APPENDIX B NEW JERSEY ADMINISTRATIVE CODE

Transcription

1 APPENDIX B NEW JERSEY ADMINISTRATIVE CODE Current Through N.J. Register Volume 47, Number 16 (47 N.J.R. 2196) Includes Adopted Rules Filed Through July 24, 2015 SUBCHAPTER 3. BASIC AUTOMOBILE INSURANCE POLICY Source and Effective Date. R d. 592, effective December 21, 1998 (operative March 22, 1999). Section 11: Purpose and scope. 11: Definitions. 11: General provisions. 11: Coverages; mandatory and optional. 11: Election of basic automobile insurance policy coverage and reporting. 11: Filing requirements. 11: Purpose and scope. (a) This subchapter provides rules to be utilized by insurers in developing the policy forms and rates for basic automobile insurance policies to be filed with and approved by the Department in accordance with the provisions of N.J.S.A. 39:6A-3.1. (b) This subchapter shall apply to all insurers writing private passenger automobile insurance on personal lines policy forms, including the New Jersey Personal Automobile Insurance Plan established by N.J.A.C. 11: : Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Basic automobile insurance policy or basic policy means that automobile insurance policy offered pursuant to N.J.S.A. 39:6A-3.1 and this subchapter. Basic policy servicing carrier means a limited assignment distribution carrier that is a participating insurer that agrees to accept assignments of basic policies pursuant to this subchapter and the procedures set forth in the PAIP plan of operation. Commissioner means the Commissioner of the Department of Banking and Insurance. Department means the Department of Banking and Insurance. Insurer means any person or persons, corporation, association, partnership, company, reciprocal exchange, or other legal entity authorized or admitted to transact private passenger automobile insurance in this State, or any one member of a group of affiliated companies that transacts business in accordance with a common rating system. Medically necessary is as defined in N.J.A.C. 11: PAIP means the New Jersey Personal Automobile Insurance Plan established pursuant to N.J.S.A. 17:29D-1 and N.J.A.C. 11:3-2. Personal injury protection or PIP means the benefits and coverages set forth at N.J.S.A. 39:6A-4 and 39:6A-3.1 and N.J.A.C. 11:3-4. Significant disfigurement means the result and/or manifestation of a serious traumatic injury that is observable as a permanent and substantial defect in the appearance and functional ability of the person injured. Significant disfigurement is a serious outward change that substantially detracts from the appearance and functional ability of the person injured.

2 11:3-3.3 APPENDIX B - REGULATIONS Standard automobile insurance policy or standard policy means that policy form filed by private passenger automobile insurers and approved by the Commissioner that contains the coverages and options pursuant to N.J.S.A. 39:6A-4. Amended. R.2000 d.454, effective November 6, 2000; R.2007 d.151, effective May 7, : General provisions. (a) All insurers writing private passenger automobile insurance and the Personal Automobile Insurance Plan shall file for approval with the Department their rates, rules and policy forms for a basic automobile insurance policy to be issued in accordance with N.J.S.A. 39:6A-3.1 and this subchapter. (b) An insurer shall make available the basic policy at either a single tier rate or at multiple tier rates, consistent with its tier rating system filed and approved pursuant to N.J.A.C. 11:3-19A. If more than one basic policy rate is offered, each shall be identified as part of a standard, non-standard or preferred tier. (c) If a named insured has elected basic automobile insurance coverage and other immediate family members or resident relatives of the named insured have higher policy limits under a standard policy, the provisions of N.J.S.A. 39:6A-4.2 shall apply and the named insured shall only be entitled to the coverages provided under his or her basic policy. (d) Basic policies shall provide the tort option provided under N.J.S.A. 39:6A-8a. (e) Initial rates by coverage for basic policies filed in accordance with this subchapter shall demonstrate consistency with the rates in the insurer's standard policy, adjusted for reduced coverage limits. (f) Insurers shall file for approval an initial basic policy rating system by January 20, (g) An insurer may write basic policies through a basic policy servicing carrier. Amended. R.2007 d.151, effective May 7, : Coverages; mandatory and optional. (a) The following coverages shall be included in all basic policies: 1. Personal injury protection medical expense benefits coverage in an amount not to exceed $15,000 per person, per accident; except that all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requiring critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician shall be covered in an amount not to exceed $250,000, including the $15,000 above. The medical expense benefits provided herein shall be in accordance with N.J.A.C. 11:3-4; and 2. Liability insurance coverage insuring against loss resulting from liability imposed by law for property damage sustained by any person arising out of the ownership, maintenance, operation or use of an automobile in an amount or limit of $5,000, exclusive of interest and costs, for damage to property in any one accident. (b) Insurers shall also make available in the basic policy, at the option of the insured, liability insurance coverage for bodily injury or death in an amount or limit of $10,000, exclusive of interest and costs, on account of the injury or death of one or more persons in any one accident. (c) Insurers may make available with the basic policy, at the option of the insured, comprehensive and collision coverage with deductibles filed and approved pursuant to N.J.A.C. 11:3-13. (d) Basic policies shall not contain any other coverages, options, limits or deductibles other than those which are set forth in (a) through (c) above. Increased policy limits, the health insurance primary option for automobile medical expense

3 PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.1 coverage and uninsured/under-insured motorist coverages shall not be provided in basic policies. 11: Election of basic automobile insurance policy coverage and reporting. No insurer shall issue a basic automobile insurance policy unless the named insured has signed a written document entitled basic automobile insurance policy coverage selection form set forth in N.J.A.C. 11: Amended. R.2003 d.95, effective March 3, 2003; R.2006 d.243, effective July 3, : Filing requirements. (a) Insurers initially filing basic policy rating systems shall include the following: 1. A complete set of policy forms and endorsements that provide the mandatory and optional coverages as set forth in this subchapter; 2. Rates and rules as necessary; 3. An actuarial memorandum that supports the rate differentials from the insurer's standard policy rates; 4. The declaration page; 5. The rating information form; and 6. The personal lines filing forms as set forth in N.J.A.C. 11:3-16.3(f) and (g). (b) Subsequent amendments to the rating systems shall be filed pursuant to N.J.A.C. 11:3-16 and other applicable statutes and rules. SUBCHAPTER 4. PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS Source and Effective Date: R.1998 d.597, effective December 21, 1998 (operative March 22, 1999). Section 11: Scope and purpose. 11: Definitions. 11: Personal injury protection benefits applicable to basic and standard policies. 11: Deductibles and co-pays. 11: Diagnostic tests. 11: Medical protocols. 11: Decision point review plans. 11:3-4.7A PIP vendor registration requirements 11: Voluntary networks. 11: Assignment of benefits; public information. 11: Reserved APPENDIX Exhibit 1. Glossary of Terms Exhibit 2. Care Path Overview Exhibit 3. Care Path 1 Exhibit 4. Care Path 2 Exhibit 5. Care Path 3 Exhibit 6. Care Path 4 Exhibit 7. Care Path 5 Exhibit 8. Care Path 6 Exhibit 9. Care Path Diagnosis Coding Exhibit 10. Addendum to Care Paths Exhibit 11. Monthly Decision Point Review/Precertification Implementation Report - Not Included 11: Scope and purpose. (a) This subchapter implements the provisions of N.J.S.A. 39:6A-3.1, 39:6A-4 and 39:6A-4.3 by identifying the personal injury

4 11:3-4.2 APPENDIX B - REGULATIONS protection medical expense benefits and emergency personal injury protection coverage for which reimbursement of eligible charges will be made by automobile insurers under basic, standard and special automobile insurance policies and by motor bus insurers under medical expense benefits coverage. (b) This subchapter applies to all insurers that issue policies of automobile insurance containing PIP coverage, emergency personal injury protection coverage and policies of motor bus insurance containing medical expense benefits coverage. (c) This subchapter shall apply to those policies that are issued or renewed on or after March 22, Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). 11: Definitions. The following words, phrases and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. Ambulatory surgery facility or ambulatory surgical center (ASC) means: 1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are performed and which is separate and apart from any other facility license. (The ambulatory surgery facility may be physically connected to another licensed facility, such as a hospital, but is corporately, financially and administratively distinct, for example, it uses a separate tax-id number); or 2. A physician-owned single operating room in an office setting that is certified by Medicare. Basic automobile insurance policy or basic policy means those private passenger automobile insurance policies issued in accordance with N.J.S.A. 39:6A- 3.1 and N.J.A.C. 11:3-3. Clinically supported means that a health care provider prior to selecting, performing or ordering the administration of a treatment or diagnostic test has: 1. Personally examined the patient to ensure that the proper medical indications exist to justify ordering the treatment or test; 2. Physically examined the patient including making an assessment of any current and/or historical subjective complaints, observations, objective findings, neurologic indications, and physical tests; 3. Considered any and all previously performed tests that relate to the injury and the results and which are relevant to the proposed treatment or test; and 4. Recorded and documented these observations, positive and negative findings and conclusions on the patient's medical records. "Days" means calendar days unless specifically designated as business days. Decision point means those junctures in the treatment of identified injuries indicated by hexagonal boxes on the Care Paths where a decision must be made about the continuation or choice of further treatment. The determination whether to administer one of the tests listed in N.J.A.C. 11:3-4.5(b) is also a decision point for both identified and all other injuries. Decision point review means the procedures in an insurer's approved decision point review plan for the insurer to receive notice and respond to requests for proposed treatment or testing at decision points. Diagnostic test means a medical service or procedure utilizing biomechanical, neurological, neurodiagnostic, radiological, vascular or any means, other than bioanalysis, intended to assist in establishing a medical, dental, physical therapy, chiropractic or psychological diagnosis, for the purpose of recommending or developing a course of treatment for the tested patient to be implemented by the treating practitioner or by the consultant. Eligible charge means the treating health care provider's usual, customary and reasonable charge or the upper limit of the medical fee schedule as found in N.J.A.C. 11:3-29.6, whichever is lower.

5 PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.2 Emergency care means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Such emergency care shall include all medically necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency care extends during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Emergency care shall be presumed when medical care is initiated at a hospital within 120 hours of the accident. Emergency personal injury protection coverage means the coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89. Health care provider or provider means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to: 1. A hospital or health care facility that is maintained by State or any political subdivision; 2. A hospital or health care facility licensed by the Department of Health and Senior Services; 3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiological and diagnostic testing, free-standing emergency clinics or offices, and private treatment centers; 4. A nonprofit voluntary visiting nurse organization providing health care services other than a hospital; 5. Hospitals or other health care facilities or treatment centers located in other States or nations; 6. Physicians licensed to practice medicine and surgery; 7. Licensed chiropractors; 8. Licensed dentists; 9. Licensed optometrists; 10. Licensed pharmacists; 11. Licensed chiropodists (podiatrists); 12. Registered bioanalytical laboratories; 13. Licensed psychologists; 14. Licensed physical therapists; 15. Certified nurse mid-wives; 16. Certified nurse practitioners/clinical nurse-specialist; 17. Licensed health maintenance organizations; 18. Licensed orthotists and prosthetists; 19. Licensed professional nurses; 20. Licensed occupational therapists; 21. Licensed speech-language pathologists; 22. Licensed audiologists; 23. Licensed physicians assistants; 24. Licensed physical therapy assistants; 25. Licensed occupational therapy assistants; and 26. Providers of other health care services or supplies, including durable medical goods. Identified injury means those injuries identified by the Department in the subchapter Appendix as being suitable for medical treatment protocols in accordance with N.J.S.A. 39:6A-3.1a and 39:6A-4a.

6 11:3-4.2 APPENDIX B - REGULATIONS Insurer means any person or persons, corporation, association, partnership, company, reciprocal exchange or other legal entity authorized or admitted to transact private passenger automobile insurance in this State, or any one member of a group of affiliated companies that transacts business in accordance with a common rating system. Insurer does not include an entity that is self-insured pursuant to N.J.S.A. 39:6-52. For purposes of communicating with insureds and providers concerning the administration of decision point review plans, insurer also means the insurer s PIP vendor. Medical expense means the reasonable and necessary expenses for treatment or services rendered by a provider, including medical, surgical, rehabilitative and diagnostic services and hospital expenses and reasonable and necessary expenses for ambulance services or other transportation, medication and other services, subject to limitations as provided for in the policy forms that are filed and approved by the Commissioner. Medically necessary or medical necessity means that the medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person, and: 1. The treatment is the most appropriate level of service that is in accordance with the standards of good practice and standard professional treatment protocols including the Care Paths in the Appendix, as applicable; 2. The treatment of the injury is not primarily for the convenience of the injured person or provider; and 3. Does not include unnecessary testing or treatment. Non-medical expense means charges for those: 1. Products and devices, not exclusively used for medical purposes or as durable medical equipment, such as any vehicles, durable goods, equipment, appurtenances, improvements to real or personal property, fixtures; and 2. Services and activities such as recreational activities, trips and leisure activities. Network means an entity other than an insurer that contracts with providers to render health care services or provide supplies at predetermined fees or reimbursement levels. Organized delivery system (ODS) means an organized delivery system certified or licensed pursuant to N.J.S.A. 17:48H-1 et seq., N.J.A.C. 11:22-4 or N.J.A.C. 11:24B. "PIP vendor" means a company used by an insurer for utilization management. Precertification or precertification request means the procedures in an insurer s approved decision point review plan for the insurer to receive notice and respond to requests for listed specific medical procedures, treatments, diagnostic tests, other services and durable medical equipment that are not subject to decision point review and that may be subject to overutilization. Standard automobile insurance policy or standard policy means a private passenger automobile insurance policy issued in accordance with N.J.S.A. 39:6A-4. "Standard professional treatment protocols" means evidence-based clinical guidelines/practice/treatment published in peer-reviewed journals. "Utilization management" means a system for administering some or all of an insurer's decision point review plan, including, but not limited to, receiving and responding to decision point review and precertification requests, making determinations of medical necessity, scheduling and performing independent medical examinations (IMEs), bill review and handling of provider appeals. Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2010 d.142, effective July 6, Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

7 PIP BENEFITS; PROTOCOLS; TESTS 11: : Personal injury protection benefits applicable to basic and standard policies. (a) Personal injury protection coverage shall provide reimbursement for all medically necessary expenses for the diagnosis and treatment of injuries sustained from a covered automobile accident up to the limits set forth in the policy and in accordance with this subchapter. (b) Personal injury protection coverage shall only provide reimbursement for clinically supported necessary non-medical expenses that are prescribed by a treating medical provider for a permanent or significant brain, spinal cord or disfiguring injuries. 11: Deductibles and co-pays. (a) Each insurer shall offer a standard $ deductible and 20 percent copayment on medical expense benefits payable between $ and $5,000. (b) Each insurer shall also offer, at appropriately reduced premiums, the option to select medical expense benefit deductibles of $500.00, $1,000, $2,000 and $2,500 in accordance with the following provisions: 1. Any medical expense deductible elected by the named insured shall apply only to the named insured and any resident relative in the named insured's household, who is not a named insured under another automobile policy and not to any other person eligible for personal injury protection benefits required to be provided in accordance with N.J.S.A. 39:6A-3.1 and 39:6A-4; 2. Premium credits calculated and represented as a percentage of the applicable premium shall be provided for each deductible. The premium percentage shall be uniform by filer on a statewide basis; and 3. The deductible option elected by the named insured shall continue in force as to subsequent renewal or replacement policies until the insurer or its authorized representative receives a properly executed coverage selection form to eliminate or change the deductible. (c) All deductibles and co-pays in (a) and (b) above shall apply on a per accident basis. (d) An insurer may file policy language that waives the co-payment and deductible in (a) and (b) above when the insured receives medical treatment from a provider that is part of an ODS that has contracted with the insurer or its PIP vendor. The insured shall not be required to elect to use the providers or facilities in such an ODS either at issuance of the policy or when the claim is made. 1. Upon receipt of notification of a claim, the insurer or its PIP vendor shall make available to the insured information about physicians and facilities in any ODS with which it has a contract. i. The information shall include a notice that the insured is not required to use the providers or facilities of an ODS with which the insurer or its PIP vendor has contracted and indicate that if the insured chooses to receive covered services from such providers or facilities, the deductible and copayments in (a) and (b) above would not apply. ii. The information shall also indicate that the insured may seek treatment from providers and facilities that are not part of an ODS with which the insurer or its PIP vendor has contracted, in which case the deductible and copayments in (a) and (b) above would apply. 2. The actual ODS access fee or 25 percent of the reduction in charges resulting from the use of the ODS provider, whichever is less, may be included within the policy limits for any single bill from an in-network provider in the ODS with billed charges of $ 10,000 or more. Example: A $10,000 charge is reduced by the ODS contract with the insurer by 45 percent to $5,500. The insurer could include the ODS access fee or $1,125 (25 percent of the $4,500 reduction), whichever is less, within the policy limits.

8 11:3-4.4 APPENDIX B - REGULATIONS (e) Failure to request decision point review or precertification where required or failure to provide clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested shall result in an additional copayment not to exceed 50 percent of the eligible charge for medically necessary diagnostic tests, treatments or durable medical goods that were provided between the time notification to the insurer was required and the time that proper notification is made and the insurer has an opportunity to respond in accordance with its approved decision point review plan. Example: Assume that all days are business days and the insurer s Decision Point Review Plan gives the insurer three days to respond to decision pint review and precertification requests. By the terms of the insurer s Decision Point Review Plan, a treating medical provider is required to make a decision point review request on day 21 of treatment (time notification was required). The provider does not give the required notification in a timely manner but continues to treat the patient. The provider then makes the notification and it is received by the insurer on day 35 (time proper notification made). The insurer responds on day 38 that the treatment can proceed (time for insurer to respond). Assuming that the treatment made between day 21 and 38 was medically necessary, it is subject to the 50 percent co-payment. 1. No insurer may impose the additional co-payment where the insurer received the required notice but failed to act in accordance with its approved decision point review plan to request further information, modify or deny reimbursement of further treatment, diagnostic tests or durable medical equipment. (f) An insurer may require that the insured advise and inform the insurer about the injury and the claim. This requirement may include the production of information from the insured regarding the facts of the accident, the nature and cause of the injury, the diagnosis and the anticipated course of treatment. 1. This information may be required to be provided as promptly as possible after the accident, and periodically thereafter. 2. An insurer may impose an additional co-payment as a penalty for failure to supply the required information. Such penalties shall result in a reduction in the amount of reimbursement of the eligible charge for medically necessary expenses that are incurred after notification to the insurer is required and until notification is received. The additional co-payment shall be an amount no greater than: i. Twenty-five percent when received 30 or more days after the accident; or ii. Fifty percent when received 60 or more days after the accident. 3. Any reduction in the amount of reimbursement for PIP claims shall be in addition to any other deductible or co-payment requirement. 4. Information about this requirement and how to comply with it shall be included in the informational materials required by N.J.A.C. 11:3-4.7(d). (g) An insurer may impose an additional co-payment not to exceed 30 percent of the eligible charge for failure to use an approved network pursuant to N.J.A.C. 11:3-4.8 for the medically necessary non-emergency benefits listed in N.J.A.C. 11:3-4.8(b). (h) For the purpose of the co-payments permitted in (e), (f) and (g) above, the percentage reduction shall be applied to the amount that the insurer would otherwise have paid to the insured or the provider after the application of the provisions of N.J.A.C. 11:3-29. Insurers may apply the co-payments and deductibles in (a) through (g) above in any order, provided that they use the same order of application for all insureds. Upon receipt of a request for PIP benefits under the policy, the insurer or its PIP vendor shall make its co-payment and deductible application methodology available to the insured and the treating medical provider upon request.

9 PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.5 (i) For private passenger automobiles insured under a commercial automobile insurance policy where no natural person is a named insured, insurers shall only provide personal injury protection with medical expense benefits coverage in an amount not to exceed $250,000 per person, per accident, with the deductible and copayment amount set forth in (a) above. Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operative October 27, 2004, section (g) operative March 4, 2005); R.2010 d.142, effective July 6, Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Diagnostic tests. (a) The personal injury protection medical expense benefits coverage shall not provide reimbursement for the following diagnostic tests, which have been determined to yield no data of any significant value in the development, evaluation and implementation of an appropriate plan of treatment for injuries sustained in motor vehicle accidents: 1. (Reserved) 2. Spinal diagnostic ultrasound; 3. Iridology; 4. Reflexology; 5. Surrogate arm mentoring; 6. Surface electromyography (surface EMG); 7. (Reserved); and 8. Mandibular tracking and stimulation. (b) The personal injury protection medical expense benefits coverage shall provide for reimbursement of the following diagnostic tests, which have been determined to have value in the evaluation of injuries, the diagnosis and development of a treatment plan for persons injured in a covered accident, when medically necessary and consistent with clinically supported findings: 1. Needle electromyography (needle EMG) when used in the evaluation and diagnosis of neuropathies and radicular syndrome where clinically supported findings reveal a loss of sensation, numbness or tingling. A needle EMG is not indicated in the evaluation of TMJ/D and is contraindicated in the presence of infection on the skin or cellulitis. This test should not normally be performed within 14 days of the traumatic event and should not be repeated where initial results are negative. Only one follow up exam is appropriate. 2. Somasensory evoked potential (SSEP), visual evoked potential (VEP), brain audio evoked potential (BAEP), or brain evoked potential (BEP), nerve conduction velocity (NCV) and H-reflex Study are reimbursable when used to evaluate neuropathies and/or signs of atrophy, but not within 21 days following the traumatic injury. 3. Electroencephalogram (EEG) when used to evaluate head injuries, where there are clinically supported findings of an altered level of sensorium and/or a suspicion of seizure disorder. This test, if indicated by clinically supported findings, can be administered immediately following the insured event. When medically necessary, repeat testing is not normally conducted more than four times per year. 4. Videofluroscopy only when used in the evaluation of hypomobility syndrome and wrist/carpal hypomobility, where there are clinically supported findings of no range or aberrant range of motion or dysmmetry of facets exist. This test should not be performed within three months following the insured event and follow up tests are not normally appropriate. 5. Magnetic resonance imaging (MRI) when used in accordance with the guidelines contained in the American College of Radiology, Appropriateness Criteria to evaluate injuries in numerous parts of the body, particularly the assessment

10 11:3-4.5 APPENDIX B - REGULATIONS of nerve root compression and/or motor loss. MRI is not normally performed within five days of the insured event. However, clinically supported indication of neurological gross motor deficits, incontinence or acute nerve root compression with neurologic symptoms may justify MRI testing during the acute phase immediately post injury. In the case of TMJ/D where there are clinical signs of internal derangement such as nonself-induced clicking, deviation, limited opening, and pain with a history of trauma to the lower jaw, an MRI is allowable to show displacement of the condylar disc, such procedure following a panographic or transcranial x-ray and six or eight weeks of conservative treatment. This TMJ/D diagnostic test may be repeated post surgery and/or post appliance therapy. 6. Computer assisted tomographic studies (CT, CAT Scan) when used to evaluate injuries in numerous aspects of the body. With the exception of suspected brain injuries, CAT Scan is not normally administered immediately post injury, but may become appropriate within five days of the insured event. Repeat CAT Scans should not be undertaken unless there is clinically supported indication of an adverse change in the patient's condition. In the case of TMJ/D where there are clinical signs of degenerative joint disease as a result of traumatic injury of the temporomandibular joint, tomograms may not be performed sooner than 12 months following traumatic injury. 7. Dynatron/cyber station/cybex when used to evaluate muscle deterioration or atrophy. These tests should not be performed within 21 days of the insured event and should not be repeated if results are negative. Repeat tests are not appropriate at less than six months intervals. 8. Sonograms/ultrasound when used in the acute phase to evaluate the abdomen and pelvis for intra-abdominal bleeding. These tests are not normally used to assess joints (knee and elbow) because other tests are more appropriate. Where MRI is performed, sonograms/ultrasound are not necessary. However, echocardiogram is appropriate in the evaluation of possible cardiac injuries when clinically supported. 9. Thermography/thermograms only when used to evaluate pain associated with reflex sympathetic dystrophy ( RSD ), in a controlled setting by a physician experienced in such use and properly trained. 10. Brain mapping, when done in conjunction with appropriate neurodiagnostic testing. (c) The terms normal, normally, appropriate and indicated as used in (b) above, are intended to recognize that no single rule can replace the good faith educated judgment of a health care provider. Thus, normal, normally, appropriate and indicated pertain to the usual, routine, customary or common experience and conclusion, which may in unusual circumstances differ from the actual judgment of course of treatment. The unusual circumstances shall be based on clinically supported findings of a health care provider. The use of these terms is intended to indicate some flexibility and avoid rigidity in the application of these rules in the decision point review required in (d) below. (d) Except as provided in (e) below, a determination to administer any of the tests in (b) above shall be subject to decision point review pursuant to N.J.A.C. 11: (e) The requirements of (b) and (d) above shall not apply to diagnostic tests administered during emergency care. (f) Pursuant to N.J.A.C. 13: (b), the personal injury protection medical expense coverage shall not provide reimbursement for the following diagnostic tests which have been identified by the New Jersey State Board of Dentistry as failing to yield data of sufficient volume to alter or influence the diagnosis or treatment plan employed to treat TMJ/D:

11 PIP BENEFITS; PROTOCOLS; TESTS 11: Mandibular tracking; 2. Surface EMG; 3. Sonography; 4. Doppler ultrasound; 5. Needle EMG; 6. Electroencephalogram (EEG); 7. Thermograms/thermographs; 8. Video fluoroscopy; and 9. Reflexology. Amended. R.2000 d.454, effective November 6, : Medical protocols. (a) Pursuant to N.J.S.A. 39:6A-3.1 and 39:6A-4, the Commissioner designates the care paths, set forth in the subchapter Appendix incorporated herein by reference, as the standard course of medically necessary treatment, including diagnostic tests, for the identified injuries. (b) Where the care path indicates a decision point either by a hexagon in the care path itself or by reference in the text to a second opinion, referral for a second independent consultative medical opinion, development of a treatment plan or mandatory case management, the policy shall provide for a decision point review in accordance with N.J.A.C. 11: (c) Treatments that vary from the care paths shall be reimbursable only when warranted by reason of medical necessity. (d) The care paths do not apply to treatment administered during emergency care. 11: Decision point review plans. (a) No insurer shall impose the co-payments permitted in N.J.A.C. 11:3-4.4(e), (f) and (g) unless it has an approved decision point review plan. 1. Initial decision point review plan filings and amendments to approved plans shall be submitted to the Department through the use of the NAIC electronic filing system SERFF (System for Electronic Rate and Form Filing). (b) No decision point or precertification requirements shall apply within 10 days of the insured event or to emergency care. This provision should not be construed so as to require reimbursement of tests and treatment that are not medically necessary. (c) A decision point review plan filing shall include the following information: 1. Identification of any PIP vendor with which the insurer has contracted and a copy of the contract between the insurer and the PIP vendor. No insurer shall contract with a PIP vendor unless the vendor is registered with the Department pursuant to N.J.A.C. 11:3-4.7A; 2. Identification of any specific medical procedures, treatments, diagnoses, diagnostic tests, other services or durable medical equipment that are subject to precertification. The inclusion of precertification requirements in a decision point review plan is optional. The medical procedures, treatments, diagnoses, diagnostic tests or durable medical equipment required to be precertified shall be those that the insurer has determined may be subject to overutiliztion and that are not already subject to decision point review. The insurer shall not require the precertification of a new-patient evaluation and management visit that is necessary for the provider to develop the plan of care that is incorporated into a precertification request for treatment or diagnostic testing; 3. Copies of the informational materials described in (d) below and an explanation of how the insurer will distribute information to policyholders, injured persons and providers at policy issuance, renewal and upon notification of claim. 4. Procedures for the prompt review, not to exceed three business days, of decision point review and precertification requests by insureds or providers. All de-

12 11:3-4.7 APPENDIX B - REGULATIONS terminations on treatments or tests shall be based on medical necessity and shall not encourage over or underutilization of benefits. Denials of decision point review and precertification requests on the basis of medical necessity shall be the determination of a physician. In the case of treatment prescribed by a dentist, the denial shall be by a dentist; 5. Procedures for the scheduling of physical examinations pursuant to (e) below; 6. An internal appeals procedure that permits the provider to provide additional information and have a rapid review of a decision to modify or deny reimbursement for a treatment or the administration of a test; 7. Reasonable restrictions on the assignment of benefits pursuant to N.J.A.C. 11:3-4.9(a); 8. An explanation of the alternatives available to the provider if reimbursement for a proposed treatment, diagnostic test or durable medical equipment is denied or modified, including insurer's internal appeal process and how to use it; and 9. The information required in order to use a network pursuant to N.J.A.C. 11:3-4.8(d), if applicable. (d) The informational materials for policyholders, injured persons and providers shall be on forms approved by the Commissioner and shall include at a minimum the information in (d)1 through 9 below. In order to make the requirements of this subchapter easier for insureds and providers to use, the Commissioner may be Order require the use of uniform forms, layouts and language of information materials. 1. How to contact the insurer or vendor to submit decision point review/precertification requests including the telephone, facsimile numbers, addresses or through a website. The insurer or its vendor shall be available, at a minimum, during normal working hours to respond to decision point review/precertification requests; 2. An explanation of the decision point review process including a list of the identified injuries and the diagnostic tests in N.J.A.C. 11:3-4.5(b). The materials shall include copies of the Care Paths or indicate how copies may be obtained; 3. A list of the medical procedures, treatments, diagnoses, diagnostic tests, durable medical equipment or other services that require precertification, if any; 4. An explanation of how the insurer will respond to decision point review/precertification requests, including time frames. The materials should indicate that: i. Telephonic responses will be followed up with a written authorization, denial or request for more information within three business days; 5. An explanation of the insurer s option to require a physical examination pursuant to (e) below; 6. An explanation of the penalty co-payments imposed for the failure to submit decision point review/precertification requests where required in accordance with N.J.A.C. 11:3-4.4(e); 7. An explanation of the insurer s voluntary network or networks for certain types of testing, durable medical equipment or prescription drugs authorized by N.J.A.C. 11:3-4.8, if any; 8. An explanation of the alternatives available to the provider if reimbursement for a proposed treatment, diagnostic test or durable medical equipment is denied or modified, including insurers internal appeal process and how to use it; and 9. An explanation of the insurer s restrictions on assignment of benefits, if any.

13 PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.7 (e) A physical examination of the injured party shall be conducted as follows: 1. The insurer shall notify the injured person or his or her designee that a physical examination is required to determine the medical necessity of further treatment, diagnostic tests or durable medical equipment. An insurer shall include reasonable procedures for the notification of the injured person and the treating medical provider where reimbursement of further treatment, diagnostic testing or durable medical equipment will be denied for failure to appear at scheduled medical examinations. 2. The appointment for the physical examination shall be scheduled within seven calendar days of receipt of the notice in (e)1 above unless the injured person agrees to extend the time period. 3. The medical examination shall be conducted by a provider in the same discipline as the treating provider. 4. The medical examination shall be conducted at a location reasonably convenient to the injured person. 5. The injured person, upon the request of the insurer, shall provide medical records and other pertinent information to the provider conducting the medical examination. The requested records shall be provided at the time of the examination or before. 6. The insurer shall notify the injured person or his or her designee and the treating medical provider whether it will reimburse for further treatment, diagnostic tests or durable medical equipment as promptly as possible but in no case later than three business days after the examination. If the examining provider prepares a written report concerning the examination, the injured person or his or her designee shall be entitled to a copy upon request. 7. Insurers may include in their decision point review plan a procedure for the denial or reimbursement for treatment, diagnostic testing or durable medical equipment after repeated unexcused failure to attend a scheduled physical examination. The procedure shall provide for adequate notification of the insured and the treating provider of the consequences of failure to attend the examination. (f) In administering decision point review and precertification, insurers shall avoid undue interruptions in a course of treatment. As part of their decision point review plans, insurers may include provisions that encourage providers to establish an agreed upon voluntary comprehensive treatment plan for all of a covered person s injuries to minimize the need for piecemeal review. An agreed comprehensive treatment plan may replace the requirements for notification to the insurer at decision points and for treatment, diagnostic testing or durable medical equipment requiring precertification. In addition, the insurer may provide that reimbursement for treatment, diagnostic tests or durable medical equipment consistent with the agreed plan will be made without review or audit. (g) An insurer shall not retrospectively deny payment for treatment, diagnostic testing or durable medical equipment on the basis of medical necessity where a decision point review or precertification request for that treatment or testing was properly submitted to the insurer unless the request involved fraud or misrepresentation, as defined in N.J.A.C. 11:16-6.2, by the provider or the person receiving the treatment, diagnostic testing or durable medical equipment. Repeal and New Rule. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). Amended. R.2006 d.243, effective July 3, 2006; R.2009 d.243, effective June 15, 2009; R.2010 d.142, effective July 6, Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

14 11:3-4.7A APPENDIX B - REGULATIONS 11:3-4.7A PIP vendor registration requirements (a) No company shall perform utilization management services for an insurer unless registered as a PIP vendor pursuant to this section. (b) Any PIP vendor working for an insurer prior to November 5, 2012 shall file for registration by February 3, (c) Application for registration shall be made on a form prescribed by the Commissioner, which can be found on the Department's website at (d) The application shall be accompanied by the applicant s business plan, which shall include the following information: 1. A statement generally describing the applicant, its facilities, personnel, and the services to be offered by the PIP vendor; 2. The name of its medical director(s) licensed to practice as physician(s) in New Jersey and a detailed explanation about how the medical director(s) provide(s) oversight of determinations of medical necessity; 3. The name and contact information of a person at the vendor who is designated to receive and handle complaints and inquiries from the Department; 4. Information on activities undertaken or to be undertaken in New Jersey by the company; 5. A demonstration of the applicant's capability to provide a sufficient number of experienced and qualified personnel in the areas of PIP utilization management, and information on staffing levels, including, but not limited to, training, hiring requirements, experience of staff in general and with PIP utilization management in particular; 6. A statement about whether the applicant is licensed or certified as an entity that has networks as that term is defined in N.J.A.C. 11:3-4.8(a) or accredited by nationally recognized accrediting agencies such as URAC ( in Health Utilization Management; and 7. A copy of the applicant's certificate of incorporation. (e) The application shall also be accompanied by the following information concerning how the applicant will handle PIP utilization management: 1. The vendor s clinical review criteria and protocols. The information shall include a descriptive flow chart of its processes used in decision-making, which shall be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers, and be based upon generally accepted medical standards and standard professional treatment protocols; 2. A copy of the vendor s policies and procedures that demonstrate that the vendor is handling utilization management in accordance with N.J.A.C. 11:3-4, 5 and 29; and 3. The mechanisms it uses to detect underutilization and overutilization of services. (f) A PIP vendor that arranges the physical examinations of injured parties pursuant to N.J.A.C. 11:3-4.7(e) shall submit the criteria it uses to select providers to be on the vendor s panel of examining providers, how it evaluates the quality of an examining provider s examination report and how it avoids conflicts of interest when examinations are ordered and scheduled. (g) Two copies of the information in (a) through (f) above shall be submitted to the Department at the following address:

15 PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.7A New Jersey Department of Banking and Insurance Office of Property and Casualty P.O. Box 325 Trenton, NJ (h) The Department shall advise the applicant if the application is incomplete not later than 60 days after receipt of the application. Notice to the applicant that the application is incomplete shall specify the missing items or information. The Department shall disapprove an incomplete application if the requested information is not provided within 30 days of the notification to the applicant. If the Department does not notify the applicant of missing items or information within 60 days of receipt, the application shall be deemed complete. (i) The Commissioner shall approve an application for registration if he or she finds that the applicant has demonstrated the ability to perform services in a manner that meets the requirements of this subchapter. (j) The Commissioner may deny an application for registration as a PIP vendor if he or she finds that any of standards established by this subchapter have not been met or for any other reasonable grounds. 1. If the application for registration is denied, the Commissioner shall notify the applicant in writing of the reasons for the denial. 2. When the Department denies an application for registration, the applicant may request a hearing within 30 days of receipt of the denial by submitting a request in writing to the address in (g) above setting forth, with specificity, the reasons that the applicant disputes the Department's denial notice. (k) Registration shall be effective for a period of two years. Registered PIP vendors shall reapply for registration 90 days prior to expiration by submitting the information in (d) through (f) above showing changes to the items previously submitted. (l) All data or information in the PIP vendor's application for registration and the vendor s contract with the insurer required to be submitted pursuant to N.J.A.C. 11:3-4.7(c)1 shall be confidential and shall not be disclosed to the public, except as follows: 1. The PIP vendor s certificate of incorporation; 2. The PIP vendor s address; 3. The names of the PIP vendor's officers and directors, or the individuals in the organization responsible for the administration of utilization management including the medical director(s); and 4. The date of registration of the PIP vendor and date that registration expires. (m) The Commissioner may suspend or revoke the registration of a PIP vendor upon finding that the PIP vendor no longer meets the standards set forth in this subchapter; that PIP utilization review services are not being provided in accordance with the requirements of this subchapter; or that the registration was granted based on false or misleading information. 1. Proceedings to revoke or suspend the registration shall be conducted pursuant to N.J.A.C. 11:17D. 2. Upon request of the PIP vendor for a hearing, the matter shall be transferred to the Office of Administrative Law for a hearing conducted pursuant to the Administratve Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1. New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

16 11:3-4.8 APPENDIX B - REGULATIONS 11: Voluntary networks. (a) No insurer shall file a decision point review plan utilizing a voluntary network or networks unless the network is a health maintenance organization licensed pursuant to N.J.S.A. 26:2J-1 et seq.; or approved by the Department as part of a selective contracting arrangement with a health benefits plan pursuant to N.J.A.C. 11:4-37 and 11:24A-4.10; or approved as part of a workers compensation managed care organization pursuant to N.J.A.C. 11:6; or is licensed or certified as an organized delivery system pursuant to N.J.A.C. 11:22-4 and 11:24B. (b) Voluntary networks may be offered for the provisions of the following types of non-emergency benefits only: 1. Magnetic Resonance Imagery; 2. Computer Assisted Tomography; 3. The electrodiagnostic tests listed in N.J.A.C. 11:3-4.5(b)1 through 3 except for needle EMGs, H-reflex and nerve conduction velocity (NCV) tests performed together by the treating physician; 4. Durable medical equipment with a cost or monthly rental in excess of $50.00; 5. Prescription drugs; or 6. Services, equipment or accomodations provided by an ambulatory surgery facility. (c) Insurers that offer voluntary networks either directly or through a PIP vendor shall meet the following requirements: 1. The insurers shall notify all insureds upon application for and issuance of the policy and upon renewal of the types of benefits for which it has voluntary networks. Use of the network by the insured is voluntary but bills for out-of-network services or equipment are subject to the penalty deductibles set forth in N.J.A.C. 11:3-4.4(g). 2. Upon receipt of a request for PIP benefits under the policy, the insurer or its PIP vendor shall make available to the insured and the treating medical provider information about approved networks and providers in the network, including addresses and telephone numbers. Insureds shall be able to choose to go to any provider in the network. (d) An insurer offering a voluntary network or networks directly or through a PIP vendor shall submit the following information to the Department with its Decision Point Review Plan: 1. A narrative description of the benefits to be offered through the network or networks; 2. The identity and a description of the network and the specific services or supplies to be provided by the network or networks; 3. A description of the procedures by which benefits may be obtained by persons using the network; 4. A statement of how the network meets the requirement of (a) above. (e) Any voluntary network used by an insurer pursuant to this subchapter shall agree to disclose to a participating provider, upon written request, a list of all the clients or other payers that are entitled to a specific rate under the network s contract with the participating provider. Repeal and New Rule. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). Amended. R.2010 d.142, effective July 6, Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

17 PIP BENEFITS; PROTOCOLS; TESTS 11: : Assignment of benefits; public information. (a) Pursuant to N.J.S.A. 39:6A-4, an insured may only assign benefits and duties under the policy to a provider of service benefits. Insurers may file for approval policy forms that include reasonable procedures for restrictions on the assignment of personal injury protection benefits and duties under the policy, consistent with the efficient administration of the coverage and the prevention of fraud. Insurers may not prohibit the assignment of benefits to providers. Reasonable restrictions may include, but are not limited to: 1. A requirement that as a condition of assignment, the provider agrees to follow the requirements of the insurer's decision point review plan for making decision point review and precertification requests; 2. A requirement that as a condition of assignment, the provider shall hold the insured harmless for penalty co-payments imposed by the insurer based on the provider's failure to follow the requirements of the insurer's decision point review plan; and/or 3. A requirement that as a condition of assignment, the provider agrees to submit disputes to alternate dispute resolution pursuant to N.J.A.C. 11:3-5. (b) Insurers shall file policy language requiring that providers who are assigned benefits by the insured or have a power of attorney from the insured make an internal appeal pursuant to N.J.A.C. 11:3-4.7B prior to making a request for dispute resolution in accordance with N.J.A.C. 11:3-5. (c) An insurer shall identify documents containing proprietary information in its decision point review plan submission. Documents containing proprietary information shall be confidential and shall not be subject to public inspection and copying pursuant to the "Right-to-Know" law, N.J.S.A. 47:1A-1 et seq. The Department shall notify the insurer prior to responding to any public record request for proprietary information. Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: (Reserved). Repealed. R.2004 d.218, effective June 7, APPENDIX - TREATMENT OF ACCIDENTAL INJURY TO THE SPINE AND BACK CARE PATHS Exhibit 1 Glossary of Terms Acute Disease--a disease with rapid onset and short course to recovery. Not chronic. Care Path--a recommended extensive course of care based on professionally recognized standards. Case Management--a method of coordinating the provision of healthcare to persons injured in automobile accidents, with the goal of ensuring continuity and quality of care and cost effective outcomes. The Case Manager may be a nurse, social worker, or physician, preferably with certification in case management. Cauda Equina--a collection of spinal roots that descend from the lower part of the spinal cord. They exist in the lower part of the vertebral canal. Chronis Disease--a disease with long duration that changes little and progresses slowly. The apposite of acute. Clinical Evaluation--the evaluation of the symptoms and signs of an injured person by a treating practitioner.

18 11: APPENDIX B - REGULATIONS Conservative Therapy--treatment which is not considered aggressive; avoiding the administration of medicine or utilization of invasive procedures until such procedures are clearly indicated. Contusion--an injury to underlying soft tissues when the skin is not broken. A bruise. Diagnostic Evaluation--the process of differentiating between two or more diseases with similar signs and symptoms through the use of evaluative procedures such as imaging, laboratory, and physical tests. Herniation--the protrusion or projection of an organ or other body structure through a defect or natural opening in a covering membrane, muscle, or bone. Independent Consultative Opinion--physical examination by a physician of similar specialty to the injured person's treating practitioner to provide a second medical opinion. The independent physician may support, refute, or provide alternatives to the current diagnosis and treatment plans. Non-Compliant--a patient who wilfully chooses not to participate in the treatment plan agreed upon by the patient and his/her healthcare provider and does not have secondary issues such as lack of transportation, pre-existing conditions or comorbidities. PT--Physical Therapy--the therapeutic use of heat, light, water, electricity, massage, exercise, and non-ionizing radiation in treatment of injuries to the soft tissue and muscles/skeleton. PT rendered to persons injured in automobile accidents must be provided by a person whose scope of licensure includes physical therapy. Radicular--pertaining to a root (such as a nerve root) disorder. Radiculopathy--a disorder of a nerve root. Sign--an objective manifestation, usually indicative of a disease or disorder. Signs can be observed by the clinician, as opposed to symptoms, which are perceived only by the affected individual. Soft Tissue Injury--injuries sustained to the muscle, skin, connective tissue. Spine--the vertebral column. Spinal Shock--an acute condition resulting from spinal cord severance. Characterized by a total sensory loss and loss of reflexes below the level of injury and flaccid paralysis. Sprain--an injury at a joint where a ligament is stretched or torn. Strain--an injury caused by the over-stretching or tearing of a muscle or tendon. In its most severe form, the muscle ruptures. Symptom--a subjective manifestation, usually indicative of a disease or disorder. Symptoms are experienced only by the affected individual, as opposed to signs, which can be observed by others. Treatment Plan--specific medical, surgical, chiropractic, acupuncture, or psychiatric procedures used to improve the signs or symptoms associated with injuries sustained in automobile accidents, e.g., physical therapy, surgery, administration of medications, etc.

19 . PIP BENEFITS; PROTOCOLS; TESTS 11: NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

20 11: APPENDIX B - REGULATIONS 1, 2, 3, 4 See Addendum to Care Paths

21 PIP BENEFITS; PROTOCOLS; TESTS 11: NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

22 11: APPENDIX B - REGULATIONS 4 See Addendum to Care Paths ICD-9 CODES CARE PATH 1

23 PIP BENEFITS; PROTOCOLS; TESTS 11: NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

24 11: APPENDIX B - REGULATIONS 1, 2, 4 See Addendum to Care Paths ICD-9 CODES

25 PIP BENEFITS; PROTOCOLS; TESTS 11: , 2, 3, 4 See Addendum to Care Paths NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

26 11: APPENDIX B - REGULATIONS ICD-9 CODES See Addendum to Care Paths 1,3 See Addendum to Care Paths CARE PATH 3

27 PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10

28 11: APPENDIX B - REGULATIONS NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

29 PIP BENEFITS; PROTOCOLS; TESTS 11: NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier. ICD-9 CODES

30 11: APPENDIX B - REGULATIONS See Addendum to Care Paths CARE PATH 5

31 PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10

32 11: APPENDIX B - REGULATIONS NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

33 PIP BENEFITS; PROTOCOLS; TESTS 11: EXHIBIT 9 TREATMENT OF ACCIDENTAL INJURY TO THE SPINE AND BACK CARE PATH DIAGNOSIS CODING The following International Classification of Diseases, 9th Revision Clinical Modification--fifth edition ICD-9-CM diagnostic codes are associated with Care Path 1 through Care Path 6 for treatment of Accidental Injury to the Spine and Back and are included on each appropriate Care Path. The ICD9 codes referenced do not include codes for multiple diagnoses or co-morbidity. Care Path Disorders of muscle, ligament and fascia Spasm of muscle Non allopathic lesions--not elsewhere classified Somatic dysfunction of cervical region Sprains and strains of neck Sprains and strains of back, unspecified site Contusion of back Contusion of back, excludes interscapular region Injury to cervical root Care Path Displacement of cervical intervertebral disc without myelopathy Displacement of intervertebral disc, site unspecified, without myelopathy Intervertebral disc disorder with myelopathy, unspecified region Intervertebral disc disorder with myelopathy, cervical region Disorders of muscle, ligament and fascia Non allopathic lesions--not elsewhere classified Injury to cervical root Care Path Disorders of muscle, ligament and fascia Spasm of muscle Non allopathic lesions--not elsewhere classified Somatic dysfunction of thoracic region Somatic dysfunction of rib cage Sprains and strains, thoracic Sprains and strains of back, unspecified site Contusion of back Contusion of back, interscapular region Care Path Displacement of cervical intervertebral disc without myelopathy Displacement of thoracic or lumbar intervertebral disc without myelopathy Displacement of thoracic intervertebral disc without myelopathy Displacement of intervertebral disc, site unspecified, without myelopathy Intervertebral disc disorder with myelopathy, unspecified region Intervertebral disc disorder with myelopathy, thoracic region Disorders of muscle, ligament and fascia

34 11: APPENDIX B - REGULATIONS Non allopathic lesions--not elsewhere classified Care Path Disorders of muscle, ligament and fascia Spasm of muscle Non allopathic lesions--not elsewhere classified Somatic dysfunction of lumbar region Somatic dysfunction of sacral region 846 Sprains and strains of sacroiliac region Sprains and strains of lumbosacral (joint) (ligament) Sprains and strains of sacroiliac ligament Sprains and strains of sacrospinatus (ligament) Sprains and strains of sacrotuberous (ligament) Sprains and strains of other specified sites of sacroiliac region Sprains and strains, unspecified site of sacroiliac region Sprains and strains, lumbar Sprains and strains, sacrum Sprains and strains, coccyx Sprains and strains, unspecified site of back Contusion of back Contusion of back, excludes interscapular region Injury to lumbar root Injury to sacral root Care Path Displacement of thoracic or lumbar intervertebral disc without myelopathy Displacement of lumbar intervertebral disc without myelopathy Displacement of intervertebral disc, site unspecified, without myelopathy Intervertebral disc disorder with myelopathy, unspecified region Intervertebral disc disorder with myelopathy, lumbar region Disorders of muscle, ligament and fascia Non allopathic lesions--not elsewhere classified Injury to sacral root The following ICD-9-CM supplemental classification of external causes of injury may be used in addition to the specific diagnostic codes noted above and on each Care Path: E 810 through E 819, selected E 820 series codes. These codes may be used to indicate cause of injury as motor vehicle accident but should not be used without an associated diagnostic code. EXHIBIT 10 ADDENDUM TO CARE PATHS 1. Medications Muscle Relaxants Muscle relaxants are an option in the treatment of patients with acute neck, thoracic, and low back problems. While probably more effective than placebo, muscle relaxants have not been shown to be more effective than NSAIDs. No additional benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone.

