APPENDIX B
NEW JERSEY ADMINISTRATIVE CODE
Current Through N.J. Register Volume 47, Number 16 (47 N.J.R. 2196)
Includes Adopted Rules Filed Through July 24, 2015
SUBCHAPTER 3. BASIC AUTOMOBILE INSURANCE POLICY
Source and Effective Date. R. 1998 d. 592, effective December 21, 1998 (operative March 22, 1999).
Section
11:3-3.1.
11:3-3.2.
11:3-3.3.
11:3-3.4.
11:3-3.5.
11:3-3.6.
Purpose and scope.
Definitions.
General provisions.
Coverages; mandatory and optional.
Election of basic automobile insurance policy coverage and
reporting.
Filing requirements.
11:3-3.1. Purpose and scope. (a) This subchapter provides rules to be utilized
by insurers in developing the policy forms and rates for basic automobile insurance policies to be filed with and approved by the Department in accordance with
the provisions of N.J.S.A. 39:6A-3.1.
(b) This subchapter shall apply to all insurers writing private passenger automobile insurance on personal lines policy forms, including the New Jersey Personal Automobile Insurance Plan established by N.J.A.C. 11:3-2.
11:3-3.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates
otherwise:
“Basic automobile insurance policy” or “basic policy” means that automobile
insurance policy offered pursuant to N.J.S.A. 39:6A-3.1 and this subchapter.
“Basic policy servicing carrier” means a limited assignment distribution carrier
that is a participating insurer that agrees to accept assignments of basic policies
pursuant to this subchapter and the procedures set forth in the PAIP plan of operation.
“Commissioner” means the Commissioner of the Department of Banking and
Insurance.
“Department” means the Department of Banking and Insurance.
“Insurer” means any person or persons, corporation, association, partnership,
company, reciprocal exchange, or other legal entity authorized or admitted to
transact private passenger automobile insurance in this State, or any one member
of a group of affiliated companies that transacts business in accordance with a
common rating system.
“Medically necessary” is as defined in N.J.A.C. 11:3-4.2.
“PAIP” means the New Jersey Personal Automobile Insurance Plan established
pursuant to N.J.S.A. 17:29D-1 and N.J.A.C. 11:3-2.
“Personal injury protection” or “PIP” means the benefits and coverages set
forth at N.J.S.A. 39:6A-4 and 39:6A-3.1 and N.J.A.C. 11:3-4.
“Significant disfigurement” means the result and/or manifestation of a serious
traumatic injury that is observable as a permanent and substantial defect in the appearance and functional ability of the person injured. “Significant disfigurement”
is a serious outward change that substantially detracts from the appearance and
functional ability of the person injured.
11:3-3.3
APPENDIX B - REGULATIONS
“Standard automobile insurance policy” or “standard policy” means that policy
form filed by private passenger automobile insurers and approved by the Commissioner that contains the coverages and options pursuant to N.J.S.A. 39:6A-4.
Amended. R.2000 d.454, effective November 6, 2000; R.2007 d.151, effective May 7, 2007.
11:3-3.3. General provisions. (a) All insurers writing private passenger automobile insurance and the Personal Automobile Insurance Plan shall file for approval with the Department their rates, rules and policy forms for a basic automobile insurance policy to be issued in accordance with N.J.S.A. 39:6A-3.1 and this
subchapter.
(b) An insurer shall make available the basic policy at either a single tier rate
or at multiple tier rates, consistent with its tier rating system filed and approved
pursuant to N.J.A.C. 11:3-19A. If more than one basic policy rate is offered, each
shall be identified as part of a standard, non-standard or preferred tier.
(c) If a named insured has elected basic automobile insurance coverage and
other immediate family members or resident relatives of the named insured have
higher policy limits under a standard policy, the provisions of N.J.S.A. 39:6A-4.2
shall apply and the named insured shall only be entitled to the coverages provided
under his or her basic policy.
(d) Basic policies shall provide the tort option provided under N.J.S.A. 39:6A-8a.
(e) Initial rates by coverage for basic policies filed in accordance with this subchapter shall demonstrate consistency with the rates in the insurer's standard policy, adjusted for reduced coverage limits.
(f) Insurers shall file for approval an initial basic policy rating system by January 20, 1999.
(g) An insurer may write basic policies through a basic policy servicing carrier.
Amended. R.2007 d.151, effective May 7, 2007.
11:3-3.4. Coverages; mandatory and optional. (a) The following coverages
shall be included in all basic policies:
1. Personal injury protection medical expense benefits coverage in an amount
not to exceed $15,000 per person, per accident; except that all medically necessary
treatment of permanent or significant brain injury, spinal cord injury or disfigurement or medically necessary treatment of other permanent or significant injuries
rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requiring critical care and can be safely discharged or transferred to another facility in the judgment of the attending
physician shall be covered in an amount not to exceed $250,000, including the
$15,000 above. The medical expense benefits provided herein shall be in accordance with N.J.A.C. 11:3-4; and
2. Liability insurance coverage insuring against loss resulting from liability imposed by law for property damage sustained by any person arising out of the ownership, maintenance, operation or use of an automobile in an amount or limit of
$5,000, exclusive of interest and costs, for damage to property in any one accident.
(b) Insurers shall also make available in the basic policy, at the option of the
insured, liability insurance coverage for bodily injury or death in an amount or
limit of $10,000, exclusive of interest and costs, on account of the injury or death
of one or more persons in any one accident.
(c) Insurers may make available with the basic policy, at the option of the insured, comprehensive and collision coverage with deductibles filed and approved
pursuant to N.J.A.C. 11:3-13.
(d) Basic policies shall not contain any other coverages, options, limits or deductibles other than those which are set forth in (a) through (c) above. Increased
policy limits, the health insurance primary option for automobile medical expense
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.1
coverage and uninsured/under-insured motorist coverages shall not be provided in
basic policies.
11:3-3.5. Election of basic automobile insurance policy coverage and reporting. No insurer shall issue a basic automobile insurance policy unless the
named insured has signed a written document entitled “basic automobile insurance policy coverage selection form” set forth in N.J.A.C. 11:3-15.7.
Amended. R.2003 d.95, effective March 3, 2003; R.2006 d.243, effective July 3, 2006.
11:3-3.6. Filing requirements. (a) Insurers initially filing basic policy rating
systems shall include the following:
1. A complete set of policy forms and endorsements that provide the mandatory
and optional coverages as set forth in this subchapter;
2. Rates and rules as necessary;
3. An actuarial memorandum that supports the rate differentials from the insurer's standard policy rates;
4. The declaration page;
5. The rating information form; and
6. The personal lines filing forms as set forth in N.J.A.C. 11:3-16.3(f) and (g).
(b) Subsequent amendments to the rating systems shall be filed pursuant to
N.J.A.C. 11:3-16 and other applicable statutes and rules.
SUBCHAPTER 4. PERSONAL INJURY PROTECTION BENEFITS;
MEDICAL PROTOCOLS; DIAGNOSTIC TESTS
Source and Effective Date: R.1998 d.597, effective December 21, 1998 (operative March 22, 1999).
Section
11:3-4.1.
11:3-4.2.
11:3-4.3.
11:3-4.4.
11:3-4.5.
11:3-4.6.
11:3-4.7.
11:3-4.7A
11:3-4.8.
11:3-4.9.
11:3-4.10.
APPENDIX
Scope and purpose.
Definitions.
Personal injury protection benefits applicable to basic and standard
policies.
Deductibles and co-pays.
Diagnostic tests.
Medical protocols.
Decision point review plans.
PIP vendor registration requirements
Voluntary networks.
Assignment of benefits; public information.
Reserved
Exhibit 1. Glossary of Terms
Exhibit 2. Care Path Overview
Exhibit 3. Care Path 1
Exhibit 4. Care Path 2
Exhibit 5. Care Path 3
Exhibit 6. Care Path 4
Exhibit 7. Care Path 5
Exhibit 8. Care Path 6
Exhibit 9. Care Path Diagnosis Coding
Exhibit 10. Addendum to Care Paths
Exhibit 11. Monthly Decision Point Review/Precertification
Implementation Report - Not Included
11:3-4.1. Scope and purpose. (a) This subchapter implements the provisions
of N.J.S.A. 39:6A-3.1, 39:6A-4 and 39:6A-4.3 by identifying the personal injury
11:3-4.2
APPENDIX B - REGULATIONS
protection medical expense benefits and emergency personal injury protection
coverage for which reimbursement of eligible charges will be made by automobile
insurers under basic, standard and special automobile insurance policies and by
motor bus insurers under medical expense benefits coverage.
(b) This subchapter applies to all insurers that issue policies of automobile insurance containing PIP coverage, emergency personal injury protection coverage
and policies of motor bus insurance containing medical expense benefits coverage.
(c) This subchapter shall apply to those policies that are issued or renewed on
or after March 22, 1999.
Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004).
11:3-4.2. Definitions. The following words, phrases and terms, when used in
this subchapter, shall have the following meanings unless the context clearly indicates otherwise.
“Ambulatory surgery facility” or “ambulatory surgical center” (ASC) means:
1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey
in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are performed and which is separate and apart from any other facility license. (The ambulatory surgery facility may be physically connected to another licensed facility,
such as a hospital, but is corporately, financially and administratively distinct, for
example, it uses a separate tax-id number); or
2. A physician-owned single operating room in an office setting that is certified
by Medicare.
“Basic automobile insurance policy” or “basic policy” means those private passenger automobile insurance policies issued in accordance with N.J.S.A. 39:6A3.1 and N.J.A.C. 11:3-3.
“Clinically supported” means that a health care provider prior to selecting, performing or ordering the administration of a treatment or diagnostic test has:
1. Personally examined the patient to ensure that the proper medical indications
exist to justify ordering the treatment or test;
2. Physically examined the patient including making an assessment of any current and/or historical subjective complaints, observations, objective findings, neurologic indications, and physical tests;
3. Considered any and all previously performed tests that relate to the injury
and the results and which are relevant to the proposed treatment or test; and
4. Recorded and documented these observations, positive and negative findings and conclusions on the patient's medical records.
"Days" means calendar days unless specifically designated as business days.
“Decision point” means those junctures in the treatment of identified injuries
indicated by hexagonal boxes on the Care Paths where a decision must be made
about the continuation or choice of further treatment. The determination whether
to administer one of the tests listed in N.J.A.C. 11:3-4.5(b) is also a decision point
for both identified and all other injuries.
“Decision point review” means the procedures in an insurer's approved decision point review plan for the insurer to receive notice and respond to requests for
proposed treatment or testing at decision points.
“Diagnostic test” means a medical service or procedure utilizing biomechanical, neurological, neurodiagnostic, radiological, vascular or any means, other than
bioanalysis, intended to assist in establishing a medical, dental, physical therapy,
chiropractic or psychological diagnosis, for the purpose of recommending or developing a course of treatment for the tested patient to be implemented by the
treating practitioner or by the consultant.
“Eligible charge” means the treating health care provider's usual, customary
and reasonable charge or the upper limit of the medical fee schedule as found in
N.J.A.C. 11:3-29.6, whichever is lower.
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.2
“Emergency care” means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to
result in: death; serious impairment to bodily functions; or serious dysfunction of
a bodily organ or part. Such emergency care shall include all medically necessary
care immediately following an automobile accident, including, but not limited to,
immediate pre-hospitalization care, transportation to a hospital or trauma center,
emergency room care, surgery, critical and acute care. Emergency care extends
during the period of initial hospitalization until the patient is discharged from
acute care by the attending physician. Emergency care shall be presumed when
medical care is initiated at a hospital within 120 hours of the accident.
“Emergency personal injury protection coverage” means the coverage provided
by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89.
“Health care provider” or “provider” means those persons licensed or certified
to perform health care treatment or services compensable as medical expenses and
shall include, but not be limited to:
1. A hospital or health care facility that is maintained by State or any political
subdivision;
2. A hospital or health care facility licensed by the Department of Health and
Senior Services;
3. Other hospitals or health care facilities designated by the Department of
Health and Senior Services to provide health care services, or other facilities, including facilities for radiological and diagnostic testing, free-standing emergency
clinics or offices, and private treatment centers;
4. A nonprofit voluntary visiting nurse organization providing health care services other than a hospital;
5. Hospitals or other health care facilities or treatment centers located in other
States or nations;
6. Physicians licensed to practice medicine and surgery;
7. Licensed chiropractors;
8. Licensed dentists;
9. Licensed optometrists;
10. Licensed pharmacists;
11. Licensed chiropodists (podiatrists);
12. Registered bioanalytical laboratories;
13. Licensed psychologists;
14. Licensed physical therapists;
15. Certified nurse mid-wives;
16. Certified nurse practitioners/clinical nurse-specialist;
17. Licensed health maintenance organizations;
18. Licensed orthotists and prosthetists;
19. Licensed professional nurses;
20. Licensed occupational therapists;
21. Licensed speech-language pathologists;
22. Licensed audiologists;
23. Licensed physicians assistants;
24. Licensed physical therapy assistants;
25. Licensed occupational therapy assistants; and
26. Providers of other health care services or supplies, including durable medical goods.
“Identified injury” means those injuries identified by the Department in the
subchapter Appendix as being suitable for medical treatment protocols in accordance with N.J.S.A. 39:6A-3.1a and 39:6A-4a.
11:3-4.2
APPENDIX B - REGULATIONS
“Insurer” means any person or persons, corporation, association, partnership,
company, reciprocal exchange or other legal entity authorized or admitted to transact private passenger automobile insurance in this State, or any one member of a
group of affiliated companies that transacts business in accordance with a common rating system. Insurer does not include an entity that is self-insured pursuant
to N.J.S.A. 39:6-52. For purposes of communicating with insureds and providers
concerning the administration of decision point review plans, “insurer” also
means the insurer’s PIP vendor.
“Medical expense” means the reasonable and necessary expenses for treatment
or services rendered by a provider, including medical, surgical, rehabilitative and
diagnostic services and hospital expenses and reasonable and necessary expenses
for ambulance services or other transportation, medication and other services,
subject to limitations as provided for in the policy forms that are filed and approved by the Commissioner.
“Medically necessary” or “medical necessity” means that the medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person, and:
1. The treatment is the most appropriate level of service that is in accordance
with the standards of good practice and standard professional treatment protocols
including the Care Paths in the Appendix, as applicable;
2. The treatment of the injury is not primarily for the convenience of the injured
person or provider; and
3. Does not include unnecessary testing or treatment.
“Non-medical expense” means charges for those:
1. Products and devices, not exclusively used for medical purposes or as durable medical equipment, such as any vehicles, durable goods, equipment, appurtenances, improvements to real or personal property, fixtures; and
2. Services and activities such as recreational activities, trips and leisure activities.
“Network” means an entity other than an insurer that contracts with providers
to render health care services or provide supplies at predetermined fees or reimbursement levels.
“Organized delivery system” (ODS) means an organized delivery system certified or licensed pursuant to N.J.S.A. 17:48H-1 et seq., N.J.A.C. 11:22-4 or
N.J.A.C. 11:24B.
"PIP vendor" means a company used by an insurer for utilization management.
“Precertification” or “precertification request” means the procedures in an insurer’s approved decision point review plan for the insurer to receive notice and
respond to requests for listed specific medical procedures, treatments, diagnostic
tests, other services and durable medical equipment that are not subject to decision
point review and that may be subject to overutilization.
“Standard automobile insurance policy” or “standard policy” means a private
passenger automobile insurance policy issued in accordance with N.J.S.A. 39:6A-4.
"Standard professional treatment protocols" means evidence-based clinical
guidelines/practice/treatment published in peer-reviewed journals.
"Utilization management" means a system for administering some or all of an
insurer's decision point review plan, including, but not limited to, receiving and
responding to decision point review and precertification requests, making determinations of medical necessity, scheduling and performing independent medical
examinations (IMEs), bill review and handling of provider appeals.
Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2010 d.142, effective July 6, 2010. Administrative correction. See: 42
N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.4
11:3-4.3. Personal injury protection benefits applicable to basic and standard policies. (a) Personal injury protection coverage shall provide reimbursement for all medically necessary expenses for the diagnosis and treatment of injuries sustained from a covered automobile accident up to the limits set forth in the
policy and in accordance with this subchapter.
(b) Personal injury protection coverage shall only provide reimbursement for
clinically supported necessary non-medical expenses that are prescribed by a
treating medical provider for a permanent or significant brain, spinal cord or disfiguring injuries.
11:3-4.4. Deductibles and co-pays. (a) Each insurer shall offer a standard
$250.00 deductible and 20 percent copayment on medical expense benefits payable between $250.00 and $5,000.
(b) Each insurer shall also offer, at appropriately reduced premiums, the option
to select medical expense benefit deductibles of $500.00, $1,000, $2,000 and
$2,500 in accordance with the following provisions:
1. Any medical expense deductible elected by the named insured shall apply
only to the named insured and any resident relative in the named insured's household, who is not a named insured under another automobile policy and not to any
other person eligible for personal injury protection benefits required to be provided in accordance with N.J.S.A. 39:6A-3.1 and 39:6A-4;
2. Premium credits calculated and represented as a percentage of the applicable
premium shall be provided for each deductible. The premium percentage shall be
uniform by filer on a statewide basis; and
3. The deductible option elected by the named insured shall continue in force
as to subsequent renewal or replacement policies until the insurer or its authorized
representative receives a properly executed coverage selection form to eliminate
or change the deductible.
(c) All deductibles and co-pays in (a) and (b) above shall apply on a per accident basis.
(d) An insurer may file policy language that waives the co-payment and deductible in (a) and (b) above when the insured receives medical treatment from a
provider that is part of an ODS that has contracted with the insurer or its PIP vendor. The insured shall not be required to elect to use the providers or facilities in
such an ODS either at issuance of the policy or when the claim is made.
1. Upon receipt of notification of a claim, the insurer or its PIP vendor shall
make available to the insured information about physicians and facilities in any
ODS with which it has a contract.
i. The information shall include a notice that the insured is not required to use
the providers or facilities of an ODS with which the insurer or its PIP vendor has
contracted and indicate that if the insured chooses to receive covered services
from such providers or facilities, the deductible and copayments in (a) and (b)
above would not apply.
ii. The information shall also indicate that the insured may seek treatment from
providers and facilities that are not part of an ODS with which the insurer or its
PIP vendor has contracted, in which case the deductible and copayments in (a) and
(b) above would apply.
2. The actual ODS access fee or 25 percent of the reduction in charges resulting
from the use of the ODS provider, whichever is less, may be included within the
policy limits for any single bill from an in-network provider in the ODS with
billed charges of $ 10,000 or more.
Example: A $10,000 charge is reduced by the ODS contract with the insurer by
45 percent to $5,500. The insurer could include the ODS access fee or $1,125 (25
percent of the $4,500 reduction), whichever is less, within the policy limits.
11:3-4.4
APPENDIX B - REGULATIONS
(e) Failure to request decision point review or precertification where required
or failure to provide clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested shall result in an additional copayment not to exceed 50 percent of the eligible charge for medically necessary
diagnostic tests, treatments or durable medical goods that were provided between
the time notification to the insurer was required and the time that proper notification is made and the insurer has an opportunity to respond in accordance with its
approved decision point review plan.
Example: Assume that all days are business days and the insurer’s Decision
Point Review Plan gives the insurer three days to respond to decision pint review
and precertification requests. By the terms of the insurer’s Decision Point Review
Plan, a treating medical provider is required to make a decision point review request on day 21 of treatment (time notification was required). The provider does
not give the required notification in a timely manner but continues to treat the patient. The provider then makes the notification and it is received by the insurer on
day 35 (time proper notification made). The insurer responds on day 38 that the
treatment can proceed (time for insurer to respond). Assuming that the treatment
made between day 21 and 38 was medically necessary, it is subject to the 50 percent co-payment.
1. No insurer may impose the additional co-payment where the insurer received
the required notice but failed to act in accordance with its approved decision point
review plan to request further information, modify or deny reimbursement of further treatment, diagnostic tests or durable medical equipment.
(f) An insurer may require that the insured advise and inform the insurer about
the injury and the claim. This requirement may include the production of information from the insured regarding the facts of the accident, the nature and cause of
the injury, the diagnosis and the anticipated course of treatment.
1. This information may be required to be provided as promptly as possible after the accident, and periodically thereafter.
2. An insurer may impose an additional co-payment as a penalty for failure to
supply the required information. Such penalties shall result in a reduction in the
amount of reimbursement of the eligible charge for medically necessary expenses
that are incurred after notification to the insurer is required and until notification
is received. The additional co-payment shall be an amount no greater than:
i. Twenty-five percent when received 30 or more days after the accident; or
ii. Fifty percent when received 60 or more days after the accident.
3. Any reduction in the amount of reimbursement for PIP claims shall be in addition to any other deductible or co-payment requirement.
4. Information about this requirement and how to comply with it shall be included in the informational materials required by N.J.A.C. 11:3-4.7(d).
(g) An insurer may impose an additional co-payment not to exceed 30 percent
of the eligible charge for failure to use an approved network pursuant to N.J.A.C.
11:3-4.8 for the medically necessary non-emergency benefits listed in N.J.A.C.
11:3-4.8(b).
(h) For the purpose of the co-payments permitted in (e), (f) and (g) above, the
percentage reduction shall be applied to the amount that the insurer would otherwise have paid to the insured or the provider after the application of the provisions
of N.J.A.C. 11:3-29. Insurers may apply the co-payments and deductibles in (a)
through (g) above in any order, provided that they use the same order of application for all insureds. Upon receipt of a request for PIP benefits under the policy,
the insurer or its PIP vendor shall make its co-payment and deductible application
methodology available to the insured and the treating medical provider upon request.
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.5
(i) For private passenger automobiles insured under a commercial automobile
insurance policy where no natural person is a named insured, insurers shall only
provide personal injury protection with medical expense benefits coverage in an
amount not to exceed $250,000 per person, per accident, with the deductible and
copayment amount set forth in (a) above.
Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operative October 27, 2004, section (g) operative March 4, 2005); R.2010 d.142, effective July 6, 2010.
Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5,
2012 (operative January 4, 2013).
11:3-4.5. Diagnostic tests. (a) The personal injury protection medical expense
benefits coverage shall not provide reimbursement for the following diagnostic
tests, which have been determined to yield no data of any significant value in the
development, evaluation and implementation of an appropriate plan of treatment
for injuries sustained in motor vehicle accidents:
1. (Reserved)
2. Spinal diagnostic ultrasound;
3. Iridology;
4. Reflexology;
5. Surrogate arm mentoring;
6. Surface electromyography (surface EMG);
7. (Reserved); and
8. Mandibular tracking and stimulation.
(b) The personal injury protection medical expense benefits coverage shall
provide for reimbursement of the following diagnostic tests, which have been determined to have value in the evaluation of injuries, the diagnosis and development of a treatment plan for persons injured in a covered accident, when medically
necessary and consistent with clinically supported findings:
1. Needle electromyography (needle EMG) when used in the evaluation and
diagnosis of neuropathies and radicular syndrome where clinically supported findings reveal a loss of sensation, numbness or tingling. A needle EMG is not indicated in the evaluation of TMJ/D and is contraindicated in the presence of infection on the skin or cellulitis. This test should not normally be performed within 14
days of the traumatic event and should not be repeated where initial results are
negative. Only one follow up exam is appropriate.
2. Somasensory evoked potential (SSEP), visual evoked potential (VEP),
brain audio evoked potential (BAEP), or brain evoked potential (BEP), nerve conduction velocity (NCV) and H-reflex Study are reimbursable when used to evaluate neuropathies and/or signs of atrophy, but not within 21 days following the traumatic injury.
3. Electroencephalogram (EEG) when used to evaluate head injuries, where
there are clinically supported findings of an altered level of sensorium and/or a
suspicion of seizure disorder. This test, if indicated by clinically supported findings, can be administered immediately following the insured event. When medically necessary, repeat testing is not normally conducted more than four times per
year.
4. Videofluroscopy only when used in the evaluation of hypomobility syndrome and wrist/carpal hypomobility, where there are clinically supported findings of no range or aberrant range of motion or dysmmetry of facets exist. This
test should not be performed within three months following the insured event and
follow up tests are not normally appropriate.
5. Magnetic resonance imaging (MRI) when used in accordance with the
guidelines contained in the American College of Radiology, Appropriateness Criteria to evaluate injuries in numerous parts of the body, particularly the assessment
11:3-4.5
APPENDIX B - REGULATIONS
of nerve root compression and/or motor loss. MRI is not normally performed
within five days of the insured event. However, clinically supported indication of
neurological gross motor deficits, incontinence or acute nerve root compression
with neurologic symptoms may justify MRI testing during the acute phase immediately post injury. In the case of TMJ/D where there are clinical signs of internal
derangement such as nonself-induced clicking, deviation, limited opening, and
pain with a history of trauma to the lower jaw, an MRI is allowable to show displacement of the condylar disc, such procedure following a panographic or transcranial x-ray and six or eight weeks of conservative treatment. This TMJ/D diagnostic test may be repeated post surgery and/or post appliance therapy.
6. Computer assisted tomographic studies (CT, CAT Scan) when used to evaluate injuries in numerous aspects of the body. With the exception of suspected
brain injuries, CAT Scan is not normally administered immediately post injury,
but may become appropriate within five days of the insured event. Repeat CAT
Scans should not be undertaken unless there is clinically supported indication of
an adverse change in the patient's condition. In the case of TMJ/D where there are
clinical signs of degenerative joint disease as a result of traumatic injury of the
temporomandibular joint, tomograms may not be performed sooner than 12
months following traumatic injury.
7. Dynatron/cyber station/cybex when used to evaluate muscle deterioration
or atrophy. These tests should not be performed within 21 days of the insured
event and should not be repeated if results are negative. Repeat tests are not appropriate at less than six months intervals.
8. Sonograms/ultrasound when used in the acute phase to evaluate the abdomen and pelvis for intra-abdominal bleeding. These tests are not normally used to
assess joints (knee and elbow) because other tests are more appropriate. Where
MRI is performed, sonograms/ultrasound are not necessary. However, echocardiogram is appropriate in the evaluation of possible cardiac injuries when clinically supported.
9. Thermography/thermograms only when used to evaluate pain associated
with reflex sympathetic dystrophy (“RSD”), in a controlled setting by a physician
experienced in such use and properly trained.
10. Brain mapping, when done in conjunction with appropriate neurodiagnostic testing.
(c) The terms “normal,” “normally,” “appropriate” and “indicated” as used in
(b) above, are intended to recognize that no single rule can replace the good faith
educated judgment of a health care provider. Thus, “normal,” “normally,” “appropriate” and “indicated” pertain to the usual, routine, customary or common experience and conclusion, which may in unusual circumstances differ from the actual
judgment of course of treatment. The unusual circumstances shall be based on
clinically supported findings of a health care provider. The use of these terms is
intended to indicate some flexibility and avoid rigidity in the application of these
rules in the decision point review required in (d) below.
(d) Except as provided in (e) below, a determination to administer any of the
tests in (b) above shall be subject to decision point review pursuant to N.J.A.C.
11:3-4.7.
(e) The requirements of (b) and (d) above shall not apply to diagnostic tests
administered during emergency care.
(f) Pursuant to N.J.A.C. 13:30-8.22(b), the personal injury protection medical
expense coverage shall not provide reimbursement for the following diagnostic
tests which have been identified by the New Jersey State Board of Dentistry as
failing to yield data of sufficient volume to alter or influence the diagnosis or treatment plan employed to treat TMJ/D:
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.7
1. Mandibular tracking;
2. Surface EMG;
3. Sonography;
4. Doppler ultrasound;
5. Needle EMG;
6. Electroencephalogram (EEG);
7. Thermograms/thermographs;
8. Video fluoroscopy; and
9. Reflexology.
Amended. R.2000 d.454, effective November 6, 2000.
11:3-4.6. Medical protocols. (a) Pursuant to N.J.S.A. 39:6A-3.1 and 39:6A-4,
the Commissioner designates the care paths, set forth in the subchapter Appendix
incorporated herein by reference, as the standard course of medically necessary
treatment, including diagnostic tests, for the identified injuries.
(b) Where the care path indicates a decision point either by a hexagon in the
care path itself or by reference in the text to a second opinion, referral for a second
independent consultative medical opinion, development of a treatment plan or
mandatory case management, the policy shall provide for a decision point review
in accordance with N.J.A.C. 11:3-4.7.
(c) Treatments that vary from the care paths shall be reimbursable only when
warranted by reason of medical necessity.
(d) The care paths do not apply to treatment administered during emergency
care.
11:3-4.7. Decision point review plans. (a) No insurer shall impose the co-payments permitted in N.J.A.C. 11:3-4.4(e), (f) and (g) unless it has an approved decision point review plan.
1. Initial decision point review plan filings and amendments to approved plans
shall be submitted to the Department through the use of the NAIC electronic filing
system SERFF (System for Electronic Rate and Form Filing).
(b) No decision point or precertification requirements shall apply within 10
days of the insured event or to emergency care. This provision should not be construed so as to require reimbursement of tests and treatment that are not medically
necessary.
(c) A decision point review plan filing shall include the following information:
1. Identification of any PIP vendor with which the insurer has contracted and a
copy of the contract between the insurer and the PIP vendor. No insurer shall contract with a PIP vendor unless the vendor is registered with the Department pursuant to N.J.A.C. 11:3-4.7A;
2. Identification of any specific medical procedures, treatments, diagnoses, diagnostic tests, other services or durable medical equipment that are subject to precertification. The inclusion of precertification requirements in a decision point review plan is optional. The medical procedures, treatments, diagnoses, diagnostic
tests or durable medical equipment required to be precertified shall be those that
the insurer has determined may be subject to overutiliztion and that are not already
subject to decision point review. The insurer shall not require the precertification
of a new-patient evaluation and management visit that is necessary for the provider to develop the plan of care that is incorporated into a precertification request for
treatment or diagnostic testing;
3. Copies of the informational materials described in (d) below and an explanation of how the insurer will distribute information to policyholders, injured persons and providers at policy issuance, renewal and upon notification of claim.
4. Procedures for the prompt review, not to exceed three business days, of decision point review and precertification requests by insureds or providers. All de-
11:3-4.7
APPENDIX B - REGULATIONS
terminations on treatments or tests shall be based on medical necessity and shall
not encourage over or underutilization of benefits. Denials of decision point review and precertification requests on the basis of medical necessity shall be the
determination of a physician. In the case of treatment prescribed by a dentist, the
denial shall be by a dentist;
5. Procedures for the scheduling of physical examinations pursuant to (e) below;
6. An internal appeals procedure that permits the provider to provide additional
information and have a rapid review of a decision to modify or deny reimbursement for a treatment or the administration of a test;
7. Reasonable restrictions on the assignment of benefits pursuant to N.J.A.C.
11:3-4.9(a);
8. An explanation of the alternatives available to the provider if reimbursement
for a proposed treatment, diagnostic test or durable medical equipment is denied
or modified, including insurer's internal appeal process and how to use it; and
9. The information required in order to use a network pursuant to N.J.A.C.
11:3-4.8(d), if applicable.
(d) The informational materials for policyholders, injured persons and providers shall be on forms approved by the Commissioner and shall include at a minimum the information in (d)1 through 9 below. In order to make the requirements
of this subchapter easier for insureds and providers to use, the Commissioner may
be Order require the use of uniform forms, layouts and language of information
materials.
1. How to contact the insurer or vendor to submit decision point review/precertification requests including the telephone, facsimile numbers, e-mail addresses or
through a website. The insurer or its vendor shall be available, at a minimum, during normal working hours to respond to decision point review/precertification requests;
2. An explanation of the decision point review process including a list of the
identified injuries and the diagnostic tests in N.J.A.C. 11:3-4.5(b). The materials
shall include copies of the Care Paths or indicate how copies may be obtained;
3. A list of the medical procedures, treatments, diagnoses, diagnostic tests, durable medical equipment or other services that require precertification, if any;
4. An explanation of how the insurer will respond to decision point review/precertification requests, including time frames. The materials should indicate that:
i. Telephonic responses will be followed up with a written authorization, denial
or request for more information within three business days;
5. An explanation of the insurer’s option to require a physical examination pursuant to (e) below;
6. An explanation of the penalty co-payments imposed for the failure to submit
decision point review/precertification requests where required in accordance with
N.J.A.C. 11:3-4.4(e);
7. An explanation of the insurer’s voluntary network or networks for certain
types of testing, durable medical equipment or prescription drugs authorized by
N.J.A.C. 11:3-4.8, if any;
8. An explanation of the alternatives available to the provider if reimbursement
for a proposed treatment, diagnostic test or durable medical equipment is denied
or modified, including insurers internal appeal process and how to use it; and
9. An explanation of the insurer’s restrictions on assignment of benefits, if any.
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.7
(e) A physical examination of the injured party shall be conducted as follows:
1. The insurer shall notify the injured person or his or her designee that a physical examination is required to determine the medical necessity of further treatment, diagnostic tests or durable medical equipment. An insurer shall include reasonable procedures for the notification of the injured person and the treating medical provider where reimbursement of further treatment, diagnostic testing or
durable medical equipment will be denied for failure to appear at scheduled medical examinations.
2. The appointment for the physical examination shall be scheduled within seven calendar days of receipt of the notice in (e)1 above unless the injured person
agrees to extend the time period.
3. The medical examination shall be conducted by a provider in the same discipline as the treating provider.
4. The medical examination shall be conducted at a location reasonably convenient to the injured person.
5. The injured person, upon the request of the insurer, shall provide medical
records and other pertinent information to the provider conducting the medical examination. The requested records shall be provided at the time of the examination
or before.
6. The insurer shall notify the injured person or his or her designee and the
treating medical provider whether it will reimburse for further treatment, diagnostic tests or durable medical equipment as promptly as possible but in no case later
than three business days after the examination. If the examining provider prepares
a written report concerning the examination, the injured person or his or her designee shall be entitled to a copy upon request.
7. Insurers may include in their decision point review plan a procedure for the
denial or reimbursement for treatment, diagnostic testing or durable medical
equipment after repeated unexcused failure to attend a scheduled physical examination. The procedure shall provide for adequate notification of the insured and
the treating provider of the consequences of failure to attend the examination.
(f) In administering decision point review and precertification, insurers shall
avoid undue interruptions in a course of treatment. As part of their decision point
review plans, insurers may include provisions that encourage providers to establish an agreed upon voluntary comprehensive treatment plan for all of a covered
person’s injuries to minimize the need for piecemeal review. An agreed comprehensive treatment plan may replace the requirements for notification to the insurer
at decision points and for treatment, diagnostic testing or durable medical equipment requiring precertification. In addition, the insurer may provide that reimbursement for treatment, diagnostic tests or durable medical equipment consistent
with the agreed plan will be made without review or audit.
(g) An insurer shall not retrospectively deny payment for treatment, diagnostic
testing or durable medical equipment on the basis of medical necessity where a decision point review or precertification request for that treatment or testing was
properly submitted to the insurer unless the request involved fraud or misrepresentation, as defined in N.J.A.C. 11:16-6.2, by the provider or the person receiving
the treatment, diagnostic testing or durable medical equipment.
Repeal and New Rule. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). Amended.
R.2006 d.243, effective July 3, 2006; R.2009 d.243, effective June 15, 2009; R.2010 d.142, effective
July 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective
November 5, 2012 (operative January 4, 2013).
11:3-4.7A
APPENDIX B - REGULATIONS
11:3-4.7A PIP vendor registration requirements (a) No company shall perform utilization management services for an insurer unless registered as a PIP vendor pursuant to this section.
(b) Any PIP vendor working for an insurer prior to November 5, 2012 shall file
for registration by February 3, 2013.
(c) Application for registration shall be made on a form prescribed by the Commissioner, which can be found on the Department's website at http://
www.state.nj.us/dobi/pipinfo/aicrapg.htm.
(d) The application shall be accompanied by the applicant’s business plan,
which shall include the following information:
1. A statement generally describing the applicant, its facilities, personnel, and
the services to be offered by the PIP vendor;
2. The name of its medical director(s) licensed to practice as physician(s) in
New Jersey and a detailed explanation about how the medical director(s) provide(s) oversight of determinations of medical necessity;
3. The name and contact information of a person at the vendor who is designated to receive and handle complaints and inquiries from the Department;
4. Information on activities undertaken or to be undertaken in New Jersey by
the company;
5. A demonstration of the applicant's capability to provide a sufficient number
of experienced and qualified personnel in the areas of PIP utilization management,
and information on staffing levels, including, but not limited to, training, hiring
requirements, experience of staff in general and with PIP utilization management
in particular;
6. A statement about whether the applicant is licensed or certified as an entity
that has networks as that term is defined in N.J.A.C. 11:3-4.8(a) or accredited by
nationally recognized accrediting agencies such as URAC (http://www.urac.org/)
in Health Utilization Management; and
7. A copy of the applicant's certificate of incorporation.
(e) The application shall also be accompanied by the following information
concerning how the applicant will handle PIP utilization management:
1. The vendor’s clinical review criteria and protocols. The information shall include a descriptive flow chart of its processes used in decision-making, which
shall be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers, and be
based upon generally accepted medical standards and standard professional treatment protocols;
2. A copy of the vendor’s policies and procedures that demonstrate that the
vendor is handling utilization management in accordance with N.J.A.C. 11:3-4, 5
and 29; and
3. The mechanisms it uses to detect underutilization and overutilization of services.
(f) A PIP vendor that arranges the physical examinations of injured parties pursuant to N.J.A.C. 11:3-4.7(e) shall submit the criteria it uses to select providers to
be on the vendor’s panel of examining providers, how it evaluates the quality of
an examining provider’s examination report and how it avoids conflicts of interest
when examinations are ordered and scheduled.
(g) Two copies of the information in (a) through (f) above shall be submitted to
the Department at the following address:
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.7A
New Jersey Department of Banking and Insurance
Office of Property and Casualty
P.O. Box 325
Trenton, NJ 08625-0325
(h) The Department shall advise the applicant if the application is incomplete
not later than 60 days after receipt of the application. Notice to the applicant that
the application is incomplete shall specify the missing items or information. The
Department shall disapprove an incomplete application if the requested information is not provided within 30 days of the notification to the applicant. If the Department does not notify the applicant of missing items or information within 60
days of receipt, the application shall be deemed complete.
(i) The Commissioner shall approve an application for registration if he or she
finds that the applicant has demonstrated the ability to perform services in a manner that meets the requirements of this subchapter.
(j) The Commissioner may deny an application for registration as a PIP vendor
if he or she finds that any of standards established by this subchapter have not been
met or for any other reasonable grounds.
1. If the application for registration is denied, the Commissioner shall notify the
applicant in writing of the reasons for the denial.
2. When the Department denies an application for registration, the applicant
may request a hearing within 30 days of receipt of the denial by submitting a request in writing to the address in (g) above setting forth, with specificity, the reasons that the applicant disputes the Department's denial notice.
(k) Registration shall be effective for a period of two years. Registered PIP vendors shall reapply for registration 90 days prior to expiration by submitting the information in (d) through (f) above showing changes to the items previously submitted.
(l) All data or information in the PIP vendor's application for registration and
the vendor’s contract with the insurer required to be submitted pursuant to
N.J.A.C. 11:3-4.7(c)1 shall be confidential and shall not be disclosed to the public,
except as follows:
1. The PIP vendor’s certificate of incorporation;
2. The PIP vendor’s address;
3. The names of the PIP vendor's officers and directors, or the individuals in the
organization responsible for the administration of utilization management including the medical director(s); and
4. The date of registration of the PIP vendor and date that registration expires.
(m) The Commissioner may suspend or revoke the registration of a PIP vendor
upon finding that the PIP vendor no longer meets the standards set forth in this
subchapter; that PIP utilization review services are not being provided in accordance with the requirements of this subchapter; or that the registration was granted
based on false or misleading information.
1. Proceedings to revoke or suspend the registration shall be conducted pursuant to N.J.A.C. 11:17D.
2. Upon request of the PIP vendor for a hearing, the matter shall be transferred
to the Office of Administrative Law for a hearing conducted pursuant to the Administratve Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq., and the
Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).
11:3-4.8
APPENDIX B - REGULATIONS
11:3-4.8. Voluntary networks. (a) No insurer shall file a decision point review
plan utilizing a voluntary network or networks unless the network is a health
maintenance organization licensed pursuant to N.J.S.A. 26:2J-1 et seq.; or approved by the Department as part of a selective contracting arrangement with a
health benefits plan pursuant to N.J.A.C. 11:4-37 and 11:24A-4.10; or approved
as part of a workers’ compensation managed care organization pursuant to
N.J.A.C. 11:6; or is licensed or certified as an organized delivery system pursuant
to N.J.A.C. 11:22-4 and 11:24B.
(b) Voluntary networks may be offered for the provisions of the following types
of non-emergency benefits only:
1. Magnetic Resonance Imagery;
2. Computer Assisted Tomography;
3. The electrodiagnostic tests listed in N.J.A.C. 11:3-4.5(b)1 through 3 except
for needle EMGs, H-reflex and nerve conduction velocity (NCV) tests performed
together by the treating physician;
4. Durable medical equipment with a cost or monthly rental in excess of
$50.00;
5. Prescription drugs; or
6. Services, equipment or accomodations provided by an ambulatory surgery
facility.
(c) Insurers that offer voluntary networks either directly or through a PIP vendor shall meet the following requirements:
1. The insurers shall notify all insureds upon application for and issuance of the
policy and upon renewal of the types of benefits for which it has voluntary networks. Use of the network by the insured is voluntary but bills for out-of-network
services or equipment are subject to the penalty deductibles set forth in N.J.A.C.
11:3-4.4(g).
2. Upon receipt of a request for PIP benefits under the policy, the insurer or its
PIP vendor shall make available to the insured and the treating medical provider
information about approved networks and providers in the network, including addresses and telephone numbers. Insureds shall be able to choose to go to any provider in the network.
(d) An insurer offering a voluntary network or networks directly or through a
PIP vendor shall submit the following information to the Department with its Decision Point Review Plan:
1. A narrative description of the benefits to be offered through the network or
networks;
2. The identity and a description of the network and the specific services or supplies to be provided by the network or networks;
3. A description of the procedures by which benefits may be obtained by persons using the network;
4. A statement of how the network meets the requirement of (a) above.
(e) Any voluntary network used by an insurer pursuant to this subchapter shall
agree to disclose to a participating provider, upon written request, a list of all the
clients or other payers that are entitled to a specific rate under the network’s contract with the participating provider.
Repeal and New Rule. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). Amended.
R.2010 d.142, effective July 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a). Amended.
R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
11:3-4.9. Assignment of benefits; public information. (a) Pursuant to
N.J.S.A. 39:6A-4, an insured may only assign benefits and duties under the policy
to a provider of service benefits. Insurers may file for approval policy forms that
include reasonable procedures for restrictions on the assignment of personal injury protection benefits and duties under the policy, consistent with the efficient administration of the coverage and the prevention of fraud. Insurers may not prohibit
the assignment of benefits to providers. Reasonable restrictions may include, but
are not limited to:
1. A requirement that as a condition of assignment, the provider agrees to follow the requirements of the insurer's decision point review plan for making decision point review and precertification requests;
2. A requirement that as a condition of assignment, the provider shall hold the
insured harmless for penalty co-payments imposed by the insurer based on the
provider's failure to follow the requirements of the insurer's decision point review
plan; and/or
3. A requirement that as a condition of assignment, the provider agrees to submit disputes to alternate dispute resolution pursuant to N.J.A.C. 11:3-5.
(b) Insurers shall file policy language requiring that providers who are assigned
benefits by the insured or have a power of attorney from the insured make an internal appeal pursuant to N.J.A.C. 11:3-4.7B prior to making a request for dispute
resolution in accordance with N.J.A.C. 11:3-5.
(c) An insurer shall identify documents containing proprietary information in
its decision point review plan submission. Documents containing proprietary information shall be confidential and shall not be subject to public inspection and
copying pursuant to the "Right-to-Know" law, N.J.S.A. 47:1A-1 et seq. The Department shall notify the insurer prior to responding to any public record request
for proprietary information.
Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operative
October 27, 2004); R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).
11:3-4.10. (Reserved).
Repealed. R.2004 d.218, effective June 7, 2004.
APPENDIX - TREATMENT OF ACCIDENTAL INJURY TO THE SPINE
AND BACK CARE PATHS
Exhibit 1
Glossary of Terms
Acute Disease--a disease with rapid onset and short course to recovery. Not
chronic.
Care Path--a recommended extensive course of care based on professionally
recognized standards.
Case Management--a method of coordinating the provision of healthcare to
persons injured in automobile accidents, with the goal of ensuring continuity and
quality of care and cost effective outcomes. The Case Manager may be a nurse,
social worker, or physician, preferably with certification in case management.
Cauda Equina--a collection of spinal roots that descend from the lower part of
the spinal cord. They exist in the lower part of the vertebral canal.
Chronis Disease--a disease with long duration that changes little and progresses slowly. The apposite of acute.
Clinical Evaluation--the evaluation of the symptoms and signs of an injured
person by a treating practitioner.
11:3-4.10
APPENDIX B - REGULATIONS
Conservative Therapy--treatment which is not considered aggressive; avoiding
the administration of medicine or utilization of invasive procedures until such procedures are clearly indicated.
Contusion--an injury to underlying soft tissues when the skin is not broken. A
bruise.
Diagnostic Evaluation--the process of differentiating between two or more diseases with similar signs and symptoms through the use of evaluative procedures
such as imaging, laboratory, and physical tests.
Herniation--the protrusion or projection of an organ or other body structure
through a defect or natural opening in a covering membrane, muscle, or bone.
Independent Consultative Opinion--physical examination by a physician of
similar specialty to the injured person's treating practitioner to provide a second
medical opinion. The independent physician may support, refute, or provide alternatives to the current diagnosis and treatment plans.
Non-Compliant--a patient who wilfully chooses not to participate in the treatment plan agreed upon by the patient and his/her healthcare provider and does not
have secondary issues such as lack of transportation, pre-existing conditions or comorbidities.
PT--Physical Therapy--the therapeutic use of heat, light, water, electricity, massage, exercise, and non-ionizing radiation in treatment of injuries to the soft tissue
and muscles/skeleton. PT rendered to persons injured in automobile accidents
must be provided by a person whose scope of licensure includes physical therapy.
Radicular--pertaining to a root (such as a nerve root) disorder.
Radiculopathy--a disorder of a nerve root.
Sign--an objective manifestation, usually indicative of a disease or disorder.
Signs can be observed by the clinician, as opposed to symptoms, which are
perceived only by the affected individual.
Soft Tissue Injury--injuries sustained to the muscle, skin, connective tissue.
Spine--the vertebral column.
Spinal Shock--an acute condition resulting from spinal cord severance. Characterized by a total sensory loss and loss of reflexes below the level of injury and
flaccid paralysis.
Sprain--an injury at a joint where a ligament is stretched or torn.
Strain--an injury caused by the over-stretching or tearing of a muscle or tendon.
In its most severe form, the muscle ruptures.
Symptom--a subjective manifestation, usually indicative of a disease or disorder. Symptoms are experienced only by the affected individual, as opposed to
signs, which can be observed by others.
Treatment Plan--specific medical, surgical, chiropractic, acupuncture, or psychiatric procedures used to improve the signs or symptoms associated with injuries sustained in automobile accidents, e.g., physical therapy, surgery, administration of medications, etc.
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
.
NOTE: These Care Paths identify typical courses of intervention. There may be patients
who require more or less treatment. However, cases that deviate from the Care Paths may
be subject to more careful scrutiny and may require documentation of the special
circumstances. Treatments must be based on patient need and professional judgment.
Deviations may be justified by individual circumstances, such as pre-existing conditions
and/or comorbidities. The Care Paths are only intended for use when the injury was caused
by a motor vehicle accident (MVA). If at any point in the decision making process the
healthcare provider finds evidence that the injury was not caused by a MVA, the provider
must contact the patient’s PIP carrier and medical insurance carrier.
11:3-4.10
APPENDIX B - REGULATIONS
1, 2, 3, 4 See Addendum to Care Paths
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less
treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require
documentation of the special circumstances. Treatments must be based on patient need and professional judgment.
Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The
Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point
in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the
provider must contact the patient’s PIP carrier and medical insurance carrier.
11:3-4.10
APPENDIX B - REGULATIONS
4 See Addendum to Care Paths
ICD-9 CODES
728.0
728.85
739.0
739.1
847.0
847.9
922.3
922.31
953.0
CARE PATH 1
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
NOTE: These Care Paths identify typical courses of intervention. There may be patients
who require more or less treatment. However, cases that deviate from the Care Paths may
be subject to more careful scrutiny and may require documentation of the special
circumstances. Treatments must be based on patient need and professional judgment.
Deviations may be justified by individual circumstances, such as pre-existing conditions
and/or comorbidities. The Care Paths are only intended for use when the injury was caused
by a motor vehicle accident (MVA). If at any point in the decision making process the
healthcare provider finds evidence that the injury was not caused by a MVA, the provider
must contact the patient’s PIP carrier and medical insurance carrier.
11:3-4.10
APPENDIX B - REGULATIONS
1, 2, 4 See Addendum to Care Paths
ICD-9 CODES
722.0
722.2
722.70
722.71
728.0
739.0
953.0
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
1, 2, 3, 4 See Addendum to Care Paths
NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more
or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny
and may require documentation of the special circumstances. Treatments must be based on patient need and
professional judgment. Deviations may be justified by individual circumstances, such as pre-existing
conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a
motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds
evidence that the injury was not caused by a MVA, the provider must contact the patient’s PIP carrier and
medical insurance carrier.
11:3-4.10
APPENDIX B - REGULATIONS
ICD-9 CODES
728.0
728.85
739.0
739.7
739.8
847.1
847.9
922.3
922.33
953.2
4 See Addendum to Care Paths
CARE PATH 3
1,3 See Addendum to Care Paths
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
11:3-4.10
APPENDIX B - REGULATIONS
NOTE: These Care Paths identify typical courses of intervention. There may be patients
who require more or less treatment. However, cases that deviate from the Care Paths may
be subject to more careful scrutiny and may require documentation of the special
circumstances. Treatments must be based on patient need and professional judgment.
Deviations may be justified by individual circumstances, such as pre-existing conditions
and/or comorbidities. The Care Paths are only intended for use when the injury was caused
by a motor vehicle accident (MVA). If at any point in the decision making process the
healthcare provider finds evidence that the injury was not caused by a MVA, the provider
must contact the patient’s PIP carrier and medical insurance carrier.
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less
treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require
documentation of the special circumstances. Treatments must be based on patient need and professional judgment.
Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care
Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the
decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider
must contact the patient’s PIP carrier and medical insurance carrier.
ICD-9 CODES
11:3-4.10
728.0
728.85
739.0
739.3
739.4
846
846.0
846.1
846.2
846.3
APPENDIX B - REGULATIONS
846.8
846.9
847.2
847.3
847.4
847.9
922.3
922.31
953.2
953.3
CARE PATH 5
4 See Addendum to Care Paths
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
11:3-4.10
APPENDIX B - REGULATIONS
NOTE: These Care Paths identify typical courses of intervention. There may be patients
who require more or less treatment. However, cases that deviate from the Care Paths may
be subject to more careful scrutiny and may require documentation of the special
circumstances. Treatments must be based on patient need and professional judgment.
Deviations may be justified by individual circumstances, such as pre-existing conditions
and/or comorbidities. The Care Paths are only intended for use when the injury was caused
by a motor vehicle accident (MVA). If at any point in the decision making process the
healthcare provider finds evidence that the injury was not caused by a MVA, the provider
must contact the patient’s PIP carrier and medical insurance carrier.
PIP BENEFITS; PROTOCOLS; TESTS
11:3-4.10
EXHIBIT 9
TREATMENT OF ACCIDENTAL INJURY TO THE SPINE AND BACK
CARE PATH DIAGNOSIS CODING
The following International Classification of Diseases, 9th Revision Clinical
Modification--fifth edition ICD-9-CM diagnostic codes are associated with Care
Path 1 through Care Path 6 for treatment of Accidental Injury to the Spine and
Back and are included on each appropriate Care Path. The ICD9 codes referenced
do not include codes for multiple diagnoses or co-morbidity.
Care Path 1
728.0 Disorders of muscle, ligament and fascia
728.85 Spasm of muscle
739.0 Non allopathic lesions--not elsewhere classified
739.1 Somatic dysfunction of cervical region
847.0 Sprains and strains of neck
847.9 Sprains and strains of back, unspecified site
922.3 Contusion of back
922.31 Contusion of back, excludes interscapular region
953.0 Injury to cervical root
Care Path 2
722.0 Displacement of cervical intervertebral disc without myelopathy
722.2 Displacement of intervertebral disc, site unspecified, without myelopathy
722.70 Intervertebral disc disorder with myelopathy, unspecified region
722.71 Intervertebral disc disorder with myelopathy, cervical region
728.0 Disorders of muscle, ligament and fascia
739.0 Non allopathic lesions--not elsewhere classified
953.0 Injury to cervical root
Care Path 3
728.0 Disorders of muscle, ligament and fascia
728.85 Spasm of muscle
739.0 Non allopathic lesions--not elsewhere classified
739.2 Somatic dysfunction of thoracic region
739.8 Somatic dysfunction of rib cage
847.1 Sprains and strains, thoracic
847.9 Sprains and strains of back, unspecified site
922.3 Contusion of back
922.33 Contusion of back, interscapular region
Care Path 4
722.0 Displacement of cervical intervertebral disc without myelopathy
722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.11 Displacement of thoracic intervertebral disc without myelopathy
722.2 Displacement of intervertebral disc, site unspecified, without myelopathy
722.70 Intervertebral disc disorder with myelopathy, unspecified region
722.72 Intervertebral disc disorder with myelopathy, thoracic region
728.0 Disorders of muscle, ligament and fascia
11:3-4.10
739.0
APPENDIX B - REGULATIONS
Non allopathic lesions--not elsewhere classified
Care Path 5
728.0 Disorders of muscle, ligament and fascia
728.85 Spasm of muscle
739.0 Non allopathic lesions--not elsewhere classified
739.3 Somatic dysfunction of lumbar region
739.4 Somatic dysfunction of sacral region
846
Sprains and strains of sacroiliac region
846.0 Sprains and strains of lumbosacral (joint) (ligament)
846.1 Sprains and strains of sacroiliac ligament
846.2 Sprains and strains of sacrospinatus (ligament)
846.3 Sprains and strains of sacrotuberous (ligament)
846.8 Sprains and strains of other specified sites of sacroiliac region
846.9 Sprains and strains, unspecified site of sacroiliac region
847.2 Sprains and strains, lumbar
847.3 Sprains and strains, sacrum
847.4 Sprains and strains, coccyx
847.9 Sprains and strains, unspecified site of back
922.3 Contusion of back
922.31 Contusion of back, excludes interscapular region
953.2 Injury to lumbar root
953.3 Injury to sacral root
Care Path 6
722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.10 Displacement of lumbar intervertebral disc without myelopathy
722.2 Displacement of intervertebral disc, site unspecified, without myelopathy
722.70 Intervertebral disc disorder with myelopathy, unspecified region
722.73 Intervertebral disc disorder with myelopathy, lumbar region
728.0 Disorders of muscle, ligament and fascia
739.0 Non allopathic lesions--not elsewhere classified
953.3 Injury to sacral root
The following ICD-9-CM supplemental classification of external causes of injury may be used in addition to the specific diagnostic codes noted above and on
each Care Path:
• E 810 through E 819, selected E 820 series codes.
These codes may be used to indicate cause of injury as motor vehicle accident
but should not be used without an associated diagnostic code.
EXHIBIT 10
ADDENDUM TO CARE PATHS
1. Medications
Muscle Relaxants
• Muscle relaxants are an option in the treatment of patients with acute neck,
thoracic, and low back problems. While probably more effective than placebo,
muscle relaxants have not been shown to be more effective than NSAIDs.
• No additional benefit is gained by using muscle relaxants in combination with
NSAIDs over using NSAIDs alone.
PIP DISPUTE RESOLUTION
11:3-5
• Muscle relaxants have potential side effects in 30 percent of patients. When
considering the option of using relaxants, the clinician should balance the
potential patient's intolerance of other agents.
Opioid Analgesics
• When used for a time-limited course, opioid analgesics are an option in the
management of patients with acute neck, thoracic, and low back problems. The
decision to use opioids should be guided by consideration of their potential
complications relative to other options.
• Opioids appear to be more effective in relieving neck, thoracic, and low back
symptoms than safer analgesics, such as acetaminophen or aspirin or other
NSAIDs.
• Clinicians should be aware of the side effects of opioids, such as decreased
reaction time, clouded judgment, and drowsiness, which lead to early
discontinuation by as many as 35 percent of patients.
• Patients should be warned about dependence and the danger of opioids while
operating heavy machinery.
Oral Steroids
• Oral steroids are not recommended for the treatment of acute neck, thoracic,
or low back problems.
• A potential for severe side effects is associated with the extended use of oral
steroids or steroids in high doses.
2. Who May Perform Spinal Manipulation:
Spinal manipulation may be performed by those providers licensed or certified
to perform this procedure within their scope of practice.
3. Spinal Manipulation
A course of spinal manipulation/chiropractic care may be considered as conservative therapy on all Care Paths. If there is no improvement within one month,
then immediate reevaluation is indicated to determine appropriate further treatment and treatment options, including referral to other health care providers and/
or modification of conservative therapy.
When findings suggest progressive or severe neurologic deficits, an appropriate diagnostic assessment to rule out serious neurologic conditions is indicated in
any conservative therapy.
4. Mental Health/Rehabilitation Assessment Option If Patient Has Not
Responded To Treatment
A mental health/rehabilitation assessment can be obtained if psychological/
psychosocial or psychiatric distress is obvious from the history, i.e., presence of
“non-organic” physical signs, repetitive back injuries, failed previous treatments,
litigation or disability compensation claims, family or financial problems, apparent secondary gain, boredom and dissatisfaction with job, frequent bouts of pain,
depression, alcohol and substance abuse, extreme obesity, and apparent psychiatric behavior.
SUBCHAPTER 5. PERSONAL INJURY PROTECTION DISPUTE
RESOLUTION
Source and Effective Date.R. 1998 d. 592, effective December 21, 1998 (operative March 22, 1999).
Section
11:3-5.1.
Purpose and scope.
11:3-5.2
11:3-5.2.
11:3-5.3.
11:3-5.4.
11:3-5.5.
11:3-5.6.
11:3-5.7.
11:3-5.8.
11:3-5.9.
11:3-5.10.
11:3-5.11.
11:3-5.12.
APPENDIX B - REGULATIONS
Definitions.
Designation of the administrator.
Dispute resolution organizations.
Dispute resolution professionals.
Conduct of PIP dispute resolution proceedings.
Recordkeeping.
Medical review organizations.
Standards for medical review organizations.
Medical review organization certification process.
Fees.
Prohibition of conflicts of interest.
11:3-5.1. Purpose and scope. (a) The purpose of this subchapter is to establish
procedures for the resolution of disputes concerning the payment of medical expense and other benefits provided by the personal injury protection coverage in
policies of automobile insurance. This subchapter implements N.J.S.A. 39:6A-5.1
and 5.2, which provide that PIP disputes shall be resolved by binding alternate dispute resolution as provided in the policy form approved by the Commissioner.
This subchapter also implements provisions of N.J.S.A. 2A:23A-1 et seq., as applicable to PIP dispute resolution.
(b) This subchapter shall apply to disputes arising under policies of private passenger automobile insurance, on either a personal lines or commercial lines policy
form, that provide medical expense benefits and other benefits under personal injury protection coverage, as follows:
1. PIP benefits under a standard automobile insurance policy pursuant to
N.J.S.A. 39:6A-4;
2. PIP benefits under a basic automobile insurance policy pursuant to N.J.S.A.
39:6A-3.1;
3. PIP benefits provided by the UCJF pursuant to N.J.S.A. 39:6-86.1; and
4. Additional PIP benefits provided pursuant to N.J.S.A. 39:6A-10.
(c) This subchapter shall apply to policies issued or renewed on or after March
22, 1999 in accordance with the approved policy terms.
11:3-5.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates
otherwise:
“Administrator” means the dispute resolution organization designated by the
Commissioner pursuant to N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.3.
“Basic policy” means an automobile insurance policy issued pursuant to
N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3.
“Commissioner” means the Commissioner of the New Jersey Department of
Banking and Insurance.
“Control” or “controlled” means the possession, direct or indirect, of the power
to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial
contract for goods or nonmanagement services, or otherwise, unless the power is
the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls,
holds the power to vote, or holds proxies representing, 10 percent or more of the
voting securities of any other person, provided that no such presumption of control
shall of itself relieve any person so presumed to have control from any require-
PIP DISPUTE RESOLUTION
11:3-5.2
ment of P.L. 1970, c.22 (N.J.S.A. 17:27A-1 et seq.). This presumption may be rebutted by a showing made in the manner provided by N.J.S.A. 17:27A-3j that control does not exist in fact. The Commissioner may determine, after furnishing all
persons in interest notice and an opportunity to be heard, and making specific findings of fact to support such determination, that control exists in fact, notwithstanding the absence of a presumption to that effect.
“Department” means the New Jersey Department of Banking and Insurance.
“Dispute resolution organization” or “DRO” means an organization that meets
the standards set forth in N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.4.
“Dispute resolution professional” or “DRP” means a natural person who meets
the standards set forth in N.J.A.C. 11:3-5.5.
"In-person proceeding" or "in-person case" means a PIP dispute where the parties or their representatives appear in person or telephonically before the DRP to
present their cases in accordance with the rules of the dispute resolution organization.
“Medical review organization” or “MRO” means an organization of health care
professionals who are licensed in New Jersey, which is certified by the Commissioner to engage in unbiased medical review of the medical care provided to persons injured in automobile accidents in accordance with N.J.S.A. 39:6A-5.2 and
this subchapter. The term includes either;
1. Any peer review organization with which the Federal Health Care Financing
Administration or the State contracts for medical review of Medicare or medical
assistance services; or
2. Any independent health care review company.
"On-the-papers proceeding" or "on-the-papers case" means a PIP dispute
where the parties or their representatives submit written documentation supporting their case and the DRP decides the case based solely upon the documentation
without any in person or telephonic appearances by the parties or their representatives in accordance with the rules of the dispute resolution organization. On-thepapers proceedings are only permitted where all parties consent or where there is
no further treatment at issue and the amount at issue in the dispute is less than $
1,000.
“Personal Automobile Insurance Plan” or “PAIP” means the personal lines automobile insurance residual market mechanism established pursuant to N.J.S.A.
17:29D-1 by N.J.A.C. 11:3-2.
“Personal injury protection” or “PIP” means the coverage provided by a policy
of automobile insurance pursuant to N.J.S.A. 39:6A-3.1, 39:6A-4 or the emergency personal injury protection coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89.
“PIP dispute” includes, but is not limited to, matters concerning:
1. Interpretation of the insurance contract's PIP provisions;
2. Whether the medical treatment or diagnostic tests are in accordance with the
provisions of applicable statutes and rules for the basic and standard policies and
in compliance with the terms of the policy;
3. Eligibility of the treatment or service for compensation or reimbursement,
including whether the injury is causally related to the accident and the application
of deductible and copayment provisions;
4. Eligibility of the provider performing the service to be compensated or reimbursed under the terms of the policy and the provisions of N.J.A.C. 11:3-4, and
11:3-5.3
APPENDIX B - REGULATIONS
including whether the provider is licensed or certified to perform the treatment or
service;
5. Whether the treatment was actually performed;
6. Whether the diagnostic tests performed are recognized by the Professional
Boards in the Division of Consumer Affairs, Department of Law and Public Safety, administered in accordance with their standards, and approved by the Commissioner at N.J.A.C. 11:3-4;
7. The necessity and appropriateness of consultation with other health care providers;
8. Disputes involving the application of, or adherence to, the automobile insurance medical fee schedule at N.J.A.C. 11:3-29;
9. Whether the treatment or service is reasonable, necessary and in accordance
with medical protocols adopted by the Commissioner at N.J.A.C. 11:3-4; or
10. Amounts claimed for PIP income continuation benefits, essential services
benefits, death benefits and funeral expense benefits.
“Provider” or “health care provider” is as defined at N.J.A.C. 11:3-4.2.
“Standard policy” means an automobile insurance policy including PIP coverage as provided in N.J.S.A. 39:6A-4.
“UCJF” means the Unsatisfied Claim and Judgement Fund created pursuant to
N.J.S.A. 39:6-61 et seq.
Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2012 d.187, effective
November 5, 2012 (operative January 4, 2013).
11:3-5.3. Designation of the administrator. (a) The Commissioner shall designate a dispute resolution organization as the administrator of the PIP alternate
dispute resolution system by entering into a contract with a dispute resolution organization.
(b) The contract designating the administrator shall be for a term not to exceed
five years, but may be extended according to its terms until a new administrator is
designated and substituted. Nothing in this subsection shall prohibit an administrator from succeeding itself, if so designated in accordance with N.J.S.A. 39:6A5.1 and this subchapter. The contract may provide for adjustments in the price paid
for services performed over the life of the contract.
(c) The Commissioner shall request competitive proposals from among qualified dispute resolution organizations interested in serving as administrator.
(d) Dispute resolution organizations shall submit the following documents and
information in connection with their proposal to serve as administrator:
1. A dispute resolution plan that describes how the organization shall meet the
requirements of the Act and these rules, which shall include procedures and rules
governing the dispute resolution process to ensure adherence to the standards of
performance set forth in N.J.S.A. 39:6A-5.1 and 5.2 and this subchapter;
2. A description of the organization and biographical information about the key
personnel that shall be responsible for executing the duties of the administrator;
3. A description of the management information systems that shall be utilized
by the organization;
4. A draft budget for at least the first two years;
5. A cost proposal, which shall provide for the payment of the administrator's
expenses, including the cost of dispute resolution professionals, from fees generated from the users of the system;
PIP DISPUTE RESOLUTION
11:3-5.4
6. Such other information as may be provided by law, and that the Commissioner or the Treasurer may request in order to understand and evaluate the applicant's
proposal.
11:3-5.4. Dispute resolution organizations. (a) In order to be eligible for designation as administrator, a dispute resolution organization shall meet the following criteria:
1. The dispute resolution organization shall not be owned or controlled by an
insurer or affiliate of an insurer;
2. The dispute resolution organization shall utilize full-time dispute resolution
professionals that meet the standards set forth in N.J.A.C. 11:3-5.5. For the purpose of this paragraph, “full-time” shall be construed to include persons who work
fewer than five days per week, but who do not engage in other, conflicting employment;
3. The dispute resolution organization shall utilize an advisory council composed of parties who are users of the dispute resolution mechanism in connection
with the selection of dispute resolution professionals and the periodic review of
the organization's rules and processes;
4. The dispute resolution organization shall utilize procedures to avoid conflicts of interests as prohibited at N.J.A.C. 11:3-5.12;
5. The dispute resolution organization shall arrange for proceedings in locations reasonably convenient to the parties;
6. The dispute resolution organization shall maintain published rules for the
conduct of the proceedings, and shall make them available to the parties and the
public upon request;
7. The dispute resolution organization shall perform its functions in a prompt
and efficient manner, giving due regard to the nature of the proceeding and the
need for special attention when required by the exigencies of a particular matter;
and
8. The dispute resolution organization shall provide sufficient oversight and
training of its dispute resolution professionals so as to promote fair, efficient and
consistent determinations consistent with substantive law and with rules adopted
by the Commissioner.
(b) The dispute resolution organization shall develop and maintain a dispute
resolution plan approved by the Commissioner that sets forth its procedures and
rules. The dispute resolution plan shall be reviewed at least annually and revisions
made upon approval by the Commissioner. The plan shall include the following
elements:
1. The plan shall provide that PIP dispute resolution be initiated by written notice to the administrator and to all other parties of the party's demand for dispute
resolution, which notice shall set forth concisely the claims, and where appropriate the defenses, in dispute and the relief sought. Where the arbitration is filed by
a provider acting as an assignee of benefits or with a power of attorney from the
insured, the notice shall include proof of compliance with the internal appeal process required by N.J.A.C. 11:3-4.7B. All notices shall also include such other information as may be required for administrative purposes;
2. The plan shall provide for consolidation of claims into a single proceeding
where appropriate in order to promote prompt, efficient resolution of PIP disputes
consistent with fairness and due process of law;
3. The plan shall provide the assigned dispute resolution professional with sufficient authority to provide all relief and to determine all claims arising under PIP
11:3-5.5
APPENDIX B - REGULATIONS
coverage, but may provide for limited, procedural or emergent matters to be determined by one or more specially designated dispute resolution professionals;
i. Emergent or expedited relief shall be granted upon demonstration that immediate and irreparable loss or damage will result in the absence of such relief;
4. The plan shall provide for the assignment of a medical review organization
to review the case and report its determination when requested pursuant to
N.J.S.A. 39:6A-5.2 and this subchapter;
5. The plan shall provide for the prompt, fair and efficient resolution of PIP disputes, including in-person and on-the-papers proceedings in accordance with the
rules of the dispute resolution organization. The plan shall also provide that alternate procedures may be utilized when appropriate, which may include mediation,
conferences to promote consensual resolution and expedited hearings upon receipt
of a medical review organization report, consistent with principles of substantive
law and rules adopted by the Commissioner;
6. The plan shall provide for a procedure whereby a demand for arbitration
based on an insurer's denial of a decision point review or precertification request
as not medically necessary, as defined in N.J.A.C. 11:3-4.2, may be submitted directly to an MRO for an expedited determination of medical necessity. No DRP
will be assigned and no attorney fees may be charged. The administrator shall set
a fee for handling such requests in addition to the MRO fee. The plan shall provide
that if the expedited MRO review does not resolve the dispute, the claimant/insured may continue with the standard arbitration procedure before a DRP; and
7. The plan shall provide for the fair and efficient conduct of adversarial proceedings when other methods of dispute resolution are either unsuccessful or inappropriate, consistent with traditional notions of due process and fundamental
fairness. It shall address, at least, the following procedural issues;
i. Discovery;
ii. Receipt of evidence by the dispute resolution professional;
iii. Submission of briefs or memoranda of law and fact;
iv. Provision for decisions without testimony on consent of parties;
v. Notice and place of hearing;
vi. Methods to request adjournments;
vii. Presentation of testimony and evidence at a hearing; and
viii. Supplementation of the record.
(c) If consistent with its dispute resolution plan, a dispute resolution organization may utilize one or more dispute resolution professionals specifically to handle
preliminary matters on actions including motions to disqualify an appointed DRP.
Amended. R.2010 d.142, effective July 6, 2004; R.2010 d.142, effective July 6, 2010. Administrative
correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative
January 4, 2013).
11:3-5.5. Dispute resolution professionals. (a) A dispute resolution professional employed by the dispute resolution organization shall be either:
1. An attorney licensed to practice in New Jersey with at least 10 years of experience in cases involving personal injury or workers' compensation;
2. A former judge of the Superior Court or the Workers' Compensation Court,
or a former Administrative Law Judge; or
3. Any other person, qualified by education and at least 10 years' experience,
with sufficient understanding of automobile insurance claims and practices, contract law, and judicial or alternate dispute resolution practices nd procedures.
(b) Dispute resolution professionals shall avoid conflicts of interest as prohibited at N.J.A.C. 11:3-5.12 in any matter assigned to them for determination.
PIP DISPUTE RESOLUTION
11:3-5.6
1. Dispute resolution professionals shall complete and file with the dispute resolution organization a conflict of interest questionnaire that shall provide sufficient detail about financial interests of themselves and their immediate family so
as to avoid any assignment to a particular case where there is a conflict of interest.
Conflict of interest questionnaires shall remain confidential with the dispute resolution organization, and the information set forth therein shall only be disclosed as
necessary to individuals responsible for assigning cases to dispute resolution professionals, or reviewing motions to disqualify an assigned dispute resolution professional.
2. If during the course of an assignment a dispute resolution professional determines that he or she has conflict of interest, based upon facts determined in the
course of the proceedings, then the DRP shall promptly advise the administrator
of the circumstances, who shall assign another DRP.
3. A party may challenge the assignment of a particular DRP by submitting the
specific grounds for challenge in accordance with the rules of the dispute resolution organization approved by the Commissioner. The rules of the dispute resolution organization approved by the Commissioner shall provide that a party may
challenge the assignment of the DRP as follows:
i. When the party receives notification of the assignment of the DRP for an inperson case; or
ii. As part of the appeal process provided in the rules for on-the-papers cases.
(c) Dispute resolution professionals shall be compensated by the administrator
in accordance with the terms of the contract designating the administrator. Compensation shall not be contingent in any way upon the decision or determination
of the DRP.
(d) Dispute resolution professionals shall create and maintain such records as
may be necessary to carry out their responsibilities and provide such records to the
administrator as required in the contract designating the administrator.
Amended. R.2006 d.243, effective July 3, 2006; R.2012 d.187, effective November 5, 2012 (operative
January 4, 2013).
11:3-5.6. Conduct of PIP dispute resolution proceedings. (a) A request for
dispute resolution of a PIP dispute may be made by the injured party, the insured,
a provider who is an assignee of PIP benefits pursuant to N.J.A.C. 11:3-4.9 or the
insurer, in accordance with the terms of the policy as approved by the Commissioner. The request for dispute resolution may include a request for review by a
medical review organization. The request shall be made to the administrator and
copies sent to other parties.
1. Every insurer shall establish a single address where requests for dispute resolution shall be sent. Insurers shall notify the administrator of the address and any
changes thereto. The administrator shall make the list of insurer addresses available to the user community on a web page and any other available means of communication.
2. Providers who are the assignee of benefits by the insured or have a power of
attorney from the insured shall follow the insurer's internal appeal process mandated by N.J.A.C. 11:3-4.7B before making a request for dispute resolution in accordance with (a) above. The dispute resolution organization's plan shall include
a procedure for how the provider shall demonstrate that this requirement has been
satisfied.
(b) Upon receipt of the request, the administrator shall promptly assign the
matter to a dispute resolution professional. For in-person proceedings, the administrator shall notify all parties of the DRP assigned at the time the assignment is
11:3-5.6
APPENDIX B - REGULATIONS
made. For on-the-papers proceedings, the parties will receive notice of the DRP
assigned at the time the decision is issued.
(c) If the request for dispute resolution includes a request for review by a medical review organization, the administrator shall refer the matter to a certified medical review organization contemporaneously with the assignment of the DRP, and
shall notify the parties and the DRP that the matter has been referred. If the initial
request does not include a request for review by a medical review organization,
then a request for such review may be made by any party to the assigned DRP. The
DRP may refer a matter to a MRO on his or her own initiative upon a finding that
the dispute concerns the diagnosis, medical necessity of treatment or diagnostic
test administered to the injured person, whether the injury is causally related to the
accident or is the product of a preexisting condition, or the protocols utilized by a
provider. Whenever a DRP receives or initiates a request for MRO review, he or
she shall transmit it to the administrator for referral who shall refer the matter to a
certified MRO and notify the parties that the matter has been referred.
1. The administrator shall refer cases on a random or rotating basis to an MRO
that does not have a conflict of interest, in accordance with the administrator's dispute resolution plan. Referrals shall be made in such a manner so as not to disclose
the medical reviewer the identity of the insurer, nor to disclose to the insurer the
identity of the medical reviewer.
2. Upon request of the MRO, a provider whose services are the subject of review shall promptly furnish a written report of the history, condition, treatment
dates and results of diagnostic tests performed, and shall produce and permit the
copying and inspection of all records relating to the history, treatment and condition of the injured person, and shall submit all necessary documentation as requested. Upon request of the MRO through the administrator, the insurer shall
submit any and all documentation concerning its review of the treatment and testing of the injured person, and any reports by its reviewing provider why reimbursement for the treatment, test or item of durable medical equipment was denied.
3. The MRO may request an injured person to submit to a mental or physical
examination by an independent provider in the same discipline as the treating providers who is not affiliated with either the treating provider, the insurer or the
MRO health care provider performing the review. Any such examination shall be
conducted in a place reasonably convenient to the injured person. The MRO shall
make available to the examining provider any pertinent medical records.
4. If at any time the MRO determines that it has a conflict of interest in performing a particular review, it shall notify the administrator which shall refer the
case to another MRO.
i. Under such circumstances, the first-assigned MRO shall transmit to the newly assigned MRO such documents from the treating provider and the insurer as it
has accumulated on the case, as may be directed by the administrator.
ii. The first-assigned MRO shall not be entitled to any reimbursement for work
performed on the transferred case.
(d) Determination by the dispute resolution professional shall be in writing and
shall state the issues in dispute, the DRP's findings and legal conclusions based on
the record of the proceedings and the determination of the medical review organization, if any. The findings and conclusions shall be made in accordance with applicable principles of substantive law, the provisions of the policy and the Department's rules. The award shall set forth a decision on all issues submitted by the
parties for resolution.
PIP DISPUTE RESOLUTION
11:3-5.6
1. If the DRP finds that the determination of a medical review organization is
overcome by a preponderance of the evidence, the reasons supporting that finding
shall be set forth in the written determination.
2. The award shall apportion the costs of the proceedings, regardless of who
initiated the proceedings, in a reasonable and equitable manner consistent with the
resolution of the issues in dispute.
(e) Pursuant to N.J.S.A. 39:6A-5.2(g), the costs of the proceedings shall be apportioned by the DRP and the award may include reasonable attorney's fees for a
successful claimant in an amount consonant with the award. Where attorney's fees
for a successful claimant are requested, the DRP shall make the following analysis
consistent with the jurisprudence of this State to determine reasonable attorney's
fees, and shall address each item below in the award:
1. Calculate the "lodestar," which is the number of hours reasonably expended
by the successful claimant's counsel in the arbitration multiplied by a reasonable
hourly rate in accordance with the standards in Rule 1.5 of the Supreme Court's
Rules of Professional Conduct (http://www.judiciary.state.nj.us/rules/appendices/
rpc.htm#P65_6482).
i. The "lodestar" calculation shall exclude hours not reasonably expended;
ii. If the DRP determines that the hours expended exceed those that competent
counsel reasonably would have expended to achieve a comparable result, in the
context of the damages prospectively recoverable, the interests vindicated, and the
underlying statutory objectives, then the DRP shall reduce the hours expended in
the "lodestar" calculation accordingly; and
iii. The "lodestar" total calculation may also be reduced if the claimant has only
achieved partial or limited success and the DRP determines that the "lodestar" total calculation is therefore an excessive amount. If the same evidence adduced to
support a successful claim was also offered on an unsuccessful claim, the DRP
should consider whether it is nevertheless reasonable to award legal fees for the
time expended on the unsuccessful claim.
2. DRPs, in cases when the amount actually recovered is less than the attorney's
fee request, shall also analyze whether the attorney's fees are consonant with the
amount of the award. This analysis will focus on whether the amount of the attorney's fee request is compatible and/or consistent with the amount of the arbitration
award. Additionally, where a request for attorney's fees is grossly disproportionate
to the amount of the award, the DRP's review must make a heightened review of
the "lodestar" calculation described in (e)1 above.
(f) The award shall be signed by the dispute resolution professional. The original shall be filed with the administrator, and copies provided to each party. If the
award requires payment by the insurer for a treatment or test, payment shall be
made together with any accrued interest ordered in the award pursuant to N.J.S.A.
39:6A-5, within 45 days of the insurer's receipt of a copy of the determination, unless one of the actions permitted in (g) below has been filed. Where the arbitration
has been filed by a provider who is the assignee of benefits pursuant to N.J.A.C.
11:3-4.9, the payment shall be made payable to the provider.
(g) The final determination of the dispute resolution professional shall be binding upon the parties, but subject to clarification/modification and/or appeal as provided by the rules of the dispute resolution organization, and/or vacation, modification or correction by the Superior Court in an action filed pursuant to N.J.S.A.
2A:23A-13 for review of the award.
Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004; R.2012
d.187, effective November 5, 2012 (operative January 4, 2013). Administrative correction. See: 45
N.J.R. 214(a).
11:3-5.7
APPENDIX B - REGULATIONS
11:3-5.7. Recordkeeping. (a) The administrator shall maintain records of all
determinations for a period of five years.
(b) The administrator shall file a copy of each determination, except consent
determinations, with the Department in either hard copy or electronic form, as provided in the contract designating the administrator.
1. Any determination filed with the Department shall be indexed and coded so
as to facilitate retrieval.
2. The name of any injured party, except when appearing in the caption of the
matter or used as identification of the particular case, shall be redacted in the copy
filed with the Department so as to protect the privacy of the injured person.
(c) The administrator shall keep such other records as may be required by the
Commissioner and as set forth in the contract designating the administrator.
11:3-5.8. Medical review organizations. (a) Medical review organizations
shall be authorized to determine in connection with the PIP dispute resolution process set forth in this subchapter:
1. Whether the medical treatment or diagnostic test is medically necessary;
2. Whether the treatment is in accordance with medically recognized standard
protocols including those protocols approved by the Commissioner and set forth
in N.J.A.C. 11:3-4;
3. Whether the treatment is consistent with symptoms or diagnosis of the injury;
4. Whether the injury is causally related to the accident;
5. Whether the treatment is of a palliative rather than a restorative nature; and
6. Whether medical procedures and tests that have been repeated are medically
necessary.
(b) The findings of a medical review organization shall be presumed to be correct, but may be rebutted by a preponderance of the evidence submitted to the dispute resolution professional.
11:3-5.9. Standards for medical review organizations. (a) Medical review
organizations shall be capable of performing medical reviews for all primary specialties and disciplines.
(b) Medical review organizations shall employ a medical director to actively
participate in the review of cases to assure quality and consistency.
(c) Medical review organizations shall utilize health care providers in the same
discipline as the treating provider to perform the reviews who meet the following
standards:
1. Reviewing health care providers shall be active practitioners who obtain a
minimum of one-half of their income from practice in their area of specialty;
2. Reviewing health care providers shall be licensed in New Jersey and board
certified in their specialty;
3. Reviewing health care providers shall have at least two years' experience in
medical review, or be certified as a medical review physician; and
4. Reviewing health care providers shall have completed an orientation with
the MRO, including medical review instruction and report writing.
(d) A medical review organization shall have adequate procedures in place to
assure confidentiality of patient records.
1. All MRO files shall be indexed and referred to by reference number rather
than patient name.
2. Medical files shall be maintained in a secure area of the MRO’s offices.
3. Only the MRO shall request additional documents relating to the injured person's medical condition, or direct that the injured person be physically examined.
PIP DISPUTE RESOLUTION
11:3-5.10
(e) A medical review organization shall utilize procedures to provide for the
fair and open exchange of information and records related to the review between
the treating health care provider, any provider that has reviewed the case on behalf
of the insurer, and the MRO's reviewing health care provider.
(f) A medical review organization shall complete its review and submit its report to the dispute resolution professional in accordance with the medical exigencies of the case, but in no event in excess of 20 business days from receipt of medical records from the treating health care provider.
(g) A medical review organization shall have a procedure for obtaining mental
or physical examinations of injured persons that may be required in the course of
its review.
(h) A medical review organization shall utilize written review procedures. In
reaching its determinations, the MRO shall consider all information submitted by
the parties and information deemed appropriate by the MRO, including: pertinent
medical records, consulting physician reports and other documents submitted by
the parties; applicable commonly accepted protocols, professional standards and
practices by national standard setting organizations, and protocols and diagnostic
tests approved by the Commissioner and set forth in N.J.A.C. 11:3-4.
(i) A medical review organization shall utilize audit procedures to ensure compliance with statutory and regulatory requirements.
(j) A medical review organization shall retain records of its determinations for
five years.
11:3-5.10. Medical review organization certification process. (a) The Commissioner shall certify a medical review organization to provide medical review
services in connection with the resolutions of PIP disputes if the Commissioner
determines that the MRO complies with the standards set forth in N.J.A.C. 11:35.9 to provide an impartial review of the medical necessity or appropriateness of
treatments, health care services or items of durable medical equipment for which
medical expense benefits may be provided under personal injury protection coverage.
(b) For the purpose of obtaining certification by the Commissioner to act as a
medical review organization to perform medical review in connection with the
resolution of PIP disputes, an MRO shall submit two copies of a written application that sets forth the information in (b) below to:
Medical Review Organization Certification
New Jersey Department of Banking and Insurance
PO Box 325
Trenton, NJ 08625-0325
(c) The MRO application shall include the following:
1. A list of the names, addresses and specialties of the individual health care
providers that will provide the medical review services. If the MRO will be limited
in its service area, the application shall provide a map of the service area, including the providers by specialty;
2. A copy of the MRO's certificate of incorporation and by-laws;
3. A diagram of the MRO's organizational structure;
4. The location of the MRO's place of business where it administers its services
and maintains its records;
11:3-5.10
APPENDIX B - REGULATIONS
5. A listing and biography of the MRO's officers and directors, or the individuals in the organization responsible for administration of medical reviews, including the medical director;
6. A detailed description of the MRO's experience in the review of medical
care;
7. A description of its procedures for review of medical treatments, diagnostic
tests and items of durable medical equipment in conjunction with PIP medical expense benefits;
8. A current list identifying all property/casualty insurers, health insurers,
health maintenance organizations and health care providers with whom the MRO
maintains any health related business arrangement. The list shall include a brief
description of the nature of the arrangement, so as to permit the administrator to
avoid assignments that may create a conflict of interest;
9. The fee(s) for determination by the MRO;
10. Such other information as the Commissioner may specifically request in
connection with the certification of a particular applicant; and
11. A fee in the amount of $1,000 payable to the Department of Banking and
Insurance.
(d) The materials specified in (c) above shall be retained by the Department and
may be referred to the Department of Health and Senior Services for consultation
as necessary. Any significant changes in the materials filed with the Department
shall be reported as an amendment to the materials filed within 30 days of the
change.
(e) The Department, in consultation with the Department of Health and Senior
Services, shall review the materials and grant or deny certification within 45 days
of receipt of a complete filing. The Commissioner may extend the time an additional 30 days for good cause shown, and shall notify the applicant of any extension. A decision to deny certification shall be in writing and include an explanation of the reason for the denial.
(f) Initial certification shall be effective for a period of two years. Certified
MROs shall reapply for certification 90 days prior to expiration by submitting the
items set forth in (b)1, 6, 7, 8, 9 and 10 above and any changes to items previously
submitted in (b)2, 3, 4 and 5 above. Renewal certification may be effective for a
period of up to five years.
(g) All data or information in the MRO's application for certification shall be
confidential and shall not be disclosed to the public, except as follows:
1. The MRO's certificate of incorporation;
2. The MRO's address;
3. The names of the MRO's officers and directors, or the individuals in the organization responsible for the administration of medical reviews including the
medical director; and
4. The date of certification of the MRO and date that certification expires.
(h) Upon certification, the Department shall advise the administrator of the
name and address of the MRO, any limitations on its geographical service area and
information about persons with whom it maintains health related business arrangements.
(i) The Commissioner may suspend or revoke the certification of an MRO upon
finding that the MRO no longer meets the standards set forth in N.J.A.C. 11:3-5.9;
that medical review services are not being provided in accordance with the re-
AUTOMOBILE REPARATION REFORM
11:3-5.12
quirements of this subchapter; or that the certification was granted based on false
or misleading information.
1. Proceedings to revoke or suspend the certification shall be conducted pursuant to N.J.A.C. 11:17D.
2. Upon request of the MRO for a hearing, the matter shall be transferred to the
Office of Administrative Law for a hearing conducted pursuant to the Uniform
Administrative Procedure Rules, N.J.A.C. 1:1.
Amended. R.2006 d.243, effective July 3, 2006; R.2010 d.142, effective July 6, 2010. Administrative
correction. See: 42 N.J.R. 2129(a).
11:3-5.11. Fees. When a mental or physical examination is performed in connection with the medical review organization's services, the health care provider
performing the examination shall be paid the fee provided for that service set forth
on the Department's medical fee schedule, N.J.A.C. 11:3-29.
Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2010 d.142, effective
July 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a).
11:3-5.12. Prohibition of conflicts of interest. (a) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall have any personal or financial interest, direct
or indirect, or engage in any business or transaction which is in conflict with the
proper conduct of his or her duties under this subchapter.
(b) No administrator or employee thereof, dispute resolution professional,
medical review organization or reviewing health care provider shall act in such capacity in any matter wherein he or she has a direct or indirect personal or financial
interest that might reasonably be expected to impair his or her objectivity or independence of judgment.
(c) No administrator or employee thereof, dispute resolution professional,
medical review organization or reviewing health care provider shall accept any
gift, favor, service or other thing of value under circumstances from which it might
be reasonably inferred that such gift, service or other thing of value was given or
offered for the purpose of influencing him or her in the conduct of duties under
this subchapter.
(d) No dispute resolution professional shall accept from any person, whether
directly or indirectly and whether by him or herself or through a spouse or any
family member or through any partner or associate or controlled business, any gift,
favor, service, employment or offer of employment or any other thing of value
which he or she knows or has reason to believe is offered with the intent to influence the performance of his or her duties as a dispute resolution professional.
(e) No dispute resolution professional shall make any determination in any PIP
dispute in which he or she directly or indirectly or through a spouse, family member or by partner or associate or controlled business has any personal or financial
interest.
SUBCHAPTER 7. AUTOMOBILE REPARATION REFORM ACT
Section
11:3-7.1.
Purpose.
11:3-7.2.
General requirements applicable to additional personal injury
protection benefits.
11:3-7.3.
Personal injury protection policy forms or endorsements.
11:3-7.4.
Minimum schedule of additional personal injury protection
coverage benefits.
11:3-7.1
11:3-7.5.
11:3-7.6.
APPENDIX B - REGULATIONS
Notice requirements.
Cancellation of automobile coverage for nonpayment of premium.
11:3-7.1. Purpose. This subchapter implements certain provisions of the Automobile Reparation Reform Act, N.J.S.A. 39:6A-1 et seq., including the Commissioner’s authority to establish the amounts and terms of additional personal injury protection benefits that must be made available to insureds electing a standard
automobile insurance policy pursuant to N.J.S.A. 39:6A-4.
Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).
11:3-7.2. General requirements applicable to additional personal injury
protection benefits. (a) In addition to the personal injury protection benefits that
insurers must provide pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, insurers shall
make available to the named insured, and, at his or her option, to any resident relatives in the named insured’s household who are not named insureds on another
standard or basic policy, additional income continuation benefits, essential services benefits, death benefits and funeral expense benefits pursuant to N.J.S.A.
39:6A-10 and this subchapter.
(b) The additional benefit indicated in each option that an insurer may offer for
income continuation benefits and essential services benefits represents the aggregate of the basic and additional personal injury protection benefits.
(c) Any additional income continuation benefits that an insurer may offer shall
be limited to 75 percent of the insured’s weekly income.
(d) The limits which are applicable to any additional personal injury protection
benefits that an insurer may offer shall apply on a per person, per accident basis.
(e) Each insurer shall make available as an option additional income continuation benefits for as long as the disability persists.
1. Each insurer shall furnish rates for such benefits upon the request of the insured.
(f) Any additional death benefits which an insurer may offer shall be payable
without regard to the period of time elapsing between the date of the accident and
the date of death provided death occurs within two years of the accident and results from bodily injury from that accident.
1. The requirements of (f) above shall apply to any claim for additional death
benefits where death occurs on or after April 21, 1986.
i. With respect to any claim presented on or after the effective date of this subchapter, each insurer shall disclose the availability of additional death benefits in
conformance with the applicable provisions of N.J.A.C. 11:2-17.1 et seq.
ii. With respect to any claim initiated prior to the effective date of this subchapter, each insurer shall take appropriate steps to determine whether additional death
benefits are payable, pursuant to (fl above. These steps shall include, but need not
be limited to, review of claims closed on or after April 21, 1986 for the purpose of
ascertaining the applicability of additional death benefits. Upon determining that
such benefits are payable, each insurer shall provide written notice to eligible beneficiaries and process the claim in accord with N.J.S.A. 39:6A-5 and the applicable provisions of N.J.A.C. 11:2-17.1 et seq.
(g) In addition to the minimum schedule of additional personal injury protection benefits set forth at N.J.A.C. 11:3-7.4(b), any insurer may provide other additional personal injury protection benefit options subject to review and approval
of its filing by the Department of Insurance. Any additional options offered by the
AUTOMOBILE REPARATION REFORM
11:3-7.4
insurer must be in compliance with the standards and requirements set forth in this
subchapter.
(h) Insurers may also make available to named insureds covered under N.J.S.A.
39:6A-4, and at their option, to resident relatives in the household of the named
insured or to other persons provided medical expense coverage pursuant to this
statutory provision, or both, additional first party medical expense benefit coverage pursuant to N.J.S.A. 39:6A-l0.
Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); R. 1998 d. 591,
effective December 21, 1998 (operative March 22, 1999); R. 2001 d. 44, effective February 5, 2001.
11:3-7.3. Personal injury protection policy forms or endorsements. (a) All
policy forms or endorsements that provide personal injury protection benefits required by N.J.S.A. 39:6A-4 shall specify that such benefits shall be afforded by
the insurer of the injured person subject to any deductibles or exclusions elected
by the policyholder pursuant to N.J.S.A. 39:6A-4.3. The required personal injury
protection benefits are set forth below:
1. Medical expense benefits;
2. Income continuation benefits;
3. Essential services benefits;
4. Death benefits; and
5. Funeral expense benefits.
(b) Each policy form or endorsement covering an automobile as defined at
N.J.S.A. 39:6A-2 shall include excess medical payments coverage, corresponding
to Section II, Extended Medical Expense Benefits Coverage of the personal automobile policy. Insurers must include a minimum coverage of $1,000 and may offer coverage of $10,000.
(c) Each policy form or endorsement providing additional personal injury protection benefits shall specify that, pursuant to N.J.S.A. 39:6A-10, additional death
benefits under the policy shall be payable without regard to the period of time
elapsing between the date of the accident and the date of death provided death occurs within two years of the accident and results from bodily injury from that accident
Amended. R. 1996 d. 58, effective February 5, 1996.
11:3-7.4. Minimum schedule of additional personal injury protection coverage benefits. (a) Every rate filer’s schedule of rates for additional personal injury protection benefits, other than medical expense benefits, shall provide at least
the benefit schedules set forth in Table 1 in (b) below.
(b) The additional personal injury protection coverage table follows:
Income
Option Weekly
Total
1
$100
$10,400
2
125
13,000
3
175
18,200
4
250
26,000
5
400
41,600
6
500
52,000
7
600
62,400
8
700
72,800
Table 1
Essential Services
Per Day Total
$12
$8,760
20
14,600
20
14,600
20
14,600
20
14,600
20
14,600
20
14,600
20
14,600
Death
$10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
Funeral
Expense
$2,000
2,000
2,000
2,000
2,000
2,000
2,000
2,000
11:3-7.5
9
10
11
12
13
14
15
16
APPENDIX B - REGULATIONS
100
125
175
250
400
500
600
700
unlimited
unlimited
unlimited
unlimited
unlimited
unlimited
unlimited
unlimited
12
20
20
20
20
20
20
20
8,760
14,600
14,600
14,600
14,600
14,600
14,600
14,600
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
2,000
2,000
2,000
2,000
2,000
2,000
2,000
2,000
Amended. R. 1990, d. 580, effective November 19, 1990 (operative January 1, 1991).
11:3-7.5. Notice requirement. (a) Additional personal injury protection benefits that are required to be offered by an insurer shall be offered by the insurer at
least annually as part of the Coverage Selection Form required pursuant to
N.J.S.A. 39:6A-23 and N.J.A.C. 11:3-15.
1. The buyer’s guide and coverage selection form specified at N.J.S.A. 39:6A23 and any rules promulgated thereunder shall meet the requirements of (a) above.
(b) Each insurer shall distribute copies of this subchapter to every person responsible for the handling and settlement of claims subject to this subchapter. Every insurer shall satisfy itself that all such responsible persons are thoroughly conversant with and are complying with this subchapter.
Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); Amended. R.
1996 d. 58, effective February 5, 1996.
11:3-7.6. Cancellation of automobile coverage for nonpayment of premium. (a) This rule applies to all automobile policies delivered or issued for delivery
in this State, insuring a single individual or husband and wife resident of the same
household, as named insured, and under which the insured vehicles therein designated are of the following types only:
1. A motor vehicle of the private passenger or station wagon type that is not
used as a public or livery conveyance for passengers, not rented to others; or
2. Any other four-wheel motor vehicle with a load capacity of 1,500 pounds or
less which is not customarily used in the occupation, profession or business of insured, other than farming or ranching, provided, however, that this rule shall not
apply to any policy insuring more than four automobiles, or to any policy covering
garage, automobile sales agency, repair shop, service station or public parking
place operation hazards.
(b) The effective date of the cancellation of a policy for nonpayment of premium shall not be earlier than 10 days prior to the last full day of which premium
received by the company prior to the date of preparation of the cancellation notice,
would pay for coverage on a pro rata basis. In calculating the effective date of the
cancellation as provided in this section, the premium applicable to the coverage
provided by the policy and the premium received by the company at or prior to the
time cancellation notice was prepared shall be the premium used for the calculation and determination of such effective date.
(c) Cancellation for nonpayment of premium does not include cancellation at
the request of a premium finance company or of a producer of record under
N.J.A.C. 11:17C-2.2(d).
(d) No cancellation notice shall be mailed prior to 30 days in advance of its effective date.
(e) The rule shall not apply to deposits accompanying New Jersey Automobile
Personal Insurance Plan or Commercial Automobile Insurance Plan applications
MOPED INSURANCE
11:3-11.1
which are insufficient under Plan rules or those of any succeeding residual market
availability plan.
Amended. R. 1996 d. 58, effective February 5, 1996. Administrative correction. 40 N.J.R. 5043.
SUBCHAPTER 11. MOPED INSURANCE
Section
11:3-11.1.
Required coverages for mopeds.
11:3-11.1. Required coverages for mopeds. (a) No policy insuring against
loss resulting from liability imposed by law for bodily injury, death and property
damage sustained by any person arising out of the ownership, operation or use of
a motorized bicycle as defined in N.J.S.A. 39:1-1, as amended, shall be issued in
the State to the owner (or parent or guardian of an owner under 18 years of age)
of any motorized bicycle principally garaged or operated in this State unless it includes coverage for the owner and operator in the following minimum amounts or
limits.
1. Bodily injury;
i. An amount or limit of $15,000, exclusive of interest and costs, on account of
injury to, or death of, one person, in any one accident; and
ii. An amount or limit, subject to such limit for any one person so injured or
killed, of $30,000, exclusive of interest and costs, On account of injury to or death
of more than one person, in any one accident.
2. Property damage: An amount or limit of $5,000 in the aggregate or damage
to property of others resulting from one accident.
(b) Every liability insurance policy as described in (a) above, issued or renewed
on or after April 22, 1985, shall provide personal injury protection coverage benefits, in accordance with N.J.S.A. 39:6A-4, to pedestrians who sustain bodily injury in this State caused by the named insured’s motorized bicycle or caused by
being struck by or from the motorized bicycle.
1. Every rating organization and insurer making its own rates for policies covering motorized bicycles shall submit to the Commissioner of insurance filings of
rules, rates and forms within 30 days of the effective date of this subsection.
(c) Every business entity or individual owner who rents motorized bicycles
shall maintain liability insurance coverage pursuant to N.J.S.A. 39:4-14.3e in the
minimum amounts or limits set forth in subsection (a) of his section.
(d) Any such coverages as described in subsections (a), (b) and (c) above shall
describe the make and model, piston displacement, and serial number (VIN) of
each motorized bicycle insured. This information shall also constitute the description of vehicle required on insurance identification cards, and N.J.A.C. 11:3-5.1
through 6.4 shall apply to moped coverage except where the language is clearly
inappropriate.
