Practitioner Fee Schedule (pdf)- Updated 04/01/09 - State of Illinois

Healthcare and Family Services
Practitioner Fee Schedule Key
For charges submitted by Physicians, Advanced Practice Nurses, Imaging
Centers, Portable X-ray Companies, School-Based/Linked Health Centers, Local
Health Departments, Encounter Rate Clinics, Independent Laboratories,
Fee-For-Service Hospitals, and Optometrists and Dentists Providing Medical
Services
Revised 04-01-09
*95951 appears on the fee schedule twice; © indicates child professional and technical
components, (A) indicates adult professional and technical components
HCPCS
Note
COLUMN
HEADING
A
B
C
COLUMN DESCRIPTION
CPT-4 or HCPCS Procedure Code
Special billing information applies to the code.
Professional and Technical components are each reimbursed at
50% of the state maximum.
To bill quantities: Number of tests performed on a single date
of service should be billed using the days/units field. When the
quantity exceeds 5, the claim must be submitted on paper and
must be accompanied by supporting documentation.
Professional and technical components are each reimbursed at
50% of the state maximum, rounded to the nearest cent.
To bill quantities:
For bilateral, submit the procedure code, use modifier 50, and
show quantity “1” in days/units field.
For multiples that are not bilateral, claims must be submitted on
paper. Submit the procedure code on one service section, and
in the next service section submit the unlisted procedure code for
any quantity beyond the first, listing total number and name of
additional tests in the description field, and attach documentation
of all tests performed.
Reimbursement for professional and technical components split
at a rate other than 50%.
To bill quantities: Claims for multiple quantities must be
submitted on paper. Submit the procedure code on one service
section, and in the next service section submit the unlisted
procedure code for any quantity beyond the first, listing total
number and name of additional tests in the description field, and
attach documentation of all tests performed.
1

D
E
F
G
H
I
J
K
L
M
N
Code is billable by encounter rate clinic only.
Vaccine is supplied through the Vaccines For Children (VFC)
program. The department reimburses for the administrative cost
(practice expense) of the vaccine only, for ages 0-18 years, as
shown in the Unit Price column.
Vaccine is not available through the VFC. The department
reimburses for the vaccine when it is medically necessary.
Vaccine is supplied for children, but not adults, through the VFC.
The department reimburses for the administrative cost (practice
expense) of the vaccine only, for ages 0-18 years, as shown in
the Unit Price column, and for the vaccine for adults, ages 19
years and older, as shown in the State Max column when
medically necessary.
CLIA “A” rate for the full test.
CLIA “W” rate for the waived test.
Covered only for blood lead draws as a Healthy Kids service for
ages 0-20 years, and must be billed with the U1 modifier as
documentation that the service meets this description.
Prior approval required for surgeon and assistant surgeon.
Anesthesia services for these codes must be billed using the
anesthesia five-digit procedure code.
Number of eyes tested should be billed using the days/units field;
quantity is either 1 or 2.
Age restricted to 9-26 years. Vaccine is supplied through the
VFC Program for ages 9-18 years. The department reimburses
VFC-enrolled providers for administrative cost (practice expense)
as shown in the unit price column. The department reimburses
for the vaccine for ages 19-26 years, and ages 9-26 years for
non-VFC providers as shown in the State Max column.
Additional information is provided at
.
Prior approval required for physician-purchased and
administered drug. Prior approval guidelines are provided at
.
P
Add-on applies only when the Primary Care Physician provides
services.
2

Q
State maximum amount now includes the Maternal Child Health
Add-on amount for all providers.
Prog Cov
Eff Date
HP
APL
NDC Ind
Surg Ind
Program
Coverage
Effective
Date
Hand Price
Indicator
Ambulatory
Procedure
Listing
NDC
indicator
Surgery
Indicator
M1 (26) Modifier 1
(26)
M2 (TC) Modifier 2
(TC)
02-Title XIX coverage only (limited Transitional Assistance
coverage)
04-Medicaid covered services
09-Qualified Medicare Beneficiary (QMB) coverage only
(See Chap 100 Section 120.12, posted on our website at
.
Effective date of codes added on or after 01/01/07 or date
of change in payment policy.
If “Y”, special pricing methodology is applied.
Anesthesia: Claims may be submitted electronically or on
paper following the billing guidelines posted on our
website at
.
Medical/surgical procedure: Claims must be submitted on
paper. The name of the procedure and total number of
times performed must be submitted in the description field
and the procedure note must be attached.
To bill quantities: The number listed in the days/units
field must be “1” and the actual quantity must be included
in the description/note field.
Drugs: May be submitted electronically or on paper. The
claim must contain the name of the drug, strength of the
drug, and the amount given in the description/note field
and must be billed according to NDC billing guidelines
available on our website at
.
To bill quantities: The number listed in the days/units
field must be “1” and the actual quantity must be included
in the description/note field.
Column has been removed to allow addition of more
pertinent information. APL information may be viewed on
our website at
.
If “Y”, the 11-digit NDC must be billed according to NDC
billing guidelines available on our website at
.
B = Obstetrical service
N = Not considered surgical
I = Incidental. Procedure may not pay separately when
billed with other surgical codes.
M = Major. Reimbursement for procedure includes 30-
day postoperative care.
Rate paid for the professional component of the
procedure.
Rate paid for the technical component of the procedure.
3

Assist
Surg
Assistant
Surgeon
“Y” indicates services of an assistant at surgery may be
paid.
CoSurg Co-Surgeon “Y” indicates services of a co-surgeon may be paid.
Unit Price
Price for each unit when multiple quantities are billable or
base amount payable for ages 0-20 years when followed
by “©”.
Max Qty Maximum
Quantity
The maximum quantity payable for the code.
To bill quantities when the maximum quantity is
greater than 1:
Submit number of units performed or dispensed on a
single date of service in the days/units field
To bill quantities when the maximum quantity is 1,
note field is blank, and HP is “N”:
For bilateral procedures, submit the procedure code, use
modifier “RT” and show quantity “1” in days/units field and
in the subsequent service section submit the procedure
code, use modifier “LT”, and show quantity “1” in
days/units field.
For multiples that are not bilateral, claims must be
submitted on paper. Submit the procedure code on one
service section, and in the next service section submit the
unlisted procedure code for any quantity beyond the first,
listing total # and name of additional procedures in the
description field, and attach documentation of all
State Max
Add-ons
State
Maximum
Surgical addon
Child add-on
Adult add-on
procedures performed.
The maximum allowable reimbursement (reflects
combined professional and technical components where
applicable).
or base amount payable for ages 21 years and older
when followed by “(A)”.
Surg: The amount added to the state maximum when the
procedure is performed in the practitioner’s office. This
amount covers such items as casting and surgical
supplies.
Child: The amount added to the state maximum for
services rendered to ages 0-20 years. Preventive
medicine and Evaluation and Management code add-ons
are payable only to Primary Care Providers.
Adult: The amount added to the state maximum for
services rendered to ages 21 years and older. Preventive
medicine and Evaluation and Management code add-ons
are payable only to Primary Care Providers.
4

MODIFIERS RECOGNIZED IN PROCESSING ILLINOIS
HEALTHCARE AND FAMILY SERVICE CLAIMS
MODIFIER DESCRIPTION
Updated 04/01/09
HOW PAYMENT IS AFFECTED
25 Significant, separately identifiable E&M service same physician same day May allow E&M payment separate from another service
26 Professional component
Pays professional component only (*see practitioner fee schedule,
Notes A, B, C)
50 Bilateral procedure
Bill procedure code one time with modifier and quantity "1" to
indicate bilaterals performed (*see practitioner fee schedule, Note
B)
51 Multiple procedures
Applies only to billing multiple NDCs (**see Informational Notice to
Physicians dated 12-21-07)
52 Reduced services
Goes to hand pricing, requires attachment of additional
information
53 Discontinued procedure Not payable; bill only for services completed
59 Distinct procedural service Applies to Medicare crossovers only
62 Two surgeons Each surgeon is paid at 50% state maximum
73 Discontinued outpatient procedure prior to anesthesia administration Not payable; bill only for services completed
74 Discontinued outpatient procedure after anesthesia administration Not payable; bill only for services completed
76 Repeat procedure by same physician
Applies only to billing multiple NDCs (**see Informational Notice to
Physicians dated 12-21-07)
80 Assistant surgeon Payment is based on minutes billed
81 Minimum assistant surgeon Payment is based on minutes billed
82 Assistant surgeon when qualified resident surgeon not available Payment is based on minutes billed
90 Reference (outside) laboratory Not payable for APL or inpatient procedures
91 Repeat clinical diagnostic laboratory test Applies to Medicare crossovers only
AH Clinical psychologist Billable only by FQHC and RHC
AJ Clinical social worker Billable only by FQHC and RHC
AS
Physician assistant, nurse practitioner, or clinical nurse specialist services for
assistant at surgery
Payment is based on minutes billed
AT Acute Treatment
Sterilization permit not required when procedure performed for
acute reason and not for sterilization purposes
Processes separately from same CPT with different eyelid
E1 Upper left eyelid
modifier

E2
E3
E4
EP
Lower left eyelid
Upper right eyelid
Lower right eyelid
Service provided as part of medicaid early periodic screening diagnosis and
treatment (EPSDT) program
Processes separately from same CPT with different eyelid
modifier
Processes separately from same CPT with different eyelid
modifier
Processes separately from same CPT with different eyelid
modifier
Service is processed as a Healthy Kids service
F1 Left hand, second digit Processes separately from same CPT with different digit modifier
F2 Left hand, third digit Processes separately from same CPT with different digit modifier
F3 Left hand, fourth digit Processes separately from same CPT with different digit modifier
F4 Left hand, fifth digit Processes separately from same CPT with different digit modifier
F5 Right hand, thumb Processes separately from same CPT with different digit modifier
F6 Right hand, second digit Processes separately from same CPT with different digit modifier
F7 Right hand, third digit Processes separately from same CPT with different digit modifier
F8 Right hand, fourth digit Processes separately from same CPT with different digit modifier
F9 Right hand, fifth digit Processes separately from same CPT with different digit modifier
FA Left hand, thumb Processes separately from same CPT with different digit modifier
FP Service provided as part of family planning program Service is processed as a family planning service
GN Outpatient speech therapy See Therapists Provider Notice dated 061605
GO Outpatient occupational therapy See Therapists Provider Notice dated 061605
GP Outpatient physical therapy See Therapists Provider Notice dated 061605
GZ Item or service expected to be denied as not reasonable and necessary Not payable
HD Pregnant/parenting women's program Service is processed as a postpartum depression screening
Inpatient/outpatient psychiatric consultation or inpatient psychiatric
subsequent care rate (**see Physician Provider Notice dated
HE Mental health program
102903)

HO Masters degree level; added 060108 effective 10/22/07 Billable only by FQHC and RHC
LC Left circumflex coronary artery
Processes separately from same CPT with different coronary
artery modifier
LD Left anterior descending coronary artery
Processes separately from same CPT with different coronary
artery modifier
LT Left side Processes separately from same CPT with RT modifier
NU New equipment Processes as Purchase
P1 Normal, healthy patient Anesthesia converts to modifying units "0"
P2 Patient with mild systemic disease Anesthesia converts to modifying units "1"
P3 Patient with severe systemic disease Anesthesia converts to modifying units "2"
P4 Patient with severe systemic disease that is a constant threat to life Anesthesia converts to modifying units "3"
P5 Moribund patient not expected to survive without the operation Anesthesia converts to modifying units "4"
P6
Declared brain-dead patient whose organs are being removed for donor
purposes Anesthesia converts to modifying units "0"
QL Patient pronounced dead after ambulance called Not payable
QM Ambulance service provided under arrangement by a provider of services Not payable
QW CLIA waived test
Processes at the waived CLIA rate (*see practitioner fee
schedule, Note I)
RC Right coronary artery
Processes separately from same CPT with different coronary
artery modifier
RR Rental Processes as rental
RT Right side Processes separately from same CPT with LT modifier
SL State supplied vaccine
Processes HPV vaccine to Obstetricians not enrolled with VFC
(**see Physician Provider Notice dated 061507)
T1 Left foot, second digit Processes separately from same CPT with different digit modifier
T2 Left foot, third digit Processes separately from same CPT with different digit modifier
T3 Left foot, fourth digit Processes separately from same CPT with different digit modifier
T4 Left foot, fifth digit Processes separately from same CPT with different digit modifier
T5 Right foot, great toe Processes separately from same CPT with different digit modifier
T6 Right foot, second digit Processes separately from same CPT with different digit modifier

T7 Right foot, third digit Processes separately from same CPT with different digit modifier
T8 Right foot, fourth digit Processes separately from same CPT with different digit modifier
T9 Right foot, fifth digit Processes separately from same CPT with different digit modifier
TA Left foot, great toe Processes separately from same CPT with different digit modifier
TC Technical component
Pays technical component only (*see practitioner fee schedule,
Notes A, B, C)
TT Individualized service provided to more than one patient in same setting
Processes as coincident visit Long Term care(**see Physician
Provider Notice dated 102903)
U1 Local modifier-Blood lead draw
Blood specimen drawn for lead analysis as part of Healthy Kids
program (***see Chapter HK-200 Section 202.1)
U2 Local modifier-Home Health nursing assessment visit
Processes as assessment visit only (***see Home Health
Handbook Section R-203.1)
U4 Local modifier-Pregnancy resulting from rape Claim requires abortion payment application HFS form 2390
U6 Local modifier-Service provided within 60 days of hospital discharge
Processes as therapy visit within 60 days of hospital
discharge(***see Therapy Providers Handbook Section J-211)
U7 Local modifier-Pregnancy resulting from incest Claim requires abortion payment application HFS form 2390
U8 Local modifier-Pregnancy threatening the mother's life Claim requires abortion payment application HFS form 2390
* Practitioner Fee Schedule is posted on our website at
http://www.hfs.illinois.gov/feeschedule/
**Provider Informational Notices are posted on our website at
http://www.hfs.illinois.gov/releases/
***Provider Handbooks are posted on our website at
http://www.hfs.illinois.gov/handbooks/

Health Care and Family Services Revised 4/1/09
Practitioner Fee Schedule
Add-On's
Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00102 04 Y M
00103 04 Y M
00104 02 N N 44.40
00120 04 Y M
00124 04 Y I
00126 04 Y I
00140 04 Y M
00142 04 Y M
00144 04 Y M
00145 04 Y M
00147 04 Y M
00148 04 Y I
00160 04 Y M
00162 04 Y M
00164 04 Y I
0016T 04 Y Y
00170 04 Y I
00172 04 Y M
Wednesday, April 01, 2009 Page 1 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00174 04 Y M
00176 04 Y M
0017T 04 Y M
00190 04 Y M
00192 04 Y M
0019T 04 Y I
00210 04 Y M
00211 04 1/1/2009 Y M
00212 04 Y M
00214 04 Y M
00215 04 Y M
00216 04 Y M
00218 04 Y M
00220 04 Y M
00222 04 Y M
00300 04 Y M
0030T 04 Y N
00320 04 Y M
00322 04 Y M
00326 04 Y M
00350 04 Y M
Wednesday, April 01, 2009 Page 2 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00352 04 Y M
00400 04 Y I
00402 04 Y M
00404 04 Y M
00406 04 Y M
00410 04 N I 112.40
0042T B 04 N N 141.22 141.22 282.45
00450 04 Y M
00452 04 Y M
00454 04 Y I
00470 04 Y M
00472 04 Y M
00474 04 Y M
0048T 04 Y M Y
00500 04 Y M
0051T 04 Y M Y Y
00520 04 Y M
00522 04 Y I
00524 04 Y M
00528 04 Y M
00529 04 Y N
Wednesday, April 01, 2009 Page 3 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
0052T 04 Y M Y Y
00530 04 Y M
00532 04 Y I
00534 04 Y M
00537 04 Y I
00539 04 Y M
0053T 04 Y M Y Y
00540 04 Y M
00541 04 Y M
00542 04 Y M
00546 04 Y M
00548 04 Y M
00550 04 Y M
00560 04 Y M
00561 04 Y M
00562 04 Y M
00563 04 Y M
00566 04 Y M
00567 04 1/1/2009 Y M
00580 04 Y M
00600 04 Y M
Wednesday, April 01, 2009 Page 4 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00604 04 Y M
00620 04 Y M
00622 04 Y M
00625 04 1/1/2007 Y M
00626 04 1/1/2007 Y N
0062T 04 N M 509.95
00630 04 Y M
00632 04 Y M
00634 04 Y M
00635 04 Y I
0063T 04 Y M
00640 04 Y M
00670 04 Y M
00700 04 Y M
00702 04 Y I
00730 04 Y M
0073T 04 N N 364.51
00740 04 Y M
00750 04 Y M
00752 04 Y M
00754 04 Y M
Wednesday, April 01, 2009 Page 5 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00756 04 Y M
0075T 04 N I 83.00
0076T 04 N I 83.00
00770 04 Y M
0077T 04 N M Y Y 449.50
0078T 04 N M Y Y 1,148.60
00790 04 Y M
00792 04 Y M
00794 04 Y M
00796 04 Y M
00797 04 Y M
0079T 04 Y M Y Y
00800 04 Y M
00802 04 Y M
0080T 04 Y N
00810 04 Y M
0081T 04 Y M
00820 04 Y M
00830 04 Y M
00832 04 Y M
00834 04 Y M
Wednesday, April 01, 2009 Page 6 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00836 04 Y M
00840 04 Y M
00842 04 Y I
00844 04 Y M
00846 04 Y M
00848 04 Y M
0084T 04 N I 118.20
00851 04 Y M
00860 04 Y M
00862 04 Y M
00864 04 Y M
00865 04 Y M
00866 04 Y M
00868 04 Y M
00870 04 Y M
00872 04 Y M
00873 04 Y M
00880 04 Y M
00882 04 Y M
00902 04 Y M
00904 04 Y M
Wednesday, April 01, 2009 Page 7 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00906 04 Y M
00908 04 Y M
00910 04 Y M
00912 04 Y M
00914 04 Y M
00916 04 Y M
00918 04 Y M
00920 04 Y M
00921 04 Y M
00922 04 Y M
00924 04 Y M
00926 04 Y M
00928 04 Y M
00930 04 Y M
00932 04 Y M
00934 04 Y M
00936 04 Y M
00938 04 Y M
00940 04 Y I
00942 04 Y M
00944 04 Y M
Wednesday, April 01, 2009 Page 8 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
00948 04 Y I
00950 04 Y I
00952 04 Y I
0095T 04 Y M Y
0101T 04 Y M
0102T 04 Y M
01112 04 Y I
01120 04 Y M
01130 04 Y I
01140 04 Y M
01150 04 Y M
01160 04 Y M
01170 04 Y M
01173 04 Y M
01180 04 Y M
01190 04 Y M
01200 04 Y M
01202 04 Y M
01210 04 Y M
01212 04 Y M
01214 04 Y M
Wednesday, April 01, 2009 Page 9 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
01215 04 Y I
01220 04 Y M
01230 04 Y M
01232 04 Y M
01234 04 Y M
0123T 04 Y M
0124T 04 Y M
01250 04 Y M
01260 04 Y M
01270 04 Y M
01272 04 Y M
01274 04 Y M
01320 04 Y M
01340 04 Y M
01360 04 Y M
01380 04 Y M
01382 04 Y M
01390 04 Y M
01392 04 Y M
01400 04 Y M
01402 04 Y M
Wednesday, April 01, 2009 Page 10 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
01404 04 Y M
01420 04 Y I
01430 04 Y M
01432 04 Y M
0143T 04 Y N
01440 04 Y M
01442 04 Y M
01444 04 Y M
01462 04 Y M
01464 04 Y M
01470 04 Y M
01472 04 Y M
01474 04 Y M
0147T C 04 N N 21.37 88.48 109.85
01480 04 Y M
01482 04 Y M
01484 04 Y M
01486 04 Y M
01490 04 Y I
01500 04 Y M
01502 04 Y M
Wednesday, April 01, 2009 Page 11 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
01520 04 Y M
01522 04 Y M
01610 04 Y M
01620 04 Y M
01622 04 Y M
01630 04 Y M
01632 04 Y M
01634 04 Y M
01636 04 Y M
01638 04 Y M
01650 04 Y M
01652 04 Y M
01654 04 Y M
01656 04 Y M
01670 04 Y M
01680 04 Y I
01682 04 Y I
01710 04 Y M
01712 04 Y M
01714 04 Y M
01716 04 Y M
Wednesday, April 01, 2009 Page 12 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
01730 04 Y M
01732 04 Y M
01740 04 Y M
01742 04 Y M
01744 04 Y M
01756 04 Y M
01758 04 Y M
01760 04 Y M
01770 04 Y M
01772 04 Y M
01780 04 Y M
01782 04 Y M
01810 04 Y M
01820 04 Y M
01829 04 N M 356.10
01830 04 Y M
01832 04 Y M
01840 04 Y M
01842 04 Y M
01844 04 Y M
01850 04 Y M
Wednesday, April 01, 2009 Page 13 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
01852 04 Y M
01860 04 Y M
01916 04 Y I
01920 04 Y M
01922 04 Y I
01924 04 Y M
01925 04 Y M
01926 04 Y I
01930 04 Y M
01931 04 Y M
01932 04 Y M
01933 04 Y M
01935 04 1/1/2008 Y M
01936 04 1/1/2008 Y M
01951 04 Y I
01952 04 Y I
01953 04 Y I
01958 04 Y M
01960 09 Y M
01961 04 Y M
01962 04 Y M
Wednesday, April 01, 2009 Page 14 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
01963 04 Y M
01965 04 Y M
01967 04 Y M
01968 04 Y M
01969 04 Y M
01991 04 Y I
01992 04 Y I
01996 04 N I 14.25
01999 04 Y M
0500F 04 N B 44.10
0502F 04 N B 44.10
0503F 04 N B 50.15
10021 04 N I 49.80
10022 04 N I 56.70
10040 04 N I 35.20
10060 04 N I 36.00
10061 04 N I 66.50
10080 04 N I 70.65.
10081 04 N I 131.80
10120 04 N I 39.05
10121 04 N I 77.60
Wednesday, April 01, 2009 Page 15 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
10140 04 N I 41.50
10160 04 N I 35.95
10180 04 N I Y 130.55
11000 04 N I 77.70
11001 04 N I 20.85
11004 04 N M Y Y 154.43
11005 04 N M Y Y 154.43
11006 04 N M Y Y 154.43
11008 04 N M Y Y 154.43
11010 04 N I 127.60
11011 04 N I 157.90
11012 04 N I 218.40
11040 04 N I 34.10
11041 04 N I Y 51.90
11042 04 N I Y Y 70.55
11043 04 N M Y 170.55
11044 04 N M Y 219.35
11055 04 N I 22.15
11056 04 Y I
11057 04 Y I
11100 04 N I 50.20 17.00
Wednesday, April 01, 2009 Page 16 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
11101 04 N I 22.15
11200 04 N I 35.65 17.00
11201 04 N I 15.20
11300 04 N I 21.10
11301 04 N I 29.20
11302 04 N I 37.50
11303 04 N I 45.70
11305 04 N I 22.25
11306 04 N I 31.25
11307 04 N I 37.50
11308 04 N I 45.70
11310 04 N I 32.40
11311 04 N I 40.55
11312 04 N I 48.80
11313 04 N I 57.10
11400 04 N I 39.05 17.00
11401 04 N I 50.20 17.00
11402 04 N I 64.80 17.00
11403 04 N I 77.90 17.00
11404 04 N I 92.40 17.00
11406 04 N I 108.00 17.00
Wednesday, April 01, 2009 Page 17 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
11420 04 N I 38.30 17.00
11421 04 N I 50.85 17.00
11422 04 N I 64.80 17.00
11423 04 N I 77.90 17.00
11424 04 N I 92.40 17.00
11426 04 N I 127.48 17.00
11440 04 N I 54.15 17.00
11441 04 N I 75.30 17.00
11442 04 N I 96.40 17.00
11443 04 N I 111.00 17.00
11444 04 N I 117.55 17.00
11446 04 N I 146.37 17.00
11450 04 N M Y 215.40 34.00
11451 04 N M Y 244.10 34.00
11462 04 N M Y 215.40 34.00
11463 04 N M Y 232.20
11470 04 N M Y 291.30
11471 04 N M Y 297.00
11600 04 N I 54.15 17.00
11601 04 N I 75.30 17.00
11602 04 N I 96.40 17.00
Wednesday, April 01, 2009 Page 18 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
11603 04 N I 117.55 17.00
11604 04 N I 138.75 17.00
11606 04 N M 185.52 17.00
11620 04 N I 54.15 17.00
11621 04 N I 75.30 17.00
11622 04 N I 96.40 17.00
11623 04 N I 117.55 17.00
11624 04 N I 138.75 17.00
11626 04 N M 185.52 17.00
11640 04 N I 107.00 17.00
11641 04 N I 149.25 17.00
11642 04 N M 192.95 17.00
11643 04 N M 235.20 17.00
11644 04 N M 278.80 17.00
11646 04 N M 294.77 17.00
11719 04 N I 15.90
11720 04 N I 15.90
11721 04 N I 18.10
11730 04 N I 34.30 17.00
11732 04 N I 14.45
11740 04 N I 36.00
Wednesday, April 01, 2009 Page 19 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
11750 04 N I 61.85 34.00
11752 04 N M Y 167.40 34.00
11755 04 N I 38.80
11760 04 N I 60.80 17.00
11762 04 N I 87.75 17.00
11765 04 N I 38.40
11770 04 N M 215.40 34.00
11771 04 N M Y 291.30
11772 04 N M Y 341.25
11900 04 N I 21.10 17.00
11901 04 Y I
11920 09 Y M Y Y
11921 04 N I 63.57
11922 04 N I 16.13
11950 09 Y M
11951 09 Y M
11952 09 Y M
11954 09 Y M
11960 04 N M Y 350.05
11970 04 N M 475.70
11971 04 N I Y Y 135.00
Wednesday, April 01, 2009 Page 20 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
11975 04 N I 108.00
11976 04 N I 108.00
11977 04 N I 108.00
11980 04 N M 108.00
11981 04 N I 72.30
11982 04 N I 87.00
11983 04 N I 108.00
12001 04 N I Y 53.10 17.00
12002 04 N I 58.40 17.00
12004 04 N I 69.70 17.00
12005 04 N I 100.40 17.00
12006 04 N I 145.80 17.00
12007 04 Y M
12011 04 N I 56.40 17.00
12013 04 N I 64.00 17.00
12014 04 N I 112.90 17.00
12015 04 N I 125.50 17.00
12016 04 N I 200.75 17.00
12017 04 N M 259.20 17.00
12018 04 N M 272.63
12020 04 N I 139.30 17.00
Wednesday, April 01, 2009 Page 21 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
12021 04 N I 88.70 17.00
12031 04 N I 64.70 17.00
12032 04 N I 81.60 17.00
12034 04 N I 106.65 17.00
12035 04 N I 144.30 17.00
12036 04 N M 194.50 17.00
12037 04 N M 261.12
12041 04 N I 72.10 17.00
12042 04 N I 94.10 17.00
12044 04 N I 119.20 17.00
12045 04 N I 156.85 17.00
12046 04 N M 207.10 17.00
12047 04 N M 270.45
12051 04 N I 74.70 17.00
12052 04 N I 94.10 17.00
12053 04 N I 112.90 17.00
12054 04 N I 131.80 17.00
12055 04 N I 169.40 17.00
12056 04 N M 219.60 17.00
12057 04 N M 305.68
13100 04 N I 110.04
Wednesday, April 01, 2009 Page 22 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
13101 04 N I 127.57
13102 04 Y I
13120 04 N I 114.98
13121 04 N I 138.55
13122 04 Y I
13131 04 N I 127.85
13132 04 N I 178.18
13133 04 Y I
13150 04 N I 150.67
13151 04 N I 160.83
13152 04 N I 205.55
13153 04 Y I
13160 04 N M Y 295.88
14000 04 N M 224.25
14001 04 N M 291.69
14020 04 N M Y 244.40
14021 04 N M Y 328.07
14040 04 N M Y 277.07
14041 04 N M Y 375.10
14060 04 N M Y 299.29
14061 04 N M Y 405.20
Wednesday, April 01, 2009 Page 23 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
14300 04 N M Y 389.59
14350 04 N M 270.20
15002 04 1/1/2007 Y M Y
15003 04 1/1/2007 Y M Y
15004 04 1/1/2007 Y M Y
15005 04 1/1/2007 Y M Y
15040 04 N M 71.01
15050 04 N M Y 131.80
15100 04 N M Y 263.55
15101 04 Y M Y Y
15110 04 N M 71.01
15111 04 N M Y 71.00
15115 04 N M Y 382.21
15116 04 N M Y 84.01
15120 04 N M Y 307.90
15121 04 Y M Y
15130 04 N M Y 297.44
15131 04 N M Y 50.11
15135 04 N M Y 414.03
15136 04 N M Y 50.41
15150 04 N M Y 330.87
Wednesday, April 01, 2009 Page 24 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
15151 04 N M Y 66.75
15152 04 N M Y 83.39
15155 04 N M Y 354.66
15156 04 N M Y 92.48
15157 04 N M Y 100.77
15170 04 N M Y 167.63
15171 04 N M Y 50.29
15175 04 N M Y 249.07
15176 04 N M Y 79.42
15200 04 N M Y 318.60
15201 04 Y M Y
15220 04 N M Y 307.90
15221 04 Y M Y
15240 04 N M Y 308.96
15241 04 Y M Y
15260 04 N M Y 332.72
15261 04 Y M Y
15300 04 N M Y 141.69
15301 04 N M Y 32.90
15320 04 N M Y 165.11
15321 04 N M Y 49.16
Wednesday, April 01, 2009 Page 25 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
15330 04 N M Y 141.50
15331 04 N M Y 32.90
15335 04 N M Y 158.29
15336 04 N M Y 47.01
15340 04 N M Y 143.60
15341 04 N M Y 16.19
15360 04 N M Y 153.62
15361 04 N M Y 37.29
15365 04 N M Y 162.56
15366 04 N M Y 46.85
15400 04 N M Y 165.30
15401 04 Y M Y Y
15420 04 N M Y 183.07
15421 04 N M Y 49.73
15430 04 N M Y 267.39
15431 04 Y M Y
15570 04 N M Y 298.24
15572 04 N M Y 292.34
15574 04 N M Y 466.61
15576 04 N M Y 296.30
15600 04 N M Y 259.81
Wednesday, April 01, 2009 Page 26 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
15610 04 N M Y 97.47
15620 04 N M Y 158.26
15630 04 N M Y 310.61
15650 04 N M Y 168.27
15731 04 1/1/2007 N M Y 168.27
15732 04 N M Y Y 536.60
15734 04 N M Y Y 569.25
15736 04 N M Y 512.70
15738 04 N M Y 520.25
15740 04 N M Y 321.69
15750 04 N M Y 339.54
15756 04 N M Y Y 1,306.65
15757 04 N M Y Y 1,306.65
15758 04 N M Y Y 1,306.65
15760 04 N M Y 300.05
15770 04 N M Y 307.90
15775 09 Y M
15776 09 Y M
15780 09 Y M
15781 09 Y M
15782 09 Y M
Wednesday, April 01, 2009 Page 27 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
15783 09 Y M
15786 09 Y I
15787 09 Y M
15819 04 N M Y 274.36
15820 04 N M 651.10
15821 04 N M 651.10
15822 04 N M 651.10
15823 04 N M 651.10
15830 04 1/1/2007 Y M Y
15832 04 N M 340.15
15833 04 N M 306.75
15834 04 N M 308.30
15835 04 N M 319.10
15836 04 N M 265.30
15837 04 N M 255.00
15838 04 N M Y 219.35
15839 04 N M Y 237.80
15840 04 N M Y 891.10
15841 04 N M Y 663.96
15842 04 N M Y 1,063.03
15845 04 N M Y 355.83
Wednesday, April 01, 2009 Page 28 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
15847 04 1/1/2007 Y M Y
15850 04 N I 31.40
15851 04 N I 48.60
15852 04 N I Y 31.95
15860 04 N I Y 55.50
15876 04 Y M
15877 04 Y M
15878 04 Y M
15879 04 Y M
15920 04 N M Y 374.55
15922 04 N M Y 449.50
15931 04 N M Y Y 449.50
15933 04 N M Y 674.20
15934 04 N M Y Y 749.20
15935 04 N M Y Y 749.20
15936 04 N M Y 749.20
15937 04 N M Y Y 749.20
15940 04 N M Y 449.50
15941 04 N M Y 524.40
15944 04 N M Y 524.40
15945 04 N M Y 600.00
Wednesday, April 01, 2009 Page 29 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
15946 04 N M Y 674.20
15950 04 N M Y 449.50
15951 04 N M Y 524.40
15952 04 N M Y 524.40
15953 04 N M Y 599.35
15956 04 N M Y 727.40
15958 04 N M Y 727.40
15962 04 Y M Y Y
15963 04 Y M Y Y
15999 04 Y M Y Y
16000 04 N I Y 45.80
16020 04 N I 24.90 17.00
16025 04 N I 49.50 34.00
16030 04 N I 61.65 34.00
16035 04 N M 92.79 34.00
16036 04 N M 36.74
17000 04 N I 52.70
17003 04 N I 8.85 13 115.05
17004 04 N I Y 86.59
17106 04 N I 125.35
17107 04 N M 238.80
Wednesday, April 01, 2009 Page 30 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
17108 04 N M 372.30
17110 04 N I 74.90
17111 04 N I 43.05
17250 04 N I 18.90
17260 04 N I 40.60
17261 04 N I 60.70
17262 04 N I 80.85
17263 04 N I 100.90
17264 04 N I 117.55
17266 04 N M 162.00
17270 04 N I 45.25
17271 04 N I 64.50
17272 04 N I 85.60
17273 04 N I 106.75
17274 04 N I 117.20
17276 04 N M 162.00
17280 04 N I 96.20
17281 04 N I 127.70
17282 04 N M 171.30
17283 04 N M 213.60
17284 04 N M 257.10
Wednesday, April 01, 2009 Page 31 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
17286 04 Y I
17311 04 1/1/2007 N M 216.00
17312 04 1/1/2007 Y M
17313 04 1/1/2007 Y M
17314 04 1/1/2007 Y M
17315 04 1/1/2007 Y M
17340 04 N I 26.20
17360 04 N I 38.65
17380 04 Y I
17999 04 Y M Y Y
19000 04 N I 37.40
19001 04 N I 17.80
19020 04 N I 135.90
19030 04 N I 102.50
19100 04 N I 59.60
19101 04 N M 192.85 34.00
19102 04 N M 164.85 34.00
19103 04 N M 324.90 34.00
19105 04 1/1/2007 Y M
19110 04 N M 240.00 34.00
19112 04 N M 240.00
Wednesday, April 01, 2009 Page 32 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
19120 04 N M 240.00 34.00
19125 04 N M 240.00
19126 04 N M 74.45
19260 04 N M Y 430.64
19271 04 N M Y 534.45
19272 04 N M Y 598.34
19290 04 N I 59.40
19291 04 N I 27.00
19295 04 N I 63.10
19296 04 N I 109.01
19297 04 N I 109.01
19298 04 N I 109.01
19300 04 1/1/2007 N M Y 374.55
19301 04 1/1/2007 N M Y 310.80
19302 04 1/1/2007 N M Y 601.45
19303 04 1/1/2007 N M Y 461.95
19304 04 1/1/2007 N M Y 574.35
19305 04 1/1/2007 N M Y 787.95
19306 04 1/1/2007 N M Y 948.90
19307 04 1/1/2007 N M Y 738.10
19316 04 N M Y 567.10
Wednesday, April 01, 2009 Page 33 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
19318 04 N M Y 374.60
19324 04 N M Y 567.10
19325 04 N M Y 567.10
19328 04 N M Y 240.00
19330 04 N M Y 240.00
19340 04 N M Y 310.80
19342 04 N M Y 354.20
19350 04 N M Y 310.55
19355 04 N M Y Y 275.00
19357 04 N M Y 532.30
19361 04 N M Y 609.80
19364 04 N M Y 558.15
19366 04 N M Y 558.15
19367 04 N M Y Y 755.20
19368 04 N M Y 1,306.65
19369 04 N M Y 852.25
19370 04 N M Y 242.70
19371 04 N M Y 297.00
19380 04 N M Y 280.40
19396 04 N M 136.88
19499 04 Y M Y
Wednesday, April 01, 2009 Page 34 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
20000 04 N I 59.80 17.00
20005 04 N I 125.50 17.00
20100 04 N M Y 372.65
20101 04 N M Y 599.35
20102 04 N M Y 480.00
20103 04 N M Y 189.37 34.00
20150 04 Y M Y
20200 04 N I 113.60 17.00
20205 04 N M 252.35 17.00
20206 04 N I 53.50 17.00
20220 04 N I 90.10
20225 04 N I 187.30 34.00
20240 04 N M 220.55
20245 04 N M 289.90
20250 04 N M 163.05
20251 04 N M 277.50
20500 04 N I 61.40
20501 04 N I 105.90
20520 04 N M 107.00 17.00
20525 04 N M 167.80
20526 04 N I 31.35
Wednesday, April 01, 2009 Page 35 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
20550 04 N I 31.75
20551 04 N I 31.75
20552 04 N I 31.75
20553 04 N I 31.75
20555 04 1/1/2008 N I 176.10
20600 04 N I 30.40 17.00
20605 04 N I 33.00 17.00
20610 04 N I 31.80 17.00
20612 04 N I 31.80
20615 04 N I 73.35
20650 04 N I Y 141.50
20660 04 N M Y 192.85
20661 04 N M 192.85
20662 04 N I 203.85
20663 04 N I 170.05
20664 04 N M Y 271.45
20665 04 N I 134.60
20670 04 N I 134.60
20680 04 N M Y 233.00
20690 04 N I Y Y 172.80
20692 04 N I Y 297.00
Wednesday, April 01, 2009 Page 36 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
20693 04 N I Y 243.00
20694 04 N I Y 152.95
20696 04 1/1/2009 N M Y 332.64
20697 04 1/1/2009 N I 349.27
20802 04 Y M Y Y
20805 04 Y M Y Y
20808 04 Y M Y Y
20816 04 Y M Y Y
20822 04 Y M Y Y
20824 04 Y M Y Y
20827 04 Y M Y Y
20838 04 Y M Y Y
20900 04 N M Y Y 224.70
20902 04 N M Y Y 374.55
20910 04 Y M Y Y
20912 04 Y M Y Y
20920 04 N M Y Y 168.10
20922 04 N M Y Y 231.10
20924 04 N M Y Y 212.90
20926 04 Y M Y Y
20930 09 Y M
Wednesday, April 01, 2009 Page 37 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
20931 09 Y M
20936 09 Y M
20937 09 Y M
20938 09 Y M
20950 04 N I 44.80
20955 04 Y M Y Y
20956 04 Y M Y Y
20957 04 Y M Y Y
20962 04 Y M Y Y
20969 04 Y M Y Y
20970 04 Y M Y Y
20972 04 Y M Y Y
20973 04 Y M Y Y
20974 09 Y M
20975 04 N I Y 82.90
20979 04 N I 176.70
20982 04 N M Y 220.57
20985 04 1/1/2008 N M Y 83.23
20999 04 Y M Y
21010 04 N M Y 374.55
21015 04 N M Y 224.36
Wednesday, April 01, 2009 Page 38 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21025 04 N M Y Y 299.70
21026 04 N M Y Y 299.70
21029 04 Y M Y
21030 04 N M Y 299.70
21031 04 N M Y 299.70
21032 04 N M Y 299.70
21034 04 N M Y 421.10
21040 04 N M Y 299.70
21044 04 N M Y 350.55
21045 04 N M Y Y 1,678.65
21046 04 N M Y Y 397.20
21047 04 Y M Y Y
21048 04 Y M Y Y
21049 04 Y M Y Y
21050 04 N M Y 524.40
21060 04 N M Y 524.40
21070 04 N M Y 299.70
21073 04 1/1/2008 N M Y 188.93
21076 04 Y I
21077 04 Y I
21079 04 Y I
Wednesday, April 01, 2009 Page 39 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21080 04 Y I
21081 04 Y I
21082 04 Y I
21083 04 Y I
21084 04 Y I
21085 04 Y I
21086 04 Y I
21087 04 Y I
21088 04 Y I
21089 04 Y I
21100 04 N M 192.85
21110 04 N M Y 176.70
21116 04 N I 73.20
21120 04 N M Y Y 1,198.70
21121 04 N M Y Y 1,198.70
21122 04 N M Y Y 1,414.70
21123 04 N M Y Y 1,522.70
21125 04 N M Y Y 1,198.70
21127 04 N M Y Y 1,306.65
21137 04 N M Y Y 958.60
21138 04 N M Y Y 1,198.70
Wednesday, April 01, 2009
Page 40 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21139 04 N M Y Y 1,522.70
21141 04 N M Y Y 1,198.70
21142 04 N M Y Y 1,306.65
21143 04 N M Y Y 1,414.70
21145 04 N M Y Y 1,306.65
21146 04 N M Y Y 1,522.70
21147 04 N M Y Y 1,522.70
21150 04 N M Y Y 1,306.65
21151 04 N M Y Y 1,522.70
21154 04 N M Y Y 1,306.65
21155 04 N M Y Y 1,522.70
21159 04 N M Y Y 1,522.70
21160 04 N M Y Y 1,522.70
21172 04 N M Y Y 1,522.70
21175 04 N M Y Y 1,522.70
21179 04 N M Y Y 1,414.70
21180 04 N M Y Y 1,522.70
21181 04 N M Y Y 958.60
21182 04 N M Y Y 1,522.70
21183 04 N M Y Y 1,522.70
21184 04 N M Y Y 1,630.70
Wednesday, April 01, 2009 Page 41 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21188 04 N M Y Y 1,306.65
21193 04 N M Y Y 1,198.70
21194 04 N M Y Y 1,414.70
21195 04 N M Y Y 1,198.70
21196 04 N M Y Y 1,198.70
21198 04 N M Y Y 958.60
21199 04 N M Y Y 700.70
