2 0 1 1 M E D I C A R E F E E S C H E D U L E Attached is a report of the 2011 Medicare Fees for your locality. The fee schedule amounts and the codes that have been added for 2011 are effective for services performed on or after January 1 2011. The Medicare Fees report is formatted in three columns and reads from left to right. The 2011 Medicare Fees report includes the following information: PROC/MOD CPT or HCPCS code along with -TC (Technical componnt) -26 (Professional component) or -53 (Discontinued procedure) modifiers when applicable. NOTE: "F" - Facility Fee. These amounts apply when the service is performed in a facility setting: Inpatient Hospital (Place of Service (POS) 21) Outpatient Hospital (POS 22) Emergency Room of Hospital(POS 23) Ambulatory Surgical Center (POS 24 - Note: ASC is only treated as a facility setting when an ASC list procedure is performed in an ASC) Military Treatment Facility (POS 26) Skilled Nursing Facility (POS 31) Hospice (POS 34) Ambulance via Land (POS 41) Ambulance via Air or Water (POS 42) Inpatient Psychiatric Facility (POS 51) Psychiatric Facility Partial Hospitalization (POS 52) Community Mental Health Center (POS 53) Psychiatric Residential Treatment Facility (POS 56) and Comprehensive Inpatient Rehabilitation Facility (POS 61). "N" - Non-Facility Fee. These amounts apply when the service is performed in a place of service setting other than listed in the "F" - Facility Fee description above. "C" - The payment for the Technical Component is capped at the OPPS amount. 2011 NOTE: Medicare is applying a new Multiple Procedure Payment Reduction (MPPR) to the practice expense (PE) payment of select therapy services paid under the physician fee schedule. The reduction will be similar to that currently applied to multiple surgical procedures and to diagnostic imaging procedures. The MPPR services are: 92506, 92507, 92508, 92526, 92597, 92607, 92609, 96125, 97001, 97002, 97003, 97004, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762, G0281, G0283 and G0329. To find these fee rates, go to our website: < www.trailblazerhealth.com/tools/fee schedule/medicarefeeschedule.aspx > PAR FEE: Allowed amount for participating physicians. NPAR FEE: Allowed amount for non-participating physicians. LC FEE: The maximum limiting charge amount that can be charged for that service on a non- assigned claim. Anesthesia Note: A new line with "ANSCF" has been added to the fee report. The dollar values represent the 2011 anesthesia conversion factor for the locality. Please note the ANSCF is not a valid procedure code. Providers are required to bill with the CPT-4 code range 00100 to 01999 for anesthesia services. Drug Fees Note: The Drug and Biological Fees are not included in the Medicare Fee Schedule locality reports. Please visit our Web page: www.TrailBlazerHealth.com to obtain the 2011 fees as they become available. Payable Note: A fee schedule amount has been given for each procedure code listed in the Medicare Fee Schedule Data Base. However based on Medicare policy the specific procedure may not be payable by the Medicare program. Visit us on the Web at www.TrailBlazerHealth.com.

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 001 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ANSCF 11 20.23 19.22 22.10 A9500 N 11 188.00 178.60 205.39 A9502 N 11 200.00 190.00 218.50 A9503 N 11 19.31 18.34 21.09 A9505 N 11 34.20 32.49 37.36 A9508 N 11 402.79 382.65 440.05 A9510 N 11 39.90 37.91 43.60 A9512 N 11 3.93 3.73 04.29 A9516 N 11 28.32 26.90 30.94 A9517 N 11 21.00 19.95 22.94 A9521 N 11 567.61 539.23 620.11 A9524 N 11 61.75 58.66 67.46 A9526 N 11 143.00 135.85 156.23 A9528 N 11 46.79 44.45 51.12 A9529 N 11 109.00 103.55 119.08 A9530 N 11 9.66 9.18 10.56 A9531 N 11 9.59 9.11 10.48 A9532 N 11 282.00 267.90 308.09 A9537 N 11 40.00 38.00 43.70 A9538 N 11 40.81 38.77 44.59 A9539 N 11 13.68 13.00 14.95 A9540 N 11 20.00 19.00 21.85 A9541 N 11 48.74 46.30 53.25 A9542 N 11 2769.63 2631.15 3025.82 A9544 N 11 1279.00 1215.05 1397.31 A9545 N 11 22896.90 21752.06 25014.87 A9546 N 11 235.83 224.04 257.65 A9548 N 11 320.39 304.37 350.03 A9551 N 11 124.50 118.28 136.02 A9552 N 11 195.00 185.25 213.04 A9553 N 11 257.18 244.32 280.97 A9554 N 11 640.40 608.38 699.64 A9555 N 11 260.00 247.00 284.05 A9557 N 11 424.18 402.97 463.42 A9558 N 11 42.16 40.05 46.06 A9559 N 11 88.59 84.16 96.78 A9561 N 11 34.00 32.30 37.15 A9562 N 11 279.00 265.05 304.81 A9563 N 11 46.57 44.24 50.88 A9564 N 11 158.88 150.94 173.58 A9568 N 11 1235.00 1173.25 1349.24 G0101 N 11 34.87 33.13 38.10 G0101 F 11 26.05 24.75 28.46 G0102 N 11 18.29 17.38 19.99 G0102 F 11 8.52 8.09 09.30 G0104 N 11 128.72 122.28 140.62 G0104 F 11 59.75 56.76 65.27 G0105 N 11 370.95 352.40 405.26 G0105 F 11 208.75 198.31 228.06 G0105 53 N 11 128.72 122.28 140.62 G0105 53 F 11 59.75 56.76 65.27 G0106 11 199.27 189.31 217.71 G0106 TC 11 152.04 144.44 166.11 G0106 26 11 47.23 44.87 51.60 G0108 11 52.51 49.88 57.36 G0109 11 17.86 16.97 19.52 G0117 11 46.52 44.19 50.82 G0118 11 31.83 30.24 34.78 G0120 C11 126.52 120.19 138.22 G0120 TC C11 79.28 75.32 86.62 G0120 26 11 47.23 44.87 51.60 G0121 N 11 370.95 352.40 405.26 G0121 F 11 208.75 198.31 228.06 G0121 53 N 11 128.72 122.28 140.62 G0121 53 F 11 59.75 56.76 65.27 G0124 11 27.55 26.17 30.10 G0127 N 11 20.18 19.17 22.05 G0127 F 11 7.89 7.50 08.63 G0128 11 8.93 8.48 09.75 G0130 11 31.24 29.68 34.13 G0130 TC 11 20.70 19.67 22.62 G0130 26 11 10.54 10.01 11.51 G0141 11 27.55 26.17 30.10 G0166 11 141.96 134.86 155.09 G0168 N 11 80.86 76.82 88.34 G0168 F 11 24.79 23.55 27.08 G0179 11 38.34 36.42 41.88 G0180 11 50.45 47.93 55.12 G0181 11 100.11 95.10 109.37 G0182 11 101.37 96.30 110.75 G0202 11 131.38 124.81 143.53 G0202 TC 11 97.55 92.67 106.57 G0202 26 11 33.83 32.14 36.96 G0204 11 157.23 149.37 171.78 G0204 TC 11 115.50 109.73 126.19 G0204 26 11 41.72 39.63 45.57 G0206 11 124.45 118.23 135.96 G0206 TC 11 90.62 86.09 99.00 G0206 26 11 33.83 32.14 36.96 G0237 11 9.36 8.89 10.22 G0238 11 9.99 9.49 10.91 G0239 11 10.94 10.39 11.95 G0245 N 11 65.37 62.10 71.42 G0245 F 11 44.90 42.66 49.06 G0246 N 11 38.02 36.12 41.54 G0246 F 11 22.90 21.76 25.02 G0247 N 11 54.44 51.72 59.48 G0247 F 11 23.57 22.39 25.75 G0248 11 129.68 123.20 141.68 G0249 11 114.56 108.83 125.15 G0250 11 8.86 8.42 09.68 G0268 N 11 48.50 46.08 52.99 G0268 F 11 31.17 29.61 34.05 G0270 N 11 26.68 25.35 29.15 G0270 F 11 24.79 23.55 27.08 G0271 11 13.45 12.78 14.70 G0275 11 12.82 12.18 14.01 G0278 11 12.82 12.18 14.01 G0281 11 12.01 11.41 13.12 G0283 11 12.01 11.41 13.12 G0288 11 80.54 76.51 87.99 G0289 11 83.67 79.49 91.41 G0329 11 8.57 8.14 09.36 G0339 11 1917.41 1821.54 2094.77 G0340 11 1408.89 1338.45 1539.22 G0341 N 11 1176.83 1117.99 1285.69 G0341 F 11 368.96 350.51 403.09 G0342 11 649.03 616.58 709.07 G0343 11 1087.14 1032.78 1187.70 G0364 N 11 11.65 11.07 12.73 G0364 F 11 8.50 8.08 09.29 G0365 C11 153.97 146.27 168.21 G0365 TC C11 141.96 134.86 155.09 G0365 26 11 12.01 11.41 13.12 G0372 N 11 9.78 9.29 10.68 G0372 F 11 8.21 7.80 08.97 G0389 11 105.03 99.78 114.75 G0389 TC 11 76.76 72.92 83.86 G0389 26 11 28.26 26.85 30.88 G0396 N 11 31.82 30.23 34.76 G0396 F 11 30.24 28.73 33.04 G0397 N 11 65.21 61.95 71.24 G0397 F 11 63.63 60.45 69.52 G0398 11 154.99 147.24 169.33 G0398 TC 11 51.66 49.08 56.44 G0398 26 11 103.32 98.15 112.87 G0399 11 129.16 122.70 141.11 G0399 TC 11 36.17 34.36 39.51 G0399 26 11 87.83 83.44 95.96 G0400 11 103.32 98.15 112.87 G0400 TC 11 31.00 29.45 33.87 G0400 26 11 72.33 68.71 79.02 G0402 N 11 141.99 134.89 155.12 G0402 F 11 121.52 115.44 132.76 G0403 N 11 18.52 17.59 20.23 G0403 F 11 17.89 17.00 19.55 G0404 11 9.99 9.49 10.91 G0405 N 11 8.52 8.09 09.30 G0405 F 11 7.89 7.50 08.63 G0406 11 37.04 35.19 40.47 G0407 11 67.00 63.65 73.20 G0408 11 96.20 91.39 105.10 G0409 11 9.36 8.89 10.22 G0412 11 676.52 642.69 739.09 G0413 11 989.09 939.64 1080.59 G0414 11 940.91 893.86 1027.94 G0415 11 1290.26 1225.75 1409.61 G0416 11 547.41 520.04 598.05 G0416 TC 11 382.59 363.46 417.98 G0416 26 11 164.82 156.58 180.07 G0417 11 1063.39 1010.22 1161.75 G0417 TC 11 747.00 709.65 816.10 G0417 26 11 316.38 300.56 345.64 G0418 11 1825.99 1734.69 1994.89 G0418 TC 11 1275.82 1212.03 1393.83 G0418 26 11 550.17 522.66 601.06 G0419 11 2164.33 2056.11 2364.53 G0419 TC 11 1530.94 1454.39 1672.55 G0419 26 11 633.39 601.72 691.98 G0420 11 106.66 101.33 116.53 G0421 11 25.23 23.97 27.57 G0422 11 66.04 62.74 72.15 G0423 11 66.04 62.74 72.15 G0424 N 11 28.78 27.34 31.44 G0424 F 11 13.98 13.28 15.27 G0425 11 96.43 91.61 105.35 G0426 11 131.49 124.92 143.66 G0427 11 193.51 183.83 211.40 G0429 N 11 83.38 79.21 91.09 G0429 F 11 63.54 60.36 69.41 G0436 N 11 13.42 12.75 14.66 G0436 F 11 11.53 10.95 12.59 G0437 N 11 27.12 25.76 29.62 G0437 F 11 25.23 23.97 27.57 G0438 11 154.27 146.56 168.54 G0439 11 102.99 97.84 112.52 G0440 N 11 166.94 158.59 182.38 G0440 F 11 113.39 107.72 123.88 G0441 N 11 44.41 42.19 48.52 G0441 F 11 24.88 23.64 27.19 G9041 11 33.17 31.51 36.24 G9042 11 16.60 15.77 18.14 G9043 11 16.60 15.77 18.14 G9044 11 14.37 13.65 15.70 M0064 N 11 43.98 41.78 48.05 M0064 F 11 15.63 14.85 17.08 P3001 11 27.55 26.17 30.10 Q0035 11 17.26 16.40 18.86 Q0035 TC 11 9.36 8.89 10.22 Q0035 26 11 7.89 7.50 08.63 Q0091 N 11 40.97 38.92 44.76 Q0091 F 11 17.98 17.08 19.64 Q0092 11 18.81 17.87 20.55 R0070 11 239.64 227.66 261.81 R0075 11 239.64 227.66 261.81 0073T 11 481.80 457.71 526.37 0075T 11 1104.12 1048.91 1206.25 0075T TC 11 1030.49 978.97 1125.82 0075T 26 11 67.73 64.34 73.99 0171T 11 635.91 604.11 694.73 0172T 11 265.46 252.19 290.02 10021 N 11 133.21 126.55 145.53 10021 F 11 66.43 63.11 72.58 10022 N 11 128.55 122.12 140.44 10022 F 11 62.72 59.58 68.52 10040 N 11 95.29 90.53 104.11 10040 F 11 83.64 79.46 91.38 10060 N 11 102.77 97.63 112.27 10060 F 11 87.34 82.97 95.42 10061 N 11 171.66 163.08 187.54 10061 F 11 150.87 143.33 164.83 10080 N 11 155.62 147.84 170.02 10080 F 11 92.00 87.40 100.51 10081 N 11 240.40 228.38 262.64 10081 F 11 157.25 149.39 171.80 10120 N 11 126.12 119.81 137.78 10120 F 11 85.49 81.22 93.40 10121 N 11 244.81 232.57 267.46 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 002 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 10121 F 11 172.05 163.45 187.97 10140 N 11 144.86 137.62 158.26 10140 F 11 109.58 104.10 119.72 10160 N 11 117.30 111.44 128.16 10160 F 11 88.95 84.50 97.18 10180 N 11 218.54 207.61 238.75 10180 F 11 164.05 155.85 179.23 11000 N 11 49.24 46.78 53.80 11000 F 11 28.45 27.03 31.08 11001 N 11 20.01 19.01 21.86 11001 F 11 14.34 13.62 15.66 11004 11 552.71 525.07 603.83 11005 11 736.42 699.60 804.54 11006 11 673.87 640.18 736.21 11008 11 258.70 245.77 282.64 11010 N 11 440.32 418.30 481.05 11010 F 11 262.68 249.55 286.98 11011 N 11 482.78 458.64 527.44 11011 F 11 281.84 267.75 307.91 11012 N 11 648.48 616.06 708.47 11012 F 11 403.13 382.97 440.42 11042 N 11 81.43 77.36 88.96 11042 F 11 44.89 42.65 49.05 11043 N 11 178.78 169.84 195.32 11043 F 11 115.48 109.71 126.17 11044 N 11 273.06 259.41 298.32 11044 F 11 200.30 190.29 218.83 11045 N 11 28.87 27.43 31.54 11045 F 11 16.90 16.06 18.47 11046 N 11 50.46 47.94 55.13 11046 F 11 35.97 34.17 39.30 11047 N 11 82.95 78.80 90.62 11047 F 11 62.48 59.36 68.26 11055 N 11 45.22 42.96 49.40 11055 F 11 19.70 18.72 21.53 11056 N 11 54.39 51.67 59.42 11056 F 11 27.94 26.54 30.52 11057 N 11 64.52 61.29 70.48 11057 F 11 36.17 34.36 39.51 11100 N 11 95.86 91.07 104.73 11100 F 11 47.04 44.69 51.39 11101 N 11 30.82 29.28 33.67 11101 F 11 23.89 22.70 26.11 11200 N 11 78.56 74.63 85.82 11200 F 11 66.27 62.96 72.40 11201 N 11 17.69 16.81 19.33 11201 F 11 15.80 15.01 17.26 11300 N 11 63.33 60.16 69.18 11300 F 11 28.37 26.95 30.99 11301 N 11 86.19 81.88 94.16 11301 F 11 48.40 45.98 52.88 11302 N 11 103.12 97.96 112.65 11302 F 11 60.28 57.27 65.86 11303 N 11 121.51 115.43 132.74 11303 F 11 70.80 67.26 77.35 11305 N 11 63.90 60.71 69.82 11305 F 11 32.41 30.79 35.41 11306 N 11 88.43 84.01 96.61 11306 F 11 52.21 49.60 57.04 11307 N 11 104.60 99.37 114.28 11307 F 11 62.40 59.28 68.17 11308 N 11 116.30 110.49 127.06 11308 F 11 72.52 68.89 79.22 11310 N 11 78.42 74.50 85.68 11310 F 11 41.26 39.20 45.08 11311 N 11 99.02 94.07 108.18 11311 F 11 60.28 57.27 65.86 11312 N 11 115.11 109.35 125.75 11312 F 11 69.76 66.27 76.21 11313 N 11 143.03 135.88 156.26 11313 F 11 93.27 88.61 101.90 11400 N 11 109.54 104.06 119.67 11400 F 11 72.05 68.45 78.72 11401 N 11 134.03 127.33 146.43 11401 F 11 94.98 90.23 103.76 11402 N 11 149.23 141.77 163.04 11402 F 11 104.82 99.58 114.52 11403 N 11 171.63 163.05 187.51 11403 F 11 133.52 126.84 145.87 11404 N 11 195.09 185.34 213.14 11404 F 11 147.84 140.45 161.52 11406 N 11 278.18 264.27 303.91 11406 F 11 222.75 211.61 243.35 11420 N 11 109.54 104.06 119.67 11420 F 11 75.53 71.75 82.51 11421 N 11 142.21 135.10 155.37 11421 F 11 102.84 97.70 112.36 11422 N 11 158.44 150.52 173.10 11422 F 11 124.43 118.21 135.94 11423 N 11 183.66 174.48 200.65 11423 F 11 144.92 137.67 158.32 11424 N 11 211.09 200.54 230.62 11424 F 11 165.73 157.44 181.06 11426 N 11 302.24 287.13 330.20 11426 F 11 252.79 240.15 276.17 11440 N 11 120.58 114.55 131.73 11440 F 11 93.18 88.52 101.80 11441 N 11 151.94 144.34 165.99 11441 F 11 120.76 114.72 131.93 11442 N 11 171.32 162.75 187.16 11442 F 11 134.47 127.75 146.91 11443 N 11 204.39 194.17 223.30 11443 F 11 165.33 157.06 180.62 11444 N 11 257.25 244.39 281.05 11444 F 11 210.95 200.40 230.46 11446 N 11 354.55 336.82 387.34 11446 F 11 301.01 285.96 328.85 11450 N 11 333.04 316.39 363.85 11450 F 11 225.01 213.76 245.82 11451 N 11 425.84 404.55 465.23 11451 F 11 291.35 276.78 318.30 11462 N 11 326.95 310.60 357.19 11462 F 11 216.08 205.28 236.07 11463 N 11 434.83 413.09 475.05 11463 F 11 296.25 281.44 323.66 11470 N 11 364.68 346.45 398.42 11470 F 11 254.44 241.72 277.98 11471 N 11 451.46 428.89 493.22 11471 F 11 315.08 299.33 344.23 11600 N 11 170.60 162.07 186.38 11600 F 11 109.18 103.72 119.28 11601 N 11 207.79 197.40 227.01 11601 F 11 139.13 132.17 152.00 11602 N 11 227.24 215.88 248.26 11602 F 11 153.22 145.56 167.39 11603 N 11 258.46 245.54 282.37 11603 F 11 182.24 173.13 199.10 11604 N 11 286.17 271.86 312.64 11604 F 11 200.19 190.18 218.71 11606 N 11 405.43 385.16 442.93 11606 F 11 295.82 281.03 323.18 11620 N 11 173.78 165.09 189.85 11620 F 11 111.10 105.55 121.38 11621 N 11 209.39 198.92 228.76 11621 F 11 140.42 133.40 153.41 11622 N 11 235.83 224.04 257.65 11622 F 11 161.81 153.72 176.78 11623 N 11 275.89 262.10 301.42 11623 F 11 199.04 189.09 217.45 11624 N 11 309.90 294.41 338.57 11624 F 11 225.18 213.92 246.01 11626 N 11 374.24 355.53 408.86 11626 F 11 277.55 263.67 303.22 11640 N 11 180.46 171.44 197.16 11640 F 11 115.90 110.11 126.63 11641 N 11 218.58 207.65 238.80 11641 F 11 148.02 140.62 161.71 11642 N 11 250.67 238.14 273.86 11642 F 11 174.45 165.73 190.59 11643 N 11 295.44 280.67 322.77 11643 F 11 217.96 207.06 238.12 11644 N 11 363.96 345.76 397.62 11644 F 11 270.10 256.60 295.09 11646 N 11 476.95 453.10 521.07 11646 F 11 376.47 357.65 411.30 11719 N 11 19.86 18.87 21.70 11719 F 11 7.89 7.50 08.63 11720 N 11 28.88 27.44 31.56 11720 F 11 14.71 13.97 16.07 11721 N 11 39.73 37.74 43.40 11721 F 11 24.93 23.68 27.23 11730 N 11 88.96 84.51 97.19 11730 F 11 50.54 48.01 55.21 11732 N 11 40.75 38.71 44.52 11732 F 11 26.26 24.95 28.69 11740 N 11 42.86 40.72 46.83 11740 F 11 29.63 28.15 32.37 11750 N 11 200.82 190.78 219.40 11750 F 11 162.40 154.28 177.42 11752 N 11 289.08 274.63 315.82 11752 F 11 244.67 232.44 267.31 11755 N 11 122.29 116.18 133.61 11755 F 11 76.31 72.49 83.36 11760 N 11 196.74 186.90 214.94 11760 F 11 122.41 116.29 133.73 11762 N 11 249.95 237.45 273.07 11762 F 11 177.51 168.63 193.92 11765 N 11 125.18 118.92 136.76 11765 F 11 64.08 60.88 70.01 11770 N 11 243.65 231.47 266.19 11770 F 11 167.11 158.75 182.56 11771 N 11 505.42 480.15 552.17 11771 F 11 392.04 372.44 428.31 11772 N 11 606.08 575.78 662.15 11772 F 11 511.27 485.71 558.57 11900 N 11 52.02 49.42 56.83 11900 F 11 29.97 28.47 32.74 11901 N 11 65.91 62.61 72.00 11901 F 11 46.70 44.37 51.03 11920 N 11 162.56 154.43 177.59 11920 F 11 108.38 102.96 118.40 11921 N 11 187.40 178.03 204.73 11921 F 11 127.87 121.48 139.70 11922 N 11 56.27 53.46 61.48 11922 F 11 28.24 26.83 30.85 11950 N 11 66.10 62.80 72.22 11950 F 11 46.25 43.94 50.53 11951 N 11 93.15 88.49 101.76 11951 F 11 67.64 64.26 73.90 11952 N 11 120.84 114.80 132.02 11952 F 11 90.61 86.08 98.99 11954 N 11 149.26 141.80 163.07 11954 F 11 109.58 104.10 119.72 11960 11 842.42 800.30 920.35 11970 11 569.99 541.49 622.71 11971 N 11 427.77 406.38 467.34 11971 F 11 290.45 275.93 317.32 11976 N 11 135.35 128.58 147.87 11976 F 11 90.94 86.39 99.35 11980 N 11 97.42 92.55 106.43 11980 F 11 76.95 73.10 84.07 11981 N 11 125.36 119.09 136.95 11981 F 11 79.06 75.11 86.38 11982 N 11 140.28 133.27 153.26 11982 F 11 94.30 89.59 103.03 11983 N 11 210.18 199.67 229.62 11983 F 11 168.92 160.47 184.54 12001 N 11 89.37 84.90 97.64 12001 F 11 51.89 49.30 56.70 12002 N 11 105.11 99.85 114.83 12002 F 11 66.69 63.36 72.86 12004 N 11 124.95 118.70 136.51 12004 F 11 81.17 77.11 88.68 12005 N 11 161.07 153.02 175.97 12005 F 11 106.90 101.56 116.79 12006 N 11 194.49 184.77 212.49 12006 F 11 130.55 124.02 142.62 12007 N 11 226.78 215.44 247.76 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 003 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 12007 F 11 156.86 149.02 171.37 12011 N 11 107.14 101.78 117.05 12011 F 11 62.10 59.00 67.85 12013 N 11 115.30 109.54 125.97 12013 F 11 70.26 66.75 76.76 12014 N 11 136.75 129.91 149.40 12014 F 11 87.30 82.94 95.38 12015 N 11 167.71 159.32 183.22 12015 F 11 107.24 101.88 117.16 12016 N 11 209.89 199.40 229.31 12016 F 11 142.17 135.06 155.32 12017 11 163.02 154.87 178.10 12018 11 192.99 183.34 210.84 12020 N 11 248.64 236.21 271.64 12020 F 11 173.68 165.00 189.75 12021 N 11 148.13 140.72 161.83 12021 F 11 127.98 121.58 139.82 12031 N 11 224.77 213.53 245.56 12031 F 11 151.70 144.12 165.74 12032 N 11 282.95 268.80 309.12 12032 F 11 183.42 174.25 200.39 12034 N 11 282.39 268.27 308.51 12034 F 11 191.36 181.79 209.06 12035 N 11 341.94 324.84 373.57 12035 F 11 220.99 209.94 241.43 12036 N 11 373.75 355.06 408.32 12036 F 11 252.81 240.17 276.20 12037 N 11 418.97 398.02 457.72 12037 F 11 292.99 278.34 320.09 12041 N 11 234.91 223.16 256.63 12041 F 11 161.21 153.15 176.12 12042 N 11 269.18 255.72 294.08 12042 F 11 187.61 178.23 204.96 12044 N 11 318.35 302.43 347.79 12044 F 11 199.30 189.34 217.74 12045 N 11 341.29 324.23 372.86 12045 F 11 226.96 215.61 247.95 12046 N 11 403.96 383.76 441.32 12046 F 11 268.53 255.10 293.37 12047 N 11 438.68 416.75 479.26 12047 F 11 289.39 274.92 316.16 12051 N 11 248.53 236.10 271.52 12051 F 11 171.36 162.79 187.21 12052 N 11 283.78 269.59 310.03 12052 F 11 204.73 194.49 223.66 12053 N 11 313.12 297.46 342.08 12053 F 11 203.51 193.33 222.33 12054 N 11 332.05 315.45 362.77 12054 F 11 213.94 203.24 233.73 12055 N 11 399.07 379.12 435.99 12055 F 11 256.39 243.57 280.11 12056 N 11 477.82 453.93 522.02 12056 F 11 324.43 308.21 354.44 12057 N 11 544.97 517.72 595.38 12057 F 11 359.45 341.48 392.70 13100 N 11 290.44 275.92 317.31 13100 F 11 220.84 209.80 241.27 13101 N 11 369.24 350.78 403.40 13101 F 11 269.40 255.93 294.32 13102 N 11 100.29 95.28 109.57 13102 F 11 71.31 67.74 77.90 13120 N 11 302.37 287.25 330.34 13120 F 11 231.50 219.93 252.92 13121 N 11 411.75 391.16 449.83 13121 F 11 309.07 293.62 337.66 13122 N 11 110.92 105.37 121.18 13122 F 11 81.63 77.55 89.18 13131 N 11 334.13 317.42 365.03 13131 F 11 261.06 248.01 285.21 13132 N 11 541.97 514.87 592.10 13132 F 11 445.59 423.31 486.81 13133 N 11 157.44 149.57 172.01 13133 F 11 126.57 120.24 138.28 13150 N 11 332.12 315.51 362.84 13150 F 11 259.05 246.10 283.02 13151 N 11 378.85 359.91 413.90 13151 F 11 301.06 286.01 328.91 13152 N 11 524.07 497.87 572.55 13152 F 11 404.39 384.17 441.80 13153 N 11 172.68 164.05 188.66 13153 F 11 136.14 129.33 148.73 13160 11 756.29 718.48 826.25 14000 N 11 577.31 548.44 630.71 14000 F 11 474.63 450.90 518.54 14001 N 11 746.34 709.02 815.37 14001 F 11 623.82 592.63 681.52 14020 N 11 648.96 616.51 708.99 14020 F 11 540.61 513.58 590.62 14021 N 11 816.93 776.08 892.49 14021 F 11 691.26 656.70 755.21 14040 N 11 717.25 681.39 783.60 14040 F 11 609.54 579.06 665.92 14041 N 11 889.62 845.14 971.91 14041 F 11 751.98 714.38 821.54 14060 N 11 729.60 693.12 797.09 14060 F 11 645.19 612.93 704.87 14061 N 11 954.70 906.97 1043.02 14061 F 11 802.58 762.45 876.82 14301 N 11 1028.83 977.39 1124.00 14301 F 11 864.42 821.20 944.38 14302 11 221.09 210.04 241.55 14350 11 681.01 646.96 744.00 15002 N 11 311.43 295.86 340.24 15002 F 11 213.16 202.50 232.88 15003 N 11 67.68 64.30 73.95 15003 F 11 42.80 40.66 46.76 15004 N 11 367.74 349.35 401.75 15004 F 11 259.08 246.13 283.05 15005 N 11 112.45 106.83 122.85 15005 F 11 85.37 81.10 93.27 15040 N 11 233.55 221.87 255.15 15040 F 11 119.54 113.56 130.59 15050 N 11 517.48 491.61 565.35 15050 F 11 418.90 397.96 457.65 15100 N 11 797.83 757.94 871.63 15100 F 11 671.22 637.66 733.31 15101 N 11 172.02 163.42 187.93 15101 F 11 104.62 99.39 114.30 15110 N 11 788.04 748.64 860.94 15110 F 11 688.82 654.38 752.54 15111 N 11 110.26 104.75 120.46 15111 F 11 99.24 94.28 108.42 15115 N 11 803.70 763.52 878.05 15115 F 11 712.99 677.34 778.94 15116 N 11 158.47 150.55 173.13 15116 F 11 144.62 137.39 158.00 15120 N 11 883.97 839.77 965.74 15120 F 11 741.92 704.82 810.54 15121 N 11 246.37 234.05 269.16 15121 F 11 161.33 153.26 176.25 15130 N 11 624.07 592.87 681.80 15130 F 11 526.75 500.41 575.47 15131 N 11 94.57 89.84 103.32 15131 F 11 86.38 82.06 94.37 15135 N 11 808.49 768.07 883.28 15135 F 11 719.35 683.38 785.89 15136 N 11 84.11 79.90 91.89 15136 F 11 78.44 74.52 85.70 15150 N 11 641.89 609.80 701.27 15150 F 11 589.29 559.83 643.80 15151 N 11 123.20 117.04 134.60 15151 F 11 114.38 108.66 124.96 15152 N 11 145.25 137.99 158.69 15152 F 11 135.80 129.01 148.36 15155 N 11 610.67 580.14 667.16 15155 F 11 567.20 538.84 619.67 15156 N 11 157.91 150.01 172.51 15156 F 11 149.09 141.64 162.89 15157 N 11 157.34 149.47 171.89 15157 F 11 146.00 138.70 159.51 15170 N 11 403.49 383.32 440.82 15170 F 11 348.05 330.65 380.25 15171 N 11 88.08 83.68 96.23 15171 F 11 83.35 79.18 91.06 15175 N 11 485.02 460.77 529.89 15175 F 11 433.05 411.40 473.11 15176 N 11 138.43 131.51 151.24 15176 F 11 129.30 122.84 141.27 15200 N 11 759.21 721.25 829.44 15200 F 11 625.98 594.68 683.88 15201 N 11 137.08 130.23 149.76 15201 F 11 75.97 72.17 83.00 15220 N 11 714.75 679.01 780.86 15220 F 11 583.41 554.24 637.38 15221 N 11 126.94 120.59 138.68 15221 F 11 68.67 65.24 75.03 15240 N 11 865.52 822.24 945.58 15240 F 11 755.60 717.82 825.49 15241 N 11 171.51 162.93 187.37 15241 F 11 107.88 102.49 117.86 15260 N 11 940.09 893.09 1027.05 15260 F 11 818.52 777.59 894.23 15261 N 11 200.42 190.40 218.96 15261 F 11 136.49 129.67 149.12 15300 N 11 323.11 306.95 352.99 15300 F 11 273.66 259.98 298.98 15301 N 11 58.69 55.76 64.12 15301 F 11 53.65 50.97 58.62 15320 N 11 348.99 331.54 381.27 15320 F 11 295.45 280.68 322.78 15321 N 11 88.04 83.64 96.19 15321 F 11 81.43 77.36 88.96 15330 N 11 299.98 284.98 327.73 15330 F 11 249.27 236.81 272.33 15331 N 11 59.64 56.66 65.16 15331 F 11 55.23 52.47 60.34 15335 N 11 298.15 283.24 325.73 15335 F 11 249.33 236.86 272.39 15336 N 11 84.25 80.04 92.05 15336 F 11 76.06 72.26 83.10 15340 N 11 291.25 276.69 318.19 15340 F 11 249.05 236.60 272.09 15341 N 11 43.47 41.30 47.50 15341 F 11 24.88 23.64 27.19 15360 N 11 331.37 314.80 362.02 15360 F 11 282.86 268.72 309.03 15361 N 11 61.59 58.51 67.29 15361 F 11 56.23 53.42 61.43 15365 N 11 319.23 303.27 348.76 15365 F 11 275.13 261.37 300.58 15366 N 11 76.85 73.01 83.96 15366 F 11 69.92 66.42 76.38 15400 N 11 375.16 356.40 409.86 15400 F 11 332.02 315.42 362.73 15401 N 11 84.03 79.83 91.80 15401 F 11 53.80 51.11 58.78 15420 N 11 408.41 387.99 446.19 15420 F 11 361.17 343.11 394.58 15421 N 11 107.57 102.19 117.52 15421 F 11 81.11 77.05 88.61 15430 N 11 501.05 476.00 547.40 15430 F 11 480.89 456.85 525.38 15570 N 11 826.22 784.91 902.65 15570 F 11 676.30 642.49 738.86 15572 N 11 807.38 767.01 882.06 15572 F 11 690.53 656.00 754.40 15574 N 11 845.36 803.09 923.55 15574 F 11 722.21 686.10 789.02 15576 N 11 751.26 713.70 820.76 15576 F 11 635.99 604.19 694.82 15600 N 11 298.69 283.76 326.32 15600 F 11 190.66 181.13 208.30 15610 N 11 314.15 298.44 343.21 15610 F 11 223.44 212.27 244.11 15620 N 11 404.94 384.69 442.39 15620 F 11 301.63 286.55 329.53 15630 N 11 428.40 406.98 468.03 15630 F 11 326.99 310.64 357.24 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 004 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 15650 N 11 473.71 450.02 517.52 15650 F 11 364.42 346.20 398.13 15731 N 11 1066.99 1013.64 1165.69 15731 F 11 966.52 918.19 1055.92 15732 N 11 1404.08 1333.88 1533.96 15732 F 11 1257.94 1195.04 1374.30 15734 N 11 1422.75 1351.61 1554.35 15734 F 11 1265.89 1202.60 1382.99 15736 N 11 1252.10 1189.50 1367.93 15736 F 11 1090.52 1035.99 1191.39 15738 N 11 1333.14 1266.48 1456.45 15738 F 11 1182.59 1123.46 1291.98 15740 N 11 958.13 910.22 1046.75 15740 F 11 823.01 781.86 899.14 15750 11 861.36 818.29 941.03 15756 11 2235.36 2123.59 2442.13 15757 11 2217.66 2106.78 2422.80 15758 11 2207.59 2097.21 2411.79 15760 N 11 794.34 754.62 867.81 15760 F 11 672.45 638.83 734.65 15770 11 626.63 595.30 684.60 15775 N 11 271.84 258.25 296.99 15775 F 11 202.87 192.73 221.64 15776 N 11 397.81 377.92 434.61 15776 F 11 295.77 280.98 323.13 15780 N 11 765.86 727.57 836.71 15780 F 11 595.15 565.39 650.20 15781 N 11 504.42 479.20 551.08 15781 F 11 405.21 384.95 442.69 15782 N 11 512.94 487.29 560.38 15782 F 11 372.46 353.84 406.92 15783 N 11 452.39 429.77 494.24 15783 F 11 352.55 334.92 385.16 15786 N 11 223.71 212.52 244.40 15786 F 11 130.79 124.25 142.89 15787 N 11 44.25 42.04 48.35 15787 F 11 16.85 16.01 18.41 15788 N 11 412.22 391.61 450.35 15788 F 11 229.23 217.77 250.44 15789 N 11 520.91 494.86 569.09 15789 F 11 399.97 379.97 436.97 15792 N 11 395.71 375.92 432.31 15792 F 11 244.52 232.29 267.13 15793 N 11 450.31 427.79 491.96 15793 F 11 341.64 324.56 373.24 15819 11 665.79 632.50 727.38 15820 N 11 518.78 492.84 566.77 15820 F 11 472.17 448.56 515.84 15821 N 11 553.74 526.05 604.96 15821 F 11 501.78 476.69 548.19 15822 N 11 402.75 382.61 440.00 15822 F 11 357.40 339.53 390.46 15823 N 11 567.42 539.05 619.91 15823 F 11 516.40 490.58 564.17 15830 11 1092.01 1037.41 1193.02 15832 11 863.69 820.51 943.59 15833 11 811.46 770.89 886.52 15834 11 816.87 776.03 892.43 15835 11 864.44 821.22 944.40 15836 11 675.31 641.54 737.77 15837 N 11 767.47 729.10 838.47 15837 F 11 650.93 618.38 711.14 15838 11 544.47 517.25 594.84 15839 N 11 801.07 761.02 875.17 15839 F 11 680.44 646.42 743.38 15840 11 964.02 915.82 1053.19 15841 11 1600.28 1520.27 1748.31 15842 11 2403.83 2283.64 2626.19 15845 11 924.71 878.47 1010.24 15851 N 11 87.70 83.32 95.82 15851 F 11 43.61 41.43 47.64 15852 11 44.38 42.16 48.48 15860 11 102.95 97.80 112.47 15920 11 558.13 530.22 609.75 15922 11 719.59 683.61 786.15 15931 11 625.24 593.98 683.08 15933 11 774.22 735.51 845.84 15934 11 861.09 818.04 940.75 15935 11 1019.36 968.39 1113.65 15936 11 831.15 789.59 908.03 15937 11 972.51 923.88 1062.46 15940 11 644.46 612.24 704.08 15941 11 835.35 793.58 912.62 15944 11 830.84 789.30 907.70 15945 11 922.40 876.28 1007.72 15946 11 1534.44 1457.72 1676.38 15950 11 529.87 503.38 578.89 15951 11 797.96 758.06 871.77 15952 11 778.68 739.75 850.71 15953 11 856.42 813.60 935.64 15956 11 1077.73 1023.84 1177.42 15958 11 1099.62 1044.64 1201.34 16000 N 11 63.53 60.35 69.40 16000 F 11 43.68 41.50 47.73 16020 N 11 76.30 72.49 83.36 16020 F 11 53.31 50.64 58.24 16025 N 11 137.01 130.16 149.68 16025 F 11 108.35 102.93 118.37 16030 N 11 164.46 156.24 179.68 16030 F 11 123.20 117.04 134.60 16035 11 192.46 182.84 210.27 16036 11 77.59 73.71 84.77 17000 N 11 74.62 70.89 81.52 17000 F 11 52.26 49.65 57.10 17003 N 11 6.70 6.37 07.33 17003 F 11 4.18 3.97 04.57 17004 N 11 161.61 153.53 176.56 17004 F 11 126.65 120.32 138.37 17106 N 11 318.87 302.93 348.37 17106 F 11 260.92 247.87 285.05 17107 N 11 413.41 392.74 451.65 17107 F 11 336.24 319.43 367.34 17108 N 11 589.86 560.37 644.43 17108 F 11 493.80 469.11 539.48 17110 N 11 101.51 96.43 110.89 17110 F 11 64.35 61.13 70.30 17111 N 11 121.05 115.00 132.25 17111 F 11 80.10 76.10 87.52 17250 N 11 69.92 66.42 76.38 17250 F 11 33.70 32.02 36.82 17260 N 11 88.27 83.86 96.44 17260 F 11 64.33 61.11 70.28 17261 N 11 132.80 126.16 145.08 17261 F 11 87.13 82.77 95.19 17262 N 11 161.41 153.34 176.34 17262 F 11 111.02 105.47 121.29 17263 N 11 177.74 168.85 194.18 17263 F 11 122.93 116.78 134.30 17264 N 11 190.45 180.93 208.07 17264 F 11 131.23 124.67 143.37 17266 N 11 216.20 205.39 236.20 17266 F 11 152.89 145.25 167.04 17270 N 11 138.67 131.74 151.50 17270 F 11 94.57 89.84 103.32 17271 N 11 152.37 144.75 166.46 17271 F 11 106.07 100.77 115.89 17272 N 11 173.91 165.21 189.99 17272 F 11 122.25 116.14 133.56 17273 N 11 193.78 184.09 211.70 17273 F 11 138.03 131.13 150.80 17274 N 11 228.84 217.40 250.01 17274 F 11 168.68 160.25 184.29 17276 N 11 264.99 251.74 289.50 17276 F 11 202.00 191.90 220.69 17280 N 11 129.96 123.46 141.98 17280 F 11 86.18 81.87 94.15 17281 N 11 164.96 156.71 180.22 17281 F 11 119.29 113.33 130.33 17282 N 11 191.24 181.68 208.93 17282 F 11 138.01 131.11 150.78 17283 N 11 230.14 218.63 251.42 17283 F 11 172.19 163.58 188.12 17284 N 11 267.16 253.80 291.87 17284 F 11 204.17 193.96 223.05 17286 N 11 338.20 321.29 369.48 17286 F 11 273.32 259.65 298.60 17311 N 11 627.02 595.67 685.02 17311 F 11 366.55 348.22 400.45 17312 N 11 373.72 355.03 408.28 17312 F 11 194.82 185.08 212.84 17313 N 11 571.73 543.14 624.61 17313 F 11 328.90 312.46 359.33 17314 N 11 346.61 329.28 378.67 17314 F 11 180.63 171.60 197.34 17315 N 11 75.53 71.75 82.51 17315 F 11 51.28 48.72 56.03 17340 N 11 46.71 44.37 51.03 17340 F 11 44.82 42.58 48.97 17360 N 11 123.28 117.12 134.69 17360 F 11 95.88 91.09 104.75 19000 N 11 101.91 96.81 111.33 19000 F 11 42.07 39.97 45.97 19001 N 11 25.17 23.91 27.50 19001 F 11 20.76 19.72 22.68 19020 N 11 413.11 392.45 451.32 19020 F 11 272.95 259.30 298.20 19030 N 11 152.18 144.57 166.26 19030 F 11 75.02 71.27 81.96 19100 N 11 132.54 125.91 144.80 19100 F 11 64.83 61.59 70.83 19101 N 11 302.34 287.22 330.30 19101 F 11 201.55 191.47 220.19 19102 N 11 200.21 190.20 218.73 19102 F 11 98.80 93.86 107.94 19103 N 11 511.75 486.16 559.08 19103 F 11 183.88 174.69 200.89 19105 N 11 1892.38 1797.76 2067.42 19105 F 11 184.66 175.43 201.74 19110 N 11 429.07 407.62 468.76 19110 F 11 306.86 291.52 335.25 19112 N 11 402.49 382.37 439.73 19112 F 11 277.77 263.88 303.46 19120 N 11 438.14 416.23 478.66 19120 F 11 372.63 354.00 407.10 19125 N 11 486.45 462.13 531.45 19125 F 11 414.32 393.60 452.64 19126 11 150.45 142.93 164.37 19260 11 1121.47 1065.40 1225.21 19271 11 1519.15 1443.19 1659.67 19272 11 1680.51 1596.48 1835.95 19290 N 11 149.82 142.33 163.68 19290 F 11 62.58 59.45 68.37 19291 N 11 63.80 60.61 69.70 19291 F 11 30.73 29.19 33.57 19295 11 83.69 79.51 91.44 19296 N 11 3663.13 3479.97 4001.97 19296 F 11 195.10 185.35 213.15 19297 11 88.15 83.74 96.30 19298 N 11 1131.42 1074.85 1236.08 19298 F 11 309.69 294.21 338.34 19300 N 11 464.13 440.92 507.06 19300 F 11 365.86 347.57 399.71 19301 11 589.42 559.95 643.94 19302 11 812.88 772.24 888.08 19303 11 912.59 866.96 997.00 19304 11 518.58 492.65 566.55 19305 11 1030.71 979.17 1126.05 19306 11 1085.64 1031.36 1186.06 19307 11 1086.20 1031.89 1186.67 19316 11 724.68 688.45 791.72 19318 11 1051.96 999.36 1149.26 19324 11 448.26 425.85 489.73 19325 11 606.42 576.10 662.52 19328 11 462.26 439.15 505.02 19330 11 591.00 561.45 645.67 19340 11 819.60 778.62 895.41 19342 11 868.69 825.26 949.05 19350 N 11 776.88 738.04 848.75 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 005 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 19350 F 11 634.20 602.49 692.86 19355 N 11 649.08 616.63 709.12 19355 F 11 526.56 500.23 575.26 19357 11 1387.00 1317.65 1515.30 19361 11 1588.96 1509.51 1735.94 19364 11 2628.82 2497.38 2871.99 19366 11 1295.69 1230.91 1415.55 19367 11 1704.73 1619.49 1862.41 19368 11 2107.96 2002.56 2302.94 19369 11 1946.06 1848.76 2126.07 19370 11 643.62 611.44 703.16 19371 11 737.79 700.90 806.04 19380 11 725.33 689.06 792.42 19396 N 11 223.20 212.04 243.85 19396 F 11 127.77 121.38 139.59 20005 N 11 277.76 263.87 303.45 20005 F 11 217.29 206.43 237.39 20100 11 558.93 530.98 610.63 20101 N 11 368.31 349.89 402.37 20101 F 11 187.52 178.14 204.86 20102 N 11 435.04 413.29 475.28 20102 F 11 234.41 222.69 256.09 20103 N 11 524.32 498.10 572.82 20103 F 11 327.15 310.79 357.41 20150 11 922.28 876.17 1007.60 20200 N 11 181.22 172.16 197.98 20200 F 11 87.37 83.00 95.45 20205 N 11 249.46 236.99 272.54 20205 F 11 141.43 134.36 154.51 20206 N 11 230.56 219.03 251.88 20206 F 11 57.65 54.77 62.99 20220 N 11 152.74 145.10 166.87 20220 F 11 71.48 67.91 78.10 20225 N 11 567.05 538.70 619.51 20225 F 11 107.83 102.44 117.81 20240 11 210.23 199.72 229.68 20245 11 588.64 559.21 643.09 20250 11 351.55 333.97 384.07 20251 11 384.44 365.22 420.00 20500 N 11 102.60 97.47 112.09 20500 F 11 84.02 79.82 91.79 20501 N 11 115.29 109.53 125.96 20501 F 11 37.50 35.63 40.97 20520 N 11 179.43 170.46 196.03 20520 F 11 133.76 127.07 146.13 20525 N 11 432.82 411.18 472.86 20525 F 11 231.25 219.69 252.64 20526 N 11 69.46 65.99 75.89 20526 F 11 53.71 51.02 58.67 20550 N 11 53.13 50.47 58.04 20550 F 11 38.96 37.01 42.56 20551 N 11 54.08 51.38 59.09 20551 F 11 40.22 38.21 43.94 20552 N 11 49.53 47.05 54.11 20552 F 11 35.04 33.29 38.28 20553 N 11 56.05 53.25 61.24 20553 F 11 39.36 37.39 43.00 20555 11 312.60 296.97 341.52 20600 N 11 50.16 47.65 54.80 20600 F 11 36.93 35.08 40.34 20605 N 11 54.53 51.80 59.57 20605 F 11 38.79 36.85 42.38 20610 N 11 72.10 68.50 78.78 20610 F 11 46.90 44.56 51.24 20612 N 11 54.27 51.56 59.29 20612 F 11 39.47 37.50 43.13 20615 N 11 201.68 191.60 220.34 20615 F 11 148.45 141.03 162.18 20650 N 11 182.66 173.53 199.56 20650 F 11 143.29 136.13 156.55 20660 11 226.81 215.47 247.79 20661 11 447.20 424.84 488.57 20662 11 406.74 386.40 444.36 20663 11 423.53 402.35 462.70 20664 11 742.84 705.70 811.56 20665 N 11 103.20 98.04 112.75 20665 F 11 87.77 83.38 95.89 20670 N 11 354.90 337.16 387.73 20670 F 11 137.89 131.00 150.65 20680 N 11 561.47 533.40 613.41 20680 F 11 394.85 375.11 431.38 20690 11 536.51 509.68 586.13 20692 11 1009.70 959.22 1103.10 20693 11 423.91 402.71 463.12 20694 N 11 390.46 370.94 426.58 20694 F 11 312.67 297.04 341.60 20696 11 1023.23 972.07 1117.88 20697 11 1552.04 1474.44 1695.61 20802 11 2211.78 2101.19 2416.37 20805 11 2677.87 2543.98 2925.58 20808 11 3908.21 3712.80 4269.72 20816 11 2030.37 1928.85 2218.18 20822 11 1775.56 1686.78 1939.80 20824 11 2032.73 1931.09 2220.75 20827 11 1843.70 1751.52 2014.25 20838 11 2269.03 2155.58 2478.92 20900 N 11 381.15 362.09 416.40 20900 F 11 216.43 205.61 236.45 20902 11 306.16 290.85 334.48 20910 11 397.15 377.29 433.88 20912 11 458.63 435.70 501.06 20920 11 378.69 359.76 413.72 20922 N 11 555.66 527.88 607.06 20922 F 11 461.49 438.42 504.18 20924 11 470.07 446.57 513.56 20926 11 406.07 385.77 443.64 20931 11 105.45 100.18 115.21 20937 11 159.43 151.46 174.18 20938 11 174.13 165.42 190.23 20950 N 11 226.01 214.71 246.92 20950 F 11 84.59 80.36 92.41 20955 11 2416.33 2295.51 2639.84 20956 11 2485.60 2361.32 2715.52 20957 11 2421.52 2300.44 2645.51 20962 11 2463.09 2339.94 2690.93 20969 11 2673.25 2539.59 2920.53 20970 11 2655.05 2522.30 2900.65 20972 11 2209.39 2098.92 2413.76 20973 11 2576.98 2448.13 2815.35 20974 N 11 64.12 60.91 70.05 20974 F 11 44.90 42.66 49.06 20975 11 165.10 156.85 180.38 20979 N 11 48.72 46.28 53.22 20979 F 11 32.02 30.42 34.98 20982 N 11 3323.52 3157.34 3630.94 20982 F 11 369.18 350.72 403.33 20985 11 139.89 132.90 152.84 21010 11 683.38 649.21 746.59 21011 N 11 308.07 292.67 336.57 21011 F 11 235.63 223.85 257.43 21012 11 325.72 309.43 355.84 21013 N 11 476.86 453.02 520.97 21013 F 11 380.17 361.16 415.33 21014 11 502.71 477.57 549.21 21015 11 616.54 585.71 673.57 21016 11 994.59 944.86 1086.59 21025 N 11 825.90 784.61 902.30 21025 F 11 703.06 667.91 768.10 21026 N 11 561.88 533.79 613.86 21026 F 11 461.41 438.34 504.09 21029 N 11 714.18 678.47 780.24 21029 F 11 602.36 572.24 658.08 21030 N 11 470.77 447.23 514.31 21030 F 11 384.78 365.54 420.37 21031 N 11 354.86 337.12 387.69 21031 F 11 269.50 256.03 294.43 21032 N 11 360.85 342.81 394.23 21032 F 11 266.99 253.64 291.69 21034 N 11 1251.49 1188.92 1367.26 21034 F 11 1110.39 1054.87 1213.10 21040 N 11 474.32 450.60 518.19 21040 F 11 384.55 365.32 420.12 21044 11 835.16 793.40 912.41 21045 11 1164.75 1106.51 1272.49 21046 11 1026.98 975.63 1121.97 21047 11 1231.98 1170.38 1345.94 21048 11 1050.28 997.77 1147.44 21049 11 1181.80 1122.71 1291.12 21050 11 822.08 780.98 898.13 21060 11 764.90 726.66 835.66 21070 11 589.45 559.98 643.98 21073 N 11 356.97 339.12 389.99 21073 F 11 235.71 223.92 257.51 21076 N 11 911.68 866.10 996.02 21076 F 11 780.97 741.92 853.21 21077 N 11 2271.75 2158.16 2481.88 21077 F 11 1979.16 1880.20 2162.23 21079 N 11 1541.87 1464.78 1684.50 21079 F 11 1311.00 1245.45 1432.27 21080 N 11 1740.84 1653.80 1901.87 21080 F 11 1467.13 1393.77 1602.84 21081 N 11 1597.32 1517.45 1745.07 21081 F 11 1339.05 1272.10 1462.92 21082 N 11 1497.76 1422.87 1636.30 21082 F 11 1248.63 1186.20 1364.13 21083 N 11 1399.66 1329.68 1529.13 21083 F 11 1132.57 1075.94 1237.33 21084 N 11 1639.67 1557.69 1791.34 21084 F 11 1348.02 1280.62 1472.71 21085 N 11 722.61 686.48 789.45 21085 F 11 582.14 553.03 635.98 21086 N 11 1668.52 1585.09 1822.85 21086 F 11 1448.05 1375.65 1582.00 21087 N 11 1665.37 1582.10 1819.42 21087 F 11 1443.33 1371.16 1576.83 21100 N 11 604.59 574.36 660.51 21100 F 11 346.95 329.60 379.04 21110 N 11 716.28 680.47 782.54 21110 F 11 606.36 576.04 662.45 21116 N 11 136.06 129.26 148.65 21116 F 11 39.68 37.70 43.36 21120 N 11 590.95 561.40 645.61 21120 F 11 477.57 453.69 521.74 21121 N 11 720.19 684.18 786.81 21121 F 11 606.49 576.17 662.60 21122 11 660.08 627.08 721.14 21123 11 825.89 784.60 902.29 21125 N 11 2806.92 2666.57 3066.56 21125 F 11 739.51 702.53 807.91 21127 N 11 3434.98 3263.23 3752.71 21127 F 11 831.51 789.93 908.42 21137 11 672.89 639.25 735.14 21138 11 837.51 795.63 914.97 21139 11 939.85 892.86 1026.79 21141 11 1288.44 1224.02 1407.62 21142 11 1299.29 1234.33 1419.48 21143 11 1373.79 1305.10 1500.87 21145 11 1427.36 1355.99 1559.39 21146 11 1606.78 1526.44 1755.41 21147 11 1564.89 1486.65 1709.65 21150 11 1566.50 1488.18 1711.41 21151 11 1857.40 1764.53 2029.21 21154 11 2012.81 1912.17 2199.00 21155 11 2072.54 1968.91 2264.25 21159 11 2652.92 2520.27 2898.31 21160 11 2576.64 2447.81 2814.98 21172 11 1694.21 1609.50 1850.93 21175 11 2204.43 2094.21 2408.34 21179 11 1433.14 1361.48 1565.70 21180 11 1575.93 1497.13 1721.70 21181 11 673.63 639.95 735.94 21182 11 1886.97 1792.62 2061.51 21183 11 2122.61 2016.48 2318.95 21184 11 2336.29 2219.48 2552.40 21188 11 1525.99 1449.69 1667.14 21193 11 1228.75 1167.31 1342.41 21194 11 1325.20 1258.94 1447.78 21195 11 1271.88 1208.29 1389.53 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 006 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 21196 11 1391.59 1322.01 1520.31 21198 11 1096.86 1042.02 1198.32 21199 11 971.77 923.18 1061.66 21206 11 1139.35 1082.38 1244.74 21208 N 11 1673.64 1589.96 1828.45 21208 F 11 787.34 747.97 860.17 21209 N 11 776.71 737.87 848.55 21209 F 11 616.71 585.87 673.75 21210 N 11 2007.05 1906.70 2192.71 21210 F 11 793.81 754.12 867.24 21215 N 11 3482.54 3308.41 3804.67 21215 F 11 840.01 798.01 917.71 21230 11 729.92 693.42 797.43 21235 N 11 683.37 649.20 746.58 21235 F 11 540.06 513.06 590.02 21240 11 1039.44 987.47 1135.59 21242 11 953.07 905.42 1041.23 21243 11 1569.42 1490.95 1714.59 21244 11 998.73 948.79 1091.11 21245 N 11 1061.17 1008.11 1159.33 21245 F 11 857.70 814.82 937.04 21246 11 793.76 754.07 867.18 21247 11 1528.76 1452.32 1670.17 21248 N 11 1010.49 959.97 1103.97 21248 F 11 834.12 792.41 911.27 21249 N 11 1391.98 1322.38 1520.74 21249 F 11 1184.11 1124.90 1293.64 21255 11 1304.09 1238.89 1424.72 21256 11 1120.84 1064.80 1224.52 21260 11 1262.64 1199.51 1379.44 21261 11 2073.30 1969.64 2265.09 21263 11 1805.81 1715.52 1972.85 21267 11 1503.08 1427.93 1642.12 21268 11 1723.06 1636.91 1882.45 21270 N 11 887.88 843.49 970.01 21270 F 11 687.25 652.89 750.82 21275 11 785.23 745.97 857.87 21280 11 526.14 499.83 574.80 21282 11 346.48 329.16 378.53 21295 11 164.64 156.41 179.87 21296 11 376.94 358.09 411.80 21310 N 11 103.56 98.38 113.14 21310 F 11 26.71 25.37 29.18 21315 N 11 250.52 237.99 273.69 21315 F 11 141.86 134.77 154.99 21320 N 11 236.65 224.82 258.54 21320 F 11 129.24 122.78 141.20 21325 11 441.39 419.32 482.22 21330 11 535.26 508.50 584.78 21335 11 691.45 656.88 755.41 21336 11 609.51 579.03 665.88 21337 N 11 372.07 353.47 406.49 21337 F 11 274.75 261.01 300.16 21338 11 697.18 662.32 761.67 21339 11 752.16 714.55 821.73 21340 11 736.89 700.05 805.06 21343 11 1079.25 1025.29 1179.08 21344 11 1535.47 1458.70 1677.51 21345 N 11 737.97 701.07 806.23 21345 F 11 603.16 573.00 658.95 21346 11 878.20 834.29 959.43 21347 11 1040.73 988.69 1136.99 21348 11 1100.11 1045.10 1201.87 21355 N 11 416.25 395.44 454.76 21355 F 11 312.31 296.69 341.19 21356 N 11 461.55 438.47 504.24 21356 F 11 353.84 336.15 386.57 21360 11 501.26 476.20 547.63 21365 11 1053.78 1001.09 1151.25 21366 11 1190.28 1130.77 1300.39 21385 11 659.74 626.75 720.76 21386 11 625.02 593.77 682.84 21387 11 703.06 667.91 768.10 21390 11 746.22 708.91 815.25 21395 11 922.79 876.65 1008.15 21400 N 11 170.51 161.98 186.28 21400 F 11 139.64 132.66 152.56 21401 N 11 439.72 417.73 480.39 21401 F 11 280.35 266.33 306.28 21406 11 519.12 493.16 567.13 21407 11 609.49 579.02 665.87 21408 11 847.58 805.20 925.98 21421 N 11 693.17 658.51 757.29 21421 F 11 591.44 561.87 646.15 21422 11 625.68 594.40 683.56 21423 11 770.19 731.68 841.43 21431 11 693.04 658.39 757.15 21432 11 657.40 624.53 718.21 21433 11 1588.26 1508.85 1735.18 21435 11 1236.77 1174.93 1351.17 21436 11 1928.43 1832.01 2106.81 21440 N 11 511.37 485.80 558.67 21440 F 11 422.23 401.12 461.29 21445 N 11 703.06 667.91 768.10 21445 F 11 578.33 549.41 631.82 21450 N 11 536.78 509.94 586.43 21450 F 11 441.66 419.58 482.52 21451 N 11 699.41 664.44 764.11 21451 F 11 587.28 557.92 641.61 21452 N 11 537.53 510.65 