2012 Medicare Physician Fee Schedule for ... - WPS Medicare

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGED7111 73.79 70.10 80.62D7140 73.79 70.10 80.62D7210 156.25 148.44 170.71D7220 156.25 148.44 170.71D7230 255.89 243.10 279.57D7240 255.89 243.10 279.57G0101 35.89 34.10 39.22# G0101 26.46 25.14 28.91G0102 18.40 17.48 20.10# G0102 8.66 8.23 9.46G0104 135.16 128.40 147.66# G0104 62.59 59.46 68.38G0105 384.26 365.05 419.81# G0105 216.18 205.37 236.18G0105 53 135.16 128.40 147.66# G0105 53 62.59 59.46 68.38G0106 205.75 195.46 224.78G0106 TC 159.33 151.36 174.06G0106 26 46.41 44.09 50.70G0108 51.93 49.33 56.73G0109 15.78 14.99 17.24G0117 49.08 46.63 53.62G0118 34.11 32.40 37.26G0120 205.75 195.46 224.78G0120 TC 159.33 151.36 174.06G0120 26 46.41 44.09 50.70G0121 384.26 365.05 419.81# G0121 216.18 205.37 236.18G0121 53 135.16 128.40 147.66# G0121 53 62.59 59.46 68.38G0124 28.27 26.86 30.89G0127 20.92 19.87 22.85# G0127 7.72 7.33 8.43G0128 9.37 8.90 10.24G0130 32.09 30.49 35.06G0130 TC 21.41 20.34 23.39G0130 26 10.68 10.15 11.67G0141 28.27 26.86 30.89G0166 139.51 132.53 152.41# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.1 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEG0168 90.24 85.73 98.59# G0168 25.83 24.54 28.22G0179 39.03 37.08 42.64G0180 50.65 48.12 55.34G0181 101.79 96.70 111.21G0182 103.05 97.90 112.59G0202 131.21 124.65 143.35G0202 TC 97.13 92.27 106.11G0202 26 34.08 32.38 37.24G0204 158.41 150.49 173.06G0204 TC 115.98 110.18 126.71G0204 26 42.43 40.31 46.36G0206 125.24 118.98 136.83G0206 TC 91.16 86.60 99.59G0206 26 34.08 32.38 37.24G0237 9.47 9.00 10.35G0238 10.10 9.60 11.04G0239 11.67 11.09 12.75G0245 61.62 58.54 67.32# G0245 41.51 39.43 45.34G0246 35.89 34.10 39.22# G0246 20.81 19.77 22.74G0247 61.52 58.44 67.21# G0247 23.50 22.33 25.68G0248 115.03 109.28 125.67G0249 105.92 100.62 115.71G0250 9.00 8.55 9.83G0268 49.82 47.33 54.43# G0268 31.59 30.01 34.51G0270 28.66 27.23 31.31# G0270 26.46 25.14 28.91G0271 14.53 13.80 15.87# G0271 14.21 13.50 15.53G0275 12.33 11.71 13.47G0278 12.33 11.71 13.47G0281 12.77 12.13 13.95G0283 12.77 12.13 13.95G0288 57.86 54.97 63.22G0289 86.38 82.06 94.37# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.2 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEG0329 9.32 8.85 10.18G0339 407.71 387.32 445.42G0340 667.43 634.06 729.17G0341 961.97 913.87 1,050.95# G0341 319.19 303.23 348.71G0342 638.30 606.39 697.35G0343 1,103.90 1,048.71 1,206.02G0364 11.78 11.19 12.87# G0364 8.64 8.21 9.44C G0365 152.60 144.97 166.72C G0365 TC 140.48 133.46 153.48G0365 26 12.11 11.50 13.23G0372 9.29 8.83 10.15# G0372 8.35 7.93 9.12G0389 105.39 100.12 115.14G0389 TC 77.65 73.77 84.84G0389 26 27.75 26.36 30.31G0396 33.63 31.95 36.74# G0396 32.06 30.46 35.03G0397 66.32 63.00 72.45# G0397 64.75 61.51 70.74G0398 198.44 188.52 216.80G0398 TC 116.79 110.95 127.59G0398 26 81.65 77.57 89.21G0399 198.44 188.52 216.80G0399 TC 116.79 110.95 127.59G0399 26 81.65 77.57 89.21G0400 198.44 188.52 216.80G0400 TC 116.79 110.95 127.59G0400 26 81.65 77.57 89.21G0402 150.85 143.31 164.81# G0402 121.32 115.25 132.54G0403 18.14 17.23 19.81# G0403 17.82 16.93 19.47G0404 9.79 9.30 10.70G0405 8.35 7.93 9.12# G0405 8.04 7.64 8.79G0406 37.43 35.56 40.89G0407 68.44 65.02 74.77# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.3 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEG0408 98.20 93.29 107.28G0409 9.16 8.70 10.01G0412 706.39 671.07 771.73G0413 1,035.38 983.61 1,131.15G0414 981.91 932.81 1,072.73G0415 1,346.58 1,279.25 1,471.14G0416 627.92 596.52 686.00G0416 TC 451.19 428.63 492.92G0416 26 176.72 167.88 193.06G0417 1,221.12 1,160.06 1,334.07G0417 TC 880.97 836.92 962.46G0417 26 340.14 323.13 371.60G0418 2,094.73 1,989.99 2,288.49G0418 TC 1,504.28 1,429.07 1,643.43G0418 26 590.45 560.93 645.07G0419 2,486.36 2,362.04 2,716.35G0419 TC 1,805.25 1,714.99 1,972.24G0419 26 681.11 647.05 744.11G0420 103.81 98.62 113.41G0421 24.08 22.88 26.31G0422 67.48 64.11 73.73G0423 67.48 64.11 73.73G0424 29.47 28.00 32.20# G0424 14.08 13.38 15.39G0425 97.66 92.78 106.70G0426 132.34 125.72 144.58G0427 194.40 184.68 212.38G0429 98.56 93.63 107.67# G0429 73.43 69.76 80.22G0436 13.25 12.59 14.48# G0436 11.67 11.09 12.75G0437 27.54 26.16 30.08# G0437 25.34 24.07 27.68G0438 160.59 152.56 175.44G0439 106.50 101.18 116.36G0442 16.54 15.71 18.07# G0442 9.00 8.55 9.83G0443 24.58 23.35 26.85# G0443 22.69 21.56 24.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.4 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEG0444 16.54 15.71 18.07# G0444 9.00 8.55 9.83G0445 24.58 23.35 26.85# G0445 22.69 21.56 24.79G0446 24.58 23.35 26.85# G0446 22.69 21.56 24.79G0447 24.58 23.35 26.85# G0447 22.69 21.56 24.79G0451 9.16 8.70 10.01M0064 46.57 44.24 50.88# M0064 15.16 14.40 16.56P3001 28.27 26.86 30.89Q0035 17.51 16.63 19.12Q0035 TC 9.47 9.00 10.35Q0035 26 8.04 7.64 8.79Q0091 42.27 40.16 46.18# Q0091 18.71 17.77 20.44Q0092 20.78 19.74 22.70R0070 168.41 159.99 183.99R0075 168.41 159.99 183.990050T 735.95 699.15 804.020073T 439.26 417.30 479.900075T 5,830.41 5,538.89 6,369.720075T TC 4,664.33 4,431.11 5,095.780075T 26 1,166.08 1,107.78 1,273.950076T 5,830.41 5,538.89 6,369.720076T TC 4,664.33 4,431.11 5,095.780076T 26 1,166.08 1,107.78 1,273.950163T 1,796.19 1,706.38 1,962.340171T 782.44 743.32 854.820172T 149.51 142.03 163.3310021 139.51 132.53 152.41# 10021 69.45 65.98 75.8810022 130.32 123.80 142.37# 10022 63.72 60.53 69.6110040 98.32 93.40 107.41# 10040 86.06 81.76 94.0210060 108.10 102.70 118.11# 10060 90.82 86.28 99.22# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.5 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE10061 190.44 180.92 208.06# 10061 167.82 159.43 183.3410080 165.04 156.79 180.31# 10080 97.50 92.63 106.5210081 256.04 243.24 279.73# 10081 166.50 158.18 181.9110120 132.88 126.24 145.18# 10120 89.52 85.04 97.8010121 258.98 246.03 282.93# 10121 180.13 171.12 196.7910140 152.17 144.56 166.24# 10140 113.52 107.84 124.0210160 122.20 116.09 133.50# 10160 92.04 87.44 100.5610180 233.04 221.39 254.60# 10180 173.35 164.68 189.3811000 50.83 48.29 55.53# 11000 28.53 27.10 31.1711001 20.41 19.39 22.30# 11001 14.13 13.42 15.4311004 574.61 545.88 627.7611005 775.29 736.53 847.0111006 700.06 665.06 764.8211008 272.17 258.56 297.3411010 468.73 445.29 512.08# 11010 275.20 261.44 300.6611011 513.57 487.89 561.07# 11011 296.17 281.36 323.5611012 680.81 646.77 743.79# 11012 419.42 398.45 458.2211042 103.20 98.04 112.75# 11042 58.27 55.36 63.6611043 222.95 211.80 243.57# 11043 155.40 147.63 169.7711044 309.95 294.45 338.62# 11044 232.67 221.04 254.2011045 39.56 37.58 43.22# 11045 26.68 25.35 29.1511046 69.88 66.39 76.35# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.6 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 11046 54.49 51.77 59.5411047 118.20 112.29 129.13# 11047 96.52 91.69 105.4411055 47.14 44.78 51.50# 11055 19.81 18.82 21.6411056 52.98 50.33 57.88# 11056 22.82 21.68 24.9311057 66.72 63.38 72.89# 11057 35.93 34.13 39.2511100 98.49 93.57 107.61# 11100 48.22 45.81 52.6811101 31.48 29.91 34.40# 11101 24.26 23.05 26.5111200 82.18 78.07 89.78# 11200 69.30 65.84 75.7211201 18.24 17.33 19.93# 11201 16.35 15.53 17.8611300 66.09 62.79 72.21# 11300 29.33 27.86 32.0411301 88.86 84.42 97.08# 11301 49.59 47.11 54.1811302 106.18 100.87 116.00# 11302 61.57 58.49 67.2611303 125.41 119.14 137.01# 11303 72.95 69.30 79.7011305 66.09 62.79 72.21# 11305 32.48 30.86 35.4911306 91.11 86.55 99.53# 11306 52.47 49.85 57.3311307 107.04 101.69 116.94# 11307 62.75 59.61 68.5511308 118.75 112.81 129.73# 11308 72.25 68.64 78.9411310 81.27 77.21 88.79# 11310 42.31 40.19 46.2211311 102.10 97.00 111.55# 11311 61.88 58.79 67.6111312 118.40 112.48 129.35# 11312 71.59 68.01 78.21# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.7 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE11313 147.44 140.07 161.08# 11313 95.60 90.82 104.4411400 115.11 109.35 125.75# 11400 75.84 72.05 82.8611401 140.38 133.36 153.36# 11401 99.86 94.87 109.1011402 156.42 148.60 170.89# 11402 109.92 104.42 120.0811403 180.73 171.69 197.44# 11403 141.14 134.08 154.1911404 205.61 195.33 224.63# 11404 155.66 147.88 170.0611406 295.62 280.84 322.97# 11406 236.56 224.73 258.4411420 114.83 109.09 125.45# 11420 78.38 74.46 85.6311421 148.83 141.39 162.60# 11421 107.05 101.70 116.9611422 165.92 157.62 181.26# 11422 130.11 123.60 142.1411423 192.08 182.48 209.85# 11423 151.87 144.28 165.9211424 221.54 210.46 242.03# 11424 173.48 164.81 189.5311426 317.73 301.84 347.12# 11426 265.58 252.30 290.1511440 126.39 120.07 138.08# 11440 98.11 93.20 107.1811441 159.14 151.18 173.86# 11441 126.47 120.15 138.1711442 179.19 170.23 195.76# 11442 140.86 133.82 153.8911443 214.11 203.40 233.91# 11443 172.96 164.31 188.9611444 269.19 255.73 294.09# 11444 220.81 209.77 241.2411446 371.88 353.29 406.28# 11446 315.01 299.26 344.1511450 355.05 337.30 387.90# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.8 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 11450 240.07 228.07 262.2811451 455.60 432.82 497.74# 11451 311.40 295.83 340.2011462 350.77 333.23 383.21# 11462 231.70 220.12 253.1411463 461.79 438.70 504.51# 11463 313.81 298.12 342.8411470 387.19 367.83 423.00# 11470 269.69 256.21 294.6411471 482.62 458.49 527.26# 11471 336.22 319.41 367.3211600 179.93 170.93 196.57# 11600 114.89 109.15 125.5211601 216.52 205.69 236.54# 11601 144.57 137.34 157.9411602 236.04 224.24 257.88# 11602 159.07 151.12 173.7911603 268.98 255.53 293.86# 11603 189.50 180.03 207.0311604 299.30 284.34 326.99# 11604 209.13 198.67 228.4711606 427.52 406.14 467.06# 11606 310.65 295.12 339.3911620 182.78 173.64 199.69# 11620 116.49 110.67 127.2711621 218.11 207.20 238.28# 11621 145.85 138.56 159.3411622 244.41 232.19 267.02# 11622 167.44 159.07 182.9311623 287.05 272.70 313.61# 11623 206.94 196.59 226.0811624 323.81 307.62 353.76# 11624 234.90 223.16 256.6311626 392.12 372.51 428.39# 11626 289.38 274.91 316.1511640 189.14 179.68 206.63# 11640 121.28 115.22 132.5011641 226.93 215.58 247.92# 11641 153.10 145.45 167.27# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.9 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE11642 259.51 246.53 283.51# 11642 180.03 171.03 196.6811643 307.28 291.92 335.71# 11643 226.22 214.91 247.1511644 379.65 360.67 414.77# 11644 281.00 266.95 306.9911646 497.59 472.71 543.62# 11646 390.77 371.23 426.9111719 20.92 19.87 22.85# 11719 7.72 7.33 8.4311720 29.89 28.40 32.66# 11720 14.81 14.07 16.1811721 41.83 39.74 45.70# 11721 24.86 23.62 27.1611730 91.88 87.29 100.38# 11730 50.41 47.89 55.0711732 34.29 32.58 37.47# 11732 20.47 19.45 22.3711740 45.10 42.85 49.28# 11740 30.65 29.12 33.4911750 208.71 198.27 228.01# 11750 166.61 158.28 182.0211752 302.06 286.96 330.00# 11752 251.48 238.91 274.7511755 126.51 120.18 138.21# 11755 77.18 73.32 84.3211760 215.11 204.35 235.00# 11760 129.35 122.88 141.3111762 263.09 249.94 287.43# 11762 181.41 172.34 198.1911765 150.94 143.39 164.90# 11765 86.85 82.51 94.8911770 259.95 246.95 283.99# 11770 177.32 168.45 193.7211771 540.50 513.48 590.50# 11771 417.35 396.48 455.9511772 655.22 622.46 715.83# 11772 550.29 522.78 601.2011900 53.23 50.57 58.16# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.10 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 11900 30.93 29.38 33.7911901 67.36 63.99 73.59# 11901 47.88 45.49 52.3111920 169.13 160.67 184.77# 11920 114.15 108.44 124.7111921 194.45 184.73 212.44# 11921 133.82 127.13 146.2011922 58.86 55.92 64.31# 11922 29.33 27.86 32.0411950 68.36 64.94 74.68# 11950 47.62 45.24 52.0311951 102.65 97.52 112.15# 11951 74.37 70.65 81.2511952 137.26 130.40 149.96# 11952 101.76 96.67 111.1711954 155.50 147.73 169.89# 11954 114.98 109.23 125.6111960 875.57 831.79 956.5611970 600.58 570.55 656.1311971 450.38 427.86 492.04# 11971 308.06 292.66 336.5611976 140.62 133.59 153.63# 11976 95.38 90.61 104.2011980 100.84 95.80 110.17# 11980 79.79 75.80 87.1711981 130.11 123.60 142.14# 11981 80.79 76.75 88.2611982 146.29 138.98 159.83# 11982 96.02 91.22 104.9011983 209.88 199.39 229.30# 11983 168.73 160.29 184.3312001 89.29 84.83 97.55# 12001 48.77 46.33 53.2812002 106.98 101.63 116.87# 12002 63.62 60.44 69.5112004 126.55 120.22 138.25# 12004 78.48 74.56 85.7412005 163.89 155.70 179.06# 12005 104.82 99.58 114.52# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.11 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE12006 197.74 187.85 216.03# 12006 128.00 121.60 139.8412007 230.00 218.50 251.28# 12007 156.17 148.36 170.6112011 107.42 102.05 117.36# 12011 59.98 56.98 65.5312013 117.61 111.73 128.49# 12013 67.34 63.97 73.5712014 138.61 131.68 151.43# 12014 84.58 80.35 92.4012015 170.82 162.28 186.62# 12015 104.54 99.31 114.2112016 212.58 201.95 232.24# 12016 140.63 133.60 153.6412017 161.60 153.52 176.5512018 187.32 177.95 204.6412020 261.99 248.89 286.22# 12020 181.56 172.48 198.3512021 159.18 151.22 173.90# 12021 136.25 129.44 148.8612031 223.92 212.72 244.63# 12031 148.21 140.80 161.9212032 289.67 275.19 316.47# 12032 189.77 180.28 207.3212034 295.53 280.75 322.86# 12034 200.65 190.62 219.2112035 361.44 343.37 394.88# 12035 233.89 222.20 255.5312036 402.79 382.65 440.05# 12036 274.61 260.88 300.0112037 453.00 430.35 494.90# 12037 320.73 304.69 350.3912041 228.58 217.15 249.72# 12041 151.93 144.33 165.9812042 276.08 262.28 301.62# 12042 194.71 184.97 212.7212044 336.42 319.60 367.54# 12044 208.87 198.43 228.1912045 374.62 355.89 409.27# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.12 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 12045 257.12 244.26 280.9012046 428.89 407.45 468.57# 12046 294.42 279.70 321.6612047 493.39 468.72 539.03# 12047 331.28 314.72 361.9312051 247.29 234.93 270.17# 12051 167.81 159.42 183.3312052 283.56 269.38 309.79# 12052 201.25 191.19 219.8712053 327.47 311.10 357.77# 12053 212.17 201.56 231.7912054 348.89 331.45 381.17# 12054 223.85 212.66 244.5612055 443.00 420.85 483.98# 12055 289.38 274.91 316.1512056 515.18 489.42 562.83# 12056 359.35 341.38 392.5912057 590.03 560.53 644.61# 12057 390.85 371.31 427.0113100 299.83 284.84 327.57# 13100 227.88 216.49 248.9613101 380.04 361.04 415.20# 13101 277.00 263.15 302.6213102 104.93 99.68 114.63# 13102 74.14 70.43 80.9913120 311.71 296.12 340.54# 13120 238.82 226.88 260.9113121 424.59 403.36 463.86# 13121 318.71 302.77 348.1913122 115.34 109.57 126.01# 13122 84.86 80.62 92.7113131 344.10 326.90 375.94# 13131 268.39 254.97 293.2213132 557.77 529.88 609.36# 13132 457.87 434.98 500.2313133 162.31 154.19 177.32# 13133 130.27 123.76 142.3213150 343.63 326.45 375.42# 13150 268.23 254.82 293.04# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.13 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE13151 389.58 370.10 425.62# 13151 309.16 293.70 337.7613152 539.16 512.20 589.03# 13152 414.44 393.72 452.7813153 179.66 170.68 196.28# 13153 141.02 133.97 154.0713160 790.98 751.43 864.1414000 601.32 571.25 656.94# 14000 493.25 468.59 538.8814001 774.30 735.59 845.93# 14001 644.86 612.62 704.5114020 674.32 640.60 736.69# 14020 559.65 531.67 611.4214021 844.36 802.14 922.46# 14021 710.84 675.30 776.6014040 740.69 703.66 809.21# 14040 626.65 595.32 684.6214041 915.16 869.40 999.81# 14041 769.70 731.22 840.9014060 753.52 715.84 823.22# 14060 664.29 631.08 725.7414061 981.72 932.63 1,072.52# 14061 821.49 780.42 897.4814301 1,056.35 1,003.53 1,154.06# 14301 880.42 836.40 961.8614302 221.83 210.74 242.3514350 703.95 668.75 769.0615002 329.79 313.30 360.30# 15002 223.29 212.13 243.9515003 72.32 68.70 79.01# 15003 45.30 43.04 49.5015004 381.65 362.57 416.96# 15004 266.35 253.03 290.9815005 120.40 114.38 131.54# 15005 90.56 86.03 98.9315040 243.96 231.76 266.52# 15040 124.89 118.65 136.4515050 545.93 518.63 596.42# 15050 435.34 413.57 475.61# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.14 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE15100 836.76 794.92 914.16# 15100 705.44 670.17 770.7015101 179.62 170.64 196.24# 15101 109.24 103.78 119.3515110 838.36 796.44 915.91# 15110 735.94 699.14 804.0115111 112.30 106.69 122.69# 15111 101.30 96.24 110.6815115 842.08 799.98 919.98# 15115 744.38 707.16 813.2315116 167.01 158.66 182.46# 15116 152.56 144.93 166.6715120 837.42 795.55 914.88# 15120 697.61 662.73 762.1415121 207.20 196.84 226.37# 15121 132.75 126.11 145.0315130 654.17 621.46 714.68# 15130 554.26 526.55 605.5315131 99.72 94.73 108.94# 15131 91.55 86.97 100.0215135 846.92 804.57 925.26# 15135 751.10 713.55 820.5815136 84.23 80.02 92.02# 15136 78.57 74.64 85.8415150 674.46 640.74 736.85# 15150 619.16 588.20 676.4315151 118.86 112.92 129.86# 15151 109.75 104.26 119.9015152 162.93 154.78 178.00# 15152 153.50 145.83 167.7015155 666.23 632.92 727.86# 15155 611.25 580.69 667.7915156 175.71 166.92 191.96# 15156 167.22 158.86 182.6915157 176.41 167.59 192.73# 15157 164.15 155.94 179.3315200 797.49 757.62 871.26# 15200 655.49 622.72 716.1315201 143.93 136.73 157.24# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.15 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 15201 79.52 75.54 86.8715220 745.04 707.79 813.96# 15220 605.55 575.27 661.5615221 132.44 125.82 144.69# 15221 71.81 68.22 78.4515240 901.58 856.50 984.98# 15240 785.33 746.06 857.9715241 178.68 169.75 195.21# 15241 111.45 105.88 121.7615260 976.78 927.94 1,067.13# 15260 844.51 802.28 922.6215261 209.06 198.61 228.40# 15261 140.58 133.55 153.5815271 138.38 131.46 151.18# 15271 86.23 81.92 94.2115272 26.20 24.89 28.62# 15272 17.09 16.24 18.68# 15273 205.47 195.20 224.4815273 285.89 271.60 312.3415274 67.00 63.65 73.20# 15274 43.44 41.27 47.4615275 149.28 141.82 163.09# 15275 100.27 95.26 109.5515276 32.71 31.07 35.73# 15276 24.54 23.31 26.8115277 288.63 274.20 315.33# 15277 212.91 202.26 232.6015278 78.98 75.03 86.28# 15278 53.85 51.16 58.8315570 880.27 836.26 961.70# 15570 720.36 684.34 786.9915572 852.40 809.78 931.25# 15572 726.74 690.40 793.9615574 883.45 839.28 965.17# 15574 752.13 714.52 821.7015576 782.13 743.02 854.47# 15576 661.17 628.11 722.3315600 313.16 297.50 342.13# 15600 201.94 191.84 220.62# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.16 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE15610 336.20 319.39 367.30# 15610 235.04 223.29 256.7815620 422.22 401.11 461.28# 15620 316.35 300.53 345.6115630 444.02 421.82 485.09# 15630 339.40 322.43 370.7915650 491.40 466.83 536.85# 15650 377.67 358.79 412.6115731 1,110.92 1,055.37 1,213.68# 15731 1,004.73 954.49 1,097.6615732 1,274.79 1,211.05 1,392.71# 15732 1,125.56 1,069.28 1,229.6715734 1,484.06 1,409.86 1,621.34# 15734 1,320.38 1,254.36 1,442.5115736 1,305.77 1,240.48 1,426.55# 15736 1,142.41 1,085.29 1,248.0815738 1,393.05 1,323.40 1,521.91# 15738 1,238.48 1,176.56 1,353.0415740 984.74 935.50 1,075.83# 15740 842.11 800.00 920.0015750 898.94 853.99 982.0915756 2,335.76 2,218.97 2,551.8215757 2,294.54 2,179.81 2,506.7815758 2,298.28 2,183.37 2,510.8815760 828.22 786.81 904.83# 15760 698.79 663.85 763.4315770 658.66 625.73 719.5915775 280.09 266.09 306.00# 15775 208.46 198.04 227.7515776 386.78 367.44 422.56# 15776 288.45 274.03 315.1315777 211.00 200.45 230.5215780 798.24 758.33 872.08# 15780 615.08 584.33 671.9815781 523.69 497.51 572.14# 15781 418.75 397.81 457.4815782 567.07 538.72 619.53# 15782 412.82 392.18 451.0115783 464.89 441.65 507.90# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.17 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 15783 363.10 344.95 396.6915786 233.61 221.93 255.22# 15786 135.27 128.51 147.7915787 46.30 43.99 50.59# 15787 17.40 16.53 19.0115788 431.34 409.77 471.24# 15788 239.07 227.12 261.1915789 532.11 505.50 581.33# 15789 409.27 388.81 447.1315792 410.38 389.86 448.34# 15792 252.04 239.44 275.3615793 465.56 442.28 508.62# 15793 352.15 334.54 384.7215819 741.45 704.38 810.0415820 548.82 521.38 599.59# 15820 499.81 474.82 546.0415821 587.21 557.85 641.53# 15821 531.92 505.32 581.1215822 426.17 404.86 465.59# 15822 378.10 359.20 413.0815823 593.74 564.05 648.66# 15823 538.77 511.83 588.6015830 1,149.96 1,092.46 1,256.3315832 889.05 844.60 971.2915833 858.97 816.02 938.4215834 871.02 827.47 951.5915835 837.84 795.95 915.3415836 737.17 700.31 805.3615837 830.49 788.97 907.32# 15837 693.51 658.83 757.6515838 562.54 534.41 614.5715839 848.29 805.88 926.76# 15839 718.85 682.91 785.3515840 1,003.77 953.58 1,096.6215841 1,595.33 1,515.56 1,742.8915842 2,449.45 2,326.98 2,676.0315845 962.16 914.05 1,051.1615847 311.53 295.95 340.3415851 92.70 88.07 101.28# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.18 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 15851 45.58 43.30 49.8015852 46.30 43.99 50.5915860 109.73 104.24 119.8815920 595.73 565.94 650.8315922 765.22 726.96 836.0015931 663.76 630.57 725.1615933 820.70 779.67 896.6215934 904.83 859.59 988.5315935 1,085.74 1,031.45 1,186.1715936 879.67 835.69 961.0415937 1,023.78 972.59 1,118.4815940 679.81 645.82 742.6915941 879.59 835.61 960.9515944 880.40 836.38 961.8415945 974.25 925.54 1,064.3715946 1,618.42 1,537.50 1,768.1315950 567.74 539.35 620.2515951 855.01 812.26 934.1015952 892.64 848.01 975.2115953 976.26 927.45 1,066.5715956 1,137.34 1,080.47 1,242.5415958 1,159.39 1,101.42 1,266.63# 16000 45.34 43.07 49.5316000 66.39 63.07 72.5316020 76.82 72.98 83.93# 16020 52.00 49.40 56.8116025 141.09 134.04 154.15# 16025 109.36 103.89 119.4716030 174.11 165.40 190.21# 16030 129.82 123.33 141.8316035 198.29 188.38 216.6416036 82.56 78.43 90.1917000 76.87 73.03 83.98# 17000 53.94 51.24 58.9317003 6.83 6.49 7.46# 17003 4.32 4.10 4.7217004 164.84 156.60 180.09# 17004 128.72 122.28 140.6217106 328.04 311.64 358.39# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.19 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 17106 267.41 254.04 292.1517107 423.03 401.88 462.16# 17107 343.23 326.07 374.9817108 618.97 588.02 676.22# 17108 514.36 488.64 561.9417110 104.65 99.42 114.33# 17110 66.64 63.31 72.8117111 124.41 118.19 135.92# 17111 82.31 78.19 89.9217250 73.60 69.92 80.41# 17250 35.27 33.51 38.5417260 90.45 85.93 98.82# 17260 67.20 63.84 73.4217261 137.30 130.44 150.01# 17261 89.55 85.07 97.8317262 167.21 158.85 182.68# 17262 113.80 108.11 124.3317263 182.99 173.84 199.92# 17263 126.44 120.12 138.1417264 196.41 186.59 214.58# 17264 135.15 128.39 147.6517266 222.53 211.40 243.11# 17266 157.50 149.63 172.0717270 143.45 136.28 156.72# 17270 97.58 92.70 106.6117271 156.61 148.78 171.10# 17271 108.85 103.41 118.9217272 178.54 169.61 195.05# 17272 125.45 119.18 137.0617273 199.26 189.30 217.70# 17273 141.77 134.68 154.8817274 235.59 223.81 257.38# 17274 173.38 164.71 189.4217276 274.49 260.77 299.89# 17276 208.83 198.39 228.1517280 134.47 127.75 146.91# 17280 88.60 84.17 96.8017281 170.55 162.02 186.32# 17281 122.49 116.37 133.83# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.20 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE17282 196.10 186.30 214.25# 17282 141.43 134.36 154.5117283 235.77 223.98 257.58# 17283 176.70 167.87 193.0517284 269.13 255.67 294.02# 17284 205.67 195.39 224.7017286 349.66 332.18 382.01# 17286 282.11 268.00 308.2017311 633.20 601.54 691.77# 17311 373.70 355.02 408.2717312 376.89 358.05 411.76# 17312 198.44 188.52 216.8017313 577.35 548.48 630.75# 17313 335.13 318.37 366.1317314 349.41 331.94 381.73# 17314 184.16 174.95 201.1917315 76.03 72.23 83.06# 17315 52.15 49.54 56.9717340 49.01 46.56 53.54# 17340 46.81 44.47 51.1417360 124.62 118.39 136.15# 17360 96.66 91.83 105.6019000 104.22 99.01 113.86# 19000 42.96 40.81 46.9319001 25.54 24.26 27.90# 19001 21.14 20.08 23.0919020 443.07 420.92 484.06# 19020 291.95 277.35 318.9519030 152.99 145.34 167.14# 19030 75.39 71.62 82.3619100 141.28 134.22 154.35# 19100 68.40 64.98 74.7319101 323.45 307.28 353.37# 19101 214.12 203.41 233.9219102 202.06 191.96 220.75# 19102 99.96 94.96 109.2019103 518.18 492.27 566.11# 19103 187.05 177.70 204.3619105 2,604.43 2,474.21 2,845.34# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.21 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 19105 193.83 184.14 211.7619110 457.66 434.78 500.00# 19110 326.97 310.62 357.2119112 432.12 410.51 472.09# 19112 297.65 282.77 325.1919120 468.16 444.75 511.46# 19120 396.84 377.00 433.5519125 519.72 493.73 567.79# 19125 441.18 419.12 481.9919126 158.47 150.55 173.1319260 1,180.63 1,121.60 1,289.8419271 1,602.88 1,522.74 1,751.1519272 1,770.72 1,682.18 1,934.5119290 151.27 143.71 165.27# 19290 62.67 59.54 68.4719291 64.42 61.20 70.38# 19291 30.80 29.26 33.6519295 84.25 80.04 92.0519296 3,802.94 3,612.79 4,154.71# 19296 205.41 195.14 224.4119297 92.64 88.01 101.2119298 1,088.93 1,034.48 1,189.65# 19298 314.19 298.48 343.2519300 495.81 471.02 541.67# 19300 392.45 372.83 428.7519301 628.18 596.77 686.2919302 868.62 825.19 948.9719303 973.82 925.13 1,063.9019304 551.91 524.31 602.9619305 1,095.71 1,040.92 1,197.0619306 1,158.17 1,100.26 1,265.3019307 1,154.97 1,097.22 1,261.8019316 762.22 724.11 832.7319318 1,101.69 1,046.61 1,203.6019324 474.65 450.92 518.5619325 637.70 605.82 696.6919328 487.68 463.30 532.8019330 623.47 592.30 681.1519340 933.14 886.48 1,019.45# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.22 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE19342 913.27 867.61 997.7519350 810.91 770.36 885.91# 19350 666.40 633.08 728.0419355 680.76 646.72 743.73# 19355 555.72 527.93 607.1219357 1,473.63 1,399.95 1,609.9419361 1,590.20 1,510.69 1,737.2919364 2,757.67 2,619.79 3,012.7619366 1,362.78 1,294.64 1,488.8419367 1,788.22 1,698.81 1,953.6319368 2,208.38 2,097.96 2,412.6519369 2,044.12 1,941.91 2,233.2019370 677.34 643.47 739.9919371 775.47 736.70 847.2119380 764.04 725.84 834.7219396 267.43 254.06 292.17# 19396 143.64 136.46 156.9320005 289.72 275.23 316.51# 20005 225.63 214.35 246.5020100 591.14 561.58 645.8220101 420.00 399.00 458.85# 20101 202.91 192.76 221.6720102 453.30 430.64 495.24# 20102 246.58 234.25 269.3920103 558.03 530.13 609.65# 20103 344.39 327.17 376.2520150 973.73 925.04 1,063.8020200 195.54 185.76 213.62# 20200 93.12 88.46 101.7320205 267.19 253.83 291.90# 20205 150.00 142.50 163.8820206 230.86 219.32 252.22# 20206 57.76 54.87 63.1020220 157.50 149.63 172.07# 20220 71.11 67.55 77.6820225 547.35 519.98 597.98# 20225 108.78 103.34 118.8420240 216.02 205.22 236.0020245 611.92 581.32 668.52# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.23 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE20250 373.10 354.45 407.6220251 404.84 384.60 442.2920500 103.54 98.36 113.11# 20500 84.69 80.46 92.5320501 114.81 109.07 125.43# 20501 37.53 35.65 41.0020520 191.20 181.64 208.89# 20520 141.25 134.19 154.3220525 458.26 435.35 500.65# 20525 243.37 231.20 265.8820526 72.28 68.67 78.97# 20526 55.31 52.54 60.4220527 73.43 69.76 80.22# 20527 58.35 55.43 63.7420550 55.14 52.38 60.24# 20550 40.06 38.06 43.7720551 56.40 53.58 61.62# 20551 41.32 39.25 45.1420552 51.72 49.13 56.50# 20552 36.32 34.50 39.6820553 59.18 56.22 64.65# 20553 40.96 38.91 44.7520555 324.43 308.21 354.4420600 52.03 49.43 56.84# 20600 37.58 35.70 41.0620605 54.96 52.21 60.04# 20605 39.57 37.59 43.2320610 67.07 63.72 73.28# 20610 48.54 46.11 53.0320612 56.58 53.75 61.81# 20612 40.56 38.53 44.3120615 221.50 210.43 241.99# 20615 154.58 146.85 168.8820650 190.89 181.35 208.55# 20650 147.85 140.46 161.5320660 240.89 228.85 263.1820661 486.32 462.00 531.3020662 421.26 400.20 460.2320663 397.08 377.23 433.81# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.24 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE20664 841.35 799.28 919.1720665 100.56 95.53 109.86# 20665 86.42 82.10 94.4220670 364.65 346.42 398.38# 20670 143.16 136.00 156.4020680 590.79 561.25 645.44# 20680 413.28 392.62 451.5120690 567.03 538.68 619.4820692 1,070.69 1,017.16 1,169.7320693 440.66 418.63 481.4220694 406.45 386.13 444.05# 20694 326.02 309.72 356.1820696 1,068.88 1,015.44 1,167.7620697 1,797.40 1,707.53 1,963.6620802 2,245.92 2,133.62 2,453.6620805 2,848.14 2,705.73 3,111.5920808 3,931.78 3,735.19 4,295.4720816 2,065.54 1,962.26 2,256.6020822 1,769.00 1,680.55 1,932.6320824 2,148.91 2,041.46 2,347.6820827 1,826.88 1,735.54 1,995.8720838 2,493.27 2,368.61 2,723.9020900 399.90 379.91 436.90# 20900 214.85 204.11 234.7320902 308.82 293.38 337.3920910 435.24 413.48 475.5020912 474.15 450.44 518.0120920 389.84 370.35 425.9020922 582.48 553.36 636.36# 20922 482.89 458.75 527.5620924 491.27 466.71 536.7220926 425.95 404.65 465.3520931 112.14 106.53 122.5120937 167.15 158.79 182.6120938 183.89 174.70 200.9120950 236.61 224.78 258.50# 20950 88.33 83.91 96.5020955 2,496.49 2,371.67 2,727.4220956 2,593.81 2,464.12 2,833.74# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.25 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE20957 2,642.93 2,510.78 2,887.4020962 2,240.76 2,128.72 2,448.0320969 2,763.88 2,625.69 3,019.5420970 2,750.61 2,613.08 3,005.0420972 2,196.52 2,086.69 2,399.6920973 2,680.73 2,546.69 2,928.6920974 70.40 66.88 76.91# 20974 47.78 45.39 52.2020975 173.43 164.76 189.4720979 51.03 48.48 55.75# 20979 32.81 31.17 35.8520982 3,516.88 3,341.04 3,842.20# 20982 374.90 356.16 409.5820985 145.65 138.37 159.1321010 717.42 681.55 783.7821011 337.12 320.26 368.30# 21011 252.61 239.98 275.9821012 329.72 313.23 360.2121013 508.38 482.96 555.40# 21013 396.22 376.41 432.8721014 511.72 486.13 559.0521015 673.55 639.87 735.8521016 1,025.86 974.57 1,120.7621025 853.73 811.04 932.70# 21025 725.55 689.27 792.6621026 587.08 557.73 641.39# 21026 479.32 455.35 523.6521029 751.52 713.94 821.03# 21029 632.45 600.83 690.9521030 492.29 467.68 537.83# 21030 400.24 380.23 437.2621031 368.21 349.80 402.27# 21031 278.67 264.74 304.4521032 374.02 355.32 408.62# 21032 276.00 262.20 301.5321034 1,295.81 1,231.02 1,415.67# 21034 1,146.89 1,089.55 1,252.9821040 494.44 469.72 540.18# 21040 400.19 380.18 437.21# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.26 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE21044 865.20 821.94 945.2321045 1,208.64 1,148.21 1,320.4421046 1,062.62 1,009.49 1,160.9121047 1,271.25 1,207.69 1,388.8421048 1,088.47 1,034.05 1,189.1621049 1,211.77 1,151.18 1,323.8621050 857.52 814.64 936.8421060 810.04 769.54 884.9721070 607.38 577.01 663.5621073 370.57 352.04 404.85# 21073 248.36 235.94 271.3321076 947.11 899.75 1,034.71# 21076 804.17 763.96 878.5521077 2,363.68 2,245.50 2,582.33# 21077 2,030.35 1,928.83 2,218.1521079 1,601.16 1,521.10 1,749.27# 21079 1,349.82 1,282.33 1,474.6821080 1,801.17 1,711.11 1,967.78# 21080 1,503.97 1,428.77 1,643.0921081 1,657.32 1,574.45 1,810.62# 21081 1,376.46 1,307.64 1,503.7921082 1,560.50 1,482.48 1,704.85# 21082 1,287.48 1,223.11 1,406.5821083 1,445.62 1,373.34 1,579.34# 21083 1,154.70 1,096.97 1,261.5221084 1,702.91 1,617.76 1,860.42# 21084 1,387.18 1,317.82 1,515.4921085 788.24 748.83 861.15# 21085 626.76 595.42 684.7321086 1,749.34 1,661.87 1,911.15# 21086 1,492.98 1,418.33 1,631.0821087 1,743.68 1,656.50 1,904.98# 21087 1,481.67 1,407.59 1,618.7321100 682.24 648.13 745.35# 21100 374.98 356.23 409.6621110 747.72 710.33 816.88# 21110 631.16 599.60 689.5421116 140.60 133.57 153.61# 21116 41.01 38.96 44.80# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.27 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE21120 654.89 622.15 715.47# 21120 524.19 497.98 572.6821121 725.63 689.35 792.75# 21121 607.82 577.43 664.0421122 623.72 592.53 681.4121123 813.14 772.48 888.3521125 2,871.47 2,727.90 3,137.09# 21125 772.52 733.89 843.9721127 3,839.41 3,647.44 4,194.56# 21127 832.21 790.60 909.1921137 742.40 705.28 811.0721138 869.66 826.18 950.1121139 1,030.80 979.26 1,126.1521141 1,361.02 1,292.97 1,486.9221142 1,388.45 1,319.03 1,516.8821143 1,441.91 1,369.81 1,575.2821145 1,490.24 1,415.73 1,628.0921146 1,712.20 1,626.59 1,870.5821147 1,604.94 1,524.69 1,753.3921150 1,606.86 1,526.52 1,755.5021151 1,875.66 1,781.88 2,049.1621154 2,113.55 2,007.87 2,309.0521155 2,115.09 2,009.34 2,310.7421159 2,463.81 2,340.62 2,691.7121160 2,567.63 2,439.25 2,805.1421172 1,771.75 1,683.16 1,935.6321175 2,273.71 2,160.02 2,484.0221179 1,426.48 1,355.16 1,558.4321180 1,540.18 1,463.17 1,682.6521181 691.63 657.05 755.6121182 1,922.68 1,826.55 2,100.5321183 2,293.38 2,178.71 2,505.5221184 2,349.57 2,232.09 2,566.9021188 1,564.01 1,485.81 1,708.6821193 1,290.15 1,225.64 1,409.4921194 1,359.50 1,291.53 1,485.2621195 1,316.23 1,250.42 1,437.9821196 1,440.46 1,368.44 1,573.7121198 1,132.11 1,075.50 1,236.83# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.28 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE21199 1,000.49 950.47 1,093.0421206 1,168.68 1,110.25 1,276.7921208 1,812.07 1,721.47 1,979.69# 21208 830.93 789.38 907.7921209 805.40 765.13 879.90# 21209 640.15 608.14 699.3621210 2,105.68 2,000.40 2,300.46# 21210 821.99 780.89 898.0221215 3,743.30 3,556.14 4,089.56# 21215 883.75 839.56 965.4921230 763.37 725.20 833.9821235 709.69 674.21 775.34# 21235 559.21 531.25 610.9421240 1,066.70 1,013.37 1,165.3821242 978.77 929.83 1,069.3021243 1,625.38 1,544.11 1,775.7321244 1,036.48 984.66 1,132.3621245 1,095.46 1,040.69 1,196.79# 21245 881.51 837.43 963.0421246 815.86 775.07 891.3321247 1,648.29 1,565.88 1,800.7621248 1,049.02 996.57 1,146.06# 21248 863.04 819.89 942.8721249 1,440.94 1,368.89 1,574.22# 21249 1,197.15 1,137.29 1,307.8821255 1,356.94 1,289.09 1,482.4521256 1,166.84 1,108.50 1,274.7821260 1,194.28 1,134.57 1,304.7621261 2,144.98 2,037.73 2,343.3921263 1,827.35 1,735.98 1,996.3821267 1,522.81 1,446.67 1,663.6721268 1,772.94 1,684.29 1,936.9321270 931.68 885.10 1,017.87# 21270 716.79 680.95 783.0921275 829.87 788.38 906.6421280 559.41 531.44 611.1621282 367.25 348.89 401.2221295 178.04 169.14 194.5121296 414.24 393.53 452.56# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.29 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE21310 117.63 111.75 128.51# 21310 27.78 26.39 30.3521315 268.57 255.14 293.41# 21315 149.50 142.03 163.3321320 248.18 235.77 271.14# 21320 133.82 127.13 146.2021325 457.57 434.69 499.8921330 554.77 527.03 606.0821335 715.53 679.75 781.7121336 631.75 600.16 690.1821337 391.61 372.03 427.83# 21337 288.25 273.84 314.9221338 734.78 698.04 802.7521339 774.79 736.05 846.4621340 799.95 759.95 873.9421343 1,193.59 1,133.91 1,304.0021344 1,573.47 1,494.80 1,719.0221345 770.99 732.44 842.31# 21345 625.53 594.25 683.3921346 901.32 856.25 984.6921347 1,085.74 1,031.45 1,186.1721348 1,083.48 1,029.31 1,183.7121355 422.55 401.42 461.63# 21355 317.30 301.44 346.6621356 482.73 458.59 527.38# 21356 368.68 350.25 402.7921360 519.12 493.16 567.1321365 1,098.39 1,043.47 1,199.9921366 1,189.82 1,130.33 1,299.8821385 678.01 644.11 740.7321386 647.68 615.30 707.6021387 731.54 694.96 799.2021390 782.77 743.63 855.1721395 964.30 916.09 1,053.5021400 181.83 172.74 198.65# 21400 149.16 141.70 162.9621401 467.19 443.83 510.40# 21401 297.54 282.66 325.0621406 545.06 517.81 595.48# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.30 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE21407 638.20 606.29 697.2321408 894.58 849.85 977.3321421 756.79 718.95 826.79# 21421 634.58 602.85 693.2821422 649.60 617.12 709.6921423 786.16 746.85 858.8821431 661.77 628.68 722.9821432 699.53 664.55 764.2321433 1,640.71 1,558.67 1,792.4721435 1,344.68 1,277.45 1,469.0721436 2,035.87 1,934.08 2,224.1921440 542.03 514.93 592.17# 21440 445.27 423.01 486.4621445 725.06 688.81 792.13# 21445 594.37 564.65 649.3521450 571.86 543.27 624.76# 21450 466.30 442.99 509.4421451 714.58 678.85 780.68# 21451 603.37 573.20 659.1821452 575.75 546.96 629.00# 21452 337.92 321.02 369.1721453 860.50 817.48 940.10# 21453 746.15 708.84 815.1721454 568.99 540.54 621.6221461 2,001.50 1,901.43 2,186.64# 21461 910.71 865.17 994.9521462 2,101.25 1,996.19 2,295.62# 21462 995.06 945.31 1,087.1121465 931.64 885.06 1,017.8221470 1,182.90 1,123.76 1,292.3221480 91.95 87.35 100.45# 21480 31.94 30.34 34.8921485 652.66 620.03 713.03# 21485 549.93 522.43 600.7921490 909.05 863.60 993.1421495 689.99 655.49 753.8121497 692.72 658.08 756.79# 21497 581.82 552.73 635.6421501 434.20 412.49 474.36# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.31 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 21501 312.62 296.99 341.5421502 520.72 494.68 568.8821510 502.92 477.77 549.44# 21550 153.42 145.75 167.6121550 248.62 236.19 271.6221552 437.76 415.87 478.2521554 717.48 681.61 783.8521555 400.37 380.35 437.40# 21555 300.46 285.44 328.2621556 515.45 489.68 563.1321557 913.34 867.67 997.8221558 1,330.99 1,264.44 1,454.1121600 557.14 529.28 608.6721610 1,169.39 1,110.92 1,277.5621615 646.27 613.96 706.0521616 835.35 793.58 912.6221620 509.69 484.21 556.8421627 541.00 513.95 591.0421630 1,238.10 1,176.20 1,352.6321632 1,226.29 1,164.98 1,339.7321685 983.75 934.56 1,074.7421700 387.48 368.11 423.3321705 618.84 587.90 676.0921720 493.91 469.21 539.5921725 468.88 445.44 512.2621740 1,175.13 1,116.37 1,283.8321742 882.18 838.07 963.7821750 696.50 661.68 760.9321800 103.76 98.57 113.36# 21800 106.59 101.26 116.4521805 258.76 245.82 282.6921810 504.37 479.15 551.0221820 133.35 126.68 145.68# 21820 136.18 129.37 148.7821825 546.50 519.18 597.0621920 248.19 235.78 271.15# 21920 157.71 149.82 172.2921925 423.92 402.72 463.13# 21925 340.35 323.33 371.83# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.32 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE21930 454.08 431.38 496.09# 21930 356.06 338.26 389.0021931 461.47 438.40 504.1621932 649.33 616.86 709.3921933 727.30 690.94 794.5821935 1,010.96 960.41 1,104.4721936 1,386.70 1,317.37 1,514.9822010 921.58 875.50 1,006.8322015 904.85 859.61 988.5522100 895.82 851.03 978.6822101 899.85 854.86 983.0922102 798.19 758.28 872.0222103 141.89 134.80 155.0222110 1,062.67 1,009.54 1,160.9722112 1,044.69 992.46 1,141.3322114 970.89 922.35 1,060.7022116 139.76 132.77 152.6922206 2,311.94 2,196.34 2,525.7922207 2,354.53 2,236.80 2,572.3222208 585.15 555.89 639.2722210 1,738.76 1,651.82 1,899.5922212 1,438.80 1,366.86 1,571.8922214 1,449.99 1,377.49 1,584.1122216 362.92 344.77 396.4922220 1,590.29 1,510.78 1,737.4022222 1,492.80 1,418.16 1,630.8822224 1,548.76 1,471.32 1,692.0222226 364.21 346.00 397.9022305 182.30 173.19 199.17# 22305 166.59 158.26 182.0022310 293.37 278.70 320.51# 22310 272.00 258.40 297.1622315 851.92 809.32 930.72# 22315 752.01 714.41 821.5722318 1,612.63 1,532.00 1,761.8022319 1,803.13 1,712.97 1,969.9222325 1,411.17 1,340.61 1,541.7022326 1,462.92 1,389.77 1,598.2422327 1,452.76 1,380.12 1,587.14# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.33 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE22328 283.34 269.17 309.5522505 116.30 110.49 127.0622520 2,108.90 2,003.46 2,303.98# 22520 502.57 477.44 549.0622521 2,097.42 1,992.55 2,291.43# 22521 477.89 454.00 522.1022522 223.19 212.03 243.8322523 7,106.95 6,751.60 7,764.34# 22523 560.03 532.03 611.8322524 7,049.54 6,697.06 7,701.62# 22524 531.83 505.24 581.0322525 4,406.29 4,185.98 4,813.88# 22525 256.77 243.93 280.5222532 1,758.88 1,670.94 1,921.5822533 1,653.69 1,571.01 1,806.6622534 362.27 344.16 395.7822548 1,935.11 1,838.35 2,114.1022551 1,706.34 1,621.02 1,864.1722552 393.14 373.48 429.5022554 1,259.21 1,196.25 1,375.6922556 1,641.81 1,559.72 1,793.6822558 1,518.63 1,442.70 1,659.1122585 336.85 320.01 368.0122590 1,556.40 1,478.58 1,700.3722595 1,481.33 1,407.26 1,618.3522600 1,265.88 1,202.59 1,382.9822610 1,235.63 1,173.85 1,349.9322612 1,573.61 1,494.93 1,719.1722614 391.65 372.07 427.8822630 1,522.28 1,446.17 1,663.1022632 319.91 303.91 349.5022633 1,830.58 1,739.05 1,999.9122634 496.91 472.06 542.8722800 1,330.87 1,264.33 1,453.9822802 2,071.51 1,967.93 2,263.1222804 2,383.20 2,264.04 2,603.6522808 1,799.70 1,709.72 1,966.1822810 2,007.91 1,907.51 2,193.6422812 2,166.02 2,057.72 2,366.38# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.34 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE22818 2,133.61 2,026.93 2,330.9722819 2,717.97 2,582.07 2,969.3822830 795.31 755.54 868.8722840 763.27 725.11 833.8822842 764.12 725.91 834.8022843 811.33 770.76 886.3722844 975.28 926.52 1,065.5022845 738.45 701.53 806.7622846 765.96 727.66 836.8122847 885.09 840.84 966.9722848 357.19 339.33 390.2322849 1,284.39 1,220.17 1,403.2022850 707.88 672.49 773.3622851 408.98 388.53 446.8122852 676.18 642.37 738.7322855 1,105.07 1,049.82 1,207.2922856 1,644.91 1,562.66 1,797.0622857 1,636.11 1,554.30 1,787.4522861 1,987.28 1,887.92 2,171.1122862 2,061.80 1,958.71 2,252.5222864 1,898.96 1,804.01 2,074.6122865 