/G ADD                          A               $672.80         20110101
15130       DERM AUTOGRAFT TRNK/ARM/LEG                                           $440.55         20120901
15130       DERM AUTOGRAFT TRNK/ARM/LEG                           A               $471.22         20110101
15131       DERM AUTOGRAFT T/A/L ADD-ON                                             $64.97        20120901
15131       DERM AUTOGRAFT T/A/L ADD-ON                           A               $449.59         20110101
15135       DERM AUTOGRAFT FACE/NCK/HF/G                                          $569.22         20120901
15135       DERM AUTOGRAFT FACE/NCK/HF/G                          A               $471.22         20110101
15136       DERM AUTOGRAFT F/N/HF/G ADD                                             $57.08        20120901
15136       DERM AUTOGRAFT F/N/HF/G ADD                           A               $449.59         20110101
15150       CULT SKIN GRFT T/ARM/LEG                                              $463.48         20120901
15150       CULT SKIN GRFT T/ARM/LEG                              A               $192.02         20110101
15151       CULT SKIN GRFT T/A/L ADDL                                               $84.59        20120901
15151       CULT SKIN GRFT T/A/L ADDL                             A               $170.40         20110101
15152       CULT SKIN GRAFT T/A/L                                                 $108.04         20120901
15152       CULT SKIN GRAFT T/A/L                                 A               $170.40         20110101
15155       CULT SKIN GRAFT F/N/HF/G                                              $451.25         20120901
15155       CULT SKIN GRAFT F/N/HF/G                              A               $192.02         20110101
15156       CULT SKIN GRFT F/N/HFG ADD                                            $118.48         20120901
15156       CULT SKIN GRFT F/N/HFG ADD                            A               $170.40         20110101
15157       CULT EPIDERM GRFT F/N/HFG                                             $121.03         20120901
15157       CULT EPIDERM GRFT F/N/HFG                             A               $170.40         20110101



                                              Page 10
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
15200       SKIN FULL GRAFT TRUNK                                                  $531.77        20120901
15200       SKIN FULL GRAFT TRUNK                                 A                $483.46        20110101
15201       SKIN FULL GRAFT TRUNK ADD-ON                                            $95.55        20120901
15201       SKIN FULL GRAFT TRUNK ADD-ON                          A                $447.74        20110101
15220       SKIN FULL GRAFT SCLP/ARM/LEG                                           $501.19        20120901
15220       SKIN FULL GRAFT SCLP/ARM/LEG                          A                $471.22        20110101
15221       SKIN FULL GRAFT ADD-ON                                                  $89.18        20120901
15221       SKIN FULL GRAFT ADD-ON                                A                $168.54        20110101
15240       SKIN FULL GRFT FACE/GENIT/HF                                           $606.93        20120901
15240       SKIN FULL GRFT FACE/GENIT/HF                          A                $483.46        20110101
15241       SKIN FULL GRAFT ADD-ON                                                 $119.76        20120901
15241       SKIN FULL GRAFT ADD-ON                                A                $168.54        20110101
15260       SKIN FULL GRAFT EEN LIPS                                               $660.19        20120901
15260       SKIN FULL GRAFT EEN LIPS                              A                $471.22        20110101
15261       SKIN FULL GRAFT ADD-ON                                                 $140.39        20120901
15261       SKIN FULL GRAFT ADD-ON                                A                $447.74        20110101
15271       SKIN SUB GRAFT TRNK/ARM/LEG                                            $100.39        20120901
15272       SKIN SUB GRAFT T/A/L ADD-ON                                             $20.38        20120901
15273       SKIN SUB GRFT T/ARM/LG CHILD                                           $221.93        20120901
15274       SKN SUB GRFT T/A/L CHILD ADD                                            $52.23        20120901
15275       SKIN SUB GRAFT FACE/NK/HF/G                                            $115.93        20120901
15276       SKIN SUB GRAFT F/N/HF/G ADDL                                            $25.23        20120901
15277       SKN SUB GRFT F/N/HF/G CHILD                                            $223.20        20120901
15278       SKN SUB GRFT F/N/HF/G CH ADD                                            $61.41        20120901
15570       FORM SKIN PEDICLE FLAP                                                 $582.73        20120901
15570       FORM SKIN PEDICLE FLAP                                A                $672.80        20110101
15572       FORM SKIN PEDICLE FLAP                                                 $564.89        20120901
15572       FORM SKIN PEDICLE FLAP                                A                $672.80        20110101
15574       FORM SKIN PEDICLE FLAP                                                 $594.45        20120901
15574       FORM SKIN PEDICLE FLAP                                A                $672.80        20110101
15576       FORM SKIN PEDICLE FLAP                                                 $528.20        20120901
15576       FORM SKIN PEDICLE FLAP                                A                $672.80        20110101
15600       SKIN GRAFT                                                             $208.94        20120901
15600       SKIN GRAFT                                            A                $672.80        20110101
15610       SKIN GRAFT                                                             $215.05        20120901
15610       SKIN GRAFT                                            A                $672.80        20110101
15620       SKIN GRAFT                                                             $283.59        20120901
15620       SKIN GRAFT                                            A                $695.77        20110101
15630       SKIN GRAFT                                                             $299.90        20120901
15630       SKIN GRAFT                                            A                $672.80        20110101
15650       TRANSFER SKIN PEDICLE FLAP                                             $332.77        20120901
15650       TRANSFER SKIN PEDICLE FLAP                            A                $712.41        20110101
15731       FOREHEAD FLAP W/VASC PEDICLE                                           $753.44        20120901
15731       FOREHEAD FLAP W/VASC PEDICLE                          A                $672.80        20110101
15732       MUSCLE-SKIN GRAFT HEAD/NECK                                            $995.76        20120901
15732       MUSCLE-SKIN GRAFT HEAD/NECK                           A                $672.80        20110101
15734       MUSCLE-SKIN GRAFT TRUNK         80                                     $203.38        20120901
15734       MUSCLE-SKIN GRAFT TRUNK         81                                     $203.38        20120901
15734       MUSCLE-SKIN GRAFT TRUNK         82                                     $203.38        20120901
15734       MUSCLE-SKIN GRAFT TRUNK         AS                                     $203.38        20120901
15734       MUSCLE-SKIN GRAFT TRUNK                                              $1,016.91        20120901
15734       MUSCLE-SKIN GRAFT TRUNK                               A                $672.80        20110101
15736       MUSCLE-SKIN GRAFT ARM                                                  $890.53        20120901
15736       MUSCLE-SKIN GRAFT ARM                                 A                $672.80        20110101
15738       MUSCLE-SKIN GRAFT LEG           80                                     $190.59        20120901
15738       MUSCLE-SKIN GRAFT LEG           81                                     $190.59        20120901
15738       MUSCLE-SKIN GRAFT LEG           82                                     $190.59        20120901
15738       MUSCLE-SKIN GRAFT LEG           AS                                     $190.59        20120901
15738       MUSCLE-SKIN GRAFT LEG                                                  $952.95        20120901



                                              Page 11
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
15738       MUSCLE-SKIN GRAFT LEG                                 A                $672.80        20110101
15740       ISLAND PEDICLE FLAP GRAFT                                              $673.69        20120901
15740       ISLAND PEDICLE FLAP GRAFT                             A                $471.22        20110101
15750       NEUROVASCULAR PEDICLE GRAFT     80                                     $122.76        20120901
15750       NEUROVASCULAR PEDICLE GRAFT     81                                     $122.76        20120901
15750       NEUROVASCULAR PEDICLE GRAFT     82                                     $122.76        20120901
15750       NEUROVASCULAR PEDICLE GRAFT     AS                                     $122.76        20120901
15750       NEUROVASCULAR PEDICLE GRAFT                                            $613.81        20120901
15750       NEUROVASCULAR PEDICLE GRAFT                           A                $660.56        20110101
15756       FREE MYO/SKIN FLAP MICROVASC    80                                     $319.21        20120901
15756       FREE MYO/SKIN FLAP MICROVASC    81                                     $319.21        20120901
15756       FREE MYO/SKIN FLAP MICROVASC    82                                     $319.21        20120901
15756       FREE MYO/SKIN FLAP MICROVASC    AS                                     $319.21        20120901
15756       FREE MYO/SKIN FLAP MICROVASC                                         $1,596.07        20120901
15757       FREE SKIN FLAP MICROVASC        80                                     $316.72        20120901
15757       FREE SKIN FLAP MICROVASC        81                                     $316.72        20120901
15757       FREE SKIN FLAP MICROVASC        82                                     $316.72        20120901
15757       FREE SKIN FLAP MICROVASC        AS                                     $316.72        20120901
15757       FREE SKIN FLAP MICROVASC                                             $1,583.58        20120901
15758       FREE FASCIAL FLAP MICROVASC     80                                     $315.34        20120901
15758       FREE FASCIAL FLAP MICROVASC     81                                     $315.34        20120901
15758       FREE FASCIAL FLAP MICROVASC     82                                     $315.34        20120901
15758       FREE FASCIAL FLAP MICROVASC     AS                                     $315.34        20120901
15758       FREE FASCIAL FLAP MICROVASC                                          $1,576.70        20120901
15760       COMPOSITE SKIN GRAFT                                                   $557.76        20120901
15760       COMPOSITE SKIN GRAFT                                  A                $660.56        20110101
15770       DERMA-FAT-FASCIA GRAFT          80                                      $88.52        20120901
15770       DERMA-FAT-FASCIA GRAFT          81                                      $88.52        20120901
15770       DERMA-FAT-FASCIA GRAFT          82                                      $88.52        20120901
15770       DERMA-FAT-FASCIA GRAFT          AS                                      $88.52        20120901
15770       DERMA-FAT-FASCIA GRAFT                                                 $442.59        20120901
15770       DERMA-FAT-FASCIA GRAFT                                A                $672.80        20110101
15822       REVISION OF UPPER EYELID                                               $281.04        20120901
15822       REVISION OF UPPER EYELID                              A                $672.80        20110101
15823       REVISION OF UPPER EYELID                                               $452.27        20120901
15823       REVISION OF UPPER EYELID                              A                $712.41        20110101
15836       EXCISE EXCESSIVE SKIN TISSUE    80                                      $98.15        20120901
15836       EXCISE EXCESSIVE SKIN TISSUE    81                                      $98.15        20120901
15836       EXCISE EXCESSIVE SKIN TISSUE    82                                      $98.15        20120901
15836       EXCISE EXCESSIVE SKIN TISSUE    AS                                      $98.15        20120901
15836       EXCISE EXCESSIVE SKIN TISSUE                                           $490.74        20120901
15840       GRAFT FOR FACE NERVE PALSY                                             $684.39        20120901
15840       GRAFT FOR FACE NERVE PALSY                            A                $695.77        20110101
15841       GRAFT FOR FACE NERVE PALSY      80                                     $222.95        20120901
15841       GRAFT FOR FACE NERVE PALSY      81                                     $222.95        20120901
15841       GRAFT FOR FACE NERVE PALSY      82                                     $222.95        20120901
15841       GRAFT FOR FACE NERVE PALSY      AS                                     $222.95        20120901
15841       GRAFT FOR FACE NERVE PALSY                                           $1,114.75        20120901
15841       GRAFT FOR FACE NERVE PALSY                            A                $695.77        20110101
15842       FLAP FOR FACE NERVE PALSY       80                                     $341.02        20120901
15842       FLAP FOR FACE NERVE PALSY       81                                     $341.02        20120901
15842       FLAP FOR FACE NERVE PALSY       82                                     $341.02        20120901
15842       FLAP FOR FACE NERVE PALSY       AS                                     $341.02        20120901
15842       FLAP FOR FACE NERVE PALSY                                            $1,705.12        20120901
15842       FLAP FOR FACE NERVE PALSY                             A                $766.96        20110101
15845       SKIN AND MUSCLE REPAIR FACE     80                                     $129.95        20120901
15845       SKIN AND MUSCLE REPAIR FACE     81                                     $129.95        20120901
15845       SKIN AND MUSCLE REPAIR FACE     82                                     $129.95        20120901
15845       SKIN AND MUSCLE REPAIR FACE     AS                                     $129.95        20120901



                                              Page 12
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
15845       SKIN AND MUSCLE REPAIR FACE                                           $649.74        20120901
15845       SKIN AND MUSCLE REPAIR FACE                          A                $695.77        20110101
15850       REMOVAL OF SUTURES                                                     $57.33        20120901
15851       REMOVAL OF SUTURES                                                     $61.15        20120901
15852       DRESSING CHANGE NOT FOR BURN                                           $32.36        20120901
15860       TEST FOR BLOOD FLOW IN GRAFT                                           $78.22        20120901
15920       REMOVAL OF TAIL BONE ULCER                                            $395.96        20120901
15920       REMOVAL OF TAIL BONE ULCER                           A                $152.98        20110101
15922       REMOVAL OF TAIL BONE ULCER     80                                      $97.84        20120901
15922       REMOVAL OF TAIL BONE ULCER     81                                      $97.84        20120901
15922       REMOVAL OF TAIL BONE ULCER     82                                      $97.84        20120901
15922       REMOVAL OF TAIL BONE ULCER     AS                                      $97.84        20120901
15922       REMOVAL OF TAIL BONE ULCER                                            $489.22        20120901
15922       REMOVAL OF TAIL BONE ULCER                           A                $695.77        20110101
15931       REMOVE SACRUM PRESSURE SORE                                           $449.47        20120901
15931       REMOVE SACRUM PRESSURE SORE                          A                $659.74        20110101
15933       REMOVE SACRUM PRESSURE SORE                                           $553.68        20120901
15933       REMOVE SACRUM PRESSURE SORE                          A                $659.74        20110101
15934       REMOVE SACRUM PRESSURE SORE                                           $614.83        20120901
15934       REMOVE SACRUM PRESSURE SORE                          A                $672.80        20110101
15935       REMOVE SACRUM PRESSURE SORE    80                                     $146.36        20120901
15935       REMOVE SACRUM PRESSURE SORE    81                                     $146.36        20120901
15935       REMOVE SACRUM PRESSURE SORE    82                                     $146.36        20120901
15935       REMOVE SACRUM PRESSURE SORE    AS                                     $146.36        20120901
15935       REMOVE SACRUM PRESSURE SORE                                           $731.79        20120901
15935       REMOVE SACRUM PRESSURE SORE                          A                $695.77        20110101
15936       REMOVE SACRUM PRESSURE SORE                                           $593.68        20120901
15936       REMOVE SACRUM PRESSURE SORE                          A                $506.42        20110101
15937       REMOVE SACRUM PRESSURE SORE                                           $692.80        20120901
15937       REMOVE SACRUM PRESSURE SORE                          A                $695.77        20110101
15940       REMOVE HIP PRESSURE SORE                                              $459.91        20120901
15940       REMOVE HIP PRESSURE SORE                             A                $659.74        20110101
15941       REMOVE HIP PRESSURE SORE                                              $597.76        20120901
15941       REMOVE HIP PRESSURE SORE                             A                $659.74        20110101
15944       REMOVE HIP PRESSURE SORE                                              $589.10        20120901
15944       REMOVE HIP PRESSURE SORE                             A                $672.80        20110101
15945       REMOVE HIP PRESSURE SORE                                              $653.56        20120901
15945       REMOVE HIP PRESSURE SORE                             A                $695.77        20110101
15946       REMOVE HIP PRESSURE SORE                                            $1,094.11        20120901
15946       REMOVE HIP PRESSURE SORE                             A                $695.77        20110101
15950       REMOVE THIGH PRESSURE SORE                                            $380.42        20120901
15950       REMOVE THIGH PRESSURE SORE                           A                $659.74        20110101
15951       REMOVE THIGH PRESSURE SORE     80                                     $107.73        20120901
15951       REMOVE THIGH PRESSURE SORE     81                                     $107.73        20120901
15951       REMOVE THIGH PRESSURE SORE     82                                     $107.73        20120901
15951       REMOVE THIGH PRESSURE SORE     AS                                     $107.73        20120901
15951       REMOVE THIGH PRESSURE SORE                                            $538.65        20120901
15951       REMOVE THIGH PRESSURE SORE                           A                $682.70        20110101
15952       REMOVE THIGH PRESSURE SORE     80                                     $113.39        20120901
15952       REMOVE THIGH PRESSURE SORE     81                                     $113.39        20120901
15952       REMOVE THIGH PRESSURE SORE     82                                     $113.39        20120901
15952       REMOVE THIGH PRESSURE SORE     AS                                     $113.39        20120901
15952       REMOVE THIGH PRESSURE SORE                                            $566.93        20120901
15952       REMOVE THIGH PRESSURE SORE                           A                $483.46        20110101
15953       REMOVE THIGH PRESSURE SORE                                            $643.12        20120901
15953       REMOVE THIGH PRESSURE SORE                           A                $506.42        20110101
15956       REMOVE THIGH PRESSURE SORE                                            $765.42        20120901
15956       REMOVE THIGH PRESSURE SORE                           A                $483.46        20110101
15958       REMOVE THIGH PRESSURE SORE                                            $779.94        20120901



                                             Page 13
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
15958       REMOVE THIGH PRESSURE SORE                            A                $506.42        20110101
16000       INITIAL TREATMENT OF BURNS                                              $45.35        20120901
16020       DRESS/DEBRID P-THICK BURN S                                             $53.00        20120901
16025       DRESS/DEBRID P-THICK BURN M                                             $97.33        20120901
16025       DRESS/DEBRID P-THICK BURN M                           A                 $49.89        20110101
16030       DRESS/DEBRID P-THICK BURN L                                            $116.19        20120901
16030       DRESS/DEBRID P-THICK BURN L                           A                 $56.14        20110101
16035       INCISION OF BURN SCAB INITI                                            $142.18        20120901
16035       INCISION OF BURN SCAB INITI                           A                 $49.39        20110101
16036       ESCHAROTOMY ADDL INCISION                                               $57.58        20120901
17000       DESTRUCT PREMALG LESION                                                 $51.98        20120901
17003       DESTRUCT PREMALG LES 2-14                                                $4.84        20120901
17004       DESTROY PREMAL LESIONS 15/                                             $114.66        20120901
17106       DESTRUCTION OF SKIN LESIONS                                            $224.99        20120901
17107       DESTRUCTION OF SKIN LESIONS                                            $293.53        20120901
17108       DESTRUCTION OF SKIN LESIONS                                            $415.58        20120901
17110       DESTRUCT B9 LESION 1-14                                                 $70.58        20120901
17111       DESTRUCT LESION 15 OR MORE                                              $84.59        20120901
17250       CHEMICAL CAUTERY TISSUE                                                 $47.90        20120901
17260       DESTRUCTION OF SKIN LESIONS                                             $62.17        20120901
17261       DESTRUCTION OF SKIN LESIONS                                             $93.00        20120901
17262       DESTRUCTION OF SKIN LESIONS                                            $113.39        20120901
17263       DESTRUCTION OF SKIN LESIONS                                            $125.11        20120901
17264       DESTRUCTION OF SKIN LESIONS                                            $133.77        20120901
17266       DESTRUCTION OF SKIN LESIONS                                            $152.37        20120901
17270       DESTRUCTION OF SKIN LESIONS                                             $97.08        20120901
17271       DESTRUCTION OF SKIN LESIONS                                            $107.02        20120901
17272       DESTRUCTION OF SKIN LESIONS                                            $122.05        20120901
17273       DESTRUCTION OF SKIN LESIONS                                            $136.32        20120901
17274       DESTRUCTION OF SKIN LESIONS                                            $161.54        20120901
17276       DESTRUCTION OF SKIN LESIONS                                            $187.53        20120901
17280       DESTRUCTION OF SKIN LESIONS                                             $90.71        20120901
17281       DESTRUCTION OF SKIN LESIONS                                            $115.93        20120901
17282       DESTRUCTION OF SKIN LESIONS                                            $134.28        20120901
17283       DESTRUCTION OF SKIN LESIONS                                            $162.31        20120901
17284       DESTRUCTION OF SKIN LESIONS                                            $188.81        20120901
17286       DESTRUCTION OF SKIN LESIONS                                            $239.77        20120901
17311       MOHS 1 STAGE H/N/HF/G                                                  $445.39        20120901
17312       MOHS ADDL STAGE                                                        $265.25        20120901
17313       MOHS 1 STAGE T/A/L                                                     $406.15        20120901
17314       MOHS ADDL STAGE T/A/L                                                  $245.88        20120901
17315       MOHS SURG ADDL BLOCK                                                    $53.51        20120901
17340       CRYOTHERAPY OF SKIN                                                     $32.87        20120901
17360       SKIN PEEL THERAPY                                                       $87.14        20120901
19000       DRAINAGE OF BREAST LESION                                               $72.62        20120901
19001       DRAIN BREAST LESION ADD-ON                                              $18.35        20120901
19020       INCISION OF BREAST LESION                                              $286.90        20120901
19020       INCISION OF BREAST LESION                             A                $551.78        20110101
19030       INJECTION FOR BREAST X-RAY                                             $109.82        20120901
19100       BX BREAST PERCUT W/O IMAGE                                              $92.49        20120901
19100       BX BREAST PERCUT W/O IMAGE                            A                $156.46        20110101
19101       BIOPSY OF BREAST OPEN                                                  $212.25        20120901
19101       BIOPSY OF BREAST OPEN                                 A                $680.26        20110101
19102       BX BREAST PERCUT W/IMAGE                                               $144.73        20120901
19102       BX BREAST PERCUT W/IMAGE                              A                $233.75        20110101
19103       BX BREAST PERCUT W/DEVICE                                              $365.64        20120901
19103       BX BREAST PERCUT W/DEVICE                             A                $448.29        20110101
19105       CRYOSURG ABLATE FA EACH                                              $1,373.63        20120901
19110       NIPPLE EXPLORATION                                                     $298.88        20120901



                                              Page 14
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
19110       NIPPLE EXPLORATION                                    A                $680.26        20110101
19112       EXCISE BREAST DUCT FISTULA                                             $279.77        20120901
19112       EXCISE BREAST DUCT FISTULA                            A                $692.50        20110101
19120       REMOVAL OF BREAST LESION                                               $310.09        20120901
19120       REMOVAL OF BREAST LESION                              A                $692.50        20110101
19125       EXCISION BREAST LESION                                                 $344.49        20120901
19125       EXCISION BREAST LESION                                A                $692.50        20110101
19126       EXCISION ADDL BREAST LESION                                            $109.82        20120901
19126       EXCISION ADDL BREAST LESION                           A                $692.50        20110101
19260       REMOVAL OF CHEST WALL LESION   80                                      $162.05        20120901
19260       REMOVAL OF CHEST WALL LESION   81                                      $162.05        20120901
19260       REMOVAL OF CHEST WALL LESION   82                                      $162.05        20120901
19260       REMOVAL OF CHEST WALL LESION   AS                                      $162.05        20120901
19260       REMOVAL OF CHEST WALL LESION                                           $810.26        20120901
19271       REVISION OF CHEST WALL         80                                      $220.15        20120901
19271       REVISION OF CHEST WALL         81                                      $220.15        20120901
19271       REVISION OF CHEST WALL         82                                      $220.15        20120901
19271       REVISION OF CHEST WALL         AS                                      $220.15        20120901
19271       REVISION OF CHEST WALL                                               $1,100.74        20120901
19272       EXTENSIVE CHEST WALL SURGERY   80                                      $244.15        20120901
19272       EXTENSIVE CHEST WALL SURGERY   81                                      $244.15        20120901
19272       EXTENSIVE CHEST WALL SURGERY   82                                      $244.15        20120901
19272       EXTENSIVE CHEST WALL SURGERY   AS                                      $244.15        20120901
19272       EXTENSIVE CHEST WALL SURGERY                                         $1,220.75        20120901
19290       PLACE NEEDLE WIRE BREAST                                               $107.27        20120901
19291       PLACE NEEDLE WIRE BREAST                                                $46.12        20120901
19295       PLACE BREAST CLIP PERCUT                                                $59.11        20120901
19296       PLACE PO BREAST CATH FOR RAD   80                                      $507.46        20120901
19296       PLACE PO BREAST CATH FOR RAD   81                                      $507.46        20120901
19296       PLACE PO BREAST CATH FOR RAD   82                                      $507.46        20120901
19296       PLACE PO BREAST CATH FOR RAD   AS                                      $507.46        20120901
19296       PLACE PO BREAST CATH FOR RAD                                         $2,537.30        20120901
19296       PLACE PO BREAST CATH FOR RAD                          A              $1,655.77        20110101
19297       PLACE BREAST CATH FOR RAD                                               $64.46        20120901
19298       PLACE BREAST RAD TUBE/CATHS    80                                      $167.35        20120901
19298       PLACE BREAST RAD TUBE/CATHS    81                                      $167.35        20120901
19298       PLACE BREAST RAD TUBE/CATHS    82                                      $167.35        20120901
19298       PLACE BREAST RAD TUBE/CATHS    AS                                      $167.35        20120901
19298       PLACE BREAST RAD TUBE/CATHS                                            $836.76        20120901
19298       PLACE BREAST RAD TUBE/CATHS                           A              $1,655.77        20110101
19301       PARTICAL MASTECTOMY                                                    $422.97        20120901
19301       PARTICAL MASTECTOMY                                   A                $692.50        20110101
19302       P-MASTECTOMY W/LN REMOVAL                                              $587.57        20120901
19302       P-MASTECTOMY W/LN REMOVAL                             A              $1,199.88        20110101
19303       MAST SIMPLE COMPLETE           80                                      $131.12        20120901
19303       MAST SIMPLE COMPLETE           81                                      $131.12        20120901
19303       MAST SIMPLE COMPLETE           82                                      $131.12        20120901
19303       MAST SIMPLE COMPLETE           AS                                      $131.12        20120901
19303       MAST SIMPLE COMPLETE                                                   $655.60        20120901
19303       MAST SIMPLE COMPLETE                                  A                $941.74        20110101
19304       MAST SUBQ                                                              $369.21        20120901
19304       MAST SUBQ                                             A                $941.74        20110101
19305       MAST RADICAL                   80                                      $148.34        20120901
19305       MAST RADICAL                   81                                      $148.34        20120901
19305       MAST RADICAL                   82                                      $148.34        20120901
19305       MAST RADICAL                   AS                                      $148.34        20120901
19305       MAST RADICAL                                                           $741.72        20120901
19306       MAST RAD URBAN TYPE            80                                      $155.73        20120901
19306       MAST RAD URBAN TYPE            81                                      $155.73        20120901



                                                Page 15
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
19306       MAST RAD URBAN TYPE             82                                      $155.73        20120901
19306       MAST RAD URBAN TYPE             AS                                      $155.73        20120901
19306       MAST RAD URBAN TYPE                                                     $778.67        20120901
19307       MAST MOD RAD                    80                                      $156.19        20120901
19307       MAST MOD RAD                    81                                      $156.19        20120901
19307       MAST MOD RAD                    82                                      $156.19        20120901
19307       MAST MOD RAD                    AS                                      $156.19        20120901
19307       MAST MOD RAD                                                            $780.96        20120901
19318       REDUCTION OF LARGE BREAST       80                                      $149.72        20120901
19318       REDUCTION OF LARGE BREAST       81                                      $149.72        20120901
19318       REDUCTION OF LARGE BREAST       82                                      $149.72        20120901
19318       REDUCTION OF LARGE BREAST       AS                                      $149.72        20120901
19318       REDUCTION OF LARGE BREAST                                               $748.60        20120901
19318       REDUCTION OF LARGE BREAST                              A              $1,130.05        20110101
19324       ENLARGE BREAST                                                          $322.07        20120901
19324       ENLARGE BREAST                                         A              $1,130.05        20110101
19325       ENLARGE BREAST WITH IMPLANT                                             $428.32        20120901
19325       ENLARGE BREAST WITH IMPLANT                            A              $1,655.77        20110101
19328       REMOVAL OF BREAST IMPLANT                                               $326.14        20120901
19328       REMOVAL OF BREAST IMPLANT                              A                $884.91        20110101
19330       REMOVAL OF IMPLANT MATERIAL                                             $417.62        20120901
19330       REMOVAL OF IMPLANT MATERIAL                            A                $884.91        20110101
19340       IMMEDIATE BREAST PROSTHESIS                                             $540.69        20120901
19340       IMMEDIATE BREAST PROSTHESIS                            A              $1,094.84        20110101
19342       DELAYED BREAST PROSTHESIS                                               $614.32        20120901
19342       DELAYED BREAST PROSTHESIS                              A              $1,497.14        20110101
19350       BREAST RECONSTRUCTION                                                   $550.11        20120901
19350       BREAST RECONSTRUCTION                                  A                $715.47        20110101
19355       CORRECT INVERTED NIPPLES                                                $467.30        20120901
19355       CORRECT INVERTED NIPPLES                               A                $941.74        20110101
19357       BREAST RECONSTRUCTION           80                                      $207.76        20120901
19357       BREAST RECONSTRUCTION           81                                      $207.76        20120901
19357       BREAST RECONSTRUCTION           82                                      $207.76        20120901
19357       BREAST RECONSTRUCTION           AS                                      $207.76        20120901
19357       BREAST RECONSTRUCTION                                                 $1,038.82        20120901
19357       BREAST RECONSTRUCTION                                  A              $1,536.75        20110101
19361       BREAST RECONSTR W/LAT FLAP      80                                      $223.97        20120901
19361       BREAST RECONSTR W/LAT FLAP      81                                      $223.97        20120901
19361       BREAST RECONSTR W/LAT FLAP      82                                      $223.97        20120901
19361       BREAST RECONSTR W/LAT FLAP      AS                                      $223.97        20120901
19361       BREAST RECONSTR W/LAT FLAP                                            $1,119.85        20120901
19364       BREAST RECONSTRUCTION           80                                      $375.01        20120901
19364       BREAST RECONSTRUCTION           81                                      $375.01        20120901
19364       BREAST RECONSTRUCTION           82                                      $375.01        20120901
19364       BREAST RECONSTRUCTION           AS                                      $375.01        20120901
19364       BREAST RECONSTRUCTION                                                 $1,875.07        20120901
19366       BREAST RECONSTRUCTION           80                                      $186.00        20120901
19366       BREAST RECONSTRUCTION           81                                      $186.00        20120901
19366       BREAST RECONSTRUCTION           82                                      $186.00        20120901
19366       BREAST RECONSTRUCTION           AS                                      $186.00        20120901
19366       BREAST RECONSTRUCTION                                                   $930.02        20120901
19366       BREAST RECONSTRUCTION                                  A                $958.38        20110101
19367       BREAST RECONSTRUCTION           80                                      $242.72        20120901
19367       BREAST RECONSTRUCTION           81                                      $242.72        20120901
19367       BREAST RECONSTRUCTION           82                                      $242.72        20120901
19367       BREAST RECONSTRUCTION           AS                                      $242.72        20120901
19367       BREAST RECONSTRUCTION                                                 $1,213.61        20120901
19368       BREAST RECONSTRUCTION           80                                      $300.26        20120901
19368       BREAST RECONSTRUCTION           81                                      $300.26        20120901



                                                 Page 16
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
19368       BREAST RECONSTRUCTION          82                                     $300.26        20120901
19368       BREAST RECONSTRUCTION          AS                                     $300.26        20120901
19368       BREAST RECONSTRUCTION                                               $1,501.28        20120901
19369       BREAST RECONSTRUCTION          80                                     $276.61        20120901
19369       BREAST RECONSTRUCTION          81                                     $276.61        20120901
19369       BREAST RECONSTRUCTION          82                                     $276.61        20120901
19369       BREAST RECONSTRUCTION          AS                                     $276.61        20120901
19369       BREAST RECONSTRUCTION                                               $1,383.05        20120901
19371       REMOVAL OF BREAST CAPSULE                                             $521.32        20120901
19371       REMOVAL OF BREAST CAPSULE                            A                $941.74        20110101
19380       REVISE BREAST RECONSTRUCTION                                          $512.66        20120901
19380       REVISE BREAST RECONSTRUCTION                         A              $1,146.69        20110101
20005       ID ABSCESS SUBFASCIAL                                                 $199.25        20120901
20005       ID ABSCESS SUBFASCIAL                                A                $614.48        20110101
20100       EXPLORE WOUND NECK             80                                      $80.77        20120901
20100       EXPLORE WOUND NECK             81                                      $80.77        20120901
20100       EXPLORE WOUND NECK             82                                      $80.77        20120901
20100       EXPLORE WOUND NECK             AS                                      $80.77        20120901
20100       EXPLORE WOUND NECK                                                    $403.86        20120901
20101       EXPLORE WOUND CHEST                                                   $256.07        20120901
20102       EXPLORE WOUND ABDOMEN                                                 $303.72        20120901
20103       EXPLORE WOUND EXTREMITY        80                                      $73.43        20120901
20103       EXPLORE WOUND EXTREMITY        81                                      $73.43        20120901
20103       EXPLORE WOUND EXTREMITY        82                                      $73.43        20120901
20103       EXPLORE WOUND EXTREMITY        AS                                      $73.43        20120901
20103       EXPLORE WOUND EXTREMITY                                               $367.17        20120901
20150       EXCISE EPIPHYSEAL BAR          80                                     $128.32        20120901
20150       EXCISE EPIPHYSEAL BAR          81                                     $128.32        20120901
20150       EXCISE EPIPHYSEAL BAR          82                                     $128.32        20120901
20150       EXCISE EPIPHYSEAL BAR          AS                                     $128.32        20120901
20150       EXCISE EPIPHYSEAL BAR                                                 $641.59        20120901
20200       MUSCLE BIOPSY                                                         $125.11        20120901
20200       MUSCLE BIOPSY                                        A                $505.90        20110101
20205       DEEP MUSCLE BIOPSY                                                    $173.52        20120901
20205       DEEP MUSCLE BIOPSY                                   A                $518.15        20110101
20206       NEEDLE BIOPSY MUSCLE                                                  $164.86        20120901
20206       NEEDLE BIOPSY MUSCLE                                 A                $233.75        20110101
20220       BONE BIOPSY TROCAR/NEEDLE                                             $112.11        20120901
20220       BONE BIOPSY TROCAR/NEEDLE                            A                $245.29        20110101
20225       BONE BIOPSY TROCAR/NEEDLE                                             $417.11        20120901
20225       BONE BIOPSY TROCAR/NEEDLE                            A                $500.64        20110101
20240       BONE BIOPSY EXCISIONAL                                                $151.35        20120901
20240       BONE BIOPSY EXCISIONAL                               A                $647.50        20110101
20245       BONE BIOPSY EXCISIONAL                                                $419.91        20120901
20245       BONE BIOPSY EXCISIONAL                               A                $659.74        20110101
20250       OPEN BONE BIOPSY                                                      $251.23        20120901
20250       OPEN BONE BIOPSY                                     A                $626.73        20110101
20251       OPEN BONE BIOPSY               80                                      $55.29        20120901
20251       OPEN BONE BIOPSY               81                                      $55.29        20120901
20251       OPEN BONE BIOPSY               82                                      $55.29        20120901
20251       OPEN BONE BIOPSY               AS                                      $55.29        20120901
20251       OPEN BONE BIOPSY                                                      $276.46        20120901
20251       OPEN BONE BIOPSY                                     A                $626.73        20110101
20500       INJECTION OF SINUS TRACT                                               $74.15        20120901
20501       INJECT SINUS TRACT FOR X-RAY                                           $82.81        20120901
20520       REMOVAL OF FOREIGN BODY                                               $125.36        20120901
20525       REMOVAL OF FOREIGN BODY                                               $301.68        20120901
20525       REMOVAL OF FOREIGN BODY                              A                $659.74        20110101
20526       THER INJECTION CARP TUNNEL                                             $49.18        20120901



                                             Page 17
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price         Effective Date
20527       INJ DUPUYTREN CORD W/ENZYME                                            $56.82        20120901
20550       INJ TENDON SHEATH/LIGAMENT                                             $37.71        20120901
20551       INJ TENDON ORIGIN/INSERTION                                            $37.97        20120901
20555       PLACE NDL MUSC/TIS FOR RT                                             $230.85        20120901
20600       DRAIN/INJECT JOINT/BURSA                                               $35.42        20120901
20605       DRAIN/INJECT JOINT/BURSA                                               $38.47        20120901
20610       DRAIN/INJECT JOINT/BURSA                                               $50.45        20120901
20615       TREATMENT OF BONE CYST                                                $141.16        20120901
20650       INSERT AND REMOVE BONE PIN                                            $127.91        20120901
20650       INSERT AND REMOVE BONE PIN                            A               $626.73        20110101
20660       APPLY REM FIXATION DEVICE                                             $165.62        20120901
20661       APPLICATION OF HEAD BRACE                                             $316.72        20120901
20662       APPLICATION OF PELVIS BRACE                                           $302.96        20120901
20662       APPLICATION OF PELVIS BRACE                           A               $705.54        20110101
20663       APPLICATION OF THIGH BRACE                                            $298.37        20120901
20663       APPLICATION OF THIGH BRACE                            A               $705.54        20110101
20664       APPLICATION OF HALO                                                   $541.45        20120901
20665       REMOVAL OF FIXATION DEVICE                                             $76.44        20120901
20670       REMOVAL OF SUPPORT IMPLANT                                            $249.45        20120901
20670       REMOVAL OF SUPPORT IMPLANT                            A               $484.29        20110101
20680       REMOVAL OF SUPPORT IMPLANT     80                                      $78.53        20120901
20680       REMOVAL OF SUPPORT IMPLANT     81                                      $78.53        20120901
20680       REMOVAL OF SUPPORT IMPLANT     82                                      $78.53        20120901
20680       REMOVAL OF SUPPORT IMPLANT     AS                                      $78.53        20120901
20680       REMOVAL OF SUPPORT IMPLANT                                            $392.65        20120901
20680       REMOVAL OF SUPPORT IMPLANT                            A               $659.74        20110101
20690       APPLY BONE FIXATION DEVICE                                            $380.16        20120901
20690       APPLY BONE FIXATION DEVICE                            A               $849.00        20110101
20692       APPLY BONE FIXATION DEVICE     80                                     $142.38        20120901
20692       APPLY BONE FIXATION DEVICE     81                                     $142.38        20120901
20692       APPLY BONE FIXATION DEVICE     82                                     $142.38        20120901
20692       APPLY BONE FIXATION DEVICE     AS                                     $142.38        20120901
20692       APPLY BONE FIXATION DEVICE                                            $711.91        20120901
20692       APPLY BONE FIXATION DEVICE                            A               $861.25        20110101
20693       ADJUST BONE FIXATION DEVICE                                           $302.70        20120901
20693       ADJUST BONE FIXATION DEVICE                           A               $626.73        20110101
20694       REMOVE BONE FIXATION DEVICE                                           $275.44        20120901
20694       REMOVE BONE FIXATION DEVICE                           A               $592.86        20110101
20802       REPLANTATION ARM COMPLETE      80                                     $320.18        20120901
20802       REPLANTATION ARM COMPLETE      81                                     $320.18        20120901
20802       REPLANTATION ARM COMPLETE      82                                     $320.18        20120901
20802       REPLANTATION ARM COMPLETE      AS                                     $320.18        20120901
20802       REPLANTATION ARM COMPLETE                                           $1,600.91        20120901
20805       REPLANT FOREARM COMPLETE       80                                     $424.24        20120901
20805       REPLANT FOREARM COMPLETE       81                                     $424.24        20120901
20805       REPLANT FOREARM COMPLETE       82                                     $424.24        20120901
20805       REPLANT FOREARM COMPLETE       AS                                     $424.24        20120901
20805       REPLANT FOREARM COMPLETE                                            $2,121.21        20120901
20808       REPLANTATION HAND COMPLETE     80                                     $561.48        20120901
20808       REPLANTATION HAND COMPLETE     81                                     $561.48        20120901
20808       REPLANTATION HAND COMPLETE     82                                     $561.48        20120901
20808       REPLANTATION HAND COMPLETE     AS                                     $561.48        20120901
20808       REPLANTATION HAND COMPLETE                                          $2,807.39        20120901
20816       REPLANTATION DIGIT COMPLETE    80                                     $290.27        20120901
20816       REPLANTATION DIGIT COMPLETE    81                                     $290.27        20120901
20816       REPLANTATION DIGIT COMPLETE    82                                     $290.27        20120901
20816       REPLANTATION DIGIT COMPLETE    AS                                     $290.27        20120901
20816       REPLANTATION DIGIT COMPLETE                                         $1,451.34        20120901
20822       REPLANTATION DIGIT COMPLETE    80                                     $253.27        20120901



                                                Page 18
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
20822       REPLANTATION DIGIT COMPLETE     81                                      $253.27        20120901
20822       REPLANTATION DIGIT COMPLETE     82                                      $253.27        20120901
20822       REPLANTATION DIGIT COMPLETE     AS                                      $253.27        20120901
20822       REPLANTATION DIGIT COMPLETE                                           $1,266.36        20120901
20824       REPLANTATION THUMB COMPLETE     80                                      $297.91        20120901
20824       REPLANTATION THUMB COMPLETE     81                                      $297.91        20120901
20824       REPLANTATION THUMB COMPLETE     82                                      $297.91        20120901
20824       REPLANTATION THUMB COMPLETE     AS                                      $297.91        20120901
20824       REPLANTATION THUMB COMPLETE                                           $1,489.56        20120901
20827       REPLANTATION THUMB COMPLETE     80                                      $264.18        20120901
20827       REPLANTATION THUMB COMPLETE     81                                      $264.18        20120901
20827       REPLANTATION THUMB COMPLETE     82                                      $264.18        20120901
20827       REPLANTATION THUMB COMPLETE     AS                                      $264.18        20120901
20827       REPLANTATION THUMB COMPLETE                                           $1,320.88        20120901
20838       REPLANTATION FOOT COMPLETE      80                                      $332.57        20120901
20838       REPLANTATION FOOT COMPLETE      81                                      $332.57        20120901
20838       REPLANTATION FOOT COMPLETE      82                                      $332.57        20120901
20838       REPLANTATION FOOT COMPLETE      AS                                      $332.57        20120901
20838       REPLANTATION FOOT COMPLETE                                            $1,662.82        20120901
20900       REMOVAL OF BONE FOR GRAFT       80                                       $53.10        20120901
20900       REMOVAL OF BONE FOR GRAFT       81                                       $53.10        20120901
20900       REMOVAL OF BONE FOR GRAFT       82                                       $53.10        20120901
20900       REMOVAL OF BONE FOR GRAFT       AS                                       $53.10        20120901
20900       REMOVAL OF BONE FOR GRAFT                                               $265.50        20120901
20900       REMOVAL OF BONE FOR GRAFT                              A                $861.25        20110101
20902       REMOVAL OF BONE FOR GRAFT       80                                       $45.20        20120901
20902       REMOVAL OF BONE FOR GRAFT       81                                       $45.20        20120901
20902       REMOVAL OF BONE FOR GRAFT       82                                       $45.20        20120901
20902       REMOVAL OF BONE FOR GRAFT       AS                                       $45.20        20120901
20902       REMOVAL OF BONE FOR GRAFT                                               $226.01        20120901
20902       REMOVAL OF BONE FOR GRAFT                              A                $884.21        20110101
20910       REMOVE CARTILAGE FOR GRAFT                                              $282.83        20120901
20910       REMOVE CARTILAGE FOR GRAFT                             A                $672.80        20110101
20912       REMOVE CARTILAGE FOR GRAFT                                              $324.62        20120901
20912       REMOVE CARTILAGE FOR GRAFT                             A                $672.80        20110101
20920       REMOVAL OF FASCIA FOR GRAFT                                             $268.81        20120901
20920       REMOVAL OF FASCIA FOR GRAFT                            A                $506.42        20110101
20922       REMOVAL OF FASCIA FOR GRAFT     80                                       $80.47        20120901
20922       REMOVAL OF FASCIA FOR GRAFT     81                                       $80.47        20120901
20922       REMOVAL OF FASCIA FOR GRAFT     82                                       $80.47        20120901
20922       REMOVAL OF FASCIA FOR GRAFT     AS                                       $80.47        20120901
20922       REMOVAL OF FASCIA FOR GRAFT                                             $402.33        20120901
20922       REMOVAL OF FASCIA FOR GRAFT                            A                $483.46        20110101
20924       REMOVAL OF TENDON FOR GRAFT     80                                       $66.86        20120901
20924       REMOVAL OF TENDON FOR GRAFT     81                                       $66.86        20120901
20924       REMOVAL OF TENDON FOR GRAFT     82                                       $66.86        20120901
20924       REMOVAL OF TENDON FOR GRAFT     AS                                       $66.86        20120901
20924       REMOVAL OF TENDON FOR GRAFT                                             $334.30        20120901
20924       REMOVAL OF TENDON FOR GRAFT                            A                $884.21        20110101
20926       REMOVAL OF TISSUE FOR GRAFT                                             $292.26        20120901
20930       SP BONE ALGRFT MORSEL ADD-ON                                             $54.75        20110801
20931       SP BONE ALGRFT STRUCT ADD-ON                                             $77.20        20120901
20936       SP BONE AGRFT LOCAL ADD-ON                                              $123.32        20110801
20937       SP BONE AGRFT MORSEL ADD-ON     80                                       $23.29        20120901
20937       SP BONE AGRFT MORSEL ADD-ON     81                                       $23.29        20120901
20937       SP BONE AGRFT MORSEL ADD-ON     82                                       $23.29        20120901
20937       SP BONE AGRFT MORSEL ADD-ON     AS                                       $23.29        20120901
20937       SP BONE AGRFT MORSEL ADD-ON                                             $116.44        20120901
20938       SP BONE AGRFT STRUCT ADD-ON     80                                       $25.43        20120901



                                                 Page 19
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price         Effective Date
20938       SP BONE AGRFT STRUCT ADD-ON     81                                     $25.43        20120901
20938       SP BONE AGRFT STRUCT ADD-ON     82                                     $25.43        20120901
20938       SP BONE AGRFT STRUCT ADD-ON     AS                                     $25.43        20120901
20938       SP BONE AGRFT STRUCT ADD-ON                                           $127.15        20120901
20950       FLUID PRESSURE MUSCLE                                                 $156.96        20120901
20955       FIBULA BONE GRAFT MICROVASC     80                                    $344.85        20120901
20955       FIBULA BONE GRAFT MICROVASC     81                                    $344.85        20120901
20955       FIBULA BONE GRAFT MICROVASC     82                                    $344.85        20120901
20955       FIBULA BONE GRAFT MICROVASC     AS                                    $344.85        20120901
20955       FIBULA BONE GRAFT MICROVASC                                         $1,724.23        20120901
20956       ILIAC BONE GRAFT MICROVASC      80                                    $357.43        20120901
20956       ILIAC BONE GRAFT MICROVASC      81                                    $357.43        20120901
20956       ILIAC BONE GRAFT MICROVASC      82                                    $357.43        20120901
20956       ILIAC BONE GRAFT MICROVASC      AS                                    $357.43        20120901
20956       ILIAC BONE GRAFT MICROVASC                                          $1,787.17        20120901
20957       MT BONE GRAFT MICROVASC         80                                    $349.53        20120901
20957       MT BONE GRAFT MICROVASC         81                                    $349.53        20120901
20957       MT BONE GRAFT MICROVASC         82                                    $349.53        20120901
20957       MT BONE GRAFT MICROVASC         AS                                    $349.53        20120901
20957       MT BONE GRAFT MICROVASC                                             $1,747.67        20120901
20962       OTHER BONE GRAFT MICROVASC      80                                    $351.37        20120901
20962       OTHER BONE GRAFT MICROVASC      81                                    $351.37        20120901
20962       OTHER BONE GRAFT MICROVASC      82                                    $351.37        20120901
20962       OTHER BONE GRAFT MICROVASC      AS                                    $351.37        20120901
20962       OTHER BONE GRAFT MICROVASC                                          $1,756.85        20120901
20969       BONE/SKIN GRAFT MICROVASC       80                                    $382.05        20120901
20969       BONE/SKIN GRAFT MICROVASC       81                                    $382.05        20120901
20969       BONE/SKIN GRAFT MICROVASC       82                                    $382.05        20120901
20969       BONE/SKIN GRAFT MICROVASC       AS                                    $382.05        20120901
20969       BONE/SKIN GRAFT MICROVASC                                           $1,910.24        20120901
20970       BONE/SKIN GRAFT ILIAC CREST     80                                    $385.41        20120901
20970       BONE/SKIN GRAFT ILIAC CREST     81                                    $385.41        20120901
20970       BONE/SKIN GRAFT ILIAC CREST     82                                    $385.41        20120901
20970       BONE/SKIN GRAFT ILIAC CREST     AS                                    $385.41        20120901
20970       BONE/SKIN GRAFT ILIAC CREST                                         $1,927.05        20120901
20972       BONE/SKIN GRAFT METATARSAL      80                                    $327.32        20120901
20972       BONE/SKIN GRAFT METATARSAL      81                                    $327.32        20120901
20972       BONE/SKIN GRAFT METATARSAL      82                                    $327.32        20120901
20972       BONE/SKIN GRAFT METATARSAL      AS                                    $327.32        20120901
20972       BONE/SKIN GRAFT METATARSAL                                          $1,636.58        20120901
20972       BONE/SKIN GRAFT METATARSAL                            A             $1,683.34        20110101
20973       BONE/SKIN GRAFT GREAT TOE       80                                    $350.40        20120901
20973       BONE/SKIN GRAFT GREAT TOE       81                                    $350.40        20120901
20973       BONE/SKIN GRAFT GREAT TOE       82                                    $350.40        20120901
20973       BONE/SKIN GRAFT GREAT TOE       AS                                    $350.40        20120901
20973       BONE/SKIN GRAFT GREAT TOE                                           $1,752.00        20120901
20973       BONE/SKIN GRAFT GREAT TOE                             A             $1,683.34        20110101
20974       ELECTRICAL BONE STIMULATION                                            $43.83        20120901
20975       ELECTRICAL BONE STIMULATION     80                                     $23.80        20120901
20975       ELECTRICAL BONE STIMULATION     81                                     $23.80        20120901
20975       ELECTRICAL BONE STIMULATION     82                                     $23.80        20120901
20975       ELECTRICAL BONE STIMULATION     AS                                     $23.80        20120901
20975       ELECTRICAL BONE STIMULATION                                           $118.99        20120901
20979       US BONE STIMULATION                                                    $34.40        20120901
21010       INCISION OF JAW JOINT                                                 $492.78        20120901
21010       INCISION OF JAW JOINT                                 A               $685.37        20110101
21011       EXC FACE LES SC 2 CM                                                  $216.07        20120901
21012       EXC FACE LES SBQ 2 CM/                                                $232.12        20120901
21013       EXC FACE TUM DEEP 2 CM                                                $336.08        20120901



                                              Page 20
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
21014       EXC FACE TUM DEEP 2 CM/                                                $358.76        20120901
21015       RESECT FACE TUM 2 CM                                                   $426.79        20120901
21015       RESECT FACE TUM 2 CM                                  A                $560.76        20110101
21016       RESECT FACE TUM 2 CM/                                                  $500.00        20100101
21025       EXCISION OF BONE LOWER JAW                                             $579.92        20120901
21025       EXCISION OF BONE LOWER JAW                            A              $1,118.46        20110101
21026       EXCISION OF FACIAL BONES                                               $390.10        20120901
21026       EXCISION OF FACIAL BONES                              A              $1,118.46        20110101
21029       CONTOUR OF FACE BONE LESION                                            $500.94        20120901
21029       CONTOUR OF FACE BONE LESION                           A              $1,118.46        20110101
21030       EXCISE MAX/ZYGOMA B9 TUMOR                                             $326.14        20120901
21031       REMOVE EXOSTOSIS MANDIBLE                                              $245.37        20120901
21032       REMOVE EXOSTOSIS MAXILLA                                               $249.45        20120901
21034       EXCISE MAX/ZYGOMA MAL TUMOR    80                                      $176.07        20120901
21034       EXCISE MAX/ZYGOMA MAL TUMOR    81                                      $176.07        20120901
21034       EXCISE MAX/ZYGOMA MAL TUMOR    82                                      $176.07        20120901
21034       EXCISE MAX/ZYGOMA MAL TUMOR    AS                                      $176.07        20120901
21034       EXCISE MAX/ZYGOMA MAL TUMOR                                            $880.33        20120901
21034       EXCISE MAX/ZYGOMA MAL TUMOR                           A              $1,130.71        20110101
21040       EXCISE MANDIBLE LESION                                                 $328.95        20120901
21040       EXCISE MANDIBLE LESION                                A                $685.37        20110101
21044       REMOVAL OF JAW BONE LESION     80                                      $118.48        20120901
21044       REMOVAL OF JAW BONE LESION     81                                      $118.48        20120901
21044       REMOVAL OF JAW BONE LESION     82                                      $118.48        20120901
21044       REMOVAL OF JAW BONE LESION     AS                                      $118.48        20120901
21044       REMOVAL OF JAW BONE LESION                                             $592.41        20120901
21044       REMOVAL OF JAW BONE LESION                            A              $1,118.46        20110101
21045       EXTENSIVE JAW SURGERY          80                                      $165.26        20120901
21045       EXTENSIVE JAW SURGERY          81                                      $165.26        20120901
21045       EXTENSIVE JAW SURGERY          82                                      $165.26        20120901
21045       EXTENSIVE JAW SURGERY          AS                                      $165.26        20120901
21045       EXTENSIVE JAW SURGERY                                                  $826.32        20120901
21046       REMOVE MANDIBLE CYST COMPLEX   80                                      $144.11        20120901
21046       REMOVE MANDIBLE CYST COMPLEX   81                                      $144.11        20120901
21046       REMOVE MANDIBLE CYST COMPLEX   82                                      $144.11        20120901
21046       REMOVE MANDIBLE CYST COMPLEX   AS                                      $144.11        20120901
21046       REMOVE MANDIBLE CYST COMPLEX                                           $720.57        20120901
21046       REMOVE MANDIBLE CYST COMPLEX                          A              $1,118.46        20110101
21047       EXCISE LWR JAW CYST W/REPAIR   80                                      $174.59        20120901
21047       EXCISE LWR JAW CYST W/REPAIR   81                                      $174.59        20120901
21047       EXCISE LWR JAW CYST W/REPAIR   82                                      $174.59        20120901
21047       EXCISE LWR JAW CYST W/REPAIR   AS                                      $174.59        20120901
21047       EXCISE LWR JAW CYST W/REPAIR                                           $872.94        20120901
21047       EXCISE LWR JAW CYST W/REPAIR                          A              $1,118.46        20110101
21048       REMOVE MAXILLA CYST COMPLEX    80                                      $146.87        20120901
21048       REMOVE MAXILLA CYST COMPLEX    81                                      $146.87        20120901
21048       REMOVE MAXILLA CYST COMPLEX    82                                      $146.87        20120901
21048       REMOVE MAXILLA CYST COMPLEX    AS                                      $146.87        20120901
21048       REMOVE MAXILLA CYST COMPLEX                                            $734.33        20120901
21049       EXCIS UPPR JAW CYST W/REPAIR   80                                      $169.03        20120901
21049       EXCIS UPPR JAW CYST W/REPAIR   81                                      $169.03        20120901
21049       EXCIS UPPR JAW CYST W/REPAIR   82                                      $169.03        20120901
21049       EXCIS UPPR JAW CYST W/REPAIR   AS                                      $169.03        20120901
21049       EXCIS UPPR JAW CYST W/REPAIR                                           $845.17        20120901
21050       REMOVAL OF JAW JOINT                                                   $585.02        20120901
21050       REMOVAL OF JAW JOINT                                  A              $1,130.71        20110101
21060       REMOVE JAW JOINT CARTILAGE     80                                      $108.65        20120901
21060       REMOVE JAW JOINT CARTILAGE     81                                      $108.65        20120901
21060       REMOVE JAW JOINT CARTILAGE     82                                      $108.65        20120901



                                                Page 21
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
21060       REMOVE JAW JOINT CARTILAGE      AS                                      $108.65        20120901
21060       REMOVE JAW JOINT CARTILAGE                                              $543.23        20120901
21060       REMOVE JAW JOINT CARTILAGE                             A              $1,118.46        20110101
21070       REMOVE CORONOID PROCESS                                                 $421.69        20120901
21070       REMOVE CORONOID PROCESS                                A              $1,130.71        20110101
21076       PREPARE FACE/ORAL PROSTHESIS                                            $630.63        20120901
21077       PREPARE FACE/ORAL PROSTHESIS                                          $1,558.87        20120901
21079       PREPARE FACE/ORAL PROSTHESIS                                          $1,066.08        20120901
21080       PREPARE FACE/ORAL PROSTHESIS                                          $1,206.48        20120901
21081       PREPARE FACE/ORAL PROSTHESIS                                          $1,105.32        20120901
21082       PREPARE FACE/ORAL PROSTHESIS                                          $1,029.65        20120901
21083       PREPARE FACE/ORAL PROSTHESIS                                            $957.28        20120901
21084       PREPARE FACE/ORAL PROSTHESIS                                          $1,131.31        20120901
21085       PREPARE FACE/ORAL PROSTHESIS                                            $493.29        20120901
21086       PREPARE FACE/ORAL PROSTHESIS                                          $1,133.35        20120901
21087       PREPARE FACE/ORAL PROSTHESIS                                          $1,132.33        20120901
21100       MAXILLOFACIAL FIXATION                                                  $461.70        20120901
21100       MAXILLOFACIAL FIXATION                                 A              $1,118.46        20110101
21110       INTERDENTAL FIXATION                                                    $491.51        20120901
21116       INJECTION JAW JOINT X-RAY                                                $97.33        20120901
21120       RECONSTRUCTION OF CHIN                                                  $412.27        20120901
21120       RECONSTRUCTION OF CHIN                                 A                $790.42        20110101
21121       RECONSTRUCTION OF CHIN          80                                       $98.45        20120901
21121       RECONSTRUCTION OF CHIN          81                                       $98.45        20120901
21121       RECONSTRUCTION OF CHIN          82                                       $98.45        20120901
21121       RECONSTRUCTION OF CHIN          AS                                       $98.45        20120901
21121       RECONSTRUCTION OF CHIN                                                  $492.27        20120901
21121       RECONSTRUCTION OF CHIN                                 A                $790.42        20110101
21137       REDUCTION OF FOREHEAD           80                                       $98.30        20120901
21137       REDUCTION OF FOREHEAD           81                                       $98.30        20120901
21137       REDUCTION OF FOREHEAD           82                                       $98.30        20120901
21137       REDUCTION OF FOREHEAD           AS                                       $98.30        20120901
21137       REDUCTION OF FOREHEAD                                                   $491.51        20120901
21138       REDUCTION OF FOREHEAD           80                                      $118.99        20120901
21138       REDUCTION OF FOREHEAD           81                                      $118.99        20120901
21138       REDUCTION OF FOREHEAD           82                                      $118.99        20120901
21138       REDUCTION OF FOREHEAD           AS                                      $118.99        20120901
21138       REDUCTION OF FOREHEAD                                                   $594.96        20120901
21139       REDUCTION OF FOREHEAD           80                                      $129.18        20120901
21139       REDUCTION OF FOREHEAD           81                                      $129.18        20120901
21139       REDUCTION OF FOREHEAD           82                                      $129.18        20120901
21139       REDUCTION OF FOREHEAD           AS                                      $129.18        20120901
21139       REDUCTION OF FOREHEAD                                                   $645.92        20120901
21141       RECONSTRUCT MIDFACE LEFORT      80                                      $183.81        20120901
21141       RECONSTRUCT MIDFACE LEFORT      81                                      $183.81        20120901
21141       RECONSTRUCT MIDFACE LEFORT      82                                      $183.81        20120901
21141       RECONSTRUCT MIDFACE LEFORT      AS                                      $183.81        20120901
21141       RECONSTRUCT MIDFACE LEFORT                                              $919.06        20120901
21142       RECONSTRUCT MIDFACE LEFORT      80                                      $185.09        20120901
21142       RECONSTRUCT MIDFACE LEFORT      81                                      $185.09        20120901
21142       RECONSTRUCT MIDFACE LEFORT      82                                      $185.09        20120901
21142       RECONSTRUCT MIDFACE LEFORT      AS                                      $185.09        20120901
21142       RECONSTRUCT MIDFACE LEFORT                                              $925.43        20120901
21143       RECONSTRUCT MIDFACE LEFORT      80                                      $190.95        20120901
21143       RECONSTRUCT MIDFACE LEFORT      81                                      $190.95        20120901
21143       RECONSTRUCT MIDFACE LEFORT      82                                      $190.95        20120901
21143       RECONSTRUCT MIDFACE LEFORT      AS                                      $190.95        20120901
21143       RECONSTRUCT MIDFACE LEFORT                                              $954.74        20120901
21145       RECONSTRUCT MIDFACE LEFORT      80                                      $203.13        20120901



                                                 Page 22
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
21145       RECONSTRUCT MIDFACE LEFORT     81                                     $203.13        20120901
21145       RECONSTRUCT MIDFACE LEFORT     82                                     $203.13        20120901
21145       RECONSTRUCT MIDFACE LEFORT     AS                                     $203.13        20120901
21145       RECONSTRUCT MIDFACE LEFORT                                          $1,015.63        20120901
21146       RECONSTRUCT MIDFACE LEFORT     80                                     $227.64        20120901
21146       RECONSTRUCT MIDFACE LEFORT     81                                     $227.64        20120901
21146       RECONSTRUCT MIDFACE LEFORT     82                                     $227.64        20120901
21146       RECONSTRUCT MIDFACE LEFORT     AS                                     $227.64        20120901
21146       RECONSTRUCT MIDFACE LEFORT                                          $1,138.19        20120901
21147       RECONSTRUCT MIDFACE LEFORT     80                                     $224.99        20120901
21147       RECONSTRUCT MIDFACE LEFORT     81                                     $224.99        20120901
21147       RECONSTRUCT MIDFACE LEFORT     82                                     $224.99        20120901
21147       RECONSTRUCT MIDFACE LEFORT     AS                                     $224.99        20120901
21147       RECONSTRUCT MIDFACE LEFORT                                          $1,124.94        20120901
21150       RECONSTRUCT MIDFACE LEFORT     80                                     $215.51        20120901
21150       RECONSTRUCT MIDFACE LEFORT     81                                     $215.51        20120901
21150       RECONSTRUCT MIDFACE LEFORT     82                                     $215.51        20120901
21150       RECONSTRUCT MIDFACE LEFORT     AS                                     $215.51        20120901
21150       RECONSTRUCT MIDFACE LEFORT                                          $1,077.55        20120901
21151       RECONSTRUCT MIDFACE LEFORT     80                                     $269.02        20120901
21151       RECONSTRUCT MIDFACE LEFORT     81                                     $269.02        20120901
21151       RECONSTRUCT MIDFACE LEFORT     82                                     $269.02        20120901
21151       RECONSTRUCT MIDFACE LEFORT     AS                                     $269.02        20120901
21151       RECONSTRUCT MIDFACE LEFORT                                          $1,345.09        20120901
21154       RECONSTRUCT MIDFACE LEFORT     80                                     $276.05        20120901
21154       RECONSTRUCT MIDFACE LEFORT     81                                     $276.05        20120901
21154       RECONSTRUCT MIDFACE LEFORT     82                                     $276.05        20120901
21154       RECONSTRUCT MIDFACE LEFORT     AS                                     $276.05        20120901
21154       RECONSTRUCT MIDFACE LEFORT                                          $1,380.25        20120901
21155       RECONSTRUCT MIDFACE LEFORT     80                                     $295.98        20120901
21155       RECONSTRUCT MIDFACE LEFORT     81                                     $295.98        20120901
21155       RECONSTRUCT MIDFACE LEFORT     82                                     $295.98        20120901
21155       RECONSTRUCT MIDFACE LEFORT     AS                                     $295.98        20120901
21155       RECONSTRUCT MIDFACE LEFORT                                          $1,479.88        20120901
21159       RECONSTRUCT MIDFACE LEFORT     80                                     $363.09        20120901
21159       RECONSTRUCT MIDFACE LEFORT     81                                     $363.09        20120901
21159       RECONSTRUCT MIDFACE LEFORT     82                                     $363.09        20120901
21159       RECONSTRUCT MIDFACE LEFORT     AS                                     $363.09        20120901
21159       RECONSTRUCT MIDFACE LEFORT                                          $1,815.45        20120901
21160       RECONSTRUCT MIDFACE LEFORT     80                                     $371.91        20120901
21160       RECONSTRUCT MIDFACE LEFORT     81                                     $371.91        20120901
21160       RECONSTRUCT MIDFACE LEFORT     82                                     $371.91        20120901
21160       RECONSTRUCT MIDFACE LEFORT     AS                                     $371.91        20120901
21160       RECONSTRUCT MIDFACE LEFORT                                          $1,859.53        20120901
21172       RECONSTRUCT ORBIT/FOREHEAD     80                                     $238.90        20120901
21172       RECONSTRUCT ORBIT/FOREHEAD     81                                     $238.90        20120901
21172       RECONSTRUCT ORBIT/FOREHEAD     82                                     $238.90        20120901
21172       RECONSTRUCT ORBIT/FOREHEAD     AS                                     $238.90        20120901
21172       RECONSTRUCT ORBIT/FOREHEAD                                          $1,194.50        20120901
21175       RECONSTRUCT ORBIT/FOREHEAD     80                                     $311.67        20120901
21175       RECONSTRUCT ORBIT/FOREHEAD     81                                     $311.67        20120901
21175       RECONSTRUCT ORBIT/FOREHEAD     82                                     $311.67        20120901
21175       RECONSTRUCT ORBIT/FOREHEAD     AS                                     $311.67        20120901
21175       RECONSTRUCT ORBIT/FOREHEAD                                          $1,558.36        20120901
21179       RECONSTRUCT ENTIRE FOREHEAD    80                                     $199.20        20120901
21179       RECONSTRUCT ENTIRE FOREHEAD    81                                     $199.20        20120901
21179       RECONSTRUCT ENTIRE FOREHEAD    82                                     $199.20        20120901
21179       RECONSTRUCT ENTIRE FOREHEAD    AS                                     $199.20        20120901
21179       RECONSTRUCT ENTIRE FOREHEAD                                           $996.01        20120901



                                             Page 23
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
21180       RECONSTRUCT ENTIRE FOREHEAD     80                                      $218.77        20120901
21180       RECONSTRUCT ENTIRE FOREHEAD     81                                      $218.77        20120901
21180       RECONSTRUCT ENTIRE FOREHEAD     82                                      $218.77        20120901
21180       RECONSTRUCT ENTIRE FOREHEAD     AS                                      $218.77        20120901
21180       RECONSTRUCT ENTIRE FOREHEAD                                           $1,093.86        20120901
21181       CONTOUR CRANIAL BONE LESION                                             $462.72        20120901
21181       CONTOUR CRANIAL BONE LESION                            A                $790.42        20110101
21182       RECONSTRUCT CRANIAL BONE        80                                      $271.97        20120901
21182       RECONSTRUCT CRANIAL BONE        81                                      $271.97        20120901
21182       RECONSTRUCT CRANIAL BONE        82                                      $271.97        20120901
21182       RECONSTRUCT CRANIAL BONE        AS                                      $271.97        20120901
21182       RECONSTRUCT CRANIAL BONE                                              $1,359.87        20120901
21183       RECONSTRUCT CRANIAL BONE        80                                      $312.69        20120901
21183       RECONSTRUCT CRANIAL BONE        81                                      $312.69        20120901
21183       RECONSTRUCT CRANIAL BONE        82                                      $312.69        20120901
21183       RECONSTRUCT CRANIAL BONE        AS                                      $312.69        20120901
21183       RECONSTRUCT CRANIAL BONE                                              $1,563.45        20120901
21184       RECONSTRUCT CRANIAL BONE        80                                      $329.41        20120901
21184       RECONSTRUCT CRANIAL BONE        81                                      $329.41        20120901
21184       RECONSTRUCT CRANIAL BONE        82                                      $329.41        20120901
21184       RECONSTRUCT CRANIAL BONE        AS                                      $329.41        20120901
21184       RECONSTRUCT CRANIAL BONE                                              $1,647.03        20120901
21188       RECONSTRUCTION OF MIDFACE       80                                      $221.98        20120901
21188       RECONSTRUCTION OF MIDFACE       81                                      $221.98        20120901
21188       RECONSTRUCTION OF MIDFACE       82                                      $221.98        20120901
21188       RECONSTRUCTION OF MIDFACE       AS                                      $221.98        20120901
21188       RECONSTRUCTION OF MIDFACE                                             $1,109.91        20120901
21193       RECONST LWR JAW W/O GRAFT       80                                      $167.20        20120901
21193       RECONST LWR JAW W/O GRAFT       81                                      $167.20        20120901
21193       RECONST LWR JAW W/O GRAFT       82                                      $167.20        20120901
21193       RECONST LWR JAW W/O GRAFT       AS                                      $167.20        20120901
21193       RECONST LWR JAW W/O GRAFT                                               $836.00        20120901
21194       RECONST LWR JAW W/GRAFT         80                                      $189.57        20120901
21194       RECONST LWR JAW W/GRAFT         81                                      $189.57        20120901
21194       RECONST LWR JAW W/GRAFT         82                                      $189.57        20120901
21194       RECONST LWR JAW W/GRAFT         AS                                      $189.57        20120901
21194       RECONST LWR JAW W/GRAFT                                                 $947.86        20120901
21195       RECONST LWR JAW W/O FIXATION    80                                      $179.99        20120901
21195       RECONST LWR JAW W/O FIXATION    81                                      $179.99        20120901
21195       RECONST LWR JAW W/O FIXATION    82                                      $179.99        20120901
21195       RECONST LWR JAW W/O FIXATION    AS                                      $179.99        20120901
21195       RECONST LWR JAW W/O FIXATION                                            $899.95        20120901
21196       RECONST LWR JAW W/FIXATION      80                                      $195.38        20120901
21196       RECONST LWR JAW W/FIXATION      81                                      $195.38        20120901
21196       RECONST LWR JAW W/FIXATION      82                                      $195.38        20120901
21196       RECONST LWR JAW W/FIXATION      AS                                      $195.38        20120901
21196       RECONST LWR JAW W/FIXATION                                              $976.90        20120901
21198       RECONSTR LWR JAW SEGMENT        80                                      $154.21        20120901
21198       RECONSTR LWR JAW SEGMENT        81                                      $154.21        20120901
21198       RECONSTR LWR JAW SEGMENT        82                                      $154.21        20120901
21198       RECONSTR LWR JAW SEGMENT        AS                                      $154.21        20120901
21198       RECONSTR LWR JAW SEGMENT                                                $771.02        20120901
21199       RECONSTR LWR JAW W/ADVANCE      80                                      $138.76        20120901
21199       RECONSTR LWR JAW W/ADVANCE      81                                      $138.76        20120901
21199       RECONSTR LWR JAW W/ADVANCE      82                                      $138.76        20120901
21199       RECONSTR LWR JAW W/ADVANCE      AS                                      $138.76        20120901
21199       RECONSTR LWR JAW W/ADVANCE                                              $693.82        20120901
21206       RECONSTRUCT UPPER JAW BONE      80                                      $158.49        20120901
21206       RECONSTRUCT UPPER JAW BONE      81                                      $158.49        20120901



                                                 Page 24
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
21206       RECONSTRUCT UPPER JAW BONE     82                                      $158.49        20120901
21206       RECONSTRUCT UPPER JAW BONE     AS                                      $158.49        20120901
21206       RECONSTRUCT UPPER JAW BONE                                             $792.43        20120901
21206       RECONSTRUCT UPPER JAW BONE                            A              $1,170.32        20110101
21208       AUGMENTATION OF FACIAL BONES                                         $1,160.10        20120901
21208       AUGMENTATION OF FACIAL BONES                          A              $1,223.51        20110101
21209       REDUCTION OF FACIAL BONES      80                                      $111.04        20120901
21209       REDUCTION OF FACIAL BONES      81                                      $111.04        20120901
21209       REDUCTION OF FACIAL BONES      82                                      $111.04        20120901
21209       REDUCTION OF FACIAL BONES      AS                                      $111.04        20120901
21209       REDUCTION OF FACIAL BONES                                              $555.21        20120901
21209       REDUCTION OF FACIAL BONES                             A              $1,170.32        20110101
21210       FACE BONE GRAFT                                                      $1,359.36        20120901
21210       FACE BONE GRAFT                                       A              $1,223.51        20110101
21215       LOWER JAW BONE GRAFT                                                   $591.90        20120901
21215       LOWER JAW BONE GRAFT                                  A              $1,223.51        20110101
21230       RIB CARTILAGE GRAFT                                                    $525.14        20120901
21230       RIB CARTILAGE GRAFT                                   A              $1,223.51        20110101
21235       EAR CARTILAGE GRAFT                                                    $478.51        20120901
21235       EAR CARTILAGE GRAFT                                   A                $790.42        20110101
21240       RECONSTRUCTION OF JAW JOINT    80                                      $146.61        20120901
21240       RECONSTRUCTION OF JAW JOINT    81                                      $146.61        20120901
21240       RECONSTRUCTION OF JAW JOINT    82                                      $146.61        20120901
21240       RECONSTRUCTION OF JAW JOINT    AS                                      $146.61        20120901
21240       RECONSTRUCTION OF JAW JOINT                                            $733.06        20120901
21240       RECONSTRUCTION OF JAW JOINT                           A              $1,153.67        20110101
21242       RECONSTRUCTION OF JAW JOINT    80                                      $134.99        20120901
21242       RECONSTRUCTION OF JAW JOINT    81                                      $134.99        20120901
21242       RECONSTRUCTION OF JAW JOINT    82                                      $134.99        20120901
21242       RECONSTRUCTION OF JAW JOINT    AS                                      $134.99        20120901
21242       RECONSTRUCTION OF JAW JOINT                                            $674.97        20120901
21242       RECONSTRUCTION OF JAW JOINT                           A              $1,170.32        20110101
21243       RECONSTRUCTION OF JAW JOINT    80                                      $223.15        20120901
21243       RECONSTRUCTION OF JAW JOINT    81                                      $223.15        20120901
21243       RECONSTRUCTION OF JAW JOINT    82                                      $223.15        20120901
21243       RECONSTRUCTION OF JAW JOINT    AS                                      $223.15        20120901
21243       RECONSTRUCTION OF JAW JOINT                                          $1,115.77        20120901
21243       RECONSTRUCTION OF JAW JOINT                           A              $1,170.32        20110101
21244       RECONSTRUCTION OF LOWER JAW    80                                      $140.55        20120901
21244       RECONSTRUCTION OF LOWER JAW    81                                      $140.55        20120901
21244       RECONSTRUCTION OF LOWER JAW    82                                      $140.55        20120901
21244       RECONSTRUCTION OF LOWER JAW    AS                                      $140.55        20120901
21244       RECONSTRUCTION OF LOWER JAW                                            $702.74        20120901
21244       RECONSTRUCTION OF LOWER JAW                           A              $1,223.51        20110101
21245       RECONSTRUCTION OF JAW          80                                      $149.47        20120901
21245       RECONSTRUCTION OF JAW          81                                      $149.47        20120901
21245       RECONSTRUCTION OF JAW          82                                      $149.47        20120901
21245       RECONSTRUCTION OF JAW          AS                                      $149.47        20120901
21245       RECONSTRUCTION OF JAW                                                  $747.33        20120901
21245       RECONSTRUCTION OF JAW                                 A              $1,223.51        20110101
21246       RECONSTRUCTION OF JAW          80                                      $113.23        20120901
21246       RECONSTRUCTION OF JAW          81                                      $113.23        20120901
21246       RECONSTRUCTION OF JAW          82                                      $113.23        20120901
21246       RECONSTRUCTION OF JAW          AS                                      $113.23        20120901
21246       RECONSTRUCTION OF JAW                                                  $566.17        20120901
21246       RECONSTRUCTION OF JAW                                 A              $1,223.51        20110101
21247       RECONSTRUCT LOWER JAW BONE     80                                      $219.79        20120901
21247       RECONSTRUCT LOWER JAW BONE     81                                      $219.79        20120901
21247       RECONSTRUCT LOWER JAW BONE     82                                      $219.79        20120901