35 PIP DISPUTE RESOLUTION 11:3-5 Muscle relaxants have potential side effects in 30 percent of patients. When considering the option of using relaxants, the clinician should balance the potential patient's intolerance of other agents. Opioid Analgesics When used for a time-limited course, opioid analgesics are an option in the management of patients with acute neck, thoracic, and low back problems. The decision to use opioids should be guided by consideration of their potential complications relative to other options. Opioids appear to be more effective in relieving neck, thoracic, and low back symptoms than safer analgesics, such as acetaminophen or aspirin or other NSAIDs. Clinicians should be aware of the side effects of opioids, such as decreased reaction time, clouded judgment, and drowsiness, which lead to early discontinuation by as many as 35 percent of patients. Patients should be warned about dependence and the danger of opioids while operating heavy machinery. Oral Steroids Oral steroids are not recommended for the treatment of acute neck, thoracic, or low back problems. A potential for severe side effects is associated with the extended use of oral steroids or steroids in high doses. 2. Who May Perform Spinal Manipulation: Spinal manipulation may be performed by those providers licensed or certified to perform this procedure within their scope of practice. 3. Spinal Manipulation A course of spinal manipulation/chiropractic care may be considered as conservative therapy on all Care Paths. If there is no improvement within one month, then immediate reevaluation is indicated to determine appropriate further treatment and treatment options, including referral to other health care providers and/ or modification of conservative therapy. When findings suggest progressive or severe neurologic deficits, an appropriate diagnostic assessment to rule out serious neurologic conditions is indicated in any conservative therapy. 4. Mental Health/Rehabilitation Assessment Option If Patient Has Not Responded To Treatment A mental health/rehabilitation assessment can be obtained if psychological/ psychosocial or psychiatric distress is obvious from the history, i.e., presence of non-organic physical signs, repetitive back injuries, failed previous treatments, litigation or disability compensation claims, family or financial problems, apparent secondary gain, boredom and dissatisfaction with job, frequent bouts of pain, depression, alcohol and substance abuse, extreme obesity, and apparent psychiatric behavior. SUBCHAPTER 5. PERSONAL INJURY PROTECTION DISPUTE RESOLUTION Source and Effective Date.R d. 592, effective December 21, 1998 (operative March 22, 1999). Section 11: Purpose and scope.

36 11:3-5.2 APPENDIX B - REGULATIONS 11: Definitions. 11: Designation of the administrator. 11: Dispute resolution organizations. 11: Dispute resolution professionals. 11: Conduct of PIP dispute resolution proceedings. 11: Recordkeeping. 11: Medical review organizations. 11: Standards for medical review organizations. 11: Medical review organization certification process. 11: Fees. 11: Prohibition of conflicts of interest. 11: Purpose and scope. (a) The purpose of this subchapter is to establish procedures for the resolution of disputes concerning the payment of medical expense and other benefits provided by the personal injury protection coverage in policies of automobile insurance. This subchapter implements N.J.S.A. 39:6A-5.1 and 5.2, which provide that PIP disputes shall be resolved by binding alternate dispute resolution as provided in the policy form approved by the Commissioner. This subchapter also implements provisions of N.J.S.A. 2A:23A-1 et seq., as applicable to PIP dispute resolution. (b) This subchapter shall apply to disputes arising under policies of private passenger automobile insurance, on either a personal lines or commercial lines policy form, that provide medical expense benefits and other benefits under personal injury protection coverage, as follows: 1. PIP benefits under a standard automobile insurance policy pursuant to N.J.S.A. 39:6A-4; 2. PIP benefits under a basic automobile insurance policy pursuant to N.J.S.A. 39:6A-3.1; 3. PIP benefits provided by the UCJF pursuant to N.J.S.A. 39:6-86.1; and 4. Additional PIP benefits provided pursuant to N.J.S.A. 39:6A-10. (c) This subchapter shall apply to policies issued or renewed on or after March 22, 1999 in accordance with the approved policy terms. 11: Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Administrator means the dispute resolution organization designated by the Commissioner pursuant to N.J.S.A. 39:6A-5.1 and N.J.A.C. 11: Basic policy means an automobile insurance policy issued pursuant to N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3. Commissioner means the Commissioner of the New Jersey Department of Banking and Insurance. Control or controlled means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds the power to vote, or holds proxies representing, 10 percent or more of the voting securities of any other person, provided that no such presumption of control shall of itself relieve any person so presumed to have control from any require-

37 PIP DISPUTE RESOLUTION 11:3-5.2 ment of P.L. 1970, c.22 (N.J.S.A. 17:27A-1 et seq.). This presumption may be rebutted by a showing made in the manner provided by N.J.S.A. 17:27A-3j that control does not exist in fact. The Commissioner may determine, after furnishing all persons in interest notice and an opportunity to be heard, and making specific findings of fact to support such determination, that control exists in fact, notwithstanding the absence of a presumption to that effect. Department means the New Jersey Department of Banking and Insurance. Dispute resolution organization or DRO means an organization that meets the standards set forth in N.J.S.A. 39:6A-5.1 and N.J.A.C. 11: Dispute resolution professional or DRP means a natural person who meets the standards set forth in N.J.A.C. 11: "In-person proceeding" or "in-person case" means a PIP dispute where the parties or their representatives appear in person or telephonically before the DRP to present their cases in accordance with the rules of the dispute resolution organization. Medical review organization or MRO means an organization of health care professionals who are licensed in New Jersey, which is certified by the Commissioner to engage in unbiased medical review of the medical care provided to persons injured in automobile accidents in accordance with N.J.S.A. 39:6A-5.2 and this subchapter. The term includes either; 1. Any peer review organization with which the Federal Health Care Financing Administration or the State contracts for medical review of Medicare or medical assistance services; or 2. Any independent health care review company. "On-the-papers proceeding" or "on-the-papers case" means a PIP dispute where the parties or their representatives submit written documentation supporting their case and the DRP decides the case based solely upon the documentation without any in person or telephonic appearances by the parties or their representatives in accordance with the rules of the dispute resolution organization. On-thepapers proceedings are only permitted where all parties consent or where there is no further treatment at issue and the amount at issue in the dispute is less than $ 1,000. Personal Automobile Insurance Plan or PAIP means the personal lines automobile insurance residual market mechanism established pursuant to N.J.S.A. 17:29D-1 by N.J.A.C. 11:3-2. Personal injury protection or PIP means the coverage provided by a policy of automobile insurance pursuant to N.J.S.A. 39:6A-3.1, 39:6A-4 or the emergency personal injury protection coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89. PIP dispute includes, but is not limited to, matters concerning: 1. Interpretation of the insurance contract's PIP provisions; 2. Whether the medical treatment or diagnostic tests are in accordance with the provisions of applicable statutes and rules for the basic and standard policies and in compliance with the terms of the policy; 3. Eligibility of the treatment or service for compensation or reimbursement, including whether the injury is causally related to the accident and the application of deductible and copayment provisions; 4. Eligibility of the provider performing the service to be compensated or reimbursed under the terms of the policy and the provisions of N.J.A.C. 11:3-4, and

38 11:3-5.3 APPENDIX B - REGULATIONS including whether the provider is licensed or certified to perform the treatment or service; 5. Whether the treatment was actually performed; 6. Whether the diagnostic tests performed are recognized by the Professional Boards in the Division of Consumer Affairs, Department of Law and Public Safety, administered in accordance with their standards, and approved by the Commissioner at N.J.A.C. 11:3-4; 7. The necessity and appropriateness of consultation with other health care providers; 8. Disputes involving the application of, or adherence to, the automobile insurance medical fee schedule at N.J.A.C. 11:3-29; 9. Whether the treatment or service is reasonable, necessary and in accordance with medical protocols adopted by the Commissioner at N.J.A.C. 11:3-4; or 10. Amounts claimed for PIP income continuation benefits, essential services benefits, death benefits and funeral expense benefits. Provider or health care provider is as defined at N.J.A.C. 11: Standard policy means an automobile insurance policy including PIP coverage as provided in N.J.S.A. 39:6A-4. UCJF means the Unsatisfied Claim and Judgement Fund created pursuant to N.J.S.A. 39:6-61 et seq. Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Designation of the administrator. (a) The Commissioner shall designate a dispute resolution organization as the administrator of the PIP alternate dispute resolution system by entering into a contract with a dispute resolution organization. (b) The contract designating the administrator shall be for a term not to exceed five years, but may be extended according to its terms until a new administrator is designated and substituted. Nothing in this subsection shall prohibit an administrator from succeeding itself, if so designated in accordance with N.J.S.A. 39:6A- 5.1 and this subchapter. The contract may provide for adjustments in the price paid for services performed over the life of the contract. (c) The Commissioner shall request competitive proposals from among qualified dispute resolution organizations interested in serving as administrator. (d) Dispute resolution organizations shall submit the following documents and information in connection with their proposal to serve as administrator: 1. A dispute resolution plan that describes how the organization shall meet the requirements of the Act and these rules, which shall include procedures and rules governing the dispute resolution process to ensure adherence to the standards of performance set forth in N.J.S.A. 39:6A-5.1 and 5.2 and this subchapter; 2. A description of the organization and biographical information about the key personnel that shall be responsible for executing the duties of the administrator; 3. A description of the management information systems that shall be utilized by the organization; 4. A draft budget for at least the first two years; 5. A cost proposal, which shall provide for the payment of the administrator's expenses, including the cost of dispute resolution professionals, from fees generated from the users of the system;

39 PIP DISPUTE RESOLUTION 11: Such other information as may be provided by law, and that the Commissioner or the Treasurer may request in order to understand and evaluate the applicant's proposal. 11: Dispute resolution organizations. (a) In order to be eligible for designation as administrator, a dispute resolution organization shall meet the following criteria: 1. The dispute resolution organization shall not be owned or controlled by an insurer or affiliate of an insurer; 2. The dispute resolution organization shall utilize full-time dispute resolution professionals that meet the standards set forth in N.J.A.C. 11: For the purpose of this paragraph, full-time shall be construed to include persons who work fewer than five days per week, but who do not engage in other, conflicting employment; 3. The dispute resolution organization shall utilize an advisory council composed of parties who are users of the dispute resolution mechanism in connection with the selection of dispute resolution professionals and the periodic review of the organization's rules and processes; 4. The dispute resolution organization shall utilize procedures to avoid conflicts of interests as prohibited at N.J.A.C. 11:3-5.12; 5. The dispute resolution organization shall arrange for proceedings in locations reasonably convenient to the parties; 6. The dispute resolution organization shall maintain published rules for the conduct of the proceedings, and shall make them available to the parties and the public upon request; 7. The dispute resolution organization shall perform its functions in a prompt and efficient manner, giving due regard to the nature of the proceeding and the need for special attention when required by the exigencies of a particular matter; and 8. The dispute resolution organization shall provide sufficient oversight and training of its dispute resolution professionals so as to promote fair, efficient and consistent determinations consistent with substantive law and with rules adopted by the Commissioner. (b) The dispute resolution organization shall develop and maintain a dispute resolution plan approved by the Commissioner that sets forth its procedures and rules. The dispute resolution plan shall be reviewed at least annually and revisions made upon approval by the Commissioner. The plan shall include the following elements: 1. The plan shall provide that PIP dispute resolution be initiated by written notice to the administrator and to all other parties of the party's demand for dispute resolution, which notice shall set forth concisely the claims, and where appropriate the defenses, in dispute and the relief sought. Where the arbitration is filed by a provider acting as an assignee of benefits or with a power of attorney from the insured, the notice shall include proof of compliance with the internal appeal process required by N.J.A.C. 11:3-4.7B. All notices shall also include such other information as may be required for administrative purposes; 2. The plan shall provide for consolidation of claims into a single proceeding where appropriate in order to promote prompt, efficient resolution of PIP disputes consistent with fairness and due process of law; 3. The plan shall provide the assigned dispute resolution professional with sufficient authority to provide all relief and to determine all claims arising under PIP

40 11:3-5.5 APPENDIX B - REGULATIONS coverage, but may provide for limited, procedural or emergent matters to be determined by one or more specially designated dispute resolution professionals; i. Emergent or expedited relief shall be granted upon demonstration that immediate and irreparable loss or damage will result in the absence of such relief; 4. The plan shall provide for the assignment of a medical review organization to review the case and report its determination when requested pursuant to N.J.S.A. 39:6A-5.2 and this subchapter; 5. The plan shall provide for the prompt, fair and efficient resolution of PIP disputes, including in-person and on-the-papers proceedings in accordance with the rules of the dispute resolution organization. The plan shall also provide that alternate procedures may be utilized when appropriate, which may include mediation, conferences to promote consensual resolution and expedited hearings upon receipt of a medical review organization report, consistent with principles of substantive law and rules adopted by the Commissioner; 6. The plan shall provide for a procedure whereby a demand for arbitration based on an insurer's denial of a decision point review or precertification request as not medically necessary, as defined in N.J.A.C. 11:3-4.2, may be submitted directly to an MRO for an expedited determination of medical necessity. No DRP will be assigned and no attorney fees may be charged. The administrator shall set a fee for handling such requests in addition to the MRO fee. The plan shall provide that if the expedited MRO review does not resolve the dispute, the claimant/insured may continue with the standard arbitration procedure before a DRP; and 7. The plan shall provide for the fair and efficient conduct of adversarial proceedings when other methods of dispute resolution are either unsuccessful or inappropriate, consistent with traditional notions of due process and fundamental fairness. It shall address, at least, the following procedural issues; i. Discovery; ii. Receipt of evidence by the dispute resolution professional; iii. Submission of briefs or memoranda of law and fact; iv. Provision for decisions without testimony on consent of parties; v. Notice and place of hearing; vi. Methods to request adjournments; vii. Presentation of testimony and evidence at a hearing; and viii. Supplementation of the record. (c) If consistent with its dispute resolution plan, a dispute resolution organization may utilize one or more dispute resolution professionals specifically to handle preliminary matters on actions including motions to disqualify an appointed DRP. Amended. R.2010 d.142, effective July 6, 2004; R.2010 d.142, effective July 6, Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Dispute resolution professionals. (a) A dispute resolution professional employed by the dispute resolution organization shall be either: 1. An attorney licensed to practice in New Jersey with at least 10 years of experience in cases involving personal injury or workers' compensation; 2. A former judge of the Superior Court or the Workers' Compensation Court, or a former Administrative Law Judge; or 3. Any other person, qualified by education and at least 10 years' experience, with sufficient understanding of automobile insurance claims and practices, contract law, and judicial or alternate dispute resolution practices nd procedures. (b) Dispute resolution professionals shall avoid conflicts of interest as prohibited at N.J.A.C. 11: in any matter assigned to them for determination.

41 PIP DISPUTE RESOLUTION 11: Dispute resolution professionals shall complete and file with the dispute resolution organization a conflict of interest questionnaire that shall provide sufficient detail about financial interests of themselves and their immediate family so as to avoid any assignment to a particular case where there is a conflict of interest. Conflict of interest questionnaires shall remain confidential with the dispute resolution organization, and the information set forth therein shall only be disclosed as necessary to individuals responsible for assigning cases to dispute resolution professionals, or reviewing motions to disqualify an assigned dispute resolution professional. 2. If during the course of an assignment a dispute resolution professional determines that he or she has conflict of interest, based upon facts determined in the course of the proceedings, then the DRP shall promptly advise the administrator of the circumstances, who shall assign another DRP. 3. A party may challenge the assignment of a particular DRP by submitting the specific grounds for challenge in accordance with the rules of the dispute resolution organization approved by the Commissioner. The rules of the dispute resolution organization approved by the Commissioner shall provide that a party may challenge the assignment of the DRP as follows: i. When the party receives notification of the assignment of the DRP for an inperson case; or ii. As part of the appeal process provided in the rules for on-the-papers cases. (c) Dispute resolution professionals shall be compensated by the administrator in accordance with the terms of the contract designating the administrator. Compensation shall not be contingent in any way upon the decision or determination of the DRP. (d) Dispute resolution professionals shall create and maintain such records as may be necessary to carry out their responsibilities and provide such records to the administrator as required in the contract designating the administrator. Amended. R.2006 d.243, effective July 3, 2006; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Conduct of PIP dispute resolution proceedings. (a) A request for dispute resolution of a PIP dispute may be made by the injured party, the insured, a provider who is an assignee of PIP benefits pursuant to N.J.A.C. 11:3-4.9 or the insurer, in accordance with the terms of the policy as approved by the Commissioner. The request for dispute resolution may include a request for review by a medical review organization. The request shall be made to the administrator and copies sent to other parties. 1. Every insurer shall establish a single address where requests for dispute resolution shall be sent. Insurers shall notify the administrator of the address and any changes thereto. The administrator shall make the list of insurer addresses available to the user community on a web page and any other available means of communication. 2. Providers who are the assignee of benefits by the insured or have a power of attorney from the insured shall follow the insurer's internal appeal process mandated by N.J.A.C. 11:3-4.7B before making a request for dispute resolution in accordance with (a) above. The dispute resolution organization's plan shall include a procedure for how the provider shall demonstrate that this requirement has been satisfied. (b) Upon receipt of the request, the administrator shall promptly assign the matter to a dispute resolution professional. For in-person proceedings, the administrator shall notify all parties of the DRP assigned at the time the assignment is

42 11:3-5.6 APPENDIX B - REGULATIONS made. For on-the-papers proceedings, the parties will receive notice of the DRP assigned at the time the decision is issued. (c) If the request for dispute resolution includes a request for review by a medical review organization, the administrator shall refer the matter to a certified medical review organization contemporaneously with the assignment of the DRP, and shall notify the parties and the DRP that the matter has been referred. If the initial request does not include a request for review by a medical review organization, then a request for such review may be made by any party to the assigned DRP. The DRP may refer a matter to a MRO on his or her own initiative upon a finding that the dispute concerns the diagnosis, medical necessity of treatment or diagnostic test administered to the injured person, whether the injury is causally related to the accident or is the product of a preexisting condition, or the protocols utilized by a provider. Whenever a DRP receives or initiates a request for MRO review, he or she shall transmit it to the administrator for referral who shall refer the matter to a certified MRO and notify the parties that the matter has been referred. 1. The administrator shall refer cases on a random or rotating basis to an MRO that does not have a conflict of interest, in accordance with the administrator's dispute resolution plan. Referrals shall be made in such a manner so as not to disclose the medical reviewer the identity of the insurer, nor to disclose to the insurer the identity of the medical reviewer. 2. Upon request of the MRO, a provider whose services are the subject of review shall promptly furnish a written report of the history, condition, treatment dates and results of diagnostic tests performed, and shall produce and permit the copying and inspection of all records relating to the history, treatment and condition of the injured person, and shall submit all necessary documentation as requested. Upon request of the MRO through the administrator, the insurer shall submit any and all documentation concerning its review of the treatment and testing of the injured person, and any reports by its reviewing provider why reimbursement for the treatment, test or item of durable medical equipment was denied. 3. The MRO may request an injured person to submit to a mental or physical examination by an independent provider in the same discipline as the treating providers who is not affiliated with either the treating provider, the insurer or the MRO health care provider performing the review. Any such examination shall be conducted in a place reasonably convenient to the injured person. The MRO shall make available to the examining provider any pertinent medical records. 4. If at any time the MRO determines that it has a conflict of interest in performing a particular review, it shall notify the administrator which shall refer the case to another MRO. i. Under such circumstances, the first-assigned MRO shall transmit to the newly assigned MRO such documents from the treating provider and the insurer as it has accumulated on the case, as may be directed by the administrator. ii. The first-assigned MRO shall not be entitled to any reimbursement for work performed on the transferred case. (d) Determination by the dispute resolution professional shall be in writing and shall state the issues in dispute, the DRP's findings and legal conclusions based on the record of the proceedings and the determination of the medical review organization, if any. The findings and conclusions shall be made in accordance with applicable principles of substantive law, the provisions of the policy and the Department's rules. The award shall set forth a decision on all issues submitted by the parties for resolution.

43 PIP DISPUTE RESOLUTION 11: If the DRP finds that the determination of a medical review organization is overcome by a preponderance of the evidence, the reasons supporting that finding shall be set forth in the written determination. 2. The award shall apportion the costs of the proceedings, regardless of who initiated the proceedings, in a reasonable and equitable manner consistent with the resolution of the issues in dispute. (e) Pursuant to N.J.S.A. 39:6A-5.2(g), the costs of the proceedings shall be apportioned by the DRP and the award may include reasonable attorney's fees for a successful claimant in an amount consonant with the award. Where attorney's fees for a successful claimant are requested, the DRP shall make the following analysis consistent with the jurisprudence of this State to determine reasonable attorney's fees, and shall address each item below in the award: 1. Calculate the "lodestar," which is the number of hours reasonably expended by the successful claimant's counsel in the arbitration multiplied by a reasonable hourly rate in accordance with the standards in Rule 1.5 of the Supreme Court's Rules of Professional Conduct ( rpc.htm#p65_6482). i. The "lodestar" calculation shall exclude hours not reasonably expended; ii. If the DRP determines that the hours expended exceed those that competent counsel reasonably would have expended to achieve a comparable result, in the context of the damages prospectively recoverable, the interests vindicated, and the underlying statutory objectives, then the DRP shall reduce the hours expended in the "lodestar" calculation accordingly; and iii. The "lodestar" total calculation may also be reduced if the claimant has only achieved partial or limited success and the DRP determines that the "lodestar" total calculation is therefore an excessive amount. If the same evidence adduced to support a successful claim was also offered on an unsuccessful claim, the DRP should consider whether it is nevertheless reasonable to award legal fees for the time expended on the unsuccessful claim. 2. DRPs, in cases when the amount actually recovered is less than the attorney's fee request, shall also analyze whether the attorney's fees are consonant with the amount of the award. This analysis will focus on whether the amount of the attorney's fee request is compatible and/or consistent with the amount of the arbitration award. Additionally, where a request for attorney's fees is grossly disproportionate to the amount of the award, the DRP's review must make a heightened review of the "lodestar" calculation described in (e)1 above. (f) The award shall be signed by the dispute resolution professional. The original shall be filed with the administrator, and copies provided to each party. If the award requires payment by the insurer for a treatment or test, payment shall be made together with any accrued interest ordered in the award pursuant to N.J.S.A. 39:6A-5, within 45 days of the insurer's receipt of a copy of the determination, unless one of the actions permitted in (g) below has been filed. Where the arbitration has been filed by a provider who is the assignee of benefits pursuant to N.J.A.C. 11:3-4.9, the payment shall be made payable to the provider. (g) The final determination of the dispute resolution professional shall be binding upon the parties, but subject to clarification/modification and/or appeal as provided by the rules of the dispute resolution organization, and/or vacation, modification or correction by the Superior Court in an action filed pursuant to N.J.S.A. 2A:23A-13 for review of the award. Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). Administrative correction. See: 45 N.J.R. 214(a).

44 11:3-5.7 APPENDIX B - REGULATIONS 11: Recordkeeping. (a) The administrator shall maintain records of all determinations for a period of five years. (b) The administrator shall file a copy of each determination, except consent determinations, with the Department in either hard copy or electronic form, as provided in the contract designating the administrator. 1. Any determination filed with the Department shall be indexed and coded so as to facilitate retrieval. 2. The name of any injured party, except when appearing in the caption of the matter or used as identification of the particular case, shall be redacted in the copy filed with the Department so as to protect the privacy of the injured person. (c) The administrator shall keep such other records as may be required by the Commissioner and as set forth in the contract designating the administrator. 11: Medical review organizations. (a) Medical review organizations shall be authorized to determine in connection with the PIP dispute resolution process set forth in this subchapter: 1. Whether the medical treatment or diagnostic test is medically necessary; 2. Whether the treatment is in accordance with medically recognized standard protocols including those protocols approved by the Commissioner and set forth in N.J.A.C. 11:3-4; 3. Whether the treatment is consistent with symptoms or diagnosis of the injury; 4. Whether the injury is causally related to the accident; 5. Whether the treatment is of a palliative rather than a restorative nature; and 6. Whether medical procedures and tests that have been repeated are medically necessary. (b) The findings of a medical review organization shall be presumed to be correct, but may be rebutted by a preponderance of the evidence submitted to the dispute resolution professional. 11: Standards for medical review organizations. (a) Medical review organizations shall be capable of performing medical reviews for all primary specialties and disciplines. (b) Medical review organizations shall employ a medical director to actively participate in the review of cases to assure quality and consistency. (c) Medical review organizations shall utilize health care providers in the same discipline as the treating provider to perform the reviews who meet the following standards: 1. Reviewing health care providers shall be active practitioners who obtain a minimum of one-half of their income from practice in their area of specialty; 2. Reviewing health care providers shall be licensed in New Jersey and board certified in their specialty; 3. Reviewing health care providers shall have at least two years' experience in medical review, or be certified as a medical review physician; and 4. Reviewing health care providers shall have completed an orientation with the MRO, including medical review instruction and report writing. (d) A medical review organization shall have adequate procedures in place to assure confidentiality of patient records. 1. All MRO files shall be indexed and referred to by reference number rather than patient name. 2. Medical files shall be maintained in a secure area of the MRO s offices. 3. Only the MRO shall request additional documents relating to the injured person's medical condition, or direct that the injured person be physically examined.

45 PIP DISPUTE RESOLUTION 11: (e) A medical review organization shall utilize procedures to provide for the fair and open exchange of information and records related to the review between the treating health care provider, any provider that has reviewed the case on behalf of the insurer, and the MRO's reviewing health care provider. (f) A medical review organization shall complete its review and submit its report to the dispute resolution professional in accordance with the medical exigencies of the case, but in no event in excess of 20 business days from receipt of medical records from the treating health care provider. (g) A medical review organization shall have a procedure for obtaining mental or physical examinations of injured persons that may be required in the course of its review. (h) A medical review organization shall utilize written review procedures. In reaching its determinations, the MRO shall consider all information submitted by the parties and information deemed appropriate by the MRO, including: pertinent medical records, consulting physician reports and other documents submitted by the parties; applicable commonly accepted protocols, professional standards and practices by national standard setting organizations, and protocols and diagnostic tests approved by the Commissioner and set forth in N.J.A.C. 11:3-4. (i) A medical review organization shall utilize audit procedures to ensure compliance with statutory and regulatory requirements. (j) A medical review organization shall retain records of its determinations for five years. 11: Medical review organization certification process. (a) The Commissioner shall certify a medical review organization to provide medical review services in connection with the resolutions of PIP disputes if the Commissioner determines that the MRO complies with the standards set forth in N.J.A.C. 11:3-5.9 to provide an impartial review of the medical necessity or appropriateness of treatments, health care services or items of durable medical equipment for which medical expense benefits may be provided under personal injury protection coverage. (b) For the purpose of obtaining certification by the Commissioner to act as a medical review organization to perform medical review in connection with the resolution of PIP disputes, an MRO shall submit two copies of a written application that sets forth the information in (b) below to: Medical Review Organization Certification New Jersey Department of Banking and Insurance PO Box 325 Trenton, NJ (c) The MRO application shall include the following: 1. A list of the names, addresses and specialties of the individual health care providers that will provide the medical review services. If the MRO will be limited in its service area, the application shall provide a map of the service area, including the providers by specialty; 2. A copy of the MRO's certificate of incorporation and by-laws; 3. A diagram of the MRO's organizational structure; 4. The location of the MRO's place of business where it administers its services and maintains its records;

46 11: APPENDIX B - REGULATIONS 5. A listing and biography of the MRO's officers and directors, or the individuals in the organization responsible for administration of medical reviews, including the medical director; 6. A detailed description of the MRO's experience in the review of medical care; 7. A description of its procedures for review of medical treatments, diagnostic tests and items of durable medical equipment in conjunction with PIP medical expense benefits; 8. A current list identifying all property/casualty insurers, health insurers, health maintenance organizations and health care providers with whom the MRO maintains any health related business arrangement. The list shall include a brief description of the nature of the arrangement, so as to permit the administrator to avoid assignments that may create a conflict of interest; 9. The fee(s) for determination by the MRO; 10. Such other information as the Commissioner may specifically request in connection with the certification of a particular applicant; and 11. A fee in the amount of $1,000 payable to the Department of Banking and Insurance. (d) The materials specified in (c) above shall be retained by the Department and may be referred to the Department of Health and Senior Services for consultation as necessary. Any significant changes in the materials filed with the Department shall be reported as an amendment to the materials filed within 30 days of the change. (e) The Department, in consultation with the Department of Health and Senior Services, shall review the materials and grant or deny certification within 45 days of receipt of a complete filing. The Commissioner may extend the time an additional 30 days for good cause shown, and shall notify the applicant of any extension. A decision to deny certification shall be in writing and include an explanation of the reason for the denial. (f) Initial certification shall be effective for a period of two years. Certified MROs shall reapply for certification 90 days prior to expiration by submitting the items set forth in (b)1, 6, 7, 8, 9 and 10 above and any changes to items previously submitted in (b)2, 3, 4 and 5 above. Renewal certification may be effective for a period of up to five years. (g) All data or information in the MRO's application for certification shall be confidential and shall not be disclosed to the public, except as follows: 1. The MRO's certificate of incorporation; 2. The MRO's address; 3. The names of the MRO's officers and directors, or the individuals in the organization responsible for the administration of medical reviews including the medical director; and 4. The date of certification of the MRO and date that certification expires. (h) Upon certification, the Department shall advise the administrator of the name and address of the MRO, any limitations on its geographical service area and information about persons with whom it maintains health related business arrangements. (i) The Commissioner may suspend or revoke the certification of an MRO upon finding that the MRO no longer meets the standards set forth in N.J.A.C. 11:3-5.9; that medical review services are not being provided in accordance with the re-

47 AUTOMOBILE REPARATION REFORM 11: quirements of this subchapter; or that the certification was granted based on false or misleading information. 1. Proceedings to revoke or suspend the certification shall be conducted pursuant to N.J.A.C. 11:17D. 2. Upon request of the MRO for a hearing, the matter shall be transferred to the Office of Administrative Law for a hearing conducted pursuant to the Uniform Administrative Procedure Rules, N.J.A.C. 1:1. Amended. R.2006 d.243, effective July 3, 2006; R.2010 d.142, effective July 6, Administrative correction. See: 42 N.J.R. 2129(a). 11: Fees. When a mental or physical examination is performed in connection with the medical review organization's services, the health care provider performing the examination shall be paid the fee provided for that service set forth on the Department's medical fee schedule, N.J.A.C. 11:3-29. Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2010 d.142, effective July 6, Administrative correction. See: 42 N.J.R. 2129(a). 11: Prohibition of conflicts of interest. (a) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall have any personal or financial interest, direct or indirect, or engage in any business or transaction which is in conflict with the proper conduct of his or her duties under this subchapter. (b) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall act in such capacity in any matter wherein he or she has a direct or indirect personal or financial interest that might reasonably be expected to impair his or her objectivity or independence of judgment. (c) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall accept any gift, favor, service or other thing of value under circumstances from which it might be reasonably inferred that such gift, service or other thing of value was given or offered for the purpose of influencing him or her in the conduct of duties under this subchapter. (d) No dispute resolution professional shall accept from any person, whether directly or indirectly and whether by him or herself or through a spouse or any family member or through any partner or associate or controlled business, any gift, favor, service, employment or offer of employment or any other thing of value which he or she knows or has reason to believe is offered with the intent to influence the performance of his or her duties as a dispute resolution professional. (e) No dispute resolution professional shall make any determination in any PIP dispute in which he or she directly or indirectly or through a spouse, family member or by partner or associate or controlled business has any personal or financial interest. SUBCHAPTER 7. AUTOMOBILE REPARATION REFORM ACT Section 11: Purpose. 11: General requirements applicable to additional personal injury protection benefits. 11: Personal injury protection policy forms or endorsements. 11: Minimum schedule of additional personal injury protection coverage benefits.

48 11:3-7.1 APPENDIX B - REGULATIONS 11: Notice requirements. 11: Cancellation of automobile coverage for nonpayment of premium. 11: Purpose. This subchapter implements certain provisions of the Automobile Reparation Reform Act, N.J.S.A. 39:6A-1 et seq., including the Commissioner s authority to establish the amounts and terms of additional personal injury protection benefits that must be made available to insureds electing a standard automobile insurance policy pursuant to N.J.S.A. 39:6A-4. Amended. R d. 591, effective December 21, 1998 (operative March 22, 1999). 11: General requirements applicable to additional personal injury protection benefits. (a) In addition to the personal injury protection benefits that insurers must provide pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, insurers shall make available to the named insured, and, at his or her option, to any resident relatives in the named insured s household who are not named insureds on another standard or basic policy, additional income continuation benefits, essential services benefits, death benefits and funeral expense benefits pursuant to N.J.S.A. 39:6A-10 and this subchapter. (b) The additional benefit indicated in each option that an insurer may offer for income continuation benefits and essential services benefits represents the aggregate of the basic and additional personal injury protection benefits. (c) Any additional income continuation benefits that an insurer may offer shall be limited to 75 percent of the insured s weekly income. (d) The limits which are applicable to any additional personal injury protection benefits that an insurer may offer shall apply on a per person, per accident basis. (e) Each insurer shall make available as an option additional income continuation benefits for as long as the disability persists. 1. Each insurer shall furnish rates for such benefits upon the request of the insured. (f) Any additional death benefits which an insurer may offer shall be payable without regard to the period of time elapsing between the date of the accident and the date of death provided death occurs within two years of the accident and results from bodily injury from that accident. 1. The requirements of (f) above shall apply to any claim for additional death benefits where death occurs on or after April 21, i. With respect to any claim presented on or after the effective date of this subchapter, each insurer shall disclose the availability of additional death benefits in conformance with the applicable provisions of N.J.A.C. 11: et seq. ii. With respect to any claim initiated prior to the effective date of this subchapter, each insurer shall take appropriate steps to determine whether additional death benefits are payable, pursuant to (fl above. These steps shall include, but need not be limited to, review of claims closed on or after April 21, 1986 for the purpose of ascertaining the applicability of additional death benefits. Upon determining that such benefits are payable, each insurer shall provide written notice to eligible beneficiaries and process the claim in accord with N.J.S.A. 39:6A-5 and the applicable provisions of N.J.A.C. 11: et seq. (g) In addition to the minimum schedule of additional personal injury protection benefits set forth at N.J.A.C. 11:3-7.4(b), any insurer may provide other additional personal injury protection benefit options subject to review and approval of its filing by the Department of Insurance. Any additional options offered by the

49 AUTOMOBILE REPARATION REFORM 11:3-7.4 insurer must be in compliance with the standards and requirements set forth in this subchapter. (h) Insurers may also make available to named insureds covered under N.J.S.A. 39:6A-4, and at their option, to resident relatives in the household of the named insured or to other persons provided medical expense coverage pursuant to this statutory provision, or both, additional first party medical expense benefit coverage pursuant to N.J.S.A. 39:6A-l0. Amended. R d. 580, effective November 19, 1990 (operative January 1, 1991); R d. 591, effective December 21, 1998 (operative March 22, 1999); R d. 44, effective February 5, : Personal injury protection policy forms or endorsements. (a) All policy forms or endorsements that provide personal injury protection benefits required by N.J.S.A. 39:6A-4 shall specify that such benefits shall be afforded by the insurer of the injured person subject to any deductibles or exclusions elected by the policyholder pursuant to N.J.S.A. 39:6A-4.3. The required personal injury protection benefits are set forth below: 1. Medical expense benefits; 2. Income continuation benefits; 3. Essential services benefits; 4. Death benefits; and 5. Funeral expense benefits. (b) Each policy form or endorsement covering an automobile as defined at N.J.S.A. 39:6A-2 shall include excess medical payments coverage, corresponding to Section II, Extended Medical Expense Benefits Coverage of the personal automobile policy. Insurers must include a minimum coverage of $1,000 and may offer coverage of $10,000. (c) Each policy form or endorsement providing additional personal injury protection benefits shall specify that, pursuant to N.J.S.A. 39:6A-10, additional death benefits under the policy shall be payable without regard to the period of time elapsing between the date of the accident and the date of death provided death occurs within two years of the accident and results from bodily injury from that accident Amended. R d. 58, effective February 5, : Minimum schedule of additional personal injury protection coverage benefits. (a) Every rate filer s schedule of rates for additional personal injury protection benefits, other than medical expense benefits, shall provide at least the benefit schedules set forth in Table 1 in (b) below. (b) The additional personal injury protection coverage table follows: Table 1 Income Essential Services Funeral Option Weekly Total Per Day Total Death Expense 1 $100 $10,400 $12 $8,760 $10,000 $2, , ,600 10,000 2, , ,600 10,000 2, , ,600 10,000 2, , ,600 10,000 2, , ,600 10,000 2, , ,600 10,000 2, , ,600 10,000 2,000

50 11:3-7.5 APPENDIX B - REGULATIONS unlimited 12 8,760 10,000 2, unlimited 20 14,600 10,000 2, unlimited 20 14,600 10,000 2, unlimited 20 14,600 10,000 2, unlimited 20 14,600 10,000 2, unlimited 20 14,600 10,000 2, unlimited 20 14,600 10,000 2, unlimited 20 14,600 10,000 2,000 Amended. R. 1990, d. 580, effective November 19, 1990 (operative January 1, 1991). 11: Notice requirement. (a) Additional personal injury protection benefits that are required to be offered by an insurer shall be offered by the insurer at least annually as part of the Coverage Selection Form required pursuant to N.J.S.A. 39:6A-23 and N.J.A.C. 11: The buyer s guide and coverage selection form specified at N.J.S.A. 39:6A- 23 and any rules promulgated thereunder shall meet the requirements of (a) above. (b) Each insurer shall distribute copies of this subchapter to every person responsible for the handling and settlement of claims subject to this subchapter. Every insurer shall satisfy itself that all such responsible persons are thoroughly conversant with and are complying with this subchapter. Amended. R d. 580, effective November 19, 1990 (operative January 1, 1991); Amended. R d. 58, effective February 5, : Cancellation of automobile coverage for nonpayment of premium. (a) This rule applies to all automobile policies delivered or issued for delivery in this State, insuring a single individual or husband and wife resident of the same household, as named insured, and under which the insured vehicles therein designated are of the following types only: 1. A motor vehicle of the private passenger or station wagon type that is not used as a public or livery conveyance for passengers, not rented to others; or 2. Any other four-wheel motor vehicle with a load capacity of 1,500 pounds or less which is not customarily used in the occupation, profession or business of insured, other than farming or ranching, provided, however, that this rule shall not apply to any policy insuring more than four automobiles, or to any policy covering garage, automobile sales agency, repair shop, service station or public parking place operation hazards. (b) The effective date of the cancellation of a policy for nonpayment of premium shall not be earlier than 10 days prior to the last full day of which premium received by the company prior to the date of preparation of the cancellation notice, would pay for coverage on a pro rata basis. In calculating the effective date of the cancellation as provided in this section, the premium applicable to the coverage provided by the policy and the premium received by the company at or prior to the time cancellation notice was prepared shall be the premium used for the calculation and determination of such effective date. (c) Cancellation for nonpayment of premium does not include cancellation at the request of a premium finance company or of a producer of record under N.J.A.C. 11:17C-2.2(d). (d) No cancellation notice shall be mailed prior to 30 days in advance of its effective date. (e) The rule shall not apply to deposits accompanying New Jersey Automobile Personal Insurance Plan or Commercial Automobile Insurance Plan applications

51 MOPED INSURANCE 11: which are insufficient under Plan rules or those of any succeeding residual market availability plan. Amended. R d. 58, effective February 5, Administrative correction. 40 N.J.R SUBCHAPTER 11. MOPED INSURANCE Section 11: Required coverages for mopeds. 11: Required coverages for mopeds. (a) No policy insuring against loss resulting from liability imposed by law for bodily injury, death and property damage sustained by any person arising out of the ownership, operation or use of a motorized bicycle as defined in N.J.S.A. 39:1-1, as amended, shall be issued in the State to the owner (or parent or guardian of an owner under 18 years of age) of any motorized bicycle principally garaged or operated in this State unless it includes coverage for the owner and operator in the following minimum amounts or limits. 1. Bodily injury; i. An amount or limit of $15,000, exclusive of interest and costs, on account of injury to, or death of, one person, in any one accident; and ii. An amount or limit, subject to such limit for any one person so injured or killed, of $30,000, exclusive of interest and costs, On account of injury to or death of more than one person, in any one accident. 2. Property damage: An amount or limit of $5,000 in the aggregate or damage to property of others resulting from one accident. (b) Every liability insurance policy as described in (a) above, issued or renewed on or after April 22, 1985, shall provide personal injury protection coverage benefits, in accordance with N.J.S.A. 39:6A-4, to pedestrians who sustain bodily injury in this State caused by the named insured s motorized bicycle or caused by being struck by or from the motorized bicycle. 1. Every rating organization and insurer making its own rates for policies covering motorized bicycles shall submit to the Commissioner of insurance filings of rules, rates and forms within 30 days of the effective date of this subsection. (c) Every business entity or individual owner who rents motorized bicycles shall maintain liability insurance coverage pursuant to N.J.S.A. 39:4-14.3e in the minimum amounts or limits set forth in subsection (a) of his section. (d) Any such coverages as described in subsections (a), (b) and (c) above shall describe the make and model, piston displacement, and serial number (VIN) of each motorized bicycle insured. This information shall also constitute the description of vehicle required on insurance identification cards, and N.J.A.C. 11:3-5.1 through 6.4 shall apply to moped coverage except where the language is clearly inappropriate. (e) The policy period for the coverages described is subsection (a) of this section shall commence at 12:01 A.M. of the effective date shown in the policy declaration page, unless expressly set forth in the policy or in a binder or other contracts for temporary insurance. (f) Any insurer authorized to write motor vehicle coverage may write moped coverage. Adopted. R d. 12, eff. January 19, Amended. R d. 72, effective February 19, 1985 (operative April 22, 1985); R d. 44, effective February 5, 2001.

52 11:3-14 APPENDIX B - REGULATIONS SUBCHAPTER 14. PERSONAL INJURY PROTECTION OPTIONS Section 11: Purpose. 11: Scope. 11: Optional medical expense benefit deductibles for personal injury protection coverage. 11: Optional exclusion of income continuation benefits, essential services benefits, death benefits and funeral expense benefits. 11: Option to choose health care insurance coverage as primary coverage. 11: Refund or credit of unearned premium. 11: Filing requirements. 11: Application of the option to choose health care insurance coverage as the primary insurer. 11: Purpose. This subchapter establishes rules for the provision of optional deductibles and benefits for personal injury protection offered under standard private passenger automobile insurance policies pursuant to N.J.S.A. 39:6A- 4. Amended. R d. 117, effective February 21, 1989; R d. 58, effective February 5, 1996; R d. 591, effective December 21, 1998 (operative March 22, 1999). 11: Scope. This subchapter applies to every insurer, including any residual market mechanism created by any New Jersey statute, authorized to transact the business of automobile insurance in this State. Amended. R d. 580, effective November 19, 1990 (operative January 1, 1991) 11: Optional medical expense benefits for standard policies. (a) With respect to personal injury protection under standard automobile insurance policies, issued pursuant to N.J.S.A. 39:6A-4, each insurer shall make available as an option, at appropriately reduced premiums, medical expense benefits in amounts of $150,000, $75,000, $50,000, and $15,000. If none of these options is affirmatively chosen in writing, the policy shall provide medical expense benefits in an amount not to exceed $250,000 per person per accident. (b) Notwithstanding (a) above, if an optional medical expense benefit option is chosen, the policy shall provide that medical expense benefits shall be paid in an amount not to exceed $250,000, inclusive of any limit of medical expense benefits pursuant to (a) above, for all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requires critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician. (c) Significant disfigurement as used in (b) above means the result and/or manifestation of a serious traumatic injury that is observable as a permanent and substantial defect in the appearance and functional ability of the person injured. Significant disfigurement is a serious outward change that substantially detracts from the appearance and functional ability of the person injured. Amended. R d. 480, eff. November 5, 1984; R d. 117, effective February 21, 1989; R d. 58, effective February 5, 1996; R d. 591, effective December 21, 1998 (operative March 22, 1999); R.2000 d.454, effective November 6, 2000.

53 PIP OPTIONS 11: : Optional exclusion of income continuation benefits, essential services benefits, death benefits and funeral expense benefits. (a) Automobile insurers offering personal injury protection coverage pursuant to N.J.S.A. 39:6A- 4 shall, at an appropriate reduced premium, provide the named insured the option to exclude all of the following benefits from such coverage: 1. Income continuation benefits; 2. Essential services benefits; 3. Death benefits; 4. Funeral expense benefits. (b) Election of the exclusion shall result in the elimination of all elements of personal injury protection coverage except medical expense benefits. (c) An exclusion elected by the named insured in accordance with this subchapter shall apply only to the named insured, and any resident relative in the named insured s household, who is not a named insured under another automobile insurance policy but not to any other person eligible for personal injury protection benefits to be provided under that policy in accordance with N.J.S.A. 39:6A-4. (d) Additional personal injury protection coverage pursuant to N.J.S.A. 39:6Al0 shall not be available to any named insured selecting the exclusion or to any relative resident in his household. (e) No new automobile insurance policy shall be issued on or after July 1, 1984 unless the option to exclude personal injury protection benefits in accord with this section is made available to the applicant. In the case of any automobile policy expected to be in force on July 1, 1984, the named insured shall be provided not later than May 15, 1984 with the opportunity to elect, effective July l, 1984, the personal injury protection coverage exclusion in accord with this section. Any notice of renewal of an automobile insurance policy with an effective date subsequent to July 1, 1984 shall be accompanied by a notice to the named insured providing the opportunity to elect personal injury protection coverage exclusion in accord with this subchapter. (f) A premium credit calculated and represented as a percentage of the applicable premium shall be provided for the exclusion. The premium percentage shall be uniform by filer on a statewide basis. (g) The buyer s guide and written notice specified in N.J.S.A. 39:6A-23 shall satisfy the requirements of this subchapter. (h) Should an applicant or named insured fail to elect the exclusion, full personal injury protection coverage pursuant to N.J.S.A. 39:6A-4 shall be deemed to have been selected and an appropriate premium shall be charged. (i) The exclusion elected by a named insured shall continue in force as to subsequent renewal or replacement policies until the insurer or its authorized representative receives a properly executed written request for its elimination. Amended. R.1984 d. 480, eff. November 5, 1984; R d. 58, effective February 5, 1996; R d. 591, effective December 21, 1998 (operative March 22, 1999). 11: Option to choose health care insurance coverage as primary coverage. (a) Pursuant to N.J.S.A. 39:6A-4.3, for policies issued or renewed on or after January 1, 1991, an insurer shall provide the option that other health insurance coverage or benefits of the insured, including health care services provided by a health maintenance organization and any coverage or benefits provided under any Federal or State program, are the primary coverage for medical expense benefits for personal injury protection coverage; provided, however, that this op-

54 11: APPENDIX B - REGULATIONS tion shall not apply to any coverage or benefits provided pursuant to Medicare or Medicaid. (b) The Coverage Selection Form (see N.J.A.C. 11:3-15.7) shall require insureds or prospective insureds to identify the health insurer(s) providing primary personal injury protection medical expense benefits. This identification shall fulfill the requirement in N.J.S.A. 39:6A-4.3 that named insureds provide proof that they and members of their family residing in the household are covered by health insurance coverage or benefits. Amended. R.1984 d.480, eff. November 5, Repealed. R d. 117,effective February 21, Adopted. R d. 580, effective November 19, 1990 (operative January 1, 1991). 11: Refund or credit of unearned premium. Every automobile insurer offering personal injury protection coverage shall establish a fair, practicable and non-discriminatory plan for the refund or application of credit of any unearned premium resulting from the selection of any deductible and/or exclusion option pursuant to this subchapter. Amended. R d. 117, effective February 21, : Filing requirements. (a) Every automobile filer shall submit to the Commissioner for approval filings of rates or manual rules which provide the optional medical expense benefit deductibles for personal injury protection coverage. (b) Within 30 days of the effective date of this subchapter, every automobile filer shall submit to the Commissioner for approval filings of rates or manual rules which provide the optional exclusion from personal injury protection coverage of income continuation benefits, essential service benefits, death benefits, and funeral expense benefits. (c) All filings submitted for approval pursuant to this subchapter, and all changes and amendments thereto, shall be prepared in accordance with insurance laws and regulations, including the applicable provisions of N.J.S.A. 17:29A-1 et seq. and N.J.A.C. 11:1-2 and the Department s existing filing procedures. (d) The filing of a rating organization shall be applicable to the members and subscribers of the organization who have authorized the organization to file on their behalf. Amended. R d. 117, effective February 21, : Application of the option to choose health care insurance coverage as the primary insurer. When an insured or prospective insured elects to have a health insurer provide primary personal injury protection medical expenses benefits, the medical expenses benefits available to the insured under his or her automobile policy s personal injury protection provisions shall become a secondary benefits provider. The order of benefit determination shall be in accordance with N.J.A.C. 11:3-37. Adopted. R d. 90, effective January 25, SUBCHAPTER 15. BUYER S GUIDE, COVERAGE SELECTION FORM, AND AUTOMOBILE INSURANCE CONSUMER BILL OF RIGHTS FOR STANDARD AND BASIC POLICIES Section 11: Purpose. 11: Scope. 11: Definitions.

55 BUYER S GUIDE; COVERAGE SELECTION FORM 11: : Compliance. 11: New Jersey Auto Insurance Buyer's Guide. 11: Minimum standards for Coverage Selection Forms. 11: Use of Coverage Selection Form; availability. 11: New Jersey Automobile Insurance Consumer Bill of Rights. 11: Penalties. 11: (Reserved). 11: (Reserved). APPENDIX Exhibit 1. Standard Policy Coverage Selection Form Exhibit 2. Certification of Compliance with N.J.A.C. 11:3-15.6(g)4 Exhibit 3. Basic Policy Coverage Selection Form 11: Purpose. (a) N.J.S.A. 39:6A-23 requires the Commissioner of the Department of Banking and Insurance to promulgate standards for the written notice to be provided to applicants for private passenger automobile insurance and to policyholders offered renewal of coverage. This written notice includes one of two versions of the Buyer's Guide and one of two versions of the Coverage Selection Form. (b) N.J.S.A. 17:29A-52a requires every insurer writing private passenger automobile insurance in this State to provide each insured at least annually and each applicant for insurance with an Automobile Insurance Consumer Bill of Rights. The Automobile Insurance Consumer Bill of Rights shall contain the information necessary, relevant or appropriate to improve the understanding of the rights and responsibilities of consumers and insurers regarding automobile insurance. (c) This subchapter implements the statutory requirements in (a) and (b) above and establishes the necessary minimum standards insurers shall use in giving notice of available coverages, options and rate credits and of the rights and responsibilities of consumers and insurers regarding automobile insurance. Adopted. R.1989 d.117, effective February 21, Amended. R.1990 d.580, effective November 19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, : Scope. (a) This subchapter applies to every insurer authorized to transact the business of private passenger automobile insurance in this State and to any automobile residual market mechanism created by any New Jersey statute. (b) This subchapter applies to every personal lines private passenger automobile insurance policies and individually-owned private passenger automobiles written on commercial insurance policies. Adopted. R.1989 d.117, effective February 21, Amended. R d. 580, effective November 19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effective March 15, : Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Basic automobile insurance policy or basic policy means those private passenger automobile insurance policies issued in accordance with N.J.S.A. 39:6A- 3.1 and N.J.A.C. 11:3-3. Commissioner means the Commissioner of the Department of Banking and Insurance. Department means the Department of Banking and Insurance of the State of New Jersey.