(e) The policy period for the coverages described is subsection (a) of this section shall commence at 12:01 A.M. of the effective date shown in the policy declaration page, unless expressly set forth in the policy or in a binder or other contracts for temporary insurance.
(f) Any insurer authorized to write motor vehicle coverage may write moped
coverage.
Adopted. R. 1978 d. 12, eff. January 19, 1978. Amended. R. 1985 d. 72, effective February 19, 1985
(operative April 22, 1985); R. 2001 d. 44, effective February 5, 2001.
11:3-14
APPENDIX B - REGULATIONS
SUBCHAPTER 14. PERSONAL INJURY PROTECTION OPTIONS
Section
11:3-14.1. Purpose.
11:3-14.2. Scope.
11:3-14.3. Optional medical expense benefit deductibles for personal injury
protection coverage.
11:3-14.4. Optional exclusion of income continuation benefits, essential
services benefits, death benefits and funeral expense benefits.
11:3-14.5. Option to choose health care insurance coverage as primary
coverage.
11:3-14.6. Refund or credit of unearned premium.
11:3-14.7. Filing requirements.
11:3-14.8. Application of the option to choose health care insurance coverage
as the primary insurer.
11:3-14.1. Purpose. This subchapter establishes rules for the provision of optional deductibles and benefits for personal injury protection offered under standard private passenger automobile insurance policies pursuant to N.J.S.A. 39:6A4.
Amended. R. 1989 d. 117, effective February 21, 1989; R. 1996 d. 58, effective February 5, 1996; R.
1998 d. 591, effective December 21, 1998 (operative March 22, 1999).
11:3-14.2. Scope. This subchapter applies to every insurer, including any residual market mechanism created by any New Jersey statute, authorized to transact the business of automobile insurance in this State.
Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991)
11:3-14.3. Optional medical expense benefits for standard policies. (a)
With respect to personal injury protection under standard automobile insurance
policies, issued pursuant to N.J.S.A. 39:6A-4, each insurer shall make available as
an option, at appropriately reduced premiums, medical expense benefits in
amounts of $150,000, $75,000, $50,000, and $15,000. If none of these options is
affirmatively chosen in writing, the policy shall provide medical expense benefits
in an amount not to exceed $250,000 per person per accident.
(b) Notwithstanding (a) above, if an optional medical expense benefit option is
chosen, the policy shall provide that medical expense benefits shall be paid in an
amount not to exceed $250,000, inclusive of any limit of medical expense benefits
pursuant to (a) above, for all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient
is stable, no longer requires critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician.
(c) “Significant disfigurement” as used in (b) above means the result and/or
manifestation of a serious traumatic injury that is observable as a permanent and
substantial defect in the appearance and functional ability of the person injured.
“Significant disfigurement” is a serious outward change that substantially detracts
from the appearance and functional ability of the person injured.
Amended. R. 1984 d. 480, eff. November 5, 1984; R. 1989 d. 117, effective February 21, 1989; R.
1996 d. 58, effective February 5, 1996; R. 1998 d. 591, effective December 21, 1998 (operative March
22, 1999); R.2000 d.454, effective November 6, 2000.
PIP OPTIONS
11:3-14.5
11:3-14.4. Optional exclusion of income continuation benefits, essential
services benefits, death benefits and funeral expense benefits. (a) Automobile
insurers offering personal injury protection coverage pursuant to N.J.S.A. 39:6A4 shall, at an appropriate reduced premium, provide the named insured the option
to exclude all of the following benefits from such coverage:
1. Income continuation benefits;
2. Essential services benefits;
3. Death benefits;
4. Funeral expense benefits.
(b) Election of the exclusion shall result in the elimination of all elements of
personal injury protection coverage except medical expense benefits.
(c) An exclusion elected by the named insured in accordance with this subchapter shall apply only to the named insured, and any resident relative in the named
insured’s household, who is not a named insured under another automobile insurance policy but not to any other person eligible for personal injury protection benefits to be provided under that policy in accordance with N.J.S.A. 39:6A-4.
(d) Additional personal injury protection coverage pursuant to N.J.S.A. 39:6Al0 shall not be available to any named insured selecting the exclusion or to any relative resident in his household.
(e) No new automobile insurance policy shall be issued on or after July 1, 1984
unless the option to exclude personal injury protection benefits in accord with this
section is made available to the applicant. In the case of any automobile policy expected to be in force on July 1, 1984, the named insured shall be provided not later
than May 15, 1984 with the opportunity to elect, effective July l, 1984, the personal injury protection coverage exclusion in accord with this section. Any notice of
renewal of an automobile insurance policy with an effective date subsequent to
July 1, 1984 shall be accompanied by a notice to the named insured providing the
opportunity to elect personal injury protection coverage exclusion in accord with
this subchapter.
(f) A premium credit calculated and represented as a percentage of the applicable premium shall be provided for the exclusion. The premium percentage shall
be uniform by filer on a statewide basis.
(g) The buyer’s guide and written notice specified in N.J.S.A. 39:6A-23 shall
satisfy the requirements of this subchapter.
(h) Should an applicant or named insured fail to elect the exclusion, full personal injury protection coverage pursuant to N.J.S.A. 39:6A-4 shall be deemed to
have been selected and an appropriate premium shall be charged.
(i) The exclusion elected by a named insured shall continue in force as to subsequent renewal or replacement policies until the insurer or its authorized representative receives a properly executed written request for its elimination.
Amended. R.1984 d. 480, eff. November 5, 1984; R. 1996 d. 58, effective February 5, 1996; R. 1998
d. 591, effective December 21, 1998 (operative March 22, 1999).
11:3-14.5. Option to choose health care insurance coverage as primary
coverage. (a) Pursuant to N.J.S.A. 39:6A-4.3, for policies issued or renewed on
or after January 1, 1991, an insurer shall provide the option that other health insurance coverage or benefits of the insured, including health care services provided by a health maintenance organization and any coverage or benefits provided
under any Federal or State program, are the primary coverage for medical expense
benefits for personal injury protection coverage; provided, however, that this op-
11:3-14.6
APPENDIX B - REGULATIONS
tion shall not apply to any coverage or benefits provided pursuant to Medicare or
Medicaid.
(b) The Coverage Selection Form (see N.J.A.C. 11:3-15.7) shall require insureds or prospective insureds to identify the health insurer(s) providing primary
personal injury protection medical expense benefits. This identification shall fulfill the requirement in N.J.S.A. 39:6A-4.3 that named insureds provide proof that
they and members of their family residing in the household are covered by health
insurance coverage or benefits.
Amended. R.1984 d.480, eff. November 5, 1984. Repealed. R. 1989 d. 117,effective February 21,
1989. Adopted. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991).
11:3-14.6. Refund or credit of unearned premium. Every automobile insurer
offering personal injury protection coverage shall establish a fair, practicable and
non-discriminatory plan for the refund or application of credit of any unearned
premium resulting from the selection of any deductible and/or exclusion option
pursuant to this subchapter.
Amended. R. 1989 d. 117, effective February 21, 1989.
11:3-14.7. Filing requirements. (a) Every automobile filer shall submit to the
Commissioner for approval filings of rates or manual rules which provide the optional medical expense benefit deductibles for personal injury protection coverage.
(b) Within 30 days of the effective date of this subchapter, every automobile
filer shall submit to the Commissioner for approval filings of rates or manual rules
which provide the optional exclusion from personal injury protection coverage of
income continuation benefits, essential service benefits, death benefits, and funeral expense benefits.
(c) All filings submitted for approval pursuant to this subchapter, and all changes and amendments thereto, shall be prepared in accordance with insurance laws
and regulations, including the applicable provisions of N.J.S.A. 17:29A-1 et seq.
and N.J.A.C. 11:1-2 and the Department’s existing filing procedures.
(d) The filing of a rating organization shall be applicable to the members and
subscribers of the organization who have authorized the organization to file on
their behalf.
Amended. R. 1989 d. 117, effective February 21, 1989.
11:3-14.8. Application of the option to choose health care insurance coverage as the primary insurer. When an insured or prospective insured elects to
have a health insurer provide primary personal injury protection medical expenses
benefits, the medical expenses benefits available to the insured under his or her
automobile policy’s personal injury protection provisions shall become a secondary benefits provider. The order of benefit determination shall be in accordance
with N.J.A.C. 11:3-37.
Adopted. R. 1991 d. 90, effective January 25, 1991.
SUBCHAPTER 15. BUYER’S GUIDE, COVERAGE SELECTION FORM,
AND AUTOMOBILE INSURANCE CONSUMER BILL OF RIGHTS FOR
STANDARD AND BASIC POLICIES
Section
11:3-15.1. Purpose.
11:3-15.2. Scope.
11:3-15.3. Definitions.
BUYER’S GUIDE; COVERAGE SELECTION FORM 11:3-15.3
11:3-15.4.
11:3-15.5.
11:3-15.6.
11:3-15.7.
11:3-15.8.
11:3-15.9.
11:3-15.10.
11:3-15.11.
APPENDIX
Exhibit 1.
Exhibit 2.
Exhibit 3.
Compliance.
New Jersey Auto Insurance Buyer's Guide.
Minimum standards for Coverage Selection Forms.
Use of Coverage Selection Form; availability.
New Jersey Automobile Insurance Consumer Bill of Rights.
Penalties.
(Reserved).
(Reserved).
Standard Policy Coverage Selection Form
Certification of Compliance with N.J.A.C. 11:3-15.6(g)4
Basic Policy Coverage Selection Form
11:3-15.1. Purpose. (a) N.J.S.A. 39:6A-23 requires the Commissioner of the
Department of Banking and Insurance to promulgate standards for the written notice to be provided to applicants for private passenger automobile insurance and
to policyholders offered renewal of coverage. This written notice includes one of
two versions of the Buyer's Guide and one of two versions of the Coverage Selection Form.
(b) N.J.S.A. 17:29A-52a requires every insurer writing private passenger automobile insurance in this State to provide each insured at least annually and each
applicant for insurance with an Automobile Insurance Consumer Bill of Rights.
The Automobile Insurance Consumer Bill of Rights shall contain the information
necessary, relevant or appropriate to improve the understanding of the rights and
responsibilities of consumers and insurers regarding automobile insurance.
(c) This subchapter implements the statutory requirements in (a) and (b) above
and establishes the necessary minimum standards insurers shall use in giving notice of available coverages, options and rate credits and of the rights and responsibilities of consumers and insurers regarding automobile insurance.
Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1990 d.580, effective November
19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March
22, 1999); R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011.
11:3-15.2. Scope. (a) This subchapter applies to every insurer authorized to
transact the business of private passenger automobile insurance in this State and
to any automobile residual market mechanism created by any New Jersey statute.
(b) This subchapter applies to every personal lines private passenger automobile insurance policies and individually-owned private passenger automobiles
written on commercial insurance policies.
Adopted. R.1989 d.117, effective February 21, 1989. Amended. R. 1990 d. 580, effective November
19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March
22, 1999); R.2004 d.117, effective March 15, 2004.
11:3-15.3. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates
otherwise.
“Basic automobile insurance policy” or “basic policy” means those private passenger automobile insurance policies issued in accordance with N.J.S.A. 39:6A3.1 and N.J.A.C. 11:3-3.
“Commissioner” means the Commissioner of the Department of Banking and
Insurance.
“Department” means the Department of Banking and Insurance of the State of
New Jersey.
11:3-15.4
APPENDIX B - REGULATIONS
“Insurer” means any person, corporation, association, partnership, company,
reciprocal exchange and any other legal entity issuing a contract of private passenger automobile insurance, including any residual market mechanism established
pursuant to any New Jersey statute. As appropriate, “insurer” shall also mean a
servicing carrier for a residual market mechanism.
“Private passenger automobile insurance policy” means a Standard policy as
defined in N.J.S.A. 39:6a-3 or a Basic policy as defined in N.J.S.A. 39:6A-3.1 providing direct insurance on an automobile as defined in N.J.S.A. 39:6A-2.
“Standard automobile insurance policy” or “standard policy” means a private
passenger automobile insurance policy issued in accordance with N.J.S.A. 39:6A3 that includes the personal injury protection coverage described in N.J.S.A.
39:6A-4.
Adopted. R. 1989 d. 117, effective February 21, 1989. Amended. R. 1989 d. 624, effective December
18, 1989 (operative January 1, 1990); R. 1990 d. 580, effective November 19, 1990 (operative January
1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d. 117, effective March 15, 2004.
11:3-15.4. Compliance. (a) No new private passenger automobile insurance
policy or renewal shall be issued unless the application for the policy or renewal
offer is accompanied by a Buyer's Guide, a Coverage Selection Form and an Automobile Insurance Consumer Bill of Rights that meet the minimum standards
prescribed in this subchapter.
1. The renewal offer shall include the appropriate Buyer’s Guide and Coverage
Selection Form for the policy being renewed.
2. Where application for or renewal of an insurance policy is made via the Internet, compliance with (a) above shall be satisfied by having the Buyer’s Guide,
Coverage Selection Form and Automobile Insurance Consumer Bill of Rights
readily available to the applicant/insured on the insurer’s website. In addition to
being readily available on the insurer’s website, this information also may be
placed on the producer’s website, if provided or authorized by the insurer.
3. Where application for or renewal of an insurance policy is made via the telephone and coverage is bound during the telephonic transaction, compliance with
(a) above shall be satisfied if the insurer, with the agreement of the applicant or
insured, sends the insured the Buyer’s Guide, a completed Coverage Selection
Form showing the coverage choices made by the insured, and an Automobile Insurance Consumer Bill of Rights within five business days after the telephonic
transaction is completed. Insureds may alter coverages based on their review of
such documents by returning a signed Coverage Selection Form with the changes
noted therein, or electronically, provided that the requirements of N.J.S.A.
12A:12-1 et seq. are satisfied and that such process is made available by the insurer. Such alterations shall be effective in accordance with N.J.A.C. 11:3-15.7(d)2.
(b) The Buyer's Guide, Coverage Selection Form and Automobile Insurance
Consumer Bill of Rights incorporate and therefore satisfy any and all other notice
requirements previously set forth for the coverage options required by the New
Jersey Automobile Reparation Reform Act, the New Jersey Automobile Insurance
Reform Act of 1982, the New Jersey Automobile Insurance Freedom of Choice
and Cost Containment Act of 1984, the Automobile Insurance Cost Reduction Act
of 1998 and P.L. 2003, c.89.
(c) As of June 6, 2011, each insurer that becomes authorized to write private
passenger automobile insurance shall make a filing pursuant to N.J.A.C. 11:1-2.
The filing shall consist of a certification in the form set forth in Exhibit 2 in the
BUYER’S GUIDE; COVERAGE SELECTION FORM 11:3-15.5
subchapter Appendix, incorporated herein by reference, that the Lawsuit Option
rate differentials in its Standard Policy Coverage Selection Form were calculated
in accordance with N.J.A.C. 11:3-15.6(g)4.
(d) An insurer may change the Lawsuit Option rate differentials in its approved
Standard Policy Coverage Selection Forms by making a filing pursuant to
N.J.A.C. 11:1-2 that specifies the effective date of the revised rate differentials
that will be used and that includes the certification required by (c) above.
Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1996 d.58, effective February 5,
1996; R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effective
March 15, 2004; R.2005 d.83, effective March 7, 2005; R.2011 d.166, effective June 6, 2011.
11:3-15.5. New Jersey Auto Insurance Buyer's Guide. (a) There are established two Buyer’s Guides for use by insurers: a personal lines Buyer’s Guide and
a commercial lines Buyer’s Guide for individually owned vehicles written on
commercial policies. The Buyer’s Guides shall be available on the Department’s
website.
1. The personal lines Buyer’s Guide can be found at http://www.state.nj.us/
dobi/division_insurance/byguide.doc.
2. The commercial Buyer’s Guide can be found at http://www.state.nj.us/dobi/
division_insurance/commbyguide.doc.
(b) The Buyer’s Guide shall be reproduced in the format presented on the website, duplicating the information provided therein and, to the extent practicable,
the layout, fonts, type-point sizes, colors and illustrations. Notwithstanding the
foregoing, consistent with the requirements of N.J.A.C. 11:2-18.4, all text in the
Buyer’s Guide shall be printed on at least 10-point type on paper of a quality sufficient to assure that the printing does not bleed form one side to the other.
(c) The Department shall notify insurers of any changes to the Buyer’s Guides
by Bulletin. Insurers shall provide the Buyer’s Guide, as revised, for new and renewal business as soon as practicable, but no later than 90 days after the date of
the Bulletin. The Buyer’s Guide shall provide general descriptions of:
1. How to begin to shop for auto insurance;
2. The types of policies available and the basic differences between them;
3. Various insurance coverages such as Personal Injury Protection (PIP), Liability (including bodily injury and property damage liability coverage), Uninsured/Underinsured Motorists, Collision and Comprehensive;
4. Policy terms such as limits, deductibles, producer and direct writer;
5. PIP options such as deductibles and health care primary and PIP package
coverage such as income continuation, essential services, death benefit and funeral expense benefit;
6. Comprehensive and Collision options such as limits, deductibles and named
driver exclusions;
7. A Lawsuit Limitation Selection Guide that explains the tort threshold options with a warning that insurance companies and their producers shall not be
held liable for the consumer’s choice of right to sue options; and
8. Information on how the consumer can contact the Department of Banking
and Insurance.
(d) In addition, the Buyer’s Guide may include company-specific information,
such as its name and/or company logo, contact information and company-specific
coverage options, provided that the information is consistent with the purposes of
this subchapter.
11:3-15.6
APPENDIX B - REGULATIONS
(e) The Buyer’s Guide shall contain a statement advising the insured or applicant that additional information concerning coverages or premiums is available by
contacting the insurer or the producer. Insurers that write at least two percent of
the New Jersey private passenger automobile market shall provide a toll-free telephone number for this purpose.
(f) As required by N.J.S.A. 17:29E-11, the Buyer’s Guide shall contain a notice
describing the functions of the Insurance Claims Ombudsman, the mailing address
of the Ombudsman and a toll-free information telephone number.
Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1989 d. 624, effective December
18, 1989 (operative January 1, 1990); R.1990 d.580, effective November 19, 1990 (operative January
1, 1991). Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22,
1999). Amended. R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011.
11:3-15.6. Minimum standards for Coverage Selection Forms. (a) Each insurer shall have a separate Coverage Selection Form for the Standard Policy and
for the Basic Policy using the text found in the Appendix, Exhibits 1 and 3 incorporated herein by reference.
(b) The Coverage Selection Forms shall contain a statement advising the insured or applicant that additional information concerning coverages or premiums
is available by contacting the insurer or the producer. Insurers that write at least
two percent of the New Jersey private passenger automobile market shall provide
a toll-free telephone number for this purpose.
(c) Except as otherwise provided in the text, each Coverage Selection Form
shall be printed in at least 10-point type on a paper size that is easily readable.
(d) In addition to the required text, each Coverage Selection Form shall include
space at the top for the consumer's name and any other necessary information such
as policy number, etc. The bottom of each Coverage Selection Form shall have
space for the consumer's signature and date.
1. Text in the Appendix, Exhibits 1 and 3 in italics, thus, is instructions or options for the insurer and should not be printed in the Coverage Selection Form.
2. Text in uppercase letters denotes section headings, defined terms or is
for emphasis. Insurers are not restricted to uppercase for these purposes in formatting the Coverage Selection Forms.
(e) An insurer may expand the form to solicit additional relevant information,
including, but not limited to, the names of resident relatives eligible for PIP benefits.
(f) Each Coverage Selection Form shall include the range of premium rate differences as indicated by the text in the Exhibits. Each insurer shall determine the
range of premium rate differences for use in these sections. Premium rate differences for the Lawsuit Options in the Standard Policy Coverage Selection Form,
Appendix, Exhibit 1 shall be calculated according to (g) below. When the range of
premium rate differences on a Coverage Selection Form changes for any reason,
including, but not limited to, rate changes, a new Coverage Selection Form with
the current numbers shall be filed with the Department in accordance with
N.J.A.C. 11:3-15.4(d).
(g) Each insurer shall calculate the percentage and dollar change in premium
(or rate) from the selection of the No Limitation on Lawsuit Option in accordance
with (g)1 through 4 below. In these calculations, premium (or rate) shall include
any expense fee.
BUYER’S GUIDE; COVERAGE SELECTION FORM 11:3-15.6
1. The Percentage Change Calculation: The range of percentage increase in the
bodily injury liability premium arising from the selection of the No Limitation on
Lawsuit Option shall be calculated as follows:
i. The low end of the percentage range shall be produced by calculating the percentage increase in the bodily injury liability premium of a policy with a
$250,000/$500,000 split limit or a $500,000 single limit for a change from the
Limitation on Lawsuit Option to the No Limitation on Lawsuit Option. This calculation shall be made for the territory with the lowest basic limit Limitation on
Lawsuit Option rate, and shall assume standard tier, pleasure usage by an age 3064, married male principal operator.
ii. The high end of the percentage range shall be produced by making the same
type of calculation using a policy with minimum limits for the territory with the
highest basic limit Limitation on Lawsuit Option rate, and shall assume business
usage by a standard-tier, 22 year old, unmarried male principal operator.
2. The Dollar Change Calculation: The range of dollar increase in the bodily
injury liability premium arising from the selection of the No Limitation on Lawsuit Option shall be determined by subtracting the Limitation on Lawsuit Option
rate from the comparable No Limitation on Lawsuit Option rate for the following
two rating examples:
i. The low end of the dollar range shall be a policy with minimum limits for the
territory with the lowest basic limit Limitation on Lawsuit Option rate, and shall
assume standard tier, pleasure usage by an age 30-64, married male principal operator.
ii. The high end of the dollar range shall be calculated at a $250,000/$500,000
split limit or a $500,000 single limit policy for the territory with the highest basic
limit Limitation on Lawsuit Threshold Option, and shall assume business usage
by a standard tier, 22 year old, unmarried male principal operator.
iii. Because the range of the possible additional dollar cost will depend upon
territory, bodily injury liability loss limits, and other factors, insurers shall be permitted to use round numbers to represent the approximate range of the cost increase. For example, if the smallest dollar rate increase was $54.00 and the largest
$305.00, the insurer may use the range $50.00 to $310.00 on its Coverage Selection Form.
3. Premium Basis for Single Limit Liability Coverage:
i. For single limit liability coverage, the percentage range calculation that is described in (g)1 above shall be based upon the applicable liability rate. This calculation shall be made on the basis of a combined rate containing a charge for bodily
injury liability, and property damage liability.
ii. For single limit liability coverage, the dollar range calculation that is described in (g)2 above shall be based upon the applicable liability rate. In contrast
to the procedure in (g)3i above, the dollar change calculation shall be made on the
basis of a complete rate containing a charge for bodily injury liability, personal injury protection (PIP), and property damage liability.
4. Insurers shall prepare:
i. An example showing the calculation of the high and low values for the percentage and dollar change ranges;
ii. Data about the insurer's territorial rates to confirm that the highest and lowest
basic limit Limitation on Lawsuit Option rates have been used in the example. A
rating page showing a list of Standard tier, basic limit rates by territory shall be
sufficient;
11:3-15.7
APPENDIX B - REGULATIONS
iii. Data about the insurer's increased limits liability rating, vehicle usage, and
type of driver factors to confirm that the proper relativities have been used in the
example. The appropriate rating pages shall be sufficient; and
iv. For those insurers offering only single limit liability coverage, an explanation of the procedure used to develop the bodily injury liability rate from which
the percentage and dollar change amounts have been determined. This explanation
shall include an example of the calculation methodology.
Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999);
R.2011 d.166, effective June 6, 2011.
11:3-15.7. Use of Coverage Selection Form; availability. (a) For all new policies, an insurer or an insurance producer shall receive a Coverage Selection Form
signed by the named insured and indicating the prospective insured's coverage
choices. Coverage shall not become effective until the signed Coverage Selection
Form is received from the named insured, unless otherwise authorized by law.
(b) For the mid-term policy changes set forth in (b)1 through 5 below, the insurer shall receive a Coverage Selection Form signed by the named insured prior
to making the change.
1. Change of policy type to Standard or Basic;
2. Change of Lawsuit Option (Standard Policy only):
3. Change of primary coverage for PIP medical expense benefits coverage
(from or to Health Insurer Primary) (Standard Policy only);
4. Change in PIP Medical Expense Coverage Limit (Standard Policy only); and
5. Addition or deletion of Liability Coverage (Basic Policy only).
(c) An insurer may require that other policy changes be made by signed Coverage Selection Form.
(d) All coverage changes that are required to be made by a signed Coverage
Selection Form, either by this subchapter or by the insurer, shall become effective
in the following manner, except when coverage for comprehensive or collision is
effected by a required inspection pursuant to N.J.A.C. 11:3-36.
1. For new policies, the choices on the Coverage Selection Form shall be effective on the policy effective date;
2. For mid-term policy changes, the choices on the Coverage Selection Form
shall be effective the day following the date of postmark or, when personal delivery is made or if the postmark is illegible, the day following receipt of the signed
Coverage Selection Form by the insurer or an insurance producer. If the change is
made electronically, the change shall be effective the day following date of receipt
as determined in accordance with N.J.S.A. 12A:12-15;
3. For changes upon renewal, the changes shall be effective on the date of the
next policy renewal if postmarked or received by the insurer or by an insurance
producer prior to the renewal date.
New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended. R.
2001 d. 44, effective February 5, 2001; R.2004 d.117, effective March 15, 2004; R.2005 d.83, effective
March 7, 2005.
11:3-15.8. New Jersey Automobile Insurance Consumer Bill of Rights. (a)
The insurer shall produce a Consumer Bill of Rights by reproducing the New Jersey Automobile Insurance Consumer Bill of Rights available on the Department’s
website at http:www.state.nj.us/dobi/autorights.pdf. The Department shall notify
insurers of any changes to the Consumer Bill of Rights by Bulletin. Insurers shall
BUYER’S GUIDE; COVERAGE SELECTION FORM11:3-15.11
provide the Consumer Bill of Rights, as revised, with new and renewal business
60 days after the date of the Bulletin.
(b) The Consumer Bill of Rights shall be reproduced in the format as presented
on the website, duplicating the language provided therein, and to the extent practicable, the layout, fonts, type-point sizes, colors and illustrations. Notwithstanding the foregoing, all language bolded on the Consumer Bill of Rights as depicted
on the Department’s website shall be bolded and no type-point sizes less than 10
point shall be used.
(c) The Consumer Bill of Rights shall contain:
1. An overview containing the purpose of the Bill of Rights;
2. The consumer’s obligations with regard to their insurance;
3. The duties of the insurer concerning the application process;
4. The consumer’s general insurance rights regarding denials and right to purchase;
5. The consumer’s right to appeal a cancellation of insurance;
6. Instructions on how to be an educated insurance consumer; and
7. A statement advising the insured or applicant that additional information
concerning the Coverage Selection Form and Buyer’s Guide is available by contacting the insurer or the producer.
Amended. R.2006 d.243, effective July 3, 2006.
11:3-15.9. Penalties. Failure to comply with the provisions of this subchapter
may result in the imposition of penalties as prescribed by law.
Recodified from N.J.A.C. 11:3-15.11 by R.1998 d.595, effective December 21, 1998 (operative March
22, 1999); Re-recodified from 11:3-15.8 by R.2004 d.117, effective March 15, 2004.
11:3-15.10. (Reserved).
Repealed by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999).
11:3-15.11. (Reserved).
Recodified to N.J.A.C. 11:3-15.11 by R.1998 d.595, effective December 21, 1998 (operative March
22, 1999).
EXHIBIT 1
STANDARD POLICY COVERAGE SELECTION FORM
Name:___________________________________________________
This Coverage Selection Form is for a STANDARD POLICY, see Buyer's
Guide, page insert page # here. A BASIC POLICY with the minimum of required
coverages is also available for a lower premium. A SPECIAL POLICY with a
very low premium is also available for persons enrolled in Medicaid. Contact your
insurer or producer for more information.
BODILY INJURY LIABILITY--Buyer's Guide page insert page # here
Choose the Bodily Injury Liability Limits that you want:
________________________________________________________
________________________________________________________
________________________________________________________
At least four of the most popular coverage limits shall be listed, including the
lowest limit offered. If a complete list is not provided, state that other coverage
limits are available.
PROPERTY DAMAGE LIABILITY--Buyer's Guide page insert page # here
Choose the Property Damage Limits you want:
________________________________________________________
________________________________________________________
11:3-15.11
APPENDIX B - REGULATIONS
________________________________________________________
At least four of the most popular coverage limits shall be listed, including the
lowest limit offered. If a complete list is not provided, state that other coverage
limits are available. For insurers offering combined single limits, substitute at
least four of the most popular combined single limits, including the lowest offered.
PERSONAL INJURY PROTECTION (PIP)--Buyer's Guide insert page # here
[ ] I choose the standard PIP Medical Expense Limit of $250,000. Include higher limit if offered
[ ] I choose one of the lower PIP Medical Expense Limits below.
WARNING: Prior to insert effective date of P.L. 1998, c.21, all auto insurance
policies had PIP Medical Expense Benefit limits of $250,000. The limits below
provide you with less coverage. Warning must be in at least 12 point type.
[ ] $150,000* for a ___% to ___% reduction in the PIP premium
[ ] $75,000* for a ___% to ___% reduction in the PIP premium
[ ] $50,000* for a ___% to ___% reduction in the PIP premium
[ ] $15,000* for a ___% to ___% reduction in the PIP premium
* Even if you choose one of the amounts above, all medically necessary treatment over the policy limit up to $250,000 will be paid for permanent or significant
brain injury, spinal cord injury or disfigurement or treatment of other permanent
or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until a doctor says that you no longer require critical care.
Choose the PIP Medical Expenses Deductible you want:
[ ] $250 deductible, minimum required by law.
[ ] $500 deductible, for a ___% to ___% reduction in the PIP premium.
[ ] $1,000 deductible, for a ___% to ___% reduction in the PIP premium.
[ ] $2,000 deductible, for a ___% to ___% reduction in the PIP premium.
[ ] $2,500 deductible, for a ___% to ___% reduction in the PIP premium.
Health Insurer for PIP Option
[ ] I choose the health insurer for PIP option--Buyer's Guide, page insert page
# here.
The name of my health insurer(s) is (are):
1._____________________________________________________
Policy/Group #/Certificate #
2._____________________________________________________
Policy/Group #/Certificate #_________________________________
Extra PIP Package Coverage Options
The Extra PIP Package benefits include income continuation, essential services, death benefits and funeral expense benefits--Buyer's Guide page insert page #
here
You may choose not to have the Extra PIP Package benefits for a ___% to___%
savings in the ___ PIP premium. Include the range of percentage savings and
the base PIP premium
I choose PIP Medical Expense Only
You may choose to have higher limits for the Extra PIP Package of Income
Continuation, Essential Services, Death and Funeral Benefits. Buyer's Guide page
insert page # here
Insert a chart listing options and choices
BUYER’S GUIDE; COVERAGE SELECTION FORM11:3-15.11
UNINSURED/UNDERINSURED
MOTORIST
COVERAGE--Buyer's
Guide, Page insert page # here
You may choose one of the following higher limits of Uninsured/Underinsured
Motorist Coverage, up to your Bodily Injury Liability Insurance Limit.
_______________________________________________________
_______________________________________________________
_______________________________________________________
List the same options available for bodily injury liability coverage above. Other options may also be listed.
COLLISION COVERAGE--Buyer's Guide, page insert page # here
[ ] No, I choose not to be covered for collision damage.
[ ] Yes, I choose to be covered for collision damage with the default $750 deductible.
[ ] Yes, I choose to be covered for collision damage with the deductible circled
here: $1,000, $1,500 or $2,000. This premium will be less than the premium with
the default $750 deductible. Details available from company or insurance producer (i.e., agent or broker).
[ ] Yes, I choose to be covered for collision damage with the deductible circled
here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance
producer.
Insert provision for coverage/no coverage per car if available
COMPREHENSIVE COVERAGE Buyer’s Guide page insert page # here. If
appropriate, use the term “other than collision” coverage throughout this section
[ ] No, I choose not to be covered for comprehensive damage.
[ ] Yes, I choose to be covered for comprehensive damage with the default $750
deductible.
[ ] Yes, I choose to be covered for comprehensive damage with the deductible
circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance
producer.
[ ] Yes, I choose to be covered for comprehensive damage with the deductible
circled here: $100, $150, $200, $250 or $500. This premium will be more than the
premium with the default $750 deductible. Details available from insurer or insurance producer.
Insert provision for coverage/no coverage per car if available
For both collision and comprehensive, if either the $200 deductible or $250 deductible is not offered, that option may be deleted from this form. Also, all other
available collision and comprehensive deductibles shall be listed where appropriate.
WARNING: Insurers or their producers or representatives shall not be held liable for choices you make for insurance coverages or limits as long as your choices provide at least the minimum coverage required by law. Insurers or their producers or representatives also shall not be held liable if you choose not to purchase
higher limits of PIP medical expense coverage, higher limits of uninsured/underinsured motorists coverage, collision coverage or comprehensive coverage. Insurers, their producers and representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17:28-1.9 for more information. Warning must be in at least 12 point type.
11:3-15.11
APPENDIX B - REGULATIONS
LAWSUIT OPTIONS, Buyer's Guide, page insert page # here
[ ] I want the Limitation on Lawsuit Option.
[ ] I want the No Limitation on Lawsuit Option. My bodily injury liability premium will be ___% to ___% higher if I select the No Limitation on Lawsuit option
instead of the Limitation on Lawsuit option, depending upon where my car is garaged, my bodily injury liability coverage limit, and other factors. Per vehicle, my
bodily injury liability premium at current rates will be $___ to $___ higher on each
___renewal of my policy if I select the No Limitation on Lawsuit option instead
of the Lawsuit option. I understand that I can contact my insurer or my insurance
producer for specific details.
Insurance companies writing six month policies should insert the word “semiannual” in the blank space above. Companies writing 12 month policies should
insert the word “annual.”
Insurance companies writing single limit liability coverage may add a footnote
to inform insureds that the policy declaration page will not include a specific premium for “bodily injury liability” coverage.
WARNING: Insurance companies or their producers or representatives shall
not be held liable for your choice of lawsuit option (limitation on lawsuit option
or no limitation on lawsuit option). Insurers or their producers or representatives
also shall not be liable if the limitation on lawsuit option is imposed by law because no choice was made on the coverage selection form. Insurers, their producers or representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17:28-1.9 for more information. Warning must
be in at least 12 point type.
STATEMENT OF INSURED or APPLICANT:
I have read the Buyer's Guide outlining the coverage options available to me.
The limits available for PIP medical expense coverage and uninsured and underinsured motorists coverage have been explained to me. My choices are shown
above. I agree that each of these choices will apply for all vehicles insured by my
policy and to each subsequent renewal, continuation, replacement or amendment
until the insurer or its insurance producer receives my request that a change be
made.
For new policyholders, I understand that:
(a) If I do not make a choice to have the No Limitation on Lawsuit Option, I
will receive the Limitation on Lawsuit option;
(b) If I carry collision and/or comprehensive coverage without making a written choice of deductible, I will receive the default $750 deductible;
(c) If I do not choose to have my health insurer provide PIP medical expense
benefits, my auto insurer will provide PIP medical expense benefits; and
(d) If I do not choose a lower PIP medical expense limit, I will receive the
$250,000 limit.
I understand that if this is a policy renewal and if I do not complete choices, I
will receive the same coverage as in my previous policy except when changes are
required by a law becoming effective during the term of my previous policy. I understand that these choices take effect in the following manner:
(1) For new policies, on the effective date of the policy;
(2) For mid-term policy changes, on the day following the date of postmark or,
when personal delivery is made or the postmark is illegible, the day following receipt of this form by the insurer or producer; and
BUYER’S GUIDE; COVERAGE SELECTION FORM11:3-15.11
(3) For changes upon renewal, on the date of the next policy renewal if postmarked or received by the insurance company or by an insurance producer prior
to the renewal date.
ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR
MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS
STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED
IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL AND
CRIMINAL PENALTIES.
Please check the appropriate box to which this form applies:
[ ] New Policy [ ] Mid-Term Change [ ] Renewal Change
SIGNATURE OF NAMED INSURED
OR APPLICANT________________________________________
DATE __________________
EXHIBIT 2
CERTIFICATION OF COMPLIANCE WITH N.J.A.C. 11:3-15.6(G)4
I hereby certify that the Lawsuit Option rate differentials in the Standard Policy
Coverage Selection Form for __________________ (Name of Insurance Company) were calculated in accordance with N.J.A.C. 11:3-15.6(g)4.
_______________________
Signature
_______________________
Print Name
_______________________
Title
_______________________
Telephone Number
EXHIBIT 3
BASIC POLICY COVERAGE SELECTION FORM
Name:_______________________________________________
This Coverage Selection Form is for a BASIC POLICY, see Buyer's Guide,
page insert page # here. A STANDARD POLICY with more coverages and higher
limits is also available for a higher premium. A SPECIAL POLICY with a very
low premium is also available for persons enrolled in Medicaid. Contact your insurer or producer for more information.
BODILY INJURY LIABILITY--Buyer's Guide page--insert page # here
[ ] Yes, I choose the $10,000 Bodily Injury Liability Limit.
[ ] No, I do not choose to have Bodily Injury Liability Coverage.
WARNING: If you do not choose to have Bodily Injury Liability Coverage and
you are at fault in an accident where people are injured or die, you will be responsible for paying for the pain, suffering and other personal hardships and some economic damages, such as lost wages that you cause. Your insurer will not pay a
judgment against you or pay for a lawyer to defend you if you are sued. Your assets will be at risk, including having money deducted from your wages if a judgment is entered against you. Warning must be in at least 12 point type.
WARNING: Insurers or their producers or representatives shall not be held liable for choices you make for insurance coverages or limits as long as your choices provide at least the minimum coverage required by law. Insurers or their producers or representatives also shall not be held liable if you choose to purchase a
11:3-15.11
APPENDIX B - REGULATIONS
basic policy instead of a standard policy, or if you choose not to purchase bodily
injury liability coverage, collision coverage or comprehensive coverage. Insurers,
their producers and representatives can lose this limitation on liability for failing
to act in accordance with the law. See N.J.S.A. 17:28-1.9 for more information.
PERSONAL INJURY PROTECTION--Buyer's Guide, page insert page # here
WARNING: For a BASIC POLICY, the limit on PIP Medical Expense Coverage is $15,000 but includes up to $250,000 for emergency care of certain catastrophic injuries (See Buyer's Guide page insert page # here). Prior to insert effective date of P.L. 1998, c.21, all automobile insurance policies had PIP Medical Expense limits of $250,000. The PIP Medical Expense Coverage for a BASIC
POLICY is significantly less than previously required by law. Warning must be in
at least 12 point type.
Choose the PIP Medical Expenses Deductible you
want:
[ ] $250 deductible, minimum required by law.
[ ] $500 deductible, for a ___% to ___% reduction in the PIP premium.
[ ] $1,000 deductible, for a ___% to ___% reduction in the PIP premium.
[ ] $2,000 deductible, for a ___% to ___% reduction in the PIP premium.
[ ] $2,500 deductible, for a ___% to ___% reduction in the PIP premium.
COLLISION COVERAGE--Buyer's Guide, page insert page # here
[ ] No, I choose not to be covered for collision damage.
[ ] Yes, I choose to be covered for collision damage with the basic deductible.
[ ] Yes, I choose to be covered for collision damage with the deductible circled
here: $1,000, $1,500 or $2,000. This premium will be less than the premium with
the default $750 deductible. Details available from insurer or insurance producer.
[ ] Yes, I choose to be covered for collision damage with the deductible circled
here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance
producer.
Insert provision for coverage/no coverage per car if available
COMPREHENSIVE COVERAGE Buyer's Guide page insert page # here. If
appropriate, use the term “other than collision” coverage throughout this section
[ ] No, I choose not to be covered for comprehensive damage.
[ ] Yes, I choose to be covered for comprehensive damage with the default $750
deductible.
[ ] Yes, I choose to be covered for comprehensive damage with the deductible
circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance
producer.
[ ] Yes, I choose to be covered for comprehensive damage with the deductible
circled here: $100, $150, $200, $250 or $500. This premium will be more than the
premium with the $750 deductible. Details available from insurer or insurance
producer.
Insert provision for coverage/no coverage per car if available.
These sections should be omitted by insurers that do not offer collision and
comprehensive coverage in the Basic Policy. For both collision and comprehensive, if either the $200 deductible or $250 deductible is not offered, that option
may be deleted from this form. Also, all other available collision and comprehensive deductibles shall be listed where appropriate.
STATEMENT OF INSURED or APPLICANT:
NOTIFICATION BY MEDICAL PROVIDERS
11:3-15
I have read the Buyer's Guide outlining the coverage options available to me. I
understand that this is a BASIC POLICY with the minimum coverages required
by law and that a Standard Policy with higher limits and additional coverages is
available. The option to buy Bodily Liability Coverage has been explained to me.
My choices are shown above. I agree that each of these choices will apply for all
vehicles insured by my policy and to each subsequent renewal, continuation, replacement or amendment until the insurer or its insurance producer receives my
request that a change be made.
For new policyholders, I understand that:
(a) Unless I choose to have the $10,000 Bodily Injury Liability Coverage, I will
not receive any Bodily Injury Liability Coverage;
(b) If I choose collision or comprehensive coverage without making a written
choice of deductible, I will receive the $750 deductible; I understand that if this is
a policy renewal and if I do not complete choices, I will receive the same coverage
as in my previous policy except when changes are required by a law becoming effective during the term of my previous policy.
I understand that these choices take effect in the following manner:
(1) For new policies, on the effective date of the policy;
(2) For mid-term policy changes, on the date of postmark or, when personal delivery is made or if the postmark is illegible, the day following receipt of this Form
by the insurers or by a producer; and
(3) For changes upon renewal, on the date of the next policy renewal if postmarked or received by the insurance company or by an insurance producer prior
to the renewal date.
ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR
MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS
STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED
IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL AND
CRIMINAL PENALTIES.
Please check the appropriate box to which this form
applies.
[ ] NEW POLICY [ ] Mid-Term Change [ ] Renewal Change
SIGNATURE OF NAMED INSURED
OR APPLICANT_________________________________________
DATE ________________________________________________
New Rule, R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended,
R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011.
SUBCHAPTER 25. PRIVATE PASSENGER AUTOMOBILE
INSURANCE: NOTIFICATION BY TREATING HEALTH CARE
PROVIDERS
Source and Effective Date. R.1997 d.14, effective January 6, 1997.
Section
11:3-25.1. Purpose and scope.
11:3-25.2. Definitions.
11:3-25.3. Notification of commencement of treatment.
11:3-25.4. Content of notice and proof of receipt.
11:3-25.5. Late notification.
11:3-25.6. Standards for adjustment of reduction.
11:3-25.7. Payment from insurers only.
11:3-25.1
APPENDIX B - REGULATIONS
11:3-25.8. Procedure for appeals.
11:3-25.9. Reporting requirement.
11:3-25.10. Compliance.
APPENDIX A
Notification of Commencement of Medical Treatment
APPENDIX B
Address for Notification of Commencement of Medical Treatment
11:3-25.1 Purpose and scope. (a) The purpose of this subchapter is to implement N.J.S.A. 39:6A-5, as amended by P.L. 1995, c.407, by establishing procedures to be followed by treating medical providers to give timely notification of
the commencement of medical treatment for injuries sustained in automobile accidents. The subchapter sets forth:
1. Time limits for the filing of notification of the commencement of treatment
for PIP claims;
2. The actions to be taken upon failure to comply with the notification time
limits, including reduction or denial of claim payments;
3. The factors to be considered in evaluation of a late notification; and
4. The rights of providers when payment is reduced or denied for failure to
comply with the notification requirements.
(b) This subchapter shall apply to every insurer authorized to transact the business of automobile insurance in this State. The subchapter applies to treatment for
injuries resulting from automobile accidents that occur after July 8, 1996.
11:3-25.2 Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates
otherwise.
“Coverage status” means the status of PIP coverage for an injured party pursuant to N.J.S.A. 39:6A-5.
“Department” means the Department of Banking and Insurance of the State of
New Jersey.
“Eligible charge” means the treating medical provider's usual, customary and
reasonable charge or the upper limit on the medical fee schedule as found in
N.J.A.C. 11:3-29.6, whichever is lower subject to provisions of N.J.A.C. 11:329.4.
“Emergency care” means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious
dysfunction of a bodily organ or part. Such emergency care shall include all necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospital care, transportation to a hospital or trauma center,
emergency room care, surgery, critical and acute care. Emergency care extends
during the period of initial hospitalization until the patient is discharged from
acute care by the attending physician.
“Multiple treating medical provider” means a treating health care provider as
defined herein that provides emergency care, in association with one or more other
treating medical providers.
“Notification” or “notice” means a written communication, transmitted by
mail, facsimile or electronic message (“E-mail”).
NOTIFICATION BY MEDICAL PROVIDERS
11:3-25.2
“Personal injury protection” or “PIP” means the coverage set forth at N.J.S.A.
39:6A-4, 39:6A-3.1, or the emergency personal injury protection coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003,
c.89.
“PIP information” means: the name and address of the insured and the name
and address of the injured party, if different; the name of the PIP insurer and the
address established by the insurer for notification of commencement of medical
treatment pursuant to N.J.A.C. 11:3-25.3(c); the policy number of the insurance
policy providing PIP benefits; and the date of the accident/injury. A treating medical provider may obtain this information from the insured, the injured party, the
hospital, a police report or any other reasonably available source.
“Secondary medical providers” means those health care providers who provide
medical products, care and services to a person injured in an automobile accident
only after having received a prescription from a treating health care provider. Secondary medical providers shall include, but are not limited to, pharmacists, visiting nurses, prosthetics fabricators and providers of durable medical equipment
products. Notwithstanding the existence of a prescription of a treating medical
provider, physical therapists, chiropractors and any secondary medical provider
who seeks payment of an eligible charge in excess of $500.00 for individual services or products provided on one occasion or in the course of 30 days shall not
be considered secondary medical providers.
“Treating health care provider” means those persons licensed or certified to
perform health care treatment or services compensable as medical expenses and
shall include, but not be limited to:
1. A hospital or health care facility which is maintained by a state or any of its
political subdivisions;
2. A hospital or health care facility licensed by the Department of Health and
Senior Services;
3. Other hospitals or health care facilities designated by the Department of
Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency
clinics or offices, and private treatment centers;
4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital;
5. Hospitals or other health care facilities or treatment centers located in other
states or nations;
6. Physicians licensed to practice medicine and surgery;
7. Licensed chiropractors;
8. Licensed dentists;
9. Licensed optometrists;
10. Licensed pharmacists;
11. Licensed chiropodists (podiatrists);
12. Registered bio-analytical laboratories;
13. Licensed psychologists;
14. Licensed physical therapists;
15. Certified nurse-midwives;
16. Certified nurse-practitioners/clinical nurse-specialists
17. Licensed health maintenance organizations;
18. Licensed orthotists and prosthetists;
19. Licensed professional nurses;
20. Licensed occupational therapists;
21. Licensed speech-language pathologists;
22. Licensed audiologists;
11:3-25.3
APPENDIX B - REGULATIONS
23. Licensed physician assistants;
24. Licensed physical therapists assistants;
25. Licensed occupational therapy assistants; and
26. Providers of other health care services or supplies, including durable medical goods.
Amended. R 1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, effective June 7, 2004.
11:3-25.3 Notification of commencement of treatment
(a) When medical treatment is rendered for which a claim for payment will be
made pursuant to the PIP coverage of a private passenger automobile insurance
policy, a treating health care provider shall provide notice to the PIP insurer no later than 21 days following the date of the commencement of such treatment.
(b) In accordance with the PIP information provided by the injured party or the
insured, notice shall be sent by the treating health care provider to the insurer at
the address established by the insurer for the receipt of such notice.
(c) Insurers shall establish one address where notice must be sent by treating
health care providers pursuant to these rules. Insurers shall provide this address,
and may provide a facsimile transmission number, and E-mail address if any, on
all insurance identification cards issued by the insurer after January 6, 1997.
(d) In accordance with the provisions of N.J.A.C. 11:3-25.10, insurers shall file
with the Department the address, and may provide a facsimile transmission number, and E-mail address, if any, where notice of commencement of treatment
should be sent. Insurers shall also include the name and telephone number of a
contact person at the insurer for this purpose. Such information shall be added to
a list of insurer addresses maintained by the Department.
(e) Notice sent to the address printed on a valid insurance identification card or
on the Department's current list of addresses shall be presumed to have been sent
to the proper address.
(f) Within 14 days after receiving notice of the commencement of treatment,
the insurer shall notify the treating health care provider of the coverage status of
the person receiving treatment. If the notice from the insurer states that the coverage status of the person receiving treatment is unknown, the insurer shall make a
determination of coverage and provide written confirmation to the treating health
care provider no later than 60 days from receipt of notice of commencement of
treatment. Examples where the coverage status may not be known are when the
injured person is not a named insured, principal or occasional operator, or is not
otherwise listed as a resident of the insured household on the most recent information provided to the insurer by the named insured.
(g) The notice requirements set forth in (a) through (c) above and the eligible
charge reductions contained in N.J.A.C. 11:3-25.5 shall not apply to secondary
medical providers, except as noted in the definition of that term found in N.J.A.C.
11:3-25.2.
(h) In calculating the time for notice in (a) and (f) above, the day treatment begins or the day the insurer receives notice from the treating health care provider is
not to be included. If the last day for providing notice falls on a Saturday, Sunday
or legal holiday, the time runs to the next business day.
Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).
11:3-25.4 Content of notice and proof of receipt
(a) The treating health care provider shall send the written notice required by
N.J.A.C. 11:3-25.3(a) to the PIP insurer on either:
NOTIFICATION BY MEDICAL PROVIDERS
11:3-25.5
1.The “Notification of Commencement of Medical Treatment Form” found in
Appendix A, appended to and incorporated by reference in this subchapter; or
2.A bill or invoice rendered by the treating health care provider that includes
the information required in the “Notification of Commencement of Medical Treatment Form” in Appendix A.
(b) When any notice required by this subchapter is mailed, the postmark shall
be the proof of mailing. The insurer shall retain evidence of untimely mailing of
the notice whenever it denies or reduces payment pursuant to N.J.A.C. 11:3-25.5.
(c) If facsimile or E-mail notice is authorized by the insurer, and any notice required by this subchapter is sent by facsimile or by E-mail, the proof of notice
shall be the facsimile transmission receipt generated by the sender's facsimile machine, a copy of the E-mail message showing the date and time of transmittal or
an acknowledgment of receipt generated by the receiving system. Nothing in this
section shall prohibit treating health care providers and insurers from mutually
agreeing to accept other proofs of notice for electronic transmissions. It shall be
the responsibility of the treating health care provider to retain proof of notice of
commencement of treatment transmitted by facsimile or other electronic means.
(d) Any notice given pursuant to this subchapter shall be deemed to have been
made on the date of postmark or the date of transmission in the case of facsimile
transmission and E-mail.
(e) When a bill or invoice is used to provide notice of the commencement of
treatment in accordance with this subchapter, it shall not be deemed to constitute
notice unless the following message appears on the first page of the bill or invoice:
“21 DAY NOTICE” or “FIRST BILL 21 DAY NOTICE.” this message shall be
in contrasting color ink and be in at least 12 point capital letters. Use of a rubber
stamp or affixed label is acceptable for purposes of complying with this subsection.
Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).
11:3-25.5 Late notification
(a) In the event notice of commencement of medical treatment is made after 21
days, the insurer shall advise the treating health care provider in writing of the late
notification and may reserve the right to deny or reduce payment in accordance
with (b) below.
(b) Where notice of the commencement of medical treatment is not timely provided in accordance with this subchapter, an insurer may apply the following reductions to the eligible charges:
1. 22 to 30 days after the commencement of treatment: 10 percent reduction.
2. 31 to 60 days after the commencement of treatment: 25 percent reduction.
3. 61 to 120 days after the commencement of treatment: 50 percent reduction.
4. 121 to 160 days after the commencement of treatment: 75 percent reduction.
5. 161 or more days from the commencement of treatment: 100 percent reduction.
(c) If notice is not provided as required by this subchapter, the reduction formula set forth in (b) above shall apply to all eligible charges for which the treating
health care provider seeks payment through such late notice.
(d) Insurers shall not reduce an eligible charge under the following circumstances:
1. When the provider is a multiple treating health care provider giving emergency care as defined in N.J.A.C. 11:3-25.2;
2. When the provider is a secondary medical provider as defined in N.J.A.C.
11:3-25.2;
11:3-25.6
APPENDIX B - REGULATIONS
3. When the medical condition of the injured party made it impossible to comply with the notice requirement; or
4. When the provider has submitted a request for decision point review or precertification of treatment, diagnostic testing or durable medical equipment in accordance with an insurer’s decision point review plan approved in accordance
with N.J.A.C. 11:3-4.7
Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, effective June 7, 2004.
11:3-25.6 Standards for adjustment of reduction
(a) Notwithstanding the reductions set forth in N.J.A.C. 11:3-25.5(b), insurers
may choose to pay the full or a less reduced amount of an eligible charge based
upon consideration of the following factors:
1. Whether the treating health care provider has previously provided untimely
notice under this subchapter or has established a pattern of untimely notice;
2. The cost of medical treatment provided by the treating health care provider
between the time treatment commenced, when notice was due and when it was
provided;
3. The injured party was a pedestrian who did not have PIP coverage as the
named insured or resident relative under another policy and the circumstances are
such that additional time is necessary to identity the policy under which coverage
is being provided;
4. Any potential adverse impact on the public and
5. Such other factors as the insurer may determine.
(b) Within 60 days of receipt of notice, or such additional time as may be afforded under N.J.S.A. 39:6A-5g, the insurer shall give the treating health care provider notice of its final determination as to payment, reduction or denial of payment of an eligible charge. Such notice shall be clearly labeled “Final Determination,” and it shall refer clearly to the injured party, the insured, the claim number,
the date of accident, the date of first treatment, the date notice of the commencement of treatment was made and the acceptance or rejection of any of the standards of adjustment of the reduction in (a) above and N.J.A.C. 11:3-25.5(b).
Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).
11:3-25.7 Responsibility for payment
Whenever an eligible charge has been reduced or denied pursuant to N.J.A.C.
11:3-25.5(b), the treating health care provider shall not seek to obtain payment directly from the insured or the person receiving treatment.
Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).
11:3-25.8 Procedure for appeals
A treating health care provider who fails to notify the insurer within 21 days
and whose claim has been reduced or denied by the insurer pursuant to N.J.A.C.
11:3-25.5(b) may, in the discretion of a judge of Superior Court, be permitted to
refile such claim provided that the insurer has not been substantially prejudiced
thereby. Application to the court for permission to refile a claim shall be made
within 14 days of the receipt of the insurer's final determination of reduction or
denial of payment and shall be made upon motion based upon affidavits showing
sufficient reasons for the failure to notify the insurer within 21 days of the commencement of treatment.
Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).
NOTIFICATION BY MEDICAL PROVIDERS
11:3-25.10
11:3-25.9 Reporting requirement
(a) By February 5, 1997, every insurer shall file with the Department the address, facsimile number (if notice by facsimile is permitted) and E-mail address,
if any, of the designated location for the filing of notice required under this subchapter. Insurers shall use Appendix B, appended to and incorporated by reference
in this subchapter, to report the information required by this subsection.
(b) Insurers shall complete and file the information in Appendix B by January
1 of each year.
(c) Completed copies of Appendix B shall be submitted to:
Department of Banking and Insurance
Director of Public Affairs
PO Box 325
Trenton, New Jersey 08625-0325
11:3-25.10. Compliance.
For treatments rendered between January 6, 1997 and July 6, 1997, all eligible
charge reductions set forth in N.J.A.C. 11:3-25.5(b) shall be reduced by 50 percent
(for example, a 10 percent reduction shall be five percent, a 25 percent reduction
shall be 12.5 percent, etc.).
APPENDIX A
Notification of Commencement of Medical Treatment
(to be filed with insurer)
Name, address and phone No. of Treating Health Care Provider:
________________________________________________________________
Fax No. (optional)_________________________________________________
Name and address of patient:
_____________________________
_____________________________
_____________________________
_____________________________
Name and address of insured:
(if different)
________________________________
________________________________
________________________________
________________________________
Insurer Name: ___________________________________________________
Insurer Address:
________________________________________________________________
________________________________ Policy No.______________________
Date of accident/injury: ____________________________________________
Date of first treatment: ____________________________________________
APPENDIX B
Address for Notification of Commencement of Medical Treatment
Insurance Co. Name: ______________________________________________
11:3-26.1
APPENDIX B - REGULATIONS
NAIC Group #: _________________
NAIC Company #: _____________
Address established by insurer for the filing of the notification of the
commencement of PIP treatment by Treating Health Care Providers
Address:
_____________________________________
_____________________________________
_____________________________________
Facsimile No: ___________________________________________________
E-mail: _________________________________________________________
Contact Person: _________________________________________________
Phone: _________________________________________________________
To be filed with:
Department of Banking and Insurance
Division of Public Affairs
PO Box 325
Trenton, New Jersey 08625-0325
Attn: Notification of Treatment List
SUBCHAPTER 26. UNSATISFIED CLAIM AND JUDGMENT FUND:
NOTICE OF INTENT
Section
11:3-26.1. Claim information.
11:3-26.2. Claim filing; form.
11:3-26.1. Claim information. (a) Notice of intention to make a claim under
N.J.S.A. 39:6-65 shall contain the following information:
1. The claimant’s name, address, date of birth and social security number;
2. The time, date, location, municipality and county in which the loss occurred;
3. The identity of the operators and vehicles involved in the accident, including
the name and address of the owner and operator and the license plate number of
the vehicle;
4. Such witnesses to said accident as are then known;
5. A short description of the accident, including the claimant’s role or position
therein;
6. A description of the injuries then known, and attached thereto a medical certificate if then available. In any event the medical certificate shall be filed as soon
as available;
7. A description of the damage sustained to property, and attached thereto an
estimate of the cost of repairs if then available; and
8. The policy number of any insurance applicable to the accident, including the
name and address of all insurance companies involved.
Amended. R. 1991 d. 45, effective February 4, 1991; Amended. R. 1996 d. 58, effective February 5,
1996.
11:3-26.2. Claim filing; form. (a) A Notice of Intention to Make Claim under
N.J.S.A. 39:6-65 may be filed on the form designated by the Unsatisfied Claim
UCJF
11:3-28
and Judgment Fund Board identified as a “Notice of Intention to Make Claim”,
incorporated herein by reference as Appendix A [See Appendix C-20]
(b) A written notice to the Board in any other form that contains the information required by this section shall be acceptable.
(c) A notice of intention to make a claim that does not contain the items identified in N.J.A.C. 11:3-26.1(a)1 through 8 shall be returned to the sender and
deemed to be not filed with the Unsatisfied Claim and Judgment Fund (UCJF) for
the purpose of complying with N.J.S.A. 39:6-65 and shall not toll the statute of
limitations.
Amended. R.1991 d.45, effective February 4, 1991; R.1996 d.58, effective February 5, 1996; R.1997
d.85, effective February 18, 1997; R.2006 d.243, effective July 3, 2006.
SUBCHAPTER 27. UNSATISFIED CLAIM AND JUDGMENT FUND
BOARD
Section
11:3-27.1. Uninsured’s Current Financial Status.
11:3-27.1. Uninsured’s Current Financial Status. (a) Upon review of a case
by the Unsatisfied Claim and Judgment Fund Board’s designee, if the designee
does not have sufficient current information to determine whether or not the uninsured’s installment payment is reasonable, a request will be addressed to the uninsured asking for a statement of current financial status.
(b) If the uninsured fails to furnish a completed statement of current financial
status within a time period to be established by the executive director, the Unsatisfied Claim and Judgment Fund Board’s designee will request the Director of
Motor Vehicles to suspend the license and all registrations of the uninsured pursuant to N.J.S.A. 39:5-30 and 39:5-87, for failure to furnish this information.
Amended. R.2006 d.243, effective July 3, 2006.
SUBCHAPTER 28. UNSATISFIED CLAIM AND JUDGMENT FUND’S
REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID
BY INSURERS
Section
11:3-28.1. Purpose and scope.
11:3-28.2. Definitions.
11:3-28.3. Report of such claims when the carrier has paid at least $50,000 for
medical expense benefits.
11:3-28.4. Notice of change in the amount of reserves.
11:3-28.5. Supplemental form to be submitted to the Fund.
11:3-28.6. Insurer's continuing obligation to investigate claims.
11:3-28.7. Reimbursement of excess medical expense benefits paid by insurers.
11:3-28.8. Audits.
11:3-28.9. Reporting of losses for personal injury protection payments in
excess of $75,000.
11:3-28.10. Insurers' obligations to investigate and audit bills for medical
benefits.
11:3-28.11. Modifications to vehicles.
11:3-28.12. Modifications to a claimant's residence.
11:3-28.13. Insurer's obligation to obtain recovery of payments for paid medical
expense benefit claims.
11:3-28.1
APPENDIX B - REGULATIONS
11:3-28.14. Insurer’s responsibility upon assignment of an uninsured motorist
claim.
11:3-28.15. Reserved.
11:3-28.16. Reserved.
11:3-28.17. Reserved.
11:3-28.1 Purpose and scope
(a) The purpose of this subchapter is to establish procedures to ensure that
only appropriate, reimbursable claims are submitted to the Fund by insurers by requiring investigation of the medical necessity for certain claims; requiring the audit of claims of $10,000 or more submitted by licensed providers of health care
services or claims of $25,000 or more by health care facilities; and requiring prior
approval of claims for alterations to vehicles and residences. This subchapter also
requires insurers to pursue the proper, alternative sources for reimbursement
where such other sources of funds are available.
(b) This subchapter applies to all insurers authorized in this State to write the
kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1. In accordance with N.J.S.A. 39:6-73.1, reimbursement for medical expense benefits may
be sought from the Fund on account of personal injury to any one person in any
one accident occurring on or after February 19, 1978.
(c) N.J.A.C. 11:3-28.13 establishes standards for insurers to demonstrate diligent pursuit of any potentially responsible tortfeasor for the purpose of recovering
PIP medical expense benefits paid on behalf of the injured party by the Fund. Insurers shall obtain reimbursement from the Fund for excess medical expense benefit payments once they comply with the standards established herein. The purpose of these provisions are to contain costs for automobile insurance in this State.
Accordingly, consistent with this purpose and N.J.S.A. 39:6A-9.1, for accidents
occurring outside this State, insurers are expected to assert appropriate legal remedies to pursue recovery actions against potentially responsible tortfeasors, consistent with the legal rights and remedies asserted by the injured party.
Repeal and New Rule, R.1993 d.583, effective November 15, 1993. See:25 N.J.R. 2636(b), 25 N.J.R.
5219(a). Amended. R. 2001 d. 151, effective May 7, 2001.
11:3-28.2 Definitions
The following words and terms, when used in this subchapter, shall have the
following meanings unless the context clearly indicates otherwise:
“Board” means the Board of the New Jersey Property-Liability Insurance
Guaranty Association created in accordance with N.J.S.A. 17:30A-1 et seq.
“Diagnosis related groups” or “DRG” means a patient classification scheme in
which cases are grouped by shared characteristics of principal diagnosis, secondary diagnosis, age, surgical procedure, and other complications. Each DRG exhibits a consistent amount of resource consumption as measured by some unit (for example, length of stay or dollars).
“Excess medical expense benefits” means medical expense benefits paid in
accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 that are in excess of $75,000 resulting from personal injury to any one person in any one accident.
“Fund” means the Unsatisfied Claim and Judgment Fund established pursuant to N.J.S.A. 39:6-61 et seq.
“Health care facility” means a health care provider that is a facility or institution, whether public or private, engaged principally in providing services for diagnosis of treatment of pain, injury, deformity or physical condition, including,
but not limited to, a general hospital, special hospital, public health center, diag-
UCJF
11:3-28.2
nostic center, treatment center, rehabilitation center, extended care facility, skilled
nursing home, nursing home, intermediate care facility, outpatient clinic, dispensary or residential health care facility.
“Health care provider” or “provider” means those persons licensed or certified to perform health care treatment or services compensable as medical expenses
and shall include, but not be limited to:
1. A hospital or health care facility which is maintained by a state or any of its
political subdivisions;
2. A hospital or health care facility licensed by the Department of Health and
Senior Services;
3. Other hospitals or health care facilities designated by the Department of
Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency
clinics or offices, and private treatment centers;
4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital;
5. Hospitals or other health care facilities or treatment centers located in other
states or nations;
6. Physicians licensed to practice medicine and surgery;
7. Licensed chiropractors;
8. Licensed dentists;
9. Licensed optometrists;
10. Licensed pharmacists;
11. Licensed chiropodists (podiatrists);
12. Registered bio-analytical laboratories;
13. Licensed psychologists;
14. Licensed physical therapists;
15. Certified nurse-midwives;
16. Certified nurse-practitioners/clinical nurse-specialists
17. Licensed health maintenance organizations;
18. Licensed orthotists and prosthetists;
19. Licensed professional nurses;
20. Licensed occupational therapists;
21. Licensed speech-language pathologists;
22. Licensed audiologists;
23. Licensed physician assistants;
24. Licensed physical therapists assistants;
25. Licensed occupational therapy assistants; and
26. Providers of other health care services or supplies, including durable medical goods.
“Health care service” means the preadmission, outpatient, inpatient and postdischarge care provided in or by a health care facility, and such other items or services as are necessary for such care, which are provided by or under the supervision of a physician for the purpose of diagnosis or treatment of pain, injury, disability, deformity or physical condition, including, but not limited to, nursing
service, home care nursing and other paramedical service, ambulance service, service provided by an intern, resident in training or physician whose compensation
is provided through agreement with a health care facility, laboratory service, medical social service, drugs, biologicals, supplies, appliances, equipment, bed and
board.
“Insurer” means any person authorized or admitted in this State to write the
kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1, pursuant
11:3-28.3
APPENDIX B - REGULATIONS
to N.J.S.A. 17:17-1et seq. or 17:32-1 et seq., as applicable. “Insurer” shall not include a surplus lines insurer eligible to write business pursuant to N.J.S.A. 17:226.40 et seq.
“Licensed nursing personnel” or “licensed nurse” means a nurse licensed by
the New Jersey State Board of Nursing or the equivalent from another jurisdiction.
“Medical expense benefits” means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 and N.J.A.C. 11:3-4.
“Medically necessary” is as defined in N.J.A.C. 11:3-4.2.
“Per diem” means a daily fixed charge which includes room and board and
other fees for services and supplies.
“PIP coverage” means personal injury protection coverage as described at
N.J.S.A. 39:6A-4 or 39:6A-3.1.
“Person” means any individual, association, company, corporation, insurer,
joint stock company, organization, partnership, society, syndicate, trust, any combination of the foregoing acting in concert or any other entity.
“Pre-screen means an off-site review of the billings from a health care facility
to determine whether the care given and amounts charged are appropriate.
“Provider” means any person that furnishes services or equipment for medical
expense benefits for which payment is required to be made under PIP coverage in
automobile insurance policies, but does not include health care facilities.
“Reimbursement” refers to reimbursement to insurers by the Fund as provided at N.J.S.A. 39:6-73.1.
“Uninsured motorist claims” means claims submitted against operators of
uninsured vehicles and hit and run claims submitted pursuant to N.J.S. 39:6-61.
New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.1994 d.597, effective December 5, 1994; R.1997 d.535, effective December 15, 1997; R.1998 d.591, effective December 21,
1998 (operative March 22, 1999); R.2006 d.243, effective July 3, 2006.
11:3-28.3 Report of such claims when the carrier has paid at least $50,000
for medical expense benefits
In cases where the potential exposure to the automobile liability insurer exceeds $75,000, the insurer shall report on form UCJF Form 1(321) (incorporated
herein by reference as Form 1 in Appendix A) [Publishers note: not included herein] whenever medical expense benefits in a total amount of $50,000 have been
paid on account of personal injury to any one person in any one accident.
Recodified from 11:3-28.2 and amended by R.1993 d.583, effective November 15, 1993. See: 25
N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, 1997.
11:3-28.4 Notice of change in the amount of reserves
Whenever an automobile liability insurer has paid medical expense benefits
on account of personal injury to any one person in any one accident in a total
amount of $50,000, said insurer shall notify the Fund of any changes in the amount
of reserves established for payment of the claim or closing of the file.
Recodified from 11:3-28.3 and amended by R.1993 d.583, effective November 15, 1993. See: 25
N.J.R. 2636(b), 25 N.J.R. 5219(a).
11:3-28.5 Supplemental form to be submitted to the Fund
(a) UCJF Form 2(RR) (incorporated herein by reference as Form 2 in Appendix A), shall be filed with the Fund within 90 days after an automobile insurer
has paid medical expense benefits on account of personal injury to any one person
in any one accident in a total amount in excess of $75,000. Such form together
with UCJF Form 3(323) (incorporated herein by reference as Form 3 in Appendix
A) [Publishers note: not included herein] shall be filed each quarter thereafter that
the insurer seeks reimbursement.
UCJF
11:3-28.7
(b) Any office of an insurer seeking reimbursement of funds from the UCJF for
personal injury protection medical expense must also complete and file with the
UCJF a New Jersey Information Questionnaire, UCJF Form 4(W-9) (incorporated
herein by reference as Form 4 in Appendix A) [Publishers note: not included herein].
Recodified from 11:3-28.4 and amended by R.1993 d.583, effective November 15, 1993. See: 25
N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, 1997.
11:3-28.6 Insurer's continuing obligation to investigate claims
(a) An automobile liability insurer shall be required to discharge its duty of
investigating claims where the potential exposure to the insurer exceeds $75,000.
Said insurer's duty and obligation with regard to claim handling shall exist and
continue to exist notwithstanding this rule. The Executive Director may direct
such investigations as often as he or she deems necessary. All expenses relating to
the investigation of claims, including expenses for medical examinations, file
maintenance and cost containment measures, are the responsibility of the automobile liability insurer.
(b) The failure to properly discharge the duty of investigating a claim may
result in the imposition of a penalty, to be determined by the Board’s designee,
against the insurer's request for reimbursement.
Amended. R.1991 d.45, effective February 4, 1991. Recodified from 11:3-28.5 and amended by
R.1993 d.583, effective November 15, 1993. Amended. R.2006 d.243, effective July 3, 2006.
11:3-28.7 Reimbursement of excess medical benefits paid by insurers
(a) Insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefit claim payments as soon as practicable after the close of the quarter for which reimbursement is sought for claim
payments of $20,000 or more. For claim payments of less than $20,000, insurers
shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefits either quarterly or at the close of the calendar year
in which such expenses are incurred. Insurers shall not be reimbursed for interest,
attorney fees or punitive damages.
1. Regardless of the size of a claim payment for excess medical expense benefits, an insurer shall submit to the Fund a request for reimbursement within a period of two years from the date of payment by the insurer of the excess medical
expense benefit for which reimbursement is sought.
2. Failure to comply with the requirements set forth in (a) 1 above shall result
in a denial by the Fund of the reimbursement request which was omitted from the
quarterly submission.
(b) The Fund shall not reimburse an insurer for excess medical expense benefits if it is determined that there are multiple insurance policies applicable to a
claim unless an insurer has expended medical benefits in an amount exceeding
$75,000 on account of personal injury to any one person in any one accident.
Where there are two or more different primary insurers liable, the Fund shall not
reimburse such an insurer for excess medical expense benefits unless each primary insurer has expended medical benefits in an amount exceeding $75,000 on account of personal injury to any one person in any one accident.
(c) Where the Fund has reimbursed an insurer for excess medical expense
benefits and thereafter determines that there were or are multiple insurance policies applicable to the underlying claim, the insurer shall return all moneys paid
from the Fund. The insurer(s) shall apportion the medical benefits payment and
make individual application to the Fund where the potential exposure to the insur-
11:3-28.8
APPENDIX B - REGULATIONS
er(s) exceeds $75,000 on account of personal injury to any one person in any one
accident.
(d) Whenever an insurer recovers amounts expended by it for medical benefits, it shall not be reimbursed for excess medical expense benefits unless it has
fully repaid the amount previously reimbursed by the Fund.
Recodified from 11:3-28.6 and amended by R.1993 d.583, effective November 15, 1993. Amended.
R.2006 d.243, effective July 3, 2006; R.2007 d.61, effective February 20, 2007.
11:3-28.8 Audits
Upon request of the Fund, the insurer(s) shall present for audit at the direction
of the Executive Director at a New Jersey location all policy and claim records on
which notice of potential for payment of excess medical expense benefits have
been submitted.
Recodified from 11:3-28.7 and amended by R.1993 d.583, effective November 15, 1993. See: 25
N.J.R. 2636(b), 25 N.J.R. 5219(a).
11:3-28.9 Reporting of losses for personal injury protection payments in
excess of $75,000
(a) For purposes of completing page 14, Exhibit of Premiums and Losses, of
the annual statement filed pursuant to N.J.S.A. 17:23-1, the insurer shall include
the total amount of losses for private passenger automobile and commercial automobile personal injury protection payments (lines 19.1 and 19.3), including those
in excess of $75,000. Insurers shall also provide a footnote on page 14 that indicates the amount of losses reported, excluding losses from payments of private
passenger automobile and commercial automobile personal injury protection payments in excess of $75,000.
(b) For purposes of completing Schedule F of the annual statement, insurers
shall consider the assumption and reimbursement by the Fund of private passenger
automobile and commercial automobile personal injury protection payments in
excess of $75,000 as a reinsurance transaction. Insurers shall consider assessments paid to the UCJF pursuant to N.J.S.A. 39:6-63 based on the insurer's premiums for private passenger automobile liability insurance (including PIP) and commercial automobile liability insurance (including PIP) as ceded premium, pro rated for the appropriate line of business on which the assessment was based.
(c) Insurers shall comply with the provisions of this section beginning with
the annual statement due March 1, 1994 (covering the calendar year ended December 31, 1993). For purposes of completing the annual statement due March 1,
1993 (covering the calendar year ended December 31, 1992), insurers shall file by
no later than July 1, 1993 a supplemental page 14 and schedule F of the annual
statement in accordance with the provisions of this section.
New Rule, R.1993 d.178, effective April 19, 1993. See:24 N.J.R. 3215(a), 24 N.J.R. 1769(a). Recodified from 11:3-28.8 and amended by R.1993 d.583, effective November 15, 1993. See: 25 N.J.R.
2636(b), 25 N.J.R. 5219(a).
11:3-28.10 Insurers' obligations to investigate and audit bills for medical
benefits
(a) For purposes of reimbursement by the Fund, an insurer shall conduct an
investigation and audit of claims submitted by health care facilities where such
claims are equal to or in excess of $25,000 and an on-site audit where such claims
are equal to or in excess of $50,000.
1. Failure of an insurer to complete an audit in accordance with
these rules shall result in a 20 percent reduction in payment to the insurer by
the Fund of the unaudited, reimbursable bill.
UCJF
11:3-28.11
2. Per diem billings for health care facilities are not subject to the audit requirements set forth in this subchapter.
3. An insurer shall conduct any such audit to determine whether the level of
care, need and charges are appropriate.
4. An insurer may pay 80 percent of the provider's bill prior to completion of
the initial on-site audit. The remaining amount due, if any, shall be paid following
completion of the insurer's audit.
5. Annual on-site audits shall be completed in 12-month intervals, from the initial on-site audit and shall be filed with the Fund within 90 days of completion of
the audit; and
6. Whenever a change in services occurs such as, but not limited to, the level
of care, the daily boom rate or additional charges, an insurer shall conduct an onsite audit and shall provide the audit and auditor's statement to the Fund with the
next reimbursement request.
7. All other audits shall be conducted prior to payment to the health care facility
and may be performed on a pre-screen basis as set forth in (e) below.
(b) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by providers other than health care facilities where such claims are equal to or in excess of $10,000.
1. Failure of an insurer to complete an audit in accordance with this subchapter
shall result in a 20 percent reduction in payment to the insurer by the Fund of the
unaudited, reimbursable bill.
(c) The thresholds in (a) and (b) above are cumulative for each confinement
associated with damages resulting from bodily injuries arising out of the ownership, maintenance or use of a motor vehicle in this State and shall incorporate all
claims submitted per confinement by the provider.
(d) To be eligible for reimbursement by the Fund, insurers shall audit, prior
to payment, bills submitted for continuous treatment from any provider which exceed or may exceed the applicable threshold.
(e) Audits of all providers conducted pursuant to this subchapter, including
the audit of DRG bills and any successor pricing, shall be performed by:
1. Licensed nursing personnel with two years experience or training in required
auditing and hospital practices; or
2. An outside auditing firm retained by the insurer for such purposes.
(f) Audits performed shall include, but not be limited to, confirmation of
compliance with the medical fee schedule set forth at N.J.A.C. 11:3-29 including
those situations where the insurer does not provide the primary coverage to the
claimant.
(g) An insurer is not required to conduct a separate, independent audit, if it
has obtained a true copy of an audit conducted by the primary insurer or health
insurer.
(h) Insurers shall append copies of audits conducted, including those conducted by the primary insurer or health insurer, and the auditor's statements with
the reimbursement request filed with the Fund in accordance with N.J.A.C. 11:328.7.
New Rule. R.1993 d.583, effective November 15, 1993. Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999); R.2006 d.243, effective July 3, 2006.
11:3-28.11 Modifications to vehicles. (a) An insurer shall obtain prior approval from the Fund for modifications to a claimant's vehicle, or vehicle to be used
for the benefit of the claimant, the cost of which may be reimbursed by the Fund.
(b) An insurer shall submit a written request to the Fund, including a Van
Purchase and Modification Agreement seeking approval of modifications which
11:3-28.12
APPENDIX B - REGULATIONS
are equal to or in excess of $1,000, within 30 days of a claimant's request for modifications.
(c) A request to obtain prior approval from the Fund shall include the following:
1. A written recommendation for the modification by the claimant's primary
care physician including:
i. Where the claimant is the operator of the vehicle, current findings on the
claimant's physical ability to drive and a copy of the claimant's current driver's license
ii.A brief analysis of the medical necessity and medical purpose for the requested modifications
iii. A description of the purpose for which the vehicle will be used and
iv.Verification that the requested modifications are necessitated by injuries
sustained by the claimant in the subject accident
2. A cost benefit analysis, supported by appropriate documentation, comparing
the cost of modifying the claimant's vehicle to the cost of alternate methods of
transporting the claimant. This analysis shall incorporate an evaluation of the anticipated miles to be driven per year for medically necessary health care services,
including a breakdown reflecting the number of miles to be driven to obtain health
care service and the frequency of such services, the cost per mile of alternate
means of such transportation, as well as the useful life of the vehicle
3.An agreement between the insurer and the claimant setting forth, but not limited to:
i. The claimant's responsibility to maintain insurance on the vehicle; and
ii. The claimant's responsibility to repair and maintain the vehicle; and
4.Any additional information specifically requested by the Fund with regard to
a particular application for approval.
(d) The insurer may independently evaluate, or be required by the Fund to
evaluate, the claimant by a physician chosen by the insurer and approved by the
Fund, at the insurer's cost, to determine whether a medical necessity and medical
purpose exist for modifications to the vehicle. The evaluation shall include a review of the elements considered in the primary evaluation as set forth at (c) above.
(e) The Fund shall not approve modifications to a vehicle unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident, are required
for a medical purpose and the modifications are shown to be cost effective or as
the Fund may otherwise determine.
(f) A request for modifications may be denied for failure to fulfill any of the
above conditions.
New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.2006 d.243, effective July 3,
2006.
11:3-28.12 Modifications to a claimant's residence
(a) An insurer shall obtain prior approval from the Fund for any modifications to a claimant's primary residence the cost of which may be reimbursed by the
Fund.
(b) An insurer shall submit a written request to the Fund, seeking approval
of modifications which are equal to or in excess of $10,000, within 30 days of a
claimant's request for modifications.
(c) A request to obtain prior approval from the Fund shall include the following:
1. A written recommendation for the modification by the claimant's primary
care physician including:
UCJF
11:3-28.12
i. A brief analysis of the medical necessity for the requested modifications and
ii. Verification that the requested modifications are necessitated by injuries
sustained by the claimant in the subject accident;
2. Medical documentation estimating the claimant's life expectancy;
3. A cost benefit analysis, supported by appropriate documentation, which establishes that the proposed modifications are more cost effective than long term
residential care services. The analysis shall include, in accordance with Appendix
B incorporated herein by reference [Publishers note: not included herein], an evaluation based on the life expectancy of the claimant and a comparison between the
costs of the modifications and home care to be provided, to the costs of other residential care alternatives;
4. An evaluation prepared by an independent consultant experienced in barrier
free designs that sets forth the type of modifications required and the costs of such
modifications.
5. An agreement setting forth the responsibilities regarding the obligations of
the claimant, the owner of the property or both and the insurer for, but not limited
to:
i. The claimant's or property owner's responsibility for:
1) The expenses for upkeep of the residence
2) Maintenance of insurance on the property; and
3) Repayment to the insurer in the event of the claimant's relocation, death or
upon the sale of the modified premises; and
ii. The insurer's obligation to remove nonessential equipment;
6. A repayment agreement with an amortization provision which provides an
amortization term and amount, once a modification is determined to be cost effective, calculated in accordance with the formula provided in Appendix B to this
subchapter; and
7. Any other additional information specifically requested by the Fund with regard to a particular application for approval.
(d) The insurer may independently evaluate, or be required by the Fund to
evaluate, the claimant by a physician chosen by the insurer and approved by the
Fund, at the insurer's cost, to determine whether a medical necessity for the modifications exist. The evaluation shall include a review of the elements considered
in the primary evaluation as set forth at (c) above.
(e) The Fund shall not approve modifications to a residence unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident and the
modifications are shown to be cost effective or as the Fund may otherwise determine.
(f) A request for modification may be denied for failure to fulfill any of the
above requirements.
(g) Where a request for modifications is approved, the insurer shall record a
lien against the modified property in the county in which the property is located
and shall file a copy of the recorded lien with the Fund within 30 days.
1. This provision shall not apply to rental property.
(h) Where a claimant seeks to modify rental property, the insurer shall obtain:
1. A written consent from the owner of the property which permits the modifications and indemnifies the insurer and the Fund from any other liabilities relating
thereto and
11:3-28.13
APPENDIX B - REGULATIONS
2. A written agreement between the claimant and the insurer in which the
claimant agrees to reimburse the insurer for the unamortized costs of the improvements in the event of the claimant's relocation or death.
(i) Upon the claimant's relocation or death, the claimant, the claimant's estate
or the owner of the property against which the lien is recorded, shall reimburse the
insurer for the unamortized cost of the modifications to the claimant's residence.
(j) The claimant, the claimant's estate or the owner of the property against
which the lien was recorded, shall have a reasonable period in which to reimburse
the insurer.
(k) Where repayment by the claimant or the claimant's estate is required pursuant to this section, interest shall accrue at the prevailing rate of post judgment
interest as set forth in the rules governing civil practice in the New Jersey Court
Rules in effect at the time of execution of the repayment agreement, until the
amount owed is paid in full.
(l) Within 30 days from the date of the claimant's relocation or death, the
insurer shall so notify the Fund in writing and shall include the terms of repayment
by the claimant to the insurer. The insurer shall repay the Fund for such reimbursement.
1.The insurer shall be required to repay the Fund within 60 days from receipt
of any and all partial payments or from the receipt of a payment made in full by
the claimant.
(m) A warrant discharging the lien shall be filed by the insurer when the full
amount owed to the insurer, in accordance with the amortization agreement, is satisfied.
New Rule, R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a).
11:3-28.13 Insurer's obligation to obtain recovery of payments for paid
medical expense benefit claims
(a) The Fund shall reimburse insurers for paid medical expense benefit claims
if an insurer demonstrates that it has diligently pursued all potentially responsible
tortfeasors within the time prescribed at N.J.S.A. 39:6A-9.1, or any other applicable limitation period.
1. An insurer shall demonstrate, in accordance with (c) below, that it has diligently pursued any potentially responsible tortfeasor to obtain reimbursement of
PIP medical expense benefit claim payments made by the insurer from the Fund.
2. Where the insurer has failed to diligently pursue any potentially responsible
tortfeasor as set forth in (c) below, the Fund shall be entitled to discontinue reimbursements on that claim. The Fund shall also be entitled to recover from the insurer any reimbursement payments already made to the insurer on that claim, after
notice and opportunity for a hearing in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and Uniform Administrative Procedure Rules,
N.J.A.C. 1:1.
3. An insurer shall obtain prior approval from the Fund before settling or compromising a claim against a potentially responsible tortfeasor or a tortfeasor.
(b) Any and all expenses and fees incurred by the insurer as a result of the pursuit of a potentially responsible tortfeasor, shall be borne by the insurer.
(c) For purposes of this section, “diligently pursue” means that the insurer has
either prosecuted or is prosecuting an action, including by agreement or arbitration, in matters subject to N.J.S.A. 39:6A-9.1, against all potentially responsible
tortfeasors, or determined not to do so after:
1. Examining or reviewing the following documents, where applicable:
UCJF
11:3-28.14
i. Police accident reports, including fatal accident reports and supplemental reports;
ii. Statements of the parties involved;
iii. Witness statements;
iv. Central Index Bureau return results;
v. Information about the assets of uninsured tortfeasors;
vi. Scene photographs and diagrams;
vii. Reports of blood alcohol content;
viii. Relevant court records and information on any related suits, arbitrations,
settlements or judgments, either within or outside the State, including, but not limited to:
(1) Pleadings;
(2) Transcripts of depositions and other related discovery materials; and
(3) Amounts of settlements or judgments; and
ix. Information about the amount of any potentially responsible tortfeasor's insurance liability limits, including, but not limited to, umbrella and excess insurance policies; and
2. Considering the following factors in determining whether to prosecute an action against potentially responsible tortfeasors:
i. The liability of the parties involved;
ii. Relevant law regarding right of recovery actions; and
iii. The basis for denial of coverage by the insurer of the potentially responsible
tortfeasor.
(d) Insurers shall file a certification, in the form of Appendix C incorporated
herein by reference, that they have diligently pursued recovery of medical expense
benefits, and that the insurer has not received from any source reimbursement,
contribution, or indemnification of the excess medical benefits paid by the insurer
for which reimbursement from the Fund is sought. This certification shall be
signed by an officer of the insurer or other person authorized to sign the certification on behalf of the insurer, and shall be filed no later than two years from the
date of the accident, prior to expiration of any applicable statute of limitations, or
at the time filing for reimbursement is made, whichever occurs first. Failure to file
the certification shall result in denial of reimbursement to the insurer by the Fund.
(e) All recovery amounts obtained or that should have been obtained from the
tortfeasor will be deducted from the reimbursement claim.
New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.2001 d.151, effective May 7,
2001; R.2006 d.243, effective July 3, 2006.
11:3-28.14 Insurer's responsibility upon assignment of an uninsured motorist claim. (a) An insurer shall, within 10 business days of receipt of a claim assignment and accompanying instruction sheet (see Appendix B, Item 1, incorporated herein by reference) from the Fund, submit a letter to the Fund which:
1. Acknowledges receipt of the assignment and the accompanying instruction
sheet; and
2. Provides the names and telephone numbers of the case handler or manager,
the claim investigator and the claim adjuster.
(b) An insurer shall, within 10 business days from the date it assigns the claim
to defense counsel, provide the Fund with the name, address and telephone number of defense counsel.
11:3-28.15
APPENDIX B - REGULATIONS
(c) An insurer shall, within 10 business days, provide written notice to the Fund
of any changes, substitutions or replacements which occur with respect to any of
the persons identified pursuant to (a)2 or (b) above.
New Rule, R.1994 d.597, effective December 5, 1994. See: 26 N.J.R. 2190(a), 26 N.J.R. 4772(a).
11:3-28.15 (Reserved)
Repealed. R.2006 d.243, effective July 3, 2006.
11:3-28.16 (Reserved)
11:3-28.17 (Reserved)
Repealed. R.2006 d.243, effective July 3, 2006.
SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE
INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS
MEDICAL EXPENSE INSURANCE COVERAGE
Section
11:3-29.1. Purpose and scope.
11:3-29.2. Definitions.
11:3-29.3. Regions.
11:3-29.4. Application of Medical Fee Schedules.
11:3-29.5. ASC facility fees; hospital outpatient surgical facility fees.
11:3-29.6. Balance billing prohibited
APPENDIX
11:3-29.1. Purpose and scope. (a) Every policy of automobile insurance and
motor bus insurance issued in this State shall provide that the automobile insurer's
limit of liability for medically necessary expenses payable under PIP coverage,
and the motor bus insurer's limit of liability for medically necessary expenses payable under medical expense benefits coverage, is the fee set forth in this subchapter or the usual, customary and reasonable fee, whichever is less.
(b) This subchapter implements the provisions of N.J.S.A. 39:6A-4.6 to establish medical fee schedules on a regional basis for the reimbursement of health care
providers providing services or equipment for medical expense benefits for which
payment is required to be made by automobile insurers under PIP coverage and by
motor bus insurers under medical expense benefits coverage.
(c) This subchapter applies to all insurers who issue policies of automobile insurance containing PIP coverage and policies of motor bus insurance containing
medical expense benefits coverage.
(d) This subchapter does not apply to the following:
1. Other coverages contained in an automobile or motor bus insurance policy
such as coverage for bodily injury liability;
2. Any other kind of insurance including health insurance, even when the
health insurer may be required pursuant to its health insurance contract to pay benefits to, or on behalf of, a person who sustained bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile or
motor bus, or as a pedestrian, caused by an automobile or motor bus or an object
propelled by or from an automobile or motor bus;
3. Medical services or equipment provided outside of the geographic boundaries of New Jersey except as set forth in N.J.A.C. 11:3-29.4(d)2; and
MEDICAL FEE SCHEDULES
11:3-29.2
4. Inpatient services provided by acute care hospitals, trauma centers, rehabilitation facilities, other specialized hospitals, residential alcohol treatment facilities
and nursing homes, except as specifically set forth in this subchapter.
Amended: R.1993 d. 25, effective January 4, 1993; R.2001 d.158, effective May 21, 2001; R.2007
d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4,
2013).
11:3-29.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates
otherwise:
“Ambulatory surgery facility” or “ASC” means:
1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey
in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are performed and which is separate and apart from any other facility license. (The ambulatory surgery facility may be physically connected to another licensed facility,
such as a hospital, but is corporately, financially and administratively distinct, for
example, it uses a separate tax-id number); or
2. A physician-owned single operating room in an office setting that is certified
by Medicare.
“Basic Life Support” (“BLS”) means volunteer ambulance services, whose
personnel are not required to be Emergency Medical Technicians, and municipal
and proprietary ambulance services whose personnel are required to be Emergency Medical Technicians.
“Bilateral surgery” means identical procedures (requiring use of the same CPT
code) performed on the same anatomic site but on opposite sides of the body. Furthermore, each procedure is performed through its own separate incision.
"CDT" means the American Dental Association's Current Dental Terminology
2011-2012, copyright 2010.
“Co-surgery” means two surgeons (each in a different specialty) are required
to perform a specific procedure. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of one procedure simultaneously.
"CPT" means the American Medical Association's Current Procedural Terminology, Fourth Edition, Version 2011, coding system. Current Procedural Terminology (CPT) is copyright 2011 American Medical Association (AMA), all rights
reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained in the CPT.
Applicable Federal Acquisition Regulation and Defense Federal Acquisition Regulation Supplement (FARS/DFARS), 48 CFR, restrictions apply to government
use. CPT<(R)> is a trademark of the American Medical Association.
"Eligible charge or expense" means the usual, customary and reasonable
charge as determined pursuant to N.J.A.C. 11:3-29.4(e)1 or the upper limit in the
fee schedule, whichever is lower.
“Emergency care” means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to
result in: death; serious impairment to bodily functions; or serious dysfunction of
a bodily organ or part. Such emergency care shall include all medically necessary
care immediately following an automobile accident, including, but not limited to,
immediate pre-hospitalization care, transportation to a hospital or trauma center,
emergency room care, surgery, critical and acute care. Emergency care extends
11:3-29.2
APPENDIX B - REGULATIONS
during the period of initial hospitalization until the patient is discharged from
acute care by the attending physician.
“Global service” means the sum of the technical and professional components.
“HCPCS” means the Federal Center for Medicare and Medicaid Services
(CMS) Common Procedure Code System.
“Health care provider” or “provider” is as defined in N.J.A.C. 11:3-4.
“Health insurance” means a contract or agreement whereby an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the bodily injury,
disability, sickness, death by accident or accidental means of a human being, or
because of any expense relating thereto, or because of any expense incurred in prevention of sickness, and includes every risk pertaining to any of the enumerated
risks. As used in this subchapter, health insurance includes workers' compensation
coverage but does not include any PIP coverage.
“Health insurer” includes any insurer issuing a policy of health insurance as defined in this subchapter.
"Hospital" means a general acute care hospital, a long-term acute care hospital
or a comprehensive rehabilitation hospital.
"Hospital outpatient" means a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital. When a patient with
a known diagnosis enters a hospital for a specific surgical procedure or other treatment that is expected to keep him or her in the hospital for only a few hours (less
than 24), he or she is considered an outpatient for coverage purposes regardless of
the hour he or she came to the hospital; whether he or she used a bed; or whether
he or she remained in the hospital past midnight.
"Hospital outpatient surgical facility" or "HOSF" means a facility where hospital outpatients are treated.
“Medically necessary” or “medical necessity” means that:
1. The medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person;
2. The treatment is the most appropriate level of service that is in accordance
with the standards of good practice and the provisions of N.J.A.C. 11:3-4, as applicable;
3. The treatment is not primarily for the convenience of the injured person or
provider;
4. The treatment is not unnecessary; and
5. The treatment does not include unnecessary testing.
“Modifier” means an addition to the five-digit CPT code of either two letters
or numbers that indicates that a service or procedure was performed that has been
altered by some specific circumstance but not changed in its definition or code.
“Motor bus” means motor bus as defined in N.J.S.A. 17:28-1.5.
“Motor bus insurer” includes any insurer issuing a policy of insurance on a motor bus the owner, registered owner, or operator of which is required to maintain
medical expense benefits coverage pursuant to N.J.S.A. 17:28-1.6.
“Multiple surgeries” means additional procedures, unrelated to the major procedure and adding significant time or complexity, performed on the same patient
at the same operative session or on the same day. Co-surgeons, surgical teams, or
assistants-at-surgery may participate in performing multiple surgeries on the same
patient on the same day.
MEDICAL FEE SCHEDULES
11:3-29.4
“PIP coverage” means personal injury protection coverage described in
N.J.S.A. 39:6A-3.1(a), 39:6A-4a and 39:6A-10 as amended.
“PIP insurer” includes any insurer issuing a policy of automobile insurance on
any vehicle that contains PIP coverage.
“Powered traction device” means VAX-D, DRX or similar devices determined
by the Federal Food and Drug Administration to provide traction services.
“Three-digit zip code” refers to the first three digits of the U.S. postal code.
"Trauma services" means the care provided in the Level I or Level II trauma
hospital to patients whose arrival requires trauma center activation. It does not include transportation to the hospital, treatment of patients whose arrival at the hospital does not require trauma activiation or outpatient visits after a patient who has
received trauma care is discharged from acute care.
Amended. R 1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993
d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1,
1995); R.2001, d.158, effective May 21, 2001; R.2003 d.143, effective April 7, 2003; R.2007 d.305,
effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).
11:3-29.3. Regions. (a) The Regions in Appendix, Exhibit 1, Physicians' Fee
Schedule, Exhibit 2, Dental Fee Schedule and Exhibit 4, Ambulance Services, are
as follows:
1. South Region consists of Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 077, 080,
081, 082, 083, 084, 086 and 087. The South Region also includes: 08501, 08505,
08510, 08511, 08514 through 08527, 08533 through 08535, 08540 through
08550, 08554, 08555 and 08560 through 08562.
2. North Region consists of Bergen, Essex, Hudson, Hunterdon, Middlesex,
Morris, Passaic, Somerset, Sussex, Union and Warren counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 070, 071,
072, 073, 074, 075, 076, 078, 079, 088 and 089. The North Region also includes:
08502, 08504, 08512, 08528, 08530, 08536, 08551, 08553, 08556 through 08559
and 08570.
Amended. R.2001 d.253, effective July 16, 2001; R.2007 d.305, effective October 1, 2007; R.2012
d.187, effective November 5, 2012 (operative January 4, 2013).
11:3-29.4. Application of Medical Fee Schedules. (a) Nothing in this subchapter shall compel the PIP insurer or a motor bus insurer to pay more for any
service or equipment than the usual, customary and reasonable fee, even if such
fee is well below the automobile insurer's or motor bus insurer's limit of liability
as set forth in the fee schedules. Insurers are not required to pay for services or
equipment that are not medically necessary.
1. The fees for physicians' services in subchapter Appendix, Exhibit 1, the provisions in (f)1 through 7 below and the non-physician facility fees in subchapter
Appendix, Exhibit 7 shall not apply to trauma services at Level I and Level II trauma hospitals. Bills for services subject to the trauma services exemption shall use
the modifier "-TS".
2. The non-physician facility fees in subchapter Appendix, Exhibit 7 shall not
apply to services provided in hospital emergency rooms. The bills for these services shall use the modifier "-ER".
3. The physician fees for surgical services (CPT 10000 though 69999) provided
in emergency care in acute care hospitals that are not subject to the trauma care
exemption shall be reimbursed at 150 percent of the physicians' fees in subchapter
Appendix, Exhibit 1. The bills for these services shall use the modifier "-ER".
11:3-29.4
APPENDIX B - REGULATIONS
4. Except as provided in (a)1 through 3 above, the fees in Appendix, Exhibits
1 through 7 apply regardless of the site of service.
(b) The region used to determine the proper fee set forth in the schedules shall
be determined by the region in which the services were rendered or the equipment
was provided or, in the case of elective services or equipment provided to New
Jersey residents outside the State, by the region in which the insured resides.
(c) The fees set forth in the schedule for durable medical equipment, subchapter
Appendix, Exhibit 5, are retail prices, which may include purchase prices for both
new and used equipment, and/or monthly rentals. New equipment shall be distinguished with the use of modifier-NU, used equipment with modifier-UE and rental equipment with modifier-RR.
1. The insurer's total limit of liability for the rental of a single item of durable
medical equipment set forth in the schedule is 15 times the monthly rental fee or
the purchase price of the item, whichever is less.
2. For the provision and billing of durable medical equipment, payors shall follow the relevant provisions of Chapter 20 of the Medicare Claims Processing
Manual, updated periodically by CMS and incorporated by reference, that were in
effect at the time the service was provided (http://www.cms.gov/manuals/downloads/clm104c20.pdf).
(d) The insurer's limit of liability for any medical expense benefit for service or
equipment provided outside the State of New Jersey shall be as follows:
1. When the service or equipment is provided by reason of emergency or medical necessity, the reasonable and necessary costs shall not exceed fees that are
usual, customary and reasonable for that provider in the geographic location
where the service or equipment is provided.
2. When the service or equipment is provided by reason of the election by the
insured to receive treatment outside the State of New Jersey, the reasonable and
necessary costs shall not exceed fees set forth in the fee schedules for the geographic region in which the insured resides.