                                                Page 25
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
21247       RECONSTRUCT LOWER JAW BONE     AS                                     $219.79        20120901
21247       RECONSTRUCT LOWER JAW BONE                                          $1,098.95        20120901
21248       RECONSTRUCTION OF JAW                                                 $704.78        20120901
21248       RECONSTRUCTION OF JAW                                A              $1,223.51        20110101
21249       RECONSTRUCTION OF JAW                                                 $971.30        20120901
21249       RECONSTRUCTION OF JAW                                A              $1,223.51        20110101
21255       RECONSTRUCT LOWER JAW BONE     80                                     $187.13        20120901
21255       RECONSTRUCT LOWER JAW BONE     81                                     $187.13        20120901
21255       RECONSTRUCT LOWER JAW BONE     82                                     $187.13        20120901
21255       RECONSTRUCT LOWER JAW BONE     AS                                     $187.13        20120901
21255       RECONSTRUCT LOWER JAW BONE                                            $935.63        20120901
21256       RECONSTRUCTION OF ORBIT        80                                     $158.54        20120901
21256       RECONSTRUCTION OF ORBIT        81                                     $158.54        20120901
21256       RECONSTRUCTION OF ORBIT        82                                     $158.54        20120901
21256       RECONSTRUCTION OF ORBIT        AS                                     $158.54        20120901
21256       RECONSTRUCTION OF ORBIT                                               $792.68        20120901
21260       REVISE EYE SOCKETS             80                                     $168.63        20120901
21260       REVISE EYE SOCKETS             81                                     $168.63        20120901
21260       REVISE EYE SOCKETS             82                                     $168.63        20120901
21260       REVISE EYE SOCKETS             AS                                     $168.63        20120901
21260       REVISE EYE SOCKETS                                                    $843.13        20120901
21261       REVISE EYE SOCKETS             80                                     $308.00        20120901
21261       REVISE EYE SOCKETS             81                                     $308.00        20120901
21261       REVISE EYE SOCKETS             82                                     $308.00        20120901
21261       REVISE EYE SOCKETS             AS                                     $308.00        20120901
21261       REVISE EYE SOCKETS                                                  $1,540.01        20120901
21263       REVISE EYE SOCKETS             80                                     $261.27        20120901
21263       REVISE EYE SOCKETS             81                                     $261.27        20120901
21263       REVISE EYE SOCKETS             82                                     $261.27        20120901
21263       REVISE EYE SOCKETS             AS                                     $261.27        20120901
21263       REVISE EYE SOCKETS                                                  $1,306.36        20120901
21267       REVISE EYE SOCKETS             80                                     $213.01        20120901
21267       REVISE EYE SOCKETS             81                                     $213.01        20120901
21267       REVISE EYE SOCKETS             82                                     $213.01        20120901
21267       REVISE EYE SOCKETS             AS                                     $213.01        20120901
21267       REVISE EYE SOCKETS                                                  $1,065.06        20120901
21267       REVISE EYE SOCKETS                                   A              $1,223.51        20110101
21268       REVISE EYE SOCKETS             80                                     $266.32        20120901
21268       REVISE EYE SOCKETS             81                                     $266.32        20120901
21268       REVISE EYE SOCKETS             82                                     $266.32        20120901
21268       REVISE EYE SOCKETS             AS                                     $266.32        20120901
21268       REVISE EYE SOCKETS                                                  $1,331.58        20120901
21270       AUGMENTATION CHEEK BONE        80                                     $122.51        20120901
21270       AUGMENTATION CHEEK BONE        81                                     $122.51        20120901
21270       AUGMENTATION CHEEK BONE        82                                     $122.51        20120901
21270       AUGMENTATION CHEEK BONE        AS                                     $122.51        20120901
21270       AUGMENTATION CHEEK BONE                                               $612.54        20120901
21270       AUGMENTATION CHEEK BONE                              A              $1,170.32        20110101
21275       REVISION ORBITOFACIAL BONES    80                                     $110.69        20120901
21275       REVISION ORBITOFACIAL BONES    81                                     $110.69        20120901
21275       REVISION ORBITOFACIAL BONES    82                                     $110.69        20120901
21275       REVISION ORBITOFACIAL BONES    AS                                     $110.69        20120901
21275       REVISION ORBITOFACIAL BONES                                           $553.43        20120901
21275       REVISION ORBITOFACIAL BONES                          A              $1,223.51        20110101
21280       REVISION OF EYELID                                                    $368.95        20120901
21280       REVISION OF EYELID                                   A              $1,170.32        20110101
21282       REVISION OF EYELID                                                    $242.06        20120901
21282       REVISION OF EYELID                                   A                $550.32        20110101
21295       REVISION OF JAW MUSCLE/BONE                                           $118.48        20120901



                                             Page 26
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
21295       REVISION OF JAW MUSCLE/BONE                           A                $246.86        20110101
21296       REVISION OF JAW MUSCLE/BONE                                            $284.10        20120901
21296       REVISION OF JAW MUSCLE/BONE                           A                $663.74        20110101
21310       TREATMENT OF NOSE FRACTURE                                              $70.32        20120901
21310       TREATMENT OF NOSE FRACTURE                            A                 $56.54        20110101
21315       TREATMENT OF NOSE FRACTURE                                             $171.74        20120901
21315       TREATMENT OF NOSE FRACTURE                            A                $441.97        20110101
21320       TREATMENT OF NOSE FRACTURE                                             $163.33        20120901
21320       TREATMENT OF NOSE FRACTURE                            A                $498.46        20110101
21325       TREATMENT OF NOSE FRACTURE                                             $310.09        20120901
21325       TREATMENT OF NOSE FRACTURE                            A                $720.58        20110101
21330       TREATMENT OF NOSE FRACTURE                                             $374.56        20120901
21330       TREATMENT OF NOSE FRACTURE                            A                $737.22        20110101
21335       TREATMENT OF NOSE FRACTURE                                             $488.96        20120901
21335       TREATMENT OF NOSE FRACTURE                            A                $790.42        20110101
21336       TREAT NASAL SEPTAL FRACTURE                                            $425.26        20120901
21336       TREAT NASAL SEPTAL FRACTURE                           A                $741.74        20110101
21337       TREAT NASAL SEPTAL FRACTURE                                            $258.11        20120901
21337       TREAT NASAL SEPTAL FRACTURE                           A                $498.46        20110101
21338       TREAT NASOETHMOID FRACTURE                                             $486.92        20120901
21338       TREAT NASOETHMOID FRACTURE                            A                $720.58        20110101
21339       TREAT NASOETHMOID FRACTURE      80                                     $109.36        20120901
21339       TREAT NASOETHMOID FRACTURE      81                                     $109.36        20120901
21339       TREAT NASOETHMOID FRACTURE      82                                     $109.36        20120901
21339       TREAT NASOETHMOID FRACTURE      AS                                     $109.36        20120901
21339       TREAT NASOETHMOID FRACTURE                                             $546.80        20120901
21339       TREAT NASOETHMOID FRACTURE                            A                $737.22        20110101
21340       TREATMENT OF NOSE FRACTURE                                             $529.47        20120901
21340       TREATMENT OF NOSE FRACTURE                            A              $1,153.67        20110101
21343       TREATMENT OF SINUS FRACTURE     80                                     $157.06        20120901
21343       TREATMENT OF SINUS FRACTURE     81                                     $157.06        20120901
21343       TREATMENT OF SINUS FRACTURE     82                                     $157.06        20120901
21343       TREATMENT OF SINUS FRACTURE     AS                                     $157.06        20120901
21343       TREATMENT OF SINUS FRACTURE                                            $785.29        20120901
21344       TREATMENT OF SINUS FRACTURE     80                                     $218.47        20120901
21344       TREATMENT OF SINUS FRACTURE     81                                     $218.47        20120901
21344       TREATMENT OF SINUS FRACTURE     82                                     $218.47        20120901
21344       TREATMENT OF SINUS FRACTURE     AS                                     $218.47        20120901
21344       TREATMENT OF SINUS FRACTURE                                          $1,092.33        20120901
21345       TREAT NOSE/JAW FRACTURE                                                $525.14        20120901
21345       TREAT NOSE/JAW FRACTURE                               A                $790.42        20110101
21346       TREAT NOSE/JAW FRACTURE                                                $623.50        20120901
21347       TREAT NOSE/JAW FRACTURE         80                                     $143.10        20120901
21347       TREAT NOSE/JAW FRACTURE         81                                     $143.10        20120901
21347       TREAT NOSE/JAW FRACTURE         82                                     $143.10        20120901
21347       TREAT NOSE/JAW FRACTURE         AS                                     $143.10        20120901
21347       TREAT NOSE/JAW FRACTURE                                                $715.48        20120901
21348       TREAT NOSE/JAW FRACTURE         80                                     $151.20        20120901
21348       TREAT NOSE/JAW FRACTURE         81                                     $151.20        20120901
21348       TREAT NOSE/JAW FRACTURE         82                                     $151.20        20120901
21348       TREAT NOSE/JAW FRACTURE         AS                                     $151.20        20120901
21348       TREAT NOSE/JAW FRACTURE                                                $755.99        20120901
21355       TREAT CHEEK BONE FRACTURE                                              $286.65        20120901
21355       TREAT CHEEK BONE FRACTURE                             A              $1,130.71        20110101
21356       TREAT CHEEK BONE FRACTURE                                              $321.81        20120901
21360       TREAT CHEEK BONE FRACTURE       80                                      $70.43        20120901
21360       TREAT CHEEK BONE FRACTURE       81                                      $70.43        20120901
21360       TREAT CHEEK BONE FRACTURE       82                                      $70.43        20120901
21360       TREAT CHEEK BONE FRACTURE       AS                                      $70.43        20120901



                                              Page 27
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
21360       TREAT CHEEK BONE FRACTURE                                              $352.13        20120901
21360       TREAT CHEEK BONE FRACTURE                             A                $800.03        20110101
21365       TREAT CHEEK BONE FRACTURE      80                                      $149.72        20120901
21365       TREAT CHEEK BONE FRACTURE      81                                      $149.72        20120901
21365       TREAT CHEEK BONE FRACTURE      82                                      $149.72        20120901
21365       TREAT CHEEK BONE FRACTURE      AS                                      $149.72        20120901
21365       TREAT CHEEK BONE FRACTURE                                              $748.60        20120901
21366       TREAT CHEEK BONE FRACTURE      80                                      $167.40        20120901
21366       TREAT CHEEK BONE FRACTURE      81                                      $167.40        20120901
21366       TREAT CHEEK BONE FRACTURE      82                                      $167.40        20120901
21366       TREAT CHEEK BONE FRACTURE      AS                                      $167.40        20120901
21366       TREAT CHEEK BONE FRACTURE                                              $837.02        20120901
21385       TREAT EYE SOCKET FRACTURE      80                                       $93.87        20120901
21385       TREAT EYE SOCKET FRACTURE      81                                       $93.87        20120901
21385       TREAT EYE SOCKET FRACTURE      82                                       $93.87        20120901
21385       TREAT EYE SOCKET FRACTURE      AS                                       $93.87        20120901
21385       TREAT EYE SOCKET FRACTURE                                              $469.34        20120901
21386       TREAT EYE SOCKET FRACTURE      80                                       $89.79        20120901
21386       TREAT EYE SOCKET FRACTURE      81                                       $89.79        20120901
21386       TREAT EYE SOCKET FRACTURE      82                                       $89.79        20120901
21386       TREAT EYE SOCKET FRACTURE      AS                                       $89.79        20120901
21386       TREAT EYE SOCKET FRACTURE                                              $448.96        20120901
21387       TREAT EYE SOCKET FRACTURE      80                                      $100.29        20120901
21387       TREAT EYE SOCKET FRACTURE      81                                      $100.29        20120901
21387       TREAT EYE SOCKET FRACTURE      82                                      $100.29        20120901
21387       TREAT EYE SOCKET FRACTURE      AS                                      $100.29        20120901
21387       TREAT EYE SOCKET FRACTURE                                              $501.45        20120901
21390       TREAT EYE SOCKET FRACTURE      80                                      $105.23        20120901
21390       TREAT EYE SOCKET FRACTURE      81                                      $105.23        20120901
21390       TREAT EYE SOCKET FRACTURE      82                                      $105.23        20120901
21390       TREAT EYE SOCKET FRACTURE      AS                                      $105.23        20120901
21390       TREAT EYE SOCKET FRACTURE                                              $526.16        20120901
21390       TREAT EYE SOCKET FRACTURE                             A              $1,377.50        20110101
21395       TREAT EYE SOCKET FRACTURE      80                                      $127.25        20120901
21395       TREAT EYE SOCKET FRACTURE      81                                      $127.25        20120901
21395       TREAT EYE SOCKET FRACTURE      82                                      $127.25        20120901
21395       TREAT EYE SOCKET FRACTURE      AS                                      $127.25        20120901
21395       TREAT EYE SOCKET FRACTURE                                              $636.24        20120901
21400       TREAT EYE SOCKET FRACTURE                                              $117.46        20120901
21400       TREAT EYE SOCKET FRACTURE                             A                $268.48        20110101
21401       TREAT EYE SOCKET FRACTURE      80                                       $61.66        20120901
21401       TREAT EYE SOCKET FRACTURE      81                                       $61.66        20120901
21401       TREAT EYE SOCKET FRACTURE      82                                       $61.66        20120901
21401       TREAT EYE SOCKET FRACTURE      AS                                       $61.66        20120901
21401       TREAT EYE SOCKET FRACTURE                                              $308.31        20120901
21401       TREAT EYE SOCKET FRACTURE                             A                $510.71        20110101
21406       TREAT EYE SOCKET FRACTURE      80                                       $71.04        20120901
21406       TREAT EYE SOCKET FRACTURE      81                                       $71.04        20120901
21406       TREAT EYE SOCKET FRACTURE      82                                       $71.04        20120901
21406       TREAT EYE SOCKET FRACTURE      AS                                       $71.04        20120901
21406       TREAT EYE SOCKET FRACTURE                                              $355.19        20120901
21406       TREAT EYE SOCKET FRACTURE                             A              $1,377.50        20110101
21407       TREAT EYE SOCKET FRACTURE      80                                       $86.38        20120901
21407       TREAT EYE SOCKET FRACTURE      81                                       $86.38        20120901
21407       TREAT EYE SOCKET FRACTURE      82                                       $86.38        20120901
21407       TREAT EYE SOCKET FRACTURE      AS                                       $86.38        20120901
21407       TREAT EYE SOCKET FRACTURE                                              $431.89        20120901
21407       TREAT EYE SOCKET FRACTURE                             A              $1,377.50        20110101
21408       TREAT EYE SOCKET FRACTURE      80                                      $119.60        20120901



                                                Page 28
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
21408       TREAT EYE SOCKET FRACTURE       81                                      $119.60        20120901
21408       TREAT EYE SOCKET FRACTURE       82                                      $119.60        20120901
21408       TREAT EYE SOCKET FRACTURE       AS                                      $119.60        20120901
21408       TREAT EYE SOCKET FRACTURE                                               $598.02        20120901
21421       TREAT MOUTH ROOF FRACTURE                                               $488.71        20120901
21421       TREAT MOUTH ROOF FRACTURE                              A                $720.58        20110101
21422       TREAT MOUTH ROOF FRACTURE       80                                       $88.26        20120901
21422       TREAT MOUTH ROOF FRACTURE       81                                       $88.26        20120901
21422       TREAT MOUTH ROOF FRACTURE       82                                       $88.26        20120901
21422       TREAT MOUTH ROOF FRACTURE       AS                                       $88.26        20120901
21422       TREAT MOUTH ROOF FRACTURE                                               $441.31        20120901
21423       TREAT MOUTH ROOF FRACTURE       80                                      $107.17        20120901
21423       TREAT MOUTH ROOF FRACTURE       81                                      $107.17        20120901
21423       TREAT MOUTH ROOF FRACTURE       82                                      $107.17        20120901
21423       TREAT MOUTH ROOF FRACTURE       AS                                      $107.17        20120901
21423       TREAT MOUTH ROOF FRACTURE                                               $535.84        20120901
21431       TREAT CRANIOFACIAL FRACTURE     80                                      $100.24        20120901
21431       TREAT CRANIOFACIAL FRACTURE     81                                      $100.24        20120901
21431       TREAT CRANIOFACIAL FRACTURE     82                                      $100.24        20120901
21431       TREAT CRANIOFACIAL FRACTURE     AS                                      $100.24        20120901
21431       TREAT CRANIOFACIAL FRACTURE                                             $501.19        20120901
21432       TREAT CRANIOFACIAL FRACTURE     80                                       $89.94        20120901
21432       TREAT CRANIOFACIAL FRACTURE     81                                       $89.94        20120901
21432       TREAT CRANIOFACIAL FRACTURE     82                                       $89.94        20120901
21432       TREAT CRANIOFACIAL FRACTURE     AS                                       $89.94        20120901
21432       TREAT CRANIOFACIAL FRACTURE                                             $449.72        20120901
21433       TREAT CRANIOFACIAL FRACTURE     80                                      $229.83        20120901
21433       TREAT CRANIOFACIAL FRACTURE     81                                      $229.83        20120901
21433       TREAT CRANIOFACIAL FRACTURE     82                                      $229.83        20120901
21433       TREAT CRANIOFACIAL FRACTURE     AS                                      $229.83        20120901
21433       TREAT CRANIOFACIAL FRACTURE                                           $1,149.15        20120901
21435       TREAT CRANIOFACIAL FRACTURE     80                                      $177.54        20120901
21435       TREAT CRANIOFACIAL FRACTURE     81                                      $177.54        20120901
21435       TREAT CRANIOFACIAL FRACTURE     82                                      $177.54        20120901
21435       TREAT CRANIOFACIAL FRACTURE     AS                                      $177.54        20120901
21435       TREAT CRANIOFACIAL FRACTURE                                             $887.72        20120901
21436       TREAT CRANIOFACIAL FRACTURE     80                                      $272.64        20120901
21436       TREAT CRANIOFACIAL FRACTURE     81                                      $272.64        20120901
21436       TREAT CRANIOFACIAL FRACTURE     82                                      $272.64        20120901
21436       TREAT CRANIOFACIAL FRACTURE     AS                                      $272.64        20120901
21436       TREAT CRANIOFACIAL FRACTURE                                           $1,363.18        20120901
21440       TREAT DENTAL RIDGE FRACTURE                                             $351.88        20120901
21440       TREAT DENTAL RIDGE FRACTURE                            A                $224.85        20110101
21445       TREAT DENTAL RIDGE FRACTURE     80                                       $97.49        20120901
21445       TREAT DENTAL RIDGE FRACTURE     81                                       $97.49        20120901
21445       TREAT DENTAL RIDGE FRACTURE     82                                       $97.49        20120901
21445       TREAT DENTAL RIDGE FRACTURE     AS                                       $97.49        20120901
21445       TREAT DENTAL RIDGE FRACTURE                                             $487.43        20120901
21445       TREAT DENTAL RIDGE FRACTURE                            A                $720.58        20110101
21450       TREAT LOWER JAW FRACTURE                                                $366.66        20120901
21450       TREAT LOWER JAW FRACTURE                               A                $111.17        20110101
21451       TREAT LOWER JAW FRACTURE                                                $474.69        20120901
21451       TREAT LOWER JAW FRACTURE                               A                $271.95        20110101
21452       TREAT LOWER JAW FRACTURE                                                $378.89        20120901
21452       TREAT LOWER JAW FRACTURE                               A                $498.46        20110101
21453       TREAT LOWER JAW FRACTURE                                                $557.25        20120901
21453       TREAT LOWER JAW FRACTURE                               A              $1,130.71        20110101
21454       TREAT LOWER JAW FRACTURE        80                                       $73.69        20120901
21454       TREAT LOWER JAW FRACTURE        81                                       $73.69        20120901



                                                 Page 29
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price         Effective Date
21454       TREAT LOWER JAW FRACTURE        82                                     $73.69        20120901
21454       TREAT LOWER JAW FRACTURE        AS                                     $73.69        20120901
21454       TREAT LOWER JAW FRACTURE                                              $368.44        20120901
21454       TREAT LOWER JAW FRACTURE                              A               $737.22        20110101
21461       TREAT LOWER JAW FRACTURE                                              $606.93        20120901
21461       TREAT LOWER JAW FRACTURE                              A             $1,153.67        20110101
21462       TREAT LOWER JAW FRACTURE                                              $667.07        20120901
21462       TREAT LOWER JAW FRACTURE                              A             $1,170.32        20110101
21465       TREAT LOWER JAW FRACTURE        80                                    $124.70        20120901
21465       TREAT LOWER JAW FRACTURE        81                                    $124.70        20120901
21465       TREAT LOWER JAW FRACTURE        82                                    $124.70        20120901
21465       TREAT LOWER JAW FRACTURE        AS                                    $124.70        20120901
21465       TREAT LOWER JAW FRACTURE                                              $623.50        20120901
21465       TREAT LOWER JAW FRACTURE                              A             $1,153.67        20110101
21470       TREAT LOWER JAW FRACTURE        80                                    $160.73        20120901
21470       TREAT LOWER JAW FRACTURE        81                                    $160.73        20120901
21470       TREAT LOWER JAW FRACTURE        82                                    $160.73        20120901
21470       TREAT LOWER JAW FRACTURE        AS                                    $160.73        20120901
21470       TREAT LOWER JAW FRACTURE                                              $803.64        20120901
21480       RESET DISLOCATED JAW                                                   $58.60        20120901
21480       RESET DISLOCATED JAW                                  A                $56.54        20110101
21485       RESET DISLOCATED JAW                                                  $428.32        20120901
21485       RESET DISLOCATED JAW                                  A               $498.46        20110101
21490       REPAIR DISLOCATED JAW           80                                    $124.19        20120901
21490       REPAIR DISLOCATED JAW           81                                    $124.19        20120901
21490       REPAIR DISLOCATED JAW           82                                    $124.19        20120901
21490       REPAIR DISLOCATED JAW           AS                                    $124.19        20120901
21490       REPAIR DISLOCATED JAW                                                 $620.95        20120901
21490       REPAIR DISLOCATED JAW                                 A             $1,130.71        20110101
21495       TREAT HYOID BONE FRACTURE       80                                     $91.27        20120901
21495       TREAT HYOID BONE FRACTURE       81                                     $91.27        20120901
21495       TREAT HYOID BONE FRACTURE       82                                     $91.27        20120901
21495       TREAT HYOID BONE FRACTURE       AS                                     $91.27        20120901
21495       TREAT HYOID BONE FRACTURE                                             $456.35        20120901
21495       TREAT HYOID BONE FRACTURE                             A               $550.84        20110101
21497       INTERDENTAL WIRING                                                    $433.67        20120901
21497       INTERDENTAL WIRING                                    A               $498.46        20110101
21501       DRAIN NECK/CHEST LESION                                               $288.69        20120901
21501       DRAIN NECK/CHEST LESION                               A               $551.78        20110101
21502       DRAIN CHEST LESION              80                                     $70.83        20120901
21502       DRAIN CHEST LESION              81                                     $70.83        20120901
21502       DRAIN CHEST LESION              82                                     $70.83        20120901
21502       DRAIN CHEST LESION              AS                                     $70.83        20120901
21502       DRAIN CHEST LESION                                                    $354.17        20120901
21502       DRAIN CHEST LESION                                    A               $614.48        20110101
21510       DRAINAGE OF BONE LESION                                               $310.60        20120901
21550       BIOPSY OF NECK/CHEST                                                  $166.13        20120901
21550       BIOPSY OF NECK/CHEST                                  A               $560.76        20110101
21552       EXC NECK LES SC 3 CM/                                                 $310.09        20120901
21554       EXC NECK TUM DEEP 5 CM/                                               $509.09        20120901
21555       EXC NECK LES SC 3 CM                                                  $267.29        20120901
21555       EXC NECK LES SC 3 CM                                  A               $135.59        20110101
21556       EXC NECK TUM DEEP 5 CM                                                $340.67        20120901
21556       EXC NECK TUM DEEP 5 CM                                A               $749.54        20110101
21557       RESECT NECK TUM 5 CM            80                                    $116.95        20120901
21557       RESECT NECK TUM 5 CM            81                                    $116.95        20120901
21557       RESECT NECK TUM 5 CM            82                                    $116.95        20120901
21557       RESECT NECK TUM 5 CM            AS                                    $116.95        20120901
21557       RESECT NECK TUM 5 CM                                                  $584.77        20120901



                                              Page 30
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
21558       RESECT NECK TUM 5 CM/                                                 $956.01         20120901
21600       PARTIAL REMOVAL OF RIB          80                                      $74.71        20120901
21600       PARTIAL REMOVAL OF RIB          81                                      $74.71        20120901
21600       PARTIAL REMOVAL OF RIB          82                                      $74.71        20120901
21600       PARTIAL REMOVAL OF RIB          AS                                      $74.71        20120901
21600       PARTIAL REMOVAL OF RIB                                                $373.54         20120901
21600       PARTIAL REMOVAL OF RIB                                A               $849.00         20110101
21610       PARTIAL REMOVAL OF RIB          80                                    $152.01         20120901
21610       PARTIAL REMOVAL OF RIB          81                                    $152.01         20120901
21610       PARTIAL REMOVAL OF RIB          82                                    $152.01         20120901
21610       PARTIAL REMOVAL OF RIB          AS                                    $152.01         20120901
21610       PARTIAL REMOVAL OF RIB                                                $760.07         20120901
21610       PARTIAL REMOVAL OF RIB                                A               $849.00         20110101
21615       REMOVAL OF RIB                  80                                      $91.73        20120901
21615       REMOVAL OF RIB                  81                                      $91.73        20120901
21615       REMOVAL OF RIB                  82                                      $91.73        20120901
21615       REMOVAL OF RIB                  AS                                      $91.73        20120901
21615       REMOVAL OF RIB                                                        $458.64         20120901
21616       REMOVAL OF RIB AND NERVES       80                                    $114.00         20120901
21616       REMOVAL OF RIB AND NERVES       81                                    $114.00         20120901
21616       REMOVAL OF RIB AND NERVES       82                                    $114.00         20120901
21616       REMOVAL OF RIB AND NERVES       AS                                    $114.00         20120901
21616       REMOVAL OF RIB AND NERVES                                             $569.99         20120901
21620       PARTIAL REMOVAL OF STERNUM      80                                      $70.63        20120901
21620       PARTIAL REMOVAL OF STERNUM      81                                      $70.63        20120901
21620       PARTIAL REMOVAL OF STERNUM      82                                      $70.63        20120901
21620       PARTIAL REMOVAL OF STERNUM      AS                                      $70.63        20120901
21620       PARTIAL REMOVAL OF STERNUM                                            $353.15         20120901
21627       STERNAL DEBRIDEMENT             80                                      $74.20        20120901
21627       STERNAL DEBRIDEMENT             81                                      $74.20        20120901
21627       STERNAL DEBRIDEMENT             82                                      $74.20        20120901
21627       STERNAL DEBRIDEMENT             AS                                      $74.20        20120901
21627       STERNAL DEBRIDEMENT                                                   $370.99         20120901
21630       EXTENSIVE STERNUM SURGERY       80                                    $171.79         20120901
21630       EXTENSIVE STERNUM SURGERY       81                                    $171.79         20120901
21630       EXTENSIVE STERNUM SURGERY       82                                    $171.79         20120901
21630       EXTENSIVE STERNUM SURGERY       AS                                    $171.79         20120901
21630       EXTENSIVE STERNUM SURGERY                                             $858.93         20120901
21632       EXTENSIVE STERNUM SURGERY       80                                    $172.60         20120901
21632       EXTENSIVE STERNUM SURGERY       81                                    $172.60         20120901
21632       EXTENSIVE STERNUM SURGERY       82                                    $172.60         20120901
21632       EXTENSIVE STERNUM SURGERY       AS                                    $172.60         20120901
21632       EXTENSIVE STERNUM SURGERY                                             $863.01         20120901
21700       REVISION OF NECK MUSCLE         80                                      $57.84        20120901
21700       REVISION OF NECK MUSCLE         81                                      $57.84        20120901
21700       REVISION OF NECK MUSCLE         82                                      $57.84        20120901
21700       REVISION OF NECK MUSCLE         AS                                      $57.84        20120901
21700       REVISION OF NECK MUSCLE                                               $289.20         20120901
21700       REVISION OF NECK MUSCLE                               A               $614.48         20110101
21705       REVISION OF NECK MUSCLE/RIB     80                                      $85.92        20120901
21705       REVISION OF NECK MUSCLE/RIB     81                                      $85.92        20120901
21705       REVISION OF NECK MUSCLE/RIB     82                                      $85.92        20120901
21705       REVISION OF NECK MUSCLE/RIB     AS                                      $85.92        20120901
21705       REVISION OF NECK MUSCLE/RIB                                           $429.59         20120901
21720       REVISION OF NECK MUSCLE         80                                      $58.60        20120901
21720       REVISION OF NECK MUSCLE         81                                      $58.60        20120901
21720       REVISION OF NECK MUSCLE         82                                      $58.60        20120901
21720       REVISION OF NECK MUSCLE         AS                                      $58.60        20120901
21720       REVISION OF NECK MUSCLE                                               $293.02         20120901



                                              Page 31
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
21720       REVISION OF NECK MUSCLE                               A               $626.73         20110101
21725       REVISION OF NECK MUSCLE        80                                       $70.63        20120901
21725       REVISION OF NECK MUSCLE        81                                       $70.63        20120901
21725       REVISION OF NECK MUSCLE        82                                       $70.63        20120901
21725       REVISION OF NECK MUSCLE        AS                                       $70.63        20120901
21725       REVISION OF NECK MUSCLE                                               $353.15         20120901
21725       REVISION OF NECK MUSCLE                               A                 $51.91        20110101
21740       RECONSTRUCTION OF STERNUM      80                                     $145.39         20120901
21740       RECONSTRUCTION OF STERNUM      81                                     $145.39         20120901
21740       RECONSTRUCTION OF STERNUM      82                                     $145.39         20120901
21740       RECONSTRUCTION OF STERNUM      AS                                     $145.39         20120901
21740       RECONSTRUCTION OF STERNUM                                             $726.94         20120901
21750       REPAIR OF STERNUM SEPARATION   80                                       $98.05        20120901
21750       REPAIR OF STERNUM SEPARATION   81                                       $98.05        20120901
21750       REPAIR OF STERNUM SEPARATION   82                                       $98.05        20120901
21750       REPAIR OF STERNUM SEPARATION   AS                                       $98.05        20120901
21750       REPAIR OF STERNUM SEPARATION                                          $490.24         20120901
21800       TREATMENT OF RIB FRACTURE                                               $65.48        20120901
21800       TREATMENT OF RIB FRACTURE                             A                 $59.66        20110101
21805       TREATMENT OF RIB FRACTURE                                             $173.77         20120901
21805       TREATMENT OF RIB FRACTURE                             A               $706.54         20110101
21810       TREATMENT OF RIB FRACTURES     80                                       $67.93        20120901
21810       TREATMENT OF RIB FRACTURES     81                                       $67.93        20120901
21810       TREATMENT OF RIB FRACTURES     82                                       $67.93        20120901
21810       TREATMENT OF RIB FRACTURES     AS                                       $67.93        20120901
21810       TREATMENT OF RIB FRACTURES                                            $339.65         20120901
21820       TREAT STERNUM FRACTURE                                                  $87.14        20120901
21820       TREAT STERNUM FRACTURE                                A                 $59.66        20110101
21825       TREAT STERNUM FRACTURE         80                                       $76.85        20120901
21825       TREAT STERNUM FRACTURE         81                                       $76.85        20120901
21825       TREAT STERNUM FRACTURE         82                                       $76.85        20120901
21825       TREAT STERNUM FRACTURE         AS                                       $76.85        20120901
21825       TREAT STERNUM FRACTURE                                                $384.24         20120901
21920       BIOPSY SOFT TISSUE OF BACK                                            $167.15         20120901
21925       BIOPSY SOFT TISSUE OF BACK                                            $278.24         20120901
21925       BIOPSY SOFT TISSUE OF BACK                            A               $647.50         20110101
21930       EXC BACK LES SC 3 CM                                                  $303.21         20120901
21930       EXC BACK LES SC 3 CM                                  A               $141.50         20110101
21931       EXC BACK LES SC 3 CM/                                                 $324.62         20120901
21932       EXC BACK TUM DEEP 5 CM                                                $466.03         20120901
21933       EXC BACK TUM DEEP 5 CM/                                               $513.93         20120901
21935       RESECT BACK TUM 5 CM                                                  $699.94         20120901
21935       RESECT BACK TUM 5 CM                                  A               $560.76         20110101
21936       RESECT BACK TUM 5 CM/                                                 $996.01         20120901
22010       ID P-SPINE C/T/CERV-THOR                                              $619.67         20120901
22015       ID P-SPINE L/S/LS                                                     $613.05         20120901
22100       REMOVE PART OF NECK VERTEBRA   80                                     $114.41         20120901
22100       REMOVE PART OF NECK VERTEBRA   81                                     $114.41         20120901
22100       REMOVE PART OF NECK VERTEBRA   82                                     $114.41         20120901
22100       REMOVE PART OF NECK VERTEBRA   AS                                     $114.41         20120901
22100       REMOVE PART OF NECK VERTEBRA                                          $572.03         20120901
22101       REMOVE PART THORAX VERTEBRA    80                                     $116.04         20120901
22101       REMOVE PART THORAX VERTEBRA    81                                     $116.04         20120901
22101       REMOVE PART THORAX VERTEBRA    82                                     $116.04         20120901
22101       REMOVE PART THORAX VERTEBRA    AS                                     $116.04         20120901
22101       REMOVE PART THORAX VERTEBRA                                           $580.18         20120901
22102       REMOVE PART LUMBAR VERTEBRA    80                                     $109.05         20120901
22102       REMOVE PART LUMBAR VERTEBRA    81                                     $109.05         20120901
22102       REMOVE PART LUMBAR VERTEBRA    82                                     $109.05         20120901



                                                Page 32
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
22102       REMOVE PART LUMBAR VERTEBRA    AS                                     $109.05        20120901
22102       REMOVE PART LUMBAR VERTEBRA                                           $545.27        20120901
22102       REMOVE PART LUMBAR VERTEBRA                          A              $1,577.58        20110101
22103       REMOVE EXTRA SPINE SEGMENT     80                                      $19.77        20120901
22103       REMOVE EXTRA SPINE SEGMENT     81                                      $19.77        20120901
22103       REMOVE EXTRA SPINE SEGMENT     82                                      $19.77        20120901
22103       REMOVE EXTRA SPINE SEGMENT     AS                                      $19.77        20120901
22103       REMOVE EXTRA SPINE SEGMENT                                             $98.86        20120901
22103       REMOVE EXTRA SPINE SEGMENT                           A              $1,577.58        20110101
22110       REMOVE PART OF NECK VERTEBRA   80                                     $141.06        20120901
22110       REMOVE PART OF NECK VERTEBRA   81                                     $141.06        20120901
22110       REMOVE PART OF NECK VERTEBRA   82                                     $141.06        20120901
22110       REMOVE PART OF NECK VERTEBRA   AS                                     $141.06        20120901
22110       REMOVE PART OF NECK VERTEBRA                                          $705.29        20120901
22112       REMOVE PART THORAX VERTEBRA    80                                     $139.99        20120901
22112       REMOVE PART THORAX VERTEBRA    81                                     $139.99        20120901
22112       REMOVE PART THORAX VERTEBRA    82                                     $139.99        20120901
22112       REMOVE PART THORAX VERTEBRA    AS                                     $139.99        20120901
22112       REMOVE PART THORAX VERTEBRA                                           $699.94        20120901
22114       REMOVE PART LUMBAR VERTEBRA    80                                     $132.50        20120901
22114       REMOVE PART LUMBAR VERTEBRA    81                                     $132.50        20120901
22114       REMOVE PART LUMBAR VERTEBRA    82                                     $132.50        20120901
22114       REMOVE PART LUMBAR VERTEBRA    AS                                     $132.50        20120901
22114       REMOVE PART LUMBAR VERTEBRA                                           $662.48        20120901
22116       REMOVE EXTRA SPINE SEGMENT     80                                      $19.36        20120901
22116       REMOVE EXTRA SPINE SEGMENT     81                                      $19.36        20120901
22116       REMOVE EXTRA SPINE SEGMENT     82                                      $19.36        20120901
22116       REMOVE EXTRA SPINE SEGMENT     AS                                      $19.36        20120901
22116       REMOVE EXTRA SPINE SEGMENT                                             $96.82        20120901
22210       REVISION OF NECK SPINE         80                                     $235.94        20120901
22210       REVISION OF NECK SPINE         81                                     $235.94        20120901
22210       REVISION OF NECK SPINE         82                                     $235.94        20120901
22210       REVISION OF NECK SPINE         AS                                     $235.94        20120901
22210       REVISION OF NECK SPINE                                              $1,179.72        20120901
22212       REVISION OF THORAX SPINE                                              $978.43        20120901
22214       REVISION OF LUMBAR SPINE       80                                     $197.27        20120901
22214       REVISION OF LUMBAR SPINE       81                                     $197.27        20120901
22214       REVISION OF LUMBAR SPINE       82                                     $197.27        20120901
22214       REVISION OF LUMBAR SPINE       AS                                     $197.27        20120901
22214       REVISION OF LUMBAR SPINE                                              $986.33        20120901
22216       REVISE EXTRA SPINE SEGMENT     80                                      $50.50        20120901
22216       REVISE EXTRA SPINE SEGMENT     81                                      $50.50        20120901
22216       REVISE EXTRA SPINE SEGMENT     82                                      $50.50        20120901
22216       REVISE EXTRA SPINE SEGMENT     AS                                      $50.50        20120901
22216       REVISE EXTRA SPINE SEGMENT                                            $252.51        20120901
22220       REVISION OF NECK SPINE         80                                     $214.18        20120901
22220       REVISION OF NECK SPINE         81                                     $214.18        20120901
22220       REVISION OF NECK SPINE         82                                     $214.18        20120901
22220       REVISION OF NECK SPINE         AS                                     $214.18        20120901
22220       REVISION OF NECK SPINE                                              $1,070.92        20120901
22222       REVISION OF THORAX SPINE       80                                     $195.99        20120901
22222       REVISION OF THORAX SPINE       81                                     $195.99        20120901
22222       REVISION OF THORAX SPINE       82                                     $195.99        20120901
22222       REVISION OF THORAX SPINE       AS                                     $195.99        20120901
22222       REVISION OF THORAX SPINE                                              $979.96        20120901
22224       REVISION OF LUMBAR SPINE       80                                     $210.62        20120901
22224       REVISION OF LUMBAR SPINE       81                                     $210.62        20120901
22224       REVISION OF LUMBAR SPINE       82                                     $210.62        20120901
22224       REVISION OF LUMBAR SPINE       AS                                     $210.62        20120901



                                             Page 33
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
22224       REVISION OF LUMBAR SPINE                                              $1,053.09        20120901
22226       REVISE EXTRA SPINE SEGMENT      80                                       $50.55        20120901
22226       REVISE EXTRA SPINE SEGMENT      81                                       $50.55        20120901
22226       REVISE EXTRA SPINE SEGMENT      82                                       $50.55        20120901
22226       REVISE EXTRA SPINE SEGMENT      AS                                       $50.55        20120901
22226       REVISE EXTRA SPINE SEGMENT                                              $252.76        20120901
22305       TREAT SPINE PROCESS FRACTURE                                            $121.28        20120901
22305       TREAT SPINE PROCESS FRACTURE                           A                 $59.66        20110101
22310       TREAT SPINE FRACTURE                                                    $195.18        20120901
22310       TREAT SPINE FRACTURE                                   A                $135.07        20110101
22315       TREAT SPINE FRACTURE                                                    $568.46        20120901
22315       TREAT SPINE FRACTURE                                   A                $462.00        20110101
22318       TREAT ODONTOID FX W/O GRAFT     80                                      $216.68        20120901
22318       TREAT ODONTOID FX W/O GRAFT     81                                      $216.68        20120901
22318       TREAT ODONTOID FX W/O GRAFT     82                                      $216.68        20120901
22318       TREAT ODONTOID FX W/O GRAFT     AS                                      $216.68        20120901
22318       TREAT ODONTOID FX W/O GRAFT                                           $1,083.41        20120901
22319       TREAT ODONTOID FX W/GRAFT       80                                      $240.28        20120901
22319       TREAT ODONTOID FX W/GRAFT       81                                      $240.28        20120901
22319       TREAT ODONTOID FX W/GRAFT       82                                      $240.28        20120901
22319       TREAT ODONTOID FX W/GRAFT       AS                                      $240.28        20120901
22319       TREAT ODONTOID FX W/GRAFT                                             $1,201.38        20120901
22325       TREAT SPINE FRACTURE            80                                      $189.67        20120901
22325       TREAT SPINE FRACTURE            81                                      $189.67        20120901
22325       TREAT SPINE FRACTURE            82                                      $189.67        20120901
22325       TREAT SPINE FRACTURE            AS                                      $189.67        20120901
22325       TREAT SPINE FRACTURE                                                    $948.37        20120901
22326       TREAT NECK SPINE FRACTURE       80                                      $197.01        20120901
22326       TREAT NECK SPINE FRACTURE       81                                      $197.01        20120901
22326       TREAT NECK SPINE FRACTURE       82                                      $197.01        20120901
22326       TREAT NECK SPINE FRACTURE       AS                                      $197.01        20120901
22326       TREAT NECK SPINE FRACTURE                                               $985.06        20120901
22327       TREAT THORAX SPINE FRACTURE     80                                      $195.28        20120901
22327       TREAT THORAX SPINE FRACTURE     81                                      $195.28        20120901
22327       TREAT THORAX SPINE FRACTURE     82                                      $195.28        20120901
22327       TREAT THORAX SPINE FRACTURE     AS                                      $195.28        20120901
22327       TREAT THORAX SPINE FRACTURE                                             $976.39        20120901
22328       TREAT EACH ADD SPINE FX         80                                       $39.04        20120901
22328       TREAT EACH ADD SPINE FX         81                                       $39.04        20120901
22328       TREAT EACH ADD SPINE FX         82                                       $39.04        20120901
22328       TREAT EACH ADD SPINE FX         AS                                       $39.04        20120901
22328       TREAT EACH ADD SPINE FX                                                 $195.18        20120901
22505       MANIPULATION OF SPINE                                                    $78.99        20120901
22505       MANIPULATION OF SPINE                                  A                $452.90        20110101
22520       PERCUT VERTEBROPLASTY THOR                                              $366.91        20120901
22521       PERCUT VERTEBROPLASTY LUMB                                              $346.53        20120901
22532       LAT THORAX SPINE FUSION         80                                      $238.44        20120901
22532       LAT THORAX SPINE FUSION         81                                      $238.44        20120901
22532       LAT THORAX SPINE FUSION         82                                      $238.44        20120901
22532       LAT THORAX SPINE FUSION         AS                                      $238.44        20120901
22532       LAT THORAX SPINE FUSION                                               $1,192.21        20120901
22533       LAT LUMBAR SPINE FUSION         80                                      $225.45        20120901
22533       LAT LUMBAR SPINE FUSION         81                                      $225.45        20120901
22533       LAT LUMBAR SPINE FUSION         82                                      $225.45        20120901
22533       LAT LUMBAR SPINE FUSION         AS                                      $225.45        20120901
22533       LAT LUMBAR SPINE FUSION                                               $1,127.24        20120901
22534       LAT THOR/LUMB ADDL SEG          80                                       $50.30        20120901
22534       LAT THOR/LUMB ADDL SEG          81                                       $50.30        20120901
22534       LAT THOR/LUMB ADDL SEG          82                                       $50.30        20120901



                                                 Page 34
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price         Effective Date
22534       LAT THOR/LUMB ADDL SEG          AS                                      $50.30        20120901
22534       LAT THOR/LUMB ADDL SEG                                                 $251.49        20120901
22548       NECK SPINE FUSION               80                                     $256.79        20120901
22548       NECK SPINE FUSION               81                                     $256.79        20120901
22548       NECK SPINE FUSION               82                                     $256.79        20120901
22548       NECK SPINE FUSION               AS                                     $256.79        20120901
22548       NECK SPINE FUSION                                                    $1,283.94        20120901
22551       NECK SPINE FUSEREMOV BEL C2     80                                     $260.92        20120901
22551       NECK SPINE FUSEREMOV BEL C2     81                                     $260.92        20120901
22551       NECK SPINE FUSEREMOV BEL C2     82                                     $260.92        20120901
22551       NECK SPINE FUSEREMOV BEL C2     AS                                     $260.92        20120901
22551       NECK SPINE FUSEREMOV BEL C2                                          $1,304.58        20120901
22552       ADDL NECK SPINE FUSION          80                                      $60.80        20120901
22552       ADDL NECK SPINE FUSION          81                                      $60.80        20120901
22552       ADDL NECK SPINE FUSION          82                                      $60.80        20120901
22552       ADDL NECK SPINE FUSION          AS                                      $60.80        20120901
22552       ADDL NECK SPINE FUSION                                                 $303.98        20120901
22554       NECK SPINE FUSION               80                                     $170.56        20120901
22554       NECK SPINE FUSION               81                                     $170.56        20120901
22554       NECK SPINE FUSION               82                                     $170.56        20120901
22554       NECK SPINE FUSION               AS                                     $170.56        20120901
22554       NECK SPINE FUSION                                                      $852.82        20120901
22556       THORAX SPINE FUSION             80                                     $224.12        20120901
22556       THORAX SPINE FUSION             81                                     $224.12        20120901
22556       THORAX SPINE FUSION             82                                     $224.12        20120901
22556       THORAX SPINE FUSION             AS                                     $224.12        20120901
22556       THORAX SPINE FUSION                                                  $1,120.61        20120901
22558       LUMBAR SPINE FUSION             80                                     $207.61        20120901
22558       LUMBAR SPINE FUSION             81                                     $207.61        20120901
22558       LUMBAR SPINE FUSION             82                                     $207.61        20120901
22558       LUMBAR SPINE FUSION             AS                                     $207.61        20120901
22558       LUMBAR SPINE FUSION                                                  $1,038.06        20120901
22585       ADDITIONAL SPINAL FUSION        80                                      $46.58        20120901
22585       ADDITIONAL SPINAL FUSION        81                                      $46.58        20120901
22585       ADDITIONAL SPINAL FUSION        82                                      $46.58        20120901
22585       ADDITIONAL SPINAL FUSION        AS                                      $46.58        20120901
22585       ADDITIONAL SPINAL FUSION                                               $232.89        20120901
22590       SPINE SKULL SPINAL FUSION       80                                     $209.14        20120901
22590       SPINE SKULL SPINAL FUSION       81                                     $209.14        20120901
22590       SPINE SKULL SPINAL FUSION       82                                     $209.14        20120901
22590       SPINE SKULL SPINAL FUSION       AS                                     $209.14        20120901
22590       SPINE SKULL SPINAL FUSION                                            $1,045.70        20120901
22595       NECK SPINAL FUSION              80                                     $198.80        20120901
22595       NECK SPINAL FUSION              81                                     $198.80        20120901
22595       NECK SPINAL FUSION              82                                     $198.80        20120901
22595       NECK SPINAL FUSION              AS                                     $198.80        20120901
22595       NECK SPINAL FUSION                                                     $993.97        20120901
22600       NECK SPINE FUSION               80                                     $169.75        20120901
22600       NECK SPINE FUSION               81                                     $169.75        20120901
22600       NECK SPINE FUSION               82                                     $169.75        20120901
22600       NECK SPINE FUSION               AS                                     $169.75        20120901
22600       NECK SPINE FUSION                                                      $848.74        20120901
22610       THORAX SPINE FUSION             80                                     $166.54        20120901
22610       THORAX SPINE FUSION             81                                     $166.54        20120901
22610       THORAX SPINE FUSION             82                                     $166.54        20120901
22610       THORAX SPINE FUSION             AS                                     $166.54        20120901
22610       THORAX SPINE FUSION                                                    $832.69        20120901
22612       LUMBAR SPINE FUSION             80                                     $214.59        20120901
22612       LUMBAR SPINE FUSION             81                                     $214.59        20120901



                                                 Page 35
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
22612       LUMBAR SPINE FUSION             82                                      $214.59        20120901
22612       LUMBAR SPINE FUSION             AS                                      $214.59        20120901
22612       LUMBAR SPINE FUSION                                                   $1,072.96        20120901
22614       SPINE FUSION EXTRA SEGMENT      80                                       $54.27        20120901
22614       SPINE FUSION EXTRA SEGMENT      81                                       $54.27        20120901
22614       SPINE FUSION EXTRA SEGMENT      82                                       $54.27        20120901
22614       SPINE FUSION EXTRA SEGMENT      AS                                       $54.27        20120901
22614       SPINE FUSION EXTRA SEGMENT                                              $271.36        20120901
22630       LUMBAR SPINE FUSION             80                                      $206.44        20120901
22630       LUMBAR SPINE FUSION             81                                      $206.44        20120901
22630       LUMBAR SPINE FUSION             82                                      $206.44        20120901
22630       LUMBAR SPINE FUSION             AS                                      $206.44        20120901
22630       LUMBAR SPINE FUSION                                                   $1,032.19        20120901
22632       SPINE FUSION EXTRA SEGMENT      80                                       $44.23        20120901
22632       SPINE FUSION EXTRA SEGMENT      81                                       $44.23        20120901
22632       SPINE FUSION EXTRA SEGMENT      82                                       $44.23        20120901
22632       SPINE FUSION EXTRA SEGMENT      AS                                       $44.23        20120901
22632       SPINE FUSION EXTRA SEGMENT                                              $221.17        20120901
22633       LUMBAR SPINE FUSION COMBINED    80                                      $279.21        20120901
22633       LUMBAR SPINE FUSION COMBINED    81                                      $279.21        20120901
22633       LUMBAR SPINE FUSION COMBINED    82                                      $279.21        20120901
22633       LUMBAR SPINE FUSION COMBINED    AS                                      $279.21        20120901
22633       LUMBAR SPINE FUSION COMBINED                                          $1,396.05        20120901
22634       SPINE FUSION EXTRA SEGMENT      80                                       $74.81        20120901
22634       SPINE FUSION EXTRA SEGMENT      81                                       $74.81        20120901
22634       SPINE FUSION EXTRA SEGMENT      82                                       $74.81        20120901
22634       SPINE FUSION EXTRA SEGMENT      AS                                       $74.81        20120901
22634       SPINE FUSION EXTRA SEGMENT                                              $374.05        20120901
22800       FUSION OF SPINE                 80                                      $181.57        20120901
22800       FUSION OF SPINE                 81                                      $181.57        20120901
22800       FUSION OF SPINE                 82                                      $181.57        20120901
22800       FUSION OF SPINE                 AS                                      $181.57        20120901
22800       FUSION OF SPINE                                                         $907.85        20120901
22802       FUSION OF SPINE                 80                                      $285.43        20120901
22802       FUSION OF SPINE                 81                                      $285.43        20120901
22802       FUSION OF SPINE                 82                                      $285.43        20120901
22802       FUSION OF SPINE                 AS                                      $285.43        20120901
22802       FUSION OF SPINE                                                       $1,427.13        20120901
22804       FUSION OF SPINE                 80                                      $329.25        20120901
22804       FUSION OF SPINE                 81                                      $329.25        20120901
22804       FUSION OF SPINE                 82                                      $329.25        20120901
22804       FUSION OF SPINE                 AS                                      $329.25        20120901
22804       FUSION OF SPINE                                                       $1,646.26        20120901
22808       FUSION OF SPINE                 80                                      $247.36        20120901
22808       FUSION OF SPINE                 81                                      $247.36        20120901
22808       FUSION OF SPINE                 82                                      $247.36        20120901
22808       FUSION OF SPINE                 AS                                      $247.36        20120901
22808       FUSION OF SPINE                                                       $1,236.80        20120901
22810       FUSION OF SPINE                 80                                      $276.61        20120901
22810       FUSION OF SPINE                 81                                      $276.61        20120901
22810       FUSION OF SPINE                 82                                      $276.61        20120901
22810       FUSION OF SPINE                 AS                                      $276.61        20120901
22810       FUSION OF SPINE                                                       $1,383.05        20120901
22812       FUSION OF SPINE                 80                                      $297.76        20120901
22812       FUSION OF SPINE                 81                                      $297.76        20120901
22812       FUSION OF SPINE                 82                                      $297.76        20120901
22812       FUSION OF SPINE                 AS                                      $297.76        20120901
22812       FUSION OF SPINE                                                       $1,488.80        20120901
22818       KYPHECTOMY 1-2 SEGMENTS         80                                      $294.85        20120901



                                                 Page 36
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1       Mod 2     Rate Type   Price          Effective Date
22818       KYPHECTOMY 1-2 SEGMENTS          81                                     $294.85        20120901
22818       KYPHECTOMY 1-2 SEGMENTS          82                                     $294.85        20120901
22818       KYPHECTOMY 1-2 SEGMENTS          AS                                     $294.85        20120901
22818       KYPHECTOMY 1-2 SEGMENTS                                               $1,474.27        20120901
22819       KYPHECTOMY 3 OR MORE             80                                     $363.60        20120901
22819       KYPHECTOMY 3 OR MORE             81                                     $363.60        20120901
22819       KYPHECTOMY 3 OR MORE             82                                     $363.60        20120901
22819       KYPHECTOMY 3 OR MORE             AS                                     $363.60        20120901
22819       KYPHECTOMY 3 OR MORE                                                  $1,818.00        20120901
22830       EXPLORATION OF SPINAL FUSION     80                                     $107.88        20120901
22830       EXPLORATION OF SPINAL FUSION     81                                     $107.88        20120901
22830       EXPLORATION OF SPINAL FUSION     82                                     $107.88        20120901
22830       EXPLORATION OF SPINAL FUSION     AS                                     $107.88        20120901
22830       EXPLORATION OF SPINAL FUSION                                            $539.41        20120901
22840       INSERT SPINE FIXATION DEVICE     80                                     $105.79        20120901
22840       INSERT SPINE FIXATION DEVICE     81                                     $105.79        20120901
22840       INSERT SPINE FIXATION DEVICE     82                                     $105.79        20120901
22840       INSERT SPINE FIXATION DEVICE     AS                                     $105.79        20120901
22840       INSERT SPINE FIXATION DEVICE                                            $528.96        20120901
22842       INSERT SPINE FIXATION DEVICE     80                                     $106.00        20120901
22842       INSERT SPINE FIXATION DEVICE     81                                     $106.00        20120901
22842       INSERT SPINE FIXATION DEVICE     82                                     $106.00        20120901
22842       INSERT SPINE FIXATION DEVICE     AS                                     $106.00        20120901
22842       INSERT SPINE FIXATION DEVICE                                            $529.98        20120901
22843       INSERT SPINE FIXATION DEVICE     80                                     $112.52        20120901
22843       INSERT SPINE FIXATION DEVICE     81                                     $112.52        20120901
22843       INSERT SPINE FIXATION DEVICE     82                                     $112.52        20120901
22843       INSERT SPINE FIXATION DEVICE     AS                                     $112.52        20120901
22843       INSERT SPINE FIXATION DEVICE                                            $562.60        20120901
22844       INSERT SPINE FIXATION DEVICE     80                                     $136.52        20120901
22844       INSERT SPINE FIXATION DEVICE     81                                     $136.52        20120901
22844       INSERT SPINE FIXATION DEVICE     82                                     $136.52        20120901
22844       INSERT SPINE FIXATION DEVICE     AS                                     $136.52        20120901
22844       INSERT SPINE FIXATION DEVICE                                            $682.61        20120901
22845       INSERT SPINE FIXATION DEVICE     80                                     $101.77        20120901
22845       INSERT SPINE FIXATION DEVICE     81                                     $101.77        20120901
22845       INSERT SPINE FIXATION DEVICE     82                                     $101.77        20120901
22845       INSERT SPINE FIXATION DEVICE     AS                                     $101.77        20120901
22845       INSERT SPINE FIXATION DEVICE                                            $508.84        20120901
22846       INSERT SPINE FIXATION DEVICE     80                                     $105.59        20120901
22846       INSERT SPINE FIXATION DEVICE     81                                     $105.59        20120901
22846       INSERT SPINE FIXATION DEVICE     82                                     $105.59        20120901
22846       INSERT SPINE FIXATION DEVICE     AS                                     $105.59        20120901
22846       INSERT SPINE FIXATION DEVICE                                            $527.95        20120901
22847       INSERT SPINE FIXATION DEVICE     80                                     $120.16        20120901
22847       INSERT SPINE FIXATION DEVICE     81                                     $120.16        20120901
22847       INSERT SPINE FIXATION DEVICE     82                                     $120.16        20120901
22847       INSERT SPINE FIXATION DEVICE     AS                                     $120.16        20120901
22847       INSERT SPINE FIXATION DEVICE                                            $600.82        20120901
22848       INSERT PELV FIXATION DEVICE      80                                      $49.94        20120901
22848       INSERT PELV FIXATION DEVICE      81                                      $49.94        20120901
22848       INSERT PELV FIXATION DEVICE      82                                      $49.94        20120901
22848       INSERT PELV FIXATION DEVICE      AS                                      $49.94        20120901
22848       INSERT PELV FIXATION DEVICE                                             $249.70        20120901
22849       REINSERT SPINAL FIXATION         80                                     $175.35        20120901
22849       REINSERT SPINAL FIXATION         81                                     $175.35        20120901
22849       REINSERT SPINAL FIXATION         82                                     $175.35        20120901
22849       REINSERT SPINAL FIXATION         AS                                     $175.35        20120901
22849       REINSERT SPINAL FIXATION                                                $876.77        20120901



                                               Page 37
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price         Effective Date
22850       REMOVE SPINE FIXATION DEVICE   80                                    $95.65        20120901
22850       REMOVE SPINE FIXATION DEVICE   81                                    $95.65        20120901
22850       REMOVE SPINE FIXATION DEVICE   82                                    $95.65        20120901
22850       REMOVE SPINE FIXATION DEVICE   AS                                    $95.65        20120901
22850       REMOVE SPINE FIXATION DEVICE                                        $478.26        20120901
22851       APPLY SPINE PROSTH DEVICE      80                                    $56.57        20120901
22851       APPLY SPINE PROSTH DEVICE      81                                    $56.57        20120901
22851       APPLY SPINE PROSTH DEVICE      82                                    $56.57        20120901
22851       APPLY SPINE PROSTH DEVICE      AS                                    $56.57        20120901
22851       APPLY SPINE PROSTH DEVICE                                           $282.83        20120901
22852       REMOVE SPINE FIXATION DEVICE   80                                    $91.37        20120901
22852       REMOVE SPINE FIXATION DEVICE   81                                    $91.37        20120901
22852       REMOVE SPINE FIXATION DEVICE   82                                    $91.37        20120901
22852       REMOVE SPINE FIXATION DEVICE   AS                                    $91.37        20120901
22852       REMOVE SPINE FIXATION DEVICE                                        $456.86        20120901
22855       REMOVE SPINE FIXATION DEVICE   80                                   $149.52        20120901
22855       REMOVE SPINE FIXATION DEVICE   81                                   $149.52        20120901
22855       REMOVE SPINE FIXATION DEVICE   82                                   $149.52        20120901
22855       REMOVE SPINE FIXATION DEVICE   AS                                   $149.52        20120901
22855       REMOVE SPINE FIXATION DEVICE                                        $747.58        20120901
22900       EXC ABDL TUM DEEP 5 CM         80                                    $69.82        20120901
22900       EXC ABDL TUM DEEP 5 CM         81                                    $69.82        20120901
22900       EXC ABDL TUM DEEP 5 CM         82                                    $69.82        20120901
22900       EXC ABDL TUM DEEP 5 CM         AS                                    $69.82        20120901
22900       EXC ABDL TUM DEEP 5 CM                                              $349.08        20120901
22900       EXC ABDL TUM DEEP 5 CM                              A               $749.54        20110101
22901       EXC ABDL TUM DEEP 5 CM/                                             $458.89        20120901
22902       EXC ABD LES SC 3 CM                                                 $288.94        20120901
22903       EXC ABD LES SC 3 CM/                                                $303.47        20120901
22904       RESECT ABD TUM 5 CM                                                 $719.05        20120901
22905       RESECT ABD TUM 5 CM/                                                $932.31        20120901
23000       REMOVAL OF CALCIUM DEPOSITS    80                                    $69.61        20120901
23000       REMOVAL OF CALCIUM DEPOSITS    81                                    $69.61        20120901
23000       REMOVAL OF CALCIUM DEPOSITS    82                                    $69.61        20120901
23000       REMOVAL OF CALCIUM DEPOSITS    AS                                    $69.61        20120901
23000       REMOVAL OF CALCIUM DEPOSITS                                         $348.06        20120901
23000       REMOVAL OF CALCIUM DEPOSITS                         A               $505.90        20110101
23020       RELEASE SHOULDER JOINT         80                                    $91.32        20120901
23020       RELEASE SHOULDER JOINT         81                                    $91.32        20120901
23020       RELEASE SHOULDER JOINT         82                                    $91.32        20120901
23020       RELEASE SHOULDER JOINT         AS                                    $91.32        20120901
23020       RELEASE SHOULDER JOINT                                              $456.60        20120901
23020       RELEASE SHOULDER JOINT                              A             $1,204.90        20110101
23030       DRAIN SHOULDER LESION                                               $273.40        20120901
23030       DRAIN SHOULDER LESION                               A               $530.16        20110101
23031       DRAIN SHOULDER BURSA                                                $249.19        20120901
23031       DRAIN SHOULDER BURSA                                A               $564.03        20110101
23035       DRAIN SHOULDER BONE LESION     80                                    $90.61        20120901
23035       DRAIN SHOULDER BONE LESION     81                                    $90.61        20120901
23035       DRAIN SHOULDER BONE LESION     82                                    $90.61        20120901
23035       DRAIN SHOULDER BONE LESION     AS                                    $90.61        20120901
23035       DRAIN SHOULDER BONE LESION                                          $453.03        20120901
23035       DRAIN SHOULDER BONE LESION                          A               $626.73        20110101
23040       EXPLORATORY SHOULDER SURGERY   80                                    $95.19        20120901
23040       EXPLORATORY SHOULDER SURGERY   81                                    $95.19        20120901
23040       EXPLORATORY SHOULDER SURGERY   82                                    $95.19        20120901
23040       EXPLORATORY SHOULDER SURGERY   AS                                    $95.19        20120901
23040       EXPLORATORY SHOULDER SURGERY                                        $475.97        20120901
23040       EXPLORATORY SHOULDER SURGERY                        A               $861.25        20110101



                                             Page 38
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
23044       EXPLORATORY SHOULDER SURGERY                                           $378.63        20120901
23044       EXPLORATORY SHOULDER SURGERY                          A                $884.21        20110101
23065       BIOPSY SHOULDER TISSUES                                                $140.39        20120901
23065       BIOPSY SHOULDER TISSUES                               A                 $66.78        20110101
23066       BIOPSY SHOULDER TISSUES                                                $331.75        20120901
23066       BIOPSY SHOULDER TISSUES                               A                $647.50        20110101
23071       EXC SHOULDER LES SC 3 CM/                                              $288.43        20120901
23073       EXC SHOULDER TUM DEEP 5 CM/                                            $477.50        20120901
23075       EXC SHOULDER LES SC 3 CM                                               $240.02        20120901
23075       EXC SHOULDER LES SC 3 CM                              A                $104.25        20110101
23076       EXC SHOULDER TUM DEEP 5 CM                                             $360.29        20120901
23076       EXC SHOULDER TUM DEEP 5 CM                            A                $560.76        20110101
23077       RESECT SHOULDER TUM 5 CM       80                                      $156.60        20120901
23077       RESECT SHOULDER TUM 5 CM       81                                      $156.60        20120901
23077       RESECT SHOULDER TUM 5 CM       82                                      $156.60        20120901
23077       RESECT SHOULDER TUM 5 CM       AS                                      $156.60        20120901
23077       RESECT SHOULDER TUM 5 CM                                               $783.00        20120901
23077       RESECT SHOULDER TUM 5 CM                              A                $560.76        20110101
23078       RESECT SHOULDER TUM 5 CM/                                              $970.28        20120901
23100       BIOPSY OF SHOULDER JOINT       80                                       $64.57        20120901
23100       BIOPSY OF SHOULDER JOINT       81                                       $64.57        20120901
23100       BIOPSY OF SHOULDER JOINT       82                                       $64.57        20120901
23100       BIOPSY OF SHOULDER JOINT       AS                                       $64.57        20120901
23100       BIOPSY OF SHOULDER JOINT                                               $322.83        20120901
23100       BIOPSY OF SHOULDER JOINT                              A                $614.48        20110101
23101       SHOULDER JOINT SURGERY                                                 $295.06        20120901
23101       SHOULDER JOINT SURGERY                                A                $954.05        20110101
23105       REMOVE SHOULDER JOINT LINING   80                                       $84.08        20120901
23105       REMOVE SHOULDER JOINT LINING   81                                       $84.08        20120901
23105       REMOVE SHOULDER JOINT LINING   82                                       $84.08        20120901
23105       REMOVE SHOULDER JOINT LINING   AS                                       $84.08        20120901
23105       REMOVE SHOULDER JOINT LINING                                           $420.42        20120901
23105       REMOVE SHOULDER JOINT LINING                          A                $884.21        20110101
23106       INCISION OF COLLARBONE JOINT                                           $316.97        20120901
23106       INCISION OF COLLARBONE JOINT                          A                $884.21        20110101
23107       EXPLORE TREAT SHOULDER JOINT   80                                       $87.29        20120901
23107       EXPLORE TREAT SHOULDER JOINT   81                                       $87.29        20120901
23107       EXPLORE TREAT SHOULDER JOINT   82                                       $87.29        20120901
23107       EXPLORE TREAT SHOULDER JOINT   AS                                       $87.29        20120901
23107       EXPLORE TREAT SHOULDER JOINT                                           $436.47        20120901
23107       EXPLORE TREAT SHOULDER JOINT                          A                $884.21        20110101
23120       PARTIAL REMOVAL COLLAR BONE    80                                       $76.19        20120901
23120       PARTIAL REMOVAL COLLAR BONE    81                                       $76.19        20120901
23120       PARTIAL REMOVAL COLLAR BONE    82                                       $76.19        20120901
23120       PARTIAL REMOVAL COLLAR BONE    AS                                       $76.19        20120901
23120       PARTIAL REMOVAL COLLAR BONE                                            $380.93        20120901
23120       PARTIAL REMOVAL COLLAR BONE                           A                $900.86        20110101
23125       REMOVAL OF COLLAR BONE         80                                       $93.10        20120901
23125       REMOVAL OF COLLAR BONE         81                                       $93.10        20120901
23125       REMOVAL OF COLLAR BONE         82                                       $93.10        20120901
23125       REMOVAL OF COLLAR BONE         AS                                       $93.10        20120901
23125       REMOVAL OF COLLAR BONE                                                 $465.52        20120901
23125       REMOVAL OF COLLAR BONE                                A                $900.86        20110101
23130       REMOVE SHOULDER BONE PART                                              $398.51        20120901
23130       REMOVE SHOULDER BONE PART                             A              $1,256.75        20110101
23140       REMOVAL OF BONE LESION                                                 $342.20        20120901
23140       REMOVAL OF BONE LESION                                A                $649.69        20110101
23145       REMOVAL OF BONE LESION         80                                       $91.63        20120901
23145       REMOVAL OF BONE LESION         81                                       $91.63        20120901



                                                Page 39
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price         Effective Date
23145       REMOVAL OF BONE LESION         82                                      $91.63        20120901
23145       REMOVAL OF BONE LESION         AS                                      $91.63        20120901
23145       REMOVAL OF BONE LESION                                                $458.13        20120901
23145       REMOVAL OF BONE LESION                                A               $900.86        20110101
23146       REMOVAL OF BONE LESION                                                $399.78        20120901
23146       REMOVAL OF BONE LESION                                A               $900.86        20110101
23150       REMOVAL OF HUMERUS LESION      80                                      $86.99        20120901
23150       REMOVAL OF HUMERUS LESION      81                                      $86.99        20120901
23150       REMOVAL OF HUMERUS LESION      82                                      $86.99        20120901
23150       REMOVAL OF HUMERUS LESION      AS                                      $86.99        20120901
23150       REMOVAL OF HUMERUS LESION                                             $434.94        20120901
23150       REMOVAL OF HUMERUS LESION                             A               $884.21        20110101
23155       REMOVAL OF HUMERUS LESION      80                                     $104.77        20120901
23155       REMOVAL OF HUMERUS LESION      81                                     $104.77        20120901
23155       REMOVAL OF HUMERUS LESION      82                                     $104.77        20120901
23155       REMOVAL OF HUMERUS LESION      AS                                     $104.77        20120901
23155       REMOVAL OF HUMERUS LESION                                             $523.87        20120901
23155       REMOVAL OF HUMERUS LESION                             A               $900.86        20110101
23156       REMOVAL OF HUMERUS LESION      80                                      $89.13        20120901
23156       REMOVAL OF HUMERUS LESION      81                                      $89.13        20120901
23156       REMOVAL OF HUMERUS LESION      82                                      $89.13        20120901
23156       REMOVAL OF HUMERUS LESION      AS                                      $89.13        20120901
23156       REMOVAL OF HUMERUS LESION                                             $445.65        20120901
23156       REMOVAL OF HUMERUS LESION                             A               $900.86        20110101
23170       REMOVE COLLAR BONE LESION                                             $355.45        20120901
23170       REMOVE COLLAR BONE LESION                             A               $849.00        20110101
23172       REMOVE SHOULDER BLADE LESION   80                                      $73.03        20120901
23172       REMOVE SHOULDER BLADE LESION   81                                      $73.03        20120901
23172       REMOVE SHOULDER BLADE LESION   82                                      $73.03        20120901
23172       REMOVE SHOULDER BLADE LESION   AS                                      $73.03        20120901
23172       REMOVE SHOULDER BLADE LESION                                          $365.13        20120901
23172       REMOVE SHOULDER BLADE LESION                          A               $849.00        20110101
23174       REMOVE HUMERUS LESION          80                                      $99.73        20120901
23174       REMOVE HUMERUS LESION          81                                      $99.73        20120901
23174       REMOVE HUMERUS LESION          82                                      $99.73        20120901
23174       REMOVE HUMERUS LESION          AS                                      $99.73        20120901
23174       REMOVE HUMERUS LESION                                                 $498.64        20120901
23174       REMOVE HUMERUS LESION                                 A               $849.00        20110101
23180       REMOVE COLLAR BONE LESION                                             $451.25        20120901
23180       REMOVE COLLAR BONE LESION                             A               $884.21        20110101
23182       REMOVE SHOULDER BLADE LESION   80                                      $87.55        20120901
23182       REMOVE SHOULDER BLADE LESION   81                                      $87.55        20120901
23182       REMOVE SHOULDER BLADE LESION   82                                      $87.55        20120901
23182       REMOVE SHOULDER BLADE LESION   AS                                      $87.55        20120901
23182       REMOVE SHOULDER BLADE LESION                                          $437.75        20120901
23182       REMOVE SHOULDER BLADE LESION                          A               $884.21        20110101
23184       REMOVE HUMERUS LESION          80                                      $98.20        20120901
23184       REMOVE HUMERUS LESION          81                                      $98.20        20120901
23184       REMOVE HUMERUS LESION          82                                      $98.20        20120901
23184       REMOVE HUMERUS LESION          AS                                      $98.20        20120901
23184       REMOVE HUMERUS LESION                                                 $491.00        20120901
23184       REMOVE HUMERUS LESION                                 A               $884.21        20110101
23190       PARTIAL REMOVAL OF SCAPULA     80                                      $74.15        20120901
23190       PARTIAL REMOVAL OF SCAPULA     81                                      $74.15        20120901
23190       PARTIAL REMOVAL OF SCAPULA     82                                      $74.15        20120901
23190       PARTIAL REMOVAL OF SCAPULA     AS                                      $74.15        20120901
23190       PARTIAL REMOVAL OF SCAPULA                                            $370.73        20120901
23190       PARTIAL REMOVAL OF SCAPULA                            A               $884.21        20110101
23195       REMOVAL OF HEAD OF HUMERUS     80                                      $99.68        20120901



                                                Page 40
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price         Effective Date
23195       REMOVAL OF HEAD OF HUMERUS     81                                     $99.68        20120901
23195       REMOVAL OF HEAD OF HUMERUS     82                                     $99.68        20120901
23195       REMOVAL OF HEAD OF HUMERUS     AS                                     $99.68        20120901
23195       REMOVAL OF HEAD OF HUMERUS                                           $498.39        20120901
23195       REMOVAL OF HEAD OF HUMERUS                           A               $900.86        20110101
23200       RESECT CLAVICLE TUMOR          80                                    $183.56        20120901
23200       RESECT CLAVICLE TUMOR          81                                    $183.56        20120901
23200       RESECT CLAVICLE TUMOR          82                                    $183.56        20120901
23200       RESECT CLAVICLE TUMOR          AS                                    $183.56        20120901
23200       RESECT CLAVICLE TUMOR                                                $917.79        20120901
23210       RESECT SCAPULA TUMOR           80                                    $214.59        20120901
23210       RESECT SCAPULA TUMOR           81                                    $214.59        20120901
23210       RESECT SCAPULA TUMOR           82                                    $214.59        20120901
23210       RESECT SCAPULA TUMOR           AS                                    $214.59        20120901
23210       RESECT SCAPULA TUMOR                                               $1,072.96        20120901
23220       RESECT PROX HUMERUS TUMOR      80                                    $238.19        20120901
23220       RESECT PROX HUMERUS TUMOR      81                                    $238.19        20120901
23220       RESECT PROX HUMERUS TUMOR      82                                    $238.19        20120901
23220       RESECT PROX HUMERUS TUMOR      AS                                    $238.19        20120901
23220       RESECT PROX HUMERUS TUMOR                                          $1,190.94        20120901
23330       REMOVE SHOULDER FOREIGN BODY                                         $147.02        20120901
23330       REMOVE SHOULDER FOREIGN BODY                         A               $260.88        20110101
23331       REMOVE SHOULDER FOREIGN BODY                                         $388.06        20120901
23331       REMOVE SHOULDER FOREIGN BODY                         A               $625.87        20110101
23332       REMOVE SHOULDER FOREIGN BODY   80                                    $117.51        20120901
23332       REMOVE SHOULDER FOREIGN BODY   81                                    $117.51        20120901
23332       REMOVE SHOULDER FOREIGN BODY   82                                    $117.51        20120901
23332       REMOVE SHOULDER FOREIGN BODY   AS                                    $117.51        20120901
23332       REMOVE SHOULDER FOREIGN BODY                                         $587.57        20120901
23350       INJECTION FOR SHOULDER X-RAY                                          $99.88        20120901
23395       MUSCLE TRANSFER SHOULDER/ARM   80                                    $171.94        20120901
23395       MUSCLE TRANSFER SHOULDER/ARM   81                                    $171.94        20120901
23395       MUSCLE TRANSFER SHOULDER/ARM   82                                    $171.94        20120901
23395       MUSCLE TRANSFER SHOULDER/ARM   AS                                    $171.94        20120901
23395       MUSCLE TRANSFER SHOULDER/ARM                                         $859.70        20120901
23395       MUSCLE TRANSFER SHOULDER/ARM                         A             $1,256.75        20110101
23397       MUSCLE TRANSFERS               80                                    $153.24        20120901
23397       MUSCLE TRANSFERS               81                                    $153.24        20120901
23397       MUSCLE TRANSFERS               82                                    $153.24        20120901
23397       MUSCLE TRANSFERS               AS                                    $153.24        20120901
23397       MUSCLE TRANSFERS                                                     $766.18        20120901
23397       MUSCLE TRANSFERS                                     A             $2,321.22        20110101
23400       FIXATION OF SHOULDER BLADE     80                                    $129.85        20120901
23400       FIXATION OF SHOULDER BLADE     81                                    $129.85        20120901
23400       FIXATION OF SHOULDER BLADE     82                                    $129.85        20120901
23400       FIXATION OF SHOULDER BLADE     AS                                    $129.85        20120901
23400       FIXATION OF SHOULDER BLADE                                           $649.23        20120901
23400       FIXATION OF SHOULDER BLADE                           A               $954.05        20110101
23405       INCISION OF TENDON MUSCLE      80                                     $83.47        20120901
23405       INCISION OF TENDON MUSCLE      81                                     $83.47        20120901
23405       INCISION OF TENDON MUSCLE      82                                     $83.47        20120901
23405       INCISION OF TENDON MUSCLE      AS                                     $83.47        20120901
23405       INCISION OF TENDON MUSCLE                                            $417.36        20120901
23405       INCISION OF TENDON MUSCLE                            A               $849.00        20110101
23406       INCISE TENDONS MUSCLES         80                                    $104.11        20120901
23406       INCISE TENDONS MUSCLES         81                                    $104.11        20120901
23406       INCISE TENDONS MUSCLES         82                                    $104.11        20120901
23406       INCISE TENDONS MUSCLES         AS                                    $104.11        20120901
23406       INCISE TENDONS MUSCLES                                               $520.56        20120901



                                             Page 41
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
23406       INCISE TENDONS MUSCLES                                A                $849.00        20110101
23410       REPAIR ROTATOR CUFF ACUTE      80                                      $109.82        20120901
23410       REPAIR ROTATOR CUFF ACUTE      81                                      $109.82        20120901
23410       REPAIR ROTATOR CUFF ACUTE      82                                      $109.82        20120901
23410       REPAIR ROTATOR CUFF ACUTE      AS                                      $109.82        20120901
23410       REPAIR ROTATOR CUFF ACUTE                                              $549.09        20120901
23410       REPAIR ROTATOR CUFF ACUTE                             A              $1,256.75        20110101
23412       REPAIR ROTATOR CUFF CHRONIC    80                                      $114.46        20120901
23412       REPAIR ROTATOR CUFF CHRONIC    81                                      $114.46        20120901
23412       REPAIR ROTATOR CUFF CHRONIC    82                                      $114.46        20120901
23412       REPAIR ROTATOR CUFF CHRONIC    AS                                      $114.46        20120901
23412       REPAIR ROTATOR CUFF CHRONIC                                            $572.28        20120901
23412       REPAIR ROTATOR CUFF CHRONIC                           A              $1,309.94        20110101
23415       RELEASE OF SHOULDER LIGAMENT                                           $458.89        20120901
23415       RELEASE OF SHOULDER LIGAMENT                          A              $1,256.75        20110101
23420       REPAIR OF SHOULDER             80                                      $129.64        20120901
23420       REPAIR OF SHOULDER             81                                      $129.64        20120901
23420       REPAIR OF SHOULDER             82                                      $129.64        20120901
23420       REPAIR OF SHOULDER             AS                                      $129.64        20120901
23420       REPAIR OF SHOULDER                                                     $648.21        20120901
23420       REPAIR OF SHOULDER                                    A              $1,309.94        20110101
23430       REPAIR BICEPS TENDON           80                                       $98.05        20120901
23430       REPAIR BICEPS TENDON           81                                       $98.05        20120901
23430       REPAIR BICEPS TENDON           82                                       $98.05        20120901
23430       REPAIR BICEPS TENDON           AS                                       $98.05        20120901
23430       REPAIR BICEPS TENDON                                                   $490.24        20120901
23430       REPAIR BICEPS TENDON                                  A              $1,240.11        20110101
23440       REMOVE/TRANSPLANT TENDON       80                                      $101.00        20120901
23440       REMOVE/TRANSPLANT TENDON       81                                      $101.00        20120901
23440       REMOVE/TRANSPLANT TENDON       82                                      $101.00        20120901
23440       REMOVE/TRANSPLANT TENDON       AS                                      $101.00        20120901
23440       REMOVE/TRANSPLANT TENDON                                               $505.01        20120901
23440       REMOVE/TRANSPLANT TENDON                              A              $1,240.11        20110101
23450       REPAIR SHOULDER CAPSULE        80                                      $126.89        20120901
23450       REPAIR SHOULDER CAPSULE        81                                      $126.89        20120901
23450       REPAIR SHOULDER CAPSULE        82                                      $126.89        20120901
23450       REPAIR SHOULDER CAPSULE        AS                                      $126.89        20120901
23450       REPAIR SHOULDER CAPSULE                                                $634.45        20120901
23450       REPAIR SHOULDER CAPSULE                               A              $2,268.02        20110101
23455       REPAIR SHOULDER CAPSULE        80                                      $134.99        20120901
23455       REPAIR SHOULDER CAPSULE        81                                      $134.99        20120901
23455       REPAIR SHOULDER CAPSULE        82                                      $134.99        20120901
23455       REPAIR SHOULDER CAPSULE        AS                                      $134.99        20120901
23455       REPAIR SHOULDER CAPSULE                                                $674.97        20120901
23455       REPAIR SHOULDER CAPSULE                               A              $2,321.22        20110101
23460       REPAIR SHOULDER CAPSULE        80                                      $146.41        20120901
23460       REPAIR SHOULDER CAPSULE        81                                      $146.41        20120901
23460       REPAIR SHOULDER CAPSULE        82                                      $146.41        20120901
23460       REPAIR SHOULDER CAPSULE        AS                                      $146.41        20120901
23460       REPAIR SHOULDER CAPSULE                                                $732.04        20120901
23460       REPAIR SHOULDER CAPSULE                               A              $2,268.02        20110101
23462       REPAIR SHOULDER CAPSULE        80                                      $143.86        20120901
23462       REPAIR SHOULDER CAPSULE        81                                      $143.86        20120901
23462       REPAIR SHOULDER CAPSULE        82                                      $143.86        20120901
23462       REPAIR SHOULDER CAPSULE        AS                                      $143.86        20120901
23462       REPAIR SHOULDER CAPSULE                                                $719.30        20120901
23462       REPAIR SHOULDER CAPSULE                               A              $1,309.94        20110101
23465       REPAIR SHOULDER CAPSULE        80                                      $149.77        20120901
23465       REPAIR SHOULDER CAPSULE        81                                      $149.77        20120901