2,020.01 1,919.01 2,206.8622900 536.11 509.30 585.7022901 654.59 621.86 715.1422902 417.56 396.68 456.18# 22902 316.71 300.87 346.0022903 426.47 405.15 465.9222904 1,037.82 985.93 1,133.8222905 1,318.18 1,252.27 1,440.1123000 540.99 513.94 591.03# 23000 353.43 335.76 386.1223020 669.35 635.88 731.2623030 414.61 393.88 452.96# 23030 247.47 235.10 270.3723031 391.97 372.37 428.23# 23031 209.44 198.97 228.8223035 661.29 628.23 722.4623040 697.94 663.04 762.5023044 556.09 528.29 607.53# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.35 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE23065 210.55 200.02 230.02# 23065 165.31 157.04 180.6023066 511.83 486.24 559.18# 23066 336.84 320.00 368.0023071 409.50 389.03 447.3823073 679.16 645.20 741.9823075 420.90 399.86 459.84# 23075 301.51 286.43 329.3923076 526.76 500.42 575.4823077 1,129.78 1,073.29 1,234.2823078 1,401.61 1,331.53 1,531.2623100 479.74 455.75 524.1123101 438.14 416.23 478.6623105 617.65 586.77 674.7923106 474.17 450.46 518.0323107 639.66 607.68 698.8323120 564.79 536.55 617.0323125 684.67 650.44 748.0123130 587.45 558.08 641.7923140 512.68 487.05 560.1123145 672.22 638.61 734.4023146 595.52 565.74 650.6023150 638.19 606.28 697.2223155 767.97 729.57 839.0123156 655.19 622.43 715.7923170 534.59 507.86 584.0423172 543.53 516.35 593.8023174 732.32 695.70 800.0623180 654.29 621.58 714.8223182 637.31 605.44 696.2623184 714.35 678.63 780.4223190 548.14 520.73 598.8423195 730.92 694.37 798.5323200 1,432.07 1,360.47 1,564.5423210 1,680.72 1,596.68 1,836.1823220 1,844.25 1,752.04 2,014.8523330 226.64 215.31 247.61# 23330 146.84 139.50 160.4323331 572.53 543.90 625.49# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.36 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE23332 858.67 815.74 938.1023350 139.15 132.19 152.02# 23350 49.93 47.43 54.5423395 1,254.93 1,192.18 1,371.0123397 1,113.15 1,057.49 1,216.1123400 945.03 897.78 1,032.4523405 610.27 579.76 666.7223406 757.15 719.29 827.1823410 800.23 760.22 874.2523412 831.62 790.04 908.5523415 673.77 640.08 736.0923420 944.03 896.83 1,031.3523430 725.10 688.85 792.1823440 736.25 699.44 804.3623450 923.70 877.52 1,009.1523455 979.45 930.48 1,070.0523460 1,062.98 1,009.83 1,161.3023462 1,046.33 994.01 1,143.1123465 1,092.60 1,037.97 1,193.6723466 1,093.35 1,038.68 1,194.4823470 1,181.51 1,122.43 1,290.7923472 1,464.92 1,391.67 1,600.4223480 796.73 756.89 870.4223485 936.24 889.43 1,022.8423490 862.20 819.09 941.9523491 987.33 937.96 1,078.6523500 207.33 196.96 226.50# 23500 209.52 199.04 228.9023505 331.87 315.28 362.57# 23505 314.27 298.56 343.3423515 697.68 662.80 762.2223520 216.80 205.96 236.85# 23520 219.62 208.64 239.9423525 356.00 338.20 388.93# 23525 330.87 314.33 361.4823530 545.96 518.66 596.4623532 602.22 572.11 657.9323540 212.48 201.86 232.14# 23540 214.37 203.65 234.20# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.37 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE23545 318.91 302.96 348.40# 23545 291.27 276.71 318.2223550 551.86 524.27 602.9123552 637.59 605.71 696.5723570 219.49 208.52 239.80# 23570 225.15 213.89 245.9723575 378.70 359.77 413.74# 23575 355.77 337.98 388.6823585 955.50 907.73 1,043.8923600 307.39 292.02 335.82# 23600 287.60 273.22 314.2023605 444.14 421.93 485.22# 23605 408.96 388.51 446.7923615 860.06 817.06 939.6223616 1,219.56 1,158.58 1,332.3723620 255.11 242.35 278.70# 23620 242.54 230.41 264.9723625 359.26 341.30 392.50# 23625 336.33 319.51 367.4423630 755.86 718.07 825.7823650 293.46 278.79 320.61# 23650 270.21 256.70 295.2123655 378.77 359.83 413.8023660 564.44 536.22 616.6523665 403.64 383.46 440.98# 23665 377.56 358.68 412.4823670 845.87 803.58 924.1223675 523.18 497.02 571.57# 23675 480.14 456.13 524.5523680 901.46 856.39 984.8523700 188.56 179.13 206.0023800 998.81 948.87 1,091.2023802 1,242.82 1,180.68 1,357.7823900 1,340.14 1,273.13 1,464.1023920 1,086.71 1,032.37 1,187.2323921 414.14 393.43 452.4423930 337.60 320.72 368.83# 23930 210.05 199.55 229.4823931 269.78 256.29 294.73# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.38 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 23931 153.54 145.86 167.7423935 487.22 462.86 532.2924000 460.33 437.31 502.9124006 691.18 656.62 755.1124065 245.10 232.85 267.78# 24065 163.41 155.24 178.5324066 583.95 554.75 637.96# 24066 396.39 376.57 433.0624071 398.02 378.12 434.8424073 679.64 645.66 742.5124075 468.63 445.20 511.98# 24075 318.46 302.54 347.9224076 523.79 497.60 572.2424077 1,006.10 955.80 1,099.1724079 1,310.77 1,245.23 1,432.0124100 399.39 379.42 436.3324101 481.52 457.44 526.0624102 595.79 566.00 650.9024105 332.99 316.34 363.7924110 566.12 537.81 618.4824115 712.81 677.17 778.7524116 837.30 795.44 914.7624120 509.67 484.19 556.8224125 596.62 566.79 651.8124126 626.34 595.02 684.2724130 489.96 465.46 535.2824134 725.06 688.81 792.1324136 601.69 571.61 657.3524138 648.49 616.07 708.4824140 684.83 650.59 748.1824145 575.09 546.34 628.2924147 602.98 572.83 658.7524149 1,137.74 1,080.85 1,242.9824150 1,479.71 1,405.72 1,616.5824152 1,271.73 1,208.14 1,389.3624155 827.99 786.59 904.5824160 585.44 556.17 639.6024164 479.96 455.96 524.3524200 194.16 184.45 212.12# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.39 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 24200 134.15 127.44 146.5624201 527.46 501.09 576.25# 24201 353.10 335.45 385.7724220 152.63 145.00 166.75# 24220 66.23 62.92 72.3624300 389.60 370.12 425.6424301 731.29 694.73 798.9424305 560.19 532.18 612.0124310 460.80 437.76 503.4224320 756.34 718.52 826.3024330 694.64 659.91 758.9024331 718.35 682.43 784.7924332 589.85 560.36 644.4124340 594.84 565.10 649.8724341 721.15 685.09 787.8524342 756.62 718.79 826.6124343 681.38 647.31 744.4124344 1,070.21 1,016.70 1,169.2124345 677.61 643.73 740.2924346 1,065.81 1,012.52 1,164.4024357 427.48 406.11 467.0324358 505.29 480.03 552.0324359 638.18 606.27 697.2124360 873.36 829.69 954.1424361 979.62 930.64 1,070.2424362 1,032.32 980.70 1,127.8124363 1,463.25 1,390.09 1,598.6024365 618.48 587.56 675.6924366 661.35 628.28 722.5224400 798.03 758.13 871.8524410 934.76 888.02 1,021.2224420 961.79 913.70 1,050.7624430 1,031.06 979.51 1,126.4424435 1,047.87 995.48 1,144.8024470 640.11 608.10 699.3224495 637.96 606.06 696.9724498 843.72 801.53 921.7624500 337.28 320.42 368.48# 24500 307.43 292.06 335.87# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.40 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE24505 477.40 453.53 521.56# 24505 434.67 412.94 474.8824515 851.43 808.86 930.1924516 837.68 795.80 915.1724530 359.94 341.94 393.23# 24530 326.64 310.31 356.8624535 589.37 559.90 643.89# 24535 546.96 519.61 597.5524538 719.40 683.43 785.9424545 902.98 857.83 986.5024546 1,015.47 964.70 1,109.4124560 303.40 288.23 331.46# 24560 271.67 258.09 296.8024565 503.69 478.51 550.29# 24565 464.10 440.90 507.0424566 690.56 656.03 754.4324575 710.88 675.34 776.6424576 319.46 303.49 349.01# 24576 288.05 273.65 314.7024577 519.88 493.89 567.97# 24577 478.10 454.20 522.3324579 810.63 770.10 885.6224582 775.70 736.92 847.4624586 1,060.28 1,007.27 1,158.3624587 1,055.00 1,002.25 1,152.5924600 347.62 330.24 379.78# 24600 319.03 303.08 348.5424605 449.35 426.88 490.9124615 689.63 655.15 753.4224620 532.12 505.51 581.3424635 665.67 632.39 727.2524640 128.52 122.09 140.40# 24640 89.24 84.78 97.5024650 246.28 233.97 269.07# 24650 225.86 214.57 246.7624655 418.83 397.89 457.57# 24655 383.33 364.16 418.7824665 628.93 597.48 687.1024666 709.92 674.42 775.58# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.41 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE24670 274.69 260.96 300.10# 24670 248.30 235.89 271.2724675 435.96 414.16 476.28# 24675 400.15 380.14 437.1624685 631.62 600.04 690.0524800 797.60 757.72 871.3824802 973.36 924.69 1,063.3924900 706.16 670.85 771.4824920 660.06 627.06 721.1224925 544.66 517.43 595.0424930 747.15 709.79 816.2624931 746.19 708.88 815.2124935 992.61 942.98 1,084.4324940 952.99 905.34 1,041.1425000 326.02 309.72 356.1825001 327.43 311.06 357.7225020 555.55 527.77 606.9425023 1,072.16 1,018.55 1,171.3325024 760.77 722.73 831.1425025 1,187.44 1,128.07 1,297.2825028 500.55 475.52 546.8525031 353.65 335.97 386.3725035 580.34 551.32 634.0225040 547.62 520.24 598.2825065 242.93 230.78 265.40# 25065 159.99 151.99 174.7925066 350.38 332.86 382.7925071 417.15 396.29 455.7325073 520.26 494.25 568.3925075 462.79 439.65 505.60# 25075 311.36 295.79 340.1625076 502.19 477.08 548.6425077 861.81 818.72 941.5325078 1,155.31 1,097.54 1,262.1725085 438.72 416.78 479.3025100 332.35 315.73 363.0925101 389.11 369.65 425.1025105 467.68 444.30 510.9525107 595.90 566.11 651.03# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.42 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE25109 516.65 490.82 564.4425110 332.88 316.24 363.6825111 306.96 291.61 335.3525112 373.14 354.48 407.6525115 748.86 711.42 818.1325116 593.18 563.52 648.0525118 368.29 349.88 402.3625119 486.05 461.75 531.0125120 494.75 470.01 540.5125125 598.13 568.22 653.4525126 589.57 560.09 644.1025130 432.60 410.97 472.6225135 550.12 522.61 601.0025136 475.76 451.97 519.7725145 511.40 485.83 558.7025150 550.45 522.93 601.3725151 581.19 552.13 634.9525170 1,412.94 1,342.29 1,543.6325210 473.49 449.82 517.2925215 600.08 570.08 655.5925230 416.60 395.77 455.1425240 416.17 395.36 454.6625246 156.55 148.72 171.03# 25246 72.98 69.33 79.7325248 410.27 389.76 448.2225250 510.01 484.51 557.1925251 696.34 661.52 760.7525259 392.11 372.50 428.3825260 623.77 592.58 681.4725263 618.62 587.69 675.8425265 738.11 701.20 806.3825270 490.99 466.44 536.4125272 552.00 524.40 603.0625274 666.53 633.20 728.1825275 657.79 624.90 718.6425280 559.50 531.53 611.2625290 443.54 421.36 484.5625295 519.23 493.27 567.2625300 677.16 643.30 739.80# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.43 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE25301 625.35 594.08 683.1925310 612.12 581.51 668.7425312 712.24 676.63 778.1225315 762.27 724.16 832.7825316 866.18 822.87 946.3025320 955.73 907.94 1,044.1325332 822.62 781.49 898.7125335 858.85 815.91 938.3025337 861.65 818.57 941.3625350 667.70 634.32 729.4725355 757.33 719.46 827.3825360 649.07 616.62 709.1125365 901.36 856.29 984.7325370 902.48 857.36 985.9625375 773.19 734.53 844.7125390 761.23 723.17 831.6525391 983.00 933.85 1,073.9325392 1,001.41 951.34 1,094.0425393 1,116.87 1,061.03 1,220.1825394 759.14 721.18 829.3625400 797.31 757.44 871.0625405 1,023.73 972.54 1,118.4225415 957.63 909.75 1,046.2125420 1,154.44 1,096.72 1,261.2325425 962.08 913.98 1,051.0825426 1,093.14 1,038.48 1,194.2525430 678.96 645.01 741.7625431 763.07 724.92 833.6625440 748.97 711.52 818.2525441 875.89 832.10 956.9225442 762.09 723.99 832.5925443 757.19 719.33 827.2325444 767.49 729.12 838.4925445 698.99 664.04 763.6525446 1,140.74 1,083.70 1,246.2625447 800.16 760.15 874.1725449 1,015.80 965.01 1,109.7625450 592.59 562.96 647.4025455 653.08 620.43 713.49# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.44 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE25490 657.22 624.36 718.0125491 731.43 694.86 799.0925492 890.30 845.79 972.6625500 255.67 242.89 279.32# 25500 234.62 222.89 256.3225505 479.97 455.97 524.37# 25505 441.64 419.56 482.4925515 646.50 614.18 706.3125520 538.00 511.10 587.77# 25520 511.61 486.03 558.9325525 762.74 724.60 833.2925526 933.65 886.97 1,020.0225530 245.73 233.44 268.46# 25530 222.48 211.36 243.0625535 467.12 443.76 510.32# 25535 434.76 413.02 474.9725545 602.30 572.19 658.0225560 258.94 245.99 282.89# 25560 234.43 222.71 256.1225565 498.65 473.72 544.78# 25565 454.66 431.93 496.7225574 648.54 616.11 708.5325575 871.36 827.79 951.9625600 301.73 286.64 329.64# 25600 283.20 269.04 309.4025605 532.55 505.92 581.81# 25605 502.39 477.27 548.8625606 640.21 608.20 699.4325607 707.99 672.59 773.4825608 795.19 755.43 868.7425609 1,013.04 962.39 1,106.7525622 287.31 272.94 313.88# 25622 261.54 248.46 285.7325624 448.85 426.41 490.37# 25624 409.90 389.41 447.8225628 696.88 662.04 761.3525630 290.02 275.52 316.85# 25630 266.14 252.83 290.7525635 428.43 407.01 468.06# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.45 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 25635 390.10 370.60 426.1925645 548.58 521.15 599.3225650 304.25 289.04 332.40# 25650 284.77 270.53 311.1125651 466.21 442.90 509.3425652 600.53 570.50 656.0825660 391.07 371.52 427.2525670 584.73 555.49 638.8125671 508.63 483.20 555.6825675 417.70 396.82 456.34# 25675 383.46 364.29 418.9325676 608.39 577.97 664.6725680 455.25 432.49 497.3625685 711.07 675.52 776.8525690 458.29 435.38 500.6925695 611.76 581.17 668.3525800 711.79 676.20 777.6325805 822.25 781.14 898.3125810 843.61 801.43 921.6425820 594.22 564.51 649.1925825 732.19 695.58 799.9225830 917.92 872.02 1,002.8225900 700.27 665.26 765.0525905 689.25 654.79 753.0125907 563.19 535.03 615.2825909 673.82 640.13 736.1525915 1,039.01 987.06 1,135.1225920 671.21 637.65 733.3025922 547.66 520.28 598.3225924 610.91 580.36 667.4125927 774.20 735.49 845.8125929 580.77 551.73 634.4925931 663.51 630.33 724.8826010 245.53 233.25 268.24# 26010 131.49 124.92 143.6626011 368.16 349.75 402.21# 26011 178.09 169.19 194.5726020 416.61 395.78 455.1526025 405.20 384.94 442.68# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.46 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE26030 477.06 453.21 521.1926034 517.94 492.04 565.8526035 823.16 782.00 899.3026037 553.54 525.86 604.7426040 297.11 282.25 324.5926045 449.59 427.11 491.1826055 530.88 504.34 579.99# 26055 294.31 279.59 321.5326060 255.36 242.59 278.9826070 299.11 284.15 326.7726075 312.04 296.44 340.9126080 372.49 353.87 406.9526100 317.67 301.79 347.0626105 321.96 305.86 351.7426110 307.44 292.07 335.8826111 408.69 388.26 446.5026113 535.73 508.94 585.2826115 505.26 480.00 552.00# 26115 325.56 309.28 355.6726116 508.07 482.67 555.0726117 718.74 682.80 785.2226118 1,043.37 991.20 1,139.8826121 577.32 548.45 630.7226123 804.00 763.80 878.3726125 271.55 257.97 296.6726130 443.42 421.25 484.4426135 532.06 505.46 581.2826140 486.93 462.58 531.9726145 494.44 469.72 540.1826160 543.21 516.05 593.46# 26160 318.27 302.36 347.7126170 390.69 371.16 426.8326180 426.28 404.97 465.7226185 533.97 507.27 583.3626200 434.94 413.19 475.1726205 581.52 552.44 635.3126210 424.88 403.64 464.1926215 541.76 514.67 591.8726230 481.88 457.79 526.46# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.47 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE26235 476.03 452.23 520.0626236 424.77 403.53 464.0626250 1,003.29 953.13 1,096.1026260 759.57 721.59 829.8326262 609.10 578.65 665.4526320 332.84 316.20 363.6326340 314.35 298.63 343.4226341 94.19 89.48 102.90# 26341 71.88 68.29 78.5326350 675.99 642.19 738.5226352 773.53 734.85 845.0826356 1,040.82 988.78 1,137.1026357 825.70 784.42 902.0826358 872.87 829.23 953.6126370 725.80 689.51 792.9426372 842.38 800.26 920.3026373 805.92 765.62 880.4626390 796.13 756.32 869.7726392 937.89 891.00 1,024.6526410 535.83 509.04 585.4026412 650.14 617.63 710.2726415 654.25 621.54 714.7726416 820.76 779.72 896.6826418 546.10 518.80 596.6226420 681.29 647.23 744.3126426 500.39 475.37 546.6826428 717.24 681.38 783.5926432 471.33 447.76 514.9226433 504.81 479.57 551.5126434 611.95 581.35 668.5526437 590.09 560.59 644.6826440 589.15 559.69 643.6426442 918.90 872.96 1,003.9026445 546.80 519.46 597.3826449 688.51 654.08 752.1926450 383.40 364.23 418.8626455 383.06 363.91 418.5026460 372.23 353.62 406.6626471 583.57 554.39 637.55# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.48 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE26474 458.02 435.12 500.3926476 556.83 528.99 608.3426477 554.98 527.23 606.3126478 592.85 563.21 647.6926479 591.83 562.24 646.5826480 715.89 680.10 782.1226483 807.90 767.51 882.6426485 770.33 731.81 841.5826489 878.03 834.13 959.2526490 755.72 717.93 825.6226492 839.33 797.36 916.9626494 759.65 721.67 829.9226496 819.25 778.29 895.0326497 824.31 783.09 900.5526498 1,095.45 1,040.68 1,196.7826499 789.86 750.37 862.9326500 597.91 568.01 653.2126502 673.91 640.21 736.2426508 591.56 561.98 646.2826510 566.51 538.18 618.9126516 669.32 635.85 731.2326517 796.17 756.36 869.8126518 796.14 756.33 869.7826520 617.74 586.85 674.8826525 618.57 587.64 675.7926530 517.65 491.77 565.5426531 601.57 571.49 657.2126535 396.25 376.44 432.9126536 666.22 632.91 727.8526540 626.68 595.35 684.6526541 763.91 725.71 834.5726542 647.73 615.34 707.6426545 661.76 628.67 722.9726546 945.83 898.54 1,033.3226548 728.96 692.51 796.3926550 1,549.55 1,472.07 1,692.8826551 2,910.29 2,764.78 3,179.5026553 2,614.85 2,484.11 2,856.7326554 3,111.14 2,955.58 3,398.92# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.49 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE26555 1,315.72 1,249.93 1,437.4226556 2,795.98 2,656.18 3,054.6126560 554.60 526.87 605.9026561 911.01 865.46 995.2826562 1,231.16 1,169.60 1,345.0426565 650.06 617.56 710.1926567 647.48 615.11 707.3826568 854.57 811.84 933.6226580 1,462.23 1,389.12 1,597.4926587 907.00 861.65 990.9026590 1,234.45 1,172.73 1,348.6426591 414.65 393.92 453.0126593 568.20 539.79 620.7626596 722.55 686.42 789.3826600 275.61 261.83 301.10# 26600 258.65 245.72 282.5826605 304.78 289.54 332.97# 26605 278.39 264.47 304.1426607 437.47 415.60 477.9426608 458.56 435.63 500.9726615 550.54 523.01 601.4626641 345.85 328.56 377.84# 26641 317.57 301.69 346.9426645 402.80 382.66 440.06# 26645 371.07 352.52 405.4026650 458.61 435.68 501.0326665 603.35 573.18 659.1626670 315.60 299.82 344.79# 26670 287.95 273.55 314.5826675 428.62 407.19 468.27# 26675 395.64 375.86 432.2426676 481.19 457.13 525.7026685 554.49 526.77 605.7926686 601.20 571.14 656.8126700 304.82 289.58 333.02# 26700 286.28 271.97 312.7726705 391.30 371.74 427.50# 26705 359.25 341.29 392.4826706 422.97 401.82 462.09# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.50 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE26715 550.54 523.01 601.4626720 186.58 177.25 203.84# 26720 173.39 164.72 189.4326725 322.07 305.97 351.87# 26725 291.28 276.72 318.2326727 450.79 428.25 492.4926735 572.59 543.96 625.5526740 215.46 204.69 235.39# 26740 202.26 192.15 220.9726742 352.08 334.48 384.65# 26742 320.66 304.63 350.3226746 712.82 677.18 778.7626750 174.12 165.41 190.22# 26750 173.18 164.52 189.2026755 299.49 284.52 327.20# 26755 261.79 248.70 286.0126756 400.67 380.64 437.7426765 477.26 453.40 521.4126770 259.76 246.77 283.79# 26770 240.91 228.86 263.1926775 364.26 346.05 397.96# 26775 330.02 313.52 360.5526776 424.13 402.92 463.3626785 519.69 493.71 567.7726820 748.90 711.46 818.1826841 692.52 657.89 756.5726842 753.08 715.43 822.7426843 700.99 665.94 765.8326844 790.15 750.64 863.2426850 658.86 625.92 719.8126852 757.12 719.26 827.1526860 532.83 506.19 582.1226861 102.24 97.13 111.7026862 692.04 657.44 756.0626863 227.24 215.88 248.2626910 686.99 652.64 750.5426951 614.96 584.21 671.8426952 616.77 585.93 673.8226990 602.67 572.54 658.42# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.51 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE26991 677.62 643.74 740.30# 26991 509.23 483.77 556.3426992 931.41 884.84 1,017.5727000 422.54 401.41 461.6227001 524.25 498.04 572.7527003 573.52 544.84 626.5727005 706.30 670.99 771.6427006 715.47 679.70 781.6627025 894.18 849.47 976.8927027 811.86 771.27 886.9627030 911.43 865.86 995.7427033 949.94 902.44 1,037.8127035 1,012.30 961.69 1,105.9427036 981.80 932.71 1,072.6227040 324.83 308.59 354.88# 27040 194.77 185.03 212.7827041 661.18 628.12 722.3427043 461.78 438.69 504.4927045 735.97 699.17 804.0527047 460.99 437.94 503.63# 27047 363.29 345.13 396.9027048 587.95 558.55 642.3327049 1,317.70 1,251.82 1,439.5927050 375.82 357.03 410.5827052 555.81 528.02 607.2227054 663.04 629.89 724.3727057 912.39 866.77 996.7927059 1,774.50 1,685.78 1,938.6527060 442.18 420.07 483.0827062 439.47 417.50 480.1327065 492.27 467.66 537.8127066 788.00 748.60 860.8927067 1,005.91 955.61 1,098.9527070 827.62 786.24 904.1827071 888.77 844.33 970.9827075 2,063.06 1,959.91 2,253.9027076 2,430.36 2,308.84 2,655.1727077 2,769.73 2,631.24 3,025.9327078 1,956.94 1,859.09 2,137.95# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.52 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27080 491.34 466.77 536.7927086 239.06 227.11 261.18# 27086 143.86 136.67 157.1727087 614.06 583.36 670.8627090 807.64 767.26 882.3527091 1,565.83 1,487.54 1,710.6727093 184.12 174.91 201.15# 27093 68.82 65.38 75.1927095 227.57 216.19 248.62# 27095 80.23 76.22 87.6527096 162.87 154.73 177.94# 27096 80.24 76.23 87.6627097 656.65 623.82 717.3927098 659.08 626.13 720.0527100 799.54 759.56 873.4927105 839.96 797.96 917.6527110 939.33 892.36 1,026.2127111 807.10 766.75 881.7627120 1,261.91 1,198.81 1,378.6327122 1,075.78 1,021.99 1,175.2927125 1,105.77 1,050.48 1,208.0527130 1,412.70 1,342.07 1,543.3827132 1,646.66 1,564.33 1,798.9827134 1,890.62 1,796.09 2,065.5027137 1,448.60 1,376.17 1,582.6027138 1,507.56 1,432.18 1,647.0127140 872.28 828.67 952.9727146 1,249.76 1,187.27 1,365.3627147 1,436.30 1,364.49 1,569.1627151 1,541.15 1,464.09 1,683.7027156 1,676.85 1,593.01 1,831.9627158 1,364.79 1,296.55 1,491.0327161 1,187.48 1,128.11 1,297.3327165 1,341.93 1,274.83 1,466.0527170 1,151.36 1,093.79 1,257.8627175 647.03 614.68 706.8827176 891.38 846.81 973.8327177 1,084.31 1,030.09 1,184.6027178 889.81 845.32 972.12# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.53 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27179 948.80 901.36 1,036.5627181 1,091.92 1,037.32 1,192.9227185 639.51 607.53 698.6627187 967.01 918.66 1,056.4627193 454.53 431.80 496.57# 27193 459.87 436.88 502.4127194 676.83 642.99 739.4427200 170.45 161.93 186.22# 27200 176.42 167.60 192.7427202 542.28 515.17 592.4527220 511.15 485.59 558.43# 27220 506.76 481.42 553.6327222 952.98 905.33 1,041.1327226 1,029.40 977.93 1,124.6227227 1,628.40 1,546.98 1,779.0327228 1,860.53 1,767.50 2,032.6327230 456.64 433.81 498.88# 27230 452.87 430.23 494.7627232 747.52 710.14 816.6627235 886.25 841.94 968.2327236 1,168.64 1,110.21 1,276.7427238 442.30 420.19 483.2227240 934.26 887.55 1,020.6827244 1,202.05 1,141.95 1,313.2427245 1,208.33 1,147.91 1,320.1027246 370.40 351.88 404.66# 27246 371.98 353.38 406.3927248 727.13 690.77 794.3927250 191.79 182.20 209.5327252 739.19 702.23 807.5627253 918.47 872.55 1,003.4327254 1,242.22 1,180.11 1,357.1327256 290.78 276.24 317.68# 27256 232.98 221.33 254.5327257 327.17 310.81 357.4327258 1,081.55 1,027.47 1,181.5927259 1,515.96 1,440.16 1,656.1827265 385.30 366.04 420.9527266 562.34 534.22 614.35# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.54 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27267 417.57 396.69 456.1927268 514.78 489.04 562.4027269 1,208.64 1,148.21 1,320.4427275 173.27 164.61 189.3027280 1,007.29 956.93 1,100.4727282 818.84 777.90 894.5927284 1,569.38 1,490.91 1,714.5527286 1,620.03 1,539.03 1,769.8827290 1,577.91 1,499.01 1,723.8627295 1,236.39 1,174.57 1,350.7627301 642.23 610.12 701.64# 27301 486.09 461.79 531.0627303 619.45 588.48 676.7527305 461.78 438.69 504.4927306 345.35 328.08 377.2927307 459.79 436.80 502.3227310 709.21 673.75 774.8127323 258.85 245.91 282.80# 27323 173.40 164.73 189.4427324 378.46 359.54 413.4727325 496.55 471.72 542.4827326 489.49 465.02 534.7727327 431.25 409.69 471.14# 27327 305.59 290.31 333.8627328 592.98 563.33 647.8327329 1,017.73 966.84 1,111.8727330 394.49 374.77 430.9927331 458.96 436.01 501.4127332 619.44 588.47 676.7427333 564.78 536.54 617.0227334 662.36 629.24 723.6327335 742.61 705.48 811.3027337 411.70 391.12 449.7927339 736.28 699.47 804.3927340 355.74 337.95 388.6427345 465.53 442.25 508.5927347 509.59 484.11 556.7327350 631.15 599.59 689.5327355 583.95 554.75 637.96# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.55 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27356 715.15 679.39 781.3027357 789.47 750.00 862.5027358 276.11 262.30 301.6527360 827.94 786.54 904.5227364 1,536.57 1,459.74 1,678.7027365 1,971.81 1,873.22 2,154.2027370 161.77 153.68 176.73# 27370 51.49 48.92 56.2627372 575.79 547.00 629.05# 27372 391.06 371.51 427.2427380 574.11 545.40 627.2127381 775.77 736.98 847.5327385 557.43 529.56 608.9927386 806.31 765.99 880.8927390 430.21 408.70 470.0127391 556.04 528.24 607.4827392 687.16 652.80 750.7227393 491.79 467.20 537.2827394 630.92 599.37 689.2827395 852.41 809.79 931.2627396 595.18 565.42 650.2327397 886.84 842.50 968.8827400 671.04 637.49 733.1127403 621.21 590.15 678.6727405 656.68 623.85 717.4327407 763.23 725.07 833.8327409 938.18 891.27 1,024.9627412 1,615.05 1,534.30 1,764.4527415 1,337.41 1,270.54 1,461.1227416 950.75 903.21 1,038.6927418 810.09 769.59 885.0327420 721.71 685.62 788.4627422 722.16 686.05 788.9627424 724.49 688.27 791.5127425 429.70 408.22 469.4527427 697.78 662.89 762.3227428 1,083.52 1,029.34 1,183.7427429 1,215.89 1,155.10 1,328.3727430 718.89 682.95 785.39# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.56 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27435 783.46 744.29 855.9327437 640.43 608.41 699.6727438 818.73 777.79 894.4627440 767.51 729.13 838.5027441 792.96 753.31 866.3127442 846.20 803.89 924.4727443 792.89 753.25 866.2427445 1,225.31 1,164.04 1,338.6527446 1,082.85 1,028.71 1,183.0227447 1,509.02 1,433.57 1,648.6127448 797.67 757.79 871.4627450 991.75 942.16 1,083.4827454 1,264.43 1,201.21 1,381.3927455 916.13 870.32 1,000.8727457 938.64 891.71 1,025.4727465 1,216.62 1,155.79 1,329.1627466 1,153.39 1,095.72 1,260.0827468 1,309.06 1,243.61 1,430.1527470 1,151.61 1,094.03 1,258.1327472 1,239.29 1,177.33 1,353.9327475 640.43 608.41 699.6727477 710.35 674.83 776.0527479 835.21 793.45 912.4727485 649.95 617.45 710.0727486 1,379.46 1,310.49 1,507.0627487 1,729.69 1,643.21 1,889.6927488 1,174.58 1,115.85 1,283.2327495 1,102.85 1,047.71 1,204.8727496 516.05 490.25 563.7927497 555.56 527.78 606.9527498 619.84 588.85 677.1827499 624.91 593.66 682.7127500 497.28 472.42 543.28# 27500 461.47 438.40 504.1627501 485.98 461.68 530.93# 27501 481.59 457.51 526.1427502 758.53 720.60 828.6927503 778.76 739.82 850.7927506 1,307.92 1,242.52 1,428.90# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.57 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27507 953.82 906.13 1,042.0527508 503.83 478.64 550.44# 27508 475.24 451.48 519.2027509 622.70 591.57 680.3127510 674.99 641.24 737.4327511 982.15 933.04 1,073.0027513 1,225.79 1,164.50 1,339.1827514 957.33 909.46 1,045.8827516 482.89 458.75 527.56# 27516 454.61 431.88 496.6627517 662.75 629.61 724.0527519 877.41 833.54 958.5727520 306.53 291.20 334.88# 27520 279.83 265.84 305.7227524 731.89 695.30 799.6027530 293.17 278.51 320.29# 27530 271.81 258.22 296.9527532 592.96 563.31 647.81# 27532 558.40 530.48 610.0527535 881.70 837.62 963.2627536 1,163.15 1,104.99 1,270.7427538 452.12 429.51 493.94# 27538 424.16 402.95 463.3927540 793.71 754.02 867.1227550 476.05 452.25 520.09# 27550 442.75 420.61 483.7027552 605.31 575.04 661.3027556 863.05 819.90 942.8927557 1,033.08 981.43 1,128.6427558 1,175.51 1,116.73 1,284.2427560 360.13 342.12 393.44# 27560 334.06 317.36 364.9627562 461.06 438.01 503.7127566 868.54 825.11 948.8827570 144.30 137.09 157.6527580 1,407.05 1,336.70 1,537.2127590 816.53 775.70 892.0627591 866.26 822.95 946.3927592 690.10 655.60 753.94# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.58 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27594 508.43 483.01 555.4627596 723.26 687.10 790.1727598 734.04 697.34 801.9427600 412.62 391.99 450.7927601 429.64 408.16 469.3827602 502.28 477.17 548.7527603 515.11 489.35 562.75# 27603 382.22 363.11 417.5827604 453.54 430.86 495.49# 27604 327.25 310.89 357.5227605 330.11 313.60 360.64# 27605 182.45 173.33 199.3327606 280.32 266.30 306.2527607 597.83 567.94 653.1327610 634.92 603.17 693.6527612 542.99 515.84 593.2227613 242.67 230.54 265.12# 27613 160.36 152.34 175.1927614 554.09 526.39 605.35# 27614 398.58 378.65 435.4527615 1,003.70 953.52 1,096.5527616 1,251.83 1,189.24 1,367.6327618 423.37 402.20 462.53# 27618 301.16 286.10 329.0227619 474.69 450.96 518.6027620 442.95 420.80 483.9227625 558.88 530.94 610.5827626 617.64 586.76 674.7727630 533.94 507.24 583.33# 27630 358.01 340.11 391.1327632 409.42 388.95 447.2927634 674.82 641.08 737.2427635 575.46 546.69 628.6927637 738.23 701.32 806.5227638 754.58 716.85 824.3827640 820.89 779.85 896.8327641 656.14 623.33 716.8327645 1,693.92 1,609.22 1,850.6027646 1,465.25 1,391.99 1,600.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.59 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27647 1,022.65 971.52 1,117.2527648 154.54 146.81 168.83# 27648 50.87 48.33 55.5827650 648.35 615.93 708.3227652 681.06 647.01 744.0627654 690.45 655.93 754.3227656 583.31 554.14 637.26# 27656 372.82 354.18 407.3127658 363.51 345.33 397.1327659 476.87 453.03 520.9827664 351.97 334.37 384.5327665 403.20 383.04 440.5027675 477.68 453.80 521.8727676 603.43 573.26 659.2527680 419.59 398.61 458.4027681 523.03 496.88 571.4127685 625.89 594.60 683.79# 27685 451.52 428.94 493.2827686 541.96 514.86 592.0927687 444.27 422.06 485.3727690 614.94 584.19 671.8227691 731.16 694.60 798.7927692 106.18 100.87 116.0027695 470.30 446.79 513.8127696 549.14 521.68 599.9327698 628.35 596.93 686.4727700 580.13 551.12 633.7927702 952.94 905.29 1,041.0827703 1,112.97 1,057.32 1,215.9227704 560.04 532.04 611.8527705 743.76 706.57 812.5627707 388.66 369.23 424.6127709 1,144.92 1,087.67 1,250.8227712 1,076.04 1,022.24 1,175.5827715 1,038.02 986.12 1,134.0427720 855.19 812.43 934.2927722 862.53 819.40 942.3127724 1,246.05 1,183.75 1,361.3127725 1,186.19 1,126.88 1,295.91# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.60 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27726 940.49 893.47 1,027.4927727 995.38 945.61 1,087.4527730 565.59 537.31 617.9127732 373.74 355.05 408.3127734 582.98 553.83 636.9027740 610.13 579.62 666.5627742 736.59 699.76 804.7227745 736.34 699.52 804.4527750 328.69 312.26 359.10# 27750 301.99 286.89 329.9227752 517.26 491.40 565.11# 27752 480.19 456.18 524.6127756 558.04 530.14 609.6627758 867.53 824.15 947.7727759 976.26 927.45 1,066.5727760 317.66 301.78 347.05# 27760 290.01 275.51 316.8427762 461.70 438.62 504.41# 27762 424.32 403.10 463.5727766 590.86 561.32 645.5227767 265.76 252.47 290.34# 27767 267.02 253.67 291.7227768 416.28 395.47 454.7927769 706.58 671.25 771.9427780 289.35 274.88 316.11# 27780 263.58 250.40 287.9627781 406.86 386.52 444.50# 27781 378.90 359.96 413.9527784 694.44 659.72 758.6827786 300.26 285.25 328.04# 27786 271.99 258.39 297.1527788 405.27 385.01 442.76# 27788 372.29 353.68 406.7327792 637.21 605.35 696.1527808 316.41 300.59 345.68# 27808 284.99 270.74 311.3527810 453.14 430.48 495.05# 27810 414.50 393.78 452.8527814 752.70 715.07 822.33# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.61 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE27816 301.65 286.57 329.56# 27816 271.49 257.92 296.6127818 466.56 443.23 509.71# 27818 422.26 401.15 461.3227822 821.13 780.07 897.0827823 932.80 886.16 1,019.0827824 298.23 283.32 325.82# 27824 289.12 274.66 315.8627825 526.88 500.54 575.62# 27825 481.01 456.96 525.5027826 808.81 768.37 883.6327827 1,056.94 1,004.09 1,154.7027828 1,266.89 1,203.55 1,384.0827829 662.62 629.49 723.9127830 357.85 339.96 390.95# 27830 334.29 317.58 365.2227831 379.78 360.79 414.9127832 725.20 688.94 792.2827840 352.47 334.85 385.0827842 477.23 453.37 521.3827846 716.18 680.37 782.4327848 798.62 758.69 872.4927860 171.57 162.99 187.4427870 1,016.60 965.77 1,110.6427871 675.41 641.64 737.8927880 923.25 877.09 1,008.6527881 871.71 828.12 952.3427882 612.84 582.20 669.5327884 577.28 548.42 630.6827886 663.03 629.88 724.3627888 675.16 641.40 737.6127889 668.15 634.74 729.9527892 547.29 519.93 597.9227893 583.19 554.03 637.1327894 849.80 807.31 928.4128001 258.82 245.88 282.76# 28001 164.88 156.64 180.1428002 434.19 412.48 474.35# 28002 321.72 305.63 351.47# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.62 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE28003 677.14 643.28 739.77# 28003 550.84 523.30 601.8028005 572.38 543.76 625.3228008 409.92 389.42 447.83# 28008 286.14 271.83 312.6028010 223.07 211.92 243.71# 28010 203.28 193.12 222.0928011 317.14 301.28 346.47# 28011 286.66 272.33 313.1828020 500.33 475.31 546.61# 28020 345.76 328.47 377.7428022 455.50 432.73 497.64# 28022 312.87 297.23 341.8128024 429.26 407.80 468.97# 28024 293.23 278.57 320.3628035 499.50 474.53 545.71# 28035 346.81 329.47 378.8928039 507.62 482.24 554.58# 28039 348.96 331.51 381.2428041 459.32 436.35 501.8028043 371.10 352.55 405.43# 28043 257.05 244.20 280.8328045 479.83 455.84 524.22# 28045 342.54 325.41 374.2228046 726.84 690.50 794.0828047 1,007.73 957.34 1,100.9428050 439.14 417.18 479.76# 28050 294.31 279.59 321.5328052 409.87 389.38 447.79# 28052 271.95 258.35 297.1028054 358.17 340.26 391.30# 28054 231.56 219.98 252.9828055 367.53 349.15 401.5228060 485.89 461.60 530.84# 28060 343.88 326.69 375.6928062 557.43 529.56 608.99# 28062 396.89 377.05 433.6128070 499.08 474.13 545.25# 28070 343.25 326.09 375.00# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.63 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE28072 489.32 464.85 534.58# 28072 330.35 313.83 360.9028080 489.52 465.04 534.80# 28080 350.02 332.52 382.4028086 515.06 489.31 562.71# 28086 348.55 331.12 380.7928088 445.41 423.14 486.61# 28088 288.64 274.21 315.3428090 443.15 420.99 484.14# 28090 298.95 284.00 326.6028092 400.16 380.15 437.17# 28092 261.92 248.82 286.1428100 567.28 538.92 619.76# 28100 394.17 374.46 430.6328102 461.11 438.05 503.7628103 389.43 369.96 425.4528104 487.72 463.33 532.83# 28104 336.61 319.78 367.7528106 422.92 401.77 462.0428107 497.78 472.89 543.82# 28107 344.15 326.94 375.9828108 410.27 389.76 448.22# 28108 277.06 263.21 302.6928110 435.97 414.17 476.30# 28110 280.14 266.13 306.0528111 481.45 457.38 525.99# 28111 324.68 308.45 354.7228112 465.55 442.27 508.61# 28112 305.95 290.65 334.2528113 563.28 535.12 615.39# 28113 413.42 392.75 451.6628114 1,027.71 976.32 1,122.77# 28114 813.76 773.07 889.0328116 724.56 688.33 791.58# 28116 557.73 529.84 609.3228118 561.10 533.05 613.01# 28118 400.56 380.53 437.6128119 498.51 473.58 544.62# 28119 350.85 333.31 383.31# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.64 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE28120 640.57 608.54 699.82# 28120 476.89 453.05 521.0128122 578.94 549.99 632.49# 28122 435.05 413.30 475.3028124 450.63 428.10 492.32# 28124 319.93 303.93 349.5228126 373.15 354.49 407.66# 28126 241.83 229.74 264.2028130 645.51 613.23 705.2128140 583.03 553.88 636.96# 28140 436.63 414.80 477.0228150 408.71 388.27 446.51# 28150 275.82 262.03 301.3328153 390.37 370.85 426.48# 28153 256.85 244.01 280.6128160 398.80 378.86 435.69# 28160 263.39 250.22 287.7528171 825.84 784.55 902.2328173 750.85 713.31 820.3128175 471.82 448.23 515.4628190 239.69 227.71 261.87# 28190 130.04 123.54 142.0728192 448.83 426.39 490.35# 28192 307.45 292.08 335.8928193 510.55 485.02 557.77# 28193 363.20 345.04 396.8028200 453.55 430.87 495.50# 28200 306.83 291.49 335.2128202 565.22 536.96 617.50# 28202 413.16 392.50 451.3828208 439.95 417.95 480.64# 28208 298.26 283.35 325.8528210 543.36 516.19 593.62# 28210 396.33 376.51 432.9928220 424.89 403.65 464.20# 28220 293.57 278.89 320.7228222 482.86 458.72 527.53# 28222 343.06 325.91 374.8028225 383.93 364.73 419.44# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.65 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 28225 250.41 237.89 273.5728226 445.64 423.36 486.86# 28226 301.13 286.07 328.9828230 408.27 387.86 446.04# 28230 275.38 261.61 300.8528232 370.30 351.79 404.56# 28232 239.92 227.92 262.1128234 388.33 368.91 424.25# 28234 257.32 244.45 281.1228238 649.39 616.92 709.46# 28238 481.62 457.54 526.1728240 417.00 396.15 455.57# 28240 283.48 269.31 309.7128250 541.81 514.72 591.93# 28250 389.12 369.66 425.1128260 667.48 634.11 729.23# 28260 507.26 481.90 554.1928261 933.27 886.61 1,019.60# 28261 753.25 715.59 822.93# 28262 1,132.94 1,076.29 1,237.7328262 1,385.22 1,315.96 1,513.3528264 896.89 852.05 979.86# 28264 691.42 656.85 755.3828270 465.29 442.03 508.33# 28270 324.86 308.62 354.9128272 371.22 352.66 405.56# 28272 246.81 234.47 269.6428280 502.34 477.22 548.80# 28280 348.40 330.98 380.6328285 498.35 473.43 544.44# 28285 359.18 341.22 392.4028286 429.90 408.41 469.67# 28286 292.92 278.27 320.0128288 575.18 546.42 628.38# 28288 418.73 397.79 457.4628289 703.20 668.04 768.25# 28289 535.44 508.67 584.9728290 558.76 530.82 610.44# 28290 386.28 366.97 422.02# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.66 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE28292 751.26 713.70 820.76# 28292 582.55 553.42 636.4328293 989.25 939.79 1,080.76# 28293 689.22 654.76 752.9728294 712.44 676.82 778.34# 28294 520.17 494.16 568.2828296 682.90 648.76 746.07# 28296 508.54 483.11 555.5828297 785.84 746.55 858.53# 28297 576.60 547.77 629.9428298 683.50 649.33 746.73# 28298 491.54 466.96 537.0028299 857.85 814.96 937.20# 28299 660.87 627.83 722.0028300 643.61 611.43 703.1428302 686.02 651.72 749.4828304 772.42 733.80 843.87# 28304 581.10 552.05 634.8628305 628.28 596.87 686.4028306 585.98 556.68 640.18# 28306 395.91 376.11 432.5328307 669.32 635.85 731.23# 28307 452.55 429.92 494.4128308 531.06 504.51 580.19# 28308 362.98 344.83 396.5528309 866.90 823.56 947.0928310 510.52 484.99 557.74# 28310 343.70 326.52 375.5028312 479.74 455.75 524.11# 28312 310.09 294.59 338.7828313 495.09 470.34 540.89# 28313 348.69 331.26 380.9528315 454.12 431.41 496.12# 28315 315.25 299.49 344.4128320 602.31 572.19 658.0228322 752.71 715.07 822.33# 28322 563.58 535.40 615.7128340 556.76 528.92 608.26# 28340 406.59 386.26 444.20# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.67 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE28341 645.41 613.14 705.11# 28341 483.61 459.43 528.3428344 459.65 436.67 502.17# 28344 303.51 288.33 331.5828345 504.84 479.60 551.54# 28345 361.90 343.81 395.3828360 1,042.33 990.21 1,138.7428400 235.98 224.18 257.81# 28400 216.50 205.68 236.5328405 368.46 350.04 402.55# 28405 337.99 321.09 369.2528406 512.48 486.86 559.8928415 1,089.16 1,034.70 1,189.9128420 1,211.08 1,150.53 1,323.1128430 223.08 211.93 243.72# 28430 198.89 188.95 217.2928435 276.61 262.78 302.20# 28435 253.04 240.39 276.4528436 428.01 406.61 467.6028445 1,045.69 993.41 1,142.4228446 1,187.58 1,128.20 1,297.4328450 205.68 195.40 224.71# 28450 183.69 174.51 200.6928455 276.46 262.64 302.04# 28455 251.33 238.76 274.5728456 296.17 281.36 323.5628465 600.84 570.80 656.4228470 202.06 191.96 220.75# 28470 182.58 173.45 199.4728475 247.60 235.22 270.50# 28475 222.47 211.35 243.0528476 332.83 316.19 363.6228485 511.81 486.22 559.1528490 136.13 129.32 148.72# 28490 117.90 112.01 128.8128495 168.76 160.32 184.37# 28495 144.26 137.05 157.6128496 405.03 384.78 442.50# 28496 219.67 208.69 239.99# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.68 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE28505 639.26 607.30 698.40# 28505 483.43 459.26 528.1528510 115.61 109.83 126.30# 28510 112.78 107.14 123.2128515 151.07 143.52 165.05# 28515 135.05 128.30 147.5528525 545.74 518.45 596.22# 28525 388.03 368.63 423.9228530 108.07 102.67 118.07# 28530 96.76 91.92 105.7128531 339.41 322.44 370.81# 28531 187.35 177.98 204.6828540 193.13 183.47 210.99# 28540 175.85 167.06 192.1228545 271.63 258.05 296.76# 28545 243.04 230.89 265.5228546 525.90 499.61 574.55# 28546 318.24 302.33 347.6828555 852.01 809.41 930.82# 28555 655.66 622.88 716.3128570 155.07 147.32 169.42# 28570 134.65 127.92 147.1128575 341.46 324.39 373.05# 28575 311.61 296.03 340.4328576 373.11 354.45 407.6228585 855.78 812.99 934.94# 28585 685.81 651.52 749.2528600 205.29 195.03 224.28# 28600 178.90 169.96 195.4528605 300.02 285.02 327.77# 28605 272.69 259.06 297.9228606 380.69 361.66 415.9128615 770.11 731.60 841.3428630 147.42 140.05 161.06# 28630 106.58 101.25 116.4428635 171.80 163.21 187.69# 28635 131.58 125.00 143.7528636 285.98 271.68 312.43# 28636 191.10 181.55 208.78# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.69 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE28645 620.39 589.37 677.78# 28645 467.08 443.73 510.2928660 