(e) Except as noted in (e)1 through 3 below, the insurer's limit of liability for
any medical expense benefit for any service or equipment not set forth in or not
covered by the fee schedules shall be a reasonable amount considering the fee
schedule amount for similar services or equipment in the region where the service
or equipment was provided or, in the case of elective services or equipment provided outside the State, the region in which the insured resides. When a CPT,
CDT, or HCPCS code for the service performed has been changed since the fee
schedule rule was last amended, the provider shall always bill the actual and correct code found in the most recent version of the American Medical Association's
Current Procedural Terminology or the American Dental Association's Current
Dental Terminology. The amount that the insurer pays for the service shall be in
accordance with this subsection. Where the fee schedule does not contain a reference to similar services or equipment as set forth in the preceding sentence, the
insurer's limit of liability for any medical expense benefit for any service or equipment not set forth in the fee schedules shall not exceed the usual, customary and
reasonable fee.
1. For the purposes of this subchapter, determination of the usual, reasonable
and customary fee means that the provider submits to the insurer his or her usual
and customary fee by means of explanations of benefits from payors showing the
provider's billed and paid fee(s). The insurer determines the reasonableness of the
provider's fee by comparison of its experience with that provider and with other
providers in the region. National databases of fees, such as those published by
FAIR Health (www.fairhealthus.org) or Wasserman (http://www.medfees.com/),
MEDICAL FEE SCHEDULES
11:3-29.4
for example, are evidence of the reasonableness of fees for the provider's geographic region or ZIP code. The use of national databases of fees is not limited to
the above examples. When using a database as evidence of the reasonableness of
a fee, the insurer shall identify the database used, the edition date, the geozip, and
the percentile.
2. All applicable provisions of this section concerning billing and payment apply to fees for services provided outside of New Jersey and to fees that are not on
the fee schedule.
3. Codes in Appendix, Exhibit 1 that do not have an amount in the ASC facility
fee column are not reimbursable if performed in an ASC and are not subject to the
provision in (e) above concerning services not set forth in or covered by the fee
schedules.
(f) Except as specifically stated to the contrary, the following shall apply to
physician charges for multiple and bilateral surgeries (CPT 10000 through
69999), co-surgeries and assistant surgeons:
1. For multiple surgeries, rank the surgical procedures in descending order by
the fee amount, using the fee schedule or UCR amount, as appropriate. The highest valued procedure is reimbursed at 100 percent of the eligible charge. Additional procedures are reported with the modifier "-51" and are reimbursed at 50 percent of the eligible charge. If any of the multiple surgeries are bilateral surgeries
using the modifier "-50," consider the bilateral procedure at 150 percent as one
payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions.
2. There are two types of procedures that are exempt from the multiple procedure reduction. Codes in CPT that have the note, "Modifier -51 exempt" shall be
reimbursed at 100 percent of the eligible charge. In addition, some related procedures are commonly carried out in addition to the primary procedure. These procedure codes contain a specific descriptor that includes the words, "each additional" or "list separately in addition to the primary procedure." These add-on codes
cannot be reported as stand-alone codes but when reported with the primary procedure are not subject to the 50 percent multiple procedure reduction.
3. The terminology for some procedure codes includes the terms "bilateral" or
"unilateral or bilateral." The payment adjustment rules for bilateral surgeries do
not apply to procedures identified by CPT as "bilateral" or "unilateral or bilateral"
since the fee schedule reflects any additional work required for bilateral surgeries.
If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral) and is performed bilaterally, providers must report the procedure with modifier "-50" as a single line item. Reimbursement for bilateral surgeries reported with the modifier "-50" shall be 150 percent of the eligible charge.
4. For co-surgeries, each surgeon bills for the procedure with a modifier "-62".
For co-surgeries (modifier 62), the fee schedule amount applicable to the payment
for each co-surgeon is 62.5 percent of the eligible charge.
5. The eligible charge for medically necessary assistant surgeon expenses shall
be 20 percent of the primary physician's allowable fee determined pursuant to the
fee schedule and rules. Assistant surgeon expenses shall be reported using modifier -80, -81 or -82 as designated in CPT. When the assistant surgeon is someone
other than a physician surgeon, the reimbursement shall not exceed 85 percent of
the amount that would have been reimbursed had a physician surgeon provided the
service. Non-physician assistant surgeon services shall be reported using modifier-AS.
6. The necessity for co-surgeons and assistant surgeons for an operation shall
be determined by reference to authorities such as the Medicare physician fee
11:3-29.4
APPENDIX B - REGULATIONS
schedule database (www.cms.gov). Fees for assistant surgeons and co-surgeons
are not rendered eligible for reimbursement simply because it is the policy of a
provider or an outpatient surgical facility that one be present.
7. It is the responsibility of providers that are acting as co-surgeons or assistant
surgeons to include the correct modifier in their bills, especially as they may not
be submitted to the insurer at the same time. If a surgeon submits a bill without a
modifier and is paid 100 percent of the eligible charge and the insurer subsequently receives a bill from a co-surgeon or assistant surgeon for the same procedure,
the insurer shall notify both providers that it has already paid 100 percent of the
eligible charge and that it cannot reimburse the co-surgeon or assistant surgeon
until the overpayment has been offset or refunded.
8. Prosthetic and other devices, including neuro-stimulators, internal/external
fixators, single use spine wands and spine probes, tissue grafts, plates, screws, anchors and wires, whether implanted, inserted, or otherwise applied by covered surgical procedures shall be reimbursed at no more than the invoice for the device
plus 20 percent. This provision applies regardless of where the procedure is performed, including trauma centers, hospital emergency rooms, inpatient surgeries
and outpatient surgical facilities.
(g) Except as specifically stated to the contrary in this subchapter, the fee
schedules shall be interpreted in accordance with the following, incorporated
hererin by reference, as amended and supplemented: the relevant chapters of the
Medicare Claims Processing Manual, updated periodically by CMS, that were in
effect at the time the service was provided. The Medicare Claims Processing Manual
is
available
at
https:
//www.cms.gov/Manuals/IOM/itemdetail.asp?itemID=CMS018912; the NCCI Policy Manual for Medicare Services, as
updated periodically by CMS and available at http://www.cms.gov/NationalCorrectCodInitEd/Downloads/NCCI_Policy_Manual.zip; Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service, available from CMS at https://
www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf; and the
CPT Assistant available from the American Medical Association (www.AMAbookstore.com).
1. Artificially separating or partitioning what is inherently one total procedure
into subparts that are integral to the whole for the purpose of increasing medical
fees is prohibited. Such practice is commonly referred to as "unbundling" or "fragmented" billing. Providers and payors shall use the National Correct Coding Initiative (NCCI) Edits, incorporated herein by reference, as updated quarterly by
CMS and available at http://www.cms.hhs.gov/NationalCorrectCodInitEd/. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an
NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used. For more information on the criteria for the use of modifiers,
see the NCCI Policy Manual and Modifier 59 Article referenced in (g) above.
2. CPT 97010 (application of hot/cold packs) is bundled into the payment for
other services and shall not be reimbursed separately.
3. X-ray digitization or computer aided radiographic mensuration reported under CPT 76499 or any other code are not reimbursable under PIP.
4. Kinesio taping or other taping is not reimbursable under PIP. Kinesio taping
shall not be billed using the strapping codes, CPT 29200 through 29280 and 29520
through 29590.
5. Platelet Rich Plasma (PRP) injections are only reimbursable for treatment of
chronically injured tendons that have failed to improve despite appropriate con-
MEDICAL FEE SCHEDULES
11:3-29.4
servative treatments. PRP injections shall be billed under code 0232T in subchapter Appendix, Exhibit 1.
6. Leads, pads, batteries and any other supplies for use of TENS or EMS devices are included in the fee for the rental of the unit and are not separately reimbursable when rented. For purchase of the unit, the first month's supply of leads, pads,
batteries and any other supplies for TENS or EMS units are included.
7. The eligible charge for an office visit includes reviewing the report of an imaging study when the provider of the imaging study has billed for the technical and
professional component of the service. In these circumstances, it is not appropriate
for the provider to bill for an office visit, CPT 76140 or for the physician component of the imaging study. CPT 76140 is not reimbursable. Where a provider in a
different practice or facility performs a medically necessary review of an imaging
study and produces a written report as part of a consultation, the provider shall bill
the professional component (modifier -26) for each specific radiology service.
8. When CPT 77003, fluoroscopic guidance, can be billed separately and is not
included as part of another procedure, it is reimbursable only per spinal region, not
per level.
9. HCPCS code G0289 is an add-on code and should be added to the knee arthroscopy code for the major procedure being performed. This code is only to be
reported once per extra compartment, even if chondroplasty, loose body removal
and foreign body removal are all performed. The code may be reported twice if
the physician performs these procedures in two compartments in addition to the
compartment where the main procedure was performed.
i. This code shall be reported only when the physician spends at least 15 minutes in the additional compartment performing the procedure. It shall not be reported if the reason for performing the procedure is due to a problem caused by
the arthroscopic procedure itself. This code is to be used when a procedure is performed in the lateral, medial, or patellar compartments in addition to the main procedure. The billing of CPT codes 29874 and 29877 is not permitted with other arthroscopic procedures on the same knee and CPT code 29874 shall not be used to
report the services described by code G0289.
10. Appendix J of the CPT manual, Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves may be used as a reference for the appropriate reimbursement of this type of Electrodiagnostic testing.
11. Moderate (conscious) sedation performed by the physician who also furnishes the medical or surgical service cannot be reimbursed separately for the procedures listed in Appendix G of the CPT manual. In that case, payment for the sedation is bundled into the payment for the medical or surgical service. As a result,
CPT codes 99143 through 99145 are not reimbursable for the procedures in Appendix G of the CPT manual.
12. CPT codes 99148 through 99150 are only reimburseable when a second
physician other than the provider performing the diagnostic or therapeutic services provides moderate sedation in a facility setting (for example, hospital, outpatient hospital/ambulatory surgery center or skilled nursing facility). CPT codes
99148 through 99150 are not reimburseable for services performed by a second
physician in a physician office, freestanding imaging center or for any procedure
code identified in CPT as including moderate (conscious) sedation.
13. CPT 22505, "Manipulation of spine requiring anesthesia, any region," if
medically necessary, can only be reported once for any and all regions manipulated on that date.
(h) To be reimbursable, nerve conduction studies (NCS) (CPT 95900 - 95904)
must be interpreted by a provider who was on site and directly supervised or per-
11:3-29.4
APPENDIX B - REGULATIONS
formed the nerve conduction study in accordance with N.J.A.C. 13:35-2.6(n)3.
Needle Electromyography (EMG) interpretation must be performed in the same
facility on the same day by the same physician who performed and/or supervised
the needle EMG.
(i) The reporting of nerve conduction studies and needle electromyography
(EMG) (CPT 95860 through 95872) results should be integrated into a unified diagnostic impression. Separate reports for needle EMG and NCS are not reimbursable under the codes above in this subsection.
(j) For surgery and many other procedures, it is established practice to include
follow-up care and visits as part of the basic procedure charge. Such charges shall
not be subject to additional billings. The existence of a CPT code, per se, does not
imply the right to receive separate compensation for the procedure/sub-procedure
so described. If a procedure is judged to be part of the primary procedure, only the
charges for the primary procedure are eligible. As identified in CPT, separate procedures are commonly carried out as an integral part of another procedure. They
shall not be billed in conjunction with the other procedure, but may be billed when
performed independently of the other procedure.
(k) CPT codes for procedures described in CPT as "unlisted procedure" or "unlisted service" (example: 64999 Unlisted procedure nervous system) are not reimbursable without documentation from the provider describing the procedure or
service performed, demonstrating its medical appropriateness and indicating why
it is not duplicative of a code for a listed procedure or service. Documentation may
include the existence of temporary or AMA Category III or HCPCS codes for the
procedure or information in the AMA CPT Assistant publication. In submitting
bills for unlisted codes, the provider should base the fee on a comparable procedure. It is never appropriate for the provider to bill an unlisted code for a list of
services that have CPT codes. Providers that intend to use unlisted codes in nonemergency situations are encouraged to notify the insurer in advance through the
precertification process. Based on the information submitted by the provider, the
insurer shall determine whether the CPT coding is appropriate.
(l) Certain CPT codes are listed in the fee schedule with three entries. There is
a global fee with no modifier, a technical component with modifier "TC" and a
physician component with modifier "-26". Services with physician component
amounts of zero in the fee schedule are considered to be 100 percent technical. A
provider shall not bill the global fee and a technical or physician component. The
technical or physician component shall be billed when only that part of the service
is being provided.
(m) The daily maximum allowable fee shall be $ 105.00 for the Physical Medicine and Rehabilitation CPT codes listed in subchapter Appendix, Exhibit 6, incorporated herein by reference, that are commonly provided together. The daily
maximum applies when such services are performed for the same patient on the
same date. In determining whether a provider has reached the daily maximum, the
insurer shall apply the NCCI edits. The daily maximum applies to all providers,
including dentists. However, when the provider can demonstrate that the severity
or extent of the injury is such that extraordinary time and effort is needed for effective treatment, the insurer shall reimburse in excess of the daily maximum.
Such injuries could include, but are not limited to, severe brain injury and nonsoft-tissue injuries to more than one part of the body. Such injuries would not include diagnoses for which there are care paths in N.J.A.C. 11:3-4. Treatment that
the provider believes should not be subject to the daily maximum shall be billed
using modifier -22 as designated in CPT for unusual procedural services. Unless
already provided to the insurer as part of a decision point review or precertifica-
MEDICAL FEE SCHEDULES
11:3-29.5
tion request, the billing shall be accompanied by documentation of why the extraordinary time and effort for treatment was needed.
1. Supervised modalities and those therapeutic procedures that do not list a specific time increment in their description shall be limited to one unit per day.
2. CPT 97012 is the appropriate code for billing powered traction therapy.
3. CPT 97026 is the appropriate code for billing cold or low-powered laser
therapy.
4. HPCPS code G0283 is the appropriate code for billing unattended electrical
stimulation.
5. Pursuant to N.J.S.A. 39:6A-4, physical therapy, as defined in N.J.S.A. 45:937.13, shall not be reimbursable under PIP unless rendered by a licensed physical
therapist pursuant to a referral from a licensed physician, dentist, podiatrist or chiropractor within the scope of the respective practices.
(n) Follow-up evaluation and management services for the re-examination of
an established patient shall be reimbursed in addition to physical medicine and rehabilitation procedures only when any of the circumstances set forth in (n)1
through 4 below is present and not more than twice in any 30-day period. Modifier
-25 shall be added to an evaluation and management service when a significant
separately identifiable evaluation and management service is provided and documented as medically necessary as follows:
1. There is a definite measurable change in the patient's condition requiring significant change in the treatment plan;
2. The patient fails to respond to treatment, requiring a change in the treatment
plan;
3. The patient's condition becomes permanent and stationary, or the patient is
ready for discharge; or
4. It is medically necessary to provide evaluation services over and above those
normally provided during the therapeutic services.
(o) Regardless of the specific codes that are included in a DPR/Precertification
request, the insurer's reimbursement for those services shall be consistent with the
rules contained in this subchapter, including the NCCI edits and the CPT Manual
current at the time the services were provided.
(p) The ANES code on the Physicians' Fee Schedule is the conversion factor
for anesthesia units. Payors shall follow the Medicare Claims Processing Manual
and other guidelines for calculating the number of units for the various CPT codes
for the administration of anesthesia and other billing situations, such as directing
or supervising Certified Nurse Anesthetists and other non-physician anesthesia
providers. These can be found at: www.cms.hhs.gov/center/anesth.asp.
Amended. R.1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993
d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1,
1995); R.2001 d.158, effective May 21, 2001; R.2001 d.253, effective July 16, 2001; R.2003 d.143,
effective April 7, 2003; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November
5, 2012 (operative January 4, 2013); R.2014 d.004, effective January 6, 2014.
11:3-29.5 ASC facility fees; hospital outpatient surgical facility fees. (a)
ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do
not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered
if the services were furnished in a hospital on an inpatient or outpatient basis, including:
1. Use of operating and recovery rooms, patient preparation areas, waiting
rooms, and other areas used by the patient or offered for use to persons accompanying the patient;
11:3-29.6
APPENDIX B - REGULATIONS
2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient's care;
3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances,
and equipment;
4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates
those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/
ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services
that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to
Medicare
(see:
https://www.cms.gov/HospitalOutpatientPPS/Downloads/
CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgical
procedures and are not permitted to be reimbursed separately in a HOSF;
5. Administrative, recordkeeping, and housekeeping items and services;
6. Blood, blood plasma, platelets, etc.;
7. Anesthesia materials, including the anesthetic itself, and any materials,
whether disposable or re-usable, necessary for its administration; and
8. Implantable DME and prosthetics.
(b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The
hospital outpatient surgical facility fee is the maximum that can be reimbursed for
outpatient procedures performed in an HOSF. The hospital outpatient facility fees
in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through 8 above.
(c) The sale, lease or rental of durable medical equipment (DME) to patients
for use in their homes are not included in the ASC or HOSF fee. If the ASC or
HOSF furnishes items of DME to patients, billing for such items should be made
in accordance with subchapter Appendix, Exhibit 5.
(d) When multiple procedures are performed in an ASC or in an HOSF in the
same operative session, the ASC facility fee or the HOSF fee, as applicable, for
the procedure with the highest payment amount is reimbursed at 100 percent and
reimbursement of any additional procedures furnished in the same session is 50
percent of the applicable facility fee.
1. A procedure performed bilaterally in one operative session is reported as two
procedures and is subject to the multiple procedure reduction formula.
2. Subchapter Appendices, Exhibit 1, the Physicians’ and ASC Facility Fee
Schedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp and http:/
/www.cms.gov/HospitalOutpatientPPS/) are exempt from the multiple procedure
reduction formula.
New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).
11:3-29.6 ASC facility fees; hospital outpatient surgical facility fees (a)
ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do
not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered
if the services were furnished in a hospital on an inpatient or outpatient basis, including:
1. Use of operating and recovery rooms, patient preparation areas, waiting
rooms, and other areas used by the patient or offered for use to persons accompanying the patient;
MEDICAL FEE SCHEDULES
11:3-29.6
2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient’s care;
3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances,
and equipment;
4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates
those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/
ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services
that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to
Medicare
(see:
https://www.cms.gov/HospitalOutpatientPPS/Downloads/
CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgical
procedures and are not permitted to be reimbursed separately in a HOSF;
5. Administrative, recordkeeping, and housekeeping items and services;
6. Blood, blood plasma, platelets, etc.;
7. Anesthesia materials, including the anesthetic itself, and any materials,
whether disposable or re-usable, necessary for its administration; and
8. Implantable DME and prosthetics.
(b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The
hospital outpatient surgical facility fee is the maximum that can be reimbursed for
outpatient procedures performed in an HOSF. The hospital outpatient facility fees
in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through 8 above.
(c) The sale, lease or rental of durable medical equipment (DME) to patients
for use in their homes are not included in the ASC or HOSF fee. If the ASC or
HOSF furnishes items of DME to patients, billing for such items should be made
in accordance with subchapter Appendix, Exhibit 5.
(d) When multiple procedures are performed in an ASC or in an HOSF in the
same operative session, the ASC facility fee or the HOSF fee, as applicable, for
the procedure with the highest payment amount is reimbursed at 100 percent and
reimbursement of any additional procedures furnished in the same session is 50
percent of the applicable facility fee.
1. A procedure performed bilaterally in one operative session is reported as two
procedures and is subject to the multiple procedure reduction formula.
2. Subchapter Appendices, Exhibit 1, the Physicians’ and ASC Facility Fee
Schedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp and http:/
/www.cms.gov/HospitalOutpatientPPS/) are exempt from the multiple procedure
reduction formula.
New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).
11:3-29.6. Balance billing prohibited. No health care provider may demand
or request any payment from any person in excess of those permitted by the medical fee schedules and this subchapter, nor shall any person be liable to any health
care provider for any amount of money that results from the charging of fees in
excess of those permitted by the medical fee schedules and this subchapter.
Amended. R. 2001, d. 158, effective May 21, 2001. Recodified from N.J.A.C. 11:3-29.5 by R.2012
d.187, effective November 5, 2012 (operative January 4, 2013).
11:3-29.6
APPENDIX B - REGULATIONS
APPENDIX: AUTOMOBILE INSURANCE PERSONAL INJURY
PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE
COVERAGE
Exhibit 1
Physicians’ & Ambulatory Surgical Center (ASC) Facility Fee Schedule
Payment
Indi
cator
(See
PhysPhysbotician’s
ician’s
ASC
ASC
tom)
Fees
Fees
Fees
Fees
for)
CPT Mod Description
North
South
North South codes)
*Current Procedural Teminology (CPT) is copyright 2010 American Medical Association
(AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related
listings are included in CPT. The AMA assumes no liability for the data contained herein.
Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the
American Medical Association.
Anes
0232T
G0283
00289
10060
10061
10120
10121
10140
10160
10180
11000
11001
11010
11011
11012
11042
11043
11044
11045
11046
11047
11055
11056
11057
11100
11101
11200
11300
11301
11302
11305
11306
11310
11311
11400
11401
11402
11403
11404
11406
ANESTHESIA BASE UNITS
86.47
NJX PLATELET PLASMA
63.95
ELECTRICAL STIMULATION,
20.14
(UNATTENDED), TO ONE OR
MORE AREAS
ARTHRO, LOOSE BODY + CHONDRO 483.50
DRAIN SKIN ABSCESS
176.46
DRAIN SKIN ABSCESS
290.74
REMOVE FOREIGN BODY
219.66
REMOVE FOREIGN BODY
423.57
DRAIN HEMATOMA/FLUID
250.71
PUNCTURE DRAIN LESION
203.36
COMPLEX DRAIN WOUND
381.01
DEBRIDE INFECTED SKIN
84.28
DEBRIDE INFECTED SKIN, ADDED
33.67
DEBRIDE SKIN, FX
770.97
DEBRIDE SKIN/MUSCLE, FX
842.60
DEBRIDE SKIN/MUSCLEBONE, FX 1,128.89
DEBRIDE SKIN/TISSUE
141.88
DEBRIDE TISSUE/MUSCLE
309.64
DEBRIDETISSUE/MUSCLE/BONE
467.58
DEBRIDE SUBQ TISSUE ADD-ON
50.08
DEBRIDE MUSCLE/FASCIA ADD-ON 86.02
DEBRIDE BONE ADD-ON
141.04
TRIM SKIN LESION
78.70
TRIM SKIN LESIONS, 2 TO 4
93.59
TRIM SKIN LESIONS, OVER 4
110.23
BIOPSY SKIN LESION
168.53
BIOPSY SKIN, ADDED
52.52
REMOVE SKIN TAGS
136.42
SHAVE SKIN LESION
111.63
SHAVE SKIN LESION
150.18
SHAVE SKIN LESION
179.35
SHAVE SKIN LESION
110.55
SHAVE SKIN LESION
152.62
SHAVE SKIN LESION
137.16
SHAVE SKIN LESION
171.78
EXCISE TRT-EXT BENIGN+MARG
0.5 < CM
192.83
EXCISE TRT-EXT BENIGN+MARG
0.6-1 CM
234.32
EXCISE TRT-EXT BENIGN+MARG
1.1-2 CM
260.75
EXCISE TRT-EXT BENIGN+MARG
2.1-3 CM
298.16
EXCISE TRT-EXT BENIGN+MARG
3.1-4 CM
338.86
EXCISE TRT-EXT BENIGN+MARG
84.36
63.95
19.26
89.55
82.44
467.0
168.00
278.25
208.52
403.23
238.43
193.31
362.70
80.26
32.24
732.08
801.49
1,074.42
134.65
294.89
447.17
47.78
82.37
135.27
74.56
88.93
104.93
159.57
50.16
129.65
105.61
142.55
170.36
104.93
145.18
130.09
163.30
198.84
198.84
297.15
2,411.70
321.75
198.84
2,694.69
102.96
3.93
678.84
678.84
678.84
364.44
364.44
1,132.98
364.44
364.44
1,132.98
111.15
121.44
121.44
199.77
58.50
121.44
121.44
121.44
121.44
121.44
121.44
121.44
121.44
183.03
183.03
273.51
2,219.85
296.13
183.03
2,480.34
94.77
31.23
624.84
624.84
624.84
335.43
335.43
1,042.83
335.43
335.43
1,042.83
102.30
111.78
111.78
183.90
53.85
111.78
111.78
111.78
111.78
111.78
111.78
111.78
111.78
182.50
283.11
260.58
222.41
319.41
294.00
247.62
350.97
323.04
283.70
379.02
348.87
322.54
2,411.70
2,219.85
X
X, N1
MEDICAL FEE SCHEDULES
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11719
11720
11721
11730
11732
11740
11750
11752
11760
11762
11765
11900
11901
11950
11951
11960
11981
11982
12001
12002
12004
12005
12006
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
> 4.0 CM
457.22
EXCISE H-F-NECK-SP BENIGN+MARG
0.5 <
191.28
EXCISE H-F-NECK-SP BENIGN+MARG
0.6-1
247.34
EXCISE H-F-NECK-SP BENIGN+MARG
1.1-2
275.21
EXCISE H-F-NECK-SP BENIGN+MARG
2.1-3
317.92
EXCISE H-F-NECK-SP BENIGN+MARG
3.1-4
364.37
EXCISE H-F-NECK-SP BENIGN+MARG
> 4 CM
516.41
EXCISE FACE-MM BENIGN+MARG
0.5 < CM
211.84
EXCISE FACE-MM BENIGN+MARG
0.6-1 CM
264.80
EXCISE FACE-MM BENIGN+MARG
1.1-2 CM
298.23
EXCISE FACE-MM BENIGN+MARG
2.1-3 CM
353.37
EXCISE FACE-MM BENIGN+MARG
3.1-4 CM
442.21
TRIM NAIL(S)
34.77
DEBRIDE NAIL, 1-5
49.82
DEBRIDE NAIL, 6 OR MORE
67.33
REMOVE NAIL PLATE
151.98
REMOVE NAIL PLATE, ADDED
68.85
DRAIN BLOOD UNDER NAIL
75.08
REMOVE NAIL BED
343.28
REMOVE NAIL BED/FINGER TIP
494.47
REPAIR NAIL BED
346.62
RECONSTRUCT NAIL BED
429.68
EXCISE NAIL FOLD, TOE
223.00
INJECTION INTO SKIN LESIONS
90.58
ADDED SKIN LESIONS INJECTION
113.27
THERAPY FOR CONTOUR DEFECTS 113.05
THERAPY FOR CONTOUR DEFECTS 160.21
INSERT TISSUE EXPANDER(S)
1,436.90
INSERT DRUG IMPLANT DEVICE
216.27
REMOVE DRUG IMPLANT DEVICE 240.23
REPAIR SUPERFICIAL WOUND(S)
156.46
REPAIR SUPERFICIAL WOUND(S)
182.44
REPAIR SUPERFICIAL WOUND(S)
215.99
REPAIR SUPERFICIAL WOUND(S)
277.27
REPAIR SUPERFICIAL WOUND(S)
334.76
REPAIR SUPERFICIAL WOUND(S)
187.04
REPAIR SUPERFICIAL WOUND(S)
200.42
REPAIR SUPERFICIAL WOUND(S)
236.44
REPAIR SUPERFICIAL WOUND(S)
289.42
REPAIR SUPERFICIAL WOUND(S)
360.23
REPAIR SUPERFICIAL WOUND(S)
268.51
REPAIR SUPERFICIAL WOUND(S)
319.54
CLOSE SPLIT WOUND
431.60
CLOSE SPLIT WOUND
254.10
INTERMED WOUND REPAIR
S/TRT/EXT
392.46
INTERMED WOUND REPAIR
S/TRT/EXT
496.44
INTERMED WOUND REPAIR
S/TRT/EXT
491.15
INTERMED WOUND REPAIR
S/TRT/EXT
596.60
INTERMED WOUND REPAIR
S/TRT/EXT
649.31
INTERMED WOUND REPAIR
S/TRT/EXT
726.61
INTERMED WOUND REPAIR
N-HF/GENITAL
408.73
INTERMED WOUND REPAIR
N-HG/GENITAL
468.02
INTERMED WOUND REPAIR
11:3-29.6
457.22
2,411.70
2,219.85
181.36
266.76
245.52
235.08
324.03
298.26
261.73
354.48
326.28
302.76
394.26
362.88
347.38
2,411.70
2,219.85
494.20
3,188.13
2,934.54
200.73
301.83
277.83
251.60
350.97
323.04
283.53
388.41
357.51
336.68
431.67
397.35
422.12
32.88
47.36
64.26
144.74
65.77
71.04
327.09
471.49
328.23
409.09
209.99
86.02
108.02
107.85
153.19
1,374.88
206.20
229.28
148.50
173.64
205.84
264.61
319.54
177.76
190.64
225.30
275.96
344.19
260.21
309.13
410.59
242.74
1,132.98 1,042.83
51.48
47.37
64.35
59.25
76.02
69.99
121.44
111.78
76.02
69.99
57.72
53.13
411.81
379.05
582.60
536.25
177.81
163.68
531.12
488.88
121.44
111.78
121.44
111.78
121.44
111.78
131.01
120.60
175.47
161.52
2,972.49 2,736.03
89.55
82.44
89.55
82.44
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81
163.68
177.81 1
63.68
619.29
570.03
421.80
388.26
372.69
177.81
163.68
470.58
421.80
388.26
467.17
177.81
163.68
567.24
177.81
163.68
618.41
421.80
388.26
692.45
421.80
388.26
388.48
177.81
163.68
444.84
177.81
163.68
X
X
11:3-29.6
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
13101
13102
13120
13121
13122
13131
13132
13133
13150
13151
13152
13153
13160
14000
14001
14020
14021
14040
14041
14060
14061
14301
14302
15002
15003
15004
15005
15050
15100
15101
15120
15121
15130
15170
15171
15175
15220
15221
15240
15241
15260
15330
APPENDIX B - REGULATIONS
N-HG/GENITAL
555.19
INTERMED WOUND REPAIR
N-HG/GENITAL
592.76
INTERMED WOUND REPAIR
N-HG/GENITAL
703.34
INTERMED WOUND REPAIR
N-HG/GENITAL
763.38
INTERMED WOUND REPAIR
FACE/MM
432.90
INTERMED WOUND REPAIR
FACE/MM
494.15
INTERMED WOUND REPAIR
FACE/MM
545.55
INTERMED WOUND REPAIR
FACE/MM
577.47
INTERMED WOUND REPAIR
FACE/MM
691.03
INTERMED WOUND REPAIR
FACE/MM
826.26
INTERMED WOUND REPAIR
FACE/MM
942.59
REPAIR WOUND OR LESION
503.63
REPAIR WOUND OR LESION
640.87
REPAIR WOUND/LESION, ADDED
172.70
REPAIR WOUND OR LESION
523.71
REPAIR WOUND OR LESION
714.49
REPAIR WOUND/LESION, ADDED
190.24
REPAIR WOUND OR LESION
577.33
REPAIR WOUND OR LESION
932.23
REPAIR WOUND/LESION, ADDED
267.99
REPAIR WOUND OR LESION
573.56
REPAIR WOUND OR LESION
652.83
REPAIR WOUND OR LESION
901.38
REPAIR WOUND/LESION, ADDED
294.26
LATE CLOSE WOUND
1,274.88
SKIN TISSUE REARRANGEMENT 1,001.58
SKIN TISSUE REARRANGEMENT 1,289.02
SKIN TISSUE REARRANGEMENT 1,124.57
SKIN TISSUE REARRANGEMENT 1,408.28
SKIN TISSUE REARRANGEMENT 1,235.25
SKIN TISSUE REARRANGEMENT 1,529.97
SKIN TISSUE REARRANGEMENT 1,251.46
SKIN TISSUE REARRANGEMENT 1,643.34
SKIN TISSUE REARRANGEMENT 1,770.48
SKIN TISSUE REARRANGE ADDED 369.95
WOUND PREP, TRUNK/ARM/LEG
538.12
WOUND PREP, ADDED 100 CM
117.04
WOUND PREP, F/N/HF/G
631.19
WOUND PREP, F/N/HF/G, ADDED CM 191.65
SKIN PINCH GRAFT
898.35
SKIN SPLIT GRAFT,
TRUNK/ARM/LEG
1,374.74
SKIN SPLIT GRAFT T/A/L, ADDED
300.62
SKIN SPLIT A-GRAFT
FAC/NEC/HF/G
1,518.58
SKIN SPLIT A-GRAFT F/N/HF/G
ADDED
428.19
DERM AUTOGRAFT,
TRUNK/ARM/LEG
1,077.48
ACELLULAR GRAFT
TRUNK/ARMS/LEGS
684.41
ACELLULAR GRAFT T/ARM/LEG,
ADDED
147.18
ACELLULAR GRAFT, F/N/HF/G
810.60
SKIN FULL GRAFT SCALP/ARM/LEG1,237.46
SKIN FULL GRAFT, ADDED
222.58
SKIN FULL GRAFT
FACE/GENITAL/HF
1,491.27
SKIN FULL GRAFT, ADDED
297.89
SKIN FULL GRAFT EEN & LIPS
1,614.97
APPLY ACELLULAR ALLOGRAFT
T/ARM/LEG
513.93
527.51
177.81
163.68
564.13
421.80
388.26
669.51
421.80
388.26
726.74
421.80
388.26
411.35
421.80
388.26
469.44
177.81
163.68
518.41
177.81
163.68
549.29
177.81
163.68
658.09
421.80
388.26
786.00
421.80
388.26
896.60
479.30
609.63
164.94
498.53
679.65
181.88
549.97
889.11
256.52
546.58
622.29
859.71
281.64
1,226.45
953.82
1,229.26
1,070.90
1,342.85
1,177.91
1,459.32
1,194.92
1,566.97
1,689.95
356.41
513.17
111.70
602.33
183.76
854.77
421.80
619.29
619.29
619.29
421.80
421.80
177.81
421.80
619.29
421.80
619.29
619.29
619.29
421.80
2,972.49
2,296.11
2,296.11
2,296.11
2,296.11
2,296.11
2,296.11
2,296.11
2,296.11
2,972.49
2,972.49
619.29
619.29
619.29
619.29
619.29
388.26
570.03
570.03
570.03
388.26
388.26
163.68
388.26
570.03
388.26
570.03
570.03
570.03
388.26
2,736.03
2,113.44
2,113.44
2,113.44
2,113.44
2,113.44
2,113.44
2,113.44
2,113.44
2,736.03
2,736.03
570.03
570.03
570.03
570.03
570.03
1,313.41
285.81
2,972.49
2,972.49
2,736.03
2,736.03
1,450.58
2,972.49
2,736.03
407.69
2,972.49
2,736.03
1,028.66
2,296.11
2,113.44
656.88
619.29
570.03
142.17
779.34
1,178.97
211.34
421.80
619.29
2,296.11
619.29
388.26
570.03
2,113.44
570.03
1,422.47
283.58
1,541.12
2,296.11
619.29
2,296.11
2,113.44
570.03
2,113.44
491.81
619.29
570.03
MEDICAL FEE SCHEDULES
15331
15340
15341
15365
15366
15430
15431
15570
15572
15574
15576
15620
15732
15734
15736
15738
15756
15770
15780
15781
15782
15786
15787
15823
15830
15832
15851
15852
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
16000
16020
16025
16030
17000
17003
17004
17106
17107
17108
17110
17111
17250
17261
17262
19000
19120
19125
19290
20100
20101
20102
20103
20520
20525
20526
20550
20551
20552
APPLY ACELLULAR GRAFT T/A/L,
ADDED
100.16
APPLY CULT SKIN SUBSTITUTE
497.48
APPLY CULT SKIN SUB, ADDED
75.02
APPLY CULT DERM SUB F/N/HF/G
542.33
APPLY CULT DERM F/KF/G ADDED 126.15
APPLY ACELLULAR XENOGRAFT
861.84
APPLY ACELLULAR XENOGRAFT
ADDED
328.03
FORM SKIN PEDICLE FLAP
1,424.66
FORM SKIN PEDICLE FLAP
1,388.47
FORM SKIN PEDICLE FLAP
1,451.66
FORM SKIN PEDICLE FLAP
1,291.01
SKIN GRAFT
709.40
MUSCLE-SKIN GRAFT, HEAD/NECK 2,390.54
MUSCLE-SKIN GRAFT, TRUNK
2,429.96
MUSCLE-SKIN GRAFT, ARM
2,142.30
MUSCLE-SKIN GRAFT, LEG
2,272.44
FREE MYO/SKIN FLAP MICROVASC 3,749.52
DERMA-FAT-FASCIA GRAFT
1,066.42
ABRASION TREAT SKIN
1,322.37
ABRASION TREAT SKIN
879.47
ABRASION TREAT SKIN
900.92
ABRASION, LESION, SING
391.74
ABRASION, LESIONS, ADDED
78.22 7
REVISE UPPER EYELID
979.35
EXCISE SKIN ABD
979.35
EXCISE EXCESSIVE SKIN TISSUE
979.35
REMOVE SUTURES
152.95
DRESSING CHANGE NOT FOR BURN 73.04
REMOVE HIP PRESSURE SORE
1,088.76
REMOVE HIP PRESSURE SORE
1,419.04
REMOVE HIP PRESSURE SORE
1,410.54
REMOVE HIP PRESSURE SORE
1,566.36
REMOVE HIP PRESSURE SORE
2,593.22
REMOVE THIGH PRESSURE SORE
898.37
REMOVE THIGH PRESSURE SORE 1,357.84
REMOVE THIGH PRESSURE SORE 1,316.96
REMOVE THIGH PRESSURE SORE 1,445.87
REMOVE THIGH PRESSURE SORE 1,823.53
REMOVE THIGH PRESSURE SORE 1,864.20
INITIAL TREAT BURN(S)
107.89
DRESS/DEBRIDE P-THICK BURN, S 132.50
DRESS/DEBRIDE P-THICK BURN, M 234.02
DRESS/DEBRIDE P-THICK BURN, L 282.60
DESTROY PREMALIG LESION
130.90
DESTROY PREMALIG LES, 2-14
11.64
DESTROY PREMALIG LESIONS 15+ 279.11
DESTROY SKIN LESIONS
550.21
DESTROY SKIN LESIONS
713.68
DESTROY SKIN LESIONS
1,013.03
DESTROY B9 LESION, 1-14
180.01
DSTRJ B9 SK TGS/CUTAN VASC 15/> 213.26
CHEM CAUT GRANLTJ TISS PROUD 123.93
FLESH SINUS/FSTL
DESTROY SKIN LESIONS
32.56
DESTROY SKIN LESIONS
281.00
DRAIN BREAST LESION
179.37
REMOVE BREAST LESION
750.90
EXCISE BREAST LESION
832.58
PLACE NEEDLE WIRE, BREAST
262.84
EXPLORE WOUND, NECK
927.38
EXPLORE WOUND, CHEST
648.74
EXPLORE WOUND, ABDOMEN
764.14
EXPLORE WOUND, EXTREMITY
914.65 8
REMOVE FOREIGN BODY
311.74
REMOVE FOREIGN BODY
763.77
THERAPEUTIC INJECTION,
CARP TUNNEL
118.45
INJECT TENDON SHEATH/LIGAMENT 89.97
INJECT TENDON ORIGIN/INSERT
91.72
INJECT TRIGGER POINT, 1/2 MUSCLE 129.69
11:3-29.6
96.58
475.21
71.44
517.83
121.79
822.78
619.29
421.80
421.80
421.80
421.80
619.29
570.03
388.26
388.26
388.26
388.26
570.03
316.57
1,361.15
1,326.28
1,386.66
1,232.56
673.04
2,290.95
2,329.20
2,051.77
2,179.61
3,610.13
1,022.37
1,259.08
835.31
853.46
371.66
3.91
934.65
934.65
934.65
145.19
70.73
1,047.78
1,362.70
1,354.92
1,504.31
2,494.79
863.19
1,302.86
1,267.76
1,391.23
1,754.01
1,791.74
103.23
125.94
223.91
269.99
123.98
11.07
265.83
524.12
679.99
967.87
169.92
201.74
117.07
619.29
2,972.49
2,972.49
2,972.49
2,972.49
2,972.49
2,972.49
2,972.49
2,972.49
2,972.49
570.03
2,736.03
2,736.03
2,736.03
2,736.03
2,736.03
2,736.03
2,736.03
2,736.03
2,736.03
2,972.49
1,641.36
678.84
678.84
121.44
119.34
2,972.49
3,188.13
3,188.13
207.09
89.55
3,188.13
3,188.13
2,972.49
2,972.49
2,972.49
3,188.13
3,188.13
2,296.11
2,296.11
2,296.11
2,296.11
113.49
173.16
199.77
199.77
121.44
15.21
343.95
364.44
364.44
364.44
121.44
199.77
190.68
2,736.03
1,510.80
624.84
624.84
111.78
109.86
2,736.03
2,934.54
2,934.54
190.59
82.44
2,934.54
2,934.54
2,736.03
2,736.03
2,736.03
2,934.54
2,934.54
2,113.44
2,113.44
2,113.44
2,113.44
104.46
159.39
183.90
183.90
111.78
14.01
316.59
335.43
335.43
335.43
111.78
183.90
175.53
199.77
199.77
263.25
3,413.91
3,413.91
183.90
183.90
242.31
3,142.35
3,142.35
220.55
266.92
169.75
719.29
797.97
248.72
897.30
615.47
725.33
69.73
296.49
723.36
1,735.95
401.28
3,188.13
1,597.86
369.36
2,934.54
113.27
86.03
87.67
123.83
127.50
95.94
99.45
94.77
117.36
88.29
91.53
87.21
X
X, N1
11:3-29.6
20553
20600
20605
20610
20612
20615
20650
20662
20663
20665
20670
20680
20690
20692
20693
20694
20696
20697
20900
20902
20910
20912
20920
20922
20924
20926
20931
20950
20955
20974
20975
20979
20985
21060
21070
21073
21085
21110
21116
21209
21210
21240
21242
21243
21244
21245
21246
21247
21248
21249
21310
21315
21320
21325
21330
21335
21356
21360
21365
21366
21385
21386
21390
21395
21400
21401
21406
21407
21408
21450
21451
APPENDIX B - REGULATIONS
INJECT TRIGGER POINTS, =/> 3
256.49
DRAIN/INJ, JOINTBURSA
85.46
DRAIN/INJ, JOINTBURSA
93.41
DRAIN/INJ, JOINTBURSA
168.19
ASPIRATE/INJECT GANGLION CYST 92.67
TREAT BONE CYST
347.60
INSERT & REMOVE BONE PIN
313.04
APPLY PELVIS BRACE
680.98
APPLY THIGH BRACE
724.98
REMOVE FIXATION DEVICE
REMOVE SUPPORT IMPLANT
2,411.70
REMOVE SUPPORT IMPLANT
976.54
APPLY BONE FIXATION DEVICE
2,428.13
APPLY BONE FIXATION DEVICE
4,571.37
ADJUST BONE FIXATION DEVICE 1,941.73
REMOVE BONE FIXATION DEVICE 1,824.61
COMP MULTIPLANE EXT FIXATION 4,555.72
COMP EXT FIXATE STRUT CHANGE 7,725.55
REMOVE BONE FOR GRAFT
673.98
REMOVE BONE FOR GRAFT
519.31
REMOVE CARTILAGE FOR GRAFT 1,037.67
REMOVE CARTILAGE FOR GRAFT 1,198.06
REMOVE FASCIA FOR GRAFT
985.25
REMOVE FASCIA FOR GRAFT
1,471.19
REMOVE TENDON FOR GRAFT
800.25
REMOVE TISSUE FOR GRAFT
692.39
SP BONE ALLOGRAFT STRUCT,
ADDED
480.89
FLUID PRESSURE, MUSCLE
1,090.10
FIBULA BONE GRAFT, MICROVASC10,896.00
ELECTRICAL BONE STIMULATION 388.51
ELECTRICAL BONE STIMULATION 968.04
US BONE STIMULATION
288.61
COMPUTER-ASSIST DIR MS PX
233.28
REMOVE JAW JOINT CARTILAGE 1,303.59
REMOVE CORONOID PROCESS
2,683.05
MANIPULATE TMJ W/ANESTH
625.03
PREPARE FACE/ORAL PROSTHESIS 1,453.19
INTERDENTAL FIXATION
1,453.19
INJECTION, JAW JOINT X-RAY
242.27
REDUCE FACIAL BONES
1,356.76
FACE BONE GRAFT
3,584.38
RECONSTRUCT JAW JOINT
3,361.24
RECONSTRUCT JAW JOINT
3,085.47
RECONSTRUCT JAW JOINT
5,070.37
RECONSTRUCT LOWER JAW
1,701.06
RECONSTRUCT JAW
1,819.98
RECONSTRUCT JAW
1,327.80
RECONSTRUCT LOWER JAW BONE 2,579.70
RECONSTRUCT JAW
1,730.48
RECONSTRUCT JAW
2,370.58
TREAT NOSE FX
185.45
TREAT NOSE FX
443.93
TREAT NOSE FX
417.47
TREAT NOSE FX
772.19
TREAT NOSE FX
926.89
TREAT NOSE FX
1,181.49
TREAT CHEEK BONE FX
2,159.27
TREAT CHEEK BONE FX
2,285.49
TREAT CHEEK BONE FX
4,774.53
TREAT CHEEK BONE FX
5,417.56
TREAT EYE SOCKET FX
3,005.24
TREAT EYE SOCKET FX
2,849.94
TREAT EYE SOCKET FX
3,399.51
TREAT EYE SOCKET FX
4,165.36
TREAT EYE SOCKET FX
807.13
TREAT EYE SOCKET FX
2,088.19
TREAT EYE SOCKET FX
2,367.98
TREAT EYE SOCKET FX
2,782.80
TREAT EYE SOCKET FX
3,870.37
TREAT LOWER JAW FX
954.01
TREAT LOWER JAW FX
1,231.95
244.86
81.58
89.07
160.06
88.43
330.96
298.60
652.96
694.28
2,219.85
929.22
2,338.02
4,397.67
1,861.31
1,737.34
4,376.97
7,206.79
637.99
498.66
992.57
1,147.49
943.49
1,405.30
767.01
664.11
465.78
1,027.35
10,491.67
369.13
932.18
275.42
225.44
1,251.23
2,569.88
593.86
1,375.54
1,375.54
228.15
1,290.12
3,377.47
3,224.68
2,959.40
4,866.28
1,626.83
1,735.61
1,275.95
2,482.80
1,651.07
2,265.59
174.76
419.60
394.98
732.88
881.33
1,128.42
2,052.68
2,187.85
4,590.46
5,210.50
2,877.79
2,739.14
3,262.80
3,999.96
765.31
1,978.92
2,266.67
2,670.16
3,718.17
901.26
1,165.53
107.64
97.11
109.98
157.95
106.47
430.50
3,064.83
3,064.83
3,064.83
89.55
99.06
89.37
101.22
145.38
98.01
396.27
2,821.05
2,821.05
2,821.05
82.44
3,188.13
4,301.40
4,301.40 3
3,064.83
3,064.83
4,301.40
2,779.53
4,301.40
4,301.40
2,972.49
2,972.49
2,296.11
2,296.11
4,301.40
619.29
2,934.54
3,959.25
,959.25
2,821.05
2,821.05
3,959.25
2,558.43
3,959.25
3,959.25
2,736.03
2,736.03
2,113.44
2,113.44
3,959.25
570.03
198.84
183.03
89.55
82.44
5,961.75
5,961.75
832.95
1,265.82
1,056.45
5,487.51
5,487.51
766.71
1,165.11
972.42
5,961.75
5,961.75
5,961.75
5,961.75
5,961.75
5,961.75
5,961.75
5,961.75
5,961.75
5,961.75
5,961.75
151.17
2,313.03
2,313.03
3,421.41
3,421.41
3,421.41
3,421.41
3,421.41
5,487.51
5,487.51
5,487.51
5,487.51
5,487.51
5,487.51
5,487.51
5,487.51
5,487.51
5,487.51
5,487.51
139.14
2,129.04
2,129.04
3,149.25
3,149.25
3,149.25
3,149.25
3,149.25
5,961.75
5,487.51
1,056.45
2,313.03
5,961.75
5,961.75
972.42
2,129.04
5,487.51
5,487.51
474.09
1,056.45
436.38
972.42
X
X, N1
X
X, N1
X, N1
MEDICAL FEE SCHEDULES
21452
21453
21454
21461
21462
21465
21470
21800
21820
21825
22305
22310
22315
22505
22520
22521
22522
22554
22585
22845
22851
23120
23125
23130
23331
23332
23350
23405
23406
23410
23412
23415
23420
23430
23440
23470
23472
23480
23485
23500
23505
23515
23520
23525
23530
23540
23545
23550
23552
23570
23600
23605
23615
23616
23620
23625
23630
23650
23655
23700
24220
24300
24305
24340
24341
11:3-29.6
TREAT LOWER JAW FX
969.53
911.95 2,313.03 2,129.04
TREAT LOWER JAW FX
1,437.35 1,360.70 5,961.75 5,487.51
TREAT LOWER JAW FX
889.43
850.92 3,421.41 3,149.25
TREAT LOWER JAW FX
3,370.55 3,171.80 5,961.75 5,487.51
TREAT LOWER JAW FX
3,567.33 3,359.58 5,961.75 5,487.51
TREAT LOWER JAW FX
1,514.36 1,453.74 5,961.75 5,487.51
TREAT LOWER JAW FX
1,919.57 1,843.61
TREAT RIB FX
164.26
156.32
210.60
193.83
TREAT STERNUM FX
217.62
207.24
210.60
193.83
TREAT STERNUM FX
900.11
864.97
TREAT SPINE PROCESS FX
210.60
193.83
TREAT SPINE FX
734.37
675.96
TREAT SPINE FX
3,738.68 3,578.03 2,779.53 2,558.43
MANIPULATE SPINE
214.24
206.29 2,074.56 1,909.53
PERCUT VERTEBROPLASTY THORACIC
4,301.40 3,959.25
PERCUT VERTEBROPLASTY LUMBAR
4,301.40 3,959.25
PERCUT VERTEBROPLASTY ADDED
4,301.40 3,959.25
NECK SPINE FUSION
6,185.12 5,961.42
ADDED SPINAL FUSION
1,650.20 1,597.95
INSERT SPINE FIXATION DEVICE 4,518.17 4,376.06
APPLY SPINE PROSTH DEVICE
2,507.61 2,427.54
PARTIAL REMOVE COLLAR BONE 3,521.55 3,374.09 4,301.40 3,959.25
REMOVE COLLAR BONE
4,270.68 4,099.77 4,301.40 3,959.25
REMOVE SHOULDER BONE, PART 3,681.64 3,527.78 6,312.78 5,810.61
REMOVE SHOULDER FOREIGN
BODY
3,576.37 3,428.03 3,188.13 2,934.54
REMOVE SHOULDER FOREIGN
BODY
5,348.95 5,138.14
INJECTION FOR SHOULDER X-RAY 245.78
232.06
TX SHO AREA 1 TDN
989.02
949.25 4,301.40 3,959.25
TX SHO AREA MLT TDN THRU SM
INC
1,228.87 1,180.78 4,301.40 3,959.25
OPEN REPAIR OF ROTATOR CUFF,
RECENT
3,500.51 3,361.17 6,312.78 5,810.61
OPEN REPAIR OF ROTATOR CUFF,
OLD
3,640.20 3,495.88 6,312.78 5,810.61
CORACOACROMIAL LIGM RLS
+-ACROMP
1,096.46 1,051.70 6,312.78 5,810.61
RECONSTRUCTION ROTATOR CUFF,
OLD
4,128.82 3,965.45 6,312.78 5,810.61
TENODIS LONG TDN BICEPS
1,169.96 1,123.11 6,312.78 5,810.61
RESCJ/TRNSPLJ LONG TDN BICEPS 1,192.02 1,145.18 6,312.78 5,810.61
RECONSTRUCT SHOULDER JOINT 5,149.21 4,954.04
RECONSTRUCT SHOULDER JOINT 6,369.05 6,131.80
REVISE COLLAR BONE
3,481.15 3,344.49 6,312.78 5,810.61
REVISE COLLAR BONE
4,080.99 3,923.94 11,871.09 10,926.78
TREAT CLAVICLE FX
517.10
320.37
210.60
193.83
TREAT CLAVICLE FX
836.78
519.25 2,779.53 2,558.43
TREAT CLAVICLE FX
2,182.75 2,094.37 8,925.39 8,215.41
TREAT CLAVICLE DISLOCATION
543.64
518.10
734.37
675.96
TREAT CLAVICLE DISLOCATION
889.99
848.39
734.37
675.96
TREAT CLAVICLE DISLOCATION 1,683.11 1,615.14 6,420.90 5,910.15
TREAT CLAVICLE DISLOCATION
526.02
501.82
210.60
193.83
TREAT CLAVICLE DISLOCATION
963.58
919.00
734.37
675.96
TREAT CLAVICLE DISLOCATION 1,729.78 1,659.14 6,420.90 5,910.15
TREAT CLAVICLE DISLOCATION 1,992.63 1,911.66 6,420.90 5,910.15
TREAT SHOULDER BLADE FX
550.00
524.31
210.60
193.83
TREAT HUMERUS FX
774.56
479.33
210.60
193.83
TREAT HUMERUS FX
1,118.44
693.94 2,779.53 2,558.43
TREAT HUMERUS FX
3,210.58 1,336.23 8,925.39 8,215.41
TREAT HUMERUS FX
4,569.61 1,904.53 8,925.39 8,215.41
TREAT HUMERUS FX
640.51
609.71
210.60
193.83
TREAT HUMERUS FX
910.15
868.61 2,779.53 2,558.43
TREAT HUMERUS FX
2,340.39 2,246.76 8,925.39 8,215.41
TREAT SHOULDER DISLOCATION
713.19
443.19
210.60
193.83
TREAT SHOULDER DISLOCATION
941.00
585.27 2,074.56 1,909.53
FIXATE SHOULDER
470.07
338.09 2,074.56 1,909.53
INJECTION FOR ELBOW X-RAY
265.46
251.25
MANIPULATE ELBOW W/ANESTH
640.74
610.08 2,074.56 1,909.53
ARM TENDON LENGTHENING
912.18
874.28 4,301.40 3,959.25
REPAIR BICEPS TENDON
2,601.25 2,494.51 6,312.78 5,810.61
REPAIR ARM TENDON/MUSCLE
3,143.66 3,012.32 6,312.78 5,810.61
X, N1
X, N1
11:3-29.6
24342
24343
24500
24505
24515
24516
24530
24535
24545
24546
24560
24565
24575
24576
24577
24579
25000
25001
25020
25023
25024
25025
25118
25215
25246
25259
25260
25263
25265
25270
25272
25274
25295
25500
25505
25515
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25606
25607
25608
25609
25622
25624
25628
25630
25635
25645
25650
25652
25670
25671
25676
25680
25685
26055
26116
26140
26145
APPENDIX B - REGULATIONS
REPAIR RUPTURED TENDON
3,306.76
REPAIR ELBOW LAT LIGAMENT
W/TISS
2,987.14
TREAT HUMERUS FX
549.29
TREAT HUMERUS FX
780.56
TREAT HUMERUS FX
1,381.32
TREAT HUMERUS FX
1,358.43
TREAT HUMERUS FX
588.23
TREAT HUMERUS FX
965.43
TREAT HUMERUS FX
1,456.68
TREAT RUS FX
1,648.10
TREAT HUMERUS FX
494.20
TREAT HUMERUS FX
817.85
TREAT RUS FX
1,155.33
TREAT HUMERUS FX
524.86
TREAT HUMERUS FX
846.15
TREAT RUS FX
1,314.50
INCISE TENDON SHEATH
547.09
INCISE FLEXOR CARPI RADIALIS
536.36
DECOMPRESS FOREARM 1 SPACE 1,767.91
DECOMPRESS FOREARM 1 SPACE 3,363.81
DECOMPRESS FOREARM 2 SPACES 2,353.42
DECOMPRESS FOREARM 2 SPACES 3,669.10
EXCISE WRIST TENDON SHEATH
607.03
REMOVE WRIST BONES
1,898.51
INJECTION FOR WRIST X-RAY
268.94
MANIPULATE WRIST W/ANESTH
644.82
REPAIR FOREARM TENDON/MUSCLE2,008.73
REPAIR FOREARM TENDON/MUSCLE1,999.71
REPAIR FOREARM TENDON/MUSCLE2,368.51
REPAIR FOREARM TENDON/MUSCLE1,592.68
REPAIR FOREARM TENDON/MUSCLE1,784.09
REPAIR FOREARM TENDON/MUSCLE2,130.04
RELEASE WRIST/FOREARM TENDON 876.95
TREAT FX RADIUS
413.29
TREAT FX RADIUS
781.41
TREAT FX RADIUS
1,050.48
TREAT FX RADIUS
1,246.06
TREAT FX RADIUS
1,533.29
TREAT FX ULNA
402.85
TREAT FX ULNA
760.01
TREAT FX ULNA
981.64
TREAT FX RADIUS & ULNA
808.02
TREAT FX RADIUS & ULNA
1,566.66
TREAT FX RADIUS & ULNA
2,025.40
TREAT FX RADIUS/ULNA
2,717.76
TREAT FX RADIUSIULNA
869.76
TREAT FX RADIUS/ULNA
1,865.53
TREAT FX DISTAL RADIAL
2,018.97
TREAT FX RADIAL
EXTRA-ARTICULAR
2,204.51
TREAT FX RADIAL
INTRA-ARTICULAR
2,472.05
TREAT FX RADIAL 3+ FRAG
3,148.22
TREAT WRIST BONE FX
900.97
TREAT WRIST BONE FX
1,384.38
TREAT WRIST BONE FX
2,177.02
TREAT WRIST BONE FX
909.36
TREAT WRIST BONE FX
1,342.79
TREAT WRIST BONE FX
1,718.80
TREAT WRIST BONE FX
953.03
TREAT FX ULNAR STYLOID
1,879.79
TREAT FX ULNAR STYLOID
1,831.97
TREAT FX ULNAR STYLOID
1,598.39
TREAT WRIST DISLOCATION
1,911.46
TREAT WRIST FX
1,383.37
TREAT WRIST FX
2,218.61
INCISE FINGER TENDON SHEATH
910.15
EXCISE HAND TUMOR DEEP
< 1.5 CM
1,590.71
REVISE FINGER JOINT, EACH
1,527.77
TENDON EXCISE PALM/FINGER
2,479.64
3,175.53
6,312.78
5,810.61
2,862.45
522.97
744.97
1,326.32
1,305.28
560.15
922.74
1,399.91
1,583.95
470.24
781.01
1,108.02
499.14
808.13
1,261.84
521.24
511.94
1,684.75
3,221.26
2,260.29
3,530.71
580.07
1,818.66
254.91
613.89
1,921.52
1,913.76
2,270.10
1,522.50
1,706.99
2,040.87
838.58
393.45
745.83
1,007.25
1,195.16
1,471.52
382.70
725.62
940.37
769.13
1,496.29
1,942.13
2,608.67
827.89
1,783.62
1,933.22
4,301.40
210.60
210.60
8,925.39
8,925.39
210.60
734.37
8,925.39
8,925.39
210.60
210.60
8,925.39
210.60
210.60
8,925.39
3,064.83
3,064.83
4,301.40
,301.40
4,301.40
4,301.40
4,301.40
4,301.40
3,959.25
193.83
193.83
8,215.41
8,215.41
193.83
675.96
8,215.41
8,215.41
193.83
193.83
8,215.41
193.83
193.83
8,215.41
2,821.05
2,821.05
3,959.25
3,959.25
3,959.25
3,959.25
3,959.25
3,959.25
2,779.53
4,301.40
4,301.40
4,301.40
4,301.40
4,301.40
4,301.40
3,064.83
210.60
734.37
6,420.90
6,420.90
6,420.90
210.60
210.60
6,420.90
210.60
734.37
8,925.39
8,925.39
210.60
734.37
3,542.43
2,558.43
3,959.25
3,959.25
3,959.25
3,959.25
3,959.25
3,959.25
2,821.05
193.83
675.96
5,910.15
5,910.15
5,910.15
193.83
193.83
5,910.15
193.83
675.96
8,215.41
8,215.41
193.83
675.96
3,260.64
2,113.59
8,925.39
8,215.41
2,371.92
3,022.40
857.05
1,319.72
2,087.90
866.26
1,280.29
1,648.07
908.21
1,801.28
1,757.00
1,529.90
1,832.38
1,326.99
2,130.23
858.58
8,925.39
8,925.39
210.60
734.37
6,420.90
210.60
210.60
6,420.90
210.60
6,420.90
3,542.43
3,542.43
3,542.43
210.60
3,542.43
2,289.75
8,215.41
8,215.41
193.83
675.96
5,910.15
193.83
193.83
5,910.15
193.83
5,910.15
3,260.64
3,260.64
3,260.64
193.83
3,260.64
2,107.62
1,523.59
1,462.59
2,374.52
2,411.70
2,289.75
2,289.75
2,219.85
2,107.62
2,107.62
X, N1
MEDICAL FEE SCHEDULES
26340
26410
26418
26445
26480
26525
26540
26600
26605
26607
26608
26615
26720
26725
26727
26735
26740
26742
26746
26750
26755
27036
27093
27095
27096
27130
27132
27193
27194
27227
27228
27236
27245
27275
27403
27405
27420
27422
27424
27447
27487
27500
27501
27502
27503
27506
27507
27508
27509
27510
27511
27513
27514
27520
27524
27530
27532
27535
27536
27538
27540
27570
27685
27686
27690
27691
27692
27695
27696
27698
27750
27752
MANIPULATE FINGER W/ANESTH
521.42
REPAIR HAND TENDON
1,739.49
REPAIR FINGER TENDON
2,125.52
RELEASE HAND/FINGER TENDON 1,786.60
TRANSPLANT HAND TENDON
2,307.21
RELEASE FINGER CONTRACTURE 2,010.20
REPAIR HAND JOINT
2,010.67
TREAT METACARPAL FX
447.47
TREAT METACARPAL FX
499.07
TREAT METACARPAL FX
702.97
TREAT METACARPAL FX
1,155.32
TREAT METACARPAL FX
1,371.83
TREAT FINGER FX, EACH
303.29
TREAT FINGER FX, EACH
526.64
TREAT FINGER FX, EACH
739.96
TREAT FINGER FX, EACH
925.25
TREAT FINGER FX, EACH
352.67
TREAT FINGER FX, EACH
571.25
TREAT FINGER FX, EACH
1,143.63
TREAT FINGER FX, EACH
280.86
TREAT FINGER FX, EACH
484.57
EXCISE HIP JOINT/MUSCLE
3,050.71
INJECTION FOR HIP X-RAY
313.73
INJECTION FOR HIP X-RAY
384.77
INJECT SACROILIAC JOINT
586.47
TOTAL HIP ARTHROPLASTY
5,258.22
TOTAL HIP ARTHROPLASTY
6,133.86
TREAT PELVIC RING FX
1,417.56
TREAT PELVIC RING FX
2,095.30
TREAT HIP FX(S)
5,066.90
TREAT HIP FX(S)
5,779.51
TREAT THIGH FX
3,627.64
TREAT THIGH FX
3,775.02
MANIPULATE HIP JOINT
323.19
REPAIR KNEE CARTILAGE
3,103.82
REPAIR KNEE LIGAMENT
3,282.44
REVISE UNSTABLE KNEECAP
2,261.71
REVISE UNSTABLE KNEECAP
2,252.47
REVISION/REMOVE KNEECAP
2,255.28
TOTAL KNEE ARTHROPLASTY
4,684.46
REVISE/REPLACE KNEE JOINT
4,295.95
TREAT THIGH FX
2,180.66
TREAT THIGH FX
2,131.34
TREAT THIGH FX
3,311.93
TREAT THIGH FX
3,407.62
TREAT THIGH FX
5,689.32
TREAT THIGH FX
4,156.52
TREAT THIGH FX
2,209.66
TREAT THIGH FX
2,744.11
TREAT THIGH FX
2,936.26
TREAT THIGH FX
4,295.44
TREAT THIGH FX
5,359.94
TREAT THIGH FX
4,219.76
TREAT KNEECAP FX
1,349.20
TREAT KNEECAP FX
3,198.15
TREAT KNEE FX
1,671.35
TREAT KNEE FX
2,604.20
TREAT KNEE FX
3,857.40
TREAT KNEE FX
5,066.57
TREAT KNEE FX(S)
1,987.87
TREAT KNEE FX
3,478.82
FIXATE KNEE JOINT
235.46
REVISE LOWER LEG TENDON
2,767.45
REVISE LOWER LEG TENDONS
2,372.88
REVISE LOWER LEG TENDON
2,704.36
REVISE LOWER LEG TENDON
3,202.39
REVISE ADDEDITIONAL LEG TENDON461.41
REPAIR ANKLE LIGAMENT
1,477.41
REPAIR ANKLE LIGAMENTS
1,723.72
REPAIR ANKLE LIGAMENT
1,965.63
TREAT TIBIA FX
1,446.76
TREAT TIBIA FX
2,273.94
495.05
1,650.91
2,014.58
1,692.75
2,192.78
1,907.42
1,914.55
425.44
474.91
672.84
1,104.12
1,313.19
288.37
502.01
706.95
886.02
335.26
545.14
1,096.98
267.55
461.98
2,932.10
296.32
363.23
554.47
5,062.44
5,907.48
1,359.02
2,013.65
4,879.61
5,567.94
3,490.04
3,630.86
309.59
2,978.06
3,149.55
2,171.44
2,162.50
2,165.35
4,509.75
4,137.99
2,087.12
2,042.54
3,184.79
3,273.56
5,472.85
3,999.46
2,113.32
2,628.26
2,821.17
4,134.33
5,162.29
4,059.34
1,284.12
3,070.62
1,593.30
2,492.86
3,711.25
4,872.90
1,897.12
3,340.36
225.20
2,634.16
2,276.62
2,595.44
3,073.42
445.92
1,416.90
1,656.05
1,888.89
1,377.78
2,173.81
11:3-29.6
734.37
2,289.75
2,289.75
2,289.75
3,971.19
2,289.75
2,289.75
210.60
210.60
2,779.53
3,542.43
6,420.90
210.60
210.60
3,542.43
3,542.43
210.60
210.60
3,542.43
210.60
210.60
675.96
2,107.62
2,107.62
2,107.62
3,655.32
2,107.62
2,107.62
193.83
193.83
2,558.43
3,260.64
5,910.15
193.83
193.83
3,260.64
3,260.64
193.83
193.83
3,260.64
193.83
193.83
X, N1
X, N1
1,012.32
931.80
210.60
2,074.56
193.83
1,909.53
2,074.56
4,301.40
6,312.78
6,312.78
6,312.78
6,312.78
1,909.53
3,959.25
5,810.61
5,810.61
5,810.61
5,810.61
34.37
210.60
2,779.53
210.60
675.96
193.83
2,558.43
193.83
210.60
3,542.43
734.37
193.83
3,260.64
675.96
210.60
193.83
210.60
2,779.53
193.83
2,558.43
210.60
193.83
2,074.56
4,301.40
4,301.40
6,312.78
6,312.78
6,312.78
4,301.40
4,301.40
4,301.40
210.60
2,779.53
1,909.53
3,959.25
3,959.25
5,810.61
5,810.61
5,810.61
3,959.25
3,959.25
3,959.25
193.83
2,558.43
11:3-29.6
27758
27759
27760
27762
27766
27786
27788
27792
27808
27810
27814
27816
27818
27822
27823
27824
27825
27826
27827
27828
27829
27840
27842
27846
27848
27860
28120
28122
28400
28405
28415
28420
28430
28435
28436
28445
28470
28475
28476
28485
28725
28730
28740
28750
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
29240
29260
29280
29345
29355
29365
29405
29425
29450
29505
29515
29520
29530
29540
29550
29580
29581
APPENDIX B - REGULATIONS
TREAT TIBIA FX
3,785.47
TREAT TIBIA FX
4,257.79
CLOSED TREAT MEDIAL ANKLE FX 999.35
CLOSED TREAT MED ANKLE FX
W/MANIP
1,452.26
OPEN TREAT MEDIAL ANKLE FX 1,856.02
TREAT ANKLE FX
491.69
TREAT ANKLE FX
662.30
TREAT ANKLE FX
1,121.80
TREAT ANKLE FX
518.87
TREAT ANKLE FX
739.42
TREAT ANKLE FX
1,223.81
TREAT ANKLE FX
491.32
TREAT ANKLE FX
756.19
TREAT ANKLE FX
1,342.67
TREAT ANKLE FX
1,523.63
TREAT LOWER LEG FX
936.08
TREAT LOWER LEG FX
1,653.18
TREAT LOWER LEG FX
2,537.97
TREAT LOWER LEG FX
3,313.36
TREAT LOWER LEG FX
3,955.96
TREAT LOWER LEG JOINT
2,062.48
TREAT ANKLE DISLOCATION
1,072.56
TREAT ANKLE DISLOCATION
1,488.26
TREAT ANKLE DISLOCATION
2,235.14
TREAT ANKLE DISLOCATION
2,511.52
FIXATE ANKLE JOINT
276.66
PART REMOVE ANKLE/HEEL
1,107.25
PARTIAL REMOVE FOOT BONE
1,028.92
TREAT HEEL FX
389.18
TREAT HEEL FX
613.23
TREAT HEEL FX
1,782.79
TREAT/GRAFT HEEL FX
2,997.32
TREAT ANKLE FX
563.23
TREAT ANKLE FX
827.86
TREAT ANKLE FX
1,073.70
TREAT ANKLE FX
2,583.35
TREAT METATARSAL FX
511.87
TREAT METATARSAL FX
622.83
TREAT METATARSAL FX
843.05
TREAT METATARSAL FX
1,291.11
FUSE FOOT BONES
1,926.38
FUSE FOOT BONES
2,050.42
FUSE FOOT BONES
2,079.28
FUSE BIG TOE JOINT
2,027.14
APPLY LONG ARM CAST
149.13
APPLY FOREARM CAST
139.52
APPLY HANDIWRIST CAST
147.51
APPLY FINGER CAST
117.72
APPLY LONG ARM SPLINT
155.41
APPLY FOREARM SPLINT
125.21
APPLY FOREARM SPLINT
141.72
APPLY FINGER SPLINT
72.44
APPLY FINGER SPLINT
92.77
STRAP CHEST
82.75
STRAP SHOULDER
89.29
STRAP ELBOW OR WRIST
80.59
STRAP HAND OR FINGER
78.61
APPLY LONG LEG CAST
212.03
APPLY LONG LEG CAST
219.66
APPLY LONG LEG CAST
191.79
APPLY SHORT LEG CAST
138.97
APPLY SHORT LEG CAST
147.75
APPLY LEG CAST
226.46
APPLY LONG LEG SPLINT
121.67
APPLY LOWER LEG SPLINT
112.71
STRAP HIP
77.82
STRAP KNEE
81.60
STRAP ANKLE AND/OR FT
53.90
STRAP TOES
44.24
APPLY PASTE BOOT
82.79
APPLY MULTILAY COMPRESS LWR
3,636.72
4,093.54
951.28
6,420.90
8,925.39
210.60
5,910.15
8,215.41
193.83
1,387.19
1,778.54
467.93
632.08
1,076.61
493.37
706.28
1,174.68
467.71
722.98
1,287.42
1,462.35
892.85
1,582.18
2,434.01
3,179.78
3,800.93
1,976.64
1,028.51
1,426.77
2,146.41
2,412.81
265.27
1,057.06
981.54
369.98
585.90
1,712.47
2,880.42
535.64
789.27
1,025.26
2,483.99
486.88
594.36
802.80
1,237.46
1,852.85
1,969.71
1,981.86
1,930.24
141.80
132.52
140.22
111.61
148.00
118.86
134.82
69.28
88.41
78.96
85.21
76.70
74.72
202.15
209.65
182.59
132.16
140.72
217.10
115.58
107.26
74.05
77.69
51.17
41.67
78.81
2,779.53
6,420.90
210.60
210.60
6,420.90
210.60
210.60
6,420.90
210.60
734.37
6,420.90
8,925.39
210.60
2,779.53
6,420.90
8,925.39
8,925.39
6,420.90
210.60
2,074.56
6,420.90
6,420.90
2,074.56
3,014.25
3,014.25
210.60
2,779.53
8,925.39
6,420.90
210.60
210.60
3,542.43
6,420.90
210.60
210.60
3,542.43
6,420.90
7,371.54
7,371.54
7,371.54
7,371.54
194.19
187.17
149.40
149.40
149.40
147.42
149.40
67.86
97.11
94.77
101.79
100.62
101.79
255.03
255.03
240.99
178.98
181.32
149.40
149.40
141.54
97.11
100.62
72.54
72.54
102.96
2,558.43
5,910.15
193.83
193.83
5,910.15
193.83
193.83
5,910.15
193.83
675.96
5,910.15
8,215.41
193.83
2,558.43
5,910.15
8,215.41
8,215.41
5,910.15
193.83
1,909.53
5,910.15
5,910.15
1,909.53
2,774.49
2,774.49
193.83
2,558.43
8,215.41
5,910.15
193.83
193.83
3,260.64
,910.15
193.83
193.83
3,260.64
5,910.15
6,785.16
6,785.16
6,785.16
6,785.16
178.74
172.29
137.52
137.52
137.52
135.69
137.52
62.46
89.37
87.21
93.69
92.61
93.69
234.75
234.75
221.82
164.73
166.89
137.52
137.52
130.29
89.37
92.61
66.78
66.78
94.77
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
MEDICAL FEE SCHEDULES
29590
29700
29705
29710
29740
29800
29804
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29828
29830
29834
29835
29837
29840
29844
29845
29846
29847
29848
29850
29855
29860
29861
29862
29863
29870
29871
29873
29874
29875
29876
29879
29880
29881
29882
29883
29884
29886
29887
29888
29889
29891
29894
29895
29897
29898
29899
30100
30130
30140
30200
30300
30310
30520
30802
30901
30903
30905
LEG
152.30
APPLY FOOT SPLINT
82.51
REMOVE/REVISE CAST
103.41
REMOVE/REVISE CAST
104.21
REMOVE/REVISE CAST
190.34
WEDGE CAST
141.31
JAW ARTHROSCOPY/SURG
2,870.02
JAW ARTHROSCOPY/SURG
3,578.52
SHOULDER ARTHROSCOPY, DIAG 2,575.75
SHOULDER ARTHROSCOPY/SURG 5,808.16
SHOULDER ARTHROSCOPY/SURG 5,671.51
SHOULDER ARTHROSCOPY/SURG 3,210.18
SHOULDER ARTHROSCOPY/SURG 2,953.64
SHOULDER ARTHROSCOPY/SURG 3,233.10
SHOULDER ARTHROSCOPY/SURG 3,144.95
SHOULDER ARTHROSCOPY/SURG 3,430.85
SHOULDER ARTHROSCOPY/SURG 3,689.94
SHOULDER ARTHROSCOPY/SURG 3,202.11
SHOULDER ARTHROSCOPY/SURG3,650,34
ARTHROSCOPY ROTATOR CUFF
REPAIR
4,596.05
ARTHROSCOPY BICEPS TENODESIS3,899.18
ELBOW ARTHROSCOPY
1,932.85
ELBOW ARTHROSCOPY/SURG
2,095.15
ELBOW ARTHROSCOPY/SURG
2,154.22
ELBOW ARTHROSCOPY/SURG
2,251.82
WRIST ARTHROSCOPY
1,918.73
WRIST ARTHROSCOPY/SURG
2,115.96
WRIST ARTHROSCOPY/SURG
2,440.18
WRIST ARTHROSCOPY/SURG
2,218.96
WRIST ARTHROSCOPY/SURG
2,310.86
WRIST ENDOSCOPY/SURG
2,159.31
KNEE ARTHROSCOPY/SURG
2,540.30
TIBIAL ARTHROSCOPY/SURG
3,347.13
HIP ARTHROSCOPY, DIAG
2,809.81
HIP ARTHROSCOPY/SURG
3,088.61
HIP ARTHROSCOPY/SURG
3,469.37
HIP ARTHROSCOPY/SURG
3,458.24
KNEE ARTHROSCOPY, DIAG
2,543.44
KNEE ARTHROSCOPY/DRAIN
2,182.27
KNEE ARTHROSCOPY/SURG
2,221.06
KNEE ARTHROSCOPY/SURG
2,291.42
KNEE ARTHROSCOPY/SURG
2,712.06
KNEE ARTHROSCOPY/SURG
3,584.57
KNEE ARTHROSCOPY/SURG
2,818.03
KNEE ARTHROSCOPY/SURG
3,774.79
KNEE ARTHROSCOPY/SURG
3,531.15
KNEE ARTHROSCOPY/SURG
3,812.37
KNEE ARTHROSCOPY/SURG
3,576.15
KNEE ARTHROSCOPY/SURG
2,635.72
KNEE ARTHROSCOPY/SURG
2,695.10
KNEE ARTHROSCOPY/SURG
3,168.57
KNEE ARTHROSCOPY/SURG
4,211.31
KNEE ARTHROSCOPY/SURG
5,187.05
ANKLE ARTHROSCOPY/SURG
2,944.29
ANKLE ARTHROSCOPY/SURG
2,194.01
ANKLE ARTHROSCOPY/SURG
2,096.49
ANKLE ARTHROSCOPY/SURG
2,198.99
ANKLE ARTHROSCOPY/SURG
2,437.92
ANKLE ARTHROSCOPY/SURG
4,454.29
INTRANASAL BIOPSY
231.61
EXCISE INFERIOR TURBINATE
616.48
RESECT INFERIOR TURBINATE
714.07
INJECTION TREAT NOSE
185.69
REMOVE NASAL FOREIGN BODY
377.61
REMOVE NASAL FOREIGN BODY
333.88
REPAIR NASAL SEPTUM
1,533.94
ABLATE INF TURBINATE
SUBMUCOSAL
475.96
CONTROL NOSEBLEED
154.98
CONTROL NOSEBLEED
323.03
CONTROL NOSEBLEED
400.32
143.77
79.00
98.21
99.48
181.78
135.19
2,751.17
3,434.24
2,467.98
5,582.08
5,449.31
3,078.79
2,833.12
3,101.41
3,016.12
3,290.80
3,539.41
3,071.26
3,504.39
11:3-29.6
149.40
83.04
139.20
119.34
217.62
149.40
3,997.71
3,997.71
3,997.71
6,462.39
6,462.39
6,462.39
6,462.39
6,462.39
3,997.71
6,462.39
3,997.71
6,462.39
6,462.39
137.52
76.44
128.13
109.86
200.31
137.52
3,679.71
3,679.71
3,679.71
5,948.34
5,948.34
5,948.34
5,948.34
5,948.34
3,679.71
5,948.34
3,679.71
5,948.34
5,948.34
4,418.87 6,462.39 5,948.34
3,748.17 6,462.39 5,948.34
1,852.70 3,997.71 3,679.71
2,008.15 3,997.71 3,679.71
2,065.19 3,997.71 3,679.71
2,159.47 3,997.71 3,679.71
1,837.85 3,997.71 3,679.71
2,027.77 3,997.71 3,679.71
2,339.75 3,997.7
3,679.71
2,126.68 3,997.71 3,679.71
2,216.47 6,462.39 5,948.34
2,067.30 3,997.71 3,679.71
2,439.30 3,997.71 3,679.71
3,213.03 6,462.39 5,948.34
2,697.02 6,462.39 5,948.34
2,966.10 6,462.39 5,948.34
3,330.41 6,462.39 5,948.34
3,320.12 6,462.39 5,948.34
2,416.34 3,997.71 3,679.71
2,092.01 3,997.71 3,679.71
2,124.42 3,997.71 3,679.71
2,197.95 3,997.71 3,679.71
2,599.81 3,997.71 3,679.71
3,439.85 3,997.71 3,679.71
2,704.52 3,997.71 3,679.71
3,623.53 3,997.71 3,679.71
3,388.20 3,997.71 3,679.71
3,660.32 3,997.71 3,679.71
3,435.01 3,997.71 3,679.71
2,528.41 3,997.71 3,679.71
2,585.53 3,997.71 3,679.71
3,041.28 3,997.71 3,679.71
4,048.82 11,871.09 10,926.78
4,985.30 11,871.09 10,926.78
2,825.65 6,462.39 5,948.34
2,106.44 3,997.71 3,679.71
2,013.20 3,997.71 3,679.71
2,111.07 3,997.71 3,679.71
2,342.16 3,997.71 3,679.71
4,283.43 6,462.39 5,948.34
218.73
357.99
329.52
585.09 2,313.03 2,129.04
676.41 3,421.41 3,149.25
175.48
283.11
260.58
355.40
89.55
82.44
317.27 2,313.03 2,129.04
1,462.07 3,421.41 3,149.25
450.01
147.82
305.90
379.29
2;313.03
151.17
151.17
151.17
2,129.04
139.14
139.14
139.14
X
X
X
X
X
X
11:3-29.6
30930
31000
31020
31231
31237
31238
31255
31256
31267
31500
31505
31515
31525
31575
31579
31600
31605
31622
31624
31645
31646
32405
29877
32551
32601
32651
32653
33210
33212
36000
36005
36010
36011
36013
36014
36140
36200
36215
36216
36217
36218
36245
36246
36247
36248
36400
36406
36410
36425
36430
36471
36513
36514
36515
36555
36556
36558
36569
36571
36576
36578
36580
36584
36589
36592
36593
36598
36600
36620
36625
36800
36810
APPENDIX B - REGULATIONS
THERAPEUTIC FX, NASAL INF TURB 199.28
IRRIGATE MAXILLARY SINUS
295.86
EXPLORE MAXILLARY SINUS
793.30
NASAL ENDOSCOPY, DIAG
316.52
NASAL/SINUS ENDOSCOPY, SURG 533.18
NASAL/SINUS ENDOSCOPY, SURG 547.19
REMOVE ETHMOID SINUS
1,735.89
EXPLORE MAXILLARY SINUS
1,228.03
ENDOSCOPY, MAXILLARY SINUS
983.83
INSERT EMERGENCY AIRWAY
169.29
DIAGNOSTIC LARYNGOSCOPY
137.08
LARYNGOSCOPY FOR ASPIRATION 342.57
DIAG LARYNGOSCOPY EXCL NB
409.68
DIAGNOSTIC LARYNGOSCOPY
188.42
DIAGNOSTIC LARYNGOSCOPY
352.14
INCISE WINDPIPE
629.61
INCISE WINDPIPE
287.29
DIAG BRONCHOSCOPE/WASH
515.11
DIAG BRONCHOSCOPE/LAVAGE
516.04
BRONCHOSCOPY, CLEAR AIRWAYS 493.95
BRONCHOSCOPY, RECLEAR AIRWAY451.44
BIOPSY LUNG OR MEDIASTINUM
154.47
KNEE ARTHROSCOPY/SURG
3,398.38
INSERT CHEST TUBE
523.12
THORACOSCOPY, DIAGNOSTIC
499.24
THORACOSCOPY, SURGICAL
1,750.69
THORACOSCOPY, SURGICAL
1,686.57
INSERT HEART ELECTRODE
297.55
INSERT PULSE GENERATOR
564.31
PLACE NEEDLE IN VEIN
41.55
INJECTION EXT VENOGRAPHY
590.62
PLACE CATHETER IN VEIN
952.65
PLACE CATHETER IN VEIN
1,569.24
PLACE CATHETER IN ARTERY
1,386.90
PLACE CATHETER IN ARTERY
1,452.05
ESTABLISH ACCESS TO ARTERY
818.12
PLACE CATHETER IN AORTA
1,104.48
PLACE CATHETER IN ARTERY
1,968.28
PLACE CATHETER IN ARTERY
2,164.58
PLACE CATHETER IN ARTERY
3,554.81
PLACE CATHETER IN ARTERY
325.68
PLACE CATHETER IN ARTERY
2,078.60
PLACE CATHETER IN ARTERY
2,094.97
PLACE CATHETER IN ARTERY
3,310.67
PLACE CATHETER IN ARTERY
272.11
BLOOD DRAW < 3 YRS FEM/JUGULAR 46.92
BLOOD DRAW < 3 YRS OTHER VEIN 28.17
NON-ROUTINE BL DRAW > 3 YRS
29.91
VEIN ACCESS CUTDOWN > 1 YR
62.34
BLOOD TRANSFUSION SERVICE
59.91
INJECTION THERAPY VEINS
290.72
APHERESIS PLATELETS
158.96
APHERESIS PLASMA
878.54
APHERESIS, ADSORP/REINFUSE
3,313.31
INSERT NON-TUNNEL CV CATH
442.67
INSERT NON-TUNNEL CV CATH
383.48
INSERT TUNNELED CV CATH
1,353.89
INSERT PICC CATH
430.72
INSERT PICVAD CATH
2,151.26
REPAIR TUNNELED CV CATH
619.78
REPLACE TUNNELED CV CATH
855.29
REPLACE CVAD CATH
375.27
REPLACE PICC CATH
360.67
REMOVE TUNNELED CV CATH
271.78
COLLECT BLOOD PICC
44.20
DECLOT VASCULAR DEVICE
49.44
INJECT W/FLUOR, EVAL CV DEVICE 189.67
WITHDRAW ARTERIAL BLOOD
50.41
INSERT CATHETER, ARTERY
210.31
INSERT CATHETER, ARTERY
169.68
INSERT CANNULA
261.61
INSERT CANNULA
340.24
189.73 2,313.03
279.40
457.44
748.88 3,421.41
298.37
268.32
505.96 2,927.49
519.83 2,927.49
1,673.26 4,128.33
1,181.96 4,128.33
947.97 4,128.33
164.70
315.78
129.60
124.02
324.79 2,927.49
389.77 2,927.49
178.87
253.86
335.06
445.74
609.27
278.92 1,056.45
488.50 1,400.82
489.32 1,400.82
469.51 1,400.82
428.67 1,400.82
149.43 1,298.73
3,259.86 3,997.71
506.94
483.47
1,694.03
1,632.06
288.11 3,763.15
544.12 11,119.83
39.31
553.75
895.82
1,473.07
1,301.48
1,363.05
769.44
1,039.78
1,850.35
2,035.32
3,335.12
306.84
1,953.45
1,970.56
3,107.79
256.86
44.88
26.82
28.45
60.40
35.67
55.92
119.34
276.37
121.44
153.73 1,652.49
824.72 1,652.49
3,095.86 4,195.89
420.24 1,516.71
364.91 1,516.71
1,277.30 2,289.41
406.86 1,516.71
2,023.38 2,289.41
588.02 1,516.71
808.35 2,289.41
353.82 1,516.71
339.77 1,516.71
260.38
844.41
41.25
46.14
98.28
178.99
298.32
47.90
204.69
164.90
251.45 4,009.88
329.61 4,009.88
2,129.04
421.05
3,149.25
246.99
2,694.60
2,694.60
3,799.92
3,799.92
3,799.92
290.67
114.15
2,694.60
2,694.60
233.67
410.28
X
972.42
1,289.40
1,289.40
1,289.40
1,289.40
1,195.41
3,679.71
3,209.05
9,530.10
32.82
109.86
111.78
1,521.03
1,521.03
3,862.11
1,396.08
1,396.08
2,017.01
1,396.08
2,017.01
1,396.08
2,017.01
1,396.08
1,396.08
777.24
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X, N1
X
X
X
X
X
X, N1
90.45
274.59
X, N1
X, N1
X, N1
3,637.55
3,637.55
MEDICAL FEE SCHEDULES
36815
36818
36833
36860
37140
37609
37620
37650
38100
37204
38115
38200
38206
38220
38221
38230
39501
43235
43236
43239
43246
43248
43249
43255
43259
43260
43450
43760
43830
44139
44500
45300
45330
45355
45378
46040
46600
47000
49080
49320
49421
49505
50392
50394
51600
51610
51700
51701
51702
51703
51705
51720
51725
51725
51725
51726
51726
51726
51741
51741
51741
51784
51784
51784
51797
51797
51797
51798
TC
26
TC
26
TC
26
TC
26
TC
26
INSERT CANNULA
244.77
236.68
AV FUSE, UPPER ARM, CEPHALIC 1,105.69 1,069.72
AV FISTULA REVISION
1,079.72 1,045.86
EXTERNAL CANNULA DECLOTTING 331.55
315.10
REVISE CIRCULATION
2,310.08 2,235.33
TEMPORAL ARTERY PROCEDURE
503.08
478.98
REVISE MAJOR VEIN
2,029.20 1,958.69
REVISE MAJOR VEIN
1,545.07 1,493.80
REMOVE SPLEEN, TOTAL
1,765.00 1,708.45
TRANSCATHETER OCCLUSION
1,460.69 1,414.57
REPAIR RUPTURED SPLEEN
1,947.72 1,885.34
INJECTION FOR SPLEEN X-RAY
234.86
227.73
HARVEST AUTO STEM CELLS
292.33
282.03
BONE MARROW ASPIRATION
250.35
236.57
BONE MARROW BIOPSY
269.34
254.87
BONE MARROW COLLECTION
838.42
806.23
REPAIR DIAPHRAGM LACERATION 1,328.67 1,283.88
UPPER GI ENDOSCOPY, DIAGNOSIS 490.49
464.67
UPPER GI SCOPE W/SUBMUCOSA
INJECT
608.49
576.22
UPPER GI ENDOSCOPY, BIOPSY
567.52
537.88
PLACE GASTROSTOMY TUBE
403.59
389.45
UPPER GI ENDOSCOPY/GUIDE WIRE 303.20
292.10
ESOPH ENDOSCOPY, DILATION
279.64
269.41
OPERATIVE UPPER GI ENDOSCOPY 453.95
437.69
ENDOSCOPIC ULTRASOUND EXAM 488.13
470.63
ENDO
CHOLANGIOPANCREATOGRAPHY 556.81
536.98
DILATE ESOPHAGUS
258.48
245.26
CHANGE GASTROSTOMY TUBE
684.75
641.43
PLACE GASTROSTOMY TUBE
1,076.48 1,038.48
MOBILIZATION COLON
187.28
181.69
INTRODUCE GASTROINTESTINAL
TUBE
38.60
37.33
PROCTOSIGMOIDOSCOPY DIAG
187.75
177.52
DIAGNOSTIC SIGMOIDOSCOPY
227.77
215.31
SURGICAL COLONOSCOPY
324.09
312.96
DIAGNOSTIC COLONOSCOPY
647.09
614.70
INCISE RECTAL ABSCESS
811.58
773.85
DIAGNOSTIC ANOSCOPY
136.30
128.76
NEEDLE BIOPSY LIVER
575.57
542.24
PUNCTURE, PERITONEAL CAVITY 269.24
254.87
DIAG LAP SEPARATE PROC
508.88
490.86
INSERT ABDOM DRAIN, PERM
425.09
409.71
PART RPR I/HERNIA INIT REDUCT
>5 YR
799.46
771.01
INSERT KIDNEY DRAIN
289.62
279.48
INJECTION FOR KIDNEY X-RAY
173.81
164.23
INJECTION FOR BLADDER X-RAY
328.90
309.24
INJECTION FOR BLADDER X-RAY
184.26
174.79
IRRIGATION BLADDER
143.15
135.97
INSERT BLADDER CATHETER
98.42
93.21
INSERT TEMP BLADDER CATH
128.12
120.92
INSERT BLADDER CATH, COMPLEX 227.44
216.26
CHANGE BLADDER TUBE
186.01
176.43
TREAT BLADDER LESION
185.88
177.55
SIMPLE CYSTOMETROGRAM
349.50
330.16
SIMPLE CYSTOMETROGRAM
228.20
212.91
SIMPLE CYSTOMETROGRAM
121.30
117.25
COMPLEX CYSTOMETROGRAM
514.29
484.52
COMPLEX CYSTOMETROGRAMI
375.98
350.82
COMPLEX CYSTOMETROGRAM
138.31
133.68
ELECTRO-UROFLOWMETRY, FIRST 72.56
68.17
ELECTRO-UROFLOWMETRY, FIRST 45.36
42.35
ELECTRO-UROFLOWMETRY, FIRST 27.20
25.82
ANAL/URINARY MUSCLE STUDY
340.60 321,93
ANAL/URINARY MUSCLE STUDY
217.71.