21206 04 N M Y 1,198.70
21208 04 N M Y Y 1,198.70
21209 04 N M Y Y 1,198.70
21210 04 N M Y Y 636.80
21215 04 N M Y Y 1,048.85
21230 04 N M Y Y 957.25
21235 04 N M Y Y 449.50
21240 04 N M Y Y 599.35
21242 04 N M Y Y 599.35
21243 04 N M Y Y 1,198.70
21244 04 N M Y Y 1,198.70
21245 04 N M Y Y 1,198.70
21246 04 N M Y Y 1,198.70
21247 04 N M Y Y 1,306.65
Wednesday, April 01, 2009 Page 42 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21248 04 N M Y Y 1,198.70
21249 04 N M Y Y 1,198.70
21255 04 N M Y Y 1,306.65
21256 04 N M Y Y 1,306.65
21260 04 N M Y Y 1,306.65
21261 04 N M Y Y 1,522.70
21263 04 N M Y Y 1,522.70
21267 04 N M Y Y 1,306.65
21268 04 N M Y Y 1,522.70
21270 04 N M Y Y 1,048.85
21275 04 N M Y Y 1,048.85
21280 04 N M Y Y 359.30
21282 04 N M Y Y 359.30
21295 04 N M Y Y 449.50
21296 04 N M Y Y 449.50
21299 04 Y M Y Y
21310 04 N I 138.75
21315 04 N M 176.20
21320 04 N M 280.25
21325 04 N M Y 337.10
21330 04 N M Y 424.45
Wednesday, April 01, 2009 Page 43 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21335 04 N M Y 571.60
21336 04 N M Y 337.10
21337 04 N M Y Y 224.70
21338 04 N M Y Y 334.40
21339 04 N M Y Y 457.70
21340 04 N M Y Y 749.20
21343 04 N M Y 898.95
21344 04 N M Y 1,048.85
21345 04 N M Y Y 749.20
21346 04 N M Y Y 749.20
21347 04 N M Y Y 766.90
21348 04 N M Y 954.20
21355 04 N M Y 149.80
21356 04 N M Y 539.65
21360 04 N M Y 539.65
21365 04 N M Y Y 689.50
21366 04 N M Y Y 954.20
21385 04 N M Y Y 599.35
21386 04 N M Y Y 599.35
21387 04 N M Y Y 749.20
21390 04 N M Y Y 861.50
Wednesday, April 01, 2009 Page 44 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21395 04 N M Y Y 861.50
21400 04 N I 149.80
21401 04 N M Y 224.70
21406 04 N M Y 599.35
21407 04 N M Y 749.20
21408 04 N M Y 749.20
21421 04 N M Y 457.70
21422 04 N M Y 678.40
21423 04 N M Y 828.20
21431 04 N M Y 524.40
21432 04 N M Y 749.20
21433 04 N M Y Y 898.95
21435 04 N M Y Y 1,048.85
21436 04 N M Y 1,048.85
21440 04 N M 374.55
21445 04 N M Y 599.35
21450 04 N I 117.60
21451 04 N M Y Y 498.10
21452 04 N I Y Y 112.40
21453 04 N M Y Y 498.10
21454 04 N M Y Y 498.10
Wednesday, April 01, 2009 Page 45 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21461 04 N M Y 706.15
21462 04 N M Y 706.15
21465 04 N M Y 498.10
21470 04 N M Y 885.20
21480 04 N M 240.00
21485 04 N M 240.00
21490 04 N M Y 749.20
21495 04 N M Y 449.50
21497 04 N M 149.80
21499 04 Y M Y
21501 04 N I 115.30 17.00
21502 04 N M 224.70
21510 04 N M 224.70
21550 04 N I 99.10 17.00
21555 04 N I 124.00 17.00
21556 04 N I 158.50
21557 04 Y M Y Y
21600 04 N M Y 299.70
21610 04 N M Y 399.50
21615 04 N M Y 449.50
21616 04 N M Y 599.35
Wednesday, April 01, 2009 Page 46 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21620 04 N M Y 250.40
21627 04 Y M Y
21630 04 N M Y Y 749.20
21632 04 N M Y Y 749.20
21685 04 N M Y 491.50
21700 04 N M Y 374.55
21705 04 N M Y 449.50
21720 04 N M Y 577.10
21725 04 N M Y 599.35
21740 04 N M Y 898.95
21742 04 N M Y 898.95
21743 04 N M Y 898.95
21750 04 N M Y 368.20
21800 04 N I 52.70
21805 04 N I 111.00
21810 04 N M Y 242.40
21820 04 N I 74.90
21825 04 N M 374.55
21899 04 Y M
21920 04 N I 113.50 17.00
21925 04 N M 180.20 17.00
Wednesday, April 01, 2009 Page 47 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
21930 04 N M 149.80
21935 04 Y M Y Y
22010 04 N M Y 453.30
22015 04 N M Y 449.25
22100 04 N M Y 311.40
22101 04 N M Y 315.50
22102 04 N M Y 299.70
22103 04 Y M Y Y
22110 04 N M Y 718.70
22112 04 N M Y 718.70
22114 04 N M Y 718.70
22116 04 Y M Y Y
22206 04 1/1/2008 N M Y Y 1270.13
22207 04 1/1/2008 N M Y Y 1253.30
22208 04 1/1/2008 N M Y Y 325.80
22210 04 N M Y Y 973.90
22212 04 N M Y Y 973.90
22214 04 N M Y Y 973.90
22216 04 Y M Y Y
22220 04 N M Y Y 973.90
22222 04 N M Y Y 973.90
Wednesday, April 01, 2009 Page 48 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
22224 04 N M Y Y 973.90
22226 04 Y M Y Y
22305 04 N M 259.40
22310 04 N I 98.80
22315 04 N M 276.20
22318 04 N M Y Y 1,417.20
22319 04 N M Y Y 1,558.90
22325 04 N M Y 599.35
22326 04 N M Y 627.30
22327 04 N M Y 608.50
22328 04 Y M Y Y
22505 04 N I 149.80
22520 04 N M Y Y 353.85
22521 04 N M Y 331.90
22522 04 N M Y 116.00
22523 04 N M Y 343.13
22524 04 N M Y 328.66
22525 04 N M Y 158.82
22526 04 1/1/2007 N M 509.95
22527 04 1/1/2007 Y M
22532 04 N M Y 876.68
Wednesday, April 01, 2009 Page 49 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
22533 04 N M Y 816.43
22534 04 N M Y 208.02
22548 04 N M Y 1,642.15
22554 04 N M Y Y 1,642.65
22556 04 N M Y Y 1,642.65
22558 04 N M Y Y 1,642.65
22585 04 Y M Y Y
22590 04 N M Y Y 1,198.70
22595 04 N M Y Y 1,198.70
22600 04 N M Y Y 1,198.70
22610 04 N M Y Y 1,198.70
22612 04 N M Y Y 1,198.70
22614 04 Y M Y Y
22630 04 N M Y Y 1,198.70
22632 04 Y M Y Y
22800 04 N M Y Y 1,086.30
22802 04 N M Y Y 1,086.30
22804 04 N M Y Y 1,782.30
22808 04 N M Y Y 1,086.30
22810 04 N M Y Y 1,086.30
22812 04 N M Y Y 1,086.30
Wednesday, April 01, 2009 Page 50 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
22818 04 N M Y Y 1,610.65
22819 04 N M Y Y 1,610.65
22830 04 N M Y Y 443.39
22840 04 N M Y Y 1,872.90
22841 04 N M Y Y 1,872.90
22842 04 N M Y Y 1,872.90
22843 04 N M Y Y 1,872.90
22844 04 N M Y Y 1,872.90
22845 04 N M Y Y 1,872.90
22846 04 N M Y Y 1,872.90
22847 04 N M Y Y 1,872.90
22848 04 N M Y Y 351.00
22849 04 N M Y Y 1,134.10
22850 04 N M Y 449.50
22851 04 N M Y Y 750.70
22852 04 N M Y Y 449.50
22855 04 N M Y 449.50
22856 04 1/1/2009 N M Y Y 925.00
22857 04 1/1/2007 N M Y 938.71
22861 04 1/1/2009 N M Y Y 1121.33
22862 04 1/1/2007 N M Y 1104.45
Wednesday, April 01, 2009 Page 51 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
22864 04 1/1/2009 N M Y 1051.39
22865 04 1/1/2007 N M Y 1166.35
22899 04 Y M Y Y
22900 04 N M Y 224.70
22999 04 Y M Y
23000 04 N M Y 359.30
23020 04 N M Y 299.70
23030 04 N I 125.50 17.00
23031 04 N I 99.10 17.00
23035 04 N M Y 317.40
23040 04 N M Y 599.35
23044 04 N M Y 599.35
23065 04 N I 113.60 17.00
23066 04 N I 149.25 17.00
23075 04 N M 224.70
23076 04 N M Y 449.50
23077 04 Y M Y Y
23100 04 N M Y 374.55
23101 04 N M Y 599.35
23105 04 N M Y 599.35
23106 04 N M Y 599.35
Wednesday, April 01, 2009 Page 52 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
23107 04 N M Y Y 473.50
23120 04 N M Y 362.00
23125 04 N M Y 718.70
23130 04 N M Y 362.00
23140 04 N M Y 264.90
23145 04 N M Y 480.00
23146 04 N M Y 480.00
23150 04 N M Y 275.80
23155 04 N M Y 480.00
23156 04 N M Y 480.00
23170 04 N M Y 240.00
23172 04 N M Y 240.00
23174 04 N M Y 480.00
23180 04 N M Y 299.70
23182 04 N M Y 480.00
23184 04 N M Y 480.00
23190 04 N M Y 480.00
23195 04 N M Y 599.35
23200 04 N M Y 718.70
23210 04 N M Y 718.70
23220 04 N M Y 718.70
Wednesday, April 01, 2009 Page 53 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
23221 04 N M Y 839.35
23222 04 N M Y 1,048.85
23330 04 N I 17.00 107.00
23331 04 N M Y 233.00
23332 04 Y M
23350 04 N I 88.30
23395 04 N M Y 501.35
23397 04 N M Y 599.35
23400 04 N M Y 839.35
23405 04 N M Y 299.70
23406 04 N M Y 449.50
23410 04 N M Y 779.70
23412 04 N M Y 779.70
23415 04 N M Y 674.20
23420 04 N M Y 674.20
23430 04 N M Y 449.50
23440 04 N M Y 449.50
23450 04 N M Y 839.35
23455 04 N M Y 839.35
23460 04 N M Y 839.35
23462 04 N M Y 839.35
Wednesday, April 01, 2009 Page 54 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
23465 04 N M Y 733.85
23466 04 N M Y 584.40
23470 04 N M Y 839.35
23472 04 N M Y 1,498.30
23480 04 N M Y 480.00
23485 04 N M Y 486.90
23490 04 N M Y Y 379.40
23491 04 N M Y Y 464.45
23500 04 N I 112.40
23505 04 N M 187.30
23515 04 N M Y 419.00
23520 04 N I 112.40
23525 04 N M 162.30
23530 04 N M Y 720.00
23532 04 N I Y 786.60
23540 04 N I 112.40
23545 04 N M 228.90
23550 04 N M Y 503.60
23552 04 N M Y 561.85
23570 04 N I 79.60
23575 04 N M 241.35
Wednesday, April 01, 2009 Page 55 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
23585 04 N M Y 449.50
23600 04 N M 194.20
23605 04 N M 277.50
23615 04 N M Y 545.25
23616 04 N M Y 975.25
23620 04 N I 111.00
23625 04 N M 163.70
23630 04 N M Y 524.40
23650 04 N M 178.90
23655 04 N M 255.20
23660 04 N M Y 419.00
23665 04 N M 206.70
23670 04 N M Y 842.10
23675 04 N M 299.70
23680 04 N M Y 599.35
23700 04 N M 194.20
23800 04 N M Y 839.35
23802 04 N M Y 839.35
23900 04 N M Y 1198.70
23920 04 N M Y 1048.85
23921 04 N M Y 224.70
Wednesday, April 01, 2009 Page 56 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
23929 04 Y M Y
23930 04 N M 179.70 17.00
23931 04 N I 141.30 17.00
23935 04 N M Y 240.00
24000 04 N M Y 299.70
24006 04 N M Y 380.15
24065 04 N I 113.60 17.00
24066 04 N M Y 264.25 17.00
24075 04 N M 149.80
24076 04 N M Y 224.70
24077 04 Y M Y Y
24100 04 N M Y 299.70
24101 04 N M Y 480.00
24102 04 N M Y 524.40
24105 04 N M 380.15
24110 04 N M Y 527.20
24115 04 N M Y 749.20
24116 04 N M Y 749.20
24120 04 N M Y 449.50
24125 04 N M Y 749.20
24126 04 N M Y 749.20
Wednesday, April 01, 2009 Page 57 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
24130 04 N M Y 492.55
24134 04 N M Y 351.00
24136 04 N M Y 262.80
24138 04 N M Y 254.80
24140 04 N M Y 480.00
24145 04 N M Y 480.00
24147 04 N M Y 480.00
24149 04 Y M Y
24150 04 N M Y 1198.70
24151 04 N M Y 1198.70
24152 04 N M Y 958.60
24153 04 N M Y 1048.85
24155 04 N M Y 749.20
24160 04 N M Y 299.70
24164 04 N M 492.55
24200 04 N M 169.30
24201 04 N M Y 245.55
24220 04 N I 105.15
24300 04 N I 66.70
24301 04 N M Y 453.70
24305 04 N M Y 359.30
Wednesday, April 01, 2009 Page 58 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
24310 04 N M Y 188.70
24320 04 N M Y 599.35
24330 04 N M Y 599.35
24331 04 N M Y 599.35
24332 04 N M Y 326.30
24340 04 N M Y 299.70
24341 04 N M Y 274.20
24342 04 N M Y 535.45
24343 04 N M Y 430.15
24344 04 N M Y 651.95
24345 04 N M Y 430.15
24346 04 N M Y 651.95
24357 04 1/1/2008 N M Y 233.94
24358 04 1/1/2008 N M Y 275.71
24359 04 1/1/2008 N M Y 341.04
24360 04 N M Y 718.70
24361 04 N M Y 1123.70
24362 04 N M Y 1123.70
24363 04 N M Y 1123.70
24365 04 N M Y 1123.70
24366 04 N M Y 1123.70
Wednesday, April 01, 2009 Page 59 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
24400 04 N M Y 541.05
24410 04 N M Y 481.65
24420 04 N M Y 898.95
24430 04 N M Y 636.80
24435 04 N M Y 958.60
24470 04 N M Y 374.55
24495 04 N M Y 299.70
24498 04 N M Y Y 491.50
24500 04 N M 153.95
24505 04 N M 295.50
24515 04 N M Y 624.30
24516 04 N M Y 624.30
24530 04 N M 299.70
24535 04 N M 334.40
24538 04 N M Y 405.10
24545 04 N M Y 718.70
24546 04 N M Y 718.70
24560 04 N M 199.75
24565 04 N M 242.80
24566 04 N M Y 257.30
24575 04 N M Y 718.70
Wednesday, April 01, 2009 Page 60 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
24576 04 N M 188.70
24577 04 N M 245.55
24579 04 N M Y 718.70
24582 04 N M Y 405.10
24586 04 N M Y 480.65
24587 04 N M Y 1123.70
24600 04 N M 208.05
24605 04 N M 242.80
24615 04 N M Y 419.00
24620 04 N M 259.40
24635 04 N M Y 482.80
24640 04 N M 180.30
24650 04 N I 142.90
24655 04 N M Y 208.05
24665 04 N M Y 400.90
24666 04 N M Y 449.50
24670 04 N M 181.65
24675 04 N M 206.70
24685 04 N M Y 556.35
24800 04 N M Y 718.70
24802 04 N M Y 839.35
Wednesday, April 01, 2009 Page 61 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
24900 04 N M Y 313.50
24920 04 N M Y 595.20
24925 04 N M Y 262.20
24930 04 N M Y 595.20
24931 04 N M Y 674.20
24935 04 N M Y 599.35
24940 04 N M Y 621.10
24999 04 Y M Y
25000 04 N M Y 351.00
25001 04 N M Y 207.95
25020 04 N M Y 388.50
25023 04 N M Y 394.80
25024 04 N M Y 458.20
25025 04 N M Y 588.15
25028 04 N I 179.25 17.00
25031 04 N M 232.55 17.00
25035 04 N M 287.60
25040 04 N M Y 480.00
25065 04 N I 113.60 17.00
25066 04 N I 149.25 17.00
25075 04 N M Y 149.80
Wednesday, April 01, 2009 Page 62 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
25076 04 N M Y 262.20
25077 04 Y M Y Y
25085 04 N M Y 262.20
25100 04 N M Y 419.00
25101 04 N M Y 480.00
25105 04 N M Y 480.00
25107 04 N M Y 480.00
25109 04 1/1/2007 N M Y 240.00
25110 04 N M 217.80
25111 04 N M 214.00 34.00
25112 04 N M 214.00 34.00
25115 04 N M Y 599.35
25116 04 N M Y 599.35
25118 04 N M Y 480.00
25119 04 N M Y 659.00
25120 04 N M Y 599.35
25125 04 N M Y 674.20
25126 04 N M Y 674.20
25130 04 N M Y 299.70
25135 04 N M Y 449.50
25136 04 N M Y 449.50
Wednesday, April 01, 2009 Page 63 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
25145 04 N M Y 359.30
25150 04 N M Y 359.30
25151 04 N M Y 359.30
25170 04 Y M Y
25210 04 N M Y 480.00
25215 04 N M Y 480.00
25230 04 N M Y 299.70
25240 04 N M Y 359.30
25246 04 N I 96.90
25248 04 N M 181.25
25250 04 N M 224.70
25251 04 N M 339.50
25259 04 N M 230.15
25260 04 N M Y 283.50
25263 04 N M Y 302.60
25265 04 N M Y 484.20
25270 04 N M Y 369.05
25272 04 N M Y 256.85
25274 04 N M Y 359.30
25275 04 N M Y 442.50
25280 04 N M Y 359.30
Wednesday, April 01, 2009 Page 64 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
25290 04 N M Y 302.40
25295 04 N M Y 277.50
25300 04 N M Y 359.30
25301 04 N M Y 359.30
25310 04 N M Y 480.00
25312 04 N M Y 524.40
25315 04 N M Y 480.00
25316 04 N M Y 524.40
25320 04 N M Y 449.50
25332 04 N M Y 749.20
25335 04 N M Y 749.20
25337 04 N M Y 718.70
25350 04 N M Y 374.55
25355 04 N M Y 480.00
25360 04 N M Y 316.10
25365 04 N M Y 561.85
25370 04 N M Y 480.00
25375 04 N M Y 524.40
25390 04 N M Y 599.35
25391 40 N M Y 898.95
25392 04 N M Y 898.95
Wednesday, April 01, 2009 Page 65 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
25393 04 N M Y 898.95
25394 04 N M Y 514.80
25400 04 N M Y 524.40
25405 04 N M Y 599.35
25415 04 N M Y 488.00
25420 04 N M Y 839.35
25425 04 N M Y 599.35
25426 04 N M Y 749.20
25430 04 N M Y 451.90
25431 04 N M Y 449.10
25440 04 N M Y 599.35
25441 04 N M Y 659.00
25442 04 N M Y 659.00
25443 04 N M Y 749.20
25444 04 N M Y 749.20
25445 04 N M Y 749.20
25446 04 N M Y 898.95
25447 04 Y M Y
25449 04 N M Y 659.00
25450 04 N M Y 299.70
25455 04 N M Y 449.50
Wednesday, April 01, 2009 Page 66 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
25490 04 N M Y Y 356.50
25491 04 N M Y Y 365.60
25492 04 N M Y Y 459.05
25500 04 N I 112.40
25505 04 N M 210.90
25515 04 N M Y 554.90
25520 04 N M 267.80
25525 04 N M Y 443.95
25526 04 N M Y 592.40
25530 04 N M 199.75
25535 04 N M 240.00
25545 04 N M Y 538.20
25560 04 N M 176.20
25565 04 N M 292.60
25574 04 N M Y 538.20
25575 04 N M Y 592.40
25600 04 N M 155.35
25605 04 N M 294.10
25606 04 1/1/2007 N M 301.00
25607 04 1/1/2007 N M 443.95
25608 04 1/1/2007 N M 443.95
Wednesday, April 01, 2009 Page 67 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
25609 04 1/1/2007 N M 443.95
25622 04 N I 147.10
25624 04 N I 181.10
25628 04 N M Y 335.70
25630 04 N M 201.10
25635 04 N I 174.60
25645 04 N M Y 335.70
25650 04 N I Y Y 126.90
25651 04 N M Y 271.25
25652 04 N M Y 374.00
25660 04 N I 139.00
25670 04 N M Y 266.70
25671 04 N M Y 205.30
25675 04 N I 168.25
25676 04 N M Y 270.40
25680 04 N M 240.00
25685 04 N M Y 449.50
25690 04 N I 188.65
25695 04 N M Y 276.50
25800 04 N M Y 718.70
25805 04 N M Y 786.60
Wednesday, April 01, 2009 Page 68 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
25810 04 N M Y 839.35
25820 04 N M Y 664.25
25825 04 N M Y 718.70
25830 04 N M Y 786.60
25900 04 N M Y 359.30
25905 04 N M Y 359.30
25907 04 N M Y 290.30
25909 04 N M Y 359.30
25915 04 N M Y 1198.70
25920 04 N M Y 359.30
25922 04 N M Y 244.50
25924 04 N M Y 359.30
25927 04 N M Y 302.60
25929 04 N M Y 236.30
25931 04 N M Y 285.80
25999 04 Y M
26010 04 N I 76.25
26011 04 N I 97.40
26020 04 N M 191.80
26025 04 N M 201.60
26030 04 N M 237.15
Wednesday, April 01, 2009 Page 69 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26034 04 N M Y 240.00
26035 04 N M Y 321.65
26037 04 N M Y 265.20
26040 04 N M Y 264.90
26045 04 N M Y 449.50
26055 04 N M Y 235.80
26060 04 N I Y 107.90
26070 04 N M Y 224.70
26075 04 N M Y 224.70
26080 04 N M Y 187.30
26100 04 N M Y 299.70
26105 04 N M Y 262.20
26110 04 N M Y 187.30
26115 04 N M Y 149.80
26116 04 N M Y 224.70
26117 04 Y M Y Y
26121 04 N M Y 449.50
26123 04 N M Y 524.40
26125 04 Y M Y
26130 04 N M Y 374.55
26135 04 N M Y 270.60
Wednesday, April 01, 2009 Page 70 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26140 04 N M Y 245.35
26145 04 N M Y 252.80
26160 04 N M Y 210.10 34.00
26170 04 N M Y 240.00
26180 04 N M Y 240.00
26185 04 Y M Y
26200 04 N M Y 299.70
26205 04 N M Y 374.55
26210 04 N M Y 224.70
26215 04 N M Y 314.95
26230 04 N M Y 299.70
26235 04 N M Y 224.70
26236 04 N M Y 204.05
26250 04 N M Y 449.50
26255 04 N M Y 524.40
26260 04 N M Y 374.55
26261 04 N M Y 449.50
26262 04 N M Y 299.70
26320 04 N M Y 233.00
26340 04 N I 139.70
26350 04 N M Y 274.40
Wednesday, April 01, 2009 Page 71 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26352 04 N M Y 480.00
26356 04 N M Y 359.30
26357 04 N M Y Y 359.30
26358 04 N M Y 599.35
26370 04 N M Y 307.20
26372 04 N M Y 480.00
26373 04 N M Y 480.00
26390 04 N M Y 480.00
26392 04 N M Y 480.00
26410 04 N M Y 222.00
26412 04 N M Y 299.70
26415 04 N M Y Y 306.95
26416 04 N M Y Y 414.90
26418 04 N M Y 201.65
26420 04 N M Y 299.70
26426 04 N M Y 480.00
26428 04 N M Y 599.35
26432 04 N M Y 359.30
26433 04 N M Y 222.00
26434 04 N M Y 359.30
26437 04 N M Y 225.10
Wednesday, April 01, 2009 Page 72 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26440 04 N M Y 417.60
26442 04 N M Y 627.05
26445 04 N M Y 240.00
26449 04 N M Y 359.30
26450 04 N M Y 240.00
26455 04 N M Y 240.00
26460 04 N M Y 240.00
26471 04 N M Y 299.70
26474 04 N M Y 359.30
26476 04 N M Y 359.30
26477 04 N M Y 359.30
26478 04 N M Y Y 359.30
26479 04 N M Y Y 359.30
26480 04 N M Y 480.00
26483 04 N M Y 480.00
26485 04 N M Y 480.00
26489 04 N M Y 561.85
26490 04 N M Y 356.60
26492 04 N M Y 449.50
26494 04 N M Y 356.60
26496 04 Y M Y
Wednesday, April 01, 2009 Page 73 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26497 04 N M Y 374.55
26498 04 N M Y 693.70
26499 04 N M Y 374.55
26500 04 N M Y 226.50
26502 04 N M Y 419.00
26508 04 N M Y 232.55
26510 04 N M Y 442.90
26514 04 Y I
26516 04 N M Y 255.00
26517 04 N M Y 374.55
26518 04 N M Y 416.20
26520 04 N M Y 262.20
26525 04 N M Y 262.20
26530 04 N M Y 289.30
26531 04 N M Y 337.10
26535 04 N M Y 524.40
26536 04 N M Y 524.40
26540 04 N M Y 346.75
26541 04 N M Y 374.55
26542 04 N M Y 374.55
26545 04 N M Y 299.70
Wednesday, April 01, 2009 Page 74 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26546 04 Y M Y
26548 04 N M Y Y 299.70
26550 04 N M Y 680.50
26551 04 Y M Y Y
26553 04 Y M Y Y
26554 04 Y M Y Y
26555 04 N M Y 571.10
26556 04 Y M Y Y
26560 04 N M Y 584.05
26561 04 N M Y 639.60
26562 04 N M Y 898.95
26565 04 N M Y 359.30
26567 04 N M Y 359.30
26568 04 N M Y 415.85
26580 04 N M Y 579.05
26587 04 N M Y Y 259.20
26590 04 N M Y 587.40
26591 04 N M Y 237.60
26593 04 N M Y 259.20
26596 04 Y M Y
26600 04 N I 93.70
Wednesday, April 01, 2009 Page 75 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26605 04 N I 138.75
26607 04 N M Y 299.70
26608 04 N M Y 299.70
26615 04 N M Y 299.70
26641 04 N M 166.40
26645 04 N M 166.40
26650 04 N M Y 240.00
26665 04 N M Y 374.55
26670 04 N I 134.25
26675 04 N I 181.55
26676 04 N M Y 262.20
26685 04 N M Y 233.30
26686 04 N M Y 280.80
26700 04 N I 107.00
26705 04 N M 166.40
26706 04 N M Y 237.85
26715 04 N M Y 274.65
26720 04 N I 97.05
26725 04 N I 130.35
26727 04 N M Y 171.00
26735 04 N M Y 263.55
Wednesday, April 01, 2009 Page 76 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26740 04 N I 97.05
26742 04 N I 150.50
26746 04 N M Y 263.55
26750 04 N I 97.05
26755 04 N I 104.10
26756 04 N M Y 224.70
26765 04 N M Y 285.80
26770 04 N I 92.50
26775 04 N I 132.45
26776 04 N M Y 224.70
26785 04 N I Y 148.60
26820 04 N M Y 310.10
26841 04 N M Y 299.70
26842 04 N M Y 374.55
26843 04 N M Y 299.70
26844 04 N M Y 374.55
26850 04 N M Y 262.20
26852 04 N M Y 301.70
26860 04 N M Y 200.65
26861 04 N M Y 90.10
26862 04 N M Y 274.60
Wednesday, April 01, 2009 Page 77 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
26863 04 N M Y 119.25
26910 04 N M Y 271.90
26951 04 N M Y 271.90
26952 04 N M Y 259.40
26989 04 Y M Y
26990 04 N I 262.45 17.00
26991 04 N I 215.80 17.00
26992 04 N M Y 418.80
27000 04 N M Y 197.00
27001 04 N M Y 202.20
27003 04 N M Y 299.70
27005 04 N M Y 274.65
27006 04 N M Y 289.20
27025 04 N M Y 374.55
27027 04 1/1/2009 N M Y 367.57
27030 04 N M Y 524.40
27033 04 N M Y 599.35
27035 04 N M Y 599.35
27036 04 Y M Y
27040 04 N I 113.60 17.00
27041 04 N I Y 258.20 17.00
Wednesday, April 01, 2009 Page 78 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27047 04 N M 224.70
27048 04 N M Y 374.55
27049 04 Y M Y Y
27050 04 N M Y 524.40
27052 04 N M Y 524.40
27054 04 N M Y 749.20
27057 04 1/1/2009 N Y 374.55
27060 04 N M Y 277.50
27062 04 N M Y 374.55
27065 04 N M Y 599.35
27066 04 N M Y 674.20
27067 04 N M Y 749.20
27070 04 N M Y 419.00
27071 04 N M Y 480.00
27075 04 N M Y 599.35
27076 04 N M Y Y 681.10
27077 04 N M Y 723.20
27078 04 N M Y 599.35
27079 04 N M Y 599.35
27080 04 N M Y 359.30
27086 04 N I 107.00 17.00
Wednesday, April 01, 2009 Page 79 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27087 04 N M Y 247.20 17.00
27090 04 N M Y 412.00
27091 04 N M Y 694.45
27093 04 N I 106.70
27095 04 N I 111.70
27096 04 N I 172.50
27097 04 N M Y 290.25
27098 04 N M Y 345.70
27100 04 N M Y 561.85
27105 04 N M Y 636.80
27110 04 N M Y 674.20
27111 04 N M Y 674.20
27120 04 N M Y 898.95
27122 04 N M Y 954.50
27125 04 N M Y 1026.65
27130 04 N M Y 1749.50
27132 04 N M Y 1798.05
27134 04 N M Y 1048.85
27137 04 N M Y 1048.85
27138 04 N M Y 1048.85
27140 04 N M Y 718.70
Wednesday, April 01, 2009 Page 80 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27146 04 N M Y 718.70
27147 04 N M Y 839.35
27151 04 N M Y 1011.40
27156 04 N M Y 1123.70
27158 04 N M Y 583.00
27161 04 N M Y 749.20
27165 04 N M Y 898.95
27170 04 N M Y 898.95
27175 04 N M Y 599.35
27176 04 N M Y 599.35
27177 04 N M Y 958.60
27178 04 N M Y 958.60
27179 04 N M Y 839.35
27181 04 N M Y 958.60
27185 04 N M Y 779.70
27187 04 N M Y Y 950.50
27193 04 N I 170.80
27194 04 N I Y 272.40
27200 04 N M 149.80
27202 04 N M Y 374.55
27215 04 N M Y 674.20
Wednesday, April 01, 2009 Page 81 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27216 04 N M Y 550.90
27217 04 N M Y 599.35
27218 04 N M Y 599.35
27220 04 N M 412.00
27222 04 N M Y 412.00
27226 04 N M Y 930.90
27227 04 N M Y 930.90
27228 04 N M Y 1198.70
27230 04 N I 179.15
27232 04 N M Y 449.50
27235 04 N M Y 674.20
27236 04 N M Y 1019.70
27238 04 N I 183.80
27240 04 N M Y 449.50
27244 04 N M Y 933.80
27245 04 N M Y 933.80
27246 04 N I 167.00
27248 04 N M Y 779.70
27250 04 N M 242.80
27252 04 N M 284.90
27253 04 N M Y 599.35
Wednesday, April 01, 2009 Page 82 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27254 04 N M Y 606.30
27256 04 N M 208.05
27257 04 N M Y 277.50
27258 04 N M Y 733.85
27259 04 N M Y 958.60
27265 04 N M 242.80
27266 04 N M Y 283.00
27267 04 1/1/2008 N M Y Y 220.82
27268 04 1/1/2008 N M Y Y 273.08
27269 04 1/1/2008 N M Y Y 655.58
27275 04 N M Y 240.00
27280 04 N M Y 958.60
27282 04 N M Y 958.60
27284 04 N M Y 898.95
27286 04 N M Y 1033.50
27290 04 N M Y Y 1678.65
27295 04 N M Y 1198.70
27299 04 Y M Y
27301 04 N M 242.10
27303 04 N M Y 298.20
27305 04 N M Y 374.55
Wednesday, April 01, 2009 Page 83 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27306 04 N M Y 374.55
27307 04 N M Y 561.85
27310 04 N M 486.90
27323 04 N I 113.60 17.00
27324 04 N M Y 264.25 17.00
27325 04 1/1/2007 N M Y 412.00
27326 04 1/1/2007 N M Y 412.00
27327 04 N I Y 156.30
27328 04 N M Y 295.50
27329 04 Y M Y Y
27330 04 N M Y 374.55
27331 04 N M Y 599.35
27332 04 N M Y 621.50
27333 04 N M Y 621.50
27334 04 N M Y 621.50
27335 04 N M Y 621.50
27340 04 N M Y 240.00
27345 04 N M Y 381.50
27347 04 N M Y 381.50
27350 04 N M Y 636.80
27355 04 N M Y 599.35
Wednesday, April 01, 2009 Page 84 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27356 04 N M Y 674.20
27357 04 N M Y 674.20
27358 04 N M Y 674.20
27360 04 N M Y 480.00
27365 04 N M Y 898.95
27370 04 N I 101.10
27372 04 N M Y 174.10
27380 04 N M Y 412.00
27381 04 N M Y 524.40
27385 04 N M Y 419.00
27386 04 N M Y 524.40
27390 04 N M Y 359.30
27391 04 N M Y 458.40
27392 04 N M Y 661.15
27393 04 N M Y 359.30
27394 04 N M Y 458.40
27395 04 N M Y 661.15
27396 04 N M Y 599.35
27397 04 N M Y 550.90
27400 04 N M Y 599.35
27403 04 N M Y Y 621.50
Wednesday, April 01, 2009 Page 85 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27405 04 N M Y 524.40
27407 04 N M Y 524.40
27409 04 N M Y 674.20
27412 04 N M 621.50
27415 04 N M 621.50
27416 04 1/1/2008 N M Y 513.32
27418 04 N M Y 486.10
27420 04 N M Y 620.10
27422 04 N M Y 620.10
27424 04 N M Y 636.80
27425 04 N M Y Y 561.85
27427 04 N M Y Y 524.40
27428 04 N M Y Y 621.10
27429 04 N M Y Y 674.20
27430 04 N M Y 561.85
27435 04 N M Y 524.40
27437 04 N M Y 599.35
27438 04 N M Y 958.60
27440 04 N M Y 599.35
27441 04 N M Y 599.35
27442 04 N M Y 881.00
Wednesday, April 01, 2009 Page 86 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27443 04 N M Y 881.00
27445 04 N M Y 1473.35
27446 04 N M Y 1473.35
27447 04 N M Y 1473.35
27448 04 N M Y 599.35
27450 04 N M Y 689.50
27454 04 N M Y 749.20
27455 04 N M Y 524.40
27457 04 N M Y 524.40
27465 04 N M Y 749.20
27466 04 N M Y 898.95
27468 04 N M Y 1198.70
27470 04 N M Y 839.35
27472 04 N M Y 958.60
27475 04 N M Y 659.00
27477 04 N M Y 659.00
27479 04 N M Y 958.60
27485 04 N M Y 561.85
27486 04 N M Y 736.60
27487 04 N M Y 1473.30
27488 04 N M 524.65
Wednesday, April 01, 2009 Page 87 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27495 04 Y M Y Y
27496 04 N M Y 374.55
27497 04 N M Y 374.55
27498 04 N M Y 383.45
27499 04 N M Y 383.45
27500 04 N M 257.40
27501 04 N M 263.20
27502 04 N M Y 338.50
27503 04 N M Y 338.50
27506 04 N M Y Y 910.10
27507 04 N M Y 910.10
27508 04 N M 209.00
27509 04 N M Y 524.40
27510 04 N M 524.40
27511 04 N M Y 836.55
27513 04 N M Y 826.30
27514 04 N M Y 836.55
27516 04 N M 599.35
27517 04 N M 599.35
27519 04 N M Y 836.55
27520 04 N M 191.50
Wednesday, April 01, 2009 Page 88 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27524 04 N M Y 629.90
27530 04 N M 288.50
27532 04 N M 321.90
27535 04 N M Y 839.35
27536 04 N M Y 839.35
27538 04 N M 213.65
27540 04 N M Y 958.60
27550 04 N M 194.25
27552 04 N M 227.40
27556 04 N M Y 656.20
27557 04 N M Y 749.20
27558 04 N M Y 749.20
27560 04 N I 149.80
27562 04 N M 187.80
27566 04 N M Y 383.25
27570 04 N I 66.70
27580 04 N M Y 1384.60
27590 04 N M Y 649.25
27591 04 N M Y 749.20
27592 04 N M Y 574.35
27594 04 N M Y 224.70
Wednesday, April 01, 2009 Page 89 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27596 04 N M Y 574.35
27598 04 N M Y 480.00
27599 04 Y M Y
27600 04 N M Y 189.80
27601 04 N M Y 190.20
27602 04 N M Y 262.20
27603 04 N M Y 211.60 17.00
27604 04 N I 156.50 17.00
27605 04 N M Y 359.30
27606 04 N M Y 359.30
27607 04 N M Y 292.30
27610 04 N M Y 480.00
27612 04 N M Y 374.55
27613 04 N I 113.60 17.00
27614 04 N I 264.25 17.00
27615 04 N M Y Y 521.56
27618 04 N I 186.90
27619 04 N M Y 268.40
27620 04 N M Y 480.00
27625 04 N M Y 480.00
27626 04 N M Y 480.00
Wednesday, April 01, 2009 Page 90 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27630 04 N M Y 188.65
27635 04 N M Y 374.55
27637 04 N M Y 599.35
27638 04 N M Y 599.35
27640 04 N M 407.80
27641 04 N M Y 335.00
27645 04 N M Y 599.35
27646 04 N M Y 599.35
27647 04 N M Y 449.50
27648 04 N I 82.75
27650 04 N M Y 359.30
27652 04 N M Y 480.00
27654 04 N M Y 449.50
27656 04 N M Y 299.70
27658 04 N M Y 224.70
27659 04 N M Y 416.20
27664 04 N M Y 182.50
27665 04 N M Y 302.40
27675 04 N M Y 239.30
27676 04 N M Y 313.20
27680 04 N M Y 381.50
Wednesday, April 01, 2009 Page 91 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27681 04 N M Y 231.00
27685 04 N M Y 262.20
27686 04 N M Y 257.00
27687 04 N M Y 262.20
27690 04 N M Y 299.70
27691 04 N M Y 524.40
27692 04 N M Y 149.80
27695 04 N M Y 374.55
27696 04 N M Y 561.85
27698 04 N M Y 453.70
27700 04 N M Y 718.70
27702 04 N M Y 749.20
27703 04 Y M Y
27704 04 N M Y 249.35
27705 04 N M Y 412.00
27707 04 N M Y 359.30
27709 04 N M Y 524.40
27712 04 N M Y 674.20
27715 04 N M Y 749.20
27720 04 N M Y 629.90
27722 04 N M Y 733.85
Wednesday, April 01, 2009 Page 92 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27724 04 N M Y 840.75
27725 04 N M Y 840.75
27726 04 1/1/2008 N M Y 478.66
27727 04 N M Y 648.10
27730 04 N M Y 412.00
27732 04 N M Y 314.95
27734 04 N M Y 599.35
27740 04 N M Y 839.35
27742 04 N M Y 839.35
27745 04 N M Y Y 378.05
27750 04 N M 208.05
27752 04 N M 320.45
27756 04 N M Y 738.10
27758 04 N M Y 839.35
27759 04 N M Y 839.35
27760 04 N M 166.40
27762 04 N M 235.80
27766 04 N M Y 535.45
27767 04 1/1/2008 N M Y 131.63
27768 04 1/1/2008 N M Y 208.32
27769 04 1/1/2008 N M Y 362.81
Wednesday, April 01, 2009 Page 93 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27780 04 N M 152.60
27781 04 N M 217.80
27784 04 N M Y 416.20
27786 04 N M 152.60
27788 04 N M 222.00
27792 04 N M Y 299.70
27808 04 N M 208.05
27810 04 N M 305.15
27814 04 N M Y 610.45
27816 04 N M 224.70
27818 04 N M 369.05
27822 04 N M Y 599.35
27823 04 N M Y 599.35
27824 04 N M Y 232.20
27825 04 N M Y 286.20
27826 04 N M Y 515.70
27827 04 N M Y 638.00
27828 04 N M Y 696.90
27829 04 N M Y 412.00
27830 04 N M 153.75
27831 04 N M 224.70
Wednesday, April 01, 2009 Page 94 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
27832 04 N M Y 599.35
27840 04 N M 138.20
27842 04 N M 208.05
27846 04 N M Y 378.70
27848 04 N M Y 481.90
27860 04 N I 77.10
27870 04 N M Y 659.00
27871 04 N M Y 659.00
27880 04 N M Y 613.20
27881 04 N M Y 674.20
27882 04 N M Y 588.20
27884 04 N M Y 252.65
27886 04 N M Y 374.55
27888 04 N M Y 599.35
27889 04 N M Y 374.55
27892 04 N M Y 220.40
27893 04 N M Y 212.80
27894 04 N M Y 293.20
27899 04 Y M Y
28001 04 N M 136.05 17.00
28002 04 N M Y 143.95
Wednesday, April 01, 2009 Page 95 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28003 04 N M Y 246.85
28005 04 N M Y 270.50
28008 04 N I 147.95
28010 04 N I Y 123.35
28011 04 Y M Y
28020 04 N M Y 224.70
28022 04 N M Y 153.65
28024 04 N I Y 146.15
28035 04 N M Y 524.40
28043 04 N M Y 149.80
28045 04 N M Y 224.70
28046 04 Y M Y Y
28050 04 N M Y 299.70
28052 04 N M Y 299.70
28054 04 N M Y 224.70
28055 04 1/1/2007 N M Y 302.40
28060 04 N M Y 224.70
28062 04 Y M Y
28070 04 N M Y 224.70
28072 04 N M Y 161.90
28080 04 N M Y 180.30
Wednesday, April 01, 2009 Page 96 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28086 04 N M Y 184.50
28088 04 N M Y 184.50
28090 04 N M Y 175.75 34.00
28092 04 N M Y 211.35 34.00
28100 04 N M Y 224.70
28102 04 N M Y 718.70
28103 04 N M Y 718.70
28104 04 N M Y 259.40
28106 04 N M Y 449.50
28107 04 N M Y 449.50
28108 04 N M Y 259.40
28110 04 N M Y 359.30
28111 04 N M Y 359.30
28112 04 N M Y 314.95
28113 04 N M Y 314.95
28114 04 N M Y 943.40
28116 04 N M Y 346.75
28118 04 N M Y 346.75
28119 04 N M Y 264.90
28120 04 N M Y 259.40
28122 04 N M Y 253.90
Wednesday, April 01, 2009 Page 97 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28124 04 N M Y 259.40
28126 04 N M Y 209.40
28130 04 N M Y 412.00
28140 04 N M Y 394.00
28150 04 N M Y 209.40
28153 04 N M Y 144.70
28160 04 N M Y 224.70
28171 04 Y M Y Y
28173 04 Y M Y Y
28175 04 Y M Y Y
28190 04 N I 107.00 17.00
28192 04 N M Y 159.80 17.00
28193 04 N M Y 180.30
28200 04 N M Y 353.75
28202 04 N M Y 480.00
28208 04 N M 299.70
28210 04 N M Y 378.05
28220 04 N M Y 212.30
28222 04 Y M Y
28225 04 N M Y 212.30
28226 04 Y M Y
Wednesday, April 01, 2009 Page 98 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28230 04 N M Y 173.40
28232 04 N I Y 121.10
28234 04 N I Y 121.05
28238 04 N M Y 299.70
28240 04 N M Y 140.75
28250 04 N M Y 359.30
28260 04 N M Y 299.70
28261 04 N M Y 363.45
28262 04 N M Y 524.40
28264 04 N M Y 449.50
28270 04 N M Y 299.70
28272 04 N M Y 224.70
28280 04 N M Y 162.35
28285 04 N M Y 270.50
28286 04 N M Y 337.10
28288 04 N M Y 299.70
28289 04 N M Y 359.30
28290 04 N M Y 424.45
28292 04 N M Y 359.30
28293 04 N M Y 359.30
28294 04 N M Y 359.30
Wednesday, April 01, 2009 Page 99 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28296 04 N M Y 419.00
28297 04 N M Y 419.00
28298 04 N M Y 359.30
28299 04 N M Y 384.89
28300 04 N M Y 374.55
28302 04 N M Y 337.90
28304 04 N M Y 283.60
28305 04 N M Y 373.70
28306 04 N M Y 262.20
28307 04 N M Y 299.70
28308 04 N M Y 202.50
28309 04 N M Y 358.05
28310 04 N M Y 262.20
28312 04 N M Y 169.85
28313 04 N M Y 167.10
28315 04 N M Y 224.70
28320 04 N M Y 378.05
28322 04 N M Y 244.90
28340 04 N M Y 270.00
28341 04 N M Y 307.90
28344 04 N M Y 172.80
Wednesday, April 01, 2009 Page 100 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28345 04 N M Y 216.00
28360 04 Y M Y
28400 04 N I 114.20
28405 04 N M Y 228.90
28406 04 N M Y 231.65
28415 04 N M Y 642.45
28420 04 N M Y 671.85
28430 04 N M 109.00
28435 04 N M Y 215.05
28436 04 N M Y 318.60
28445 04 N M Y 718.70
28446 04 1/1/2008 N M Y Y 626.74
28450 04 N M 98.00
28455 04 N M 277.50
28456 04 N M Y 313.20
28465 04 N M Y 599.35
28470 04 N I 97.05
28475 04 N M 173.40
28476 04 N M Y 237.85
28485 04 N M Y 301.00
28490 04 N I 55.40
Wednesday, April 01, 2009 Page 101 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28495 04 N I 69.30
28496 04 N M Y 113.60
28505 04 N M Y 230.80
28510 04 N I 41.60
28515 04 N I 97.05
28525 04 N I Y 202.90
28530 04 N I 57.30
28531 04 N M Y 224.70
28540 04 N I 138.75
28545 04 N I 152.60
28546 04 N I Y 134.60
28555 04 N M Y 480.00
28570 04 N I 113.65
28575 04 N M 151.15
28576 04 N M Y 262.20
28585 04 N M Y 427.20
28600 04 N M 299.70
28605 04 N M 299.70
28606 04 N M Y 299.70
28615 04 N M Y 368.45
28630 04 N I 112.40
Wednesday, April 01, 2009 Page 102 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28635 04 N M 262.20
28636 04 N M Y 262.20
28645 04 N M Y 240.00
28660 04 N I 104.10
28665 04 N I 117.85
28666 04 N M Y 133.35
28675 04 N M Y 241.35
28705 04 N M Y 599.35
28715 04 N M Y 599.35
28725 04 N M Y 480.00
28730 04 N M Y 480.00
28735 04 N M Y 599.35
28737 04 N M Y 599.35
28740 04 N M Y 337.10
28750 04 N M Y 262.20
28755 04 N M Y 169.10
28760 04 N M Y 239.10
28800 04 N M Y 485.50
28805 04 N M Y 482.80
28810 04 N M Y 419.00
28820 04 N I Y 167.10
Wednesday, April 01, 2009 Page 103 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
28825 04 N I Y 145.60
28890 04 N M 121.80
28899 04 Y M Y
29000 04 N I 156.80
29010 04 N I 141.50
29015 04 N I 188.70
29020 04 N I 205.30
29025 04 N I 227.50
29035 04 N I 152.60
29040 04 N I 181.65
29044 04 N I 173.40
29046 04 N I 187.30
29049 04 N I 66.10 34.00
29055 04 N I 115.80 34.00
29058 04 N I 79.30 34.00
29065 04 N I 59.45 34.00
29075 04 N I 59.45 34.00
29085 04 N I 49.30 17.00
29086 04 N I 30.70
29105 04 N I 42.10 17.00
29125 04 N I 32.15 17.00
Wednesday, April 01, 2009 Page 104 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
29126 04 N I 39.30 17.00
29130 04 N I 23.00 17.00
29131 04 N I 23.50 17.00
29200 04 N I 24.25
29220 04 N I 23.00
29240 04 N I 37.40
29260 04 N I 19.95
29280 04 N I 19.30
29305 04 N I 166.40
29325 04 N I 194.20
29345 04 N I 79.30 34.00
29355 04 N I 92.40 34.00
29358 04 N I 174.40 34.00
29365 04 N I 79.30 34.00
29405 04 N I 70.00 34.00
29425 04 N I 75.30 34.00
29435 04 N I 79.30 34.00
29440 04 N I 29.80
29445 04 N I 91.65
29450 04 N I 43.50 17.00
29505 04 N I 43.50 17.00
Wednesday, April 01, 2009 Page 105 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
29515 04 N I 35.85 17.00
29520 04 N I Y 21.40
29530 04 N I 21.80
29540 04 N I 15.40
29550 04 N I 14.20
29580 04 N I 27.00 17.00
29590 04 N I 22.15
29700 04 N I 24.15
29705 04 N I 25.60
29710 04 N I 56.80
29715 04 N I 94.30
29720 04 N I 59.60
29730 04 N I 36.00
29740 04 N I 46.55
29750 04 N I 44.30
29799 04 Y I
29800 04 N M Y 374.55
29804 04 N M Y 355.80
29805 04 N M Y 325.20
29806 04 N M Y 673.30
29807 04 N M Y 673.30
Wednesday, April 01, 2009 Page 106 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
29819 04 N M Y 480.00
29820 04 N M Y 480.00
29821 04 N M Y 480.00
29822 04 N M Y 480.00
29823 04 N M Y 480.00
29824 04 N M Y 526.45
29825 04 N M Y 480.00
29826 04 N M Y 480.00
29827 04 N M Y 674.20
29828 04 1/1/2008 N M Y 484.90
29830 04 N M Y 394.50
29834 04 N M Y 480.00
29835 04 N M Y 480.00
29836 04 N M Y 480.00
29837 04 N M Y 480.00
29838 04 N M Y 480.00