109.59 104.11 119.73# 28660 85.72 81.43 93.6428665 148.05 140.65 161.75# 28665 128.57 122.14 140.4628666 185.80 176.51 202.9928675 558.20 530.29 609.83# 28675 397.97 378.07 434.7828705 1,261.17 1,198.11 1,377.8328715 913.92 868.22 998.4528725 749.59 712.11 818.9328730 723.33 687.16 790.2328735 773.54 734.86 845.0928737 666.43 633.11 728.0828740 819.35 778.38 895.14# 28740 612.63 582.00 669.3028750 793.34 753.67 866.72# 28750 584.10 554.90 638.1428755 480.34 456.32 524.77# 28755 320.12 304.11 349.7328760 752.70 715.07 822.33# 28760 562.31 534.19 614.3228800 543.52 516.34 593.7928805 742.97 705.82 811.6928810 434.20 412.49 474.3628820 548.22 520.81 598.93# 28820 387.37 368.00 423.2028825 526.12 499.81 574.78# 28825 367.16 348.80 401.1228890 321.81 305.72 351.58# 28890 219.07 208.12 239.3429000 300.54 285.51 328.34# 29000 167.96 159.56 183.4929010 207.78 197.39 227.00# 29010 137.72 130.83 150.4529015 265.34 252.07 289.88# 29015 170.15 161.64 185.8929020 207.62 197.24 226.83# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.70 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 29020 132.85 126.21 145.1429025 270.69 257.16 295.73# 29025 174.87 166.13 191.0529035 238.81 226.87 260.90# 29035 138.59 131.66 151.4129040 216.51 205.68 236.53# 29040 146.14 138.83 159.6529044 266.15 252.84 290.77# 29044 161.54 153.46 176.4829046 271.97 258.37 297.13# 29046 175.21 166.45 191.4229049 91.51 86.93 99.97# 29049 66.06 62.76 72.1729055 207.79 197.40 227.01# 29055 133.33 126.66 145.6629058 94.43 89.71 103.17# 29058 77.46 73.59 84.6329065 91.36 86.79 99.81# 29065 66.22 62.91 72.3529075 85.34 81.07 93.23# 29075 60.21 57.20 65.7829085 90.00 85.50 98.33# 29085 64.55 61.32 70.5229086 72.71 69.07 79.43# 29086 48.83 46.39 53.3529105 83.09 78.94 90.78# 29105 57.64 54.76 62.9729125 60.77 57.73 66.39# 29125 37.84 35.95 41.3429126 72.65 69.02 79.37# 29126 47.21 44.85 51.5829130 38.73 36.79 42.31# 29130 27.73 26.34 30.2929131 49.59 47.11 54.18# 29131 32.94 31.29 35.9829200 49.71 47.22 54.30# 29200 38.08 36.18 41.6129240 53.95 51.25 58.94# 29240 41.69 39.61 45.55# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.71 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE29260 49.13 46.67 53.67# 29260 35.93 34.13 39.2529280 47.40 45.03 51.78# 29280 34.52 32.79 37.7129305 231.26 219.70 252.66# 29305 153.66 145.98 167.8829325 256.82 243.98 280.58# 29325 172.94 164.29 188.9329345 130.05 123.55 142.08# 29345 98.63 93.70 107.7629355 135.52 128.74 148.05# 29355 105.04 99.79 114.7629358 150.96 143.41 164.92# 29358 101.01 95.96 110.3529365 116.71 110.87 127.50# 29365 85.60 81.32 93.5229405 78.36 74.44 85.61# 29405 57.94 55.04 63.3029425 76.11 72.30 83.15# 29425 55.69 52.91 60.8529435 114.19 108.48 124.75# 29435 83.41 79.24 91.1329440 54.04 51.34 59.04# 29440 34.88 33.14 38.1129445 132.47 125.85 144.73# 29445 104.19 98.98 113.8329450 139.75 132.76 152.67# 29450 112.42 106.80 122.8229505 76.18 72.37 83.23# 29505 47.28 44.92 51.6629515 67.44 64.07 73.68# 29515 47.96 45.56 52.3929520 46.85 44.51 51.19# 29520 34.60 32.87 37.8029530 49.18 46.72 53.73# 29530 36.30 34.49 39.6629540 34.79 33.05 38.01# 29540 25.36 24.09 27.7029550 28.98 27.53 31.66# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.72 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 29550 18.93 17.98 20.6829580 49.86 47.37 54.48# 29580 34.78 33.04 38.0029581 57.25 54.39 62.55# 29581 12.33 11.71 13.4729582 65.37 62.10 71.42# 29582 15.10 14.35 16.5029583 40.60 38.57 44.36# 29583 11.07 10.52 12.1029584 65.37 62.10 71.42# 29584 15.10 14.35 16.5029590 50.62 48.09 55.30# 29590 37.11 35.25 40.5429700 62.31 59.19 68.07# 29700 33.72 32.03 36.8329705 63.54 60.36 69.41# 29705 45.94 43.64 50.1929710 105.07 99.82 114.79# 29710 77.74 73.85 84.9329715 83.17 79.01 90.86# 29715 53.64 50.96 58.6029720 78.41 74.49 85.66# 29720 42.59 40.46 46.5329730 62.20 59.09 67.95# 29730 43.98 41.78 48.0529740 87.71 83.32 95.82# 29740 63.84 60.65 69.7529750 99.47 94.50 108.68# 29750 75.91 72.11 82.9329800 500.81 475.77 547.1429804 631.32 599.75 689.7129805 456.48 433.66 498.7129806 1,036.26 984.45 1,132.1229807 1,009.04 958.59 1,102.3829819 569.28 540.82 621.9429820 524.44 498.22 572.9529821 575.03 546.28 628.2229822 558.94 530.99 610.6429823 610.59 580.06 667.07# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.73 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE29824 657.84 624.95 718.6929825 568.97 540.52 621.6029826 175.42 166.65 191.6529827 1,053.02 1,000.37 1,150.4329828 899.70 854.72 982.9329830 440.32 418.30 481.0529834 477.80 453.91 522.0029835 490.61 466.08 535.9929836 566.27 537.96 618.6529837 514.29 488.58 561.8729838 574.13 545.42 627.2329840 440.23 418.22 480.9529843 467.31 443.94 510.5329844 484.12 459.91 528.9029845 558.53 530.60 610.1929846 506.05 480.75 552.8629847 526.45 500.13 575.1529848 492.87 468.23 538.4629850 544.65 517.42 595.0329851 907.91 862.51 991.8929855 764.78 726.54 835.5229856 972.31 923.69 1,062.2429860 644.75 612.51 704.3929861 706.38 671.06 771.7229862 795.10 755.35 868.6529863 795.15 755.39 868.7029866 1,020.86 969.82 1,115.2929867 1,244.00 1,181.80 1,359.0729868 1,636.40 1,554.58 1,787.7729870 564.38 536.16 616.58# 29870 398.50 378.58 435.3729871 497.81 472.92 543.8629873 504.35 479.13 551.0029874 522.50 496.38 570.8429875 480.64 456.61 525.1029876 637.29 605.43 696.2429877 604.42 574.20 660.3329879 644.36 612.14 703.9629880 555.95 528.15 607.37# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.74 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE29881 532.93 506.28 582.2229882 679.54 645.56 742.3929883 819.84 778.85 895.6829884 603.11 572.95 658.8929885 729.44 692.97 796.9229886 615.79 585.00 672.7529887 726.11 689.80 793.2729888 966.56 918.23 1,055.9629889 1,182.00 1,122.90 1,291.3429891 669.10 635.65 731.0029892 627.54 596.16 685.5829893 577.01 548.16 630.38# 29893 412.07 391.47 450.1929894 500.03 475.03 546.2829895 475.45 451.68 519.4329897 503.20 478.04 549.7529898 556.78 528.94 608.2829899 1,018.51 967.58 1,112.7229900 450.37 427.85 492.0329901 517.55 491.67 565.4229902 583.84 554.65 637.8529904 615.73 584.94 672.6829905 665.79 632.50 727.3829906 700.72 665.68 765.5329907 848.43 806.01 926.9129914 997.61 947.73 1,089.8929915 1,016.27 965.46 1,110.2829916 1,016.27 965.46 1,110.2830000 223.95 212.75 244.66# 30000 116.82 110.98 127.6330020 223.53 212.35 244.20# 30020 116.72 110.88 127.5130100 136.85 130.01 149.51# 30100 67.73 64.34 73.99# 30110 128.07 121.67 139.9230110 222.64 211.51 243.2430115 419.38 398.41 458.1730117 834.64 792.91 911.85# 30117 327.89 311.50 358.23# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.75 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE30118 751.32 713.75 820.8130120 504.32 479.10 550.97# 30120 430.49 408.97 470.3230124 275.90 262.11 301.4330125 595.85 566.06 650.9730130 368.49 350.07 402.5830140 425.67 404.39 465.0530150 757.18 719.32 827.2230160 761.10 723.05 831.5130200 110.30 104.79 120.51# 30200 58.78 55.84 64.2230210 145.03 137.78 158.45# 30210 97.28 92.42 106.2830220 290.84 276.30 317.75# 30220 123.39 117.22 134.8030300 221.90 210.81 242.43# 30300 121.99 115.89 133.2730310 200.72 190.68 219.2830320 440.52 418.49 481.2630400 990.75 941.21 1,082.3930410 1,250.15 1,187.64 1,365.7930420 1,342.11 1,275.00 1,466.2530430 906.80 861.46 990.6830435 1,105.23 1,049.97 1,207.4730450 1,482.83 1,408.69 1,619.9930460 746.11 708.80 815.1230462 1,542.07 1,464.97 1,684.7230465 961.86 913.77 1,050.8430520 605.94 575.64 661.9930540 667.98 634.58 729.7730545 897.55 852.67 980.5730560 261.63 248.55 285.83# 30560 135.02 128.27 147.5130580 613.30 582.64 670.04# 30580 485.44 461.17 530.3530600 558.50 530.58 610.17# 30600 422.78 401.64 461.8930620 605.81 575.52 661.8530630 610.58 580.05 667.06# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.76 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE30801 220.14 209.13 240.50# 30801 132.18 125.57 144.4130802 281.69 267.61 307.75# 30802 185.55 176.27 202.7130901 93.53 88.85 102.18# 30901 56.46 53.64 61.6930903 195.56 185.78 213.65# 30903 79.95 75.95 87.3430905 243.22 231.06 265.72# 30905 101.22 96.16 110.5830906 271.65 258.07 296.78# 30906 131.53 124.95 143.6930915 565.41 537.14 617.7130920 817.47 776.60 893.0930930 120.57 114.54 131.7231000 173.49 164.82 189.54# 31000 101.55 96.47 110.9431002 194.62 184.89 212.6231020 466.78 443.44 509.96# 31020 346.14 328.83 378.1531030 664.15 630.94 725.58# 31030 506.75 481.41 553.6231032 557.20 529.34 608.7431040 743.16 706.00 811.9031050 473.62 449.94 517.4331051 628.61 597.18 686.7631070 426.97 405.62 466.4631075 764.25 726.04 834.9531080 1,002.21 952.10 1,094.9231081 1,417.17 1,346.31 1,548.2631084 1,135.11 1,078.35 1,240.1031085 1,307.99 1,242.59 1,428.9831086 1,096.46 1,041.64 1,197.8931087 1,062.19 1,009.08 1,160.4431090 992.28 942.67 1,084.0731200 536.73 509.89 586.3731201 720.00 684.00 786.6031205 864.72 821.48 944.7031225 1,827.16 1,735.80 1,996.17# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.77 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE31230 2,037.61 1,935.73 2,226.0931231 185.38 176.11 202.53# 31231 75.42 71.65 82.4031233 258.80 245.86 282.74# 31233 136.28 129.47 148.8931235 292.25 277.64 319.29# 31235 160.30 152.29 175.1331237 316.95 301.10 346.27# 31237 179.98 170.98 196.6331238 326.01 309.71 356.17# 31238 195.31 185.54 213.3731239 665.23 631.97 726.7731240 159.96 151.96 174.7531254 272.13 258.52 297.3031255 398.96 379.01 435.8631256 196.65 186.82 214.8431267 316.17 300.36 345.4131276 503.85 478.66 550.4631287 231.39 219.82 252.7931288 268.49 255.07 293.3331290 1,148.91 1,091.46 1,255.1831291 1,222.06 1,160.96 1,335.1031292 991.48 941.91 1,083.2031293 1,076.34 1,022.52 1,175.9031294 1,233.65 1,171.97 1,347.7731295 2,004.09 1,903.89 2,189.47# 31295 167.47 159.10 182.9731296 2,033.00 1,931.35 2,221.05# 31296 199.84 189.85 218.3331297 1,997.29 1,897.43 2,182.04# 31297 164.12 155.91 179.3031300 1,236.51 1,174.68 1,350.8831320 638.13 606.22 697.1531360 2,036.91 1,935.06 2,225.3231365 2,523.43 2,397.26 2,756.8531367 2,161.41 2,053.34 2,361.3431368 2,397.57 2,277.69 2,619.3431370 2,028.89 1,927.45 2,216.5731375 1,924.79 1,828.55 2,102.83# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.78 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE31380 1,896.42 1,801.60 2,071.8431382 2,081.89 1,977.80 2,274.4731390 2,813.06 2,672.41 3,073.2731395 2,950.48 2,802.96 3,223.4031400 979.10 930.15 1,069.6731420 821.42 780.35 897.4031500 109.44 103.97 119.5731502 34.41 32.69 37.5931505 80.49 76.47 87.94# 31505 48.13 45.72 52.5831510 206.45 196.13 225.55# 31510 120.37 114.35 131.5031511 207.01 196.66 226.16# 31511 128.78 122.34 140.6931512 203.75 193.56 222.59# 31512 129.92 123.42 141.9331513 131.57 124.99 143.7431515 203.21 193.05 222.01# 31515 109.59 104.11 119.7331520 156.01 148.21 170.4431525 246.72 234.38 269.54# 31525 159.07 151.12 173.7931526 157.29 149.43 171.8431527 194.71 184.97 212.7231528 144.73 137.49 158.1131529 161.71 153.62 176.6631530 198.29 188.38 216.6431531 212.69 202.06 232.3731535 189.71 180.22 207.2531536 211.35 200.78 230.9031540 242.77 230.63 265.2231541 265.48 252.21 290.0431545 363.56 345.38 397.1931546 551.97 524.37 603.0331560 314.60 298.87 343.7031561 343.70 326.52 375.5031570 334.77 318.03 365.73# 31570 228.90 217.46 250.0831571 250.10 237.60 273.24# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.79 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE31575 111.55 105.97 121.87# 31575 75.11 71.35 82.0531576 219.05 208.10 239.32# 31576 122.60 116.47 133.9431577 235.88 224.09 257.70# 31577 147.92 140.52 161.6031578 274.65 260.92 300.06# 31578 170.66 162.13 186.4531579 208.80 198.36 228.11# 31579 140.62 133.59 153.6331580 1,194.79 1,135.05 1,305.3131582 1,863.95 1,770.75 2,036.3631584 1,484.56 1,410.33 1,621.8831587 986.56 937.23 1,077.8131588 1,121.76 1,065.67 1,225.5231590 870.44 826.92 950.9631595 749.85 712.36 819.2131600 396.13 376.32 432.7731601 258.84 245.90 282.7931603 222.57 211.44 243.1631605 182.14 173.03 198.9831610 700.95 665.90 765.7931611 528.77 502.33 577.6831612 79.59 75.61 86.95# 31612 47.23 44.87 51.6031613 441.93 419.83 482.8031614 737.24 700.38 805.4431615 178.30 169.39 194.80# 31615 127.10 120.75 138.8631620 265.65 252.37 290.23# 31620 67.10 63.75 73.3131622 303.35 288.18 331.41# 31622 145.32 138.05 158.7631623 321.12 305.06 350.82# 31623 144.87 137.63 158.2731624 302.59 287.46 330.58# 31624 145.50 138.23 158.9631625 325.77 309.48 355.90# 31625 168.69 160.26 184.30# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.80 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE31626 429.34 407.87 469.05# 31626 203.46 193.29 222.2831627 1,220.19 1,159.18 1,333.06# 31627 93.90 89.21 102.5931628 373.37 354.70 407.91# 31628 187.07 177.72 204.3831629 585.76 556.47 639.94# 31629 201.54 191.46 220.1831630 201.55 191.47 220.1931631 228.98 217.53 250.1631632 69.65 66.17 76.10# 31632 48.60 46.17 53.1031633 85.33 81.06 93.22# 31633 62.39 59.27 68.1631634 2,051.07 1,948.52 2,240.80# 31634 210.99 200.44 230.5131635 338.92 321.97 370.27# 31635 187.18 177.82 204.4931636 222.97 211.82 243.5931637 75.38 71.61 82.3531638 256.36 243.54 280.0731640 257.07 244.22 280.8531641 256.74 243.90 280.4931643 174.27 165.56 190.3931645 303.47 288.30 331.55# 31645 158.95 151.00 173.6531646 274.52 260.79 299.91# 31646 138.17 131.26 150.9531656 291.75 277.16 318.73# 31656 107.96 102.56 117.9431715 52.00 49.40 56.8131717 263.03 249.88 287.36# 31717 107.83 102.44 117.8131720 50.61 48.08 55.2931725 93.47 88.80 102.1231730 1,050.23 997.72 1,147.38# 31730 146.37 139.05 159.9131750 1,334.05 1,267.35 1,457.4531755 1,687.05 1,602.70 1,843.11# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.81 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE31760 1,388.48 1,319.06 1,516.9231766 1,867.80 1,774.41 2,040.5731770 1,349.15 1,281.69 1,473.9431775 1,409.43 1,338.96 1,539.8031780 1,184.60 1,125.37 1,294.1831781 1,415.07 1,344.32 1,545.9731785 1,069.54 1,016.06 1,168.4731786 1,470.41 1,396.89 1,606.4231800 696.46 661.64 760.8931805 823.73 782.54 899.9231820 426.74 405.40 466.21# 31820 325.26 309.00 355.3531825 592.41 562.79 647.21# 31825 476.79 452.95 520.8931830 430.65 409.12 470.49# 31830 337.34 320.47 368.5432035 721.28 685.22 788.0032036 781.80 742.71 854.1232096 813.89 773.20 889.1832097 813.89 773.20 889.1832098 764.78 726.54 835.5232100 837.29 795.43 914.7432110 1,475.86 1,402.07 1,612.3832120 882.13 838.02 963.7232124 939.03 892.08 1,025.8932140 1,002.67 952.54 1,095.4232141 1,546.95 1,469.60 1,690.0432150 1,012.71 962.07 1,106.3832151 1,019.51 968.53 1,113.8132160 786.23 746.92 858.9632200 1,145.04 1,087.79 1,250.9632201 870.02 826.52 950.50# 32201 196.13 186.32 214.2732215 804.93 764.68 879.3832220 1,606.96 1,526.61 1,755.6032225 1,006.82 956.48 1,099.9532310 930.16 883.65 1,016.2032320 1,614.96 1,534.21 1,764.3432400 143.11 135.95 156.34# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.82 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 32400 86.56 82.23 94.5632405 220.21 209.20 240.58# 32405 100.20 95.19 109.4732420 108.38 102.96 118.4032421 146.42 139.10 159.97# 32421 75.11 71.35 82.0532422 186.22 176.91 203.45# 32422 120.25 114.24 131.3832440 1,589.74 1,510.25 1,736.7932442 3,100.53 2,945.50 3,387.3332445 3,565.76 3,387.47 3,895.5932480 1,503.68 1,428.50 1,642.7832482 1,608.05 1,527.65 1,756.8032484 1,459.37 1,386.40 1,594.3632486 2,393.99 2,274.29 2,615.4332488 2,421.15 2,300.09 2,645.1032491 1,494.36 1,419.64 1,632.5932501 250.79 238.25 273.9932503 1,847.43 1,755.06 2,018.3232504 2,084.69 1,980.46 2,277.5332505 937.94 891.04 1,024.7032506 159.68 151.70 174.4632507 159.68 151.70 174.4632540 1,742.53 1,655.40 1,903.7132550 756.73 718.89 826.72# 32550 224.22 213.01 244.9632551 170.18 161.67 185.9232552 188.37 178.95 205.79# 32552 164.81 156.57 180.0632553 559.10 531.15 610.82# 32553 207.55 197.17 226.7532560 242.57 230.44 265.01# 32560 81.09 77.04 88.6032561 92.17 87.56 100.69# 32561 70.81 67.27 77.3632562 83.25 79.09 90.95# 32562 63.46 60.29 69.3332601 314.52 298.79 343.6132604 490.55 466.02 535.92# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.83 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE32606 470.16 446.65 513.6532607 312.64 297.01 341.5632608 384.34 365.12 419.8932609 265.40 252.13 289.9532650 673.13 639.47 735.3932651 1,100.48 1,045.46 1,202.2832652 1,673.04 1,589.39 1,827.8032653 1,063.38 1,010.21 1,161.7432654 1,186.53 1,127.20 1,296.2832655 964.66 916.43 1,053.8932656 805.91 765.61 880.4532658 723.27 687.11 790.1832659 740.15 703.14 808.6132661 809.20 768.74 884.0532662 905.25 859.99 988.9932663 1,421.40 1,350.33 1,552.8832664 858.71 815.77 938.1432665 1,230.71 1,169.17 1,344.5532666 876.71 832.87 957.8032667 159.68 151.70 174.4632668 160.72 152.68 175.5832669 1,355.00 1,287.25 1,480.3432670 1,618.28 1,537.37 1,767.9832671 1,798.47 1,708.55 1,964.8332672 1,537.17 1,460.31 1,679.3632673 1,208.48 1,148.06 1,320.2732674 218.83 207.89 239.0732800 950.80 903.26 1,038.7532810 910.85 865.31 995.1132815 2,828.95 2,687.50 3,090.6332820 1,350.70 1,283.17 1,475.6532851 3,353.04 3,185.39 3,663.2032852 3,675.20 3,491.44 4,015.1632853 4,642.17 4,410.06 5,071.5732854 4,944.14 4,696.93 5,401.4732855 284.86 270.62 311.2132856 344.86 327.62 376.7632900 1,402.85 1,332.71 1,532.6232905 1,354.48 1,286.76 1,479.77# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.84 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE32906 1,676.74 1,592.90 1,831.8432940 1,248.59 1,186.16 1,364.0832960 136.35 129.53 148.96# 32960 103.67 98.49 113.2632997 353.24 335.58 385.9232998 2,733.21 2,596.55 2,986.03# 32998 286.80 272.46 313.3333010 120.89 114.85 132.0833011 122.03 115.93 133.3233015 512.88 487.24 560.3333020 888.23 843.82 970.3933025 812.34 771.72 887.4833030 2,005.51 1,905.23 2,191.0133031 2,469.89 2,346.40 2,698.3633050 1,017.39 966.52 1,111.5033120 2,124.17 2,017.96 2,320.6533130 1,416.01 1,345.21 1,546.9933140 1,619.98 1,538.98 1,769.8333141 138.18 131.27 150.9633202 788.59 749.16 861.5333203 820.11 779.10 895.9733206 459.08 436.13 501.5533207 488.26 463.85 533.4333208 527.65 501.27 576.4633210 181.51 172.43 198.2933211 185.40 176.13 202.5533212 332.73 316.09 363.5033213 350.75 333.21 383.1933214 483.91 459.71 528.6733215 305.72 290.43 333.9933216 376.13 357.32 410.9233217 374.48 355.76 409.1233218 392.87 373.23 429.2133220 396.27 376.46 432.9333221 352.12 334.51 384.6933222 345.77 328.48 377.7533223 415.25 394.49 453.6633224 512.06 486.46 559.4333225 460.97 437.92 503.61# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.85 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE33226 492.81 468.17 538.4033227 335.95 319.15 367.0233228 350.47 332.95 382.8933229 364.98 346.73 398.7433230 379.21 360.25 414.2933231 393.72 374.03 430.1333233 237.14 225.28 259.0733234 488.38 463.96 533.5533235 637.53 605.65 696.5033236 801.60 761.52 875.7533237 840.31 798.29 918.0333238 954.70 906.97 1,043.0233240 386.06 366.76 421.7733241 222.96 211.81 243.5833243 1,390.73 1,321.19 1,519.3733244 857.28 814.42 936.5833249 910.48 864.96 994.7033250 1,498.03 1,423.13 1,636.6033251 1,663.56 1,580.38 1,817.4433254 1,398.81 1,328.87 1,528.2033255 1,685.49 1,601.22 1,841.4033256 2,012.73 1,912.09 2,198.9033257 594.68 564.95 649.6933258 668.03 634.63 729.8233259 864.34 821.12 944.2933261 1,671.57 1,587.99 1,826.1933262 365.35 347.08 399.1433263 379.86 360.87 415.0033264 394.38 374.66 430.8633265 1,383.33 1,314.16 1,511.2833266 1,891.56 1,796.98 2,066.5333282 321.60 305.52 351.3533284 229.95 218.45 251.2233300 2,491.36 2,366.79 2,721.8133305 4,186.06 3,976.76 4,573.2733310 1,185.26 1,126.00 1,294.9033315 1,946.58 1,849.25 2,126.6433320 1,084.72 1,030.48 1,185.0533321 1,216.66 1,155.83 1,329.20# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.86 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE33322 1,420.21 1,349.20 1,551.5833330 1,459.03 1,386.08 1,593.9933332 1,433.76 1,362.07 1,566.3833335 1,931.27 1,834.71 2,109.9233400 2,336.04 2,219.24 2,552.1333401 1,440.95 1,368.90 1,574.2433403 1,530.90 1,454.36 1,672.5133404 1,798.86 1,708.92 1,965.2633405 2,347.65 2,230.27 2,564.8133406 2,951.12 2,803.56 3,224.0933410 2,608.38 2,477.96 2,849.6533411 3,446.72 3,274.38 3,765.5433412 3,261.32 3,098.25 3,562.9933413 3,320.82 3,154.78 3,628.0033414 2,219.30 2,108.34 2,424.5933415 2,099.48 1,994.51 2,293.6933416 2,082.10 1,978.00 2,274.7033417 1,703.11 1,617.95 1,860.6433420 1,463.44 1,390.27 1,598.8133422 1,727.73 1,641.34 1,887.5433425 2,791.83 2,652.24 3,050.0833426 2,449.79 2,327.30 2,676.4033427 2,520.09 2,394.09 2,753.2033430 2,879.28 2,735.32 3,145.6233460 2,491.22 2,366.66 2,721.6633463 3,161.88 3,003.79 3,454.3633464 2,504.58 2,379.35 2,736.2533465 2,824.84 2,683.60 3,086.1433468 2,511.84 2,386.25 2,744.1933470 1,258.42 1,195.50 1,374.8333471 1,358.03 1,290.13 1,483.6533472 1,377.66 1,308.78 1,505.1033474 2,198.44 2,088.52 2,401.8033475 2,401.61 2,281.53 2,623.7633476 1,555.66 1,477.88 1,699.5633478 1,614.74 1,534.00 1,764.1033496 1,709.18 1,623.72 1,867.2833500 1,618.43 1,537.51 1,768.1433501 1,152.71 1,095.07 1,259.33# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.87 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE33502 1,305.25 1,239.99 1,425.9933503 1,330.42 1,263.90 1,453.4933504 1,502.97 1,427.82 1,641.9933505 2,123.83 2,017.64 2,320.2933506 2,100.23 1,995.22 2,294.5033507 1,760.97 1,672.92 1,923.8633508 16.55 15.72 18.0833510 1,993.03 1,893.38 2,177.3933511 2,187.88 2,078.49 2,390.2633512 2,484.93 2,360.68 2,714.7833513 2,552.61 2,424.98 2,788.7333514 2,698.27 2,563.36 2,947.8633516 2,814.22 2,673.51 3,074.5433517 192.81 183.17 210.6533518 423.93 402.73 463.1433519 561.22 533.16 613.1333521 674.92 641.17 737.3533522 759.10 721.15 829.3233523 862.19 819.08 941.9433530 540.30 513.29 590.2833533 1,929.03 1,832.58 2,107.4733534 2,264.90 2,151.66 2,474.4133535 2,524.45 2,398.23 2,757.9633536 2,721.03 2,584.98 2,972.7333542 2,692.19 2,557.58 2,941.2233545 3,168.82 3,010.38 3,461.9433548 3,056.54 2,903.71 3,339.2733572 238.81 226.87 260.9033600 1,746.72 1,659.38 1,908.2933602 1,668.42 1,585.00 1,822.7533606 1,852.75 1,760.11 2,024.1333608 1,835.04 1,743.29 2,004.7833610 1,808.41 1,717.99 1,975.6933611 2,066.75 1,963.41 2,257.9233612 2,021.45 1,920.38 2,208.4433615 2,043.48 1,941.31 2,232.5133617 2,202.62 2,092.49 2,406.3633619 2,754.75 2,617.01 3,009.5633620 1,687.68 1,603.30 1,843.80# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.88 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE33621 905.26 860.00 989.0033622 3,550.05 3,372.55 3,878.4333641 1,675.26 1,591.50 1,830.2333645 1,776.56 1,687.73 1,940.8933647 1,877.71 1,783.82 2,051.3933660 1,808.17 1,717.76 1,975.4233665 1,973.91 1,875.21 2,156.4933670 2,040.40 1,938.38 2,229.1433675 2,031.39 1,929.82 2,219.2933676 2,151.83 2,044.24 2,350.8833677 2,236.24 2,124.43 2,443.0933681 1,876.57 1,782.74 2,050.1533684 1,950.27 1,852.76 2,130.6733688 1,941.71 1,844.62 2,121.3133690 1,213.04 1,152.39 1,325.2533692 2,019.99 1,918.99 2,206.8433694 2,015.86 1,915.07 2,202.3333697 2,107.11 2,001.75 2,302.0133702 1,588.42 1,509.00 1,735.3533710 2,113.63 2,007.95 2,309.1433720 1,577.54 1,498.66 1,723.4633722 1,710.32 1,624.80 1,868.5233724 1,577.28 1,498.42 1,723.1833726 2,105.06 1,999.81 2,299.7833730 2,128.06 2,021.66 2,324.9133732 1,695.60 1,610.82 1,852.4433735 1,308.29 1,242.88 1,429.3133736 1,441.68 1,369.60 1,575.0433737 1,344.89 1,277.65 1,469.3033750 1,407.97 1,337.57 1,538.2133755 1,342.96 1,275.81 1,467.1833762 1,372.02 1,303.42 1,498.9333764 1,312.88 1,247.24 1,434.3333766 1,386.66 1,317.33 1,514.9333767 1,460.62 1,387.59 1,595.7333768 447.44 425.07 488.8333770 2,226.13 2,114.82 2,432.0433771 2,273.06 2,159.41 2,483.3233774 1,852.69 1,760.06 2,024.07# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.89 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE33775 1,957.06 1,859.21 2,138.0933776 2,066.22 1,962.91 2,257.3533777 2,006.98 1,906.63 2,192.6233778 2,430.48 2,308.96 2,655.3033779 2,483.64 2,359.46 2,713.3833780 2,534.84 2,408.10 2,769.3233781 2,395.31 2,275.54 2,616.8733782 3,270.41 3,106.89 3,572.9233783 3,541.60 3,364.52 3,869.2033786 2,354.36 2,236.64 2,572.1433788 1,580.39 1,501.37 1,726.5833800 958.31 910.39 1,046.9533802 1,107.13 1,051.77 1,209.5433803 1,217.65 1,156.77 1,330.2933813 1,275.66 1,211.88 1,393.6633814 1,624.15 1,542.94 1,774.3833820 996.65 946.82 1,088.8433822 1,072.92 1,019.27 1,172.1633824 1,196.58 1,136.75 1,307.2633840 1,286.67 1,222.34 1,405.6933845 1,379.80 1,310.81 1,507.4333851 1,351.56 1,283.98 1,476.5833852 1,422.90 1,351.76 1,554.5233853 1,896.93 1,802.08 2,072.3933860 3,291.04 3,126.49 3,595.4633863 3,237.49 3,075.62 3,536.9633864 3,311.86 3,146.27 3,618.2133870 2,589.13 2,459.67 2,828.6233875 2,808.29 2,667.88 3,068.0633877 3,720.21 3,534.20 4,064.3333880 1,871.05 1,777.50 2,044.1333881 1,610.16 1,529.65 1,759.1033883 1,165.65 1,107.37 1,273.4833884 426.80 405.46 466.2833886 1,012.54 961.91 1,106.2033889 833.67 791.99 910.7933891 1,027.63 976.25 1,122.6933910 2,661.82 2,528.73 2,908.0433915 1,398.42 1,328.50 1,527.78# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.90 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE33916 4,197.27 3,987.41 4,585.5233917 1,492.83 1,418.19 1,630.9233920 1,864.12 1,770.91 2,036.5533922 1,479.38 1,405.41 1,616.2233924 292.50 277.88 319.5633925 1,759.93 1,671.93 1,922.7233926 2,486.27 2,361.96 2,716.2533933 398.19 378.28 435.0233935 5,052.29 4,799.68 5,519.6333944 279.97 265.97 305.8733945 4,958.25 4,710.34 5,416.8933960 1,012.77 962.13 1,106.4533961 555.85 528.06 607.2733967 267.50 254.13 292.2533968 34.73 32.99 37.9433970 366.65 348.32 400.5733971 725.82 689.53 792.9633973 531.91 505.31 581.1133974 908.26 862.85 992.2833975 1,340.45 1,273.43 1,464.4433976 1,642.78 1,560.64 1,794.7433977 1,183.30 1,124.14 1,292.7633978 1,404.51 1,334.28 1,534.4233979 2,038.59 1,936.66 2,227.1633980 1,970.54 1,872.01 2,152.8133981 859.87 816.88 939.4133982 2,010.77 1,910.23 2,196.7633983 2,361.07 2,243.02 2,579.4734001 1,009.90 959.41 1,103.3234051 960.40 912.38 1,049.2434101 631.19 599.63 689.5734111 631.72 600.13 690.1534151 1,462.03 1,388.93 1,597.2734201 1,078.02 1,024.12 1,177.7434203 1,006.28 955.97 1,099.3734401 1,492.85 1,418.21 1,630.9434421 764.84 726.60 835.5934451 1,532.25 1,455.64 1,673.9934471 1,229.11 1,167.65 1,342.80# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.91 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE34490 641.94 609.84 701.3234501 951.56 903.98 1,039.5834502 1,573.14 1,494.48 1,718.6534510 1,174.67 1,115.94 1,283.3334520 1,053.08 1,000.43 1,150.4934530 983.66 934.48 1,074.6534800 1,175.61 1,116.83 1,284.3534802 1,299.70 1,234.72 1,419.9334803 1,340.72 1,273.68 1,464.7334804 1,300.26 1,235.25 1,420.5434805 1,243.42 1,181.25 1,358.4434806 107.23 101.87 117.1534808 214.45 203.73 234.2934812 352.42 334.80 385.0234813 248.30 235.89 271.2734820 507.30 481.94 554.2334825 726.44 690.12 793.6434826 214.35 203.63 234.1734830 1,877.51 1,783.63 2,051.1734831 2,011.78 1,911.19 2,197.8734832 2,019.00 1,918.05 2,205.7634833 637.47 605.60 696.4434834 287.20 272.84 313.7734900 930.00 883.50 1,016.0335001 1,184.99 1,125.74 1,294.6035002 1,305.55 1,240.27 1,426.3135005 1,112.53 1,056.90 1,215.4435011 1,044.53 992.30 1,141.1535013 1,295.09 1,230.34 1,414.8935021 1,269.93 1,206.43 1,387.3935022 1,468.93 1,395.48 1,604.8035045 1,019.95 968.95 1,114.2935081 1,838.70 1,746.77 2,008.7935082 2,294.65 2,179.92 2,506.9135091 1,890.17 1,795.66 2,065.0135092 2,735.67 2,598.89 2,988.7235102 1,985.04 1,885.79 2,168.6635103 2,353.40 2,235.73 2,571.0935111 1,393.01 1,323.36 1,521.86# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.92 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE35112 1,862.54 1,769.41 2,034.8235121 1,714.92 1,629.17 1,873.5535122 2,152.01 2,044.41 2,351.0735131 1,462.99 1,389.84 1,598.3235132 1,788.36 1,698.94 1,953.7835141 1,163.31 1,105.14 1,270.9135142 1,395.00 1,325.25 1,524.0435151 1,312.72 1,247.08 1,434.1435152 1,490.31 1,415.79 1,628.1635180 928.24 881.83 1,014.1035182 1,789.33 1,699.86 1,954.8435184 1,067.36 1,013.99 1,166.0935188 1,101.49 1,046.42 1,203.3835189 1,624.79 1,543.55 1,775.0835190 784.90 745.66 857.5135201 971.31 922.74 1,061.1535206 800.77 760.73 874.8435207 736.66 699.83 804.8035211 1,420.83 1,349.79 1,552.2635216 2,074.78 1,971.04 2,266.7035221 1,477.62 1,403.74 1,614.3035226 871.91 828.31 952.5635231 1,249.23 1,186.77 1,364.7935236 1,020.24 969.23 1,114.6135241 1,486.65 1,412.32 1,624.1735246 1,532.03 1,455.43 1,673.7435251 1,746.43 1,659.11 1,907.9835256 1,064.07 1,010.87 1,162.5035261 1,097.88 1,042.99 1,199.4435266 901.13 856.07 984.4835271 1,426.69 1,355.36 1,558.6635276 1,487.90 1,413.51 1,625.5435281 1,670.80 1,587.26 1,825.3535286 978.33 929.41 1,068.8235301 1,100.75 1,045.71 1,202.5735302 1,180.98 1,121.93 1,290.2235303 1,299.95 1,234.95 1,420.1935304 1,340.74 1,273.70 1,464.7635305 1,293.04 1,228.39 1,412.65# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.93 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE35306 473.70 450.02 517.5235311 1,598.98 1,519.03 1,746.8835321 935.60 888.82 1,022.1435331 1,530.97 1,454.42 1,672.5835341 1,444.07 1,371.87 1,577.6535351 1,347.36 1,279.99 1,471.9935355 1,094.18 1,039.47 1,195.3935361 1,622.05 1,540.95 1,772.0935363 1,818.91 1,727.96 1,987.1535371 861.89 818.80 941.6235372 1,030.90 979.36 1,126.2635390 167.19 158.83 182.6535400 156.70 148.87 171.2035450 536.73 509.89 586.3735452 371.83 353.24 406.2335458 511.76 486.17 559.1035460 326.48 310.16 356.6835471 2,622.14 2,491.03 2,864.68# 35471 545.49 518.22 595.9535472 1,947.94 1,850.54 2,128.12# 35472 374.91 356.16 409.5835475 2,197.64 2,087.76 2,400.92# 35475 495.48 470.71 541.3235476 1,658.94 1,575.99 1,812.39# 35476 313.67 297.99 342.6935500 336.30 319.49 367.4135501 1,599.32 1,519.35 1,747.2535506 1,405.44 1,335.17 1,535.4535508 1,429.71 1,358.22 1,561.9535509 1,514.24 1,438.53 1,654.3135510 1,312.87 1,247.23 1,434.3135511 1,305.28 1,240.02 1,426.0235512 1,285.93 1,221.63 1,404.8735515 1,405.13 1,334.87 1,535.1035516 1,291.78 1,227.19 1,411.2735518 1,222.13 1,161.02 1,335.1735521 1,305.97 1,240.67 1,426.7735522 1,248.44 1,186.02 1,363.9235523 1,344.00 1,276.80 1,468.32# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.94 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE35525 1,198.97 1,139.02 1,309.8735526 1,790.13 1,700.62 1,955.7135531 2,114.41 2,008.69 2,309.9935533 1,606.62 1,526.29 1,755.2335535 1,805.51 1,715.23 1,972.5135536 1,798.06 1,708.16 1,964.3835537 2,221.67 2,110.59 2,427.1835538 2,490.05 2,365.55 2,720.3835539 2,330.73 2,214.19 2,546.3235540 2,680.49 2,546.47 2,928.4435556 1,473.53 1,399.85 1,609.8335558 1,299.53 1,234.55 1,419.7335560 1,818.30 1,727.39 1,986.5035563 1,533.08 1,456.43 1,674.8935565 1,390.96 1,321.41 1,519.6235566 1,762.32 1,674.20 1,925.3335570 1,441.06 1,369.01 1,574.3635571 1,404.98 1,334.73 1,534.9435572 362.54 344.41 396.0735583 1,517.15 1,441.29 1,657.4835585 1,768.42 1,680.00 1,932.0035587 1,448.37 1,375.95 1,582.3435600 266.16 252.85 290.7835601 1,489.87 1,415.38 1,627.6935606 1,237.01 1,175.16 1,351.4335612 1,107.23 1,051.87 1,209.6535616 1,154.12 1,096.41 1,260.8735621 1,161.00 1,102.95 1,268.3935623 1,398.16 1,328.25 1,527.4935626 1,630.06 1,548.56 1,780.8435631 1,944.31 1,847.09 2,124.1535632 1,714.43 1,628.71 1,873.0235633 1,883.19 1,789.03 2,057.3835634 1,714.50 1,628.78 1,873.1035636 1,699.37 1,614.40 1,856.5635637 1,817.06 1,726.21 1,985.1435638 1,853.32 1,760.65 2,024.7535642 1,160.54 1,102.51 1,267.8935645 1,015.60 964.82 1,109.54# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.95 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE35646 1,809.66 1,719.18 1,977.0635647 1,631.52 1,549.94 1,782.4335650 1,123.76 1,067.57 1,227.7135654 1,443.36 1,371.19 1,576.8735656 1,139.57 1,082.59 1,244.9835661 1,144.23 1,087.02 1,250.0735663 1,326.78 1,260.44 1,449.5135665 1,237.64 1,175.76 1,352.1235666 1,338.49 1,271.57 1,462.3135671 1,179.97 1,120.97 1,289.1235681 83.95 79.75 91.7135682 374.25 355.54 408.8735683 435.58 413.80 475.8735685 209.99 199.49 229.4135686 174.28 165.57 190.4135691 1,007.76 957.37 1,100.9835693 986.29 936.98 1,077.5335694 1,049.67 997.19 1,146.7735695 1,091.30 1,036.74 1,192.2535697 156.12 148.31 170.5635700 161.14 153.08 176.0435701 576.23 547.42 629.5335721 470.91 447.36 514.4635741 530.01 503.51 579.0435761 395.18 375.42 431.7335800 709.74 674.25 775.3935820 2,049.76 1,947.27 2,239.3635840 1,161.63 1,103.55 1,269.0835860 851.79 809.20 930.5835870 1,324.31 1,258.09 1,446.8035875 624.26 593.05 682.0135876 996.29 946.48 1,088.4535879 975.70 926.92 1,065.9635881 1,078.68 1,024.75 1,178.4635883 1,268.48 1,205.06 1,385.8235884 1,315.11 1,249.35 1,436.7535901 519.98 493.98 568.0835903 589.54 560.06 644.0735905 1,789.98 1,700.48 1,955.55# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.96 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE35907 2,013.12 1,912.46 2,199.3336002 159.31 151.34 174.04# 36002 107.79 102.40 117.7636005 327.41 311.04 357.70# 36005 48.74 46.30 53.2536010 514.86 489.12 562.49# 36010 122.78 116.64 134.1436011 860.55 817.52 940.15# 36011 159.02 151.07 173.7336012 855.32 812.55 934.43# 36012 179.23 170.27 195.8136013 791.43 751.86 864.64# 36013 131.68 125.10 143.8736014 807.23 766.87 881.90# 36014 150.62 143.09 164.5536015 875.94 832.14 956.96# 36015 174.09 165.39 190.2036100 511.08 485.53 558.36# 36100 164.24 156.03 179.4336120 431.03 409.48 470.90# 36120 102.10 97.00 111.5536140 447.98 425.58 489.42# 36140 105.23 99.97 114.9736147 821.84 780.75 897.86# 36147 186.60 177.27 203.8636148 252.35 239.73 275.69# 36148 49.09 46.64 53.6436160 506.13 480.82 552.94# 36160 130.08 123.58 142.1236200 637.66 605.78 696.65# 36200 157.61 149.73 172.1936215 1,100.82 1,045.78 1,202.65# 36215 246.60 234.27 269.4136216 1,223.58 1,162.40 1,336.76# 36216 279.82 265.83 305.7036217 2,014.83 1,914.09 2,201.20# 36217 332.78 316.14 363.5636218 186.60 177.27 203.86# 36218 53.08 50.43 57.99# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.97 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE36245 1,059.28 1,006.32 1,157.27# 36245 249.36 236.89 272.4236246 977.83 928.94 1,068.28# 36246 276.30 262.49 301.8636247 1,641.57 1,559.49 1,793.41# 36247 329.29 312.83 359.7536248 151.10 143.55 165.08# 36248 51.82 49.23 56.6136251 1,376.19 1,307.38 1,503.49# 36251 279.75 265.76 305.6236252 1,514.56 1,438.83 1,654.65# 36252 364.39 346.17 398.1036253 2,103.12 1,997.96 2,297.65# 36253 389.66 370.18 425.7136254 2,189.13 2,079.67 2,391.62# 36254 420.37 399.35 459.2536260 628.71 597.27 686.8636261 392.08 372.48 428.3536262 297.22 282.36 324.7136400 27.32 25.95 29.84# 36400 19.15 18.19 20.9236405 25.25 23.99 27.59# 36405 16.46 15.64 17.9936406 16.64 15.81 18.18# 36406 8.79 8.35 9.6036410 16.96 16.11 18.53# 36410 9.42 8.95 10.2936420 51.00 48.45 55.7236425 39.61 37.63 43.2736430 31.78 30.19 34.7236440 56.36 53.54 61.5736450 106.92 101.57 116.8136455 115.45 109.68 126.1336460 356.28 338.47 389.2436468 148.05 140.65 161.7536469 148.05 140.65 161.7536470 144.41 137.19 157.77# 36470 80.95 76.90 88.4436471 170.90 162.36 186.71# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.98 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 36471 101.16 96.10 110.5236475 1,714.57 1,628.84 1,873.17# 36475 360.51 342.48 393.8536476 387.55 368.17 423.40# 36476 177.37 168.50 193.7836478 1,361.58 1,293.50 1,487.53# 36478 358.76 340.82 391.9436479 402.28 382.17 439.50# 36479 177.03 168.18 193.4136481 1,618.95 1,538.00 1,768.70# 36481 357.57 339.69 390.6436500 181.17 172.11 197.9336510 97.99 93.09 107.05# 36510 60.91 57.86 66.5436511 94.18 89.47 102.8936512 90.49 85.97 98.8736513 99.24 94.28 108.4236514 489.72 465.23 535.01# 36514 92.30 87.69 100.8436515 2,028.36 1,926.94 2,215.98# 36515 92.46 87.84 101.0236516 1,950.57 1,853.04 2,131.00# 36516 70.28 66.77 76.7936522 1,289.49 1,225.02 1,408.77# 36522 99.42 94.45 108.6236555 262.28 249.17 286.55# 36555 121.22 115.16 132.4336556 228.01 216.61 249.10# 36556 121.19 115.13 132.4036557 949.45 901.98 1,037.28# 36557 323.00 306.85 352.8836558 758.95 721.00 829.15# 36558 278.59 264.66 304.3636560 1,260.69 1,197.66 1,377.31# 36560 357.78 339.89 390.8736561 1,139.73 1,082.74 1,245.15# 36561 354.63 336.90 387.4436563 1,265.08 1,201.83 1,382.10# 36563 377.24 358.38 412.14# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.99 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE36565 971.65 923.07 1,061.53# 36565 354.63 336.90 387.4436566 4,735.33 4,498.56 5,173.34# 36566 381.29 362.23 416.5636568 277.68 263.80 303.37# 36568 94.84 90.10 103.6236569 237.83 225.94 259.83# 36569 90.80 86.26 99.2036570 1,122.35 1,066.23 1,226.16# 36570 304.57 289.34 332.7436571 1,237.09 1,175.24 1,351.53# 36571 320.66 304.63 350.3236575 156.51 148.68 170.98# 36575 35.55 33.77 38.8436576 365.34 347.07 399.13# 36576 194.12 184.41 212.0736578 496.67 471.84 542.62# 36578 215.49 204.72 235.4336580 206.87 196.53 226.01# 36580 66.43 63.11 72.5836581 726.04 689.74 793.20# 36581 196.98 187.13 215.2036582 1,061.46 1,008.39 1,159.65# 36582 306.83 291.49 335.2136583 1,127.91 1,071.51 1,232.24# 36583 322.39 306.27 352.2136584 195.65 185.87 213.75# 36584 65.27 62.01 71.3136585 1,070.67 1,017.14 1,169.71# 36585 279.29 265.33 305.1336589 163.64 155.46 178.78# 36589 139.14 132.18 152.0136590 284.29 270.08 310.59# 36590 204.18 193.97 223.0736591 21.41 20.34 23.3936592 24.24 23.03 26.4836593 27.70 26.32 30.2736595 546.69 519.36 597.26# 36595 185.08 175.83 202.20# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.100 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE36596 128.13 121.72 139.98# 36596 44.88 42.64 49.0436597 119.65 113.67 130.72# 36597 60.58 57.55 66.1836598 106.59 101.26 116.45# 36598 41.87 39.78 45.7536600 29.58 28.10 32.32# 36600 15.13 14.37 16.5336620 50.95 48.40 55.6636625 108.15 102.74 118.1536640 128.55 122.12 140.4436660 76.36 72.54 83.4236680 59.85 56.86 65.3936800 161.46 153.39 176.4036810 215.39 204.62 235.3136815 152.60 144.97 166.7236818 690.57 656.04 754.4536819 764.06 725.86 834.7436820 829.70 788.22 906.4536821 710.93 675.38 776.6936822 387.96 368.56 423.8436823 1,335.82 1,269.03 1,459.3836825 807.52 767.14 882.2136830 679.30 645.34 742.1436831 471.11 447.55 514.6836832 598.76 568.82 654.1436833 677.18 643.32 739.8236835 500.09 475.09 546.3536838 1,197.63 1,137.75 1,308.4136860 199.14 189.18 217.56# 36860 108.35 102.93 118.3736861 154.76 147.02 169.0736870 1,809.02 1,718.57 1,976.36# 36870 301.96 286.86 329.8937140 2,232.35 2,120.73 2,438.8437145 2,091.82 1,987.23 2,285.3137160 2,123.65 2,017.47 2,320.0937180 2,051.47 1,948.90 2,241.2437181 2,240.16 2,128.15 2,447.37# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.101 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE37182 840.77 798.73 918.5437183 5,329.91 5,063.41 5,822.92# 37183 396.86 377.02 433.5737184 2,234.08 2,122.38 2,440.74# 37184 461.24 438.18 503.9137185 731.70 695.12 799.39# 37185 170.91 162.36 186.7137186 1,433.25 1,361.59 1,565.83# 37186 260.15 247.14 284.2137187 2,118.07 2,012.17 2,314.00# 37187 414.66 393.93 453.0237188 1,780.56 1,691.53 1,945.26# 37188 294.55 279.82 321.7937191 2,482.93 2,358.78 2,712.60# 37191 238.20 226.29 260.2337192 1,679.35 1,595.38 1,834.69# 37192 368.96 350.51 403.0937193 1,603.95 1,523.75 1,752.31# 37193 368.64 350.21 402.7437195 382.14 363.03 417.4837200 222.93 211.78 243.5537201 276.99 263.14 302.6137202 334.26 317.55 365.1837203 1,265.04 1,201.79 1,382.06# 37203 262.21 249.10 286.4737204 902.66 857.53 986.1637205 4,040.45 3,838.43 4,414.19# 37205 437.58 415.70 478.0637206 2,412.91 2,292.26 2,636.10# 37206 216.88 206.04 236.9537207 442.79 420.65 483.7537208 214.29 203.58 234.1237209 113.78 108.09 124.3037210 3,413.92 3,243.22 3,729.70# 37210 527.35 500.98 576.1337215 1,115.12 1,059.36 1,218.2637220 3,075.19 2,921.43 3,359.64# 37220 424.57 403.34 463.8437221 4,584.11 4,354.90 5,008.14# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.102 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 37221 516.59 490.76 564.3737222 887.25 842.89 969.32# 37222 192.63 183.00 210.4537223 2,507.91 2,382.51 2,739.89# 37223 218.58 207.65 238.8037224 3,695.77 3,510.98 4,037.63# 37224 467.39 444.02 510.6237225 10,446.36 9,924.04 11,412.65# 37225 631.47 599.90 689.8937226 8,809.53 8,369.05 9,624.41# 37226 516.78 490.94 564.5837227 14,122.82 13,416.68 15,429.18# 