587.25 21452 F 11 315.48 299.71 344.67 21453 N 11 815.21 774.45 890.62 21453 F 11 712.85 677.21 778.79 21454 11 524.18 497.97 572.67 21461 N 11 1876.43 1782.61 2050.00 21461 F 11 871.70 828.12 952.34 21462 N 11 1993.86 1894.17 2178.30 21462 F 11 959.21 911.25 1047.94 21465 11 890.96 846.41 973.37 21470 11 1137.34 1080.47 1242.54 21480 N 11 85.05 80.80 92.92 21480 F 11 30.56 29.03 33.38 21485 N 11 628.26 596.85 686.38 21485 F 11 531.25 504.69 580.39 21490 11 873.79 830.10 954.62 21495 11 659.13 626.17 720.10 21497 N 11 626.99 595.64 684.99 21497 F 11 535.02 508.27 584.51 21501 N 11 413.11 392.45 451.32 21501 F 11 298.78 283.84 326.42 21502 11 477.48 453.61 521.65 21510 11 437.96 416.06 478.47 21550 N 11 238.84 226.90 260.94 21550 F 11 148.77 141.33 162.53 21552 11 426.38 405.06 465.82 21554 11 701.17 666.11 766.03 21555 N 11 379.73 360.74 414.85 21555 F 11 286.82 272.48 313.35 21556 11 482.70 458.57 527.36 21557 11 838.46 796.54 916.02 21558 11 1304.34 1239.12 1424.99 21600 11 524.04 497.84 572.52 21610 11 1062.78 1009.64 1161.09 21615 11 620.27 589.26 677.65 21616 11 757.48 719.61 827.55 21620 11 490.58 466.05 535.96 21627 11 513.68 488.00 561.20 21630 11 1191.96 1132.36 1302.21 21632 11 1179.70 1120.72 1288.83 21685 11 954.66 906.93 1042.97 21700 11 401.66 381.58 438.82 21705 11 568.98 540.53 621.61 21720 11 411.18 390.62 449.21 21725 11 496.82 471.98 542.78 21740 11 983.48 934.31 1074.46 21750 11 664.23 631.02 725.67 21800 N 11 94.48 89.76 103.22 21800 F 11 96.69 91.86 105.64 21805 11 243.52 231.34 266.04 21810 11 484.52 460.29 529.33 21820 N 11 125.21 118.95 136.79 21820 F 11 127.41 121.04 139.20 21825 11 527.83 501.44 576.66 21920 N 11 238.81 226.87 260.90 21920 F 11 151.57 143.99 165.59 21925 N 11 397.10 377.25 433.84 21925 F 11 319.62 303.64 349.19 21930 N 11 428.26 406.85 467.88 21930 F 11 337.87 320.98 369.13 21931 11 445.03 422.78 486.20 21932 11 634.61 602.88 693.31 21933 11 699.45 664.48 764.15 21935 11 965.09 916.84 1054.37 21936 11 1357.02 1289.17 1482.55 22010 11 864.43 821.21 944.39 22015 11 852.44 809.82 931.29 22100 11 796.94 757.09 870.65 22101 11 780.04 741.04 852.20 22102 11 760.48 722.46 830.83 22103 11 135.36 128.59 147.88 22110 11 979.86 930.87 1070.50 22112 11 966.09 917.79 1055.46 22114 11 922.84 876.70 1008.21 22116 11 132.50 125.88 144.76 22206 11 2204.93 2094.68 2408.88 22207 11 2222.61 2111.48 2428.20 22208 11 552.61 524.98 603.73 22210 11 1635.11 1553.35 1786.35 22212 11 1360.65 1292.62 1486.51 22214 11 1368.23 1299.82 1494.79 22216 11 345.76 328.47 377.74 22220 11 1485.47 1411.20 1622.88 22222 11 1395.02 1325.27 1524.06 22224 11 1464.97 1391.72 1600.48 22226 11 346.10 328.80 378.12 22305 N 11 172.43 163.81 188.38 22305 F 11 158.25 150.34 172.89 22310 N 11 276.25 262.44 301.81 22310 F 11 257.04 244.19 280.82 22315 N 11 803.53 763.35 877.85 22315 F 11 709.98 674.48 775.65 22318 11 1493.81 1419.12 1631.99 22319 11 1659.18 1576.22 1812.65 22325 11 1314.44 1248.72 1436.03 22326 11 1362.56 1294.43 1488.59 22327 11 1358.86 1290.92 1484.56 22328 11 266.35 253.03 290.98 22505 11 111.09 105.54 121.37 22520 N 11 2080.42 1976.40 2272.86 22520 F 11 499.00 474.05 545.16 22521 N 11 2040.39 1938.37 2229.13 22521 F 11 471.57 447.99 515.19 22522 11 220.14 209.13 240.50 22523 11 551.39 523.82 602.39 22524 11 529.99 503.49 579.01 22525 11 247.23 234.87 270.10 22532 11 1646.18 1563.87 1798.45 22533 11 1558.12 1480.21 1702.24 22534 11 343.70 326.52 375.50 22548 11 1779.11 1690.15 1943.67 22551 11 1606.88 1526.54 1755.52 22552 11 376.07 357.27 410.86 22554 11 1173.62 1114.94 1282.18 22556 11 1547.85 1470.46 1691.03 22558 11 1436.22 1364.41 1569.07 22585 11 317.66 301.78 347.05 22590 11 1444.94 1372.69 1578.59 22595 11 1374.52 1305.79 1501.66 22600 11 1175.78 1116.99 1284.54 22610 11 1155.55 1097.77 1262.44 22612 11 1481.66 1407.58 1618.72 22614 11 370.95 352.40 405.26 22630 11 1423.88 1352.69 1555.59 22632 11 301.95 286.85 329.88 22800 11 1256.14 1193.33 1372.33 22802 11 1972.43 1873.81 2154.88 22804 11 2275.83 2162.04 2486.35 22808 11 1707.36 1621.99 1865.29 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 007 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 22810 11 1902.70 1807.57 2078.71 22812 11 2073.17 1969.51 2264.94 22818 11 2050.29 1947.78 2239.95 22819 11 2503.74 2378.55 2735.33 22830 11 747.80 710.41 816.97 22840 11 722.36 686.24 789.18 22842 11 724.07 687.87 791.05 22843 11 770.45 731.93 841.72 22844 11 935.25 888.49 1021.76 22845 11 693.84 659.15 758.02 22846 11 720.17 684.16 786.78 22847 11 816.64 775.81 892.18 22848 11 342.29 325.18 373.96 22849 11 1209.14 1148.68 1320.98 22850 11 663.39 630.22 724.75 22851 11 386.32 367.00 422.05 22852 11 634.72 602.98 693.43 22855 11 1031.09 979.54 1126.47 22856 11 1531.14 1454.58 1672.77 22857 11 1572.29 1493.68 1717.73 22861 11 1875.86 1782.07 2049.38 22862 11 1795.80 1706.01 1961.91 22864 11 1760.79 1672.75 1923.66 22865 11 1903.76 1808.57 2079.86 22900 11 493.64 468.96 539.30 22901 11 623.19 592.03 680.83 22902 N 11 409.51 389.03 447.38 22902 F 11 321.64 305.56 351.39 22903 11 419.18 398.22 457.95 22904 11 974.30 925.59 1064.43 22905 11 1267.06 1203.71 1384.27 23000 N 11 506.31 480.99 553.14 23000 F 11 336.55 319.72 367.68 23020 11 637.17 605.31 696.11 23030 N 11 393.87 374.18 430.31 23030 F 11 237.34 225.47 259.29 23031 N 11 366.41 348.09 400.30 23031 F 11 198.53 188.60 216.89 23035 11 631.95 600.35 690.40 23040 11 666.15 632.84 727.77 23044 11 527.98 501.58 576.82 23065 N 11 199.57 189.59 218.03 23065 F 11 157.05 149.20 171.58 23066 N 11 478.32 454.40 522.56 23066 F 11 318.01 302.11 347.43 23071 11 396.58 376.75 433.26 23073 11 657.46 624.59 718.28 23075 N 11 367.69 349.31 401.71 23075 F 11 268.16 254.75 292.96 23076 11 500.99 475.94 547.33 23077 11 1080.61 1026.58 1180.57 23078 11 1318.26 1252.35 1440.20 23100 11 456.11 433.30 498.30 23101 11 414.44 393.72 452.78 23105 11 588.96 559.51 643.44 23106 11 449.09 426.64 490.64 23107 11 610.91 580.36 667.41 23120 11 535.71 508.92 585.26 23125 11 653.46 620.79 713.91 23130 11 560.38 532.36 612.21 23140 11 480.58 456.55 525.03 23145 11 642.19 610.08 701.59 23146 11 564.64 536.41 616.87 23150 11 608.17 577.76 664.42 23155 11 733.99 697.29 801.88 23156 11 625.52 594.24 683.38 23170 11 504.43 479.21 551.09 23172 11 515.67 489.89 563.37 23174 11 699.76 664.77 764.49 23180 11 628.29 596.88 686.41 23182 11 614.22 583.51 671.04 23184 11 684.79 650.55 748.13 23190 11 522.51 496.38 570.84 23195 11 698.43 663.51 763.04 23200 11 1320.67 1254.64 1442.84 23210 11 1545.91 1468.61 1688.90 23220 11 1706.87 1621.53 1864.76 23330 N 11 209.86 199.37 229.28 23330 F 11 138.36 131.44 151.16 23331 11 544.78 517.54 595.17 23332 11 820.20 779.19 896.07 23350 N 11 138.93 131.98 151.78 23350 F 11 49.48 47.01 54.06 23395 11 1198.07 1138.17 1308.90 23397 11 1067.58 1014.20 1166.33 23400 11 906.00 860.70 989.81 23405 11 581.86 552.77 635.69 23406 11 725.06 688.81 792.13 23410 11 765.79 727.50 836.63 23412 11 796.90 757.06 870.62 23415 11 643.69 611.51 703.24 23420 11 903.76 858.57 987.36 23430 11 688.72 654.28 752.42 23440 11 703.19 668.03 768.23 23450 11 883.80 839.61 965.55 23455 11 939.39 892.42 1026.28 23460 11 1019.89 968.90 1114.24 23462 11 1002.41 952.29 1095.13 23465 11 1043.06 990.91 1139.55 23466 11 1041.34 989.27 1137.66 23470 11 1132.58 1075.95 1237.34 23472 11 1403.88 1333.69 1533.74 23480 11 762.67 724.54 833.22 23485 11 896.20 851.39 979.10 23490 11 812.12 771.51 887.24 23491 11 945.28 898.02 1032.72 23500 N 11 194.04 184.34 211.99 23500 F 11 194.99 185.24 213.03 23505 N 11 315.36 299.59 344.53 23505 F 11 298.67 283.74 326.30 23515 11 667.12 633.76 728.82 23520 N 11 203.74 193.55 222.58 23520 F 11 205.95 195.65 225.00 23525 N 11 333.76 317.07 364.63 23525 F 11 306.99 291.64 335.39 23530 11 514.34 488.62 561.91 23532 11 575.15 546.39 628.35 23540 N 11 198.11 188.20 216.43 23540 F 11 198.42 188.50 216.78 23545 N 11 290.22 275.71 317.07 23545 F 11 265.97 252.67 290.57 23550 11 528.25 501.84 577.12 23552 11 608.98 578.53 665.31 23570 N 11 206.44 196.12 225.54 23570 F 11 210.85 200.31 230.36 23575 N 11 356.97 339.12 389.99 23575 F 11 335.87 319.08 366.94 23585 11 906.41 861.09 990.25 23600 N 11 289.42 274.95 316.19 23600 F 11 269.58 256.10 294.52 23605 N 11 421.03 399.98 459.98 23605 F 11 388.28 368.87 424.20 23615 11 820.03 779.03 895.88 23616 11 1171.91 1113.31 1280.31 23620 N 11 239.23 227.27 261.36 23620 F 11 226.95 215.60 247.94 23625 N 11 342.60 325.47 374.29 23625 F 11 320.87 304.83 350.55 23630 11 716.24 680.43 782.49 23650 N 11 270.54 257.01 295.56 23650 F 11 248.80 236.36 271.81 23655 11 357.22 339.36 390.26 23660 11 537.61 510.73 587.34 23665 N 11 382.17 363.06 417.52 23665 F 11 358.55 340.62 391.71 23670 11 803.60 763.42 877.93 23675 N 11 497.71 472.82 543.74 23675 F 11 458.03 435.13 500.40 23680 11 857.51 814.63 936.82 23700 11 179.44 170.47 196.04 23800 11 956.56 908.73 1045.04 23802 11 1183.34 1124.17 1292.80 23900 11 1268.65 1205.22 1386.00 23920 11 1029.75 978.26 1125.00 23921 11 405.82 385.53 443.36 23930 N 11 323.06 306.91 352.95 23930 F 11 200.54 190.51 219.09 23931 N 11 255.47 242.70 279.11 23931 F 11 145.86 138.57 159.36 23935 11 463.62 440.44 506.51 24000 11 438.61 416.68 479.18 24006 11 659.67 626.69 720.69 24065 N 11 234.77 223.03 256.48 24065 F 11 156.97 149.12 171.49 24066 N 11 548.44 521.02 599.17 24066 F 11 374.27 355.56 408.89 24071 11 386.73 367.39 422.50 24073 11 659.93 626.93 720.97 24075 N 11 445.42 423.15 486.62 24075 F 11 300.85 285.81 328.68 24076 11 489.29 464.83 534.55 24077 11 936.37 889.55 1022.98 24079 11 1215.86 1155.07 1328.33 24100 11 378.28 359.37 413.28 24101 11 460.22 437.21 502.79 24102 11 568.27 539.86 620.84 24105 11 315.24 299.48 344.40 24110 11 539.93 512.93 589.87 24115 11 680.23 646.22 743.15 24116 11 801.50 761.43 875.64 24120 11 484.75 460.51 529.59 24125 11 567.94 539.54 620.47 24126 11 598.18 568.27 653.51 24130 11 466.59 443.26 509.75 24134 11 695.20 660.44 759.51 24136 11 567.43 539.06 619.92 24138 11 617.98 587.08 675.14 24140 11 658.60 625.67 719.52 24145 11 553.06 525.41 604.22 24147 11 578.28 549.37 631.78 24149 11 1086.44 1032.12 1186.94 24150 11 1374.14 1305.43 1501.24 24152 11 1168.79 1110.35 1276.90 24155 11 791.33 751.76 864.52 24160 11 560.18 532.17 612.00 24164 11 458.76 435.82 501.19 24200 N 11 184.16 174.95 201.19 24200 F 11 127.78 121.39 139.60 24201 N 11 505.30 480.04 552.05 24201 F 11 337.11 320.25 368.29 24220 N 11 151.50 143.93 165.52 24220 F 11 65.83 62.54 71.92 24300 11 369.11 350.65 403.25 24301 11 697.22 662.36 761.71 24305 11 535.89 509.10 585.47 24310 11 439.25 417.29 479.88 24320 11 722.34 686.22 789.15 24330 11 664.59 631.36 726.06 24331 11 746.64 709.31 815.71 24332 11 562.99 534.84 615.07 24340 11 566.93 538.58 619.37 24341 11 683.67 649.49 746.91 24342 11 724.21 688.00 791.20 24343 11 651.03 618.48 711.25 24344 11 1017.85 966.96 1112.00 24345 11 647.25 614.89 707.12 24346 11 1019.42 968.45 1113.72 24357 11 409.89 389.40 447.81 24358 11 482.81 458.67 527.47 24359 11 608.06 577.66 664.31 24360 11 836.94 795.09 914.35 24361 11 939.86 892.87 1026.80 24362 11 989.20 939.74 1080.70 24363 11 1401.92 1331.82 1531.59 24365 11 592.19 562.58 646.97 24366 11 633.33 601.66 691.91 24400 11 761.50 723.43 831.94 24410 11 979.03 930.08 1069.59 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 008 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 24420 11 920.41 874.39 1005.55 24430 11 984.14 934.93 1075.17 24435 11 1000.36 950.34 1092.89 24470 11 602.35 572.23 658.06 24495 11 608.35 577.93 664.62 24498 11 807.92 767.52 882.65 24500 N 11 315.96 300.16 345.18 24500 F 11 287.93 273.53 314.56 24505 N 11 451.80 429.21 493.59 24505 F 11 412.43 391.81 450.58 24515 11 813.80 773.11 889.08 24516 11 801.66 761.58 875.82 24530 N 11 338.58 321.65 369.90 24530 F 11 307.72 292.33 336.18 24535 N 11 561.31 533.24 613.23 24535 F 11 521.63 495.55 569.88 24538 11 688.16 653.75 751.81 24545 11 860.11 817.10 939.67 24546 11 973.33 924.66 1063.36 24560 N 11 283.78 269.59 310.03 24560 F 11 253.86 241.17 277.35 24565 N 11 474.03 450.33 517.88 24565 F 11 437.49 415.62 477.96 24566 11 657.84 624.95 718.69 24575 11 678.28 644.37 741.03 24576 N 11 300.73 285.69 328.54 24576 F 11 271.12 257.56 296.19 24577 N 11 490.63 466.10 536.02 24577 F 11 451.89 429.30 493.70 24579 11 773.96 735.26 845.55 24582 11 737.29 700.43 805.49 24586 11 1015.76 964.97 1109.72 24587 11 1014.94 964.19 1108.82 24600 N 11 325.80 309.51 355.94 24600 F 11 298.72 283.78 326.35 24605 11 425.30 404.04 464.65 24615 11 661.61 628.53 722.81 24620 11 509.07 483.62 556.16 24635 11 651.40 618.83 711.65 24640 N 11 114.80 109.06 125.42 24640 F 11 81.41 77.34 88.94 24650 N 11 230.74 219.20 252.08 24650 F 11 210.90 200.36 230.41 24655 N 11 391.70 372.12 427.94 24655 F 11 359.25 341.29 392.48 24665 11 600.61 570.58 656.17 24666 11 678.51 644.58 741.27 24670 N 11 258.07 245.17 281.95 24670 F 11 232.87 221.23 254.41 24675 N 11 412.59 391.96 450.75 24675 F 11 379.52 360.54 414.62 24685 11 601.63 571.55 657.28 24800 11 756.13 718.32 826.07 24802 11 931.53 884.95 1017.69 24900 11 674.22 640.51 736.59 24920 11 670.81 637.27 732.86 24925 11 519.28 493.32 567.32 24930 11 710.93 675.38 776.69 24931 11 734.68 697.95 802.64 24935 11 901.44 856.37 984.83 25000 11 315.68 299.90 344.89 25001 11 311.29 295.73 340.09 25020 11 531.17 504.61 580.30 25023 11 1021.81 970.72 1116.33 25024 11 721.08 685.03 787.78 25025 11 1130.24 1073.73 1234.79 25028 11 475.59 451.81 519.58 25031 11 334.06 317.36 364.96 25035 11 569.57 541.09 622.25 25040 11 524.57 498.34 573.09 25065 N 11 233.69 222.01 255.31 25065 F 11 154.95 147.20 169.28 25066 11 339.38 322.41 370.77 25071 11 406.69 386.36 444.31 25073 11 508.53 483.10 555.57 25075 N 11 440.38 418.36 481.11 25075 F 11 301.48 286.41 329.37 25076 11 478.97 455.02 523.27 25077 11 820.08 779.08 895.94 25078 11 1062.97 1009.82 1161.29 25085 11 423.00 401.85 462.13 25100 11 318.46 302.54 347.92 25101 11 373.92 355.22 408.50 25105 11 450.72 428.18 492.41 25107 11 571.99 543.39 624.90 25109 11 492.41 467.79 537.96 25110 11 323.18 307.02 353.07 25111 11 292.38 277.76 319.42 25112 11 355.20 337.44 388.06 25115 11 730.00 693.50 797.53 25116 11 581.67 552.59 635.48 25118 11 353.52 335.84 386.22 25119 11 464.63 441.40 507.61 25120 11 487.90 463.51 533.04 25125 11 575.65 546.87 628.90 25126 11 577.95 549.05 631.41 25130 11 416.20 395.39 454.70 25135 11 517.91 492.01 565.81 25136 11 456.04 433.24 498.23 25145 11 503.36 478.19 549.92 25150 11 529.94 503.44 578.96 25151 11 568.75 540.31 621.36 25170 11 1321.33 1255.26 1443.55 25210 11 454.61 431.88 496.66 25215 11 579.67 550.69 633.29 25230 11 401.08 381.03 438.18 25240 11 401.79 381.70 438.96 25246 N 11 154.19 146.48 168.45 25246 F 11 71.99 68.39 78.65 25248 11 395.53 375.75 432.11 25250 11 486.89 462.55 531.93 25251 11 666.47 633.15 728.12 25259 11 371.32 352.75 405.66 25260 11 609.59 579.11 665.98 25263 11 606.51 576.18 662.61 25265 11 721.62 685.54 788.37 25270 11 482.06 457.96 526.65 25272 11 541.84 514.75 591.96 25274 11 648.04 615.64 707.99 25275 11 624.78 593.54 682.57 25280 11 550.19 522.68 601.08 25290 11 447.46 425.09 488.85 25295 11 511.92 486.32 559.27 25300 11 635.87 604.08 694.69 25301 11 600.09 570.09 655.60 25310 11 599.76 569.77 655.24 25312 11 696.12 661.31 760.51 25315 11 746.18 708.87 815.20 25316 11 854.53 811.80 933.57 25320 11 912.44 866.82 996.84 25332 11 785.59 746.31 858.26 25335 11 791.56 751.98 864.78 25337 11 827.68 786.30 904.25 25350 11 654.84 622.10 715.42 25355 11 740.71 703.67 809.22 25360 11 635.99 604.19 694.82 25365 11 877.24 833.38 958.39 25370 11 961.34 913.27 1050.26 25375 11 878.89 834.95 960.19 25390 11 745.62 708.34 814.59 25391 11 956.95 909.10 1045.47 25392 11 974.72 925.98 1064.88 25393 11 1109.55 1054.07 1212.18 25394 11 726.09 689.79 793.26 25400 11 779.42 740.45 851.52 25405 11 998.28 948.37 1090.63 25415 11 944.11 896.90 1031.44 25420 11 1123.42 1067.25 1227.34 25425 11 949.67 902.19 1037.52 25426 11 1046.32 994.00 1143.10 25430 11 655.45 622.68 716.08 25431 11 728.31 691.89 795.67 25440 11 717.45 681.58 783.82 25441 11 869.95 826.45 950.42 25442 11 738.96 702.01 807.31 25443 11 725.34 689.07 792.43 25444 11 748.93 711.48 818.20 25445 11 669.32 635.85 731.23 25446 11 1097.25 1042.39 1198.75 25447 11 764.28 726.07 834.98 25449 11 972.97 924.32 1062.97 25450 11 524.04 497.84 572.52 25455 11 588.56 559.13 643.00 25490 11 658.62 625.69 719.54 25491 11 716.21 680.40 782.46 25492 11 867.15 823.79 947.36 25500 N 11 238.13 226.22 260.15 25500 F 11 218.28 207.37 238.48 25505 N 11 452.75 430.11 494.63 25505 F 11 417.79 396.90 456.44 25515 11 616.75 585.91 673.80 25520 N 11 507.35 481.98 554.28 25520 F 11 482.78 458.64 527.44 25525 11 732.15 695.54 799.87 25526 11 901.34 856.27 984.71 25530 N 11 230.34 218.82 251.64 25530 F 11 208.29 197.88 227.56 25535 N 11 440.64 418.61 481.40 25535 F 11 411.35 390.78 449.40 25545 11 574.75 546.01 627.91 25560 N 11 241.62 229.54 263.97 25560 F 11 218.00 207.10 238.17 25565 N 11 472.97 449.32 516.72 25565 F 11 432.34 410.72 472.33 25574 11 618.06 587.16 675.23 25575 11 832.18 790.57 909.16 25600 N 11 260.01 247.01 284.06 25600 F 11 236.70 224.87 258.60 25605 N 11 564.63 536.40 616.86 25605 F 11 534.40 507.68 583.83 25606 11 613.54 582.86 670.29 25607 11 672.76 639.12 734.99 25608 11 756.54 718.71 826.52 25609 11 965.03 916.78 1054.30 25622 N 11 268.85 255.41 293.72 25622 F 11 244.29 232.08 266.89 25624 N 11 415.83 395.04 454.30 25624 F 11 379.93 360.93 415.07 25628 11 666.17 632.86 727.79 25630 N 11 272.57 258.94 297.78 25630 F 11 248.94 236.49 271.96 25635 N 11 402.98 382.83 440.25 25635 F 11 364.87 346.63 398.62 25645 11 524.04 497.84 572.52 25650 N 11 285.94 271.64 312.39 25650 F 11 266.10 252.80 290.72 25651 11 442.35 420.23 483.26 25652 11 573.51 544.83 626.55 25660 11 368.30 349.89 402.37 25670 11 560.09 532.09 611.90 25671 11 484.98 460.73 529.84 25675 N 11 390.70 371.17 426.85 25675 F 11 359.52 341.54 392.77 25676 11 583.55 554.37 637.53 25680 11 424.01 402.81 463.23 25685 11 679.39 645.42 742.23 25690 11 433.56 411.88 473.66 25695 11 585.57 556.29 639.73 25800 11 684.82 650.58 748.17 25805 11 790.82 751.28 863.97 25810 11 808.37 767.95 883.14 25820 11 566.72 538.38 619.14 25825 11 700.36 665.34 765.14 25830 11 878.52 834.59 959.78 25900 11 680.45 646.43 743.39 25905 11 670.03 636.53 732.01 25907 11 586.08 556.78 640.30 25909 11 655.91 623.11 716.58 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 009 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 25915 11 1061.22 1008.16 1159.38 25920 11 640.30 608.29 699.53 25922 11 486.49 462.17 531.50 25924 11 593.44 563.77 648.34 25927 11 735.71 698.92 803.76 25929 11 546.16 518.85 596.68 25931 11 640.43 608.41 699.67 26010 N 11 231.52 219.94 252.93 26010 F 11 124.12 117.91 135.60 26011 N 11 350.51 332.98 382.93 26011 F 11 169.72 161.23 185.41 26020 11 396.64 376.81 433.33 26025 11 385.16 365.90 420.79 26030 11 453.60 430.92 495.56 26034 11 492.76 468.12 538.34 26035 11 781.09 742.04 853.35 26037 11 527.83 501.44 576.66 26040 11 283.40 269.23 309.61 26045 11 428.67 407.24 468.33 26055 N 11 509.62 484.14 556.76 26055 F 11 278.12 264.21 303.84 26060 11 243.47 231.30 266.00 26070 11 280.02 266.02 305.92 26075 11 293.95 279.25 321.14 26080 11 354.54 336.81 387.33 26100 11 300.69 285.66 328.51 26105 11 305.02 289.77 333.24 26110 11 292.62 277.99 319.69 26111 11 397.59 377.71 434.37 26113 11 521.46 495.39 569.70 26115 N 11 509.16 483.70 556.26 26115 F 11 316.40 300.58 345.67 26116 11 485.02 460.77 529.89 26117 11 677.70 643.82 740.39 26118 11 1018.09 967.19 1112.27 26121 11 551.88 524.29 602.93 26123 11 767.45 729.08 838.44 26125 11 262.23 249.12 286.49 26130 11 421.65 400.57 460.66 26135 11 509.00 483.55 556.08 26140 11 465.02 441.77 508.04 26145 11 471.98 448.38 515.64 26160 N 11 517.22 491.36 565.06 26160 F 11 301.47 286.40 329.36 26170 11 372.89 354.25 407.39 26180 11 405.13 384.87 442.60 26185 11 498.58 473.65 544.70 26200 11 414.82 394.08 453.19 26205 11 556.57 528.74 608.05 26210 11 405.56 385.28 443.07 26215 11 516.69 490.86 564.49 26230 11 461.34 438.27 504.01 26235 11 456.21 433.40 498.41 26236 11 405.65 385.37 443.18 26250 11 919.89 873.90 1004.99 26260 11 720.44 684.42 787.08 26262 11 553.56 525.88 604.76 26320 11 318.01 302.11 347.43 26340 11 297.54 282.66 325.06 26350 11 649.98 617.48 710.10 26352 11 742.10 705.00 810.75 26356 11 992.95 943.30 1084.80 26357 11 793.02 753.37 866.38 26358 11 846.81 804.47 925.14 26370 11 700.09 665.09 764.85 26372 11 810.96 770.41 885.97 26373 11 774.70 735.97 846.37 26390 11 763.12 724.96 833.70 26392 11 889.61 845.13 971.90 26410 11 515.76 489.97 563.47 26412 11 626.14 594.83 684.05 26415 11 643.69 611.51 703.24 26416 11 767.36 728.99 838.34 26418 11 523.01 496.86 571.39 26420 11 648.76 616.32 708.77 26426 11 496.47 471.65 542.40 26428 11 687.77 653.38 751.39 26432 11 452.79 430.15 494.67 26433 11 484.49 460.27 529.31 26434 11 585.84 556.55 640.03 26437 11 567.47 539.10 619.97 26440 11 567.49 539.12 619.99 26442 11 878.66 834.73 959.94 26445 11 527.40 501.03 576.18 26449 11 677.46 643.59 740.13 26450 11 367.90 349.51 401.94 26455 11 366.47 348.15 400.37 26460 11 356.79 338.95 389.79 26471 11 560.64 532.61 612.50 26474 11 545.64 518.36 596.11 26476 11 534.13 507.42 583.53 26477 11 530.31 503.79 579.36 26478 11 569.74 541.25 622.44 26479 11 567.32 538.95 619.79 26480 11 687.54 653.16 751.13 26483 11 773.05 734.40 844.56 26485 11 740.62 703.59 809.13 26489 11 830.98 789.43 907.84 26490 11 726.32 690.00 793.50 26492 11 804.79 764.55 879.23 26494 11 728.99 692.54 796.42 26496 11 786.28 746.97 859.02 26497 11 791.13 751.57 864.31 26498 11 1052.15 999.54 1149.47 26499 11 756.92 719.07 826.93 26500 11 572.85 544.21 625.84 26502 11 652.05 619.45 712.37 26508 11 575.84 547.05 629.11 26510 11 543.95 516.75 594.26 26516 11 640.64 608.61 699.90 26517 11 754.58 716.85 824.38 26518 11 767.79 729.40 838.81 26520 11 595.51 565.73 650.59 26525 11 596.25 566.44 651.41 26530 11 494.33 469.61 540.05 26531 11 575.95 547.15 629.22 26535 11 376.91 358.06 411.77 26536 11 631.95 600.35 690.40 26540 11 602.33 572.21 658.04 26541 11 732.41 695.79 800.16 26542 11 623.37 592.20 681.03 26545 11 636.83 604.99 695.74 26546 11 903.37 858.20 986.93 26548 11 699.94 664.94 764.68 26550 11 1452.63 1380.00 1587.00 26551 11 2833.40 2691.73 3095.49 26553 11 2821.30 2680.24 3082.28 26554 11 3102.63 2947.50 3389.63 26555 11 1263.05 1199.90 1379.89 26556 11 2705.33 2570.06 2955.57 26560 11 531.46 504.89 580.62 26561 11 867.25 823.89 947.47 26562 11 1180.09 1121.09 1289.25 26565 11 620.11 589.10 677.47 26567 11 621.99 590.89 679.52 26568 11 819.76 778.77 895.59 26580 11 1257.99 1195.09 1374.35 26587 11 956.09 908.29 1044.53 26590 11 1170.35 1111.83 1278.60 26591 11 397.72 377.83 434.50 26593 11 545.40 518.13 595.85 26596 11 685.67 651.39 749.10 26600 N 11 256.45 243.63 280.17 26600 F 11 239.75 227.76 261.92 26605 N 11 286.74 272.40 313.26 26605 F 11 261.86 248.77 286.09 26607 11 410.36 389.84 448.32 26608 11 436.93 415.08 477.34 26615 11 521.59 495.51 569.84 26641 N 11 324.61 308.38 354.64 26641 F 11 298.47 283.55 326.08 26645 N 11 379.45 360.48 414.55 26645 F 11 349.85 332.36 382.21 26650 11 437.15 415.29 477.58 26665 11 573.21 544.55 626.23 26670 N 11 296.59 281.76 324.02 26670 F 11 269.81 256.32 294.77 26675 N 11 403.72 383.53 441.06 26675 F 11 372.85 354.21 407.34 26676 11 457.62 434.74 499.95 26685 11 526.08 499.78 574.75 26686 11 573.82 545.13 626.90 26700 N 11 283.85 269.66 310.11 26700 F 11 266.52 253.19 291.17 26705 N 11 372.24 353.63 406.67 26705 F 11 341.68 324.60 373.29 26706 11 401.13 381.07 438.23 26715 11 519.11 493.15 567.12 26720 N 11 173.78 165.09 189.85 26720 F 11 160.55 152.52 175.40 26725 N 11 304.17 288.96 332.30 26725 F 11 274.56 260.83 299.95 26727 11 430.34 408.82 470.14 26735 11 541.61 514.53 591.71 26740 N 11 202.41 192.29 221.13 26740 F 11 190.12 180.61 207.70 26742 N 11 331.19 314.63 361.82 26742 F 11 301.59 286.51 329.49 26746 11 673.08 639.43 735.34 26750 N 11 161.91 153.81 176.88 26750 F 11 160.02 152.02 174.82 26755 N 11 280.05 266.05 305.96 26755 F 11 245.40 233.13 268.10 26756 11 380.83 361.79 416.06 26765 11 449.46 426.99 491.04 26770 N 11 241.54 229.46 263.88 26770 F 11 223.59 212.41 244.27 26775 N 11 342.25 325.14 373.91 26775 F 11 309.50 294.03 338.13 26776 11 404.15 383.94 441.53 26785 11 490.57 466.04 535.95 26820 11 718.96 683.01 785.46 26841 11 666.30 632.99 727.94 26842 11 722.53 686.40 789.36 26843 11 672.36 638.74 734.55 26844 11 748.52 711.09 817.75 26850 11 634.01 602.31 692.66 26852 11 728.50 692.08 795.89 26860 11 512.20 486.59 559.58 26861 11 98.63 93.70 107.76 26862 11 663.42 630.25 724.79 26863 11 220.13 209.12 240.49 26910 11 655.41 622.64 716.04 26951 11 584.28 555.07 638.33 26952 11 592.32 562.70 647.11 26990 11 573.54 544.86 626.59 26991 N 11 643.53 611.35 703.05 26991 F 11 483.85 459.66 528.61 26992 11 893.05 848.40 975.66 27000 11 406.42 386.10 444.02 27001 11 499.08 474.13 545.25 27003 11 546.45 519.13 597.00 27005 11 674.61 640.88 737.01 27006 11 683.62 649.44 746.86 27025 11 843.63 801.45 921.67 27027 11 789.78 750.29 862.83 27030 11 873.94 830.24 954.78 27033 11 909.40 863.93 993.52 27035 11 1067.74 1014.35 1166.50 27036 11 937.07 890.22 1023.75 27040 N 11 311.41 295.84 340.22 27040 F 11 186.69 177.36 203.96 27041 11 632.18 600.57 690.66 27043 11 445.03 422.78 486.20 27045 11 706.53 671.20 771.88 27047 N 11 448.11 425.70 489.56 27047 F 11 354.88 337.14 387.71 27048 11 551.72 524.13 602.75 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 010 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 27049 11 1228.39 1166.97 1342.02 27050 11 348.23 330.82 380.44 27052 11 525.30 499.04 573.90 27054 11 632.61 600.98 691.13 27057 11 888.87 844.43 971.09 27059 11 1732.76 1646.12 1893.04 27060 11 415.41 394.64 453.84 27062 11 418.61 397.68 457.33 27065 11 465.59 442.31 508.66 27066 11 752.58 714.95 822.19 27067 11 963.64 915.46 1052.78 27070 11 789.40 749.93 862.42 27071 11 845.41 803.14 923.61 27075 11 1967.17 1868.81 2149.13 27076 11 2253.75 2141.06 2462.22 27077 11 2640.31 2508.29 2884.53 27078 11 1800.18 1710.17 1966.70 27080 11 466.79 443.45 509.97 27086 N 11 224.74 213.50 245.53 27086 F 11 136.55 129.72 149.18 27087 11 584.44 555.22 638.50 27090 11 772.23 733.62 843.66 27091 11 1497.70 1422.82 1636.24 27093 N 11 177.44 168.57 193.86 27093 F 11 67.20 63.84 73.42 27095 N 11 216.96 206.11 237.03 27095 F 11 78.06 74.16 85.28 27096 N 11 173.45 164.78 189.50 27096 F 11 67.94 64.54 74.22 27097 11 624.49 593.27 682.26 27098 11 617.19 586.33 674.28 27100 11 764.66 726.43 835.39 27105 11 804.07 763.87 878.45 27110 11 896.80 851.96 979.75 27111 11 816.16 775.35 891.65 27120 11 1210.29 1149.78 1322.25 27122 11 1030.06 978.56 1125.34 27125 11 1057.15 1004.29 1154.93 27130 11 1351.85 1284.26 1476.90 27132 11 1578.45 1499.53 1724.46 27134 11 1816.02 1725.22 1984.00 27137 11 1389.80 1320.31 1518.36 27138 11 1446.20 1373.89 1579.97 27140 11 834.66 792.93 911.87 27146 11 1193.30 1133.64 1303.69 27147 11 1376.36 1307.54 1503.67 27151 11 1461.26 1388.20 1596.43 27156 11 1606.64 1526.31 1755.26 27158 11 1303.65 1238.47 1424.24 27161 11 1137.31 1080.44 1242.51 27165 11 1283.97 1219.77 1402.74 27170 11 1103.58 1048.40 1205.66 27175 11 618.83 587.89 676.07 27176 11 851.67 809.09 930.45 27177 11 1038.48 986.56 1134.54 27178 11 848.84 806.40 927.36 27179 11 908.37 862.95 992.39 27181 11 1042.85 990.71 1139.32 27185 11 570.41 541.89 623.17 27187 11 925.59 879.31 1011.21 27193 N 11 432.07 410.47 472.04 27193 F 11 436.79 414.95 477.19 27194 11 647.08 614.73 706.94 27200 N 11 160.46 152.44 175.31 27200 F 11 165.18 156.92 180.46 27202 11 557.24 529.38 608.79 27220 N 11 486.32 462.00 531.30 27220 F 11 482.54 458.41 527.17 27222 11 910.20 864.69 994.39 27226 11 979.70 930.72 1070.33 27227 11 1564.33 1486.11 1709.03 27228 11 1786.26 1696.95 1951.49 27230 N 11 433.16 411.50 473.23 27230 F 11 429.06 407.61 468.75 27232 11 715.96 680.16 782.18 27235 11 849.03 806.58 927.57 27236 11 1116.80 1060.96 1220.10 27238 11 419.55 398.57 458.36 27240 11 889.91 845.41 972.22 27244 11 1149.16 1091.70 1255.46 27245 11 1161.44 1103.37 1268.88 27246 N 11 352.55 334.92 385.16 27246 F 11 353.50 335.83 386.20 27248 11 697.12 662.26 761.60 27250 11 193.25 183.59 211.13 27252 11 703.23 668.07 768.28 27253 11 879.44 835.47 960.79 27254 11 1185.87 1126.58 1295.57 27256 N 11 270.23 256.72 295.23 27256 F 11 220.79 209.75 241.21 27257 11 311.91 296.31 340.76 27258 11 1035.61 983.83 1131.40 27259 11 1452.90 1380.26 1587.30 27265 11 361.13 343.07 394.53 27266 11 537.10 510.25 586.79 27267 11 392.51 372.88 428.81 27268 11 486.43 462.11 531.43 27269 11 1146.33 1089.01 1252.36 27275 11 164.57 156.34 179.79 27280 11 957.90 910.01 1046.51 27282 11 773.39 734.72 844.93 27284 11 1487.14 1412.78 1624.70 27286 11 1555.58 1477.80 1699.47 27290 11 1501.23 1426.17 1640.10 27295 11 1189.00 1129.55 1298.98 27301 N 11 609.00 578.55 665.33 27301 F 11 461.59 438.51 504.29 27303 11 591.59 562.01 646.31 27305 11 437.16 415.30 477.60 27306 11 346.03 328.73 378.04 27307 11 436.09 414.29 476.43 27310 11 676.42 642.60 738.99 27323 N 11 247.88 235.49 270.81 27323 F 11 166.94 158.59 182.38 27324 11 358.96 341.01 392.16 27325 11 502.20 477.09 548.65 27326 11 462.01 438.91 504.75 27327 N 11 402.23 382.12 439.44 27327 F 11 292.94 278.29 320.03 27328 11 546.05 518.75 596.56 27329 11 970.70 922.17 1060.50 27330 11 374.18 355.47 408.79 27331 11 437.11 415.25 477.54 27332 11 591.51 561.93 646.22 27333 11 538.59 511.66 588.41 27334 11 631.30 599.74 689.70 27335 11 708.95 673.50 774.53 27337 11 397.84 377.95 434.64 27339 11 715.98 680.18 782.21 27340 11 338.21 321.30 369.50 27345 11 442.78 420.64 483.74 27347 11 483.01 458.86 527.69 27350 11 602.37 572.25 658.09 27355 11 557.28 529.42 608.83 27356 11 682.54 648.41 745.67 27357 11 754.69 716.96 824.50 27358 11 267.12 253.76 291.82 27360 11 788.61 749.18 861.56 27364 11 1488.07 1413.67 1625.72 27365 11 1828.98 1737.53 1998.16 27370 N 11 156.30 148.49 170.76 27370 F 11 50.16 47.65 54.80 27372 N 11 548.85 521.41 599.62 27372 F 11 374.04 355.34 408.64 27380 11 546.48 519.16 597.03 27381 11 740.53 703.50 809.03 27385 11 584.24 555.03 638.28 27386 11 770.13 731.62 841.36 27390 11 409.28 388.82 447.14 27391 11 530.43 503.91 579.50 27392 11 655.01 622.26 715.60 27393 11 466.86 443.52 510.05 27394 11 601.35 571.28 656.97 27395 11 816.33 775.51 891.84 27396 11 569.05 540.60 621.69 27397 11 847.31 804.94 925.68 27400 11 640.84 608.80 700.12 27403 11 593.00 563.35 647.85 27405 11 626.71 595.37 684.68 27407 11 725.15 688.89 792.22 27409 11 898.31 853.39 981.40 27412 11 1543.87 1466.68 1686.68 27415 11 1279.05 1215.10 1397.37 27416 11 906.92 861.57 990.81 27418 11 773.52 734.84 845.07 27420 11 692.46 657.84 756.52 27422 11 689.59 655.11 753.38 27424 11 690.52 655.99 754.39 27425 11 409.50 389.03 447.38 27427 11 665.22 631.96 726.75 27428 11 1033.50 981.83 1129.10 27429 11 1156.32 1098.50 1263.28 27430 11 686.32 652.00 749.80 27435 11 744.98 707.73 813.89 27437 11 612.11 581.50 668.73 27438 11 781.51 742.43 853.79 27440 11 727.92 691.52 795.25 27441 11 751.64 714.06 821.17 27442 11 808.37 767.95 883.14 27443 11 758.65 720.72 828.83 27445 11 1174.73 1115.99 1283.39 27446 11 1037.42 985.55 1133.38 27447 11 1445.01 1372.76 1578.67 27448 11 761.93 723.83 832.40 27450 11 947.39 900.02 1035.02 27454 11 1208.06 1147.66 1319.81 27455 11 877.35 833.48 958.50 27457 11 900.87 855.83 984.20 27465 11 1163.02 1104.87 1270.60 27466 11 1101.93 1046.83 1203.85 27468 11 1252.83 1190.19 1368.72 27470 11 1102.16 1047.05 1204.11 27472 11 1186.22 1126.91 1295.95 27475 11 569.90 541.41 622.62 27477 11 679.97 645.97 742.87 27479 11 820.77 779.73 896.69 27485 11 622.02 590.92 679.56 27486 11 1321.17 1255.11 1443.38 27487 11 1658.91 1575.96 1812.35 27488 11 1123.08 1066.93 1226.97 27495 11 1056.22 1003.41 1153.92 27496 11 484.93 460.68 529.78 27497 11 523.09 496.94 571.48 27498 11 579.69 550.71 633.32 27499 11 630.20 598.69 688.49 27500 N 11 472.73 449.09 516.45 27500 F 11 439.66 417.68 480.33 27501 N 11 463.53 440.35 506.40 27501 F 11 458.50 435.58 500.92 27502 11 727.87 691.48 795.20 27503 11 746.46 709.14 815.51 27506 11 1250.67 1188.14 1366.36 27507 11 914.35 868.63 998.92 27508 N 11 478.01 454.11 522.23 27508 F 11 451.24 428.68 492.98 27509 11 595.97 566.17 651.10 27510 11 643.86 611.67 703.42 27511 11 945.73 898.44 1033.21 27513 11 1182.25 1123.14 1291.61 27514 11 927.79 881.40 1013.61 27516 N 11 456.58 433.75 498.81 27516 F 11 430.44 408.92 470.26 27517 11 632.79 601.15 691.32 27519 11 848.90 806.46 927.43 27520 N 11 287.76 273.37 314.38 27520 F 11 262.25 249.14 286.51 27524 11 699.40 664.43 764.09 27530 N 11 358.32 340.40 391.46 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 011 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 27530 F 11 334.38 317.66 365.31 27532 N 11 564.59 536.36 616.81 27532 F 11 533.10 506.45 582.42 27535 11 848.50 806.08 926.99 27536 11 1113.14 1057.48 1216.10 27538 N 11 427.32 405.95 466.84 27538 F 11 401.18 381.12 438.29 27540 11 760.85 722.81 831.23 27550 N 11 451.88 429.29 493.68 27550 F 11 421.01 399.96 459.95 27552 11 576.99 548.14 630.36 27556 11 834.77 793.03 911.98 27557 11 999.53 949.55 1091.98 27558 11 1134.44 1077.72 1239.38 27560 N 11 340.29 323.28 371.77 27560 F 11 313.52 297.84 342.52 27562 11 435.75 413.96 476.05 27566 11 830.57 789.04 907.40 27570 11 137.23 130.37 149.93 27580 11 1348.21 1280.80 1472.92 27590 11 779.41 740.44 851.51 27591 11 852.10 809.50 930.93 27592 11 662.00 628.90 723.24 27594 11 479.25 455.29 523.58 27596 11 691.54 656.96 755.50 27598 11 701.42 666.35 766.30 27600 11 393.52 373.84 429.92 27601 11 415.93 395.13 454.40 27602 11 482.69 458.56 527.34 27603 N 11 489.54 465.06 534.82 27603 F 11 364.82 346.58 398.57 27604 N 11 429.17 407.71 468.87 27604 F 11 315.15 299.39 344.30 27605 N 11 320.51 304.48 350.15 27605 F 11 178.14 169.23 194.61 27606 11 271.19 257.63 296.27 27607 11 572.05 543.45 624.97 27610 11 609.41 578.94 665.78 27612 11 526.03 499.73 574.69 27613 N 11 232.10 220.50 253.58 27613 F 11 154.94 147.19 169.27 27614 N 11 523.54 497.36 571.96 27614 F 11 381.81 362.72 417.13 27615 11 951.52 903.94 1039.53 27616 11 1215.94 1155.14 1328.41 27618 N 11 404.42 384.20 441.83 27618 F 11 295.13 280.37 322.43 27619 11 467.00 443.65 510.20 27620 11 427.54 406.16 467.08 27625 11 542.61 515.48 592.80 27626 11 590.14 560.63 644.72 27630 N 11 501.85 476.76 548.27 27630 F 11 342.79 325.65 374.50 27632 11 394.44 374.72 430.93 27634 11 641.28 609.22 700.60 27635 11 552.07 524.47 603.14 27637 11 705.41 670.14 770.66 27638 11 723.75 687.56 790.69 27640 11 796.11 756.30 869.75 27641 11 635.08 603.33 693.83 27645 11 1572.37 1493.75 1717.81 27646 11 1356.72 1288.88 1482.21 27647 11 1033.54 981.86 1129.14 27648 N 11 150.00 142.50 163.88 27648 F 11 49.84 47.35 54.45 27650 11 624.51 593.28 682.27 27652 11 668.41 634.99 730.24 27654 11 668.73 635.29 730.58 27656 N 11 536.05 509.25 585.64 27656 F 11 347.39 330.02 379.52 27658 11 353.32 335.65 386.00 27659 11 460.02 437.02 502.57 27664 11 340.01 323.01 371.46 27665 11 385.06 365.81 420.68 27675 11 464.48 441.26 507.45 27676 11 581.04 551.99 634.79 27680 11 403.86 383.67 441.22 27681 11 495.16 470.40 540.96 27685 N 11 594.82 565.08 649.84 27685 F 11 438.91 416.96 479.50 27686 11 520.44 494.42 568.58 27687 11 428.71 407.27 468.36 27690 11 596.15 566.34 651.29 27691 11 702.16 667.05 767.11 27692 11 103.10 97.95 112.64 27695 11 453.52 430.84 495.47 27696 11 534.66 507.93 584.12 27698 11 607.55 577.17 663.75 27700 11 565.65 537.37 617.98 27702 11 921.06 875.01 1006.26 27703 11 1066.64 1013.31 1165.31 27704 11 533.64 506.96 583.00 27705 11 713.08 677.43 779.04 27707 11 371.90 353.31 406.31 27709 11 1088.92 1034.47 1189.64 27712 11 1029.69 978.21 1124.94 27715 11 991.81 942.22 1083.55 27720 11 818.29 777.38 893.99 27722 11 823.83 782.64 900.04 27724 11 1195.95 1136.15 1306.57 27725 11 1133.58 1076.90 1238.44 27726 11 893.28 848.62 975.91 27727 11 938.48 891.56 1025.29 27730 11 540.05 513.05 590.01 27732 11 394.39 374.67 430.87 27734 11 558.78 530.84 610.47 27740 11 592.59 562.96 647.40 27742 11 662.76 629.62 724.06 27745 11 701.82 666.73 766.74 27750 N 11 309.25 293.79 337.86 27750 F 11 284.37 270.15 310.67 27752 N 11 491.33 466.76 536.77 27752 F 11 456.68 433.85 498.93 27756 11 529.87 503.38 578.89 27758 11 829.32 787.85 906.03 27759 11 934.60 887.87 1021.05 27760 N 11 298.89 283.95 326.54 27760 F 11 272.75 259.11 297.98 27762 N 11 438.80 416.86 479.39 27762 F 11 404.15 383.94 441.53 27766 11 565.49 537.22 617.80 27767 N 11 247.55 235.17 270.45 27767 F 11 248.81 236.37 271.83 27768 11 390.02 370.52 426.10 27769 11 667.05 633.70 728.76 27780 N 11 270.44 256.92 295.46 27780 F 11 246.19 233.88 268.96 27781 N 11 383.98 364.78 419.50 27781 F 11 357.83 339.94 390.93 27784 11 659.60 626.62 720.61 27786 N 11 282.79 268.65 308.95 27786 F 11 256.02 243.22 279.70 27788 N 11 384.05 364.85 419.58 27788 F 11 353.49 335.82 386.19 27792 11 660.36 627.34 721.44 27808 N 11 297.45 282.58 324.97 27808 F 11 267.84 254.45 292.62 27810 N 11 429.29 407.83 469.00 27810 F 11 394.02 374.32 430.47 27814 11 720.41 684.39 787.05 27816 N 11 282.92 268.77 309.09 27816 F 11 254.89 242.15 278.47 27818 N 11 440.57 418.54 481.32 27818 F 11 400.57 380.54 437.62 27822 11 787.92 748.52 860.80 27823 11 896.45 851.63 979.37 27824 N 11 281.64 267.56 307.69 27824 F 11 272.51 258.88 297.71 27825 N 11 501.84 476.75 548.26 27825 F 11 459.63 436.65 502.15 27826 11 774.90 736.16 846.58 27827 11 1013.04 962.39 1106.75 27828 11 1213.86 1153.17 1326.15 27829 11 628.55 597.12 686.69 27830 N 11 335.50 318.73 366.54 27830 F 11 313.76 298.07 342.78 27831 11 358.46 340.54 391.62 27832 11 686.03 651.73 749.49 27840 11 328.39 311.97 358.77 27842 11 454.32 431.60 496.34 27846 11 685.39 651.12 748.79 27848 11 770.66 732.13 841.95 27860 11 163.17 155.01 178.26 27870 11 977.96 929.06 1068.42 27871 11 645.68 613.40 705.41 27880 11 882.32 838.20 963.93 27881 11 835.51 793.73 912.79 27882 11 590.46 560.94 645.08 27884 11 553.27 525.61 604.45 27886 11 630.49 598.97 688.82 27888 11 651.77 619.18 712.06 27889 11 645.03 612.78 704.70 27892 11 516.07 490.27 563.81 27893 11 545.23 517.97 595.67 27894 11 805.37 765.10 879.87 28001 N 11 248.67 236.24 271.68 28001 F 11 163.01 154.86 178.09 28002 N 11 470.30 446.79 513.81 28002 F 11 358.49 340.57 391.66 28003 N 11 627.74 596.35 685.80 28003 F 11 514.04 488.34 561.59 28005 11 565.41 537.14 617.71 28008 N 11 393.33 373.66 429.71 28008 F 11 280.57 266.54 306.52 28010 N 11 216.36 205.54 236.37 28010 F 11 198.72 188.78 217.10 28011 N 11 306.83 291.49 335.21 28011 F 11 280.05 266.05 305.96 28020 N 11 478.44 454.52 522.70 28020 F 11 337.66 320.78 368.90 28022 N 11 434.44 412.72 474.63 28022 F 11 306.25 290.94 334.58 28024 N 11 410.71 390.17 448.70 28024 F 11 288.19 273.78 314.85 28035 N 11 474.72 450.98 518.63 28035 F 11 337.08 320.23 368.26 28039 N 11 459.14 436.18 501.61 28039 F 11 323.71 307.52 353.65 28041 11 424.88 403.64 464.19 28043 N 11 347.85 330.46 380.03 28043 F 11 253.04 240.39 276.45 28045 N 11 463.14 439.98 505.98 28045 F 11 333.37 316.70 364.21 28046 11 707.61 672.23 773.06 28047 11 891.56 846.98 974.03 28050 N 11 400.25 380.24 437.28 28050 F 11 278.05 264.15 303.77 28052 N 11 387.54 368.16 423.38 28052 F 11 264.08 250.88 288.51 28054 N 11 349.50 332.03 381.83 28054 F 11 231.70 220.12 253.14 28055 11 363.12 344.96 396.70 28060 N 11 466.97 443.62 510.16 28060 F 11 337.52 320.64 368.74 28062 N 11 539.56 512.58 589.47 28062 F 11 390.90 371.36 427.06 28070 N 11 473.95 450.25 517.79 28070 F 11 334.11 317.40 365.01 28072 N 11 463.46 440.29 506.33 28072 F 11 321.73 305.64 351.49 28080 N 11 463.63 440.45 506.52 28080 F 11 337.96 321.06 369.22 28086 N 11 491.30 466.74 536.75 28086 F 11 338.22 321.31 369.51 28088 N 11 431.00 409.45 470.87 28088 F 11 285.18 270.92 311.56 28090 N 11 422.86 401.72 461.98 28090 F 11 291.84 277.25 318.84 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 012 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 28092 N 11 383.94 364.74 419.45 28092 F 11 257.01 244.16 280.78 28100 N 11 540.45 513.43 590.44 28100 F 11 382.02 362.92 417.36 28102 11 528.04 501.64 576.89 28103 11 392.35 372.73 428.64 28104 N 11 463.78 440.59 506.68 28104 F 11 328.35 311.93 358.72 28106 11 421.55 400.47 460.54 28107 N 11 489.93 465.43 535.24 28107 F 11 344.73 327.49 376.61 28108 N 11 393.50 373.83 429.90 28108 F 11 272.24 258.63 297.42 28110 N 11 414.46 393.74 452.80 28110 F 11 273.04 259.39 298.30 28111 N 11 465.19 441.93 508.22 28111 F 11 318.74 302.80 348.22 28112 N 11 445.39 423.12 486.59 28112 F 11 299.24 284.28 326.92 28113 N 11 539.44 512.47 589.34 28113 F 11 402.43 382.31 439.66 28114 N 11 976.04 927.24 1066.33 28114 F 11 783.29 744.13 855.75 28116 N 11 688.42 654.00 752.10 28116 F 11 540.39 513.37 590.38 28118 N 11 534.35 507.63 583.77 28118 F 11 389.47 370.00 425.50 28119 N 11 474.38 450.66 518.26 28119 F 11 341.78 324.69 373.39 28120 N 11 646.82 614.48 706.65 28120 F 11 495.01 470.26 540.80 28122 N 11 602.57 572.44 658.31 28122 F 11 471.86 448.27 515.51 28124 N 11 433.32 411.65 473.40 28124 F 11 314.58 298.85 343.68 28126 N 11 354.73 336.99 387.54 28126 F 11 236.62 224.79 258.51 28130 11 645.81 613.52 705.55 28140 N 11 564.21 536.00 616.40 28140 F 11 427.83 406.44 467.41 28150 N 11 393.61 373.93 430.02 28150 F 11 271.09 257.54 296.17 28153 N 11 371.25 352.69 405.59 28153 F 11 249.99 237.49 273.11 28160 N 11 379.55 360.57 414.66 28160 F 11 257.66 244.78 281.50 28171 11 808.10 767.70 882.86 28173 11 726.35 690.03 793.53 28175 11 457.38 434.51 499.69 28190 N 11 227.81 216.42 248.88 28190 F 11 126.71 120.37 138.43 28192 N 11 429.33 407.86 469.04 28192 F 11 300.82 285.78 328.65 28193 N 11 488.19 463.78 533.35 28193 F 11 354.96 337.21 387.79 28200 N 11 430.84 409.30 470.70 28200 F 11 299.18 284.22 326.85 28202 N 11 548.98 521.53 599.76 28202 F 11 407.56 387.18 445.26 28208 N 11 420.15 399.14 459.01 28208 F 11 291.33 276.76 318.27 28210 N 11 524.62 498.39 573.15 28210 F 11 389.19 369.73 425.19 28220 N 11 407.39 387.02 445.07 28220 F 11 288.33 273.91 315.00 28222 N 11 467.26 443.90 510.49 28222 F 11 340.02 323.02 371.47 28225 N 11 358.77 340.83 391.95 28225 F 11 241.29 229.23 263.61 28226 N 11 428.38 406.96 468.00 28226 F 11 297.99 283.09 325.55 28230 N 11 391.36 371.79 427.56 28230 F 11 271.67 258.09 296.80 28232 N 11 352.21 334.60 384.79 28232 F 11 235.04 223.29 256.78 28234 N 11 369.20 350.74 403.35 28234 F 11 251.09 238.54 274.32 28238 N 11 618.88 