                                                Page 42
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
23465       REPAIR SHOULDER CAPSULE        82                                     $149.77        20120901
23465       REPAIR SHOULDER CAPSULE        AS                                     $149.77        20120901
23465       REPAIR SHOULDER CAPSULE                                               $748.86        20120901
23465       REPAIR SHOULDER CAPSULE                              A              $2,268.02        20110101
23466       REPAIR SHOULDER CAPSULE        80                                     $149.41        20120901
23466       REPAIR SHOULDER CAPSULE        81                                     $149.41        20120901
23466       REPAIR SHOULDER CAPSULE        82                                     $149.41        20120901
23466       REPAIR SHOULDER CAPSULE        AS                                     $149.41        20120901
23466       REPAIR SHOULDER CAPSULE                                               $747.07        20120901
23466       REPAIR SHOULDER CAPSULE                              A              $1,309.94        20110101
23470       RECONSTRUCT SHOULDER JOINT     80                                     $163.02        20120901
23470       RECONSTRUCT SHOULDER JOINT     81                                     $163.02        20120901
23470       RECONSTRUCT SHOULDER JOINT     82                                     $163.02        20120901
23470       RECONSTRUCT SHOULDER JOINT     AS                                     $163.02        20120901
23470       RECONSTRUCT SHOULDER JOINT                                            $815.11        20120901
23472       RECONSTRUCT SHOULDER JOINT     80                                     $202.31        20120901
23472       RECONSTRUCT SHOULDER JOINT     81                                     $202.31        20120901
23472       RECONSTRUCT SHOULDER JOINT     82                                     $202.31        20120901
23472       RECONSTRUCT SHOULDER JOINT     AS                                     $202.31        20120901
23472       RECONSTRUCT SHOULDER JOINT                                          $1,011.56        20120901
23480       REVISION OF COLLAR BONE                                               $545.53        20120901
23480       REVISION OF COLLAR BONE                              A              $1,240.11        20110101
23485       REVISION OF COLLAR BONE        80                                     $128.73        20120901
23485       REVISION OF COLLAR BONE        81                                     $128.73        20120901
23485       REVISION OF COLLAR BONE        82                                     $128.73        20120901
23485       REVISION OF COLLAR BONE        AS                                     $128.73        20120901
23485       REVISION OF COLLAR BONE                                               $643.62        20120901
23485       REVISION OF COLLAR BONE                              A              $2,321.22        20110101
23490       REINFORCE CLAVICLE             80                                     $113.79        20120901
23490       REINFORCE CLAVICLE             81                                     $113.79        20120901
23490       REINFORCE CLAVICLE             82                                     $113.79        20120901
23490       REINFORCE CLAVICLE             AS                                     $113.79        20120901
23490       REINFORCE CLAVICLE                                                    $568.97        20120901
23490       REINFORCE CLAVICLE                                   A              $1,217.14        20110101
23491       REINFORCE SHOULDER BONES       80                                     $135.71        20120901
23491       REINFORCE SHOULDER BONES       81                                     $135.71        20120901
23491       REINFORCE SHOULDER BONES       82                                     $135.71        20120901
23491       REINFORCE SHOULDER BONES       AS                                     $135.71        20120901
23491       REINFORCE SHOULDER BONES                                              $678.53        20120901
23491       REINFORCE SHOULDER BONES                             A              $2,228.42        20110101
23500       TREAT CLAVICLE FRACTURE                                               $136.32        20120901
23500       TREAT CLAVICLE FRACTURE                              A                 $59.66        20110101
23505       TREAT CLAVICLE FRACTURE                                               $221.93        20120901
23505       TREAT CLAVICLE FRACTURE                              A                $462.00        20110101
23515       TREAT CLAVICLE FRACTURE        80                                      $94.79        20120901
23515       TREAT CLAVICLE FRACTURE        81                                      $94.79        20120901
23515       TREAT CLAVICLE FRACTURE        82                                      $94.79        20120901
23515       TREAT CLAVICLE FRACTURE        AS                                      $94.79        20120901
23515       TREAT CLAVICLE FRACTURE                                               $473.93        20120901
23515       TREAT CLAVICLE FRACTURE                              A              $1,671.34        20110101
23520       TREAT CLAVICLE DISLOCATION                                            $141.67        20120901
23520       TREAT CLAVICLE DISLOCATION                           A                $135.07        20110101
23525       TREAT CLAVICLE DISLOCATION                                            $226.01        20120901
23525       TREAT CLAVICLE DISLOCATION                           A                $135.07        20110101
23530       TREAT CLAVICLE DISLOCATION     80                                      $72.41        20120901
23530       TREAT CLAVICLE DISLOCATION     81                                      $72.41        20120901
23530       TREAT CLAVICLE DISLOCATION     82                                      $72.41        20120901
23530       TREAT CLAVICLE DISLOCATION     AS                                      $72.41        20120901
23530       TREAT CLAVICLE DISLOCATION                                            $362.07        20120901



                                             Page 43
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
23530       TREAT CLAVICLE DISLOCATION                            A              $1,190.44        20110101
23532       TREAT CLAVICLE DISLOCATION      80                                      $81.89        20120901
23532       TREAT CLAVICLE DISLOCATION      81                                      $81.89        20120901
23532       TREAT CLAVICLE DISLOCATION      82                                      $81.89        20120901
23532       TREAT CLAVICLE DISLOCATION      AS                                      $81.89        20120901
23532       TREAT CLAVICLE DISLOCATION                                             $409.46        20120901
23532       TREAT CLAVICLE DISLOCATION                            A                $741.74        20110101
23540       TREAT CLAVICLE DISLOCATION                                             $139.63        20120901
23540       TREAT CLAVICLE DISLOCATION                            A                 $59.66        20110101
23545       TREAT CLAVICLE DISLOCATION                                             $202.82        20120901
23545       TREAT CLAVICLE DISLOCATION                            A                $135.07        20110101
23550       TREAT CLAVICLE DISLOCATION      80                                      $75.47        20120901
23550       TREAT CLAVICLE DISLOCATION      81                                      $75.47        20120901
23550       TREAT CLAVICLE DISLOCATION      82                                      $75.47        20120901
23550       TREAT CLAVICLE DISLOCATION      AS                                      $75.47        20120901
23550       TREAT CLAVICLE DISLOCATION                                             $377.36        20120901
23550       TREAT CLAVICLE DISLOCATION                            A              $1,190.44        20110101
23552       TREAT CLAVICLE DISLOCATION      80                                      $86.94        20120901
23552       TREAT CLAVICLE DISLOCATION      81                                      $86.94        20120901
23552       TREAT CLAVICLE DISLOCATION      82                                      $86.94        20120901
23552       TREAT CLAVICLE DISLOCATION      AS                                      $86.94        20120901
23552       TREAT CLAVICLE DISLOCATION                                             $434.69        20120901
23552       TREAT CLAVICLE DISLOCATION                            A              $1,213.40        20110101
23570       TREAT SHOULDER BLADE FX                                                $144.73        20120901
23570       TREAT SHOULDER BLADE FX                               A                 $59.66        20110101
23575       TREAT SHOULDER BLADE FX                                                $249.45        20120901
23575       TREAT SHOULDER BLADE FX                               A                $135.07        20110101
23585       TREAT SCAPULA FRACTURE          80                                     $129.54        20120901
23585       TREAT SCAPULA FRACTURE          81                                     $129.54        20120901
23585       TREAT SCAPULA FRACTURE          82                                     $129.54        20120901
23585       TREAT SCAPULA FRACTURE          AS                                     $129.54        20120901
23585       TREAT SCAPULA FRACTURE                                                 $647.70        20120901
23585       TREAT SCAPULA FRACTURE                                A              $1,671.34        20110101
23600       TREAT HUMERUS FRACTURE                                                 $202.57        20120901
23600       TREAT HUMERUS FRACTURE                                A                 $53.12        20110101
23605       TREAT HUMERUS FRACTURE                                                 $296.84        20120901
23615       TREAT HUMERUS FRACTURE          80                                     $117.16        20120901
23615       TREAT HUMERUS FRACTURE          81                                     $117.16        20120901
23615       TREAT HUMERUS FRACTURE          82                                     $117.16        20120901
23615       TREAT HUMERUS FRACTURE          AS                                     $117.16        20120901
23615       TREAT HUMERUS FRACTURE                                                 $585.79        20120901
23615       TREAT HUMERUS FRACTURE                                A              $1,694.30        20110101
23616       TREAT HUMERUS FRACTURE          80                                     $169.03        20120901
23616       TREAT HUMERUS FRACTURE          81                                     $169.03        20120901
23616       TREAT HUMERUS FRACTURE          82                                     $169.03        20120901
23616       TREAT HUMERUS FRACTURE          AS                                     $169.03        20120901
23616       TREAT HUMERUS FRACTURE                                                 $845.17        20120901
23616       TREAT HUMERUS FRACTURE                                A              $1,694.30        20110101
23620       TREAT HUMERUS FRACTURE                                                 $167.15        20120901
23625       TREAT HUMERUS FRACTURE                                                 $241.30        20120901
23625       TREAT HUMERUS FRACTURE                                A                $462.00        20110101
23630       TREAT HUMERUS FRACTURE          80                                     $101.72        20120901
23630       TREAT HUMERUS FRACTURE          81                                     $101.72        20120901
23630       TREAT HUMERUS FRACTURE          82                                     $101.72        20120901
23630       TREAT HUMERUS FRACTURE          AS                                     $101.72        20120901
23630       TREAT HUMERUS FRACTURE                                                 $508.58        20120901
23630       TREAT HUMERUS FRACTURE                                A              $1,710.95        20110101
23650       TREAT SHOULDER DISLOCATION                                             $191.35        20120901
23650       TREAT SHOULDER DISLOCATION                            A                 $59.66        20110101



                                              Page 44
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
23655       TREAT SHOULDER DISLOCATION                                             $251.49        20120901
23655       TREAT SHOULDER DISLOCATION                            A                $431.28        20110101
23660       TREAT SHOULDER DISLOCATION     80                                       $76.64        20120901
23660       TREAT SHOULDER DISLOCATION     81                                       $76.64        20120901
23660       TREAT SHOULDER DISLOCATION     82                                       $76.64        20120901
23660       TREAT SHOULDER DISLOCATION     AS                                       $76.64        20120901
23660       TREAT SHOULDER DISLOCATION                                             $383.22        20120901
23660       TREAT SHOULDER DISLOCATION                            A              $1,190.44        20110101
23665       TREAT DISLOCATION/FRACTURE                                             $269.58        20120901
23665       TREAT DISLOCATION/FRACTURE                            A                $135.07        20110101
23670       TREAT DISLOCATION/FRACTURE     80                                      $114.56        20120901
23670       TREAT DISLOCATION/FRACTURE     81                                      $114.56        20120901
23670       TREAT DISLOCATION/FRACTURE     82                                      $114.56        20120901
23670       TREAT DISLOCATION/FRACTURE     AS                                      $114.56        20120901
23670       TREAT DISLOCATION/FRACTURE                                             $572.79        20120901
23670       TREAT DISLOCATION/FRACTURE                            A              $1,671.34        20110101
23675       TREAT DISLOCATION/FRACTURE                                             $350.10        20120901
23675       TREAT DISLOCATION/FRACTURE                            A                 $59.66        20110101
23680       TREAT DISLOCATION/FRACTURE     80                                      $122.51        20120901
23680       TREAT DISLOCATION/FRACTURE     81                                      $122.51        20120901
23680       TREAT DISLOCATION/FRACTURE     82                                      $122.51        20120901
23680       TREAT DISLOCATION/FRACTURE     AS                                      $122.51        20120901
23680       TREAT DISLOCATION/FRACTURE                                             $612.54        20120901
23680       TREAT DISLOCATION/FRACTURE                            A              $1,190.44        20110101
23700       FIXATION OF SHOULDER                                                   $128.16        20120901
23700       FIXATION OF SHOULDER                                  A                $431.28        20110101
23800       FUSION OF SHOULDER JOINT       80                                      $137.08        20120901
23800       FUSION OF SHOULDER JOINT       81                                      $137.08        20120901
23800       FUSION OF SHOULDER JOINT       82                                      $137.08        20120901
23800       FUSION OF SHOULDER JOINT       AS                                      $137.08        20120901
23800       FUSION OF SHOULDER JOINT                                               $685.41        20120901
23800       FUSION OF SHOULDER JOINT                              A              $2,251.38        20110101
23802       FUSION OF SHOULDER JOINT       80                                      $168.68        20120901
23802       FUSION OF SHOULDER JOINT       81                                      $168.68        20120901
23802       FUSION OF SHOULDER JOINT       82                                      $168.68        20120901
23802       FUSION OF SHOULDER JOINT       AS                                      $168.68        20120901
23802       FUSION OF SHOULDER JOINT                                               $843.39        20120901
23802       FUSION OF SHOULDER JOINT                              A              $1,309.94        20110101
23900       AMPUTATION OF ARM GIRDLE       80                                      $180.30        20120901
23900       AMPUTATION OF ARM GIRDLE       81                                      $180.30        20120901
23900       AMPUTATION OF ARM GIRDLE       82                                      $180.30        20120901
23900       AMPUTATION OF ARM GIRDLE       AS                                      $180.30        20120901
23900       AMPUTATION OF ARM GIRDLE                                               $901.48        20120901
23920       AMPUTATION AT SHOULDER JOINT   80                                      $146.20        20120901
23920       AMPUTATION AT SHOULDER JOINT   81                                      $146.20        20120901
23920       AMPUTATION AT SHOULDER JOINT   82                                      $146.20        20120901
23920       AMPUTATION AT SHOULDER JOINT   AS                                      $146.20        20120901
23920       AMPUTATION AT SHOULDER JOINT                                           $731.02        20120901
23921       AMPUTATION FOLLOW-UP SURGERY                                           $272.89        20120901
23921       AMPUTATION FOLLOW-UP SURGERY                          A                $447.74        20110101
23930       DRAINAGE OF ARM LESION                                                 $227.79        20120901
23930       DRAINAGE OF ARM LESION                                A                $530.16        20110101
23931       DRAINAGE OF ARM BURSA                                                  $176.58        20120901
23935       DRAIN ARM/ELBOW BONE LESION                                            $326.91        20120901
23935       DRAIN ARM/ELBOW BONE LESION                           A                $614.48        20110101
24000       EXPLORATORY ELBOW SURGERY                                              $311.11        20120901
24000       EXPLORATORY ELBOW SURGERY                             A                $884.21        20110101
24006       RELEASE ELBOW JOINT            80                                       $94.07        20120901
24006       RELEASE ELBOW JOINT            81                                       $94.07        20120901



                                                Page 45
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price         Effective Date
24006       RELEASE ELBOW JOINT             82                                      $94.07        20120901
24006       RELEASE ELBOW JOINT             AS                                      $94.07        20120901
24006       RELEASE ELBOW JOINT                                                    $470.36        20120901
24006       RELEASE ELBOW JOINT                                    A               $884.21        20110101
24065       BIOPSY ARM/ELBOW SOFT TISSUE                                           $163.58        20120901
24066       BIOPSY ARM/ELBOW SOFT TISSUE                                           $381.69        20120901
24066       BIOPSY ARM/ELBOW SOFT TISSUE                           A               $505.90        20110101
24071       EXC ARM/ELBOW LES SC 3 CM/                                             $280.03        20120901
24073       EX ARM/ELBOW TUM DEEP 5 CM/                                            $480.04        20120901
24075       EXC ARM/ELBOW LES SC 3 CM                                              $311.88        20120901
24075       EXC ARM/ELBOW LES SC 3 CM                              A               $168.06        20110101
24076       EX ARM/ELBOW TUM DEEP 5 CM                                             $347.04        20120901
24076       EX ARM/ELBOW TUM DEEP 5 CM                             A               $560.76        20110101
24077       RESECT ARM/ELBOW TUM 5 CM                                              $665.79        20120901
24077       RESECT ARM/ELBOW TUM 5 CM                              A               $560.76        20110101
24079       RESECT ARM/ELBOW TUM 5 CM/                                             $894.35        20120901
24100       BIOPSY ELBOW JOINT LINING       80                                      $53.41        20120901
24100       BIOPSY ELBOW JOINT LINING       81                                      $53.41        20120901
24100       BIOPSY ELBOW JOINT LINING       82                                      $53.41        20120901
24100       BIOPSY ELBOW JOINT LINING       AS                                      $53.41        20120901
24100       BIOPSY ELBOW JOINT LINING                                              $267.03        20120901
24100       BIOPSY ELBOW JOINT LINING                              A               $592.86        20110101
24101       EXPLORE/TREAT ELBOW JOINT       80                                      $65.33        20120901
24101       EXPLORE/TREAT ELBOW JOINT       81                                      $65.33        20120901
24101       EXPLORE/TREAT ELBOW JOINT       82                                      $65.33        20120901
24101       EXPLORE/TREAT ELBOW JOINT       AS                                      $65.33        20120901
24101       EXPLORE/TREAT ELBOW JOINT                                              $326.65        20120901
24101       EXPLORE/TREAT ELBOW JOINT                              A               $884.21        20110101
24102       REMOVE ELBOW JOINT LINING       80                                      $81.03        20120901
24102       REMOVE ELBOW JOINT LINING       81                                      $81.03        20120901
24102       REMOVE ELBOW JOINT LINING       82                                      $81.03        20120901
24102       REMOVE ELBOW JOINT LINING       AS                                      $81.03        20120901
24102       REMOVE ELBOW JOINT LINING                                              $405.13        20120901
24102       REMOVE ELBOW JOINT LINING                              A               $884.21        20110101
24105       REMOVAL OF ELBOW BURSA                                                 $221.17        20120901
24105       REMOVAL OF ELBOW BURSA                                 A               $626.73        20110101
24110       REMOVE HUMERUS LESION                                                  $383.98        20120901
24110       REMOVE HUMERUS LESION                                  A               $614.48        20110101
24115       REMOVE/GRAFT BONE LESION        80                                      $95.35        20120901
24115       REMOVE/GRAFT BONE LESION        81                                      $95.35        20120901
24115       REMOVE/GRAFT BONE LESION        82                                      $95.35        20120901
24115       REMOVE/GRAFT BONE LESION        AS                                      $95.35        20120901
24115       REMOVE/GRAFT BONE LESION                                               $476.73        20120901
24115       REMOVE/GRAFT BONE LESION                               A               $861.25        20110101
24116       REMOVE/GRAFT BONE LESION        80                                     $114.71        20120901
24116       REMOVE/GRAFT BONE LESION        81                                     $114.71        20120901
24116       REMOVE/GRAFT BONE LESION        82                                     $114.71        20120901
24116       REMOVE/GRAFT BONE LESION        AS                                     $114.71        20120901
24116       REMOVE/GRAFT BONE LESION                                               $573.55        20120901
24116       REMOVE/GRAFT BONE LESION                               A               $861.25        20110101
24120       REMOVE ELBOW LESION                                                    $343.73        20120901
24120       REMOVE ELBOW LESION                                    A               $626.73        20110101
24125       REMOVE/GRAFT BONE LESION        80                                      $80.67        20120901
24125       REMOVE/GRAFT BONE LESION        81                                      $80.67        20120901
24125       REMOVE/GRAFT BONE LESION        82                                      $80.67        20120901
24125       REMOVE/GRAFT BONE LESION        AS                                      $80.67        20120901
24125       REMOVE/GRAFT BONE LESION                                               $403.35        20120901
24125       REMOVE/GRAFT BONE LESION                               A               $861.25        20110101
24126       REMOVE/GRAFT BONE LESION        80                                      $85.21        20120901



                                                 Page 46
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price         Effective Date
24126       REMOVE/GRAFT BONE LESION       81                                     $85.21        20120901
24126       REMOVE/GRAFT BONE LESION       82                                     $85.21        20120901
24126       REMOVE/GRAFT BONE LESION       AS                                     $85.21        20120901
24126       REMOVE/GRAFT BONE LESION                                             $426.03        20120901
24126       REMOVE/GRAFT BONE LESION                             A               $861.25        20110101
24130       REMOVAL OF HEAD OF RADIUS                                            $331.49        20120901
24130       REMOVAL OF HEAD OF RADIUS                            A               $861.25        20110101
24134       REMOVAL OF ARM BONE LESION     80                                     $99.47        20120901
24134       REMOVAL OF ARM BONE LESION     81                                     $99.47        20120901
24134       REMOVAL OF ARM BONE LESION     82                                     $99.47        20120901
24134       REMOVAL OF ARM BONE LESION     AS                                     $99.47        20120901
24134       REMOVAL OF ARM BONE LESION                                           $497.37        20120901
24134       REMOVAL OF ARM BONE LESION                           A               $849.00        20110101
24136       REMOVE RADIUS BONE LESION                                            $399.78        20120901
24136       REMOVE RADIUS BONE LESION                            A               $849.00        20110101
24138       REMOVE ELBOW BONE LESION       80                                     $87.70        20120901
24138       REMOVE ELBOW BONE LESION       81                                     $87.70        20120901
24138       REMOVE ELBOW BONE LESION       82                                     $87.70        20120901
24138       REMOVE ELBOW BONE LESION       AS                                     $87.70        20120901
24138       REMOVE ELBOW BONE LESION                                             $438.51        20120901
24138       REMOVE ELBOW BONE LESION                             A               $849.00        20110101
24140       PARTIAL REMOVAL OF ARM BONE    80                                     $94.33        20120901
24140       PARTIAL REMOVAL OF ARM BONE    81                                     $94.33        20120901
24140       PARTIAL REMOVAL OF ARM BONE    82                                     $94.33        20120901
24140       PARTIAL REMOVAL OF ARM BONE    AS                                     $94.33        20120901
24140       PARTIAL REMOVAL OF ARM BONE                                          $471.63        20120901
24140       PARTIAL REMOVAL OF ARM BONE                          A               $861.25        20110101
24145       PARTIAL REMOVAL OF RADIUS                                            $396.21        20120901
24145       PARTIAL REMOVAL OF RADIUS                            A               $861.25        20110101
24147       PARTIAL REMOVAL OF ELBOW                                             $411.76        20120901
24147       PARTIAL REMOVAL OF ELBOW                             A               $849.00        20110101
24149       RADICAL RESECTION OF ELBOW     80                                    $154.46        20120901
24149       RADICAL RESECTION OF ELBOW     81                                    $154.46        20120901
24149       RADICAL RESECTION OF ELBOW     82                                    $154.46        20120901
24149       RADICAL RESECTION OF ELBOW     AS                                    $154.46        20120901
24150       RESECT DISTAL HUMERUS TUMOR    80                                    $192.22        20120901
24150       RESECT DISTAL HUMERUS TUMOR    81                                    $192.22        20120901
24150       RESECT DISTAL HUMERUS TUMOR    82                                    $192.22        20120901
24150       RESECT DISTAL HUMERUS TUMOR    AS                                    $192.22        20120901
24150       RESECT DISTAL HUMERUS TUMOR                                          $961.11        20120901
24152       RESECT RADIUS TUMOR            80                                    $161.90        20120901
24152       RESECT RADIUS TUMOR            81                                    $161.90        20120901
24152       RESECT RADIUS TUMOR            82                                    $161.90        20120901
24152       RESECT RADIUS TUMOR            AS                                    $161.90        20120901
24152       RESECT RADIUS TUMOR                                                  $809.50        20120901
24152       RESECT RADIUS TUMOR                                  A             $1,492.74        20110101
24155       REMOVAL OF ELBOW JOINT         80                                    $113.13        20120901
24155       REMOVAL OF ELBOW JOINT         81                                    $113.13        20120901
24155       REMOVAL OF ELBOW JOINT         82                                    $113.13        20120901
24155       REMOVAL OF ELBOW JOINT         AS                                    $113.13        20120901
24155       REMOVAL OF ELBOW JOINT                                               $565.66        20120901
24155       REMOVAL OF ELBOW JOINT                               A             $1,217.14        20110101
24160       REMOVE ELBOW JOINT IMPLANT                                           $398.00        20120901
24160       REMOVE ELBOW JOINT IMPLANT                           A               $849.00        20110101
24164       REMOVE RADIUS HEAD IMPLANT                                           $326.40        20120901
24164       REMOVE RADIUS HEAD IMPLANT                           A               $861.25        20110101
24200       REMOVAL OF ARM FOREIGN BODY                                          $128.16        20120901
24201       REMOVAL OF ARM FOREIGN BODY                                          $354.43        20120901
24201       REMOVAL OF ARM FOREIGN BODY                          A               $505.90        20110101



                                             Page 47
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
24220       INJECTION FOR ELBOW X-RAY                                             $110.07        20120901
24300       MANIPULATE ELBOW W/ANESTH                                             $257.35        20120901
24301       MUSCLE/TENDON TRANSFER         80                                      $99.83        20120901
24301       MUSCLE/TENDON TRANSFER         81                                      $99.83        20120901
24301       MUSCLE/TENDON TRANSFER         82                                      $99.83        20120901
24301       MUSCLE/TENDON TRANSFER         AS                                      $99.83        20120901
24301       MUSCLE/TENDON TRANSFER                                                $499.15        20120901
24301       MUSCLE/TENDON TRANSFER                               A                $884.21        20110101
24305       ARM TENDON LENGTHENING                                                $380.67        20120901
24305       ARM TENDON LENGTHENING                               A                $884.21        20110101
24310       REVISION OF ARM TENDON                                                $312.89        20120901
24310       REVISION OF ARM TENDON                               A                $626.73        20110101
24320       REPAIR OF ARM TENDON           80                                     $103.14        20120901
24320       REPAIR OF ARM TENDON           81                                     $103.14        20120901
24320       REPAIR OF ARM TENDON           82                                     $103.14        20120901
24320       REPAIR OF ARM TENDON           AS                                     $103.14        20120901
24320       REPAIR OF ARM TENDON                                                  $515.72        20120901
24320       REPAIR OF ARM TENDON                                 A              $1,217.14        20110101
24330       REVISION OF ARM MUSCLES        80                                      $94.89        20120901
24330       REVISION OF ARM MUSCLES        81                                      $94.89        20120901
24330       REVISION OF ARM MUSCLES        82                                      $94.89        20120901
24330       REVISION OF ARM MUSCLES        AS                                      $94.89        20120901
24330       REVISION OF ARM MUSCLES                                               $474.44        20120901
24330       REVISION OF ARM MUSCLES                              A              $2,228.42        20110101
24331       REVISION OF ARM MUSCLES        80                                     $104.82        20120901
24331       REVISION OF ARM MUSCLES        81                                     $104.82        20120901
24331       REVISION OF ARM MUSCLES        82                                     $104.82        20120901
24331       REVISION OF ARM MUSCLES        AS                                     $104.82        20120901
24331       REVISION OF ARM MUSCLES                                               $524.12        20120901
24331       REVISION OF ARM MUSCLES                              A              $1,217.14        20110101
24332       TENOLYSIS TRICEPS                                                     $400.29        20120901
24340       REPAIR OF BICEPS TENDON        80                                      $80.82        20120901
24340       REPAIR OF BICEPS TENDON        81                                      $80.82        20120901
24340       REPAIR OF BICEPS TENDON        82                                      $80.82        20120901
24340       REPAIR OF BICEPS TENDON        AS                                      $80.82        20120901
24340       REPAIR OF BICEPS TENDON                                               $404.11        20120901
24340       REPAIR OF BICEPS TENDON                              A              $1,217.14        20110101
24341       REPAIR ARM TENDON/MUSCLE       80                                      $96.98        20120901
24341       REPAIR ARM TENDON/MUSCLE       81                                      $96.98        20120901
24341       REPAIR ARM TENDON/MUSCLE       82                                      $96.98        20120901
24341       REPAIR ARM TENDON/MUSCLE       AS                                      $96.98        20120901
24341       REPAIR ARM TENDON/MUSCLE                                              $484.88        20120901
24341       REPAIR ARM TENDON/MUSCLE                             A              $1,217.14        20110101
24342       REPAIR OF RUPTURED TENDON      80                                     $103.70        20120901
24342       REPAIR OF RUPTURED TENDON      81                                     $103.70        20120901
24342       REPAIR OF RUPTURED TENDON      82                                     $103.70        20120901
24342       REPAIR OF RUPTURED TENDON      AS                                     $103.70        20120901
24342       REPAIR OF RUPTURED TENDON                                             $518.52        20120901
24342       REPAIR OF RUPTURED TENDON                            A              $1,217.14        20110101
24343       REPR ELBOW LAT LIGMNT W/TISS                                          $463.74        20120901
24345       REPR ELBW MED LIGMNT W/TISSU                                          $460.68        20120901
24345       REPR ELBW MED LIGMNT W/TISSU                         A                $849.00        20110101
24346       RECONSTRUCT ELBOW MED LIGMNT                                          $728.22        20120901
24360       RECONSTRUCT ELBOW JOINT        80                                     $119.81        20120901
24360       RECONSTRUCT ELBOW JOINT        81                                     $119.81        20120901
24360       RECONSTRUCT ELBOW JOINT        82                                     $119.81        20120901
24360       RECONSTRUCT ELBOW JOINT        AS                                     $119.81        20120901
24360       RECONSTRUCT ELBOW JOINT                                               $599.03        20120901
24360       RECONSTRUCT ELBOW JOINT                              A              $1,095.93        20110101



                                             Page 48
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
24361       RECONSTRUCT ELBOW JOINT        80                                     $134.79        20120901
24361       RECONSTRUCT ELBOW JOINT        81                                     $134.79        20120901
24361       RECONSTRUCT ELBOW JOINT        82                                     $134.79        20120901
24361       RECONSTRUCT ELBOW JOINT        AS                                     $134.79        20120901
24361       RECONSTRUCT ELBOW JOINT                                               $673.95        20120901
24361       RECONSTRUCT ELBOW JOINT                              A              $5,034.78        20110101
24362       RECONSTRUCT ELBOW JOINT        80                                     $141.77        20120901
24362       RECONSTRUCT ELBOW JOINT        81                                     $141.77        20120901
24362       RECONSTRUCT ELBOW JOINT        82                                     $141.77        20120901
24362       RECONSTRUCT ELBOW JOINT        AS                                     $141.77        20120901
24362       RECONSTRUCT ELBOW JOINT                                               $708.85        20120901
24362       RECONSTRUCT ELBOW JOINT                              A              $1,533.29        20110101
24363       REPLACE ELBOW JOINT            80                                     $201.09        20120901
24363       REPLACE ELBOW JOINT            81                                     $201.09        20120901
24363       REPLACE ELBOW JOINT            82                                     $201.09        20120901
24363       REPLACE ELBOW JOINT            AS                                     $201.09        20120901
24363       REPLACE ELBOW JOINT                                                 $1,005.44        20120901
24363       REPLACE ELBOW JOINT                                  A              $5,087.98        20110101
24365       RECONSTRUCT HEAD OF RADIUS     80                                      $84.54        20120901
24365       RECONSTRUCT HEAD OF RADIUS     81                                      $84.54        20120901
24365       RECONSTRUCT HEAD OF RADIUS     82                                      $84.54        20120901
24365       RECONSTRUCT HEAD OF RADIUS     AS                                      $84.54        20120901
24365       RECONSTRUCT HEAD OF RADIUS                                            $422.71        20120901
24365       RECONSTRUCT HEAD OF RADIUS                           A              $1,095.93        20110101
24366       RECONSTRUCT HEAD OF RADIUS     80                                      $90.40        20120901
24366       RECONSTRUCT HEAD OF RADIUS     81                                      $90.40        20120901
24366       RECONSTRUCT HEAD OF RADIUS     82                                      $90.40        20120901
24366       RECONSTRUCT HEAD OF RADIUS     AS                                      $90.40        20120901
24366       RECONSTRUCT HEAD OF RADIUS                                            $452.02        20120901
24366       RECONSTRUCT HEAD OF RADIUS                           A              $5,034.78        20110101
24400       REVISION OF HUMERUS            80                                     $109.05        20120901
24400       REVISION OF HUMERUS            81                                     $109.05        20120901
24400       REVISION OF HUMERUS            82                                     $109.05        20120901
24400       REVISION OF HUMERUS            AS                                     $109.05        20120901
24400       REVISION OF HUMERUS                                                   $545.27        20120901
24400       REVISION OF HUMERUS                                  A              $1,240.11        20110101
24410       REVISION OF HUMERUS            80                                     $139.89        20120901
24410       REVISION OF HUMERUS            81                                     $139.89        20120901
24410       REVISION OF HUMERUS            82                                     $139.89        20120901
24410       REVISION OF HUMERUS            AS                                     $139.89        20120901
24410       REVISION OF HUMERUS                                                   $699.43        20120901
24410       REVISION OF HUMERUS                                  A              $1,240.11        20110101
24420       REVISION OF HUMERUS            80                                     $131.58        20120901
24420       REVISION OF HUMERUS            81                                     $131.58        20120901
24420       REVISION OF HUMERUS            82                                     $131.58        20120901
24420       REVISION OF HUMERUS            AS                                     $131.58        20120901
24420       REVISION OF HUMERUS                                                   $657.89        20120901
24420       REVISION OF HUMERUS                                  A              $1,217.14        20110101
24430       REPAIR OF HUMERUS              80                                     $140.80        20120901
24430       REPAIR OF HUMERUS              81                                     $140.80        20120901
24430       REPAIR OF HUMERUS              82                                     $140.80        20120901
24430       REPAIR OF HUMERUS              AS                                     $140.80        20120901
24430       REPAIR OF HUMERUS                                                     $704.01        20120901
24430       REPAIR OF HUMERUS                                    A              $2,228.42        20110101
24435       REPAIR HUMERUS WITH GRAFT      80                                     $142.84        20120901
24435       REPAIR HUMERUS WITH GRAFT      81                                     $142.84        20120901
24435       REPAIR HUMERUS WITH GRAFT      82                                     $142.84        20120901
24435       REPAIR HUMERUS WITH GRAFT      AS                                     $142.84        20120901
24435       REPAIR HUMERUS WITH GRAFT                                             $714.20        20120901



                                             Page 49
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
24435       REPAIR HUMERUS WITH GRAFT                            A              $2,251.38        20110101
24470       REVISION OF ELBOW JOINT        80                                      $84.80        20120901
24470       REVISION OF ELBOW JOINT        81                                      $84.80        20120901
24470       REVISION OF ELBOW JOINT        82                                      $84.80        20120901
24470       REVISION OF ELBOW JOINT        AS                                      $84.80        20120901
24470       REVISION OF ELBOW JOINT                                               $423.99        20120901
24470       REVISION OF ELBOW JOINT                              A              $1,217.14        20110101
24495       DECOMPRESSION OF FOREARM                                              $436.22        20120901
24495       DECOMPRESSION OF FOREARM                             A                $849.00        20110101
24498       REINFORCE HUMERUS              80                                     $115.83        20120901
24498       REINFORCE HUMERUS              81                                     $115.83        20120901
24498       REINFORCE HUMERUS              82                                     $115.83        20120901
24498       REINFORCE HUMERUS              AS                                     $115.83        20120901
24498       REINFORCE HUMERUS                                                     $579.16        20120901
24498       REINFORCE HUMERUS                                    A              $2,228.42        20110101
24500       TREAT HUMERUS FRACTURE                                                $221.17        20120901
24500       TREAT HUMERUS FRACTURE                               A                 $59.66        20110101
24505       TREAT HUMERUS FRACTURE                                                $318.25        20120901
24505       TREAT HUMERUS FRACTURE                               A                 $59.66        20110101
24515       TREAT HUMERUS FRACTURE         80                                     $116.34        20120901
24515       TREAT HUMERUS FRACTURE         81                                     $116.34        20120901
24515       TREAT HUMERUS FRACTURE         82                                     $116.34        20120901
24515       TREAT HUMERUS FRACTURE         AS                                     $116.34        20120901
24515       TREAT HUMERUS FRACTURE                                                $581.71        20120901
24515       TREAT HUMERUS FRACTURE                               A              $1,694.30        20110101
24516       TREAT HUMERUS FRACTURE         80                                     $114.97        20120901
24516       TREAT HUMERUS FRACTURE         81                                     $114.97        20120901
24516       TREAT HUMERUS FRACTURE         82                                     $114.97        20120901
24516       TREAT HUMERUS FRACTURE         AS                                     $114.97        20120901
24516       TREAT HUMERUS FRACTURE                                                $574.83        20120901
24516       TREAT HUMERUS FRACTURE                               A              $1,694.30        20110101
24530       TREAT HUMERUS FRACTURE                                                $236.96        20120901
24530       TREAT HUMERUS FRACTURE                               A                 $59.66        20110101
24535       TREAT HUMERUS FRACTURE                                                $397.23        20120901
24535       TREAT HUMERUS FRACTURE                               A                $135.07        20110101
24538       TREAT HUMERUS FRACTURE                                                $490.49        20120901
24538       TREAT HUMERUS FRACTURE                               A                $706.54        20110101
24545       TREAT HUMERUS FRACTURE         80                                     $122.81        20120901
24545       TREAT HUMERUS FRACTURE         81                                     $122.81        20120901
24545       TREAT HUMERUS FRACTURE         82                                     $122.81        20120901
24545       TREAT HUMERUS FRACTURE         AS                                     $122.81        20120901
24545       TREAT HUMERUS FRACTURE                                                $614.07        20120901
24545       TREAT HUMERUS FRACTURE                               A              $1,694.30        20110101
24546       TREAT HUMERUS FRACTURE         80                                     $139.63        20120901
24546       TREAT HUMERUS FRACTURE         81                                     $139.63        20120901
24546       TREAT HUMERUS FRACTURE         82                                     $139.63        20120901
24546       TREAT HUMERUS FRACTURE         AS                                     $139.63        20120901
24546       TREAT HUMERUS FRACTURE                                                $698.15        20120901
24546       TREAT HUMERUS FRACTURE                               A              $1,710.95        20110101
24560       TREAT HUMERUS FRACTURE                                                $198.49        20120901
24560       TREAT HUMERUS FRACTURE                               A                 $59.66        20110101
24565       TREAT HUMERUS FRACTURE                                                $331.24        20120901
24565       TREAT HUMERUS FRACTURE                               A                 $59.66        20110101
24566       TREAT HUMERUS FRACTURE                                                $466.79        20120901
24566       TREAT HUMERUS FRACTURE                               A                $706.54        20110101
24575       TREAT HUMERUS FRACTURE         80                                      $96.77        20120901
24575       TREAT HUMERUS FRACTURE         81                                      $96.77        20120901
24575       TREAT HUMERUS FRACTURE         82                                      $96.77        20120901
24575       TREAT HUMERUS FRACTURE         AS                                      $96.77        20120901



                                             Page 50
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
24575       TREAT HUMERUS FRACTURE                                                 $483.87        20120901
24575       TREAT HUMERUS FRACTURE                                A              $1,671.34        20110101
24576       TREAT HUMERUS FRACTURE                                                 $209.45        20120901
24576       TREAT HUMERUS FRACTURE                                A                 $59.66        20110101
24577       TREAT HUMERUS FRACTURE                                                 $343.73        20120901
24577       TREAT HUMERUS FRACTURE                                A                $135.07        20110101
24579       TREAT HUMERUS FRACTURE          80                                     $110.53        20120901
24579       TREAT HUMERUS FRACTURE          81                                     $110.53        20120901
24579       TREAT HUMERUS FRACTURE          82                                     $110.53        20120901
24579       TREAT HUMERUS FRACTURE          AS                                     $110.53        20120901
24579       TREAT HUMERUS FRACTURE                                                 $552.66        20120901
24579       TREAT HUMERUS FRACTURE                                A              $1,671.34        20110101
24582       TREAT HUMERUS FRACTURE                                                 $522.09        20120901
24582       TREAT HUMERUS FRACTURE                                A                $706.54        20110101
24586       TREAT ELBOW FRACTURE            80                                     $145.80        20120901
24586       TREAT ELBOW FRACTURE            81                                     $145.80        20120901
24586       TREAT ELBOW FRACTURE            82                                     $145.80        20120901
24586       TREAT ELBOW FRACTURE            AS                                     $145.80        20120901
24586       TREAT ELBOW FRACTURE                                                   $728.98        20120901
24586       TREAT ELBOW FRACTURE                                  A              $1,694.30        20110101
24587       TREAT ELBOW FRACTURE            80                                     $145.39        20120901
24587       TREAT ELBOW FRACTURE            81                                     $145.39        20120901
24587       TREAT ELBOW FRACTURE            82                                     $145.39        20120901
24587       TREAT ELBOW FRACTURE            AS                                     $145.39        20120901
24587       TREAT ELBOW FRACTURE                                                   $726.94        20120901
24587       TREAT ELBOW FRACTURE                                  A              $1,710.95        20110101
24600       TREAT ELBOW DISLOCATION                                                $232.38        20120901
24600       TREAT ELBOW DISLOCATION                               A                 $59.66        20110101
24605       TREAT ELBOW DISLOCATION                                                $300.66        20120901
24605       TREAT ELBOW DISLOCATION                               A                $452.90        20110101
24615       TREAT ELBOW DISLOCATION         80                                      $94.53        20120901
24615       TREAT ELBOW DISLOCATION         81                                      $94.53        20120901
24615       TREAT ELBOW DISLOCATION         82                                      $94.53        20120901
24615       TREAT ELBOW DISLOCATION         AS                                      $94.53        20120901
24615       TREAT ELBOW DISLOCATION                                                $472.65        20120901
24615       TREAT ELBOW DISLOCATION                               A              $1,671.34        20110101
24620       TREAT ELBOW FRACTURE                                                   $361.56        20120901
24620       TREAT ELBOW FRACTURE                                  A                $462.00        20110101
24635       TREAT ELBOW FRACTURE            80                                      $94.63        20120901
24635       TREAT ELBOW FRACTURE            81                                      $94.63        20120901
24635       TREAT ELBOW FRACTURE            82                                      $94.63        20120901
24635       TREAT ELBOW FRACTURE            AS                                      $94.63        20120901
24635       TREAT ELBOW FRACTURE                                                   $473.16        20120901
24635       TREAT ELBOW FRACTURE                                  A              $1,671.34        20110101
24640       TREAT ELBOW DISLOCATION                                                 $78.99        20120901
24650       TREAT RADIUS FRACTURE                                                  $160.78        20120901
24655       TREAT RADIUS FRACTURE                                                  $276.97        20120901
24655       TREAT RADIUS FRACTURE                                 A                $135.07        20110101
24665       TREAT RADIUS FRACTURE           80                                      $85.36        20120901
24665       TREAT RADIUS FRACTURE           81                                      $85.36        20120901
24665       TREAT RADIUS FRACTURE           82                                      $85.36        20120901
24665       TREAT RADIUS FRACTURE           AS                                      $85.36        20120901
24665       TREAT RADIUS FRACTURE                                                  $426.79        20120901
24665       TREAT RADIUS FRACTURE                                 A              $1,213.40        20110101
24666       TREAT RADIUS FRACTURE           80                                      $96.82        20120901
24666       TREAT RADIUS FRACTURE           81                                      $96.82        20120901
24666       TREAT RADIUS FRACTURE           82                                      $96.82        20120901
24666       TREAT RADIUS FRACTURE           AS                                      $96.82        20120901
24666       TREAT RADIUS FRACTURE                                                  $484.12        20120901



                                              Page 51
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
24666       TREAT RADIUS FRACTURE                                A              $1,694.30        20110101
24670       TREAT ULNAR FRACTURE                                                  $180.40        20120901
24670       TREAT ULNAR FRACTURE                                 A                 $59.66        20110101
24675       TREAT ULNAR FRACTURE                                                  $290.47        20120901
24675       TREAT ULNAR FRACTURE                                 A                 $59.66        20110101
24685       TREAT ULNAR FRACTURE           80                                      $85.56        20120901
24685       TREAT ULNAR FRACTURE           81                                      $85.56        20120901
24685       TREAT ULNAR FRACTURE           82                                      $85.56        20120901
24685       TREAT ULNAR FRACTURE           AS                                      $85.56        20120901
24685       TREAT ULNAR FRACTURE                                                  $427.81        20120901
24685       TREAT ULNAR FRACTURE                                 A              $1,190.44        20110101
24800       FUSION OF ELBOW JOINT          80                                     $107.22        20120901
24800       FUSION OF ELBOW JOINT          81                                     $107.22        20120901
24800       FUSION OF ELBOW JOINT          82                                     $107.22        20120901
24800       FUSION OF ELBOW JOINT          AS                                     $107.22        20120901
24800       FUSION OF ELBOW JOINT                                                 $536.10        20120901
24800       FUSION OF ELBOW JOINT                                A              $1,240.11        20110101
24802       FUSION/GRAFT OF ELBOW JOINT    80                                     $133.36        20120901
24802       FUSION/GRAFT OF ELBOW JOINT    81                                     $133.36        20120901
24802       FUSION/GRAFT OF ELBOW JOINT    82                                     $133.36        20120901
24802       FUSION/GRAFT OF ELBOW JOINT    AS                                     $133.36        20120901
24802       FUSION/GRAFT OF ELBOW JOINT                                           $666.81        20120901
24802       FUSION/GRAFT OF ELBOW JOINT                          A              $1,256.75        20110101
24900       AMPUTATION OF UPPER ARM        80                                      $96.11        20120901
24900       AMPUTATION OF UPPER ARM        81                                      $96.11        20120901
24900       AMPUTATION OF UPPER ARM        82                                      $96.11        20120901
24900       AMPUTATION OF UPPER ARM        AS                                      $96.11        20120901
24900       AMPUTATION OF UPPER ARM                                               $480.55        20120901
24920       AMPUTATION OF UPPER ARM        80                                      $95.30        20120901
24920       AMPUTATION OF UPPER ARM        81                                      $95.30        20120901
24920       AMPUTATION OF UPPER ARM        82                                      $95.30        20120901
24920       AMPUTATION OF UPPER ARM        AS                                      $95.30        20120901
24920       AMPUTATION OF UPPER ARM                                               $476.48        20120901
24925       AMPUTATION FOLLOW-UP SURGERY   80                                      $73.84        20120901
24925       AMPUTATION FOLLOW-UP SURGERY   81                                      $73.84        20120901
24925       AMPUTATION FOLLOW-UP SURGERY   82                                      $73.84        20120901
24925       AMPUTATION FOLLOW-UP SURGERY   AS                                      $73.84        20120901
24925       AMPUTATION FOLLOW-UP SURGERY                                          $369.21        20120901
24925       AMPUTATION FOLLOW-UP SURGERY                         A                $626.73        20110101
24930       AMPUTATION FOLLOW-UP SURGERY   80                                     $101.16        20120901
24930       AMPUTATION FOLLOW-UP SURGERY   81                                     $101.16        20120901
24930       AMPUTATION FOLLOW-UP SURGERY   82                                     $101.16        20120901
24930       AMPUTATION FOLLOW-UP SURGERY   AS                                     $101.16        20120901
24930       AMPUTATION FOLLOW-UP SURGERY                                          $505.78        20120901
24931       AMPUTATE UPPER ARM IMPLANT     80                                     $106.15        20120901
24931       AMPUTATE UPPER ARM IMPLANT     81                                     $106.15        20120901
24931       AMPUTATE UPPER ARM IMPLANT     82                                     $106.15        20120901
24931       AMPUTATE UPPER ARM IMPLANT     AS                                     $106.15        20120901
24931       AMPUTATE UPPER ARM IMPLANT                                            $530.75        20120901
24935       REVISION OF AMPUTATION                                                $710.13        20120901
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                                             $224.73        20120901
25000       INCISION OF TENDON SHEATH                            A                $626.73        20110101
25001       INCISE FLEXOR CARPI RADIALIS                                          $217.60        20120901
25020       DECOMPRESS FOREARM 1 SPACE                                            $373.54        20120901



                                             Page 52
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
25020       DECOMPRESS FOREARM 1 SPACE                           A               $861.25         20110101
25023       DECOMPRESS FOREARM 1 SPACE                                           $730.51         20120901
25023       DECOMPRESS FOREARM 1 SPACE                           A               $861.25         20110101
25024       DECOMPRESS FOREARM 2 SPACES                                          $514.95         20120901
25024       DECOMPRESS FOREARM 2 SPACES                          A               $861.25         20110101
25025       DECOMPRESS FOREARM 2 SPACES                                          $806.19         20120901
25025       DECOMPRESS FOREARM 2 SPACES                          A               $861.25         20110101
25028       DRAINAGE OF FOREARM LESION                                           $335.57         20120901
25028       DRAINAGE OF FOREARM LESION                           A               $592.86         20110101
25031       DRAINAGE OF FOREARM BURSA                                            $244.86         20120901
25031       DRAINAGE OF FOREARM BURSA                            A               $614.48         20110101
25035       TREAT FOREARM BONE LESION                                            $413.54         20120901
25035       TREAT FOREARM BONE LESION                            A               $614.48         20110101
25040       EXPLORE/TREAT WRIST JOINT                                            $375.07         20120901
25040       EXPLORE/TREAT WRIST JOINT                            A               $900.86         20110101
25065       BIOPSY FOREARM SOFT TISSUES                                          $162.56         20120901
25065       BIOPSY FOREARM SOFT TISSUES                          A                 $93.34        20110101
25066       BIOPSY FOREARM SOFT TISSUES                                          $243.84         20120901
25066       BIOPSY FOREARM SOFT TISSUES                          A               $647.50         20110101
25071       EXC FOREARM LES SC 3 CM/                                             $293.27         20120901
25073       EXC FOREARM TUM DEEP 3 CM/                                           $365.13         20120901
25075       EXC FOREARM LES SC 3 CM                                              $241.04         20120901
25075       EXC FOREARM LES SC 3 CM                              A               $112.65         20110101
25076       EXC FOREARM TUM DEEP 3 CM                                            $341.69         20120901
25076       EXC FOREARM TUM DEEP 3 CM                            A               $560.76         20110101
25077       RESECT FOREARM/WRIST TUM3CM                                          $587.82         20120901
25077       RESECT FOREARM/WRIST TUM3CM                          A               $560.76         20110101
25078       RESECT FORARM/WRIST TUM 3CM                                          $781.22         20120901
25085       INCISION OF WRIST CAPSULE      80                                      $60.54        20120901
25085       INCISION OF WRIST CAPSULE      81                                      $60.54        20120901
25085       INCISION OF WRIST CAPSULE      82                                      $60.54        20120901
25085       INCISION OF WRIST CAPSULE      AS                                      $60.54        20120901
25085       INCISION OF WRIST CAPSULE                                            $302.70         20120901
25085       INCISION OF WRIST CAPSULE                            A               $626.73         20110101
25100       BIOPSY OF WRIST JOINT                                                $226.26         20120901
25100       BIOPSY OF WRIST JOINT                                A               $614.48         20110101
25101       EXPLORE/TREAT WRIST JOINT                                            $265.50         20120901
25101       EXPLORE/TREAT WRIST JOINT                            A               $861.25         20110101
25105       REMOVE WRIST JOINT LINING                                            $322.07         20120901
25105       REMOVE WRIST JOINT LINING                            A               $884.21         20110101
25107       REMOVE WRIST JOINT CARTILAGE   80                                      $81.18        20120901
25107       REMOVE WRIST JOINT CARTILAGE   81                                      $81.18        20120901
25107       REMOVE WRIST JOINT CARTILAGE   82                                      $81.18        20120901
25107       REMOVE WRIST JOINT CARTILAGE   AS                                      $81.18        20120901
25107       REMOVE WRIST JOINT CARTILAGE                                         $405.90         20120901
25107       REMOVE WRIST JOINT CARTILAGE                         A               $861.25         20110101
25109       EXCISE TENDON FOREARM/WRIST                                          $347.55         20120901
25110       REMOVE WRIST TENDON LESION                                           $232.63         20120901
25110       REMOVE WRIST TENDON LESION                           A               $626.73         20110101
25111       REMOVE WRIST TENDON LESION                                           $206.39         20120901
25111       REMOVE WRIST TENDON LESION                           A               $626.73         20110101
25112       REREMOVE WRIST TENDON LESION                                         $251.49         20120901
25112       REREMOVE WRIST TENDON LESION                         A               $649.69         20110101
25115       REMOVE WRIST/FOREARM LESION                                          $525.91         20120901
25115       REMOVE WRIST/FOREARM LESION                          A               $649.69         20110101
25116       REMOVE WRIST/FOREARM LESION                                          $420.67         20120901
25116       REMOVE WRIST/FOREARM LESION                          A               $649.69         20110101
25118       EXCISE WRIST TENDON SHEATH                                           $250.72         20120901
25118       EXCISE WRIST TENDON SHEATH                           A               $849.00         20110101



                                             Page 53
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price         Effective Date
25119       PARTIAL REMOVAL OF ULNA        80                                     $66.45        20120901
25119       PARTIAL REMOVAL OF ULNA        81                                     $66.45        20120901
25119       PARTIAL REMOVAL OF ULNA        82                                     $66.45        20120901
25119       PARTIAL REMOVAL OF ULNA        AS                                     $66.45        20120901
25119       PARTIAL REMOVAL OF ULNA                                              $332.26        20120901
25119       PARTIAL REMOVAL OF ULNA                              A               $861.25        20110101
25120       REMOVAL OF FOREARM LESION                                            $355.19        20120901
25120       REMOVAL OF FOREARM LESION                            A               $861.25        20110101
25125       REMOVE/GRAFT FOREARM LESION                                          $419.15        20120901
25125       REMOVE/GRAFT FOREARM LESION                          A               $861.25        20110101
25126       REMOVE/GRAFT FOREARM LESION    80                                     $84.08        20120901
25126       REMOVE/GRAFT FOREARM LESION    81                                     $84.08        20120901
25126       REMOVE/GRAFT FOREARM LESION    82                                     $84.08        20120901
25126       REMOVE/GRAFT FOREARM LESION    AS                                     $84.08        20120901
25126       REMOVE/GRAFT FOREARM LESION                                          $420.42        20120901
25126       REMOVE/GRAFT FOREARM LESION                          A               $861.25        20110101
25130       REMOVAL OF WRIST LESION                                              $295.31        20120901
25130       REMOVAL OF WRIST LESION                              A               $861.25        20110101
25135       REMOVE GRAFT WRIST LESION      80                                     $74.50        20120901
25135       REMOVE GRAFT WRIST LESION      81                                     $74.50        20120901
25135       REMOVE GRAFT WRIST LESION      82                                     $74.50        20120901
25135       REMOVE GRAFT WRIST LESION      AS                                     $74.50        20120901
25135       REMOVE GRAFT WRIST LESION                                            $372.52        20120901
25135       REMOVE GRAFT WRIST LESION                            A               $861.25        20110101
25136       REMOVE GRAFT WRIST LESION      80                                     $65.03        20120901
25136       REMOVE GRAFT WRIST LESION      81                                     $65.03        20120901
25136       REMOVE GRAFT WRIST LESION      82                                     $65.03        20120901
25136       REMOVE GRAFT WRIST LESION      AS                                     $65.03        20120901
25136       REMOVE GRAFT WRIST LESION                                            $325.12        20120901
25136       REMOVE GRAFT WRIST LESION                            A               $861.25        20110101
25145       REMOVE FOREARM BONE LESION     80                                     $73.38        20120901
25145       REMOVE FOREARM BONE LESION     81                                     $73.38        20120901
25145       REMOVE FOREARM BONE LESION     82                                     $73.38        20120901
25145       REMOVE FOREARM BONE LESION     AS                                     $73.38        20120901
25145       REMOVE FOREARM BONE LESION                                           $366.91        20120901
25145       REMOVE FOREARM BONE LESION                           A               $849.00        20110101
25150       PARTIAL REMOVAL OF ULNA                                              $379.14        20120901
25150       PARTIAL REMOVAL OF ULNA                              A               $849.00        20110101
25151       PARTIAL REMOVAL OF RADIUS      80                                     $82.96        20120901
25151       PARTIAL REMOVAL OF RADIUS      81                                     $82.96        20120901
25151       PARTIAL REMOVAL OF RADIUS      82                                     $82.96        20120901
25151       PARTIAL REMOVAL OF RADIUS      AS                                     $82.96        20120901
25151       PARTIAL REMOVAL OF RADIUS                                            $414.81        20120901
25151       PARTIAL REMOVAL OF RADIUS                            A               $849.00        20110101
25170       RESECT RADIUS/ULNAR TUMOR      80                                    $185.85        20120901
25170       RESECT RADIUS/ULNAR TUMOR      81                                    $185.85        20120901
25170       RESECT RADIUS/ULNAR TUMOR      82                                    $185.85        20120901
25170       RESECT RADIUS/ULNAR TUMOR      AS                                    $185.85        20120901
25170       RESECT RADIUS/ULNAR TUMOR                                            $929.26        20120901
25210       REMOVAL OF WRIST BONE                                                $323.09        20120901
25210       REMOVAL OF WRIST BONE                                A               $861.25        20110101
25215       REMOVAL OF WRIST BONES         80                                     $82.76        20120901
25215       REMOVAL OF WRIST BONES         81                                     $82.76        20120901
25215       REMOVAL OF WRIST BONES         82                                     $82.76        20120901
25215       REMOVAL OF WRIST BONES         AS                                     $82.76        20120901
25215       REMOVAL OF WRIST BONES                                               $413.80        20120901
25215       REMOVAL OF WRIST BONES                               A               $884.21        20110101
25230       PARTIAL REMOVAL OF RADIUS                                            $284.61        20120901
25230       PARTIAL REMOVAL OF RADIUS                            A               $884.21        20110101



                                             Page 54
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
25240       PARTIAL REMOVAL OF ULNA                                               $287.16         20120901
25240       PARTIAL REMOVAL OF ULNA                               A               $884.21         20110101
25246       INJECTION FOR WRIST X-RAY                                             $111.86         20120901
25248       REMOVE FOREARM FOREIGN BODY                                           $287.16         20120901
25248       REMOVE FOREARM FOREIGN BODY                           A               $614.48         20110101
25250       REMOVAL OF WRIST PROSTHESIS    80                                       $69.25        20120901
25250       REMOVAL OF WRIST PROSTHESIS    81                                       $69.25        20120901
25250       REMOVAL OF WRIST PROSTHESIS    82                                       $69.25        20120901
25250       REMOVAL OF WRIST PROSTHESIS    AS                                       $69.25        20120901
25250       REMOVAL OF WRIST PROSTHESIS                                           $346.27         20120901
25250       REMOVAL OF WRIST PROSTHESIS                           A               $827.38         20110101
25251       REMOVAL OF WRIST PROSTHESIS    80                                       $95.24        20120901
25251       REMOVAL OF WRIST PROSTHESIS    81                                       $95.24        20120901
25251       REMOVAL OF WRIST PROSTHESIS    82                                       $95.24        20120901
25251       REMOVAL OF WRIST PROSTHESIS    AS                                       $95.24        20120901
25251       REMOVAL OF WRIST PROSTHESIS                                           $476.22         20120901
25251       REMOVAL OF WRIST PROSTHESIS                           A               $827.38         20110101
25259       MANIPULATE WRIST W/ANESTHES                                           $258.62         20120901
25260       REPAIR FOREARM TENDON/MUSCLE                                          $440.55         20120901
25260       REPAIR FOREARM TENDON/MUSCLE                          A               $884.21         20110101
25263       REPAIR FOREARM TENDON/MUSCLE   80                                       $88.11        20120901
25263       REPAIR FOREARM TENDON/MUSCLE   81                                       $88.11        20120901
25263       REPAIR FOREARM TENDON/MUSCLE   82                                       $88.11        20120901
25263       REPAIR FOREARM TENDON/MUSCLE   AS                                       $88.11        20120901
25263       REPAIR FOREARM TENDON/MUSCLE                                          $440.55         20120901
25263       REPAIR FOREARM TENDON/MUSCLE                          A               $849.00         20110101
25265       REPAIR FOREARM TENDON/MUSCLE   80                                     $104.82         20120901
25265       REPAIR FOREARM TENDON/MUSCLE   81                                     $104.82         20120901
25265       REPAIR FOREARM TENDON/MUSCLE   82                                     $104.82         20120901
25265       REPAIR FOREARM TENDON/MUSCLE   AS                                     $104.82         20120901
25265       REPAIR FOREARM TENDON/MUSCLE                                          $524.12         20120901
25265       REPAIR FOREARM TENDON/MUSCLE                          A               $861.25         20110101
25270       REPAIR FOREARM TENDON/MUSCLE                                          $350.86         20120901
25270       REPAIR FOREARM TENDON/MUSCLE                          A               $884.21         20110101
25272       REPAIR FOREARM TENDON/MUSCLE                                          $394.43         20120901
25272       REPAIR FOREARM TENDON/MUSCLE                          A               $861.25         20110101
25274       REPAIR FOREARM TENDON/MUSCLE                                          $471.63         20120901
25274       REPAIR FOREARM TENDON/MUSCLE                          A               $884.21         20110101
25275       REPAIR FOREARM TENDON SHEATH                                          $445.90         20120901
25275       REPAIR FOREARM TENDON SHEATH                          A               $884.21         20110101
25280       REVISE WRIST/FOREARM TENDON                                           $400.29         20120901
25280       REVISE WRIST/FOREARM TENDON                           A               $884.21         20110101
25290       INCISE WRIST/FOREARM TENDON                                           $331.49         20120901
25290       INCISE WRIST/FOREARM TENDON                           A               $861.25         20110101
25295       RELEASE WRIST/FOREARM TENDON                                          $372.01         20120901
25295       RELEASE WRIST/FOREARM TENDON                          A               $626.73         20110101
25300       FUSION OF TENDONS AT WRIST     80                                       $90.86        20120901
25300       FUSION OF TENDONS AT WRIST     81                                       $90.86        20120901
25300       FUSION OF TENDONS AT WRIST     82                                       $90.86        20120901
25300       FUSION OF TENDONS AT WRIST     AS                                       $90.86        20120901
25300       FUSION OF TENDONS AT WRIST                                            $454.31         20120901
25300       FUSION OF TENDONS AT WRIST                            A               $861.25         20110101
25301       FUSION OF TENDONS AT WRIST     80                                       $85.71        20120901
25301       FUSION OF TENDONS AT WRIST     81                                       $85.71        20120901
25301       FUSION OF TENDONS AT WRIST     82                                       $85.71        20120901
25301       FUSION OF TENDONS AT WRIST     AS                                       $85.71        20120901
25301       FUSION OF TENDONS AT WRIST                                            $428.57         20120901
25301       FUSION OF TENDONS AT WRIST                            A               $861.25         20110101
25310       TRANSPLANT FOREARM TENDON      80                                       $86.89        20120901



                                                Page 55
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price         Effective Date
25310       TRANSPLANT FOREARM TENDON      81                                     $86.89        20120901
25310       TRANSPLANT FOREARM TENDON      82                                     $86.89        20120901
25310       TRANSPLANT FOREARM TENDON      AS                                     $86.89        20120901
25310       TRANSPLANT FOREARM TENDON                                            $434.43        20120901
25310       TRANSPLANT FOREARM TENDON                            A             $1,217.14        20110101
25312       TRANSPLANT FOREARM TENDON      80                                    $101.10        20120901
25312       TRANSPLANT FOREARM TENDON      81                                    $101.10        20120901
25312       TRANSPLANT FOREARM TENDON      82                                    $101.10        20120901
25312       TRANSPLANT FOREARM TENDON      AS                                    $101.10        20120901
25312       TRANSPLANT FOREARM TENDON                                            $505.52        20120901
25312       TRANSPLANT FOREARM TENDON                            A             $1,240.11        20110101
25315       REVISE PALSY HAND TENDONS      80                                    $108.60        20120901
25315       REVISE PALSY HAND TENDONS      81                                    $108.60        20120901
25315       REVISE PALSY HAND TENDONS      82                                    $108.60        20120901
25315       REVISE PALSY HAND TENDONS      AS                                    $108.60        20120901
25315       REVISE PALSY HAND TENDONS                                            $542.98        20120901
25315       REVISE PALSY HAND TENDONS                            A             $1,217.14        20110101
25316       REVISE PALSY HAND TENDONS      80                                    $124.50        20120901
25316       REVISE PALSY HAND TENDONS      81                                    $124.50        20120901
25316       REVISE PALSY HAND TENDONS      82                                    $124.50        20120901
25316       REVISE PALSY HAND TENDONS      AS                                    $124.50        20120901
25316       REVISE PALSY HAND TENDONS                                            $622.48        20120901
25316       REVISE PALSY HAND TENDONS                            A             $2,228.42        20110101
25320       REPAIR/REVISE WRIST JOINT      80                                    $129.29        20120901
25320       REPAIR/REVISE WRIST JOINT      81                                    $129.29        20120901
25320       REPAIR/REVISE WRIST JOINT      82                                    $129.29        20120901
25320       REPAIR/REVISE WRIST JOINT      AS                                    $129.29        20120901
25320       REPAIR/REVISE WRIST JOINT                                            $646.43        20120901
25320       REPAIR/REVISE WRIST JOINT                            A             $1,217.14        20110101
25332       REVISE WRIST JOINT             80                                    $111.91        20120901
25332       REVISE WRIST JOINT             81                                    $111.91        20120901
25332       REVISE WRIST JOINT             82                                    $111.91        20120901
25332       REVISE WRIST JOINT             AS                                    $111.91        20120901
25332       REVISE WRIST JOINT                                                   $559.54        20120901
25332       REVISE WRIST JOINT                                   A             $1,095.93        20110101
25335       REALIGNMENT OF HAND            80                                    $117.46        20120901
25335       REALIGNMENT OF HAND            81                                    $117.46        20120901
25335       REALIGNMENT OF HAND            82                                    $117.46        20120901
25335       REALIGNMENT OF HAND            AS                                    $117.46        20120901
25335       REALIGNMENT OF HAND                                                  $587.31        20120901
25335       REALIGNMENT OF HAND                                  A             $1,217.14        20110101
25337       RECONSTRUCT ULNA/RADIOULNAR                                          $587.82        20120901
25337       RECONSTRUCT ULNA/RADIOULNAR                          A             $1,256.75        20110101
25350       REVISION OF RADIUS             80                                     $95.19        20120901
25350       REVISION OF RADIUS             81                                     $95.19        20120901
25350       REVISION OF RADIUS             82                                     $95.19        20120901
25350       REVISION OF RADIUS             AS                                     $95.19        20120901
25350       REVISION OF RADIUS                                                   $475.97        20120901
25350       REVISION OF RADIUS                                   A             $1,217.14        20110101
25355       REVISION OF RADIUS             80                                    $107.73        20120901
25355       REVISION OF RADIUS             81                                    $107.73        20120901
25355       REVISION OF RADIUS             82                                    $107.73        20120901
25355       REVISION OF RADIUS             AS                                    $107.73        20120901
25355       REVISION OF RADIUS                                                   $538.65        20120901
25355       REVISION OF RADIUS                                   A             $1,217.14        20110101
25360       REVISION OF ULNA               80                                     $92.65        20120901
25360       REVISION OF ULNA               81                                     $92.65        20120901
25360       REVISION OF ULNA               82                                     $92.65        20120901
25360       REVISION OF ULNA               AS                                     $92.65        20120901



                                             Page 56
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
25360       REVISION OF ULNA                                                        $463.23        20120901
25360       REVISION OF ULNA                                       A              $1,217.14        20110101
25365       REVISE RADIUS ULNA              80                                      $127.15        20120901
25365       REVISE RADIUS ULNA              81                                      $127.15        20120901
25365       REVISE RADIUS ULNA              82                                      $127.15        20120901
25365       REVISE RADIUS ULNA              AS                                      $127.15        20120901
25365       REVISE RADIUS ULNA                                                      $635.73        20120901
25365       REVISE RADIUS ULNA                                     A              $1,217.14        20110101
25370       REVISE RADIUS OR ULNA           80                                      $139.12        20120901
25370       REVISE RADIUS OR ULNA           81                                      $139.12        20120901
25370       REVISE RADIUS OR ULNA           82                                      $139.12        20120901
25370       REVISE RADIUS OR ULNA           AS                                      $139.12        20120901
25370       REVISE RADIUS OR ULNA                                                   $695.60        20120901
25370       REVISE RADIUS OR ULNA                                  A              $1,217.14        20110101
25375       REVISE RADIUS ULNA              80                                      $123.27        20120901
25375       REVISE RADIUS ULNA              81                                      $123.27        20120901
25375       REVISE RADIUS ULNA              82                                      $123.27        20120901
25375       REVISE RADIUS ULNA              AS                                      $123.27        20120901
25375       REVISE RADIUS ULNA                                                      $616.36        20120901
25375       REVISE RADIUS ULNA                                     A              $1,240.11        20110101
25390       SHORTEN RADIUS OR ULNA          80                                      $108.14        20120901
25390       SHORTEN RADIUS OR ULNA          81                                      $108.14        20120901
25390       SHORTEN RADIUS OR ULNA          82                                      $108.14        20120901
25390       SHORTEN RADIUS OR ULNA          AS                                      $108.14        20120901
25390       SHORTEN RADIUS OR ULNA                                                  $540.69        20120901
25390       SHORTEN RADIUS OR ULNA                                 A              $1,217.14        20110101
25391       LENGTHEN RADIUS OR ULNA         80                                      $138.92        20120901
25391       LENGTHEN RADIUS OR ULNA         81                                      $138.92        20120901
25391       LENGTHEN RADIUS OR ULNA         82                                      $138.92        20120901
25391       LENGTHEN RADIUS OR ULNA         AS                                      $138.92        20120901
25391       LENGTHEN RADIUS OR ULNA                                                 $694.58        20120901
25391       LENGTHEN RADIUS OR ULNA                                A              $1,240.11        20110101
25392       SHORTEN RADIUS ULNA             80                                      $141.57        20120901
25392       SHORTEN RADIUS ULNA             81                                      $141.57        20120901
25392       SHORTEN RADIUS ULNA             82                                      $141.57        20120901
25392       SHORTEN RADIUS ULNA             AS                                      $141.57        20120901
25392       SHORTEN RADIUS ULNA                                                     $707.83        20120901
25392       SHORTEN RADIUS ULNA                                    A                $861.25        20110101
25393       LENGTHEN RADIUS ULNA            80                                      $157.82        20120901
25393       LENGTHEN RADIUS ULNA            81                                      $157.82        20120901
25393       LENGTHEN RADIUS ULNA            82                                      $157.82        20120901
25393       LENGTHEN RADIUS ULNA            AS                                      $157.82        20120901
25393       LENGTHEN RADIUS ULNA                                                    $789.12        20120901
25393       LENGTHEN RADIUS ULNA                                   A              $1,240.11        20110101
25394       REPAIR CARPAL BONE SHORTEN                                              $518.77        20120901
25400       REPAIR RADIUS OR ULNA           80                                      $113.39        20120901
25400       REPAIR RADIUS OR ULNA           81                                      $113.39        20120901
25400       REPAIR RADIUS OR ULNA           82                                      $113.39        20120901
25400       REPAIR RADIUS OR ULNA           AS                                      $113.39        20120901
25400       REPAIR RADIUS OR ULNA                                                   $566.93        20120901
25400       REPAIR RADIUS OR ULNA                                  A              $1,217.14        20110101
25405       REPAIR/GRAFT RADIUS OR ULNA     80                                      $144.93        20120901
25405       REPAIR/GRAFT RADIUS OR ULNA     81                                      $144.93        20120901
25405       REPAIR/GRAFT RADIUS OR ULNA     82                                      $144.93        20120901
25405       REPAIR/GRAFT RADIUS OR ULNA     AS                                      $144.93        20120901
25405       REPAIR/GRAFT RADIUS OR ULNA                                             $724.65        20120901
25405       REPAIR/GRAFT RADIUS OR ULNA                            A              $2,251.38        20110101
25415       REPAIR RADIUS ULNA              80                                      $136.88        20120901
25415       REPAIR RADIUS ULNA              81                                      $136.88        20120901



                                                 Page 57
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
25415       REPAIR RADIUS ULNA              82                                      $136.88        20120901
25415       REPAIR RADIUS ULNA              AS                                      $136.88        20120901
25415       REPAIR RADIUS ULNA                                                      $684.39        20120901
25415       REPAIR RADIUS ULNA                                     A              $2,228.42        20110101
25420       REPAIR/GRAFT RADIUS ULNA        80                                      $163.17        20120901
25420       REPAIR/GRAFT RADIUS ULNA        81                                      $163.17        20120901
25420       REPAIR/GRAFT RADIUS ULNA        82                                      $163.17        20120901
25420       REPAIR/GRAFT RADIUS ULNA        AS                                      $163.17        20120901
25420       REPAIR/GRAFT RADIUS ULNA                                                $815.87        20120901
25420       REPAIR/GRAFT RADIUS ULNA                               A              $2,251.38        20110101
25425       REPAIR/GRAFT RADIUS OR ULNA     80                                      $139.32        20120901
25425       REPAIR/GRAFT RADIUS OR ULNA     81                                      $139.32        20120901
25425       REPAIR/GRAFT RADIUS OR ULNA     82                                      $139.32        20120901
25425       REPAIR/GRAFT RADIUS OR ULNA     AS                                      $139.32        20120901
25425       REPAIR/GRAFT RADIUS OR ULNA                                             $696.62        20120901
25425       REPAIR/GRAFT RADIUS OR ULNA                            A              $1,217.14        20110101
25426       REPAIR/GRAFT RADIUS ULNA        80                                      $149.92        20120901
25426       REPAIR/GRAFT RADIUS ULNA        81                                      $149.92        20120901
25426       REPAIR/GRAFT RADIUS ULNA        82                                      $149.92        20120901
25426       REPAIR/GRAFT RADIUS ULNA        AS                                      $149.92        20120901
25426       REPAIR/GRAFT RADIUS ULNA                                                $749.62        20120901
25426       REPAIR/GRAFT RADIUS ULNA                               A              $1,240.11        20110101
25430       VASC GRAFT INTO CARPAL BONE                                             $467.81        20120901
25431       REPAIR NONUNION CARPAL BONE                                             $519.54        20120901
25440       REPAIR/GRAFT WRIST BONE         80                                      $102.58        20120901
25440       REPAIR/GRAFT WRIST BONE         81                                      $102.58        20120901
25440       REPAIR/GRAFT WRIST BONE         82                                      $102.58        20120901
25440       REPAIR/GRAFT WRIST BONE         AS                                      $102.58        20120901
25440       REPAIR/GRAFT WRIST BONE                                                 $512.91        20120901
25440       REPAIR/GRAFT WRIST BONE                                A              $2,251.38        20110101
25441       RECONSTRUCT WRIST JOINT         80                                      $122.76        20120901
25441       RECONSTRUCT WRIST JOINT         81                                      $122.76        20120901
25441       RECONSTRUCT WRIST JOINT         82                                      $122.76        20120901
25441       RECONSTRUCT WRIST JOINT         AS                                      $122.76        20120901
25441       RECONSTRUCT WRIST JOINT                                                 $613.81        20120901
25441       RECONSTRUCT WRIST JOINT                                A              $5,034.78        20110101
25442       RECONSTRUCT WRIST JOINT         80                                      $105.03        20120901
25442       RECONSTRUCT WRIST JOINT         81                                      $105.03        20120901
25442       RECONSTRUCT WRIST JOINT         82                                      $105.03        20120901
25442       RECONSTRUCT WRIST JOINT         AS                                      $105.03        20120901
25442       RECONSTRUCT WRIST JOINT                                                 $525.14        20120901
25442       RECONSTRUCT WRIST JOINT                                A              $5,034.78        20110101
25443       RECONSTRUCT WRIST JOINT         80                                      $103.70        20120901
25443       RECONSTRUCT WRIST JOINT         81                                      $103.70        20120901
25443       RECONSTRUCT WRIST JOINT         82                                      $103.70        20120901
25443       RECONSTRUCT WRIST JOINT         AS                                      $103.70        20120901
25443       RECONSTRUCT WRIST JOINT                                                 $518.52        20120901
25443       RECONSTRUCT WRIST JOINT                                A              $1,533.29        20110101
25444       RECONSTRUCT WRIST JOINT         80                                      $100.95        20120901
25444       RECONSTRUCT WRIST JOINT         81                                      $100.95        20120901
25444       RECONSTRUCT WRIST JOINT         82                                      $100.95        20120901
25444       RECONSTRUCT WRIST JOINT         AS                                      $100.95        20120901
25444       RECONSTRUCT WRIST JOINT                                                 $504.76        20120901
25444       RECONSTRUCT WRIST JOINT                                A              $1,533.29        20110101
25445       RECONSTRUCT WRIST JOINT                                                 $476.99        20120901
25445       RECONSTRUCT WRIST JOINT                                A              $1,533.29        20110101
25446       WRIST REPLACEMENT               80                                      $156.85        20120901
25446       WRIST REPLACEMENT               81                                      $156.85        20120901
25446       WRIST REPLACEMENT               82                                      $156.85        20120901