37227 762.55 724.42 833.0837228 5,275.03 5,011.28 5,762.97# 37228 571.95 543.35 624.8537229 10,339.03 9,822.08 11,295.39# 37229 739.03 702.08 807.3937230 8,198.95 7,789.00 8,957.35# 37230 712.03 676.43 777.8937231 13,156.39 12,498.57 14,373.36# 37231 773.81 735.12 845.3937232 1,185.14 1,125.88 1,294.76# 37232 206.83 196.49 225.9637233 1,444.82 1,372.58 1,578.47# 37233 340.21 323.20 371.6837234 3,769.10 3,580.65 4,117.75# 37234 283.10 268.95 309.2937235 4,027.49 3,826.12 4,400.04# 37235 401.69 381.61 438.8537250 111.10 105.55 121.3837251 83.53 79.35 91.2537500 710.00 674.50 775.6837565 735.52 698.74 803.5537600 721.63 685.55 788.3837605 829.95 788.45 906.7237606 565.89 537.60 618.2437607 386.68 367.35 422.4537609 304.61 289.38 332.79# 37609 207.53 197.15 226.72# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.103 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE37615 508.06 482.66 555.0637616 1,106.65 1,051.32 1,209.0237617 1,339.88 1,272.89 1,463.8237618 390.57 371.04 426.7037619 1,645.69 1,563.41 1,797.9237650 545.26 518.00 595.7037660 1,287.46 1,223.09 1,406.5537700 257.98 245.08 281.8437718 447.47 425.10 488.8737722 496.92 472.07 542.8837735 646.21 613.90 705.9937760 642.21 610.10 701.6237761 563.98 535.78 616.1537765 660.74 627.70 721.86# 37765 464.07 440.87 507.0037766 783.65 744.47 856.14# 37766 567.82 539.43 620.3437780 263.08 249.93 287.4237785 356.07 338.27 389.01# 37785 266.54 253.21 291.1937788 1,378.69 1,309.76 1,506.2237790 474.80 451.06 518.7238100 1,125.86 1,069.57 1,230.0138101 1,136.00 1,079.20 1,241.0838102 258.44 245.52 282.3538115 1,241.71 1,179.62 1,356.5638120 1,028.74 977.30 1,123.9038200 144.83 137.59 158.2338205 76.90 73.06 84.0238206 78.62 74.69 85.8938220 150.72 143.18 164.66# 38220 59.30 56.34 64.7938221 156.99 149.14 171.51# 38221 72.79 69.15 79.5238230 182.80 173.66 199.7138232 182.80 173.66 199.7138240 121.02 114.97 132.2238241 120.61 114.58 131.7738242 92.00 87.40 100.51# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.104 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE38300 268.35 254.93 293.17# 38300 180.70 171.67 197.4238305 449.50 427.03 491.0838308 439.18 417.22 479.8038380 562.62 534.49 614.6638381 807.81 767.42 882.5338382 693.24 658.58 757.3738500 317.92 302.02 347.32# 38500 246.92 234.57 269.7638505 119.83 113.84 130.92# 38505 69.87 66.38 76.3438510 506.24 480.93 553.07# 38510 413.87 393.18 452.1638520 456.20 433.39 498.4038525 421.97 400.87 461.0038530 537.65 510.77 587.3938542 510.32 484.80 557.5238550 489.90 465.41 535.2238555 980.53 931.50 1,071.2338562 684.34 650.12 747.6438564 687.56 653.18 751.1638570 524.53 498.30 573.0538571 780.88 741.84 853.1238572 932.22 885.61 1,018.4538700 794.80 755.06 868.3238720 1,331.04 1,264.49 1,454.1638724 1,437.25 1,365.39 1,570.2038740 671.06 637.51 733.1438745 851.51 808.93 930.2738746 223.23 212.07 243.8838747 262.64 249.51 286.9438760 823.98 782.78 900.2038765 1,261.60 1,198.52 1,378.3038770 786.77 747.43 859.5438780 1,010.10 959.60 1,103.5438790 82.17 78.06 89.7738792 39.46 37.49 43.1138794 286.26 271.95 312.7438900 133.91 127.21 146.29# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.105 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE39000 499.08 474.13 545.2539010 803.18 763.02 877.4739200 891.57 846.99 974.0439220 1,149.95 1,092.45 1,256.3239400 510.80 485.26 558.0539501 838.92 796.97 916.5239503 6,023.53 5,722.35 6,580.7039540 857.64 814.76 936.9739541 931.87 885.28 1,018.0739545 902.44 857.32 985.9239560 781.36 742.29 853.6339561 1,231.55 1,169.97 1,345.4740490 124.10 117.90 135.59# 40490 73.21 69.55 79.9840500 490.69 466.16 536.08# 40500 358.12 340.21 391.2440510 470.45 446.93 513.97# 40510 350.75 333.21 383.1940520 479.36 455.39 523.70# 40520 354.95 337.20 387.7840525 551.83 524.24 602.8840527 621.02 589.97 678.4740530 529.94 503.44 578.96# 40530 400.82 380.78 437.9040650 416.84 396.00 455.40# 40650 290.23 275.72 317.0840652 477.21 453.35 521.35# 40652 349.98 332.48 382.3540654 556.84 529.00 608.35# 40654 420.49 399.47 459.3940700 938.10 891.20 1,024.8840701 1,150.33 1,092.81 1,256.7340702 804.01 763.81 878.3840720 1,025.07 973.82 1,119.8940761 1,025.65 974.37 1,120.5340800 200.16 190.15 218.67# 40800 126.96 120.61 138.7040801 301.54 286.46 329.43# 40801 215.45 204.68 235.38# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.106 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE40804 208.10 197.70 227.36# 40804 129.87 123.38 141.8940805 342.38 325.26 374.05# 40805 219.86 208.87 240.2040806 140.19 133.18 153.16# 40806 36.51 34.68 39.88# 40808 105.03 99.78 114.7540808 177.61 168.73 194.0440810 198.30 188.39 216.65# 40810 125.10 118.85 136.6840812 275.11 261.35 300.55# 40812 191.54 181.96 209.2540814 369.45 350.98 403.63# 40814 296.87 282.03 324.3340816 390.09 370.59 426.18# 40816 310.92 295.37 339.6840818 340.70 323.67 372.22# 40818 263.42 250.25 287.7940819 295.37 280.60 322.69# 40819 228.45 217.03 249.5840820 255.43 242.66 279.06# 40820 168.09 159.69 183.6440830 252.62 239.99 275.99# 40830 161.82 153.73 176.7940831 321.42 305.35 351.15# 40831 220.26 209.25 240.6440840 773.79 735.10 845.37# 40840 603.20 573.04 659.0040842 774.42 735.70 846.06# 40842 620.17 589.16 677.5340843 1,057.66 1,004.78 1,155.50# 40843 848.43 806.01 926.9140844 1,337.30 1,270.44 1,461.01# 40844 1,103.88 1,048.69 1,205.9940845 1,434.40 1,362.68 1,567.08# 40845 1,214.49 1,153.77 1,326.8441000 156.18 148.37 170.63# 41000 109.68 104.20 119.8341005 212.84 202.20 232.53# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.107 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 41005 123.93 117.73 135.3941006 346.06 328.76 378.07# 41006 255.58 242.80 279.2241007 347.84 330.45 380.02# 41007 244.48 232.26 267.1041008 361.87 343.78 395.35# 41008 261.65 248.57 285.8641009 383.77 364.58 419.27# 41009 284.49 270.27 310.8141010 199.65 189.67 218.12# 41010 108.22 102.81 118.2341015 410.07 389.57 448.01# 41015 330.90 314.36 361.5141016 421.40 400.33 460.38# 41016 340.03 323.03 371.4841017 423.29 402.13 462.45# 41017 340.98 323.93 372.5241018 478.84 454.90 523.14# 41018 400.29 380.28 437.3241019 449.62 427.14 491.2141100 164.00 155.80 179.17# 41100 107.13 101.77 117.0441105 165.70 157.42 181.03# 41105 110.09 104.59 120.2841108 143.38 136.21 156.64# 41108 89.03 84.58 97.2741110 207.51 197.13 226.70# 41110 130.85 124.31 142.9641112 322.48 306.36 352.31# 41112 247.39 235.02 270.2741113 351.90 334.31 384.46# 41113 273.35 259.68 298.6341114 625.85 594.56 683.7441115 242.40 230.28 264.82# 41115 145.32 138.05 158.7641116 319.95 303.95 349.54# 41116 216.59 205.76 236.6241120 1,034.97 983.22 1,130.7041130 1,285.64 1,221.36 1,404.56# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.108 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE41135 2,123.25 2,017.09 2,319.6541140 2,161.05 2,053.00 2,360.9541145 2,728.06 2,591.66 2,980.4141150 2,165.79 2,057.50 2,366.1341153 2,346.82 2,229.48 2,563.9041155 2,950.09 2,802.59 3,222.9841250 246.80 234.46 269.63# 41250 148.47 141.05 162.2141251 266.13 252.82 290.74# 41251 172.19 163.58 188.1241252 305.93 290.63 334.22# 41252 210.11 199.60 229.5441500 449.40 426.93 490.9741510 404.41 384.19 441.8241512 612.31 581.69 668.9441520 334.32 317.60 365.24# 41520 247.61 235.23 270.5141530 3,135.55 2,978.77 3,425.59# 41530 399.47 379.50 436.4341800 249.47 237.00 272.55# 41800 139.51 132.53 152.4141805 232.18 220.57 253.66# 41805 163.06 154.91 178.1541806 346.15 328.84 378.17# 41806 256.93 244.08 280.6941822 276.16 262.35 301.70# 41822 175.94 167.14 192.2141823 408.43 388.01 446.21# 41823 312.30 296.69 341.1941825 201.36 191.29 219.98# 41825 120.62 114.59 131.7841826 294.38 279.66 321.61# 41826 203.90 193.71 222.7741827 420.89 399.85 459.83# 41827 299.62 284.64 327.3441828 291.66 277.08 318.64# 41828 207.46 197.09 226.6541830 372.83 354.19 407.32# 41830 273.56 259.88 298.86# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.109 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE41872 399.50 379.53 436.46# 41872 284.20 269.99 310.4941874 353.68 336.00 386.40# 41874 246.24 233.93 269.0242000 152.44 144.82 166.54# 42000 102.48 97.36 111.9642100 145.83 138.54 159.32# 42100 107.82 102.43 117.7942104 208.21 197.80 227.47# 42104 137.21 130.35 149.9042106 260.92 247.87 285.05# 42106 174.53 165.80 190.6742107 447.49 425.12 488.89# 42107 340.99 323.94 372.5342120 981.07 932.02 1,071.8242140 248.76 236.32 271.77# 42140 154.51 146.78 168.8042145 700.08 665.08 764.8442160 228.47 217.05 249.61# 42160 146.79 139.45 160.3742180 240.49 228.47 262.74# 42180 183.00 173.85 199.9342182 317.95 302.05 347.36# 42182 257.00 244.15 280.7742200 852.65 810.02 931.5242205 865.52 822.24 945.5842210 1,098.44 1,043.52 1,200.0542215 673.31 639.64 735.5942220 515.12 489.36 562.7642225 884.47 840.25 966.2942226 893.88 849.19 976.5742227 845.95 803.65 924.2042235 729.22 692.76 796.6742260 805.52 765.24 880.03# 42260 659.43 626.46 720.4342280 160.11 152.10 174.92# 42280 109.85 104.36 120.0142281 202.21 192.10 220.92# 42281 151.00 143.45 164.97# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.110 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE42300 206.03 195.73 225.09# 42300 151.99 144.39 166.0542305 426.40 405.08 465.8442310 159.88 151.89 174.67# 42310 124.38 118.16 135.8842320 246.60 234.27 269.41# 42320 175.28 166.52 191.5042330 227.96 216.56 249.04# 42330 163.87 155.68 179.0342335 366.35 348.03 400.23# 42335 255.45 242.68 279.0842340 458.38 435.46 500.78# 42340 335.54 318.76 366.5742400 103.92 98.72 113.53# 42400 54.91 52.16 59.9842405 292.65 278.02 319.72# 42405 223.85 212.66 244.5642408 446.86 424.52 488.20# 42408 325.28 309.02 355.3742409 328.03 311.63 358.37# 42409 221.53 210.45 242.0242410 619.42 588.45 676.7242415 1,057.92 1,005.02 1,155.7742420 1,191.17 1,131.61 1,301.3542425 835.39 793.62 912.6642426 1,351.36 1,283.79 1,476.3642440 413.50 392.83 451.7542450 445.07 422.82 486.24# 42450 356.16 338.35 389.1042500 425.18 403.92 464.51# 42500 339.10 322.15 370.4742505 546.77 519.43 597.34# 42505 449.06 426.61 490.6042507 510.46 484.94 557.6842508 710.90 675.36 776.6642509 867.57 824.19 947.8242510 626.05 594.75 683.9642550 131.06 124.51 143.19# 42550 61.63 58.55 67.33# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.111 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE42600 474.81 451.07 518.73# 42600 348.52 331.09 380.7542650 82.00 77.90 89.59# 42650 58.12 55.21 63.4942660 103.56 98.38 113.14# 42660 76.54 72.71 83.6242665 308.61 293.18 337.16# 42665 206.19 195.88 225.2642700 186.48 177.16 203.73# 42700 135.59 128.81 148.1342720 450.44 427.92 492.11# 42720 391.69 372.11 427.9342725 804.80 764.56 879.2442800 156.51 148.68 170.98# 42800 111.90 106.31 122.2642802 230.83 219.29 252.18# 42802 133.75 127.06 146.1242804 194.88 185.14 212.91# 42804 113.19 107.53 123.6642806 219.63 208.65 239.95# 42806 132.60 125.97 144.8742808 224.43 213.21 245.19# 42808 161.91 153.81 176.8842809 168.96 160.51 184.59# 42809 130.63 124.10 142.7242810 382.61 363.48 418.00# 42810 286.78 272.44 313.3142815 554.49 526.77 605.7942820 289.22 274.76 315.9742821 300.42 285.40 328.2142825 241.67 229.59 264.0342826 250.62 238.09 273.8042830 206.56 196.23 225.6642831 222.11 211.00 242.6542835 189.95 180.45 207.5242836 239.92 227.92 262.1142842 981.46 932.39 1,072.2542844 1,355.08 1,287.33 1,480.4342845 2,203.49 2,093.32 2,407.32# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.112 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE42860 187.54 178.16 204.8842870 571.87 543.28 624.7742890 1,398.81 1,328.87 1,528.2042892 1,857.75 1,764.86 2,029.5942894 2,343.65 2,226.47 2,560.4442900 338.95 322.00 370.3042950 784.80 745.56 857.3942953 949.27 901.81 1,037.0842955 743.04 705.89 811.7742960 168.00 159.60 183.5442961 418.06 397.16 456.7342962 516.42 490.60 564.1942970 399.57 379.59 436.5342971 455.65 432.87 497.8042972 510.46 484.94 557.6843020 533.59 506.91 582.9543030 517.17 491.31 565.0143045 1,314.64 1,248.91 1,436.2543100 623.06 591.91 680.7043101 1,017.17 966.31 1,111.2643107 2,542.46 2,415.34 2,777.6443108 4,429.70 4,208.22 4,839.4543112 2,706.69 2,571.36 2,957.0643113 4,509.26 4,283.80 4,926.3743116 5,151.59 4,894.01 5,628.1143117 2,474.46 2,350.74 2,703.3543118 3,748.55 3,561.12 4,095.2943121 2,886.99 2,742.64 3,154.0443122 2,537.86 2,410.97 2,772.6243123 4,644.82 4,412.58 5,074.4743124 3,845.50 3,653.23 4,201.2143130 785.42 746.15 858.0743135 1,491.59 1,417.01 1,629.5643200 210.46 199.94 229.93# 43200 103.96 98.76 113.5743201 298.20 283.29 325.78# 43201 127.61 121.23 139.4143202 276.58 262.75 302.16# 43202 115.10 109.35 125.75# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.113 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE43204 219.19 208.23 239.4643205 223.50 212.33 244.1843215 154.31 146.59 168.5843216 209.10 198.65 228.45# 43216 143.75 136.56 157.0443217 370.39 351.87 404.65# 43217 170.58 162.05 186.3643219 170.89 162.35 186.7043220 126.43 120.11 138.1343226 140.86 133.82 153.8943227 210.33 199.81 229.7843228 222.34 211.22 242.9043231 189.82 180.33 207.3843232 259.88 246.89 283.9243234 274.31 260.59 299.68# 43234 120.69 114.66 131.8643235 289.28 274.82 316.04# 43235 144.77 137.53 158.1643236 367.26 348.90 401.24# 43236 174.36 165.64 190.4943237 233.33 221.66 254.9143238 291.47 276.90 318.4443239 334.14 317.43 365.04# 43239 170.78 162.24 186.5843240 395.05 375.30 431.6043241 155.13 147.37 169.4843242 421.29 400.23 460.2643243 266.04 252.74 290.6543244 293.62 278.94 320.7843245 187.38 178.01 204.7143246 251.00 238.45 274.2243247 199.63 189.65 218.1043248 187.37 178.00 204.7043249 172.74 164.10 188.7243250 188.48 179.06 205.9243251 217.29 206.43 237.3943255 280.98 266.93 306.9743256 253.21 240.55 276.6343257 319.36 303.39 348.90# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.114 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE43258 265.67 252.39 290.2543259 301.96 286.86 329.8943260 344.77 327.53 376.6643261 362.11 344.00 395.6043262 425.64 404.36 465.0143263 420.30 399.29 459.1843264 510.80 485.26 558.0543265 572.99 544.34 625.9943267 424.07 402.87 463.3043268 431.29 409.73 471.1943269 471.74 448.15 515.3743271 425.32 404.05 464.6643272 425.64 404.36 465.0143273 126.58 120.25 138.2943279 1,272.34 1,208.72 1,390.0343280 1,061.85 1,008.76 1,160.0743281 1,532.96 1,456.31 1,674.7643282 1,724.16 1,637.95 1,883.6443283 159.63 151.65 174.4043300 612.25 581.64 668.8943305 1,090.64 1,036.11 1,191.5343310 1,506.49 1,431.17 1,645.8543312 1,634.15 1,552.44 1,785.3143313 2,855.06 2,712.31 3,119.1643314 2,879.47 2,735.50 3,145.8343320 1,365.44 1,297.17 1,491.7543325 1,327.96 1,261.56 1,450.7943327 808.44 768.02 883.2243328 1,188.45 1,129.03 1,298.3843330 1,288.94 1,224.49 1,408.1643331 1,358.39 1,290.47 1,484.0443332 1,153.24 1,095.58 1,259.9243333 1,251.96 1,189.36 1,367.7643334 1,264.22 1,201.01 1,381.1643335 1,361.70 1,293.62 1,487.6643336 1,494.45 1,419.73 1,632.6943337 1,633.62 1,551.94 1,784.7343338 130.49 123.97 142.5743340 1,350.70 1,283.17 1,475.65# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.115 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE43341 1,424.74 1,353.50 1,556.5343350 1,232.24 1,170.63 1,346.2243351 1,327.22 1,260.86 1,449.9943352 1,077.40 1,023.53 1,177.0643360 2,371.11 2,252.55 2,590.4343361 2,644.08 2,511.88 2,888.6643400 1,468.16 1,394.75 1,603.9643401 1,518.17 1,442.26 1,658.6043405 1,449.20 1,376.74 1,583.2543410 1,079.36 1,025.39 1,179.2043415 2,532.04 2,405.44 2,766.2643420 1,009.73 959.24 1,103.1343425 1,448.16 1,375.75 1,582.1143450 152.37 144.75 166.46# 43450 88.59 84.16 96.7843453 284.40 270.18 310.71# 43453 95.58 90.80 104.4243456 575.70 546.92 628.96# 43456 154.08 146.38 168.3443458 375.95 357.15 410.72# 43458 180.22 171.21 196.8943460 221.54 210.46 242.0343496 1,977.17 1,878.31 2,160.0643500 767.69 729.31 838.7143501 1,318.61 1,252.68 1,440.5843502 1,490.67 1,416.14 1,628.5643510 933.84 887.15 1,020.2243520 680.09 646.09 743.0043605 816.79 775.95 892.3443610 958.54 910.61 1,047.2043611 1,190.08 1,130.58 1,300.1743620 1,929.19 1,832.73 2,107.6443621 2,218.59 2,107.66 2,423.8143622 2,253.58 2,140.90 2,462.0443631 1,420.26 1,349.25 1,551.6443632 1,982.56 1,883.43 2,165.9443633 1,876.58 1,782.75 2,050.1643634 2,078.28 1,974.37 2,270.5343635 110.53 105.00 120.75# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.116 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE43640 1,150.90 1,093.36 1,257.3643641 1,171.22 1,112.66 1,279.5643644 1,697.65 1,612.77 1,854.6943645 1,817.03 1,726.18 1,985.1143647 1,183.40 1,124.23 1,292.8643648 1,360.91 1,292.86 1,486.7943651 637.03 605.18 695.9643652 745.25 707.99 814.1943653 555.25 527.49 606.6143752 39.91 37.91 43.6043753 20.18 19.17 22.0543754 79.61 75.63 86.97# 43754 30.91 29.36 33.7643755 120.99 114.94 132.18# 43755 56.27 53.46 61.4843756 219.67 208.69 239.99# 43756 50.33 47.81 54.9843757 310.64 295.11 339.38# 43757 76.59 72.76 83.6743760 430.95 409.40 470.81# 43760 48.61 46.18 53.1143761 115.79 110.00 126.50# 43761 102.28 97.17 111.7543770 1,091.24 1,036.68 1,192.1843771 1,241.80 1,179.71 1,356.6743772 934.06 887.36 1,020.4643773 1,241.17 1,179.11 1,355.9843774 939.87 892.88 1,026.8143800 909.54 864.06 993.6743810 992.96 943.31 1,084.8143820 1,305.76 1,240.47 1,426.5443825 1,274.55 1,210.82 1,392.4443830 680.11 646.10 743.0243831 576.33 547.51 629.6443832 1,029.93 978.43 1,125.1943840 1,325.38 1,259.11 1,447.9843843 1,248.95 1,186.50 1,364.4843845 1,914.37 1,818.65 2,091.4543846 1,592.96 1,513.31 1,740.31# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.117 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE43847 1,758.91 1,670.96 1,921.6043848 1,888.45 1,794.03 2,063.1343850 1,591.29 1,511.73 1,738.4943855 1,653.14 1,570.48 1,806.0543860 1,598.70 1,518.77 1,746.5943865 1,672.39 1,588.77 1,827.0943870 694.19 659.48 758.4043880 1,562.01 1,483.91 1,706.5043881 1,183.40 1,124.23 1,292.8643882 1,360.91 1,292.86 1,486.7943886 347.58 330.20 379.7343887 315.25 299.49 344.4143888 443.73 421.54 484.7744005 1,070.60 1,017.07 1,169.6344010 846.55 804.22 924.8544015 140.97 133.92 154.0144020 951.96 904.36 1,040.0144021 959.93 911.93 1,048.7244025 967.00 918.65 1,056.4544050 914.14 868.43 998.6944055 1,466.70 1,393.37 1,602.3844100 113.00 107.35 123.4544110 830.03 788.53 906.8144111 962.37 914.25 1,051.3944120 1,196.72 1,136.88 1,307.4144121 238.54 226.61 260.6044125 1,155.97 1,098.17 1,262.9044126 2,411.75 2,291.16 2,634.8344127 2,791.54 2,651.96 3,049.7544128 239.95 227.95 262.1444130 1,279.47 1,215.50 1,397.8344139 119.25 113.29 130.2844140 1,313.17 1,247.51 1,434.6444141 1,779.84 1,690.85 1,944.4844143 1,629.78 1,548.29 1,780.5344144 1,731.46 1,644.89 1,891.6244145 1,628.00 1,546.60 1,778.5944146 2,070.10 1,966.60 2,261.5944147 1,895.46 1,800.69 2,070.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.118 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE44150 1,826.75 1,735.41 1,995.7244151 2,091.41 1,986.84 2,284.8744155 2,035.59 1,933.81 2,223.8844156 2,255.89 2,143.10 2,464.5744157 2,128.91 2,022.46 2,325.8344158 2,183.47 2,074.30 2,385.4544160 1,215.40 1,154.63 1,327.8244180 900.57 855.54 983.8744186 637.98 606.08 696.9944187 1,079.64 1,025.66 1,179.5144188 1,196.40 1,136.58 1,307.0744202 1,359.04 1,291.09 1,484.7544203 239.32 227.35 261.4544204 1,510.87 1,435.33 1,650.6344205 1,314.05 1,248.35 1,435.6044206 1,723.32 1,637.15 1,882.7244207 1,796.11 1,706.30 1,962.2544208 1,950.91 1,853.36 2,131.3644210 1,759.94 1,671.94 1,922.7344211 2,202.19 2,092.08 2,405.8944212 2,022.05 1,920.95 2,209.0944213 186.55 177.22 203.8044227 1,639.37 1,557.40 1,791.0144300 823.98 782.78 900.2044310 1,022.13 971.02 1,116.6744312 577.66 548.78 631.1044314 986.37 937.05 1,077.6144316 1,381.24 1,312.18 1,509.0144320 1,176.08 1,117.28 1,284.8744322 965.76 917.47 1,055.0944340 604.51 574.28 660.4244345 1,028.92 977.47 1,124.0944346 1,156.18 1,098.37 1,263.1344360 156.34 148.52 170.8044361 171.98 163.38 187.8944363 205.89 195.60 224.9444364 219.81 208.82 240.1444365 196.78 186.94 214.9844366 258.19 245.28 282.07# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.119 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE44369 264.18 250.97 288.6244370 284.60 270.37 310.9344372 254.98 242.23 278.5644373 204.99 194.74 223.9544376 302.78 287.64 330.7944377 319.83 303.84 349.4244378 410.30 389.79 448.2644379 435.90 414.11 476.2344380 67.54 64.16 73.7844382 81.61 77.53 89.1644383 163.60 155.42 178.7344385 249.23 236.77 272.29# 44385 105.34 100.07 115.0844386 340.53 323.50 372.03# 44386 125.95 119.65 137.6044388 342.64 325.51 374.34# 44388 165.45 157.18 180.7644389 389.21 369.75 425.21# 44389 184.37 175.15 201.4244390 438.49 416.57 479.06# 44390 217.32 206.45 237.4244391 492.37 467.75 537.91# 44391 249.84 237.35 272.9544392 430.64 409.11 470.48# 44392 218.90 207.96 239.1544393 495.85 471.06 541.72# 44393 276.88 263.04 302.5044394 489.72 465.23 535.01# 44394 255.04 242.29 278.6344397 273.94 260.24 299.2844500 24.10 22.90 26.3444602 1,378.53 1,309.60 1,506.0444603 1,582.47 1,503.35 1,728.8544604 1,035.92 984.12 1,131.7444605 1,283.48 1,219.31 1,402.2144615 1,054.19 1,001.48 1,151.7044620 847.98 805.58 926.4244625 999.46 949.49 1,091.9144626 1,576.46 1,497.64 1,722.29# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.120 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE44640 1,376.75 1,307.91 1,504.1044650 1,424.31 1,353.09 1,556.0544660 1,314.59 1,248.86 1,436.1944661 1,526.17 1,449.86 1,667.3444680 1,053.27 1,000.61 1,150.7044700 997.14 947.28 1,089.3744701 165.31 157.04 180.6044720 241.99 229.89 264.3744721 380.18 361.17 415.3544800 744.61 707.38 813.4944820 820.70 779.67 896.6244850 731.97 695.37 799.6844900 754.51 716.78 824.3044901 877.67 833.79 958.86# 44901 167.34 158.97 182.8244950 627.93 596.53 686.0144955 82.84 78.70 90.5144960 854.43 811.71 933.4744970 583.72 554.53 637.7145000 409.61 389.13 447.5045005 254.75 242.01 278.31# 45005 152.96 145.31 167.1145020 551.37 523.80 602.3745100 288.12 273.71 314.7745108 355.62 337.84 388.5245110 1,812.38 1,721.76 1,980.0245111 1,066.09 1,012.79 1,164.7145112 1,850.44 1,757.92 2,021.6145113 1,943.79 1,846.60 2,123.5945114 1,774.98 1,686.23 1,939.1645116 1,535.93 1,459.13 1,678.0045119 1,910.18 1,814.67 2,086.8745120 1,546.74 1,469.40 1,689.8145121 1,696.98 1,612.13 1,853.9545123 1,090.00 1,035.50 1,190.8345126 2,821.29 2,680.23 3,082.2645130 1,065.92 1,012.62 1,164.5145135 1,332.01 1,265.41 1,455.2245136 1,771.86 1,683.27 1,935.76# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.121 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE45150 380.75 361.71 415.9745160 990.03 940.53 1,081.6145171 589.60 560.12 644.1445172 800.96 760.91 875.0545190 668.97 635.52 730.8545300 114.54 108.81 125.13# 45300 52.02 49.42 56.8345303 875.15 831.39 956.10# 45303 89.42 84.95 97.6945305 184.75 175.51 201.84# 45305 77.62 73.74 84.8045307 215.96 205.16 235.93# 45307 101.60 96.52 111.0045308 195.97 186.17 214.10# 45308 85.39 81.12 93.2945309 211.05 200.50 230.58# 45309 91.35 86.78 99.8045315 219.36 208.39 239.65# 45315 108.15 102.74 118.1545317 228.06 216.66 249.16# 45317 115.90 110.11 126.6345320 227.07 215.72 248.08# 45320 106.11 100.80 115.9245321 106.13 100.82 115.9445327 120.74 114.70 131.9145330 135.16 128.40 147.66# 45330 62.59 59.46 68.3845331 161.93 153.83 176.90# 45331 75.22 71.46 82.1845332 282.91 268.76 309.07# 45332 110.44 104.92 120.66# 45333 109.49 104.02 119.6245333 286.68 272.35 313.2045334 162.72 154.58 177.7745335 260.70 247.67 284.82# 45335 91.68 87.10 100.1745337 141.28 134.22 154.3545338 311.04 295.49 339.81# 45338 140.45 133.43 153.44# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.122 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE45339 331.69 315.11 362.38# 45339 185.29 176.03 202.4345340 461.67 438.59 504.38# 45340 115.46 109.69 126.1445341 155.73 147.94 170.1345342 238.23 226.32 260.2745345 172.89 164.25 188.8945355 203.46 193.29 222.2845378 384.26 365.05 419.81# 45378 216.18 205.37 236.1845378 53 135.16 128.40 147.66# 45378 53 62.59 59.46 68.3845379 490.86 466.32 536.27# 45379 270.32 256.80 295.3245380 458.54 435.61 500.95# 45380 258.42 245.50 282.3345381 456.46 433.64 498.69# 45381 245.03 232.78 267.7045382 598.39 568.47 653.74# 45382 329.14 312.68 359.5845383 554.28 526.57 605.56# 45383 334.68 317.95 365.6445384 456.07 433.27 498.26# 45384 269.77 256.28 294.7245385 517.08 491.23 564.91# 45385 306.59 291.26 334.9545386 651.12 618.56 711.34# 45386 265.00 251.75 289.5145387 343.43 326.26 375.2045391 293.75 279.06 320.9245392 378.47 359.55 413.4845395 1,946.28 1,848.97 2,126.3245397 2,100.43 1,995.41 2,294.7245400 1,129.63 1,073.15 1,234.1245402 1,500.59 1,425.56 1,639.3945500 506.95 481.60 553.8445505 568.53 540.10 621.1245520 141.28 134.22 154.35# 45520 38.55 36.62 42.11# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.123 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE45540 1,035.97 984.17 1,131.8045541 902.56 857.43 986.0445550 1,432.84 1,361.20 1,565.3845560 685.01 650.76 748.3745562 1,083.39 1,029.22 1,183.6045563 1,602.29 1,522.18 1,750.5145800 1,173.75 1,115.06 1,282.3245805 1,421.71 1,350.62 1,553.2145820 1,140.41 1,083.39 1,245.9045825 1,425.80 1,354.51 1,557.6945900 195.98 186.18 214.1145905 163.40 155.23 178.5145910 190.19 180.68 207.7845915 310.03 294.53 338.71# 45915 217.67 206.79 237.8145990 104.91 99.66 114.6146020 260.94 247.89 285.07# 46020 224.18 212.97 244.9246030 131.05 124.50 143.18# 46030 87.39 83.02 95.4746040 502.80 477.66 549.31# 46040 396.61 376.78 433.3046045 414.22 393.51 452.5446050 187.29 177.93 204.62# 46050 93.98 89.28 102.6746060 455.48 432.71 497.6246070 226.65 215.32 247.6246080 235.55 223.77 257.34# 46080 155.44 147.67 169.8246083 168.05 159.65 183.60# 46083 103.33 98.16 112.8846200 411.22 390.66 449.26# 46200 307.54 292.16 335.9846220 193.27 183.61 211.15# 46220 114.73 108.99 125.3446221 252.64 240.01 276.01# 46221 183.21 174.05 200.1646230 258.39 245.47 282.29# 46230 167.91 159.51 183.44# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.124 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE46250 433.37 411.70 473.46# 46250 301.73 286.64 329.6446255 478.29 454.38 522.54# 46255 340.68 323.65 372.2046257 404.38 384.16 441.7846258 448.05 425.65 489.5046260 456.24 433.43 498.4446261 506.35 481.03 553.1846262 532.75 506.11 582.0346270 475.82 452.03 519.83# 46270 373.40 354.73 407.9446275 504.15 478.94 550.78# 46275 395.45 375.68 432.0346280 449.32 426.85 490.8846285 497.20 472.34 543.19# 46285 392.90 373.26 429.2546288 525.66 499.38 574.2946320 172.93 164.28 188.92# 46320 107.58 102.20 117.5346500 219.82 208.83 240.15# 46500 124.31 118.09 135.8046505 273.28 259.62 298.56# 46505 231.18 219.62 252.5646600 82.27 78.16 89.88# 46600 38.91 36.96 42.5046604 560.20 532.19 612.02# 46604 64.44 61.22 70.4046606 211.64 201.06 231.22# 46606 74.98 71.23 81.9146608 219.18 208.22 239.45# 46608 78.74 74.80 86.0246610 213.15 202.49 232.86# 46610 79.32 75.35 86.6546611 166.66 158.33 182.08# 46611 80.58 76.55 88.0346612 250.21 237.70 273.36# 46612 92.81 88.17 101.4046614 121.13 115.07 132.33# 46614 63.32 60.15 69.17# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.125 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE46615 140.15 133.14 153.11# 46615 92.40 87.78 100.9546700 629.79 598.30 688.0546705 489.22 464.76 534.4746706 161.17 153.11 176.0846707 451.63 429.05 493.4146710 1,067.24 1,013.88 1,165.9646712 1,972.67 1,874.04 2,155.1546715 472.81 449.17 516.5546716 1,101.45 1,046.38 1,203.3446730 1,737.40 1,650.53 1,898.1146735 1,971.76 1,873.17 2,154.1546740 2,080.78 1,976.74 2,273.2546742 2,370.47 2,251.95 2,589.7446744 3,264.47 3,101.25 3,566.4446746 3,428.61 3,257.18 3,745.7646748 3,716.65 3,530.82 4,060.4446750 742.54 705.41 811.2246751 589.19 559.73 643.6946753 566.77 538.43 619.1946754 283.30 269.14 309.51# 46754 221.41 210.34 241.8946760 1,056.48 1,003.66 1,154.2146761 907.89 862.50 991.8846762 894.49 849.77 977.2446900 226.10 214.80 247.02# 46900 133.73 127.04 146.1046910 238.86 226.92 260.96# 46910 130.79 124.25 142.8946916 221.24 210.18 241.71# 46916 140.50 133.48 153.5046917 435.48 413.71 475.77# 46917 129.80 123.31 141.8146922 249.60 237.12 272.69# 46922 130.84 124.30 142.9546924 504.41 479.19 551.07# 46924 179.57 170.59 196.1846930 197.15 187.29 215.38# 46930 143.75 136.56 157.04# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.126 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE46940 216.29 205.48 236.30# 46940 142.78 135.64 155.9946942 201.85 191.76 220.52# 46942 127.71 121.32 139.5246945 286.66 272.33 313.18# 46945 214.09 203.39 233.9046946 294.03 279.33 321.23# 46946 215.80 205.01 235.7646947 369.68 351.20 403.8847000 252.59 239.96 275.95# 47000 100.54 95.51 109.8447001 101.75 96.66 111.1647010 1,168.22 1,109.81 1,276.2847011 181.37 172.30 198.1547015 1,130.84 1,074.30 1,235.4547100 819.11 778.15 894.8747120 2,269.26 2,155.80 2,479.1747122 3,351.58 3,184.00 3,661.6047125 2,999.55 2,849.57 3,277.0147130 3,224.78 3,063.54 3,523.0747135 4,794.47 4,554.75 5,237.9647136 4,050.50 3,847.98 4,425.1847140 3,431.00 3,259.45 3,748.3747141 3,798.86 3,608.92 4,150.2647142 4,598.31 4,368.39 5,023.6547143 493.14 468.48 538.7547144 493.14 468.48 538.7547145 493.14 468.48 538.7547146 324.94 308.69 354.9947147 378.82 359.88 413.8647300 1,103.69 1,048.51 1,205.7947350 1,339.60 1,272.62 1,463.5147360 1,820.51 1,729.48 1,988.9047361 2,951.30 2,803.74 3,224.3047362 1,408.89 1,338.45 1,539.2247370 1,205.23 1,144.97 1,316.7247371 1,231.77 1,170.18 1,345.7147380 1,399.67 1,329.69 1,529.1447381 1,451.31 1,378.74 1,585.55# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.127 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE47382 4,582.56 4,353.43 5,006.44# 47382 772.97 734.32 844.4747400 2,107.04 2,001.69 2,301.9447420 1,309.97 1,244.47 1,431.1447425 1,332.83 1,266.19 1,456.1247460 1,242.63 1,180.50 1,357.5847480 847.01 804.66 925.3647490 334.17 317.46 365.0847500 96.93 92.08 105.8947505 37.21 35.35 40.6547510 462.66 439.53 505.4647511 572.41 543.79 625.3647525 479.12 455.16 523.43# 47525 88.61 84.18 96.8147530 1,351.58 1,284.00 1,476.60# 47530 347.19 329.83 379.3047550 163.10 154.95 178.1947552 312.05 296.45 340.9247553 312.87 297.23 341.8147554 485.51 461.23 530.4147555 370.47 351.95 404.7447556 419.72 398.73 458.5447560 264.94 251.69 289.4447561 289.51 275.03 316.2847562 729.60 693.12 797.0947563 699.69 664.71 764.4247564 1,068.45 1,015.03 1,167.2847570 756.20 718.39 826.1547600 1,055.08 1,002.33 1,152.6847605 958.55 910.62 1,047.2147610 1,226.17 1,164.86 1,339.5947612 1,239.11 1,177.15 1,353.7247620 1,340.42 1,273.40 1,464.4147630 539.00 512.05 588.8647700 1,025.23 973.97 1,120.0747701 1,707.60 1,622.22 1,865.5547711 1,520.49 1,444.47 1,661.1447712 1,955.12 1,857.36 2,135.9647715 1,295.79 1,231.00 1,415.65# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.128 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE47720 1,121.38 1,065.31 1,225.1147721 1,320.06 1,254.06 1,442.1747740 1,277.91 1,214.01 1,396.1147741 1,440.01 1,368.01 1,573.2147760 2,194.45 2,084.73 2,397.4447765 2,960.85 2,812.81 3,234.7347780 2,407.49 2,287.12 2,630.1947785 3,163.16 3,005.00 3,455.7547800 1,543.42 1,466.25 1,686.1947801 1,001.70 951.62 1,094.3647802 1,488.88 1,414.44 1,626.6147900 1,329.51 1,263.03 1,452.4848000 1,808.44 1,718.02 1,975.7248001 2,262.39 2,149.27 2,471.6648020 1,148.84 1,091.40 1,255.1148100 864.56 821.33 944.5348102 516.54 490.71 564.32# 48102 239.76 227.77 261.9448105 2,794.16 2,654.45 3,052.6248120 1,077.10 1,023.25 1,176.7448140 1,523.34 1,447.17 1,664.2548145 1,594.94 1,515.19 1,742.4748146 1,831.41 1,739.84 2,000.8248148 1,216.69 1,155.86 1,329.2448150 3,029.02 2,877.57 3,309.2148152 2,824.06 2,682.86 3,085.2948153 3,024.71 2,873.47 3,304.4948154 2,835.28 2,693.52 3,097.5548155 1,768.72 1,680.28 1,932.3248400 108.34 102.92 118.3648500 1,119.29 1,063.33 1,222.8348510 1,053.15 1,000.49 1,150.5648511 884.47 840.25 966.29# 48511 196.45 186.63 214.6248520 1,070.10 1,016.60 1,169.0948540 1,279.57 1,215.59 1,397.9348545 1,311.52 1,245.94 1,432.8348547 1,751.68 1,664.10 1,913.7248548 1,627.63 1,546.25 1,778.19# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.129 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE48551 225.67 214.39 246.5548552 232.52 220.89 254.0248554 2,481.65 2,357.57 2,711.2148556 1,237.21 1,175.35 1,351.6549000 752.83 715.19 822.4749002 1,020.41 969.39 1,114.8049010 924.78 878.54 1,010.3249020 1,554.25 1,476.54 1,698.0249021 841.97 799.87 919.85# 49021 165.57 157.29 180.8849040 979.71 930.72 1,070.3349041 873.48 829.81 954.28# 49041 196.13 186.32 214.2749060 1,079.46 1,025.49 1,179.3149061 853.96 811.26 932.95# 49061 181.01 171.96 197.7549062 728.19 691.78 795.5549082 155.23 147.47 169.59# 49082 68.20 64.79 74.5149083 291.71 277.12 318.69# 49083 105.41 100.14 115.1649084 96.93 92.08 105.8949180 154.56 146.83 168.85# 49180 85.13 80.87 93.0049203 1,168.73 1,110.29 1,276.8349204 1,490.20 1,415.69 1,628.0449205 1,711.50 1,625.93 1,869.8249215 2,156.66 2,048.83 2,356.1549220 949.21 901.75 1,037.0149250 567.78 539.39 620.3049255 771.63 733.05 843.0149320 319.88 303.89 349.4749321 338.75 321.81 370.0849322 363.64 345.46 397.2849323 631.54 599.96 689.9549324 386.04 366.74 421.7549325 412.55 391.92 450.7149326 186.54 177.21 203.7949327 128.95 122.50 140.88# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.130 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE49400 141.21 134.15 154.27# 49400 94.72 89.98 103.4849402 834.56 792.83 911.7549411 523.84 497.65 572.30# 49411 190.83 181.29 208.4849412 80.19 76.18 87.6149418 1,485.41 1,411.14 1,622.81# 49418 226.86 215.52 247.8549419 431.78 410.19 471.7249421 245.76 233.47 268.4949422 375.71 356.92 410.4649423 534.11 507.40 583.51# 49423 72.28 68.67 78.9749424 141.83 134.74 154.95# 49424 38.47 36.55 42.0349425 740.23 703.22 808.7049426 621.61 590.53 679.1149427 44.61 42.38 48.7449428 468.60 445.17 511.9549429 438.02 416.12 478.5449435 119.03 113.08 130.0449436 180.97 171.92 197.7149440 1,018.68 967.75 1,112.91# 49440 222.89 211.75 243.5149441 1,129.54 1,073.06 1,234.02# 49441 253.64 240.96 277.1049442 924.04 877.84 1,009.52# 49442 212.45 201.83 232.1049446 951.77 904.18 1,039.81# 49446 162.90 154.76 177.9749450 649.46 616.99 709.54# 49450 66.37 63.05 72.5149451 684.73 650.49 748.06# 49451 91.58 87.00 100.0549452 847.35 804.98 925.73# 49452 140.79 133.75 153.8149460 725.60 689.32 792.72# 49460 47.94 45.54 52.3749465 163.04 154.89 178.12# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.131 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 49465 30.15 28.64 32.9449491 751.73 714.14 821.2649492 931.75 885.16 1,017.9349495 396.04 376.24 432.6849496 585.10 555.85 639.2349500 396.27 376.46 432.9349501 587.67 558.29 642.0349505 505.07 479.82 551.7949507 571.85 543.26 624.7549520 615.00 584.25 671.8949521 699.30 664.34 763.9949525 557.31 529.44 608.8649540 654.83 622.09 715.4049550 560.13 532.12 611.9449553 614.50 583.78 671.3549555 582.94 553.79 636.8649557 704.89 669.65 770.1049560 718.71 682.77 785.1949561 908.12 862.71 992.1249565 749.08 711.63 818.3749566 918.50 872.58 1,003.4749568 263.90 250.71 288.3249570 403.30 383.14 440.6149572 499.76 474.77 545.9949580 319.92 303.92 349.5149582 467.02 443.67 510.2249585 430.61 409.08 470.4449587 462.65 439.52 505.4549590 556.07 528.27 607.5149600 712.88 677.24 778.8349605 4,862.50 4,619.38 5,312.2949606 1,107.98 1,052.58 1,210.4749610 669.98 636.48 731.9549611 528.49 502.07 577.3849650 414.73 393.99 453.0949651 540.39 513.37 590.3849652 666.53 633.20 728.1849653 832.72 791.08 909.7449654 757.81 719.92 827.91# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.132 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE49655 925.32 879.05 1,010.9149656 819.94 778.94 895.7849657 1,178.84 1,119.90 1,287.8949900 792.60 752.97 865.9249904 1,432.47 1,360.85 1,564.9849905 347.84 330.45 380.0249906 1,977.17 1,878.31 2,160.0650010 721.93 685.83 788.7050020 1,031.71 980.12 1,127.1450021 893.81 849.12 976.49# 50021 165.26 157.00 180.5550040 912.93 867.28 997.3750045 916.72 870.88 1,001.5150060 1,124.27 1,068.06 1,228.2750065 1,189.55 1,130.07 1,299.5850070 1,200.06 1,140.06 1,311.0750075 1,440.64 1,368.61 1,573.9050080 858.88 815.94 938.3350081 1,261.88 1,198.79 1,378.6150100 896.50 851.68 979.4350120 934.28 887.57 1,020.7150125 1,010.90 960.36 1,104.4150130 1,019.09 968.14 1,113.3650135 1,106.26 1,050.95 1,208.5950200 567.97 539.57 620.51# 50200 142.27 135.16 155.4350205 735.93 699.13 804.0050220 1,030.60 979.07 1,125.9350225 1,180.70 1,121.67 1,289.9250230 1,265.90 1,202.61 1,383.0050234 1,284.70 1,220.47 1,403.5450236 1,447.53 1,375.15 1,581.4250240 1,306.70 1,241.37 1,427.5850250 1,205.41 1,145.14 1,316.9150280 942.18 895.07 1,029.3350290 875.76 831.97 956.7750320 1,398.51 1,328.58 1,527.8750323 268.98 255.53 293.8650325 158.27 150.36 172.91# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.133 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE50327 213.54 202.86 233.2950328 186.55 177.22 203.8050329 172.94 164.29 188.9350340 918.86 872.92 1,003.8650360 2,500.92 2,375.87 2,732.2550365 2,808.80 2,668.36 3,068.6150370 1,164.61 1,106.38 1,272.3450380 1,959.64 1,861.66 2,140.9150382 1,178.79 1,119.85 1,287.83# 50382 271.79 258.20 296.9350384 968.36 919.94 1,057.93# 50384 247.35 234.98 270.2350385 1,141.27 1,084.21 1,246.84# 50385 231.13 219.57 252.5150386 742.83 705.69 811.54# 50386 174.50 165.78 190.6550387 545.97 518.67 596.47# 50387 98.60 93.67 107.7250389 296.18 281.37 323.58# 50389 53.96 51.26 58.9550390 96.20 91.39 105.1050391 121.12 115.06 132.32# 50391 98.18 93.27 107.2650392 176.57 167.74 192.9050393 214.77 204.03 234.6350394 97.22 92.36 106.21# 50394 48.52 46.09 53.0050395 178.24 169.33 194.7350396 114.86 109.12 125.4950398 493.27 468.61 538.90# 50398 72.28 68.67 78.9750400 1,142.20 1,085.09 1,247.8550405 1,378.97 1,310.02 1,506.5250500 1,255.26 1,192.50 1,371.3850520 1,019.98 968.98 1,114.3350525 1,396.07 1,326.27 1,525.2150526 1,387.02 1,317.67 1,515.3250540 1,126.65 1,070.32 1,230.8750541 908.43 863.01 992.46# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.134 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE50542 1,151.87 1,094.28 1,258.4250543 1,471.46 1,397.89 1,607.5750544 1,233.89 1,172.20 1,348.0350545 1,327.79 1,261.40 1,450.6150546 1,186.56 1,127.23 1,296.3150547 1,572.14 1,493.53 1,717.5650548 1,332.73 1,266.09 1,456.0050551 353.18 335.52 385.85# 50551 291.92 277.32 318.9250553 378.00 359.10 412.97# 50553 312.96 297.31 341.9150555 404.45 384.23 441.86# 50555 338.47 321.55 369.7850557 411.64 391.06 449.72# 50557 343.15 325.99 374.8950561 467.83 444.44 511.11# 50561 391.80 372.21 428.0450562 576.40 547.58 629.7250570 487.55 463.17 532.6550572 528.48 502.06 577.3750574 562.00 533.90 613.9950575 710.01 674.51 775.6950576 559.93 531.93 611.7250580 603.24 573.08 659.0450590 788.73 749.29 861.68# 50590 556.24 528.43 607.6950592 3,053.03 2,900.38 3,335.44# 50592 357.16 339.30 390.2050593 4,358.05 4,140.15 4,761.17# 50593 471.18 447.62 514.7650600 924.75 878.51 1,010.2950605 959.78 911.79 1,048.5650610 932.19 885.58 1,018.4250620 891.67 847.09 974.1550630 877.49 833.62 958.6650650 1,021.95 970.85 1,116.4850660 1,126.75 1,070.41 1,230.9750684 120.78 114.74 131.95# 50684 48.84 46.40 53.36# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.135 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE50686 137.00 130.15 149.67# 50686 90.19 85.68 98.5350688 77.84 73.95 85.0450690 94.02 89.32 102.72# 50690 68.26 64.85 74.5850700 911.67 866.09 996.0050715 1,167.07 1,108.72 1,275.0350722 1,039.58 987.60 1,135.7450725 1,081.16 1,027.10 1,181.1750727 497.44 472.57 543.4650728 684.03 649.83 747.3050740 1,202.72 1,142.58 1,313.9750750 1,139.26 1,082.30 1,244.6550760 1,112.99 1,057.34 1,215.9450770 1,128.89 1,072.45 1,233.3250780 1,092.04 1,037.44 1,193.0650782 1,138.95 1,082.00 1,244.3050783 1,102.20 1,047.09 1,204.1550785 1,194.48 1,134.76 1,304.9750800 912.47 866.85 996.8850810 1,368.83 1,300.39 1,495.4550815 1,204.79 1,144.55 1,316.2350820 1,299.93 1,234.93 1,420.1750825 1,638.41 1,556.49 1,789.9650830 1,774.97 1,686.22 1,939.1550840 1,212.46 1,151.84 1,324.6250845 1,231.49 1,169.92 1,345.4150860 930.43 883.91 1,016.5050900 832.77 791.13 909.8050920 868.44 825.02 948.7750930 1,210.00 1,149.50 1,321.9350940 872.57 828.94 953.2850945 960.55 912.52 1,049.4050947 1,363.68 1,295.50 1,489.8350948 1,261.10 1,198.05 1,377.7650951 