587.94 676.13 28238 F 11 468.01 444.61 511.30 28240 N 11 400.99 380.94 438.08 28240 F 11 279.41 265.44 305.26 28250 N 11 518.34 492.42 566.28 28250 F 11 380.39 361.37 415.58 28260 N 11 632.14 600.53 690.61 28260 F 11 491.36 466.79 536.81 28261 N 11 890.99 846.44 973.41 28261 F 11 733.51 696.83 801.35 28262 N 11 1271.31 1207.74 1388.90 28262 F 11 1060.29 1007.28 1158.37 28264 N 11 840.07 798.07 917.78 28264 F 11 667.79 634.40 729.56 28270 N 11 443.16 421.00 484.15 28270 F 11 317.17 301.31 346.51 28272 N 11 356.63 338.80 389.62 28272 F 11 242.93 230.78 265.40 28280 N 11 475.09 451.34 519.04 28280 F 11 338.40 321.48 369.70 28285 N 11 426.48 405.16 465.93 28285 F 11 304.27 289.06 332.42 28286 N 11 413.62 392.94 451.88 28286 F 11 288.27 273.86 314.94 28288 N 11 547.37 520.00 598.00 28288 F 11 407.53 387.15 445.22 28289 N 11 672.61 638.98 734.83 28289 F 11 520.80 494.76 568.97 28290 N 11 529.09 502.64 578.04 28290 F 11 375.70 356.92 410.46 28292 N 11 720.71 684.67 787.37 28292 F 11 567.32 538.95 619.79 28293 N 11 953.44 905.77 1041.64 28293 F 11 675.64 641.86 738.14 28294 N 11 671.25 637.69 733.34 28294 F 11 500.86 475.82 547.19 28296 N 11 659.14 626.18 720.11 28296 F 11 499.14 474.18 545.31 28297 N 11 753.28 715.62 822.96 28297 F 11 563.99 535.79 616.16 28298 N 11 656.06 623.26 716.75 28298 F 11 481.89 457.80 526.47 28299 N 11 828.23 786.82 904.84 28299 F 11 648.70 616.27 708.71 28300 11 623.04 591.89 680.67 28302 11 648.09 615.69 708.04 28304 N 11 732.82 696.18 800.61 28304 F 11 562.74 534.60 614.79 28305 11 626.83 595.49 684.81 28306 N 11 556.32 528.50 607.78 28306 F 11 384.04 364.84 419.57 28307 N 11 640.90 608.86 700.19 28307 F 11 436.49 414.67 476.87 28308 N 11 504.67 479.44 551.36 28308 F 11 352.54 334.91 385.15 28309 11 842.68 800.55 920.63 28310 N 11 490.06 465.56 535.39 28310 F 11 337.31 320.44 368.51 28312 N 11 452.95 430.30 494.85 28312 F 11 301.14 286.08 328.99 28313 N 11 477.32 453.45 521.47 28313 F 11 345.36 328.09 377.30 28315 N 11 431.76 410.17 471.70 28315 F 11 307.04 291.69 335.44 28320 11 581.23 552.17 635.00 28322 N 11 713.70 678.02 779.72 28322 F 11 544.25 517.04 594.60 28340 N 11 544.06 516.86 594.39 28340 F 11 403.90 383.71 441.27 28341 N 11 629.03 597.58 687.22 28341 F 11 479.42 455.45 523.77 28344 N 11 411.74 391.15 449.82 28344 F 11 281.34 267.27 307.36 28345 N 11 497.18 472.32 543.17 28345 F 11 363.32 345.15 396.92 28360 11 973.44 924.77 1063.49 28400 N 11 223.61 212.43 244.29 28400 F 11 205.35 195.08 224.34 28405 N 11 359.17 341.21 392.39 28405 F 11 331.46 314.89 362.12 28406 11 487.04 462.69 532.09 28415 11 1054.91 1002.16 1152.48 28420 11 1149.74 1092.25 1256.09 28430 N 11 210.65 200.12 230.14 28430 F 11 187.66 178.28 205.02 28435 N 11 310.50 294.98 339.23 28435 F 11 282.78 268.64 308.94 28436 11 404.26 384.05 441.66 28445 11 996.33 946.51 1088.49 28446 11 1130.65 1074.12 1235.24 28450 N 11 193.92 184.22 211.85 28450 F 11 173.45 164.78 189.50 28455 N 11 267.52 254.14 292.26 28455 F 11 245.47 233.20 268.18 28456 11 277.50 263.63 303.17 28465 11 572.04 543.44 624.96 28470 N 11 191.46 181.89 209.17 28470 F 11 172.87 164.23 188.86 28475 N 11 236.60 224.77 258.49 28475 F 11 214.55 203.82 234.39 28476 11 317.08 301.23 346.41 28485 11 497.44 472.57 543.46 28490 N 11 127.18 120.82 138.94 28490 F 11 110.80 105.26 121.05 28495 N 11 159.28 151.32 174.02 28495 F 11 137.86 130.97 150.62 28496 N 11 389.25 369.79 425.26 28496 F 11 212.87 202.23 232.56 28505 N 11 612.57 581.94 669.23 28505 F 11 465.48 442.21 508.54 28510 N 11 109.40 103.93 119.52 28510 F 11 106.88 101.54 116.77 28515 N 11 143.72 136.53 157.01 28515 F 11 129.86 123.37 141.88 28525 N 11 518.63 492.70 566.61 28525 F 11 371.23 352.67 405.57 28530 N 11 104.16 98.95 113.79 28530 F 11 94.39 89.67 103.12 28531 N 11 329.27 312.81 359.73 28531 F 11 179.98 170.98 196.63 28540 N 11 184.31 175.09 201.35 28540 F 11 169.19 160.73 184.84 28545 N 11 247.77 235.38 270.69 28545 F 11 224.15 212.94 244.88 28546 N 11 475.36 451.59 519.33 28546 F 11 296.15 281.34 323.54 28555 N 11 800.48 760.46 874.53 28555 F 11 622.22 591.11 679.78 28570 N 11 151.98 144.38 166.04 28570 F 11 133.72 127.03 146.08 28575 N 11 318.02 302.12 347.44 28575 F 11 292.51 277.88 319.56 28576 11 347.83 330.44 380.01 28585 N 11 846.01 803.71 924.27 28585 F 11 683.81 649.62 747.06 28600 N 11 196.50 186.68 214.68 28600 F 11 172.88 164.24 188.88 28605 N 11 256.16 243.35 279.85 28605 F 11 236.00 224.20 257.83 28606 11 362.80 344.66 396.36 28615 11 734.61 697.88 802.56 28630 N 11 138.40 131.48 151.20 28630 F 11 102.50 97.38 111.99 28635 N 11 162.63 154.50 177.68 28635 F 11 127.04 120.69 138.79 28636 N 11 250.09 237.59 273.23 28636 F 11 174.82 166.08 190.99 28645 N 11 584.72 555.48 638.80 28645 F 11 448.35 425.93 489.82 28660 N 11 101.59 96.51 110.99 28660 F 11 80.81 76.77 88.29 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 013 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 28665 N 11 142.96 135.81 156.18 28665 F 11 125.63 119.35 137.25 28666 11 189.48 180.01 207.01 28675 N 11 529.62 503.14 578.61 28675 F 11 380.64 361.61 415.85 28705 11 1223.17 1162.01 1336.31 28715 11 914.17 868.46 998.73 28725 11 746.77 709.43 815.84 28730 11 791.74 752.15 864.97 28735 11 749.34 711.87 818.65 28737 11 647.72 615.33 707.63 28740 N 11 784.44 745.22 857.00 28740 F 11 593.26 563.60 648.14 28750 N 11 761.67 723.59 832.13 28750 F 11 566.08 537.78 618.45 28755 N 11 457.98 435.08 500.34 28755 F 11 312.15 296.54 341.02 28760 N 11 725.98 689.68 793.13 28760 F 11 551.49 523.92 602.51 28800 11 532.30 505.69 581.54 28805 11 717.79 681.90 784.19 28810 11 417.54 396.66 456.16 28820 N 11 483.22 459.06 527.92 28820 F 11 327.63 311.25 357.94 28825 N 11 533.90 507.21 583.29 28825 F 11 383.66 364.48 419.15 28890 N 11 315.43 299.66 344.61 28890 F 11 214.65 203.92 234.51 29000 N 11 267.64 254.26 292.40 29000 F 11 158.03 150.13 172.65 29010 N 11 256.52 243.69 280.24 29010 F 11 151.32 143.75 165.31 29015 N 11 216.90 206.06 236.97 29015 F 11 149.18 141.72 162.98 29020 N 11 196.66 186.83 214.85 29020 F 11 123.28 117.12 134.69 29025 N 11 227.92 216.52 249.00 29025 F 11 157.05 149.20 171.58 29035 N 11 224.11 212.90 244.84 29035 F 11 131.83 125.24 144.03 29040 N 11 215.08 204.33 234.98 29040 F 11 144.53 137.30 157.90 29044 N 11 247.36 234.99 270.24 29044 F 11 153.50 145.83 167.70 29046 N 11 244.32 232.10 266.92 29046 F 11 163.38 155.21 178.49 29049 N 11 84.11 79.90 91.89 29049 F 11 61.11 58.05 66.76 29055 N 11 193.81 184.12 211.74 29055 F 11 126.73 120.39 138.45 29058 N 11 93.22 88.56 101.84 29058 F 11 74.95 71.20 81.88 29065 N 11 85.49 81.22 93.40 29065 F 11 62.81 59.67 68.62 29075 N 11 79.75 75.76 87.12 29075 F 11 57.07 54.22 62.35 29085 N 11 84.72 80.48 92.55 29085 F 11 61.41 58.34 67.09 29086 N 11 67.30 63.94 73.53 29086 F 11 46.20 43.89 50.47 29105 N 11 77.79 73.90 84.99 29105 F 11 54.80 52.06 59.87 29125 N 11 62.01 58.91 67.75 29125 F 11 39.96 37.96 43.65 29126 N 11 70.87 67.33 77.43 29126 F 11 48.83 46.39 53.35 29130 N 11 36.85 35.01 40.26 29130 F 11 26.77 25.43 29.24 29131 N 11 46.65 44.32 50.97 29131 F 11 31.22 29.66 34.11 29200 N 11 48.74 46.30 53.25 29200 F 11 37.40 35.53 40.86 29240 N 11 52.66 50.03 57.53 29240 F 11 40.70 38.67 44.47 29260 N 11 46.91 44.56 51.24 29260 F 11 34.63 32.90 37.84 29280 N 11 45.64 43.36 49.86 29280 F 11 33.04 31.39 36.10 29305 N 11 216.76 205.92 236.81 29305 F 11 146.52 139.19 160.07 29325 N 11 240.90 228.86 263.19 29325 F 11 164.99 156.74 180.25 29345 N 11 122.38 116.26 133.70 29345 F 11 94.04 89.34 102.74 29355 N 11 127.26 120.90 139.04 29355 F 11 99.86 94.87 109.10 29358 N 11 141.18 134.12 154.24 29358 F 11 96.46 91.64 105.39 29365 N 11 110.22 104.71 120.42 29365 F 11 81.87 77.78 89.45 29405 N 11 80.14 76.13 87.55 29405 F 11 59.04 56.09 64.50 29425 N 11 85.87 81.58 93.82 29425 F 11 63.82 60.63 69.72 29435 N 11 107.07 101.72 116.98 29435 F 11 79.35 75.38 86.69 29440 N 11 44.18 41.97 48.27 29440 F 11 30.01 28.51 32.79 29445 N 11 129.57 123.09 141.55 29445 F 11 102.17 97.06 111.62 29450 N 11 134.90 128.16 147.38 29450 F 11 110.33 104.81 120.53 29505 N 11 69.73 66.24 76.18 29505 F 11 44.53 42.30 48.65 29515 N 11 65.19 61.93 71.22 29515 F 11 45.98 43.68 50.23 29520 N 11 45.40 43.13 49.60 29520 F 11 33.75 32.06 36.87 29530 N 11 47.59 45.21 51.99 29530 F 11 34.99 33.24 38.23 29540 N 11 31.08 29.53 33.96 29540 F 11 22.27 21.16 24.33 29550 N 11 24.85 23.61 27.15 29550 F 11 15.09 14.34 16.49 29580 N 11 48.00 45.60 52.44 29580 F 11 33.83 32.14 36.96 29581 N 11 85.92 81.62 93.86 29581 F 11 30.49 28.97 33.32 29590 N 11 49.32 46.85 53.88 29590 F 11 37.04 35.19 40.47 29700 N 11 59.13 56.17 64.60 29700 F 11 32.36 30.74 35.35 29705 N 11 60.68 57.65 66.30 29705 F 11 44.31 42.09 48.40 29710 N 11 110.27 104.76 120.47 29710 F 11 78.46 74.54 85.72 29715 N 11 78.14 74.23 85.36 29715 F 11 51.37 48.80 56.12 29720 N 11 73.40 69.73 80.19 29720 F 11 40.96 38.91 44.75 29730 N 11 58.86 55.92 64.31 29730 F 11 42.48 40.36 46.41 29740 N 11 82.79 78.65 90.45 29740 F 11 60.74 57.70 66.36 29750 N 11 92.83 88.19 101.42 29750 F 11 72.04 68.44 78.71 29800 11 486.03 461.73 530.99 29804 11 607.81 577.42 664.03 29805 11 435.56 413.78 475.85 29806 11 990.53 941.00 1082.15 29807 11 966.70 918.37 1056.13 29819 11 544.37 517.15 594.72 29820 11 501.14 476.08 547.49 29821 11 548.45 521.03 599.18 29822 11 533.05 506.40 582.36 29823 11 581.99 552.89 635.82 29824 11 625.78 594.49 683.66 29825 11 543.11 515.95 593.34 29826 11 620.61 589.58 678.02 29827 11 1008.73 958.29 1102.03 29828 11 855.47 812.70 934.61 29830 11 420.47 399.45 459.37 29834 11 456.34 433.52 498.55 29835 11 469.14 445.68 512.53 29836 11 541.05 514.00 591.10 29837 11 490.91 466.36 536.31 29838 11 549.49 522.02 600.32 29840 11 416.54 395.71 455.07 29843 11 446.30 423.99 487.59 29844 11 461.32 438.25 503.99 29845 11 533.14 506.48 582.45 29846 11 484.27 460.06 529.07 29847 11 503.83 478.64 550.44 29848 11 469.30 445.84 512.72 29850 11 555.71 527.92 607.11 29851 11 869.72 826.23 950.16 29855 11 731.40 694.83 799.05 29856 11 932.38 885.76 1018.62 29860 11 613.77 583.08 670.54 29861 11 675.95 642.15 738.47 29862 11 758.26 720.35 828.40 29863 11 755.97 718.17 825.90 29866 11 976.43 927.61 1066.75 29867 11 1189.25 1129.79 1299.26 29868 11 1567.86 1489.47 1712.89 29870 N 11 539.43 512.46 589.33 29870 F 11 380.06 361.06 415.22 29871 11 475.12 451.36 519.06 29873 11 480.46 456.44 524.91 29874 11 499.83 474.84 546.07 29875 11 459.13 436.17 501.60 29876 11 608.76 578.32 665.07 29877 11 576.58 547.75 629.91 29879 11 615.41 584.64 672.34 29880 11 641.68 609.60 701.04 29881 11 599.57 569.59 655.03 29882 11 648.32 615.90 708.29 29883 11 783.05 743.90 855.49 29884 11 574.95 546.20 628.13 29885 11 696.75 661.91 761.20 29886 11 588.04 558.64 642.44 29887 11 692.30 657.69 756.34 29888 11 924.50 878.28 1010.02 29889 11 1137.53 1080.65 1242.75 29891 11 645.85 613.56 705.59 29892 11 620.90 589.86 678.34 29893 N 11 553.37 525.70 604.56 29893 F 11 402.19 382.08 439.39 29894 11 482.27 458.16 526.88 29895 11 461.71 438.62 504.41 29897 11 482.96 458.81 527.63 29898 11 538.34 511.42 588.13 29899 11 980.19 931.18 1070.86 29900 11 424.25 403.04 463.50 29901 11 479.14 455.18 523.46 29902 11 498.40 473.48 544.50 29904 11 585.97 556.67 640.17 29905 11 633.17 601.51 691.74 29906 11 666.39 633.07 728.03 29907 11 808.39 767.97 883.17 29914 11 966.04 917.74 1055.40 29915 11 984.46 935.24 1075.53 29916 11 984.46 935.24 1075.53 30000 N 11 214.04 203.34 233.84 30000 F 11 111.99 106.39 122.35 30020 N 11 212.01 201.41 231.62 30020 F 11 112.48 106.86 122.89 30100 N 11 130.82 124.28 142.92 30100 F 11 65.63 62.35 71.70 30110 N 11 212.25 201.64 231.89 30110 F 11 123.74 117.55 135.18 30115 11 403.62 383.44 440.96 30117 N 11 789.40 749.93 862.42 30117 F 11 315.07 299.32 344.22 30118 11 725.34 689.07 792.43 30120 N 11 484.80 460.56 529.64 30120 F 11 418.03 397.13 456.70 30124 11 256.97 244.12 280.74 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 014 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 30125 11 576.32 547.50 629.63 30130 11 353.76 336.07 386.48 30140 11 407.15 386.79 444.81 30150 11 734.17 697.46 802.08 30160 11 738.69 701.76 807.02 30200 N 11 105.00 99.75 114.71 30200 F 11 56.81 53.97 62.07 30210 N 11 138.59 131.66 151.41 30210 F 11 93.87 89.18 102.56 30220 N 11 276.05 262.25 301.59 30220 F 11 119.20 113.24 130.23 30300 N 11 210.62 200.09 230.10 30300 F 11 115.82 110.03 126.53 30310 11 192.33 182.71 210.12 30320 11 424.24 403.03 463.48 30400 11 962.56 914.43 1051.59 30410 11 1133.72 1077.03 1238.58 30420 11 1296.63 1231.80 1416.57 30430 11 846.35 804.03 924.63 30435 11 1133.62 1076.94 1238.48 30450 11 1449.84 1377.35 1583.95 30460 11 718.98 683.03 785.48 30462 11 1465.59 1392.31 1601.16 30465 11 926.70 880.37 1012.43 30520 11 580.27 551.26 633.95 30540 11 640.38 608.36 699.61 30545 11 825.15 783.89 901.47 30560 N 11 249.87 237.38 272.99 30560 F 11 130.19 123.68 142.23 30580 N 11 590.29 560.78 644.90 30580 F 11 470.92 447.37 514.48 30600 N 11 538.57 511.64 588.39 30600 F 11 411.01 390.46 449.03 30620 11 581.17 552.11 634.93 30630 11 588.68 559.25 643.14 30801 N 11 209.48 199.01 228.86 30801 F 11 126.02 119.72 137.68 30802 N 11 269.58 256.10 294.52 30802 F 11 178.24 169.33 194.73 30901 N 11 90.16 85.65 98.50 30901 F 11 54.57 51.84 59.62 30903 N 11 183.55 174.37 200.53 30903 F 11 77.41 73.54 84.57 30905 N 11 227.79 216.40 248.86 30905 F 11 98.34 93.42 107.43 30906 N 11 258.64 245.71 282.57 30906 F 11 128.88 122.44 140.81 30915 11 545.28 518.02 595.72 30920 11 787.53 748.15 860.37 30930 11 115.38 109.61 126.05 31000 N 11 167.11 158.75 182.56 31000 F 11 98.77 93.83 107.90 31002 11 188.11 178.70 205.51 31020 N 11 447.06 424.71 488.42 31020 F 11 331.15 314.59 361.78 31030 N 11 643.03 610.88 702.51 31030 F 11 489.33 464.86 534.59 31032 11 536.90 510.06 586.57 31040 11 706.00 670.70 771.31 31050 11 459.06 436.11 501.53 31051 11 605.97 575.67 662.02 31070 11 410.51 389.98 448.48 31075 11 738.65 701.72 806.98 31080 11 962.30 914.19 1051.32 31081 11 1269.04 1205.59 1386.43 31084 11 1103.22 1048.06 1205.27 31085 11 1229.60 1168.12 1343.34 31086 11 1058.90 1005.96 1156.85 31087 11 1030.67 979.14 1126.01 31090 11 954.76 907.02 1043.07 31200 11 510.97 485.42 558.23 31201 11 690.16 655.65 754.00 31205 11 824.38 783.16 900.63 31225 11 1761.33 1673.26 1924.25 31230 11 1967.99 1869.59 2150.03 31231 N 11 177.75 168.86 194.19 31231 F 11 73.50 69.83 80.30 31233 N 11 248.87 236.43 271.89 31233 F 11 132.33 125.71 144.57 31235 N 11 282.42 268.30 308.55 31235 F 11 156.12 148.31 170.56 31237 N 11 305.82 290.53 334.11 31237 F 11 175.11 166.35 191.30 31238 N 11 315.07 299.32 344.22 31238 F 11 190.35 180.83 207.95 31239 11 639.13 607.17 698.25 31240 11 155.64 147.86 170.04 31254 11 265.50 252.23 290.06 31255 11 389.43 369.96 425.45 31256 11 192.00 182.40 209.76 31267 11 308.62 293.19 337.17 31276 11 491.38 466.81 536.83 31287 11 225.51 214.23 246.36 31288 11 261.86 248.77 286.09 31290 11 1114.54 1058.81 1217.63 31291 11 1178.37 1119.45 1287.37 31292 11 960.91 912.86 1049.79 31293 11 1047.24 994.88 1144.11 31294 11 1200.27 1140.26 1311.30 31295 N 11 1888.07 1793.67 2062.72 31295 F 11 166.17 157.86 181.54 31296 N 11 3532.70 3356.07 3859.48 31296 F 11 198.52 188.59 216.88 31297 N 11 3498.72 3323.78 3822.35 31297 F 11 162.65 154.52 177.70 31300 11 1196.61 1136.78 1307.30 31320 11 613.30 582.64 670.04 31360 11 1953.16 1855.50 2133.83 31365 11 2427.51 2306.13 2652.05 31367 11 2083.81 1979.62 2276.56 31368 11 2315.05 2199.30 2529.20 31370 11 1956.33 1858.51 2137.29 31375 11 1854.65 1761.92 2026.21 31380 11 1826.62 1735.29 1995.58 31382 11 2005.07 1904.82 2190.54 31390 11 2694.96 2560.21 2944.24 31395 11 2847.07 2704.72 3110.43 31400 11 947.06 899.71 1034.67 31420 11 794.78 755.04 868.30 31500 11 105.13 99.87 114.85 31502 11 33.76 32.07 36.88 31505 N 11 77.75 73.86 84.94 31505 F 11 46.57 44.24 50.88 31510 N 11 198.72 188.78 217.10 31510 F 11 116.52 110.69 127.29 31511 N 11 198.57 188.64 216.94 31511 F 11 123.29 117.13 134.70 31512 N 11 196.80 186.96 215.00 31512 F 11 125.94 119.64 137.59 31513 11 127.90 121.51 139.74 31515 N 11 195.76 185.97 213.87 31515 F 11 105.68 100.40 115.46 31520 11 150.88 143.34 164.84 31525 N 11 236.95 225.10 258.87 31525 F 11 154.43 146.71 168.72 31526 11 153.43 145.76 167.62 31527 11 189.11 179.65 206.60 31528 11 140.50 133.48 153.50 31529 11 157.39 149.52 171.95 31530 11 192.59 182.96 210.40 31531 11 207.17 196.81 226.33 31535 11 184.74 175.50 201.83 31536 11 206.15 195.84 225.22 31540 11 236.79 224.95 258.69 31541 11 258.68 245.75 282.61 31545 11 354.18 336.47 386.94 31546 11 536.73 509.89 586.37 31560 11 306.73 291.39 335.10 31561 11 335.49 318.72 366.53 31570 N 11 325.28 309.02 355.37 31570 F 11 222.60 211.47 243.19 31571 11 243.98 231.78 266.55 31575 N 11 108.46 103.04 118.50 31575 F 11 73.18 69.52 79.95 31576 N 11 211.93 201.33 231.53 31576 F 11 119.65 113.67 130.72 31577 N 11 229.08 217.63 250.27 31577 F 11 144.04 136.84 157.37 31578 N 11 266.05 252.75 290.66 31578 F 11 165.89 157.60 181.24 31579 N 11 203.63 193.45 222.47 31579 F 11 136.54 129.71 149.17 31580 11 1150.72 1093.18 1257.16 31582 11 1805.76 1715.47 1972.79 31584 11 1437.03 1365.18 1569.96 31587 11 953.20 905.54 1041.37 31588 11 1084.33 1030.11 1184.63 31590 11 839.89 797.90 917.59 31595 11 724.77 688.53 791.81 31600 11 380.60 361.57 415.81 31601 11 252.44 239.82 275.79 31603 11 214.98 204.23 234.86 31605 11 175.34 166.57 191.56 31610 11 674.46 640.74 736.85 31611 11 508.43 483.01 555.46 31612 N 11 76.58 72.75 83.66 31612 F 11 46.02 43.72 50.28 31613 11 422.43 401.31 461.51 31614 11 707.52 672.14 772.96 31615 N 11 172.69 164.06 188.67 31615 F 11 123.24 117.08 134.64 31620 N 11 260.07 247.07 284.13 31620 F 11 65.74 62.45 71.82 31622 N 11 294.96 280.21 322.24 31622 F 11 140.63 133.60 153.64 31623 N 11 317.01 301.16 346.33 31623 F 11 141.57 134.49 154.66 31624 N 11 296.54 281.71 323.97 31624 F 11 141.89 134.80 155.02 31625 N 11 319.02 303.07 348.53 31625 F 11 164.38 156.16 179.58 31626 N 11 418.02 397.12 456.69 31626 F 11 202.58 192.45 221.32 31627 N 11 1182.33 1123.21 1291.69 31627 F 11 98.86 93.92 108.01 31628 N 11 373.75 355.06 408.32 31628 F 11 183.19 174.03 200.13 31629 N 11 577.58 548.70 631.01 31629 F 11 197.42 187.55 215.68 31630 11 195.74 185.95 213.84 31631 11 222.92 211.77 243.54 31632 N 11 68.09 64.69 74.39 31632 F 11 47.62 45.24 52.03 31633 N 11 83.35 79.18 91.06 31633 F 11 60.99 57.94 66.63 31634 N 11 1679.18 1595.22 1834.50 31634 F 11 198.55 188.62 216.91 31635 N 11 327.29 310.93 357.57 31635 F 11 182.40 173.28 199.27 31636 11 216.19 205.38 236.19 31637 11 74.77 71.03 81.68 31638 11 247.08 234.73 269.94 31640 11 249.50 237.03 272.58 31641 11 249.52 237.04 272.60 31643 11 169.28 160.82 184.94 31645 N 11 286.26 271.95 312.74 31645 F 11 154.92 147.17 169.25 31646 N 11 260.55 247.52 284.65 31646 F 11 134.56 127.83 147.00 31656 N 11 288.72 274.28 315.42 31656 F 11 106.35 101.03 116.18 31715 11 51.82 49.23 56.61 31717 N 11 268.43 255.01 293.26 31717 F 11 106.23 100.92 116.06 31720 11 49.81 47.32 54.42 31725 11 91.63 87.05 100.11 31730 N 11 946.78 899.44 1034.36 31730 F 11 142.37 135.25 155.54 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 015 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 31750 11 1285.83 1221.54 1404.77 31755 11 1625.51 1544.23 1775.86 31760 11 1323.96 1257.76 1446.42 31766 11 1715.61 1629.83 1874.30 31770 11 1284.25 1220.04 1403.05 31775 11 1315.14 1249.38 1436.79 31780 11 1147.42 1090.05 1253.56 31781 11 1358.50 1290.58 1484.17 31785 11 1039.82 987.83 1136.00 31786 11 1408.38 1337.96 1538.65 31800 11 662.18 629.07 723.43 31805 11 784.70 745.47 857.29 31820 N 11 408.83 388.39 446.65 31820 F 11 313.40 297.73 342.39 31825 N 11 569.87 541.38 622.59 31825 F 11 461.21 438.15 503.87 31830 N 11 412.53 391.90 450.69 31830 F 11 325.28 309.02 355.37 32035 11 687.22 652.86 750.79 32036 11 741.66 704.58 810.27 32095 11 604.80 574.56 660.74 32100 11 920.73 874.69 1005.89 32110 11 1400.81 1330.77 1530.39 32120 11 839.51 797.53 917.16 32124 11 891.12 846.56 973.54 32140 11 950.48 902.96 1038.40 32141 11 1469.39 1395.92 1605.31 32150 11 960.61 912.58 1049.47 32151 11 971.58 923.00 1061.45 32160 11 745.07 707.82 813.99 32200 11 1086.18 1031.87 1186.65 32201 N 11 863.29 820.13 943.15 32201 F 11 196.51 186.68 214.68 32215 11 768.67 730.24 839.78 32220 11 1532.25 1455.64 1673.99 32225 11 958.00 910.10 1046.62 32310 11 881.06 837.01 962.56 32320 11 1539.15 1462.19 1681.52 32400 N 11 142.01 134.91 155.15 32400 F 11 85.63 81.35 93.55 32402 11 542.86 515.72 593.08 32405 N 11 95.19 90.43 103.99 32405 F 11 94.88 90.14 103.66 32420 11 106.94 101.59 116.83 32421 N 11 146.54 139.21 160.09 32421 F 11 74.41 70.69 81.29 32422 N 11 185.88 176.59 203.08 32422 F 11 119.11 113.15 130.12 32440 11 1519.43 1443.46 1659.98 32442 11 2730.50 2593.98 2983.08 32445 11 3368.56 3200.13 3680.15 32480 11 1437.16 1365.30 1570.10 32482 11 1536.32 1459.50 1678.43 32484 11 1393.59 1323.91 1522.50 32486 11 2272.96 2159.31 2483.21 32488 11 2305.94 2190.64 2519.24 32491 11 1432.25 1360.64 1564.74 32500 11 1393.03 1323.38 1521.89 32501 11 239.29 227.33 261.43 32503 11 1751.13 1663.57 1913.11 32504 11 1992.27 1892.66 2176.56 32540 11 1654.78 1572.04 1807.85 32550 N 11 742.61 705.48 811.30 32550 F 11 218.20 207.29 238.38 32551 11 165.84 157.55 181.18 32552 N 11 175.86 167.07 192.13 32552 F 11 154.76 147.02 169.07 32553 N 11 576.58 547.75 629.91 32553 F 11 197.36 187.49 215.61 32560 N 11 243.05 230.90 265.54 32560 F 11 79.90 75.91 87.30 32561 N 11 90.81 86.27 99.21 32561 F 11 68.76 65.32 75.12 32562 N 11 81.08 77.03 88.58 32562 F 11 61.86 58.77 67.59 32601 11 298.85 283.91 326.50 32602 11 323.87 307.68 353.83 32603 11 421.28 400.22 460.25 32604 11 468.89 445.45 512.27 32605 11 372.52 353.89 406.97 32606 11 449.38 426.91 490.95 32650 11 643.09 610.94 702.58 32651 11 1046.57 994.24 1143.38 32652 11 1589.24 1509.78 1736.25 32653 11 1008.92 958.47 1102.24 32654 11 1126.67 1070.34 1230.89 32655 11 916.92 871.07 1001.73 32656 11 770.17 731.66 841.41 32657 11 759.02 721.07 829.23 32658 11 691.11 656.55 755.03 32659 11 708.25 672.84 773.77 32660 11 1009.78 959.29 1103.18 32661 11 772.45 733.83 843.90 32662 11 865.95 822.65 946.05 32663 11 1353.55 1285.87 1478.75 32664 11 817.53 776.65 893.15 32665 11 1173.39 1114.72 1281.93 32800 11 901.67 856.59 985.08 32810 11 866.71 823.37 946.88 32815 11 2674.76 2541.02 2922.17 32820 11 1290.54 1226.01 1409.91 32851 11 2494.82 2370.08 2725.59 32852 11 2760.56 2622.53 3015.91 32853 11 2967.23 2818.87 3241.70 32854 11 3246.25 3083.94 3546.53 32856 11 184.60 175.37 201.68 32900 11 1333.91 1267.21 1457.29 32905 11 1289.82 1225.33 1409.13 32906 11 1597.49 1517.62 1745.26 32940 11 1188.57 1129.14 1298.51 32960 N 11 132.25 125.64 144.49 32960 F 11 99.18 94.22 108.35 32997 11 343.13 325.97 374.87 32998 N 11 2685.72 2551.43 2934.14 32998 F 11 286.67 272.34 313.19 33010 11 118.81 112.87 129.80 33011 11 118.46 112.54 129.42 33015 11 504.56 479.33 551.23 33020 11 847.50 805.13 925.90 33025 11 775.48 736.71 847.22 33030 11 1249.26 1186.80 1364.82 33031 11 1390.59 1321.06 1519.22 33050 11 969.45 920.98 1059.13 33120 11 1511.73 1436.14 1651.56 33130 11 1343.79 1276.60 1468.09 33140 11 1546.04 1468.74 1689.05 33141 11 134.54 127.81 146.98 33202 11 753.60 715.92 823.31 33203 11 791.32 751.75 864.51 33206 11 451.80 429.21 493.59 33207 11 481.42 457.35 525.95 33208 11 520.01 494.01 568.11 33210 11 178.70 169.77 195.24 33211 11 181.41 172.34 198.19 33212 11 334.82 318.08 365.79 33213 11 381.89 362.80 417.22 33214 11 476.79 452.95 520.89 33215 11 302.34 287.22 330.30 33216 11 373.19 354.53 407.71 33217 11 370.91 352.36 405.21 33218 11 389.09 369.64 425.09 33220 11 392.35 372.73 428.64 33222 11 341.95 324.85 373.58 33223 11 410.79 390.25 448.79 33224 11 504.01 478.81 550.63 33225 11 454.60 431.87 496.65 33226 11 485.23 460.97 530.12 33233 11 236.39 224.57 258.26 33234 11 482.28 458.17 526.90 33235 11 629.23 597.77 687.44 33236 11 761.71 723.62 832.16 33237 11 817.80 776.91 893.45 33238 11 908.78 863.34 992.84 33240 11 459.63 436.65 502.15 33241 11 222.77 211.63 243.37 33243 11 1337.57 1270.69 1461.29 33244 11 847.42 805.05 925.81 33249 11 901.03 855.98 984.38 33250 11 1433.88 1362.19 1566.52 33251 11 1591.86 1512.27 1739.11 33254 11 1332.67 1266.04 1455.95 33255 11 1617.16 1536.30 1766.75 33256 11 1921.95 1825.85 2099.73 33257 11 568.83 540.39 621.45 33258 11 640.00 608.00 699.20 33259 11 826.03 784.73 902.44 33261 11 1583.65 1504.47 1730.14 33265 11 1319.27 1253.31 1441.31 33266 11 1803.09 1712.94 1969.88 33282 11 320.57 304.54 350.22 33284 11 230.54 219.01 251.86 33300 11 2356.39 2238.57 2574.36 33305 11 3962.80 3764.66 4329.36 33310 11 1131.40 1074.83 1236.05 33315 11 1446.42 1374.10 1580.22 33320 11 1035.99 984.19 1131.82 33321 11 1157.60 1099.72 1264.68 33322 11 1359.44 1291.47 1485.19 33330 11 1388.46 1319.04 1516.90 33332 11 1362.33 1294.21 1488.34 33335 11 1841.31 1749.24 2011.63 33400 11 2237.70 2125.82 2444.69 33401 11 1404.85 1334.61 1534.80 33403 11 1461.08 1388.03 1596.23 33404 11 1720.74 1634.70 1879.91 33405 11 2248.96 2136.51 2456.99 33406 11 2816.76 2675.92 3077.31 33410 11 2493.72 2369.03 2724.38 33411 11 3282.99 3118.84 3586.67 33412 11 2413.94 2293.24 2637.23 33413 11 3172.07 3013.47 3465.49 33414 11 2122.62 2016.49 2318.96 33415 11 1976.13 1877.32 2158.92 33416 11 1984.76 1885.52 2168.35 33417 11 1633.56 1551.88 1784.66 33420 11 1386.56 1317.23 1514.81 33422 11 1650.15 1567.64 1802.79 33425 11 2652.07 2519.47 2897.39 33426 11 2344.05 2226.85 2560.88 33427 11 2413.34 2292.67 2636.57 33430 11 2745.04 2607.79 2998.96 33460 11 2357.34 2239.47 2575.39 33463 11 3003.05 2852.90 3280.84 33464 11 2386.39 2267.07 2607.13 33465 11 2681.90 2547.81 2929.98 33468 11 1823.17 1732.01 1991.81 33470 11 1228.40 1166.98 1342.03 33471 11 1218.61 1157.68 1331.33 33472 11 1193.57 1133.89 1303.97 33474 11 2075.08 1971.33 2267.03 33475 11 2284.47 2170.25 2495.79 33476 11 1473.66 1399.98 1609.98 33478 11 1534.37 1457.65 1676.30 33496 11 1633.46 1551.79 1784.56 33500 11 1540.87 1463.83 1683.40 33501 11 1092.79 1038.15 1193.87 33502 11 1241.04 1178.99 1355.84 33503 11 1302.09 1236.99 1422.54 33504 11 1422.32 1351.20 1553.88 33505 11 2016.47 1915.65 2203.00 33506 11 2118.46 2012.54 2314.42 33507 11 1683.56 1599.38 1839.29 33508 11 15.91 15.11 17.38 33510 11 1914.72 1818.98 2091.83 33511 11 2097.75 1992.86 2291.79 33512 11 2379.41 2260.44 2599.51 33513 11 2438.22 2316.31 2663.76 33514 11 2581.72 2452.63 2820.52 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 016 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 33516 11 2686.49 2552.17 2935.00 33517 11 184.15 174.94 201.18 33518 11 403.69 383.51 441.04 33519 11 535.12 508.36 584.61 33521 11 644.38 612.16 703.98 33522 11 725.55 689.27 792.66 33523 11 823.86 782.67 900.07 33530 11 514.31 488.59 561.88 33533 11 1852.37 1759.75 2023.71 33534 11 2173.70 2065.02 2374.77 33535 11 2421.27 2300.21 2645.24 33536 11 2603.87 2473.68 2844.73 33542 11 2559.44 2431.47 2796.19 33545 11 3009.00 2858.55 3287.33 33548 11 2918.21 2772.30 3188.15 33572 11 228.71 217.27 249.86 33600 11 1662.42 1579.30 1816.20 33602 11 1590.07 1510.57 1737.16 33606 11 1742.91 1655.76 1904.12 33608 11 1756.55 1668.72 1919.03 33610 11 1721.36 1635.29 1880.58 33611 11 1916.64 1820.81 2093.93 33612 11 1934.05 1837.35 2112.95 33615 11 1954.77 1857.03 2135.58 33617 11 2095.39 1990.62 2289.21 33619 11 2661.30 2528.24 2907.48 33620 11 1612.33 1531.71 1761.47 33621 11 868.22 824.81 948.53 33622 11 3404.20 3233.99 3719.09 33641 11 1598.84 1518.90 1746.74 33645 11 1547.22 1469.86 1690.34 33647 11 1653.78 1571.09 1806.75 33660 11 1816.01 1725.21 1983.99 33665 11 1879.40 1785.43 2053.24 33670 11 1940.23 1843.22 2119.70 33675 11 1930.12 1833.61 2108.65 33676 11 1886.10 1791.80 2060.57 33677 11 1865.87 1772.58 2038.47 33681 11 1795.05 1705.30 1961.10 33684 11 1854.23 1761.52 2025.75 33688 11 1837.61 1745.73 2007.59 33690 11 1187.37 1128.00 1297.20 33692 11 1623.24 1542.08 1773.39 33694 11 1921.05 1825.00 2098.75 33697 11 2046.83 1944.49 2236.16 33702 11 1506.60 1431.27 1645.96 33710 11 1731.92 1645.32 1892.12 33720 11 1503.46 1428.29 1642.53 33722 11 1616.29 1535.48 1765.80 33724 11 1510.70 1435.17 1650.45 33726 11 2056.71 1953.87 2246.95 33730 11 1935.96 1839.16 2115.03 33732 11 1611.38 1530.81 1760.43 33735 11 1256.70 1193.87 1372.95 33736 11 1369.73 1301.24 1496.43 33737 11 1258.08 1195.18 1374.46 33750 11 1317.67 1251.79 1439.56 33755 11 1257.18 1194.32 1373.47 33762 11 1188.51 1129.08 1298.44 33764 11 1266.64 1203.31 1383.81 33766 11 1313.05 1247.40 1434.51 33767 11 1383.44 1314.27 1511.41 33768 11 391.66 372.08 427.89 33770 11 2064.79 1961.55 2255.78 33771 11 2026.42 1925.10 2213.87 33774 11 1759.33 1671.36 1922.06 33775 11 1723.61 1637.43 1883.04 33776 11 1820.16 1729.15 1988.52 33777 11 1682.29 1598.18 1837.91 33778 11 2187.85 2078.46 2390.23 33779 11 2171.69 2063.11 2372.58 33780 11 2226.55 2115.22 2432.50 33781 11 2153.37 2045.70 2352.56 33782 11 3118.92 2962.97 3407.42 33783 11 3370.91 3202.36 3682.71 33786 11 2065.96 1962.66 2257.06 33788 11 1393.27 1323.61 1522.15 33800 11 955.92 908.12 1044.34 33802 11 1075.79 1022.00 1175.30 33803 11 1113.91 1058.21 1216.94 33813 11 1250.03 1187.53 1365.66 33814 11 1486.26 1411.95 1623.74 33820 11 950.87 903.33 1038.83 33822 11 947.70 900.32 1035.37 33824 11 1159.50 1101.53 1266.76 33840 11 1227.90 1166.51 1341.49 33845 11 1319.79 1253.80 1441.87 33851 11 1347.64 1280.26 1472.30 33852 11 1359.30 1291.34 1485.04 33853 11 1816.45 1725.63 1984.47 33860 11 3134.40 2977.68 3424.33 33863 11 3090.84 2936.30 3376.75 33864 11 3164.62 3006.39 3457.35 33870 11 2473.06 2349.41 2701.82 33875 11 1948.55 1851.12 2128.79 33877 11 3542.71 3365.57 3870.41 33880 11 1801.93 1711.83 1968.60 33881 11 1550.14 1472.63 1693.52 33883 11 1123.56 1067.38 1227.49 33884 11 409.69 389.21 447.59 33886 11 972.82 924.18 1062.81 33889 11 800.00 760.00 874.00 33891 11 988.13 938.72 1079.53 33910 11 1638.13 1556.22 1789.65 33915 11 1330.79 1264.25 1453.89 33916 11 1597.71 1517.82 1745.49 33917 11 1438.66 1366.73 1571.74 33920 11 1776.04 1687.24 1940.33 33922 11 1352.25 1284.64 1477.34 33924 11 278.39 264.47 304.14 33925 11 1690.19 1605.68 1846.53 33926 11 2464.50 2341.28 2692.47 33935 11 3381.19 3212.13 3693.95 33945 11 4693.39 4458.72 5127.53 33960 11 966.85 918.51 1056.29 33961 11 538.61 511.68 588.43 33967 11 262.77 249.63 287.07 33968 11 33.76 32.07 36.88 33970 11 354.24 336.53 387.01 33971 11 697.98 663.08 762.54 33973 11 514.13 488.42 561.68 33974 11 878.19 834.28 959.42 33975 11 1077.90 1024.01 1177.61 33976 11 1193.50 1133.83 1303.90 33977 11 1174.68 1115.95 1283.34 33978 11 1303.24 1238.08 1423.79 33979 11 2356.51 2238.68 2574.48 33980 11 3536.71 3359.87 3863.85 34001 11 971.15 922.59 1060.98 34051 11 962.66 914.53 1051.71 34101 11 606.66 576.33 662.78 34111 11 606.52 576.19 662.62 34151 11 1401.88 1331.79 1531.56 34201 11 1027.30 975.94 1122.33 34203 11 968.55 920.12 1058.14 34401 11 1467.89 1394.50 1603.68 34421 11 738.04 701.14 806.31 34451 11 1481.69 1407.61 1618.75 34471 11 1147.71 1090.32 1253.87 34490 11 613.26 582.60 669.99 34501 11 923.22 877.06 1008.62 34502 11 1511.62 1436.04 1651.45 34510 11 1107.40 1052.03 1209.83 34520 11 1018.39 967.47 1112.59 34530 11 957.70 909.82 1046.29 34800 11 1135.88 1079.09 1240.95 34802 11 1255.05 1192.30 1371.15 34803 11 1296.69 1231.86 1416.64 34804 11 1255.88 1193.09 1372.05 34805 11 1192.86 1133.22 1303.20 34806 11 103.56 98.38 113.14 34808 11 205.86 195.57 224.91 34812 11 337.72 320.83 368.95 34813 11 238.53 226.60 260.59 34820 11 487.40 463.03 532.48 34825 11 703.58 668.40 768.66 34826 11 206.66 196.33 225.78 34830 11 1811.20 1720.64 1978.74 34831 11 1932.60 1835.97 2111.37 34832 11 1947.40 1850.03 2127.53 34833 11 611.75 581.16 668.33 34834 11 276.48 262.66 302.06 34900 11 903.88 858.69 987.49 35001 11 1131.90 1075.31 1236.61 35002 11 1163.43 1105.26 1271.05 35005 11 1098.18 1043.27 1199.76 35011 11 998.99 949.04 1091.40 35013 11 1250.12 1187.61 1365.75 35021 11 1184.56 1125.33 1294.13 35022 11 1388.08 1318.68 1516.48 35045 11 980.27 931.26 1070.95 35081 11 1761.73 1673.64 1924.69 35082 11 2198.01 2088.11 2401.33 35091 11 1816.76 1725.92 1984.81 35092 11 2618.52 2487.59 2860.73 35102 11 1903.09 1807.94 2079.13 35103 11 2255.32 2142.55 2463.93 35111 11 1430.56 1359.03 1562.88 35112 11 1756.17 1668.36 1918.61 35121 11 1657.01 1574.16 1810.28 35122 11 1928.27 1831.86 2106.64 35131 11 1402.35 1332.23 1532.06 35132 11 1672.14 1588.53 1826.81 35141 11 1115.05 1059.30 1218.20 35142 11 1335.91 1269.11 1459.48 35151 11 1258.82 1195.88 1375.26 35152 11 1440.44 1368.42 1573.68 35180 11 912.14 866.53 996.51 35182 11 1702.69 1617.56 1860.19 35184 11 1016.53 965.70 1110.56 35188 11 818.87 777.93 894.62 35189 11 1652.28 1569.67 1805.12 35190 11 747.77 710.38 816.94 35201 11 933.70 887.02 1020.07 35206 11 766.77 728.43 837.69 35207 11 705.15 669.89 770.37 35211 11 1356.02 1288.22 1481.45 35216 11 1973.77 1875.08 2156.34 35221 11 1406.50 1336.18 1536.61 35226 11 838.20 796.29 915.73 35231 11 1164.96 1106.71 1272.72 35236 11 974.72 925.98 1064.88 35241 11 1426.29 1354.98 1558.23 35246 11 1490.17 1415.66 1628.01 35251 11 1666.14 1582.83 1820.25 35256 11 1020.38 969.36 1114.76 35261 11 1046.04 993.74 1142.80 35266 11 861.95 818.85 941.68 35271 11 1360.63 1292.60 1486.49 35276 11 1416.89 1346.05 1547.96 35281 11 1594.71 1514.97 1742.22 35286 11 941.11 894.05 1028.16 35301 11 1055.28 1002.52 1152.90 35302 11 1125.98 1069.68 1230.13 35303 11 1242.17 1180.06 1357.07 35304 11 1286.52 1222.19 1405.52 35305 11 1239.34 1177.37 1353.98 35306 11 474.45 450.73 518.34 35311 11 1516.60 1440.77 1656.89 35321 11 896.55 851.72 979.48 35331 11 1475.10 1401.35 1611.55 35341 11 1379.55 1310.57 1507.16 35351 11 1294.10 1229.40 1413.81 35355 11 1049.60 997.12 1146.69 35361 11 1565.85 1487.56 1710.69 35363 11 1730.62 1644.09 1890.70 35371 11 828.46 787.04 905.10 35372 11 990.45 940.93 1082.07 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 017 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 35390 11 160.30 152.29 175.13 35400 11 150.50 142.98 164.43 35450 11 515.91 490.11 563.63 35452 11 358.65 340.72 391.83 35458 11 489.94 465.44 535.26 35460 11 312.77 297.13 341.70 35471 N 11 2746.52 2609.19 3000.57 35471 F 11 537.38 510.51 587.09 35472 N 11 1987.90 1888.51 2171.79 35472 F 11 364.59 346.36 398.31 35475 N 11 2162.74 2054.60 2362.79 35475 F 11 485.25 460.99 530.14 35476 N 11 1634.20 1552.49 1785.36 35476 F 11 308.84 293.40 337.41 35500 11 322.61 306.48 352.45 35501 11 1578.60 1499.67 1724.62 35506 11 1344.32 1277.10 1468.67 35508 11 1416.51 1345.68 1547.53 35509 11 1497.64 1422.76 1636.17 35510 11 1269.75 1206.26 1387.20 35511 11 1240.64 1178.61 1355.40 35512 11 1241.35 1179.28 1356.17 35515 11 1346.62 1279.29 1471.18 35516 11 1237.84 1175.95 1352.34 35518 11 1184.82 1125.58 1294.42 35521 11 1333.16 1266.50 1456.48 35522 11 1232.75 1171.11 1346.78 35523 11 1295.65 1230.87 1415.50 35525 11 1151.63 1094.05 1258.16 35526 11 1653.72 1571.03 1806.68 35531 11 2038.09 1936.19 2226.62 35533 11 1638.28 1556.37 1789.83 35535 11 1827.86 1736.47 1996.94 35536 11 1732.02 1645.42 1892.23 35537 11 2254.59 2141.86 2463.14 35538 11 2527.30 2400.94 2761.08 35539 11 2240.30 2128.29 2447.53 35540 11 2562.53 2434.40 2799.56 35548 11 1191.74 1132.15 1301.97 35549 11 1382.57 1313.44 1510.46 35551 11 1526.25 1449.94 1667.43 35556 11 1409.79 1339.30 1540.20 35558 11 1243.36 1181.19 1358.37 35560 11 1756.80 1668.96 1919.30 35563 11 1356.46 1288.64 1481.94 35565 11 1333.04 1266.39 1456.35 35566 11 1689.02 1604.57 1845.26 35570 11 1417.13 1346.27 1548.21 35571 11 1349.39 1281.92 1474.21 35572 11 347.63 330.25 379.79 35583 11 1458.24 1385.33 1593.13 35585 11 1695.88 1611.09 1852.75 35587 11 1395.78 1325.99 1524.89 35600 11 255.67 242.89 279.32 35601 11 1467.48 1394.11 1603.23 35606 11 1188.31 1128.89 1298.22 35612 11 908.03 862.63 992.02 35616 11 1183.44 1124.27 1292.91 35621 11 1113.11 1057.45 1216.07 35623 11 1426.32 1355.00 1558.25 35626 11 1564.95 1486.70 1709.71 35631 11 1866.21 1772.90 2038.84 35632 11 1735.61 1648.83 1896.15 35633 11 1895.82 1801.03 2071.18 35634 11 1715.34 1629.57 1874.01 35636 11 1730.02 1643.52 1890.05 35637 11 1729.77 1643.28 1889.77 35638 11 1767.68 1679.30 1931.20 35642 11 1088.55 1034.12 1189.24 35645 11 1036.17 984.36 1132.01 35646 11 1733.90 1647.21 1894.29 35647 11 1574.04 1495.34 1719.64 35650 11 1078.34 1024.42 1178.08 35651 11 1352.53 1284.90 1477.64 35654 11 1388.14 1318.73 1516.54 35656 11 1093.59 1038.91 1194.75 35661 11 1098.10 1043.20 1199.68 35663 11 1266.58 1203.25 1383.74 35665 11 1188.23 1128.82 1298.14 35666 11 1284.44 1220.22 1403.25 35671 11 1131.52 1074.94 1236.18 35681 11 80.44 76.42 87.88 35682 11 358.04 340.14 391.16 35683 11 419.10 398.15 457.87 35685 11 201.62 191.54 220.27 35686 11 167.43 159.06 182.92 35691 11 975.21 926.45 1065.42 35693 11 863.81 820.62 943.71 35694 11 1029.49 978.02 1124.72 35695 11 1054.34 1001.62 1151.86 35697 11 150.10 142.60 163.99 35700 11 154.53 146.80 168.82 35701 11 546.98 519.63 597.57 35721 11 453.78 431.09 495.75 35741 11 503.35 478.18 549.91 35761 11 377.35 358.48 412.25 35800 11 482.40 458.28 527.02 35820 11 1941.63 1844.55 2121.23 35840 11 629.42 597.95 687.64 35860 11 405.90 385.61 443.45 35870 11 1351.02 1283.47 1475.99 35875 11 598.75 568.81 654.13 35876 11 953.28 905.62 1041.46 35879 11 936.49 889.67 1023.12 35881 11 1036.66 984.83 1132.55 35883 11 1214.12 1153.41 1326.42 35884 11 1262.31 1199.19 1379.07 35901 11 504.65 479.42 551.33 35903 11 567.46 539.09 619.95 35905 11 1727.61 1641.23 1887.41 35907 11 1936.78 1839.94 2115.93 36000 N 11 23.49 22.32 25.67 36000 F 11 9.32 8.85 10.18 36002 N 11 158.47 150.55 173.13 36002 F 11 106.19 100.88 116.01 36005 N 11 324.92 308.67 354.97 36005 F 11 48.07 45.67 52.52 36010 N 11 529.28 502.82 578.24 36010 F 11 120.46 114.44 131.61 36011 N 11 866.95 823.60 947.14 36011 F 11 156.09 148.29 170.53 36012 N 11 841.03 798.98 918.83 36012 F 11 176.47 167.65 192.80 36013 N 11 764.23 726.02 834.92 36013 F 11 127.69 121.31 139.51 36014 N 11 803.36 763.19 877.67 36014 F 11 150.13 142.62 164.01 36015 N 11 873.52 829.84 954.32 36015 F 11 173.68 165.00 189.75 36100 N 11 500.25 475.24 546.53 36100 F 11 158.51 150.58 173.17 36120 N 11 425.42 404.15 464.77 36120 F 11 99.44 94.47 108.64 36140 N 11 453.56 430.88 495.51 36140 F 11 102.70 97.57 112.21 36147 N 11 771.18 732.62 842.51 36147 F 11 182.83 173.69 199.74 36148 N 11 243.01 230.86 265.49 36148 F 11 48.37 45.95 52.84 36160 N 11 492.39 467.77 537.94 36160 F 11 127.67 121.29 139.48 36200 N 11 613.93 583.23 670.71 36200 F 11 153.45 145.78 167.65 36215 N 11 1090.75 1036.21 1191.64 36215 F 11 241.93 229.83 264.30 36216 N 11 1200.26 1140.25 1311.29 36216 F 11 273.64 259.96 298.95 36217 N 11 1958.20 1860.29 2139.33 36217 F 11 325.75 309.46 355.88 36218 N 11 181.90 172.81 198.73 36218 F 11 51.82 49.23 56.61 36245 N 11 1150.16 1092.65 1256.55 36245 F 11 245.91 233.61 268.65 36246 N 11 1162.34 1104.22 1269.85 36246 F 11 271.00 257.45 296.07 36247 N 11 1825.50 1734.23 1994.36 36247 F 11 322.82 306.68 352.68 36248 N 11 152.92 145.27 167.06 36248 F 11 51.19 48.63 55.92 36260 11 590.39 560.87 645.00 36261 11 366.18 347.87 400.05 36262 11 276.96 263.11 302.58 36400 N 11 27.59 26.21 30.14 36400 F 11 16.89 16.05 18.46 36405 N 11 22.70 21.57 24.81 36405 F 11 15.45 14.68 16.88 36406 N 11 16.25 15.44 17.76 36406 F 11 9.00 8.55 09.83 36410 N 11 17.19 16.33 18.78 36410 F 11 9.00 8.55 09.83 36420 11 45.56 43.28 49.77 36425 11 38.09 36.19 41.62 36430 11 32.35 30.73 35.34 36440 11 53.70 51.02 58.67 36450 11 110.72 105.18 120.96 36455 11 116.94 111.09 127.75 36460 11 340.84 323.80 372.37 36470 N 11 134.99 128.24 147.48 36470 F 11 68.53 65.10 74.87 36471 N 11 166.26 157.95 181.64 36471 F 11 97.29 92.43 106.29 36475 N 11 1719.60 1633.62 1878.66 36475 F 11 346.68 329.35 378.75 36476 N 11 376.92 358.07 411.78 36476 F 11 169.68 161.20 185.38 36478 N 11 1361.09 1293.04 1487.00 36478 F 11 345.34 328.07 377.28 36479 N 11 388.56 369.13 424.50 36479 F 11 169.34 160.87 185.00 36481 N 11 1185.72 1126.43 1295.39 36481 F 11 351.71 334.12 384.24 36500 11 177.95 169.05 194.41 36510 N 11 99.51 94.53 108.71 36510 F 11 58.25 55.34 63.64 36511 11 91.10 86.55 99.53 36512 11 89.22 84.76 97.47 36513 11 95.53 90.75 104.36 36514 N 11 485.12 460.86 529.99 36514 F 11 89.53 85.05 97.81 36515 N 11 1802.23 1712.12 1968.94 36515 F 11 89.16 84.70 97.41 36516 N 11 1989.59 1890.11 2173.63 36516 F 11 66.12 62.81 72.23 36522 N 11 1268.58 1205.15 1385.92 36522 F 11 97.87 92.98 106.93 36555 N 11 255.76 242.97 279.42 36555 F 11 119.38 113.41 130.42 36556 N 11 222.09 210.99 242.64 36556 F 11 117.21 111.35 128.05 36557 N 11 879.49 835.52 960.85 36557 F 11 305.32 290.05 333.56 36558 N 11 760.07 722.07 830.38 36558 F 11 273.46 259.79 298.76 36560 N 11 1190.94 1131.39 1301.10 36560 F 11 347.48 330.11 379.63 36561 N 11 1110.61 1055.08 1213.34 36561 F 11 341.16 324.10 372.72 36563 N 11 1179.20 1120.24 1288.28 36563 F 11 356.52 338.69 389.49 36565 N 11 942.66 895.53 1029.86 36565 F 11 338.88 321.94 370.23 36566 N 11 4180.62 3971.59 4567.33 36566 F 11 363.92 345.72 397.58 36568 N 11 281.31 267.24 307.33 36568 F 11 93.28 88.62 101.91 36569 N 11 243.89 231.70 266.46 36569 F 11 90.82 86.28 99.22 36570 N 11 1061.32 1008.25 1159.49 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 018 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 36570 F 11 294.07 279.37 321.28 36571 N 11 1193.04 1133.39 1303.40 36571 F 11 307.05 291.70 335.46 36575 N 11 152.29 144.68 166.38 36575 F 11 34.49 32.77 37.69 36576 N 11 353.40 335.73 386.09 36576 F 11 187.73 178.34 205.09 36578 N 11 482.91 458.76 527.57 36578 F 11 210.15 199.64 229.59 36580 N 11 210.68 200.15 230.17 36580 F 11 65.48 62.21 71.54 36581 N 11 721.03 684.98 787.73 36581 F 11 195.04 185.29 213.08 36582 N 11 1034.95 983.20 1130.68 36582 F 11 297.94 283.04 325.50 36583 N 11 1150.92 1093.37 1257.38 36583 F 11 313.76 298.07 342.78 36584 N 11 202.33 192.21 221.04 36584 F 11 65.64 62.36 71.71 36585 N 11 1040.82 988.78 1137.10 36585 F 11 274.21 260.50 299.58 36589 N 11 159.92 151.92 174.71 36589 F 11 135.35 128.58 147.87 36590 N 11 270.55 257.02 295.57 36590 F 11 195.59 185.81 213.68 36591 11 21.33 20.26 23.30 36592 11 23.85 22.66 26.06 36593 11 26.68 25.35 29.15 36595 N 11 556.69 528.86 608.19 36595 F 11 183.78 174.59 200.78 36596 N 11 127.92 121.52 139.75 36596 F 11 44.14 41.93 48.22 36597 N 11 119.52 113.54 130.57 36597 F 11 60.63 57.60 66.24 36598 N 11 107.05 101.70 116.96 36598 F 11 