29840 04 N M Y Y 356.10
29843 04 N M Y Y 356.10
29844 04 N M Y Y 480.00
29845 04 N M Y Y 480.00
29846 04 N M Y Y 356.10
Wednesday, April 01, 2009 Page 107 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
29847 04 N M Y Y 480.00
29848 04 N M Y 456.00
29850 04 N M Y 675.10
29851 04 N M Y 958.60
29855 04 N M Y 629.90
29856 04 N M Y 839.35
29860 04 N M Y 374.55
29861 04 N M Y 486.90
29862 04 N M Y 599.35
29863 04 N M Y 599.35
29866 04 Y M
29867 04 Y M
29868 04 Y M
29870 04 N M Y 374.55
29871 04 N M Y 374.55
29873 04 N M Y 374.55
29874 04 N M Y 486.90
29875 04 N M Y 599.35
29876 04 N M Y 599.35
29877 04 N M Y 599.35
29879 04 N M Y 599.35
Wednesday, April 01, 2009 Page 108 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
29880 04 N M Y Y 621.50
29881 04 N M Y 621.50
29882 04 N M Y 621.50
29883 04 N M Y Y 599.35
29884 04 N M Y 599.35
29885 04 N M Y Y 621.50
29886 04 N M Y 599.35
29887 04 N M Y 599.35
29888 04 N M Y Y 621.50
29889 04 N M Y Y 621.50
29891 04 N M Y 480.00
29892 04 N M Y 480.00
29893 04 N M 171.90
29894 04 N M 480.00
29895 04 N M Y 480.00
29897 04 N M 480.00
29898 04 N M Y 480.00
29899 04 N M Y 659.00
29900 04 N M Y 288.60
29901 04 N M Y 318.80
29902 04 N M Y 342.55
Wednesday, April 01, 2009 Page 109 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
29904 04 1/1/2008 N M Y 323.37
29905 04 1/1/2008 N M Y 347.96
29906 04 1/1/2008 N M Y 366.46
29907 04 1/1/2008 N M Y 451.20
29999 04 Y M Y
30000 04 N I 46.70 17.00
30020 04 N I 47.80 17.00
30100 04 N I 55.40 17.00
30110 04 N I 57.10 17.00
30115 04 N M 156.80
30117 04 N I 109.30
30118 04 N I 299.35
30120 04 N M Y 480.00
30124 04 N I 89.10 17.00
30125 04 N I 218.95
30130 04 N M 180.30
30140 04 N M Y 180.30
30150 04 Y M Y
30160 04 Y M Y Y
30200 04 N I 24.90
30210 04 N I 34.80
Wednesday, April 01, 2009 Page 110 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
30220 04 N I Y Y 56.00
30300 04 N I 39.05
30310 04 N I 74.90
30320 04 N I 152.60
30400 04 N M Y Y 749.20
30410 04 N M Y 749.20
30420 04 N M Y Y 980.85
30430 04 N M Y 374.55
30435 04 Y M Y Y
30450 04 N M Y 599.35
30460 04 N M Y Y 599.35
30462 04 N M Y Y 815.50
30465 04 N M Y 547.60
30520 04 N M Y 417.60
30540 04 N M Y Y 524.40
30545 04 N M Y Y 674.20
30560 04 N I 42.00
30580 04 N M Y 374.55
30600 04 N M Y 374.55
30620 04 N M 524.40
30630 04 N M Y Y 524.40
Wednesday, April 01, 2009 Page 111 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
30801 04 N I 50.05
30802 04 N I 71.15
30901 04 N I Y Y 74.90
30903 04 N I Y Y 71.40 17.00
30905 04 N I 80.75 17.00
30906 04 N I 85.70 17.00
30915 04 N M 359.30
30920 04 N M 359.30
30930 04 N I Y Y 90.10
30999 04 Y M Y
31000 04 N I 39.35
31002 04 N I 51.50
31020 04 N M 180.30
31030 04 N M 480.00
31032 04 N M Y Y 718.70
31040 04 N M Y 359.30
31050 04 N M Y 412.00
31051 04 N M Y 412.00
31070 04 N M 180.30
31075 04 N M Y 599.35
31080 04 N M Y 898.95
Wednesday, April 01, 2009 Page 112 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
31081 04 N M Y 898.95
31084 04 N M Y 898.95
31085 04 N M Y 898.95
31086 04 N M Y 898.95
31087 04 N M Y 898.95
31090 04 N M Y 718.70
31200 04 N M Y 262.20
31201 04 N M 449.50
31205 04 N M Y 449.50
31225 04 N M Y 898.95
31230 04 N M Y 1,198.70
31231 04 N I 107.00
31233 04 N I 112.40
31235 04 N I 107.00
31237 04 N I 102.55
31238 04 N I 113.10
31239 04 Y M
31240 04 N M 221.90
31254 04 N M Y 262.20
31255 04 N M Y 449.50
31256 04 N M Y 180.30
Wednesday, April 01, 2009 Page 113 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
31267 04 N M Y 224.70
31276 04 N M 253.30
31287 04 N M 205.95
31288 04 N M 412.00
31290 04 Y M
31291 04 Y M
31292 04 N M 451.50
31293 04 N M 492.15
31294 04 N M 581.00
31299 04 Y M Y
31300 04 N M Y 524.40
31320 04 N M 299.70
31360 04 N M Y Y 1,198.70
31365 04 N M Y Y 1,537.15
31367 04 N M Y Y 958.60
31368 04 N M Y Y 1,537.15
31370 04 N M Y Y 958.60
31375 04 N M Y Y 958.60
31380 04 N M Y 958.60
31382 04 N M Y Y 958.60
31390 04 N M Y Y 1,537.15
Wednesday, April 01, 2009 Page 114 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
31395 04 N M Y Y 1,728.25
31400 04 N M Y 749.20
31420 04 N M Y Y 524.40
31500 04 N I 55.50
31502 04 N I Y 28.50
31505 04 N I 37.40
31510 04 N I 74.90
31511 04 N I 202.50
31512 04 N M 202.50
31513 04 N M Y Y 235.80
31515 04 N I 107.00 17.00
31520 04 N I 112.40
31525 04 N I 107.00 17.00
31526 04 N I 192.95 17.00
31527 04 N M Y Y 192.95 17.00
31528 04 N I Y Y 192.95 17.00
31529 04 N I Y Y 192.95 17.00
31530 04 N M 192.95 34.00
31531 04 N M 224.60 34.00
31535 04 N I 224.60 34.00
31536 04 N I 224.60 34.00
Wednesday, April 01, 2009 Page 115 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
31540 04 N M 268.20 34.00
31541 04 N M 268.20 34.00
31545 04 N M 268.20
31546 04 N M 577.16
31560 04 N M Y 499.45 34.00
31561 04 N M 499.45 34.00
31570 04 N M 224.60 34.00
31571 04 N M 224.60 34.00
31575 04 N I Y Y 107.00 34.00
31576 04 N I Y Y 224.60 34.00
31577 04 N M Y Y 192.95 34.00
31578 04 N M Y Y 268.20 34.00
31579 04 N I 192.95
31580 04 N M Y 524.35
31582 04 N M Y 686.80
31584 04 N M 591.60
31587 04 N M Y Y 524.35
31588 04 Y M Y
31590 04 N M Y Y 839.35
31595 04 N M Y Y 360.70
31599 04 Y M Y
Wednesday, April 01, 2009 Page 116 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
31600 04 N I 266.40
31601 04 N I 284.40
31603 04 N I Y 266.40
31605 04 N I 266.40
31610 04 N I 289.40
31611 04 N M Y Y 374.60
31612 04 N I 149.80
31613 04 N M Y Y 208.05
31614 04 Y M Y Y
31615 04 N I 107.00 17.00
31620 04 Y I 56.70
31622 04 N I 235.20 56.70
31623 04 N I 235.20
31624 04 N I 270.50
31625 04 N I 235.20 56.70
31628 04 N I 246.95
31629 04 N I 235.20
31630 04 N M 251.10
31631 04 N M Y 251.10
31632 04 N I 30.94
31633 04 N I 38.51
Wednesday, April 01, 2009 Page 117 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
31635 04 N M 239.15 56.70
31636 04 N M Y 251.10
31637 04 N M Y 251.10
31638 04 N M Y 251.10
31640 04 N M 251.10
31641 04 N M 251.10
31643 04 N I 235.95
31645 04 N I 219.35 56.70
31646 04 N I 219.35 56.70
31656 04 N I 270.50
31715 04 N I 74.90
31717 04 N I 230.25
31720 04 N I 224.70
31725 04 N I 224.70
31730 04 N I Y 88.90
31750 04 N M Y Y 713.50
31755 04 N M Y 527.50
31760 04 N M Y Y 1,123.70
31766 04 N M Y Y 1,198.70
31770 04 N M Y Y 1,048.85
31775 04 N M Y Y 1,123.70
Wednesday, April 01, 2009 Page 118 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
31780 04 N M Y Y 749.20
31781 04 N M Y Y 1,123.70
31785 04 N M Y Y 1,198.70
31786 04 N M Y Y 1,198.70
31800 04 N M Y Y 524.40
31805 04 N M Y Y 749.20
31820 04 N M 214.00 34.00
31825 04 N M Y 374.55
31830 04 N M Y 166.75
31899 04 Y M Y
32035 04 N M Y 524.40
32036 04 N M Y 331.15
32095 04 N M Y 419.00
32100 04 N M Y 811.50
32110 04 N M Y 811.50
32120 04 N M Y 599.35
32124 04 N M Y 599.35
32140 04 N M Y 599.35
32141 04 N M Y 599.35
32150 04 N M Y 599.35
32151 04 N M Y 599.35
Wednesday, April 01, 2009 Page 119 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
32160 04 N M Y 374.55
32200 04 N M Y 480.00
32201 04 N M 434.45
32215 04 N M Y 599.35
32220 04 N M Y 749.20
32225 04 N M Y 599.35
32310 04 N M Y 958.60
32320 04 N M Y 1,198.70
32400 04 N I 71.40 34.00
32402 04 N M Y 524.40
32405 04 N I 107.00 34.00
32420 04 N I 107.00 34.00
32421 04 1/1/2008 N I 87.98
32422 04 1/1/2008 N I 108.51
32440 04 N M Y Y 1,198.70
32442 04 N M Y Y 1,414.70
32445 04 N M Y Y 1,198.70
32480 04 N M Y Y 1,213.95
32482 04 N M Y Y 1,213.95
32484 04 N M Y Y 1,213.95
32486 04 N M Y Y 1,350.15
Wednesday, April 01, 2009 Page 120 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
32488 04 N M Y Y 1,213.95
32491 04 N M Y Y 1,213.95
32500 04 N M Y 718.70
32501 04 N M Y Y 324.05
32503 04 N M Y 1,050.34
32504 04 N M Y 1,203.13
32540 04 N M Y Y 958.60
32550 04 1/1/2008 N M 127.01 318.46
32551 04 1/1/2008 N M 224.70
32560 04 1/1/2008 N I 198.20
32601 04 N I Y 167.20
32602 04 N I Y 181.35
32603 04 N I Y 302.40
32604 04 N I Y 302.40
32605 04 N I Y 314.95
32606 04 N I Y 314.95
32650 04 N M Y 349.85
32651 04 N M Y 426.10
32652 04 N M Y 591.40
32653 04 N M Y 418.50
32654 04 N M Y 400.80
Wednesday, April 01, 2009 Page 121 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
32655 04 N M Y 838.95
32656 04 N M Y 523.85
32657 04 N M Y 523.85
32658 04 N M Y 415.90
32659 04 N M Y 415.55
32660 04 N M Y 648.10
32661 04 N M Y 523.85
32662 04 N M Y 598.40
32663 04 N M Y 1,213.85
32664 04 N M Y 749.20
32665 04 N M Y 1,082.10
32800 04 Y M Y Y
32810 04 N M 398.40
32815 04 N M Y 813.26
32820 04 Y M Y
32850 04 N M Y 1,134.10
32851 04 N M Y Y 2,106.30
32852 04 N M Y Y 2,397.40
32853 04 N M Y Y 3,402.50
32854 04 N M Y Y 3,834.55
32900 04 N M Y 564.90
Wednesday, April 01, 2009 Page 122 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
32905 04 N M Y 749.20
32906 04 N M Y 772.90
32940 04 N M Y Y 571.55
32960 04 N I 299.70
32997 04 N M 246.40
32998 04 1/1/2007 N M 214.24
32999 04 Y M Y
33010 04 N I 61.25
33011 04 N I 57.55
33015 04 N I 204.05
33020 04 N M Y Y 733.85
33025 04 N M Y Y 839.35
33030 04 N M Y Y 839.35
33031 04 N M Y Y 2,397.40
33050 04 N M Y Y 1,048.85
33120 04 N M Y Y 2,397.40
33130 04 N M Y Y 749.20
33140 04 Y M Y
33141 04 Y M Y
33202 04 1/1/2007 N M Y 861.50
33203 04 1/1/2007 N M Y 349.85
Wednesday, April 01, 2009 Page 123 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33206 04 N M Y 861.50
33207 04 N M Y Y 861.50
33208 04 N M Y 861.50
33210 04 N I Y 240.00
33211 04 N I Y 240.00
33212 04 N I Y 240.00
33213 04 N I Y 240.00
33214 04 N M Y 299.70
33215 04 N M 299.70
33216 04 N M Y 299.70
33217 04 N M Y 299.70
33218 04 N M 299.70
33220 04 N M 245.65
33222 04 N M Y 299.70
33223 04 N M Y 299.70
33224 04 N M Y Y 299.70
33225 04 N M Y Y 299.70
33226 04 N M Y Y 299.70
33233 04 N M Y 167.40
33234 04 N M Y 351.00
33235 04 N M Y 351.00
Wednesday, April 01, 2009 Page 124 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33236 04 N M Y Y 419.00
33237 04 N M Y Y 433.95
33238 04 N M Y Y 452.80
33240 04 Y I Y
33241 04 Y I Y
33243 04 Y M Y Y
33244 04 Y I Y
33249 04 N M Y 642.60
33250 04 N M Y Y 1,798.10
33251 04 N M Y Y 2,397.40
33254 04 1/1/2007 N M Y 2,397.40
33255 04 1/1/2007 N M Y 2,397.40
33256 04 1/1/2007 N M Y 2,397.40
33257 04 1/1/2008 N M Y 327.74
33258 04 1/1/2008 N M Y 371.27
33259 04 1/1/2008 N M 489.48
33261 04 N M Y Y 2,397.40
33265 04 1/1/2007 N M Y 2,397.40
33266 04 1/1/2007 N M Y 2,397.40
33282 04 N M 584.80
33284 04 N M 444.05
Wednesday, April 01, 2009 Page 125 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33300 04 N M Y Y 629.90
33305 04 N M Y Y 2,397.40
33310 04 N M Y Y 1,048.85
33315 04 N M Y Y 2,397.40
33320 04 N M Y Y 749.20
33321 04 N M Y Y 1,798.05
33322 04 N M Y Y 2,397.40
33330 04 N M Y Y 1,198.70
33332 04 N M Y Y 2,397.40
33335 04 N M Y Y 2,397.40
33400 04 N M Y Y 2,397.40
33401 04 N M Y Y 2,397.40
33403 04 N M Y Y 2,397.40
33404 04 Y M Y Y
33405 04 N M Y Y 2,397.40
33406 04 N M Y Y 2,397.40
33410 04 N M Y 2,397.40
33411 04 N M Y Y 2,397.40
33412 04 N M Y Y 2,397.40
33413 04 N M Y Y 2,397.40
33414 04 Y M Y Y
Wednesday, April 01, 2009 Page 126 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33415 04 N M Y Y 1,198.70
33416 04 N M Y Y 2,397.40
33417 04 Y M Y Y
33420 04 N M Y Y 1,048.85
33422 04 N M Y Y 2,397.40
33425 04 N M Y Y 2,397.40
33426 04 N M Y Y 2,397.40
33427 04 N M Y Y 2,397.40
33430 04 N M Y Y 2,397.40
33460 04 N M Y Y 2,397.40
33463 04 N M Y Y 2,397.40
33464 04 N M Y Y 2,397.40
33465 04 N M Y Y 2,397.40
33468 04 N M Y Y 2,397.40
33470 04 N M Y Y 749.20
33471 04 N M Y Y 1,198.70
33472 04 N M Y Y 1,198.70
33474 04 N M Y Y 2,397.40
33475 04 N M Y Y 2,397.40
33476 04 N M Y Y 1,198.70
33478 04 N M Y Y 2,277.50
Wednesday, April 01, 2009 Page 127 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33496 04 N M Y Y 2,397.40
33500 04 N M Y Y 2,397.40
33501 04 N M Y Y 1,198.70
33502 04 N M Y Y 749.20
33503 04 N M Y Y 2,397.40
33504 04 N M Y Y 2,397.40
33505 04 Y M Y Y
33506 04 Y M Y Y
33507 04 N M Y Y 1,014.99
33508 04 N M Y Y 17.04
33510 04 N M Y Y 2,397.40
33511 04 N M Y Y 2,397.40
33512 04 N M Y Y 2,397.40
33513 04 N M Y Y 2,397.40
33514 04 N M Y Y 2,397.40
33516 04 N M Y Y 2,397.40
33517 04 N M Y Y 2,397.40
33518 04 N M Y Y 2,397.40
33519 04 N M Y Y 2,397.40
33521 04 N M Y Y 2,397.40
33522 04 N M Y Y 2,397.40
Wednesday, April 01, 2009 Page 128 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33523 04 N M Y Y 2,397.40
33530 04 N M Y Y 2,397.40
33533 04 N M Y Y 2,397.40
33534 04 N M Y Y 2,397.40
33535 04 N M Y Y 2,397.40
33536 04 N M Y Y 2,397.40
33542 04 N M Y Y 1,198.70
33545 04 N M Y Y 2,397.40
33548 04 N M Y 1,333.12
33572 04 N M Y Y 2,397.40
33600 04 Y M Y Y
33602 04 Y M Y Y
33606 04 Y M Y Y
33608 04 Y M Y Y
33610 04 Y M Y Y
33611 04 Y M Y Y
33612 04 Y M Y Y
33615 04 N M Y Y 2,397.40
33617 04 N M Y Y 2,397.40
33619 04 N M Y Y 2,397.40
33641 04 N M Y Y 2,397.40
Wednesday, April 01, 2009 Page 129 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33645 04 N M Y Y 2,397.40
33647 04 N M Y Y 2,397.40
33660 04 N M Y Y 2,397.40
33665 04 N M Y Y 2,397.40
33670 04 N M Y Y 2,397.40
33675 04 1/1/2007 N M Y 2,397.40
33676 04 1/1/2007 N M Y 2,397.40
33677 04 1/1/2007 N M Y 2,397.40
33681 04 N M Y Y 2,397.40
33684 04 N M Y Y 2,397.40
33688 04 N M Y Y 2,397.40
33690 04 N M Y Y 958.60
33692 04 N M Y Y 2,397.40
33694 04 N M Y Y 2,397.40
33697 04 N M Y Y 2,996.80
33702 04 N M Y Y 2,397.40
33710 04 N M Y Y 2,397.40
33720 04 N M Y Y 2,397.40
33722 04 Y M Y Y
33724 04 1/1/2007 N M Y 2,397.40
33726 04 1/1/2007 N M 2,721.45
Wednesday, April 01, 2009 Page 130 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33730 04 N M Y Y 2,721.45
33732 04 N M Y Y 2,397.40
33735 04 N M Y Y 1,198.70
33736 04 N M Y Y 2,397.40
33737 04 N M Y Y 2,397.40
33750 04 N M Y Y 1,079.30
33755 04 N M Y Y 1,079.30
33762 04 N M Y Y 1,079.30
33764 04 N M Y Y 1,198.70
33766 04 N M Y Y 1,079.30
33767 04 N M Y Y 2,397.40
33768 04 N M Y Y 255.00
33770 04 N M Y Y 2,996.80
33771 04 N M Y Y 2,996.80
33774 04 N M Y Y 2,397.40
33775 04 N M Y Y 2,397.40
33776 04 N M Y Y 2,996.60
33777 04 N M Y Y 2,996.60
33778 04 N M Y Y 2,397.40
33779 04 N M Y Y 2,397.40
33780 04 N M Y Y 2,996.60
Wednesday, April 01, 2009 Page 131 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33781 04 N M Y Y 2,996.60
33786 04 N M Y Y 2,397.40
33788 04 N M Y Y 2,057.80
33800 04 N M Y Y 1,123.70
33802 04 N M Y Y 1,123.70
33803 04 N M Y Y 1,501.75
33813 04 N M Y Y 1,797.95
33814 04 N M Y Y 2,397.40
33820 04 N M Y Y 839.35
33822 04 N M Y Y 839.35
33824 04 N M Y Y 1,079.30
33840 04 N M Y Y 1,198.70
33845 04 N M Y Y 1,198.70
33851 04 N M Y Y 1,198.70
33852 04 N M Y Y 2,397.40
33853 04 N M Y Y 2,397.40
33860 04 N M Y Y 2,397.40
33861 04 N M Y Y 2,397.40
33863 04 N M Y Y 2,397.40
33864 04 1/1/2008 N M Y 1794.48
33870 04 N M Y Y 2,397.40
Wednesday, April 01, 2009 Page 132 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33875 04 Y M Y Y
33877 04 Y M Y Y
33880 04 N M Y Y 1,042.97
33881 04 N M Y Y 894.71
33883 04 N M Y Y 662.83
33884 04 N M Y Y 249.09
33886 04 N M Y Y 571.51
33889 04 N M Y Y 499.99
33891 04 N M Y Y 636.67
33910 04 N M Y Y 2,397.40
33915 04 Y M Y Y
33916 04 N M Y Y 2,397.40
33917 04 N M Y Y 2,397.40
33920 04 N M Y Y 2,397.40
33922 04 N M Y Y 2,397.40
33924 04 N M Y Y 324.05
33925 04 N M Y Y 1,037.68
33926 04 N M Y Y 1,407.80
33930 04 N M Y 1,306.65
33935 04 N M Y Y 4,104.60
33940 04 N M Y 1,198.70
Wednesday, April 01, 2009 Page 133 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
33945 04 N M Y Y 2,894.30
33960 04 N I 453.70
33961 04 N I 295.60
33967 04 N I 230.20
33968 04 N M 162.00
33970 04 N M 689.50
33971 04 N M Y Y 334.80
33973 04 N M Y Y 689.50
33974 04 N M Y Y 419.25
33975 04 N M Y Y 1,350.15
33976 04 N M Y Y 1,674.20
33977 04 N M Y Y 1,215.15
33978 04 N M Y Y 1,458.20
33979 04 N M Y Y 730.85
33980 04 N M Y Y 787.90
33999 04 Y M Y Y
34001 04 N M Y 718.70
34051 04 N M Y 718.70
34101 04 N M Y 718.70
34111 04 N M Y 718.70
34151 04 N M Y 718.70
Wednesday, April 01, 2009 Page 134 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
34201 04 N M Y 718.70
34203 04 N M Y 718.70
34401 04 N M Y 718.70
34421 04 N M Y 718.70
34451 04 N M Y 898.95
34471 04 N M Y 599.35
34490 04 N M Y 599.35
34501 04 N M Y Y 480.00
34502 04 Y M Y Y
34510 04 N M Y Y 480.00
34520 04 N M Y Y 480.00
34530 04 N M Y Y 599.35
34800 04 N M Y 819.60
34802 04 N M Y 904.75
34803 04 N M Y Y 1,148.60
34804 04 N M Y 904.75
34805 04 N M Y Y 669.46
34806 04 1/1/2008 N M Y 59.78
34808 04 N M Y Y 156.10
34812 04 N M Y Y 255.70
34813 04 N M Y Y 181.55
Wednesday, April 01, 2009 Page 135 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
34820 04 N M Y Y 369.05
34825 04 N M Y Y 488.60
34826 04 N M Y Y 156.10
34830 04 N M Y Y 1,276.30
34831 04 N M Y Y 1,379.95
34832 04 N M Y Y 1,379.95
34833 04 N M Y Y 488.60
34834 04 N M Y Y 369.05
34900 04 N M Y Y 488.60
35001 04 N M Y 1,123.70
35002 04 N M Y 1,306.65
35005 04 N M Y 1,414.70
35011 04 N M Y 898.95
35013 04 N M Y 1,198.70
35021 04 N M Y 1,198.70
35022 04 N M Y 1,414.70
35045 04 N M Y 599.35
35081 04 N M Y 1,198.70
35082 04 N M Y 1,630.70
35091 04 N M Y 1,198.70
35092 04 N M Y 1,630.70
Wednesday, April 01, 2009 Page 136 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35102 04 N M Y 1,198.70
35103 04 N M Y Y 1,630.70
35111 04 N M Y 1,198.70
35112 04 N M Y 1,630.70
35121 04 N M Y 1198.70
35122 04 N M Y 1630.70
35131 04 N M Y 958.60
35132 04 N M Y 1,198.70
35141 04 N M Y 958.60
35142 04 N M Y 1,198.70
35151 04 N M Y 958.60
35152 04 N M Y 1,198.70
35180 04 N M Y 1,198.70
35182 04 N M Y 952.10
35184 04 N M Y 599.35
35188 04 N M Y 1,198.70
35189 04 N M Y 952.10
35190 04 N M Y 599.35
35201 04 N M Y 1,198.70
35206 04 N M Y 599.35
35207 04 N M Y 341.20
Wednesday, April 01, 2009 Page 137 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35211 04 N M Y 1,498.30
35216 04 N M Y 1,198.70
35221 04 N M Y 1,198.70
35226 04 N M Y 599.35
35231 04 N M Y 599.35
35236 04 N M Y 599.35
35241 04 N M Y 1498.30
35246 04 N M Y 1,198.70
35251 04 N M Y 1198.70
35256 04 N M Y 599.35
35261 04 N M Y 599.35
35266 04 N M Y 599.35
35271 04 N M Y 1498.30
35276 04 N M Y 1198.70
35281 04 N M Y 1198.70
35286 04 N M Y 599.35
35301 04 N M Y 1101.60
35302 04 1/1/2007 N M Y 958.60
35303 04 1/1/2007 N M Y 958.60
35304 04 1/1/2007 N M Y 958.60
35305 04 1/1/2007 N M Y 958.60
Wednesday, April 01, 2009 Page 138 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35306 04 1/1/2007 N M Y 958.60
35311 04 N M Y 749.20
35321 04 N M Y 749.20
35331 04 N M Y 1198.70
35341 04 N M Y 958.60
35351 04 N M Y 958.60
35355 04 N M Y 958.60
35361 04 N M Y 1,198.70
35363 04 N M Y 1,198.70
35371 04 N M Y 958.60
35372 04 N M Y Y 1,021.15
35390 04 Y M Y Y
35400 04 Y I
35450 04 N M 682.80
35452 04 N M 682.80
35454 04 N M 682.80
35456 04 N M 479.00
35458 04 N M 479.00
35459 04 N M 479.00
35460 04 N M 479.00
35470 04 N M 479.00
Wednesday, April 01, 2009 Page 139 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35471 04 N M 479.00
35472 04 N M Y 479.00
35473 04 N M 479.00
35474 04 N M 479.00
35475 04 N M 479.00
35476 04 N M 479.00
35480 04 N M Y Y 1,101.20
35481 04 N M Y Y 1,198.70
35482 04 N M Y Y 958.60
35483 04 N M Y Y 958.60
35484 04 N M Y Y 749.20
35485 04 N M Y 958.60
35490 04 N M Y 1,024.15
35491 04 N M Y 1,024.15
35492 04 N M Y 1,024.15
35493 04 N M Y 718.50
35494 04 N M Y 718.50
35495 04 N M Y 718.50
35500 04 N M Y 209.75
35501 04 N M Y 839.35
35506 04 N M Y 958.60
Wednesday, April 01, 2009 Page 140 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35508 04 N M Y 958.60
35509 04 N M Y 958.60
35510 04 N M Y Y 708.05
35511 04 N M Y 958.60
35512 04 N M Y Y 694.72
35515 04 N M Y 958.60
35516 04 N M Y 958.60
35518 04 N M Y 958.60
35521 04 N M Y 1,198.70
35522 04 N M Y Y 674.99
35523 04 1/1/2008 N M Y Y 726.14
35525 04 N M Y Y 644.91
35526 04 N M Y 958.60
35531 04 N M Y 958.60
35533 04 N M Y 1,198.70
35535 04 1/1/2009 N M Y 1109.75
35536 04 N M Y 958.60
35537 04 1/1/2007 N M Y 1,198.70
35538 04 1/1/2007 N M Y 1,198.70
35539 04 1/1/2007 N M Y 839.35
35540 04 1/1/2007 N M Y 839.35
Wednesday, April 01, 2009 Page 141 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35548 04 N M Y 839.35
35549 04 N M Y Y 1,198.70
35551 04 N M Y Y 1,198.70
35556 04 N M Y Y 958.60
35558 04 N M Y Y 1,079.30
35560 04 N M Y 1,198.70
35563 04 N M Y Y 1,198.70
35565 04 N M Y Y 1,198.70
35566 04 N M Y Y 958.60
35570 04 1/1/2009 N M Y Y 958.60
35571 04 N M Y Y 958.60
35572 04 N M Y Y 209.75
35583 04 N M Y Y 958.60
35585 04 N M Y Y 958.60
35587 04 N M Y Y 958.60
35600 04 N M Y Y 192.75
35601 04 N M Y Y 839.35
35606 04 N M Y Y 958.60
35612 04 N M Y Y 958.60
35616 04 N M Y 958.60
35621 04 N M Y Y 1,198.70
Wednesday, April 01, 2009 Page 142 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35623 04 N M Y Y 1,306.65
35626 04 N M Y 958.60
35631 04 N M Y Y 1,198.70
35632 04 1/1/2009 N M Y Y 1198.70
35633 04 1/1/2009 N M Y Y 1198.70
35634 04 1/1/2009 N M Y Y 1198.70
35636 04 N M Y Y 1,079.30
35637 04 1/1/2007 N M Y 1,198.70
35638 04 1/1/2007 N M Y 1,198.70
35642 04 N M Y 958.60
35645 04 N M Y 958.60
35646 04 N M Y Y 1,198.70
35647 04 N M Y Y 1,053.80
35650 04 N M Y 1,079.30
35651 04 N M Y Y 1,198.70
35654 04 N M Y 1,198.70
35656 04 N M Y Y 958.60
35661 04 N M Y Y 1,079.30
35663 04 N M Y Y 1,198.70
35665 04 N M Y Y 1,198.70
35666 04 N M Y Y 958.60
Wednesday, April 01, 2009 Page 143 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35671 04 N M Y Y 958.60
35681 04 Y M Y
35682 04 N M Y 314.60
35683 04 N M Y 314.60
35685 04 N I Y 146.50
35686 04 N I 129.25
35691 04 N M Y Y 1,198.70
35693 04 N M Y Y 1,198.70
35694 04 N M Y Y 1,198.70
35695 04 N M Y Y 1,198.70
35697 04 N M Y Y 90.02
35700 04 Y M Y Y
35701 04 N M Y Y 374.55
35721 04 N M Y Y 299.70
35741 04 N M Y Y 299.70
35761 04 Y M
35800 04 N M Y Y 374.55
35820 04 N M Y Y 524.40
35840 04 N M Y 480.00
35860 04 N M Y 449.50
35870 04 Y M Y
Wednesday, April 01, 2009 Page 144 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
35875 04 N M Y 449.50
35876 04 N M Y Y 455.15
35879 04 N M Y 599.35
35881 04 N M Y 789.80
35883 04 1/1/2007 N M Y 599.35
35884 04 1/1/2007 N M Y 599.35
35901 04 N M Y Y 599.35
35903 04 N M Y Y 449.50
35905 04 N M Y Y 811.50
35907 04 N M Y Y 599.35
36000 09 Y I
36002 04 Y I
36005 04 N I 136.65
36010 04 N I 224.70
36011 04 N I 249.35
36012 04 N I 264.80
36013 04 N I 213.50
36014 04 N I 213.50
36015 04 N I 249.35
36100 04 N I 213.65
36120 04 N I 233.00
Wednesday, April 01, 2009 Page 145 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
36140 04 N I 188.70
36145 04 N I 188.70
36160 04 N I 202.50
36200 04 N I 224.70
36215 04 N I 198.90
36216 04 N I 264.80
36217 04 N I 281.00
36218 04 N I 281.00
36245 04 N I 213.50
36246 04 N I 264.80
36247 04 N I 281.00
36248 04 N I 281.00
36260 04 Y M
36261 04 Y M
36262 04 Y M
36299 04 Y I Y
36400 04 N I 16.65
36405 04 N I 16.65
36406 04 N I 16.65
36410 04 N I 16.65
36415 J 04 N I 4.10
Wednesday, April 01, 2009 Page 146 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
36416 J 04 5/1/2007 N I 4.10
36420 04 N I 37.40
36425 04 N I 37.40
36430 04 N I 16.65
36440 04 N I 28.80
36450 04 N I 308.00
36455 04 N I 338.50
36460 04 N I 176.90
36470 04 Y I 17.00
36471 04 Y I 17.00
36475 04 N M 213.52
36476 04 N M 104.57
36478 04 N M 213.52
36479 04 N M 104.57
36481 04 N I 264.80
36500 04 N I 71.05
36510 04 N I 25.20
36511 04 Y I
36512 04 Y I
36513 04 Y I
36514 04 Y I
Wednesday, April 01, 2009 Page 147 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
36515 04 Y I
36516 04 Y I
36522 04 N M Y Y 599.30
36555 04 N I 74.38
36556 04 N I 67.13
36557 04 N I 166.18
36558 04 N I 158.02
36560 04 N I 196.66
36561 04 N I 190.09
36563 04 N I 197.81
36565 04 N I 190.09
36566 04 N I 203.24
36568 04 N I 55.01
36569 04 N I 51.61
36570 04 N I 171.97
36571 04 N I 171.37
36575 04 N I 33.10
36576 04 N I 112.21
36578 04 N I 126.75
36580 04 N I 38.25
36581 04 N I 118.78
Wednesday, April 01, 2009 Page 148 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
36582 04 N I 171.77
36583 04 N I 173.17
36584 04 N I 38.64
36585 04 N I 161.21
36589 04 N I 78.73
36590 04 N I 107.54
36593 04 1/1/2008 N I 22.14
36595 04 N I 107.23
36596 04 N I 25.85
36597 04 N I 34.37
36598 04 N I 67.51
36600 09 Y I
36620 04 N I 37.40
36625 04 N I 52.70
36640 04 N I 74.90
36660 04 N I 37.40
36680 04 N I 90.10
36800 04 N M 424.45
36810 04 N M 424.45
36815 04 N I 112.40
36818 04 N M Y 850.30
Wednesday, April 01, 2009 Page 149 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
36819 04 N M Y 850.30
36820 04 N M 541.15
36821 04 N M 578.55
36822 04 N M Y Y 599.30
36823 04 N M Y 578.55
36825 04 N M 578.55
36830 04 N M 578.55
36831 04 N M 578.55
36832 04 N M 578.55
36833 04 N M Y 578.55
36834 04 N M Y 599.35
36835 04 N M 578.55
36838 04 N M 666.71
36860 04 N I 112.40
36861 04 N I 419.00
36870 04 N M Y 884.80
37140 04 N M Y Y 1198.70
37145 04 N M Y Y 1079.30
37160 04 N M Y Y 1079.30
37180 04 N M Y Y 1079.30
37181 04 N M Y 1079.30
Wednesday, April 01, 2009 Page 150 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
37182 04 N M Y 910.70
37183 04 N I Y 429.07
37184 04 N M 265.81
37185 04 N I 97.64
37186 04 N M 146.50
37187 04 N M 247.12
37188 04 N I 178.38
37195 04 N M 472.40
37200 04 N I 189.00
37201 04 N I 472.40
37202 04 N I 189.00
37203 04 N M 682.80
37204 04 N M Y 682.80
37205 04 N M Y 910.70
37206 04 Y M
37207 04 N M 910.70
37208 04 Y M
37209 04 N M 213.50
37210 04 1/1/2007 N M 682.80
37215 04 N M Y 910.70
37216 04 N M Y 910.70
Wednesday, April 01, 2009 Page 151 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
37250 04 N I 89.10
37251 04 N I 57.65
37500 04 N I 299.70
37501 04 Y I
37565 04 N M Y 374.55
37600 04 N M Y 374.55
37605 04 N M Y 449.50
37606 04 N M Y 449.50
37607 04 N M Y Y 262.20
37609 04 N I 112.40
37615 04 N M Y 374.55
37616 04 N M Y 524.40
37617 04 N M Y 524.40
37618 04 N M Y 262.20
37620 04 N M Y 449.50
37650 04 N M Y 374.55
37660 04 N M Y 449.50
37700 04 N M Y 203.95
37718 04 N I Y 227.39
37722 04 N I Y 275.02
37735 04 N M Y 419.00
Wednesday, April 01, 2009 Page 152 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
37760 04 N M Y 299.70
37765 04 N M 245.90
37766 04 N M 298.81
37780 04 N M 149.80
37785 04 N I 131.25
37788 04 Y M
37790 04 Y M Y
37799 04 Y M Y
38100 04 N M Y Y 770.00
38101 04 N M Y 770.00
38102 04 Y M Y Y
38115 04 N M Y 770.00
38120 04 N M Y 770.00
38129 04 Y M Y
38200 04 N I 66.50
38204 09 Y I
38205 04 Y I
38206 04 Y I
38207 09 Y I
38208 09 Y I
38209 09 Y I
Wednesday, April 01, 2009 Page 153 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
38210 09 Y I
38211 09 Y I
38212 09 Y I
38213 09 Y I
38214 09 Y I
38215 09 Y I
38220 04 N I 50.15
38221 04 N I Y 78.45
38230 04 N M Y 660.65
38240 04 N M Y Y 220.20
38241 04 N M Y Y 220.20
38242 04 N I Y 80.55
38300 04 N I 71.40 17.00
38305 04 N I 156.95 17.00
38308 04 N M 246.47
38380 04 N M Y 556.25
38381 04 N M Y 811.60
38382 04 N M Y 612.15
38500 04 N I 85.70 17.00
38505 04 N I 106.80 17.00
38510 04 N I 127.70
Wednesday, April 01, 2009 Page 154 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
38520 04 N I 157.90
38525 04 N I 135.60
38530 04 N I 189.25
38542 04 N I Y Y 185.45
38550 04 N M 224.70
38555 04 N M Y 656.60
38562 04 N M Y 480.00
38564 04 N M Y 599.35
38570 04 N M Y 302.40
38571 04 N M Y 599.35
38572 04 N M Y 599.35
38589 04 Y M Y
38700 04 N M Y 786.60
38720 04 N M Y 861.50
38724 04 N M Y Y 645.45
38740 04 N M Y 524.40
38745 04 N M Y 524.40
38746 04 N M Y Y 216.02
38747 04 N M Y Y 158.57
38760 04 N M 299.70
38765 04 N M Y 918.40
Wednesday, April 01, 2009 Page 155 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
38770 04 N M Y 918.40
38780 04 N M Y 998.80
38790 04 N I 220.85
38792 04 N I 105.40
38794 04 Y M
38999 04 Y M Y
39000 04 N M Y Y 718.70
39010 04 N M Y Y 718.70
39200 04 N M Y 749.20
39220 04 N M Y 749.20
39400 04 N I 314.95
39499 04 Y M Y
39501 04 N M Y Y 648.60
39502 04 N M Y Y 826.50
39503 04 N M Y Y 960.55
39520 04 N M Y Y 682.60
39530 04 N M Y Y 682.60
39531 04 N M Y Y 735.45
39540 04 N M Y Y 682.60
39541 04 N M Y Y 682.60
39545 04 N M Y Y 682.60
Wednesday, April 01, 2009 Page 156 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
39560 04 N M Y Y 708.60
39561 04 N M Y 803.05
39599 04 Y M Y
40490 04 N I 46.25 17.00
40500 04 N M 165.10
40510 04 N I 170.45
40520 04 N M Y Y 524.40
40525 04 N M Y Y 629.90
40527 04 N M Y Y 718.70
40530 04 N M Y Y 524.35
40650 04 N M Y Y 629.90
40652 04 N M Y Y 629.90
40654 04 N M Y Y 629.90
40700 04 N M Y Y 718.70
40701 04 N M Y Y 958.60
40702 04 N M Y 958.60
40720 04 N M Y Y 718.70
40761 04 N M Y Y 802.00
40799 04 Y M Y
40800 04 N I 39.90 17.00
40801 04 N I 76.15
Wednesday, April 01, 2009 Page 157 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
40804 04 N I 44.10 17.00
40805 04 N I 89.10
40806 04 N I 35.65 17.00
40808 04 N I 50.20 17.00
40810 04 N I 50.95 17.00
40812 04 N I 73.70 17.00
40814 04 N I 117.65
40816 04 N I 142.70 34.00
40818 04 N I 113.40
40819 04 N M 149.80
40820 04 N I 142.70 17.00
40830 04 N I 107.00 17.00
40831 04 N I 132.75 17.00
40840 04 N M Y Y 252.00
40842 04 N M Y Y 251.05
40843 04 N M Y Y 347.20
40844 04 N M Y Y 496.90
40845 04 N M Y Y 629.10
40899 04 Y M Y
41000 04 N I 44.65 17.00
41005 04 N I 41.70 17.00
Wednesday, April 01, 2009 Page 158 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
41006 04 N I 93.60
41007 04 N I 102.95 17.00
41008 04 N I 92.70 17.00
41009 04 N I 116.50
41010 04 N I 42.45 17.00
41015 04 N I 106.45 17.00
41016 04 N I 130.40 17.00
41017 04 N I 113.10 17.00
41018 04 N I 154.95
41019 04 1/1/2008 N I Y 259.65
41100 04 N I 88.50 17.00
41105 04 N I 181.00 17.00
41108 04 N I 88.50 17.00
41110 04 N M 214.00 17.00
41112 04 N M 299.70
41113 04 N M 299.70
41114 04 N M 249.70
41115 04 N M 224.70
41116 04 N M 224.70
41120 04 N M Y Y 524.40
41130 04 N M Y Y 524.40
Wednesday, April 01, 2009 Page 159 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
41135 04 N M Y Y 861.50
41140 04 N M Y Y 735.65
41145 04 N M Y Y 1048.85
41150 04 N M Y Y 1498.30
41153 04 N M Y Y 1498.30
41155 04 N M Y Y 1798.05
41250 04 N I 71.40 34.00
41251 04 N I 74.10 34.00
41252 04 N I 95.25 34.00
41500 04 N I 121.70
41510 04 N M 374.55
41512 04 1/1/2009 N I 71.40
41520 04 N I 92.70
41530 04 1/1/2009 N I 222.81
41599 04 Y M Y
41800 04 N I 39.70 17.00
41805 04 N I 42.30 17.00
41806 04 N I 90.10
41820 04 N I 99.05
41821 04 N I 71.60
41822 04 N I 90.10
Wednesday, April 01, 2009 Page 160 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
41823 04 N M 169.40
41825 04 N I 76.95
41826 04 N M 224.70
41827 04 N M 299.70
41828 04 N I 110.35
41830 04 N M 224.70
41850 04 N I 41.25
41870 04 N M Y Y 169.40
41872 04 N M 169.40
41874 04 N M 169.40
41899 04 Y M Y
42000 04 N I 43.05 17.00
42100 04 N I 50.20 34.00
42104 04 N I 79.30 34.00
42106 04 N M Y Y 480.00
42107 04 N M Y Y 506.40
42120 04 N M Y Y 647.90
42140 04 N M 184.50
42145 04 N M Y 359.30
42160 04 N I 64.10 17.00
42180 04 N M Y Y 149.80
Wednesday, April 01, 2009 Page 161 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
42182 04 N M Y Y 215.90
42200 04 N M Y Y 718.70
42205 04 N M Y Y 718.70
42210 04 N M Y Y 850.80
42215 04 N M Y Y 491.50
42220 04 N M Y Y 718.70
42225 04 N M Y Y 986.35
42226 04 N M Y Y 784.75
42227 04 N M Y Y 784.75
42235 04 N M Y Y 374.55
42260 04 N M Y Y 718.70
42280 04 N I Y Y 53.85
42281 04 N I Y 58.45
42299 04 Y M Y
42300 04 N I 79.30 17.00
42305 04 N I 164.90
42310 04 N I 79.30 17.00
42320 04 N I 113.60 17.00
42330 04 N I 113.60 34.00
42335 04 N M 240.00
42340 04 N M 240.00
Wednesday, April 01, 2009 Page 162 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
42400 04 N I 113.60 17.00
42405 04 N I 113.60 34.00
42408 04 N I 137.80 34.00
42409 04 N I 113.60 34.00
42410 04 N M Y Y 749.20
42415 04 N M Y Y 754.65
42420 04 N M Y Y 867.10
42425 04 N M Y Y 892.00
42426 04 N M Y Y 1079.30
42440 04 N M Y 480.00
42450 04 N M Y Y 480.00
42500 04 N M Y Y 359.30
42505 04 N M Y Y 359.30
42507 04 N M Y Y 767.60
42508 04 N M Y Y 839.35
42509 04 N M Y Y 1079.30
42510 04 N M Y Y 839.35
42550 04 N I 109.95
42600 04 N M 359.30
42650 04 N I 30.40 17.00
42660 04 N I 34.30 17.00
Wednesday, April 01, 2009 Page 163 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
42665 04 N I 160.20
42699 04 Y M Y
42700 04 N I 79.30 34.00
42720 04 N I 157.30
42725 04 N I 291.90
42800 04 N I 79.30 34.00
42802 04 N I 79.30 34.00
42804 04 N I 79.30 34.00
42806 04 N I 79.30 34.00
42808 04 N M 192.95 34.00
42809 04 N M 202.50 34.00
42810 04 N M 374.55
42815 04 N M Y 431.40
42820 04 N M 194.20
42821 04 N M 202.50
42825 04 N M 194.20
42826 04 N M 202.50
42830 04 N M 142.90
42831 04 N M 142.90
42835 04 N M 142.90
42836 04 N M 142.90
Wednesday, April 01, 2009 Page 164 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
42842 04 N M Y 702.10
42844 04 N M Y 810.10
42845 04 N M Y 918.15
42860 04 N I 119.25 34.00
42870 04 N I 156.65 34.00
42890 04 N M Y Y 958.60
42892 04 N M Y Y 912.80
42894 04 N M Y Y 1188.20
42900 04 Y M Y Y 34.00
42950 04 N M Y Y 939.50
42953 04 Y M Y Y
42955 04 N M 266.40
42960 04 N I 74.90 34.00
42961 04 N M 150.80
42962 04 N M 220.10
42970 04 N I 131.20 34.00
42971 04 N M 173.40
42972 04 N M 206.40
42999 04 Y M Y
43020 04 N M Y Y 480.00
43030 04 N M Y Y 819.10
Wednesday, April 01, 2009 Page 165 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43045 04 N M Y Y 839.35
43100 04 N M Y Y 749.20
43101 04 N M Y Y 749.20
43107 04 N M Y Y 1467.80
43108 04 N M Y Y 1782.30
43112 04 N M Y Y 1467.80
43113 04 N M Y Y 1782.30
43116 04 N M Y Y 2106.30
43117 04 N M Y Y 1467.80
43118 04 N M Y Y 1782.30
43121 04 N M Y Y 1467.80
43122 04 N M Y Y 1467.80
43123 04 N M Y Y 1782.30
43124 04 Y M Y Y
43130 04 N M Y Y 718.70
43135 04 N M Y Y 718.70
43200 04 N I 186.20 56.70
43201 04 N I 113.55
43202 04 N I 199.50 56.70
43204 04 N M Y Y 256.60
43205 04 N M 256.60
Wednesday, April 01, 2009 Page 166 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43215 04 N I 244.50 56.70
43216 04 N I 244.50
43217 04 N I 244.50 56.70
43219 04 N I 244.50 56.70
43220 04 N I 142.70 56.70
43226 04 N M 224.60 56.70
43227 04 N I 235.20 56.70
43228 04 N M 235.20 56.70
43231 04 N I Y 158.20
43232 04 N I Y 183.70
43234 04 N I 159.35 56.70
43235 04 N I 239.15 56.70
43236 04 N I 239.15
43237 04 N I 117.67
43238 04 N I 145.34
43239 04 N I 249.70 56.70
43240 04 N I Y 201.55
43241 04 N I 249.70 56.70
43242 04 N I Y 201.55
43243 04 N M 256.60
43244 04 N M 256.60
Wednesday, April 01, 2009 Page 167 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43245 04 N I 249.70 56.70
43246 04 N I Y 249.70 56.70
43247 04 N M 249.70 56.70
43248 04 N I 295.95
43249 04 N I 113.40
43250 04 N I 249.70
43251 04 N I 249.70 56.70
43255 04 N I 249.70 56.70
43256 04 N M Y 159.35
43257 04 N I 170.53
43258 04 N M 249.70
43259 04 N I 240.30
43260 04 N I 264.25 56.70
43261 04 N I 264.25
43262 04 N M 390.10 56.70
43263 04 N I Y Y 264.25 56.70
43264 04 N M 390.10 56.70
43265 04 N M 390.10
43267 04 N I 264.25 56.70
43268 04 N M 358.60 56.70
43269 04 N M 358.60
Wednesday, April 01, 2009 Page 168 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43271 04 N M 358.60 56.70
43272 04 N M 390.10 56.70
43273 04 1/1/2009 N M Y 117.03
43279 04 1/1/2009 N M Y 682.60
43280 04 N M Y Y 682.60
43289 04 Y M Y
43300 04 N M Y Y 786.60
43305 04 N M Y Y 1258.35
43310 04 N M Y Y 839.35
43312 04 N M Y Y 1258.35
43313 04 N M Y Y 1188.50
43314 04 N M Y Y 1564.90
43320 04 N M Y Y 958.60
43324 04 N M Y Y 682.60
43325 04 N M Y Y 749.20
43326 04 N M Y 749.20
43330 04 N M Y Y 1082.10
43331 04 N M Y Y 1082.10
43340 04 N M Y Y 1198.70
43341 04 N M Y Y 1082.10
43350 04 N M Y Y 839.35
Wednesday, April 01, 2009 Page 169 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43351 04 N M Y Y 839.35
43352 04 N M Y Y 839.35
43360 04 N M Y Y 1467.80
43361 04 N M Y Y 1782.30
43400 04 N M Y Y 480.00
43401 04 N M Y 822.80
43405 04 Y M Y Y
43410 04 N M Y Y 480.00
43415 04 N M Y Y 839.35
43420 04 N M Y Y 480.00
43425 04 N M Y Y 839.35
43450 04 N I 74.90
43453 04 N I 74.90
43456 04 N I 112.40
43458 04 N I 142.70
43460 04 N I 93.05
43496 04 N M Y Y 1778.60
43499 04 Y M Y
43500 04 N M Y Y 599.35
43501 04 N M Y Y 599.35
43502 04 N M Y Y 658.90
Wednesday, April 01, 2009 Page 170 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43510 04 N M Y Y 599.35
43520 04 N M Y Y 599.35
43600 04 N I 108.20
43605 04 N M Y Y 599.35
43610 04 N M Y Y 718.70