56 11: APPENDIX B - REGULATIONS Insurer means any person, corporation, association, partnership, company, reciprocal exchange and any other legal entity issuing a contract of private passenger automobile insurance, including any residual market mechanism established pursuant to any New Jersey statute. As appropriate, insurer shall also mean a servicing carrier for a residual market mechanism. Private passenger automobile insurance policy means a Standard policy as defined in N.J.S.A. 39:6a-3 or a Basic policy as defined in N.J.S.A. 39:6A-3.1 providing direct insurance on an automobile as defined in N.J.S.A. 39:6A-2. Standard automobile insurance policy or standard policy means a private passenger automobile insurance policy issued in accordance with N.J.S.A. 39:6A- 3 that includes the personal injury protection coverage described in N.J.S.A. 39:6A-4. Adopted. R d. 117, effective February 21, Amended. R d. 624, effective December 18, 1989 (operative January 1, 1990); R d. 580, effective November 19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d. 117, effective March 15, : Compliance. (a) No new private passenger automobile insurance policy or renewal shall be issued unless the application for the policy or renewal offer is accompanied by a Buyer's Guide, a Coverage Selection Form and an Automobile Insurance Consumer Bill of Rights that meet the minimum standards prescribed in this subchapter. 1. The renewal offer shall include the appropriate Buyer s Guide and Coverage Selection Form for the policy being renewed. 2. Where application for or renewal of an insurance policy is made via the Internet, compliance with (a) above shall be satisfied by having the Buyer s Guide, Coverage Selection Form and Automobile Insurance Consumer Bill of Rights readily available to the applicant/insured on the insurer s website. In addition to being readily available on the insurer s website, this information also may be placed on the producer s website, if provided or authorized by the insurer. 3. Where application for or renewal of an insurance policy is made via the telephone and coverage is bound during the telephonic transaction, compliance with (a) above shall be satisfied if the insurer, with the agreement of the applicant or insured, sends the insured the Buyer s Guide, a completed Coverage Selection Form showing the coverage choices made by the insured, and an Automobile Insurance Consumer Bill of Rights within five business days after the telephonic transaction is completed. Insureds may alter coverages based on their review of such documents by returning a signed Coverage Selection Form with the changes noted therein, or electronically, provided that the requirements of N.J.S.A. 12A:12-1 et seq. are satisfied and that such process is made available by the insurer. Such alterations shall be effective in accordance with N.J.A.C. 11:3-15.7(d)2. (b) The Buyer's Guide, Coverage Selection Form and Automobile Insurance Consumer Bill of Rights incorporate and therefore satisfy any and all other notice requirements previously set forth for the coverage options required by the New Jersey Automobile Reparation Reform Act, the New Jersey Automobile Insurance Reform Act of 1982, the New Jersey Automobile Insurance Freedom of Choice and Cost Containment Act of 1984, the Automobile Insurance Cost Reduction Act of 1998 and P.L. 2003, c.89. (c) As of June 6, 2011, each insurer that becomes authorized to write private passenger automobile insurance shall make a filing pursuant to N.J.A.C. 11:1-2. The filing shall consist of a certification in the form set forth in Exhibit 2 in the

57 BUYER S GUIDE; COVERAGE SELECTION FORM 11: subchapter Appendix, incorporated herein by reference, that the Lawsuit Option rate differentials in its Standard Policy Coverage Selection Form were calculated in accordance with N.J.A.C. 11:3-15.6(g)4. (d) An insurer may change the Lawsuit Option rate differentials in its approved Standard Policy Coverage Selection Forms by making a filing pursuant to N.J.A.C. 11:1-2 that specifies the effective date of the revised rate differentials that will be used and that includes the certification required by (c) above. Adopted. R.1989 d.117, effective February 21, Amended. R.1996 d.58, effective February 5, 1996; R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effective March 15, 2004; R.2005 d.83, effective March 7, 2005; R.2011 d.166, effective June 6, : New Jersey Auto Insurance Buyer's Guide. (a) There are established two Buyer s Guides for use by insurers: a personal lines Buyer s Guide and a commercial lines Buyer s Guide for individually owned vehicles written on commercial policies. The Buyer s Guides shall be available on the Department s website. 1. The personal lines Buyer s Guide can be found at dobi/division_insurance/byguide.doc. 2. The commercial Buyer s Guide can be found at division_insurance/commbyguide.doc. (b) The Buyer s Guide shall be reproduced in the format presented on the website, duplicating the information provided therein and, to the extent practicable, the layout, fonts, type-point sizes, colors and illustrations. Notwithstanding the foregoing, consistent with the requirements of N.J.A.C. 11:2-18.4, all text in the Buyer s Guide shall be printed on at least 10-point type on paper of a quality sufficient to assure that the printing does not bleed form one side to the other. (c) The Department shall notify insurers of any changes to the Buyer s Guides by Bulletin. Insurers shall provide the Buyer s Guide, as revised, for new and renewal business as soon as practicable, but no later than 90 days after the date of the Bulletin. The Buyer s Guide shall provide general descriptions of: 1. How to begin to shop for auto insurance; 2. The types of policies available and the basic differences between them; 3. Various insurance coverages such as Personal Injury Protection (PIP), Liability (including bodily injury and property damage liability coverage), Uninsured/Underinsured Motorists, Collision and Comprehensive; 4. Policy terms such as limits, deductibles, producer and direct writer; 5. PIP options such as deductibles and health care primary and PIP package coverage such as income continuation, essential services, death benefit and funeral expense benefit; 6. Comprehensive and Collision options such as limits, deductibles and named driver exclusions; 7. A Lawsuit Limitation Selection Guide that explains the tort threshold options with a warning that insurance companies and their producers shall not be held liable for the consumer s choice of right to sue options; and 8. Information on how the consumer can contact the Department of Banking and Insurance. (d) In addition, the Buyer s Guide may include company-specific information, such as its name and/or company logo, contact information and company-specific coverage options, provided that the information is consistent with the purposes of this subchapter.

58 11: APPENDIX B - REGULATIONS (e) The Buyer s Guide shall contain a statement advising the insured or applicant that additional information concerning coverages or premiums is available by contacting the insurer or the producer. Insurers that write at least two percent of the New Jersey private passenger automobile market shall provide a toll-free telephone number for this purpose. (f) As required by N.J.S.A. 17:29E-11, the Buyer s Guide shall contain a notice describing the functions of the Insurance Claims Ombudsman, the mailing address of the Ombudsman and a toll-free information telephone number. Adopted. R.1989 d.117, effective February 21, Amended. R.1989 d. 624, effective December 18, 1989 (operative January 1, 1990); R.1990 d.580, effective November 19, 1990 (operative January 1, 1991). Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended. R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, : Minimum standards for Coverage Selection Forms. (a) Each insurer shall have a separate Coverage Selection Form for the Standard Policy and for the Basic Policy using the text found in the Appendix, Exhibits 1 and 3 incorporated herein by reference. (b) The Coverage Selection Forms shall contain a statement advising the insured or applicant that additional information concerning coverages or premiums is available by contacting the insurer or the producer. Insurers that write at least two percent of the New Jersey private passenger automobile market shall provide a toll-free telephone number for this purpose. (c) Except as otherwise provided in the text, each Coverage Selection Form shall be printed in at least 10-point type on a paper size that is easily readable. (d) In addition to the required text, each Coverage Selection Form shall include space at the top for the consumer's name and any other necessary information such as policy number, etc. The bottom of each Coverage Selection Form shall have space for the consumer's signature and date. 1. Text in the Appendix, Exhibits 1 and 3 in italics, thus, is instructions or options for the insurer and should not be printed in the Coverage Selection Form. 2. Text in uppercase letters denotes section headings, defined terms or is for emphasis. Insurers are not restricted to uppercase for these purposes in formatting the Coverage Selection Forms. (e) An insurer may expand the form to solicit additional relevant information, including, but not limited to, the names of resident relatives eligible for PIP benefits. (f) Each Coverage Selection Form shall include the range of premium rate differences as indicated by the text in the Exhibits. Each insurer shall determine the range of premium rate differences for use in these sections. Premium rate differences for the Lawsuit Options in the Standard Policy Coverage Selection Form, Appendix, Exhibit 1 shall be calculated according to (g) below. When the range of premium rate differences on a Coverage Selection Form changes for any reason, including, but not limited to, rate changes, a new Coverage Selection Form with the current numbers shall be filed with the Department in accordance with N.J.A.C. 11:3-15.4(d). (g) Each insurer shall calculate the percentage and dollar change in premium (or rate) from the selection of the No Limitation on Lawsuit Option in accordance with (g)1 through 4 below. In these calculations, premium (or rate) shall include any expense fee.

59 BUYER S GUIDE; COVERAGE SELECTION FORM 11: The Percentage Change Calculation: The range of percentage increase in the bodily injury liability premium arising from the selection of the No Limitation on Lawsuit Option shall be calculated as follows: i. The low end of the percentage range shall be produced by calculating the percentage increase in the bodily injury liability premium of a policy with a $250,000/$500,000 split limit or a $500,000 single limit for a change from the Limitation on Lawsuit Option to the No Limitation on Lawsuit Option. This calculation shall be made for the territory with the lowest basic limit Limitation on Lawsuit Option rate, and shall assume standard tier, pleasure usage by an age 30-64, married male principal operator. ii. The high end of the percentage range shall be produced by making the same type of calculation using a policy with minimum limits for the territory with the highest basic limit Limitation on Lawsuit Option rate, and shall assume business usage by a standard-tier, 22 year old, unmarried male principal operator. 2. The Dollar Change Calculation: The range of dollar increase in the bodily injury liability premium arising from the selection of the No Limitation on Lawsuit Option shall be determined by subtracting the Limitation on Lawsuit Option rate from the comparable No Limitation on Lawsuit Option rate for the following two rating examples: i. The low end of the dollar range shall be a policy with minimum limits for the territory with the lowest basic limit Limitation on Lawsuit Option rate, and shall assume standard tier, pleasure usage by an age 30-64, married male principal operator. ii. The high end of the dollar range shall be calculated at a $250,000/$500,000 split limit or a $500,000 single limit policy for the territory with the highest basic limit Limitation on Lawsuit Threshold Option, and shall assume business usage by a standard tier, 22 year old, unmarried male principal operator. iii. Because the range of the possible additional dollar cost will depend upon territory, bodily injury liability loss limits, and other factors, insurers shall be permitted to use round numbers to represent the approximate range of the cost increase. For example, if the smallest dollar rate increase was $54.00 and the largest $305.00, the insurer may use the range $50.00 to $ on its Coverage Selection Form. 3. Premium Basis for Single Limit Liability Coverage: i. For single limit liability coverage, the percentage range calculation that is described in (g)1 above shall be based upon the applicable liability rate. This calculation shall be made on the basis of a combined rate containing a charge for bodily injury liability, and property damage liability. ii. For single limit liability coverage, the dollar range calculation that is described in (g)2 above shall be based upon the applicable liability rate. In contrast to the procedure in (g)3i above, the dollar change calculation shall be made on the basis of a complete rate containing a charge for bodily injury liability, personal injury protection (PIP), and property damage liability. 4. Insurers shall prepare: i. An example showing the calculation of the high and low values for the percentage and dollar change ranges; ii. Data about the insurer's territorial rates to confirm that the highest and lowest basic limit Limitation on Lawsuit Option rates have been used in the example. A rating page showing a list of Standard tier, basic limit rates by territory shall be sufficient;

60 11: APPENDIX B - REGULATIONS iii. Data about the insurer's increased limits liability rating, vehicle usage, and type of driver factors to confirm that the proper relativities have been used in the example. The appropriate rating pages shall be sufficient; and iv. For those insurers offering only single limit liability coverage, an explanation of the procedure used to develop the bodily injury liability rate from which the percentage and dollar change amounts have been determined. This explanation shall include an example of the calculation methodology. Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2011 d.166, effective June 6, : Use of Coverage Selection Form; availability. (a) For all new policies, an insurer or an insurance producer shall receive a Coverage Selection Form signed by the named insured and indicating the prospective insured's coverage choices. Coverage shall not become effective until the signed Coverage Selection Form is received from the named insured, unless otherwise authorized by law. (b) For the mid-term policy changes set forth in (b)1 through 5 below, the insurer shall receive a Coverage Selection Form signed by the named insured prior to making the change. 1. Change of policy type to Standard or Basic; 2. Change of Lawsuit Option (Standard Policy only): 3. Change of primary coverage for PIP medical expense benefits coverage (from or to Health Insurer Primary) (Standard Policy only); 4. Change in PIP Medical Expense Coverage Limit (Standard Policy only); and 5. Addition or deletion of Liability Coverage (Basic Policy only). (c) An insurer may require that other policy changes be made by signed Coverage Selection Form. (d) All coverage changes that are required to be made by a signed Coverage Selection Form, either by this subchapter or by the insurer, shall become effective in the following manner, except when coverage for comprehensive or collision is effected by a required inspection pursuant to N.J.A.C. 11: For new policies, the choices on the Coverage Selection Form shall be effective on the policy effective date; 2. For mid-term policy changes, the choices on the Coverage Selection Form shall be effective the day following the date of postmark or, when personal delivery is made or if the postmark is illegible, the day following receipt of the signed Coverage Selection Form by the insurer or an insurance producer. If the change is made electronically, the change shall be effective the day following date of receipt as determined in accordance with N.J.S.A. 12A:12-15; 3. For changes upon renewal, the changes shall be effective on the date of the next policy renewal if postmarked or received by the insurer or by an insurance producer prior to the renewal date. New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended. R d. 44, effective February 5, 2001; R.2004 d.117, effective March 15, 2004; R.2005 d.83, effective March 7, : New Jersey Automobile Insurance Consumer Bill of Rights. (a) The insurer shall produce a Consumer Bill of Rights by reproducing the New Jersey Automobile Insurance Consumer Bill of Rights available on the Department s website at The Department shall notify insurers of any changes to the Consumer Bill of Rights by Bulletin. Insurers shall

61 BUYER S GUIDE; COVERAGE SELECTION FORM11: provide the Consumer Bill of Rights, as revised, with new and renewal business 60 days after the date of the Bulletin. (b) The Consumer Bill of Rights shall be reproduced in the format as presented on the website, duplicating the language provided therein, and to the extent practicable, the layout, fonts, type-point sizes, colors and illustrations. Notwithstanding the foregoing, all language bolded on the Consumer Bill of Rights as depicted on the Department s website shall be bolded and no type-point sizes less than 10 point shall be used. (c) The Consumer Bill of Rights shall contain: 1. An overview containing the purpose of the Bill of Rights; 2. The consumer s obligations with regard to their insurance; 3. The duties of the insurer concerning the application process; 4. The consumer s general insurance rights regarding denials and right to purchase; 5. The consumer s right to appeal a cancellation of insurance; 6. Instructions on how to be an educated insurance consumer; and 7. A statement advising the insured or applicant that additional information concerning the Coverage Selection Form and Buyer s Guide is available by contacting the insurer or the producer. Amended. R.2006 d.243, effective July 3, : Penalties. Failure to comply with the provisions of this subchapter may result in the imposition of penalties as prescribed by law. Recodified from N.J.A.C. 11: by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); Re-recodified from 11: by R.2004 d.117, effective March 15, : (Reserved). Repealed by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). 11: (Reserved). Recodified to N.J.A.C. 11: by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). EXHIBIT 1 STANDARD POLICY COVERAGE SELECTION FORM Name: This Coverage Selection Form is for a STANDARD POLICY, see Buyer's Guide, page insert page # here. A BASIC POLICY with the minimum of required coverages is also available for a lower premium. A SPECIAL POLICY with a very low premium is also available for persons enrolled in Medicaid. Contact your insurer or producer for more information. BODILY INJURY LIABILITY--Buyer's Guide page insert page # here Choose the Bodily Injury Liability Limits that you want: At least four of the most popular coverage limits shall be listed, including the lowest limit offered. If a complete list is not provided, state that other coverage limits are available. PROPERTY DAMAGE LIABILITY--Buyer's Guide page insert page # here Choose the Property Damage Limits you want:

62 11: APPENDIX B - REGULATIONS At least four of the most popular coverage limits shall be listed, including the lowest limit offered. If a complete list is not provided, state that other coverage limits are available. For insurers offering combined single limits, substitute at least four of the most popular combined single limits, including the lowest offered. PERSONAL INJURY PROTECTION (PIP)--Buyer's Guide insert page # here [ ] I choose the standard PIP Medical Expense Limit of $250,000. Include higher limit if offered [ ] I choose one of the lower PIP Medical Expense Limits below. WARNING: Prior to insert effective date of P.L. 1998, c.21, all auto insurance policies had PIP Medical Expense Benefit limits of $250,000. The limits below provide you with less coverage. Warning must be in at least 12 point type. [ ] $150,000* for a % to % reduction in the PIP premium [ ] $75,000* for a % to % reduction in the PIP premium [ ] $50,000* for a % to % reduction in the PIP premium [ ] $15,000* for a % to % reduction in the PIP premium * Even if you choose one of the amounts above, all medically necessary treatment over the policy limit up to $250,000 will be paid for permanent or significant brain injury, spinal cord injury or disfigurement or treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until a doctor says that you no longer require critical care. Choose the PIP Medical Expenses Deductible you want: [ ] $250 deductible, minimum required by law. [ ] $500 deductible, for a % to % reduction in the PIP premium. [ ] $1,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,500 deductible, for a % to % reduction in the PIP premium. Health Insurer for PIP Option [ ] I choose the health insurer for PIP option--buyer's Guide, page insert page # here. The name of my health insurer(s) is (are): 1. Policy/Group #/Certificate # 2. Policy/Group #/Certificate # Extra PIP Package Coverage Options The Extra PIP Package benefits include income continuation, essential services, death benefits and funeral expense benefits--buyer's Guide page insert page # here You may choose not to have the Extra PIP Package benefits for a % to % savings in the PIP premium. Include the range of percentage savings and the base PIP premium I choose PIP Medical Expense Only You may choose to have higher limits for the Extra PIP Package of Income Continuation, Essential Services, Death and Funeral Benefits. Buyer's Guide page insert page # here Insert a chart listing options and choices

63 BUYER S GUIDE; COVERAGE SELECTION FORM11: UNINSURED/UNDERINSURED MOTORIST COVERAGE--Buyer's Guide, Page insert page # here You may choose one of the following higher limits of Uninsured/Underinsured Motorist Coverage, up to your Bodily Injury Liability Insurance Limit. List the same options available for bodily injury liability coverage above. Other options may also be listed. COLLISION COVERAGE--Buyer's Guide, page insert page # here [ ] No, I choose not to be covered for collision damage. [ ] Yes, I choose to be covered for collision damage with the default $750 deductible. [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from company or insurance producer (i.e., agent or broker). [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available COMPREHENSIVE COVERAGE Buyer s Guide page insert page # here. If appropriate, use the term other than collision coverage throughout this section [ ] No, I choose not to be covered for comprehensive damage. [ ] Yes, I choose to be covered for comprehensive damage with the default $750 deductible. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance producer. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available For both collision and comprehensive, if either the $200 deductible or $250 deductible is not offered, that option may be deleted from this form. Also, all other available collision and comprehensive deductibles shall be listed where appropriate. WARNING: Insurers or their producers or representatives shall not be held liable for choices you make for insurance coverages or limits as long as your choices provide at least the minimum coverage required by law. Insurers or their producers or representatives also shall not be held liable if you choose not to purchase higher limits of PIP medical expense coverage, higher limits of uninsured/underinsured motorists coverage, collision coverage or comprehensive coverage. Insurers, their producers and representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17: for more information. Warning must be in at least 12 point type.

64 11: APPENDIX B - REGULATIONS LAWSUIT OPTIONS, Buyer's Guide, page insert page # here [ ] I want the Limitation on Lawsuit Option. [ ] I want the No Limitation on Lawsuit Option. My bodily injury liability premium will be % to % higher if I select the No Limitation on Lawsuit option instead of the Limitation on Lawsuit option, depending upon where my car is garaged, my bodily injury liability coverage limit, and other factors. Per vehicle, my bodily injury liability premium at current rates will be $ to $ higher on each renewal of my policy if I select the No Limitation on Lawsuit option instead of the Lawsuit option. I understand that I can contact my insurer or my insurance producer for specific details. Insurance companies writing six month policies should insert the word semiannual in the blank space above. Companies writing 12 month policies should insert the word annual. Insurance companies writing single limit liability coverage may add a footnote to inform insureds that the policy declaration page will not include a specific premium for bodily injury liability coverage. WARNING: Insurance companies or their producers or representatives shall not be held liable for your choice of lawsuit option (limitation on lawsuit option or no limitation on lawsuit option). Insurers or their producers or representatives also shall not be liable if the limitation on lawsuit option is imposed by law because no choice was made on the coverage selection form. Insurers, their producers or representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17: for more information. Warning must be in at least 12 point type. STATEMENT OF INSURED or APPLICANT: I have read the Buyer's Guide outlining the coverage options available to me. The limits available for PIP medical expense coverage and uninsured and underinsured motorists coverage have been explained to me. My choices are shown above. I agree that each of these choices will apply for all vehicles insured by my policy and to each subsequent renewal, continuation, replacement or amendment until the insurer or its insurance producer receives my request that a change be made. For new policyholders, I understand that: (a) If I do not make a choice to have the No Limitation on Lawsuit Option, I will receive the Limitation on Lawsuit option; (b) If I carry collision and/or comprehensive coverage without making a written choice of deductible, I will receive the default $750 deductible; (c) If I do not choose to have my health insurer provide PIP medical expense benefits, my auto insurer will provide PIP medical expense benefits; and (d) If I do not choose a lower PIP medical expense limit, I will receive the $250,000 limit. I understand that if this is a policy renewal and if I do not complete choices, I will receive the same coverage as in my previous policy except when changes are required by a law becoming effective during the term of my previous policy. I understand that these choices take effect in the following manner: (1) For new policies, on the effective date of the policy; (2) For mid-term policy changes, on the day following the date of postmark or, when personal delivery is made or the postmark is illegible, the day following receipt of this form by the insurer or producer; and

65 BUYER S GUIDE; COVERAGE SELECTION FORM11: (3) For changes upon renewal, on the date of the next policy renewal if postmarked or received by the insurance company or by an insurance producer prior to the renewal date. ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATE- MENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL AND CRIMINAL PENALTIES. Please check the appropriate box to which this form applies: [ ] New Policy [ ] Mid-Term Change [ ] Renewal Change SIGNATURE OF NAMED INSURED OR APPLICANT DATE EXHIBIT 2 CERTIFICATION OF COMPLIANCE WITH N.J.A.C. 11:3-15.6(G)4 I hereby certify that the Lawsuit Option rate differentials in the Standard Policy Coverage Selection Form for (Name of Insurance Company) were calculated in accordance with N.J.A.C. 11:3-15.6(g)4. Signature Print Name Title Telephone Number EXHIBIT 3 BASIC POLICY COVERAGE SELECTION FORM Name: This Coverage Selection Form is for a BASIC POLICY, see Buyer's Guide, page insert page # here. A STANDARD POLICY with more coverages and higher limits is also available for a higher premium. A SPECIAL POLICY with a very low premium is also available for persons enrolled in Medicaid. Contact your insurer or producer for more information. BODILY INJURY LIABILITY--Buyer's Guide page--insert page # here [ ] Yes, I choose the $10,000 Bodily Injury Liability Limit. [ ] No, I do not choose to have Bodily Injury Liability Coverage. WARNING: If you do not choose to have Bodily Injury Liability Coverage and you are at fault in an accident where people are injured or die, you will be responsible for paying for the pain, suffering and other personal hardships and some economic damages, such as lost wages that you cause. Your insurer will not pay a judgment against you or pay for a lawyer to defend you if you are sued. Your assets will be at risk, including having money deducted from your wages if a judgment is entered against you. Warning must be in at least 12 point type. WARNING: Insurers or their producers or representatives shall not be held liable for choices you make for insurance coverages or limits as long as your choices provide at least the minimum coverage required by law. Insurers or their producers or representatives also shall not be held liable if you choose to purchase a

66 11: APPENDIX B - REGULATIONS basic policy instead of a standard policy, or if you choose not to purchase bodily injury liability coverage, collision coverage or comprehensive coverage. Insurers, their producers and representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17: for more information. PERSONAL INJURY PROTECTION--Buyer's Guide, page insert page # here WARNING: For a BASIC POLICY, the limit on PIP Medical Expense Coverage is $15,000 but includes up to $250,000 for emergency care of certain catastrophic injuries (See Buyer's Guide page insert page # here). Prior to insert effective date of P.L. 1998, c.21, all automobile insurance policies had PIP Medical Expense limits of $250,000. The PIP Medical Expense Coverage for a BASIC POLICY is significantly less than previously required by law. Warning must be in at least 12 point type. Choose the PIP Medical Expenses Deductible you want: [ ] $250 deductible, minimum required by law. [ ] $500 deductible, for a % to % reduction in the PIP premium. [ ] $1,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,500 deductible, for a % to % reduction in the PIP premium. COLLISION COVERAGE--Buyer's Guide, page insert page # here [ ] No, I choose not to be covered for collision damage. [ ] Yes, I choose to be covered for collision damage with the basic deductible. [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance producer. [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available COMPREHENSIVE COVERAGE Buyer's Guide page insert page # here. If appropriate, use the term other than collision coverage throughout this section [ ] No, I choose not to be covered for comprehensive damage. [ ] Yes, I choose to be covered for comprehensive damage with the default $750 deductible. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance producer. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available. These sections should be omitted by insurers that do not offer collision and comprehensive coverage in the Basic Policy. For both collision and comprehensive, if either the $200 deductible or $250 deductible is not offered, that option may be deleted from this form. Also, all other available collision and comprehensive deductibles shall be listed where appropriate. STATEMENT OF INSURED or APPLICANT:

67 NOTIFICATION BY MEDICAL PROVIDERS 11:3-15 I have read the Buyer's Guide outlining the coverage options available to me. I understand that this is a BASIC POLICY with the minimum coverages required by law and that a Standard Policy with higher limits and additional coverages is available. The option to buy Bodily Liability Coverage has been explained to me. My choices are shown above. I agree that each of these choices will apply for all vehicles insured by my policy and to each subsequent renewal, continuation, replacement or amendment until the insurer or its insurance producer receives my request that a change be made. For new policyholders, I understand that: (a) Unless I choose to have the $10,000 Bodily Injury Liability Coverage, I will not receive any Bodily Injury Liability Coverage; (b) If I choose collision or comprehensive coverage without making a written choice of deductible, I will receive the $750 deductible; I understand that if this is a policy renewal and if I do not complete choices, I will receive the same coverage as in my previous policy except when changes are required by a law becoming effective during the term of my previous policy. I understand that these choices take effect in the following manner: (1) For new policies, on the effective date of the policy; (2) For mid-term policy changes, on the date of postmark or, when personal delivery is made or if the postmark is illegible, the day following receipt of this Form by the insurers or by a producer; and (3) For changes upon renewal, on the date of the next policy renewal if postmarked or received by the insurance company or by an insurance producer prior to the renewal date. ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATE- MENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL AND CRIMINAL PENALTIES. Please check the appropriate box to which this form applies. [ ] NEW POLICY [ ] Mid-Term Change [ ] Renewal Change SIGNATURE OF NAMED INSURED OR APPLICANT DATE New Rule, R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended, R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, SUBCHAPTER 25. PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS Source and Effective Date. R.1997 d.14, effective January 6, Section 11: Purpose and scope. 11: Definitions. 11: Notification of commencement of treatment. 11: Content of notice and proof of receipt. 11: Late notification. 11: Standards for adjustment of reduction. 11: Payment from insurers only.

68 11: APPENDIX B - REGULATIONS 11: Procedure for appeals. 11: Reporting requirement. 11: Compliance. APPENDIX A Notification of Commencement of Medical Treatment APPENDIX B Address for Notification of Commencement of Medical Treatment 11: Purpose and scope. (a) The purpose of this subchapter is to implement N.J.S.A. 39:6A-5, as amended by P.L. 1995, c.407, by establishing procedures to be followed by treating medical providers to give timely notification of the commencement of medical treatment for injuries sustained in automobile accidents. The subchapter sets forth: 1. Time limits for the filing of notification of the commencement of treatment for PIP claims; 2. The actions to be taken upon failure to comply with the notification time limits, including reduction or denial of claim payments; 3. The factors to be considered in evaluation of a late notification; and 4. The rights of providers when payment is reduced or denied for failure to comply with the notification requirements. (b) This subchapter shall apply to every insurer authorized to transact the business of automobile insurance in this State. The subchapter applies to treatment for injuries resulting from automobile accidents that occur after July 8, : Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Coverage status means the status of PIP coverage for an injured party pursuant to N.J.S.A. 39:6A-5. Department means the Department of Banking and Insurance of the State of New Jersey. Eligible charge means the treating medical provider's usual, customary and reasonable charge or the upper limit on the medical fee schedule as found in N.J.A.C. 11:3-29.6, whichever is lower subject to provisions of N.J.A.C. 11: Emergency care means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Such emergency care shall include all necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospital care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency care extends during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Multiple treating medical provider means a treating health care provider as defined herein that provides emergency care, in association with one or more other treating medical providers. Notification or notice means a written communication, transmitted by mail, facsimile or electronic message ( ).

69 NOTIFICATION BY MEDICAL PROVIDERS 11: Personal injury protection or PIP means the coverage set forth at N.J.S.A. 39:6A-4, 39:6A-3.1, or the emergency personal injury protection coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89. PIP information means: the name and address of the insured and the name and address of the injured party, if different; the name of the PIP insurer and the address established by the insurer for notification of commencement of medical treatment pursuant to N.J.A.C. 11:3-25.3(c); the policy number of the insurance policy providing PIP benefits; and the date of the accident/injury. A treating medical provider may obtain this information from the insured, the injured party, the hospital, a police report or any other reasonably available source. Secondary medical providers means those health care providers who provide medical products, care and services to a person injured in an automobile accident only after having received a prescription from a treating health care provider. Secondary medical providers shall include, but are not limited to, pharmacists, visiting nurses, prosthetics fabricators and providers of durable medical equipment products. Notwithstanding the existence of a prescription of a treating medical provider, physical therapists, chiropractors and any secondary medical provider who seeks payment of an eligible charge in excess of $ for individual services or products provided on one occasion or in the course of 30 days shall not be considered secondary medical providers. Treating health care provider means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to: 1. A hospital or health care facility which is maintained by a state or any of its political subdivisions; 2. A hospital or health care facility licensed by the Department of Health and Senior Services; 3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency clinics or offices, and private treatment centers; 4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital; 5. Hospitals or other health care facilities or treatment centers located in other states or nations; 6. Physicians licensed to practice medicine and surgery; 7. Licensed chiropractors; 8. Licensed dentists; 9. Licensed optometrists; 10. Licensed pharmacists; 11. Licensed chiropodists (podiatrists); 12. Registered bio-analytical laboratories; 13. Licensed psychologists; 14. Licensed physical therapists; 15. Certified nurse-midwives; 16. Certified nurse-practitioners/clinical nurse-specialists 17. Licensed health maintenance organizations; 18. Licensed orthotists and prosthetists; 19. Licensed professional nurses; 20. Licensed occupational therapists; 21. Licensed speech-language pathologists; 22. Licensed audiologists;

70 11: APPENDIX B - REGULATIONS 23. Licensed physician assistants; 24. Licensed physical therapists assistants; 25. Licensed occupational therapy assistants; and 26. Providers of other health care services or supplies, including durable medical goods. Amended. R 1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, effective June 7, : Notification of commencement of treatment (a) When medical treatment is rendered for which a claim for payment will be made pursuant to the PIP coverage of a private passenger automobile insurance policy, a treating health care provider shall provide notice to the PIP insurer no later than 21 days following the date of the commencement of such treatment. (b) In accordance with the PIP information provided by the injured party or the insured, notice shall be sent by the treating health care provider to the insurer at the address established by the insurer for the receipt of such notice. (c) Insurers shall establish one address where notice must be sent by treating health care providers pursuant to these rules. Insurers shall provide this address, and may provide a facsimile transmission number, and address if any, on all insurance identification cards issued by the insurer after January 6, (d) In accordance with the provisions of N.J.A.C. 11: , insurers shall file with the Department the address, and may provide a facsimile transmission number, and address, if any, where notice of commencement of treatment should be sent. Insurers shall also include the name and telephone number of a contact person at the insurer for this purpose. Such information shall be added to a list of insurer addresses maintained by the Department. (e) Notice sent to the address printed on a valid insurance identification card or on the Department's current list of addresses shall be presumed to have been sent to the proper address. (f) Within 14 days after receiving notice of the commencement of treatment, the insurer shall notify the treating health care provider of the coverage status of the person receiving treatment. If the notice from the insurer states that the coverage status of the person receiving treatment is unknown, the insurer shall make a determination of coverage and provide written confirmation to the treating health care provider no later than 60 days from receipt of notice of commencement of treatment. Examples where the coverage status may not be known are when the injured person is not a named insured, principal or occasional operator, or is not otherwise listed as a resident of the insured household on the most recent information provided to the insurer by the named insured. (g) The notice requirements set forth in (a) through (c) above and the eligible charge reductions contained in N.J.A.C. 11: shall not apply to secondary medical providers, except as noted in the definition of that term found in N.J.A.C. 11: (h) In calculating the time for notice in (a) and (f) above, the day treatment begins or the day the insurer receives notice from the treating health care provider is not to be included. If the last day for providing notice falls on a Saturday, Sunday or legal holiday, the time runs to the next business day. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999). 11: Content of notice and proof of receipt (a) The treating health care provider shall send the written notice required by N.J.A.C. 11:3-25.3(a) to the PIP insurer on either:

71 NOTIFICATION BY MEDICAL PROVIDERS 11: The Notification of Commencement of Medical Treatment Form found in Appendix A, appended to and incorporated by reference in this subchapter; or 2.A bill or invoice rendered by the treating health care provider that includes the information required in the Notification of Commencement of Medical Treatment Form in Appendix A. (b) When any notice required by this subchapter is mailed, the postmark shall be the proof of mailing. The insurer shall retain evidence of untimely mailing of the notice whenever it denies or reduces payment pursuant to N.J.A.C. 11: (c) If facsimile or notice is authorized by the insurer, and any notice required by this subchapter is sent by facsimile or by , the proof of notice shall be the facsimile transmission receipt generated by the sender's facsimile machine, a copy of the message showing the date and time of transmittal or an acknowledgment of receipt generated by the receiving system. Nothing in this section shall prohibit treating health care providers and insurers from mutually agreeing to accept other proofs of notice for electronic transmissions. It shall be the responsibility of the treating health care provider to retain proof of notice of commencement of treatment transmitted by facsimile or other electronic means. (d) Any notice given pursuant to this subchapter shall be deemed to have been made on the date of postmark or the date of transmission in the case of facsimile transmission and . (e) When a bill or invoice is used to provide notice of the commencement of treatment in accordance with this subchapter, it shall not be deemed to constitute notice unless the following message appears on the first page of the bill or invoice: 21 DAY NOTICE or FIRST BILL 21 DAY NOTICE. this message shall be in contrasting color ink and be in at least 12 point capital letters. Use of a rubber stamp or affixed label is acceptable for purposes of complying with this subsection. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999). 11: Late notification (a) In the event notice of commencement of medical treatment is made after 21 days, the insurer shall advise the treating health care provider in writing of the late notification and may reserve the right to deny or reduce payment in accordance with (b) below. (b) Where notice of the commencement of medical treatment is not timely provided in accordance with this subchapter, an insurer may apply the following reductions to the eligible charges: to 30 days after the commencement of treatment: 10 percent reduction to 60 days after the commencement of treatment: 25 percent reduction to 120 days after the commencement of treatment: 50 percent reduction to 160 days after the commencement of treatment: 75 percent reduction or more days from the commencement of treatment: 100 percent reduction. (c) If notice is not provided as required by this subchapter, the reduction formula set forth in (b) above shall apply to all eligible charges for which the treating health care provider seeks payment through such late notice. (d) Insurers shall not reduce an eligible charge under the following circumstances: 1. When the provider is a multiple treating health care provider giving emergency care as defined in N.J.A.C. 11:3-25.2; 2. When the provider is a secondary medical provider as defined in N.J.A.C. 11:3-25.2;

72 11: APPENDIX B - REGULATIONS 3. When the medical condition of the injured party made it impossible to comply with the notice requirement; or 4. When the provider has submitted a request for decision point review or precertification of treatment, diagnostic testing or durable medical equipment in accordance with an insurer s decision point review plan approved in accordance with N.J.A.C. 11:3-4.7 Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, effective June 7, : Standards for adjustment of reduction (a) Notwithstanding the reductions set forth in N.J.A.C. 11:3-25.5(b), insurers may choose to pay the full or a less reduced amount of an eligible charge based upon consideration of the following factors: 1. Whether the treating health care provider has previously provided untimely notice under this subchapter or has established a pattern of untimely notice; 2. The cost of medical treatment provided by the treating health care provider between the time treatment commenced, when notice was due and when it was provided; 3. The injured party was a pedestrian who did not have PIP coverage as the named insured or resident relative under another policy and the circumstances are such that additional time is necessary to identity the policy under which coverage is being provided; 4. Any potential adverse impact on the public and 5. Such other factors as the insurer may determine. (b) Within 60 days of receipt of notice, or such additional time as may be afforded under N.J.S.A. 39:6A-5g, the insurer shall give the treating health care provider notice of its final determination as to payment, reduction or denial of payment of an eligible charge. Such notice shall be clearly labeled Final Determination, and it shall refer clearly to the injured party, the insured, the claim number, the date of accident, the date of first treatment, the date notice of the commencement of treatment was made and the acceptance or rejection of any of the standards of adjustment of the reduction in (a) above and N.J.A.C. 11:3-25.5(b). Amended. R d. 591, effective December 21, 1998 (operative March 22, 1999). 11: Responsibility for payment Whenever an eligible charge has been reduced or denied pursuant to N.J.A.C. 11:3-25.5(b), the treating health care provider shall not seek to obtain payment directly from the insured or the person receiving treatment. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999). 11: Procedure for appeals A treating health care provider who fails to notify the insurer within 21 days and whose claim has been reduced or denied by the insurer pursuant to N.J.A.C. 11:3-25.5(b) may, in the discretion of a judge of Superior Court, be permitted to refile such claim provided that the insurer has not been substantially prejudiced thereby. Application to the court for permission to refile a claim shall be made within 14 days of the receipt of the insurer's final determination of reduction or denial of payment and shall be made upon motion based upon affidavits showing sufficient reasons for the failure to notify the insurer within 21 days of the commencement of treatment. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).

73 NOTIFICATION BY MEDICAL PROVIDERS 11: : Reporting requirement (a) By February 5, 1997, every insurer shall file with the Department the address, facsimile number (if notice by facsimile is permitted) and address, if any, of the designated location for the filing of notice required under this subchapter. Insurers shall use Appendix B, appended to and incorporated by reference in this subchapter, to report the information required by this subsection. (b) Insurers shall complete and file the information in Appendix B by January 1 of each year. (c) Completed copies of Appendix B shall be submitted to: Department of Banking and Insurance Director of Public Affairs PO Box 325 Trenton, New Jersey : Compliance. For treatments rendered between January 6, 1997 and July 6, 1997, all eligible charge reductions set forth in N.J.A.C. 11:3-25.5(b) shall be reduced by 50 percent (for example, a 10 percent reduction shall be five percent, a 25 percent reduction shall be 12.5 percent, etc.). APPENDIX A Notification of Commencement of Medical Treatment (to be filed with insurer) Name, address and phone No. of Treating Health Care Provider: Fax No. (optional) Name and address of patient: Name and address of insured: (if different) Insurer Name: Insurer Address: Policy No. Date of accident/injury: Date of first treatment: APPENDIX B Address for Notification of Commencement of Medical Treatment Insurance Co. Name:

74 11: APPENDIX B - REGULATIONS NAIC Group #: NAIC Company #: Address established by insurer for the filing of the notification of the commencement of PIP treatment by Treating Health Care Providers Address: Facsimile No: Contact Person: Phone: To be filed with: Department of Banking and Insurance Division of Public Affairs PO Box 325 Trenton, New Jersey Attn: Notification of Treatment List SUBCHAPTER 26. UNSATISFIED CLAIM AND JUDGMENT FUND: NOTICE OF INTENT Section 11: Claim information. 11: Claim filing; form. 11: Claim information. (a) Notice of intention to make a claim under N.J.S.A. 39:6-65 shall contain the following information: 1. The claimant s name, address, date of birth and social security number; 2. The time, date, location, municipality and county in which the loss occurred; 3. The identity of the operators and vehicles involved in the accident, including the name and address of the owner and operator and the license plate number of the vehicle; 4. Such witnesses to said accident as are then known; 5. A short description of the accident, including the claimant s role or position therein; 6. A description of the injuries then known, and attached thereto a medical certificate if then available. In any event the medical certificate shall be filed as soon as available; 7. A description of the damage sustained to property, and attached thereto an estimate of the cost of repairs if then available; and 8. The policy number of any insurance applicable to the accident, including the name and address of all insurance companies involved. Amended. R d. 45, effective February 4, 1991; Amended. R d. 58, effective February 5, : Claim filing; form. (a) A Notice of Intention to Make Claim under N.J.S.A. 39:6-65 may be filed on the form designated by the Unsatisfied Claim

75 UCJF 11:3-28 and Judgment Fund Board identified as a Notice of Intention to Make Claim, incorporated herein by reference as Appendix A [See Appendix C-20] (b) A written notice to the Board in any other form that contains the information required by this section shall be acceptable. (c) A notice of intention to make a claim that does not contain the items identified in N.J.A.C. 11:3-26.1(a)1 through 8 shall be returned to the sender and deemed to be not filed with the Unsatisfied Claim and Judgment Fund (UCJF) for the purpose of complying with N.J.S.A. 39:6-65 and shall not toll the statute of limitations. Amended. R.1991 d.45, effective February 4, 1991; R.1996 d.58, effective February 5, 1996; R.1997 d.85, effective February 18, 1997; R.2006 d.243, effective July 3, SUBCHAPTER 27. UNSATISFIED CLAIM AND JUDGMENT FUND BOARD Section 11: Uninsured s Current Financial Status. 11: Uninsured s Current Financial Status. (a) Upon review of a case by the Unsatisfied Claim and Judgment Fund Board s designee, if the designee does not have sufficient current information to determine whether or not the uninsured s installment payment is reasonable, a request will be addressed to the uninsured asking for a statement of current financial status. (b) If the uninsured fails to furnish a completed statement of current financial status within a time period to be established by the executive director, the Unsatisfied Claim and Judgment Fund Board s designee will request the Director of Motor Vehicles to suspend the license and all registrations of the uninsured pursuant to N.J.S.A. 39:5-30 and 39:5-87, for failure to furnish this information. Amended. R.2006 d.243, effective July 3, SUBCHAPTER 28. UNSATISFIED CLAIM AND JUDGMENT FUND S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS Section 11: Purpose and scope. 11: Definitions. 11: Report of such claims when the carrier has paid at least $50,000 for medical expense benefits. 11: Notice of change in the amount of reserves. 11: Supplemental form to be submitted to the Fund. 11: Insurer's continuing obligation to investigate claims. 11: Reimbursement of excess medical expense benefits paid by insurers. 11: Audits. 11: Reporting of losses for personal injury protection payments in excess of $75, : Insurers' obligations to investigate and audit bills for medical benefits. 11: Modifications to vehicles. 11: Modifications to a claimant's residence. 11: Insurer's obligation to obtain recovery of payments for paid medical expense benefit claims.

76 11: APPENDIX B - REGULATIONS 11: Insurer s responsibility upon assignment of an uninsured motorist claim. 11: Reserved. 11: Reserved. 11: Reserved. 11: Purpose and scope (a) The purpose of this subchapter is to establish procedures to ensure that only appropriate, reimbursable claims are submitted to the Fund by insurers by requiring investigation of the medical necessity for certain claims; requiring the audit of claims of $10,000 or more submitted by licensed providers of health care services or claims of $25,000 or more by health care facilities; and requiring prior approval of claims for alterations to vehicles and residences. This subchapter also requires insurers to pursue the proper, alternative sources for reimbursement where such other sources of funds are available. (b) This subchapter applies to all insurers authorized in this State to write the kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1. In accordance with N.J.S.A. 39:6-73.1, reimbursement for medical expense benefits may be sought from the Fund on account of personal injury to any one person in any one accident occurring on or after February 19, (c) N.J.A.C. 11: establishes standards for insurers to demonstrate diligent pursuit of any potentially responsible tortfeasor for the purpose of recovering PIP medical expense benefits paid on behalf of the injured party by the Fund. Insurers shall obtain reimbursement from the Fund for excess medical expense benefit payments once they comply with the standards established herein. The purpose of these provisions are to contain costs for automobile insurance in this State. Accordingly, consistent with this purpose and N.J.S.A. 39:6A-9.1, for accidents occurring outside this State, insurers are expected to assert appropriate legal remedies to pursue recovery actions against potentially responsible tortfeasors, consistent with the legal rights and remedies asserted by the injured party. Repeal and New Rule, R.1993 d.583, effective November 15, See:25 N.J.R. 2636(b), 25 N.J.R. 5219(a). Amended. R d. 151, effective May 7, : Definitions The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Board means the Board of the New Jersey Property-Liability Insurance Guaranty Association created in accordance with N.J.S.A. 17:30A-1 et seq. Diagnosis related groups or DRG means a patient classification scheme in which cases are grouped by shared characteristics of principal diagnosis, secondary diagnosis, age, surgical procedure, and other complications. Each DRG exhibits a consistent amount of resource consumption as measured by some unit (for example, length of stay or dollars). Excess medical expense benefits means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 that are in excess of $75,000 resulting from personal injury to any one person in any one accident. Fund means the Unsatisfied Claim and Judgment Fund established pursuant to N.J.S.A. 39:6-61 et seq. Health care facility means a health care provider that is a facility or institution, whether public or private, engaged principally in providing services for diagnosis of treatment of pain, injury, deformity or physical condition, including, but not limited to, a general hospital, special hospital, public health center, diag-

77 UCJF 11: nostic center, treatment center, rehabilitation center, extended care facility, skilled nursing home, nursing home, intermediate care facility, outpatient clinic, dispensary or residential health care facility. Health care provider or provider means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to: 1. A hospital or health care facility which is maintained by a state or any of its political subdivisions; 2. A hospital or health care facility licensed by the Department of Health and Senior Services; 3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency clinics or offices, and private treatment centers; 4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital; 5. Hospitals or other health care facilities or treatment centers located in other states or nations; 6. Physicians licensed to practice medicine and surgery; 7. Licensed chiropractors; 8. Licensed dentists; 9. Licensed optometrists; 10. Licensed pharmacists; 11. Licensed chiropodists (podiatrists); 12. Registered bio-analytical laboratories; 13. Licensed psychologists; 14. Licensed physical therapists; 15. Certified nurse-midwives; 16. Certified nurse-practitioners/clinical nurse-specialists 17. Licensed health maintenance organizations; 18. Licensed orthotists and prosthetists; 19. Licensed professional nurses; 20. Licensed occupational therapists; 21. Licensed speech-language pathologists; 22. Licensed audiologists; 23. Licensed physician assistants; 24. Licensed physical therapists assistants; 25. Licensed occupational therapy assistants; and 26. Providers of other health care services or supplies, including durable medical goods. Health care service means the preadmission, outpatient, inpatient and postdischarge care provided in or by a health care facility, and such other items or services as are necessary for such care, which are provided by or under the supervision of a physician for the purpose of diagnosis or treatment of pain, injury, disability, deformity or physical condition, including, but not limited to, nursing service, home care nursing and other paramedical service, ambulance service, service provided by an intern, resident in training or physician whose compensation is provided through agreement with a health care facility, laboratory service, medical social service, drugs, biologicals, supplies, appliances, equipment, bed and board. Insurer means any person authorized or admitted in this State to write the kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1, pursuant

78 11: APPENDIX B - REGULATIONS to N.J.S.A. 17:17-1et seq. or 17:32-1 et seq., as applicable. Insurer shall not include a surplus lines insurer eligible to write business pursuant to N.J.S.A. 17: et seq. Licensed nursing personnel or licensed nurse means a nurse licensed by the New Jersey State Board of Nursing or the equivalent from another jurisdiction. Medical expense benefits means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 and N.J.A.C. 11:3-4. Medically necessary is as defined in N.J.A.C. 11: Per diem means a daily fixed charge which includes room and board and other fees for services and supplies. PIP coverage means personal injury protection coverage as described at N.J.S.A. 39:6A-4 or 39:6A-3.1. Person means any individual, association, company, corporation, insurer, joint stock company, organization, partnership, society, syndicate, trust, any combination of the foregoing acting in concert or any other entity. Pre-screen means an off-site review of the billings from a health care facility to determine whether the care given and amounts charged are appropriate. Provider means any person that furnishes services or equipment for medical expense benefits for which payment is required to be made under PIP coverage in automobile insurance policies, but does not include health care facilities. Reimbursement refers to reimbursement to insurers by the Fund as provided at N.J.S.A. 39: Uninsured motorist claims means claims submitted against operators of uninsured vehicles and hit and run claims submitted pursuant to N.J.S. 39:6-61. New Rule. R.1993 d.583, effective November 15, Amended. R.1994 d.597, effective December 5, 1994; R.1997 d.535, effective December 15, 1997; R.1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2006 d.243, effective July 3, : Report of such claims when the carrier has paid at least $50,000 for medical expense benefits In cases where the potential exposure to the automobile liability insurer exceeds $75,000, the insurer shall report on form UCJF Form 1(321) (incorporated herein by reference as Form 1 in Appendix A) [Publishers note: not included herein] whenever medical expense benefits in a total amount of $50,000 have been paid on account of personal injury to any one person in any one accident. Recodified from 11: and amended by R.1993 d.583, effective November 15, See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, : Notice of change in the amount of reserves Whenever an automobile liability insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount of $50,000, said insurer shall notify the Fund of any changes in the amount of reserves established for payment of the claim or closing of the file. Recodified from 11: and amended by R.1993 d.583, effective November 15, See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11: Supplemental form to be submitted to the Fund (a) UCJF Form 2(RR) (incorporated herein by reference as Form 2 in Appendix A), shall be filed with the Fund within 90 days after an automobile insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount in excess of $75,000. Such form together with UCJF Form 3(323) (incorporated herein by reference as Form 3 in Appendix A) [Publishers note: not included herein] shall be filed each quarter thereafter that the insurer seeks reimbursement.