47.84 45.45 52.27 36600 N 11 29.19 27.73 31.89 36600 F 11 15.02 14.27 16.41 36620 11 49.23 46.77 53.79 36625 11 103.31 98.14 112.86 36640 11 121.56 115.48 132.80 36660 11 72.01 68.41 78.67 36680 11 57.44 54.57 62.76 36800 11 155.13 147.37 169.48 36810 11 205.99 195.69 225.04 36815 11 146.51 139.18 160.06 36818 11 661.56 628.48 722.75 36819 11 787.78 748.39 860.65 36820 11 793.54 753.86 866.94 36821 11 675.76 641.97 738.27 36822 11 369.52 351.04 403.70 36823 11 1270.12 1206.61 1387.60 36825 11 802.46 762.34 876.69 36830 11 649.42 616.95 709.49 36831 11 450.90 428.36 492.61 36832 11 573.32 544.65 626.35 36833 11 647.89 615.50 707.83 36835 11 469.29 445.83 512.70 36838 11 1149.41 1091.94 1255.73 36860 N 11 191.07 181.52 208.75 36860 F 11 103.83 98.64 113.44 36861 11 147.59 140.21 161.24 36870 N 11 1759.43 1671.46 1922.18 36870 F 11 297.69 282.81 325.23 37140 11 1385.55 1316.27 1513.71 37145 11 1452.50 1379.88 1586.86 37160 11 1280.56 1216.53 1399.01 37180 11 1431.09 1359.54 1563.47 37181 11 1545.08 1467.83 1688.00 37182 11 843.75 801.56 921.79 37183 N 11 5062.93 4809.78 5531.25 37183 F 11 398.98 379.03 435.88 37184 N 11 2249.92 2137.42 2458.03 37184 F 11 451.50 428.93 493.27 37185 N 11 742.99 705.84 811.72 37185 F 11 166.92 158.57 182.36 37186 N 11 1462.53 1389.40 1597.81 37186 F 11 254.33 241.61 277.85 37187 N 11 2143.64 2036.46 2341.93 37187 F 11 411.03 390.48 449.05 37188 N 11 1807.53 1717.15 1974.72 37188 F 11 294.46 279.74 321.70 37200 11 223.70 212.52 244.40 37201 11 273.48 259.81 298.78 37202 11 329.47 313.00 359.95 37203 N 11 1268.27 1204.86 1385.59 37203 F 11 260.40 247.38 284.49 37204 11 896.48 851.66 979.41 37205 N 11 4038.67 3836.74 4412.25 37205 F 11 431.11 409.55 470.98 37206 N 11 2427.66 2306.28 2652.22 37206 F 11 212.22 201.61 231.85 37207 11 426.07 404.77 465.49 37208 11 205.91 195.61 224.95 37209 11 112.68 107.05 123.11 37210 N 11 3370.18 3201.67 3681.92 37210 F 11 530.18 503.67 579.22 37215 11 1093.94 1039.24 1195.13 37220 N 11 2945.85 2798.56 3218.34 37220 F 11 410.10 389.60 448.04 37221 N 11 4352.62 4134.99 4755.24 37221 F 11 500.33 475.31 546.61 37222 N 11 850.52 807.99 929.19 37222 F 11 186.26 176.95 203.49 37223 N 11 2395.68 2275.90 2617.29 37223 F 11 211.74 201.15 231.32 37224 N 11 3538.87 3361.93 3866.22 37224 F 11 451.93 429.33 493.73 37225 N 11 9979.83 9480.84 10902.97 37225 F 11 607.85 577.46 664.08 37226 N 11 8361.59 7943.51 9135.04 37226 F 11 508.97 483.52 556.05 37227 N 11 13490.72 12816.18 14738.61 37227 F 11 734.16 697.45 802.07 37228 N 11 5035.67 4783.89 5501.47 37228 F 11 551.88 524.29 602.93 37229 N 11 9895.88 9401.09 10811.25 37229 F 11 711.61 676.03 777.43 37230 N 11 7779.41 7390.44 8499.01 37230 F 11 689.32 654.85 753.08 37231 N 11 12476.15 11852.34 13630.19 37231 F 11 749.20 711.74 818.50 37232 N 11 1132.24 1075.63 1236.97 37232 F 11 199.64 189.66 218.11 37233 N 11 1384.68 1315.45 1512.77 37233 F 11 327.67 311.29 357.98 37234 N 11 3600.07 3420.07 3933.08 37234 F 11 273.77 260.08 299.09 37235 N 11 3847.76 3655.37 4203.68 37235 F 11 388.54 369.11 424.48 37250 11 108.07 102.67 118.07 37251 11 80.61 76.58 88.07 37500 11 681.66 647.58 744.72 37565 11 693.52 658.84 757.67 37600 11 696.82 661.98 761.28 37605 11 794.28 754.57 867.76 37606 11 495.26 470.50 541.08 37607 11 369.89 351.40 404.11 37609 N 11 288.61 274.18 315.31 37609 F 11 196.64 186.81 214.83 37615 11 493.50 468.83 539.15 37616 11 1060.24 1007.23 1158.31 37617 11 1270.78 1207.24 1388.33 37618 11 373.24 354.58 407.77 37620 11 637.22 605.36 696.16 37650 11 479.98 455.98 524.38 37660 11 1214.89 1154.15 1327.27 37700 11 246.89 234.55 269.73 37718 11 427.02 405.67 466.52 37722 11 475.36 451.59 519.33 37735 11 617.81 586.92 674.96 37760 11 629.81 598.32 688.07 37761 11 549.53 522.05 600.36 37765 N 11 632.87 601.23 691.41 37765 F 11 446.73 424.39 488.05 37766 N 11 753.88 716.19 823.62 37766 F 11 546.95 519.60 597.54 37780 11 254.55 241.82 278.09 37785 N 11 342.43 325.31 374.11 37785 F 11 255.18 242.42 278.78 37788 11 1337.07 1270.22 1460.75 37790 11 470.79 447.25 514.34 38100 11 1060.56 1007.53 1158.66 38101 11 1068.06 1014.66 1166.86 38102 11 245.47 233.20 268.18 38115 11 1173.49 1114.82 1282.04 38120 11 970.31 921.79 1060.06 38200 11 140.91 133.86 153.94 38205 11 77.04 73.19 84.17 38206 11 77.72 73.83 84.90 38220 N 11 141.88 134.79 155.01 38220 F 11 58.73 55.79 64.16 38221 N 11 154.20 146.49 168.46 38221 F 11 72.94 69.29 79.68 38230 11 320.57 304.54 350.22 38240 11 120.38 114.36 131.51 38241 11 120.24 114.23 131.36 38242 11 91.88 87.29 100.38 38300 N 11 254.57 241.84 278.12 38300 F 11 171.74 163.15 187.62 38305 11 429.57 408.09 469.30 38308 11 416.16 395.35 454.65 38380 11 541.27 514.21 591.34 38381 11 770.92 732.37 842.23 38382 11 631.64 600.06 690.07 38500 N 11 299.62 284.64 327.34 38500 F 11 233.48 221.81 255.08 38505 N 11 118.32 112.40 129.26 38505 F 11 69.50 66.03 75.93 38510 N 11 482.10 458.00 526.70 38510 F 11 395.17 375.41 431.72 38520 11 433.75 412.06 473.87 38525 11 397.19 377.33 433.93 38530 11 506.90 481.56 553.79 38542 11 489.41 464.94 534.68 38550 11 458.27 435.36 500.66 38555 11 933.94 887.24 1020.33 38562 11 654.79 622.05 715.36 38564 11 655.90 623.11 716.58 38570 11 510.78 485.24 558.03 38571 11 779.96 740.96 852.10 38572 11 895.47 850.70 978.31 38700 11 763.46 725.29 834.08 38720 11 1272.83 1209.19 1390.57 38724 11 1380.82 1311.78 1508.55 38740 11 632.71 601.07 691.23 38745 11 803.70 763.52 878.05 38746 11 250.38 237.86 273.54 38747 11 250.07 237.57 273.21 38760 11 782.43 743.31 854.81 38765 11 1205.90 1145.61 1317.45 38770 11 771.92 733.32 843.32 38780 11 984.47 935.25 1075.54 38790 11 79.22 75.26 86.55 38792 11 38.07 36.17 41.60 38794 11 285.60 271.32 312.02 38900 11 128.84 122.40 140.76 39000 11 473.86 450.17 517.70 39010 11 767.07 728.72 838.03 39200 11 849.79 807.30 928.40 39220 11 1098.06 1043.16 1199.63 39400 11 486.13 461.82 531.09 39501 11 794.21 754.50 867.68 39503 11 5672.81 5389.17 6197.55 39540 11 814.04 773.34 889.34 39541 11 881.93 837.83 963.50 39545 11 854.20 811.49 933.21 39560 11 744.50 707.28 813.37 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 019 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 39561 11 1168.97 1110.52 1277.10 40490 N 11 121.15 115.09 132.35 40490 F 11 71.38 67.81 77.98 40500 N 11 471.09 447.54 514.67 40500 F 11 345.42 328.15 377.37 40510 N 11 451.45 428.88 493.21 40510 F 11 338.06 321.16 369.33 40520 N 11 460.79 437.75 503.41 40520 F 11 341.42 324.35 373.00 40525 11 527.47 501.10 576.27 40527 11 607.01 576.66 663.16 40530 N 11 508.94 483.49 556.01 40530 F 11 386.42 367.10 422.17 40650 N 11 387.66 368.28 423.52 40650 F 11 273.01 259.36 298.26 40652 N 11 451.94 429.34 493.74 40652 F 11 332.57 315.94 363.33 40654 N 11 532.43 505.81 581.68 40654 F 11 402.98 382.83 440.25 40700 11 916.95 871.10 1001.77 40701 11 1061.71 1008.62 1159.91 40702 11 796.29 756.48 869.95 40720 11 930.26 883.75 1016.31 40761 11 1033.80 982.11 1129.43 40800 N 11 190.46 180.94 208.08 40800 F 11 121.49 115.42 132.73 40801 N 11 288.66 274.23 315.36 40801 F 11 208.34 197.92 227.61 40804 N 11 195.53 185.75 213.61 40804 F 11 122.78 116.64 134.14 40805 N 11 299.94 284.94 327.68 40805 F 11 213.32 202.65 233.05 40806 N 11 97.43 92.56 106.44 40806 F 11 29.40 27.93 32.12 40808 N 11 170.60 162.07 186.38 40808 F 11 101.30 96.24 110.68 40810 N 11 189.52 180.04 207.05 40810 F 11 120.23 114.22 131.35 40812 N 11 263.97 250.77 288.39 40812 F 11 185.23 175.97 202.37 40814 N 11 355.74 337.95 388.64 40814 F 11 286.76 272.42 313.28 40816 N 11 374.28 355.57 408.91 40816 F 11 299.95 284.95 327.69 40818 N 11 328.21 311.80 358.57 40818 F 11 255.45 242.68 279.08 40819 N 11 282.73 268.59 308.88 40819 F 11 220.05 209.05 240.41 40820 N 11 244.91 232.66 267.56 40820 F 11 162.07 153.97 177.07 40830 N 11 228.27 216.86 249.39 40830 F 11 150.48 142.96 164.40 40831 N 11 303.82 288.63 331.92 40831 F 11 210.60 200.07 230.08 40840 N 11 780.94 741.89 853.17 40840 F 11 612.12 581.51 668.74 40842 N 11 749.13 711.67 818.42 40842 F 11 598.26 568.35 653.60 40843 N 11 994.06 944.36 1086.01 40843 F 11 777.99 739.09 849.95 40844 N 11 1306.02 1240.72 1426.83 40844 F 11 1098.46 1043.54 1200.07 40845 N 11 1385.19 1315.93 1513.32 40845 F 11 1179.52 1120.54 1288.62 41000 N 11 150.13 142.62 164.01 41000 F 11 105.72 100.43 115.49 41005 N 11 206.90 196.56 226.04 41005 F 11 120.60 114.57 131.76 41006 N 11 335.34 318.57 366.36 41006 F 11 247.78 235.39 270.70 41007 N 11 334.45 317.73 365.39 41007 F 11 236.50 224.68 258.38 41008 N 11 346.49 329.17 378.55 41008 F 11 253.26 240.60 276.69 41009 N 11 368.81 350.37 402.93 41009 F 11 275.26 261.50 300.73 41010 N 11 190.51 180.98 208.13 41010 F 11 104.21 99.00 113.85 41015 N 11 404.65 384.42 442.08 41015 F 11 321.19 305.13 350.90 41016 N 11 404.84 384.60 442.29 41016 F 11 328.62 312.19 359.02 41017 N 11 408.30 387.89 446.07 41017 F 11 329.88 313.39 360.40 41018 N 11 462.24 439.13 505.00 41018 F 11 380.35 361.33 415.53 41019 11 451.25 428.69 492.99 41100 N 11 157.37 149.50 171.93 41100 F 11 103.83 98.64 113.44 41105 N 11 159.07 151.12 173.79 41105 F 11 106.47 101.15 116.32 41108 N 11 136.94 130.09 149.60 41108 F 11 85.92 81.62 93.86 41110 N 11 197.55 187.67 215.82 41110 F 11 125.74 119.45 137.37 41112 N 11 309.63 294.15 338.27 41112 F 11 238.45 226.53 260.51 41113 N 11 338.05 321.15 369.32 41113 F 11 263.72 250.53 288.11 41114 11 606.66 576.33 662.78 41115 N 11 226.69 215.36 247.66 41115 F 11 141.97 134.87 155.10 41116 N 11 305.66 290.38 333.94 41116 F 11 208.65 198.22 227.95 41120 11 998.38 948.46 1090.73 41130 11 1237.96 1176.06 1352.47 41135 11 2053.48 1950.81 2243.43 41140 11 2091.88 1987.29 2285.38 41145 11 2635.66 2503.88 2879.46 41150 11 2085.29 1981.03 2278.18 41153 11 2267.95 2154.55 2477.73 41155 11 2836.66 2694.83 3099.05 41250 N 11 223.09 211.94 243.73 41250 F 11 138.05 131.15 150.82 41251 N 11 234.64 222.91 256.35 41251 F 11 157.48 149.61 172.05 41252 N 11 290.56 276.03 317.43 41252 F 11 201.74 191.65 220.40 41500 11 425.01 403.76 464.32 41510 11 359.21 341.25 392.44 41512 11 591.97 562.37 646.73 41520 N 11 323.03 306.88 352.91 41520 F 11 240.83 228.79 263.11 41530 N 11 2995.90 2846.11 3273.03 41530 F 11 387.39 368.02 423.22 41800 N 11 226.43 215.11 247.38 41800 F 11 128.80 122.36 140.71 41805 N 11 222.55 211.42 243.13 41805 F 11 157.35 149.48 171.90 41806 N 11 330.41 313.89 360.97 41806 F 11 246.63 234.30 269.45 41822 N 11 266.59 253.26 291.25 41822 F 11 169.27 160.81 184.93 41823 N 11 396.04 376.24 432.68 41823 F 11 303.13 287.97 331.17 41825 N 11 193.25 183.59 211.13 41825 F 11 117.98 112.08 128.89 41826 N 11 277.93 264.03 303.63 41826 F 11 195.72 185.93 213.82 41827 N 11 402.72 382.58 439.97 41827 F 11 289.02 274.57 315.76 41828 N 11 281.56 267.48 307.60 41828 F 11 202.19 192.08 220.89 41830 N 11 359.69 341.71 392.97 41830 F 11 264.57 251.34 289.04 41872 N 11 341.46 324.39 373.05 41872 F 11 251.38 238.81 274.63 41874 N 11 340.90 323.86 372.44 41874 F 11 238.85 226.91 260.95 42000 N 11 146.35 139.03 159.88 42000 F 11 98.48 93.56 107.59 42100 N 11 140.08 133.08 153.04 42100 F 11 103.85 98.66 113.46 42104 N 11 198.41 188.49 216.76 42104 F 11 131.64 125.06 143.82 42106 N 11 249.42 236.95 272.49 42106 F 11 169.42 160.95 185.09 42107 N 11 429.17 407.71 468.87 42107 F 11 328.38 311.96 358.75 42120 11 941.75 894.66 1028.86 42140 N 11 237.18 225.32 259.12 42140 F 11 148.67 141.24 162.43 42145 11 675.75 641.96 738.25 42160 N 11 221.08 210.03 241.53 42160 F 11 142.97 135.82 156.19 42180 N 11 220.15 209.14 240.51 42180 F 11 169.44 160.97 185.12 42182 N 11 306.75 291.41 335.12 42182 F 11 250.06 237.56 273.19 42200 11 829.99 788.49 906.76 42205 11 908.88 863.44 992.96 42210 11 996.64 946.81 1088.83 42215 11 678.94 644.99 741.74 42220 11 504.43 479.21 551.09 42225 11 867.85 824.46 948.13 42226 11 870.57 827.04 951.10 42227 11 831.46 789.89 908.37 42235 11 704.14 668.93 769.27 42260 N 11 777.42 738.55 849.33 42260 F 11 639.78 607.79 698.96 42280 N 11 151.85 144.26 165.90 42280 F 11 104.61 99.38 114.29 42281 N 11 192.57 182.94 210.38 42281 F 11 145.33 138.06 158.77 42300 N 11 196.89 187.05 215.11 42300 F 11 146.18 138.87 159.70 42305 11 412.90 392.26 451.10 42310 N 11 152.95 145.30 167.10 42310 F 11 119.56 113.58 130.62 42320 N 11 236.01 224.21 257.84 42320 F 11 169.56 161.08 185.24 42330 N 11 219.06 208.11 239.33 42330 F 11 158.27 150.36 172.91 42335 N 11 350.95 333.40 383.41 42335 F 11 247.32 234.95 270.19 42340 N 11 437.58 415.70 478.06 42340 F 11 323.88 307.69 353.84 42400 N 11 101.08 96.03 110.43 42400 F 11 54.15 51.44 59.16 42405 N 11 282.74 268.60 308.89 42405 F 11 216.91 206.06 236.97 42408 N 11 429.65 408.17 469.40 42408 F 11 315.32 299.55 344.48 42409 N 11 313.29 297.63 342.27 42409 F 11 214.08 203.38 233.89 42410 11 596.72 566.88 651.91 42415 11 1071.77 1018.18 1170.91 42420 11 1227.79 1166.40 1341.36 42425 11 809.41 768.94 884.28 42426 11 1310.01 1244.51 1431.19 42440 11 449.11 426.65 490.65 42450 N 11 427.92 406.52 467.50 42450 F 11 344.14 326.93 375.97 42500 N 11 408.58 388.15 446.37 42500 F 11 327.63 311.25 357.94 42505 N 11 526.51 500.18 575.21 42505 F 11 435.80 414.01 476.11 42507 11 492.95 468.30 538.55 42508 11 676.64 642.81 739.23 42509 11 780.82 741.78 853.05 42510 11 605.33 575.06 661.32 42550 N 11 131.28 124.72 143.43 42550 F 11 61.36 58.29 67.03 42600 N 11 457.08 434.23 499.36 42600 F 11 338.03 321.13 369.30 42650 N 11 78.52 74.59 85.78 42650 F 11 56.47 53.65 61.70 42660 N 11 100.48 95.46 109.78 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 020 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 42660 F 11 74.66 70.93 81.57 42665 N 11 294.59 279.86 321.84 42665 F 11 199.16 189.20 217.58 42700 N 11 178.20 169.29 194.68 42700 F 11 130.33 123.81 142.38 42720 N 11 434.89 413.15 475.12 42720 F 11 379.77 360.78 414.90 42725 11 780.73 741.69 852.94 42800 N 11 149.86 142.37 163.73 42800 F 11 107.97 102.57 117.96 42802 N 11 223.13 211.97 243.77 42802 F 11 129.59 123.11 141.58 42804 N 11 187.95 178.55 205.33 42804 F 11 109.84 104.35 120.00 42806 N 11 211.26 200.70 230.81 42806 F 11 128.43 122.01 140.31 42808 N 11 215.82 205.03 235.78 42808 F 11 157.24 149.38 171.79 42809 N 11 161.01 152.96 175.90 42809 F 11 125.10 118.85 136.68 42810 N 11 366.62 348.29 400.53 42810 F 11 275.60 261.82 301.09 42815 11 533.44 506.77 582.79 42820 11 280.19 266.18 306.11 42821 11 291.61 277.03 318.58 42825 11 252.44 239.82 275.79 42826 11 242.53 230.40 264.96 42830 11 199.21 189.25 217.64 42831 11 214.63 203.90 234.49 42835 11 171.48 162.91 187.35 42836 11 232.55 220.92 254.06 42842 11 944.47 897.25 1031.84 42844 11 1308.77 1243.33 1429.83 42845 11 2131.96 2025.36 2329.16 42860 11 180.73 171.69 197.44 42870 11 550.82 523.28 601.77 42890 11 1344.90 1277.66 1469.31 42892 11 1775.92 1687.12 1940.19 42894 11 2253.25 2140.59 2461.68 42900 11 328.78 312.34 359.19 42950 11 756.74 718.90 826.74 42953 11 918.82 872.88 1003.81 42955 11 714.22 678.51 780.29 42960 11 162.89 154.75 177.96 42961 11 404.81 384.57 442.26 42962 11 499.54 474.56 545.74 42970 11 378.47 359.55 413.48 42971 11 440.88 418.84 481.67 42972 11 493.77 469.08 539.44 43020 11 511.67 486.09 559.00 43030 11 500.98 475.93 547.32 43045 11 1249.42 1186.95 1364.99 43100 11 601.52 571.44 657.16 43101 11 966.29 917.98 1055.68 43107 11 2421.84 2300.75 2645.86 43108 11 4315.79 4100.00 4715.00 43112 11 2568.03 2439.63 2805.57 43113 11 4257.58 4044.70 4651.41 43116 11 4923.96 4677.76 5379.42 43117 11 2355.33 2237.56 2573.19 43118 11 3525.13 3348.87 3851.20 43121 11 2727.18 2590.82 2979.44 43122 11 2399.59 2279.61 2621.55 43123 11 4354.18 4136.47 4756.94 43124 11 3729.22 3542.76 4074.17 43130 11 756.13 718.32 826.07 43135 11 1423.06 1351.91 1554.70 43200 N 11 203.20 193.04 222.00 43200 F 11 100.53 95.50 109.83 43201 N 11 277.54 263.66 303.21 43201 F 11 124.46 118.24 135.98 43202 N 11 265.47 252.20 290.03 43202 F 11 110.83 105.29 121.08 43204 11 214.27 203.56 234.09 43205 11 216.47 205.65 236.50 43215 11 148.71 141.27 162.46 43216 N 11 195.98 186.18 214.11 43216 F 11 138.34 131.42 151.13 43217 N 11 355.37 337.60 388.24 43217 F 11 164.51 156.28 179.72 43219 11 164.97 156.72 180.23 43220 11 122.51 116.38 133.84 43226 11 136.44 129.62 149.06 43227 11 202.95 192.80 221.72 43228 11 215.22 204.46 235.13 43231 11 183.89 174.70 200.91 43232 11 253.27 240.61 276.70 43234 N 11 262.82 249.68 287.13 43234 F 11 116.04 110.24 126.78 43235 N 11 278.93 264.98 304.73 43235 F 11 140.03 133.03 152.98 43236 N 11 345.95 328.65 377.95 43236 F 11 169.57 161.09 185.25 43237 11 227.65 216.27 248.71 43238 11 284.04 269.84 310.32 43239 N 11 323.47 307.30 353.40 43239 F 11 165.36 157.09 180.65 43240 11 383.46 364.29 418.93 43241 11 150.12 142.61 164.00 43242 11 409.66 389.18 447.56 43243 11 258.62 245.69 282.54 43244 11 285.84 271.55 312.28 43245 11 181.49 172.42 198.28 43246 11 242.82 230.68 265.28 43247 11 193.47 183.80 211.37 43248 11 182.17 173.06 199.02 43249 11 167.95 159.55 183.48 43250 11 182.00 172.90 198.84 43251 11 210.58 200.05 230.06 43255 11 273.16 259.50 298.43 43256 11 246.11 233.80 268.87 43257 11 307.79 292.40 336.26 43258 11 257.94 245.04 281.80 43259 11 293.91 279.21 321.09 43260 11 335.38 318.61 366.40 43261 11 352.49 334.87 385.10 43262 11 414.18 393.47 452.49 43263 11 408.35 387.93 446.12 43264 11 497.27 472.41 543.27 43265 11 557.76 529.87 609.35 43267 11 412.60 391.97 450.77 43268 11 419.53 398.55 458.33 43269 11 458.95 436.00 501.40 43271 11 413.86 393.17 452.15 43272 11 414.18 393.47 452.49 43273 11 123.95 117.75 135.41 43279 11 1203.46 1143.29 1314.78 43280 11 1002.59 952.46 1095.33 43281 11 1476.91 1403.06 1613.52 43282 11 1659.80 1576.81 1813.33 43283 11 154.22 146.51 168.49 43300 11 591.60 562.02 646.32 43305 11 1058.82 1005.88 1156.76 43310 11 1434.72 1362.98 1567.43 43312 11 1565.01 1486.76 1709.77 43313 11 2647.59 2515.21 2892.49 43314 11 2752.46 2614.84 3007.07 43320 11 1299.86 1234.87 1420.10 43325 11 1241.76 1179.67 1356.62 43327 11 774.08 735.38 845.69 43328 11 1130.79 1074.25 1235.39 43330 11 1222.91 1161.76 1336.02 43331 11 1295.90 1231.11 1415.78 43332 11 1109.00 1053.55 1211.58 43333 11 1204.52 1144.29 1315.93 43334 11 1217.68 1156.80 1330.32 43335 11 1312.28 1246.67 1433.67 43336 11 1434.24 1362.53 1566.91 43337 11 1565.23 1486.97 1710.02 43338 11 127.43 121.06 139.22 43340 11 1276.14 1212.33 1394.18 43341 11 1397.15 1327.29 1526.38 43350 11 1146.73 1089.39 1252.80 43351 11 1250.44 1187.92 1366.11 43352 11 1023.43 972.26 1118.10 43360 11 2173.95 2065.25 2375.04 43361 11 2430.16 2308.65 2654.95 43400 11 1447.40 1375.03 1581.28 43401 11 1417.19 1346.33 1548.28 43405 11 1417.93 1347.03 1549.08 43410 11 979.27 930.31 1069.86 43415 11 1625.64 1544.36 1776.01 43420 11 971.90 923.31 1061.81 43425 11 1426.28 1354.97 1558.22 43450 N 11 147.65 140.27 161.31 43450 F 11 85.92 81.62 93.86 43453 N 11 276.71 262.87 302.30 43453 F 11 92.77 88.13 101.35 43456 N 11 559.61 531.63 611.37 43456 F 11 149.53 142.05 163.36 43458 N 11 364.31 346.09 398.00 43458 F 11 175.33 166.56 191.54 43460 11 213.84 203.15 233.62 43500 11 723.74 687.55 790.68 43501 11 1240.62 1178.59 1355.38 43502 11 1404.49 1334.27 1534.41 43510 11 889.11 844.65 971.35 43520 11 645.94 613.64 705.69 43605 11 773.48 734.81 845.03 43610 11 904.61 859.38 988.29 43611 11 1126.53 1070.20 1230.73 43620 11 1824.84 1733.60 1993.64 43621 11 2096.40 1991.58 2290.32 43622 11 2125.71 2019.42 2322.33 43631 11 1340.60 1273.57 1464.61 43632 11 1865.77 1772.48 2038.35 43633 11 1767.77 1679.38 1931.29 43634 11 1954.92 1857.17 2135.75 43635 11 104.76 99.52 114.45 43640 11 1085.75 1031.46 1186.18 43641 11 1100.93 1045.88 1202.76 43644 11 1603.39 1523.22 1751.70 43645 11 1713.44 1627.77 1871.94 43647 11 415.36 394.59 453.78 43651 11 599.09 569.14 654.51 43652 11 701.10 666.05 765.96 43653 11 520.25 494.24 568.38 43752 11 39.74 37.75 43.41 43753 11 20.07 19.07 21.93 43754 N 11 73.84 70.15 80.67 43754 F 11 30.06 28.56 32.84 43755 N 11 113.13 107.47 123.59 43755 F 11 55.18 52.42 60.28 43756 N 11 203.68 193.50 222.53 43756 F 11 49.66 47.18 54.26 43757 N 11 262.59 249.46 286.88 43757 F 11 72.04 68.44 78.71 43760 N 11 375.50 356.73 410.24 43760 F 11 47.31 44.94 51.68 43761 N 11 114.71 108.97 125.32 43761 F 11 101.17 96.11 110.53 43770 11 1028.83 977.39 1124.00 43771 11 1172.32 1113.70 1280.76 43772 11 883.10 838.95 964.79 43773 11 1172.32 1113.70 1280.76 43774 11 885.77 841.48 967.70 43800 11 857.99 815.09 937.35 43810 11 934.11 887.40 1020.51 43820 11 1228.65 1167.22 1342.30 43825 11 1203.22 1143.06 1314.52 43830 11 641.22 609.16 700.53 43831 11 541.06 514.01 591.11 43832 11 974.08 925.38 1064.19 43840 11 1245.25 1182.99 1360.44 43843 11 1174.55 1115.82 1283.19 43845 11 1807.33 1716.96 1974.50 43846 11 1506.36 1431.04 1645.70 43847 11 1653.65 1570.97 1806.62 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 021 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 43848 11 1783.39 1694.22 1948.35 43850 11 1497.58 1422.70 1636.11 43855 11 1558.49 1480.57 1702.66 43860 11 1511.26 1435.70 1651.06 43865 11 1576.01 1497.21 1721.79 43870 11 653.92 621.22 714.40 43880 11 1475.48 1401.71 1611.97 43886 11 325.42 309.15 355.52 43887 11 295.40 280.63 322.72 43888 11 417.29 396.43 455.89 44005 11 1010.50 959.98 1103.98 44010 11 798.48 758.56 872.34 44015 11 134.23 127.52 146.65 44020 11 896.96 852.11 979.93 44021 11 906.28 860.97 990.12 44025 11 911.59 866.01 995.91 44050 11 861.65 818.57 941.36 44055 11 1381.47 1312.40 1509.26 44100 11 109.69 104.21 119.84 44110 11 782.83 743.69 855.24 44111 11 909.32 863.85 993.43 44120 11 1128.94 1072.49 1233.36 44121 11 226.49 215.17 247.45 44125 11 1091.76 1037.17 1192.75 44126 11 2270.24 2156.73 2480.24 44127 11 2629.92 2498.42 2873.18 44128 11 227.49 216.12 248.54 44130 11 1204.15 1143.94 1315.53 44139 11 113.52 107.84 124.02 44140 11 1239.93 1177.93 1354.62 44141 11 1673.98 1590.28 1828.82 44143 11 1538.06 1461.16 1680.33 44144 11 1630.83 1549.29 1781.68 44145 11 1540.40 1463.38 1682.89 44146 11 1953.16 1855.50 2133.83 44147 11 1785.85 1696.56 1951.04 44150 11 1720.52 1634.49 1879.66 44151 11 1970.25 1871.74 2152.50 44155 11 1919.26 1823.30 2096.80 44156 11 2120.01 2014.01 2316.11 44157 11 2004.63 1904.40 2190.06 44158 11 2052.22 1949.61 2242.05 44160 11 1147.05 1089.70 1253.16 44180 11 850.93 808.38 929.64 44186 11 602.66 572.53 658.41 44187 11 1018.46 967.54 1112.67 44188 11 1128.61 1072.18 1233.01 44202 11 1282.92 1218.77 1401.59 44203 11 226.55 215.22 247.50 44204 11 1428.86 1357.42 1561.03 44205 11 1244.24 1182.03 1359.33 44206 11 1628.11 1546.70 1778.71 44207 11 1700.38 1615.36 1857.66 44208 11 1848.48 1756.06 2019.47 44210 11 1663.15 1579.99 1816.99 44211 11 2067.81 1964.42 2259.08 44212 11 1909.74 1814.25 2086.39 44213 11 177.34 168.47 193.74 44227 11 1549.01 1471.56 1692.29 44300 11 777.30 738.44 849.21 44310 11 966.29 917.98 1055.68 44312 11 549.62 522.14 600.46 44314 11 935.30 888.54 1021.82 44316 11 1299.71 1234.72 1419.93 44320 11 1108.79 1053.35 1211.35 44322 11 902.51 857.38 985.99 44340 11 567.93 539.53 620.46 44345 11 971.22 922.66 1061.06 44346 11 1091.48 1036.91 1192.45 44360 11 152.10 144.50 166.18 44361 11 167.33 158.96 182.80 44363 11 199.41 189.44 217.86 44364 11 213.69 203.01 233.46 44365 11 190.72 181.18 208.36 44366 11 251.33 238.76 274.57 44369 11 256.87 244.03 280.63 44370 11 277.38 263.51 303.04 44372 11 246.49 234.17 269.30 44373 11 198.38 188.46 216.73 44376 11 293.45 278.78 320.60 44377 11 310.81 295.27 339.56 44378 11 399.08 379.13 436.00 44379 11 422.88 401.74 462.00 44380 11 65.64 62.36 71.71 44382 11 79.52 75.54 86.87 44383 11 163.48 155.31 178.61 44385 N 11 236.90 225.06 258.82 44385 F 11 101.78 96.69 111.19 44386 N 11 325.54 309.26 355.65 44386 F 11 120.81 114.77 131.99 44388 N 11 326.55 310.22 356.75 44388 F 11 159.30 151.34 174.04 44389 N 11 373.90 355.21 408.49 44389 F 11 177.99 169.09 194.45 44390 N 11 435.16 413.40 475.41 44390 F 11 215.31 204.54 235.22 44391 N 11 476.85 453.01 520.96 44391 F 11 242.52 230.39 264.95 44392 N 11 410.27 389.76 448.22 44392 F 11 210.58 200.05 230.06 44393 N 11 475.92 452.12 519.94 44393 F 11 268.05 254.65 292.85 44394 N 11 473.62 449.94 517.43 44394 F 11 246.85 234.51 269.69 44397 11 265.90 252.61 290.50 44500 11 23.86 22.67 26.07 44602 11 1297.90 1233.01 1417.96 44603 11 1489.35 1414.88 1627.11 44604 11 978.67 929.74 1069.20 44605 11 1210.06 1149.56 1321.99 44615 11 996.54 946.71 1088.72 44620 11 800.47 760.45 874.52 44625 11 944.03 896.83 1031.35 44626 11 1490.18 1415.67 1628.02 44640 11 1301.59 1236.51 1421.99 44650 11 1347.74 1280.35 1472.40 44660 11 1274.32 1210.60 1392.19 44661 11 1454.66 1381.93 1589.22 44680 11 989.10 939.65 1080.60 44700 11 945.42 898.15 1032.87 44701 11 156.89 149.05 171.41 44720 11 244.63 232.40 267.26 44721 11 360.54 342.51 393.89 44800 11 702.21 667.10 767.17 44820 11 775.11 736.35 846.80 44850 11 688.43 654.01 752.11 44900 11 710.58 675.05 776.31 44901 N 11 879.65 835.67 961.02 44901 F 11 165.94 157.64 181.29 44950 11 592.41 562.79 647.21 44955 11 78.58 74.65 85.85 44960 11 804.77 764.53 879.21 44970 11 549.61 522.13 600.45 45000 11 387.56 368.18 423.41 45005 N 11 236.67 224.84 258.57 45005 F 11 143.12 135.96 156.35 45020 11 516.43 490.61 564.20 45100 11 270.53 257.00 295.55 45108 11 332.04 315.44 362.76 45110 11 1713.15 1627.49 1871.61 45111 11 1007.18 956.82 1100.34 45112 11 1755.40 1667.63 1917.77 45113 11 1825.86 1734.57 1994.76 45114 11 1669.30 1585.84 1823.72 45116 11 1464.23 1391.02 1599.67 45119 11 1809.94 1719.44 1977.36 45120 11 1461.55 1388.47 1596.74 45121 11 1596.87 1517.03 1744.58 45123 11 1031.81 980.22 1127.25 45126 11 2689.93 2555.43 2938.74 45130 11 1007.32 956.95 1100.49 45135 11 1255.63 1192.85 1371.78 45136 11 1686.28 1601.97 1842.27 45150 11 366.35 348.03 400.23 45160 11 927.72 881.33 1013.53 45171 11 563.57 535.39 615.70 45172 11 770.38 731.86 841.64 45190 11 629.82 598.33 688.08 45300 N 11 106.14 100.83 115.95 45300 F 11 48.81 46.37 53.33 45303 N 11 815.32 774.55 890.73 45303 F 11 83.98 79.78 91.75 45305 N 11 169.92 161.42 185.63 45305 F 11 73.23 69.57 80.01 45307 N 11 190.95 181.40 208.61 45307 F 11 94.57 89.84 103.32 45308 N 11 179.48 170.51 196.09 45308 F 11 80.27 76.26 87.70 45309 N 11 191.29 181.73 208.99 45309 F 11 87.67 83.29 95.78 45315 N 11 211.99 201.39 231.60 45315 F 11 102.38 97.26 111.85 45317 N 11 204.93 194.68 223.88 45317 F 11 109.18 103.72 119.28 45320 N 11 198.88 188.94 217.28 45320 F 11 101.56 96.48 110.95 45321 11 100.68 95.65 110.00 45327 11 118.79 112.85 129.78 45330 N 11 128.72 122.28 140.62 45330 F 11 59.75 56.76 65.27 45331 N 11 160.34 152.32 175.17 45331 F 11 72.47 68.85 79.18 45332 N 11 267.43 254.06 292.17 45332 F 11 105.85 100.56 115.64 45333 N 11 270.26 256.75 295.26 45333 F 11 105.54 100.26 115.30 45334 11 158.02 150.12 172.64 45335 N 11 235.95 224.15 257.77 45335 F 11 88.24 83.83 96.40 45337 11 136.41 129.59 149.03 45338 N 11 296.93 282.08 324.39 45338 F 11 135.99 129.19 148.57 45339 N 11 313.85 298.16 342.88 45339 F 11 179.68 170.70 196.31 45340 N 11 423.50 402.33 462.68 45340 F 11 111.05 105.50 121.33 45341 11 151.49 143.92 165.51 45342 11 231.28 219.72 252.68 45345 11 168.14 159.73 183.69 45355 11 195.07 185.32 213.12 45378 N 11 370.95 352.40 405.26 45378 F 11 208.75 198.31 228.06 45378 53 N 11 128.72 122.28 140.62 45378 53 F 11 59.75 56.76 65.27 45379 N 11 473.38 449.71 517.17 45379 F 11 261.41 248.34 285.59 45380 N 11 443.59 421.41 484.62 45380 F 11 250.51 237.98 273.68 45381 N 11 431.69 410.11 471.63 45381 F 11 237.67 225.79 259.66 45382 N 11 580.96 551.91 634.70 45382 F 11 319.85 303.86 349.44 45383 N 11 533.23 506.57 582.56 45383 F 11 323.16 307.00 353.05 45384 N 11 439.30 417.34 479.94 45384 F 11 261.03 247.98 285.18 45385 N 11 500.36 475.34 546.64 45385 F 11 297.21 282.35 324.70 45386 N 11 617.99 587.09 675.15 45386 F 11 256.10 243.30 279.80 45387 11 332.96 316.31 363.76 45391 11 285.96 271.66 312.41 45392 11 366.72 348.38 400.64 45395 11 1845.18 1752.92 2015.86 45397 11 1996.28 1896.47 2180.94 45400 11 1068.19 1014.78 1167.00 45402 11 1422.26 1351.15 1553.82 45500 11 476.68 452.85 520.78 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 022 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 45505 11 532.01 505.41 581.22 45520 N 11 128.00 121.60 139.84 45520 F 11 36.66 34.83 40.05 45540 11 980.64 931.61 1071.35 45541 11 853.05 810.40 931.96 45550 11 1355.14 1287.38 1480.49 45560 11 656.96 624.11 717.73 45562 11 1030.32 978.80 1125.62 45563 11 1504.65 1429.42 1643.83 45800 11 1129.24 1072.78 1233.70 45805 11 1335.16 1268.40 1458.66 45820 11 1105.29 1050.03 1207.53 45825 11 1353.64 1285.96 1478.85 45900 11 184.28 175.07 201.33 45905 11 154.70 146.97 169.02 45910 11 181.16 172.10 197.92 45915 N 11 291.26 276.70 318.21 45915 F 11 205.91 195.61 224.95 45990 11 100.35 95.33 109.63 46020 N 11 242.43 230.31 264.86 46020 F 11 209.67 199.19 229.07 46030 N 11 121.75 115.66 133.01 46030 F 11 82.07 77.97 89.67 46040 N 11 468.44 445.02 511.77 46040 F 11 371.75 353.16 406.13 46045 11 387.69 368.31 423.56 46050 N 11 171.70 163.12 187.59 46050 F 11 87.60 83.22 95.70 46060 11 425.38 404.11 464.73 46070 11 208.96 198.51 228.29 46080 N 11 218.68 207.75 238.91 46080 F 11 146.56 139.23 160.11 46083 N 11 158.99 151.04 173.70 46083 F 11 98.20 93.29 107.28 46200 N 11 378.54 359.61 413.55 46200 F 11 286.57 272.24 313.08 46220 N 11 179.65 170.67 196.27 46220 F 11 107.84 102.45 117.82 46221 N 11 234.41 222.69 256.09 46221 F 11 171.42 162.85 187.28 46230 N 11 241.06 229.01 263.36 46230 F 11 158.23 150.32 172.87 46250 N 11 404.67 384.44 442.11 46250 F 11 283.41 269.24 309.63 46255 N 11 445.61 423.33 486.83 46255 F 11 319.63 303.65 349.20 46257 11 378.44 359.52 413.45 46258 11 420.05 399.05 458.91 46260 11 427.38 406.01 466.91 46261 11 478.65 454.72 522.93 46262 11 499.38 474.41 545.57 46270 N 11 443.05 420.90 484.04 46270 F 11 348.25 330.84 380.47 46275 N 11 467.91 444.51 511.19 46275 F 11 369.64 351.16 403.83 46280 11 419.88 398.89 458.72 46285 N 11 460.33 437.31 502.91 46285 F 11 367.10 348.75 401.06 46288 11 493.47 468.80 539.12 46320 N 11 160.20 152.19 175.02 46320 F 11 100.99 95.94 110.33 46500 N 11 201.67 191.59 220.33 46500 F 11 116.95 111.10 127.77 46505 N 11 255.98 243.18 279.66 46505 F 11 216.93 206.08 236.99 46600 N 11 76.89 73.05 84.01 46600 F 11 36.57 34.74 39.95 46604 N 11 507.31 481.94 554.23 46604 F 11 61.32 58.25 66.99 46606 N 11 197.83 187.94 216.13 46606 F 11 70.58 67.05 77.11 46608 N 11 204.29 194.08 223.19 46608 F 11 74.84 71.10 81.77 46610 N 11 200.77 190.73 219.34 46610 F 11 75.10 71.35 82.05 46611 N 11 157.13 149.27 171.66 46611 F 11 76.18 72.37 83.23 46612 N 11 236.62 224.79 258.51 46612 F 11 88.27 83.86 96.44 46614 N 11 115.28 109.52 125.95 46614 F 11 61.11 58.05 66.76 46615 N 11 131.91 125.31 144.11 46615 F 11 88.13 83.72 96.28 46700 11 592.52 562.89 647.32 46705 11 452.96 430.31 494.86 46706 11 153.58 145.90 167.79 46707 11 442.35 420.23 483.26 46710 11 1005.24 954.98 1098.23 46712 11 1924.57 1828.34 2102.59 46715 11 454.92 432.17 497.00 46716 11 1079.33 1025.36 1179.16 46730 11 1671.24 1587.68 1825.83 46735 11 1938.78 1841.84 2118.12 46740 11 1952.85 1855.21 2133.49 46742 11 2279.91 2165.91 2490.80 46744 11 3153.90 2996.21 3445.64 46746 11 3385.58 3216.30 3698.75 46748 11 3601.31 3421.24 3934.43 46750 11 704.66 669.43 769.84 46751 11 568.78 540.34 621.39 46753 11 534.27 507.56 583.69 46754 N 11 264.92 251.67 289.42 46754 F 11 206.65 196.32 225.77 46760 11 999.66 949.68 1092.13 46761 11 860.97 817.92 940.61 46762 11 848.56 806.13 927.05 46900 N 11 211.89 201.30 231.50 46900 F 11 127.17 120.81 138.93 46910 N 11 220.05 209.05 240.41 46910 F 11 122.73 116.59 134.08 46916 N 11 213.10 202.45 232.82 46916 F 11 135.30 128.54 147.82 46917 N 11 413.84 393.15 452.12 46917 F 11 123.13 116.97 134.52 46922 N 11 232.24 220.63 253.72 46922 F 11 123.27 117.11 134.68 46924 N 11 473.61 449.93 517.42 46924 F 11 170.30 161.79 186.06 46930 N 11 190.39 180.87 208.00 46930 F 11 138.74 131.80 151.57 46940 N 11 200.72 190.68 219.28 46940 F 11 135.21 128.45 147.72 46942 N 11 187.46 178.09 204.80 46942 F 11 121.00 114.95 132.19 46945 N 11 264.22 251.01 288.66 46945 F 11 199.97 189.97 218.47 46946 N 11 275.77 261.98 301.28 46946 F 11 203.96 193.76 222.82 46947 11 346.70 329.37 378.78 47000 N 11 322.66 306.53 352.51 47000 F 11 94.63 89.90 103.39 47001 11 96.84 92.00 105.80 47010 11 1105.64 1050.36 1207.91 47011 11 181.86 172.77 198.69 47015 11 1062.73 1009.59 1161.03 47100 11 772.09 733.49 843.51 47120 11 2148.38 2040.96 2347.10 47122 11 3176.49 3017.67 3470.32 47125 11 2844.54 2702.31 3107.66 47130 11 3054.14 2901.43 3336.64 47135 11 4524.91 4298.66 4943.46 47136 11 3841.06 3649.01 4196.36 47140 11 3283.12 3118.96 3586.80 47141 11 3663.55 3480.37 4002.43 47142 11 4335.45 4118.68 4736.48 47143 11 203.55 193.37 222.38 47146 11 307.69 292.31 336.16 47147 11 358.82 340.88 392.01 47300 11 1039.94 987.94 1136.13 47350 11 1263.41 1200.24 1380.28 47360 11 1727.05 1640.70 1886.81 47361 11 2797.08 2657.23 3055.81 47362 11 1324.40 1258.18 1446.91 47370 11 1144.97 1087.72 1250.88 47371 11 1165.41 1107.14 1273.21 47380 11 1334.71 1267.97 1458.17 47381 11 1329.54 1263.06 1452.52 47382 N 11 4318.11 4102.20 4717.53 47382 F 11 775.74 736.95 847.49 47400 11 1986.96 1887.61 2170.75 47420 11 1235.76 1173.97 1350.07 47425 11 1253.94 1191.24 1369.93 47460 11 1176.35 1117.53 1285.16 47480 11 796.03 756.23 869.66 47490 11 346.56 329.23 378.61 47500 11 96.67 91.84 105.62 47505 11 37.18 35.32 40.62 47510 11 462.41 439.29 505.18 47511 11 573.75 545.06 626.82 47525 N 11 479.45 455.48 523.80 47525 F 11 93.94 89.24 102.63 47530 N 11 1352.06 1284.46 1477.13 47530 F 11 347.97 330.57 380.16 47550 11 155.08 147.33 169.43 47552 11 311.21 295.65 340.00 47553 11 312.29 296.68 341.18 47554 11 472.31 448.69 515.99 47555 11 371.29 352.73 405.64 47556 11 420.86 399.82 459.79 47560 11 251.16 238.60 274.39 47561 11 274.12 260.41 299.47 47562 11 685.71 651.42 749.13 47563 11 694.93 660.18 759.21 47564 11 796.91 757.06 870.62 47570 11 712.81 677.17 778.75 47600 11 991.33 941.76 1083.02 47605 11 903.29 858.13 986.85 47610 11 1156.18 1098.37 1263.13 47612 11 1168.74 1110.30 1276.85 47620 11 1269.69 1206.21 1387.14 47630 11 534.67 507.94 584.13 47700 11 965.27 917.01 1054.56 47701 11 1623.79 1542.60 1773.99 47711 11 1437.05 1365.20 1569.98 47712 11 1841.80 1749.71 2012.17 47715 11 1217.85 1156.96 1330.50 47720 11 1050.80 998.26 1148.00 47721 11 1241.06 1179.01 1355.86 47740 11 1200.75 1140.71 1311.82 47741 11 1354.70 1286.97 1480.02 47760 11 2067.97 1964.57 2259.26 47765 11 2775.32 2636.55 3032.03 47780 11 2267.18 2153.82 2476.89 47785 11 2972.72 2824.08 3247.69 47800 11 1455.35 1382.58 1589.97 47801 11 979.91 930.91 1070.55 47802 11 1401.07 1331.02 1530.67 47900 11 1255.55 1192.77 1371.69 48000 11 1718.41 1632.49 1877.36 48001 11 2133.98 2027.28 2331.37 48020 11 1081.47 1027.40 1181.51 48100 11 816.79 775.95 892.34 48102 N 11 508.93 483.48 556.00 48102 F 11 240.27 228.26 262.50 48105 11 2636.37 2504.55 2880.23 48120 11 1019.84 968.85 1114.18 48140 11 1441.32 1369.25 1574.64 48145 11 1501.64 1426.56 1640.54 48146 11 1721.55 1635.47 1880.79 48148 11 1143.85 1086.66 1249.66 48150 11 2867.72 2724.33 3132.98 48152 11 2662.20 2529.09 2908.45 48153 11 2863.67 2720.49 3128.56 48154 11 2671.15 2537.59 2918.23 48155 11 1667.02 1583.67 1821.22 48400 11 99.95 94.95 109.19 48500 11 1051.07 998.52 1148.30 48510 11 995.98 946.18 1088.11 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 023 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 48511 N 11 879.98 835.98 961.38 48511 F 11 196.83 186.99 215.04 48520 11 1007.52 957.14 1100.71 48540 11 1195.53 1135.75 1306.11 48545 11 1232.41 1170.79 1346.41 48547 11 1649.09 1566.64 1801.64 48548 11 1536.17 1459.36 1678.26 48552 11 221.11 210.05 241.56 48554 11 2331.59 2215.01 2547.26 48556 11 1158.97 1101.02 1266.17 49000 11 712.37 676.75 778.26 49002 11 959.93 911.93 1048.72 49010 11 881.29 837.23 962.81 49020 11 1470.66 1397.13 1606.70 49021 N 11 836.84 795.00 914.25 49021 F 11 165.66 157.38 180.99 49040 11 924.56 878.33 1010.08 49041 N 11 863.29 820.13 943.15 49041 F 11 196.51 186.68 214.68 49060 11 1025.52 974.24 1120.38 49061 N 11 844.62 802.39 922.75 49061 F 11 181.63 172.55 198.43 49062 11 693.32 658.65 757.45 49080 N 11 153.80 146.11 168.03 49080 F 11 66.87 63.53 73.06 49081 N 11 153.23 145.57 167.41 49081 F 11 64.73 61.49 70.71 49180 N 11 155.03 147.28 169.37 49180 F 11 85.10 80.85 92.98 49203 11 1110.55 1055.02 1213.27 49204 11 1414.96 1344.21 1545.84 49205 11 1622.60 1541.47 1772.69 49215 11 2045.21 1942.95 2234.39 49220 11 895.03 850.28 977.82 49250 11 536.42 509.60 586.04 49255 11 727.71 691.32 795.02 49320 11 303.32 288.15 331.37 49321 11 320.83 304.79 350.51 49322 11 345.60 328.32 377.57 49323 11 596.68 566.85 651.88 49324 11 365.05 346.80 398.82 49325 11 390.59 371.06 426.72 49326 11 177.13 168.27 193.51 49327 11 124.25 118.04 135.75 49400 N 11 148.72 141.28 162.47 49400 F 11 93.60 88.92 102.26 49402 11 789.88 750.39 862.95 49411 N 11 490.21 465.70 535.56 49411 F 11 189.74 180.25 207.29 49412 11 77.65 73.77 84.84 49418 N 11 1413.15 1342.49 1543.86 49418 F 11 222.60 211.47 243.19 49419 11 412.93 392.28 451.12 49421 11 252.99 240.34 276.39 49422 11 356.82 338.98 389.83 49423 N 11 531.40 504.83 580.55 49423 F 11 72.81 69.17 79.55 49424 N 11 142.38 135.26 155.55 49424 F 11 38.44 36.52 42.00 49425 11 702.20 667.09 767.15 49426 11 594.27 564.56 649.24 49427 11 44.49 42.27 48.61 49428 11 403.62 383.44 440.96 49429 11 424.78 403.54 464.07 49435 11 112.22 106.61 122.60 49436 11 171.69 163.11 187.58 49440 N 11 1016.59 965.76 1110.62 49440 F 11 221.00 209.95 241.44 49441 N 11 1126.82 1070.48 1231.05 49441 F 11 251.23 238.67 274.47 49442 N 11 946.23 898.92 1033.76 49442 F 11 208.59 198.16 227.88 49446 N 11 939.69 892.71 1026.62 49446 F 11 163.31 155.14 178.41 49450 N 11 668.47 635.05 730.31 49450 F 11 65.95 62.65 72.05 49451 N 11 677.79 643.90 740.49 49451 F 11 91.64 87.06 100.12 49452 N 11 843.80 801.61 921.85 49452 F 11 141.44 134.37 154.53 49460 N 11 736.63 699.80 804.77 49460 F 11 47.50 45.13 51.90 49465 N 11 161.42 153.35 176.35 49465 F 11 30.39 28.87 33.20 49491 11 723.76 687.57 790.71 49492 11 877.06 833.21 958.19 49495 11 370.20 351.69 404.44 49496 11 563.60 535.42 615.73 49500 11 352.36 334.74 384.95 49501 11 552.05 524.45 603.12 49505 11 475.54 451.76 519.52 49507 11 584.76 555.52 638.85 49520 11 579.43 550.46 633.03 49521 11 703.90 668.71 769.02 49525 11 524.71 498.47 573.24 49540 11 620.84 589.80 678.27 49550 11 527.75 501.36 576.56 49553 11 578.31 549.39 631.80 49555 11 548.20 520.79 598.91 49557 11 665.15 631.89 726.67 49560 11 678.23 644.32 740.97 49561 11 856.58 813.75 935.81 49565 11 706.02 670.72 771.33 49566 11 865.65 822.37 945.73 49568 11 250.07 237.57 273.21 49570 11 378.05 359.15 413.02 49572 11 469.42 445.95 512.84 49580 11 298.89 283.95 326.54 49582 11 437.85 415.96 478.35 49585 11 404.74 384.50 442.18 49587 11 478.63 454.70 522.91 49590 11 523.83 497.64 572.29 49600 11 673.48 639.81 735.78 49605 11 4611.57 4380.99 5038.14 49606 11 1045.51 993.23 1142.21 49610 11 632.48 600.86 690.99 49611 11 524.91 498.66 573.46 49650 11 390.03 370.53 426.11 49651 11 507.67 482.29 554.63 49652 11 690.89 656.35 754.80 49653 11 865.71 822.42 945.78 49654 11 794.36 754.64 867.84 49655 11 955.99 908.19 1044.42 49656 11 797.14 757.28 870.87 49657 11 1147.33 1089.96 1253.45 49900 11 749.70 712.22 819.05 49904 11 1364.67 1296.44 1490.91 49905 11 332.05 315.45 362.77 50010 11 707.40 672.03 772.83 50020 11 1008.45 958.03 1101.73 50021 N 11 883.77 839.58 965.52 50021 F 11 165.35 157.08 180.64 50040 11 912.97 867.32 997.42 50045 11 916.45 870.63 1001.22 50060 11 1126.76 1070.42 1230.98 50065 11 1187.44 1128.07 1297.28 50070 11 1174.97 1116.22 1283.65 50075 11 1444.00 1371.80 1577.57 50080 11 860.83 817.79 940.46 50081 11 1264.34 1201.12 1381.29 50100 11 939.97 892.97 1026.92 50120 11 934.39 887.67 1020.82 50125 11 992.79 943.15 1084.62 50130 11 1022.03 970.93 1116.57 50135 11 1107.46 1052.09 1209.90 50200 N 11 540.52 513.49 590.51 50200 F 11 141.15 134.09 154.20 50205 11 699.06 664.11 763.73 50220 11 1021.41 970.34 1115.89 50225 11 1175.62 1116.84 1284.37 50230 11 1265.78 1202.49 1382.86 50234 11 1285.36 1221.09 1404.25 50236 11 1450.47 1377.95 1584.64 50240 11 1307.98 1242.58 1428.97 50250 11 1207.49 1147.12 1319.19 50280 11 938.97 892.02 1025.82 50290 11 894.75 850.01 977.51 50320 11 1333.38 1266.71 1456.72 50323 11 126.05 119.75 137.71 50325 11 129.80 123.31 141.81 50327 11 204.08 193.88 222.96 50328 11 178.60 169.67 195.12 50329 11 169.15 160.69 184.79 50340 11 862.50 819.38 942.29 50360 11 2360.59 2242.56 2578.94 50365 11 2654.97 2522.22 2900.55 50370 11 1102.94 1047.79 1204.96 50380 11 1859.88 1766.89 2031.92 50382 N 11 1196.84 1137.00 1307.55 50382 F 11 273.37 259.70 298.66 50384 N 11 1000.35 950.33 1092.88 50384 F 11 248.23 235.82 271.19 50385 N 11 1167.68 1109.30 1275.70 50385 F 11 232.87 221.23 254.41 50386 N 11 761.71 723.62 832.16 50386 F 11 175.88 167.09 192.15 50387 N 11 553.77 526.08 604.99 50387 F 11 98.97 94.02 108.12 50389 N 11 308.00 292.60 336.49 50389 F 11 54.14 51.43 59.14 50390 11 96.21 91.40 105.11 50391 N 11 123.12 116.96 134.50 50391 F 11 98.87 93.93 108.02 50392 11 177.00 168.15 193.37 50393 11 215.49 204.72 235.43 50394 N 11 98.60 93.67 107.72 50394 F 11 48.84 46.40 53.36 50395 11 178.72 169.78 195.25 50396 11 114.94 109.19 125.57 50398 N 11 500.85 475.81 547.18 50398 F 11 72.81 69.17 79.55 50400 11 1142.21 1085.10 1247.87 50405 11 1378.78 1309.84 1506.32 50500 11 1189.70 1130.22 1299.75 50520 11 1019.17 968.21 1113.44 50525 11 1384.40 1315.18 1512.46 50526 11 1368.14 1299.73 1494.69 50540 11 1123.50 1067.33 1227.43 50541 11 909.55 864.07 993.68 50542 11 1155.03 1097.28 1261.87 50543 11 1473.31 1399.64 1609.59 50544 11 1235.98 1174.18 1350.31 50545 11 1329.43 1262.96 1452.40 50546 11 1184.79 1125.55 1294.38 50547 11 1503.95 1428.75 1643.06 50548 11 1336.59 1269.76 1460.22 50551 N 11 357.20 339.34 390.24 50551 F 11 292.95 278.30 320.05 50553 N 11 378.94 359.99 413.99 50553 F 11 312.17 296.56 341.04 50555 N 11 408.17 387.76 445.92 50555 F 11 339.20 322.24 370.58 50557 N 11 415.55 394.77 453.99 50557 F 11 344.06 326.86 375.89 50561 N 11 472.12 448.51 515.79 50561 F 11 393.07 373.42 429.43 50562 11 578.45 549.53 631.96 50570 11 489.42 464.95 534.69 50572 11 530.22 503.71 579.27 50574 11 563.72 535.53 615.86 50575 11 711.93 676.33 777.78 50576 11 561.93 533.83 613.90 50580 11 603.84 573.65 659.70 50590 N 11 836.13 794.32 913.47 50590 F 11 557.39 529.52 608.95 50592 N 11 3208.16 3047.75 3504.91 50592 F 11 357.44 339.57 