43611 04 N M Y Y 564.99
43620 04 N M Y Y 1011.40
43621 04 N M Y Y 1011.40
43622 04 N M Y Y 1173.40
43631 04 N M Y Y 915.65
43632 04 N M Y Y 915.65
43633 04 N M Y Y 915.65
43634 04 N M Y Y 1077.70
43635 04 N M Y Y 1026.65
43640 04 N M Y Y 812.90
43641 04 N M Y 812.90
43644 K 04 N M Y 942.28
43645 K 04 N M Y 1017.05
43647 04 1/1/2007 N M Y 399.59
43648 04 1/1/2007 N M 399.50
43651 04 N M Y 524.40
Wednesday, April 01, 2009 Page 171 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43652 04 N M Y 524.40
43653 04 N M Y 399.50
43659 04 Y M Y
43752 04 N I Y 35.05
43760 04 N I 35.65 17.00
43761 04 N I 48.50
43770 K 04 N I Y 565.47
43771 K 04 N I Y 652.01
43772 K 04 N I Y 497.20
43773 K 04 N I Y 652.27
43774 K 04 N I Y 497.78
43800 04 N M Y Y 699.20
43810 04 N M Y Y 718.70
43820 04 N M Y Y 718.70
43825 04 N M Y YY 898.95
43830 04 N M Y Y 399.50
43831 04 N M Y Y 399.50
43832 04 N M Y Y 399.50
43840 04 N M Y Y 678.40
43842 K 04 N M Y 718.70
43843 K 04 N M Y 718.70
Wednesday, April 01, 2009 Page 172 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
43845 K 04 N M Y 982.18
43846 K 04 N M Y Y 770.00
43847 K 04 N M Y Y 986.00
43848 K 04 N M Y Y 770.00
43850 04 N M Y Y 718.70
43855 04 N M Y Y 793.60
43860 04 N M Y Y 718.70
43865 04 N M Y Y 793.60
43870 04 N M Y Y 240.00
43880 04 N M Y Y 958.60
43881 04 1/1/2007 N M Y 599.35
43882 04 1/1/2007 N M Y 599.35
43886 04 N I Y 152.73
43887 04 N I Y 151.56
43888 04 N I Y 215.38
43999 04 Y M Y
44005 04 N M Y Y 643.65
44010 04 N M Y Y 599.35
44015 04 N M Y 399.50
44020 04 N M Y Y 599.35
44021 04 N M Y Y 599.35
Wednesday, April 01, 2009 Page 173 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
44025 04 N M Y Y 599.35
44050 04 N M Y Y 599.35
44055 04 N M Y 599.35
44100 04 N I 108.20
44110 04 N M Y Y 599.35
44111 04 N M Y Y 599.35
44120 04 N M Y Y 806.10
44121 04 N M Y Y 403.05
44125 04 N M Y Y 733.85
44126 04 N M Y Y 1039.70
44127 04 N M Y Y 1195.80
44128 04 N M Y Y 175.20
44130 04 N M Y Y 718.70
44132 04 N M Y Y 1039.70
44133 04 N M Y Y 1039.70
44135 04 N M Y Y 1180.95
44136 04 N M Y Y 1180.95
44137 04 N M Y 806.10
44139 04 N M Y Y 108.00
44140 04 N M Y Y 951.80
44141 04 N M Y Y 951.80
Wednesday, April 01, 2009 Page 174 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
44143 04 N M Y Y 951.80
44144 04 N M Y Y 951.80
44145 04 N M Y Y 958.60
44146 04 N M Y Y 951.80
44147 04 N M Y Y 1198.70
44150 04 N M Y Y 1079.30
44151 04 N M Y Y 1079.10
44155 04 N M Y Y 1198.70
44156 04 N M Y Y 1198.70
44157 04 1/1/2007 N M Y 1198.70
44158 04 1/1/2007 N M Y 1198.70
44160 04 N M Y Y 1198.70
44180 04 N I Y 479.20
44186 04 N I Y 335.80
44187 04 N I Y 553.18
44188 04 N I Y 607.88
44202 04 N M Y 806.10
44203 04 N M Y Y 191.80
44204 04 N M Y Y 973.80
44205 04 N M Y Y 861.80
44206 04 N M Y Y 951.80
Wednesday, April 01, 2009 Page 175 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
44207 04 N M Y Y 958.60
44208 04 N M Y Y 951.80
44210 04 N M Y Y 1255.88
44211 04 N M Y Y 1079.30
44212 04 N M Y Y 1198.70
44213 04 N I Y 110.46
44227 04 N I Y 864.06
44238 04 Y M Y Y
44300 04 N M Y Y 599.35
44310 04 N M Y Y 629.90
44312 04 N M Y Y 374.55
44314 04 N M Y Y 599.35
44316 04 N M Y Y 535.45
44320 04 N M Y Y 535.45
44322 04 N M Y Y 535.45
44340 04 N M Y Y 299.70
44345 04 N M Y Y 480.00
44346 04 N M Y Y 951.80
44360 04 N I 264.25 56.70
44361 04 N I 285.40 56.70
44363 04 N M Y 285.40 56.70
Wednesday, April 01, 2009 Page 176 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
44364 04 N M 356.70 56.70
44365 04 N M 356.70
44366 04 N M 285.40 56.70
44369 04 N M 285.40 56.70
44370 04 N M 158.30
44372 04 N M 285.40
44373 04 N M 356.70
44376 04 N I 318.30
44377 04 N I 318.30
44378 04 N M 318.30
44379 04 N M 258.55
44380 04 N I 182.30 56.70
44382 04 N I 218.00 56.70
44383 04 N I 88.30
44385 04 N I 182.30 56.70
44386 04 N I 182.30 56.70
44388 04 N I 192.85 56.70
44389 04 N I 192.85 56.70
44390 04 N I 192.85 56.70
44391 04 N I 283.40 56.70
44392 04 N M 230.80 56.70
Wednesday, April 01, 2009 Page 177 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
44393 04 N M 230.80 56.70
44394 04 N M 318.30
44397 04 N M 165.00
44500 04 N I 99.10
44602 04 N M Y Y 599.35
44603 04 N M Y Y 674.20
44604 04 N M Y Y 599.35
44605 04 N M Y Y 718.70
44615 04 N M Y Y 599.35
44620 04 N M Y Y 359.30
44625 04 N M Y Y 729.70
44626 04 N M Y Y 729.70
44640 04 N M Y Y 480.00
44650 04 N M Y Y 629.90
44660 04 N M Y Y 958.60
44661 04 N M Y Y 958.60
44680 04 N M Y Y 599.35
44700 04 N M Y Y 480.00
44701 04 N I 72.34
44799 04 Y M Y
44800 04 N M Y Y 480.00
Wednesday, April 01, 2009 Page 178 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
44820 04 N M Y Y 599.35
44850 04 N M Y Y 480.00
44899 04 Y M Y
44900 04 N M Y 310.80
44901 04 N M Y 310.80
44950 04 N M Y 374.55
44955 04 N M Y 374.55
44960 04 N M Y 480.00
44970 04 N M Y 374.55
44979 04 Y M Y
45000 04 N M 170.65
45005 04 N I 107.00 34.00
45020 04 N I 134.00
45100 04 N I 118.00
45108 04 N M Y 262.20
45110 04 N M Y Y 1079.30
45111 04 N M Y Y 1079.30
45112 04 N M Y Y 1079.30
45113 04 N M Y Y 1631.05
45114 04 N M Y Y 1138.70
45116 04 N M Y Y 1079.30
Wednesday, April 01, 2009 Page 179 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
45119 04 N M Y Y 1630.70
45120 04 N M Y Y 1198.70
45121 04 N M Y Y 1450.40
45123 04 N M Y Y 540.00
45126 04 Y M Y
45130 04 N M Y 383.70
45135 04 N M Y 524.40
45136 04 N M Y Y 1028.70
45150 04 Y I Y
45160 04 N M Y 1138.70
45170 04 N M Y 257.70
45190 04 N I Y 240.00
45300 04 N I 42.30 17.00
45303 04 N I 42.30 17.00
45305 04 N I 72.60 17.00
45307 04 N M 72.60 17.00
45308 04 N I 125.50
45309 04 N I 125.50
45315 04 N I 107.00 17.00
45317 04 N I 76.85 17.00
45320 04 N M Y 201.30 56.70
Wednesday, April 01, 2009 Page 180 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
45321 04 N I 125.50 17.00
45327 04 N I 61.65
45330 04 N I 107.00 34.00
45331 04 N I 142.70 34.00
45332 04 N I 125.50 34.00
45333 04 N M 161.20 34.00
45334 04 N I 142.70 34.00
45335 04 N I 68.14
45337 04 N I 125.50 34.00
45338 04 N M 161.20
45339 04 N M 201.30
45340 04 N I 42.30
45341 04 N I 137.30
45342 04 N I 158.60
45345 04 N M 106.05
45355 04 N I 112.40 56.70
45378 04 N I 214.00 56.70
45379 04 N M 214.00 56.70
45380 04 N I 214.00 56.70
45381 04 N I 184.28
45382 04 N M 283.40 56.70
Wednesday, April 01, 2009 Page 181 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
45383 04 N M 285.40 56.70
45384 04 N M 285.40
45385 04 N M 285.40 56.70
45386 04 N I 108.86
45387 04 N M 215.35
45391 04 N M Y 204.00
45392 04 N I Y 214.00
45395 04 N I Y 1015.28
45397 04 N I Y 1103.45
45400 04 N I Y 592.90
45402 04 N I Y 805.75
45499 04 Y I Y
45500 04 N M Y 419.00
45505 04 N M Y 419.00
45520 04 N I 74.90
45540 04 N M Y 599.35
45541 04 N M Y 599.35
45550 04 N M Y Y 749.20
45560 04 N M Y 227.70
45562 04 N M Y Y 496.12
45563 04 N M Y Y 756.60
Wednesday, April 01, 2009 Page 182 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
45800 04 N M Y Y 599.35
45805 04 N M Y Y 674.20
45820 04 N M Y Y 599.35
45825 04 N M Y Y 674.20
45900 04 N I 44.40
45905 04 N I 58.05
45910 04 N I 73.40
45915 04 N I 77.60
45990 04 N I Y 58.42
45999 04 Y M Y
46020 04 N I 140.75
46030 04 N I 71.40 34.00
46040 04 N M 149.80
46045 04 N M 149.80
46050 04 N I 71.40 34.00
46060 04 N M 471.70
46070 04 N I 81.20
46080 04 N I 119.25
46083 04 N I 64.10 17.00
46200 04 N M 262.20
46210 04 N I 93.50 17.00
Wednesday, April 01, 2009 Page 183 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
46211 04 N I 129.45 17.00
46220 04 N I 71.40 17.00
46221 04 N I 107.00 17.00
46230 04 N I 84.65 17.00
46250 04 N M 248.30 34.00
46255 04 N M 342.65
46257 04 N M 417.60
46258 04 N M 471.70
46260 04 N M 449.50
46261 04 N M 524.40
46262 04 N M 578.55
46270 04 N M 471.70
46275 04 N M 471.70
46280 04 N M Y 471.70
46285 04 N M 471.70
46288 04 N M Y Y 471.70
46320 04 N I 62.90 17.00
46500 04 N I 51.50 17.00
46505 04 N I Y 102.99
46600 04 N I 19.80 17.00
46604 04 N I 34.10 17.00
Wednesday, April 01, 2009 Page 184 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
46606 04 N I 24.20 17.00
46608 04 N I 49.85 17.00
46610 04 N I 71.40 17.00
46611 04 N I 71.40
46612 04 N I 89.85 17.00
46614 04 N I 62.00 17.00
46615 04 N I 91.06
46700 04 N M Y 299.70
46705 04 N M Y 299.70
46706 04 N I Y 62.32
46710 04 N I 530.10
46712 04 N I 1118.22
46715 04 N M Y 449.50
46716 04 N M Y 449.50
46730 04 N M Y 571.25
46735 04 N M Y Y 1079.30
46740 04 N M Y Y 788.65
46742 04 N M Y Y 1079.30
46744 04 N M Y Y 918.15
46746 04 N M Y Y 1139.40
46748 04 N M Y Y 1139.40
Wednesday, April 01, 2009 Page 185 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
46750 04 N M Y 419.00
46751 04 N M Y 419.00
46753 04 N I Y 187.90
46754 04 N I 134.60
46760 04 N M Y 524.40
46761 04 N M Y 524.40
46762 04 N M Y 739.90
46900 04 N I 62.70 17.00
46910 04 N I 108.30 17.00
46916 04 N I 108.30 34.00
46917 04 N I 108.30 34.00
46922 04 N I 108.30 17.00
46924 04 N M 181.00 17.00
46930 04 1/1/2009 N M 127.20
46937 04 N I 96.95 34.00
46938 04 N I 148.20 34.00
46940 04 N I 68.50 17.00
46942 04 N I 61.15 17.00
46945 04 N I 72.45 17.00
46946 04 N I 112.40
46947 04 N M 342.65
Wednesday, April 01, 2009 Page 186 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
46999 04 Y M Y
47000 04 N I 106.80
47001 04 N I 65.90
47010 04 N M Y 599.35
47011 04 N M Y Y 599.35
47015 04 N M Y Y 480.00
47100 04 N M Y 480.00
47120 04 N M Y 682.60
47122 04 N M Y Y 1048.85
47125 04 N M Y Y 1048.85
47130 04 N M Y Y 1048.85
47133 04 N M Y Y 1048.85
47135 04 N M Y Y 3299.30
47136 04 N M Y Y 3299.30
47140 04 N M Y Y 1660.18
47141 04 N M Y Y 2001.23
47142 04 N M Y Y 2201.17
47300 04 N M Y 718.70
47350 04 N M Y 659.00
47360 04 N M Y 697.90
47361 04 N M Y 810.10
Wednesday, April 01, 2009 Page 187 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
47362 04 N M Y 523.85
47370 04 N M Y Y 761.10
47371 04 N M Y Y 761.10
47379 04 Y M Y Y
47380 04 N M Y Y 892.80
47381 04 N M Y 892.80
47382 04 N M 474.20
47399 04 Y M Y
47400 04 N M Y 718.70
47420 04 N M Y 647.90
47425 04 N M Y 682.60
47460 04 N M Y 463.80
47480 04 N M Y 647.90
47490 04 N M 599.35
47500 04 N I 50.75
47505 04 N I 127.50
47510 04 N M 230.75
47511 04 N M 284.60
47525 04 N I Y 129.90
47530 04 N M 199.80
47550 04 N M 94.30
Wednesday, April 01, 2009 Page 188 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
47552 04 N I 135.70
47553 04 N I 155.75
47554 04 N I 220.30
47555 04 N I 169.10
47556 04 N I 187.90
47560 04 N M Y 299.70
47561 04 N M Y 317.60
47562 04 N M Y 647.90
47563 04 N M Y 699.20
47564 04 N M Y 801.90
47570 04 N M Y 685.40
47579 04 Y M Y
47600 04 N M Y 647.90
47605 04 N M Y 699.20
47610 04 N M Y 801.90
47612 04 N M Y 801.90
47620 04 N M Y 801.90
47630 04 N M Y 299.70
47700 04 N M Y 449.50
47701 04 N M Y Y 685.40
47711 04 N M Y Y 801.90
Wednesday, April 01, 2009 Page 189 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
47712 04 N M Y Y 1198.70
47715 04 N M Y Y 862.30
47720 04 N M Y Y 685.40
47721 04 N M Y Y 1044.70
47740 04 N M Y Y 685.40
47741 04 N M Y Y 1044.70
47760 04 N M Y Y 685.40
47765 04 N M Y Y 1438.70
47780 04 N M Y Y 770.00
47785 04 N M Y Y 1438.70
47800 04 N M Y Y 770.00
47801 04 N M Y 621.95
47802 04 N M Y 948.90
47900 04 N M Y Y 621.95
47999 04 Y M
48000 04 N M Y 718.70
48001 04 N M Y Y 801.90
48020 04 N M Y 839.35
48100 04 N M Y 480.00
48102 04 N I Y 154.90
48105 04 1/1/2007 N M Y 810.10
Wednesday, April 01, 2009 Page 190 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
48120 04 N M Y 599.35
48140 04 N M Y Y 839.35
48145 04 N M Y Y 1438.70
48146 04 N M Y 1438.70
48148 04 N M Y 859.00
48150 04 N M Y Y 1438.70
48152 04 N M Y Y 1438.70
48153 04 N M Y Y 1438.70
48154 04 N M Y Y 1438.70
48155 04 N M Y Y 1438.70
48160 04 N M Y Y 2397.40
48400 04 N I 47.30
48500 04 N M Y 839.35
48510 04 N M Y 839.35
48511 04 N M Y Y 839.35
48520 04 N M Y Y 839.35
48540 04 N M Y Y 839.35
48545 04 N M Y Y 599.35
48547 04 N M Y Y 718.70
48548 04 1/1/2007 N M Y 958.60
48550 04 N M Y Y 599.35
Wednesday, April 01, 2009 Page 191 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
48554 04 N M Y Y 2397.40
48556 04 N M Y 599.35
48999 04 Y M Y
49000 04 N M Y 480.00
49002 04 N M Y 480.00
49010 04 N M Y 480.00
49020 04 N M Y 480.00
49021 04 N M 314.60
49040 04 N M Y 480.00
49041 04 N M Y Y 480.00
49060 04 N M Y 480.00
49061 04 N M Y Y 480.00
49062 04 N M Y 480.00
49080 04 N I 71.40 34.00
49081 04 N I 71.40 34.00
49180 04 N I 106.80
49203 04 1/1/2008 N M Y 480.00
49204 04 1/1/2008 N M Y 704.75
49205 04 1/1/2008 N M Y 947.27
49215 04 N M Y Y 766.90
49220 04 N M Y 998.80
Wednesday, April 01, 2009 Page 192 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
49250 04 N M Y 374.55
49255 04 N M Y 599.35
49320 04 N M Y 302.40
49321 04 N M Y 302.40
49322 04 Y M Y
49323 04 N M Y 480.00
49324 04 1/1/2007 N M Y 480.00
49325 04 1/1/2007 N M Y 480.00
49326 04 1/1/2007 N M Y 480.00
49329 04 Y M Y
49400 04 N I 47.00
49402 04 1/1/2007 N M Y 406.05
49419 04 N M Y 180.46
49420 04 N I 74.90
49421 04 N M 299.70
49422 04 N M 240.00
49423 04 N M 262.20
49424 04 N I 20.95
49425 04 N M Y Y 718.70
49426 04 Y M Y
49427 04 N I 37.40
Wednesday, April 01, 2009 Page 193 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
49428 04 Y M Y Y
49429 04 Y M Y Y
49435 04 1/1/2007 N M 60.90
49436 04 1/1/2007 N M 88.75
49440 04 1/1/2008 N I Y 133.76 465.96
49441 04 1/1/2008 N I Y 144.19 563.56
49442 04 1/1/2008 N I Y 119.66 457.55
49446 04 1/1/2008 N I Y 94.47 493.61
49450 04 1/1/2008 Y I Y
49451 04 1/1/2008 Y I Y
49452 04 1/1/2008 Y I Y
49460 04 1/1/2008 N I Y 27.00 406.44
49465 04 1/1/2008 N I Y 17.80 73.55
49491 04 N M Y Y 433.70
49492 04 N M Y Y 535.00
49495 04 N M Y 362.00
49496 04 N M Y 362.00
49500 04 N M Y 362.00
49501 04 N M Y 387.05
49505 04 N M Y 387.05
49507 04 N M Y 387.05
Wednesday, April 01, 2009 Page 194 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
49520 04 N M Y 409.20
49521 04 N M Y 387.05
49525 04 N M Y 464.80
49540 04 N M Y 337.10
49550 04 N M Y 409.20
49553 04 N M Y 409.20
49555 04 N M Y 460.60
49557 04 N M Y 460.60
49560 04 N M Y 503.60
49561 04 N M Y 503.60
49565 04 N M Y 546.65
49566 04 N M Y 572.50
49568 04 N M Y 460.60
49570 04 N M Y 345.50
49572 04 N M Y 345.50
49580 04 N M Y Y 342.65
49582 04 N M Y 374.55
49585 04 N M Y 374.55
49587 04 N M Y 374.55
49590 04 N M Y 374.55
49600 04 N M Y 275.80
Wednesday, April 01, 2009 Page 195 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
49605 04 N M Y 573.10
49606 04 Y M Y
49610 04 N M Y 599.35
49611 04 N M Y 449.50
49650 04 N M Y 387.05
49651 04 N M Y 409.20
49652 04 1/1/2009 N M Y 387.05
49653 04 1/1/2009 N M Y 387.05
49654 04 1/1/2009 N M Y 387.05
49655 04 1/1/2009 N M Y 387.05
49656 04 1/1/2009 N M Y 387.05
49657 04 1/1/2009 N M Y 387.05
49659 04 Y M Y
49900 04 N M Y 307.05
49904 04 N M Y Y 617.40
49905 04 N M Y Y 442.90
49906 04 N M Y Y 1306.65
49999 04 Y M Y
50010 04 N M Y 480.00
50020 04 N M Y 398.35
50021 04 N M 299.70
Wednesday, April 01, 2009 Page 196 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
50040 04 N M Y 775.60
50045 04 N M Y 718.70
50060 04 N M Y 718.70
50065 04 N M Y 599.35
50070 04 N M Y 749.20
50075 04 N M Y 749.20
50080 04 N M 434.20
50081 04 N M 600.55
50100 04 N M Y 767.20
50120 04 N M Y 839.35
50125 04 N M Y 839.35
50130 04 N M Y 837.90
50135 04 Y M Y Y
50200 04 N I 112.40
50205 04 N M Y 480.00
50220 04 N M Y Y 933.80
50225 04 N M Y Y 933.80
50230 04 N M Y Y 1057.20
50234 04 N M Y Y 933.80
50236 04 Y M Y Y
50240 04 N M Y 749.20
Wednesday, April 01, 2009 Page 197 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
50250 04 N M Y 373.74
50280 04 N M Y 718.70
50290 04 N M Y 718.70
50300 04 Y M Y
50320 04 N M Y Y 933.80
50323 09 Y M
50328 09 Y M
50340 04 N M Y 933.80
50360 04 N M Y Y 1366.60
50365 04 N M Y Y 1833.45
50370 04 N M Y Y 933.80
50380 04 Y M Y Y
50382 04 N I 163.58
50384 04 N I 148.92
50385 04 1/1/2008 N M Y 137.81 572.99
50386 04 1/1/2008 N M Y 104.23 356.14
50387 04 N I 59.20
50389 04 N I 32.75
50390 04 N I 119.25
50391 04 N I 117.95
50392 04 N I 119.25
Wednesday, April 01, 2009 Page 198 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
50393 04 N I Y Y 119.25
50394 04 N I 117.35
50395 04 N I 119.25
50396 04 N I 50.20 34.00
50398 04 N I 36.70 34.00
50400 04 N M Y Y 958.60
50405 04 N M Y Y 958.60
50500 04 N M Y 718.70
50520 04 N M Y 480.00
50525 04 N M Y 674.20
50526 04 N M Y 674.20
50540 04 N M Y Y 1198.70
50541 04 N M Y 718.70
50542 04 N M Y Y 718.70
50543 04 N M Y Y 749.20
50544 04 N M Y 958.60
50545 04 N M Y Y 906.40
50546 04 N M 933.80
50547 04 N M Y Y 933.80
50548 04 N M Y 933.80
50549 04 Y M Y
Wednesday, April 01, 2009 Page 199 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
50551 04 N I 151.00 56.70
50553 04 N I 245.35 56.70
50555 04 N I 250.35 56.70
50557 04 N I 294.80 56.70
50561 04 N I 301.85 56.70
50562 04 N M 301.95
50570 04 N I 204.70
50572 04 N I 268.20
50574 04 N I 281.05
50575 04 N I 365.15
50576 04 N I 294.80
50580 04 N I 269.70
50590 04 N M Y Y 749.20
50592 04 N I 214.22
50593 04 1/1/2008 N M Y 267.81 2228.0
50600 04 N M Y 718.70
50605 04 N M Y 738.10
50610 04 N M Y 738.10
50620 04 N M Y 738.10
50630 04 N M Y 738.10
50650 04 N M Y 599.35
Wednesday, April 01, 2009 Page 200 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
50660 04 N M Y Y 599.35
50684 04 N I 120.00 17.00
50686 04 N I 64.10 34.00
50688 04 N I 37.40 34.00
50690 04 N I 129.70 17.00
50700 04 N M Y 958.60
50715 04 N M Y 749.20
50722 04 N M Y 749.20
50725 04 N M Y 958.60
50727 04 N M Y Y 455.80
50728 04 N M Y Y 567.10
50740 04 N M Y 958.60
50750 04 N M Y 958.60
50760 04 N M Y 958.60
50770 04 N M Y 958.60
50780 04 N M Y 958.60
50782 04 N M Y Y 945.15
50783 04 N M Y Y 945.15
50785 04 N M Y 958.60
50800 04 N M Y 718.70
50810 04 N M Y 718.70
Wednesday, April 01, 2009 Page 201 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
50815 04 N M Y 718.70
50820 04 N M Y 718.70
50825 04 N M Y Y 1438.70
50830 04 Y M Y Y
50840 04 N M Y 718.70
50845 04 Y M Y
50860 04 N M Y 958.60
50900 04 N M Y Y 958.60
50920 04 N M Y 480.00
50930 04 N M Y 629.90
50940 04 N M Y 934.70
50945 04 N M Y 738.10
50947 04 N M Y Y 973.55
50948 04 N M Y 890.50
50949 04 Y M Y Y
50951 04 N I 152.60 56.70
50953 04 N I 251.25 56.70
50955 04 N I 235.50 56.70
50957 04 N I 236.20 56.70
50961 04 N M 297.95 56.70
50970 04 N I 187.70
Wednesday, April 01, 2009 Page 202 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
50972 04 N I 152.10
50974 04 N I 243.40
50976 04 N I 236.20
50980 04 N M 262.20
51020 04 N M Y 524.40
51030 04 N M Y 524.40
51040 04 N M Y 449.50
51045 04 N M Y 449.50
51050 04 N M Y 599.35
51060 04 N M Y 738.10
51065 04 N M Y 738.10
51080 04 N M Y 599.35
51100 04 1/1/2008 N I 22.55 13.02
51101 04 1/1/2008 N I 30.11 41.49
51102 04 1/1/2008 N I 141.08 47.69
51500 04 N M Y 599.35
51520 04 N M Y 480.00
51525 04 N M Y 718.70
51530 04 N M Y 599.35
51535 04 N M Y 599.35
51550 04 N M Y 599.35
Wednesday, April 01, 2009 Page 203 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
51555 04 N M Y 599.35
51565 04 N M Y Y 958.60
51570 04 N M Y Y 749.20
51575 04 N M Y Y 1198.70
51580 04 N M Y Y 1438.70
51585 04 N M Y Y 1438.70
51590 04 N M Y Y 1438.70
51595 04 N M Y Y 1498.30
51596 04 N M Y Y 1438.70
51597 04 N M Y Y 1498.30
51600 04 N I 121.35 17.00
51605 04 N I 121.35 17.00
51610 04 N I 130.80 17.00
51700 04 N I 44.60
51701 04 N I 24.02
51702 04 N I 24.02
51703 04 N I 26.18
51705 04 N I 38.85 17.00
51710 04 N I 66.85 17.00
51715 04 N I 295.95
51720 04 N I 66.85 17.00
Wednesday, April 01, 2009 Page 204 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
51725 04 N I 44.40
51726 04 N I 50.05
51736 04 N I 17.30
51741 04 N I 52.70
51772 04 N I 45.00
51784 04 N I 52.70
51785 04 N I 52.70
51792 04 N I 74.90
51795 04 N I 51.50
51797 04 N I 45.00
51798 A 04 N I 8.78 8.78 17.56
51800 04 N M Y 599.35
51820 04 N M Y 839.35
51840 04 N M Y 631.25
51841 04 N M Y 631.25
51845 04 N M Y 631.25
51860 04 N M Y Y 599.35
51865 04 N M Y Y 599.35
51880 04 N M 216.65
51900 04 N M Y 958.60
51920 04 N M Y 958.60
Wednesday, April 01, 2009 Page 205 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
51925 04 N M Y 958.60
51940 04 N M Y 839.35
51960 04 N M Y 1105.80
51980 04 N M Y 449.50
51990 04 N M Y 631.25
51992 04 N M Y 631.25
51999 04 Y M
52000 04 N I 85.90 56.70
52001 04 N I 90.40
52005 04 N I 118.90 56.70
52007 04 N M 154.60 56.70
52010 04 N I 118.90 56.70
52204 04 N I 163.90 56.70
52214 04 N M 178.30 56.70
52224 04 N M 295.95 56.70
52234 04 N M 374.55
52235 04 N M 374.55
52240 04 N M 524.40
52250 04 N I 141.30 56.70
52260 04 N I 149.80
52265 04 N I 142.70 56.70
Wednesday, April 01, 2009 Page 206 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
52270 04 N M 180.30
52275 04 N M 194.20
52276 04 N M 209.40
52277 04 N M 180.30
52281 04 N I 134.80 56.70
52282 04 N I 204.10 56.70
52283 04 N I 149.80
52285 04 N I 135.70
52290 04 N M 184.50
52300 04 N M 240.00
52301 04 N M 240.00
52305 04 N M 297.00
52310 04 N I 180.30 56.70
52315 04 N M 239.00 56.70
52317 04 N M Y Y 342.15 56.70
52318 04 N M Y Y 339.25 56.70
52320 04 N M 249.70 56.70
52325 04 N M 379.40
52327 04 N I 295.95
52330 04 N M 260.80 56.70
52332 04 N I 138.90
Wednesday, April 01, 2009 Page 207 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
52334 04 N M 308.35
52341 04 N M 224.45
52342 04 N M 242.90
52343 04 N M 269.10
52344 04 N M 287.60
52345 04 N M 306.60
52346 04 N M 344.90
52351 04 N I 178.30
52352 04 N M 293.75
52353 04 N M 262.20
52354 04 N M 249.70
52355 04 N M 337.00
52400 04 N M 398.85
52402 04 N M 537.15
52450 04 N M 249.00
52500 04 N M 480.00
52601 04 N M 775.60
52630 04 N M 599.35
52640 04 N M 486.90
52647 04 N M 599.35
52648 04 N M 599.35
Wednesday, April 01, 2009 Page 208 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
52649 04 1/1/2008 N M Y 562.42
52700 04 N M 314.95
52920 04 Y Y
53000 04 N M Y 240.00
53010 04 N M 314.95
53020 04 N I 67.80 17.00
53025 04 N I 58.60 17.00
53040 04 N I 197.80 17.00
53060 04 N I 95.30 17.00
53080 04 Y M 17.00
53085 04 Y M
53200 04 N I 92.70 17.00
53210 04 N M 449.50
53215 04 N M 524.40
53220 04 N M 449.50
53230 04 N M Y 599.35
53235 04 N M Y 599.35
53240 04 N M 449.50
53250 04 Y M 34.00
53260 04 N I 113.60 34.00
53265 04 N I 115.00 34.00
Wednesday, April 01, 2009 Page 209 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
53270 04 N I 113.60 34.00
53275 04 N I 122.20 34.00
53400 04 N M Y 599.35
53405 04 N M Y 599.35
53410 04 N M Y 599.35
53415 04 N M Y 745.30
53420 04 N M Y 599.35
53425 04 N M Y 449.50
53430 04 N M 517.40
53431 04 N M 709.95
53440 04 N M 599.35
53442 04 N M Y 449.50
53444 04 N M 540.40
53445 04 Y M
53446 04 N M 494.90
53447 04 N M 449.50
53448 04 N M 842.25
53449 04 Y M
53450 04 N M 164.30
53460 04 N M 224.70
53500 04 N M Y Y 386.25
Wednesday, April 01, 2009 Page 210 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
53502 04 Y M
53505 04 Y M
53510 04 Y M
53515 04 Y M
53520 04 N M 314.95
53600 04 N I 52.80
53601 04 N I 47.80
53605 04 N I 47.80
53620 04 N I 75.10
53621 04 N I 69.55
53660 04 N I 41.80
53661 04 N I 42.10
53665 04 N I 36.00
53850 04 N M 576.80
53852 04 N M 576.80
53899 04 Y M Y
54000 04 N I 74.90 17.00
54001 04 N I 87.85 17.00
54015 04 N I 156.75 17.00
54050 04 N I 52.70 17.00
54055 04 N I 72.10 17.00
Wednesday, April 01, 2009 Page 211 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
54056 04 N I 71.40 17.00
54057 04 N I 71.40 17.00
54060 04 N I 88.50 17.00
54065 04 N I 107.00 34.00
54100 04 N I 88.50 17.00
54105 04 N I 114.25 17.00
54110 04 N M 321.45
54111 04 N M 585.75
54112 04 N M 717.90
54115 04 Y M
54120 04 N M Y 285.10
54125 04 N M Y 449.50
54130 04 N M Y Y 749.20
54135 04 N M Y Y 749.20
54150 04 N I 77.50
54160 04 N I 99.80
54161 04 N I 146.70 34.00
54162 04 N I 97.25
54163 04 N I 137.40
54164 04 N I 120.30
54200 04 N I 38.60
Wednesday, April 01, 2009 Page 212 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
54205 04 Y I
54220 04 N M 299.70
54230 04 N I 38.20
54231 04 N I 118.80
54235 04 N I Y 37.40
54240 09 Y I
54250 04 N I 54.55
54300 04 N M Y Y 425.80
54304 04 N M Y 670.10
54308 04 N M Y 599.35
54312 04 N M Y 670.10
54316 04 N M Y 670.10
54318 04 N M Y 670.10
54322 04 N M Y 480.00
54324 04 N M Y 538.00
54326 04 N M Y 670.10
54328 04 N M Y 958.60
54332 04 N M Y Y 670.10
54336 04 N M Y Y 958.60
54340 04 N M Y 538.00
54344 04 N M Y 670.10
Wednesday, April 01, 2009 Page 213 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
54348 04 N M Y 958.60
54352 04 Y M Y Y
54360 04 N M Y Y 690.78
54380 04 N M Y 386.30
54385 04 N M Y 446.00
54390 04 N M Y 600.70
54400 09 Y M
54401 09 Y M
54405 09 Y M
54406 09 Y M
54408 09 Y M
54410 09 Y M
54411 09 Y M
54415 09 Y M
54416 09 Y M
54417 09 Y M
54420 04 N M Y 409.20
54430 04 N M Y 409.20
54435 04 N M 405.10
54440 04 N M Y 224.70
54450 04 N I 37.45
Wednesday, April 01, 2009 Page 214 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
54500 04 N I 68.20 17.00
54505 04 N I 113.60 17.00
54512 04 N M 356.05
54520 04 N M Y 351.00
54522 04 N M 404.20
54530 04 N M Y 958.60
54535 04 N M Y 958.60
54550 04 N M Y 359.30
54560 04 N M Y 480.00
54600 04 N M Y 359.30
54620 04 N M Y 299.70
54640 04 N M Y 504.90
54650 04 N M Y 480.00
54660 09 Y M
54670 04 Y M
54680 04 Y M Y
54690 04 N M Y 351.00
54692 04 N M Y 504.90
54699 04 Y M Y
54700 04 N I 128.30 17.00
54800 04 N I 119.25
Wednesday, April 01, 2009 Page 215 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
54830 04 N M 299.70
54840 04 N M 299.70
54860 04 N M 359.30
54861 04 N M 480.00
54865 04 1/1/2007 N M 179.47
54900 04 N M Y 480.00
54901 04 N M Y 599.35
55000 04 N I 42.35 17.00
55040 04 N M Y 299.70
55041 04 N M 449.50
55060 04 N M Y 259.40
55100 04 N I 110.90 17.00
55110 04 Y M
55120 04 N I 129.30 17.00
55150 04 N I 206.10
55175 04 Y M
55180 04 Y M Y
55200 04 N I 147.95 56.70
55250 04 N I 147.95 56.70
55300 04 N I 112.40
55400 04 Y M Y
Wednesday, April 01, 2009 Page 216 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
55450 04 N M 150.40 56.70
55500 04 N M 359.30
55520 04 N M 240.00
55530 04 N M 359.30
55535 04 N M Y 359.30
55540 04 N M Y 480.00
55550 04 N M Y 359.30
55559 04 Y M Y
55600 04 N I 178.30
55605 04 N M 223.60
55650 04 N M Y 958.60
55680 04 N I Y 299.70
55700 04 N I 113.60 17.00
55705 04 N M 187.30
55706 04 1/1/2009 N I 291.03
55720 04 N M 359.30
55725 04 N M 359.30
55801 04 N M Y 839.35
55810 04 N M Y 1198.70
55812 04 N M Y 1678.65
55815 04 N M Y 1809.25
Wednesday, April 01, 2009 Page 217 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
55821 04 N M Y 958.60
55831 04 N M Y 958.60
55840 04 N M Y Y 1198.70
55842 04 N M Y 1285.40
55845 04 N M Y Y 1438.70
55860 04 Y M Y
55862 04 Y M Y
55865 04 Y M Y Y
55866 04 Y M Y Y
55870 09 Y I
55873 04 N M Y 739.15
55875 04 1/1/2007 N M Y 359.30
55876 04 1/1/2007 N M Y 59.34
55899 04 Y M Y Y
55920 04 1/1/2008 N M Y 246.06
56405 04 N I 95.05
56420 04 N I 103.05 17.00
56440 04 N M 202.50
56441 04 N I 127.90
56442 04 1/1/2007 N I 68.65
56501 04 N I Y 52.70 17.00
Wednesday, April 01, 2009 Page 218 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
56515 04 N M Y 181.00 34.00
56605 04 N I 108.30
56606 04 N I 35.65
56620 04 N M Y 335.70
56625 04 N M Y 480.00
56630 04 N M Y 524.40
56631 04 N M Y 511.20
56632 04 N M Y 599.65
56633 04 N M Y 524.40
56634 04 N M Y 599.35
56637 04 N M Y 749.20
56640 04 N M Y 749.20
56700 04 N I 113.60
56740 04 N M 226.10
56800 04 N I 119.25
56805 04 N M 496.90
56810 04 N M Y 190.00
56820 04 N I 37.40
56821 04 N I 50.20
57000 04 N M 202.55
57010 04 N M 224.70
Wednesday, April 01, 2009 Page 219 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
57020 04 N I 79.30 17.00
57022 04 N I 109.50
57023 04 N I 109.50
57061 04 N I 45.40 17.00
57065 04 N I 91.35
57100 04 N I 107.00 17.00
57105 04 N I 107.00 17.00
57106 04 N M Y 299.70
57107 04 N M Y 544.50
57109 04 N M Y 782.80
57110 04 N M Y 374.30
57111 04 N M Y 782.80
57112 04 N M Y 1022.80
57120 04 N M Y 299.70
57130 04 N M 180.30
57135 04 N I 121.55 17.00
57150 04 N I 18.25
57155 04 N I 257.40
57160 04 N I 27.65
57170 04 N I 28.60
57180 04 N I 48.75 17.00
Wednesday, April 01, 2009 Page 220 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
57200 04 N M 188.90 34.00
57210 04 N M 206.05 34.00
57220 04 N M 355.10
57230 04 N M 517.40
57240 04 N M Y 355.10
57250 04 N M Y 314.95
57260 04 N M Y 525.80
57265 04 N M Y 532.80
57267 04 N M 167.79
57268 04 N M Y 532.80
57270 04 N M Y 480.00
57280 04 N M 599.35
57282 04 N M Y 480.00
57283 04 N M Y 599.35
57284 04 N M 532.80
57285 04 1/1/2008 N M Y Y 352.36
57287 04 N M Y 467.50
57288 04 N M Y Y 631.25
57289 04 N M Y 674.20
57291 04 Y M Y Y
57292 04 Y M Y Y
Wednesday, April 01, 2009 Page 221 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
57295 04 N M 269.31
57296 04 1/1/2007 N M 481.19
57300 04 N M Y 466.15
57305 04 N M Y 1127.90
57307 04 N M Y 1127.90
57308 04 N M Y Y 728.35
57310 04 N M Y 718.70
57311 04 N M Y 799.70
57320 04 N M Y 597.90
57330 04 N M Y 524.40
57335 04 N M 466.15
57400 04 N I 111.00
57410 04 N I 53.30
57415 04 N I Y 111.00
57420 04 N I 37.40
57421 04 N I 50.20
57423 04 1/1/2008 N M Y Y 497.75
57425 04 N M Y 487.77
57452 04 N I 37.40
57454 04 N I 50.20 34.00
57455 04 N I 50.20
Wednesday, April 01, 2009 Page 222 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
57456 04 N I 50.20
57460 04 N I Y 77.00 34.00
57461 04 N I 172.05
57500 04 N I 142.70 17.00
57505 04 N I 48.55
57510 04 N I 60.60
57511 04 N I 58.10
57513 04 N I 131.10
57520 04 N M 321.90
57522 04 N M 305.80 34.00
57530 04 N M Y 308.00
57531 04 N M Y Y 1030.80
57540 04 N M Y 599.35
57545 04 N M Y 599.35
57550 04 N M Y 599.35
57555 04 N M Y 674.20
57556 04 N M Y 674.20
57558 04 1/1/2007 N I 149.80
57700 04 N M 313.50
57720 04 N M 559.30
57800 04 N I 119.25
Wednesday, April 01, 2009 Page 223 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
58100 04 N I 52.90 34.00
58110 04 N M 24.90
58120 04 N M 206.85
58140 04 N M Y 718.70
58145 04 N M Y 718.70
58146 04 N M Y 718.70
58150 04 N M Y 772.70
58152 04 N M Y 1096.05
58180 04 N M Y 652.05
58200 04 N M Y 772.70
58210 04 N M Y 1030.80
58240 04 N M Y 1423.45
58260 04 N M Y 725.60
58262 04 N M Y 725.60
58263 04 N M Y 725.60
58267 04 N M Y 856.00
58270 04 N M Y 856.00
58275 04 N M Y 875.40
58280 04 N M Y 800.50
58285 04 N M Y 950.30
58290 04 N M Y 725.60
Wednesday, April 01, 2009 Page 224 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
58291 04 N M Y 725.60
58292 04 N M Y 725.60
58293 04 N M Y 856.00
58294 04 N M Y 856.00
58300 04 N I 44.00
58301 04 N I 37.40
58340 04 N I 93.40
58346 04 N I 274.00
58350 04 N I 37.50
58353 04 N I Y 150.60
58356 04 N M 201.30
58400 04 N M Y 449.50
58410 04 N M Y 449.50
58520 04 N M Y 480.00
58540 04 N M Y 501.38
58541 04 1/1/2007 N M Y 433.94
58542 04 1/1/2007 N M Y 479.33
58543 04 1/1/2007 N M Y 487.55
58544 04 1/1/2007 N M Y 528.11
58545 04 N M Y 480.00
58546 04 N M Y 480.00
Wednesday, April 01, 2009 Page 225 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
58548 04 1/1/2007 N M Y 924.56
58550 04 N M Y 725.60
58552 04 N M Y 725.00
58553 04 N M Y 725.00
58554 04 N M Y 725.00
58555 04 N I 95.75
58558 04 N I 145.80
58559 04 N I 160.80
58560 04 N I 160.80
58561 04 N M 361.85
58562 04 N M 361.85
58563 04 N I 300.43
58565 04 N M 327.45
58570 04 1/1/2008 N M Y Y 496.17
58571 04 1/1/2008 N M Y Y 542.05
58572 04 1/1/2008 N M Y Y 617.19
58573 04 1/1/2008 N M Y Y 693.59
58578 04 Y M
58579 04 Y M
58600 04 N M Y 327.45
58605 04 N M Y 327.45
Wednesday, April 01, 2009 Page 226 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
58611 04 N M Y 97.30
58615 04 N M 327.45
58660 04 N M Y 302.40
58661 04 N M Y 480.00
58662 04 N M Y 302.40
58670 04 N M 363.45
58671 04 N M 363.45
58672 09 Y M
58673 04 N M Y 480.00
58679 04 Y M
58700 04 N M Y 481.90
58720 04 N M Y 525.85
58740 04 N M Y 480.00
58752 09 Y M
58770 04 N M Y 480.00
58800 04 N M Y 359.30
58805 04 N M Y 480.00
58820 04 N M Y 240.00
58822 04 N M Y 480.00
58823 04 N M 302.90
58825 04 Y M Y
Wednesday, April 01, 2009 Page 227 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
58900 04 N M Y 480.00
58920 04 N M Y 529.95
58925 04 N M Y 524.40
58940 04 N M Y 554.90
58943 04 N M Y Y 958.60
58950 04 N M Y Y 704.70
58951 04 N M Y Y 898.95
58952 04 N M Y Y 958.60
58953 04 N M Y Y 1241.75
58954 04 N M Y Y 1350.35
58956 04 N M Y Y 1241.75
58957 04 1/1/2007 N M Y 749.43
58958 04 1/1/2007 N M Y 830.11
58960 04 N M Y Y 599.35
58999 04 Y M Y
59000 04 N I 58.35 34.00
59001 04 N B Y 89.80
59012 04 N I 115.00
59015 04 Y I
59020 C 04 N I 7.90 25.80 33.70
59025 C 04 N I 7.90 25.80 33.70
Wednesday, April 01, 2009 Page 228 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
59030 04 N I 79.00
59050 04 N I 25.40
59051 09 Y N
59070 04 N I 158.55
59074 04 N I 158.55
59076 04 N M Y 257.88
59100 04 N M Y 540.00
59120 04 N M Y 540.00
59121 04 N M Y 540.00
59130 04 N M Y 540.00
59135 04 N M Y 696.15
59136 04 N M Y 540.00
59140 04 N M Y 540.00
59150 04 N M Y 540.00
59151 04 N M Y 540.00
59160 04 N M 199.95
59200 04 N B 27.80
59300 04 N B 74.95
59320 04 N M 282.45
59325 04 N M Y 540.10
59350 04 N M Y 540.00
Wednesday, April 01, 2009 Page 229 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
59409 Q 04 4/1/2009 N B 924.45
59410 Q 04 4/1/2009 N B 924.45
59412 04 N B 72.95
59414 04 N B 67.50
59430 04 N B 50.15
59510 09 Y N
59514 Q 04 4/1/2009 N B Y 1070.45
59515 Q 04 4/1/2009 N B Y 1070.45
59525 04 N M Y 299.30
59610 09 Y N
59612 Q 04 4/1/2009 N B 924.45
59614 Q 04 4/1/2009 N B 924.45
59618 09 Y B
59620 Q 04 4/1/2009 N B Y 1070.45
59622 Q 04 4/1/2009 N B Y 1070.45
59812 04 N M 298.70
59820 04 N M 199.95
59821 04 N M Y 298.70
59830 04 N M Y 223.70
59840 04 N M Y 199.95
59841 04 N B 199.95
Wednesday, April 01, 2009 Page 230 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
59850 04 N M Y 199.95
59851 04 N M Y 199.95
59855 04 N M Y 199.95
59856 04 N M Y 199.95
59857 04 N M Y 199.95
59866 09 Y M
59870 04 N M Y 389.25
59871 04 N I Y 66.95
59897 04 Y M Y
59898 09 Y B
59899 04 Y B Y
60000 04 N I 113.60 17.00
60100 04 N I 50.20 17.00
60200 04 N M Y 360.70
60210 04 N M Y Y 550.90
60212 04 N M Y Y 718.70
60220 04 N M Y Y 703.30
60225 04 N M Y Y 703.30
60240 04 N M Y Y 718.70
60252 04 N M Y Y 1198.70
60254 04 N M Y Y 1198.70
Wednesday, April 01, 2009 Page 231 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
60260 04 N M Y Y 718.70
60270 04 N M Y Y 839.35
60271 04 N M Y Y 749.20
60280 04 N M Y Y 718.70
60281 04 N M Y 718.70
60300 04 1/1/2008 N I 27.75 27.05
60500 04 N M Y Y 839.35
60502 04 N M Y Y 839.35
60505 04 N M Y Y 839.35
60512 04 N M Y Y 135.00
60520 04 N M Y Y 749.20
60521 04 N M Y Y 839.35
60522 04 N M Y Y 1198.70
60540 04 N M Y Y 839.35
60545 04 N M Y Y 958.60
60600 04 N M Y Y 839.35
60605 04 N M Y Y 839.35
60650 04 N M Y 839.35
60659 04 Y M Y
60699 04 Y M Y
61000 04 N I 112.40
Wednesday, April 01, 2009 Page 232 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61020 04 N I 112.40
61026 04 N M 62.15
61050 04 N I 112.40
61055 04 N M 157.50
61070 04 N I 112.40
61105 04 N M Y Y 359.30
61107 04 N M Y 359.30
61108 04 N M Y 599.35
61120 04 N M Y Y 359.30
61140 04 N M Y Y 510.30
61150 04 N M Y Y 958.60
61151 04 N I Y Y 330.80
61154 04 N M Y Y 599.35
61156 04 N M Y Y 599.35
61210 04 N M Y Y 449.50
61215 04 N M Y 449.50
61250 04 N M Y Y 449.50
61253 04 N M Y Y 449.50
61304 04 N M Y Y 749.20
61305 04 N M Y Y 886.90
61312 04 N M Y Y 861.50
Wednesday, April 01, 2009 Page 233 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61313 04 N M Y Y 861.50
61314 04 N M Y Y 861.50
61315 04 N M Y Y 1198.70
61316 04 Y M Y Y
61320 04 N M Y Y 1123.70
61321 04 N M Y Y 1123.70
61322 04 N M Y Y 1123.70
61323 04 N M Y Y 1123.70
61330 04 N M Y Y 973.90
61332 04 N M Y Y 973.90
61333 04 N M Y Y 1198.70
61334 04 N M Y Y 1198.70
61340 04 N M Y Y 839.35
61343 04 N M Y Y 1738.80
61345 04 N M Y Y 1198.70
61440 04 N M Y Y 839.35
61450 04 N M Y Y 839.35
61458 04 N M Y Y 893.25
61460 04 N M Y Y 891.30
61470 04 N M Y Y 958.60
61480 04 N M Y Y 958.60
Wednesday, April 01, 2009 Page 234 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61490 04 N M Y Y 1198.70
61500 04 N M Y Y 1198.70
61501 04 N M Y Y 1198.70
61510 04 N M Y Y 1198.70
61512 04 N M Y Y 1198.70
61514 04 N M Y Y 1198.70
61516 04 N M Y Y 1198.70
61517 04 N I Y 49.85
61518 04 N M Y Y 1198.70
61519 04 N M Y Y 1271.10