203.13
ANAL/URINARY MUSCLE STUDY
122.90
118.80
INTRAABDOMINAL PRESSURE TEST 225.40
212.42
INTRAABDOMINAL PRESSURE TEST 159.49
148.82
INTRAABDOMINAL PRESSURE TEST 65.91
63.61
US URINE CAPACITY MEASURE
33.71
31.48
11:3-29.6
4,009.88
5,565.66
5,565.66
313.14
3,637.55
5,122.95
5,122.95
288.21
2,411.70
2,219.85
3,662.31
3,370.98
8,466.97
7,482.97
1,652.49
381.36
393.09
4,195.89
1,521.03
351.03
361.80
3,862.11
1,184.82
1,090.56
1,184.82
1,184.82
1,184.82
1,184.82
1,184.82
1,184.82
1,184.82
1,090.56
1,090.56
1,090.56
1,090.56
1,090.56
1,090.56
1,090.56
3,099.69
875.61
313.14
2,853.12
805.98
288.21
844.41
283.11
345.12
1,246.23
1,246.23
3,247.68
89.55
1,298.73
742.11
5,156.19
3,521.06
777.24
260.58
317.67
1,147.08
1,147.08
2,989.32
82.44
1,195.41
683.10
4,746.03
3,192.08
4,412.82
2,344.41
4,061.82
2,157.93
X, N1
X
X
X
X, N1
X, N1
X, N1
189.51
89.55
89.55
148.20
256.20
205.92
174.45
82.44
82.44
136.41
235.83
189.54
428.43
394.35
428.43
394.35
90.09
82.92
148.20
136.41
271.74
250.14
66.69
61.38
X
X
X
11:3-29.6
APPENDIX B - REGULATIONS
52000
CYSTOSCOPY
348.14
52005
CYSTOSCOPY & URETER CATHETER 482.13
52204
CYSTOSCOPY W/BIOPSY(S)
706.29
52281
CYSTOSCOPY & TREAT
481.96
52310
CYSTOSCOPY & TREAT
412.14
52332
CYSTOSCOPY & TREAT
837.81
52351
CYSTOURETERO & OR PYELOSCOPE 511.15
53600
DILATE URETHRA STRICTURE
139.91
53601
DILATE URETHRA STRICTURE
137.75
53660
DILATE URETHRA
121.77
53661
DILATE URETHRA
120.54
54235
PENILE INJECTION
149.95
57452
EXAM CERVIX W/SCOPE
174.20
57500
BIOPSY CERVIX
213.96
57511
CRYOCAUTERY CERVIX
234.32
58340
CATHETER FOR HYSTERORRHAPHY 203.46
58558
HYSTEROSCOPY, BIOPSY
576.77
59000
AMNIOCENTESIS, DIAGNOSTIC
208.66
59025
FETAL NON-STRESS TEST
117.18
59025 TC FETAL NON-STRESS TEST
45,58
59025 26 FETAL NON-STRESS TEST
71.58
59841
ABORTION
611.45
61107
DRILL SKULL FOR IMPLANTATION 1,155.41
61790
TREAT TRIGEMINAL NERVE
2,552.34
62263
EPIDURAL LYSIS MULT SESSIONS 1,788.44
62264
EPIDURAL LYSIS ON SINGLE DAY 1,033.30
62270
SPINAL FLUID TAP, DIAGNOSTIC
391.43
62273
INJECT EPIDURAL PATCH
414.98
62280
TREAT SPINAL CORD LESION
817.78
62281
TREAT SPINAL CORD LESION
650.31
62282
TREAT SPINAL CANAL LESION
743.51
62284
INJECTION FOR MYELOGRAM
544.03
62287
PERCUTANEOUS DISKECTOMY
5,347.03
62290
INJECT FOR SPINE DISK X-RAY
1,256.74
62291
INJECT FOR SPINE DISK X-RAY
1,184.82
62292
INJECTION INTO DISK LESION
1,982.34
62310
INJECT SPINE C/T
1,021.73
62311
INJECT SPINE L/S (CD)
879.37
62318
INJECT SPINE W/CATH, C/T
749.21
62319
INJECT SPINE W/CATH L/S (CD)
475.01
62350
IMPLANT SPINAL CANAL CATH
62355
REMOVE SPINAL CANAL CATHETER
62360
INSERT SPINE INFUSION DEVICE
62362
IMPLANT SPINE INFUSION PUMP
62365
REMOVE SPINE INFUSION DEVICE
62367
ANALYZE SPINE INFUSION PUMP
62368
ANALYZE SPINE INFUSION PUMP
63075
NECK SPINE DISK SURG
10,012.99
63076
NECK SPINE DISK SURG
1,837.46
63650
IMPLANT NEUROELECTRODES
63655
IMPLANT NEUROELECTRODES
63685
INSERT/REDO SPINE N GENERATOR
63688
REVISE/REMOVE NEURORECEIVER
64400
NERVE BLOCK INJ, TRIGEMINAL
64402
NERVE BLOCK INJ, FACIAL
280.41
64405
NERVE BLOCK INJ, OCCIPITAL
278.84
64412
NERVE BLOCK INJ, SPINAL ACCESSORY
64413
NERVE BLOCK INJ, CERV PLEXUS
294.62
64415
NERVE BLOCK INJ, BRACHIAL
PLEXUS
304.42
64416
NERVE BLOCK CONT INFUSE,
B PLEX
191.93
64417
NERVE BLOCK INJ, AXILLARY
320.99
64418
NERVE BLOCK INJ,
SUPRASCAPULAR
344.67
64420
NERVE BLOCK INJ, INTERCOSTAL,
SING
343.60
64421
NERVE BLOCK INJ, INTERCOSTAL,
MULT
493.86
64425
NERVE BLOCK INJ, ILIO-ING/HYPOGI321.93
64430
NERVE BLOCK INJ, PUDENDAL
64435
NERVE BLOCK INJ, PARACERV
352.78
331.01
456.37
666.08
456.89
392.33
788.80
493.07
133.85
131.17
115.58
114.44
143.17
167.01
203.21
224.50
192.36
552.42
199.11
112.00
42.59
69.41
589.83
1,120.28
2,349.30
1,102.21
638.56
371.51
396.26
775.41
618.08
703.87
514.23
5,141.26
1,191.64
1,123.82
1,907.34
967.17
831.58
709.56
451.01
992.58
3,512.94
3,512.94
2,344.41
2,344.41
3,512.94
3,512.94
146.22
148.20
148.20
148.20
168.48
171.99
286.62
218.10
913.62
3,233.49
3,233.49
2,157.93
2,157.93
3,233.49
3,233.49
134.61
136.41
136.41
136.41
155.07
158.31
263.82
200.76
3,079.32
248.01
2,834.37
228.30
58.50
53.85
2,758.50
2,539.05
1,012.32
1,706.88
517.89
1,012.32
1,012.32
1,012.32
1,012.32
931.80
1,571.10
476.70
931.80
931.80
931.80
931.80
4,972.53
4,576.98
X, N1
X, N1
X, N1
X, N1
1,012.32
931.80
1,012.32
931.80
1,012.32
931.80
1,012.32
931.80
1,706.88 1,571.10
5,591.79 5,146.98
1,706.88 1,571.10
5,591.79 5,146.98
22,241.41 18,893.98
4,972.53 4,576.98
76.02
69.99
102.96
94.77
X
X
9,659.93
1,779.74
7,941.86 6,926.39
10,702.41 9,271.65
24,642.86 20,858.66
3,880.14 3,571.47
237.48
218.58
267.23
219.96
202.47
266.46
202.38
186.30
352.14
324.12
281.16
221.13
203.55
290.12
186.58
305.45
51.7.89
1,012.32
517.89
476.70
931.80
476.70
327.13
303.00
278.91
325.60
517.89
476.70
468.06
307.96
1,012.32
221.13
1,012.32
287.79
931.80
203.55
931.80
264.90
335.81
X
X
X
MEDICAL FEE SCHEDULES
64445
64446
64447
64448
64449
64450
64455
64479
64480
64483
64484
64490
64491
64492
64493
64494
64495
64505
64510
64517
64520
64550
64555
64561
64565
64600
64605
64610
64612
64613
64614
64620
64622
64623
64626
64627
64640
64680
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64818
65205
65210
65220
65222
65265
67412
69210
69310
69320
69666
69667
69990
70030
70030
70030
70100
70100
70110
70100
TC
26
TC
26
NERVE BLOCK INJ, SCIATIC, SING
333.50
NERVE BLOCK INJ, SCIATIC, CONT INF
NERVE BLOCK INJ, FEM, SING
295.21
NERVE BLOCK INJ, FEM, CONT INF
NERVE BLOCK INJ, LUMBAR PLEXUS199.08
NERVE BLOCK, OTHER PERIPHERAL 253.98
NERVE BLOCK INJ, PLANTAR DIGIT
INJECT FORAMEN EPIDURAL C/T
670.71
INJECT FORAMEN EPIDURAL, ADDED397.14
INJECT FORAMEN EPIDURAL L/S
611.76
INJECT FORAMEN EPIDURAL, ADDED268.13
INJECT PARAVERT F JNT C/T 1 LEV 494.93
INJECT PARAVERT F JNT C/T 2 LEV 241.80
INJECT PARAVERT F JNT C/T 3 LEV 244.49
INJECT PARAVERT F JNT L/S 1 LEV 442.52
INJECT PARAVERT F JNT L/S 2 LEV 218.85
INJECT PARAVERT F JNT L/S 3 LEV 222.43
NERVE BLOCK SPHENOPALATINE
GANGLIA
241.39
NERVE BLOCK STELLATE GANGLION340.64
NERVE BLOCK INJ, HYPOGAS PLXS 429.82
NERVE BLOCK LUMBAR/THORACIC 486.86
APPLY NEUROSTIMULATOR
25.38
IMPLANT NEUROELECTRODES
IMPLANT NEUROELECTRODES
IMPLANT NEUROELECTRODES
286.59
INJECTION TREAT NERVE
673.41
INJECTION TREAT NERVE
1,063.67
INJECTION TREAT NERVE
1,180.01
DESTROY NERVE, FACE MUSCLE
316.60
DESTROY NERVE, NECK MUSCLE
302.92
DESTROY NERVE, EXTREMITY MUSC324.01
INJECTION TREAT NERVE
385.92
DESTROY PARAVERTEBRAL NERVE
L/S
634.27
DESTROY PARAVERT NERVE, ADDED317.51
DESTROY PARAVERTEBRAL NERVE
C/T
751.82
DESTROY PARAVERT NERVE,
ADDED
436.29
INJECTION TREAT NERVE
404.68
INJECTION TREAT NERVE
594.94
REVISE FINGER/TOE NERVE
REVISE HAND/FOOT NERVE
REVISE ARM/LEG NERVE
REVISE SCIATIC NERVE
REVISE ARM NERVE(S)
REVISE LOW BACK NERVE(S)
REVISE CRANIAL NERVE
REVISE ULNAR NERVE AT ELBOW
REVISE ULNAR NERVE AT WRIST
CARPAL TUNNEL SURG
2,074.12
REMOVE SYMPATHETIC NERVES 1,606.35
REMOVE FOREIGN BODY EYE
132.40
REMOVE FOREIGN BODY EYE
164.76
REMOVE FOREIGN BODY EYE
136.80
REMOVE FOREIGN BODY EYE
181.46
REMOVE FOREIGN BODY EYE
2,640.72
EXPLORE/TREAT EYE SOCKET
2,070.04
REMOVE IMPACTED EAR WAX
80.59
REBUILD OUTER EAR CANAL
1,786.26
REBUILD OUTER EAR CANAL
2,511.83
REPAIR MIDDLE EAR STRUCTURES3,035.82
REPAIR MIDDLE EAR STRUCTURES3,041.01
MICROSURG, ADDED
529.56
X-RAY EYE FOR FOREIGN BODY
48.10
X-RAY EYE FOR FOREIGN BODY
34.87
X-RAY EYE FOR FOREIGN BODY
13.22
X-RAY JAW < 4 VIEWS
55.59
X-RAY JAW < 4 VIEWS
41.28
X-RAY JAW MINIMUM 4 VIEWS
66.14
X-RAY JAW < 4 VIEWS
14.31
317.51
11:3-29.6
267.93
1,012.32
221.13
1,012.32
1,012.32
190.68
71.37
1,012.32
517.89
1,012.32
517.89
1,012.32
355.95
355.95
1,012.32
355.95
355.95
246.60
931.80
203.55
931.80
931.80
175.53
65.70
931.80
476.70
931.80
476.70
931.80
327.66
327.66
931.80
327.66
327.66
166.14
1,012.32
1,012.32
1,012.32
152.91
931.80
931.80
931.80
272.61
638.56
1,007.56
1,125.84
303.63
290.62
310.13
368.07
7,941.86
7,941.86
7,941.86
1,706.88
2,552.34
2,552.34
278.43
260.91
295.98
1,012.32
6,926.39
6,926.39
6,926.39
1,571.10
2,349.30
2,349.30
256.26
240.15
272.43
931.80
601.31
300.33
1,706.88
1,012.32
1,571.10
931.80
713.75
1,012.32
931.80
411.90
386.40
563.72
355.95
393.09
1,012.32
2,552.34
2,552.34
2,552.34
2,552.34
2,552.34
2,552.34
2,552.34
2,552.34
2,552.34
2,552.34
327.66
361.80
931.80
2,349.30
2,349.30
2,349.30
2,349.30
2,349.30
2,349.30
2,349.30
2,349.30
2,349.30
2,349.30
90.09
117.00
129.36
127.50
3,125.70
2,669.28
89.55
5,961.75
5,961.75
5,961.75
5,961.75
82.92
107.70
119.07
117.36
2,877.06
2,456.94
82.44
5,487.51
5,487.51
5,487.51
5,487.51
69.03
63.54
81.87
75.36
281.61
193.27
242.28
635.70
377.32
578.07
254.31
469.59
230.50
233.01
419.26
208.33
211.68
230.83
322.89
410.19
459.82
24.14
1,982.69
1,552.19
126.72
157.50
130.87
173.50
2,533.79
1,979.70
76.92
1,698.11
2,392.78
2,897.99
2,902.91
513.23
45.35
32.57
12.79
52.37
38.54
62.37
13.83
X
X
X
X
X
X
X
X
X, N1
11:3-29.6
70110
70110
70120
70120
70120
70130
70130
70130
70140
70140
70140
70150
70150
70150
70160
70160
70160
70190
70190
70190
70200
70200
70200
70210
70210
70210
70220
70220
70220
70250
70250
70250
70260
70260
70260
70300
70300
70300
70310
70310
70310
70320
70320
70320
70328
70328
70328
70330
70330
70330
70332
70332
70332
70336
70336
70336
70350
70350
70350
70355
70355
APPENDIX B - REGULATIONS
TC X-RAY JAW MINIMUM 4 VIEWS
26 X-RAY JAW MINIMUM 4 VIEWS
X-RAY MASTOIDS < 3 VIEWS/SIDE
TC X-RAY MASTOIDS < 3 VIEWS/SIDE
26 X-RAY MASTOIDS < 3 VIEWS/SIDE
X-RAY MASTOIDS MINIMUM
3 VIEWS/SIDE
TC X-RAY MASTOIDS MINIMUM
3 VIEWS/SIDE
26 X-RAY MASTOIDS MINIMUM
3 VIEWS/SIDE
X-RAY FACIAL BONES < 3 VIEWS
TC X-RAY FACIAL BONES < 3 VIEWS
26 X-RAY FACIAL BONES < 3 VIEWS
X-RAY FACIAL BONES MINIMUM
3 VIEWS
TC X-RAY FACIAL BONES MINIMUM
3 VIEWS
26 X-RAY FACIAL BONES MINIMUM
3 VIEWS
X-RAY NASAL BONES MINIMUM
3 VIEWS
TC X-RAY NASAL BONES M 3 VIEWS
26 X-RAY NASAL BONES MINIMUM
3 VIEWS
X-RAY OPTIC FORAMINA
TC X-RAY OPTIC FORAMINA
26 X-RAY OPTIC FORAMINA
X-RAY ORBITS, MINIMUM 4 VIEWS
TC X-RAY ORBITS, MINIMUM 4 VIEWS
26 X-RAY ORBITS, MINIMUM 4 VIEWS
X-RAY SINUSES < 3 VIEWS
TC X-RAY SINUSES < 3 VIEWS
26 X-RAY SINUSES < 3 VIEWS
X-RAY SINUSES MINIMUM 3 VIEWS
TC X-RAY SINUSES MINIMUM 3 VIEWS
26 X-RAY SINUSES MINIMUM 3 VIEWS
X-RAY SKULL < 4 VIEWS
TC X-RAY SKULL < 4 VIEWS
26 X-RAY SKULL < 4 VIEWS
X-RAY SKULL MINIMUM 4 VIEWS
TC X-RAY SKULL MIN 4 VIEWS
26 X-RAY SKULL MINIMUM 4 VIEWS
X-RAY TEETH SINGLE VIEW
TC X-RAY TEETH SINGLE VIEW
26 X-RAY TEETH SINGLE VIEW
X-RAY TEETH < FULL MOUTH
TC X-RAY TEETH < FULL MOUTH
26 X-RAY TEETH < FULL MOUTH
X-RAY TEETH FULL MOUTH
TC X-RAY TEETH FULL MOUTH
26 X-RAY TEETH FULL MOUTH
X-RAY TMJ UNILATERAL
TC X-RAY TMJ UNILATERAL
26 X-RAY TMJ UNILATERAL
X-RAY TMJ BILATERAL
TC X-RAY TMJ BILATERAL
26 X-RAY TMJ BILATERAL
TMJ ARTHOGRAPHY; RAD SUPER &
INTERP
TC TMJ ARTHOGRAPHY; RAD SUPER &
INTERP
26 TMJ ARTHOGRAPHY; RAD SUPER &
INTERP
MRI TMJ
TC MRI TMJ
26 MRI TMJ
CEPHALOORAM, ORTHODONTIC
TC CEPHALOGRAM, ORTHODONTIC
26 CEPHALOGRAM, ORTHODONTIC
ORTHOPANTOGRAM
TC ORTHOPANTOGRAM
47.11
19.03
59.09
44.78
14.31
43.97
18.40
55.62
41.81
13.83
87.24
80.31
87.24
80.31
93.99
88.58
68.07
63.54
87.24
80.31
25.92
50.86
35.46
15.40
25.05
47.98
33.11
14.86
70.20
64.62
71.88
67.76
51.76
48.32
87.24
80.31
20.12
19.44
55.66
42.45
52.41
39.63
84.21
77.52
13.22
60.03
43.61
16.41
74.07
52.34
21.71
52.17
38.37
13.80
64.97
45.94
19.03
62.13
43.03
19.10
78.86
52.92
25.92
24.17
15.08
9.09
63.31
49.44
13.88
83.72
66.90
18.09
52.10
37.79
14.31
81.34
62.24
19.10
12.79
56.57
40.71
15.86
69.85
48.86
20.98
49.16
35.83
13.33
61.29
42.89
18.40
58.62
40.17
18.45
74.45
49.41
25.05
22.85
14.10
8.75
59.51
46.14
13.37
79.89
62.44
17.45
49.11
35.29
13.83
76.54
58.09
18.45
86.55
79.68
87.24
80.31
76.02
69.99
87.24
80.31
85.38
78.60
105.30
96.93
29.22
26.91
59.04
54.36
59.04
54.36
74.85
68.91
87.24
80.31
143.03
134.89
N1
98.34
91.77
N1
44.68
763.99
649.78
114.20
35.29
20.32
14.96
35.64
19.16
43.10
716.59
606.18
110.43
33.41
18.99
14.41
33.81
17.91
N1
664.20
611.37
39.78
36.60
37.44
34.44
MEDICAL FEE SCHEDULES
70355
70360
70360
70360
70450
70450
70450
70460
70460
70460
70470
70470
70470
70480
70480
70480
70481
70481
70481
70482
70482
70482
70486
70486
70486
70487
70487
70487
70488
70488
70488
70490
70490
70490
70491
70491
70491
70492
70492
70492
70496
70496
70496
70498
70498
70498
70540
70540
70540
70542
70542
70542
70543
70543
70543
70544
70544
70544
70545
70545
70545
70546
70546
70546
70547
70547
26 ORTHOPANTOGRAM
16.50
X-RAY NECK SOFT TISSUE
46.36
TC X-RAY NECK SOFT TISSUE
33.13
26 X-RAY NECK SOFT TISSUE
13.22
CT HEAD/BRAIN W/O DYE
426.03
TC CT HEAD/BRAIN W/O DYE
341.76
26 CT HEAD/BRAIN W/O DYE
84.27
CT HEAD/BRAIN W/DYE
431.97
TC CT HEAD/BRAIN W/DYE
344.66
26 CT HEAD/BRAIN W/DYE
87.31
CT HEAD/BRAIN W/O & W/DYE
523.38
TC CT HEAD/BRAIN W/O & W/DYE
424.43
26 CT HEAD/BRAIN W/O & W/DYE
98.95
CT ORBIT/EAR/FOSSA W/O DYE
531.46
TC CT ORBIT/EAR/FOSSA W/O DYE
431.99
26 CT ORBITBAR/FOSSA W/O DYE
99.46
CT ORBIT/EAR/FOSSA W/DYE
617.99
TC CT ORBIT/EAR/FOSSA W/DYE
510.61
26 CT ORBITBAR/FOSSA W/DYE
107.38
CT ORBIT/EAR/FOSSA W/O & W/DYE 698.40
TC CT ORBIT/EAR/FOSSA W/O & W/DYE 586.31
26 CT ORBIT/EAR/FOSSA W/O & W/DYE 112.09
CT MAXILLOFACIAL W/O DYE
442.37
TC CT MAXILLOFACIAL W/O DYE
353.98
26 CT MAXILLOFACIAL W/O DYE
88.41
CT MAXILLOFACIAL W/DYE
533.63
TC CT MAXILLOFACIAL W/DYE
432.58
26 CT MAXILLOFACIAL W/DYE
101.05
CT MAXILLOFACIAL W/O & W/DYE 649.72
TC CT MAXILLOFACIAL W/O & W/DYE 539.73
26 CT MAXILLOFACIAL W/O &W/DYE 109.99
CT SOFT TISSUE NECK W/O DYE
432.46
TC CT SOFT TISSUE NECK W/O DYE
333.02
26 CT SOFT TISSUE NECK W/O DYE
99.46
CT SOFT TISSUE NECK W/DYE
521.98
TC CT SOFT TISSUE NECK W/DYE
415.11
26 CT SOFT TISSUE NECK W/DYE
106.87
CT SOFT TISSUE NECK W/O & W/DYE632.03
TC CT SOFT TISSUE NECK W/O & W/DYE519.93
26 CT SOFT TISSUE NECK W/O & W/DYE112.09
CT ANGIOGRAPHY, HEAD
1,008.14
TC CT ANGIOGRAPHY, HEAD
871.63
26 CT ANGIOGRAPHY, HEAD
136.51
CT ANGIOGRAPHY, NECK
1,025.62
TC CT ANGIOGRAPHY, NECK
889.10
26 CT ANGIOGRAPHY, NECK
136.51
MRI ORBIT/FACE/NECK W/O DYE
849.38
TC MRI ORBIT/FACE/NECK W/O DYE
744.69
26 MRI ORBIT/FACE/NECK W/O DYE
104.69
MRI ORBIT/FACE/NECK W/DYE
948.56
TC MRI ORBIT/FACE/NECK W/DYE
822.72
26 MRI ORBIT/FACE/NECK W/DYE
125.84
MRI ORBIT/FACE/NECK W/O &
W/DYE
1,239.11
TC MRI ORBIT/FACE/NECK W/O &
W/DYE
1,073.12
26 MRI ORBIT/FACE/NECK W/O &
W/DYE
166.00
MR ANGIOGRAPHY HEAD W/O DYE 930.92
TC MR ANGIOGRAPHY HEAD W/O DYE 837.86
26 MR ANGIOGRAPHY HEAD W/O DYE 93.07
MR ANGIOGRAPHY HEAD W/DYE
925.11
TC MR ANGIOGRAPHY HEAD W/DYE
832.04
26 MR ANGIOGRAPHY HEAD W/DYE
93.07
MR ANGIOGRAPH HEAD W/O &
W/DYE
1,457.83
TC MR ANGIOGRAPH HEAD W/O &
W/DYE
1,317.67
26 MR ANGIOGRAPH HEAD W/O &
W/DYE
140.15
MR ANGIOGRAPHY NECK W/O DYE 929.19
TC MR ANGIOGRAPHY NECK W/O DYE 836.11
15.90
43.73
30.94
12.79
400.31
318.85
81.46
405.92
321.55
84.38
491.61
395.96
95.65
499.17
403.02
96.15
580.17
476.35
103.82
655.36
546.96
108.39
415.65
330.23
85.42
501.24
403.56
97.69
609.86
503.52
106.35
406.83
310.68
96.15
490.57
387.27
103.30
593.43
485.04
108.39
945.09
813.13
131.96
961.39
829.43
131.96
795.95
694.71
101.24
889.20
767.50
121.69
11:3-29.6
65.52
60.30
375.45
345.60
580.71
534.51
647.37
595.86
375.45
345.60
580.71
534.51
647.37
595.86
375.45
345.60
580.71
534.51
647.37
595.86
375.45
345.60
580.71
534.51
647.37
595.86
655.71
603.54
655.71
603.54
664.20
611.37
846.36
779.04
1,033.50
951.27
664.20
611.37
846.36
779.04
1,229.21
1,033.50
951.27
135.51
869.99
779.99
664.20
611.37
1,161.59
1,001.07
160.53
871.62
781.62
90.00
866.18
776.19
90.00
1,364.72
11:3-29.6
APPENDIX B - REGULATIONS
70547 26 MR ANGIOGRAPHY NECK W/O DYE 93.07
90.00
70548
MR ANGIOGRAPHY NECK W/DYE
975.77
913.44
70548 TC MR ANGIOGRAPHY NECK W/DYE
882.71
823.45
70548 26 MR ANGIOGRAPHY NECK W/DYE
93.07
90.00
70549
MR ANGIOGRAPH NECK W/O &
W/DYE
1,458.47 1,365.29
70549
TC MR ANGIOGRAPH NECK W/O &
W/DYE
1,318.84 1,230.29
70549 26 MR ANGIOGRAPH NECK W/O &
W/DYE
139.64
135.00
70551
MRI BRAIN W/O DYE
878.11
823.06
70551 TC MRI BRAIN W/O DYE
763.33
712.09
70551 26 MRI BRAIN W/0 DYE
114.78
110.97
70552
MRI BRAIN W/DYE
978.74
917.78
70552 TC MRI BRAIN W/DYE
839.60
783.26
70552 26 MRI BRAIN W/DYE
139.14
134.52
70553
MRI BRAIN W/O & W/DYE
1,228.68 1,152.44
70553 TC MRI BRAIN W/O & W/DYE
1,045.16
974.99
70553 26 MRI BRAIN W/O & W/DYE
183.52
177.45
70554
FMRI BRAIN BY TECH
964.57
905.39
70554 TC FMRI BRAIN BY TECH
799.43
745.77
70554 26 FMRI BRAIN BY TECH
165.14
159.62
70555 26 FMRI BRAIN BY PHYS/PSYCH
203.10
196.49
71010
CHEST X-RAY SINGLE VIEW FRONTAL46.85
44.31
71010 TC CHEST X-RAY SINGLE VIEW FRONTAL30.48
28.47
71010 26 CHEST X-RAY SINGLE VIEW FRONTAL16.37
15.84
71020
CHEST X-RAY 2 VIEWS FRONTAL &
LATERAL
55.78
52.69
71020 TC CHEST X-RAY 2 VIEWS FRONTAL &
LATERAL
37.56
35.08
71020 26 CHEST X-RAY 2 VIEWS FRONTAL &
LATERAL
18.23
17.61
71021
CHEST X-RAY 2 VIEWS W/APICAL
LORD PROC
63.65
60.11
71021 TC CHEST X-RAY 2 VIEWS W/APICAL
LORD PROC
43.03
40.17
71021 26 CHEST X-RAY 2 VIEWS W/APICAL
LORD PROC
20.62
19.94
71022
CHEST X-RAY 2 VIEWS W/OBLIQUE
PROJ
77.92
73.51
71022 TC CHEST X-RAY 2 VIEWS W/OBLIQUE
PROJ
54.09
50.49
71022 26 CHEST X-RAY 2 VIEWS W/OBLIQUE
PROJ
23.82
23.01
71030
CHEST X-RAY MINIMUM 4 VIEWS
77.34
72.96
71030 TC CHEST X-RAY MINIMUM 4 VIEWS
53.50
49.95
'71030 26 CHEST X-RAY MINIMUM 4 VIEWS
23.82
23.01
71035
CHEST X-RAY SPECIAL VIEWS
59.67
56.18
71035 TC CHEST X-RAY SPECIAL VIEWS
45.36
42.35
71035 26 CHEST X-RAY SPECIAL VIEWS
14.31
13.83
71040
CONTRAST X-RAY BRONCHI
UNILATERAL
162.07
152.67
71040 TC CONTRAST X-RAY BRONCHI
UNILATERAL
118.73
110.79
71040 26 CONTRAST X-RAY BRONCHI
UNILATERAL
43.34
41.88
71090
X-RAY & PACEMAKER INSERT
169.62
163.54
71090 TC X-RAY & PACEMAKER INSERT
123.65
119.31
71090 26 X-RAY & PACEMAKER INSERT
44.62
43.09
71100
X-RAY RIBS 2 VIEWS
54.13
51.10
71100 TC X-RAY RIBS 2 VIEWS
37.20
34.75
71100 26 X-RAY RIBS 2 VIEWS
16.93
16.36
71101
X-RAY RIBS/CHEST MINIMUM 3
VIEWS
82.73
78.10
71101 TC X-RAY RIBS/CHEST MINIMUM 3
VIEWS
56.88
53.10
71101 26 X-RAY RIBS/CHEST MINIMUM 3
VIEWS
25.85
25.00
71110
X-RAY RIBS BILATERAL 3 VIEWS
68.31
64.46
71110 TC X-RAY RIBS BILATERAL 3 VIEWS
47.69
44.52
71110 26 X-RAY RIBS BILATERAL 3 VIEWS
20.62
19.94
71111
X-RAY RIBS/CHEST MINIMUM 4 VIEWS88.32
83.23
846.36
779.04
1,033.50
951.27
664.20
611.37
846.36
779.04
1,033.50
951.27
664.20
611.37
50.31
46.29
69.03
63.54
85.38
78.60
87.24
80.31
87.24
80.31
87.24
80.31
N1
N1
N1
N1
N1
N1
73.71
67.86
87.24
80.31
87.24
80.31
MEDICAL FEE SCHEDULES
71111
71111
71120
71120
71120
71130
71130
71130
71250
71250
71250
71260
71260
71260
71270
71270
71270
71275
71275
71275
71550
71550
71550
71552
71552
71552
71555
71555
71555
72010
72010
72010
72020
72020
72020
72040
72040
72040
72050
72050
72050
72052
72052
72052
72069
72069
72069
72070
72070
72070
72072
72072
72072
72074
72074
72074
72080
TC X-RAY RIBS/CHEST MINIMUM 4 VIEWS63.99
59.73
26 X-RAY RIBS/CHEST 4 VIEWS
24.33
23.50
X-RAY STE MINIMUM 2 VIEWS
53.70
50.65
TC X-RAY STERNUM MINIMUM 2 VIEWS 38.37
35.83
26 X-RAY STERNUM MINIMUM 2 VIEWS 15.33
14.82
X-RAY STERNOCLAV JOINT MINIMUM62.87
59.24
3 VIEWS
TC X-RAY STERNOCLAV JOINT MINIMUM45.94
42.89
3 VIEWS
26 X-RAY STERNOCLAV JOINT MINIMUM16.93
16.36
3 VIEWS
CT THORAX W/O DYE
423.62
397.82
TC CT THORAX W/O DYE
344.07
320.99
26 CT THORAX W/O DYE
79.55
76.82
CT THORAX W/DYE
525.35
493.37
TC CT THORAX W/DYE
428.51
399.76
26 CT THORAX W/DYE
96.85
93.61
CT THORAX W/O &W/DYE
646.01
606.26
TC CT THORAX W/O & W/DYE
539.14
502.96
26 CT THORAX W/O & W/DYE
106.87
103.30
CT ANGIOGRAPHY, CHEST
802.43
753.64
TC CT ANGIOGRAPHY, CHEST
652.69
608.89
26 CT ANGIOGRAPHY, CHEST
149.74
144.75
MRI CHEST W/O DYE
960.37
899.74
TC MRI CHEST W/O DYE
847.76
790.86
26 MRI CHEST W/O DYE
112.61
108.88
MRI CHEST W/O & W/DYE
1,425.20 1,335.46
TC MRI CHEST W/O & W/DYE
1,249.54 1,165.66
26 MRI CHEST W/O & W/DYE
175.66
169.81
MRI ANGIO CHEST W OR W/O DYE 940.15
881.81
TC MRI ANGIO CHEST W OR W/O DYE 798.85
745.23
26 MRI ANGIO CHEST W OR W/O DYE 141.30
136.58
X-RAY SPINE ANTEROPOST &
LATERAL
124.49
117.37
TC X-RAY SPINE ANTEROPOST &
LATERAL
89.03
83.09
26 X-RAY SPINE ANTEROPOST &
LATERAL
35.46
34.28
X-RAY SPINE SINGLE VIEW SPECIFY
LEVEL
40.10
37.84
TC X-RAY SPINE SINGLE VIEW SPECIFY
LEVEL
27.88
26.05
26 X-RAY SPINE SINGLE VIEW SPECIFY
LEVEL
12.21
11.79
X-RAY NECK SPINE CERV 2/3 VIEWS 102.52
96.69
TC X-RAY NECK SPINE CERV 2/3 VIEWS 73.56
68.66
26 X-RAY NECK SPINE CERV 2/3 VIEWS 28.96
28.03
X-RAY NECK SPINE CERV MINIMUM 4
VIEWS
119.60
112.79
TC X-RAY NECK SPINE CERV MINIMUM
4 VIEWS
86.14
80.40
26 X-RAY NECK SPINE CERV MINIMUM 4
VIEWS
33.46
32.39
X-RAY NECK SPINE COMPLETE
147.68
139.10
TC X-RAY NECK SPINE COMPLETE
110.33
102.97
26 X-RAY NECK SPINE COMPLETE
37.35
36.13
X-RAY TRUNK SPINE STANDING
62.74
59.20
TC X-RAY TRUNK SPINE STANDING
44.20
41.25
26 X-RAY TRUNK SPINE STANDING
18.55
17.95
X-RAY THORACIC SPINE 2 VIEWS
80.74
76.17
TC X-RAY THORACIC SPINE 2 VIEWS
55.96
52.26
26 X-RAY THORACIC SPINE 2 VIEWS
24.78
23.92
X-RAY THORACIC SPINE 3 VIEWS
63.45
59.80
TC X-RAY THORACIC SPINE 3 VIEWS
46.53
43.43
26 X-RAY THORACIC SPINE 3 VIEWS
16.93
16.36
X-RAY THORACIC SPINE MINIMUM 4
VIEWS
75.09
70.66
TC X-RAY THORACIC SPINE MINIMUM 4
VIEWS
58.16
54.30
26 X-RAY THORACIC SPINE MINIMUM 4
VIEWS
16.93
16.36
X-RAY TRUNK SPINE 2 VIEWS
61.58
58.12
11:3-29.6
127.50
117.36
76.02
69.99
87.24
80.31
375.45
345.60
580.71
534.51
647.37
595.86
655.71
603.54
664.20
611.37
1,033.50
951.27
146.91
135.24
54.99
50.61
87.24
80.31
127.50
117.36
146.91
135.24
87.24
80.31
78.36
72.12
87.24
80.31
87.24
80.31
11:3-29.6
APPENDIX B - REGULATIONS
72080 TC X-RAY TRUNK SPINE 2 VIEWS
43.03
40.17
72080 26 X-RAY TRUNK SPINE 2 VIEWS
18.55
17.95
72090
X-RAY TRUNK SPINE SCOLIOSIS
STUDY
83.19
78.46
72090 TC X-RAY TRUNK SPINE SCOLIOSIS
STUDY
59.33
55.38
72090 26 X-RAY TRUNK SPINE SCOLIOSIS
STUDY
23.86
23.08
72100
X-RAY LOWER SPINE 2/3 VIEWS
68.57
64.63
72100 TC X-RAY LOWER SPINE 2/3 VIEWS
50.02
46.70
72100 26 X-RAY LOWER SPINE 2/3 VIEWS
18.55
17.95
72110
X-RAY LOWER SPINE MINIMUM 4
VIEWS
129.47
122.01
72110 TC X-RAY LOWER SPINE MINIMUM 4
VIEWS
95.06
88.72
72110 26 X-RAY LOWER SPINE MINIMUM 4
VIEWS
34.41
33.31
72114
X-RAY LOWER SPINE COMPLETE
125.68
118.29
72114 TC X-RAY LOWER SPINE COMPLETE
96.02
89.60
72114 26 X-RAY LOWER SPINE COMPLETE
29.67
28.69
72120
X-RAY LOWER SPINE BENDING
MINIMUM 4 VIEWS
87.20
82.01
72120 TC X-RAY LOWER SPINE BENDING
MINIMUM 4 VIEWS
68.65
64.08
72120 26 X-RAY LOWER SPINE BENDING
MINIMUM 4 VIEWS
18.55
17.95
72125
CT NECK SPINE W/O DYE
425.96
399.99
72125 TC CT NECK SPINE W/O DYE
346.40
323.17
72125 26 CT NECK SPINE W/O DYE
79.55
76.82
72126
CT NECK SPINE W/DYE
524.34
492.38
72126 TC CT NECK SPINE W/DYE
429.68
400.84
72126 26 CT NECK SPINE W/DYE
94.66
91.53
72127
CT NECK SPINE W/O & W/DYE
636.93
597.54
72127 TC CT NECK SPINE W/O & W/DYE
538.56
502.42
72127 26 CT NECK SPINE W/O &W/DYE
98.37
95.11
72128
CT CHEST SPINE W/O DYE
425.37
399.45
72128 TC CT CHEST SPINE W/O DYE
345.82
322.63
72128 26 CT CHEST SPINE W/O DYE
79.55
76.82
72129
CT CHEST SPINE W/DYE
525.50
493.47
72129 TC CT CHEST SPINE W/DYE
430.26
401.38
72129 26 CT CHEST SPINE W/DYE
95.24
92.07
72130
CT CHEST SPINE W/O & W/DYE
637.51
598.08
72130 TC CT CHEST SPINE W/O & W/DYE
539.14
502.96
72130 26 CT CHEST SPINE W/O & W/DYE
98.37
95.11
72131
CT LUMBAR SPINE W/O DYE
424.21
398.37
72131 TC CT LUMBAR SPINE W/O DYE
344.66
321.55
72131 26 CT LUMBAR SPINE W/O DYE
79.55
76.82
72132
CT LUMBAR SPINE W/DYE
524.34
492.38
72132 TC CT LUMBAR SPINE W/DYE
429.10
400.30
72132 26 CT LUMBAR SPINE W/DYE
95.24
92.07
72133
CT LUMBAR SPINE W/O & W/DYE
636.93
597.54
72133 TC CT LUMBAR SPINE W/O & W/DYE
538.56
502.42
72133 26 CT LUMBAR SPINE W/O & W/DYE
98.37
95.11
72141
MRI NECK SPINE W/O DYE
936.23
878.43
72141 TC MRI NECK SPINE W/O DYE
788.37
735.46
72141 26 MRI NECK SPINE W/O DYE
147.87
142.97
72142
MRI NECK SPINE W/DYE
989.34
928.01
72142 TC MRI NECK SPINE W/DYE
840.19
783.80
72142 26 MRI NECK SPINE W/DYE
149.16
144.21
72146
MRI CHEST SPINE W/O DYE
801.97
752.41
72146 TC MRI CHEST SPINE W/O DYE
677.15
631.70
72146 26 MRI CHEST SPINE W/O DYE
124.83
120.69
72147
MRI CHEST SPINE W/DYE
890.93
836.21
72147 TC MRI CHEST SPINE W/DYE
741.19
691.46
72147 26 MRI CHEST SPINE W/DYE
149.74
144.75
72148
MRI LUMBAR SPINE W/O DYE
901.45
845.45
72148 TC MRI LUMBAR SPINE W/O DYE
769.58
717.94
72148 26 MRI LUMBAR SPINE W/O DYE
131.85
127.52
72149
MRI LUMBAR SPINE W/DYE
887.91
833.04
72149 TC MRI LUMBAR SPINE W/DYE
748.77
698.52
72149 26 MRI LUMBAR SPINE W/DYE
139.14
134.52
72156
MRI NECK SPINE W/O & W/DYE
1,227.571,151,99
85.38
78.60
118.17
108.78
87.24
80.31
136.86
125.97
146.91
135.24
87.24
80.31
375.45
345.60
580.71
534.51
647.37
595.86
375.45
345.60
580.71
534.51
647.37
595.86
375.45
345.60
580.71
534.51
647.37
595.86
664.20
611.37
846.36
779.04
664.20 611,37
846.36
779.04
664.20
611.37
846.36
779.04
MEDICAL FEE SCHEDULES
72156
72156
72157
72157
72157
72158
72158
72158
72170
72170
72170
72190
72190
72190
72191
72191
72191
72192
72192
72192
72193
72193
72193
72194
72194
72194
72195
72195
72195
72196
72196
72196
72197
72197
72197
72198
72198
72198
72200
72200
72200
72202
72202
72202
72220
72220
72220
72240
72240
72240
72255
72255
72255
72265
72265
72265
72270
72270
72270
72275
72275
72275
72285
72285
72285
72291
72291
TC MRI NECK SPINE W/O &W/DYE
26 MRI NECK SPINE W/O & W/DYE
MRI CHEST SPINE W/O & W/DYE
TC MRI CHEST SPINE W/O & W/DYE
26 MRI CHEST SPINE W/O & W/DYE
MRI LUMBAR SPINE W/O & W/DYE
TC MRI LUMBAR SPINE W/O & W/DYE
26 MRI LUMBAR SPINE W/O & W/DYE
X-RAY PELVIS 1/2 VIEWS
TC X-RAY PELVIS 1/2 VIEWS
26 X-RAY PELVIS 1/2 VIEWS
X-RAY PELVIS MINIMUM 3 VIEWS
TC X-RAY PELVIS MINIMUM 3 VIEWS
26 X-RAY PELVIS MINIMUM 3 VIEWS
CT ANGIOGRAPH PELVIS W/O &
W/DYE
TC CT ANGIOGRAPH PELVIS W/O &
W/DYE
26 CT ANGIOGRAPH PELVIS W/O &
W/DYE
CT PELVIS W/O DYE
TC CT PELVIS W/O DYE
26 CT PELVIS W/O DYE
CT PELVIS W/DYE
TC CT PELVIS W/DYE
26 CT PELVIS W/DYE
CT PELVIS W/O & W/DYE
TC CT PELVIS W/O & W/DYE
26 CT PELVIS W/O & W/DYE
MRI PELVIS W/O DYE
TC MRI PELVIS W/O DYE
26 MRI PELVIS W/0 DYE
MRI PELVIS W/DYE
TC MRI PELVIS W/DYE
26 MRI PELVIS W/DYE
MRI PELVIS W/O & W/DYE
TC MRI PELVIS W/O & W/DYE
26 MRI PELVIS W/O & W/DYE
MR ANGIO PELVIS W/O & W/DYE
TC MR ANGIO PELVIS W/O & W/DYE
26 MR ANGIO PELVIS W/O & W/DYE
X-RAY EXAM SACROILIAC JOINTS
TC X-RAY EXAM SACROILIAC JOINTS
26 X-RAY EXAM SACROILIAC JOINTS
X-RAY EXAM SACROILIAC JOINTS
TC X-RAY EXAM SACROILIAC JOINTS
26 X-RAY EXAM SACROILIAC JOINTS
X-RAY TAILBONE
TC X-RAY TAILBONE
26 X-RAY TAILBONE
CONTRAST X-RAY NECK SPINE
TC CONTRAST X-RAY NECK SPINE
26 CONTRAST X-RAY NECK SPINE
CONTRAST X-RAY THORAX SPINE
TC CONTRAST X-RAY THORAX SPINE
26 CONTRAST X-RAY THORAX SPINE
CONTRAST X-RAY LOWER SPINE
TC CONTRAST X-RAY LOWER SPINE
26 CONTRAST X-RAY LOWER SPINE
CONTRAST X-RAY SPINE
TC CONTRAST X-RAY SPINE
26 CONTRAST X-RAY SPINE
EPIDUROGRAPHY
TC EPIDUROGRAPHY
26 EPIDUROGRAPHY
X-RAY C/T SPINE DISK
TC X-RAY C/T SPINE DISK
26 X-RAY C/T SPINE DISK
PERCUT VERT/SACROPLASTY,
FLUOR
TC PERCUT VERT/SACROPLASTY,
FLUOR
11:3-29.6
1,027.10
200.46
1,153.62
953.16
200.46
1,209.34
1,024.78
184.56
68.47
46.19
22.28
70.97
52.92
18.03
958.16
193.84
1,083.01
889.17
193.84
1,134.48
955.99
178.49
64.69
43.14
21.55
66.85
49.41
17.45
1,033.50
951.27
1,033.50
951.27
1,033.50
951.27
60.84
56.01
87.24
80.31
769.42
722.61
627.65
585.53
655.71
603.54
141.77
409.56
325.44
84.11
497.42
406.97
90.45
639.05
544.39
94.66
873.48
759.26
114.23
966.38
831.46
134.92
1,259.25
1,084.17
175.08
936.15
796.52
139.64
49.85
36.62
13.22
58.43
43.61
14.82
49.27
36.04
13.22
372.37
263.27
109.10
349.17
241.78
107.39
355.47
256.12
99.34
552.78
394.08
158.70
572.81
390.38
182.38
376.65
236.40
140.25
137.08
384.93
303.61
81.30
467.12
379.67
87.45
599.38
507.85
91.53
818.76
708.30
110.47
906.08
775.64
130.43
1,180.65
1,011.38
169.27
878.06
743.06
135.00
46.98
34.19
12.79
55.04
40.71
14.32
46.44
33.65
12.79
351.09
245.65
105.44
329.41
225.60
103.80
334.98
238.96
96.02
521.08
367.67
153.41
540.58
364.28
176.30
356.04
220.57
135.46
375.45
345.60
580.71
534.51
647.37
595.86
664.20
611.37
846.36
779.04
1,033.50
951.27
72.54
66.78
86.55
79.68
71.37
65.70
267.82
258.54
N1
161.82
156.18
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
11:3-29.6
APPENDIX B - REGULATIONS
72291 26 PERCUT VERT/SACROPLASTY,
FLUOR
113.43
72295
X-RAY LOWER SPINE DISK
217.08
72295 TC X-RAY LOWER SPINE DISK
151.33
72295 26 X-RAY LOWER SPINE DISK
65.74
73000
X-RAY COLLAR BONE
48.17
73000 TC X-RAY COLLAR BONE
35.46
73000 26 X-RAY COLLAR BONE
12.72
73010
X-RAY SHOULDER BLADE
51.47
73010 TC X-RAY SHOULDER BLADE
36.62
73010 26 X-RAY SHOULDER BLADE
14.85
73020
X-RAY SHOULDER 1 VIEW
39.52
73020 TC X-RAY SHOULDER 1 VIEW
27.88
73020 26 X-RAY SHOULDER 1 VIEW
11.62
73030
X-RAY SHOULDER MINIMUM 2 VIEWS74.36
73030 TC X-RAY SHOULDER MINIMUM 2 VIEWS51.56
73030 26 X-RAY SHOULDER MINIMUM 2 VIEWS22.79
73040
CONTRAST X-RAY SHOULDER
181.40
73040 TC CONTRAST X-RAY SHOULDER
138.53
73040 26 CONTRAST X-RAY SHOULDER
42.87
73060
X-RAY HUMERUS MINIMUM 2 VIEWS 49.27
73060 TC X-RAY HUMERUS MINIMUM 2 VIEWS 35.46
73060 26 X-RAY HUMERUS MINIMUM 2 VIEWS 13.80
73070
X-RAY ELBOW 2 VIEWS
47.66
73070 TC X-RAY ELBOW 2 VIEWS
35.46
73070 26 X-RAY ELBOW 2 VIEWS
12.21
73080
X-RAY ELBOW MINIMUM 3 VIEWS
57.41
73080 TC X-RAY ELBOW MINIMUM 3 VIEWS
44.20
73080 26 X-RAY ELBOW MINIMUM 3 VIEWS
13.22
73090
X-RAY FOREARM
47.01
73090 TC X-RAY FOREARM
34.29
73090 26 X-RAY FOREARM
12.72
73092
X-RAY ARM, INFANT
51.67
73092 TC X-RAY ARM, INFANT
38.95
73050
X-RAY SHOULDERS
64.63
73050 TC X-RAY SHOULDERS
47.11
73050 26 X-RAY SHOULDERS
17.54
73092 26 X-RAY ARM, INFANT
12.72
73100
X-RAY WRIST 2 VIEWS
52.13
73100 TC X-RAY WRIST 2 VIEWS
37.79
73100 26 X-RAY WRIST 2 VIEWS
14.34
73110
X-RAY WRIST MIN 3 VIEWS
70.95
73110 TC X-RAY WRIST M 3 VIEWS
55.03
73110 26 X-RAY WRIST MINIMUM 3 VIEWS
15.92
73115
CONTRAST X-RAY WRIST
183.73
73115 TC CONTRAST X-RAY WRIST
139.69
73115 26 CONTRAST X-RAY WRIST
44.04
73120
X-RAY HAND 2 VIEWS
46.43
73120 TC X-RAY HAND 2 VIEWS
33.71
73120 26 X-RAY HAND 2 VIEWS
12.72
73130
X-RAY HAND MINIMUM 3 VIEWS
62.21
73130 TC X-RAY HAND MINIMUM 3 VIEWS
46.96
73130 26 X-RAY HAND MINIMUM 3 VIEWS
15.25
73140
X-RAY FINGER(S) M 2 VIEWS
53.05
73140 TC X-RAY FINGER(S) MINIMUM 2 VIEWS 42.45
73140 26 X-RAY FINGER(S) MINIMUM 2 VIEWS 10.62
73200
CT UPPER EXTREMITY W/O DYE
414.19
73200 TC CT UPPER EXTREMITY W/O DYE
334.76
73200 26 CT UPPER EXTREMITY W/O DYE
79.42
73201
CT UPPER EXTREMITY W/DYE
506.15
73201 TC CT UPPER EXTREMITY W/DYE
415.69
73201 26 CT UPPER EXTREMITY W/DYE
90.45
73202
CT UPPER EXTREMITY W/O & W/DYE649.53
73202 TC CT UPPER EXTREMITY W/O & W/DYE554.86
73202 26 CT UPPER EXTREMITY W/O & W/DYE 94.66
73206
CT ANGIO UPR EXTREMITY W/O &
W/DYE
732.98
73206 TC CT ANGIO UPR EXTREMITY W/O &
W/DYE
592.72
73206 26 CT ANGIO UPR EXTREMITY W/O &
W/DYE
140.26
73218
MRI UPPER EXTREMITY W/O DYE
879.74
109.79
204.71
141.20
63.49
45.40
33.11
12.29
48.57
34.19
14.37
37.29
26.05
11.24
70.21
48.15
22.04
170.71
129.26
41.45
46.44
33.11
13.33
44.91
33.11
11.79
54.04
41.25
12.79
44.31
32.03
12.29
48.66
36.37
60.92
43.97
16.95
12.29
49.16
35.29
13.87
66.75
51.37
15.38
172.89
130.34
42.55
43.77
31.48
12.29
58.60
43.85
14.76
49.88
39.63
10.25
389.09
312.31
76.78
475.27
387.81
87.45
609.16
517.63
91.53
N1
N1
N1
N1
70.20
64.62
72.54
66.78
54.99
50.61
71.37
65.70
N1
N1
N1
70.20
64.62
70.20
64.62
87.24
80.31
67.86
62.46
77.19
71.07
87.24
80.31
74.85
68.91
87.24
80.31
N1
N1
N1
66.69
61.38
80.70
74.28
84.21
77.52
375.45
345.60
580.71
534.51
647.37
595.86
655.71
603.54
688.49
552.94
135.54
824.21
MEDICAL FEE SCHEDULES
73218
73218
73219
73219
73219
73220
73220
73220
73221
73221
73221
73222
73222
73222
73223
73223
73223
73225
73225
73225
73500
73500
73500
73510
73510
73510
73520
73520
73520
73525
73525
73525
73530
73530
73530
73540
73540
73540
73542
73542
73542
73550
73550
73550
73560
73560
73560
73562
73562
TC MRI UPPER EXTREMITY W/O DYE
774.97
26 MRI UPPER EXTREMITY W/O DYE
104.76
MRI UPPER EXTREMITY W/DYE
950.89
TC MRI UPPER EXTREMITY W/DYE
824.47
26 MRI UPPER EXTREMITY W/DYE
126.42
MRI UPPER EXTREMITY W/O &
W/DYE
1,255.99
TC MRI UPPER EXTREMITY W/O &
W/DYE
1,088.83
26 MRI UPPER EXTREMITY W/O &
W/DYE
167.16
MRI JOINT UPPER EXTREMITY W/O
DYE
828.31
TC MRI JOINT UPPER EXTREMITY W/O
DYE
721.40
26 MRI JOINT UPPER EXTREMITY W/O
DYE
106.89
MRI JOINT UPPER EXTREMITY
W/DYE
901.39
TC MRI JOINT UPPER EXTREMITY
W/DYE
774.97
26 MRI JOINT UPPER EXTREMITY
W/DYE
126.42
MRI JOINT UPPER EXTREMITY W/O
& W/DYE
1,191.36
TC MRI JOINT UPPER EXTREMITY W/O
& W/DYE
1,024.78
26 MRI JOINT UPPER EXTREMITY W/O
& W/DYE
166.58
MR ANGIO UPPER EXTREMITY W/O
& W/DYE
1,024.20
TC MR ANGIO UPPER EXTREMITY W/O
& W/DYE
889.10
26 MR ANGIO UPPER EXTREMITY W/O
& W/DYE
135.10
X-RAY HIP UNILATERAL 1 VIEW
45.06
TC X-RAY HIP UNILATERAL 1 VIEW
30.21
26 X-RAY HIP UNILATERAL 1 VIEW
14.85
X-RAY HIP COMPLETE MINIMUM 2
VIEWS
71.16
TC X-RAY HIP COMPLETE 2 VIEWS
51.46
26 X-RAY HIP COMPLETE MINIMUM 2
VIEWS
19.70
X-RAY HIPS MINIMUM 2 VIEWS
68.27
TC X-RAY HIPS MINIMUM 2 VIEWS
47.11
26 X-RAY HIPS MINIMUM 2 VIEWS
21.16
X-RAY HIP ARTHROGRAPHY
168.58
TC X-RAY HIP ARTHROGRAPHY
124.54
26 X-RAY HIP ARTHROGRAPHY
44.04
X-RAY HIP DURING OPERATIVE
PROCEDURE
60.32
TC X-RAY HIP DURING OPERATIVE
PROCEDURE
37.53
26 X-RAY HIP DURING OPERATIVE
PROCEDURE
23.26
X-RAY PELVIS & HIPS MINIMUM 2
VIEWS
68.71
TC X-RAY PELVIS & HIPS MINIMUM 2
VIEWS
51.76
26 X-RAY PELVIS & HIPS MINIMUM 2
VIEWS
16.95
X-RAY EXAM, SACROILIAC JOINT
137.42
TC X-RAY EXAM, SACROILIAC JOINT
91.36
26 X-RAY EXAM, SACROILIAC JOINT
46.06
X-RAY THIGH 2 VIEWS
53.51
TC X-RAY THIGH 2 VIEWS
37.60
26 X-RAY THIGH 2 VIEWS
15.91
X-RAY KNEE 1/2 VIEWS
57.41
TC X-RAY KNEE 1/2 VIEWS
40.85
26 X-RAY KNEE 1/2 VIEWS
16.56
X-RAY KNEE 3 VIEWS
74.25
TC X-RAY KNEE 3 VIEWS
55.13
722.96
101.27
891.36
769.13
122.24
11:3-29.6
664.20
611.37
846.36
779.04
1,033.50
951.27
664.20
611.37
846.36
779.04
1,033.50
951.27
59.67
54.93
87.24
80.31
87.24
80.31
1,177.35
1,015.73
161.61
776.35
672.98
103.37
845.19
722.96
122.24
1,117.06
955.99
161.07
959.93
829.43
130.50
42.59
28,22
14.37
67.09
48.03
19.06
64.45
43.97
20.48
158.76
116.22
42.55
N1
N1
N1
58.24
N1
36.22
N1
22.51
N1
64.73
48.32
16.40
129.77
85.25
44.51
50.53
35.11
15.42
54.18
38.14
16.02
69.95
51.47
87.24
80.31
N1
N1
N1
66.69
61.38
72.54
66.78
87.24
80.31
11:3-29.6
APPENDIX B - REGULATIONS
73562 26 X-RAY KNEE 3 VIEWS
19.12
73564
X-RAY KNEE, COMPLETE 4/MORE
VIEWS
85.62
73564 TC X-RAY KNEE, COMPLETE 4/MORE
VIEWS
63.21
73564 26 X-RAY KNEE, COMPLETE 4/MORE
VIEWS
22.40
73565
X-RAY KNEES STANDING
ANTEROPOST
57.28
73565 TC X-RAY KNEES STANDING
ANTEROPOST
41.87
73565 26 X-RAY KNEES STANDING
ANTEROPOST
15.43
73580
X-RAY KNEE ARTHOGRAPHY
222.68
73580 TC X-RAY KNEE ARTHOGRAPHY
176.95
73580 26 X-RAY KNEE ARTHOGRAPHY
45.73
73590
X-RAY TIBIA & FIBULA 2 VIEWS
56.34
73590 TC X-RAY TIBIA & FIBULA 2 VIEWS
40.26
73590 26 X-RAY TIBIA & FIBULA 2 VIEWS
16.06
73592
X-RAY LEG, INFANT MINIMUM 2
VIEWS
52.25
73592 TC X-RAY LEG, INFANT MINIMUM 2
VIEWS
39.53
73592 26 X-RAY LEG, INFANT MINIMUM 2
VIEWS
12.72
73600
X-RAY ANKLE 2 VIEWS
47.59
73600 TC X-RAY ANKLE 2 VIEWS
34.87
73600 26 X-RAY ANKLE 2 VIEWS
12.72
73610
X-RAY ANKLE MINIMUM 3 VIEWS
62.88
73610 TC X-RAY ANKLE MINIMUM 3 VIEWS
47.63
73610 26 X-RAY ANKLE MINIMUM 3 VIEWS
15.25
73615
CONTRAST X-RAY ANKLE
174.99
73615 TC CONTRAST X-RAY ANKLE
130.95
73615 26 CONTRAST X-RAY ANKLE
44.04
73620
X-RAY FOOT 2 VIEWS
45.84
73620 TC X-RAY FOOT 2 VIEWS
33.71
73620 26 X-RAY FOOT 2 VIEWS
12.14
73630
X-RAY FOOT MINIMUM 3 VIEWS
61.95
73630 TC X-RAY FOOT MINIMUM 3 VIEWS
46.60
73630 26 X-RAY FOOT MINIMUM 3 VIEWS
15.35
73650
X-RAY HEEL
47.01
73650 TC X-RAY HEEL
34.29
73650 26 X-RAY HEEL
12.72
73660
X-RAY TOE(S)
49.57
73660 TC X-RAY TOE(S)
39.53
73660 26 X-RAY TOE(S)
10.03
73700
CT LOWER EXTREMITY W/O DYE
414.77
73700 TC CT LOWER EXTREMITY W/O DYE
335.35
73700 26 CT LOWER EXTREMITY W/O DYE
79.42
73701
CT LOWER EXTREMITY W/DYE
510.81
73701 TC CT LOWER EXTREMITY W/DYE
420.36
73701 26 CT LOWER EXTREMITY W/DYE
90.45
73706
CT ANGIO LWR EXTREMITY W/O &
W/DYE
807.23
73706 TC CT ANGIO LWR EXTREMITY W/O &
W/DYE
658.52
73706 26 CT ANGIO LWR EXTREMITY W/O &
W/DYE
148.72
73718
MRI LOWER EXTREMITY W/O DYE 861.62
73718 TC MRI LOWER EXTREMITY W/O DYE 756.93
73718 26 MRI LOWER EXTREMITY W/O DYE 104.69
73719
MRI LOWER EXTREMITY W/DYE
947.98
73719 TC MRI LOWER EXTREMITY W/DYE
822.14
73719 26 MRI LOWER EXTREMITY W/DYE
125.84
73720
MRI LOWER EXTREMITY W/O &
W/DYE
1,257.16
73720 TC MRI LOWER EXTREMITY W/O &
W/DYE
1,090.58
73720 26 MRI LOWER EXTREMITY W/O &
W/DYE
166.58
73721
MRI JOINT LOWER EXTREMITY W/O
DYE
844.02
18.49
80.68
59.00
87.24
80.31
83.04
76.44
21.68
54.00
39.08
14.91
209.25
165.10
44.15
53.14
37.60
15.54
N1
N1
N1
65.52
60.30
78.36
72.12
69.03
63.54
81.87
75.36
49.20
36.92
12.29
44.85
32.57
12.29
59.23
44.47
14.76
164.73
122.20
42.55
43.23
31.48
11.74
58.35
43.51
14.86
44.31
32.03
12.29
46.63
36.92
9.71
389.63
312.85
76.78
479.62
392.16
87.45
N1
N1
N1
66.69
61.38
79.53
73.20
67.86
62.46
78.36
72.12
375.45
345.60
580.71
534.51
655.71
603.54
664.20
611.37
846.36
779.04
1,033.50
951.27
758.08
614.32
143.76
807.36
706.12
101.24
888.65
766.96
121.69
1,178.43
1,017.37
161.07
791.02
MEDICAL FEE SCHEDULES
73721 TC MRI JOINT LOWER EXTREMITY W/O
DYE
737.71
73721 26 MRI JOINT LOWER EXTREMITY W/O
DYE
106.31
73722
MRI JOINT LOWER EXTREMITY
W/DYE
916.47
73722 TC MRI JOINT LOWER EXTREMITY
W/DYE
788.94
73722 26 MRI JOINT LOWER EXTREMITY
W/DYE
127.53
73723
MRI JOINT LWR EXTREMITY W/O &
W/DYE
1,189.03
73723 TC MRI JOINT LWR EXTREMITY W/O &
W/DYE
1,022.45
73723 26 MRI JOINT LWR EXTREMITY W/O &
W/DYE
166.58
73725
MR ANGIO LOWER EXT W OR W/O
DYE
938.33
73725 TC MR ANGIO LOWER EXT W OR W/O
DYE
797.10
73725 26 MR ANGIO LOWER EXT W OR W/O
DYE
141.23
74000
X-RAY ABDOMEN SINGLE
ANTEROPOST
41.62
74000 TC X-RAY ABDOMEN SINGLE
ANTEROPOST
27.88
74000 26 X-RAY ABDOMEN SINGLE
ANTEROPOST
13.73
74010
X-RAY ABDOMEN ANTEROPOST &
ADDED VW
63.95
74010 TC X-RAY ABDOMEN ANTEROPOST &
ADDED VW
46.53
74010 26 X-RAY ABDOMEN ANTEROPOST &
ADDED VW
17.44
74020
X-RAY ABDOMEN COMPLETE
67.15
74020 TC X-RAY ABDOMEN COMPLETE
46.53
74020 26 X-RAY ABDOMEN COMPLETE
20.62
74022
X-RAY EXAM SERIES, ABDOMEN
80.75
74022 TC X-RAY EXAM SERIES, ABDOMEN
56.42
74022 26 X-RAY EXAM SERIES, ABDOMEN
24.33
74150
CT ABDOMEN W/O DYE
415.67
74150 TC CT ABDOMEN W/O DYE
323.11
74150 26 CT ABDOMEN W/O DYE
92.56
74160
CT ABDOMEN W/DYE
621.20
74160 TC CT ABDOMEN W/DYE
512.35
74160 26 CT ABDOMEN W/DYE
108.84
74170
CT ABDOMEN W/O & W/DYE
748.27
74170 TC CT ABDOMEN W/O & W/DYE
639.30
74170 26 CT ABDOMEN W/O & W/DYE
108.98
74175
CT ANGIO ABDOM W/O & W/DYE
817.07
74175 TC CT ANGIO ABDOM W/O & W/DYE
668.42
74175 26 CT ANGIO ABDOM W/O & W/DYE
148.66
74176
CT ANGIO ABDOM & PELVIS
357.22
74176 TC CT ANGIO ABDOM & PELVIS
225.87
74176 26 CT ANGIO ABDOM & PELVIS
131.35
74177
CT ANGIO ABDOM & PELVIS
W/CONTRAST
568.57
74177 TC CT ANGIO ABDOM & PELVIS
W/CONTRAST
430.84
74177 26 CT ANGIO ABDOM & PELVIS
W/CONTRAST
137.73
74178
CT ANGIO ABDOM & PELVIS 1+
REGNS
721.91
74178 TC CT ANGIO ABDOM & PELVIS 1+
REGNS
569.43
74178 26 CT ANGIO ABDOM & PELVIS 1+
REGNS
152.50
74181
MRI ABDOMEN W/O DYE
780.43
74181 TC MRI ABDOMEN W/O DYE
667.25
74181 26 MRI ABDOMEN W/O DYE
113.19
74183
MRI ABDOMEN W/O & W/DYE
1,261.00
74183 TC MRI ABDOMEN W/O & W/DYE
1,086.50
688.19
11:3-29.6
664.20
611.37
846.36
779.04
1,033.50
951.27
54.99
50.61
87.24
80.31
87.24
80.31
112.32
103.38
375.45
345.60
580.71
534.51
647.37
595.86
655.71
603.54
375.45
345.60
580.71
534.51
647.37
595.86
664.20
611.37
1,033.50
951.27
102.82
859.30
735.99
123.31
1,114.88
953.82
161.07
880.13
743.60
136.54
39.34
26.05
13.29
60.30
43.43
16.85
63,37
43.43
19.94
76.17
52.67
23.50
390.94
301.44
89.50
583.19
477.98
105.22
701.76
596.40
105.36
767.28
623.56
143.73
337.86
210.73
127.13
535.21
401.94
133.28
678.79
531.21
147.58
731.90
622.46
109.42
1,182.28
1,013.56
11:3-29.6
74183
74220
74220
74220
74230
74230
74230
74241
74241
74241
74246
74246
74246
74280
74280
74280
74290
74290
74290
74330
74330
74330
74400
74400
74400
74410
74410
74410
74415
74415
74415
74420
74420
74420
74425
74425
74425
74430
74430
74430
74450
74450
74450
74455
74455
74455
74475
74475
74475
74480
74480
74480
74485
74485
74485
75561
75561
75561
75572
75572
75572
75574
75574
APPENDIX B - REGULATIONS
26 MRI ABDOMEN W/O & W/DYE
174.49
CONTRAST X-RAY, ESOPHAGUS
151.79
TC CONTRAST X-RAY, ESOPHAGUS
115.82
26 CONTRAST X-RAY, ESOPHAGUS
35.97
CINE/VIDEO X-RAY, THROAT/ESOPH 153.59
TC CINE/VIDEO X-RAY, THROAT/ESOPH 112.32
26 CINE/VIDEO X-RAY, THROAT/ESOPH 41.27
X-RAY EXAM, UPPER GI TRACT
W/KUB
198.98
TC X-RAY EXAM, UPPER GI TRACT
W/KUB
146.09
26 X-RAY EXAM, UPPER GI TRACT
W/KUB
52.88
CONTRAST X-RAY UGI TRACT W/O
KUB
213.47
TC CONTRAST X-RAY UGI TRACT W/O
KUB
159.49
26 CONTRAST X-RAY UGI TRACT W/O
KUB
53.99
CONTRAST X-RAY COLON W/WO
GLUCOGEN
357.90
TC CONTRAST X-RAY COLON W/WO
GLUCOGEN
281.19
26 CONTRAST X-RAY COLON W/WO
GLUCOGEN
76.71
CONTRAST X-RAY, GALLBLADDER 115.11
TC CONTRAST X-RAY, GALLBLADDER 90.78
26 CONTRAST X-RAY, GALLBLADDER 24.33
X-RAY BILE/PANCREAS ENDOSCOPY300.56
TC X-RAY BILE/PANCREAS ENDOSCOPY230.31
26 X-RAY BILE/PANCREAS ENDOSCOPY 72.02
CONTRAST X-RAY URINARY TRACT 188.82
TC CONTRAST X-RAY URINARY TRACT 150.75
26 CONTRAST X-RAY URINARY TRACT 38.07
CONTRAST X-RAY URINARY TRACT 194.65
TC CONTRAST X-RAY URINARY TRACT 155.99
26 CONTRAST X-RAY URINARY TRACT 38.65
CONTRAST X-RAY URINARY TRACT 230.76
TC CONTRAST X-RAY URINARY TRACT 192.68
26 CONTRAST X-RAY URINARY TRACT 38.07
CONTRAST X-RAY URINARY TRACT 219.86
TC CONTRAST X-RAY URINARY TRACT 190.87
26 CONTRAST X-RAY URINARY TRACT 28.56
CONTRAST X-RAY URINARY TRACT 124.29
TC CONTRAST X-RAY URINARY TRACT 95.30
26 CONTRAST X-RAY URINARY TRACT 28.56
CONTRAST X-RAY BLADDER
102.29
TC CONTRAST X-RAY BLADDER
77.96
26 CONTRAST X-RAY BLADDER
24.33
X-RAY URETHRA/BLADDER
132.84
TC X-RAY URETHRA/BLADDER
106.33
26 X-RAY URETHRA/BLADDER
26.46
X-RAY URETHRA/BLADDER
151.71
TC X-RAY URETHRA/BLADDER
126.29
26 X-RAY URETHRA/BLADDER
25.42
X-RAY CONTROL, CATH INSERT
188.45
TC X-RAY CONTROL, OATH INSERT
146.09
26 X-RAY CONTROL, OATH INSERT
42.36
X-RAY CONTROL, OATH INSERT
189.03
TC X-RAY CONTROL, OATH INSERT
146.67
26 X-RAY CONTROL, OATH INSERT
42.36
X-RAY GUIDE, GU DILATION
186.12
TC X-RAY GUIDE, GU DILATION
143.77
26 X-RAY GUIDE, GU DILATION
42.36
CARDIAC MRI FOR MORPH W/DYE 1,022.10
TC CARDIAC MRI FOR MORPH W/DYE 816.31
26 CARDIAC MRI FOR MORPH W/DYE 205.79
CT HEART W/3D IMAGE
489.05
TC CT HEART W/3D IMAGE
358.64
26 CT HEART NV/3D IMAGE
130.41
CT ANGIO HEART W/3D IMAGE
745.46
TC CT ANGIO HEART W/3D IMAGE
565.93
168.71
142.85
108.07
34.77
144.71
104.80
39.89
167.97
154.59
167.97
154.59
167.97
154.59
167.97
154.59
274.98
253.11
167.97
154.59
187.44
136.31
51.12
200.98
148.82
52.18
336.48
262.33
74.15
108.23
84.71
23.50
290.09
222.27
69.63
177.48
140.66
36.82
182.91
145.55
37.36
216.59
179.77
36.82
212.18
184.20
27.63
119.97
91.97
27.63
96.28
72.76
23.50
128.21
102.60
25.59
142.41
117.85
24.56
177.25
136.31
40.94
177.79
136.86
40.94
175.08
134.15
40.94
960.23
761.53
198.70
460.69
334.58
126.11
701.56
527.96
N1
N1
N1
301.83
277.83
312.36
287.52
341.13
313.98
341.13
313.98
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
1,033.50
951.27
497.49
457.92
497.49
457.92
MEDICAL FEE SCHEDULES
75574
75605
75605
75605
75625
75625
75625
75630
75630
75630
75635
75635
75635
75650
75650
75650
75665
75665
75665
75671
75671
75671
75676
75676
75676
75680
75680
75680
75685
75685
75685
75705
75705
75705
75710
75710
75710
75716
75716
75716
75722
75722
75722
75724
75724
75724
75726
75726
75726
75736
75736
75736
75743
75743
75743
75774
75774
75774
75809
75809
75809
75820
75820
75820
75822
75822
75822
75825
75825
75825
75894
75894
26 CT ANGIO HEART W/3D IMAGE
179.53
CONTRAST X-RAY AORTA
360.73
TC CONTRAST X-RAY AORTA
270.12
26 CONTRAST X-RAY AORTA
90.61
CONTRAST X-RAY AORTA
361.13
TC CONTRAST X-RAY AORTA
270.70
26 CONTRAST X-RAY AORTA
90.42
X-RAY AORTA, LEG ARTERIES
417.40
TC X-RAY AORTA, LEG ARTERIES
277.11
26 X-RAY AORTA, LEG ARTERIES
140.29
CT ANGIO ABDOMINAL ARTERIES 913.36
TC CT ANGIO ABDOMINAL ARTERIES 725.35
26 CT ANGIO ABDOMINAL ARTERIES 188.01
ARTERY X-RAYS HEAD & NECK
389.94
TC ARTERY X-RAYS HEAD & NECK
272.45
26 ARTERY X-RAYS HEAD & NECK
117.50
ARTERY X-RAYS HEAD & NECK
425.00
TC ARTERY X-RAYS HEAD & NECK
319.62
26 ARTERY X-RAYS HEAD & NECK
105.39
ARTERY X-RAYS HEAD & NECK
494.52
TC ARTERY X-RAYS HEAD & NECK
363.17
26 ARTERY X-RAYS HEAD & NECK
131.36
ARTERY X-RAYS NECK UNILATERAL407.54
TC ARTERY X-RAYS NECK UNILATERAL302.73
26 ARTERY X-RAYS NECK UNILATERAL104.80
ARTERY X-RAYS NECK BILATERAL 460.30
TC ARTERY X-RAYS NECK BILATERAL 328.94
26 ARTERY X-RAYS NECK BILATERAL 131.36
ARTERY X-RAYS SPINE
409.47
TC ARTERY X-RAYS SPINE
305.65
26 ARTERY X-RAYS SPINE
103.82
ARTERY X-RAYS SPINE
472.31
TC ARTERY X-RAYS SPINE
303.32
26 ARTERY X-RAYS SPINE
169.00
ARTERY X-RAYS ARM/LEG
392.29
TC ARTERY X-RAYS ARM/LEG
304.48
26 ARTERY X-RAYS ARM/LEG
87.82
ARTERY X-RAYS ARMS/LEGS
453.48
TC ARTERY X-RAYS ARMS/LEGS
350.35
26 ARTERY X-RAYS ARMS/LEGS
103.13
ARTERY X-RAYS KIDNEY
379.94
TC ARTERY X-RAYS KIDNEY
289.33
26 ARTERY X-RAYS KIDNEY
90.61
ARTERY X-RAYS KIDNEYS
449.53
TC ARTERY X-RAYS KIDNEYS
329.39
26 ARTERY X-RAYS KIDNEYS
120.14
ARTERY X-RAYS ABDOMEN
389.19
TC ARTERY X-RAYS ABDOMEN
299.82
26 ARTERY X-RAYS ABDOMEN
89.37
ARTERY X-RAYS PELVIS
387.64
TC ARTERY X-RAYS PELVIS
299.24
26 ARTERY X-RAYS PELVIS
88.41
ARTERY X-RAYS LUNGS
408.48
TC ARTERY X-RAYS LUNGS
278.28
26 ARTERY X-RAYS LUNGS
130.20
ARTERY X-RAY, EACH VESSEL
270.73
TC ARTERY X-RAY, EACH VESSEL
242.17
26 ARTERY X-RAY, EACH VESSEL
28.56
NONVASCULAR SHUNT, X-RAY
164.52
TC NONVASCULAR SHUNT, X-RAY
127.46
26 NONVASCULAR SHUNT, X-RAY
37.06
VEIN X-RAY ARM/LEG
210.48
TC VEIN X-RAY ARM/LEG
155.41
26 VEIN X-RAY ARM/LEG
55.07
VEIN X-RAY ARMS/LEGS
256.52
TC VEIN X-RAY ARMS/LEGS
174.04
26 VEIN X-RAY ARMS/LEGS
82.47
VEIN X-RAY TRUNK
345.52
TC VEIN X-RAY TRUNK
257.32
26 VEIN X-RAY TRUNK
88.21
X-RAYS, TRANSCATH THERAPY
1,855.82
TC X-RAYS, TRANSCATH THERAPY
1,753.06
173.60
339.57
252.01
87.55
340.04
252.55
87.48
394.12
258.54
135.59
858.40
676.75
181.66
367.78
254.19
113.59
400.08
298.19
101.89
465.82
338.89
126.95
383.78
282.44
101.35
433.83
306.88
126.95
385.48
285.15
100.33
446.19
282.98
163.23
368.94
284.06
84.88
426.68
326.93
99.75
357.49
269.93
87.55
423.26
307.38
115.88
366.16
'279.71
86.44
364.59
279.17
85.42
385.48
259.62
125.85
253.58
225.94
27.63
154.76
118.93
35.83
198.23
145.01
53.22
242.15
162.39
79.77
325.41
240.06
85.35
1,791.12
1,691.80
11:3-29.6
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
11:3-29.6
75894
75898
75898
75898
75940
75940
75940
75954
75957
75960
75960
75960
75961
75961
75961
75962
75962
75962
75964
75964
75964
75978
75978
75978
75984
75984
75984
75989
75989
75989
76000
76000
76000
76001
76001
76001
76010
76010
76010
76080
76080
76080
76098
76098
76098
76100
76100
76100
76102
76102
76102
76120
76120
76120
76125
76376
76376
76376
76377
76377
76377
76380
76380
76380
76506
76506
76506
76510
APPENDIX B - REGULATIONS
26 X-RAYS, TRANSCATH THERAPY
106.24
F/U ANGIOGRAPHY
209.00
TC F/U ANGIOGRAPHY
78.78
26 F/U ANGIOGRAPHY
135.47
X-RAY PLACE VEIN FILTER
957.35
TC X-RAY PLACE VEIN FILTER
914.34
26 X-RAY PLACE VEIN FILTER
43.27
26 ILIAC ANEURYSM ENDOVASC
REPAIR
183.83
26 X-RAY, ENDOVASC THOR AO REPAIR494.34
TRANSCATH IV STENT RS & I
326.56
TC TRANSCATH IV STENT RS & I
262.56
26 TRANSCATH IV STENT RS & I
64.01
RETRIEVE BROKEN CATHETER
601.23
TC RETRIEVE BROKEN CATHETER
271.28
26 RETRIEVE BROKEN CATHETER
329.93
REPAIR ARTERIAL BLOCKAGE
360.81
TC REPAIR ARTERIAL BLOCKAGE
319.03
26 REPAIR ARTERIAL BLOCKAGE
41.78
REPAIR ARTERY BLOCKAGE, EACH 224.67
TC REPAIR ARTERY BLOCKAGE, EACH 196.17
26 REPAIR ARTERY BLOCKAGE, EACH 28.51
REPAIR VENOUS BLOCKAGE
361.40
TC REPAIR VENOUS BLOCKAGE
320.20
26 REPAIR VENOUS BLOCKAGE
41.20
X-RAY CONTROL CATHETER
CHANGE
192.29
TC X-RAY CONTROL CATHETER
CHANGE
136.20
26 X-RAY CONTROL CATHETER
CHANGE
56.09
ABSCESS DRAIN UNDER X-RAY
224.22
TC ABSCESS DRAIN UNDER X-RAY
132.70
26 ABSCESS DRAIN UNDER X-RAY
91.52
FLUOROSCOPE EXAM
304.49
TC FLUOROSCOPE EXAM
274.00
26 FLUOROSCOPE EXAM
30.50
FLUOROSCOPE EXAM, EXTENSIVE 576.95
TC FLUOROSCOPE EXAM, EXTENSIVE 453.41
26 FLUOROSCOPE EXAM, EXTENSIVE 128.39
X-RAY NOSE TO RECTUM
46.27
TC X-RAY NOSE TO RECTUM
31.96
26 X-RAY NOSE TO RECTUM
14.31
X-RAY FISTULA
103.44
TC X-RAY FISTULA
61.08
26 X-RAY FISTULA
42.36
X-RAY EXAM, BREAST SPECIMEN
31.87
TC X-RAY EXAM, BREAST SPECIMEN
19.16
26 X-RAY EXAM, BREAST SPECIMEN
12.72
X-RAY BODY SECTION
206.65
TC X-RAY BODY SECTION
158.32
26 X-RAY BODY SECTION
48.33
COMPLEX BODY SECTION X-RAYS 403.16
TC COMPLEX BODY SECTION X-RAYS 349.32
26 COMPLEX BODY SECTION X-RAYS
53.84
CINEIVIDEO X-RAYS
129.09
TC CINE/VIDEO X-RAYS
99.50
26 CINE/VIDEO X-RAYS
29.57
26 CINEIVIDEO X-RAYS, ADDED
22.84
3D RENDER W/O POST PROCESS
234.29
TC 3D RENDER W/O POST PROCESS
203.68
26 3D RENDER W/O POST PROCESS
30.61
3D RENDERING W/POST PROCESS
297.09
TC 3D RENDERING W/POST PROCESS
179.06
26 3D RENDERING W/POST PROCESS
118.06
CAT SCAN F/U STUDY
318.44
TC CAT SCAN F/U STUDY
242.75
26 CAT SCAN F/U STUDY
75.69
ECHO EXAM HEAD
202.86
TC ECHO EXAM HEAD
153.66
26 ECHO EXAM HEAD
49.18
OPHTHALMIC US, B & QUANT A
273.79
102.86
201.67
76.03
131.11
924.02
882.41
41.92
N1
N1
N1
N1
N1
N1
N1
178.42
480.01
306.84
244.95
61.89
572.18
253.09
319.08
338.03
297.65
40.39
210.63
183.04
27.61
338.57
298.73
39.85
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
181.30
N1
127.09
N1
54.21
212.28
123.82
88.45
285.18
255.66
29.51
556.98
437.54
124.16
43.68
29.86
13.83
97.94
57.01
40.94
30.18
17.91
12.29
194.40
147.72
46.68
377.88
325.88
52.00
121.49
92.87
28.62
22.06
219.61
190.07
29.54
281.18
167.09
114.10
299.62
226.49
73.13
190.94
143.37
47.56
260.13
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
63.18
58.17
N1
N1
N1
N1
N1
N1
146.91
135.24
445.38
409.95
161.73
148.86
N1
N1
N1
N1
N1
N1
N1
219.81
202.32
120.54
110.97
MEDICAL FEE SCHEDULES
76510
76510
76511
76511
76511
76512
76512
76512
76514
76514
76514
76516
76516
76516
76519
76519
76519
76536
76536
76536
76604
76604
76604
76645
76645
76645
76700
76700
76700
76705
76705
76705
76770
76770
76770
76775
76775
76775
76776
76776
76776
76800
76800
76800
76801
76801
76801
76805
76805
76805
76810
76810
76810
76811
76811
76811
76814
76814
76814
76815
76815
76815
76816
TC OPHTHALMIC US, B & QUANT A
127.46
118.93
26 OPHTHALMIC US, B &QUANT A
146.33
141.20
OPHTHALMIC US, QUANT A ONLY 163.45
154.84
TC OPHTHALMIC US, QUANT A ONLY
83.20
77.65
26 OPHTHALMIC US, QUANT A ONLY
80.25
77.19
OPHTHALMIC US, B W/NON-QUANT A151.03
143.36
TC OPHTHALMIC US, B W/NON-QUANT A 69.24
64.62
26 OPHTHALMIC US, B W/NON-QUANT A 81.81
78.74
ECHO EXAM EYE, THICKNESS
22.48
21.46
TC ECHO EXAM EYE, THICKNESS
7.50
7.03
26 ECHO EXAM EYE, THICKNESS
14.96
14.41
ECHO EXAM EYE
119.29
112.66
TC ECHO EXAM EYE
73.31
68.43
26 ECHO EXAM EYE
45.97
44.24
ECHO EXAM EYE
129.63
122.38
TC ECHO EXAM EYE
82.04
76.57
26 ECHO EXAM EYE
47.59
45.83
US EXAM HEAD & NECK
199.36
187.48
TC US EXAM HEAD & NECK
155.99 145,55
26 US EXAM HEAD & NECK
43.37
41.94
US EXAM, CHEST
147.03
138.64
TC US EXAM, CHEST
104.75
97.76
26 US EXAM, CHEST
42.28
40.88
US EXAM, BREAST(S)
161.02
151.70
TC US EXAM, BREAST(S)
118.73
110.79
26 US EXAM, BREAST(S)
42.29
40.91
US EXAM, ABDOM, COMPLETE
235.86
222.17
TC US EXAM, ABDOM, COMPLETE
167.06
161.85
26 US EXAM, ABDOM, COMPLETE
62.40
60.32
ECHO EXAM ABDOMEN
179.34
168.88
TC ECHO EXAM ABDOMEN
133.87
124.91
26 ECHO EXAM ABDOMEN
45.47
43.97
US EXAM ABDOM BACK WALL, COMP224.16
211.09
TC US EXAM ABDOM BACK WALL, COMP167.06
155.86
26 US EXAM ABDOM BACK WALL, COMP57.10
55.21
US EXAM ABDOM BACK WALL, LIM 187.57
176.53
TC US EXAM ABDOM BACK WALL, LIM 142.02
132.52
26 US EXAM ABDOM BACK WALL, LIM 45.55
44.01
US EXAM K TRANSPLANT W/DOPPLER254.87 239.78
TC US EXAM K TRANSPLANT W/DOPPLER196.17 183.04
26 US EXAM K TRANSPLANT W/DOPPLER58.70
56.76
US EXAM, SPINAL CANAL
220.65
208.77
TC US EXAM, SPINAL CANAL
135.03
125.99
26 US EXAM, SPINAL CANAL
85.62
82.78
OBSTET US < 14 WKS, SINGLE FETUS 216.53
204.54
TC OBSTET US < 14 WKS, SINGLE FETUS 140.28
130.88
26 OBSTET US < 14 WKS, SINGLE FETUS 76.26
73.65
OBSTET US >/= 14 WKS, SINGLE
FETUS
249.13
234.96
TC OBSTET US >/= 14 WKS, SINGLE
FETUS
172.87
161.31
26 OBSTET US >/= 14 WKS, SINGLE
FETUS
76.26
73.65
OBSTET US >/= 14 WKS, ADDED
FETUS
160.70
152.44
TC OBSTET US >/= 14 WKS, ADDED
FETUS
85.53
79.82
26 OBSTET US >/= 14 WKS, ADDED
FETUS
75.16
72.62
OBSTET US, DETAILED, SINGLE
FETUS
317.90
301.40
TC OBSTET US, DETAILED, SINGLE
FETUS
171.71
160.21
26 OBSTET US, DETAILED, SINGLE
FETUS
146.19
141.18
OBSTET US NUCHAL MEAS, ADDED 131.51
125.24
TC OBSTET US NUCHAL MEAS, ADDED 55.83
52.13
26 OBSTET US NUCHAL MEAS, ADDED 75.67
73.11
OBSTET US, LIMITED, FETUS(S)
152.23
143.66
TC OBSTET US, LIMITED, FETUS(S)
103.00
96.12
26 OBSTET US, LIMITED, FETUS(S)
49.23
47.55
OBSTET US, F/U, PER FETUS
194.86
183.99
11:3-29.6
255.03
234.75
166.14
152.91
138.03
127.05
14.04
12.93
120.54
110.97
163.80
150.78
186.48
171.66
120.54
110.97
120.54
110.97
186.48
171.66
186.48
171.66
186.48
171.66
186.48
171.66
186.48
171.66
186.48
171.66
186.48
171.66
186.48
171.66
170.82
157.23
296.28
272.73
111.15
102.30
120.54
110.97
11:3-29.6
76816
76816
76817
76817
76817
76818
76818
76818
76819
76819
76819
76820
76820
76820
76821
76821
76821
76826
76826
76826
76827
76827
76827
76828
76828
76828
76830
76830
76830
76856
76856
76856
76857
76857
76857
76870
76870
76870
76872
76872
76872
76881
76881
76881
76882
76882
76882
76937
76937
76937
76942
76942
76942
76998
76998
76998
77001
77001
77001
77002
77002
77002
77003
77003
77003
77011
77011
77011
77012
77012
77012
77032
APPENDIX B - REGULATIONS
TC OBSTET US, F/U, PER FETUS
26 OBSTET US, F/U, PER FETUS
TRANSVAGINAL US, OBSTETRIC
TC TRANSVAGINAL US, OBSTETRIC
26 TRANSVAGINAL US, OBSTETRIC
FETAL BIOPHYS PROFILE W/NST
TC FETAL BIOPHYS PROFILE W/NST
26 FETAL BIOPHYS PROFILE W/NST
FETAL BIOPHYS PROFILE W/O NST
TC FETAL BIOPHYS PROFILE W/O NST
26 FETAL BIOPHYS PROFILE W/O NST
UMBILICAL ARTERY ECHO
TC UMBILICAL ARTERY ECHO
26 UMBILICAL ARTERY ECHO
MIDDLE CEREBRAL ARTERY ECHO
TC MIDDLE CEREBRAL ARTERY ECHO
26 MIDDLE CEREBRAL ARTERY ECHO
ECHO EXAM FETAL HEART
TC ECHO EXAM FETAL HEART
26 ECHO EXAM FETAL HEART
ECHO EXAM FETAL HEART
TC ECHO EXAM FETAL HEART
26 ECHO EXAM FETAL HEART
ECHO EXAM FETAL HEART
TC ECHO EXAM FETAL HEART
26 ECHO EXAM FETAL HEART
TRANSVAGINAL US, NON-OB
TC TRANSVAGINAL US, NON-OB
26 TRANSVAGINAL US, NON-0B
US EXAM, PELVIC, COMPLETE
TC US EXAM, PELVIC, COMPLETE
26 US EXAM, PELVIC, COMPLETE
US EXAM, PELVIC, LIMITED
TC US EXAM, PELVIC, LIMITED
26 US EXAM, PELVIC, LIMITED
US EXAM, SCROTUM
TC US EXAM, SCROTUM
26 US EXAM, SCROTUM
US, TRANSRECTAL
TC US, TRANSRECTAL
26 US, TRANSRECTAL
US XTR NON-VASC COMPLETE
TC US XTR NON-VASC COMPLETE
26 US XTR NON-VASC COMPLETE
US XTR NON-VASC LMTD
TC US XTR NON-VASC LMTD
26 US XTR NON-VASC LMTD
US GUIDE VASCULAR ACCESS
TC US GUIDE VASCULAR ACCESS
26 US GUIDE VASCULAR ACCESS
ECHO GUIDE FOR BIOPSY
TC ECHO GUIDE FOR BIOPSY
26 ECHO GUIDE FOR BIOPSY
US GUIDE, INTRAOP
TC US GUIDE, INTRAOP
26 US GUIDE, INTRAOP
FLUOROGUIDE FOR VEIN DEVICE
TC FLUOROGUIDE FOR VEIN DEVICE
26 FLUOROGUIDE FOR VEIN DEVICE
NEEDLE LOCALIZATION BY X-RAY
TC NEEDLE LOCALIZATION BY X-RAY
26 NEEDLE LOCALIZATION BY X-RAY
FLUOROGUIDE FOR SPINE INJECT
TC FLUOROGUIDE FOR SPINE INJECT
26 FLUOROGUIDE FOR SPINE INJECT
CT SCAN FOR LOCALIZATION
TC CT SCAN FOR LOCALIZATION
26 CT SCAN FOR LOCALIZATION
CT SCAN FOR NEEDLE BIOPSY
TC CT SCAN FOR NEEDLE BIOPSY
26 CT SCAN FOR NEEDLE BIOPSY
GUIDANCE FOR NEEDLE, BREAST
129.20
65.65
172.32
114.65
57.67
202.69
121.64
81.04
152.37
92.53
59.86
76.50
38.37
38.13
162.22
107.66
54.56
208.98
145.52
63.48
109.66
65.74
43.93
79.54
36.62
42.92
210.04
156.57
53.46
209.45
155.99
53.46
171.60
140.86
30.74
208.60
158.32
50.28
236.77
181.61
55.15
192.67
147.84
44.84
48.50
17.41
31.09
57.48
33.71
23.77
334.15
281.77
52.38
293.61
197.37
101.78
193.72
163.57
30.16
289.77
190.67
99.07
236.32
130.19
106.12
819.82
724.89
94.93
271.67
182.78
88.89
91.65
120.56
63.42
162.71
106.98
55.73
191.78
113.50
78.27
144.15
86.34
57.81
72.65
35.83
36.82
153.16
100.47
52.71
197.12
135.77
61.35
103.78
61.36
42.43
75.63
34.19
41.44
197.76
146.09
51.66
197.22
145.55
51.66
161.14
131.42
29.71
196.32
147.72
48.60
222.71
169.45
53.26
181.34
137.94
43.40
46.38
16.27
30.11
54.50
31.48
23.01
313.52
262.89
50.65
283.70
190.50
98.78
181.78
152.61
29.16
273.67
177.94
95.73
224.15
121.54
102.61
767.90
676.25
91.65
256.43
170.54
85.90
86.98
120.54
110.97
120.54
110.97
186.48
171.66
184.83
170.13
76.02
69.99
120.54
110.97
291.30
268.14
120.54
110.97
72.54
66.78
186.48
171.66
186.48
171.66
120.54
110.97
186.48
171.66
186.48
171.66
186.48
171.66
33.93
31.23
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
MEDICAL FEE SCHEDULES
77032 TC GUIDANCE FOR NEEDLE, BREAST
48.27
77032 26 GUIDANCE FOR NEEDLE, BREAST
43.37
77051
COMPUTER DIAG MAMMOGRAM,
ADDED
19.23
77051 TC COMPUTER DIAG MAMMOGRAM,
ADDED
14.50
77051 26 COMPUTER DIAG MAMMOGRAM,
ADDED
4.73
77052
COMP SCREEN MAMMOGRAM, ADDED19.23
77052 TC COMP SCREEN MAMMOGRAM, ADDED14.50
77052 26 COMP SCREEN MAMMOGRAM, ADDED 4.73
77055
MAMMOGRAM, ONE BREAST
142.93
77055 TC MAMMOGRAM, ONE BREAST
88.45
77055 26 MAMMOGRAM, ONE BREAST
54.48
77056
MAMMOGRAM, BOTH BREASTS
182.95
77056 TC MAMMOGRAM, BOTH BREASTS
115.24
77056 26 MAMMOGRAM, BOTH BREASTS
67.71
77057
MAMMOGRAM, SCREENING
133.62
77057 TC MAMMOGRAM, SCREENING
79.13
77057 26 MAMMOGRAM, SCREENING
54.48
77058
MRI ONE BREAST
1,287.39
77058 TC MRI ONE BREAST
1,160.46
77058 26 MRI ONE BREAST
126.93
77059
MRI BOTH BREASTS
1,336.30
77059 TC MRI BOTH BREASTS
1,209.37
77059 26 MRI BOTH BREASTS
126.93
77072
X-RAYS FOR BONE AGE
39.21
77072 TC X-RAYS FOR BONE AGE
24.40
77072 26 X-RAYS FOR BONE AGE
14.82
77073
X-RAYS, BONE LENGTH STUDIES
65.21
77073 TC X-RAYS, BONE LENGTH STUDIES
41.87
77073 26 X-RAYS, BONE LENGTH STUDIES
23.35
77074
X-RAYS, BONE SURVEY, LIMITED
116.91
77074 TC X-RAYS, BONE SURVEY, LIMITED
81.46
77074 26 X-RAYS, BONE SURVEY, LIMITED
35.46
77075
X-RAYS, BONE SURVEY COMPLETE 172.73
77075 TC X-RAYS, BONE SURVEY COMPLETE 130.95
77075 26 X-RAYS, BONE SURVEY COMPLETE 41.78
77076
X-RAYS, BONE SURVEY, INFANT
167.39
77076 TC X-RAYS, BONE SURVEY, INFANT
114.07
77076 26 X-RAYS, BONE SURVEY, INFANT
53.32
77077
JOINT SURVEY, SINGLE VIEW
70.16
77077 TC JOINT SURVEY, SINGLE VIEW
44.20
77077 26 JOINT SURVEY, SINGLE VIEW
25.96
77080
DIAG BONE DENSITY, AXIAL
164.52
77080 TC DIAG BONE DENSITY, AXIAL
147.68
77080 26 DIAG BONE DENSITY, AXIAL
16.85
77081
DIAG BONE DENSITY/PERIPHERAL
47.72
77081 TC DIAG BONE DENSITY/PERIPHERAL
32.54
77081 26 DIAG BONE DENSITY/PERIPHERAL
15.18
77082
DIAG BONE DENSITY, VERTEBRAL FX46.47
77082 TC DIAG BONE DENSITY, VERTEBRAL FX36.44
77082 26 DIAG BONE DENSITY, VERTEBRAL FX10.03
77261
RADIATION THERAPY PLANNING
113.00
77262
RADIATION THERAPY PLANNING
170.00
77263
RADIATION THERAPY PLANNING
252.06
77280
SET RADIATION THERAPY FIELD
318.27
77280 TC SET RADIATION THERAPY FIELD
263.72
77280 26 SET RADIATION THERAPY FIELD
54.56
77285
SET RADIATION THERAPY FIELD
559.51
77285 TC SET RADIATION THERAPY FIELD
477.43
77285 26 SET RADIATION THERAPY FIELD
82.08
77290
SET RADIATION THERAPY FIELD
896.21
77290 TC SET RADIATION THERAPY FIELD
774.39
77290 26 SET RADIATION THERAPY FIELD
121.82
77295
SET RADIATION THERAPY FIELD
931.90
77295 TC SET RADIATION THERAPY FIELD
574.47
77295 26 SET RADIATION THERAPY FIELD
357.43
77300
RADIATION THERAPY DOSE PLAN 115.07
77300 TC RADIATION THERAPY DOSE PLAN
66.32
77300 26 RADIATION THERAPY DOSE PLAN
48.74
77305
TELETX ISODOSE PLAN SIMPLE
108.64
11:3-29.6
45.06
41.94
N1
N1
18.15
13.56
4.59
18.15
13.56
4.59
135.22
82.54
52.68
172.99
107.53
65.47
126.53
73.85
52.68
1,205.28
1,082.55
122.74
1,250.91
1,128.17
122.74
37.12
22.79
14.32
61.67
39.08
22.58
110.30
76.03
34.28
162.59
122.20
40.39
158.04
106.44
51.59
66.38
41.25
25.11
154.53
138.21
16.31
45.12
30.40
14.74
43.84
34.13
9.71
109.15
164.36
243.70
298.74
246.05
52.71
524.71
445.40
79.31
840.10
722.42
117.69
881.43
536.03
345.39
108.98
61.90
47.09
103.20
47.97
44.16
83.04
76.44
146.91
135.24
146.91
135.24
146.91
135.24
87.24
80.31
136.59
125.73
62.19
57.24
69.03
63.54
202.35
186.27
526.05
484.20
526.05
484.20
1,150.02
1,058.52
132.18
121.68
11:3-29.6
77305
77305
77310
77310
77310
77315
77315
77315
77321
77321
77321
77331
77331
77331
77332
77332
77332
77333
77333
77333
77334
77334
77334
77336
77371
77403
77413
77414
77417
77427
77431
77470
77470
77470
78006
78006
78006
78007
78007
78007
78102
78102
78102
78103
78103
78103
78215
78215
78215
78220
78220
78220
78223
78223
78223
78232
78232
78232
78300
78300
78300
78305
78305
78305
78306
78306
78306
78315
78315
78320
APPENDIX B - REGULATIONS
TC TELETX ISODOSE PLAN SIMPLE
54.09
50.49
107.64
99.06
26 TELETX ISODOSE PLAN SIMPLE
54.56
52.71
TELETX ISODOSE PLAN INTERMED 153.06
145.56
TC TELETX ISODOSE PLAN INTERMED 70.98
66.25
141.54
130.29
26 TELETX ISODOSE PLAN INTERMED 82.08
79.31
TELETX ISODOSE PLAN COMPLEX 232.39
220.88
TC TELETX ISODOSE PLAN COMPLEX 110.57
103.18
221.13
203.55
26 TELETX ISODOSE PLAN COMPLEX 121.82
117.69
SPECIAL TELETX PORT PLAN
176.00
166.68
TC SPECIAL TELETX PORT PLAN
102.42
95.58
204.75
188.46
26 SPECIAL TELETX PORT PLAN
73.58
71.10
SPECIAL RADIATION DOSIMETRY 101.48
96.97
TC SPECIAL RADIATION DOSIMETRY
33.13
30.94
65.52
60.30
26 SPECIAL RADIATION DOSIMETRY
68.35
66.02
RADIATION TREAT AID(S)
130.80
123.48
TC RADIATION TREAT AID(S)
88.45
82.54
176.64
162.60
26 RADIATION TREAT AID(S)
42.36
40.94
RADIATION TREAT AID(S)
95.88
91.67
TC RADIATION TREAT AID(S)
30.21
28.22
59.67
54.93
26 RADIATION TREAT AID(S)
65.67
63.45
RADIATION TREAT AID(S)
253.55
239.75
TC RADIATION TREAT AID(S)
157.16
146.64
314.70
289.68
26 RADIATION TREAT AID(S)
96.39
93.11
RADIATION PHYSICS CONSULT
89.61
83.63
178.98
164.73
SRS, MULTISOURCE
2,070.29 1,900.21 14,838.51 13,658.16
RADIATION TX SING AREA 6-10MEV 224.70
209.65
189.45
174.39
RADIATION TX 3/MORE AREA
6-10MEV
401.73
374.78
310.95
286.23
RADIATION TX 3/MORE AREA
11-19MEV
449.47
419.32
310.95
286.23
RADIOLOGY PORT FILM(S)
25.57
23.87
RADIATION TX MANAGEMENT, X5 282.30
272.51
RADIATION THERAPY MANAGEMENT155.03
149.53
SPECIAL RADIATION TREAT
330.15
313.46
TC SPECIAL RADIATION TREAT
166.48
155.32
333.42
306.90
26 SPECIAL RADIATION TREAT
163.67
158.12
THYROID IMAGING W/UPTAKE
400.08
374.61
TC THYROID IMAGING W/UPTAKE
362.01
337.79
425.13
391.32
26 THYROID IMAGING W/UPTAKE
38.07
36.82
THYROID IMAGE, MULT UPTAKES 330.70
309.92
TC THYROID IMAGE, MULT UPTAKES 292.13
272.61
425.13
391.32
26 THYROID IMAGE, MULT UPTAKES
38.58
37.32
BONE MARROW IMAGING, LTD
280.83
263.53
TC BONE MARROW IMAGING, LTD
239.14
223.18
497.82
458.22
26 BONE MARROW IMAGING, LTD
41.69
40.34
BONE MARROW IMAGING, MULT
370.12
347.33
TC BONE MARROW IMAGING, MULT
313.68
292.71
497.82
458.22
26 BONE MARROW IMAGING, MULT
56.45
54.63
LIVER & SPLEEN IMAGING
325.54
305.08
TC LIVER & SPLEEN IMAGING
287.47
268.26
513.54
472.68
26 LIVER & SPLEEN IMAGING
38.07
36.82
LIVER FUNCTION STUDY
230.17
216.05
TC LIVER FUNCTION STUDY
193.72
180.82
513.54
472.68
26 LIVER FUNCTION STUDY
36.45
35.23
HEPATOBILIARY IMAGING
560.43
525.09
TC HEPATOBILIARY IMAGING
495.93
462.72
513.54
472.68
26 HEPATOBILIARY IMAGING
64.50
62.36
SALIVARY GLAND FUNCTION EXAM 197.59
185.66
TC SALIVARY GLAND FUNCTION EXAM 163.44
152.57
463.50
426.63
26 SALIVARY GLAND FUNCTION EXAM 34.15
33.11
BONE IMAGING, LIMITED AREA
297.19
278.96
TC BONE IMAGING, LIMITED AREA
249.03
232.42
473.94
436.23
26 BONE IMAGING, LIMITED AREA
48.16
46.54
BONE IMAGING, MULTIPLE AREAS 392.22
368.16
TC BONE IMAGING, MULTIPLE AREAS 328.81
306.83
473.94
436.23
26 BONE IMAGING, MULTIPLE AREAS
63.41
61.32
BONE IMAGING, WHOLE BODY
427.52
401.16
TC BONE IMAGING, WHOLE BODY
361.42
337.25
473.94
436.23
26 BONE IMAGING, WHOLE BODY
66.11
63.91
BONE IMAGING, 3 PHASE
583.48
547.06
26 BONE IMAGING, 3 PHASE
78.23
75.64
BONE IMAGING (3D)
410.39
385.64
N1
MEDICAL FEE SCHEDULES
78320
78320
78445
78445
78445
78451
78451
78451
78452
78452
78452
78469
78469
78469
78472
78472
78472
78481
78481
78481
78494
78494
78494
78580
78580
78580
78584
78584
78584
78585
78585
78585
78588
78588
78588
78594
78594
78594
78596
78596
78596
78607
78607
78607
78707
78707
78707
78708
78315
78708
78708
78709
78709
78709
78802
78802
78802
78803
78803
78803
78805
78805
78805
78806
78806
78806
78815
78815
78815
TC BONE IMAGING (3D)
331.14
309.00
26 BONE IMAGING (3D)
79.25
76.64
VASCULAR FLOW IMAGING
289.56
271.46
TC VASCULAR FLOW IMAGING
253.11
236.21
26 VASCULAR FLOW IMAGING
36.45
35.23
HEART MUSCLE IMAGE SPECT, SING 573.80
538.92
TC HEART MUSCLE IMAGE SPECT, SING 471.47
439.91
26 HEART MUSCLE IMAGE SPECT, SING 102.33
98.99
HEART MUSCLE IMAGE SPECT, MULT806.02
756.16
TC HEART MUSCLE IMAGE SPECT, MULT685.12
639.23
26 HEART MUSCLE IMAGE SPECT, MULT120.91
116.93
HEART INFARCT IMAGE (3D)
434.71
407.96
TC HEART INFARCT IMAGE (3D)
360.26
336.16
26 HEART INFARCT IMAGE (3D)
74.45
71.81
GATED HEART, PLANAR, SING
424.29
398.43
TC GATED HEART, PLANAR, SING
347.44
324.22
26 GATED HEART, PLANAR, SING
76.85
74.22
HEART FIRST PASS, SING
352.85
331.69
TC HEART FIRST PASS, SING
273.62
255.27
26 HEART FIRST PASS, SING
79.24
76.41
HEART IMAGE, SPECT
450.67
423.55
TC HEART IMAGE, SPECT
356.18
332.36
26 HEART IMAGE, SPECT
94.49
91.19
LUNG PERFUSION IMAGING
358.61
336.54
TC LUNG PERFUSION IMAGING
302.02
281.84
26 LUNG PERFUSION IMAGING
56.59
54.70
LUNG V/Q IMAGE SINGLE BREATH 254.13
239.75
TC LUNG V/Q IMAGE SINGLE BREATH 177.41
165.60
26 LUNG V/Q IMAGE SINGLE BREATH
76.71
74.15
LUNG V/Q IMAGING
596.93
559.78
TC LUNG V/Q IMAGING
513.39
479.02
26 LUNG V/Q IMAGING
83.53
80.76
PERFUSION LUNG IMAGE
578.30
542.40
TC PERFUSION LUNG IMAGE
494.76
461.64
26 PERFUSION LUNG IMAGE
83.53
80.76
VENT IMAGE, MULT PROD, GAS
367.16
344.02
TC VENT IMAGE, MULT PROJ, GAS
327.06
305.21
26 VENT IMAGE, MULT PROJ, GAS
40.10
38.81
LUNG DIFFERENTIAL FUNCTION
628.84
589.95
TC LUNG DIFFERENTIAL FUNCTION
534.36
498.57
26 LUNG DIFFERENTIAL FUNCTION
94.47
91.38
BRAIN IMAGING (3D)
612.19
574.36
TC BRAIN IMAGING (3D)
519.80
485.00
26 BRAIN IMAGING (3D)
92.38
89.36
KID FLOW/FUNCT IMAGE W/O DRUG 399.99
375.71
TC KID FLOW/FUNCT IMAGE W/O DRUG 327.06
305.21
26 KID FLOW/FUNCT IMAGE W/O DRUG 72.93
70.51
KID FLOW/FUNCT IMAGE W/DRUG 300.23
283.29
TC BONE IMAGING, 3 PHASE
505.25
471.42
TC KID FLOW/FUNCT IMAGE W/DRUG 207.69
193.85
26 KID FLOW/FUNCT IMAGE W/DRUG
92.54
89.46
KIDNEY IMG MORPHOLOGY
VASCULAR FLOW MULTIPLE
617.12
579.46
TC KIDNEY IMG MORPHOLOGY
VASCULAR FLOW MULTIPLE
509.32
475.22
26 KIDNEY IMG MORPHOLOGY
VASCULAR FLOW MULTIPLE
107.80
104.25
TUMOR IMAGING, WHOLE BODY
553.30
518.48
TC TUMOR IMAGING, WHOLE BODY
487.77
455.12
26 TUMOR IMAGING, WHOLE BODY
65.53
63.37
TUMOR IMAGING (3D)
593.44
556.52
TC TUMOR IMAGING (3D)
511.06
476.84
26 TUMOR IMAGING (3D)
82.37
79.68
ABSCESS IMAGING, LID AREA
310.29
291.48
TC ABSCESS IMAGING, LTD AREA
254.27
237.31
26 ABSCESS IMAGING, LTD AREA
56.00
54.17
ABSCESS IMAGING, WHOLE BODY 573.09
536.94
TC ABSCESS IMAGING, WHOLE BODY 507.58
473.59
26 ABSCESS IMAGING, WHOLE BODY
65.53
63.37
PET IMAGE W/CT, SKULL-THIGH 1,978.16 1,852.07
TC PET IMAGE W/CT, SKULL-THIGH 1,785.85 1,665.93
26 PET IMAGE W/CT, SKULL-THIGH
192.33
186.13
11:3-29.6
473.94
436.23
388.05
357.18
1,471.83
1,354.74
1,471.83
1,354.74
564.39
519.48
564.39
519.48
564.39
519.48
564.39
519.48
381.24
350.91
619.65
570.36
619.65
570.36
619.65
570.36
381.24
350.91
619.65
570.36
1,154.88
1,062.99
622.62
573.09
473.94
622.62
436.23
573.09
622.62
573.09
919.98
846.78
919.98
846.78
919.98
846.78
919.98
846.78
2,018.19
1,857.66
11:3-29.6
APPENDIX B - REGULATIONS
79101
NUCLEAR RX, IV ADMIN
261.42
79101 TC NUCLEAR RX, IV ADMIN
101.83
79101 26 NUCLEAR RX, IV ADMIN
159.59
80500
LAB PATHOLOGY CONSULTATION
32.57
83020 26 ASSAY HEMOGLOBIN
ELECTROPHORESIS
30.24
83912 26 ASSAY GENETIC EXAM
28.49
84165 26 ASSAY PROTEIN E-PHORESIS, SERUM 29.66
84166 26 ASSAY PROTEIN
E-PHORESIS/URINE/CSF
29.66
84182 26 ASSAY PROTEIN, WESTERN BLOT
TEST
29.66
85060
BLOOD SMEAR INTERPRETATION
36.04
85097
BONE MARROW INTERPRETATION 139.39
85576 26 BLOOD PLATELET AGGREGATION
30.24
86255 26 FLUORESCENT ANTIBODY, SCREEN 30.24
86256 26 FLUORESCENT ANTIBODY, TITER
29.19
86334 26 IMMUNOFLX E-PHORESIS, SERUM
30.24
86335 26 IMMUNOFIX E-PHORESIS/URINE/CSF 29.66
86510
HISTOPLASMOSIS SKIN TEST
11.00
86580
TB INTRADERMAL TEST
12.75
88104
CYTOPATH FL NONGYN, SMEARS
107.49
88104 TC CYTOPATH FL NONGYN, SMEARS
64.57
88104 26 CYTOPATH FL NONGYN, SMEARS
42.92
88106
CYTOPATH FL NONGYN, FILTER
132.53
88106 TC CYTOPATH FL NONGYN, FILTER
90.20
88106 26 CYTOPATH FL NONGYN, FILTER
42.33
88108
CYTOPATH, CONCENTRATE TECH 124.96
88108 TC CYTOPATH, CONCENTRATE TECH
82.62
88108 26 CYTOPATH, CONCENTRATE TECH
42.33
88112
CYTOPATH, CELL ENHANCE TECH 166.71
88112 TC CYTOPATH, CELL ENHANCE TECH
79.13
88112 26 CYTOPATH, CELL ENHANCE TECH
87.58
88120
CYTOPATH, URINE 3-5 PROBES EA
SPEC
772.67
88120 TC CYTOPATH, URINE 3-5 PROBES EA
SPEC
692.17
88120 26 CYTOPATH, URINE 3-5 PROBES EA
SPEC
80.50
88121
CYTOPATH, URINE 3-5 PROBES
COMPUTER
652.59
88121 TC CYTOPATH, URINE 3-5 PROBES
COMPUTER
580.48
88121 26 CYTOPATH, URINE 3-5 PROBES
COMPUTER
72.11
88141
CYTOPATH, C/V, INTERPRET
46.17
88172
CYTOPATH FNA; 1ST EVAL, EACH
SITE
82.15
88172 TC CYTOPATH FNA; 1ST EVAL, EACH
SITE
35.46
88172 26 CYTOPATH FNA; 1 ST EVAL, EACH
SITE
46.68
88173
CYTOPATH FNA; INTERPRET &
REPORT
225.11
88173 TC CYTOPATH FNA; INTERPRET &
REPORT
118.73
88173 26 CYTOPATH FNA; INTERPRET &
REPORT
106.40
88177
CYTOPATH FNA; ADDED EVAL, SAME
SITE