390.51 50593 N 11 4413.28 4192.62 4821.51 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 024 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 50593 F 11 465.24 441.98 508.28 50600 11 924.84 878.60 1010.39 50605 11 929.46 882.99 1015.44 50610 11 934.17 887.46 1020.58 50620 11 893.38 848.71 976.02 50630 11 875.68 831.90 956.69 50650 11 1022.05 970.95 1116.59 50660 11 1127.39 1071.02 1231.67 50684 N 11 141.12 134.06 154.17 50684 F 11 48.84 46.40 53.36 50686 N 11 138.84 131.90 151.69 50686 F 11 91.28 86.72 99.73 50688 11 78.24 74.33 85.48 50690 N 11 95.24 90.48 104.05 50690 F 11 68.46 65.04 74.80 50700 11 911.40 865.83 995.70 50715 11 1124.86 1068.62 1228.91 50722 11 995.00 945.25 1087.04 50725 11 1107.47 1052.10 1209.92 50727 11 496.07 471.27 541.96 50728 11 681.99 647.89 745.07 50740 11 1132.78 1076.14 1237.56 50750 11 1142.92 1085.77 1248.64 50760 11 1095.22 1040.46 1196.53 50770 11 1121.82 1065.73 1225.59 50780 11 1083.56 1029.38 1183.79 50782 11 1104.60 1049.37 1206.78 50783 11 1124.66 1068.43 1228.69 50785 11 1194.31 1134.59 1304.78 50800 11 910.61 865.08 994.84 50810 11 1259.11 1196.15 1375.57 50815 11 1205.87 1145.58 1317.42 50820 11 1293.35 1228.68 1412.98 50825 11 1634.67 1552.94 1785.88 50830 11 1771.05 1682.50 1934.88 50840 11 1214.21 1153.50 1326.53 50845 11 1232.02 1170.42 1345.98 50860 11 930.69 884.16 1016.78 50900 11 828.93 787.48 905.60 50920 11 869.60 826.12 950.04 50930 11 1120.71 1064.67 1224.37 50940 11 872.01 828.41 952.67 50945 11 962.04 913.94 1051.03 50947 11 1363.14 1294.98 1489.23 50948 11 1264.90 1201.66 1381.91 50951 N 11 373.37 354.70 407.91 50951 F 11 305.34 290.07 333.58 50953 N 11 395.03 375.28 431.57 50953 F 11 337.08 320.23 368.26 50955 N 11 429.96 408.46 469.73 50955 F 11 363.19 345.03 396.78 50957 N 11 425.02 403.77 464.34 50957 F 11 352.27 334.66 384.86 50961 N 11 383.71 364.52 419.20 50961 F 11 315.99 300.19 345.22 50970 11 368.94 350.49 403.06 50972 11 356.12 338.31 389.06 50974 11 471.13 447.57 514.71 50976 11 463.96 440.76 506.87 50980 11 354.62 336.89 387.42 51020 11 461.11 438.05 503.76 51030 11 457.57 434.69 499.89 51040 11 285.42 271.15 311.82 51045 11 473.77 450.08 517.59 51050 11 465.58 442.30 508.65 51060 11 573.32 544.65 626.35 51065 11 569.86 541.37 622.58 51080 11 400.60 380.57 437.66 51100 N 11 60.45 57.43 66.04 51100 F 11 38.72 36.78 42.30 51101 N 11 122.43 116.31 133.76 51101 F 11 51.56 48.98 56.33 51102 N 11 224.65 213.42 245.43 51102 F 11 145.28 138.02 158.72 51500 11 638.17 606.26 697.20 51520 11 580.49 551.47 634.19 51525 11 848.53 806.10 927.02 51530 11 769.58 731.10 840.77 51535 11 763.07 724.92 833.66 51550 11 945.38 898.11 1032.83 51555 11 1247.16 1184.80 1362.52 51565 11 1272.96 1209.31 1390.71 51570 11 1456.67 1383.84 1591.42 51575 11 1802.73 1712.59 1969.48 51580 11 1877.65 1783.77 2051.34 51585 11 2091.29 1986.73 2284.74 51590 11 1911.10 1815.55 2087.88 51595 11 2168.16 2059.75 2368.71 51596 11 2329.98 2213.48 2545.50 51597 11 2262.18 2149.07 2471.43 51600 N 11 183.22 174.06 200.17 51600 F 11 43.69 41.51 47.74 51605 11 37.69 35.81 41.18 51610 N 11 105.99 100.69 115.79 51610 F 11 62.52 59.39 68.30 51700 N 11 82.75 78.61 90.40 51700 F 11 44.01 41.81 48.08 51701 N 11 56.24 53.43 61.44 51701 F 11 26.95 25.60 29.44 51702 N 11 72.30 68.69 78.99 51702 F 11 29.47 28.00 32.20 51703 N 11 131.88 125.29 144.08 51703 F 11 80.54 76.51 87.99 51705 N 11 106.93 101.58 116.82 51705 F 11 66.30 62.99 72.44 51710 N 11 149.01 141.56 162.79 51710 F 11 93.58 88.90 102.24 51715 N 11 284.28 270.07 310.58 51715 F 11 196.73 186.89 214.92 51720 N 11 109.59 104.11 119.73 51720 F 11 80.30 76.29 87.73 51725 11 198.21 188.30 216.55 51725 TC 11 123.38 117.21 134.79 51725 26 11 74.83 71.09 81.75 51726 11 288.43 274.01 315.11 51726 TC 11 203.20 193.04 222.00 51726 26 11 85.23 80.97 93.12 51727 11 287.33 272.96 313.90 51727 TC 11 182.28 173.17 199.15 51727 26 11 105.05 99.80 114.77 51728 11 284.84 270.60 311.19 51728 TC 11 181.65 172.57 198.46 51728 26 11 103.20 98.04 112.75 51729 11 312.08 296.48 340.95 51729 TC 11 187.94 178.54 205.32 51729 26 11 124.14 117.93 135.62 51736 11 33.00 31.35 36.05 51736 TC 11 21.33 20.26 23.30 51736 26 11 11.67 11.09 12.75 51741 11 40.25 38.24 43.98 51741 TC 11 24.48 23.26 26.75 51741 26 11 15.77 14.98 17.23 51784 11 193.53 183.85 211.43 51784 TC 11 117.71 111.82 128.59 51784 26 11 75.82 72.03 82.83 51785 11 212.43 201.81 232.08 51785 TC 11 136.29 129.48 148.90 51785 26 11 76.14 72.33 83.18 51792 11 217.83 206.94 237.98 51792 TC 11 162.75 154.61 177.80 51792 26 11 55.09 52.34 60.19 51797 11 126.82 120.48 138.55 51797 TC 11 86.21 81.90 94.19 51797 26 11 40.60 38.57 44.36 51798 11 18.18 17.27 19.86 51800 11 1030.84 979.30 1126.20 51820 11 1051.68 999.10 1148.97 51840 11 641.27 609.21 700.59 51841 11 763.12 724.96 833.70 51845 11 577.89 549.00 631.35 51860 11 720.36 684.34 786.99 51865 11 876.03 832.23 957.06 51880 11 458.15 435.24 500.53 51900 11 807.87 767.48 882.60 51920 11 742.67 705.54 811.37 51925 11 1019.22 968.26 1113.50 51940 11 1597.21 1517.35 1744.95 51960 11 1372.24 1303.63 1499.17 51980 11 701.51 666.43 766.39 51990 11 734.91 698.16 802.88 51992 11 820.32 779.30 896.20 52000 N 11 201.64 191.56 220.29 52000 F 11 124.16 117.95 135.64 52001 N 11 369.83 351.34 404.04 52001 F 11 285.10 270.85 311.48 52005 N 11 274.97 261.22 300.40 52005 F 11 131.67 125.09 143.85 52007 N 11 491.50 466.93 536.97 52007 F 11 164.25 156.04 179.45 52010 N 11 380.31 361.29 415.48 52010 F 11 161.42 153.35 176.35 52204 N 11 397.55 377.67 434.32 52204 F 11 139.91 132.91 152.85 52214 N 11 593.54 563.86 648.44 52214 F 11 206.45 196.13 225.55 52224 N 11 707.14 671.78 772.55 52224 F 11 167.93 159.53 183.46 52234 11 244.48 232.26 267.10 52235 11 286.68 272.35 313.20 52240 11 501.18 476.12 547.54 52250 11 240.92 228.87 263.20 52260 11 208.20 197.79 227.46 52265 N 11 388.19 368.78 424.10 52265 F 11 160.15 152.14 174.96 52270 N 11 373.65 354.97 408.22 52270 F 11 180.58 171.55 197.28 52275 N 11 508.51 483.08 555.54 52275 F 11 247.09 234.74 269.95 52276 11 263.86 250.67 288.27 52277 11 323.13 306.97 353.02 52281 N 11 276.23 262.42 301.78 52281 F 11 144.89 137.65 158.30 52282 11 334.29 317.58 365.22 52283 N 11 274.07 260.37 299.43 52283 F 11 199.73 189.74 218.20 52285 N 11 275.95 262.15 301.47 52285 F 11 193.74 184.05 211.66 52290 11 242.81 230.67 265.27 52300 11 281.03 266.98 307.03 52301 11 290.92 276.37 317.83 52305 11 276.97 263.12 302.59 52310 N 11 239.72 227.73 261.89 52310 F 11 150.59 143.06 164.52 52315 N 11 420.52 399.49 459.41 52315 F 11 272.49 258.87 297.70 52317 N 11 863.90 820.71 943.82 52317 F 11 345.79 328.50 377.78 52318 11 471.18 447.62 514.76 52320 11 244.88 232.64 267.54 52325 11 318.70 302.77 348.19 52327 11 260.92 247.87 285.05 52330 N 11 632.78 601.14 691.31 52330 F 11 262.07 248.97 286.32 52332 N 11 468.76 445.32 512.12 52332 F 11 144.97 137.72 158.38 52334 11 255.02 242.27 278.61 52341 11 287.80 273.41 314.42 52342 11 312.95 297.30 341.90 52343 11 348.32 330.90 380.54 52344 11 377.87 358.98 412.83 52345 11 403.02 382.87 440.30 52346 11 455.01 432.26 497.10 52351 11 311.69 296.11 340.53 52352 11 366.17 347.86 400.04 52353 11 420.69 399.66 459.61 52354 11 389.33 369.86 425.34 52355 11 463.82 440.63 506.72 52400 11 475.35 451.58 519.32 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 025 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 52402 11 265.73 252.44 290.31 52450 11 462.54 439.41 505.32 52500 11 481.12 457.06 525.62 52601 11 826.06 784.76 902.47 52630 11 437.85 415.96 478.35 52640 11 292.69 278.06 319.77 52647 N 11 1941.93 1844.83 2121.55 52647 F 11 637.99 606.09 697.00 52648 N 11 1990.10 1890.60 2174.19 52648 F 11 680.80 646.76 743.77 52649 11 955.29 907.53 1043.66 52700 11 430.90 409.36 470.76 53000 11 146.37 139.05 159.91 53010 11 289.27 274.81 316.03 53020 11 96.05 91.25 104.94 53025 11 65.50 62.23 71.56 53040 11 386.11 366.80 421.82 53060 N 11 177.94 169.04 194.40 53060 F 11 159.36 151.39 174.10 53080 11 421.10 400.05 460.06 53085 11 627.63 596.25 685.69 53200 N 11 152.42 144.80 166.52 53200 F 11 139.19 132.23 152.06 53210 11 761.76 723.67 832.22 53215 11 918.64 872.71 1003.62 53220 11 446.28 423.97 487.57 53230 11 597.77 567.88 653.06 53235 11 626.54 595.21 684.49 53240 11 420.15 399.14 459.01 53250 11 415.79 395.00 454.25 53260 N 11 196.91 187.06 215.12 53260 F 11 175.49 166.72 191.73 53265 N 11 215.30 204.54 235.22 53265 F 11 182.54 173.41 199.42 53270 N 11 206.33 196.01 225.41 53270 F 11 186.17 176.86 203.39 53275 11 260.02 247.02 284.07 53400 11 790.89 751.35 864.05 53405 11 864.99 821.74 945.00 53410 11 968.51 920.08 1058.09 53415 11 1116.75 1060.91 1220.05 53420 11 810.90 770.36 885.91 53425 11 929.09 882.64 1015.04 53430 11 947.04 899.69 1034.64 53431 11 1140.30 1083.29 1245.78 53440 11 870.68 827.15 951.22 53442 11 768.84 730.40 839.96 53444 11 784.86 745.62 857.46 53445 11 868.50 825.08 948.84 53446 11 635.49 603.72 694.28 53447 11 801.20 761.14 875.31 53448 11 1266.83 1203.49 1384.01 53449 11 604.78 574.54 660.72 53450 11 402.63 382.50 439.88 53460 11 451.30 428.74 493.05 53500 11 735.73 698.94 803.78 53502 11 477.47 453.60 521.64 53505 11 479.67 455.69 524.04 53510 11 623.32 592.15 680.97 53515 11 784.30 745.09 856.85 53520 11 548.51 521.08 599.24 53600 N 11 82.99 78.84 90.67 53600 F 11 63.15 59.99 68.99 53601 N 11 80.48 76.46 87.93 53601 F 11 52.76 50.12 57.64 53605 11 63.86 60.67 69.77 53620 N 11 117.59 111.71 128.47 53620 F 11 86.72 82.38 94.74 53621 N 11 110.65 105.12 120.89 53621 F 11 71.28 67.72 77.88 53660 N 11 70.13 66.62 76.61 53660 F 11 40.84 38.80 44.62 53661 N 11 69.52 66.04 75.95 53661 F 11 39.92 37.92 43.61 53665 11 38.04 36.14 41.56 53850 N 11 2195.29 2085.53 2398.36 53850 F 11 560.96 532.91 612.85 53852 N 11 2118.43 2012.51 2314.39 53852 F 11 613.23 582.57 669.96 53855 N 11 665.98 632.68 727.58 53855 F 11 79.53 75.55 86.88 53860 N 11 1357.32 1289.45 1482.87 53860 F 11 220.63 209.60 241.04 54000 N 11 148.87 141.43 162.64 54000 F 11 105.40 100.13 115.15 54001 N 11 184.97 175.72 202.08 54001 F 11 136.47 129.65 149.10 54015 11 304.17 288.96 332.30 54050 N 11 123.70 117.52 135.15 54050 F 11 99.13 94.17 108.30 54055 N 11 113.38 107.71 123.87 54055 F 11 88.50 84.08 96.69 54056 N 11 132.34 125.72 144.58 54056 F 11 104.94 99.69 114.64 54057 N 11 133.18 126.52 145.50 54057 F 11 91.29 86.73 99.74 54060 N 11 178.12 169.21 194.59 54060 F 11 127.09 120.74 138.85 54065 N 11 208.47 198.05 227.76 54065 F 11 163.75 155.56 178.89 54100 N 11 188.77 179.33 206.23 54100 F 11 121.05 115.00 132.25 54105 N 11 265.26 252.00 289.80 54105 F 11 211.09 200.54 230.62 54110 11 615.66 584.88 672.61 54111 11 792.41 752.79 865.71 54112 11 929.04 882.59 1014.98 54115 N 11 444.17 421.96 485.25 54115 F 11 416.77 395.93 455.32 54120 11 623.81 592.62 681.51 54125 11 803.08 762.93 877.37 54130 11 1181.24 1122.18 1290.51 54135 11 1498.95 1424.00 1637.60 54150 N 11 158.93 150.98 173.63 54150 F 11 96.89 92.05 105.86 54160 N 11 221.20 210.14 241.66 54160 F 11 142.14 135.03 155.28 54161 11 194.25 184.54 212.22 54162 N 11 259.54 246.56 283.54 54162 F 11 195.29 185.53 213.36 54163 11 215.13 204.37 235.03 54164 11 189.67 180.19 207.22 54200 N 11 106.45 101.13 116.30 54200 F 11 82.83 78.69 90.49 54205 11 527.52 501.14 576.31 54220 N 11 202.80 192.66 221.56 54220 F 11 133.19 126.53 145.51 54230 N 11 94.88 90.14 103.66 54230 F 11 78.50 74.58 85.77 54231 N 11 137.81 130.92 150.56 54231 F 11 115.45 109.68 126.13 54235 N 11 88.29 83.88 96.46 54235 F 11 72.23 68.62 78.91 54240 11 96.95 92.10 105.92 54240 TC 11 32.67 31.04 35.70 54240 26 11 64.29 61.08 70.24 54250 11 120.42 114.40 131.56 54250 TC 11 10.94 10.39 11.95 54250 26 11 109.49 104.02 119.62 54300 11 637.51 605.63 696.47 54304 11 745.59 708.31 814.56 54308 11 722.74 686.60 789.59 54312 11 827.91 786.51 904.49 54316 11 1008.85 958.41 1102.17 54318 11 709.88 674.39 775.55 54322 11 776.55 737.72 848.38 54324 11 964.26 916.05 1053.46 54326 11 922.04 875.94 1007.33 54328 11 927.87 881.48 1013.70 54332 11 1006.78 956.44 1099.91 54336 11 1169.53 1111.05 1277.71 54340 11 559.30 531.34 611.04 54344 11 958.67 910.74 1047.35 54348 11 1112.33 1056.71 1215.22 54352 11 1567.99 1489.59 1713.03 54360 11 716.35 680.53 782.61 54380 11 793.96 754.26 867.40 54385 11 964.59 916.36 1053.81 54390 11 1214.67 1153.94 1327.03 54400 11 524.38 498.16 572.88 54401 11 646.54 614.21 706.34 54405 11 800.67 760.64 874.74 54406 11 721.89 685.80 788.67 54408 11 780.70 741.67 852.92 54410 11 851.24 808.68 929.98 54411 11 1013.65 962.97 1107.42 54415 11 520.69 494.66 568.86 54416 11 700.33 665.31 765.11 54417 11 888.01 843.61 970.15 54420 11 698.63 663.70 763.26 54430 11 634.10 602.40 692.76 54435 11 411.55 390.97 449.62 54450 N 11 70.25 66.74 76.75 54450 F 11 57.34 54.47 62.64 54500 11 73.70 70.02 80.52 54505 11 208.24 197.83 227.50 54512 11 529.38 502.91 578.35 54520 11 320.60 304.57 350.26 54522 11 574.75 546.01 627.91 54530 11 498.77 473.83 544.90 54535 11 728.35 691.93 795.72 54550 11 483.33 459.16 528.03 54560 11 665.10 631.85 726.63 54600 11 446.30 423.99 487.59 54620 11 297.08 282.23 324.56 54640 11 467.04 443.69 510.24 54650 11 697.69 662.81 762.23 54660 11 350.33 332.81 382.73 54670 11 398.33 378.41 435.17 54680 11 771.97 733.37 843.38 54690 11 662.88 629.74 724.20 54692 11 751.73 714.14 821.26 54700 11 208.99 198.54 228.32 54800 11 143.70 136.52 157.00 54830 11 365.96 347.66 399.81 54840 11 317.21 301.35 346.55 54860 11 412.58 391.95 450.74 54861 11 557.39 529.52 608.95 54865 11 352.12 334.51 384.69 54900 11 757.37 719.50 827.43 54901 11 1052.24 999.63 1149.57 55000 N 11 116.66 110.83 127.45 55000 F 11 82.96 78.81 90.63 55040 11 332.62 315.99 363.39 55041 11 501.54 476.46 547.93 55060 11 373.52 354.84 408.07 55100 N 11 211.66 201.08 231.24 55100 F 11 161.58 153.50 176.53 55110 11 381.12 362.06 416.37 55120 11 349.67 332.19 382.02 55150 11 482.32 458.20 526.93 55175 11 358.00 340.10 391.12 55180 11 679.73 645.74 742.60 55200 N 11 453.76 431.07 495.73 55200 F 11 272.34 258.72 297.53 55250 N 11 403.60 383.42 440.93 55250 F 11 224.07 212.87 244.80 55300 11 180.84 171.80 197.57 55400 11 493.82 469.13 539.50 55450 N 11 362.93 344.78 396.50 55450 F 11 252.06 239.46 275.38 55500 11 381.95 362.85 417.28 55520 11 414.14 393.43 452.44 55530 11 348.00 330.60 380.19 55535 11 421.91 400.81 460.93 55540 11 497.89 473.00 543.95 55550 11 417.53 396.65 456.15 55600 11 415.88 395.09 454.35 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 026 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 55605 11 512.37 486.75 559.76 55650 11 704.54 669.31 769.71 55680 11 335.67 318.89 366.72 55700 N 11 220.52 209.49 240.91 55700 F 11 137.05 130.20 149.73 55705 11 264.21 251.00 288.65 55706 11 370.49 351.97 404.77 55720 11 444.95 422.70 486.11 55725 11 582.07 552.97 635.92 55801 11 1076.51 1022.68 1176.08 55810 11 1301.35 1236.28 1421.72 55812 11 1592.13 1512.52 1739.40 55815 11 1746.49 1659.17 1908.05 55821 11 864.66 821.43 944.64 55831 11 935.60 888.82 1022.14 55840 11 1324.54 1258.31 1447.06 55842 11 1418.21 1347.30 1549.40 55845 11 1620.97 1539.92 1770.91 55860 11 865.12 821.86 945.14 55862 11 1087.09 1032.74 1187.65 55865 11 1322.45 1256.33 1444.78 55866 11 1715.17 1629.41 1873.82 55870 N 11 172.33 163.71 188.27 55870 F 11 141.78 134.69 154.89 55873 N 11 5892.78 5598.14 6437.86 55873 F 11 824.74 783.50 901.03 55875 11 752.87 715.23 822.51 55876 N 11 133.61 126.93 145.97 55876 F 11 99.91 94.91 109.15 55920 11 430.03 408.53 469.81 56405 N 11 103.48 98.31 113.06 56405 F 11 102.22 97.11 111.68 56420 N 11 116.76 110.92 127.56 56420 F 11 87.47 83.10 95.57 56440 11 174.24 165.53 190.36 56441 N 11 139.18 132.22 152.05 56441 F 11 132.88 126.24 145.18 56442 11 45.77 43.48 50.00 56501 N 11 123.46 117.29 134.88 56501 F 11 108.34 102.92 118.36 56515 N 11 212.11 201.50 231.73 56515 F 11 188.80 179.36 206.26 56605 N 11 78.33 74.41 85.57 56605 F 11 57.86 54.97 63.22 56606 N 11 35.63 33.85 38.93 56606 F 11 28.07 26.67 30.67 56620 11 474.72 450.98 518.63 56625 11 570.55 542.02 623.32 56630 11 838.06 796.16 915.58 56631 11 1062.96 1009.81 1161.28 56632 11 1234.95 1173.20 1349.18 56633 11 1090.34 1035.82 1191.19 56634 11 1152.46 1094.84 1259.07 56637 11 1357.00 1289.15 1482.52 56640 11 1338.49 1271.57 1462.31 56700 11 177.99 169.09 194.45 56740 11 283.00 268.85 309.18 56800 11 230.32 218.80 251.62 56805 11 1092.35 1037.73 1193.39 56810 11 247.79 235.40 270.71 56820 N 11 104.45 99.23 114.11 56820 F 11 81.14 77.08 88.64 56821 N 11 139.14 132.18 152.01 56821 F 11 109.21 103.75 119.31 57000 11 181.09 172.04 197.85 57010 11 412.55 391.92 450.71 57020 N 11 89.33 84.86 97.59 57020 F 11 77.99 74.09 85.20 57022 11 159.71 151.72 174.48 57023 11 296.62 281.79 324.06 57061 N 11 107.45 102.08 117.39 57061 F 11 92.65 88.02 101.22 57065 N 11 181.35 172.28 198.12 57065 F 11 162.46 154.34 177.49 57100 N 11 83.13 78.97 90.82 57100 F 11 62.65 59.52 68.45 57105 N 11 127.78 121.39 139.60 57105 F 11 118.33 112.41 129.27 57106 11 456.27 433.46 498.48 57107 11 1336.63 1269.80 1460.27 57109 11 1527.91 1451.51 1669.24 57110 11 856.81 813.97 936.07 57111 11 1537.04 1460.19 1679.22 57112 11 1468.82 1395.38 1604.69 57120 11 487.13 462.77 532.19 57130 N 11 169.46 160.99 185.14 57130 F 11 152.14 144.53 166.21 57135 N 11 182.08 172.98 198.93 57135 F 11 164.13 155.92 179.31 57150 N 11 45.08 42.83 49.25 57150 F 11 28.07 26.67 30.67 57155 N 11 310.00 294.50 338.68 57155 F 11 173.62 164.94 189.68 57156 N 11 142.14 135.03 155.28 57156 F 11 98.36 93.44 107.46 57160 N 11 72.49 68.87 79.20 57160 F 11 45.40 43.13 49.60 57170 N 11 61.51 58.43 67.19 57170 F 11 46.08 43.78 50.35 57180 N 11 133.35 126.68 145.68 57180 F 11 100.91 95.86 110.24 57200 11 282.90 268.76 309.07 57210 11 348.30 330.89 380.52 57220 11 304.60 289.37 332.78 57230 11 380.89 361.85 416.13 57240 11 637.65 605.77 696.64 57250 11 637.86 605.97 696.87 57260 11 788.38 748.96 861.30 57265 11 868.84 825.40 949.21 57267 11 249.31 236.84 272.37 57268 11 458.56 435.63 500.97 57270 11 761.11 723.05 831.51 57280 11 915.55 869.77 1000.24 57282 11 479.22 455.26 523.55 57283 11 659.47 626.50 720.48 57284 11 787.46 748.09 860.30 57285 11 647.76 615.37 707.68 57287 11 658.65 625.72 719.58 57288 11 684.29 650.08 747.59 57289 11 705.37 670.10 770.62 57291 11 563.61 535.43 615.74 57292 11 785.42 746.15 858.07 57295 11 460.93 437.88 503.56 57296 11 907.83 862.44 991.81 57300 11 519.88 493.89 567.97 57305 11 864.84 821.60 944.84 57307 11 978.86 929.92 1069.41 57308 11 615.34 584.57 672.26 57310 11 449.16 426.70 490.71 57311 11 511.63 486.05 558.96 57320 11 517.77 491.88 565.66 57330 11 721.16 685.10 787.87 57335 11 1112.45 1056.83 1215.35 57400 11 127.99 121.59 139.83 57410 11 101.98 96.88 111.41 57415 11 152.25 144.64 166.34 57420 N 11 109.42 103.95 119.54 57420 F 11 85.80 81.51 93.74 57421 N 11 147.44 140.07 161.08 57421 F 11 116.88 111.04 127.70 57423 11 880.16 836.15 961.57 57425 11 928.31 881.89 1014.17 57426 11 802.85 762.71 877.12 57452 N 11 102.74 97.60 112.24 57452 F 11 86.99 82.64 95.04 57454 N 11 145.78 138.49 159.26 57454 F 11 129.72 123.23 141.71 57455 N 11 135.29 128.53 147.81 57455 F 11 106.00 100.70 115.81 57456 N 11 127.88 121.49 139.71 57456 F 11 98.90 93.96 108.05 57460 N 11 274.03 260.33 299.38 57460 F 11 155.92 148.12 170.34 57461 N 11 308.57 293.14 337.11 57461 F 11 180.38 171.36 197.06 57500 N 11 122.50 116.38 133.84 57500 F 11 71.79 68.20 78.43 57505 N 11 96.02 91.22 104.90 57505 F 11 86.57 82.24 94.58 57510 N 11 124.85 118.61 136.40 57510 F 11 110.05 104.55 120.23 57511 N 11 137.71 130.82 150.44 57511 F 11 125.43 119.16 137.03 57513 N 11 136.14 129.33 148.73 57513 F 11 125.75 119.46 137.38 57520 N 11 289.63 275.15 316.42 57520 F 11 258.45 245.53 282.36 57522 N 11 249.92 237.42 273.03 57522 F 11 231.02 219.47 252.39 57530 11 327.08 310.73 357.34 57531 11 1631.22 1549.66 1782.11 57540 11 742.39 705.27 811.06 57545 11 783.67 744.49 856.16 57550 11 388.38 368.96 424.30 57555 11 571.79 543.20 624.68 57556 11 541.23 514.17 591.30 57558 N 11 118.59 112.66 129.56 57558 F 11 107.89 102.50 117.88 57700 11 294.92 280.17 322.20 57720 11 292.07 277.47 319.09 57800 N 11 56.61 53.78 61.85 57800 F 11 45.91 43.61 50.15 58100 N 11 103.90 98.71 113.52 58100 F 11 83.74 79.55 91.48 58110 N 11 45.91 43.61 50.15 58110 F 11 39.29 37.33 42.93 58120 N 11 240.45 228.43 262.69 58120 F 11 207.06 196.71 226.22 58140 11 873.08 829.43 953.84 58145 11 517.40 491.53 565.26 58146 11 1103.68 1048.50 1205.78 58150 11 947.13 899.77 1034.74 58152 11 1188.93 1129.48 1298.90 58180 11 910.68 865.15 994.92 58200 11 1248.97 1186.52 1364.50 58210 11 1668.63 1585.20 1822.98 58240 11 2648.64 2516.21 2893.64 58260 11 788.57 749.14 861.51 58262 11 879.76 835.77 961.14 58263 11 946.56 899.23 1034.11 58267 11 1006.75 956.41 1099.87 58270 11 841.42 799.35 919.25 58275 11 938.28 891.37 1025.08 58280 11 1003.87 953.68 1096.73 58285 11 1253.41 1190.74 1369.35 58290 11 1099.81 1044.82 1201.54 58291 11 1192.98 1133.33 1303.33 58292 11 1257.43 1194.56 1373.74 58293 11 1306.80 1241.46 1427.68 58294 11 1163.98 1105.78 1271.65 58301 N 11 90.69 86.16 99.08 58301 F 11 65.17 61.91 71.20 58321 N 11 71.14 67.58 77.72 58321 F 11 45.00 42.75 49.16 58322 N 11 81.79 77.70 89.36 58322 F 11 56.28 53.47 61.49 58323 N 11 16.60 15.77 18.14 58323 F 11 11.88 11.29 12.98 58340 N 11 115.15 109.39 125.80 58340 F 11 55.31 52.54 60.42 58345 11 266.92 253.57 291.61 58346 11 420.20 399.19 459.07 58350 N 11 91.46 86.89 99.92 58350 F 11 74.76 71.02 81.67 58353 N 11 1005.20 954.94 1098.18 58353 F 11 209.61 199.13 229.00 58356 N 11 1862.26 1769.15 2034.52 58356 F 11 332.17 315.56 362.89 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 027 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 58400 11 421.23 400.17 460.20 58410 11 766.26 727.95 837.14 58520 11 762.86 724.72 833.43 58540 11 865.68 822.40 945.76 58541 11 819.79 778.80 895.62 58542 11 915.62 869.84 1000.32 58543 11 931.30 884.74 1017.45 58544 11 1006.77 956.43 1099.89 58545 11 852.83 810.19 931.72 58546 11 1076.98 1023.13 1176.60 58548 11 1702.73 1617.59 1860.23 58550 11 841.64 799.56 919.49 58552 11 933.83 887.14 1020.21 58553 11 1083.49 1029.32 1183.72 58554 11 1253.06 1190.41 1368.97 58555 N 11 255.04 242.29 278.63 58555 F 11 181.34 172.27 198.11 58558 N 11 338.66 321.73 369.99 58558 F 11 255.19 242.43 278.79 58559 11 328.35 311.93 358.72 58560 11 370.85 352.31 405.16 58561 11 524.58 498.35 573.10 58562 N 11 354.31 336.59 387.08 58562 F 11 277.77 263.88 303.46 58563 N 11 1645.52 1563.24 1797.73 58563 F 11 328.35 311.93 358.72 58565 N 11 1791.79 1702.20 1957.53 58565 F 11 413.52 392.84 451.77 58570 11 881.19 837.13 962.70 58571 11 976.12 927.31 1066.41 58572 11 1095.53 1040.75 1196.86 58573 11 1250.89 1188.35 1366.60 58600 11 346.66 329.33 378.73 58605 11 313.47 297.80 342.47 58611 11 74.26 70.55 81.13 58615 11 234.50 222.78 256.20 58660 11 639.67 607.69 698.84 58661 11 613.25 582.59 669.98 58662 11 671.66 638.08 733.79 58670 11 347.92 330.52 380.10 58671 11 347.61 330.23 379.76 58672 11 702.82 667.68 767.83 58673 11 764.62 726.39 835.35 58700 11 733.68 697.00 801.55 58720 11 685.16 650.90 748.54 58740 11 832.58 790.95 909.59 58750 11 861.18 818.12 940.84 58752 11 826.39 785.07 902.83 58760 11 774.51 735.78 846.15 58770 11 806.56 766.23 881.16 58800 N 11 304.06 288.86 332.19 58800 F 11 284.85 270.61 311.20 58805 11 383.45 364.28 418.92 58820 11 309.44 293.97 338.07 58822 11 683.59 649.41 746.82 58823 N 11 851.35 808.78 930.10 58823 F 11 166.94 158.59 182.38 58825 11 667.20 633.84 728.92 58900 11 411.73 391.14 449.81 58920 11 666.10 632.80 727.72 58925 11 701.51 666.43 766.39 58940 11 486.68 462.35 531.70 58943 11 1070.71 1017.17 1169.75 58950 11 1023.28 972.12 1117.94 58951 11 1316.41 1250.59 1438.18 58952 11 1485.36 1411.09 1622.75 58953 11 1838.55 1746.62 2008.61 58954 11 1993.31 1893.64 2177.69 58956 11 1255.55 1192.77 1371.69 58957 11 1430.21 1358.70 1562.51 58958 11 1576.28 1497.47 1722.09 58960 11 880.36 836.34 961.79 58970 N 11 204.58 194.35 223.50 58970 F 11 183.16 174.00 200.10 58976 N 11 231.38 219.81 252.78 58976 F 11 201.14 191.08 219.74 59000 N 11 119.38 113.41 130.42 59000 F 11 76.54 72.71 83.62 59001 11 172.87 164.23 188.86 59012 11 192.68 183.05 210.51 59015 N 11 146.75 139.41 160.32 59015 F 11 125.33 119.06 136.92 59020 11 64.41 61.19 70.37 59020 TC 11 29.52 28.04 32.25 59020 26 11 34.89 33.15 38.12 59025 11 43.96 41.76 48.02 59025 TC 11 15.98 15.18 17.46 59025 26 11 27.99 26.59 30.58 59030 11 96.18 91.37 105.08 59050 11 48.14 45.73 52.59 59051 11 39.92 37.92 43.61 59070 N 11 395.14 375.38 431.69 59070 F 11 295.61 280.83 322.95 59072 11 496.78 471.94 542.73 59074 N 11 387.58 368.20 423.43 59074 F 11 299.08 284.13 326.75 59076 11 491.42 466.85 536.88 59100 11 784.33 745.11 856.88 59120 11 749.51 712.03 818.83 59121 11 750.54 713.01 819.96 59130 11 800.61 760.58 874.67 59135 11 800.07 760.07 874.08 59136 11 828.66 787.23 905.31 59140 11 345.34 328.07 377.28 59150 11 725.05 688.80 792.12 59151 11 707.17 671.81 772.58 59160 N 11 196.91 187.06 215.12 59160 F 11 166.99 158.64 182.44 59200 N 11 68.62 65.19 74.97 59200 F 11 42.79 40.65 46.75 59300 N 11 180.54 171.51 197.24 59300 F 11 139.28 132.32 152.17 59320 11 144.09 136.89 157.42 59325 11 210.07 199.57 229.51 59350 11 264.78 251.54 289.27 59400 11 1765.45 1677.18 1928.76 59409 11 693.83 659.14 758.01 59410 11 879.58 835.60 960.94 59412 11 89.42 84.95 97.69 59414 11 78.75 74.81 86.03 59425 N 11 392.92 373.27 429.26 59425 F 11 302.84 287.70 330.86 59426 N 11 702.72 667.58 767.72 59426 F 11 534.54 507.81 583.98 59430 N 11 146.38 139.06 159.92 59430 F 11 119.61 113.63 130.67 59510 11 1964.17 1865.96 2145.85 59514 11 786.66 747.33 859.43 59515 11 1064.52 1011.29 1162.98 59525 11 460.41 437.39 503.00 59610 11 1857.87 1764.98 2029.73 59612 11 780.86 741.82 853.09 59614 11 961.30 913.24 1050.23 59618 11 1999.93 1899.93 2184.92 59620 11 818.93 777.98 894.68 59622 11 1102.54 1047.41 1204.52 59812 N 11 297.78 282.89 325.32 59812 F 11 277.62 263.74 303.30 59820 N 11 356.45 338.63 389.42 59820 F 11 334.09 317.39 365.00 59821 N 11 359.84 341.85 393.13 59821 F 11 335.59 318.81 366.63 59830 11 411.56 390.98 449.63 59840 N 11 202.40 192.28 221.12 59840 F 11 195.15 185.39 213.20 59841 N 11 358.98 341.03 392.18 59841 F 11 339.45 322.48 370.85 59850 11 333.59 316.91 364.45 59851 11 375.73 356.94 410.48 59852 11 482.37 458.25 526.99 59855 11 391.67 372.09 427.90 59856 11 460.71 437.67 503.32 59857 11 500.95 475.90 547.29 59866 11 207.37 197.00 226.55 59870 11 445.53 423.25 486.74 59871 11 126.59 120.26 138.30 60000 N 11 152.95 145.30 167.10 60000 F 11 138.47 131.55 151.28 60100 N 11 106.41 101.09 116.25 60100 F 11 77.12 73.26 84.25 60200 11 619.83 588.84 677.17 60210 11 662.45 629.33 723.73 60212 11 951.14 903.58 1039.12 60220 11 724.42 688.20 791.43 60225 11 870.73 827.19 951.27 60240 11 914.10 868.40 998.66 60252 11 1241.32 1179.25 1356.14 60254 11 1596.76 1516.92 1744.46 60260 11 1033.50 981.83 1129.10 60270 11 1301.02 1235.97 1421.37 60271 11 998.00 948.10 1090.32 60280 11 419.63 398.65 458.45 60281 11 560.62 532.59 612.48 60300 N 11 104.13 98.92 113.76 60300 F 11 47.75 45.36 52.16 60500 11 953.60 905.92 1041.81 60502 11 1197.47 1137.60 1308.24 60505 11 1309.30 1243.84 1430.42 60512 11 229.31 217.84 250.52 60520 11 972.07 923.47 1061.99 60521 11 1089.43 1034.96 1190.20 60522 11 1320.35 1254.33 1442.48 60540 11 1003.14 952.98 1095.93 60545 11 1151.16 1093.60 1257.64 60600 11 1365.34 1297.07 1491.63 60605 11 1707.78 1622.39 1865.75 60650 11 1126.29 1069.98 1230.48 61000 11 102.86 97.72 112.38 61001 11 105.54 100.26 115.30 61020 11 125.07 118.82 136.64 61026 11 118.68 112.75 129.66 61050 11 98.76 93.82 107.89 61055 11 128.67 122.24 140.58 61070 11 77.63 73.75 84.81 61105 11 414.14 393.43 452.44 61107 11 293.90 279.21 321.09 61108 11 820.89 779.85 896.83 61120 11 675.92 642.12 738.44 61140 11 1149.28 1091.82 1255.59 61150 11 1237.04 1175.19 1351.47 61151 11 902.77 857.63 986.27 61154 11 1153.69 1096.01 1260.41 61156 11 1140.96 1083.91 1246.50 61210 11 343.14 325.98 374.88 61215 11 453.51 430.83 495.45 61250 11 783.85 744.66 856.36 61253 11 798.43 758.51 872.29 61304 11 1504.97 1429.72 1644.18 61305 11 1842.10 1750.00 2012.50 61312 11 1906.97 1811.62 2083.36 61313 11 1814.56 1723.83 1982.40 61314 11 1671.80 1588.21 1826.44 61315 11 1897.99 1803.09 2073.55 61316 11 81.39 77.32 88.92 61320 11 1747.51 1660.13 1909.15 61321 11 1943.46 1846.29 2123.23 61322 11 2165.60 2057.32 2365.92 61323 11 2189.70 2080.22 2392.25 61330 11 1617.39 1536.52 1767.00 61332 11 1800.60 1710.57 1967.16 61333 11 1877.88 1783.99 2051.59 61334 11 1229.45 1167.98 1343.18 61340 11 1318.02 1252.12 1439.94 61343 11 2017.47 1916.60 2204.09 61345 11 1872.28 1778.67 2045.47 61440 11 1835.85 1744.06 2005.67 61450 11 1761.12 1673.06 1924.02 61458 11 1843.80 1751.61 2014.35 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 028 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 61460 11 1919.22 1823.26 2096.75 61470 11 1759.95 1671.95 1922.74 61480 11 1461.26 1388.20 1596.43 61490 11 1740.16 1653.15 1901.12 61500 11 1235.41 1173.64 1349.69 61501 11 1064.50 1011.28 1162.97 61510 11 1999.60 1899.62 2184.56 61512 11 2344.49 2227.27 2561.36 61514 11 1744.26 1657.05 1905.61 61516 11 1700.29 1615.28 1857.57 61517 11 81.05 77.00 88.55 61518 11 2531.41 2404.84 2765.57 61519 11 2714.41 2578.69 2965.49 61520 11 3482.31 3308.19 3804.42 61521 11 2927.39 2781.02 3198.17 61522 11 2009.69 1909.21 2195.59 61524 11 1906.39 1811.07 2082.73 61526 11 3335.08 3168.33 3643.58 61530 11 2819.13 2678.17 3079.90 61531 11 1113.88 1058.19 1216.92 61533 11 1394.85 1325.11 1523.88 61534 11 1505.54 1430.26 1644.80 61535 11 908.73 863.29 992.78 61536 11 2376.11 2257.30 2595.90 61537 11 2252.84 2140.20 2461.23 61538 11 2436.25 2314.44 2661.61 61539 11 2163.55 2055.37 2363.68 61540 11 2006.62 1906.29 2192.23 61541 11 1970.35 1871.83 2152.60 61542 11 2055.59 1952.81 2245.73 61543 11 1983.13 1883.97 2166.57 61544 11 1694.17 1609.46 1850.88 61545 11 2922.38 2776.26 3192.70 61546 11 2116.92 2011.07 2312.73 61548 11 1447.20 1374.84 1581.07 61550 11 887.68 843.30 969.80 61552 11 1128.29 1071.88 1232.66 61556 11 1508.52 1433.09 1648.05 61557 11 1542.50 1465.38 1685.19 61558 11 1626.48 1545.16 1776.93 61559 11 1976.81 1877.97 2159.67 61563 11 1818.59 1727.66 1986.81 61564 11 2212.53 2101.90 2417.19 61566 11 2070.27 1966.76 2261.77 61567 11 2362.86 2244.72 2581.43 61570 11 1703.98 1618.78 1861.60 61571 11 1826.27 1734.96 1995.20 61575 11 2281.45 2167.38 2492.49 61576 11 3366.77 3198.43 3678.19 61580 11 2308.70 2193.27 2522.26 61581 11 2560.31 2432.29 2797.13 61582 11 2728.89 2592.45 2981.32 61583 11 2651.61 2519.03 2896.88 61584 11 2607.30 2476.94 2848.48 61585 11 2898.36 2753.44 3166.46 61586 11 2140.11 2033.10 2338.07 61590 11 2909.64 2764.16 3178.78 61591 11 2935.49 2788.72 3207.03 61592 11 2905.37 2760.10 3174.12 61595 11 2217.40 2106.53 2422.51 61596 11 2384.18 2264.97 2604.72 61597 11 2662.56 2529.43 2908.84 61598 11 2510.75 2385.21 2742.99 61600 11 2002.38 1902.26 2187.60 61601 11 2180.28 2071.27 2381.96 61605 11 2084.66 1980.43 2277.49 61606 11 2764.21 2626.00 3019.90 61607 11 2665.72 2532.43 2912.29 61608 11 2977.61 2828.73 3253.04 61609 11 556.15 528.34 607.59 61610 11 1743.15 1655.99 1904.39 61611 11 375.43 356.66 410.16 61612 11 1393.42 1323.75 1522.31 61613 11 2990.26 2840.75 3266.86 61615 11 2211.86 2101.27 2416.46 61616 11 3056.42 2903.60 3339.14 61618 11 1200.98 1140.93 1312.07 61619 11 1383.70 1314.52 1511.70 61623 11 527.64 501.26 576.45 61624 11 1056.17 1003.36 1153.86 61626 11 835.47 793.70 912.76 61630 11 1210.20 1149.69 1322.14 61635 11 1312.70 1247.07 1434.13 61680 11 2077.73 1973.84 2269.92 61682 11 3869.87 3676.38 4227.84 61684 11 2606.09 2475.79 2847.16 61686 11 4158.48 3950.56 4543.14 61690 11 2003.42 1903.25 2188.74 61692 11 3371.54 3202.96 3683.40 61697 11 3883.27 3689.11 4242.48 61698 11 4243.54 4031.36 4636.06 61700 11 3158.71 3000.77 3450.89 61702 11 3689.44 3504.97 4030.72 61703 11 1243.98 1181.78 1359.05 61705 11 2377.72 2258.83 2597.65 61708 11 1982.65 1883.52 2166.05 61710 11 1750.66 1663.13 1912.60 61711 11 2395.96 2276.16 2617.58 61720 11 1137.62 1080.74 1242.85 61735 11 1386.31 1316.99 1514.54 61750 11 1287.94 1223.54 1407.07 61751 11 1256.68 1193.85 1372.93 61760 11 1432.62 1360.99 1565.14 61770 11 1465.97 1392.67 1601.57 61781 11 223.00 211.85 243.63 61782 11 184.57 175.34 201.64 61783 11 223.00 211.85 243.63 61790 11 789.91 750.41 862.97 61791 11 1016.30 965.49 1110.31 61796 11 890.66 846.13 973.05 61797 11 201.06 191.01 219.66 61798 11 1188.99 1129.54 1298.97 61799 11 277.47 263.60 303.14 61800 11 139.39 132.42 152.28 61850 11 850.55 808.02 929.22 61860 11 1436.11 1364.30 1568.95 61863 11 1373.78 1305.09 1500.85 61864 11 265.16 251.90 289.69 61867 11 2099.03 1994.08 2293.19 61868 11 467.04 443.69 510.24 61870 11 1085.85 1031.56 1186.29 61875 11 979.31 930.34 1069.89 61880 11 510.17 484.66 557.36 61885 11 498.10 473.20 544.18 61886 11 758.74 720.80 828.92 61888 11 359.04 341.09 392.25 62000 11 904.36 859.14 988.01 62005 11 1155.29 1097.53 1262.16 62010 11 1396.35 1326.53 1525.51 62100 11 1480.29 1406.28 1617.22 62115 11 1179.74 1120.75 1288.86 62116 11 1625.53 1544.25 1775.89 62117 11 1658.33 1575.41 1811.72 62120 11 1623.34 1542.17 1773.50 62121 11 1560.31 1482.29 1704.63 62140 11 956.35 908.53 1044.81 62141 11 1050.05 997.55 1147.18 62142 11 809.29 768.83 884.15 62143 11 946.80 899.46 1034.38 62145 11 1297.04 1232.19 1417.02 62146 11 1133.10 1076.45 1237.92 62147 11 1336.51 1269.68 1460.13 62148 11 117.21 111.35 128.05 62160 11 177.26 168.40 193.66 62161 11 1388.59 1319.16 1517.03 62162 11 1736.59 1649.76 1897.22 62163 11 1119.90 1063.91 1223.50 62164 11 1900.12 1805.11 2075.88 62165 11 1450.40 1377.88 1584.56 62180 11 1467.36 1393.99 1603.09 62190 11 839.11 797.15 916.72 62192 11 890.16 845.65 972.50 62194 11 372.31 353.69 406.74 62200 11 1260.01 1197.01 1376.56 62201 11 1094.20 1039.49 1195.41 62220 11 929.03 882.58 1014.97 62223 11 960.85 912.81 1049.73 62225 11 466.77 443.43 509.94 62230 11 767.68 729.30 838.70 62252 11 84.70 80.47 92.54 62252 TC 11 41.80 39.71 45.67 62252 26 11 42.90 40.76 46.87 62256 11 541.26 514.20 591.33 62258 11 1027.47 976.10 1122.52 62263 N 11 668.71 635.27 730.56 62263 F 11 382.09 362.99 417.44 62264 N 11 390.28 370.77 426.39 62264 F 11 223.35 212.18 244.01 62267 N 11 233.49 221.82 255.09 62267 F 11 152.55 144.92 166.66 62268 N 11 334.43 317.71 365.37 62268 F 11 248.13 235.72 271.08 62269 N 11 359.05 341.10 392.27 62269 F 11 254.17 241.46 277.68 62270 N 11 145.33 138.06 158.77 62270 F 11 74.47 70.75 81.36 62272 N 11 179.06 170.11 195.63 62272 F 11 79.22 75.26 86.55 62273 N 11 158.87 150.93 173.57 62273 F 11 106.90 101.56 116.79 62280 N 11 302.02 286.92 329.96 62280 F 11 152.41 144.79 166.51 62281 N 11 244.56 232.33 267.18 62281 F 11 143.15 135.99 156.39 62282 N 11 275.07 261.32 300.52 62282 F 11 132.71 126.07 144.98 62284 N 11 200.36 190.34 218.89 62284 F 11 83.20 79.04 90.90 62287 11 524.56 498.33 573.08 62290 N 11 312.55 296.92 341.46 62290 F 11 162.94 154.79 178.01 62291 N 11 295.26 280.50 322.58 62291 F 11 157.31 149.44 171.86 62292 11 520.96 494.91 569.15 62294 11 659.27 626.31 720.26 62310 N 11 216.89 206.05 236.96 62310 F 11 99.09 94.14 108.26 62311 N 11 186.08 176.78 203.30 62311 F 11 81.52 77.44 89.06 62318 N 11 223.20 212.04 243.85 62318 F 11 95.64 90.86 104.49 62319 N 11 178.36 169.44 194.86 62319 F 11 90.49 85.97 98.87 62350 11 367.13 348.77 401.09 62351 11 790.30 750.79 863.41 62355 11 277.20 263.34 302.84 62360 11 281.91 267.81 307.98 62361 11 364.13 345.92 397.81 62362 11 381.53 362.45 416.82 62365 11 304.35 289.13 332.50 62367 N 11 37.92 36.02 41.42 62367 F 11 23.43 22.26 25.60 62368 N 11 54.79 52.05 59.86 62368 F 11 36.53 34.70 39.91 63001 11 1134.66 1077.93 1239.62 63003 11 1140.54 1083.51 1246.04 63005 11 1084.13 1029.92 1184.41 63011 11 1006.16 955.85 1099.23 63012 11 1095.07 1040.32 1196.37 63015 11 1360.19 1292.18 1486.01 63016 11 1396.62 1326.79 1525.81 63017 11 1145.72 1088.43 1251.69 63020 11 1072.71 1019.07 1171.93 63030 11 890.37 845.85 972.73 63035 11 181.58 172.50 198.38 63040 11 1295.05 1230.30 1414.85 63042 11 1203.51 1143.33 1314.83 63045 11 1168.86 1110.42 1276.98 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 029 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 63046 11 1116.19 1060.38 1219.44 63047 11 1014.88 964.14 1108.76 63048 11 200.45 190.43 218.99 63050 11 1438.39 1366.47 1571.44 63051 11 1588.65 1509.22 1735.60 63055 11 1499.82 1424.83 1638.55 63056 11 1370.77 1302.23 1497.56 63057 11 303.20 288.04 331.25 63064 11 1634.31 1552.59 1785.48 63066 11 193.19 183.53 211.06 63075 11 1268.86 1205.42 1386.23 63076 11 235.05 223.30 256.80 63077 11 1397.19 1327.33 1526.43 63078 11 184.60 175.37 201.68 63081 11 1639.26 1557.30 1790.90 63082 11 252.96 240.31 276.36 63085 11 1766.96 1678.61 1930.40 63086 11 180.82 171.78 197.55 63087 11 2232.08 2120.48 2438.55 63088 11 245.59 233.31 268.31 63090 11 1841.18 1749.12 2011.49 63091 11 169.47 161.00 185.15 63101 11 2145.19 2037.93 2343.62 63102 11 2088.83 1984.39 2282.05 63103 11 276.96 263.11 302.58 63170 11 1446.15 1373.84 1579.92 63172 11 1287.59 1223.21 1406.69 63173 11 1581.67 1502.59 1727.98 63180 11 1335.57 1268.79 1459.11 63182 11 1437.33 1365.46 1570.28 63185 11 1086.10 1031.80 1186.57 63190 11 1182.45 1123.33 1291.83 63191 11 1111.72 1056.13 1214.55 63194 11 1299.09 1234.14 1419.26 63195 11 1399.64 1329.66 1529.11 63196 11 1379.31 1310.34 1506.89 63197 11 1565.51 1487.23 1710.31 63198 11 1529.74 1453.25 1671.24 63199 11 1683.23 1599.07 1838.93 63200 11 1393.55 1323.87 1522.45 63250 11 2725.18 2588.92 2977.26 63251 11 2791.45 2651.88 3049.66 63252 11 2789.22 2649.76 3047.22 63265 11 1532.43 1455.81 1674.18 63266 11 1578.39 1499.47 1724.39 63267 11 1264.66 1201.43 1381.64 63268 11 1319.72 1253.73 1441.79 63270 11 1901.39 1806.32 2077.27 63271 11 1901.33 1806.26 2077.20 63272 11 1749.31 1661.84 1911.12 63273 11 1689.48 1605.01 1845.76 63275 11 1649.16 1566.70 1801.71 63276 11 1640.25 1558.24 1791.98 63277 11 1429.93 1358.43 1562.19 63278 11 1444.30 1372.09 1577.90 63280 11 1941.88 1844.79 2121.51 63281 11 1923.31 1827.14 2101.21 63282 11 1812.25 1721.64 1979.89 63283 11 1735.00 1648.25 1895.49 63285 11 2391.31 2271.74 2612.50 63286 11 2364.96 2246.71 2583.72 63287 11 2519.99 2393.99 2753.09 63290 11 2556.73 2428.89 2793.22 63295 11 307.22 291.86 335.64 63300 11 1688.93 1604.48 1845.15 63301 11 1991.95 1892.35 2176.20 63302 11 1970.66 1872.13 2152.95 63303 11 2093.54 1988.86 2287.19 63304 11 2150.65 2043.12 2349.59 63305 11 2256.10 2143.30 2464.80 63306 11 2104.35 1999.13 2299.00 63307 11 2197.63 2087.75 2400.91 63308 11 302.33 287.21 330.29 63600 11 807.38 767.01 882.06 63610 N 11 811.94 771.34 887.04 63610 F 11 384.85 365.61 420.45 63615 11 1114.30 1058.59 1217.38 63620 11 972.45 923.83 1062.40 63621 11 230.88 219.34 252.24 63650 11 396.86 377.02 433.57 63655 11 790.26 750.75 863.36 63661 N 11 560.44 532.42 612.28 63661 F 11 312.57 296.94 341.48 63662 11 678.05 644.15 740.77 63663 N 11 801.24 761.18 875.36 63663 F 11 454.15 431.44 496.16 63664 11 705.28 670.02 770.52 63685 11 373.00 354.35 407.50 63688 11 336.64 319.81 367.78 63700 11 1170.93 1112.38 1279.24 63702 11 1296.81 1231.97 1416.77 63704 11 1477.04 1403.19 1613.67 63706 11 1668.28 1584.87 1822.60 63707 11 836.52 794.69 913.89 63709 11 1013.85 963.16 1107.63 63710 11 1014.51 963.78 1108.35 63740 11 860.10 817.10 939.67 63741 11 569.87 541.38 622.59 63744 11 605.32 575.05 661.31 63746 11 534.83 508.09 584.30 64400 N 11 105.75 100.46 115.53 64400 F 11 62.92 59.77 68.74 64402 N 11 105.79 100.50 115.58 64402 F 11 68.94 65.49 75.31 64405 N 11 105.26 100.00 115.00 64405 F 11 74.71 70.97 81.62 64408 N 11 115.81 110.02 126.52 64408 F 11 86.20 81.89 94.17 64410 N 11 138.00 131.10 150.77 64410 F 11 78.16 74.25 85.39 64412 N 11 139.46 132.49 152.36 64412 F 11 69.85 66.36 76.31 64413 N 11 111.65 106.07 121.98 64413 F 11 74.80 71.06 81.72 64415 N 11 116.10 110.30 126.85 64415 F 11 65.08 61.83 71.10 64416 11 78.55 74.62 85.81 64417 N 11 121.67 115.59 132.93 64417 F 11 67.18 63.82 73.39 64418 N 11 129.16 122.70 141.11 64418 F 11 70.26 66.75 76.76 64420 N 11 127.87 121.48 139.70 64420 F 11 63.62 60.44 69.51 64421 N 11 183.53 174.35 200.50 64421 F 11 87.47 83.10 95.57 64425 N 11 123.55 117.37 134.98 64425 F 11 89.85 85.36 98.16 64430 N 11 134.69 127.96 147.15 64430 F 11 79.25 75.29 86.58 64435 N 11 132.22 125.61 144.45 64435 F 11 78.99 75.04 86.30 64445 N 11 126.06 119.76 137.72 64445 F 11 72.20 68.59 78.88 64446 11 79.81 75.82 87.19 64447 N 11 113.00 107.35 123.45 64447 F 11 63.87 60.68 69.78 64448 11 71.03 67.48 77.60 64449 11 81.07 77.02 88.57 64450 N 11 97.00 92.15 105.97 64450 F 11 65.82 62.53 71.91 64455 N 11 46.52 44.19 50.82 64455 F 11 35.50 33.73 38.79 64479 N 11 249.32 236.85 272.38 64479 F 11 124.91 118.66 136.46 64480 N 11 118.58 112.65 129.55 64480 F 11 63.46 60.29 69.33 64483 N 11 225.71 214.42 246.58 64483 F 11 98.15 93.24 107.23 64484 N 11 100.37 95.35 109.65 64484 F 11 50.92 48.37 55.63 64490 N 11 184.82 175.58 201.92 64490 F 11 106.08 100.78 115.90 64491 N 11 92.00 87.40 100.51 64491 F 11 60.19 57.18 65.76 64492 N 11 92.94 88.29 101.53 64492 F 11 61.13 58.07 66.78 64493 N 11 164.76 156.52 180.00 64493 F 11 89.48 85.01 97.76 64494 N 11 83.04 78.89 90.72 64494 F 11 51.23 48.67 55.97 64495 N 11 84.30 80.09 92.10 64495 F 11 51.86 49.27 56.66 64505 N 11 93.21 88.55 101.83 64505 F 11 78.41 74.49 85.66 64508 N 11 97.38 92.51 106.39 64508 F 11 69.98 66.48 76.45 64510 N 11 127.20 120.84 138.97 64510 F 11 66.72 63.38 72.89 64517 N 11 164.52 156.29 179.73 64517 F 11 114.76 109.02 125.37 64520 N 11 179.40 170.43 195.99 64520 F 11 74.83 71.09 81.75 64530 N 11 181.91 172.81 198.73 64530 F 11 86.48 82.16 94.48 64550 N 11 14.85 14.11 16.23 64550 F 11 8.55 8.12 09.34 64553 N 11 193.41 183.74 211.30 64553 F 11 150.58 143.05 164.51 64555 N 11 189.95 180.45 207.52 64555 F 11 141.13 134.07 154.18 64560 N 11 216.87 206.03 236.93 64560 F 11 154.51 146.78 168.80 64561 N 11 915.52 869.74 1000.20 64561 F 11 391.42 371.85 427.63 64565 N 11 165.55 157.27 180.86 64565 F 11 117.68 111.80 128.57 64566 N 11 120.74 114.70 131.91 64566 F 11 28.77 27.33 31.43 64568 11 606.41 576.09 662.50 64569 11 587.20 557.84 641.52 64570 11 511.29 485.73 558.59 64575 11 272.65 259.02 297.87 64577 11 308.29 292.88 336.81 64580 11 282.42 268.30 308.55 64581 11 671.64 638.06 733.77 64585 N 11 273.12 259.46 298.38 64585 F 11 143.67 136.49 156.96 64590 N 11 268.75 255.31 293.61 64590 F 11 159.46 