368.99 350.54 403.12# 50951 304.27 289.06 332.4250953 391.33 371.76 427.52# 50953 336.04 319.24 367.13# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.136 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE50955 421.77 400.68 460.78# 50955 361.77 343.68 395.2350957 420.93 399.88 459.86# 50957 351.19 333.63 383.6750961 379.74 360.75 414.86# 50961 315.02 299.27 344.1650970 367.65 349.27 401.6650972 355.32 337.55 388.1850974 469.47 446.00 512.9050976 462.48 439.36 505.2650980 353.23 335.57 385.9151020 461.35 438.28 504.0251030 456.18 433.37 498.3851040 284.14 269.93 310.4251045 481.28 457.22 525.8051050 464.60 441.37 507.5851060 572.26 543.65 625.2051065 569.12 540.66 621.7651080 400.33 380.31 437.3651100 59.31 56.34 64.79# 51100 38.57 36.64 42.1451101 121.40 115.33 132.63# 51101 52.28 49.67 57.1251102 222.47 211.35 243.05# 51102 144.87 137.63 158.2751500 657.64 624.76 718.4751520 581.79 552.70 635.6151525 848.71 806.27 927.2151530 774.57 735.84 846.2251535 764.37 726.15 835.0751550 954.94 907.19 1,043.2751555 1,254.63 1,191.90 1,370.6951565 1,277.98 1,214.08 1,396.1951570 1,457.85 1,384.96 1,592.7051575 1,799.90 1,709.91 1,966.4051580 1,873.84 1,780.15 2,047.1751585 2,086.88 1,982.54 2,279.9251590 1,911.12 1,815.56 2,087.8951595 2,166.09 2,057.79 2,366.46# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.137 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE51596 2,325.74 2,209.45 2,540.8751597 2,268.35 2,154.93 2,478.1751600 180.21 171.20 196.88# 51600 43.55 41.37 47.5851605 37.43 35.56 40.8951610 104.41 99.19 114.07# 51610 62.63 59.50 68.4351700 80.93 76.88 88.41# 51700 43.86 41.67 47.9251701 54.34 51.62 59.36# 51701 27.01 25.66 29.5151702 69.73 66.24 76.18# 51702 29.52 28.04 32.2551703 128.02 121.62 139.86# 51703 80.26 76.25 87.6951705 84.80 80.56 92.64# 51705 50.25 47.74 54.90# 51710 76.71 72.87 83.8051710 89.27 84.81 97.5351715 282.84 268.70 309.01# 51715 198.02 188.12 216.3451720 107.36 101.99 117.29# 51720 79.40 75.43 86.7451725 189.02 179.57 206.5151725 TC 113.78 108.09 124.3051725 26 75.24 71.48 82.2051726 275.82 262.03 301.3351726 TC 190.85 181.31 208.5151726 26 84.98 80.73 92.8451727 298.22 283.31 325.8151727 TC 191.38 181.81 209.0851727 26 106.84 101.50 116.7351728 296.76 281.92 324.2151728 TC 193.89 184.20 211.8351728 26 102.87 97.73 112.3951729 324.50 308.28 354.5251729 TC 199.23 189.27 217.6651729 26 125.27 119.01 136.8651736 20.65 19.62 22.56# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.138 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE51736 TC 10.73 10.19 11.7251736 26 9.92 9.42 10.8351741 23.79 22.60 25.9951741 TC 11.99 11.39 13.1051741 26 11.81 11.22 12.9051784 190.64 181.11 208.2851784 TC 114.72 108.98 125.3351784 26 75.92 72.12 82.9451785 224.89 213.65 245.7051785 TC 148.02 140.62 161.7151785 26 76.86 73.02 83.9751792 210.78 200.24 230.2851792 TC 155.56 147.78 169.9551792 26 55.22 52.46 60.3351797 116.44 110.62 127.2151797 TC 76.71 72.87 83.8051797 26 39.73 37.74 43.4051798 17.96 17.06 19.6251800 1,030.92 979.37 1,126.2851820 1,058.84 1,005.90 1,156.7951840 655.19 622.43 715.7951841 779.21 740.25 851.2951845 582.36 553.24 636.2351860 738.41 701.49 806.7151865 885.07 840.82 966.9451880 462.87 439.73 505.6951900 815.42 774.65 890.8551920 746.23 708.92 815.2651925 1,010.12 959.61 1,103.5551940 1,608.19 1,527.78 1,756.9551960 1,374.11 1,305.40 1,501.2151980 701.27 666.21 766.1451990 750.69 713.16 820.1351992 847.72 805.33 926.1352000 198.32 188.40 216.66# 52000 124.49 118.27 136.0152001 364.36 346.14 398.06# 52001 284.56 270.33 310.8852005 267.53 254.15 292.27# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.139 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 52005 131.50 124.93 143.6752007 457.41 434.54 499.72# 52007 163.98 155.78 179.1552010 369.13 350.67 403.27# 52010 162.72 154.58 177.7752204 372.51 353.88 406.96# 52204 140.03 133.03 152.9852214 602.70 572.57 658.46# 52214 200.25 190.24 218.7852224 636.53 604.70 695.41# 52224 167.48 159.11 182.9852234 243.64 231.46 266.1852235 285.82 271.53 312.2652240 499.85 474.86 546.0952250 240.20 228.19 262.4252260 208.23 197.82 227.4952265 369.48 351.01 403.66# 52265 162.13 154.02 177.1252270 355.09 337.34 387.94# 52270 180.10 171.10 196.7752275 482.01 457.91 526.60# 52275 246.07 233.77 268.8452276 263.39 250.22 287.7552277 322.93 306.78 352.8052281 270.98 257.43 296.04# 52281 151.28 143.72 165.2852282 335.09 318.34 366.0952283 269.86 256.37 294.83# 52283 199.17 189.21 217.5952285 272.66 259.03 297.88# 52285 194.12 184.41 212.0752290 241.96 229.86 264.3452300 282.14 268.03 308.2352301 290.06 275.56 316.8952305 276.61 262.78 302.2052310 237.52 225.64 259.49# 52310 150.50 142.98 164.4352315 408.19 387.78 445.95# 52315 271.85 258.26 297.00# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.140 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE52317 813.77 773.08 889.04# 52317 344.72 327.48 376.6052318 469.84 446.35 513.3052320 244.18 231.97 266.7752325 318.50 302.58 347.9752327 261.21 248.15 285.3752330 550.64 523.11 601.58# 52330 261.61 248.53 285.8152332 477.83 453.94 522.03# 52332 153.93 146.23 168.1652334 254.41 241.69 277.9452341 286.48 272.16 312.9852342 311.23 295.67 340.0252343 346.77 329.43 378.8452344 376.55 357.72 411.3852345 401.31 381.24 438.4352346 453.88 431.19 495.8752351 310.92 295.37 339.6852352 365.35 347.08 399.1452353 419.23 398.27 458.0152354 388.12 368.71 424.0252355 462.49 439.37 505.2852400 473.07 449.42 516.8352402 264.80 251.56 289.2952450 461.44 438.37 504.1352500 479.81 455.82 524.1952601 829.73 788.24 906.4852630 393.26 373.60 429.6452640 304.45 289.23 332.6152647 1,811.70 1,721.12 1,979.29# 52647 637.03 605.18 695.9652648 1,861.55 1,768.47 2,033.74# 52648 680.28 646.27 743.2152649 821.16 780.10 897.1252700 435.40 413.63 475.6753000 145.85 138.56 159.3453010 288.02 273.62 314.6653020 96.01 91.21 104.8953025 66.46 63.14 72.61# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.141 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE53040 385.41 366.14 421.0653060 183.89 174.70 200.91# 53060 165.98 157.68 181.3353080 416.37 395.55 454.8853085 641.96 609.86 701.3453200 152.96 145.31 167.11# 53200 140.08 133.08 153.0453210 762.59 724.46 833.1353215 915.91 870.11 1,000.6353220 447.44 425.07 488.8353230 601.19 571.13 656.8053235 623.76 592.57 681.4653240 418.10 397.20 456.7853250 417.80 396.91 456.4553260 198.18 188.27 216.51# 53260 178.07 169.17 194.5553265 214.21 203.50 234.03# 53265 183.42 174.25 200.3953270 207.53 197.15 226.72# 53270 187.11 177.75 204.4153275 259.26 246.30 283.2553400 792.12 752.51 865.3953405 862.29 819.18 942.0653410 964.66 916.43 1,053.8953415 1,116.85 1,061.01 1,220.1653420 819.65 778.67 895.4753425 925.69 879.41 1,011.3253430 955.25 907.49 1,043.6153431 1,138.21 1,081.30 1,243.5053440 754.68 716.95 824.4953442 768.53 730.10 839.6253444 782.29 743.18 854.6653445 752.65 715.02 822.2753446 633.10 601.45 691.6753447 798.07 758.17 871.9053448 1,263.67 1,200.49 1,380.5653449 603.11 572.95 658.8953450 401.74 381.65 438.9053460 449.64 427.16 491.23# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.142 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE53500 742.12 705.01 810.7653502 477.40 453.53 521.5653505 478.34 454.42 522.5853510 621.49 590.42 678.9853515 783.00 743.85 855.4353520 547.12 519.76 597.7253600 81.63 77.55 89.18# 53600 63.10 59.95 68.9453601 78.68 74.75 85.96# 53601 52.29 49.68 57.1353605 63.64 60.46 69.5353620 115.00 109.25 125.64# 53620 86.41 82.09 94.4053621 107.50 102.13 117.45# 53621 71.05 67.50 77.6353660 68.81 65.37 75.18# 53660 40.85 38.81 44.6353661 67.90 64.51 74.19# 53661 39.93 37.93 43.6253665 38.20 36.29 41.7353850 2,024.73 1,923.49 2,212.01# 53850 560.40 532.38 612.2453852 1,957.61 1,859.73 2,138.69# 53852 612.66 582.03 669.3353855 703.49 668.32 768.57# 53855 80.18 76.17 87.6053860 1,421.25 1,350.19 1,552.72# 53860 229.93 218.43 251.1954000 144.98 137.73 158.39# 54000 105.08 99.83 114.8054001 181.69 172.61 198.50# 54001 136.45 129.63 149.0754015 303.35 288.18 331.4154050 125.44 119.17 137.05# 54050 100.94 95.89 110.2754055 113.93 108.23 124.46# 54055 89.43 84.96 97.7054056 135.28 128.52 147.80# 54056 107.32 101.95 117.24# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.143 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE54057 131.84 125.25 144.04# 54057 91.32 86.75 99.7654060 175.93 167.13 192.20# 54060 127.87 121.48 139.7054065 212.22 201.61 231.85# 54065 167.93 159.53 183.4654100 190.90 181.36 208.56# 54100 123.67 117.49 135.1154105 259.52 246.54 283.52# 54105 209.26 198.80 228.6254110 614.47 583.75 671.3154111 789.95 750.45 863.0254112 925.67 879.39 1,011.3054115 442.21 420.10 483.12# 54115 416.14 395.33 454.6354120 622.71 591.57 680.3154125 802.34 762.22 876.5554130 1,178.36 1,119.44 1,287.3654135 1,530.73 1,454.19 1,672.3254150 156.29 148.48 170.75# 54150 97.86 92.97 106.9254160 215.80 205.01 235.76# 54160 141.66 134.58 154.7754161 194.18 184.47 212.1454162 254.13 241.42 277.63# 54162 195.39 185.62 213.4654163 214.55 203.82 234.3954164 189.16 179.70 206.6654200 104.25 99.04 113.90# 54200 81.95 77.85 89.5354205 524.80 498.56 573.3454220 198.96 189.01 217.36# 54220 133.30 126.64 145.6454230 93.96 89.26 102.65# 54230 78.25 74.34 85.4954231 137.03 130.18 149.71# 54231 115.04 109.29 125.6854235 87.55 83.17 95.65# 54235 72.15 68.54 78.82# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.144 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE54240 96.25 91.44 105.1654240 TC 32.72 31.08 35.7454240 26 63.52 60.34 69.3954250 119.04 113.09 130.0554250 TC 10.73 10.19 11.7254250 26 108.30 102.89 118.3254300 633.89 602.20 692.5354304 741.13 704.07 809.6854308 724.97 688.72 792.0354312 809.04 768.59 883.8854316 1,011.65 961.07 1,105.2354318 689.74 655.25 753.5454322 772.58 733.95 844.0454324 958.57 910.64 1,047.2454326 926.51 880.18 1,012.2154328 926.07 879.77 1,011.7454332 1,002.63 952.50 1,095.3854336 1,160.72 1,102.68 1,268.0854340 559.13 531.17 610.8554344 937.61 890.73 1,024.3454348 986.24 936.93 1,077.4754352 1,404.11 1,333.90 1,533.9954360 712.92 677.27 778.8654380 868.35 824.93 948.6754385 982.54 933.41 1,073.4254390 1,238.37 1,176.45 1,352.9254400 522.28 496.17 570.6054401 644.79 612.55 704.4354405 798.17 758.26 872.0054406 719.85 683.86 786.4454408 779.04 740.09 851.1054410 847.95 805.55 926.3854411 1,010.75 960.21 1,104.2454415 519.85 493.86 567.9454416 699.16 664.20 763.8354417 886.31 841.99 968.2954420 696.04 661.24 760.4354430 631.59 600.01 690.0154435 409.70 389.22 447.60# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.145 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE54440 1,170.74 1,112.20 1,279.0354450 68.78 65.34 75.14# 54450 56.84 54.00 62.1054500 73.46 69.79 80.2654505 206.90 196.56 226.0454512 531.43 504.86 580.5954520 321.98 305.88 351.7654522 577.59 548.71 631.0254530 498.06 473.16 544.1354535 730.21 693.70 797.7654550 483.23 459.07 527.9354560 707.70 672.32 773.1754600 444.95 422.70 486.1154620 295.75 280.96 323.1054640 469.76 446.27 513.2154650 698.55 663.62 763.1654660 349.49 332.02 381.8254670 397.61 377.73 434.3954680 773.05 734.40 844.5654690 722.53 686.40 789.3654692 749.13 711.67 818.4254700 210.21 199.70 229.6654800 129.33 122.86 141.2954830 366.35 348.03 400.2354840 316.11 300.30 345.3554860 411.48 390.91 449.5554861 556.27 528.46 607.7354865 351.55 333.97 384.0754900 763.30 725.14 833.9154901 1,024.77 973.53 1,119.5655000 114.72 108.98 125.33# 55000 83.30 79.14 91.0155040 333.37 316.70 364.2155041 502.19 477.08 548.6455060 374.14 355.43 408.7455100 210.86 200.32 230.37# 55100 163.11 154.95 178.1955110 381.89 362.80 417.2255120 352.92 335.27 385.56# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.146 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE55150 483.35 459.18 528.0655175 357.04 339.19 390.0755180 683.84 649.65 747.1055200 435.41 413.64 475.69# 55200 272.36 258.74 297.5555250 382.76 363.62 418.16# 55250 222.22 211.11 242.7855300 183.03 173.88 199.9655400 491.34 466.77 536.7955450 353.94 336.24 386.68# 55450 252.15 239.54 275.4755500 389.19 369.73 425.1955520 439.23 417.27 479.8655530 348.39 330.97 380.6255535 421.89 400.80 460.9255540 524.45 498.23 572.9655550 418.78 397.84 457.5255600 414.46 393.74 452.8055605 506.87 481.53 553.7655650 705.25 669.99 770.4955680 337.37 320.50 368.5855700 215.09 204.34 234.99# 55700 137.49 130.62 150.2155705 262.82 249.68 287.1355706 363.60 345.42 397.2355720 443.93 421.73 484.9955725 582.26 553.15 636.1255801 1,076.51 1,022.68 1,176.0855810 1,301.24 1,236.18 1,421.6155812 1,589.49 1,510.02 1,736.5255815 1,742.84 1,655.70 1,904.0655821 862.70 819.57 942.5155831 932.97 886.32 1,019.2755840 1,321.26 1,255.20 1,443.4855842 1,415.99 1,345.19 1,546.9755845 1,617.63 1,536.75 1,767.2655860 862.45 819.33 942.2355862 1,083.47 1,029.30 1,183.7055865 1,318.44 1,252.52 1,440.40# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.147 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE55866 1,713.71 1,628.02 1,872.2255870 171.74 163.15 187.62# 55870 141.26 134.20 154.3355873 6,237.15 5,925.29 6,814.08# 55873 789.18 749.72 862.1855875 750.45 712.93 819.8755876 131.62 125.04 143.80# 55876 98.95 94.00 108.1055920 428.20 406.79 467.8156405 107.93 102.53 117.91# 56405 106.67 101.34 116.5456420 119.64 113.66 130.71# 56420 90.73 86.19 99.1256440 181.54 172.46 198.3356441 141.83 134.74 154.95# 56441 136.17 129.36 148.7656442 47.57 45.19 51.9756501 128.01 121.61 139.85# 56501 112.93 107.28 123.3756515 220.42 209.40 240.81# 56515 196.86 187.02 215.0756605 81.06 77.01 88.56# 56605 60.33 57.31 65.9156606 36.71 34.87 40.10# 56606 29.17 27.71 31.8756620 498.55 473.62 544.6656625 598.61 568.68 653.9856630 883.74 839.55 965.4856631 1,121.01 1,064.96 1,224.7056632 1,302.19 1,237.08 1,422.6456633 1,149.28 1,091.82 1,255.5956634 1,218.56 1,157.63 1,331.2756637 1,429.65 1,358.17 1,561.9056640 1,425.95 1,354.65 1,557.8556700 185.76 176.47 202.9456740 295.89 281.10 323.2756800 239.05 227.10 261.1756805 1,145.86 1,088.57 1,251.8656810 257.84 244.95 281.69# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.148 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE56820 108.90 103.46 118.98# 56820 85.34 81.07 93.2356821 144.35 137.13 157.70# 56821 114.51 108.78 125.1057000 183.51 174.33 200.4857010 431.17 409.61 471.0557020 93.19 88.53 101.81# 57020 81.88 77.79 89.4657022 166.79 158.45 182.2257023 309.76 294.27 338.4157061 111.32 105.75 121.61# 57061 96.55 91.72 105.4857065 189.18 179.72 206.68# 57065 169.70 161.22 185.4057100 86.45 82.13 94.45# 57100 65.72 62.43 71.7957105 132.61 125.98 144.88# 57105 123.19 117.03 134.5857106 477.13 453.27 521.2657107 1,400.41 1,330.39 1,529.9557109 1,602.52 1,522.39 1,750.7557110 895.10 850.35 977.9057111 1,606.92 1,526.57 1,755.5657112 1,619.50 1,538.53 1,769.3157120 507.25 481.89 554.1757130 175.62 166.84 191.87# 57130 158.34 150.42 172.9857135 188.65 179.22 206.10# 57135 170.74 162.20 186.5357150 45.19 42.93 49.37# 57150 29.17 27.71 31.8757155 413.96 393.26 452.25# 57155 274.16 260.45 299.5257156 183.81 174.62 200.81# 57156 138.89 131.95 151.7457160 74.66 70.93 81.57# 57160 47.33 44.96 51.7057170 61.52 58.44 67.21# 57170 48.32 45.90 52.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.149 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE57180 137.88 130.99 150.64# 57180 104.89 99.65 114.6057200 294.09 279.39 321.3057210 362.24 344.13 395.7557220 316.09 300.29 345.3357230 395.01 375.26 431.5557240 660.29 627.28 721.3757250 669.29 635.83 731.2057260 826.10 784.80 902.5257265 907.51 862.13 991.4557267 257.33 244.46 281.1357268 477.68 453.80 521.8757270 794.73 754.99 868.2457280 949.92 902.42 1,037.7857282 496.10 471.30 542.0057283 686.97 652.62 750.5157284 813.29 772.63 888.5257285 670.19 636.68 732.1857287 672.09 638.49 734.2657288 704.47 669.25 769.6457289 710.77 675.23 776.5157291 604.88 574.64 660.8457292 817.74 776.85 893.3857295 475.40 451.63 519.3757296 949.19 901.73 1,036.9957300 546.87 519.53 597.4657305 912.98 867.33 997.4357307 1,041.87 989.78 1,138.2557308 636.76 604.92 695.6657310 450.00 427.50 491.6357311 512.70 487.07 560.1357320 524.25 498.04 572.7557330 723.98 687.78 790.9557335 1,123.98 1,067.78 1,227.9557400 132.88 126.24 145.1857410 106.25 100.94 116.0857415 157.59 149.71 172.17# 57420 89.68 85.20 97.9857420 113.87 108.18 124.41# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.150 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE57421 153.38 145.71 167.57# 57421 122.59 116.46 133.9357423 918.36 872.44 1,003.3157425 966.16 917.85 1,055.5357426 848.70 806.27 927.2157452 106.60 101.27 116.46# 57452 90.89 86.35 99.3057454 151.57 143.99 165.59# 57454 135.55 128.77 148.0957455 140.69 133.66 153.71# 57455 110.84 105.30 121.1057456 133.00 126.35 145.30# 57456 103.47 98.30 113.0557460 279.36 265.39 305.20# 57460 163.12 154.96 178.2057461 315.72 299.93 344.92# 57461 188.80 179.36 206.2657500 125.09 118.84 136.67# 57500 75.14 71.38 82.0957505 99.62 94.64 108.84# 57505 90.19 85.68 98.5357510 129.36 122.89 141.32# 57510 114.59 108.86 125.1957511 143.10 135.95 156.34# 57511 130.85 124.31 142.9657513 141.53 134.45 154.62# 57513 131.47 124.90 143.6457520 300.67 285.64 328.49# 57520 269.57 256.09 294.5057522 259.68 246.70 283.71# 57522 241.15 229.09 263.4557530 341.10 324.05 372.6657531 1,723.80 1,637.61 1,883.2557540 776.67 737.84 848.5257545 819.60 778.62 895.4157550 405.27 385.01 442.7657555 597.92 568.02 653.2257556 561.47 533.40 613.4157558 123.13 116.97 134.52# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.151 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 57558 112.77 107.13 123.2057700 306.84 291.50 335.2357720 304.26 289.05 332.4157800 58.85 55.91 64.30# 57800 47.85 45.46 52.2858100 108.03 102.63 118.02# 58100 87.61 83.23 95.7158110 47.54 45.16 51.93# 58110 40.94 38.89 44.7258120 252.15 239.54 275.47# 58120 216.65 205.82 236.6958140 916.74 870.90 1,001.5458145 541.01 513.96 591.0558146 1,154.28 1,096.57 1,261.0658150 994.00 944.30 1,085.9558152 1,245.52 1,183.24 1,360.7358180 954.37 906.65 1,042.6558200 1,312.35 1,246.73 1,433.7458210 1,758.15 1,670.24 1,920.7858240 2,789.90 2,650.41 3,047.9758260 824.59 783.36 900.8658262 920.36 874.34 1,005.4958263 989.87 940.38 1,081.4458267 1,054.82 1,002.08 1,152.3958270 879.76 835.77 961.1458275 982.70 933.57 1,073.6158280 1,051.40 998.83 1,148.6558285 1,311.40 1,245.83 1,432.7058290 1,149.65 1,092.17 1,256.0058291 1,246.00 1,183.70 1,361.2658292 1,315.09 1,249.34 1,436.7458293 1,367.56 1,299.18 1,494.0658294 1,218.87 1,157.93 1,331.6258301 93.96 89.26 102.65# 58301 68.20 64.79 74.5158321 71.78 68.19 78.42# 58321 45.70 43.42 49.9358322 84.52 80.29 92.33# 58322 58.76 55.82 64.19# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.152 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE58323 16.20 15.39 17.70# 58323 12.43 11.81 13.5858340 115.37 109.60 126.04# 58340 56.94 54.09 62.2058345 278.52 264.59 304.2858346 437.96 416.06 478.4758350 94.47 89.75 103.21# 58350 77.82 73.93 85.0258353 990.47 940.95 1,082.09# 58353 218.56 207.63 238.7758356 1,846.22 1,753.91 2,017.00# 58356 347.64 330.26 379.8058400 435.32 413.55 475.5858410 801.65 761.57 875.8158520 807.20 766.84 881.8758540 906.68 861.35 990.5558541 859.42 816.45 938.9258542 960.55 912.52 1,049.4058543 976.74 927.90 1,067.0958544 1,057.68 1,004.80 1,155.5258545 893.16 848.50 975.7858546 1,126.91 1,070.56 1,231.1458548 1,799.56 1,709.58 1,966.0258550 880.44 836.42 961.8858552 978.46 929.54 1,068.9758553 1,134.50 1,077.78 1,239.4558554 1,311.95 1,246.35 1,433.3058555 280.44 266.42 306.38# 58555 189.64 180.16 207.1858558 370.46 351.94 404.73# 58558 266.79 253.45 291.4758559 343.70 326.52 375.5058560 387.68 368.30 423.5558561 548.46 521.04 599.2058562 386.16 366.85 421.88# 58562 290.02 275.52 316.8558563 1,629.27 1,547.81 1,779.98# 58563 343.38 326.21 375.1458565 1,809.72 1,719.23 1,977.11# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.153 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 58565 431.78 410.19 471.7258570 924.60 878.37 1,010.1358571 1,028.01 976.61 1,123.1058572 1,152.17 1,094.56 1,258.7458573 1,317.72 1,251.83 1,439.6058600 362.64 344.51 396.1958605 327.04 310.69 357.2958611 77.57 73.69 84.7458615 243.94 231.74 266.5058660 670.73 637.19 732.7758661 642.54 610.41 701.9758662 703.14 667.98 768.1858670 363.58 345.40 397.2158671 363.26 345.10 396.8758672 735.21 698.45 803.2258673 799.02 759.07 872.9358700 771.64 733.06 843.0258720 718.96 683.01 785.4658740 873.40 829.73 954.1958750 900.48 855.46 983.7858752 844.76 802.52 922.9058760 809.05 768.60 883.8958770 847.45 805.08 925.8458800 314.97 299.22 344.10# 58800 296.12 281.31 323.5158805 399.87 379.88 436.8658820 309.63 294.15 338.2758822 734.64 697.91 802.6058823 866.51 823.18 946.66# 58823 168.43 160.01 184.0158825 704.50 669.28 769.6758900 438.93 416.98 479.5358920 697.24 662.38 761.7458925 736.40 699.58 804.5258940 513.64 487.96 561.1558943 1,128.97 1,072.52 1,233.4058950 1,078.43 1,024.51 1,178.1958951 1,386.58 1,317.25 1,514.8458952 1,566.64 1,488.31 1,711.56# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.154 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE58953 1,938.64 1,841.71 2,117.9758954 2,101.26 1,996.20 2,295.6358956 1,323.06 1,256.91 1,445.4558957 1,513.24 1,437.58 1,653.2258958 1,662.23 1,579.12 1,815.9958960 924.71 878.47 1,010.2458970 209.07 198.62 228.41# 58970 188.02 178.62 205.4158974 134.80 128.06 147.2758976 234.10 222.40 255.76# 58976 202.68 192.55 221.4359000 124.63 118.40 136.16# 59000 81.90 77.81 89.4859001 183.67 174.49 200.6659012 204.01 193.81 222.8859015 155.93 148.13 170.35# 59015 134.25 127.54 146.6759020 68.55 65.12 74.8959020 TC 31.47 29.90 34.3959020 26 37.08 35.23 40.5159025 46.65 44.32 50.9759025 TC 17.01 16.16 18.5859025 26 29.63 28.15 32.3759030 97.23 92.37 106.2359050 51.69 49.11 56.4859051 42.93 40.78 46.9059070 410.18 389.67 448.12# 59070 317.18 301.32 346.5259072 528.42 502.00 577.3059074 418.66 397.73 457.39# 59074 322.21 306.10 352.0259076 525.91 499.61 574.5559100 841.43 799.36 919.2659120 802.88 762.74 877.1559121 803.74 763.55 878.0859130 813.34 772.67 888.5759135 825.70 784.42 902.0859136 882.73 838.59 964.3859140 354.39 336.67 387.17# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.155 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE59150 777.10 738.25 848.9959151 756.85 719.01 826.8659160 205.58 195.30 224.60# 59160 176.36 167.54 192.6759200 72.02 68.42 78.68# 59200 45.94 43.64 50.1959300 191.28 181.72 208.98# 59300 149.50 142.03 163.3359320 154.13 146.42 168.3859325 214.72 203.98 234.5859350 285.48 271.21 311.8959400 2,086.08 1,981.78 2,279.0559409 827.15 785.79 903.6659410 1,050.32 997.80 1,147.4759412 104.94 99.69 114.6459414 93.22 88.56 101.8459425 453.39 430.72 495.33# 59425 361.66 343.58 395.1259426 810.15 769.64 885.09# 59426 637.67 605.79 696.6659430 176.94 168.09 193.30# 59430 142.07 134.97 155.2259510 2,314.11 2,198.40 2,528.1659514 934.29 887.58 1,020.7259515 1,271.57 1,207.99 1,389.1959525 494.42 469.70 540.1659610 2,193.76 2,084.07 2,396.6859612 931.29 884.73 1,017.4459614 1,151.46 1,093.89 1,257.9759618 2,351.59 2,234.01 2,569.1159620 969.76 921.27 1,059.4659622 1,311.23 1,245.67 1,432.5259812 316.94 301.09 346.25# 59812 296.20 281.39 323.6059820 377.74 358.85 412.68# 59820 355.75 337.96 388.6559821 381.62 362.54 416.92# 59821 358.06 340.16 391.1859830 439.17 417.21 479.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.156 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE59840 214.82 204.08 234.69# 59840 206.96 196.61 226.1059841 383.52 364.34 418.99# 59841 363.42 345.25 397.0459850 337.64 320.76 368.8759851 401.23 381.17 438.3559852 488.21 463.80 533.3759855 418.44 397.52 457.1559856 492.70 468.07 538.2859857 503.96 478.76 550.5759866 210.45 199.93 229.9259870 473.36 449.69 517.1459871 135.54 128.76 148.0760000 158.31 150.39 172.95# 60000 142.91 135.76 156.1260100 107.30 101.94 117.23# 60100 77.77 73.88 84.9660200 648.59 616.16 708.5860210 696.64 661.81 761.0860212 997.00 947.15 1,089.2260220 699.35 664.38 764.0460225 914.27 868.56 998.8460240 906.94 861.59 990.8360252 1,298.13 1,233.22 1,418.2060254 1,649.93 1,567.43 1,802.5460260 1,081.00 1,026.95 1,180.9960270 1,353.69 1,286.01 1,478.9160271 1,042.60 990.47 1,139.0460280 435.96 414.16 476.2860281 581.40 552.33 635.1860300 108.33 102.91 118.35# 60300 48.64 46.21 53.1460500 948.08 900.68 1,035.7860502 1,258.58 1,195.65 1,375.0060505 1,380.41 1,311.39 1,508.1060512 240.39 228.37 262.6360520 1,018.86 967.92 1,113.1160521 1,138.12 1,081.21 1,243.3960522 1,383.98 1,314.78 1,512.00# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.157 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE60540 1,038.14 986.23 1,134.1660545 1,192.88 1,133.24 1,303.2360600 1,426.10 1,354.80 1,558.0260605 1,618.47 1,537.55 1,768.1860650 1,172.19 1,113.58 1,280.6261000 106.31 100.99 116.1461001 114.61 108.88 125.2161020 134.31 127.59 146.7361026 126.02 119.72 137.6861050 101.00 95.95 110.3461055 132.61 125.98 144.8861070 82.81 78.67 90.4761105 452.35 429.73 494.1961107 316.30 300.49 345.5661108 891.48 846.91 973.9561120 733.52 696.84 801.3761140 1,247.36 1,184.99 1,362.7461150 1,342.10 1,275.00 1,466.2561151 982.17 933.06 1,073.0261154 1,255.06 1,192.31 1,371.1661156 1,234.24 1,172.53 1,348.4161210 369.63 351.15 403.8261215 495.93 471.13 541.8061250 854.23 811.52 933.2561253 817.33 776.46 892.9361304 1,628.08 1,546.68 1,778.6861305 1,995.44 1,895.67 2,180.0261312 2,067.33 1,963.96 2,258.5561313 1,969.20 1,870.74 2,151.3561314 1,813.28 1,722.62 1,981.0161315 2,056.53 1,953.70 2,246.7661316 87.76 83.37 95.8861320 1,890.98 1,796.43 2,065.8961321 2,110.96 2,005.41 2,306.2261322 2,354.19 2,236.48 2,571.9561323 2,370.84 2,252.30 2,590.1561330 1,782.54 1,693.41 1,947.4261332 1,992.73 1,893.09 2,177.0561333 2,039.08 1,937.13 2,227.70# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.158 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE61334 1,230.45 1,168.93 1,344.2761340 1,431.39 1,359.82 1,563.7961343 2,181.36 2,072.29 2,383.1361345 2,026.94 1,925.59 2,214.4361440 1,988.90 1,889.46 2,172.8861450 1,908.95 1,813.50 2,085.5361458 1,993.30 1,893.64 2,177.6961460 2,084.78 1,980.54 2,277.6261470 1,779.50 1,690.53 1,944.1161480 1,611.41 1,530.84 1,760.4761490 1,882.78 1,788.64 2,056.9461500 1,322.15 1,256.04 1,444.4561501 1,141.77 1,084.68 1,247.3861510 2,168.81 2,060.37 2,369.4361512 2,538.75 2,411.81 2,773.5861514 1,892.52 1,797.89 2,067.5761516 1,842.19 1,750.08 2,012.5961517 87.42 83.05 95.5161518 2,743.61 2,606.43 2,997.3961519 2,935.05 2,788.30 3,206.5561520 3,732.78 3,546.14 4,078.0661521 3,168.28 3,009.87 3,461.3561522 2,174.41 2,065.69 2,375.5461524 2,066.67 1,963.34 2,257.8461526 3,622.09 3,440.99 3,957.1461530 3,002.81 2,852.67 3,280.5761531 1,208.62 1,148.19 1,320.4261533 1,511.04 1,435.49 1,650.8161534 1,631.35 1,549.78 1,782.2561535 986.91 937.56 1,078.1961536 2,568.27 2,439.86 2,805.8461537 2,443.24 2,321.08 2,669.2461538 2,648.24 2,515.83 2,893.2061539 2,344.48 2,227.26 2,561.3561540 2,170.78 2,062.24 2,371.5861541 2,134.40 2,027.68 2,331.8361542 2,188.45 2,079.03 2,390.8861543 2,152.94 2,045.29 2,352.0861544 1,864.81 1,771.57 2,037.31# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.159 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE61545 3,165.19 3,006.93 3,457.9761546 2,292.36 2,177.74 2,504.4061548 1,544.59 1,467.36 1,687.4661550 991.65 942.07 1,083.3861552 1,247.96 1,185.56 1,363.3961556 1,684.23 1,600.02 1,840.0261557 1,668.81 1,585.37 1,823.1861558 1,864.11 1,770.90 2,036.5461559 1,831.89 1,740.30 2,001.3561563 1,967.87 1,869.48 2,149.9061564 2,392.93 2,273.28 2,614.2761566 2,237.13 2,125.27 2,444.0661567 2,552.62 2,424.99 2,788.7461570 1,850.00 1,757.50 2,021.1361571 1,976.20 1,877.39 2,159.0061575 2,481.46 2,357.39 2,711.0061576 3,654.62 3,471.89 3,992.6761580 2,431.99 2,310.39 2,656.9561581 2,651.31 2,518.74 2,896.5561582 2,984.83 2,835.59 3,260.9361583 2,864.85 2,721.61 3,129.8561584 2,821.03 2,679.98 3,081.9861585 3,176.80 3,017.96 3,470.6561586 2,370.51 2,251.98 2,589.7861590 3,023.57 2,872.39 3,303.2561591 3,068.82 2,915.38 3,352.6961592 3,136.61 2,979.78 3,426.7561595 2,331.93 2,215.33 2,547.6361596 2,447.98 2,325.58 2,674.4261597 2,886.70 2,742.37 3,153.7361598 2,765.96 2,627.66 3,021.8161600 2,105.78 2,000.49 2,300.5661601 2,365.88 2,247.59 2,584.7361605 2,159.90 2,051.91 2,359.7061606 2,971.45 2,822.88 3,246.3161607 2,864.52 2,721.29 3,129.4861608 3,215.25 3,054.49 3,512.6661609 595.84 566.05 650.9661610 1,796.25 1,706.44 1,962.41# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.160 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE61611 372.62 353.99 407.0961612 1,391.21 1,321.65 1,519.9061613 3,248.00 3,085.60 3,548.4461615 2,261.43 2,148.36 2,470.6161616 3,287.09 3,122.74 3,591.1561618 1,288.72 1,224.28 1,407.9261619 1,469.51 1,396.03 1,605.4361623 550.82 523.28 601.7761624 1,093.14 1,038.48 1,194.2561626 845.53 803.25 923.7461630 1,242.29 1,180.18 1,357.2161635 1,358.75 1,290.81 1,484.4361680 2,248.27 2,135.86 2,456.2461682 4,182.19 3,973.08 4,569.0461684 2,825.21 2,683.95 3,086.5461686 4,491.82 4,267.23 4,907.3161690 2,170.76 2,062.22 2,371.5561692 3,647.62 3,465.24 3,985.0361697 4,204.54 3,994.31 4,593.4661698 4,606.68 4,376.35 5,032.8061700 3,408.07 3,237.67 3,723.3261702 4,002.36 3,802.24 4,372.5861703 1,347.34 1,279.97 1,471.9761705 2,582.21 2,453.10 2,821.0761708 2,030.16 1,928.65 2,217.9561710 1,956.37 1,858.55 2,137.3361711 2,595.32 2,465.55 2,835.3861720 1,246.97 1,184.62 1,362.3161735 1,560.25 1,482.24 1,704.5861750 1,393.68 1,324.00 1,522.6061751 1,360.89 1,292.85 1,486.7861760 1,560.72 1,482.68 1,705.0861770 1,597.54 1,517.66 1,745.3161781 235.33 223.56 257.0961782 192.68 183.05 210.5161783 235.33 223.56 257.0961790 858.67 815.74 938.1061791 1,099.84 1,044.85 1,201.5861796 978.46 929.54 1,068.97# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.161 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE61797 216.89 206.05 236.9661798 1,323.58 1,257.40 1,446.0161799 299.49 284.52 327.2061800 150.59 143.06 164.5261850 972.73 924.09 1,062.7061860 1,554.21 1,476.50 1,697.9861863 1,489.72 1,415.23 1,627.5161864 285.55 271.27 311.9661867 2,271.01 2,157.46 2,481.0861868 502.64 477.51 549.1461870 1,174.72 1,115.98 1,283.3861875 1,006.85 956.51 1,099.9961880 558.55 530.62 610.2161885 519.07 493.12 567.0961886 828.94 787.49 905.6161888 383.81 364.62 419.3162000 885.15 840.89 967.0262005 1,256.10 1,193.30 1,372.3062010 1,515.99 1,440.19 1,656.2262100 1,592.54 1,512.91 1,739.8562115 1,212.29 1,151.68 1,324.4362116 1,760.21 1,672.20 1,923.0362117 1,569.70 1,491.22 1,714.9062120 1,664.55 1,581.32 1,818.5262121 1,666.32 1,583.00 1,820.4562140 1,031.57 979.99 1,126.9962141 1,132.28 1,075.67 1,237.0262142 878.48 834.56 959.7462143 1,031.19 979.63 1,126.5762145 1,404.22 1,334.01 1,534.1162146 1,233.23 1,171.57 1,347.3162147 1,449.72 1,377.23 1,583.8162148 126.58 120.25 138.2962160 190.42 180.90 208.0462161 1,502.55 1,427.42 1,641.5362162 1,877.96 1,784.06 2,051.6762163 1,212.54 1,151.91 1,324.7062164 2,066.50 1,963.18 2,257.6662165 1,538.02 1,461.12 1,680.29# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.162 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE62180 1,588.95 1,509.50 1,735.9362190 911.92 866.32 996.2762192 965.63 917.35 1,054.9562194 403.81 383.62 441.1662200 1,365.23 1,296.97 1,491.5262201 1,188.32 1,128.90 1,298.2462220 1,011.00 960.45 1,104.5262223 1,043.01 990.86 1,139.4962225 511.60 486.02 558.9262230 833.22 791.56 910.2962252 86.75 82.41 94.7762252 TC 40.89 38.85 44.6862252 26 45.86 43.57 50.1162256 588.80 559.36 643.2662258 1,115.09 1,059.34 1,218.2462263 645.94 613.64 705.69# 62263 329.57 313.09 360.0562264 413.57 392.89 451.82# 62264 233.87 222.18 255.5162267 237.75 225.86 259.74# 62267 155.13 147.37 169.4862268 288.59 274.16 315.28# 62268 254.66 241.93 278.2262269 305.26 290.00 333.50# 62269 260.34 247.32 284.4262270 149.56 142.08 163.39# 62270 76.99 73.14 84.1162272 190.22 180.71 207.82# 62272 83.72 79.53 91.4662273 166.23 157.92 181.61# 62273 111.25 105.69 121.5462280 319.15 303.19 348.67# 62280 164.26 156.05 179.4662281 239.54 227.56 261.69# 62281 149.37 141.90 163.1962282 280.24 266.23 306.16# 62282 138.87 131.93 151.7262284 191.23 181.67 208.92# 62284 84.10 79.90 91.89# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.163 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE62287 544.86 517.62 595.2662290 326.98 310.63 357.22# 62290 168.95 160.50 184.5862291 310.88 295.34 339.64# 62291 162.60 154.47 177.6462292 556.37 528.55 607.8362294 787.15 747.79 859.9662310 233.57 221.89 255.17# 62310 104.76 99.52 114.4562311 197.53 187.65 215.80# 62311 85.69 81.41 93.6262318 238.00 226.10 260.02# 62318 100.08 95.08 109.3462319 176.60 167.77 192.94# 62319 95.23 90.47 104.0462350 389.59 370.11 425.6362351 857.33 814.46 936.6362355 253.25 240.59 276.6862360 301.25 286.19 329.1262361 341.20 324.14 372.7662362 379.65 360.67 414.7762365 285.73 271.44 312.1662367 39.21 37.25 42.84# 62367 24.44 23.22 26.7062368 52.85 50.21 57.74# 62368 33.37 31.70 36.4662369 116.94 111.09 127.75# 62369 34.31 32.59 37.4862370 122.98 116.83 134.35# 62370 46.01 43.71 50.2763001 1,223.65 1,162.47 1,336.8463003 1,225.27 1,164.01 1,338.6163005 1,162.55 1,104.42 1,270.0863011 1,068.22 1,014.81 1,167.0363012 1,176.95 1,118.10 1,285.8263015 1,469.62 1,396.14 1,605.5663016 1,499.84 1,424.85 1,638.5863017 1,233.95 1,172.25 1,348.0963020 1,154.94 1,097.19 1,261.77# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.164 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE63030 953.24 905.58 1,041.4263035 192.02 182.42 209.7863040 1,391.95 1,322.35 1,520.7063042 1,283.92 1,219.72 1,402.6863043 302.41 287.29 330.3863044 284.70 270.47 311.0463045 1,259.62 1,196.64 1,376.1463046 1,195.79 1,136.00 1,306.4063047 1,086.70 1,032.37 1,187.2363048 212.67 202.04 232.3563050 1,539.96 1,462.96 1,682.4063051 1,695.04 1,610.29 1,851.8363055 1,611.87 1,531.28 1,760.9763056 1,464.11 1,390.90 1,599.5463057 321.61 305.53 351.3663064 1,752.89 1,665.25 1,915.0463066 207.57 197.19 226.7763075 1,361.34 1,293.27 1,487.2663076 250.23 237.72 273.3863077 1,478.70 1,404.77 1,615.4963078 192.97 183.32 210.8263081 1,754.16 1,666.45 1,916.4263082 268.96 255.51 293.8463085 1,878.49 1,784.57 2,052.2663086 191.45 181.88 209.1663087 2,363.48 2,245.31 2,582.1163088 256.93 244.08 280.6963090 1,939.96 1,842.96 2,119.4063091 177.51 168.63 193.9263101 2,300.21 2,185.20 2,512.9863102 2,212.21 2,101.60 2,416.8463103 291.11 276.55 318.0363170 1,573.82 1,495.13 1,719.4063172 1,396.42 1,326.60 1,525.5963173 1,713.53 1,627.85 1,872.0363180 1,460.78 1,387.74 1,595.9063182 1,590.29 1,510.78 1,737.4063185 1,175.68 1,116.90 1,284.4463190 1,243.61 1,181.43 1,358.64# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.165 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE63191 1,215.51 1,154.73 1,327.9463194 1,247.33 1,184.96 1,362.7063195 1,521.02 1,444.97 1,661.7263196 1,361.37 1,293.30 1,487.3063197 1,697.40 1,612.53 1,854.4163198 1,556.06 1,478.26 1,700.0063199 1,839.39 1,747.42 2,009.5363200 1,514.21 1,438.50 1,654.2863250 2,952.55 2,804.92 3,225.6663251 3,020.39 2,869.37 3,299.7863252 3,019.11 2,868.15 3,298.3763265 1,655.51 1,572.73 1,808.6463266 1,707.11 1,621.75 1,865.0163267 1,363.57 1,295.39 1,489.7063268 1,436.92 1,365.07 1,569.8363270 2,061.25 1,958.19 2,251.9263271 2,056.16 1,953.35 2,246.3563272 1,891.04 1,796.49 2,065.9663273 1,841.36 1,749.29 2,011.6863275 1,783.92 1,694.72 1,948.9363276 1,770.67 1,682.14 1,934.4663277 1,537.69 1,460.81 1,679.9363278 1,570.61 1,492.08 1,715.8963280 2,098.32 1,993.40 2,292.4163281 2,081.66 1,977.58 2,274.2263282 1,958.27 1,860.36 2,139.4163283 1,882.52 1,788.39 2,056.6563285 2,598.00 2,468.10 2,838.3263286 2,550.29 2,422.78 2,786.2063287 2,729.53 2,593.05 2,982.0163290 2,776.43 2,637.61 3,033.2563295 332.56 315.93 363.3263300 1,821.19 1,730.13 1,989.6563301 2,175.53 2,066.75 2,376.7663302 2,149.70 2,042.22 2,348.5563303 2,209.28 2,098.82 2,413.6463304 2,331.88 2,215.29 2,547.5863305 2,467.19 2,343.83 2,695.4063306 2,209.09 2,098.64 2,413.44# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.166 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE63307 2,386.83 2,267.49 2,607.6163308 320.62 304.59 350.2863600 901.70 856.62 985.1163610 633.20 601.54 691.77# 63610 427.42 406.05 466.9663615 1,217.62 1,156.74 1,330.2563620 1,075.47 1,021.70 1,174.9663621 248.90 236.46 271.9363650 416.20 395.39 454.7063655 815.01 774.26 890.4063661 571.98 543.38 624.89# 63661 317.19 301.33 346.5363662 762.89 724.75 833.4663663 815.23 774.47 890.64# 63663 463.99 440.79 506.9163664 781.83 742.74 854.1563685 353.49 335.82 386.1963688 358.84 340.90 392.0463700 1,277.33 1,213.46 1,395.4863702 1,406.90 1,336.56 1,537.0463704 1,618.05 1,537.15 1,767.7263706 1,813.92 1,723.22 1,981.7063707 897.54 852.66 980.5663709 1,085.05 1,030.80 1,185.4263710 1,091.84 1,037.25 1,192.8463740 933.31 886.64 1,019.6463741 620.39 589.37 677.7863744 665.09 631.84 726.6263746 586.16 556.85 640.3864400 112.82 107.18 123.26# 64400 66.64 63.31 72.8164402 113.19 107.53 123.66# 64402 73.29 69.63 80.0764405 92.95 88.30 101.55# 64405 60.59 57.56 66.1964408 103.45 98.28 113.02# 64408 77.06 73.21 84.1964410 145.82 138.53 159.31# 64410 86.13 81.82 94.09# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.167 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE64412 141.38 134.31 154.46# 64412 72.57 68.94 79.2864413 118.71 112.77 129.69# 64413 78.81 74.87 86.1064415 119.10 113.15 130.12# 64415 66.00 62.70 72.1164416 80.21 76.20 87.6364417 127.16 120.80 138.92# 64417 69.98 66.48 76.4564418 132.24 125.63 144.47# 64418 72.54 68.91 79.2564420 119.93 113.93 131.02# 64420 66.52 63.19 72.6764421 169.39 160.92 185.06# 64421 92.42 87.80 100.9764425 129.68 123.20 141.68# 64425 93.55 88.87 102.2064430 134.27 127.56 146.69# 64430 80.86 76.82 88.3464435 134.74 128.00 147.20# 64435 82.59 78.46 90.2364445 130.34 123.82 142.39# 64445 73.16 69.50 79.9364446 80.84 76.80 88.3264447 119.15 113.19 130.17# 64447 65.74 62.45 71.8264448 72.10 68.50 78.7864449 83.35 79.18 91.0664450 101.27 96.21 110.64# 64450 67.65 64.27 73.9164455 46.97 44.62 51.31# 64455 35.66 33.88 38.9664479 248.00 235.60 270.94# 64479 131.13 124.57 143.2664480 119.34 113.37 130.38# 64480 65.62 62.34 71.6964483 229.15 217.69 250.34# 64483 109.14 103.68 119.2364484 95.38 90.61 104.20# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.168 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 64484 51.71 49.12 56.4964490 192.38 182.76 210.17# 64490 108.18 102.77 118.1964491 94.38 89.66 103.11# 64491 60.77 57.73 66.3964492 95.01 90.26 103.80# 64492 61.39 58.32 67.0764493 171.82 163.23 187.71# 64493 90.76 86.22 99.1564494 85.96 81.66 93.91# 64494 51.40 48.83 56.1564495 86.59 82.26 94.60# 64495 52.34 49.72 57.1864505 96.74 91.90 105.69# 64505 81.35 77.28 88.8764508 83.61 79.43 91.34# 64508 75.13 71.37 82.0864510 128.42 122.00 140.30# 64510 70.61 67.08 77.1464517 176.94 168.09 193.30# 64517 122.59 116.46 133.9364520 186.62 177.29 203.88# 64520 78.23 74.32 85.4764530 190.82 181.28 208.47# 64530 90.60 86.07 98.9864550 15.29 14.53 16.71# 64550 8.69 8.26 9.5064553 210.08 199.58 229.52# 64553 162.02 153.92 177.0164555 189.90 180.41 207.47# 64555 143.41 136.24 156.6864561 845.10 802.85 923.28# 64561 394.28 374.57 430.7664565 171.82 163.23 187.71# 64565 122.81 116.67 134.1764566 125.29 119.03 136.88# 64566 29.15 27.69 31.8464568 618.86 587.92 676.1164569 690.46 655.94 754.33# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.169 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE64570 561.30 533.24 613.2364575 290.55 276.02 317.4264580 297.16 282.30 324.6564581 671.30 637.74 733.4064585 257.89 245.00 281.75# 64585 144.16 136.95 157.4964590 262.65 249.52 286.95# 64590 159.61 151.63 174.3764595 252.69 240.06 276.07# 64595 126.08 119.78 137.7564600 390.67 371.14 426.81# 64600 214.73 203.99 234.5964605 558.93 530.98 610.63# 64605 327.71 311.32 358.0264610 727.32 690.95 794.59# 64610 481.01 456.96 525.5064611 98.08 93.18 107.16# 64611 88.34 83.92 96.5164612 169.67 161.19 185.37# 64612 156.47 148.65 170.9564613 161.51 153.43 176.44# 64613 146.43 139.11 159.9864614 171.85 163.26 187.75# 64614 152.06 144.46 166.1364620 216.99 206.14 237.06# 64620 168.93 160.48 184.5564630 222.37 211.25 242.94# 64630 185.62 176.34 202.7964632 82.26 78.15 89.87# 64632 67.81 64.42 74.0864633 