79 UCJF 11: (b) Any office of an insurer seeking reimbursement of funds from the UCJF for personal injury protection medical expense must also complete and file with the UCJF a New Jersey Information Questionnaire, UCJF Form 4(W-9) (incorporated herein by reference as Form 4 in Appendix A) [Publishers note: not included herein]. Recodified from 11: and amended by R.1993 d.583, effective November 15, See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, : Insurer's continuing obligation to investigate claims (a) An automobile liability insurer shall be required to discharge its duty of investigating claims where the potential exposure to the insurer exceeds $75,000. Said insurer's duty and obligation with regard to claim handling shall exist and continue to exist notwithstanding this rule. The Executive Director may direct such investigations as often as he or she deems necessary. All expenses relating to the investigation of claims, including expenses for medical examinations, file maintenance and cost containment measures, are the responsibility of the automobile liability insurer. (b) The failure to properly discharge the duty of investigating a claim may result in the imposition of a penalty, to be determined by the Board s designee, against the insurer's request for reimbursement. Amended. R.1991 d.45, effective February 4, Recodified from 11: and amended by R.1993 d.583, effective November 15, Amended. R.2006 d.243, effective July 3, : Reimbursement of excess medical benefits paid by insurers (a) Insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefit claim payments as soon as practicable after the close of the quarter for which reimbursement is sought for claim payments of $20,000 or more. For claim payments of less than $20,000, insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefits either quarterly or at the close of the calendar year in which such expenses are incurred. Insurers shall not be reimbursed for interest, attorney fees or punitive damages. 1. Regardless of the size of a claim payment for excess medical expense benefits, an insurer shall submit to the Fund a request for reimbursement within a period of two years from the date of payment by the insurer of the excess medical expense benefit for which reimbursement is sought. 2. Failure to comply with the requirements set forth in (a) 1 above shall result in a denial by the Fund of the reimbursement request which was omitted from the quarterly submission. (b) The Fund shall not reimburse an insurer for excess medical expense benefits if it is determined that there are multiple insurance policies applicable to a claim unless an insurer has expended medical benefits in an amount exceeding $75,000 on account of personal injury to any one person in any one accident. Where there are two or more different primary insurers liable, the Fund shall not reimburse such an insurer for excess medical expense benefits unless each primary insurer has expended medical benefits in an amount exceeding $75,000 on account of personal injury to any one person in any one accident. (c) Where the Fund has reimbursed an insurer for excess medical expense benefits and thereafter determines that there were or are multiple insurance policies applicable to the underlying claim, the insurer shall return all moneys paid from the Fund. The insurer(s) shall apportion the medical benefits payment and make individual application to the Fund where the potential exposure to the insur-

80 11: APPENDIX B - REGULATIONS er(s) exceeds $75,000 on account of personal injury to any one person in any one accident. (d) Whenever an insurer recovers amounts expended by it for medical benefits, it shall not be reimbursed for excess medical expense benefits unless it has fully repaid the amount previously reimbursed by the Fund. Recodified from 11: and amended by R.1993 d.583, effective November 15, Amended. R.2006 d.243, effective July 3, 2006; R.2007 d.61, effective February 20, : Audits Upon request of the Fund, the insurer(s) shall present for audit at the direction of the Executive Director at a New Jersey location all policy and claim records on which notice of potential for payment of excess medical expense benefits have been submitted. Recodified from 11: and amended by R.1993 d.583, effective November 15, See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11: Reporting of losses for personal injury protection payments in excess of $75,000 (a) For purposes of completing page 14, Exhibit of Premiums and Losses, of the annual statement filed pursuant to N.J.S.A. 17:23-1, the insurer shall include the total amount of losses for private passenger automobile and commercial automobile personal injury protection payments (lines 19.1 and 19.3), including those in excess of $75,000. Insurers shall also provide a footnote on page 14 that indicates the amount of losses reported, excluding losses from payments of private passenger automobile and commercial automobile personal injury protection payments in excess of $75,000. (b) For purposes of completing Schedule F of the annual statement, insurers shall consider the assumption and reimbursement by the Fund of private passenger automobile and commercial automobile personal injury protection payments in excess of $75,000 as a reinsurance transaction. Insurers shall consider assessments paid to the UCJF pursuant to N.J.S.A. 39:6-63 based on the insurer's premiums for private passenger automobile liability insurance (including PIP) and commercial automobile liability insurance (including PIP) as ceded premium, pro rated for the appropriate line of business on which the assessment was based. (c) Insurers shall comply with the provisions of this section beginning with the annual statement due March 1, 1994 (covering the calendar year ended December 31, 1993). For purposes of completing the annual statement due March 1, 1993 (covering the calendar year ended December 31, 1992), insurers shall file by no later than July 1, 1993 a supplemental page 14 and schedule F of the annual statement in accordance with the provisions of this section. New Rule, R.1993 d.178, effective April 19, See:24 N.J.R. 3215(a), 24 N.J.R. 1769(a). Recodified from 11: and amended by R.1993 d.583, effective November 15, See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11: Insurers' obligations to investigate and audit bills for medical benefits (a) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by health care facilities where such claims are equal to or in excess of $25,000 and an on-site audit where such claims are equal to or in excess of $50, Failure of an insurer to complete an audit in accordance with these rules shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill.

81 UCJF 11: Per diem billings for health care facilities are not subject to the audit requirements set forth in this subchapter. 3. An insurer shall conduct any such audit to determine whether the level of care, need and charges are appropriate. 4. An insurer may pay 80 percent of the provider's bill prior to completion of the initial on-site audit. The remaining amount due, if any, shall be paid following completion of the insurer's audit. 5. Annual on-site audits shall be completed in 12-month intervals, from the initial on-site audit and shall be filed with the Fund within 90 days of completion of the audit; and 6. Whenever a change in services occurs such as, but not limited to, the level of care, the daily boom rate or additional charges, an insurer shall conduct an onsite audit and shall provide the audit and auditor's statement to the Fund with the next reimbursement request. 7. All other audits shall be conducted prior to payment to the health care facility and may be performed on a pre-screen basis as set forth in (e) below. (b) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by providers other than health care facilities where such claims are equal to or in excess of $10, Failure of an insurer to complete an audit in accordance with this subchapter shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill. (c) The thresholds in (a) and (b) above are cumulative for each confinement associated with damages resulting from bodily injuries arising out of the ownership, maintenance or use of a motor vehicle in this State and shall incorporate all claims submitted per confinement by the provider. (d) To be eligible for reimbursement by the Fund, insurers shall audit, prior to payment, bills submitted for continuous treatment from any provider which exceed or may exceed the applicable threshold. (e) Audits of all providers conducted pursuant to this subchapter, including the audit of DRG bills and any successor pricing, shall be performed by: 1. Licensed nursing personnel with two years experience or training in required auditing and hospital practices; or 2. An outside auditing firm retained by the insurer for such purposes. (f) Audits performed shall include, but not be limited to, confirmation of compliance with the medical fee schedule set forth at N.J.A.C. 11:3-29 including those situations where the insurer does not provide the primary coverage to the claimant. (g) An insurer is not required to conduct a separate, independent audit, if it has obtained a true copy of an audit conducted by the primary insurer or health insurer. (h) Insurers shall append copies of audits conducted, including those conducted by the primary insurer or health insurer, and the auditor's statements with the reimbursement request filed with the Fund in accordance with N.J.A.C. 11: New Rule. R.1993 d.583, effective November 15, Amended. R d. 591, effective December 21, 1998 (operative March 22, 1999); R.2006 d.243, effective July 3, : Modifications to vehicles. (a) An insurer shall obtain prior approval from the Fund for modifications to a claimant's vehicle, or vehicle to be used for the benefit of the claimant, the cost of which may be reimbursed by the Fund. (b) An insurer shall submit a written request to the Fund, including a Van Purchase and Modification Agreement seeking approval of modifications which

82 11: APPENDIX B - REGULATIONS are equal to or in excess of $1,000, within 30 days of a claimant's request for modifications. (c) A request to obtain prior approval from the Fund shall include the following: 1. A written recommendation for the modification by the claimant's primary care physician including: i. Where the claimant is the operator of the vehicle, current findings on the claimant's physical ability to drive and a copy of the claimant's current driver's license ii.a brief analysis of the medical necessity and medical purpose for the requested modifications iii. A description of the purpose for which the vehicle will be used and iv.verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident 2. A cost benefit analysis, supported by appropriate documentation, comparing the cost of modifying the claimant's vehicle to the cost of alternate methods of transporting the claimant. This analysis shall incorporate an evaluation of the anticipated miles to be driven per year for medically necessary health care services, including a breakdown reflecting the number of miles to be driven to obtain health care service and the frequency of such services, the cost per mile of alternate means of such transportation, as well as the useful life of the vehicle 3.An agreement between the insurer and the claimant setting forth, but not limited to: i. The claimant's responsibility to maintain insurance on the vehicle; and ii. The claimant's responsibility to repair and maintain the vehicle; and 4.Any additional information specifically requested by the Fund with regard to a particular application for approval. (d) The insurer may independently evaluate, or be required by the Fund to evaluate, the claimant by a physician chosen by the insurer and approved by the Fund, at the insurer's cost, to determine whether a medical necessity and medical purpose exist for modifications to the vehicle. The evaluation shall include a review of the elements considered in the primary evaluation as set forth at (c) above. (e) The Fund shall not approve modifications to a vehicle unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident, are required for a medical purpose and the modifications are shown to be cost effective or as the Fund may otherwise determine. (f) A request for modifications may be denied for failure to fulfill any of the above conditions. New Rule. R.1993 d.583, effective November 15, Amended. R.2006 d.243, effective July 3, : Modifications to a claimant's residence (a) An insurer shall obtain prior approval from the Fund for any modifications to a claimant's primary residence the cost of which may be reimbursed by the Fund. (b) An insurer shall submit a written request to the Fund, seeking approval of modifications which are equal to or in excess of $10,000, within 30 days of a claimant's request for modifications. (c) A request to obtain prior approval from the Fund shall include the following: 1. A written recommendation for the modification by the claimant's primary care physician including:

83 UCJF 11: i. A brief analysis of the medical necessity for the requested modifications and ii. Verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident; 2. Medical documentation estimating the claimant's life expectancy; 3. A cost benefit analysis, supported by appropriate documentation, which establishes that the proposed modifications are more cost effective than long term residential care services. The analysis shall include, in accordance with Appendix B incorporated herein by reference [Publishers note: not included herein], an evaluation based on the life expectancy of the claimant and a comparison between the costs of the modifications and home care to be provided, to the costs of other residential care alternatives; 4. An evaluation prepared by an independent consultant experienced in barrier free designs that sets forth the type of modifications required and the costs of such modifications. 5. An agreement setting forth the responsibilities regarding the obligations of the claimant, the owner of the property or both and the insurer for, but not limited to: i. The claimant's or property owner's responsibility for: 1) The expenses for upkeep of the residence 2) Maintenance of insurance on the property; and 3) Repayment to the insurer in the event of the claimant's relocation, death or upon the sale of the modified premises; and ii. The insurer's obligation to remove nonessential equipment; 6. A repayment agreement with an amortization provision which provides an amortization term and amount, once a modification is determined to be cost effective, calculated in accordance with the formula provided in Appendix B to this subchapter; and 7. Any other additional information specifically requested by the Fund with regard to a particular application for approval. (d) The insurer may independently evaluate, or be required by the Fund to evaluate, the claimant by a physician chosen by the insurer and approved by the Fund, at the insurer's cost, to determine whether a medical necessity for the modifications exist. The evaluation shall include a review of the elements considered in the primary evaluation as set forth at (c) above. (e) The Fund shall not approve modifications to a residence unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident and the modifications are shown to be cost effective or as the Fund may otherwise determine. (f) A request for modification may be denied for failure to fulfill any of the above requirements. (g) Where a request for modifications is approved, the insurer shall record a lien against the modified property in the county in which the property is located and shall file a copy of the recorded lien with the Fund within 30 days. 1. This provision shall not apply to rental property. (h) Where a claimant seeks to modify rental property, the insurer shall obtain: 1. A written consent from the owner of the property which permits the modifications and indemnifies the insurer and the Fund from any other liabilities relating thereto and

84 11: APPENDIX B - REGULATIONS 2. A written agreement between the claimant and the insurer in which the claimant agrees to reimburse the insurer for the unamortized costs of the improvements in the event of the claimant's relocation or death. (i) Upon the claimant's relocation or death, the claimant, the claimant's estate or the owner of the property against which the lien is recorded, shall reimburse the insurer for the unamortized cost of the modifications to the claimant's residence. (j) The claimant, the claimant's estate or the owner of the property against which the lien was recorded, shall have a reasonable period in which to reimburse the insurer. (k) Where repayment by the claimant or the claimant's estate is required pursuant to this section, interest shall accrue at the prevailing rate of post judgment interest as set forth in the rules governing civil practice in the New Jersey Court Rules in effect at the time of execution of the repayment agreement, until the amount owed is paid in full. (l) Within 30 days from the date of the claimant's relocation or death, the insurer shall so notify the Fund in writing and shall include the terms of repayment by the claimant to the insurer. The insurer shall repay the Fund for such reimbursement. 1.The insurer shall be required to repay the Fund within 60 days from receipt of any and all partial payments or from the receipt of a payment made in full by the claimant. (m) A warrant discharging the lien shall be filed by the insurer when the full amount owed to the insurer, in accordance with the amortization agreement, is satisfied. New Rule, R.1993 d.583, effective November 15, See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11: Insurer's obligation to obtain recovery of payments for paid medical expense benefit claims (a) The Fund shall reimburse insurers for paid medical expense benefit claims if an insurer demonstrates that it has diligently pursued all potentially responsible tortfeasors within the time prescribed at N.J.S.A. 39:6A-9.1, or any other applicable limitation period. 1. An insurer shall demonstrate, in accordance with (c) below, that it has diligently pursued any potentially responsible tortfeasor to obtain reimbursement of PIP medical expense benefit claim payments made by the insurer from the Fund. 2. Where the insurer has failed to diligently pursue any potentially responsible tortfeasor as set forth in (c) below, the Fund shall be entitled to discontinue reimbursements on that claim. The Fund shall also be entitled to recover from the insurer any reimbursement payments already made to the insurer on that claim, after notice and opportunity for a hearing in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and Uniform Administrative Procedure Rules, N.J.A.C. 1:1. 3. An insurer shall obtain prior approval from the Fund before settling or compromising a claim against a potentially responsible tortfeasor or a tortfeasor. (b) Any and all expenses and fees incurred by the insurer as a result of the pursuit of a potentially responsible tortfeasor, shall be borne by the insurer. (c) For purposes of this section, diligently pursue means that the insurer has either prosecuted or is prosecuting an action, including by agreement or arbitration, in matters subject to N.J.S.A. 39:6A-9.1, against all potentially responsible tortfeasors, or determined not to do so after: 1. Examining or reviewing the following documents, where applicable:

85 UCJF 11: i. Police accident reports, including fatal accident reports and supplemental reports; ii. Statements of the parties involved; iii. Witness statements; iv. Central Index Bureau return results; v. Information about the assets of uninsured tortfeasors; vi. Scene photographs and diagrams; vii. Reports of blood alcohol content; viii. Relevant court records and information on any related suits, arbitrations, settlements or judgments, either within or outside the State, including, but not limited to: (1) Pleadings; (2) Transcripts of depositions and other related discovery materials; and (3) Amounts of settlements or judgments; and ix. Information about the amount of any potentially responsible tortfeasor's insurance liability limits, including, but not limited to, umbrella and excess insurance policies; and 2. Considering the following factors in determining whether to prosecute an action against potentially responsible tortfeasors: i. The liability of the parties involved; ii. Relevant law regarding right of recovery actions; and iii. The basis for denial of coverage by the insurer of the potentially responsible tortfeasor. (d) Insurers shall file a certification, in the form of Appendix C incorporated herein by reference, that they have diligently pursued recovery of medical expense benefits, and that the insurer has not received from any source reimbursement, contribution, or indemnification of the excess medical benefits paid by the insurer for which reimbursement from the Fund is sought. This certification shall be signed by an officer of the insurer or other person authorized to sign the certification on behalf of the insurer, and shall be filed no later than two years from the date of the accident, prior to expiration of any applicable statute of limitations, or at the time filing for reimbursement is made, whichever occurs first. Failure to file the certification shall result in denial of reimbursement to the insurer by the Fund. (e) All recovery amounts obtained or that should have been obtained from the tortfeasor will be deducted from the reimbursement claim. New Rule. R.1993 d.583, effective November 15, Amended. R.2001 d.151, effective May 7, 2001; R.2006 d.243, effective July 3, : Insurer's responsibility upon assignment of an uninsured motorist claim. (a) An insurer shall, within 10 business days of receipt of a claim assignment and accompanying instruction sheet (see Appendix B, Item 1, incorporated herein by reference) from the Fund, submit a letter to the Fund which: 1. Acknowledges receipt of the assignment and the accompanying instruction sheet; and 2. Provides the names and telephone numbers of the case handler or manager, the claim investigator and the claim adjuster. (b) An insurer shall, within 10 business days from the date it assigns the claim to defense counsel, provide the Fund with the name, address and telephone number of defense counsel.

86 11: APPENDIX B - REGULATIONS (c) An insurer shall, within 10 business days, provide written notice to the Fund of any changes, substitutions or replacements which occur with respect to any of the persons identified pursuant to (a)2 or (b) above. New Rule, R.1994 d.597, effective December 5, See: 26 N.J.R. 2190(a), 26 N.J.R. 4772(a). 11: (Reserved) Repealed. R.2006 d.243, effective July 3, : (Reserved) 11: (Reserved) Repealed. R.2006 d.243, effective July 3, SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE Section 11: Purpose and scope. 11: Definitions. 11: Regions. 11: Application of Medical Fee Schedules. 11: ASC facility fees; hospital outpatient surgical facility fees. 11: Balance billing prohibited APPENDIX 11: Purpose and scope. (a) Every policy of automobile insurance and motor bus insurance issued in this State shall provide that the automobile insurer's limit of liability for medically necessary expenses payable under PIP coverage, and the motor bus insurer's limit of liability for medically necessary expenses payable under medical expense benefits coverage, is the fee set forth in this subchapter or the usual, customary and reasonable fee, whichever is less. (b) This subchapter implements the provisions of N.J.S.A. 39:6A-4.6 to establish medical fee schedules on a regional basis for the reimbursement of health care providers providing services or equipment for medical expense benefits for which payment is required to be made by automobile insurers under PIP coverage and by motor bus insurers under medical expense benefits coverage. (c) This subchapter applies to all insurers who issue policies of automobile insurance containing PIP coverage and policies of motor bus insurance containing medical expense benefits coverage. (d) This subchapter does not apply to the following: 1. Other coverages contained in an automobile or motor bus insurance policy such as coverage for bodily injury liability; 2. Any other kind of insurance including health insurance, even when the health insurer may be required pursuant to its health insurance contract to pay benefits to, or on behalf of, a person who sustained bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile or motor bus, or as a pedestrian, caused by an automobile or motor bus or an object propelled by or from an automobile or motor bus; 3. Medical services or equipment provided outside of the geographic boundaries of New Jersey except as set forth in N.J.A.C. 11:3-29.4(d)2; and

87 MEDICAL FEE SCHEDULES 11: Inpatient services provided by acute care hospitals, trauma centers, rehabilitation facilities, other specialized hospitals, residential alcohol treatment facilities and nursing homes, except as specifically set forth in this subchapter. Amended: R.1993 d. 25, effective January 4, 1993; R.2001 d.158, effective May 21, 2001; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Ambulatory surgery facility or ASC means: 1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are performed and which is separate and apart from any other facility license. (The ambulatory surgery facility may be physically connected to another licensed facility, such as a hospital, but is corporately, financially and administratively distinct, for example, it uses a separate tax-id number); or 2. A physician-owned single operating room in an office setting that is certified by Medicare. Basic Life Support ( BLS ) means volunteer ambulance services, whose personnel are not required to be Emergency Medical Technicians, and municipal and proprietary ambulance services whose personnel are required to be Emergency Medical Technicians. Bilateral surgery means identical procedures (requiring use of the same CPT code) performed on the same anatomic site but on opposite sides of the body. Furthermore, each procedure is performed through its own separate incision. "CDT" means the American Dental Association's Current Dental Terminology , copyright Co-surgery means two surgeons (each in a different specialty) are required to perform a specific procedure. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of one procedure simultaneously. "CPT" means the American Medical Association's Current Procedural Terminology, Fourth Edition, Version 2011, coding system. Current Procedural Terminology (CPT) is copyright 2011 American Medical Association (AMA), all rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained in the CPT. Applicable Federal Acquisition Regulation and Defense Federal Acquisition Regulation Supplement (FARS/DFARS), 48 CFR, restrictions apply to government use. CPT<(R)> is a trademark of the American Medical Association. "Eligible charge or expense" means the usual, customary and reasonable charge as determined pursuant to N.J.A.C. 11:3-29.4(e)1 or the upper limit in the fee schedule, whichever is lower. Emergency care means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Such emergency care shall include all medically necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency care extends

88 11: APPENDIX B - REGULATIONS during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Global service means the sum of the technical and professional components. HCPCS means the Federal Center for Medicare and Medicaid Services (CMS) Common Procedure Code System. Health care provider or provider is as defined in N.J.A.C. 11:3-4. Health insurance means a contract or agreement whereby an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the bodily injury, disability, sickness, death by accident or accidental means of a human being, or because of any expense relating thereto, or because of any expense incurred in prevention of sickness, and includes every risk pertaining to any of the enumerated risks. As used in this subchapter, health insurance includes workers' compensation coverage but does not include any PIP coverage. Health insurer includes any insurer issuing a policy of health insurance as defined in this subchapter. "Hospital" means a general acute care hospital, a long-term acute care hospital or a comprehensive rehabilitation hospital. "Hospital outpatient" means a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital. When a patient with a known diagnosis enters a hospital for a specific surgical procedure or other treatment that is expected to keep him or her in the hospital for only a few hours (less than 24), he or she is considered an outpatient for coverage purposes regardless of the hour he or she came to the hospital; whether he or she used a bed; or whether he or she remained in the hospital past midnight. "Hospital outpatient surgical facility" or "HOSF" means a facility where hospital outpatients are treated. Medically necessary or medical necessity means that: 1. The medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person; 2. The treatment is the most appropriate level of service that is in accordance with the standards of good practice and the provisions of N.J.A.C. 11:3-4, as applicable; 3. The treatment is not primarily for the convenience of the injured person or provider; 4. The treatment is not unnecessary; and 5. The treatment does not include unnecessary testing. Modifier means an addition to the five-digit CPT code of either two letters or numbers that indicates that a service or procedure was performed that has been altered by some specific circumstance but not changed in its definition or code. Motor bus means motor bus as defined in N.J.S.A. 17: Motor bus insurer includes any insurer issuing a policy of insurance on a motor bus the owner, registered owner, or operator of which is required to maintain medical expense benefits coverage pursuant to N.J.S.A. 17: Multiple surgeries means additional procedures, unrelated to the major procedure and adding significant time or complexity, performed on the same patient at the same operative session or on the same day. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.

89 MEDICAL FEE SCHEDULES 11: PIP coverage means personal injury protection coverage described in N.J.S.A. 39:6A-3.1(a), 39:6A-4a and 39:6A-10 as amended. PIP insurer includes any insurer issuing a policy of automobile insurance on any vehicle that contains PIP coverage. Powered traction device means VAX-D, DRX or similar devices determined by the Federal Food and Drug Administration to provide traction services. Three-digit zip code refers to the first three digits of the U.S. postal code. "Trauma services" means the care provided in the Level I or Level II trauma hospital to patients whose arrival requires trauma center activation. It does not include transportation to the hospital, treatment of patients whose arrival at the hospital does not require trauma activiation or outpatient visits after a patient who has received trauma care is discharged from acute care. Amended. R 1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993 d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1, 1995); R.2001, d.158, effective May 21, 2001; R.2003 d.143, effective April 7, 2003; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Regions. (a) The Regions in Appendix, Exhibit 1, Physicians' Fee Schedule, Exhibit 2, Dental Fee Schedule and Exhibit 4, Ambulance Services, are as follows: 1. South Region consists of Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 077, 080, 081, 082, 083, 084, 086 and 087. The South Region also includes: 08501, 08505, 08510, 08511, through 08527, through 08535, through 08550, 08554, and through North Region consists of Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union and Warren counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 070, 071, 072, 073, 074, 075, 076, 078, 079, 088 and 089. The North Region also includes: 08502, 08504, 08512, 08528, 08530, 08536, 08551, 08553, through and Amended. R.2001 d.253, effective July 16, 2001; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Application of Medical Fee Schedules. (a) Nothing in this subchapter shall compel the PIP insurer or a motor bus insurer to pay more for any service or equipment than the usual, customary and reasonable fee, even if such fee is well below the automobile insurer's or motor bus insurer's limit of liability as set forth in the fee schedules. Insurers are not required to pay for services or equipment that are not medically necessary. 1. The fees for physicians' services in subchapter Appendix, Exhibit 1, the provisions in (f)1 through 7 below and the non-physician facility fees in subchapter Appendix, Exhibit 7 shall not apply to trauma services at Level I and Level II trauma hospitals. Bills for services subject to the trauma services exemption shall use the modifier "-TS". 2. The non-physician facility fees in subchapter Appendix, Exhibit 7 shall not apply to services provided in hospital emergency rooms. The bills for these services shall use the modifier "-ER". 3. The physician fees for surgical services (CPT though 69999) provided in emergency care in acute care hospitals that are not subject to the trauma care exemption shall be reimbursed at 150 percent of the physicians' fees in subchapter Appendix, Exhibit 1. The bills for these services shall use the modifier "-ER".

90 11: APPENDIX B - REGULATIONS 4. Except as provided in (a)1 through 3 above, the fees in Appendix, Exhibits 1 through 7 apply regardless of the site of service. (b) The region used to determine the proper fee set forth in the schedules shall be determined by the region in which the services were rendered or the equipment was provided or, in the case of elective services or equipment provided to New Jersey residents outside the State, by the region in which the insured resides. (c) The fees set forth in the schedule for durable medical equipment, subchapter Appendix, Exhibit 5, are retail prices, which may include purchase prices for both new and used equipment, and/or monthly rentals. New equipment shall be distinguished with the use of modifier-nu, used equipment with modifier-ue and rental equipment with modifier-rr. 1. The insurer's total limit of liability for the rental of a single item of durable medical equipment set forth in the schedule is 15 times the monthly rental fee or the purchase price of the item, whichever is less. 2. For the provision and billing of durable medical equipment, payors shall follow the relevant provisions of Chapter 20 of the Medicare Claims Processing Manual, updated periodically by CMS and incorporated by reference, that were in effect at the time the service was provided ( (d) The insurer's limit of liability for any medical expense benefit for service or equipment provided outside the State of New Jersey shall be as follows: 1. When the service or equipment is provided by reason of emergency or medical necessity, the reasonable and necessary costs shall not exceed fees that are usual, customary and reasonable for that provider in the geographic location where the service or equipment is provided. 2. When the service or equipment is provided by reason of the election by the insured to receive treatment outside the State of New Jersey, the reasonable and necessary costs shall not exceed fees set forth in the fee schedules for the geographic region in which the insured resides. (e) Except as noted in (e)1 through 3 below, the insurer's limit of liability for any medical expense benefit for any service or equipment not set forth in or not covered by the fee schedules shall be a reasonable amount considering the fee schedule amount for similar services or equipment in the region where the service or equipment was provided or, in the case of elective services or equipment provided outside the State, the region in which the insured resides. When a CPT, CDT, or HCPCS code for the service performed has been changed since the fee schedule rule was last amended, the provider shall always bill the actual and correct code found in the most recent version of the American Medical Association's Current Procedural Terminology or the American Dental Association's Current Dental Terminology. The amount that the insurer pays for the service shall be in accordance with this subsection. Where the fee schedule does not contain a reference to similar services or equipment as set forth in the preceding sentence, the insurer's limit of liability for any medical expense benefit for any service or equipment not set forth in the fee schedules shall not exceed the usual, customary and reasonable fee. 1. For the purposes of this subchapter, determination of the usual, reasonable and customary fee means that the provider submits to the insurer his or her usual and customary fee by means of explanations of benefits from payors showing the provider's billed and paid fee(s). The insurer determines the reasonableness of the provider's fee by comparison of its experience with that provider and with other providers in the region. National databases of fees, such as those published by FAIR Health ( or Wasserman (

91 MEDICAL FEE SCHEDULES 11: for example, are evidence of the reasonableness of fees for the provider's geographic region or ZIP code. The use of national databases of fees is not limited to the above examples. When using a database as evidence of the reasonableness of a fee, the insurer shall identify the database used, the edition date, the geozip, and the percentile. 2. All applicable provisions of this section concerning billing and payment apply to fees for services provided outside of New Jersey and to fees that are not on the fee schedule. 3. Codes in Appendix, Exhibit 1 that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC and are not subject to the provision in (e) above concerning services not set forth in or covered by the fee schedules. (f) Except as specifically stated to the contrary, the following shall apply to physician charges for multiple and bilateral surgeries (CPT through 69999), co-surgeries and assistant surgeons: 1. For multiple surgeries, rank the surgical procedures in descending order by the fee amount, using the fee schedule or UCR amount, as appropriate. The highest valued procedure is reimbursed at 100 percent of the eligible charge. Additional procedures are reported with the modifier "-51" and are reimbursed at 50 percent of the eligible charge. If any of the multiple surgeries are bilateral surgeries using the modifier "-50," consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions. 2. There are two types of procedures that are exempt from the multiple procedure reduction. Codes in CPT that have the note, "Modifier -51 exempt" shall be reimbursed at 100 percent of the eligible charge. In addition, some related procedures are commonly carried out in addition to the primary procedure. These procedure codes contain a specific descriptor that includes the words, "each additional" or "list separately in addition to the primary procedure." These add-on codes cannot be reported as stand-alone codes but when reported with the primary procedure are not subject to the 50 percent multiple procedure reduction. 3. The terminology for some procedure codes includes the terms "bilateral" or "unilateral or bilateral." The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT as "bilateral" or "unilateral or bilateral" since the fee schedule reflects any additional work required for bilateral surgeries. If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral) and is performed bilaterally, providers must report the procedure with modifier "-50" as a single line item. Reimbursement for bilateral surgeries reported with the modifier "-50" shall be 150 percent of the eligible charge. 4. For co-surgeries, each surgeon bills for the procedure with a modifier "-62". For co-surgeries (modifier 62), the fee schedule amount applicable to the payment for each co-surgeon is 62.5 percent of the eligible charge. 5. The eligible charge for medically necessary assistant surgeon expenses shall be 20 percent of the primary physician's allowable fee determined pursuant to the fee schedule and rules. Assistant surgeon expenses shall be reported using modifier -80, -81 or -82 as designated in CPT. When the assistant surgeon is someone other than a physician surgeon, the reimbursement shall not exceed 85 percent of the amount that would have been reimbursed had a physician surgeon provided the service. Non-physician assistant surgeon services shall be reported using modifier-as. 6. The necessity for co-surgeons and assistant surgeons for an operation shall be determined by reference to authorities such as the Medicare physician fee

92 11: APPENDIX B - REGULATIONS schedule database ( Fees for assistant surgeons and co-surgeons are not rendered eligible for reimbursement simply because it is the policy of a provider or an outpatient surgical facility that one be present. 7. It is the responsibility of providers that are acting as co-surgeons or assistant surgeons to include the correct modifier in their bills, especially as they may not be submitted to the insurer at the same time. If a surgeon submits a bill without a modifier and is paid 100 percent of the eligible charge and the insurer subsequently receives a bill from a co-surgeon or assistant surgeon for the same procedure, the insurer shall notify both providers that it has already paid 100 percent of the eligible charge and that it cannot reimburse the co-surgeon or assistant surgeon until the overpayment has been offset or refunded. 8. Prosthetic and other devices, including neuro-stimulators, internal/external fixators, single use spine wands and spine probes, tissue grafts, plates, screws, anchors and wires, whether implanted, inserted, or otherwise applied by covered surgical procedures shall be reimbursed at no more than the invoice for the device plus 20 percent. This provision applies regardless of where the procedure is performed, including trauma centers, hospital emergency rooms, inpatient surgeries and outpatient surgical facilities. (g) Except as specifically stated to the contrary in this subchapter, the fee schedules shall be interpreted in accordance with the following, incorporated hererin by reference, as amended and supplemented: the relevant chapters of the Medicare Claims Processing Manual, updated periodically by CMS, that were in effect at the time the service was provided. The Medicare Claims Processing Manual is available at https: // the NCCI Policy Manual for Medicare Services, as updated periodically by CMS and available at Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service, available from CMS at and the CPT Assistant available from the American Medical Association ( 1. Artificially separating or partitioning what is inherently one total procedure into subparts that are integral to the whole for the purpose of increasing medical fees is prohibited. Such practice is commonly referred to as "unbundling" or "fragmented" billing. Providers and payors shall use the National Correct Coding Initiative (NCCI) Edits, incorporated herein by reference, as updated quarterly by CMS and available at Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used. For more information on the criteria for the use of modifiers, see the NCCI Policy Manual and Modifier 59 Article referenced in (g) above. 2. CPT (application of hot/cold packs) is bundled into the payment for other services and shall not be reimbursed separately. 3. X-ray digitization or computer aided radiographic mensuration reported under CPT or any other code are not reimbursable under PIP. 4. Kinesio taping or other taping is not reimbursable under PIP. Kinesio taping shall not be billed using the strapping codes, CPT through and through Platelet Rich Plasma (PRP) injections are only reimbursable for treatment of chronically injured tendons that have failed to improve despite appropriate con-

93 MEDICAL FEE SCHEDULES 11: servative treatments. PRP injections shall be billed under code 0232T in subchapter Appendix, Exhibit Leads, pads, batteries and any other supplies for use of TENS or EMS devices are included in the fee for the rental of the unit and are not separately reimbursable when rented. For purchase of the unit, the first month's supply of leads, pads, batteries and any other supplies for TENS or EMS units are included. 7. The eligible charge for an office visit includes reviewing the report of an imaging study when the provider of the imaging study has billed for the technical and professional component of the service. In these circumstances, it is not appropriate for the provider to bill for an office visit, CPT or for the physician component of the imaging study. CPT is not reimbursable. Where a provider in a different practice or facility performs a medically necessary review of an imaging study and produces a written report as part of a consultation, the provider shall bill the professional component (modifier -26) for each specific radiology service. 8. When CPT 77003, fluoroscopic guidance, can be billed separately and is not included as part of another procedure, it is reimbursable only per spinal region, not per level. 9. HCPCS code G0289 is an add-on code and should be added to the knee arthroscopy code for the major procedure being performed. This code is only to be reported once per extra compartment, even if chondroplasty, loose body removal and foreign body removal are all performed. The code may be reported twice if the physician performs these procedures in two compartments in addition to the compartment where the main procedure was performed. i. This code shall be reported only when the physician spends at least 15 minutes in the additional compartment performing the procedure. It shall not be reported if the reason for performing the procedure is due to a problem caused by the arthroscopic procedure itself. This code is to be used when a procedure is performed in the lateral, medial, or patellar compartments in addition to the main procedure. The billing of CPT codes and is not permitted with other arthroscopic procedures on the same knee and CPT code shall not be used to report the services described by code G Appendix J of the CPT manual, Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves may be used as a reference for the appropriate reimbursement of this type of Electrodiagnostic testing. 11. Moderate (conscious) sedation performed by the physician who also furnishes the medical or surgical service cannot be reimbursed separately for the procedures listed in Appendix G of the CPT manual. In that case, payment for the sedation is bundled into the payment for the medical or surgical service. As a result, CPT codes through are not reimbursable for the procedures in Appendix G of the CPT manual. 12. CPT codes through are only reimburseable when a second physician other than the provider performing the diagnostic or therapeutic services provides moderate sedation in a facility setting (for example, hospital, outpatient hospital/ambulatory surgery center or skilled nursing facility). CPT codes through are not reimburseable for services performed by a second physician in a physician office, freestanding imaging center or for any procedure code identified in CPT as including moderate (conscious) sedation. 13. CPT 22505, "Manipulation of spine requiring anesthesia, any region," if medically necessary, can only be reported once for any and all regions manipulated on that date. (h) To be reimbursable, nerve conduction studies (NCS) (CPT ) must be interpreted by a provider who was on site and directly supervised or per-

94 11: APPENDIX B - REGULATIONS formed the nerve conduction study in accordance with N.J.A.C. 13:35-2.6(n)3. Needle Electromyography (EMG) interpretation must be performed in the same facility on the same day by the same physician who performed and/or supervised the needle EMG. (i) The reporting of nerve conduction studies and needle electromyography (EMG) (CPT through 95872) results should be integrated into a unified diagnostic impression. Separate reports for needle EMG and NCS are not reimbursable under the codes above in this subsection. (j) For surgery and many other procedures, it is established practice to include follow-up care and visits as part of the basic procedure charge. Such charges shall not be subject to additional billings. The existence of a CPT code, per se, does not imply the right to receive separate compensation for the procedure/sub-procedure so described. If a procedure is judged to be part of the primary procedure, only the charges for the primary procedure are eligible. As identified in CPT, separate procedures are commonly carried out as an integral part of another procedure. They shall not be billed in conjunction with the other procedure, but may be billed when performed independently of the other procedure. (k) CPT codes for procedures described in CPT as "unlisted procedure" or "unlisted service" (example: Unlisted procedure nervous system) are not reimbursable without documentation from the provider describing the procedure or service performed, demonstrating its medical appropriateness and indicating why it is not duplicative of a code for a listed procedure or service. Documentation may include the existence of temporary or AMA Category III or HCPCS codes for the procedure or information in the AMA CPT Assistant publication. In submitting bills for unlisted codes, the provider should base the fee on a comparable procedure. It is never appropriate for the provider to bill an unlisted code for a list of services that have CPT codes. Providers that intend to use unlisted codes in nonemergency situations are encouraged to notify the insurer in advance through the precertification process. Based on the information submitted by the provider, the insurer shall determine whether the CPT coding is appropriate. (l) Certain CPT codes are listed in the fee schedule with three entries. There is a global fee with no modifier, a technical component with modifier "TC" and a physician component with modifier "-26". Services with physician component amounts of zero in the fee schedule are considered to be 100 percent technical. A provider shall not bill the global fee and a technical or physician component. The technical or physician component shall be billed when only that part of the service is being provided. (m) The daily maximum allowable fee shall be $ for the Physical Medicine and Rehabilitation CPT codes listed in subchapter Appendix, Exhibit 6, incorporated herein by reference, that are commonly provided together. The daily maximum applies when such services are performed for the same patient on the same date. In determining whether a provider has reached the daily maximum, the insurer shall apply the NCCI edits. The daily maximum applies to all providers, including dentists. However, when the provider can demonstrate that the severity or extent of the injury is such that extraordinary time and effort is needed for effective treatment, the insurer shall reimburse in excess of the daily maximum. Such injuries could include, but are not limited to, severe brain injury and nonsoft-tissue injuries to more than one part of the body. Such injuries would not include diagnoses for which there are care paths in N.J.A.C. 11:3-4. Treatment that the provider believes should not be subject to the daily maximum shall be billed using modifier -22 as designated in CPT for unusual procedural services. Unless already provided to the insurer as part of a decision point review or precertifica-

95 MEDICAL FEE SCHEDULES 11: tion request, the billing shall be accompanied by documentation of why the extraordinary time and effort for treatment was needed. 1. Supervised modalities and those therapeutic procedures that do not list a specific time increment in their description shall be limited to one unit per day. 2. CPT is the appropriate code for billing powered traction therapy. 3. CPT is the appropriate code for billing cold or low-powered laser therapy. 4. HPCPS code G0283 is the appropriate code for billing unattended electrical stimulation. 5. Pursuant to N.J.S.A. 39:6A-4, physical therapy, as defined in N.J.S.A. 45: , shall not be reimbursable under PIP unless rendered by a licensed physical therapist pursuant to a referral from a licensed physician, dentist, podiatrist or chiropractor within the scope of the respective practices. (n) Follow-up evaluation and management services for the re-examination of an established patient shall be reimbursed in addition to physical medicine and rehabilitation procedures only when any of the circumstances set forth in (n)1 through 4 below is present and not more than twice in any 30-day period. Modifier -25 shall be added to an evaluation and management service when a significant separately identifiable evaluation and management service is provided and documented as medically necessary as follows: 1. There is a definite measurable change in the patient's condition requiring significant change in the treatment plan; 2. The patient fails to respond to treatment, requiring a change in the treatment plan; 3. The patient's condition becomes permanent and stationary, or the patient is ready for discharge; or 4. It is medically necessary to provide evaluation services over and above those normally provided during the therapeutic services. (o) Regardless of the specific codes that are included in a DPR/Precertification request, the insurer's reimbursement for those services shall be consistent with the rules contained in this subchapter, including the NCCI edits and the CPT Manual current at the time the services were provided. (p) The ANES code on the Physicians' Fee Schedule is the conversion factor for anesthesia units. Payors shall follow the Medicare Claims Processing Manual and other guidelines for calculating the number of units for the various CPT codes for the administration of anesthesia and other billing situations, such as directing or supervising Certified Nurse Anesthetists and other non-physician anesthesia providers. These can be found at: Amended. R.1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993 d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1, 1995); R.2001 d.158, effective May 21, 2001; R.2001 d.253, effective July 16, 2001; R.2003 d.143, effective April 7, 2003; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013); R.2014 d.004, effective January 6, : ASC facility fees; hospital outpatient surgical facility fees. (a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including: 1. Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;

96 11: APPENDIX B - REGULATIONS 2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient's care; 3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment; 4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare (see: CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgical procedures and are not permitted to be reimbursed separately in a HOSF; 5. Administrative, recordkeeping, and housekeeping items and services; 6. Blood, blood plasma, platelets, etc.; 7. Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and 8. Implantable DME and prosthetics. (b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The hospital outpatient surgical facility fee is the maximum that can be reimbursed for outpatient procedures performed in an HOSF. The hospital outpatient facility fees in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through 8 above. (c) The sale, lease or rental of durable medical equipment (DME) to patients for use in their homes are not included in the ASC or HOSF fee. If the ASC or HOSF furnishes items of DME to patients, billing for such items should be made in accordance with subchapter Appendix, Exhibit 5. (d) When multiple procedures are performed in an ASC or in an HOSF in the same operative session, the ASC facility fee or the HOSF fee, as applicable, for the procedure with the highest payment amount is reimbursed at 100 percent and reimbursement of any additional procedures furnished in the same session is 50 percent of the applicable facility fee. 1. A procedure performed bilaterally in one operative session is reported as two procedures and is subject to the multiple procedure reduction formula. 2. Subchapter Appendices, Exhibit 1, the Physicians and ASC Facility Fee Schedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, according to Medicare (see: and / are exempt from the multiple procedure reduction formula. New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: ASC facility fees; hospital outpatient surgical facility fees (a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including: 1. Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;

97 MEDICAL FEE SCHEDULES 11: All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient s care; 3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment; 4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare (see: CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgical procedures and are not permitted to be reimbursed separately in a HOSF; 5. Administrative, recordkeeping, and housekeeping items and services; 6. Blood, blood plasma, platelets, etc.; 7. Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and 8. Implantable DME and prosthetics. (b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The hospital outpatient surgical facility fee is the maximum that can be reimbursed for outpatient procedures performed in an HOSF. The hospital outpatient facility fees in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through 8 above. (c) The sale, lease or rental of durable medical equipment (DME) to patients for use in their homes are not included in the ASC or HOSF fee. If the ASC or HOSF furnishes items of DME to patients, billing for such items should be made in accordance with subchapter Appendix, Exhibit 5. (d) When multiple procedures are performed in an ASC or in an HOSF in the same operative session, the ASC facility fee or the HOSF fee, as applicable, for the procedure with the highest payment amount is reimbursed at 100 percent and reimbursement of any additional procedures furnished in the same session is 50 percent of the applicable facility fee. 1. A procedure performed bilaterally in one operative session is reported as two procedures and is subject to the multiple procedure reduction formula. 2. Subchapter Appendices, Exhibit 1, the Physicians and ASC Facility Fee Schedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, according to Medicare (see: and / are exempt from the multiple procedure reduction formula. New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11: Balance billing prohibited. No health care provider may demand or request any payment from any person in excess of those permitted by the medical fee schedules and this subchapter, nor shall any person be liable to any health care provider for any amount of money that results from the charging of fees in excess of those permitted by the medical fee schedules and this subchapter. Amended. R. 2001, d. 158, effective May 21, Recodified from N.J.A.C. 11: by R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

98 11: APPENDIX B - REGULATIONS APPENDIX: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE Exhibit 1 Physicians & Ambulatory Surgical Center (ASC) Facility Fee Schedule Payment Indi cator (See Phys- Phys- botician s ician s ASC ASC tom) Fees Fees Fees Fees for) CPT Mod Description North South North South codes) *Current Procedural Teminology (CPT) is copyright 2010 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Anes ANESTHESIA BASE UNITS T NJX PLATELET PLASMA X G0283 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS ARTHRO, LOOSE BODY + CHONDRO X, N DRAIN SKIN ABSCESS DRAIN SKIN ABSCESS REMOVE FOREIGN BODY REMOVE FOREIGN BODY , , DRAIN HEMATOMA/FLUID PUNCTURE DRAIN LESION COMPLEX DRAIN WOUND , , DEBRIDE INFECTED SKIN DEBRIDE INFECTED SKIN, ADDED DEBRIDE SKIN, FX DEBRIDE SKIN/MUSCLE, FX DEBRIDE SKIN/MUSCLEBONE, FX 1, , DEBRIDE SKIN/TISSUE DEBRIDE TISSUE/MUSCLE DEBRIDETISSUE/MUSCLE/BONE , , DEBRIDE SUBQ TISSUE ADD-ON DEBRIDE MUSCLE/FASCIA ADD-ON DEBRIDE BONE ADD-ON , , TRIM SKIN LESION TRIM SKIN LESIONS, 2 TO TRIM SKIN LESIONS, OVER BIOPSY SKIN LESION BIOPSY SKIN, ADDED REMOVE SKIN TAGS SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION EXCISE TRT-EXT BENIGN+MARG 0.5 < CM EXCISE TRT-EXT BENIGN+MARG CM EXCISE TRT-EXT BENIGN+MARG CM EXCISE TRT-EXT BENIGN+MARG CM EXCISE TRT-EXT BENIGN+MARG CM , , EXCISE TRT-EXT BENIGN+MARG

99 MEDICAL FEE SCHEDULES 11: > 4.0 CM , , EXCISE H-F-NECK-SP BENIGN+MARG 0.5 < EXCISE H-F-NECK-SP BENIGN+MARG EXCISE H-F-NECK-SP BENIGN+MARG EXCISE H-F-NECK-SP BENIGN+MARG EXCISE H-F-NECK-SP BENIGN+MARG , , EXCISE H-F-NECK-SP BENIGN+MARG > 4 CM , , EXCISE FACE-MM BENIGN+MARG 0.5 < CM EXCISE FACE-MM BENIGN+MARG CM EXCISE FACE-MM BENIGN+MARG CM EXCISE FACE-MM BENIGN+MARG CM EXCISE FACE-MM BENIGN+MARG CM , , TRIM NAIL(S) DEBRIDE NAIL, DEBRIDE NAIL, 6 OR MORE REMOVE NAIL PLATE REMOVE NAIL PLATE, ADDED DRAIN BLOOD UNDER NAIL REMOVE NAIL BED REMOVE NAIL BED/FINGER TIP REPAIR NAIL BED RECONSTRUCT NAIL BED EXCISE NAIL FOLD, TOE INJECTION INTO SKIN LESIONS ADDED SKIN LESIONS INJECTION THERAPY FOR CONTOUR DEFECTS THERAPY FOR CONTOUR DEFECTS INSERT TISSUE EXPANDER(S) 1, , , , INSERT DRUG IMPLANT DEVICE X REMOVE DRUG IMPLANT DEVICE X REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) CLOSE SPLIT WOUND CLOSE SPLIT WOUND INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR N-HF/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR

100 11: APPENDIX B - REGULATIONS N-HG/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM REPAIR WOUND OR LESION REPAIR WOUND OR LESION REPAIR WOUND/LESION, ADDED REPAIR WOUND OR LESION REPAIR WOUND OR LESION REPAIR WOUND/LESION, ADDED REPAIR WOUND OR LESION REPAIR WOUND OR LESION REPAIR WOUND/LESION, ADDED REPAIR WOUND OR LESION REPAIR WOUND OR LESION REPAIR WOUND OR LESION REPAIR WOUND/LESION, ADDED LATE CLOSE WOUND 1, , , , SKIN TISSUE REARRANGEMENT 1, , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGEMENT 1, , , , SKIN TISSUE REARRANGE ADDED , , WOUND PREP, TRUNK/ARM/LEG WOUND PREP, ADDED 100 CM WOUND PREP, F/N/HF/G WOUND PREP, F/N/HF/G, ADDED CM SKIN PINCH GRAFT SKIN SPLIT GRAFT, TRUNK/ARM/LEG 1, , , , SKIN SPLIT GRAFT T/A/L, ADDED , , SKIN SPLIT A-GRAFT FAC/NEC/HF/G 1, , , , SKIN SPLIT A-GRAFT F/N/HF/G ADDED , , DERM AUTOGRAFT, TRUNK/ARM/LEG 1, , , , ACELLULAR GRAFT TRUNK/ARMS/LEGS ACELLULAR GRAFT T/ARM/LEG, ADDED ACELLULAR GRAFT, F/N/HF/G SKIN FULL GRAFT SCALP/ARM/LEG1, , , , SKIN FULL GRAFT, ADDED SKIN FULL GRAFT FACE/GENITAL/HF 1, , , , SKIN FULL GRAFT, ADDED SKIN FULL GRAFT EEN & LIPS 1, , , , APPLY ACELLULAR ALLOGRAFT T/ARM/LEG

101 MEDICAL FEE SCHEDULES 11: APPLY ACELLULAR GRAFT T/A/L, ADDED APPLY CULT SKIN SUBSTITUTE APPLY CULT SKIN SUB, ADDED APPLY CULT DERM SUB F/N/HF/G APPLY CULT DERM F/KF/G ADDED APPLY ACELLULAR XENOGRAFT APPLY ACELLULAR XENOGRAFT ADDED FORM SKIN PEDICLE FLAP 1, , , , FORM SKIN PEDICLE FLAP 1, , , , FORM SKIN PEDICLE FLAP 1, , , , FORM SKIN PEDICLE FLAP 1, , , , SKIN GRAFT , , MUSCLE-SKIN GRAFT, HEAD/NECK 2, , , , MUSCLE-SKIN GRAFT, TRUNK 2, , , , MUSCLE-SKIN GRAFT, ARM 2, , , , MUSCLE-SKIN GRAFT, LEG 2, , , , FREE MYO/SKIN FLAP MICROVASC 3, , DERMA-FAT-FASCIA GRAFT 1, , , , ABRASION TREAT SKIN 1, , , , ABRASION TREAT SKIN ABRASION TREAT SKIN ABRASION, LESION, SING ABRASION, LESIONS, ADDED REVISE UPPER EYELID , , EXCISE SKIN ABD , , EXCISE EXCESSIVE SKIN TISSUE , , REMOVE SUTURES DRESSING CHANGE NOT FOR BURN X REMOVE HIP PRESSURE SORE 1, , , , REMOVE HIP PRESSURE SORE 1, , , , REMOVE HIP PRESSURE SORE 1, , , , REMOVE HIP PRESSURE SORE 1, , , , REMOVE HIP PRESSURE SORE 2, , , , REMOVE THIGH PRESSURE SORE , , REMOVE THIGH PRESSURE SORE 1, , , , REMOVE THIGH PRESSURE SORE 1, , , , REMOVE THIGH PRESSURE SORE 1, , , , REMOVE THIGH PRESSURE SORE 1, , , , REMOVE THIGH PRESSURE SORE 1, , , , INITIAL TREAT BURN(S) DRESS/DEBRIDE P-THICK BURN, S DRESS/DEBRIDE P-THICK BURN, M DRESS/DEBRIDE P-THICK BURN, L DESTROY PREMALIG LESION DESTROY PREMALIG LES, DESTROY PREMALIG LESIONS DESTROY SKIN LESIONS DESTROY SKIN LESIONS DESTROY SKIN LESIONS 1, DESTROY B9 LESION, DSTRJ B9 SK TGS/CUTAN VASC 15/> CHEM CAUT GRANLTJ TISS PROUD FLESH SINUS/FSTL DESTROY SKIN LESIONS DESTROY SKIN LESIONS DRAIN BREAST LESION REMOVE BREAST LESION , , EXCISE BREAST LESION , , PLACE NEEDLE WIRE, BREAST X, N EXPLORE WOUND, NECK EXPLORE WOUND, CHEST EXPLORE WOUND, ABDOMEN EXPLORE WOUND, EXTREMITY , , REMOVE FOREIGN BODY REMOVE FOREIGN BODY , , THERAPEUTIC INJECTION, CARP TUNNEL INJECT TENDON SHEATH/LIGAMENT INJECT TENDON ORIGIN/INSERT INJECT TRIGGER POINT, 1/2 MUSCLE

102 11: APPENDIX B - REGULATIONS INJECT TRIGGER POINTS, =/> DRAIN/INJ, JOINTBURSA DRAIN/INJ, JOINTBURSA DRAIN/INJ, JOINTBURSA ASPIRATE/INJECT GANGLION CYST TREAT BONE CYST INSERT & REMOVE BONE PIN , , APPLY PELVIS BRACE , , APPLY THIGH BRACE , , REMOVE FIXATION DEVICE X REMOVE SUPPORT IMPLANT 2, , REMOVE SUPPORT IMPLANT , , APPLY BONE FIXATION DEVICE 2, , , , APPLY BONE FIXATION DEVICE 4, , , , ADJUST BONE FIXATION DEVICE 1, , , , REMOVE BONE FIXATION DEVICE 1, , , , COMP MULTIPLANE EXT FIXATION 4, , , , COMP EXT FIXATE STRUT CHANGE 7, , , , REMOVE BONE FOR GRAFT , , REMOVE BONE FOR GRAFT , , REMOVE CARTILAGE FOR GRAFT 1, , , REMOVE CARTILAGE FOR GRAFT 1, , , , REMOVE FASCIA FOR GRAFT , , REMOVE FASCIA FOR GRAFT 1, , , , REMOVE TENDON FOR GRAFT , , REMOVE TISSUE FOR GRAFT SP BONE ALLOGRAFT STRUCT, ADDED FLUID PRESSURE, MUSCLE 1, , FIBULA BONE GRAFT, MICROVASC10, , ELECTRICAL BONE STIMULATION ELECTRICAL BONE STIMULATION X, N US BONE STIMULATION X COMPUTER-ASSIST DIR MS PX X, N REMOVE JAW JOINT CARTILAGE 1, , , , REMOVE CORONOID PROCESS 2, , , , MANIPULATE TMJ W/ANESTH PREPARE FACE/ORAL PROSTHESIS 1, , , , INTERDENTAL FIXATION 1, , , X, N INJECTION, JAW JOINT X-RAY REDUCE FACIAL BONES 1, , , , FACE BONE GRAFT 3, , , , RECONSTRUCT JAW JOINT 3, , , , RECONSTRUCT JAW JOINT 3, , , , RECONSTRUCT JAW JOINT 5, , , , RECONSTRUCT LOWER JAW 1, , , , RECONSTRUCT JAW 1, , , , RECONSTRUCT JAW 1, , , , RECONSTRUCT LOWER JAW BONE 2, , , , RECONSTRUCT JAW 1, , , , RECONSTRUCT JAW 2, , , , TREAT NOSE FX TREAT NOSE FX , , TREAT NOSE FX , , TREAT NOSE FX , , TREAT NOSE FX , , TREAT NOSE FX 1, , , , TREAT CHEEK BONE FX 2, , , , TREAT CHEEK BONE FX 2, , , , TREAT CHEEK BONE FX 4, , TREAT CHEEK BONE FX 5, , TREAT EYE SOCKET FX 3, , TREAT EYE SOCKET FX 2, , TREAT EYE SOCKET FX 3, , , , TREAT EYE SOCKET FX 4, , TREAT EYE SOCKET FX , TREAT EYE SOCKET FX 2, , , , TREAT EYE SOCKET FX 2, , , , TREAT EYE SOCKET FX 2, , , , TREAT EYE SOCKET FX 3, , TREAT LOWER JAW FX TREAT LOWER JAW FX 1, , ,

103 MEDICAL FEE SCHEDULES 11: TREAT LOWER JAW FX , , TREAT LOWER JAW FX 1, , , , TREAT LOWER JAW FX , , TREAT LOWER JAW FX 3, , , , TREAT LOWER JAW FX 3, , , , TREAT LOWER JAW FX 1, , , , TREAT LOWER JAW FX 1, , TREAT RIB FX TREAT STERNUM FX TREAT STERNUM FX TREAT SPINE PROCESS FX TREAT SPINE FX TREAT SPINE FX 3, , , , MANIPULATE SPINE , , PERCUT VERTEBROPLASTY THORACIC 4, , PERCUT VERTEBROPLASTY LUMBAR 4, , PERCUT VERTEBROPLASTY ADDED 4, , NECK SPINE FUSION 6, , ADDED SPINAL FUSION 1, , INSERT SPINE FIXATION DEVICE 4, , APPLY SPINE PROSTH DEVICE 2, , PARTIAL REMOVE COLLAR BONE 3, , , , REMOVE COLLAR BONE 4, , , , REMOVE SHOULDER BONE, PART 3, , , , REMOVE SHOULDER FOREIGN BODY 3, , , , REMOVE SHOULDER FOREIGN BODY 5, , INJECTION FOR SHOULDER X-RAY X, N TX SHO AREA 1 TDN , , TX SHO AREA MLT TDN THRU SM INC 1, , , , OPEN REPAIR OF ROTATOR CUFF, RECENT 3, , , , OPEN REPAIR OF ROTATOR CUFF, OLD 3, , , , CORACOACROMIAL LIGM RLS +-ACROMP 1, , , , RECONSTRUCTION ROTATOR CUFF, OLD 4, , , , TENODIS LONG TDN BICEPS 1, , , , RESCJ/TRNSPLJ LONG TDN BICEPS 1, , , , RECONSTRUCT SHOULDER JOINT 5, , RECONSTRUCT SHOULDER JOINT 6, , REVISE COLLAR BONE 3, , , , REVISE COLLAR BONE 4, , , , TREAT CLAVICLE FX TREAT CLAVICLE FX , , TREAT CLAVICLE FX 2, , , , TREAT CLAVICLE DISLOCATION TREAT CLAVICLE DISLOCATION TREAT CLAVICLE DISLOCATION 1, , , , TREAT CLAVICLE DISLOCATION TREAT CLAVICLE DISLOCATION TREAT CLAVICLE DISLOCATION 1, , , , TREAT CLAVICLE DISLOCATION 1, , , , TREAT SHOULDER BLADE FX TREAT HUMERUS FX TREAT HUMERUS FX 1, , , TREAT HUMERUS FX 3, , , , TREAT HUMERUS FX 4, , , , TREAT HUMERUS FX TREAT HUMERUS FX , , TREAT HUMERUS FX 2, , , , TREAT SHOULDER DISLOCATION TREAT SHOULDER DISLOCATION , , FIXATE SHOULDER , , INJECTION FOR ELBOW X-RAY X, N MANIPULATE ELBOW W/ANESTH , , ARM TENDON LENGTHENING , , REPAIR BICEPS TENDON 2, , , , REPAIR ARM TENDON/MUSCLE 3, , , ,810.61

104 11: APPENDIX B - REGULATIONS REPAIR RUPTURED TENDON 3, , , , REPAIR ELBOW LAT LIGAMENT W/TISS 2, , , , TREAT HUMERUS FX TREAT HUMERUS FX TREAT HUMERUS FX 1, , , , TREAT HUMERUS FX 1, , , , TREAT HUMERUS FX TREAT HUMERUS FX TREAT HUMERUS FX 1, , , , TREAT RUS FX 1, , , , TREAT HUMERUS FX TREAT HUMERUS FX TREAT RUS FX 1, , , , TREAT HUMERUS FX TREAT HUMERUS FX TREAT RUS FX 1, , , , INCISE TENDON SHEATH , , INCISE FLEXOR CARPI RADIALIS , , DECOMPRESS FOREARM 1 SPACE 1, , , , DECOMPRESS FOREARM 1 SPACE 3, ,221.26, , DECOMPRESS FOREARM 2 SPACES 2, , , , DECOMPRESS FOREARM 2 SPACES 3, , , , EXCISE WRIST TENDON SHEATH , , REMOVE WRIST BONES 1, , , , INJECTION FOR WRIST X-RAY X, N MANIPULATE WRIST W/ANESTH , , REPAIR FOREARM TENDON/MUSCLE2, , , , REPAIR FOREARM TENDON/MUSCLE1, , , , REPAIR FOREARM TENDON/MUSCLE2, , , , REPAIR FOREARM TENDON/MUSCLE1, , , , REPAIR FOREARM TENDON/MUSCLE1, , , , REPAIR FOREARM TENDON/MUSCLE2, , , , RELEASE WRIST/FOREARM TENDON , , TREAT FX RADIUS TREAT FX RADIUS TREAT FX RADIUS 1, , , , TREAT FX RADIUS 1, , , , TREAT FX RADIUS 1, , , , TREAT FX ULNA TREAT FX ULNA TREAT FX ULNA , , TREAT FX RADIUS & ULNA TREAT FX RADIUS & ULNA 1, , TREAT FX RADIUS & ULNA 2, , , , TREAT FX RADIUS/ULNA 2, , , , TREAT FX RADIUSIULNA TREAT FX RADIUS/ULNA 1, , TREAT FX DISTAL RADIAL 2, , , , TREAT FX RADIAL EXTRA-ARTICULAR 2, , , , TREAT FX RADIAL INTRA-ARTICULAR 2, , , , TREAT FX RADIAL 3+ FRAG 3, , , , TREAT WRIST BONE FX TREAT WRIST BONE FX 1, , TREAT WRIST BONE FX 2, , , , TREAT WRIST BONE FX TREAT WRIST BONE FX 1, , TREAT WRIST BONE FX 1, , , , TREAT WRIST BONE FX TREAT FX ULNAR STYLOID 1, , , , TREAT FX ULNAR STYLOID 1, , , , TREAT FX ULNAR STYLOID 1, , , , TREAT WRIST DISLOCATION 1, , , , TREAT WRIST FX 1, , TREAT WRIST FX 2, , , , INCISE FINGER TENDON SHEATH , , EXCISE HAND TUMOR DEEP < 1.5 CM 1, , , , REVISE FINGER JOINT, EACH 1, , , , TENDON EXCISE PALM/FINGER 2, , , ,107.62

105 MEDICAL FEE SCHEDULES 11: MANIPULATE FINGER W/ANESTH REPAIR HAND TENDON 1, , , , REPAIR FINGER TENDON 2, , , , RELEASE HAND/FINGER TENDON 1, , , , TRANSPLANT HAND TENDON 2, , , , RELEASE FINGER CONTRACTURE 2, , , , REPAIR HAND JOINT 2, , , , TREAT METACARPAL FX TREAT METACARPAL FX TREAT METACARPAL FX , , TREAT METACARPAL FX 1, , , , TREAT METACARPAL FX 1, , , , TREAT FINGER FX, EACH TREAT FINGER FX, EACH TREAT FINGER FX, EACH , , TREAT FINGER FX, EACH , , TREAT FINGER FX, EACH TREAT FINGER FX, EACH TREAT FINGER FX, EACH 1, , , , TREAT FINGER FX, EACH TREAT FINGER FX, EACH EXCISE HIP JOINT/MUSCLE 3, , INJECTION FOR HIP X-RAY X, N INJECTION FOR HIP X-RAY X, N INJECT SACROILIAC JOINT , TOTAL HIP ARTHROPLASTY 5, , TOTAL HIP ARTHROPLASTY 6, , TREAT PELVIC RING FX 1, , TREAT PELVIC RING FX 2, , , , TREAT HIP FX(S) 5, , TREAT HIP FX(S) 5, , TREAT THIGH FX 3, , TREAT THIGH FX 3, , MANIPULATE HIP JOINT , , REPAIR KNEE CARTILAGE 3, , , , REPAIR KNEE LIGAMENT 3, , , , REVISE UNSTABLE KNEECAP 2, , , , REVISE UNSTABLE KNEECAP 2, , , , REVISION/REMOVE KNEECAP 2, , , , TOTAL KNEE ARTHROPLASTY 4, , REVISE/REPLACE KNEE JOINT 4, , TREAT THIGH FX 2, , TREAT THIGH FX 2, , TREAT THIGH FX 3, , , , TREAT THIGH FX 3, , TREAT THIGH FX 5, , TREAT THIGH FX 4, , TREAT THIGH FX 2, , TREAT THIGH FX 2, , , , TREAT THIGH FX 2, , TREAT THIGH FX 4, , TREAT THIGH FX 5, , TREAT THIGH FX 4, , TREAT KNEECAP FX 1, , TREAT KNEECAP FX 3, , TREAT KNEE FX 1, , TREAT KNEE FX 2, , , , TREAT KNEE FX 3, , TREAT KNEE FX 5, , TREAT KNEE FX(S) 1, , TREAT KNEE FX 3, , FIXATE KNEE JOINT , , REVISE LOWER LEG TENDON 2, , , , REVISE LOWER LEG TENDONS 2, , , , REVISE LOWER LEG TENDON 2, , , , REVISE LOWER LEG TENDON 3, , , , REVISE ADDEDITIONAL LEG TENDON , , REPAIR ANKLE LIGAMENT 1, , , , REPAIR ANKLE LIGAMENTS 1, , , , REPAIR ANKLE LIGAMENT 1, , , , TREAT TIBIA FX 1, , TREAT TIBIA FX 2, , , ,558.43

106 11: APPENDIX B - REGULATIONS TREAT TIBIA FX 3, , , , TREAT TIBIA FX 4, , , , CLOSED TREAT MEDIAL ANKLE FX CLOSED TREAT MED ANKLE FX W/MANIP 1, , , , OPEN TREAT MEDIAL ANKLE FX 1, , , , TREAT ANKLE FX TREAT ANKLE FX TREAT ANKLE FX 1, , , , TREAT ANKLE FX TREAT ANKLE FX TREAT ANKLE FX 1, , , , TREAT ANKLE FX TREAT ANKLE FX TREAT ANKLE FX 1, , , , TREAT ANKLE FX 1, , , , TREAT LOWER LEG FX TREAT LOWER LEG FX 1, , , , TREAT LOWER LEG FX 2, , , , TREAT LOWER LEG FX 3, , , , TREAT LOWER LEG FX 3, , , , TREAT LOWER LEG JOINT 2, , , , TREAT ANKLE DISLOCATION 1, , TREAT ANKLE DISLOCATION 1, , , , TREAT ANKLE DISLOCATION 2, , , , TREAT ANKLE DISLOCATION 2, , , , FIXATE ANKLE JOINT , , PART REMOVE ANKLE/HEEL 1, , , , PARTIAL REMOVE FOOT BONE 1, , , TREAT HEEL FX TREAT HEEL FX , , TREAT HEEL FX 1, , , , TREAT/GRAFT HEEL FX 2, , , , TREAT ANKLE FX TREAT ANKLE FX TREAT ANKLE FX 1, , , , TREAT ANKLE FX 2, , ,420.90, TREAT METATARSAL FX TREAT METATARSAL FX TREAT METATARSAL FX , , TREAT METATARSAL FX 1, , , , FUSE FOOT BONES 1, , , , FUSE FOOT BONES 2, , , , FUSE FOOT BONES 2, , , , FUSE BIG TOE JOINT 2, , , , APPLY LONG ARM CAST X APPLY FOREARM CAST X APPLY HANDIWRIST CAST X APPLY FINGER CAST X APPLY LONG ARM SPLINT X APPLY FOREARM SPLINT X APPLY FOREARM SPLINT X APPLY FINGER SPLINT X APPLY FINGER SPLINT X STRAP CHEST X STRAP SHOULDER X STRAP ELBOW OR WRIST X STRAP HAND OR FINGER X APPLY LONG LEG CAST X APPLY LONG LEG CAST X APPLY LONG LEG CAST X APPLY SHORT LEG CAST X APPLY SHORT LEG CAST X APPLY LEG CAST X APPLY LONG LEG SPLINT X APPLY LOWER LEG SPLINT X STRAP HIP X STRAP KNEE X STRAP ANKLE AND/OR FT X STRAP TOES X APPLY PASTE BOOT X APPLY MULTILAY COMPRESS LWR

107 MEDICAL FEE SCHEDULES 11: LEG X APPLY FOOT SPLINT X REMOVE/REVISE CAST X REMOVE/REVISE CAST X REMOVE/REVISE CAST WEDGE CAST X JAW ARTHROSCOPY/SURG 2, , , , JAW ARTHROSCOPY/SURG 3, , , , SHOULDER ARTHROSCOPY, DIAG 2, , , , SHOULDER ARTHROSCOPY/SURG 5, , , , SHOULDER ARTHROSCOPY/SURG 5, , , , SHOULDER ARTHROSCOPY/SURG 3, , , , SHOULDER ARTHROSCOPY/SURG 2, , , , SHOULDER ARTHROSCOPY/SURG 3, , , , SHOULDER ARTHROSCOPY/SURG 3, , , , SHOULDER ARTHROSCOPY/SURG 3, , , , SHOULDER ARTHROSCOPY/SURG 3, , , , SHOULDER ARTHROSCOPY/SURG 3, , , , SHOULDER ARTHROSCOPY/SURG3,650,34 3, , , ARTHROSCOPY ROTATOR CUFF REPAIR 4, , , , ARTHROSCOPY BICEPS TENODESIS3, , , , ELBOW ARTHROSCOPY 1, , , , ELBOW ARTHROSCOPY/SURG 2, , , , ELBOW ARTHROSCOPY/SURG 2, , , , ELBOW ARTHROSCOPY/SURG 2, , , , WRIST ARTHROSCOPY 1, , , , WRIST ARTHROSCOPY/SURG 2, , , , WRIST ARTHROSCOPY/SURG 2, , , , WRIST ARTHROSCOPY/SURG 2, , , , WRIST ARTHROSCOPY/SURG 2, , , , WRIST ENDOSCOPY/SURG 2, , , , KNEE ARTHROSCOPY/SURG 2, , , , TIBIAL ARTHROSCOPY/SURG 3, , , , HIP ARTHROSCOPY, DIAG 2, , , , HIP ARTHROSCOPY/SURG 3, , , , HIP ARTHROSCOPY/SURG 3, , , , HIP ARTHROSCOPY/SURG 3, , , , KNEE ARTHROSCOPY, DIAG 2, , , , KNEE ARTHROSCOPY/DRAIN 2, , , , KNEE ARTHROSCOPY/SURG 2, , , , KNEE ARTHROSCOPY/SURG 2, , , , KNEE ARTHROSCOPY/SURG 2, , , , KNEE ARTHROSCOPY/SURG 3, , , , KNEE ARTHROSCOPY/SURG 2, , , , KNEE ARTHROSCOPY/SURG 3, , , , KNEE ARTHROSCOPY/SURG 3, , , , KNEE ARTHROSCOPY/SURG 3, , , , KNEE ARTHROSCOPY/SURG 3, , , , KNEE ARTHROSCOPY/SURG 2, , , , KNEE ARTHROSCOPY/SURG 2, , , , KNEE ARTHROSCOPY/SURG 3, , , , KNEE ARTHROSCOPY/SURG 4, , , , KNEE ARTHROSCOPY/SURG 5, , , , ANKLE ARTHROSCOPY/SURG 2, , , , ANKLE ARTHROSCOPY/SURG 2, , , , ANKLE ARTHROSCOPY/SURG 2, , , , ANKLE ARTHROSCOPY/SURG 2, , , , ANKLE ARTHROSCOPY/SURG 2, , , , ANKLE ARTHROSCOPY/SURG 4, , , , INTRANASAL BIOPSY EXCISE INFERIOR TURBINATE , , RESECT INFERIOR TURBINATE , , INJECTION TREAT NOSE REMOVE NASAL FOREIGN BODY X REMOVE NASAL FOREIGN BODY , , REPAIR NASAL SEPTUM 1, , , , ABLATE INF TURBINATE SUBMUCOSAL ; , CONTROL NOSEBLEED CONTROL NOSEBLEED CONTROL NOSEBLEED

108 11: APPENDIX B - REGULATIONS THERAPEUTIC FX, NASAL INF TURB , , IRRIGATE MAXILLARY SINUS EXPLORE MAXILLARY SINUS , , NASAL ENDOSCOPY, DIAG NASAL/SINUS ENDOSCOPY, SURG , , NASAL/SINUS ENDOSCOPY, SURG , , REMOVE ETHMOID SINUS 1, , , , EXPLORE MAXILLARY SINUS 1, , , , ENDOSCOPY, MAXILLARY SINUS , , INSERT EMERGENCY AIRWAY X DIAGNOSTIC LARYNGOSCOPY LARYNGOSCOPY FOR ASPIRATION , , DIAG LARYNGOSCOPY EXCL NB , , DIAGNOSTIC LARYNGOSCOPY DIAGNOSTIC LARYNGOSCOPY INCISE WINDPIPE INCISE WINDPIPE , DIAG BRONCHOSCOPE/WASH , , DIAG BRONCHOSCOPE/LAVAGE , , BRONCHOSCOPY, CLEAR AIRWAYS , , BRONCHOSCOPY, RECLEAR AIRWAY , , BIOPSY LUNG OR MEDIASTINUM , , KNEE ARTHROSCOPY/SURG 3, , , , INSERT CHEST TUBE THORACOSCOPY, DIAGNOSTIC THORACOSCOPY, SURGICAL 1, , THORACOSCOPY, SURGICAL 1, , INSERT HEART ELECTRODE , , INSERT PULSE GENERATOR , , PLACE NEEDLE IN VEIN X, N INJECTION EXT VENOGRAPHY X, N PLACE CATHETER IN VEIN X, N PLACE CATHETER IN VEIN 1, , X, N PLACE CATHETER IN ARTERY 1, , X, N PLACE CATHETER IN ARTERY 1, , X, N ESTABLISH ACCESS TO ARTERY X, N PLACE CATHETER IN AORTA 1, , X, N PLACE CATHETER IN ARTERY 1, , X, N PLACE CATHETER IN ARTERY 2, , X, N PLACE CATHETER IN ARTERY 3, , X, N PLACE CATHETER IN ARTERY X, N PLACE CATHETER IN ARTERY 2, , X, N PLACE CATHETER IN ARTERY 2, , X, N PLACE CATHETER IN ARTERY 3, , X, N PLACE CATHETER IN ARTERY X, N BLOOD DRAW < 3 YRS FEM/JUGULAR X, N BLOOD DRAW < 3 YRS OTHER VEIN X, N NON-ROUTINE BL DRAW > 3 YRS X, N VEIN ACCESS CUTDOWN > 1 YR X BLOOD TRANSFUSION SERVICE X INJECTION THERAPY VEINS APHERESIS PLATELETS , , X APHERESIS PLASMA , , X APHERESIS, ADSORP/REINFUSE 3, , , , X INSERT NON-TUNNEL CV CATH , , INSERT NON-TUNNEL CV CATH , , INSERT TUNNELED CV CATH 1, , , , INSERT PICC CATH , , INSERT PICVAD CATH 2, , , , REPAIR TUNNELED CV CATH , , REPLACE TUNNELED CV CATH , , REPLACE CVAD CATH , , REPLACE PICC CATH , , REMOVE TUNNELED CV CATH COLLECT BLOOD PICC X, N DECLOT VASCULAR DEVICE INJECT W/FLUOR, EVAL CV DEVICE WITHDRAW ARTERIAL BLOOD X, N INSERT CATHETER, ARTERY X, N INSERT CATHETER, ARTERY X, N INSERT CANNULA , , INSERT CANNULA , ,637.55

109 MEDICAL FEE SCHEDULES 11: INSERT CANNULA , , AV FUSE, UPPER ARM, CEPHALIC 1, , , , AV FISTULA REVISION 1, , , , EXTERNAL CANNULA DECLOTTING REVISE CIRCULATION 2, , TEMPORAL ARTERY PROCEDURE , , REVISE MAJOR VEIN 2, , REVISE MAJOR VEIN 1, , , , REMOVE SPLEEN, TOTAL 1, , TRANSCATHETER OCCLUSION 1, , , , REPAIR RUPTURED SPLEEN 1, , INJECTION FOR SPLEEN X-RAY X, N HARVEST AUTO STEM CELLS , , X BONE MARROW ASPIRATION BONE MARROW BIOPSY BONE MARROW COLLECTION , , X REPAIR DIAPHRAGM LACERATION 1, , UPPER GI ENDOSCOPY, DIAGNOSIS , , UPPER GI SCOPE W/SUBMUCOSA INJECT , , UPPER GI ENDOSCOPY, BIOPSY , , PLACE GASTROSTOMY TUBE , , UPPER GI ENDOSCOPY/GUIDE WIRE , , ESOPH ENDOSCOPY, DILATION , , OPERATIVE UPPER GI ENDOSCOPY , , ENDOSCOPIC ULTRASOUND EXAM , , ENDO CHOLANGIOPANCREATOGRAPHY , , DILATE ESOPHAGUS CHANGE GASTROSTOMY TUBE PLACE GASTROSTOMY TUBE 1, , MOBILIZATION COLON INTRODUCE GASTROINTESTINAL TUBE PROCTOSIGMOIDOSCOPY DIAG DIAGNOSTIC SIGMOIDOSCOPY SURGICAL COLONOSCOPY , , DIAGNOSTIC COLONOSCOPY , , INCISE RECTAL ABSCESS , , DIAGNOSTIC ANOSCOPY X NEEDLE BIOPSY LIVER , , PUNCTURE, PERITONEAL CAVITY DIAG LAP SEPARATE PROC , , INSERT ABDOM DRAIN, PERM , , PART RPR I/HERNIA INIT REDUCT >5 YR , , INSERT KIDNEY DRAIN , , INJECTION FOR KIDNEY X-RAY X, N INJECTION FOR BLADDER X-RAY X, N INJECTION FOR BLADDER X-RAY X, N IRRIGATION BLADDER INSERT BLADDER CATHETER X INSERT TEMP BLADDER CATH X INSERT BLADDER CATH, COMPLEX CHANGE BLADDER TUBE TREAT BLADDER LESION SIMPLE CYSTOMETROGRAM TC SIMPLE CYSTOMETROGRAM SIMPLE CYSTOMETROGRAM COMPLEX CYSTOMETROGRAM TC COMPLEX CYSTOMETROGRAMI COMPLEX CYSTOMETROGRAM ELECTRO-UROFLOWMETRY, FIRST TC ELECTRO-UROFLOWMETRY, FIRST ELECTRO-UROFLOWMETRY, FIRST ANAL/URINARY MUSCLE STUDY , TC ANAL/URINARY MUSCLE STUDY ANAL/URINARY MUSCLE STUDY INTRAABDOMINAL PRESSURE TEST TC INTRAABDOMINAL PRESSURE TEST INTRAABDOMINAL PRESSURE TEST US URINE CAPACITY MEASURE X

110 11: APPENDIX B - REGULATIONS CYSTOSCOPY CYSTOSCOPY & URETER CATHETER , , CYSTOSCOPY W/BIOPSY(S) , , CYSTOSCOPY & TREAT , , CYSTOSCOPY & TREAT , , CYSTOSCOPY & TREAT , , CYSTOURETERO & OR PYELOSCOPE , , DILATE URETHRA STRICTURE DILATE URETHRA STRICTURE DILATE URETHRA DILATE URETHRA PENILE INJECTION EXAM CERVIX W/SCOPE BIOPSY CERVIX CRYOCAUTERY CERVIX CATHETER FOR HYSTERORRHAPHY X, N HYSTEROSCOPY, BIOPSY , , AMNIOCENTESIS, DIAGNOSTIC FETAL NON-STRESS TEST TC FETAL NON-STRESS TEST 45, FETAL NON-STRESS TEST ABORTION , , DRILL SKULL FOR IMPLANTATION 1, , TREAT TRIGEMINAL NERVE 2, , EPIDURAL LYSIS MULT SESSIONS 1, , , EPIDURAL LYSIS ON SINGLE DAY 1, , , SPINAL FLUID TAP, DIAGNOSTIC INJECT EPIDURAL PATCH , TREAT SPINAL CORD LESION , TREAT SPINAL CORD LESION , TREAT SPINAL CANAL LESION , INJECTION FOR MYELOGRAM X, N PERCUTANEOUS DISKECTOMY 5, , , , INJECT FOR SPINE DISK X-RAY 1, , X, N INJECT FOR SPINE DISK X-RAY 1, , X, N INJECTION INTO DISK LESION 1, , , INJECT SPINE C/T 1, , INJECT SPINE L/S (CD) , INJECT SPINE W/CATH, C/T , INJECT SPINE W/CATH L/S (CD) , , IMPLANT SPINAL CANAL CATH 5, , REMOVE SPINAL CANAL CATHETER 1, , INSERT SPINE INFUSION DEVICE 5, , IMPLANT SPINE INFUSION PUMP 22, , REMOVE SPINE INFUSION DEVICE 4, , ANALYZE SPINE INFUSION PUMP X ANALYZE SPINE INFUSION PUMP X NECK SPINE DISK SURG 10, , NECK SPINE DISK SURG 1, , IMPLANT NEUROELECTRODES 7, , X IMPLANT NEUROELECTRODES 10, , X INSERT/REDO SPINE N GENERATOR 24, , X REVISE/REMOVE NEURORECEIVER 3, , NERVE BLOCK INJ, TRIGEMINAL NERVE BLOCK INJ, FACIAL NERVE BLOCK INJ, OCCIPITAL NERVE BLOCK INJ, SPINAL ACCESSORY NERVE BLOCK INJ, CERV PLEXUS NERVE BLOCK INJ, BRACHIAL PLEXUS NERVE BLOCK CONT INFUSE, B PLEX , NERVE BLOCK INJ, AXILLARY NERVE BLOCK INJ, SUPRASCAPULAR NERVE BLOCK INJ, INTERCOSTAL, SING NERVE BLOCK INJ, INTERCOSTAL, MULT , NERVE BLOCK INJ, ILIO-ING/HYPOGI NERVE BLOCK INJ, PUDENDAL 1, NERVE BLOCK INJ, PARACERV

111 MEDICAL FEE SCHEDULES 11: NERVE BLOCK INJ, SCIATIC, SING NERVE BLOCK INJ, SCIATIC, CONT INF 1, NERVE BLOCK INJ, FEM, SING NERVE BLOCK INJ, FEM, CONT INF 1, NERVE BLOCK INJ, LUMBAR PLEXUS , NERVE BLOCK, OTHER PERIPHERAL NERVE BLOCK INJ, PLANTAR DIGIT INJECT FORAMEN EPIDURAL C/T , INJECT FORAMEN EPIDURAL, ADDED INJECT FORAMEN EPIDURAL L/S , INJECT FORAMEN EPIDURAL, ADDED INJECT PARAVERT F JNT C/T 1 LEV , INJECT PARAVERT F JNT C/T 2 LEV INJECT PARAVERT F JNT C/T 3 LEV INJECT PARAVERT F JNT L/S 1 LEV , INJECT PARAVERT F JNT L/S 2 LEV INJECT PARAVERT F JNT L/S 3 LEV NERVE BLOCK SPHENOPALATINE GANGLIA NERVE BLOCK STELLATE GANGLION , NERVE BLOCK INJ, HYPOGAS PLXS , NERVE BLOCK LUMBAR/THORACIC , APPLY NEUROSTIMULATOR IMPLANT NEUROELECTRODES 7, , X IMPLANT NEUROELECTRODES 7, , X IMPLANT NEUROELECTRODES , , X INJECTION TREAT NERVE , , INJECTION TREAT NERVE 1, , , , INJECTION TREAT NERVE 1, , , , DESTROY NERVE, FACE MUSCLE DESTROY NERVE, NECK MUSCLE DESTROY NERVE, EXTREMITY MUSC INJECTION TREAT NERVE , DESTROY PARAVERTEBRAL NERVE L/S , , DESTROY PARAVERT NERVE, ADDED , DESTROY PARAVERTEBRAL NERVE C/T , DESTROY PARAVERT NERVE, ADDED INJECTION TREAT NERVE INJECTION TREAT NERVE , REVISE FINGER/TOE NERVE 2, , REVISE HAND/FOOT NERVE 2, , REVISE ARM/LEG NERVE 2, , REVISE SCIATIC NERVE 2, , REVISE ARM NERVE(S) 2, , REVISE LOW BACK NERVE(S) 2, , REVISE CRANIAL NERVE 2, , REVISE ULNAR NERVE AT ELBOW 2, , REVISE ULNAR NERVE AT WRIST 2, , CARPAL TUNNEL SURG 2, , , , REMOVE SYMPATHETIC NERVES 1, , REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE 2, , , , EXPLORE/TREAT EYE SOCKET 2, , , , REMOVE IMPACTED EAR WAX X REBUILD OUTER EAR CANAL 1, , , , REBUILD OUTER EAR CANAL 2, , , , REPAIR MIDDLE EAR STRUCTURES3, , , , REPAIR MIDDLE EAR STRUCTURES3, , , , MICROSURG, ADDED X, N X-RAY EYE FOR FOREIGN BODY TC X-RAY EYE FOR FOREIGN BODY X-RAY EYE FOR FOREIGN BODY X-RAY JAW < 4 VIEWS TC X-RAY JAW < 4 VIEWS X-RAY JAW MINIMUM 4 VIEWS X-RAY JAW < 4 VIEWS

112 11: APPENDIX B - REGULATIONS TC X-RAY JAW MINIMUM 4 VIEWS X-RAY JAW MINIMUM 4 VIEWS X-RAY MASTOIDS < 3 VIEWS/SIDE TC X-RAY MASTOIDS < 3 VIEWS/SIDE X-RAY MASTOIDS < 3 VIEWS/SIDE X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE TC X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE X-RAY FACIAL BONES < 3 VIEWS TC X-RAY FACIAL BONES < 3 VIEWS X-RAY FACIAL BONES < 3 VIEWS X-RAY FACIAL BONES MINIMUM 3 VIEWS TC X-RAY FACIAL BONES MINIMUM 3 VIEWS X-RAY FACIAL BONES MINIMUM 3 VIEWS X-RAY NASAL BONES MINIMUM 3 VIEWS TC X-RAY NASAL BONES M 3 VIEWS X-RAY NASAL BONES MINIMUM 3 VIEWS X-RAY OPTIC FORAMINA TC X-RAY OPTIC FORAMINA X-RAY OPTIC FORAMINA X-RAY ORBITS, MINIMUM 4 VIEWS TC X-RAY ORBITS, MINIMUM 4 VIEWS X-RAY ORBITS, MINIMUM 4 VIEWS X-RAY SINUSES < 3 VIEWS TC X-RAY SINUSES < 3 VIEWS X-RAY SINUSES < 3 VIEWS X-RAY SINUSES MINIMUM 3 VIEWS TC X-RAY SINUSES MINIMUM 3 VIEWS X-RAY SINUSES MINIMUM 3 VIEWS X-RAY SKULL < 4 VIEWS TC X-RAY SKULL < 4 VIEWS X-RAY SKULL < 4 VIEWS X-RAY SKULL MINIMUM 4 VIEWS TC X-RAY SKULL MIN 4 VIEWS X-RAY SKULL MINIMUM 4 VIEWS X-RAY TEETH SINGLE VIEW TC X-RAY TEETH SINGLE VIEW X-RAY TEETH SINGLE VIEW X-RAY TEETH < FULL MOUTH TC X-RAY TEETH < FULL MOUTH X-RAY TEETH < FULL MOUTH X-RAY TEETH FULL MOUTH TC X-RAY TEETH FULL MOUTH X-RAY TEETH FULL MOUTH X-RAY TMJ UNILATERAL TC X-RAY TMJ UNILATERAL X-RAY TMJ UNILATERAL X-RAY TMJ BILATERAL TC X-RAY TMJ BILATERAL X-RAY TMJ BILATERAL TMJ ARTHOGRAPHY; RAD SUPER & INTERP N TC TMJ ARTHOGRAPHY; RAD SUPER & INTERP N TMJ ARTHOGRAPHY; RAD SUPER & INTERP N MRI TMJ TC MRI TMJ MRI TMJ CEPHALOORAM, ORTHODONTIC TC CEPHALOGRAM, ORTHODONTIC CEPHALOGRAM, ORTHODONTIC ORTHOPANTOGRAM TC ORTHOPANTOGRAM

113 MEDICAL FEE SCHEDULES 11: ORTHOPANTOGRAM X-RAY NECK SOFT TISSUE TC X-RAY NECK SOFT TISSUE X-RAY NECK SOFT TISSUE CT HEAD/BRAIN W/O DYE TC CT HEAD/BRAIN W/O DYE CT HEAD/BRAIN W/O DYE CT HEAD/BRAIN W/DYE TC CT HEAD/BRAIN W/DYE CT HEAD/BRAIN W/DYE CT HEAD/BRAIN W/O & W/DYE TC CT HEAD/BRAIN W/O & W/DYE CT HEAD/BRAIN W/O & W/DYE CT ORBIT/EAR/FOSSA W/O DYE TC CT ORBIT/EAR/FOSSA W/O DYE CT ORBITBAR/FOSSA W/O DYE CT ORBIT/EAR/FOSSA W/DYE TC CT ORBIT/EAR/FOSSA W/DYE CT ORBITBAR/FOSSA W/DYE CT ORBIT/EAR/FOSSA W/O & W/DYE TC CT ORBIT/EAR/FOSSA W/O & W/DYE CT ORBIT/EAR/FOSSA W/O & W/DYE CT MAXILLOFACIAL W/O DYE TC CT MAXILLOFACIAL W/O DYE CT MAXILLOFACIAL W/O DYE CT MAXILLOFACIAL W/DYE TC CT MAXILLOFACIAL W/DYE CT MAXILLOFACIAL W/DYE CT MAXILLOFACIAL W/O & W/DYE TC CT MAXILLOFACIAL W/O & W/DYE CT MAXILLOFACIAL W/O &W/DYE CT SOFT TISSUE NECK W/O DYE TC CT SOFT TISSUE NECK W/O DYE CT SOFT TISSUE NECK W/O DYE CT SOFT TISSUE NECK W/DYE TC CT SOFT TISSUE NECK W/DYE CT SOFT TISSUE NECK W/DYE CT SOFT TISSUE NECK W/O & W/DYE TC CT SOFT TISSUE NECK W/O & W/DYE CT SOFT TISSUE NECK W/O & W/DYE CT ANGIOGRAPHY, HEAD 1, TC CT ANGIOGRAPHY, HEAD CT ANGIOGRAPHY, HEAD CT ANGIOGRAPHY, NECK 1, TC CT ANGIOGRAPHY, NECK CT ANGIOGRAPHY, NECK MRI ORBIT/FACE/NECK W/O DYE TC MRI ORBIT/FACE/NECK W/O DYE MRI ORBIT/FACE/NECK W/O DYE MRI ORBIT/FACE/NECK W/DYE TC MRI ORBIT/FACE/NECK W/DYE MRI ORBIT/FACE/NECK W/DYE MRI ORBIT/FACE/NECK W/O & W/DYE 1, , TC MRI ORBIT/FACE/NECK W/O & W/DYE 1, , , MRI ORBIT/FACE/NECK W/O & W/DYE MR ANGIOGRAPHY HEAD W/O DYE TC MR ANGIOGRAPHY HEAD W/O DYE MR ANGIOGRAPHY HEAD W/O DYE MR ANGIOGRAPHY HEAD W/DYE TC MR ANGIOGRAPHY HEAD W/DYE MR ANGIOGRAPHY HEAD W/DYE MR ANGIOGRAPH HEAD W/O & W/DYE 1, , TC MR ANGIOGRAPH HEAD W/O & W/DYE 1, , , MR ANGIOGRAPH HEAD W/O & W/DYE MR ANGIOGRAPHY NECK W/O DYE TC MR ANGIOGRAPHY NECK W/O DYE

114 11: APPENDIX B - REGULATIONS MR ANGIOGRAPHY NECK W/O DYE MR ANGIOGRAPHY NECK W/DYE TC MR ANGIOGRAPHY NECK W/DYE MR ANGIOGRAPHY NECK W/DYE MR ANGIOGRAPH NECK W/O & W/DYE 1, , TC MR ANGIOGRAPH NECK W/O & W/DYE 1, , , MR ANGIOGRAPH NECK W/O & W/DYE MRI BRAIN W/O DYE TC MRI BRAIN W/O DYE MRI BRAIN W/0 DYE MRI BRAIN W/DYE TC MRI BRAIN W/DYE MRI BRAIN W/DYE MRI BRAIN W/O & W/DYE 1, , TC MRI BRAIN W/O & W/DYE 1, , MRI BRAIN W/O & W/DYE FMRI BRAIN BY TECH TC FMRI BRAIN BY TECH FMRI BRAIN BY TECH FMRI BRAIN BY PHYS/PSYCH CHEST X-RAY SINGLE VIEW FRONTAL TC CHEST X-RAY SINGLE VIEW FRONTAL CHEST X-RAY SINGLE VIEW FRONTAL CHEST X-RAY 2 VIEWS FRONTAL & LATERAL TC CHEST X-RAY 2 VIEWS FRONTAL & LATERAL CHEST X-RAY 2 VIEWS FRONTAL & LATERAL CHEST X-RAY 2 VIEWS W/APICAL LORD PROC TC CHEST X-RAY 2 VIEWS W/APICAL LORD PROC CHEST X-RAY 2 VIEWS W/APICAL LORD PROC CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ TC CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ CHEST X-RAY MINIMUM 4 VIEWS TC CHEST X-RAY MINIMUM 4 VIEWS ' CHEST X-RAY MINIMUM 4 VIEWS CHEST X-RAY SPECIAL VIEWS TC CHEST X-RAY SPECIAL VIEWS CHEST X-RAY SPECIAL VIEWS CONTRAST X-RAY BRONCHI UNILATERAL N TC CONTRAST X-RAY BRONCHI UNILATERAL N CONTRAST X-RAY BRONCHI UNILATERAL N X-RAY & PACEMAKER INSERT N TC X-RAY & PACEMAKER INSERT N X-RAY & PACEMAKER INSERT N X-RAY RIBS 2 VIEWS TC X-RAY RIBS 2 VIEWS X-RAY RIBS 2 VIEWS X-RAY RIBS/CHEST MINIMUM 3 VIEWS TC X-RAY RIBS/CHEST MINIMUM 3 VIEWS X-RAY RIBS/CHEST MINIMUM 3 VIEWS X-RAY RIBS BILATERAL 3 VIEWS TC X-RAY RIBS BILATERAL 3 VIEWS X-RAY RIBS BILATERAL 3 VIEWS X-RAY RIBS/CHEST MINIMUM 4 VIEWS

115 MEDICAL FEE SCHEDULES 11: TC X-RAY RIBS/CHEST MINIMUM 4 VIEWS X-RAY RIBS/CHEST 4 VIEWS X-RAY STE MINIMUM 2 VIEWS TC X-RAY STERNUM MINIMUM 2 VIEWS X-RAY STERNUM MINIMUM 2 VIEWS X-RAY STERNOCLAV JOINT MINIMUM VIEWS TC X-RAY STERNOCLAV JOINT MINIMUM VIEWS X-RAY STERNOCLAV JOINT MINIMUM VIEWS CT THORAX W/O DYE TC CT THORAX W/O DYE CT THORAX W/O DYE CT THORAX W/DYE TC CT THORAX W/DYE CT THORAX W/DYE CT THORAX W/O &W/DYE TC CT THORAX W/O & W/DYE CT THORAX W/O & W/DYE CT ANGIOGRAPHY, CHEST TC CT ANGIOGRAPHY, CHEST CT ANGIOGRAPHY, CHEST MRI CHEST W/O DYE TC MRI CHEST W/O DYE MRI CHEST W/O DYE MRI CHEST W/O & W/DYE 1, , TC MRI CHEST W/O & W/DYE 1, , , MRI CHEST W/O & W/DYE MRI ANGIO CHEST W OR W/O DYE TC MRI ANGIO CHEST W OR W/O DYE MRI ANGIO CHEST W OR W/O DYE X-RAY SPINE ANTEROPOST & LATERAL TC X-RAY SPINE ANTEROPOST & LATERAL X-RAY SPINE ANTEROPOST & LATERAL X-RAY SPINE SINGLE VIEW SPECIFY LEVEL TC X-RAY SPINE SINGLE VIEW SPECIFY LEVEL X-RAY SPINE SINGLE VIEW SPECIFY LEVEL X-RAY NECK SPINE CERV 2/3 VIEWS TC X-RAY NECK SPINE CERV 2/3 VIEWS X-RAY NECK SPINE CERV 2/3 VIEWS X-RAY NECK SPINE CERV MINIMUM 4 VIEWS TC X-RAY NECK SPINE CERV MINIMUM 4 VIEWS X-RAY NECK SPINE CERV MINIMUM 4 VIEWS X-RAY NECK SPINE COMPLETE TC X-RAY NECK SPINE COMPLETE X-RAY NECK SPINE COMPLETE X-RAY TRUNK SPINE STANDING TC X-RAY TRUNK SPINE STANDING X-RAY TRUNK SPINE STANDING X-RAY THORACIC SPINE 2 VIEWS TC X-RAY THORACIC SPINE 2 VIEWS X-RAY THORACIC SPINE 2 VIEWS X-RAY THORACIC SPINE 3 VIEWS TC X-RAY THORACIC SPINE 3 VIEWS X-RAY THORACIC SPINE 3 VIEWS X-RAY THORACIC SPINE MINIMUM 4 VIEWS TC X-RAY THORACIC SPINE MINIMUM 4 VIEWS X-RAY THORACIC SPINE MINIMUM 4 VIEWS X-RAY TRUNK SPINE 2 VIEWS