151.49 174.21 64595 N 11 265.49 252.22 290.05 64595 F 11 125.65 119.37 137.28 64600 N 11 384.20 364.99 419.74 64600 F 11 207.83 197.44 227.06 64605 N 11 609.87 579.38 666.29 64605 F 11 325.46 309.19 355.57 64610 N 11 673.80 640.11 736.13 64610 F 11 450.50 427.98 492.18 64611 N 11 92.95 88.30 101.55 64611 F 11 84.13 79.92 91.91 64612 N 11 158.07 150.17 172.70 64612 F 11 143.90 136.71 157.22 64613 N 11 151.98 144.38 166.04 64613 F 11 134.66 127.93 147.12 64614 N 11 164.01 155.81 179.18 64614 F 11 142.59 135.46 155.78 64620 N 11 226.06 214.76 246.97 64620 F 11 161.81 153.72 176.78 64622 N 11 315.86 300.07 345.08 64622 F 11 174.75 166.01 190.91 64623 N 11 117.67 111.79 128.56 64623 F 11 48.06 45.66 52.51 64626 N 11 376.21 357.40 411.01 64626 F 11 236.37 224.55 258.23 64627 N 11 160.43 152.41 175.27 64627 F 11 56.50 53.68 61.73 64630 N 11 213.43 202.76 233.17 64630 F 11 178.78 169.84 195.32 64632 N 11 80.92 76.87 88.40 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 030 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 64632 F 11 67.38 64.01 73.61 64640 N 11 206.77 196.43 225.89 64640 F 11 160.79 152.75 175.66 64650 N 11 85.82 81.53 93.76 64650 F 11 37.94 36.04 41.45 64653 N 11 101.83 96.74 111.25 64653 F 11 49.23 46.77 53.79 64680 N 11 294.72 279.98 321.98 64680 F 11 155.19 147.43 169.54 64681 N 11 352.91 335.26 385.55 64681 F 11 191.33 181.76 209.02 64702 11 450.09 427.59 491.73 64704 11 304.89 289.65 333.10 64708 11 450.41 427.89 492.07 64712 11 515.22 489.46 562.88 64713 11 709.03 673.58 774.62 64714 11 631.14 599.58 689.52 64716 11 498.22 473.31 544.31 64718 11 540.57 513.54 590.57 64719 11 367.07 348.72 401.03 64721 N 11 391.84 372.25 428.09 64721 F 11 389.95 370.45 426.02 64722 11 321.18 305.12 350.89 64726 11 262.63 249.50 286.93 64727 11 174.75 166.01 190.91 64732 11 383.82 364.63 419.32 64734 11 398.46 378.54 435.32 64736 11 395.68 375.90 432.29 64738 11 473.51 449.83 517.30 64740 11 433.04 411.39 473.10 64742 11 450.05 427.55 491.68 64744 11 421.96 400.86 460.99 64746 11 411.07 390.52 449.10 64752 11 480.50 456.48 524.95 64755 11 844.37 802.15 922.47 64760 11 462.15 439.04 504.90 64761 11 422.54 401.41 461.62 64763 11 491.36 466.79 536.81 64766 11 560.77 532.73 612.64 64771 11 531.40 504.83 580.55 64772 11 532.84 506.20 582.13 64774 11 386.36 367.04 422.10 64776 11 365.01 346.76 398.77 64778 11 180.36 171.34 197.04 64782 11 424.85 403.61 464.15 64783 11 207.81 197.42 227.03 64784 11 681.07 647.02 744.07 64786 11 1004.83 954.59 1097.78 64787 11 232.13 220.52 253.60 64788 11 367.70 349.32 401.72 64790 11 773.34 734.67 844.87 64792 11 1038.04 986.14 1134.06 64795 11 183.64 174.46 200.63 64802 11 587.09 557.74 641.40 64804 11 783.69 744.51 856.19 64809 11 811.51 770.93 886.57 64818 11 627.76 596.37 685.83 64820 11 711.44 675.87 777.25 64821 11 641.15 609.09 700.45 64822 11 636.43 604.61 695.30 64823 11 722.45 686.33 789.28 64831 11 634.68 602.95 693.39 64832 11 323.02 306.87 352.90 64834 11 695.13 660.37 759.43 64835 11 755.86 718.07 825.78 64836 11 756.49 718.67 826.47 64837 11 343.38 326.21 375.14 64840 11 833.26 791.60 910.34 64856 11 950.32 902.80 1038.22 64857 11 989.99 940.49 1081.56 64858 11 1140.29 1083.28 1245.77 64859 11 248.68 236.25 271.69 64861 11 1209.68 1149.20 1321.58 64862 11 1344.89 1277.65 1469.30 64864 11 819.11 778.15 894.87 64865 11 1078.86 1024.92 1178.66 64866 11 1085.32 1031.05 1185.71 64868 11 984.12 934.91 1075.15 64870 11 1016.08 965.28 1110.07 64872 11 110.08 104.58 120.27 64874 11 167.32 158.95 182.79 64876 11 183.81 174.62 200.81 64885 11 1059.67 1006.69 1157.69 64886 11 1243.85 1181.66 1358.91 64890 11 1015.28 964.52 1109.20 64891 11 1102.33 1047.21 1204.29 64892 11 984.82 935.58 1075.92 64893 11 1054.28 1001.57 1151.81 64895 11 1271.44 1207.87 1389.05 64896 11 1411.35 1340.78 1541.90 64897 11 1197.52 1137.64 1308.29 64898 11 1292.85 1228.21 1412.44 64901 11 593.10 563.45 647.97 64902 11 684.48 650.26 747.80 64905 11 960.54 912.51 1049.39 64907 11 1102.84 1047.70 1204.86 64910 11 767.65 729.27 838.66 64911 11 954.93 907.18 1043.26 65091 11 583.44 554.27 637.41 65093 11 577.97 549.07 631.43 65101 11 675.70 641.92 738.21 65103 11 706.32 671.00 771.65 65105 11 779.64 740.66 851.76 65110 11 1105.01 1049.76 1207.22 65112 11 1290.98 1226.43 1410.39 65114 11 1353.12 1285.46 1478.28 65125 N 11 408.53 388.10 446.32 65125 F 11 265.85 252.56 290.44 65130 11 670.16 636.65 732.15 65135 11 681.14 647.08 744.14 65140 11 728.13 691.72 795.48 65150 11 512.82 487.18 560.26 65155 11 779.89 740.90 852.04 65175 11 591.19 561.63 645.87 65205 N 11 50.66 48.13 55.35 65205 F 11 40.58 38.55 44.33 65210 N 11 62.77 59.63 68.57 65210 F 11 49.54 47.06 54.12 65220 N 11 52.14 49.53 56.96 65220 F 11 39.23 37.27 42.86 65222 N 11 69.12 65.66 75.51 65222 F 11 54.32 51.60 59.34 65235 11 641.17 609.11 700.48 65260 11 850.85 808.31 929.56 65265 11 1005.63 955.35 1098.65 65270 N 11 236.50 224.68 258.38 65270 F 11 128.47 122.05 140.36 65272 N 11 440.09 418.09 480.80 65272 F 11 311.27 295.71 340.07 65273 11 339.66 322.68 371.08 65275 N 11 511.43 485.86 558.74 65275 F 11 417.26 396.40 455.86 65280 11 620.77 589.73 678.19 65285 11 960.01 912.01 1048.81 65286 N 11 629.72 598.23 687.96 65286 F 11 449.56 427.08 491.14 65290 11 455.46 432.69 497.59 65400 N 11 609.01 578.56 665.34 65400 F 11 543.82 516.63 594.12 65410 N 11 131.03 124.48 143.15 65410 F 11 97.96 93.06 107.02 65420 N 11 458.86 435.92 501.31 65420 F 11 338.54 321.61 369.85 65426 N 11 582.28 553.17 636.15 65426 F 11 432.98 411.33 473.03 65430 N 11 104.72 99.48 114.40 65430 F 11 95.28 90.52 104.10 65435 N 11 73.02 69.37 79.78 65435 F 11 64.51 61.28 70.47 65436 N 11 354.26 336.55 387.03 65436 F 11 340.71 323.67 372.22 65450 N 11 290.73 276.19 317.62 65450 F 11 287.58 273.20 314.18 65600 N 11 353.23 335.57 385.91 65600 F 11 309.45 293.98 338.08 65710 11 1005.79 955.50 1098.83 65730 11 1116.91 1061.06 1220.22 65750 11 1123.92 1067.72 1227.88 65755 11 1121.26 1065.20 1224.98 65756 11 1056.21 1003.40 1153.91 65770 11 1386.44 1317.12 1514.69 65772 N 11 404.45 384.23 441.86 65772 F 11 366.03 347.73 399.89 65775 11 489.41 464.94 534.68 65778 N 11 1164.54 1106.31 1272.26 65778 F 11 70.99 67.44 77.56 65779 N 11 1057.14 1004.28 1154.92 65779 F 11 274.14 260.43 299.49 65780 11 802.24 762.13 876.45 65781 11 1193.23 1133.57 1303.61 65782 11 1073.70 1020.02 1173.02 65800 N 11 135.93 129.13 148.50 65800 F 11 120.50 114.48 131.65 65805 N 11 150.13 142.62 164.01 65805 F 11 122.10 116.00 133.40 65810 11 426.97 405.62 466.46 65815 N 11 575.74 546.95 628.99 65815 F 11 436.53 414.70 476.91 65820 11 663.23 630.07 724.58 65850 11 776.93 738.08 848.79 65855 N 11 308.98 293.53 337.56 65855 F 11 273.71 260.02 299.02 65860 N 11 299.47 284.50 327.18 65860 F 11 251.91 239.31 275.21 65865 11 419.74 398.75 458.56 65870 11 541.60 514.52 591.70 65875 11 569.98 541.48 622.70 65880 11 587.49 558.12 641.84 65900 11 857.39 814.52 936.70 65920 11 711.51 675.93 777.32 65930 11 588.73 559.29 643.18 66020 N 11 163.74 155.55 178.88 66020 F 11 116.50 110.68 127.28 66030 N 11 147.49 140.12 161.14 66030 F 11 99.93 94.93 109.17 66130 N 11 644.04 611.84 703.62 66130 F 11 534.12 507.41 583.52 66150 11 772.21 733.60 843.64 66155 11 771.56 732.98 842.93 66160 11 873.87 830.18 954.71 66165 11 756.46 718.64 826.44 66170 11 1080.40 1026.38 1180.34 66172 11 1361.25 1293.19 1487.17 66174 11 922.68 876.55 1008.03 66175 11 1023.82 972.63 1118.52 66180 11 1062.31 1009.19 1160.57 66185 11 686.09 651.79 749.56 66220 11 666.60 633.27 728.26 66225 11 864.87 821.63 944.87 66250 N 11 679.76 645.77 742.64 66250 F 11 513.15 487.49 560.61 66500 11 311.72 296.13 340.55 66505 11 341.72 324.63 373.32 66600 11 732.51 695.88 800.26 66605 11 938.84 891.90 1025.69 66625 11 388.30 368.89 424.22 66630 11 520.20 494.19 568.32 66635 11 509.19 483.73 556.29 66680 11 476.78 452.94 520.88 66682 11 579.03 550.08 632.59 66700 N 11 399.67 379.69 436.64 66700 F 11 352.11 334.50 384.68 66710 N 11 404.51 384.28 441.92 66710 F 11 363.88 345.69 397.54 66711 11 567.24 538.88 619.71 66720 N 11 420.35 399.33 459.23 66720 F 11 379.09 360.14 414.16 66740 N 11 386.40 367.08 422.14 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 031 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 66740 F 11 349.55 332.07 381.88 66761 N 11 295.50 280.73 322.84 66761 F 11 252.03 239.43 275.34 66762 N 11 425.70 404.42 465.08 66762 F 11 383.81 364.62 419.31 66770 N 11 465.10 441.85 508.13 66770 F 11 426.98 405.63 466.47 66820 11 356.56 338.73 389.54 66821 N 11 295.53 280.75 322.86 66821 F 11 279.15 265.19 304.97 66825 11 684.93 650.68 748.28 66830 11 633.72 602.03 692.33 66840 11 644.19 611.98 703.78 66850 11 720.56 684.53 787.21 66852 11 779.09 740.14 851.16 66920 11 670.92 637.37 732.98 66930 11 762.77 724.63 833.32 66940 11 717.36 681.49 783.71 66982 11 973.21 924.55 1063.23 66983 11 664.64 631.41 726.12 66984 11 699.93 664.93 764.67 66985 11 695.42 660.65 759.75 66986 11 828.41 786.99 905.04 66990 11 82.25 78.14 89.86 67005 11 436.49 414.67 476.87 67010 11 492.14 467.53 537.66 67015 11 525.00 498.75 573.56 67025 N 11 660.50 627.48 721.60 67025 F 11 579.56 550.58 633.17 67027 11 785.34 746.07 857.98 67028 N 11 120.89 114.85 132.08 67028 F 11 101.36 96.29 110.73 67030 11 466.62 443.29 509.78 67031 N 11 348.95 331.50 381.23 67031 F 11 321.55 305.47 351.29 67036 11 876.74 832.90 957.84 67039 11 1140.73 1083.69 1246.24 67040 11 1297.37 1232.50 1417.38 67041 11 1212.19 1151.58 1324.32 67042 11 1387.06 1317.71 1515.37 67043 11 1477.42 1403.55 1614.08 67101 N 11 710.71 675.17 776.45 67101 F 11 618.74 587.80 675.97 67105 N 11 649.72 617.23 709.81 67105 F 11 584.84 555.60 638.94 67107 11 1123.19 1067.03 1227.08 67108 11 1469.46 1395.99 1605.39 67110 N 11 781.90 742.81 854.23 67110 F 11 700.96 665.91 765.80 67112 11 1212.19 1151.58 1324.32 67113 11 1596.39 1516.57 1744.06 67115 11 448.06 425.66 489.51 67120 N 11 600.08 570.08 655.59 67120 F 11 514.41 488.69 561.99 67121 11 837.11 795.25 914.54 67141 N 11 476.64 452.81 520.73 67141 F 11 445.77 423.48 487.00 67145 N 11 474.97 451.22 518.90 67145 F 11 449.46 426.99 491.04 67208 N 11 530.90 504.36 580.01 67208 F 11 512.95 487.30 560.40 67210 N 11 631.42 599.85 689.83 67210 F 11 611.58 581.00 668.15 67218 11 1241.90 1179.81 1356.78 67220 N 11 980.44 931.42 1071.13 67220 F 11 937.29 890.43 1023.99 67221 N 11 264.85 251.61 289.35 67221 F 11 199.97 189.97 218.47 67225 N 11 27.05 25.70 29.56 67225 F 11 25.47 24.20 27.83 67227 N 11 540.37 513.35 590.35 67227 F 11 506.67 481.34 553.54 67228 N 11 1066.09 1012.79 1164.71 67228 F 11 964.05 915.85 1053.23 67229 11 1018.92 967.97 1113.17 67250 11 715.26 679.50 781.43 67255 11 775.16 736.40 846.86 67311 11 548.35 520.93 599.07 67312 11 661.21 628.15 722.37 67314 11 616.17 585.36 673.16 67316 11 743.21 706.05 811.96 67318 11 624.61 593.38 682.39 67320 11 291.98 277.38 318.99 67331 11 287.76 273.37 314.38 67332 11 312.79 297.15 341.72 67334 11 273.10 259.45 298.37 67335 11 140.88 133.84 153.92 67340 11 324.93 308.68 354.98 67343 11 603.42 573.25 659.24 67345 N 11 221.61 210.53 242.11 67345 F 11 202.08 191.98 220.78 67346 11 189.21 179.75 206.71 67400 11 855.76 812.97 934.92 67405 11 715.86 680.07 782.08 67412 11 785.12 745.86 857.74 67413 11 790.37 750.85 863.48 67414 11 1200.96 1140.91 1312.05 67415 11 98.03 93.13 107.10 67420 11 1511.88 1436.29 1651.73 67430 11 1108.44 1053.02 1210.97 67440 11 1091.38 1036.81 1192.33 67445 11 1306.92 1241.57 1427.81 67450 11 1134.16 1077.45 1239.07 67500 N 11 77.58 73.70 84.76 67500 F 11 70.96 67.41 77.52 67505 N 11 83.09 78.94 90.78 67505 F 11 75.85 72.06 82.87 67515 N 11 89.09 84.64 97.34 67515 F 11 82.79 78.65 90.45 67550 11 891.71 847.12 974.19 67560 11 895.30 850.54 978.12 67570 11 1114.30 1058.59 1217.38 67700 N 11 236.12 224.31 257.96 67700 F 11 105.41 100.14 115.16 67710 N 11 199.17 189.21 217.59 67710 F 11 88.93 84.48 97.15 67715 N 11 210.65 200.12 230.14 67715 F 11 100.42 95.40 109.71 67800 N 11 115.43 109.66 126.11 67800 F 11 95.90 91.11 104.78 67801 N 11 148.92 141.47 162.69 67801 F 11 125.30 119.04 136.90 67805 N 11 184.80 175.56 201.89 67805 F 11 153.93 146.23 168.16 67808 11 339.01 322.06 370.37 67810 N 11 198.92 188.97 217.32 67810 F 11 86.17 81.86 94.14 67820 N 11 47.10 44.75 51.46 67820 F 11 49.31 46.84 53.87 67825 N 11 117.73 111.84 128.62 67825 F 11 111.43 105.86 121.74 67830 N 11 238.55 226.62 260.61 67830 F 11 127.68 121.30 139.50 67835 11 407.14 386.78 444.80 67840 N 11 247.90 235.51 270.84 67840 F 11 145.85 138.56 159.34 67850 N 11 197.50 187.63 215.77 67850 F 11 127.27 120.91 139.05 67875 N 11 154.65 146.92 168.96 67875 F 11 90.39 85.87 98.75 67880 N 11 414.67 393.94 453.03 67880 F 11 337.19 320.33 368.38 67882 N 11 514.59 488.86 562.19 67882 F 11 435.85 414.06 476.17 67900 N 11 584.89 555.65 639.00 67900 F 11 472.45 448.83 516.15 67901 N 11 660.27 627.26 721.35 67901 F 11 533.02 506.37 582.33 67902 11 667.41 634.04 729.15 67903 N 11 551.56 523.98 602.58 67903 F 11 453.92 431.22 495.90 67904 N 11 667.97 634.57 729.76 67904 F 11 551.11 523.55 602.08 67906 11 454.82 432.08 496.89 67908 N 11 450.94 428.39 492.65 67908 F 11 395.82 376.03 432.43 67909 N 11 490.55 466.02 535.92 67909 F 11 406.77 386.43 444.39 67911 11 516.98 491.13 564.80 67912 N 11 801.70 761.62 875.86 67912 F 11 452.10 429.50 493.93 67914 N 11 352.99 335.34 385.64 67914 F 11 266.38 253.06 291.02 67915 N 11 311.89 296.30 340.75 67915 F 11 231.57 219.99 252.99 67916 N 11 489.42 464.95 534.69 67916 F 11 397.77 377.88 434.56 67917 N 11 535.66 508.88 585.21 67917 F 11 440.22 418.21 480.94 67921 N 11 337.50 320.63 368.72 67921 F 11 250.88 238.34 274.09 67922 N 11 301.46 286.39 329.35 67922 F 11 222.72 211.58 243.32 67923 N 11 518.56 492.63 566.52 67923 F 11 431.32 409.75 471.21 67924 N 11 534.64 507.91 584.10 67924 F 11 416.53 395.70 455.06 67930 N 11 333.90 317.21 364.79 67930 F 11 228.07 216.67 249.17 67935 N 11 545.38 518.11 595.83 67935 F 11 417.19 396.33 455.78 67938 N 11 215.68 204.90 235.64 67938 F 11 105.45 100.18 115.21 67950 N 11 524.35 498.13 572.85 67950 F 11 430.17 408.66 469.96 67961 N 11 525.28 499.02 573.87 67961 F 11 421.98 400.88 461.01 67966 N 11 703.84 668.65 768.95 67966 F 11 607.78 577.39 664.00 67971 11 677.39 643.52 740.05 67973 11 875.24 831.48 956.20 67974 11 872.64 829.01 953.36 67975 11 640.26 608.25 699.49 68020 N 11 108.24 102.83 118.25 68020 F 11 101.00 95.95 110.34 68040 N 11 60.24 57.23 65.81 68040 F 11 50.17 47.66 54.81 68100 N 11 152.16 144.55 166.23 68100 F 11 90.11 85.60 98.44 68110 N 11 203.05 192.90 221.84 68110 F 11 136.90 130.06 149.57 68115 N 11 276.98 263.13 302.60 68115 F 11 167.06 158.71 182.52 68130 N 11 475.43 451.66 519.41 68130 F 11 365.83 347.54 399.67 68135 N 11 141.64 134.56 154.74 68135 F 11 136.91 130.06 149.57 68200 N 11 38.63 36.70 42.21 68200 F 11 32.02 30.42 34.98 68320 N 11 655.01 622.26 715.60 68320 F 11 495.01 470.26 540.80 68325 11 610.17 579.66 666.61 68326 11 597.40 567.53 652.66 68328 11 660.80 627.76 721.92 68330 N 11 548.67 521.24 599.43 68330 F 11 424.58 403.35 463.85 68335 11 598.67 568.74 654.05 68340 N 11 493.17 468.51 538.79 68340 F 11 367.18 348.82 401.14 68360 N 11 481.75 457.66 526.31 68360 F 11 378.44 359.52 413.45 68362 11 607.29 576.93 663.47 68371 11 366.75 348.41 400.67 68400 N 11 251.75 239.16 275.03 68400 F 11 124.51 118.28 136.02 68420 N 11 284.48 270.26 310.80 68420 F 11 155.98 148.18 170.41 68440 N 11 95.52 90.74 104.35 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 032 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 68440 F 11 89.53 85.05 97.81 68500 11 913.70 868.02 998.22 68505 11 902.82 857.68 986.33 68510 N 11 410.83 390.29 448.83 68510 F 11 276.97 263.12 302.59 68520 11 622.89 591.75 680.51 68525 11 253.25 240.59 276.68 68530 N 11 390.00 370.50 426.08 68530 F 11 242.60 230.47 265.04 68540 11 842.70 800.57 920.66 68550 11 1032.47 980.85 1127.98 68700 11 558.88 530.94 610.58 68705 N 11 214.90 204.16 234.78 68705 F 11 153.79 146.10 168.02 68720 11 696.25 661.44 760.66 68745 11 704.92 669.67 770.12 68750 11 728.23 691.82 795.59 68760 N 11 182.25 173.14 199.11 68760 F 11 134.37 127.65 146.80 68761 N 11 132.92 126.27 145.21 68761 F 11 108.36 102.94 118.38 68770 11 568.05 539.65 620.60 68801 N 11 111.33 105.76 121.62 68801 F 11 96.84 92.00 105.80 68810 N 11 216.74 205.90 236.79 68810 F 11 172.96 164.31 188.96 68811 11 189.93 180.43 207.49 68815 N 11 400.22 380.21 437.24 68815 F 11 237.70 225.82 259.69 68816 N 11 630.09 598.59 688.38 68816 F 11 230.72 219.18 252.06 68840 N 11 115.15 109.39 125.80 68840 F 11 104.76 99.52 114.45 68850 N 11 56.81 53.97 62.07 68850 F 11 52.08 49.48 56.90 69000 N 11 170.94 162.39 186.75 69000 F 11 111.73 106.14 122.06 69005 N 11 200.63 190.60 219.19 69005 F 11 149.61 142.13 163.45 69020 N 11 217.17 206.31 237.26 69020 F 11 135.28 128.52 147.80 69100 N 11 96.49 91.67 105.42 69100 F 11 47.35 44.98 51.73 69105 N 11 131.32 124.75 143.46 69105 F 11 60.77 57.73 66.39 69110 N 11 428.40 406.98 468.03 69110 F 11 309.66 294.18 338.31 69120 11 380.17 361.16 415.33 69140 11 827.75 786.36 904.31 69145 N 11 367.43 349.06 401.42 69145 F 11 236.09 224.29 257.93 69150 11 995.70 945.92 1087.81 69155 11 1603.08 1522.93 1751.37 69200 N 11 114.43 108.71 125.02 69200 F 11 53.95 51.25 58.94 69205 11 96.41 91.59 105.33 69210 N 11 47.20 44.84 51.57 69210 F 11 31.14 29.58 34.02 69220 N 11 128.75 122.31 140.66 69220 F 11 59.14 56.18 64.61 69222 N 11 206.76 196.42 225.88 69222 F 11 130.53 124.00 142.60 69300 N 11 630.22 598.71 688.52 69300 F 11 453.84 431.15 495.82 69310 11 1030.12 978.61 1125.40 69320 11 1459.07 1386.12 1594.04 69400 N 11 135.68 128.90 148.24 69400 F 11 59.14 56.18 64.61 69401 N 11 79.38 75.41 86.72 69401 F 11 46.94 44.59 51.28 69405 N 11 245.90 233.61 268.65 69405 F 11 184.48 175.26 201.55 69420 N 11 179.81 170.82 196.44 69420 F 11 114.61 108.88 125.21 69421 11 143.20 136.04 156.45 69424 N 11 120.61 114.58 131.77 69424 F 11 59.19 56.23 64.66 69433 N 11 187.49 178.12 204.84 69433 F 11 124.19 117.98 135.68 69436 11 154.85 147.11 169.18 69440 11 653.03 620.38 713.44 69450 11 514.31 488.59 561.88 69501 11 697.31 662.44 761.81 69502 11 927.01 880.66 1012.76 69505 11 1144.81 1087.57 1250.71 69511 11 1174.81 1116.07 1283.48 69530 11 1579.35 1500.38 1725.44 69535 11 2562.29 2434.18 2799.31 69540 N 11 196.04 186.24 214.18 69540 F 11 121.08 115.03 132.28 69550 11 989.94 940.44 1081.51 69552 11 1500.97 1425.92 1639.81 69554 11 2398.73 2278.79 2620.61 69601 11 998.96 949.01 1091.36 69602 11 1038.89 986.95 1134.99 69603 11 1204.27 1144.06 1315.67 69604 11 1066.64 1013.31 1165.31 69605 11 1489.74 1415.25 1627.54 69610 N 11 368.79 350.35 402.90 69610 F 11 282.18 268.07 308.28 69620 N 11 654.33 621.61 714.85 69620 F 11 465.35 442.08 508.39 69631 11 839.22 797.26 916.85 69632 11 1026.84 975.50 1121.83 69633 11 990.56 941.03 1082.18 69635 11 1162.00 1103.90 1269.49 69636 11 1313.74 1248.05 1435.26 69637 11 1309.42 1243.95 1430.54 69641 11 992.25 942.64 1084.04 69642 11 1277.76 1213.87 1395.95 69643 11 1167.73 1109.34 1275.74 69644 11 1410.51 1339.98 1540.98 69645 11 1384.06 1314.86 1512.09 69646 11 1469.53 1396.05 1605.46 69650 11 761.15 723.09 831.55 69660 11 886.28 841.97 968.27 69661 11 1156.27 1098.46 1263.23 69662 11 1107.60 1052.22 1210.05 69666 11 769.30 730.84 840.47 69667 11 770.59 732.06 841.87 69670 11 899.11 854.15 982.27 69676 11 791.83 752.24 865.08 69700 11 657.04 624.19 717.82 69711 11 824.59 783.36 900.86 69714 11 1029.74 978.25 1124.99 69715 11 1277.32 1213.45 1395.47 69717 11 1089.17 1034.71 1189.92 69718 11 1291.54 1226.96 1411.00 69720 11 1120.84 1064.80 1224.52 69725 11 1808.07 1717.67 1975.32 69740 11 1120.85 1064.81 1224.53 69745 11 1194.28 1134.57 1304.76 69801 N 11 189.85 180.36 207.41 69801 F 11 283.71 269.52 309.95 69802 11 994.68 944.95 1086.69 69805 11 1010.28 959.77 1103.74 69806 11 904.71 859.47 988.39 69820 11 820.25 779.24 896.13 69840 11 800.33 760.31 874.36 69905 11 876.96 833.11 958.08 69910 11 976.96 928.11 1067.33 69915 11 1479.78 1405.79 1616.66 69930 11 1181.08 1122.03 1290.33 69950 11 1807.73 1717.34 1974.94 69955 11 1905.92 1810.62 2082.21 69960 11 1854.90 1762.16 2026.48 69970 11 2067.51 1964.13 2258.75 69990 11 202.59 192.46 221.33 70010 11 120.41 114.39 131.55 70015 11 139.58 132.60 152.49 70015 TC 11 81.80 77.71 89.37 70015 26 11 57.78 54.89 63.12 70030 11 27.02 25.67 29.52 70030 TC 11 18.81 17.87 20.55 70030 26 11 8.21 7.80 08.97 70100 11 31.14 29.58 34.02 70100 TC 11 22.28 21.17 24.35 70100 26 11 8.86 8.42 09.68 70110 11 37.30 35.44 40.76 70110 TC 11 25.42 24.15 27.77 70110 26 11 11.87 11.28 12.97 70120 11 33.03 31.38 36.09 70120 TC 11 24.17 22.96 26.40 70120 26 11 8.86 8.42 09.68 70130 11 52.95 50.30 57.85 70130 TC 11 36.76 34.92 40.16 70130 26 11 16.19 15.38 17.69 70134 11 43.82 41.63 47.87 70134 TC 11 27.63 26.25 30.19 70134 26 11 16.19 15.38 17.69 70140 11 28.64 27.21 31.29 70140 TC 11 19.13 18.17 20.90 70140 26 11 9.52 9.04 10.40 70150 11 40.47 38.45 44.22 70150 TC 11 27.94 26.54 30.52 70150 26 11 12.53 11.90 13.69 70160 11 31.11 29.55 33.98 70160 TC 11 22.91 21.76 25.02 70160 26 11 8.21 7.80 08.97 70170 11 48.15 45.74 52.60 70170 TC 11 32.83 31.19 35.87 70170 26 11 14.66 13.93 16.02 70190 11 33.73 32.04 36.85 70190 TC 11 23.54 22.36 25.71 70190 26 11 10.20 9.69 11.14 70200 11 41.78 39.69 45.64 70200 TC 11 28.26 26.85 30.88 70200 26 11 13.52 12.84 14.77 70210 11 29.22 27.76 31.92 70210 TC 11 20.70 19.67 22.62 70210 26 11 8.52 8.09 09.30 70220 11 36.67 34.84 40.07 70220 TC 11 24.79 23.55 27.08 70220 26 11 11.87 11.28 12.97 70240 11 28.01 26.61 30.60 70240 TC 11 18.81 17.87 20.55 70240 26 11 9.20 8.74 10.05 70250 11 35.07 33.32 38.32 70250 TC 11 23.22 22.06 25.37 70250 26 11 11.85 11.26 12.95 70260 11 44.76 42.52 48.90 70260 TC 11 28.57 27.14 31.21 70260 26 11 16.19 15.38 17.69 70300 11 13.62 12.94 14.88 70300 TC 11 8.10 7.70 08.86 70300 26 11 5.52 5.24 06.03 70310 11 35.18 33.42 38.43 70310 TC 11 26.68 25.35 29.15 70310 26 11 8.50 8.08 09.29 70320 C11 39.43 37.46 43.08 70320 TC C11 28.26 26.85 30.88 70320 26 11 11.17 10.61 12.20 70328 11 29.25 27.79 31.96 70328 TC 11 20.39 19.37 22.28 70328 26 11 8.86 8.42 09.68 70330 11 45.46 43.19 49.67 70330 TC 11 33.61 31.93 36.72 70330 26 11 11.85 11.26 12.95 70332 11 80.68 76.65 88.15 70332 TC 11 53.14 50.48 58.05 70332 26 11 27.54 26.16 30.08 70336 C11 388.72 369.28 424.67 70336 TC C11 317.71 301.82 347.09 70336 26 11 71.01 67.46 77.58 70350 11 20.09 19.09 21.95 70350 TC 11 10.94 10.39 11.95 70350 26 11 9.15 8.69 09.99 70355 11 20.48 19.46 22.38 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 033 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 70355 TC 11 10.31 9.79 11.26 70355 26 11 10.17 9.66 11.11 70360 11 26.07 24.77 28.49 70360 TC 11 17.87 16.98 19.53 70360 26 11 8.21 7.80 08.97 70370 11 76.53 72.70 83.61 70370 TC 11 61.02 57.97 66.67 70370 26 11 15.51 14.73 16.94 70371 11 89.61 85.13 97.90 70371 TC 11 49.68 47.20 54.28 70371 26 11 39.93 37.93 43.62 70373 11 77.45 73.58 84.62 70373 TC 11 56.92 54.07 62.18 70373 26 11 20.53 19.50 22.43 70380 11 37.10 35.25 40.54 70380 TC 11 28.26 26.85 30.88 70380 26 11 8.84 8.40 09.66 70390 11 95.40 90.63 104.22 70390 TC 11 76.76 72.92 83.86 70390 26 11 18.63 17.70 20.36 70450 11 184.67 175.44 201.76 70450 TC 11 143.85 136.66 157.16 70450 26 11 40.82 38.78 44.60 70460 11 240.71 228.67 262.97 70460 TC 11 186.37 177.05 203.61 70460 26 11 54.34 51.62 59.36 70470 11 290.96 276.41 317.87 70470 TC 11 229.52 218.04 250.75 70470 26 11 61.44 58.37 67.13 70480 C11 241.53 229.45 263.87 70480 TC C11 179.76 170.77 196.39 70480 26 11 61.78 58.69 67.49 70481 11 342.80 325.66 374.51 70481 TC 11 276.13 262.32 301.67 70481 26 11 66.66 63.33 72.83 70482 C11 379.51 360.53 414.61 70482 TC C11 309.83 294.34 338.49 70482 26 11 69.67 66.19 76.12 70486 C11 234.75 223.01 256.46 70486 TC C11 179.76 170.77 196.39 70486 26 11 54.99 52.24 60.08 70487 11 296.70 281.87 324.15 70487 TC 11 233.93 222.23 255.56 70487 26 11 62.77 59.63 68.57 70488 11 360.22 342.21 393.54 70488 TC 11 291.88 277.29 318.88 70488 26 11 68.34 64.92 74.66 70490 C11 241.53 229.45 263.87 70490 TC C11 179.76 170.77 196.39 70490 26 11 61.78 58.69 67.49 70491 11 290.92 276.37 317.83 70491 TC 11 224.48 213.26 245.25 70491 26 11 66.44 63.12 72.59 70492 11 350.85 333.31 383.31 70492 TC 11 281.17 267.11 307.18 70492 26 11 69.67 66.19 76.12 70496 C11 398.66 378.73 435.54 70496 TC C11 313.93 298.23 342.96 70496 26 11 84.73 80.49 92.56 70498 C11 398.66 378.73 435.54 70498 TC C11 313.93 298.23 342.96 70498 26 11 84.73 80.49 92.56 70540 C11 383.04 363.89 418.47 70540 TC C11 318.02 302.12 347.44 70540 26 11 65.01 61.76 71.02 70542 C11 483.06 458.91 527.75 70542 TC C11 404.95 384.70 442.41 70542 26 11 78.11 74.20 85.33 70543 C11 597.90 568.01 653.21 70543 TC C11 494.72 469.98 540.48 70543 26 11 103.19 98.03 112.73 70544 C11 375.82 357.03 410.58 70544 TC C11 318.02 302.12 347.44 70544 26 11 57.80 54.91 63.15 70545 C11 462.75 439.61 505.55 70545 TC C11 404.95 384.70 442.41 70545 26 11 57.80 54.91 63.15 70546 C11 581.69 552.61 635.50 70546 TC C11 494.72 469.98 540.48 70546 26 11 86.97 82.62 95.01 70547 C11 375.82 357.03 410.58 70547 TC C11 318.02 302.12 347.44 70547 26 11 57.80 54.91 63.15 70548 C11 462.75 439.61 505.55 70548 TC C11 404.95 384.70 442.41 70548 26 11 57.80 54.91 63.15 70549 C11 581.46 552.39 635.25 70549 TC C11 494.72 469.98 540.48 70549 26 11 86.74 82.40 94.76 70551 C11 389.35 369.88 425.36 70551 TC C11 318.02 302.12 347.44 70551 26 11 71.32 67.75 77.91 70552 C11 491.25 466.69 536.69 70552 TC C11 404.95 384.70 442.41 70552 26 11 86.29 81.98 94.28 70553 C11 608.64 578.21 664.94 70553 TC C11 494.72 469.98 540.48 70553 26 11 113.93 108.23 124.46 70554 11 534.81 508.07 584.28 70554 TC 11 432.35 410.73 472.34 70554 26 11 102.46 97.34 111.94 70555 26 11 125.16 118.90 136.74 70557 26 11 169.71 161.22 185.40 70558 26 11 157.45 149.58 172.02 70559 26 11 159.03 151.08 173.74 71010 11 22.32 21.20 24.38 71010 TC 11 13.77 13.08 15.04 71010 26 11 8.55 8.12 09.34 71015 11 28.38 26.96 31.00 71015 TC 11 18.50 17.58 20.22 71015 26 11 9.88 9.39 10.80 71020 11 29.35 27.88 32.06 71020 TC 11 18.81 17.87 20.55 71020 26 11 10.54 10.01 11.51 71021 11 36.09 34.29 39.43 71021 TC 11 23.22 22.06 25.37 71021 26 11 12.87 12.23 14.06 71022 11 44.06 41.86 48.14 71022 TC 11 29.20 27.74 31.90 71022 26 11 14.86 14.12 16.24 71023 11 65.34 62.07 71.38 71023 TC 11 46.84 44.50 51.18 71023 26 11 18.49 17.57 20.21 71030 11 43.74 41.55 47.78 71030 TC 11 28.89 27.45 31.57 71030 26 11 14.86 14.12 16.24 71034 11 83.80 79.61 91.55 71034 TC 11 61.02 57.97 66.67 71034 26 11 22.79 21.65 24.90 71035 11 33.34 31.67 36.42 71035 TC 11 24.48 23.26 26.75 71035 26 11 8.86 8.42 09.68 71040 11 91.34 86.77 99.79 71040 TC 11 64.17 60.96 70.10 71040 26 11 27.18 25.82 29.69 71060 11 133.05 126.40 145.36 71060 TC 11 97.55 92.67 106.57 71060 26 11 35.50 33.73 38.79 71090 11 86.73 82.39 94.75 71090 TC 11 58.11 55.20 63.48 71090 26 11 27.45 26.08 29.99 71100 11 30.61 29.08 33.44 71100 TC 11 20.07 19.07 21.93 71100 26 11 10.54 10.01 11.51 71101 11 37.35 35.48 40.80 71101 TC 11 24.48 23.26 26.75 71101 26 11 12.87 12.23 14.06 71110 11 38.61 36.68 42.18 71110 TC 11 25.74 24.45 28.12 71110 26 11 12.87 12.23 14.06 71111 11 49.75 47.26 54.35 71111 TC 11 34.56 32.83 37.75 71111 26 11 15.19 14.43 16.59 71120 11 30.24 28.73 33.04 71120 TC 11 20.70 19.67 22.62 71120 26 11 9.54 9.06 10.42 71130 11 35.33 33.56 38.59 71130 TC 11 24.79 23.55 27.08 71130 26 11 10.54 10.01 11.51 71250 C11 229.05 217.60 250.24 71250 TC C11 179.76 170.77 196.39 71250 26 11 49.29 46.83 53.85 71260 11 291.83 277.24 318.83 71260 TC 11 231.72 220.13 253.15 71260 26 11 60.10 57.10 65.67 71270 11 358.00 340.10 391.12 71270 TC 11 291.57 276.99 318.54 71270 26 11 66.44 63.12 72.59 71275 C11 406.55 386.22 444.15 71275 TC C11 313.61 297.93 342.62 71275 26 11 92.94 88.29 101.53 71550 C11 388.04 368.64 423.94 71550 TC C11 318.02 302.12 347.44 71550 26 11 70.01 66.51 76.49 71551 C11 488.06 463.66 533.21 71551 TC C11 404.95 384.70 442.41 71551 26 11 83.11 78.95 90.79 71552 C11 603.85 573.66 659.71 71552 TC C11 494.72 469.98 540.48 71552 26 11 109.13 103.67 119.22 71555 11 519.75 493.76 567.82 71555 TC 11 432.04 410.44 472.01 71555 26 11 87.71 83.32 95.82 72010 11 70.06 66.56 76.54 72010 TC 11 48.10 45.70 52.56 72010 26 11 21.96 20.86 23.99 72020 11 22.56 21.43 24.64 72020 TC 11 15.03 14.28 16.42 72020 26 11 7.53 7.15 08.22 72040 11 36.73 34.89 40.12 72040 TC 11 25.42 24.15 27.77 72040 26 11 11.31 10.74 12.35 72050 11 49.87 47.38 54.49 72050 TC 11 34.56 32.83 37.75 72050 26 11 15.31 14.54 16.72 72052 11 63.22 60.06 69.07 72052 TC 11 45.58 43.30 49.80 72052 26 11 17.64 16.76 19.27 72069 11 35.16 33.40 38.41 72069 TC 11 23.85 22.66 26.06 72069 26 11 11.31 10.74 12.35 72070 11 32.18 30.57 35.16 72070 TC 11 21.33 20.26 23.30 72070 26 11 10.85 10.31 11.86 72072 11 35.65 33.87 38.95 72072 TC 11 25.11 23.85 27.43 72072 26 11 10.54 10.01 11.51 72074 11 41.95 39.85 45.83 72074 TC 11 31.41 29.84 34.32 72074 26 11 10.54 10.01 11.51 72080 11 34.53 32.80 37.72 72080 TC 11 23.22 22.06 25.37 72080 26 11 11.31 10.74 12.35 72090 11 46.56 44.23 50.86 72090 TC 11 32.04 30.44 35.01 72090 26 11 14.52 13.79 15.86 72100 11 38.31 36.39 41.85 72100 TC 11 27.00 25.65 29.50 72100 26 11 11.31 10.74 12.35 72110 11 52.39 49.77 57.24 72110 TC 11 37.08 35.23 40.51 72110 26 11 15.31 14.54 16.72 72114 11 70.06 66.56 76.54 72114 TC 11 51.88 49.29 56.68 72114 26 11 18.18 17.27 19.86 72120 11 48.39 45.97 52.87 72120 TC 11 37.08 35.23 40.51 72120 26 11 11.31 10.74 12.35 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 034 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 72125 C11 229.05 217.60 250.24 72125 TC C11 179.76 170.77 196.39 72125 26 11 49.29 46.83 53.85 72126 11 291.15 276.59 318.08 72126 TC 11 232.35 220.73 253.84 72126 26 11 58.80 55.86 64.24 72127 11 352.38 334.76 384.97 72127 TC 11 291.25 276.69 318.19 72127 26 11 61.12 58.06 66.77 72128 C11 229.05 217.60 250.24 72128 TC C11 179.76 170.77 196.39 72128 26 11 49.29 46.83 53.85 72129 11 291.78 277.19 318.77 72129 TC 11 232.67 221.04 254.20 72129 26 11 59.11 56.15 64.57 72130 11 352.69 335.06 385.32 72130 TC 11 291.57 276.99 318.54 72130 26 11 61.12 58.06 66.77 72131 C11 229.05 217.60 250.24 72131 TC C11 179.76 170.77 196.39 72131 26 11 49.29 46.83 53.85 72132 11 291.15 276.59 318.08 72132 TC 11 232.04 220.44 253.51 72132 26 11 59.11 56.15 64.57 72133 11 352.38 334.76 384.97 72133 TC 11 291.25 276.69 318.19 72133 26 11 61.12 58.06 66.77 72141 C11 395.14 375.38 431.69 72141 TC C11 317.71 301.82 347.09 72141 26 11 77.43 73.56 84.59 72142 C11 497.58 472.70 543.61 72142 TC C11 404.95 384.70 442.41 72142 26 11 92.62 87.99 101.19 72146 C11 395.14 375.38 431.69 72146 TC C11 317.71 301.82 347.09 72146 26 11 77.43 73.56 84.59 72147 11 493.80 469.11 539.48 72147 TC 11 400.86 380.82 437.94 72147 26 11 92.94 88.29 101.53 72148 C11 389.49 370.02 425.52 72148 TC C11 317.71 301.82 347.09 72148 26 11 71.78 68.19 78.42 72149 C11 491.25 466.69 536.69 72149 TC C11 404.95 384.70 442.41 72149 26 11 86.29 81.98 94.28 72156 C11 619.07 588.12 676.34 72156 TC C11 494.72 469.98 540.48 72156 26 11 124.35 118.13 135.85 72157 C11 619.07 588.12 676.34 72157 TC C11 494.72 469.98 540.48 72157 26 11 124.35 118.13 135.85 72158 C11 609.10 578.65 665.45 72158 TC C11 494.72 469.98 540.48 72158 26 11 114.38 108.66 124.96 72159 11 574.16 545.45 627.27 72159 TC 11 486.84 462.50 531.88 72159 26 11 87.32 82.95 95.39 72170 11 25.59 24.31 27.96 72170 TC 11 16.61 15.78 18.15 72170 26 11 8.98 8.53 09.81 72190 11 39.54 37.56 43.19 72190 TC 11 28.57 27.14 31.21 72190 26 11 10.97 10.42 11.98 72191 C11 401.47 381.40 438.61 72191 TC C11 313.61 297.93 342.62 72191 26 11 87.86 83.47 95.99 72192 11 228.32 216.90 249.44 72192 TC 11 175.98 167.18 192.26 72192 26 11 52.35 49.73 57.19 72193 11 276.20 262.39 301.75 72193 TC 11 220.07 209.07 240.43 72193 26 11 56.13 53.32 61.32 72194 11 353.20 335.54 385.87 72194 TC 11 294.40 279.68 321.63 72194 26 11 58.80 55.86 64.24 72195 C11 388.81 369.37 424.78 72195 TC C11 318.02 302.12 347.44 72195 26 11 70.78 67.24 77.33 72196 C11 488.69 464.26 533.90 72196 TC C11 404.95 384.70 442.41 72196 26 11 83.74 79.55 91.48 72197 C11 603.53 573.35 659.35 72197 TC C11 494.72 469.98 540.48 72197 26 11 108.81 103.37 118.88 72198 11 517.52 491.64 565.39 72198 TC 11 430.78 409.24 470.63 72198 26 11 86.74 82.40 94.76 72200 11 27.96 26.56 30.54 72200 TC 11 19.76 18.77 21.59 72200 26 11 8.21 7.80 08.97 72202 11 32.74 31.10 35.77 72202 TC 11 23.54 22.36 25.71 72202 26 11 9.20 8.74 10.05 72220 11 27.65 26.27 30.21 72220 TC 11 19.44 18.47 21.24 72220 26 11 8.21 7.80 08.97 72240 11 136.54 129.71 149.17 72240 TC 11 92.51 87.88 101.06 72240 26 11 44.03 41.83 48.10 72255 11 128.44 122.02 140.32 72255 TC 11 84.95 80.70 92.81 72255 26 11 43.48 41.31 47.51 72265 11 130.13 123.62 142.16 72265 TC 11 89.99 85.49 98.31 72265 26 11 40.14 38.13 43.85 72270 11 202.60 192.47 221.34 72270 TC 11 138.50 131.58 151.32 72270 26 11 64.11 60.90 70.04 72275 11 105.39 100.12 115.14 72275 TC 11 68.57 65.14 74.91 72275 26 11 36.81 34.97 40.22 72285 11 139.68 132.70 152.61 72285 TC 11 83.06 78.91 90.75 72285 26 11 56.62 53.79 61.86 72291 26 11 68.74 65.30 75.10 72292 11 171.21 162.65 187.05 72292 26 11 70.97 67.42 77.53 72295 11 122.57 116.44 133.91 72295 TC 11 81.80 77.71 89.37 72295 26 11 40.77 38.73 44.54 73000 11 26.99 25.64 29.49 73000 TC 11 19.13 18.17 20.90 73000 26 11 7.87 7.48 08.60 73010 11 28.74 27.30 31.40 73010 TC 11 19.76 18.77 21.59 73010 26 11 8.98 8.53 09.81 73020 11 22.25 21.14 24.31 73020 TC 11 15.03 14.28 16.42 73020 26 11 7.21 6.85 07.88 73030 11 29.07 27.62 31.76 73030 TC 11 19.44 18.47 21.24 73030 26 11 9.63 9.15 10.52 73040 11 101.38 96.31 110.76 73040 TC 11 74.87 71.13 81.80 73040 26 11 26.50 25.18 28.96 73050 11 36.05 34.25 39.39 73050 TC 11 25.42 24.15 27.77 73050 26 11 10.63 10.10 11.62 73060 11 27.65 26.27 30.21 73060 TC 11 19.13 18.17 20.90 73060 26 11 8.52 8.09 09.30 73070 11 26.65 25.32 29.12 73070 TC 11 19.13 18.17 20.90 73070 26 11 7.53 7.15 08.22 73080 11 32.06 30.46 35.03 73080 TC 11 23.85 22.66 26.06 73080 26 11 8.21 7.80 08.97 73085 11 92.02 87.42 100.53 73085 TC 11 65.42 62.15 71.47 73085 26 11 26.59 25.26 29.05 73090 11 26.36 25.04 28.80 73090 TC 11 18.50 17.58 20.22 73090 26 11 7.87 7.48 08.60 73092 11 28.88 27.44 31.56 73092 TC 11 21.02 19.97 22.97 73092 26 11 7.87 7.48 08.60 73100 11 29.03 27.58 31.72 73100 TC 11 20.39 19.37 22.28 73100 26 11 8.64 8.21 09.44 73110 11 34.26 32.55 37.43 73110 TC 11 25.74 24.45 28.12 73110 26 11 8.52 8.09 09.30 73115 11 102.64 97.51 112.14 73115 TC 11 75.50 71.73 82.49 73115 26 11 27.13 25.77 29.64 73120 11 26.05 24.75 28.46 73120 TC 11 18.18 17.27 19.86 73120 26 11 7.87 7.48 08.60 73130 11 30.17 28.66 32.96 73130 TC 11 21.96 20.86 23.99 73130 26 11 8.21 7.80 08.97 73140 11 29.44 27.97 32.17 73140 TC 11 22.91 21.76 25.02 73140 26 11 6.53 6.20 07.13 73200 C11 228.87 217.43 250.04 73200 TC C11 179.76 170.77 196.39 73200 26 11 49.12 46.66 53.66 73201 11 280.92 266.87 306.90 73201 TC 11 224.80 213.56 245.59 73201 26 11 56.13 53.32 61.32 73202 11 358.87 340.93 392.07 73202 TC 11 300.07 285.07 327.83 73202 26 11 58.80 55.86 64.24 73206 C11 400.87 380.83 437.95 73206 TC C11 313.61 297.93 342.62 73206 26 11 87.26 82.90 95.34 73218 C11 383.13 363.97 418.57 73218 TC C11 318.02 302.12 347.44 73218 26 11 65.10 61.85 71.13 73219 C11 483.38 459.21 528.09 73219 TC C11 404.95 384.70 442.41 73219 26 11 78.42 74.50 85.68 73220 C11 598.53 568.60 653.89 73220 TC C11 494.72 469.98 540.48 73220 26 11 103.82 98.63 113.42 73221 C11 384.12 364.91 419.65 73221 TC C11 318.02 302.12 347.44 73221 26 11 66.10 62.80 72.22 73222 C11 483.38 459.21 528.09 73222 TC C11 404.95 384.70 442.41 73222 26 11 78.42 74.50 85.68 73223 C11 598.22 568.31 653.56 73223 TC C11 494.72 469.98 540.48 73223 26 11 103.50 98.33 113.08 73225 11 564.86 536.62 617.11 73225 TC 11 480.86 456.82 525.34 73225 26 11 84.00 79.80 91.77 73500 11 25.27 24.01 27.61 73500 TC 11 16.29 15.48 17.80 73500 26 11 8.98 8.53 09.81 73510 11 36.39 34.57 39.76 73510 TC 11 25.42 24.15 27.77 73510 26 11 10.97 10.42 11.98 73520 11 38.41 36.49 41.96 73520 TC 11 25.42 24.15 27.77 73520 26 11 12.98 12.33 14.18 73525 11 94.45 89.73 103.19 73525 TC 11 67.31 63.94 73.53 73525 26 11 27.13 25.77 29.64 73530 11 32.70 31.07 35.73 73530 TC 11 17.78 16.89 19.42 73530 26 11 14.32 13.60 15.64 73540 11 38.26 36.35 41.80 73540 TC 11 27.94 26.54 30.52 73540 26 11 10.31 9.79 11.26 73542 11 77.97 74.07 85.18 73542 TC 11 49.36 46.89 53.92 73542 26 11 28.60 27.17 31.25 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 035 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 73550 11 26.85 25.51 29.34 73550 TC 11 18.18 17.27 19.86 73550 26 11 8.66 8.23 09.46 73560 11 28.74 27.30 31.40 73560 TC 11 19.76 18.77 21.59 73560 26 11 8.98 8.53 09.81 73562 11 34.43 32.71 37.62 73562 TC 11 24.79 23.55 27.08 73562 26 11 9.63 9.15 10.52 73564 11 39.57 37.59 43.23 73564 TC 11 28.26 26.85 30.88 73564 26 11 11.31 10.74 12.35 73565 11 31.88 30.29 34.83 73565 TC 11 22.59 21.46 24.68 73565 26 11 9.29 8.83 10.15 73580 11 123.65 117.47 135.09 73580 TC 11 95.66 90.88 104.51 73580 26 11 27.99 26.59 30.58 73590 11 26.07 24.77 28.49 73590 TC 11 17.87 16.98 19.53 73590 26 11 8.21 7.80 08.97 73592 11 29.20 27.74 31.90 73592 TC 11 21.33 20.26 23.30 73592 26 11 7.87 7.48 08.60 73600 11 26.68 25.35 29.15 73600 TC 11 18.81 17.87 20.55 73600 26 11 7.87 7.48 08.60 73610 11 30.48 28.96 33.30 73610 TC 11 22.28 21.17 24.35 73610 26 11 8.21 7.80 08.97 73615 11 97.91 93.01 106.96 73615 TC 11 70.78 67.24 77.33 73615 26 11 27.13 25.77 29.64 73620 11 25.73 24.44 28.11 73620 TC 11 18.18 17.27 19.86 73620 26 11 7.55 7.17 08.25 73630 11 29.85 28.36 32.61 73630 TC 11 21.65 20.57 23.66 73630 26 11 8.21 7.80 08.97 73650 11 26.36 25.04 28.80 73650 TC 11 18.50 17.58 20.22 73650 26 11 7.87 7.48 08.60 73660 11 27.55 26.17 30.10 73660 TC 11 21.33 20.26 23.30 73660 26 11 6.22 5.91 06.80 73700 C11 228.87 217.43 250.04 73700 TC C11 179.76 170.77 196.39 73700 26 11 49.12 46.66 53.66 73701 11 283.44 269.27 309.66 73701 TC 11 227.32 215.95 248.34 73701 26 11 56.13 53.32 61.32 73702 11 360.76 342.72 394.13 73702 TC 11 301.65 286.57 329.56 73702 26 11 59.11 56.15 64.57 73706 C11 405.87 385.58 443.42 73706 TC C11 313.61 297.93 342.62 73706 26 11 92.26 87.65 100.80 73718 C11 383.04 363.89 418.47 73718 TC C11 318.02 302.12 347.44 73718 26 11 65.01 61.76 71.02 73719 C11 483.06 458.91 527.75 73719 TC C11 404.95 384.70 442.41 73719 26 11 78.11 74.20 85.33 73720 C11 598.22 568.31 653.56 73720 TC C11 494.72 469.98 540.48 73720 26 11 103.50 98.33 113.08 73721 C11 383.81 364.62 419.31 73721 TC C11 318.02 302.12 347.44 73721 26 11 65.79 62.50 71.88 73722 C11 483.92 459.72 528.68 73722 TC C11 404.95 384.70 442.41 73722 26 11 78.97 75.02 86.27 73723 C11 598.22 568.31 653.56 73723 TC C11 494.72 469.98 540.48 73723 26 11 103.50 98.33 113.08 73725 11 518.83 492.89 566.82 73725 TC 11 431.09 409.54 470.97 73725 26 11 87.74 83.35 95.85 74000 11 23.58 22.40 25.76 74000 TC 11 15.03 14.28 16.42 74000 26 11 8.55 8.12 09.34 74010 11 35.99 34.19 39.32 74010 TC 11 25.11 23.85 27.43 74010 26 11 10.88 10.34 11.89 74020 11 37.98 36.08 41.49 74020 TC 11 25.11 23.85 27.43 74020 26 11 12.87 12.23 14.06 74022 11 45.66 43.38 49.89 74022 TC 11 30.46 28.94 33.28 74022 26 11 15.19 14.43 16.59 74150 11 232.18 220.57 253.66 74150 TC 11 174.72 165.98 190.88 74150 26 11 57.46 54.59 62.78 74160 11 313.32 297.65 342.30 74160 TC 11 251.88 239.29 275.18 74160 26 11 61.44 58.37 67.13 74170 C11 377.49 358.62 412.41 74170 TC C11 309.83 294.34 338.49 74170 26 11 67.66 64.28 73.92 74175 C11 406.10 385.80 443.67 74175 TC C11 313.93 298.23 342.96 74175 26 11 92.17 87.56 100.69 74176 11 203.99 193.79 222.86 74176 TC 11 122.12 116.01 133.41 74176 26 11 81.87 77.78 89.45 74177 11 318.83 302.89 348.32 74177 TC 11 232.98 221.33 254.53 74177 26 11 85.85 81.56 93.79 74178 11 402.91 382.76 440.17 74178 TC 11 307.95 292.55 336.43 74178 26 11 94.97 90.22 103.75 74181 C11 388.04 368.64 423.94 74181 TC C11 317.71 301.82 347.09 74181 26 11 70.33 66.81 76.83 74182 C11 488.37 463.95 533.54 74182 TC C11 404.95 384.70 442.41 74182 26 11 83.42 79.25 91.14 74183 C11 603.22 573.06 659.02 74183 TC C11 494.72 469.98 540.48 74183 26 11 108.50 103.08 118.54 74185 11 516.58 490.75 564.36 74185 TC 11 429.84 408.35 469.60 74185 26 11 86.74 82.40 94.76 74190 11 69.65 66.17 76.10 74190 TC 11 45.08 42.83 49.25 74190 26 11 23.52 22.34 25.69 74210 11 73.79 70.10 80.62 74210 TC 11 56.61 53.78 61.85 74210 26 11 17.18 16.32 18.77 74220 11 84.89 80.65 92.75 74220 TC 11 62.59 59.46 68.38 74220 26 11 22.30 21.19 24.37 74230 11 86.32 82.00 94.30 74230 TC 11 60.70 57.67 66.32 74230 26 11 25.62 24.34 27.99 74235 26 11 62.55 59.42 68.33 74240 11 105.53 100.25 115.29 74240 TC 11 72.04 68.44 78.71 74240 26 11 33.49 31.82 36.59 74241 11 111.91 106.31 122.26 74241 TC 11 78.97 75.02 86.27 74241 26 11 32.95 31.30 36.00 74245 11 166.77 158.43 182.19 74245 TC 11 122.75 116.61 134.10 74245 26 11 44.03 41.83 48.10 74246 C11 113.72 108.03 124.23 74246 TC C11 80.23 76.22 87.65 74246 26 11 33.49 31.82 36.59 74247 C11 113.72 108.03 124.23 74247 TC C11 80.23 76.22 87.65 74247 26 11 33.49 31.82 36.59 74249 C11 175.59 166.81 191.83 74249 TC C11 131.57 124.99 143.74 74249 26 11 44.03 41.83 48.10 74250 11 100.03 95.03 109.28 74250 TC 11 77.39 73.52 84.55 74250 26 11 22.64 21.51 24.74 74251 C11 164.83 156.59 180.08 74251 TC C11 131.34 124.77 143.49 74251 26 11 33.49 31.82 36.59 74260 C11 104.29 99.08 113.94 74260 TC C11 80.32 76.30 87.75 74260 26 11 23.97 22.77 26.19 74261 C11 292.15 277.54 319.17 74261 TC C11 179.53 170.55 196.13 74261 26 11 112.63 107.00 123.05 74262 C11 395.76 375.97 432.37 74262 TC C11 278.02 264.12 303.74 74262 26 11 117.74 111.85 128.63 74270 C11 114.03 108.33 124.58 74270 TC C11 80.54 76.51 87.99 74270 26 11 33.49 31.82 36.59 74280 C11 179.26 170.30 195.85 74280 TC C11 131.57 124.99 143.74 74280 26 11 47.69 45.31 52.11 74283 C11 176.46 167.64 192.79 74283 TC C11 80.23 76.22 87.65 74283 26 11 96.23 91.42 105.13 74290 11 64.24 61.03 70.18 74290 TC 11 49.05 46.60 53.59 74290 26 11 15.19 14.43 16.59 74291 11 59.85 56.86 65.39 74291 TC 11 50.31 47.79 54.96 74291 26 11 9.54 9.06 10.42 74300 11 70.57 67.04 77.10 74300 TC 11 42.33 40.21 46.24 74300 26 11 17.64 16.76 19.27 74301 11 41.57 39.49 45.41 74301 TC 11 24.95 23.70 27.26 74301 26 11 10.65 10.12 11.64 74305 11 48.50 46.08 52.99 74305 TC 11 26.97 25.62 29.46 74305 26 11 20.54 19.51 22.44 74320 11 101.78 96.69 111.19 74320 TC 11 75.50 71.73 82.49 