                                                 Page 58
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
25446       WRIST REPLACEMENT               AS                                     $156.85        20120901
25446       WRIST REPLACEMENT                                                      $784.27        20120901
25446       WRIST REPLACEMENT                                     A              $5,087.98        20110101
25447       REPAIR WRIST JOINTS             80                                     $108.54        20120901
25447       REPAIR WRIST JOINTS             81                                     $108.54        20120901
25447       REPAIR WRIST JOINTS             82                                     $108.54        20120901
25447       REPAIR WRIST JOINTS             AS                                     $108.54        20120901
25447       REPAIR WRIST JOINTS                                                    $542.72        20120901
25447       REPAIR WRIST JOINTS                                   A              $1,095.93        20110101
25449       REMOVE WRIST JOINT IMPLANT      80                                     $138.51        20120901
25449       REMOVE WRIST JOINT IMPLANT      81                                     $138.51        20120901
25449       REMOVE WRIST JOINT IMPLANT      82                                     $138.51        20120901
25449       REMOVE WRIST JOINT IMPLANT      AS                                     $138.51        20120901
25449       REMOVE WRIST JOINT IMPLANT                                             $692.55        20120901
25449       REMOVE WRIST JOINT IMPLANT                            A              $1,095.93        20110101
25450       REVISION OF WRIST JOINT                                                $396.98        20120901
25450       REVISION OF WRIST JOINT                               A              $1,217.14        20110101
25455       REVISION OF WRIST JOINT                                                $432.65        20120901
25455       REVISION OF WRIST JOINT                               A              $1,217.14        20110101
25490       REINFORCE RADIUS                80                                      $96.21        20120901
25490       REINFORCE RADIUS                81                                      $96.21        20120901
25490       REINFORCE RADIUS                82                                      $96.21        20120901
25490       REINFORCE RADIUS                AS                                      $96.21        20120901
25490       REINFORCE RADIUS                                                       $481.06        20120901
25490       REINFORCE RADIUS                                      A              $1,217.14        20110101
25491       REINFORCE ULNA                  80                                     $104.26        20120901
25491       REINFORCE ULNA                  81                                     $104.26        20120901
25491       REINFORCE ULNA                  82                                     $104.26        20120901
25491       REINFORCE ULNA                  AS                                     $104.26        20120901
25491       REINFORCE ULNA                                                         $521.32        20120901
25491       REINFORCE ULNA                                        A              $1,217.14        20110101
25492       REINFORCE RADIUS AND ULNA       80                                     $125.77        20120901
25492       REINFORCE RADIUS AND ULNA       81                                     $125.77        20120901
25492       REINFORCE RADIUS AND ULNA       82                                     $125.77        20120901
25492       REINFORCE RADIUS AND ULNA       AS                                     $125.77        20120901
25492       REINFORCE RADIUS AND ULNA                                              $628.85        20120901
25492       REINFORCE RADIUS AND ULNA                             A              $1,217.14        20110101
25500       TREAT FRACTURE OF RADIUS                                               $165.62        20120901
25505       TREAT FRACTURE OF RADIUS                                               $320.03        20120901
25505       TREAT FRACTURE OF RADIUS                              A                $135.07        20110101
25515       TREAT FRACTURE OF RADIUS        80                                      $87.91        20120901
25515       TREAT FRACTURE OF RADIUS        81                                      $87.91        20120901
25515       TREAT FRACTURE OF RADIUS        82                                      $87.91        20120901
25515       TREAT FRACTURE OF RADIUS        AS                                      $87.91        20120901
25515       TREAT FRACTURE OF RADIUS                                               $439.53        20120901
25515       TREAT FRACTURE OF RADIUS                              A              $1,190.44        20110101
25520       TREAT FRACTURE OF RADIUS                                               $355.70        20120901
25520       TREAT FRACTURE OF RADIUS                              A                $135.07        20110101
25525       TREAT FRACTURE OF RADIUS        80                                     $104.77        20120901
25525       TREAT FRACTURE OF RADIUS        81                                     $104.77        20120901
25525       TREAT FRACTURE OF RADIUS        82                                     $104.77        20120901
25525       TREAT FRACTURE OF RADIUS        AS                                     $104.77        20120901
25525       TREAT FRACTURE OF RADIUS                                               $523.87        20120901
25525       TREAT FRACTURE OF RADIUS                              A              $1,213.40        20110101
25526       TREAT FRACTURE OF RADIUS        80                                     $129.64        20120901
25526       TREAT FRACTURE OF RADIUS        81                                     $129.64        20120901
25526       TREAT FRACTURE OF RADIUS        82                                     $129.64        20120901
25526       TREAT FRACTURE OF RADIUS        AS                                     $129.64        20120901
25526       TREAT FRACTURE OF RADIUS                                               $648.21        20120901



                                              Page 59
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
25526       TREAT FRACTURE OF RADIUS                             A              $1,230.05        20110101
25530       TREAT FRACTURE OF ULNA                                                $160.01        20120901
25535       TREAT FRACTURE OF ULNA                                                $310.35        20120901
25535       TREAT FRACTURE OF ULNA                               A                 $59.66        20110101
25545       TREAT FRACTURE OF ULNA         80                                      $81.84        20120901
25545       TREAT FRACTURE OF ULNA         81                                      $81.84        20120901
25545       TREAT FRACTURE OF ULNA         82                                      $81.84        20120901
25545       TREAT FRACTURE OF ULNA         AS                                      $81.84        20120901
25545       TREAT FRACTURE OF ULNA                                                $409.21        20120901
25545       TREAT FRACTURE OF ULNA                               A              $1,190.44        20110101
25560       TREAT FRACTURE RADIUS ULNA                                            $168.42        20120901
25565       TREAT FRACTURE RADIUS ULNA                                            $334.30        20120901
25565       TREAT FRACTURE RADIUS ULNA                           A                $135.07        20110101
25574       TREAT FRACTURE RADIUS ULNA     80                                      $88.06        20120901
25574       TREAT FRACTURE RADIUS ULNA     81                                      $88.06        20120901
25574       TREAT FRACTURE RADIUS ULNA     82                                      $88.06        20120901
25574       TREAT FRACTURE RADIUS ULNA     AS                                      $88.06        20120901
25574       TREAT FRACTURE RADIUS ULNA                                            $440.29        20120901
25574       TREAT FRACTURE RADIUS ULNA                           A              $1,671.34        20110101
25575       TREAT FRACTURE RADIUS/ULNA     80                                     $118.84        20120901
25575       TREAT FRACTURE RADIUS/ULNA     81                                     $118.84        20120901
25575       TREAT FRACTURE RADIUS/ULNA     82                                     $118.84        20120901
25575       TREAT FRACTURE RADIUS/ULNA     AS                                     $118.84        20120901
25575       TREAT FRACTURE RADIUS/ULNA                                            $594.19        20120901
25575       TREAT FRACTURE RADIUS/ULNA                           A              $1,671.34        20110101
25600       TREAT FRACTURE RADIUS/ULNA                                            $181.93        20120901
25605       TREAT FRACTURE RADIUS/ULNA                                            $399.02        20120901
25605       TREAT FRACTURE RADIUS/ULNA                           A                $135.07        20110101
25606       TREAT FX DISTAL RADIAL                                                $436.98        20120901
25606       TREAT FX DISTAL RADIAL                               A                $718.78        20110101
25607       TREAT FX RAD EXTRA-ARTICUL     80                                      $95.40        20120901
25607       TREAT FX RAD EXTRA-ARTICUL     81                                      $95.40        20120901
25607       TREAT FX RAD EXTRA-ARTICUL     82                                      $95.40        20120901
25607       TREAT FX RAD EXTRA-ARTICUL     AS                                      $95.40        20120901
25607       TREAT FX RAD EXTRA-ARTICUL                                            $476.99        20120901
25607       TREAT FX RAD EXTRA-ARTICUL                           A              $1,710.95        20110101
25608       TREAT FX RAD INTRA-ARTICUL                                            $537.63        20120901
25608       TREAT FX RAD INTRA-ARTICUL                           A              $1,710.95        20110101
25609       TREAT FX RADIAL 3 FRAG                                                $686.18        20120901
25609       TREAT FX RADIAL 3 FRAG                               A              $1,710.95        20110101
25622       TREAT WRIST BONE FRACTURE                                             $187.53        20120901
25624       TREAT WRIST BONE FRACTURE                                             $293.78        20120901
25624       TREAT WRIST BONE FRACTURE                            A                $135.07        20110101
25628       TREAT WRIST BONE FRACTURE      80                                      $94.79        20120901
25628       TREAT WRIST BONE FRACTURE      81                                      $94.79        20120901
25628       TREAT WRIST BONE FRACTURE      82                                      $94.79        20120901
25628       TREAT WRIST BONE FRACTURE      AS                                      $94.79        20120901
25628       TREAT WRIST BONE FRACTURE                                             $473.93        20120901
25628       TREAT WRIST BONE FRACTURE                            A              $1,190.44        20110101
25630       TREAT WRIST BONE FRACTURE                                             $191.10        20120901
25635       TREAT WRIST BONE FRACTURE                                             $280.79        20120901
25635       TREAT WRIST BONE FRACTURE                            A                $135.07        20110101
25645       TREAT WRIST BONE FRACTURE      80                                      $74.61        20120901
25645       TREAT WRIST BONE FRACTURE      81                                      $74.61        20120901
25645       TREAT WRIST BONE FRACTURE      82                                      $74.61        20120901
25645       TREAT WRIST BONE FRACTURE      AS                                      $74.61        20120901
25645       TREAT WRIST BONE FRACTURE                                             $373.03        20120901
25645       TREAT WRIST BONE FRACTURE                            A              $1,190.44        20110101
25650       TREAT WRIST BONE FRACTURE                                             $200.02        20120901



                                             Page 60
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
25651       PIN ULNAR STYLOID FRACTURE                                             $311.88        20120901
25652       TREAT FRACTURE ULNAR STYLOID                                           $407.17        20120901
25660       TREAT WRIST DISLOCATION                                                $263.21        20120901
25660       TREAT WRIST DISLOCATION                               A                 $59.66        20110101
25670       TREAT WRIST DISLOCATION         80                                      $80.11        20120901
25670       TREAT WRIST DISLOCATION         81                                      $80.11        20120901
25670       TREAT WRIST DISLOCATION         82                                      $80.11        20120901
25670       TREAT WRIST DISLOCATION         AS                                      $80.11        20120901
25670       TREAT WRIST DISLOCATION                                                $400.55        20120901
25670       TREAT WRIST DISLOCATION                               A                $718.78        20110101
25671       PIN RADIOULNAR DISLOCATION                                             $342.20        20120901
25671       PIN RADIOULNAR DISLOCATION                            A                $684.91        20110101
25675       TREAT WRIST DISLOCATION                                                $275.69        20120901
25675       TREAT WRIST DISLOCATION                               A                 $59.66        20110101
25676       TREAT WRIST DISLOCATION         80                                      $82.86        20120901
25676       TREAT WRIST DISLOCATION         81                                      $82.86        20120901
25676       TREAT WRIST DISLOCATION         82                                      $82.86        20120901
25676       TREAT WRIST DISLOCATION         AS                                      $82.86        20120901
25676       TREAT WRIST DISLOCATION                                                $414.30        20120901
25676       TREAT WRIST DISLOCATION                               A                $706.54        20110101
25680       TREAT WRIST FRACTURE                                                   $302.45        20120901
25680       TREAT WRIST FRACTURE                                  A                 $59.66        20110101
25685       TREAT WRIST FRACTURE            80                                      $96.98        20120901
25685       TREAT WRIST FRACTURE            81                                      $96.98        20120901
25685       TREAT WRIST FRACTURE            82                                      $96.98        20120901
25685       TREAT WRIST FRACTURE            AS                                      $96.98        20120901
25685       TREAT WRIST FRACTURE                                                   $484.88        20120901
25685       TREAT WRIST FRACTURE                                  A                $718.78        20110101
25690       TREAT WRIST DISLOCATION                                                $305.51        20120901
25690       TREAT WRIST DISLOCATION                               A                $462.00        20110101
25695       TREAT WRIST DISLOCATION         80                                      $83.57        20120901
25695       TREAT WRIST DISLOCATION         81                                      $83.57        20120901
25695       TREAT WRIST DISLOCATION         82                                      $83.57        20120901
25695       TREAT WRIST DISLOCATION         AS                                      $83.57        20120901
25695       TREAT WRIST DISLOCATION                                                $417.87        20120901
25695       TREAT WRIST DISLOCATION                               A                $706.54        20110101
25800       FUSION OF WRIST JOINT           80                                      $98.05        20120901
25800       FUSION OF WRIST JOINT           81                                      $98.05        20120901
25800       FUSION OF WRIST JOINT           82                                      $98.05        20120901
25800       FUSION OF WRIST JOINT           AS                                      $98.05        20120901
25800       FUSION OF WRIST JOINT                                                  $490.24        20120901
25800       FUSION OF WRIST JOINT                                 A              $2,251.38        20110101
25805       FUSION/GRAFT OF WRIST JOINT     80                                     $113.54        20120901
25805       FUSION/GRAFT OF WRIST JOINT     81                                     $113.54        20120901
25805       FUSION/GRAFT OF WRIST JOINT     82                                     $113.54        20120901
25805       FUSION/GRAFT OF WRIST JOINT     AS                                     $113.54        20120901
25805       FUSION/GRAFT OF WRIST JOINT                                            $567.69        20120901
25805       FUSION/GRAFT OF WRIST JOINT                           A              $1,256.75        20110101
25810       FUSION/GRAFT OF WRIST JOINT     80                                     $115.22        20120901
25810       FUSION/GRAFT OF WRIST JOINT     81                                     $115.22        20120901
25810       FUSION/GRAFT OF WRIST JOINT     82                                     $115.22        20120901
25810       FUSION/GRAFT OF WRIST JOINT     AS                                     $115.22        20120901
25810       FUSION/GRAFT OF WRIST JOINT                                            $576.10        20120901
25810       FUSION/GRAFT OF WRIST JOINT                           A              $2,268.02        20110101
25820       FUSION OF HAND BONES            80                                      $80.47        20120901
25820       FUSION OF HAND BONES            81                                      $80.47        20120901
25820       FUSION OF HAND BONES            82                                      $80.47        20120901
25820       FUSION OF HAND BONES            AS                                      $80.47        20120901
25820       FUSION OF HAND BONES                                                   $402.33        20120901



                                              Page 61
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
25820       FUSION OF HAND BONES                                  A              $1,240.11        20110101
25825       FUSE HAND BONES WITH GRAFT     80                                       $99.37        20120901
25825       FUSE HAND BONES WITH GRAFT     81                                       $99.37        20120901
25825       FUSE HAND BONES WITH GRAFT     82                                       $99.37        20120901
25825       FUSE HAND BONES WITH GRAFT     AS                                       $99.37        20120901
25825       FUSE HAND BONES WITH GRAFT                                             $496.86        20120901
25825       FUSE HAND BONES WITH GRAFT                            A              $2,268.02        20110101
25830       FUSION RADIOULNAR JNT/ULNA     80                                      $124.90        20120901
25830       FUSION RADIOULNAR JNT/ULNA     81                                      $124.90        20120901
25830       FUSION RADIOULNAR JNT/ULNA     82                                      $124.90        20120901
25830       FUSION RADIOULNAR JNT/ULNA     AS                                      $124.90        20120901
25830       FUSION RADIOULNAR JNT/ULNA                                             $624.51        20120901
25830       FUSION RADIOULNAR JNT/ULNA                            A              $2,268.02        20110101
25900       AMPUTATION OF FOREARM          80                                       $98.30        20120901
25900       AMPUTATION OF FOREARM          81                                       $98.30        20120901
25900       AMPUTATION OF FOREARM          82                                       $98.30        20120901
25900       AMPUTATION OF FOREARM          AS                                       $98.30        20120901
25900       AMPUTATION OF FOREARM                                                  $491.51        20120901
25905       AMPUTATION OF FOREARM          80                                       $96.98        20120901
25905       AMPUTATION OF FOREARM          81                                       $96.98        20120901
25905       AMPUTATION OF FOREARM          82                                       $96.98        20120901
25905       AMPUTATION OF FOREARM          AS                                       $96.98        20120901
25905       AMPUTATION OF FOREARM                                                  $484.88        20120901
25907       AMPUTATION FOLLOW-UP SURGERY   80                                       $84.85        20120901
25907       AMPUTATION FOLLOW-UP SURGERY   81                                       $84.85        20120901
25907       AMPUTATION FOLLOW-UP SURGERY   82                                       $84.85        20120901
25907       AMPUTATION FOLLOW-UP SURGERY   AS                                       $84.85        20120901
25907       AMPUTATION FOLLOW-UP SURGERY                                           $424.24        20120901
25907       AMPUTATION FOLLOW-UP SURGERY                          A                $626.73        20110101
25909       AMPUTATION FOLLOW-UP SURGERY   80                                       $94.99        20120901
25909       AMPUTATION FOLLOW-UP SURGERY   81                                       $94.99        20120901
25909       AMPUTATION FOLLOW-UP SURGERY   82                                       $94.99        20120901
25909       AMPUTATION FOLLOW-UP SURGERY   AS                                       $94.99        20120901
25909       AMPUTATION FOLLOW-UP SURGERY                                           $474.95        20120901
25915       AMPUTATION OF FOREARM          80                                      $157.01        20120901
25915       AMPUTATION OF FOREARM          81                                      $157.01        20120901
25915       AMPUTATION OF FOREARM          82                                      $157.01        20120901
25915       AMPUTATION OF FOREARM          AS                                      $157.01        20120901
25915       AMPUTATION OF FOREARM                                                  $785.04        20120901
25920       AMPUTATE HAND AT WRIST         80                                       $91.12        20120901
25920       AMPUTATE HAND AT WRIST         81                                       $91.12        20120901
25920       AMPUTATE HAND AT WRIST         82                                       $91.12        20120901
25920       AMPUTATE HAND AT WRIST         AS                                       $91.12        20120901
25920       AMPUTATE HAND AT WRIST                                                 $455.58        20120901
25922       AMPUTATE HAND AT WRIST         80                                       $71.29        20120901
25922       AMPUTATE HAND AT WRIST         81                                       $71.29        20120901
25922       AMPUTATE HAND AT WRIST         82                                       $71.29        20120901
25922       AMPUTATE HAND AT WRIST         AS                                       $71.29        20120901
25922       AMPUTATE HAND AT WRIST                                                 $356.47        20120901
25922       AMPUTATE HAND AT WRIST                                A                $626.73        20110101
25924       AMPUTATION FOLLOW-UP SURGERY   80                                       $88.87        20120901
25924       AMPUTATION FOLLOW-UP SURGERY   81                                       $88.87        20120901
25924       AMPUTATION FOLLOW-UP SURGERY   82                                       $88.87        20120901
25924       AMPUTATION FOLLOW-UP SURGERY   AS                                       $88.87        20120901
25924       AMPUTATION FOLLOW-UP SURGERY                                           $444.37        20120901
25927       AMPUTATION OF HAND                                                     $518.77        20120901
25929       AMPUTATION FOLLOW-UP SURGERY   80                                       $75.57        20120901
25929       AMPUTATION FOLLOW-UP SURGERY   81                                       $75.57        20120901
25929       AMPUTATION FOLLOW-UP SURGERY   82                                       $75.57        20120901



                                                Page 62
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price         Effective Date
25929       AMPUTATION FOLLOW-UP SURGERY   AS                                     $75.57        20120901
25929       AMPUTATION FOLLOW-UP SURGERY                                         $377.87        20120901
25929       AMPUTATION FOLLOW-UP SURGERY                         A               $483.46        20110101
25931       AMPUTATION FOLLOW-UP SURGERY                                         $464.76        20120901
26010       DRAINAGE OF FINGER ABSCESS                                           $161.29        20120901
26011       DRAINAGE OF FINGER ABSCESS                                           $243.33        20120901
26011       DRAINAGE OF FINGER ABSCESS                           A               $367.10        20110101
26020       DRAIN HAND TENDON SHEATH                                             $279.52        20120901
26020       DRAIN HAND TENDON SHEATH                             A               $494.96        20110101
26025       DRAINAGE OF PALM BURSA                                               $272.13        20120901
26025       DRAINAGE OF PALM BURSA                               A               $473.34        20110101
26030       DRAINAGE OF PALM BURSAS                                              $321.56        20120901
26030       DRAINAGE OF PALM BURSAS                              A               $494.96        20110101
26034       TREAT HAND BONE LESION                                               $348.82        20120901
26034       TREAT HAND BONE LESION                               A               $494.96        20110101
26035       DECOMPRESS FINGERS/HAND                                              $553.43        20120901
26035       DECOMPRESS FINGERS/HAND                              A               $546.16        20110101
26037       DECOMPRESS FINGERS/HAND                                              $375.32        20120901
26040       RELEASE PALM CONTRACTURE                                             $198.49        20120901
26040       RELEASE PALM CONTRACTURE                             A               $799.26        20110101
26045       RELEASE PALM CONTRACTURE                                             $303.72        20120901
26045       RELEASE PALM CONTRACTURE                             A               $776.30        20110101
26055       INCISE FINGER TENDON SHEATH                                          $355.45        20120901
26055       INCISE FINGER TENDON SHEATH                          A               $494.96        20110101
26060       INCISION OF FINGER TENDON                                            $170.72        20120901
26060       INCISION OF FINGER TENDON                            A               $494.96        20110101
26070       EXPLORE/TREAT HAND JOINT                                             $196.45        20120901
26070       EXPLORE/TREAT HAND JOINT                             A               $494.96        20110101
26075       EXPLORE/TREAT FINGER JOINT                                           $207.15        20120901
26075       EXPLORE/TREAT FINGER JOINT                           A               $530.17        20110101
26080       EXPLORE/TREAT FINGER JOINT                                           $248.94        20120901
26080       EXPLORE/TREAT FINGER JOINT                           A               $530.17        20110101
26100       BIOPSY HAND JOINT LINING                                             $211.23        20120901
26100       BIOPSY HAND JOINT LINING                             A               $494.96        20110101
26105       BIOPSY FINGER JOINT LINING                                           $214.80        20120901
26105       BIOPSY FINGER JOINT LINING                           A               $473.34        20110101
26110       BIOPSY FINGER JOINT LINING                                           $205.62        20120901
26110       BIOPSY FINGER JOINT LINING                           A               $473.34        20110101
26111       EXC HAND LES SC 1.5 CM/                                              $284.36        20120901
26113       EXC HAND TUM DEEP 1.5 CM/                                            $373.54        20120901
26115       EXC HAND LES SC 1.5 CM                                               $371.24        20120901
26115       EXC HAND LES SC 1.5 CM                               A               $229.62        20110101
26116       EXC HAND TUM DEEP 1.5 CM                                             $342.96        20120901
26116       EXC HAND TUM DEEP 1.5 CM                             A               $560.76        20110101
26117       EXC HAND TUM RA 3 CM                                                 $474.95        20120901
26117       EXC HAND TUM RA 3 CM                                 A               $560.76        20110101
26118       EXC HAND TUM RA 3 CM/                                                $734.08        20120901
26121       RELEASE PALM CONTRACTURE                                             $391.63        20120901
26121       RELEASE PALM CONTRACTURE                             A               $799.26        20110101
26123       RELEASE PALM CONTRACTURE                                             $542.98        20120901
26123       RELEASE PALM CONTRACTURE                             A               $799.26        20110101
26125       RELEASE PALM CONTRACTURE                                             $189.32        20120901
26125       RELEASE PALM CONTRACTURE                             A               $530.17        20110101
26130       REMOVE WRIST JOINT LINING                                            $297.10        20120901
26130       REMOVE WRIST JOINT LINING                            A               $507.20        20110101
26135       REVISE FINGER JOINT EACH                                             $360.54        20120901
26135       REVISE FINGER JOINT EACH                             A               $799.26        20110101
26140       REVISE FINGER JOINT EACH                                             $329.20        20120901
26140       REVISE FINGER JOINT EACH                             A               $494.96        20110101



                                             Page 63
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
26145       TENDON EXCISION PALM/FINGER                                           $334.30         20120901
26145       TENDON EXCISION PALM/FINGER                           A               $507.20         20110101
26160       REMOVE TENDON SHEATH LESION                                           $359.27         20120901
26160       REMOVE TENDON SHEATH LESION                           A               $507.20         20110101
26170       REMOVAL OF PALM TENDON EACH                                           $263.21         20120901
26170       REMOVAL OF PALM TENDON EACH                           A               $507.20         20110101
26180       REMOVAL OF FINGER TENDON                                              $287.16         20120901
26180       REMOVAL OF FINGER TENDON                              A               $507.20         20110101
26185       REMOVE FINGER BONE             80                                       $70.32        20120901
26185       REMOVE FINGER BONE             81                                       $70.32        20120901
26185       REMOVE FINGER BONE             82                                       $70.32        20120901
26185       REMOVE FINGER BONE             AS                                       $70.32        20120901
26185       REMOVE FINGER BONE                                                    $351.62         20120901
26185       REMOVE FINGER BONE                                    A               $530.17         20110101
26200       REMOVE HAND BONE LESION                                               $294.04         20120901
26200       REMOVE HAND BONE LESION                               A               $494.96         20110101
26205       REMOVE/GRAFT BONE LESION                                              $396.98         20120901
26205       REMOVE/GRAFT BONE LESION                              A               $776.30         20110101
26210       REMOVAL OF FINGER LESION                                              $286.14         20120901
26210       REMOVAL OF FINGER LESION                              A               $494.96         20110101
26215       REMOVE/GRAFT FINGER LESION                                            $367.42         20120901
26215       REMOVE/GRAFT FINGER LESION                            A               $507.20         20110101
26230       PARTIAL REMOVAL OF HAND BONE                                          $327.42         20120901
26230       PARTIAL REMOVAL OF HAND BONE                          A               $599.61         20110101
26235       PARTIAL REMOVAL FINGER BONE                                           $323.09         20120901
26235       PARTIAL REMOVAL FINGER BONE                           A               $507.20         20110101
26236       PARTIAL REMOVAL FINGER BONE                                           $287.16         20120901
26236       PARTIAL REMOVAL FINGER BONE                           A               $507.20         20110101
26250       EXTENSIVE HAND SURGERY                                                $634.71         20120901
26250       EXTENSIVE HAND SURGERY                                A               $507.20         20110101
26260       RESECT PROX FINGER TUMOR       80                                       $98.45        20120901
26260       RESECT PROX FINGER TUMOR       81                                       $98.45        20120901
26260       RESECT PROX FINGER TUMOR       82                                       $98.45        20120901
26260       RESECT PROX FINGER TUMOR       AS                                       $98.45        20120901
26260       RESECT PROX FINGER TUMOR                                              $492.27         20120901
26260       RESECT PROX FINGER TUMOR                              A               $507.20         20110101
26262       RESECT DISTAL FINGER TUMOR     80                                       $76.90        20120901
26262       RESECT DISTAL FINGER TUMOR     81                                       $76.90        20120901
26262       RESECT DISTAL FINGER TUMOR     82                                       $76.90        20120901
26262       RESECT DISTAL FINGER TUMOR     AS                                       $76.90        20120901
26262       RESECT DISTAL FINGER TUMOR                                            $384.49         20120901
26262       RESECT DISTAL FINGER TUMOR                            A               $494.96         20110101
26320       REMOVAL OF IMPLANT FROM HAND                                          $223.71         20120901
26320       REMOVAL OF IMPLANT FROM HAND                          A               $505.90         20110101
26340       MANIPULATE FINGER W/ANESTH                                            $205.88         20120901
26341       MANIPULAT PALM CORD POST INJ                                            $73.89        20120901
26350       REPAIR FINGER/HAND TENDON                                             $458.64         20120901
26350       REPAIR FINGER/HAND TENDON                             A               $742.43         20110101
26352       REPAIR/GRAFT HAND TENDON       80                                     $105.03         20120901
26352       REPAIR/GRAFT HAND TENDON       81                                     $105.03         20120901
26352       REPAIR/GRAFT HAND TENDON       82                                     $105.03         20120901
26352       REPAIR/GRAFT HAND TENDON       AS                                     $105.03         20120901
26352       REPAIR/GRAFT HAND TENDON                                              $525.14         20120901
26352       REPAIR/GRAFT HAND TENDON                              A               $799.26         20110101
26356       REPAIR FINGER/HAND TENDON                                             $698.41         20120901
26356       REPAIR FINGER/HAND TENDON                             A               $799.26         20110101
26357       REPAIR FINGER/HAND TENDON      80                                     $112.47         20120901
26357       REPAIR FINGER/HAND TENDON      81                                     $112.47         20120901
26357       REPAIR FINGER/HAND TENDON      82                                     $112.47         20120901



                                                Page 64
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
26357       REPAIR FINGER/HAND TENDON       AS                                    $112.47         20120901
26357       REPAIR FINGER/HAND TENDON                                             $562.34         20120901
26357       REPAIR FINGER/HAND TENDON                             A               $799.26         20110101
26358       REPAIR/GRAFT HAND TENDON        80                                    $119.14         20120901
26358       REPAIR/GRAFT HAND TENDON        81                                    $119.14         20120901
26358       REPAIR/GRAFT HAND TENDON        82                                    $119.14         20120901
26358       REPAIR/GRAFT HAND TENDON        AS                                    $119.14         20120901
26358       REPAIR/GRAFT HAND TENDON                                              $595.72         20120901
26358       REPAIR/GRAFT HAND TENDON                              A               $799.26         20110101
26370       REPAIR FINGER/HAND TENDON                                             $495.59         20120901
26370       REPAIR FINGER/HAND TENDON                             A               $799.26         20110101
26372       REPAIR/GRAFT HAND TENDON        80                                    $115.32         20120901
26372       REPAIR/GRAFT HAND TENDON        81                                    $115.32         20120901
26372       REPAIR/GRAFT HAND TENDON        82                                    $115.32         20120901
26372       REPAIR/GRAFT HAND TENDON        AS                                    $115.32         20120901
26372       REPAIR/GRAFT HAND TENDON                                              $576.61         20120901
26372       REPAIR/GRAFT HAND TENDON                              A               $799.26         20110101
26373       REPAIR FINGER/HAND TENDON       80                                    $109.92         20120901
26373       REPAIR FINGER/HAND TENDON       81                                    $109.92         20120901
26373       REPAIR FINGER/HAND TENDON       82                                    $109.92         20120901
26373       REPAIR FINGER/HAND TENDON       AS                                    $109.92         20120901
26373       REPAIR FINGER/HAND TENDON                                             $549.60         20120901
26373       REPAIR FINGER/HAND TENDON                             A               $776.30         20110101
26390       REVISE HAND/FINGER TENDON       80                                    $108.49         20120901
26390       REVISE HAND/FINGER TENDON       81                                    $108.49         20120901
26390       REVISE HAND/FINGER TENDON       82                                    $108.49         20120901
26390       REVISE HAND/FINGER TENDON       AS                                    $108.49         20120901
26390       REVISE HAND/FINGER TENDON                                             $542.47         20120901
26390       REVISE HAND/FINGER TENDON                             A               $799.26         20110101
26392       REPAIR/GRAFT HAND TENDON        80                                    $126.38         20120901
26392       REPAIR/GRAFT HAND TENDON        81                                    $126.38         20120901
26392       REPAIR/GRAFT HAND TENDON        82                                    $126.38         20120901
26392       REPAIR/GRAFT HAND TENDON        AS                                    $126.38         20120901
26392       REPAIR/GRAFT HAND TENDON                                              $631.90         20120901
26392       REPAIR/GRAFT HAND TENDON                              A               $776.30         20110101
26410       REPAIR HAND TENDON                                                    $363.60         20120901
26410       REPAIR HAND TENDON                                    A               $507.20         20110101
26412       REPAIR/GRAFT HAND TENDON        80                                      $88.47        20120901
26412       REPAIR/GRAFT HAND TENDON        81                                      $88.47        20120901
26412       REPAIR/GRAFT HAND TENDON        82                                      $88.47        20120901
26412       REPAIR/GRAFT HAND TENDON        AS                                      $88.47        20120901
26412       REPAIR/GRAFT HAND TENDON                                              $442.33         20120901
26412       REPAIR/GRAFT HAND TENDON                              A               $776.30         20110101
26415       EXCISION HAND/FINGER TENDON                                           $463.74         20120901
26415       EXCISION HAND/FINGER TENDON                           A               $799.26         20110101
26416       GRAFT HAND OR FINGER TENDON                                           $529.73         20120901
26416       GRAFT HAND OR FINGER TENDON                           A               $776.30         20110101
26418       REPAIR FINGER TENDON                                                  $367.17         20120901
26418       REPAIR FINGER TENDON                                  A               $530.17         20110101
26420       REPAIR/GRAFT FINGER TENDON      80                                      $92.49        20120901
26420       REPAIR/GRAFT FINGER TENDON      81                                      $92.49        20120901
26420       REPAIR/GRAFT FINGER TENDON      82                                      $92.49        20120901
26420       REPAIR/GRAFT FINGER TENDON      AS                                      $92.49        20120901
26420       REPAIR/GRAFT FINGER TENDON                                            $462.46         20120901
26420       REPAIR/GRAFT FINGER TENDON                            A               $799.26         20110101
26426       REPAIR FINGER/HAND TENDON                                             $362.84         20120901
26426       REPAIR FINGER/HAND TENDON                             A               $776.30         20110101
26428       REPAIR/GRAFT FINGER TENDON                                            $487.18         20120901
26428       REPAIR/GRAFT FINGER TENDON                            A               $776.30         20110101



                                              Page 65
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
26432       REPAIR FINGER TENDON                                                  $318.75         20120901
26432       REPAIR FINGER TENDON                                  A               $507.20         20110101
26433       REPAIR FINGER TENDON                                                  $341.69         20120901
26433       REPAIR FINGER TENDON                                  A               $507.20         20110101
26434       REPAIR/GRAFT FINGER TENDON     80                                       $82.86        20120901
26434       REPAIR/GRAFT FINGER TENDON     81                                       $82.86        20120901
26434       REPAIR/GRAFT FINGER TENDON     82                                       $82.86        20120901
26434       REPAIR/GRAFT FINGER TENDON     AS                                       $82.86        20120901
26434       REPAIR/GRAFT FINGER TENDON                                            $414.30         20120901
26434       REPAIR/GRAFT FINGER TENDON                            A               $776.30         20110101
26437       REALIGNMENT OF TENDONS                                                $400.29         20120901
26437       REALIGNMENT OF TENDONS                                A               $507.20         20110101
26440       RELEASE PALM/FINGER TENDON                                            $400.04         20120901
26440       RELEASE PALM/FINGER TENDON                            A               $507.20         20110101
26442       RELEASE PALM FINGER TENDON                                            $619.42         20120901
26442       RELEASE PALM FINGER TENDON                            A               $776.30         20110101
26445       RELEASE HAND/FINGER TENDON                                            $371.24         20120901
26445       RELEASE HAND/FINGER TENDON                            A               $507.20         20110101
26449       RELEASE FOREARM/HAND TENDON                                           $488.96         20120901
26449       RELEASE FOREARM/HAND TENDON                           A               $776.30         20110101
26450       INCISION OF PALM TENDON                                               $259.39         20120901
26450       INCISION OF PALM TENDON                               A               $507.20         20110101
26455       INCISION OF FINGER TENDON                                             $257.86         20120901
26455       INCISION OF FINGER TENDON                             A               $507.20         20110101
26460       INCISE HAND/FINGER TENDON                                             $250.21         20120901
26460       INCISE HAND/FINGER TENDON                             A               $507.20         20110101
26471       FUSION OF FINGER TENDONS                                              $395.19         20120901
26471       FUSION OF FINGER TENDONS                              A               $494.96         20110101
26474       FUSION OF FINGER TENDONS       80                                       $76.44        20120901
26474       FUSION OF FINGER TENDONS       81                                       $76.44        20120901
26474       FUSION OF FINGER TENDONS       82                                       $76.44        20120901
26474       FUSION OF FINGER TENDONS       AS                                       $76.44        20120901
26474       FUSION OF FINGER TENDONS                                              $382.20         20120901
26474       FUSION OF FINGER TENDONS                              A               $494.96         20110101
26476       TENDON LENGTHENING                                                    $373.03         20120901
26476       TENDON LENGTHENING                                    A               $473.34         20110101
26477       TENDON SHORTENING                                                     $373.54         20120901
26477       TENDON SHORTENING                                     A               $473.34         20110101
26478       LENGTHENING OF HAND TENDON                                            $403.35         20120901
26478       LENGTHENING OF HAND TENDON                            A               $473.34         20110101
26479       SHORTENING OF HAND TENDON      80                                       $80.26        20120901
26479       SHORTENING OF HAND TENDON      81                                       $80.26        20120901
26479       SHORTENING OF HAND TENDON      82                                       $80.26        20120901
26479       SHORTENING OF HAND TENDON      AS                                       $80.26        20120901
26479       SHORTENING OF HAND TENDON                                             $401.31         20120901
26479       SHORTENING OF HAND TENDON                             A               $473.34         20110101
26480       TRANSPLANT HAND TENDON         80                                       $97.08        20120901
26480       TRANSPLANT HAND TENDON         81                                       $97.08        20120901
26480       TRANSPLANT HAND TENDON         82                                       $97.08        20120901
26480       TRANSPLANT HAND TENDON         AS                                       $97.08        20120901
26480       TRANSPLANT HAND TENDON                                                $485.39         20120901
26480       TRANSPLANT HAND TENDON                                A               $776.30         20110101
26483       TRANSPLANT/GRAFT HAND TENDON   80                                     $109.51         20120901
26483       TRANSPLANT/GRAFT HAND TENDON   81                                     $109.51         20120901
26483       TRANSPLANT/GRAFT HAND TENDON   82                                     $109.51         20120901
26483       TRANSPLANT/GRAFT HAND TENDON   AS                                     $109.51         20120901
26483       TRANSPLANT/GRAFT HAND TENDON                                          $547.57         20120901
26483       TRANSPLANT/GRAFT HAND TENDON                          A               $776.30         20110101
26485       TRANSPLANT PALM TENDON         80                                     $104.88         20120901



                                                Page 66
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
26485       TRANSPLANT PALM TENDON         81                                    $104.88         20120901
26485       TRANSPLANT PALM TENDON         82                                    $104.88         20120901
26485       TRANSPLANT PALM TENDON         AS                                    $104.88         20120901
26485       TRANSPLANT PALM TENDON                                               $524.38         20120901
26485       TRANSPLANT PALM TENDON                               A               $764.05         20110101
26489       TRANSPLANT/GRAFT PALM TENDON                                         $582.98         20120901
26489       TRANSPLANT/GRAFT PALM TENDON                         A               $776.30         20110101
26490       REVISE THUMB TENDON                                                  $511.89         20120901
26490       REVISE THUMB TENDON                                  A               $776.30         20110101
26492       TENDON TRANSFER WITH GRAFT     80                                    $114.41         20120901
26492       TENDON TRANSFER WITH GRAFT     81                                    $114.41         20120901
26492       TENDON TRANSFER WITH GRAFT     82                                    $114.41         20120901
26492       TENDON TRANSFER WITH GRAFT     AS                                    $114.41         20120901
26492       TENDON TRANSFER WITH GRAFT                                           $572.03         20120901
26492       TENDON TRANSFER WITH GRAFT                           A               $776.30         20110101
26494       HAND TENDON/MUSCLE TRANSFER    80                                    $103.55         20120901
26494       HAND TENDON/MUSCLE TRANSFER    81                                    $103.55         20120901
26494       HAND TENDON/MUSCLE TRANSFER    82                                    $103.55         20120901
26494       HAND TENDON/MUSCLE TRANSFER    AS                                    $103.55         20120901
26494       HAND TENDON/MUSCLE TRANSFER                                          $517.75         20120901
26494       HAND TENDON/MUSCLE TRANSFER                          A               $776.30         20110101
26496       REVISE THUMB TENDON                                                  $558.01         20120901
26496       REVISE THUMB TENDON                                  A               $776.30         20110101
26497       FINGER TENDON TRANSFER         80                                    $112.57         20120901
26497       FINGER TENDON TRANSFER         81                                    $112.57         20120901
26497       FINGER TENDON TRANSFER         82                                    $112.57         20120901
26497       FINGER TENDON TRANSFER         AS                                    $112.57         20120901
26497       FINGER TENDON TRANSFER                                               $562.85         20120901
26497       FINGER TENDON TRANSFER                               A               $776.30         20110101
26498       FINGER TENDON TRANSFER         80                                    $150.38         20120901
26498       FINGER TENDON TRANSFER         81                                    $150.38         20120901
26498       FINGER TENDON TRANSFER         82                                    $150.38         20120901
26498       FINGER TENDON TRANSFER         AS                                    $150.38         20120901
26498       FINGER TENDON TRANSFER                                               $751.91         20120901
26498       FINGER TENDON TRANSFER                               A               $799.26         20110101
26499       REVISION OF FINGER             80                                    $107.58         20120901
26499       REVISION OF FINGER             81                                    $107.58         20120901
26499       REVISION OF FINGER             82                                    $107.58         20120901
26499       REVISION OF FINGER             AS                                    $107.58         20120901
26499       REVISION OF FINGER                                                   $537.88         20120901
26499       REVISION OF FINGER                                   A               $776.30         20110101
26500       HAND TENDON RECONSTRUCTION                                           $404.37         20120901
26500       HAND TENDON RECONSTRUCTION                           A               $530.17         20110101
26502       HAND TENDON RECONSTRUCTION     80                                      $91.52        20120901
26502       HAND TENDON RECONSTRUCTION     81                                      $91.52        20120901
26502       HAND TENDON RECONSTRUCTION     82                                      $91.52        20120901
26502       HAND TENDON RECONSTRUCTION     AS                                      $91.52        20120901
26502       HAND TENDON RECONSTRUCTION                                           $457.62         20120901
26502       HAND TENDON RECONSTRUCTION                           A               $799.26         20110101
26508       RELEASE THUMB CONTRACTURE                                            $403.86         20120901
26508       RELEASE THUMB CONTRACTURE                            A               $507.20         20110101
26510       THUMB TENDON TRANSFER                                                $384.75         20120901
26510       THUMB TENDON TRANSFER                                A               $776.30         20110101
26516       FUSION OF KNUCKLE JOINT                                              $453.80         20120901
26516       FUSION OF KNUCKLE JOINT                              A               $742.43         20110101
26517       FUSION OF KNUCKLE JOINTS       80                                    $107.37         20120901
26517       FUSION OF KNUCKLE JOINTS       81                                    $107.37         20120901
26517       FUSION OF KNUCKLE JOINTS       82                                    $107.37         20120901
26517       FUSION OF KNUCKLE JOINTS       AS                                    $107.37         20120901



                                             Page 67
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
26517       FUSION OF KNUCKLE JOINTS                                               $536.86        20120901
26517       FUSION OF KNUCKLE JOINTS                              A                $776.30        20110101
26518       FUSION OF KNUCKLE JOINTS       80                                      $108.70        20120901
26518       FUSION OF KNUCKLE JOINTS       81                                      $108.70        20120901
26518       FUSION OF KNUCKLE JOINTS       82                                      $108.70        20120901
26518       FUSION OF KNUCKLE JOINTS       AS                                      $108.70        20120901
26518       FUSION OF KNUCKLE JOINTS                                               $543.49        20120901
26518       FUSION OF KNUCKLE JOINTS                              A                $776.30        20110101
26520       RELEASE KNUCKLE CONTRACTURE                                            $419.66        20120901
26520       RELEASE KNUCKLE CONTRACTURE                           A                $507.20        20110101
26525       RELEASE FINGER CONTRACTURE                                             $420.42        20120901
26525       RELEASE FINGER CONTRACTURE                            A                $507.20        20110101
26530       REVISE KNUCKLE JOINT           80                                       $70.07        20120901
26530       REVISE KNUCKLE JOINT           81                                       $70.07        20120901
26530       REVISE KNUCKLE JOINT           82                                       $70.07        20120901
26530       REVISE KNUCKLE JOINT           AS                                       $70.07        20120901
26530       REVISE KNUCKLE JOINT                                                   $350.35        20120901
26530       REVISE KNUCKLE JOINT                                  A              $1,056.32        20110101
26531       REVISE KNUCKLE WITH IMPLANT    80                                       $81.59        20120901
26531       REVISE KNUCKLE WITH IMPLANT    81                                       $81.59        20120901
26531       REVISE KNUCKLE WITH IMPLANT    82                                       $81.59        20120901
26531       REVISE KNUCKLE WITH IMPLANT    AS                                       $81.59        20120901
26531       REVISE KNUCKLE WITH IMPLANT                                            $407.93        20120901
26531       REVISE KNUCKLE WITH IMPLANT                           A              $1,586.48        20110101
26535       REVISE FINGER JOINT                                                    $264.99        20120901
26535       REVISE FINGER JOINT                                   A              $1,095.93        20110101
26536       REVISE/IMPLANT FINGER JOINT    80                                       $87.80        20120901
26536       REVISE/IMPLANT FINGER JOINT    81                                       $87.80        20120901
26536       REVISE/IMPLANT FINGER JOINT    82                                       $87.80        20120901
26536       REVISE/IMPLANT FINGER JOINT    AS                                       $87.80        20120901
26536       REVISE/IMPLANT FINGER JOINT                                            $439.02        20120901
26536       REVISE/IMPLANT FINGER JOINT                           A              $1,533.29        20110101
26540       REPAIR HAND JOINT                                                      $426.03        20120901
26540       REPAIR HAND JOINT                                     A                $530.17        20110101
26541       REPAIR HAND JOINT WITH GRAFT   80                                      $104.26        20120901
26541       REPAIR HAND JOINT WITH GRAFT   81                                      $104.26        20120901
26541       REPAIR HAND JOINT WITH GRAFT   82                                      $104.26        20120901
26541       REPAIR HAND JOINT WITH GRAFT   AS                                      $104.26        20120901
26541       REPAIR HAND JOINT WITH GRAFT                                           $521.32        20120901
26541       REPAIR HAND JOINT WITH GRAFT                          A                $869.10        20110101
26542       REPAIR HAND JOINT WITH GRAFT                                           $439.53        20120901
26542       REPAIR HAND JOINT WITH GRAFT                          A                $530.17        20110101
26545       RECONSTRUCT FINGER JOINT                                               $449.47        20120901
26545       RECONSTRUCT FINGER JOINT                              A                $799.26        20110101
26546       REPAIR NONUNION HAND           80                                      $127.40        20120901
26546       REPAIR NONUNION HAND           81                                      $127.40        20120901
26546       REPAIR NONUNION HAND           82                                      $127.40        20120901
26546       REPAIR NONUNION HAND           AS                                      $127.40        20120901
26546       REPAIR NONUNION HAND                                                   $637.00        20120901
26546       REPAIR NONUNION HAND                                  A                $799.26        20110101
26548       RECONSTRUCT FINGER JOINT                                               $495.08        20120901
26548       RECONSTRUCT FINGER JOINT                              A                $799.26        20110101
26550       CONSTRUCT THUMB REPLACEMENT    80                                      $203.79        20120901
26550       CONSTRUCT THUMB REPLACEMENT    81                                      $203.79        20120901
26550       CONSTRUCT THUMB REPLACEMENT    82                                      $203.79        20120901
26550       CONSTRUCT THUMB REPLACEMENT    AS                                      $203.79        20120901
26550       CONSTRUCT THUMB REPLACEMENT                                          $1,018.95        20120901
26550       CONSTRUCT THUMB REPLACEMENT                           A                $764.05        20110101
26551       GREAT TOE-HAND TRANSFER        80                                      $430.10        20120901



                                                Page 68
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
26551       GREAT TOE-HAND TRANSFER         81                                      $430.10        20120901
26551       GREAT TOE-HAND TRANSFER         82                                      $430.10        20120901
26551       GREAT TOE-HAND TRANSFER         AS                                      $430.10        20120901
26551       GREAT TOE-HAND TRANSFER                                               $2,150.51        20120901
26553       SINGLE TRANSFER TOE-HAND        80                                      $369.56        20120901
26553       SINGLE TRANSFER TOE-HAND        81                                      $369.56        20120901
26553       SINGLE TRANSFER TOE-HAND        82                                      $369.56        20120901
26553       SINGLE TRANSFER TOE-HAND        AS                                      $369.56        20120901
26553       SINGLE TRANSFER TOE-HAND                                              $1,847.81        20120901
26554       DOUBLE TRANSFER TOE-HAND        80                                      $453.39        20120901
26554       DOUBLE TRANSFER TOE-HAND        81                                      $453.39        20120901
26554       DOUBLE TRANSFER TOE-HAND        82                                      $453.39        20120901
26554       DOUBLE TRANSFER TOE-HAND        AS                                      $453.39        20120901
26554       DOUBLE TRANSFER TOE-HAND                                              $2,266.96        20120901
26555       POSITIONAL CHANGE OF FINGER     80                                      $181.52        20120901
26555       POSITIONAL CHANGE OF FINGER     81                                      $181.52        20120901
26555       POSITIONAL CHANGE OF FINGER     82                                      $181.52        20120901
26555       POSITIONAL CHANGE OF FINGER     AS                                      $181.52        20120901
26555       POSITIONAL CHANGE OF FINGER                                             $907.60        20120901
26555       POSITIONAL CHANGE OF FINGER                            A                $776.30        20110101
26556       TOE JOINT TRANSFER              80                                      $369.05        20120901
26556       TOE JOINT TRANSFER              81                                      $369.05        20120901
26556       TOE JOINT TRANSFER              82                                      $369.05        20120901
26556       TOE JOINT TRANSFER              AS                                      $369.05        20120901
26556       TOE JOINT TRANSFER                                                    $1,845.26        20120901
26560       REPAIR OF WEB FINGER            80                                       $73.89        20120901
26560       REPAIR OF WEB FINGER            81                                       $73.89        20120901
26560       REPAIR OF WEB FINGER            82                                       $73.89        20120901
26560       REPAIR OF WEB FINGER            AS                                       $73.89        20120901
26560       REPAIR OF WEB FINGER                                                    $369.46        20120901
26560       REPAIR OF WEB FINGER                                   A                $494.96        20110101
26561       REPAIR OF WEB FINGER            80                                      $118.43        20120901
26561       REPAIR OF WEB FINGER            81                                      $118.43        20120901
26561       REPAIR OF WEB FINGER            82                                      $118.43        20120901
26561       REPAIR OF WEB FINGER            AS                                      $118.43        20120901
26561       REPAIR OF WEB FINGER                                                    $592.16        20120901
26561       REPAIR OF WEB FINGER                                   A                $776.30        20110101
26562       REPAIR OF WEB FINGER            80                                      $160.83        20120901
26562       REPAIR OF WEB FINGER            81                                      $160.83        20120901
26562       REPAIR OF WEB FINGER            82                                      $160.83        20120901
26562       REPAIR OF WEB FINGER            AS                                      $160.83        20120901
26562       REPAIR OF WEB FINGER                                                    $804.15        20120901
26562       REPAIR OF WEB FINGER                                   A                $799.26        20110101
26565       CORRECT METACARPAL FLAW         80                                       $88.01        20120901
26565       CORRECT METACARPAL FLAW         81                                       $88.01        20120901
26565       CORRECT METACARPAL FLAW         82                                       $88.01        20120901
26565       CORRECT METACARPAL FLAW         AS                                       $88.01        20120901
26565       CORRECT METACARPAL FLAW                                                 $440.04        20120901
26565       CORRECT METACARPAL FLAW                                A                $815.90        20110101
26567       CORRECT FINGER DEFORMITY                                                $441.06        20120901
26567       CORRECT FINGER DEFORMITY                               A                $815.90        20110101
26568       LENGTHEN METACARPAL/FINGER      80                                      $116.29        20120901
26568       LENGTHEN METACARPAL/FINGER      81                                      $116.29        20120901
26568       LENGTHEN METACARPAL/FINGER      82                                      $116.29        20120901
26568       LENGTHEN METACARPAL/FINGER      AS                                      $116.29        20120901
26568       LENGTHEN METACARPAL/FINGER                                              $581.45        20120901
26568       LENGTHEN METACARPAL/FINGER                             A                $776.30        20110101
26580       REPAIR HAND DEFORMITY           80                                      $190.03        20120901
26580       REPAIR HAND DEFORMITY           81                                      $190.03        20120901



                                                 Page 69
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1       Mod 2     Rate Type   Price          Effective Date
26580       REPAIR HAND DEFORMITY            82                                     $190.03        20120901
26580       REPAIR HAND DEFORMITY            AS                                     $190.03        20120901
26580       REPAIR HAND DEFORMITY                                                   $950.15        20120901
26580       REPAIR HAND DEFORMITY                                  A                $546.81        20110101
26587       RECONSTRUCT EXTRA FINGER         80                                     $129.29        20120901
26587       RECONSTRUCT EXTRA FINGER         81                                     $129.29        20120901
26587       RECONSTRUCT EXTRA FINGER         82                                     $129.29        20120901
26587       RECONSTRUCT EXTRA FINGER         AS                                     $129.29        20120901
26587       RECONSTRUCT EXTRA FINGER                                                $646.43        20120901
26587       RECONSTRUCT EXTRA FINGER                               A                $546.81        20110101
26590       REPAIR FINGER DEFORMITY          80                                     $172.45        20120901
26590       REPAIR FINGER DEFORMITY          81                                     $172.45        20120901
26590       REPAIR FINGER DEFORMITY          82                                     $172.45        20120901
26590       REPAIR FINGER DEFORMITY          AS                                     $172.45        20120901
26590       REPAIR FINGER DEFORMITY                                                 $862.24        20120901
26590       REPAIR FINGER DEFORMITY                                A                $546.81        20110101
26591       REPAIR MUSCLES OF HAND                                                  $279.01        20120901
26591       REPAIR MUSCLES OF HAND                                 A                $776.30        20110101
26593       RELEASE MUSCLES OF HAND                                                 $383.98        20120901
26593       RELEASE MUSCLES OF HAND                                A                $507.20        20110101
26596       EXCISION CONSTRICTING TISSUE     80                                      $96.88        20120901
26596       EXCISION CONSTRICTING TISSUE     81                                      $96.88        20120901
26596       EXCISION CONSTRICTING TISSUE     82                                      $96.88        20120901
26596       EXCISION CONSTRICTING TISSUE     AS                                      $96.88        20120901
26596       EXCISION CONSTRICTING TISSUE                                            $484.37        20120901
26596       EXCISION CONSTRICTING TISSUE                           A                $494.96        20110101
26600       TREAT METACARPAL FRACTURE                                               $177.60        20120901
26605       TREAT METACARPAL FRACTURE                                               $200.27        20120901
26605       TREAT METACARPAL FRACTURE                              A                 $59.66        20110101
26607       TREAT METACARPAL FRACTURE                                               $287.67        20120901
26607       TREAT METACARPAL FRACTURE                              A                $462.00        20110101
26608       TREAT METACARPAL FRACTURE                                               $308.56        20120901
26608       TREAT METACARPAL FRACTURE                              A                $741.74        20110101
26615       TREAT METACARPAL FRACTURE                                               $365.89        20120901
26615       TREAT METACARPAL FRACTURE                              A              $1,213.40        20110101
26641       TREAT THUMB DISLOCATION                                                 $233.40        20120901
26645       TREAT THUMB FRACTURE                                                    $264.99        20120901
26645       TREAT THUMB FRACTURE                                   A                $135.07        20110101
26650       TREAT THUMB FRACTURE                                                    $308.82        20120901
26650       TREAT THUMB FRACTURE                                   A                $706.54        20110101
26665       TREAT THUMB FRACTURE                                                    $405.64        20120901
26665       TREAT THUMB FRACTURE                                   A              $1,213.40        20110101
26670       TREAT HAND DISLOCATION                                                  $210.21        20120901
26675       TREAT HAND DISLOCATION                                                  $282.06        20120901
26675       TREAT HAND DISLOCATION                                 A                $135.07        20110101
26676       PIN HAND DISLOCATION                                                    $323.60        20120901
26676       PIN HAND DISLOCATION                                   A                $706.54        20110101
26685       TREAT HAND DISLOCATION                                                  $371.50        20120901
26685       TREAT HAND DISLOCATION                                 A                $718.78        20110101
26686       TREAT HAND DISLOCATION           80                                      $81.69        20120901
26686       TREAT HAND DISLOCATION           81                                      $81.69        20120901
26686       TREAT HAND DISLOCATION           82                                      $81.69        20120901
26686       TREAT HAND DISLOCATION           AS                                      $81.69        20120901
26686       TREAT HAND DISLOCATION                                                  $408.44        20120901
26686       TREAT HAND DISLOCATION                                 A              $1,671.34        20110101
26700       TREAT KNUCKLE DISLOCATION                                               $201.29        20120901
26705       TREAT KNUCKLE DISLOCATION                                               $258.37        20120901
26705       TREAT KNUCKLE DISLOCATION                              A                 $59.66        20110101
26706       PIN KNUCKLE DISLOCATION                                                 $282.06        20120901



                                               Page 70
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
26706       PIN KNUCKLE DISLOCATION                               A               $462.00         20110101
26715       TREAT KNUCKLE DISLOCATION                                             $365.13         20120901
26715       TREAT KNUCKLE DISLOCATION                             A               $741.74         20110101
26720       TREAT FINGER FRACTURE EACH                                            $121.28         20120901
26725       TREAT FINGER FRACTURE EACH                                            $214.03         20120901
26727       TREAT FINGER FRACTURE EACH                                            $303.47         20120901
26727       TREAT FINGER FRACTURE EACH                            A               $811.58         20110101
26735       TREAT FINGER FRACTURE EACH                                            $380.93         20120901
26735       TREAT FINGER FRACTURE EACH                            A               $741.74         20110101
26740       TREAT FINGER FRACTURE EACH                                            $140.39         20120901
26742       TREAT FINGER FRACTURE EACH                                            $234.42         20120901
26742       TREAT FINGER FRACTURE EACH                            A                 $59.66        20110101
26746       TREAT FINGER FRACTURE EACH                                            $473.93         20120901
26746       TREAT FINGER FRACTURE EACH                            A               $758.39         20110101
26750       TREAT FINGER FRACTURE EACH                                            $113.64         20120901
26755       TREAT FINGER FRACTURE EACH                                            $197.72         20120901
26756       PIN FINGER FRACTURE EACH                                              $268.05         20120901
26756       PIN FINGER FRACTURE EACH                              A               $706.54         20110101
26765       TREAT FINGER FRACTURE EACH                                            $313.66         20120901
26765       TREAT FINGER FRACTURE EACH                            A               $741.74         20110101
26770       TREAT FINGER DISLOCATION                                              $171.48         20120901
26775       TREAT FINGER DISLOCATION                                              $240.53         20120901
26776       PIN FINGER DISLOCATION                                                $284.61         20120901
26776       PIN FINGER DISLOCATION                                A               $706.54         20110101
26785       TREAT FINGER DISLOCATION                                              $342.71         20120901
26785       TREAT FINGER DISLOCATION                              A               $706.54         20110101
26820       THUMB FUSION WITH GRAFT         80                                    $102.23         20120901
26820       THUMB FUSION WITH GRAFT         81                                    $102.23         20120901
26820       THUMB FUSION WITH GRAFT         82                                    $102.23         20120901
26820       THUMB FUSION WITH GRAFT         AS                                    $102.23         20120901
26820       THUMB FUSION WITH GRAFT                                               $511.13         20120901
26820       THUMB FUSION WITH GRAFT                               A               $815.90         20110101
26841       FUSION OF THUMB                                                       $471.89         20120901
26841       FUSION OF THUMB                                       A               $799.26         20110101
26842       THUMB FUSION WITH GRAFT         80                                    $102.68         20120901
26842       THUMB FUSION WITH GRAFT         81                                    $102.68         20120901
26842       THUMB FUSION WITH GRAFT         82                                    $102.68         20120901
26842       THUMB FUSION WITH GRAFT         AS                                    $102.68         20120901
26842       THUMB FUSION WITH GRAFT                                               $513.42         20120901
26842       THUMB FUSION WITH GRAFT                               A               $799.26         20110101
26843       FUSION OF HAND JOINT            80                                      $95.45        20120901
26843       FUSION OF HAND JOINT            81                                      $95.45        20120901
26843       FUSION OF HAND JOINT            82                                      $95.45        20120901
26843       FUSION OF HAND JOINT            AS                                      $95.45        20120901
26843       FUSION OF HAND JOINT                                                  $477.24         20120901
26843       FUSION OF HAND JOINT                                  A               $776.30         20110101
26844       FUSION/GRAFT OF HAND JOINT      80                                    $106.51         20120901
26844       FUSION/GRAFT OF HAND JOINT      81                                    $106.51         20120901
26844       FUSION/GRAFT OF HAND JOINT      82                                    $106.51         20120901
26844       FUSION/GRAFT OF HAND JOINT      AS                                    $106.51         20120901
26844       FUSION/GRAFT OF HAND JOINT                                            $532.53         20120901
26844       FUSION/GRAFT OF HAND JOINT                            A               $776.30         20110101
26850       FUSION OF KNUCKLE                                                     $448.70         20120901
26850       FUSION OF KNUCKLE                                     A               $799.26         20110101
26852       FUSION OF KNUCKLE WITH GRAFT    80                                    $103.14         20120901
26852       FUSION OF KNUCKLE WITH GRAFT    81                                    $103.14         20120901
26852       FUSION OF KNUCKLE WITH GRAFT    82                                    $103.14         20120901
26852       FUSION OF KNUCKLE WITH GRAFT    AS                                    $103.14         20120901
26852       FUSION OF KNUCKLE WITH GRAFT                                          $515.72         20120901



                                              Page 71
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
26852       FUSION OF KNUCKLE WITH GRAFT                           A               $799.26         20110101
26860       FUSION OF FINGER JOINT                                                 $360.03         20120901
26860       FUSION OF FINGER JOINT                                 A               $776.30         20110101
26861       FUSION OF FINGER JNT ADD-ON                                              $71.34        20120901
26861       FUSION OF FINGER JNT ADD-ON                            A               $764.05         20110101
26862       FUSION/GRAFT OF FINGER JOINT    80                                       $93.82        20120901
26862       FUSION/GRAFT OF FINGER JOINT    81                                       $93.82        20120901
26862       FUSION/GRAFT OF FINGER JOINT    82                                       $93.82        20120901
26862       FUSION/GRAFT OF FINGER JOINT    AS                                       $93.82        20120901
26862       FUSION/GRAFT OF FINGER JOINT                                           $469.09         20120901
26862       FUSION/GRAFT OF FINGER JOINT                           A               $799.26         20110101
26863       FUSE/GRAFT ADDED JOINT          80                                       $32.00        20120901
26863       FUSE/GRAFT ADDED JOINT          81                                       $32.00        20120901
26863       FUSE/GRAFT ADDED JOINT          82                                       $32.00        20120901
26863       FUSE/GRAFT ADDED JOINT          AS                                       $32.00        20120901
26863       FUSE/GRAFT ADDED JOINT                                                 $160.01         20120901
26863       FUSE/GRAFT ADDED JOINT                                 A               $776.30         20110101
26910       AMPUTATE METACARPAL BONE                                               $464.50         20120901
26910       AMPUTATE METACARPAL BONE                               A               $776.30         20110101
26951       AMPUTATION OF FINGER/THUMB                                             $408.95         20120901
26951       AMPUTATION OF FINGER/THUMB                             A               $494.96         20110101
26952       AMPUTATION OF FINGER/THUMB                                             $418.64         20120901
26952       AMPUTATION OF FINGER/THUMB                             A               $530.17         20110101
26990       DRAINAGE OF PELVIS LESION                                              $407.68         20120901
26990       DRAINAGE OF PELVIS LESION                              A               $592.86         20110101
26991       DRAINAGE OF PELVIS BURSA                                               $452.52         20120901
26991       DRAINAGE OF PELVIS BURSA                               A               $592.86         20110101
26992       DRAINAGE OF BONE LESION                                                $639.04         20120901
27000       INCISION OF HIP TENDON                                                 $291.24         20120901
27000       INCISION OF HIP TENDON                                 A               $614.48         20110101
27001       INCISION OF HIP TENDON          80                                       $71.24        20120901
27001       INCISION OF HIP TENDON          81                                       $71.24        20120901
27001       INCISION OF HIP TENDON          82                                       $71.24        20120901
27001       INCISION OF HIP TENDON          AS                                       $71.24        20120901
27001       INCISION OF HIP TENDON                                                 $356.21         20120901
27001       INCISION OF HIP TENDON                                 A               $861.25         20110101
27003       INCISION OF HIP TENDON          80                                       $77.61        20120901
27003       INCISION OF HIP TENDON          81                                       $77.61        20120901
27003       INCISION OF HIP TENDON          82                                       $77.61        20120901
27003       INCISION OF HIP TENDON          AS                                       $77.61        20120901
27003       INCISION OF HIP TENDON                                                 $388.06         20120901
27003       INCISION OF HIP TENDON                                 A               $861.25         20110101
27005       INCISION OF HIP TENDON          80                                       $96.57        20120901
27005       INCISION OF HIP TENDON          81                                       $96.57        20120901
27005       INCISION OF HIP TENDON          82                                       $96.57        20120901
27005       INCISION OF HIP TENDON          AS                                       $96.57        20120901
27005       INCISION OF HIP TENDON                                                 $482.85         20120901
27006       INCISION OF HIP TENDONS         80                                       $97.64        20120901
27006       INCISION OF HIP TENDONS         81                                       $97.64        20120901
27006       INCISION OF HIP TENDONS         82                                       $97.64        20120901
27006       INCISION OF HIP TENDONS         AS                                       $97.64        20120901
27006       INCISION OF HIP TENDONS                                                $488.20         20120901
27025       INCISION OF HIP/THIGH FASCIA                                           $602.60         20120901
27030       DRAINAGE OF HIP JOINT           80                                     $125.97         20120901
27030       DRAINAGE OF HIP JOINT           81                                     $125.97         20120901
27030       DRAINAGE OF HIP JOINT           82                                     $125.97         20120901
27030       DRAINAGE OF HIP JOINT           AS                                     $125.97         20120901
27030       DRAINAGE OF HIP JOINT                                                  $629.87         20120901
27033       EXPLORATION OF HIP JOINT        80                                     $130.56         20120901



                                                 Page 72
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1       Mod 2     Rate Type   Price          Effective Date
27033       EXPLORATION OF HIP JOINT         81                                     $130.56        20120901
27033       EXPLORATION OF HIP JOINT         82                                     $130.56        20120901
27033       EXPLORATION OF HIP JOINT         AS                                     $130.56        20120901
27033       EXPLORATION OF HIP JOINT                                                $652.80        20120901
27033       EXPLORATION OF HIP JOINT                               A              $1,217.14        20110101
27035       DENERVATION OF HIP JOINT         80                                     $151.20        20120901
27035       DENERVATION OF HIP JOINT         81                                     $151.20        20120901
27035       DENERVATION OF HIP JOINT         82                                     $151.20        20120901
27035       DENERVATION OF HIP JOINT         AS                                     $151.20        20120901
27035       DENERVATION OF HIP JOINT                                                $755.99        20120901
27036       EXCISION OF HIP JOINT/MUSCLE     80                                     $134.23        20120901
27036       EXCISION OF HIP JOINT/MUSCLE     81                                     $134.23        20120901
27036       EXCISION OF HIP JOINT/MUSCLE     82                                     $134.23        20120901
27036       EXCISION OF HIP JOINT/MUSCLE     AS                                     $134.23        20120901
27036       EXCISION OF HIP JOINT/MUSCLE                                            $671.14        20120901
27040       BIOPSY OF SOFT TISSUES                                                  $220.15        20120901
27040       BIOPSY OF SOFT TISSUES                                 A                $260.88        20110101
27041       BIOPSY OF SOFT TISSUES                                                  $456.35        20120901
27041       BIOPSY OF SOFT TISSUES                                 A                $277.24        20110101
27043       EXC HIP PELVIS LES SC 3 CM/                                             $749.54        20100101
27045       EXC HIP/PELV TUM DEEP 5 CM/                                             $515.21        20120901
27047       EXC HIP/PELVIS LES SC 3 CM                                              $324.11        20120901
27047       EXC HIP/PELVIS LES SC 3 CM                             A                $160.12        20110101
27048       EXC HIP/PELV TUM DEEP 5 CM       80                                      $78.43        20120901
27048       EXC HIP/PELV TUM DEEP 5 CM       81                                      $78.43        20120901
27048       EXC HIP/PELV TUM DEEP 5 CM       82                                      $78.43        20120901
27048       EXC HIP/PELV TUM DEEP 5 CM       AS                                      $78.43        20120901
27048       EXC HIP/PELV TUM DEEP 5 CM                                              $392.14        20120901
27048       EXC HIP/PELV TUM DEEP 5 CM                             A                $560.76        20110101
27049       RESECT HIP/PELV TUM 5 CM         80                                     $174.64        20120901
27049       RESECT HIP/PELV TUM 5 CM         81                                     $174.64        20120901
27049       RESECT HIP/PELV TUM 5 CM         82                                     $174.64        20120901
27049       RESECT HIP/PELV TUM 5 CM         AS                                     $174.64        20120901
27049       RESECT HIP/PELV TUM 5 CM                                                $873.20        20120901
27049       RESECT HIP/PELV TUM 5 CM                               A                $560.76        20110101
27050       BIOPSY OF SACROILIAC JOINT                                              $240.53        20120901
27050       BIOPSY OF SACROILIAC JOINT                             A                $626.73        20110101
27052       BIOPSY OF HIP JOINT              80                                      $74.55        20120901
27052       BIOPSY OF HIP JOINT              81                                      $74.55        20120901
27052       BIOPSY OF HIP JOINT              82                                      $74.55        20120901
27052       BIOPSY OF HIP JOINT              AS                                      $74.55        20120901
27052       BIOPSY OF HIP JOINT                                                     $372.77        20120901
27052       BIOPSY OF HIP JOINT                                    A                $626.73        20110101
27054       REMOVAL OF HIP JOINT LINING      80                                      $90.30        20120901
27054       REMOVAL OF HIP JOINT LINING      81                                      $90.30        20120901
27054       REMOVAL OF HIP JOINT LINING      82                                      $90.30        20120901
27054       REMOVAL OF HIP JOINT LINING      AS                                      $90.30        20120901
27054       REMOVAL OF HIP JOINT LINING                                             $451.51        20120901
27059       RESECT HIP/PELV TUM 5 CM/                                             $1,263.55        20120901
27060       REMOVAL OF ISCHIAL BURSA                                                $285.12        20120901
27060       REMOVAL OF ISCHIAL BURSA                               A                $666.34        20110101
27062       REMOVE FEMUR LESION/BURSA                                               $296.84        20120901
27062       REMOVE FEMUR LESION/BURSA                              A                $666.34        20110101
27065       REMOVE HIP BONE LES SUPER        80                                      $66.45        20120901
27065       REMOVE HIP BONE LES SUPER        81                                      $66.45        20120901
27065       REMOVE HIP BONE LES SUPER        82                                      $66.45        20120901
27065       REMOVE HIP BONE LES SUPER        AS                                      $66.45        20120901
27065       REMOVE HIP BONE LES SUPER                                               $332.26        20120901
27065       REMOVE HIP BONE LES SUPER                              A                $666.34        20110101



                                               Page 73
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
27066       REMOVE HIP BONE LES DEEP        80                                      $107.58        20120901
27066       REMOVE HIP BONE LES DEEP        81                                      $107.58        20120901
27066       REMOVE HIP BONE LES DEEP        82                                      $107.58        20120901
27066       REMOVE HIP BONE LES DEEP        AS                                      $107.58        20120901
27066       REMOVE HIP BONE LES DEEP                                                $537.88        20120901
27066       REMOVE HIP BONE LES DEEP                               A                $900.86        20110101
27067       REMOVE/GRAFT HIP BONE LESION    80                                      $138.05        20120901
27067       REMOVE/GRAFT HIP BONE LESION    81                                      $138.05        20120901
27067       REMOVE/GRAFT HIP BONE LESION    82                                      $138.05        20120901
27067       REMOVE/GRAFT HIP BONE LESION    AS                                      $138.05        20120901
27067       REMOVE/GRAFT HIP BONE LESION                                            $690.25        20120901
27067       REMOVE/GRAFT HIP BONE LESION                           A                $900.86        20110101
27070       PART REMOVE HIP BONE SUPER      80                                      $112.93        20120901
27070       PART REMOVE HIP BONE SUPER      81                                      $112.93        20120901
27070       PART REMOVE HIP BONE SUPER      82                                      $112.93        20120901
27070       PART REMOVE HIP BONE SUPER      AS                                      $112.93        20120901
27070       PART REMOVE HIP BONE SUPER                                              $564.64        20120901
27071       PART REMOVAL HIP BONE DEEP      80                                      $120.88        20120901
27071       PART REMOVAL HIP BONE DEEP      81                                      $120.88        20120901
27071       PART REMOVAL HIP BONE DEEP      82                                      $120.88        20120901
27071       PART REMOVAL HIP BONE DEEP      AS                                      $120.88        20120901
27071       PART REMOVAL HIP BONE DEEP                                              $604.39        20120901
27075       RESECT HIP TUMOR                80                                      $284.71        20120901
27075       RESECT HIP TUMOR                81                                      $284.71        20120901
27075       RESECT HIP TUMOR                82                                      $284.71        20120901
27075       RESECT HIP TUMOR                AS                                      $284.71        20120901
27075       RESECT HIP TUMOR                                                      $1,423.57        20120901
27076       RESECT HIP TUM INCL ACETABUL    80                                      $316.77        20120901
27076       RESECT HIP TUM INCL ACETABUL    81                                      $316.77        20120901
27076       RESECT HIP TUM INCL ACETABUL    82                                      $316.77        20120901
27076       RESECT HIP TUM INCL ACETABUL    AS                                      $316.77        20120901
27076       RESECT HIP TUM INCL ACETABUL                                          $1,583.84        20120901
27077       RESECT HIP TUM W/INNOM BONE     80                                      $378.38        20120901
27077       RESECT HIP TUM W/INNOM BONE     81                                      $378.38        20120901
27077       RESECT HIP TUM W/INNOM BONE     82                                      $378.38        20120901
27077       RESECT HIP TUM W/INNOM BONE     AS                                      $378.38        20120901
27077       RESECT HIP TUM W/INNOM BONE                                           $1,891.89        20120901
27078       RSECT HIP TUM INCL FEMUR        80                                      $250.06        20120901
27078       RSECT HIP TUM INCL FEMUR        81                                      $250.06        20120901
27078       RSECT HIP TUM INCL FEMUR        82                                      $250.06        20120901
27078       RSECT HIP TUM INCL FEMUR        AS                                      $250.06        20120901
27078       RSECT HIP TUM INCL FEMUR                                              $1,250.30        20120901
27080       REMOVAL OF TAIL BONE            80                                       $66.50        20120901
27080       REMOVAL OF TAIL BONE            81                                       $66.50        20120901
27080       REMOVAL OF TAIL BONE            82                                       $66.50        20120901
27080       REMOVAL OF TAIL BONE            AS                                       $66.50        20120901
27080       REMOVAL OF TAIL BONE                                                    $332.51        20120901
27080       REMOVAL OF TAIL BONE                                   A                $849.00        20110101
27086       REMOVE HIP FOREIGN BODY                                                 $156.96        20120901
27086       REMOVE HIP FOREIGN BODY                                A                $260.88        20110101
27087       REMOVE HIP FOREIGN BODY         80                                       $84.08        20120901
27087       REMOVE HIP FOREIGN BODY         81                                       $84.08        20120901
27087       REMOVE HIP FOREIGN BODY         82                                       $84.08        20120901
27087       REMOVE HIP FOREIGN BODY         AS                                       $84.08        20120901
27087       REMOVE HIP FOREIGN BODY                                                 $420.42        20120901
27087       REMOVE HIP FOREIGN BODY                                A                $626.73        20110101
27090       REMOVAL OF HIP PROSTHESIS       80                                      $110.63        20120901
27090       REMOVAL OF HIP PROSTHESIS       81                                      $110.63        20120901
27090       REMOVAL OF HIP PROSTHESIS       82                                      $110.63        20120901