44.48
88177 TC CYTOPATH FNA; ADDED EVAL, SAME
SITE
11.00
88177 26 CYTOPATH FNA; ADDED EVAL, SAME
SITE
33.48
88184
FLOW CYTOMETRY/ TC, 1 MARKER 143.77
88185
FLOW CYTOMETRY/TC, ADDED
86.12
88187
FLOW CYTOMETRY/READ, 2-8
105.20
88300
SURGICAL PATH, GROSS
45.28
88300 TC SURGICAL PATH, GROSS
38.37
88300 26 SURGICAL PATH, GROSS
6.91
88302
TISSUE EXAM BY PATHOLOGIST
90.32
88302 TC TISSUE EXAM BY PATHOLOGIST
80.29
248.93
95.03
153.90
31.39
29.22
27.58
28.66
28.66
28.66
34.83
132.50
29.22
29.22
28.17
29.22
28.66
10.30
11.92
101.71
60.27
41.44
125.06
84.17
40.88
117.99
77.11
40.88
158.56
73.85
84.72
723.91
645.78
78.13
611.34
541.53
69.80
44.20
78.16
33.11
45.05
213.56
110.79
102.77
42.59
10.30
32.29
134.15
80.36
101.74
42.50
35.83
6.68
84.64
74.93
203.55
187.38
MEDICAL FEE SCHEDULES
88302
88304
88304
88304
88305
88305
88305
88307
88307
88307
88309
88309
88309
88311
88311
88311
88312
88312
88312
88313
88313
88313
88331
88331
88331
88332
88332
88332
88334
88334
88334
88342
88342
88342
88346
88346
88346
88360
88360
88360
88363
88367
88367
88367
88368
88368
88368
88372
90461
90471
90472
90801
90802
90804
90805
90806
90807
90808
90809
90810
90811
90812
90813
90814
90816
26 TISSUE EXAM BY PATHOLOGIST
10.03
TISSUE EXAM BY PATHOLOGIST
105.37
TC TISSUE EXAM BY PATHOLOGIST
88.45
26 TISSUE EXAM BY PATHOLOGIST
16.93
TISSUE EXAM BY PATHOLOGIST
175.94
TC TISSUE EXAM BY PATHOLOGIST
119.31
26 TISSUE EXAM BY PATHOLOGIST
56.63
TISSUE EXAM BY PATHOLOGIST
375.59
TC TISSUE EXAM BY PATHOLOGIST
251.49
26 TISSUE EXAM BY PATHOLOGIST
124.10
TISSUE EXAM BY PATHOLOGIST
565.90
TC TISSUE EXAM BY PATHOLOGIST
349.19
26 TISSUE EXAM BY PATHOLOGIST
216.70
DECALCIFY TISSUE
30.10
TC DECALCIFY TISSUE
11.58
26 DECALCIFY TISSUE
18.52
SPECIAL STAINS GROUP 1
178.67
TC SPECIAL STAINS GROUP 1
137.94
26 SPECIAL STAINS GROUP 1
40.73
SPECIAL STAINS GROUP 2
131.42
TC SPECIAL STAINS GROUP 2
113.49
26 SPECIAL STAINS GROUP 2
17.93
PATH CONSULT INTRAOP, 1 BLOC 147.61
TC PATH CONSULT INTRAOP, 1 BLOC
54.67
26 PATH CONSULT INTRAOP, 1 BLOC
92.94
PATH CONSULT INTRAOP, ADDED
64.76
TC PATH CONSULT INTRAOP, ADDED
19.16
26 PATH CONSULT INTRAOP, ADDED
45.60
INTRAOP CYTO PATH CONSULT, 2
95.03
TC INTRAOP CYTO PATH CONSULT, 2
37.79
26 INTRAOP CYTO PATH CONSULT, 2
57.24
OHISTOCHEMISTRY
171.57
TC OHISTOCHEMISTRY
107.66
26 IMMUNOHISTOCHEMISTRY
63.91
IMMUNOFLUORESCENT STUDY
168.13
TC IMMUNOFLUORESCENT STUDY
104.17
26 IMMUNOFLUORESCENT STUDY
63.96
TUMOR OHISTOCHEM/MANUAL
202.89
TC TUMOR
IMMUNOHISTOCHEM/MANUAL
121.64
26 TUMOR
IMMUNOHISTOCHEM/MANUAL
81.26
EXAM ARCHIVAL TISSUE MOLECULAR
ANAL
62.26
INSITU HYBRIDIZATION, AUTO
428.95
TC INSITU HYBRIDIZATION, AUTO
334.76
26 INSITU HYBRIDIZATION, AUTO
94.19
INSITU HYBRIDIZATION, MANUAL 365.96
TC INSITU HYBRIDIZATION, MANUAL 270.12
26 INSITU HYBRIDIZATION, MANUAL
95.84
26 PROTEIN ANALYSIS W/PROBE
30.24
IMM ADMIN 0-18 ANY ROUTE, EA
ADDED
18.62
IMMUNIZATION ADMIN
38.26
IMMUNIZATION ADMIN, EACH ADDED18.62
PSYCH DIAG INTERVIEW
242.14
INTERACT PSYCH DIAG INTERVIEW 263.21
PSYCH, OFF, 20-30 MIN
103.95
PSYCH, OFF, 20-30 MINIMUM W/E &
M
118.52
PSYCH, OFF, 45-50 MIN
137.79
PSYCH, OFF, 45-50 MINIMUM W/E &
M
163.35
PSYCH, OFF, 75-80 MIN
202.42
PSYCH, OFF, 75-80, W/E & M
228.55
INTERACT PSYCH, OFF, 20-30 MIN
106.69
INTERACT PSYCH, 20-30, W/E & M
134.04
INTERACT PSYCH, OFF, 45-50 MIN
151.59
INTERACT PSYCH, 45-50 MINIMUM
W/E & M
177.78
INTERACT PSYCH, OFF, 75-80 MIN
218.01
PSYCH, HOSP, 20-30 MTN
84.68
9.71
98.91
82.54
16.36
166.03
111.33
54.70
354.43
234.63
119.80
535.11
325.84
209.27
28.73
10.84
17.91
168.06
128.71
39.35
123.25
105.90
17.35
140.67
51.03
89.63
61.92
17.91
44.01
90.57
35.29
55.28
162.26
100.47
61.80
159.00
97.20
61.80
192.09
113.50
78.59
59.09
403.53
312.31
91.22
344.97
252.01
92.95
29.22
17.76
36.14
17.76
233.10
253.31
100.23
114.27
133.55
157.87
196.35
221.21
103.09
129.09
146.73
171.60
211.20
82.35
11:3-29.6
11:3-29.6
90817
90818
90819
90826
90846
90847
90853
90857
90862
90880
90901
90911
90935
90945
90961
90962
91010
91010 TC
91010 26
91013
91013 TC
91013 26
92002
92004
92012
92014
92020
92025
92025
92025
92060
92060
92060
92065
92065
92065
92070
92081
92081
92081
92082
TC
26
TC
26
TC
26
TC
26
92082 TC
92082 26
92083
92083 TC
92083 26
92132
92132 TC
92132 26
92133
92133 TC
92133 26
92134
92134 TC
92134 26
APPENDIX B - REGULATIONS
PSYCH, HOSP, 20-30 MINIMUM W/E &
M
102.93
PSYCH, HOSP, 45-50 MIN
125.31
PSYCH, HOSP, 45-50 MINIMUM W/E &
M
147.22
INTERACT PSYCH, HOSP, 45-50 MIN 134.16
FAMILY PSYCH W/O PATIENT
130.28
FAMILY PSYCH W/PATIENT
162.90
GROUP PSYCHOTHERAPY
77.13
INTERACT GROUP PSYCH
57.98
MEDICATION MANAGEMENT
105.73
HYPNOTHERAPY
155.47
BIOFEEDBACK TRAIN, ANY METHOD114.92
BIOFEEDBACK PERI/URO/RECTAL 142.55
HEMODIALYSIS, ONE EVAL
116.53
DIALYSIS, ONE EVAL
166.37
ESRD SERVICE, 2-3 VISITS P MO, 20+ 129.32
ESRD SERVICE, 1 VISIT P MO, 20+
275.65
ESOPHAGUS MOTILITY STUDY
311.34
ESOPHAGUS MOTILITY STUDY
203.16
ESOPHAGUS MOTILITY STUDY
108.19
ESOPH MOTILITY STUDY
W/STIM/PERFUS
38.13
ESOPH MOTILITY STUDY
W/STIM/PERFUS
22.65
ESOPH MOTILITY STUDY
W/STIM/PERFUS
15.48
EYE EXAM, NEW PATIENT
122.24
EYE EXAM, NEW PATIENT
225.54
EYE EXAM ESTABLISHED PAT
129.52
EYE EXAM & TREAT
187.31
SPECIAL EYE EVAL
41.88
CORNEAL TOPOGRAPHY
57.23
CORNEAL TOPOGRAPHY
27.30
CORNEAL TOPOGRAPHY
29.93
SPECIAL EYE EVAL
98.24
SPECIAL EYE EVAL
39.53
SPECIAL EYE EVAL
58.70
ORTHOPTIC/PLEOPTIC TRAINING
123.66
ORTHOPTIC/PLEOPTIC TRAINING
81.42
ORTHOPTIC/PLEOPTIC TRAINING
42.22
FIT CONTACT LENS
109.22
VISUAL FIELD EXAM(S) LIMITED
80.77
VISUAL FIELD EXAM(S) LIMITED
54.67
VISUAL FIELD EXAM(S) LIMITED
26.11
VISUAL FIELD EXAM(S)
INTERMEDIATE
112.58
VISUAL FIELD EXAM(S)
INTERMEDIATE
77.96
VISUAL FIELD EXAM(S)
INTERMEDIATE
34.60
VISUAL FIELD EXAM(S) EXTENDED 140.42
VISUAL FIELD EXAM(S) EXTENDED 97.19
VISUAL FIELD EXAM(S) EXTENDED 43.24
SCAN COMP OPTH DX IMAGING, ANT
SEG
59.44
SCAN COMP OPTH DX IMAGING, ANT
SEG
26.15
SCAN COMP OPTH DX IMAGING, ANT
SEG
33.30
SCAN COMP OPTH DX IMAGING, POST
SEG
72.29
SCAN COMP OPTH DX IMAGING, POST
SEG
26.15
SCAN COMP OPTH DX IMAGING, POST
SEG
46.14
SCAN COMP OPTH DX IMAGING,
RETINA
72.29
SCAN COMP OPTH DX IMAGING,
RETINA
26.15
SCAN COMP OPTH DX IMAGING,
RETINA
46.14
99.80
122.00
142.89
130.57
126.25
157.63
74.33
55.73
101.47
150.66
109.20
135.40
112.59
160.72
124.73
265.53
293.84
189.54
104.29
36.07
21.16
14.91
116.43
215.25
123.31
178.54
40.07
54.31
25.51
28.81
93.46
36.92
56.54
116.86
76.02
40.84
103.74
76.23
51.03
25.18
106.17
72.76
33.40
132.35
90.69
41.67
56.45
24.41
32.02
68.79
24.41
44.38
68.79
24.41
44.38
MEDICAL FEE SCHEDULES
92136
OPHTHALMIC BIOMETRY
137.92
92136 TC OPHTHALMIC BIOMETRY
91.36
92136 26 OPHTHALMIC BIOMETRY
46.55
92225
SPECIAL EYE EXAM, INITIAL
40.64
92226
SPECIAL EYE EXAM, SUBSEQUENT 36.48
92227
REMOTE IMAGING RETINAL DISEASE 19.74
92228
REMOTE IMAGING MONITOR RETINAL
DIS
48.87
92228 TC REMOTE IMAGING MONITOR RETINAL
DIS
21.49
92228 26 REMOTE IMAGING MONITOR RETINAL
DIS
27.38
92230 26 FLUORESCEIN ANGIOSCOPY
93.66
92235
FLUORESCEIN ANGIOGRAPHY
217.30
92235 TC FLUORESCEIN ANGIOGRAPHY
146.09
92235 26 FLUORESCEIN ANGIOGRAPHY
71.20
92250
EYE EXAM W/PHOTOS
122.36
92250 TC EYE EXAM W/PHOTOS
86.12
92250 26 EYE EXAM W/PHOTOS
36.24
92275
ELECTRORETINOGRAPHY
234.95
92275 TC ELECTRORETINOGRAPHY
147.25
92275 26 ELECTRORETINOGRAPHY
87.69
92285
EYE PHOTOGRAPHY
47.25
92285 TC EYE PHOTOGRAPHY
40.70
92285 26 EYE PHOTOGRAPHY
6.55
92286
INTERNAL EYE PHOTOGRAPHY
198.16
92286 TC INTERNAL EYE PHOTOGRAPHY
143.19
92286 26 INTERNAL EYE PHOTOGRAPHY
54.98
92311
CONTACT LENS FITTING APHAKIA
ONE EYE
156.21
92326
REPLACE CONTACT LENS
61.08
92371
EXT PAT/AUTO ECG TO 30 DAYS,
DOWNLOAD
359.22
92504
EAR MICROSCOPY EXAM
154.22
92506
SPEECH/HEARING EVAL
50.42
92507
SPEECH/HEARING THERAPY
279.74
92508
SPEECH/HEARING THERAPY
130.75
92511
NASOPHARYNGOSCOPY
43.47
92526
ORAL FUNCTION THERAPY
267.73
92540
BASIC VESTIBULAR EVALUATION 155.00
92540 TC BASIC VESTIBULAR EVALUATION
31.96
92540 26 BASIC VESTIBULAR EVALUATION 123.04
92541
SPONTANEOUS NYSTAGMUS TEST
74.91
92541 TC SPONTANEOUS NYSTAGMUS TEST
43.03
92541 26 SPONTANEOUS NYSTAGMUS TEST
31.87
92542
POSITIONAL NYSTAGMUS TEST
74.85
92542 TC POSITIONAL NYSTAGMUS TEST
48.27
92542 26 POSITIONAL NYSTAGMUS TEST
26.59
92543
CALORIC VESTIBULAR TEST
37.56
92543 TC CALORIC VESTIBULAR TEST
29.05
92543 26 CALORIC VESTIBULAR TEST
8.51
92544
OPTOKINETIC NYSTAGMUS TEST
61.40
92544 TC OPTOKINETIC NYSTAGMUS TEST
40.70
92544 26 OPTOKINETIC NYSTAGMUS TEST
20.71
92545
OSCILLATING TRACKING TEST
57.55
92545 TC OSCILLATING TRACKING TEST
38.95
92545 26 OSCILLATING TRACKING TEST
18.60
92546
SINUSOIDAL ROTATIONAL TEST
159.00
92546 TC SINUSOIDAL ROTATIONAL TEST
136.20
92546 26 SINUSOIDAL ROTATIONAL TEST
22.81
92547
SUPPLEMENTAL ELECTRICAL TEST
8.67
92548
POSTUROGRAPHY
171.41
92548 TC POSTUROGRAPHY
131.54
92548 26 POSTUROGRAPHY
39.86
92550
TYMPANOMETRY & REFLEX THRESH 32.84
92552
PURE TONE AUDIOMETRY, AIR
43.61
92553
AUDIOMETRY, AIR & BONE
55.25
92556
SPEECH AUDIOMETRY, COMPLETE 49.44
92557
COMPREHENSIVE HEARING TEST
64.62
92563
TONE DECAY HEARING TEST
42.45
92564
SISI HEARING TEST
38.37
92565
STENGER TEST, PURE TONE
22.07
130.04
85.25
44.78
38.95
34.87
18.45
46.40
20.08
26.32
88.99
204.82
136.31
68.50
115.28
80.36
34.92
221.80
137.40
84.41
44.27
38.00
6.27
186.53
133.60
52.94
148.63
57.01
335.12
147.79
47.51
263.23
125.38
41.40
251.93
148.43
29.86
118.58
70.93
40.17
30.75
70.70
45.06
25.64
35.36
27.14
8.21
57.98
38.00
19.98
54.31
36.37
17.95
149.10
127.09
22.01
8.13
161.18
122.74
38.44
31.52
40.71
51.59
46.14
61.85
39.63
35.83
20.62
11:3-29.6
11:3-29.6
92567
92568
92570
92582
92584
92585
92585
92585
92586
92587
92587
92587
92588
92588
92588
92607
92611
92612
92613
92620
92621
92625
92626
92950
92960
92971
92975
92982
93000
93005
93010
93015
93016
93017
93018
93040
93042
93224
93225
93226
93227
93228
93229
93268
TC
26
TC
26
TC
26
93270
93272
93280
93280
93280
93281
93281
93281
93282
TC
26
TC
26
93282 TC
93282 26
93283
93283
93283
93284
93284
93284
93285
93285
93285
93288
93288
TC
26
TC
26
TC
26
TC
APPENDIX B - REGULATIONS
TYMPANOMETRY
24.64
ACOUSTIC REFLEX THRESHOLD TEST26.30
ACOUSTIC IMMITTANCE TESTING
50.43
CONDITIONING PLAY AUDIOMETRY 87.87
ELECTROCOCHLEOGRAPHY
114.07
AUDITOR EVOKE POTENT, COMPRE 292.37
AUDITOR EVOKE POTENT, COMPRE 231.02
AUDITOR EVOKE POTENT, COMPRE 61.33
AUDITOR EVOKE POTENT, LIMIT
120.48
EVOKED AUDITORY TEST
62.37
EVOKED AUDITORY TEST
51.17
EVOKED AUDITORY TEST
11.20
EVOKED AUDITORY TEST
110.73
EVOKED AUDITORY TEST
81.46
EVOKED AUDITORY TEST
29.27
EXCISE FOR SPEECH DEVICE RX, 1HR287.74
MOTION FLUOROSCOPY/SWALLOW 183.96
ENDOSCOPY SWALLOW TEST (FEES) 275.96
ENDOSCOPY SWALLOW TEST (FEES) 60.24
AUDITORY FUNCTION, 60 MIN
129.83
AUDITORY FUNCTION, + 15 MIN
29.93
TINNITUS ASSESS
99.39
EVAL AUDITORY REHAB STATUS
132.91
HEART/LUNG RESUSCITATION CPR 451.32
CARDIOVERSION ELECTRIC, EXT
395.13
CARDIOASSIST, EXTERNAL
156.11
DISSOLVE CLOT, HEART VESSEL
660.35
CORONARY ARTERY DILATION
1,011.84
ELECTROCARDIOGRAM, COMPLETE 37.35
ELECTROCARDIOGRAM, TRACING
28.57
ELECTROCARDIOGRAM REPORT
19.11
CARDIOVASCULAR STRESS TEST
152.58
CARDIOVASCULAR STRESS TEST
36.17
CARDIOVASCULAR STRESS TEST
92.53
CARDIOVASCULAR STRESS TEST
23.90
RHYTHM ECG W/R.EPORT
21.46
RHYTHM ECG, REPORT
26.83
ECG MONITOR/REPORT, 24 HRS
161.88
ECG MONITOR/RECORD, 24 HRS
48.27
ECG MONITOR/REPORT, 24 HRS
70.98
ECG MONITOR/REVIEW, 24 HRS
42.63
REMOTE 30 DAY ECG REV/REPORT
40.17
REMOTE 30 DAY ECG TECH SUPP 1,167.45
EXT PAT/AUTO ECG TO 30 DAYS,
COMPLETE
425.66
EXT PAT/AUTO ECG TO 30 DAYS,
RECORDING
26.15
EXT PAT/AUTO ECG TO 30 DAYS,
REPORT
40.30
PM DEVICE PROGRAM EVAL, DUAL 100.54
PM DEVICE PROGRAM EVAL, DUAL 36.62
PM DEVICE PROGRAM EVAL, DUAL 63.92
PM DEVICE PROGRAM EVAL, MULTI 117.04
PM DEVICE PROGRAM EVAL, MULTI 42.45
PM DEVICE PROGRAM EVAL, MULTI 74.59
ICD DEVICE PROGRAM EVAL, 1
SINGLE
107.52
ICD DEVICE PROGRAM EVAL, 1
SINGLE
37.79
ICD DEVICE PROGRAM EVAL, 1
SINGLE
69.73
ICD DEVICE PROGRAM EVAL, DUAL 137.23
ICD DEVICE PROGRAM EVAL, DUAL 43.61
ICD DEVICE PROGRAM EVAL, DUAL 93.64
ICD DEVICE PROGRAM EVAL, MULT 152.79
ICD DEVICE PROGRAM EVAL, MULT 49.44
ICD DEVICE PROGRAM EVAL, MULT 103.36
ILR DEVICE EVAL PROGRAM
71.68
ILR DEVICE EVAL PROGRAM
29.05
ILR DEVICE EVAL PROGRAM
42.63
PM DEVICE EVAL IN PERSON
64.79
PM DEVICE EVAL IN PERSON
29.63
23.52
25.28
48.49
82.00
106.44
274.71
215.57
59.14
112.42
58.58
47.78
10.80
104.24
76.03
28.22
273.29
175.16
260.78
58.07
125.03
28.81
95.70
127.66
431.31
374.58
150.32
639.20
978.97
35.40
26.72
18.46
144.27
34.87
86.34
23.06
20.46
25.94
152.38
45.06
66.25
41.07
38.85
1,089.06
398.44
24.41
38.90
95.81
34.19
61.62
111.53
39.63
71.89
102.52
35.29
67.23
131.01
40.71
90.30
145.76
46.14
99.62
68.21
27.14
41.07
61.56
27.68
MEDICAL FEE SCHEDULES
93288
93289
93289
93289
93290
93290
93290
93293
93293
93293
93294
93295
93296
93297
93299
93303
93303
93303
93306
93306
93306
93307
93307
93307
93308
93308
93308
93312
93312
93312
93313
93314
93314
93314
93320
93320
93320
93321
93321
93321
93325
93325
93325
93350
93350
93350
93351
93351
93351
93451
93451
93451
93452
93452
93452
93453
93453
93453
93454
93454
93454
93455
93455
93455
93456
93456
26 PM DEVICE EVAL IN PERSON
35.16
ICD DEVICE INTERROGATE
109.91
TC ICD DEVICE INTERROGATE
36.62
26 ICD DEVICE INTERROGATE
73.29
ICM DEVICE EVAL
49.07
TC ICM DEVICE EVAL
16.83
26 ICM DEVICE EVAL
32.24
PM PHONE R-STRIP DEVICE EVAL
93.56
TC PM PHONE R-STRIP DEVICE EVAL
68.65
26 PM PHONE R-STRIP DEVICE EVAL
24.91
PM DEVICE INTERROGATE REMOTE 54.29
ICD DEVICE INTERROGATE REMOTE 106.89
PM/ICD REMOTE TECH SERV
55.83
ICM DEVICE INTERROGATE REMOTE 40.17
ICM/ILR REMOTE TECH SERV
73.04
ECHO TRANSTHORACIC
350.40
TC ECHO TRANSTHORACIC
246.83
26 ECHO TRANSTHORACIC
103.57
TTE W/DOPPLER, COMPLETE
388.84
TC TTE W/DOPPLER, COMPLETE
282.94
26 TTE W/DOPPLER, COMPLETE
105.90
TTE W/O DOPPLER, COMPLETE
246.74
TC TTE W/O DOPPLER, COMPLETE
172.29
26 TTE W/O DOPPLER, COMPLETE
74.45
TTE, F-UP OR LIMITED
176.43
TC TTE, F-UP OR LIMITED
133.87
26 TTE, F-UP OR LIMITED
42.56
ECHO TRANSESOPHAGEAL
537.84
TC ECHO TRANSESOPHAGEAL
366.07
26 ECHO TRANSESOPHAGEAL
171.77
ECHO TRANSESOPHAGEAL
63.49
ECHO TRANSESOPHAGEAL
479.33
TC ECHO TRANSESOPHAGEAL
381.22
26 ECHO TRANSESOPHAGEAL
98.13
DOPPLER ECHO EXAM, HEART
104.18
TC DOPPLER ECHO EXAM, HEART
73.90
26 DOPPLER ECHO EXAM,. HEART
30.28
DOPPLER ECHO EXAM, HEART
48.83
TC DOPPLER ECHO EXAM, HEART
36.62
26 DOPPLER ECHO EXAM, HEART
12.21
DOPPLER COLOR FLOW, ADDED
60.50
TC DOPPLER COLOR FLOW, ADDED
54.67
26 DOPPLER COLOR FLOW, ADDED
5.81
STRESS TTE ONLY
349.1.5
TC STRESS TTE ONLY
229.95
26 STRESS TTE ONLY
119.20
STRESS TTE COMPLETE
410.89
TC STRESS TTE COMPLETE
267.09
26 STRESS TTE COMPLETE
143.81
RIGHT HEART CATH
1,284.20
TC RIGHT HEART CATH
1,053.77
26 RIGHT HEART CATH
230.43
LEFT HEART CATH
W/VENTRCLGRPHY
1,410.49
TC LEFT HEART CATH
W/VENTRCLGRPHY
1,006.61
26 LEFT HEART CATH
W/VENTRCLGRPHY403.89
392.06
R&L HEART CATH
W/VENTRICLGRPHY
1,845.72
TC R&L HEART CATH
W/VENTRICLGRPHY
1,316.32
26 R&L HEART CATH
W/VENTRICLGRPHY
529.40
CATH PLACE CORONARY ANGIO 1,455.61
TC CATH PLACE CORONARY ANGIO 1,048.53
26 CATH PLACE CORONARY ANGIO
407.08
CATH PLACE BYPASS GRAFTS
1,698.80
TC CATH PLACE BYPASS GRAFTS
1,228.98
26 CATH PLACE BYPASS GRAFTS
469.82
CATH PLACE WITH R HEART CATH 1,820.43
TC CATH PLACE WITH R HEART CATH 1,299.44
33.88
104.92
34.19
70.71
46.90
15.73
31.16
88.12
64.08
24.06
52.37
103.14
52.13
38.85
68.85
330.22
230.29
99.93
366.07
263.97
102.10
232.56
160.77
71.81
165.94
124.91
41.03
507.44
341.60
165.84
61.79
450.44
355.71
94.73
98.17
68.97
29.22
45.99
34.19
11.79
56.67
51.03
5.63
329.46
214.54
114.94
387.86
249.26
138.60
1,206.75
983.10
223.66
1,331.17
939.09
1,741.92
1,228.06
513.86
1,373.35
978.22
395.15
1,602.61
1,146.57
456.03
1,717.97
1,212.30
11:3-29.6
11:3-29.6
APPENDIX B - REGULATIONS
93456 26 CATH PLACE WITH R HEART CATH 521.00
93457
R HEART ART/GRAFT ANGIO
2,063.64
93457 TC R HEART ART/GRAFT ANGIO
1,479.36
93457 26 R HEART ART/GRAFT ANGIO
584.28
93458
L HEART ARTERY/VENTRICLE
ANGIO
1,755.96
93458 TC L HEART ARTERY/VENTRICLE
ANGIO
1,259.26
93458 26 L HEART ARTERY/VENTRICLE
ANGIO
496.71
93459
L HEART ART/GRAFT ANGIO
1,938.14
93459 TC L HEART ART/GRAFT ANGIO
1,379.22
93459 26 L HEART ART/GRAFT ANGIO
558.94
93460
R & L HEART ART/VENTRICLE
ANGIO
2,071.87
93460 TC R & L HEART ART/VENTRICLE
ANGIO
1,449.09
93460 26 R & L HEART ART/VENTRICLE
ANGIO
622.77
93461
R & L HEART ART/VENTRICLE
ANGIO
2,376.60
93461 TC R & L HEART ART/VENTRICLE
ANGIO
1,689.51
93461 26 R & L HEART ART/VENTRICLE
ANGIO
687.09
93462
L HEART CATH TRANSPLANT
PUNCTURE
316.47
93463
DRUG ADMIN & HEMODYNMIC
MEAS
167.77
93464
EXERCISE W/HEMODYNAMIC MEAS 416.35
93464 TC EXERCISE W/HEMODYNAMIC MEAS 268.95
93464 26 EXERCISE W/HEMODYNAMIC MEAS 147.39
93503
INSERT/PLACE HEART CATHETER 206.54
93563
INJECT CONGENITAL CARD CATH
87.15
93564
INJECT HEART CONGNTL ART/GRAFT 88.69
93565
INJECT L VENTR/ATRIAL ANGIO
67.02
93566
INJECT R VENTR/ATRIAL ANGIO
283.05
93567
INJECT SUPRVLV AORTOGRAPHY 231.57
93568
INJECT PULM ART HEART CATH
254.94
93609 26 MAP TACHYCARDIA, ADDED
453.72
93610 26 INTRA-ATRIAL PACING
271.48
93612 26 INTRAVENTRICULAR PACING
270.32
93620
ELECTROPHYSIOLOGY EVAL
1,831.99
93620 TC ELECTROPHYSIOLOGY EVAL
809.16
93620 26 ELECTROPHYSIOLOGY EVAL
1,055.32
93623 26 STIMULATION, PACING HEART
259.49
93641
ELECTROPHYSIOLOGY EVAL
800.92
93641 TC ELECTROPHYSIOLOGY EVAL
260.71
93641 26 ELECTROPHYSIOLOGY EVAL
538.69
93642
ELECTROPHYSIOLOGY EVAL
695.28
93642 TC ELECTROPHYSIOLOGY EVAL
293.87
93642 26 ELECTROPHYSIOLOGY EVAL
401.41
93660
TILT TABLE EVAL
267.19
93660 TC TILT TABLE EVAL
112.90
93660 26 TILT TABLE EVAL
154.29
93701
BIOIMPD TIIRC ELEC
45.94
93720
BIOIMPEDANCE, CV ANALYSIS
82.45
93722
TOTAL BODY PLETHYSMOGRAPHY 12.65
93784
AMBULATORY BP MONITORING
103.53
93798
CARDIAC REHAB/MONITOR
41.51
93875
EXTRACRANIAL STUDY
179.33
93875 TC EXTRACRANIAL STUDY
162.40
93875 26 EXTRACRANIAL STUDY
16.93
93880
EXTRACRANIAL STUDY
424.35
93880 TC EXTRACRANIAL STUDY
377.27
93880 26 EXTRACRANIAL STUDY
47.08
93882
EXTRACRANIAL STUDY
294.19
93882 TC EXTRACRANIAL STUDY
262.56
93882 26 EXTRACRANIAL STUDY
31.63
93886
INTRACRANIAL STUDY
560.39
93886 TC INTRACRANIAL STUDY
487.32
93886 26 INTRACRANIAL STUDY
73.07
505.68
1,947.25
1,380.14
567.10
1,656.97
1,174.82
482.14
1,829.23
1,286.72
542.51
1,956.36
1,351.90
604.46
2,243.12
1,576.21
666.91
307.12
162.76
394.04
250.93
143.12
200.73
84.36
85.88
64.90
266.42
218.66
240.25
439.26
262.90
261.81
1,764.36
780.90
1,021.50
251.22
770.31
250.41
521.48
661.24
274.24
387.00
254.13
105.36
148.79
42.89
77.41
12.24
97.61
39.45
167.89
151.53
16.36
397.49
351.96
45.53
275.62
244.95
30.67
525.22
454.62
70.60
MEDICAL FEE SCHEDULES
93922
93922
93922
93923
93923
93923
93924
93924
93924
93925
93925
93925
93926
93926
93926
93930
93930
93930
93931
93931
93931
93965
93965
93965
93970
93970
93970
93971
93971
93971
93975
93975
93975
93976
93976
93976
93978
93978
93978
93979
93979
93979
94002
94003
94010
94010
94010
94060
94060
94060
94070
94070
94070
94200
94200
94200
94240
94240
94240
94250
94250
94250
94260
94260
94260
94350
94350
94350
94360
94360
94360
EXTREMITY STUDY
TC EXTREMITY STUDY
26 EXTREMITY STUDY
EXTREMITY STUDY
TC EXTREMITY STUDY
26 EXTREMITY STUDY
EXTREMITY STUDY
TC EXTREMITY STUDY
26 EXTREMITY STUDY
LOWER EXTREMITY STUDY
TC LOWER EXTREMITY STUDY
26 LOWER EXTREMITY STUDY
LOWER EXTREMITY STUDY
TC LOWER EXTREMITY STUDY
26 LOWER EXTREMITY STUDY
UPPER EXTREMITY STUDY
TC UPPER EXTREMITY STUDY
26 UPPER EXTREMITY STUDY
UPPER EXTREMITY STUDY
TC UPPER EXTREMITY STUDY
26 UPPER EXTREMITY STUDY
EXTREMITY STUDY
TC EXTREMITY STUDY
26 EXTREMITY STUDY
EXTREMITY STUDY
TC EXTREMITY STUDY
26 EXTREMITY STUDY
EXTREMITY STUDY
TC EXTREMITY STUDY
26 EXTREMITY STUDY
VASCULAR STUDY
TC VASCULAR STUDY
26 VASCULAR STUDY
VASCULAR STUDY
TC VASCULAR STUDY
26 VASCULAR STUDY
VASCULAR STUDY
TC VASCULAR STUDY
26 VASCULAR STUDY
VASCULAR STUDY
TC VASCULAR STUDY
26 VASCULAR STUDY
VENT MGMT INPATIENT, INIT DAY
VENT MGMT INPATIENT, SUBCUT
DAY
BREATHING CAPACITY TEST
TC BREATHING CAPACITY TEST
26 BREATHING CAPACITY TEST
EVALUATE WHEEZING
TC EVALUATE WHEEZING
26 EVALUATE WHEEZING
EVALUATE WHEEZING
TC EVALUATE WHEEZING
26 EVALUATE WHEEZING
LUNG FUNCTION TEST (MBC/MVV)
TC LUNG FUNCTION TEST (MBC/IvIVV)
26 LUNG FUNCTION TEST (MBC/MVV)
RESIDUAL LUNG CAPACITY
TC RESIDUAL LUNG CAPACITY
26 RESIDUAL LUNG CAPACITY
EXPIRED GAS COLLECTION
TC EXPIRED GAS COLLECTION
26 EXPIRED GAS COLLECTION
THORACIC GAS VOLUME
TC THORACIC GAS VOLUME
26 THORACIC GAS VOLUME
LUNG NITROGEN WASHOUT CURVE
TC LUNG NITROGEN WASHOUT CURVE
26 LUNG NITROGEN WASHOUT CURVE
MEASURE AIRFLOW RESISTANCE
TC MEASURE AIRFLOW RESISTANCE
26 MEASURE AIRFLOW RESISTANCE
187.26
168.23
19.03
289.22
253.82
35.40
361.62
322.53
39.09
537.92
493.02
44.91
349.57
318.45
31.12
423.65
387.74
35.91
283.34
259.06
24.27
214.33
186.86
27.47
436.95
383.10
53.87
286.89
251.49
35.40
637.06
495.93
141.13
363.64
268.95
94.67
410.98
359.22
51.77
284.63
250.32
34.30
139.58
175.36
156.96
18.40
271.07
236.81
34.26
338.73
300.90
37.83
503.46
460.00
43.44
327.26
297.11
30.16
396.50
361.74
34.76
265.20
241.70
23.50
200.93
174.34
26.59
409.56
357.39
52.15
268.90
234.63
34.26
599.26
462.72
136.54
342.48
250.93
91.56
385.24
335.12
50.12
266.77
233.54
33.21
135.63
100.93
59.16
45.94
13.22
101.79
79.13
22.65
97.74
53.50
44.24
40.40
31.96
8.43
66.63
47.69
18.96
42.72
34.29
8.43
54.80
45.36
9.45
57.33
38.37
18.96
74.21
55.25
18.96
97,84
55.68
42.89
12.79
95.78
73.85
21.93
92.78
49.95
42.83
38.01
29.86
8.17
62.87
44.52
18.35
40.19
32.03
8.17
51.51
42.35
9.17
54.17
35.83
18.35
69.93
51.59
18.35
11:3-29.6
11:3-29.6
94370
94370
94370
94375
94375
94375
94620
94620
94620
94640
94660
94664
94667
94720
94720
94720
94750
94750
94750
94760
94761
94762
94770
95004
95015
95024
95027
95028
95044
95115
95117
95144
95800
95800
95800
95801
95801
95801
95803
95803
95803
95805
95805
95805
95810
95810
95810
95811
95811
95811
95812
95812
95812
95813
95813
95813
95816
95816
95816
95819
95819
95819
95822
95822
95822
95831
APPENDIX B - REGULATIONS
BREATH AIRWAY CLOSING VOLUME 56.74
TC BREATH AIRWAY CLOSING VOLUME37,79
26 BREATH AIRWAY CLOSING VOLUME 18.96
RESPIRATORY FLOW VOLUME LOOP 63.35
TC RESPIRATORY FLOW VOLUME LOOP 40.70
26 RESPIRATORY FLOW VOLUME LOOP 22.65
PULMONARY STRESS TEST/SIMPLE 103.85
TC PULMONARY STRESS TEST/SIMPLE 56.42
26 PULMONARY STRESS TEST/SIMPLE 47.44
AIRWAY INHALATION TREAT
27.30
POS AIRWAY PRESSURE, CPAP
95.91
EVALUATE PAT USE INHALER
27.30
CHEST WALL MANIPULATION
38.37
MONOXIDE DIFFUSING CAPACITY
87.61
TC MONOXIDE DIFFUSING CAPACITY
68.65
26 MONOXIDE DIFFUSING CAPACITY
18.96
PULMONARY COMPLIANCE STUDY 131.51
TC PULMONARY COMPLIANCE STUDY114,65
26 PULMONARY COMPLIANCE STUDY 16.85
MEASURE BLOOD OXYGEN LEVEL
28.25
MEASURE BLOOD OXYGEN LEVEL
46.17
MEASURE BLOOD OXYGEN LEVEL
59.35
EXHALED CARBON DIOXIDE TEST
38.28
PERCUT ALLERGY SKIN TESTS
10.93
ID ALLERGY TITRATE-DRUG/BUG
23.28
ID ALLERGY TEST, DRUG/BUG
12.68
ID ALLERGY TITRATE-AIRBORNE
8.01
ID ALLERGY TEST-DELAYED TYPE 21.49
ALLERGY PATCH TESTS
10.42
OTHERAPY, ONE INJECTION
17.41
IMMUNOTHERAPY INJECTIONS
21.49
ANTIGEN THERAPY SERVICES
21.03
SLEEP STUDY UNATT; COMP
W/SLEEP TIME
344.12
TC SLEEP STUDY UNATT; COMP
W/SLEEP TIME
252.65
26 SLEEP STUDY UNATT; COMP
W/SLEEP TIME
91.46
SLEEP STUDY UNATT; COMP
W/O SLEEP TIME
158.15
TC SLEEP STUDY UNATT; COMP
W/O SLEEP TIME
77.96
26 SLEEP STUDY UNATT; COMP
W/O SLEEP TIME
80.19
ACTIGRAPHY TESTING
271.28
TC ACTIGRAPHY TESTING
197.91
26 ACTIGRAPHY TESTING
73.37
MULTIPLE SLEEP LATENCY TEST
693.93
TC MULTIPLE SLEEP LATENCY TEST
597.18
26 MULTIPLE SLEEP LATENCY TEST
96.75
POLYSOMNOGRAPHY, 4 OR MORE 1,169.61
TC POLYSOMNOGRAPHY, 4 OR MORE 974.08
26 POLYSOMNOGRAPHY, 4 OR MORE 195.54
POLYSOMNOGRAPHY W/CPAP
1,263.07
TC POLYSOMNOGRAPHY W/CPAP
1,058.45
26 POLYSOMNOGRAPHY W/CPAP
204.62
EEG, 41-60 MINUTES
531.27
TC EEG, 41-60 MINUTES
447.02
26 EEG, 41-60 MINUTES
84.26
EEG, OVER 1 HOUR
594.86
TC EEG, OVER 1 HOUR
460.35
26 EEG, OVER 1 HOUR
134.52
EEG, AWAKE & DROWSY
378.16
TC EEG, AWAKE & DROWSY
312.51
26 EEG, AWAKE & DROWSY
65.65
EEG, AWAKE & ASLEEP
549.32
TC EEG, AWAKE & ASLEEP
464.48
26 EEG, AWAKE & ASLEEP
84.84
EEG, COMA OR SLEEP ONLY
513.22
TC EEG, COMA OR SLEEP ONLY
428.39
26 EEG, COMA OR SLEEP ONLY
84.84
LIMB MUSCLE TESTING, MANUAL
47.21
53.63
35.29
18.35
59.93
38.00
21.93
98.58
52.67
45.92
25.51
91.49
25.51
35.83
82.42
64.08
18.35
123.29
106.98
16.31
26.59
43.29
55.44
36.18
10.25
22.11
11.88
7.53
20.08
9.75
16.27
20.08
19.80
323.75
235.71
88.02
150.15
72.76
77.39
255.44
184.66
70.78
650.54
557.22
93.32
1,097.90
909.04
188.86
1,185.40
987.78
197.62
498.47
417.10
81.37
559.52
429.56
129.96
355.01
291.60
63.41
515.31
433.39
81.91
481.63
399.72
81.91
44.84
MEDICAL FEE SCHEDULES
95832
95833
95834
95851
95852
95857
95860
95860
95860
95861
95861
95861
95863
95863
95863
95864
95864
95864
95865
95865
95865
95867
TC
26
TC
26
TC
26
TC
26
TC
26
95867 TC
95867 26
95868
95868 TC
95868 26
95869
95869
95869
95870
95870
95870
95873
TC
26
TC
26
95873 TC
95873 26
95874
95874 TC
95874 26
95900
95900
95900
95903
95903
95903
95904
95904
95904
95920
95920
95920
95921
95921
95921
95922
95922
95922
95923
95923
95923
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
HAND MUSCLE TESTING, MANUAL 52.37
49.80
BODY MUSCLE TESTING, MANUAL 68.43
65.19
BODY MUSCLE TESTING, MANUAL 85.99
82.02
RANGE MOTION MEASUREMENTS
43.75
41.47
RANGE MOTION MEASUREMENTS
24.16
22.84
TENSILON TEST
76.14
72.46
MUSCLE TEST, ONE LIMB
226.85
215.44
MUSCLE TEST, ONE LIMB
107.41
100.24
MUSCLE TEST, ONE LIMB
119.46
115.20
MUSCLE TEST, 2 LIMBS
327.48
311.61
MUSCLE TEST, 2 LIMBS
136.97
127.83
MUSCLE TEST, 2 LIMBS
190.51
183.78
MUSCLE TEST, 3 LIMBS
395.17
376.08
MUSCLE TEST, 3 LIMBS
166.53
155.40
MUSCLE TEST, 3 LIMBS
228.64
220.68
MUSCLE TEST, 4 LIMBS
434.98
413.69
MUSCLE TEST, 4 LIMBS
190.71
177.96
MUSCLE TEST, 4 LIMBS
244.27
235.72
MUSCLE TEST, LARYNX
296.79
283.01
MUSCLE TEST, LARYNX
101.14
94.40
MUSCLE TEST, LARYNX
195.65
188.61
MUSCLE TEST CRANIAL NERVE
UNILAT
201.95
191.56
MUSCLE TEST CRANIAL NERVE
UNILAT
103.83
96.90
MUSCLE TEST CRANIAL NERVE
UNILAT
98.12
94.67
MUSCLE TEST CRANIAL NERVE
BILAT
272.61
258.99
MUSCLE TEST CRANIAL NERVE
BILAT
128.01
119.46
MUSCLE TEST CRANIAL NERVE
BILAT
144.60
139.53
MUSCLE TEST, THOR PARASPINAL 149.63
141.08
MUSCLE TEST, THOR PARASPTNAL 103.83
96.90
MUSCLE TEST, THOR PARASPINAL
45.80
44.18
MUSCLE TEST, NONPARASPINAL
146.04
137.74
MUSCLE TEST, NONPARASPINAL
101.14
94.40
MUSCLE TEST, NONPARASPINAL
44.91
43.33
GUIDE NERVE DESTROY, ELECT
STIM
148.73
140.25
GUIDE NERVE DESTROY, ELECT
STIM
101.14
94.40
GUIDE NERVE DESTROY, ELECT
STIM
47.60
45.85
GUIDE NERVE DESTROY, NEEDLE
EMG
141.56
133.56
GUIDE NERVE DESTROY, NEEDLE
EMG
95.76
89.38
GUIDE NERVE DESTROY, NEEDLE
EMG
45.80
44.18
MOTOR NERVE CONDUCTION TEST 153.54
144.91
MOTOR NERVE CONDUCTION TEST 102.03
95.23
MOTOR NERVE CONDUCTION TEST 51.51
49.67
MOTOR NERVE CONDUCTION TEST 176.35
166.99
MOTOR NERVE CONDUCTION TEST 102.93
96.07
MOTOR NERVE CONDUCTION TEST 73.44
70.92
SENSE NERVE CONDUCTION TEST 135.64
127.92
SENSE NERVE CONDUCTION TEST
93.97
87.71
SENSE NERVE CONDUCTION TEST
41.67
40.21
INTRAOP NERVE TEST, ADDED
392.31
374.38
INTRAOP NERVE TEST, ADDED
136.07
126.98
INTRAOP NERVE TEST, ADDED
256.23
247.38
AUTONOMIC NERVE FUNCTION TEST129.86
123.48
AUTONOMIC NERVE FUNCTION TEST 60.50
56.47
AUTONOMIC NERVE FUNCTION TEST 69.36
67.00
AUTONOMIC NERVE FUNCTION TEST161.43
153.08
AUTONOMIC NERVE FUNCTION TEST 87.28
81.46
AUTONOMIC NERVE FUNCTION TEST 74.15 71.62
AUTONOMIC NERVE FUNCTION TEST241.02
227.20
AUTONOMIC NERVE FUNCTION TEST169.96
158.59
AUTONOMIC NERVE FUNCTION TEST 71.04
68.61
11:3-29.6
11:3-29.6
95925
95925
95925
95926
95926
95926
95927
95927
95927
95928
95928
95928
95929
95929
95929
95930
95930
95930
95933
95933
95933
95934
95934
95934
95936
95936
95936
95937
95937
95937
95950
95950
95950
95951
95951
95951
95953
95953
95953
95955
95955
95955
95956
95956
95956
95957
95957
95957
95961
95961
95961
95962
95962
95962
95970
95971
95972
95973
95981
95991
95992
96000
96002
96004
96101
96102
96103
96105
96111
96116
96118
96119
APPENDIX B - REGULATIONS
SOMATOSENSORY TESTING
640.37
TC SOMATOSENSORY TESTING
538.82
26 SOMATOSENSORY TESTING
101.51
SOMATOSENSORY TESTING
393.84
TC SOMATOSENSORY TESTING
327.79
26 SOMATOSENSORY TESTING
66.05
SOMATOSENSORY TESTING
368.96
TC SOMATOSENSORY TESTING
303.59
26 SOMATOSENSORY TESTING
65.35
C MOTOR EVOKED, UPPER LIMBS
388.77
TC C MOTOR EVOKED, UPPER LIMBS
270.57
26 C MOTOR EVOKED, UPPER LIMBS
118.19
C MOTOR EVOKED, LOWER LIMBS 412.64
TC C MOTOR EVOKED, LOWER LIMBS 293.87
26 C MOTOR EVOKED, LOWER LIMBS 118.77
VISUAL EVOKED POTENTIAL TEST 225.51
TC VISUAL EVOKED POTENTIAL TEST 197.91
26 VISUAL EVOKED POTENTIAL TEST 27.60
BLINK REFLEX TEST
122.27
TC BLINK REFLEX TEST
75.05
26 BLINK REFLEX TEST
47.22
H-REFLEX TEST
155.93
TC H-REFLEX TEST
87.59
26 H-REFLEX TEST
68.32
H-REFLEX TEST
126.83
TC H-REFLEX TEST
54.09
26 H-REFLEX TEST
72.75
NEUROMUSCULAR JUNCTION TEST 105.46
TC NEUROMUSCULAR JUNCTION TEST 53.50
26 NEUROMUSCULAR JUNCTION TEST 51.95
AMBULATORY EEG MONITORING 451.58
TC AMBULATORY EEG MONITORING 332.89
26 AMBULATORY EEG MONITORING 118.70
EEG MONITORING/VIDEO RECORD 3,074.98
TC EEG MONITORING/VIDEO RECORD 2,599.66
26 EEG MONITORING/VIDEO RECORD 483.24
EEG MONITORING/COMPUTER
683.31
TC EEG MONITORING/COMPUTER
438.28
26 EEG MONITORING/COMPUTER
245.04
EEG DURING SURG
279.78
TC EEG DURING SURG
201.41
26 EEG DURING SURG
78.37
EEG MONITORING, CABLE/RADIO 1,700.99
TC EEG MONITORING, CABLE/RADIO 1,425.05
26 EEG MONITORING, CABLE/RADIO
275.95
EEG DIGITAL ANALYSIS
565.05
TC EEG DIGITAL ANALYSIS
408.70
26 EEG DIGITAL ANALYSIS
156.33
ELECTRODE STIMULATION, BRAIN 407.15
TC ELECTRODE STIMULATION, BRAIN 169.96
26 ELECTRODE STIMULATION, BRAIN 237.19
ELECTRODE STIM, BRAIN, ADDED 362.26
TC ELECTRODE STIM, BRAIN, ADDED 108.83
26 ELECTRODE STIM, BRAIN, ADDED 253.44
ANALYZE NEUROSTIM, NO PROG
97.12
ANALYZE NEUROSTIM, SIMPLE
92.71
ANALYZE NEUROSTIM, COMPLEX 170.16
ANALYZE NEUROSTIM, COMPLEX
95.10
IO ANAL GAST N-STIM SUBSEQ
49.98
SPIN/BRAIN PUMP REFILL & MAIN 174.44
CANALITH REPOSITIONING PROC
66.86
MOTION ANALYSIS, VIDEO/3D
141.90
DYNAMIC SURFACE EMG
32.84
PHYS REVIEW MOTION TESTS
174.11
PSYCHO TESTING BY PSYCH/PHYS 171.94
PSYCHO TESTING BY TECHNICIAN 110.20
PSYCHO TESTING ADMIN BY COMP 92.07
ASSESS APHASIA
169.49
DEVELOPMENTAL TEST, EXTEND
194.42
NEUROBEHAVIORAL STATUS EXAM 163.28
NEUROPSYCH TEST BY PSYCH/PHYS 175.60
NEUROPSYCH TESTING BY TEC
116.36
600.70
502.74
98.00
369.63
305.82
63.82
346.31
283.25
63.05
366.67
252.51
114.16
388.95
274.24
114.71
211.30
184.66
26.63
115.65
70.05
45.60
147.69
81.77
65.89
120.70
50.53
70.20
100.14
49.95
50.19
425.29
310.63
114.65
2,967.76
2,508.81
467.08
645.57
408.94
236.62
263.64
187.92
75.72
1,596.69
1,329.89
266.79
532.31
381.29
151.02
387.59
158.59
228.99
346.30
101.55
244.75
91.83
88.63
162.88
91.23
47.45
164.77
64.38
137.15
31.75
168.13
166.83
104.12
87.24
162.53
188.26
157.97
169.32
109.92
MEDICAL FEE SCHEDULES
96120
96125
96150
96151
96152
96153
96154
96360
96361
96365
96366
96367
96368
96370
96372
96373
96374
96375
96409
96446
96523
96900
96912
97001
97002
97003
97004
97010
97012
97016
97014
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97530
97532
97533
97535
97537
97542
97597
97598
97605
97606
97750
97755
97760
97761
97762
NEUROPSYCH TEST ADMIN W/COMP 136.91
COGNITIVE TEST BY HC PRO
147.55
ASSESS HEALTH/BEHAVE, INIT
32.30
ASSESS HEALTH/BEHAVE, SUBSEQ 31.28
INTERVENE HEALTH/BEHAVE, INDIV 29.69
INTERVENE HEALTH/BEHAVE, GROUP 7.35
INTERVENE HEALTH/BEHAVE, FAM
W/PT
29.17
HYDRATION IV INFUSION, INIT
96.36
HYDRATE IV INFUSION, ADDED
25.47
THER/PROPHY/DIAG IV INF, INIT
119.94
THER/PROPHY/DIAG IV INF ADDED 35.85
THER/PROPHY/DIAG ADDED SEQ IV
INF
55.00
THER/DIAG CONCURRENT INF
31.86
SC THER INFUSION, ADDED HR
24.80
THER/PROPHY/DIAG INJ, SC/IM
38.26
THER/PROPHY/DIAG INJ, IA
31.28
THER/PROPHY/DIAG INJ, IV PUSH
93.96
TX/PRO/DIAG INJECT NEW DRUG
ADDED
38.20
CHEMO IV PUSH, SINGLE DRUG
191.22
CHEMOTHERAPY ADM PERITONEAL
CAV
300.18
IRRIG DRUG DELIVERY DEVICE
43.31
ULTRAVIOLET LIGHT THERAPY
35.46
PHOTOCHEMOTHERAPY W/UV-A
152.50
PHYSICAL THERAPY EVAL
114.74
PHYSICAL THERAPY RE-EVAL
64.03
OT EVAL
127.54
OT RE-EVAL
78.59
APPLIC MODAL 1/> AREAS;
HOT/COLD PACKS
0.00
MECHANICAL TRACTION THERAPY 28.01
VASOPNEUMATIC DEVICE THERAPY 28.29
APPLICATION MODALITY TO 1 OR
MORE AREAS; E-STIM
0.00
PARAFFIN BATH THERAPY
15.79
WHIRLPOOL THERAPY
33.61
DIATHERMY EG, MICROWAVE
9.98
INFRARED THERAPY
8.81
ULTRAVIOLET THERAPY
10.98
ELECTRICAL STIMULATION
28.35
ELECTRIC CURRENT THERAPY
46.33
CONTRAST BATH THERAPY
26.32
ULTRASOUND THERAPY
27.40
HYDROTHERAPY
47.92
PHYSICAL THERAPY TREAT
20.42
THERAPEUTIC EXERCISES
50.87
NEUROMUSCULAR REEDUCATION
53.36
AQUATIC THERAPY/EXERCISES
67.87
GAIT TRAINING THERAPY
48.21
MASSAGE THERAPY
38.67
PHYSICAL MEDICINE PROCEDURE
27.64
MANUAL THERAPY
44.47
GROUP THERAPEUTIC PROCEDURES 30.52
THERAPEUTIC ACTIVITIES
59.96
COGNITIVE SKILLS DEVELOPMENT 61.13
SENSORY INTEGRATION
43.81
SELF CARE MANAGEMENT TRAINING51.88
COMMUNITY/WORK REINTEGRATION44.91
WHEELCHAIR MANAGEMENT
TRAINING
45.49
ACTIVE WOUND CARE/20 CM OR < 119.31
ACTIVE WOUND CARE > 20 CM
39.36
NEG PRESS WOUND TX, < 50 CM
62.93
NEG PRESS WOUND TX, > 50 CM
67.09
PHYSICAL PERFORMANCE TEST
55.79
ASSISTIVE TECHNOLOGY ASSESS
53.99
ORTHOTIC MGMT & TRAINING
56.42
PROSTHETIC TRAINING
49.44
C/O FOR ORTHOTIC/PROSTH USE
67.36
129.06
142.04
31.39
30.38
28.85
7.13
28.35
90.41
24.02
112.51
33.92
51.80
30.17
23.60
36.14
29.63
88.19
35.91
179.13
281.16
40.53
33.11
142.29
110.13
61.31
122.09
74.88
0.00
26.87
26.86
0.00
14.91
31.79
9.48
8.40
10.47
27.09
43.88
25.10
26.36
45.42
19.71
48.67
51.01
64.51
46.14
36.95
26.67
42.56
29.17
57.21
58.72
41.98
49.54
43.02
43.56
112.72
37.40
60.32
64.40
53.38
51.98
53.83
47.32
63.48
11:3-29.6
11:3-29.6
97802
97810
97811
97813
97814
98925
98926
98927
98928
98940
98941
98942
98943
99070
99071
99080
99082
99143
99144
99145
99148
99149
99150
99175
99183
99195
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
APPENDIX B - REGULATIONS
MEDICAL NUTRITION, INDIV, IN
50.58
ACUPUNCT 1/> NDLES W/O E-STIM;
INIT 15 MIN 1-1
43.74
ACUPUNCT 1 /> NDLES W/O E-STIM;
EA ADD 15 MIN 1-1
37.49
ACUPUNCT 1/> NDLES WITH E-STIM;
INIT 15 MIN 1-1
47.91
ACUPUNCT 1/> NDLES WITH E-STIM;
EA ADD 15 MIN 1-1
41.66
OSTEOPATHIC MANIPULATION 1-2
REGIONS
55.70
OSTEOPATHIC MANIPULATION 3-4
REGIONS
74.13
OSTEOPATHIC MANIPULATION 5-6
REGIONS
96.35
OSTEOPATHIC MANIPULATION 7-8
REGIONS
97.37
CHIROPRACTIC MANIPULATION 1-2
REGIONS
39.44
CHIROPRACTIC MANIPULATION 3-4
REGIONS
54.40
CHIROPRACTIC MANIPULATION 5
REGIONS
69.90
CHIROPRACTIC MANIP TX;
XTRASPINAL 1/MORE REGIONS
37.14
SUPPLIES & MATERIALS: ADDL TO
USUAL FOR OFFICE VISIT
0.00
EDUCATION SUPPLIES; S/A BOOKS,
TAPES & PAMPHLETS FOR PATIENT
EDUCATION
0.00
SPECIAL REPORTS
0.00
UNUSUAL PHYSICIAN TRAVEL
0.00
MOD SEDATION SAME PHYS, < 5 YRS 44.74
MOD SEDATION BY SAME PHYS,
5 YRS +
64.49
MOD SEDATION BY SAME PHYS,
ADDED
22.24
MOD SEDATION DIFF PHYS < 5 YRS 125.97
MOD SEDATION DIFF PHYS 5 YRS + 125.97
MOD SEDATION DIFF PHYS, ADDED 47.38
INDUCTION VOMITING
41.87
HYPERBARIC OXYGEN THERAPY
518.83
PHLEBOTOMY
227.07
OFFICE/OUTPAT VISIT, NEW PAT 10
MINS
51.25
OFFICE/OUTPAT VISIT, NEW PAT 20
MINS
87.92
OFFICE/OUTPAT VISIT, NEW PAT 30
MINS
126.87
OFFICE/OUTPAT VISIT, NEW PAT 45
MINS
193.64
OFFICE/OUTPAT VISIT, NEW PAT 60
MINS
240.25
OFFICE/OUTPAT VISIT, EST PAT 5
MINS
32.36
OFFICE/OUTPAT VISIT, EST PAT 10
MINS
51.69
OFFICE/OUTPAT VISIT, EST PAT 15
MINS
85.01
OFFICE/OUTPAT VISIT, EST PAT 25
MINS
125.71
OFFICE/OUTPAT VISIT, EST PAT 40
MINS
168.59
OBSERVATION CARE DISCHARGE 108.71
OBSERVATION CARE LOW SEVERITY 99.97
OBSERVATION CARE MODERATE
SEVERITY
167.12
OBSERVATION CARE HIGH
SEVERITY
233.75
INITIAL HOSPITAL CARE 30 MINS
151.05
INITIAL HOSPITAL CARE 50 MINS
205.62
INITIAL HOSPITAL CARE 70 MINS
301.80
48.59
32.07
27.49
35.12
30.54
53.34
71.10
92.48
93.52
37.90
52.41
67.39
36.01
0.00
0.00
0.00
0.00
43.70
62.24
21.44
121.58
121.58
45.69
39.08
494.16
212.09
48.81
83.95
121.39
185.82
230.79
30.67
49.22
81.31
120.35
161.61
104.82
96.66
161.61
226.05
146.22
198.94
291.96
MEDICAL FEE SCHEDULES
99224
99225
99226
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99281
99282
99283
99284
99285
99291
99292
99304
99305
99306
99307
99308
99309
99310
99315
99316
99334
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99355
99356
99357
99406
99407
99471
99472
SUBSEQ OBSERVATION CARE 15
MINS
43.46
41.99
SUBSEQ OBSERVATION CARE 25
MINS
76.94
74.29
SUBSEQ OBSERVATION CARE 35
MINS
115.08
111.16
SUBSEQUENT HOSPITAL CARE 15
MINS
69.00
66.70
SUBSEQUENT HOSPITAL CARE 25
MINS
107.89
104.32
SUBSEQUENT HOSPITAL CARE 35
MINS
154.90
149.80
OBSERVE/HOSP SAME DATE LOW
SEVERITY
204.82
198.08
OBSERVE/HOSP SAME DATE MOD
SEVERITY
268.27
259.39
OBSERVE/HOSP SAME DATE HIGH
SEVERITY
333.16
322.20
HOSPITAL DISCHARGE DAY 30
MINS/LESS
108.19
104.29
HOSPITAL DISCHARGE DAY > 30
MINS
158.62
152.99
OFFICE CONSULTATION 15 MINS
94.26
81.72
OFFICE CONSULTATION 30 MINS
120.18
104.19
OFFICE CONSULTATION 40 MINS
153.17
132.79
OFFICE CONSULTATION 60 MINS
200.30
173.66
OFFICE CONSULTATION 80 MINS
252.93
219.28
INPATIENT CONSULTATION 20 MINS 94.26
81.72
INPATIENT CONSULTATION 40 MINS 142.96
123.94
INPATIENT CONSULTATION 55 MINS 175.95
152.54
INPATIENT CONSULTATION 80 MINS 219.94
190.88
INPATIENT CONSULTATION 110 MINS276.50
239.71
EMERGENCY DEPT VISIT SELF
LIMIT/MINOR
122.92
119.32
EMERGENCY DEPT VISIT
LOW/MODERATE
203.58
197.73
EMERGENCY DEPT VISIT MODERATE206.43
200.51
EMERGENCY DEPT VISIT HIGH
SEVERITY
375.38
365.00
EMERGENCY DEPT VISIT HIGH
SEVERITY
519.35
505.14
CRITICAL CARE, FIRST HOUR
417.23
401.38
CRITICAL CARE, ADDED 30 MIN
185.85
179.48
NURSING FACILITY CARE, INIT
137.67
132.91
NURSING FACILITY CARE, INIT
193.13
186.59
NURSING FACILITY CARE, INIT
245.26
237.08
NURSING FACILITY CARE, SUBSEQ 66.27
63.81
NURSING FACILITY CARE, SUBSEQ 102.10
98.32
NURSING FACILITY CARE, SUBSEQ 134.06
129.12
NURSING FACILITY CARE, SUBSEQ 198.16
191.08
NURSING FACILITY DISCHARGE DAY 96.51
93.02
NURSING FACILITY DISCHARGE DAY125.11
120.65
DOMICILE/REST HOME VISIT EST PAT 91.72
88.41
HOME VISIT, NEW PATIENT 20 MINS 85.75
82.71
HOME VISIT, NEW PATIENT-30 MINS 124.20
119.95
HOME VISIT, NEW PATIENT 45 MINS 202.38
195.60
HOME VISIT, NEW PATIENT 60 MINS 272.05
262.80
HOME VISIT, NEW PATIENT 75 MINS 326.47
315.44
HOME VISIT, EST PATIENT 15 MINS 85.25
82.21
HOME VISIT, EST PATIENT 25 MINS 128.62
124.15
HOME VISIT, EST PATIENT 40 MINS 190.15
183.56
HOME VISIT, EST PATIENT 60 MINS 264.65
255.65
PROLONGED SERVICE, OFFICE
149.70
144.35
PROLONGED SERVICE, OFFICE
147.95
142.72
PROLONGED SERVICE, INPATIENT 136.17
131.58
PROLONGED SERVICE, INPATIENT 136.75
132.13
BEHAVIOR CHANGE SMOKING 3-10
MIN
21.43
20.62
BEHAVIOR CHANGE SMOKING > 10
MIN
41.50
40.03
PEDIATRIC CRITICAL CARE, INITIAL1,202.04 1,163.38
PEDIATRIC CRITICAL CARE, SUBSEQ605.11
585.66
11:3-29.6
11:3-29.6
APPENDIX B - REGULATIONS
99475
99476
PEDIATRIC CRIT CARE AGE 2-5, INIT 848.53
PEDIATRIC CRIT CARE AGE 2-5,
SUBSEQ
514.56
99478
IC, LBW INF < 1500 GM SUBSEQ
213.55
N1 = ASC Packaged Procedure no separate payment
X = ASC codes Not Subject to Multiple Procedure Reductions
822.02
498.30
206.55
Exhibit 2
Dental Fee Schedule
CDT
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
D0290
D0320
D0321
D0330
D0340
D0350
D0360
D0362
D0363
D0460
D0470
D1110
D1120
D1351
D1510
D1515
D1520
D1525
D1550
D1555
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
Description
NORTH SOUTH
periodic oral evaluation - established patient
59
52
limited oral evaluation - problem focused
91
80
comprehensive oral evaluation - new or established patient
104
92
detailed and extensive oral evaluation - problem focused, by report 190
168
re-evaluation - limited, problem focused (established patient; not
post-operative visit)
85
75
comprehensive periodontal evaluation - new or established patient
113
100
intraoral - complete series (including bitewings)
153
135
intraoral - periapical first film
34
30
intraoral - periapical each additional film
28
25
intraoral - occlusal film
51
45
extraoral - first film
80
71
extraoral - each additional film
68
60
bitewing - single film
34
30
bitewings - two films
53
47
bitewings - three films
67
59
bitewings - four films
78
69
vertical bitewings - 7 to 8 films
119
105
posterior-anterior or lateral skull and facial bone survey film
164
145
temporomandibular joint arthrogram, including injection
714
632
other temporomandibular joint films, by report
248
219
panoramic film
130
115
cephalometric film
147
130
oral/facial photographic images
88
78
cone beam ct - craniofacial data capture
691
611
cone beam - two-dimensional image reconstruction using
existing data, includes multiple images
448
397
cone beam - three-dimensional image reconstruction using
existing data, includes multiple images
482
427
pulp vitality tests
67
59
diagnostic casts
135
119
prophylaxis - adult
108
95
prophylaxis - child
79
70
sealant - per tooth
65
57
space maintainer - fixed-unilateral
374
330
space maintainer - fixed - bilateral
509
451
space maintainer - removable - unilateral
457
405
space maintainer - removable - bilateral
578
512
re-cementation of space maintainer
101
89
removal of fixed space maintainer
93
82
amalgam - one surface, primary or permanent
169
149
amalgam - two surfaces, primary or permanent
213
188
amalgam - three surfaces, primary or permanent
256
226
amalgam - four or more surfaces, primary or permanent
305
269
resin-based composite - one surface, anterior
190
168
resin-based composite - two surfaces, anterior
238
210
resin-based composite - three surfaces, anterior
298
263
resin-based composite - four or more surfaces or involving incisal
angle (anterior)
374
330
resin-based composite crown, anterior
549
486
MEDICAL FEE SCHEDULES
D2391
D2392
D2393
D2394
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
D2799
D2910
D2915
D2920
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
resin-based composite - one surface, posterior
resin-based composite - two surfaces, posterior
resin-based composite - three surfaces, posterior
resin-based composite - four or more surfaces, posterior
gold foil - one surface
gold foil - two surfaces
gold foil - three surfaces
inlay - metallic - one surface
inlay - metallic - two surfaces
inlay - metallic - three or more surfaces
onlay - metallic-two surfaces
onlay - metallic-three surfaces
onlay - metallic-four or more surfaces
inlay - porcelain/ceramic - one surface
inlay - porcelain/ceramic - two surfaces
inlay - porcelain/ceramic - three or more surfaces
onlay - porcelain/ceramic - two surfaces
onlay - porcelain/ceramic - three surfaces
onlay - porcelain/ceramic - four or more surfaces
inlay - resin-based composite - one surface
inlay - resin-based composite - two surfaces
inlay - resin-based composite - three or more surfaces
onlay - resin-based composite - two surfaces
onlay - resin-based composite - three surfaces
onlay - resin-based composite - four or more surfaces
crown - resin-based composite (indirect)
crown - 3/4 resin-based composite (indirect)
crown - resin with high noble metal
crown - resin with predominantly base metal
crown - resin with noble metal
crown - porcelain/ceramic substrate
crown - porcelain fused to high noble metal
crown - porcelain fused to predominantly base metal
crown - porcelain fused to noble metal
crown - 3/4 cast high noble metal
crown - 3/4 cast predominantly base metal
crown - 3/4 cast noble metal
crown - 3/4 porcelain/ceramic
crown - full cast high noble metal
crown - full cast predominantly base metal
crown - full cast noble metal
crown-titanium
provisional crown
recement inlay, onlay, or partial coverage restoration
recement cast or prefabricated post and core
recement crown
prefabricated stainless steel crown - primary tooth
prefabricated stainless steel crown - pennanent tooth
prefabricated resin crown
prefabricated stainless steel crown with resin window
prefabricated esthetic coated stainless steel crown - primary tooth
protective restoration
core buildup, including any pins
pin retention - per tooth, in addition to restoration
post and core in addition to crown, indirectly fabricated
each additional indirectly fabricated post - same tooth
prefabricated post and core in addition to crown
post removal (not in conjunction with endodontic therapy)
each additional prefabricated post - same tooth
11:3-29.6
209
276
338
408
772
860
938
1019
1073
1135
1183
1200
1224
1070
1142
1189
1193
1245
1302
1041
1070
1108
1121
1168
1223
1123
1197
1245
1189
1201
1358
1302
1245
1247
1250
1215
1202
1297
1305
1189
1238
1280
526
130
135
130
321
386
417
440
432
146
323
89
504
374
396
350
243
185
244
299
361
683
761
830
901
949
1005
1047
1062
1083
946
1011
1052
1056
1102
1152
921
946
980
991
1034
1082
993
1059
1102
1052
1063
1202
1152
1102
1104
1106
1075
1064
1148
1155
1052
1096
1133
466
115
119
115
284
342
369
390
383
129
285
79
446
330
351
309
215
11:3-29.6
D2960
D2961
D2962
D2970
D2971
APPENDIX B - REGULATIONS
labial veneer (resin laminate) - chairside
797
labial veneer (resin laminate) - laboratory
1160
labial veneer (porcelain laminate) - laboratory
1360
temporary crown (fractured tooth)
453
additional procedures to construct new crown under existing partial
denture framework
246
D2975 coping
717
D2980 crown repair, by report
351
D3310 endodontic therapy, anterior tooth (excluding final restoration)
865
D3320 endodontic therapy, bicuspid tooth (excluding final restoration)
996
D3330 endodontic therapy, molar (excluding final restoration)
1198
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or
tooth bounded spaces per quadrant
764
D4249 clinical crown lengthening - hard tissue
912
D4260 osseous surgery (including flap entry and closure) - four or more
contiguous teeth or tooth bounded spaces per quadrant
1272
D4261 osseous surgery (including flap entry and closure) - one to three
contiguous teeth or tooth bounded spaces per quadrant
1075
D4263 bone replacement graft - first site in quadrant
851
D4341 periodontal scaling and root planing - four or more teeth per quadrant 300
D4355 full mouth debridement to enable comprehensive evaluation and
diagnosis
217
D4381 localized delivery of antimicrobial agents via a controlled release
vehicle into diseased crevicular tissue, per tooth, by report
180
D4910 periodontal maintenance
166
D5110 complete denture-maxillary
2038
D5120 complete denture - mandibular
2042
D5130 immediate denture-maxillary
2207
D5140 immediate denture-mandibular
2207
D5211 maxillary partial denture - resin base (including any conventional
clasps, rests and teeth)
1613
D5212 mandibular partial denture - resin base (including any conventional
clasps, rests and teeth)
1613
D5213 maxillary partial denture - cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
2126
D5214 mandibular partial denture - cast metal framework with resin
denture bases (including any conventional clasps, rests and teeth)
2126
D5510 repair broken complete denture base
252
D5520 replace missing or broken teeth - complete denture (each tooth)
223
D5610 repair resin denture base
242
D5620 repair cast framework
345
D5630 repair or replace broken clasp
316
D5640 replace broken teeth - per tooth
218
D5650 add tooth to existing partial denture
267
D5660 add clasp to existing partial denture
323
D5670 replace all teeth and acrylic on cast metal framework (maxillary)
890
D5671 replace all teeth and acrylic on cast metal framework (mandibular) 901
D5710 rebase complete maxillary denture
692
D5711 rebase complete mandibular denture
686
D5720 rebase maxillary partial denture
668
D5721 rebase mandibular partial denture
668
D5730 reline complete maxillary denture (chairside)
441
D5731 reline complete mandibular denture (chairside)
440
D5740 reline maxillary partial denture (chairside)
432
D5741 reline mandibular partial denture (chairside)
440
D5750 reline complete maxillary denture (laboratory)
565
D5751 reline complete mandibular denture (laboratory)
566
D5760 reline maxillary partial denture (laboratory)
560
D5761 reline mandibular partial denture (laboratory)
560
705
1027
1203
401
217
634
310
765
881
1060
676
807
1126
951
753
265
192
159
147
1803
1807
1953
1953
1427
1427
1881
1881
223
197
214
305
279
193
236
285
787
797
612
607
591
591
391
390
383
390
500
501
496
496
MEDICAL FEE SCHEDULES
D5810
D5811
D5820
D5821
D5850
D5851
D5860
D5861
D5862
D5867
D5875
D5937
D5951
D5982
D5988
D6010
D6012
D6040
D6050
D6053
D6054
D6055
D6056
D6057
D6058
D6059
D6060
D6061
D6062
D6063
D6064
D6065
D6066
D6067
D6068
D6069
D6070
D6071
D6072
D6073
D6074
D6075
D6076
D6077
D6078
11:3-29.6
interim complete denture (maxillary)
1029
interim complete denture (mandibular)
1043
interim partial denture (maxillary)
834
interim partial denture (mandibular)
834
tissue conditioning, maxillary
249
tissue conditioning, mandibular
249
overdenture - complete, by report
2537
overdenture - partial, by report
2477
precision attachment, by report
849
replacement of replaceable part of semi-precision or precision
attachment (male or female component)
462
modification of removable prosthesis following implant surgery
466
trismus appliance (not for TMD treatment)
882
feeding aid
1031
surgical stent
529
surgical splint
902
surgical placement of implant body: endosteal implant
2377
surgical placement of interim implant body for transitional
prosthesis: endosteal implant
1872
surgical placement: eposteal implant
9819
surgical placement: transosteal implant
6885
implant/abutment supported removable denture for completely
edentulous arch
3386
implant/abutment supported removable denture for partially
edentulous arch
3321
connecting bar - implant supported or abutment supported
3506
prefabricated abutment - includes placement
962
custom abutment - includes placement
1132
abutment supported porcelain/ceramic crown
1727
abutment supported porcelain fused to metal crown (high noble metal)1734
abutment supported porcelain fused to metal crown (predominantly
base metal)
1626
abutment supported porcelain fused to metal crown (noble metal)
1622
abutment supported cast metal crown (high noble metal)
1698
abutment supported cast metal crown (predominantly base metal)
1586
abutment supported cast metal crown (noble metal)
1623
implant supported porcelain/ceramic crown
1824
implant supported porcelain fused to metal crown (titanium,
titanium alloy, high noble metal)
1838
implant supported metal crown (titanium, titanium alloy, high noble
metal)
1855
abutment supported retainer for porcelain/ceramic FPD
1731
abutment supported retainer for porcelain fused to metal FPD (high
noble metal)
1729
abutment supported retainer for porcelain fused to metal FPD
(predominantly base metal)
1641
abutment supported retainer for porcelain fused to metal FPD (noble
metal)
1643
abutment supported retainer for cast metal FPD (high noble metal) 1741
abutment supported retainer for cast metal FPD (predominantly base
metal)
1635
abutment supported retainer for cast metal FPD (noble metal)
1603
implant supported retainer for ceramic FPD
1813
implant supported retainer for porcelain fused to metal FPD
(titanium, titanium alloy, or high noble metal)
1854
implant supported retainer for cast metal FPD (titanium, titanium
alloy, or high noble metal)
1870
implant/abutment supported fixed denture for completely edentulous
arch
6621
910
922
738
738
220
220
2244
2191
751
409
413
780
912
468
799
2103
1656
8687
6091
2995
2938
3102
851
1002
1528
1534
1438
1435
1502
1403
1436
1613
1626
1641
1531
1529
1452
1453
1540
1446
1418
1604
1640
1654
5858
11:3-29.6
APPENDIX B - REGULATIONS
D6079 implantlabutment supported fixed denture for partially edentulous
arch
4784
D6080 implant maintenance procedures, including removal of
prosthesis, cleansing of prosthesis and abutments and reinsertion of
prosthesis
375
D6090 repair implant supported prosthesis, by report
889
D6091 replacement of semi-precision or precision attachment (male or
female component) of implant/abutment supported prosthesis, per
attachment
752
D6092 recement implant/abutment supported crown
189
D6093 recement implant/abutment supported fixed partial denture
216
D6094 abutment supported crown - (titanium)
1590
D6095 repair implant abutment, by report
863
D6100 implant removal, by report
904
D6190 radiographic/surgical implant index, by report
509
D6194 abutment supported retainer crown for FPD - (titanium)
1721
D6205 pontic - indirect resin based composite
1156
D6210 pontic - cast high noble metal
1296
D6211 pontic - cast predominantly base metal
1201
D6212 pontic - cast noble metal
1233
D6214 pontic-titanium
1292
D6240 pontic - porcelain fused to high noble metal
1319
D6241 pontic - porcelain fused to predominantly base metal
1215
D6242 pontic - porcelain fused to noble metal
1245
D6245 pontic - porcelain/ceramic
1358
D6250 pontic - resin with high noble metal
1255
D6251 pontic - resin with predominantly base metal
1244
D6252 pontic - resin with noble metal
1228
D6253 provisional pontic
910
D6545 retainer - cast metal for resin bonded fixed prosthesis
1019
D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis
1122
D6710 crown - indirect resin based composite
1192
D6720 crown - resin with high noble metal
1253
D6721 crown - resin with predominantly base metal
1242
D6722 crown - resin with noble metal
1245
D6740 crown - porcelain/ceramic
1364
D6750 crown - porcelain fused to high noble metal
1330
D6751 crown - porcelain fused to predominantly base metal
1217
D6752 crown - porcelain fused to noble metal
1245
D6780 crown - 3/4 cast high noble metal
1271
D6781 crown - 3/4 cast predominantly base metal
1218
D6782 crown - 3/4 cast noble metal
1245
D6783 crown - 3/4 porcelain/ceramic
1296
D6790 crown - full cast high noble metal
1298
D6791 crown - full cast predominantly base metal
1201
D6792 crown - full cast noble metal
1233
D6793 provisional retainer crown
661
D6794 crown - titanium
1250
D6920 connector bar
1182
D6930 recement fixed partial denture
205
D6940 stress breaker
528
D6950 precision attachment
789
D6970 post and core in addition to fixed partial denture retainer, indirectly
fabricated
517
D6972 prefabricated post and core in addition to fixed partial denture retainer406
D6973 core build up for retainer, including any pins
323
D6975 coping-metal
832
D6976 each additional indirectly fabricated post - same tooth
343
D6977 each additional prefabricated post - same tooth
246
4232
331
786
665
167
191
1407
763
800
451
1522
1023
1147
1063
1091
1143
1167
1075
1102
1202
1111
1101
1087
805
901
992
1055
1109
1099
1102
1207
1177
1077
1102
1125
1078
1102
1147
1149
1063
1091
585
1106
1046
181
467
698
458
360
285
736
303
217
MEDICAL FEE SCHEDULES
D6980
D6985
D7110
D7111
D7120
D7140
D7210
D7250
D7290
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7852
D7854
D7856
D7880
D7910
D7911
D7912
D7920
D7955
D7960
D7990
D8210
D8220
D8691
D8692
D8693
D9110
D9210
11:3-29.6
fixed partial denture repair, by report
455
pediatric partial denture, fixed
1073
single tooth (extraction)
n/a
extraction, coronal remnants - deciduous tooth
161
each add tooth (extraction)
n/a
extraction, erupted tooth or exposed root (elevation and/or forceps
removal)
209
surgical removal of erupted tooth requiring removal of bone and/or
sectioning of tooth, and including elevation of mucoperiosteal flap if
indicated
328
surgical removal of residual tooth roots (cutting procedure)
370
surgical repositioning of teeth
625
maxillary sinusotomy for removal of tooth fragment or foreign body 1681
maxilla - open reduction (teeth immobilized, if present)
5162
maxilla - closed reduction (teeth immobilized, if present)
4180
mandible - open reduction (teeth immobilized, if present)
5349
mandible - closed reduction (teeth immobilized, if present)
4157
malar and/or zygomatic arch - open reduction
4631
malar and/or zygomatic arch - closed reduction
3862
alveolus closed reduction may include stabilization of teeth
2257
alveolus, open reduction may include stabilization of teeth
1512
facial bones - complicated reduction with fixation and multiple
surgical approaches
7759
maxilla open reduction
5260
maxilla - closed reduction
4133
mandible - open reduction
5746
mandible - closed reduction
4273
malar and/or zygomatic arch - open reduction
5014
malar and/or zygomatic arch - closed reduction
7186
alveolus - open reduction stabilization of teeth
3294
alveolus, closed reduction stabilization of teeth
2287
facial bones - complicated reduction with fixation and multiple
surgical approaches
10128
open reduction of dislocation
5014
closed reduction of dislocation
763
manipulation under anesthesia
1166
condylectomy
6424
surgical discectomy, with/without implant
6210
disc repair
6609
synovectomy
6140
myotomy
4188
occlusal orthotic device, by report
1453
suture of recent small wounds up to 5 cm
368
complicated suture - up to 5 cm
610
complicated suture - greater than 5 cm
961
skin graft (identify defect covered, location and type of graft)
3110
repair of maxillofacial soft and/or hard tissue defect
4554
frenulectomy - also known as frenectomy or frenotomy separate procedure not incidental to another procedure
538
emergency tracheotomy
1715
removable appliance therapy
1034
fixed appliance therapy
1174
repair of orthodontic appliance
255
replacement of lost or broken retainer
405
rebonding or recementing; and/or repair, as required, of fixed
retainers
408
palliative (emergency) treatment of dental pain - minor procedure
154
local anesthesia not in conjunction with operative or surgical
procedures
91
403
949
n/a
142
n/a
185
290
327
553
1487
4567
3699
4732
3678
4097
3417
1997
1338
6864
4654
3656
5084
3781
4436
6358
2914
2023
8960
4436
675
1032
5684
5494
5847
5432
3706
1376
325
540
850
2751
3941
476
1517
914
1039
225
359
361
136
80
11:3-29.6
D9211
D9212
D9215
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9610
D9612
D9630
D9940
D9950
D9951
D9952
APPENDIX B - REGULATIONS
regional block anesthesia
113
trigeminal division block anesthesia
317
local anesthesia in conjunction with operative or surgical procedures 79
deep sedation/general anesthesia - first 30 minutes
480
deep sedation/general anesthesia - each additional 15 minutes
205
inhalation of nitrous oxide / anxiolysis, analgesia
96
intravenous conscious sedation/analgesia - first 30 minutes
509
intravenous conscious sedation/analgesia - each additional 15 minutes200
non-intravenous conscious sedation
400
consultation - diagnostic service provided by dentist or physician
other than requesting dentist or physician
158
house/extended care facility call
301
hospital or ambulatory surgical center call
357
office visit for observation (during regularly scheduled hours) - no
other services performed
94
therapeutic parenteral drug, single administration
131
therapeutic parenteral drugs, two or more administrations,
different medications
226
other drugs and/or medicaments, by report
63
occlusal guard, by report
727
occlusion analysis - mounted case
418
occlusal adjus ment - limited
223
occlusal adjustment - complete
846
100
280
70
425
181
85
451
177
354
140
266
315
83
116
200
56
643
370
197
748
Exhibit 3
Home Care Fees
Service
PRIVATE NURSING CARE
(PER HOUR)
Registered nurse
Licensed practical nurse
Home health aide
Live-in attendant (per 24-hr shift)
HOME HEALTH VISITS
(PER VISIT)
Registered nurse
Physical therapist
Speech therapist
Occupational therapist
Medical social worker
HSPCS CODE
S9123
S9124
S9122
S5126
FEE
70.00
65.00
24.00
180.00
HSPCS CODE
T1030
S9131
S9128
S9129
S9127
FEE
125.00
135.00
145.00
135.00
195.00
Exhibit 4
Ambulance Services Fee Schedule
HCPCS Description
A0425
A0426
A0427
A0428
A0429
A0431
A0433
A0434
A0436
GROUND MILEAGE, PER STATUTE MILE
AMBULANCE SERVICE, ALS, NON-EMERGENCY TRANSPORT,
LEVEL 1
AMBULANCE SERVICE, ALS, EMERGENCY TRANSPORT,
LEVEL I
AMBULANCE SERVICE, BLS, NON-EMERGENCY TRANSPORT
AMBULANCE SERVICE, BLS, EMERGENCY TRANSPORT
AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES
TRANSPORT ONE WAY (ROTARY WING)
ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)
SPECIALTY CARE TRANSPORT (SCT)
ROTARY WING AIR MILEAGE, PER STATUTE MILE
North
South
8.93
8.93
386.84
612.49
322.36
515.78
4,790.49
886.50
1,047.68
27.99
363.02
574.78
302.52
484.02
4,571.17
831.92
983.17
27.99
MEDICAL FEE SCHEDULES
11:3-29.6
Exhibit 5
Durable Medical Equipment, Prosthetics, Orthotics & Supplies
HCPCS Mod Mod2
A4216
A4217
A4217 AU
A4221
A4222
A4233 NU
A4233 NU KL
A4234 NU
A4234 NU KL
A4235 NU
A4235 NU KL
A4236 NU
A4236 NU KL
A4253 NU
A4253 NU KL
A4255
A4256
A4256 KL
A4257
A4258
A4258 KL
A4259
A4259 KL
A4265
A4280
A4310
A4311
A4312
A4313
A4314
A4315
A4316
A4320
A4321
A4322
A4326
A4327
A4328
A4330
A4331
A4332
A4333
A4334
A4336
A4338
A4340
A4344
A4346
A4349
A4351
A4352
A4353
A4354
A4355
A4356
A4357
A4358
A4360
A4361
A4362
A4363
A4364
A4366
A4367
CATG Fee
OS
$.047
SU
$3.29
OS
$3.29
SU
$23.77
SU
$49.07
IN
$0.84
IN
$0.72
IN
$3.81
IN
$3.29
IN
$2.46
IN
$2.12
IN
$1.76
IN
$1.52
IN
$38.79
IN
$33.43
SU
$4.11
SU
$10.21
SU
$8.80
SU
$13.39
SU
$18.95
SU
$16.34
SU
$12.66
SU
$10.91
SU
$3.56
PO
$5.55
OS
$7.50
OS
$13.24
OS
$16.10
OS
$19.06
OS
$25.21
OS
$27.09
OS
$28.30
OS
$5.29
OS
$0.00
OS
$3.09
OS
$11.33
OS
$44.38
OS
$10.97
OS
$7.51
OS
$3.34
OS
$0.13
OS
$2.31
OS
$5.18
OS
$1.51
OS
$11.09
OS
$33.34
OS
$14.30
OS
$17.90
OS
$2.12
OS
$1.83
OS
$6.74
OS
$7.34
OS
$12.29
OS
$9.36
OS
$47.91
OS
$9.65
OS
$6.96
OS
$0.51
OS
$19.17
OS
$3.63
OS
$2.48
OS
$3.08
OS
$1.37
OS
$7.72
Description
Sterile water/saline, 10ml
Sterile water/saline, 500 ml
Sterile water/saline, 500 ml
Maint drug infus cath per wk
Infusion supplies with pump
Alkalin batt for glucose mon
Alkalin batt for glucose mon
J-cell batt for glucose mon
J-cell batt for glucose mon
Lithium batt for glucose mon
Lithium batt for glucose mon
Silvr oxide batt glucose mon
Silvr oxide batt glucose mon
Blood glucose/reagent strips
Blood glucose/reagent strips
Glucose monitor platforms
Calibrator solution/chips
Calibrator solution/chips
Replace Lensshield Cartridge
Lancet device each
Lancet device each
Lancets per box
Lancets per box
Paraffin
Brst prsths adhsv attchmnt
Insert tray w/o bag/cath
Catheter w/o bag 2-way latex
Cath w/o bag 2-way silicone
Catheter w/bag 3-way
Cath w/drainage 2-way latex
Cath w/drainage 2-way silcne
Cath w/drainage 3-way
Irrigation tray
Cath therapeutic irrig agent
Irrigation syringe
Male external catheter
Fem urinary collect dev cup
Fem urinary collect pouch
Stool collection pouch
Extension drainage tubing
Lube sterile packet
Urinary cath anchor device
Urinary Bath leg strap
Urethral insert
Indwelling catheter latex
Indwelling catheter special
Cath indw foley 2 way silicn
Cath indw foley 3 way
Disposable male external cat
Straight tip urine catheter
Coude tip urinary catheter
Intermittent urinary cath
Cath insertion tray w/bag
Bladder irrigation tubing
Ext ureth clmp or compr dvc
Bedside drainage bag
Urinary leg or abdomen bag
Disposable ext urethral dev
Ostomy face plate
Solid skin barrier
Ostomy clamp, replacement
Adhesive, liquid or equal
Ostomy vent
Ostomy belt
11:3-29.6
A4368
A4369
A4371
A4372
A4373
A4375
A4376
A4377
A4378
A4379
A4380
A4381
A4382
A4383
A4384
A4385
A4387
A4388
A4389
A4390
A4391
A4392
A4393
A4394
A4395
A4396
A4397
A4398
A4399
A4400
A4402
A4404
A4405
A4406
A4407
A4408
A4409
A4410
A4411
A4412
A4413
A4414
A4415
A4416
A4417
A4418
A4419
A4420
A4422
A4423
A4424
A4425
A4426
A4427
A4428
A4429
A4430
A4431
A4432
A4433
A4434
A4450
A4450
A4450
A4452
A4452
A4452
A4455
AU
AV
AW
AU
AV
AW
APPENDIX B - REGULATIONS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
$0.27
$2.54
$3.83
$4.39
$6.59
$18.04
$49.96
$4.50
$32.29
$15.77
$39.20
$4.84
$25.85
$29.60
$10.10
$5.36
$0.00
$4.58
$6.53
$10.09
$7.42
$8.59
$9.49
$2.71
$0.05
$42.50
$5.03
$14.50
$12.87
$51.31
$1.46
$1.62
$3.57
$6.03
$9.20
$10.36
$6.53
$9.49
$5.36
$2.84
$5.78
$5.18
$6.30
$2.89
$3.91
$1.90
$1.83
$0.00
$0.13
$1.95
$4.99
$3.76
$2.87
$2.92
$6.84
$8.66
$8.95
$6.53
$3.77
$3.51
$3.95
$0.09
$0.09
$0.12
$0.38
$0.38
$0.42
$1.47
Ostomy filter
Skin barrier liquid per oz
Skin barrier powder per oz
Skin barrier solid 4x4 equiv
Skin barrier with flange
Drainable plastic pch w fcpl
Drainable rubber pch w fcplt
Drainable plstic pch w/o fp
Drainable rubber pch w/o fp
Urinary plastic pouch w fcpl
Urinary rubber pouch w fcplt
Urinary plastic pouch w/o fp
Urinary hvy plstc pch w/o fp
Urinary rubber pouch w/o fp
Ostomy faceplt/silicone ring
Ost skn barrier sld ext wear
Ost clsd pouch w att st barr
Drainable pch w ex wear barr
Drainable pch w st wear barr
Drainable pch ex wear convex
Urinary pouch w ex wear barr
Urinary pouch w st wear barr
Urine pch w ex wear bar conv
Ostomy pouch liq deodorant
Ostomy pouch solid deodorant
Peristomal hernia supprt blt
Irrigation supply sleeve
Ostomy irrigation bag
Ostomy irrig cone/cath w brs
Ostomy irrigation set
Lubricant per ounce
Ostomy ring each
Nonpectin based ostomy paste
Pectin based ostomy paste
Ext wear ost skn barr <=4sq"
Ext wear ost skn barr >4sq"
Ost skn barr convex <=4 sq i
Ost skn barr extnd >4 sq
Ost skn barr extnd =4sq
Ost pouch drain high output
2 pc drainable ost pouch
Ost sknbar w/o conv<=4 sq in
Ost skn barn w/o conv >4 sqi
Ost pch clsd w barrier/filtr
Ost pch w bar/bltinconv/fltr
Ost pch clsd w/o bar w filtr
Ost pch for bar w flange/flt
Ost pch clsd for bar w lk fl
Ost pouch absorbent material
Ost pch for bar w lk fl/fltr
Ost pch drain w bar & filter
Ost pch drain for barrier fl
Ost pch drain 2 piece system
Ost pch drain/barr lk flng/f
Urine ost pouch w faucet/tap
Urine ost pouch w bltinconv
Ost urine pch w b/bltin cony
Ost pch urine w barrier/tapv
Os pch urine w bar/fange/tap
Urine ost pch bar w lock fln
Ost pch urine w lock flng/ft
Non-waterproof tape
Non-waterproof tape
Non-waterproof tape
Waterproof tape
Waterproof tape
Waterproof tape
Adhesive remover per ounce
MEDICAL FEE SCHEDULES
A4456
A4461
A4463
A4481
A4483
A4556
A4557
A4558
A4559
A4561
A4562
A4595
A4604
A4605
A4608
A4611
A4611
A4611
A4612
A4612
A4612
A4613
A4613
A4613
A4614
A4615
A4616
A4617
A4618
A4618
A4618
A4619
A4620
A4623
A4624
A4625
A4626
A4628
A4629
A4630
A4633
A4635
A4635
A4635
A4636
A4636
A4636
A4636
A4636
A4636
A4637
A4637
A4637
A4637
A4637
A4637
A4638
A4638
A4638
A4639
A4640
A4640
A4640
A5051
A5052
A5053
A5054
A5055
NU
NU
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
NU
NU
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
NU
RR
UE
KE
KE
KE
KE
KE
KE
OS
SD
SD
OS
OS
SU
SU
SU
SU
PO
PO
SU
IN
IN
OX
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
SU
SU
SU
IN
IN
IN
OX
SU
OS
IN
OS
OS
TN
OS
IN
TN
IN
IN
IN
IN
TN
IN
IN
IN
IN
IN
IN
IN
TN
IN
IN
IN
IN
IN
IN
IN
IN
IN
OS
OS
OS
OS
OS
$0.26
$3.45
$13.98
$0.39
$0.00
$12.75
$18.84
$5.72
$0.11
$20.95
$52.16
$30.25
$60.46
$17.22
$52.63
$206.27
$21.39
$154.71
$71.34
$7.27
$54.40
$151.42
$15.15
$109.50
$24.97
$0.75
$0.07
$3.25
$9.33
$1.07
$7.00
$1.27
$0.62
$6.88
$2.47
$7.28
$3.35
$3.85
$4.86
$5.97
$43.09
$5.38
$0.72
$3.56
$3.24
$3.76
$0.39
$0.45
$2.36
$2.74
$1.93
$2.24
$0.27
$0.32
$1.46
$1.69
$0.00
$0.00
$0.00
$301.57
$62.79
$6.28
$47.10
$2.17
$1.56
$1.83
$1.88
$1.49
11:3-29.6
Adhesive remover, wipes
Surgicl dress hold non-reuse
Surgical dress holder reuse
Tracheostoma filter
Moisture exchanger
Electrodes, pair
Lead wires, pair
Conductive gel or paste
Coupling gel or paste
Pessary rubber, any type
Pessary, non rubber,any type
TENS suppl 2 lead per month
Tubing with heating element
Trach suction cath close sys
Transtracheal oxygen cath
Heavy duty battery
Heavy duty battery
Heavy duty battery
Battery cables
Battery cables
Battery cables
Battery charger
Battery charger
Battery charger
Hand-held PEFR meter
Cannula nasal
Tubing (oxygen) per foot
Mouth piece
Breathing circuits
Breathing circuits
Breathing circuits
Face tent
Variable concentration mask
Tracheostomy inner cannula
Tracheal suction tube
Trach care kit for new trach
Tracheostomy cleaning brush
Oropharyngeal suction cath
Tracheostomy care kit
Repl bat t.e.n.s. own by pt
Uvl replacement bulb
Underarm crutch pad
Underarm crutch pad
Underarm crutch pad
Handgrip for cane etc
Handgrip for cane etc
Handgrip for cane etc
Handgrip for cane etc
Handgrip for cane etc
Handgrip for cane etc
Repl tip cane/crutch/walker
Repl tip cane/crutch/walker
Repl tip cane/crutch/walker
Repl tip cane/crutch/walker
Repl tip cane/crutch/walker
Rcpl tip cane/crutch/walker
Repl batt pulse gen sys
Repl batt pulse gen sys
Repl batt pulse gen sys
Infrared ht sys replcmnt pad
Alternating pressure pad
Alternating pressure pad
Alternating pressure pad
Pouch clsd w barr attached
Clsd ostomy pouch w/o barr
Clsd ostomy pouch faceplate
Clsd ostomy pouch w/flange
Stoma cap
11:3-29.6
A5061
A5062
A5063
A5071
A5072
A5073
A5081
A5082
A5083
A5093
A5102
A5105
A5112
A5113
A5114
A5120 AU
A5120 AV
A5121
A5122
A5126
A5131
A5200
A5500
A5501
A5503
A5504
A5505
A5506
A5507
A5512
A5513
A6010
A6011
A6021
A6022
A6023
A6024
A6154
A6196
A6197
A6199
A6203
A6204
A6207
A6209
A6210
A6211
A6212
A6214
A6216
A6217
A6219
A6220
A6222
A6223
A6224
A6229
A6231
A6232
A6233
A6234
A6235
A6236
A6237
A6238
A6240
A6241
A6242
APPENDIX B - REGULATIONS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
PO
OS
OS
OS
OS
OS
TS
TS
TS
TS
TS
TS
TS
TS
TS
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
$3.70
$2.33
$2.84
$6.31
$3.70
$3.34
$3.47
$12.48
$0.66
$2.04
$23.54
$42.80
$30.90
$4.94
$9.39
$0.26
$0.25
$6.87
$11.47
$1.39
$16.65
$11.87
$66.76
$200.25
$29.69
$29.69
$29.69
$29.69
$29.69
$27.24
$40.65
$32.51
$2.39
$22.07
$22.07
$199.82
$6.50
$15.10
$7.72
$17.26
$5.55
$3.52
$6.54
$7.71.