429.23 407.77 468.94# 64633 229.11 217.65 250.3064634 195.33 185.56 213.39# 64634 69.04 65.59 75.4364635 421.80 400.71 460.82# 64635 224.50 213.28 245.2764636 175.65 166.87 191.90# 64636 60.04 57.04 65.6064640 211.51 200.93 231.07# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.170 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 64640 165.33 157.06 180.6264650 103.23 98.07 112.78# 64650 39.45 37.48 43.1064653 122.25 116.14 133.56# 64653 52.19 49.58 57.0264680 309.15 293.69 337.74# 64680 162.12 154.01 177.1164681 362.32 344.20 395.83# 64681 195.50 185.73 213.5964702 480.67 456.64 525.1464704 306.84 291.50 335.2364708 479.23 455.27 523.5664712 542.68 515.55 592.8864713 745.24 707.98 814.1864714 652.54 619.91 712.9064716 522.52 496.39 570.8564718 571.78 543.19 624.6764719 385.22 365.96 420.8564721 412.80 392.16 450.98# 64721 410.29 389.78 448.2564722 347.00 329.65 379.1064726 263.52 250.34 287.8964727 182.64 173.51 199.5464732 425.00 403.75 464.3164734 430.89 409.35 470.7564736 458.80 435.86 501.2464738 493.86 469.17 539.5564740 449.43 426.96 491.0064742 452.69 430.06 494.5764744 471.87 448.28 515.5264746 432.01 410.41 471.9764752 511.40 485.83 558.7064755 896.42 851.60 979.3464760 495.06 470.31 540.8664761 447.60 425.22 489.0064763 506.92 481.57 553.8164766 574.74 546.00 627.9064771 578.88 549.94 632.4364772 566.77 538.43 619.19# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.171 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE64774 405.90 385.61 443.4564776 380.14 361.13 415.3064778 180.83 171.79 197.5664782 439.72 417.73 480.3964783 213.97 203.27 233.7664784 716.69 680.86 782.9964786 1,052.57 999.94 1,149.9364787 241.45 229.38 263.7964788 385.73 366.44 421.4164790 814.15 773.44 889.4664792 1,165.97 1,107.67 1,273.8264795 191.67 182.09 209.4064802 531.72 505.13 580.9064804 783.79 744.60 856.2964809 729.25 692.79 796.7164818 662.06 628.96 723.3064820 739.80 702.81 808.2364821 685.81 651.52 749.2564822 668.21 634.80 730.0264823 760.06 722.06 830.3764831 665.15 631.89 726.6764832 337.14 320.28 368.3264834 722.10 686.00 788.9064835 791.15 751.59 864.3364836 791.15 751.59 864.3364837 348.78 331.34 381.0464840 853.92 811.22 932.9064856 994.23 944.52 1,086.2064857 1,033.93 982.23 1,129.5664858 1,072.31 1,018.69 1,171.4964859 260.94 247.89 285.0764861 1,304.87 1,239.63 1,425.5764862 1,506.65 1,431.32 1,646.0264864 859.49 816.52 939.0064865 1,106.65 1,051.32 1,209.0264866 1,116.73 1,060.89 1,220.0264868 1,012.09 961.49 1,105.7164870 1,041.70 989.62 1,138.0664872 116.15 110.34 126.89# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.172 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE64874 166.10 157.80 181.4764876 182.97 173.82 199.8964885 1,086.83 1,032.49 1,187.3664886 1,270.78 1,207.24 1,388.3364890 1,095.22 1,040.46 1,196.5364891 1,097.07 1,042.22 1,198.5564892 1,063.66 1,010.48 1,162.0564893 1,132.80 1,076.16 1,237.5864895 1,345.43 1,278.16 1,469.8864896 1,586.23 1,506.92 1,732.9664897 1,287.80 1,223.41 1,406.9264898 1,397.55 1,327.67 1,526.8264901 624.48 593.26 682.2564902 721.98 685.88 788.7664905 1,018.90 967.96 1,113.1564907 1,089.39 1,034.92 1,190.1664910 806.52 766.19 881.1264911 1,009.72 959.23 1,103.1165091 615.88 585.09 672.8565093 610.97 580.42 667.4865101 715.99 680.19 782.2265103 748.12 710.71 817.3265105 826.16 784.85 902.5865110 1,156.96 1,099.11 1,263.9865112 1,348.90 1,281.46 1,473.6865114 1,415.26 1,344.50 1,546.1865125 431.79 410.20 471.73# 65125 283.51 269.33 309.7365130 710.75 675.21 776.4965135 721.38 685.31 788.1165140 763.18 725.02 833.7765150 531.50 504.93 580.6765155 825.13 783.87 901.4565175 619.46 588.49 676.7665205 52.94 50.29 57.83# 65205 42.26 40.15 46.1765210 65.95 62.65 72.05# 65210 52.12 49.51 56.9465220 55.19 52.43 60.29# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.173 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 65220 41.36 39.29 45.1865222 72.56 68.93 79.27# 65222 56.86 54.02 62.1265235 675.08 641.33 737.5365260 883.92 839.72 965.6865265 1,071.73 1,018.14 1,170.8665270 248.36 235.94 271.33# 65270 135.26 128.50 147.7865272 459.24 436.28 501.72# 65272 324.15 307.94 354.1365273 352.46 334.84 385.0765275 542.28 515.17 592.45# 65275 440.80 418.76 481.5765280 661.13 628.07 722.2865285 1,076.34 1,022.52 1,175.9065286 660.86 627.82 721.99# 65286 473.62 449.94 517.4365290 483.42 459.25 528.1465400 641.80 609.71 701.17# 65400 573.63 544.95 626.6965410 138.91 131.96 151.75# 65410 104.04 98.84 113.6765420 480.75 456.71 525.22# 65420 355.71 337.92 388.6165426 611.87 581.28 668.47# 65426 456.04 433.24 498.2365430 110.19 104.68 120.38# 65430 100.45 95.43 109.7465435 77.04 73.19 84.17# 65435 67.92 64.52 74.2065436 374.96 356.21 409.64# 65436 361.13 343.07 394.5365450 306.80 291.46 335.18# 65450 303.34 288.17 331.4065600 372.77 354.13 407.25# 65600 327.53 311.15 357.8265710 1,057.39 1,004.52 1,155.2065730 1,174.25 1,115.54 1,282.8765750 1,178.17 1,119.26 1,287.15# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.174 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE65755 1,177.28 1,118.42 1,286.1865756 1,096.90 1,042.06 1,198.3765757 63.64 60.46 69.5365770 1,510.10 1,434.60 1,649.7965772 424.99 403.74 464.30# 65772 384.77 365.53 420.3665775 509.08 483.63 556.1765778 1,252.20 1,189.59 1,368.03# 65778 71.56 67.98 78.1865779 1,124.58 1,068.35 1,228.60# 65779 279.47 265.50 305.3365780 842.75 800.61 920.7065781 1,236.11 1,174.30 1,350.4565782 1,137.64 1,080.76 1,242.8765800 142.70 135.57 155.91# 65800 126.36 120.04 138.0565805 157.81 149.92 172.41# 65805 128.91 122.46 140.8365810 444.81 422.57 485.9665815 607.54 577.16 663.73# 65815 463.03 439.88 505.8665820 689.38 654.91 753.1565850 820.45 779.43 896.3465855 325.24 308.98 355.33# 65855 288.17 273.76 314.8265860 324.48 308.26 354.50# 65860 274.21 260.50 299.5865865 435.85 414.06 476.1765870 573.06 544.41 626.0765875 599.82 569.83 655.3065880 611.76 581.17 668.3565900 890.44 845.92 972.8165920 747.95 710.55 817.1365930 621.86 590.77 679.3966020 170.41 161.89 186.17# 66020 121.09 115.04 132.3066030 154.79 147.05 169.11# 66030 105.15 99.89 114.87# 66130 567.57 539.19 620.07# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.175 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE66130 681.92 647.82 744.9966150 805.33 765.06 879.8266155 804.68 764.45 879.1266160 909.87 864.38 994.0466165 789.44 749.97 862.4766170 1,136.87 1,080.03 1,242.0366172 1,433.37 1,361.70 1,565.9666174 946.93 899.58 1,034.5266175 1,082.77 1,028.63 1,182.9266180 1,114.20 1,058.49 1,217.2666185 727.09 690.74 794.3566220 704.97 669.72 770.1866225 919.12 873.16 1,004.1366250 718.62 682.69 785.09# 66250 545.83 518.54 596.3266500 324.60 308.37 354.6366505 355.94 338.14 388.8666600 765.45 727.18 836.2666605 976.36 927.54 1,066.6766625 408.29 387.88 446.0666630 550.74 523.20 601.6866635 529.59 503.11 578.5866680 508.89 483.45 555.9766682 617.41 586.54 674.5266700 418.35 397.43 457.04# 66700 367.77 349.38 401.7966710 429.47 408.00 469.20# 66710 386.74 367.40 422.5166711 587.50 558.13 641.8566720 444.38 422.16 485.48# 66720 399.77 379.78 436.7566740 401.95 381.85 439.13# 66740 362.68 344.55 396.2366761 295.05 280.30 322.35# 66761 245.10 232.85 267.7866762 447.89 425.50 489.33# 66762 403.59 383.41 440.9266770 484.69 460.46 529.53# 66770 444.48 422.26 485.60# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.176 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE66820 375.13 356.37 409.8366821 312.57 296.94 341.48# 66821 295.60 280.82 322.9466825 719.03 683.08 785.5466830 658.37 625.45 719.2766840 684.95 650.70 748.3166850 758.12 720.21 828.2466852 824.32 783.10 900.5766920 696.74 661.90 761.1966930 792.27 752.66 865.5666940 758.72 720.78 828.9066982 1,024.23 973.02 1,118.9766983 693.10 658.45 757.2266984 737.93 701.03 806.1866985 732.22 695.61 799.9566986 867.45 824.08 947.6966990 84.57 80.34 92.3967005 465.25 441.99 508.2967010 518.19 492.28 566.1267015 552.38 524.76 603.4767025 698.53 663.60 763.14# 67025 614.33 583.61 671.1567027 831.62 790.04 908.5567028 111.58 106.00 121.90# 67028 100.90 95.86 110.2467030 487.47 463.10 532.5767031 367.14 348.78 401.10# 67031 338.55 321.62 369.8667036 919.85 873.86 1,004.9467039 1,206.60 1,146.27 1,318.2167040 1,361.96 1,293.86 1,487.9467041 1,273.43 1,209.76 1,391.2267042 1,456.97 1,384.12 1,591.7467043 1,562.90 1,484.76 1,707.4767101 753.66 715.98 823.38# 67101 655.64 622.86 716.2967105 684.15 649.94 747.43# 67105 615.35 584.58 672.2767107 1,188.51 1,129.08 1,298.44# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.177 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE67108 1,542.76 1,465.62 1,685.4667110 820.99 779.94 896.93# 67110 736.48 699.66 804.6167112 1,273.03 1,209.38 1,390.7967113 1,677.50 1,593.63 1,832.6767115 471.98 448.38 515.6467120 636.31 604.49 695.16# 67120 547.08 519.73 597.6967121 886.38 842.06 968.3767141 505.35 480.08 552.09# 67141 472.99 449.34 516.7467145 500.26 475.25 546.54# 67145 473.55 449.87 517.3567208 552.37 524.75 603.46# 67208 533.21 506.55 582.5367210 504.84 479.60 551.54# 67210 486.62 462.29 531.6367218 1,283.67 1,219.49 1,402.4167220 557.31 529.44 608.86# 67220 521.50 495.43 569.7467221 275.64 261.86 301.14# 67221 208.41 197.99 227.6967225 27.77 26.38 30.34# 67225 26.20 24.89 28.6267227 562.42 534.30 614.45# 67227 526.61 500.28 575.3267228 1,008.32 957.90 1,101.59# 67228 939.83 892.84 1,026.7767229 1,039.10 987.15 1,135.2267250 754.25 716.54 824.0267255 821.33 780.26 897.3067311 579.49 550.52 633.1067312 703.04 667.89 768.0767314 652.44 619.82 712.7967316 791.13 751.57 864.3167318 649.45 616.98 709.5367320 301.62 286.54 329.5267331 303.61 288.43 331.6967332 329.91 313.41 360.42# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.178 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE67334 281.70 267.62 307.7667335 148.05 140.65 161.7567340 335.12 318.36 366.1167343 640.56 608.53 699.81# 67345 217.02 206.17 237.1067345 238.38 226.46 260.4367346 200.94 190.89 219.5267400 904.54 859.31 988.2167405 750.68 713.15 820.1267412 827.31 785.94 903.8367413 836.02 794.22 913.3567414 1,260.09 1,197.09 1,376.6567415 102.57 97.44 112.0667420 1,594.91 1,515.16 1,742.4367430 1,150.42 1,092.90 1,256.8467440 1,143.57 1,086.39 1,249.3567445 1,382.69 1,313.56 1,510.5967450 1,188.41 1,128.99 1,298.3467500 79.41 75.44 86.76# 67500 72.81 69.17 79.5567505 88.50 84.08 96.69# 67505 81.28 77.22 88.8067515 95.13 90.37 103.93# 67515 88.22 83.81 96.3867550 944.88 897.64 1,032.2967560 936.67 889.84 1,023.3267570 1,204.12 1,143.91 1,315.5067700 247.66 235.28 270.57# 67700 111.63 106.05 121.9667710 208.73 198.29 228.03# 67710 94.69 89.96 103.4567715 221.71 210.62 242.21# 67715 106.72 101.38 116.5967800 122.07 115.97 133.37# 67800 101.02 95.97 110.3767801 157.96 150.06 172.57# 67801 132.51 125.88 144.7667805 195.69 185.91 213.80# 67805 163.02 154.87 178.10# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.179 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE67808 359.91 341.91 393.2067810 204.47 194.25 223.39# 67810 88.85 84.41 97.0767820 49.22 46.76 53.77# 67820 51.73 49.14 56.5167825 124.16 117.95 135.64# 67825 118.19 112.28 129.1267830 250.38 237.86 273.54# 67830 135.40 128.63 147.9267835 432.11 410.50 472.0867840 259.13 246.17 283.10# 67840 153.57 145.89 167.7767850 203.99 193.79 222.86# 67850 131.73 125.14 143.9167875 162.13 154.02 177.12# 67875 95.53 90.75 104.3667880 438.06 416.16 478.58# 67880 357.63 339.75 390.7167882 545.04 517.79 595.46# 67882 463.05 439.90 505.8967900 616.14 585.33 673.13# 67900 498.64 473.71 544.7767901 714.12 678.41 780.17# 67901 566.77 538.43 619.1967902 711.73 676.14 777.5667903 578.82 549.88 632.36# 67903 478.92 454.97 523.2267904 707.04 671.69 772.44# 67904 585.77 556.48 639.9567906 471.11 447.55 514.6867908 477.79 453.90 521.99# 67908 418.10 397.20 456.7867909 518.65 492.72 566.63# 67909 431.31 409.74 471.2067911 550.02 522.52 600.9067912 833.73 792.04 910.85# 67912 473.69 450.01 517.5167914 371.36 352.79 405.71# 67914 281.82 267.73 307.89# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.180 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE67915 327.15 310.79 357.41# 67915 243.89 231.70 266.4667916 515.47 489.70 563.16# 67916 419.96 398.96 458.8067917 565.18 536.92 617.46# 67917 465.59 442.31 508.6667921 355.54 337.76 388.42# 67921 266.32 253.00 290.9567922 315.69 299.91 344.90# 67922 234.32 222.60 255.9967923 547.70 520.32 598.37# 67923 456.59 433.76 498.8267924 564.04 535.84 616.22# 67924 440.88 418.84 481.6767930 352.71 335.07 385.33# 67930 241.18 229.12 263.4967935 576.13 547.32 629.42# 67935 440.72 418.68 481.4867938 225.88 214.59 246.78# 67938 111.53 105.95 121.8467950 552.11 524.50 603.18# 67950 454.09 431.39 496.1067961 553.97 526.27 605.21# 67961 446.21 423.90 487.4967966 745.75 708.46 814.73# 67966 645.84 613.55 705.5867971 717.09 681.24 783.4367973 926.01 879.71 1,011.6767974 923.73 877.54 1,009.1767975 678.01 644.11 740.7368020 114.05 108.35 124.60# 68020 106.19 100.88 116.0168040 63.66 60.48 69.55# 68040 52.98 50.33 57.8868100 159.10 151.15 173.82# 68100 94.70 89.97 103.4768110 214.17 203.46 233.98# 68110 145.06 137.81 158.4868115 289.35 274.88 316.11# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.181 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 68115 174.99 166.24 191.1868130 493.58 468.90 539.24# 68130 379.85 360.86 414.9968135 149.19 141.73 162.99# 68135 144.16 136.95 157.4968200 40.64 38.61 44.40# 68200 34.04 32.34 37.1968320 692.68 658.05 756.76# 68320 526.17 499.86 574.8468325 648.36 615.94 708.3368326 634.72 602.98 693.4368328 700.36 665.34 765.1468330 580.35 551.33 634.03# 68330 451.54 428.96 493.3068335 636.76 604.92 695.6668340 521.56 495.48 569.80# 68340 390.86 371.32 427.0268360 510.60 485.07 557.83# 68360 403.16 383.00 440.4568362 645.48 613.21 705.1968371 381.08 362.03 416.3368400 265.12 251.86 289.64# 68400 130.66 124.13 142.7568420 297.31 282.44 324.81# 68420 162.22 154.11 177.2368440 99.72 94.73 108.94# 68440 95.33 90.56 104.1468500 976.38 927.56 1,066.6968505 956.04 908.24 1,044.4868510 432.17 410.56 472.14# 68510 293.62 278.94 320.7868520 656.07 623.27 716.7668525 267.51 254.13 292.2568530 408.81 388.37 446.63# 68530 256.13 243.32 279.8268540 884.21 840.00 966.0068550 934.02 887.32 1,020.4268700 593.78 564.09 648.7068705 225.91 214.61 246.80# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.182 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 68705 162.77 154.63 177.8268720 734.32 697.60 802.2468745 747.85 710.46 817.0368750 772.98 734.33 844.4868760 192.03 182.43 209.79# 68760 142.39 135.27 155.5668761 139.88 132.89 152.82# 68761 114.43 108.71 125.0268770 611.62 581.04 668.2068801 117.46 111.59 128.33# 68801 102.06 96.96 111.5068810 230.00 218.50 251.28# 68810 182.25 173.14 199.1168811 201.71 191.62 220.3668815 421.88 400.79 460.91# 68815 250.98 238.43 274.1968816 675.78 641.99 738.29# 68816 245.37 233.10 268.0768840 122.10 116.00 133.40# 68840 112.04 106.44 122.4168850 56.80 53.96 62.05# 68850 52.08 49.48 56.9069000 180.02 171.02 196.67# 69000 117.18 111.32 128.0269005 209.43 198.96 228.80# 69005 155.39 147.62 169.7669020 227.43 216.06 248.47# 69020 140.72 133.68 153.7369100 97.55 92.67 106.57# 69100 48.54 46.11 53.0369105 136.87 130.03 149.53# 69105 62.73 59.59 68.5369110 444.18 421.97 485.27# 69110 319.14 303.18 348.6669120 394.29 374.58 430.7769140 860.35 817.33 939.9369145 385.19 365.93 420.82# 69145 245.38 233.11 268.0869150 1,034.36 982.64 1,130.04# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.183 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE69155 1,653.59 1,570.91 1,806.5569200 120.01 114.01 131.11# 69200 56.55 53.72 61.7869205 99.47 94.50 108.6869210 49.39 46.92 53.96# 69210 32.11 30.50 35.0869220 133.68 127.00 146.05# 69220 61.11 58.05 66.7669222 215.19 204.43 235.09# 69222 135.07 128.32 147.5769300 696.64 661.81 761.08# 69300 469.81 446.32 513.2769310 1,067.32 1,013.95 1,166.0469320 1,508.04 1,432.64 1,647.5469400 142.79 135.65 156.00# 69400 61.11 58.05 66.7669401 84.31 80.09 92.10# 69401 48.81 46.37 53.3369405 255.96 243.16 279.63# 69405 190.62 181.09 208.2569420 187.36 177.99 204.69# 69420 118.87 112.93 129.8769421 147.81 140.42 161.4869424 125.88 119.59 137.53# 69424 61.47 58.40 67.1669433 195.91 186.11 214.03# 69433 128.99 122.54 140.9269436 159.56 151.58 174.3269440 678.59 644.66 741.3669450 535.30 508.54 584.8269501 722.74 686.60 789.5969502 960.26 912.25 1,049.0969505 1,185.91 1,126.61 1,295.6069511 1,215.92 1,155.12 1,328.3969530 1,632.82 1,551.18 1,783.8669535 2,644.00 2,511.80 2,888.5769540 204.51 194.28 223.42# 69540 125.65 119.37 137.2869550 1,025.69 974.41 1,120.57# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.184 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE69552 1,551.54 1,473.96 1,695.0569554 2,487.89 2,363.50 2,718.0369601 1,034.32 982.60 1,129.9969602 1,076.27 1,022.46 1,175.8369603 1,244.49 1,182.27 1,359.6169604 1,102.18 1,047.07 1,204.1369605 1,540.32 1,463.30 1,682.8069610 380.97 361.92 416.21# 69610 290.49 275.97 317.3769620 679.96 645.96 742.85# 69620 481.72 457.63 526.2769631 871.26 827.70 951.8669632 1,064.20 1,010.99 1,162.6469633 1,028.22 976.81 1,123.3369635 1,203.65 1,143.47 1,314.9969636 1,359.99 1,291.99 1,485.7969637 1,355.77 1,287.98 1,481.1869641 1,029.20 977.74 1,124.4069642 1,321.69 1,255.61 1,443.9569643 1,208.82 1,148.38 1,320.6469644 1,459.89 1,386.90 1,594.9469645 1,432.88 1,361.24 1,565.4369646 1,521.02 1,444.97 1,661.7269650 791.55 751.97 864.7769660 917.33 871.46 1,002.1869661 1,194.29 1,134.58 1,304.7769662 1,144.75 1,087.51 1,250.6469666 795.08 755.33 868.6369667 796.99 757.14 870.7169670 932.37 885.75 1,018.6169676 820.75 779.71 896.6769700 679.20 645.24 742.0369711 853.31 810.64 932.2469714 1,063.76 1,010.57 1,162.1669715 1,318.39 1,252.47 1,440.3469717 1,122.17 1,066.06 1,225.9769718 1,332.70 1,266.07 1,455.9869720 1,170.78 1,112.24 1,279.0869725 1,867.01 1,773.66 2,039.71# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.185 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE69740 1,157.59 1,099.71 1,264.6769745 1,232.63 1,171.00 1,346.6569801 194.93 185.18 212.96# 69801 205.61 195.33 224.6369805 1,044.80 992.56 1,141.4469806 935.32 888.55 1,021.8369820 848.65 806.22 927.1569840 873.27 829.61 954.0569905 908.27 862.86 992.2969910 1,009.27 958.81 1,102.6369915 1,528.72 1,452.28 1,670.1269930 1,217.34 1,156.47 1,329.9469950 1,778.39 1,689.47 1,942.8969955 1,966.44 1,868.12 2,148.3469960 1,913.66 1,817.98 2,090.6869970 2,131.05 2,024.50 2,328.1869990 217.16 206.30 237.2570010 91.55 86.97 100.0270015 148.03 140.63 161.7270015 TC 89.90 85.41 98.2270015 26 58.13 55.22 63.5070030 27.56 26.18 30.1170030 TC 19.53 18.55 21.3370030 26 8.04 7.64 8.7970100 32.93 31.28 35.9770100 TC 24.24 23.03 26.4870100 26 8.69 8.26 9.5070110 38.14 36.23 41.6670110 TC 26.13 24.82 28.5470110 26 12.01 11.41 13.1270120 34.82 33.08 38.0470120 TC 25.81 24.52 28.2070120 26 9.00 8.55 9.8370130 54.71 51.97 59.7770130 TC 38.38 36.46 41.9370130 26 16.33 15.51 17.8470134 53.77 51.08 58.7470134 TC 36.49 34.67 39.8770134 26 17.28 16.42 18.88# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.186 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE70140 29.19 27.73 31.8970140 TC 19.53 18.55 21.3370140 26 9.66 9.18 10.5670150 40.99 38.94 44.7870150 TC 28.64 27.21 31.2970150 26 12.36 11.74 13.5070160 31.96 30.36 34.9170160 TC 23.61 22.43 25.7970160 26 8.35 7.93 9.1270170 54.05 51.35 59.0570170 TC 38.01 36.11 41.5370170 26 14.76 14.02 16.1270190 34.58 32.85 37.7870190 TC 24.24 23.03 26.4870190 26 10.34 9.82 11.2970200 41.99 39.89 45.8770200 TC 28.64 27.21 31.2970200 26 13.35 12.68 14.5870210 30.08 28.58 32.8770210 TC 21.73 20.64 23.7470210 26 8.35 7.93 9.1270220 37.83 35.94 41.3370220 TC 25.81 24.52 28.2070220 26 12.01 11.41 13.1270240 28.87 27.43 31.5470240 TC 19.53 18.55 21.3370240 26 9.34 8.87 10.2070250 35.60 33.82 38.8970250 TC 23.93 22.73 26.1470250 26 11.67 11.09 12.7570260 45.60 43.32 49.8270260 TC 29.27 27.81 31.9870260 26 16.33 15.51 17.8470300 14.18 13.47 15.4970300 TC 8.53 8.10 9.3270300 26 5.65 5.37 6.1870310 36.02 34.22 39.3570310 TC 28.01 26.61 30.6070310 26 8.01 7.61 8.75# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.187 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 70320 40.89 38.85 44.68C 70320 TC 29.58 28.10 32.3270320 26 11.31 10.74 12.3570328 29.79 28.30 32.5570328 TC 21.10 20.05 23.0670328 26 8.69 8.26 9.5070330 46.60 44.27 50.9170330 TC 34.61 32.88 37.8170330 26 11.99 11.39 13.1070332 72.30 68.69 78.9970332 TC 46.55 44.22 50.8570332 26 25.76 24.47 28.14C 70336 382.58 363.45 417.97C 70336 TC 312.33 296.71 341.2270336 26 70.25 66.74 76.7570350 20.65 19.62 22.5670350 TC 11.36 10.79 12.4170350 26 9.29 8.83 10.1570355 26 10.31 9.79 11.2670355 20.42 19.40 22.3170355 TC 10.10 9.60 11.0470360 25.99 24.69 28.3970360 TC 17.96 17.06 19.6270360 26 8.04 7.64 8.7970370 81.99 77.89 89.5770370 TC 66.65 63.32 72.8270370 26 15.34 14.57 16.7670371 90.37 85.85 98.7370371 TC 50.32 47.80 54.9770371 26 40.05 38.05 43.7670373 76.34 72.52 83.4070373 TC 55.97 53.17 61.1570373 26 20.37 19.35 22.2570380 38.56 36.63 42.1270380 TC 29.58 28.10 32.3270380 26 8.98 8.53 9.8170390 97.64 92.76 106.6770390 TC 79.22 75.26 86.5570390 26 18.42 17.50 20.13# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.188 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE70450 172.75 164.11 188.7370450 TC 132.31 125.69 144.5470450 26 40.44 38.42 44.1870460 225.69 214.41 246.5770460 TC 171.90 163.31 187.8170460 26 53.79 51.10 58.7770470 241.55 229.47 263.8970470 TC 180.70 171.67 197.4270470 26 60.85 57.81 66.48C 70480 238.75 226.81 260.83C 70480 TC 177.24 168.38 193.6470480 26 61.51 58.43 67.1970481 328.28 311.87 358.6570481 TC 262.07 248.97 286.3270481 26 66.22 62.91 72.3570482 367.11 348.75 401.0670482 TC 297.88 282.99 325.4470482 26 69.23 65.77 75.64C 70486 231.69 220.11 253.13C 70486 TC 177.24 168.38 193.6470486 26 54.45 51.73 59.4970487 282.47 268.35 308.6070487 TC 220.28 209.27 240.6670487 26 62.19 59.08 67.9470488 341.27 324.21 372.8470488 TC 273.38 259.71 298.6770488 26 67.90 64.51 74.1970490 229.64 218.16 250.8870490 TC 168.13 159.72 183.6870490 26 61.51 58.43 67.1970491 276.40 262.58 301.9770491 TC 210.23 199.72 229.6870491 26 66.17 62.86 72.2970492 331.61 315.03 362.2870492 TC 262.38 249.26 286.6570492 26 69.23 65.77 75.64C 70496 396.59 376.76 433.27C 70496 TC 312.65 297.02 341.5770496 26 83.94 79.74 91.70# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.189 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 70498 396.59 376.76 433.27C 70498 TC 312.65 297.02 341.5770498 26 83.94 79.74 91.70C 70540 376.90 358.06 411.77C 70540 TC 312.33 296.71 341.2270540 26 64.57 61.34 70.54C 70542 479.81 455.82 524.19C 70542 TC 402.18 382.07 439.3870542 26 77.63 73.75 84.81C 70543 595.34 565.57 650.41C 70543 TC 492.98 468.33 538.5870543 26 102.37 97.25 111.84C 70544 369.86 351.37 404.08C 70544 TC 312.33 296.71 341.2270544 26 57.53 54.65 62.85C 70545 459.40 436.43 501.89C 70545 TC 402.18 382.07 439.3870545 26 57.22 54.36 62.51C 70546 579.30 550.34 632.89C 70546 TC 492.98 468.33 538.5870546 26 86.32 82.00 94.30C 70547 369.86 351.37 404.08C 70547 TC 312.33 296.71 341.2270547 26 57.53 54.65 62.85C 70548 460.03 437.03 502.58C 70548 TC 402.50 382.38 439.7470548 26 57.53 54.65 62.85C 70549 578.93 549.98 632.48C 70549 TC 492.98 468.33 538.5870549 26 85.96 81.66 93.91C 70551 382.90 363.76 418.32C 70551 TC 312.33 296.71 341.2270551 26 70.57 67.04 77.10C 70552 488.14 463.73 533.29C 70552 TC 402.50 382.38 439.7470552 26 85.64 81.36 93.56C 70553 606.05 575.75 662.11C 70553 TC 492.98 468.33 538.5870553 26 113.07 107.42 123.53# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.190 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE70554 506.02 480.72 552.8370554 TC 404.38 384.16 441.7870554 26 101.63 96.55 111.0370555 477.64 453.76 521.8270555 TC 402.74 382.60 439.9970555 26 125.98 119.68 137.6370557 358.23 340.32 391.3770557 TC 302.05 286.95 329.9970557 26 172.10 163.50 188.0370558 26 157.85 149.96 172.4570559 26 159.11 151.15 173.8271010 22.56 21.43 24.6471010 TC 13.87 13.18 15.1671010 26 8.69 8.26 9.5071015 29.24 27.78 31.9571015 TC 19.21 18.25 20.9971015 26 10.03 9.53 10.9671020 29.27 27.81 31.9871020 TC 18.90 17.96 20.6571020 26 10.37 9.85 11.3371021 36.31 34.49 39.6671021 TC 23.30 22.14 25.4671021 26 13.01 12.36 14.2171022 26 15.00 14.25 16.3971022 45.52 43.24 49.7371022 TC 30.52 28.99 33.3471023 64.87 61.63 70.8771023 TC 46.86 44.52 51.2071023 26 18.01 17.11 19.6871030 44.27 42.06 48.3771030 TC 29.58 28.10 32.3271030 26 14.69 13.96 16.0571034 83.30 79.14 91.0171034 TC 61.31 58.24 66.9871034 26 21.99 20.89 24.0271035 34.19 32.48 37.3571035 TC 25.50 24.23 27.8671035 26 8.69 8.26 9.5071040 92.10 87.50 100.63# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.191 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE71040 TC 65.40 62.13 71.4571040 26 26.70 25.37 29.1871060 135.71 128.92 148.2671060 TC 100.27 95.26 109.5571060 26 35.44 33.67 38.7271100 31.46 29.89 34.3771100 TC 20.78 19.74 22.7071100 26 10.68 10.15 11.6771101 37.88 35.99 41.3971101 TC 25.18 23.92 27.5171101 26 12.70 12.07 13.8871110 39.14 37.18 42.7671110 TC 26.13 24.82 28.5471110 26 13.01 12.36 14.2171111 50.89 48.35 55.6071111 TC 35.55 33.77 38.8471111 26 15.34 14.57 16.7671120 30.47 28.95 33.2971120 TC 20.78 19.74 22.7071120 26 9.68 9.20 10.5871130 35.86 34.07 39.1871130 TC 25.18 23.92 27.5171130 26 10.68 10.15 11.6771250 220.69 209.66 241.1171250 TC 171.58 163.00 187.4571250 26 49.10 46.65 53.6571260 273.83 260.14 299.1671260 TC 214.31 203.59 234.1371260 26 59.52 56.54 65.0271270 334.52 317.79 365.4671270 TC 268.66 255.23 293.5171270 26 65.86 62.57 71.96C 71275 404.31 384.09 441.70C 71275 TC 312.33 296.71 341.2271275 26 91.97 87.37 100.48C 71550 381.90 362.81 417.23C 71550 TC 312.33 296.71 341.2271550 26 69.57 66.09 76.00C 71551 485.44 461.17 530.35# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.192 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 71551 TC 402.50 382.38 439.7471551 26 82.94 78.79 90.61C 71552 600.97 570.92 656.56C 71552 TC 492.98 468.33 538.5871552 26 108.00 102.60 117.9971555 487.22 462.86 532.2971555 TC 400.30 380.29 437.3371555 26 86.92 82.57 94.9672010 74.26 70.55 81.1372010 TC 51.89 49.30 56.7072010 26 22.38 21.26 24.4572020 22.80 21.66 24.9172020 TC 15.44 14.67 16.8772020 26 7.35 6.98 8.0372040 38.16 36.25 41.6972040 TC 26.75 25.41 29.2272040 26 11.41 10.84 12.4772050 51.28 48.72 56.0372050 TC 35.86 34.07 39.1872050 26 15.41 14.64 16.8472052 65.55 62.27 71.6172052 TC 47.49 45.12 51.8972052 26 18.06 17.16 19.7372069 36.59 34.76 39.9772069 TC 25.18 23.92 27.5172069 26 11.41 10.84 12.4772070 32.41 30.79 35.4172070 TC 21.73 20.64 23.7472070 26 10.68 10.15 11.6772072 35.86 34.07 39.1872072 TC 25.50 24.23 27.8672072 26 10.37 9.85 11.3372074 42.46 40.34 46.3972074 TC 32.09 30.49 35.0672074 26 10.37 9.85 11.3372080 35.33 33.56 38.5972080 TC 23.93 22.73 26.1472080 26 11.41 10.84 12.4772090 48.74 46.30 53.25# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.193 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE72090 TC 33.98 32.28 37.1272090 26 14.76 14.02 16.1272100 35.65 33.87 38.9572100 TC 24.24 23.03 26.4872100 26 11.41 10.84 12.4772110 48.45 46.03 52.9372110 TC 33.04 31.39 36.1072110 26 15.41 14.64 16.8472114 63.29 60.13 69.1572114 TC 46.55 44.22 50.8572114 26 16.75 15.91 18.3072120 42.25 40.14 46.1672120 TC 30.52 28.99 33.3472120 26 11.72 11.13 12.8072125 224.28 213.07 245.0372125 TC 173.16 164.50 189.1872125 26 51.12 48.56 55.8472126 274.09 260.39 299.4572126 TC 215.57 204.79 235.5172126 26 58.52 55.59 63.9372127 328.26 311.85 358.6372127 TC 267.72 254.33 292.4872127 26 60.54 57.51 66.1472128 220.64 209.61 241.0572128 TC 172.53 163.90 188.4972128 26 48.11 45.70 52.5672129 274.09 260.39 299.4572129 TC 215.57 204.79 235.5172129 26 58.52 55.59 63.9372130 TC 269.92 256.42 294.8872130 26 60.85 57.81 66.4872130 330.77 314.23 361.3672131 220.01 209.01 240.3672131 TC 171.90 163.31 187.8172131 26 48.11 45.70 52.5672132 273.46 259.79 298.7672132 TC 214.94 204.19 234.8272132 26 58.52 55.59 63.9372133 330.15 313.64 360.69# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.194 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE72133 TC 269.29 255.83 294.2072133 26 60.85 57.81 66.48C 72141 389.28 369.82 425.29C 72141 TC 312.33 296.71 341.2272141 26 76.95 73.10 84.07C 72142 494.79 470.05 540.56C 72142 TC 402.50 382.38 439.7472142 26 92.29 87.68 100.83C 72146 389.28 369.82 425.29C 72146 TC 312.33 296.71 341.2272146 26 76.95 73.10 84.0772147 458.97 436.02 501.4272147 TC 366.68 348.35 400.6072147 26 92.29 87.68 100.83C 72148 383.94 364.74 419.45C 72148 TC 312.33 296.71 341.2272148 26 71.61 68.03 78.23C 72149 488.14 463.73 533.29C 72149 TC 402.18 382.07 439.3872149 26 85.95 81.65 93.9072156 614.55 583.82 671.3972156 TC 491.09 466.54 536.5272156 26 123.46 117.29 134.8872157 576.22 547.41 629.5272157 TC 452.76 430.12 494.6472157 26 123.46 117.29 134.8872158 604.26 574.05 660.1672158 TC 490.15 465.64 535.4972158 26 114.11 108.40 124.6672159 506.21 480.90 553.0472159 TC 421.35 400.28 460.3272159 26 84.86 80.62 92.7172170 25.78 24.49 28.1672170 TC 16.70 15.87 18.2572170 26 9.08 8.63 9.9272190 41.28 39.22 45.1072190 TC 30.21 28.70 33.0172190 26 11.07 10.52 12.10C 72191 399.67 379.69 436.64# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.195 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 72191 TC 312.33 296.71 341.2272191 26 87.34 82.97 95.4272192 213.33 202.66 233.0672192 TC 161.53 153.45 176.4772192 26 51.80 49.21 56.5972193 259.17 246.21 283.1472193 TC 203.32 193.15 222.1272193 26 55.85 53.06 61.0272194 331.59 315.01 362.2672194 TC 273.06 259.41 298.3272194 26 58.52 55.59 63.93C 72195 382.94 363.79 418.36C 72195 TC 312.33 296.71 341.2272195 26 70.61 67.08 77.14C 72196 485.44 461.17 530.35C 72196 TC 402.18 382.07 439.3872196 26 83.26 79.10 90.97C 72197 600.66 570.63 656.22C 72197 TC 492.98 468.33 538.5872197 26 107.68 102.30 117.6572198 487.51 463.13 532.6072198 TC 401.56 381.48 438.7072198 26 85.96 81.66 93.9172200 28.82 27.38 31.4972200 TC 20.47 19.45 22.3772200 26 8.35 7.93 9.1272202 33.27 31.61 36.3572202 TC 24.24 23.03 26.4872202 26 9.03 8.58 9.8772220 27.88 26.49 30.4672220 TC 19.53 18.55 21.3372220 26 8.35 7.93 9.1272240 131.81 125.22 144.0072240 TC 88.02 83.62 96.1672240 26 43.79 41.60 47.8472255 125.16 118.90 136.7472255 TC 81.73 77.64 89.2972255 26 43.43 41.26 47.4572265 126.52 120.19 138.22# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.196 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE72265 TC 86.76 82.42 94.7872265 26 39.76 37.77 43.4472270 198.04 188.14 216.3672270 TC 134.20 127.49 146.6172270 26 63.84 60.65 69.7572275 113.46 107.79 123.9672275 TC 75.76 71.97 82.7772275 26 37.69 35.81 41.1872285 128.06 121.66 139.9172285 TC 70.74 67.20 77.2872285 26 57.33 54.46 62.6372291 152.70 145.07 166.8372291 TC 83.68 79.50 91.4372291 26 70.82 67.28 77.3772292 335.58 318.80 366.6272292 TC 265.98 252.68 290.5872292 26 71.84 68.25 78.4972295 112.70 107.07 123.1372295 TC 71.05 67.50 77.6372295 26 41.65 39.57 45.5173000 27.85 26.46 30.4373000 TC 19.84 18.85 21.6873000 26 8.01 7.61 8.7573010 30.49 28.97 33.3273010 TC 21.10 20.05 23.0673010 26 9.39 8.92 10.2673020 23.11 21.95 25.2473020 TC 15.76 14.97 17.2273020 26 7.35 6.98 8.0373030 29.89 28.40 32.6673030 TC 20.16 19.15 22.0273030 26 9.73 9.24 10.6373040 103.77 98.58 113.3773040 TC 77.02 73.17 84.1573040 26 26.75 25.41 29.2273050 38.74 36.80 42.3273050 TC 27.70 26.32 30.2773050 26 11.04 10.49 12.0673060 28.19 26.78 30.80# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.197 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE73060 TC 19.84 18.85 21.6873060 26 8.35 7.93 9.1273070 27.51 26.13 30.0573070 TC 19.84 18.85 21.6873070 26 7.67 7.29 8.3873080 32.59 30.96 35.6073080 TC 24.24 23.03 26.4873080 26 8.35 7.93 9.1273085 96.81 91.97 105.7773085 TC 69.79 66.30 76.2573085 26 27.01 25.66 29.5173090 26.59 25.26 29.0573090 TC 18.90 17.96 20.6573090 26 7.69 7.31 8.4173092 26.91 25.56 29.3973092 TC 19.21 18.25 20.9973092 26 7.69 7.31 8.4173100 30.78 29.24 33.6373100 TC 21.73 20.64 23.7473100 26 9.05 8.60 9.8973110 35.73 33.94 39.0373110 TC 27.38 26.01 29.9173110 26 8.35 7.93 9.1273115 108.48 103.06 118.5273115 TC 81.10 77.05 88.6173115 26 27.38 26.01 29.9173120 26.91 25.56 29.3973120 TC 18.90 17.96 20.6573120 26 8.01 7.61 8.7573130 31.02 29.47 33.8973130 TC 22.67 21.54 24.7773130 26 8.35 7.93 9.1273140 31.54 29.96 34.4573140 TC 24.87 23.63 27.1773140 26 6.67 6.34 7.2973200 217.28 206.42 237.3873200 TC 168.44 160.02 184.0273200 26 48.84 46.40 53.3673201 266.08 252.78 290.70# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.198 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE73201 TC 210.23 199.72 229.6873201 26 55.85 53.06 61.0273202 340.70 323.67 372.2273202 TC 282.17 268.06 308.2773202 26 58.52 55.59 63.9373206 380.62 361.59 415.8373206 TC 294.42 279.70 321.6673206 26 86.20 81.89 94.17C 73218 376.85 358.01 411.71C 73218 TC 312.33 296.71 341.2273218 26 64.52 61.29 70.48C 73219 480.13 456.12 524.54C 73219 TC 402.18 382.07 439.3873219 26 77.94 74.04 85.15C 73220 595.97 566.17 651.10C 73220 TC 492.98 468.33 538.5873220 26 102.99 97.84 112.52C 73221 378.26 359.35 413.25C 73221 TC 312.33 296.71 341.2273221 26 65.93 62.63 72.0273222 460.65 437.62 503.2673222 TC 382.71 363.57 418.1173222 26 77.94 74.04 85.1573223 590.95 561.40 645.6173223 TC 487.95 463.55 533.0873223 26 102.99 97.84 112.5273225 486.86 462.52 531.9073225 TC 405.64 385.36 443.1673225 26 81.22 77.16 88.7373500 26.41 25.09 28.8573500 TC 17.33 16.46 18.9373500 26 9.08 8.63 9.9273510 37.82 35.93 41.3273510 TC 26.75 25.41 29.2273510 26 11.07 10.52 12.1073520 39.84 37.85 43.5373520 TC 26.44 25.12 28.8973520 26 13.40 12.73 14.6473525 100.00 95.00 109.25# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.199 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE73525 TC 72.31 68.69 78.9973525 26 27.69 26.31 30.2673530 35.68 33.90 38.9973530 TC 20.04 19.04 21.9073530 26 14.42 13.70 15.7673540 42.51 40.38 46.4473540 TC 31.47 29.90 34.3973540 26 11.04 10.49 12.0673550 27.66 26.28 30.2273550 TC 18.59 17.66 20.3173550 26 9.08 8.63 9.9273560 30.18 28.67 32.9773560 TC 20.78 19.74 22.7073560 26 9.39 8.92 10.2673562 35.86 34.07 39.1873562 TC 26.13 24.82 28.5473562 26 9.73 9.24 10.6373564 41.93 39.83 45.8073564 TC 30.21 28.70 33.0173564 26 11.72 11.13 12.8073565 34.26 32.55 37.4373565 TC 24.55 23.32 26.8273565 26 9.71 9.22 10.6073580 129.58 123.10 141.5773580 TC 101.21 96.15 110.5773580 26 28.37 26.95 30.9973590 26.62 25.29 29.0873590 TC 18.27 17.36 19.9673590 26 8.35 7.93 9.1273592 30.99 29.44 33.8673592 TC 22.98 21.83 25.1073592 26 8.01 7.61 8.7573600 27.85 26.46 30.4373600 TC 19.84 18.85 21.6873600 26 8.01 7.61 8.7573610 31.96 30.36 34.9173610 TC 23.61 22.43 25.7973610 26 8.35 7.93 9.1273615 26 27.69 26.31 30.26# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.200 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE73615 104.08 98.88 113.7173615 TC 76.39 72.57 83.4673620 26.28 24.97 28.7273620 TC 18.90 17.96 20.6573620 26 7.38 7.01 8.0673630 30.39 28.87 33.2073630 TC 22.36 21.24 24.4373630 26 8.04 7.64 8.7973650 27.22 25.86 29.7473650 TC 19.53 18.55 21.3373650 26 7.69 7.31 8.4173660 28.72 27.28 31.3773660 TC 22.36 21.24 24.4373660 26 6.36 6.04 6.9573700 217.59 206.71 237.7273700 TC 169.07 160.62 184.7173700 26 48.52 46.09 53.0073701 268.91 255.46 293.7873701 TC 213.05 202.40 232.7673701 26 55.85 53.06 61.0273702 340.70 323.67 372.2273702 TC 282.17 268.06 308.2773702 26 58.52 55.59 63.93C 73706 403.63 383.45 440.97C 73706 TC 312.33 296.71 341.2273706 26 91.29 86.73 99.74C 73718 376.90 358.06 411.77C 73718 TC 312.33 296.71 341.2273718 26 64.57 61.34 70.54C 73719 480.13 456.12 524.54C 73719 TC 402.18 382.07 439.3873719 26 77.94 74.04 85.15C 73720 595.66 565.88 650.76C 73720 TC 492.98 468.33 538.5873720 26 102.68 97.55 112.18C 73721 378.26 359.35 413.25C 73721 TC 312.33 296.71 341.2273721 26 65.93 62.63 72.0273722 471.07 447.52 514.65# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.201 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE73722 TC 392.44 372.82 428.7473722 26 78.62 74.69 85.8973723 591.57 561.99 646.2973723 TC 488.89 464.45 534.1273723 26 102.68 97.55 112.1873725 488.82 464.38 534.0473725 TC 401.87 381.78 439.0573725 26 86.95 82.60 94.9974000 23.82 22.63 26.0274000 TC 15.13 14.37 16.5374000 26 8.69 8.26 9.5074010 36.83 34.99 40.2474010 TC 25.81 24.52 28.2074010 26 11.02 10.47 12.0474020 38.51 36.58 42.0774020 TC 25.81 24.52 28.2074020 26 12.70 12.07 13.8874022 46.18 43.87 50.4574022 TC 31.15 29.59 34.0374022 26 15.03 14.28 16.4274150 218.09 207.19 238.2774150 TC 160.90 152.86 175.7974150 26 57.19 54.33 62.4874160 295.90 281.11 323.2874160 TC 235.05 223.30 256.8074160 26 60.85 57.81 66.48C 74170 375.78 356.99 410.54C 74170 TC 308.56 293.13 337.1074170 26 67.21 63.85 73.4374174 525.52 499.24 574.1374174 TC 421.66 400.58 460.6774174 26 103.85 98.66 113.46C 74175 403.99 383.79 441.36C 74175 TC 312.65 297.02 341.5774175 26 91.34 86.77 99.7974176 214.03 203.33 233.8374176 TC 132.00 125.40 144.2174176 26 82.03 77.93 89.6274177 335.51 318.73 366.54# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.202 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE74177 TC 249.81 237.32 272.9274177 26 85.69 81.41 93.6274178 425.33 404.06 464.6774178 TC 330.24 313.73 360.7974178 26 95.09 90.34 103.89C 74181 382.22 363.11 417.58C 74181 TC 312.33 296.71 341.2274181 26 69.88 66.39 76.35C 74182 485.44 461.17 530.35C 74182 TC 402.50 382.38 439.7474182 26 82.94 78.79 90.61C 74183 600.66 570.63 656.22C 74183 TC 492.98 468.33 538.5874183 26 107.68 102.30 117.6574185 486.88 462.54 531.9274185 TC 400.93 380.88 438.0174185 26 85.96 81.66 93.9174190 77.55 73.67 84.7274190 TC 51.66 49.08 56.4474190 26 23.45 22.28 25.6274210 75.50 71.73 82.4974210 TC 58.48 55.56 63.8974210 26 17.02 16.17 18.6074220 86.86 82.52 94.9074220 TC 64.77 61.53 70.7674220 26 22.09 20.99 24.1474230 88.30 83.89 96.4774230 TC 62.88 59.74 68.7074230 26 25.41 24.14 27.7674235 132.66 126.03 144.9374235 TC 103.68 98.50 113.2874235 26 63.62 60.44 69.5174240 109.82 104.33 119.9874240 TC 76.39 72.57 83.4674240 26 33.42 31.75 36.51C 74241 111.97 106.37 122.33C 74241 TC 79.22 75.26 86.5574241 26 32.75 31.11 35.7874245 170.76 162.22 186.55# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.203 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE74245 TC 127.29 120.93 139.0774245 26 43.48 41.31 47.51C 74246 112.33 106.71 122.72C 74246 TC 79.22 75.26 86.5574246 26 33.11 31.45 36.17C 74247 TC 79.22 75.26 86.5574247 26 33.11 31.45 36.17C 74247 112.33 106.71 122.72C 74249 174.85 166.11 191.03C 74249 TC 131.37 124.80 143.5274249 26 43.48 41.31 47.51C 74250 101.96 96.86 111.39C 74250 TC 79.22 75.26 86.5574250 26 22.74 21.60 24.84C 74251 164.12 155.91 179.30C 74251 TC 131.01 124.46 143.1374251 26 33.11 31.45 36.17C 74260 103.25 98.09 112.80C 74260 TC 79.17 75.21 86.4974260 26 24.08 22.88 26.31C 74261 289.64 275.16 316.43C 74261 TC 176.88 168.04 193.2574261 26 112.76 107.12 123.19C 74262 397.18 377.32 433.92C 74262 TC 277.46 263.59 303.1374262 26 119.72 113.73 130.79C 74270 112.33 106.71 122.72C 74270 TC 79.22 75.26 86.5574270 26 33.11 31.45 36.17C 74280 178.51 169.58 195.02C 74280 TC 131.37 124.80 143.5274280 26 47.14 44.78 51.50C 74283 173.99 165.29 190.08C 74283 TC 79.22 75.26 86.5574283 26 94.77 90.03 103.5374290 66.60 63.27 72.7674290 TC 51.57 48.99 56.3474290 26 15.03 14.28 16.4274291 63.77 60.58 69.67# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.204 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE74291 TC 54.09 51.39 59.1074291 26 9.68 9.20 10.5874300 53.03 50.38 57.9474300 TC 32.89 31.25 35.9474300 26 17.74 16.85 19.3874301 53.03 50.38 57.9474301 TC 41.60 39.52 45.4574301 26 10.75 10.21 11.7474305 54.06 51.36 59.0674305 TC 31.25 29.69 34.1474305 26 20.78 19.74 22.7074320 99.32 94.35 108.5074320 TC 73.56 69.88 80.3674320 26 25.76 24.47 28.1474327 133.17 126.51 145.4974327 TC 96.81 91.97 105.7774327 26 36.36 34.54 39.7274328 162.37 154.25 177.3974328 TC 124.69 118.46 136.2374328 26 34.76 33.02 37.9774329 162.37 154.25 177.3974329 TC 124.69 118.46 136.2374329 26 34.76 33.02 37.9774330 173.00 164.35 189.0074330 TC 124.69 118.46 136.2374330 26 44.49 42.27 48.6174340 132.66 126.03 144.9374340 TC 103.68 98.50 113.2874340 26 26.12 24.81 28.5374355 144.45 