116 11: APPENDIX B - REGULATIONS TC X-RAY TRUNK SPINE 2 VIEWS X-RAY TRUNK SPINE 2 VIEWS X-RAY TRUNK SPINE SCOLIOSIS STUDY TC X-RAY TRUNK SPINE SCOLIOSIS STUDY X-RAY TRUNK SPINE SCOLIOSIS STUDY X-RAY LOWER SPINE 2/3 VIEWS TC X-RAY LOWER SPINE 2/3 VIEWS X-RAY LOWER SPINE 2/3 VIEWS X-RAY LOWER SPINE MINIMUM 4 VIEWS TC X-RAY LOWER SPINE MINIMUM 4 VIEWS X-RAY LOWER SPINE MINIMUM 4 VIEWS X-RAY LOWER SPINE COMPLETE TC X-RAY LOWER SPINE COMPLETE X-RAY LOWER SPINE COMPLETE X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS TC X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS CT NECK SPINE W/O DYE TC CT NECK SPINE W/O DYE CT NECK SPINE W/O DYE CT NECK SPINE W/DYE TC CT NECK SPINE W/DYE CT NECK SPINE W/DYE CT NECK SPINE W/O & W/DYE TC CT NECK SPINE W/O & W/DYE CT NECK SPINE W/O &W/DYE CT CHEST SPINE W/O DYE TC CT CHEST SPINE W/O DYE CT CHEST SPINE W/O DYE CT CHEST SPINE W/DYE TC CT CHEST SPINE W/DYE CT CHEST SPINE W/DYE CT CHEST SPINE W/O & W/DYE TC CT CHEST SPINE W/O & W/DYE CT CHEST SPINE W/O & W/DYE CT LUMBAR SPINE W/O DYE TC CT LUMBAR SPINE W/O DYE CT LUMBAR SPINE W/O DYE CT LUMBAR SPINE W/DYE TC CT LUMBAR SPINE W/DYE CT LUMBAR SPINE W/DYE CT LUMBAR SPINE W/O & W/DYE TC CT LUMBAR SPINE W/O & W/DYE CT LUMBAR SPINE W/O & W/DYE MRI NECK SPINE W/O DYE TC MRI NECK SPINE W/O DYE MRI NECK SPINE W/O DYE MRI NECK SPINE W/DYE TC MRI NECK SPINE W/DYE MRI NECK SPINE W/DYE MRI CHEST SPINE W/O DYE TC MRI CHEST SPINE W/O DYE , MRI CHEST SPINE W/O DYE MRI CHEST SPINE W/DYE TC MRI CHEST SPINE W/DYE MRI CHEST SPINE W/DYE MRI LUMBAR SPINE W/O DYE TC MRI LUMBAR SPINE W/O DYE MRI LUMBAR SPINE W/O DYE MRI LUMBAR SPINE W/DYE TC MRI LUMBAR SPINE W/DYE MRI LUMBAR SPINE W/DYE MRI NECK SPINE W/O & W/DYE 1, ,151,99

117 MEDICAL FEE SCHEDULES 11: TC MRI NECK SPINE W/O &W/DYE 1, , MRI NECK SPINE W/O & W/DYE MRI CHEST SPINE W/O & W/DYE 1, , TC MRI CHEST SPINE W/O & W/DYE , MRI CHEST SPINE W/O & W/DYE MRI LUMBAR SPINE W/O & W/DYE 1, , TC MRI LUMBAR SPINE W/O & W/DYE 1, , MRI LUMBAR SPINE W/O & W/DYE X-RAY PELVIS 1/2 VIEWS TC X-RAY PELVIS 1/2 VIEWS X-RAY PELVIS 1/2 VIEWS X-RAY PELVIS MINIMUM 3 VIEWS TC X-RAY PELVIS MINIMUM 3 VIEWS X-RAY PELVIS MINIMUM 3 VIEWS CT ANGIOGRAPH PELVIS W/O & W/DYE TC CT ANGIOGRAPH PELVIS W/O & W/DYE CT ANGIOGRAPH PELVIS W/O & W/DYE CT PELVIS W/O DYE TC CT PELVIS W/O DYE CT PELVIS W/O DYE CT PELVIS W/DYE TC CT PELVIS W/DYE CT PELVIS W/DYE CT PELVIS W/O & W/DYE TC CT PELVIS W/O & W/DYE CT PELVIS W/O & W/DYE MRI PELVIS W/O DYE TC MRI PELVIS W/O DYE MRI PELVIS W/0 DYE MRI PELVIS W/DYE TC MRI PELVIS W/DYE MRI PELVIS W/DYE MRI PELVIS W/O & W/DYE 1, , TC MRI PELVIS W/O & W/DYE 1, , , MRI PELVIS W/O & W/DYE MR ANGIO PELVIS W/O & W/DYE TC MR ANGIO PELVIS W/O & W/DYE MR ANGIO PELVIS W/O & W/DYE X-RAY EXAM SACROILIAC JOINTS TC X-RAY EXAM SACROILIAC JOINTS X-RAY EXAM SACROILIAC JOINTS X-RAY EXAM SACROILIAC JOINTS TC X-RAY EXAM SACROILIAC JOINTS X-RAY EXAM SACROILIAC JOINTS X-RAY TAILBONE TC X-RAY TAILBONE X-RAY TAILBONE CONTRAST X-RAY NECK SPINE N TC CONTRAST X-RAY NECK SPINE N CONTRAST X-RAY NECK SPINE N CONTRAST X-RAY THORAX SPINE N TC CONTRAST X-RAY THORAX SPINE N CONTRAST X-RAY THORAX SPINE N CONTRAST X-RAY LOWER SPINE N TC CONTRAST X-RAY LOWER SPINE N CONTRAST X-RAY LOWER SPINE N CONTRAST X-RAY SPINE N TC CONTRAST X-RAY SPINE N CONTRAST X-RAY SPINE N EPIDUROGRAPHY N TC EPIDUROGRAPHY N EPIDUROGRAPHY N X-RAY C/T SPINE DISK N TC X-RAY C/T SPINE DISK N X-RAY C/T SPINE DISK N PERCUT VERT/SACROPLASTY, FLUOR N TC PERCUT VERT/SACROPLASTY, FLUOR N1

118 11: APPENDIX B - REGULATIONS PERCUT VERT/SACROPLASTY, FLUOR N X-RAY LOWER SPINE DISK N TC X-RAY LOWER SPINE DISK N X-RAY LOWER SPINE DISK N X-RAY COLLAR BONE TC X-RAY COLLAR BONE X-RAY COLLAR BONE X-RAY SHOULDER BLADE TC X-RAY SHOULDER BLADE X-RAY SHOULDER BLADE X-RAY SHOULDER 1 VIEW TC X-RAY SHOULDER 1 VIEW X-RAY SHOULDER 1 VIEW X-RAY SHOULDER MINIMUM 2 VIEWS TC X-RAY SHOULDER MINIMUM 2 VIEWS X-RAY SHOULDER MINIMUM 2 VIEWS CONTRAST X-RAY SHOULDER N TC CONTRAST X-RAY SHOULDER N CONTRAST X-RAY SHOULDER N X-RAY HUMERUS MINIMUM 2 VIEWS TC X-RAY HUMERUS MINIMUM 2 VIEWS X-RAY HUMERUS MINIMUM 2 VIEWS X-RAY ELBOW 2 VIEWS TC X-RAY ELBOW 2 VIEWS X-RAY ELBOW 2 VIEWS X-RAY ELBOW MINIMUM 3 VIEWS TC X-RAY ELBOW MINIMUM 3 VIEWS X-RAY ELBOW MINIMUM 3 VIEWS X-RAY FOREARM TC X-RAY FOREARM X-RAY FOREARM X-RAY ARM, INFANT TC X-RAY ARM, INFANT X-RAY SHOULDERS TC X-RAY SHOULDERS X-RAY SHOULDERS X-RAY ARM, INFANT X-RAY WRIST 2 VIEWS TC X-RAY WRIST 2 VIEWS X-RAY WRIST 2 VIEWS X-RAY WRIST MIN 3 VIEWS TC X-RAY WRIST M 3 VIEWS X-RAY WRIST MINIMUM 3 VIEWS CONTRAST X-RAY WRIST N TC CONTRAST X-RAY WRIST N CONTRAST X-RAY WRIST N X-RAY HAND 2 VIEWS TC X-RAY HAND 2 VIEWS X-RAY HAND 2 VIEWS X-RAY HAND MINIMUM 3 VIEWS TC X-RAY HAND MINIMUM 3 VIEWS X-RAY HAND MINIMUM 3 VIEWS X-RAY FINGER(S) M 2 VIEWS TC X-RAY FINGER(S) MINIMUM 2 VIEWS X-RAY FINGER(S) MINIMUM 2 VIEWS CT UPPER EXTREMITY W/O DYE TC CT UPPER EXTREMITY W/O DYE CT UPPER EXTREMITY W/O DYE CT UPPER EXTREMITY W/DYE TC CT UPPER EXTREMITY W/DYE CT UPPER EXTREMITY W/DYE CT UPPER EXTREMITY W/O & W/DYE TC CT UPPER EXTREMITY W/O & W/DYE CT UPPER EXTREMITY W/O & W/DYE CT ANGIO UPR EXTREMITY W/O & W/DYE TC CT ANGIO UPR EXTREMITY W/O & W/DYE CT ANGIO UPR EXTREMITY W/O & W/DYE MRI UPPER EXTREMITY W/O DYE

119 MEDICAL FEE SCHEDULES 11: TC MRI UPPER EXTREMITY W/O DYE MRI UPPER EXTREMITY W/O DYE MRI UPPER EXTREMITY W/DYE TC MRI UPPER EXTREMITY W/DYE MRI UPPER EXTREMITY W/DYE MRI UPPER EXTREMITY W/O & W/DYE 1, , TC MRI UPPER EXTREMITY W/O & W/DYE 1, , , MRI UPPER EXTREMITY W/O & W/DYE MRI JOINT UPPER EXTREMITY W/O DYE TC MRI JOINT UPPER EXTREMITY W/O DYE MRI JOINT UPPER EXTREMITY W/O DYE MRI JOINT UPPER EXTREMITY W/DYE TC MRI JOINT UPPER EXTREMITY W/DYE MRI JOINT UPPER EXTREMITY W/DYE MRI JOINT UPPER EXTREMITY W/O & W/DYE 1, , TC MRI JOINT UPPER EXTREMITY W/O & W/DYE 1, , MRI JOINT UPPER EXTREMITY W/O & W/DYE MR ANGIO UPPER EXTREMITY W/O & W/DYE 1, TC MR ANGIO UPPER EXTREMITY W/O & W/DYE MR ANGIO UPPER EXTREMITY W/O & W/DYE X-RAY HIP UNILATERAL 1 VIEW TC X-RAY HIP UNILATERAL 1 VIEW , X-RAY HIP UNILATERAL 1 VIEW X-RAY HIP COMPLETE MINIMUM 2 VIEWS TC X-RAY HIP COMPLETE 2 VIEWS X-RAY HIP COMPLETE MINIMUM 2 VIEWS X-RAY HIPS MINIMUM 2 VIEWS TC X-RAY HIPS MINIMUM 2 VIEWS X-RAY HIPS MINIMUM 2 VIEWS X-RAY HIP ARTHROGRAPHY N TC X-RAY HIP ARTHROGRAPHY N X-RAY HIP ARTHROGRAPHY N X-RAY HIP DURING OPERATIVE PROCEDURE N TC X-RAY HIP DURING OPERATIVE PROCEDURE N X-RAY HIP DURING OPERATIVE PROCEDURE N X-RAY PELVIS & HIPS MINIMUM 2 VIEWS TC X-RAY PELVIS & HIPS MINIMUM 2 VIEWS X-RAY PELVIS & HIPS MINIMUM 2 VIEWS X-RAY EXAM, SACROILIAC JOINT N TC X-RAY EXAM, SACROILIAC JOINT N X-RAY EXAM, SACROILIAC JOINT N X-RAY THIGH 2 VIEWS TC X-RAY THIGH 2 VIEWS X-RAY THIGH 2 VIEWS X-RAY KNEE 1/2 VIEWS TC X-RAY KNEE 1/2 VIEWS X-RAY KNEE 1/2 VIEWS X-RAY KNEE 3 VIEWS TC X-RAY KNEE 3 VIEWS

120 11: APPENDIX B - REGULATIONS X-RAY KNEE 3 VIEWS X-RAY KNEE, COMPLETE 4/MORE VIEWS TC X-RAY KNEE, COMPLETE 4/MORE VIEWS X-RAY KNEE, COMPLETE 4/MORE VIEWS X-RAY KNEES STANDING ANTEROPOST TC X-RAY KNEES STANDING ANTEROPOST X-RAY KNEES STANDING ANTEROPOST X-RAY KNEE ARTHOGRAPHY N TC X-RAY KNEE ARTHOGRAPHY N X-RAY KNEE ARTHOGRAPHY N X-RAY TIBIA & FIBULA 2 VIEWS TC X-RAY TIBIA & FIBULA 2 VIEWS X-RAY TIBIA & FIBULA 2 VIEWS X-RAY LEG, INFANT MINIMUM 2 VIEWS TC X-RAY LEG, INFANT MINIMUM 2 VIEWS X-RAY LEG, INFANT MINIMUM 2 VIEWS X-RAY ANKLE 2 VIEWS TC X-RAY ANKLE 2 VIEWS X-RAY ANKLE 2 VIEWS X-RAY ANKLE MINIMUM 3 VIEWS TC X-RAY ANKLE MINIMUM 3 VIEWS X-RAY ANKLE MINIMUM 3 VIEWS CONTRAST X-RAY ANKLE N TC CONTRAST X-RAY ANKLE N CONTRAST X-RAY ANKLE N X-RAY FOOT 2 VIEWS TC X-RAY FOOT 2 VIEWS X-RAY FOOT 2 VIEWS X-RAY FOOT MINIMUM 3 VIEWS TC X-RAY FOOT MINIMUM 3 VIEWS X-RAY FOOT MINIMUM 3 VIEWS X-RAY HEEL TC X-RAY HEEL X-RAY HEEL X-RAY TOE(S) TC X-RAY TOE(S) X-RAY TOE(S) CT LOWER EXTREMITY W/O DYE TC CT LOWER EXTREMITY W/O DYE CT LOWER EXTREMITY W/O DYE CT LOWER EXTREMITY W/DYE TC CT LOWER EXTREMITY W/DYE CT LOWER EXTREMITY W/DYE CT ANGIO LWR EXTREMITY W/O & W/DYE TC CT ANGIO LWR EXTREMITY W/O & W/DYE CT ANGIO LWR EXTREMITY W/O & W/DYE MRI LOWER EXTREMITY W/O DYE TC MRI LOWER EXTREMITY W/O DYE MRI LOWER EXTREMITY W/O DYE MRI LOWER EXTREMITY W/DYE TC MRI LOWER EXTREMITY W/DYE MRI LOWER EXTREMITY W/DYE MRI LOWER EXTREMITY W/O & W/DYE 1, , TC MRI LOWER EXTREMITY W/O & W/DYE 1, , , MRI LOWER EXTREMITY W/O & W/DYE MRI JOINT LOWER EXTREMITY W/O DYE

121 MEDICAL FEE SCHEDULES 11: TC MRI JOINT LOWER EXTREMITY W/O DYE MRI JOINT LOWER EXTREMITY W/O DYE MRI JOINT LOWER EXTREMITY W/DYE TC MRI JOINT LOWER EXTREMITY W/DYE MRI JOINT LOWER EXTREMITY W/DYE MRI JOINT LWR EXTREMITY W/O & W/DYE 1, , TC MRI JOINT LWR EXTREMITY W/O & W/DYE 1, , MRI JOINT LWR EXTREMITY W/O & W/DYE MR ANGIO LOWER EXT W OR W/O DYE TC MR ANGIO LOWER EXT W OR W/O DYE MR ANGIO LOWER EXT W OR W/O DYE X-RAY ABDOMEN SINGLE ANTEROPOST TC X-RAY ABDOMEN SINGLE ANTEROPOST X-RAY ABDOMEN SINGLE ANTEROPOST X-RAY ABDOMEN ANTEROPOST & ADDED VW TC X-RAY ABDOMEN ANTEROPOST & ADDED VW X-RAY ABDOMEN ANTEROPOST & ADDED VW X-RAY ABDOMEN COMPLETE , TC X-RAY ABDOMEN COMPLETE X-RAY ABDOMEN COMPLETE X-RAY EXAM SERIES, ABDOMEN TC X-RAY EXAM SERIES, ABDOMEN X-RAY EXAM SERIES, ABDOMEN CT ABDOMEN W/O DYE TC CT ABDOMEN W/O DYE CT ABDOMEN W/O DYE CT ABDOMEN W/DYE TC CT ABDOMEN W/DYE CT ABDOMEN W/DYE CT ABDOMEN W/O & W/DYE TC CT ABDOMEN W/O & W/DYE CT ABDOMEN W/O & W/DYE CT ANGIO ABDOM W/O & W/DYE TC CT ANGIO ABDOM W/O & W/DYE CT ANGIO ABDOM W/O & W/DYE CT ANGIO ABDOM & PELVIS TC CT ANGIO ABDOM & PELVIS CT ANGIO ABDOM & PELVIS CT ANGIO ABDOM & PELVIS W/CONTRAST TC CT ANGIO ABDOM & PELVIS W/CONTRAST CT ANGIO ABDOM & PELVIS W/CONTRAST CT ANGIO ABDOM & PELVIS 1+ REGNS TC CT ANGIO ABDOM & PELVIS 1+ REGNS CT ANGIO ABDOM & PELVIS 1+ REGNS MRI ABDOMEN W/O DYE TC MRI ABDOMEN W/O DYE MRI ABDOMEN W/O DYE MRI ABDOMEN W/O & W/DYE 1, , TC MRI ABDOMEN W/O & W/DYE 1, , ,

122 11: APPENDIX B - REGULATIONS MRI ABDOMEN W/O & W/DYE CONTRAST X-RAY, ESOPHAGUS TC CONTRAST X-RAY, ESOPHAGUS CONTRAST X-RAY, ESOPHAGUS CINE/VIDEO X-RAY, THROAT/ESOPH TC CINE/VIDEO X-RAY, THROAT/ESOPH CINE/VIDEO X-RAY, THROAT/ESOPH X-RAY EXAM, UPPER GI TRACT W/KUB TC X-RAY EXAM, UPPER GI TRACT W/KUB X-RAY EXAM, UPPER GI TRACT W/KUB CONTRAST X-RAY UGI TRACT W/O KUB TC CONTRAST X-RAY UGI TRACT W/O KUB CONTRAST X-RAY UGI TRACT W/O KUB CONTRAST X-RAY COLON W/WO GLUCOGEN TC CONTRAST X-RAY COLON W/WO GLUCOGEN CONTRAST X-RAY COLON W/WO GLUCOGEN CONTRAST X-RAY, GALLBLADDER TC CONTRAST X-RAY, GALLBLADDER CONTRAST X-RAY, GALLBLADDER X-RAY BILE/PANCREAS ENDOSCOPY N TC X-RAY BILE/PANCREAS ENDOSCOPY N X-RAY BILE/PANCREAS ENDOSCOPY N CONTRAST X-RAY URINARY TRACT TC CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT TC CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT TC CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT TC CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY URINARY TRACT N TC CONTRAST X-RAY URINARY TRACT N CONTRAST X-RAY URINARY TRACT N CONTRAST X-RAY BLADDER N TC CONTRAST X-RAY BLADDER N CONTRAST X-RAY BLADDER N X-RAY URETHRA/BLADDER N TC X-RAY URETHRA/BLADDER N X-RAY URETHRA/BLADDER N X-RAY URETHRA/BLADDER N TC X-RAY URETHRA/BLADDER N X-RAY URETHRA/BLADDER N X-RAY CONTROL, CATH INSERT N TC X-RAY CONTROL, OATH INSERT N X-RAY CONTROL, OATH INSERT N X-RAY CONTROL, OATH INSERT N TC X-RAY CONTROL, OATH INSERT N X-RAY CONTROL, OATH INSERT N X-RAY GUIDE, GU DILATION N TC X-RAY GUIDE, GU DILATION N X-RAY GUIDE, GU DILATION N CARDIAC MRI FOR MORPH W/DYE 1, TC CARDIAC MRI FOR MORPH W/DYE , CARDIAC MRI FOR MORPH W/DYE CT HEART W/3D IMAGE TC CT HEART W/3D IMAGE CT HEART NV/3D IMAGE CT ANGIO HEART W/3D IMAGE TC CT ANGIO HEART W/3D IMAGE

123 MEDICAL FEE SCHEDULES 11: CT ANGIO HEART W/3D IMAGE CONTRAST X-RAY AORTA N TC CONTRAST X-RAY AORTA N CONTRAST X-RAY AORTA N CONTRAST X-RAY AORTA N TC CONTRAST X-RAY AORTA N CONTRAST X-RAY AORTA N X-RAY AORTA, LEG ARTERIES N TC X-RAY AORTA, LEG ARTERIES N X-RAY AORTA, LEG ARTERIES N CT ANGIO ABDOMINAL ARTERIES N TC CT ANGIO ABDOMINAL ARTERIES N CT ANGIO ABDOMINAL ARTERIES N ARTERY X-RAYS HEAD & NECK N TC ARTERY X-RAYS HEAD & NECK N ARTERY X-RAYS HEAD & NECK N ARTERY X-RAYS HEAD & NECK N TC ARTERY X-RAYS HEAD & NECK N ARTERY X-RAYS HEAD & NECK N ARTERY X-RAYS HEAD & NECK N TC ARTERY X-RAYS HEAD & NECK N ARTERY X-RAYS HEAD & NECK N ARTERY X-RAYS NECK UNILATERAL N TC ARTERY X-RAYS NECK UNILATERAL N ARTERY X-RAYS NECK UNILATERAL N ARTERY X-RAYS NECK BILATERAL N TC ARTERY X-RAYS NECK BILATERAL N ARTERY X-RAYS NECK BILATERAL N ARTERY X-RAYS SPINE N TC ARTERY X-RAYS SPINE N ARTERY X-RAYS SPINE N ARTERY X-RAYS SPINE N TC ARTERY X-RAYS SPINE N ARTERY X-RAYS SPINE N ARTERY X-RAYS ARM/LEG N TC ARTERY X-RAYS ARM/LEG N ARTERY X-RAYS ARM/LEG N ARTERY X-RAYS ARMS/LEGS N TC ARTERY X-RAYS ARMS/LEGS N ARTERY X-RAYS ARMS/LEGS N ARTERY X-RAYS KIDNEY N TC ARTERY X-RAYS KIDNEY N ARTERY X-RAYS KIDNEY N ARTERY X-RAYS KIDNEYS N TC ARTERY X-RAYS KIDNEYS N ARTERY X-RAYS KIDNEYS N ARTERY X-RAYS ABDOMEN N TC ARTERY X-RAYS ABDOMEN ' N ARTERY X-RAYS ABDOMEN N ARTERY X-RAYS PELVIS N TC ARTERY X-RAYS PELVIS N ARTERY X-RAYS PELVIS N ARTERY X-RAYS LUNGS N TC ARTERY X-RAYS LUNGS N ARTERY X-RAYS LUNGS N ARTERY X-RAY, EACH VESSEL N TC ARTERY X-RAY, EACH VESSEL N ARTERY X-RAY, EACH VESSEL N NONVASCULAR SHUNT, X-RAY N TC NONVASCULAR SHUNT, X-RAY N NONVASCULAR SHUNT, X-RAY N VEIN X-RAY ARM/LEG N TC VEIN X-RAY ARM/LEG N VEIN X-RAY ARM/LEG N VEIN X-RAY ARMS/LEGS N TC VEIN X-RAY ARMS/LEGS N VEIN X-RAY ARMS/LEGS N VEIN X-RAY TRUNK N TC VEIN X-RAY TRUNK N VEIN X-RAY TRUNK N X-RAYS, TRANSCATH THERAPY 1, , N TC X-RAYS, TRANSCATH THERAPY 1, , N1

124 11: APPENDIX B - REGULATIONS X-RAYS, TRANSCATH THERAPY N F/U ANGIOGRAPHY N TC F/U ANGIOGRAPHY N F/U ANGIOGRAPHY N X-RAY PLACE VEIN FILTER N TC X-RAY PLACE VEIN FILTER N X-RAY PLACE VEIN FILTER N ILIAC ANEURYSM ENDOVASC REPAIR X-RAY, ENDOVASC THOR AO REPAIR TRANSCATH IV STENT RS & I N TC TRANSCATH IV STENT RS & I N TRANSCATH IV STENT RS & I N RETRIEVE BROKEN CATHETER N TC RETRIEVE BROKEN CATHETER N RETRIEVE BROKEN CATHETER N REPAIR ARTERIAL BLOCKAGE N TC REPAIR ARTERIAL BLOCKAGE N REPAIR ARTERIAL BLOCKAGE N REPAIR ARTERY BLOCKAGE, EACH N TC REPAIR ARTERY BLOCKAGE, EACH N REPAIR ARTERY BLOCKAGE, EACH N REPAIR VENOUS BLOCKAGE N TC REPAIR VENOUS BLOCKAGE N REPAIR VENOUS BLOCKAGE N X-RAY CONTROL CATHETER CHANGE N TC X-RAY CONTROL CATHETER CHANGE N X-RAY CONTROL CATHETER CHANGE N ABSCESS DRAIN UNDER X-RAY N TC ABSCESS DRAIN UNDER X-RAY N ABSCESS DRAIN UNDER X-RAY N FLUOROSCOPE EXAM N TC FLUOROSCOPE EXAM N FLUOROSCOPE EXAM N FLUOROSCOPE EXAM, EXTENSIVE N TC FLUOROSCOPE EXAM, EXTENSIVE N FLUOROSCOPE EXAM, EXTENSIVE N X-RAY NOSE TO RECTUM TC X-RAY NOSE TO RECTUM X-RAY NOSE TO RECTUM X-RAY FISTULA N TC X-RAY FISTULA N X-RAY FISTULA N X-RAY EXAM, BREAST SPECIMEN N TC X-RAY EXAM, BREAST SPECIMEN N X-RAY EXAM, BREAST SPECIMEN N X-RAY BODY SECTION TC X-RAY BODY SECTION X-RAY BODY SECTION COMPLEX BODY SECTION X-RAYS TC COMPLEX BODY SECTION X-RAYS COMPLEX BODY SECTION X-RAYS CINEIVIDEO X-RAYS TC CINE/VIDEO X-RAYS CINE/VIDEO X-RAYS CINEIVIDEO X-RAYS, ADDED N D RENDER W/O POST PROCESS N TC 3D RENDER W/O POST PROCESS N D RENDER W/O POST PROCESS N D RENDERING W/POST PROCESS N TC 3D RENDERING W/POST PROCESS N D RENDERING W/POST PROCESS N CAT SCAN F/U STUDY TC CAT SCAN F/U STUDY CAT SCAN F/U STUDY ECHO EXAM HEAD TC ECHO EXAM HEAD ECHO EXAM HEAD OPHTHALMIC US, B & QUANT A

125 MEDICAL FEE SCHEDULES 11: TC OPHTHALMIC US, B & QUANT A OPHTHALMIC US, B &QUANT A OPHTHALMIC US, QUANT A ONLY TC OPHTHALMIC US, QUANT A ONLY OPHTHALMIC US, QUANT A ONLY OPHTHALMIC US, B W/NON-QUANT A TC OPHTHALMIC US, B W/NON-QUANT A OPHTHALMIC US, B W/NON-QUANT A ECHO EXAM EYE, THICKNESS TC ECHO EXAM EYE, THICKNESS ECHO EXAM EYE, THICKNESS ECHO EXAM EYE TC ECHO EXAM EYE ECHO EXAM EYE ECHO EXAM EYE TC ECHO EXAM EYE ECHO EXAM EYE US EXAM HEAD & NECK TC US EXAM HEAD & NECK , US EXAM HEAD & NECK US EXAM, CHEST TC US EXAM, CHEST US EXAM, CHEST US EXAM, BREAST(S) TC US EXAM, BREAST(S) US EXAM, BREAST(S) US EXAM, ABDOM, COMPLETE TC US EXAM, ABDOM, COMPLETE US EXAM, ABDOM, COMPLETE ECHO EXAM ABDOMEN TC ECHO EXAM ABDOMEN ECHO EXAM ABDOMEN US EXAM ABDOM BACK WALL, COMP TC US EXAM ABDOM BACK WALL, COMP US EXAM ABDOM BACK WALL, COMP US EXAM ABDOM BACK WALL, LIM TC US EXAM ABDOM BACK WALL, LIM US EXAM ABDOM BACK WALL, LIM US EXAM K TRANSPLANT W/DOPPLER TC US EXAM K TRANSPLANT W/DOPPLER US EXAM K TRANSPLANT W/DOPPLER US EXAM, SPINAL CANAL TC US EXAM, SPINAL CANAL US EXAM, SPINAL CANAL OBSTET US < 14 WKS, SINGLE FETUS TC OBSTET US < 14 WKS, SINGLE FETUS OBSTET US < 14 WKS, SINGLE FETUS OBSTET US >/= 14 WKS, SINGLE FETUS TC OBSTET US >/= 14 WKS, SINGLE FETUS OBSTET US >/= 14 WKS, SINGLE FETUS OBSTET US >/= 14 WKS, ADDED FETUS TC OBSTET US >/= 14 WKS, ADDED FETUS OBSTET US >/= 14 WKS, ADDED FETUS OBSTET US, DETAILED, SINGLE FETUS TC OBSTET US, DETAILED, SINGLE FETUS OBSTET US, DETAILED, SINGLE FETUS OBSTET US NUCHAL MEAS, ADDED TC OBSTET US NUCHAL MEAS, ADDED OBSTET US NUCHAL MEAS, ADDED OBSTET US, LIMITED, FETUS(S) TC OBSTET US, LIMITED, FETUS(S) OBSTET US, LIMITED, FETUS(S) OBSTET US, F/U, PER FETUS

126 11: APPENDIX B - REGULATIONS TC OBSTET US, F/U, PER FETUS OBSTET US, F/U, PER FETUS TRANSVAGINAL US, OBSTETRIC TC TRANSVAGINAL US, OBSTETRIC TRANSVAGINAL US, OBSTETRIC FETAL BIOPHYS PROFILE W/NST TC FETAL BIOPHYS PROFILE W/NST FETAL BIOPHYS PROFILE W/NST FETAL BIOPHYS PROFILE W/O NST TC FETAL BIOPHYS PROFILE W/O NST FETAL BIOPHYS PROFILE W/O NST UMBILICAL ARTERY ECHO TC UMBILICAL ARTERY ECHO UMBILICAL ARTERY ECHO MIDDLE CEREBRAL ARTERY ECHO TC MIDDLE CEREBRAL ARTERY ECHO MIDDLE CEREBRAL ARTERY ECHO ECHO EXAM FETAL HEART TC ECHO EXAM FETAL HEART ECHO EXAM FETAL HEART ECHO EXAM FETAL HEART TC ECHO EXAM FETAL HEART ECHO EXAM FETAL HEART ECHO EXAM FETAL HEART TC ECHO EXAM FETAL HEART ECHO EXAM FETAL HEART TRANSVAGINAL US, NON-OB TC TRANSVAGINAL US, NON-OB TRANSVAGINAL US, NON-0B US EXAM, PELVIC, COMPLETE TC US EXAM, PELVIC, COMPLETE US EXAM, PELVIC, COMPLETE US EXAM, PELVIC, LIMITED TC US EXAM, PELVIC, LIMITED US EXAM, PELVIC, LIMITED US EXAM, SCROTUM TC US EXAM, SCROTUM US EXAM, SCROTUM US, TRANSRECTAL TC US, TRANSRECTAL US, TRANSRECTAL US XTR NON-VASC COMPLETE TC US XTR NON-VASC COMPLETE US XTR NON-VASC COMPLETE US XTR NON-VASC LMTD TC US XTR NON-VASC LMTD US XTR NON-VASC LMTD US GUIDE VASCULAR ACCESS N TC US GUIDE VASCULAR ACCESS N US GUIDE VASCULAR ACCESS N ECHO GUIDE FOR BIOPSY N TC ECHO GUIDE FOR BIOPSY N ECHO GUIDE FOR BIOPSY N US GUIDE, INTRAOP N TC US GUIDE, INTRAOP N US GUIDE, INTRAOP N FLUOROGUIDE FOR VEIN DEVICE N TC FLUOROGUIDE FOR VEIN DEVICE N FLUOROGUIDE FOR VEIN DEVICE N NEEDLE LOCALIZATION BY X-RAY N TC NEEDLE LOCALIZATION BY X-RAY N NEEDLE LOCALIZATION BY X-RAY N FLUOROGUIDE FOR SPINE INJECT N TC FLUOROGUIDE FOR SPINE INJECT N FLUOROGUIDE FOR SPINE INJECT N CT SCAN FOR LOCALIZATION N TC CT SCAN FOR LOCALIZATION N CT SCAN FOR LOCALIZATION N CT SCAN FOR NEEDLE BIOPSY N TC CT SCAN FOR NEEDLE BIOPSY N CT SCAN FOR NEEDLE BIOPSY N GUIDANCE FOR NEEDLE, BREAST N1

127 MEDICAL FEE SCHEDULES 11: TC GUIDANCE FOR NEEDLE, BREAST N GUIDANCE FOR NEEDLE, BREAST N COMPUTER DIAG MAMMOGRAM, ADDED TC COMPUTER DIAG MAMMOGRAM, ADDED COMPUTER DIAG MAMMOGRAM, ADDED COMP SCREEN MAMMOGRAM, ADDED TC COMP SCREEN MAMMOGRAM, ADDED COMP SCREEN MAMMOGRAM, ADDED MAMMOGRAM, ONE BREAST TC MAMMOGRAM, ONE BREAST MAMMOGRAM, ONE BREAST MAMMOGRAM, BOTH BREASTS TC MAMMOGRAM, BOTH BREASTS MAMMOGRAM, BOTH BREASTS MAMMOGRAM, SCREENING TC MAMMOGRAM, SCREENING MAMMOGRAM, SCREENING MRI ONE BREAST 1, , TC MRI ONE BREAST 1, , MRI ONE BREAST MRI BOTH BREASTS 1, , TC MRI BOTH BREASTS 1, , MRI BOTH BREASTS X-RAYS FOR BONE AGE TC X-RAYS FOR BONE AGE X-RAYS FOR BONE AGE X-RAYS, BONE LENGTH STUDIES TC X-RAYS, BONE LENGTH STUDIES X-RAYS, BONE LENGTH STUDIES X-RAYS, BONE SURVEY, LIMITED TC X-RAYS, BONE SURVEY, LIMITED X-RAYS, BONE SURVEY, LIMITED X-RAYS, BONE SURVEY COMPLETE TC X-RAYS, BONE SURVEY COMPLETE X-RAYS, BONE SURVEY COMPLETE X-RAYS, BONE SURVEY, INFANT TC X-RAYS, BONE SURVEY, INFANT X-RAYS, BONE SURVEY, INFANT JOINT SURVEY, SINGLE VIEW TC JOINT SURVEY, SINGLE VIEW JOINT SURVEY, SINGLE VIEW DIAG BONE DENSITY, AXIAL TC DIAG BONE DENSITY, AXIAL DIAG BONE DENSITY, AXIAL DIAG BONE DENSITY/PERIPHERAL TC DIAG BONE DENSITY/PERIPHERAL DIAG BONE DENSITY/PERIPHERAL DIAG BONE DENSITY, VERTEBRAL FX TC DIAG BONE DENSITY, VERTEBRAL FX DIAG BONE DENSITY, VERTEBRAL FX RADIATION THERAPY PLANNING RADIATION THERAPY PLANNING RADIATION THERAPY PLANNING SET RADIATION THERAPY FIELD TC SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD TC SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD TC SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD SET RADIATION THERAPY FIELD TC SET RADIATION THERAPY FIELD , , SET RADIATION THERAPY FIELD RADIATION THERAPY DOSE PLAN TC RADIATION THERAPY DOSE PLAN RADIATION THERAPY DOSE PLAN TELETX ISODOSE PLAN SIMPLE

128 11: APPENDIX B - REGULATIONS TC TELETX ISODOSE PLAN SIMPLE TELETX ISODOSE PLAN SIMPLE TELETX ISODOSE PLAN INTERMED TC TELETX ISODOSE PLAN INTERMED TELETX ISODOSE PLAN INTERMED TELETX ISODOSE PLAN COMPLEX TC TELETX ISODOSE PLAN COMPLEX TELETX ISODOSE PLAN COMPLEX SPECIAL TELETX PORT PLAN TC SPECIAL TELETX PORT PLAN SPECIAL TELETX PORT PLAN SPECIAL RADIATION DOSIMETRY TC SPECIAL RADIATION DOSIMETRY SPECIAL RADIATION DOSIMETRY RADIATION TREAT AID(S) TC RADIATION TREAT AID(S) RADIATION TREAT AID(S) RADIATION TREAT AID(S) TC RADIATION TREAT AID(S) RADIATION TREAT AID(S) RADIATION TREAT AID(S) TC RADIATION TREAT AID(S) RADIATION TREAT AID(S) RADIATION PHYSICS CONSULT SRS, MULTISOURCE 2, , , , RADIATION TX SING AREA 6-10MEV RADIATION TX 3/MORE AREA 6-10MEV RADIATION TX 3/MORE AREA 11-19MEV RADIOLOGY PORT FILM(S) N RADIATION TX MANAGEMENT, X RADIATION THERAPY MANAGEMENT SPECIAL RADIATION TREAT TC SPECIAL RADIATION TREAT SPECIAL RADIATION TREAT THYROID IMAGING W/UPTAKE TC THYROID IMAGING W/UPTAKE THYROID IMAGING W/UPTAKE THYROID IMAGE, MULT UPTAKES TC THYROID IMAGE, MULT UPTAKES THYROID IMAGE, MULT UPTAKES BONE MARROW IMAGING, LTD TC BONE MARROW IMAGING, LTD BONE MARROW IMAGING, LTD BONE MARROW IMAGING, MULT TC BONE MARROW IMAGING, MULT BONE MARROW IMAGING, MULT LIVER & SPLEEN IMAGING TC LIVER & SPLEEN IMAGING LIVER & SPLEEN IMAGING LIVER FUNCTION STUDY TC LIVER FUNCTION STUDY LIVER FUNCTION STUDY HEPATOBILIARY IMAGING TC HEPATOBILIARY IMAGING HEPATOBILIARY IMAGING SALIVARY GLAND FUNCTION EXAM TC SALIVARY GLAND FUNCTION EXAM SALIVARY GLAND FUNCTION EXAM BONE IMAGING, LIMITED AREA TC BONE IMAGING, LIMITED AREA BONE IMAGING, LIMITED AREA BONE IMAGING, MULTIPLE AREAS TC BONE IMAGING, MULTIPLE AREAS BONE IMAGING, MULTIPLE AREAS BONE IMAGING, WHOLE BODY TC BONE IMAGING, WHOLE BODY BONE IMAGING, WHOLE BODY BONE IMAGING, 3 PHASE BONE IMAGING, 3 PHASE BONE IMAGING (3D)

129 MEDICAL FEE SCHEDULES 11: TC BONE IMAGING (3D) BONE IMAGING (3D) VASCULAR FLOW IMAGING TC VASCULAR FLOW IMAGING VASCULAR FLOW IMAGING HEART MUSCLE IMAGE SPECT, SING TC HEART MUSCLE IMAGE SPECT, SING , , HEART MUSCLE IMAGE SPECT, SING HEART MUSCLE IMAGE SPECT, MULT TC HEART MUSCLE IMAGE SPECT, MULT , , HEART MUSCLE IMAGE SPECT, MULT HEART INFARCT IMAGE (3D) TC HEART INFARCT IMAGE (3D) HEART INFARCT IMAGE (3D) GATED HEART, PLANAR, SING TC GATED HEART, PLANAR, SING GATED HEART, PLANAR, SING HEART FIRST PASS, SING TC HEART FIRST PASS, SING HEART FIRST PASS, SING HEART IMAGE, SPECT TC HEART IMAGE, SPECT HEART IMAGE, SPECT LUNG PERFUSION IMAGING TC LUNG PERFUSION IMAGING LUNG PERFUSION IMAGING LUNG V/Q IMAGE SINGLE BREATH TC LUNG V/Q IMAGE SINGLE BREATH LUNG V/Q IMAGE SINGLE BREATH LUNG V/Q IMAGING TC LUNG V/Q IMAGING LUNG V/Q IMAGING PERFUSION LUNG IMAGE TC PERFUSION LUNG IMAGE PERFUSION LUNG IMAGE VENT IMAGE, MULT PROD, GAS TC VENT IMAGE, MULT PROJ, GAS VENT IMAGE, MULT PROJ, GAS LUNG DIFFERENTIAL FUNCTION TC LUNG DIFFERENTIAL FUNCTION LUNG DIFFERENTIAL FUNCTION BRAIN IMAGING (3D) TC BRAIN IMAGING (3D) , , BRAIN IMAGING (3D) KID FLOW/FUNCT IMAGE W/O DRUG TC KID FLOW/FUNCT IMAGE W/O DRUG KID FLOW/FUNCT IMAGE W/O DRUG KID FLOW/FUNCT IMAGE W/DRUG TC BONE IMAGING, 3 PHASE TC KID FLOW/FUNCT IMAGE W/DRUG KID FLOW/FUNCT IMAGE W/DRUG KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE TUMOR IMAGING, WHOLE BODY TC TUMOR IMAGING, WHOLE BODY TUMOR IMAGING, WHOLE BODY TUMOR IMAGING (3D) TC TUMOR IMAGING (3D) TUMOR IMAGING (3D) ABSCESS IMAGING, LID AREA TC ABSCESS IMAGING, LTD AREA ABSCESS IMAGING, LTD AREA ABSCESS IMAGING, WHOLE BODY TC ABSCESS IMAGING, WHOLE BODY ABSCESS IMAGING, WHOLE BODY PET IMAGE W/CT, SKULL-THIGH 1, , TC PET IMAGE W/CT, SKULL-THIGH 1, , , , PET IMAGE W/CT, SKULL-THIGH

130 11: APPENDIX B - REGULATIONS NUCLEAR RX, IV ADMIN TC NUCLEAR RX, IV ADMIN NUCLEAR RX, IV ADMIN LAB PATHOLOGY CONSULTATION ASSAY HEMOGLOBIN ELECTROPHORESIS ASSAY GENETIC EXAM ASSAY PROTEIN E-PHORESIS, SERUM ASSAY PROTEIN E-PHORESIS/URINE/CSF ASSAY PROTEIN, WESTERN BLOT TEST BLOOD SMEAR INTERPRETATION BONE MARROW INTERPRETATION BLOOD PLATELET AGGREGATION FLUORESCENT ANTIBODY, SCREEN FLUORESCENT ANTIBODY, TITER IMMUNOFLX E-PHORESIS, SERUM IMMUNOFIX E-PHORESIS/URINE/CSF HISTOPLASMOSIS SKIN TEST TB INTRADERMAL TEST CYTOPATH FL NONGYN, SMEARS TC CYTOPATH FL NONGYN, SMEARS CYTOPATH FL NONGYN, SMEARS CYTOPATH FL NONGYN, FILTER TC CYTOPATH FL NONGYN, FILTER CYTOPATH FL NONGYN, FILTER CYTOPATH, CONCENTRATE TECH TC CYTOPATH, CONCENTRATE TECH CYTOPATH, CONCENTRATE TECH CYTOPATH, CELL ENHANCE TECH TC CYTOPATH, CELL ENHANCE TECH CYTOPATH, CELL ENHANCE TECH CYTOPATH, URINE 3-5 PROBES EA SPEC TC CYTOPATH, URINE 3-5 PROBES EA SPEC CYTOPATH, URINE 3-5 PROBES EA SPEC CYTOPATH, URINE 3-5 PROBES COMPUTER TC CYTOPATH, URINE 3-5 PROBES COMPUTER CYTOPATH, URINE 3-5 PROBES COMPUTER CYTOPATH, C/V, INTERPRET CYTOPATH FNA; 1ST EVAL, EACH SITE TC CYTOPATH FNA; 1ST EVAL, EACH SITE CYTOPATH FNA; 1 ST EVAL, EACH SITE CYTOPATH FNA; INTERPRET & REPORT TC CYTOPATH FNA; INTERPRET & REPORT CYTOPATH FNA; INTERPRET & REPORT CYTOPATH FNA; ADDED EVAL, SAME SITE TC CYTOPATH FNA; ADDED EVAL, SAME SITE CYTOPATH FNA; ADDED EVAL, SAME SITE FLOW CYTOMETRY/ TC, 1 MARKER FLOW CYTOMETRY/TC, ADDED FLOW CYTOMETRY/READ, SURGICAL PATH, GROSS TC SURGICAL PATH, GROSS SURGICAL PATH, GROSS TISSUE EXAM BY PATHOLOGIST TC TISSUE EXAM BY PATHOLOGIST

131 MEDICAL FEE SCHEDULES 11: TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST TC TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST TC TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST TC TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST TC TISSUE EXAM BY PATHOLOGIST TISSUE EXAM BY PATHOLOGIST DECALCIFY TISSUE TC DECALCIFY TISSUE DECALCIFY TISSUE SPECIAL STAINS GROUP TC SPECIAL STAINS GROUP SPECIAL STAINS GROUP SPECIAL STAINS GROUP TC SPECIAL STAINS GROUP SPECIAL STAINS GROUP PATH CONSULT INTRAOP, 1 BLOC TC PATH CONSULT INTRAOP, 1 BLOC PATH CONSULT INTRAOP, 1 BLOC PATH CONSULT INTRAOP, ADDED TC PATH CONSULT INTRAOP, ADDED PATH CONSULT INTRAOP, ADDED INTRAOP CYTO PATH CONSULT, TC INTRAOP CYTO PATH CONSULT, INTRAOP CYTO PATH CONSULT, OHISTOCHEMISTRY TC OHISTOCHEMISTRY IMMUNOHISTOCHEMISTRY IMMUNOFLUORESCENT STUDY TC IMMUNOFLUORESCENT STUDY IMMUNOFLUORESCENT STUDY TUMOR OHISTOCHEM/MANUAL TC TUMOR IMMUNOHISTOCHEM/MANUAL TUMOR IMMUNOHISTOCHEM/MANUAL EXAM ARCHIVAL TISSUE MOLECULAR ANAL INSITU HYBRIDIZATION, AUTO TC INSITU HYBRIDIZATION, AUTO INSITU HYBRIDIZATION, AUTO INSITU HYBRIDIZATION, MANUAL TC INSITU HYBRIDIZATION, MANUAL INSITU HYBRIDIZATION, MANUAL PROTEIN ANALYSIS W/PROBE IMM ADMIN 0-18 ANY ROUTE, EA ADDED IMMUNIZATION ADMIN IMMUNIZATION ADMIN, EACH ADDED PSYCH DIAG INTERVIEW INTERACT PSYCH DIAG INTERVIEW PSYCH, OFF, MIN PSYCH, OFF, MINIMUM W/E & M PSYCH, OFF, MIN PSYCH, OFF, MINIMUM W/E & M PSYCH, OFF, MIN PSYCH, OFF, 75-80, W/E & M INTERACT PSYCH, OFF, MIN INTERACT PSYCH, 20-30, W/E & M INTERACT PSYCH, OFF, MIN INTERACT PSYCH, MINIMUM W/E & M INTERACT PSYCH, OFF, MIN PSYCH, HOSP, MTN

132 11: APPENDIX B - REGULATIONS PSYCH, HOSP, MINIMUM W/E & M PSYCH, HOSP, MIN PSYCH, HOSP, MINIMUM W/E & M INTERACT PSYCH, HOSP, MIN FAMILY PSYCH W/O PATIENT FAMILY PSYCH W/PATIENT GROUP PSYCHOTHERAPY INTERACT GROUP PSYCH MEDICATION MANAGEMENT HYPNOTHERAPY BIOFEEDBACK TRAIN, ANY METHOD BIOFEEDBACK PERI/URO/RECTAL HEMODIALYSIS, ONE EVAL DIALYSIS, ONE EVAL ESRD SERVICE, 2-3 VISITS P MO, ESRD SERVICE, 1 VISIT P MO, ESOPHAGUS MOTILITY STUDY TC ESOPHAGUS MOTILITY STUDY ESOPHAGUS MOTILITY STUDY ESOPH MOTILITY STUDY W/STIM/PERFUS TC ESOPH MOTILITY STUDY W/STIM/PERFUS ESOPH MOTILITY STUDY W/STIM/PERFUS EYE EXAM, NEW PATIENT EYE EXAM, NEW PATIENT EYE EXAM ESTABLISHED PAT EYE EXAM & TREAT SPECIAL EYE EVAL CORNEAL TOPOGRAPHY TC CORNEAL TOPOGRAPHY CORNEAL TOPOGRAPHY SPECIAL EYE EVAL TC SPECIAL EYE EVAL SPECIAL EYE EVAL ORTHOPTIC/PLEOPTIC TRAINING TC ORTHOPTIC/PLEOPTIC TRAINING ORTHOPTIC/PLEOPTIC TRAINING FIT CONTACT LENS VISUAL FIELD EXAM(S) LIMITED TC VISUAL FIELD EXAM(S) LIMITED VISUAL FIELD EXAM(S) LIMITED VISUAL FIELD EXAM(S) INTERMEDIATE TC VISUAL FIELD EXAM(S) INTERMEDIATE VISUAL FIELD EXAM(S) INTERMEDIATE VISUAL FIELD EXAM(S) EXTENDED TC VISUAL FIELD EXAM(S) EXTENDED VISUAL FIELD EXAM(S) EXTENDED SCAN COMP OPTH DX IMAGING, ANT SEG TC SCAN COMP OPTH DX IMAGING, ANT SEG SCAN COMP OPTH DX IMAGING, ANT SEG SCAN COMP OPTH DX IMAGING, POST SEG TC SCAN COMP OPTH DX IMAGING, POST SEG SCAN COMP OPTH DX IMAGING, POST SEG SCAN COMP OPTH DX IMAGING, RETINA TC SCAN COMP OPTH DX IMAGING, RETINA SCAN COMP OPTH DX IMAGING, RETINA