74320 26 11 26.28 24.97 28.72 74327 11 129.11 122.65 141.05 74327 TC 11 93.46 88.79 102.11 74327 26 11 35.65 33.87 38.95 74328 11 144.49 137.27 157.86 74328 TC 11 108.75 103.31 118.81 74328 26 11 34.69 32.96 37.90 74329 26 11 34.69 32.96 37.90 74330 11 154.53 146.80 168.82 74330 TC 11 108.75 103.31 118.81 74330 26 11 44.46 42.24 48.58 74340 11 118.10 112.20 129.03 74340 TC 11 90.50 85.98 98.88 74340 26 11 26.50 25.18 28.96 74355 11 129.25 122.79 141.21 74355 TC 11 90.50 85.98 98.88 74355 26 11 37.81 35.92 41.31 74360 11 136.70 129.87 149.35 74360 TC 11 108.75 103.31 118.81 74360 26 11 28.08 26.68 30.68 74363 26 11 43.38 41.21 47.39 74400 11 105.12 99.86 114.84 74400 TC 11 81.49 77.42 89.03 74400 26 11 23.63 22.45 25.82 74410 11 108.27 102.86 118.29 74410 TC 11 84.32 80.10 92.12 74410 26 11 23.95 22.75 26.16 74415 11 127.80 121.41 139.62 74415 TC 11 104.17 98.96 113.80 74415 26 11 23.63 22.45 25.82 74420 11 108.99 103.54 119.07 74420 TC 11 90.50 85.98 98.88 74420 26 11 17.64 16.76 19.27 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 036 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 74425 11 63.59 60.41 69.47 74425 TC 11 45.08 42.83 49.25 74425 26 11 17.64 16.76 19.27 74430 11 57.31 54.44 62.61 74430 TC 11 42.12 40.01 46.01 74430 26 11 15.19 14.43 16.59 74440 11 81.22 77.16 88.73 74440 TC 11 62.59 59.46 68.38 74440 26 11 18.63 17.70 20.36 74445 11 97.23 92.37 106.23 74445 TC 11 38.88 36.94 42.48 74445 26 11 56.76 53.92 62.01 74450 11 67.26 63.90 73.49 74450 TC 11 50.27 47.76 54.92 74450 26 11 16.31 15.49 17.81 74455 11 84.11 79.90 91.89 74455 TC 11 68.26 64.85 74.58 74455 26 11 15.85 15.06 17.32 74470 11 70.66 67.13 77.20 74470 TC 11 43.07 40.92 47.06 74470 26 11 26.50 25.18 28.96 74475 11 105.24 99.98 114.98 74475 TC 11 78.97 75.02 86.27 74475 26 11 26.28 24.97 28.72 74480 11 105.56 100.28 115.32 74480 TC 11 79.28 75.32 86.62 74480 26 11 26.28 24.97 28.72 74485 11 103.98 98.78 113.60 74485 TC 11 77.71 73.82 84.89 74485 26 11 26.28 24.97 28.72 74710 11 37.52 35.64 40.99 74710 TC 11 21.33 20.26 23.30 74710 26 11 16.19 15.38 17.69 74740 11 74.47 70.75 81.36 74740 TC 11 56.29 53.48 61.50 74740 26 11 18.18 17.27 19.86 74742 26 11 29.74 28.25 32.49 74775 11 97.04 92.19 106.02 74775 TC 11 62.34 59.22 68.10 74775 26 11 30.39 28.87 33.20 75557 11 421.25 400.19 460.22 75557 TC 11 306.06 290.76 334.37 75557 26 11 115.20 109.44 125.86 75559 C11 464.45 441.23 507.41 75559 TC C11 318.02 302.12 347.44 75559 26 11 146.43 139.11 159.98 75561 11 569.19 540.73 621.84 75561 TC 11 441.49 419.42 482.33 75561 26 11 127.70 121.32 139.52 75563 C11 645.14 612.88 704.81 75563 TC C11 494.72 469.98 540.48 75563 26 11 150.42 142.90 164.34 75565 11 69.42 65.95 75.84 75565 TC 11 57.24 54.38 62.54 75565 26 11 12.19 11.58 13.32 75571 C11 69.93 66.43 76.39 75571 TC C11 43.06 40.91 47.05 75571 26 11 26.86 25.52 29.35 75572 11 275.63 261.85 301.13 75572 TC 11 193.93 184.23 211.86 75572 26 11 81.70 77.62 89.26 75573 C11 357.67 339.79 390.76 75573 TC C11 238.02 226.12 260.04 75573 26 11 119.64 113.66 130.71 75574 C11 350.37 332.85 382.78 75574 TC C11 238.02 226.12 260.04 75574 26 11 112.34 106.72 122.73 75600 11 252.21 239.60 275.54 75600 TC 11 227.63 216.25 248.69 75600 26 11 24.58 23.35 26.85 75605 11 202.13 192.02 220.82 75605 TC 11 146.06 138.76 159.57 75605 26 11 56.08 53.28 61.27 75625 11 202.19 192.08 220.89 75625 TC 11 146.37 139.05 159.91 75625 26 11 55.82 53.03 60.98 75630 11 236.87 225.03 258.78 75630 TC 11 149.83 142.34 163.69 75630 26 11 87.03 82.68 95.08 75635 C11 430.25 408.74 470.05 75635 TC C11 313.53 297.85 342.53 75635 26 11 116.72 110.88 127.51 75650 11 220.06 209.06 240.42 75650 TC 11 147.31 139.94 160.93 75650 26 11 72.75 69.11 79.48 75658 11 225.14 213.88 245.96 75658 TC 11 162.75 154.61 177.80 75658 26 11 62.40 59.28 68.17 75660 11 228.64 217.21 249.79 75660 TC 11 165.27 157.01 180.56 75660 26 11 63.37 60.20 69.23 75662 11 271.91 258.31 297.06 75662 TC 11 189.98 180.48 207.55 75662 26 11 81.93 77.83 89.50 75665 11 237.80 225.91 259.80 75665 TC 11 172.83 164.19 188.82 75665 26 11 64.97 61.72 70.98 75671 11 277.63 263.75 303.31 75671 TC 11 196.27 186.46 214.43 75671 26 11 81.36 77.29 88.88 75676 11 228.35 216.93 249.47 75676 TC 11 163.69 155.51 178.84 75676 26 11 64.65 61.42 70.63 75680 11 259.22 246.26 283.20 75680 TC 11 177.87 168.98 194.33 75680 26 11 81.36 77.29 88.88 75685 11 229.55 218.07 250.78 75685 TC 11 165.27 157.01 180.56 75685 26 11 64.29 61.08 70.24 75705 11 269.28 255.82 294.19 75705 TC 11 164.01 155.81 179.18 75705 26 11 105.27 100.01 115.01 75710 11 219.31 208.34 239.59 75710 TC 11 164.64 156.41 179.87 75710 26 11 54.68 51.95 59.74 75716 11 253.14 240.48 276.55 75716 TC 11 189.35 179.88 206.86 75716 26 11 63.80 60.61 69.70 75722 11 212.53 201.90 232.19 75722 TC 11 156.45 148.63 170.92 75722 26 11 56.08 53.28 61.27 75724 11 252.45 239.83 275.80 75724 TC 11 178.01 169.11 194.48 75724 26 11 74.44 70.72 81.33 75726 11 217.48 206.61 237.60 75726 TC 11 162.12 154.01 177.11 75726 26 11 55.36 52.59 60.48 75731 11 220.98 209.93 241.42 75731 TC 11 164.64 156.41 179.87 75731 26 11 56.34 53.52 61.55 75733 11 254.29 241.58 277.82 75733 TC 11 188.72 179.28 206.17 75733 26 11 65.58 62.30 71.65 75736 11 216.79 205.95 236.84 75736 TC 11 161.80 153.71 176.77 75736 26 11 54.99 52.24 60.08 75741 11 206.25 195.94 225.33 75741 TC 11 142.59 135.46 155.78 75741 26 11 63.66 60.48 69.55 75743 11 231.19 219.63 252.57 75743 TC 11 150.46 142.94 164.38 75743 26 11 80.73 76.69 88.19 75746 11 210.64 200.11 230.13 75746 TC 11 155.19 147.43 169.54 75746 26 11 55.45 52.68 60.58 75756 11 225.71 214.42 246.58 75756 TC 11 164.95 156.70 180.21 75756 26 11 60.76 57.72 66.38 75774 11 148.58 141.15 162.32 75774 TC 11 130.94 124.39 143.05 75774 26 11 17.64 16.76 19.27 75791 C11 229.74 218.25 250.99 75791 TC C11 149.83 142.34 163.69 75791 26 11 79.91 75.91 87.30 75801 11 229.00 217.55 250.18 75801 TC 11 186.85 177.51 204.14 75801 26 11 42.02 39.92 45.91 75803 11 246.41 234.09 269.20 75803 TC 11 186.85 177.51 204.14 75803 26 11 57.47 54.60 62.79 75805 11 252.35 239.73 275.69 75805 TC 11 210.63 200.10 230.12 75805 26 11 39.83 37.84 43.52 75807 26 11 57.78 54.89 63.12 75809 11 91.84 87.25 100.34 75809 TC 11 68.89 65.45 75.27 75809 26 11 22.95 21.80 25.07 75810 11 492.61 467.98 538.18 75810 TC 11 434.57 412.84 474.77 75810 26 11 56.45 53.63 61.67 75820 11 118.15 112.24 129.08 75820 TC 11 84.01 79.81 91.78 75820 26 11 34.14 32.43 37.29 75822 11 145.24 137.98 158.68 75822 TC 11 94.09 89.39 102.80 75822 26 11 51.15 48.59 55.88 75825 11 193.86 184.17 211.80 75825 TC 11 139.13 132.17 152.00 75825 26 11 54.73 51.99 59.79 75827 11 196.15 186.34 214.29 75827 TC 11 141.96 134.86 155.09 75827 26 11 54.19 51.48 59.20 75831 11 200.97 190.92 219.56 75831 TC 11 142.28 135.17 155.45 75831 26 11 58.69 55.76 64.12 75833 11 227.80 216.41 248.87 75833 TC 11 157.39 149.52 171.95 75833 26 11 70.40 66.88 76.91 75840 11 197.19 187.33 215.43 75840 TC 11 139.44 132.47 152.34 75840 26 11 57.75 54.86 63.09 75842 11 228.43 217.01 249.56 75842 TC 11 156.45 148.63 170.92 75842 26 11 71.98 68.38 78.64 75860 11 200.16 190.15 218.67 75860 TC 11 143.85 136.66 157.16 75860 26 11 56.31 53.49 61.51 75870 11 197.72 187.83 216.00 75870 TC 11 142.59 135.46 155.78 75870 26 11 55.13 52.37 60.23 75872 11 266.07 252.77 290.69 75872 TC 11 207.16 196.80 226.32 75872 26 11 58.91 55.96 64.35 75880 11 160.99 152.94 175.88 75880 TC 11 126.21 119.90 137.89 75880 26 11 34.77 33.03 37.98 75885 11 211.92 201.32 231.52 75885 TC 11 142.28 135.17 155.45 75885 26 11 69.65 66.17 76.10 75887 11 213.76 203.07 233.53 75887 TC 11 144.48 137.26 157.85 75887 26 11 69.28 65.82 75.69 75889 11 197.41 187.54 215.67 75889 TC 11 142.28 135.17 155.45 75889 26 11 55.13 52.37 60.23 75891 11 197.72 187.83 216.00 75891 TC 11 142.59 135.46 155.78 75891 26 11 55.13 52.37 60.23 75893 11 166.83 158.49 182.26 75893 TC 11 141.33 134.26 154.40 75893 26 11 25.50 24.23 27.86 75894 26 11 65.16 61.90 71.19 75896 11 791.41 751.84 864.62 75896 TC 11 723.98 687.78 790.95 75896 26 11 65.79 62.50 71.88 75898 11 120.66 114.63 131.82 75898 TC 11 36.19 34.38 39.54 75898 26 11 82.98 78.83 90.65 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 037 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 75900 26 11 24.09 22.89 26.32 75901 11 156.46 148.64 170.94 75901 TC 11 132.83 126.19 145.12 75901 26 11 23.63 22.45 25.82 75902 11 72.34 68.72 79.03 75902 TC 11 53.46 50.79 58.41 75902 26 11 18.89 17.95 20.64 75940 11 462.48 439.36 505.26 75940 TC 11 434.57 412.84 474.77 75940 26 11 26.56 25.23 29.01 75945 C11 161.42 153.35 176.35 75945 TC C11 141.65 134.57 154.76 75945 26 11 19.77 18.78 21.60 75946 26 11 19.91 18.91 21.75 75952 26 11 223.81 212.62 244.51 75953 26 11 68.11 64.70 74.41 75954 26 11 111.94 106.34 122.29 75956 26 11 350.66 333.13 383.10 75957 26 11 300.11 285.10 327.87 75958 26 11 199.32 189.35 217.75 75959 26 11 175.32 166.55 191.53 75960 11 181.67 172.59 198.48 75960 TC 11 141.96 134.86 155.09 75960 26 11 39.71 37.72 43.38 75961 11 351.39 333.82 383.89 75961 TC 11 146.68 139.35 160.25 75961 26 11 204.70 194.47 223.64 75962 11 198.47 188.55 216.83 75962 TC 11 172.51 163.88 188.46 75962 26 11 25.96 24.66 28.36 75964 11 123.61 117.43 135.04 75964 TC 11 106.05 100.75 115.86 75964 26 11 17.55 16.67 19.17 75966 11 240.03 228.03 262.23 75966 TC 11 175.66 166.88 191.91 75966 26 11 64.37 61.15 70.32 75968 11 121.35 115.28 132.57 75968 TC 11 103.85 98.66 113.46 75968 26 11 17.50 16.63 19.12 75970 11 440.53 418.50 481.28 75970 TC 11 397.86 377.97 434.67 75970 26 11 40.82 38.78 44.60 75978 11 198.79 188.85 217.18 75978 TC 11 173.14 164.48 189.15 75978 26 11 25.65 24.37 28.03 75980 11 260.21 247.20 284.28 75980 TC 11 186.85 177.51 204.14 75980 26 11 70.56 67.03 77.08 75982 26 11 70.56 67.03 77.08 75984 11 108.44 103.02 118.47 75984 TC 11 73.61 69.93 80.42 75984 26 11 34.82 33.08 38.04 75989 11 128.73 122.29 140.63 75989 TC 11 71.72 68.13 78.35 75989 26 11 57.00 54.15 62.27 76000 11 72.37 68.75 79.06 76000 TC 11 64.17 60.96 70.10 76000 26 11 8.21 7.80 08.97 76001 11 125.00 118.75 136.56 76001 TC 11 90.50 85.98 98.88 76001 26 11 34.04 32.34 37.19 76010 11 26.10 24.80 28.52 76010 TC 11 17.24 16.38 18.84 76010 26 11 8.86 8.42 09.68 76080 11 59.26 56.30 64.75 76080 TC 11 32.98 31.33 36.03 76080 26 11 26.28 24.97 28.72 76098 11 18.18 17.27 19.86 76098 TC 11 10.31 9.79 11.26 76098 26 11 7.87 7.48 08.60 76100 C11 99.81 94.82 109.04 76100 TC C11 70.15 66.64 76.64 76100 26 11 29.67 28.19 32.42 76101 11 165.07 156.82 180.34 76101 TC 11 133.14 126.48 145.45 76101 26 11 31.92 30.32 34.87 76102 11 221.27 210.21 241.74 76102 TC 11 188.89 179.45 206.37 76102 26 11 32.38 30.76 35.37 76120 11 72.09 68.49 78.76 76120 TC 11 53.77 51.08 58.74 76120 26 11 18.32 17.40 20.01 76125 11 40.77 38.73 44.54 76125 TC 11 26.97 25.62 29.46 76125 26 11 13.95 13.25 15.24 76376 11 67.09 63.74 73.30 76376 TC 11 57.24 54.38 62.54 76376 26 11 9.86 9.37 10.78 76377 11 88.45 84.03 96.63 76377 TC 11 50.31 47.79 54.96 76377 26 11 38.15 36.24 41.68 76380 C11 152.23 144.62 166.31 76380 TC C11 105.11 99.85 114.83 76380 26 11 47.12 44.76 51.47 76506 C11 88.37 83.95 96.54 76506 TC C11 57.87 54.98 63.23 76506 26 11 30.51 28.98 33.33 76510 11 156.77 148.93 171.27 76510 TC 11 68.89 65.45 75.27 76510 26 11 87.88 83.49 96.01 76511 11 94.44 89.72 103.18 76511 TC 11 44.95 42.70 49.11 76511 26 11 49.49 47.02 54.07 76512 11 87.57 83.19 95.67 76512 TC 11 37.39 35.52 40.85 76512 26 11 50.17 47.66 54.81 76513 11 83.04 78.89 90.72 76513 TC 11 49.99 47.49 54.61 76513 26 11 33.05 31.40 36.11 76514 11 13.16 12.50 14.38 76514 TC 11 4.01 3.81 04.38 76514 26 11 9.15 8.69 09.99 76516 11 67.94 64.54 74.22 76516 TC 11 39.60 37.62 43.26 76516 26 11 28.34 26.92 30.96 76519 11 73.43 69.76 80.22 76519 TC 11 44.32 42.10 48.42 76519 26 11 29.11 27.65 31.80 76529 11 69.41 65.94 75.83 76529 TC 11 38.65 36.72 42.23 76529 26 11 30.76 29.22 33.60 76536 11 111.28 105.72 121.58 76536 TC 11 84.32 80.10 92.12 76536 26 11 26.95 25.60 29.44 76604 11 82.91 78.76 90.57 76604 TC 11 56.61 53.78 61.85 76604 26 11 26.30 24.99 28.74 76645 C11 83.74 79.55 91.48 76645 TC C11 57.55 54.67 62.87 76645 26 11 26.19 24.88 28.61 76700 C11 127.87 121.48 139.70 76700 TC C11 89.05 84.60 97.29 76700 26 11 38.83 36.89 42.42 76705 11 100.64 95.61 109.95 76705 TC 11 72.35 68.73 79.04 76705 26 11 28.29 26.88 30.91 76770 C11 124.55 118.32 136.07 76770 TC C11 89.05 84.60 97.29 76770 26 11 35.50 33.73 38.79 76775 11 105.03 99.78 114.75 76775 TC 11 76.76 72.92 83.86 76775 26 11 28.26 26.85 30.88 76776 11 142.55 135.42 155.73 76776 TC 11 106.05 100.75 115.86 76776 26 11 36.50 34.68 39.88 76800 11 126.46 120.14 138.16 76800 TC 11 72.98 69.33 79.73 76800 26 11 53.48 50.81 58.43 76801 11 123.37 117.20 134.78 76801 TC 11 75.82 72.03 82.83 76801 26 11 47.55 45.17 51.95 76802 11 66.91 63.56 73.09 76802 TC 11 27.00 25.65 29.50 76802 26 11 39.91 37.91 43.60 76805 C11 136.60 129.77 149.24 76805 TC C11 89.05 84.60 97.29 76805 26 11 47.55 45.17 51.95 76810 11 93.11 88.45 101.72 76810 TC 11 46.21 43.90 50.49 76810 26 11 46.89 44.55 51.23 76811 11 184.03 174.83 201.05 76811 TC 11 92.83 88.19 101.42 76811 26 11 91.21 86.65 99.65 76812 C11 143.11 135.95 156.34 76812 TC C11 57.87 54.98 63.23 76812 26 11 85.24 80.98 93.13 76813 11 120.60 114.57 131.76 76813 TC 11 64.17 60.96 70.10 76813 26 11 56.44 53.62 61.66 76814 11 77.38 73.51 84.54 76814 TC 11 30.15 28.64 32.94 76814 26 11 47.23 44.87 51.60 76815 11 86.48 82.16 94.48 76815 TC 11 55.66 52.88 60.81 76815 26 11 30.82 29.28 33.67 76816 C11 98.45 93.53 107.56 76816 TC C11 57.55 54.67 62.87 76816 26 11 40.90 38.86 44.69 76817 C11 93.48 88.81 102.13 76817 TC C11 57.55 54.67 62.87 76817 26 11 35.93 34.13 39.25 76818 11 116.27 110.46 127.03 76818 TC 11 65.74 62.45 71.82 76818 26 11 50.53 48.00 55.20 76819 11 87.23 82.87 95.30 76819 TC 11 49.99 47.49 54.61 76819 26 11 37.24 35.38 40.69 76820 11 44.53 42.30 48.65 76820 TC 11 20.70 19.67 22.62 76820 26 11 23.83 22.64 26.04 76821 C11 91.47 86.90 99.94 76821 TC C11 57.55 54.67 62.87 76821 26 11 33.92 32.22 37.05 76825 11 205.91 195.61 224.95 76825 TC 11 126.21 119.90 137.89 76825 26 11 79.70 75.72 87.08 76826 11 118.25 112.34 129.19 76826 TC 11 78.65 74.72 85.93 76826 26 11 39.59 37.61 43.25 76827 11 63.00 59.85 68.83 76827 TC 11 35.50 33.73 38.79 76827 26 11 27.49 26.12 30.04 76828 11 46.57 44.24 50.88 76828 TC 11 19.76 18.77 21.59 76828 26 11 26.81 25.47 29.29 76830 11 117.90 112.01 128.81 76830 TC 11 84.64 80.41 92.47 76830 26 11 33.26 31.60 36.34 76831 11 118.29 112.38 129.24 76831 TC 11 83.69 79.51 91.44 76831 26 11 34.60 32.87 37.80 76856 11 117.58 111.70 128.46 76856 TC 11 84.32 80.10 92.12 76856 26 11 33.26 31.60 36.34 76857 C11 76.50 72.68 83.58 76857 TC C11 57.55 54.67 62.87 76857 26 11 18.95 18.00 20.70 76870 11 116.74 110.90 127.54 76870 TC 11 85.58 81.30 93.50 76870 26 11 31.16 29.60 34.04 76872 C11 123.17 117.01 134.56 76872 TC C11 89.05 84.60 97.29 76872 26 11 34.12 32.41 37.27 76873 C11 164.64 156.41 179.87 76873 TC C11 89.05 84.60 97.29 76873 26 11 75.59 71.81 82.58 76881 11 107.80 102.41 117.77 76881 TC 11 79.91 75.91 87.30 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 038 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 76881 26 11 27.89 26.50 30.48 76882 11 28.70 27.27 31.36 76882 TC 11 9.36 8.89 10.22 76882 26 11 19.34 18.37 21.13 76885 C11 93.68 89.00 102.35 76885 TC C11 57.87 54.98 63.23 76885 26 11 35.82 34.03 39.13 76886 C11 87.66 83.28 95.77 76886 TC C11 57.55 54.67 62.87 76886 26 11 30.11 28.60 32.89 76930 11 85.90 81.61 93.85 76930 TC 11 52.83 50.19 57.72 76930 26 11 33.07 31.42 36.13 76932 11 87.65 83.27 95.76 76932 TC 11 52.58 49.95 57.44 76932 26 11 34.07 32.37 37.23 76936 C11 196.86 187.02 215.07 76936 TC C11 98.81 93.87 107.95 76936 26 11 98.05 93.15 107.12 76937 11 32.84 31.20 35.88 76937 TC 11 18.18 17.27 19.86 76937 26 11 14.66 13.93 16.02 76940 11 160.65 152.62 175.51 76940 TC 11 55.44 52.67 60.57 76940 26 11 100.39 95.37 109.68 76941 11 122.20 116.09 133.50 76941 TC 11 52.62 49.99 57.49 76941 26 11 66.30 62.99 72.44 76942 11 184.85 175.61 201.95 76942 TC 11 152.35 144.73 166.44 76942 26 11 32.50 30.88 35.51 76945 11 86.83 82.49 94.86 76945 TC 11 52.62 49.99 57.49 76945 26 11 32.81 31.17 35.85 76946 11 36.04 34.24 39.38 76946 TC 11 17.87 16.98 19.53 76946 26 11 18.18 17.27 19.86 76948 11 36.50 34.68 39.88 76948 TC 11 17.87 16.98 19.53 76948 26 11 18.63 17.70 20.36 76950 11 65.34 62.07 71.38 76950 TC 11 37.08 35.23 40.51 76950 26 11 28.26 26.85 30.88 76965 11 112.46 106.84 122.87 76965 TC 11 46.53 44.20 50.83 76965 26 11 65.93 62.63 72.02 76970 C11 77.09 73.24 84.23 76970 TC C11 57.55 54.67 62.87 76970 26 11 19.54 18.56 21.34 76975 11 94.47 89.75 103.21 76975 TC 11 52.58 49.95 57.44 76975 26 11 41.63 39.55 45.48 76977 11 9.71 9.22 10.60 76977 TC 11 7.16 6.80 07.82 76977 26 11 2.56 2.43 02.79 76998 11 182.66 173.53 199.56 76998 TC 11 112.09 106.49 122.46 76998 26 11 61.50 58.43 67.19 77001 11 107.05 101.70 116.96 77001 TC 11 88.42 84.00 96.60 77001 26 11 18.63 17.70 20.36 77002 11 71.23 67.67 77.82 77002 TC 11 44.64 42.41 48.77 77002 26 11 26.59 25.26 29.05 77003 11 59.09 56.14 64.56 77003 TC 11 30.46 28.94 33.28 77003 26 11 28.63 27.20 31.28 77011 11 451.07 428.52 492.80 77011 TC 11 392.04 372.44 428.31 77011 26 11 59.03 56.08 64.49 77012 11 154.25 146.54 168.52 77012 TC 11 98.81 93.87 107.95 77012 26 11 55.44 52.67 60.57 77013 11 625.52 594.24 683.38 77013 TC 11 404.93 384.68 442.38 77013 26 11 195.97 186.17 214.10 77014 11 179.63 170.65 196.25 77014 TC 11 138.50 131.58 151.32 77014 26 11 41.13 39.07 44.93 77021 11 405.43 385.16 442.93 77021 TC 11 332.20 315.59 362.93 77021 26 11 73.23 69.57 80.01 77022 11 765.10 726.85 835.88 77022 TC 11 528.25 501.84 577.12 77022 26 11 207.21 196.85 226.38 77031 11 152.73 145.09 166.85 77031 TC 11 75.50 71.73 82.49 77031 26 11 77.23 73.37 84.38 77032 11 53.01 50.36 57.91 77032 TC 11 26.05 24.75 28.46 77032 26 11 26.95 25.60 29.44 77051 11 10.68 10.15 11.67 77051 TC 11 7.79 7.40 08.51 77051 26 11 2.90 2.76 03.17 77052 11 10.68 10.15 11.67 77052 TC 11 7.79 7.40 08.51 77052 26 11 2.90 2.76 03.17 77053 11 63.71 60.52 69.60 77053 TC 11 46.53 44.20 50.83 77053 26 11 17.18 16.32 18.77 77054 11 86.12 81.81 94.08 77054 TC 11 64.17 60.96 70.10 77054 26 11 21.96 20.86 23.99 77055 11 81.62 77.54 89.17 77055 TC 11 47.79 45.40 52.21 77055 26 11 33.83 32.14 36.96 77056 11 104.31 99.09 113.95 77056 TC 11 62.28 59.17 68.05 77056 26 11 42.04 39.94 45.93 77057 11 76.58 72.75 83.66 77057 TC 11 42.75 40.61 46.70 77057 26 11 33.83 32.14 36.96 77058 C11 573.48 544.81 626.53 77058 TC C11 494.72 469.98 540.48 77058 26 11 78.76 74.82 86.04 77059 C11 573.48 544.81 626.53 77059 TC C11 494.72 469.98 540.48 77059 26 11 78.76 74.82 86.04 77071 11 43.87 41.68 47.93 77072 11 22.34 21.22 24.40 77072 TC 11 13.14 12.48 14.35 77072 26 11 9.20 8.74 10.05 77073 11 36.77 34.93 40.17 77073 TC 11 22.59 21.46 24.68 77073 26 11 14.18 13.47 15.49 77074 11 65.97 62.67 72.07 77074 TC 11 44.01 41.81 48.08 77074 26 11 21.96 20.86 23.99 77075 C11 96.11 91.30 105.00 77075 TC C11 70.15 66.64 76.64 77075 26 11 25.96 24.66 28.36 77076 11 94.84 90.10 103.62 77076 TC 11 61.65 58.57 67.36 77076 26 11 33.20 31.54 36.27 77077 11 39.70 37.72 43.38 77077 TC 11 23.85 22.66 26.06 77077 26 11 15.85 15.06 17.32 77078 C11 77.07 73.22 84.20 77078 TC C11 65.20 61.94 71.23 77078 26 11 11.87 11.28 12.97 77079 11 47.62 45.24 52.03 77079 TC 11 37.08 35.23 40.51 77079 26 11 10.54 10.01 11.51 77080 11 89.75 85.26 98.05 77080 TC 11 79.18 75.22 86.50 77080 26 11 10.56 10.03 11.53 77081 11 27.14 25.78 29.65 77081 TC 11 17.55 16.67 19.17 77081 26 11 9.59 9.11 10.48 77082 11 25.71 24.42 28.08 77082 TC 11 19.49 18.52 21.30 77082 26 11 6.22 5.91 06.80 77083 11 23.63 22.45 25.82 77083 TC 11 14.09 13.39 15.40 77083 26 11 9.54 9.06 10.42 77084 C11 395.77 375.98 432.38 77084 TC C11 318.02 302.12 347.44 77084 26 11 77.74 73.85 84.93 77261 11 69.66 66.18 76.11 77262 11 104.77 99.53 114.46 77263 11 155.45 147.68 169.83 77280 11 176.51 167.68 192.83 77280 TC 11 142.59 135.46 155.78 77280 26 11 33.92 32.22 37.05 77285 11 309.17 293.71 337.77 77285 TC 11 258.18 245.27 282.06 77285 26 11 50.99 48.44 55.71 77290 11 494.51 469.78 540.25 77290 TC 11 418.81 397.87 457.55 77290 26 11 75.70 71.92 82.71 77295 11 532.34 505.72 581.58 77295 TC 11 310.52 294.99 339.24 77295 26 11 221.82 210.73 242.34 77300 11 66.07 62.77 72.19 77300 TC 11 35.82 34.03 39.13 77300 26 11 30.25 28.74 33.05 77301 11 1950.09 1852.59 2130.48 77301 TC 11 1561.55 1483.47 1705.99 77301 26 11 388.54 369.11 424.48 77305 11 63.12 59.96 68.95 77305 TC 11 29.20 27.74 31.90 77305 26 11 33.92 32.22 37.05 77310 11 89.33 84.86 97.59 77310 TC 11 38.34 36.42 41.88 77310 26 11 50.99 48.44 55.71 77315 11 135.46 128.69 147.99 77315 TC 11 59.76 56.77 65.29 77315 26 11 75.70 71.92 82.71 77321 11 101.13 96.07 110.48 77321 TC 11 55.35 52.58 60.47 77321 26 11 45.79 43.50 50.03 77326 11 136.19 129.38 148.79 77326 TC 11 91.39 86.82 99.84 77326 26 11 44.79 42.55 48.93 77327 11 193.13 183.47 210.99 77327 TC 11 125.72 119.43 137.34 77327 26 11 67.41 64.04 73.65 77328 11 261.29 248.23 285.46 77328 TC 11 159.97 151.97 174.77 77328 26 11 101.32 96.25 110.69 77331 11 60.31 57.29 65.88 77331 TC 11 17.87 16.98 19.53 77331 26 11 42.44 40.32 46.37 77332 11 74.06 70.36 80.91 77332 TC 11 47.79 45.40 52.21 77332 26 11 26.28 24.97 28.72 77333 11 57.08 54.23 62.36 77333 TC 11 16.29 15.48 17.80 77333 26 11 40.79 38.75 44.56 77334 11 144.92 137.67 158.32 77334 TC 11 84.95 80.70 92.81 77334 26 11 59.96 56.96 65.50 77336 11 48.42 46.00 52.90 77338 11 452.70 430.07 494.58 77338 TC 11 242.17 230.06 264.57 77338 26 11 210.53 200.00 230.00 77370 11 107.68 102.30 117.65 77372 11 789.17 749.71 862.17 77373 11 1473.72 1400.03 1610.03 77401 11 23.54 22.36 25.71 77402 11 163.38 155.21 178.49 77403 11 121.49 115.42 132.73 77404 11 135.03 128.28 147.52 77406 11 136.29 129.48 148.90 77407 11 236.76 224.92 258.66 77408 11 165.27 157.01 180.56 77409 11 183.85 174.66 200.86 77411 11 182.91 173.76 199.82 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 039 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 77412 11 215.66 204.88 235.61 77413 11 217.24 206.38 237.34 77414 11 243.06 230.91 265.55 77416 11 244.32 232.10 266.92 77417 11 13.77 13.08 15.04 77418 11 481.80 457.71 526.37 77421 11 102.84 97.70 112.36 77421 TC 11 84.01 79.81 91.78 77421 26 11 18.83 17.89 20.57 77422 11 184.48 175.26 201.55 77423 11 234.56 222.83 256.25 77427 11 173.25 164.59 189.28 77431 11 94.93 90.18 103.71 77432 11 392.89 373.25 429.24 77435 N 11 650.57 618.04 710.75 77435 F 11 651.20 618.64 711.44 77470 11 191.63 182.05 209.36 77470 TC 11 89.99 85.49 98.31 77470 26 11 101.64 96.56 111.04 77520 11 809.81 769.32 884.72 77522 11 838.15 796.24 915.68 77523 11 870.91 827.36 951.46 77525 11 972.33 923.71 1062.27 77600 11 380.95 361.90 416.19 77600 TC 11 305.25 289.99 333.49 77600 26 11 75.70 71.92 82.71 77605 11 865.24 821.98 945.28 77605 TC 11 759.74 721.75 830.01 77605 26 11 105.50 100.23 115.26 77610 11 789.46 749.99 862.49 77610 TC 11 715.02 679.27 781.16 77610 26 11 74.44 70.72 81.33 77615 11 905.44 860.17 989.20 77615 TC 11 804.12 763.91 878.50 77615 26 11 101.32 96.25 110.69 77620 11 449.16 426.70 490.71 77620 TC 11 375.72 356.93 410.47 77620 26 11 73.44 69.77 80.24 77750 11 336.81 319.97 367.97 77750 TC 11 93.91 89.21 102.59 77750 26 11 242.90 230.76 265.37 77761 11 348.88 331.44 381.16 77761 TC 11 162.80 154.66 177.86 77761 26 11 186.08 176.78 203.30 77762 11 470.14 446.63 513.62 77762 TC 11 190.43 180.91 208.05 77762 26 11 279.71 265.72 305.58 77763 11 666.49 633.17 728.15 77763 TC 11 246.32 234.00 269.10 77763 26 11 420.17 399.16 459.03 77776 11 399.71 379.72 436.68 77776 TC 11 169.96 161.46 185.68 77776 26 11 229.75 218.26 251.00 77777 11 556.00 528.20 607.43 77777 TC 11 185.71 176.42 202.88 77777 26 11 370.30 351.79 404.56 77778 11 802.64 762.51 876.89 77778 TC 11 252.85 240.21 276.24 77778 26 11 549.79 522.30 600.65 77785 11 206.43 196.11 225.53 77785 TC 11 137.38 130.51 150.09 77785 26 11 69.05 65.60 75.44 77786 11 535.68 508.90 585.24 77786 TC 11 379.09 360.14 414.16 77786 26 11 156.59 148.76 171.07 77787 11 853.58 810.90 932.54 77787 TC 11 614.42 583.70 671.26 77787 26 11 239.16 227.20 261.28 77789 11 105.30 100.04 115.05 77789 TC 11 49.68 47.20 54.28 77789 26 11 55.62 52.84 60.77 77790 11 86.58 82.25 94.59 77790 TC 11 35.82 34.03 39.13 77790 26 11 50.76 48.22 55.45 78000 11 67.07 63.72 73.28 78000 TC 11 57.87 54.98 63.23 78000 26 11 9.20 8.74 10.05 78001 11 85.97 81.67 93.92 78001 TC 11 73.44 69.77 80.24 78001 26 11 12.53 11.90 13.69 78003 11 74.98 71.23 81.91 78003 TC 11 59.13 56.17 64.60 78003 26 11 15.85 15.06 17.32 78006 11 219.28 208.32 239.57 78006 TC 11 195.64 185.86 213.74 78006 26 11 23.63 22.45 25.82 78007 11 181.82 172.73 198.64 78007 TC 11 157.85 149.96 172.45 78007 26 11 23.97 22.77 26.19 78010 C11 141.09 134.04 154.15 78010 TC C11 122.89 116.75 134.26 78010 26 11 18.20 17.29 19.88 78011 C11 144.85 137.61 158.25 78011 TC C11 122.89 116.75 134.26 78011 26 11 21.96 20.86 23.99 78015 11 200.74 190.70 219.31 78015 TC 11 168.87 160.43 184.49 78015 26 11 31.87 30.28 34.82 78016 11 284.03 269.83 310.30 78016 TC 11 247.30 234.94 270.18 78016 26 11 36.73 34.89 40.12 78018 11 296.96 282.11 324.43 78018 TC 11 256.43 243.61 280.15 78018 26 11 40.53 38.50 44.28 78020 11 81.14 77.08 88.64 78020 TC 11 53.14 50.48 58.05 78020 26 11 28.00 26.60 30.59 78070 11 155.13 147.37 169.48 78070 TC 11 115.96 110.16 126.68 78070 26 11 39.17 37.21 42.79 78075 11 396.10 376.30 432.75 78075 TC 11 361.23 343.17 394.65 78075 26 11 34.87 33.13 38.10 78102 11 155.17 147.41 169.52 78102 TC 11 129.19 122.73 141.14 78102 26 11 25.99 24.69 28.39 78103 11 204.72 194.48 223.65 78103 TC 11 169.50 161.03 185.18 78103 26 11 35.21 33.45 38.47 78104 11 232.56 220.93 254.07 78104 TC 11 194.70 184.97 212.72 78104 26 11 37.86 35.97 41.37 78110 11 76.97 73.12 84.09 78110 TC 11 67.77 64.38 74.04 78110 26 11 9.20 8.74 10.05 78111 11 81.46 77.39 89.00 78111 TC 11 71.24 67.68 77.83 78111 26 11 10.22 9.71 11.17 78120 11 81.80 77.71 89.37 78120 TC 11 70.61 67.08 77.14 78120 26 11 11.19 10.63 12.22 78121 11 93.99 89.29 102.68 78121 TC 11 78.79 74.85 86.08 78121 26 11 15.19 14.43 16.59 78122 11 105.02 99.77 114.74 78122 TC 11 84.15 79.94 91.93 78122 26 11 20.87 19.83 22.80 78130 11 144.75 137.51 158.14 78130 TC 11 114.93 109.18 125.56 78130 26 11 29.83 28.34 32.59 78135 11 319.40 303.43 348.94 78135 TC 11 288.24 273.83 314.90 78135 26 11 31.16 29.60 34.04 78140 11 130.04 123.54 142.07 78140 TC 11 100.53 95.50 109.83 78140 26 11 29.51 28.03 32.23 78185 11 187.10 177.75 204.41 78185 TC 11 167.93 159.53 183.46 78185 26 11 19.17 18.21 20.94 78190 C11 212.89 202.25 232.59 78190 TC C11 161.09 153.04 176.00 78190 26 11 51.80 49.21 56.59 78191 11 165.23 156.97 180.52 78191 TC 11 135.72 128.93 148.27 78191 26 11 29.51 28.03 32.23 78195 C11 295.65 280.87 323.00 78195 TC C11 238.16 226.25 260.19 78195 26 11 57.49 54.62 62.81 78201 11 172.77 164.13 188.75 78201 TC 11 151.87 144.28 165.92 78201 26 11 20.90 19.86 22.84 78202 11 188.63 179.20 206.08 78202 TC 11 165.41 157.14 180.71 78202 26 11 23.23 22.07 25.38 78205 11 212.18 201.57 231.81 78205 TC 11 178.32 169.40 194.81 78205 26 11 33.85 32.16 36.98 78206 C11 291.22 276.66 318.16 78206 TC C11 245.72 233.43 268.44 78206 26 11 45.50 43.23 49.71 78215 11 178.96 170.01 195.51 78215 TC 11 155.33 147.56 169.69 78215 26 11 23.63 22.45 25.82 78216 11 122.15 116.04 133.45 78216 TC 11 95.17 90.41 103.97 78216 26 11 26.98 25.63 29.47 78220 11 127.48 121.11 139.28 78220 TC 11 104.62 99.39 114.30 78220 26 11 22.86 21.72 24.98 78223 C11 285.88 271.59 312.33 78223 TC C11 245.72 233.43 268.44 78223 26 11 40.16 38.15 43.87 78230 11 154.61 146.88 168.91 78230 TC 11 132.97 126.32 145.27 78230 26 11 21.64 20.56 23.64 78231 11 120.31 114.29 131.43 78231 TC 11 95.80 91.01 104.66 78231 26 11 24.51 23.28 26.77 78232 11 109.62 104.14 119.76 78232 TC 11 88.24 83.83 96.40 78232 26 11 21.38 20.31 23.36 78258 11 212.97 202.32 232.67 78258 TC 11 177.38 168.51 193.79 78258 26 11 35.59 33.81 38.88 78261 11 232.91 221.26 254.45 78261 TC 11 199.42 189.45 217.87 78261 26 11 33.49 31.82 36.59 78262 11 228.43 217.01 249.56 78262 TC 11 196.59 186.76 214.77 78262 26 11 31.84 30.25 34.79 78264 C11 258.65 245.72 282.58 78264 TC C11 221.47 210.40 241.96 78264 26 11 37.18 35.32 40.62 78270 11 75.60 71.82 82.59 78270 TC 11 66.05 62.75 72.16 78270 26 11 9.54 9.06 10.42 78271 11 79.69 75.71 87.07 78271 TC 11 70.15 66.64 76.64 78271 26 11 9.54 9.06 10.42 78272 11 84.73 80.49 92.56 78272 TC 11 72.18 68.57 78.86 78272 26 11 12.55 11.92 13.71 78278 C11 268.93 255.48 293.80 78278 TC C11 221.56 210.48 242.05 78278 26 11 47.37 45.00 51.75 78282 11 73.82 70.13 80.65 78282 TC 11 44.28 42.07 48.38 78282 26 11 18.63 17.70 20.36 78290 C11 254.62 241.89 278.17 78290 TC C11 221.79 210.70 242.31 78290 26 11 32.83 31.19 35.87 78291 11 235.82 224.03 257.63 78291 TC 11 193.76 184.07 211.68 78291 26 11 42.06 39.96 45.95 78300 11 164.48 156.26 179.70 78300 TC 11 134.54 127.81 146.98 78300 26 11 29.94 28.44 32.71 78305 11 217.20 206.34 237.29 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 040 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 78305 TC 11 177.69 168.81 194.13 78305 26 11 39.51 37.53 43.16 78306 11 236.49 224.67 258.37 78306 TC 11 195.33 185.56 213.39 78306 26 11 41.16 39.10 44.97 78315 C11 275.31 261.54 300.77 78315 TC C11 226.60 215.27 247.56 78315 26 11 48.71 46.27 53.21 78320 11 228.34 216.92 249.46 78320 TC 11 178.95 170.00 195.50 78320 26 11 49.39 46.92 53.96 78414 26 11 21.64 20.56 23.64 78428 11 181.26 172.20 198.03 78428 TC 11 143.05 135.90 156.29 78428 26 11 38.21 36.30 41.75 78445 11 159.61 151.63 174.37 78445 TC 11 136.75 129.91 149.40 78445 26 11 22.86 21.72 24.98 78451 11 318.95 303.00 348.45 78451 TC 11 254.86 242.12 278.44 78451 26 11 64.09 60.89 70.02 78452 11 446.07 423.77 487.34 78452 TC 11 370.36 351.84 404.62 78452 26 11 75.71 71.92 82.71 78453 11 273.60 259.92 298.91 78453 TC 11 226.83 215.49 247.81 78453 26 11 46.77 44.43 51.09 78454 11 394.98 375.23 431.51 78454 TC 11 332.57 315.94 363.33 78454 26 11 62.42 59.30 68.20 78456 C11 235.12 223.36 256.86 78456 TC C11 185.65 176.37 202.83 78456 26 11 49.46 46.99 54.04 78457 11 182.40 173.28 199.27 78457 TC 11 145.57 138.29 159.03 78457 26 11 36.84 35.00 40.25 78458 11 183.58 174.40 200.56 78458 TC 11 142.10 135.00 155.25 78458 26 11 41.48 39.41 45.32 78459 C11 1099.14 1044.18 1200.81 78459 TC C11 1026.37 975.05 1121.31 78459 26 11 72.77 69.13 79.50 78466 11 168.75 160.31 184.36 78466 TC 11 134.86 128.12 147.34 78466 26 11 33.89 32.20 37.03 78468 11 204.61 194.38 223.54 78468 TC 11 164.78 156.54 180.02 78468 26 11 39.83 37.84 43.52 78469 11 240.82 228.78 263.10 78469 TC 11 194.70 184.97 212.72 78469 26 11 46.12 43.81 50.38 78472 11 235.52 223.74 257.30 78472 TC 11 187.77 178.38 205.14 78472 26 11 47.75 45.36 52.16 78473 11 311.61 296.03 340.43 78473 TC 11 239.42 227.45 261.57 78473 26 11 72.19 68.58 78.87 78481 11 197.04 187.19 215.27 78481 TC 11 147.94 140.54 161.62 78481 26 11 49.10 46.65 53.65 78483 11 273.50 259.83 298.80 78483 TC 11 199.42 189.45 217.87 78483 26 11 74.08 70.38 80.94 78491 C11 1100.09 1045.09 1201.85 78491 TC C11 1026.37 975.05 1121.31 78491 26 11 73.72 70.03 80.53 78492 C11 1119.73 1063.74 1223.30 78492 TC C11 1026.37 975.05 1121.31 78492 26 11 93.36 88.69 101.99 78494 11 251.16 238.60 274.39 78494 TC 11 192.50 182.88 210.31 78494 26 11 58.67 55.74 64.10 78496 11 76.03 72.23 83.06 78496 TC 11 51.57 48.99 56.34 78496 26 11 24.46 23.24 26.73 78580 11 198.48 188.56 216.84 78580 TC 11 163.20 155.04 178.30 78580 26 11 35.28 33.52 38.55 78584 11 143.49 136.32 156.77 78584 TC 11 95.80 91.01 104.66 78584 26 11 47.69 45.31 52.11 78585 11 329.57 313.09 360.05 78585 TC 11 277.53 263.65 303.20 78585 26 11 52.03 49.43 56.84 78586 11 154.98 147.23 169.31 78586 TC 11 136.12 129.31 148.71 78586 26 11 18.86 17.92 20.61 78587 11 194.08 184.38 212.04 78587 TC 11 170.76 162.22 186.55 78587 26 11 23.32 22.15 25.47 78588 11 319.49 303.52 349.05 78588 TC 11 267.46 254.09 292.20 78588 26 11 52.03 49.43 56.84 78591 11 156.86 149.02 171.37 78591 TC 11 137.69 130.81 150.43 78591 26 11 19.17 18.21 20.94 78593 11 182.43 173.31 199.31 78593 TC 11 158.79 150.85 173.48 78593 26 11 23.63 22.45 25.82 78594 11 201.74 191.65 220.40 78594 TC 11 176.75 167.91 193.10 78594 26 11 24.99 23.74 27.30 78596 11 348.05 330.65 380.25 78596 TC 11 288.87 274.43 315.59 78596 26 11 59.18 56.22 64.65 78600 11 167.36 158.99 182.84 78600 TC 11 146.20 138.89 159.72 78600 26 11 21.16 20.10 23.12 78601 11 198.54 188.61 216.90 78601 TC 11 174.23 165.52 190.35 78601 26 11 24.31 23.09 26.55 78605 11 183.79 174.60 200.79 78605 TC 11 157.85 149.96 172.45 78605 26 11 25.94 24.64 28.34 78606 11 301.40 286.33 329.28 78606 TC 11 271.24 257.68 296.33 78606 26 11 30.16 28.65 32.95 78607 11 338.73 321.79 370.06 78607 TC 11 281.00 266.95 306.99 78607 26 11 57.73 54.84 63.07 78608 C11 1037.64 985.76 1133.62 78608 TC C11 965.90 917.61 1055.25 78608 26 11 71.74 68.15 78.37 78610 11 164.81 156.57 180.06 78610 TC 11 150.29 142.78 164.20 78610 26 11 14.52 13.79 15.86 78630 11 312.98 297.33 341.93 78630 TC 11 280.37 266.35 306.30 78630 26 11 32.61 30.98 35.63 78635 11 298.49 283.57 326.11 78635 TC 11 269.35 255.88 294.26 78635 26 11 29.14 27.68 31.83 78645 C11 250.03 237.53 273.16 78645 TC C11 222.73 211.59 243.33 78645 26 11 27.29 25.93 29.82 78647 11 323.74 307.55 353.68 78647 TC 11 281.31 267.24 307.33 78647 26 11 42.43 40.31 46.36 78650 11 306.42 291.10 334.77 78650 TC 11 277.22 263.36 302.86 78650 26 11 29.20 27.74 31.90 78660 11 164.89 156.65 180.15 78660 TC 11 138.95 132.00 151.80 78660 26 11 25.94 24.64 28.34 78700 11 164.06 155.86 179.24 78700 TC 11 142.10 135.00 155.25 78700 26 11 21.96 20.86 23.99 78701 11 198.17 188.26 216.50 78701 TC 11 174.54 165.81 190.68 78701 26 11 23.63 22.45 25.82 78707 11 222.25 211.14 242.81 78707 TC 11 176.75 167.91 193.10 78707 26 11 45.50 43.23 49.71 78708 11 169.86 161.37 185.58 78708 TC 11 112.18 106.57 122.56 78708 26 11 57.68 54.80 63.02 78709 11 342.47 325.35 374.15 78709 TC 11 275.33 261.56 300.79 78709 26 11 67.14 63.78 73.35 78710 11 207.59 197.21 226.79 78710 TC 11 177.06 168.21 193.44 78710 26 11 30.53 29.00 33.35 78725 11 95.71 90.92 104.56 78725 TC 11 77.85 73.96 85.05 78725 26 11 17.86 16.97 19.52 78730 11 69.49 66.02 75.92 78730 TC 11 61.65 58.57 67.36 78730 26 11 7.84 7.45 08.57 78740 11 206.25 195.94 225.33 78740 TC 11 178.32 169.40 194.81 78740 26 11 27.92 26.52 30.50 78761 11 198.32 188.40 216.66 78761 TC 11 163.83 155.64 178.99 78761 26 11 34.48 32.76 37.67 78800 11 174.57 165.84 190.72 78800 TC 11 143.05 135.90 156.29 78800 26 11 31.53 29.95 34.44 78801 11 235.68 223.90 257.49 78801 TC 11 197.85 187.96 216.15 78801 26 11 37.83 35.94 41.33 78802 11 304.52 289.29 332.68 78802 TC 11 263.68 250.50 288.08 78802 26 11 40.84 38.80 44.62 78803 11 327.68 311.30 358.00 78803 TC 11 276.28 262.47 301.84 78803 26 11 51.40 48.83 56.15 78804 11 540.05 513.05 590.01 78804 TC 11 489.33 464.86 534.59 78804 26 11 50.72 48.18 55.41 78805 11 172.23 163.62 188.16 78805 TC 11 137.38 130.51 150.09 78805 26 11 34.85 33.11 38.08 78806 11 315.23 299.47 344.39 78806 TC 11 274.39 260.67 299.77 78806 26 11 40.84 38.80 44.62 78807 11 327.13 310.77 357.39 78807 TC 11 276.28 262.47 301.84 78807 26 11 50.86 48.32 55.57 78808 11 40.19 38.18 43.91 78811 C11 1042.17 990.06 1138.57 78811 TC C11 965.90 917.61 1055.25 78811 26 11 76.27 72.46 83.33 78812 C11 1059.69 1006.71 1157.72 78812 TC C11 965.90 917.61 1055.25 78812 26 11 93.79 89.10 102.47 78813 C11 1063.78 1010.59 1162.18 78813 TC C11 965.90 917.61 1055.25 78813 26 11 97.88 92.99 106.94 78814 C11 1072.61 1018.98 1171.83 78814 TC C11 965.90 917.61 1055.25 78814 26 11 106.71 101.37 116.58 78815 C11 1084.68 1030.45 1185.02 78815 TC C11 965.90 917.61 1055.25 78815 26 11 118.78 112.84 129.77 78816 C11 1086.72 1032.38 1187.24 78816 TC C11 965.90 917.61 1055.25 78816 26 11 120.82 114.78 132.00 79005 11 136.05 129.25 148.64 79005 TC 11 50.62 48.09 55.30 79005 26 11 85.43 81.16 93.33 79101 11 153.77 146.08 167.99 79101 TC 11 55.03 52.28 60.12 79101 26 11 98.74 93.80 107.87 79200 11 159.17 151.21 173.89 79200 TC 11 62.59 59.46 68.38 79200 26 11 96.58 91.75 105.51 79300 26 11 78.34 74.42 85.58 79403 11 193.34 183.67 211.22 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 041 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 79403 TC 11 85.09 80.84 92.97 79403 26 11 108.25 102.84 118.27 79440 11 150.24 142.73 164.14 79440 TC 11 52.51 49.88 57.36 79440 26 11 97.73 92.84 106.77 79445 26 11 115.71 109.92 126.41 80500 N 11 19.87 18.88 21.71 80500 F 11 17.66 16.78 19.30 80502 N 11 61.90 58.81 67.63 80502 F 11 60.33 57.31 65.91 83020 26 11 18.61 17.68 20.33 83912 26 11 17.66 16.78 19.30 84165 26 11 18.29 17.38 19.99 84166 26 11 18.29 17.38 19.99 84181 26 11 18.61 17.68 20.33 84182 26 11 18.29 17.38 19.99 85060 11 22.27 21.16 24.33 85097 N 11 81.27 77.21 88.79 85097 F 11 45.36 43.09 49.55 85390 26 11 18.92 17.97 20.67 85396 11 18.29 17.38 19.99 85576 26 11 18.61 17.68 20.33 86077 N 11 49.14 46.68 53.68 86077 F 11 46.31 43.99 50.59 86078 N 11 49.46 46.99 54.04 86078 F 11 46.62 44.29 50.93 86079 N 11 49.46 46.99 54.04 86079 F 11 46.62 44.29 50.93 86255 26 11 18.61 17.68 20.33 86256 26 11 18.15 17.24 19.83 86320 26 11 18.15 17.24 19.83 86325 26 11 17.84 16.95 19.49 86327 26 11 21.25 20.19 23.22 86334 26 11 18.61 17.68 20.33 86335 26 11 18.29 17.38 19.99 86485 11 16.23 15.42 17.73 86486 11 4.64 4.41 05.07 86490 11 6.21 5.90 06.79 86510 11 5.90 5.61 06.45 86580 11 6.84 6.50 07.48 87164 26 11 18.61 17.68 20.33 87207 26 11 18.61 17.68 20.33 88104 11 61.69 58.61 67.40 88104 TC 11 34.87 33.13 38.10 88104 26 11 26.81 25.47 29.29 88106 11 75.23 71.47 82.19 88106 TC 11 48.73 46.29 53.23 88106 26 11 26.50 25.18 28.96 88107 11 94.45 89.73 103.19 88107 TC 11 57.55 54.67 62.87 88107 26 11 36.90 35.06 40.32 88108 11 71.14 67.58 77.72 88108 TC 11 44.64 42.41 48.77 88108 26 11 26.50 25.18 28.96 88112 11 97.61 92.73 106.64 88112 TC 11 42.75 40.61 46.70 88112 26 11 54.86 52.12 59.94 88120 11 425.45 404.18 464.81 88120 TC 11 374.23 355.52 408.85 88120 26 11 51.22 48.66 55.96 88121 11 359.30 341.34 392.54 88121 TC 11 313.93 298.23 342.96 88121 26 11 45.37 43.10 49.57 88125 11 20.94 19.89 22.87 88125 TC 11 8.10 7.70 08.86 88125 26 11 12.84 12.20 14.03 88141 11 27.55 26.17 30.10 88160 11 51.46 48.89 56.22 88160 TC 11 27.63 26.25 30.19 88160 26 11 23.83 22.64 26.04 88161 11 51.46 48.89 56.22 88161 TC 11 28.26 26.85 30.88 88161 26 11 23.20 22.04 25.35 88162 11 73.98 70.28 80.82 88162 TC 11 38.02 36.12 41.54 88162 26 11 35.95 34.15 39.27 88172 11 48.24 45.83 52.70 88172 TC 11 19.13 18.17 20.90 88172 26 11 29.12 27.66 31.81 88173 11 130.57 124.04 142.65 88173 TC 11 64.17 60.96 70.10 88173 26 11 66.41 63.09 72.55 88177 11 26.69 25.36 29.16 88177 TC 11 5.90 5.61 06.45 88177 26 11 20.80 19.76 22.72 88182 11 97.77 92.88 106.81 88182 TC 11 63.99 60.79 69.91 88182 26 11 33.77 32.08 36.89 88184 11 77.71 73.82 84.89 88185 11 46.53 44.20 50.83 88187 11 65.35 62.08 71.39 88188 11 81.12 77.06 88.62 88189 11 100.24 95.23 109.51 88291 11 28.12 26.71 30.72 88300 11 24.91 23.66 27.21 88300 TC 11 20.70 19.67 22.62 88300 26 11 4.21 4.00 04.60 88302 11 49.60 47.12 54.19 88302 TC 11 43.38 41.21 47.39 88302 26 11 6.22 5.91 06.80 88304 11 58.32 55.40 63.71 88304 TC 11 47.79 45.40 52.21 88304 26 11 10.54 10.01 11.51 88305 11 99.95 94.95 109.19 88305 TC 11 64.48 61.26 70.45 88305 26 11 35.47 33.70 38.76 88307 11 213.27 202.61 233.00 88307 TC 11 135.98 129.18 148.56 88307 26 11 77.30 73.44 84.46 88309 11 323.78 307.59 353.73 88309 TC 11 188.72 179.28 206.17 88309 26 11 135.07 128.32 147.57 88311 11 17.74 16.85 19.38 88311 TC 11 6.21 5.90 06.79 88311 26 11 11.53 10.95 12.59 88312 11 100.06 95.06 109.32 88312 TC 11 74.56 70.83 81.45 88312 26 11 25.50 24.23 27.86 88313 11 72.55 68.92 79.26 88313 TC 11 61.33 58.26 67.00 88313 26 11 11.22 10.66 12.26 88314 11 84.41 80.19 92.22 88314 TC 11 62.59 59.46 68.38 88314 26 11 21.82 20.73 23.84 88318 11 108.90 103.46 118.98 88318 TC 11 88.73 84.29 96.93 88318 26 11 20.17 19.16 22.03 88319 11 136.71 129.87 149.35 88319 TC 11 111.09 105.54 121.37 88319 26 11 25.62 24.34 27.99 88321 N 11 87.27 82.91 95.35 88321 F 11 78.45 74.53 85.71 88323 11 136.39 129.57 149.01 88323 TC 11 54.40 51.68 59.43 88323 26 11 81.99 77.89 89.57 88325 N 11 190.04 180.54 207.62 88325 F 11 123.58 117.40 135.01 88329 N 11 49.50 47.03 54.08 88329 F 11 33.12 31.46 36.18 88331 11 87.50 83.13 95.60 88331 TC 11 29.52 28.04 32.25 88331 26 11 57.98 55.08 63.34 88332 11 38.77 36.83 42.35 88332 TC 11 10.31 9.79 11.26 88332 26 11 28.46 27.04 31.10 88333 11 90.73 86.19 99.12 88333 TC 11 32.35 30.73 35.34 88333 26 11 58.38 55.46 63.78 88334 11 55.95 53.15 61.12 88334 TC 11 20.39 19.37 22.28 88334 26 11 35.57 33.79 38.86 88342 11 98.14 93.23 107.21 88342 TC 11 58.18 55.27 63.56 88342 26 11 39.96 37.96 43.65 88346 11 96.45 91.63 105.37 88346 TC 11 56.29 53.48 61.50 88346 26 11 40.16 38.15 43.87 88347 11 73.46 69.79 80.26 88347 TC 11 36.13 34.32 39.47 88347 26 11 37.32 35.45 40.77 88348 11 633.88 602.19 692.52 88348 TC 11 562.77 534.63 614.82 88348 26 11 71.11 67.55 77.68 88349 11 334.19 317.48 365.10 88349 TC 11 296.66 281.83 324.10 88349 26 11 37.53 35.65 41.00 88355 11 202.18 192.07 220.88 88355 TC 11 120.54 114.51 131.69 88355 26 11 81.63 77.55 89.18 88356 11 268.29 254.88 293.11 88356 TC 11 140.44 133.42 153.43 88356 26 11 127.85 121.46 139.68 88358 11 71.30 67.74 77.90 88358 TC 11 30.15 28.64 32.94 88358 26 11 41.15 39.09 44.95 88360 11 116.71 110.87 127.50 88360 TC 11 65.74 62.45 71.82 88360 26 11 50.97 48.42 55.68 88361 11 142.96 135.81 156.18 88361 TC 11 88.73 84.29 96.93 88361 26 11 54.23 51.52 59.25 88362 11 265.90 252.61 290.50 88362 TC 11 162.17 154.06 177.17 88362 26 11 103.73 98.54 113.32 88363 N 11 35.93 34.13 39.25 88363 F 11 16.40 15.58 17.92 88365 11 156.01 148.21 170.44 88365 TC 11 100.39 95.37 109.68 88365 26 11 55.63 52.85 60.78 88367 11 240.18 228.17 262.40 88367 TC 11 181.02 171.97 197.77 88367 26 11 59.17 56.21 64.64 88368 11 206.82 196.48 225.95 88368 TC 11 146.06 138.76 159.57 88368 26 11 60.76 57.72 66.38 88371 26 11 18.29 17.38 19.99 88372 26 11 18.61 17.68 20.33 88380 11 165.64 157.36 180.96 88380 TC 11 95.03 90.28 103.82 88380 26 11 70.61 67.08 77.14 88381 11 173.29 164.63 189.32 88381 TC 11 121.17 115.11 132.38 88381 26 11 52.11 49.50 56.93 88385 11 535.40 