                                                 Page 74
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
27090       REMOVAL OF HIP PROSTHESIS      AS                                      $110.63        20120901
27090       REMOVAL OF HIP PROSTHESIS                                              $553.17        20120901
27091       REMOVAL OF HIP PROSTHESIS      80                                      $215.51        20120901
27091       REMOVAL OF HIP PROSTHESIS      81                                      $215.51        20120901
27091       REMOVAL OF HIP PROSTHESIS      82                                      $215.51        20120901
27091       REMOVAL OF HIP PROSTHESIS      AS                                      $215.51        20120901
27091       REMOVAL OF HIP PROSTHESIS                                            $1,077.55        20120901
27093       INJECTION FOR HIP X-RAY                                                $124.85        20120901
27095       INJECTION FOR HIP X-RAY                                                $151.61        20120901
27096       INJECT SACROILIAC JOINT                                                $118.23        20120901
27097       REVISION OF HIP TENDON         80                                       $88.77        20120901
27097       REVISION OF HIP TENDON         81                                       $88.77        20120901
27097       REVISION OF HIP TENDON         82                                       $88.77        20120901
27097       REVISION OF HIP TENDON         AS                                       $88.77        20120901
27097       REVISION OF HIP TENDON                                                 $443.86        20120901
27097       REVISION OF HIP TENDON                                A                $861.25        20110101
27098       TRANSFER TENDON TO PELVIS      80                                       $83.93        20120901
27098       TRANSFER TENDON TO PELVIS      81                                       $83.93        20120901
27098       TRANSFER TENDON TO PELVIS      82                                       $83.93        20120901
27098       TRANSFER TENDON TO PELVIS      AS                                       $83.93        20120901
27098       TRANSFER TENDON TO PELVIS                                              $419.66        20120901
27098       TRANSFER TENDON TO PELVIS                             A                $861.25        20110101
27100       TRANSFER OF ABDOMINAL MUSCLE   80                                      $109.16        20120901
27100       TRANSFER OF ABDOMINAL MUSCLE   81                                      $109.16        20120901
27100       TRANSFER OF ABDOMINAL MUSCLE   82                                      $109.16        20120901
27100       TRANSFER OF ABDOMINAL MUSCLE   AS                                      $109.16        20120901
27100       TRANSFER OF ABDOMINAL MUSCLE                                           $545.78        20120901
27100       TRANSFER OF ABDOMINAL MUSCLE                          A              $1,240.11        20110101
27105       TRANSFER OF SPINAL MUSCLE      80                                      $114.97        20120901
27105       TRANSFER OF SPINAL MUSCLE      81                                      $114.97        20120901
27105       TRANSFER OF SPINAL MUSCLE      82                                      $114.97        20120901
27105       TRANSFER OF SPINAL MUSCLE      AS                                      $114.97        20120901
27105       TRANSFER OF SPINAL MUSCLE                                              $574.83        20120901
27105       TRANSFER OF SPINAL MUSCLE                             A              $1,240.11        20110101
27110       TRANSFER OF ILIOPSOAS MUSCLE   80                                      $128.11        20120901
27110       TRANSFER OF ILIOPSOAS MUSCLE   81                                      $128.11        20120901
27110       TRANSFER OF ILIOPSOAS MUSCLE   82                                      $128.11        20120901
27110       TRANSFER OF ILIOPSOAS MUSCLE   AS                                      $128.11        20120901
27110       TRANSFER OF ILIOPSOAS MUSCLE                                           $640.57        20120901
27110       TRANSFER OF ILIOPSOAS MUSCLE                          A              $1,240.11        20110101
27111       TRANSFER OF ILIOPSOAS MUSCLE   80                                      $115.53        20120901
27111       TRANSFER OF ILIOPSOAS MUSCLE   81                                      $115.53        20120901
27111       TRANSFER OF ILIOPSOAS MUSCLE   82                                      $115.53        20120901
27111       TRANSFER OF ILIOPSOAS MUSCLE   AS                                      $115.53        20120901
27111       TRANSFER OF ILIOPSOAS MUSCLE                                           $577.63        20120901
27111       TRANSFER OF ILIOPSOAS MUSCLE                          A              $1,240.11        20110101
27120       RECONSTRUCTION OF HIP SOCKET   80                                      $173.37        20120901
27120       RECONSTRUCTION OF HIP SOCKET   81                                      $173.37        20120901
27120       RECONSTRUCTION OF HIP SOCKET   82                                      $173.37        20120901
27120       RECONSTRUCTION OF HIP SOCKET   AS                                      $173.37        20120901
27120       RECONSTRUCTION OF HIP SOCKET                                           $866.83        20120901
27122       RECONSTRUCTION OF HIP SOCKET   80                                      $147.89        20120901
27122       RECONSTRUCTION OF HIP SOCKET   81                                      $147.89        20120901
27122       RECONSTRUCTION OF HIP SOCKET   82                                      $147.89        20120901
27122       RECONSTRUCTION OF HIP SOCKET   AS                                      $147.89        20120901
27122       RECONSTRUCTION OF HIP SOCKET                                           $739.43        20120901
27125       PARTIAL HIP REPLACEMENT        80                                      $151.66        20120901
27125       PARTIAL HIP REPLACEMENT        81                                      $151.66        20120901
27125       PARTIAL HIP REPLACEMENT        82                                      $151.66        20120901



                                                Page 75
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1          Mod 2   Rate Type   Price          Effective Date
27125       PARTIAL HIP REPLACEMENT          AS                                      $151.66        20120901
27125       PARTIAL HIP REPLACEMENT                                                  $758.28        20120901
27130       TOTAL HIP ARTHROPLASTY           80                                      $194.62        20120901
27130       TOTAL HIP ARTHROPLASTY           81                                      $194.62        20120901
27130       TOTAL HIP ARTHROPLASTY           82                                      $194.62        20120901
27130       TOTAL HIP ARTHROPLASTY           AS                                      $194.62        20120901
27130       TOTAL HIP ARTHROPLASTY                                                   $973.08        20120901
27132       TOTAL HIP ARTHROPLASTY           80                                      $227.54        20120901
27132       TOTAL HIP ARTHROPLASTY           81                                      $227.54        20120901
27132       TOTAL HIP ARTHROPLASTY           82                                      $227.54        20120901
27132       TOTAL HIP ARTHROPLASTY           AS                                      $227.54        20120901
27132       TOTAL HIP ARTHROPLASTY                                                 $1,137.68        20120901
27134       REVISE HIP JOINT REPLACEMENT     80                                      $262.60        20120901
27134       REVISE HIP JOINT REPLACEMENT     81                                      $262.60        20120901
27134       REVISE HIP JOINT REPLACEMENT     82                                      $262.60        20120901
27134       REVISE HIP JOINT REPLACEMENT     AS                                      $262.60        20120901
27134       REVISE HIP JOINT REPLACEMENT                                           $1,312.98        20120901
27137       REVISE HIP JOINT REPLACEMENT     80                                      $200.48        20120901
27137       REVISE HIP JOINT REPLACEMENT     81                                      $200.48        20120901
27137       REVISE HIP JOINT REPLACEMENT     82                                      $200.48        20120901
27137       REVISE HIP JOINT REPLACEMENT     AS                                      $200.48        20120901
27137       REVISE HIP JOINT REPLACEMENT                                           $1,002.38        20120901
27138       REVISE HIP JOINT REPLACEMENT     80                                      $208.68        20120901
27138       REVISE HIP JOINT REPLACEMENT     81                                      $208.68        20120901
27138       REVISE HIP JOINT REPLACEMENT     82                                      $208.68        20120901
27138       REVISE HIP JOINT REPLACEMENT     AS                                      $208.68        20120901
27138       REVISE HIP JOINT REPLACEMENT                                           $1,043.41        20120901
27140       TRANSPLANT FEMUR RIDGE           80                                      $119.91        20120901
27140       TRANSPLANT FEMUR RIDGE           81                                      $119.91        20120901
27140       TRANSPLANT FEMUR RIDGE           82                                      $119.91        20120901
27140       TRANSPLANT FEMUR RIDGE           AS                                      $119.91        20120901
27140       TRANSPLANT FEMUR RIDGE                                                   $599.54        20120901
27146       INCISION OF HIP BONE             80                                      $170.72        20120901
27146       INCISION OF HIP BONE             81                                      $170.72        20120901
27146       INCISION OF HIP BONE             82                                      $170.72        20120901
27146       INCISION OF HIP BONE             AS                                      $170.72        20120901
27146       INCISION OF HIP BONE                                                     $853.58        20120901
27147       REVISION OF HIP BONE             80                                      $197.62        20120901
27147       REVISION OF HIP BONE             81                                      $197.62        20120901
27147       REVISION OF HIP BONE             82                                      $197.62        20120901
27147       REVISION OF HIP BONE             AS                                      $197.62        20120901
27147       REVISION OF HIP BONE                                                     $988.11        20120901
27151       INCISION OF HIP BONES            80                                      $208.12        20120901
27151       INCISION OF HIP BONES            81                                      $208.12        20120901
27151       INCISION OF HIP BONES            82                                      $208.12        20120901
27151       INCISION OF HIP BONES            AS                                      $208.12        20120901
27151       INCISION OF HIP BONES                                                  $1,040.60        20120901
27156       REVISION OF HIP BONES            80                                      $230.75        20120901
27156       REVISION OF HIP BONES            81                                      $230.75        20120901
27156       REVISION OF HIP BONES            82                                      $230.75        20120901
27156       REVISION OF HIP BONES            AS                                      $230.75        20120901
27156       REVISION OF HIP BONES                                                  $1,153.73        20120901
27158       REVISION OF PELVIS               80                                      $186.67        20120901
27158       REVISION OF PELVIS               81                                      $186.67        20120901
27158       REVISION OF PELVIS               82                                      $186.67        20120901
27158       REVISION OF PELVIS               AS                                      $186.67        20120901
27158       REVISION OF PELVIS                                                       $933.33        20120901
27161       INCISION OF NECK OF FEMUR        80                                      $163.48        20120901
27161       INCISION OF NECK OF FEMUR        81                                      $163.48        20120901



                                                  Page 76
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
27161       INCISION OF NECK OF FEMUR       82                                     $163.48        20120901
27161       INCISION OF NECK OF FEMUR       AS                                     $163.48        20120901
27161       INCISION OF NECK OF FEMUR                                              $817.40        20120901
27165       INCISION/FIXATION OF FEMUR      80                                     $184.22        20120901
27165       INCISION/FIXATION OF FEMUR      81                                     $184.22        20120901
27165       INCISION/FIXATION OF FEMUR      82                                     $184.22        20120901
27165       INCISION/FIXATION OF FEMUR      AS                                     $184.22        20120901
27165       INCISION/FIXATION OF FEMUR                                             $921.10        20120901
27170       REPAIR/GRAFT FEMUR HEAD/NECK    80                                     $158.74        20120901
27170       REPAIR/GRAFT FEMUR HEAD/NECK    81                                     $158.74        20120901
27170       REPAIR/GRAFT FEMUR HEAD/NECK    82                                     $158.74        20120901
27170       REPAIR/GRAFT FEMUR HEAD/NECK    AS                                     $158.74        20120901
27170       REPAIR/GRAFT FEMUR HEAD/NECK                                           $793.70        20120901
27175       TREAT SLIPPED EPIPHYSIS                                                $442.33        20120901
27176       TREAT SLIPPED EPIPHYSIS         80                                     $121.74        20120901
27176       TREAT SLIPPED EPIPHYSIS         81                                     $121.74        20120901
27176       TREAT SLIPPED EPIPHYSIS         82                                     $121.74        20120901
27176       TREAT SLIPPED EPIPHYSIS         AS                                     $121.74        20120901
27176       TREAT SLIPPED EPIPHYSIS                                                $608.72        20120901
27177       TREAT SLIPPED EPIPHYSIS         80                                     $148.75        20120901
27177       TREAT SLIPPED EPIPHYSIS         81                                     $148.75        20120901
27177       TREAT SLIPPED EPIPHYSIS         82                                     $148.75        20120901
27177       TREAT SLIPPED EPIPHYSIS         AS                                     $148.75        20120901
27177       TREAT SLIPPED EPIPHYSIS                                                $743.76        20120901
27178       TREAT SLIPPED EPIPHYSIS         80                                     $121.13        20120901
27178       TREAT SLIPPED EPIPHYSIS         81                                     $121.13        20120901
27178       TREAT SLIPPED EPIPHYSIS         82                                     $121.13        20120901
27178       TREAT SLIPPED EPIPHYSIS         AS                                     $121.13        20120901
27178       TREAT SLIPPED EPIPHYSIS                                                $605.66        20120901
27179       REVISE HEAD/NECK OF FEMUR       80                                     $130.05        20120901
27179       REVISE HEAD/NECK OF FEMUR       81                                     $130.05        20120901
27179       REVISE HEAD/NECK OF FEMUR       82                                     $130.05        20120901
27179       REVISE HEAD/NECK OF FEMUR       AS                                     $130.05        20120901
27179       REVISE HEAD/NECK OF FEMUR                                              $650.25        20120901
27181       TREAT SLIPPED EPIPHYSIS         80                                     $149.11        20120901
27181       TREAT SLIPPED EPIPHYSIS         81                                     $149.11        20120901
27181       TREAT SLIPPED EPIPHYSIS         82                                     $149.11        20120901
27181       TREAT SLIPPED EPIPHYSIS         AS                                     $149.11        20120901
27181       TREAT SLIPPED EPIPHYSIS                                                $745.54        20120901
27185       REVISION OF FEMUR EPIPHYSIS                                            $415.32        20120901
27187       REINFORCE HIP BONES             80                                     $132.90        20120901
27187       REINFORCE HIP BONES             81                                     $132.90        20120901
27187       REINFORCE HIP BONES             82                                     $132.90        20120901
27187       REINFORCE HIP BONES             AS                                     $132.90        20120901
27187       REINFORCE HIP BONES                                                    $664.52        20120901
27193       TREAT PELVIC RING FRACTURE                                             $307.29        20120901
27193       TREAT PELVIC RING FRACTURE                            A                 $59.66        20110101
27194       TREAT PELVIC RING FRACTURE                                             $466.54        20120901
27194       TREAT PELVIC RING FRACTURE                            A                $452.90        20110101
27200       TREAT TAIL BONE FRACTURE                                               $112.37        20120901
27202       TREAT TAIL BONE FRACTURE        80                                      $81.13        20120901
27202       TREAT TAIL BONE FRACTURE        81                                      $81.13        20120901
27202       TREAT TAIL BONE FRACTURE        82                                      $81.13        20120901
27202       TREAT TAIL BONE FRACTURE        AS                                      $81.13        20120901
27202       TREAT TAIL BONE FRACTURE                                               $405.64        20120901
27202       TREAT TAIL BONE FRACTURE                              A              $1,178.19        20110101
27215       TREAT PELVIC FRACTURES                                                 $445.65        20120901
27216       TREAT PELVIC RING FRACTURE                                             $658.15        20120901
27217       TREAT PELVIC RING FRACTURE                                             $622.48        20120901



                                              Page 77
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
27218       TREAT PELVIC RING FRACTURE                                              $851.54        20120901
27220       TREAT HIP SOCKET FRACTURE                                               $346.02        20120901
27222       TREAT HIP SOCKET FRACTURE                                               $653.56        20120901
27226       TREAT HIP WALL FRACTURE         80                                      $139.89        20120901
27226       TREAT HIP WALL FRACTURE         81                                      $139.89        20120901
27226       TREAT HIP WALL FRACTURE         82                                      $139.89        20120901
27226       TREAT HIP WALL FRACTURE         AS                                      $139.89        20120901
27226       TREAT HIP WALL FRACTURE                                                 $699.43        20120901
27227       TREAT HIP FRACTURES             80                                      $225.14        20120901
27227       TREAT HIP FRACTURES             81                                      $225.14        20120901
27227       TREAT HIP FRACTURES             82                                      $225.14        20120901
27227       TREAT HIP FRACTURES             AS                                      $225.14        20120901
27227       TREAT HIP FRACTURES                                                   $1,125.71        20120901
27228       TREAT HIP FRACTURES             80                                      $257.60        20120901
27228       TREAT HIP FRACTURES             81                                      $257.60        20120901
27228       TREAT HIP FRACTURES             82                                      $257.60        20120901
27228       TREAT HIP FRACTURES             AS                                      $257.60        20120901
27228       TREAT HIP FRACTURES                                                   $1,288.01        20120901
27230       TREAT THIGH FRACTURE                                                    $308.05        20120901
27230       TREAT THIGH FRACTURE                                   A                 $59.66        20110101
27232       TREAT THIGH FRACTURE                                                    $515.97        20120901
27235       TREAT THIGH FRACTURE                                                    $608.21        20120901
27236       TREAT THIGH FRACTURE            80                                      $160.27        20120901
27236       TREAT THIGH FRACTURE            81                                      $160.27        20120901
27236       TREAT THIGH FRACTURE            82                                      $160.27        20120901
27236       TREAT THIGH FRACTURE            AS                                      $160.27        20120901
27236       TREAT THIGH FRACTURE                                                    $801.35        20120901
27238       TREAT THIGH FRACTURE                                                    $298.37        20120901
27238       TREAT THIGH FRACTURE                                   A                $135.07        20110101
27240       TREAT THIGH FRACTURE                                                    $639.04        20120901
27244       TREAT THIGH FRACTURE            80                                      $164.86        20120901
27244       TREAT THIGH FRACTURE            81                                      $164.86        20120901
27244       TREAT THIGH FRACTURE            82                                      $164.86        20120901
27244       TREAT THIGH FRACTURE            AS                                      $164.86        20120901
27244       TREAT THIGH FRACTURE                                                    $824.28        20120901
27245       TREAT THIGH FRACTURE            80                                      $167.30        20120901
27245       TREAT THIGH FRACTURE            81                                      $167.30        20120901
27245       TREAT THIGH FRACTURE            82                                      $167.30        20120901
27245       TREAT THIGH FRACTURE            AS                                      $167.30        20120901
27245       TREAT THIGH FRACTURE                                                    $836.51        20120901
27246       TREAT THIGH FRACTURE                                                    $250.47        20120901
27246       TREAT THIGH FRACTURE                                   A                $135.07        20110101
27248       TREAT THIGH FRACTURE            80                                      $100.34        20120901
27248       TREAT THIGH FRACTURE            81                                      $100.34        20120901
27248       TREAT THIGH FRACTURE            82                                      $100.34        20120901
27248       TREAT THIGH FRACTURE            AS                                      $100.34        20120901
27248       TREAT THIGH FRACTURE                                                    $501.70        20120901
27250       TREAT HIP DISLOCATION                                                   $148.55        20120901
27250       TREAT HIP DISLOCATION                                  A                 $59.66        20110101
27252       TREAT HIP DISLOCATION                                                   $505.52        20120901
27252       TREAT HIP DISLOCATION                                  A                $452.90        20110101
27253       TREAT HIP DISLOCATION           80                                      $126.28        20120901
27253       TREAT HIP DISLOCATION           81                                      $126.28        20120901
27253       TREAT HIP DISLOCATION           82                                      $126.28        20120901
27253       TREAT HIP DISLOCATION           AS                                      $126.28        20120901
27253       TREAT HIP DISLOCATION                                                   $631.39        20120901
27254       TREAT HIP DISLOCATION           80                                      $170.51        20120901
27254       TREAT HIP DISLOCATION           81                                      $170.51        20120901
27254       TREAT HIP DISLOCATION           82                                      $170.51        20120901



                                                 Page 78
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1          Mod 2   Rate Type   Price          Effective Date
27254       TREAT HIP DISLOCATION            AS                                      $170.51        20120901
27254       TREAT HIP DISLOCATION                                                    $852.56        20120901
27256       TREAT HIP DISLOCATION                                                    $194.41        20120901
27257       TREAT HIP DISLOCATION                                                    $225.24        20120901
27257       TREAT HIP DISLOCATION                                   A                $465.14        20110101
27258       TREAT HIP DISLOCATION            80                                      $148.45        20120901
27258       TREAT HIP DISLOCATION            81                                      $148.45        20120901
27258       TREAT HIP DISLOCATION            82                                      $148.45        20120901
27258       TREAT HIP DISLOCATION            AS                                      $148.45        20120901
27258       TREAT HIP DISLOCATION                                                    $742.23        20120901
27259       TREAT HIP DISLOCATION            80                                      $208.53        20120901
27259       TREAT HIP DISLOCATION            81                                      $208.53        20120901
27259       TREAT HIP DISLOCATION            82                                      $208.53        20120901
27259       TREAT HIP DISLOCATION            AS                                      $208.53        20120901
27259       TREAT HIP DISLOCATION                                                  $1,042.64        20120901
27265       TREAT HIP DISLOCATION                                                    $259.13        20120901
27265       TREAT HIP DISLOCATION                                   A                 $59.66        20110101
27266       TREAT HIP DISLOCATION                                                    $382.71        20120901
27266       TREAT HIP DISLOCATION                                   A                $452.90        20110101
27267       CLTX THIGH FX                                                            $278.50        20120901
27267       CLTX THIGH FX                                           A                 $53.12        20110101
27268       CLTX THIGH FX W/MNPJ                                                     $343.47        20120901
27269       OPTX THIGH FX                                                            $821.98        20120901
27275       MANIPULATION OF HIP JOINT                                                $116.95        20120901
27275       MANIPULATION OF HIP JOINT                               A                $452.90        20110101
27280       FUSION OF SACROILIAC JOINT       80                                      $137.54        20120901
27280       FUSION OF SACROILIAC JOINT       81                                      $137.54        20120901
27280       FUSION OF SACROILIAC JOINT       82                                      $137.54        20120901
27280       FUSION OF SACROILIAC JOINT       AS                                      $137.54        20120901
27280       FUSION OF SACROILIAC JOINT                                               $687.71        20120901
27282       FUSION OF PUBIC BONES            80                                      $109.36        20120901
27282       FUSION OF PUBIC BONES            81                                      $109.36        20120901
27282       FUSION OF PUBIC BONES            82                                      $109.36        20120901
27282       FUSION OF PUBIC BONES            AS                                      $109.36        20120901
27282       FUSION OF PUBIC BONES                                                    $546.80        20120901
27284       FUSION OF HIP JOINT              80                                      $211.89        20120901
27284       FUSION OF HIP JOINT              81                                      $211.89        20120901
27284       FUSION OF HIP JOINT              82                                      $211.89        20120901
27284       FUSION OF HIP JOINT              AS                                      $211.89        20120901
27284       FUSION OF HIP JOINT                                                    $1,059.46        20120901
27286       FUSION OF HIP JOINT              80                                      $223.87        20120901
27286       FUSION OF HIP JOINT              81                                      $223.87        20120901
27286       FUSION OF HIP JOINT              82                                      $223.87        20120901
27286       FUSION OF HIP JOINT              AS                                      $223.87        20120901
27286       FUSION OF HIP JOINT                                                    $1,119.34        20120901
27290       AMPUTATION OF LEG AT HIP         80                                      $214.29        20120901
27290       AMPUTATION OF LEG AT HIP         81                                      $214.29        20120901
27290       AMPUTATION OF LEG AT HIP         82                                      $214.29        20120901
27290       AMPUTATION OF LEG AT HIP         AS                                      $214.29        20120901
27290       AMPUTATION OF LEG AT HIP                                               $1,071.43        20120901
27295       AMPUTATION OF LEG AT HIP         80                                      $171.23        20120901
27295       AMPUTATION OF LEG AT HIP         81                                      $171.23        20120901
27295       AMPUTATION OF LEG AT HIP         82                                      $171.23        20120901
27295       AMPUTATION OF LEG AT HIP         AS                                      $171.23        20120901
27295       AMPUTATION OF LEG AT HIP                                                 $856.13        20120901
27301       DRAIN THIGH/KNEE LESION                                                  $429.59        20120901
27301       DRAIN THIGH/KNEE LESION                                 A                $564.03        20110101
27303       DRAINAGE OF BONE LESION          80                                       $84.49        20120901
27303       DRAINAGE OF BONE LESION          81                                       $84.49        20120901



                                                  Page 79
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price         Effective Date
27303       DRAINAGE OF BONE LESION         82                                     $84.49        20120901
27303       DRAINAGE OF BONE LESION         AS                                     $84.49        20120901
27303       DRAINAGE OF BONE LESION                                               $422.46        20120901
27305       INCISE THIGH TENDON FASCIA      80                                     $62.02        20120901
27305       INCISE THIGH TENDON FASCIA      81                                     $62.02        20120901
27305       INCISE THIGH TENDON FASCIA      82                                     $62.02        20120901
27305       INCISE THIGH TENDON FASCIA      AS                                     $62.02        20120901
27305       INCISE THIGH TENDON FASCIA                                            $310.09        20120901
27305       INCISE THIGH TENDON FASCIA                            A               $614.48        20110101
27306       INCISION OF THIGH TENDON        80                                     $49.99        20120901
27306       INCISION OF THIGH TENDON        81                                     $49.99        20120901
27306       INCISION OF THIGH TENDON        82                                     $49.99        20120901
27306       INCISION OF THIGH TENDON        AS                                     $49.99        20120901
27306       INCISION OF THIGH TENDON                                              $249.96        20120901
27306       INCISION OF THIGH TENDON                              A               $626.73        20110101
27307       INCISION OF THIGH TENDONS       80                                     $61.66        20120901
27307       INCISION OF THIGH TENDONS       81                                     $61.66        20120901
27307       INCISION OF THIGH TENDONS       82                                     $61.66        20120901
27307       INCISION OF THIGH TENDONS       AS                                     $61.66        20120901
27307       INCISION OF THIGH TENDONS                                             $308.31        20120901
27307       INCISION OF THIGH TENDONS                             A               $626.73        20110101
27310       EXPLORATION OF KNEE JOINT       80                                     $96.57        20120901
27310       EXPLORATION OF KNEE JOINT       81                                     $96.57        20120901
27310       EXPLORATION OF KNEE JOINT       82                                     $96.57        20120901
27310       EXPLORATION OF KNEE JOINT       AS                                     $96.57        20120901
27310       EXPLORATION OF KNEE JOINT                                             $482.85        20120901
27310       EXPLORATION OF KNEE JOINT                             A               $884.21        20110101
27323       BIOPSY THIGH SOFT TISSUES                                             $173.01        20120901
27323       BIOPSY THIGH SOFT TISSUES                             A               $260.88        20110101
27324       BIOPSY THIGH SOFT TISSUES                                             $254.55        20120901
27324       BIOPSY THIGH SOFT TISSUES                             A               $625.87        20110101
27325       NEURECTOMY HAMSTRING                                                  $353.92        20120901
27325       NEURECTOMY HAMSTRING                                  A               $535.29        20110101
27326       NEURECTOMY POPLITEAL                                                  $325.12        20120901
27326       NEURECTOMY POPLITEAL                                  A               $535.29        20110101
27327       EXC THIGH/KNEE LES SC 3 CM                                            $279.01        20120901
27327       EXC THIGH/KNEE LES SC 3 CM                            A               $145.81        20110101
27328       EXC THIGH/KNEE TUM DEEP 5CM                                           $383.22        20120901
27328       EXC THIGH/KNEE TUM DEEP 5CM                           A               $560.76        20110101
27329       RESECT THIGH/KNEE TUM 5 CM      80                                    $139.73        20120901
27329       RESECT THIGH/KNEE TUM 5 CM      81                                    $139.73        20120901
27329       RESECT THIGH/KNEE TUM 5 CM      82                                    $139.73        20120901
27329       RESECT THIGH/KNEE TUM 5 CM      AS                                    $139.73        20120901
27329       RESECT THIGH/KNEE TUM 5 CM                                            $698.66        20120901
27329       RESECT THIGH/KNEE TUM 5 CM                            A               $560.76        20110101
27330       BIOPSY KNEE JOINT LINING                                              $261.93        20120901
27330       BIOPSY KNEE JOINT LINING                              A               $884.21        20110101
27331       EXPLORE/TREAT KNEE JOINT        80                                     $62.17        20120901
27331       EXPLORE/TREAT KNEE JOINT        81                                     $62.17        20120901
27331       EXPLORE/TREAT KNEE JOINT        82                                     $62.17        20120901
27331       EXPLORE/TREAT KNEE JOINT        AS                                     $62.17        20120901
27331       EXPLORE/TREAT KNEE JOINT                                              $310.86        20120901
27331       EXPLORE/TREAT KNEE JOINT                              A               $884.21        20110101
27332       REMOVAL OF KNEE CARTILAGE       80                                     $84.29        20120901
27332       REMOVAL OF KNEE CARTILAGE       81                                     $84.29        20120901
27332       REMOVAL OF KNEE CARTILAGE       82                                     $84.29        20120901
27332       REMOVAL OF KNEE CARTILAGE       AS                                     $84.29        20120901
27332       REMOVAL OF KNEE CARTILAGE                                             $421.44        20120901
27332       REMOVAL OF KNEE CARTILAGE                             A               $884.21        20110101



                                              Page 80
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price         Effective Date
27333       REMOVAL OF KNEE CARTILAGE       80                                      $76.59        20120901
27333       REMOVAL OF KNEE CARTILAGE       81                                      $76.59        20120901
27333       REMOVAL OF KNEE CARTILAGE       82                                      $76.59        20120901
27333       REMOVAL OF KNEE CARTILAGE       AS                                      $76.59        20120901
27333       REMOVAL OF KNEE CARTILAGE                                              $382.96        20120901
27333       REMOVAL OF KNEE CARTILAGE                              A               $884.21        20110101
27334       REMOVE KNEE JOINT LINING        80                                      $90.05        20120901
27334       REMOVE KNEE JOINT LINING        81                                      $90.05        20120901
27334       REMOVE KNEE JOINT LINING        82                                      $90.05        20120901
27334       REMOVE KNEE JOINT LINING        AS                                      $90.05        20120901
27334       REMOVE KNEE JOINT LINING                                               $450.23        20120901
27334       REMOVE KNEE JOINT LINING                               A               $884.21        20110101
27335       REMOVE KNEE JOINT LINING        80                                     $101.56        20120901
27335       REMOVE KNEE JOINT LINING        81                                     $101.56        20120901
27335       REMOVE KNEE JOINT LINING        82                                     $101.56        20120901
27335       REMOVE KNEE JOINT LINING        AS                                     $101.56        20120901
27335       REMOVE KNEE JOINT LINING                                               $507.82        20120901
27335       REMOVE KNEE JOINT LINING                               A               $884.21        20110101
27337       EXC THIGH/KNEE LES SC 3 CM/                                            $289.20        20120901
27339       EXC THIGH/KNEE TUM DEP 5CM/                                            $520.56        20120901
27340       REMOVAL OF KNEECAP BURSA                                               $238.75        20120901
27340       REMOVAL OF KNEECAP BURSA                               A               $626.73        20110101
27345       REMOVAL OF KNEE CYST            80                                      $63.19        20120901
27345       REMOVAL OF KNEE CYST            81                                      $63.19        20120901
27345       REMOVAL OF KNEE CYST            82                                      $63.19        20120901
27345       REMOVAL OF KNEE CYST            AS                                      $63.19        20120901
27345       REMOVAL OF KNEE CYST                                                   $315.95        20120901
27345       REMOVAL OF KNEE CYST                                   A               $649.69        20110101
27347       REMOVE KNEE CYST                80                                      $68.54        20120901
27347       REMOVE KNEE CYST                81                                      $68.54        20120901
27347       REMOVE KNEE CYST                82                                      $68.54        20120901
27347       REMOVE KNEE CYST                AS                                      $68.54        20120901
27347       REMOVE KNEE CYST                                                       $342.71        20120901
27347       REMOVE KNEE CYST                                       A               $649.69        20110101
27350       REMOVAL OF KNEECAP              80                                      $85.97        20120901
27350       REMOVAL OF KNEECAP              81                                      $85.97        20120901
27350       REMOVAL OF KNEECAP              82                                      $85.97        20120901
27350       REMOVAL OF KNEECAP              AS                                      $85.97        20120901
27350       REMOVAL OF KNEECAP                                                     $429.85        20120901
27350       REMOVAL OF KNEECAP                                     A               $884.21        20110101
27355       REMOVE FEMUR LESION             80                                      $79.60        20120901
27355       REMOVE FEMUR LESION             81                                      $79.60        20120901
27355       REMOVE FEMUR LESION             82                                      $79.60        20120901
27355       REMOVE FEMUR LESION             AS                                      $79.60        20120901
27355       REMOVE FEMUR LESION                                                    $398.00        20120901
27355       REMOVE FEMUR LESION                                    A               $861.25        20110101
27356       REMOVE FEMUR LESION/GRAFT       80                                      $97.64        20120901
27356       REMOVE FEMUR LESION/GRAFT       81                                      $97.64        20120901
27356       REMOVE FEMUR LESION/GRAFT       82                                      $97.64        20120901
27356       REMOVE FEMUR LESION/GRAFT       AS                                      $97.64        20120901
27356       REMOVE FEMUR LESION/GRAFT                                              $488.20        20120901
27356       REMOVE FEMUR LESION/GRAFT                              A               $884.21        20110101
27357       REMOVE FEMUR LESION/GRAFT       80                                     $107.83        20120901
27357       REMOVE FEMUR LESION/GRAFT       81                                     $107.83        20120901
27357       REMOVE FEMUR LESION/GRAFT       82                                     $107.83        20120901
27357       REMOVE FEMUR LESION/GRAFT       AS                                     $107.83        20120901
27357       REMOVE FEMUR LESION/GRAFT                                              $539.16        20120901
27357       REMOVE FEMUR LESION/GRAFT                              A               $900.86        20110101
27358       REMOVE FEMUR LESION/FIXATION    80                                      $38.83        20120901



                                                 Page 81
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price         Effective Date
27358       REMOVE FEMUR LESION/FIXATION    81                                      $38.83        20120901
27358       REMOVE FEMUR LESION/FIXATION    82                                      $38.83        20120901
27358       REMOVE FEMUR LESION/FIXATION    AS                                      $38.83        20120901
27358       REMOVE FEMUR LESION/FIXATION                                           $194.16        20120901
27358       REMOVE FEMUR LESION/FIXATION                           A               $900.86        20110101
27360       PARTIAL REMOVAL LEG BONES       80                                     $112.72        20120901
27360       PARTIAL REMOVAL LEG BONES       81                                     $112.72        20120901
27360       PARTIAL REMOVAL LEG BONES       82                                     $112.72        20120901
27360       PARTIAL REMOVAL LEG BONES       AS                                     $112.72        20120901
27360       PARTIAL REMOVAL LEG BONES                                              $563.62        20120901
27360       PARTIAL REMOVAL LEG BONES                              A               $900.86        20110101
27364       RESECT THIGH/KNEE TUM 5 CM/                                          $1,088.25        20120901
27365       RESECT FEMUR/KNEE TUMOR         80                                     $256.43        20120901
27365       RESECT FEMUR/KNEE TUMOR         81                                     $256.43        20120901
27365       RESECT FEMUR/KNEE TUMOR         82                                     $256.43        20120901
27365       RESECT FEMUR/KNEE TUMOR         AS                                     $256.43        20120901
27365       RESECT FEMUR/KNEE TUMOR                                              $1,282.15        20120901
27370       INJECTION FOR KNEE X-RAY                                               $108.54        20120901
27372       REMOVAL OF FOREIGN BODY                                                $384.24        20120901
27372       REMOVAL OF FOREIGN BODY                                A               $752.54        20110101
27380       REPAIR OF KNEECAP TENDON        80                                      $77.87        20120901
27380       REPAIR OF KNEECAP TENDON        81                                      $77.87        20120901
27380       REPAIR OF KNEECAP TENDON        82                                      $77.87        20120901
27380       REPAIR OF KNEECAP TENDON        AS                                      $77.87        20120901
27380       REPAIR OF KNEECAP TENDON                                               $389.33        20120901
27380       REPAIR OF KNEECAP TENDON                               A               $592.86        20110101
27381       REPAIR/GRAFT KNEECAP TENDON     80                                     $106.05        20120901
27381       REPAIR/GRAFT KNEECAP TENDON     81                                     $106.05        20120901
27381       REPAIR/GRAFT KNEECAP TENDON     82                                     $106.05        20120901
27381       REPAIR/GRAFT KNEECAP TENDON     AS                                     $106.05        20120901
27381       REPAIR/GRAFT KNEECAP TENDON                                            $530.24        20120901
27381       REPAIR/GRAFT KNEECAP TENDON                            A               $626.73        20110101
27385       REPAIR OF THIGH MUSCLE          80                                      $83.32        20120901
27385       REPAIR OF THIGH MUSCLE          81                                      $83.32        20120901
27385       REPAIR OF THIGH MUSCLE          82                                      $83.32        20120901
27385       REPAIR OF THIGH MUSCLE          AS                                      $83.32        20120901
27385       REPAIR OF THIGH MUSCLE                                                 $416.60        20120901
27385       REPAIR OF THIGH MUSCLE                                 A               $626.73        20110101
27386       REPAIR/GRAFT OF THIGH MUSCLE    80                                     $110.12        20120901
27386       REPAIR/GRAFT OF THIGH MUSCLE    81                                     $110.12        20120901
27386       REPAIR/GRAFT OF THIGH MUSCLE    82                                     $110.12        20120901
27386       REPAIR/GRAFT OF THIGH MUSCLE    AS                                     $110.12        20120901
27386       REPAIR/GRAFT OF THIGH MUSCLE                                           $550.62        20120901
27386       REPAIR/GRAFT OF THIGH MUSCLE                           A               $626.73        20110101
27390       INCISION OF THIGH TENDON        80                                      $57.94        20120901
27390       INCISION OF THIGH TENDON        81                                      $57.94        20120901
27390       INCISION OF THIGH TENDON        82                                      $57.94        20120901
27390       INCISION OF THIGH TENDON        AS                                      $57.94        20120901
27390       INCISION OF THIGH TENDON                                               $289.71        20120901
27390       INCISION OF THIGH TENDON                               A               $592.86        20110101
27391       INCISION OF THIGH TENDONS       80                                      $75.52        20120901
27391       INCISION OF THIGH TENDONS       81                                      $75.52        20120901
27391       INCISION OF THIGH TENDONS       82                                      $75.52        20120901
27391       INCISION OF THIGH TENDONS       AS                                      $75.52        20120901
27391       INCISION OF THIGH TENDONS                                              $377.61        20120901
27391       INCISION OF THIGH TENDONS                              A               $614.48        20110101
27392       INCISION OF THIGH TENDONS       80                                      $93.21        20120901
27392       INCISION OF THIGH TENDONS       81                                      $93.21        20120901
27392       INCISION OF THIGH TENDONS       82                                      $93.21        20120901



                                                 Page 82
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price         Effective Date
27392       INCISION OF THIGH TENDONS      AS                                      $93.21        20120901
27392       INCISION OF THIGH TENDONS                                             $466.03        20120901
27392       INCISION OF THIGH TENDONS                             A               $626.73        20110101
27393       LENGTHENING OF THIGH TENDON    80                                      $66.76        20120901
27393       LENGTHENING OF THIGH TENDON    81                                      $66.76        20120901
27393       LENGTHENING OF THIGH TENDON    82                                      $66.76        20120901
27393       LENGTHENING OF THIGH TENDON    AS                                      $66.76        20120901
27393       LENGTHENING OF THIGH TENDON                                           $333.79        20120901
27393       LENGTHENING OF THIGH TENDON                           A               $849.00        20110101
27394       LENGTHENING OF THIGH TENDONS   80                                      $86.22        20120901
27394       LENGTHENING OF THIGH TENDONS   81                                      $86.22        20120901
27394       LENGTHENING OF THIGH TENDONS   82                                      $86.22        20120901
27394       LENGTHENING OF THIGH TENDONS   AS                                      $86.22        20120901
27394       LENGTHENING OF THIGH TENDONS                                          $431.12        20120901
27394       LENGTHENING OF THIGH TENDONS                          A               $861.25        20110101
27395       LENGTHENING OF THIGH TENDONS   80                                     $116.75        20120901
27395       LENGTHENING OF THIGH TENDONS   81                                     $116.75        20120901
27395       LENGTHENING OF THIGH TENDONS   82                                     $116.75        20120901
27395       LENGTHENING OF THIGH TENDONS   AS                                     $116.75        20120901
27395       LENGTHENING OF THIGH TENDONS                                          $583.75        20120901
27395       LENGTHENING OF THIGH TENDONS                          A             $1,217.14        20110101
27396       TRANSPLANT OF THIGH TENDON     80                                      $81.13        20120901
27396       TRANSPLANT OF THIGH TENDON     81                                      $81.13        20120901
27396       TRANSPLANT OF THIGH TENDON     82                                      $81.13        20120901
27396       TRANSPLANT OF THIGH TENDON     AS                                      $81.13        20120901
27396       TRANSPLANT OF THIGH TENDON                                            $405.64        20120901
27396       TRANSPLANT OF THIGH TENDON                            A               $861.25        20110101
27397       TRANSPLANTS OF THIGH TENDONS   80                                     $120.88        20120901
27397       TRANSPLANTS OF THIGH TENDONS   81                                     $120.88        20120901
27397       TRANSPLANTS OF THIGH TENDONS   82                                     $120.88        20120901
27397       TRANSPLANTS OF THIGH TENDONS   AS                                     $120.88        20120901
27397       TRANSPLANTS OF THIGH TENDONS                                          $604.39        20120901
27397       TRANSPLANTS OF THIGH TENDONS                          A             $1,217.14        20110101
27400       REVISE THIGH MUSCLES/TENDONS   80                                      $91.32        20120901
27400       REVISE THIGH MUSCLES/TENDONS   81                                      $91.32        20120901
27400       REVISE THIGH MUSCLES/TENDONS   82                                      $91.32        20120901
27400       REVISE THIGH MUSCLES/TENDONS   AS                                      $91.32        20120901
27400       REVISE THIGH MUSCLES/TENDONS                                          $456.60        20120901
27400       REVISE THIGH MUSCLES/TENDONS                          A             $1,217.14        20110101
27403       REPAIR OF KNEE CARTILAGE       80                                      $84.80        20120901
27403       REPAIR OF KNEE CARTILAGE       81                                      $84.80        20120901
27403       REPAIR OF KNEE CARTILAGE       82                                      $84.80        20120901
27403       REPAIR OF KNEE CARTILAGE       AS                                      $84.80        20120901
27403       REPAIR OF KNEE CARTILAGE                                              $423.99        20120901
27403       REPAIR OF KNEE CARTILAGE                              A               $884.21        20110101
27405       REPAIR OF KNEE LIGAMENT        80                                      $89.54        20120901
27405       REPAIR OF KNEE LIGAMENT        81                                      $89.54        20120901
27405       REPAIR OF KNEE LIGAMENT        82                                      $89.54        20120901
27405       REPAIR OF KNEE LIGAMENT        AS                                      $89.54        20120901
27405       REPAIR OF KNEE LIGAMENT                                               $447.68        20120901
27405       REPAIR OF KNEE LIGAMENT                               A             $1,240.11        20110101
27407       REPAIR OF KNEE LIGAMENT        80                                     $102.99        20120901
27407       REPAIR OF KNEE LIGAMENT        81                                     $102.99        20120901
27407       REPAIR OF KNEE LIGAMENT        82                                     $102.99        20120901
27407       REPAIR OF KNEE LIGAMENT        AS                                     $102.99        20120901
27407       REPAIR OF KNEE LIGAMENT                                               $514.95        20120901
27407       REPAIR OF KNEE LIGAMENT                               A             $2,251.38        20110101
27409       REPAIR OF KNEE LIGAMENTS       80                                     $128.57        20120901
27409       REPAIR OF KNEE LIGAMENTS       81                                     $128.57        20120901



                                                Page 83
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
27409       REPAIR OF KNEE LIGAMENTS       82                                      $128.57        20120901
27409       REPAIR OF KNEE LIGAMENTS       AS                                      $128.57        20120901
27409       REPAIR OF KNEE LIGAMENTS                                               $642.86        20120901
27409       REPAIR OF KNEE LIGAMENTS                              A              $1,240.11        20110101
27412       AUTOCHONDROCYTE IMPLANT KNEE   80                                      $221.93        20120901
27412       AUTOCHONDROCYTE IMPLANT KNEE                                         $1,109.65        20120901
27415       OSTEOCHONDRAL KNEE ALLOGRAFT   80                                      $183.05        20120901
27415       OSTEOCHONDRAL KNEE ALLOGRAFT                                           $915.24        20120901
27416       OSTEOCHONDRAL KNEE AUTOGRAFT                                           $647.70        20120901
27418       REPAIR DEGENERATED KNEECAP     80                                      $110.84        20120901
27418       REPAIR DEGENERATED KNEECAP     81                                      $110.84        20120901
27418       REPAIR DEGENERATED KNEECAP     82                                      $110.84        20120901
27418       REPAIR DEGENERATED KNEECAP     AS                                      $110.84        20120901
27418       REPAIR DEGENERATED KNEECAP                                             $554.19        20120901
27418       REPAIR DEGENERATED KNEECAP                            A              $1,217.14        20110101
27420       REVISION OF UNSTABLE KNEECAP   80                                       $99.12        20120901
27420       REVISION OF UNSTABLE KNEECAP   81                                       $99.12        20120901
27420       REVISION OF UNSTABLE KNEECAP   82                                       $99.12        20120901
27420       REVISION OF UNSTABLE KNEECAP   AS                                       $99.12        20120901
27420       REVISION OF UNSTABLE KNEECAP                                           $495.59        20120901
27420       REVISION OF UNSTABLE KNEECAP                          A              $1,217.14        20110101
27422       REVISION OF UNSTABLE KNEECAP   80                                       $98.76        20120901
27422       REVISION OF UNSTABLE KNEECAP   81                                       $98.76        20120901
27422       REVISION OF UNSTABLE KNEECAP   82                                       $98.76        20120901
27422       REVISION OF UNSTABLE KNEECAP   AS                                       $98.76        20120901
27422       REVISION OF UNSTABLE KNEECAP                                           $493.80        20120901
27422       REVISION OF UNSTABLE KNEECAP                          A              $1,309.94        20110101
27424       REVISION/REMOVAL OF KNEECAP    80                                       $99.02        20120901
27424       REVISION/REMOVAL OF KNEECAP    81                                       $99.02        20120901
27424       REVISION/REMOVAL OF KNEECAP    82                                       $99.02        20120901
27424       REVISION/REMOVAL OF KNEECAP    AS                                       $99.02        20120901
27424       REVISION/REMOVAL OF KNEECAP                                            $495.08        20120901
27424       REVISION/REMOVAL OF KNEECAP                           A              $1,217.14        20110101
27425       LAT RETINACULAR RELEASE OPEN                                           $289.96        20120901
27425       LAT RETINACULAR RELEASE OPEN                          A                $954.05        20110101
27427       RECONSTRUCTION KNEE            80                                       $95.24        20120901
27427       RECONSTRUCTION KNEE            81                                       $95.24        20120901
27427       RECONSTRUCTION KNEE            82                                       $95.24        20120901
27427       RECONSTRUCTION KNEE            AS                                       $95.24        20120901
27427       RECONSTRUCTION KNEE                                                    $476.22        20120901
27427       RECONSTRUCTION KNEE                                   A              $1,217.14        20110101
27428       RECONSTRUCTION KNEE            80                                      $147.84        20120901
27428       RECONSTRUCTION KNEE            81                                      $147.84        20120901
27428       RECONSTRUCTION KNEE            82                                      $147.84        20120901
27428       RECONSTRUCTION KNEE            AS                                      $147.84        20120901
27428       RECONSTRUCTION KNEE                                                    $739.17        20120901
27428       RECONSTRUCTION KNEE                                   A              $2,251.38        20110101
27429       RECONSTRUCTION KNEE            80                                      $165.98        20120901
27429       RECONSTRUCTION KNEE            81                                      $165.98        20120901
27429       RECONSTRUCTION KNEE            82                                      $165.98        20120901
27429       RECONSTRUCTION KNEE            AS                                      $165.98        20120901
27429       RECONSTRUCTION KNEE                                                    $829.88        20120901
27429       RECONSTRUCTION KNEE                                   A              $2,251.38        20110101
27430       REVISION OF THIGH MUSCLES      80                                       $98.20        20120901
27430       REVISION OF THIGH MUSCLES      81                                       $98.20        20120901
27430       REVISION OF THIGH MUSCLES      82                                       $98.20        20120901
27430       REVISION OF THIGH MUSCLES      AS                                       $98.20        20120901
27430       REVISION OF THIGH MUSCLES                                              $491.00        20120901
27430       REVISION OF THIGH MUSCLES                             A              $1,240.11        20110101



                                                Page 84
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
27435       INCISION OF KNEE JOINT          80                                      $106.46        20120901
27435       INCISION OF KNEE JOINT          81                                      $106.46        20120901
27435       INCISION OF KNEE JOINT          82                                      $106.46        20120901
27435       INCISION OF KNEE JOINT          AS                                      $106.46        20120901
27435       INCISION OF KNEE JOINT                                                  $532.28        20120901
27435       INCISION OF KNEE JOINT                                 A              $1,240.11        20110101
27437       REVISE KNEECAP                                                          $436.73        20120901
27437       REVISE KNEECAP                                         A              $1,079.29        20110101
27438       REVISE KNEECAP WITH IMPLANT     80                                      $112.01        20120901
27438       REVISE KNEECAP WITH IMPLANT     81                                      $112.01        20120901
27438       REVISE KNEECAP WITH IMPLANT     82                                      $112.01        20120901
27438       REVISE KNEECAP WITH IMPLANT     AS                                      $112.01        20120901
27438       REVISE KNEECAP WITH IMPLANT                                             $560.05        20120901
27438       REVISE KNEECAP WITH IMPLANT                            A              $1,533.29        20110101
27440       REVISION OF KNEE JOINT          80                                      $103.25        20120901
27440       REVISION OF KNEE JOINT          81                                      $103.25        20120901
27440       REVISION OF KNEE JOINT          82                                      $103.25        20120901
27440       REVISION OF KNEE JOINT          AS                                      $103.25        20120901
27440       REVISION OF KNEE JOINT                                                  $516.22        20120901
27440       REVISION OF KNEE JOINT                                 A              $1,278.32        20110101
27441       REVISION OF KNEE JOINT          80                                      $106.66        20120901
27441       REVISION OF KNEE JOINT          81                                      $106.66        20120901
27441       REVISION OF KNEE JOINT          82                                      $106.66        20120901
27441       REVISION OF KNEE JOINT          AS                                      $106.66        20120901
27441       REVISION OF KNEE JOINT                                                  $533.30        20120901
27441       REVISION OF KNEE JOINT                                 A              $1,095.93        20110101
27442       REVISION OF KNEE JOINT          80                                      $115.88        20120901
27442       REVISION OF KNEE JOINT          81                                      $115.88        20120901
27442       REVISION OF KNEE JOINT          82                                      $115.88        20120901
27442       REVISION OF KNEE JOINT          AS                                      $115.88        20120901
27442       REVISION OF KNEE JOINT                                                  $579.42        20120901
27442       REVISION OF KNEE JOINT                                 A              $1,095.93        20110101
27443       REVISION OF KNEE JOINT          80                                      $108.49        20120901
27443       REVISION OF KNEE JOINT          81                                      $108.49        20120901
27443       REVISION OF KNEE JOINT          82                                      $108.49        20120901
27443       REVISION OF KNEE JOINT          AS                                      $108.49        20120901
27443       REVISION OF KNEE JOINT                                                  $542.47        20120901
27443       REVISION OF KNEE JOINT                                 A              $1,095.93        20110101
27445       REVISION OF KNEE JOINT          80                                      $169.14        20120901
27445       REVISION OF KNEE JOINT          81                                      $169.14        20120901
27445       REVISION OF KNEE JOINT          82                                      $169.14        20120901
27445       REVISION OF KNEE JOINT          AS                                      $169.14        20120901
27445       REVISION OF KNEE JOINT                                                  $845.68        20120901
27446       REVISION OF KNEE JOINT          80                                      $149.36        20120901
27446       REVISION OF KNEE JOINT          81                                      $149.36        20120901
27446       REVISION OF KNEE JOINT          82                                      $149.36        20120901
27446       REVISION OF KNEE JOINT          AS                                      $149.36        20120901
27446       REVISION OF KNEE JOINT                                                  $746.82        20120901
27447       TOTAL KNEE ARTHROPLASTY         80                                      $208.12        20120901
27447       TOTAL KNEE ARTHROPLASTY         81                                      $208.12        20120901
27447       TOTAL KNEE ARTHROPLASTY         82                                      $208.12        20120901
27447       TOTAL KNEE ARTHROPLASTY         AS                                      $208.12        20120901
27447       TOTAL KNEE ARTHROPLASTY                                               $1,040.60        20120901
27448       INCISION OF THIGH               80                                      $109.21        20120901
27448       INCISION OF THIGH               81                                      $109.21        20120901
27448       INCISION OF THIGH               82                                      $109.21        20120901
27448       INCISION OF THIGH               AS                                      $109.21        20120901
27448       INCISION OF THIGH                                                       $546.04        20120901
27450       INCISION OF THIGH               80                                      $136.27        20120901



                                                 Page 85
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price         Effective Date
27450       INCISION OF THIGH              81                                     $136.27        20120901
27450       INCISION OF THIGH              82                                     $136.27        20120901
27450       INCISION OF THIGH              AS                                     $136.27        20120901
27450       INCISION OF THIGH                                                     $681.34        20120901
27454       REALIGNMENT OF THIGH BONE      80                                     $172.86        20120901
27454       REALIGNMENT OF THIGH BONE      81                                     $172.86        20120901
27454       REALIGNMENT OF THIGH BONE      82                                     $172.86        20120901
27454       REALIGNMENT OF THIGH BONE      AS                                     $172.86        20120901
27454       REALIGNMENT OF THIGH BONE                                             $864.28        20120901
27455       REALIGNMENT OF KNEE            80                                     $125.67        20120901
27455       REALIGNMENT OF KNEE            81                                     $125.67        20120901
27455       REALIGNMENT OF KNEE            82                                     $125.67        20120901
27455       REALIGNMENT OF KNEE            AS                                     $125.67        20120901
27455       REALIGNMENT OF KNEE                                                   $628.34        20120901
27457       REALIGNMENT OF KNEE            80                                     $129.34        20120901
27457       REALIGNMENT OF KNEE            81                                     $129.34        20120901
27457       REALIGNMENT OF KNEE            82                                     $129.34        20120901
27457       REALIGNMENT OF KNEE            AS                                     $129.34        20120901
27457       REALIGNMENT OF KNEE                                                   $646.68        20120901
27465       SHORTENING OF THIGH BONE       80                                     $166.33        20120901
27465       SHORTENING OF THIGH BONE       81                                     $166.33        20120901
27465       SHORTENING OF THIGH BONE       82                                     $166.33        20120901
27465       SHORTENING OF THIGH BONE       AS                                     $166.33        20120901
27465       SHORTENING OF THIGH BONE                                              $831.67        20120901
27466       LENGTHENING OF THIGH BONE      80                                     $158.89        20120901
27466       LENGTHENING OF THIGH BONE      81                                     $158.89        20120901
27466       LENGTHENING OF THIGH BONE      82                                     $158.89        20120901
27466       LENGTHENING OF THIGH BONE      AS                                     $158.89        20120901
27466       LENGTHENING OF THIGH BONE                                             $794.47        20120901
27468       SHORTEN/LENGTHEN THIGHS        80                                     $179.69        20120901
27468       SHORTEN/LENGTHEN THIGHS        81                                     $179.69        20120901
27468       SHORTEN/LENGTHEN THIGHS        82                                     $179.69        20120901
27468       SHORTEN/LENGTHEN THIGHS        AS                                     $179.69        20120901
27468       SHORTEN/LENGTHEN THIGHS                                               $898.42        20120901
27470       REPAIR OF THIGH                80                                     $158.28        20120901
27470       REPAIR OF THIGH                81                                     $158.28        20120901
27470       REPAIR OF THIGH                82                                     $158.28        20120901
27470       REPAIR OF THIGH                AS                                     $158.28        20120901
27470       REPAIR OF THIGH                                                       $791.41        20120901
27472       REPAIR/GRAFT OF THIGH          80                                     $170.77        20120901
27472       REPAIR/GRAFT OF THIGH          81                                     $170.77        20120901
27472       REPAIR/GRAFT OF THIGH          82                                     $170.77        20120901
27472       REPAIR/GRAFT OF THIGH          AS                                     $170.77        20120901
27472       REPAIR/GRAFT OF THIGH                                                 $853.83        20120901
27475       SURGERY TO STOP LEG GROWTH                                            $436.98        20120901
27477       SURGERY TO STOP LEG GROWTH                                            $485.65        20120901
27479       SURGERY TO STOP LEG GROWTH     80                                     $113.28        20120901
27479       SURGERY TO STOP LEG GROWTH     81                                     $113.28        20120901
27479       SURGERY TO STOP LEG GROWTH     82                                     $113.28        20120901
27479       SURGERY TO STOP LEG GROWTH     AS                                     $113.28        20120901
27479       SURGERY TO STOP LEG GROWTH                                            $566.42        20120901
27485       SURGERY TO STOP LEG GROWTH                                            $444.37        20120901
27486       REVISE/REPLACE KNEE JOINT      80                                     $190.18        20120901
27486       REVISE/REPLACE KNEE JOINT      81                                     $190.18        20120901
27486       REVISE/REPLACE KNEE JOINT      82                                     $190.18        20120901
27486       REVISE/REPLACE KNEE JOINT      AS                                     $190.18        20120901
27486       REVISE/REPLACE KNEE JOINT                                             $950.91        20120901
27487       REVISE/REPLACE KNEE JOINT      80                                     $239.36        20120901
27487       REVISE/REPLACE KNEE JOINT      81                                     $239.36        20120901



                                                Page 86
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price          Effective Date
27487       REVISE/REPLACE KNEE JOINT      82                                      $239.36        20120901
27487       REVISE/REPLACE KNEE JOINT      AS                                      $239.36        20120901
27487       REVISE/REPLACE KNEE JOINT                                            $1,196.80        20120901
27488       REMOVAL OF KNEE PROSTHESIS     80                                      $161.34        20120901
27488       REMOVAL OF KNEE PROSTHESIS     81                                      $161.34        20120901
27488       REMOVAL OF KNEE PROSTHESIS     82                                      $161.34        20120901
27488       REMOVAL OF KNEE PROSTHESIS     AS                                      $161.34        20120901
27488       REMOVAL OF KNEE PROSTHESIS                                             $806.70        20120901
27495       REINFORCE THIGH                80                                      $151.86        20120901
27495       REINFORCE THIGH                81                                      $151.86        20120901
27495       REINFORCE THIGH                82                                      $151.86        20120901
27495       REINFORCE THIGH                AS                                      $151.86        20120901
27495       REINFORCE THIGH                                                        $759.30        20120901
27496       DECOMPRESSION OF THIGH/KNEE                                            $339.90        20120901
27496       DECOMPRESSION OF THIGH/KNEE                           A                $900.86        20110101
27497       DECOMPRESSION OF THIGH/KNEE                                            $368.19        20120901
27497       DECOMPRESSION OF THIGH/KNEE                           A                $626.73        20110101
27498       DECOMPRESSION OF THIGH/KNEE    80                                       $81.08        20120901
27498       DECOMPRESSION OF THIGH/KNEE    81                                       $81.08        20120901
27498       DECOMPRESSION OF THIGH/KNEE    82                                       $81.08        20120901
27498       DECOMPRESSION OF THIGH/KNEE    AS                                       $81.08        20120901
27498       DECOMPRESSION OF THIGH/KNEE                                            $405.39        20120901
27498       DECOMPRESSION OF THIGH/KNEE                           A                $861.25        20110101
27499       DECOMPRESSION OF THIGH/KNEE    80                                       $88.82        20120901
27499       DECOMPRESSION OF THIGH/KNEE    81                                       $88.82        20120901
27499       DECOMPRESSION OF THIGH/KNEE    82                                       $88.82        20120901
27499       DECOMPRESSION OF THIGH/KNEE    AS                                       $88.82        20120901
27499       DECOMPRESSION OF THIGH/KNEE                                            $444.12        20120901
27499       DECOMPRESSION OF THIGH/KNEE                           A                $861.25        20110101
27500       TREATMENT OF THIGH FRACTURE                                            $335.06        20120901
27500       TREATMENT OF THIGH FRACTURE                           A                $135.07        20110101
27501       TREATMENT OF THIGH FRACTURE                                            $329.71        20120901
27501       TREATMENT OF THIGH FRACTURE                           A                 $59.66        20110101
27502       TREATMENT OF THIGH FRACTURE                                            $524.38        20120901
27502       TREATMENT OF THIGH FRACTURE                           A                $462.00        20110101
27503       TREATMENT OF THIGH FRACTURE                                            $533.81        20120901
27503       TREATMENT OF THIGH FRACTURE                           A                 $59.66        20110101
27506       TREATMENT OF THIGH FRACTURE    80                                      $179.48        20120901
27506       TREATMENT OF THIGH FRACTURE    81                                      $179.48        20120901
27506       TREATMENT OF THIGH FRACTURE    82                                      $179.48        20120901
27506       TREATMENT OF THIGH FRACTURE    AS                                      $179.48        20120901
27506       TREATMENT OF THIGH FRACTURE                                            $897.41        20120901
27507       TREATMENT OF THIGH FRACTURE    80                                      $131.63        20120901
27507       TREATMENT OF THIGH FRACTURE    81                                      $131.63        20120901
27507       TREATMENT OF THIGH FRACTURE    82                                      $131.63        20120901
27507       TREATMENT OF THIGH FRACTURE    AS                                      $131.63        20120901
27507       TREATMENT OF THIGH FRACTURE                                            $658.15        20120901
27508       TREATMENT OF THIGH FRACTURE                                            $338.88        20120901
27508       TREATMENT OF THIGH FRACTURE                           A                 $59.66        20110101
27509       TREATMENT OF THIGH FRACTURE                                            $423.99        20120901
27509       TREATMENT OF THIGH FRACTURE                           A                $718.78        20110101
27510       TREATMENT OF THIGH FRACTURE                                            $463.23        20120901
27510       TREATMENT OF THIGH FRACTURE                           A                $135.07        20110101
27511       TREATMENT OF THIGH FRACTURE    80                                      $136.62        20120901
27511       TREATMENT OF THIGH FRACTURE    81                                      $136.62        20120901
27511       TREATMENT OF THIGH FRACTURE    82                                      $136.62        20120901
27511       TREATMENT OF THIGH FRACTURE    AS                                      $136.62        20120901
27511       TREATMENT OF THIGH FRACTURE                                            $683.12        20120901
27513       TREATMENT OF THIGH FRACTURE    80                                      $171.17        20120901



                                                Page 87
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
27513       TREATMENT OF THIGH FRACTURE    81                                    $171.17         20120901
27513       TREATMENT OF THIGH FRACTURE    82                                    $171.17         20120901
27513       TREATMENT OF THIGH FRACTURE    AS                                    $171.17         20120901
27513       TREATMENT OF THIGH FRACTURE                                          $855.87         20120901
27514       TREATMENT OF THIGH FRACTURE    80                                    $134.74         20120901
27514       TREATMENT OF THIGH FRACTURE    81                                    $134.74         20120901
27514       TREATMENT OF THIGH FRACTURE    82                                    $134.74         20120901
27514       TREATMENT OF THIGH FRACTURE    AS                                    $134.74         20120901
27514       TREATMENT OF THIGH FRACTURE                                          $673.69         20120901
27516       TREAT THIGH FX GROWTH PLATE                                          $320.54         20120901
27516       TREAT THIGH FX GROWTH PLATE                          A                 $59.66        20110101
27517       TREAT THIGH FX GROWTH PLATE                                          $450.74         20120901
27517       TREAT THIGH FX GROWTH PLATE                          A                 $59.66        20110101
27519       TREAT THIGH FX GROWTH PLATE    80                                    $122.76         20120901
27519       TREAT THIGH FX GROWTH PLATE    81                                    $122.76         20120901
27519       TREAT THIGH FX GROWTH PLATE    82                                    $122.76         20120901
27519       TREAT THIGH FX GROWTH PLATE    AS                                    $122.76         20120901
27519       TREAT THIGH FX GROWTH PLATE                                          $613.81         20120901
27520       TREAT KNEECAP FRACTURE                                               $201.29         20120901
27520       TREAT KNEECAP FRACTURE                               A                 $59.66        20110101
27524       TREAT KNEECAP FRACTURE         80                                    $100.09         20120901
27524       TREAT KNEECAP FRACTURE         81                                    $100.09         20120901
27524       TREAT KNEECAP FRACTURE         82                                    $100.09         20120901
27524       TREAT KNEECAP FRACTURE         AS                                    $100.09         20120901
27524       TREAT KNEECAP FRACTURE                                               $500.43         20120901
27530       TREAT KNEE FRACTURE                                                  $251.74         20120901
27530       TREAT KNEE FRACTURE                                  A                 $59.66        20110101
27532       TREAT KNEE FRACTURE                                                  $400.04         20120901
27532       TREAT KNEE FRACTURE                                  A               $462.00         20110101
27535       TREAT KNEE FRACTURE            80                                    $122.36         20120901
27535       TREAT KNEE FRACTURE            81                                    $122.36         20120901
27535       TREAT KNEE FRACTURE            82                                    $122.36         20120901
27535       TREAT KNEE FRACTURE            AS                                    $122.36         20120901
27535       TREAT KNEE FRACTURE                                                  $611.77         20120901
27536       TREAT KNEE FRACTURE            80                                    $159.71         20120901
27536       TREAT KNEE FRACTURE            81                                    $159.71         20120901
27536       TREAT KNEE FRACTURE            82                                    $159.71         20120901
27536       TREAT KNEE FRACTURE            AS                                    $159.71         20120901
27536       TREAT KNEE FRACTURE                                                  $798.54         20120901
27538       TREAT KNEE FRACTURES                                                 $300.66         20120901
27538       TREAT KNEE FRACTURES                                 A                 $59.66        20110101
27540       TREAT KNEE FRACTURE            80                                    $109.16         20120901
27540       TREAT KNEE FRACTURE            81                                    $109.16         20120901
27540       TREAT KNEE FRACTURE            82                                    $109.16         20120901
27540       TREAT KNEE FRACTURE            AS                                    $109.16         20120901
27540       TREAT KNEE FRACTURE                                                  $545.78         20120901
27550       TREAT KNEE DISLOCATION                                               $320.03         20120901
27550       TREAT KNEE DISLOCATION                               A                 $59.66        20110101
27552       TREAT KNEE DISLOCATION                                               $410.48         20120901
27552       TREAT KNEE DISLOCATION                               A               $431.28         20110101
27556       TREAT KNEE DISLOCATION         80                                    $120.78         20120901
27556       TREAT KNEE DISLOCATION         81                                    $120.78         20120901
27556       TREAT KNEE DISLOCATION         82                                    $120.78         20120901
27556       TREAT KNEE DISLOCATION         AS                                    $120.78         20120901
27556       TREAT KNEE DISLOCATION                                               $603.88         20120901
27557       TREAT KNEE DISLOCATION         80                                    $144.73         20120901
27557       TREAT KNEE DISLOCATION         81                                    $144.73         20120901
27557       TREAT KNEE DISLOCATION         82                                    $144.73         20120901
27557       TREAT KNEE DISLOCATION         AS                                    $144.73         20120901



                                             Page 88
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
27557       TREAT KNEE DISLOCATION                                                $723.63        20120901
27558       TREAT KNEE DISLOCATION         80                                     $163.94        20120901
27558       TREAT KNEE DISLOCATION         81                                     $163.94        20120901
27558       TREAT KNEE DISLOCATION         82                                     $163.94        20120901
27558       TREAT KNEE DISLOCATION         AS                                     $163.94        20120901
27558       TREAT KNEE DISLOCATION                                                $819.69        20120901
27560       TREAT KNEECAP DISLOCATION                                             $237.98        20120901
27560       TREAT KNEECAP DISLOCATION                            A                 $59.66        20110101
27562       TREAT KNEECAP DISLOCATION                                             $307.03        20120901
27562       TREAT KNEECAP DISLOCATION                            A                $431.28        20110101
27566       TREAT KNEECAP DISLOCATION      80                                     $119.25        20120901
27566       TREAT KNEECAP DISLOCATION      81                                     $119.25        20120901
27566       TREAT KNEECAP DISLOCATION      82                                     $119.25        20120901
27566       TREAT KNEECAP DISLOCATION      AS                                     $119.25        20120901
27566       TREAT KNEECAP DISLOCATION                                             $596.23        20120901
27566       TREAT KNEECAP DISLOCATION                            A              $1,178.19        20110101
27570       FIXATION OF KNEE JOINT                                                 $97.08        20120901
27570       FIXATION OF KNEE JOINT                               A                $431.28        20110101
27580       FUSION OF KNEE                 80                                     $193.85        20120901
27580       FUSION OF KNEE                 81                                     $193.85        20120901
27580       FUSION OF KNEE                 82                                     $193.85        20120901
27580       FUSION OF KNEE                 AS                                     $193.85        20120901
27580       FUSION OF KNEE                                                        $969.26        20120901
27590       AMPUTATE LEG AT THIGH          80                                     $113.69        20120901
27590       AMPUTATE LEG AT THIGH          81                                     $113.69        20120901
27590       AMPUTATE LEG AT THIGH          82                                     $113.69        20120901
27590       AMPUTATE LEG AT THIGH          AS                                     $113.69        20120901
27590       AMPUTATE LEG AT THIGH                                                 $568.46        20120901
27591       AMPUTATE LEG AT THIGH          80                                     $123.93        20120901
27591       AMPUTATE LEG AT THIGH          81                                     $123.93        20120901
27591       AMPUTATE LEG AT THIGH          82                                     $123.93        20120901
27591       AMPUTATE LEG AT THIGH          AS                                     $123.93        20120901
27591       AMPUTATE LEG AT THIGH                                                 $619.67        20120901
27592       AMPUTATE LEG AT THIGH          80                                      $95.91        20120901
27592       AMPUTATE LEG AT THIGH          81                                      $95.91        20120901
27592       AMPUTATE LEG AT THIGH          82                                      $95.91        20120901
27592       AMPUTATE LEG AT THIGH          AS                                      $95.91        20120901
27592       AMPUTATE LEG AT THIGH                                                 $479.53        20120901
27594       AMPUTATION FOLLOW-UP SURGERY                                          $346.78        20120901
27594       AMPUTATION FOLLOW-UP SURGERY                         A                $626.73        20110101
27596       AMPUTATION FOLLOW-UP SURGERY                                          $501.70        20120901
27598       AMPUTATE LOWER LEG AT KNEE     80                                     $101.46        20120901
27598       AMPUTATE LOWER LEG AT KNEE     81                                     $101.46        20120901
27598       AMPUTATE LOWER LEG AT KNEE     82                                     $101.46        20120901
27598       AMPUTATE LOWER LEG AT KNEE     AS                                     $101.46        20120901
27598       AMPUTATE LOWER LEG AT KNEE                                            $507.31        20120901
27600       DECOMPRESSION OF LOWER LEG                                            $285.63        20120901
27600       DECOMPRESSION OF LOWER LEG                           A                $626.73        20110101
27601       DECOMPRESSION OF LOWER LEG                                            $298.37        20120901
27601       DECOMPRESSION OF LOWER LEG                           A                $626.73        20110101
27602       DECOMPRESSION OF LOWER LEG     80                                      $70.58        20120901
27602       DECOMPRESSION OF LOWER LEG     81                                      $70.58        20120901
27602       DECOMPRESSION OF LOWER LEG     82                                      $70.58        20120901
27602       DECOMPRESSION OF LOWER LEG     AS                                      $70.58        20120901
27602       DECOMPRESSION OF LOWER LEG                                            $352.90        20120901
27602       DECOMPRESSION OF LOWER LEG                           A                $626.73        20110101
27603       DRAIN LOWER LEG LESION                                                $342.71        20120901
27603       DRAIN LOWER LEG LESION                               A                $551.78        20110101
27604       DRAIN LOWER LEG BURSA                                                 $299.14        20120901



                                             Page 89
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
27604       DRAIN LOWER LEG BURSA                                A               $614.48         20110101
27605       INCISION OF ACHILLES TENDON                                          $229.07         20120901
27605       INCISION OF ACHILLES TENDON                          A               $588.75         20110101
27606       INCISION OF ACHILLES TENDON                                          $195.18         20120901
27606       INCISION OF ACHILLES TENDON                          A               $592.86         20110101
27607       TREAT LOWER LEG BONE LESION                                          $409.21         20120901
27607       TREAT LOWER LEG BONE LESION                          A               $614.48         20110101
27610       EXPLORE/TREAT ANKLE JOINT                                            $435.45         20120901
27610       EXPLORE/TREAT ANKLE JOINT                            A               $849.00         20110101
27612       EXPLORATION OF ANKLE JOINT     80                                      $75.22        20120901
27612       EXPLORATION OF ANKLE JOINT     81                                      $75.22        20120901
27612       EXPLORATION OF ANKLE JOINT     82                                      $75.22        20120901
27612       EXPLORATION OF ANKLE JOINT     AS                                      $75.22        20120901
27612       EXPLORATION OF ANKLE JOINT                                           $376.08         20120901
27612       EXPLORATION OF ANKLE JOINT                           A               $861.25         20110101
27613       BIOPSY LOWER LEG SOFT TISSUE                                         $161.54         20120901
27614       BIOPSY LOWER LEG SOFT TISSUE                                         $367.68         20120901
27614       BIOPSY LOWER LEG SOFT TISSUE                         A               $647.50         20110101
27615       RESECT LEG/ANKLE TUM 5 CM                                            $680.06         20120901
27615       RESECT LEG/ANKLE TUM 5 CM                            A               $560.76         20110101
27616       RESECT LEG/ANKLE TUM 5 CM/                                           $887.72         20120901
27618       EXC LEG/ANKLE TUM 3 CM                                               $282.83         20120901
27618       EXC LEG/ANKLE TUM 3 CM                               A               $150.35         20110101
27619       EXC LEG/ANKLE TUM DEEP 5 CM                                          $339.14         20120901
27619       EXC LEG/ANKLE TUM DEEP 5 CM                          A               $560.76         20110101
27620       EXPLORE/TREAT ANKLE JOINT      80                                      $61.10        20120901
27620       EXPLORE/TREAT ANKLE JOINT      81                                      $61.10        20120901
27620       EXPLORE/TREAT ANKLE JOINT      82                                      $61.10        20120901
27620       EXPLORE/TREAT ANKLE JOINT      AS                                      $61.10        20120901
27620       EXPLORE/TREAT ANKLE JOINT                                            $305.51         20120901
27620       EXPLORE/TREAT ANKLE JOINT                            A               $884.21         20110101
27625       REMOVE ANKLE JOINT LINING      80                                      $78.07        20120901
27625       REMOVE ANKLE JOINT LINING      81                                      $78.07        20120901
27625       REMOVE ANKLE JOINT LINING      82                                      $78.07        20120901
27625       REMOVE ANKLE JOINT LINING      AS                                      $78.07        20120901
27625       REMOVE ANKLE JOINT LINING                                            $390.35         20120901
27625       REMOVE ANKLE JOINT LINING                            A               $884.21         20110101
27626       REMOVE ANKLE JOINT LINING      80                                      $84.85        20120901
27626       REMOVE ANKLE JOINT LINING      81                                      $84.85        20120901
27626       REMOVE ANKLE JOINT LINING      82                                      $84.85        20120901
27626       REMOVE ANKLE JOINT LINING      AS                                      $84.85        20120901
27626       REMOVE ANKLE JOINT LINING                                            $424.24         20120901
27626       REMOVE ANKLE JOINT LINING                            A               $884.21         20110101
27630       REMOVAL OF TENDON LESION                                             $348.06         20120901
27630       REMOVAL OF TENDON LESION                             A               $626.73         20110101
27632       EXC LEG/ANKLE LES SC 3 CM/                                           $285.63         20120901
27634       EXC LEG/ANKLE TUM DEP 5 CM/                                          $465.26         20120901
27635       REMOVE LOWER LEG BONE LESION                                         $393.92         20120901
27635       REMOVE LOWER LEG BONE LESION                         A               $861.25         20110101
27637       REMOVE/GRAFT LEG BONE LESION   80                                    $100.54         20120901
27637       REMOVE/GRAFT LEG BONE LESION   81                                    $100.54         20120901
27637       REMOVE/GRAFT LEG BONE LESION   82                                    $100.54         20120901
27637       REMOVE/GRAFT LEG BONE LESION   AS                                    $100.54         20120901
27637       REMOVE/GRAFT LEG BONE LESION                                         $502.72         20120901
27637       REMOVE/GRAFT LEG BONE LESION                         A               $861.25         20110101
27638       REMOVE/GRAFT LEG BONE LESION   80                                    $104.21         20120901
27638       REMOVE/GRAFT LEG BONE LESION   81                                    $104.21         20120901
27638       REMOVE/GRAFT LEG BONE LESION   82                                    $104.21         20120901
27638       REMOVE/GRAFT LEG BONE LESION   AS                                    $104.21         20120901