61520 04 N M Y Y 1604.85
61521 04 N M Y Y 1351.20
61522 04 N M Y Y 1198.70
61524 04 N M Y Y 1198.70
61526 04 N M Y Y 1499.10
61530 04 N M Y Y 1327.00
61531 04 N M Y 1138.70
61533 04 N M Y Y 1138.70
61534 04 N M Y Y 1198.70
61535 04 Y M Y Y
61536 04 N M Y Y 1198.70
Wednesday, April 01, 2009 Page 235 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61537 04 N M Y Y 939.13
61538 04 N M Y Y 1198.70
61539 04 N M Y Y 1198.70
61540 04 N M Y Y 1134.13
61541 04 N M Y Y 1701.95
61542 04 N M Y Y 1198.70
61543 04 N M Y Y 1198.70
61544 04 N M Y Y 1198.70
61545 04 N M Y Y 1283.15
61546 04 N M Y Y 1198.70
61548 04 N M Y Y 1198.70
61550 04 N M Y Y 898.95
61552 04 N M Y Y 1198.70
61556 04 N M Y Y 1144.65
61557 04 N M Y Y 1690.50
61558 04 N M Y Y 1689.90
61559 04 N M Y Y 1689.90
61563 04 Y M Y Y
61564 04 Y M Y
61566 04 N M Y Y 1116.28
61567 04 N M Y Y 1270.28
Wednesday, April 01, 2009 Page 236 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61570 04 N M Y Y 1198.70
61571 04 N M Y Y 1198.70
61575 04 N M Y Y 1198.70
61576 04 N M Y Y 1630.70
61580 04 N M Y Y 1198.70
61581 04 N M Y 1630.70
61582 04 N M Y Y 1198.70
61583 04 N M Y Y 1306.65
61584 04 N M Y Y 1306.65
61585 04 N M Y Y 1630.70
61586 04 N M Y Y 1306.65
61590 04 N M Y Y 1630.70
61591 04 N M Y Y 1630.70
61592 04 N M Y Y 1630.70
61595 04 N M Y Y 1414.70
61596 04 N M Y Y 1630.70
61597 04 N M Y Y 1630.70
61598 04 N M Y Y 1522.70
61600 04 N M Y Y 1198.70
61601 04 N M Y Y 1198.70
61605 04 N M Y Y 1138.70
Wednesday, April 01, 2009 Page 237 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61606 04 N M Y Y 1198.70
61607 04 N M Y Y 1198.70
61608 04 N M Y Y 1274.80
61609 04 N M Y Y 1198.70
61610 04 N M Y Y 1306.65
61611 04 N M Y Y 1198.70
61612 04 N M Y Y 1306.65
61613 04 N M Y Y 1244.80
61615 04 N M Y Y 1198.70
61616 04 N M Y Y 1306.65
61618 04 N M Y Y 958.60
61619 04 Y M Y Y
61623 04 N I 241.20
61624 04 N M 682.80
61626 04 N M 682.80
61630 04 Y M
61635 04 Y M
61640 04 Y M
61641 04 Y M
61642 04 Y M
61680 04 N M Y Y 1048.85
Wednesday, April 01, 2009 Page 238 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61682 04 N M Y Y 1784.20
61684 04 N M Y Y 1231.20
61686 04 N M Y Y 1871.15
61690 04 N M Y Y 973.90
61692 04 N M Y Y 1480.90
61697 04 N M Y Y 2267.10
61698 04 N M Y 2182.15
61700 04 N M Y Y 1498.85
61702 04 N M Y Y 1481.20
61703 04 N M Y Y 718.70
61705 04 N M Y Y 1198.70
61708 04 N M Y Y 1198.70
61710 04 N M Y Y 787.40
61711 04 N M Y Y 1158.10
61720 04 N M Y Y 1198.70
61735 04 N M Y Y 1198.70
61750 04 N M Y Y 1306.65
61751 04 N M Y Y 1198.70
61760 04 N M Y Y 1138.70
61770 04 N M Y Y 749.20
61790 04 N M Y Y 749.20
Wednesday, April 01, 2009 Page 239 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
61791 04 N M Y Y 1198.70
61795 04 N M Y Y 230.30
61796 04 1/1/2009 N M Y 1198.70
61797 04 1/1/2009 N M Y 1198.70
61798 04 1/1/2009 N N 1198.70
61799 04 1/1/2009 N M Y 1198.70
61800 04 1/1/2009 N M Y 1198.70
61850 04 N M Y Y 749.20
61860 04 N M Y Y 1198.70
61863 04 N M Y Y 574.19
61867 04 N M Y Y 843.83
61870 04 N M Y Y 958.60
61875 04 N M Y Y 958.60
61880 04 N M Y Y 749.20
61885 04 N M Y Y 749.20
61886 04 N M Y Y 749.20
61888 04 N M Y Y 749.20
62000 04 N M Y Y 789.30
62005 04 N M Y Y 1347.10
62010 04 N M Y Y 1347.10
62100 04 N M Y Y 1198.70
Wednesday, April 01, 2009 Page 240 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
62115 04 N M Y 1296.20
62116 04 N M Y 1458.20
62117 04 N M Y 1458.20
62120 04 N M Y Y 698.40
62121 04 N M Y Y 1198.70
62140 04 N M Y Y 749.20
62141 04 N M Y Y 1048.85
62142 04 N M Y Y 749.20
62143 04 N M Y Y 1048.85
62145 04 N M Y Y 1198.70
62146 04 N M Y Y 1350.15
62147 04 N M Y Y 1458.20
62148 04 N M Y Y 105.00
62160 04 N M Y Y 156.52
62161 04 N M Y Y 985.60
62162 04 N M Y Y 1036.85
62163 04 N M Y Y 861.50
62164 04 N M Y Y 1198.70
62165 04 N M Y Y 1198.70
62180 04 N M Y Y 839.35
62190 04 N M Y Y 839.35
Wednesday, April 01, 2009 Page 241 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
62192 04 N M Y Y 761.60
62194 04 N M Y Y 599.35
62200 04 N M Y Y 839.35
62201 04 N M Y Y 1048.85
62220 04 N M Y Y 839.35
62223 04 N M Y Y 761.60
62225 04 N M Y Y 374.55
62230 04 N M Y Y 374.55
62252 04 N I Y 54.20
62256 04 N M Y Y 225.80
62258 04 N M Y Y 599.35
62263 04 N M 193.60
62264 04 N M 193.60
62267 04 1/1/2009 N M 481.80
62268 04 N M 449.50
62269 04 N M 449.50
62270 04 N I 53.70
62272 04 N I 59.10
62273 04 N I 74.90
62280 04 N I 158.20
62281 04 N I 81.10
Wednesday, April 01, 2009 Page 242 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
62282 04 N I 158.20
62284 04 N I 158.20
62287 04 N M Y 481.80
62290 04 N I 158.20
62291 04 N I 158.20
62292 04 N M Y 852.05
62294 04 N M 852.05
62310 04 N I 85.90
62311 04 N I 86.00
62318 04 Y M
62319 04 Y M
62350 04 N M Y Y 545.10
62351 04 N M Y Y 839.35
62355 04 N M Y Y 180.30
62360 04 N M Y Y 545.10
62361 04 N M Y Y 545.10
62362 04 N M Y Y 545.10
62365 04 N M Y Y 162.00
62367 04 N I 27.55
62368 04 N I 40.45
63001 04 N M Y Y 1102.95
Wednesday, April 01, 2009 Page 243 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
63003 04 N M Y Y 1102.95
63005 04 N M Y Y 1102.95
63011 04 N M Y Y 881.00
63012 04 N M Y 1404.20
63015 04 N M Y Y 1161.20
63016 04 N M Y Y 1161.20
63017 04 N M Y Y 1161.20
63020 04 Y M Y Y
63030 04 N M Y Y 1129.30
63035 04 Y M Y Y
63040 04 N M Y Y 1129.30
63042 04 N M Y Y 1129.30
63043 04 Y M Y
63044 04 Y M Y
63045 04 N M Y Y 1129.30
63046 04 N M Y Y 1129.30
63047 04 N M Y Y 1129.30
63048 04 Y M Y Y
63050 04 N M Y Y 843.88
63051 04 N M Y Y 947.11
63055 04 N M Y Y 1291.70
Wednesday, April 01, 2009 Page 244 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
63056 04 N M Y Y 1291.70
63057 04 Y M Y Y
63064 04 N M Y Y 1198.70
63066 04 Y M Y Y
63075 04 N M Y Y 1198.70
63076 04 N M Y Y 1198.70
63077 04 N M Y Y 1198.70
63078 04 N M Y Y 1198.70
63081 04 N M Y Y 1291.70
63082 04 Y M Y Y
63085 04 N M Y Y 1291.70
63086 04 Y M Y Y
63087 04 N M Y Y 1291.70
63088 04 Y M Y Y
63090 04 N M Y Y 1291.70
63091 04 Y M Y Y
63101 04 N M Y Y 1153.57
63102 04 N M Y Y 1153.57
63103 04 Y M Y Y
63170 04 N M Y Y 1291.70
63172 04 N M Y Y 1198.70
Wednesday, April 01, 2009 Page 245 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
63173 04 N M Y Y 1393.75
63180 04 N M Y Y 1198.70
63182 04 N M Y Y 1198.70
63185 04 N M Y Y 839.35
63190 04 N M Y Y 1079.30
63191 04 Y M Y Y
63194 04 N M Y Y 958.60
63195 04 N M Y Y 958.60
63196 04 N M Y Y 958.60
63197 04 N M Y Y 958.60
63198 04 N M Y Y 1291.70
63199 04 Y M Y Y
63200 04 N M Y Y 1198.70
63250 04 N M Y Y 1198.70
63251 04 N M Y Y 1198.70
63252 04 N M Y Y 1224.30
63265 04 N M Y Y 1198.70
63266 04 N M Y Y 1198.70
63267 04 N M Y Y 1198.70
63268 04 N M Y Y 1198.70
63270 04 N M Y Y 1198.70
Wednesday, April 01, 2009 Page 246 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
63271 04 N M Y Y 1198.70
63272 04 N M Y Y 1198.70
63273 04 N M Y Y 1198.70
63275 04 N M Y Y 1198.70
63276 04 N M Y Y 1198.70
63277 04 N M Y Y 1198.70
63278 04 N M Y Y 1198.70
63280 04 N M Y Y 1198.70
63281 04 N M Y Y 1198.70
63282 04 N M Y Y 1198.70
63283 04 N M Y Y 1198.70
63285 04 N M Y Y 1198.70
63286 04 N M Y Y 1198.70
63287 04 N M Y Y 1198.70
63290 04 N M Y Y 1198.70
63295 04 N M Y Y 190.18
63300 04 N M Y Y 1606.30
63301 04 N M Y Y 1615.70
63302 04 N M Y Y 1291.70
63303 04 N M Y Y 1291.70
63304 04 N M Y Y 1291.70
Wednesday, April 01, 2009 Page 247 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
63305 04 N M Y Y 1291.70
63306 04 N M Y Y 1291.70
63307 04 N M Y Y 1291.70
63308 04 Y M Y
63600 04 N M Y Y 898.95
63610 04 N M Y Y 599.35
63615 04 N M Y Y 898.95
63620 04 1/1/2009 N M Y 629.27
63621 04 1/1/2009 N M Y 201.37
63650 04 N M Y Y 524.40
63655 04 N M Y Y 733.85
63660 04 N M Y Y 374.55
63685 04 N M Y Y 599.35
63688 04 N M Y Y 374.55
63700 04 N M Y Y 599.35
63702 04 N M Y 599.35
63704 04 N M Y Y 630.10
63706 04 N M Y Y 689.00
63707 04 N M Y Y 1198.70
63709 04 N M Y Y 1198.70
63710 04 N M Y Y 1102.95
Wednesday, April 01, 2009 Page 248 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
63740 04 N M Y Y 839.35
63741 04 N M Y Y 324.05
63744 04 N M Y Y 374.55
63746 04 N M Y Y 194.05
64400 04 N I 74.90
64402 04 N I 74.90
64405 04 N I 74.90
64408 04 N I 52.40
64410 04 N I 49.40
64412 04 N I 46.65
64413 04 N I 52.70
64415 04 N I 52.70
64416 04 N I 74.90
64417 04 N I 48.40
64418 04 N I 47.15
64420 04 N I 43.25
64421 04 N I 56.40
64425 04 N I 52.65
64430 04 N I 51.10
64435 04 N I 50.55
64445 04 N I 53.20
Wednesday, April 01, 2009 Page 249 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
64446 04 N I 74.90
64447 04 N I 53.20
64448 04 N I 74.90
64449 04 N I 81.40
64450 04 N I 38.95
64455 04 1/1/2009 N M 38.95
64470 04 N I 88.05
64472 04 N I 74.90
64475 04 N I 77.90
64476 04 N I 74.90
64479 04 N I 95.90
64480 04 N I 85.75
64483 04 N I 88.25
64484 04 N I 83.20
64505 04 N I 59.60
64508 04 N I 59.60
64510 04 N I 59.60
64517 04 N I 64.40
64520 04 N I 56.20
64530 04 N I 58.70
64550 04 N I 22.15
Wednesday, April 01, 2009 Page 250 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
64553 04 N I 149.80
64555 04 N I 60.80
64560 04 N I 97.20
64561 04 N M 171.50
64565 04 Y I
64573 04 N M Y 599.35
64575 04 N M Y Y 599.35
64577 04 N M Y 599.35
64580 04 N M Y 599.35
64581 04 N M Y Y 332.00
64585 04 N I Y 149.80
64590 04 N M Y 599.35
64595 04 N M 149.80
64600 04 N I 100.00
64605 04 N I 140.65
64610 04 N I 233.00
64612 04 N I 71.15
64613 04 N I 71.15
64614 04 N I 27.10
64620 04 N I 80.90
64622 04 N I 99.70
Wednesday, April 01, 2009 Page 251 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
64623 04 N I 48.20
64626 04 N I 113.40
64627 04 N I 66.50
64630 04 N I 88.50
64632 04 1/1/2009 N I 90.50
64640 04 N I 90.50
64650 04 N I 22.42
64653 04 N I 28.36
64680 04 N M 224.70
64681 04 N I 116.11
64702 04 N M Y Y 524.40
64704 04 N M Y Y 524.40
64708 04 N M Y Y 524.40
64712 04 N M Y Y 524.40
64713 04 N M Y Y 647.90
64714 04 N M Y Y 647.90
64716 04 Y M Y Y
64718 04 N M Y Y 524.40
64719 04 N M Y Y 524.40
64721 04 N M Y Y 524.40
64722 04 N M Y Y 524.40
Wednesday, April 01, 2009 Page 252 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
64726 04 N M Y Y 524.40
64727 04 N M Y Y 524.40
64732 04 N I Y Y 148.20
64734 04 N M Y Y 158.30
64736 04 N M 224.70
64738 04 N M Y Y 374.55
64740 04 N M Y Y 224.70
64742 04 N M Y Y 224.70
64744 04 N M Y Y 607.60
64746 04 N I Y Y 181.05
64752 04 N M Y Y 524.40
64755 04 N M Y Y 524.40
64760 04 N M Y Y 524.40
64761 04 N M Y Y 299.70
64763 04 N M Y Y 224.70
64766 04 N M Y Y 374.55
64771 04 N M Y 374.55
64772 04 N M Y Y 374.55
64774 04 N I Y 144.55 34.00
64776 04 N M Y Y 180.30
64778 04 Y M Y Y
Wednesday, April 01, 2009 Page 253 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
64782 04 N M Y Y 240.00
64783 04 N M Y Y 120.60
64784 04 N M Y Y 359.30
64786 04 N M Y Y 470.15
64787 04 N M Y Y 124.70
64788 04 N I Y 139.60 34.00
64790 04 N M Y Y 359.30
64792 04 Y M Y Y
64795 04 N I 112.40
64802 04 N M Y Y 480.00
64804 04 N M Y Y 599.35
64809 04 N M Y Y 749.20
64818 04 N M Y Y 653.40
64820 04 Y M Y Y
64821 04 N M Y 407.40
64822 04 N M Y 407.40
64823 04 N M Y 471.00
64831 04 N M Y Y 252.45
64832 04 N M Y Y 139.00
64834 04 N M Y Y 299.70
64835 04 N M Y Y 599.35
Wednesday, April 01, 2009 Page 254 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
64836 04 N M Y Y 599.35
64837 04 N M Y Y 299.70
64840 04 N M Y Y 449.50
64856 04 N M Y Y 449.50
64857 04 N M Y Y 449.50
64858 04 N M Y Y 599.35
64859 04 N M Y Y 229.70
64861 04 N M Y Y 718.70
64862 04 N M Y Y 718.70
64864 04 N M Y Y 599.35
64865 04 N M Y Y 861.50
64866 04 N M Y Y 599.35
64868 04 N M Y Y 599.35
64870 04 N M Y Y 599.35
64872 04 N M Y Y 449.50
64874 04 N M Y Y 749.20
64876 04 N M Y Y 524.40
64885 04 N M Y Y 507.15
64886 04 N M Y Y 600.65
64890 04 N M Y Y 455.90
64891 04 N M Y Y 457.30
Wednesday, April 01, 2009 Page 255 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
64892 04 N M Y Y 557.45
64893 04 N M Y Y 557.45
64895 04 N M Y Y 551.10
64896 04 N M Y Y 619.50
64897 04 N M Y Y 665.50
64898 04 N M Y Y 665.50
64901 04 N M Y Y 316.55
64902 04 N M Y Y 359.70
64905 04 Y M Y Y
64907 04 Y M Y Y
64910 04 1/1/2007 Y M
64911 04 1/1/2007 Y M
64999 04 Y M Y Y
65091 04 N M 359.30
65093 04 N M 480.00
65101 04 N M 359.30
65103 04 N M 480.00
65105 04 N M 599.35
65110 04 N M 898.95
65112 04 N M 973.90
65114 04 N M 1048.85
Wednesday, April 01, 2009 Page 256 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
65125 04 Y M
65130 04 N M 749.20
65135 04 N M 449.50
65140 04 N M 599.35
65150 04 N M 524.40
65155 04 N M 475.25
65175 04 N M 236.70
65205 04 N I 58.15
65210 04 N I 62.60
65220 04 N I 73.50
65222 04 N I 64.60
65235 04 N M 480.00
65260 04 N M 480.00
65265 04 N M 480.00
65270 04 N M 107.00 17.00
65272 04 N M 142.70 17.00
65273 04 N M 224.70
65275 04 N M 359.30
65280 04 N M 599.35
65285 04 N M 599.35
65286 04 N M 359.30
Wednesday, April 01, 2009 Page 257 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
65290 04 N M 449.50
65400 04 N M 323.30
65410 04 N I 51.40 17.00
65420 04 N M Y 273.30
65426 04 N M 348.15
65430 04 N I 78.50 17.00
65435 04 N I 48.55
65436 04 N I 125.25
65450 04 N I Y 135.40
65600 04 N M 240.00
65710 04 N M 839.25
65730 04 N M Y 1317.95
65750 04 N M 1317.95
65755 04 N M Y 1317.95
65756 04 1/1/2009 N M 839.35
65760 04 N M 1560.80
65765 04 N M 1560.80
65767 04 N M Y 1560.80
65770 04 Y M
65772 04 N M Y 1252.00
65775 04 N M Y 648.10
Wednesday, April 01, 2009 Page 258 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
65780 04 N M Y Y 403.90
65781 04 N M Y Y 617.78
65782 04 N M Y Y 532.61
65800 04 N M 240.00
65805 04 N M 299.70
65810 04 N M 299.70
65815 04 N M 480.00
65820 04 N M 599.35
65850 04 N M Y 599.35
65855 04 N M 599.35
65860 04 N M Y 299.70
65865 04 N M 299.70
65870 04 N M 297.00
65875 04 N M 324.05
65880 04 N M 299.70
65900 04 N M 378.05
65920 04 Y M
65930 04 N M 480.00
66020 04 N M 180.30
66030 04 N M 180.30
66130 04 N M 273.30
Wednesday, April 01, 2009 Page 259 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
66150 04 N M 718.70
66155 04 N M 718.70
66160 04 N M 718.70
66165 04 N M 599.35
66170 04 N M Y 718.70
66172 04 N M Y 810.10
66180 04 N M Y 799.70
66185 04 N M Y 351.00
66220 04 N M 550.90
66225 04 N M 675.10
66250 04 Y M
66500 04 N M 149.80
66505 04 N M 240.00
66600 04 N M 581.30
66605 04 N M 581.30
66625 04 N M 581.30
66630 04 N M 581.30
66635 04 N M 581.30
66680 04 N M 471.70
66682 04 N M Y Y 471.70
66700 04 N M 341.30
Wednesday, April 01, 2009 Page 260 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
66710 04 N M 341.30
66711 04 N M 341.30
66720 04 N M Y 341.30
66740 04 N M 569.30
66761 04 N M 449.50
66762 04 N M 449.50
66770 04 N M 374.55
66820 04 N M Y 299.70
66821 04 N M 299.70
66825 04 N M Y 299.70
66830 04 N M Y 374.55
66840 04 N M Y 751.90
66850 04 N M Y 751.90
66852 04 N M Y 751.90
66920 04 N M Y 751.90
66930 04 N M Y 751.90
66940 04 N M Y 751.90
66982 04 N M 587.60
66983 04 N M Y 1051.60
66984 04 N M 1051.60
66985 04 N M 574.75
Wednesday, April 01, 2009 Page 261 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
66986 04 N M 546.00
66990 09 Y N
66999 04 Y M Y
67005 04 N M Y 749.20
67010 04 N M Y 749.20
67015 04 N M Y 861.50
67025 04 N M Y 818.45
67027 04 N M Y 524.35
67028 04 N M Y 287.10
67030 04 N M Y 818.45
67031 04 N M 818.45
67036 04 N M Y 1086.30
67039 04 N M Y 1086.30
67040 04 N M Y Y 1086.30
67041 04 1/1/2008 N M Y Y 613.65
67042 04 1/1/2008 N M Y Y 703.00
67043 04 1/1/2008 N M Y Y 737.55
67101 04 N M 434.30
67105 04 N M 457.20
67107 04 N M Y 980.85
67108 04 N M Y 1086.30
Wednesday, April 01, 2009 Page 262 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
67110 04 N M Y 434.30
67112 04 Y M
67113 04 1/1/2008 N M Y Y 809.66
67115 04 N M Y 735.60
67120 04 N M 958.60
67121 04 Y M Y
67141 04 N M 443.95
67145 04 N M Y 443.95
67208 04 N M Y 443.95
67210 04 N M Y 443.95
67218 04 N M 486.10
67220 04 N M Y 443.95
67221 04 N M Y 225.30
67225 04 N I 42.55
67227 04 N M Y 443.95
67228 04 N M 466.15
67229 04 1/1/2008 N M 532.19
67250 04 N M 749.20
67255 04 N M 898.95
67299 04 Y M Y
67311 04 N M Y 511.90
Wednesday, April 01, 2009 Page 263 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
67312 04 N M Y 511.90
67314 04 N M Y 511.90
67316 04 N M Y 511.90
67318 04 N M Y 550.90
67320 04 N M Y 647.20
67331 04 N M Y 374.55
67332 04 N M Y 511.90
67334 04 N M Y 511.90
67335 09 Y N
67340 04 N M Y 405.10
67343 04 N M Y 399.60
67345 04 N M Y 100.00
67346 04 1/1/2007 N I 107.00
67399 04 Y M Y
67400 04 N M Y 681.10
67405 04 N M Y 524.40
67412 04 N M Y 839.35
67413 04 N M Y 839.35
67414 04 N M Y 797.40
67415 04 N I 56.80 17.00
67420 04 N M Y 1079.30
Wednesday, April 01, 2009 Page 264 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
67430 04 N M 1079.30
67440 04 N M 681.10
67445 04 N M Y 1025.40
67450 04 N M Y 681.10
67500 04 N I 78.20
67505 04 N M 74.90
67515 04 N I 74.90
67550 04 N M 415.85
67560 04 N M 340.90
67570 04 N M Y 797.40
67599 04 Y M Y
67700 04 N I 73.50
67710 04 N M 224.70
67715 04 N I 59.60
67800 04 N I 77.20 17.00
67801 04 N I 91.85 17.00
67805 04 N M 99.05 17.00
67808 04 N I 112.80
67810 04 N I 68.10 17.00
67820 04 N I 30.50
67825 04 N I 88.50
Wednesday, April 01, 2009 Page 265 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
67830 04 N I 112.60
67835 04 N M 187.30
67840 04 N I 93.30 17.00
67850 04 N I 90.20
67875 04 N M Y 187.30
67880 04 N M 187.30
67882 04 N M Y 231.50
67900 04 N M Y 216.00
67901 04 N M 685.40
67902 04 N M 685.40
67903 04 N M 685.40
67904 04 N M Y 685.40
67906 04 N M 749.20
67908 04 N M 749.20
67909 04 N M 749.20
67911 04 N M 749.20
67912 04 N M Y 221.64
67914 04 N M 359.30
67915 04 N I 133.90
67916 04 N M 299.70
67917 04 N M 359.30
Wednesday, April 01, 2009 Page 266 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
67921 04 N M 359.30
67922 04 N I 130.70
67923 04 N M 299.70
67924 04 N M 359.30
67930 04 N M 189.00 17.00
67935 04 N M 244.50 17.00
67938 04 N I 80.90 17.00
67950 04 N M 359.30
67961 04 N M 324.05
67966 04 N M 345.70
67971 04 N M 449.50
67973 04 N M 449.50
67974 04 N M 449.50
67975 04 N M 449.50
67999 04 Y M Y
68020 04 N I 72.55 17.00
68040 04 N I 71.40 17.00
68100 04 N I 77.60 17.00
68110 04 N M 180.30
68115 04 N M 180.30
68130 04 N M 224.70
Wednesday, April 01, 2009 Page 267 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
68135 04 N M 224.70
68200 04 N I 56.60
68320 04 N M 449.50
68325 04 N M 531.30
68326 04 N M 531.30
68328 04 N M 531.30
68330 04 N M 299.70
68335 04 N M 524.40
68340 04 N M 299.70
68360 04 N M 240.00
68362 04 N M 359.30
68371 04 N M Y 191.25
68399 04 Y M Y Y
68400 04 N I 103.60 17.00
68420 04 N I 117.70 17.00
68440 04 N I 66.90 17.00
68500 04 N M 599.35
68505 04 N M 336.45
68510 04 N I 191.40 17.00
68520 04 N M 599.35
68525 04 N I 124.50 17.00
Wednesday, April 01, 2009 Page 268 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
68530 04 N I 174.60 17.00
68540 04 N M 599.35
68550 04 N M 648.10
68700 04 N M 359.30
68705 04 N I 93.60
68720 04 N M Y Y 839.35
68745 04 N M 839.35
68750 04 N M Y 858.70
68760 04 N I 84.10
68761 04 N I 75.50
68770 04 Y M
68801 04 N I 71.70
68810 04 N I 103.50
68811 04 N I 115.10
68815 04 N I 143.40
68816 04 1/1/2008 N I 115.00 205.23
68840 04 N I 83.30
68850 04 N I 116.35
68899 04 Y M Y
69000 04 N I 42.40 17.00
69005 04 N I 64.10 17.00
Wednesday, April 01, 2009 Page 269 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
69020 04 N I 44.60 17.00
69100 04 N I 31.15 17.00
69105 04 N I 50.20 17.00
69110 04 N M 209.40
69120 04 N M 240.00
69140 04 N M 480.00
69145 04 N I 90.10
69150 04 N M Y 718.70
69155 04 N M Y 1198.70
69200 04 N I 26.60
69205 04 N I 74.90
69210 04 N I 21.40
69220 04 N I Y Y 28.50
69222 04 N I Y Y 57.30
69300 09 Y M
69310 04 N M 694.40
69320 04 N M 958.60
69399 04 Y M Y
69400 04 N I 28.15
69401 04 N I 22.15
69405 04 N I Y Y 115.10
Wednesday, April 01, 2009 Page 270 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
69420 04 N I 43.80 17.00
69421 04 N I 56.60
69424 04 N I 30.35
69433 04 N I 76.60 34.00
69436 04 N I 80.50
69440 04 N M 599.35
69450 04 N I 191.10
69501 04 N M Y Y 692.20
69502 04 N M Y Y 692.20
69505 04 N M Y Y 749.20
69511 04 N M Y Y 839.35
69530 04 N M Y Y 1198.70
69535 04 N M Y Y 1198.70
69540 04 N I Y 50.20 17.00
69550 04 N I Y 363.60 17.00
69552 04 N M Y 674.20
69554 04 N M Y Y 954.95
69601 04 N M Y Y 695.05
69602 04 N M Y 695.05
69603 04 N M Y Y 695.05
69604 04 N M Y Y 695.05
Wednesday, April 01, 2009 Page 271 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
69605 04 N M Y Y 695.05
69610 04 Y M Y Y
69620 04 Y M Y Y
69631 04 N M Y Y 749.20
69632 04 N M Y Y 749.20
69633 04 N M Y 861.50
69635 04 N M Y Y 749.20
69636 04 N M Y Y 749.20
69637 04 N M Y 861.50
69641 04 N M Y Y 1048.85
69642 04 N M Y Y 1048.85
69643 04 N M Y Y 1048.85
69644 04 N M Y 1048.85
69645 04 N M Y Y 1048.85
69646 04 N M Y Y 1048.85
69650 04 N M Y Y 743.65
69660 04 N M Y Y 749.20
69661 04 N M Y Y 749.20
69662 04 N M Y Y 749.20
69666 04 N M Y Y 749.20
69667 04 N M Y Y 749.20
Wednesday, April 01, 2009 Page 272 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
69670 04 N M Y Y 1079.30
69676 04 N M Y Y 834.50
69700 04 N M Y Y 299.70
69710 04 N M 918.15
69711 04 N M Y 550.90
69714 04 N M Y 604.65
69715 04 N M Y 765.85
69717 04 N M Y 623.25
69718 04 N M Y 775.20
69720 04 N M Y Y 749.20
69725 04 N M Y Y 749.20
69740 04 N M Y Y 599.35
69745 04 N M Y Y 947.20
69799 04 Y M Y
69801 04 N M Y Y 749.20
69802 04 N M Y Y 749.20
69805 04 N M Y Y 749.20
69806 04 N M Y Y 749.20
69820 04 N M Y Y 749.20
69840 04 N M Y Y 749.20
69905 04 N M Y Y 1198.70
Wednesday, April 01, 2009 Page 273 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
69910 04 N M Y 1198.70
69915 04 N M Y Y 1198.70
69930 04 N M Y 1296.20
69949 04 Y M Y
69950 04 N M Y Y 1079.30
69955 04 N M Y Y 1079.30
69960 04 N M Y Y 1198.70
69970 04 N M Y Y 1188.20
69979 04 Y M Y
69990 09 Y N
70010 04 N I 28.70
70015 04 N I 39.20
70030 A 04 N N 10.75 10.75 21.50
70100 A 04 N N 11.40 11.40 22.80
70110 A 04 N N 15.65 15.65 31.30
70120 A 04 N N 11.40 11.40 22.80
70130 A 04 N N 15.65 15.65 31.30
70134 A 04 N N 20.25 20.25 40.50
70140 A 04 N N 14.35 14.35 28.70
70150 A 04 N N 17.62 15.62 35.25
70160 A 04 N N 10.47 10.47 20.95
Wednesday, April 01, 2009 Page 274 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
70170 04 N I 18.30
70190 A 04 N N 11.40 11.40 22.80
70200 A 04 N N 17.62 17.62 35.25
70210 A 04 N N 11.10 11.10 22.20
70220 A 04 N N 14.35 14.35 28.70
70240 A 04 N N 11.40 11.40 22.80
70250 A 04 N N 10.75 10.75 21.50
70260 A 04 N N 17.62 17.62 35.25
70300 A 04 N N 5.90 5.90 11.80
70310 A 04 N N 7.17 7.17 14.35
70320 A 04 N N 14.35 14.35 28.70
70328 A 04 N N 14.35 14.35 28.70
70330 A 04 N N 14.35 14.35 28.70
70332 04 N I 23.30
70336 B 04 N N 148.30 148.30 296.60
70350 A 04 N N 7.17 7.17 14.35
70355 A 04 N N 14.35 14.35 28.70
70360 A 04 N N 7.17 7.17 14.35
70370 A 04 N N 13.07 13.07 26.15
70371 A 04 N N 12.70 12.70 25.40
70373 04 N I 20.20
Wednesday, April 01, 2009 Page 275 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
70380 A 04 N N 11.10 11.10 22.20
70390 04 N I 22.20
70450 B 04 N N 123.58 123.58 247.15
70460 B 04 N N 141.23 141.22 282.45
70470 B 04 N N 141.22 141.22 282.45
70480 B 04 N N 31.35 31.35 62.70
70481 B 04 N N 37.95 37.95 75.90
70482 B 04 N N 54.92 54.92 109.95
70486 B 04 N N 31.35 31.35 62.70
70487 B 04 N N 37.95 37.95 75.90
70488 B 04 N N 54.92 54.92 109.85
70490 B 04 N N 31.35 31.35 62.70
70491 B 04 N N 37.95 37.95 75.90
70492 B 04 N N 54.92 54.92 109.85
70496 B 04 N N 123.52 123.52 247.05
70498 B 04 N N 123.52 123.52 247.05
70540 B 04 N N 148.30 148.30 296.60
70542 B 04 N N 148.30 148.30 296.60
70543 B 04 N N 223.93 223.92 447.85
70544 B 04 N N 148.30 148.30 296.60
70545 B 04 N N 148.30 148.30 296.60
Wednesday, April 01, 2009 Page 276 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
70546 B 04 N N 204.77 204.78 409.55
70547 B 04 N N 148.30 148.30 296.60
70548 B 04 N N 148.30 148.30 296.60
70549 B 04 N N 204.77 204.78 409.55
70551 B 04 N N 148.30 148.30 296.60
70552 B 04 N N 148.30 148.30 296.60
70553 B 04 N N 148.30 148.30 296.60
70554 C 04 1/1/2007 N N 50.42 246.18 1 296.60
70555 04 1/1/2007 N N 64.32
70557 04 N M 79.06
70558 04 N M 87.53
70559 04 N N 88.02
71010 A 04 N N 8.50 8.50 17.00
71015 A 04 N N 10.75 10.75 21.50
71020 A 04 N N 10.75 10.75 21.50
71021 A 04 N N 10.75 10.75 21.50
71022 A 04 N N 10.75 10.75 21.50
71023 A 04 N N 10.75 10.75 21.50
71030 A 04 N N 14.35 14.35 28.70
71034 A 04 N N 14.35 14.35 28.70
71035 A 04 N N 14.35 14.35 28.70
Wednesday, April 01, 2009 Page 277 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
71040 04 N I 32.70
71060 04 N I 52.30
71090 04 N I 103.30
71100 A 04 N N 10.75 10.75 21.50
71101 A 04 N N 12.40 12.40 24.80
71110 A 04 N N 13.07 13.08 26.15
71111 A 04 N N 14.35 14.35 28.70
71120 A 04 N N 10.75 10.75 21.50
71130 A 04 N N 14.35 14.35 28.70
71250 B 04 N N 31.35 31.35 62.70
71260 B 04 N N 37.95 37.95 75.90
71270 B 04 N N 54.93 54.92 109.85
71275 B 04 N N 132.50 132.50 265.00
71550 B 04 N N 148.30 148.30 296.60
71551 B 04 N N 148.30 148.30 296.60
71552 B 04 N N 224.03 224.02 448.05
71555 B 04 N N 148.30 148.30 296.60
72010 A 04 N N 35.95 35.95 71.90
72020 A 04 N N 12.07 12.08 24.15
72040 A 04 N N 12.07 12.08 24.15
72050 A 04 N N 17.63 17.62 35.25
Wednesday, April 01, 2009 Page 278 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
72052 A 04 N N 18.25 18.25 36.50
72069 A 04 N N 11.40 11.40 22.80
72070 A 04 N N 11.40 11.40 22.80
72072 A 04 N N 10.47 10.48 20.95
72074 A 04 N N 10.75 10.75 21.50
72080 A 04 N N 12.70 12.70 25.40
72090 A 04 N N 29.45 29.45 58.90
72100 A 04 N N 14.35 14.35 28.70
72110 A 04 N N 18.95 18.95 37.90
72114 A 04 N N 18.95 18.95 37.90
72120 A 04 N N 18.95 18.95 37.90
72125 B 04 N N 31.35 31.35 62.70
72126 B 04 N N 37.95 37.95 75.90
72127 B 04 N N 54.93 54.92 109.85
72128 B 04 N N 31.35 31.35 62.70
72129 B 04 N N 37.95 37.95 75.90
72130 B 04 N N 54.93 54.92 109.85
72131 B 04 N N 31.35 31.35 62.70
72132 B 04 N N 37.95 37.95 75.90
72133 B 04 N N 54.93 54.92 109.85
72141 B 04 N N 148.30 148.30 296.60
Wednesday, April 01, 2009 Page 279 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
72142 B 04 N N 148.30 148.30 296.60
72146 B 04 N N 148.30 148.30 296.60
72147 B 04 N N 148.30 148.30 296.60
72148 B 04 N N 148.30 148.30 296.60
72149 B 04 N N 148.30 148.30 296.60
72156 B 04 N N 148.30 148.30 296.60
72157 B 04 N N 148.30 148.30 296.60
72158 B 04 N N 148.30 148.30 296.60
72159 B 04 N N 148.30 148.30 296.60
72170 A 04 N N 7.85 7.85 15.70
72190 A 04 N N 17.63 17.62 35.25
72191 B 04 N N 128.30 128.30 256.60
72192 B 04 N N 31.35 31.35 62.70
72193 B 04 N N 37.95 37.95 75.90
72194 B 04 N N 54.93 54.92 109.85
72195 B 04 N N 148.30 148.30 296.60
72196 B 04 N N 148.30 148.30 296.60
72197 B 04 N N 226.15 226.15 452.30
72198 B 04 N N 148.30 148.30 296.60
72200 A 04 N N 10.75 10.75 21.50
72202 A 04 N N 11.40 11.40 22.80
Wednesday, April 01, 2009 Page 280 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
72220 A 04 N N 10.75 10.75 21.50
72240 04 N I 65.35
72255 04 N I 52.30
72265 04 N N 52.30
72270 04 N N 99.35
72275 04 N I 57.45
72285 04 N I 52.30
72291 04 1/1/2007 N I 78.05
72292 04 1/1/2007 N I 62.50
72295 04 N I 45.80
73000 A 04 N N 7.50 7.50 15.00
73010 A 04 N N 10.75 10.75 21.50
73020 A 04 N N 10.75 10.75 21.50
73030 A 04 N N 11.10 11.10 22.20
73040 C 04 N I 6.03 17.47 23.50
73050 A 04 N N 10.07 10.08 20.15
73060 A 04 N N 7.85 7.85 15.70
73070 A 04 N N 9.80 9.80 19.60
73080 A 04 N N 10.75 10.75 21.50
73085 04 N I 22.20
73090 A 04 N N 9.15 9.15 18.30
Wednesday, April 01, 2009 Page 281 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
73092 A 04 N N 7.17 7.18 14.35
73100 A 04 N N 10.75 10.75 21.50
73110 A 04 N N 11.10 11.10 22.20
73115 04 N I 30.10
73120 A 04 N N 8.50 8.50 17.00
73130 A 04 N N 9.15 9.15 18.30
73140 A 04 N N 7.17 7.18 14.35
73200 B 04 N N 31.35 31.35 62.70
73201 B 04 N N 37.95 37.95 75.90
73202 B 04 N N 54.93 54.92 109.85
73206 B 04 N N 115.55 115.55 231.10
73218 B 04 N N 148.30 148.30 296.60
73219 B 04 N N 148.30 148.30 296.60
73220 B 04 N N 148.30 148.30 296.60
73221 B 04 N N 148.30 148.30 296.60
73222 B 04 N N 148.30 148.30 296.60
73223 B 04 N N 223.92 223.92 447.85
73225 B 04 N N 148.30 148.30 296.60
73500 A 04 N N 10.75 10.75 21.50
73510 A 04 N N 14.35 14.35 28.70
73520 A 04 N N 19.60 19.60 39.20
Wednesday, April 01, 2009 Page 282 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
73525 C 04 N I 14.02 38.28 52.30
73530 A 04 N N 24.85 24.85 49.70
73540 A 04 N N 17.00 17.00 34.00
73542 04 N I 120.90
73550 A 04 N N 10.75 10.75 21.50
73560 A 04 N N 9.80 9.80 19.60
73562 A 04 N N 10.10 10.10 20.20
73564 A 04 N N 11.10 11.10 22.20
73565 A 04 N N 16.70 16.70 33.40
73580 04 N I 37.90
73590 A 04 N N 10.75 10.75 21.50
73592 A 04 N N 10.75 10.75 21.50
73600 A 04 N N 10.75 10.75 21.50
73610 A 04 N N 14.35 14.35 28.70
73615 04 N I 26.15
73620 A 04 N N 8.50 8.50 17.00
73630 A 04 N N 10.75 10.75 21.50
73650 A 04 N N 8.50 8.50 17.00
73660 A 04 N N 7.17 7.17 14.35
73700 B 04 N N 31.35 31.35 62.70
73701 B 04 N N 37.95 37.95 75.90
Wednesday, April 01, 2009 Page 283 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
73702 B 04 N N 54.92 54.92 109.85
73706 B 04 N N 115.55 115.55 231.10
73718 B 04 N N 148.30 148.30 296.60
73719 B 04 N N 148.30 148.30 296.60
73720 B 04 N N 148.30 148.30 296.60
73721 B 04 N N 148.30 148.30 296.60
73722 B 04 N N 148.30 148.30 296.60
73723 B 04 N N 223.92 223.92 447.85
73725 B 04 N N 148.30 148.30 296.60
74000 A 04 N N 10.75 10.75 21.50
74010 A 04 N N 12.70 12.70 25.40
74020 A 04 N N 12.70 12.70 25.40
74022 A 04 N N 20.95 20.95 41.90
74150 B 04 N N 31.35 31.35 62.70
74160 B 04 N N 37.95 37.95 75.90
74170 B 04 N N 54.92 54.92 109.85
74175 B 04 N N 128.32 128.32 256.65
74181 B 04 N N 148.30 148.30 296.60
74182 B 04 N N 148.30 148.30 296.60
74183 B 04 N N 226.15 226.15 452.30
74185 B 04 N N 148.30 148.30 296.60
Wednesday, April 01, 2009 Page 284 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
74190 04 N I 21.50
74210 A 04 N N 14.35 14.35 28.70
74220 A 04 N N 14.35 14.35 28.70
74230 A 04 N N 12.70 12.70 25.40
74235 04 N I 122.40
74240 B 04 N N 24.85 24.85 49.70
74241 B 04 N N 25.50 25.50 51.00
74245 B 04 N N 32.02 32.02 64.05
74246 B 04 N N 26.15 26.15 52.30
74247 B 04 N N 26.80 26.80 53.60
74249 B 04 N N 32.02 32.02 64.05
74250 B 04 N N 21.57 21.57 43.15
74251 B 04 N N 29.45 29.45 58.90
74260 B 04 N N 18.25 18.25 36.50
74270 B 04 N N 24.85 24.85 49.70
74280 B 04 N N 29.45 29.45 58.90
74283 B 04 N N 29.45 29.45 58.90
74290 B 04 N N 17.62 17.62 35.25
74291 B 04 N N 17.62 17.62 35.25
74300 04 N I 35.25
74301 04 Y I
Wednesday, April 01, 2009 Page 285 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
74305 04 N I 35.25
74320 04 N I 57.55
74327 04 N I 168.65
74328 04 N I 64.05
74329 04 N I 92.80
74330 04 N I 100.65
74340 04 N I 51.00
74355 04 N I 118.60
74360 04 N I 44.90
74363 04 N I 170.00
74400 B 04 N N 24.85 24.85 49.70
74410 B 04 N N 28.77 28.77 57.55
74415 B 04 N N 28.77 28.77 57.55
74420 B 04 N N 14.35 14.35 28.70
74425 04 N I 28.70
74430 04 N I 23.50
74440 04 N I 32.70
74445 04 N I 28.70
74450 04 N I 26.15
74455 04 N I 26.15
74470 04 N I 18.30
Wednesday, April 01, 2009 Page 286 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
74475 04 N I 14.35
74480 04 N I 71.90
74485 04 N I 28.50
74710 B 04 N N 22.90 22.90 45.80
74740 C 04 N I 10.65 28.55 39.20
74742 04 N I 39.20
74775 04 N N 71.20
75557 C 04 1/1/2008 Y N 68.87 230.81 Y 299.68
75558 04 1/1/2008 Y N
75559 C 04 1/1/2008 Y N 87.60 344.24 Y 431.84
75560 04 1/1/2008 Y N
75561 C 04 1/1/2008 N N 76.18 325.65 Y 401.83
75562 04 1/1/2008 Y N
75563 C 04 1/1/2008 Y N 90.99 404.09 Y 495.08
75564 04 1/1/2008 Y N
75600 04 N I 109.85
75605 04 N I 77.20
75625 04 N I 98.10
75630 04 N I 130.80
75635 C 04 N I 51.14 230.26 281.40
75650 04 N I 163.40
Wednesday, April 01, 2009 Page 287 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
75658 04 N I 78.45
75660 04 N I 84.90
75662 04 N I 130.80
75665 04 N I 98.10
75671 04 N I 130.80
75676 04 N I 78.45
75680 04 N I 104.60
75685 04 N I 78.45
75705 04 N I 98.10
75710 04 N I 78.45
75716 04 N I 111.10
75722 04 N I 78.45
75724 04 N I 111.10
75726 04 N I 91.45
75731 04 N I 91.45
75733 04 N I 115.10
75736 04 N I 91.45
75741 04 N I 91.45
75743 04 N I 117.60
75746 04 N I 65.35
75756 04 N I 39.20
Wednesday, April 01, 2009 Page 288 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
75774 04 N I 25.10
75790 04 N I 84.90
75801 04 N I 35.25
75803 04 N I 75.90
75805 04 N I 77.20
75807 04 N I 91.45
75809 04 N I 77.20
75810 04 N I 91.45
75820 04 N I 45.80
75822 04 N I 65.35
75825 04 N I 78.45
75827 04 N I 100.65
75831 04 N I 91.45
75833 04 N I 111.10
75840 04 N I 57.55
75842 04 N I 91.45
75860 04 N I 78.45
75870 04 N I 52.30
75872 04 N I 130.80
75880 04 N I 28.70
75885 04 N I 64.30
Wednesday, April 01, 2009 Page 289 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
75887 04 N I 54.60
75889 04 N I 128.20
75891 04 N I 93.40
75893 04 N I 98.10
75894 04 N I 64.05
75896 04 N I 64.05
75898 04 N I 56.20
75900 04 N I 201.20
75901 04 N I 66.60
75902 04 N I 66.60
75940 04 N I 66.60
75945 04 N I 64.05
75946 04 N I 49.40
75952 04 N I 162.85
75953 04 N I 68.30
75954 04 N I 83.00
75956 04 N M Y 221.10
75957 04 N M Y 189.42
75958 04 N M Y 126.26
75959 04 N M Y 110.52
75960 04 N I 83.00
Wednesday, April 01, 2009 Page 290 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
75961 04 N I 62.15
75962 04 N I 83.00
75964 04 N I 83.00
75966 04 N I 83.00
75968 04 N I 83.00
75970 04 N I 78.90
75978 04 N I 65.35
75980 04 N I 83.00
75982 04 N I 41.90
75984 04 N I 53.60
75989 04 N I 84.90
75992 04 N I 83.00
75993 04 Y I
75994 04 N I 83.00
75995 04 N I 83.00
75996 04 Y I
76000 04 N I 32.70
76001 04 N I 56.45
76010 A 04 N N 16.20 16.20 32.40
76080 04 N I 26.15
76098 A 04 N N 6.20 6.20 12.40
Wednesday, April 01, 2009 Page 291 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
76100 A 04 N N 24.85 24.85 49.70
76101 A 04 N N 17.62 17.62 35.25
76102 A 04 N N 24.85 24.85 49.70
76120 A 04 N N 10.47 10.47 20.95
76125 A 04 N N 24.85 24.85 49.70
76140 04 N N 19.60
76150 B 04 Y N
76350 B 04 Y N
76376 C 04 N I 6.18 66.99 1 73.17
76377 C 04 N I 24.33 72.94 1 97.27
76380 04 N N 59.55
76390 B 04 N I 148.30 148.30 296.60
76496 A 04 Y I
76497 B 04 Y I
76498 B 04 Y I
76499 04 Y N
76506 B 04 N N 32.02 32.02 64.05
76510 A 04 N N 32.67 32.67 65.35
76511 A 04 N N 24.85 24.85 49.70
76512 A 04 N N 32.67 32.67 65.35
76513 A 04 N N 32.67 32.67 65.35
Wednesday, April 01, 2009 Page 292 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
76514 C 04 N N 5.20 1.37 1 6.57
76516 A 04 N N 24.85 24.85 49.70
76519 A 04 N N 24.90 24.90 49.80
76529 A 04 N N 32.67 32.67 65.35
76536 B 04 N N 34.00 34.00 68.00
76604 B 04 N N 31.35 31.35 62.70
76645 B 04 N N 31.35 31.35 62.70
76700 B 04 N N 37.95 37.95 75.90
76705 B 04 N N 31.35 31.35 62.70
76770 B 04 N N 37.95 37.95 75.90
76775 B 04 N N 31.35 31.35 62.70
76776 C 04 1/1/2007 N N 53.13 22.77 1 75.90
76800 B 04 N N 37.95 37.95 75.90
76801 B 04 N N 35.95 35.95 71.90
76802 B 04 N N 22.52 22.52 45.05
76805 B 04 N N 35.95 35.95 71.90
76810 B 04 N N 22.52 22.52 45.05
76811 B 04 N N 35.95 35.95 71.90
76812 B 04 N N 22.52 22.52 45.05
76813 C 04 1/1/2007 N N 32.36 39.54 1 71.90
76814 C 04 1/1/2007 N N 25.23 19.82 1 45.05
Wednesday, April 01, 2009 Page 293 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
76815 B 04 N N 35.95 35.95 71.90
76816 B 04 N N 35.95 35.95 71.90
76817 B 04 N N 35.95 35.95 71.90
76818 B 04 N N 31.97 31.97 63.95
76819 B 04 N N 15.55 15.55 31.10
76820 B 04 N N 35.95 35.95 71.90
76821 B 04 N N 35.95 35.95 71.90
76825 B 04 N N 35.95 35.95 71.90
76826 B 04 N N 35.95 35.95 71.90
76827 B 04 N N 35.95 35.95 71.90
76828 B 04 N N 35.95 35.95 71.90
76830 B 04 N N 35.95 35.95 71.90
76831 B 04 N N 35.95 35.90 71.90
76856 B 04 N N 35.95 35.95 71.90
76857 B 04 N N 35.95 35.95 71.90
76870 B 04 N N 24.85 24.85 49.70
76872 B 04 N N 35.95 35.95 71.90
76873 B 04 N N 71.35 71.35 142.70
76880 B 04 N N 24.85 24.85 49.70
76885 B 04 N N 35.95 35.95 71.90
76886 B 04 N N 35.95 35.95 71.90
Wednesday, April 01, 2009 Page 294 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
76930 04 N I 56.20
76932 04 N I 65.35
76936 04 N I 56.20
76937 C 04 N I 9.21 9.60 1 18.81