137.23 157.8174355 TC 103.68 98.50 113.2874355 26 38.47 36.55 42.0374360 154.02 146.32 168.2774360 TC 124.69 118.46 136.2374360 26 28.32 26.90 30.9474363 144.45 137.23 157.8174363 TC 103.68 98.50 113.2874363 26 43.23 41.07 47.2374400 107.36 101.99 117.29# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.205 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE74400 TC 83.93 79.73 91.6974400 26 23.43 22.26 25.6074410 108.61 103.18 118.6674410 TC 84.87 80.63 92.7274410 26 23.74 22.55 25.9374415 130.92 124.37 143.0374415 TC 107.49 102.12 117.4474415 26 23.43 22.26 25.6074420 123.39 117.22 134.8074420 TC 103.68 98.50 113.2874420 26 17.74 16.85 19.3874425 71.37 67.80 77.9774425 TC 51.66 49.08 56.4474425 26 17.43 16.56 19.0474430 48.38 45.96 52.8574430 TC 33.35 31.68 36.4374430 26 15.03 14.28 16.4274440 79.42 75.45 86.7774440 TC 61.00 57.95 66.6474440 26 18.42 17.50 20.1374445 107.00 101.65 116.9074445 TC 44.53 42.30 48.6574445 26 56.58 53.75 61.8174450 75.87 72.08 82.8974450 TC 57.69 54.81 63.0374450 26 16.41 15.59 17.9374455 84.22 80.01 92.0174455 TC 68.54 65.11 74.8874455 26 15.68 14.90 17.1474470 78.46 74.54 85.7274470 TC 49.50 47.03 54.0874470 26 26.12 24.81 28.5374475 100.58 95.55 109.8874475 TC 74.82 71.08 81.7474475 26 25.76 24.47 28.1474480 100.89 95.85 110.2374480 TC 75.14 71.38 82.0974480 26 25.76 24.47 28.1474485 100.58 95.55 109.88# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.206 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE74485 TC 74.82 71.08 81.7474485 26 25.76 24.47 28.1474710 36.49 34.67 39.8774710 TC 20.47 19.45 22.3774710 26 16.02 15.22 17.5074740 75.87 72.08 82.8974740 TC 57.86 54.97 63.2274740 26 18.01 17.11 19.6874742 71.63 68.05 78.2674742 TC 52.48 49.86 57.3474742 26 30.12 28.61 32.9074775 91.49 86.92 99.9674775 TC 57.69 54.81 63.0374775 26 30.15 28.64 32.9475557 389.68 370.20 425.7375557 TC 276.52 262.69 302.0975557 26 113.16 107.50 123.63C 75559 454.81 432.07 496.88C 75559 TC 312.33 296.71 341.2275559 26 142.48 135.36 155.6675561 523.59 497.41 572.0275561 TC 398.41 378.49 435.2675561 26 125.17 118.91 136.7575563 628.94 597.49 687.1175563 TC 483.24 459.08 527.9475563 26 145.70 138.42 159.1875565 61.70 58.62 67.4175565 TC 50.00 47.50 54.6375565 26 11.70 11.12 12.79C 75571 69.17 65.71 75.57C 75571 TC 42.46 40.34 46.3975571 26 26.70 25.37 29.1875572 294.23 279.52 321.4575572 TC 213.05 202.40 232.7675572 26 81.18 77.12 88.69C 75573 360.25 342.24 393.58C 75573 TC 241.64 229.56 263.9975573 26 118.61 112.68 129.58C 75574 353.26 335.60 385.94# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.207 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 75574 TC 241.64 229.56 263.9975574 26 111.62 106.04 121.9575600 228.00 216.60 249.0975600 TC 203.94 193.74 222.8075600 26 24.05 22.85 26.2875605 175.55 166.77 191.7975605 TC 120.38 114.36 131.5175605 26 55.17 52.41 60.2775625 177.27 168.41 193.6775625 TC 121.95 115.85 133.2375625 26 55.32 52.55 60.4375630 209.13 198.67 228.4775630 TC 123.52 117.34 134.9475630 26 85.62 81.34 93.54C 75635 427.71 406.32 467.27C 75635 TC 312.75 297.11 341.6875635 26 114.96 109.21 125.5975650 195.78 185.99 213.8975650 TC 123.83 117.64 135.2975650 26 71.95 68.35 78.6075658 200.86 190.82 219.4475658 TC 139.23 132.27 152.1175658 26 61.64 58.56 67.3475660 213.55 202.87 233.3075660 TC 150.85 143.31 164.8175660 26 62.70 59.57 68.5175662 253.67 240.99 277.1475662 TC 173.26 164.60 189.2975662 26 80.41 76.39 87.8575665 221.43 210.36 241.9175665 TC 156.50 148.68 170.9875665 26 64.93 61.68 70.9375671 261.36 248.29 285.5375671 TC 180.80 171.76 197.5275671 26 80.56 76.53 88.0175676 209.18 198.72 228.5375676 TC 144.57 137.34 157.9475676 26 64.61 61.38 70.5975680 239.27 227.31 261.41# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.208 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE75680 TC 158.70 150.77 173.3975680 26 80.56 76.53 88.0175685 212.17 201.56 231.7975685 TC 148.02 140.62 161.7175685 26 64.15 60.94 70.0875705 256.19 243.38 279.8975705 TC 151.79 144.20 165.8375705 26 104.40 99.18 114.0675710 195.87 186.08 213.9975710 TC 142.05 134.95 155.1975710 26 53.82 51.13 58.8075716 230.91 219.36 252.2675716 TC 167.60 159.22 183.1075716 26 63.31 60.14 69.1675726 195.39 185.62 213.4675726 TC 140.48 133.46 153.4875726 26 54.91 52.16 59.9875731 188.59 179.16 206.0375731 TC 133.57 126.89 145.9275731 26 55.02 52.27 60.1175733 226.21 214.90 247.1475733 TC 162.89 154.75 177.9675733 26 63.32 60.15 69.1775736 192.41 182.79 210.2175736 TC 138.60 131.67 151.4275736 26 53.82 51.13 58.8075741 181.70 172.62 198.5175741 TC 119.12 113.16 130.1375741 26 62.58 59.45 68.3775743 207.54 197.16 226.7375743 TC 127.92 121.52 139.7575743 26 79.62 75.64 86.9975746 188.43 179.01 205.8675746 TC 133.57 126.89 145.9275746 26 54.86 52.12 59.9475756 207.08 196.73 226.2475756 TC 146.14 138.83 159.6575756 26 60.95 57.90 66.5975774 123.35 117.18 134.76# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.209 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE75774 TC 105.92 100.62 115.7175774 26 17.43 16.56 19.0475791 319.20 303.24 348.7375791 TC 239.76 227.77 261.9475791 26 79.44 75.47 86.7975801 260.56 247.53 284.6675801 TC 214.13 203.42 233.9375801 26 44.17 41.96 48.2575803 276.93 263.08 302.5475803 TC 214.13 203.42 233.9375803 26 57.60 54.72 62.9375805 286.18 271.87 312.6575805 TC 241.52 229.44 263.8675805 26 39.86 37.87 43.5575807 26 57.60 54.72 62.9375807 429.27 407.81 468.9875807 TC 362.28 344.17 395.80C 75809 92.85 88.21 101.44C 75809 TC 69.79 66.30 76.2575809 26 23.06 21.91 25.2075810 558.22 530.31 609.8675810 TC 496.95 472.10 542.9275810 26 56.26 53.45 61.4775820 120.84 114.80 132.0275820 TC 87.07 82.72 95.1375820 26 33.76 32.07 36.8875822 149.26 141.80 163.0775822 TC 98.38 93.46 107.4875822 26 50.88 48.34 55.5975825 170.26 161.75 186.0175825 TC 115.66 109.88 126.3675825 26 54.59 51.86 59.6475827 173.35 164.68 189.3875827 TC 119.43 113.46 130.4875827 26 53.92 51.22 58.9075831 179.85 170.86 196.4975831 TC 119.43 113.46 130.4875831 26 60.42 57.40 66.0175833 204.16 193.95 223.04# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.210 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE75833 TC 134.51 127.78 146.9575833 26 69.65 66.17 76.1075840 178.59 169.66 195.1175840 TC 117.86 111.97 128.7775840 26 60.73 57.69 66.3475842 206.99 196.64 226.1475842 TC 135.46 128.69 147.9975842 26 71.53 67.95 78.1475860 175.60 166.82 191.8475860 TC 120.06 114.06 131.1775860 26 55.54 52.76 60.6775870 173.66 164.98 189.7375870 TC 118.80 112.86 129.7975870 26 54.86 52.12 59.9475872 260.69 247.66 284.8175872 TC 201.43 191.36 220.0675872 26 59.26 56.30 64.7575880 125.86 119.57 137.5175880 TC 92.41 87.79 100.9675880 26 33.45 31.78 36.5575885 187.69 178.31 205.0675885 TC 118.80 112.86 129.7975885 26 68.89 65.45 75.2775887 187.55 178.17 204.9075887 TC 120.06 114.06 131.1775887 26 67.48 64.11 73.7375889 173.98 165.28 190.0775889 TC 119.43 113.46 130.4875889 26 54.54 51.81 59.5875891 174.29 165.58 190.4275891 TC 119.75 113.76 130.8275891 26 54.54 51.81 59.5875893 143.83 136.64 157.1475893 TC 118.80 112.86 129.7975893 26 25.03 23.78 27.3575894 1,024.88 973.64 1,119.6975894 TC 952.98 905.33 1,041.1375894 26 65.49 62.22 71.5575896 899.50 854.53 982.71# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.211 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE75896 TC 828.65 787.22 905.3075896 26 65.81 62.52 71.9075898 130.69 124.16 142.7875898 TC 41.64 39.56 45.4975898 26 83.23 79.07 90.9375900 899.50 854.53 982.7175900 TC 828.65 787.22 905.3075900 26 23.84 22.65 26.0575901 164.22 156.01 179.4175901 TC 140.80 133.76 153.8275901 26 23.43 22.26 25.6075902 73.84 70.15 80.6775902 TC 54.71 51.97 59.7775902 26 19.13 18.17 20.90C 75945 160.32 152.30 175.15C 75945 TC 140.48 133.46 153.4875945 26 19.83 18.84 21.6775946 101.59 96.51 110.9975946 TC 90.00 85.50 98.3375946 26 20.25 19.24 22.1375952 26 230.30 218.79 251.6175953 26 70.25 66.74 76.7575954 26 114.75 109.01 125.3675956 26 361.66 343.58 395.1275957 26 309.52 294.04 338.1575958 26 206.20 195.89 225.2775959 26 181.06 172.01 197.8175960 151.05 143.50 165.0375960 TC 111.89 106.30 122.2575960 26 39.16 37.20 42.7875961 331.38 314.81 362.0375961 TC 129.17 122.71 141.1275961 26 202.21 192.10 220.9275962 167.18 158.82 182.6475962 TC 141.74 134.65 154.8575962 26 25.44 24.17 27.8075964 108.32 102.90 118.3475964 TC 90.53 86.00 98.9075964 26 17.79 16.90 19.44# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.212 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE75966 205.84 195.55 224.8875966 TC 143.00 135.85 156.2375966 26 62.84 59.70 68.6675968 104.40 99.18 114.0675968 TC 87.39 83.02 95.4775968 26 17.02 16.17 18.6075970 500.39 475.37 546.6875970 TC 455.19 432.43 497.2975970 26 40.54 38.51 44.2975978 170.95 162.40 186.7675978 TC 145.51 138.23 158.9675978 26 25.44 24.17 27.8075980 291.41 276.84 318.3775980 TC 214.13 203.42 233.9375980 26 70.03 66.53 76.5175982 291.41 276.84 318.3775982 TC 214.13 203.42 233.9375982 26 70.03 66.53 76.5175984 108.95 103.50 119.0375984 TC 74.51 70.78 81.4075984 26 34.45 32.73 37.6475989 125.63 119.35 137.2575989 TC 69.48 66.01 75.9175989 26 56.15 53.34 61.3476000 61.18 58.12 66.8476000 TC 52.83 50.19 57.7276000 26 8.35 7.93 9.1276001 141.02 133.97 154.0776001 TC 103.68 98.50 113.2876001 26 34.51 32.78 37.7076010 26.02 24.72 28.4376010 TC 17.33 16.46 18.9376010 26 8.69 8.26 9.5076080 58.79 55.85 64.2376080 TC 33.04 31.39 36.1076080 26 25.76 24.47 28.1476098 17.80 16.91 19.4576098 TC 10.10 9.60 11.0476098 26 7.69 7.31 8.41# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.213 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 76100 100.15 95.14 109.41C 76100 TC 69.79 66.30 76.2576100 26 30.36 28.84 33.1776101 156.54 148.71 171.0276101 TC 122.89 116.75 134.2676101 26 33.65 31.97 36.7776102 210.67 200.14 230.1676102 TC 176.61 167.78 192.9576102 26 34.06 32.36 37.2176120 73.14 69.48 79.9076120 TC 54.71 51.97 59.7776120 26 18.42 17.50 20.1376125 45.74 43.45 49.9776125 TC 31.25 29.69 34.1476125 26 14.05 13.35 15.3576376 62.20 59.09 67.9576376 TC 52.52 49.89 57.3776376 26 9.68 9.20 10.5876377 83.06 78.91 90.7576377 TC 45.29 43.03 49.4876377 26 37.77 35.88 41.26C 76380 145.45 138.18 158.91C 76380 TC 98.70 93.77 107.8476380 26 46.75 44.41 51.07C 76506 88.61 84.18 96.81C 76506 TC 58.17 55.26 63.5576506 26 30.44 28.92 33.2676510 164.69 156.46 179.9376510 TC 72.94 69.29 79.6876510 26 91.75 87.16 100.2376511 95.87 91.08 104.7476511 TC 45.92 43.62 50.1676511 26 49.95 47.45 54.5776512 88.48 84.06 96.6776512 TC 37.44 35.57 40.9176512 26 51.04 48.49 55.7676513 86.65 82.32 94.6776513 TC 53.14 50.48 58.0576513 26 33.51 31.83 36.60# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.214 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE76514 14.05 13.35 15.3576514 TC 4.76 4.52 5.2076514 26 9.29 8.83 10.1576516 71.26 67.70 77.8676516 TC 42.46 40.34 46.3976516 26 28.80 27.36 31.4676519 77.01 73.16 84.1376519 TC 47.17 44.81 51.5376519 26 29.84 28.35 32.6076529 73.01 69.36 79.7676529 TC 41.52 39.44 45.3676529 26 31.49 29.92 34.4176536 115.39 109.62 126.0676536 TC 88.64 84.21 96.8476536 26 26.75 25.41 29.22C 76604 84.27 80.06 92.07C 76604 TC 58.17 55.26 63.5576604 26 26.10 24.80 28.52C 76645 84.29 80.08 92.09C 76645 TC 58.17 55.26 63.5576645 26 26.12 24.81 28.53C 76700 127.72 121.33 139.53C 76700 TC 88.96 84.51 97.1976700 26 38.77 36.83 42.3576705 103.22 98.06 112.7776705 TC 75.14 71.38 82.0976705 26 28.09 26.69 30.69C 76770 124.40 118.18 135.91C 76770 TC 88.96 84.51 97.1976770 26 35.44 33.67 38.7276775 105.39 100.12 115.1476775 TC 77.65 73.77 84.8476775 26 27.75 26.36 30.3176776 146.44 139.12 159.9976776 TC 110.32 104.80 120.5276776 26 36.12 34.31 39.4676800 126.99 120.64 138.7476800 TC 73.88 70.19 80.7276800 26 53.11 50.45 58.02# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.215 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE76801 124.38 118.16 135.8876801 TC 77.02 73.17 84.1576801 26 47.36 44.99 51.7476802 66.46 63.14 72.6176802 TC 26.75 25.41 29.2276802 26 39.71 37.72 43.38C 76805 136.31 129.49 148.91C 76805 TC 88.96 84.51 97.1976805 26 47.36 44.99 51.7476810 94.82 90.08 103.5976810 TC 47.80 45.41 52.2276810 26 47.02 44.67 51.3776811 183.72 174.53 200.7176811 TC 91.79 87.20 100.2876811 26 91.94 87.34 100.44C 76812 144.14 136.93 157.47C 76812 TC 58.17 55.26 63.5576812 26 85.97 81.67 93.9276813 121.47 115.40 132.7176813 TC 64.45 61.23 70.4176813 26 57.01 54.16 62.2876814 78.82 74.88 86.1176814 TC 30.84 29.30 33.7076814 26 47.98 45.58 52.4276815 26 30.66 29.13 33.5076815 87.88 83.49 96.0176815 TC 57.23 54.37 62.53C 76816 99.50 94.53 108.71C 76816 TC 58.17 55.26 63.5576816 26 41.33 39.26 45.15C 76817 94.22 89.51 102.94C 76817 TC 58.17 55.26 63.5576817 26 36.04 34.24 39.3876818 118.88 112.94 129.8876818 TC 67.91 64.51 74.1976818 26 50.97 48.42 55.6876819 87.98 83.58 96.1276819 TC 50.63 48.10 55.3276819 26 37.35 35.48 40.80# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.216 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE76820 42.25 40.14 46.1676820 TC 18.27 17.36 19.9676820 26 23.98 22.78 26.20C 76821 92.51 87.88 101.06C 76821 TC 58.17 55.26 63.5576821 26 34.34 32.62 37.5176825 211.35 200.78 230.9076825 TC 131.37 124.80 143.5276825 26 79.98 75.98 87.3876826 123.96 117.76 135.4276826 TC 83.93 79.73 91.6976826 26 40.02 38.02 43.7276827 61.63 58.55 67.3376827 TC 33.98 32.28 37.1276827 26 27.65 26.27 30.2176828 45.24 42.98 49.4376828 TC 18.59 17.66 20.3176828 26 26.65 25.32 29.1276830 121.08 115.03 132.2876830 TC 88.02 83.62 96.1676830 26 33.06 31.41 36.1276831 122.41 116.29 133.7376831 TC 87.39 83.02 95.4776831 26 35.02 33.27 38.2676856 119.82 113.83 130.9076856 TC 87.07 82.72 95.1376856 26 32.75 31.11 35.78C 76857 76.91 73.06 84.02C 76857 TC 58.17 55.26 63.5576857 26 18.74 17.80 20.4776870 119.11 113.15 130.1276870 TC 88.33 83.91 96.5076870 26 30.78 29.24 33.63C 76872 122.38 116.26 133.70C 76872 TC 88.96 84.51 97.1976872 26 33.42 31.75 36.51C 76873 163.79 155.60 178.94C 76873 TC 88.96 84.51 97.1976873 26 74.83 71.09 81.75# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.217 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE76881 115.63 109.85 126.3376881 TC 85.82 81.53 93.7676881 26 29.81 28.32 32.5776882 33.58 31.90 36.6976882 TC 10.10 9.60 11.0476882 26 23.47 22.30 25.65C 76885 93.92 89.22 102.60C 76885 TC 58.17 55.26 63.5576885 26 35.75 33.96 39.05C 76886 86.86 82.52 94.90C 76886 TC 58.17 55.26 63.5576886 26 28.69 27.26 31.3576930 82.60 78.47 90.2476930 TC 50.63 48.10 55.3276930 26 31.97 30.37 34.9376932 97.68 92.80 106.7276932 TC 61.06 58.01 66.7176932 26 33.06 31.41 36.12C 76936 196.79 186.95 214.99C 76936 TC 98.70 93.77 107.8476936 26 98.10 93.20 107.1876937 33.66 31.98 36.7876937 TC 18.90 17.96 20.6576937 26 14.76 14.02 16.1276940 193.20 183.54 211.0776940 TC 72.42 68.80 79.1276940 26 102.50 97.38 111.9976941 134.19 127.48 146.6076941 TC 60.23 57.22 65.8076941 26 65.32 62.05 71.3676942 192.70 183.07 210.5376942 TC 160.27 152.26 175.1076942 26 32.43 30.81 35.4376945 96.36 91.54 105.2776945 TC 60.23 57.22 65.8076945 26 33.37 31.70 36.4676946 33.77 32.08 36.8976946 TC 15.44 14.67 16.8776946 26 18.32 17.40 20.01# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.218 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE76948 34.50 32.78 37.7076948 TC 15.44 14.67 16.8776948 26 19.05 18.10 20.8276950 52.61 49.98 57.4876950 TC 24.55 23.32 26.8276950 26 28.06 26.66 30.6676965 99.47 94.50 108.6876965 TC 34.29 32.58 37.4776965 26 65.17 61.91 71.20C 76970 77.95 74.05 85.16C 76970 TC 58.17 55.26 63.5576970 26 19.78 18.79 21.6176975 105.48 100.21 115.2476975 TC 61.06 58.01 66.7176975 26 42.42 40.30 46.3576977 8.40 7.98 9.1876977 TC 5.70 5.42 6.2376977 26 2.69 2.56 2.9476998 114.44 108.72 125.0376998 TC 50.14 47.63 54.7776998 26 64.44 61.22 70.4077001 111.47 105.90 121.7977001 TC 93.04 88.39 101.6577001 26 18.42 17.50 20.1377002 73.87 70.18 80.7177002 TC 47.17 44.81 51.5377002 26 26.70 25.37 29.1877003 61.46 58.39 67.1577003 TC 32.09 30.49 35.0677003 26 29.37 27.90 32.0977011 TC 278.09 264.19 303.8277011 26 58.66 55.73 64.0977011 336.75 319.91 367.9077012 139.01 132.06 151.8777012 TC 84.56 80.33 92.3877012 26 54.45 51.73 59.4977013 621.40 590.33 678.8877013 TC 423.46 402.29 462.6377013 26 195.77 185.98 213.88# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.219 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE77014 135.05 128.30 147.5577014 TC 93.99 89.29 102.6877014 26 41.07 39.02 44.8777021 389.43 369.96 425.4577021 TC 316.42 300.60 345.6977021 26 73.02 69.37 79.7877022 629.25 597.79 687.4677022 TC 416.58 395.75 455.1177022 26 205.90 195.61 224.9577031 139.59 132.61 152.5077031 TC 62.25 59.14 68.0177031 26 77.34 73.47 84.4977032 51.62 49.04 56.4077032 TC 24.87 23.63 27.1777032 26 26.75 25.41 29.2277051 10.31 9.79 11.2677051 TC 7.28 6.92 7.9677051 26 3.03 2.88 3.3177052 10.31 9.79 11.2677052 TC 7.28 6.92 7.9677052 26 3.03 2.88 3.3177053 59.79 56.80 65.3277053 TC 43.09 40.94 47.0877053 26 16.70 15.87 18.2577054 81.49 77.42 89.0377054 TC 59.74 56.75 65.2677054 26 21.75 20.66 23.7677055 83.14 78.98 90.8377055 TC 49.37 46.90 53.9477055 26 33.76 32.07 36.8877056 106.25 100.94 116.0877056 TC 64.45 61.23 70.4177056 26 41.80 39.71 45.6777057 77.17 73.31 84.3177057 TC 43.40 41.23 47.4177057 26 33.76 32.07 36.88C 77058 571.26 542.70 624.11C 77058 TC 492.98 468.33 538.5877058 26 78.28 74.37 85.53# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.220 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 77059 570.95 542.40 623.76C 77059 TC 492.98 468.33 538.5877059 26 77.97 74.07 85.1877071 47.92 45.52 52.3577072 22.27 21.16 24.3377072 TC 13.24 12.58 14.4777072 26 9.03 8.58 9.8777073 37.40 35.53 40.8677073 TC 22.98 21.83 25.1077073 26 14.42 13.70 15.7677074 66.72 63.38 72.8977074 TC 44.98 42.73 49.1477074 26 21.75 20.66 23.76C 77075 95.86 91.07 104.73C 77075 TC 69.79 66.30 76.2577075 26 26.07 24.77 28.4977076 103.24 98.08 112.7977076 TC 69.48 66.01 75.9177076 26 33.76 32.07 36.8877077 40.33 38.31 44.0677077 TC 23.93 22.73 26.1477077 26 16.41 15.59 17.93C 77078 77.73 73.84 84.92C 77078 TC 66.02 62.72 72.1377078 26 11.70 11.12 12.7977080 91.46 86.89 99.9277080 TC 80.76 76.72 88.2377080 26 10.71 10.17 11.7077081 27.38 26.01 29.9177081 TC 16.70 15.87 18.2577081 26 10.68 10.15 11.6777082 26.04 24.74 28.4577082 TC 19.68 18.70 21.5177082 26 6.36 6.04 6.95C 77084 389.28 369.82 425.29C 77084 TC 312.33 296.71 341.2277084 26 76.95 73.10 84.0777261 69.80 66.31 76.2677262 105.07 99.82 114.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.221 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE77263 155.61 147.83 170.0077280 175.14 166.38 191.3477280 TC 141.42 134.35 154.5077280 26 33.71 32.02 36.8277285 308.73 293.29 337.2877285 TC 257.98 245.08 281.8477285 26 50.75 48.21 55.4477290 499.30 474.34 545.4977290 TC 424.18 402.97 463.4277290 26 75.12 71.36 82.0677295 474.85 451.11 518.7877295 TC 254.05 241.35 277.5577295 26 220.81 209.77 241.2477300 64.34 61.12 70.2977300 TC 34.29 32.58 37.4777300 26 30.05 28.55 32.8377301 1,855.98 1,763.18 2,027.6677301 TC 1,469.51 1,396.03 1,605.4377301 26 386.47 367.15 422.2277305 59.53 56.55 65.0377305 TC 25.81 24.52 28.2077305 26 33.71 32.02 36.8277310 85.05 80.80 92.9277310 TC 34.29 32.58 37.4777310 26 50.75 48.21 55.4477315 131.41 124.84 143.5777315 TC 56.29 53.48 61.5077315 26 75.12 71.36 82.0677321 93.53 88.85 102.1877321 TC 47.80 45.41 52.2277321 26 45.73 43.44 49.9677326 135.68 128.90 148.2477326 TC 90.94 86.39 99.3577326 26 44.73 42.49 48.8677327 26 67.14 63.78 73.3577327 191.07 181.52 208.7577327 TC 123.93 117.73 135.3977328 256.88 244.04 280.6577328 TC 156.03 148.23 170.46# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.222 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE77328 26 100.85 95.81 110.1877331 59.71 56.72 65.2377331 TC 17.64 16.76 19.2777331 26 42.06 39.96 45.9577332 72.93 69.28 79.6777332 TC 46.86 44.52 51.2077332 26 26.07 24.77 28.4977333 52.72 50.08 57.5977333 TC 12.30 11.69 13.4477333 26 40.41 38.39 44.1577334 140.52 133.49 153.5177334 TC 81.10 77.05 88.6177334 26 59.42 56.45 64.9277336 43.09 40.94 47.0877338 466.24 442.93 509.3777338 TC 259.39 246.42 283.3877338 26 206.86 196.52 226.0077370 104.82 99.58 114.5277372 773.41 734.74 844.9577373 1,473.48 1,399.81 1,609.7877401 20.47 19.45 22.3777402 169.07 160.62 184.7177403 123.52 117.34 134.9477404 137.97 131.07 150.7377406 140.48 133.46 153.4877407 233.48 221.81 255.0877408 169.07 160.62 184.7177409 188.24 178.83 205.6577411 187.29 177.93 204.6277412 224.68 213.45 245.4777413 222.48 211.36 243.0677414 249.81 237.32 272.9277416 250.75 238.21 273.9477417 13.24 12.58 14.4777418 439.26 417.30 479.9077421 80.92 76.87 88.4077421 TC 62.57 59.44 68.3677421 26 18.35 17.43 20.0477422 233.48 221.81 255.08# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.223 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE77423 241.64 229.56 263.9977427 173.54 164.86 189.5977431 95.29 90.53 104.1177432 393.13 373.47 429.4977435 598.07 568.17 653.40# 77435 589.59 560.11 644.1377469 291.99 277.39 319.0077470 166.25 157.94 181.6377470 TC 65.40 62.13 71.4577470 26 100.85 95.81 110.1877520 733.00 696.35 800.8077522 753.00 715.35 822.6577523 893.00 848.35 975.6077525 951.00 903.45 1,038.9777600 389.13 369.67 425.1277600 TC 314.00 298.30 343.0577600 26 75.12 71.36 82.0677605 658.16 625.25 719.0477605 TC 548.06 520.66 598.7677605 26 110.10 104.60 120.2977610 616.58 585.75 673.6177610 TC 542.09 514.99 592.2477610 26 74.50 70.78 81.4077615 920.23 874.22 1,005.3577615 TC 819.38 778.41 895.1777615 26 100.85 95.81 110.1877620 510.30 484.79 557.5177620 TC 436.26 414.45 476.6277620 26 74.03 70.33 80.8877750 337.82 320.93 369.0777750 TC 95.97 91.17 104.8577750 26 241.85 229.76 264.2277761 351.21 333.65 383.7077761 TC 165.76 157.47 181.0977761 26 185.45 176.18 202.6177762 469.86 446.37 513.3377762 TC 191.26 181.70 208.9677762 26 278.60 264.67 304.3777763 666.76 633.42 728.43# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.224 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE77763 TC 248.54 236.11 271.5377763 26 418.22 397.31 456.9177776 398.96 379.01 435.8677776 TC 169.27 160.81 184.9377776 26 229.69 218.21 250.9477777 545.48 518.21 595.9477777 TC 176.50 167.68 192.8377777 26 368.98 350.53 403.1177778 801.50 761.43 875.6477778 TC 254.56 241.83 278.1077778 26 546.94 519.59 597.5377785 219.74 208.75 240.0677785 TC 150.95 143.40 164.9177785 26 68.79 65.35 75.1577786 527.94 501.54 576.7777786 TC 371.59 353.01 405.9677786 26 156.34 148.52 170.8077787 873.75 830.06 954.5777787 TC 635.96 604.16 694.7877787 26 237.80 225.91 259.8077789 106.33 101.01 116.1677789 TC 51.26 48.70 56.0177789 26 55.07 52.32 60.1777790 86.88 82.54 94.9277790 TC 36.81 34.97 40.2277790 26 50.08 47.58 54.7278000 69.40 65.93 75.8278000 TC 60.37 57.35 65.9578000 26 9.03 8.58 9.8778001 88.53 84.10 96.7278001 TC 76.18 72.37 83.2378001 26 12.36 11.74 13.5078003 77.94 74.04 85.1578003 TC 62.25 59.14 68.0178003 26 15.68 14.90 17.14C 78006 227.78 216.39 248.85C 78006 TC 204.36 194.14 223.2678006 26 23.43 22.26 25.6078007 217.76 206.87 237.90# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.225 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78007 TC 193.99 184.29 211.9378007 26 23.77 22.58 25.97C 78010 140.71 133.67 153.72C 78010 TC 122.67 116.54 134.0278010 26 18.04 17.14 19.71C 78011 144.06 136.86 157.39C 78011 TC 122.31 116.19 133.6278011 26 21.75 20.66 23.7678015 206.63 196.30 225.7578015 TC 175.14 166.38 191.3478015 26 31.49 29.92 34.4178016 282.37 268.25 308.4978016 TC 247.08 234.73 269.9478016 26 35.29 33.53 38.56C 78018 298.55 283.62 326.16C 78018 TC 258.71 245.77 282.6478018 26 39.84 37.85 43.5378020 80.31 76.29 87.7378020 TC 52.83 50.19 57.7278020 26 27.48 26.11 30.0378070 151.41 143.84 165.4278070 TC 112.94 107.29 123.3878070 26 38.48 36.56 42.0478075 402.59 382.46 439.8378075 TC 368.40 349.98 402.4878075 26 34.18 32.47 37.3478102 159.45 151.48 174.2078102 TC 133.67 126.99 146.0478102 26 25.78 24.49 28.1678103 210.29 199.78 229.7578103 TC 175.45 166.68 191.6878103 26 34.84 33.10 38.0778104 235.24 223.48 257.0078104 TC 197.76 187.87 216.0578104 26 37.48 35.61 40.9578110 80.18 76.17 87.6078110 TC 71.15 67.59 77.7378110 26 9.03 8.58 9.8778111 78.69 74.76 85.97# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.226 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78111 TC 68.95 65.50 75.3378111 26 9.74 9.25 10.6478120 83.11 78.95 90.7978120 TC 72.09 68.49 78.7678120 26 11.02 10.47 12.0478121 92.77 88.13 101.3578121 TC 77.75 73.86 84.9478121 26 15.03 14.28 16.4278122 97.20 92.34 106.1978122 TC 76.81 72.97 83.9278122 26 20.39 19.37 22.2878130 147.46 140.09 161.1078130 TC 117.70 111.82 128.5978130 26 29.76 28.27 32.5178135 340.07 323.07 371.5378135 TC 308.98 293.53 337.5678135 26 31.09 29.54 33.9778140 128.56 122.13 140.4578140 TC 99.11 94.15 108.2778140 26 29.44 27.97 32.1778185 196.66 186.83 214.8578185 TC 177.97 169.07 194.4378185 26 18.69 17.76 20.42C 78190 200.40 190.38 218.94C 78190 TC 147.71 140.32 161.3778190 26 52.69 50.06 57.5778191 157.51 149.63 172.0778191 TC 128.06 121.66 139.9178191 26 29.44 27.97 32.17C 78195 293.30 278.64 320.44C 78195 TC 236.40 224.58 258.2778195 26 56.90 54.06 62.1778201 175.55 166.77 191.7978201 TC 154.72 146.98 169.0378201 26 20.83 19.79 22.7678202 195.06 185.31 213.1178202 TC 172.31 163.69 188.2478202 26 22.75 21.61 24.8578205 208.93 198.48 228.25# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.227 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78205 TC 175.77 166.98 192.0378205 26 33.16 31.50 36.23C 78206 315.77 299.98 344.98C 78206 TC 270.96 257.41 296.0278206 26 44.81 42.57 48.9678215 183.80 174.61 200.8078215 TC 160.37 152.35 175.2078215 26 23.43 22.26 25.6078216 118.98 113.03 129.9878216 TC 92.51 87.88 101.0678216 26 26.46 25.14 28.91C 78226 305.46 290.19 333.72C 78226 TC 270.96 257.41 296.0278226 26 34.50 32.78 37.70C 78227 312.48 296.86 341.39C 78227 TC 270.96 257.41 296.0278227 26 41.51 39.43 45.3478230 161.39 153.32 176.3278230 TC 139.64 132.66 152.5678230 26 21.75 20.66 23.7678231 119.69 113.71 130.7778231 TC 95.34 90.57 104.1678231 26 24.35 23.13 26.6078232 101.12 96.06 110.4778232 TC 80.58 76.55 88.0378232 26 20.55 19.52 22.4578258 220.58 209.55 240.9878258 TC 185.51 176.23 202.6678258 26 35.08 33.33 38.3378261 239.35 227.38 261.4978261 TC 206.24 195.93 225.3278261 26 33.11 31.45 36.1778262 237.29 225.43 259.2478262 TC 205.93 195.63 224.9778262 26 31.36 29.79 34.26C 78264 262.89 249.75 287.21C 78264 TC 225.09 213.84 245.9278264 26 37.80 35.91 41.3078270 77.91 74.01 85.11# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.228 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78270 TC 68.22 64.81 74.5378270 26 9.68 9.20 10.5878271 83.56 79.38 91.2978271 TC 73.88 70.19 80.7278271 26 9.68 9.20 10.5878272 26 12.70 12.07 13.8878272 85.10 80.85 92.9878272 TC 72.41 68.79 79.11C 78278 271.87 258.28 297.02C 78278 TC 225.04 213.79 245.8678278 26 46.83 44.49 51.1678282 238.14 226.23 260.1678282 TC 217.19 206.33 237.2878282 26 18.42 17.50 20.13C 78290 257.50 244.63 281.32C 78290 TC 225.04 213.79 245.8678290 26 32.46 30.84 35.4778291 241.79 229.70 264.1678291 TC 200.27 190.26 218.8078291 26 41.51 39.43 45.3478300 169.37 160.90 185.0478300 TC 139.95 132.95 152.8978300 26 29.42 27.95 32.1478305 223.38 212.21 244.0478305 TC 184.25 175.04 201.3078305 26 39.13 37.17 42.7578306 240.43 228.41 262.6778306 TC 199.96 189.96 218.4578306 26 40.47 38.45 44.22C 78315 276.03 262.23 301.56C 78315 TC 227.87 216.48 248.9578315 26 48.16 45.75 52.6178320 224.30 213.09 245.0578320 TC 175.77 166.98 192.0378320 26 48.53 46.10 53.0278414 130.06 123.56 142.0978414 TC 105.28 100.02 115.0278414 26 22.38 21.26 24.4578428 179.85 170.86 196.49# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.229 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78428 TC 142.78 135.64 155.9978428 26 37.07 35.22 40.5078445 164.54 156.31 179.7678445 TC 142.47 135.35 155.6578445 26 22.07 20.97 24.1278451 337.03 320.18 368.2178451 TC 272.85 259.21 298.0978451 26 64.19 60.98 70.1378452 469.35 445.88 512.7678452 TC 394.16 374.45 430.6278452 26 75.18 71.42 82.1378453 290.17 275.66 317.0178453 TC 243.63 231.45 266.1778453 26 46.54 44.21 50.8478454 414.26 393.55 452.5878454 TC 352.38 334.76 384.9778454 26 61.88 58.79 67.61C 78456 191.63 182.05 209.36C 78456 TC 143.00 135.85 156.2378456 26 48.64 46.21 53.14C 78457 179.56 170.58 196.17C 78457 TC 143.10 135.95 156.3478457 26 36.46 34.64 39.8478458 180.89 171.85 197.6378458 TC 140.27 133.26 153.2578458 26 40.62 38.59 44.38C 78459 1,028.35 976.93 1,123.47C 78459 TC 957.00 909.15 1,045.5278459 26 71.35 67.78 77.9578466 167.36 158.99 182.8478466 TC 134.30 127.59 146.7378466 26 33.06 31.41 36.1278468 202.83 192.69 221.5978468 TC 164.14 155.93 179.3278468 26 38.69 36.76 42.2778469 230.17 218.66 251.4678469 TC 186.14 176.83 203.3578469 26 44.03 41.83 48.1078472 231.94 220.34 253.39# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.230 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78472 TC 185.19 175.93 202.3278472 26 46.75 44.41 51.0778473 299.88 284.89 327.6278473 TC 229.49 218.02 250.7278473 26 70.39 66.87 76.9078481 189.38 179.91 206.9078481 TC 142.05 134.95 155.1978481 26 47.33 44.96 51.7078483 258.41 245.49 282.3178483 TC 187.39 178.02 204.7278483 26 71.02 67.47 77.5978491 494.48 469.76 540.2278491 TC 410.31 389.79 448.2678491 26 72.29 68.68 78.9878492 790.92 751.37 864.0878492 TC 686.08 651.78 749.5578492 26 91.27 86.71 99.7278494 235.32 223.55 257.0878494 TC 178.60 169.67 195.1278494 26 56.73 53.89 61.9778496 60.16 57.15 65.7278496 TC 36.18 34.37 39.5378496 26 23.98 22.78 26.2078579 162.70 154.57 177.7678579 TC 139.90 132.91 152.8578579 26 22.80 21.66 24.9178580 210.22 199.71 229.6778580 TC 175.45 166.68 191.6878580 26 34.76 33.02 37.9778582 300.40 285.38 328.1978582 TC 251.17 238.61 274.4078582 26 49.24 46.78 53.8078597 183.75 174.56 200.7478597 TC 149.96 142.46 163.8378597 26 33.80 32.11 36.9378598 281.51 267.43 307.5478598 TC 243.00 230.85 265.4878598 26 38.51 36.58 42.0778600 171.94 163.34 187.84# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.231 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78600 TC 151.26 143.70 165.2678600 26 20.68 19.65 22.6078601 203.02 192.87 221.8078601 TC 178.91 169.96 195.4578601 26 24.11 22.90 26.3478605 188.30 178.89 205.7278605 TC 162.89 154.75 177.9678605 26 25.41 24.14 27.7678606 315.10 299.35 344.2578606 TC 285.41 271.14 311.8178606 26 29.69 28.21 32.4478607 TC 289.50 275.03 316.2878607 26 56.88 54.04 62.1578607 346.38 329.06 378.42C 78608 1,027.77 976.38 1,122.84C 78608 TC 957.00 909.15 1,045.5278608 26 70.77 67.23 77.3178610 167.81 159.42 183.3378610 TC 153.46 145.79 167.6678610 26 14.35 13.63 15.6778630 324.73 308.49 354.7678630 TC 292.64 278.01 319.7178630 26 32.09 30.49 35.0678635 315.34 299.57 344.5178635 TC 286.67 272.34 313.1978635 26 28.67 27.24 31.33C 78645 248.99 236.54 272.02C 78645 TC 222.22 211.11 242.7878645 26 26.78 25.44 29.2678647 326.66 310.33 356.8878647 TC 284.78 270.54 311.1278647 26 41.88 39.79 45.7678650 314.86 299.12 343.9978650 TC 286.04 271.74 312.5078650 26 28.82 27.38 31.4978660 176.36 167.54 192.6778660 TC 150.01 142.51 163.8978660 26 26.36 25.04 28.8078700 167.99 159.59 183.53# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.232 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78700 TC 146.24 138.93 159.7778700 26 21.75 20.66 23.7678701 203.28 193.12 222.0978701 TC 179.85 170.86 196.4978701 26 23.43 22.26 25.6078707 224.04 212.84 244.7778707 TC 179.22 170.26 195.8078707 26 44.81 42.57 48.9678708 165.05 156.80 180.3278708 TC 108.54 103.11 118.5878708 26 56.51 53.68 61.7378709 351.35 333.78 383.8578709 TC 285.10 270.85 311.4878709 26 66.25 62.94 72.3878710 202.05 191.95 220.7478710 TC 172.63 164.00 188.6078710 26 29.43 27.96 32.1578725 99.21 94.25 108.3978725 TC 81.83 77.74 89.4078725 26 17.38 16.51 18.9978730 72.44 68.82 79.1478730 TC 64.77 61.53 70.7678730 26 7.67 7.29 8.3878740 218.57 207.64 238.7978740 TC 190.85 181.31 208.5178740 26 27.72 26.33 30.2878761 202.65 192.52 221.4078761 TC 168.54 160.11 184.1378761 26 34.10 32.40 37.2678800 180.21 171.20 196.8878800 TC 148.44 141.02 162.1778800 26 31.77 30.18 34.7178801 234.59 222.86 256.2978801 TC 197.13 187.27 215.3678801 26 37.46 35.59 40.9378802 309.23 293.77 337.8478802 TC 269.08 255.63 293.9778802 26 40.15 38.14 43.8678803 329.67 313.19 360.17# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.233 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE78803 TC 279.44 265.47 305.2978803 26 50.23 47.72 54.8878804 548.07 520.67 598.7778804 TC 498.20 473.29 544.2878804 26 49.86 47.37 54.4878805 174.42 165.70 190.5678805 TC 139.95 132.95 152.8978805 26 34.47 32.75 37.6678806 319.60 303.62 349.1678806 TC 279.44 265.47 305.2978806 26 40.15 38.14 43.8678807 330.57 314.04 361.1578807 TC 280.70 266.67 306.6778807 26 49.87 47.38 54.4978808 40.21 38.20 43.93C 78811 1,033.56 981.88 1,129.16C 78811 TC 957.00 909.15 1,045.5278811 26 76.56 72.73 83.64C 78812 1,050.19 997.68 1,147.33C 78812 TC 957.00 909.15 1,045.5278812 26 93.19 88.53 101.81C 78813 1,054.56 1,001.83 1,152.10C 78813 TC 957.00 909.15 1,045.5278813 26 97.56 92.68 106.58C 78814 1,063.98 1,010.78 1,162.40C 78814 TC 957.00 909.15 1,045.5278814 26 106.98 101.63 116.87C 78815 1,075.39 1,021.62 1,174.86C 78815 TC 957.00 909.15 1,045.5278815 26 118.39 112.47 129.34C 78816 1,076.49 1,022.67 1,176.07C 78816 TC 957.00 909.15 1,045.5278816 26 119.49 113.52 130.5579005 131.72 125.13 143.9079005 TC 47.49 45.12 51.8979005 26 84.24 80.03 92.0379101 148.79 141.35 162.5579101 TC 51.26 48.70 56.0179101 26 97.54 92.66 106.56# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.234 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE79200 157.55 149.67 172.1279200 TC 61.63 58.55 67.3379200 26 95.93 91.13 104.8079300 261.32 248.25 285.4979300 TC 169.11 160.65 184.7579300 26 82.49 78.37 90.1379403 184.73 175.49 201.8179403 TC 78.69 74.76 85.9779403 26 106.03 100.73 115.8479440 150.03 142.53 163.9179440 TC 52.83 50.19 57.7279440 26 97.20 92.34 106.1979445 148.82 141.38 162.5979445 TC 48.74 46.30 53.2579445 26 114.73 108.99 125.3480500 19.34 18.37 21.13# 80500 17.46 16.59 19.0880502 61.95 58.85 67.68# 80502 60.38 57.36 65.9683020 26 19.03 18.08 20.7983912 26 18.08 17.18 19.7684165 26 18.71 17.77 20.4484166 26 18.71 17.77 20.4484181 26 18.71 17.77 20.4484182 26 17.77 16.88 19.4185060 22.69 21.56 24.7985097 79.68 75.70 87.06# 85097 45.44 43.17 49.6585390 26 19.03 18.08 20.7985396 18.71 17.77 20.4485576 26 19.03 18.08 20.7986077 49.84 47.35 54.45# 86077 46.70 44.37 51.0386078 50.15 47.64 54.79# 86078 47.01 44.66 51.3686079 50.15 47.64 54.79# 86079 47.01 44.66 51.3686255 26 19.03 18.08 20.7986256 26 17.98 17.08 19.64# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.235 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE86320 26 17.98 17.08 19.6486325 26 17.98 17.08 19.6486327 26 21.36 20.29 23.3386334 26 18.71 17.77 20.4486335 26 18.71 17.77 20.4486485 11.56 10.98 12.6386486 5.08 4.83 5.5586490 6.02 5.72 6.5886510 6.02 5.72 6.5886580 7.28 6.92 7.9687164 26 18.71 17.77 20.4487207 26 19.03 18.08 20.7988104 64.09 60.89 70.0288104 TC 37.44 35.57 40.9188104 26 26.65 25.32 29.1288106 68.30 64.89 74.6288106 TC 50.00 47.50 54.6388106 26 18.30 17.39 20.0088108 66.60 63.27 72.7688108 TC 45.60 43.32 49.8288108 26 21.00 19.95 22.9488112 97.91 93.01 106.9688112 TC 42.78 40.64 46.7488112 26 55.13 52.37 60.2388120 440.45 418.43 481.1988120 TC 389.40 369.93 425.4288120 26 51.05 48.50 55.7888121 379.51 360.53 414.6188121 TC 334.32 317.60 365.2488121 26 45.18 42.92 49.3688125 21.20 20.14 23.1688125 TC 8.53 8.10 9.3288125 26 12.67 12.04 13.8588141 28.27 26.86 30.8988160 52.93 50.28 57.8288160 TC 29.27 27.81 31.9888160 26 23.67 22.49 25.8688161 54.19 51.48 59.2088161 TC 30.84 29.30 33.70# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.236 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE88161 26 23.35 22.18 25.5188162 81.36 77.29 88.8888162 TC 44.35 42.13 48.4588162 26 37.01 35.16 40.4388172 50.60 48.07 55.2888172 TC 17.64 16.76 19.2788172 26 32.96 31.31 36.0188173 132.07 125.47 144.2988173 TC 65.71 62.42 71.7888173 26 66.36 63.04 72.5088177 26.65 25.32 29.1288177 TC 6.33 6.01 6.9188177 26 20.31 19.29 22.1888182 96.57 91.74 105.5088182 TC 62.98 59.83 68.8088182 26 33.58 31.90 36.6988184 76.39 72.57 83.4688185 46.23 43.92 50.5188187 65.54 62.26 71.6088188 82.21 78.10 89.8288189 101.01 95.96 110.3588291 28.53 27.10 31.1788300 26.38 25.06 28.8288300 TC 22.04 20.94 24.0888300 26 4.34 4.12 4.7488302 51.96 49.36 56.7688302 TC 45.60 43.32 49.8288302 26 6.36 6.04 6.9588304 57.85 54.96 63.2088304 TC 47.17 44.81 51.5388304 26 10.68 10.15 11.6788305 99.77 94.78 109.0088305 TC 64.45 61.23 70.4188305 26 35.32 33.55 38.5888307 220.88 209.84 241.3288307 TC 143.62 136.44 156.9188307 26 77.25 73.39 84.4088309 335.88 319.09 366.9588309 TC 199.96 189.96 218.45# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.237 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE88309 26 135.92 129.12 148.4988311 18.32 17.40 20.0188311 TC 6.65 6.32 7.2788311 26 11.67 11.09 12.7588312 87.91 83.51 96.0488312 TC 62.57 59.44 68.3688312 26 25.34 24.07 27.6888313 61.36 58.29 67.0388313 TC 50.00 47.50 54.6388313 26 11.36 10.79 12.4188314 75.11 71.35 82.0588314 TC 53.77 51.08 58.7488314 26 21.34 20.27 23.3188319 92.07 87.47 100.5988319 TC 66.34 63.02 72.4788319 26 25.73 24.44 28.1188321 87.71 83.32 95.82# 88321 79.23 75.27 86.5688323 131.65 125.07 143.8388323 TC 51.57 48.99 56.3488323 26 80.08 76.08 87.49# 88325 122.13 116.02 133.4288325 188.74 179.30 206.2088329 50.96 48.41 55.67# 88329 33.69 32.01 36.8188331 88.67 84.24 96.8888331 TC 31.15 29.59 34.0388331 26 57.52 54.64 62.8488332 39.35 37.38 42.9988332 TC 10.73 10.19 11.7288332 26 28.61 27.18 31.2688333 92.93 88.28 101.5288333 TC 34.29 32.58 37.4788333 26 58.64 55.71 64.0788334 57.72 54.83 63.0588334 TC 21.73 20.64 23.7488334 26 35.99 34.19 39.3288342 99.82 94.83 109.0588342 TC 59.74 56.75 65.26# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.238 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE88342 26 40.08 38.08 43.7988346 97.86 92.97 106.9288346 TC 57.54 54.66 62.8688346 26 40.32 38.30 44.0588347 70.53 67.00 77.0588347 TC 34.29 32.58 37.4788347 26 36.23 34.42 39.5888348 653.62 620.94 714.0888348 TC 582.86 553.72 636.7888348 26 70.76 67.22 77.3088349 364.89 346.65 398.6588349 TC 327.25 310.89 357.5288349 26 37.64 35.76 41.1288355 184.22 175.01 201.2688355 TC 103.41 98.24 112.9888355 26 80.81 76.77 88.2988356 260.46 247.44 284.5688356 TC 134.66 127.93 147.1288356 26 125.80 119.51 137.4488358 72.43 68.81 79.1388358 TC 31.15 29.59 34.0388358 26 41.28 39.22 45.1088360 114.30 108.59 124.8888360 TC 64.14 60.93 70.0788360 26 50.16 47.65 54.8088361 143.15 135.99 156.3988361 TC 88.33 83.91 96.5088361 26 54.81 52.07 59.8888362 285.36 271.09 311.7588362 TC 180.22 171.21 196.8988362 26 105.15 99.89 114.8788363 33.79 32.10 36.92# 88363 15.57 14.79 17.0188365 156.34 148.52 170.8088365 TC 100.90 95.86 110.2488365 26 55.45 52.68 60.5888367 247.50 235.13 270.4088367 TC 188.24 178.83 205.6588367 26 59.26 56.30 64.75# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.239 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE88368 208.13 197.72 227.3888368 TC 147.71 140.32 161.3788368 26 60.42 57.40 66.0188371 26 18.40 17.48 20.1088372 26 16.20 15.39 17.7088380 172.73 164.09 188.7088380 TC 99.64 94.66 108.8688380 26 73.09 69.44 79.8688381 152.21 144.60 166.2988381 TC 102.15 97.04 111.6088381 26 50.05 47.55 54.6888385 512.29 486.68 559.6888385 TC 450.66 428.13 492.3588385 26 61.62 58.54 67.3288386 580.56 551.53 634.2688386 TC 498.42 473.50 544.5388386 26 82.15 78.04 89.7588387 33.77 32.08 36.8988387 TC 6.02 5.72 6.5888387 26 27.75 26.36 30.3188388 29.55 28.07 32.2888388 TC 7.59 7.21 8.2988388 26 21.96 20.86 23.9989049 248.27 235.86 271.24# 89049 64.17 60.96 70.1089060 26 18.71 17.77 20.4489220 15.13 14.37 16.5389230 2.56 2.43 2.7990460 23.12 21.96 25.2590461 12.07 11.47 13.1990471 22.80 21.66 24.9190472 11.44 10.87 12.5090473 20.92 19.87 22.8590474 11.12 10.56 12.1490801 148.63 141.20 162.38# 90801 118.47 112.55 129.4390802 161.80 153.71 176.77# 90802 127.55 121.17 139.3590804 63.24 60.08 69.09# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.240 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 90804 51.04 48.49 55.7690805 