                                             Page 90
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1          Mod 2   Rate Type   Price          Effective Date
27638       REMOVE/GRAFT LEG BONE LESION                                            $521.07        20120901
27638       REMOVE/GRAFT LEG BONE LESION                           A                $861.25        20110101
27640       PARTIAL REMOVAL OF TIBIA                                                $573.05        20120901
27640       PARTIAL REMOVAL OF TIBIA                               A              $1,204.90        20110101
27641       PARTIAL REMOVAL OF FIBULA                                               $458.89        20120901
27641       PARTIAL REMOVAL OF FIBULA                              A                $849.00        20110101
27645       RESECT TIBIA TUMOR              80                                      $219.99        20120901
27645       RESECT TIBIA TUMOR              81                                      $219.99        20120901
27645       RESECT TIBIA TUMOR              82                                      $219.99        20120901
27645       RESECT TIBIA TUMOR              AS                                      $219.99        20120901
27645       RESECT TIBIA TUMOR                                                    $1,099.97        20120901
27646       RESECT FIBULA TUMOR             80                                      $189.32        20120901
27646       RESECT FIBULA TUMOR             81                                      $189.32        20120901
27646       RESECT FIBULA TUMOR             82                                      $189.32        20120901
27646       RESECT FIBULA TUMOR             AS                                      $189.32        20120901
27646       RESECT FIBULA TUMOR                                                     $946.58        20120901
27647       RESECT TALUS/CALCANEUS TUM      80                                      $147.38        20120901
27647       RESECT TALUS/CALCANEUS TUM      81                                      $147.38        20120901
27647       RESECT TALUS/CALCANEUS TUM      82                                      $147.38        20120901
27647       RESECT TALUS/CALCANEUS TUM      AS                                      $147.38        20120901
27647       RESECT TALUS/CALCANEUS TUM                                              $736.88        20120901
27647       RESECT TALUS/CALCANEUS TUM                             A              $1,217.14        20110101
27648       INJECTION FOR ANKLE X-RAY                                               $104.98        20120901
27650       REPAIR ACHILLES TENDON          80                                       $89.28        20120901
27650       REPAIR ACHILLES TENDON          81                                       $89.28        20120901
27650       REPAIR ACHILLES TENDON          82                                       $89.28        20120901
27650       REPAIR ACHILLES TENDON          AS                                       $89.28        20120901
27650       REPAIR ACHILLES TENDON                                                  $446.41        20120901
27650       REPAIR ACHILLES TENDON                                 A              $1,217.14        20110101
27652       REPAIR/GRAFT ACHILLES TENDON                                            $481.83        20120901
27652       REPAIR/GRAFT ACHILLES TENDON                           A              $2,228.42        20110101
27654       REPAIR OF ACHILLES TENDON       80                                       $95.65        20120901
27654       REPAIR OF ACHILLES TENDON       81                                       $95.65        20120901
27654       REPAIR OF ACHILLES TENDON       82                                       $95.65        20120901
27654       REPAIR OF ACHILLES TENDON       AS                                       $95.65        20120901
27654       REPAIR OF ACHILLES TENDON                                               $478.26        20120901
27654       REPAIR OF ACHILLES TENDON                              A              $1,217.14        20110101
27656       REPAIR LEG FASCIA DEFECT        80                                       $72.47        20120901
27656       REPAIR LEG FASCIA DEFECT        81                                       $72.47        20120901
27656       REPAIR LEG FASCIA DEFECT        82                                       $72.47        20120901
27656       REPAIR LEG FASCIA DEFECT        AS                                       $72.47        20120901
27656       REPAIR LEG FASCIA DEFECT                                                $362.33        20120901
27656       REPAIR LEG FASCIA DEFECT                               A                $614.48        20110101
27658       REPAIR OF LEG TENDON EACH       80                                       $50.55        20120901
27658       REPAIR OF LEG TENDON EACH       81                                       $50.55        20120901
27658       REPAIR OF LEG TENDON EACH       82                                       $50.55        20120901
27658       REPAIR OF LEG TENDON EACH       AS                                       $50.55        20120901
27658       REPAIR OF LEG TENDON EACH                                               $252.76        20120901
27658       REPAIR OF LEG TENDON EACH                              A                $592.86        20110101
27659       REPAIR OF LEG TENDON EACH       80                                       $65.64        20120901
27659       REPAIR OF LEG TENDON EACH       81                                       $65.64        20120901
27659       REPAIR OF LEG TENDON EACH       82                                       $65.64        20120901
27659       REPAIR OF LEG TENDON EACH       AS                                       $65.64        20120901
27659       REPAIR OF LEG TENDON EACH                                               $328.18        20120901
27659       REPAIR OF LEG TENDON EACH                              A                $614.48        20110101
27664       REPAIR OF LEG TENDON EACH                                               $241.04        20120901
27664       REPAIR OF LEG TENDON EACH                              A                $849.00        20110101
27665       REPAIR OF LEG TENDON EACH       80                                       $55.39        20120901
27665       REPAIR OF LEG TENDON EACH       81                                       $55.39        20120901



                                                 Page 91
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1          Mod 2   Rate Type   Price         Effective Date
27665       REPAIR OF LEG TENDON EACH      82                                      $55.39        20120901
27665       REPAIR OF LEG TENDON EACH      AS                                      $55.39        20120901
27665       REPAIR OF LEG TENDON EACH                                             $276.97        20120901
27665       REPAIR OF LEG TENDON EACH                             A               $849.00        20110101
27675       REPAIR LOWER LEG TENDONS       80                                      $67.01        20120901
27675       REPAIR LOWER LEG TENDONS       81                                      $67.01        20120901
27675       REPAIR LOWER LEG TENDONS       82                                      $67.01        20120901
27675       REPAIR LOWER LEG TENDONS       AS                                      $67.01        20120901
27675       REPAIR LOWER LEG TENDONS                                              $335.06        20120901
27675       REPAIR LOWER LEG TENDONS                              A               $614.48        20110101
27676       REPAIR LOWER LEG TENDONS       80                                      $83.17        20120901
27676       REPAIR LOWER LEG TENDONS       81                                      $83.17        20120901
27676       REPAIR LOWER LEG TENDONS       82                                      $83.17        20120901
27676       REPAIR LOWER LEG TENDONS       AS                                      $83.17        20120901
27676       REPAIR LOWER LEG TENDONS                                              $415.83        20120901
27676       REPAIR LOWER LEG TENDONS                              A               $861.25        20110101
27680       RELEASE OF LOWER LEG TENDON                                           $287.16        20120901
27680       RELEASE OF LOWER LEG TENDON                           A               $861.25        20110101
27681       RELEASE OF LOWER LEG TENDONS                                          $349.84        20120901
27681       RELEASE OF LOWER LEG TENDONS                          A               $849.00        20110101
27685       REVISION OF LOWER LEG TENDON   80                                      $82.50        20120901
27685       REVISION OF LOWER LEG TENDON   81                                      $82.50        20120901
27685       REVISION OF LOWER LEG TENDON   82                                      $82.50        20120901
27685       REVISION OF LOWER LEG TENDON   AS                                      $82.50        20120901
27685       REVISION OF LOWER LEG TENDON                                          $412.52        20120901
27685       REVISION OF LOWER LEG TENDON                          A               $861.25        20110101
27686       REVISE LOWER LEG TENDONS                                              $372.01        20120901
27686       REVISE LOWER LEG TENDONS                              A               $861.25        20110101
27687       REVISION OF CALF TENDON        80                                      $61.36        20120901
27687       REVISION OF CALF TENDON        81                                      $61.36        20120901
27687       REVISION OF CALF TENDON        82                                      $61.36        20120901
27687       REVISION OF CALF TENDON        AS                                      $61.36        20120901
27687       REVISION OF CALF TENDON                                               $306.78        20120901
27687       REVISION OF CALF TENDON                               A               $861.25        20110101
27690       REVISE LOWER LEG TENDON        80                                      $84.95        20120901
27690       REVISE LOWER LEG TENDON        81                                      $84.95        20120901
27690       REVISE LOWER LEG TENDON        82                                      $84.95        20120901
27690       REVISE LOWER LEG TENDON        AS                                      $84.95        20120901
27690       REVISE LOWER LEG TENDON                                               $424.75        20120901
27690       REVISE LOWER LEG TENDON                               A             $1,240.11        20110101
27691       REVISE LOWER LEG TENDON        80                                     $100.39        20120901
27691       REVISE LOWER LEG TENDON        81                                     $100.39        20120901
27691       REVISE LOWER LEG TENDON        82                                     $100.39        20120901
27691       REVISE LOWER LEG TENDON        AS                                     $100.39        20120901
27691       REVISE LOWER LEG TENDON                                               $501.96        20120901
27691       REVISE LOWER LEG TENDON                               A             $1,240.11        20110101
27692       REVISE ADDITIONAL LEG TENDON   80                                      $14.98        20120901
27692       REVISE ADDITIONAL LEG TENDON   81                                      $14.98        20120901
27692       REVISE ADDITIONAL LEG TENDON   82                                      $14.98        20120901
27692       REVISE ADDITIONAL LEG TENDON   AS                                      $14.98        20120901
27692       REVISE ADDITIONAL LEG TENDON                                           $74.91        20120901
27692       REVISE ADDITIONAL LEG TENDON                          A             $1,217.14        20110101
27695       REPAIR OF ANKLE LIGAMENT                                              $326.91        20120901
27695       REPAIR OF ANKLE LIGAMENT                              A               $849.00        20110101
27696       REPAIR OF ANKLE LIGAMENTS                                             $383.73        20120901
27696       REPAIR OF ANKLE LIGAMENTS                             A               $849.00        20110101
27698       REPAIR OF ANKLE LIGAMENT       80                                      $87.40        20120901
27698       REPAIR OF ANKLE LIGAMENT       81                                      $87.40        20120901
27698       REPAIR OF ANKLE LIGAMENT       82                                      $87.40        20120901



                                                Page 92
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price         Effective Date
27698       REPAIR OF ANKLE LIGAMENT        AS                                     $87.40        20120901
27698       REPAIR OF ANKLE LIGAMENT                                              $436.98        20120901
27698       REPAIR OF ANKLE LIGAMENT                              A               $849.00        20110101
27700       REVISION OF ANKLE JOINT         80                                     $82.05        20120901
27700       REVISION OF ANKLE JOINT         81                                     $82.05        20120901
27700       REVISION OF ANKLE JOINT         82                                     $82.05        20120901
27700       REVISION OF ANKLE JOINT         AS                                     $82.05        20120901
27700       REVISION OF ANKLE JOINT                                               $410.23        20120901
27700       REVISION OF ANKLE JOINT                               A             $1,095.93        20110101
27702       RECONSTRUCT ANKLE JOINT         80                                    $132.70        20120901
27702       RECONSTRUCT ANKLE JOINT         81                                    $132.70        20120901
27702       RECONSTRUCT ANKLE JOINT         82                                    $132.70        20120901
27702       RECONSTRUCT ANKLE JOINT         AS                                    $132.70        20120901
27702       RECONSTRUCT ANKLE JOINT                                               $663.50        20120901
27703       RECONSTRUCTION ANKLE JOINT      80                                    $154.21        20120901
27703       RECONSTRUCTION ANKLE JOINT      81                                    $154.21        20120901
27703       RECONSTRUCTION ANKLE JOINT      82                                    $154.21        20120901
27703       RECONSTRUCTION ANKLE JOINT      AS                                    $154.21        20120901
27703       RECONSTRUCTION ANKLE JOINT                                            $771.02        20120901
27704       REMOVAL OF ANKLE IMPLANT                                              $379.14        20120901
27704       REMOVAL OF ANKLE IMPLANT                              A               $614.48        20110101
27705       INCISION OF TIBIA               80                                    $102.23        20120901
27705       INCISION OF TIBIA               81                                    $102.23        20120901
27705       INCISION OF TIBIA               82                                    $102.23        20120901
27705       INCISION OF TIBIA               AS                                    $102.23        20120901
27705       INCISION OF TIBIA                                                     $511.13        20120901
27705       INCISION OF TIBIA                                     A             $1,204.90        20110101
27707       INCISION OF FIBULA                                                    $262.44        20120901
27707       INCISION OF FIBULA                                    A               $614.48        20110101
27709       INCISION OF TIBIA FIBULA        80                                    $154.87        20120901
27709       INCISION OF TIBIA FIBULA        81                                    $154.87        20120901
27709       INCISION OF TIBIA FIBULA        82                                    $154.87        20120901
27709       INCISION OF TIBIA FIBULA        AS                                    $154.87        20120901
27709       INCISION OF TIBIA FIBULA                                              $774.34        20120901
27709       INCISION OF TIBIA FIBULA                              A               $849.00        20110101
27712       REALIGNMENT OF LOWER LEG        80                                    $147.43        20120901
27712       REALIGNMENT OF LOWER LEG        81                                    $147.43        20120901
27712       REALIGNMENT OF LOWER LEG        82                                    $147.43        20120901
27712       REALIGNMENT OF LOWER LEG        AS                                    $147.43        20120901
27712       REALIGNMENT OF LOWER LEG                                              $737.14        20120901
27715       REVISION OF LOWER LEG           80                                    $143.25        20120901
27715       REVISION OF LOWER LEG           81                                    $143.25        20120901
27715       REVISION OF LOWER LEG           82                                    $143.25        20120901
27715       REVISION OF LOWER LEG           AS                                    $143.25        20120901
27715       REVISION OF LOWER LEG                                                 $716.24        20120901
27720       REPAIR OF TIBIA                 80                                    $117.41        20120901
27720       REPAIR OF TIBIA                 81                                    $117.41        20120901
27720       REPAIR OF TIBIA                 82                                    $117.41        20120901
27720       REPAIR OF TIBIA                 AS                                    $117.41        20120901
27720       REPAIR OF TIBIA                                                       $587.06        20120901
27722       REPAIR/GRAFT OF TIBIA           80                                    $117.56        20120901
27722       REPAIR/GRAFT OF TIBIA           81                                    $117.56        20120901
27722       REPAIR/GRAFT OF TIBIA           82                                    $117.56        20120901
27722       REPAIR/GRAFT OF TIBIA           AS                                    $117.56        20120901
27722       REPAIR/GRAFT OF TIBIA                                                 $587.82        20120901
27724       REPAIR/GRAFT OF TIBIA           80                                    $172.30        20120901
27724       REPAIR/GRAFT OF TIBIA           81                                    $172.30        20120901
27724       REPAIR/GRAFT OF TIBIA           82                                    $172.30        20120901
27724       REPAIR/GRAFT OF TIBIA           AS                                    $172.30        20120901



                                              Page 93
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
27724       REPAIR/GRAFT OF TIBIA                                                  $861.48        20120901
27725       REPAIR OF LOWER LEG             80                                     $162.05        20120901
27725       REPAIR OF LOWER LEG             81                                     $162.05        20120901
27725       REPAIR OF LOWER LEG             82                                     $162.05        20120901
27725       REPAIR OF LOWER LEG             AS                                     $162.05        20120901
27725       REPAIR OF LOWER LEG                                                    $810.26        20120901
27726       REPAIR FIBULA NONUNION                                                 $635.22        20120901
27726       REPAIR FIBULA NONUNION                                A              $1,457.14        20110101
27727       REPAIR OF LOWER LEG             80                                     $132.70        20120901
27727       REPAIR OF LOWER LEG             81                                     $132.70        20120901
27727       REPAIR OF LOWER LEG             82                                     $132.70        20120901
27727       REPAIR OF LOWER LEG             AS                                     $132.70        20120901
27727       REPAIR OF LOWER LEG                                                    $663.50        20120901
27730       REPAIR OF TIBIA EPIPHYSIS                                              $384.49        20120901
27730       REPAIR OF TIBIA EPIPHYSIS                             A                $849.00        20110101
27732       REPAIR OF FIBULA EPIPHYSIS                                             $274.93        20120901
27732       REPAIR OF FIBULA EPIPHYSIS                            A                $849.00        20110101
27734       REPAIR LOWER LEG EPIPHYSES                                             $375.07        20120901
27734       REPAIR LOWER LEG EPIPHYSES                            A                $849.00        20110101
27740       REPAIR OF LEG EPIPHYSES         80                                      $89.89        20120901
27740       REPAIR OF LEG EPIPHYSES         81                                      $89.89        20120901
27740       REPAIR OF LEG EPIPHYSES         82                                      $89.89        20120901
27740       REPAIR OF LEG EPIPHYSES         AS                                      $89.89        20120901
27740       REPAIR OF LEG EPIPHYSES                                                $449.47        20120901
27740       REPAIR OF LEG EPIPHYSES                               A                $849.00        20110101
27742       REPAIR OF LEG EPIPHYSES         80                                      $95.80        20120901
27742       REPAIR OF LEG EPIPHYSES         81                                      $95.80        20120901
27742       REPAIR OF LEG EPIPHYSES         82                                      $95.80        20120901
27742       REPAIR OF LEG EPIPHYSES         AS                                      $95.80        20120901
27742       REPAIR OF LEG EPIPHYSES                                                $479.02        20120901
27742       REPAIR OF LEG EPIPHYSES                               A              $1,204.90        20110101
27745       REINFORCE TIBIA                 80                                     $100.75        20120901
27745       REINFORCE TIBIA                 81                                     $100.75        20120901
27745       REINFORCE TIBIA                 82                                     $100.75        20120901
27745       REINFORCE TIBIA                 AS                                     $100.75        20120901
27745       REINFORCE TIBIA                                                        $503.74        20120901
27745       REINFORCE TIBIA                                       A              $2,228.42        20110101
27750       TREATMENT OF TIBIA FRACTURE                                            $216.58        20120901
27750       TREATMENT OF TIBIA FRACTURE                           A                 $59.66        20110101
27752       TREATMENT OF TIBIA FRACTURE                                            $347.29        20120901
27752       TREATMENT OF TIBIA FRACTURE                           A                $462.00        20110101
27756       TREATMENT OF TIBIA FRACTURE     80                                      $75.52        20120901
27756       TREATMENT OF TIBIA FRACTURE     81                                      $75.52        20120901
27756       TREATMENT OF TIBIA FRACTURE     82                                      $75.52        20120901
27756       TREATMENT OF TIBIA FRACTURE     AS                                      $75.52        20120901
27756       TREATMENT OF TIBIA FRACTURE                                            $377.61        20120901
27756       TREATMENT OF TIBIA FRACTURE                           A                $718.78        20110101
27758       TREATMENT OF TIBIA FRACTURE     80                                     $118.69        20120901
27758       TREATMENT OF TIBIA FRACTURE     81                                     $118.69        20120901
27758       TREATMENT OF TIBIA FRACTURE     82                                     $118.69        20120901
27758       TREATMENT OF TIBIA FRACTURE     AS                                     $118.69        20120901
27758       TREATMENT OF TIBIA FRACTURE                                            $593.43        20120901
27758       TREATMENT OF TIBIA FRACTURE                           A              $1,213.40        20110101
27759       TREATMENT OF TIBIA FRACTURE     80                                     $134.18        20120901
27759       TREATMENT OF TIBIA FRACTURE     81                                     $134.18        20120901
27759       TREATMENT OF TIBIA FRACTURE     82                                     $134.18        20120901
27759       TREATMENT OF TIBIA FRACTURE     AS                                     $134.18        20120901
27759       TREATMENT OF TIBIA FRACTURE                                            $670.89        20120901
27759       TREATMENT OF TIBIA FRACTURE                           A              $1,694.30        20110101



                                              Page 94
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
27760       CLTX MEDIAL ANKLE FX                                                   $209.45        20120901
27760       CLTX MEDIAL ANKLE FX                                  A                 $59.66        20110101
27762       CLTX MED ANKLE FX W/MNPJ                                               $310.60        20120901
27762       CLTX MED ANKLE FX W/MNPJ                              A                $462.00        20110101
27766       OPTX MEDIAL ANKLE FX                                                   $402.33        20120901
27766       OPTX MEDIAL ANKLE FX                                  A              $1,190.44        20110101
27767       CLTX POST ANKLE FX                                                     $171.48        20120901
27767       CLTX POST ANKLE FX                                    A                 $53.12        20110101
27768       CLTX POST ANKLE FX W/MNPJ                                              $272.13        20120901
27768       CLTX POST ANKLE FX W/MNPJ                             A                 $53.12        20110101
27769       OPTX POST ANKLE FX                                                     $471.38        20120901
27769       OPTX POST ANKLE FX                                    A              $1,457.14        20110101
27780       TREATMENT OF FIBULA FRACTURE                                           $188.30        20120901
27780       TREATMENT OF FIBULA FRACTURE                          A                 $59.66        20110101
27781       TREATMENT OF FIBULA FRACTURE                                           $270.34        20120901
27781       TREATMENT OF FIBULA FRACTURE                          A                $462.00        20110101
27784       TREATMENT OF FIBULA FRACTURE                                           $468.32        20120901
27784       TREATMENT OF FIBULA FRACTURE                          A              $1,190.44        20110101
27786       TREATMENT OF ANKLE FRACTURE                                            $198.23        20120901
27786       TREATMENT OF ANKLE FRACTURE                           A                 $59.66        20110101
27788       TREATMENT OF ANKLE FRACTURE                                            $271.11        20120901
27788       TREATMENT OF ANKLE FRACTURE                           A                 $59.66        20110101
27792       TREATMENT OF ANKLE FRACTURE                                            $469.85        20120901
27792       TREATMENT OF ANKLE FRACTURE                           A              $1,190.44        20110101
27808       TREATMENT OF ANKLE FRACTURE                                            $207.66        20120901
27808       TREATMENT OF ANKLE FRACTURE                           A                 $59.66        20110101
27810       TREATMENT OF ANKLE FRACTURE                                            $304.23        20120901
27810       TREATMENT OF ANKLE FRACTURE                           A                $135.07        20110101
27814       TREATMENT OF ANKLE FRACTURE     80                                     $103.04        20120901
27814       TREATMENT OF ANKLE FRACTURE     81                                     $103.04        20120901
27814       TREATMENT OF ANKLE FRACTURE     82                                     $103.04        20120901
27814       TREATMENT OF ANKLE FRACTURE     AS                                     $103.04        20120901
27814       TREATMENT OF ANKLE FRACTURE                                            $515.21        20120901
27814       TREATMENT OF ANKLE FRACTURE                           A              $1,190.44        20110101
27816       TREATMENT OF ANKLE FRACTURE                                            $197.22        20120901
27816       TREATMENT OF ANKLE FRACTURE                           A                 $59.66        20110101
27818       TREATMENT OF ANKLE FRACTURE                                            $313.66        20120901
27818       TREATMENT OF ANKLE FRACTURE                           A                $135.07        20110101
27822       TREATMENT OF ANKLE FRACTURE     80                                     $112.77        20120901
27822       TREATMENT OF ANKLE FRACTURE     81                                     $112.77        20120901
27822       TREATMENT OF ANKLE FRACTURE     82                                     $112.77        20120901
27822       TREATMENT OF ANKLE FRACTURE     AS                                     $112.77        20120901
27822       TREATMENT OF ANKLE FRACTURE                                            $563.87        20120901
27822       TREATMENT OF ANKLE FRACTURE                           A              $1,190.44        20110101
27823       TREATMENT OF ANKLE FRACTURE     80                                     $128.42        20120901
27823       TREATMENT OF ANKLE FRACTURE     81                                     $128.42        20120901
27823       TREATMENT OF ANKLE FRACTURE     82                                     $128.42        20120901
27823       TREATMENT OF ANKLE FRACTURE     AS                                     $128.42        20120901
27823       TREATMENT OF ANKLE FRACTURE                                            $642.10        20120901
27823       TREATMENT OF ANKLE FRACTURE                           A              $1,671.34        20110101
27824       TREAT LOWER LEG FRACTURE                                               $198.23        20120901
27824       TREAT LOWER LEG FRACTURE                              A                 $59.66        20110101
27825       TREAT LOWER LEG FRACTURE                                               $356.72        20120901
27825       TREAT LOWER LEG FRACTURE                              A                $462.00        20110101
27826       TREAT LOWER LEG FRACTURE        80                                     $110.23        20120901
27826       TREAT LOWER LEG FRACTURE        81                                     $110.23        20120901
27826       TREAT LOWER LEG FRACTURE        82                                     $110.23        20120901
27826       TREAT LOWER LEG FRACTURE        AS                                     $110.23        20120901
27826       TREAT LOWER LEG FRACTURE                                               $551.13        20120901



                                              Page 95
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1       Mod 2     Rate Type   Price          Effective Date
27826       TREAT LOWER LEG FRACTURE                               A              $1,190.44        20110101
27827       TREAT LOWER LEG FRACTURE         80                                     $144.93        20120901
27827       TREAT LOWER LEG FRACTURE         81                                     $144.93        20120901
27827       TREAT LOWER LEG FRACTURE         82                                     $144.93        20120901
27827       TREAT LOWER LEG FRACTURE         AS                                     $144.93        20120901
27827       TREAT LOWER LEG FRACTURE                                                $724.65        20120901
27827       TREAT LOWER LEG FRACTURE                               A              $1,671.34        20110101
27828       TREAT LOWER LEG FRACTURE         80                                     $174.03        20120901
27828       TREAT LOWER LEG FRACTURE         81                                     $174.03        20120901
27828       TREAT LOWER LEG FRACTURE         82                                     $174.03        20120901
27828       TREAT LOWER LEG FRACTURE         AS                                     $174.03        20120901
27828       TREAT LOWER LEG FRACTURE                                                $870.14        20120901
27828       TREAT LOWER LEG FRACTURE                               A              $1,694.30        20110101
27829       TREAT LOWER LEG JOINT            80                                      $89.23        20120901
27829       TREAT LOWER LEG JOINT            81                                      $89.23        20120901
27829       TREAT LOWER LEG JOINT            82                                      $89.23        20120901
27829       TREAT LOWER LEG JOINT            AS                                      $89.23        20120901
27829       TREAT LOWER LEG JOINT                                                   $446.15        20120901
27829       TREAT LOWER LEG JOINT                                  A              $1,178.19        20110101
27830       TREAT LOWER LEG DISLOCATION                                             $233.14        20120901
27830       TREAT LOWER LEG DISLOCATION                            A                 $59.66        20110101
27831       TREAT LOWER LEG DISLOCATION                                             $251.74        20120901
27831       TREAT LOWER LEG DISLOCATION                            A                $462.00        20110101
27832       TREAT LOWER LEG DISLOCATION      80                                      $96.98        20120901
27832       TREAT LOWER LEG DISLOCATION      81                                      $96.98        20120901
27832       TREAT LOWER LEG DISLOCATION      82                                      $96.98        20120901
27832       TREAT LOWER LEG DISLOCATION      AS                                      $96.98        20120901
27832       TREAT LOWER LEG DISLOCATION                                             $484.88        20120901
27832       TREAT LOWER LEG DISLOCATION                            A              $1,178.19        20110101
27840       TREAT ANKLE DISLOCATION                                                 $234.16        20120901
27840       TREAT ANKLE DISLOCATION                                A                $135.07        20110101
27842       TREAT ANKLE DISLOCATION                                                 $321.30        20120901
27842       TREAT ANKLE DISLOCATION                                A                $431.28        20110101
27846       TREAT ANKLE DISLOCATION          80                                      $98.30        20120901
27846       TREAT ANKLE DISLOCATION          81                                      $98.30        20120901
27846       TREAT ANKLE DISLOCATION          82                                      $98.30        20120901
27846       TREAT ANKLE DISLOCATION          AS                                      $98.30        20120901
27846       TREAT ANKLE DISLOCATION                                                 $491.51        20120901
27846       TREAT ANKLE DISLOCATION                                A              $1,190.44        20110101
27848       TREAT ANKLE DISLOCATION          80                                     $111.04        20120901
27848       TREAT ANKLE DISLOCATION          81                                     $111.04        20120901
27848       TREAT ANKLE DISLOCATION          82                                     $111.04        20120901
27848       TREAT ANKLE DISLOCATION          AS                                     $111.04        20120901
27848       TREAT ANKLE DISLOCATION                                                 $555.21        20120901
27848       TREAT ANKLE DISLOCATION                                A              $1,190.44        20110101
27860       FIXATION OF ANKLE JOINT                                                 $117.21        20120901
27860       FIXATION OF ANKLE JOINT                                A                $431.28        20110101
27870       FUSION OF ANKLE JOINT OPEN       80                                     $140.70        20120901
27870       FUSION OF ANKLE JOINT OPEN       81                                     $140.70        20120901
27870       FUSION OF ANKLE JOINT OPEN       82                                     $140.70        20120901
27870       FUSION OF ANKLE JOINT OPEN       AS                                     $140.70        20120901
27870       FUSION OF ANKLE JOINT OPEN                                              $703.50        20120901
27870       FUSION OF ANKLE JOINT OPEN                             A              $2,251.38        20110101
27871       FUSION OF TIBIOFIBULAR JOINT     80                                      $92.49        20120901
27871       FUSION OF TIBIOFIBULAR JOINT     81                                      $92.49        20120901
27871       FUSION OF TIBIOFIBULAR JOINT     82                                      $92.49        20120901
27871       FUSION OF TIBIOFIBULAR JOINT     AS                                      $92.49        20120901
27871       FUSION OF TIBIOFIBULAR JOINT                                            $462.46        20120901
27871       FUSION OF TIBIOFIBULAR JOINT                           A              $2,251.38        20110101



                                               Page 96
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1       Mod 2     Rate Type   Price          Effective Date
27880       AMPUTATION OF LOWER LEG        80                                    $128.47         20120901
27880       AMPUTATION OF LOWER LEG        81                                    $128.47         20120901
27880       AMPUTATION OF LOWER LEG        82                                    $128.47         20120901
27880       AMPUTATION OF LOWER LEG        AS                                    $128.47         20120901
27880       AMPUTATION OF LOWER LEG                                              $642.35         20120901
27881       AMPUTATION OF LOWER LEG        80                                    $121.28         20120901
27881       AMPUTATION OF LOWER LEG        81                                    $121.28         20120901
27881       AMPUTATION OF LOWER LEG        82                                    $121.28         20120901
27881       AMPUTATION OF LOWER LEG        AS                                    $121.28         20120901
27881       AMPUTATION OF LOWER LEG                                              $606.42         20120901
27882       AMPUTATION OF LOWER LEG        80                                      $86.33        20120901
27882       AMPUTATION OF LOWER LEG        81                                      $86.33        20120901
27882       AMPUTATION OF LOWER LEG        82                                      $86.33        20120901
27882       AMPUTATION OF LOWER LEG        AS                                      $86.33        20120901
27882       AMPUTATION OF LOWER LEG                                              $431.63         20120901
27884       AMPUTATION FOLLOW-UP SURGERY                                         $400.29         20120901
27884       AMPUTATION FOLLOW-UP SURGERY                         A               $626.73         20110101
27886       AMPUTATION FOLLOW-UP SURGERY                                         $457.11         20120901
27888       AMPUTATION OF FOOT AT ANKLE    80                                      $94.94        20120901
27888       AMPUTATION OF FOOT AT ANKLE    81                                      $94.94        20120901
27888       AMPUTATION OF FOOT AT ANKLE    82                                      $94.94        20120901
27888       AMPUTATION OF FOOT AT ANKLE    AS                                      $94.94        20120901
27888       AMPUTATION OF FOOT AT ANKLE                                          $474.69         20120901
27889       AMPUTATION OF FOOT AT ANKLE                                          $471.38         20120901
27889       AMPUTATION OF FOOT AT ANKLE                          A               $861.25         20110101
27892       DECOMPRESSION OF LEG                                                 $371.24         20120901
27892       DECOMPRESSION OF LEG                                 A               $861.25         20110101
27893       DECOMPRESSION OF LEG                                                 $374.05         20120901
27893       DECOMPRESSION OF LEG                                 A               $861.25         20110101
27894       DECOMPRESSION OF LEG           80                                    $116.04         20120901
27894       DECOMPRESSION OF LEG           81                                    $116.04         20120901
27894       DECOMPRESSION OF LEG           82                                    $116.04         20120901
27894       DECOMPRESSION OF LEG           AS                                    $116.04         20120901
27894       DECOMPRESSION OF LEG                                                 $580.18         20120901
27894       DECOMPRESSION OF LEG                                 A               $861.25         20110101
28001       DRAINAGE OF BURSA OF FOOT                                            $173.26         20120901
28002       TREATMENT OF FOOT INFECTION                                          $330.22         20120901
28002       TREATMENT OF FOOT INFECTION                          A               $626.73         20110101
28003       TREATMENT OF FOOT INFECTION                                          $446.92         20120901
28003       TREATMENT OF FOOT INFECTION                          A               $626.73         20110101
28005       TREAT FOOT BONE LESION                                               $408.19         20120901
28005       TREAT FOOT BONE LESION                               A               $622.62         20110101
28008       INCISION OF FOOT FASCIA                                              $274.16         20120901
28008       INCISION OF FOOT FASCIA                              A               $622.62         20110101
28010       INCISION OF TOE TENDON                                               $152.37         20120901
28011       INCISION OF TOE TENDONS                                              $216.33         20120901
28011       INCISION OF TOE TENDONS                              A               $622.62         20110101
28020       EXPLORATION OF FOOT JOINT                                            $329.97         20120901
28020       EXPLORATION OF FOOT JOINT                            A               $610.38         20110101
28022       EXPLORATION OF FOOT JOINT                                            $302.19         20120901
28022       EXPLORATION OF FOOT JOINT                            A               $610.38         20110101
28024       EXPLORATION OF TOE JOINT                                             $286.14         20120901
28024       EXPLORATION OF TOE JOINT                             A               $610.38         20110101
28035       DECOMPRESSION OF TIBIA NERVE                                         $331.75         20120901
28035       DECOMPRESSION OF TIBIA NERVE                         A               $570.50         20110101
28039       EXC FOOT/TOE TUM SC 1.5 CM/                                          $326.91         20120901
28041       EXC FOOT/TOE TUM DEP 1.5CM/                                          $308.31         20120901
28043       EXC FOOT/TOE TUM SC 1.5 CM                                           $235.44         20120901
28043       EXC FOOT/TOE TUM SC 1.5 CM                           A               $113.56         20110101



                                             Page 97
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price          Effective Date
28045       EXC FOOT/TOE TUM DEEP 1.5CM                                            $323.60        20120901
28045       EXC FOOT/TOE TUM DEEP 1.5CM                           A                $155.80        20110101
28046       RESECT FOOT/TOE TUMOR 3 CM                                             $506.54        20120901
28046       RESECT FOOT/TOE TUMOR 3 CM                            A                $560.76        20110101
28047       RESECT FOOT/TOE TUMOR 3 CM/                                            $649.74        20120901
28050       BIOPSY OF FOOT JOINT LINING                                            $285.38        20120901
28050       BIOPSY OF FOOT JOINT LINING                           A                $610.38        20110101
28052       BIOPSY OF FOOT JOINT LINING                                            $272.38        20120901
28052       BIOPSY OF FOOT JOINT LINING                           A                $610.38        20110101
28054       BIOPSY OF TOE JOINT LINING                                             $245.63        20120901
28054       BIOPSY OF TOE JOINT LINING                            A                $610.38        20110101
28055       NEURECTOMY FOOT                                                        $261.93        20120901
28055       NEURECTOMY FOOT                                       A                $570.50        20110101
28060       PARTIAL REMOVAL FOOT FASCIA                                            $324.62        20120901
28060       PARTIAL REMOVAL FOOT FASCIA                           A                $610.38        20110101
28062       REMOVAL OF FOOT FASCIA                                                 $377.87        20120901
28062       REMOVAL OF FOOT FASCIA                                A                $622.62        20110101
28070       REMOVAL OF FOOT JOINT LINING                                           $321.30        20120901
28070       REMOVAL OF FOOT JOINT LINING                          A                $622.62        20110101
28072       REMOVAL OF FOOT JOINT LINING                                           $321.56        20120901
28072       REMOVAL OF FOOT JOINT LINING                          A                $622.62        20110101
28080       REMOVAL OF FOOT LESION                                                 $319.52        20120901
28080       REMOVAL OF FOOT LESION                                A                $622.62        20110101
28086       EXCISE FOOT TENDON SHEATH       80                                      $68.49        20120901
28086       EXCISE FOOT TENDON SHEATH       81                                      $68.49        20120901
28086       EXCISE FOOT TENDON SHEATH       82                                      $68.49        20120901
28086       EXCISE FOOT TENDON SHEATH       AS                                      $68.49        20120901
28086       EXCISE FOOT TENDON SHEATH                                              $342.45        20120901
28086       EXCISE FOOT TENDON SHEATH                             A                $610.38        20110101
28088       EXCISE FOOT TENDON SHEATH                                              $290.47        20120901
28088       EXCISE FOOT TENDON SHEATH                             A                $610.38        20110101
28090       REMOVAL OF FOOT LESION                                                 $293.02        20120901
28090       REMOVAL OF FOOT LESION                                A                $622.62        20110101
28092       REMOVAL OF TOE LESIONS                                                 $264.99        20120901
28092       REMOVAL OF TOE LESIONS                                A                $622.62        20110101
28100       REMOVAL OF ANKLE/HEEL LESION    80                                      $75.42        20120901
28100       REMOVAL OF ANKLE/HEEL LESION    81                                      $75.42        20120901
28100       REMOVAL OF ANKLE/HEEL LESION    82                                      $75.42        20120901
28100       REMOVAL OF ANKLE/HEEL LESION    AS                                      $75.42        20120901
28100       REMOVAL OF ANKLE/HEEL LESION                                           $377.10        20120901
28100       REMOVAL OF ANKLE/HEEL LESION                          A                $610.38        20110101
28102       REMOVE/GRAFT FOOT LESION        80                                      $70.32        20120901
28102       REMOVE/GRAFT FOOT LESION        81                                      $70.32        20120901
28102       REMOVE/GRAFT FOOT LESION        82                                      $70.32        20120901
28102       REMOVE/GRAFT FOOT LESION        AS                                      $70.32        20120901
28102       REMOVE/GRAFT FOOT LESION                                               $351.62        20120901
28102       REMOVE/GRAFT FOOT LESION                              A              $1,360.09        20110101
28103       REMOVE/GRAFT FOOT LESION        80                                      $57.69        20120901
28103       REMOVE/GRAFT FOOT LESION        81                                      $57.69        20120901
28103       REMOVE/GRAFT FOOT LESION        82                                      $57.69        20120901
28103       REMOVE/GRAFT FOOT LESION        AS                                      $57.69        20120901
28103       REMOVE/GRAFT FOOT LESION                                               $288.43        20120901
28103       REMOVE/GRAFT FOOT LESION                              A              $1,360.09        20110101
28104       REMOVAL OF FOOT LESION          80                                      $64.57        20120901
28104       REMOVAL OF FOOT LESION          81                                      $64.57        20120901
28104       REMOVAL OF FOOT LESION          82                                      $64.57        20120901
28104       REMOVAL OF FOOT LESION          AS                                      $64.57        20120901
28104       REMOVAL OF FOOT LESION                                                 $322.83        20120901
28104       REMOVAL OF FOOT LESION                                A                $610.38        20110101



                                              Page 98
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1       Mod 2     Rate Type   Price         Effective Date
28106       REMOVE/GRAFT FOOT LESION        80                                     $61.51        20120901
28106       REMOVE/GRAFT FOOT LESION        81                                     $61.51        20120901
28106       REMOVE/GRAFT FOOT LESION        82                                     $61.51        20120901
28106       REMOVE/GRAFT FOOT LESION        AS                                     $61.51        20120901
28106       REMOVE/GRAFT FOOT LESION                                              $307.54        20120901
28106       REMOVE/GRAFT FOOT LESION                              A             $1,360.09        20110101
28107       REMOVE/GRAFT FOOT LESION        80                                     $69.61        20120901
28107       REMOVE/GRAFT FOOT LESION        81                                     $69.61        20120901
28107       REMOVE/GRAFT FOOT LESION        82                                     $69.61        20120901
28107       REMOVE/GRAFT FOOT LESION        AS                                     $69.61        20120901
28107       REMOVE/GRAFT FOOT LESION                                              $348.06        20120901
28107       REMOVE/GRAFT FOOT LESION                              A             $1,360.09        20110101
28108       REMOVAL OF TOE LESIONS                                                $272.13        20120901
28110       PART REMOVAL OF METATARSAL                                            $286.14        20120901
28110       PART REMOVAL OF METATARSAL                            A               $622.62        20110101
28111       PART REMOVAL OF METATARSAL                                            $324.62        20120901
28111       PART REMOVAL OF METATARSAL                            A               $622.62        20110101
28112       PART REMOVAL OF METATARSAL                                            $308.05        20120901
28112       PART REMOVAL OF METATARSAL                            A               $622.62        20110101
28113       PART REMOVAL OF METATARSAL                                            $374.05        20120901
28113       PART REMOVAL OF METATARSAL                            A               $622.62        20110101
28114       REMOVAL OF METATARSAL HEADS     80                                    $136.88        20120901
28114       REMOVAL OF METATARSAL HEADS     81                                    $136.88        20120901
28114       REMOVAL OF METATARSAL HEADS     82                                    $136.88        20120901
28114       REMOVAL OF METATARSAL HEADS     AS                                    $136.88        20120901
28114       REMOVAL OF METATARSAL HEADS                                           $684.39        20120901
28114       REMOVAL OF METATARSAL HEADS                           A               $622.62        20110101
28116       REVISION OF FOOT                                                      $480.55        20120901
28116       REVISION OF FOOT                                      A               $622.62        20110101
28118       REMOVAL OF HEEL BONE            80                                     $74.35        20120901
28118       REMOVAL OF HEEL BONE            81                                     $74.35        20120901
28118       REMOVAL OF HEEL BONE            82                                     $74.35        20120901
28118       REMOVAL OF HEEL BONE            AS                                     $74.35        20120901
28118       REMOVAL OF HEEL BONE                                                  $371.75        20120901
28118       REMOVAL OF HEEL BONE                                  A               $645.58        20110101
28119       REMOVAL OF HEEL SPUR                                                  $329.97        20120901
28119       REMOVAL OF HEEL SPUR                                  A               $645.58        20110101
28120       PART REMOVAL OF ANKLE/HEEL                                            $448.45        20120901
28120       PART REMOVAL OF ANKLE/HEEL                            A               $715.42        20110101
28122       PARTIAL REMOVAL OF FOOT BONE    80                                     $84.85        20120901
28122       PARTIAL REMOVAL OF FOOT BONE    81                                     $84.85        20120901
28122       PARTIAL REMOVAL OF FOOT BONE    82                                     $84.85        20120901
28122       PARTIAL REMOVAL OF FOOT BONE    AS                                     $84.85        20120901
28122       PARTIAL REMOVAL OF FOOT BONE                                          $424.24        20120901
28122       PARTIAL REMOVAL OF FOOT BONE                          A               $622.62        20110101
28124       PARTIAL REMOVAL OF TOE                                                $301.43        20120901
28126       PARTIAL REMOVAL OF TOE                                                $245.37        20120901
28126       PARTIAL REMOVAL OF TOE                                A               $622.62        20110101
28130       REMOVAL OF ANKLE BONE           80                                     $88.16        20120901
28130       REMOVAL OF ANKLE BONE           81                                     $88.16        20120901
28130       REMOVAL OF ANKLE BONE           82                                     $88.16        20120901
28130       REMOVAL OF ANKLE BONE           AS                                     $88.16        20120901
28130       REMOVAL OF ANKLE BONE                                                 $440.80        20120901
28130       REMOVAL OF ANKLE BONE                                 A               $622.62        20110101
28140       REMOVAL OF METATARSAL                                                 $400.04        20120901
28140       REMOVAL OF METATARSAL                                 A               $622.62        20110101
28150       REMOVAL OF TOE                                                        $273.15        20120901
28150       REMOVAL OF TOE                                        A               $622.62        20110101
28153       PARTIAL REMOVAL OF TOE                                                $255.82        20120901



                                              Page 99
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
28153       PARTIAL REMOVAL OF TOE                               A                $622.62        20110101
28160       PARTIAL REMOVAL OF TOE                                                $262.44        20120901
28160       PARTIAL REMOVAL OF TOE                               A                $622.62        20110101
28171       RESECT TARSAL TUMOR            80                                     $116.80        20120901
28171       RESECT TARSAL TUMOR            81                                     $116.80        20120901
28171       RESECT TARSAL TUMOR            82                                     $116.80        20120901
28171       RESECT TARSAL TUMOR            AS                                     $116.80        20120901
28171       RESECT TARSAL TUMOR                                                   $584.00        20120901
28171       RESECT TARSAL TUMOR                                  A                $622.62        20110101
28173       RESECT METATARSAL TUMOR                                               $524.38        20120901
28173       RESECT METATARSAL TUMOR                              A                $622.62        20110101
28175       RESECT PHALANX OF TOE TUMOR                                           $327.42        20120901
28175       RESECT PHALANX OF TOE TUMOR                          A                $622.62        20110101
28190       REMOVAL OF FOOT FOREIGN BODY                                          $156.70        20120901
28192       REMOVAL OF FOOT FOREIGN BODY                                          $298.63        20120901
28192       REMOVAL OF FOOT FOREIGN BODY                         A                $505.90        20110101
28193       REMOVAL OF FOOT FOREIGN BODY                                          $341.69        20120901
28193       REMOVAL OF FOOT FOREIGN BODY                         A                $277.24        20110101
28200       REPAIR OF FOOT TENDON                                                 $297.86        20120901
28200       REPAIR OF FOOT TENDON                                A                $622.62        20110101
28202       REPAIR/GRAFT OF FOOT TENDON    80                                      $78.22        20120901
28202       REPAIR/GRAFT OF FOOT TENDON    81                                      $78.22        20120901
28202       REPAIR/GRAFT OF FOOT TENDON    82                                      $78.22        20120901
28202       REPAIR/GRAFT OF FOOT TENDON    AS                                      $78.22        20120901
28202       REPAIR/GRAFT OF FOOT TENDON                                           $391.12        20120901
28202       REPAIR/GRAFT OF FOOT TENDON                          A                $622.62        20110101
28208       REPAIR OF FOOT TENDON                                                 $290.47        20120901
28208       REPAIR OF FOOT TENDON                                A                $622.62        20110101
28210       REPAIR/GRAFT OF FOOT TENDON    80                                      $73.64        20120901
28210       REPAIR/GRAFT OF FOOT TENDON    81                                      $73.64        20120901
28210       REPAIR/GRAFT OF FOOT TENDON    82                                      $73.64        20120901
28210       REPAIR/GRAFT OF FOOT TENDON    AS                                      $73.64        20120901
28210       REPAIR/GRAFT OF FOOT TENDON                                           $368.19        20120901
28210       REPAIR/GRAFT OF FOOT TENDON                          A              $1,360.09        20110101
28220       RELEASE OF FOOT TENDON                                                $283.59        20120901
28222       RELEASE OF FOOT TENDONS                                               $325.89        20120901
28222       RELEASE OF FOOT TENDONS                              A                $588.75        20110101
28225       RELEASE OF FOOT TENDON                                                $248.18        20120901
28225       RELEASE OF FOOT TENDON                               A                $588.75        20110101
28226       RELEASE OF FOOT TENDONS                                               $290.47        20120901
28226       RELEASE OF FOOT TENDONS                              A                $588.75        20110101
28230       INCISION OF FOOT TENDONS                                              $272.13        20120901
28232       INCISION OF TOE TENDON                                                $242.82        20120901
28234       INCISION OF FOOT TENDON                                               $253.78        20120901
28234       INCISION OF FOOT TENDON                              A                $610.38        20110101
28238       REVISION OF FOOT TENDON        80                                      $86.73        20120901
28238       REVISION OF FOOT TENDON        81                                      $86.73        20120901
28238       REVISION OF FOOT TENDON        82                                      $86.73        20120901
28238       REVISION OF FOOT TENDON        AS                                      $86.73        20120901
28238       REVISION OF FOOT TENDON                                               $433.67        20120901
28238       REVISION OF FOOT TENDON                              A              $1,360.09        20110101
28240       RELEASE OF BIG TOE                                                    $280.53        20120901
28240       RELEASE OF BIG TOE                                   A                $610.38        20110101
28250       REVISION OF FOOT FASCIA        80                                      $72.01        20120901
28250       REVISION OF FOOT FASCIA        81                                      $72.01        20120901
28250       REVISION OF FOOT FASCIA        82                                      $72.01        20120901
28250       REVISION OF FOOT FASCIA        AS                                      $72.01        20120901
28250       REVISION OF FOOT FASCIA                                               $360.03        20120901
28250       REVISION OF FOOT FASCIA                              A                $622.62        20110101



                                             Page 100
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price         Effective Date
28260       RELEASE OF MIDFOOT JOINT        80                                     $88.06        20120901
28260       RELEASE OF MIDFOOT JOINT        81                                     $88.06        20120901
28260       RELEASE OF MIDFOOT JOINT        82                                     $88.06        20120901
28260       RELEASE OF MIDFOOT JOINT        AS                                     $88.06        20120901
28260       RELEASE OF MIDFOOT JOINT                                              $440.29        20120901
28260       RELEASE OF MIDFOOT JOINT                              A               $622.62        20110101
28261       REVISION OF FOOT TENDON                                               $626.30        20120901
28261       REVISION OF FOOT TENDON                               A               $622.62        20110101
28262       REVISION OF FOOT AND ANKLE      80                                    $179.89        20120901
28262       REVISION OF FOOT AND ANKLE      81                                    $179.89        20120901
28262       REVISION OF FOOT AND ANKLE      82                                    $179.89        20120901
28262       REVISION OF FOOT AND ANKLE      AS                                    $179.89        20120901
28262       REVISION OF FOOT AND ANKLE                                            $899.44        20120901
28262       REVISION OF FOOT AND ANKLE                            A               $645.58        20110101
28264       RELEASE OF MIDFOOT JOINT        80                                    $107.27        20120901
28264       RELEASE OF MIDFOOT JOINT        81                                    $107.27        20120901
28264       RELEASE OF MIDFOOT JOINT        82                                    $107.27        20120901
28264       RELEASE OF MIDFOOT JOINT        AS                                    $107.27        20120901
28264       RELEASE OF MIDFOOT JOINT                                              $536.35        20120901
28264       RELEASE OF MIDFOOT JOINT                              A             $1,326.22        20110101
28270       RELEASE OF FOOT CONTRACTURE                                           $305.76        20120901
28270       RELEASE OF FOOT CONTRACTURE                           A               $622.62        20110101
28272       RELEASE OF TOE JOINT EACH                                             $247.67        20120901
28280       FUSION OF TOES                                                        $332.26        20120901
28280       FUSION OF TOES                                        A               $610.38        20110101
28285       REPAIR OF HAMMERTOE                                                   $295.31        20120901
28285       REPAIR OF HAMMERTOE                                   A               $622.62        20110101
28286       REPAIR OF HAMMERTOE                                                   $286.40        20120901
28286       REPAIR OF HAMMERTOE                                   A               $645.58        20110101
28288       PARTIAL REMOVAL OF FOOT BONE                                          $376.85        20120901
28288       PARTIAL REMOVAL OF FOOT BONE                          A               $622.62        20110101
28289       REPAIR HALLUX RIGIDUS           80                                     $94.07        20120901
28289       REPAIR HALLUX RIGIDUS           81                                     $94.07        20120901
28289       REPAIR HALLUX RIGIDUS           82                                     $94.07        20120901
28289       REPAIR HALLUX RIGIDUS           AS                                     $94.07        20120901
28289       REPAIR HALLUX RIGIDUS                                                 $470.36        20120901
28289       REPAIR HALLUX RIGIDUS                                 A               $622.62        20110101
28290       CORRECTION OF BUNION                                                  $365.38        20120901
28290       CORRECTION OF BUNION                                  A               $843.75        20110101
28293       CORRECTION OF BUNION                                                  $665.28        20120901
28293       CORRECTION OF BUNION                                  A               $856.00        20110101
28294       CORRECTION OF BUNION            80                                     $95.60        20120901
28294       CORRECTION OF BUNION            81                                     $95.60        20120901
28294       CORRECTION OF BUNION            82                                     $95.60        20120901
28294       CORRECTION OF BUNION            AS                                     $95.60        20120901
28294       CORRECTION OF BUNION                                                  $478.00        20120901
28294       CORRECTION OF BUNION                                  A               $856.00        20110101
28296       CORRECTION OF BUNION            80                                     $92.65        20120901
28296       CORRECTION OF BUNION            81                                     $92.65        20120901
28296       CORRECTION OF BUNION            82                                     $92.65        20120901
28296       CORRECTION OF BUNION            AS                                     $92.65        20120901
28296       CORRECTION OF BUNION                                                  $463.23        20120901
28296       CORRECTION OF BUNION                                  A               $856.00        20110101
28297       CORRECTION OF BUNION            80                                    $105.95        20120901
28297       CORRECTION OF BUNION            81                                    $105.95        20120901
28297       CORRECTION OF BUNION            82                                    $105.95        20120901
28297       CORRECTION OF BUNION            AS                                    $105.95        20120901
28297       CORRECTION OF BUNION                                                  $529.73        20120901
28297       CORRECTION OF BUNION                                  A               $856.00        20110101



                                              Page 101
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price         Effective Date
28298       CORRECTION OF BUNION            80                                     $91.52        20120901
28298       CORRECTION OF BUNION            81                                     $91.52        20120901
28298       CORRECTION OF BUNION            82                                     $91.52        20120901
28298       CORRECTION OF BUNION            AS                                     $91.52        20120901
28298       CORRECTION OF BUNION                                                  $457.62        20120901
28298       CORRECTION OF BUNION                                  A               $856.00        20110101
28299       CORRECTION OF BUNION            80                                    $116.85        20120901
28299       CORRECTION OF BUNION            81                                    $116.85        20120901
28299       CORRECTION OF BUNION            82                                    $116.85        20120901
28299       CORRECTION OF BUNION            AS                                    $116.85        20120901
28299       CORRECTION OF BUNION                                                  $584.26        20120901
28299       CORRECTION OF BUNION                                  A               $895.61        20110101
28300       INCISION OF HEEL BONE           80                                     $89.43        20120901
28300       INCISION OF HEEL BONE           81                                     $89.43        20120901
28300       INCISION OF HEEL BONE           82                                     $89.43        20120901
28300       INCISION OF HEEL BONE           AS                                     $89.43        20120901
28300       INCISION OF HEEL BONE                                                 $447.17        20120901
28300       INCISION OF HEEL BONE                                 A             $1,347.85        20110101
28302       INCISION OF ANKLE BONE          80                                     $91.58        20120901
28302       INCISION OF ANKLE BONE          81                                     $91.58        20120901
28302       INCISION OF ANKLE BONE          82                                     $91.58        20120901
28302       INCISION OF ANKLE BONE          AS                                     $91.58        20120901
28302       INCISION OF ANKLE BONE                                                $457.88        20120901
28302       INCISION OF ANKLE BONE                                A               $610.38        20110101
28304       INCISION OF MIDFOOT BONES       80                                    $102.12        20120901
28304       INCISION OF MIDFOOT BONES       81                                    $102.12        20120901
28304       INCISION OF MIDFOOT BONES       82                                    $102.12        20120901
28304       INCISION OF MIDFOOT BONES       AS                                    $102.12        20120901
28304       INCISION OF MIDFOOT BONES                                             $510.62        20120901
28304       INCISION OF MIDFOOT BONES                             A             $1,347.85        20110101
28305       INCISE/GRAFT MIDFOOT BONES      80                                     $91.07        20120901
28305       INCISE/GRAFT MIDFOOT BONES      81                                     $91.07        20120901
28305       INCISE/GRAFT MIDFOOT BONES      82                                     $91.07        20120901
28305       INCISE/GRAFT MIDFOOT BONES      AS                                     $91.07        20120901
28305       INCISE/GRAFT MIDFOOT BONES                                            $455.33        20120901
28305       INCISE/GRAFT MIDFOOT BONES                            A             $1,360.09        20110101
28306       INCISION OF METATARSAL          80                                     $77.15        20120901
28306       INCISION OF METATARSAL          81                                     $77.15        20120901
28306       INCISION OF METATARSAL          82                                     $77.15        20120901
28306       INCISION OF METATARSAL          AS                                     $77.15        20120901
28306       INCISION OF METATARSAL                                                $385.77        20120901
28306       INCISION OF METATARSAL                                A               $645.58        20110101
28307       INCISION OF METATARSAL                                                $467.05        20120901
28307       INCISION OF METATARSAL                                A               $645.58        20110101
28308       INCISION OF METATARSAL          80                                     $69.76        20120901
28308       INCISION OF METATARSAL          81                                     $69.76        20120901
28308       INCISION OF METATARSAL          82                                     $69.76        20120901
28308       INCISION OF METATARSAL          AS                                     $69.76        20120901
28308       INCISION OF METATARSAL                                                $348.82        20120901
28308       INCISION OF METATARSAL                                A               $610.38        20110101
28309       INCISION OF METATARSALS         80                                    $121.03        20120901
28309       INCISION OF METATARSALS         81                                    $121.03        20120901
28309       INCISION OF METATARSALS         82                                    $121.03        20120901
28309       INCISION OF METATARSALS         AS                                    $121.03        20120901
28309       INCISION OF METATARSALS                                               $605.15        20120901
28309       INCISION OF METATARSALS                               A             $1,383.06        20110101
28310       REVISION OF BIG TOE                                                   $339.39        20120901
28310       REVISION OF BIG TOE                                   A               $622.62        20110101
28312       REVISION OF TOE                                                       $312.89        20120901



                                              Page 102
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
28312       REVISION OF TOE                                      A                $622.62        20110101
28313       REPAIR DEFORMITY OF TOE                                               $331.49        20120901
28313       REPAIR DEFORMITY OF TOE                              A                $610.38        20110101
28315       REMOVAL OF SESAMOID BONE                                              $300.66        20120901
28315       REMOVAL OF SESAMOID BONE                             A                $645.58        20110101
28320       REPAIR OF FOOT BONES           80                                      $84.08        20120901
28320       REPAIR OF FOOT BONES           81                                      $84.08        20120901
28320       REPAIR OF FOOT BONES           82                                      $84.08        20120901
28320       REPAIR OF FOOT BONES           AS                                      $84.08        20120901
28320       REPAIR OF FOOT BONES                                                  $420.42        20120901
28320       REPAIR OF FOOT BONES                                 A              $1,383.06        20110101
28322       REPAIR OF METATARSALS          80                                     $100.03        20120901
28322       REPAIR OF METATARSALS          81                                     $100.03        20120901
28322       REPAIR OF METATARSALS          82                                     $100.03        20120901
28322       REPAIR OF METATARSALS          AS                                     $100.03        20120901
28322       REPAIR OF METATARSALS                                                 $500.17        20120901
28322       REPAIR OF METATARSALS                                A              $1,383.06        20110101
28340       RESECT ENLARGED TOE TISSUE                                            $385.51        20120901
28340       RESECT ENLARGED TOE TISSUE                           A                $645.58        20110101
28341       RESECT ENLARGED TOE                                                   $445.14        20120901
28341       RESECT ENLARGED TOE                                  A                $645.58        20110101
28344       REPAIR EXTRA TOES                                                     $293.02        20120901
28344       REPAIR EXTRA TOES                                    A                $645.58        20110101
28345       REPAIR WEBBED TOES                                                    $353.66        20120901
28345       REPAIR WEBBED TOES                                   A                $645.58        20110101
28360       RECONSTRUCT CLEFT FOOT         80                                     $133.82        20120901
28360       RECONSTRUCT CLEFT FOOT         81                                     $133.82        20120901
28360       RECONSTRUCT CLEFT FOOT         82                                     $133.82        20120901
28360       RECONSTRUCT CLEFT FOOT         AS                                     $133.82        20120901
28360       RECONSTRUCT CLEFT FOOT                                                $669.10        20120901
28400       TREATMENT OF HEEL FRACTURE                                            $156.45        20120901
28400       TREATMENT OF HEEL FRACTURE                           A                 $59.66        20110101
28405       TREATMENT OF HEEL FRACTURE                                            $250.47        20120901
28405       TREATMENT OF HEEL FRACTURE                           A                $462.00        20110101
28406       TREATMENT OF HEEL FRACTURE                                            $345.76        20120901
28406       TREATMENT OF HEEL FRACTURE                           A                $706.54        20110101
28415       TREAT HEEL FRACTURE            80                                     $151.71        20120901
28415       TREAT HEEL FRACTURE            81                                     $151.71        20120901
28415       TREAT HEEL FRACTURE            82                                     $151.71        20120901
28415       TREAT HEEL FRACTURE            AS                                     $151.71        20120901
28415       TREAT HEEL FRACTURE                                                   $758.54        20120901
28415       TREAT HEEL FRACTURE                                  A              $1,671.34        20110101
28420       TREAT/GRAFT HEEL FRACTURE      80                                     $163.33        20120901
28420       TREAT/GRAFT HEEL FRACTURE      81                                     $163.33        20120901
28420       TREAT/GRAFT HEEL FRACTURE      82                                     $163.33        20120901
28420       TREAT/GRAFT HEEL FRACTURE      AS                                     $163.33        20120901
28420       TREAT/GRAFT HEEL FRACTURE                                             $816.63        20120901
28420       TREAT/GRAFT HEEL FRACTURE                            A              $1,213.40        20110101
28430       TREATMENT OF ANKLE FRACTURE                                           $147.02        20120901
28435       TREATMENT OF ANKLE FRACTURE                                           $213.01        20120901
28435       TREATMENT OF ANKLE FRACTURE                          A                 $59.66        20110101
28436       TREATMENT OF ANKLE FRACTURE                                           $283.34        20120901
28436       TREATMENT OF ANKLE FRACTURE                          A                $706.54        20110101
28445       TREAT ANKLE FRACTURE           80                                     $143.76        20120901
28445       TREAT ANKLE FRACTURE           81                                     $143.76        20120901
28445       TREAT ANKLE FRACTURE           82                                     $143.76        20120901
28445       TREAT ANKLE FRACTURE           AS                                     $143.76        20120901
28445       TREAT ANKLE FRACTURE                                                  $718.79        20120901
28445       TREAT ANKLE FRACTURE                                 A              $1,190.44        20110101



                                             Page 103
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price          Effective Date
28446       OSTEOCHONDRAL TALUS AUTOGRFT                                         $806.44        20120901
28446       OSTEOCHONDRAL TALUS AUTOGRFT                        A              $1,683.34        20110101
28450       TREAT MIDFOOT FRACTURE EACH                                          $135.55        20120901
28455       TREAT MIDFOOT FRACTURE EACH                                          $188.30        20120901
28456       TREAT MIDFOOT FRACTURE                                               $188.04        20120901
28456       TREAT MIDFOOT FRACTURE                              A                $706.54        20110101
28465       TREAT MIDFOOT FRACTURE EACH                                          $409.72        20120901
28465       TREAT MIDFOOT FRACTURE EACH                         A              $1,190.44        20110101
28470       TREAT METATARSAL FRACTURE                                            $134.28        20120901
28475       TREAT METATARSAL FRACTURE                                            $167.40        20120901
28476       TREAT METATARSAL FRACTURE                                            $221.17        20120901
28476       TREAT METATARSAL FRACTURE                           A                $706.54        20110101
28485       TREAT METATARSAL FRACTURE                                            $354.43        20120901
28485       TREAT METATARSAL FRACTURE                           A              $1,213.40        20110101
28490       TREAT BIG TOE FRACTURE                                                $88.16        20120901
28495       TREAT BIG TOE FRACTURE                                               $110.07        20120901
28496       TREAT BIG TOE FRACTURE                                               $264.99        20120901
28496       TREAT BIG TOE FRACTURE                              A                $706.54        20110101
28505       TREAT BIG TOE FRACTURE                                               $428.57        20120901
28505       TREAT BIG TOE FRACTURE                              A                $718.78        20110101
28510       TREATMENT OF TOE FRACTURE                                             $75.93        20120901
28515       TREATMENT OF TOE FRACTURE                                             $99.63        20120901
28525       TREAT TOE FRACTURE                                                   $361.05        20120901
28525       TREAT TOE FRACTURE                                  A                $718.78        20110101
28530       TREAT SESAMOID BONE FRACTURE                                          $72.11        20120901
28531       TREAT SESAMOID BONE FRACTURE                                         $251.49        20120901
28531       TREAT SESAMOID BONE FRACTURE                        A                $718.78        20110101
28540       TREAT FOOT DISLOCATION                                               $128.42        20120901
28545       TREAT FOOT DISLOCATION                                               $167.15        20120901
28545       TREAT FOOT DISLOCATION                              A                $684.91        20110101
28546       TREAT FOOT DISLOCATION                                               $314.42        20120901
28546       TREAT FOOT DISLOCATION                              A                $706.54        20110101
28555       REPAIR FOOT DISLOCATION        80                                    $112.62        20120901
28555       REPAIR FOOT DISLOCATION        81                                    $112.62        20120901
28555       REPAIR FOOT DISLOCATION        82                                    $112.62        20120901
28555       REPAIR FOOT DISLOCATION        AS                                    $112.62        20120901
28555       REPAIR FOOT DISLOCATION                                              $563.11        20120901
28555       REPAIR FOOT DISLOCATION                             A              $1,178.19        20110101
28570       TREAT FOOT DISLOCATION                                               $107.53        20120901
28575       TREAT FOOT DISLOCATION                                               $218.87        20120901
28575       TREAT FOOT DISLOCATION                              A                $462.00        20110101
28576       TREAT FOOT DISLOCATION                                               $241.81        20120901
28576       TREAT FOOT DISLOCATION                              A                $718.78        20110101
28585       REPAIR FOOT DISLOCATION        80                                    $120.37        20120901
28585       REPAIR FOOT DISLOCATION        81                                    $120.37        20120901
28585       REPAIR FOOT DISLOCATION        82                                    $120.37        20120901
28585       REPAIR FOOT DISLOCATION        AS                                    $120.37        20120901
28585       REPAIR FOOT DISLOCATION                                              $601.84        20120901
28585       REPAIR FOOT DISLOCATION                             A                $718.78        20110101
28600       TREAT FOOT DISLOCATION                                               $135.55        20120901
28605       TREAT FOOT DISLOCATION                                               $184.22        20120901
28605       TREAT FOOT DISLOCATION                              A                 $59.66        20110101
28606       TREAT FOOT DISLOCATION                                               $257.86        20120901
28606       TREAT FOOT DISLOCATION                              A                $706.54        20110101
28615       REPAIR FOOT DISLOCATION        80                                    $104.47        20120901
28615       REPAIR FOOT DISLOCATION        81                                    $104.47        20120901
28615       REPAIR FOOT DISLOCATION        82                                    $104.47        20120901
28615       REPAIR FOOT DISLOCATION        AS                                    $104.47        20120901
28615       REPAIR FOOT DISLOCATION                                              $522.34        20120901



                                            Page 104
                                   DMAP Fee for Service Fee Schedule
                                           September 2012


Procedure
Code        Description                      Mod 1        Mod 2    Rate Type   Price          Effective Date
28615       REPAIR FOOT DISLOCATION                                A              $1,190.44        20110101
28630       TREAT TOE DISLOCATION                                                    $96.31        20120901
28635       TREAT TOE DISLOCATION                                                   $112.11        20120901
28635       TREAT TOE DISLOCATION                                  A                $431.28        20110101
28636       TREAT TOE DISLOCATION                                                   $187.28        20120901
28636       TREAT TOE DISLOCATION                                  A                $718.78        20110101
28645       REPAIR TOE DISLOCATION                                                  $406.66        20120901
28645       REPAIR TOE DISLOCATION                                 A                $718.78        20110101
28660       TREAT TOE DISLOCATION                                                    $71.34        20120901
28665       TREAT TOE DISLOCATION                                                   $100.90        20120901
28665       TREAT TOE DISLOCATION                                  A                $431.28        20110101
28666       TREAT TOE DISLOCATION                                                   $133.01        20120901
28666       TREAT TOE DISLOCATION                                  A                $718.78        20110101
28675       REPAIR OF TOE DISLOCATION                                               $371.24        20120901
28675       REPAIR OF TOE DISLOCATION                              A                $718.78        20110101
28705       FUSION OF FOOT BONES             80                                     $176.88        20120901
28705       FUSION OF FOOT BONES             81                                     $176.88        20120901
28705       FUSION OF FOOT BONES             82                                     $176.88        20120901
28705       FUSION OF FOOT BONES             AS                                     $176.88        20120901
28705       FUSION OF FOOT BONES                                                    $884.41        20120901
28705       FUSION OF FOOT BONES                                   A              $1,383.06        20110101
28715       FUSION OF FOOT BONES             80                                     $131.48        20120901
28715       FUSION OF FOOT BONES             81                                     $131.48        20120901
28715       FUSION OF FOOT BONES             82                                     $131.48        20120901
28715       FUSION OF FOOT BONES             AS                                     $131.48        20120901
28715       FUSION OF FOOT BONES                                                    $657.38        20120901
28715       FUSION OF FOOT BONES                                   A              $2,251.38        20110101
28725       FUSION OF FOOT BONES             80                                     $107.27        20120901
28725       FUSION OF FOOT BONES             81                                     $107.27        20120901
28725       FUSION OF FOOT BONES             82                                     $107.27        20120901
28725       FUSION OF FOOT BONES             AS                                     $107.27        20120901
28725       FUSION OF FOOT BONES                                                    $536.35        20120901
28725       FUSION OF FOOT BONES                                   A              $1,383.06        20110101
28730       FUSION OF FOOT BONES             80                                     $113.23        20120901
28730       FUSION OF FOOT BONES             81                                     $113.23        20120901
28730       FUSION OF FOOT BONES             82                                     $113.23        20120901
28730       FUSION OF FOOT BONES             AS                                     $113.23        20120901
28730       FUSION OF FOOT BONES                                                    $566.17        20120901
28730       FUSION OF FOOT BONES                                   A              $1,383.06        20110101
28735       FUSION OF FOOT BONES             80                                     $107.63        20120901
28735       FUSION OF FOOT BONES             81                                     $107.63        20120901
28735       FUSION OF FOOT BONES             82                                     $107.63        20120901
28735       FUSION OF FOOT BONES             AS                                     $107.63        20120901
28735       FUSION OF FOOT BONES                                                    $538.14        20120901
28735       FUSION OF FOOT BONES                                   A              $1,383.06        20110101
28737       REVISION OF FOOT BONES           80                                      $93.97        20120901
28737       REVISION OF FOOT BONES           81                                      $93.97        20120901
28737       REVISION OF FOOT BONES           82                                      $93.97        20120901
28737       REVISION OF FOOT BONES           AS                                      $93.97        20120901
28737       REVISION OF FOOT BONES                                                  $469.85        20120901
28737       REVISION OF FOOT BONES                                 A              $1,399.70        20110101
28740       FUSION OF FOOT BONES             80                                     $110.12        20120901
28740       FUSION OF FOOT BONES             81                                     $110.12        20120901
28740       FUSION OF FOOT BONES             82                                     $110.12        20120901
28740       FUSION OF FOOT BONES             AS                                     $110.12        20120901
28740       FUSION OF FOOT BONES                                                    $550.62        20120901
28740       FUSION OF FOOT BONES                                   A              $1,383.06        20110101
28750       FUSION OF BIG TOE JOINT                                                 $535.33        20120901
28750       FUSION OF BIG TOE JOINT                                A              $1,383.06        20110101



                                               Page 105
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
28755       FUSION OF BIG TOE JOINT                                                $318.25        20120901
28755       FUSION OF BIG TOE JOINT                               A                $645.58        20110101
28760       FUSION OF BIG TOE JOINT         80                                     $101.21        20120901
28760       FUSION OF BIG TOE JOINT         81                                     $101.21        20120901
28760       FUSION OF BIG TOE JOINT         82                                     $101.21        20120901
28760       FUSION OF BIG TOE JOINT         AS                                     $101.21        20120901
28760       FUSION OF BIG TOE JOINT                                                $506.03        20120901
28760       FUSION OF BIG TOE JOINT                               A              $1,383.06        20110101
28800       AMPUTATION OF MIDFOOT           80                                      $77.15        20120901
28800       AMPUTATION OF MIDFOOT           81                                      $77.15        20120901
28800       AMPUTATION OF MIDFOOT           82                                      $77.15        20120901
28800       AMPUTATION OF MIDFOOT           AS                                      $77.15        20120901
28800       AMPUTATION OF MIDFOOT                                                  $385.77        20120901
28805       AMPUTATION THRU METATARSAL      80                                     $104.37        20120901
28805       AMPUTATION THRU METATARSAL      81                                     $104.37        20120901
28805       AMPUTATION THRU METATARSAL      82                                     $104.37        20120901
28805       AMPUTATION THRU METATARSAL      AS                                     $104.37        20120901
28805       AMPUTATION THRU METATARSAL                                             $521.83        20120901
28810       AMPUTATION TOE METATARSAL                                              $302.45        20120901
28810       AMPUTATION TOE METATARSAL                             A                $610.38        20110101
28820       AMPUTATION OF TOE                                                      $340.41        20120901
28820       AMPUTATION OF TOE                                     A                $610.38        20110101
28825       PARTIAL AMPUTATION OF TOE                                              $374.81        20120901
28825       PARTIAL AMPUTATION OF TOE                             A                $610.38        20110101
29000       APPLICATION OF BODY CAST                                               $160.78        20120901
29010       APPLICATION OF BODY CAST                                               $143.96        20120901
29015       APPLICATION OF BODY CAST                                               $153.90        20120901
29020       APPLICATION OF BODY CAST                                               $138.61        20120901
29025       APPLICATION OF BODY CAST                                               $169.44        20120901
29035       APPLICATION OF BODY CAST                                               $151.35        20120901
29040       APPLICATION OF BODY CAST                                               $149.31        20120901
29044       APPLICATION OF BODY CAST                                               $164.86        20120901
29046       APPLICATION OF BODY CAST                                               $178.61        20120901
29049       APPLICATION OF FIGURE EIGHT                                             $57.08        20120901
29055       APPLICATION OF SHOULDER CAST                                           $133.26        20120901
29058       APPLICATION OF SHOULDER CAST                                            $71.60        20120901
29065       APPLICATION OF LONG ARM CAST                                            $59.88        20120901
29075       APPLICATION OF FOREARM CAST                                             $55.55        20120901
29085       APPLY HAND/WRIST CAST                                                   $58.86        20120901
29086       APPLY FINGER CAST                                                       $45.86        20120901
29105       APPLY LONG ARM SPLINT                                                   $54.78        20120901
29125       APPLY FOREARM SPLINT                                                    $43.06        20120901
29126       APPLY FOREARM SPLINT                                                    $49.43        20120901
29130       APPLICATION OF FINGER SPLINT                                            $25.99        20120901
29131       APPLICATION OF FINGER SPLINT                                            $32.61        20120901
29200       STRAPPING OF CHEST                                                      $34.40        20120901
29240       STRAPPING OF SHOULDER                                                   $37.46        20120901
29260       STRAPPING OF ELBOW OR WRIST                                             $32.87        20120901
29280       STRAPPING OF HAND OR FINGER                                             $31.85        20120901
29305       APPLICATION OF HIP CAST                                                $149.57        20120901
29325       APPLICATION OF HIP CASTS                                               $166.38        20120901
29345       APPLICATION OF LONG LEG CAST                                            $86.12        20120901
29355       APPLICATION OF LONG LEG CAST                                            $88.93        20120901
29358       APPLY LONG LEG CAST BRACE                                               $97.59        20120901
29365       APPLICATION OF LONG LEG CAST                                            $77.20        20120901
29405       APPLY SHORT LEG CAST                                                    $56.06        20120901
29425       APPLY SHORT LEG CAST                                                    $60.39        20120901
29435       APPLY SHORT LEG CAST                                                    $75.42        20120901
29440       ADDITION OF WALKER TO CAST                                              $33.63        20120901



                                              Page 106
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price         Effective Date
29445       APPLY RIGID LEG CAST                                                 $92.75        20120901
29450       APPLICATION OF LEG CAST                                              $97.08        20120901
29505       APPLICATION LONG LEG SPLINT                                          $48.92        20120901
29515       APPLICATION LOWER LEG SPLINT                                         $45.35        20120901
29520       STRAPPING OF HIP                                                     $31.85        20120901
29530       STRAPPING OF KNEE                                                    $33.38        20120901
29540       STRAPPING OF ANKLE AND/OR FT                                         $27.01        20120901
29550       STRAPPING OF TOES                                                    $26.50        20120901
29580       APPLICATION OF PASTE BOOT                                            $33.63        20120901
29581       APPLY MULTLAY COMPRS LWR LEG                                         $60.90        20120901
29582       APPLY MULTLAY COMPRS UPR LEG                                         $52.23        20120901
29583       APPLY MULTLAY COMPRS UPR ARM                                         $32.36        20120901
29584       APPL MULTLAY COMPRS ARM/HAND                                         $52.23        20120901
29590       APPLICATION OF FOOT SPLINT                                           $35.42        20120901
29700       REMOVAL/REVISION OF CAST                                             $41.02        20120901
29705       REMOVAL/REVISION OF CAST                                             $42.81        20120901
29710       REMOVAL/REVISION OF CAST                                             $77.20        20120901
29715       REMOVAL/REVISION OF CAST                                             $56.06        20120901
29720       REPAIR OF BODY CAST                                                  $50.71        20120901
29730       WINDOWING OF CAST                                                    $41.53        20120901
29740       WEDGING OF CAST                                                      $59.37        20120901
29750       WEDGING OF CLUBFOOT CAST                                             $67.01        20120901
29800       JAW ARTHROSCOPY/SURGERY                                             $345.76        20120901
29800       JAW ARTHROSCOPY/SURGERY                             A               $816.73        20110101
29804       JAW ARTHROSCOPY/SURGERY        80                                    $86.28        20120901
29804       JAW ARTHROSCOPY/SURGERY        81                                    $86.28        20120901
29804       JAW ARTHROSCOPY/SURGERY        82                                    $86.28        20120901
29804       JAW ARTHROSCOPY/SURGERY        AS                                    $86.28        20120901
29804       JAW ARTHROSCOPY/SURGERY                                             $431.38        20120901
29804       JAW ARTHROSCOPY/SURGERY                             A               $816.73        20110101
29805       SHOULDER ARTHROSCOPY DX                                             $310.09        20120901
29805       SHOULDER ARTHROSCOPY DX                             A               $816.73        20110101
29806       SHOULDER ARTHROSCOPY/SURGERY                                        $710.64        20120901
29806       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29807       SHOULDER ARTHROSCOPY/SURGERY                                        $692.04        20120901
29807       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29819       SHOULDER ARTHROSCOPY/SURGERY                                        $388.32        20120901
29819       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29820       SHOULDER ARTHROSCOPY/SURGERY   80                                    $71.60        20120901
29820       SHOULDER ARTHROSCOPY/SURGERY   81                                    $71.60        20120901
29820       SHOULDER ARTHROSCOPY/SURGERY   82                                    $71.60        20120901
29820       SHOULDER ARTHROSCOPY/SURGERY   AS                                    $71.60        20120901
29820       SHOULDER ARTHROSCOPY/SURGERY                                        $357.99        20120901
29820       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29821       SHOULDER ARTHROSCOPY/SURGERY   80                                    $78.38        20120901
29821       SHOULDER ARTHROSCOPY/SURGERY   81                                    $78.38        20120901
29821       SHOULDER ARTHROSCOPY/SURGERY   82                                    $78.38        20120901
29821       SHOULDER ARTHROSCOPY/SURGERY   AS                                    $78.38        20120901
29821       SHOULDER ARTHROSCOPY/SURGERY                                        $391.88        20120901
29821       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29822       SHOULDER ARTHROSCOPY/SURGERY   80                                    $76.19        20120901
29822       SHOULDER ARTHROSCOPY/SURGERY   81                                    $76.19        20120901
29822       SHOULDER ARTHROSCOPY/SURGERY   82                                    $76.19        20120901
29822       SHOULDER ARTHROSCOPY/SURGERY   AS                                    $76.19        20120901
29822       SHOULDER ARTHROSCOPY/SURGERY                                        $380.93        20120901
29822       SHOULDER ARTHROSCOPY/SURGERY                        A               $816.73        20110101
29823       SHOULDER ARTHROSCOPY/SURGERY   80                                    $83.27        20120901
29823       SHOULDER ARTHROSCOPY/SURGERY   81                                    $83.27        20120901
29823       SHOULDER ARTHROSCOPY/SURGERY   82                                    $83.27        20120901