76940 C 04 N I 55.84 35.48 1 91.32
76941 04 N I 56.20
76942 04 N I 60.10
76945 04 N I 49.70
76946 04 N I 51.00
76950 B 04 N N 31.35 31.35 62.70
76965 B 04 N N 24.85 24.85 49.70
76970 A 04 Y N
76975 04 N I 51.00
76977 B 04 N N 17.25 17.25 34.50
76998 04 1/1/2007 N N 33.37
76999 04 Y N
77001 C 04 1/1/2007 N N 8.75 29.29 1 38.04
77002 C 04 1/1/2007 N N 13.27 24.63 1 37.90
77003 C 04 1/1/2007 N N 20.40 31.90 1 52.30
77011 C 04 1/1/2007 N N 7.31 48.89 1 56.20
77012 C 04 1/1/2007 N N 10.12 46.08 1 56.20
Wednesday, April 01, 2009 Page 295 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
77013 04 N N 233.70
77014 C 04 1/1/2007 N N 14.05 42.15 1 56.20
77021 C 04 1/1/2007 N N 53.61 281.44 1 335.05
77022 C 04 1/1/2007 N N 53.61 281.44 1 335.05
77031 C 04 1/1/2007 N N 26.08 9.17 1 35.25
77032 C 04 1/1/2007 N N 13.75 21.50 1 35.25
77051 C 04 1/1/2007 N N 1.89 8.07 1 9.96
77052 C 04 1/1/2007 N N 1.89 8.07 1 9.96
77053 C 04 1/1/2007 N N 9.18 41.82 1 51.00
77054 C 04 1/1/2007 N N 11.44 60.06 1 71.50
77055 C 04 1/1/2007 N N 17.64 21.56 1 39.20
77056 C 04 1/1/2007 N N 31.64 40.26 1 71.90
77057 C 04 1/1/2007 N N 30.20 41.70 1 71.90
77058 C 04 1/1/2007 N N 29.66 266.94 1 296.60
77059 C 04 1/1/2007 N N 23.73 272.87 1 296.60
77071 04 1/1/2007 N N 15.53
77072 C 04 1/1/2007 N N 8.81 12.69 1 21.50
77073 C 04 1/1/2007 N N 9.18 19.52 1 28.70
77074 C 04 1/1/2007 N N 20.72 36.83 1 57.55
77075 C 04 1/1/2007 N N 30.41 67.69 1 98.10
77076 C 04 1/1/2007 N N 16.92 18.33 1 35.25
Wednesday, April 01, 2009 Page 296 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
77077 C 04 1/1/2007 N N 12.57 29.33 1 41.90
77078 C 04 1/1/2007 N N 3.20 32.40 1 35.60
77079 C 04 1/1/2007 N N 3.92 31.68 1 35.60
77080 C 04 1/1/2007 N N 9.81 88.29 1 98.10
77081 C 04 1/1/2007 N N 28.45 69.65 1 98.10
77082 C 04 1/1/2007 N N 24.53 73.57 1 98.10
77083 C 04 1/1/2007 N N 30.10 73.70 1 103.80
77084 C 04 1/1/2007 N N 48.83 238.43 1 287.26
77261 09 Y N
77262 09 Y N
77263 09 Y I
77280 09 Y N
77285 09 Y N
77290 09 Y N
77295 09 Y N
77299 09 Y N
77300 09 Y N
77301 09 Y N
77305 09 Y N
77310 09 Y N
77315 09 Y N
Wednesday, April 01, 2009 Page 297 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
77321 09 Y N
77326 09 Y N
77327 09 Y N
77328 09 Y N
77331 09 Y N
77332 09 Y N
77333 09 Y N
77334 09 Y N
77336 09 Y N
77370 09 Y N
77371 04 1/1/2007 N N 574.13
77372 04 1/1/2007 N N 435.96
77373 04 1/1/2007 N N 812.27
77399 09 Y N 1
77401 B 04 N N 12.07 12.07 24.15
77402 B 04 N N 12.07 12.07 24.15
77403 B 04 N N 13.00 13.00 26.00
77404 B 04 N N 13.85 13.85 27.70
77406 B 04 N N 15.05 15.05 30.10
77407 B 04 N N 19.47 19.47 38.95
77408 B 04 N N 21.00 21.00 42.00
Wednesday, April 01, 2009 Page 298 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
77409 B 04 N N 22.90 22.90 45.80
77411 B 04 N N 23.70 23.70 47.40
77412 B 04 N N 21.00 21.00 42.00
77413 B 04 N N 21.80 21.80 43.60
77414 B 04 N N 22.90 22.90 45.80
77416 B 04 N N 24.55 24.55 49.10
77417 09 Y N
77418 B 04 N N 123.25 123.25 246.50
77421 C 04 N I 11.99 69.33 81.32
77422 04 N I 35.73
77423 04 N I 46.14
77427 04 N N 70.85
77431 04 N N 35.65
77432 04 N I 254.60
77435 04 1/1/2007 N N 350.19
77470 04 N N 240.10
77499 04 Y N
77520 B 04 N N 35.42 35.42 70.85
77522 04 Y N
77523 B 04 N N 44.87 44.87 89.75
77525 04 Y N
Wednesday, April 01, 2009 Page 299 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
77600 04 N N 21.30
77605 04 N N 28.45
77610 04 N N 58.80
77615 B 04 N N 35.30 35.30 70.60
77620 04 N N 74.10
77750 04 N N 105.98 35.32 141.30
77761 04 N I 143.53 112.77 256.30
77762 04 N I 158.90 97.40 256.30
77763 04 N I 169.15 87.15 256.30
77776 04 N I 94.11 62.74 156.85
77777 04 N I 124.50 58.60 183.10
77778 04 N I 146.47 62.78 209.25
77785 04 1/1/2009 N 29.96 44.93 74.89
77786 04 1/1/2009 N 66.97 156.28 223.25
77787 04 1/1/2009 N 106.26 225.80 332.06
77789 04 N N 55.12 41.58 96.70
77790 04 N N 22.65 13.30 35.95
77799 04 Y N
78000 B 04 N N 10.75 10.75 21.50
78001 B 04 N N 14.35 14.35 28.70
78003 B 04 N N 15.05 15.05 30.10
Wednesday, April 01, 2009 Page 300 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
78006 B 04 N N 32.67 32.67 65.35
78007 B 04 N N 32.67 32.67 65.35
78010 B 04 N N 32.67 32.67 65.35
78011 B 04 N N 35.30 35.30 70.60
78015 B 04 N N 39.22 39.22 78.45
78016 B 04 N N 49.05 49.05 98.10
78018 04 N N 84.90
78020 04 N N 78.45
78070 B 04 N N 29.45 29.45 58.90
78075 B 04 N N 32.67 32.67 65.35
78099 04 Y N
78102 B 04 N N 42.45 42.45 84.90
78103 B 04 N N 58.80 58.80 117.60
78104 B 04 N N 58.80 58.80 117.60
78110 B 04 N N 10.47 10.47 20.95
78111 B 04 N N 16.35 16.35 32.70
78120 B 04 N N 16.35 16.35 32.70
78121 B 04 N N 28.77 28.77 57.55
78122 A 04 N N 28.77 28.77 57.55
78130 B 04 N N 32.67 32.67 65.35
78135 B 04 N N 39.22 39.22 78.45
Wednesday, April 01, 2009 Page 301 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
78140 B 04 N N 21.57 21.57 43.15
78185 B 04 N N 49.05 49.05 98.10
78190 04 Y N
78191 04 N N 18.65
78195 B 04 N N 49.05 49.05 98.10
78199 04 Y N
78201 B 04 N N 65.40 65.40 130.80
78202 B 04 N N 65.40 65.40 130.80
78205 B 04 N N 65.40 65.40 130.80
78206 B 04 N N 65.40 65.40 130.80
78215 B 04 N N 65.40 65.40 130.80
78216 B 04 N N 65.40 65.40 130.80
78220 B 04 N N 32.67 32.67 65.35
78223 B 04 N N 35.30 35.30 70.60
78230 B 04 N N 16.35 16.35 32.70
78231 04 N N 28.70
78232 04 N N 14.25
78258 B 04 N N 35.30 35.30 70.60
78261 04 N N 28.70
78262 04 N N 28.70
78264 04 N N 41.90
Wednesday, April 01, 2009 Page 302 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
78267 04 Y N
78268 B 04 N N 30.58 30.58 61.17
78270 B 04 N N 16.35 16.35 32.70
78271 B 04 N N 16.35 16.35 32.70
78272 B 04 N N 16.35 16.35 32.70
78278 C 04 N N 9.64 32.26 41.90
78282 B 04 N N 22.90 22.90 45.80
78290 B 04 N N 49.05 49.05 98.10
78291 B 04 N N 12.45 12.45 24.90
78299 04 Y N
78300 B 04 N N 39.22 39.22 78.45
78305 B 04 N N 58.80 58.80 117.60
78306 B 04 N N 58.80 58.80 117.60
78315 B 04 N N 17.62 17.62 35.25
78320 B 04 N N 33.67 33.67 67.35
78350 B 04 N N 62.25 62.25 124.50
78351 B 04 N N 74.75 74.75 149.50
78399 04 Y N
78414 04 N N 49.70
78428 04 N N 49.70
78445 B 04 N N 24.85 24.85 49.70
Wednesday, April 01, 2009 Page 303 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
78456 B 04 N N 70.85 70.85 141.70
78457 04 N N 60.10
78458 04 N N 84.90
78459 B 04 N N 65.40 65.40 130.80
78460 B 04 N N 24.85 24.85 49.70
78461 B 04 N N 32.67 32.67 65.35
78464 B 04 N N 65.40 65.40 130.80
78465 B 04 N N 65.40 65.40 130.80
78466 B 04 N N 24.85 24.85 49.70
78468 B 04 N N 24.85 24.85 49.70
78469 B 04 N N 65.40 65.40 130.80
78472 B 04 N N 32.67 32.67 65.35
78473 B 04 N N 37.20 37.20 74.40
78478 B 04 N N 23.60 23.60 47.20
78480 B 04 N N 23.60 23.60 47.20
78481 B 04 N N 24.85 24.85 49.70
78483 B 04 N N 31.07 31.07 62.15
78491 B 04 N I 65.40 65.40 130.80
78492 B 04 N I 65.40 65.40 130.80
78494 B 04 N N 31.07 31.07 62.15
78496 B 04 N N 31.07 31.07 62.15
Wednesday, April 01, 2009 Page 304 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
78499 04 Y N
78580 B 04 N N 32.67 32.67 65.35
78584 B 04 N N 35.30 35.30 70.60
78585 B 04 N N 35.30 35.30 70.60
78586 B 04 N N 32.67 32.67 65.35
78587 B 04 N N 32.67 32.67 65.35
78588 B 04 N N 32.67 32.67 65.35
78591 B 04 N N 32.67 32.67 65.35
78593 B 04 N N 32.67 32.67 65.35
78594 B 04 N N 35.95 35.95 71.90
78596 B 04 N N 35.95 35.95 71.90
78599 A 04 Y N
78600 B 04 N N 49.05 49.05 98.10
78601 B 04 N N 65.40 65.40 130.80
78605 B 04 N N 49.05 49.05 98.10
78606 B 04 N N 65.40 65.40 130.80
78607 B 04 N N 65.40 65.40 130.80
78608 B 04 N N 65.40 65.40 130.80
78609 B 04 N N 65.40 65.40 130.80
78610 B 04 N N 65.40 65.40 130.80
78630 B 04 N N 49.05 49.05 98.10
Wednesday, April 01, 2009 Page 305 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
78635 B 04 N N 49.05 49.05 98.10
78645 B 04 N N 20.95 20.95 41.90
78647 B 04 N N 24.85 24.85 49.70
78650 B 04 N N 20.95 20.95 41.90
78660 B 04 N N 16.35 16.35 32.70
78699 04 Y N
78700 B 04 N N 39.22 39.22 78.45
78701 B 04 N N 39.22 39.22 78.45
78707 B 04 N N 42.45 42.45 84.90
78708 B 04 N N 47.20 47.20 94.40
78709 B 04 N N 47.20 47.20 94.40
78710 B 04 N N 39.22 39.22 78.45
78725 B 04 N N 39.22 39.22 78.45
78730 04 N N 28.70
78740 B 04 N N 17.62 17.62 35.25
78761 B 04 N N 24.85 24.85 49.70
78799 04 Y N
78800 B 04 N N 32.02 32.02 64.05
78801 B 04 N N 35.95 35.95 71.90
78802 B 04 N N 42.45 42.45 84.90
78803 B 04 N N 32.02 32.02 64.05
Wednesday, April 01, 2009 Page 306 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
78804 C 04 N N 29.65 86.89 116.54
78805 B 04 N N 32.02 32.02 64.05
78806 B 04 N N 42.45 42.45 84.90
78807 B 04 N N 32.02 32.02 64.05
78808 09 1/1/2009 Y
78811 B 04 N N 65.40 65.40 130.80
78812 B 04 N N 65.40 65.40 130.80
78813 B 04 N N 65.40 65.40 130.80
78814 B 04 N N 65.40 65.40 130.80
78815 B 04 N N 65.40 65.40 130.80
78816 B 04 N N 65.40 65.40 130.80
78999 04 Y N
79005 04 N N 52.50
79101 04 N N 57.30
79200 C 04 N N 61.51 56.11 117.62
79300 B 04 N N 70.60 70.60 141.20
79403 C 04 N N 65.05 82.93 147.98
79440 B 04 N N 52.95 52.95 105.90
79445 04 Y N
79999 04 Y N
80047 04 10/1/2008 Y N
Wednesday, April 01, 2009 Page 307 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
80048 B 04 10/1/2008 N N 4.14 4.14 8.28
80051 A 04 10/1/2008 N N 3.43 3.43 6.86
80053 B 04 10/1/2008 N N 5.18 5.18 10.36
80055 B 04 10/1/2008 N N 15.71 15.71 31.42
80061 B 04 10/1/2008 N N 3.11 3.11 6.22
80069 B 04 10/1/2008 N N 4.26 4.26 8.52
80074 B 04 10/1/2008 N N 19.24 19.24 38.48
80076 B 04 10/1/2008 N N 3.99 3.99 7.98
80100 09 Y N
80101 B 04 10/1/2008 N N 6.71 6.71 13.42
80102 09 Y N
80103 A 09 Y N
80150 A 04 10/1/2008 N N 2.70 2.70 5.40
80152 A 04 10/1/2008 N N 5.25 5.25 10.50
80154 A 04 10/1/2008 N N 3.75 3.75 7.50
80156 A 04 10/1/2008 N N 4.43 4.43 8.86
80157 A 04 10/1/2008 N N 3.90 3.90 7.80
80158 A 04 10/1/2008 N N 6.32 6.32 12.64
80160 A 04 10/1/2008 N N 3.95 3.95 7.90
80162 A 04 10/1/2008 N N 6.49 6.49 12.98
80164 A 04 10/1/2008 N N 4.43 4.43 8.86
Wednesday, April 01, 2009 Page 308 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
80166 A 04 10/1/2008 N N 6.71 6.71 13.42
80168 A 04 10/1/2008 N N 5.66 5.66 11.32
80170 A 04 10/1/2008 N N 2.94 2.94 5.88
80172 A 04 10/1/2008 N N 4.82 4.82 9.64
80173 A 04 10/1/2008 N N 5.70 5.70 11.40
80174 A 04 10/1/2008 N N 5.25 5.25 10.50
80176 A 04 10/1/2008 N N .86 .86 1.72
80178 A 04 10/1/2008 N N 3.23 3.23 6.46
80182 A 04 10/1/2008 N N 4.43 4.43 8.86
80184 A 04 10/1/2008 N N 4.43 4.43 8.86
80185 A 04 10/1/2008 N N 6.49 6.49 12.98
80186 A 04 10/1/2008 N N 6.75 6.75 13.50
80188 A 04 10/1/2008 N N 5.48 5.48 10.96
80190 A 04 10/1/2008 N N 4.61 4.61 9.22
80192 A 04 10/1/2008 N N 4.61 4.61 9.22
80194 A 04 10/1/2008 N N 5.25 5.25 10.50
80195 04 10/1/2008 N N 4.31 4.31 8.62
80196 A 04 10/1/2008 N N 2.70 2.70 5.40
80197 A 04 10/1/2008 N N 5.25 5.25 10.50
80198 A 04 10/1/2008 N N 4.61 4.61 9.22
80200 A 04 10/1/2008 N N 4.39 4.39 8.78
Wednesday, April 01, 2009 Page 309 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
80201 A 04 10/1/2008 N N 5.66 5.66 11.32
80202 A 04 10/1/2008 N N 6.64 6.64 13.28
80299 A 04 10/1/2008 Y N
80400 B 04 10/1/2008 N N 13.48 13.48 26.96
80402 B 04 10/1/2008 N N 22.29 22.29 44.58
80406 B 04 10/1/2008 N N 22.73 22.73 45.46
80408 B 04 10/1/2008 N N 61.43 61.43 122.86
80410 B 04 10/1/2008 N N 12.60 12.60 25.20
80412 B 04 10/1/2008 N N 80.89 80.89 161.78
80414 B 04 10/1/2008 N N 25.28 25.28 50.56
80415 B 04 10/1/2008 N N 10.20 10.20 20.40
80416 B 04 10/1/2008 N N 64.61 64.61 129.22
80417 B 04 10/1/2008 N N 21.54 21.54 43.08
80418 B 04 10/1/2008 Y N
80420 B 04 10/1/2008 N N 29.51 29.51 59.02
80422 B 04 10/1/2008 N N 19.99 19.99 39.98
80424 B 04 10/1/2008 N N 15.15 15.15 30.30
80426 B 04 10/1/2008 N N 60.11 60.11 120.22
80428 B 04 10/1/2008 N N 17.64 17.64 35.28
80430 B 04 10/1/2008 N N 24.39 24.39 48.78
80432 B 04 10/1/2008 N N 47.72 47.72 95.44
Wednesday, April 01, 2009 Page 310 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
80434 B 04 10/1/2008 N N 44.86 44.86 89.92
80435 B 04 10/1/2008 N N 33.30 33.30 66.60
80436 B 04 10/1/2008 N N 29.03 29.03 58.06
80438 B 04 10/1/2008 N N 24.68 24.68 49.36
80439 B 04 10/1/2008 N N 32.89 32.89 65.78
80440 B 04 10/1/2008 N N 20.23 20.23 40.46
80500 04 N N 12.40
80502 04 N N 49.80
81000 A 04 10/1/2008 N N 1.31 1.31 2.62
81001 A 04 10/1/2008 N N 1.43 1.43 2.86
81002 04 N N 1.30 1.30 2.60
81003 A 04 10/1/2008 N N 1.09 1.09 2.18
81005 A 04 10/1/2008 N N .86 .86 1.72
81007 A 04 10/1/2008 N N 1.26 1.26 2.52
81015 A 04 10/1/2008 N N 1.31 1.31 2.62
81020 A 04 10/1/2008 N N 1.39 1.39 2.78
81025 A 04 10/1/2008 N N 1.29 1.29 2.58
81050 A 04 10/1/2008 N N 1.28 1.28 2.56
81099 A 04 10/1/2008 Y N
82000 A 04 10/1/2008 N N 3.96 3.96 7.92
82003 A 04 10/1/2008 N N 3.96 3.96 7.92
Wednesday, April 01, 2009 Page 311 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82009 A 04 10/1/2008 N N .86 .86 1.72
82010 A 04 10/1/2008 N N .86 .86 1.72
82013 A 04 10/1/2008 N N 2.70 2.70 5.40
82016 A 04 10/1/2008 N N 2.55 2.55 5.10
82017 A 04 10/1/2008 N N 5.82 5.82 11.64
82024 A 04 10/1/2008 N N 6.71 6.71 13.42
82030 B 04 10/1/2008 N N 4.43 4.43 8.86
82040 A 04 10/1/2008 N N 2.25 2.25 4.50
82042 A 04 10/1/2008 N N 2.25 2.25 4.50
82043 A 04 10/1/2008 N N 1.97 1.97 3.94
82044 A 04 10/1/2008 N N 1.97 1.97 3.94
82045 A 04 10/1/2008 Y N
82055 A 04 10/1/2008 N N 4.31 4.31 8.62
82075 A 04 10/1/2008 N N 2.51 2.51 5.02
82085 B 04 10/1/2008 N N 3.15 3.15 6.30
82088 A 04 10/1/2008 N N 19.95 19.95 39.90
82101 A 04 10/1/2008 N N 8.85 8.85 17.70
82103 B 04 10/1/2008 N N 4.43 4.43 8.86
82104 B 04 10/1/2008 N N 3.58 3.58 7.16
82105 B 04 10/1/2008 N N 8.21 8.21 16.42
82106 B 04 10/1/2008 N N 3.11 3.11 6.22
Wednesday, April 01, 2009 Page 312 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82107 B 04 10/1/2008 N N 14.72 14.72 29.44
82108 A 04 10/1/2008 N N 2.51 2.51 5.02
82120 A 04 10/1/2008 N N 1.84 1.84 3.68
82127 A 04 10/1/2008 N N 2.55 2.55 5.10
82128 A 04 10/1/2008 N N 2.55 2.55 5.10
82131 A 04 10/1/2008 N N 5.81 5.81 11.62
82135 B 04 10/1/2008 N N 4.43 4.43 8.86
82136 A 04 10/1/2008 N N 5.81 5.81 11.62
82139 A 04 10/1/2008 N N 5.81 5.81 11.62
82140 A 04 10/1/2008 N N 3.58 3.58 7.16
82143 A 04 10/1/2008 N N 3.36 3.36 6.72
82145 A 04 10/1/2008 N N 5.25 5.25 10.50
82150 A 04 10/1/2008 N N 3.19 3.19 6.38
82154 B 04 10/1/2008 N N 8.40 8.40 16.80
82157 B 04 10/1/2008 N N 8.40 8.40 16.80
82160 A 04 10/1/2008 N N 2.70 2.70 5.40
82163 B 04 10/1/2008 N N 3.75 3.75 7.50
82164 B 04 10/1/2008 N N 3.58 3.58 7.16
82172 A 04 10/1/2008 N N 6.00 6.00 12.00
82175 A 04 10/1/2008 N N 4.43 4.43 8.86
82180 B 04 10/1/2008 N N 2.51 2.51 5.02
Wednesday, April 01, 2009 Page 313 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82190 A 04 10/1/2008 N N 7.31 7.31 14.62
82205 A 04 10/1/2008 N N 4.43 4.43 8.86
82232 A 04 10/1/2008 N N 3.96 3.96 7.92
82239 B 04 10/1/2008 N N 8.38 8.38 16.76
82240 B 04 10/1/2008 N N 6.38 6.38 12.76
82247 A 04 10/1/2008 N N 2.33 2.33 4.66
82248 A 04 10/1/2008 N N 2.33 2.33 4.66
82252 A 04 10/1/2008 N N 1.31 1.31 2.62
82261 B 04 10/1/2008 N N 8.25 8.25 16.50
82270 A 04 10/1/2008 N N 1.24 1.24 2.48
82271 A 04 10/1/2008 N N 1.02 1.02 2.04
82272 A 04 10/1/2008 N N 1.02 1.02 2.04
82274 A 04 10/1/2008 N N 5.00 5.00 10.00
82286 A 04 10/1/2008 N N 2.01 2.01 4.02
82300 A 04 10/1/2008 N N 3.34 3.34 6.68
82306 B 04 10/1/2008 N N 4.43 4.43 8.86
82307 04 10/1/2008 N N 8.85 8.85 17.70
82308 A 04 10/1/2008 N N 3.15 3.15 6.30
82310 A 04 10/1/2008 N N 2.33 2.33 4.66
82330 A 04 10/1/2008 N N 6.68 6.68 13.36
82331 A 04 10/1/2008 N N 2.08 2.08 4.16
Wednesday, April 01, 2009 Page 314 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82340 A 04 10/1/2008 N N 2.70 2.70 5.40
82355 A 04 10/1/2008 N N 2.33 2.33 4.66
82360 A 04 10/1/2008 N N 4.54 4.54 9.08
82365 A 04 10/1/2008 N N 2.33 2.33 4.66
82370 A 04 10/1/2008 N N 2.33 2.33 4.66
82373 A 04 10/1/2008 N N 2.81 2.81 5.62
82374 A 04 10/1/2008 N N 2.40 2.40 4.80
82375 A 04 10/1/2008 N N 2.33 2.33 4.66
82376 A 04 10/1/2008 N N 2.33 2.33 4.66
82378 B 04 10/1/2008 N N 6.71 6.71 13.42
82379 A 04 10/1/2008 N N 5.81 5.81 11.62
82380 A 04 10/1/2008 N N 2.33 2.33 4.66
82382 B 04 10/1/2008 N N 7.58 7.58 15.16
82383 B 04 10/1/2008 N N 7.58 7.58 15.16
82384 B 04 10/1/2008 N N 7.58 7.58 15.16
82387 B 04 10/1/2008 N N 5.74 5.74 11.48
82390 B 04 10/1/2008 N N 4.43 4.43 8.86
82397 A 04 10/1/2008 N N 6.92 6.92 13.84
82415 A 04 10/1/2008 N N 4.43 4.43 8.86
82435 A 04 10/1/2008 N N 2.25 2.25 4.50
82436 A 04 10/1/2008 N N 2.33 2.33 4.66
Wednesday, April 01, 2009 Page 315 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82438 A 04 10/1/2008 N N 2.40 2.40 4.80
82441 A 04 10/1/2008 N N 2.14 2.14 4.28
82465 A 04 10/1/2008 N N 2.12 2.12 4.24
82480 A 04 10/1/2008 N N 3.58 3.58 7.16
82482 A 04 10/1/2008 N N 1.31 1.31 2.62
82485 A 04 10/1/2008 N N 5.04 5.04 10.08
82486 B 04 10/1/2008 N N 3.58 3.58 7.15
82487 B 04 10/1/2008 N N 4.22 4.22 8.44
82488 B 04 10/1/2008 N N 6.41 6.41 12.82
82489 B 04 10/1/2008 N N 1.69 1.69 3.38
82491 B 04 10/1/2008 N N 6.09 6.09 12.18
82492 B 04 10/1/2008 N N 6.09 6.09 12.18
82495 A 04 10/1/2008 N N 6.71 6.71 13.42
82507 A 04 10/1/2008 N N 2.70 2.70 5.40
82520 A 04 10/1/2008 N N 3.58 3.58 7.16
82523 09 Y N
82525 A 04 10/1/2008 N N 5.55 5.55 11.10
82528 B 04 10/1/2008 N N 8.85 8.85 17.70
82530 A 04 10/1/2008 N N 6.71 6.71 13.42
82533 A 04 10/1/2008 N N 6.71 6.71 13.42
82540 A 04 10/1/2008 N N 2.25 2.25 4.50
Wednesday, April 01, 2009 Page 316 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82541 B 04 10/1/2008 N N 3.58 3.58 7.16
82542 B 04 10/1/2008 N N 6.09 6.09 12.18
82543 B 04 10/1/2008 N N 6.09 6.09 12.18
82544 B 04 10/1/2008 N N 6.09 6.09 12.18
82550 A 04 10/1/2008 N N 3.04 3.04 6.08
82552 A 04 10/1/2008 N N 3.15 3.15 6.30
82553 A 04 10/1/2008 N N 3.71 3.71 7.42
82554 A 04 10/1/2008 N N 3.08 3.08 6.16
82565 A 04 10/1/2008 N N 2.33 2.33 4.66
82570 A 04 10/1/2008 N N 2.33 2.33 4.66
82575 B 04 10/1/2008 N N 4.61 4.61 9.22
82585 B 04 10/1/2008 N N 4.20 4.20 8.40
82595 B 04 10/1/2008 N N 2.33 2.33 4.66
82600 A 04 10/1/2008 N N 3.34 3.34 6.68
82607 B 04 10/1/2008 N N 6.00 6.00 12.00
82608 B 04 10/1/2008 N N 6.01 6.01 12.02
82610 04 10/1/2008 N N 4.28 4.28 8.56
82615 A 04 10/1/2008 N N 3.15 3.15 6.30
82626 B 04 10/1/2008 N N 4.43 4.43 8.86
82627 B 04 10/1/2008 N N 3.48 3.48 7.96
82633 B 04 10/1/2008 N N 5.04 5.04 10.08
Wednesday, April 01, 2009 Page 317 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82634 A 04 10/1/2008 N N 7.76 7.76 15.52
82638 A 04 10/1/2008 N N 3.58 3.58 7.16
82646 A 04 10/1/2008 N N 1.76 1.76 3.52
82649 A 04 10/1/2008 N N 4.43 4.43 8.86
82651 B 04 10/1/2008 N N 10.09 10.09 20.18
82652 04 10/1/2008 N N 8.03 8.03 16.06
82654 B 04 10/1/2008 N N 1.69 1.69 3.38
82656 A 04 10/1/2008 N N 3.63 3.63 7.26
82657 A 04 10/1/2008 N N 6.09 6.09 12.18
82658 A 04 10/1/2008 N N 6.09 6.09 12.18
82664 B 04 10/1/2008 N N 13.53 13.53 27.06
82666 B 04 10/1/2008 N N 4.43 4.43 8.86
82668 B 04 10/1/2008 N N 5.21 5.21 10.42
82670 A 04 10/1/2008 N N 5.06 5.06 10.12
82671 B 04 10/1/2008 N N 8.85 8.85 17.70
82672 B 04 10/1/2008 N N 8.85 8.85 17.70
82677 B 04 10/1/2008 N N 5.06 5.06 10.12
82679 B 04 10/1/2008 N N 5.06 5.06 10.12
82690 A 04 10/1/2008 N N 4.22 4.22 8.44
82693 A 04 10/1/2008 N N 7.31 7.31 14.62
82696 B 04 10/1/2008 N N 5.04 5.04 10.08
Wednesday, April 01, 2009 Page 318 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82705 A 04 10/1/2008 N N 1.28 1.28 2.56
82710 A 04 10/1/2008 N N 1.54 1.54 3.08
82715 A 04 10/1/2008 N N 1.61 1.61 3.22
82725 A 04 10/1/2008 N N 1.31 1.31 2.62
82726 B 04 10/1/2008 N N 6.09 6.09 12.18
82728 A 04 10/1/2008 N N 3.58 3.58 7.16
82731 B 04 10/1/2008 N N 18.39 18.39 36.78
82735 A 04 10/1/2008 N N 3.58 3.58 7.16
82742 A 04 10/1/2008 N N 3.58 3.58 7.16
82746 B 04 10/1/2008 N N 5.73 5.73 11.46
82747 B 04 10/1/2008 N N 6.64 6.64 13.28
82757 A 04 10/1/2008 N N 3.98 3.98 7.96
82759 A 04 10/1/2008 N N 2.33 2.33 4.66
82760 A 04 10/1/2008 N N 2.33 2.33 4.66
82775 A 04 10/1/2008 N N 6.71 6.71 13.42
82776 A 04 10/1/2008 N N 2.51 2.51 5.02
82784 A 04 10/1/2008 N N 4.54 4.54 9.08
82785 A 04 10/1/2008 N N 3.58 3.58 7.16
82787 A 04 10/1/2008 N N 3.94 3.94 7.88
82800 A 04 10/1/2008 N N 2.33 2.33 4.66
82803 A 04 10/1/2008 N N 5.44 5.44 10.88
Wednesday, April 01, 2009 Page 319 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82805 A 04 10/1/2008 N N 5.44 5.44 10.88
82810 A 04 10/1/2008 N N 2.85 2.85 5.70
82820 A 04 10/1/2008 N N 4.89 4.89 9.78
82926 A 04 10/1/2008 N N 2.66 2.66 5.32
82928 A 04 10/1/2008 N N 1.76 1.76 3.52
82938 04 10/1/2008 N N 8.40 8.40 16.80
82941 B 04 10/1/2008 N N 3.96 3.96 7.92
82943 A 04 10/1/2008 N N 3.51 3.51 7.02
82945 A 04 10/1/2008 N N 1.54 1.54 3.08
82946 B 04 10/1/2008 N N 5.25 5.25 10.50
82947 A 04 10/1/2008 N N 1.91 1.91 3.82
82948 A 04 10/1/2008 N N .86 .86 1.72
82950 A 04 10/1/2008 N N 2.33 2.33 4.66
82951 B 04 10/1/2008 N N 6.30 6.30 12.60
82952 A 04 10/1/2008 N N 1.91 1.91 3.82
82953 A 04 10/1/2008 N N 2.33 2.33 4.66
82955 A 04 10/1/2008 N N 4.31 4.31 8.62
82960 A 04 10/1/2008 N N 2.96 2.96 5.92
82962 A 04 10/1/2008 N N .84 .84 1.68
82963 B 04 10/1/2008 N N 6.32 6.32 12.64
82965 A 04 10/1/2008 N N 3.58 3.58 7.16
Wednesday, April 01, 2009 Page 320 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
82975 B 04 10/1/2008 N N 2.70 2.70 5.40
82977 A 04 10/1/2008 N N 2.70 2.70 5.40
82978 A 04 10/1/2008 N N 4.80 4.80 9.60
82979 A 04 10/1/2008 N N 1.76 1.76 3.52
82980 A 04 10/1/2008 N N 3.08 3.08 6.16
82985 B 04 10/1/2008 N N 6.71 6.71 13.42
83001 A 04 10/1/2008 N N 9.09 9.09 18.18
83002 A 04 10/1/2008 N N 4.43 4.43 8.86
83003 A 04 10/1/2008 N N 4.43 4.43 8.86
83008 A 04 10/1/2008 N N 5.63 5.63 11.26
83009 A 04 10/1/2008 N N 21.18 21.18 42.36
83010 A 04 10/1/2008 N N 4.43 4.43 8.86
83012 A 04 10/1/2008 N N 3.34 3.34 6.68
83013 B 04 10/1/2008 N N 4.31 4.31 8.62
83014 B 04 10/1/2008 N N 3.83 3.83 7.66
83015 B 04 10/1/2008 N N 9.23 9.23 18.46
83018 A 04 10/1/2008 N N 2.33 2.33 4.66
83020 B 04 10/1/2008 N N 4.31 4.31 8.62
83021 B 04 10/1/2008 N N 6.09 6.09 12.18
83026 A 04 10/1/2008 N N 1.14 1.14 2.28
83030 A 04 10/1/2008 N N 1.61 1.61 3.22
Wednesday, April 01, 2009 Page 321 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
83033 A 04 10/1/2008 N N 2.93 2.93 5.86
83036 B 04 10/1/2008 N N 3.15 3.15 6.30
83037 04 10/1/2008 N N .74 .74 1.48
83045 A 04 10/1/2008 N N 2.33 2.33 4.66
83050 A 04 10/1/2008 N N 1.50 1.50 3.00
83051 A 04 10/1/2008 N N 1.61 1.61 3.22
83055 A 04 10/1/2008 N N 1.61 1.61 3.22
83060 A 04 10/1/2008 N N 1.61 1.61 3.22
83065 A 04 10/1/2008 N N 1.61 1.61 3.22
83068 A 04 10/1/2008 N N 1.61 1.61 3.22
83069 A 04 10/1/2008 N N .77 .77 1.54
83070 A 04 10/1/2008 N N 1.31 1.31 2.62
83071 A 04 10/1/2008 N N 1.61 1.61 3.22
83080 B 04 10/1/2008 N N 5.81 5.81 11.62
83088 B 04 10/1/2008 N N 8.85 8.85 17.70
83090 B 04 10/1/2008 N N 6.60 6.60 13.20
83150 B 04 10/1/2008 N N 5.48 5.48 10.96
83491 B 04 10/1/2008 N N 3.58 3.58 7.16
83497 B 04 10/1/2008 N N 6.32 6.32 12.64
83498 B 04 10/1/2008 N N 4.43 4.43 8.86
83499 B 04 10/1/2008 N N 8.03 8.03 16.06
Wednesday, April 01, 2009 Page 322 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
83500 B 04 10/1/2008 N N 7.14 7.14 14.28
83505 B 04 10/1/2008 N N 8.85 8.85 17.70
83516 A 04 10/1/2008 N N 4.39 4.39 8.78
83518 A 04 10/1/2008 N N 4.14 4.14 8.28
83519 A 04 10/1/2008 N N 6.60 6.60 13.20
83520 A 04 10/1/2008 N N 6.34 6.34 12.68
83525 A 04 10/1/2008 N N 4.43 4.43 8.86
83527 A 04 10/1/2008 N N 4.43 4.43 8.86
83528 A 04 10/1/2008 N N 3.98 3.98 7.96
83540 A 04 10/1/2008 N N 3.19 3.19 6.38
83550 A 04 10/1/2008 N N 4.28 4.28 8.56
83570 A 04 10/1/2008 N N 3.58 3.58 7.16
83582 B 04 10/1/2008 N N 6.09 6.09 12.18
83586 B 04 10/1/2008 N N 3.28 3.28 6.56
83593 B 04 10/1/2008 N N 7.76 7.76 15.52
83605 A 04 10/1/2008 N N 4.43 4.43 8.86
83615 A 04 10/1/2008 N N 2.96 2.96 5.92
83625 B 04 10/1/2008 N N 5.21 5.21 10.42
83630 04 10/1/2008 N N 3.61 3.61 7.22
83631 B 04 10/1/2008 N N 6.17 6.17 12.34
83632 B 04 10/1/2008 N N 4.43 4.43 8.86
Wednesday, April 01, 2009 Page 323 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
83633 A 04 10/1/2008 N N 2.70 2.70 5.40
83634 A 04 10/1/2008 N N 2.96 2.96 5.92
83655 B 04 10/1/2008 N N 5.93 5.93 11.96
83661 B 04 10/1/2008 N N 6.71 6.71 13.42
83662 B 04 10/1/2008 N N 6.21 6.21 12.42
83663 B 04 10/1/2008 N N 3.68 3.68 7.36
83664 B 04 10/1/2008 N N 1.86 1.86 3.72
83670 B 04 10/1/2008 N N 3.15 3.15 6.30
83690 A 04 10/1/2008 N N 3.36 3.36 6.72
83695 B 04 10/1/2008 N N 4.07 4.07 8.14
83698 04 10/1/2008 N N 8.92 8.92 17.84
83700 04 10/1/2008 N N 3.54 3.54 7.08
83701 04 10/1/2008 N N 7.80 7.80 15.60
83704 04 10/1/2008 N N 9.92 9.92 19.84
83718 B 04 10/1/2008 N N 4.01 4.01 8.02
83719 B 04 10/1/2008 N N 5.70 5.70 11.40
83721 B 04 10/1/2008 N N 4.67 4.67 9.34
83727 A 04 10/1/2008 N N 4.43 4.43 8.86
83735 A 04 10/1/2008 N N 3.28 3.28 6.56
83775 A 04 10/1/2008 N N 2.78 2.78 5.56
83785 A 04 10/1/2008 N N .64 .64 1.28
Wednesday, April 01, 2009 Page 324 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
83788 A 04 10/1/2008 N N 3.58 3.58 7.16
83789 A 04 10/1/2008 N N 3.58 3.58 7.16
83805 A 04 10/1/2008 N N 3.53 3.53 7.06
83825 A 04 10/1/2008 N N 3.96 3.96 7.92
83835 B 04 10/1/2008 N N 6.71 6.71 13.42
83840 A 04 10/1/2008 N N 4.43 4.43 8.86
83857 A 04 10/1/2008 N N 1.31 1.31 2.62
83858 A 04 10/1/2008 N N 3.96 3.96 7.92
83864 B 04 10/1/2008 N N 5.25 5.25 10.50
83866 B 04 10/1/2008 N N 4.46 4.46 8.92
83872 A 04 10/1/2008 N N 1.31 1.31 2.62
83873 B 04 10/1/2008 N N 4.82 4.82 9.64
83874 B 04 10/1/2008 N N 6.32 6.32 12.64
83876 B 04 1/1/2009 N N 5.68 5.68 11.36
83880 B 04 10/1/2008 N N 7.43 7.43 14.86
83883 A 04 10/1/2008 N N 5.22 5.22 10.44
83885 A 04 10/1/2008 N N 3.96 3.96 7.92
83887 A 04 10/1/2008 N N 3.34 3.34 6.68
83890 B 04 N N 2.62 2.62 5.25
83891 B 04 N N 2.62 2.62 5.25
83892 B 04 N N 2.52 2.52 5.05
Wednesday, April 01, 2009 Page 325 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
83893 B 04 N N 2.62 2.62 5.25
83894 B 04 N N 2.52 2.52 5.05
83896 B 04 N N 2.62 2.62 5.25
83897 B 04 N N 2.62 2.62 5.25
83898 B 04 N N 10.95 10.95 21.90
83900 B 04 N N 14.05 14.05 28.10
83901 B 04 N N 10.95 10.95 21.90
83902 B 04 N N 9.25 9.25 18.50
83903 B 04 N N 10.95 10.95 21.90
83904 B 04 N N 10.95 10.95 21.90
83905 B 04 N N 10.95 10.95 21.90
83906 B 04 N N 10.95 10.95 21.90
83907 B 04 N N 5.59 5.59 11.19
83908 B 04 N N 7.02 7.02 14.05
83909 B 04 N N 7.02 7.02 14.05
83912 B 04 N N 2.62 2.62 5.25
83913 B 04 1/1/2007 N N 5.60 5.60 11.20
83914 B 04 N N 7.02 7.02 14.05
83915 B 04 10/1/2008 N N 2.70 2.70 5.40
83916 B 04 10/1/2008 N N 3.34 3.34 6.68
83918 B 04 10/1/2008 N N 8.06 8.06 16.12
Wednesday, April 01, 2009 Page 326 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
83919 B 04 10/1/2008 N N 8.06 8.06 16.12
83921 B 04 10/1/2008 N N 6.45 6.45 12.90
83925 A 04 10/1/2008 N N 8.48 8.48 16.96
83930 A 04 10/1/2008 N N 2.33 2.33 4.66
83935 A 04 10/1/2008 N N 2.33 2.33 4.66
83937 04 10/1/2008 N N 6.71 6.71 13.42
83945 A 04 10/1/2008 N N 1.54 1.54 3.08
83950 B 04 10/1/2008 N N 22.41 22.41 44.82
83951 B 04 1/1/2009 N N 20.50 20.50 41.00
83970 B 04 10/1/2008 N N 15.56 15.56 31.12
83986 A 04 10/1/2008 N N 1.76 1.76 3.52
83992 A 04 10/1/2008 N N 2.33 2.33 4.66
83993 04 10/1/2008 N N 6.17 6.17 12.34
84022 A 04 10/1/2008 N N 2.70 2.70 5.40
84030 A 04 10/1/2008 N N 2.63 2.63 5.26
84035 A 04 10/1/2008 N N .86 .86 1.72
84060 A 04 10/1/2008 N N 3.58 3.58 7.16
84061 A 04 10/1/2008 N N 3.15 3.15 6.30
84066 A 04 10/1/2008 N N 1.54 1.54 3.08
84075 A 04 10/1/2008 N N 2.51 2.51 5.02
84078 A 04 10/1/2008 N N 3.58 3.58 7.16
Wednesday, April 01, 2009 Page 327 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
84080 A 04 10/1/2008 N N 4.43 4.43 8.86
84081 A 04 10/1/2008 N N 1.26 1.26 2.52
84085 A 04 10/1/2008 N N 1.76 1.76 3.52
84087 A 04 10/1/2008 N N 2.78 2.78 5.56
84100 A 04 10/1/2008 N N 2.33 2.33 4.66
84105 A 04 10/1/2008 N N 1.13 1.13 2.26
84106 A 04 10/1/2008 N N 2.10 2.10 4.20
84110 A 04 10/1/2008 N N 2.33 2.33 4.66
84119 B 04 10/1/2008 N N 4.22 4.22 8.44
84120 B 04 10/1/2008 N N 6.71 6.71 13.42
84126 B 04 10/1/2008 N N 10.95 10.95 21.90
84127 B 04 10/1/2008 N N 5.48 5.48 10.96
84132 A 04 10/1/2008 N N 2.25 2.25 4.50
84133 A 04 10/1/2008 N N 2.10 2.10 4.20
84134 A 04 10/1/2008 N N 2.79 2.79 5.58
84135 B 04 10/1/2008 N N 3.96 3.96 7.92
84138 B 04 10/1/2008 N N 4.43 4.43 8.86
84140 04 10/1/2008 N N 4.43 4.43 8.86
84143 04 10/1/2008 N N 4.61 4.61 9.22
84144 A 04 10/1/2008 N N 4.61 4.61 9.22
84146 A 04 10/1/2008 N N 6.71 6.71 13.42
Wednesday, April 01, 2009 Page 328 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
84150 A 04 10/1/2008 N N 1.76 1.76 3.52
84152 B 04 10/1/2008 N N 7.20 7.20 14.40
84153 B 04 10/1/2008 N N 6.60 6.60 13.20
84154 B 04 10/1/2008 N N 6.60 6.60 13.20
84155 A 04 10/1/2008 N N 1.80 1.80 3.60
84156 B 04 10/1/2008 N N 1.15 1.15 2.30
84157 B 04 10/1/2008 N N 1.15 1.15 2.30
84160 A 04 10/1/2008 N N 1.31 1.31 2.62
84163 04 10/1/2008 N N 4.79 4.79 9.58
84165 B 04 10/1/2008 N N 5.25 5.25 10.50
84166 04 10/1/2008 N N 5.61 5.61 11.22
84181 B 04 10/1/2008 N N 8.33 8.33 16.66
84182 B 04 10/1/2008 N N 8.80 8.80 17.60
84202 A 04 10/1/2008 N N 1.76 1.76 3.52
84203 A 04 10/1/2008 N N 1.31 1.31 2.62
84206 B 04 10/1/2008 N N 3.58 3.58 7.16
84207 B 04 10/1/2008 N N 6.00 6.00 12.00
84210 A 04 10/1/2008 N N 3.58 3.58 7.16
84220 A 04 10/1/2008 N N 2.33 2.33 4.66
84228 A 04 10/1/2008 N N 5.25 5.25 10.50
84233 B 04 10/1/2008 N N 16.50 16.50 33.00
Wednesday, April 01, 2009 Page 329 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
84234 B 04 10/1/2008 N N 2.70 2.70 5.40
84235 A 04 10/1/2008 N N 2.70 2.70 5.40
84238 B 04 10/1/2008 N N 10.01 10.01 20.02
84244 A 04 10/1/2008 N N 10.76 10.76 21.52
84252 B 04 10/1/2008 N N 1.31 1.31 2.62
84255 A 04 10/1/2008 N N 2.40 2.40 4.80
84260 A 04 10/1/2008 N N 2.51 2.51 5.02
84270 B 04 10/1/2008 N N 8.19 8.19 16.38
84275 A 04 10/1/2008 N N 1.76 1.76 3.52
84285 A 04 10/1/2008 N N 1.80 1.80 3.60
84295 A 04 10/1/2008 N N 2.33 2.33 4.66
84300 A 04 10/1/2008 N N 2.12 2.12 4.24
84302 B 04 10/1/2008 N N 1.28 1.28 2.56
84305 B 04 10/1/2008 N N 7.54 7.54 15.08
84307 B 04 10/1/2008 N N 7.54 7.54 15.08
84311 A 04 10/1/2008 N N 3.44 3.44 6.88
84315 A 04 10/1/2008 N N 1.22 1.22 2.44
84375 A 04 10/1/2008 N N 2.33 2.33 4.66
84376 A 04 10/1/2008 N N 2.70 2.70 5.40
84377 A 04 10/1/2008 N N 2.70 2.70 5.40
84378 A 04 10/1/2008 N N 2.96 2.96 5.92
Wednesday, April 01, 2009 Page 330 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
84379 A 04 10/1/2008 N N 2.96 2.96 5.92
84392 A 04 10/1/2008 N N 2.33 2.33 4.66
84402 A 04 10/1/2008 N N 9.17 9.17 18.34
84403 A 04 10/1/2008 N N 12.64 12.64 25.28
84425 B 04 10/1/2008 N N 6.41 6.41 12.82
84430 B 04 10/1/2008 N N 3.58 3.58 7.16
84432 B 04 10/1/2008 N N 7.86 7.86 15.72
84436 B 04 10/1/2008 N N 3.36 3.36 6.72
84437 B 04 10/1/2008 N N 3.19 3.19 6.38
84439 B 04 10/1/2008 N N 4.43 4.43 8.86
84442 B 04 10/1/2008 N N 4.43 4.43 8.86
84443 B 04 10/1/2008 N N 8.21 8.21 16.42
84445 B 04 10/1/2008 N N 13.48 13.48 26.96
84446 B 04 10/1/2008 N N 4.43 4.43 8.86
84449 04 10/1/2008 N N 6.71 6.71 13.42
84450 A 04 10/1/2008 N N 2.51 2.51 5.02
84460 A 04 10/1/2008 N N 2.59 2.59 5.18
84466 A 04 10/1/2008 N N 4.39 4.39 8.78
84478 B 04 10/1/2008 N N 2.70 2.70 5.40
84479 B 04 10/1/2008 N N 3.19 3.19 6.38
84480 B 04 10/1/2008 N N 4.78 4.78 9.56
Wednesday, April 01, 2009 Page 331 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
84481 B 04 10/1/2008 N N 5.06 5.06 10.12
84482 B 04 10/1/2008 N N 3.41 3.41 6.82
84484 A 04 10/1/2008 N N 3.71 3.71 7.42
84485 A 04 10/1/2008 N N 2.70 2.70 5.40
84488 B 04 10/1/2008 N N 2.70 2.70 5.40
84490 B 04 10/1/2008 N N 2.70 2.70 5.40
84510 B 04 10/1/2008 N N 5.10 5.10 10.20
84512 A 04 10/1/2008 N N 3.71 3.71 7.42
84520 A 04 10/1/2008 N N 1.93 1.93 3.86
84525 A 04 10/1/2008 N N .86 .86 1.72
84540 A 04 10/1/2008 N N 1.76 1.76 3.52
84545 A 04 10/1/2008 N N 2.01 2.01 4.02
84550 A 04 10/1/2008 N N 2.21 2.21 4.42
84560 A 04 10/1/2008 N N 1.31 1.31 2.62
84577 A 04 10/1/2008 N N 2.70 2.70 5.40
84578 A 04 10/1/2008 N N .86 .86 1.72
84580 A 04 10/1/2008 N N 2.01 2.01 4.02
84583 A 04 10/1/2008 N N 1.31 1.31 2.62
84585 B 04 10/1/2008 N N 7.58 7.58 15.16
84586 B 04 10/1/2008 N N 3.49 3.49 6.98
84588 B 04 10/1/2008 N N 2.33 2.33 4.66
Wednesday, April 01, 2009 Page 332 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
84590 B 04 10/1/2008 N N 2.33 2.33 4.66
84591 B 04 10/1/2008 N N 4.54 4.54 9.08
84597 B 04 10/1/2008 N N 2.51 2.51 5.02
84600 A 04 10/1/2008 N N 1.76 1.76 3.52
84620 A 04 10/1/2008 N N 3.75 3.75 7.50
84630 B 04 10/1/2008 N N 5.04 5.04 10.08
84681 B 04 10/1/2008 N N 6.41 6.41 12.82
84702 B 04 10/1/2008 N N 4.43 4.43 8.86
84703 B 04 10/1/2008 N N 3.58 3.58 7.16
84704 04 10/1/2008 N N 4.73 4.73 9.46
84999 A 04 10/1/2008 Y N
85002 A 04 10/1/2008 N N .86 .86 1.72
85004 A 04 10/1/2008 N N 1.70 1.70 3.40
85007 A 04 N N 1.75 1.75 3.50
85008 A 04 10/1/2008 N N 1.69 1.69 3.38
85009 A 04 N N 1.75 1.75 3.50
85013 A 04 10/1/2008 N N 1.16 1.16 2.32
85014 A 04 10/1/2008 N N 1.16 1.16 2.32
85018 A 04 10/1/2008 N N 1.16 1.16 2.32
85025 A 04 10/1/2008 N N 2.87 2.87 5.74
85027 A 04 10/1/2008 N N 2.87 2.87 5.74
Wednesday, April 01, 2009 Page 333 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
85032 A 04 N N 1.50 1.50 3.00
85041 A 04 10/1/2008 N N .86 .86 1.72
85044 04 N N 1.75 1.75 3.50
85045 A 04 10/1/2008 N N 1.31 1.31 2.62
85046 A 04 10/1/2008 N N 2.74 2.74 5.48
85048 A 04 10/1/2008 N N .86 .86 1.72
85049 A 04 10/1/2008 N N 1.17 1.17 2.34
85055 A 04 10/1/2008 N N 4.25 4.25 8.50
85060 04 N N 4.50
85097 04 N N 22.40
85130 B 04 10/1/2008 N N 5.82 5.82 11.64
85170 A 04 10/1/2008 N N 2.23 2.23 4.46
85175 A 04 10/1/2008 N N 2.23 2.23 4.46
85210 B 04 10/1/2008 N N 4.43 4.43 8.86
85220 B 04 10/1/2008 N N 4.43 4.43 8.86
85230 B 04 10/1/2008 N N 4.43 4.43 8.86
85240 B 04 10/1/2008 N N 4.43 4.43 8.86
85244 B 04 10/1/2008 N N 3.58 3.58 7.16
85245 B 04 10/1/2008 N N 3.60 3.60 7.20
85246 B 04 10/1/2008 N N 3.60 3.60 7.20
85247 B 04 10/1/2008 N N 6.94 6.94 13.88
Wednesday, April 01, 2009 Page 334 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
85250 B 04 10/1/2008 N N 4.43 4.43 8.86
85260 B 04 10/1/2008 N N 4.43 4.43 8.86
85270 B 04 10/1/2008 N N 4.43 4.43 8.86
85280 B 04 10/1/2008 N N 4.43 4.43 8.86
85290 B 04 10/1/2008 N N 4.43 4.43 8.86
85291 B 04 10/1/2008 N N 4.35 4.35 8.70
85292 B 04 10/1/2008 N N 5.63 5.63 11.26
85293 B 04 10/1/2008 N N 5.63 5.63 11.26
85300 B 04 10/1/2008 N N 4.43 4.43 8.86
85301 B 04 10/1/2008 N N 5.29 5.29 10.58
85302 B 04 10/1/2008 N N 5.89 5.89 11.78
85303 B 04 10/1/2008 N N 5.85 5.85 11.70
85305 B 04 10/1/2008 N N 5.66 5.66 11.32
85306 B 04 10/1/2008 N N 5.85 5.85 11.70
85307 B 04 10/1/2008 N N 6.00 6.00 12.00
85335 A 04 10/1/2008 N N 5.29 5.29 10.58
85337 A 04 10/1/2008 N N 5.10 5.10 10.20
85345 A 04 10/1/2008 N N 1.50 1.50 3.00
85347 A 04 10/1/2008 N N 1.31 1.31 2.62
85348 A 04 10/1/2008 N N 1.84 1.84 3.68
85360 A 04 10/1/2008 N N 2.96 2.96 5.92
Wednesday, April 01, 2009 Page 335 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
85362 A 04 10/1/2008 N N 1.31 1.31 2.62
85366 A 04 10/1/2008 N N 2.74 2.74 5.48
85370 A 04 10/1/2008 N N 2.74 2.74 5.48
85378 B 04 10/1/2008 N N 3.49 3.49 6.98
85379 B 04 10/1/2008 N N 3.75 3.75 7.50
85380 B 04 10/1/2008 N N 2.67 2.67 5.34
85384 A 04 10/1/2008 N N 2.63 2.63 5.26
85385 A 04 10/1/2008 N N 2.63 2.63 5.26
85390 A 04 N N 1.62 1.62 3.25
85396 A 04 N N 5.84 5.84 11.69
85397 B 04 1/1/2009 N N 6.21 6.21 12.42
85400 A 04 10/1/2008 N N 2.33 2.33 4.66
85410 A 04 10/1/2008 N N 2.33 2.33 4.66
85415 A 04 10/1/2008 N N 4.31 4.31 8.62
85420 A 04 10/1/2008 N N 2.33 2.33 4.66
85421 A 04 10/1/2008 N N 3.23 3.23 6.46
85441 A 04 10/1/2008 N N 2.04 2.04 4.08
85445 A 04 10/1/2008 N N .86 .86 1.72
85460 A 04 10/1/2008 N N 1.61 1.61 3.22
85461 A 04 10/1/2008 N N 1.58 1.58 3.16
85475 A 04 10/1/2008 N N 4.35 4.35 8.70
Wednesday, April 01, 2009 Page 336 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
85520 B 04 10/1/2008 N N 3.15 3.15 6.30
85525 B 04 10/1/2008 N N 5.38 5.38 10.76
85530 B 04 10/1/2008 N N 3.15 3.15 6.30
85536 A 04 10/1/2008 N N 2.53 2.53 5.06
85540 A 04 10/1/2008 N N 1.76 1.76 3.52
85547 A 04 10/1/2008 N N 1.14 1.14 2.28
85549 A 04 10/1/2008 N N 3.58 3.58 7.16