$7.85
$20.92
$30.84
$10.19
$10.80
$0.05
$0.00
$1.00
$2.71
$2.24
$2.54
$3.79
$3.79
$4.89
$7.22
$20.15
$6.87
$17.66
$28.61
$8.31
$23.93
$12.85
$2.70
$6.37
Pouch drainable w barrier at
Drnble ostomy pouch w/o barr
Drain ostomy pouch w/flange
Urinary pouch w/barrier
Urinary pouch w/o barrier
Urinary pouch on barn w/flng
Continent stoma plug
Continent stoma catheter
Stoma absorptive cover
Ostomy accessory convex inse
Bedside drain btl w/wo tube
Urinary suspensory
Urinary leg bag
Latex leg strap
Foam/fabric leg strap
Skin barrier, wipe or swab
Skin barrier, wipe or swab
Solid skin barrier 6x6
Solid skin barrier 8x8
Disk/foam pad +or- adhesive
Appliance cleaner
Percutaneous catheter anchor
Diab shoe for density insert
Diabetic custom molded shoe
Diabetic shoe w/roller/rockr
Diabetic shoe with wedge
Diab shoe w/metatarsal bar
Diabetic shoe w/off set heel
Modification diabetic shoe
Multi den insert direct form
Multi den insert custom mold
Collagen based wound filler
Collagen gel/paste wound fil
Collagen dressing <=16 sq in
Collagen drsg>16<=48 sq in
Collagen dressing >48 sq in
Collagen dsg wound filler
Wound pouch each
Alginate dressing <=16 sq in
Alginate drsg >16 <=48 sq in
Alginate drsg wound filler
Composite drsg <= 16 sq in
Composite drsg >1 6<=48 sq in
Contact layer >16<= 48 sq in
Foam drsg <=16 sq in w/o bdr
Foam drg >16<=48 sq in w/o b
Foam drg > 48 sq in w/o brdr
Foam drg <=16 sq in w/border
Foam drg > 48 sq in w/border
Non-sterile gauze<=16 sq in
Non-sterile gauze>16<=48 sq
Gauze <= 16 sq in w/border
Gauze >16 <=48 sq in w/bordr
Gauze <=16 in no w/sal w/o b
Gauze >16<=48 no w/sal w/o b
Gauze > 48 in no w/sal w/o b
Gauze >16<=48 sq in watr/sal
Hydrogel dsg<=16 sq in
Hydrogel dsg>16<=48 sq in
Hydrogel dressing >48 sq in
Hydrocolld drg <=16 w/o bdr
Hydrocoil d drg >16<=48 w/o b
Hydrocolld drg > 48 in w/o b
Hydrocolld drg <=16 in w/bdr
Hydrocolld drg >16<=48 w/bdr
Hydrocolld drg filler paste
Hydrocolloid drg filler dry
Hydrogel drg <=16 in w/o bdr
MEDICAL FEE SCHEDULES
A6243
A6244
A6245
A6246
A6247
A6248
A6251
A6252
A6253
A6254
A6255
A6257
A6258
A6259
A6266
A6402
A6403
A6407
A6410
A6411
A6441
A6442
A6443
A6444
A6445
A6446
A6447
A6448
A6449
A6450
A6451
A6452
A6453
A6454
A6455
A6456
A6457
A6501
A6502
A6503
A6504
A6505
A6506
A6507
A6508
A6509
A6510
A6511
A6513
A6531
A6532
A6545
A6545
A6550
A7000
A7000
A7001
A7002
A7003
A7004
A7005
A7006
A7007
A7008
A7009
A7010
A7012
A7013
AW
AW
AW
NU
NU KE
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SU
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$12.93
$41.24
$7.63
$10.42
$24.97
$17.05
$2.09
$3.41
$6.66
$1.27
$3.18
$1.61
$4.52
$11.49
$2.02
$0.13
$0.45
$1.97
$0.41
$0.00
$0.70
$0.18
$0.30
$0.59
$0.34
$0.43
$0.70
$1.22
$1.84
$0.00
$0.00
$6.21
$0.64
$0.81
$1.46
$1.34
$1.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$45.43
$64.01
$0.00
$89.45
$24.82
$7.54
$8.75
$31.32
$3.63
$2.87
$1.61
$29.18
$8.55
$4.17
$11.55
$39.80
$24.48
$3.76
$0.79
11:3-29.6
Hydrogel drg >16<=48 w/o bdr
Hydrogel drg >48 in w/o bdr
Hydrogel drg <= 16 in w/bdr
Hydrogel drg >16<=48 in w/b
Hydrogel dig > 48 sq in w/b
Hydrogel drsg gel filler
Absorpt drg <=16 sq in w/o b
Absorpt drg >16 <=48 w/o bdr
Absorpt drg > 48 sq in w/o b
Absorpt drg <=16 sq in w/bdr
Absorpt drg >16<=48 in w/bdr
Transparent film <= 16 sq in
Transparent film >16<=48 in
Transparent film > 48 sq in
Impreg gauze no h20/sal/yard
Sterile gauze <= 16 sq in
Sterile gauze>16 <= 48 sq in
Packing strips, non-impreg
Sterile eye pad
Non-sterile eye pad
Pad band w>=3" <5"/yd
Conform band n/s w<3"/yd
Conform band n/s w>=3"<5"/yd
Conform band n/s w>=5"/yd
Conform band s w <3"/yd
Conform band s w>=3" <5"/yd
Confom band s w >=5"/yd
Lt compres band <3"/yd
Lt compres band >=3" <5"/yd
Lt compres band >=5"/yd
Mod compres band w>=3"<5"/yd
High compres band w>=3"<5"yd
Self-adher band w <3"/yd
Self-adher band w>=3" <5"/yd
Self-adher band >=5"/yd
Zinc paste band w >=3"<5"/yd
Tubular dressing
Compres burngarment bodysuit
Compres burngarment chinstrp
Compres burngarment facehood
Cmprsburngarment glove-wrist
Cmprsburngarment glove-elbow
Cmprsbumgrmt glove-axilla
Cmprs burngarment foot-knee
Cmprs burngarment foot-thigh
Compres bum garment jacket
Compres bum garment leotard
Compres burn garment panty
Compress bum mask face/neck
Compression stocking BK30-40
Compression stocking BK40-50
Grad comp non-elastic BK
Grad comp non-elastic BK
Neg pres wound ther drsg set
Disposable canister for pump
Disposable canister for pump
Nondisposable pump canister
Tubing used w suction pump
Nebulizer administration set
Disposable nebulizer sml vol
Nondisposable nebulizer set
Filtered nebulizer admin set
Lg vol nebulizer disposable
Disposable nebulizer prefill
Nebulizer reservoir bottle
Disposable corrugated tubing
Nebulizer water collec devic
Disposable compressor filter
11:3-29.6
A7014
A7015
A7016
A7017
A7017
A7017
A7018
A7025
A7026
A7027
A7028
A7029
A7030
A7031
A7032
A7033
A7034
A7035
A7036
A7037
A7038
A7039
A7040
A7041
A7042
A7043
A7044
A7045
A7045
A7045
A7046
A7501
A7502
A7503
A7504
A7505
A7506
A7507
A7508
A7509
A7520
A7521
A7522
A7524
A7525
A7526
A7527
A8000
A8000
A8000
A8001
A8001
A8001
A8002
A8002
A8002
A8003
A8003
A8003
A8004
A8004
A8004
E0100
E0100
E0100
E0105
E0105
E0105
NU
NU
NU
NU
RR
UE
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
RR
UE
NU
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
APPENDIX B - REGULATIONS
IN
IN
IN
IN
IN
IN
SU
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
PO
PO
PO
PO
IN
IN
IN
IN
IN
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$4.24
$1.73
$6.85
$140.74
$14.07
$105.55
$0.40
$456,69
$30.19
$188.32
$52.02
$21.25
$170.72
$63.14
$36.68
$25.71
$106.46
$32.06
$16.47
$35.49
$4.15
$13.87
$41.45
$77.90
$173.36
$29.52
$109.42
$17.62
$1.76
$13.21
$17.66
$110.28
$52.41
$11.90
$0.70
$4.91
$0.35
$2.61
$3.01
$1.48
$49.85
$49.40
$47.42
$81.27
$2.17
$3.54
$3.76
$161.02
$16.10
$120.78
$161.02
$16.10
$120.78
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$19.69
$5.30
$15.25
$51.57
$7.91
$38.05
Compressor nondispos filter
Aerosol mask used w nebulizer
Nebulizer dome & mouthpiece
Nebulizer not used w oxygen
Nebulizer not used w oxygen
Nebulizer not used w oxygen
Water distilled w/nebulizer
Replace chest compress vest
Replace chst cmprss sys hose
Combination oral/nasal mask
Repl oral cushion combo mask
Repl nasal pillow comb mask
CPAP full face mask
Replacement facemask interfa
Replacement nasal cushion
Replacement nasal pillows
Nasal application device
Pos airway press headgear
Pos airway press chinstrap
Pos airway pressure tubing
Pos airway pressure filter
Filter, non disposable w pap
One way chest drain valve
Water seal drain container
Implanted pleural catheter
Vacuum drainagebottle/tubing
PAP oral interface
Repl exhalation port for PAP
Repl exhalation port for PAP
Repl exhalation port for PAP
Repl water chamber, PAP dev
Tracheostoma valve w diaphra
Replacement diaphragm/fplate
HMES filter holder or cap
Tracheostoma HMES filter
HMES or trach valve housing
HMES/trachvalve adhesivedisk
Integrated filter & holder
Housing & Integrated Adhesiv
Heat & moisture exchange sys
Trach/laryn tube non-cuffed
Trach/laryn tube cuffed
Trach/laryn tube stainless
Tracheostoma stent/stud/bttn
Tracheostomy mask
Tracheostomy tube collar
Trach/laryn tube plug/stop
Soft protect helmet prefab
Soft protect helmet prefab
Soft protect helmet prefab
Hard protect helmet prefab
Hard protect helmet prefab
Hard protect helmet prefab
Soft protect helmet custom
Soft protect helmet custom
Soft protect helmet custom
Hard protect helmet custom
Hard protect helmet custom
Hard protect helmet custom
Repl soft interface, helmet
Repl soft interface, helmet
Repl soft interface, helmet
Cane adjust/fixed with tip
Cane adjust/fixed with tip
Cane adjust/fixed with tip
Cane adjust/fixed quad/3 pro
Cane adjust/fixed quad/3 pro
Cane adjust/fixed quad/3 pro
MEDICAL FEE SCHEDULES
E0110
E0110
E0110
E0111
E0111
E0111
E0112
E0112
E0112
E0113
E0113
E0113
E0114
E0114
E0114
E0116
E0116
E0116
E0117
E0117
E0117
E0130
E0130
E0130
E0135
E0135
E0135
E0140
E0140
E0140
E0141
E0141
E0141
E0143
E0143
E0143
E0144
E0144
E0144
E0147
E0147
E0147
E0148
E0148
E0148
E0149
E0149
E0149
E0153
E0153
E0153
E0154
E0154
E0154
E0155
E0155
E0155
E0156
E0156
E0156
E0157
E0157
E0157
E0158
E0158
E0158
E0159
E0159
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$76.20
$14.27
$57.14
$55.92
$8.75
$43.16
$38.85
$8.87
$29.64
$22.19
$5.41
$16.65
$49.55
$9.00
$37.45
$24.98
$5.67
$18.73
$202.35
$20.22
$151.78
$63.42
$15.22
$47.52
$67.40
$15.62
$49.48
$326.44
$32.65
$244.84
$104.34
$20.24
$78.26
$108.81
$19.54
$81.43
$288.20
$24.51
$183.72
$520.20
$52.02
$390.17
$114.98
$11.51
$86.23
$202.00
$20.20
$151.49
$72.85
$8.23
$54.63
$63.81
$7.75
$48.48
$28.56
$3.48
$21.77
$23.92
$3.06
$17.96
$63.02
$8.14
$47.2
$29.12
$3.21
$21.98
$16.12
$1.63
11:3-29.6
Crutch forearm pair
Crutch forearm pair
Crutch foreann pair
Crutch forearm each
Crutch forearm each
Crutch foreariu each
Crutch underarm pair wood
Crutch underarm pair wood
Crutch underarm pair wood
Crutch underarm each wood
Crutch underarm each wood
Crutch underarm each wood
Crutch underarm pair no wood
Crutch underarm pair no wood
Crutch underarm pair no wood
Crutch underarm each no wood
Crutch underann each no wood
Crutch underamn each no wood
Underarm springassist crutch
Underarm springassist crutch
Underarm springassist crutch
Walker rigid adjust/fixed ht
Walker rigid adjust/fixed ht
Walker rigid adjust/fixed ht
Walker folding adjust/fixed
Walker folding adjust/fixed
Walker folding adjust/fixed
Walker w trunk support
Walker w trunk support
Walker w trunk support
Rigid wheeled walker adj/fix
Rigid wheeled walker adj/fix
Rigid wheeled walker adj/fix
Walker folding wheeled w/o s
Walker folding wheeled w/o s
Walker folding wheeled w/o s
Enclosed walker w rear seat
Enclosed walker w rear seat
Enclosed walker w rear seat
Walker variable wheel resist
Walker variable wheel resist
Walker variable wheel resist
Heavyduty walker no wheels
Heavyduty walker no wheels
Heavyduty walker no wheels
Heavy duty wheeled walker
Heavy duty wheeled walker
Heavy duty wheeled walker
Forearm crutch platform atta
Forearm crutch platform atta
Forearm crutch platform atta
Walker platform attachment
Walker platform attachment
Walker platform attachment
Walker wheel attachment,pair
Walker wheel attachment,pair
Walker wheel attachment,pair
Walker seat attachment
Walker seat attachment
Walker seat attachment
Walker crutch attachment
Walker crutch attachment
Walker crutch attachment
Walker leg extenders set of4
Walker leg extenders set of4
Walker leg extenders set of4
Brake for wheeled walker
Brake for wheeled walker
11:3-29.6
E0159
E0160
E0160
E0160
E0161
E0161
E0161
E0162
E0162
E0162
E0163
E0163
E0163
E0165
E0167
E0167
E0167
E0168
E0168
E0168
E0170
E0171
E0175
E0175
E0175
E0181
E0182
E0184
E0184
E0184
E0185
E0185
E0185
E0186
E0187
E0188
E0188
E0188
E0189
E0189
E0189
E0191
E0191
E0191
E0193
E0194
E0196
E0197
E0197
E0197
E0198
E0198
E0198
E0199
E0199
E0199
E0200
E0200
E0200
E0202
E0205
E0205
E0205
E0210
E0210
E0210
E0215
E0215
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
RR
RR
NU
RR
UE
RR
RR
NU
RR
UE
NU
RR
UE
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
APPENDIX B - REGULATIONS
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
CR
CR
IN
IN
IN
CR
CR
IN
IN
IN
IIN
IN
IN
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
$12.11
$29.50
$4.55
$22.11
$27.54
$3.75
$20.62
$152.99
$16.05
$118.65
$115.80
$25.65
$80.80
$19.13
$12.60
$1.32
$9.49
$158.47
$15.93
$118.84
$168.76
$30.37
$69.54
$5.91
$43.50
$27.36
$27.49
$173.77
$25.80
$133.27
$285.47
$47.19
$219.09
$21.32
$23.70
$27.75
$3.26
$20.84
$46.38
$5.91
$34.79
$10.49
$1.07
$7.83
$786.82
$3,307.35
$28.99
$197.76
$32.10
$173.71
$197.76
$24.10
$150.07
$33.65
$3.35
$25.24
$70.75
$11.30
$53.09
$65.74
$173.20
$20.84
$129.90
$34.27
$3.22
$25.70
$63.22
$6.95
Brake for wheeled walker
Sitz type bath or equipment
Sitz type bath or equipment
Sitz type bath or equipment
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath chair
Sitz bath chair
Sitz bath chair
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with detacharm
Commode chair pail or pan
Commode chair pail or pan
Comninode chair pail or pan
Heavyduty/wide commode chair
Heavyduty/wide commode chair
Heavyduty/wide commode chair
Commode chair electric
Commode chair non-electric
Commode chair foot rest
Commode chair foot rest
Commode chair foot rest
Press pad alternating w/ pum
Replace pump, alt press pad
Dry pressure mattress
Dry pressure mattress
Dry pressure mattress
Gel pressure mattress pad
Gel pressure mattress pad
Gel pressure mattress pad
Air pressure mattress
Water pressure mattress
Synthetic sheepskin pad
Synthetic sheepskin pad
Synthetic sheepskin pad
Lambswool sheepskin pad
Lambswool sheepskin pad
Lambswool sheepskin pad
Protector heel or elbow
Protector heel or elbow
Protector heel or elbow
Powered air flotation bed
Air fluidized bed
Gel pressure mattress
Air pressure pad for mattres
Air pressure pad for mattres
Air pressure pad for mattres
Water pressure pad for mattr
Water pressure pad for mattr
Water pressure pad for mattr
Dry pressure pad for mattres
Dry pressure pad for mattres
Dry pressure pad for mattres
Heat lamp without stand
Heat lamp without stand
Heat lamp without stand
Phototherapy light w/ photom
Heat lamp with stand
Heat lamp with stand
Heat lamp with stand
Electric heat pad standard
Electric heat pad standard
Electric heat pad standard
Electric heat pad moist
Electric heat pad moist
MEDICAL FEE SCHEDULES
E0215
E0217
E0217
E0217
E0220
E0220
E0220
E0225
E0225
E0225
E0230
E0230
E0230
E0235
E0236
E0238
E0238
E0238
E0239
E0239
E0239
E0249
E0249
E0249
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0271
E0271
E0271
E0272
E0272
E0272
E0275
E0275
E0275
E0276
E0276
E0276
E0277
E0280
E0280
E0280
E0290
E0291
E0292
E0293
E0294
E0295
E0296
E0297
E0300
E0300
E0300
E0301
E0302
E0303
E0304
E0305
E0310
E0310
E0310
E0316
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
RR
RR
RR
RR
RR
NU
RR
UE
RR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
CR
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
CR
CR
CR
CR
CR
CR
CR
CR
IN
IN
IN
CR
CR
CR
CR
CR
IN
IN
IN
CR
$47.43
$443.10
$49.33
$332.30
$7.56
$0.79
$5.65
$346.87
$34.20
$260.14
$7.57
$0.85
$5.66
$18.12
$40.19
$28.38
$2.86
$20.87
$472.32
$47.24
$354.26
$104.58
$11.50
$78.44
$84.09
$61.24
$91.93
$64.12
$127.12
$105.34
$173.87
$160.72
$191.13
$20.87
$143.32
$176.39
$19.12
$132.29
$16.08
$1.68
$12.05
$13.97
$1.65
$11.05
$584.14
$33.49
$3.72
$25.11
$57.49
$41.77
$64.65
$62.16
$100.88
$100.88
$127.56
$127.31
$2,568.95
$256.89
$1,926.71
$228.58
$647.47
$258.68
$697.46
$13.69
$175.70
$20.60
$132.95
$191.21
11:3-29.6
Electric heat pad moist
Water circ heat pad w pump
Water circ heat pad w pump
Water circ heat pad w pump
Hot water bottle
Hot water bottle
Hot water bottle
Hydrocollator unit
Hydrocollator unit
Hydrocollator unit
Ice cap or collar
Ice cap or collar
Ice cap or collar
Paraffin bath unit portable
Pump for water circulating p
Heat pad non-electric moist
Heat pad non-electric moist
Heat pad non-electric moist
Hydrocollator unit portable
Hydrocollator unit portable
Hydrocollator unit portable
Pad water circulating heat u
Pad water circulating heat u
Pad water circulating heat u
Hosp bed fixed ht w/ mattres
Hosp bed fixd ht w/o mattres
Hospital bed var ht w/ mattr
Hospital bed var ht w/o matt
Hosp bed semi-electr w/ matt
Hosp bed semi-electr w/o mat
Hosp bed total electr w/ mat
Hosp bed total elec w/o matt
Mattress innerspring
Mattress innerspring
Mattress innerspring
Mattress foam rubber
Mattress foam rubber
Mattress foam rubber
Bed pan standard
Bed pan standard
Bed pan standard
Bed pan fracture
Bed pan fracture
Bed pan fracture
Powered pres-redu air mattrs
Bed cradle
Bed cradle
Bed cradle
Hosp bed fx ht w/o rails w/m
Hosp bed fx ht w/o rail w/o
Hosp bed var ht w/o rail w/o
Hosp bed var ht w/o rail w/
Hosp bed semi-elect w/ matt
Hosp bed semi-elect w/o matt
Hosp bed total elect w/ matt
Hosp bed total elect w/o mat
Enclosed ped crib hosp grade
Enclosed ped crib hosp grade
Enclosed ped crib hosp grade
HD hosp bed, 350-600 lbs
Ex hd hosp bed > 600 lbs
Hosp bed hvy dty xtra wide
Hosp bed xtra hvy dty x wide
Rails bed side half length
Rails bed side full length
Rails bed side full length
Rails bed side full length
Bed safety enclosure
11:3-29.6
E0325
E0325
E0325
E0326
E0326
E0326
E0371
E0372
E0373
E0424
E0431
E0433
E0434
E0439
E0441
E0442
E0443
E0444
E0450
E0457
E0457
E0457
E0459
E0460
E0461
E0462
E0463
E0464
E0470
E0471
E0472
E0480
E0482
E0483
E0484
E0484
E0484
E0485
E0485
E0485
E0486
E0486
E0486
E0500
E0550
E0560
E0560
E0560
E0561
E0561
E0561
E0562
E0562
E0562
E0565
E0570
E0571
E0572
E0574
E0575
E0580
E0580
E0580
E0585
E0600
E0601
E0602
E0602
APPENDIX B - REGULATIONS
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
RR
NU
RR
UE
RR
RR
RR
NU
RR
IN
IN
IN
IN
IN
IN
CR
CR
CR
OX
OX
OX
OX
OX
OX
OX
OX
OX
FS
IN
IN
IN
CR
FS
FS
CR
FS
FS
CR
CR
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
FS
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
CR
CR
FS
IN
IN
IN
CR
CR
CR
IN
IN
$9.03
$1.59
$6.48
$11.03
$1.25
$8.26
$377.47
$458.01
$524.67
$173.17
$28.77
$51.63
$28.77
$173.17
$77.45
$77.45
$77,45
$77.45
$1,002.25
$645.24
$64.52
$483.89
$53.43
$654.71
$1,002.25
$305.97
$1,476.70
$1,476.70
$197.39
$493.99
$493.99
$46.14
$423.71
$1,116.29
$38.77
$3.87
$29.09
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$115.26
$52.64
$131.95
$15.46
$98.96
$96.84
$9.67
$72.62
$272.60
$27.25
$204.45
$54.45
$16.91
$29.69
$37.73
$39.87
$107.92
$121.31
$12.13
$90.97
$36.82
$46.23
$90.59
$31.00
$3.11
Urinal male jug-type
Urinal male jug-type
Urinal male jug-type
Urinal female jug-type
Urinal female jug-type
Urinal female jug-type
Nonpower mattress overlay
Powered air mattress overlay
Nonpowered pressure mattress
Stationary compressed gas 02
Portable gaseous 02
Portable liquid oxygen sys
Portable liquid 02
Stationary liquid 02
Stationary 02 contents, gas
Stationary 02 contents, liq
Portable 02 contents, gas
Portable 02 contents, liquid
Vol control vent invasiv int
Chest shell
Chest shell
Chest shell
Chest wrap
Neg press vent portabl/statn
Vol control vent noninv int
Rocking bed w/ or w/o side r
Press supp vent invasive int
Press supp vent noninv int
RAD w/o backup non-inv intfc
RAD w/backup non inv mine
RAD w backup invasive intrfc
Percussor elect/pneum home m
Cough stimulating device
Chest compression gen system
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Oral device/appliance prefab
Oral device/appliance prefab
Oral device/appliance prefab
Oral device/appliance cusfab
Oral device/appliance cusfab
Oral device/appliance cusfab
Ippb all types
Humidif extens supple w ippb
Humidifier supplemental w/ i
Humidifier supplemental w/ i
Humidifier supplemental w/ i
Humidifier nonheated w PAP
Humidifier nonheated w PAP
Humidifier nonheated w PAP
Humidifier heated used w PAP
Humidifier heated used w PAP
Humidifier heated used w PAP
Compressor air power source
Nebulizer with compression
Aerosol compressor for svneb
Aerosol compressor adjust pr
Ultrasonic generator w svneb
Nebulizer ultrasonic
Nebulizer for use w/regulat
Nebulizer for use w/regulat
Nebulizer for use w/ regulat
Nebulizer w/ compressor & he
Suction pump portab hom modl
Cont airway pressure device
Manual breast pump
Manual breast pump
MEDICAL FEE SCHEDULES
E0602
E0605
E0605
E0605
E0606
E0607
E0607
E0607
E0610
E0610
E0610
E0615
E0615
E0615
E0617
E0617
E0618
E0619
E0620
E0620
E0620
E0621
E0621
E0621
E0627
E0627
E0627
E0628
E0628
E0628
E0629
E0629
E0629
E0630
E0635
E0636
E0650
E0650
E0650
E0651
E0651
E0651
E0652
E0652
E0652
E0655
E0655
E0655
E0656
E0656
E0656
E0657
E0657
E0657
E0660
E0660
E0660
E0665
E0665
B0665
E0666
E0666
E0666
E0667
E0667
E0667
E0668
E0668
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR KF
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$23.25
$27.75
$3.22
$22.86
$20.48
$70.16
$7.01
$52.61
$249.75
$26.34
$187.34
$442.62
$61.43
$331.97
$319.25
$354.45
$257.49
$0.00
$918.11
$91.80
$688.58
$85.67
$9.71
$64.58
$347.25
$34.73
$260.41
$347.25
$34.73
$260.41
$347.25
$34.73
$260.41
$101.67
$109.21
$1,107.29
$686.85
$93.31
$515.15
$964.34
$96.44
$723.26
$4,731.54
$467.63
$4,126.23
$109.78
$13.31
$82.31
$606.60
$60.59
$455.01
$569.88
$56.89
$427.44
$167.74
$17.46
$115.91
$122.26
$14.77
$91.82
$144.98
$14.94
$108.77
$339.96
$34.00
$254.96
$394.37
$38.92
11:3-29.6
Manual breast pump
Vaporizer room type
Vaporizer room type
Vaporizer room type
Drainage board postural
Blood glucose monitor home
Blood glucose monitor home
Blood glucose monitor home
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Automatic ext defibrillator
Automatic ext defibrillator
Apnea monitor
Apnea monitor w recorder
Cap bld skin piercing laser
Cap bld skin piercing laser
Cap bld skin piercing laser
Patient lift sling or seat
Patient lift sling or seat
Patient lift sling or seat
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Patient lift hydraulic
Patient lift electric
PT support & positioning sys
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneum compressor segmental
Pneum compressor segmental
Pneum compressor segmental
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneumatic appliance half arm
Pneumatic appliance half arm
Pneumatic appliance half arm
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic chest
Segmental pneumatic chest
Segmental pneumatic chest
Pneumatic appliance full leg
Pneumatic appliance full leg
Pneumatic appliance full leg
Pneumatic appliance full ainl
Pneumatic appliance full arm
Pneumatic appliance full aim
Pneumatic appliance half leg
Pneumatic appliance half leg
Pneumatic appliance half leg
Seg pneumatic appl full leg
Seg pneumatic appl full leg
Seg pneumatic appl full leg
Seg pneumatic appl full arm
Seg pneumatic appl full arm
11:3-29.6
E0668
E0669
E0669
E0669
E0671
E0671
E0671
E0672
E0672
E0672
E0673
E0673
E0673
E0675
E0691
E0691
E0691
E0692
E0692
E0692
E0693
E0693
E0693
E0694
E0694
E0694
E0705
E0705
E0705
E0720
E0730
E0731
E0740
E0740
E0740
E0744
E0745
E0745
E0747
E0747
E0747
E0748
E0748
E0748
E0749
E0760
E0760
E0760
E0762
E0762
E0762
E0764
.E0764
E0764
E0765
E0765
E0765
E0776
E0776
E0776
E0779
E0780
E0781
E0782
E0782
E0782
E0783
E0783
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
NU
NU
RR
UE
RR
NU
RR
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
NU
RR
UE
NU
RR
APPENDIX B - REGULATIONS
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
KF
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
TE
TE
IN
IN
IN
IN
CR
IN
CR
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
CR
IN
IN
IN
IN
IN
$295.79
$182.76
$18.28
'$137.09
$436.12
$43.62
$327.08
$338.87
$33.89
$254.16
$281.58
$28.16
$211.21
$403.78
$943.52
$94.35
$707.64
$1,184.79
$118.47
$888.60
$1,460.53
$146.06
$1,095.40
$4,648.71
$464.87
$3,486.56
$49.59
$5.01
$37.21
$95.00
$100.00
$374.52
$549.01
$54.90
$411.79
$96.15
$200.00
$20.00
$3,963.48
$396.32
$2,972.60
$4,085.24
$408.52
$3,063.94
$298.59
$3,394.76
$339.49
$2,546.07
$1,154.54
$115.46
$865.88
$11,620.16
$1,162.00
$8,715.13
$88.34
$8.85
$66.28
$127.77
$19.58
$94.01
$17.57
$10.89
$236.39
$4,508.08
$450.83
$3,381.07
$8,202.34
$820.25
Seg pneumatic appl full arm
Seg pneumatic appli half leg
Seg pneumatic appli half leg
Seg pneumatic appli half leg
Pressure pneum appl full leg
Pressure pneum appl full leg
Pressure pneum appl full leg
Pressure pneum appl full arm
Pressure pneum appl full arm
Pressure pneum appl full arm
Pressure pneum appl half leg
Pressure pneum appl half leg
Pressure pneLun appl half leg
Pneumatic compression device
Uvl pnl 2 sq ft or less
Uvl pnl 2 sq ft or less
Uvl pnl 2 sq ft or less
Uvl sys panel 4 ft
Uvl sys panel 4 ft
Uv1 sys panel 4 ft
Uvl sys panel 6 ft
Uvl sys panel 6 ft
Uvl sys panel 6 ft
Uvl and cabinet sys 6 ft
Uvl and cabinet sys 6 ft
Uvl and cabinet sys 6 ft
Transfer device
Transfer device
Transfer device
Tens two lead
Tens four lead
Conductive garment for tens/
Incontinence treatment systm
Incontinence treatment systm
Incontinence treatment systm
Neuromuscular stim for scoli
Neuromuscular stim for shock
Neuromuscular stim for shock
Elec osteogen stim not spine
Elec osteogen stim not spine
Elec osteogen stim not spine
Elec osteogen stim spinal
Elec osteogen stim spinal
Elec osteogen stim spinal
Elec osteogen stim implanted
Osteogen ultrasound stimltor
Osteogen ultrasound stimltor
Osteogen ultrasound stimltor
Trans elec jt stim dev sys
Trans elec jt stim dev sys
Trans elec jt stim dev sys
Functional neuromuscularstim
Functional neuromuscularstim
Functional neuromuscularstim
Nerve stimulator for tx n&v
Nerve stimulator for tx n&v
Nerve stimulator for tx n&v
Iv pole
Iv pole
Iv pole
Amb infusion pump mechanical
Mech amb infusion pump <8hrs
External ambulatory infus pu
Non-programble infusion pump
Non-programble infusion pump
Non-programble infusion pump
Programmable infusion pump
Programmable infusion pump
MEDICAL FEE SCHEDULES
E0783
E0784
E0785
E0786
E0786
E0786
E0791
E0840
E0840
E0840
E0849
E0849
E0849
E0850
E0850
E0850
E0855
E0855
E0855
E0856
E0856
E0856
E0860
E0860
E0860
E0870
E0870
E0870
E0880
E0880
E0880
E0890
E0890
E0890
E0900
E0900
E0900
E0910
E0911
E0912
E0920
E0930
E0935
E0940
E0941
E0942
E0942
E0942
E0944
E0944
E0944
E0945
E0945
E0945
E0946
E0947
E0947
E0947
E0948
E0948
E0948
E0950
E0950
E0950
E0950
E0950
E0950
E0951
UE
RR
KF
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
KF
KF
KF
KF
KE
KE
KE
IN
CR
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
CR
CR
FS
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$6,151.77
$438.45
$421.71
$8,082.48
$808.25
$6,061.88
$282.21
$65.40
$14.57
$49.03
$541.08
$54.11
$405.78
$93.76
$12.88
$70.33
$527.76
$52.77
$395.81
$161.73
$16.19
$121.31
$35.74
$6.84
$26.81
$110.31
$13.88
$82.74
$112.05
$20.70
$84.80
$107.47
$34.47
$86.56
$114.35
$29.00
$85.79
$17.70
$45.11
$103.60
$41.67
$41.67
$23.87
$28.67
$40.67
$20.84
$2.46
$15.62
$43.08
$4.83
$32.32
$46.54
$4.66
$36.03
$62.12
$636.78
$66.03
$477.58
$615.92
$61.57
$434.39
$94.07
$109.15
$9.42
$10.93
$70.56
$81.87
$17.18
11:3-29.6
Programmable infusion pump
Ext amb infusn pump insulin
Replacement impl pump cachet
Implantable pump replacement
Implantable pump replacement
Implantable pump replacement
Parenteral infusion pump sta
Tract frame attach headboard
Tract frame attach headboard
Tract frame attach headboard
Cervical pneum trac equip
Cervical pneurn trac equip
Cervical pneum trac equip
Traction stand free standing
Traction stand free standing
Traction stand free standing
Cervical traction equipment
Cervical traction equipment
Cervical traction equipment
Cervic collar w air bladder
Cervic collar w air bladder
Cervic collar w air bladder
Tract equip cervical tract
Tract equip cervical tract
Tract equip cervical tract
Tract frame attach footboard
Tract frame attach footboard
Tract frame attach footboard
Trac stand free stand extreme
Trac stand free stand extreme
Trac stand free stand extreme
Traction frame attach pelvic
Traction frame attach pelvic
Traction frame attach pelvic
Trac stand free stand pelvic
Trac stand free stand pelvic
Trac stand free stand pelvic
Trapeze bar attached to bed
HD trapeze bar attach to bed
HD trapeze bar free standing
Fracture frame attached to b
Fracture frame free standing
Cont pas motion exercise dev
Trapeze bar free standing
Gravity assisted traction de
Cervical head harness/halter
Cervical head harness/halter
Cervical head harness/halter
Pelvic belt/harness/boot
Pelvic belt/harness/boot
Pelvic belt/haniess/boot
Belt/harness extremity
Belt/harness extremity
Belt/harness extremity
Fracture frame dual w cross
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts cc
Fracture frame attachmnts cc
Fracture frame attachmnts cc
Tray
Tray
Tray
Tray
Tray
Tray
Loop heel
11:3-29.6
E0951
E0951
E0951
E0951
E0951
E0952
E0952
E0952
E0952
E0952
E0952
E0955
E0955
E0955
E0955
E0955
E0955
E0956
E0956
E0956
E0956
E0956
E0956
E0957
E0957
E0957
E0957
E0957
E0957
E0958
E0959
E0959
E0959
E0960
E0960
E0960
E0960
E0960
E0960
E0961
E0961
E0961
E0966
E0966
E0966
E0967
E0967
E0967
E0968
E0969
E0969
E0969
E0971
E0971
E0971
E0973
E0973
E0973
E0973
E0973
E0973
E0974
E0974
E0974
E0978
E0978
E0978
E0978
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NIT
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
RR
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
NU
RR
RR
APPENDIX B - REGULATIONS
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
TN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
TN
IN
IN
IN
TN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$19.93
$1.72
$2.00
$12.87
$14.93
$17.04
$19.77
$1.71
$1.98
$12.79
$14.84
$182.97
$212.29
$18.31
$21.24
$137.23
$159.21
$89.21
$103.51
$8.93
$10.36
$66.91
$77.63
$124.83
$144.83
$12.48
$14.48
$93.62
$108.62
$44.53
$46.42
$4.67
$35.13
$82.34
$95.53
$8.24
$9.56
$61.76
$71.65
$26.55
$2.77
$13.26
$67.97
$6.79
$50.98
$68.94
$6.89
$51.71
$18.83
$153.50
$15.36
$115.12
$45.56
$4.56
$34.19
$104.05
$120.72
$9.91
$11.50
$78.04
$90.54
$82.33
$8.73
$62.21
$38.64
$44.84
$3.87
$4.49
Loop heel
Loop heel
Loop heel
Loop heel
Loop heel
Toe loop/holder, each
Toe loop/holder, each
Toe loop/holder, each
Toe loop/holder, each
Toe loop/holder, each
Toe loop/holder, each
Cushioned headrest
Cushioned headrest
Cushioned headrest
Cushioned headrest
Cushioned headrest
Cushioned headrest
W/c lateral trunk/hip suppor
W/c lateral trunk/hip suppor
W/C lateral trunk/hip suppor
W/c lateral trunk/hip suppor
W/c lateral trunk/hip suppor
W/c lateral trunk/hip suppor
W/c medial thigh support
W/c medial thigh support
W/c medial thigh support
W/c medial thigh support
W/c medial thigh support
W/c medial thigh support
Whlchr att- cony 1 arm drive
Amputee adapter
Amputee adapter
Amputee adapter
W/c shoulder harness/straps
W/c shoulder harness/straps
W/c shoulder harness/straps
W/c shoulder harness/straps
W/c shoulder harness/straps
W/c shoulder harness/straps
Wheelchair brake extension
Wheelchair brake extension
Wheelchair brake extension
Wheelchair head rest extensi
Wheelchair head rest extensi
Wheelchair head rest extensi
Manual we hand rim w project
Manual we hand rim w project
Manual we hand rim w project
Wheelchair commode seat
Wheelchair narrowing device
Wheelchair narrowing device
Wheelchair narrowing device
Wheelchair anti-tipping devi
Wheelchair anti-tipping devi
Wheelchair anti-tipping devi
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access det adj armrest
W/Ch access anti-rollback
W/Ch access anti-rollback
W/Ch access anti-rollback
W/C acc,saf belt pelv strap
W/C acc,saf belt pelv strap
W/C acc,saf belt pelv strap
W/C acc,saf belt pelv strap
MEDICAL FEE SCHEDULES
E0978
E0978
E0980
E0980
B0980
E0981
E0981
E0981
E0981
E0981
E0981
E0982
E0982
E0982
E0982
B0982
E0982
E0983
E0984
E0984
E0984
E0985
E0985
E0985
E0986
E0986
E0986
E0990
E0990
E0990
E0990
E0990
E0990
E0992
E0992
E0992
E0994
E0994
E0994
E0995
E0995
E0995
E0995
E0995
E0995
E1002
E1002
E1002
E1002
E1002
E1002
E1003
E1003
E1003
E1003
E1003
E1003
E1004
E1004
E1004
E1004
E1004
E1004
E1005
E1005
E1005
E1005
E1005
UE
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
I
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
N
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$28.65
$33.24
$34.71
$3.47
$25.89
$42.67
$49.51
$4.34
$5.04
$32.31
$37.49
$46.63
$54.11
$4.66
$5.41
$34.97
$40.57
$246.77
$1,705.19
$158.56
$1,315.78
$212.99
$21.32
$159.73
$5,107.45
$510.75
$3,830.61
$90.33
$104.81
$11.96
$13.88
$70.58
$81.89
$84.92
$8.25
$63.70
$17.65
$1.76
$13.25
$23.92
$27.75
$2.40
$2.78
$17.96
$20.84
$3,668.16
$4,255.87
$366.81
$425.59
$2,751.11
$3,191.90
$3,974.13
$4,610.87
$397.42
$461.10
$2,980.60
$3,458.15
$4,406.49
$5,112.50
$440.64
$511.25
$3,304.85
$3,834.36
$4,769.68
$5,533.88
$476.96
$553.38
$3,577.27
11:3-29.6
W/C acc,saf belt pelv strap
W/C acc,saf belt pelv strap
Wheelchair safety vest
Wheelchair safety vest
Wheelchair safety vest
Seat upholstery, replacement
Seat upholstery, replacement
Seat upholstery, replacement
Seat upholstery, replacement
Seat upholstery, replacement
Seat upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Back upholstery, replacement
Add pwr joystick
Add pwr tiller
Add pwr tiller
Add pwr tiller
W/c seat lift mechanism
W/c seat lift mechanism
W/c seat lift mechanism
Man w/c push-rim pow assist
Man w/c push-rim pow assist
Man w/c push-rim pow assist
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair elevating leg res
Wheelchair. solid seat insert
Wheelchair solid seat insert
Wheelchair solid seat insert
Wheelchair arm rest
Wheelchair arm rest
Wheelchair arm rest
Wheelchair calf rest
Wheelchair calf rest
Wheelchair calf rest
Wheelchair calf rest
Wheelchair calf rest
Wheelchair calf rest
Pwr seat tilt
Pwr seat tilt
Pwr seat tilt
Pwr seat tilt
Pwr seat tilt
Pwr seat tilt
Pwr seat recline
Pwr seat recline
Pwr seat recline
Pwr seat recline
Pwr seat recline
Pwr seat recline
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline mech
Pwr seat recline pwr
Pwr seat recline pwr
Pwr seat recline pwr
Pwr seat recline pwr
Pwr seat recline pwr
11:3-29.6
E1005
E1006
E1006
E1006
E1006
E1006
E1006
B1007
E1007
E1007
E1007
E1007
E1007
E1008
E1008
E1008
E1008
E1008
E1008
E1009
E1009
E1009
E1010
E1010
E1010
E1010
E1010
E1010
E1011
E101 l
E1011
E1014
E1014
E1014
E1015
E1015
E1015
E1016
E1016
E1016
E1016
E1016
E1016
E1017
E1017
E1017
E1018
E1018
E1018
E1020
E1020
E1020
E1020
E1020
E1020
E1028
E1028
E1028
E1028
E1028
E1028
B1029
E1029
E1029
E1029
E1029
E1029
E1030
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
APPENDIX B - REGULATIONS
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KB
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$4,150.42
$5,842.41
$6,778.49
$584.22
$677.83
$4,381.81
$5,083.87
$7,910.85
$9,178.33
$791.09
$917.84
$5,933.13
$6,883.74
$7,911.56
$9,179.15
$791.15
$917.91
$5,933.68
$6,884.38
$0.00
$0.00
$0.00
$1,035.13
$1,200.98
$103.51
$120.10
$776.36
$900.75
$0.00
$0.00
$0.00
$383.40
$38.35
$287.54
$120.44
$12.03
$90.32
$118.84
$137.88
$11.89
$13.80
$89.12
$103.40
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$220.29
$255.58
$22.01
$25.54
$165.21
$191.68
$186.92
$216.87
$18.69
$21.68
$140.18
$162.63
$334.43
$388.02
$33.44
$38.80
$250.82
$291.01
$1,054.57
Pwr seat recline pwr
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/o shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo w/shear
Pwr seat combo pwr shear
Pwr seat combo pwr shear
Pwr seat combo pwr shear
Pwr seat combo pwr shear
Pwr seat combo pwr shear
Pwr seat combo pwr shear
Add mech leg elevation
Add mech leg elevation
Add mech leg elevation
Add pwr leg elevation
Add pwr leg elevation
Add pwr leg elevation
Add pwr leg elevation
Add pwr leg elevation
Add pwr leg elevation
Ped wc modify width adjustm
Ped wc modify width adjustm
Ped wc modify width adjust
Reclining back add ped w/c
Reclining back add ped w/c
Reclining back add ped w/c
Shock absorber for man w/c
Shock absorber for man w/c
Shock absorber for man w/c
Shock absorber for power w/c
Shock absorber for power w/c
Shock absorber for power w/c
Shock absorber for power w/c
Shock absorber for power w/c
Shock absorber for power w/c
HD shck absrbr for hd man wc
HD shck absrbr for hd man wc
HD shck absrbr for hd man wc
HD slick absrber for hd powwc
HD shck absrber for hd powwc
HD sgck absrber for hd powwc
Residual limb support system
Residual limb support system
Residual limb support system
Residual limb support system
Residual limb support system
Residual limb support system
W/c manual swingaway
W/c manual swingaway
W/c manual swingaway
W/c manual swingaway
W/c manual swingaway
W/c manual swingaway
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray fixed
W/c vent tray gimbaled
MEDICAL FEE SCHEDULES
E1030
E1030
E1030
E1030
E1030
E1031
E1035
E1036
E1037
E1038
E1039
E1050
E1060
E1070
E1083
E1084
E1087
E1088
E1092
E1093
E1100
E1110
E1150
E1160
E1161
E1161
E1161
E1170
E1171
E1172
E1180
E1190
E1195
E1200
E1221
E1222
E1223
E1224
E1225
E1226
E1226
E1226
E1227
E1227
E1227
E1228
E1230
E1230
E1230
E1231
E1231
E1231
E1232
E1232
E1232
E1233
E1233
E1233
E1234
E1234
E1234
E1235
E1235
E1235
E1236
E1236
E1236
E1237
NU KE
RR
RR KE
UE
UE KE
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
IN
IN
IN
IN
IN
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
IN
IN
IN
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$1,223.53
$105.46
$122.36
$790.93
$917.66
$53.04
$643.86
$902.63
$113.91
$18.93
$35.91
$106.93
$118.97
$115.01
$75.78
$103.01
$121.80
$158.31
$134.94
$116.05
$109.00
$106.74
$82.07
$64.53
$2,484.39
$248.44
$1,863.30
$90.63
$72.10
$92.72
$99.11
$114.51
$112.12
$85.27
$44.02
$71.18
$77.72
$85.21
$47.46
$572.93
$58.97
$429.66
$291.38
$28.67
$218.56
$25.01
$2,136.81
$233.57
$1,596.51
$0.00
$0.00
$0.00
$2,245.33
$224.54
$1,684.01
$2,326.52
$232.65
$1,744.88
$2,025.40
$202.56
$1,519.04
$1,950.30
$195.04
$1,462.72
$1,720.67
$172.06
$1,290.50
$1,735.70
11:3-29.6
W/o vent tray gimbaled
W/c vent tray gimbaled
W/c vent tray gimbaled
W/c vent tray gimbaled
W/c vent tray gimbaled
Rollabout chair with casters
Patient transfer system <300
Patient transfer system >300
Transport chair, ped size
Transport chair pt wt<=3001b
Transport chair pt wt >3001b
Whelchr fxd full length arms
Wheelchair detachable arms
Wheelchair detachable foot r
Hemi-wheelchair fixed arms
Hemi-wheelchair detachable a
Wheelchair lightwt fixed arm
Wheelchair lightweight det a
Wheelchair wide w/ leg rests
Wheelchair wide w/ foot rest
Whchr s-recl fxd arm leg res
Wheelchair semi-reel detach
Wheelchair standard w/ leg r
Wheelchair fixed arms
Manual adult we w tiltinspac
Manual adult we w tiltinspac
Manual adult we w tiltinspac
Whlchr ampu fxd arm leg rest
Wheelchair amputee w/o leg r
Wheelchair amputee detach ar
Wheelchair amputee w/ foot r
Wheelchair amputee w/ leg re
Wheelchair amputee heavy dut
Wheelchair amputee fixed arm
Wheelchair spec size w foot
Wheelchair spec size w/ leg
Wheelchair spec size w foot
Wheelchair spec size w/ leg
Manual semi-reclining back
Manual fully reclining back
Manual fully reclining back
Manual fully reclining back
Wheelchair spec sz spec ht a
Wheelchair spec sz spec ht a
Wheelchair spec sz spec ht a
Wheelchair spec sz spec ht b
Power operated vehicle
Power operated vehicle
Power operated vehicle
Rigid ped w/c tilt-in-space
Rigid ped w/c tilt-in-space
Rigid ped w/c tilt-in-space
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Rigid ped wc adjustable
Rigid ped wc adjustable
Rigid ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Rgd ped wc adjstabl w/o seat
11:3-29.6
E1237
E1237
E1238
E1238
E1238
E1240
E1270
E1280
E1295
E1296
E1296
E1296
E1297
E1297
E1297
E1298
E1298
E1298
E1310
E1310
E1310
E1353
E1355
E1372
E1372
E1372
E1390
E1391
E1392
E1405
E1406
E1700
E1700
E1700
E1701
E1702
E1800
E1801
E1802
E1805
E1806
E1810
E1811
E1812
E1815
E1816
E1818
E1820
E1820
E1820
E1821
E1821
E1821
E1825
E1830
E1840
E1841
E2000
E2100
E2100
E2100
E2101
E2101
E2101
E2120
E2201
E2201
E2201
RR
UE
NU
RR
UE
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
RR
NU
RR
UE
APPENDIX B - REGULATIONS
IN
IN
IN
IN
IN
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
OX
OX
IN
IN
IN
OX
OX
OX
OX
OX
IN
IN
IN
SU
SU
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
CR
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
$173.57
$1,301.79
$1,720.67
$172.06
$1,290.50
$108.17
$80.68
$128.96
$124.10
$438.81
$44.57
$329.11
$93.36
$10.37
$70.01
$401.01
$40.11
$300.75
$2,254.77
$192.85
$1,691.08
$29.75
$22.40
$171.18
$24.87
$107.70
$173.17
$173.17
$51.63
$209.99
$190.08
$307.77
$30.18
$230.83
$10.89
$21.85
$109.34
$127.14
$343.14
$118.01
$104.34
$118.01
$132.16
$90.29
$118.01
$134.24
$137.05
$85.83
$8.58
$64.38
$110.51
$11.04
$82.90
$118.01
$118.01
$390.41
$475.65
$51.05
$666.03
$66.60
$499.54
$197.99
$19.80
$148.49
$297.70
$391.76
$39.18
$293.82
Rgd ped wc adjstabl w/o seat
Rgd ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
Whchr litwt det arm leg rest
Wheelchair lightweight leg r
Whchr h-duty det arm leg res
Wheelchair heavy duty fixed
Wheelchair special seat heig
Wheelchair special seat heig
Wheelchair special seat heig
Wheelchair special seat dept
Wheelchair special seat dept
Wheelchair special seat dept
Wheelchair spec seat depth/w
Wheelchair spec seat depth/w
Wheelchair spec seat depth/w
Whirlpool non-portable
Whirlpool non-portable
Whirlpool non-portable
Oxygen supplies regulator
Oxygen supplies stand/rack
Oxy suppl heater for nebuliz
Oxy suppl heater for nebuliz
Oxy suppl heater for nebuliz
Oxygen concentrator
Oxygen concentrator, dual
Portable oxygen concentrator
O2/water vapor enrich wheat
O2/water vapor enrich w/o he
Jaw motion rehab system
Jaw motion rehab system
Jaw motion rehab system
Repl cushions for jaw motion
Repl measr scales jaw motion
Adjust elbow ext/flex device
SPS elbow device
Adjst forearm pro/sup device
Adjust wrist ext/flex device
SPS wrist device
Adjust knee ext/flex device
SPS knee device
Knee ext/flex w act res ctrl
Adjust ankle ext/flex device
SPS ankle device
SPS forearm device
Soft interface material
Soft interface material
Soft interface material
Replacement interface SPSD
Replacement interface SPSD
Replacement interface SPSD
Adjust finger ext/flex devc
Adjust toe ext/flex device
Adj shoulder ext/flex device
Static str shldr dev rom adj
Gastric suction pump hme mdl
Bld glucose monitor w voice
Bld glucose monitor w voice
Bld glucose monitor w voice
Bld glucose monitor w lance
Bld glucose monitor w lance
Bld glucose monitor w lance
Pulse gen sys tx endolymp fl
Man w/ch acc seat w>=20"<24"
Man w/ch ace seat w>=20"<24"
Man w/ch ace seat w>=20"<24"
MEDICAL FEE SCHEDULES
E2202
E2202
E2202
E2203
E2203
E2203
E2204
E2204
E2204
E2205
E2205
E2205
E2206
E2206
E2206
E2207
E2207
E2207
E2208
E2208
E2208
E2208
E2208
E2208
E2209
E2209
E2209
E2209
E2209
E2209
E2210
E2210
E2210
E2210
E2210
E2210
E2211
E2211
E2211
E2212
E2212
E2212
E2213
E2213
E2213
E2214
E2214
E2214
E2215
E2215
E2215
E2216
E2216
E2216
E2217
E2217
E2217
E2218
E2218
E2218
E2219
E2219
E2219
E2220
E2220
E2220
E2221
E2221
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$497.68
$49.77
$373.28
$503.00 F
$50.28
$377.24
$854.07
$85.42
$640.55
$34.30
$3.41
$25.73
$42.71
$4.26
$32.03
$45.52
$4.56
$34.14
$107.50
$124.72
$10.74
$12.46
$80.63
$93.54
$96.98
$112.52
$9.72
$11.28
$72.74
$84.40
$5.93
$6.88
$0.51
$0.59
$4.45
$5.17
$42.96
$4.21
$30.77
$6.17
$0.64
$4.64
$31.92
$3.20
$23.92
$37.80
$4.16
$28.34
$10.08
$1.00
$7.54
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$43.94
$4.96
$32.96
$29.95
$2.89
$22.80
$26.83
$2.71
11:3-29.6
Seat width 24-27 in
Seat width 24-27 in
Seat width 24-27 in
rame depth less than 22 in
Frame depth less than 22 in
Frame depth less than 22 in
Frame depth 22 to 25 in
Frame depth 22 to 25 in
Frame depth 22 to 25 in
Manual we accessory, handrim
Manual we accessory, handrim
Manual we accessory, handrim
Complete wheel lock assembly
Complete wheel lock assembly
Complete wheel lock assembly
Crutch and cane holder
Crutch and cane holder
Crutch and cane holder
Cylinder tank carrier
Cylinder tank carrier
Cylinder tank carrier
Cylinder tank carrier
Cylinder tank carrier
Cylinder tank carrier
Arm trough each
Arm trough each
Arm trough each
Arm trough each
Arm trough each
Arm trough each
Wheelchair bearings
Wheelchair bearings
Wheelchair bearings
Wheelchair bearings
Wheelchair bearings
Wheelchair bearings
Pneumatic propulsion tire
Pneumatic propulsion tire
Pneumatic propulsion tire
Pneumatic prop tire tube
Pneumatic prop tire tube
Pneumatic prop tire tube
Pneumatic prop tire insert
Pneumatic prop tire insert
Pneumatic prop tire insert
Pneumatic caster tire each
Pneumatic caster tire each
Pneumatic caster tire each
Pneumatic caster tire tube
Pneumatic caster tire tube
Pneumatic caster tire tube
Foam filled propulsion tire
Foam filled propulsion tire
Foam filled propulsion tire
Foam filled caster tire each
Foam filled caster tire each
Foam filled caster tire each
Foam propulsion tire each
Foam propulsion tire each
Foam propulsion tire each
Foam caster tire any size ea
Foam caster tire any size ea
Foam caster tire any size ea
Solid propulsion tire each
Solid propulsion tire each
Solid propulsion tire each
Solid caster tire each
Solid caster tire each
11:3-29.6
E2221
E2222
E2222
E2222
E2224
E2224
E2224
E2225
E2225
E2225
E2226
E2226
E2226
E2227
E2227
E2227
E2228
E2228
E2228
E2231
E2231
E2231
E2310
E2310
E2310
E2310
E2310
E2310
E2311
E2311
E2311
E2311
E2311
E2311
E2312
E2312
E2312
E2312
E2312
E2312
E2313
E2313
E23 13
E2321
E2321
E2321
E2321
E2321
E2321
E2321
E2321
E2321
E2322
E2322
E2322
E2322
E2322
E2322
B2322
E2322
E2322
E2323
E2323
E2323
E2323
E2323
E2323
E2324
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
NU
NU
RR
RR
RR
UE
UE
UE
NU
NU
NU
RR
RR
RR
UE
UE
UE
NU
NU
RR
RR
UE
UE
NU
APPENDIX B - REGULATIONS
KE
KE
KE
KE
KE
KE
KC
KC
KC
KC
KE
KC
KE
KC
KE
KC
KE
KC
KE
KC
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$20.14
$22.11
$2.19
$16.60
$102.96
$10.80
$77.23
$18.27
$1.83
$13.69
$39.84
$3.98
$29.88
$1,888.65
$188.85
$1,416.48
$983.07
$98.30
$737.33
$161.36
$16.14
$121.01
$1,059.07
$1,228.75
$105.90
$122.87
$794.30
$921.56
$2,144.13
$2,487.66
$214.42
$248.78
$1,608.09
$1,865.75
$2,036.14
$2,596.84
$203.62
$259.69
$1,527.08
$1,947.62
$323.33
$32.35
$242.50
$1,438.14
$2,342.55
$1,668.56
$143.82
$234.26
$166.87
$1,078.62
$1,756.91
$1,251.43
$1,276.38
$2,480.72
$1,480.88
$127.63
$248.07
$148.08
$957.29
$1,860.54
$1,110.67
$62.59
$72.62
$6.26
$7.27
$46.94
$54.46
$39.66
Solid caster tire each
Solid caster integrated whl
Solid caster integrated whl
Solid caster integrated whl
Propulsion whl excludes tire
Propulsion whl excludes tire
Propulsion whl excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster fork replacement only
Caster fork replacement only
Caster fork replacement only
Gear reduction drive wheel
Gear reduction drive wheel
Gear reduction drive wheel
Mwc acc, wheelchair brake
Mwc acc, wheelchair brake
Mwc acc, wheelchair brake
Solid seat support base
Solid seat support base
Solid seat support base
Electro connect btvv control
Electro connect btw control
Electro connect btw control
Electro connect btw control
Electro connect btw control
Electro connect btw control
Electro connect btw 2 sys
Electro connect btw 2 sys
Electro connect btw 2 sys
Electro connect btw 2 sys
Electro connect btw 2 sys
Electro connect btw 2 sys
Mini-prop remote joystick
Mini-prop remote joystick
Mini-prop remote joystick
Mini-prop remote joystick
Mini-prop remote joystick
Mini-prop remote joystick
PWC harness, expand control
PWC harness, expand control
PWC harness, expand control
Hand interface joystick
Hand interface joystick
Hand interface joystick
Hand interface joystick
Hand interface joystick
Hand interface joystick
Hand interface joystick
Hand interface joystick
Hand interface joystick
Mult mech switches
Mult mech switches
Mult mech switches
Mult mech switches
Mult mech switches
Mult mech switches
Mult mech switches
Mult mech switches
Mult mech switches
Special joystick handle
Special joystick handle
Special joystick handle
Special joystick handle
Special joystick handle
Special joystick handle
Chin cup interface
MEDICAL FEE SCHEDULES
E2324
E2324
E2324
E2324
E2324
E2325
E2325
E2325
E2325
E2325
E2325
E2326
E2326
E2326
E2326
E2326
E2326
E2327
E2327
E2327
E2327
E2327
E2327
E2327
E2327
E2327
E2328
E2328
E2328
E2328
E2328
E2328
E2329
E2329
E2329
E2329
E2329
E2329
E2330
E2330
E2330
E2330
E2330
E2330
E2340
E2340
E2340
E2341
E2341
E2341
E2342
E2342
E2342
E2343
E2343
E2343
E2351
E2351
E2351
E2351
E2351
E2351
E2360
E2360
E2360
E2361
E2361
E2361
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
NU
RR
RR
RR
UE
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
NU
RR
KE
KE
KE
KE
KE
KE
KE
KE
KE
KC
KE
KC
KE
KC
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$46.01
$3.95
$4.59
$29.75
$34.51
$1,218.88
$1,414.17
$121.90
$141.44
$914.17
$1,060.64
$314.16
$364.50
$31.43
$36.47
$235.61
$273.36
$2,364.20
$3,591.81
$2,743.00
$236.42
$359.18
$274.30
$1,773.15
$2,693.85
$2,057.24
$4,484.56
$5,203.09
$448.45
$520.30
$3,363.43
$3,902.33
$1,598.35
$1,854.44
$159.83
$185.44
$1,198.76
$1,390.83
$3,096.99
$3,593.19
$309.69
$359.31
$2,322.75
$2,694.91
$376.28
$37.64
$282.23
$564.46
$56.45
$423.35
$470.38
$47.04
$352.79
$752.62
$75.25
$564.46
$632.26
$733.56
$63.24
$73.37
$474.18
$550.16
$117.96
$11.85
$88.47
$126.22 22nf sealed leadacid battery
$146.44 22nf sealed leadacid battery
$12.62 22nf sealed leadacid battery
11:3-29.6
Chin cup interface
Chin cup interface
Chin cup interface
Chin cup interface
Chin cup interface
Sip and puff interface
Sip and puff interface
Sip and puff interface
Sip and puff interface
Sip and puff interface
Sip and puff interface
Breath tube kit
Breath tube kit
Breath tube kit
Breath tube kit
Breath tube kit
Breath tube kit
Head control interface mech
Head control interface mech
Head control interface mech
Head control interface mech
Head control interface mech
Head control interface mech
Head control interface mech
Head control interface mech
Head control interface mech
Head/extremity control inter
Head/extremity control inter
Head/extremity control inter
Head/extremity control inter
Head/extremity control inter
Head/extremity control inter
Head control nonproportional
Head control nonproportional
Head control nonproportional
Head control nonproportional
Head control nonproportional
Head control nonproportional
Head control proximity switc
Head control proximity switc
Head control proximity switc
Head control proximity switc
Head control proximity switc
Head control proximity switc
W/c wdth 20-23 in seat frame
W/c wdth 20-23 in seat frame
W/c wdth 20-23 in seat frame
W/o wdth 24-27 in seat frame
W/c wdth 24-27 in seat frame
W/c wdth 24-27 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 22-25 in seat frame
W/c dpth 22-25 in seat frame
W/c dpth 22-25 in seat frame
Electronic SGD interface
Electronic SGD interface
Electronic SGD interface
Electronic SGD interface
Electronic SGD interface
Electronic SGD interface
22nf nonsealed leadacid
22nf nonsealed leadacid
22nf nonsealed leadacid
11:3-29.6
E2361
E2361
E2361
E2362
E2362
E2362
E2363
E2363
E2363
E2363
E2363
E2363
E2364
E2364
E2364
E2365
E2365
E2365
E2365
E2365
E2365
E2366
E2366
E2366
E2366
E2366
E2366
E2367
E2367
E2367
E2367
E2367
E2367
E2368
E2368
E2368
E2368
E2368
E2368
E2369
E2369
E2369
E2369
E2369
E2369
E2370
E2370
E2370
E2370
E2370
E2370
E2371
E2371
E2371
E2371
E2371
E2371
E2372
E2372
E2372
E2373
E2373
E2373
E2373
E2373
E2373
E2373
E2373
RR
UE
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
NU
NU
RR
RR
RR
UE
UE
APPENDIX B - REGULATIONS
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KC
KE
KC
KE
KC
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$14.65 22nf sealed leadacid battery
$94.68 22nf sealed leadacid battery
$109.85 22nf sealed leadacid battery
$96.58 Gr24 nonsealed leadacid
$9.66 Gr24 nonsealed leadacid
$72.43 Gr24 nonsealed leadacid
$168.33 Gr24 sealed leadacid battery
$195.30 Gr24 sealed leadacid battery
$16.84 Gr24 sealed leadacid battery
$19.54 Gr24 sealed leadacid battery
$126.25 Gr24 sealed leadacid battery
$146.48 Gr24 sealed leadacid battery
$117.96 Ulnonsealed leadacid battery
$11.85 U1 nonsealed leadacid battery
$88.47 U1 nonsealed leadacid battery
$101.51 U1 sealed leadacid battery
$117.78 U 1 sealed leadacid battery
$10.15 U1 sealed leadacid battery
$11.78 Ul sealed leadacid battery
$76.16 U1 sealed leadacid battery
$88.36 U1 sealed leadacid battery
$238.58 Battery charger, single mode
$276.80 Battery charger, single mode
$23.92 Battery charger, single mode
$27.75 Battery charger, single mode
$178.94 Battery charger, single mode
$207.61 Battery charger, single mode
$379.27 Battery charger, dual mode
$440.03 Battery charger, dual mode
$37.93 Battery charger, dual mode
$44.01 Battery charger, dual mode
$$284.45
$330.03
$467.50
$542.40
$46.76
$54.25
$350.63
$406.81
$407.20
$472.44
$40.73
$47.25
$305.39
$354.32
$726.57
$842.98
$72.66
$84.30
$544.92
$632.23
$136.42
$158.28
$13.65
$15.83
$102.32
$118.71
$0.00
$0.00
$0.00
$709.72
$1,094.99
$709.72
$70.99
$109.51
$70.99
$532.31
$821.26
Battery charger, dual mode
Battery charger, dual mode
Power we motor replacement
Power we motor replacement
Power we motor replacement
Power we motor replacement
Power we motor replacement
Power we motor replacement
Pwr we gear box replacement
Pwr we gear box replacement
Pwr we gear box replacement
Pwr we gear box replacement
Pwr we gear box replacement
Pwr we gear box replacement
Pwr we motor/gear box combo
Pwr we motor/gear box combo
Pwr we motor/gear box combo
Pwr we motor/gear box combo
Pwr we motor/gear box combo
Pwr we motor/gear box combo
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Gr27 sealed leadacid battery
Gr27 non-sealed leadacid
Gr27 non-sealed leadacid
Gr27 non-sealed leadacid
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
Hand/chin ctrl spec joystick
MEDICAL FEE SCHEDULES
E2373
E2374
E2374
E2374
E2374
E2374
E2374
E2375
E2375
E2375
E2375
E2375
E2375
E2376
E2376
E2376
E2376
E2376
E2376
E2377
E2377
E2377
E2377
E2377
E2377
E2381
E2381
E2381
E2381
E2381
E2381
E2382
E2382
E2382
E2382
E2382
E2382
E2383
E2383
E2383
E2383
E2383
E2383
E2384
E2384
E2384
E2384
E2384
E2384
E2385
E2385
E2385
E2385
E2385
E2385
E2386
E2386
E2386
E2386
E2386
E2386
E2387
E2387
E2387
E2387
E2387
E2387
E2388
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$532.31
$483.29
$560.72
$48.33
$56.07
$362.48
$420.56
$775.19
$899.39
$77.51
$89.93
$581.37
$674.52
$1,214.75
$1,409.38
$121.48
$140.94
$911.08
$1,057.06
$439.57
$510.00
$43.95
$50.99
$329.69
$382.52
$68.94
$79.99
$6.91
$8.01
$51.71
$60.00
$18.80
$21.81
$1.87
$2.17
$14.09
$16.35
$137.45
$159.47
$13.75 I
$15.95
$103.09
$119.61
$73.22
$84.96
$7.34
$8.52
$54.92
$63.71
$44.80
$51.98
$4.49
$5.21
$33.58
$38.97
$136.21
$158.04
$13.62
$15.80
$102.15
$118.51
$61.08
$70.86
$6.11
$7.09
$45.84
$53.18
$45.60
11:3-29.6
Hand/chin ctrl spec joystick
Hand/chin ctrl std j oystick
Hand/chin ctrl std joystick
Hand/chin ctrl std joystick
Hand/chin ctrl std joystick
Hand/chin ctrl std joystick
Hand/chin ctrl std joystick
Non-expandable controller
Non-expandable controller
Non-expandable controller
Non-expandable controller
Non-expandable controller
Non-expandable controller
Expandable controller, repl
Expandable controller, repl
Expandable controller, repl
Expandable controller, repl
Expandable controller, repl
Expandable controller, repl
Expandable controller, initl
Expandable controller, initl
Expandable controller, initl
Expandable controller, initl
Expandable controller, initl
Expandable controller, initl
Pneum drive wheel tire
Pneum drive wheel tire
Pneurn drive wheel tire
Pneum drive wheel tire
Pneum drive wheel tire
Pneuin drive wheel tire
Tube, pneurn wheel drive tire
Tube, pneum wheel drive tire
Tube, pneum wheel drive tire
Tube, pneum wheel drive tire
Tube, pneum wheel drive tire
Tube, pneum wheel drive tire
Insert, pneum wheel drive
Insert, pneum wheel drive
nsert, pneum wheel drive
Insert, pneum wheel drive
Insert, pneum wheel drive
Insert, pneum wheel drive
Pneumatic caster tire
Pneumatic caster tire
Pneumatic caster tire
Pneumatic caster tire
Pneumatic caster tire
Pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Tube, pneumatic caster tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled drive wheel tire
Foam filled caster tire
Foam filled caster tire
Foam filled caster tire
Foam filled caster tire
Foam filled caster tire
Foam filled caster tire
Foam drive wheel tire
11:3-29.6
E2388
E2388
E2388
E2388
E2388
E2389
E2389
E2389
E2389
E2389
E2389
E2390
E2390
E2390
E2390
E2390
E2390
E2391
E2391
E2391
E2391
E2391
E2391
E2392
E2392
E2392
E2392
E2392
E2392
E2394
E2394
E2394
E2394
E2394
E2394
E2395
E2395
E2395
E2395
E2395
E2395
E2396
E2396
E2396
E2396
E2396
E2396
E2397
E2397
E2397
E2402
E2500
E2500
E2500
E2502
E2502
E2502
E2504
E2504
E2504
E2506
E2506
E2506
B2508
E2508
E2508
E2510
E2510
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
APPENDIX B - REGULATIONS
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$52.91
$4.56
$5.29
$34.21
$39.69
$24.76
$28.73
$2.48
$2.88
$18.56
$21.54
$38.72
$44.93
$3.87
$4.49
$29.02
$33.67
$18.55
$21.53
$1.86
$2.15
$13.92
$16.15
$48.76
$56.57
$4.89
$5.67
$36.57
$42.43
$69.46
$80.59
$6.96
$8.07
$52.10
$60.45
$49.37
$57.28
$4.94
$5,73
$37.04
$42.98
$60.19
$69.84
$6.45
$7.49
$45.15
$52.38
$434.84
$43.48
$326.12
$1,553.40
$410.61
$41.07
$307.95
$1,255.59
$125.57
$941.70
$1,656.29
$165.65
$1,242.20
$2,428.61
$242.85
$1,821.42
$3,755.44
$375.55
$2,816.59
$7,106.66
$710.66
Foam drive wheel tire
Foam drive wheel tire
Foam drive wheel tire
Foam drive wheel tire
Foam drive wheel tire
Foam caster tire
Foam caster tire
Foam caster tire
Foam caster tire
Foam caster tire
Foam caster tire
Solid drive wheel tire
Solid drive wheel tire
Solid drive wheel tire
Solid drive wheel tire
Solid drive wheel tire
Solid drive wheel tire
Solid caster tire
Solid caster tire
Solid caster tire
Solid caster tire
Solid caster tire
Solid caster tire
Solid caster tire, integrate
Solid caster tire, integrate
Solid caster tire, integrate
Solid caster tire, integrate
Solid caster tire, integrate
Solid caster tire, integrate
Drive wheel excludes tire
Drive wheel excludes tire
Drive wheel excludes tire
Drive wheel excludes tire
Drive wheel excludes tire
Drive wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster wheel excludes tire
Caster fork
Caster fork
Caster fork
Caster fork
Caster fork
Caster fork
Pwc ace, lith-based battery
Pwc ace, lith-based battery
Pwc ace, lith-based battery
Neg press wound therapy pump
SGD digitized pre-rec <=8min
SGD digitized pre-rec <=8min
SGD digitized pre-rec <=8min
SGD prerec msg >8min <=20min
SGD prerec msg >8min <=20min
SGD prerec msg >8min <=20min
SGD prerec msg>20min <=40min
SGD prerec msg>20min <=40min
SGD prerec msg>20min <=40min
SGD prerec msg > 40 min
SGD prerec msg > 40 min
SGD prerec msg > 40 min
SGD spelling phys contact
SGD spelling phys contact
SGD spelling phys contact
SGD w multi methods msg/accs
SGD w multi methods msg/accs
MEDICAL FEE SCHEDULES
E2510
E2511
E2511
E2511
E2512
E2512
E2512
E2601
E2601
E2601
E2601
E2601
E2601
E2602
E2602
E2602
E2602
E2602
E2602
E2603
E2603
E2603
E2603
E2603
E2603
E2604
E2604
E2604
E2604
E2604
E2604
E2605
E2605
E2605
E2605
E2605
E2605
E2606
E2606
E2606
E2606
E2606
E2606
E2607
E2607
E2607
E2607
E2607
E2607
E2608
E2608
E2608
E2608
E2608
E2608
E2611
E2611
E2611
E2611
E2611
E2611
E2612
E2612
E2612
E2612
E2612
E2612
E2613
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
TIE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$5,329.99
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$55,35
$64.22
$5.55
$6.44
$41.51
$48.16
$108.06
$125.37
$10.81
$12.54
$81.04
$94.03
$137.19
$159.17
$13.73
$15.93
$102.89
$119.37
$170.51
$197.83
$17.04
$19.77
$127.90
$148.40
$243.60
$282.63
$24.37
$28.28
$182.73
$212.01
$380.04
$440.93
$38.02
$44.11
$285.02
$330.69
$262.31
$304.34
$26.24
$30.44
$196.74
$228.26
$315.02
$365.49
$31.49
$36.54
$236.27
$274.12
$282.68
$327.97
$28.26
$32.79
$212.03
$246.00
$382.40
$443.67
$38.24
$44.36
$286.79
$332.73
$355.70
11:3-29.6
OD w multi methods msg/accs
SGD sftwre prgrm for PC/PDA
SGD sftwre prgrm for PC/PDA
SGD sftwre prgrm for PC/PDA
SGD accessory, mounting sys
SGD accessory, mounting sys
SGD accessory, mounting sys
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Gen w/c cushion wdth >=22 in
Skin protect we cus wd <22in
Skin protect we cus wd <22in
Skin protect wc cus wd <22in
Skin protect wc cus wd <22in
Skin protect wc cus wd <22in
Skin protect wc cus wd <22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Position back cush wd <22in
11:3-29.6
E2613
E2613
E2613
E2613
E2613
E2614
E2614
E2614
E2614
E2614
E2614
E2615
E2615
E2615
E2615
E2615
E2615
E2616
E2616
E2616
E2616
E2616
E2616
E2619
E2619
E2619
E2619
E2619
E2619
E2620
E2620
E2620
E2620
E2620
E2620
E2621
E2621
E2621
E2621
E2621
E2621
K0001
K0002
K0003
K0004
K0005
K0005
K0005
K0006
K0007
K0010
K0011
K0011
K0012
K0015
K0015
K0015
K0015
K0015
K0015
K0017
K0017
K0017
K0017
K0017
K0017
K0018
K0018
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
RR
RR
RR
RR
NU
RR
UE
RR
RR
RR
RR
RR
RR
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
APPENDIX B - REGULATIONS
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KF
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
CR
IN
IN
IN
CR
CR
CR
CR
CR
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$412.69
$35.58
$41.28
$266.78
$309.52
$492.26
$571.13
$49.23
$57.12
$369.21
$428.37
$409.35
$474.94
$40.94
$47.50
$307.00
$356.19
$550.76
$639.01
$55.08
$63.90
$413.09
$479.27
$46.44
$53.89
$4.64
$5.39
$34.85
$40.44
$495.67
$575.09
$49.57
$57.51
$371.76
$431.33
$520.16
$603.50
$52.01
$60.34
$390.13
$452.63
$55.10
$85.92
$94.07
$119.83
$1,941.20
$194.10
$1,455.88
$128.51
$178.30
$380.20
$521.87
$579.42
$320.12
$164.44
$190.79
$16.45
$19.09
$123.32
$143.08
$46.25
$53.67
$4.62
$5.37
$34.69
$40.25
$25.84
$29.98
Position back cush wd <22in
Position back cush wd <22in
Position back cush wd <22in
Position back cush wd <22in
Position back cush wd <22in
Position back cush wd>=22in
Position back cush wd>=22in
Position back cush wd>=22in
Position back cush wd>=22in
Position back cush wd>=22in
Position back cush wd>=22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth <22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Pos back post/lat wdth>=22in
Replace cover w/c seat cush
Replace cover w/c seat cush
Replace cover w/c seat cush
Replace cover w/c seat cush
Replace cover w/c seat cush
Replace cover w/c seat cush
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd <22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
WC planar back cush wd>=22in
Standard wheelchair
Stnd hemi (low seat) whlchr
Lightweight wheelchair
High strength ltwt whlchr
Ultralightweight wheelchair
Ultralightweight wheelchair
Ultralightweight wheelchair
Heavy duty wheelchair
Extra heavy duty wheelchair
Stnd wt frame power whlchr
Stnd wt pwr whlchr w control
Stnd wt pwr whlchr w control
Ltwt portbl power whlchr
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrest
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrst upper
Detach adjust armrst upper
MEDICAL FEE SCHEDULES
K0018
K0018
K0018
K0018
K0019
K0019
K0019
K0019
K0019
K0019
K0020
K0020
K0020
K0020
K0020
K0020
K0037
K0037
K0037
K0037
K0037
K0037
K0038
K0038
K0038
K0038
K0038
K0038
K0039
K0039
K0039
K0039
K0039
K0039
K0040
K0040
K0040
K0040
K0040
K0040
K0041
K0041
K0041
K0041
K0041
K0041
K0042
K0042
K0042
K0042
K0042
K0042
K0043
K0043
K0043
K0043
K0043
K0043
K0044
K0044
K0044
K0044
K0044
K0044
K0045
K0045
K0045
K0045
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$6.74
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$2.57
$2.98
$19.39
$22.50
$14.80
$17.17
$1.48
$1.72
$11.09
$12.86
$42.05
$48.78
$4.21
$4.88
$31.52
$36.57
$43.58
$50.57
$3.89
$4.52
$32.70
$37.94
$21.96
$25.47
$2.20
$2.55
$16.47
$19.11
$48.76
$56.57
$4.89
$5.67
$36.57
$42.43
$67.58
$78.40
$7.82
$50.67
$58.79
$47.89
$55.57
$4.81
$5.58
$35.92
$41.67
$32.97
$38.25
$3.29
$3.81
$24.72
$28.69
$17.67
$20.51
$1.76
$2.05
$13.27
$15.39
$15.06
$17.47
$1.51
$1.75
$11.29
$13.10
$51.24
$59.45
$5.13
$5.95
11:3-29.6
Detach adjust armrst upper
Detach adjust armrst upper
Detach adjust armrst upper
Detach adjust armrst upper
Arm pad each
Arm pad each
Arm pad each
Arm pad each
Arm pad each
Arm pad each
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
Leg strap each
Leg strap each
Leg strap each
Leg strap each
Leg strap each
Leg strap each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Large size footplate each
Large size footplate each
Large size footplate each
Large size footplate each
Large size footplate each
Large size footplate each
Standard size footplate each
Standard size footplate each
Standard size footplate each
Standard size footplate each
Standard size footplate each
Standard size footplate each
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst lower extension tube
Ftrst upper hanger bracket
Ftrst upper hanger bracket
Ftrst upper hanger bracket
Ftrst upper hanger bracket
Ftrst upper hanger bracket
Ftrst upper hanger bracket
Footrest complete assembly
Footrest complete assembly
Footrest complete assembly
Footrest complete assembly
11:3-29.6
K0045
K0045
K0046
K0046
K0046
K0046
K0046
K0046
K0047
K0047
K0047
K0047
K0047
K0047
K0050
K0050
K0050
K0050
K0050
K0050
K0051
K0051
K0051
K0051
K0051
K0051
K0052
K0052
K0052
K0052
K0052
K0052
K0053
K0053
K0053
K0053
K0053
K0053
K0056
K0056
K0056
K0065
K0065
K0065
K0069
K0069
K0069
K0070
K0070
K0070
K0071
K0071
K0071
K0072
K0072
K0072
K0073
K0073
K0073
K0077
K0077
K0077
K0098
K0098
K0098
K0098
K0098
K0098
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
RR
RR
UE
UE
APPENDIX B - REGULATIONS
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
$38.44
$44.59
$17.67
$20.51
$1.76
$2.05
$13.27
$15.39
$69.21
$80.30
$6.94
$8.05
$51.89
$60.21
$29.41
$34.13
$2.93
$3.40
$22.07
$25.61
$47.61
$55.24
$4.79
$5.55
$35.69
$41.41
$83.66
$97.06
$8.36
$9.70
$62.73
$72.79
$92.32
$107.11
$9.22
$10.70
$69.24
$80.34
$99.86
$9.99
$74.91
$46.68
$4.67
$35.01
$104.92
$10.49
$78.69
$192.32
$19.25
$144.24
$114.71
$11.48
$86.02
$69.05
$6.90
$51.79
$36.54
$3.65
$27.41
$61.79
$6.17
$46.34
$24.63
$28.57
$2.46
$2.86
$18.45
$21.41
Footrest complete assembly
Footrest complete assembly
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst low extension
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Elevat legrst up hangr brack
Ratchet assembly
Ratchet assembly
Ratchet assembly
Ratchet assembly
Ratchet assembly
Ratchet assembly
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Cam relese assem ftrst/lgrst
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Spoke protectors
Spoke protectors
Spoke protectors
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl compl pneum tire
Rear whl compl pneum tire
Rear whl compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Frnt cstr cmpl sem-pneum tir
Frnt cstr cmpl sem-pneum tir
Frnt cstr cmpl sem-pneum tir
Caster pin lock each
Caster pin lock each
Caster pin lock each
Front caster assem complete
Front caster assem complete
Front caster assem complete
Drive belt power wheelchair
Drive belt power wheelchair
Drive belt power wheelchair
Drive belt power wheelchair
Drive belt power wheelchair
Drive belt power wheelchair
MEDICAL FEE SCHEDULES
K0105
K0105
K0105
K0195
K0195
K0455
K0552
K0601
K0602
K0603
K0604
K0605
K0606
K0607
K0607
K0607
K0607
K0607
K0607
K0608
K0608
K0608
K0608
K0608
K0608
K0609
K0609
K0672
K0730
K0730
K0730
K0733
K0733
K0733
K0733
K0733
K0733
K0734
K0734
K0734
K0734
K0734
K0734
K0735
K0735
K0735
K0735
K0735
K0735
K0736
K0736
K0736
K0736
K0736
K0736
K0737
K0737
K0737
K0737
K0737
K0737
K0738
K0800
K0800
K0800
K0801
K0801
K0801
NU
RR
UE
RR
RR KE
RR
NU
NU
NU
NU
NU
RR
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
KF
KF
KF
KF
KF
KF
KF
KF
NU
RR
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
NU
NU
RR
RR
UE
UE
RR
NU
RR
UE
NU
RR
UE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
KE
IN
IN
IN
CR
CR
FS
SU
IN
IN
IN
IN
IN
CR
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
SU
SU
PO
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
OX
IN
IN
IN
IN
IN
IN
$104.40
$10.43
$78.30
$16.21
$18.80
$236.39
$2.78
$1.16
$6.68
$0.60
$6.39
$15.33
$2,644.18
$203.94
$226.42
$20.40
$22.65
$152.95
$169.82
$127.27
$141.31
$12.75
$14.14
$95.46
$105.98
$846.39
$939.71
$74.92
$1,810.22
$181.02
$1,357.66
$27.34
$31.72
$2.75
$3.19
$20.52
$23.80
$299.98
$348.04
$30.00
$34.81
$224.98
$261.03
$381.71
$442.87
$38.18
$44.30
$286.28
$332.15
$302.44
$350.90
$30.25
$35.09
$226.85
$263.19
$382.87
$444.21
$38.28
$44.42
$287.15
$333.15
$51.63
$1,169.96
$117.00
$877.47
$1,886.22
$188.60
$1,414.65
11:3-29.6
Iv hanger
Iv hanger
Iv hanger
Elevating whlchair leg rests
Elevating whlchair leg rests
Pump uninterrupted infusion
Supply/ext inf pump syr type
Repl batt silver oxide 1.5 v
Repl batt silver oxide 3 v
Repl batt alkaline 1.5 v
Repl batt lithium 3.6 v
Repl batt lithium 4.5 v
AED garment w elec analysis
Repl batt for AED
Repl batt for AED
Repl batt for AED
Repl batt for AED
Repl batt for AED
Repl batt for AED
Repl garment for AED
Repl garment for AED
Repl garment for AED
Repl garment for AED
Repl garment for AED
Repl garment for AED
Repl electrode for AED
Repl electrode for AED
Removable soft interface LE
Ctrl dose inh drug deliv sys
Ctrl dose inh drug deliv sys
Ctrl dose inh drug deliv sys
12-24hr sealed lead acid
12-24hr sealed lead acid
12-24hr sealed lead acid
12-24hr sealed lead acid
12-24hr sealed lead acid
12-24hr sealed lead acid
Adj skin pro w/c cus wd<22in
Adj skin pro w/c cus wd<22in
Adj skin pro w/c cus wd<22in
Adj skin pro w/c cus wd<22in
Adj skin pro w/c cus wd<22in
Adj skin pro w/c cus wd<22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro/pos wc cus<22in
Adj skin pro/pos wc cus<22in
Adj skin pro/pos wc cus<22in
Adj skin pro/pos wc cus<22in
Adj skin pro/pos wc cus<22in
Adj skin pro/pos wc cus<22in
Adj skin pro/pos wc cus>=22”
Adj skin pro/pos wc cus>=22”
Adj skin pro/pos wc cus>=22”
Adj skin pro/pos wc cus>=22”
Adj skin pro/pos wc cus>=22”
Adj skin pro/pos wc cus>=22”
Portable gas oxygen system
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
11:3-29.6
K0802
K0802
K0802
K0806
K0806
K0806
K0807
K0807
K0807
K0808
K0808
K0808
K0813
K0814
K0815
K0816
K0820
K0821
K0822
K0823
K0824
K0825
K0826
K0827
K0828
K0829
K0835
K0836
K0837
K0838
K0839
K0840
K0841
K0842
K0843
K0848
K0849
K0850
K0851
K0852
K0853
K0854
K0855
K0856
K0857
K0858
K0859
K0860
K0861
K0861
K0862
K0863
K0864
L0112
L0113
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0220
L0430
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR KF
RR
RR
RR
APPENDIX B - REGULATIONS
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$2,134.59
$213.45
$1,600.95
$1,415.34
$141.53
$1,061.50
$2,147.61
$214.76
$1,610.72
$3,322.80
$332.27
$2,492.09
$218.32
$279.45
$318.23
$304.75
$233.18
$299.35
$361.77
$364.14
$438.26
$401.20
$567.37
$482.45
$625.19
$574.10
$367.19
$380.78
$438.26
$392.07
$567.37
$859.60
$390.83
$390.83
$470.56
$478.24
$459.80
$554.75
$533.38
$640.98
$658.44
$872.29
$824.01
$513.34
$523.63
$636.90
$607.41
$909.90
$514.17
$662.31
$636.90
$909.90
$1,082.79
$1,236.93
$252.02
$22.46
$184.17
$54.20
$104.69
$141.88
$546.01
$123.90
$232.58
$343.37
$459.91
$442.87
$130.69
$1,258.46
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
PWC gp 1 std port seat/back
PWC gp 1 std port cap chair
PWC gp 1 std seat/back
PWC gp 1 std cap chair
PWC gp 2 std port seat/back
PWC gp 2 std port cap chair
PWC gp 2 std seat/back
PWC gp 2 std cap chair
PWC gp 2 hd seat/back
PWC gp 2 hd cap chair
PWC gp 2 vhd seat/back
PWC gp vhd cap chair
PWC gp 2 xtra hd seat/back
PWC gp 2 xtra hd cap chair
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt cap
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt cap
PWC gp2 vhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt cap
PWC gp2 hd mult pow opt s/b
PWC gp 3 std seat/back
PWC gp 3 std cap chair
PWC gp 3 hd seat/back
PWC gp 3 hd cap chair
PWC gp 3 vhd seat/back
PWC gp 3 vhd cap chair
PWC gp 3 xhd seat/back
PWC gp 3 xhd cap chair
PWC gp3 std sing pow opt s/b
PWC gp3 std sing pow opt cap
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt cap
PWC gp3 vhd sing pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 hd mult pow opt s/b
PWC gp3 vhd mult pow opt s/b
PWC gp3 xhd mult pow opt s/b
Cranial cervical orthosis
Cranial cervical torticollis
Cerv flexible non-adjustable
Flex thermoplastic collar mo
Cervical semi-rigid adjustab
Cerv semi-rig adj molded chn
Cerv semi-rig wire occ/mand
Cervical collar molded to pt
Cerv col thermplas foam 2 pi
Cerv col foam 2 piece w thor
Cer post col occ/man sup adj
Cerv collar supp adj cerv ba
Cerv col supp adj bar & thor
Thor rib belt custom fabrica
Dewall posture protector
MEDICAL FEE SCHEDULES
L0450
L0452
L0454
L0456
L0458
L0460
L0462
L0464
L0466
L0468
L0470
L0472
L0480
L0482
L0484
L0486
L0488
L0490
L0491
L0492
L0621
L0622
L0623
L0624
L0625
L0626
L0627
L0628
L0629
L0630
L0631
L0632
L0633
L0634
L0635
L0636
L0637
L0638
L0639
L0640
L0700
L0710
L0810
L0820
L0830
L0859
L0861
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984
L1000
L1001
L1005
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$172.35
$0.00
$306.51
$878.98
$788.16
$887.12
$1,103.45
$1,313.63
$316.31
$388.08
$629.34
$409.96
$1,455.56
$1,622.12
$1,611.53
$1,713.40
$887.12
$250.01
$678.74
$445.87
$81.90
$218.72
$0.00
$0.00
$48.67
$68.88
$363.27
$74.14
$0.00
$143.13
$907.25
$0.00
$253.42
$0.00
$861.51
$1,277.69
$949.40
$1,165.59
$949.40
$924.76
$1,711.65
$1,776.81
$2,217.73
$1,828.81
$2,654.88
$1,031.40
$190.48
$100.15
$96.54
$151.58
$135.38
$162.97
$14.78
$13.78
$55.43
$1,718.88
$0.00
$2,828.58
$56.82
$73.18
$140.77
$53.86
$66.05
$70.49
$80.97
$76.18
$46.86
$130.32
11:3-29.6
TLSO flex prefab thoracic
tlso flex custom fab thoraci
TLSO flex prefab sacrococ-T9
TLSO flex prefab
TLSO 2Mod symphis-xipho pre
TLSO2Mod symphysis-stern pre
TLSO 3Mod sacro-scap pre
TLSO 4Mod sacro-scap pre
TLSO rigid frame pre soft ap
TLSO rigid frame prefab pelv
TLSO rigid frame pre subclav
TLSO rigid frame hyperex pre
TLSO rigid plastic custom fa
TLSO rigid lined custom fab
TLSO rigid plastic cust fab
TLSO rigidlined cust fab two
TLSO rigid lined pre one pie
TLSO rigid plastic pre one
TLSO 2 piece rigid shell
TLSO 3 piece rigid shell
SIO flex pelvisacral prefab
SIO flex pelvisacral custom
SIO panel prefab
SIO panel custom
LO flexibl L1-below L5 pre
LO sag stays/panels pre-fab
LO sagitt rigid panel prefab
LO flex w/o rigid stays pre
LSO flex w/rigid stays cust
LSO post rigid panel pre
LSO sag-coro rigid frame pre
LSO sag rigid frame cust
LSO flexion control prefab
LSO flexion control custom
LSO sagit rigid panel prefab
LSO sagittal rigid panel cus
LSO sag-coronal panel prefab
LSO sag-coronal panel custom
LSO s/c shell/panel prefab
LSO s/c shell/panel custom
Ctlso a-p-l control molded
Ctlso a-p-l control w/ inter
Halo cervical into jckt vest
Halo cervical into body jack
Halo cerv into milwaukee typ
MRI compatible system
Halo repl liner/interface
Tlso corset front
Lso corset front
Tlso full corset
Lso full corset
Axillary crutch extension
Peroneal straps pair
Stocking supp grips set of f
Protective body sock each
Ctlso milwauke initial model
CTLSO infant immobilizer
Tension based scoliosis orth
Ctlso axilla sling
Kyphosis pad
Kyphosis pad floating
Lumbar bolster pad
Lumbar or lumbar rib pad
Sternal pad
Thoracic pad
Trapezius sling
Outrigger
Outrigger bil w/ vert extens
11:3-29.6
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1500
L1510
L1520
L1600
L1610
L1620
L1630
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
L1710
L1720
L1730
L1755
L1810
L1820
L1830
L1831
L1832
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1850
L1860
L1900
L1902
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
L1980
APPENDIX B - REGULATIONS
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$85.17
$138.22
$216.23
$33.62
$1,326.54
$295.37
$250.09
$641.70
$66.35
$61.17
$64.05
$65.60
$78.46
$66.54
$1,885.67
$1,878.10
$1,608.16
$1,356.53
$2,516.64
$109.10
$40.61
$125.53
$143.46
$456.47
$196.02
$315.03
$144.89
$1,031.57
$1,007.06
$1,029.73
$1,708.96
$1,292.91
$1,513.50
$1,115.63
$983.88
$1,379.70
$90.95
$124.61
$87.80
$260.10
$686.31
$744.08
$117.92
$876.12
$792.96
$1,384.28
$869.76
$1,141.23
$508.31
$267.60
$1,106.55
$228.40
$88.45
$411.73
$102.82
$497.28
$281.66
$316.64
$200.28
$788.63
$531.48
$783.73
$840.82
$742.21
$625.71
$799.03
$414.24
$348.77
Lumbar
Ring flange plastic/leather
Ring flange plas/leather mol
Covers for upright each
Furnsh initial orthosis only
Lateral thoracic extension
Anterior thoracic extension
Milwaukee type superstructur
Lumbar derotation pad
Anterior asis pad
Anterior thoracic derotation
Abdominal pad
Rib gusset (elastic) each
Lateral trochanteric pad
Body jacket mold to patient
Post-operative body jacket
Thkao mobility frame
Thkao standing frame
Thkao swivel walker
Abduct hip flex frejka w cvr
Abduct hip flex frejka covr
Abduct hip flex pavlik harne
Abduct control hip semi-flex
Pelv band/spread bar thigh c
HO abduction hip adjustable
HO bi thighcuffs w sprdr bar
HO abduction static plastic
Pelvic & hip control thigh c
Post-op hip abduct custom fa
HO post-op hip abduction
Combination bilateral HO
Leg perthes orth toronto typ
Legg perthes orth newington
Legg perthes orthosis trilat
Legg perthes orth scottish r
Legg perthes patten bottom t
Ko elastic with joints
Ko elas w/ condyle pads & jo
Ko immobilizer canvas longit
Knee orth pos locking join
KO adj jnt pos rigid support
Ko w/0 joint rigid molded to
Rigid KO wo joints
Ko derot ant cruciate custom
KO single upright custom fit
Ko w/adj jt rot cntrl molded
Ko w/ adj flex/ext rotat cus
Ko w adj flex/ext rotat mold
KO adjustable w air chambers
Ko swedish type
Ko supracondylar socket mold
Afo sprng wir drsflx calf bd
Afo ankle gauntlet
Afo molded ankle gauntlet
Afo multiligamentus ankle su
AFO supramalleolar custom
Afo sing bar clasp attach sh
Afo sing upright w/ adjust s
Afo plastic
Afo rig ant tib prefab TCF/=
Afo molded to patient plasti
Afo molded plas rig ant tib
Afo spiral molded to pt plas
AFO spiral prefabricated
Afo pos solid ank plastic mo
Afo plastic molded w/ankle j
AFO w/ankle joint, prefab
Afo sing solid stirrup calf
MEDICAL FEE SCHEDULES
L1990
L2000
L2005
L2010
L2020
L2030
L2034
L2035
L2036
L2037
L2038
L2040
L2050
L2060
L2070
L2080
L2090
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2250
L2260
L2265
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2387
L2390
L2395
L2397
L2405
L2415
L2425
L2430
L2492
L2500
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$450.06
$968.33
$3,621.39
$1,043.76
$1,074.01
$1,101.22
$1,842.24
$155.72
$2,094.38
$1,853.19
$1,590.19
$150.31
$413.47
$520.42
$114.59
$323.11
$371.24
$738.57
$1,097.86
$501.71
$654.70
$720.29
$1,351.75
$1,749.02
$910.62
$1,091.80
$1,334.99
$99.15
$77.60
$104.88
$140.15
$338.08
$79.61
$385.26
$41.70
$62.19
$78.65
$64.96
$87.95
$70.80
$300.84
$226.29
$99.70
$46.48
$106.72
$442.02
$303.93
$104.15
$208.49
$443.25
$192.33
$411.27
$1,002.62
$58.41
$289.79
$95.66
$104.23
$113.40
$140.12
$98.79
$132.46
$99.93
$77.05
$107.33
$126.68
$126.68
$98.36
$267.09
11:3-29.6
Afo doub solid stirrup calf
Kafo sing fre stirr thi/calf
KAFO sng/dbl mechanical act
Kafo sng solid stirrup w/o j
Kafo dbl solid stirrup band/
Kafo dbl solid stirrup w/o j
KAFO pla sin up w/wo k/a cus
KAFO plastic pediatric size
Kafo plas doub free knee mol
Kafo plas sing free knee mol
Kafo w/o joint multi-axis an
Hkafo torsion bil rot straps
Hkafo torsion cable hip pelv