                                            Page 107
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price         Effective Date
29823       SHOULDER ARTHROSCOPY/SURGERY   AS                                    $83.27        20120901
29823       SHOULDER ARTHROSCOPY/SURGERY                                        $416.34        20120901
29823       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29824       SHOULDER ARTHROSCOPY/SURGERY   80                                    $89.43        20120901
29824       SHOULDER ARTHROSCOPY/SURGERY   81                                    $89.43        20120901
29824       SHOULDER ARTHROSCOPY/SURGERY   82                                    $89.43        20120901
29824       SHOULDER ARTHROSCOPY/SURGERY   AS                                    $89.43        20120901
29824       SHOULDER ARTHROSCOPY/SURGERY                                        $447.17        20120901
29824       SHOULDER ARTHROSCOPY/SURGERY                        A               $856.34        20110101
29825       SHOULDER ARTHROSCOPY/SURGERY   80                                    $77.61        20120901
29825       SHOULDER ARTHROSCOPY/SURGERY   81                                    $77.61        20120901
29825       SHOULDER ARTHROSCOPY/SURGERY   82                                    $77.61        20120901
29825       SHOULDER ARTHROSCOPY/SURGERY   AS                                    $77.61        20120901
29825       SHOULDER ARTHROSCOPY/SURGERY                                        $388.06        20120901
29825       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29826       SHOULDER ARTHROSCOPY/SURGERY   80                                    $88.98        20120901
29826       SHOULDER ARTHROSCOPY/SURGERY   81                                    $88.98        20120901
29826       SHOULDER ARTHROSCOPY/SURGERY   82                                    $88.98        20120901
29826       SHOULDER ARTHROSCOPY/SURGERY   AS                                    $88.98        20120901
29826       SHOULDER ARTHROSCOPY/SURGERY                                        $444.88        20120901
29826       SHOULDER ARTHROSCOPY/SURGERY                        A             $1,270.96        20110101
29827       ARTHROSCOP ROTATOR CUFF REPR   80                                   $145.03        20120901
29827       ARTHROSCOP ROTATOR CUFF REPR   81                                   $145.03        20120901
29827       ARTHROSCOP ROTATOR CUFF REPR   82                                   $145.03        20120901
29827       ARTHROSCOP ROTATOR CUFF REPR   AS                                   $145.03        20120901
29827       ARTHROSCOP ROTATOR CUFF REPR                                        $725.16        20120901
29827       ARTHROSCOP ROTATOR CUFF REPR                        A             $1,310.57        20110101
29828       ARTHROSCOPY BICEPS TENODESIS                                        $612.28        20120901
29828       ARTHROSCOPY BICEPS TENODESIS                        A             $1,564.50        20110101
29830       ELBOW ARTHROSCOPY                                                   $299.39        20120901
29830       ELBOW ARTHROSCOPY                                   A               $816.73        20110101
29834       ELBOW ARTHROSCOPY/SURGERY      80                                    $65.08        20120901
29834       ELBOW ARTHROSCOPY/SURGERY      81                                    $65.08        20120901
29834       ELBOW ARTHROSCOPY/SURGERY      82                                    $65.08        20120901
29834       ELBOW ARTHROSCOPY/SURGERY      AS                                    $65.08        20120901
29834       ELBOW ARTHROSCOPY/SURGERY                                           $325.38        20120901
29834       ELBOW ARTHROSCOPY/SURGERY                           A               $816.73        20110101
29835       ELBOW ARTHROSCOPY/SURGERY      80                                    $66.81        20120901
29835       ELBOW ARTHROSCOPY/SURGERY      81                                    $66.81        20120901
29835       ELBOW ARTHROSCOPY/SURGERY      82                                    $66.81        20120901
29835       ELBOW ARTHROSCOPY/SURGERY      AS                                    $66.81        20120901
29835       ELBOW ARTHROSCOPY/SURGERY                                           $334.04        20120901
29835       ELBOW ARTHROSCOPY/SURGERY                           A               $816.73        20110101
29836       ELBOW ARTHROSCOPY/SURGERY      80                                    $77.20        20120901
29836       ELBOW ARTHROSCOPY/SURGERY      81                                    $77.20        20120901
29836       ELBOW ARTHROSCOPY/SURGERY      82                                    $77.20        20120901
29836       ELBOW ARTHROSCOPY/SURGERY      AS                                    $77.20        20120901
29836       ELBOW ARTHROSCOPY/SURGERY                                           $386.02        20120901
29836       ELBOW ARTHROSCOPY/SURGERY                           A               $816.73        20110101
29837       ELBOW ARTHROSCOPY/SURGERY      80                                    $70.02        20120901
29837       ELBOW ARTHROSCOPY/SURGERY      81                                    $70.02        20120901
29837       ELBOW ARTHROSCOPY/SURGERY      82                                    $70.02        20120901
29837       ELBOW ARTHROSCOPY/SURGERY      AS                                    $70.02        20120901
29837       ELBOW ARTHROSCOPY/SURGERY                                           $350.10        20120901
29837       ELBOW ARTHROSCOPY/SURGERY                           A               $816.73        20110101
29838       ELBOW ARTHROSCOPY/SURGERY                                           $391.63        20120901
29838       ELBOW ARTHROSCOPY/SURGERY                           A               $816.73        20110101
29840       WRIST ARTHROSCOPY                                                   $296.08        20120901
29840       WRIST ARTHROSCOPY                                   A               $816.73        20110101



                                            Page 108
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
29843       WRIST ARTHROSCOPY/SURGERY                                             $317.48        20120901
29843       WRIST ARTHROSCOPY/SURGERY                            A                $816.73        20110101
29844       WRIST ARTHROSCOPY/SURGERY                                             $327.42        20120901
29844       WRIST ARTHROSCOPY/SURGERY                            A                $816.73        20110101
29845       WRIST ARTHROSCOPY/SURGERY                                             $377.36        20120901
29845       WRIST ARTHROSCOPY/SURGERY                            A                $816.73        20110101
29846       WRIST ARTHROSCOPY/SURGERY                                             $343.73        20120901
29846       WRIST ARTHROSCOPY/SURGERY                            A                $816.73        20110101
29847       WRIST ARTHROSCOPY/SURGERY      80                                      $71.90        20120901
29847       WRIST ARTHROSCOPY/SURGERY      81                                      $71.90        20120901
29847       WRIST ARTHROSCOPY/SURGERY      82                                      $71.90        20120901
29847       WRIST ARTHROSCOPY/SURGERY      AS                                      $71.90        20120901
29847       WRIST ARTHROSCOPY/SURGERY                                             $359.52        20120901
29847       WRIST ARTHROSCOPY/SURGERY                            A              $1,270.96        20110101
29848       WRIST ENDOSCOPY/SURGERY                                               $331.24        20120901
29848       WRIST ENDOSCOPY/SURGERY                              A                $975.35        20110101
29850       KNEE ARTHROSCOPY/SURGERY                                              $389.33        20120901
29850       KNEE ARTHROSCOPY/SURGERY                             A                $839.70        20110101
29851       KNEE ARTHROSCOPY/SURGERY       80                                     $124.60        20120901
29851       KNEE ARTHROSCOPY/SURGERY       81                                     $124.60        20120901
29851       KNEE ARTHROSCOPY/SURGERY       82                                     $124.60        20120901
29851       KNEE ARTHROSCOPY/SURGERY       AS                                     $124.60        20120901
29851       KNEE ARTHROSCOPY/SURGERY                                              $622.99        20120901
29851       KNEE ARTHROSCOPY/SURGERY                             A              $1,293.92        20110101
29855       TIBIAL ARTHROSCOPY/SURGERY     80                                     $104.62        20120901
29855       TIBIAL ARTHROSCOPY/SURGERY     81                                     $104.62        20120901
29855       TIBIAL ARTHROSCOPY/SURGERY     82                                     $104.62        20120901
29855       TIBIAL ARTHROSCOPY/SURGERY     AS                                     $104.62        20120901
29855       TIBIAL ARTHROSCOPY/SURGERY                                            $523.10        20120901
29855       TIBIAL ARTHROSCOPY/SURGERY                           A              $1,293.92        20110101
29856       TIBIAL ARTHROSCOPY/SURGERY     80                                     $133.72        20120901
29856       TIBIAL ARTHROSCOPY/SURGERY     81                                     $133.72        20120901
29856       TIBIAL ARTHROSCOPY/SURGERY     82                                     $133.72        20120901
29856       TIBIAL ARTHROSCOPY/SURGERY     AS                                     $133.72        20120901
29856       TIBIAL ARTHROSCOPY/SURGERY                                            $668.60        20120901
29856       TIBIAL ARTHROSCOPY/SURGERY                           A              $1,293.92        20110101
29860       HIP ARTHROSCOPY DX                                                    $436.47        20120901
29860       HIP ARTHROSCOPY DX                                   A              $1,293.92        20110101
29861       HIP ARTHRO W/FB REMOVAL        80                                      $96.31        20120901
29861       HIP ARTHRO W/FB REMOVAL        81                                      $96.31        20120901
29861       HIP ARTHRO W/FB REMOVAL        82                                      $96.31        20120901
29861       HIP ARTHRO W/FB REMOVAL        AS                                      $96.31        20120901
29861       HIP ARTHRO W/FB REMOVAL                                               $481.57        20120901
29861       HIP ARTHRO W/FB REMOVAL                              A              $1,293.92        20110101
29862       HIP ARTHR0 W/DEBRIDEMENT       80                                     $108.14        20120901
29862       HIP ARTHR0 W/DEBRIDEMENT       81                                     $108.14        20120901
29862       HIP ARTHR0 W/DEBRIDEMENT       82                                     $108.14        20120901
29862       HIP ARTHR0 W/DEBRIDEMENT       AS                                     $108.14        20120901
29862       HIP ARTHR0 W/DEBRIDEMENT                                              $540.69        20120901
29862       HIP ARTHR0 W/DEBRIDEMENT                             A              $1,429.58        20110101
29863       HIP ARTHR0 W/SYNOVECTOMY       80                                     $107.93        20120901
29863       HIP ARTHR0 W/SYNOVECTOMY       81                                     $107.93        20120901
29863       HIP ARTHR0 W/SYNOVECTOMY       82                                     $107.93        20120901
29863       HIP ARTHR0 W/SYNOVECTOMY       AS                                     $107.93        20120901
29863       HIP ARTHR0 W/SYNOVECTOMY                                              $539.67        20120901
29863       HIP ARTHR0 W/SYNOVECTOMY                             A              $1,293.92        20110101
29870       KNEE ARTHROSCOPY DX                                                   $381.18        20120901
29870       KNEE ARTHROSCOPY DX                                  A                $816.73        20110101
29871       KNEE ARTHROSCOPY/DRAINAGE                                             $338.12        20120901



                                             Page 109
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
29871       KNEE ARTHROSCOPY/DRAINAGE                            A               $816.73         20110101
29873       KNEE ARTHROSCOPY/SURGERY                                             $339.90         20120901
29873       KNEE ARTHROSCOPY/SURGERY                             A               $816.73         20110101
29874       KNEE ARTHROSCOPY/SURGERY       80                                      $71.19        20120901
29874       KNEE ARTHROSCOPY/SURGERY       81                                      $71.19        20120901
29874       KNEE ARTHROSCOPY/SURGERY       82                                      $71.19        20120901
29874       KNEE ARTHROSCOPY/SURGERY       AS                                      $71.19        20120901
29874       KNEE ARTHROSCOPY/SURGERY                                             $355.96         20120901
29874       KNEE ARTHROSCOPY/SURGERY                             A               $816.73         20110101
29875       KNEE ARTHROSCOPY/SURGERY       80                                      $65.43        20120901
29875       KNEE ARTHROSCOPY/SURGERY       81                                      $65.43        20120901
29875       KNEE ARTHROSCOPY/SURGERY       82                                      $65.43        20120901
29875       KNEE ARTHROSCOPY/SURGERY       AS                                      $65.43        20120901
29875       KNEE ARTHROSCOPY/SURGERY                                             $327.16         20120901
29875       KNEE ARTHROSCOPY/SURGERY                             A               $839.70         20110101
29876       KNEE ARTHROSCOPY/SURGERY                                             $433.67         20120901
29876       KNEE ARTHROSCOPY/SURGERY                             A               $839.70         20110101
29877       KNEE ARTHROSCOPY/SURGERY       80                                      $82.10        20120901
29877       KNEE ARTHROSCOPY/SURGERY       81                                      $82.10        20120901
29877       KNEE ARTHROSCOPY/SURGERY       82                                      $82.10        20120901
29877       KNEE ARTHROSCOPY/SURGERY       AS                                      $82.10        20120901
29877       KNEE ARTHROSCOPY/SURGERY                                             $410.48         20120901
29877       KNEE ARTHROSCOPY/SURGERY                             A               $839.70         20110101
29879       KNEE ARTHROSCOPY/SURGERY       80                                      $87.80        20120901
29879       KNEE ARTHROSCOPY/SURGERY       81                                      $87.80        20120901
29879       KNEE ARTHROSCOPY/SURGERY       82                                      $87.80        20120901
29879       KNEE ARTHROSCOPY/SURGERY       AS                                      $87.80        20120901
29879       KNEE ARTHROSCOPY/SURGERY                                             $439.02         20120901
29879       KNEE ARTHROSCOPY/SURGERY                             A               $816.73         20110101
29880       KNEE ARTHROSCOPY/SURGERY       80                                      $91.58        20120901
29880       KNEE ARTHROSCOPY/SURGERY       81                                      $91.58        20120901
29880       KNEE ARTHROSCOPY/SURGERY       82                                      $91.58        20120901
29880       KNEE ARTHROSCOPY/SURGERY       AS                                      $91.58        20120901
29880       KNEE ARTHROSCOPY/SURGERY                                             $457.88         20120901
29880       KNEE ARTHROSCOPY/SURGERY                             A               $839.70         20110101
29881       KNEE ARTHROSCOPY/SURGERY       80                                      $85.46        20120901
29881       KNEE ARTHROSCOPY/SURGERY       81                                      $85.46        20120901
29881       KNEE ARTHROSCOPY/SURGERY       82                                      $85.46        20120901
29881       KNEE ARTHROSCOPY/SURGERY       AS                                      $85.46        20120901
29881       KNEE ARTHROSCOPY/SURGERY                                             $427.30         20120901
29881       KNEE ARTHROSCOPY/SURGERY                             A               $839.70         20110101
29882       KNEE ARTHROSCOPY/SURGERY                                             $462.46         20120901
29882       KNEE ARTHROSCOPY/SURGERY                             A               $816.73         20110101
29883       KNEE ARTHROSCOPY/SURGERY       80                                    $112.21         20120901
29883       KNEE ARTHROSCOPY/SURGERY       81                                    $112.21         20120901
29883       KNEE ARTHROSCOPY/SURGERY       82                                    $112.21         20120901
29883       KNEE ARTHROSCOPY/SURGERY       AS                                    $112.21         20120901
29883       KNEE ARTHROSCOPY/SURGERY                                             $561.07         20120901
29883       KNEE ARTHROSCOPY/SURGERY                             A               $816.73         20110101
29884       KNEE ARTHROSCOPY/SURGERY       80                                      $81.89        20120901
29884       KNEE ARTHROSCOPY/SURGERY       81                                      $81.89        20120901
29884       KNEE ARTHROSCOPY/SURGERY       82                                      $81.89        20120901
29884       KNEE ARTHROSCOPY/SURGERY       AS                                      $81.89        20120901
29884       KNEE ARTHROSCOPY/SURGERY                                             $409.46         20120901
29884       KNEE ARTHROSCOPY/SURGERY                             A               $816.73         20110101
29885       KNEE ARTHROSCOPY/SURGERY       80                                      $99.32        20120901
29885       KNEE ARTHROSCOPY/SURGERY       81                                      $99.32        20120901
29885       KNEE ARTHROSCOPY/SURGERY       82                                      $99.32        20120901
29885       KNEE ARTHROSCOPY/SURGERY       AS                                      $99.32        20120901



                                             Page 110
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                   Mod 1        Mod 2    Rate Type   Price          Effective Date
29885       KNEE ARTHROSCOPY/SURGERY                                             $496.61        20120901
29885       KNEE ARTHROSCOPY/SURGERY                            A              $1,270.96        20110101
29886       KNEE ARTHROSCOPY/SURGERY                                             $418.89        20120901
29886       KNEE ARTHROSCOPY/SURGERY                            A                $816.73        20110101
29887       KNEE ARTHROSCOPY/SURGERY      80                                      $98.76        20120901
29887       KNEE ARTHROSCOPY/SURGERY      81                                      $98.76        20120901
29887       KNEE ARTHROSCOPY/SURGERY      82                                      $98.76        20120901
29887       KNEE ARTHROSCOPY/SURGERY      AS                                      $98.76        20120901
29887       KNEE ARTHROSCOPY/SURGERY                                             $493.80        20120901
29887       KNEE ARTHROSCOPY/SURGERY                            A                $816.73        20110101
29888       KNEE ARTHROSCOPY/SURGERY      80                                     $132.75        20120901
29888       KNEE ARTHROSCOPY/SURGERY      81                                     $132.75        20120901
29888       KNEE ARTHROSCOPY/SURGERY      82                                     $132.75        20120901
29888       KNEE ARTHROSCOPY/SURGERY      AS                                     $132.75        20120901
29888       KNEE ARTHROSCOPY/SURGERY                                             $663.75        20120901
29888       KNEE ARTHROSCOPY/SURGERY                            A              $2,228.42        20110101
29889       KNEE ARTHROSCOPY/SURGERY      80                                     $162.97        20120901
29889       KNEE ARTHROSCOPY/SURGERY      81                                     $162.97        20120901
29889       KNEE ARTHROSCOPY/SURGERY      82                                     $162.97        20120901
29889       KNEE ARTHROSCOPY/SURGERY      AS                                     $162.97        20120901
29889       KNEE ARTHROSCOPY/SURGERY                                             $814.85        20120901
29889       KNEE ARTHROSCOPY/SURGERY                            A              $2,228.42        20110101
29891       ANKLE ARTHROSCOPY/SURGERY     80                                      $92.54        20120901
29891       ANKLE ARTHROSCOPY/SURGERY     81                                      $92.54        20120901
29891       ANKLE ARTHROSCOPY/SURGERY     82                                      $92.54        20120901
29891       ANKLE ARTHROSCOPY/SURGERY     AS                                      $92.54        20120901
29891       ANKLE ARTHROSCOPY/SURGERY                                            $462.72        20120901
29891       ANKLE ARTHROSCOPY/SURGERY                           A              $1,270.96        20110101
29892       ANKLE ARTHROSCOPY/SURGERY     80                                      $97.38        20120901
29892       ANKLE ARTHROSCOPY/SURGERY     81                                      $97.38        20120901
29892       ANKLE ARTHROSCOPY/SURGERY     82                                      $97.38        20120901
29892       ANKLE ARTHROSCOPY/SURGERY     AS                                      $97.38        20120901
29892       ANKLE ARTHROSCOPY/SURGERY                                            $486.92        20120901
29892       ANKLE ARTHROSCOPY/SURGERY                           A              $2,228.42        20110101
29893       SCOPE PLANTAR FASCIOTOMY                                             $385.00        20120901
29893       SCOPE PLANTAR FASCIOTOMY                            A                $765.27        20110101
29894       ANKLE ARTHROSCOPY/SURGERY     80                                      $68.75        20120901
29894       ANKLE ARTHROSCOPY/SURGERY     81                                      $68.75        20120901
29894       ANKLE ARTHROSCOPY/SURGERY     82                                      $68.75        20120901
29894       ANKLE ARTHROSCOPY/SURGERY     AS                                      $68.75        20120901
29894       ANKLE ARTHROSCOPY/SURGERY                                            $343.73        20120901
29894       ANKLE ARTHROSCOPY/SURGERY                           A                $816.73        20110101
29895       ANKLE ARTHROSCOPY/SURGERY     80                                      $66.10        20120901
29895       ANKLE ARTHROSCOPY/SURGERY     81                                      $66.10        20120901
29895       ANKLE ARTHROSCOPY/SURGERY     82                                      $66.10        20120901
29895       ANKLE ARTHROSCOPY/SURGERY     AS                                      $66.10        20120901
29895       ANKLE ARTHROSCOPY/SURGERY                                            $330.48        20120901
29895       ANKLE ARTHROSCOPY/SURGERY                           A                $816.73        20110101
29897       ANKLE ARTHROSCOPY/SURGERY     80                                      $69.46        20120901
29897       ANKLE ARTHROSCOPY/SURGERY     81                                      $69.46        20120901
29897       ANKLE ARTHROSCOPY/SURGERY     82                                      $69.46        20120901
29897       ANKLE ARTHROSCOPY/SURGERY     AS                                      $69.46        20120901
29897       ANKLE ARTHROSCOPY/SURGERY                                            $347.29        20120901
29897       ANKLE ARTHROSCOPY/SURGERY                           A                $816.73        20110101
29898       ANKLE ARTHROSCOPY/SURGERY     80                                      $77.36        20120901
29898       ANKLE ARTHROSCOPY/SURGERY     81                                      $77.36        20120901
29898       ANKLE ARTHROSCOPY/SURGERY     82                                      $77.36        20120901
29898       ANKLE ARTHROSCOPY/SURGERY     AS                                      $77.36        20120901
29898       ANKLE ARTHROSCOPY/SURGERY                                            $386.79        20120901



                                            Page 111
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
29898       ANKLE ARTHROSCOPY/SURGERY                             A                $816.73        20110101
29899       ANKLE ARTHROSCOPY/SURGERY       80                                     $141.11        20120901
29899       ANKLE ARTHROSCOPY/SURGERY       81                                     $141.11        20120901
29899       ANKLE ARTHROSCOPY/SURGERY       82                                     $141.11        20120901
29899       ANKLE ARTHROSCOPY/SURGERY       AS                                     $141.11        20120901
29899       ANKLE ARTHROSCOPY/SURGERY                                              $705.54        20120901
29899       ANKLE ARTHROSCOPY/SURGERY                             A              $1,270.96        20110101
29900       MCP JOINT ARTHROSCOPY DX                                               $282.57        20120901
29901       MCP JOINT ARTHROSCOPY SURG                                             $336.85        20120901
29902       MCP JOINT ARTHROSCOPY SURG                                             $389.08        20120901
29904       SUBTALAR ARTHRO W/FB RMVL                                              $416.34        20120901
29904       SUBTALAR ARTHRO W/FB RMVL                             A                $958.87        20110101
29905       SUBTALAR ARTHRO W/EXC                                                  $449.21        20120901
29905       SUBTALAR ARTHRO W/EXC                                 A                $958.87        20110101
29906       SUBTALAR ARTHRO W/DEB                                                  $472.91        20120901
29906       SUBTALAR ARTHRO W/DEB                                 A                $958.87        20110101
29907       SUBTALAR ARTHRO W/FUSION                                               $575.59        20120901
29907       SUBTALAR ARTHRO W/FUSION                              A              $1,564.50        20110101
30000       DRAINAGE OF NOSE LESION                                                $148.29        20120901
30020       DRAINAGE OF NOSE LESION                                                $144.73        20120901
30100       INTRANASAL BIOPSY                                                       $89.69        20120901
30110       REMOVAL OF NOSE POLYPS                                                 $146.00        20120901
30115       REMOVAL OF NOSE POLYPS                                                 $281.55        20120901
30115       REMOVAL OF NOSE POLYPS                                A                $498.46        20110101
30117       REMOVAL OF INTRANASAL LESION                                           $534.06        20120901
30117       REMOVAL OF INTRANASAL LESION                          A                $510.71        20110101
30118       REMOVAL OF INTRANASAL LESION                                           $511.89        20120901
30118       REMOVAL OF INTRANASAL LESION                          A                $697.62        20110101
30124       REMOVAL OF NOSE LESION                                                 $179.89        20120901
30124       REMOVAL OF NOSE LESION                                A                $244.19        20110101
30125       REMOVAL OF NOSE LESION          80                                      $81.18        20120901
30125       REMOVAL OF NOSE LESION          81                                      $81.18        20120901
30125       REMOVAL OF NOSE LESION          82                                      $81.18        20120901
30125       REMOVAL OF NOSE LESION          AS                                      $81.18        20120901
30125       REMOVAL OF NOSE LESION                                                 $405.90        20120901
30125       REMOVAL OF NOSE LESION                                A              $1,118.46        20110101
30130       EXCISE INFERIOR TURBINATE                                              $246.14        20120901
30130       EXCISE INFERIOR TURBINATE                             A                $510.71        20110101
30140       RESECT INFERIOR TURBINATE                                              $281.55        20120901
30140       RESECT INFERIOR TURBINATE                             A                $685.37        20110101
30150       PARTIAL REMOVAL OF NOSE                                                $521.07        20120901
30150       PARTIAL REMOVAL OF NOSE                               A              $1,130.71        20110101
30160       REMOVAL OF NOSE                 80                                     $104.57        20120901
30160       REMOVAL OF NOSE                 81                                     $104.57        20120901
30160       REMOVAL OF NOSE                 82                                     $104.57        20120901
30160       REMOVAL OF NOSE                 AS                                     $104.57        20120901
30160       REMOVAL OF NOSE                                                        $522.85        20120901
30160       REMOVAL OF NOSE                                       A              $1,153.67        20110101
30200       INJECTION TREATMENT OF NOSE                                             $72.11        20120901
30210       NASAL SINUS THERAPY                                                     $95.30        20120901
30220       INSERT NASAL SEPTAL BUTTON                                             $188.04        20120901
30300       REMOVE NASAL FOREIGN BODY                                              $144.47        20120901
30310       REMOVE NASAL FOREIGN BODY                                              $134.53        20120901
30310       REMOVE NASAL FOREIGN BODY                             A                $476.85        20110101
30320       REMOVE NASAL FOREIGN BODY                                              $296.59        20120901
30320       REMOVE NASAL FOREIGN BODY                             A                $498.46        20110101
30400       RECONSTRUCTION OF NOSE                                                 $678.53        20120901
30400       RECONSTRUCTION OF NOSE                                A              $1,153.67        20110101
30410       RECONSTRUCTION OF NOSE          80                                     $160.47        20120901



                                              Page 112
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
30410       RECONSTRUCTION OF NOSE          81                                     $160.47        20120901
30410       RECONSTRUCTION OF NOSE          82                                     $160.47        20120901
30410       RECONSTRUCTION OF NOSE          AS                                     $160.47        20120901
30410       RECONSTRUCTION OF NOSE                                                 $802.37        20120901
30410       RECONSTRUCTION OF NOSE                                A              $1,170.32        20110101
30420       RECONSTRUCTION OF NOSE                                                 $915.24        20120901
30420       RECONSTRUCTION OF NOSE                                A              $1,170.32        20110101
30430       REVISION OF NOSE                80                                     $120.01        20120901
30430       REVISION OF NOSE                81                                     $120.01        20120901
30430       REVISION OF NOSE                82                                     $120.01        20120901
30430       REVISION OF NOSE                AS                                     $120.01        20120901
30430       REVISION OF NOSE                                                       $600.05        20120901
30430       REVISION OF NOSE                                      A                $697.62        20110101
30435       REVISION OF NOSE                80                                     $154.97        20120901
30435       REVISION OF NOSE                81                                     $154.97        20120901
30435       REVISION OF NOSE                82                                     $154.97        20120901
30435       REVISION OF NOSE                AS                                     $154.97        20120901
30435       REVISION OF NOSE                                                       $774.85        20120901
30435       REVISION OF NOSE                                      A              $1,170.32        20110101
30450       REVISION OF NOSE                80                                     $206.69        20120901
30450       REVISION OF NOSE                81                                     $206.69        20120901
30450       REVISION OF NOSE                82                                     $206.69        20120901
30450       REVISION OF NOSE                AS                                     $206.69        20120901
30450       REVISION OF NOSE                                                     $1,033.47        20120901
30450       REVISION OF NOSE                                      A              $1,223.51        20110101
30460       REVISION OF NOSE                80                                     $104.72        20120901
30460       REVISION OF NOSE                81                                     $104.72        20120901
30460       REVISION OF NOSE                82                                     $104.72        20120901
30460       REVISION OF NOSE                AS                                     $104.72        20120901
30460       REVISION OF NOSE                                                       $523.61        20120901
30460       REVISION OF NOSE                                      A              $1,223.51        20110101
30462       REVISION OF NOSE                80                                     $203.28        20120901
30462       REVISION OF NOSE                81                                     $203.28        20120901
30462       REVISION OF NOSE                82                                     $203.28        20120901
30462       REVISION OF NOSE                AS                                     $203.28        20120901
30462       REVISION OF NOSE                                                     $1,016.40        20120901
30462       REVISION OF NOSE                                      A              $1,289.34        20110101
30465       REPAIR NASAL STENOSIS           80                                     $130.66        20120901
30465       REPAIR NASAL STENOSIS           81                                     $130.66        20120901
30465       REPAIR NASAL STENOSIS           82                                     $130.66        20120901
30465       REPAIR NASAL STENOSIS           AS                                     $130.66        20120901
30465       REPAIR NASAL STENOSIS                                                  $653.31        20120901
30465       REPAIR NASAL STENOSIS                                 A              $1,289.34        20110101
30520       REPAIR OF NASAL SEPTUM                                                 $404.37        20120901
30520       REPAIR OF NASAL SEPTUM                                A                $720.58        20110101
30540       REPAIR NASAL DEFECT             80                                      $89.38        20120901
30540       REPAIR NASAL DEFECT             81                                      $89.38        20120901
30540       REPAIR NASAL DEFECT             82                                      $89.38        20120901
30540       REPAIR NASAL DEFECT             AS                                      $89.38        20120901
30540       REPAIR NASAL DEFECT                                                    $446.92        20120901
30540       REPAIR NASAL DEFECT                                   A              $1,170.32        20110101
30545       REPAIR NASAL DEFECT             80                                     $119.76        20120901
30545       REPAIR NASAL DEFECT             81                                     $119.76        20120901
30545       REPAIR NASAL DEFECT             82                                     $119.76        20120901
30545       REPAIR NASAL DEFECT             AS                                     $119.76        20120901
30545       REPAIR NASAL DEFECT                                                    $598.78        20120901
30545       REPAIR NASAL DEFECT                                   A              $1,170.32        20110101
30560       RELEASE OF NASAL ADHESIONS                                             $171.23        20120901
30560       RELEASE OF NASAL ADHESIONS                            A                $111.17        20110101



                                              Page 113
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
30580       REPAIR UPPER JAW FISTULA                                               $411.25        20120901
30580       REPAIR UPPER JAW FISTULA                              A              $1,153.67        20110101
30600       REPAIR MOUTH/NOSE FISTULA                                              $377.10        20120901
30600       REPAIR MOUTH/NOSE FISTULA                             A              $1,153.67        20110101
30620       INTRANASAL RECONSTRUCTION                                              $406.15        20120901
30620       INTRANASAL RECONSTRUCTION                             A              $1,223.51        20110101
30630       REPAIR NASAL SEPTUM DEFECT                                             $413.29        20120901
30630       REPAIR NASAL SEPTUM DEFECT                            A                $790.42        20110101
30801       ABLATE INF TURBINATE SUPERF                                            $143.71        20120901
30801       ABLATE INF TURBINATE SUPERF                           A                $246.86        20110101
30802       ABLATE INF TURBINATE SUBMUC                                            $186.26        20120901
30802       ABLATE INF TURBINATE SUBMUC                           A                $476.85        20110101
30901       CONTROL OF NOSEBLEED                                                    $68.54        20120901
30903       CONTROL OF NOSEBLEED                                                   $126.38        20120901
30903       CONTROL OF NOSEBLEED                                  A                 $41.57        20110101
30905       CONTROL OF NOSEBLEED                                                   $157.21        20120901
30905       CONTROL OF NOSEBLEED                                  A                 $41.57        20110101
30906       REPEAT CONTROL OF NOSEBLEED                                            $179.63        20120901
30906       REPEAT CONTROL OF NOSEBLEED                           A                 $41.57        20110101
30915       LIGATION NASAL SINUS ARTERY                                            $385.00        20120901
30915       LIGATION NASAL SINUS ARTERY                           A                $724.00        20110101
30920       LIGATION UPPER JAW ARTERY                                              $555.72        20120901
30920       LIGATION UPPER JAW ARTERY                             A                $736.25        20110101
30930       THER FX NASAL INF TURBINATE                                             $80.52        20120901
30930       THER FX NASAL INF TURBINATE                           A                $533.67        20110101
31000       IRRIGATION MAXILLARY SINUS                                             $114.66        20120901
31002       IRRIGATION SPHENOID SINUS                                              $131.73        20120901
31020       EXPLORATION MAXILLARY SINUS                                            $308.82        20120901
31020       EXPLORATION MAXILLARY SINUS                           A                $685.37        20110101
31030       EXPLORATION MAXILLARY SINUS                                            $448.19        20120901
31030       EXPLORATION MAXILLARY SINUS                           A              $1,130.71        20110101
31032       EXPLORE SINUS REMOVE POLYPS                                            $377.10        20120901
31032       EXPLORE SINUS REMOVE POLYPS                           A              $1,153.67        20110101
31040       EXPLORATION BEHIND UPPER JAW                                           $499.41        20120901
31050       EXPLORATION SPHENOID SINUS                                             $324.11        20120901
31050       EXPLORATION SPHENOID SINUS                            A              $1,118.46        20110101
31051       SPHENOID SINUS SURGERY                                                 $424.75        20120901
31051       SPHENOID SINUS SURGERY                                A              $1,153.67        20110101
31070       EXPLORATION OF FRONTAL SINUS                                           $286.40        20120901
31070       EXPLORATION OF FRONTAL SINUS                          A                $685.37        20110101
31075       EXPLORATION OF FRONTAL SINUS    80                                     $104.01        20120901
31075       EXPLORATION OF FRONTAL SINUS    81                                     $104.01        20120901
31075       EXPLORATION OF FRONTAL SINUS    82                                     $104.01        20120901
31075       EXPLORATION OF FRONTAL SINUS    AS                                     $104.01        20120901
31075       EXPLORATION OF FRONTAL SINUS                                           $520.05        20120901
31075       EXPLORATION OF FRONTAL SINUS                          A              $1,153.67        20110101
31080       REMOVAL OF FRONTAL SINUS        80                                     $134.79        20120901
31080       REMOVAL OF FRONTAL SINUS        81                                     $134.79        20120901
31080       REMOVAL OF FRONTAL SINUS        82                                     $134.79        20120901
31080       REMOVAL OF FRONTAL SINUS        AS                                     $134.79        20120901
31080       REMOVAL OF FRONTAL SINUS                                               $673.95        20120901
31080       REMOVAL OF FRONTAL SINUS                              A              $1,153.67        20110101
31081       REMOVAL OF FRONTAL SINUS        80                                     $176.07        20120901
31081       REMOVAL OF FRONTAL SINUS        81                                     $176.07        20120901
31081       REMOVAL OF FRONTAL SINUS        82                                     $176.07        20120901
31081       REMOVAL OF FRONTAL SINUS        AS                                     $176.07        20120901
31081       REMOVAL OF FRONTAL SINUS                                               $880.33        20120901
31081       REMOVAL OF FRONTAL SINUS                              A              $1,153.67        20110101
31084       REMOVAL OF FRONTAL SINUS        80                                     $156.40        20120901



                                              Page 114
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
31084       REMOVAL OF FRONTAL SINUS       81                                     $156.40        20120901
31084       REMOVAL OF FRONTAL SINUS       82                                     $156.40        20120901
31084       REMOVAL OF FRONTAL SINUS       AS                                     $156.40        20120901
31084       REMOVAL OF FRONTAL SINUS                                              $781.98        20120901
31084       REMOVAL OF FRONTAL SINUS                             A              $1,153.67        20110101
31085       REMOVAL OF FRONTAL SINUS       80                                     $183.91        20120901
31085       REMOVAL OF FRONTAL SINUS       81                                     $183.91        20120901
31085       REMOVAL OF FRONTAL SINUS       82                                     $183.91        20120901
31085       REMOVAL OF FRONTAL SINUS       AS                                     $183.91        20120901
31085       REMOVAL OF FRONTAL SINUS                                              $919.57        20120901
31085       REMOVAL OF FRONTAL SINUS                             A              $1,153.67        20110101
31086       REMOVAL OF FRONTAL SINUS       80                                     $149.26        20120901
31086       REMOVAL OF FRONTAL SINUS       81                                     $149.26        20120901
31086       REMOVAL OF FRONTAL SINUS       82                                     $149.26        20120901
31086       REMOVAL OF FRONTAL SINUS       AS                                     $149.26        20120901
31086       REMOVAL OF FRONTAL SINUS                                              $746.31        20120901
31086       REMOVAL OF FRONTAL SINUS                             A              $1,153.67        20110101
31087       REMOVAL OF FRONTAL SINUS       80                                     $146.10        20120901
31087       REMOVAL OF FRONTAL SINUS       81                                     $146.10        20120901
31087       REMOVAL OF FRONTAL SINUS       82                                     $146.10        20120901
31087       REMOVAL OF FRONTAL SINUS       AS                                     $146.10        20120901
31087       REMOVAL OF FRONTAL SINUS                                              $730.51        20120901
31087       REMOVAL OF FRONTAL SINUS                             A              $1,153.67        20110101
31090       EXPLORATION OF SINUSES                                                $667.32        20120901
31090       EXPLORATION OF SINUSES                               A              $1,170.32        20110101
31200       REMOVAL OF ETHMOID SINUS                                              $356.47        20120901
31200       REMOVAL OF ETHMOID SINUS                             A              $1,118.46        20110101
31201       REMOVAL OF ETHMOID SINUS                                              $484.37        20120901
31201       REMOVAL OF ETHMOID SINUS                             A              $1,170.32        20110101
31205       REMOVAL OF ETHMOID SINUS       80                                     $115.68        20120901
31205       REMOVAL OF ETHMOID SINUS       81                                     $115.68        20120901
31205       REMOVAL OF ETHMOID SINUS       82                                     $115.68        20120901
31205       REMOVAL OF ETHMOID SINUS       AS                                     $115.68        20120901
31205       REMOVAL OF ETHMOID SINUS                                              $578.40        20120901
31205       REMOVAL OF ETHMOID SINUS                             A              $1,130.71        20110101
31225       REMOVAL OF UPPER JAW           80                                     $248.99        20120901
31225       REMOVAL OF UPPER JAW           81                                     $248.99        20120901
31225       REMOVAL OF UPPER JAW           82                                     $248.99        20120901
31225       REMOVAL OF UPPER JAW           AS                                     $248.99        20120901
31225       REMOVAL OF UPPER JAW                                                $1,244.95        20120901
31230       REMOVAL OF UPPER JAW           80                                     $278.70        20120901
31230       REMOVAL OF UPPER JAW           81                                     $278.70        20120901
31230       REMOVAL OF UPPER JAW           82                                     $278.70        20120901
31230       REMOVAL OF UPPER JAW           AS                                     $278.70        20120901
31230       REMOVAL OF UPPER JAW                                                $1,393.50        20120901
31231       NASAL ENDOSCOPY DX                                                    $122.56        20120901
31233       NASAL/SINUS ENDOSCOPY DX                                              $173.01        20120901
31233       NASAL/SINUS ENDOSCOPY DX                             A                 $60.82        20110101
31235       NASAL/SINUS ENDOSCOPY DX                                              $197.72        20120901
31235       NASAL/SINUS ENDOSCOPY DX                             A                $584.26        20110101
31237       NASAL/SINUS ENDOSCOPY SURG                                            $213.78        20120901
31237       NASAL/SINUS ENDOSCOPY SURG                           A                $605.89        20110101
31238       NASAL/SINUS ENDOSCOPY SURG                                            $220.66        20120901
31238       NASAL/SINUS ENDOSCOPY SURG                           A                $584.26        20110101
31239       NASAL/SINUS ENDOSCOPY SURG                                            $451.51        20120901
31239       NASAL/SINUS ENDOSCOPY SURG                           A                $824.12        20110101
31240       NASAL/SINUS ENDOSCOPY SURG                                            $111.35        20120901
31240       NASAL/SINUS ENDOSCOPY SURG                           A                $605.89        20110101
31254       REVISION OF ETHMOID SINUS                                             $190.34        20120901



                                             Page 115
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
31254       REVISION OF ETHMOID SINUS                             A                $801.16        20110101
31255       REMOVAL OF ETHMOID SINUS                                               $279.52        20120901
31255       REMOVAL OF ETHMOID SINUS                              A                $840.77        20110101
31256       EXPLORATION MAXILLARY SINUS                                            $137.34        20120901
31256       EXPLORATION MAXILLARY SINUS                           A                $801.16        20110101
31267       ENDOSCOPY MAXILLARY SINUS                                              $221.42        20120901
31267       ENDOSCOPY MAXILLARY SINUS                             A                $801.16        20110101
31276       SINUS ENDOSCOPY SURGICAL                                               $353.15        20120901
31276       SINUS ENDOSCOPY SURGICAL                              A                $801.16        20110101
31287       NASAL/SINUS ENDOSCOPY SURG                                             $161.80        20120901
31287       NASAL/SINUS ENDOSCOPY SURG                            A                $801.16        20110101
31288       NASAL/SINUS ENDOSCOPY SURG                                             $187.53        20120901
31288       NASAL/SINUS ENDOSCOPY SURG                            A                $801.16        20110101
31291       NASAL/SINUS ENDOSCOPY SURG                                             $842.62        20120901
31292       NASAL/SINUS ENDOSCOPY SURG                                             $686.18        20120901
31293       NASAL/SINUS ENDOSCOPY SURG                                             $747.84        20120901
31294       NASAL/SINUS ENDOSCOPY SURG                                             $857.91        20120901
31295       SINUS ENDO W/BALLOON DIL        80                                     $306.37        20120901
31295       SINUS ENDO W/BALLOON DIL        81                                     $306.37        20120901
31295       SINUS ENDO W/BALLOON DIL        82                                     $306.37        20120901
31295       SINUS ENDO W/BALLOON DIL        AS                                     $306.37        20120901
31295       SINUS ENDO W/BALLOON DIL                                             $1,531.86        20120901
31295       SINUS ENDO W/BALLOON DIL                              A                $959.17        20110101
31296       SINUS ENDO W/BALLOON DIL        80                                     $572.84        20120901
31296       SINUS ENDO W/BALLOON DIL        81                                     $572.84        20120901
31296       SINUS ENDO W/BALLOON DIL        82                                     $572.84        20120901
31296       SINUS ENDO W/BALLOON DIL        AS                                     $572.84        20120901
31296       SINUS ENDO W/BALLOON DIL                                             $2,864.21        20120901
31296       SINUS ENDO W/BALLOON DIL                              A                $959.17        20110101
31297       SINUS ENDO W/BALLOON DIL                                             $2,837.20        20120901
31297       SINUS ENDO W/BALLOON DIL                              A                $959.17        20110101
31300       REMOVAL OF LARYNX LESION        80                                     $168.73        20120901
31300       REMOVAL OF LARYNX LESION        81                                     $168.73        20120901
31300       REMOVAL OF LARYNX LESION        82                                     $168.73        20120901
31300       REMOVAL OF LARYNX LESION        AS                                     $168.73        20120901
31300       REMOVAL OF LARYNX LESION                                               $843.64        20120901
31300       REMOVAL OF LARYNX LESION                              A                $737.22        20110101
31320       DIAGNOSTIC INCISION LARYNX                                             $426.28        20120901
31320       DIAGNOSTIC INCISION LARYNX                            A              $1,118.46        20110101
31360       REMOVAL OF LARYNX               80                                     $275.08        20120901
31360       REMOVAL OF LARYNX               81                                     $275.08        20120901
31360       REMOVAL OF LARYNX               82                                     $275.08        20120901
31360       REMOVAL OF LARYNX               AS                                     $275.08        20120901
31360       REMOVAL OF LARYNX                                                    $1,375.41        20120901
31365       REMOVAL OF LARYNX               80                                     $343.22        20120901
31365       REMOVAL OF LARYNX               81                                     $343.22        20120901
31365       REMOVAL OF LARYNX               82                                     $343.22        20120901
31365       REMOVAL OF LARYNX               AS                                     $343.22        20120901
31365       REMOVAL OF LARYNX                                                    $1,716.08        20120901
31367       PARTIAL REMOVAL OF LARYNX       80                                     $294.04        20120901
31367       PARTIAL REMOVAL OF LARYNX       81                                     $294.04        20120901
31367       PARTIAL REMOVAL OF LARYNX       82                                     $294.04        20120901
31367       PARTIAL REMOVAL OF LARYNX       AS                                     $294.04        20120901
31367       PARTIAL REMOVAL OF LARYNX                                            $1,470.20        20120901
31368       PARTIAL REMOVAL OF LARYNX       80                                     $327.11        20120901
31368       PARTIAL REMOVAL OF LARYNX       81                                     $327.11        20120901
31368       PARTIAL REMOVAL OF LARYNX       82                                     $327.11        20120901
31368       PARTIAL REMOVAL OF LARYNX       AS                                     $327.11        20120901
31368       PARTIAL REMOVAL OF LARYNX                                            $1,635.56        20120901



                                              Page 116
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
31370       PARTIAL REMOVAL OF LARYNX      80                                     $275.64        20120901
31370       PARTIAL REMOVAL OF LARYNX      81                                     $275.64        20120901
31370       PARTIAL REMOVAL OF LARYNX      82                                     $275.64        20120901
31370       PARTIAL REMOVAL OF LARYNX      AS                                     $275.64        20120901
31370       PARTIAL REMOVAL OF LARYNX                                           $1,378.21        20120901
31375       PARTIAL REMOVAL OF LARYNX      80                                     $261.17        20120901
31375       PARTIAL REMOVAL OF LARYNX      81                                     $261.17        20120901
31375       PARTIAL REMOVAL OF LARYNX      82                                     $261.17        20120901
31375       PARTIAL REMOVAL OF LARYNX      AS                                     $261.17        20120901
31375       PARTIAL REMOVAL OF LARYNX                                           $1,305.85        20120901
31380       PARTIAL REMOVAL OF LARYNX      80                                     $257.04        20120901
31380       PARTIAL REMOVAL OF LARYNX      81                                     $257.04        20120901
31380       PARTIAL REMOVAL OF LARYNX      82                                     $257.04        20120901
31380       PARTIAL REMOVAL OF LARYNX      AS                                     $257.04        20120901
31380       PARTIAL REMOVAL OF LARYNX                                           $1,285.21        20120901
31382       PARTIAL REMOVAL OF LARYNX      80                                     $282.37        20120901
31382       PARTIAL REMOVAL OF LARYNX      81                                     $282.37        20120901
31382       PARTIAL REMOVAL OF LARYNX      82                                     $282.37        20120901
31382       PARTIAL REMOVAL OF LARYNX      AS                                     $282.37        20120901
31382       PARTIAL REMOVAL OF LARYNX                                           $1,411.85        20120901
31390       REMOVAL OF LARYNX PHARYNX      80                                     $381.49        20120901
31390       REMOVAL OF LARYNX PHARYNX      81                                     $381.49        20120901
31390       REMOVAL OF LARYNX PHARYNX      82                                     $381.49        20120901
31390       REMOVAL OF LARYNX PHARYNX      AS                                     $381.49        20120901
31390       REMOVAL OF LARYNX PHARYNX                                           $1,907.43        20120901
31395       RECONSTRUCT LARYNX PHARYNX     80                                     $402.58        20120901
31395       RECONSTRUCT LARYNX PHARYNX     81                                     $402.58        20120901
31395       RECONSTRUCT LARYNX PHARYNX     82                                     $402.58        20120901
31395       RECONSTRUCT LARYNX PHARYNX     AS                                     $402.58        20120901
31395       RECONSTRUCT LARYNX PHARYNX                                          $2,012.92        20120901
31400       REVISION OF LARYNX             80                                     $133.36        20120901
31400       REVISION OF LARYNX             81                                     $133.36        20120901
31400       REVISION OF LARYNX             82                                     $133.36        20120901
31400       REVISION OF LARYNX             AS                                     $133.36        20120901
31400       REVISION OF LARYNX                                                    $666.81        20120901
31400       REVISION OF LARYNX                                   A              $1,118.46        20110101
31420       REMOVAL OF EPIGLOTTIS          80                                     $112.42        20120901
31420       REMOVAL OF EPIGLOTTIS          81                                     $112.42        20120901
31420       REMOVAL OF EPIGLOTTIS          82                                     $112.42        20120901
31420       REMOVAL OF EPIGLOTTIS          AS                                     $112.42        20120901
31420       REMOVAL OF EPIGLOTTIS                                                 $562.09        20120901
31420       REMOVAL OF EPIGLOTTIS                                A              $1,118.46        20110101
31500       INSERT EMERGENCY AIRWAY                                                $77.46        20120901
31502       CHANGE OF WINDPIPE AIRWAY                                              $24.21        20120901
31505       DIAGNOSTIC LARYNGOSCOPY                                                $54.02        20120901
31510       LARYNGOSCOPY WITH BIOPSY                                              $139.12        20120901
31510       LARYNGOSCOPY WITH BIOPSY                             A                $605.89        20110101
31511       REMOVE FOREIGN BODY LARYNX                                            $139.63        20120901
31511       REMOVE FOREIGN BODY LARYNX                           A                 $60.82        20110101
31512       REMOVAL OF LARYNX LESION                                              $137.85        20120901
31512       REMOVAL OF LARYNX LESION                             A                $605.89        20110101
31513       INJECTION INTO VOCAL CORD                                              $91.47        20120901
31513       INJECTION INTO VOCAL CORD                            A                 $60.82        20110101
31515       LARYNGOSCOPY FOR ASPIRATION                                           $137.34        20120901
31515       LARYNGOSCOPY FOR ASPIRATION                          A                $584.26        20110101
31520       DX LARYNGOSCOPY NEWBORN                                               $107.27        20120901
31525       DX LARYNGOSCOPY EXCL NB                                               $165.87        20120901
31525       DX LARYNGOSCOPY EXCL NB                              A                $584.26        20110101
31526       DX LARYNGOSCOPY W/OPER SCOPE                                          $109.56        20120901



                                             Page 117
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price          Effective Date
31526       DX LARYNGOSCOPY W/OPER SCOPE                        A                $605.89        20110101
31527       LARYNGOSCOPY FOR TREATMENT                                           $134.79        20120901
31527       LARYNGOSCOPY FOR TREATMENT                          A                $767.30        20110101
31528       LARYNGOSCOPY AND DILATION                                            $100.39        20120901
31528       LARYNGOSCOPY AND DILATION                           A                $605.89        20110101
31529       LARYNGOSCOPY AND DILATION                                            $112.62        20120901
31529       LARYNGOSCOPY AND DILATION                           A                $605.89        20110101
31530       LARYNGOSCOPY W/FB REMOVAL                                            $137.85        20120901
31530       LARYNGOSCOPY W/FB REMOVAL                           A                $605.89        20110101
31531       LARYNGOSCOPY W/FB OP SCOPE                                           $148.55        20120901
31531       LARYNGOSCOPY W/FB OP SCOPE                          A                $618.13        20110101
31535       LARYNGOSCOPY W/BIOPSY                                                $132.24        20120901
31535       LARYNGOSCOPY W/BIOPSY                               A                $605.89        20110101
31536       LARYNGOSCOPY W/BX OP SCOPE                                           $147.53        20120901
31536       LARYNGOSCOPY W/BX OP SCOPE                          A                $618.13        20110101
31540       LARYNGOSCOPY W/EXC OF TUMOR                                          $169.70        20120901
31540       LARYNGOSCOPY W/EXC OF TUMOR                         A                $618.13        20110101
31541       LARYNSCOP W/TUMR EXC SCOPE                                           $185.49        20120901
31541       LARYNSCOP W/TUMR EXC SCOPE                          A                $641.10        20110101
31545       REMOVE VC LESION W/SCOPE                                             $254.04        20120901
31546       REMOVE VC LESION SCOPE/GRAFT                                         $384.49        20120901
31560       LARYNGOSCOP W/ARYTENOIDECTOM                                         $219.89        20120901
31560       LARYNGOSCOP W/ARYTENOIDECTOM                        A                $840.77        20110101
31561       LARYNSCOP REMVE CART SCOP                                            $240.53        20120901
31561       LARYNSCOP REMVE CART SCOP                           A                $840.77        20110101
31570       LARYNGOSCOPE W/VC INJ                                                $229.57        20120901
31570       LARYNGOSCOPE W/VC INJ                               A                $605.89        20110101
31571       LARYNGOSCOP W/VC INJ SCOPE                                           $175.05        20120901
31571       LARYNGOSCOP W/VC INJ SCOPE                          A                $788.91        20110101
31575       DIAGNOSTIC LARYNGOSCOPY                                               $75.93        20120901
31576       LARYNGOSCOPY WITH BIOPSY                                             $148.29        20120901
31576       LARYNGOSCOPY WITH BIOPSY                            A                $605.89        20110101
31577       REMOVE FOREIGN BODY LARYNX                                           $160.52        20120901
31577       REMOVE FOREIGN BODY LARYNX                          A                $151.28        20110101
31578       REMOVAL OF LARYNX LESION                                             $186.51        20120901
31578       REMOVAL OF LARYNX LESION                            A                $788.91        20110101
31579       DIAGNOSTIC LARYNGOSCOPY                                              $143.96        20120901
31580       REVISION OF LARYNX             80                                    $161.44        20120901
31580       REVISION OF LARYNX             81                                    $161.44        20120901
31580       REVISION OF LARYNX             82                                    $161.44        20120901
31580       REVISION OF LARYNX             AS                                    $161.44        20120901
31580       REVISION OF LARYNX                                                   $807.21        20120901
31580       REVISION OF LARYNX                                  A              $1,170.32        20110101
31582       REVISION OF LARYNX                                                 $1,274.51        20120901
31582       REVISION OF LARYNX                                  A              $1,170.32        20110101
31584       TREAT LARYNX FRACTURE          80                                    $203.28        20120901
31584       TREAT LARYNX FRACTURE          81                                    $203.28        20120901
31584       TREAT LARYNX FRACTURE          82                                    $203.28        20120901
31584       TREAT LARYNX FRACTURE          AS                                    $203.28        20120901
31584       TREAT LARYNX FRACTURE                                              $1,016.40        20120901
31587       REVISION OF LARYNX             80                                    $135.04        20120901
31587       REVISION OF LARYNX             81                                    $135.04        20120901
31587       REVISION OF LARYNX             82                                    $135.04        20120901
31587       REVISION OF LARYNX             AS                                    $135.04        20120901
31587       REVISION OF LARYNX                                                   $675.22        20120901
31588       REVISION OF LARYNX             80                                    $153.03        20120901
31588       REVISION OF LARYNX             81                                    $153.03        20120901
31588       REVISION OF LARYNX             82                                    $153.03        20120901
31588       REVISION OF LARYNX             AS                                    $153.03        20120901



                                            Page 118
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
31588       REVISION OF LARYNX                                                    $765.16        20120901
31588       REVISION OF LARYNX                                   A              $1,170.32        20110101
31590       REINNERVATE LARYNX             80                                     $117.21        20120901
31590       REINNERVATE LARYNX             81                                     $117.21        20120901
31590       REINNERVATE LARYNX             82                                     $117.21        20120901
31590       REINNERVATE LARYNX             AS                                     $117.21        20120901
31590       REINNERVATE LARYNX                                                    $586.04        20120901
31590       REINNERVATE LARYNX                                   A              $1,170.32        20110101
31595       LARYNX NERVE SURGERY           80                                     $102.02        20120901
31595       LARYNX NERVE SURGERY           81                                     $102.02        20120901
31595       LARYNX NERVE SURGERY           82                                     $102.02        20120901
31595       LARYNX NERVE SURGERY           AS                                     $102.02        20120901
31595       LARYNX NERVE SURGERY                                                  $510.11        20120901
31595       LARYNX NERVE SURGERY                                 A              $1,118.46        20110101
31600       INCISION OF WINDPIPE                                                  $276.97        20120901
31601       INCISION OF WINDPIPE           80                                      $36.18        20120901
31601       INCISION OF WINDPIPE           81                                      $36.18        20120901
31601       INCISION OF WINDPIPE           82                                      $36.18        20120901
31601       INCISION OF WINDPIPE           AS                                      $36.18        20120901
31601       INCISION OF WINDPIPE                                                  $180.91        20120901
31603       INCISION OF WINDPIPE                                                  $156.19        20120901
31605       INCISION OF WINDPIPE                                                  $128.42        20120901
31610       INCISION OF WINDPIPE                                                  $476.99        20120901
31611       SURGERY/SPEECH PROSTHESIS      80                                      $71.24        20120901
31611       SURGERY/SPEECH PROSTHESIS      81                                      $71.24        20120901
31611       SURGERY/SPEECH PROSTHESIS      82                                      $71.24        20120901
31611       SURGERY/SPEECH PROSTHESIS      AS                                      $71.24        20120901
31611       SURGERY/SPEECH PROSTHESIS                                             $356.21        20120901
31611       SURGERY/SPEECH PROSTHESIS                            A                $697.62        20110101
31612       PUNCTURE/CLEAR WINDPIPE                                                $53.51        20120901
31612       PUNCTURE/CLEAR WINDPIPE                              A                $663.74        20110101
31613       REPAIR WINDPIPE OPENING                                               $296.59        20120901
31613       REPAIR WINDPIPE OPENING                              A                $685.37        20110101
31614       REPAIR WINDPIPE OPENING                                               $495.33        20120901
31614       REPAIR WINDPIPE OPENING                              A              $1,118.46        20110101
31615       VISUALIZATION OF WINDPIPE                                             $121.79        20120901
31615       VISUALIZATION OF WINDPIPE                            A                $246.86        20110101
31622       DX BRONCHOSCOPE/WASH                                                  $210.46        20120901
31622       DX BRONCHOSCOPE/WASH                                 A                $312.98        20110101
31623       DX BRONCHOSCOPE/BRUSH                                                 $227.79        20120901
31623       DX BRONCHOSCOPE/BRUSH                                A                $334.61        20110101
31624       DX BRONCHOSCOPE/LAVAGE                                                $212.50        20120901
31624       DX BRONCHOSCOPE/LAVAGE                               A                $334.61        20110101
31625       BRONCHOSCOPY W/BIOPSYS                                                $229.32        20120901
31625       BRONCHOSCOPY W/BIOPSYS                               A                $334.61        20110101
31626       BRONCHOSCOPY W/MARKERS                                                $297.61        20120901
31628       BRONCHOSCOPY/LUNG BX EACH                                             $271.36        20120901
31628       BRONCHOSCOPY/LUNG BX EACH                            A                $334.61        20110101
31629       BRONCHOSCOPY/NEEDLE BX EACH                                           $414.81        20120901
31629       BRONCHOSCOPY/NEEDLE BX EACH                          A                $334.61        20110101
31630       BRONCHOSCOPY DILATE/FX REPR                                           $143.20        20120901
31630       BRONCHOSCOPY DILATE/FX REPR                          A                $707.93        20110101
31631       BRONCHOSCOPY DILATE W/STENT                                           $163.07        20120901
31631       BRONCHOSCOPY DILATE W/STENT                          A                $707.93        20110101
31632       BRONCHOSCOPY/LUNG BX ADDL                                              $48.92        20120901
31633       BRONCHOSCOPY/NEEDLE BX ADDL                                            $60.13        20120901
31634       BRONCH W/BALLOON OCCLUSION     80                                     $271.67        20120901
31634       BRONCH W/BALLOON OCCLUSION     81                                     $271.67        20120901
31634       BRONCH W/BALLOON OCCLUSION     82                                     $271.67        20120901



                                             Page 119
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
31634       BRONCH W/BALLOON OCCLUSION     AS                                     $271.67        20120901
31634       BRONCH W/BALLOON OCCLUSION                                          $1,358.34        20120901
31634       BRONCH W/BALLOON OCCLUSION                           A                $325.46        20110101
31635       BRONCHOSCOPY W/FB REMOVAL                                             $235.94        20120901
31635       BRONCHOSCOPY W/FB REMOVAL                            A                $334.61        20110101
31636       BRONCHOSCOPY BRONCH STENTS                                            $158.49        20120901
31637       BRONCHOSCOPY STENT ADD-ON                                              $54.02        20120901
31638       BRONCHOSCOPY REVISE STENT                                             $181.16        20120901
31640       BRONCHOSCOPY W/TUMOR EXCISE                                           $182.69        20120901
31640       BRONCHOSCOPY W/TUMOR EXCISE                          A                $707.93        20110101
31641       BRONCHOSCOPY TREAT BLOCKAGE                                           $181.93        20120901
31641       BRONCHOSCOPY TREAT BLOCKAGE                          A                $707.93        20110101
31643       DIAG BRONCHOSCOPE/CATHETER                                            $123.07        20120901
31643       DIAG BRONCHOSCOPE/CATHETER                           A                $334.61        20110101
31645       BRONCHOSCOPY CLEAR AIRWAYS                                            $205.62        20120901
31645       BRONCHOSCOPY CLEAR AIRWAYS                           A                $312.98        20110101
31646       BRONCHOSCOPY RECLEAR AIRWAY                                           $186.51        20120901
31646       BRONCHOSCOPY RECLEAR AIRWAY                          A                $312.98        20110101
31656       BRONCHOSCOPY INJ FOR X-RAY                                             $77.71        20120901
31656       BRONCHOSCOPY INJ FOR X-RAY                           A                $312.98        20110101
31715       INJECTION FOR BRONCHUS X-RAY                                           $38.22        20120901
31717       BRONCHIAL BRUSH BIOPSY                                                $192.37        20120901
31717       BRONCHIAL BRUSH BIOPSY                               A                $151.28        20110101
31720       CLEARANCE OF AIRWAYS                                                   $36.18        20120901
31720       CLEARANCE OF AIRWAYS                                 A                 $18.81        20110101
31725       CLEARANCE OF AIRWAYS                                                   $66.25        20120901
31730       INTRO WINDPIPE WIRE/TUBE                                              $620.95        20120901
31730       INTRO WINDPIPE WIRE/TUBE                             A                $151.28        20110101
31750       REPAIR OF WINDPIPE             80                                     $180.45        20120901
31750       REPAIR OF WINDPIPE             81                                     $180.45        20120901
31750       REPAIR OF WINDPIPE             82                                     $180.45        20120901
31750       REPAIR OF WINDPIPE             AS                                     $180.45        20120901
31750       REPAIR OF WINDPIPE                                                    $902.25        20120901
31750       REPAIR OF WINDPIPE                                   A              $1,170.32        20110101
31755       REPAIR OF WINDPIPE             80                                     $227.23        20120901
31755       REPAIR OF WINDPIPE             81                                     $227.23        20120901
31755       REPAIR OF WINDPIPE             82                                     $227.23        20120901
31755       REPAIR OF WINDPIPE             AS                                     $227.23        20120901
31755       REPAIR OF WINDPIPE                                                  $1,136.15        20120901
31755       REPAIR OF WINDPIPE                                   A              $1,118.46        20110101
31760       REPAIR OF WINDPIPE             80                                     $195.64        20120901
31760       REPAIR OF WINDPIPE             81                                     $195.64        20120901
31760       REPAIR OF WINDPIPE             82                                     $195.64        20120901
31760       REPAIR OF WINDPIPE             AS                                     $195.64        20120901
31760       REPAIR OF WINDPIPE                                                    $978.18        20120901
31766       RECONSTRUCTION OF WINDPIPE     80                                     $256.99        20120901
31766       RECONSTRUCTION OF WINDPIPE     81                                     $256.99        20120901
31766       RECONSTRUCTION OF WINDPIPE     82                                     $256.99        20120901
31766       RECONSTRUCTION OF WINDPIPE     AS                                     $256.99        20120901
31766       RECONSTRUCTION OF WINDPIPE                                          $1,284.96        20120901
31770       REPAIR/GRAFT OF BRONCHUS       80                                     $189.88        20120901
31770       REPAIR/GRAFT OF BRONCHUS       81                                     $189.88        20120901
31770       REPAIR/GRAFT OF BRONCHUS       82                                     $189.88        20120901
31770       REPAIR/GRAFT OF BRONCHUS       AS                                     $189.88        20120901
31770       REPAIR/GRAFT OF BRONCHUS                                              $949.38        20120901
31775       RECONSTRUCT BRONCHUS           80                                     $197.11        20120901
31775       RECONSTRUCT BRONCHUS           81                                     $197.11        20120901
31775       RECONSTRUCT BRONCHUS           82                                     $197.11        20120901
31775       RECONSTRUCT BRONCHUS           AS                                     $197.11        20120901



                                             Page 120
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
31775       RECONSTRUCT BRONCHUS                                                  $985.57        20120901
31780       RECONSTRUCT WINDPIPE           80                                     $165.26        20120901
31780       RECONSTRUCT WINDPIPE           81                                     $165.26        20120901
31780       RECONSTRUCT WINDPIPE           82                                     $165.26        20120901
31780       RECONSTRUCT WINDPIPE           AS                                     $165.26        20120901
31780       RECONSTRUCT WINDPIPE                                                  $826.32        20120901
31781       RECONSTRUCT WINDPIPE           80                                     $208.12        20120901
31781       RECONSTRUCT WINDPIPE           81                                     $208.12        20120901
31781       RECONSTRUCT WINDPIPE           82                                     $208.12        20120901
31781       RECONSTRUCT WINDPIPE           AS                                     $208.12        20120901
31781       RECONSTRUCT WINDPIPE                                                $1,040.60        20120901
31785       REMOVE WINDPIPE LESION         80                                     $149.77        20120901
31785       REMOVE WINDPIPE LESION         81                                     $149.77        20120901
31785       REMOVE WINDPIPE LESION         82                                     $149.77        20120901
31785       REMOVE WINDPIPE LESION         AS                                     $149.77        20120901
31785       REMOVE WINDPIPE LESION                                                $748.86        20120901
31786       REMOVE WINDPIPE LESION         80                                     $209.29        20120901
31786       REMOVE WINDPIPE LESION         81                                     $209.29        20120901
31786       REMOVE WINDPIPE LESION         82                                     $209.29        20120901
31786       REMOVE WINDPIPE LESION         AS                                     $209.29        20120901
31786       REMOVE WINDPIPE LESION                                              $1,046.46        20120901
31800       REPAIR OF WINDPIPE INJURY                                             $467.56        20120901
31805       REPAIR OF WINDPIPE INJURY      80                                     $117.16        20120901
31805       REPAIR OF WINDPIPE INJURY      81                                     $117.16        20120901
31805       REPAIR OF WINDPIPE INJURY      82                                     $117.16        20120901
31805       REPAIR OF WINDPIPE INJURY      AS                                     $117.16        20120901
31805       REPAIR OF WINDPIPE INJURY                                             $585.79        20120901
31820       CLOSURE OF WINDPIPE LESION                                            $286.14        20120901
31820       CLOSURE OF WINDPIPE LESION                           A                $663.74        20110101
31825       REPAIR OF WINDPIPE DEFECT                                             $400.80        20120901
31825       REPAIR OF WINDPIPE DEFECT                            A                $685.37        20110101
31830       REVISE WINDPIPE SCAR                                                  $287.92        20120901
31830       REVISE WINDPIPE SCAR                                 A                $685.37        20110101
32035       THORACOSTOMY W/RIB RESECTION   80                                      $99.93        20120901
32035       THORACOSTOMY W/RIB RESECTION   81                                      $99.93        20120901
32035       THORACOSTOMY W/RIB RESECTION   82                                      $99.93        20120901
32035       THORACOSTOMY W/RIB RESECTION   AS                                      $99.93        20120901
32035       THORACOSTOMY W/RIB RESECTION                                          $499.66        20120901
32036       THORACOSTOMY W/FLAP DRAINAGE   80                                     $108.44        20120901
32036       THORACOSTOMY W/FLAP DRAINAGE   81                                     $108.44        20120901
32036       THORACOSTOMY W/FLAP DRAINAGE   82                                     $108.44        20120901
32036       THORACOSTOMY W/FLAP DRAINAGE   AS                                     $108.44        20120901
32036       THORACOSTOMY W/FLAP DRAINAGE                                          $542.21        20120901
32096       OPEN WEDGE/BX LUNG INFILTR     80                                     $123.58        20120901
32096       OPEN WEDGE/BX LUNG INFILTR     81                                     $123.58        20120901
32096       OPEN WEDGE/BX LUNG INFILTR     82                                     $123.58        20120901
32096       OPEN WEDGE/BX LUNG INFILTR     AS                                     $123.58        20120901
32096       OPEN WEDGE/BX LUNG INFILTR                                            $617.89        20120901
32097       OPEN WEDGE/BX LUNG NODULE      80                                     $123.58        20120901
32097       OPEN WEDGE/BX LUNG NODULE      81                                     $123.58        20120901
32097       OPEN WEDGE/BX LUNG NODULE      82                                     $123.58        20120901
32097       OPEN WEDGE/BX LUNG NODULE      AS                                     $123.58        20120901
32097       OPEN WEDGE/BX LUNG NODULE                                             $617.89        20120901
32098       OPEN BIOPSY OF LUNG PLEURA     80                                     $116.14        20120901
32098       OPEN BIOPSY OF LUNG PLEURA     81                                     $116.14        20120901
32098       OPEN BIOPSY OF LUNG PLEURA     82                                     $116.14        20120901
32098       OPEN BIOPSY OF LUNG PLEURA     AS                                     $116.14        20120901
32098       OPEN BIOPSY OF LUNG PLEURA                                            $580.69        20120901
32100       EXPLORATION OF CHEST           80                                     $135.81        20120901



                                             Page 121
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
32100       EXPLORATION OF CHEST           81                                     $135.81        20120901
32100       EXPLORATION OF CHEST           82                                     $135.81        20120901
32100       EXPLORATION OF CHEST           AS                                     $135.81        20120901
32100       EXPLORATION OF CHEST                                                  $679.04        20120901
32110       EXPLORE/REPAIR CHEST           80                                     $205.73        20120901
32110       EXPLORE/REPAIR CHEST           81                                     $205.73        20120901
32110       EXPLORE/REPAIR CHEST           82                                     $205.73        20120901
32110       EXPLORE/REPAIR CHEST           AS                                     $205.73        20120901
32110       EXPLORE/REPAIR CHEST                                                $1,028.63        20120901
32120       RE-EXPLORATION OF CHEST        80                                     $123.43        20120901
32120       RE-EXPLORATION OF CHEST        81                                     $123.43        20120901
32120       RE-EXPLORATION OF CHEST        82                                     $123.43        20120901
32120       RE-EXPLORATION OF CHEST        AS                                     $123.43        20120901
32120       RE-EXPLORATION OF CHEST                                               $617.13        20120901
32124       EXPLORE CHEST FREE ADHESIONS   80                                     $131.07        20120901
32124       EXPLORE CHEST FREE ADHESIONS   81                                     $131.07        20120901
32124       EXPLORE CHEST FREE ADHESIONS   82                                     $131.07        20120901
32124       EXPLORE CHEST FREE ADHESIONS   AS                                     $131.07        20120901
32124       EXPLORE CHEST FREE ADHESIONS                                          $655.35        20120901
32140       REMOVAL OF LUNG LESIONS        80                                     $140.29        20120901
32140       REMOVAL OF LUNG LESIONS        81                                     $140.29        20120901
32140       REMOVAL OF LUNG LESIONS        82                                     $140.29        20120901
32140       REMOVAL OF LUNG LESIONS        AS                                     $140.29        20120901
32140       REMOVAL OF LUNG LESIONS                                               $701.46        20120901
32141       REMOVE/TREAT LUNG LESIONS      80                                     $216.63        20120901
32141       REMOVE/TREAT LUNG LESIONS      81                                     $216.63        20120901
32141       REMOVE/TREAT LUNG LESIONS      82                                     $216.63        20120901
32141       REMOVE/TREAT LUNG LESIONS      AS                                     $216.63        20120901
32141       REMOVE/TREAT LUNG LESIONS                                           $1,083.15        20120901
32150       REMOVAL OF LUNG LESIONS        80                                     $141.26        20120901
32150       REMOVAL OF LUNG LESIONS        81                                     $141.26        20120901
32150       REMOVAL OF LUNG LESIONS        82                                     $141.26        20120901
32150       REMOVAL OF LUNG LESIONS        AS                                     $141.26        20120901
32150       REMOVAL OF LUNG LESIONS                                               $706.31        20120901
32151       REMOVE LUNG FOREIGN BODY       80                                     $143.40        20120901
32151       REMOVE LUNG FOREIGN BODY       81                                     $143.40        20120901
32151       REMOVE LUNG FOREIGN BODY       82                                     $143.40        20120901
32151       REMOVE LUNG FOREIGN BODY       AS                                     $143.40        20120901
32151       REMOVE LUNG FOREIGN BODY                                              $717.01        20120901
32160       OPEN CHEST HEART MASSAGE       80                                     $109.31        20120901
32160       OPEN CHEST HEART MASSAGE       81                                     $109.31        20120901
32160       OPEN CHEST HEART MASSAGE       82                                     $109.31        20120901
32160       OPEN CHEST HEART MASSAGE       AS                                     $109.31        20120901
32160       OPEN CHEST HEART MASSAGE                                              $546.55        20120901
32200       DRAIN OPEN LUNG LESION         80                                     $159.05        20120901
32200       DRAIN OPEN LUNG LESION         81                                     $159.05        20120901
32200       DRAIN OPEN LUNG LESION         82                                     $159.05        20120901
32200       DRAIN OPEN LUNG LESION         AS                                     $159.05        20120901
32200       DRAIN OPEN LUNG LESION                                                $795.23        20120901
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                                              $612.03        20120901
32215       TREAT CHEST LINING             80                                     $113.08        20120901
32215       TREAT CHEST LINING             81                                     $113.08        20120901
32215       TREAT CHEST LINING             82                                     $113.08        20120901
32215       TREAT CHEST LINING             AS                                     $113.08        20120901
32215       TREAT CHEST LINING                                                    $565.40        20120901
32220       RELEASE OF LUNG                80                                     $225.85        20120901



                                             Page 122
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
32220       RELEASE OF LUNG                81                                     $225.85        20120901
32220       RELEASE OF LUNG                82                                     $225.85        20120901
32220       RELEASE OF LUNG                AS                                     $225.85        20120901
32220       RELEASE OF LUNG                                                     $1,129.27        20120901
32225       PARTIAL RELEASE OF LUNG        80                                     $140.96        20120901
32225       PARTIAL RELEASE OF LUNG        81                                     $140.96        20120901
32225       PARTIAL RELEASE OF LUNG        82                                     $140.96        20120901
32225       PARTIAL RELEASE OF LUNG        AS                                     $140.96        20120901
32225       PARTIAL RELEASE OF LUNG                                               $704.78        20120901
32310       REMOVAL OF CHEST LINING        80                                     $129.90        20120901
32310       REMOVAL OF CHEST LINING        81                                     $129.90        20120901
32310       REMOVAL OF CHEST LINING        82                                     $129.90        20120901
32310       REMOVAL OF CHEST LINING        AS                                     $129.90        20120901
32310       REMOVAL OF CHEST LINING                                               $649.49        20120901
32320       FREE/REMOVE CHEST LINING       80                                     $226.62        20120901
32320       FREE/REMOVE CHEST LINING       81                                     $226.62        20120901
32320       FREE/REMOVE CHEST LINING       82                                     $226.62        20120901
32320       FREE/REMOVE CHEST LINING       AS                                     $226.62        20120901
32320       FREE/REMOVE CHEST LINING                                            $1,133.10        20120901
32400       NEEDLE BIOPSY CHEST LINING                                            $102.68        20120901
32400       NEEDLE BIOPSY CHEST LINING                           A                $296.06        20110101
32405       PERCUT BX LUNG/MEDIASTINUM                                             $70.58        20120901
32405       PERCUT BX LUNG/MEDIASTINUM                           A                $296.06        20110101
32420       PUNCTURE/CLEAR LUNG                                                    $78.99        20120901
32420       PUNCTURE/CLEAR LUNG                                  A                $176.07        20110101
32421       THORACENTESIS FOR ASPIRATION                                          $106.00        20120901
32421       THORACENTESIS FOR ASPIRATION                         A                $176.07        20110101
32440       REMOVE LUNG PNEUMONECTOMY      80                                     $224.84        20120901
32440       REMOVE LUNG PNEUMONECTOMY      81                                     $224.84        20120901
32440       REMOVE LUNG PNEUMONECTOMY      82                                     $224.84        20120901
32440       REMOVE LUNG PNEUMONECTOMY      AS                                     $224.84        20120901
32440       REMOVE LUNG PNEUMONECTOMY                                           $1,124.18        20120901
32442       SLEEVE PNEUMONECTOMY           80                                     $396.21        20120901
32442       SLEEVE PNEUMONECTOMY           81                                     $396.21        20120901
32442       SLEEVE PNEUMONECTOMY           82                                     $396.21        20120901
32442       SLEEVE PNEUMONECTOMY           AS                                     $396.21        20120901
32442       SLEEVE PNEUMONECTOMY                                                $1,981.07        20120901
32445       REMOVAL OF LUNG EXTRAPLEURAL   80                                     $496.25        20120901
32445       REMOVAL OF LUNG EXTRAPLEURAL   81                                     $496.25        20120901
32445       REMOVAL OF LUNG EXTRAPLEURAL   82                                     $496.25        20120901
32445       REMOVAL OF LUNG EXTRAPLEURAL   AS                                     $496.25        20120901
32445       REMOVAL OF LUNG EXTRAPLEURAL                                        $2,481.24        20120901
32480       PARTIAL REMOVAL OF LUNG        80                                     $212.45        20120901
32480       PARTIAL REMOVAL OF LUNG        81                                     $212.45        20120901
32480       PARTIAL REMOVAL OF LUNG        82                                     $212.45        20120901
32480       PARTIAL REMOVAL OF LUNG        AS                                     $212.45        20120901
32480       PARTIAL REMOVAL OF LUNG                                             $1,062.26        20120901
32482       BILOBECTOMY                    80                                     $227.03        20120901
32482       BILOBECTOMY                    81                                     $227.03        20120901
32482       BILOBECTOMY                    82                                     $227.03        20120901
32482       BILOBECTOMY                    AS                                     $227.03        20120901
32482       BILOBECTOMY                                                         $1,135.13        20120901
32484       SEGMENTECTOMY                  80                                     $206.13        20120901
32484       SEGMENTECTOMY                  81                                     $206.13        20120901
32484       SEGMENTECTOMY                  82                                     $206.13        20120901
32484       SEGMENTECTOMY                  AS                                     $206.13        20120901
32484       SEGMENTECTOMY                                                       $1,030.67        20120901
32486       SLEEVE LOBECTOMY               80                                     $336.29        20120901
32486       SLEEVE LOBECTOMY               81                                     $336.29        20120901