85555 A 04 10/1/2008 N N 2.33 2.33 4.66
85557 A 04 10/1/2008 N N 2.33 2.33 4.66
85576 A 04 10/1/2008 N N 2.55 2.55 5.10
85597 A 04 10/1/2008 N N 2.74 2.74 5.48
85610 A 04 10/1/2008 N N 1.91 1.91 3.82
85611 A 04 10/1/2008 N N 1.93 1.93 3.86
85612 B 04 10/1/2008 N N 2.78 2.78 5.56
85613 B 04 10/1/2008 N N 3.51 3.51 7.02
85635 B 04 10/1/2008 N N 1.31 1.31 2.62
85651 A 04 N N 2.30 2.30 4.60
85652 A 04 10/1/2008 N N 1.31 1.31 2.62
85660 A 04 10/1/2008 N N 2.33 2.33 4.66
85670 A 04 10/1/2008 N N 2.33 2.33 4.66
85675 A 04 10/1/2008 N N 3.19 3.19 6.38
Wednesday, April 01, 2009 Page 337 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
85705 A 04 10/1/2008 N N 4.35 4.35 8.70
85730 A 04 10/1/2008 N N 2.94 2.94 5.88
85732 A 04 10/1/2008 N N 3.19 3.19 6.38
85810 A 04 10/1/2008 N N 2.70 2.70 5.40
85999 A 04 10/1/2008 Y N
86000 A 04 N N 3.70 3.70 7.40
86001 A 04 N N 2.72 2.72 5.45
86003 A 04 N N 0.57 0.57 1.15
86005 A 04 N N 5.20 5.20 10.40
86021 A 04 N N 3.10 3.10 6.20
86022 A 04 N N 9.52 9.52 19.05
86023 B 04 N N 4.70 4.70 9.40
86038 B 04 N N 7.90 7.90 15.80
86039 B 04 N N 5.35 5.35 10.70
86060 B 04 N N 4.30 4.30 8.60
86063 B 04 N N 3.77 3.77 7.55
86077 04 N N 39.30
86078 04 N N 16.85
86079 04 N N 20.35
86140 B 04 N N 2.35 2.35 4.70
86141 B 04 N N 8.45 8.45 16.90
Wednesday, April 01, 2009 Page 338 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86146 B 04 N N 13.30 13.30 26.60
86147 B 04 N N 6.35 6.35 12.70
86148 B 04 N N 6.35 6.35 12.70
86155 A 04 N N 4.30 4.30 8.60
86156 B 04 N N 2.62 2.62 5.25
86157 B 04 N N 3.30 3.30 6.60
86160 A 04 N N 4.62 4.62 9.25
86161 A 04 N N 5.15 5.15 10.30
86162 B 04 N N 8.95 8.95 17.90
86171 09 Y N
86185 04 N N 4.20 4.20 8.40
86200 04 N N 5.42 5.42 10.85
86215 B 04 N N 5.90 5.90 11.80
86225 B 04 N N 5.90 5.90 11.80
86226 B 04 N N 6.67 6.67 13.35
86235 A 04 N N 5.90 5.90 11.80
86243 A 04 N N 5.90 5.90 11.80
86255 A 04 N N 3.60 3.60 7.20
86256 A 04 N N 5.90 5.90 11.80
86277 A 04 N N 10.27 10.27 20.55
86280 A 04 N N 4.10 4.10 8.20
Wednesday, April 01, 2009 Page 339 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86294 A 04 Y N
86300 B 04 N N 10.85 10.85 21.70
86301 B 04 N N 10.85 10.85 21.70
86304 B 04 N N 10.85 10.85 21.70
86308 B 04 N N 2.40 2.40 4.80
86309 B 04 N N 4.25 4.25 8.50
86310 B 04 N N 4.82 4.82 9.65
86316 A 04 N N 5.05 5.05 10.10
86317 09 Y
86318 A 04 N N 8.45 8.45 16.90
86320 B 04 N N 10.65 10.65 21.30
86325 B 04 N N 5.90 5.90 11.80
86327 B 04 N N 7.00 7.00 14.00
86329 A 04 N N 9.15 9.15 18.30
86331 A 04 N N 5.90 5.90 11.80
86332 B 04 N N 9.40 9.40 18.80
86334 B 04 N N 13.95 13.95 27.90
86335 A 04 N N 12.30 12.30 24.60
86336 B 04 N N 10.87 10.87 21.75
86337 B 04 N N 5.90 5.90 11.80
86340 A 04 N N 5.90 5.90 11.80
Wednesday, April 01, 2009 Page 340 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86341 04 N N 11.80
86343 B 04 N N 8.07 8.07 16.15
86344 A 04 N N 1.15 1.15 2.30
86353 B 04 N N 5.90 5.90 11.80
86355 04 N N 15.81 15.81 31.62
86356 04 1/1/2008 N N 11.33
86357 04 N N 15.81 15.81 31.62
86359 B 04 N N 3.82 3.82 7.65
86360 B 04 N N 4.85 4.85 9.70
86361 B 04 N N 4.85 4.85 9.70
86367 04 N N 15.81 15.81 31.62
86376 A 04 N N 4.20 4.20 8.40
86378 B 04 N N 6.95 6.95 13.90
86382 A 04 N N 3.60 3.60 7.20
86384 A 04 N N 2.35 2.35 4.70
86403 A 04 N N 3.00 3.00 6.00
86406 A 04 N N 5.90 5.90 11.80
86430 B 04 N N 3.10 3.10 6.20
86431 B 04 N N 3.62 3.62 7.25
86480 04 N N 25.97 25.97 51.95
86485 B 04 N N 2.00 2.00 4.00
Wednesday, April 01, 2009 Page 341 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86486 04 1/1/2008 Y N
86490 B 04 N N 2.57 2.57 5.15
86510 B 04 N N 2.57 2.57 5.15
86580 04 N N 4.00
86590 B 04 N N 5.90 5.90 11.80
86592 B 04 N N 2.00 2.00 4.00
86593 B 04 N N 2.00 2.00 4.00
86602 B 04 N N 5.10 5.10 10.20
86603 A 04 N N 7.40 7.40 14.80
86606 B 04 N N 5.10 5.10 10.20
86609 B 04 N N 5.12 5.12 10.25
86611 B 04 N N 5.30 5.30 10.60
86612 B 04 N N 5.10 5.10 10.20
86615 B 04 N N 5.95 5.95 11.90
86617 B 04 N N 10.10 10.10 20.20
86618 B 04 N N 11.10 11.10 22.20
86619 B 04 N N 5.10 5.10 10.20
86622 B 04 N N 5.10 5.10 10.20
86625 B 04 N N 4.85 4.85 9.70
86628 B 04 N N 5.10 5.10 10.20
86631 B 04 N N 7.70 7.70 15.40
Wednesday, April 01, 2009 Page 342 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86632 B 04 N N 8.27 8.27 16.55
86635 B 04 N N 5.10 5.10 10.20
86638 B 04 N N 5.10 5.10 10.20
86641 B 04 N N 5.10 5.10 10.20
86644 B 04 N N 6.67 6.67 13.35
86645 B 04 N N 9.12 9.12 18.25
86648 B 04 N N 9.60 9.60 19.20
86651 B 04 N N 8.00 8.00 16.00
86652 B 04 N N 8.00 8.00 16.00
86653 B 04 N N 7.80 7.80 15.60
86654 B 04 N N 8.00 8.00 16.00
86658 B 04 N N 8.50 8.50 17.00
86663 B 04 N N 8.57 8.57 17.15
86664 B 04 N N 8.80 8.80 17.60
86665 B 04 N N 9.60 9.60 19.20
86666 B 04 N N 5.30 5.30 10.60
86668 B 04 N N 5.10 5.10 10.20
86671 B 04 N N 8.01 8.01 16.02
86674 B 04 N N 5.10 5.10 10.20
86677 B 04 N N 7.50 7.50 15.00
86682 B 04 Y N
Wednesday, April 01, 2009 Page 343 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86684 B 04 N N 9.60 9.60 19.20
86687 B 04 N N 5.10 5.10 10.20
86688 B 04 N N 6.72 6.72 13.45
86689 B 04 N N 11.19 11.19 22.39
86692 B 04 N N 5.05 5.05 10.10
86694 B 04 N N 6.67 6.67 13.35
86695 B 04 N N 7.65 7.65 15.30
86696 B 04 N N 10.10 10.10 20.20
86698 B 04 N N 8.15 8.15 16.30
86701 B 04 3/1/2009 N N 6.48 6.48 12.96
86702 B 04 N N 5.10 5.10 10.20
86703 B 04 3/1/2009 N N 10.01 10.01 20.02
86704 B 04 N N 7.85 7.85 15.70
86705 B 04 N N 7.70 7.70 15.40
86706 B 04 N N 7.00 7.00 14.00
86707 B 04 N N 4.77 4.77 9.55
86708 B 04 N N 4.77 4.77 9.55
86709 B 04 N N 2.77 2.77 5.55
86710 B 04 N N 8.85 8.85 17.70
86713 B 04 N N 2.62 2.62 5.25
86717 B 04 N N 5.10 5.10 10.20
Wednesday, April 01, 2009 Page 344 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86720 B 04 N N 5.10 5.10 10.20
86723 B 04 N N 8.32 8.32 16.65
86727 B 04 N N 7.80 7.80 15.60
86729 B 04 N N 7.65 7.65 15.30
86732 B 04 N N 5.10 5.10 10.20
86735 B 04 N N 6.35 6.35 12.70
86738 B 04 N N 5.10 5.10 10.20
86741 B 04 N N 5.10 5.10 10.20
86744 B 04 N N 5.10 5.10 10.20
86747 B 04 N N 9.80 9.80 19.60
86750 B 04 N N 5.10 5.10 10.20
86753 B 04 N N 8.08 8.08 16.17
86756 B 04 N N 8.42 8.42 16.85
86757 B 04 N N 10.10 10.10 20.20
86759 B 04 N N 8.40 8.40 16.80
86762 B 04 N N 4.10 4.10 8.20
86765 B 04 N N 4.10 4.10 8.20
86768 B 04 N N 5.10 5.10 10.20
86771 B 04 N N 5.10 5.10 10.20
86774 B 04 N N 9.65 9.65 19.30
86777 B 04 N N 6.35 6.35 12.70
Wednesday, April 01, 2009 Page 345 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86778 B 04 N N 9.40 9.40 18.80
86781 B 04 N N 8.64 8.64 17.29
86784 B 04 N N 5.10 5.10 10.20
86787 B 04 N N 7.50 7.50 15.00
86788 B 04 1/1/2007 N N 7.06 7.06 14.12
86789 B 04 1/1/2007 N N 6.03 6.03 12.07
86790 B 04 N N 8.42 8.42 16.85
86793 B 04 N N 5.10 5.10 10.20
86800 B 04 N N 5.90 5.90 11.80
86803 B 04 N N 8.42 8.42 16.85
86804 B 04 N N 6.20 6.20 12.40
86805 B 04 N N 23.90 23.90 47.80
86806 B 04 N N 21.72 21.72 43.45
86807 B 04 N N 18.05 18.05 36.10
86808 B 04 N N 13.55 13.55 27.10
86812 B 04 N N 3.10 3.10 6.20
86813 B 04 N N 8.42 8.42 16.85
86816 B 04 N N 7.50 7.50 15.00
86817 B 04 N N 14.00 14.00 28.00
86821 B 04 N N 28.05 28.05 56.10
86822 B 04 N N 13.35 13.35 26.70
Wednesday, April 01, 2009 Page 346 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86849 A 04 Y N
86850 A 04 N N 2.82 2.82 5.65
86860 A 04 N N 5.95 5.95 11.90
86870 A 04 N N 7.17 7.17 14.35
86880 A 04 N N 2.90 2.90 5.80
86885 A 04 N N 3.05 3.05 6.10
86886 A 04 N N 3.10 3.10 6.20
86890 04 N N 40.40
86891 04 N N 101.80
86900 A 04 N N 1.75 1.75 3.50
86901 A 04 N N 2.35 2.35 4.70
86903 A 04 N N 6.15 6.15 12.30
86904 A 04 N N 6.20 6.20 12.40
86905 A 04 N N 2.47 2.47 4.95
86906 A 04 N N 2.30 2.30 4.60
86910 A 04 N N 12.02 12.02 24.05
86911 A 04 N N 3.40 3.40 6.80
86920 A 04 N N 2.35 2.35 4.70
86921 A 04 N N 4.70 4.70 9.40
86922 A 04 N N 4.70 4.70 9.40
86927 09 Y N
Wednesday, April 01, 2009 Page 347 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
86930 09 Y N
86931 09 Y N
86932 09 Y N
86940 A 04 N N 2.77 2.77 5.55
86941 A 04 N N 2.35 2.35 4.70
86945 04 N N 6.60
86950 04 N N 25.70
86965 04 N N 5.05
86970 04 N N 10.10
86971 04 N N 8.20
86972 04 N N 8.20
86975 04 N N 8.20
86976 04 N N 8.20
86977 04 N N 8.20
86978 04 N N 10.10
86985 A 04 N N 4.10 4.10 8.20
86999 A 04 Y N
87001 B 04 N N 8.60 8.60 17.20
87003 B 04 N N 8.95 8.95 17.90
87015 A 04 N N 3.60 3.60 7.20
87040 B 04 N N 6.75 6.75 13.50
Wednesday, April 01, 2009 Page 348 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87045 B 04 N N 6.15 6.15 12.30
87046 B 04 N N 1.20 1.20 2.40
87070 B 04 N N 3.10 3.10 6.20
87071 09 Y N
87073 09 Y N
87075 B 04 N N 6.17 6.17 12.35
87076 09 Y N
87077 09 Y N
87081 B 04 N N 2.90 2.90 5.80
87084 B 04 N N 3.00 3.00 6.00
87086 B 04 N N 5.25 5.25 10.50
87088 09 N Y 6.20
87101 B 04 N N 3.10 3.10 6.20
87102 B 04 N N 3.10 3.10 6.20
87103 B 04 N N 3.10 3.10 6.20
87106 09 Y N
87107 09 Y N
87109 B 04 N N 4.77 4.77 9.55
87110 B 04 N N 8.42 8.42 16.85
87116 B 04 N N 5.85 5.85 11.70
87118 09 Y N
Wednesday, April 01, 2009 Page 349 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87140 B 04 N N 0.57 0.57 1.15
87143 B 04 N N 3.60 3.60 7.20
87147 B 04 N N 1.60 1.60 3.20
87149 09 Y N
87152 09 Y N
87158 B 04 N N 0.57 0.57 1.15
87164 04 N N 14.00
87166 04 N N 14.75
87168 B 04 N N 2.25 2.25 4.50
87169 B 04 N N 2.25 2.25 4.50
87172 A 04 N N 2.25 2.25 4.50
87176 A 04 N N 3.85 3.85 7.70
87177 A 04 N N 3.60 3.60 7.20
87181 B 04 N 6.20
87184 B 04 N N 4.50 4.50 9.00
87185 A 04 N N 2.47 2.47 4.95
87186 B 04 N N 5.65 5.65 11.30
87187 B 04 N N 4.30 4.30 8.60
87188 B 04 N N 4.32 4.32 8.65
87190 04 N N 7.40
87197 B 04 N N 6.40 6.40 12.80
Wednesday, April 01, 2009 Page 350 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87205 B 04 N N 1.75 1.75 3.50
87206 B 04 N N 2.10 2.10 Y 4.20
87207 B 04 N N 1.75 1.75 3.50
87209 B 04 N N 7.53 7.53 15.06
87210 B 04 N N 2.35 2.35 4.70
87220 B 04 N N 2.35 2.35 4.70
87230 B 04 N N 7.50 7.50 15.00
87250 04 N N 12.80
87252 B 04 N N 6.40 6.40 12.80
87253 B 04 N N 7.50 7.50 15.00
87254 A 04 N N 3.20 3.20 6.40
87255 A 04 N N 11.83 11.83 23.66
87260 B 04 N N 7.85 7.85 15.70
87265 B 04 N N 7.85 7.85 15.70
87267 B 04 N N 4.19 4.19 8.38
87269 B 04 N N 5.02 5.02 10.05
87270 B 04 N N 7.85 7.85 15.70
87271 B 04 N N 4.19 4.19 8.38
87272 B 04 N N 7.85 7.85 15.70
87273 B 04 N N 6.25 6.25 12.50
87274 B 04 N N 7.85 7.85 15.70
Wednesday, April 01, 2009 Page 351 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87275 B 04 N N 6.25 6.25 12.50
87276 B 04 N N 7.85 7.85 15.70
87277 B 04 N N 6.25 6.25 12.50
87278 B 04 N N 7.85 7.85 15.70
87279 A 04 N N 6.25 6.25 12.50
87280 B 04 N N 7.85 7.85 15.70
87281 B 04 N N 6.25 6.25 12.50
87283 B 04 N N 6.25 6.25 12.50
87285 B 04 N N 7.85 7.85 15.70
87290 B 04 N N 7.85 7.85 15.70
87299 A 04 Y N
87300 A 04 N N 3.10 3.10 6.20
87301 B 04 N N 7.85 7.85 15.70
87305 B 04 N N 7.85 7.85 15.70
87320 B 04 N N 7.85 7.85 15.70
87324 B 04 N N 7.85 7.85 15.70
87327 B 04 N N 6.25 6.25 12.50
87328 B 04 N N 7.85 7.85 15.70
87329 B 04 N N 5.02 5.02 10.05
87332 B 04 N N 7.85 7.85 15.70
87335 B 04 N N 7.85 7.85 15.70
Wednesday, April 01, 2009 Page 352 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87336 B 04 N N 6.25 6.25 12.50
87337 B 04 N N 6.25 6.25 12.50
87338 B 04 N N 9.40 9.40 18.80
87339 B 04 N N 6.25 6.25 12.50
87340 B 04 N N 6.75 6.75 13.50
87341 B 04 N N 5.40 5.40 10.80
87350 B 04 N N 7.52 7.52 15.05
87380 B 04 N N 10.70 10.70 21.40
87385 B 04 N N 7.85 7.85 15.70
87390 B 04 N N 11.50 11.50 23.00
87391 B 04 N N 11.50 11.50 23.00
87400 B 04 N N 3.10 3.10 6.20
87420 B 04 N N 7.85 7.85 15.70
87425 B 04 N N 7.85 7.85 15.70
87427 B 04 N N 6.25 6.25 12.50
87430 B 04 N N 7.85 7.85 15.70
87449 A 04 N N 7.84 7.84 15.68
87450 A 04 Y N
87451 B 04 N N 5.00 5.00 10.00
87470 B 04 N N 13.10 13.10 26.20
87471 B 04 N N 22.90 22.90 45.80
Wednesday, April 01, 2009 Page 353 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87472 B 04 N N 27.95 27.95 55.91
87475 B 04 N N 13.10 13.10 26.20
87476 B 04 N N 22.90 22.90 45.80
87477 B 04 N N 27.95 27.95 55.91
87480 B 04 N N 13.10 13.10 26.20
87481 B 04 N N 22.90 22.90 45.80
87482 B 04 N N 27.25 27.25 54.50
87485 B 04 N N 13.10 13.10 26.20
87486 B 04 N N 22.90 22.90 45.80
87487 B 04 N N 27.95 27.95 55.91
87490 B 04 N N 13.10 13.10 26.20
87491 B 04 N N 22.90 22.90 45.80
87492 B 04 N N 22.81 22.81 45.63
87495 B 04 N N 13.10 13.10 26.20
87496 B 04 N N 22.90 22.90 45.80
87497 B 04 N N 22.81 22.81 45.63
87498 B 04 N N 22.91 22.91 45.83
87500 04 1/1/2008 N N 29.42
87510 B 04 N N 13.10 13.10 26.20
87511 B 04 N N 22.90 22.90 45.80
87512 B 04 Y N
Wednesday, April 01, 2009 Page 354 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87515 B 04 N N 13.10 13.10 26.20
87516 B 04 N N 22.90 22.90 45.80
87517 B 04 N N 27.95 27.95 55.90
87520 B 04 N N 13.10 13.10 26.20
87521 B 04 N N 22.90 22.90 45.80
87522 B 04 N N 27.95 27.95 55.90
87525 B 04 N N 13.10 13.10 26.20
87526 B 04 N N 22.90 22.90 45.80
87527 B 04 Y N
87528 B 04 N N 13.10 13.10 26.20
87529 B 04 N N 22.90 22.90 45.80
87530 B 04 Y N
87531 B 04 N N 13.10 13.10 26.20
87532 B 04 N N 22.90 22.90 45.80
87533 B 04 Y N
87534 B 04 N N 13.10 13.10 26.20
87535 B 04 N N 22.90 22.90 45.80
87536 B 04 N N 43.45 43.45 86.90
87537 B 04 N N 13.10 13.10 26.20
87538 B 04 N N 22.90 22.90 45.80
87539 B 04 Y N
Wednesday, April 01, 2009 Page 355 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87540 B 04 N N 13.10 13.10 26.20
87541 B 04 N N 22.90 22.90 45.80
87542 B 04 Y N
87550 B 04 N N 13.10 13.10 26.20
87551 B 04 N N 22.90 22.90 45.80
87552 B 04 Y N
87555 B 04 N N 13.10 13.10 26.20
87556 B 04 N N 22.90 22.90 45.80
87557 B 04 Y N
87560 B 04 N N 13.10 13.10 26.20
87561 B 04 N N 22.90 22.90 45.80
87562 B 04 Y N
87580 B 04 N N 13.10 13.10 26.20
87581 B 04 N N 22.90 22.90 45.80
87582 B 04 Y N
87590 B 04 N N 13.10 13.10 26.20
87591 B 04 N N 22.90 22.90 45.80
87592 B 04 Y N
87620 B 04 N N 13.10 13.10 26.20
87621 B 04 N N 22.90 22.90 45.80
87622 B 04 Y N
Wednesday, April 01, 2009 Page 356 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87640 B 04 N N 22.91 22.91 45.83
87641 B 04 N N 22.91 22.91 45.83
87650 B 04 N N 13.10 13.10 26.20
87651 B 04 N N 22.90 22.90 45.80
87652 04 Y N
87653 B 04 N N 22.91 22.92 45.83
87660 B 04 N N 8.40 8.40 16.81
87797 A 04 N N 13.10 13.10 26.20
87798 A 04 N N 22.91 22.91 45.83
87799 A 04 N N 25.94 25.94 51.89
87800 B 04 N N 10.47 10.47 20.95
87801 B 04 N N 18.30 18.30 36.60
87802 B 04 N N 7.82 7.82 15.65
87803 B 04 N N 7.82 7.82 15.65
87804 B 04 N N 7.82 7.82 15.65
87807 04 N N 10.06
87808 04 N N 7.82 7.82 15.65
87809 04 1/1/2008 N N 10.06
87810 B 04 N N 7.85 7.85 15.70
87850 B 04 N N 7.85 7.85 15.70
87880 I 04 N N 4.20
Wednesday, April 01, 2009 Page 357 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
87880 H 04 N N 7.85 7.85 15.70
87899 A 04 Y N
87900 04 N N 162.20
87901 04 N N 168.05
87902 B 04 N N 84.02 84.02 168.05
87903 04 N N 682.72
87904 04 N N 32.44 9 291.96
87905 B 04 1/1/2009 N N 5.27 5.27 10.54
87999 A 04 Y N
88104 B 04 N N 5.90 5.90 11.80
88106 B 04 N N 5.90 5.90 11.80
88107 B 04 N N 5.90 5.90 11.80
88108 B 04 N N 4.45 4.45 8.90
88112 C 04 N N 29.33 23.68 63.61
88125 B 04 N N 1.67 1.67 3.35
88130 B 04 N N 7.00 7.00 14.00
88140 B 04 N N 4.77 4.77 9.55
88141 04 N N 3.50
88142 04 N N 3.35
88143 04 N N 3.50
88147 04 N N 3.50
Wednesday, April 01, 2009 Page 358 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
88148 04 N N 3.50
88150 04 N N 1 3.50
88152 04 N N 3.50
88153 04 N N 3.50
88154 04 N N 3.50
88155 04 N N 1 4.10
88160 B 04 N N 5.90 5.90 11.80
88161 B 04 N N 5.62 5.62 11.25
88162 B 04 N N 11.80 11.80 23.60
88164 04 N N 3.50
88165 04 N N 3.50
88166 04 N N 3.50
88167 04 N N 3.50
88172 04 N N 16.85
88173 B 04 N N 14.00 14.00 28.00
88174 B 04 N N 7.46 7.46 14.93
88175 B 04 N N 9.20 9.20 18.41
88182 B 04 N N 15.25 15.25 30.50
88184 04 N N 2.10
88185 04 N N 1.05 24 25.20
88187 04 N N 40.11
Wednesday, April 01, 2009 Page 359 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
88188 04 N N 50.00
88189 04 N N 65.85
88199 A 04 Y N
88230 B 04 N N 45.40 45.40 90..80
88233 B 04 N N 58.77 58.77 117.55
88235 B 04 N N 66.80 66.80 133.60
88237 B 04 N N 53.47 53.47 106.95
88239 B 04 N N 66.80 66.80 133.60
88240 A 09 Y N
88241 A 09 Y N
88245 B 04 N N 43.82 43.82 87.65
88248 B 04 N N 44.12 44.12 88.25
88249 B 04 N N 43.77 43.77 87.55
88261 B 04 N N 58.90 58.90 117.80
88262 B 04 N N 81.37 81.37 162.75
88263 B 04 N N 94.37 94.37 188.75
88264 B 04 N N 81.37 81.37 162.75
88267 B 04 N N 44.30 44.30 88.60
88269 B 04 N N 38.17 38.17 76.35
88271 B 04 N N 9.45 9.45 18.90
88272 B 04 N N 16.52 16.52 33.05
Wednesday, April 01, 2009 Page 360 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
88273 B 04 N N 20.95 20.95 41.90
88274 B 04 N N 22.70 22.70 45.40
88275 B 04 N N 26.20 26.20 52.40
88280 B 04 N N 16.35 16.35 32.70
88283 B 04 N N 12.27 12.27 24.55
88285 B 04 N N 12.40 12.40 24.80
88289 B 04 N N 8.55 8.55 17.10
88291 B 04 N N 2.62 2.62 5.25
88299 A 04 Y N
88300 A 04 N N 6.52 6.52 13.05
88302 A 04 N N 10.47 10.47 20.95
88304 A 04 N N 18.67 18.67 37.35
88305 A 04 N N 20.55 20.55 41.10
88307 A 04 N N 21.80 21.80 43.60
88309 A 04 N N 23.70 23.70 47.40
88311 B 04 N N 5.75 5.75 11.50
88312 A 04 N N 5.90 5.90 11.80
88313 A 04 N N 3.35 3.35 6.70
88314 B 04 N N 3.10 3.10 6.20
88318 B 04 N N 20.90 20.90 41.80
88319 B 04 N N 11.20 11.20 22.40
Wednesday, April 01, 2009 Page 361 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
88321 04 N N 6.20
88323 04 N N 17.90
88325 04 N N 19.90
88329 04 N N 48.55
88331 04 N N 48.55
88332 04 N N 19.90
88333 04 N N 50.86
88334 04 N N 26.40
88342 A 04 N N 6.72 6.72 Y 13.45
88346 A 04 N N 8.42 8.42 16.85
88347 A 04 N N 8.42 8.42 16.85
88348 B 04 N N 23.60 23.60 47.20
88349 B 04 N N 35.35 35.35 70.70
88355 B 04 N N 54.30 54.30 108.60
88356 B 04 N N 54.30 54.30 108.60
88358 B 04 N N 54.30 54.30 108.60
88360 A 04 N N 30.91 30.91 61.83
88361 C 04 N N 24.79 35.80 72.70
88362 A 04 Y N
88365 04 N N 40.81
88367 A 04 N N 57.57 57.57 115.15
Wednesday, April 01, 2009 Page 362 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
88368 04 N N 105.20
88371 B 04 N N 14.22 14.22 28.45
88372 B 04 N N 14.85 14.85 29.70
88380 B 04 Y N
88381 C 04 1/1/2008 N N 31.82 83.72 115.54
88384 04 Y N
88385 04 N N 46.41
88386 04 N N 58.39
88399 A 04 Y N
88720 B 04 1/1/2009 N N 2.20 2.20 4.40
88740 B 04 1/1/2009 N N 2.20 2.20 4.40
88741 B 04 1/1/2009 N N 2.20 2.20 4.40
89049 B 04 N N 18.52 18.52 37.05
89050 B 04 N N 1.75 1.75 3.50
89051 B 04 N N 3.10 3.10 6.20
89055 A 04 N N 1.49 1.49 2.98
89060 B 04 N N 4.67 4.67 9.35
89100 B 04 N N 3.10 3.10 6.20
89105 B 04 N N 29.75 29.75 59.50
89125 B 04 N N 1.67 1.67 3.35
89130 A 04 N I 14.60 14.60 29.20
Wednesday, April 01, 2009 Page 363 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
89132 A 04 Y N
89135 B 04 N N 14.60 14.60 29.20
89136 B 04 Y N
89140 B 04 N N 23.60 23.60 47.20
89141 A 04 N N 14.00 14.00 28.00
89160 B 04 N N 0.67 0.67 1.35
89190 B 04 N N 1.67 1.67 3.35
89225 B 04 N N 1.40 1.40 2.80
89235 B 04 N N 2.30 2.30 4.61
89240 A 04 Y N
89250 09 Y N
89310 B 04 N N 3.35 3.35 6.70
89321 09 Y N
89322 04 1/1/2008 N N 11.36
90375 04 Y Y N
90376 04 Y Y N
90378 04 Y Y N
90379 04 Y Y N
90384 04 N Y N 107.70
90385 04 N Y N 37.70
90386 04 Y Y N
Wednesday, April 01, 2009 Page 364 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
90393 04 Y Y N
90399 04 Y Y N
90471 09 Y N
90472 09 Y N
90473 09 Y N
90474 09 Y N
90476 F 04 Y N
90477 F 04 Y N
90581 F 04 Y N
90585 F 04 Y N
90586 F 04 Y N
90632 G 04 N N 6.40 56.15
90633 E 04 N N 6.40
90634 E 04 N N 6.40
90636 G 04 N N 6.40 111.18
90645 E 04 N N 6.40
90646 E 04 N N 6.40
90647 E 04 N N 6.40
90648 E 04 N N 6.40
90649 M 04 Y N 6.40 149.33
90655 E 04 N N 6.40
Wednesday, April 01, 2009 Page 365 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
90656 G 04 N N 6.40 11.19
90657 E 04 N N 6.40
90658 G 04 N N 6.40 11.19
90660 G 04 N N 6.40 22.37
90665 09 Y Y N
90669 E 04 N N 6.40
90675 F 04 Y N
90676 F 04 Y N
90680 E 04 N N 6.40
90681 E 04 8/1/2008 N N 6.40
90690 09 Y N
90691 09 Y N
90692 09 Y N
90693 09 Y N
90696 E 04 8/1/2008 N N 6.40
90698 E 04 8/1/2008 N N 6.40
90700 E 04 N N 6.40
90701 E 04 N N 6.40
90702 F 04 N N 2.70
90703 F 04 N N 1.85 1.85
90704 F 04 Y N
Wednesday, April 01, 2009 Page 366 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
90705 F 04 Y N
90706 F 04 Y N
90707 G 04 N N 6.40 39.70
90708 F 04 Y N
90710 E 04 N N 6.40
90712 F 04 N N 14.00
90713 E 04 N N 6.40
90714 G 04 N N 6.40 18.92
90715 G 04 N N 6.40 38.28
90716 G 04 N N 6.40 46.60
90717 09 Y N
90718 G 04 N N 6.40 2.70
90719 F 04 N N 3.40
90721 F 04 N N 35.25
90723 E 04 N N 6.40
90725 09 Y N
90727 09 Y N
90732 G 04 N N 6.40 14.60
90733 F 04 N N 85.00
90734 G 04 N N 6.40 116.78
90735 F 04 N N 243.80 243.80
Wednesday, April 01, 2009 Page 367 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
90736 F 04 N N 190.02
90738 F 04 7/1/2008 Y
90740 F 04 Y N
90743 F 04 Y N
90744 E 04 N N 6.40
90746 G 04 N N 6.40 74.38
90747 F 04 Y N
90748 E 04 N N 6.40
90749 F 04 Y N
90801 02 2/1/2009 N N 67.50 52.11
90802 02 2/1/2009 N N 27.55 92.06
90804 02 N N 27.55
90805 02 N N 30.90
90806 02 N N 47.50
90807 02 N N 47.50
90808 02 N N 64.80
90809 02 N N 67.50
90810 02 N N 31.70
90811 02 N N 34.85
90812 02 N N 47.50
90813 02 N N 47.50
Wednesday, April 01, 2009 Page 368 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
90814 02 N N 63.45
90815 02 N N 66.30
90816 02 N N 31.65
90817 02 N N 31.65
90818 02 N N 47.50
90819 02 N N 47.50
90821 02 N N 65.90
90822 02 N N 68.30
90823 02 N N 33.30
90824 02 N N 35.95
90826 02 N N 47.50
90827 02 N N 48.65
90828 02 N N 65.05
90829 02 N N 66.90
90845 D 04 N N
90846 09 Y N
90847 02 N N 61.20
90849 02 N N 61.20
90853 02 N N 33.70
90857 09 Y N
90862 04 N N 22.45
Wednesday, April 01, 2009 Page 369 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
90865 02 N N 63.40
90870 04 N I 44.40
90875 02 N N 28.70
90876 02 N N 47.50
90880 09 Y N
90885 09 Y N
90887 09 Y N
90889 09 Y N
90899 02 Y N
90901 09 Y I
90911 09 Y I
90935 04 N I 35.75
90937 04 N I 61.70
90940 04 Y I
90945 04 N I 36.50
90947 04 N N 60.90
90951 04 1/1/2009 N I 252.35
90952 04 1/1/2009 N I 252.35
90953 04 1/1/2009 N I 252.35
90954 04 1/1/2009 N I 213.65
90955 04 1/1/2009 N I 213.65
Wednesday, April 01, 2009 Page 370 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
90956 04 1/1/2009 N I 213.65
90957 04 1/1/2009 N I 213.65
90958 04 1/1/2009 N I 213.65
90959 04 1/1/2009 N I 213.65
90960 04 1/1/2009 N I 213.65
90961 04 1/1/2009 N I 213.65
90962 04 1/1/2009 N I 213.65
90963 04 1/1/2009 N I 252.35
90964 04 1/1/2009 N I 213.65
90965 04 1/1/2009 N I 213.65
90966 04 1/1/2009 N I 213.65
90967 04 1/1/2009 N I 8.30
90968 04 1/1/2009 N I 7.10
90969 04 1/1/2009 N I 7.10
90970 04 1/1/2009 N I 7.10
90989 09 Y I
90993 09 Y I
90997 04 Y N
90999 04 Y I
91000 04 N I 20.80
91010 04 N I 52.70
Wednesday, April 01, 2009 Page 371 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
91011 04 N I 60.60
91012 04 N I 74.90
91020 04 N I 74.90
91022 C 04 N N 42.72 75.37 1 118.09
91030 04 N I 74.90
91034 C 04 N I 31.17 99.11 1 130.28
91035 04 N I 255.62
91037 04 N I 84.00
91038 C 04 N I 32.73 40.00 72.73
91040 04 N I 248.27
91052 04 N I 25.65
91055 04 N I 27.85
91065 04 N I 29.65
91105 04 N I 40.85
91110 C 04 N I 140.95 563.92 704.90
91111 C 04 N N 28.37 343.76 372.13
91120 04 N I 245.00
91122 04 N I 57.20
91123 04 N I 194.20
91132 04 Y I
91133 04 Y I
Wednesday, April 01, 2009 Page 372 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
91299 04 Y I
92002 04 N N 27.55
92004 04 N N 46.45
92012 04 N N 23.30
92014 04 N N 44.45
92015 04 N I 18.45
92018 04 N I 152.60
92019 04 N I 152.60
92020 04 N I 19.50
92025 C 04 N I 9.04 6.29 15.33
92060 04 N I 24.90
92065 04 N I 22.15
92070 09 Y N
92081 04 N I 20.45
92082 04 N I 30.50
92083 04 N I 37.40
92100 04 N I 23.80
92120 04 N I 22.30
92130 04 N I 24.55
92135 L 04 N I 26.35 26.35 52.70
92136 04 N I 50.05
Wednesday, April 01, 2009 Page 373 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
92140 04 N I 22.15
92225 04 N I 30.50
92226 04 N I 30.50
92230 B 04 N I 22.20 22.20 44.40
92235 B 04 N I 26.35 26.35 52.70
92240 B 04 N I 28.25 28.25 56.50
92250 B 04 N I 22.20 22.20 44.40
92260 B 04 N I 26.35 26.35 52.70
92265 04 N I 74.90
92270 04 N I 52.70
92275 B 04 N I 26.35 26.35 52.70
92283 04 N I 22.15
92284 B 04 N I 7.60 7.60 15.20
92285 04 N I 30.50
92286 04 N I 52.70
92287 04 N I 69.30
92310 04 Y N
92311 09 Y N
92312 09 Y N
92313 09 Y N
92314 09 Y N
Wednesday, April 01, 2009 Page 374 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
92315 09 Y N
92316 09 Y N
92317 09 Y N
92325 09 Y N
92326 09 Y N
92340 04 N N 30.09
92341 09 Y N
92342 09 Y N
92352 09 Y N
92353 09 Y N
92354 09 Y N
92355 09 Y N
92358 09 Y N
92370 04 N N 4.76
92371 09 Y N
92499 04 Y I
92502 04 N I 52.70
92504 04 N I 37.40
92506 04 N I 37.40
92507 04 N I 19.85
92508 09 Y I
Wednesday, April 01, 2009 Page 375 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
92511 04 N I 112.40
92512 04 N I 20.05
92516 04 N I 15.90
92520 04 N I 30.50
92526 04 Y I
92531 04 N I 30.50
92532 04 N I 30.50
92533 04 N I 22.15
92534 04 N I 22.15
92541 04 N I 22.15
92542 04 N I 22.15
92543 04 N I 22.15
92544 04 N I 22.15
92545 04 N I 22.15
92546 04 N I 22.15
92547 04 N I 22.15
92548 04 N I 39.35
92551 04 N N 15.20 1 15.20
92552 04 N I 15.20
92553 04 N I 15.20
92555 04 N I 15.20
Wednesday, April 01, 2009 Page 376 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
92556 04 N I 15.20
92557 04 N I 37.40
92559 09 Y N
92560 04 N I 15.20
92561 04 N I 26.35
92562 04 N N 7.60
92563 04 N N 15.20
92564 04 N N 15.20
92565 04 N N 15.20
92567 04 N N 15.20
92568 04 N N 13.70
92569 04 N N 14.68
92571 04 N N 15.20
92572 04 N N 15.20
92575 04 N N 15.20
92576 04 N N 15.20
92577 04 N N 12.20
92579 04 N N 22.15
92582 04 N N 22.15
92583 04 N N 15.15
92584 04 N I 74.90
Wednesday, April 01, 2009 Page 377 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
92585 04 N I 53.75
92586 04 N I 47.80
92587 04 N I 52.70
92588 04 N I 61.00
92590 04 N I 37.40
92591 04 N I 37.40
92592 04 N I 15.20
92593 04 N I 15.20
92594 04 N I 15.20
92595 04 N I 15.20
92596 04 N I 15.20
92597 04 N I 43.18
92601 04 N I 55.01
92602 04 N I 38.72
92603 04 N I 37.18
92604 04 N I 25.49
92605 04 N I 24.90
92606 04 N I 24.90
92607 04 N I 45.85
92608 04 N N 9.25
92609 04 N I 24.90
Wednesday, April 01, 2009 Page 378 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
92610 04 N I 18.00
92611 04 N I 19.55
92612 04 N I 30.25
92613 04 N I 30.25
92614 04 N I 30.25
92615 04 N I 30.25
92616 04 N I 44.00
92617 04 N I 44.00
92620 04 N I 24.46
92621 04 N I 6.63
92625 04 N I 24.06
92626 09 Y N
92627 09 Y N
92630 09 Y N
92633 09 Y N
92640 04 N N 26.67
92700 04 Y I
92950 04 N I Y Y 112.50
92953 04 Y I Y Y
92960 04 N I 112.40
92961 04 N I 112.40
Wednesday, April 01, 2009 Page 379 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
92970 04 Y I
92971 04 Y I
92973 04 N I Y 156.50
92974 04 N I 183.90
92975 04 Y M
92977 04 Y M
92978 04 N I 120.70
92979 04 N I 74.20
92980 04 N M Y 910.70
92981 04 Y M Y
92982 04 N M Y 718.70
92984 04 Y M Y
92986 04 N M Y 682.80
92987 04 N M Y Y 682.80
92990 04 N M Y 682.80
92992 04 N M Y 898.75
92993 04 N M Y 958.60
92995 04 N M Y 898.75
92996 04 Y M Y
92997 04 N M Y 718.70
92998 04 Y M Y
Wednesday, April 01, 2009 Page 380 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93000 A 04 N I 11.08 11.07 22.15
93005 04 N I 11.05
93010 04 N I 11.05 5 55.25
93012 04 N I 39.50
93014 04 N I 13.90
93015 04 N I 67.90
93016 04 N I 21.60
93017 04 N I 27.90
93018 04 N I 22.15
93024 04 N I 59.60
93025 04 N I Y 168.20
93040 A 04 N I 3.80 3.80 7.60
93041 04 N I 3.80
93042 04 N I 4.20
93224 04 N I 180.30
93225 04 N I 135.90
93226 04 N I 44.40
93227 04 N I 44.40
93228 04 1/1/2009 N N 21.60
93229 04 1/1/2009 N N 39.50
93230 04 N I 158.70
Wednesday, April 01, 2009 Page 381 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93231 04 N I 135.90
93232 04 N I 44.40
93233 04 N I 44.40
93235 04 N I 180.30
93236 04 N I 44.40
93237 04 N I 44.40
93268 04 N I 73.70
93270 04 N I 21.60
93271 04 N I 39.50
93272 04 N I 21.60
93278 04 N I 27.00
93279 C 04 1/1/2009 N N 20.88 10.77 31.65
93280 C 04 1/1/2009 N N 24.99 12.22 37.21
93281 C 04 1/1/2009 N N 29.15 14.38 43.53
93282 C 04 1/1/2009 N N 27.37 13.05 40.42
93283 C 04 1/1/2009 N N 34.44 14.76 49.20
93284 C 04 1/1/2009 N N 40.86 16.67 57.53
93285 C 04 1/1/2009 N N 17.11 10.19 27.30
93286 C 04 1/1/2009 N N 8.92 6.62 15.54
93287 C 04 1/1/2009 N N 12.86 7.72 20.58
93288 C 04 1/1/2009 N N 13.95 10.38 24.33
Wednesday, April 01, 2009 Page 382 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93289 C 04 1/1/2009 N N 25.21 12.22 37.43
93290 C 04 1/1/2009 N N 12.50 6.00 18.50
93291 C 04 1/1/2009 N N 14.21 9.17 23.38
93292 C 04 1/1/2009 N N 13.95 7.33 21.28
93293 C 04 1/1/2009 N N 9.93 23.46 33.39
93294 04 1/1/2009 N N 21.33
93295 04 1/1/2009 N N 38.37
93296 04 1/1/2009 N N 19.30
93297 04 1/1/2009 N N 15.02
93298 04 1/1/2009 N N 17.11
93299 04 1/1/2009 Y N
93303 B 04 N I 49.05 49.05 98.10
93304 B 04 N I 26.50 26.50 53.00
93306 C 04 1/1/2009 N N 27.30 63.70 91.00
93307 B 04 N I 45.50 45.50 91.00
93308 B 04 N I 26.35 26.35 52.70
93312 B 04 N I 81.85 81.85 163.70
93313 B 04 N I 55.50 55.50 111.00
93314 B 04 N I 47.15 47.15 94.30
93315 B 04 N I 81.85 81.85 163.70
93316 B 04 N I 55.50 55.50 111.00
Wednesday, April 01, 2009 Page 383 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93317 B 04 N I 53.13 53.12 106.25
93318 B 04 N I 81.85 81.85 163.70
93320 B 04 N I 19.90 19.90 39.80
93321 B 04 N I 12.95 12.95 25.90
93325 B 04 N I 25.17 25.17 50.35
93350 B 04 N I 81.85 81.85 163.70
93351 04 1/1/2009 N I 214.45
93352 04
93501 04 N I 371.00
93503 04 N I 149.80
93505 04 N I 154.80
93508 04 N I 318.80
93510 04 N I 727.50
93511 04 N I 723.20
93514 04 N I 783.70
93524 04 N I 963.70
93526 04 N I 969.95
93527 04 N I 991.50
93528 04 N I 1008.05
93529 04 N I 899.70
93530 04 N I 399.90
Wednesday, April 01, 2009 Page 384 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93531 04 N I 1021.95
93532 04 N I 1050.75
93533 04 N I 940.30
93539 04 N I 74.90
93540 04 N I 74.90
93541 04 N I 74.90
93542 04 N I 74.90
93543 04 N I 74.90
93544 04 N I 74.90
93545 04 N I 299.70
93555 04 N I 121.00
93556 04 N I 181.35
93561 04 N I 109.20
93562 04 N I 149.80
93571 B 04 N I 57.82 57.82 115.65
93572 B 04 N I 52.75 52.75 105.50
93580 04 Y M Y
93581 04 Y M Y
93600 04 N I 224.70
93602 04 N I 224.70
93603 04 N I 224.70
Wednesday, April 01, 2009 Page 385 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93609 04 N I 282.40
93610 04 N I 224.70
93612 04 N I 224.70
93613 04 N I 252.15
93615 04 N I 224.70
93616 04 N I 374.60
93618 04 N I 374.60
93619 04 N I 343.70
93620 04 N I 489.60
93621 04 N I 374.60
93622 04 N I 374.60
93623 04 N I 374.60
93624 04 N I 224.70
93631 04 N I 310.95
93640 04 N I 222.35
93641 04 N I 293.55
93642 04 N I 262.25
93650 04 N M 550.90
93651 04 N M 550.90
93652 04 N M 550.90
93660 04 N I 69.30
Wednesday, April 01, 2009 Page 386 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93662 04 N I 205.00
93668 04 N N 28.35
93701 04 N I 30.10
93720 04 N I 74.90
93721 04 N I 44.40
93722 04 N I 22.15
93724 04 N I 224.70
93740 04 N I 7.60
93745 04 N I 36.90
93770 04 N I 16.65
93784 04 N I 180.30
93786 04 N I 134.60
93788 04 N I 44.40
93790 04 N I 44.40
93797 04 N N 21.10
93798 04 N I 43.35
93799 04 Y I Y
93875 A 04 N I 25.03 25.02 50.05
93880 A 04 N I 39.40 39.40 78.80
93882 A 04 N I 26.20 26.20 52.40
93886 A 04 N I 47.15 47.15 94.30
Wednesday, April 01, 2009 Page 387 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93888 A 04 N I 31.53 31.52 63.05
93890 A 04 N I 84.30 84.30 168.60
93892 A 04 N I 70.87 70.86 141.73
93893 A 04 N I 69.56 69.56 139.12
93922 A 04 N I 25.03 25.02 50.05
93923 A 04 N I 25.47 25.47 50.95
93924 A 04 N I 28.00 28.00 56.00
93925 A 04 N I 39.40 39.40 78.80
93926 A 04 N I 26.35 26.35 52.70
93930 A 04 N I 40.07 40.08 80.15
93931 A 04 N I 26.60 26.60 53.20
93965 A 04 N I 25.03 25.02 50.05
93970 C 04 N I 17.38 70.17 87.55
93971 C 04 N I 10.77 47.48 58.25
93975 A 04 N I 59.60 59.60 119.20
93976 A 04 N I 39.85 39.85 79.70
93978 A 04 N I 41.15 41.15 82.30
93979 A 04 N I 27.40 27.40 54.80
93980 A 04 N I 45.83 45.82 91.65
93981 A 04 N I 33.65 33.65 67.30
93982 04 1/1/2008 N N 22.25
Wednesday, April 01, 2009 Page 388 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
93990 A 04 N I 40.93 40.92 81.85
94002 04 N I 46.34
94003 04 N I 33.61
94004 04 N I 24.47
94010 C 04 N I 7.65 29.75 37.40
94014 04 N I 52.90
94015 04 N I 29.90
94016 04 N I 23.00
94060 C 04 N I 12.50 40.20 52.70
94070 C 04 N I 15.25 37.45 52.70
94150 C 04 N I 1.60 6.00 7.60
94200 C 04 N I 1.55 15.10 16.65
94240 C 04 N I 4.50 26.00 30.50
94250 C 04 N I 3.20 4.40 7.60
94260 C 04 N I 4.45 10.75 15.20
94350 C 04 N I 1.60 51.10 52.70
94360 C 04 N I 1.60 21.20 22.80
94370 C 04 N I 4.45 10.75 15.20
94375 C 04 N I 7.70 36.70 44.40
94400 C 04 N I 4.45 17.70 22.15
94450 C 04 N I 4.45 17.70 22.15
Wednesday, April 01, 2009 Page 389 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
94452 A 04 N I 14.29 14.28 28.57
94453 A 04 N I 20.21 20.21 40.42
94610 04 N N 35.06
94620 C 04 N I 12.30 29.80 42.10
94621 04 N I 59.00
94640 04 N N 14.50
94642 04 N N 22.05
94644 04 N N 17.87
94645 04 N N 6.92
94660 09 Y I
94662 04 Y I
94664 04 N N 15.20
94667 04 N N 15.20
94668 04 N N 8.20
94680 C 04 N I 7.65 29.75 37.40
94681 C 04 N I 7.70 36.70 44.40
94690 C 04 N I 4.50 26.00 30.50
94720 C 04 N I 9.40 28.00 37.40
94725 C 04 N I 3.40 34.00 37.40
94750 C 04 N I 4.45 17.70 22.15
94760 C 04 N I 1.50 2.90 4.40
Wednesday, April 01, 2009 Page 390 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
94761 C 04 N I 4.45 10.75 15.20
94762 C 04 N I 7.55 14.60 22.15
94770 C 04 N I 1.60 13.60 15.20
94772 04 Y I
94774 04 N I 52.90
94777 04 N N 23.00
94799 04 Y I
95004 04 N N 1.70 65 110.50
95010 04 N N 6.60 65 429.00
95012 04 N I 9.31
95015 04 N N 6.95 80 556.00
95024 04 N N 2.50 40 100.00
95027 04 N N 4.10 40 164.00
95028 04 N N 3.85 40 154.00
95044 04 N N 3.40 65 221.00
95052 04 N N 4.10 200 820.00
95056 04 N N 2.90 1 2.90
95060 04 N N 7.20
95065 04 N N 7.20
95070 04 N N 105.40
95071 04 N N 59.04
Wednesday, April 01, 2009 Page 391 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
95075 04 N N 38.84
95115 04 N I 6.50
95117 04 N I 8.30
95120 04 N I 6.50
95125 04 N I 8.30
95130 04 N I 4.20
95131 04 N I 8.60
95132 04 N I 12.75
95133 04 N I 17.00
95134 04 N I 21.30
95144 04 N I 14.30
95145 04 N I 21.60
95146 04 N I 32.40
95147 04 N I 37.80
95148 04 N I 43.25
95149 04 N I 48.60
95165 04 N I 36.00
95170 04 N I 12.30
95180 04 N N 47.50
95199 04 Y I
95250 04 Y N
Wednesday, April 01, 2009 Page 392 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
95251 04 N N 15.40
95803 04 1/1/2009 Y N
95805 A 04 N I 76.05 76.05 152.10
95806 A 04 N I 55.27 55.28 110.55
95807 A 04 N I 77.35 77.35 154.70
95808 A 04 N I 96.65 96.65 193.30
95810 A 04 N I 130.80 130.80 261.60
95811 A 04 N I 136.15 136.15 272.30
95812 A 04 N I 29.40 29.40 58.80
95813 A 04 N I 40.90 40.90 81.80
95816 A 04 N I 28.55 28.55 57.10
95819 A 04 N I 26.35 26.35 52.70
95822 A 04 N I 27.65 27.65 55.30
95824 A 04 N I 26.35 26.35 52.70
95827 A 04 N I 33.40 33.40 66.80
95829 04 N I 163.50
95830 04 N I 79.10
95831 04 N I 25.60
95832 04 N I 22.15
95833 04 N I 52.70
95834 04 N I 52.70
Wednesday, April 01, 2009 Page 393 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
95851 04 N I 30.50
95852 04 N I 30.50
95857 04 N I 25.60
95860 04 N I 37.40
95861 04 N I 56.80
95863 04 N I 65.70
95864 04 N I 85.30
95865 C 04 N I 50.72 13.65 64.37
95866 C 04 N I 39.54 4.56 44.10
95867 04 N I 30.70
95868 04 N I 46.30
95869 04 N I 52.70
95870 04 N I 52.70
95872 04 N I 56.80
95873 C 04 N I 11.58 4.30 15.88
95874 C 04 N N 11.76 4.30 16.06
95875 04 N I 36.60
95900 04 Y I
95903 04 Y I
95904 04 Y I
95920 04 Y M
Wednesday, April 01, 2009 Page 394 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
95921 04 N I 44.50
95922 04 N I 44.50
95923 04 N I 44.80
95925 04 N I 74.90
95926 04 N I 74.90
95927 04 N I 74.90
95928 04 N I 97.05
95929 04 N I 100.85
95930 04 N I 52.70
95933 04 N I 30.50
95934 04 N I 37.40
95936 04 N I 37.40