Hkafo torsion ball bearing j
Hkafo torsion unilat rot str
Hkafo unilat torsion cable
Hkafo unilat torsion ball br
Afo tib fx cast plaster mold
Afo tib fx cast molded to pt
Afo tibial fracture soft
Afo tib fx semi-rigid
Afo tibial fracture rigid
Kafo fem fx cast thermoplas
Kafo fem fx cast molded to p
Kafo femoral fx cast soft
Kafo fem fx cast semi-rigid
Kafo femoral fx cast rigid
Plas shoe insert w ank joint
Drop lock knee
Limited motion knee joint
Adj motion knee jnt lerman t
Quadrilateral brim
Waist belt
Pelvic band & belt thigh fla
Limited ankle motion ea jnt
Dorsiflexion assist each joi
Dorsi & plantar flex ass/res
Split flat caliper stirr & p
Rocker bottom, contact AFO
Round caliper and plate atta
Foot plate molded stirrup at
Reinforced solid stirrup
Long tongue stirrup
Varus/valgus strap padded/li
Plastic mod low ext pad/line
Molded inner boot
Abduction bar jointed adjust
Abduction bar-straight
Non-molded lacer
Lacer molded to patient mode
Anterior swing band
Pre-tibial shell molded to p
Prosthetic type socket molde
Extended steel shank
Patten bottom
Torsion ank & half solid sti
Torsion straight knee joint
Straight knee joint heavy du
Add LE poly knee custom KAFO
Offset knee joint each
Offset knee joint heavy duty
Suspension sleeve lower ext
Knee joint drop lock ea jnt
Knee joint cam lock each joi
Knee disc/dial lock/adj flex
Knee jnt ratchet lock ea jnt
Knee lift loop drop lock rin
Thi/glut/ischia wgt bearing
11:3-29.6
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L3000
L3001
L3002
L3003
L3010
L3020
L3030
L3031
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
L3150
L3170
L3224
L3225
L3300
L3310
L3330
L3332
L3334
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
APPENDIX B - REGULATIONS
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$715.81
$480.56
$1,187.84
$579.90
$259.22
$365.67
$295.50
$403.26
$450.84
$173.88
$239.94
$301.83
$259.63
$300.21
$1,765.80
$1,823.23
$255.33
$379.36
$104.32
$157.80
$178.37
$165.80
$83.30
$115.44
$63.27
$115.14
$68.99
$31.59
$80.83
$90.31
$66.13
$84.45
$97.94
$43.76
$56.28
$277.61
$116.89
$142.73
$154.00
$154.00
$175.35
$67.45
$0.00
$41.58
$41.58
$65.19
$28.07
$28.07
$35.98
$38.21
$78.69
$71.94
$44.98
$54.83
$61.58
$46.07
$71.94
$500.16
$65.19
$33.72
$75.32
$20.24
$31.47
$43.81
$43.81
$43.81
$35.98
$82.04
Th/wght bear quad-lat brim m
Th/wght bear quad-lat brim c
Th/wght bear nar m-l brim mo
Th/wght bear nar m-l brim cu
Thigh/wght bear lacer non-mo
Thigh/wght bear lacer molded
Thigh/wght bear high roll cu
Hip clevis type 2 posit jnt
Pelvic control pelvic sling
Hip clevis/thrust bearing fr
Hip clevis/thrust bearing lo
Pelvic control hip heavy dut
Hip joint adjustable flexion
Hip adj flex ext abduct cont
Plastic mold recipro hip & c
Metal frame recipro hip & ca
Pelvic control band & belt u
Pelvic control band & belt b
Pelv & thor control gluteal
Thoracic control thoracic ba
Thorac cont paraspinal uprig
Thorac cont lat support upri
Plating chrome/nickel pr bar
Carbon graphite lamination
Extension per extension per
Ortho sidebar disconnect
Non-corrosive finish
Drop lock retainer each
Knee control full kneecap
Knee cap medial or lateral p
Knee control condylar pad
Soft interface below knee se
Soft interface above knee se
Tibial length sock fx or equ
Femoral lgth sock fx or equa
Ft insert ucb berkeley shell
Foot insert remov molded spe
Foot insert plastazote or eq
Foot insert silicone gel eac
Foot longitudinal arch suppo
Foot longitud/metatarsal sup
Foot arch support remov prem
Foot lamin/prepreg composite
Ft arch suprt premold longit
Foot arch supp premold metat
Foot arch supp longitud/meta
Arch suprt att to sho longit
Arch supp att to shoe metata
Arch supp att to shoe long/m
Hallus-valgus nght dynamic s
Abduction rotation bar shoe
Abduct rotation bar w/o shoe
Foot plastic heel stabilizer
Woman’s shoe oxford brace
Man’s shoe oxford brace
Sho lift taper to metatarsal
Shoe lift elev heel/sole neo
Lifts elevation metal extens
Shoe lifts tapered to one-ha
Shoe lifts elevation heel /i
Shoe wedge sach
Shoe heel wedge
Shoe sole wedge outside sole
Shoe sole wedge between sole
Shoe clubfoot wedge
Shoe outflare wedge
Shoe metatarsal bar wedge ro
Shoe metatarsal bar between
MEDICAL FEE SCHEDULES
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3500
L3510
L3520
L3530
L3540
L3550
L3560
L3570
L3580
L3590
L3595
L3600
L3610
L3620
L3630
L3640
L3650
L3660
L3670
L3671
L3672
L3673
L3675
L3702
L3710
L3720
L3730
L3740
L3760
L3762
L3763
L3764
L3765
L3766
L3806
L3807
L3808
L3900
L3901
L3904
L3905
L3906
L3908
L3912
L3913
L3915
L3917
L3919
L3921
L3923
L3925
L3927
L3929
L3931
L3933
L3935
L3956
L3960
L3961
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$48.33
$141.62
$67.45
$93.29
$35.98
$30.33
$51.71
$55.07
$55.07
$25.85
$25.85
$28.07
$28.07
$44.98
$7.85
$20.24
$75.32
$57.32
$47.20
$37.09
$67.45
$88.78
$67.45
$88.78
$38.21
$56.44
$87.15
$111.07
$724.74
$901.26
$982.26
$141.14
$232.24
$106.90
$722.52
$974.00
$1,092.33
$402.22
$86.49
$619.76
$779.98
$1,031.30
$1,092.07
$365.35
$201.12
$326.34
$1,072.01
$1,472.96
$2,426.16
$797.64
$338.28
$66.19
$78.57
$217.84
$427.53
$84.97
$217.84
$258.36
$72.07
$40.89
$28.10
$64.76
$158.21
$171.61
$177.68
$0.00
$624.54
$1,351.31
11:3-29.6
Full sole/heel wedge between
Sho heel count plast reinfor
Heel leather reinforced
Shoe heel sach cushion type
Shoe heel new leather standa
Shoe heel new rubber standar
Shoe heel thomas with wedge
Shoe heel thomas extend to b
Shoe heel pad & depress for
Ortho shoe add leather insol
Orthopedic shoe add rub insl
O shoe add felt w leath insl
Ortho shoe add half sole
Ortho shoe add full sole
O shoe add standard toe tap
O shoe add horseshoe toe tap
O shoe add instep extension
O shoe add instep velcro clo
O shoe convert to sof counte
Ortho shoe add march bar
Trans shoe calip plate exist
Trans shoe caliper plate new
Trans shoe solid stirrup exi
Trans shoe solid stirrup new
Shoe dennis browne splint bo
Shlder fig 8 abduct restrain
Abduct restrainer canvas&web
Acromio/clavicular canvas&we
SO cap design w/o jnts CF
SO airplane w/o jnts CF
SO airplane w/joint CF
Canvas vest SO
EO w/o joints CF
Elbow elastic with metal joi
Forearm/arm cuffs free motio
Forearm/arm cuffs ext/flex a
Cuffs adj lock w/ active con
EO withjoint, Prefabricated
Rigid EO wo joints
EWHO rigid w/o jnts CF
EWHO w/joint(s) CF
EWHFO rigid w/o jnts CF
EWHFO w/joint(s) CF
WHFO w/joint(s) custom fab
WHFO,no joint, prefabricated
WHFO, rigid w/o joints
Hinge extension/flex wrist/f
Hinge ext/flex wrist finger
Whfo electric custom fitted
WHO w/nontorsion jnt(s) CF
WHO w/o joints CF
Wrist cock-up non-molded
Flex glove w/elastic finger
HFO w/o joints CF
WHO w nontor jnt(s) prefab
Prefab metacarpl fx orthosis
HO w/o joints CF
HFO w/joint(s) CF
HFO w/o joints PF
FO pip/dip with joint/spring
FO pip/dip w/o joint/spring
HFO nontorsion joint, prefab
WHFO nontorsion joint prefab
FO w/o joints CF
FO nontorsion joint CF
Add joint upper ext orthosis
Sewho airplan desig abdu pos
SEWHO cap design w/o jnts CF
11:3-29.6
L3962
L3964
L3964
L3964
L3965
L3965
L3965
L3966
L3966
L3966
L3967
L3968
L3968
L3968
L3969
L3969
L3969
L3970
L3970
L3970
L3971
L3972
L3972
L3972
L3973
L3974
L3974
L3974
L3975
L3976
L3977
L3978
L3980
L3982
L3984
L3995
L4000
L4002
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4350
L4360
L4370
L4380
L4386
L4392
L4394
L4396
L4398
L5000
L5010
L5020
L5050
L5060
L5100
L5105
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
APPENDIX B - REGULATIONS
PO
IN
IN
IN
IN
IN
IN
IN
IN
IN
PO
IN
IN
IN
IN
IN
IN
IN
IN
IN
PO
IN
IN
IN
PO
IN
IN
IN
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$594.43
$652.17
$65.21
$489.09
$1,040.67
$104.09
$780.50
$783.97
$78.40
$587.98
$1,595.45
$992.10
$99.20
$744.08
$675.03
$67.52
$506.29
$277.53
$27.75
$208.14
$1,514.45
$176.47
$17.65
$132.35
$1,595.45
$149.68
$14.98
$112.26
$1,351.31
$1,351.31
$1,514.45
$1,595.45
$292.85
$412.38
$305.04
$36.12
$1,079.50
$0.00
$670.03
$930.03
$569.94
$408.64
$277.72
$466.04
$226.33
$269.06
$238.27
$87.52
$91.00
$109.71
$94.65
$420.05
$75.68
$243.20
$159.83
$112.46
$140.12
$20.80
$15.17
$148.29
$68.28
$455.74
$1,393.98
$1,787.52
$2,206.49
$3,321.74
$2,286.02
$3,818.81
Sewho erbs palsey design abd
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Mobile arm supports reclining
Mobile arm supports reclining
Mobile arm supports reclinin
SEWHO airplane w/o jnts CF
Friction dampening arm supp
Friction dampening arm supp
Friction dampening arm sup
Monosuspension arm/hand supp
Monosuspension arm/hand supp
Monosuspension arm/hand supp
Elevat proximal arm support
Elevat proximal arm support
Elevat proximal arm support
SEWHO cap design w/jnt(s) CF
Offset/lat rocker arm w/ ela
Offset/lat rocker arm w/ ela
Offset/lat rocker arm w/ ela
SEWHO airplane w/jnt(s) CF
Mobile arm support supinator
Mobile arm support supinator
Mobile arm support supinator
SEWHFO cap design w/o jnt CF
SEWHFO airplane w/o jnts CF
SEWHFO cap desgn w/jnt(s) CF
SEWHFO airplane w/jnt(s) CF
Upp ext fx orthosis humeral
Upper ext fx orthosis rad/ul
Upper ext fx orthosis wrist
Sock fracture or equal each
Repl girdle milwaukee orth
Replace strap, any orthosis
Replace trilateral socket br
Replace quadlat socket brim
Replace socket brim cust fit
Replace molded thigh lacer
Replace non-molded thigh lac
Replace molded calf lacer
Replace non-molded calf lace
Replace high roll cuff
Replace prox & dist upright
Repl met band kafo-afo prox
Repl met band kafo-afo calf/
Repl leath cuff kafo prox th
Repl leath cuff kafo-afo cal
Replace pretibial shell
Ankle control orthosi prefab
Pneumati walking boot prefab
Pneumatic full leg splint
Pneumatic knee splint
Non-pneum walk boot prefab
Replace AFO soft interface
Replace foot drop spint
Static AFO
Foot drop splint recumbent
Sho insert w arch toe filler
Mold socket ank hgt w/ toe f
Tibial tubercle hgt w/ toe f
Ank symes mold sckt sach ft
Symes met fr leath socket ar
Molded socket shin sach foot
Plast socket jts/thgh lacer
MEDICAL FEE SCHEDULES
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5311
L5321
L5331
L5341
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$3,518.16
$3,445.23
$2,981.01
$2,918.33
$2,663.70
$3,431.32
$4,998.89
$4,639.02
$4,592.63
$2,071.00
$3,026.74
$2,964.57
$4,194.98
$4,592.78
$1,085.58
$376.87
$1,371.04
$605.19
$408.79
$491.84
$1,158.45
$1,568.85
$1,313.18
$1,584.72
$1,557.95
$1,710.89
$1,632.56
$2,048.48
$2,063.30
$2,338.67
$2,307.80
$2,406.26
$4,009.37
$4,435.46
$1,867.47
$1,453.26
$2,210.50
$1,494.20
$1,225.04
$505.39
$267.34
$296.69
$435.99
$378.87
$430.06
$449.66
$382.20
$408.92
$528.42
$218.16
$321.65
$306.44
$332.45
$528.12
$1,288.34
$769.02
$666.91
$1,403.89
$532.75
$719.69
$523.31
$751.02
$659.98
$1,717.33
$587.11
$1,083.21
$393.25
$524.95
11:3-29.6
Mold sckt ext knee shin sach
Mold socket bent knee shin s
Kne sing axis fric shin sach
No knee/ankle joints w/ ft b
No knee joint with artic ali
Fem focal defic constant fri
Hip canad sing axi cons fric
Tilt table locking hip sing
Hemipelvect canad sing axis
BK mold socket SACH ft endo
Knee disart, SACH ft, endo
AK open end SACH
Hip disart canadian SACH ft
Hemipelvectomy canadian SACH
Postop dress & 1 cast chg bk
Postop dsg bk ea add cast ch
Postop dsg & 1 cast chg ak/d
Postop dsg ak ea add cast ch
Postop app non-wgt bear dsg
Postop app non-wgt bear dsg
Init bk ptb plaster direct
Init ak ischal plstr direct
Prep BK ptb plaster molded
Perp BK ptb thermopls direct
Prep BK ptb thermopls molded
Prep BK ptb open end socket
Prep BK ptb laminated socket
Prep AK ischial plast molded
Prep AK ischial direct form
Prep AK ischial thermo mold
Prep AK ischial open end
Prep AK ischial laminated
Hip disartic sach thermopls
Hip disart sach laminat mold
Above knee hydracadence
Ak 4 bar link w/fric swing
Ak 4 bar ling w/hydraul swig
4-bar link above knee w/swng
Ak univ multiplex sys frict
AK/BK self-aligning unit ea
Test socket symes
Test socket below knee
Test socket knee disarticula
Test socket above knee
Test socket hip disarticulate
Test socket hemipelvectomy
Below knee acrylic socket
Syme typ expandabl wall sckt
Ak/knee disartic acrylic soc
Symes type ptb brim design s
Symes type poster opening so
Symes type medial opening so
Below knee total contact
Below knee leather socket
Below knee wood socket
Knee disarticulat leather so
Above knee leather socket
Hip flex inner socket ext fr
Above knee wood socket
Bk flex inner socket ext fra
Below knee cushion socket
Below knee suction socket
Above knee cushion socket
Isch containmt/narrow m-l so
Tot contact ak/knee disart s
Ak flex inner socket ext fra
Suction susp ak/knee disart
Knee disart expand wall sock
11:3-29.6
L5654
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5703
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
L5782
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
APPENDIX B - REGULATIONS
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$316.80
$307.80
$437.29
$353.07
$550.50
$461.84
$70.93
$94.93
$253.22
$448.66
$268.96
$602.72
$326.85
$444.73
$35.81
$502.25
$351.57
$1,164.74
$588.04
$1,164.74
$44.57
$113.41
$61.44
$73.46
$93.38
$119.86
$163.63
$171.09
$181.28
$72.41
$118.13
$171.57
$2,516.16
$3,121.51
$3,934.19
$2,098.10
$513.04
$940.57
$917.40
$1,232.53
$341.39
$512.58
$444.22
$391.36
$657.41
$821.69
$814.38
$1,695.67
$1,569.07
$2,388.06
$1,032.69
$3,542.95
$3,735.08
$468.63
$648.55
$968.46
$453.75
$657.83
$509.89
$3,288.54
$767.09
$928.33
$1,904.52
$1,712.64
$2,812.31
$3,112.56
$1,836.77
$3,198.98
Socket insert symes
Socket insert below knee
Socket insert knee articulat
Socket insert above knee
Multi-durometer symes
Multi-durometer below knee
Below knee cuff suspension
Socket insert w/o lock lower
Bk molded supracondylar susp
BK/AK locking mechanism
Bk removable medial brim sus
Socket insert w lock mech
Bk knee joints single axis p
Bk knee joints polycentric p
Bk joint covers pair
Socket insert w/o lock mech
Bk thigh lacer non-molded
Intl custm cong/latyp insert
Bk thigh lacer glut/ischia m
Initial custom socket insert
Bk fork strap
Below knee sus/seal sleeve
Bk back check
Bk waist belt webbing
Bk waist belt padded and lin
Ak pelvic control belt light
Ak pelvic control belt pad/l
Ak sleeve susp neoprene/equa
Ak/knee disartic pelvic join
Ak/knee disartic pelvic band
Ak/knee disartic silesian ba
Shoulder harness
Replace socket below knee
Replace socket above knee
Replace socket hip
Symes ankle w/o (SACH) foot
Custom shape cover BK
Custom shape cover AK
Custom shape cvr knee disart
Custom shape cvr hip disart
Kne-shin exo sng axi mnl loc
Knee-shin exo mnl lock ultra
Knee-shin exo frict swg & st
Knee-shin exo variable frict
Knee-shin exo mech stance ph
Knee-shin exo frct swg & sta
Knee-shin pneum swg frct exo
Knee-shin exo fluid swing ph
Knee-shin ext jnts fld swg e
Knee-shin fluid swg & stance
Knee-shin pneum/hydra pneum
Lower limb pros vacuum pump
HD low limb pros vacuum pump
Exoskeletal bk ultralt mater
Exoskeletal ak ultra-light m
Exoskel hip ultra-light mate
Endoskel knee-shin mnl lock
Endo knee-shin mnl lck ultra
Endo knee-shin frct swg & st
Endo knee-shin hydral swg ph
Endo knee-shin polyc mch sta
Endo knee-shin frct swg & st
Endo knee-shin pneum swg frc
Endo knee-shin fluid swing p
Miniature knee joint
Endo knee-shin fluid swg/sta
Endo knee-shin pneum/swg pha
Multi-axial knee/shin system
MEDICAL FEE SCHEDULES
L5845
L5848
L5850
L5855
L5856
L5857
L5858
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5962
L5964
L5966
L5968
L5970
L5971
L5972
L5973
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L6000
L6010
L6020
L6025
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$1,587.11
$952.18
$120.91
$278.56
$21,353.09
$7,639.05
$16,456.85
$357.37
$478.58
$303.07
$3,040.28
$491.52
$796.83
$1,154.32
$530.18
$919.55
$1,184.53
$3,217.78
$183.19
$183.19
$317.89
$15,410.73
$210.19
$410.50
$637.40
$263.23
$2,058.12
$4,391.63
$2,799.03
$521.45
$513.84
$255.06
$571.58
$6,369.90
$1,768.94
$1,606.45
$1,225.74
$1,400.35
$1,243.46
$7,085.97
$1,998.97
$2,604.97
$2,314.64
$2,455.06
$2,667.06
$2,886.40
$2,460.70
$3,692.89
$2,552.59
$4,078.78
$2,912.39
$1,541.44
$4,710.70
$2,873.00
$2,442.68
$1,248.88
$1,780.73
$2,292.98
$482.97
$396.54
$2,436.00
$2,798.60
$2,883.85
$3,439.51
$4,204.05
$1,413.43
$1,248.88
$1,895.51
11:3-29.6
Knee-shin sys stance flexion
Knee-shin sys hydraul stance
Endo ak/hip knee extens assi
Mech hip extension assist
Elec knee-shin swing/stance
Elec knee-shin swing only
Stance phase only
Endo below knee alignable sy
Endo ak/hip alignable system
Above knee manual lock
High activity knee frame
Endo bk ultra-light material
Endo ak ultra-light material
Endo hip ultra-light material
Below knee flex cover system
Above knee flex cover system
Hip flexible cover system
Multiaxial ankle w dorsiflex
Foot external keel sach foot
SACH foot, replacement
Flexible keel foot
Ank-foot sys dors-plant flex
Foot single axis ankle/foot
Combo ankle/foot prosthesis
Energy storing foot
Ft prosth multiaxial ankl/ft
Multi-axial ankle/ft prosth
Flex foot system
Flex-walk sys low ext prosth
Exoskeletal axial rotation u
Endoskeletal axial rotation
Lwr ext dynamic prosth pylon
Multi-axial rotation unit
Shank ft w vert load pylon
Vertical shock reducing pylo
User adjustable heel height
Par hand robin-aids thum rem
Hand robin-aids little/ring
Part hand robin-aids no fing
Part hand disart myoelectric
Wrst MLd sck flx hng tri pad
Wrst mold sock w/exp interfa
Elb mold sock flex hinge pad
Elbow mold sock suspension t
Elbow mold doub splt soc ste
Elbow stump activated lock h
Elbow mold outsid lock hinge
Elbow molded w/ expand inter
Elbow inter loc elbow forarm
Shlder disart int lock elbow
Shoulder passive restor comp
Shoulder passive restor cap
Thoracic intern lock elbow
Thoracic passive restor comp
Thoracic passive restor cap
Postop dsg cast chg wrst/elb
Postop dsg cast chg elb dis/
Postop dsg cast chg shlder/t
Postop ea cast chg & realign
Postop applicat rigid dsg on
Below elbow prosth tiss shap
Elb disart prosth tiss shap
Above elbow prosth tiss shap
Shldr disar prosth tiss shap
Scap thorac prosth tiss shap
Wrist/elbow bowden cable mol
Wrist/elbow bowden cbl dir f
Elbow fair lead cable molded
11:3-29.6
L6586
L6588
L6590
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6677
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
L6703
L6704
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6721
L6722
L6805
L6810
L6881
APPENDIX B - REGULATIONS
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$1,698.83
$2,602.47
$2,423.98
$225.59
$222.75
$150.17
$364.58
$165.77
$68.22
$273.49
$2,025.37
$578.59
$3,334.81
$479.73
$432.10
$158.07
$194.40
$58.60
$182.27
$331.20
$2,214.36
$336.88
$192.94
$261.51
$291.09
$2,792.80
$459.77
$2,880.38
$349.67
$72.10
$82.79
$48.11
$53.31
$184.88
$122.61
$131.59
$262.67
$263.73
$282.84
$401.49
$540.30
$529.49
$491.68
$810.35
$697.00
$332.43
$511.61
$2,513.89
$602.72
$502.25
$1,164.74
$1,164.74
$448.66
$390.97
$529.24
$314.73
$1,236.49
$828.61
$1,109.29
$595.31
$1,096.10
$1,383.40
$1,171.72
$2,082.62
$1,795.38
$360.23
$168.25
$3,620.07
Elbow fair lead cable dir fo
Shdr fair lead cable molded
Shdr fair lead cable direct
Polycentric hinge pair
Single pivot hinge pair
Flexible metal hinge pair
Additional switch, ext power
Disconnect locking wrist uni
Disconnect insert locking wr
Flexion/extension wrist unit
Flex/ext wrist w/wo friction
Spring-ass rot wrst w/ latch
Flex/ext/rotation wrist unit
Rotation wrst w/ cable lock
Quick disconn hook adapter o
Lamination collar w/ couplin
Stainless steel any wrist
Latex suspension sleeve each
Lift assist for elbow
Nudge control elbow lock
Elec lock on manual pw elbow
Shoulder abduction joint pai
Excursion amplifier pulley t
Excursion amplifier lever ty
Shoulder flexion-abduction j
Multipo locking shoulder jnt
Shoulder lock actuator
Ext pwrd shlder lock/unlock
Shoulder universal joint
Standard control cable extra
Heavy duty control cable
Teflon or equal cable lining
Hook to hand cable adapter
Harness chest/shlder saddle
Harness figure of 8 sing con
Harness figure of 8 dual con
UE triple control harness
Test sock wrist disart/bel e
Test sock elbw disart/above
Test socket shldr disart/tho
Suction socket
Frame typ socket bel elbow/w
Frame typ sock above elb/dis
Frame typ socket shoulder di
Frame typ sock interscap-tho
Removable insert each
Silicone gel insert or equal
Lockingelbow forearm cntrbal
Elbow socket ins use w/lock
Elbow socket ins use w/o lck
Cus elbo skt in for con/atyp
Cus elbo skt in not con/atyp
Below/above elbow lock mech
Term dev, passive hand mitt
Term dev, sport/rec/work att
Term dev mech hook vol open
Term dev mech hook vol close
Term dev mech hand vol open
Term dev mech hand vol close
Ped term dev, hook, vol open
Ped term dev, hook, vol clos
Ped term dev, hand, vol open
Ped term dev, hand, vol clos
Hook/hand, hvy dty, vol open
Hook/hand, hvy dty, vol clos
Term dev modifier wrist unit
Term dev precision pinch dev
Term dev auto grasp feature
MEDICAL FEE SCHEDULES
L6882
L6883
L6884
L6885
L6890
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7007
L7008
L7009
L7040
L7045
L7170
L7180
L7181
L7185
L7186
L7190
L7191
L7260
L7261
L7266
L7272
L7274
L7360
L7362
L7364
L7366
L7367
L7368
L7400
L7401
L7402
L7403
L7404
L7405
L7900
L8000
L8001
L8002
L8015
L8020
L8030
L8031
L8032
L8035
L8040
L8040
L8040
L8041
L8041
L8041
L8042
KM
KN
KM
KN
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$2,745.98
$1,908.47
$2,098.76
$2,873.00
$204.56
$503.66
$1,601.01
$1,581.91
$1,644.79
$564.67
$6,019.63
$6,949.58
$6,056.96
$7,079.68
$8,389.82
$9,406.38
$8,995.16
$10,772.93
$10,865.31
$12,783.55
$13,155.45
$14,414.20
$3,535.52
$5,543.02
$3,354.86
$2,752.06
$1,457.92
$5,288.82
$32,424.45
$35,479.56
$6,467.88
$9,853.56
$9,085.38
$10,187.64
$1,775.14
$3,231.43
$893.04
$2,007.51
$5,662.80
$273.48
$252.04
$479.23
$645.54
$344.74
$446.90
$271.39
$303.82
$328.10
$326.09
$492.16
$643.68
$465.26
$33.23
$111.06
$146.08
$53.08
$216.32
$291.72
$291.72
$34.69
$3,244.08
$2,461.37
$2,338.31
$984.54
$2,966.74
$2,818.41
$1,186.69
$3,333.44
11:3-29.6
Microprocessor control uplmb
Replc sockt below e/w disa
Replc sockt above elbow disa
Replc sockt shldr dis/interc
Prefab glove for term device
Custom glove for term device
Hand restorat thumb/1 finger
Hand restoration multiple fi
Hand restoration no fingers
Hand restoration replacmnt g
Wrist disarticul switch ctrl
Wrist disart myoelectronic c
Below elbow switch control
Below elbow myoelectronic ct
Elbow disarticulation switch
Elbow disart myoelectronic c
Above elbow switch control
Above elbow myoelectronic ct
Shldr disartic switch contro
Shldr disartic myoelectronic
Interscapular-thor switch ct
Interscap-thor myoelectronic
Adult electric hand
Pediatric electric hand
Adult electric hook
Prehensile actuator
Pediatric electric hook
Electronic elbow hosmer swit
Electronic elbow sequential
Electronic elbo simultaneous
Electron elbow adolescent sw
Electron elbow child switch
Elbow adolescent myoelectron
Elbow child myoelectronic ct
Electron wrist rotator otto
Electron wrist rotator utah
Servo control steeper or equ
Analogue control unb or equa
Proportional ctl 12 volt uta
Six volt bat otto bock/eq ea
Battery chrgr six volt otto
Twelve volt battery utah/equ
Battery chrgr 12 volt utah/e
Replacemnt lithium ionbatter
Lithium ion battery charger
Add UE prost be/wd, ultlite
Add UE prost a/e ultlite mat
Add UE prost s/d ultlite mat
Add UE prost b/e acrylic
Add UE prost a/e acrylic
Add UE prost s/d acrylic
Male vacuum erection system
Mastectomy bra
Breast prosthesis bra & form
Brst prsth bra & bilat form
Ext breastprosthesis garment
Mastectomy form
Breast prosthes w/o adhesive
Breast prosthesis w adhesive
Reusable nipple prosthesis
Custom breast prosthesis
Nasal prosthesis
Nasal prosthesis
Nasal prosthesis
Midfacial prosthesis
Midfacial prosthesis
Midfacial prosthesis
Orbital prosthesis
11:3-29.6
L8042
L8042
L8043
L8043
L8043
L8044
L8044
L8044
L8045
L8045
L8045
L8046
L8046
L8046
L8047
L8047
L8047
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8500
L8501
L8507
L8509
L8510
L8511
L8512
L8513
L8514
L8515
L8600
L8603
L8606
L8609
L8610
L8612
L8613
L8614
L8615
L8616
L8617
L8618
L8619
L8621
L8622
L8623
L8624
L8627
L8628
L8629
L8630
L8631
L8641
L8642
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
APPENDIX B - REGULATIONS
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$3,166.75
$1,333.37
$3,733.45
$3,546.76
$1,493.37
$4,133.46
$3,926.79
$1,653.38
$2,598.34
$2,468.43
$1,039.33
$2,666.74
$2,533.42
$1,066.70
$1,366.71
$1,298.39
$546.68
$76.08
$159.29
$48.22
$44.53
$18.93
$22.92
$21.68
$66.49
$20.33
$23.50
$19.82
$48.81
$60.12
$44.00
$6.02
$8.30
$10.08
$685.49
$108.96
$37.10
$96.71
$223.74
$64.40
$1.91
$4.60
$83.50
$55.89
$563.24
$393.90
$193.99
$5,769.31
$625.30
$597.23
$302.32
$17,284.73
$399.36
$93.02
$81.24
$23.22
$7,420.22
$0.55
$0.29
$57.28
$142.80
$6,324.80
$1,095.43
$158.55
$303.88
$1,957.77
$315.74
$276.79
Orbital prosthesis
Orbital prosthesis
Upper facial prosthesis
Upper facial prosthesis
Upper facial prosthesis
Hemi-facial prosthesis
Hemi-facial prosthesis
Hemi-facial prosthesis
Auricular prosthesis
Auricular prosthesis
Auricular prosthesis
Partial facial prosthesis
Partial facial prosthesis
Partial facial prosthesis
Nasal septal prosthesis
Nasal septal prosthesis
Nasal septal prosthesis
Truss single w/ standard pad
Truss double w/ standard pad
Truss addition to std pad wa
Truss add to std pad scrotal
Sheath below knee
Sheath above knee
Sheath upper limb
Pros sheath/sock w gel cushn
Prosthetic sock multi ply BK
Prosthetic sock multi ply AK
Pros sock multi ply upper lm
Shrinker below knee
Shrinker above knee
Shrinker upper limb
Pros sock single ply BK
Pros sock single ply AK
Pros sock single ply upper l
Artificial larynx
Tracheostomy speaking valve
Trach-esoph voice pros pt in
Trach-esoph voice pros md in
Voice amplifier
Indwelling trach insert
Gel cap for trach voice pros
Trach pros cleaning device
Repl trach puncture dilator
Gel cap app device for trach
Implant breast silicone/eq
Collagen imp urinary 2.5 ml
Synthetic implnt urinary 1ml
Artificial cornea
Ocular implant
Aqueous shunt prosthesis
Ossicular implant
Cochlear device
Coch implant headset replace
Coch implant microphone repl
Coch implant trans coil repl
Coch implant tran cable repl
Coch imp ext proc/contr rplc
Repl zinc air battery
Repl alkaline battery
Lith ion batt CID,non-earlvl
Lith ion batt CID, ear level
CID ext speech process repl
CID ext controller repl
CID transmit coil and cable
Metacarpophalangeal implant
MCP joint repl 2 pc or more
Metatarsal joint implant
Hallux implant
MEDICAL FEE SCHEDULES
L8658
L8659
L8670
L8680
L8681
L8682
L8683
L8684
L8685
L8686
L8687
L8688
L8689
L8690
L8691
L8695
Q0480
Q0481
Q0482
Q0483
Q0484
Q0485
Q0486
Q0487
Q0489
Q0490
Q0491
Q0492
Q0493
Q0494
Q0495
Q0496
Q0497
Q0498
Q0499
Q0500
Q0501
Q0502
Q0503
Q0504
Q0506
V2020
V2100
V2101
V2102
V2103
V2104
V2105
V2106
V2107
V2108
V2109
V2110
V2111
V2112
V2113
V2114
V2115
V2118
V2121
V2200
V2201
V2202
V2203
V2204
V2205
V2206
V2207
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$275.29
$1,708.71
$502.09
$406.73
$1,297.42
$5,278.95
$4,646.68
$614.20
$11,579.27
$7,388.47
$15,069.25
$9,615.40
$1,527.41
$4,212.39
$2,361.18
$14.74
$79,750.51
$12,866.81
$4,030.13
$16,602.32
$3,224.12
$311.28
$259.09
$302.26
$14,393.32
$622.58
$978.78
$78.84
$224.53
$190.00
$3,698.71
$1,327.53
$414.53
$454.83
$147.78
$27.04
$452.21
$575.73
$1,151.46
$607.60
$756.33
$56.55
$47.11
$49.64
$57.49
$40.91
$45.30
$49.32
$54.46
$52.05
$51.82
$57.62
$58.84
$61.34
$66.96
$73.58
$81.74
$68.90
$75.59
$76.05
$61.66
$66.76
$75.75
$62.20
$63.86
$69.62
$70.32
$64.74
11:3-29.6
Interphalangeal joint spacer
Interphalangeal joint repl
Vascular graft, synthetic
Implt neurostim elctr each
Pt prgrm for implt neurostim
Implt neurostim radiofq rec
Radiofq trsmtr for implt neu
Radiof trsmtr implt scrl neu
Implt nrostm pls gen sng rec
Implt nrostm pls gen sng non
Implt nrostm pls gen dua rec
Implt nrostm pls gen dua non
External recharg sys intern
Aud osseo dev, int/ext comp
Osseointegrated snd proc rpl
External recharg sys extern
Driver pneumatic vad, rep
Microprcsr cu elec vad, rep
Microprcsr cu combo vad, rep
Monitor elec vad, rep
Monitor elec or comb vad rep
Monitor cable elec vad, rep
Mon cable elec/pneum vad rep
Leads any type vad, rep only
Pwr pck base combo vad, rep
Emr pwr source elec vad, rep
Emr pwr source combo vad rep
Emr pwr cbl elec vad, rep
Emr pwr cbl combo vad, rep
Emr hd pmp elec/combo, rep
Charger elec/combo vad, rep
Battery elec/combo vad, rep
Bat clps elec/comb vad, rep
Holster elec/combo vad, rep
Belt/vest elec/combo vad rep
Filters elec/combo vad, rep
Shwr cov elec/combo vad, rep
Mobility cart pneum vad, rep
Battery pneum vad replacemnt
Pwr adpt pneum vad, rep veh
Lith-ion batt elec/pneum VAD
Vision svcs frames purchases
Lens spher single plano 4.00
Single visn sphere 4.12-7.00
Singl visn sphere 7.12-20.00
Spherocylindr 4.00d/12-2.00d
Spherocylindr 4.00d/2.12-4d
Spherocylinder 4.00d/4.25-6d
Spherocylinder 4.00d/>6.00d
Spherocylinder 4.25d/12-2d
Spherocylinder 4.25d/2.12-4d
Spherocylinder 4.25d/4.25-6d
Spherocylinder 4.25d/over 6d
Spherocylindr 7.25d/.25-2.25
Spherocylindr 7.25d/2.25-4d
Spherocylindr 7.25d/4.25-6d
Spherocylinder over 12.00d
Lens lenticular bifocal
Lens aniseikonic single
Lenticular lens, single
Lens spher bifoc plano 4.00d
Lens sphere bifocal 4.12-7.0
Lens sphere bifocal 7.12-20.
Lens sphcyl bifocal 4.00d/.1
Lens sphcy bifocal 4.00d/2.1
Lens sphcy bifocal 4.00d/4.2
Lens sphcy bifocal 4.00d/ove
Lens sphcy bifocal 4.25-7d/.
11:3-29.6
V2208
V2209
V2210
V2211
V2212
V2213
V2214
V2215
V2218
V2219
V2220
V2221
V2300
V2301
V2302
V2303
V2304
V2305
V2306
V2307
V2308
V2309
V2310
V2311
V2312
V2313
V2314
V2315
V2318
V2319
V2320
V2321
V2410
V2430
V2500
V2501
V2502
V2503
V2510
V2511
V2512
V2513
V2520
V2521
V2522
V2523
V2530
V2531
V2623
V2624
V2625
V2626
V2627
V2628
V2700
V2710
V2715
V2718
V2730
V2744
V2745
V2750
V2755
V2760
V2762
V2770
V2780
V2782
APPENDIX B - REGULATIONS
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
$66.85
$67.97
$72.61
$75.41
$76.61
$79.47
$96.83
$90.00
$117.06
$50.39
$43.43
$87.23
$76.06
$73.45
$74.50
$72.61
$78.29
$80.77
$82.90
$79.89
$80.01
$82.31
$83.69
$80.66
$81.17
$91.43
$104.24
$129.87
$176.41
$51.33
$63.01
$128.30
$99.73
$129.96
$97.75
$148.90
$183.43
$168.94
$113.95
$191.73
$226.56
$190.21
$125.43
$218.37
$212.51
$169.30
$201.17
$489.09
$1,045.38
$54.91
$333.85
$179.96
$1,426.01
$278.76
$45.54
$77.11
$13.98
$31.89
$19.02
$14.98
$12.02
$18.47
$14.99
$15.31
$52.77
$22.59
$11.30
$57.00
Lens sphcy bifocal 4.25-7/2.
Lens sphcy bifocal 4.25-7/4.
Lens sphcy bifocal 4.25-7/ov
Lens sphcy bifo 7.25-12/.25Lens sphcyl bifo 7.25-12/2.2
Lens sphcyl bifo 7.25-12/4.2
Lens sphcyl bifocal over 12.
Lens lenticular bifocal
Lens aniseikonic bifocal
Lens bifocal seg width over
Lens bifocal add over 3.25d
Lenticular lens, bifocal
Lens sphere trifocal 4.00d
Lens sphere trifocal 4.12-7.
Lens sphere trifocal 7.12-20
Lens sphcy trifocal 4.0/.12Lens sphcy trifocal 4.0/2.25
Lens sphcy trifocal 4.0/4.25
Lens sphcyl trifocal 4.00/>6
Lens sphcy trifocal 4.25-7/.
Lens sphc trifocal 4.25-7/2.
Lens sphc trifocal 4.25-7/4.
Lens sphc trifocal 4.25-7/>6
Lens sphc trifo 7.25-12/.25Lens sphc trifo 7.25-12/2.25
Lens sphc trifo 7.25-12/4.25
Lens sphcyl trifocal over 12
Lens lenticular trifocal
Lens aniseikonic trifocal
Lens trifocal seg width > 28
Lens trifocal add over 3.25d
Lenticular lens, trifocal
Lens variab asphericity sing
Lens variable asphericity bi
Contact lens pmma spherical
Cntct lens pmma-toric/prism
Contact lens pmma bifocal
Cntct lens pmma color vision
Cntct gas permeable sphericl
Cntct toric prism ballast
Cntct lens gas permbl bifocl
Contact lens extended wear
Contact lens hydrophilic
Cntct lens hydrophilic toric
Cntct lens hydrophil bifocl
Cntct lens hydrophil extend
Contact lens gas impermeable
Contact lens gas permeable
Plastic eye prosth custom
Polishing artifical eye
Enlargemnt of eye prosthesis
Reduction of eye prosthesis
Scleral cover shell
Fabrication & fitting
Balance lens
Glass/plastic slab off prism
Prism lens/es
Fresnell prism press-on lens
Special base curve
Tint photochromatic lens/es
Tint, any color/solid/grad
Anti-reflective coating
UV lens/es
Scratch resistant coating
Polarization, any lens
Occluder lens/es
Oversize lens/es
Lens, 1.54-1.65 p/1.60-1.79g
MEDICAL FEE SCHEDULES
V2783
V2784
V2786
Modifiers:
(MOD)
Categories:
(CATG)
11:3-29.6
PO
$64.27
Lens, >= 1.66 p/>=1.80 g
PO
$41.80
Lens polycarb or equal
PO
$0.00
Occupational multifocal lens
NU
Purchased, New
RR
Rented
UE
Purchased, Used
KM Replacement of Facial Prosthesis including new impression/moulage
KN
Replacement of Facial Prosthesis using previous master mold
AU
Urological, ostomy or trach item
AV
Item with prosthetic/orthotic device
AW Item with a surgical dressing
KE
Bid Under Round I of the DMEPOS Competitive Bid Program ForUse With
NonCompetitive Bid Base Equipment KF--Class III device
KL
DMEPOS Item Delivered Via Mail
KC Replacement of Special Power Wheelchair Interface
IN
Inexpensive and Other Routinely Purchased Items
FS
Frequently Serviced Items
CR
Capped Rental Items
OX
Oxygen and Oxygen Equipment
OS
Ostomy, Tracheostomy & Urological Items
SD
Surgical Dressings
PO
Prosthetics & Orthotics
SU
Supplies
TE
Transcutaneous Electrical Nerve Stimulators
TS
Therapeutic Shoes
Exhibit 6
Codes Subject to the Daily Maximum
CPT*/HCPSC Description
*Current Procedural Terminology (CPT) is copyright 2010 American Medical Association (AIvIA).
All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in
CPT. the AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.
29200 STRAP CHEST
29240 STRAP SHOULDER
29260 STRAP ELBOW OR WRIST
29280 STRAP HAND OR FINGER
29520 STRAP HIP
29530 STRAP KNEE
29540 STRAP ANKLE AND/OR FT
29550 STRAP TOES
29580 APPLY PASTE BOOT
29581 APPLY MULTILAY COMPRESS LWR
LEG
29590 APPLY FOOT SPLINT
29799 CAST/STRAP PROCEDURE
97012 MECHANICAL TRACTION THERAPY
SUPERVISED
includes treatment
MODALITY
with VAX-D,
DRX and similar
machines
G0283 ELECTRICAL STIMULATION,
(UNATTENDED), TO ONE OR MORE
AREAS
97016 VASOPNEUMATIC DEVICE THERAPY
SUPERVISED
MODALITY
97018 PARAFFIN BATH THERAPY
SUPERVISED
MODALITY
97022 WHIRLPOOL THERAPY
SUPERVISED
MODALITY
97024 DIATHERMY EG, MICROWAVE
SUPERVISED
MODALITY
97026 INFRARED THERAPY
SUPERVISED
MODALITY
97028 ULTRAVIOLET THERAPY
SUPERVISED
11:3-29.6
APPENDIX B - REGULATIONS
97032
APPLICATION OF A MODALITY TO
ONE OR MORE AREAS; ELECTRICAL
STIMULATION (MANUAL), EACH 15
MINUTES
97033
IONTOPHORESIS, EACH 15 MINUTES
97034
CONTRAST BATHS, EACH 15 MINUTES
97035
ULTRASOUND, EACH 15 MINUTES
97036
HUBBARD TANK, EACH 15 MINUTES
97039
UNLISTED PHYSICAL MEDICINE &
REHAB MODALITY
THERAPEUTIC PROCEDURE, 1 OR
MORE AREAS, EACH 15 MINUTES;
THERAPEUTIC EXERCISES TO
DEVELOP STRENGTH AND ENDURANCE,
RANGE OF MOTION AND FLEXIBILITY
NEUROMUSCULAR REEDUCATION OF
MOVEMENT, BALANCE COORDINATION,
KINESTHETIC SENSE, POSTURE, AND/OR
PROPRIOCEPTION FOR SITTING OR
STANDING ACTIVITIES
AQUATIC THERAPY WITH
THERAPEUTIC EXERCISES
MASSAGE THERAPY
97110
97112
97113
97124
97139
97140
97150
UNLISTED PHYSICAL MEDICINE
PROCEDURE
MANUAL THERAPY TECHNIQUES (eg
MOBILIZATION/IvIANIPULATION,
MANUAL LYMPHATIC DRAINAGE,
MANUAL TRACTION, 1 OR
MORE REGIONS, EACH 15 MINUTES
GROUP THERAPEUTIC PROCEDURES,
(2 OR MORE INDIVIDUALS)
97530
THERAPEUTIC ACTIVITIES, (USE OF
DYNAMIC ACTIVITIES TO IMPROVE
FUNCTIONAL PERFORMANCE)
97535
SELF CARE MANAGEMENT TRAINING
MODALITY
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
CONSTANT
ATTENDANCE
OF PROVIDER
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONE-
MEDICAL FEE SCHEDULES
97810
ACUPUNCTURE, 1 OR MORE NEEDLES,
WITHOUT ELECTRICAL STIMULATION,
INITIAL 15 MINUTES
97811
ACUPUNCTURE, 1 OR MORE NEEDLES,
WITHOUT ELECTRICAL STIMULATION,
EACH ADDITIONAL 15 MINUTES,
WITH REINSERTION OF NEEDLES
97813
ACUPUNCTURE, 1 OR MORE NEEDLES,
WITH ELECTRICAL STIMULATION,
INITIAL 15 MINUTES PATIENT
97814
ACUPUNCTURE, 1 OR MORE NEEDLES,
WITH ELECTRICAL STIMULATION,
EACH ADDITIONAL 15 MINUTES, WITH
REINSERTION OF NEEDLES
11:3-29.6
ON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
DIRECT ONEON-ONE
CONTACT
REQUIRED
DIRECT ONEON-ONE
PATIENT
CONTACT
REQUIRED
98925
OSTEOPATHIC MANIPULATION 1-2
REGIONS
98926 OSTEOPATHIC MANIPULATION 3-4
REGIONS
98927 OSTEOPATHIC MANIPULATION 5-6
REGIONS
98928 OSTEOPATHIC MANIPULATION 7-8
REGIONS
98929 OSTEOPATHIC MANIPULATION 9-10
REGIONS
98940 CHIROPRACTIC MANIPULATION 1-2
REGIONS
98941 CHIROPRACTIC MANIPULATION 3-4
REGIONS
98942 CHIROPRACTIC MANIPULATION 5
REGIONS
98943 CHIROPRACTIC MANIPULATION
EXTRASPINAL, 1 OR MORE REGIONS
NOTE: FOR CHIROPRACTIC MANIPULATIVE TREATMENT, THE 5 SPINAL REGIONS REFERRED TO ARE: CERVICAL REGION (INCLUDES ATLANTO-OCCIPITAL JOINT); THORACIC REGION (INCLUDES COSTOVERTEBRAL AND COSTOTRANSVERSE JOINTS);
LUMBAR REGION; SACRAL REGION; AND PELVIC (SACRO-ILIAC JOINT) REGION. THE
FIVE EXTRA-SPINAL REGIONS REFERRED TO ARE: HEAD (INCLUDING TEMPOROMANDIBULAR JOINT, EXCLUDING ATLANTO-OCCIPITAL) (EXCLUDING COSTOTRANSVERSE
AND COSTOVERTEBRAL JOINTS AND ABDOMEN)
NOTE: FOR OSTEOMANIPULATIVE TREATMENT, THE BODY REGIONS REFERRED TO
ARE: HEAD REGION; CERVICAL REGION; THORACIC REGION; LUMBAR REGION; SACRAL REGION; PELVIC REGION; LOWER EXTREMITIES; UPPER EXTREMITIES; RIB CAGE
REGION; ABDOMEN AND VISCERA REGION
NOTE: FOR STRAPPING, THIS IS A REPLACEMENT PROCEDURE USED DURING OR AFTER THE PERIOD OF FOLLOW-UP CARE OR WHEN THE APPLICATION IS AN INITIAL SERVICE PERFORMED WITHOUT A RESTORATIVE TREATMENT TO STABILIZE OR PROTECT
A FRACTURE, INJURY OR DISLOCATION AND/OR TO AFFORD COMFORT TO A PATIENT.
Exhibit 7
Hospital Outpatient Surgical Facility (HOSF) Fees
CPT*
DESCRIPTION
0232T NJX PLATELET PLASMA
Hospital
Outpatient
Surgical
Facility
Fees North
182.27
Hospital
Not
Outpatient
Subject
Surgical to Multiple
Facility Procedure
Fees South Reductions
156.22
Packaged
Item; No
Separate
Payment
Ancillary
Services
Separate
Payment
AS
11:3-29.6
APPENDIX B - REGULATIONS
G0289 ARTHRO, LOOSE BODY +
CHONDRO
10060 DRAIN SKIN ABSCESS
404.79
10061 DRAIN SKIN ABSCESS
404.79
10120 REMOVE FOREIGN BODY
741.84
10121 REMOVE FOREIGN BODY
4,909.21
10140 DRAIN HEMATOMA/FLUID
3,533.67
10160 PUNCTURE DRAIN LESION
404.79
10180 COMPLEX DRAIN WOUND
5,485.22
11000 DEBRIDE INFECTED SKIN
741.84
11001 DEBRIDE INFECTED SKIN,
ADDED
247.20
11010 DEBRIDE SKIN, FX
1,381.84
11011 DEBRIDE SKIN/MUSCLE, FX 1,381.84
11012 DEBRIDE SKIN/MUSCLE/BONE,
FX
1,381.84
11042 DEBRIDE SKIN/TISSUE
741.84
11043 DEBRIDE TISSUE/MUSCLE
741.84
11044 DEBRIDE TISSUE/MUSCLE
BONE
2,306.26
11045 DEBRIDE SUBQ TISSUE
ADD-ON
741.84
11046 DEBRIDE MUSCLE/FASCIA
ADD-ON
741.84
11047 DEBRIDE BONE ADD-ON
2,306.26
11055 TRIM SKIN LESION
247.20
11056 TRIM SKIN LESIONS, 2 TO 4
247.20
11057 TRIM SKIN LESIONS, OVER 4 247.20
11100 BIOPSY SKIN LESION
406.64
11101 BIOPSY SKIN, ADDED
247.20
11200 REMOVE SKIN TAGS
247.20
11300 SHAVE SKIN LESION
247.20
11301 SHAVE SKIN LESION
247.20
11302 SHAVE SKIN LESION
247.20
11305 SHAVE SKIN LESION
247.20
11306 SHAVE SKIN LESION
247.20
11310 SHAVE SKIN LESION
247.20
11311 SHAVE SKIN LESION
247.20
11400 EXCISE TRT-EXT BENIGN+
MARG 0.5 < CM
1,381.84
11401 EXCISE TRT-EXT BENIGN+
MARG 0.6-1 CM
1,381.84
11402 EXCISE TRT-EXT BENIGN+
MARG 1.1-2 CM
1,381.84
11403 EXCISE TRT-EXT BENIGN+
MARG 2.1-3 CM
2,306.26
11404 EXCISE TRT-EXT BENIGN+
MARG 3.1-4 CM
4,909.21
11406 EXCISE TRT-EXT BENIGN+
MARG > 4.0 CM
4,909.21
11420 EXCISE H-F-NECK-SP
BENIGN+MARG 0.5 <
2,306.26
11421 EXCISE H-F-NECK-SP
BENIGN+MARG 0.6-1
2,306.26
11422 EXCISE H-F-NECK-SP
BENIGN+MARG 1.1-2
2,306.26
11423 EXCISE H-F-NECK-SP
BENIGN+MARG 2.1-3
4,909.21
11424 EXCISE H-F-NECK-SP
BENIGN+MARG 3.1-4
4,909.21
11426 EXCISE H-F-NECK-SP
BENIGN+MARG > 4 CM
6,489.68
X
346.94
346.94
635.83
4,207.68
3,028.71
346.94
4,701.38
635.83
211.88
1,184.38
1,184.38
1,184.38
635.83
635.83
1,976.70
635.83
635.83
1,976.70
211.88
211.88
211.88
348.53
211.88
211.88
211.88
211.88
211.88
211.88
211.88
211.88
211.88
1,184.38
1,184.38
1,184.38
1,976.70
4,042.57
4,042.57
1,976.70
1,976.70
1,976.70
4,207.68
4,207.68
5,562.30
N1
MEDICAL FEE SCHEDULES
11440
11441
11442
11443
11444
11719
11720
11721
11730
11732
11740
11750
11752
11760
11762
11765
11900
11901
11950
11951
11960
11981
11982
12001
12002
12004
12005
12006
12011
12013
12014
12015
12016
12017
12018
12020
12021
EXCISE FACE-MM
BENIGN+MARG 0.5 < CM
1,381.84
EXCISE FACE-MM
BENIGN+MARG 0.6-1 CM
1,381.84
EXCISE FACE-MM
BENIGN+MARG 1.1-2 CM
2,306.26
EXCISE FACE-MM
BENIGN+MARG 2.1-3 CM
2,306.26
EXCISE FACE-MM
BENIGN+MARG 3.1-4 CM
2,306.26
TRIM NAIL(S)
117.49
DEBRIDE NAIL, 1-5
247.20
DEBRIDE NAIL, 6 OR MORE
247.20
REMOVE NAIL PLATE
247.20
REMOVE NAIL PLATE, ADDED 247.20
DRAIN BLOOD UNDER NAIL
117.49
REMOVE NAIL BED
1,381.84
REMOVE NAIL BED/FINGER
TIP
6,489.68
REPAIR NAIL BED
361.97
RECONSTRUCT NAIL BED
4,673.83
EXCISE NAIL FOLD, TOE
247.20
INJECTION INTO SKIN
LESIONS
247.20
ADDED SKIN LESIONS
INJECTION
247.20
THERAPY FOR CONTOUR
DEFECTS
361.97
THERAPY FOR CONTOUR
DEFECTS
361.97
INSERT TISSUE
EXPANDER(S)
6,050.71
INSERT DRUG IMPLANT
DEVICE
182.27
REMOVE DRUG IMPLANT
DEVICE
182.27
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
REPAIR SUPERFICIAL
WOUND(S)
361.97
CLOSE SPLIT WOUND
1,260.61
CLOSE SPLIT WOUND
858.58
11:3-29.6
1,184.38
1,184.38
1,976.70
1,976.70
1,976.70
100.70
211.88
211.88
211.88
211.88
100.70
1,184.38
5,562.30
310.24
4,005.94
211.88
211.88
211.88
310.24
310.24
5,186.06
156.22
AS
156.22
AS
310.24
310.24
310.24
310.24
310.24
310.24
310.24
310.24
310.24
310.24
310.24
310.24
1,080.47
735.89
11:3-29.6
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
13101
13102
13120
13121
13122
13131
13132
13133
13150
13151
13152
13153
13160
14000
14001
14020
APPENDIX B - REGULATIONS
INTERMED WOUND REPAIR
S/TRT/EXT
INTERMED WOUND REPAIR
S/TRT/EXT
INTERMED WOUND REPAIR
S/TRT/EXT
INTERMED WOUND REPAIR
S/TRT/EXT
INTERMED WOUND REPAIR
S/TRT/EXT
INTERMED WOUND REPAIR
S/TRT/EXT
INTERMED WOUND REPAIR
N-HF/GENITAL
INTERMED WOUND REPAIR
N-HG/GENITAL
INTERMED WOUND REPAIR
N-HG/GENITAL
INTERMED WOUND REPAIR
N-HG/GENITAL
INTERMED WOUND REPAIR
N-HG/GENITAL
INTERMED WOUND REPAIR
N-HG/GENITAL
INTERMED WOUND REPAIR
FACE/MM
INTERMED WOUND REPAIR
FACE/MM
INTERMED WOUND REPAIR
FACE/MM
INTERMED WOUND REPAIR
FACE/MM
INTERMED WOUND REPAIR
FACE/MM
INTERMED WOUND REPAIR
FACE/MM
INTERMED WOUND REPAIR
FACE/MM
REPAIR WOUND OR LESION
REPAIR WOUND OR LESION
REPAIR WOUND/LESION,
ADDED
REPAIR WOUND OR LESION
REPAIR WOUND OR LESION
REPAIR WOUND/LESION,
ADDED
REPAIR WOUND OR LESION
REPAIR WOUND OR LESION
REPAIR WOUND/LESION,
ADDED
REPAIR WOUND OR LESION
REPAIR WOUND OR LESION
REPAIR WOUND OR LESION
REPAIR WOUND/LESION,
ADDED
LATE CLOSE WOUND
SKIN TISSUE
REARRANGEMENT
SKIN TISSUE
REARRANGEMENT
SKIN TISSUE
REARRANGEMENT
361.97
310.24
858.58
735.89
361.97
310.24
361.97
310.24
858.58
735.89
858.58
735.89
361.97
310.24
361.97
310.24
361.97
310.24
858.58
735.89
858.58
735.89
858.58
735.89
858.58
735.89
361.97
310.24
361.97
310.24
361.97
310.24
858.58
735.89
858.58
735.89
858.58
1,260.61
1,260.61
735.89
1,080.47
1,080.47
1,260.61
858.58
858.58
1,080.47
735.89
735.89
361.97
858.58
1,260.61
310.24
735.89
1,080.47
858.58
1,260.61
1,260.61
1,260.61
735.89
1,080.47
1,080.47
1,080.47
858.58
6,050.71
735.89
5,186.06
4,673.83
4,005.94
4,673.83
4,005.94
4,673.83
4,005.94
MEDICAL FEE SCHEDULES
14021
14040
14041
14060
14061
14301
14302
15002
15003
15004
15005
15050
15100
15101
15120
15121
15130
15170
15171
15175
15220
15221
15240
15241
15260
15330
15331
15340
15341
15365
15366
15430
15431
15570
SKIN TISSUE
REARRANGEMENT
4,673.83
SKIN TISSUE
REARRANGEMENT
4,673.83
SKIN TISSUE
REARRANGEMENT
4,673.83
SKIN TISSUE
REARRANGEMENT
4,673.83
SKIN TISSUE
REARRANGEMENT
4,673.83
SKIN TISSUE
REARRANGEMENT
6,050.71
SKIN TISSUE REARRANGE
ADDED
6,050.71
WOUND PREP,
TRUNK/ARM/LEG
1,260.61
WOUND PREP, ADDED 100
CM
1,260.61
WOUND PREP, F/N/HF/G
1,260.61
WOUND PREP, F/N/HF/G,
ADDED CM
1,260.61
SKIN PINCH GRAFT
1,260.61
SKIN SPLIT GRAFT,
TRUNK/ARM/LEG
6,050.71
SKIN SPLIT GRAFT T/A/L,
ADDED
6,050.71
SKIN SPLIT A-GRAFT
FAC/NECK/HF/G
6,050.71
SKIN SPLIT A-GRAFT
F/N/HF/G ADDED
6,050.71
DERM AUTOGRAFT,
TRUNK/ARM/LEG
4,673.83
ACELLULAR GRAFT
TRUNK/ARMS/LEGS
1,260.61
ACELLULAR GRAFT
T/ARM/LEG, ADDED
858.58
ACELLULAR GRAFT, F/N/HF/G1,260.61
SKIN FULL GRAFT
SCALP/ARM/LEG
4,673.83
SKIN FULL GRAFT, ADDED 1,260.61
SKIN FULL GRAFT
FACE/GENITAL/HF
4,673.83
SKIN FULL GRAFT, ADDED 1,260.61
SKIN FULL GRAFT EEN &
LIPS
4,673.83
APPLY ACELLULAR
ALLOGRAFT T/ARM/LEG
1,260.61
APPLY ACELLULAR GRAFT
T/A/L, ADDED
1,260.61
APPLY CULT SKIN
SUBSTITUTE
858.58
APPLY CULT SKIN SUB,
ADDED
858.58
APPLY CULT DERM SUB
F/N/HF/G
858.58
APPLY CULT DERM F/HF/G
ADDED
858.58
APPLY ACELLULAR
XENOGRAFT
1,260.61
APPLY ACELLULAR
XENOGRAFT ADDED
1,260.61
FORM SKIN PEDICLE FLAP 6,050.71
4,005.94
4,005.94
4,005.94
4,005.94
4,005.94
5,186.06
5,186.06
1,080.47
1,080.47
1,080.47
1,080.47
1,080.47
5,186.06
5,186.06
5,186.06
5,186.06
4,005.94
1,080.47
735.89
1,080.47
4,005.94
1,080.47
4,005.94
1,080.47
4,005.94
1,080.47
1,080.47
735.89
735.89
735.89
735.89
1,080.47
1,080.47
5,186.06
11:3-29.6
11:3-29.6
15572
15574
15576
15620
15732
15734
15736
15738
15770
15780
15781
15782
15786
15787
15823
15830
15832
15851
15852
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
16000
16020
16025
16030
17000
17003
17004
17106
17107
17108
17110
17111
17250
17261
17262
19000
APPENDIX B - REGULATIONS
FORM SKIN PEDICLE FLAP 6,050.71
FORM SKIN PEDICLE FLAP 6,050.71
FORM SKIN PEDICLE FLAP 6,050.71
SKIN GRAFT
6,050.71
MUSCLE-SKIN GRAFT,
HEAD/NECK
6,050.71
MUSCLE-SKIN GRAFT,
TRUNK
6,050.71
MUSCLE-SKIN GRAFT, ARM 6,050.71
MUSCLE-SKIN GRAFT, LEG 6,050.71
DERMA-FAT-FASCIA GRAFT 6,050.71
ABRASION TREAT SKIN
6,489.68
ABRASION TREAT SKIN
1,381.84
ABRASION TREAT SKIN
1,381.84
ABRASION, LESION, SING
247.20
ABRASION, LESIONS, ADDED 247.20
REVISE UPPER EYELID
6,050.71
EXCISE SKIN ABD
6,489.68
EXCISE EXCESSIVE SKIN
TISSUE
6,489.68
REMOVE SUTURES
741.84
DRESSING CHANGE NOT FOR
BURN
182.27
REMOVE HIP PRESSURE SORE6,489.68
REMOVE HIP PRESSURE SORE6,489.68
REMOVE HIP PRESSURE SORE6,050.71
REMOVE HIP PRESSURE SORE6,050.71
REMOVE HIP PRESSURE SORE6,050.71
REMOVE THIGH PRESSURE
SORE
6,489.68
REMOVE THIGH PRESSURE
SORE
6,489.68
REMOVE THIGH PRESSURE
SORE
4,673.83
REMOVE THIGH PRESSURE
SORE
4,673.83
REMOVE THIGH PRESSURE
SORE
4,673.83
REMOVE THIGH PRESSURE
SORE
4,673.83
INITIAL TREAT BURN(S)
247.20
DRESS/DEBRIDE P-THICK
BURN, S
406.64
DRESS/DEBRIDE P-THICK
BURN, M
406.64
DRESS/DEBRIDE P-THICK
BURN, L
406.64
DESTROY PREMALIG LESION 247.20
DESTROY PREMALIG LES, 2-14 117.49
DESTROY PREMALIG LESIONS
15+
741.84
DESTROY SKIN LESIONS
741.84
DESTROY SKIN LESIONS
741.84
DESTROY SKIN LESIONS
741.84
DESTROY B9 LESION, 1-14
247.20
DSTRJ B9 SK TGS/CUTAN VASC
15/>
406.64
CHEM CAUT GRANLTJ TISS
PROUD FLESH SINUS/FSTL
406.64
DESTROY SKIN LESIONS
406.64
DESTROY SKIN LESIONS
406.64
DRAIN BREAST LESION
1,244.88
5,186.06
5,186.06
5,186.06
5,186.06
5,186.06
5,186.06
5,186.06
5,186.06
5,186.06
5,562.30
1,184.38
1,184.38
211.88
211.88
5,186.06
5,562.30
5,562.30
635.83
156.22
5,562.30
5,562.30
5,186.06
5,186.06
5,186.06
5,562.30
5,562.30
4,005.94
4,005.94
4,005.94
4,005.94
211.88
348.53
348.53
348.53
211.88
100.70
635.83
635.83
635.83
635.83
211.88
348.53
348.53
348.53
348.53
1,066.98
AS
MEDICAL FEE SCHEDULES
19120
19125
19290
20100
20101
20102
20103
20520
20525
20526
20550
20551
20552
20553
20600
20605
20610
20612
20615
20650
20660
20662
20663
20665
20670
20680
20690
20692
20693
20694
20696
20697
20900
20902
20910
20912
20920
20922
20924
20926
20950
20975
REMOVE BREAST LESION
6,949.27
EXCISE BREAST LESION
6,949.27
PLACE NEEDLE WIRE,
BREAST
EXPLORE WOUND, NECK
2,150.53
EXPLORE WOUND, CHEST
6,050.71
EXPLORE WOUND,
ABDOMEN
6,050.71
EXPLORE WOUND,
EXTREMITY
3,533.67
REMOVE FOREIGN BODY
6,238.69
REMOVE FOREIGN BODY
6,489.68
THERAPEUTIC INJECTION,
CARP TUNNEL
724.57
INJECT TENDON
SHEATH/LIGAMENT
724.57
INJECT TENDON
ORIGIN/INSERT
724.57
INJECT TRIGGER POINT, 1/2
MUSCLE
724.57
INJECT TRIGGER POINTS, =/>
3
724.57
DRAIN/INJ, JOINT/BURSA
724.57
DRAIN/INJ, JOINT/BURSA
724.57
DRAIN/INJ, JOINT/BURSA
724.57
ASPIRATE/INJECT GANGLION
CYST
724.57
TREAT BONE CYST
1,244.88
INSERT & REMOVE BONE
PIN
6,238.69
APPLY, REM FIXATION
DEVICE
1,494.88
APPLY PELVIS BRACE
6,238.69
APPLY THIGH BRACE
6,238.69
REMOVE FIXATION DEVICE
182.27
REMOVE SUPPORT IMPLANT 4,909.21
REMOVE SUPPORT IMPLANT 6,489.68
APPLY BONE FIXATION
DEVICE
8,755.84
APPLY BONE FIXATION
DEVICE
8,755.84
ADJUST BONE FIXATION
DEVICE
6,238.69
REMOVE BONE FIXATION
DEVICE
6,238.69
COMP MULTIPLANE EXT
FIXATION
8,755.84
COMP EXT FIXATE STRUT
CHANGE
5,657.91
REMOVE BONE FOR GRAFT 8,755.84
REMOVE BONE FOR GRAFT 8,755.84
REMOVE CARTILAGE FOR
GRAFT
6,050.71
REMOVE CARTILAGE FOR
GRAFT
6,050.71
REMOVE FASCIA FOR GRAFT 4,673.83
REMOVE FASCIA FOR GRAFT 4,673.83
REMOVE TENDON FOR
GRAFT
8,755.84
REMOVE TISSUE FOR GRAFT 1,260.61
FLUID PRESSURE, MUSCLE
404.79
ELECTRICAL BONE
11:3-29.6
5,956.21
5,956.21
N1
1,843.22
5,186.06
5,186.06
3,028.71
5,347.18
5,562.30
621.03
621.03
621.03
621.03
621.03
621.03
621.03
621.03
621.03
1,066.98
5,347.18
1,281.26
5,347.18
5,347.18
156.22
4,207.68
5,562.30
7,504.63
7,504.63
5,347.18
5,347.18
7,504.63
4,849.39
7,504.63
7,504.63
5,186.06
5,186.06
4,005.94
4,005.94
7,504.63
1,080.47
346.94
AS
11:3-29.6
20979
20985
21060
21070
21073
21085
21110
21116
21209
21210
21240
21242
21243
21244
21245
21246
21248
21249
21310
21315
21320
21325
21330
21335
21356
21360
21365
21385
21386
21390
21395
21400
21401
21406
21407
21408
21450
21451
21452
21453
21454
21461
21462
21465
21470
21800
21820
22222
22305
22310
22315
22505
22520
22521
APPENDIX B - REGULATIONS
STIMULATION
US BONE STIMULATION
182.27
COMPUTER-ASSIST DIR MS
PX
REMOVE JAW JOINT
CARTILAGE
12,135.56
REMOVE CORONOID
PROCESS
12,135.56
MANIPULATE TMJ
W/ANESTH
2,150.53
PREPARE FACE/ORAL
PROSTHESIS
4,708.37
INTERDENTAL FIXATION
2,150.53
INJECTION, JAW JOINT
X-RAY
REDUCE FACIAL BONES
12,135.56
FACE BONE GRAFT
12,135.56
RECONSTRUCT JAW JOINT 12,135.56
RECONSTRUCT JAW JOINT 12,135.56
RECONSTRUCT JAW JOINT 12,135.56
RECONSTRUCT LOWER JAW 12,135.56
RECONSTRUCT JAW
12,135.56
RECONSTRUCT JAW
12,135.56
RECONSTRUCT JAW
12,135.56
RECONSTRUCT JAW
12,135.56
TREAT NOSE FX
307.68
TREAT NOSE FX
4,708.37
TREAT NOSE FX
4,708.37
TREAT NOSE FX
6,964.52
TREAT NOSE FX
6,964.52
TREAT NOSE FX
6,964.52
TREAT CHEEK BONE FX
6,964.52
TREAT CHEEK BONE FX
6,964.52
TREAT CHEEK BONE FX
12,135.56
TREAT EYE SOCKET FX
12,135.56
TREAT EYE SOCKET FX
12,135.56
TREAT EYE SOCKET FX
12,135.56
TREAT EYE SOCKET FX
12,135.56
TREAT EYE SOCKET FX
2,150.53
TREAT EYE SOCKET FX
4,708.37
TREAT EYE SOCKET FX
12,135.56
TREAT EYE SOCKET FX
12,135.56
TREAT EYE SOCKET FX
12,135.56
TREAT LOWER JAW FX
965.03
TREAT LOWER JAW FX
2,150.53
TREAT LOWER JAW FX
4,708.37
TREAT LOWER JAW FX
12,135.56
TREAT LOWER JAW FX
6,964.52
TREAT LOWER JAW FX
12,135.56
TREAT LOWER JAW FX
12,135.56
TREAT LOWER JAW FX
12,135.56
TREAT LOWER JAW FX
12,135.56
TREAT RIB FX
428.68
TREAT STERNUM FX
428.68
REVISE THORAX SPINE
13,940.72
TREAT SPINE PROCESS FX
428.68
TREAT SPINE FX
1,494.88
TREAT SPINE FX
5,657.91
MANIPULATE SPINE
4,222.92
PERCUT VERTEBROPLASTY
THORACIC
8,755.84
PERCUT VERTEBROPLASTY
N1
156.22
AS
N1
10,401.38
10,401.38
1,843.22
4,035.54
1,843.22
N1
10,401.38
10,401.38
10,401.38
10,401.38
10,401.38
10,401.38
10,401.38
10,401.38
10,401.38
10,401.38
263.71
4,035.54
4,035.54
5,969.29
5,969.29
5,969.29
5,969.29
5,969.29
10,401.38
10,401.38
10,401.38
10,401.38
10,401.38
1,843.22
4,035.54
10,401.38
10,401.38
10,401.38
827.13
1,843.22
4,035.54
10,401.38
5,969.29
10,401.38
10,401.38
10,401.38
10,401.38
367.42
367.42
11,948.58
367.42
1,281.26
4,849.39
3,619.46
7,504.63
MEDICAL FEE SCHEDULES
22522
22612
22614
22851
23120
23125
23130
23331
23350
23405
23406
23410
23412
23415
23420
23430
23440
23470
23480
23485
23500
23505
23515
23520
23525
23530
23540
23545
23550
23552
23570
23600
23605
23615
23616
23620
23625
23630
23650
LUMBAR
8,755.84
PERCUT VERTEBROPLASTY
ADDED
8,755.84
LUMBAR SPINE FUSION
13,940.72
SPINE FUSION, EXTRA
SEGMENT
13,940.72
APPLY SPINE PROSTH
DEVICE
6,238.69
PARTIAL REMOVE COLLAR
BONE
8,755.84
REMOVE COLLAR BONE
8,755.84
REMOVE SHOULDER BONE,
PART
12,850.12
REMOVE SHOULDER
FOREIGN BODY
6,489.68
INJECTION FOR SHOULDER
X-RAY
TX SHO AREA 1 TDN
8,755.84
TX SHO AREA MLT TDN
THRU SM INC
8,755.84
OPEN REPAIR OF ROTATOR
CUFF, RECENT
12,850.12
OPEN REPAIR OF ROTATOR
CUFF, OLD
12,850.12
CORACOACROMIAL LIGM
RLS +-ACROMP
12,850.12
RECONSTRUCTION ROTATOR
CUFF, OLD
12,850.12
TENODIS LONG TDN BICEPS 12,850.12
RESCJ/TRNSPLJ LONG TDN
BICEPS
12,850.12
RECONSTRUCT SHOULDER
JOINT
19,460.64
REVISE COLLAR BONE
12,850.12
REVISE COLLAR BONE
24,164.43
TREAT CLAVICLE FX
428.68
TREAT CLAVICLE FX
5,657.91
TREAT CLAVICLE FX
18,168.29
TREAT CLAVICLE
DISLOCATION
1,494.88
TREAT CLAVICLE
DISLOCATION
1,494.88
TREAT CLAVICLE
DISLOCATION
13,070.23
TREAT CLAVICLE
DISLOCATION
428.68
TREAT CLAVICLE
DISLOCATION
1,494.88
TREAT CLAVICLE
DISLOCATION
13,070.23
TREAT CLAVICLE
DISLOCATION
13,070.23
TREAT SHOULDER BLADE
FX
428.68
TREAT HUMERUS FX
428.68
TREAT HUMERUS FX
5,657.91
TREAT HUMERUS FX
18,168.29
TREAT HUMERUS FX
18,168.29
TREAT HUMERUS FX
428.68
TREAT HUMERUS FX
5,657.91
TREAT HUMERUS FX
18,168.29
TREAT SHOULDER
11:3-29.6
7,504.63
7,504.63
11,948.58
11,948.58
5,347.18
7,504.63
7,504.63
11,013.83
5,562.30
N1
7,504.63
7,504.63
11,013.83
11,013.83
11,013.83
11,013.83
11,013.83
11,013.83
17,581.99
11,013.83
20,711.32
367.42
4,849.39
15,572.03
1,281.26
1,281.26
11,202.49
367.42
1,281.26
11,202.49
11,202.49
367.42
367.42
4,849.39
15,572.03
15,572.03
367.42
4,849.39
15,572.03
11:3-29.6
23655
23700
24220
24300
24305
24340
24341
24342
24343
24500
24505
24515
24516
24530
24535
24545
24546
24560
24565
24575
24576
24577
24579
25000
25001
25020
25023
25024
25025
25118
25215
25246
25259
25260
25263
25265
25270
25272
25274
25295
APPENDIX B - REGULATIONS
DISLOCATION
TREAT SHOULDER
DISLOCATION
FIXATE SHOULDER
INJECTION FOR ELBOW
X-RAY
MANIPULATE ELBOW
W/ANESTH
ARM TENDON
LENGTHENING
REPAIR BICEPS TENDON
REPAIR ARM
TENDON/MUSCLE
REPAIR RUPTURED
TENDON
REPAIR ELBOW LAT
LIGAMENT W/TISS
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
TREAT HUMERUS FX
INCISE TENDON SHEATH
INCISE FLEXOR CARPI
RADIALIS
DECOMPRESS FOREARM 1
SPACE
DECOMPRESS FOREARM 1
SPACE
DECOMPRESS FOREARM 2
SPACES
DECOMPRESS FOREARM 2
SPACES
EXCISE WRIST TENDON
SHEATH
REMOVE WRIST BONES
INJECTION FOR WRIST
X-RAY
MANIPULATE WRIST
W/ANESTH
REPAIR FOREARM
TENDON/MUSCLE
REPAIR FOREARM
TENDON/MUSCLE
REPAIR FOREARM
TENDON/MUSCLE
REPAIR FOREARM
TENDON/MUSCLE
REPAIR FOREARM
TENDON/MUSCLE
REPAIR FOREARM
TENDON/MUSCLE
RELEASE WRIST/FOREARM
428.68
367.42
4,222.92
4,222.92
3,619.46
3,619.46
N1
4,222.92
3,619.46
8,755.84
12,850.12
7,504.63
11,013.83
12,850.12
11,013.83
12,850.12
11,013.83
8,755.84
428.68
428.68
18,168.29
18,168.29
428.68
1,494.88
18,168.29
18,168.29
428.68
428.68
18,168.29
428.68
428.68
18,168.29
6,238.69
7,504.63
367.42
367.42
15,572.03
15,572.03
367.42
1,281.26
15,572.03
15,572.03
367.42
367.42
15,572.03
367.42
367.42
15,572.03
5,347.18
6,238.69
5,347.18
8,755.84
7,504.63
8,755.84
7,504.63
8,755.84
7,504.63
8,755.84
7,504.63
8,755.84
8,755.84
7,504.63
7,504.63
N1
5,657.91
4,849.39
8,755.84
7,504.63
8,755.84
7,504.63
8,755.84
7,504.63
8,755.84
7,504.63
8,755.84
7,504.63
8,755.84
7,504.63
MEDICAL FEE SCHEDULES
25500
25505
25515
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25606
25607
25608
25609
25622
25624
25628
25630
25635
25645
25650
25652
25670
25671
25676
25680
25685
26055
26116
26140
26145
26340
26410
26418
26445
26480
26525
26540
26600
26605
26607
26608
26615
26720
26725
26727
26735
26740
TENDON
6,238.69
TREAT FX RADIUS
428.68
TREAT FX RADIUS
1,494.88
TREAT FX RADIUS
13,070.23
TREAT FX RADIUS
13,070.23
TREAT FX RADIUS
13,070.23
TREAT FX ULNA
428.68
TREAT FX ULNA
428.68
TREAT FX ULNA
13,070.23
TREAT FX RADIUS & ULNA
428.68
TREAT FX RADIUS & ULNA 1,494.88
TREAT FX RADIUS & ULNA 18,168.29
TREAT FX RADIUS/ULNA
18,168.29
TREAT FX RADIUS/ULNA
428.68
TREAT FX RADIUS/ULNA
1,494.88
TREAT FX DISTAL RADIAL
7,210.82
TREAT FX RADIAL
EXTRA-ARTICULAR
18,168.29
TREAT FX RADIAL
INTRA-ARTICULAR
18,168.29
TREAT FX RADIAL 3+ FRAG 18,168.29
TREAT WRIST BONE FX
428.68
TREAT WRIST BONE FX
1,494.88
TREAT WRIST BONE FX
13,070.23
TREAT WRIST BONE FX
428.68
TREAT WRIST BONE FX
428.68
TREAT WRIST BONE FX
13,070.23
TREAT WRIST BONE FX
428.68
TREAT FX ULNAR STYLOID 13,070.23
TREAT FX ULNAR STYLOID 7,210.82
TREAT FX ULNAR STYLOID 7,210.82
TREAT WRIST DISLOCATION 7,210.82
TREAT WRIST FX
428.68
TREAT WRIST FX
7,210.82
INCISE FINGER TENDON
SHEATH
4,660.94
EXCISE HAND TUMOR DEEP
< 1.5 CM
4,909.21
REVISE FINGER JOINT, EACH 4,660.94
TENDON EXCISE
PALM/FINGER
4,660.94
MANIPULATE FINGER
W/ANESTH
1,494.88
REPAIR HAND TENDON
4,660.94
REPAIR FINGER TENDON
4,660.94
RELEASE HAND/FINGER
TENDON
4,660.94
TRANSPLANT HAND
TENDON
8,083.67
RELEASE FINGER
CONTRACTURE
4,660.94
REPAIR HAND JOINT
4,660.94
TREAT METACARPAL FX
428.68
TREAT METACARPAL FX
428.68
TREAT METACARPAL FX
5,657.91
TREAT METACARPAL FX
7,210.82
TREAT METACARPAL FX
13,070.23
TREAT FINGER FX, EACH
428.68
TREAT FINGER FX, EACH
428.68
TREAT FINGER FX, EACH
7,210.82
TREAT FINGER FX, EACH
7,210.82
TREAT FINGER FX, EACH
428.68
5,347.18
367.42
1,281.26
11,202.49
11,202.49
11,202.49
367.42
367.42
11,202.49
367.42
1,281.26
15,572.03
15,572.03
367.42
1,281.26
6,180.39
15,572.03
15,572.03
15,572.03
367.42
1,281.26
11,202.49
367.42
367.42
11,202.49
367.42
11,202.49
6,180.39
6,180.39
6,180.39
367.42
6,180.39
3,994.89
4,207.68
3,994.89
3,994.89
1,281.26
3,994.89
3,994.89
3,994.89
6,928.51
3,994.89
3,994.89
367.42
367.42
4,849.39
6,180.39
11,202.49
367.42
367.42
6,180.39
6,180.39
367.42
11:3-29.6
11:3-29.6
26742
26746
26750
26755
27093
27095
27193
27194
27275
27403
27405
27420
27422
27424
27500
27501
27502
27503
27508
27509
27510
27520
27524
27530
27532
27538
27570
27685
27686
27690
27691
27692
27695
27696
27698
27750
27752
27758
27759
27760
27762
27766
27786
27788
27792
27808
27810
27814
27816
27818
27822
APPENDIX B - REGULATIONS
TREAT FINGER FX, EACH
428.68
TREAT FINGER FX, EACH
7,210.82
TREAT FINGER FX, EACH
428.68
TREAT FINGER FX, EACH
428.68
INJECTION FOR HIP X-RAY
INJECTION FOR HIP X-RAY
TREAT PELVIC RING FX
428.68
TREAT PELVIC RING FX
4,222.92
MANIPULATE HIP JOINT
4,222.92
REPAIR KNEE CARTILAGE
8,755.84
REPAIR KNEE LIGAMENT
12,850.12
REVISE UNSTABLE
KNEECAP
12,850.12
REVISE UNSTABLE
KNEECAP
12,850.12
REVISION/REMOVE
KNEECAP
12,850.12
TREAT THIGH FX
1,494.88
TREAT THIGH FX
428.68
TREAT THIGH FX
5,657.91
TREAT THIGH FX
428.68
TREAT THIGH FX
428.68
TREAT THIGH FX
7,210.82
TREAT THIGH FX
1,494.88
TREAT KNEECAP FX
428.68
TREAT KNEECAP FX
13,070.23
TREAT KNEE FX
428.68
TREAT KNEE FX
5,657.91
TREAT KNEE FX(S)
428.68
FIXATE KNEE JOINT
4,222.92
REVISE LOWER LEG
TENDON
8,755.84
REVISE LOWER LEG
TENDONS
8,755.84
REVISE LOWER LEG
TENDON
12,850.12
REVISE LOWER LEG
TENDON
12,850.12
REVISE ADDEDITIONAL
LEG TENDON
12,850.12
REPAIR ANKLE LIGAMENT 8,755.84
REPAIR ANKLE LIGAMENTS 8,755.84
REPAIR ANKLE LIGAMENT 8,755.84
TREAT TIBIA FX
428.68
TREAT TIBIA FX
5,657.91
TREAT TIBIA FX
13,070.23
TREAT TIBIA FX
18,168.29
CLOSED TREAT MEDIAL
ANKLE FX
428.68
CLOSED TREAT MED
ANKLE FX W/MANIP
5,657.91
OPEN TREAT MEDIAL
ANKLE FX
13,070.23
TREAT ANKLE FX
428.68
TREAT ANKLE FX
428.68
TREAT ANKLE FX
13,070.23
TREAT ANKLE FX
428.68
TREAT ANKLE FX
428.68
TREAT ANKLE FX
13,070.23
TREAT ANKLE FX
428.68
TREAT ANKLE FX
1,494.88
TREAT ANKLE FX
13,070.23
367.42
6,180.39
367.42
367.42
N1
N1
367.42
3,619.46
3,619.46
7,504.63
11,013.83
11,013.83
11,013.83
11,013.83
1,281.26
367.42
4,849.39
367.42
367.42
6,180.39
1,281.26
367.42
11,202.49
367.42
4,849.39
367.42
3,619.46
7,504.63
7,504.63
11,013.83
11,013.83
11,013.83
7,504.63
7,504.63
7,504.63
367.42
4,849.39
11,202.49
15,572.03
367.42
4,849.39
11,202.49
367.42
367.42
11,202.49
367.42
367.42
11,202.49
367.42
1,281.26
11,202.49
MEDICAL FEE SCHEDULES
27823
27824
27825
27826
27827
27828
27829
27840
27842
27846
27848
27860
28120
28122
28400
28405
28415
28420
28430
28435
28436
28445
28470
28475
28476
28485
28725
28730
28740
28750
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
29240
29260
29280
29345
29355
29365
29405
29425
29450
29505
29515
29520
29530
29540
29550
29580
29581
TREAT ANKLE FX
18,168.29
TREAT LOWER LEG FX
428.68
TREAT LOWER LEG FX
5,657.91
TREAT LOWER LEG FX
13,070.23
TREAT LOWER LEG FX
18,168.29
TREAT LOWER LEG FX
18,168.29
TREAT LOWER LEG JOINT 13,070.23
TREAT ANKLE
DISLOCATION
428.68
TREAT ANKLE
DISLOCATION
4,222.92
TREAT ANKLE
DISLOCATION
13,070.23
TREAT ANKLE
DISLOCATION
13,070.23
FIXATE ANKLE JOINT
4,222.92
PART REMOVE ANKLE/HEEL 6,135.71
PARTIAL REMOVE FOOT
BONE
6,135.71
TREAT HEEL FX
428.68
TREAT HEEL FX
5,657.91
TREAT HEEL FX
18,168.29
TREAT/GRAFT HEEL FX
13,070.23
TREAT ANKLE FX
428.68
TREAT ANKLE FX
428.68
TREAT ANKLE FX
7,210.82
TREAT ANKLE FX
13,070.23
TREAT METATARSAL FX
428.68
TREAT METATARSAL FX
428.68
TREAT METATARSAL FX
7,210.82
TREAT METATARSAL FX
13,070.23
FUSE FOOT BONES
15,005.30
FUSE FOOT BONES
15,005.30
FUSE FOOT BONES
15,005.30
FUSE BIG TOE JOINT
15,005.30
APPLY LONG ARM CAST
691.49
APPLY
FOREARM CAST
APPLY HAND/WRIST CAST
APPLY FINGER CAST
304.17
APPLY LONG ARM SPLINT
304.17
APPLY FOREARM SPLINT
304.17
APPLY FOREARM SPLINT
304.17
APPLY FINGER SPLINT
304.17
APPLY FINGER SPLINT
304.17
STRAP CHEST
304.17
STRAP SHOULDER
304.17
STRAP ELBOW OR WRIST
304.17
STRAP HAND OR FINGER
304.17
APPLY LONG LEG CAST
691.49
APPLY LONG LEG CAST
691.49
APPLY LONG LEG CAST
691.49
APPLY SHORT LEG CAST
691.49
APPLY SHORT LEG CAST
691.49
APPLY LEG CAST
304.17
APPLY LONG LEG SPLINT
304.17
APPLY LOWER LEG SPLINT
304.17
STRAP HIP
304.17
STRAP KNEE
304.17
STRAP ANKLE AND/OR FT
304.17
STRAP TOES
304.17
APPLY PASTE BOOT
304.17
APPLY MULTILAY COMPRESS
11:3-29.6
15,572.03
367.42
4,849.39
11,202.49
15,572.03
15,572.03
11,202.49
367.42
3,619.46
11,202.49
11,202.49
3,619.46
5,258.91
5,258.91
367.42
4,849.39
15,572.03
11,202.49
367.42
367.42
6,180.39
11,202.49
367.42
367.42
6,180.39
11,202.49
12,861.03
12,861.03
12,861.03
12,861.03
592.68 X
691.49
304.17
260.71
260.71
260.71
260.71
260.71
260.71
260.71
260.71
260.71
260.71
592.68
592.68
592.68
592.68
592.68
260.71
260.71
260.71
260.71
260.71
260.71
260.71
260.71
592.68
260.71
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
11:3-29.6
29590
29700
29705
29710
29740
29800
29804
29805
29806
29807
29819
29820
APPENDIX B - REGULATIONS
LWR LEG
APPLY FOOT SPLINT
REMOVE/REVISE CAST
REMOVE/REVISE CAST
REMOVE/REVISE CAST
WEDGE CAST
JAW ARTHROSCOPY/SURG
JAW ARTHROSCOPY/SURG
SHOULDER ARTHROSCOPY,
DIAG
SHOULDER
ARTHROSCOPY/SURG
SHOULDER
ARTHROSCOPY/SURG
SHOULDER
ARTHROSCOPY/SURG
SHOULDER
ARTHROSCOPY/SURG
304.17
304.17
304.17
304.17
691.49
304.17
8,137.61
8,137.61
260.71
260.71
260.71
260.71
592.68
260.71
6,974.74
6,974.74
8,137.61
6,974.74
13,154.68
11,274.87
13,154.68
11,274.87
13,154.68
11,274.87
13,154.68
11,274.87
29821
29822
29823
29824
29825
29826
29827
29828
29830
29834
29835
29837
29840
29844
29845
29846
29847
29848
29850
29855
29860
29861
29862
29863
29870
29871
29873
29874
29875
29876
29877
29879
SHOULDER
ARTHROSCOPY/SURG
13,154.68
SHOULDER
ARTHROSCOPY/SURG
8,137.61
SHOULDER
ARTHROSCOPY/SURG
13,154.68
SHOULDER
ARTHROSCOPY/SURG
8,137.61
SHOULDER
ARTHROSCOPY/SURG
13,154.68
SHOULDER
ARTHROSCOPY/SURG
13,154.68
ARTHROSCOPY ROTATOR
CUFF REPAIR
13,154.68
ARTHROSCOPY BICEPS
TENODESIS
13,154.68
ELBOW ARTHROSCOPY
8,137.61
ELBOW
ARTHROSCOPY/SURG
8,137.61
ELBOW
ARTHROSCOPY/SURG
8,137.61
ELBOW
ARTHROSCOPY/SURG
8,137.61
WRIST ARTHROSCOPY
8,137.61
WRIST ARTHROSCOPY/SURG 8,137.61
WRIST ARTHROSCOPY/SURG 8,137.61
WRIST ARTHROSCOPY/SURG 8,137.61
WRIST ARTHROSCOPY/SURG13,154.68
WRIST ENDOSCOPY/SURG
8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
TIBIAL ARTHROSCOPY/SURG13,154.68
HIP ARTHROSCOPY, DIAG 13,154.68
HIP ARTHROSCOPY/SURG 13,154.68
HIP ARTHROSCOPY/SURG 13,154.68
HIP ARTHROSCOPY/SURG 13,154.68
KNEE ARTHROSCOPY, DIAG 8,137.61
KNEE ARTHROSCOPY/DRAIN 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
11,274.87
6,974.74
11,274.87
6,974.74
11,274.87
11,274.87
11,274.87
11,274.87
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
11,274.87
6,974.74
6,974.74
11,274.87
11,274.87
11,274.87
11,274.87
11,274.87
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
X
X
X
X
X
X
MEDICAL FEE SCHEDULES
29880
29881
29882
29883
29884
29886
29887
29888
29889
29891
29894
29895
29897
29898
29899
30100
30130
30140
30200
30300
30310
30520
30802
30901
30903
30905
30930
31000
31020
31231
31237
31238
31255
31256
31267
31500
31505
31515
31525
31575
31579
31600
31605
31622
31624
31645
31646
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 8,137.61
KNEE ARTHROSCOPY/SURG 24,164.43
KNEE ARTHROSCOPY/SURG 24,164.43
ANKLE
ARTHROSCOPY/SURG
13,154.68
ANKLE ARTHROSCOPY/SURG8,137.61
ANKLE ARTHROSCOPY/SURG8,137.61
ANKLE ARTHROSCOPY/SURG8,137.61
ANKLE ARTHROSCOPY/SURG8,137.61
ANKLE ARTHROSCOPY/SURG13,154.68
INTRANASAL BIOPSY
2,150.53
EXCISE INFERIOR
TURBINATE
4,708.37
RESECT INFERIOR
TURBINATE
6,964.52
INJECTION TREAT NOSE
2,150.53
REMOVE NASAL FOREIGN
BODY
182.27
REMOVE NASAL FOREIGN
BODY
4,708.37
REPAIR NASAL SEPTUM
6,964.52
ABLATE INF TURBINATE
SUBMUCOSAL
4,708.37
CONTROL NOSEBLEED
307.68
CONTROL NOSEBLEED
307.68
CONTROL NOSEBLEED
307.68
THERAPEUTIC FX, NASAL
INF TURB
4,708.37
IRRIGATE MAXILLARY SINUS 965.03
EXPLORE MAXILLARY SINUS6,964.52
NASAL ENDOSCOPY, DIAG
546.21
NASAL/SINUS ENDOSCOPY,
SURG
5,959.12
NASAL/SINUS ENDOSCOPY,
SURG
5,959.12
REMOVE ETHMOID SINUS
8,403.49
EXPLORE MAXILLARY SINUS8,403.49
ENDOSCOPY, MAXILLARY
SINUS
8,403.49
INSERT EMERGENCY
AIRWAY
642.80
DIAGNOSTIC LARYNGOSCOPY 252.44
LARYNGOSCOPY FOR
ASPIRATION
5,959.12
DIAG LARYNGOSCOPY EXCL
NB
5,959.12
DIAGNOSTIC LARYNGOSCOPY 546.21
DIAGNOSTIC LARYNGOSCOPY1,147.30
INCISE WINDPIPE
6,964.52
INCISE WINDPIPE
2,150.53
DIAG BRONCHOSCOPE/WASH2,851.45
DIAG BRONCHOSCOPE/LAVAGE2,851.45
BRONCHOSCOPY, CLEAR
AIRWAYS
2,851.45
BRONCHOSCOPY, RECLEAR
AIRWAY
2,851.45
11:3-29.6
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
6,974.74
20,711.32
20,711.32
11,274.87
6,974.74
6,974.74
6,974.74
6,974.74
11,274.87
1,843.22
4,035.54
5,969.29
1,843.22
156.22
AS
4,035.54
5,969.29
4,035.54
263.71
263.71
263.71
4,035.54
827.13
5,969.29
468.15
5,107.56
5,107.56
7,202.63
7,202.63
7,202.63
550.94
216.37
5,107.56
5,107.56
468.15
983.35
5,969.29
1,843.22
2,443.97
2,443.97
2,443.97
2,443.97
X
11:3-29.6
32405
32551
32601
33210
33212
36000
36005
36010
36011
36013
36014
36140
36200
36215
36216
36217
36218
36245
36246
36247
36248
36400
36406
36410
36425
36430
36471
36513
36514
36515
36555
36556
36558
36569
36571
36576
36578
36580
36584
36589
36592
36593
36598
36600
APPENDIX B - REGULATIONS
BIOPSY LUNG OR
MEDIASTINUM
2,643.63
INSERT CHEST TUBE
1,510.65
THORACOSCOPY,
DIAGNOSTIC
9,461.41
INSERT HEART ELECTRODE 9,299.39
INSERT PULSE GENERATOR 12,451.20
PLACE NEEDLE IN VEIN
INJECTION EXT
VENOGRAPHY
PLACE CATHETER IN VEIN
PLACE CATHETER IN VEIN
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
ESTABLISH ACCESS TO
ARTERY
PLACE CATHETER IN AORTA
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
PLACE CATHETER IN ARTERY
BLOOD DRAW < 3 YRS
FEM/JUGULAR
BLOOD DRAW < 3 YRS OTHER
VEIN
NON-ROUTINE BL DRAW > 3
YRS
VEIN ACCESS CUTDOWN > 1
YR
72.62
BLOOD TRANSFUSION
SERVICE
921.03
INJECTION THERAPY VEINS
247.20
APHERESIS PLATELETS
3,363.75
APHERESIS PLASMA
3,363.75
APHERESIS,
ADSORP/REINFUSE
8,540.97
INSERT NON-TUNNEL CV
CATH
3,087.37
INSERT NON-TUNNEL CV
CATH
3,087.37
INSERT TUNNELED CV
CATH
5,241.41
INSERT PICC CATH
3,087.37
INSERT PICVAD CATH
5,241.41
REPAIR TUNNELED CV
CATH
3,087.37
REPLACE TUNNELED CV
CATH
5,241.41
REPLACE CVAD CATH
3,087.37
REPLACE PICC CATH
3,087.37
REMOVE TUNNELED CV
CATH
1,718.86
COLLECT BLOOD PICC
171.82
DECLOT VASCULAR DEVICE 637.44
INJECT W/FLUOR, EVAL CV
DEVICE
637.44
WITHDRAW ARTERIAL
BLOOD
72.62
2,265.85
1,294.77
8,109.37
8,275.58
11,516.42
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
62.24
AS
789.41
211.88
2,883.07
2,883.07
X
X
7,320.46
X
2,646.18
2,646.18
4,907.68
2,646.18
4,907.68
2,646.18
4,907.68
2,646.18
2,646.18
1,473.23
147.27
546.35
546.35
62.24
X
MEDICAL FEE SCHEDULES
36620
36625
36800
36810
36815
36818
36833
36860
37204
37609
37620
37650
38200
43235
43236
43239
43246
43248
43249
43255
43259
43260
43450
43760
43830
44500
46040
46600
47000
49080
49320
49421
49505
50392
50394
51600
51610
51700
51701
INSERT CATHETER, ARTERY
INSERT CATHETER, ARTERY
INSERT CANNULA
8,505.69
INSERT CANNULA
8,505.69
INSERT CANNULA
8,505.69
AV FUSE, UPPER ARM,
CEPHALIC
11,329.30
AV FISTULA REVISION
11,329.30
EXTERNAL CANNULA
DECLOTTING
637.44
TRANSCATHETER
OCCLUSION
19,232.98
TEMPORAL ARTERY
PROCEDURE
4,909.21
REVISE MAJOR VEIN
11,946.47
REVISE MAJOR VEIN
7,454.87
INJECTION FOR SPLEEN
X-RAY
UPPER GI ENDOSCOPY,
DIAGNOSIS
2,411.81
UPPER GI SCOPE
W/SUBMUCOSA INJECT
2,411.81
UPPER GI ENDOSCOPY,
BIOPSY
2,411.81
PLACE GASTROSTOMY
TUBE
2,411.81
UPPER GI ENDOSCOPY/GUIDE
WIRE
2,411.81
ESOPH ENDOSCOPY,
DILATION
2,411.81
OPERATIVE UPPER GI
ENDOSCOPY
2,411.81
ENDOSCOPIC ULTRASOUND
EXAM
2,411.81
ENDO CHOLANGIOPANCREATOGRAPHY
6,309.66
DILATE ESOPHAGUS
1,782.37
CHANGE GASTROSTOMY
TUBE
637.44
PLACE GASTROSTOMY
TUBE
4,529.06
INTRODUCE
GASTROINTESTINAL TUBE 1,718.86
INCISE RECTAL ABSCESS
6,610.91
DIAGNOSTIC ANOSCOPY
182.27
NEEDLE BIOPSY LIVER
2,643.63
PUNCTURE, PERITONEAL
CAVITY
1,510.65
DIAG LAP SEPARATE PROC 10,495.79
INSERT ABDOM DRAIN,
PERM
7,481.94
PART RPR I/HERNIA INIT
REDUCE >5 YR
8,982.66
INSERT KIDNEY DRAIN
4,772.16
INJECTION FOR KIDNEY
X-RAY
INJECTION FOR BLADDER
X-RAY
INJECTION FOR BLADDER
X-RAY
IRRIGATION BLADDER
553.11
INSERT BLADDER CATHETER 182.27
11:3-29.6
N1
N1
7,354.12
7,354.12
7,354.12
9,710.33
9,710.33
546.35
16,856.39
4,207.68
10,239.31
6,389.56
N1
2,067.16
2,067.16
2,067.16
2,067.16
2,067.16
2,067.16
2,067.16
2,067.16
5,408.00
1,527.67
546.35
3,881.86
1,473.23
5,666.21
156.22
2,265.85
AS
1,294.77
8,995.94
6,471.31
7,699.03
4,090.22
N1
N1
N1
474.07
156.22
AS
11:3-29.6
51702
51703
51705
51720
51725
51726
51741
51784
51797
51798
52000
52005
52204
52281
52310
52332
52351
53600
53601
53660
53661
54235
57452
57500
57511
58340
58558
59000
59025
59841
61790
62263
62264
62270
62273
62280
62281
62282
62284
62287
62290
APPENDIX B - REGULATIONS
INSERT TEMP BLADDER
CATH
182.27
INSERT BLADDER CATH,
COMPLEX
301.69
CHANGE BLADDER TUBE
553.11
TREAT BLADDER LESION
872.10
SIMPLE CYSTOMETROGRAM 872.10
COMPLEX
CYSTOMETROGRAM
872.10
ELECTRO-UROFLOWMETRY,
FIRST
301.69
ANAL/URINARY MUSCLE
STUDY
301.69
INTRAABDOMINAL PRESSURE
TEST
553.11
US URINE CAPACITY
MEASURE
182.27
CYSTOSCOPY
2,020.50
CYSTOSCOPY & URETER
CATHETER
7,150.85
CYSTOSCOPY W/BIOPSY(S) 7,150.85
CYSTOSCOPY & TREAT
4,772.16
CYSTOSCOPY & TREAT
4,772.16
CYSTOSCOPY & TREAT
7,150.85
CYSTOURETERO & OR
PYELOSCOPE
7,150.85
DILATE URETHRA
STRICTURE
874.07
DILATE URETHRA
STRICTURE
301.69
DILATE URETHRA
301.69
DILATE URETHRA
301.69
PENILE INJECTION
872.10
EXAM CERVIX W/SCOPE
443.98
BIOPSY CERVIX
1,783.00
CRYOCAUTERY CERVIX
443.98
CATHETER FOR
HYSTERORRHAPHY
HYSTEROSCOPY, BIOPSY
6,268.18
AMNIOCENTESIS,
DIAGNOSTIC
983.13
FETAL NON-STRESS TEST
443.98
ABORTION
5,615.09
TREAT TRIGEMINAL NERVE 5,195.44
EPIDURAL LYSIS MULT
SESSIONS
2,060.68
EPIDURAL LYSIS ON SINGLE
DAY
3,474.53
SPINAL FLUID TAP,
DIAGNOSTIC
1,054.25
INJECT EPIDURAL PATCH
2,060.68
TREAT SPINAL CORD L
ESION
2,060.68
TREAT SPINAL CORD
LESION
2,060.68
TREAT SPINAL CANAL
LESION
2,060.68
INJECTION FOR
MYELOGRAM
PERCUTANEOUS
DISKECTOMY
10,121.96
INJECT FOR SPINE DISK
156.22
AS
258.58
474.07
747.48
747.48
747.48
258.58
258.58
474.07
156.22
1,731.77
AS
6,128.99
6,128.99
4,090.22
4,090.22
6,128.99
6,128.99
749.17
258.58
258.58
258.58
747.48
380.53
1,528.21
380.53
N1
5,372.45
842.64
380.53
4,812.69
4,453.01
1,766.21
2,978.02
903.60
1,766.21
1,766.21
1,766.21
1,766.21
N1
8,675.52
MEDICAL FEE SCHEDULES
62291
62292
62310
62311
62318
62319
62350
62355
62360
62362
62365
62367
62368
63020
63030
63035
63040
63042
63045
63046
63047
63048
63056
63057
63075
63076
63650
63655
63685
63688
64400
64402
64405
64412
64413
64415
64416
64417
X-RAY
INJECT FOR SPINE DISK
X-RAY
INJECTION INTO DISK
LESION
2,060.68
INJECT SPINE C/T
2,060.68
INJECT SPINE L/S (CD)
2,060.68
INJECT SPINE W/CATH, C/T 2,060.68
INJECT SPINE W/CATH L/S
(CD)
3,474.53
IMPLANT SPINAL CANAL
CATH
11,382.48
REMOVE SPINAL CANAL
CATHETER
3,474.53
INSERT SPINE INFUSION
DEVICE
11,382.48
IMPLANT SPINE INFUSION
PUMP
22,227.97
REMOVE SPINE INFUSION
DEVICE
10,121.96
ANALYZE SPINE INFUSION
PUMP
657.70
ANALYZE SPINE INFUSION
PUMP
657.70
NECK SPINE DISK SURG
13,940.72
LOW BACK DISK SURG
13,940.72
SPINAL DISK SURG, ADDED 13,940.72
LAMINOTOMY, SINGLE
CERV
13,940.72
LAMINOTOMY, SINGLE
LUMBAR
13,940.72
REMOVE SPINAL LAMINA 13,940.72
REMOVE SPINAL LAMINA 13,940.72
REMOVE SPINAL LAMINA 13,940.72
REMOVE SPINAL LAMINA,
ADDED
13,940.72
DECOMPRESS SPINAL CORD13,940.72
DECOMPRESS SPINE CORD,
ADDED
13,940.72
NECK SPINE DISK SURG
13,940.72
NECK SPINE DISK SURG
13,940.72
IMPLANT
NEUROELECTRODES
17,950.74
IMPLANT
NEUROELECTRODES
13,352.79
INSERT/REDO SPINE N
GENERATOR
23,191.56
REVISE/REMOVE
NEURORECEIVER
7,898.33
NERVE BLOCK INJ,
TRIGEMINAL
724.57
NERVE BLOCK INJ, FACIAL
724.57
NERVE BLOCK INJ, OCCIPITAL1,054.25
NERVE BLOCK INJ, SPINAL
ACCESSORY
2,060.68
NERVE BLOCK INJ, CERV
PLEXUS
1,054.25
NERVE BLOCK INJ,
BRACHIAL PLEXUS
1,054.25
NERVE BLOCK CONT INFUSE,
B PLEX
2,060.68
NERVE BLOCK INJ,
11:3-29.6
N1
N1
1,766.21
1,766.21
1,766.21
1,766.21
2,978.02
9,755.92
2,978.02
9,755.92
20,941.63
8,675.52
563.72 X
563.72
11,948.58
11,948.58
11,948.58
X
11,948.58
11,948.58
11,948.58
11,948.58
11,948.58
11,948.58
11,948.58
11,948.58
11,948.58
11,948.58
9,545.51
X
12,138.59
X
22,061.87
X
6,769.65
621.03
621.03
903.60
1,766.21
903.60
903.60
1,766.21
11:3-29.6
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64449
64450
64455
64479
64480
64483
64484
64490
64491
64492
64493
64494
64495
64505
64510
64517
64520
64555
64561
64565
64600
64605
APPENDIX B - REGULATIONS
AXILLARY
1,054.25
NERVE BLOCK INJ,
SUPRASCAPULAR
1,054.25
NERVE BLOCK INJ,
INTERCOSTAL, SING
1,054.25
NERVE BLOCK INJ,
INTERCOSTAL, MULT
2,060.68
NERVE BLOCK INJ,
ILIO-ING/HYPOGI
1,054.25
NERVE BLOCK INJ,
PUDENDAL
2,060.68
NERVE BLOCK INJ,
PARACERV
1,054.25
NERVE BLOCK INJ, SCIATIC,
SING
2,060.68
NERVE BLOCK INJ, SCIATIC,
CONT INF
2,060.68
NERVE BLOCK INJ, FEM, SING1,054.25
NERVE BLOCK INJ, FEM,
CONT INF
2,060.68
NERVE BLOCK INJ, LUMBAR
PLEXUS
2,060.68
NERVE BLOCK, OTHER
PERIPHERAL
1,054.25
NERVE BLOCK INJ, PLANTAR
DIGIT
724.57
INJECT FORAMEN EPIDURAL
C/T
2,060.68
INJECT FORAMEN EPIDURAL,
ADDED
1,054.25
INJECT FORAMEN EPIDURAL
L/S
2,060.68
INJECT FORAMEN EPIDURAL,
ADDED
1,054.25
INJECT PARAVERT F JNT C/T
1 LEV
2,060.68
INJECT PARAVERT F JNT C/T
2 LEV
724.57
INJECT PARAVERT F JNT C/T
3 LEV
724.57
INJECT PARAVERT F JNT L/S
1 LEV
2,060.68
INJECT PARAVERT F JNT L/S
2 LEV
724.57
INJECT PARAVERT F JNT L/S
3 LEV
724.57
NERVE BLOCK
SPHENOPALATINE GANGLIA 724.57
NERVE BLOCK STELLATE
GANGLION
2,060.68
NERVE BLOCK INJ, HYPOGAS
PLXS
2,060.68
NERVE BLOCK
LUMBAR/THORACIC
2,060.68
IMPLANT
NEUROELECTRODES
10,600.82
IMPLANT
NEUROELECTRODES
10,600.82
IMPLANT
NEUROELECTRODES
10,600.82
INJECTION TREAT NERVE
3,474.53
INJECTION TREAT NERVE
5,195.44
903.60
903.60
903.60
1,766.21
903.60
1,766.21
903.60
1,766.21
1,766.21
903.60
1,766.21
1,766.21
903.60
621.03
1,766.21
903.60
1,766.21
903.60
1,766.21
621.03
621.03
1,766.21
621.03
621.03
621.03
1,766.21
1,766.21
1,766.21
9,545.51
X
9,545.51
X
9,545.51
2,978.02
4,453.01
X
MEDICAL FEE SCHEDULES
64610
64612
64613
64614
64620
64622
64623
64626
64627
64640
64680
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
65205
65210
65220
65222
65265
67412
69210
69310
69320
69666
69667
69990
70030
70100
70110
70120
70130
70140
70150
70160
INJECTION TREAT NERVE
5,195.44
DESTROY NERVE, FACE
MUSCLE
724.57
DESTROY NERVE, NECK
MUSCLE
1,054.25
DESTROY NERVE,
EXTREMITY MUSC
1,054.25
INJECTION TREAT NERVE
2,060.68
DESTROY PARAVERTEBRAL
NERVE L/S
3,474.53
DESTROY PARAVERT NERVE,
ADDED
2,060.68
DESTROY PARAVERTEBRAL
NERVE C/T
2,060.68
DESTROY PARAVERT NERVE,
ADDED
724.57
INJECTION TREAT NERVE
2,060.68
INJECTION TREAT NERVE
2,060.68
REVISE FINGER/TOE NERVE 5,195.44
REVISE HAND/FOOT NERVE 5,195.44
REVISE ARM/LEG NERVE
5,195.44
REVISE SCIATIC NERVE
5,195.44
REVISE ARM NERVE(S)
5,195.44
REVISE LOW BACK NERVE(S) 5,195.44
REVISE CRANIAL NERVE
5,195.44
REVISE ULNAR NERVE AT
ELBOW
5,195.44
REVISE ULNAR NERVE AT
WRIST
5,195.44
CARPAL TUNNEL SURG
5,195.44
REMOVE FOREIGN BODY EYE 263.33
REMOVE FOREIGN BODY EYE 263.33
REMOVE FOREIGN BODY EYE 263.33
REMOVE FOREIGN BODY EYE 263.33
REMOVE FOREIGN BODY EYE6,362.61
EXPLORE/TREAT EYE
SOCKET
5,433.49
REMOVE IMPACTED EAR
WAX
182.27
REBUILD OUTER EAR
CANAL
12,135.56
REBUILD OUTER EAR
CANAL
12,135.56
REPAIR MIDDLE EAR
STRUCTURES
12,135.56
REPAIR MIDDLE EAR
STRUCTURES
12,135.56
MICROSURG, ADDED
X-RAY EYE FOR FOREIGN
BODY
177.57
X-RAY JAW < 4 VIEWS
177.57
X-RAY JAW MINIMUM 4
VIEWS
177.57
X-RAY MASTOIDS < 3
VIEWS/SIDE
177.57
X-RAY MASTOIDS MINIMUM
3 VIEWS/SIDE
177.57
X-RAY FACIAL BONES < 3
VIEWS
177.57
X-RAY FACIAL BONES
MINIMUM 3 VIEWS
177.57
X-RAY NASAL BONES
11:3-29.6
4,453.01
621.03
903.60
903.60
1,766.21
2,978.02
1,766.21
1,766.21
621.03
1,766.21
1,766.21
4,453.01
4,453.01
4,453.01
4,453.01
4,453.01
4,453.01
4,453.01
4,453.01
4,453.01
4,453.01
225.70
225.70
225.70
225.70
5,453.39
X
X
X
X
4,657.04
156.22
AS
10,401.38
10,401.38
10,401.38
10,401.38
N1
152.20
152.20
AS
AS
152.20
AS
152.20
AS
152.20
AS
152.20
AS
152.20
AS
11:3-29.6
70190
70200
70210
70220
70250
70260
70300
70310
70320
70328
70330
70332
70336
70350
70355
70360
70450
70460
70470
70480
70481
70482
70486
70487
70488
70490
70491
70492
70496
70498
70540
70542
70543
70544
70545
70546
70547
70548
70549
APPENDIX B - REGULATIONS
MINIMUM 3 VIEWS
177.57
X-RAY OPTIC FORAMINA
177.57
X-RAY ORBITS, MINIMUM 4
VIEWS
177.57
X-RAY SINUSES < 3 VIEWS
177.57
X-RAY SINUSES MINIMUM 3
VIEWS
177.57
X-RAY SKULL < 4 VIEWS
177.57
X-RAY SKULL MINIMUM 4
VIEWS
299.09
X-RAY TEETH SINGLE VIEW
120.17
X-RAY TEETH < FULL MOUTH 120.17
X-RAY TEETH FULL MOUTH
120.17
X-RAY TMJ UNILATERAL
177.57
X-RAY TMJ BILATERAL
177.57
TMJ ARTHOGRAPHY; RAD
SUPER & INTERP
1,084.37
MRI TMJ
1,352.04
CEPHALOGRAM,
ORTHODONTIC
177.57
ORTHOPANTOGRAM
120.17
X-RAY NECK SOFT TISSUE
177.57
CT HEAD/BRAIN W/O DYE
764.27
CT HEAD/BRAIN W/DYE
1,182.03
CT HEAD/BRAIN W/O &
W/DYE
1,317.77
CT ORBIT/EAR/FOSSA W/O
DYE
764.27
CT ORBIT/EAR/FOSSA W/DYE 1,182.03
CT ORBIT/EAR/FOSSA W/O &
W/DYE
1,317.77
CT MAXILLOFACIAL W/O
DYE
764.27
CT MAXILLOFACIAL W/DYE 1,182.03
CT MAXILLOFACIAL W/O &
W/DYE
1,317.77
CT SOFT TISSUE NECK W/O
DYE
764.27
CT SOFT TISSUE NECK
W/DYE
1,182.03
CT SOFT TISSUE NECK W/O
& W/DYE
1,317.77
CT ANGIOGRAPHY, HEAD
1,334.69
CT ANGIOGRAPHY, NECK
1,334.69
MRI ORBIT/FACE/NECK W/O
DYE
1,352.04
MRI ORBIT/FACE/NECK
W/DYE
1,722.84
MRI ORBIT/FACE/NECK W/O