                                             Page 123
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
32486       SLEEVE LOBECTOMY               82                                     $336.29        20120901
32486       SLEEVE LOBECTOMY               AS                                     $336.29        20120901
32486       SLEEVE LOBECTOMY                                                    $1,681.43        20120901
32488       COMPLETION PNEUMONECTOMY       80                                     $340.21        20120901
32488       COMPLETION PNEUMONECTOMY       81                                     $340.21        20120901
32488       COMPLETION PNEUMONECTOMY       82                                     $340.21        20120901
32488       COMPLETION PNEUMONECTOMY       AS                                     $340.21        20120901
32488       COMPLETION PNEUMONECTOMY                                            $1,701.04        20120901
32501       REPAIR BRONCHUS ADD-ON         80                                      $35.67        20120901
32501       REPAIR BRONCHUS ADD-ON         81                                      $35.67        20120901
32501       REPAIR BRONCHUS ADD-ON         82                                      $35.67        20120901
32501       REPAIR BRONCHUS ADD-ON         AS                                      $35.67        20120901
32501       REPAIR BRONCHUS ADD-ON                                                $178.36        20120901
32503       RESECT APICAL LUNG TUMOR       80                                     $258.88        20120901
32503       RESECT APICAL LUNG TUMOR       81                                     $258.88        20120901
32503       RESECT APICAL LUNG TUMOR       82                                     $258.88        20120901
32503       RESECT APICAL LUNG TUMOR       AS                                     $258.88        20120901
32503       RESECT APICAL LUNG TUMOR                                            $1,294.38        20120901
32504       RESECT APICAL LUNG TUM/CHEST   80                                     $296.43        20120901
32504       RESECT APICAL LUNG TUM/CHEST   81                                     $296.43        20120901
32504       RESECT APICAL LUNG TUM/CHEST   82                                     $296.43        20120901
32504       RESECT APICAL LUNG TUM/CHEST   AS                                     $296.43        20120901
32504       RESECT APICAL LUNG TUM/CHEST                                        $1,482.17        20120901
32505       WEDGE RESECT OF LUNG INITIAL   80                                     $142.54        20120901
32505       WEDGE RESECT OF LUNG INITIAL   81                                     $142.54        20120901
32505       WEDGE RESECT OF LUNG INITIAL   82                                     $142.54        20120901
32505       WEDGE RESECT OF LUNG INITIAL   AS                                     $142.54        20120901
32505       WEDGE RESECT OF LUNG INITIAL                                          $712.68        20120901
32506       WEDGE RESECT OF LUNG ADD-ON    80                                      $24.05        20120901
32506       WEDGE RESECT OF LUNG ADD-ON    81                                      $24.05        20120901
32506       WEDGE RESECT OF LUNG ADD-ON    82                                      $24.05        20120901
32506       WEDGE RESECT OF LUNG ADD-ON    AS                                      $24.05        20120901
32506       WEDGE RESECT OF LUNG ADD-ON                                           $120.27        20120901
32540       REMOVAL OF LUNG LESION         80                                     $244.35        20120901
32540       REMOVAL OF LUNG LESION         81                                     $244.35        20120901
32540       REMOVAL OF LUNG LESION         82                                     $244.35        20120901
32540       REMOVAL OF LUNG LESION         AS                                     $244.35        20120901
32540       REMOVAL OF LUNG LESION                                              $1,221.77        20120901
32550       INSERT PLEURAL CATH                                                   $528.71        20120901
32550       INSERT PLEURAL CATH                                  A                $976.18        20110101
32551       INSERTION OF CHEST TUBE                                               $122.56        20120901
32552       REMOVE LUNG CATHETER                                                  $127.91        20120901
32553       INS MARK THOR FOR RT PERQ                                             $409.21        20120901
32560       TREAT PLEURODESIS W/AGENT                                             $177.09        20120901
32561       LYSE CHEST FIBRIN INIT DAY                                             $66.25        20120901
32562       LYSE CHEST FIBRIN SUBQ DAY                                             $59.37        20120901
32601       THORACOSCOPY DIAGNOSTIC                                               $220.91        20120901
32604       THORACOSCOPY WBX SAC                                                  $348.31        20120901
32606       THORACOSCOPY W/BX MED SPACE                                           $333.28        20120901
32607       THORACOSCOPY W/BX INFILTRATE                                          $236.71        20120901
32608       THORACOSCOPY W/BX NODULE                                              $290.73        20120901
32609       THORACOSCOPY W/BX PLEURA                                              $201.04        20120901
32650       THORACOSCOPY W/PLEURODESIS     80                                      $94.68        20120901
32650       THORACOSCOPY W/PLEURODESIS     81                                      $94.68        20120901
32650       THORACOSCOPY W/PLEURODESIS     82                                      $94.68        20120901
32650       THORACOSCOPY W/PLEURODESIS     AS                                      $94.68        20120901
32650       THORACOSCOPY W/PLEURODESIS                                            $473.42        20120901
32651       THORACOSCOPY REMOVE CORTEX     80                                     $153.75        20120901
32651       THORACOSCOPY REMOVE CORTEX     81                                     $153.75        20120901



                                             Page 124
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price          Effective Date
32651       THORACOSCOPY REMOVE CORTEX     82                                    $153.75        20120901
32651       THORACOSCOPY REMOVE CORTEX     AS                                    $153.75        20120901
32651       THORACOSCOPY REMOVE CORTEX                                           $768.73        20120901
32652       THORACOSCOPY REM TOTL CORTEX   80                                    $234.16        20120901
32652       THORACOSCOPY REM TOTL CORTEX   81                                    $234.16        20120901
32652       THORACOSCOPY REM TOTL CORTEX   82                                    $234.16        20120901
32652       THORACOSCOPY REM TOTL CORTEX   AS                                    $234.16        20120901
32652       THORACOSCOPY REM TOTL CORTEX                                       $1,170.81        20120901
32653       THORACOSCOPY REMOV FB/FIBRIN   80                                    $148.34        20120901
32653       THORACOSCOPY REMOV FB/FIBRIN   81                                    $148.34        20120901
32653       THORACOSCOPY REMOV FB/FIBRIN   82                                    $148.34        20120901
32653       THORACOSCOPY REMOV FB/FIBRIN   AS                                    $148.34        20120901
32653       THORACOSCOPY REMOV FB/FIBRIN                                         $741.72        20120901
32654       THORACOSCOPY CONTRL BLEEDING   80                                    $165.93        20120901
32654       THORACOSCOPY CONTRL BLEEDING   81                                    $165.93        20120901
32654       THORACOSCOPY CONTRL BLEEDING   82                                    $165.93        20120901
32654       THORACOSCOPY CONTRL BLEEDING   AS                                    $165.93        20120901
32654       THORACOSCOPY CONTRL BLEEDING                                         $829.63        20120901
32655       THORACOSCOPY RESECT BULLAE     80                                    $134.94        20120901
32655       THORACOSCOPY RESECT BULLAE     81                                    $134.94        20120901
32655       THORACOSCOPY RESECT BULLAE     82                                    $134.94        20120901
32655       THORACOSCOPY RESECT BULLAE     AS                                    $134.94        20120901
32655       THORACOSCOPY RESECT BULLAE                                           $674.71        20120901
32656       THORACOSCOPY W/PLEURECTOMY     80                                    $113.49        20120901
32656       THORACOSCOPY W/PLEURECTOMY     81                                    $113.49        20120901
32656       THORACOSCOPY W/PLEURECTOMY     82                                    $113.49        20120901
32656       THORACOSCOPY W/PLEURECTOMY     AS                                    $113.49        20120901
32656       THORACOSCOPY W/PLEURECTOMY                                           $567.44        20120901
32658       THORACOSCOPY W/SAC FB REMOVE   80                                    $102.02        20120901
32658       THORACOSCOPY W/SAC FB REMOVE   81                                    $102.02        20120901
32658       THORACOSCOPY W/SAC FB REMOVE   82                                    $102.02        20120901
32658       THORACOSCOPY W/SAC FB REMOVE   AS                                    $102.02        20120901
32658       THORACOSCOPY W/SAC FB REMOVE                                         $510.11        20120901
32659       THORACOSCOPY W/SAC DRAINAGE    80                                    $104.37        20120901
32659       THORACOSCOPY W/SAC DRAINAGE    81                                    $104.37        20120901
32659       THORACOSCOPY W/SAC DRAINAGE    82                                    $104.37        20120901
32659       THORACOSCOPY W/SAC DRAINAGE    AS                                    $104.37        20120901
32659       THORACOSCOPY W/SAC DRAINAGE                                          $521.83        20120901
32661       THORACOSCOPY W/PERICARD EXC    80                                    $114.05        20120901
32661       THORACOSCOPY W/PERICARD EXC    81                                    $114.05        20120901
32661       THORACOSCOPY W/PERICARD EXC    82                                    $114.05        20120901
32661       THORACOSCOPY W/PERICARD EXC    AS                                    $114.05        20120901
32661       THORACOSCOPY W/PERICARD EXC                                          $570.24        20120901
32662       THORACOSCOPY W/MEDIAST EXC     80                                    $127.96        20120901
32662       THORACOSCOPY W/MEDIAST EXC     81                                    $127.96        20120901
32662       THORACOSCOPY W/MEDIAST EXC     82                                    $127.96        20120901
32662       THORACOSCOPY W/MEDIAST EXC     AS                                    $127.96        20120901
32662       THORACOSCOPY W/MEDIAST EXC                                           $639.80        20120901
32663       THORACOSCOPY W/LOBECTOMY       80                                    $200.27        20120901
32663       THORACOSCOPY W/LOBECTOMY       81                                    $200.27        20120901
32663       THORACOSCOPY W/LOBECTOMY       82                                    $200.27        20120901
32663       THORACOSCOPY W/LOBECTOMY       AS                                    $200.27        20120901
32663       THORACOSCOPY W/LOBECTOMY                                           $1,001.36        20120901
32664       THORACOSCOPY W/ TH NRV EXC     80                                    $120.67        20120901
32664       THORACOSCOPY W/ TH NRV EXC     81                                    $120.67        20120901
32664       THORACOSCOPY W/ TH NRV EXC     82                                    $120.67        20120901
32664       THORACOSCOPY W/ TH NRV EXC     AS                                    $120.67        20120901
32664       THORACOSCOPY W/ TH NRV EXC                                           $603.37        20120901
32665       THORACOSCOP W/ESOPH MUSC EXC   80                                    $175.10        20120901



                                            Page 125
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price          Effective Date
32665       THORACOSCOP W/ESOPH MUSC EXC   81                                    $175.10        20120901
32665       THORACOSCOP W/ESOPH MUSC EXC   82                                    $175.10        20120901
32665       THORACOSCOP W/ESOPH MUSC EXC   AS                                    $175.10        20120901
32665       THORACOSCOP W/ESOPH MUSC EXC                                         $875.49        20120901
32666       THORACOSCOPY W/WEDGE RESECT    80                                    $133.31        20120901
32666       THORACOSCOPY W/WEDGE RESECT    81                                    $133.31        20120901
32666       THORACOSCOPY W/WEDGE RESECT    82                                    $133.31        20120901
32666       THORACOSCOPY W/WEDGE RESECT    AS                                    $133.31        20120901
32666       THORACOSCOPY W/WEDGE RESECT                                          $666.56        20120901
32667       THORACOSCOPY W/W RESECT ADDL   80                                     $24.05        20120901
32667       THORACOSCOPY W/W RESECT ADDL   81                                     $24.05        20120901
32667       THORACOSCOPY W/W RESECT ADDL   82                                     $24.05        20120901
32667       THORACOSCOPY W/W RESECT ADDL   AS                                     $24.05        20120901
32667       THORACOSCOPY W/W RESECT ADDL                                         $120.27        20120901
32669       THORACOSCOPY REMOVE SEGMENT    80                                    $205.37        20120901
32669       THORACOSCOPY REMOVE SEGMENT    81                                    $205.37        20120901
32669       THORACOSCOPY REMOVE SEGMENT    82                                    $205.37        20120901
32669       THORACOSCOPY REMOVE SEGMENT    AS                                    $205.37        20120901
32669       THORACOSCOPY REMOVE SEGMENT                                        $1,026.84        20120901
32670       THORACOSCOPY BILOBECTOMY       80                                    $245.07        20120901
32670       THORACOSCOPY BILOBECTOMY       81                                    $245.07        20120901
32670       THORACOSCOPY BILOBECTOMY       82                                    $245.07        20120901
32670       THORACOSCOPY BILOBECTOMY       AS                                    $245.07        20120901
32670       THORACOSCOPY BILOBECTOMY                                           $1,225.33        20120901
32671       THORACOSCOPY PNEUMONECTOMY     80                                    $272.08        20120901
32671       THORACOSCOPY PNEUMONECTOMY     81                                    $272.08        20120901
32671       THORACOSCOPY PNEUMONECTOMY     82                                    $272.08        20120901
32671       THORACOSCOPY PNEUMONECTOMY     AS                                    $272.08        20120901
32671       THORACOSCOPY PNEUMONECTOMY                                         $1,360.38        20120901
32672       THORACOSCOPY FOR LVRS          80                                    $232.73        20120901
32672       THORACOSCOPY FOR LVRS          81                                    $232.73        20120901
32672       THORACOSCOPY FOR LVRS          82                                    $232.73        20120901
32672       THORACOSCOPY FOR LVRS          AS                                    $232.73        20120901
32672       THORACOSCOPY FOR LVRS                                              $1,163.67        20120901
32673       THORACOSCOPY W/THYMUS RESECT   80                                    $183.41        20120901
32673       THORACOSCOPY W/THYMUS RESECT   81                                    $183.41        20120901
32673       THORACOSCOPY W/THYMUS RESECT   82                                    $183.41        20120901
32673       THORACOSCOPY W/THYMUS RESECT   AS                                    $183.41        20120901
32673       THORACOSCOPY W/THYMUS RESECT                                         $917.03        20120901
32674       THORACOSCOPY LYMPH NODE EXC    80                                     $32.97        20120901
32674       THORACOSCOPY LYMPH NODE EXC    81                                     $32.97        20120901
32674       THORACOSCOPY LYMPH NODE EXC    82                                     $32.97        20120901
32674       THORACOSCOPY LYMPH NODE EXC    AS                                     $32.97        20120901
32674       THORACOSCOPY LYMPH NODE EXC                                          $164.86        20120901
32800       REPAIR LUNG HERNIA             80                                    $130.61        20120901
32800       REPAIR LUNG HERNIA             81                                    $130.61        20120901
32800       REPAIR LUNG HERNIA             82                                    $130.61        20120901
32800       REPAIR LUNG HERNIA             AS                                    $130.61        20120901
32800       REPAIR LUNG HERNIA                                                   $653.05        20120901
32810       CLOSE CHEST AFTER DRAINAGE     80                                    $127.65        20120901
32810       CLOSE CHEST AFTER DRAINAGE     81                                    $127.65        20120901
32810       CLOSE CHEST AFTER DRAINAGE     82                                    $127.65        20120901
32810       CLOSE CHEST AFTER DRAINAGE     AS                                    $127.65        20120901
32810       CLOSE CHEST AFTER DRAINAGE                                           $638.27        20120901
32815       CLOSE BRONCHIAL FISTULA        80                                    $393.97        20120901
32815       CLOSE BRONCHIAL FISTULA        81                                    $393.97        20120901
32815       CLOSE BRONCHIAL FISTULA        82                                    $393.97        20120901
32815       CLOSE BRONCHIAL FISTULA        AS                                    $393.97        20120901
32815       CLOSE BRONCHIAL FISTULA                                            $1,969.86        20120901



                                            Page 126
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
32820       RECONSTRUCT INJURED CHEST       80                                     $190.90        20120901
32820       RECONSTRUCT INJURED CHEST       81                                     $190.90        20120901
32820       RECONSTRUCT INJURED CHEST       82                                     $190.90        20120901
32820       RECONSTRUCT INJURED CHEST       AS                                     $190.90        20120901
32820       RECONSTRUCT INJURED CHEST                                              $954.48        20120901
32851       LUNG TRANSPLANT SINGLE          80                                     $367.63        20120901
32851       LUNG TRANSPLANT SINGLE          81                                     $367.63        20120901
32851       LUNG TRANSPLANT SINGLE          82                                     $367.63        20120901
32851       LUNG TRANSPLANT SINGLE          AS                                     $367.63        20120901
32851       LUNG TRANSPLANT SINGLE                                               $1,838.13        20120901
32852       LUNG TRANSPLANT WITH BYPASS     80                                     $406.86        20120901
32852       LUNG TRANSPLANT WITH BYPASS     81                                     $406.86        20120901
32852       LUNG TRANSPLANT WITH BYPASS     82                                     $406.86        20120901
32852       LUNG TRANSPLANT WITH BYPASS     AS                                     $406.86        20120901
32852       LUNG TRANSPLANT WITH BYPASS                                          $2,034.32        20120901
32853       LUNG TRANSPLANT DOUBLE          80                                     $438.15        20120901
32853       LUNG TRANSPLANT DOUBLE          81                                     $438.15        20120901
32853       LUNG TRANSPLANT DOUBLE          82                                     $438.15        20120901
32853       LUNG TRANSPLANT DOUBLE          AS                                     $438.15        20120901
32853       LUNG TRANSPLANT DOUBLE                                               $2,190.77        20120901
32854       LUNG TRANSPLANT WITH BYPASS     80                                     $479.02        20120901
32854       LUNG TRANSPLANT WITH BYPASS     81                                     $479.02        20120901
32854       LUNG TRANSPLANT WITH BYPASS     82                                     $479.02        20120901
32854       LUNG TRANSPLANT WITH BYPASS     AS                                     $479.02        20120901
32854       LUNG TRANSPLANT WITH BYPASS                                          $2,395.12        20120901
32856       PREPARE DONOR LUNG DOUBLE                                              $358.07        20081013
32900       REMOVAL OF RIBS                 80                                     $195.02        20120901
32900       REMOVAL OF RIBS                 81                                     $195.02        20120901
32900       REMOVAL OF RIBS                 82                                     $195.02        20120901
32900       REMOVAL OF RIBS                 AS                                     $195.02        20120901
32900       REMOVAL OF RIBS                                                        $975.12        20120901
32905       REVISE REPAIR CHEST WALL        80                                     $190.64        20120901
32905       REVISE REPAIR CHEST WALL        81                                     $190.64        20120901
32905       REVISE REPAIR CHEST WALL        82                                     $190.64        20120901
32905       REVISE REPAIR CHEST WALL        AS                                     $190.64        20120901
32905       REVISE REPAIR CHEST WALL                                               $953.21        20120901
32906       REVISE REPAIR CHEST WALL        80                                     $236.56        20120901
32906       REVISE REPAIR CHEST WALL        81                                     $236.56        20120901
32906       REVISE REPAIR CHEST WALL        82                                     $236.56        20120901
32906       REVISE REPAIR CHEST WALL        AS                                     $236.56        20120901
32906       REVISE REPAIR CHEST WALL                                             $1,182.78        20120901
32940       REVISION OF LUNG                80                                     $175.10        20120901
32940       REVISION OF LUNG                81                                     $175.10        20120901
32940       REVISION OF LUNG                82                                     $175.10        20120901
32940       REVISION OF LUNG                AS                                     $175.10        20120901
32940       REVISION OF LUNG                                                       $875.49        20120901
32960       THERAPEUTIC PNEUMOTHORAX                                                $99.63        20120901
32997       TOTAL LUNG LAVAGE                                                      $253.02        20120901
33010       DRAINAGE OF HEART SAC                                                   $89.43        20120901
33010       DRAINAGE OF HEART SAC                                 A                $176.07        20110101
33011       REPEAT DRAINAGE OF HEART SAC                                            $88.93        20120901
33011       REPEAT DRAINAGE OF HEART SAC                          A                $176.07        20110101
33015       INCISION OF HEART SAC                                                  $377.36        20120901
33020       INCISION OF HEART SAC           80                                     $124.85        20120901
33020       INCISION OF HEART SAC           81                                     $124.85        20120901
33020       INCISION OF HEART SAC           82                                     $124.85        20120901
33020       INCISION OF HEART SAC           AS                                     $124.85        20120901
33020       INCISION OF HEART SAC                                                  $624.26        20120901
33025       INCISION OF HEART SAC           80                                     $114.61        20120901



                                              Page 127
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
33025       INCISION OF HEART SAC          81                                     $114.61        20120901
33025       INCISION OF HEART SAC          82                                     $114.61        20120901
33025       INCISION OF HEART SAC          AS                                     $114.61        20120901
33025       INCISION OF HEART SAC                                                 $573.05        20120901
33030       PARTIAL REMOVAL OF HEART SAC   80                                     $184.32        20120901
33030       PARTIAL REMOVAL OF HEART SAC   81                                     $184.32        20120901
33030       PARTIAL REMOVAL OF HEART SAC   82                                     $184.32        20120901
33030       PARTIAL REMOVAL OF HEART SAC   AS                                     $184.32        20120901
33030       PARTIAL REMOVAL OF HEART SAC                                          $921.61        20120901
33031       PARTIAL REMOVAL OF HEART SAC   80                                     $205.93        20120901
33031       PARTIAL REMOVAL OF HEART SAC   81                                     $205.93        20120901
33031       PARTIAL REMOVAL OF HEART SAC   82                                     $205.93        20120901
33031       PARTIAL REMOVAL OF HEART SAC   AS                                     $205.93        20120901
33031       PARTIAL REMOVAL OF HEART SAC                                        $1,029.65        20120901
33050       RESECT HEART SAC LESION        80                                     $142.38        20120901
33050       RESECT HEART SAC LESION        81                                     $142.38        20120901
33050       RESECT HEART SAC LESION        82                                     $142.38        20120901
33050       RESECT HEART SAC LESION        AS                                     $142.38        20120901
33050       RESECT HEART SAC LESION                                               $711.91        20120901
33120       REMOVAL OF HEART LESION        80                                     $224.12        20120901
33120       REMOVAL OF HEART LESION        81                                     $224.12        20120901
33120       REMOVAL OF HEART LESION        82                                     $224.12        20120901
33120       REMOVAL OF HEART LESION        AS                                     $224.12        20120901
33120       REMOVAL OF HEART LESION                                             $1,120.61        20120901
33130       REMOVAL OF HEART LESION        80                                     $208.27        20120901
33130       REMOVAL OF HEART LESION        81                                     $208.27        20120901
33130       REMOVAL OF HEART LESION        82                                     $208.27        20120901
33130       REMOVAL OF HEART LESION        AS                                     $208.27        20120901
33130       REMOVAL OF HEART LESION                                             $1,041.37        20120901
33140       HEART REVASCULARIZE TMR                                             $1,145.33        20120901
33141       HEART TMR W/OTHER PROCEDURE    80                                      $20.28        20120901
33141       HEART TMR W/OTHER PROCEDURE    81                                      $20.28        20120901
33141       HEART TMR W/OTHER PROCEDURE    82                                      $20.28        20120901
33141       HEART TMR W/OTHER PROCEDURE    AS                                      $20.28        20120901
33141       HEART TMR W/OTHER PROCEDURE                                           $101.41        20120901
33202       INSERT EPICARD ELTRD OPEN                                             $557.76        20120901
33203       INSERT EPICARD ELTRD ENDO                                             $589.61        20120901
33206       INSERT HEART PM ATRIAL                                                $338.88        20120901
33207       INSERT HEART PM VENTRICULAR                                           $361.56        20120901
33208       INSRT HEART PM ATRIAL VENT                                            $391.12        20120901
33210       INSERT ELECTRD/PM CATH SNGL                                           $135.04        20120901
33211       INSERT CARD ELECTRODES DUAL                                           $136.32        20120901
33212       INSERT PULSE GEN SNGL LEAD                                            $251.23        20120901
33213       INSERT PULSE GEN DUAL LEADS                                           $287.41        20120901
33214       UPGRADE OF PACEMAKER SYSTEM                                           $357.48        20120901
33215       REPOSITION PACING-DEFIB LEAD                                          $227.28        20120901
33216       INSERT 1 ELECTRODE PM-DEFIB                                           $280.79        20120901
33217       INSERT 2 ELECTRODE PM-DEFIB                                           $278.50        20120901
33218       REPAIR LEAD PACE-DEFIB ONE                                            $291.49        20120901
33220       REPAIR LEAD PACE-DEFIB DUAL                                           $294.55        20120901
33221       INSERT PULSE GEN MULT LEADS                                           $268.05        20120901
33222       REVISE POCKET PACEMAKER                                               $255.82        20120901
33222       REVISE POCKET PACEMAKER                              A                $471.22        20110101
33223       REVISE POCKET FOR DEFIB                                               $309.33        20120901
33224       INSERT PACING LEAD CONNECT                                            $380.42        20120901
33225       L VENTRIC PACING LEAD ADD-ON                                          $343.73        20120901
33226       REPOSITION L VENTRIC LEAD                                             $366.15        20120901
33227       REMOVEREPLACE PM GEN SINGL                                            $255.82        20120901
33228       REMVREPLC PM GEN DUAL LEAD                                            $266.78        20120901



                                             Page 128
                                DMAP Fee for Service Fee Schedule
                                        September 2012


Procedure
Code        Description                    Mod 1       Mod 2    Rate Type   Price          Effective Date
33229       REMVREPLC PM GEN MULT LEADS                                          $201.29        20120901
33230       INSRT PULSE GEN W/DUAL LEADS                                         $288.43        20120901
33231       INSRT PULSE GEN W/MULT LEADS                                         $299.39        20120901
33233       REMOVAL OF PM GENERATOR                                              $177.60        20120901
33234       REMOVAL OF PACEMAKER SYSTEM                                          $362.58        20120901
33235       REMOVAL PACEMAKER ELECTRODE                                          $472.40        20120901
33236       REMOVE ELECTRODE/THORACOTOMY                                         $563.11        20120901
33237       REMOVE ELECTRODE/THORACOTOMY                                         $610.50        20120901
33238       REMOVE ELECTRODE/THORACOTOMY   80                                    $133.87        20120901
33238       REMOVE ELECTRODE/THORACOTOMY   81                                    $133.87        20120901
33238       REMOVE ELECTRODE/THORACOTOMY   82                                    $133.87        20120901
33238       REMOVE ELECTRODE/THORACOTOMY   AS                                    $133.87        20120901
33238       REMOVE ELECTRODE/THORACOTOMY                                         $669.36        20120901
33240       INSRT PULSE GEN W/SINGL LEAD                                         $346.78        20120901
33241       REMOVE PULSE GENERATOR                                               $167.66        20120901
33243       REMOVE ELTRD/THORACOTOMY       80                                    $199.10        20120901
33243       REMOVE ELTRD/THORACOTOMY       81                                    $199.10        20120901
33243       REMOVE ELTRD/THORACOTOMY       82                                    $199.10        20120901
33243       REMOVE ELTRD/THORACOTOMY       AS                                    $199.10        20120901
33243       REMOVE ELTRD/THORACOTOMY                                             $995.50        20120901
33244       REMOVE ELTRD TRANSVEN                                                $638.27        20120901
33249       NSERT PACE-DEFIB W/LEAD                                              $679.55        20120901
33250       ABLATE HEART DYSRHYTHM FOCUS   80                                    $212.61        20120901
33250       ABLATE HEART DYSRHYTHM FOCUS   81                                    $212.61        20120901
33250       ABLATE HEART DYSRHYTHM FOCUS   82                                    $212.61        20120901
33250       ABLATE HEART DYSRHYTHM FOCUS   AS                                    $212.61        20120901
33250       ABLATE HEART DYSRHYTHM FOCUS                                       $1,063.03        20120901
33251       ABLATE HEART DYSRHYTHM FOCUS   80                                    $235.79        20120901
33251       ABLATE HEART DYSRHYTHM FOCUS   81                                    $235.79        20120901
33251       ABLATE HEART DYSRHYTHM FOCUS   82                                    $235.79        20120901
33251       ABLATE HEART DYSRHYTHM FOCUS   AS                                    $235.79        20120901
33251       ABLATE HEART DYSRHYTHM FOCUS                                       $1,178.96        20120901
33254       ABLATE ATRIA LMTD              80                                    $197.16        20120901
33254       ABLATE ATRIA LMTD              81                                    $197.16        20120901
33254       ABLATE ATRIA LMTD              82                                    $197.16        20120901
33254       ABLATE ATRIA LMTD              AS                                    $197.16        20120901
33254       ABLATE ATRIA LMTD                                                    $985.82        20120901
33255       ABLATE ATRIA W/O BYPASS EXT    80                                    $240.53        20120901
33255       ABLATE ATRIA W/O BYPASS EXT    81                                    $240.53        20120901
33255       ABLATE ATRIA W/O BYPASS EXT    82                                    $240.53        20120901
33255       ABLATE ATRIA W/O BYPASS EXT    AS                                    $240.53        20120901
33255       ABLATE ATRIA W/O BYPASS EXT                                        $1,202.66        20120901
33256       ABLATE ATRIA W/BYPASS EXTEN    80                                    $286.19        20120901
33256       ABLATE ATRIA W/BYPASS EXTEN    81                                    $286.19        20120901
33256       ABLATE ATRIA W/BYPASS EXTEN    82                                    $286.19        20120901
33256       ABLATE ATRIA W/BYPASS EXTEN    AS                                    $286.19        20120901
33256       ABLATE ATRIA W/BYPASS EXTEN                                        $1,430.96        20120901
33257       ABLATE ATRIA LMTD ADD-ON       80                                     $83.98        20120901
33257       ABLATE ATRIA LMTD ADD-ON                                             $419.91        20120901
33258       ABLATE ATRIA X10SV ADD-ON                                            $472.91        20120901
33259       ABLATE ATRIA W/BYPASS ADD-ON   80                                    $122.20        20120901
33259       ABLATE ATRIA W/BYPASS ADD-ON                                         $611.01        20120901
33261       ABLATE HEART DYSRHYTHM FOCUS   80                                    $235.08        20120901
33261       ABLATE HEART DYSRHYTHM FOCUS   81                                    $235.08        20120901
33261       ABLATE HEART DYSRHYTHM FOCUS   82                                    $235.08        20120901
33261       ABLATE HEART DYSRHYTHM FOCUS   AS                                    $235.08        20120901
33261       ABLATE HEART DYSRHYTHM FOCUS                                       $1,175.39        20120901
33262       REMVREPLC CVD GEN SING LEAD                                          $277.99        20120901
33263       REMVREPLC CVD GEN DUAL LEAD                                          $288.94        20120901



                                            Page 129
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
33264       REMVREPLC CVD GEN MULT LEAD                                            $299.90        20120901
33265       ABLATE ATRIA LMTD ENDO          80                                     $195.69        20120901
33265       ABLATE ATRIA LMTD ENDO          81                                     $195.69        20120901
33265       ABLATE ATRIA LMTD ENDO          82                                     $195.69        20120901
33265       ABLATE ATRIA LMTD ENDO          AS                                     $195.69        20120901
33265       ABLATE ATRIA LMTD ENDO                                                 $978.43        20120901
33266       ABLATE ATRIA X10SV ENDO         80                                     $268.00        20120901
33266       ABLATE ATRIA X10SV ENDO         81                                     $268.00        20120901
33266       ABLATE ATRIA X10SV ENDO         82                                     $268.00        20120901
33266       ABLATE ATRIA X10SV ENDO         AS                                     $268.00        20120901
33266       ABLATE ATRIA X10SV ENDO                                              $1,339.99        20120901
33282       IMPLANT PAT-ACTIVE HT RECORD                                           $241.30        20120901
33284       REMOVE PAT-ACTIVE HT RECORD                                            $173.26        20120901
33300       REPAIR OF HEART WOUND           80                                     $347.70        20120901
33300       REPAIR OF HEART WOUND           81                                     $347.70        20120901
33300       REPAIR OF HEART WOUND           82                                     $347.70        20120901
33300       REPAIR OF HEART WOUND           AS                                     $347.70        20120901
33300       REPAIR OF HEART WOUND                                                $1,738.50        20120901
33305       REPAIR OF HEART WOUND           80                                     $585.89        20120901
33305       REPAIR OF HEART WOUND           81                                     $585.89        20120901
33305       REPAIR OF HEART WOUND           82                                     $585.89        20120901
33305       REPAIR OF HEART WOUND           AS                                     $585.89        20120901
33305       REPAIR OF HEART WOUND                                                $2,929.44        20120901
33310       EXPLORATORY HEART SURGERY       80                                     $167.45        20120901
33310       EXPLORATORY HEART SURGERY       81                                     $167.45        20120901
33310       EXPLORATORY HEART SURGERY       82                                     $167.45        20120901
33310       EXPLORATORY HEART SURGERY       AS                                     $167.45        20120901
33310       EXPLORATORY HEART SURGERY                                              $837.27        20120901
33315       EXPLORATORY HEART SURGERY       80                                     $214.54        20120901
33315       EXPLORATORY HEART SURGERY       81                                     $214.54        20120901
33315       EXPLORATORY HEART SURGERY       82                                     $214.54        20120901
33315       EXPLORATORY HEART SURGERY       AS                                     $214.54        20120901
33315       EXPLORATORY HEART SURGERY                                            $1,072.71        20120901
33320       REPAIR MAJOR BLOOD VESSELS      80                                     $152.98        20120901
33320       REPAIR MAJOR BLOOD VESSELS      81                                     $152.98        20120901
33320       REPAIR MAJOR BLOOD VESSELS      82                                     $152.98        20120901
33320       REPAIR MAJOR BLOOD VESSELS      AS                                     $152.98        20120901
33320       REPAIR MAJOR BLOOD VESSELS                                             $764.91        20120901
33321       REPAIR MAJOR VESSEL             80                                     $170.92        20120901
33321       REPAIR MAJOR VESSEL             81                                     $170.92        20120901
33321       REPAIR MAJOR VESSEL             82                                     $170.92        20120901
33321       REPAIR MAJOR VESSEL             AS                                     $170.92        20120901
33321       REPAIR MAJOR VESSEL                                                    $854.60        20120901
33322       REPAIR MAJOR BLOOD VESSELS      80                                     $201.29        20120901
33322       REPAIR MAJOR BLOOD VESSELS      81                                     $201.29        20120901
33322       REPAIR MAJOR BLOOD VESSELS      82                                     $201.29        20120901
33322       REPAIR MAJOR BLOOD VESSELS      AS                                     $201.29        20120901
33322       REPAIR MAJOR BLOOD VESSELS                                           $1,006.46        20120901
33330       INSERT MAJOR VESSEL GRAFT       80                                     $207.66        20120901
33330       INSERT MAJOR VESSEL GRAFT       81                                     $207.66        20120901
33330       INSERT MAJOR VESSEL GRAFT       82                                     $207.66        20120901
33330       INSERT MAJOR VESSEL GRAFT       AS                                     $207.66        20120901
33330       INSERT MAJOR VESSEL GRAFT                                            $1,038.31        20120901
33332       INSERT MAJOR VESSEL GRAFT       80                                     $202.52        20120901
33332       INSERT MAJOR VESSEL GRAFT       81                                     $202.52        20120901
33332       INSERT MAJOR VESSEL GRAFT       82                                     $202.52        20120901
33332       INSERT MAJOR VESSEL GRAFT       AS                                     $202.52        20120901
33332       INSERT MAJOR VESSEL GRAFT                                            $1,012.58        20120901
33335       INSERT MAJOR VESSEL GRAFT       80                                     $273.50        20120901



                                              Page 130
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
33335       INSERT MAJOR VESSEL GRAFT      81                                     $273.50        20120901
33335       INSERT MAJOR VESSEL GRAFT      82                                     $273.50        20120901
33335       INSERT MAJOR VESSEL GRAFT      AS                                     $273.50        20120901
33335       INSERT MAJOR VESSEL GRAFT                                           $1,367.51        20120901
33400       REPAIR OF AORTIC VALVE         80                                     $332.16        20120901
33400       REPAIR OF AORTIC VALVE         81                                     $332.16        20120901
33400       REPAIR OF AORTIC VALVE         82                                     $332.16        20120901
33400       REPAIR OF AORTIC VALVE         AS                                     $332.16        20120901
33400       REPAIR OF AORTIC VALVE                                              $1,660.79        20120901
33401       VALVULOPLASTY OPEN             80                                     $209.80        20120901
33401       VALVULOPLASTY OPEN             81                                     $209.80        20120901
33401       VALVULOPLASTY OPEN             82                                     $209.80        20120901
33401       VALVULOPLASTY OPEN             AS                                     $209.80        20120901
33401       VALVULOPLASTY OPEN                                                  $1,049.01        20120901
33403       VALVULOPLASTY W/CP BYPASS      80                                     $217.34        20120901
33403       VALVULOPLASTY W/CP BYPASS      81                                     $217.34        20120901
33403       VALVULOPLASTY W/CP BYPASS      82                                     $217.34        20120901
33403       VALVULOPLASTY W/CP BYPASS      AS                                     $217.34        20120901
33403       VALVULOPLASTY W/CP BYPASS                                           $1,086.72        20120901
33404       PREPARE HEART-AORTA CONDUIT    80                                     $255.92        20120901
33404       PREPARE HEART-AORTA CONDUIT    81                                     $255.92        20120901
33404       PREPARE HEART-AORTA CONDUIT    82                                     $255.92        20120901
33404       PREPARE HEART-AORTA CONDUIT    AS                                     $255.92        20120901
33404       PREPARE HEART-AORTA CONDUIT                                         $1,279.61        20120901
33405       REPLACEMENT OF AORTIC VALVE    80                                     $334.35        20120901
33405       REPLACEMENT OF AORTIC VALVE    81                                     $334.35        20120901
33405       REPLACEMENT OF AORTIC VALVE    82                                     $334.35        20120901
33405       REPLACEMENT OF AORTIC VALVE    AS                                     $334.35        20120901
33405       REPLACEMENT OF AORTIC VALVE                                         $1,671.74        20120901
33406       REPLACEMENT OF AORTIC VALVE    80                                     $418.89        20120901
33406       REPLACEMENT OF AORTIC VALVE    81                                     $418.89        20120901
33406       REPLACEMENT OF AORTIC VALVE    82                                     $418.89        20120901
33406       REPLACEMENT OF AORTIC VALVE    AS                                     $418.89        20120901
33406       REPLACEMENT OF AORTIC VALVE                                         $2,094.46        20120901
33410       REPLACEMENT OF AORTIC VALVE    80                                     $370.07        20120901
33410       REPLACEMENT OF AORTIC VALVE    81                                     $370.07        20120901
33410       REPLACEMENT OF AORTIC VALVE    82                                     $370.07        20120901
33410       REPLACEMENT OF AORTIC VALVE    AS                                     $370.07        20120901
33410       REPLACEMENT OF AORTIC VALVE                                         $1,850.36        20120901
33411       REPLACEMENT OF AORTIC VALVE    80                                     $487.13        20120901
33411       REPLACEMENT OF AORTIC VALVE    81                                     $487.13        20120901
33411       REPLACEMENT OF AORTIC VALVE    82                                     $487.13        20120901
33411       REPLACEMENT OF AORTIC VALVE    AS                                     $487.13        20120901
33411       REPLACEMENT OF AORTIC VALVE                                         $2,435.63        20120901
33412       REPLACEMENT OF AORTIC VALVE    80                                     $359.37        20120901
33412       REPLACEMENT OF AORTIC VALVE    81                                     $359.37        20120901
33412       REPLACEMENT OF AORTIC VALVE    82                                     $359.37        20120901
33412       REPLACEMENT OF AORTIC VALVE    AS                                     $359.37        20120901
33412       REPLACEMENT OF AORTIC VALVE                                         $1,796.85        20120901
33413       REPLACEMENT OF AORTIC VALVE    80                                     $471.02        20120901
33413       REPLACEMENT OF AORTIC VALVE    81                                     $471.02        20120901
33413       REPLACEMENT OF AORTIC VALVE    82                                     $471.02        20120901
33413       REPLACEMENT OF AORTIC VALVE    AS                                     $471.02        20120901
33413       REPLACEMENT OF AORTIC VALVE                                         $2,355.12        20120901
33414       REPAIR OF AORTIC VALVE         80                                     $316.05        20120901
33414       REPAIR OF AORTIC VALVE         81                                     $316.05        20120901
33414       REPAIR OF AORTIC VALVE         82                                     $316.05        20120901
33414       REPAIR OF AORTIC VALVE         AS                                     $316.05        20120901
33414       REPAIR OF AORTIC VALVE                                              $1,580.27        20120901



                                             Page 131
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
33415       REVISION SUBVALVULAR TISSUE     80                                     $292.82        20120901
33415       REVISION SUBVALVULAR TISSUE     81                                     $292.82        20120901
33415       REVISION SUBVALVULAR TISSUE     82                                     $292.82        20120901
33415       REVISION SUBVALVULAR TISSUE     AS                                     $292.82        20120901
33415       REVISION SUBVALVULAR TISSUE                                          $1,464.08        20120901
33416       REVISE VENTRICLE MUSCLE         80                                     $293.89        20120901
33416       REVISE VENTRICLE MUSCLE         81                                     $293.89        20120901
33416       REVISE VENTRICLE MUSCLE         82                                     $293.89        20120901
33416       REVISE VENTRICLE MUSCLE         AS                                     $293.89        20120901
33416       REVISE VENTRICLE MUSCLE                                              $1,469.43        20120901
33417       REPAIR OF AORTIC VALVE          80                                     $242.37        20120901
33417       REPAIR OF AORTIC VALVE          81                                     $242.37        20120901
33417       REPAIR OF AORTIC VALVE          82                                     $242.37        20120901
33417       REPAIR OF AORTIC VALVE          AS                                     $242.37        20120901
33417       REPAIR OF AORTIC VALVE                                               $1,211.83        20120901
33420       REVISION OF MITRAL VALVE                                               $982.51        20120901
33422       REVISION OF MITRAL VALVE        80                                     $244.56        20120901
33422       REVISION OF MITRAL VALVE        81                                     $244.56        20120901
33422       REVISION OF MITRAL VALVE        82                                     $244.56        20120901
33422       REVISION OF MITRAL VALVE        AS                                     $244.56        20120901
33422       REVISION OF MITRAL VALVE                                             $1,222.79        20120901
33425       REPAIR OF MITRAL VALVE          80                                     $391.98        20120901
33425       REPAIR OF MITRAL VALVE          81                                     $391.98        20120901
33425       REPAIR OF MITRAL VALVE          82                                     $391.98        20120901
33425       REPAIR OF MITRAL VALVE          AS                                     $391.98        20120901
33425       REPAIR OF MITRAL VALVE                                               $1,959.92        20120901
33426       REPAIR OF MITRAL VALVE          80                                     $348.11        20120901
33426       REPAIR OF MITRAL VALVE          81                                     $348.11        20120901
33426       REPAIR OF MITRAL VALVE          82                                     $348.11        20120901
33426       REPAIR OF MITRAL VALVE          AS                                     $348.11        20120901
33426       REPAIR OF MITRAL VALVE                                               $1,740.54        20120901
33427       REPAIR OF MITRAL VALVE          80                                     $359.17        20120901
33427       REPAIR OF MITRAL VALVE          81                                     $359.17        20120901
33427       REPAIR OF MITRAL VALVE          82                                     $359.17        20120901
33427       REPAIR OF MITRAL VALVE          AS                                     $359.17        20120901
33427       REPAIR OF MITRAL VALVE                                               $1,795.83        20120901
33430       REPLACEMENT OF MITRAL VALVE     80                                     $406.86        20120901
33430       REPLACEMENT OF MITRAL VALVE     81                                     $406.86        20120901
33430       REPLACEMENT OF MITRAL VALVE     82                                     $406.86        20120901
33430       REPLACEMENT OF MITRAL VALVE     AS                                     $406.86        20120901
33430       REPLACEMENT OF MITRAL VALVE                                          $2,034.32        20120901
33460       REVISION OF TRICUSPID VALVE     80                                     $366.71        20120901
33460       REVISION OF TRICUSPID VALVE     81                                     $366.71        20120901
33460       REVISION OF TRICUSPID VALVE     82                                     $366.71        20120901
33460       REVISION OF TRICUSPID VALVE     AS                                     $366.71        20120901
33460       REVISION OF TRICUSPID VALVE                                          $1,833.54        20120901
33463       VALVULOPLASTY TRICUSPID         80                                     $444.47        20120901
33463       VALVULOPLASTY TRICUSPID         81                                     $444.47        20120901
33463       VALVULOPLASTY TRICUSPID         82                                     $444.47        20120901
33463       VALVULOPLASTY TRICUSPID         AS                                     $444.47        20120901
33463       VALVULOPLASTY TRICUSPID                                              $2,222.37        20120901
33464       VALVULOPLASTY TRICUSPID         80                                     $353.31        20120901
33464       VALVULOPLASTY TRICUSPID         81                                     $353.31        20120901
33464       VALVULOPLASTY TRICUSPID         82                                     $353.31        20120901
33464       VALVULOPLASTY TRICUSPID         AS                                     $353.31        20120901
33464       VALVULOPLASTY TRICUSPID                                              $1,766.53        20120901
33465       REPLACE TRICUSPID VALVE         80                                     $397.13        20120901
33465       REPLACE TRICUSPID VALVE         81                                     $397.13        20120901
33465       REPLACE TRICUSPID VALVE         82                                     $397.13        20120901



                                              Page 132
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
33465       REPLACE TRICUSPID VALVE        AS                                     $397.13        20120901
33465       REPLACE TRICUSPID VALVE                                             $1,985.66        20120901
33468       REVISION OF TRICUSPID VALVE    80                                     $272.13        20120901
33468       REVISION OF TRICUSPID VALVE    81                                     $272.13        20120901
33468       REVISION OF TRICUSPID VALVE    82                                     $272.13        20120901
33468       REVISION OF TRICUSPID VALVE    AS                                     $272.13        20120901
33468       REVISION OF TRICUSPID VALVE                                         $1,360.63        20120901
33470       REVISION OF PULMONARY VALVE    80                                     $178.00        20120901
33470       REVISION OF PULMONARY VALVE    81                                     $178.00        20120901
33470       REVISION OF PULMONARY VALVE    82                                     $178.00        20120901
33470       REVISION OF PULMONARY VALVE    AS                                     $178.00        20120901
33470       REVISION OF PULMONARY VALVE                                           $890.02        20120901
33471       VALVOTOMY PULMONARY VALVE      80                                     $176.63        20120901
33471       VALVOTOMY PULMONARY VALVE      81                                     $176.63        20120901
33471       VALVOTOMY PULMONARY VALVE      82                                     $176.63        20120901
33471       VALVOTOMY PULMONARY VALVE      AS                                     $176.63        20120901
33471       VALVOTOMY PULMONARY VALVE                                             $883.14        20120901
33472       REVISION OF PULMONARY VALVE    80                                     $177.29        20120901
33472       REVISION OF PULMONARY VALVE    81                                     $177.29        20120901
33472       REVISION OF PULMONARY VALVE    82                                     $177.29        20120901
33472       REVISION OF PULMONARY VALVE    AS                                     $177.29        20120901
33472       REVISION OF PULMONARY VALVE                                           $886.45        20120901
33474       REVISION OF PULMONARY VALVE    80                                     $305.86        20120901
33474       REVISION OF PULMONARY VALVE    81                                     $305.86        20120901
33474       REVISION OF PULMONARY VALVE    82                                     $305.86        20120901
33474       REVISION OF PULMONARY VALVE    AS                                     $305.86        20120901
33474       REVISION OF PULMONARY VALVE                                         $1,529.31        20120901
33475       REPLACEMENT PULMONARY VALVE    80                                     $339.04        20120901
33475       REPLACEMENT PULMONARY VALVE    81                                     $339.04        20120901
33475       REPLACEMENT PULMONARY VALVE    82                                     $339.04        20120901
33475       REPLACEMENT PULMONARY VALVE    AS                                     $339.04        20120901
33475       REPLACEMENT PULMONARY VALVE                                         $1,695.18        20120901
33476       REVISION OF HEART CHAMBER      80                                     $217.70        20120901
33476       REVISION OF HEART CHAMBER      81                                     $217.70        20120901
33476       REVISION OF HEART CHAMBER      82                                     $217.70        20120901
33476       REVISION OF HEART CHAMBER      AS                                     $217.70        20120901
33476       REVISION OF HEART CHAMBER                                           $1,088.51        20120901
33478       REVISION OF HEART CHAMBER      80                                     $227.79        20120901
33478       REVISION OF HEART CHAMBER      81                                     $227.79        20120901
33478       REVISION OF HEART CHAMBER      82                                     $227.79        20120901
33478       REVISION OF HEART CHAMBER      AS                                     $227.79        20120901
33478       REVISION OF HEART CHAMBER                                           $1,138.96        20120901
33496       REPAIR PROSTH VALVE CLOT       80                                     $242.52        20120901
33496       REPAIR PROSTH VALVE CLOT       81                                     $242.52        20120901
33496       REPAIR PROSTH VALVE CLOT       82                                     $242.52        20120901
33496       REPAIR PROSTH VALVE CLOT       AS                                     $242.52        20120901
33496       REPAIR PROSTH VALVE CLOT                                            $1,212.59        20120901
33500       REPAIR HEART VESSEL FISTULA    80                                     $228.66        20120901
33500       REPAIR HEART VESSEL FISTULA    81                                     $228.66        20120901
33500       REPAIR HEART VESSEL FISTULA    82                                     $228.66        20120901
33500       REPAIR HEART VESSEL FISTULA    AS                                     $228.66        20120901
33500       REPAIR HEART VESSEL FISTULA                                         $1,143.29        20120901
33501       REPAIR HEART VESSEL FISTULA    80                                     $161.90        20120901
33501       REPAIR HEART VESSEL FISTULA    81                                     $161.90        20120901
33501       REPAIR HEART VESSEL FISTULA    82                                     $161.90        20120901
33501       REPAIR HEART VESSEL FISTULA    AS                                     $161.90        20120901
33501       REPAIR HEART VESSEL FISTULA                                           $809.50        20120901
33502       CORONARY ARTERY CORRECTION     80                                     $183.86        20120901
33502       CORONARY ARTERY CORRECTION     81                                     $183.86        20120901



                                             Page 133
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
33502       CORONARY ARTERY CORRECTION     82                                     $183.86        20120901
33502       CORONARY ARTERY CORRECTION     AS                                     $183.86        20120901
33502       CORONARY ARTERY CORRECTION                                            $919.32        20120901
33503       CORONARY ARTERY GRAFT          80                                     $194.92        20120901
33503       CORONARY ARTERY GRAFT          81                                     $194.92        20120901
33503       CORONARY ARTERY GRAFT          82                                     $194.92        20120901
33503       CORONARY ARTERY GRAFT          AS                                     $194.92        20120901
33503       CORONARY ARTERY GRAFT                                                 $974.61        20120901
33504       CORONARY ARTERY GRAFT          80                                     $210.67        20120901
33504       CORONARY ARTERY GRAFT          81                                     $210.67        20120901
33504       CORONARY ARTERY GRAFT          82                                     $210.67        20120901
33504       CORONARY ARTERY GRAFT          AS                                     $210.67        20120901
33504       CORONARY ARTERY GRAFT                                               $1,053.34        20120901
33505       REPAIR ARTERY W/TUNNEL         80                                     $299.34        20120901
33505       REPAIR ARTERY W/TUNNEL         81                                     $299.34        20120901
33505       REPAIR ARTERY W/TUNNEL         82                                     $299.34        20120901
33505       REPAIR ARTERY W/TUNNEL         AS                                     $299.34        20120901
33505       REPAIR ARTERY W/TUNNEL                                              $1,496.70        20120901
33506       REPAIR ARTERY TRANSLOCATION    80                                     $297.66        20120901
33506       REPAIR ARTERY TRANSLOCATION    81                                     $297.66        20120901
33506       REPAIR ARTERY TRANSLOCATION    82                                     $297.66        20120901
33506       REPAIR ARTERY TRANSLOCATION    AS                                     $297.66        20120901
33506       REPAIR ARTERY TRANSLOCATION                                         $1,488.29        20120901
33507       REPAIR ART INTRAMURAL          80                                     $250.57        20120901
33507       REPAIR ART INTRAMURAL          81                                     $250.57        20120901
33507       REPAIR ART INTRAMURAL          82                                     $250.57        20120901
33507       REPAIR ART INTRAMURAL          AS                                     $250.57        20120901
33507       REPAIR ART INTRAMURAL                                               $1,252.85        20120901
33508       ENDOSCOPIC VEIN HARVEST        80                                       $2.34        20120901
33508       ENDOSCOPIC VEIN HARVEST        81                                       $2.34        20120901
33508       ENDOSCOPIC VEIN HARVEST        82                                       $2.34        20120901
33508       ENDOSCOPIC VEIN HARVEST        AS                                       $2.34        20120901
33508       ENDOSCOPIC VEIN HARVEST                                                $11.72        20120901
33510       CABG VEIN SINGLE               80                                     $284.71        20120901
33510       CABG VEIN SINGLE               81                                     $284.71        20120901
33510       CABG VEIN SINGLE               82                                     $284.71        20120901
33510       CABG VEIN SINGLE               AS                                     $284.71        20120901
33510       CABG VEIN SINGLE                                                    $1,423.57        20120901
33511       CABG VEIN TWO                  80                                     $311.93        20120901
33511       CABG VEIN TWO                  81                                     $311.93        20120901
33511       CABG VEIN TWO                  82                                     $311.93        20120901
33511       CABG VEIN TWO                  AS                                     $311.93        20120901
33511       CABG VEIN TWO                                                       $1,559.63        20120901
33512       CABG VEIN THREE                80                                     $353.51        20120901
33512       CABG VEIN THREE                81                                     $353.51        20120901
33512       CABG VEIN THREE                82                                     $353.51        20120901
33512       CABG VEIN THREE                AS                                     $353.51        20120901
33512       CABG VEIN THREE                                                     $1,767.55        20120901
33513       CABG VEIN FOUR                 80                                     $361.82        20120901
33513       CABG VEIN FOUR                 81                                     $361.82        20120901
33513       CABG VEIN FOUR                 82                                     $361.82        20120901
33513       CABG VEIN FOUR                 AS                                     $361.82        20120901
33513       CABG VEIN FOUR                                                      $1,809.08        20120901
33514       CABG VEIN FIVE                 80                                     $383.98        20120901
33514       CABG VEIN FIVE                 81                                     $383.98        20120901
33514       CABG VEIN FIVE                 82                                     $383.98        20120901
33514       CABG VEIN FIVE                 AS                                     $383.98        20120901
33514       CABG VEIN FIVE                                                      $1,919.92        20120901
33516       CABG VEIN SIX OR MORE          80                                     $399.22        20120901



                                             Page 134
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
33516       CABG VEIN SIX OR MORE          81                                     $399.22        20120901
33516       CABG VEIN SIX OR MORE          82                                     $399.22        20120901
33516       CABG VEIN SIX OR MORE          AS                                     $399.22        20120901
33516       CABG VEIN SIX OR MORE                                               $1,996.10        20120901
33517       CABG ARTERY-VEIN SINGLE        80                                      $27.37        20120901
33517       CABG ARTERY-VEIN SINGLE        81                                      $27.37        20120901
33517       CABG ARTERY-VEIN SINGLE        82                                      $27.37        20120901
33517       CABG ARTERY-VEIN SINGLE        AS                                      $27.37        20120901
33517       CABG ARTERY-VEIN SINGLE                                               $136.83        20120901
33518       CABG ARTERY-VEIN TWO           80                                      $59.98        20120901
33518       CABG ARTERY-VEIN TWO           81                                      $59.98        20120901
33518       CABG ARTERY-VEIN TWO           82                                      $59.98        20120901
33518       CABG ARTERY-VEIN TWO           AS                                      $59.98        20120901
33518       CABG ARTERY-VEIN TWO                                                  $299.90        20120901
33519       CABG ARTERY-VEIN THREE         80                                      $79.60        20120901
33519       CABG ARTERY-VEIN THREE         81                                      $79.60        20120901
33519       CABG ARTERY-VEIN THREE         82                                      $79.60        20120901
33519       CABG ARTERY-VEIN THREE         AS                                      $79.60        20120901
33519       CABG ARTERY-VEIN THREE                                                $398.00        20120901
33521       CABG ARTERY-VEIN FOUR          80                                      $95.91        20120901
33521       CABG ARTERY-VEIN FOUR          81                                      $95.91        20120901
33521       CABG ARTERY-VEIN FOUR          82                                      $95.91        20120901
33521       CABG ARTERY-VEIN FOUR          AS                                      $95.91        20120901
33521       CABG ARTERY-VEIN FOUR                                                 $479.53        20120901
33522       CABG ARTERY-VEIN FIVE          80                                     $108.09        20120901
33522       CABG ARTERY-VEIN FIVE          81                                     $108.09        20120901
33522       CABG ARTERY-VEIN FIVE          82                                     $108.09        20120901
33522       CABG ARTERY-VEIN FIVE          AS                                     $108.09        20120901
33522       CABG ARTERY-VEIN FIVE                                                 $540.43        20120901
33523       CABG ART-VEIN SIX OR MORE      80                                     $122.76        20120901
33523       CABG ART-VEIN SIX OR MORE      81                                     $122.76        20120901
33523       CABG ART-VEIN SIX OR MORE      82                                     $122.76        20120901
33523       CABG ART-VEIN SIX OR MORE      AS                                     $122.76        20120901
33523       CABG ART-VEIN SIX OR MORE                                             $613.81        20120901
33530       CORONARY ARTERY BYPASS/REOP    80                                      $76.39        20120901
33530       CORONARY ARTERY BYPASS/REOP    81                                      $76.39        20120901
33530       CORONARY ARTERY BYPASS/REOP    82                                      $76.39        20120901
33530       CORONARY ARTERY BYPASS/REOP    AS                                      $76.39        20120901
33530       CORONARY ARTERY BYPASS/REOP                                           $381.95        20120901
33533       CABG ARTERIAL SINGLE           80                                     $275.74        20120901
33533       CABG ARTERIAL SINGLE           81                                     $275.74        20120901
33533       CABG ARTERIAL SINGLE           82                                     $275.74        20120901
33533       CABG ARTERIAL SINGLE           AS                                     $275.74        20120901
33533       CABG ARTERIAL SINGLE                                                $1,378.72        20120901
33534       CABG ARTERIAL TWO              80                                     $323.34        20120901
33534       CABG ARTERIAL TWO              81                                     $323.34        20120901
33534       CABG ARTERIAL TWO              82                                     $323.34        20120901
33534       CABG ARTERIAL TWO              AS                                     $323.34        20120901
33534       CABG ARTERIAL TWO                                                   $1,616.71        20120901
33535       CABG ARTERIAL THREE            80                                     $360.13        20120901
33535       CABG ARTERIAL THREE            81                                     $360.13        20120901
33535       CABG ARTERIAL THREE            82                                     $360.13        20120901
33535       CABG ARTERIAL THREE            AS                                     $360.13        20120901
33535       CABG ARTERIAL THREE                                                 $1,800.67        20120901
33536       CABG ARTERIAL FOUR OR MORE     80                                     $387.09        20120901
33536       CABG ARTERIAL FOUR OR MORE     81                                     $387.09        20120901
33536       CABG ARTERIAL FOUR OR MORE     82                                     $387.09        20120901
33536       CABG ARTERIAL FOUR OR MORE     AS                                     $387.09        20120901
33536       CABG ARTERIAL FOUR OR MORE                                          $1,935.46        20120901



                                             Page 135
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                  Mod 1          Mod 2    Rate Type   Price          Effective Date
33542       REMOVAL OF HEART LESION      80                                       $378.58        20120901
33542       REMOVAL OF HEART LESION      81                                       $378.58        20120901
33542       REMOVAL OF HEART LESION      82                                       $378.58        20120901
33542       REMOVAL OF HEART LESION      AS                                       $378.58        20120901
33542       REMOVAL OF HEART LESION                                             $1,892.91        20120901
33545       REPAIR OF HEART DAMAGE       80                                       $445.34        20120901
33545       REPAIR OF HEART DAMAGE       81                                       $445.34        20120901
33545       REPAIR OF HEART DAMAGE       82                                       $445.34        20120901
33545       REPAIR OF HEART DAMAGE       AS                                       $445.34        20120901
33545       REPAIR OF HEART DAMAGE                                              $2,226.70        20120901
33548       RESTORE/REMODEL VENTRICLE    80                                       $433.67        20120901
33548       RESTORE/REMODEL VENTRICLE    81                                       $433.67        20120901
33548       RESTORE/REMODEL VENTRICLE    82                                       $433.67        20120901
33548       RESTORE/REMODEL VENTRICLE    AS                                       $433.67        20120901
33548       RESTORE/REMODEL VENTRICLE                                           $2,168.35        20120901
33572       OPEN CORONARY ENDARTERECTOMY 80                                        $34.09        20120901
33572       OPEN CORONARY ENDARTERECTOMY 81                                        $34.09        20120901
33572       OPEN CORONARY ENDARTERECTOMY 82                                        $34.09        20120901
33572       OPEN CORONARY ENDARTERECTOMY AS                                        $34.09        20120901
33572       OPEN CORONARY ENDARTERECTOMY                                          $170.46        20120901
33600       CLOSURE OF VALVE             80                                       $245.73        20120901
33600       CLOSURE OF VALVE             81                                       $245.73        20120901
33600       CLOSURE OF VALVE             82                                       $245.73        20120901
33600       CLOSURE OF VALVE             AS                                       $245.73        20120901
33600       CLOSURE OF VALVE                                                    $1,228.65        20120901
33602       CLOSURE OF VALVE             80                                       $237.17        20120901
33602       CLOSURE OF VALVE             81                                       $237.17        20120901
33602       CLOSURE OF VALVE             82                                       $237.17        20120901
33602       CLOSURE OF VALVE             AS                                       $237.17        20120901
33602       CLOSURE OF VALVE                                                    $1,185.84        20120901
33606       ANASTOMOSIS/ARTERY-AORTA     80                                       $256.07        20120901
33606       ANASTOMOSIS/ARTERY-AORTA     81                                       $256.07        20120901
33606       ANASTOMOSIS/ARTERY-AORTA     82                                       $256.07        20120901
33606       ANASTOMOSIS/ARTERY-AORTA     AS                                       $256.07        20120901
33606       ANASTOMOSIS/ARTERY-AORTA                                            $1,280.37        20120901
33608       REPAIR ANOMALY W/CONDUIT     80                                       $260.51        20120901
33608       REPAIR ANOMALY W/CONDUIT     81                                       $260.51        20120901
33608       REPAIR ANOMALY W/CONDUIT     82                                       $260.51        20120901
33608       REPAIR ANOMALY W/CONDUIT     AS                                       $260.51        20120901
33608       REPAIR ANOMALY W/CONDUIT                                            $1,302.54        20120901
33610       REPAIR BY ENLARGEMENT        80                                       $255.21        20120901
33610       REPAIR BY ENLARGEMENT        81                                       $255.21        20120901
33610       REPAIR BY ENLARGEMENT        82                                       $255.21        20120901
33610       REPAIR BY ENLARGEMENT        AS                                       $255.21        20120901
33610       REPAIR BY ENLARGEMENT                                               $1,276.04        20120901
33611       REPAIR DOUBLE VENTRICLE      80                                       $285.07        20120901
33611       REPAIR DOUBLE VENTRICLE      81                                       $285.07        20120901
33611       REPAIR DOUBLE VENTRICLE      82                                       $285.07        20120901
33611       REPAIR DOUBLE VENTRICLE      AS                                       $285.07        20120901
33611       REPAIR DOUBLE VENTRICLE                                             $1,425.35        20120901
33612       REPAIR DOUBLE VENTRICLE      80                                       $286.96        20120901
33612       REPAIR DOUBLE VENTRICLE      81                                       $286.96        20120901
33612       REPAIR DOUBLE VENTRICLE      82                                       $286.96        20120901
33612       REPAIR DOUBLE VENTRICLE      AS                                       $286.96        20120901
33612       REPAIR DOUBLE VENTRICLE                                             $1,434.78        20120901
33615       REPAIR MODIFIED FONTAN       80                                       $290.62        20120901
33615       REPAIR MODIFIED FONTAN       81                                       $290.62        20120901
33615       REPAIR MODIFIED FONTAN       82                                       $290.62        20120901
33615       REPAIR MODIFIED FONTAN       AS                                       $290.62        20120901



                                             Page 136
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
33615       REPAIR MODIFIED FONTAN                                               $1,453.12        20120901
33617       REPAIR SINGLE VENTRICLE         80                                     $310.19        20120901
33617       REPAIR SINGLE VENTRICLE         81                                     $310.19        20120901
33617       REPAIR SINGLE VENTRICLE         82                                     $310.19        20120901
33617       REPAIR SINGLE VENTRICLE         AS                                     $310.19        20120901
33617       REPAIR SINGLE VENTRICLE                                              $1,550.97        20120901
33619       REPAIR SINGLE VENTRICLE         80                                     $384.29        20120901
33619       REPAIR SINGLE VENTRICLE         81                                     $384.29        20120901
33619       REPAIR SINGLE VENTRICLE         82                                     $384.29        20120901
33619       REPAIR SINGLE VENTRICLE         AS                                     $384.29        20120901
33619       REPAIR SINGLE VENTRICLE                                              $1,921.45        20120901
33620       APPLY RL PULM ART BANDS         80                                     $259.54        20120901
33620       APPLY RL PULM ART BANDS         81                                     $259.54        20120901
33620       APPLY RL PULM ART BANDS         82                                     $259.54        20120901
33620       APPLY RL PULM ART BANDS         AS                                     $259.54        20120901
33620       APPLY RL PULM ART BANDS                                              $1,297.70        20120901
33621       TRANSTHOR CATH FOR STENT        80                                     $139.38        20120901
33621       TRANSTHOR CATH FOR STENT        81                                     $139.38        20120901
33621       TRANSTHOR CATH FOR STENT        82                                     $139.38        20120901
33621       TRANSTHOR CATH FOR STENT        AS                                     $139.38        20120901
33621       TRANSTHOR CATH FOR STENT                                               $696.88        20120901
33622       REDO COMPL CARDIAC ANOMALY      80                                     $546.60        20120901
33622       REDO COMPL CARDIAC ANOMALY      81                                     $546.60        20120901
33622       REDO COMPL CARDIAC ANOMALY      82                                     $546.60        20120901
33622       REDO COMPL CARDIAC ANOMALY      AS                                     $546.60        20120901
33622       REDO COMPL CARDIAC ANOMALY                                           $2,732.98        20120901
33641       REPAIR HEART SEPTUM DEFECT      80                                     $236.51        20120901
33641       REPAIR HEART SEPTUM DEFECT      81                                     $236.51        20120901
33641       REPAIR HEART SEPTUM DEFECT      82                                     $236.51        20120901
33641       REPAIR HEART SEPTUM DEFECT      AS                                     $236.51        20120901
33641       REPAIR HEART SEPTUM DEFECT                                           $1,182.53        20120901
33645       REVISION OF HEART VEINS         80                                     $229.63        20120901
33645       REVISION OF HEART VEINS         81                                     $229.63        20120901
33645       REVISION OF HEART VEINS         82                                     $229.63        20120901
33645       REVISION OF HEART VEINS         AS                                     $229.63        20120901
33645       REVISION OF HEART VEINS                                              $1,148.13        20120901
33647       REPAIR HEART SEPTUM DEFECTS     80                                     $257.25        20120901
33647       REPAIR HEART SEPTUM DEFECTS     81                                     $257.25        20120901
33647       REPAIR HEART SEPTUM DEFECTS     82                                     $257.25        20120901
33647       REPAIR HEART SEPTUM DEFECTS     AS                                     $257.25        20120901
33647       REPAIR HEART SEPTUM DEFECTS                                          $1,286.23        20120901
33660       REPAIR OF HEART DEFECTS         80                                     $255.46        20120901
33660       REPAIR OF HEART DEFECTS         81                                     $255.46        20120901
33660       REPAIR OF HEART DEFECTS         82                                     $255.46        20120901
33660       REPAIR OF HEART DEFECTS         AS                                     $255.46        20120901
33660       REPAIR OF HEART DEFECTS                                              $1,277.31        20120901
33665       REPAIR OF HEART DEFECTS         80                                     $292.46        20120901
33665       REPAIR OF HEART DEFECTS         81                                     $292.46        20120901
33665       REPAIR OF HEART DEFECTS         82                                     $292.46        20120901
33665       REPAIR OF HEART DEFECTS         AS                                     $292.46        20120901
33665       REPAIR OF HEART DEFECTS                                              $1,462.30        20120901
33670       REPAIR OF HEART CHAMBERS        80                                     $288.89        20120901
33670       REPAIR OF HEART CHAMBERS        81                                     $288.89        20120901
33670       REPAIR OF HEART CHAMBERS        82                                     $288.89        20120901
33670       REPAIR OF HEART CHAMBERS        AS                                     $288.89        20120901
33670       REPAIR OF HEART CHAMBERS                                             $1,444.46        20120901
33675       CLOSE MULT VSD                  80                                     $286.90        20120901
33675       CLOSE MULT VSD                  81                                     $286.90        20120901
33675       CLOSE MULT VSD                  82                                     $286.90        20120901



                                              Page 137
                                 DMAP Fee for Service Fee Schedule
                                         September 2012


Procedure
Code        Description                    Mod 1        Mod 2    Rate Type   Price          Effective Date
33675       CLOSE MULT VSD                 AS                                     $286.90        20120901
33675       CLOSE MULT VSD                                                      $1,434.52        20120901
33676       CLOSE MULT VSD W/RESECTION     80                                     $274.22        20120901
33676       CLOSE MULT VSD W/RESECTION     81                                     $274.22        20120901
33676       CLOSE MULT VSD W/RESECTION     82                                     $274.22        20120901
33676       CLOSE MULT VSD W/RESECTION     AS                                     $274.22        20120901
33676       CLOSE MULT VSD W/RESECTION                                          $1,371.08        20120901
33677       CL MULT VSD W/REM PUL BAND     80                                     $284.92        20120901
33677       CL MULT VSD W/REM PUL BAND     81                                     $284.92        20120901
33677       CL MULT VSD W/REM PUL BAND     82                                     $284.92        20120901
33677       CL MULT VSD W/REM PUL BAND     AS                                     $284.92        20120901
33677       CL MULT VSD W/REM PUL BAND                                          $1,424.59        20120901
33681       REPAIR HEART SEPTUM DEFECT     80                                     $265.76        20120901
33681       REPAIR HEART SEPTUM DEFECT     81                                     $265.76        20120901
33681       REPAIR HEART SEPTUM DEFECT     82                                     $265.76        20120901
33681       REPAIR HEART SEPTUM DEFECT     AS                                     $265.76        20120901
33681       REPAIR HEART SEPTUM DEFECT                                          $1,328.78        20120901
33684       REPAIR HEART SEPTUM DEFECT     80                                     $288.13        20120901
33684       REPAIR HEART SEPTUM DEFECT     81                                     $288.13        20120901
33684       REPAIR HEART SEPTUM DEFECT     82                                     $288.13        20120901
33684       REPAIR HEART SEPTUM DEFECT     AS                                     $288.13        20120901
33684       REPAIR HEART SEPTUM DEFECT                                          $1,440.64        20120901
33688       REPAIR HEART SEPTUM DEFECT     80                                     $273.20        20120901
33688       REPAIR HEART SEPTUM DEFECT     81                                     $273.20        20120901
33688       REPAIR HEART SEPTUM DEFECT     82                                     $273.20        20120901
33688       REPAIR HEART SEPTUM DEFECT     AS                                     $273.20        20120901
33688       REPAIR HEART SEPTUM DEFECT                                          $1,365.98        20120901
33690       REINFORCE PULMONARY ARTERY     80                                     $169.90        20120901
33690       REINFORCE PULMONARY ARTERY     81                                     $169.90        20120901
33690       REINFORCE PULMONARY ARTERY     82                                     $169.90        20120901
33690       REINFORCE PULMONARY ARTERY     AS                                     $169.90        20120901
33690       REINFORCE PULMONARY ARTERY                                            $849.50        20120901
33692       REPAIR OF HEART DEFECTS        80                                     $235.89        20120901
33692       REPAIR OF HEART DEFECTS        81                                     $235.89        20120901
33692       REPAIR OF HEART DEFECTS        82                                     $235.89        20120901
33692       REPAIR OF HEART DEFECTS        AS                                     $235.89        20120901
33692       REPAIR OF HEART DEFECTS                                             $1,179.47        20120901
33694       REPAIR OF HEART DEFECTS        80                                     $286.19        20120901
33694       REPAIR OF HEART DEFECTS        81                                     $286.19        20120901
33694       REPAIR OF HEART DEFECTS        82                                     $286.19        20120901
33694       REPAIR OF HEART DEFECTS        AS                                     $286.19        20120901
33694       REPAIR OF HEART DEFECTS                                             $1,430.96        20120901
33697       REPAIR OF HEART DEFECTS        80                                     $305.76        20120901
33697       REPAIR OF HEART DEFECTS        81                                     $305.76        20120901
33697       REPAIR OF HEART DEFECTS        82                                     $305.76        20120901
33697       REPAIR OF HEART DEFECTS        AS                                     $305.76        20120901
33697       REPAIR OF HEART DEFECTS                                             $1,528.80        20120901
33702       REPAIR OF HEART DEFECTS        80                                     $223.15        20120901
33702       REPAIR OF HEART DEFECTS        81                                     $223.15        20120901
33702       REPAIR OF HEART DEFECTS        82                                     $223.15        20120901
33702       REPAIR OF HEART DEFECTS        AS                                     $223.15        20120901
33702       REPAIR OF HEART DEFECTS                                             $1,115.77        20120901
33710       REPAIR OF HEART DEFECTS        80                                     $260.92        20120901
33710       REPAIR OF HEART DEFECTS        81                                     $260.92        20120901
33710       REPAIR OF HEART DEFECTS        82                                     $260.92        20120901
33710       REPAIR OF HEART DEFECTS        AS                                     $260.92        20120901
33710       REPAIR OF HEART DEFECTS                                             $1,304.58        20120901
33720       REPAIR OF HEART DEFECT         80                                     $223.05        20120901
33720       REPAIR OF HEART DEFECT         81                                     $223.05        20120901



                                             Page 138
                                  DMAP Fee for Service Fee Schedule
                                          September 2012


Procedure
Code        Description                     Mod 1        Mod 2    Rate Type   Price          Effective Date
33720       REPAIR OF HEART DEFECT          82                                     $223.05        20120901
33720       REPAIR OF HEART DEFECT          AS                                     $223.05        20120901
33720       REPAIR OF HEART DEFECT                                               $1,115.26        20120901
33722       REPAIR OF HEART DEFECT          80                                     $234.67        20120901
33722       REPAIR OF HEART DEFECT          81                                     $234.67        20120901
33722       REPAIR OF HEART DEFECT          82                                     $234.67        20120901
33722       REPAIR OF HEART DEFECT          AS                                     $234.67        20120901
33722       REPAIR OF HEART DEFECT                                               $1,173.35        20120901
33724       REPAIR VENOUS ANOMALY           80                                     $224.89        20120901
33724       REPAIR VENOUS ANOMALY           81                                     $224.89        20120901
33724       REPAIR VENOUS ANOMALY           82                                     $224.89        20120901
33724       REPAIR VENOUS ANOMALY           AS                                     $224.89        20120901
33724       REPAIR VENOUS ANOMALY                                                $1,124.43        20120901
33726       REPAIR PUL VENOUS STENOSIS      80                                     $298.27        20120901
33726       REPAIR PUL VENOUS STENOSIS      81                                     $298.27        20120901
33726       REPAIR PUL VENOUS STENOSIS      82                                     $298.27        20120901
33726       REPAIR PUL VENOUS STENOSIS      AS                                     $298.27        20120901
33726       REPAIR PUL VENOUS STENOSIS                                           $1,491.34        20120901
33730       REPAIR HEART-VEIN DEFECTS       80                                     $286.60        20120901
33730       REPAIR HEART-VEIN DEFECTS       81                                     $286.60        20120901
33730       REPAIR HEART-VEIN DEFECTS       82                                     $286.60        20120901
33730       REPAIR HEART-VEIN DEFECTS       AS                                     $286.60        20120901
33730       REPAIR HEART-VEIN DEFEC