73.64 69.96 80.45# 90805 59.78 56.79 65.3190806 84.99 80.74 92.85# 90806 78.06 74.16 85.2890807 102.30 97.19 111.77# 90807 88.44 84.02 96.6290808 124.32 118.10 135.82# 90808 117.39 111.52 128.2590809 143.00 135.85 156.23# 90809 130.47 123.95 142.5490810 65.25 61.99 71.29# 90810 56.34 53.52 61.5590811 83.61 79.43 91.34# 90811 65.79 62.50 71.8890812 92.87 88.23 101.46# 90812 82.98 78.83 90.6590813 110.85 105.31 121.11# 90813 93.37 88.70 102.0190814 133.25 126.59 145.58# 90814 121.71 115.62 132.9690815 152.97 145.32 167.12# 90815 135.83 129.04 148.4090816 54.12 51.41 59.12# 90816 55.77 52.98 60.9390817 64.84 61.60 70.84# 90817 65.50 62.23 71.5690818 80.12 76.11 87.53# 90818 82.76 78.62 90.4190819 92.82 88.18 101.41# 90819 93.81 89.12 102.4990821 118.49 112.57 129.46# 90821 122.45 116.33 133.7890822 133.21 126.55 145.53# 90822 135.20 128.44 147.7190823 59.70 56.72 65.23# 90823 61.02 57.97 66.6790824 70.19 66.68 76.68# 90824 71.18 67.62 77.76# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.241 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE90826 85.07 80.82 92.94# 90826 87.71 83.32 95.8290827 96.75 91.91 105.70# 90827 98.07 93.17 107.1590828 122.42 116.30 133.75# 90828 126.38 120.06 138.0790829 137.81 130.92 150.56# 90829 139.79 132.80 152.7290845 76.98 73.13 84.10# 90845 74.78 71.04 81.7090846 80.86 76.82 88.34# 90846 77.72 73.83 84.9090847 100.44 95.42 109.73# 90847 92.59 87.96 101.1590849 31.54 29.96 34.45# 90849 27.46 26.09 30.0090853 30.60 29.07 33.43# 90853 28.09 26.69 30.6990857 35.10 33.35 38.35# 90857 29.45 27.98 32.1890862 56.73 53.89 61.97# 90862 43.53 41.35 47.5590865 154.71 146.97 169.02# 90865 122.66 116.53 134.0190867 356.81 338.97 389.82# 90867 170.20 161.69 185.9490868 168.81 160.37 184.43# 90868 23.35 22.18 25.5190869 437.03 415.18 477.46# 90869 115.33 109.56 125.9990870 162.61 154.48 177.65# 90870 105.43 100.16 115.1890880 95.36 90.59 104.18# 90880 89.39 84.92 97.6690901 37.25 35.39 40.70# 90901 19.97 18.97 21.8290911 81.54 77.46 89.08# 90911 43.84 41.65 47.9090935 71.51 67.93 78.12# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.242 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE90937 101.90 96.81 111.3390945 81.46 77.39 89.0090947 120.76 114.72 131.9390951 912.70 867.07 997.1390954 779.31 740.34 851.3990955 439.86 417.87 480.5590956 303.80 288.61 331.9090957 622.31 591.19 679.8790958 421.35 400.28 460.3290959 282.68 268.55 308.8390960 275.56 261.78 301.0590961 229.23 217.77 250.4490962 174.19 165.48 190.3090963 527.67 501.29 576.4890964 454.12 431.41 496.1290965 432.69 411.06 472.7290966 228.29 216.88 249.4190967 17.62 16.74 19.2590968 14.66 13.93 16.0290969 14.32 13.60 15.6490970 7.64 7.26 8.3590997 86.69 82.36 94.7191010 176.54 167.71 192.8791010 TC 109.69 104.21 119.8491010 26 66.85 63.51 73.0491013 22.88 21.74 25.0091013 TC 13.56 12.88 14.8191013 26 9.32 8.85 10.1891020 230.69 219.16 252.0391020 TC 155.56 147.78 169.9591020 26 75.12 71.36 82.0691022 172.47 163.85 188.4391022 TC 97.13 92.27 106.1191022 26 75.34 71.57 82.3191030 135.53 128.75 148.0691030 TC 87.70 83.32 95.8291030 26 47.82 45.43 52.2491034 187.21 177.85 204.5391034 TC 137.03 130.18 149.71# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.243 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE91034 26 50.18 47.67 54.8291035 469.22 445.76 512.6291035 TC 386.79 367.45 422.5791035 26 82.43 78.31 90.0691037 158.14 150.23 172.7691037 TC 106.55 101.22 116.4091037 26 51.59 49.01 56.3691038 373.27 354.61 407.8091038 TC 315.79 300.00 345.0091038 26 57.48 54.61 62.8091040 298.06 283.16 325.6391040 TC 251.07 238.52 274.3091040 26 46.99 44.64 51.3491065 82.94 78.79 90.6191065 TC 72.62 68.99 79.3491065 26 10.31 9.79 11.2691110 878.11 834.20 959.3391110 TC 687.45 653.08 751.0491110 26 190.67 181.14 208.3191111 709.75 674.26 775.4091111 TC 657.29 624.43 718.0991111 26 52.46 49.84 57.3291117 138.37 131.45 151.17# 91117 147.80 140.41 161.4791120 379.99 360.99 415.1491120 TC 330.55 314.02 361.1291120 26 49.44 46.97 54.0291122 214.42 203.70 234.2691122 TC 127.29 120.93 139.0791122 26 87.13 82.77 95.1991132 26 27.59 26.21 30.1491132 149.22 141.76 163.0291132 TC 121.63 115.55 132.8891133 173.51 164.83 189.5591133 TC 138.28 131.37 151.0891133 26 35.23 33.47 38.4992002 75.23 71.47 82.19# 92002 46.32 44.00 50.6092004 138.89 131.95 151.74# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.244 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 92004 95.85 91.06 104.7292012 79.10 75.15 86.42# 92012 50.20 47.69 54.8492014 114.81 109.07 125.43# 92014 76.48 72.66 83.5692018 136.16 129.35 148.7592019 65.67 62.39 71.7592020 25.62 24.34 27.99# 92020 20.28 19.27 22.1692025 34.63 32.90 37.8492025 TC 16.07 15.27 17.5692025 26 18.56 17.63 20.2792060 59.81 56.82 65.3492060 TC 23.30 22.14 25.4692060 26 36.52 34.69 39.8992065 48.82 46.38 53.3492065 TC 31.47 29.90 34.3992065 26 17.36 16.49 18.9692071 36.31 34.49 39.66# 92071 32.54 30.91 35.5592072 115.98 110.18 126.71# 92072 93.99 89.29 102.6892081 46.23 43.92 50.5192081 TC 29.90 28.41 32.6792081 26 16.33 15.51 17.8492082 65.70 62.42 71.7892082 TC 44.03 41.83 48.1092082 26 21.67 20.59 23.6892083 84.14 79.93 91.9292083 TC 57.23 54.37 62.5392083 26 26.91 25.56 29.3992100 90.00 85.50 98.33# 92100 48.21 45.80 52.6792132 35.36 33.59 38.6392132 TC 15.44 14.67 16.8792132 26 19.92 18.92 21.7692133 42.98 40.83 46.9592133 TC 15.13 14.37 16.5392133 26 27.85 26.46 30.43# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.245 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE92134 42.98 40.83 46.9592134 TC 15.13 14.37 16.5392134 26 27.85 26.46 30.4392136 81.94 77.84 89.5292136 TC 52.83 50.19 57.7292136 26 29.11 27.65 31.8092140 58.01 55.11 63.38# 92140 25.65 24.37 28.0392225 25.34 24.07 27.68# 92225 20.62 19.59 22.5392226 22.59 21.46 24.68# 92226 17.88 16.99 19.5492227 11.36 10.79 12.4192228 32.80 31.16 35.8392228 TC 12.62 11.99 13.7992228 26 20.18 19.17 22.0592230 54.87 52.13 59.95# 92230 31.62 30.04 34.5592235 128.93 122.48 140.8592235 TC 84.56 80.33 92.3892235 26 44.37 42.15 48.47C 92240 190.95 181.40 208.61C 92240 TC 131.06 124.51 143.1992240 26 59.90 56.91 65.45C 92250 64.09 60.89 70.02C 92250 TC 41.52 39.44 45.3692250 26 22.57 21.44 24.6692260 17.54 16.66 19.16# 92260 10.63 10.10 11.6292265 77.94 74.04 85.1592265 TC 34.92 33.17 38.1592265 26 43.01 40.86 46.9992270 87.15 82.79 95.2192270 TC 47.17 44.81 51.5392270 26 39.97 37.97 43.6792275 142.70 135.57 155.9192275 TC 87.70 83.32 95.8292275 26 55.00 52.25 60.0992283 48.93 46.48 53.45# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.246 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE92283 TC 40.26 38.25 43.9992283 26 8.66 8.23 9.4692284 56.96 54.11 62.2392284 TC 45.29 43.03 49.4892284 26 11.67 11.09 12.7592285 22.85 21.71 24.9792285 TC 19.21 18.25 20.9992285 26 3.64 3.46 3.98C 92286 102.68 97.55 112.18C 92286 TC 68.54 65.11 74.8892286 26 34.14 32.43 37.2992287 114.79 109.05 125.41# 92287 44.42 42.20 48.5392311 95.28 90.52 104.10# 92311 55.07 52.32 60.1792312 108.48 103.06 118.52# 92312 62.30 59.19 68.0792313 94.71 89.97 103.47# 92313 48.84 46.40 53.3692315 71.12 67.56 77.69# 92315 23.06 21.91 25.2092316 95.92 91.12 104.79# 92316 37.48 35.61 40.9592317 69.09 65.64 75.49# 92317 20.71 19.67 22.6292325 34.61 32.88 37.8192326 33.04 31.39 36.1092502 94.16 89.45 102.8792504 29.11 27.65 31.80# 92504 9.32 8.85 10.1892506 155.19 147.43 169.5492507 72.87 69.23 79.6192508 21.65 20.57 23.6692511 135.27 128.51 147.79# 92511 47.62 45.24 52.0392512 58.77 55.83 64.20# 92512 27.67 26.29 30.2392516 67.25 63.89 73.47# 92516 22.64 21.51 24.74# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.247 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE92520 67.20 63.84 73.42# 92520 39.55 37.57 43.2192526 80.52 76.49 87.9692540 96.54 91.71 105.4792540 TC 20.47 19.45 22.3792540 26 76.07 72.27 83.1192541 35.71 33.92 39.0192541 TC 16.07 15.27 17.5692541 26 19.63 18.65 21.4592542 34.27 32.56 37.4492542 TC 17.64 16.76 19.2792542 26 16.62 15.79 18.1692543 18.27 17.36 19.9692543 TC 12.93 12.28 14.1292543 26 5.34 5.07 5.8392544 28.43 27.01 31.0692544 TC 15.44 14.67 16.8792544 26 12.98 12.33 14.1892545 26.46 25.14 28.9192545 TC 14.82 14.08 16.1992545 26 11.65 11.07 12.7392546 94.48 89.76 103.2292546 TC 80.16 76.15 87.5792546 26 14.32 13.60 15.6492547 5.39 5.12 5.8992548 98.80 93.86 107.9492548 TC 74.19 70.48 81.0592548 26 24.61 23.38 26.8992550 20.13 19.12 21.9992552 27.38 26.01 29.9192553 33.35 31.68 36.4392555 20.16 19.15 22.0292556 31.47 29.90 34.3992557 37.85 35.96 41.35# 92557 33.45 31.78 36.5592561 33.35 31.68 36.4392562 35.86 34.07 39.1892563 27.38 26.01 29.9192564 23.61 22.43 25.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.248 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE92565 14.50 13.78 15.8592567 14.40 13.68 15.73# 92567 11.26 10.70 12.3192568 15.58 14.80 17.0292570 31.12 29.56 33.99# 92570 28.92 27.47 31.5992571 22.67 21.54 24.7792572 29.27 27.81 31.9892575 60.37 57.35 65.9592576 31.47 29.90 34.3992577 16.39 15.57 17.9192579 41.57 39.49 45.41# 92579 37.17 35.31 40.6192582 58.80 55.86 64.2492583 43.09 40.94 47.0892584 65.71 62.42 71.7892585 116.08 110.28 126.8292585 TC 91.16 86.60 99.5992585 26 24.92 23.67 27.2292586 74.19 70.48 81.0592587 27.19 25.83 29.7092587 TC 9.47 9.00 10.3592587 26 17.72 16.83 19.3592588 41.18 39.12 44.9992588 TC 13.56 12.88 14.8192588 26 27.62 26.24 30.1892596 39.95 37.95 43.6492597 80.31 76.29 87.7392601 139.47 132.50 152.38# 92601 121.87 115.78 133.1592602 88.27 83.86 96.44# 92602 70.04 66.54 76.5292603 140.91 133.86 153.94# 92603 119.86 113.87 130.9592604 83.95 79.75 91.71# 92604 66.36 63.04 72.5092607 136.98 130.13 149.6592608 44.45 42.23 48.5692609 97.59 92.71 106.62# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.249 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE92610 86.38 82.06 94.37# 92610 65.65 62.37 71.7392611 94.70 89.97 103.4792612 160.45 152.43 175.29# 92612 65.88 62.59 71.9892613 36.93 35.08 40.3492614 144.11 136.90 157.44# 92614 66.51 63.18 72.6692615 32.90 31.26 35.9592616 193.92 184.22 211.85# 92616 97.16 92.30 106.1592617 40.60 38.57 44.3692620 85.65 81.37 93.58# 92620 77.79 73.90 84.9992621 20.45 19.43 22.34# 92621 17.62 16.74 19.2592625 64.84 61.60 70.84# 92625 59.18 56.22 64.6592626 85.07 80.82 92.94# 92626 74.70 70.97 81.6292627 21.02 19.97 22.97# 92627 17.57 16.69 19.1992640 111.07 105.52 121.35# 92640 97.87 92.98 106.9392950 286.34 272.02 312.82# 92950 181.41 172.34 198.1992953 10.71 10.17 11.7092960 207.97 197.57 227.21# 92960 120.64 114.61 131.8092961 241.36 229.29 263.6892970 173.44 164.77 189.4992971 92.84 88.20 101.4392973 181.46 172.39 198.2592974 165.98 157.68 181.3392975 401.31 381.24 438.4392977 112.94 107.29 123.3892978 280.13 266.12 306.0492978 TC 179.98 170.98 196.6392978 26 89.82 85.33 98.13# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.250 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE92979 171.69 163.11 187.5892979 TC 91.13 86.57 99.5692979 26 72.13 68.52 78.8092980 828.11 786.70 904.7192981 230.27 218.76 251.5792982 613.59 582.91 670.3592984 164.28 156.07 179.4892986 1,364.55 1,296.32 1,490.7792987 1,406.35 1,336.03 1,536.4392990 1,099.12 1,044.16 1,200.7892992 1,310.79 1,245.25 1,432.0492993 1,310.79 1,245.25 1,432.0492995 675.55 641.77 738.0492996 180.47 171.45 197.1792997 660.14 627.13 721.2092998 329.46 312.99 359.9493000 18.14 17.23 19.8193005 9.79 9.30 10.7093010 8.35 7.93 9.1293015 83.80 79.61 91.5593016 21.65 20.57 23.6693017 47.49 45.12 51.8993018 14.66 13.93 16.0293024 108.88 103.44 118.9693024 TC 52.20 49.59 57.0393024 26 56.67 53.84 61.9293025 168.99 160.54 184.6293025 TC 132.31 125.69 144.5493025 26 36.67 34.84 40.0793040 12.43 11.81 13.5893041 5.39 5.12 5.8993042 7.04 6.69 7.6993224 92.93 88.28 101.5293225 27.07 25.72 29.5893226 39.95 37.95 43.6493227 25.92 24.62 28.3193228 25.07 23.82 27.3993229 640.64 608.61 699.9093268 221.43 210.36 241.91# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.251 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE93270 11.36 10.79 12.4193271 185.72 176.43 202.8993272 24.35 23.13 26.6093278 31.23 29.67 34.1293278 TC 18.90 17.96 20.6593278 26 12.33 11.71 13.4793279 48.71 46.27 53.2193279 TC 16.70 15.87 18.2593279 26 32.01 30.41 34.9793280 56.88 54.04 62.1593280 TC 18.90 17.96 20.6593280 26 37.98 36.08 41.4993281 65.71 62.42 71.7893281 TC 21.73 20.64 23.7493281 26 43.98 41.78 48.0593282 60.86 57.82 66.4993282 TC 19.53 18.55 21.3393282 26 41.33 39.26 45.1593283 78.35 74.43 85.5993283 TC 22.36 21.24 24.4393283 26 55.99 53.19 61.1793284 86.78 82.44 94.8193284 TC 25.50 24.23 27.8693284 26 61.28 58.22 66.9593285 40.42 38.40 44.1693285 TC 15.13 14.37 16.5393285 26 25.29 24.03 27.6393286 24.76 23.52 27.0593286 TC 10.73 10.19 11.7293286 26 14.03 13.33 15.3393287 33.01 31.36 36.0693287 TC 11.99 11.39 13.1093287 26 21.02 19.97 22.9793288 36.41 34.59 39.7893288 TC 15.44 14.67 16.8793288 26 20.97 19.92 22.9193289 63.24 60.08 69.0993289 TC 18.90 17.96 20.6593289 26 44.34 42.12 48.44# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.252 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE93290 28.87 27.43 31.5493290 TC 8.85 8.41 9.6793290 26 20.03 19.03 21.8893291 34.84 33.10 38.0793291 TC 13.87 13.18 15.1693291 26 20.97 19.92 22.9193292 31.39 29.82 34.2993292 TC 10.42 9.90 11.3993292 26 20.97 19.92 22.9193293 51.20 48.64 55.9493293 TC 36.18 34.37 39.5393293 26 15.03 14.28 16.4293294 32.38 30.76 35.3793295 64.10 60.90 70.0493296 27.38 26.01 29.9193297 24.76 23.52 27.0593298 26.02 24.72 28.4393299 129.59 123.11 141.5893303 195.61 185.83 213.7093303 TC 132.63 126.00 144.9093303 26 62.98 59.83 68.8093304 126.57 120.24 138.2893304 TC 90.53 86.00 98.9093304 26 36.04 34.24 39.3893306 200.32 190.30 218.8593306 TC 137.03 130.18 149.7193306 26 63.30 60.14 69.1693307 124.82 118.58 136.3793307 TC 79.85 75.86 87.2493307 26 44.97 42.72 49.1393308 95.42 90.65 104.2593308 TC 70.11 66.60 76.5993308 26 25.32 24.05 27.6693312 297.50 282.63 325.0293312 TC 193.36 183.69 211.2493312 26 104.13 98.92 113.7693313 41.48 39.41 45.3293314 268.15 254.74 292.9593314 TC 208.76 198.32 228.07# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.253 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE93314 26 59.40 56.43 64.8993315 303.59 288.41 331.6793315 TC 147.37 140.00 161.0093315 26 138.49 131.57 151.3193316 43.37 41.20 47.3893317 258.02 245.12 281.8993317 TC 193.45 183.78 211.3593317 26 91.39 86.82 99.8493318 450.48 427.96 492.1593318 TC 280.50 266.48 306.4593318 26 110.67 105.14 120.9193320 51.05 48.50 55.7893320 TC 32.72 31.08 35.7493320 26 18.32 17.40 20.0193321 25.31 24.04 27.6593321 TC 17.96 17.06 19.6293321 26 7.35 6.98 8.0393325 26.36 25.04 28.8093325 TC 22.67 21.54 24.7793325 26 3.69 3.51 4.0493350 195.77 185.98 213.8893350 TC 124.46 118.24 135.9893350 26 71.31 67.74 77.9093351 228.99 217.54 250.1793351 TC 143.41 136.24 156.6893351 26 85.58 81.30 93.5093352 32.91 31.26 35.9593451 750.39 712.87 819.8093451 TC 604.92 574.67 660.8793451 26 145.47 138.20 158.9393452 832.50 790.88 909.5193452 TC 577.59 548.71 631.0293452 26 254.91 242.16 278.4893453 1,089.96 1,035.46 1,190.7893453 TC 756.08 718.28 826.0293453 26 333.87 317.18 364.7693454 857.74 814.85 937.0893454 TC 601.15 571.09 656.7593454 26 256.59 243.76 280.32# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.254 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE93455 1,001.25 951.19 1,093.8793455 TC 704.88 669.64 770.0993455 26 296.37 281.55 323.7893456 1,073.50 1,019.83 1,172.8093456 TC 745.09 707.84 814.0293456 26 328.41 311.99 358.7993457 1,216.72 1,155.88 1,329.2693457 TC 848.45 806.03 926.9393457 26 368.27 349.86 402.3493458 1,035.44 983.67 1,131.2293458 TC 722.15 686.04 788.9593458 26 313.29 297.63 342.2793459 1,143.67 1,086.49 1,249.4693459 TC 790.96 751.41 864.1293459 26 352.71 335.07 385.3393460 1,223.71 1,162.52 1,336.9093460 TC 831.17 789.61 908.0593460 26 392.54 372.91 428.8593461 1,402.56 1,332.43 1,532.2993461 TC 969.14 920.68 1,058.7893461 26 433.42 411.75 473.5193462 199.74 189.75 218.2193463 105.51 100.23 115.2693464 252.81 240.17 276.2093464 TC 159.96 151.96 174.7593464 26 92.85 88.21 101.4493503 132.75 126.11 145.0393505 762.19 724.08 832.6993505 TC 525.12 498.86 573.6993505 26 237.07 225.22 259.0093530 930.77 884.23 1,016.8693530 TC 677.06 643.21 739.6993530 26 232.67 221.04 254.2093531 2,429.88 2,308.39 2,654.6593531 TC 1,936.91 1,840.06 2,116.0793531 26 458.17 435.26 500.5593532 3,037.34 2,885.47 3,318.2993532 TC 2,421.15 2,300.09 2,645.1093532 26 547.54 520.16 598.18# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.255 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE93533 2,429.88 2,308.39 2,654.6593533 TC 1,936.91 1,840.06 2,116.0793533 26 367.28 348.92 401.2693561 49.11 46.65 53.6593561 TC 22.43 21.31 24.5193561 26 24.44 23.22 26.7093562 22.69 21.56 24.7993562 TC 13.99 13.29 15.2893562 26 7.38 7.01 8.0693563 54.30 51.59 59.3393564 55.66 52.88 60.8193565 42.24 40.13 46.1593566 168.53 160.10 184.12# 93566 41.92 39.82 45.7993567 136.77 129.93 149.42# 93567 47.24 44.88 51.6193568 152.88 145.24 167.03# 93568 43.23 41.07 47.2393571 279.04 265.09 304.8593571 TC 179.98 170.98 196.6393571 26 89.46 84.99 97.7493572 26 71.87 68.28 78.5293580 1,005.31 955.04 1,098.3093581 1,346.09 1,278.79 1,470.6193600 201.88 191.79 220.5693600 TC 78.81 74.87 86.1093600 26 116.49 110.67 127.2793602 167.72 159.33 183.2393602 TC 44.41 42.19 48.5293602 26 116.49 110.67 127.2793603 191.00 181.45 208.6793603 TC 67.46 64.09 73.7093603 26 116.49 110.67 127.2793609 397.41 377.54 434.1793609 TC 109.11 103.65 119.2093609 26 276.11 262.30 301.6593610 230.13 218.62 251.4193610 TC 54.89 52.15 59.9793610 26 166.03 157.73 181.39# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.256 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE93612 240.74 228.70 263.0193612 TC 64.92 61.67 70.9293612 26 165.40 157.13 180.7093613 386.85 367.51 422.6493615 63.32 60.15 69.1793615 TC 12.80 12.16 13.9893615 26 48.40 45.98 52.8893616 403.93 383.73 441.2993616 TC 158.22 150.31 172.8693616 26 66.03 62.73 72.1493618 403.93 383.73 441.2993618 TC 158.22 150.31 172.8693618 26 234.95 223.20 256.6893619 741.64 704.56 810.2493619 TC 307.88 292.49 336.3693619 26 405.95 385.65 443.5093620 815.81 775.02 891.2793620 TC 338.67 321.74 370.0093620 26 641.02 608.97 700.3293621 354.32 336.60 387.0993621 TC 229.40 217.93 250.6293621 26 115.81 110.02 126.5293622 504.42 479.20 551.0893622 TC 336.28 319.47 367.3993622 26 171.05 162.50 186.8893623 397.59 377.71 434.3793623 TC 232.60 220.97 254.1293623 26 157.94 150.04 172.5593624 368.24 349.83 402.3093624 TC 79.89 75.90 87.2993624 26 266.30 252.99 290.9493631 1,931.57 1,834.99 2,110.2493631 TC 1,515.25 1,439.49 1,655.4193631 26 411.23 390.67 449.2793640 487.44 463.07 532.5393640 TC 285.69 271.41 312.1293640 26 193.94 184.24 211.8893641 627.23 595.87 685.2593641 TC 285.69 271.41 312.12# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.257 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE93641 26 327.61 311.23 357.9193642 384.86 365.62 420.4693642 TC 145.92 138.62 159.4193642 26 238.94 226.99 261.0493650 589.19 559.73 643.6993651 898.01 853.11 981.0893652 977.42 928.55 1,067.8393660 151.12 143.56 165.0993660 TC 58.80 55.86 64.2493660 26 92.33 87.71 100.8793662 365.33 347.06 399.1293662 TC 217.88 206.99 238.0493662 26 139.97 132.97 152.9293701 23.93 22.73 26.1493724 272.29 258.68 297.4893724 TC 34.29 32.58 37.4793724 26 238.00 226.10 260.0293745 92.19 87.58 100.7293745 TC 35.64 33.86 38.9493745 26 56.56 53.73 61.7993750 51.67 49.09 56.45# 93750 43.50 41.33 47.5393784 55.50 52.73 60.6493786 28.95 27.50 31.6393788 8.22 7.81 8.9893790 18.32 17.40 20.0193797 16.23 15.42 17.73# 93797 9.00 8.55 9.8393798 24.03 22.83 26.25# 93798 13.66 12.98 14.93C 93880 169.59 161.11 185.28C 93880 TC 140.48 133.46 153.4893880 26 29.10 27.65 31.80C 93882 160.32 152.30 175.15C 93882 TC 140.48 133.46 153.4893882 26 19.83 18.84 21.67C 93886 185.51 176.23 202.66C 93886 TC 140.12 133.11 153.0893886 26 45.39 43.12 49.59# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.258 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 93888 88.53 84.10 96.72C 93888 TC 58.12 55.21 63.4993888 26 30.41 28.89 33.22C 93890 136.97 130.12 149.64C 93890 TC 88.91 84.46 97.1393890 26 48.06 45.66 52.51C 93892 144.32 137.10 157.67C 93892 TC 88.91 84.46 97.1393892 26 55.41 52.64 60.54C 93893 144.64 137.41 158.02C 93893 TC 88.91 84.46 97.1393893 26 55.73 52.94 60.8893922 96.89 92.05 105.8693922 TC 85.19 80.93 93.0793922 26 11.70 11.12 12.7993923 150.34 142.82 164.2493923 TC 128.54 122.11 140.4393923 26 21.80 20.71 23.8293924 189.12 179.66 206.6193924 TC 164.67 156.44 179.9193924 26 24.44 23.22 26.70C 93925 168.33 159.91 183.90C 93925 TC 140.53 133.50 153.5393925 26 27.79 26.40 30.36C 93926 108.14 102.73 118.14C 93926 TC 88.96 84.51 97.1993926 26 19.18 18.22 20.95C 93930 162.94 154.79 178.01C 93930 TC 140.48 133.46 153.4893930 26 22.45 21.33 24.53C 93931 104.06 98.86 113.69C 93931 TC 88.96 84.51 97.1993931 26 15.10 14.35 16.5093965 118.61 112.68 129.5893965 TC 101.53 96.45 110.9293965 26 17.09 16.24 18.68C 93970 173.71 165.02 189.77C 93970 TC 140.48 133.46 153.4893970 26 33.23 31.57 36.31# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.259 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGEC 93971 110.76 105.22 121.00C 93971 TC 88.96 84.51 97.1993971 26 21.80 20.71 23.82C 93975 227.94 216.54 249.02C 93975 TC 140.53 133.50 153.5393975 26 87.41 83.04 95.50C 93976 198.72 188.78 217.10C 93976 TC 140.48 133.46 153.4893976 26 58.23 55.32 63.62C 93978 172.38 163.76 188.32C 93978 TC 140.48 133.46 153.4893978 26 31.90 30.31 34.86C 93979 110.42 104.90 120.64C 93979 TC 88.96 84.51 97.1993979 26 21.46 20.39 23.4593980 163.90 155.71 179.0793980 TC 103.41 98.24 112.9893980 26 60.49 57.47 66.0993981 109.74 104.25 119.8993981 TC 88.33 83.91 96.5093981 26 21.41 20.34 23.3993982 41.25 39.19 45.07C 93990 101.07 96.02 110.42C 93990 TC 88.60 84.17 96.8093990 26 12.48 11.86 13.6494002 90.52 85.99 98.8994003 64.72 61.48 70.7094004 47.27 44.91 51.6594010 33.85 32.16 36.9894010 TC 25.81 24.52 28.2094010 26 8.04 7.64 8.7994011 98.62 93.69 107.7494012 155.98 148.18 170.4194013 32.40 30.78 35.4094014 45.13 42.87 49.3094015 21.73 20.64 23.7494016 23.40 22.23 25.5694060 57.02 54.17 62.3094060 TC 44.66 42.43 48.79# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.260 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE94060 26 12.36 11.74 13.5094070 58.01 55.11 63.3894070 TC 29.90 28.41 32.6794070 26 28.11 26.70 30.7194200 23.64 22.46 25.8394200 TC 18.27 17.36 19.9694200 26 5.36 5.09 5.8594250 24.89 23.65 27.2094250 TC 19.53 18.55 21.3394250 26 5.36 5.09 5.8594375 37.04 35.19 40.4794375 TC 22.67 21.54 24.7794375 26 14.37 13.65 15.7094400 53.61 50.93 58.5794400 TC 35.24 33.48 38.5094400 26 18.38 17.46 20.0894450 60.21 57.20 65.7894450 TC 41.52 39.44 45.3694450 26 18.69 17.76 20.4294452 54.63 51.90 59.6994452 TC 40.58 38.55 44.3394452 26 14.06 13.36 15.3694453 74.35 70.63 81.2294453 TC 56.29 53.48 61.5094453 26 18.06 17.16 19.7394610 58.37 55.45 63.7794620 57.17 54.31 62.4694620 TC 27.38 26.01 29.9194620 26 29.79 28.30 32.5594621 155.13 147.37 169.4894621 TC 88.33 83.91 96.5094621 26 66.80 63.46 72.9894640 16.39 15.57 17.9194642 28.55 27.12 31.1994644 40.26 38.25 43.9994645 13.24 12.58 14.4794660 58.48 55.56 63.89# 94660 36.48 34.66 39.8694662 35.54 33.76 38.82# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.261 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE94664 15.76 14.97 17.2294667 22.36 21.24 24.4394668 22.04 20.94 24.0894680 55.76 52.97 60.9294680 TC 43.40 41.23 47.4194680 26 12.36 11.74 13.5094681 50.58 48.05 55.2694681 TC 41.21 39.15 45.0294681 26 9.37 8.90 10.2494690 48.35 45.93 52.8294690 TC 44.66 42.43 48.7994690 26 3.69 3.51 4.0494726 50.47 47.95 55.1494726 TC 38.43 36.51 41.9994726 26 12.04 11.44 13.1694727 39.74 37.75 43.4194727 TC 27.70 26.32 30.2794727 26 12.04 11.44 13.1694728 39.74 37.75 43.4194728 TC 27.70 26.32 30.2794728 26 12.04 11.44 13.1694729 49.87 47.38 54.4994729 TC 41.83 39.74 45.7094729 26 8.04 7.64 8.7994750 74.53 70.80 81.4294750 TC 63.83 60.64 69.7494750 26 10.71 10.17 11.7094760 2.88 2.74 3.1594761 4.45 4.23 4.8694762 14.19 13.48 15.5094770 14.99 14.24 16.3894780 48.22 45.81 52.68# 94780 23.08 21.93 25.2294781 18.72 17.78 20.45# 94781 8.04 7.64 8.7995004 6.05 5.75 6.6195010 11.65 11.07 12.73# 95010 5.36 5.09 5.8595012 18.90 17.96 20.65# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.262 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95015 6.80 6.46 7.43# 95015 3.03 2.88 3.3195024 7.30 6.94 7.98# 95024 1.02 0.97 1.1295027 4.79 4.55 5.2395028 12.62 11.99 13.7995044 5.70 5.42 6.2395052 6.33 6.01 6.9195056 40.58 38.55 44.3395060 29.58 28.10 32.3295065 23.30 22.14 25.4695070 31.78 30.19 34.7295071 62.88 59.74 68.7095075 60.81 57.77 66.44# 95075 45.42 43.15 49.6295115 9.16 8.70 10.0195117 11.05 10.50 12.0895144 11.83 11.24 12.93# 95144 3.03 2.88 3.3195145 19.06 18.11 20.83# 95145 3.03 2.88 3.3195146 33.51 31.83 36.60# 95146 3.03 2.88 3.3195147 31.00 29.45 33.87# 95147 3.03 2.88 3.3195148 45.45 43.18 49.66# 95148 3.03 2.88 3.3195149 60.84 57.80 66.47# 95149 3.03 2.88 3.3195165 12.15 11.54 13.27# 95165 3.35 3.18 3.6695170 9.00 8.55 9.83# 95170 3.03 2.88 3.3195180 130.97 124.42 143.08# 95180 99.55 94.57 108.7695250 145.82 138.53 159.3195251 41.07 39.02 44.8795800 151.60 144.02 165.6295800 TC 102.15 97.04 111.60# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.263 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95800 26 49.45 46.98 54.0395801 82.67 78.54 90.3295801 TC 35.55 33.77 38.8495801 26 47.12 44.76 51.4795803 155.29 147.53 169.6695803 TC 112.21 106.60 122.5995803 26 43.09 40.94 47.0895805 389.03 369.58 425.0295805 TC 331.02 314.47 361.6495805 26 58.01 55.11 63.3895806 173.32 164.65 189.3595806 TC 112.62 106.99 123.0495806 26 60.70 57.67 66.3295807 464.04 440.84 506.9795807 TC 403.26 383.10 440.5795807 26 60.78 57.74 66.4095808 625.26 594.00 683.1095808 TC 539.92 512.92 589.8695808 26 85.33 81.06 93.2295810 619.28 588.32 676.5795810 TC 500.07 475.07 546.3395810 26 119.21 113.25 130.2495811 660.17 627.16 721.2395811 TC 535.94 509.14 585.5195811 26 124.23 118.02 135.7295812 341.85 324.76 373.4795812 TC 288.87 274.43 315.5995812 26 52.98 50.33 57.8895813 397.48 377.61 434.2595813 TC 312.79 297.15 341.7295813 26 84.68 80.45 92.5295816 314.25 298.54 343.3295816 TC 260.91 247.86 285.0495816 26 53.35 50.68 58.2895819 356.30 338.49 389.2695819 TC 303.32 288.15 331.3795819 26 52.98 50.33 57.8895822 325.20 308.94 355.2895822 TC 272.22 258.61 297.40# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.264 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95822 26 52.98 50.33 57.8895824 26 37.06 35.21 40.4995827 623.01 591.86 680.6495827 TC 569.67 541.19 622.3795827 26 53.35 50.68 58.2895829 1,561.42 1,483.35 1,705.8595829 TC 1,259.12 1,196.16 1,375.5895829 26 302.31 287.19 330.2795830 190.82 181.28 208.47# 95830 84.95 80.70 92.8195831 26.96 25.61 29.45# 95831 14.39 13.67 15.7295832 25.41 24.14 27.76# 95832 15.05 14.30 16.4595833 35.53 33.75 38.81# 95833 21.07 20.02 23.0295834 46.33 44.01 50.61# 95834 29.05 27.60 31.7495851 17.12 16.26 18.70# 95851 7.38 7.01 8.0695852 15.10 14.35 16.50# 95852 5.68 5.40 6.2195857 48.08 45.68 52.53# 95857 27.66 26.28 30.2295860 91.31 86.74 99.7595860 TC 43.09 40.94 47.0895860 26 48.22 45.81 52.6895861 133.14 126.48 145.4595861 TC 56.29 53.48 61.5095861 26 76.86 73.02 83.9795863 161.13 153.07 176.0395863 TC 68.22 64.81 74.5395863 26 92.90 88.26 101.5095864 174.32 165.60 190.4495864 TC 75.45 71.68 82.4395864 26 98.87 93.93 108.0295865 119.03 113.08 130.0495865 TC 40.58 38.55 44.3395865 26 78.46 74.54 85.72# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.265 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95866 106.31 100.99 116.1495866 TC 44.35 42.13 48.4595866 26 61.96 58.86 67.6995867 86.78 82.44 94.8195867 TC 47.80 45.41 52.2295867 26 38.98 37.03 42.5895868 116.44 110.62 127.2195868 TC 58.48 55.56 63.8995868 26 57.96 55.06 63.3295869 63.90 60.71 69.8295869 TC 45.92 43.62 50.1695869 26 17.98 17.08 19.6495870 61.39 58.32 67.0795870 TC 43.09 40.94 47.0895870 26 18.30 17.39 20.0095872 179.05 170.10 195.6295872 TC 38.38 36.46 41.9395872 26 140.67 133.64 153.6995873 62.65 59.52 68.4595873 TC 43.40 41.23 47.4195873 26 19.24 18.28 21.0295874 59.50 56.53 65.0195874 TC 40.89 38.85 44.6895874 26 18.61 17.68 20.3395875 106.23 100.92 116.0695875 TC 51.89 49.30 56.7095875 26 54.34 51.62 59.3695885 TC 35.24 33.48 38.5095885 26 17.30 16.44 18.9195885 52.54 49.91 57.4095886 83.35 79.18 91.0695886 TC 37.12 35.26 40.5595886 26 46.23 43.92 50.5195887 74.01 70.31 80.8695887 TC 37.75 35.86 41.2495887 26 36.26 34.45 39.6295900 60.58 57.55 66.1895900 TC 39.63 37.65 43.3095900 26 20.94 19.89 22.87# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.266 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95903 71.20 67.64 77.7995903 TC 41.21 39.15 45.0295903 26 30.00 28.50 32.7895904 53.46 50.79 58.4195904 TC 36.49 34.67 39.8795904 26 16.96 16.11 18.5395905 62.44 59.32 68.2295905 TC 59.74 56.75 65.2695905 26 2.69 2.56 2.9495920 159.61 151.63 174.3795920 TC 55.34 52.57 60.4695920 26 104.26 99.05 113.9195921 80.16 76.15 87.5795921 TC 36.49 34.67 39.8795921 26 43.66 41.48 47.7095922 100.11 95.10 109.3795922 TC 53.46 50.79 58.4195922 26 46.65 44.32 50.9795923 148.38 140.96 162.1095923 TC 103.72 98.53 113.3195923 26 44.66 42.43 48.7995925 155.14 147.38 169.4995925 TC 128.86 122.42 140.7895925 26 26.28 24.97 28.7295926 150.53 143.00 164.4595926 TC 123.83 117.64 135.2995926 26 26.70 25.37 29.1895927 152.31 144.69 166.3995927 TC 126.03 119.73 137.6995927 26 26.28 24.97 28.7295928 239.74 227.75 261.9195928 TC 165.40 157.13 180.7095928 26 74.34 70.62 81.2195929 243.51 231.33 266.0395929 TC 169.17 160.71 184.8295929 26 74.34 70.62 81.2195930 140.51 133.48 153.5095930 TC 123.20 117.04 134.6095930 26 17.30 16.44 18.91# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.267 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95933 76.52 72.69 83.5995933 TC 47.17 44.81 51.5395933 26 29.34 27.87 32.0595934 58.30 55.39 63.7095934 TC 33.35 31.68 36.4395934 26 24.95 23.70 27.2695936 47.41 45.04 51.8095936 TC 20.47 19.45 22.3795936 26 26.94 25.59 29.4395937 66.04 62.74 72.1595937 TC 33.67 31.99 36.7995937 26 32.38 30.76 35.3795938 275.61 261.83 301.1095938 TC 232.95 221.30 254.5095938 26 42.67 40.54 46.6295939 433.91 412.21 474.0495939 TC 321.59 305.51 351.3495939 26 112.32 106.70 122.7195950 279.66 265.68 305.5395950 TC 205.30 195.04 224.3095950 26 74.36 70.64 81.2495951 1,737.46 1,650.59 1,898.1895951 TC 1,389.28 1,319.82 1,517.7995951 26 303.35 288.18 331.4195953 405.45 385.18 442.9695953 TC 252.74 240.10 276.1295953 26 152.71 145.07 166.8395954 381.65 362.57 416.9695954 TC 265.98 252.68 290.5895954 26 115.67 109.89 126.3795955 181.97 172.87 198.8095955 TC 132.31 125.69 144.5495955 26 49.66 47.18 54.2695956 1,099.33 1,044.36 1,201.0195956 TC 925.39 879.12 1,010.9995956 26 173.94 165.24 190.0395957 362.63 344.50 396.1895957 TC 264.89 251.65 289.4095957 26 97.74 92.85 106.78# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.268 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95958 469.52 446.04 512.9595958 TC 260.33 247.31 284.4195958 26 209.19 198.73 228.5495961 258.61 245.68 282.5395961 TC 110.64 105.11 120.8895961 26 147.97 140.57 161.6695962 227.19 215.83 248.2095962 TC 68.85 65.41 75.2295962 26 158.34 150.42 172.9895965 2,067.40 1,964.03 2,258.6395965 TC 1,653.92 1,571.22 1,806.9095965 26 406.78 386.44 444.4195966 1,035.49 983.72 1,131.2895966 TC 828.39 786.97 905.0295966 26 203.01 192.86 221.7995967 517.75 491.86 565.6495967 TC 414.20 393.49 452.5195967 26 177.10 168.25 193.4995970 60.13 57.12 65.69# 95970 22.74 21.60 24.8495971 55.49 52.72 60.63# 95971 39.15 37.19 42.7795972 104.53 99.30 114.20# 95972 76.26 72.45 83.3295973 59.99 56.99 65.54# 95973 47.11 44.75 51.4695974 184.77 175.53 201.86# 95974 151.16 143.60 165.1495975 99.62 94.64 108.84# 95975 85.48 81.21 93.3995978 224.38 213.16 245.13# 95978 181.03 171.98 197.78# 95979 83.54 79.36 91.2695979 97.36 92.49 106.3695980 44.99 42.74 49.1595981 30.47 28.95 33.29# 95981 16.96 16.11 18.5395982 48.76 46.32 53.27# 95982 34.31 32.59 37.48# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.269 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE95990 79.32 75.35 86.6595991 109.71 104.22 119.85# 95991 38.08 36.18 41.6195992 41.17 39.11 44.98# 95992 37.09 35.24 40.5396000 93.23 88.57 101.8696001 97.34 92.47 106.3496002 20.70 19.67 22.6296003 18.40 17.48 20.1096004 109.04 103.59 119.1396020 239.11 227.15 261.2296020 TC 84.61 80.38 92.4496020 26 169.18 160.72 184.8396101 80.62 76.59 88.08# 96101 75.60 71.82 82.5996102 69.95 66.45 76.42# 96102 22.19 21.08 24.2496103 59.92 56.92 65.46# 96103 23.79 22.60 25.9996105 98.72 93.78 107.8596111 122.28 116.17 133.60# 96111 117.25 111.39 128.1096116 87.68 83.30 95.80# 96116 82.34 78.22 89.9596118 90.99 86.44 99.41# 96118 74.97 71.22 81.9096119 65.58 62.30 71.65# 96119 22.23 21.12 24.2996120 83.17 79.01 90.86# 96120 23.79 22.60 25.9996125 96.23 91.42 105.1396150 20.21 19.20 22.08# 96150 19.90 18.91 21.7596151 19.53 18.55 21.33# 96151 19.22 18.26 21.0096152 18.53 17.60 20.24# 96152 18.22 17.31 19.9196153 4.40 4.18 4.8196154 18.19 17.28 19.87# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.270 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE# 96154 17.88 16.99 19.5496360 53.37 50.70 58.3196361 14.42 13.70 15.7696365 67.62 64.24 73.8896366 20.31 19.29 22.1896367 30.39 28.87 33.2096368 18.09 17.19 19.7796369 173.49 164.82 189.5496370 14.97 14.22 16.3596371 79.53 75.55 86.8896372 22.80 21.66 24.9196373 18.72 17.78 20.4596374 52.14 49.53 56.9696375 21.05 20.00 23.0096401 68.30 64.89 74.6296402 31.65 30.07 34.5896405 79.74 75.75 87.11# 96405 29.47 28.00 32.2096406 113.82 108.13 124.35# 96406 43.14 40.98 47.1396409 103.30 98.14 112.8696411 58.17 55.26 63.5596413 128.85 122.41 140.7796415 28.82 27.38 31.4996416 128.45 122.03 140.3396417 66.36 63.04 72.5096420 99.81 94.82 109.0496422 159.50 151.53 174.2696423 73.53 69.85 80.3396425 167.45 159.08 182.9496440 772.64 734.01 844.11# 96440 139.27 132.31 152.1696446 178.82 169.88 195.36# 96446 20.80 19.76 22.7296450 177.35 168.48 193.75# 96450 79.96 75.96 87.3596521 127.09 120.74 138.8596522 103.22 98.06 112.7796523 23.40 22.23 25.56# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.271 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE96542 115.58 109.80 126.27# 96542 40.81 38.77 44.5996567 126.03 119.73 137.6996570 57.19 54.33 62.4896571 26.15 24.84 28.5796900 19.84 18.85 21.6896904 65.71 62.42 71.7896910 66.65 63.32 72.8296912 85.50 81.23 93.4196913 119.12 113.16 130.1396920 165.01 156.76 180.27# 96920 64.79 61.55 70.7896921 167.57 159.19 183.07# 96921 65.16 61.90 71.1996922 237.44 225.57 259.41# 96922 117.12 111.26 127.9597001 71.25 67.69 77.8497002 39.42 37.45 43.0797003 79.42 75.45 86.7797004 48.53 46.10 53.0297012 15.16 14.40 16.5697016 17.49 16.62 19.1197018 9.63 9.15 10.5297022 20.92 19.87 22.8597024 6.18 5.87 6.7597026 5.55 5.27 6.0697028 6.86 6.52 7.5097032 17.67 16.79 19.3197033 29.01 27.56 31.6997034 16.31 15.49 17.8197035 11.91 11.31 13.0197036 29.37 27.90 32.0997110 29.50 28.03 32.2397112 30.76 29.22 33.6097113 38.90 36.96 42.5097116 26.23 24.92 28.6697124 24.22 23.01 26.4697140 27.57 26.19 30.1297150 18.98 18.03 20.73# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.272 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE97530 32.31 30.69 35.2997532 24.77 23.53 27.0697533 27.28 25.92 29.8197535 32.02 30.42 34.9897537 27.93 26.53 30.5197542 28.56 27.13 31.2097597 71.02 67.47 77.59# 97597 23.58 22.40 25.7697598 23.71 22.52 25.90# 97598 11.15 10.59 12.1897605 39.54 37.56 43.19# 97605 26.66 25.33 29.1397606 42.28 40.17 46.20# 97606 29.40 27.93 32.1297750 31.17 29.61 34.0597755 34.13 32.42 37.2897760 35.26 33.50 38.5397761 30.86 29.32 33.7297762 41.55 39.47 45.3997802 32.95 31.30 36.00# 97802 30.76 29.22 33.6097803 28.66 27.23 31.31# 97803 26.46 25.14 28.9197804 14.53 13.80 15.87# 97804 14.21 13.50 15.5398925 29.63 28.15 32.37# 98925 22.72 21.58 24.8298926 42.22 40.11 46.13# 98926 34.05 32.35 37.2098927 55.49 52.72 60.63# 98927 45.13 42.87 49.3098928 68.19 64.78 74.50# 98928 57.19 54.33 62.4898929 81.56 77.48 89.10# 98929 68.68 65.25 75.0498940 24.61 23.38 26.89# 98940 19.98 18.98 21.8398941 34.45 32.73 37.64# 98941 29.53 28.05 32.26# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.273 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE98942 43.94 41.74 48.00# 98942 39.02 37.07 42.6399143 27.54 26.16 30.0899144 25.98 24.68 28.3899145 9.05 8.60 9.8999148 68.86 65.42 75.2399149 64.54 61.31 70.5199150 18.50 17.58 20.2299170 128.96 122.51 140.89# 99170 87.18 82.82 95.2499175 17.64 16.76 19.2799183 206.92 196.57 226.06# 99183 117.70 111.82 128.5999195 86.33 82.01 94.3199201 40.73 38.69 44.49# 99201 25.33 24.06 27.6799202 69.70 66.22 76.15# 99202 48.03 45.63 52.4799203 101.50 96.43 110.89# 99203 73.53 69.85 80.3399204 155.80 148.01 170.21# 99204 124.70 118.47 136.2499205 193.75 184.06 211.67# 99205 159.82 151.83 174.6099211 18.74 17.80 20.47# 99211 9.00 8.55 9.8399212 40.73 38.69 44.49# 99212 24.71 23.47 26.9999213 67.92 64.52 74.20# 99213 48.76 46.32 53.2799214 100.56 95.53 109.86# 99214 74.80 71.06 81.7299215 135.35 128.58 147.87# 99215 105.19 99.93 114.9299217 68.47 65.05 74.8199218 92.65 88.02 101.2299219 127.36 120.99 139.1499220 174.83 166.09 191.0099221 96.72 91.88 105.66# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.274 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE99222 130.77 124.23 142.8699223 191.89 182.30 209.6599224 38.11 36.20 41.6399225 68.71 65.27 75.0699226 98.78 93.84 107.9299231 37.43 35.56 40.8999232 68.44 65.02 74.7799233 98.20 93.29 107.2899234 129.07 122.62 141.0199235 161.64 153.56 176.5999236 208.17 197.76 227.4299238 68.11 64.70 74.4199239 100.72 95.68 110.0399281 20.18 19.17 22.0599282 39.73 37.74 43.4099283 59.62 56.64 65.1499284 113.68 108.00 124.2099285 166.65 158.32 182.0799291 260.10 247.10 284.17# 99291 213.92 203.22 233.7099292 117.06 111.21 127.89# 99292 107.32 101.95 117.2499304 87.93 83.53 96.0699305 124.34 118.12 135.8499306 157.76 149.87 172.3599307 41.46 39.39 45.3099308 64.34 61.12 70.2999309 84.57 80.34 92.3999310 125.92 119.62 137.5699315 68.16 64.75 74.4699316 97.84 92.95 106.8999318 89.80 85.31 98.1199324 53.58 50.90 58.5499325 77.37 73.50 84.5399326 132.41 125.79 144.6699327 175.73 166.94 191.9899328 204.18 193.97 223.0799334 57.19 54.33 62.4899335 89.20 84.74 97.45# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.275 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE99336 126.21 119.90 137.8999337 181.75 172.66 198.5699341 52.95 50.30 57.8599342 77.10 73.25 84.2499343 126.28 119.97 137.9799344 172.69 164.06 188.6799345 206.48 196.16 225.5899347 53.24 50.58 58.1799348 80.30 76.29 87.7399349 120.53 114.50 131.6899350 167.72 159.33 183.2399354 94.09 89.39 102.80# 99354 87.81 83.42 95.9399355 92.52 87.89 101.07# 99355 86.24 81.93 94.2299356 86.71 82.37 94.7399357 86.40 82.08 94.3999406 13.25 12.59 14.48# 99406 11.36 10.79 12.4199407 25.96 24.66 28.36# 99407 24.39 23.17 26.6599460 91.51 86.93 99.9799461 90.10 85.60 98.44# 99461 61.82 58.73 67.5499462 41.09 39.04 44.9099463 107.92 102.52 117.9099464 70.57 67.04 77.1099465 142.29 135.18 155.4699466 263.30 250.14 287.6699467 116.63 110.80 127.4299468 886.28 841.97 968.2799469 396.89 377.05 433.6199471 756.22 718.41 826.1799472 384.30 365.09 419.8599475 538.63 511.70 588.4699476 326.59 310.26 356.8099477 332.20 315.59 362.9399478 132.51 125.88 144.7699479 121.70 115.62 132.96# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.276 of 277

http://www.wpsmedicare.comWPS Medicare2012 Medicare Physician Fee Schedule for Michigan Loc 99Effective January 1, 2012All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2011 by the AmericanMedical Association. All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein. ApplicableFARS/DFARS restrictions apply to government use. Current Dental Terminology copyright © 2002, 2005American Dental Association. All rights reserved.Participating Anesthesia Conversion Factor for MI Loc 99 = $21.40NOTE PROCEDURE CODE MOD PAR AMOUNT NON-PAR AMOUNT LIMITING CHARGE99480 114.84 109.10 125.47# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.277 of 277