508.63 584.92 88385 TC 11 471.24 447.68 514.83 88385 26 11 64.16 60.95 70.09 88386 11 597.67 567.79 652.96 88386 TC 11 513.44 487.77 560.94 88386 26 11 84.23 80.02 92.02 88387 11 38.84 36.90 42.44 88387 TC 11 8.10 7.70 08.86 88387 26 11 30.74 29.20 33.58 88388 11 22.67 21.54 24.77 88388 TC 11 4.01 3.81 04.38 88388 26 11 18.67 17.74 20.40 89049 N 11 238.82 226.88 260.91 89049 F 11 64.02 60.82 69.94 89060 26 11 18.61 17.68 20.33 89220 11 14.72 13.98 16.08 89230 11 2.75 2.61 03.00 90460 11 21.75 20.66 23.76 90461 11 10.99 10.44 12.01 90471 11 21.75 20.66 23.76 90472 11 10.99 10.44 12.01 90473 11 21.75 20.66 23.76 90474 11 10.99 10.44 12.01 90801 N 11 148.67 141.24 162.43 90801 F 11 120.32 114.30 131.45 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 042 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 90802 N 11 161.38 153.31 176.31 90802 F 11 131.46 124.89 143.62 90804 N 11 64.30 61.09 70.25 90804 F 11 52.40 49.78 57.25 90805 N 11 73.22 69.56 79.99 90805 F 11 60.66 57.63 66.27 90806 N 11 86.88 82.54 94.92 90806 F 11 80.27 76.26 87.70 90807 N 11 101.76 96.67 111.17 90807 F 11 89.52 85.04 97.80 90808 N 11 128.06 121.66 139.91 90808 F 11 121.44 115.37 132.68 90809 N 11 143.17 136.01 156.41 90809 F 11 131.60 125.02 143.77 90810 N 11 66.48 63.16 72.63 90810 F 11 57.21 54.35 62.50 90811 N 11 82.26 78.15 89.87 90811 F 11 66.38 63.06 72.52 90812 N 11 95.11 90.35 103.90 90812 F 11 84.85 80.61 92.70 90813 N 11 110.31 104.79 120.51 90813 F 11 94.44 89.72 103.18 90814 N 11 137.18 130.32 149.87 90814 F 11 126.60 120.27 138.31 90815 N 11 155.18 147.42 169.53 90815 F 11 139.30 132.34 152.19 90816 N 11 54.15 51.44 59.16 90816 F 11 57.13 54.27 62.41 90817 N 11 65.06 61.81 71.08 90817 F 11 66.05 62.75 72.16 90818 N 11 80.35 76.33 87.78 90818 F 11 84.98 80.73 92.84 90819 N 11 93.24 88.58 101.87 90819 F 11 94.56 89.83 103.30 90821 N 11 119.23 113.27 130.26 90821 F 11 125.52 119.24 137.13 90822 N 11 134.01 127.31 146.41 90822 F 11 136.33 129.51 148.94 90823 N 11 59.06 56.11 64.53 90823 F 11 61.71 58.62 67.41 90824 N 11 70.12 66.61 76.60 90824 F 11 71.44 67.87 78.05 90826 N 11 85.95 81.65 93.90 90826 F 11 90.25 85.74 98.60 90827 N 11 97.49 92.62 106.51 90827 F 11 99.15 94.19 108.32 90828 N 11 124.14 117.93 135.62 90828 F 11 130.76 124.22 142.85 90829 N 11 138.26 131.35 151.05 90829 F 11 140.91 133.86 153.94 90845 N 11 77.53 73.65 84.70 90845 F 11 75.33 71.56 82.29 90846 N 11 82.04 77.94 89.63 90846 F 11 79.52 75.54 86.87 90847 N 11 102.11 97.00 111.55 90847 F 11 94.55 89.82 103.29 90849 N 11 32.70 31.07 35.73 90849 F 11 28.60 27.17 31.25 90853 N 11 30.81 29.27 33.66 90853 F 11 28.60 27.17 31.25 90857 N 11 35.32 33.55 38.58 90857 F 11 30.91 29.36 33.76 90862 N 11 55.55 52.77 60.69 90862 F 11 43.58 41.40 47.61 90865 N 11 152.23 144.62 166.31 90865 F 11 123.88 117.69 135.34 90870 N 11 159.89 151.90 174.69 90870 F 11 105.09 99.84 114.82 90880 N 11 97.96 93.06 107.02 90880 F 11 91.04 86.49 99.46 90901 N 11 34.95 33.20 38.18 90901 F 11 19.51 18.53 21.31 90911 N 11 82.54 78.41 90.17 90911 F 11 43.80 41.61 47.85 90935 11 72.27 68.66 78.96 90937 11 103.17 98.01 112.71 90945 11 79.71 75.72 87.08 90947 11 120.85 114.81 132.03 90951 11 922.58 876.45 1007.92 90954 11 774.80 736.06 846.47 90955 11 437.38 415.51 477.84 90956 11 299.99 284.99 327.74 90957 11 619.12 588.16 676.38 90958 11 419.03 398.08 457.79 90959 11 278.98 265.03 304.78 90960 11 274.40 260.68 299.78 90961 11 225.63 214.35 246.50 90962 11 168.59 160.16 184.18 90963 11 527.12 500.76 575.87 90964 11 448.07 425.67 489.52 90965 11 427.06 405.71 466.57 90966 11 224.37 213.15 245.12 90967 11 18.10 17.20 19.78 90968 11 14.83 14.09 16.20 90969 11 14.49 13.77 15.84 90970 11 7.50 7.13 08.20 90997 11 86.21 81.90 94.19 91010 11 176.34 167.52 192.65 91010 TC 11 109.83 104.34 119.99 91010 26 11 66.50 63.18 72.66 91013 11 21.69 20.61 23.70 91013 TC 11 12.20 11.59 13.33 91013 26 11 9.49 9.02 10.37 91020 11 222.72 211.58 243.32 91020 TC 11 148.26 140.85 161.98 91020 26 11 74.46 70.74 81.35 91022 11 172.81 164.17 188.80 91022 TC 11 97.24 92.38 106.24 91022 26 11 75.58 71.80 82.57 91030 11 132.53 125.90 144.79 91030 TC 11 84.64 80.41 92.47 91030 26 11 47.89 45.50 52.33 91034 11 185.28 176.02 202.42 91034 TC 11 135.35 128.58 147.87 91034 26 11 49.93 47.43 54.54 91035 11 454.27 431.56 496.29 91035 TC 11 371.88 353.29 406.28 91035 26 11 82.39 78.27 90.01 91037 11 153.52 145.84 167.72 91037 TC 11 102.28 97.17 111.75 91037 26 11 51.25 48.69 55.99 91038 11 279.37 265.40 305.21 91038 TC 11 221.96 210.86 242.49 91038 26 11 57.41 54.54 62.72 91040 11 319.85 303.86 349.44 91040 TC 11 271.41 257.84 296.52 91040 26 11 48.44 46.02 52.92 91065 11 74.02 70.32 80.87 91065 TC 11 63.85 60.66 69.76 91065 26 11 10.17 9.66 11.11 91110 11 860.46 817.44 940.06 91110 TC 11 670.15 636.64 732.14 91110 26 11 190.31 180.79 207.91 91111 11 684.88 650.64 748.24 91111 TC 11 632.36 600.74 690.85 91111 26 11 52.53 49.90 57.39 91117 N 11 134.74 128.00 147.20 91117 F 11 143.24 136.08 156.49 91120 11 358.47 340.55 391.63 91120 TC 11 310.46 294.94 339.18 91120 26 11 48.01 45.61 52.45 91122 11 215.40 204.63 235.32 91122 TC 11 128.73 122.29 140.63 91122 26 11 86.67 82.34 94.69 91132 11 131.97 125.37 144.18 91132 TC 11 104.80 99.56 114.49 91132 26 11 27.17 25.81 29.68 91133 11 161.20 153.14 176.11 91133 TC 11 126.21 119.90 137.89 91133 26 11 34.99 33.24 38.23 92002 N 11 71.50 67.93 78.12 92002 F 11 45.04 42.79 49.21 92004 N 11 133.23 126.57 145.56 92004 F 11 93.23 88.57 101.86 92012 N 11 75.69 71.91 82.70 92012 F 11 48.60 46.17 53.10 92014 N 11 110.05 104.55 120.23 92014 F 11 74.15 70.44 81.01 92018 11 133.31 126.64 145.64 92019 11 64.69 61.46 70.68 92020 N 11 24.91 23.66 27.21 92020 F 11 19.87 18.88 21.71 92025 11 33.14 31.48 36.20 92025 TC 11 14.72 13.98 16.08 92025 26 11 18.42 17.50 20.13 92060 11 57.43 54.56 62.74 92060 TC 11 21.33 20.26 23.30 92060 26 11 36.10 34.30 39.45 92065 11 45.78 43.49 50.01 92065 TC 11 28.57 27.14 31.21 92065 26 11 17.21 16.35 18.80 92070 N 11 63.44 60.27 69.31 92070 F 11 36.35 34.53 39.71 92081 11 45.44 43.17 49.65 92081 TC 11 29.52 28.04 32.25 92081 26 11 15.92 15.12 17.39 92082 11 63.23 60.07 69.08 92082 TC 11 42.12 40.01 46.01 92082 26 11 21.12 20.06 23.07 92083 11 79.00 75.05 86.31 92083 TC 11 52.51 49.88 57.36 92083 26 11 26.49 25.17 28.95 92100 N 11 85.94 81.64 93.89 92100 F 11 47.20 44.84 51.57 92120 N 11 70.24 66.73 76.74 92120 F 11 41.57 39.49 45.41 92130 N 11 77.88 73.99 85.09 92130 F 11 42.61 40.48 46.55 92132 11 34.22 32.51 37.39 92132 TC 11 14.09 13.39 15.40 92132 26 11 20.13 19.12 21.99 92133 11 42.15 40.04 46.05 92133 TC 11 14.09 13.39 15.40 92133 26 11 28.07 26.67 30.67 92134 11 42.15 40.04 46.05 92134 TC 11 14.09 13.39 15.40 92134 26 11 28.07 26.67 30.67 92136 11 78.02 74.12 85.24 92136 TC 11 49.36 46.89 53.92 92136 26 11 28.65 27.22 31.30 92140 N 11 55.47 52.70 60.61 92140 F 11 25.23 23.97 27.57 92225 N 11 24.30 23.09 26.55 92225 F 11 20.21 19.20 22.08 92226 N 11 21.83 20.74 23.85 92226 F 11 17.42 16.55 19.03 92227 11 10.62 10.09 11.60 92228 11 28.29 26.88 30.91 92228 TC 11 11.57 10.99 12.64 92228 26 11 16.72 15.88 18.26 92230 N 11 54.37 51.65 59.40 92230 F 11 31.06 29.51 33.94 92235 11 122.61 116.48 133.95 92235 TC 11 78.97 75.02 86.27 92235 26 11 43.64 41.46 47.68 92240 C11 206.16 195.85 225.23 92240 TC C11 147.31 139.94 160.93 92240 26 11 58.85 55.91 64.30 92250 11 68.95 65.50 75.33 92250 TC 11 46.53 44.20 50.83 92250 26 11 22.42 21.30 24.50 92260 N 11 16.79 15.95 18.34 92260 F 11 10.49 9.97 11.47 92265 11 74.28 70.57 81.16 92265 TC 11 32.67 31.04 35.70 92265 26 11 41.61 39.53 45.46 92270 11 82.61 78.48 90.25 92270 TC 11 43.06 40.91 47.05 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 043 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 92270 26 11 39.54 37.56 43.19 92275 11 133.41 126.74 145.75 92275 TC 11 79.60 75.62 86.96 92275 26 11 53.81 51.12 58.79 92283 11 45.29 43.03 49.48 92283 TC 11 36.76 34.92 40.16 92283 26 11 8.52 8.09 09.30 92284 11 55.22 52.46 60.33 92284 TC 11 43.69 41.51 47.74 92284 26 11 11.53 10.95 12.59 92285 11 25.78 24.49 28.16 92285 TC 11 21.96 20.86 23.99 92285 26 11 3.82 3.63 04.17 92286 11 111.38 105.81 121.68 92286 TC 11 77.39 73.52 84.55 92286 26 11 33.99 32.29 37.13 92287 N 11 109.38 103.91 119.50 92287 F 11 43.24 41.08 47.24 92311 N 11 91.12 86.56 99.54 92311 F 11 53.95 51.25 58.94 92312 N 11 103.79 98.60 113.39 92312 F 11 61.90 58.81 67.63 92313 N 11 89.41 84.94 97.68 92313 F 11 47.83 45.44 52.26 92315 N 11 65.65 62.37 71.73 92315 F 11 22.19 21.08 24.24 92316 N 11 88.27 83.86 96.44 92316 F 11 36.30 34.49 39.66 92317 N 11 65.60 62.32 71.67 92317 F 11 20.87 19.83 22.80 92325 11 31.09 29.54 33.97 92326 11 32.98 31.33 36.03 92502 11 92.90 88.26 101.50 92504 N 11 28.39 26.97 31.02 92504 F 11 9.49 9.02 10.37 92506 11 156.66 148.83 171.15 92507 11 78.84 74.90 86.14 92508 11 25.61 24.33 27.98 92511 N 11 150.08 142.58 163.97 92511 F 11 57.80 54.91 63.15 92512 N 11 58.11 55.20 63.48 92512 F 11 27.87 26.48 30.45 92516 N 11 63.80 60.61 69.70 92516 F 11 22.54 21.41 24.62 92520 N 11 64.19 60.98 70.13 92520 F 11 39.62 37.64 43.29 92526 11 89.96 85.46 98.28 92540 11 93.36 88.69 101.99 92540 TC 11 17.24 16.38 18.84 92540 26 11 76.13 72.32 83.17 92541 11 43.02 40.87 47.00 92541 TC 11 23.22 22.06 25.37 92541 26 11 19.80 18.81 21.63 92542 11 42.53 40.40 46.46 92542 TC 11 26.05 24.75 28.46 92542 26 11 16.48 15.66 18.01 92543 11 20.86 19.82 22.79 92543 TC 11 15.66 14.88 17.11 92543 26 11 5.20 4.94 05.68 92544 11 34.80 33.06 38.02 92544 TC 11 21.96 20.86 23.99 92544 26 11 12.84 12.20 14.03 92545 11 32.52 30.89 35.52 92545 TC 11 21.02 19.97 22.97 92545 26 11 11.51 10.93 12.57 92546 11 87.79 83.40 95.91 92546 TC 11 73.61 69.93 80.42 92546 26 11 14.18 13.47 15.49 92547 11 4.64 4.41 05.07 92548 11 95.87 91.08 104.74 92548 TC 11 71.09 67.54 77.67 92548 26 11 24.78 23.54 27.07 92550 11 19.99 18.99 21.84 92552 11 23.54 22.36 25.71 92553 11 29.83 28.34 32.59 92555 11 17.24 16.38 18.84 92556 11 26.68 25.35 29.15 92557 N 11 38.71 36.77 42.29 92557 F 11 34.93 33.18 38.16 92561 11 30.15 28.64 32.94 92562 11 29.20 27.74 31.90 92563 11 22.91 21.76 25.02 92564 11 20.70 19.67 22.62 92565 11 11.88 11.29 12.98 92567 N 11 14.58 13.85 15.93 92567 F 11 12.06 11.46 13.18 92568 N 11 16.07 15.27 17.56 92568 F 11 15.75 14.96 17.20 92570 N 11 30.71 29.17 33.55 92570 F 11 28.82 27.38 31.49 92571 11 18.50 17.58 20.22 92572 11 29.20 27.74 31.90 92575 11 45.58 43.30 49.80 92576 11 24.48 23.26 26.75 92577 11 15.03 14.28 16.42 92579 N 11 41.79 39.70 45.66 92579 F 11 38.01 36.11 41.53 92582 11 47.47 45.10 51.87 92583 11 32.98 31.33 36.03 92584 11 61.65 58.57 67.36 92585 11 105.95 100.65 115.75 92585 TC 11 81.17 77.11 88.68 92585 26 11 24.78 23.54 27.07 92586 11 65.11 61.85 71.13 92587 11 34.48 32.76 37.67 92587 TC 11 27.63 26.25 30.19 92587 26 11 6.85 6.51 07.49 92588 11 62.14 59.03 67.88 92588 TC 11 44.01 41.81 48.08 92588 26 11 18.13 17.22 19.80 92596 11 36.76 34.92 40.16 92597 11 93.23 88.57 101.86 92601 N 11 139.87 132.88 152.81 92601 F 11 124.75 118.51 136.29 92602 N 11 86.08 81.78 94.05 92602 F 11 72.85 69.21 79.59 92603 N 11 136.59 129.76 149.22 92603 F 11 119.90 113.91 131.00 92604 N 11 80.78 76.74 88.25 92604 F 11 67.23 63.87 73.45 92607 11 167.18 158.82 182.64 92608 11 49.89 47.40 54.51 92609 11 110.51 104.98 120.73 92610 N 11 99.94 94.94 109.18 92610 F 11 66.87 63.53 73.06 92611 11 107.82 102.43 117.79 92612 N 11 157.19 149.33 171.73 92612 F 11 65.53 62.25 71.59 92613 N 11 37.00 35.15 40.42 92613 F 11 36.69 34.86 40.09 92614 N 11 140.18 133.17 153.15 92614 F 11 65.85 62.56 71.94 92615 11 32.80 31.16 35.83 92616 N 11 190.25 180.74 207.85 92616 F 11 96.71 91.87 105.65 92617 11 40.67 38.64 44.44 92620 N 11 79.65 75.67 87.02 92620 F 11 74.92 71.17 81.85 92621 N 11 18.42 17.50 20.13 92621 F 11 16.84 16.00 18.40 92625 N 11 61.00 57.95 66.64 92625 F 11 57.54 54.66 62.86 92626 N 11 80.66 76.63 88.12 92626 F 11 74.67 70.94 81.58 92627 N 11 19.63 18.65 21.45 92627 F 11 17.74 16.85 19.38 92640 N 11 92.80 88.16 101.38 92640 F 11 87.76 83.37 95.88 92950 N 11 267.26 253.90 291.99 92950 F 11 168.68 160.25 184.29 92953 11 10.88 10.34 11.89 92960 N 11 227.67 216.29 248.73 92960 F 11 123.73 117.54 135.17 92961 11 243.78 231.59 266.33 92970 11 172.60 163.97 188.57 92971 11 95.40 90.63 104.22 92973 11 179.28 170.32 195.87 92974 11 164.31 156.09 179.50 92975 11 396.03 376.23 432.66 92977 11 85.41 81.14 93.31 92978 11 252.79 240.15 276.17 92978 TC 11 157.19 149.33 171.73 92978 26 11 92.24 87.63 100.77 92979 11 155.65 147.87 170.05 92979 TC 11 79.25 75.29 86.58 92979 26 11 73.88 70.19 80.72 92980 11 818.03 777.13 893.70 92981 11 227.37 216.00 248.40 92982 11 606.17 575.86 662.24 92984 11 162.11 154.00 177.10 92986 11 1349.11 1281.65 1473.90 92987 11 1392.49 1322.87 1521.30 92990 11 1083.37 1029.20 1183.58 92995 11 667.54 634.16 729.28 92996 11 178.60 169.67 195.12 92997 11 643.23 611.07 702.73 92998 11 323.46 307.29 353.38 93000 11 18.52 17.59 20.23 93005 11 9.99 9.49 10.91 93010 11 8.52 8.09 09.30 93015 11 87.27 82.91 95.35 93016 11 22.45 21.33 24.53 93017 11 49.99 47.49 54.61 93018 11 14.83 14.09 16.20 93024 11 110.81 105.27 121.06 93024 TC 11 52.51 49.88 57.36 93024 26 11 58.30 55.39 63.70 93025 11 180.41 171.39 197.10 93025 TC 11 142.59 135.46 155.78 93025 26 11 37.82 35.93 41.32 93040 11 12.48 11.86 13.64 93041 11 5.27 5.01 05.76 93042 11 7.21 6.85 07.88 93224 11 98.04 93.14 107.11 93225 11 28.89 27.45 31.57 93226 11 42.75 40.61 46.70 93227 11 26.40 25.08 28.84 93228 11 24.97 23.72 27.28 93229 11 631.41 599.84 689.82 93268 11 233.47 221.80 255.07 93270 11 14.09 13.39 15.40 93271 11 194.24 184.53 212.21 93272 11 25.14 23.88 27.46 93278 11 32.89 31.25 35.94 93278 TC 11 20.70 19.67 22.62 93278 26 11 12.19 11.58 13.32 93279 11 50.08 47.58 54.72 93279 TC 11 16.92 16.07 18.48 93279 26 11 33.16 31.50 36.23 93280 11 59.20 56.24 64.68 93280 TC 11 19.76 18.77 21.59 93280 26 11 39.44 37.47 43.09 93281 11 68.97 65.52 75.35 93281 TC 11 22.91 21.76 25.02 93281 26 11 46.07 43.77 50.34 93282 11 63.49 60.32 69.37 93282 TC 11 20.39 19.37 22.28 93282 26 11 43.11 40.95 47.09 93283 11 81.47 77.40 89.01 93283 TC 11 23.54 22.36 25.71 93283 26 11 57.94 55.04 63.30 93284 11 90.54 86.01 98.91 93284 TC 11 26.68 25.35 29.15 93284 26 11 63.85 60.66 69.76 93285 11 42.06 39.96 45.95 93285 TC 11 15.66 14.88 17.11 93285 26 11 26.40 25.08 28.84 93286 11 25.14 23.88 27.46 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 044 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 93286 TC 11 10.94 10.39 11.95 93286 26 11 14.20 13.49 15.51 93287 11 33.07 31.42 36.13 93287 TC 11 11.88 11.29 12.98 93287 26 11 21.19 20.13 23.15 93288 11 37.74 35.85 41.23 93288 TC 11 15.98 15.18 17.46 93288 26 11 21.77 20.68 23.78 93289 11 65.24 61.98 71.28 93289 TC 11 19.76 18.77 21.59 93289 26 11 45.49 43.22 49.70 93290 11 29.24 27.78 31.95 93290 TC 11 9.05 8.60 09.89 93290 26 11 20.19 19.18 22.06 93291 11 36.17 34.36 39.51 93291 TC 11 14.40 13.68 15.73 93291 26 11 21.77 20.68 23.78 93292 11 32.70 31.07 35.73 93292 TC 11 10.94 10.39 11.95 93292 26 11 21.77 20.68 23.78 93293 11 52.59 49.96 57.45 93293 TC 11 37.08 35.23 40.51 93293 26 11 15.51 14.73 16.94 93294 11 33.39 31.72 36.48 93295 11 65.81 62.52 71.90 93296 11 30.15 28.64 32.94 93297 11 24.97 23.72 27.28 93298 11 26.86 25.52 29.35 93303 11 197.75 187.86 216.04 93303 TC 11 133.46 126.79 145.81 93303 26 11 64.29 61.08 70.24 93304 11 125.92 119.62 137.56 93304 TC 11 89.05 84.60 97.29 93304 26 11 36.87 35.03 40.28 93306 11 218.54 207.61 238.75 93306 TC 11 152.98 145.33 167.13 93306 26 11 65.55 62.27 71.61 93307 11 139.26 132.30 152.15 93307 TC 11 93.14 88.48 101.75 93307 26 11 46.12 43.81 50.38 93308 11 98.78 93.84 107.92 93308 TC 11 72.35 68.73 79.04 93308 26 11 26.42 25.10 28.87 93312 11 304.74 289.50 332.93 93312 TC 11 197.85 187.96 216.15 93312 26 11 106.90 101.56 116.79 93313 11 40.17 38.16 43.88 93314 11 267.06 253.71 291.77 93314 TC 11 206.04 195.74 225.10 93314 26 11 61.02 57.97 66.67 93315 26 11 140.01 133.01 152.96 93316 11 43.32 41.15 47.32 93317 11 317.73 301.84 347.12 93317 26 11 90.41 85.89 98.77 93318 26 11 109.22 103.76 119.32 93320 11 58.72 55.78 64.15 93320 TC 11 39.91 37.91 43.60 93320 26 11 18.81 17.87 20.55 93321 11 27.28 25.92 29.81 93321 TC 11 19.76 18.77 21.59 93321 26 11 7.53 7.15 08.22 93325 11 33.07 31.42 36.13 93325 TC 11 29.52 28.04 32.25 93325 26 11 3.55 3.37 03.88 93350 11 198.06 188.16 216.38 93350 TC 11 124.32 118.10 135.82 93350 26 11 73.74 70.05 80.56 93351 11 233.25 221.59 254.83 93351 TC 11 144.31 137.09 157.65 93351 26 11 88.95 84.50 97.18 93352 11 34.09 32.39 37.25 93451 11 709.07 673.62 774.66 93451 TC 11 569.82 541.33 622.53 93451 26 11 139.25 132.29 152.13 93452 11 788.13 748.72 861.03 93452 TC 11 544.31 517.09 594.65 93452 26 11 243.82 231.63 266.37 93453 11 1031.56 979.98 1126.98 93453 TC 11 711.78 676.19 777.62 93453 26 11 319.78 303.79 349.36 93454 11 812.79 772.15 887.97 93454 TC 11 566.98 538.63 619.42 93454 26 11 245.81 233.52 268.55 93455 11 948.38 900.96 1036.10 93455 TC 11 664.54 631.31 726.01 93455 26 11 283.85 269.66 310.11 93456 11 1017.51 966.63 1111.62 93456 TC 11 702.65 667.52 767.65 93456 26 11 314.87 299.13 344.00 93457 11 1152.99 1095.34 1259.64 93457 TC 11 799.97 759.97 873.97 93457 26 11 353.02 335.37 385.68 93458 11 980.90 931.86 1071.64 93458 TC 11 680.91 646.86 743.89 93458 26 11 299.98 284.98 327.73 93459 11 1083.59 1029.41 1183.82 93459 TC 11 745.80 708.51 814.79 93459 26 11 337.79 320.90 369.04 93460 11 1159.96 1101.96 1267.25 93460 TC 11 783.59 744.41 856.07 93460 26 11 376.37 357.55 411.18 93461 11 1328.67 1262.24 1451.58 93461 TC 11 913.58 867.90 998.09 93461 26 11 415.09 394.34 453.49 93462 11 191.27 181.71 208.97 93463 11 101.73 96.64 111.14 93464 11 235.03 223.28 256.77 93464 TC 11 145.43 138.16 158.88 93464 26 11 89.61 85.13 97.90 93503 11 128.02 121.62 139.86 93505 11 746.98 709.63 816.07 93505 TC 11 511.55 485.97 558.87 93505 26 11 235.43 223.66 257.21 93530 11 821.05 780.00 897.00 93530 TC 11 585.43 556.16 639.58 93530 26 11 228.69 217.26 249.85 93531 11 2130.89 2024.35 2328.00 93531 TC 11 1673.31 1589.64 1828.09 93531 26 11 449.58 427.10 491.17 93532 26 11 534.64 507.91 584.10 93533 26 11 359.08 341.13 392.30 93561 11 43.73 41.54 47.77 93561 TC 11 18.39 17.47 20.09 93561 26 11 23.88 22.69 26.09 93562 11 19.48 18.51 21.29 93562 TC 11 11.35 10.78 12.40 93562 26 11 7.24 6.88 07.91 93563 11 53.85 51.16 58.83 93564 11 54.76 52.02 59.82 93565 11 41.44 39.37 45.28 93566 N 11 158.29 150.38 172.94 93566 F 11 41.44 39.37 45.28 93567 N 11 131.16 124.60 143.29 93567 F 11 46.75 44.41 51.07 93568 N 11 143.22 136.06 156.47 93568 F 11 42.43 40.31 46.36 93571 11 251.78 239.19 275.07 93571 TC 11 157.19 149.33 171.73 93571 26 11 91.70 87.12 100.19 93572 26 11 73.17 69.51 79.94 93580 11 989.37 939.90 1080.89 93581 11 1313.12 1247.46 1434.58 93600 11 181.55 172.47 198.34 93600 TC 11 67.83 64.44 74.11 93600 26 11 115.05 109.30 125.70 93602 11 151.90 144.31 165.96 93602 TC 11 38.36 36.44 41.91 93602 26 11 114.73 108.99 125.34 93603 11 171.48 162.91 187.35 93603 TC 11 58.11 55.20 63.48 93603 26 11 114.73 108.99 125.34 93609 11 361.81 343.72 395.28 93609 TC 11 94.30 89.59 103.03 93609 26 11 272.19 258.58 297.37 93610 11 208.31 197.89 227.57 93610 TC 11 46.88 44.54 51.22 93610 26 11 163.10 154.95 178.19 93612 11 217.35 206.48 237.45 93612 TC 11 55.76 52.97 60.92 93612 26 11 162.47 154.35 177.50 93613 11 381.75 362.66 417.06 93615 11 59.54 56.56 65.04 93615 TC 11 11.06 10.51 12.09 93615 26 11 49.89 47.40 54.51 93616 26 11 65.42 62.15 71.47 93618 11 364.92 346.67 398.67 93618 TC 11 137.03 130.18 149.71 93618 26 11 232.23 220.62 253.71 93619 11 669.05 635.60 730.94 93619 TC 11 266.52 253.19 291.17 93619 26 11 401.15 381.09 438.25 93620 11 919.22 873.26 1004.25 93620 TC 11 301.06 286.01 328.91 93620 26 11 632.92 601.27 691.46 93621 26 11 114.37 108.65 124.95 93622 26 11 168.16 159.75 183.71 93623 26 11 155.61 147.83 170.00 93624 11 336.62 319.79 367.76 93624 TC 11 68.83 65.39 75.20 93624 26 11 263.56 250.38 287.94 93631 26 11 395.84 376.05 432.46 93640 11 435.40 413.63 475.67 93640 TC 11 247.95 235.55 270.88 93640 26 11 191.39 181.82 209.09 93641 11 565.06 536.81 617.33 93641 TC 11 247.95 235.55 270.88 93641 26 11 323.15 306.99 353.04 93642 11 406.81 386.47 444.44 93642 TC 11 158.79 150.85 173.48 93642 26 11 248.02 235.62 270.96 93650 11 581.71 552.62 635.51 93651 11 885.69 841.41 967.62 93652 11 963.99 915.79 1053.16 93660 11 156.43 148.61 170.90 93660 TC 11 61.02 57.97 66.67 93660 26 11 95.42 90.65 104.25 93662 26 11 143.16 136.00 156.40 93701 11 24.79 23.55 27.08 93720 11 45.60 43.32 49.82 93721 11 37.71 35.82 41.19 93722 11 7.89 7.50 08.63 93724 11 288.88 274.44 315.61 93724 TC 11 42.75 40.61 46.70 93724 26 11 246.13 233.82 268.89 93745 11 56.74 53.90 61.99 93745 TC 11 39.73 37.74 43.40 93745 26 11 17.02 16.17 18.60 93750 N 11 49.41 46.94 53.98 93750 F 11 43.11 40.95 47.09 93784 11 58.32 55.40 63.71 93786 11 28.89 27.45 31.57 93788 11 10.94 10.39 11.95 93790 11 18.49 17.57 20.21 93797 N 11 17.05 16.20 18.63 93797 F 11 9.18 8.72 10.03 93798 N 11 24.23 23.02 26.47 93798 F 11 14.15 13.44 15.46 93875 11 98.32 93.40 107.41 93875 TC 11 87.79 83.40 95.91 93875 26 11 10.54 10.01 11.51 93880 C11 171.13 162.57 186.96 93880 TC C11 141.96 134.86 155.09 93880 26 11 29.17 27.71 31.87 93882 C11 161.10 153.05 176.01 93882 TC C11 141.65 134.57 154.76 93882 26 11 19.45 18.48 21.25 93886 C11 187.41 178.04 204.75 93886 TC C11 141.96 134.86 155.09 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 045 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 93886 26 11 45.45 43.18 49.66 93888 C11 87.80 83.41 95.92 93888 TC C11 57.64 54.76 62.97 93888 26 11 30.17 28.66 32.96 93890 C11 136.94 130.09 149.60 93890 TC C11 89.13 84.67 97.37 93890 26 11 47.80 45.41 52.22 93892 C11 144.46 137.24 157.83 93892 TC C11 89.13 84.67 97.37 93892 26 11 55.33 52.56 60.44 93893 C11 144.78 137.54 158.17 93893 TC C11 89.13 84.67 97.37 93893 26 11 55.65 52.87 60.80 93922 11 102.81 97.67 112.32 93922 TC 11 90.94 86.39 99.35 93922 26 11 11.87 11.28 12.97 93923 11 159.11 151.15 173.82 93923 TC 11 137.24 130.38 149.94 93923 26 11 21.87 20.78 23.90 93924 11 198.60 188.67 216.97 93924 TC 11 174.40 165.68 190.53 93924 26 11 24.20 22.99 26.44 93925 C11 169.74 161.25 185.44 93925 TC C11 141.87 134.78 155.00 93925 26 11 27.86 26.47 30.44 93926 C11 108.48 103.06 118.52 93926 TC C11 89.36 84.89 97.62 93926 26 11 19.12 18.16 20.88 93930 C11 164.17 155.96 179.35 93930 TC C11 141.96 134.86 155.09 93930 26 11 22.21 21.10 24.27 93931 C11 104.36 99.14 114.01 93931 TC C11 89.36 84.89 97.62 93931 26 11 15.00 14.25 16.39 93965 11 118.00 112.10 128.92 93965 TC 11 101.02 95.97 110.37 93965 26 11 16.99 16.14 18.56 93970 C11 175.16 166.40 191.36 93970 TC C11 141.96 134.86 155.09 93970 26 11 33.20 31.54 36.27 93971 C11 111.23 105.67 121.52 93971 TC C11 89.36 84.89 97.62 93971 26 11 21.87 20.78 23.90 93975 C11 229.21 217.75 250.41 93975 TC C11 141.87 134.78 155.00 93975 26 11 87.34 82.97 95.42 93976 C11 200.33 190.31 218.86 93976 TC C11 141.65 134.57 154.76 93976 26 11 58.68 55.75 64.11 93978 C11 173.83 165.14 189.91 93978 TC C11 141.96 134.86 155.09 93978 26 11 31.87 30.28 34.82 93979 C11 110.58 105.05 120.81 93979 TC C11 89.36 84.89 97.62 93979 26 11 21.22 20.16 23.18 93980 11 165.87 157.58 181.22 93980 TC 11 104.80 99.56 114.49 93980 26 11 61.07 58.02 66.72 93981 11 112.55 106.92 122.96 93981 TC 11 91.25 86.69 99.69 93981 26 11 21.30 20.24 23.28 93982 11 40.31 38.29 44.03 93990 C11 101.37 96.30 110.75 93990 TC C11 89.13 84.67 97.37 93990 26 11 12.24 11.63 13.37 94002 11 87.64 83.26 95.75 94003 11 63.00 59.85 68.83 94004 11 45.97 43.67 50.22 94010 11 33.00 31.35 36.05 94010 TC 11 24.79 23.55 27.08 94010 26 11 8.21 7.80 08.97 94011 11 95.40 90.63 104.22 94012 11 147.11 139.75 160.71 94013 11 30.27 28.76 33.07 94014 11 46.47 44.15 50.77 94015 11 22.59 21.46 24.68 94016 11 23.88 22.69 26.09 94060 11 56.97 54.12 62.24 94060 TC 11 42.75 40.61 46.70 94060 26 11 14.23 13.52 15.55 94070 11 56.57 53.74 61.80 94070 TC 11 28.89 27.45 31.57 94070 26 11 27.68 26.30 30.25 94200 11 22.46 21.34 24.54 94200 TC 11 17.24 16.38 18.84 94200 26 11 5.23 4.97 05.72 94240 11 37.64 35.76 41.12 94240 TC 11 25.74 24.45 28.12 94240 26 11 11.90 11.31 13.01 94250 11 23.72 22.53 25.91 94250 TC 11 18.50 17.58 20.22 94250 26 11 5.23 4.97 05.72 94260 11 30.38 28.86 33.19 94260 TC 11 24.48 23.26 26.75 94260 26 11 5.90 5.61 06.45 94350 11 32.60 30.97 35.62 94350 TC 11 20.70 19.67 22.62 94350 26 11 11.90 11.31 13.01 94360 11 41.73 39.64 45.59 94360 TC 11 29.83 28.34 32.59 94360 26 11 11.90 11.31 13.01 94370 11 32.28 30.67 35.27 94370 TC 11 20.39 19.37 22.28 94370 26 11 11.90 11.31 13.01 94375 11 36.19 34.38 39.54 94375 TC 11 21.96 20.86 23.99 94375 26 11 14.23 13.52 15.55 94400 11 50.58 48.05 55.26 94400 TC 11 32.35 30.73 35.34 94400 26 11 18.23 17.32 19.92 94450 11 55.62 52.84 60.77 94450 TC 11 37.08 35.23 40.51 94450 26 11 18.54 17.61 20.25 94452 11 53.82 51.13 58.80 94452 TC 11 39.91 37.91 43.60 94452 26 11 13.91 13.21 15.19 94453 11 72.94 69.29 79.68 94453 TC 11 54.72 51.98 59.78 94453 26 11 18.23 17.32 19.92 94610 11 57.07 54.22 62.35 94620 11 60.14 57.13 65.70 94620 TC 11 30.46 28.94 33.28 94620 26 11 29.67 28.19 32.42 94621 11 153.87 146.18 168.11 94621 TC 11 87.16 82.80 95.22 94621 26 11 66.71 63.37 72.88 94640 11 14.72 13.98 16.08 94644 11 37.08 35.23 40.51 94645 11 13.46 12.79 14.71 94660 N 11 56.57 53.74 61.80 94660 F 11 35.47 33.70 38.76 94662 11 34.84 33.10 38.07 94664 11 14.72 13.98 16.08 94667 11 20.70 19.67 22.62 94668 11 20.07 19.07 21.93 94680 11 54.96 52.21 60.04 94680 TC 11 42.75 40.61 46.70 94680 26 11 12.21 11.60 13.34 94681 11 53.24 50.58 58.17 94681 TC 11 44.01 41.81 48.08 94681 26 11 9.23 8.77 10.09 94690 11 47.87 45.48 52.30 94690 TC 11 44.32 42.10 48.42 94690 26 11 3.55 3.37 03.88 94720 11 48.97 46.52 53.50 94720 TC 11 37.08 35.23 40.51 94720 26 11 11.90 11.31 13.01 94725 11 55.90 53.11 61.08 94725 TC 11 43.69 41.51 47.74 94725 26 11 12.21 11.60 13.34 94750 11 72.52 68.89 79.22 94750 TC 11 61.96 58.86 67.69 94750 26 11 10.56 10.03 11.53 94760 11 2.43 2.31 02.66 94761 11 4.01 3.81 04.38 94762 11 18.50 17.58 20.22 94770 11 21.53 20.45 23.52 95004 11 5.92 5.62 06.46 95010 11 17.29 16.43 18.89 95012 11 19.13 18.17 20.90 95015 N 11 13.51 12.83 14.75 95015 F 11 7.53 7.15 08.22 95024 11 6.87 6.53 07.51 95027 11 4.35 4.13 04.75 95028 11 11.57 10.99 12.64 95044 11 5.58 5.30 06.10 95052 11 6.53 6.20 07.13 95056 11 37.71 35.82 41.19 95060 11 26.37 25.05 28.81 95065 11 22.59 21.46 24.68 95070 11 35.19 33.43 38.44 95071 11 47.16 44.80 51.52 95075 N 11 61.54 58.46 67.23 95075 F 11 46.42 44.10 50.72 95115 11 9.36 8.89 10.22 95117 11 11.57 10.99 12.64 95144 N 11 11.72 11.13 12.80 95144 F 11 3.21 3.05 03.51 95145 N 11 17.70 16.82 19.34 95145 F 11 3.21 3.05 03.51 95146 N 11 30.93 29.38 33.79 95146 F 11 3.21 3.05 03.51 95147 N 11 29.04 27.59 31.73 95147 F 11 3.21 3.05 03.51 95148 N 11 41.95 39.85 45.83 95148 F 11 3.21 3.05 03.51 95149 N 11 55.81 53.02 60.97 95149 F 11 3.21 3.05 03.51 95165 N 11 11.72 11.13 12.80 95165 F 11 3.21 3.05 03.51 95170 N 11 9.20 8.74 10.05 95170 F 11 3.21 3.05 03.51 95180 N 11 135.09 128.34 147.59 95180 F 11 102.01 96.91 111.45 95250 11 137.24 130.38 149.94 95251 11 40.50 38.48 44.25 95800 11 192.72 183.08 210.54 95800 TC 11 136.61 129.78 149.25 95800 26 11 56.11 53.30 61.30 95801 11 91.81 87.22 100.30 95801 TC 11 42.12 40.01 46.01 95801 26 11 49.69 47.21 54.29 95803 11 152.35 144.73 166.44 95803 TC 11 107.00 101.65 116.90 95803 26 11 45.35 43.08 49.54 95805 11 382.75 363.61 418.15 95805 TC 11 322.80 306.66 352.66 95805 26 11 59.95 56.95 65.49 95806 11 171.22 162.66 187.06 95806 TC 11 110.29 104.78 120.50 95806 26 11 60.93 57.88 66.56 95807 11 437.46 415.59 477.93 95807 TC 11 376.14 357.33 410.93 95807 26 11 61.32 58.25 66.99 95808 11 605.04 574.79 661.01 95808 TC 11 517.87 491.98 565.78 95808 26 11 87.17 82.81 95.23 95810 11 647.84 615.45 707.77 95810 TC 11 526.29 499.98 574.98 95810 26 11 121.55 115.47 132.79 95811 11 698.94 663.99 763.59 95811 TC 11 571.87 543.28 624.77 95811 26 11 127.07 120.72 138.83 95812 11 294.04 279.34 321.24 95812 TC 11 241.63 229.55 263.98 95812 26 11 52.41 49.79 57.26 95813 11 332.47 315.85 363.23 95813 TC 11 248.79 236.35 271.80 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 046 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 95813 26 11 83.68 79.50 91.43 95816 11 272.53 258.90 297.74 95816 TC 11 219.58 208.60 239.89 95816 26 11 52.95 50.30 57.85 95819 11 303.80 288.61 331.90 95819 TC 11 251.08 238.53 274.31 95819 26 11 52.72 50.08 57.59 95822 11 284.28 270.07 310.58 95822 TC 11 231.55 219.97 252.97 95822 26 11 52.72 50.08 57.59 95824 26 11 36.36 34.54 39.72 95827 11 519.97 493.97 568.07 95827 TC 11 467.34 443.97 510.57 95827 26 11 52.64 50.01 57.51 95829 11 1398.12 1328.21 1527.44 95829 TC 11 1097.52 1042.64 1199.04 95829 26 11 300.60 285.57 328.41 95830 N 11 179.69 170.71 196.32 95830 F 11 83.00 78.85 90.68 95831 N 11 27.21 25.85 29.73 95831 F 11 14.29 13.58 15.62 95832 N 11 26.29 24.98 28.73 95832 F 11 14.95 14.20 16.33 95833 N 11 35.09 33.34 38.34 95833 F 11 21.87 20.78 23.90 95834 N 11 44.06 41.86 48.14 95834 F 11 28.63 27.20 31.28 95851 N 11 16.37 15.55 17.88 95851 F 11 7.55 7.17 08.25 95852 N 11 13.73 13.04 15.00 95852 F 11 5.54 5.26 06.05 95857 N 11 44.43 42.21 48.54 95857 F 11 27.42 26.05 29.96 95860 11 85.81 81.52 93.75 95860 TC 11 37.71 35.82 41.19 95860 26 11 48.10 45.70 52.56 95861 11 124.87 118.63 136.42 95861 TC 11 48.10 45.70 52.56 95861 26 11 76.77 72.93 83.87 95863 11 150.71 143.17 164.65 95863 TC 11 58.50 55.58 63.92 95863 26 11 92.22 87.61 100.75 95864 11 165.50 157.23 180.81 95864 TC 11 67.00 63.65 73.20 95864 26 11 98.50 93.58 107.62 95865 11 114.33 108.61 124.90 95865 TC 11 35.50 33.73 38.79 95865 26 11 78.82 74.88 86.11 95866 11 98.64 93.71 107.77 95866 TC 11 36.76 34.92 40.16 95866 26 11 61.88 58.79 67.61 95867 11 75.94 72.14 82.96 95867 TC 11 36.45 34.63 39.82 95867 26 11 39.49 37.52 43.15 95868 11 103.28 98.12 112.84 95868 TC 11 44.95 42.70 49.11 95868 26 11 58.33 55.41 63.72 95869 11 54.92 52.17 60.00 95869 TC 11 36.45 34.63 39.82 95869 26 11 18.47 17.55 20.18 95870 11 53.66 50.98 58.63 95870 TC 11 35.50 33.73 38.79 95870 26 11 18.15 17.24 19.83 95872 11 170.82 162.28 186.62 95872 TC 11 32.35 30.73 35.34 95872 26 11 138.47 131.55 151.28 95873 11 54.60 51.87 59.65 95873 TC 11 35.50 33.73 38.79 95873 26 11 19.10 18.15 20.87 95874 11 52.08 49.48 56.90 95874 TC 11 33.61 31.93 36.72 95874 26 11 18.47 17.55 20.18 95875 11 99.53 94.55 108.73 95875 TC 11 45.58 43.30 49.80 95875 26 11 53.95 51.25 58.94 95900 11 56.62 53.79 61.86 95900 TC 11 35.82 34.03 39.13 95900 26 11 20.80 19.76 22.72 95903 11 65.71 62.42 71.78 95903 TC 11 36.13 34.32 39.47 95903 26 11 29.57 28.09 32.30 95904 11 49.80 47.31 54.41 95904 TC 11 32.98 31.33 36.03 95904 26 11 16.82 15.98 18.38 95905 11 78.06 74.16 85.28 95905 TC 11 75.19 71.43 82.14 95905 26 11 2.87 2.73 03.14 95920 11 151.22 143.66 165.21 95920 TC 11 47.79 45.40 52.21 95920 26 11 103.44 98.27 113.01 95921 11 75.90 72.11 82.93 95921 TC 11 32.67 31.04 35.70 95921 26 11 43.23 41.07 47.23 95922 11 93.37 88.70 102.01 95922 TC 11 47.16 44.80 51.52 95922 26 11 46.21 43.90 50.49 95923 11 135.97 129.17 148.55 95923 TC 11 91.88 87.29 100.38 95923 26 11 44.09 41.89 48.17 95925 11 146.36 139.04 159.90 95925 TC 11 120.23 114.22 131.35 95925 26 11 26.13 24.82 28.54 95926 11 141.78 134.69 154.89 95926 TC 11 115.19 109.43 125.84 95926 26 11 26.59 25.26 29.05 95927 11 133.13 126.47 145.44 95927 TC 11 106.68 101.35 116.55 95927 26 11 26.45 25.13 28.90 95928 11 219.54 208.56 239.84 95928 TC 11 146.20 138.89 159.72 95928 26 11 73.35 69.68 80.13 95929 11 232.46 220.84 253.97 95929 TC 11 158.79 150.85 173.48 95929 26 11 73.66 69.98 80.48 95930 11 124.16 117.95 135.64 95930 TC 11 107.00 101.65 116.90 95930 26 11 17.16 16.30 18.75 95933 11 69.78 66.29 76.23 95933 TC 11 40.54 38.51 44.29 95933 26 11 29.23 27.77 31.94 95934 11 53.06 50.41 57.97 95934 TC 11 27.94 26.54 30.52 95934 26 11 25.12 23.86 27.44 95936 11 44.02 41.82 48.09 95936 TC 11 17.24 16.38 18.84 95936 26 11 26.79 25.45 29.27 95937 11 61.02 57.97 66.67 95937 TC 11 28.89 27.45 31.57 95937 26 11 32.13 30.52 35.10 95950 11 253.58 240.90 277.04 95950 TC 11 179.90 170.91 196.55 95950 26 11 73.69 70.01 80.51 95951 11 959.88 911.89 1048.67 95951 TC 11 632.50 600.88 691.01 95951 26 11 297.93 283.03 325.48 95953 11 388.75 369.31 424.71 95953 TC 11 236.90 225.06 258.82 95953 26 11 151.85 144.26 165.90 95954 11 292.33 277.71 319.37 95954 TC 11 181.70 172.62 198.51 95954 26 11 110.63 105.10 120.87 95955 11 157.66 149.78 172.25 95955 TC 11 108.89 103.45 118.97 95955 26 11 48.77 46.33 53.28 95956 11 941.92 894.82 1029.04 95956 TC 11 769.95 731.45 841.17 95956 26 11 171.97 163.37 187.88 95957 11 317.97 302.07 347.38 95957 TC 11 221.02 209.97 241.47 95957 26 11 96.95 92.10 105.92 95958 11 428.73 407.29 468.38 95958 TC 11 221.70 210.62 242.21 95958 26 11 207.03 196.68 226.18 95961 11 238.82 226.88 260.91 95961 TC 11 91.88 87.29 100.38 95961 26 11 146.94 139.59 160.53 95962 11 216.11 205.30 236.10 95962 TC 11 58.81 55.87 64.25 95962 26 11 157.30 149.44 171.86 95965 26 11 402.28 382.17 439.50 95966 11 540.23 513.22 590.20 95966 TC 11 324.14 307.93 354.12 95966 26 11 200.90 190.86 219.49 95967 11 446.41 424.09 487.70 95967 TC 11 267.85 254.46 292.63 95967 26 11 174.32 165.60 190.44 95970 N 11 55.26 52.50 60.38 95970 F 11 22.19 21.08 24.24 95971 N 11 54.87 52.13 59.95 95971 F 11 38.49 36.57 42.06 95972 N 11 101.09 96.04 110.45 95972 F 11 74.31 70.59 81.18 95973 N 11 57.02 54.17 62.30 95973 F 11 45.37 43.10 49.57 95974 N 11 176.52 167.69 192.84 95974 F 11 148.17 140.76 161.87 95975 N 11 95.77 90.98 104.63 95975 F 11 84.12 79.91 91.90 95978 N 11 212.94 202.29 232.63 95978 F 11 176.71 167.87 193.05 95979 N 11 93.56 88.88 102.21 95979 F 11 81.91 77.81 89.48 95980 11 42.48 40.36 46.41 95981 N 11 28.83 27.39 31.50 95981 F 11 16.23 15.42 17.73 95982 N 11 45.27 43.01 49.46 95982 F 11 32.67 31.04 35.70 95990 11 69.66 66.18 76.11 95991 N 11 99.11 94.15 108.27 95991 F 11 36.44 34.62 39.81 95992 N 11 40.80 38.76 44.57 95992 F 11 36.70 34.87 40.10 96000 11 87.92 83.52 96.05 96001 11 97.20 92.34 106.19 96002 11 20.28 19.27 22.16 96003 11 17.98 17.08 19.64 96004 11 107.40 102.03 117.33 96020 26 11 169.28 160.82 184.94 96101 N 11 80.85 76.81 88.33 96101 F 11 77.39 73.52 84.55 96102 N 11 62.71 59.57 68.51 96102 F 11 22.71 21.57 24.81 96103 N 11 52.97 50.32 57.87 96103 F 11 23.68 22.50 25.88 96105 11 102.89 97.75 112.41 96110 11 7.47 7.10 08.17 96111 N 11 121.28 115.22 132.50 96111 F 11 116.87 111.03 127.68 96116 N 11 88.15 83.74 96.30 96116 F 11 83.11 78.95 90.79 96118 N 11 94.08 89.38 102.79 96118 F 11 76.76 72.92 83.86 96119 N 11 66.47 63.15 72.62 96119 F 11 22.69 21.56 24.79 96120 N 11 77.22 73.36 84.36 96120 F 11 23.37 22.20 25.53 96125 11 90.54 86.01 98.91 96150 N 11 20.68 19.65 22.60 96150 F 11 20.37 19.35 22.25 96151 N 11 20.00 19.00 21.85 96151 F 11 19.69 18.71 21.52 96152 N 11 19.01 18.06 20.77 96152 F 11 18.69 17.76 20.42 96153 N 11 4.57 4.34 04.99 96153 F 11 4.26 4.05 04.66 96154 N 11 18.67 17.74 20.40 96154 F 11 18.35 17.43 20.04 96360 11 53.07 50.42 57.98 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 047 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 96361 11 14.31 13.59 15.63 96365 11 66.09 62.79 72.21 96366 11 20.52 19.49 22.41 96367 11 30.94 29.39 33.80 96368 11 18.29 17.38 19.99 96369 11 158.69 150.76 173.37 96370 11 14.53 13.80 15.87 96371 11 74.24 70.53 81.11 96372 11 21.75 20.66 23.76 96373 11 17.97 17.07 19.63 96374 11 51.84 49.25 56.64 96375 11 21.26 20.20 23.23 96401 11 67.57 64.19 73.82 96402 11 32.83 31.19 35.87 96405 N 11 80.71 76.67 88.17 96405 F 11 29.06 27.61 31.75 96406 N 11 111.24 105.68 121.53 96406 F 11 42.27 40.16 46.18 96409 11 104.73 99.49 114.41 96411 11 58.82 55.88 64.26 96413 11 136.01 129.21 148.59 96415 11 29.36 27.89 32.07 96416 11 149.52 142.04 163.35 96417 11 67.35 63.98 73.58 96420 11 100.83 95.79 110.16 96422 11 162.25 154.14 177.26 96423 11 74.09 70.39 80.95 96425 11 166.17 157.86 181.54 96440 N 11 676.77 642.93 739.37 96440 F 11 138.50 131.58 151.32 96446 N 11 164.40 156.18 179.61 96446 F 11 20.15 19.14 22.01 96450 N 11 187.09 177.74 204.40 96450 F 11 82.21 78.10 89.82 96521 11 123.55 117.37 134.98 96522 11 103.08 97.93 112.62 96523 11 23.63 22.45 25.82 96542 N 11 119.31 113.34 130.34 96542 F 11 42.14 40.03 46.03 96567 11 121.17 115.11 132.38 96570 11 56.28 53.47 61.49 96571 11 26.21 24.90 28.64 96900 11 19.13 18.17 20.90 96904 11 62.91 59.76 68.72 96910 11 64.17 60.96 70.10 96912 11 82.43 78.31 90.06 96913 11 114.56 108.83 125.15 96920 N 11 163.13 154.97 178.22 96920 F 11 64.87 61.63 70.87 96921 N 11 163.50 155.33 178.63 96921 F 11 64.60 61.37 70.58 96922 N 11 236.01 224.21 257.84 96922 F 11 116.64 110.81 127.43 97001 11 69.63 66.15 76.07 97002 11 38.39 36.47 41.94 97003 11 76.56 72.73 83.64 97004 11 46.27 43.96 50.55 97012 11 14.71 13.97 16.07 97016 11 16.42 15.60 17.94 97018 11 8.88 8.44 09.71 97022 11 19.23 18.27 21.01 97024 11 5.73 5.44 06.26 97026 11 5.10 4.85 05.58 97028 11 6.41 6.09 07.00 97032 11 16.91 16.06 18.47 97033 11 26.70 25.37 29.18 97034 11 15.55 14.77 16.99 97035 11 11.46 10.89 12.52 97036 11 27.69 26.31 30.26 97110 11 28.43 27.01 31.06 97112 11 29.69 28.21 32.44 97113 11 36.91 35.06 40.32 97116 11 25.16 23.90 27.49 97124 11 23.14 21.98 25.28 97140 11 26.81 25.47 29.29 97150 11 18.22 17.31 19.91 97530 11 30.93 29.38 33.79 97532 11 24.31 23.09 26.55 97533 11 26.52 25.19 28.97 97535 11 30.95 29.40 33.81 97537 11 27.17 25.81 29.68 97542 11 27.49 26.12 30.04 97597 N 11 67.60 64.22 73.85 97597 F 11 23.19 22.03 25.33 97598 N 11 22.70 21.57 24.81 97598 F 11 11.04 10.49 12.06 97605 N 11 37.20 35.34 40.64 97605 F 11 25.87 24.58 28.27 97606 N 11 39.67 37.69 43.34 97606 F 11 28.33 26.91 30.95 97750 11 29.83 28.34 32.59 97755 11 33.09 31.44 36.16 97760 11 33.30 31.64 36.39 97761 11 29.52 28.04 32.25 97762 11 38.01 36.11 41.53 97802 N 11 30.66 29.13 33.50 97802 F 11 28.77 27.33 31.43 97803 N 11 26.68 25.35 29.15 97803 F 11 24.79 23.55 27.08 97804 11 13.45 12.78 14.70 98925 N 11 28.89 27.45 31.57 98925 F 11 21.64 20.56 23.64 98926 N 11 38.83 36.89 42.42 98926 F 11 30.96 29.41 33.82 98927 N 11 50.63 48.10 55.32 98927 F 11 40.87 38.83 44.65 98928 N 11 59.13 56.17 64.60 98928 F 11 48.10 45.70 52.56 98929 N 11 68.17 64.76 74.47 98929 F 11 56.20 53.39 61.40 98940 N 11 24.16 22.95 26.39 98940 F 11 19.84 18.85 21.68 98941 N 11 33.43 31.76 36.52 98941 F 11 29.41 27.94 32.13 98942 N 11 43.22 41.06 47.22 98942 F 11 38.90 36.96 42.50 99082 11 .88 .84 00.97 99143 N 11 60.07 57.07 65.63 99143 F 11 38.23 36.32 41.77 99144 11 33.73 32.04 36.85 99145 11 9.20 8.74 10.05 99148 N 11 60.07 57.07 65.63 99148 F 11 38.23 36.32 41.77 99149 11 40.88 38.84 44.67 99150 11 13.29 12.63 14.52 99170 N 11 137.16 130.30 149.85 99170 F 11 90.86 86.32 99.27 99175 11 22.59 21.46 24.68 99183 N 11 196.30 186.49 214.46 99183 F 11 113.46 107.79 123.96 99195 11 79.57 75.59 86.93 99201 N 11 38.95 37.00 42.55 99201 F 11 24.78 23.54 27.07 99202 N 11 67.52 64.14 73.76 99202 F 11 47.05 44.70 51.41 99203 N 11 97.74 92.85 106.78 99203 F 11 71.60 68.02 78.22 99204 N 11 150.80 143.26 164.75 99204 F 11 121.19 115.13 132.40 99205 N 11 188.19 178.78 205.60 99205 F 11 156.07 148.27 170.51 99211 N 11 18.63 17.70 20.36 99211 F 11 8.86 8.42 09.68 99212 N 11 39.27 37.31 42.91 99212 F 11 24.15 22.94 26.38 99213 N 11 65.73 62.44 71.81 99213 F 11 47.47 45.10 51.87 99214 N 11 97.65 92.77 106.69 99214 F 11 73.09 69.44 79.86 99215 N 11 131.57 124.99 143.74 99215 F 11 103.23 98.07 112.78 99217 11 66.73 63.39 72.90 99218 11 62.01 58.91 67.75 99219 11 103.62 98.44 113.21 99220 11 144.89 137.65 158.30 99221 11 93.28 88.62 101.91 99222 11 127.08 120.73 138.84 99223 11 186.89 177.55 204.18 99224 11 26.82 25.48 29.30 99225 11 47.62 45.24 52.03 99226 11 71.22 67.66 77.81 99231 11 37.04 35.19 40.47 99232 11 67.00 63.65 73.20 99233 11 96.20 91.39 105.10 99234 11 126.33 120.01 138.01 99235 11 166.14 157.83 181.50 99236 11 206.47 196.15 225.57 99238 11 66.50 63.18 72.66 99239 11 97.61 92.73 106.64 99281 11 20.07 19.07 21.93 99282 11 39.05 37.10 42.67 99283 11 59.15 56.19 64.62 99284 11 111.52 105.94 121.83 99285 11 163.67 155.49 178.81 99291 N 11 253.24 240.58 276.67 99291 F 11 209.46 198.99 228.84 99292 N 11 114.25 108.54 124.82 99292 F 11 105.12 99.86 114.84 99304 11 84.42 80.20 92.23 99305 11 118.73 112.79 129.71 99306 11 151.42 143.85 165.43 99307 11 40.59 38.56 44.34 99308 11 62.43 59.31 68.21 99309 11 82.20 78.09 89.80 99310 11 121.78 115.69 133.04 99315 11 59.20 56.24 64.68 99316 11 77.04 73.19 84.17 99318 11 86.84 82.50 94.88 99324 11 52.92 50.27 57.81 99325 11 76.60 72.77 83.69 99326 11 130.17 123.66 142.21 99327 11 171.08 162.53 186.91 99328 11 200.18 190.17 218.70 99334 11 56.22 53.41 61.42 99335 11 87.18 82.82 95.24 99336 11 122.99 116.84 134.37 99337 11 176.96 168.11 193.33 99341 11 52.60 49.97 57.47 99342 11 76.51 72.68 83.58 99343 11 125.02 118.77 136.59 99344 11 168.04 159.64 183.59 99345 11 201.90 191.81 220.58 99347 11 52.27 49.66 57.11 99348 11 79.22 75.26 86.55 99349 11 117.32 111.45 128.17 99350 11 163.39 155.22 178.50 99354 N 11 91.94 87.34 100.44 99354 F 11 86.27 81.96 94.25 99355 N 11 90.99 86.44 99.41 99355 F 11 85.32 81.05 93.21 99356 11 84.23 80.02 92.02 99357 11 84.54 80.31 92.36 99406 N 11 13.11 12.45 14.32 99406 F 11 11.53 10.95 12.59 99407 N 11 25.55 24.27 27.91 99407 F 11 23.97 22.77 26.19 99460 11 56.01 53.21 61.19 99461 N 11 86.84 82.50 94.88 99461 F 11 61.33 58.26 67.00 99462 11 30.17 28.66 32.96 99463 11 76.41 72.59 83.48 99464 11 69.57 66.09 76.00 99465 11 133.86 127.17 146.25 99466 11 248.36 235.94 271.33 99467 11 114.66 108.93 125.27 99468 11 865.64 822.36 945.71 99469 11 379.00 360.05 414.06 99471 11 749.86 712.37 819.23 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **

MFI00A11 FSY-2011 "STATE OK" M E D I C A R E F E E S C H E D U L E "ALL OF OKLAHOMA" 09/12/2011 PAGE 048 PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE PROC MOD NOTE PAR FEE NPAR FEE LC FEE ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- ----- -- ---- -------- -------- -------- 99472 11 376.90 358.06 411.77 99475 11 527.83 501.44 576.66 99476 11 319.62 303.64 349.19 99477 11 334.37 317.65 365.30 99478 11 132.50 125.88 144.76 99479 11 121.66 115.58 132.92 99480 11 113.54 107.86 124.04 *** All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2010 by the American Medical Association. **