& W/DYE
2,103.77
MR ANGIOGRAPHY HEAD
W/O DYE
1,352.04
MR ANGIOGRAPHY HEAD
W/DYE
1,722.84
MR ANGIOGRAPH HEAD W/O
& W/DYE
2,103.77
MR ANGIOGRAPHY NECK
W/O DYE
1,352.04
MR ANGIOGRAPHY NECK
W/DYE
1,722.84
MR ANGIOGRAPH NECK W/O
& W/DYE
2,103.77
152.20
152.20
AS
AS
152.20
152.20
AS
AS
152.20
152.20
AS
AS
256.35
103.00
103.00
103.00
152.20
152.20
AS
AS
AS
AS
AS
AS
929.42
1,158.83
152.20
103.00
152.20
655.06
1,013.12
1,129.46
655.06
1,013.12
1,129.46
655.06
1,013.12
1,129.46
655.06
1,013.12
1,129.46
1,143.96
1,143.96
1,158.83
1,476.64
1,803.14
1,158.83
1,476.64
1,803.14
1,158.83
1,476.64
1,803.14
AS
AS
AS
MEDICAL FEE SCHEDULES
70551
70552
70553
70554
70555
71010
71020
71021
71022
71030
71035
71040
71090
71100
71101
71110
71111
71120
71130
71250
71260
71270
71275
71550
71552
72010
72020
72040
72050
72052
72069
72070
72072
72074
72080
72090
72100
72110
72114
MRI BRAIN W/O DYE
1,352.04
MRI BRAIN W/DYE
1,722.84
MRI BRAIN W/O & W/DYE
2,103.77
FMRI BRAIN BY TECH
1,352.04
FMRI BRAIN BY PHYS/PSYCH 1,352.04
CHEST X-RAY SINGLE VIEW
FRONTAL
177.57
CHEST X-RAY 2 VIEWS
FRONTAL & LATERAL
177.57
CHEST X-RAY 2 VIEWS
W/APICAL LORD PROC
177.57
CHEST X-RAY 2 VIEWS
W/OBLIQUE PROJ
177.57
CHEST X-RAY MINIMUM 4
VIEWS
177.57
CHEST X-RAY SPECIAL VIEWS 177.57
CONTRAST X-RAY BRONCHI
UNILATERAL
906.64
X-RAY & PACEMAKER INSERT
X-RAY RIBS 2 VIEWS
177.57
X-RAY RIBS/CHEST MINIMUM
3 VIEWS
177.57
X-RAY RIBS BILATERAL 3
VIEWS
177.57
X-RAY RIBS/CHEST MINIMUM
4 VIEWS
299.09
X-RAY STERNUM MINIMUM
2 VIEWS
177.57
X-RAY STERNOCLAV JOINT
MINIMUM 3 VIEWS
177.57
CT THORAX W/O DYE
764.27
CT THORAX W/DYE
1,182.03
CT THORAX W/O & W/DYE 1,317.77
CT ANGIOGRAPHY, CHEST
1,334.69
MRI CHEST W/O DYE
1,352.04
MRI CHEST W/O & W/DYE
2,103.77
X-RAY SPINE ANTEROPOST
& LATERAL
299.09
X-RAY SPINE SINGLE VIEW
SPECIFY LEVEL
177.57
X-RAY NECK SPINE CERV 2/3
VIEWS
177.57
X-RAY NECK SPINE CERV
MINIMUM 4 VIEWS
299.09
X-RAY NECK SPINE
COMPLETE
299.09
X-RAY TRUNK SPINE
STANDING
177.57
X-RAY THORACIC SPINE 2
VIEWS
177.57
X-RAY THORACIC SPINE 3
VIEWS
177.57
X-RAY THORACIC SPINE
MINIMUM 4 VIEWS
177.57
X-RAY TRUNK SPINE 2 VIEWS 177.57
X-RAY TRUNK SPINE
SCOLIOSIS STUDY
299.09
X-RAY LOWER SPINE 2/3
VIEWS
177.57
X-RAY LOWER SPINE
MINIMUM 4 VIEWS
299.09
X-RAY LOWER SPINE
1,158.83
1,476.64
1,803.14
1,158.83
1,158.83
11:3-29.6
X
152.20
152.20
152.20
AS
152.20
AS
152.20
152.20
AS
AS
777.08
N1
152.20
AS
152.20
AS
152.20
AS
256.35
AS
152.20
AS
152.20
655.06
1,013.12
1,129.46
1,143.96
1,158.83
1,803.14
AS
256.35
AS
152.20
AS
152.20
AS
256.35
AS
256.35
AS
152.20
AS
152.20
AS
152.20
AS
152.20
152.20
AS
AS
256.35
AS
152.20
AS
256.35
AS
11:3-29.6
72120
72125
72126
72127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72170
72190
72191
72192
72193
72194
72195
72196
72197
72200
72202
72220
72240
72255
72265
72270
72275
72285
72291
72295
73000
73010
73020
73030
73040
APPENDIX B - REGULATIONS
COMPLETE
299.09
X-RAY LOWER SPINE
BENDING MINIMUM 4 VIEWS 177.57
CT NECK SPINE W/O DYE
764.27
CT NECK SPINE W/DYE
1,182.03
CT NECK SPINE W/O &
W/DYE
1,317.77
CT CHEST SPINE W/O DYE
764.27
CT CHEST SPINE W/DYE
1,182.03
CT CHEST SPINE W/O &
W/DYE
1,317.77
CT LUMBAR SPINE W/O DYE 764.27
CT LUMBAR SPINE W/DYE
1,182.03
CT LUMBAR SPINE W/O &
W/DYE
1,317.77
MRI NECK SPINE W/O DYE
1,352.04
MRI NECK SPINE W/DYE
1,722.84
MRI CHEST SPINE W/O DYE 1,352.04
MRI CHEST SPINE W/DYE
1,722.84
MRI LUMBAR SPINE W/O
DYE
1,352.04
MRI LUMBAR SPINE W/DYE 1,722.84
MRI NECK SPINE W/O &
W/DYE
2,103.77
MRI CHEST SPINE W/O &
W/DYE
2,103.77
MRI LUMBAR SPINE W/O &
W/DYE
2,103.77
X-RAY PELVIS 1/2 VIEWS
177.57
X-RAY PELVIS MINIMUM 3
VIEWS
177.57
CT ANGIOGRAPH PELVIS W/O
& W/DYE
1,334.69
CT PELVIS W/O DYE
764.27
CT PELVIS W/DYE
1,182.03
CT PELVIS W/O & W/DYE
1,317.77
MRI PELVIS W/O DYE
1,352.04
MRI PELVIS W/DYE
1,722.84
MRI PELVIS W/O & W/DYE
2,103.77
X-RAY EXAM SACROILIAC
JOINTS
177.57
X-RAY EXAM SACROILIAC
JOINTS
177.57
X-RAY TAILBONE
177.57
CONTRAST X-RAY NECK
SPINE
1,967.75
CONTRAST X-RAY THORAX
SPINE
1,967.75
CONTRAST X-RAY LOWER
SPINE
1,967.75
CONTRAST X-RAY SPINE
1,967.75
EPIDUROGRAPHY
X-RAY C/T SPINE DISK
6,593.09
PERCUT
VERT/SACROPLASTY, FLUOR
X-RAY LOWER SPINE DISK 6,593.09
X-RAY COLLAR BONE
177.57
X-RAY SHOULDER BLADE
177.57
X-RAY SHOULDER 1 VIEW
177.57
X-RAY SHOULDER MINIMUM
2 VIEWS
177.57
CONTRAST X-RAY
256.35
AS
152.20
655.06
1,013.12
AS
1,129.46
655.06
1,013.12
1,129.46
655.06
1,013.12
1,129.46
1,158.83
1,476.64
1,158.83
1,476.64
1,158.83
1,476.64
1,803.14
1,803.14
1,803.14
152.20
AS
152.20
AS
1,143.96
655.06
1,013.12
1,129.46
1,158.83
1,476.64
1,803.14
152.20
AS
152.20
152.20
AS
AS
1,686.56
1,686.56
1,686.56
1,686.56
N1
5,650.93
N1
5,650.93
152.20
152.20
152.20
AS
AS
AS
152.20
AS
MEDICAL FEE SCHEDULES
73050
73060
73070
73080
73090
73092
73100
73110
73115
73120
73130
73140
73200
73201
73202
73206
73218
73219
73220
73221
73222
73223
73500
73510
73520
73525
73530
73540
73542
73550
73560
73562
73564
73565
73580
73590
73592
SHOULDER
1,084.37
X-RAY SHOULDERS
177.57
X-RAY HUMERUS MINIMUM 2
VIEWS
177.57
X-RAY ELBOW 2 VIEWS
177.57
X-RAY ELBOW MINIMUM 3
VIEWS
177.57
X-RAY FOREARM
177.57
X-RAY ARM, INFANT
177.57
X-RAY WRIST 2 VIEWS
177.57
X-RAY WRIST MINIMUM 3
VIEWS
177.57
CONTRAST X-RAY WRIST
1,084.37
X-RAY HAND 2 VIEWS
177.57
X-RAY HAND MINIMUM 3
VIEWS
177.57
X-RAY FINGER(S) MINIMUM 2
VIEWS
177.57
CT UPPER EXTREMITY W/O
DYE
764.27
CT UPPER EXTREMITY
W/DYE
1,182.03
CT UPPER EXTREMITY W/O
& W/DYE
1,317.77
CT ANGIO UPR EXTREMITY
W/O & W/DYE
1,334.69
MRI UPPER EXTREMITY
W/O DYE
1,352.04
MRI UPPER EXTREMITY
W/DYE
1,722.84
MRI UPPER EXTREMITY W/O
& W/DYE
2,103.77
MRI JOINT UPPER
EXTREMITY W/O DYE
1,352.04
MRI JOINT UPPER
EXTREMITY W/DYE
1,722.84
MRI JOINT UPPER
EXTREMITY W/O & W/DYE 2,103.77
X-RAY HIP UNILATERAL
1 VIEW
177.57
X-RAY HIP COMPLETE
MINIMUM 2 VIEWS
177.57
X-RAY HIPS MINIMUM 2
VIEWS
177.57
X-RAY HIP ARTHROGRAPHY 1,084.37
X-RAY HIP DURING
OPERATIVE PROCEDURE
X-RAY PELVIS & HIPS
MINIMUM 2 VIEWS
177.57
X-RAY EXAM, SACROILIAC
JOINT
1,084.37
X-RAY THIGH 2 VIEWS
177.57
X-RAY KNEE 1/2 VIEWS
177.57
X-RAY KNEE 3 VIEWS
177.57
X-RAY KNEE, COMPLETE
4/MORE VIEWS
177.57
X-RAY KNEES STANDING
ANTEROPOST
177.57
X-RAY KNEE ARTHOGRAPHY 1,084.37
X-RAY TIBIA & FIBULA 2
VIEWS
177.57
X-RAY LEG, INFANT MINIMUM
11:3-29.6
929.42
152.20
AS
152.20
152.20
AS
AS
152.20
152.20
152.20
152.20
AS
AS
AS
AS
152.20
929.42
152.20
AS
AS
152.20
AS
152.20
AS
655.06
1,013.12
1,129.46
1,143.96
1,158.83
1,476.64
1,803.14
1,158.83
1,476.64
1,803.14
152.20
AS
152.20
AS
152.20
929.42
AS
N1
152.20
AS
929.42
152.20
152.20
152.20
AS
AS
AS
152.20
AS
152.20
929.42
AS
152.20
AS
11:3-29.6
73600
73610
73615
73620
73630
73650
73660
73700
73701
73706
73718
73719
73720
73721
73722
73723
74000
74010
74020
74022
74150
74160
74170
74175
74176
74177
74178
74181
74183
74220
74230
74241
74246
74280
74290
74330
74400
APPENDIX B - REGULATIONS
2 VIEWS
177.57
X-RAY ANKLE 2 VIEWS
177.57
X-RAY ANKLE MINIMUM 3
VIEWS
177.57
CONTRAST X-RAY ANKLE
1,084.37
X-RAY FOOT 2 VIEWS
177.57
X-RAY FOOT MINIMUM 3
VIEWS
177.57
X-RAY HEEL
177.57
X-RAY TOE(S)
177.57
CT LOWER EXTREMITY W/O
DYE
764.27
CT LOWER EXTREMITY
W/DYE
1,182.03
CT ANGIO LWR EXTREMITY
W/O & W/DYE
1,334.69
MRI LOWER EXTREMITY
W/O DYE
1,352.04
MRI LOWER EXTREMITY
W/DYE
1,722.84
MRI LOWER EXTREMITY
W/O & W/DYE
2,103.77
MRI JOINT LOWER
EXTREMITY W/O DYE
1,352.04
MRI JOINT LOWER
EXTREMITY W/DYE
1,722.84
MRI JOINT LWR EXTREMITY
W/O & W/DYE
2,103.77
X-RAY ABDOMEN SINGLE
ANTEROPOST
177.57
X-RAY ABDOMEN
ANTEROPOST & ADDED VW 177.57
X-RAY ABDOMEN COMPLETE 177.57
X-RAY EXAM SERIES,
ABDOMEN
299.09
CT ABDOMEN W/O DYE
764.27
CT ABDOMEN W/DYE
1,182.03
CT ABDOMEN W/O & W/DYE 1,317.77
CT ANGIO ABDOM W/O &
W/DYE
1,334.69
CT ANGIO ABDOM & PELVIS 764.27
CT ANGIO ABDOM & PELVIS
W/CONTRAST
1,182.03
CT ANGIO ABDOM & PELVIS
1+ REGNS
1,317.77
MRI ABDOMEN W/O DYE
1,352.04
MRI ABDOMEN W/O & W/DYE2,103.77
CONTRAST X-RAY,
ESOPHAGUS
341.90
CINE/VIDEO X-RAY,
THROAT/ESOPH
341.90
X-RAY EXAM, UPPER GI
TRACT W/KUB
341.90
CONTRAST X-RAY UGI TRACT
W/O KUB
341.90
CONTRAST X-RAY COLON
W/WO GLUCOGEN
559.77
CONTRAST X-RAY,
GALLBLADDER
341.90
X-RAY BILE/PANCREAS
ENDOSCOPY
CONTRAST X-RAY URINARY
152.20
152.20
AS
AS
152.20
929.42
152.20
AS
152.20
152.20
152.20
AS
AS
AS
AS
655.06
1,013.12
1,143.96
1,158.83
1,476.64
1,803.14
1,158.83
1,476.64
1,803.14
152.20
AS
152.20
152.20
AS
AS
256.35
655.06
1,013.12
1,129.46
AS
1,143.96
655.06
1,013.12
1,129.46
1,158.83
1,803.14
293.04
X
293.04
X
293.04
X
293.04
X
479.78
X
293.04
X
N1
MEDICAL FEE SCHEDULES
74410
74415
74420
74425
74430
74450
74455
74475
74480
74485
75561
75572
75574
75605
75625
75630
75635
75650
75665
75671
75676
75680
75685
75705
75710
75716
75722
75724
75726
75736
75743
75774
75809
75820
75822
75825
75894
75898
75940
75960
75961
75962
75964
75978
75984
TRACT
694.37
CONTRAST X-RAY URINARY
TRACT
694.37
CONTRAST X-RAY URINARY
TRACT
694.37
CONTRAST X-RAY URINARY
TRACT
694.37
CONTRAST X-RAY URINARY
TRACT
694.37
CONTRAST X-RAY BLADDER 694.37
X-RAY URETHRA/BLADDER
694.37
X-RAY URETHRA/BLADDER
694.37
X-RAY CONTROL, CATH
INSERT
4,772.16
X-RAY CONTROL, CATH
INSERT
4,772.16
X-RAY GUIDE, GU DILATION 4,772.16
CARDIAC MRI FOR MORPH
W/DYE
2,103.77
CT HEART W/3D IMAGE
1,012.70
CT ANGIO HEART W/3D
IMAGE
1,012.70
CONTRAST X-RAY AORTA
7,990.03
CONTRAST X-RAY AORTA
7,990.03
X-RAY AORTA, LEG
ARTERIES
7,990.03
CT ANGIO ABDOMINAL
ARTERIES
1,334.69
ARTERY X-RAYS HEAD &
NECK
12,970.25
ARTERY X-RAYS HEAD &
NECK
7,990.03
ARTERY X-RAYS HEAD &
NECK
ARTERY X-RAYS NECK
UNILATERAL
7,990.03
ARTERY X-RAYS NECK
BILATERAL
7,990.03
ARTERY X-RAYS SPINE
7,990.03
ARTERY X-RAYS SPINE
7,990.03
ARTERY X-RAYS ARM/LEG 7,990.03
ARTERY X-RAYS ARMS/LEGS 7,990.03
ARTERY X-RAYS KIDNEY
7,990.03
ARTERY X-RAYS KIDNEYS
7,990.03
ARTERY X-RAYS ABDOMEN 7,990.03
ARTERY X-RAYS PELVIS
7,990.03
ARTERY X-RAYS LUNGS
7,990.03
ARTERY X-RAY, EACH VESSEL
NONVASCULAR SHUNT, X-RAY 299.09
VEIN X-RAY ARM/LEG
2,833.55
VEIN X-RAY ARMS/LEGS
2,833.55
VEIN X-RAY TRUNK
7,990.03
X-RAYS, TRANSCATH
THERAPY
F/U ANGIOGRAPHY
299.09
X-RAY PLACE VEIN FILTER
TRANSCATH IV STENT RS & I
RETRIEVE BROKEN CATHETER
REPAIR ARTERIAL BLOCKAGE12,095.18
REPAIR ARTERY BLOCKAGE, EACH
REPAIR VENOUS BLOCKAGE 8,317.24
X-RAY CONTROL CATHETER
CHANGE
11:3-29.6
595.14
X
595.14
X
595.14
X
595.14
X
595.14
595.14
595.14
595.14
4,090.22
4,090.22
4,090.22
1,803.14
867.98
867.98
6,848.25
6,848.25
X
X
6,848.25
1,143.96
11,116.79
6,848.25
12,970.25
11,116.79
6,848.25
6,848.25
6,848.25
6,848.25
6,848.25
6,848.25
6,848.25
6,848.25
6,848.25
6,848.25
6,848.25
N1
256.35
2,428.63
2,428.63
6,848.25
N1
256.35
N1
N1
N1
10,542.37
N1
7,228.17
N1
11:3-29.6
75989
76000
76001
76010
76080
76098
76100
76102
76120
76125
76376
76377
76380
76506
76510
76511
76512
76514
76516
76519
76536
76604
76645
76700
76705
76770
76775
76776
76800
76801
76805
76810
76811
76814
76815
76816
76817
76818
76819
76820
76821
76826
76827
APPENDIX B - REGULATIONS
ABSCESS DRAIN UNDER X-RAY
FLUOROSCOPE EXAM
329.21
FLUOROSCOPE EXAM,
EXTENSIVE
X-RAY NOSE TO RECTUM
177.57
X-RAY FISTULA
906.64
X-RAY EXAM, BREAST
SPECIMEN
1,605.07
X-RAY BODY SECTION
299.09
COMPLEX BODY SECTION
X-RAYS
906.64
CINE/VIDEO X-RAYS
329.21
CINE/VIDEO X-RAYS, ADDED
3D RENDER W/O POST PROCESS
3D RENDERING W/POST PROCESS
CAT SCAN F/U STUDY
447.45
ECHO EXAM HEAD
245.43
OPHTHALMIC US, B & QUANT
A
691.93
OPHTHALMIC US, QUANT A
ONLY
379.59
OPHTHALMIC US, B
W/NON-QUANT A
379.59
ECHO EXAM EYE, THICKNESS 72.62
ECHO EXAM EYE
245.43
ECHO EXAM EYE
379.59
US EXAM HEAD & NECK
379.59
US EXAM, CHEST
245.43
US EXAM, BREAST(S)
245.43
US EXAM, ABDOM, COMPLETE 379.59
ECHO EXAM ABDOMEN
379.59
US EXAM ABDOM BACK
WALL, COMP
379.59
US EXAM ABDOM BACK WALL,
LIM
379.59
US EXAM K TRANSPLANT
W/DOPPLER
379.59
US EXAM, SPINAL CANAL
379.59
OBSTET US < 14 WKS, SINGLE
FETUS
379.59
OBSTET US >/= 14 WKS, SINGLE
FETUS
379.59
OBSTET US >/= 14 WKS, ADDED
FETUS
379.59
OBSTET US, DETAILED, SINGLE
FETUS
603.18
OBSTET US NUCHAL MEAS,
ADDED
245.43
OBSTET US, LIMITED,
FETUS(S)
245.43
OBSTET US, F/U, PER FETUS
245.43
TRANSVAGINAL US,
OBSTETRIC
245.43
FETAL BIOPHYS PROFILE
W/NST
379.59
FETAL BIOPHYS PROFILE W/O
NST
379.59
UMBILICAL ARTERY ECHO
245.43
MIDDLE CEREBRAL ARTERY
ECHO
245.43
ECHO EXAM FETAL HEART 1,586.46
ECHO EXAM FETAL HEART
245.43
N1
282.16
N1
152.20
777.08
AS
1,375.71
256.35
AS
777.08
282.16
AS
AS
N1
N1
N1
383.51
210.36
X
X
593.05
325.35
X
325.35
62.24
210.36
325.35
325.35
210.36
210.36
325.35
325.35
X
AS
X
X
X
X
325.35
325.35
325.35
325.35
X
325.35
X
325.35
X
325.35
X
516.98
X
210.36
X
210.36
210.36
X
X
210.36
X
325.35
X
325.35
210.36
X
X
210.36
1,359.76
210.36
X
X
X
MEDICAL FEE SCHEDULES
76828
76830
76856
76857
76870
76872
76881
76882
76937
76942
76998
77001
77002
77003
77011
77012
77032
77072
77073
77074
77075
77076
77077
77080
77081
77082
77280
77285
77290
77295
77300
77305
77310
77315
77321
77331
77332
77333
77334
77336
77371
ECHO EXAM FETAL HEART
245.43
TRANSVAGINAL US, NON-OB 379.59
US EXAM, PELVIC, COMPLETE 379.59
US EXAM, PELVIC, LIMITED
245.43
US EXAM, SCROTUM
379.59
US, TRANSRECTAL
379.59
US XTR NON-VASC COMPLETE 379.59
US XTR NON-VASC LMTD
245.43
US GUIDE VASCULAR ACCESS
ECHO GUIDE FOR BIOPSY
US GUIDE, INTRAOP
FLUOROGUIDE FOR VEIN
DEVICE
NEEDLE LOCALIZATION BY
X-RAY
FLUOROGUIDE FOR SPINE
INJECT
CT SCAN FOR LOCALIZATION
CT SCAN FOR NEEDLE BIOPSY
GUIDANCE FOR NEEDLE,
BREAST
X-RAYS FOR BONE AGE
X-RAYS, BONE LENGTH
STUDIES
177.57
X-RAYS, BONE SURVEY,
LIMITED
299.09
X-RAYS, BONE SURVEY
COMPLETE
299.09
X-RAYS, BONE SURVEY,
INFANT
299.09
JOINT SURVEY, SINGLE VIEW 177.57
DIAG BONE DENSITY, AXIAL 278.03
DIAG BONE
DENSITY/PERIPHERAL
126.60
DIAG BONE DENSITY,
VERTEBRAL FX
177.57
SET RADIATION THERAPY
FIELD
411.92
SET RADIATION THERAPY
FIELD
1,070.85
SET RADIATION THERAPY
FIELD
1,070.85
SET RADIATION THERAPY
FIELD
3,653.77
RADIATION THERAPY DOSE
PLAN
411.92
TELETX ISODOSE PLAN
SIMPLE
411.92
TELETX ISODOSE PLAN
INTERMED
411.92
TELETX ISODOSE PLAN
COMPLEX
1,070.85
SPECIAL TELETX PORT
PLAN
1,070.85
SPECIAL RADIATION
DOSIMETRY
411.92
RADIATION TREAT AID(S)
787.38
RADIATION TREAT AID(S)
787.38
RADIATION TREAT AID(S)
787.38
RADIATION PHYSICS
CONSULT
411.92
SRS, MULTISOURCE
30,204.85
210.36
325.35
325.35
210.36
325.35
325.35
325.35
210.36
11:3-29.6
X
X
X
X
X
N1
N1
N1
N1
N1
N1
N1
N1
N1
177.57
152.20
AS
152.20
AS
256.35
AS
256.35
AS
256.35
152.20
238.30
AS
AS
X
108.51
X
152.20
X
353.06
AS
917.82
AS
917.82
AS
3,131.64
AS
353.06
AS
353.06
AS
353.06
AS
917.82
AS
917.82
AS
353.06
674.86
674.86
674.86
AS
AS
AS
AS
353.06
25,888.56
AS
X
11:3-29.6
77403
77413
77414
77417
77470
78006
78007
78102
78103
78215
78220
78223
78232
78300
78305
78306
78315
78320
78445
78451
78452
78469
78472
78481
78494
78580
78584
78585
78588
78594
78596
78607
78707
78708
78709
78802
78803
78805
78806
78815
APPENDIX B - REGULATIONS
RADIATION TX SING AREA
6-10MEV
385.67
RADIATION TX 3/MORE
AREA 6-10MEV
632.95
RADIATION TX 3/MORE
AREA 11-19MEV
632.95
RADIOLOGY PORT FILM(S)
SPECIAL RADIATION TREAT 1,532.02
THYROID IMAGING
W/UPTAKE
865.36
THYROID IMAGE, MULT
UPTAKES
865.36
BONE MARROW IMAGING,
LTD
1,013.33
BONE MARROW IMAGING,
MULT
1,013.33
LIVER & SPLEEN IMAGING 1,045.30
LIVER FUNCTION STUDY
1,045.30
HEPATOBILIARY IMAGING
1,045.30
SALIVARY GLAND FUNCTION
EXAM
943.46
BONE IMAGING, LIMITED
AREA
964.75
BONE IMAGING, MULTIPLE
AREAS
964.75
BONE IMAGING, WHOLE BODY 964.75
BONE IMAGING, 3 PHASE
964.75
BONE IMAGING (3D)
964.75
VASCULAR FLOW IMAGING
789.90
HEART MUSCLE IMAGE SPECT,
SING
2,995.98
HEART MUSCLE IMAGE SPECT,
MULT
2,995.98
HEART INFARCT IMAGE (3D) 1,148.83
GATED HEART, PLANAR,
SING
1,148.83
HEART FIRST PASS, SING
1,148.83
HEART IMAGE, SPECT
1,148.83
LUNG PERFUSION IMAGING
776.02
LUNG V/Q IMAGE SINGLE
BREATH
1,261.32
LUNG V/Q IMAGING
1,261.32
PERFUSION LUNG IMAGE
1,261.32
VENT IMAGE, MULT PROJ,
GAS
776.02
LUNG DIFFERENTIAL
FUNCTION
1,261.32
BRAIN IMAGING (3D)
2,350.85
KID FLOW/FUNCT IMAGE W/O
DRUG
1,267.39
KID FLOW/FUNCT IMAGE
W/DRUG
1,267.39
KIDNEY IMG MORPHOLOGY
VASCULAR FLOW MULTIPLE 1,267.39
TUMOR IMAGING, WHOLE
BODY
1,872.66
TUMOR IMAGING (3D)
1,872.66
ABSCESS IMAGING, LTD
AREA
1,872.66
ABSCESS IMAGING, WHOLE
BODY
1,872.66
PET IMAGE W/CT,
330.55
X
542.50
X
542.50
X
1,313.09
X
741.70
X
741.70
X
868.52
X
868.52
895.93
895.93
895.93
X
X
X
X
808.64
X
826.89
X
826.89
826.89
826.89
826.89
677.02
X
X
X
X
X
2,567.85
X
2,567.85
984.67
X
X
984.67
984.67
984.67
665.13
X
X
X
X
1,081.07
1,081.07
1,081.07
X
X
X
665.13
X
1,081.07
2,014.92
X
X
1,086.28
X
1,086.28
X
1,086.28
X
1,605.05
1,605.05
X
X
1,605.05
X
1,605.05
X
N1
MEDICAL FEE SCHEDULES
11:3-29.6
SKULL-THIGH
4,108.15
3,521.09
X
NUCLEAR RX, IV ADMIN
883.62
757.35
X
CYTOPATH, C/V, INTERPRET
N1
FIT CONTACT LENS
N1
EAR MICROSCOPY EXAM
N1
SUPPLEMENTAL ELECTRICAL
TEST
N1
92621 AUDITORY FUNCTION, + 15
MIN
N1
93314 ECHO TRANSESOPHAGEAL
N1
93320 DOPPLER ECHO EXAM,
HEART
N1
93321 DOPPLER ECHO EXAM,
HEART
N1
93325 DOPPLER COLOR FLOW,
ADDED
N1
93463 DRUG ADMIN & HEMODYNMIC
MEAS
N1
93464 EXERCISE W/HEMODYNAMIC
MEAS
N1
93563 INJECT CONGENITAL CARD
CATH
N1
93564 INJECT HEART CONGNTL
ART/GRAFT
N1
93565 INJECT L VENTR/ATRIAL ANGIO
N1
93566 INJECT R VENTR/ATRIAL ANGIO
N1
93567 INJECT SUPRVLV AORTOGRAPHY
N1
93568 INJECT PULM ART HEART CATH
N1
93609 MAP TACHYCARDIA, ADDED
N1
93623 STIMULATION, PACING HEART
N1
93641 ELECTROPHYSIOLOGY EVAL
N1
94760 MEASURE BLOOD OXYGEN LEVEL
N1
94761 MEASURE BLOOD OXYGEN LEVEL
N1
95873 GUIDE NERVE DESTROY, ELECT
STIM
N1
95874 GUIDE NERVE DESTROY, NEEDLE
EMG
N1
95920 INTRAOP NERVE TEST, ADDED
N1
95955 EEG DURING SURG
N1
95957 EEG DIGITAL ANALYSIS
N1
96368 THER/DIAG CONCURRENT INF
N1
99143 MOD SEDATION SAME PHYS, < 5
YRS
N1
99144 MOD SEDATION BY SAME PHYS, 5
YRS +
N1
99145 MOD SEDATION BY SAME PHYS,
ADDED
N1
99148 MOD SEDATION DIFF PHYS < 5
YRS
N1
99149 MOD SEDATION DIFF PHYS 5 YRS +
N1
99150 MOD SEDATION DIFF PHYS, ADDED
N1
99175 INDUCTION VOMITING
N1
99292 CRITICAL CARE, ADDED 30 MIN
N1
99354 PROLONGED SERVICE, OFFICE
N1
99355 PROLONGED SERVICE, OFFICE
N1
New Rule. R.2001 d.253, effective July 16, 2001; R.2002 d.59, effective March 4, 2002; R.2003 d.143,
effective April 7, 2003; R.2004 d.481, effective December 20, 2004; R.2007 d.305, effective October
1, 2007; R.2009 d.194, effective June 15, 2009; R.2009 d.209, effective July 6, 2009. Repeal and New
Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). Amended. R.2014 d.004,
effective January 6, 2014.
79101
88141
92070
92504
92547
11:3-30
APPENDIX B - REGULATIONS
SUBCHAPTER 30. MOTOR VEHICLE SELF-INSURANCE
Section
11:3-30.1. Purpose.
11:3-30.2. Scope.
11:3-30.3. Definitions.
11:3-30.4. General requirements.
11:3-30.5. Certificate of self-insurance.
11:3-30.6. Renewals.
11:3-30.7. Surety bond requirement.
11:3-30.8. Audits and examinations.
11:3-30.9. Public entities.
11:3-30.10. Cancellation of certificate of self-insurance.
11:3-30.1. Purpose. This subchapter sets forth the filing requirements for motor vehicle self-insurers pursuant to N.J.S.A. 39:6-50.1, and 39:6-52 to 39:6-54.
11:3-30.2. Scope. The provisions of this subchapter apply to any person seeking to qualify as a motor vehicle self-insurer in New Jersey, except public entities
pursuant to N.J.S.A. 39:6-54.
11:3-30.3. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates
otherwise.
“Applicant” means a person applying for a certificate of self-insurance who
does not currently possess a valid certificate.
“Association” means the New Jersey Automobile Full Insurance Underwriting
Association created pursuant to N.J.S.A. 17:30E-1 et seq.
“Certificate” means certificate of self-insurance.
“Certificate holder” means a person who currently possesses a valid certificate
of self-insurance.
“Certified public accountant” means an independent certified public accountant or accounting firm in good standing with the American Institute of Certified
Public Accountants and in all states in which they are licensed to do business.
“Commissioner” means the Commissioner of Banking and Insurance.
“Motorized bicycle” means a pedal bicycle having a helper motor characterized in that either the maximum piston displacement is less than 50 cubic centimeters (cc.) or said motor is rated at no more than 1.5 brake horsepower and said bicycle is capable of a maximum speed of no more than 25 miles per hour on a flat
surface.
“Motor vehicle” means all vehicles propelled otherwise than by muscular power, excepting such vehicles as run upon rails or tracks and motorized bicycles.
“Person” means a natural person, firm, co-partnership, association or corporation.
“Public entity” means this State, any political subdivision of this State or any
municipality therein.
Amended. R. 2001 d. 44, effective February 5, 2001.
11:3-30.4. General requirements. (a) Any person in whose name more than
25 motor vehicles are registered or in whose name more than 25 motor vehicles
MOTOR VEHICLE SELF-INSURANCE
11:3-30.6
are leased may qualify as a self-insurer by obtaining a certificate of self-insurance
issued at the discretion of the Commissioner as provided in this subchapter.
(b) All filings for certificates of self-insurance, renewals, and any other filings
deemed necessary by the Commissioner pursuant to this subchapter shall be sent
to:
New Jersey Department of Banking and Insurance
Financial Exams Division
20 West State Street
PO Box 325
Trenton, New Jersey 08625-0325
Attention: Self-insurers
Amended. R. 2001 d. 44, effective February 5, 2001.
11:3-30.5. Certificate of self-insurance. (a) Any person applying for a certificate of self-insurance shall submit the following to the Commissioner:
1. A completed application form on forms to be provided by the Commissioner;
2. The most current financial statement and financial statements for the two
years immediately preceding the date of such current financial statement:
i. All financial statements shall be certified by a Certified Public Accountant:
ii. If the applicant is a subsidiary of a corporation, the applicant shall also submit the financial statements of the subsidiary’s ultimate parent corporation;
iii. If the applicant is a corporation, the Commissioner may also include the
name of any subsidiary corporation under the control of that corporation in the
certificate of self-insurance if the ultimate parent corporation guarantees that it
will discharge the subsidiary’s liability as evidenced by the filing of an indemnity
agreement. If the ultimate parent corporation does not provide such a guarantee,
the subsidiary shall make a separate application and receive independent qualification as a self-insurer. If the name of the subsidiary is included in the certificate
of self-insurance of the ultimate parent corporation and ownership of the ultimate
parent or subsidiary corporation changes, the ultimate parent or subsidiary shall
reapply for a certificate of self-insurance within 30 days of the ownership change;
and
3. A 51,000 filing fee.
(b) After the submission of an application, the Commissioner may require an
additional fee to cover the costs of further examinations which may include a credit report to be prepared by a credit agency acceptable to the Commissioner.
(c) If an application is approved and the Commissioner receives notification
from the Association that the applicant has paid any applicable policy constant or
RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively, the
Commissioner shall issue a certificate of self-insurance to the applicant. (d) All
certificates of self-insurance are valid from the date of issuance until June 30 immediately following and may be renewed thereafter, pursuant to N.J.A.C. 11:330.6, for a one year period beginning July 1 and ending June 30 the following year.
11:3-30.6. Renewals. (a) Any certificate holder applying for renewal shall submit the following so that it is received by the Commissioner not later than June l
of the year of the expiration date of such certificate:
1. An accident and claim activity report on forms to be provided by the Commissioner;
2. A financial statement for the calendar year immediately preceding the expiration date of the certificate of self-insurance certified by a Certified Public Accountant;
11:3-30.7
APPENDIX B - REGULATIONS
3. An updated vehicle listing which shall include a listing of the vehicles subject to any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1
and 17:30E-1 et seq., respectively;
4. A $1,000 renewal fee; and
5. Any other information that is substantially different from the information
provided in the original application form or from the information provided in the
last renewal period.
(b) After the submission of an application for renewal, the Commissioner may
require an additional fee to cover the costs of further examinations which may include a credit report to be prepared by a credit agency acceptable to the Commissioner.
(c) If an application for renewal is approved and the Commissioner receives
notification from the Association that the certificate holder has paid any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et
seq., respectively, the Commissioner shall issue a new certificate of self-insurance.
11:3-30.7. Surety bond requirement. (a) The Commissioner may require the
furnishing of a surety bond and for evidence of excess insurance.
(b) If the applicant or certificate holder is required to furnish a surety bond, the
surety bond shall be in an amount of not less than 5300.000, with an additional
510,000 for each vehicle registered or leased in the applicant’s or certificate holder’s name over the minimum required to qualify as self-insurer under this subchapter. up to a maximum amount of 51,000,000.
11:3-30.8. Audits and examinations. (a) The Commissioner may make or
cause to be made audits or examinations as may be necessary to determine the
ability of the applicant or the certificate holder to discharge its financial obligations as a self-insurer.
(b) The applicant or certificate holder shall pay the reasonable expenses of the
audit or examination.
11:3-30.9. Public entities. (a) This subchapter does not apply to any motor vehicle owned by the United States, this State, any political subdivision of this State
or any municipality therein; nor to any motor vehicle which is subject to the requirements of law requiring insurance or other security on certain types of vehicles, other than the requirements of N.J.S.A. 39:6A-1 et seq. or N.J.S.A. 39:6B-1
et seq.
(b) Notwithstanding the provisions in (a) to the contrary, any public entity that
currently has or will establish in the future a self-insurance program or plans to
discontinue a self-insurance program currently in effect, shall notify the Commissioner in writing that it currently has, will establish or discontinue such a program.
11:3-30.10. Cancellation of certificate of self-insurance. After a hearing conducted pursuant to the Administrative Procedure Act, N.J.S.A. 52:148-1 et seq.,
and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1, upon not less than
five days’ notice, the Commissioner may cancel a certificate of self-insurance
upon reasonable grounds including, but not limited to, failure to pay any judgment
within 30 days after such judgment has become final.
SUBCHAPTER 34. ELIGIBLE PERSONS QUALIFICATIONS AND
AUTOMOBILE INSURANCE ELIGIBILITY POINTS SCHEDULE
Section
11:3-34.1. Purpose.
11:3-34.2. Scope.
INSURANCE ELIGIBILITY
11:3-34.3
11:3-34.3. Definitions.
11:3-34.4. Eligible person qualifications.
11:3-34.5. Automobile insurance eligibility points.
APPENDIX Schedule of Automobile Insurance Eligibility Points
11:3-34.1. Purpose. The purpose of this subchapter is to set forth the requirements for determining who can qualify as an “eligible person”, and to provide the
schedule for “automobile insurance eligibility points” pursuant to N.J.S.A.
17:33B-13 and 14.
Amended. R. 1996 d. 58, effective February 5, 1996.
11:3-34.2. Scope. (a) The provisions of this subchapter apply to all insurers
which write personal private passenger automobile insurance and all persons who
are required to procure automobile insurance coverage in this State.
(b) Except to the extent that the definition of eligible and ineligible persons at
N.J.A.C. 11:3-34.4 is utilized for nonrenewals pursuant to N.J.A.C. 11:3-8, this
subchapter shall become inoperative on and after January 1, 2009, unless and until
the Commissioner by Order makes the requirements of N.J.S.A. 17:33B-15a and
b operative pursuant to the limited circumstances set forth in N.J.S.A. 17:33B15d(3), upon a determination made after a hearing conducted pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq., and Uniform Administrative Procedure Rules, N.J.A.C. 1:1, that a competitive market does not exist
among insurers authorized to write private passenger automobile insurance in this
State, or the Commissioner certifies by Order that the Personal Automobile Insurance Plan is insuring 10 percent or more of the aggregate number of private passenger automobile non-fleet exposures being written in this State. A notice of the
issuance by the Commissioner of such an Order shall be published in the New Jersey Register.
Amended. R. 2008 d. 380, effective December 15, 2008 (operative January 1, 2009); R.2011 d.242,
effective September 19, 2011.
11:3-34.3. Definitions. The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates
otherwise.
“At-fault accident” is any accident involving a driver insured under the policy:
1. Where a driver is proportionately responsible based on the number of vehicles involved. A driver is proportionately responsible if 50 percent responsible for
an accident involving two drivers; if 33 1/3 percent responsible for an accident involving three drivers, etc.; and
2. Which results in a total payment by the insurer of at least $500.00 for an accident occurring before June 9, 2003; or at least $1,000 for an accident occurring
on or after June 9, 2003. The $1,000 dollar amount may be adjusted in $100.00 or
$250.00 increments by Order of the Commissioner not more frequently than every
36 months. The Order shall reflect the cumulative increases or decreases in the
components of the Consumer Price Index, All Urban Consumers (CPI-U) for the
Northeast Region, and the adjusted amount shall apply to automobile accidents
occurring at least 120 days after the effective date of the adjustment. The adjustment shall be reflected in this definition through a notice of administrative change
published in the New Jersey Register.
An at-fault accident shall not include the following:
1. Involvement in an accident in which the motor vehicle owned or operated by
the insured or other driver insured under the policy was lawfully parked;
11:3-34.4
APPENDIX B - REGULATIONS
2. Involvement in an accident in which the motor vehicle was struck by a hit
and run driver, if such accident was reported to the proper authorities within 24
hours;
3. Involvement in an accident in connection with which neither the named insured nor any other driver insured under the policy was convicted of a moving
traffic violation and the owner or operator of another vehicle involved in such accident was so convicted;
4. For physical damage losses other than collision;
5. For an accident in which the motor vehicle was struck in the rear by another
vehicle and a driver insured under the policy has not been convicted of a moving
violation in connection with the accident; or
6. For an accident occurring as a result of operation of any motor vehicle in response to an emergency if the operator at the time of the accident was responding
to the call to duty as a paid or volunteer member of any police or fire department,
first aid squad or any law enforcement agency.
“Automobile” means an automobile as defined in N.J.S.A. 39:6A-2.
“Automobile insurance” means insurance for an automobile including any or
all of the following coverages: bodily injury liability, and property damage liability, comprehensive and collision coverages, uninsured and underinsured motorist
coverage, personal injury protection coverage, additional personal injury protection coverage and any other automobile insurance required by law.
“Automobile insurance eligibility points” means points calculated under the
schedule promulgated by the Commissioner pursuant to this subchapter.
“Commissioner” means the Commissioner of Banking and Insurance of the
State of New Jersey.
“Department” means the Department of Banking and Insurance of the State of
New Jersey.
“State” means the State of New Jersey.
Amended. R. 2001 d. 44, effective February 5, 2001; R. 2003 d.469, effective December 1, 2003.
11:3-34.4. Eligible person qualifications. (a) An “eligible person” is a person
who is an owner or registrant of an automobile registered and principally garaged
in this State or who is a resident and holds a valid New Jersey driver's license to
operate an automobile, but does not include any person:
1. Who, during the three-year period immediately preceding application for, or
renewal of, an automobile insurance policy has been convicted pursuant to
N.J.S.A. 39:4-50 or N.J.S.A. 39:4-50.4a or for an offense of a substantially similar
nature committed in another jurisdiction;
2. Who has been convicted of a crime of the first, second or third degree resulting from the use of a motor vehicle; or has been convicted of theft of a motor vehicle;
3. Whose driver's license to operate an automobile is under suspension or revocation;
4. Who has been convicted, within the five-year period immediately preceding
application for or renewal of a policy of automobile insurance, of fraud or intent
to defraud involving an insurance claim or an application for insurance;
5. Who has been successfully denied, with the immediately preceding five
years' payment by an insurer of a claim in excess of $1,000 under an automobile
insurance policy, if there was evidence of fraud or intent to defraud involving the
automobile insurance claim or application. For the purpose of this section:
i. If the claim has been subject to litigation between the insurer and the insured
in which the insurer defended against payment of the claim in whole or in part on
INSURANCE ELIGIBILITY
11:3-34.4
grounds of fraud, it shall be conclusively presumed that the claim was successfully
denied if judgment was entered for the insurer in the litigation; and conclusively
presumed that the claim was not successfully denied if judgment was entered for
the insured;
ii. If the claim has not been subject to litigation between the insurer and the insured, but the insurer denied the claim without payment by reason of fraud, it shall
be presumed that the claim was successfully denied. This presumption may be
overcome in an administrative proceeding pursuant to N.J.A.C. 11:3-33;
iii. If the incident was not reported to the New Jersey Office of Insurance Fraud
Prosecutor pursuant to N.J.S.A. 17:33A-9 it shall be presumed that there was no
evidence of fraud or intent to defraud;
6. Whose automobile insurance policy has been cancelled for nonpayment of
premiums or financed premium with a lapse of coverage of at least 30 days, within
the immediately preceding two-year period, unless the premium due on a policy
for which application has been made is paid in full before issuance or renewal of
the policy. For the purpose of this section, “paid in full” shall not include any
transaction in which a lender obtains authority from an insured to cancel the policy
and receive a refund from the insurer in the event the insured defaults on a loan
used to pay the premium;
7. Who fails to obtain or maintain membership or qualification for membership
in a club, group, or organization, if membership is a uniform requirement of the
insurer as a condition of providing insurance, and if the dues or charges, if any, or
other conditions for membership or qualifications for membership are applied uniformly throughout this State, are not expressed as a percentage of the insurance
premium, and do not vary with respect to the rating classification of the member
or potential member except for the purpose of offering a membership fee to family
units. Membership fees, if applicable, may vary in accordance with the amount or
type of coverage if the purchase of additional coverage, either as to type or
amount, is not a condition for reduction of dues or fees;
8. Whose driving record for the three year period immediately preceding the
application for or renewal of a policy of automobile insurance has an accumulation of seven or more automobile insurance eligibility points as determined in
N.J.A.C. 11:3-34.5;
9. Who, during the three-year period immediately preceding application for, or
renewal of, an automobile insurance policy, has knowingly provided materially
false or misleading information in connection with an application for insurance,
renewal of insurance or claim for benefits under an insurance policy;
10. Who is a named insured or who is insured under the same policy as a person
whose driver's license is suspended or revoked and either:
i. The suspended or revoked driver has been convicted of a violation of
N.J.S.A. 39:6B-2 within the previous three years; or
ii. With the exception of a conviction for violating N.J.S.A. 39:3-40i, other evidence exists indicating that the suspended or revoked driver has been operating a
vehicle during the period of suspension or revocation;or
11. Who, for the purposes of nonrenewals under N.J.A.C. 11:3-8 only, does not
satisfy the insurer’s acceptance criteria as set forth in N.J.A.C. 11:3-8.12.
(b) An “eligible person” includes a person who is an owner or registrant of an
automobile registered in this State or who holds a valid New Jersey driver's license
to operate an automobile and is domiciled in this State who is temporarily residing
out-of-State and whose car may be principally garaged in another state while the
11:3-34.5
APPENDIX B - REGULATIONS
person either is a full time student or is in the military service and is stationed outof-State.
Amended: R. 1992, d. 481; R. 1996 d.246, effective June 3, 1996; R. 2001 d. 44, effective February
5, 2001; R. 2003 d. 469, effective December 1, 2003; R.2007 d.373, effective December 3, 2007;
R.2011 d.242, effective September 19, 2011.
11:3-34.5. Automobile insurance eligibility points. (a) Automobile insurance eligibility points shall be accumulated as a result of convictions, suspensions,
revocations and determinations of responsibility for civil infractions in accordance with the schedule set forth in the Appendix to this subchapter herein incorporated by reference.
(b) Automobile eligibility points are cumulative and accrue for all violations
and occurrences set forth on Schedules 1 and 2. Automobile insurance eligibility
points shall be deemed to accrue as follows:
1. Points for an at-fault accident shall accrue on the date that total payment by
the insurer equals or exceeds $1,000 or such other amount as may be prescribed
by Order of the Commissioner issued pursuant to N.J.S.A. 17:33B-14. The
amount under such Order shall be reflected in this paragraph through a notice of
administrative change published in the New Jersey Register. An insurer may, at its
option, use the date of the accident or date of first payment provided, however, that
the insurer shall not underwrite or rate any policy based on the accident until total
payment by the insurer equals or exceeds $1,00; and further provided that the insurer shall use the optional date consistently in all cases.
2. Points for conviction of motor vehicle violations and other events that are set
forth on an abstract of drivers license records available from the New Jersey Motor Vehicle Commission, or a comparable agency of another state, shall accrue
when the event is recorded in the agency's records as evidenced by an abstract.
3. When an eligible person is involved in an at-fault accident and has not accrued any eligibility points during the three-year period immediately preceding
the date of that accident, no eligibility points for a two- or three-point violation, as
set forth in Schedule 2 of the Appendix, shall accrue along with the points assessed in accordance with Schedule 1 for the at-fault accident, when the violation
arises out of the same incident which results in 1the assessment of points for the
at-fault accident. However, violations that arise out of the same incident may be
considered by insurers for purposes of tier placement pursuant to N.J.A.C. 11:319A.
4. Points for each full year of court-imposed driver's license suspension within
the preceding three years and points for each full year within the immediately preceding three years that a person has not held a driver's license shall accrue on the
date of application for insurance. However, in accordance with Schedule 1, eligibility points assessed for failure to hold a drivers’ license in the previous three
years are not cumulative to points assessed for the suspension of a drivers license.
(c) Automobile insurance eligibility points set forth on Schedule 2 of the Appendix represent motor vehicle points established by the New Jersey Motor Vehicle Commission by rule, N.J.A.C. 13:19-10.1, which is hereby incorporated by
reference. Any additions, deletions or modifications to N.J.A.C. 13:19-10.1 shall
likewise be incorporated as of the effective date of amendment. Schedule 2 is included in the Appendix for convenience.
(d) The reference in Appendix Schedule 1 and Schedule 2 to provisions of the
New Jersey Statutes Annotated is meant for convenience to assist in the quick
identification of the nature of the event. If the event takes place in a state or prov-
INSURANCE ELIGIBILITY
11:3-34.5
ince other than New Jersey, Schedule 1 and 2 should be consulted for identification of the specific misconduct committed and the assessment of the appropriate
number of insurance eligibility points to be assessed.
(e) In addition to the motor vehicle violation and insurance eligibility points
specifically enumerated on Schedule 2 of the Appendix pertaining to the New Jersey Turnpike, Atlantic City Expressway, and the Garden State Parkway, for any
other motor vehicle violations that occur on the New Jersey Turnpike (N.J.A.C.
19:9), the Atlantic City Expressway (N.J.A.C. 19:2-2.1), the Garden State Parkway (N.J.A.C. 19:8) or for any other moving violation at any location, Schedules
1 and 2 shall be consulted for identification of the specific misconduct committed
and the determination of the appropriate number of insurance eligibility points to
be assessed.
Amended. R.2001 d.44, effective February 5, 2001; R.2002 d.330, effective October 7, 2002; R.2003
d.469, effective December 1, 2003; R.2006 d.243, effective July 3, 2006; R.2007 d.373, effective December 3, 2007.
APPENDIX
Schedule of Automobile Insurance Eligibility Points
Schedule 1
N.J.S.A.
DMV
Section
Event
Number Event
Identifier(s)
If applicableDescription
If applicable Points
39:4-50
Operating a motor vehicle under the
influence of alcohol or drugs
0450; 3261 9
39:4-50.4 Refusal to submit to a chemical test
4504
9
2C:11-2
Vehicular homicide
C115
9
39:3-40
Operating a motor vehicle while driving
a through privilege is suspended
0340
9
h and j
39:6B-2
Operating a motor vehicle without liability insurance06B2 9
39:6A-15 Misrepresentation of insurance coverage
6A15
9
Each at fault accident
5
*For each full year of a court imposed driver’s license suspension
within the preceding 3 years
3
*For each full year within the immediately preceding 3 years that
a person has not held a driver’s license
1
Involved in a fatal accident
EFTL
4
NFTL
2
39:3-37
Obtaining a driver’s license or registration
through deception
0337; 0312; 05D5;
1312; MSNJ;
MSOS
5
39:3-38
Make or use counterfeit plate or plates
other than issued
0338
5
39:3-38.1 Make, alter or counterfeit driver’s license
or registration
3381
5
Failure to verify insurance involved in an
automobile accident
FVIA
2
* Points for failure to hold a driver’s license in the previous three years are not
cumulative to points for driver’s license suspension.
11:3-34.5
APPENDIX B - REGULATIONS
Schedule 2
N.J.S.A.
Section
Number
27:23-29
Offense
Moving against traffic-New Jersey Turnpike, Garden
State Parkway, and Atlantic City Expressway
27:23-29 Improper passing-New Jersey Turnpike, Garden State
Parkway, and Atlantic City Expressway
27:23-29 Unlawful use of median strip-New Jersey Turnpike,
Garden State Parkway, and Atlantic City Expressway
39:3-20
Operating constructor vehicle in excess of 30 mph
39:4-14.3 Operating motorized bicycle on a restricted highway
39:4-14.3d More than one person on a motorized bike
39:4-35
Failure to yield to pedestrian in crosswalk
39:4-36
Failure to yield to pedestrian in crosswalk; passing a
vehicle yielding to pedestrian in crosswalk
39:4-41
Driving through a safety zone
39:4-52 &
39:5C-1
Racing on highway
39:4-55
Improper action or omission on grades and curves
39:4-57
Failure to observe direction of officer
39:4-66
Failure to stop vehicle before crossing sidewalk
39:4-66.1 Failure to yield to pedestrians or vehicles while entering
or leaving highway
39:4-71
Operating a motor vehicle on a sidewalk
39:4-80
Failure to obey direction of officer
39:4-81
Failure to observe traffic signals
39:4-82
Failure to keep right
39:4-82.1 Improper operating of vehicle on divided highway or
divider
39:4-83
Failure to keep right at intersection
39:4-84
Failure to pass to right of vehicle proceeding in opposite
direction
39:4-85
Improper passing on right or off roadway
39:4-85.1 Wrong way on a one-way street
39:4-86
Improper passing in no passing zone
39:4-87
Failure to yield to overtaking vehicle
39:4-88
Failure to observe traffic lanes
39:4-89
Tailgating
39:4-90
Failure to yield at intersection
39:4-90.1 Failure to use proper entrances to limited access highways
39:4-91 &
39:4-92
Failure to yield to emergency vehicles
39:4-96
Reckless driving
39:4-97
Careless driving
39:4-97a Destruction of agricultural or recreational property
39:4-97.1 Slow speed blocking traffic
39:4-98 &
39:4-99
Exceeding maximum speed 1-14 mph over limit
Exceeding maximum speed 15-29 mph over limit
Exceeding maximum speed 30 mph or more over limit
Points
2
4
2
3
2
2
2
2
2
5
2
2
2
2
2
2
2
2
2
2
5
4
2
4
2
2
5
2
2
2
5
2
2
2
2
4
5
BENEFIT DETERMINATION: PIP - HEALTH
39:4-105
39:4-115
39:4-119
39:4-122
39:4-123
39:4-124
39:4-125
39:4-126
39:4-127
39:4-127.1
39:4-127.2
39:4-128
Failure to stop for traffic light
Improper turn at traffic light
Failure to stop at flashing red signal
Failure to stop for police whistle
Improper right or left turn
Improper turn from approved turning course
Improper “U” turn
Failure to give proper signal
Improper backing or turning in street
Improper crossing of railroad grade crossing
Improper crossing of bridge
Improper crossing of railroad grade crossing by certain
vehicles
39:4-128.1 Improper passing of school bus
39:4-128.4 Improper passing of a frozen -dessert truck
39:4-129 Leaving the scene of an accident
No personal injury
Personal injury
39:4-144 Failure to observe “stop” or “yield” signs
39:5D-4 Moving violation out-of-state
11:3-37.2
2
3
2
2
3
3
3
2
2
2
2
2
5
4
2
8
2
2
Amended. R. 1996 d. 58, effective February 5, 1996; R.2007 d.373, effective December 3, 2007.
SUBCHAPTER 37. ORDER OF BENEFIT DETERMINATION BETWEEN
AUTOMOBILE PERSONAL INJURY PROTECTION AND HEALTH
INSURANCE
Section
11:3-37.1. Purpose and scope.
11:3-37.2. Definitions.
11:3-37.3. Health benefits providers.
11:3-37.4. Application of the PIP-as-secondary coverage option.
11:3-37.5. Health benefit plan standards and the PIP premium reduction.
11:3-37.6. Order of benefits determination when PIP is secondary coverage.
11:3-37.7. Determination of PIP medical benefits payable when PIP is
secondary coverage.
11:3-37.8. Health benefits plan coverage ineligibility.
11:3-37.9. Determination of benefits when PIP is primary coverage.
11:3-37.10. Explanation of benefits.
11:3-37.11. Dispute as to primacy of coverage.
11:3-37.12. Eligibility under two or more automobile policies.
11:3-37.13. Penalties.
11:3-37.14. Severability.
11:3-37.1. Purpose and scope. The purpose of this subchapter is to establish
guidelines for the order of benefit determination between a plan of health insurance and personal injury protection provided through an automobile policy pursuant to N.J.S.A. 39:6A-4, when a named insured elects to have his or her personal
injury protection become secondary coverage for the provision of benefits for
medical expenses incurred due to injuries sustained in an automobile accident.
This subchapter also sets forth the requirements for the order of benefit determination between a plan of health insurance and personal injury protection provided
pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, when personal injury protection is primary coverage. The provisions of this subchapter shall apply to all automobile
11:3-37.2
APPENDIX B - REGULATIONS
policies, as that term is defined at N.J.S.A. 39:6A-2a, issued to New Jersey residents, or renewed on or after January 1. 1991, and to all health benefits plans
which have been or will be delivered or issued for delivery in this State.
Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).
11:3-37.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates
otherwise.
“Actual benefits” means those benefits determined to be payable for allowable
expenses.
“Allowable expense” means a medically necessary, reasonable and customary
item of expense covered by an insured's health benefits plan(s) or PIP plan as an
eligible expense, at least in part. When a plan provides benefits in the form of services, the reasonable monetary value of each such service shall be considered as
both an allowable expense and a paid benefit.
“Benefits” means the provision of the following in consideration of payment of
premiums or fees on a prepaid or postpaid basis:
1. Services, including supplies;
2. Payment of expenses incurred;
3. A combination of 1 and 2 above; or
4. An indemnification.
“Eligible expense” means:
1. In the case of health benefits plans, that portion of the medical expenses incurred for treatment of an injury which is covered under the terms and conditions
of the plan, without application of the deductible(s) and copayment(s), if any.
2. In the case of PIP plans, that portion of the medical expenses incurred for
treatment of an injury which, without considering any deductible and copayment,
shall not exceed:
i. The percent or dollar amounts specified on the medical fee schedules, or the
actual billed expense, whichever is less; or
ii. The reasonable amount, as determined by the automobile insurer, considering the medical fee schedules for similar services or equipment in the region
where the service or equipment was provided, when an incurred medical expense
is not included on the medical fee schedules.
“Health benefits provider” means any person, whether subject to the regulation
of the New Jersey Department of Banking and Insurance, Department of Health
and Senior Services, or both, or not otherwise subject to such regulation, who contracts to provide health services, provide reimbursement for the cost of health services in whole or in part, or to provide for indemnity in the event health services
are used, in return for a prepaid or postpaid premium or fee or other consideration,
including, but not limited to:
1. Insurers, as defined at N.J.S.A. 17B:17-2;
2. Hospital service corporations, as defined at N.J.S.A. 17:48-1;
3. Medical service corporations, as defined at N.J.S.A. 17:48A-1;
4. Health service corporations, as defined at N.J.S.A. 17:48E-1;
5. Health maintenance organizations, as defined at N.J.S.A. 26:2J-2;
6. Dental service corporations, as defined at N.J.S.A. 17:48C-2;
7. Dental plan organizations, as defined at N.J.S.A. 17:48D-2;
8. Medicare;
9. Medicaid;
10. State Employees Health Benefits Plan;
11. CHAMPUS;
12. Self-insured programs; and
BENEFIT DETERMINATION: PIP - HEALTH
11:3-37.2
13. An entity organized under the laws of any other state or jurisdiction which
delivers certificates to residents of New Jersey evidencing coverage under a contract issued and delivered in a state or jurisdiction other than New Jersey.
“Hospital expenses,” when used by the automobile insurance PIP plan, means
those expenses defined at N.J.S.A. 39:6A-2f.
“Injury” means bodily injury sustained by an insured as a result of an accident
while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an object propelled by or from an automobile.
“Insured” means a person eligible for coverage, at least in part, for medical expenses incurred for treatment of injuries, under an automobile policy PIP medical
expense provision, and who meets the definition of a named insured or family
member.
1. Named insured means the person or persons identified as the insured in the
automobile policy and if an individual, that person's spouse, if the spouse is a resident of the same household, except that if the spouse ceases to be a resident of the
household of the named insured, coverage for that spouse shall continue until the
expiration of full term of any policy period in effect at the time of the cessation of
residency.
2. Family member means any relative of the named insured or the named insured's spouse who:
i. Is related to the named insured or named insured's spouse by blood, marriage,
adoption or guardianship;
ii. Resides in the household of the named insured or spouse of the named insured; and
iii. Is not a named insured under another automobile policy.
“Medical expenses” is as defined in N.J.A.C. 11:3-4.2.
“Medical fee schedule” means that list of services, procedures and supplies to
which have been assigned a maximum fee or percentage of a fee payable by an
automobile insurer for expenses incurred as a result of the rendering to an insured
any of those specific services, procedures or supplies for injuries, which list is set
forth at N.J.A.C. 11:3-29.
“Out-of-State automobile insurance coverage” or “OSAIC” means any coverage for medical expenses under an automobile insurance policy other than PIP, as
PIP is defined herein, including automobile insurance policies issued in another
state or jurisdiction.
“PIP” means personal injury protection coverage provided as part of an automobile insurance policy pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, issued in
New Jersey, specifically those provisions for medical expenses coverage.
“Plan” means any policy, contract, certificate, booklet, evidence of enrollment,
program, or other such term which evidences the existence of a relationship between a health benefits provider or PIP carrier and an insured with respect to the
provisions of hospital, medical, surgical, dental and/or other health care related
benefits, at least in part.
“Primary coverage” means coverage by any plan which determines its actual
benefits payable on allowable expenses incurred by an insured for treatment of injuries without taking into consideration the existence of any coverage for which
the insured may be eligible provided secondary in accordance with this subchapter. There may be more than one plan providing the insured primary coverage.
11:3-37.3
APPENDIX B - REGULATIONS
“Secondary coverage” means coverage by any plan which determines its actual
benefits payable on all allowable expenses incurred by an insured for treatment of
injuries after all plans providing primary coverage have considered expenses incurred and paid actual benefits.
Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999); R. 2001 d.
44, effective February 5, 2001.
11:3-37.3. Health benefits providers. (a) Nothing in this subchapter shall be
construed as requiring any health benefits provider to offer, provide, or continue
coverage to or for any individual or group, except as may be set forth by other laws
of this State, or of the Federal government.
(b) Nothing in this subchapter shall be construed as requiring any health benefits provider to provide coverage for any treatment or service not otherwise covered under the terms of the applicable health benefits plan.
(c) No health benefits contract or policy delivered or issued for delivery in this
State, or renewed, continued or converted on or after January 1. 1991, shall contain any provision, rider, waiver of endorsement or other instrument which restricts, limits or excludes coverage, directly or indirectly, of services or expenses
otherwise eligible under the policy or contract on the grounds that such expenses
or services would be covered under an automobile policy PIP provision for which
the insured would be eligible had the named insured on the automobile policy not
selected the PIP-as-secondary coverage option.
(d) No health benefits contract or policy delivered or issued for delivery in this
State, or renewed, continued or converted on or after January 1. 1991, shall contain any provision, rider, waiver or endorsement, or other instrument which restricts, limits or excludes coverage, directly or indirectly, of services or expenses
otherwise eligible under the policy or contract on the grounds that:
1. Such expenses arise from an automobile-related injury;
2. Such expenses are covered or paid by PIP; or
3. Such expenses are covered or paid by OSAIC except for reductions in benefits when the health benefits contract provides secondary coverage as defined in
and permitted by this rule.
(e) A health benefits contract or policy may provide that it is always primary to
OSAIC, or may provide that it will determine its benefits as if it were secondary
to any OSAIC. If the health benefits contract or policy provides that it will determine its benefits as if it were secondary to OSAIC and the OSAIC either contains
a provision that it is always excess or secondary, or refuses to cooperate in determining the amount of benefits payable by the health benefits plan as secondary
coverage provider, the health benefits plan shall provide primary coverage.
11:3-37.4. Application of the PIP-as-secondary coverage option. (a) When
a named insured elects the PIP option, whereby the named insured intends that
medical expenses incurred for treatment of an injury are to be covered by a health
benefits provider or providers, as evidenced on the Coverage Selection Form, then
the medical expense provisions of the PIP coverage shall be considered to be secondary coverage for the purposes of the order of benefit determination, and all
health benefits plans of an insured subject to the PIP option elected shall be considered to be primary coverage.
(b) The election by the named insured to make PIP medical expense provisions
secondary coverage shall apply to only the named insured and family members of
the named insured who reside in the named insured’s household and are not named
insureds under other automobile policies.
(c) The election by the named insured to make PIP medical expense provisions
secondary coverage shall continue in force as to subsequent renewal or replace-
BENEFIT DETERMINATION: PIP - HEALTH
11:3-37.5
ment policies until the automobile policy insurer or its authorized representative
receives a properly executed written request revoking the selection of this option.
(d) In the event that an insured is ineligible for health plan coverage of medical
expenses, or is eligible for coverage under a dental expense or dental service plan
only when an injury occurs, despite the selection of the PIP-as-secondary coverage option by the named insured, benefits shall be provided to the insured through
PIP coverage in accordance with N.J.A.C. 11:3-37.8.
11:3-37.5. Health benefit plan standards and the PIP premium reduction.
(a) An automobile insurer may eliminate the premium reduction on the base rate
applicable to the amount of medical expense benefit chosen in conjunction with
the PIP-as-secondary coverage option election if the automobile insurer complies
with (b) below, and verifies that the coverage specified by the named insured:
1. Excludes the provision of benefits for treatment of injuries of an eligible insured when expenses incurred in relation to treatment of those injuRes are eligible
expenses under an automobile policy’s PIP provisions; or
2. Provides that it is always secondary, or otherwise will not be a primary provider of benefits;
3. Provides benefits only for dental expenses or dental services; or
4. Provides benefits only for prescription drugs.
(b) An automobile carrier shall notify a named insured if the automobile insurer
determines that the health benefits plan(s) specified by the named insured contain
exclusionary or restrictive coverage provisions as set forth in (a) above, or if the
automobile insurer determines that one or more of the insureds covered under the
automobile insurance policy is not provided coverage by at least one of the health
benefit plan(s) specified by the named insured, and, therefore, the named insured’s
premium reduction for PIP medical expense benefits will be eliminated.
1. The notice shall be in writing and shall specify the reasons why the automobile insurer believes the named insured’s health plan coverage is not in compliance
with this subchapter.
2. The automobile insurer may include in the notice a demand for payment of
the premium reduction difference with an explanation that failure to pay the indicated premium reduction difference may result in early cancellation of the automobile policy in accordance with (c) below.
3. The notice shall be sent no later than 30 days prior to the date of cancellation
as calculated in accordance with (c) below. A notice which is sent 30 days prior to
the date of cancellation shall either contain a statement that it is a notice of cancellation, or be attached to a notice of cancellation, setting forth the effective date
of cancellation.
(c) The effective date of the cancellation of a policy for nonpayment of premium shall not be earlier than 10 days prior to the last full day of which premium
received by the company, prior to the date of preparation of the cancellation notice, would pay for coverage on a pro rata basis. In calculating the effective date
of the cancellation, the premium applicable to the coverage provided by the policy
and the premium received by the company at or prior to the time the cancellation
notice was prepared shall be the premium used for the calculation and determination of such effective date.
1. No cancellation in accordance with (c) above shall be effective unless prior
thereto, the automobile insurer shall have notified the named insured that the premium reduction difference had to be paid to avoid cancellation, as specified in
(b)2 above.
2. No cancellation notice shall be mailed prior to 30 days in advance of its effective date.
(d) If the insured provides payment of the full premium amount and subsequently provides proof that coverage is not restricted in the manner set forth in ac-
11:3-37.6
APPENDIX B - REGULATIONS
cordance with (a) above, or that all insureds under the automobile policy were provided coverage by a health benefits plan at the time notification of noncoverage
was sent, and that such coverage continues and is not restricted in the manner set
forth in accordance with (a) above, the automobile insurer shall refund the monies
paid in excess of the full reduction, or shall credit any excess paid on the reduced
premium to the extent any premium payment is still unpaid on the policy.
11:3-37.6. Order of benefits determination when PIP is secondary coverage. (a) When the named insured of an automobile policy has selected the PIP-assecondary coverage option, all health benefits plans for which the insured is eligible shall provide coverage for the allowable expenses incurred by the insured due
to an automobile-related injury prior to any benefits for medical expenses being
paid by a PIP plan.
(b) If the insured is eligible for coverage under more than one group health benefits plan, the group health benefits plans shall coordinate benefits with one another in accordance with the rules set forth for such plans at N.J.A.C. 11:4-28.
(c) The PIP plan shall provide benefits for allowable expenses remaining uncovered after all health benefits plans for which the insured is eligible have paid
benefits towards those allowable expenses.
(d) The PIP plan shall continue to be liable for expenses related to the same occurrence as the expenses are incurred, whether or not the health benefits plan(s) in
force at the time of the accident terminate(s) coverage, or benefits provided under
the health benefits plan(s) are exhausted subsequent to the occurrence of the accident, up to the maximum PIP benefits available to the insured under the terms of
the automobile policy.
(e) Total benefits paid by an insured’s health benefits and PIP plans shall not
exceed the amount of total allowable expenses.
11:3-37.7. Determination of PIP medical benefits payable when PIP is secondary coverage. (a) In calculating the actual benefits to be paid by the automobile insurer when the PIP-as-secondary coverage option has been selected, the automobile insurer shall first determine the amount of eligible expenses which
would have been paid after application of the deductible and copayment limitations had the PIP-as-secondary coverage option not been selected.
1. In the event the remaining allowable expenses are less than the benefits calculated pursuant to (a) above, the automobile insurer shall pay actual benefits
equal to the remaining allowable expenses, without reducing the remaining allowable expenses by its deductible or copayments.
2. In the event the remaining allowable expenses are greater than the benefits
calculated pursuant to (a) above, the actual benefits paid by the automobile insurer
shall be the benefits calculated pursuant to (a) above, without reducing the remaining allowable expenses by its deductible or copayments.
(b) In paying actual benefits, the automobile insurer shall not:
1. Reduce its actual benefits payable on account of any deductibles or copayments of the health benefits plans which have provided benefits ahead of the PIP
plan due to the selection of the PIP-as-secondary coverage option: or
2. Reduce its actual benefits payable for any allowable expense remaining uncovered which item of expense otherwise would not be an eligible expense under
the PIP plan, except as set forth by (c) below.
(c) In determining remaining uncovered allowable expenses, the automobile
insurer shall not consider any amount for items of expense which exceed the dollar
or percent amounts recognized by the medical fee schedules promulgated pursuant to N.J.S.A. 39:6A-4.6.
BENEFIT DETERMINATION: PIP - HEALTH
11:3-37.9
(d) The total amount of benefits to be provided through the PIP medical expense provisions for each insured per accident or occurrence shall not exceed the
maximum PIP benefits as provided for by the terms of the policy.
11:3-37.8. Health benefits plan coverage ineligibility. (a) When, subsequent
to the selection of the PIP-as-secondary coverage option by a named insured, it is
determined that an insured did not have health coverage in effect at the time of an
injury, or had health coverage in effect at the time of any injury which is such that
the PIP-as-secondary coverage option selection could have been invalidated by
the automobile insurer and elimination of the premium reduction amount effected
in accordance with N.J.A.C. 11:3-37.5(a), but was not, then the insured shall be
provided benefits for incurred medical expenses through the PIP medical expense
provision.
1. Benefits payable shall be subject to a per accident deductible equalling the
total of $750.00 plus the PIP deductible selected by the named insured of the policy.
2. Benefits payable shall be subject to a 20 percent copayment for amounts less
than $5,000 after the deductible has been satisfied.
3. Determination of the amount of benefits payable shall be made in accordance
with medical fee schedules promulgated pursuant to N.J.S.A. 39:6A-4.6 and set
forth at N.J.A.C. 11:3-29, or on a reasonable basis, as determined by the automobile insurer, considering the medical fee schedules for similar services or equipment in the region where the service or equipment was provided, when an item of
expense is not included on the medical fee schedules.
4. Total benefits paid for each insured eligible for benefits in any one accident
shall not exceed the maximum PIP benefits provided for by the terms of the policy.
(b) All items of medical expense incurred by the insured for treatment of an injury shall be eligible expense to the extent the treatment or procedure from which
the expenses arose is recognized on the medical fee schedules, or are reasonable
medical expenses in accordance with N.J.S.A. 39:6A-4.
(c) The automobile insurer shall be entitled to recover, for the contract period
in which the automobile-related injury occurred, the difference between the reduced premiums paid on the policy and the amount of premium which would have
been due on the policy had the named insured not selected the PIP-as-secondary
coverage option, and no premium reduction shall be provided on that policy for
the PIP-as-secondary coverage option during the remainder of that current contract period.
11:3-37.9. Determination of benefits when PIP is primary coverage. (a)
When no election has been made by a named insured to make his or her health
benefits plan(s) primary coverage provider(s), so that the PIP plan will provide
primary coverage for medical expenses incurred for treatment of injuries, the PIP
plan shall provide benefits to the insured without consideration of any benefits for
which the insured may be eligible under any health benefits plan.
(b) Actual benefits paid by the PIP plan shall be medical expenses, subject to
the policy limits and supplication of any deductible and copayment provided for
by the terms of the automobile policy, approved by the Commissioner pursuant to
N.J.S.A. 39:6A-4 or 39:6A-3.1, and any rules promulgated thereunder.
(c) Actual benefits payable by a health benefits plan, when the PIP plan is providing primary coverage for medical expenses incurred for treatment of injuries,
shall be the lesser of the remaining uncovered allowable expenses or the actual
benefits that would have been payable had the health benefits plan been providing
coverage primary to the PIP plan.
1. Actual benefits payable may be reduced by the deductible(s) and copayment
requirements applicable by the terms of the health benefits plan, and shall not ex-
11:3-37.10
APPENDIX B - REGULATIONS
ceed the amount of actual benefits that would have been payable had the health
benefits plan been providing coverage primary to the PIP plan.
2. Allowable expenses remaining uncovered, which the health benefits plan(s)
shall consider when the PIP plan is providing primary coverage, include:
i. Any PIP deductible(s);
ii. Any PIP copayment amounts;
iii. Any expenses which exceed the medical expense coverage limits of the PIP
plan per person per accident, as set forth by the terms of the automobile policy;
and
iv. Any expenses not covered by the PIP plan when such expense was determined to be in excess of the reasonable charge for an item of expense not listed on
the medical fee schedules, but for which the automobile insurer determined a reasonable charge based on the medical fee schedule for a similar item of expense in
the region where the service or equipment was provided.
(d) When a health benefits plan provides hospital expense or service benefits
only, or medical expense or service benefits only, and is not otherwise a part of a
basic health benefits package, all allowable expenses remaining uncovered shall
be considered by that health benefits plan for the provision of benefits, without regard as to whether the expenses are hospital-related or medical-related expenses.
Actual benefits paid by that health benefits plan for the allowable expenses remaining uncovered shall not exceed the total actual benefits which would have
been payable had the health benefits plan been providing coverage primary to the
PIP plan.
(e) When there is one health benefits plan providing insureds hospital expense
or service benefits and another health benefits plan providing insureds medical expense or service benefits as two separate parts of one basic health benefits plan
package, the hospital benefits plan and the medical benefits plan shall both consider all allowable expenses remaining uncovered and shall apportion such allowable expenses between the two plans on a pro-rata basis without regard as to
whether the expenses are hospital-related or medical-related expenses. Actual
benefits paid by each plan of the health benefits plan package shall not exceed the
total actual benefits which would have been payable by each plan had the health
benefits plan package been providing primary coverage.
(f) No insured shall be liable to a health care provider for any fees for services
or supplies which exceed the dollar or percentage amounts recognized for those
services or supplies on the medical fee schedules.
(g) No health benefits plan shall seek repayment from or withhold payment to
an insured for amounts paid to the insured in consideration of charges which were
in excess of the amounts set forth in the medical fee schedules.
(h) If there is more than one group health benefits plan providing secondary
coverage to an insured, these plans may coordinate their benefits with one another
in accordance with N.J.A.C. 11:4-28.
Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).
11:3-37.10. Explanation of benefits. (a) Automobile insurers shall develop
and utilize an explanation of benefits form to be provided with the payment of
benefits for expenses incurred for treatment of injuries which clearly identifies
and explains the following:
1. Each procedure for which a claim has been made;
2. Eligible expense related to each procedure with an indication of whether the
eligible expense is based on the medical fee schedules or is the reasonable charge
as determined by the automobile insurer;
3. Actual benefits paid;
4. Any deductible or copayment applied;
BENEFIT DETERMINATION: PIP - HEALTH
11:3-37.12
5. A concise explanation why any item of expense is considered an ineligible
expense, when this occurs; and
6. A statement to insureds that no health care provider may demand or request
any payment from any person in excess of those permitted by N.J.A.C. 11:3-29,
and that no person is liable to any health care provider for any amount of money
which results from the charging of fees in excess of those permitted by N.J.A.C.
11:3-29, pursuant to N.J.S.A. 39:6A-4.6.
Amended by R. 1994 d. 564, effective November 21, 1994 (operative January 1, 1995).
11:3-37.11. Dispute as to primacy of coverage. (a) If, subsequent to the selection of the PIP-as-secondary coverage option by the named insured, injuries are
sustained by an insured eligible for health benefits plan coverage, but a dispute exists between the health benefits provider and the automobile insurer, then the
health benefits provider shall provide benefit as if it were the primary coverage
provider and no PIP benefits were available to the insured. In no event shall the
provision of benefits be unreasonably delayed by either a health benefits provider
or an automobile insurer.
(b) If the health benefits provider asserts that it is not subject to N.J.A.C. 11:337.3, and thus, will not act as the primary coverage provider then the automobile
insurer shall assume the role of primary coverage provider, and provide its benefits in accordance with N.J.A.C. 11:3-37.8. The automobile insurer shall be entitled to recover premium reductions in accordance with N.J.A.C. 11:3-37.8(c).
11:3-37.12. Eligibility under two or more automobile policies. (a) If an insured is eligible for coverage of medical expenses under more than one automobile policy, the determination as to which automobile policy will assume coverage
responsibility for that insured shall be as follows:
1. A named insured shall receive benefits for medical expenses under the terms
of the automobile policy on which he or she, or his or her spouse, is identified as
the named insured.
2. A family member who is a child of a named insured or the named insured’s
spouse shall receive benefits for medical expenses under the automobile policy of
the named insured, subject to the following:
i. If the child is a child of more than one named insured or of more than one
spouse of a named insured, the child shall receive benefits under the terms of the
automobile policy of the named insured who has legal custody of that child or
whose spouse has legal custody of that child.
ii. If the child is a child of more than one named insured or of more than one
named insured’s spouse, and legal custody of that child has either never been
awarded, or has been awarded jointly, then the child shall receive benefits under
the terms of the automobile policy of the named insured whose birthday occurs
earliest in the calendar year.
iii. If the child is a named insured or the spouse of a named insured, (a)1 above
shall apply.
3. If neither (a)1 nor (a)2 above apply to an adult or child family member, then
that family member shall receive benefits for medical expenses under the terms of
the automobile policy of the named insured whose birthday occurs earliest in the
calendar year.
4. If an automobile policy identifies more than one person as a named insured
on the automobile policy, the birthday of the named insured whose birthday occurs
earliest in the calendar year shall be considered the determinant birthday on that
automobile policy.
(b) An insured shall not receive benefits for medical expenses under more than
one automobile policy.
11:3-37.13
APPENDIX B - REGULATIONS
(c) If an automobile policy PIP plan provides benefits for medical expenses for
an insured who is eligible for medical expense benefits under more than one automobile policy PIP plan, the automobile insurer of the paying PIP plan may seek
equitable pro rata contributions from the other automobile policy PIP plan(s) for
the benefits actually paid by the paying PIP plan.
11:3-37.13. Penalties. Each automobile policy or health benefits plan subject
to the terms of this subchapter which fails to comply with the terms herein shall
be in violation of this subchapter. Failure to comply with the terms of this subchapter may result in the assessment of any and all penalties in accordance with
the laws of this State.
11:3-37.14. Severability. If any provision of this subchapter or application
thereof to any person or circumstance is held invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances
shall not be affected thereby.