95937 04 N I 37.40
95950 C 04 N I 61.31 118.99 180.30
95951 C 04 2/1/2009 N I 81.51 *© 326.05 *© 407.56 51.66
95951 C 04 N I 71.18 *(A) 284.72 *(A) 355.90
95953 C 04 N I 77.53 102.77 180.30
95954 C 04 N I 119.09 106.61 1 224.70
95955 04 N I 62.05
95956 C 04 N I 100.41 294.32 394.73
95957 C 04 N I 65.03 37.30 102.33
Wednesday, April 01, 2009 Page 395 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
95958 04 N I 142.05
95961 04 N I 180.30
95962 04 Y I
95965 A 04 N I 138.25 138.25 276.50
95966 A 04 N I 93.83 93.82 187.65
95967 A 04 N I 82.35 82.35 164.70
95970 04 N I 41.90
95971 04 N I 41.90
95972 04 N I 41.90
95973 04 N I 41.90
95974 04 N I 68.50
95975 04 N I 41.90
95978 04 N I 110.51
95979 04 N I 53.28
95980 04 1/1/2008 N I Y 22.92
95981 04 1/1/2008 N I Y 8.89 6.41
95982 04 1/1/2008 N I Y 18.00 5.81
95990 04 N I 29.41
95991 04 N I 29.41
95992 04 1/1/2009 N N 22.15
95999 04 Y I Y
Wednesday, April 01, 2009 Page 396 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
96000 04 N I 82.00
96001 04 N N 97.80
96002 04 N I 19.20
96003 04 N I 17.90
96004 04 N I 67.50
96020 04 N I 85.31
96040 04 8/1/2008 N N 40.20
96105 04 N I 52.70
96110 04 N N 16.07 2 32.15
96111 04 N N 16.07 2 32.15
96116 09 Y I
96118 09 Y N
96119 09 Y N
96120 09 Y N
96125 09 1/1/2008 N N 46.07 7.81
96150 04 Y N
96151 04 Y N
96152 04 Y N
96153 04 Y N
96154 04 Y N
96155 04 Y N
Wednesday, April 01, 2009 Page 397 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
96360 04 1/1/2009 N N 19.11
96361 04 1/1/2009 N N 152.90 8 1223.20
96365 04 1/1/2009 N I 19.11
96366 04 1/1/2009 N I 152.90 8 1223.20
96367 04 1/1/2009 N I 19.11
96368 04 1/1/2009 N I 19.11
96369 04 1/1/2009 N I 84.51
96370 04 1/1/2009 N M 9.15
96371 04 1/1/2009 N I 36.95
96372 04 1/1/2009 N I 9.81
96373 04 1/1/2009 N I 10.26
96374 04 1/1/2009 N I 29.55
96375 04 1/1/2009 N I 27.98 2 55.96
96376 04 1/1/2009 Y M
96379 04 1/1/2009 Y
96401 04 N I 22.15
96402 04 N I 18.39
96405 04 Y I
96406 04 Y I
96409 04 N I 62.22
96411 04 N I 36.36
Wednesday, April 01, 2009 Page 398 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
96413 04 N I 25.40
96415 04 N I 19.11 8 152.90
96416 04 N I 22.15
96417 04 N I 25.40
96420 04 N I 37.40
96422 04 N I 37.40
96423 04 N I 14.17 8 113.40
96425 04 N I 33.80
96440 04 N I 102.00
96445 04 N I 101.30
96450 04 N I 83.20
96521 04 N I 32.90
96522 04 N I 34.70
96523 09 Y N
96542 04 Y I
96549 04 Y I
96567 04 Y I
96570 04 Y I
96571 04 Y I
96900 04 N I 6.60
96902 04 N N 10.50
Wednesday, April 01, 2009 Page 399 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
96910 04 N I 9.55
96912 04 N I 10.95
96913 04 N I 30.05
96920 04 Y I
96921 04 Y I
96922 04 Y I
96999 04 Y I
97001 09 Y I
97002 09 Y I
97003 09 Y I
97004 09 Y I
97005 04 Y N
97006 04 Y N
97010 04 N I 4.40
97012 04 N I 7.70
97014 04 N I 6.50
97016 04 N I 7.00
97018 04 N I 5.95
97022 04 N I 6.50
97024 04 N I 4.50
97026 04 N I 4.40
Wednesday, April 01, 2009
Page 400 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
97028 04 N I 4.70
97032 04 N I 7.40
97033 04 N I 7.70
97034 04 N I 6.40
97035 04 N I 5.50
97036 04 N I 8.95
97039 04 Y I
97110 04 N N 10.40
97112 04 N I 10.90
97113 04 N N 11.50
97116 04 N I 9.75
97124 04 N I 8.90
97139 04 Y I
97140 04 N I 11.80
97150 04 N I 8.40
97530 04 N I 22.15
97532 09 Y I
97533 04 N I 18.75
97535 04 N I 11.20
97537 04 N I 11.00
97542 04 N I 7.55
Wednesday, April 01, 2009 Page 401 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
97545 04 N I 27.00
97546 09 Y I
97597 04 N I 27.78
97598 04 N I 35.97
97602 04 N I 28.35
97605 04 Y I
97606 04 Y I
97750 04 N I 22.15
97760 09 Y N
97761 09 Y N
97762 09 Y N
97799 04 Y I
97802 09 Y N
97803 09 Y N
97804 09 Y N
98925 04 N I 12.55
98926 04 N I 17.60
98927 04 N I 22.05
98928 04 N I 25.50
98929 04 N I 28.60
98940 09 Y N
Wednesday, April 01, 2009 Page 402 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
98941 02 Y N
98942 09 Y N
98943 09 Y N
99000 09 Y N
99001 09 Y N
99002 09 Y N
99056 04 N N 14.35
99058 04 N N 14.35
99070 04 Y N
99071 09 Y N
99075 09 Y N
99078 09 Y N
99082 04 Y N
99090 09 Y N
99091 09 Y N
99100 09 Y N
99116 09 Y N
99135 09 Y N
99140 09 Y N
99143 04 N I 76.70
99144 04 N I 76.70
Wednesday, April 01, 2009 Page 403 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99145 04 N I 38.35 2 76.70
99148 04 N I 38.35
99149 04 N I 38.35
99150 04 N I 19.17 2 38.35
99170 04 N I 58.90
99172 04 Y I
99173 04 N N 7.45 1 7.45
99175 09 Y N
99183 04 N I 60.50
99185 04 Y I
99186 04 Y I
99190 04 Y I Y
99191 04 Y I Y
99192 04 Y I Y
99195 04 N I 33.25
99199 04 Y I Y Y
99201 P 04 2/1/2009 N N 27.95 1 27.95 1.60 1.60
99202 P 04 2/1/2009 N N 32.00 1 32.00 1.60 1.60
99203 P 04 2/1/2009 N N 41.60 1 41.60 1.95 1.95
99204 P 04 2/1/2009 N N 66.40 1 66.40 3.25 3.25
99205 P 04 2/1/2009 N N 70.85 1 70.85 3.25 3.25
Wednesday, April 01, 2009 Page 404 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99211 P 04 2/1/2009 N N 12.30 1 12.30 .58 .58
99212 P 04 2/1/2009 N N 24.25 1 24.25 1.40 1.40
99213 P 04 2/1/2009 N N 28.35 1 28.35 18.21 18.21
99214 P 04 2/1/2009 N N 42.50 1 42.50 30.47 30.47
99215 P 04 2/1/2009 N N 48.00 1 48.00 1.95 1.95
99217 09 Y N
99218 04 N N 69.55
99219 04 N N 69.55
99220 04 N N 69.55
99221 04 N N 33.90
99222 04 N N 51.40
99223 04 N N 69.00
99231 04 N N 16.40
99232 04 N N 24.90
99233 04 N N 35.05
99234 04 N N 69.55
99235 04 N N 76.65
99236 04 N N 94.20
99238 04 N N 29.65
99239 04 N N 39.05
99241 04 2/1/2009 N N 32.15 7.04
Wednesday, April 01, 2009 Page 405 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99242 04 2/1/2009 N N 40.20 32.71
99243 04 2/1/2009 N N 51.30 48.56
99244 04 2/1/2009 N N 71.40 75.84
99245 04 2/1/2009 N N 92.80 90.02
99251 04 N N 32.15
99252 04 N N 33.95
99253 04 N N 46.45
99254 04 N N 66.40
99255 04 N N 87.10
99281 04 N N 14.35
99282 04 N N 24.20
99283 04 N N 32.20
99284 04 N N 44.00
99285 04 N N 69.25
99288 09 Y N
99291 04 2/1/2009 N N 84.90 55.20
99292 04 N N 42.35
99304 04 N N 27.55
99305 04 N N 36.10
99306 04 N N 47.70
99307 04 N N 14.80
Wednesday, April 01, 2009 Page 406 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99308 04 N N 18.91
99309 04 N N 23.40
99310 04 N N 32.05
99315 04 N N 26.55
99316 04 N N 34.00
99318 04 N N 23.10
99324 04 N N 18.60
99325 04 N N 26.70
99326 04 N N 34.85
99327 04 N N 42.95
99328 04 N N 51.05
99334 04 N N 16.00
99335 04 N N 21.00
99336 04 N N 26.05
99337 04 N N 31.05
99341 04 N N 27.95
99342 04 N N 37.40
99343 04 N N 54.90
99344 04 N N 70.55
99345 04 N N 85.55
99347 04 N N 24.25
Wednesday, April 01, 2009 Page 407 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99348 04 N N 31.30
99349 04 N N 47.50
99350 04 N N 68.85
99354 04 Y I
99355 04 Y I
99356 04 Y I
99357 04 Y I
99358 09 Y I
99359 09 Y I
99360 09 Y I
99374 09 Y N
99377 09 Y N
99379 09 Y N
99380 09 Y N
99381 P 04 N N 32.15 59.75
99382 P 04 N N 32.15 66.50
99383 P 04 N N 32.15 64.45
99384 P 04 N N 32.15 72.81
99385 P 04 2/1/2009 N N 32.15 C 66.40 (A) 72.81 38.56
99386 P 04 2/1/2009 N N 66.40 38.56
99387 P 04 2/1/2009 N N 66.40 38.56
Wednesday, April 01, 2009
Page 408 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99391 P 04 N N 32.15 C 32.15 37.37
99392 P 04 N N 32.15 C 32.15 45.72
99393 P 04 N N 32.15 C 32.15 44.69
99394 P 04 N N 32.15 C 32.15 52.47
99395 P 04 N N 32.15 C 42.50 A 53.50 43.15
99396 P 04 N N 42.50 43.15
99397 P 04 N N 42.50 43.15
99420 04 N N 14.60 1 14.60
99450 09 Y N
99455 09 Y N
99456 09 Y N
99460 04 1/1/2009 N 38.75
99461 04 1/1/2009 N 16.40
99462 04 1/1/2009 N 16.40
99463 04 1/1/2009 N 42.55
99464 04 1/1/2009 N 83.70
99465 04 1/1/2009 N 94.50
99466 04 1/1/2009 Y I
99467 04 1/1/2009 Y
99468 04 2/1/2009 N 586.70
99469 04 2/1/2009 N 251.69
Wednesday, April 01, 2009 Page 409 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99471 04 2/1/2009 N 510.67
99472 04 2/1/2009 N 249.51
99475 04 1/1/2009 N 84.90
99476 04 1/1/2009 N 42.35
99477 04 2/1/2009 N N 220.73
99478 04 2/1/2009 N 88.85
99479 04 1/1/2009 N 81.22
99480 04 2/1/2009 N 79.04
99499 04 Y N
99500 04 Y N
99501 04 Y N
99502 04 Y N
99503 04 Y N
99504 04 Y N
99505 04 Y N
99506 04 Y N
99507 04 Y N
99509 04 Y N
99510 04 N N 24.25
99511 04 Y N
99512 04 Y N
Wednesday, April 01, 2009 Page 410 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
99600 04 Y N
99999 04 Y N Y Y
A4206 04 N N 0.13 5 0.65
A4207 04 N N 0.05 5 0.25
A4208 04 N N 0.27 5 1.35
A4209 04 N N 0.26 5 1.30
A4212 04 N N 2.53 1 2.53
A4213 04 N N 0.32 5 1.60
A4215 04 N N 0.05 5 0.25
A4261 04 N N 61.17
A4267 04 N N 0.45 30 13.62
A4268 04 N N 1.12 30 33.82
A4269 04 Y Y N
A9502 09 Y N
A9503 09 Y N
A9507 09 Y N
A9526 09 Y N
A9527 04 1/1/2007 Y N
A9528 09 Y N
A9529 09 Y N
A9530 09 Y N
Wednesday, April 01, 2009 Page 411 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
A9531 09 Y N
A9532 09 Y N
A9543 04 Y Y N
A9545 04 Y Y N
A9563 04 Y N
A9564 04 Y N
A9605 09 Y N
D1203 04 N N 26.00
E0720 09 Y
G0008 04 N N 3.70
G0009 04 N N 3.70
G0010 04 N N 3.70
G0101 04 N I 32.86
G0102 04 N I 28.35
G0103 B 04 N N 8.80 8.80 17.60
G0104 04 Y I
G0105 04 N I 214.00
G0108 09 Y N
G0109 09 Y N
G0111 09 Y N
G0117 04 Y I
Wednesday, April 01, 2009 Page 412 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G0118 04 Y I
G0121 04 Y I
G0123 04 N N 3.50
G0124 04 N N 11.45
G0125 04 N N 920.70
G0127 04 N N 14.35
G0128 09 Y N
G0130 B 04 N N 48.52 48.52 97.05
G0141 04 N N 11.45
G0143 04 N N 3.45
G0144 04 N N 3.45
G0145 04 N N 3.45
G0147 04 N N 3.45
G0148 04 N N 3.45
G0159 04 N M Y 449.50
G0166 04 N I 66.70
G0168 04 N I 22.55
G0169 04 Y I
G0170 04 Y M Y Y
G0173 04 Y M Y
G0175 09 Y N
Wednesday, April 01, 2009 Page 413 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G0179 09 Y N
G0180 09 Y N
G0181 09 Y N
G0182 09 Y N
G0186 04 Y I
G0202 B 04 N N 35.95 35.95 71.90
G0204 B 04 N N 35.95 35.95 71.90
G0206 B 04 N N 19.60 19.60 39.20
G0219 B 04 N N 35.25 35.25 70.50
G0237 04 Y I
G0238 04 Y I
G0239 04 Y I
G0245 09 Y N
G0246 09 Y N
G0247 09 Y N
G0248 09 Y N
G0249 09 Y N
G0250 09 Y N
G0251 04 Y N Y Y
G0252 04 N N 35.25 35.25 70.50
G0255 04 Y I
Wednesday, April 01, 2009 Page 414 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G0256 04 N I 256.30
G0257 04 N I 35.75
G0259 04 N I 172.50
G0260 04 N I 31.80
G0261 04 N I 256.30
G0265 09 Y N
G0266 09 Y N
G0268 04 N I 21.40
G0269 04 Y I
G0270 09 Y N
G0271 09 Y N
G0275 04 N I 78.45
G0278 04 N I 78.45
G0281 04 Y I
G0282 04 Y I
G0283 04 Y I
G0288 B 04 Y I
G0289 04 Y M Y
G0290 04 Y M Y
G0291 04 Y N M Y
G0293 09 Y M
Wednesday, April 01, 2009 Page 415 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G0294 09 Y I
G0295 09 Y I
G0297 04 N M Y 256.00
G0300 04 N M Y 470.00
G0306 A 04 N N 2.69 2.69 5.39
G0307 A 04 N N 3.21 3.21 6.42
G0328 A 04 N N 6.66 6.66 13.33
G0329 04 N I 9.05
G0339 B 04 Y N Y
G0340 B 04 Y N Y
G0365 A 04 N I 25.03 25.02 50.05
G0377 04 1/1/2007 N N 9.81
G0380 04 1/1/2007 N N 14.35
G0381 04 1/1/2007 N N 24.20
G0382 04 1/1/2007 N N 32.20
G0383 04 1/1/2007 N N 44.00
G0384 04 1/1/2007 N N 69.25
G0392 04 1/1/2007 N M 479.00
G0393 04 1/1/2007 N M 479.00
G0394 04 1/1/2007 N N 2.72
G0402 09 1/1/2009 Y N
Wednesday, April 01, 2009 Page 416 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G0412 04 1/1/2009 N Y 674.20
G0413 04 1/1/2009 N Y 550.90
G0414 04 1/1/2009 N Y 599.35
G0415 04 1/1/2009 N Y 599.35
G3001 04 Y Y N
G9001 09 Y N
G9002 09 Y N
G9003 09 Y N
G9004 09 Y N
G9005 09 Y N
G9006 09 Y N
G9007 09 Y N
G9008 04 Y N
G9009 09 Y N
G9010 09 Y N
G9011 09 Y N
G9012 09 Y N
G9016 09 Y N
G9021 09 Y N
G9022 09 Y N
G9023 09 Y N
Wednesday, April 01, 2009 Page 417 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G9024 09 Y N
G9025 09 Y N
G9026 09 Y N
G9027 09 Y N
G9028 09 Y N
G9029 09 Y N
G9030 09 Y N
G9031 09 Y N
G9032 09 Y N
G9033 09 Y Y N
G9034 09 Y N
G9050 09 Y N
G9051 09 Y N
G9052 09 Y N
G9053 09 Y N
G9054 09 Y N
G9055 09 Y N
G9056 09 Y N
G9057 09 Y N
G9058 09 Y N
G9059 09 Y N
Wednesday, April 01, 2009 Page 418 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G9060 09 Y N
G9061 09 Y N
G9062 09 Y N
G9063 09 Y N
G9064 09 Y N
G9065 09 Y N
G9066 09 Y N
G9067 09 Y N
G9068 09 Y N
G9069 09 Y N
G9070 09 Y N
G9071 09 Y N
G9072 09 Y N
G9073 09 Y N
G9074 09 Y N
G9075 09 Y N
G9077 09 Y N
G9078 09 Y N
G9079 09 Y N
G9080 09 Y N
G9083 09 Y N
Wednesday, April 01, 2009 Page 419 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G9084 09 Y N
G9085 09 Y N
G9086 09 Y N
G9087 09 Y N
G9088 09 Y N
G9089 09 Y N
G9090 09 Y N
G9091 09 Y N
G9092 09 Y N
G9093 09 Y N
G9094 09 Y N
G9095 09 Y N
G9096 09 Y N
G9097 09 Y N
G9098 09 Y N
G9099 09 Y N
G9100 09 Y N
G9101 09 Y N
G9102 09 Y N
G9103 09 Y N
G9104 09 Y N
Wednesday, April 01, 2009 Page 420 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
G9105 09 Y N
G9106 09 Y N
G9107 09 Y N
G9108 09 Y N
G9109 09 Y N
G9110 09 Y N
G9111 09 Y N
G9112 09 Y N
G9113 09 Y N
G9114 09 Y N
G9115 09 Y N
G9116 09 Y N
G9117 09 Y N
G9123 09 Y N
G9124 09 Y N
G9125 09 Y N
G9126 09 Y N
G9128 09 Y N
G9129 09 Y N
G9130 09 Y N
H0033 04 N N 118.10 1 118.10
Wednesday, April 01, 2009 Page 421 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
H1000 04 N N 14.60
J0120 04 N Y N 5.49 1 5.49
J0128 04 N Y N 80.66 10 806.60
J0129 04 1/1/2007 N Y N 22.98 75 1723.50
J0132 04 N Y N 0.32 2 0.64
J0133 04 N Y N 0.14 10 1.40
J0135 04 N Y N 862.86 8 6902.88
J0150 04 N Y 39.55 5 197.75
J0152 04 N Y N 87.14 3 261.42
J0170 04 N Y N 0.14 24 3.36
J0180 04 N Y N 149.52 105 15699.60
J0190 04 Y Y N
J0200 04 Y Y N
J0205 04 N Y N 44.74 8 357.92
J0207 04 N Y N 540.07 2 1080.14
J0210 04 N N 0.83 16 13.28
J0215 N 04 Y Y N
J0220 04 1/1/2008 Y Y
J0256 04 N Y N 2.94 600 1764.00
J0278 04 N Y N 1.37 3 4.11
J0280 04 N N 0.67 6 4.02
Wednesday, April 01, 2009 Page 422 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J0282 04 N Y N 0.77 5 3.85
J0285 04 N Y N 17.36 6 104.16
J0287 04 N Y N 23.92 50 1196.00
J0288 04 N Y N 15.94 40 637.60
J0289 04 N Y N 39.12 50 1956.00
J0290 04 N Y N 3.39 4 13.56
J0295 04 N Y N 9.39 8 75.12
J0300 04 Y N
J0348 04 1/1/2007 Y Y N
J0350 04 Y Y N
J0360 04 N Y N 15.92 12 191.04
J0364 04 1/1/2007 N Y N 4.95 6 29.70
J0365 04 N Y N 2.82 1 2.82
J0370 04 N Y N 1.85
J0380 04 N N 13.31 10 133.10
J0390 04 N Y N 3.50
J0395 04 N Y N 191.39 1 191.39
J0400 04 1/1/2008 N Y 2.61 120 313.20
J0456 04 N Y N 30.58 1 30.58
J0460 04 N N 0.61 10 6.10
J0470 04 N N 28.55 5 142.75
Wednesday, April 01, 2009 Page 423 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J0475 04 N Y N 257.19 12 3086.28
J0476 04 N Y N 83.73 1 83.73
J0480 04 N Y N 1,765.65 1 1765.65
J0500 04 N N 17.81 4 71.24
J0515 04 N Y N 4.10 8 32.80
J0520 04 N Y N 5.42 2 10.84
J0530 04 N Y N 4.05 4 16.20
J0540 04 N Y N 8.10 2 16.20
J0550 04 N Y N 16.20 1 16.20
J0560 04 N Y N 16.36 4 65.44
J0570 04 N Y N 33.25 2 66.50
J0580 04 N Y N 53.78 1 53.78
J0583 04 N Y N 1.81 10 18.10
J0585 N 04 Y Y N
J0587 09 Y N N
J0592 04 N Y N 1.24 6 7.44
J0594 04 1/1/2007 N Y N 15.07 60 904.20
J0595 04 N Y N 3.17 2 6.34
J0600 04 N Y N 48.14 2 96.28
J0610 04 N N 0.55 10 5.50
J0620 04 N Y N 12.49 6 74.94
Wednesday, April 01, 2009 Page 424 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J0630 04 N Y N 45.30 2 90.60
J0636 04 N Y N 1.11 40 44.40
J0637 04 N Y N 41.05 14 574.70
J0640 04 N Y N 3.73 30 111.90
J0641 04 1/1/2009 N Y N 1.23 150 184.50
J0690 04 N Y N 1.83 4 7.32
J0692 04 N Y N 9.49 8 75.92
J0694 04 N Y N 9.54 12 114.48
J0695 04 Y Y
J0696 04 N Y N 16.42 16 262.72
J0697 04 N Y N Y Y 5.43 4 21.72
J0698 04 N Y N 8.49 10 84.90
J0702 04 N Y N 3.02 4 12.08
J0704 04 N Y N 4.03 3 12.09
J0706 04 N Y N 4.05 4 16.20
J0710 04 N Y N 1.63 2 3.26
J0713 04 N Y N 7.08 12 84.96
J0715 04 N Y N 5.90 12 70.80
J0720 04 N Y N 6.71 7 46.97
J0725 04 Y Y N
J0735 04 N Y N 74.44 2 148.88
Wednesday, April 01, 2009 Page 425 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J0740 04 N Y N 885.21 2 1770.42
J0743 04 N Y N 18.88 6 113.28
J0744 04 N Y N 15.55 5 77.75
J0745 04 N Y N 0.55 12 6.60
J0760 04 N Y N 7.72 2 15.44
J0770 04 N Y N 29.73 4 118.92
J0780 04 N Y N 7.90 10 79.00
J0795 04 N Y N 5.15 10 51.50
J0800 04 N N 129.26 2 258.52
J0835 04 N Y N 88.55 1 88.55
J0878 04 N Y N 0.35 500 175.00
J0881 04 N Y N 5.54 500 2770.00
J0882 04 N Y N 5.54 500 2770.00
J0885 04 N Y N 15.16 80 1212.80
J0886 04 N Y N 15.16 80 1212.80
J0894 04 1/1/2007 Y Y N
J0895 04 N Y N Y Y 15.36 6 92.16
J0900 04 Y N
J0945 04 N Y N 0.77 10 7.70
J0950 04 N Y N 8.10
J0970 04 N Y N 34.14 1 34.14
Wednesday, April 01, 2009 Page 426 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J1000 04 N Y N 6.35 1 6.35
J1015 04 N Y N 18.63
J1020 04 N Y N 2.20 8 17.60
J1030 04 N Y N 4.93 4 19.72
J1040 04 N Y N 9.87 4 39.48
J1051 04 N Y N 20.56 9 185.04
J1055 04 N Y N 61.69 1 61.69
J1060 04 Y Y N
J1070 04 N Y N 6.18 3 18.54
J1080 04 N Y N 11.80 2 23.60
J1094 04 N Y N 0.86 32 27.52
J1100 04 N Y N 0.10 40 4.00
J1110 04 N N 50.87 3 152.61
J1120 04 N N 22.42 2 44.84
J1160 04 N Y N 2.53 3 7.59
J1162 04 N Y N 755.86 80 60468.80
J1165 04 N Y N 0.40 20 8.00
J1170 04 N Y N 1.78 2 3.56
J1180 04 Y N
J1190 04 N Y N 255.72 4 1022.88
J1200 04 N Y N 0.79 2 1.58
Wednesday, April 01, 2009 Page 427 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J1205 04 N Y N 10.99 1 10.99
J1212 04 N N 50.97 1 50.97
J1230 04 N N 3.62 6 21.72
J1240 04 N N 0.27 8 2.16
J1245 04 N Y N 5.09 6 30.54
J1250 04 N Y N 3.99 1 3.99
J1260 04 N Y N 4.85 20 97.00
J1265 04 N Y N 0.06 7 0.42
J1267 04 1/1/2009 N Y N 0.95 50 47.50
J1270 04 N Y N 6.00 4 24.00
J1300 04 1/1/2008 N Y 207.34 90 18660.60
J1320 04 N N 2.62 15 39.30
J1324 04 1/1/2007 N Y N 31.46 90 2831.40
J1325 04 N Y N 22.18 3 66.54
J1327 04 N Y N 24.32 5 121.60
J1330 04 Y N
J1335 04 N Y N 23.76 2 47.52
J1364 04 N Y N 12.25 8 98.00
J1380 04 N Y N 0.55 4 2.20
J1390 04 N Y N 1.12 2 2.24
J1405 04 N Y N 10.00
Wednesday, April 01, 2009 Page 428 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J1410 04 N Y N 68.03 4 272.12
J1430 04 N Y N 41.74 1 41.74
J1435 04 N Y N 0.19 5 0.95
J1436 04 Y Y N
J1438 04 N Y N 186.86 4 747.44
J1440 04 N Y N 197.17 2 394.34
J1441 04 N Y N 363.48 1 363.48
J1450 04 N Y N 103.11 2 206.22
J1451 04 N Y N 13.79 1 13.79
J1452 04 Y Y N
J1453 04 1/1/2009 N Y N 1.89 115 217.35
J1455 04 N Y N 88.16 2 176.32
J1457 04 Y Y N
J1458 04 1/1/2007 Y Y N
J1459 04 1/1/2009 N Y N 45.87 112 5137.44
J1460 04 N Y N 14.21 156 2216.76
J1470 04 Y Y N
J1480 04 Y Y N
J1490 04 Y Y N
J1500 04 Y Y N
J1510 04 Y Y N
Wednesday, April 01, 2009 Page 429 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J1520 04 Y Y N
J1530 04 Y Y N
J1540 04 Y Y N
J1550 04 Y Y N
J1560 04 Y Y N
J1561 04 1/1/2008 Y Y N
J1562 04 1/1/2007 N Y N 14.95 140 2093.00
J1565 04 N Y N 19.00 4 76.00
J1566 04 Y Y N
J1568 04 1/1/2008 Y Y N
J1569 04 1/1/2008 Y Y N
J1570 04 N Y N 61.95 2 123.90
J1571 04 1/1/2008 N Y N 79.74 9 717.66
J1572 04 1/1/2008 Y Y N
J1573 04 1/1/2008 Y Y N
J1580 04 N Y N 0.70 5 3.50
J1590 04 Y Y N
J1595 04 Y Y N
J1600 04 N N 10.80 1 10.80
J1626 04 N Y N 19.45 20 389.00
J1630 04 N N 2.37 40 94.80
Wednesday, April 01, 2009 Page 430 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J1631 04 N Y N 23.86 6 143.16
J1640 04 N Y N 7.65 1 7.65
J1642 04 N Y N 0.03 5 0.15
J1644 04 N Y N 1.18 10 11.80
J1645 04 N Y N 19.89 4 79.56
J1650 04 N Y N 7.40 84 621.60
J1652 04 N Y N 43.36 20 867.20
J1655 04 N Y N 4.51 20 90.20
J1670 04 N N 107.66 1 107.66
J1675 04 N Y N 3.39 10 33.90
J1700 04 Y Y N
J1710 04 N Y N 5.83 5 29.15
J1720 04 N Y N 2.26 10 22.60
J1730 04 Y N
J1740 04 1/1/2007 N Y N 167.69 3 503.07
J1742 04 N Y N 302.88 1 302.88
J1743 04 1/1/2008 Y Y N
J1756 04 N Y N 0.67 100 67.00
J1785 04 N Y N 4.61 400 1844.00
J1790 04 N Y N 4.23 1 4.23
J1800 04 N Y N 8.22 3 24.66
Wednesday, April 01, 2009 Page 431 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J1810 04 Y Y N
J1815 04 N Y N 0.23 20 4.60
J1817 04 N Y N 2.17 2 4.34
J1825 04 N Y N 601.23 1 601.23
J1835 04 N Y N 44.31 8 354.48
J1840 04 N N 2.93 3 8.79
J1850 04 N N 0.43 14 6.02
J1885 04 N Y N 1.05 8 8.40
J1930 04 1/1/2009 N Y N 31.24 90 2811.60
J1931 04 Y Y N
J1940 04 N Y N 0.45 10 4.50
J1945 04 N Y N 179.93 1 179.93
J1950 04 N Y N 591.46 2 1182.92
J1953 04 1/1/2009 N Y N 0.81 50 40.50
J1955 04 N Y N 11.67 4 46.68
J1956 04 N Y N 22.65 2 45.30
J1960 04 N Y N 3.94 2 7.88
J1980 04 N N 10.99 8 87.92
J1990 04 N Y N 26.22 3 78.66
J2001 04 N Y N 0.06 20 1.20
J2010 04 N Y N 3.52 4 14.08
Wednesday, April 01, 2009 Page 432 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J2020 04 N Y N 42.60 6 255.60
J2060 04 N Y N 1.18 4 4.72
J2150 04 N Y N 1.01 8 8.08
J2175 04 N Y N 0.87 6 5.22
J2180 04 Y Y N
J2185 04 N Y N 6.15 10 61.50
J2210 04 N N 6.71 1 6.71
J2248 04 1/1/2007 N Y N 2.32 150 348.00
J2250 04 N Y N 0.62 10 6.20
J2260 04 N Y N 35.45 1 35.45
J2270 04 N Y N 0.78 10 7.80
J2271 04 N Y N 1.81 3 5.43
J2275 04 N Y N 2.49 10 24.90
J2278 04 N Y N 7.58 50 379.00
J2280 04 N Y N 10.90 4 43.60
J2300 04 N Y N 0.66 16 10.56
J2310 04 N N N 5.57 2 11.14
J2315 04 1/1/2007 N Y N 2.27 380 862.60
J2320 04 N N 4.02 4 16.08
J2321 04 N N 8.04 2 16.08
J2322 04 N N 16.94 1 16.94
Wednesday, April 01, 2009 Page 433 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J2323 04 1/1/2008 N Y N 8.01 300 2403.08
J2325 04 N Y N 31.68 5 158.40
J2353 04 Y Y N
J2354 04 N Y N 3.39 20 67.80
J2355 04 N Y N 305.04 1 305.04
J2357 04 Y Y N
J2360 04 N N 20.43 1 20.43
J2370 04 N N 2.65 1 2.65
J2400 04 N Y N 16.66 2 33.32
J2405 04 N Y N 6.38 40 255.20
J2410 04 N Y N 3.23 10 32.30
J2425 04 N Y N 13.70 100 1370.00
J2430 04 N Y N 237.76 3 713.28
J2440 04 N N 2.96 3 8.88
J2460 04 N Y N 0.71 10 7.10
J2469 04 N Y N 35.64 10 356.40
J2501 04 N Y N 5.82 20 116.40
J2503 04 N Y N 1239.83 1 1239.83
J2504 04 N Y N 195.38 1 195.38
J2505 04 N Y N 3243.53 1 3243.53
J2510 04 N Y N 10.86 1 10.86
Wednesday, April 01, 2009 Page 434 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J2513 04 N N 76.09 1 76.09
J2515 04 N N 5.24 4 20.96
J2540 04 N Y N 2.92 1 2.92
J2543 04 N Y N 12.38 12 148.56
J2545 04 N Y N 40.10 1 40.10
J2550 04 N Y N 0.48 1 0.48
J2560 04 N N 1.85 5 9.25
J2590 04 N N 3.57 3 10.71
J2597 04 N Y N 3.61 4 14.44
J2650 04 Y N
J2670 04 Y N
J2675 04 N Y N 3.28 3 9.84
J2680 04 N Y N 21.30 4 85.20
J2690 04 N Y N 2.96 1 2.96
J2700 04 N Y N 1.26 20 25.20
J2710 04 N Y N 1.56 8 12.48
J2720 04 N Y N 0.79 5 3.95
J2724 04 1/1/2008 Y Y N
J2730 04 N Y N 108.03 3 324.09
J2760 04 N N 67.28 2 134.56
J2765 04 N Y N 0.40 14 5.60
Wednesday, April 01, 2009 Page 435 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J2770 04 N N N 110.30 4 441.20
J2778 04 1/1/2008 N Y N 485.97 5 2429.85
J2780 04 N Y N 1.50 2 3.00
J2783 04 N Y N 133.87 3 401.61
J2785 04 1/1/2009 N Y N 63.03 4 252.12
J2788 04 N Y N 33.03 6 198.18
J2790 04 N Y N 99.92 1 99.92
J2791 04 1/1/2008 Y Y N
J2792 04 N Y N 23.58 340 8017.20
J2794 04 Y Y N
J2795 04 N N N 0.36 2 0.72
J2800 04 N N 15.49 3 46.47
J2810 04 Y Y N
J2820 04 N Y N 37.21 15 558.15
J2910 04 N Y N 16.70 1 16.70
J2916 04 N Y N 8.56 10 85.60
J2920 04 N Y N 1.73 3 5.19
J2930 04 N Y N 2.88 4 11.52
J2940 04 N Y N 52.69 2 105.38
J2941 04 N Y N 35.68 20 713.60
J2993 04 N N N 1,503.32 2 3006.64
Wednesday, April 01, 2009 Page 436 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J2994 04 Y Y N
J2995 04 Y Y N
J2996 04 N Y N 280.60
J2997 04 N Y N 40.41 4 161.64
J3000 04 N Y N 9.06 2 18.12
J3010 04 N Y N 0.29 20 5.80
J3030 04 N Y N 65.71 1 65.71
J3070 04 N N 2.49 12 29.88
J3101 04 1/1/2009 N Y N 59.91 50 2995.57
J3105 04 N Y N 19.09 3 57.27
J3110 04 N Y N 12.25 2 24.50
J3120 04 N N 8.46 4 33.84
J3130 04 N N 16.93 2 33.86
J3140 04 N Y N 0.41 4 1.64
J3150 04 N N 0.83 4 3.32
J3230 04 N Y N 12.86 8 102.88
J3240 04 N Y N 822.41 1 822.41
J3243 04 1/1/2007 N N 1.33 100 133.00
J3246 04 N Y N 105.80 1 105.80
J3250 04 N Y N 5.46 4 21.84
J3260 04 N Y N 7.73 5 38.65
Wednesday, April 01, 2009 Page 437 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J3265 04 N Y N 2.03 10 20.30
J3280 04 Y Y N
J3285 04 N Y N 64.79 2 129.58
J3300 04 1/1/2009 N Y N 3.86 4 15.44
J3301 04 N N N 1.78 8 14.24
J3302 04 N Y N 0.54 32 17.28
J3303 04 N Y 1.76 4 7.04
J3305 04 N Y N 175.99 5 879.95
J3310 04 N Y N 1.75
J3315 04 N Y N 604.34 3 1813.02
J3320 04 N Y N 35.36 1 35.36
J3350 04 Y N
J3360 04 N Y N 0.14 6 0.84
J3364 04 N Y N 56.42 2 112.84
J3365 04 N Y N Y Y 538.08 2 1076.16
J3370 04 N Y N 3.34 4 13.36
J3396 04 N Y N 11.20 150 1680.00
J3400 04 N Y N 3.80
J3410 04 N Y N 0.27 4 1.08
J3411 04 N Y N 0.84 2 1.68
J3415 04 N Y N 0.61 5 3.05
Wednesday, April 01, 2009 Page 438 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J3420 04 N Y N 0.18 1 0.18
J3430 04 N Y N 0.19 25 4.87
J3465 04 N Y N 5.72 60 343.20
J3470 04 N N 24.92 1 24.92
J3471 04 N Y N 0.13 999 129.87
J3472 04 N Y N 0.13 1,000 130.00
J3473 04 1/1/2007 Y Y N
J3475 04 N Y N 0.07 20 1.40
J3480 04 N Y N 0.13 20 2.60
J3485 04 N Y N 1.21 50 60.50
J3486 04 N Y N 23.84 4 95.36
J3487 04 N Y N 237.65 4 950.60
J3488 04 1/1/2008 Y Y N
J3490 04 Y Y N
J3520 04 N Y N 1.40 20 28.00
J3530 04 Y N
J3590 04 Y Y N
J7030 04 N Y N 1.30 2 2.60
J7040 04 N Y N 1.17 2 2.34
J7042 04 N Y N 1.52 2 3.04
J7050 04 N Y N 3.64 2 7.28
Wednesday, April 01, 2009 Page 439 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J7060 04 N Y N 4.24 2 8.48
J7070 04 N Y N 1.43 2 2.86
J7100 04 Y N
J7110 04 Y N
J7120 04 N Y N 1.61 2 3.22
J7130 04 Y N
J7186 04 1/1/2009 N Y N 1.04
J7187 04 1/1/2007 Y Y N
J7189 04 N Y N 1.15 1,000 1150.00
J7190 04 N Y N 0.75 1250 937.50
J7191 04 N Y N 2.18 550 1199.00
J7192 04 N Y N 0.67 2000 1340.00
J7193 04 N Y N 0.91 812 738.92
J7194 04 N Y N 0.47 1000 470.00
J7195 04 N Y N 1.03 1000 1030.00
J7198 04 N Y N 1.15 615 707.25
J7199 04 Y Y N
J7300 04 N Y N 423.10
J7302 04 N Y N 530.86 1 530.86
J7303 04 N Y N 43.80 3 131.40
J7304 04 N Y N 15.67 9 141.03
Wednesday, April 01, 2009 Page 440 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J7306 04 Y Y N
J7307 04 1/1/2008 N Y N 651.69 1 651.69
J7308 04 N Y N 105.91 1 105.91
J7310 04 N Y N 4,984.32 1 4984.32
J7311 04 1/1/2007 Y Y N
J7318 04 N N 4.92 25 123.00
J7319 04 Y Y N
J7321 04 1/1/2008 Y Y N
J7322 04 1/1/2008 Y Y N
J7323 04 1/1/2008 Y Y N
J7324 04 1/1/2008 Y Y N
J7330 04 Y N
J7500 09 Y N N
J7501 04 N N N 72.21 5 361.05
J7502 04 N Y N 6.70 15 100.50
J7504 04 N Y N 359.26 12 4311.12
J7505 04 N Y N 980.75 1 980.75
J7506 04 N Y N 0.02 20 0.40
J7507 04 N Y N 4.12 20 82.40
J7509 04 N Y N 0.31 12 3.72
J7510 04 N Y N 0.11 40 4.40
Wednesday, April 01, 2009 Page 441 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J7511 04 N N N 429.89 1 429.89
J7513 04 N Y N 512.28 4 2049.12
J7515 04 N Y N 1.67 20 33.40
J7516 04 N Y N 24.77 3 74.31
J7517 04 N Y N 3.21 8 25.68
J7518 04 Y Y N
J7520 04 N Y N 8.31 6 49.86
J7525 04 N Y N 164.48 1 164.48
J7599 04 Y Y N
J7604 04 1/1/2008 N Y N 5.53 1 5.53
J7605 04 1/1/2008 N Y N 5.73 1 5.73
J7606 04 1/1/2009 N Y N 6.13 1 6.13
J7607 04 1/1/2007 Y Y N
J7608 04 N Y N 3.28 4 13.12
J7609 04 1/1/2007 Y Y N
J7610 04 1/1/2007 Y Y N
J7611 04 4/1/2008 N Y 0.03 5 0.15
J7612 04 4/1/2008 N Y 1.15 5 5.75
J7613 04 4/1/2008 N Y 0.06 5 0.30
J7614 04 4/1/2008 N Y 2.11 5 10.55
J7615 04 1/1/2007 Y Y N
Wednesday, April 01, 2009 Page 442 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J7620 04 Y Y N
J7625 04 N Y N 1.10
J7626 04 N Y N 4.91 4 19.64
J7627 04 N Y N 0.09 4 0.36
J7628 04 Y Y N
J7629 04 Y Y N
J7630 04 N Y N 1.10
J7631 04 N Y N 0.33 2 0.66
J7632 04 1/1/2008 N Y N 0.33 2 0.66
J7633 04 N Y N 5.16 2 10.32
J7634 04 1/1/2007 Y Y N
J7635 04 N Y N 0.40 2 0.80
J7636 04 Y Y N
J7637 04 N Y N 11.21 1 11.21
J7638 04 Y Y N
J7639 04 N Y N 22.56 2 45.12
J7640 04 N Y N 1.85 5 9.25
J7642 04 Y Y N
J7644 04 N Y N 0.40 5 2.00
J7645 04 1/1/2007 Y Y N
J7647 04 1/1/2007 Y Y N
Wednesday, April 01, 2009 Page 443 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J7648 04 Y Y N
J7649 04 Y Y N
J7650 04 1/1/2007 Y Y N
J7657 04 1/1/2007 Y Y N
J7658 04 Y Y N
J7659 04 Y Y N
J7660 04 1/1/2007 Y Y N
J7665 04 N Y N 2.15
J7667 04 1/1/2007 Y Y N
J7668 04 Y Y N
J7669 04 N Y N 0.54 1 0.54
J7670 04 1/1/2007 Y Y N
J7674 04 N Y N 0.47 2 0.94
J7676 04 1/1/2008 Y Y N
J7680 04 Y Y N
J7681 04 Y Y N
J7682 04 N Y N 63.79 1 63.79
J7683 04 Y Y N
J7684 04 Y Y N
J7685 04 1/1/2007 Y Y N
J7699 04 Y Y N
Wednesday, April 01, 2009 Page 444 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J7799 04 Y Y N
J8499 04 Y Y N
J8501 04 Y Y N
J8510 04 Y Y N
J8520 04 N Y N 3.91 100 391.00
J8521 04 N Y N 13.07 200 2614.00
J8530 04 N Y N 1.91 60 114.60
J8560 04 N Y N 63.56 4 254.24
J8565 04 N Y N 70.68 1 70.68
J8600 04 N Y N 5.39 3 16.17
J8610 04 N Y N 0.36 12 4.32
J8700 04 N Y N 8.84 50 442.00
J8705 04 1/1/2009 N Y N 82.16 10 821.60
J8999 04 Y Y N
J9000 04 N Y N 11.67 20 233.40
J9001 04 N Y N 459.35 10 4593.50
J9010 04 N N N 637.29 3 1911.87
J9015 04 N Y N 891.57 1 891.57
J9017 04 N Y N 39.87 15 598.05
J9020 04 N Y N 65.70 2 131.40
J9025 04 N Y N 4.93 185 912.05
Wednesday, April 01, 2009 Page 445 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J9027 04 Y Y N
J9031 04 N Y N 190.89 1 190.89
J9033 04 1/1/2009 N Y N 22.42 300 6726.00
J9035 04 N Y N 68.53 100 6853.00
J9040 04 N Y N 248.46 3 745.38
J9041 04 N Y N 36.12 35 1264.20
J9045 04 N Y N 28.98 20 579.60
J9050 04 N Y N 169.76 8 1358.08
J9055 04 N Y N 59.81 100 5981.00
J9060 04 N Y N 40.78 30 1223.40
J9062 04 N Y N 203.90 4 815.60
J9065 04 N Y N 47.78 10 477.80
J9070 04 N Y N 2.87 20 57.40
J9080 04 N Y N 5.74 10 57.46
J9090 04 N Y N 13.49 4 53.96
J9091 04 N Y N 28.78 2 57.56
J9092 04 N Y N 44.59 1 44.59
J9093 04 N Y N 2.87 20 57.40
J9094 04 N Y N 9.99 4 39.96
J9095 04 N Y N 13.49 4 53.96
J9096 04 N Y N 28.78 2 57.56
Wednesday, April 01, 2009 Page 446 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J9097 04 N Y N 44.59 2 89.18
J9098 04 N Y N 454.56 5 2272.80
J9100 04 N Y N 3.18 60 190.80
J9110 04 N Y N 9.01 4 36.04
J9120 04 N Y N 14.54 3 43.62
J9130 04 N Y N 11.76 10 117.60
J9140 04 N Y N 19.65 5 98.25
J9150 04 N Y N 32.68 6 196.08
J9151 04 N Y N 67.74 8 541.92
J9160 04 N Y N 1,694.66 6 10167.96
J9165 04 Y Y N
J9170 04 N Y N 386.82 13 5028.66
J9175 04 Y Y N
J9178 04 N Y N 29.87 100 2987.00
J9181 04 N Y N 13.38 45 602.10
J9185 04 N Y N 292.33 1 292.33
J9190 04 N Y N 3.18 12 38.16
J9200 04 N Y N 127.44 1 127.44
J9201 04 N Y N 142.20 10 1422.00
J9202 04 N Y N 468.51 3 1405.53
J9206 04 N Y N 152.95 44 6729.80
Wednesday, April 01, 2009 Page 447 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J9207 04 1/1/2009 N Y N 76.58 90 6892.20
J9208 04 N N N 134.50 5 672.50
J9209 04 N N N 35.75 25 893.75
J9211 04 N Y N 417.26 10 4172.60
J9212 04 N Y N 14.16 90 1274.40
J9213 04 N Y N 42.02 1 42.02
J9214 04 N Y N 14.16 90 1274.40
J9215 04 N Y N 8.23 20 164.60
J9216 04 N Y N 379.81 2 759.62
J9217 04 N Y N 736.43 6 4418.58
J9218 04 N Y N 154.69 12 1856.28
J9219 04 N Y N 5,666.17 1 5666.17
J9225 04 N Y N 5,500.00 1 5,500.00
J9226 04 1/1/2008 N Y N 15,400.00 1 15,400.00
J9230 04 N Y N 12.59 3 37.77
J9245 04 N Y N 1948.76 1 1948.76
J9250 04 N Y N 0.21 20 4.20
J9260 04 N Y N 2.24 600 1344.00
J9261 04 1/1/2007 N Y N 117.01 30 3510.30
J9263 04 N Y N 10.30 400 4120.00
J9264 04 N Y N 9.91 500 4955.00
Wednesday, April 01, 2009 Page 448 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J9265 04 N Y N 146.69 15 2200.35
J9266 04 N Y N 1,894.04 5 9470.20
J9268 04 N Y N 2,354.63 1 2354.63
J9270 04 N Y N 98.41 1 98.41
J9280 04 N Y N 92.36 8 738.88
J9290 04 N Y N 369.46 2 738.92
J9291 04 N Y N 895.77 1 895.77
J9293 04 N Y N 411.65 5 2058.25
J9300 04 N Y N 2,751.34 3 8254.02
J9303 04 1/1/2008 Y Y N
J9305 04 N Y N 49.80 100 4980.00
J9310 04 N Y N 546.80 10 5468.00
J9320 04 N Y N 185.66 1 185.66
J9330 04 1/1/2009 N Y N 57.45 25 1436.25
J9340 04 N Y N 104.60 3 313.80
J9350 04 N Y N Y 972.24 3 2916.72
J9355 04 N Y N 66.34 100 6634.00
J9357 04 N Y N 552.65 1 552.65
J9360 04 N Y N 1.01 20 20.20
J9370 04 N Y N 15.97 4 63.88
J9375 04 N Y N 31.94 1 31.94
Wednesday, April 01, 2009 Page 449 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
J9380 04 N Y N 79.86 1 79.86
J9390 04 N Y N 119.14 8 953.12
J9395 04 N Y N 196.11 10 1961.10
J9600 04 N Y N 3,005.31 2 6010.62
J9999 04 Y N
M0064 02 N N 10.00
M0075 04 Y N
M0076 04 Y N
P3000 04 N N 3.55
P3001 04 N N 11.45
P7001 A 04 N N 6.40 6.40 12.80
P9041 09 Y N
P9043 09 Y N
P9045 09 Y N
P9046 09 Y N
P9047 09 Y N
P9048 09 Y N
P9050 04 Y N
P9604 04 N N 2.90
P9612 09 Y N
P9615 09 Y N
Wednesday, April 01, 2009 Page 450 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
Q0044 02 N N 7.60
Q0081 04 Y I
Q0083 04 N I 19.00
Q0084 04 N I 19.00
Q0085 04 N I 19.00
Q0111 B 04 N N 2.40 2.40 4.80
Q0112 B 04 N N 2.40 2.40 4.80
Q0113 B 04 N N 2.40 2.40 4.80
Q0114 B 04 N N 2.40 2.40 4.80
Q0163 04 N Y N 0.09 2 0.18
Q0164 04 N Y N 0.44 10 4.40
Q0165 04 N Y N 0.64 5 3.20
Q0166 04 N Y N 46.88 2 93.76
Q0168 04 N Y N 10.47 2 20.94
Q0169 04 N Y N 0.28 4 1.12
Q0170 04 N Y N 0.57 2 1.14
Q0171 04 N Y N 0.27 5 1.35
Q0172 04 N Y N 0.41 16 6.56
Q0173 04 N Y N 0.28 4 1.12
Q0174 04 N Y N 0.60 6 3.60
Q0175 04 N Y N 0.79 6 4.74
Wednesday, April 01, 2009 Page 451 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
Q0176 04 N Y N 0.96 3 2.88
Q0177 04 N Y N 0.09 16 1.44
Q0178 04 N Y N 0.11 8 0.88
Q0179 04 N Y N 28.80 4 115.20
Q0180 04 N Y N 75.99 1 75.99
Q0181 04 Y Y N
Q0515 04 Y Y N
Q2004 04 Y Y N
Q2009 04 N Y N 7.30 40 292.00
Q2017 04 N Y N 320.97 6 1925.82
Q3014 09 Y N
Q3025 04 Y Y N
Q3026 04 N Y N 55.40
Q3031 04 Y N
Q4001 09 Y N
Q4002 09 Y N
Q4003 09 Y N
Q4004 09 Y N
Q4005 09 Y N
Q4011 09 Y N
Q4013 09 Y N
Wednesday, April 01, 2009 Page 452 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
Q4014 09 Y N
Q4015 09 Y N
Q4016 09 Y N
Q4018 09 Y N
Q4019 09 Y N
Q4020 09 Y N
Q4024 09 Y N
Q4025 09 Y N
Q4026 09 Y N
Q4027 09 Y N
Q4028 09 Y N
Q4029 09 Y N
Q4031 09 Y N
Q4033 09 Y N
Q4035 09 Y N
Q4036 09 Y N
Q4037 09 Y N
Q4041 09 Y N
Q4044 09 Y N
Q4045 09 Y N
Q4046 09 Y N
Wednesday, April 01, 2009 Page 453 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
Q4047 09 Y N
Q4048 09 Y N
Q4049 09 Y N
Q4050 09 Y N
Q4051 09 Y N
Q4080 04 Y Y N
Q4081 04 1/1/2007 N Y N 1.56 800 1248.00
Q4083 04 1/1/2007 N Y N 145.54 2 291.08
Q4084 04 1/1/2007 N Y N 244.63 2 489.26
Q4085 04 1/1/2007 N Y N 123.87 2 247.74
Q4086 04 1/1/2007 N N 260.53 2 521.06
Q4087 04 7/1/2007 Y
Q4088 04 7/1/2007 Y
Q4089 04 7/1/2007 Y
Q4090 04 7/1/2007 Y
Q4091 04 Y
Q4092 04 Y
Q4100 04 1/1/2009 Y
Q4101 04 1/1/2009 Y
Q4102 04 1/1/2009 Y
Q4103 04 1/1/2009 Y
Wednesday, April 01, 2009 Page 454 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
Q4104 04 1/1/2009 Y
Q4105 04 1/1/2009 Y
Q4106 04 1/1/2009 Y
Q4107 04 1/1/2009 Y
Q4108 04 1/1/2009 Y
Q4109 04 1/1/2009 Y
Q4110 04 1/1/2009 Y
Q4111 04 1/1/2009 Y
Q4112 04 1/1/2009 Y
Q4113 04 1/1/2009 Y
Q4114 04 1/1/2009 Y
R0070 04 N N 4.10
R0075 04 N N 4.10
R0076 09 Y N
R454Z 04 1/1/2009 N 19.11
S0017 04 N Y N 1.01 6 6.06
S0021 04 Y Y N
S0023 04 N Y N 1.04 4 4.16
S0028 04 N Y N 1.24 2 2.48
S0030 04 N Y N 27.61 3 82.83
S0032 04 N Y N 6.58 3 19.74
Wednesday, April 01, 2009 Page 455 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
S0034 04 N Y N 27.50 2 55.00
S0039 04 N Y N 5.86 12 70.32
S0040 04 N Y N 15.64 10 156.40
S0073 04 N Y N 14.90 16 238.40
S0074 04 N Y N 7.28 12 87.36
S0077 04 N Y N 2.74 6 16.44
S0078 04 N Y N 109.50 2 219.00
S0080 04 N Y N 40.10 1 40.10
S0081 04 N Y N 2.16 12 25.92
S0088 04 N Y N 25.42 6 152.52
S0092 04 N Y N 97.36 1 97.36
S0093 04 N Y N 9.05 1 9.05
S0142 04 Y Y N
S0145 04 Y Y N
S0146 04 Y Y N
S0155 04 Y Y N
S0162 04 N N 341.92
S0166 04 N Y N 6.07 4 24.28
S0190 04 N Y N 306.10
S0191 04 N Y N 2.40
S0195 04 N N 72.27
Wednesday, April 01, 2009 Page 456 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax Surg Child Adult
S0630 04 N I 24.35
S1015 04 Y N
S1016 04 Y N
S2066 04 1/1/2008 Y M
S2067 04 1/1/2008 Y M
S2068 04 Y M Y
S2070 04 N I 198.98
S2075 04 Y M Y
S2079 04 Y M Y Y
S2080 04 N M Y 388.70
S2083 04 N N 10.00
S2118 04 1/1/2009 Y N
S2225 04 N I 43.80 17.00
S2270 04 1/1/2009 Y N
S2325 04 Y M Y
S3626 04 Y N
S3628 04 4/1/2008
S3711 04 1/1/2009 Y N
S4981 04 Y I
S4989 04 Y N
S4990 09 Y N
Wednesday, April 01, 2009 Page 457 of 458

Hcpcs Note ProgCov Eff Date HP NDC Ind SurgInd M1 (26) M2 (TC) Assist Surg Co-Surg Unitprice MaxQty StateMax
Surg Child Adult
S4993
04
N
Y
N
1.35
91
122.85
S9123
09
Y
N
S9124
09
Y
N
S9125
09
Y
N
S9127
09
Y
N
S9460
09
Y
N
S9474
09
Y
N
S9480
04
N
N
T1015
D
04
Y
N
0.0000
1
T1029
04
N
N
Y
41.30
Wednesday, April 01, 2009 Page 458 of 458