133 MEDICAL FEE SCHEDULES 11: OPHTHALMIC BIOMETRY TC OPHTHALMIC BIOMETRY OPHTHALMIC BIOMETRY SPECIAL EYE EXAM, INITIAL SPECIAL EYE EXAM, SUBSEQUENT REMOTE IMAGING RETINAL DISEASE REMOTE IMAGING MONITOR RETINAL DIS TC REMOTE IMAGING MONITOR RETINAL DIS REMOTE IMAGING MONITOR RETINAL DIS FLUORESCEIN ANGIOSCOPY FLUORESCEIN ANGIOGRAPHY TC FLUORESCEIN ANGIOGRAPHY FLUORESCEIN ANGIOGRAPHY EYE EXAM W/PHOTOS TC EYE EXAM W/PHOTOS EYE EXAM W/PHOTOS ELECTRORETINOGRAPHY TC ELECTRORETINOGRAPHY ELECTRORETINOGRAPHY EYE PHOTOGRAPHY TC EYE PHOTOGRAPHY EYE PHOTOGRAPHY INTERNAL EYE PHOTOGRAPHY TC INTERNAL EYE PHOTOGRAPHY INTERNAL EYE PHOTOGRAPHY CONTACT LENS FITTING APHAKIA ONE EYE REPLACE CONTACT LENS EXT PAT/AUTO ECG TO 30 DAYS, DOWNLOAD EAR MICROSCOPY EXAM SPEECH/HEARING EVAL SPEECH/HEARING THERAPY SPEECH/HEARING THERAPY NASOPHARYNGOSCOPY ORAL FUNCTION THERAPY BASIC VESTIBULAR EVALUATION TC BASIC VESTIBULAR EVALUATION BASIC VESTIBULAR EVALUATION SPONTANEOUS NYSTAGMUS TEST TC SPONTANEOUS NYSTAGMUS TEST SPONTANEOUS NYSTAGMUS TEST POSITIONAL NYSTAGMUS TEST TC POSITIONAL NYSTAGMUS TEST POSITIONAL NYSTAGMUS TEST CALORIC VESTIBULAR TEST TC CALORIC VESTIBULAR TEST CALORIC VESTIBULAR TEST OPTOKINETIC NYSTAGMUS TEST TC OPTOKINETIC NYSTAGMUS TEST OPTOKINETIC NYSTAGMUS TEST OSCILLATING TRACKING TEST TC OSCILLATING TRACKING TEST OSCILLATING TRACKING TEST SINUSOIDAL ROTATIONAL TEST TC SINUSOIDAL ROTATIONAL TEST SINUSOIDAL ROTATIONAL TEST SUPPLEMENTAL ELECTRICAL TEST POSTUROGRAPHY TC POSTUROGRAPHY POSTUROGRAPHY TYMPANOMETRY & REFLEX THRESH PURE TONE AUDIOMETRY, AIR AUDIOMETRY, AIR & BONE SPEECH AUDIOMETRY, COMPLETE COMPREHENSIVE HEARING TEST TONE DECAY HEARING TEST SISI HEARING TEST STENGER TEST, PURE TONE

134 11: APPENDIX B - REGULATIONS TYMPANOMETRY ACOUSTIC REFLEX THRESHOLD TEST ACOUSTIC IMMITTANCE TESTING CONDITIONING PLAY AUDIOMETRY ELECTROCOCHLEOGRAPHY AUDITOR EVOKE POTENT, COMPRE TC AUDITOR EVOKE POTENT, COMPRE AUDITOR EVOKE POTENT, COMPRE AUDITOR EVOKE POTENT, LIMIT EVOKED AUDITORY TEST TC EVOKED AUDITORY TEST EVOKED AUDITORY TEST EVOKED AUDITORY TEST TC EVOKED AUDITORY TEST EVOKED AUDITORY TEST EXCISE FOR SPEECH DEVICE RX, 1HR MOTION FLUOROSCOPY/SWALLOW ENDOSCOPY SWALLOW TEST (FEES) ENDOSCOPY SWALLOW TEST (FEES) AUDITORY FUNCTION, 60 MIN AUDITORY FUNCTION, + 15 MIN TINNITUS ASSESS EVAL AUDITORY REHAB STATUS HEART/LUNG RESUSCITATION CPR CARDIOVERSION ELECTRIC, EXT CARDIOASSIST, EXTERNAL DISSOLVE CLOT, HEART VESSEL CORONARY ARTERY DILATION 1, ELECTROCARDIOGRAM, COMPLETE ELECTROCARDIOGRAM, TRACING ELECTROCARDIOGRAM REPORT CARDIOVASCULAR STRESS TEST CARDIOVASCULAR STRESS TEST CARDIOVASCULAR STRESS TEST CARDIOVASCULAR STRESS TEST RHYTHM ECG W/R.EPORT RHYTHM ECG, REPORT ECG MONITOR/REPORT, 24 HRS ECG MONITOR/RECORD, 24 HRS ECG MONITOR/REPORT, 24 HRS ECG MONITOR/REVIEW, 24 HRS REMOTE 30 DAY ECG REV/REPORT REMOTE 30 DAY ECG TECH SUPP 1, , EXT PAT/AUTO ECG TO 30 DAYS, COMPLETE EXT PAT/AUTO ECG TO 30 DAYS, RECORDING EXT PAT/AUTO ECG TO 30 DAYS, REPORT PM DEVICE PROGRAM EVAL, DUAL TC PM DEVICE PROGRAM EVAL, DUAL PM DEVICE PROGRAM EVAL, DUAL PM DEVICE PROGRAM EVAL, MULTI TC PM DEVICE PROGRAM EVAL, MULTI PM DEVICE PROGRAM EVAL, MULTI ICD DEVICE PROGRAM EVAL, 1 SINGLE TC ICD DEVICE PROGRAM EVAL, 1 SINGLE ICD DEVICE PROGRAM EVAL, 1 SINGLE ICD DEVICE PROGRAM EVAL, DUAL TC ICD DEVICE PROGRAM EVAL, DUAL ICD DEVICE PROGRAM EVAL, DUAL ICD DEVICE PROGRAM EVAL, MULT TC ICD DEVICE PROGRAM EVAL, MULT ICD DEVICE PROGRAM EVAL, MULT ILR DEVICE EVAL PROGRAM TC ILR DEVICE EVAL PROGRAM ILR DEVICE EVAL PROGRAM PM DEVICE EVAL IN PERSON TC PM DEVICE EVAL IN PERSON

135 MEDICAL FEE SCHEDULES 11: PM DEVICE EVAL IN PERSON ICD DEVICE INTERROGATE TC ICD DEVICE INTERROGATE ICD DEVICE INTERROGATE ICM DEVICE EVAL TC ICM DEVICE EVAL ICM DEVICE EVAL PM PHONE R-STRIP DEVICE EVAL TC PM PHONE R-STRIP DEVICE EVAL PM PHONE R-STRIP DEVICE EVAL PM DEVICE INTERROGATE REMOTE ICD DEVICE INTERROGATE REMOTE PM/ICD REMOTE TECH SERV ICM DEVICE INTERROGATE REMOTE ICM/ILR REMOTE TECH SERV ECHO TRANSTHORACIC TC ECHO TRANSTHORACIC ECHO TRANSTHORACIC TTE W/DOPPLER, COMPLETE TC TTE W/DOPPLER, COMPLETE TTE W/DOPPLER, COMPLETE TTE W/O DOPPLER, COMPLETE TC TTE W/O DOPPLER, COMPLETE TTE W/O DOPPLER, COMPLETE TTE, F-UP OR LIMITED TC TTE, F-UP OR LIMITED TTE, F-UP OR LIMITED ECHO TRANSESOPHAGEAL TC ECHO TRANSESOPHAGEAL ECHO TRANSESOPHAGEAL ECHO TRANSESOPHAGEAL ECHO TRANSESOPHAGEAL TC ECHO TRANSESOPHAGEAL ECHO TRANSESOPHAGEAL DOPPLER ECHO EXAM, HEART TC DOPPLER ECHO EXAM, HEART DOPPLER ECHO EXAM,. HEART DOPPLER ECHO EXAM, HEART TC DOPPLER ECHO EXAM, HEART DOPPLER ECHO EXAM, HEART DOPPLER COLOR FLOW, ADDED TC DOPPLER COLOR FLOW, ADDED DOPPLER COLOR FLOW, ADDED STRESS TTE ONLY TC STRESS TTE ONLY STRESS TTE ONLY STRESS TTE COMPLETE TC STRESS TTE COMPLETE STRESS TTE COMPLETE RIGHT HEART CATH 1, , TC RIGHT HEART CATH 1, RIGHT HEART CATH LEFT HEART CATH W/VENTRCLGRPHY 1, , TC LEFT HEART CATH W/VENTRCLGRPHY 1, LEFT HEART CATH W/VENTRCLGRPHY R&L HEART CATH W/VENTRICLGRPHY 1, , TC R&L HEART CATH W/VENTRICLGRPHY 1, , R&L HEART CATH W/VENTRICLGRPHY CATH PLACE CORONARY ANGIO 1, , TC CATH PLACE CORONARY ANGIO 1, CATH PLACE CORONARY ANGIO CATH PLACE BYPASS GRAFTS 1, , TC CATH PLACE BYPASS GRAFTS 1, , CATH PLACE BYPASS GRAFTS CATH PLACE WITH R HEART CATH 1, , TC CATH PLACE WITH R HEART CATH 1, ,212.30

136 11: APPENDIX B - REGULATIONS CATH PLACE WITH R HEART CATH R HEART ART/GRAFT ANGIO 2, , TC R HEART ART/GRAFT ANGIO 1, , R HEART ART/GRAFT ANGIO L HEART ARTERY/VENTRICLE ANGIO 1, , TC L HEART ARTERY/VENTRICLE ANGIO 1, , L HEART ARTERY/VENTRICLE ANGIO L HEART ART/GRAFT ANGIO 1, , TC L HEART ART/GRAFT ANGIO 1, , L HEART ART/GRAFT ANGIO R & L HEART ART/VENTRICLE ANGIO 2, , TC R & L HEART ART/VENTRICLE ANGIO 1, , R & L HEART ART/VENTRICLE ANGIO R & L HEART ART/VENTRICLE ANGIO 2, , TC R & L HEART ART/VENTRICLE ANGIO 1, , R & L HEART ART/VENTRICLE ANGIO L HEART CATH TRANSPLANT PUNCTURE DRUG ADMIN & HEMODYNMIC MEAS EXERCISE W/HEMODYNAMIC MEAS TC EXERCISE W/HEMODYNAMIC MEAS EXERCISE W/HEMODYNAMIC MEAS INSERT/PLACE HEART CATHETER INJECT CONGENITAL CARD CATH INJECT HEART CONGNTL ART/GRAFT INJECT L VENTR/ATRIAL ANGIO INJECT R VENTR/ATRIAL ANGIO INJECT SUPRVLV AORTOGRAPHY INJECT PULM ART HEART CATH MAP TACHYCARDIA, ADDED INTRA-ATRIAL PACING INTRAVENTRICULAR PACING ELECTROPHYSIOLOGY EVAL 1, , TC ELECTROPHYSIOLOGY EVAL ELECTROPHYSIOLOGY EVAL 1, , STIMULATION, PACING HEART ELECTROPHYSIOLOGY EVAL TC ELECTROPHYSIOLOGY EVAL ELECTROPHYSIOLOGY EVAL ELECTROPHYSIOLOGY EVAL TC ELECTROPHYSIOLOGY EVAL ELECTROPHYSIOLOGY EVAL TILT TABLE EVAL TC TILT TABLE EVAL TILT TABLE EVAL BIOIMPD TIIRC ELEC BIOIMPEDANCE, CV ANALYSIS TOTAL BODY PLETHYSMOGRAPHY AMBULATORY BP MONITORING CARDIAC REHAB/MONITOR EXTRACRANIAL STUDY TC EXTRACRANIAL STUDY EXTRACRANIAL STUDY EXTRACRANIAL STUDY TC EXTRACRANIAL STUDY EXTRACRANIAL STUDY EXTRACRANIAL STUDY TC EXTRACRANIAL STUDY EXTRACRANIAL STUDY INTRACRANIAL STUDY TC INTRACRANIAL STUDY INTRACRANIAL STUDY

137 MEDICAL FEE SCHEDULES 11: EXTREMITY STUDY TC EXTREMITY STUDY EXTREMITY STUDY EXTREMITY STUDY TC EXTREMITY STUDY EXTREMITY STUDY EXTREMITY STUDY TC EXTREMITY STUDY EXTREMITY STUDY LOWER EXTREMITY STUDY TC LOWER EXTREMITY STUDY LOWER EXTREMITY STUDY LOWER EXTREMITY STUDY TC LOWER EXTREMITY STUDY LOWER EXTREMITY STUDY UPPER EXTREMITY STUDY TC UPPER EXTREMITY STUDY UPPER EXTREMITY STUDY UPPER EXTREMITY STUDY TC UPPER EXTREMITY STUDY UPPER EXTREMITY STUDY EXTREMITY STUDY TC EXTREMITY STUDY EXTREMITY STUDY EXTREMITY STUDY TC EXTREMITY STUDY EXTREMITY STUDY EXTREMITY STUDY TC EXTREMITY STUDY EXTREMITY STUDY VASCULAR STUDY TC VASCULAR STUDY VASCULAR STUDY VASCULAR STUDY TC VASCULAR STUDY VASCULAR STUDY VASCULAR STUDY TC VASCULAR STUDY VASCULAR STUDY VASCULAR STUDY TC VASCULAR STUDY VASCULAR STUDY VENT MGMT INPATIENT, INIT DAY VENT MGMT INPATIENT, SUBCUT DAY , BREATHING CAPACITY TEST TC BREATHING CAPACITY TEST BREATHING CAPACITY TEST EVALUATE WHEEZING TC EVALUATE WHEEZING EVALUATE WHEEZING EVALUATE WHEEZING TC EVALUATE WHEEZING EVALUATE WHEEZING LUNG FUNCTION TEST (MBC/MVV) TC LUNG FUNCTION TEST (MBC/IvIVV) LUNG FUNCTION TEST (MBC/MVV) RESIDUAL LUNG CAPACITY TC RESIDUAL LUNG CAPACITY RESIDUAL LUNG CAPACITY EXPIRED GAS COLLECTION TC EXPIRED GAS COLLECTION EXPIRED GAS COLLECTION THORACIC GAS VOLUME TC THORACIC GAS VOLUME THORACIC GAS VOLUME LUNG NITROGEN WASHOUT CURVE TC LUNG NITROGEN WASHOUT CURVE LUNG NITROGEN WASHOUT CURVE MEASURE AIRFLOW RESISTANCE TC MEASURE AIRFLOW RESISTANCE MEASURE AIRFLOW RESISTANCE

138 11: APPENDIX B - REGULATIONS BREATH AIRWAY CLOSING VOLUME TC BREATH AIRWAY CLOSING VOLUME37, BREATH AIRWAY CLOSING VOLUME RESPIRATORY FLOW VOLUME LOOP TC RESPIRATORY FLOW VOLUME LOOP RESPIRATORY FLOW VOLUME LOOP PULMONARY STRESS TEST/SIMPLE TC PULMONARY STRESS TEST/SIMPLE PULMONARY STRESS TEST/SIMPLE AIRWAY INHALATION TREAT POS AIRWAY PRESSURE, CPAP EVALUATE PAT USE INHALER CHEST WALL MANIPULATION MONOXIDE DIFFUSING CAPACITY TC MONOXIDE DIFFUSING CAPACITY MONOXIDE DIFFUSING CAPACITY PULMONARY COMPLIANCE STUDY TC PULMONARY COMPLIANCE STUDY114, PULMONARY COMPLIANCE STUDY MEASURE BLOOD OXYGEN LEVEL MEASURE BLOOD OXYGEN LEVEL MEASURE BLOOD OXYGEN LEVEL EXHALED CARBON DIOXIDE TEST PERCUT ALLERGY SKIN TESTS ID ALLERGY TITRATE-DRUG/BUG ID ALLERGY TEST, DRUG/BUG ID ALLERGY TITRATE-AIRBORNE ID ALLERGY TEST-DELAYED TYPE ALLERGY PATCH TESTS OTHERAPY, ONE INJECTION IMMUNOTHERAPY INJECTIONS ANTIGEN THERAPY SERVICES SLEEP STUDY UNATT; COMP W/SLEEP TIME TC SLEEP STUDY UNATT; COMP W/SLEEP TIME SLEEP STUDY UNATT; COMP W/SLEEP TIME SLEEP STUDY UNATT; COMP W/O SLEEP TIME TC SLEEP STUDY UNATT; COMP W/O SLEEP TIME SLEEP STUDY UNATT; COMP W/O SLEEP TIME ACTIGRAPHY TESTING TC ACTIGRAPHY TESTING ACTIGRAPHY TESTING MULTIPLE SLEEP LATENCY TEST TC MULTIPLE SLEEP LATENCY TEST MULTIPLE SLEEP LATENCY TEST POLYSOMNOGRAPHY, 4 OR MORE 1, , TC POLYSOMNOGRAPHY, 4 OR MORE POLYSOMNOGRAPHY, 4 OR MORE POLYSOMNOGRAPHY W/CPAP 1, , TC POLYSOMNOGRAPHY W/CPAP 1, POLYSOMNOGRAPHY W/CPAP EEG, MINUTES TC EEG, MINUTES EEG, MINUTES EEG, OVER 1 HOUR TC EEG, OVER 1 HOUR EEG, OVER 1 HOUR EEG, AWAKE & DROWSY TC EEG, AWAKE & DROWSY EEG, AWAKE & DROWSY EEG, AWAKE & ASLEEP TC EEG, AWAKE & ASLEEP EEG, AWAKE & ASLEEP EEG, COMA OR SLEEP ONLY TC EEG, COMA OR SLEEP ONLY EEG, COMA OR SLEEP ONLY LIMB MUSCLE TESTING, MANUAL

139 MEDICAL FEE SCHEDULES 11: HAND MUSCLE TESTING, MANUAL BODY MUSCLE TESTING, MANUAL BODY MUSCLE TESTING, MANUAL RANGE MOTION MEASUREMENTS RANGE MOTION MEASUREMENTS TENSILON TEST MUSCLE TEST, ONE LIMB TC MUSCLE TEST, ONE LIMB MUSCLE TEST, ONE LIMB MUSCLE TEST, 2 LIMBS TC MUSCLE TEST, 2 LIMBS MUSCLE TEST, 2 LIMBS MUSCLE TEST, 3 LIMBS TC MUSCLE TEST, 3 LIMBS MUSCLE TEST, 3 LIMBS MUSCLE TEST, 4 LIMBS TC MUSCLE TEST, 4 LIMBS MUSCLE TEST, 4 LIMBS MUSCLE TEST, LARYNX TC MUSCLE TEST, LARYNX MUSCLE TEST, LARYNX MUSCLE TEST CRANIAL NERVE UNILAT TC MUSCLE TEST CRANIAL NERVE UNILAT MUSCLE TEST CRANIAL NERVE UNILAT MUSCLE TEST CRANIAL NERVE BILAT TC MUSCLE TEST CRANIAL NERVE BILAT MUSCLE TEST CRANIAL NERVE BILAT MUSCLE TEST, THOR PARASPINAL TC MUSCLE TEST, THOR PARASPTNAL MUSCLE TEST, THOR PARASPINAL MUSCLE TEST, NONPARASPINAL TC MUSCLE TEST, NONPARASPINAL MUSCLE TEST, NONPARASPINAL GUIDE NERVE DESTROY, ELECT STIM TC GUIDE NERVE DESTROY, ELECT STIM GUIDE NERVE DESTROY, ELECT STIM GUIDE NERVE DESTROY, NEEDLE EMG TC GUIDE NERVE DESTROY, NEEDLE EMG GUIDE NERVE DESTROY, NEEDLE EMG MOTOR NERVE CONDUCTION TEST TC MOTOR NERVE CONDUCTION TEST MOTOR NERVE CONDUCTION TEST MOTOR NERVE CONDUCTION TEST TC MOTOR NERVE CONDUCTION TEST MOTOR NERVE CONDUCTION TEST SENSE NERVE CONDUCTION TEST TC SENSE NERVE CONDUCTION TEST SENSE NERVE CONDUCTION TEST INTRAOP NERVE TEST, ADDED TC INTRAOP NERVE TEST, ADDED INTRAOP NERVE TEST, ADDED AUTONOMIC NERVE FUNCTION TEST TC AUTONOMIC NERVE FUNCTION TEST AUTONOMIC NERVE FUNCTION TEST AUTONOMIC NERVE FUNCTION TEST TC AUTONOMIC NERVE FUNCTION TEST AUTONOMIC NERVE FUNCTION TEST AUTONOMIC NERVE FUNCTION TEST TC AUTONOMIC NERVE FUNCTION TEST AUTONOMIC NERVE FUNCTION TEST

140 11: APPENDIX B - REGULATIONS SOMATOSENSORY TESTING TC SOMATOSENSORY TESTING SOMATOSENSORY TESTING SOMATOSENSORY TESTING TC SOMATOSENSORY TESTING SOMATOSENSORY TESTING SOMATOSENSORY TESTING TC SOMATOSENSORY TESTING SOMATOSENSORY TESTING C MOTOR EVOKED, UPPER LIMBS TC C MOTOR EVOKED, UPPER LIMBS C MOTOR EVOKED, UPPER LIMBS C MOTOR EVOKED, LOWER LIMBS TC C MOTOR EVOKED, LOWER LIMBS C MOTOR EVOKED, LOWER LIMBS VISUAL EVOKED POTENTIAL TEST TC VISUAL EVOKED POTENTIAL TEST VISUAL EVOKED POTENTIAL TEST BLINK REFLEX TEST TC BLINK REFLEX TEST BLINK REFLEX TEST H-REFLEX TEST TC H-REFLEX TEST H-REFLEX TEST H-REFLEX TEST TC H-REFLEX TEST H-REFLEX TEST NEUROMUSCULAR JUNCTION TEST TC NEUROMUSCULAR JUNCTION TEST NEUROMUSCULAR JUNCTION TEST AMBULATORY EEG MONITORING TC AMBULATORY EEG MONITORING AMBULATORY EEG MONITORING EEG MONITORING/VIDEO RECORD 3, , TC EEG MONITORING/VIDEO RECORD 2, , EEG MONITORING/VIDEO RECORD EEG MONITORING/COMPUTER TC EEG MONITORING/COMPUTER EEG MONITORING/COMPUTER EEG DURING SURG TC EEG DURING SURG EEG DURING SURG EEG MONITORING, CABLE/RADIO 1, , TC EEG MONITORING, CABLE/RADIO 1, , EEG MONITORING, CABLE/RADIO EEG DIGITAL ANALYSIS TC EEG DIGITAL ANALYSIS EEG DIGITAL ANALYSIS ELECTRODE STIMULATION, BRAIN TC ELECTRODE STIMULATION, BRAIN ELECTRODE STIMULATION, BRAIN ELECTRODE STIM, BRAIN, ADDED TC ELECTRODE STIM, BRAIN, ADDED ELECTRODE STIM, BRAIN, ADDED ANALYZE NEUROSTIM, NO PROG ANALYZE NEUROSTIM, SIMPLE ANALYZE NEUROSTIM, COMPLEX ANALYZE NEUROSTIM, COMPLEX IO ANAL GAST N-STIM SUBSEQ SPIN/BRAIN PUMP REFILL & MAIN CANALITH REPOSITIONING PROC MOTION ANALYSIS, VIDEO/3D DYNAMIC SURFACE EMG PHYS REVIEW MOTION TESTS PSYCHO TESTING BY PSYCH/PHYS PSYCHO TESTING BY TECHNICIAN PSYCHO TESTING ADMIN BY COMP ASSESS APHASIA DEVELOPMENTAL TEST, EXTEND NEUROBEHAVIORAL STATUS EXAM NEUROPSYCH TEST BY PSYCH/PHYS NEUROPSYCH TESTING BY TEC

141 MEDICAL FEE SCHEDULES 11: NEUROPSYCH TEST ADMIN W/COMP COGNITIVE TEST BY HC PRO ASSESS HEALTH/BEHAVE, INIT ASSESS HEALTH/BEHAVE, SUBSEQ INTERVENE HEALTH/BEHAVE, INDIV INTERVENE HEALTH/BEHAVE, GROUP INTERVENE HEALTH/BEHAVE, FAM W/PT HYDRATION IV INFUSION, INIT HYDRATE IV INFUSION, ADDED THER/PROPHY/DIAG IV INF, INIT THER/PROPHY/DIAG IV INF ADDED THER/PROPHY/DIAG ADDED SEQ IV INF THER/DIAG CONCURRENT INF SC THER INFUSION, ADDED HR THER/PROPHY/DIAG INJ, SC/IM THER/PROPHY/DIAG INJ, IA THER/PROPHY/DIAG INJ, IV PUSH TX/PRO/DIAG INJECT NEW DRUG ADDED CHEMO IV PUSH, SINGLE DRUG CHEMOTHERAPY ADM PERITONEAL CAV IRRIG DRUG DELIVERY DEVICE ULTRAVIOLET LIGHT THERAPY PHOTOCHEMOTHERAPY W/UV-A PHYSICAL THERAPY EVAL PHYSICAL THERAPY RE-EVAL OT EVAL OT RE-EVAL APPLIC MODAL 1/> AREAS; HOT/COLD PACKS MECHANICAL TRACTION THERAPY VASOPNEUMATIC DEVICE THERAPY APPLICATION MODALITY TO 1 OR MORE AREAS; E-STIM PARAFFIN BATH THERAPY WHIRLPOOL THERAPY DIATHERMY EG, MICROWAVE INFRARED THERAPY ULTRAVIOLET THERAPY ELECTRICAL STIMULATION ELECTRIC CURRENT THERAPY CONTRAST BATH THERAPY ULTRASOUND THERAPY HYDROTHERAPY PHYSICAL THERAPY TREAT THERAPEUTIC EXERCISES NEUROMUSCULAR REEDUCATION AQUATIC THERAPY/EXERCISES GAIT TRAINING THERAPY MASSAGE THERAPY PHYSICAL MEDICINE PROCEDURE MANUAL THERAPY GROUP THERAPEUTIC PROCEDURES THERAPEUTIC ACTIVITIES COGNITIVE SKILLS DEVELOPMENT SENSORY INTEGRATION SELF CARE MANAGEMENT TRAINING COMMUNITY/WORK REINTEGRATION WHEELCHAIR MANAGEMENT TRAINING ACTIVE WOUND CARE/20 CM OR < ACTIVE WOUND CARE > 20 CM NEG PRESS WOUND TX, < 50 CM NEG PRESS WOUND TX, > 50 CM PHYSICAL PERFORMANCE TEST ASSISTIVE TECHNOLOGY ASSESS ORTHOTIC MGMT & TRAINING PROSTHETIC TRAINING C/O FOR ORTHOTIC/PROSTH USE

142 11: APPENDIX B - REGULATIONS MEDICAL NUTRITION, INDIV, IN ACUPUNCT 1/> NDLES W/O E-STIM; INIT 15 MIN ACUPUNCT 1 /> NDLES W/O E-STIM; EA ADD 15 MIN ACUPUNCT 1/> NDLES WITH E-STIM; INIT 15 MIN ACUPUNCT 1/> NDLES WITH E-STIM; EA ADD 15 MIN OSTEOPATHIC MANIPULATION 1-2 REGIONS OSTEOPATHIC MANIPULATION 3-4 REGIONS OSTEOPATHIC MANIPULATION 5-6 REGIONS OSTEOPATHIC MANIPULATION 7-8 REGIONS CHIROPRACTIC MANIPULATION 1-2 REGIONS CHIROPRACTIC MANIPULATION 3-4 REGIONS CHIROPRACTIC MANIPULATION 5 REGIONS CHIROPRACTIC MANIP TX; XTRASPINAL 1/MORE REGIONS SUPPLIES & MATERIALS: ADDL TO USUAL FOR OFFICE VISIT EDUCATION SUPPLIES; S/A BOOKS, TAPES & PAMPHLETS FOR PATIENT EDUCATION SPECIAL REPORTS UNUSUAL PHYSICIAN TRAVEL MOD SEDATION SAME PHYS, < 5 YRS MOD SEDATION BY SAME PHYS, 5 YRS MOD SEDATION BY SAME PHYS, ADDED MOD SEDATION DIFF PHYS < 5 YRS MOD SEDATION DIFF PHYS 5 YRS MOD SEDATION DIFF PHYS, ADDED INDUCTION VOMITING HYPERBARIC OXYGEN THERAPY PHLEBOTOMY OFFICE/OUTPAT VISIT, NEW PAT 10 MINS OFFICE/OUTPAT VISIT, NEW PAT 20 MINS OFFICE/OUTPAT VISIT, NEW PAT 30 MINS OFFICE/OUTPAT VISIT, NEW PAT 45 MINS OFFICE/OUTPAT VISIT, NEW PAT 60 MINS OFFICE/OUTPAT VISIT, EST PAT 5 MINS OFFICE/OUTPAT VISIT, EST PAT 10 MINS OFFICE/OUTPAT VISIT, EST PAT 15 MINS OFFICE/OUTPAT VISIT, EST PAT 25 MINS OFFICE/OUTPAT VISIT, EST PAT 40 MINS OBSERVATION CARE DISCHARGE OBSERVATION CARE LOW SEVERITY OBSERVATION CARE MODERATE SEVERITY OBSERVATION CARE HIGH SEVERITY INITIAL HOSPITAL CARE 30 MINS INITIAL HOSPITAL CARE 50 MINS INITIAL HOSPITAL CARE 70 MINS

143 MEDICAL FEE SCHEDULES 11: SUBSEQ OBSERVATION CARE 15 MINS SUBSEQ OBSERVATION CARE 25 MINS SUBSEQ OBSERVATION CARE 35 MINS SUBSEQUENT HOSPITAL CARE 15 MINS SUBSEQUENT HOSPITAL CARE 25 MINS SUBSEQUENT HOSPITAL CARE 35 MINS OBSERVE/HOSP SAME DATE LOW SEVERITY OBSERVE/HOSP SAME DATE MOD SEVERITY OBSERVE/HOSP SAME DATE HIGH SEVERITY HOSPITAL DISCHARGE DAY 30 MINS/LESS HOSPITAL DISCHARGE DAY > 30 MINS OFFICE CONSULTATION 15 MINS OFFICE CONSULTATION 30 MINS OFFICE CONSULTATION 40 MINS OFFICE CONSULTATION 60 MINS OFFICE CONSULTATION 80 MINS INPATIENT CONSULTATION 20 MINS INPATIENT CONSULTATION 40 MINS INPATIENT CONSULTATION 55 MINS INPATIENT CONSULTATION 80 MINS INPATIENT CONSULTATION 110 MINS EMERGENCY DEPT VISIT SELF LIMIT/MINOR EMERGENCY DEPT VISIT LOW/MODERATE EMERGENCY DEPT VISIT MODERATE EMERGENCY DEPT VISIT HIGH SEVERITY EMERGENCY DEPT VISIT HIGH SEVERITY CRITICAL CARE, FIRST HOUR CRITICAL CARE, ADDED 30 MIN NURSING FACILITY CARE, INIT NURSING FACILITY CARE, INIT NURSING FACILITY CARE, INIT NURSING FACILITY CARE, SUBSEQ NURSING FACILITY CARE, SUBSEQ NURSING FACILITY CARE, SUBSEQ NURSING FACILITY CARE, SUBSEQ NURSING FACILITY DISCHARGE DAY NURSING FACILITY DISCHARGE DAY DOMICILE/REST HOME VISIT EST PAT HOME VISIT, NEW PATIENT 20 MINS HOME VISIT, NEW PATIENT-30 MINS HOME VISIT, NEW PATIENT 45 MINS HOME VISIT, NEW PATIENT 60 MINS HOME VISIT, NEW PATIENT 75 MINS HOME VISIT, EST PATIENT 15 MINS HOME VISIT, EST PATIENT 25 MINS HOME VISIT, EST PATIENT 40 MINS HOME VISIT, EST PATIENT 60 MINS PROLONGED SERVICE, OFFICE PROLONGED SERVICE, OFFICE PROLONGED SERVICE, INPATIENT PROLONGED SERVICE, INPATIENT BEHAVIOR CHANGE SMOKING 3-10 MIN BEHAVIOR CHANGE SMOKING > 10 MIN PEDIATRIC CRITICAL CARE, INITIAL1, , PEDIATRIC CRITICAL CARE, SUBSEQ

144 11: APPENDIX B - REGULATIONS PEDIATRIC CRIT CARE AGE 2-5, INIT PEDIATRIC CRIT CARE AGE 2-5, SUBSEQ IC, LBW INF < 1500 GM SUBSEQ N1 = ASC Packaged Procedure no separate payment X = ASC codes Not Subject to Multiple Procedure Reductions Exhibit 2 Dental Fee Schedule CDT Description NORTH SOUTH D0120 periodic oral evaluation - established patient D0140 limited oral evaluation - problem focused D0150 comprehensive oral evaluation - new or established patient D0160 detailed and extensive oral evaluation - problem focused, by report D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) D0180 comprehensive periodontal evaluation - new or established patient D0210 intraoral - complete series (including bitewings) D0220 intraoral - periapical first film D0230 intraoral - periapical each additional film D0240 intraoral - occlusal film D0250 extraoral - first film D0260 extraoral - each additional film D0270 bitewing - single film D0272 bitewings - two films D0273 bitewings - three films D0274 bitewings - four films D0277 vertical bitewings - 7 to 8 films D0290 posterior-anterior or lateral skull and facial bone survey film D0320 temporomandibular joint arthrogram, including injection D0321 other temporomandibular joint films, by report D0330 panoramic film D0340 cephalometric film D0350 oral/facial photographic images D0360 cone beam ct - craniofacial data capture D0362 D0363 cone beam - two-dimensional image reconstruction using existing data, includes multiple images cone beam - three-dimensional image reconstruction using existing data, includes multiple images D0460 pulp vitality tests D0470 diagnostic casts D1110 prophylaxis - adult D1120 prophylaxis - child D1351 sealant - per tooth D1510 space maintainer - fixed-unilateral D1515 space maintainer - fixed - bilateral D1520 space maintainer - removable - unilateral D1525 space maintainer - removable - bilateral D1550 re-cementation of space maintainer D1555 removal of fixed space maintainer D2140 amalgam - one surface, primary or permanent D2150 amalgam - two surfaces, primary or permanent D2160 amalgam - three surfaces, primary or permanent D2161 amalgam - four or more surfaces, primary or permanent D2330 resin-based composite - one surface, anterior D2331 resin-based composite - two surfaces, anterior D2332 resin-based composite - three surfaces, anterior D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) D2390 resin-based composite crown, anterior

145 MEDICAL FEE SCHEDULES 11: D2391 resin-based composite - one surface, posterior D2392 resin-based composite - two surfaces, posterior D2393 resin-based composite - three surfaces, posterior D2394 resin-based composite - four or more surfaces, posterior D2410 gold foil - one surface D2420 gold foil - two surfaces D2430 gold foil - three surfaces D2510 inlay - metallic - one surface D2520 inlay - metallic - two surfaces D2530 inlay - metallic - three or more surfaces D2542 onlay - metallic-two surfaces D2543 onlay - metallic-three surfaces D2544 onlay - metallic-four or more surfaces D2610 inlay - porcelain/ceramic - one surface D2620 inlay - porcelain/ceramic - two surfaces D2630 inlay - porcelain/ceramic - three or more surfaces D2642 onlay - porcelain/ceramic - two surfaces D2643 onlay - porcelain/ceramic - three surfaces D2644 onlay - porcelain/ceramic - four or more surfaces D2650 inlay - resin-based composite - one surface D2651 inlay - resin-based composite - two surfaces D2652 inlay - resin-based composite - three or more surfaces D2662 onlay - resin-based composite - two surfaces D2663 onlay - resin-based composite - three surfaces D2664 onlay - resin-based composite - four or more surfaces D2710 crown - resin-based composite (indirect) D2712 crown - 3/4 resin-based composite (indirect) D2720 crown - resin with high noble metal D2721 crown - resin with predominantly base metal D2722 crown - resin with noble metal D2740 crown - porcelain/ceramic substrate D2750 crown - porcelain fused to high noble metal D2751 crown - porcelain fused to predominantly base metal D2752 crown - porcelain fused to noble metal D2780 crown - 3/4 cast high noble metal D2781 crown - 3/4 cast predominantly base metal D2782 crown - 3/4 cast noble metal D2783 crown - 3/4 porcelain/ceramic D2790 crown - full cast high noble metal D2791 crown - full cast predominantly base metal D2792 crown - full cast noble metal D2794 crown-titanium D2799 provisional crown D2910 recement inlay, onlay, or partial coverage restoration D2915 recement cast or prefabricated post and core D2920 recement crown D2930 prefabricated stainless steel crown - primary tooth D2931 prefabricated stainless steel crown - pennanent tooth D2932 prefabricated resin crown D2933 prefabricated stainless steel crown with resin window D2934 prefabricated esthetic coated stainless steel crown - primary tooth D2940 protective restoration D2950 core buildup, including any pins D2951 pin retention - per tooth, in addition to restoration D2952 post and core in addition to crown, indirectly fabricated D2953 each additional indirectly fabricated post - same tooth D2954 prefabricated post and core in addition to crown D2955 post removal (not in conjunction with endodontic therapy) D2957 each additional prefabricated post - same tooth

146 11: APPENDIX B - REGULATIONS D2960 labial veneer (resin laminate) - chairside D2961 labial veneer (resin laminate) - laboratory D2962 labial veneer (porcelain laminate) - laboratory D2970 temporary crown (fractured tooth) D2971 additional procedures to construct new crown under existing partial denture framework D2975 coping D2980 crown repair, by report D3310 endodontic therapy, anterior tooth (excluding final restoration) D3320 endodontic therapy, bicuspid tooth (excluding final restoration) D3330 endodontic therapy, molar (excluding final restoration) D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D4249 clinical crown lengthening - hard tissue D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant D4261 osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant D4263 bone replacement graft - first site in quadrant D4341 periodontal scaling and root planing - four or more teeth per quadrant D4355 full mouth debridement to enable comprehensive evaluation and diagnosis D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report D4910 periodontal maintenance D5110 complete denture-maxillary D5120 complete denture - mandibular D5130 immediate denture-maxillary D5140 immediate denture-mandibular D5211 D5212 D5213 D5214 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) mandibular partial denture - resin base (including any conventional clasps, rests and teeth) maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5510 repair broken complete denture base D5520 replace missing or broken teeth - complete denture (each tooth) D5610 repair resin denture base D5620 repair cast framework D5630 repair or replace broken clasp D5640 replace broken teeth - per tooth D5650 add tooth to existing partial denture D5660 add clasp to existing partial denture D5670 replace all teeth and acrylic on cast metal framework (maxillary) D5671 replace all teeth and acrylic on cast metal framework (mandibular) D5710 rebase complete maxillary denture D5711 rebase complete mandibular denture D5720 rebase maxillary partial denture D5721 rebase mandibular partial denture D5730 reline complete maxillary denture (chairside) D5731 reline complete mandibular denture (chairside) D5740 reline maxillary partial denture (chairside) D5741 reline mandibular partial denture (chairside) D5750 reline complete maxillary denture (laboratory) D5751 reline complete mandibular denture (laboratory) D5760 reline maxillary partial denture (laboratory) D5761 reline mandibular partial denture (laboratory)

147 MEDICAL FEE SCHEDULES 11: D5810 interim complete denture (maxillary) D5811 interim complete denture (mandibular) D5820 interim partial denture (maxillary) D5821 interim partial denture (mandibular) D5850 tissue conditioning, maxillary D5851 tissue conditioning, mandibular D5860 overdenture - complete, by report D5861 overdenture - partial, by report D5862 precision attachment, by report D5867 replacement of replaceable part of semi-precision or precision attachment (male or female component) D5875 modification of removable prosthesis following implant surgery D5937 trismus appliance (not for TMD treatment) D5951 feeding aid D5982 surgical stent D5988 surgical splint D6010 surgical placement of implant body: endosteal implant D6012 surgical placement of interim implant body for transitional prosthesis: endosteal implant D6040 surgical placement: eposteal implant D6050 surgical placement: transosteal implant D6053 implant/abutment supported removable denture for completely edentulous arch D6054 implant/abutment supported removable denture for partially edentulous arch D6055 connecting bar - implant supported or abutment supported D6056 prefabricated abutment - includes placement D6057 custom abutment - includes placement D6058 abutment supported porcelain/ceramic crown D6059 abutment supported porcelain fused to metal crown (high noble metal) D6060 abutment supported porcelain fused to metal crown (predominantly base metal) D6061 abutment supported porcelain fused to metal crown (noble metal) D6062 abutment supported cast metal crown (high noble metal) D6063 abutment supported cast metal crown (predominantly base metal) D6064 abutment supported cast metal crown (noble metal) D6065 implant supported porcelain/ceramic crown D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) D6068 abutment supported retainer for porcelain/ceramic FPD D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) D6072 abutment supported retainer for cast metal FPD (high noble metal) D6073 abutment supported retainer for cast metal FPD (predominantly base metal) D6074 abutment supported retainer for cast metal FPD (noble metal) D6075 implant supported retainer for ceramic FPD D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) D6078 implant/abutment supported fixed denture for completely edentulous arch

148 11: APPENDIX B - REGULATIONS D6079 implantlabutment supported fixed denture for partially edentulous arch D6080 implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis D6090 repair implant supported prosthesis, by report D6091 replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment D6092 recement implant/abutment supported crown D6093 recement implant/abutment supported fixed partial denture D6094 abutment supported crown - (titanium) D6095 repair implant abutment, by report D6100 implant removal, by report D6190 radiographic/surgical implant index, by report D6194 abutment supported retainer crown for FPD - (titanium) D6205 pontic - indirect resin based composite D6210 pontic - cast high noble metal D6211 pontic - cast predominantly base metal D6212 pontic - cast noble metal D6214 pontic-titanium D6240 pontic - porcelain fused to high noble metal D6241 pontic - porcelain fused to predominantly base metal D6242 pontic - porcelain fused to noble metal D6245 pontic - porcelain/ceramic D6250 pontic - resin with high noble metal D6251 pontic - resin with predominantly base metal D6252 pontic - resin with noble metal D6253 provisional pontic D6545 retainer - cast metal for resin bonded fixed prosthesis D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis D6710 crown - indirect resin based composite D6720 crown - resin with high noble metal D6721 crown - resin with predominantly base metal D6722 crown - resin with noble metal D6740 crown - porcelain/ceramic D6750 crown - porcelain fused to high noble metal D6751 crown - porcelain fused to predominantly base metal D6752 crown - porcelain fused to noble metal D6780 crown - 3/4 cast high noble metal D6781 crown - 3/4 cast predominantly base metal D6782 crown - 3/4 cast noble metal D6783 crown - 3/4 porcelain/ceramic D6790 crown - full cast high noble metal D6791 crown - full cast predominantly base metal D6792 crown - full cast noble metal D6793 provisional retainer crown D6794 crown - titanium D6920 connector bar D6930 recement fixed partial denture D6940 stress breaker D6950 precision attachment D6970 post and core in addition to fixed partial denture retainer, indirectly fabricated D6972 prefabricated post and core in addition to fixed partial denture retainer D6973 core build up for retainer, including any pins D6975 coping-metal D6976 each additional indirectly fabricated post - same tooth D6977 each additional prefabricated post - same tooth

149 MEDICAL FEE SCHEDULES 11: D6980 fixed partial denture repair, by report D6985 pediatric partial denture, fixed D7110 single tooth (extraction) n/a n/a D7111 extraction, coronal remnants - deciduous tooth D7120 each add tooth (extraction) n/a n/a D7140 extraction, erupted tooth or exposed root (elevation and/or forceps D7210 removal) surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7250 surgical removal of residual tooth roots (cutting procedure) D7290 surgical repositioning of teeth D7560 maxillary sinusotomy for removal of tooth fragment or foreign body D7610 maxilla - open reduction (teeth immobilized, if present) D7620 maxilla - closed reduction (teeth immobilized, if present) D7630 mandible - open reduction (teeth immobilized, if present) D7640 mandible - closed reduction (teeth immobilized, if present) D7650 malar and/or zygomatic arch - open reduction D7660 malar and/or zygomatic arch - closed reduction D7670 alveolus closed reduction may include stabilization of teeth D7671 alveolus, open reduction may include stabilization of teeth D7680 facial bones - complicated reduction with fixation and multiple surgical approaches D7710 maxilla open reduction D7720 maxilla - closed reduction D7730 mandible - open reduction D7740 mandible - closed reduction D7750 malar and/or zygomatic arch - open reduction D7760 malar and/or zygomatic arch - closed reduction D7770 alveolus - open reduction stabilization of teeth D7771 alveolus, closed reduction stabilization of teeth D7780 facial bones - complicated reduction with fixation and multiple surgical approaches D7810 open reduction of dislocation D7820 closed reduction of dislocation D7830 manipulation under anesthesia D7840 condylectomy D7850 surgical discectomy, with/without implant D7852 disc repair D7854 synovectomy D7856 myotomy D7880 occlusal orthotic device, by report D7910 suture of recent small wounds up to 5 cm D7911 complicated suture - up to 5 cm D7912 complicated suture - greater than 5 cm D7920 skin graft (identify defect covered, location and type of graft) D7955 repair of maxillofacial soft and/or hard tissue defect D7960 frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure D7990 emergency tracheotomy D8210 removable appliance therapy D8220 fixed appliance therapy D8691 repair of orthodontic appliance D8692 replacement of lost or broken retainer D8693 rebonding or recementing; and/or repair, as required, of fixed retainers D9110 palliative (emergency) treatment of dental pain - minor procedure D9210 local anesthesia not in conjunction with operative or surgical procedures 91 80

150 11: APPENDIX B - REGULATIONS D9211 regional block anesthesia D9212 trigeminal division block anesthesia D9215 local anesthesia in conjunction with operative or surgical procedures D9220 deep sedation/general anesthesia - first 30 minutes D9221 deep sedation/general anesthesia - each additional 15 minutes D9230 inhalation of nitrous oxide / anxiolysis, analgesia D9241 intravenous conscious sedation/analgesia - first 30 minutes D9242 intravenous conscious sedation/analgesia - each additional 15 minutes D9248 non-intravenous conscious sedation D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician D9410 house/extended care facility call D9420 hospital or ambulatory surgical center call D9430 office visit for observation (during regularly scheduled hours) - no other services performed D9610 therapeutic parenteral drug, single administration D9612 therapeutic parenteral drugs, two or more administrations, different medications D9630 other drugs and/or medicaments, by report D9940 occlusal guard, by report D9950 occlusion analysis - mounted case D9951 occlusal adjus ment - limited D9952 occlusal adjustment - complete Exhibit 3 Home Care Fees Service PRIVATE NURSING CARE (PER HOUR) HSPCS CODE FEE Registered nurse S Licensed practical nurse S Home health aide S Live-in attendant (per 24-hr shift) S HOME HEALTH VISITS (PER VISIT) HSPCS CODE FEE Registered nurse T Physical therapist S Speech therapist S Occupational therapist S Medical social worker S Exhibit 4 Ambulance Services Fee Schedule HCPCS Description North South A0425 A0426 A0427 GROUND MILEAGE, PER STATUTE MILE AMBULANCE SERVICE, ALS, NON-EMERGENCY TRANSPORT, LEVEL AMBULANCE SERVICE, ALS, EMERGENCY TRANSPORT, LEVEL I A0428 AMBULANCE SERVICE, BLS, NON-EMERGENCY TRANSPORT A0429 AMBULANCE SERVICE, BLS, EMERGENCY TRANSPORT A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES TRANSPORT ONE WAY (ROTARY WING) 4, , A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) A0434 SPECIALTY CARE TRANSPORT (SCT) 1, A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE

151 MEDICAL FEE SCHEDULES 11: Exhibit 5 Durable Medical Equipment, Prosthetics, Orthotics & Supplies HCPCS ModMod2 CATGFee Description A4216 OS $.047 Sterile water/saline, 10ml A4217 SU $3.29 Sterile water/saline, 500 ml A4217 AU OS $3.29 Sterile water/saline, 500 ml A4221 SU $23.77 Maint drug infus cath per wk A4222 SU $49.07 Infusion supplies with pump A4233 NU IN $0.84 Alkalin batt for glucose mon A4233 NU KL IN $0.72 Alkalin batt for glucose mon A4234 NU IN $3.81 J-cell batt for glucose mon A4234 NU KL IN $3.29 J-cell batt for glucose mon A4235 NU IN $2.46 Lithium batt for glucose mon A4235 NU KL IN $2.12 Lithium batt for glucose mon A4236 NU IN $1.76 Silvr oxide batt glucose mon A4236 NU KL IN $1.52 Silvr oxide batt glucose mon A4253 NU IN $38.79 Blood glucose/reagent strips A4253 NU KL IN $33.43 Blood glucose/reagent strips A4255 SU $4.11 Glucose monitor platforms A4256 SU $10.21 Calibrator solution/chips A4256 KL SU $8.80 Calibrator solution/chips A4257 SU $13.39 Replace Lensshield Cartridge A4258 SU $18.95 Lancet device each A4258 KL SU $16.34 Lancet device each A4259 SU $12.66 Lancets per box A4259 KL SU $10.91 Lancets per box A4265 SU $3.56 Paraffin A4280 PO $5.55 Brst prsths adhsv attchmnt A4310 OS $7.50 Insert tray w/o bag/cath A4311 OS $13.24 Catheter w/o bag 2-way latex A4312 OS $16.10 Cath w/o bag 2-way silicone A4313 OS $19.06 Catheter w/bag 3-way A4314 OS $25.21 Cath w/drainage 2-way latex A4315 OS $27.09 Cath w/drainage 2-way silcne A4316 OS $28.30 Cath w/drainage 3-way A4320 OS $5.29 Irrigation tray A4321 OS $0.00 Cath therapeutic irrig agent A4322 OS $3.09 Irrigation syringe A4326 OS $11.33 Male external catheter A4327 OS $44.38 Fem urinary collect dev cup A4328 OS $10.97 Fem urinary collect pouch A4330 OS $7.51 Stool collection pouch A4331 OS $3.34 Extension drainage tubing A4332 OS $0.13 Lube sterile packet A4333 OS $2.31 Urinary cath anchor device A4334 OS $5.18 Urinary Bath leg strap A4336 OS $1.51 Urethral insert A4338 OS $11.09 Indwelling catheter latex A4340 OS $33.34 Indwelling catheter special A4344 OS $14.30 Cath indw foley 2 way silicn A4346 OS $17.90 Cath indw foley 3 way A4349 OS $2.12 Disposable male external cat A4351 OS $1.83 Straight tip urine catheter A4352 OS $6.74 Coude tip urinary catheter A4353 OS $7.34 Intermittent urinary cath A4354 OS $12.29 Cath insertion tray w/bag A4355 OS $9.36 Bladder irrigation tubing A4356 OS $47.91 Ext ureth clmp or compr dvc A4357 OS $9.65 Bedside drainage bag A4358 OS $6.96 Urinary leg or abdomen bag A4360 OS $0.51 Disposable ext urethral dev A4361 OS $19.17 Ostomy face plate A4362 OS $3.63 Solid skin barrier A4363 OS $2.48 Ostomy clamp, replacement A4364 OS $3.08 Adhesive, liquid or equal A4366 OS $1.37 Ostomy vent A4367 OS $7.72 Ostomy belt

152 11: APPENDIX B - REGULATIONS A4368 OS $0.27 Ostomy filter A4369 OS $2.54 Skin barrier liquid per oz A4371 OS $3.83 Skin barrier powder per oz A4372 OS $4.39 Skin barrier solid 4x4 equiv A4373 OS $6.59 Skin barrier with flange A4375 OS $18.04 Drainable plastic pch w fcpl A4376 OS $49.96 Drainable rubber pch w fcplt A4377 OS $4.50 Drainable plstic pch w/o fp A4378 OS $32.29 Drainable rubber pch w/o fp A4379 OS $15.77 Urinary plastic pouch w fcpl A4380 OS $39.20 Urinary rubber pouch w fcplt A4381 OS $4.84 Urinary plastic pouch w/o fp A4382 OS $25.85 Urinary hvy plstc pch w/o fp A4383 OS $29.60 Urinary rubber pouch w/o fp A4384 OS $10.10 Ostomy faceplt/silicone ring A4385 OS $5.36 Ost skn barrier sld ext wear A4387 OS $0.00 Ost clsd pouch w att st barr A4388 OS $4.58 Drainable pch w ex wear barr A4389 OS $6.53 Drainable pch w st wear barr A4390 OS $10.09 Drainable pch ex wear convex A4391 OS $7.42 Urinary pouch w ex wear barr A4392 OS $8.59 Urinary pouch w st wear barr A4393 OS $9.49 Urine pch w ex wear bar conv A4394 OS $2.71 Ostomy pouch liq deodorant A4395 OS $0.05 Ostomy pouch solid deodorant A4396 OS $42.50 Peristomal hernia supprt blt A4397 OS $5.03 Irrigation supply sleeve A4398 OS $14.50 Ostomy irrigation bag A4399 OS $12.87 Ostomy irrig cone/cath w brs A4400 OS $51.31 Ostomy irrigation set A4402 OS $1.46 Lubricant per ounce A4404 OS $1.62 Ostomy ring each A4405 OS $3.57 Nonpectin based ostomy paste A4406 OS $6.03 Pectin based ostomy paste A4407 OS $9.20 Ext wear ost skn barr <=4sq" A4408 OS $10.36 Ext wear ost skn barr >4sq" A4409 OS $6.53 Ost skn barr convex <=4 sq i A4410 OS $9.49 Ost skn barr extnd >4 sq A4411 OS $5.36 Ost skn barr extnd =4sq A4412 OS $2.84 Ost pouch drain high output A4413 OS $ pc drainable ost pouch A4414 OS $5.18 Ost sknbar w/o conv<=4 sq in A4415 OS $6.30 Ost skn barn w/o conv >4 sqi A4416 OS $2.89 Ost pch clsd w barrier/filtr A4417 OS $3.91 Ost pch w bar/bltinconv/fltr A4418 OS $1.90 Ost pch clsd w/o bar w filtr A4419 OS $1.83 Ost pch for bar w flange/flt A4420 OS $0.00 Ost pch clsd for bar w lk fl A4422 OS $0.13 Ost pouch absorbent material A4423 OS $1.95 Ost pch for bar w lk fl/fltr A4424 OS $4.99 Ost pch drain w bar & filter A4425 OS $3.76 Ost pch drain for barrier fl A4426 OS $2.87 Ost pch drain 2 piece system A4427 OS $2.92 Ost pch drain/barr lk flng/f A4428 OS $6.84 Urine ost pouch w faucet/tap A4429 OS $8.66 Urine ost pouch w bltinconv A4430 OS $8.95 Ost urine pch w b/bltin cony A4431 OS $6.53 Ost pch urine w barrier/tapv A4432 OS $3.77 Os pch urine w bar/fange/tap A4433 OS $3.51 Urine ost pch bar w lock fln A4434 OS $3.95 Ost pch urine w lock flng/ft A4450 AU OS $0.09 Non-waterproof tape A4450 AV OS $0.09 Non-waterproof tape A4450 AW OS $0.12 Non-waterproof tape A4452 AU OS $0.38 Waterproof tape A4452 AV OS $0.38 Waterproof tape A4452 AW OS $0.42 Waterproof tape A4455 OS $1.47 Adhesive remover per ounce

153 MEDICAL FEE SCHEDULES 11: A4456 OS $0.26 Adhesive remover, wipes A4461 SD $3.45 Surgicl dress hold non-reuse A4463 SD $13.98 Surgical dress holder reuse A4481 OS $0.39 Tracheostoma filter A4483 OS $0.00 Moisture exchanger A4556 SU $12.75 Electrodes, pair A4557 SU $18.84 Lead wires, pair A4558 SU $5.72 Conductive gel or paste A4559 SU $0.11 Coupling gel or paste A4561 PO $20.95 Pessary rubber, any type A4562 PO $52.16 Pessary, non rubber,any type A4595 SU $30.25 TENS suppl 2 lead per month A4604 NU IN $60.46 Tubing with heating element A4605 NU IN $17.22 Trach suction cath close sys A4608 OX $52.63 Transtracheal oxygen cath A4611 NU IN $ Heavy duty battery A4611 RR IN $21.39 Heavy duty battery A4611 UE IN $ Heavy duty battery A4612 NU IN $71.34 Battery cables A4612 RR IN $7.27 Battery cables A4612 UE IN $54.40 Battery cables A4613 NU IN $ Battery charger A4613 RR IN $15.15 Battery charger A4613 UE IN $ Battery charger A4614 IN $24.97 Hand-held PEFR meter A4615 SU $0.75 Cannula nasal A4616 SU $0.07 Tubing (oxygen) per foot A4617 SU $3.25 Mouth piece A4618 NU IN $9.33 Breathing circuits A4618 RR IN $1.07 Breathing circuits A4618 UE IN $7.00 Breathing circuits A4619 OX $1.27 Face tent A4620 SU $0.62 Variable concentration mask A4623 OS $6.88 Tracheostomy inner cannula A4624 NU IN $2.47 Tracheal suction tube A4625 OS $7.28 Trach care kit for new trach A4626 OS $3.35 Tracheostomy cleaning brush A4628 NU TN $3.85 Oropharyngeal suction cath A4629 OS $4.86 Tracheostomy care kit A4630 NU IN $5.97 Repl bat t.e.n.s. own by pt A4633 NU TN $43.09 Uvl replacement bulb A4635 NU IN $5.38 Underarm crutch pad A4635 RR IN $0.72 Underarm crutch pad A4635 UE IN $3.56 Underarm crutch pad A4636 NU IN $3.24 Handgrip for cane etc A4636 NU KE TN $3.76 Handgrip for cane etc A4636 RR IN $0.39 Handgrip for cane etc A4636 RR KE IN $0.45 Handgrip for cane etc A4636 UE IN $2.36 Handgrip for cane etc A4636 UE KE IN $2.74 Handgrip for cane etc A4637 NU IN $1.93 Repl tip cane/crutch/walker A4637 NU KE IN $2.24 Repl tip cane/crutch/walker A4637 RR IN $0.27 Repl tip cane/crutch/walker A4637 RR KE TN $0.32 Repl tip cane/crutch/walker A4637 UE IN $1.46 Repl tip cane/crutch/walker A4637 UE KE IN $1.69 Rcpl tip cane/crutch/walker A4638 NU IN $0.00 Repl batt pulse gen sys A4638 RR IN $0.00 Repl batt pulse gen sys A4638 UE IN $0.00 Repl batt pulse gen sys A4639 NU IN $ Infrared ht sys replcmnt pad A4640 NU IN $62.79 Alternating pressure pad A4640 RR IN $6.28 Alternating pressure pad A4640 UE IN $47.10 Alternating pressure pad A5051 OS $2.17 Pouch clsd w barr attached A5052 OS $1.56 Clsd ostomy pouch w/o barr A5053 OS $1.83 Clsd ostomy pouch faceplate A5054 OS $1.88 Clsd ostomy pouch w/flange A5055 OS $1.49 Stoma cap

154 11: APPENDIX B - REGULATIONS A5061 OS $3.70 Pouch drainable w barrier at A5062 OS $2.33 Drnble ostomy pouch w/o barr A5063 OS $2.84 Drain ostomy pouch w/flange A5071 OS $6.31 Urinary pouch w/barrier A5072 OS $3.70 Urinary pouch w/o barrier A5073 OS $3.34 Urinary pouch on barn w/flng A5081 OS $3.47 Continent stoma plug A5082 OS $12.48 Continent stoma catheter A5083 OS $0.66 Stoma absorptive cover A5093 OS $2.04 Ostomy accessory convex inse A5102 OS $23.54 Bedside drain btl w/wo tube A5105 OS $42.80 Urinary suspensory A5112 OS $30.90 Urinary leg bag A5113 OS $4.94 Latex leg strap A5114 OS $9.39 Foam/fabric leg strap A5120 AU OS $0.26 Skin barrier, wipe or swab A5120 AV PO $0.25 Skin barrier, wipe or swab A5121 OS $6.87 Solid skin barrier 6x6 A5122 OS $11.47 Solid skin barrier 8x8 A5126 OS $1.39 Disk/foam pad +or- adhesive A5131 OS $16.65 Appliance cleaner A5200 OS $11.87 Percutaneous catheter anchor A5500 TS $66.76 Diab shoe for density insert A5501 TS $ Diabetic custom molded shoe A5503 TS $29.69 Diabetic shoe w/roller/rockr A5504 TS $29.69 Diabetic shoe with wedge A5505 TS $29.69 Diab shoe w/metatarsal bar A5506 TS $29.69 Diabetic shoe w/off set heel A5507 TS $29.69 Modification diabetic shoe A5512 TS $27.24 Multi den insert direct form A5513 TS $40.65 Multi den insert custom mold A6010 SD $32.51 Collagen based wound filler A6011 SD $2.39 Collagen gel/paste wound fil A6021 SD $22.07 Collagen dressing <=16 sq in A6022 SD $22.07 Collagen drsg>16<=48 sq in A6023 SD $ Collagen dressing >48 sq in A6024 SD $6.50 Collagen dsg wound filler A6154 SD $15.10 Wound pouch each A6196 SD $7.72 Alginate dressing <=16 sq in A6197 SD $17.26 Alginate drsg >16 <=48 sq in A6199 SD $5.55 Alginate drsg wound filler A6203 SD $3.52 Composite drsg <= 16 sq in A6204 SD $6.54 Composite drsg >1 6<=48 sq in A6207 SD $7.71. Contact layer >16<= 48 sq in A6209 SD $7.85 Foam drsg <=16 sq in w/o bdr A6210 SD $20.92 Foam drg >16<=48 sq in w/o b A6211 SD $30.84 Foam drg > 48 sq in w/o brdr A6212 SD $10.19 Foam drg <=16 sq in w/border A6214 SD $10.80 Foam drg > 48 sq in w/border A6216 SD $0.05 Non-sterile gauze<=16 sq in A6217 SD $0.00 Non-sterile gauze>16<=48 sq A6219 SD $1.00 Gauze <= 16 sq in w/border A6220 SD $2.71 Gauze >16 <=48 sq in w/bordr A6222 SD $2.24 Gauze <=16 in no w/sal w/o b A6223 SD $2.54 Gauze >16<=48 no w/sal w/o b A6224 SD $3.79 Gauze > 48 in no w/sal w/o b A6229 SD $3.79 Gauze >16<=48 sq in watr/sal A6231 SD $4.89 Hydrogel dsg<=16 sq in A6232 SD $7.22 Hydrogel dsg>16<=48 sq in A6233 SD $20.15 Hydrogel dressing >48 sq in A6234 SD $6.87 Hydrocolld drg <=16 w/o bdr A6235 SD $17.66 Hydrocoil d drg >16<=48 w/o b A6236 SD $28.61 Hydrocolld drg > 48 in w/o b A6237 SD $8.31 Hydrocolld drg <=16 in w/bdr A6238 SD $23.93 Hydrocolld drg >16<=48 w/bdr A6240 SD $12.85 Hydrocolld drg filler paste A6241 SD $2.70 Hydrocolloid drg filler dry A6242 SD $6.37 Hydrogel drg <=16 in w/o bdr

155 MEDICAL FEE SCHEDULES 11: A6243 SD $12.93 Hydrogel drg >16<=48 w/o bdr A6244 SD $41.24 Hydrogel drg >48 in w/o bdr A6245 SD $7.63 Hydrogel drg <= 16 in w/bdr A6246 SD $10.42 Hydrogel drg >16<=48 in w/b A6247 SD $24.97 Hydrogel dig > 48 sq in w/b A6248 SD $17.05 Hydrogel drsg gel filler A6251 SD $2.09 Absorpt drg <=16 sq in w/o b A6252 SD $3.41 Absorpt drg >16 <=48 w/o bdr A6253 SD $6.66 Absorpt drg > 48 sq in w/o b A6254 SD $1.27 Absorpt drg <=16 sq in w/bdr A6255 SD $3.18 Absorpt drg >16<=48 in w/bdr A6257 SD $1.61 Transparent film <= 16 sq in A6258 SD $4.52 Transparent film >16<=48 in A6259 SD $11.49 Transparent film > 48 sq in A6266 SD $2.02 Impreg gauze no h20/sal/yard A6402 SD $0.13 Sterile gauze <= 16 sq in A6403 SD $0.45 Sterile gauze>16 <= 48 sq in A6407 SD $1.97 Packing strips, non-impreg A6410 SD $0.41 Sterile eye pad A6411 SD $0.00 Non-sterile eye pad A6441 SD $0.70 Pad band w>=3" <5"/yd A6442 SD $0.18 Conform band n/s w<3"/yd A6443 SD $0.30 Conform band n/s w>=3"<5"/yd A6444 SD $0.59 Conform band n/s w>=5"/yd A6445 SD $0.34 Conform band s w <3"/yd A6446 SD $0.43 Conform band s w>=3" <5"/yd A6447 SD $0.70 Confom band s w >=5"/yd A6448 SD $1.22 Lt compres band <3"/yd A6449 SD $1.84 Lt compres band >=3" <5"/yd A6450 SD $0.00 Lt compres band >=5"/yd A6451 SD $0.00 Mod compres band w>=3"<5"/yd A6452 SD $6.21 High compres band w>=3"<5"yd A6453 SD $0.64 Self-adher band w <3"/yd A6454 SD $0.81 Self-adher band w>=3" <5"/yd A6455 SD $1.46 Self-adher band >=5"/yd A6456 SD $1.34 Zinc paste band w >=3"<5"/yd A6457 SD $1.20 Tubular dressing A6501 SD $0.00 Compres burngarment bodysuit A6502 SD $0.00 Compres burngarment chinstrp A6503 SD $0.00 Compres burngarment facehood A6504 SD $0.00 Cmprsburngarment glove-wrist A6505 SD $0.00 Cmprsburngarment glove-elbow A6506 SD $0.00 Cmprsbumgrmt glove-axilla A6507 SD $0.00 Cmprs burngarment foot-knee A6508 SD $0.00 Cmprs burngarment foot-thigh A6509 SD $0.00 Compres bum garment jacket A6510 SD $0.00 Compres bum garment leotard A6511 SD $0.00 Compres burn garment panty A6513 SD $0.00 Compress bum mask face/neck A6531 AW SD $45.43 Compression stocking BK30-40 A6532 AW SD $64.01 Compression stocking BK40-50 A6545 SD $0.00 Grad comp non-elastic BK A6545 AW SD $89.45 Grad comp non-elastic BK A6550 SU $24.82 Neg pres wound ther drsg set A7000 NU IN $7.54 Disposable canister for pump A7000 NU KE IN $8.75 Disposable canister for pump A7001 NU IN $31.32 Nondisposable pump canister A7002 NU IN $3.63 Tubing used w suction pump A7003 NU IN $2.87 Nebulizer administration set A7004 NU IN $1.61 Disposable nebulizer sml vol A7005 NU IN $29.18 Nondisposable nebulizer set A7006 NU IN $8.55 Filtered nebulizer admin set A7007 NU IN $4.17 Lg vol nebulizer disposable A7008 NU IN $11.55 Disposable nebulizer prefill A7009 NU IN $39.80 Nebulizer reservoir bottle A7010 NU IN $24.48 Disposable corrugated tubing A7012 NU IN $3.76 Nebulizer water collec devic A7013 NU IN $0.79 Disposable compressor filter

156 11: APPENDIX B - REGULATIONS A7014 NU IN $4.24 Compressor nondispos filter A7015 NU IN $1.73 Aerosol mask used w nebulizer A7016 NU IN $6.85 Nebulizer dome & mouthpiece A7017 NU IN $ Nebulizer not used w oxygen A7017 RR IN $14.07 Nebulizer not used w oxygen A7017 UE IN $ Nebulizer not used w oxygen A7018 SU $0.40 Water distilled w/nebulizer A7025 NU IN $456,69 Replace chest compress vest A7026 NU IN $30.19 Replace chst cmprss sys hose A7027 NU IN $ Combination oral/nasal mask A7028 NU IN $52.02 Repl oral cushion combo mask A7029 NU IN $21.25 Repl nasal pillow comb mask A7030 NU IN $ CPAP full face mask A7031 NU IN $63.14 Replacement facemask interfa A7032 NU IN $36.68 Replacement nasal cushion A7033 NU IN $25.71 Replacement nasal pillows A7034 NU IN $ Nasal application device A7035 NU IN $32.06 Pos airway press headgear A7036 NU IN $16.47 Pos airway press chinstrap A7037 NU IN $35.49 Pos airway pressure tubing A7038 NU IN $4.15 Pos airway pressure filter A7039 NU IN $13.87 Filter, non disposable w pap A7040 PO $41.45 One way chest drain valve A7041 PO $77.90 Water seal drain container A7042 PO $ Implanted pleural catheter A7043 PO $29.52 Vacuum drainagebottle/tubing A7044 NU IN $ PAP oral interface A7045 NU IN $17.62 Repl exhalation port for PAP A7045 RR IN $1.76 Repl exhalation port for PAP A7045 UE IN $13.21 Repl exhalation port for PAP A7046 NU IN $17.66 Repl water chamber, PAP dev A7501 OS $ Tracheostoma valve w diaphra A7502 OS $52.41 Replacement diaphragm/fplate A7503 OS $11.90 HMES filter holder or cap A7504 OS $0.70 Tracheostoma HMES filter A7505 OS $4.91 HMES or trach valve housing A7506 OS $0.35 HMES/trachvalve adhesivedisk A7507 OS $2.61 Integrated filter & holder A7508 OS $3.01 Housing & Integrated Adhesiv A7509 OS $1.48 Heat & moisture exchange sys A7520 OS $49.85 Trach/laryn tube non-cuffed A7521 OS $49.40 Trach/laryn tube cuffed A7522 OS $47.42 Trach/laryn tube stainless A7524 OS $81.27 Tracheostoma stent/stud/bttn A7525 OS $2.17 Tracheostomy mask A7526 OS $3.54 Tracheostomy tube collar A7527 OS $3.76 Trach/laryn tube plug/stop A8000 NU IN $ Soft protect helmet prefab A8000 RR IN $16.10 Soft protect helmet prefab A8000 UE IN $ Soft protect helmet prefab A8001 NU IN $ Hard protect helmet prefab A8001 RR IN $16.10 Hard protect helmet prefab A8001 UE IN $ Hard protect helmet prefab A8002 NU IN $0.00 Soft protect helmet custom A8002 RR IN $0.00 Soft protect helmet custom A8002 UE IN $0.00 Soft protect helmet custom A8003 NU IN $0.00 Hard protect helmet custom A8003 RR IN $0.00 Hard protect helmet custom A8003 UE IN $0.00 Hard protect helmet custom A8004 NU IN $0.00 Repl soft interface, helmet A8004 RR IN $0.00 Repl soft interface, helmet A8004 UE IN $0.00 Repl soft interface, helmet E0100 NU IN $19.69 Cane adjust/fixed with tip E0100 RR IN $5.30 Cane adjust/fixed with tip E0100 UE IN $15.25 Cane adjust/fixed with tip E0105 NU IN $51.57 Cane adjust/fixed quad/3 pro E0105 RR IN $7.91 Cane adjust/fixed quad/3 pro E0105 UE IN $38.05 Cane adjust/fixed quad/3 pro

157 MEDICAL FEE SCHEDULES 11: E0110 NU IN $76.20 Crutch forearm pair E0110 RR IN $14.27 Crutch forearm pair E0110 UE IN $57.14 Crutch foreann pair E0111 NU IN $55.92 Crutch forearm each E0111 RR IN $8.75 Crutch forearm each E0111 UE IN $43.16 Crutch foreariu each E0112 NU IN $38.85 Crutch underarm pair wood E0112 RR IN $8.87 Crutch underarm pair wood E0112 UE IN $29.64 Crutch underarm pair wood E0113 NU IN $22.19 Crutch underarm each wood E0113 RR IN $5.41 Crutch underarm each wood E0113 UE IN $16.65 Crutch underarm each wood E0114 NU IN $49.55 Crutch underarm pair no wood E0114 RR IN $9.00 Crutch underarm pair no wood E0114 UE IN $37.45 Crutch underarm pair no wood E0116 NU IN $24.98 Crutch underarm each no wood E0116 RR IN $5.67 Crutch underann each no wood E0116 UE IN $18.73 Crutch underamn each no wood E0117 NU IN $ Underarm springassist crutch E0117 RR IN $20.22 Underarm springassist crutch E0117 UE IN $ Underarm springassist crutch E0130 NU IN $63.42 Walker rigid adjust/fixed ht E0130 RR IN $15.22 Walker rigid adjust/fixed ht E0130 UE IN $47.52 Walker rigid adjust/fixed ht E0135 NU IN $67.40 Walker folding adjust/fixed E0135 RR IN $15.62 Walker folding adjust/fixed E0135 UE IN $49.48 Walker folding adjust/fixed E0140 NU IN $ Walker w trunk support E0140 RR IN $32.65 Walker w trunk support E0140 UE IN $ Walker w trunk support E0141 NU IN $ Rigid wheeled walker adj/fix E0141 RR IN $20.24 Rigid wheeled walker adj/fix E0141 UE IN $78.26 Rigid wheeled walker adj/fix E0143 NU IN $ Walker folding wheeled w/o s E0143 RR IN $19.54 Walker folding wheeled w/o s E0143 UE IN $81.43 Walker folding wheeled w/o s E0144 NU IN $ Enclosed walker w rear seat E0144 RR IN $24.51 Enclosed walker w rear seat E0144 UE IN $ Enclosed walker w rear seat E0147 NU IN $ Walker variable wheel resist E0147 RR IN $52.02 Walker variable wheel resist E0147 UE IN $ Walker variable wheel resist E0148 NU IN $ Heavyduty walker no wheels E0148 RR IN $11.51 Heavyduty walker no wheels E0148 UE IN $86.23 Heavyduty walker no wheels E0149 NU IN $ Heavy duty wheeled walker E0149 RR IN $20.20 Heavy duty wheeled walker E0149 UE IN $ Heavy duty wheeled walker E0153 NU IN $72.85 Forearm crutch platform atta E0153 RR IN $8.23 Forearm crutch platform atta E0153 UE IN $54.63 Forearm crutch platform atta E0154 NU IN $63.81 Walker platform attachment E0154 RR IN $7.75 Walker platform attachment E0154 UE IN $48.48 Walker platform attachment E0155 NU IN $28.56 Walker wheel attachment,pair E0155 RR IN $3.48 Walker wheel attachment,pair E0155 UE IN $21.77 Walker wheel attachment,pair E0156 NU IN $23.92 Walker seat attachment E0156 RR IN $3.06 Walker seat attachment E0156 UE IN $17.96 Walker seat attachment E0157 NU IN $63.02 Walker crutch attachment E0157 RR IN $8.14 Walker crutch attachment E0157 UE IN $47.2 Walker crutch attachment E0158 NU IN $29.12 Walker leg extenders set of4 E0158 RR IN $3.21 Walker leg extenders set of4 E0158 UE IN $21.98 Walker leg extenders set of4 E0159 NU IN $16.12 Brake for wheeled walker E0159 RR IN $1.63 Brake for wheeled walker

158 11: APPENDIX B - REGULATIONS E0159 UE IN $12.11 Brake for wheeled walker E0160 NU IN $29.50 Sitz type bath or equipment E0160 RR IN $4.55 Sitz type bath or equipment E0160 UE IN $22.11 Sitz type bath or equipment E0161 NU IN $27.54 Sitz bath/equipment w/faucet E0161 RR IN $3.75 Sitz bath/equipment w/faucet E0161 UE IN $20.62 Sitz bath/equipment w/faucet E0162 NU IN $ Sitz bath chair E0162 RR IN $16.05 Sitz bath chair E0162 UE IN $ Sitz bath chair E0163 NU IN $ Commode chair with fixed arm E0163 RR IN $25.65 Commode chair with fixed arm E0163 UE IN $80.80 Commode chair with fixed arm E0165 RR CR $19.13 Commode chair with detacharm E0167 NU IN $12.60 Commode chair pail or pan E0167 RR IN $1.32 Commode chair pail or pan E0167 UE IN $9.49 Comninode chair pail or pan E0168 NU IN $ Heavyduty/wide commode chair E0168 RR IN $15.93 Heavyduty/wide commode chair E0168 UE IN $ Heavyduty/wide commode chair E0170 RR CR $ Commode chair electric E0171 RR CR $30.37 Commode chair non-electric E0175 NU IN $69.54 Commode chair foot rest E0175 RR IN $5.91 Commode chair foot rest E0175 UE IN $43.50 Commode chair foot rest E0181 RR CR $27.36 Press pad alternating w/ pum E0182 RR CR $27.49 Replace pump, alt press pad E0184 NU IN $ Dry pressure mattress E0184 RR IN $25.80 Dry pressure mattress E0184 UE IN $ Dry pressure mattress E0185 NU IIN $ Gel pressure mattress pad E0185 RR IN $47.19 Gel pressure mattress pad E0185 UE IN $ Gel pressure mattress pad E0186 RR CR $21.32 Air pressure mattress E0187 RR CR $23.70 Water pressure mattress E0188 NU IN $27.75 Synthetic sheepskin pad E0188 RR IN $3.26 Synthetic sheepskin pad E0188 UE IN $20.84 Synthetic sheepskin pad E0189 NU IN $46.38 Lambswool sheepskin pad E0189 RR IN $5.91 Lambswool sheepskin pad E0189 UE IN $34.79 Lambswool sheepskin pad E0191 NU IN $10.49 Protector heel or elbow E0191 RR IN $1.07 Protector heel or elbow E0191 UE IN $7.83 Protector heel or elbow E0193 RR CR $ Powered air flotation bed E0194 RR CR $3, Air fluidized bed E0196 RR CR $28.99 Gel pressure mattress E0197 NU IN $ Air pressure pad for mattres E0197 RR IN $32.10 Air pressure pad for mattres E0197 UE IN $ Air pressure pad for mattres E0198 NU IN $ Water pressure pad for mattr E0198 RR IN $24.10 Water pressure pad for mattr E0198 UE IN $ Water pressure pad for mattr E0199 NU IN $33.65 Dry pressure pad for mattres E0199 RR IN $3.35 Dry pressure pad for mattres E0199 UE IN $25.24 Dry pressure pad for mattres E0200 NU IN $70.75 Heat lamp without stand E0200 RR IN $11.30 Heat lamp without stand E0200 UE IN $53.09 Heat lamp without stand E0202 RR CR $65.74 Phototherapy light w/ photom E0205 NU IN $ Heat lamp with stand E0205 RR IN $20.84 Heat lamp with stand E0205 UE IN $ Heat lamp with stand E0210 NU IN $34.27 Electric heat pad standard E0210 RR IN $3.22 Electric heat pad standard E0210 UE IN $25.70 Electric heat pad standard E0215 NU IN $63.22 Electric heat pad moist E0215 RR IN $6.95 Electric heat pad moist

159 MEDICAL FEE SCHEDULES 11: E0215 UE IN $47.43 Electric heat pad moist E0217 NU IN $ Water circ heat pad w pump E0217 RR IN $49.33 Water circ heat pad w pump E0217 UE IN $ Water circ heat pad w pump E0220 NU IN $7.56 Hot water bottle E0220 RR IN $0.79 Hot water bottle E0220 UE IN $5.65 Hot water bottle E0225 NU IN $ Hydrocollator unit E0225 RR IN $34.20 Hydrocollator unit E0225 UE IN $ Hydrocollator unit E0230 NU IN $7.57 Ice cap or collar E0230 RR IN $0.85 Ice cap or collar E0230 UE IN $5.66 Ice cap or collar E0235 RR CR $18.12 Paraffin bath unit portable E0236 RR CR $40.19 Pump for water circulating p E0238 NU IN $28.38 Heat pad non-electric moist E0238 RR IN $2.86 Heat pad non-electric moist E0238 UE IN $20.87 Heat pad non-electric moist E0239 NU IN $ Hydrocollator unit portable E0239 RR IN $47.24 Hydrocollator unit portable E0239 UE IN $ Hydrocollator unit portable E0249 NU IN $ Pad water circulating heat u E0249 RR IN $11.50 Pad water circulating heat u E0249 UE IN $78.44 Pad water circulating heat u E0250 RR CR $84.09 Hosp bed fixed ht w/ mattres E0251 RR CR $61.24 Hosp bed fixd ht w/o mattres E0255 RR CR $91.93 Hospital bed var ht w/ mattr E0256 RR CR $64.12 Hospital bed var ht w/o matt E0260 RR CR $ Hosp bed semi-electr w/ matt E0261 RR CR $ Hosp bed semi-electr w/o mat E0265 RR CR $ Hosp bed total electr w/ mat E0266 RR CR $ Hosp bed total elec w/o matt E0271 NU IN $ Mattress innerspring E0271 RR IN $20.87 Mattress innerspring E0271 UE IN $ Mattress innerspring E0272 NU IN $ Mattress foam rubber E0272 RR IN $19.12 Mattress foam rubber E0272 UE IN $ Mattress foam rubber E0275 NU IN $16.08 Bed pan standard E0275 RR IN $1.68 Bed pan standard E0275 UE IN $12.05 Bed pan standard E0276 NU IN $13.97 Bed pan fracture E0276 RR IN $1.65 Bed pan fracture E0276 UE IN $11.05 Bed pan fracture E0277 RR CR $ Powered pres-redu air mattrs E0280 NU IN $33.49 Bed cradle E0280 RR IN $3.72 Bed cradle E0280 UE IN $25.11 Bed cradle E0290 RR CR $57.49 Hosp bed fx ht w/o rails w/m E0291 RR CR $41.77 Hosp bed fx ht w/o rail w/o E0292 RR CR $64.65 Hosp bed var ht w/o rail w/o E0293 RR CR $62.16 Hosp bed var ht w/o rail w/ E0294 RR CR $ Hosp bed semi-elect w/ matt E0295 RR CR $ Hosp bed semi-elect w/o matt E0296 RR CR $ Hosp bed total elect w/ matt E0297 RR CR $ Hosp bed total elect w/o mat E0300 NU IN $2, Enclosed ped crib hosp grade E0300 RR IN $ Enclosed ped crib hosp grade E0300 UE IN $1, Enclosed ped crib hosp grade E0301 RR CR $ HD hosp bed, lbs E0302 RR CR $ Ex hd hosp bed > 600 lbs E0303 RR CR $ Hosp bed hvy dty xtra wide E0304 RR CR $ Hosp bed xtra hvy dty x wide E0305 RR CR $13.69 Rails bed side half length E0310 NU IN $ Rails bed side full length E0310 RR IN $20.60 Rails bed side full length E0310 UE IN $ Rails bed side full length E0316 RR CR $ Bed safety enclosure

160 11: APPENDIX B - REGULATIONS E0325 NU IN $9.03 Urinal male jug-type E0325 RR IN $1.59 Urinal male jug-type E0325 UE IN $6.48 Urinal male jug-type E0326 NU IN $11.03 Urinal female jug-type E0326 RR IN $1.25 Urinal female jug-type E0326 UE IN $8.26 Urinal female jug-type E0371 RR CR $ Nonpower mattress overlay E0372 RR CR $ Powered air mattress overlay E0373 RR CR $ Nonpowered pressure mattress E0424 RR OX $ Stationary compressed gas 02 E0431 RR OX $28.77 Portable gaseous 02 E0433 RR OX $51.63 Portable liquid oxygen sys E0434 RR OX $28.77 Portable liquid 02 E0439 RR OX $ Stationary liquid 02 E0441 OX $77.45 Stationary 02 contents, gas E0442 OX $77.45 Stationary 02 contents, liq E0443 OX $77,45 Portable 02 contents, gas E0444 OX $77.45 Portable 02 contents, liquid E0450 RR FS $1, Vol control vent invasiv int E0457 NU IN $ Chest shell E0457 RR IN $64.52 Chest shell E0457 UE IN $ Chest shell E0459 RR CR $53.43 Chest wrap E0460 RR FS $ Neg press vent portabl/statn E0461 RR FS $1, Vol control vent noninv int E0462 RR CR $ Rocking bed w/ or w/o side r E0463 RR FS $1, Press supp vent invasive int E0464 RR FS $1, Press supp vent noninv int E0470 RR CR $ RAD w/o backup non-inv intfc E0471 RR CR $ RAD w/backup non inv mine E0472 RR CR $ RAD w backup invasive intrfc E0480 RR CR $46.14 Percussor elect/pneum home m E0482 RR CR $ Cough stimulating device E0483 RR CR $1, Chest compression gen system E0484 NU IN $38.77 Non-elec oscillatory pep dvc E0484 RR IN $3.87 Non-elec oscillatory pep dvc E0484 UE IN $29.09 Non-elec oscillatory pep dvc E0485 NU IN $0.00 Oral device/appliance prefab E0485 RR IN $0.00 Oral device/appliance prefab E0485 UE IN $0.00 Oral device/appliance prefab E0486 NU IN $0.00 Oral device/appliance cusfab E0486 RR IN $0.00 Oral device/appliance cusfab E0486 UE IN $0.00 Oral device/appliance cusfab E0500 RR FS $ Ippb all types E0550 RR CR $52.64 Humidif extens supple w ippb E0560 NU IN $ Humidifier supplemental w/ i E0560 RR IN $15.46 Humidifier supplemental w/ i E0560 UE IN $98.96 Humidifier supplemental w/ i E0561 NU IN $96.84 Humidifier nonheated w PAP E0561 RR IN $9.67 Humidifier nonheated w PAP E0561 UE IN $72.62 Humidifier nonheated w PAP E0562 NU IN $ Humidifier heated used w PAP E0562 RR IN $27.25 Humidifier heated used w PAP E0562 UE IN $ Humidifier heated used w PAP E0565 RR CR $54.45 Compressor air power source E0570 RR CR $16.91 Nebulizer with compression E0571 RR CR $29.69 Aerosol compressor for svneb E0572 RR CR $37.73 Aerosol compressor adjust pr E0574 RR CR $39.87 Ultrasonic generator w svneb E0575 RR FS $ Nebulizer ultrasonic E0580 NU IN $ Nebulizer for use w/regulat E0580 RR IN $12.13 Nebulizer for use w/regulat E0580 UE IN $90.97 Nebulizer for use w/ regulat E0585 RR CR $36.82 Nebulizer w/ compressor & he E0600 RR CR $46.23 Suction pump portab hom modl E0601 RR CR $90.59 Cont airway pressure device E0602 NU IN $31.00 Manual breast pump E0602 RR IN $3.11 Manual breast pump

161 MEDICAL FEE SCHEDULES 11: E0602 UE IN $23.25 Manual breast pump E0605 NU IN $27.75 Vaporizer room type E0605 RR IN $3.22 Vaporizer room type E0605 UE IN $22.86 Vaporizer room type E0606 RR CR $20.48 Drainage board postural E0607 NU IN $70.16 Blood glucose monitor home E0607 RR IN $7.01 Blood glucose monitor home E0607 UE IN $52.61 Blood glucose monitor home E0610 NU IN $ Pacemaker monitr audible/vis E0610 RR IN $26.34 Pacemaker monitr audible/vis E0610 UE IN $ Pacemaker monitr audible/vis E0615 NU IN $ Pacemaker monitr digital/vis E0615 RR IN $61.43 Pacemaker monitr digital/vis E0615 UE IN $ Pacemaker monitr digital/vis E0617 RR CR $ Automatic ext defibrillator E0617 RR KF CR $ Automatic ext defibrillator E0618 RR CR $ Apnea monitor E0619 RR CR $0.00 Apnea monitor w recorder E0620 NU IN $ Cap bld skin piercing laser E0620 RR IN $91.80 Cap bld skin piercing laser E0620 UE IN $ Cap bld skin piercing laser E0621 NU IN $85.67 Patient lift sling or seat E0621 RR IN $9.71 Patient lift sling or seat E0621 UE IN $64.58 Patient lift sling or seat E0627 NU IN $ Seat lift incorp lift-chair E0627 RR IN $34.73 Seat lift incorp lift-chair E0627 UE IN $ Seat lift incorp lift-chair E0628 NU IN $ Seat lift for pt furn-electr E0628 RR IN $34.73 Seat lift for pt furn-electr E0628 UE IN $ Seat lift for pt furn-electr E0629 NU IN $ Seat lift for pt furn-non-el E0629 RR IN $34.73 Seat lift for pt furn-non-el E0629 UE IN $ Seat lift for pt furn-non-el E0630 RR CR $ Patient lift hydraulic E0635 RR CR $ Patient lift electric E0636 RR CR $1, PT support & positioning sys E0650 NU IN $ Pneuma compresor non-segment E0650 RR IN $93.31 Pneuma compresor non-segment E0650 UE IN $ Pneuma compresor non-segment E0651 NU IN $ Pneum compressor segmental E0651 RR IN $96.44 Pneum compressor segmental E0651 UE IN $ Pneum compressor segmental E0652 NU IN $4, Pneum compres w/cal pressure E0652 RR IN $ Pneum compres w/cal pressure E0652 UE IN $4, Pneum compres w/cal pressure E0655 NU IN $ Pneumatic appliance half arm E0655 RR IN $13.31 Pneumatic appliance half arm E0655 UE IN $82.31 Pneumatic appliance half arm E0656 NU IN $ Segmental pneumatic trunk E0656 RR IN $60.59 Segmental pneumatic trunk E0656 UE IN $ Segmental pneumatic trunk E0657 NU IN $ Segmental pneumatic chest E0657 RR IN $56.89 Segmental pneumatic chest E0657 UE IN $ Segmental pneumatic chest E0660 NU IN $ Pneumatic appliance full leg E0660 RR IN $17.46 Pneumatic appliance full leg E0660 UE IN $ Pneumatic appliance full leg E0665 NU IN $ Pneumatic appliance full ainl E0665 RR IN $14.77 Pneumatic appliance full arm B0665 UE IN $91.82 Pneumatic appliance full aim E0666 NU IN $ Pneumatic appliance half leg E0666 RR IN $14.94 Pneumatic appliance half leg E0666 UE IN $ Pneumatic appliance half leg E0667 NU IN $ Seg pneumatic appl full leg E0667 RR IN $34.00 Seg pneumatic appl full leg E0667 UE IN $ Seg pneumatic appl full leg E0668 NU IN $ Seg pneumatic appl full arm E0668 RR IN $38.92 Seg pneumatic appl full arm

162 11: APPENDIX B - REGULATIONS E0668 UE IN $ Seg pneumatic appl full arm E0669 NU IN $ Seg pneumatic appli half leg E0669 RR IN $18.28 Seg pneumatic appli half leg E0669 UE IN '$ Seg pneumatic appli half leg E0671 NU IN $ Pressure pneum appl full leg E0671 RR IN $43.62 Pressure pneum appl full leg E0671 UE IN $ Pressure pneum appl full leg E0672 NU IN $ Pressure pneum appl full arm E0672 RR IN $33.89 Pressure pneum appl full arm E0672 UE IN $ Pressure pneum appl full arm E0673 NU IN $ Pressure pneum appl half leg E0673 RR IN $28.16 Pressure pneum appl half leg E0673 UE IN $ Pressure pnelun appl half leg E0675 RR CR $ Pneumatic compression device E0691 NU IN $ Uvl pnl 2 sq ft or less E0691 RR IN $94.35 Uvl pnl 2 sq ft or less E0691 UE IN $ Uvl pnl 2 sq ft or less E0692 NU IN $1, Uvl sys panel 4 ft E0692 RR IN $ Uvl sys panel 4 ft E0692 UE IN $ Uv1 sys panel 4 ft E0693 NU IN $1, Uvl sys panel 6 ft E0693 RR IN $ Uvl sys panel 6 ft E0693 UE IN $1, Uvl sys panel 6 ft E0694 NU IN $4, Uvl and cabinet sys 6 ft E0694 RR IN $ Uvl and cabinet sys 6 ft E0694 UE IN $3, Uvl and cabinet sys 6 ft E0705 NU IN $49.59 Transfer device E0705 RR IN $5.01 Transfer device E0705 UE IN $37.21 Transfer device E0720 NU TE $95.00 Tens two lead E0730 NU TE $ Tens four lead E0731 NU IN $ Conductive garment for tens/ E0740 NU IN $ Incontinence treatment systm E0740 RR IN $54.90 Incontinence treatment systm E0740 UE IN $ Incontinence treatment systm E0744 RR CR $96.15 Neuromuscular stim for scoli E0745 NU IN $ Neuromuscular stim for shock E0745 RR CR $20.00 Neuromuscular stim for shock E0747 NU KF IN $3, Elec osteogen stim not spine E0747 RR KF IN $ Elec osteogen stim not spine E0747 UE KF IN $2, Elec osteogen stim not spine E0748 NU KF IN $4, Elec osteogen stim spinal E0748 RR KF IN $ Elec osteogen stim spinal E0748 UE KF IN $3, Elec osteogen stim spinal E0749 RR KF CR $ Elec osteogen stim implanted E0760 NU KF IN $3, Osteogen ultrasound stimltor E0760 RR KF IN $ Osteogen ultrasound stimltor E0760 UE KF IN $2, Osteogen ultrasound stimltor E0762 NU IN $1, Trans elec jt stim dev sys E0762 RR IN $ Trans elec jt stim dev sys E0762 UE IN $ Trans elec jt stim dev sys E0764 NU KF IN $11, Functional neuromuscularstim.e0764 RR KF IN $1, Functional neuromuscularstim E0764 UE KF IN $8, Functional neuromuscularstim E0765 NU IN $88.34 Nerve stimulator for tx n&v E0765 RR IN $8.85 Nerve stimulator for tx n&v E0765 UE IN $66.28 Nerve stimulator for tx n&v E0776 NU IN $ Iv pole E0776 RR IN $19.58 Iv pole E0776 UE IN $94.01 Iv pole E0779 RR CR $17.57 Amb infusion pump mechanical E0780 NU IN $10.89 Mech amb infusion pump <8hrs E0781 RR CR $ External ambulatory infus pu E0782 NU KF IN $4, Non-programble infusion pump E0782 RR KF IN $ Non-programble infusion pump E0782 UE KF IN $3, Non-programble infusion pump E0783 NU KF IN $8, Programmable infusion pump E0783 RR KF IN $ Programmable infusion pump

163 MEDICAL FEE SCHEDULES 11: E0783 UE KF IN $6, Programmable infusion pump E0784 RR CR $ Ext amb infusn pump insulin E0785 KF IN $ Replacement impl pump cachet E0786 NU KF IN $8, Implantable pump replacement E0786 RR KF IN $ Implantable pump replacement E0786 UE KF IN $6, Implantable pump replacement E0791 RR CR $ Parenteral infusion pump sta E0840 NU IN $65.40 Tract frame attach headboard E0840 RR IN $14.57 Tract frame attach headboard E0840 UE IN $49.03 Tract frame attach headboard E0849 NU IN $ Cervical pneum trac equip E0849 RR IN $54.11 Cervical pneurn trac equip E0849 UE IN $ Cervical pneum trac equip E0850 NU IN $93.76 Traction stand free standing E0850 RR IN $12.88 Traction stand free standing E0850 UE IN $70.33 Traction stand free standing E0855 NU IN $ Cervical traction equipment E0855 RR IN $52.77 Cervical traction equipment E0855 UE IN $ Cervical traction equipment E0856 NU IN $ Cervic collar w air bladder E0856 RR IN $16.19 Cervic collar w air bladder E0856 UE IN $ Cervic collar w air bladder E0860 NU IN $35.74 Tract equip cervical tract E0860 RR IN $6.84 Tract equip cervical tract E0860 UE IN $26.81 Tract equip cervical tract E0870 NU IN $ Tract frame attach footboard E0870 RR IN $13.88 Tract frame attach footboard E0870 UE IN $82.74 Tract frame attach footboard E0880 NU IN $ Trac stand free stand extreme E0880 RR IN $20.70 Trac stand free stand extreme E0880 UE IN $84.80 Trac stand free stand extreme E0890 NU IN $ Traction frame attach pelvic E0890 RR IN $34.47 Traction frame attach pelvic E0890 UE IN $86.56 Traction frame attach pelvic E0900 NU IN $ Trac stand free stand pelvic E0900 RR IN $29.00 Trac stand free stand pelvic E0900 UE IN $85.79 Trac stand free stand pelvic E0910 RR CR $17.70 Trapeze bar attached to bed E0911 RR CR $45.11 HD trapeze bar attach to bed E0912 RR CR $ HD trapeze bar free standing E0920 RR CR $41.67 Fracture frame attached to b E0930 RR CR $41.67 Fracture frame free standing E0935 RR FS $23.87 Cont pas motion exercise dev E0940 RR CR $28.67 Trapeze bar free standing E0941 RR CR $40.67 Gravity assisted traction de E0942 NU IN $20.84 Cervical head harness/halter E0942 RR IN $2.46 Cervical head harness/halter E0942 UE IN $15.62 Cervical head harness/halter E0944 NU IN $43.08 Pelvic belt/harness/boot E0944 RR IN $4.83 Pelvic belt/harness/boot E0944 UE IN $32.32 Pelvic belt/haniess/boot E0945 NU IN $46.54 Belt/harness extremity E0945 RR IN $4.66 Belt/harness extremity E0945 UE IN $36.03 Belt/harness extremity E0946 RR CR $62.12 Fracture frame dual w cross E0947 NU IN $ Fracture frame attachmnts pe E0947 RR IN $66.03 Fracture frame attachmnts pe E0947 UE IN $ Fracture frame attachmnts pe E0948 NU IN $ Fracture frame attachmnts cc E0948 RR IN $61.57 Fracture frame attachmnts cc E0948 UE IN $ Fracture frame attachmnts cc E0950 NU IN $94.07 Tray E0950 NU KE IN $ Tray E0950 RR IN $9.42 Tray E0950 RR KE IN $10.93 Tray E0950 UE IN $70.56 Tray E0950 UE KE IN $81.87 Tray E0951 NU IN $17.18 Loop heel

164 11: APPENDIX B - REGULATIONS E0951 NU KE IN $19.93 Loop heel E0951 RR IN $1.72 Loop heel E0951 RR KE IN $2.00 Loop heel E0951 UE IN $12.87 Loop heel E0951 UE KE IN $14.93 Loop heel E0952 NU IN $17.04 Toe loop/holder, each E0952 NU KE IN $19.77 Toe loop/holder, each E0952 RR IN $1.71 Toe loop/holder, each E0952 RR KE IN $1.98 Toe loop/holder, each E0952 UE IN $12.79 Toe loop/holder, each E0952 UE KE IN $14.84 Toe loop/holder, each E0955 NU IN $ Cushioned headrest E0955 NIT KE IN $ Cushioned headrest E0955 RR IN $18.31 Cushioned headrest E0955 RR KE IN $21.24 Cushioned headrest E0955 UE IN $ Cushioned headrest E0955 UE KE IN $ Cushioned headrest E0956 NU IN $89.21 W/c lateral trunk/hip suppor E0956 NU KE IN $ W/c lateral trunk/hip suppor E0956 RR IN $8.93 W/C lateral trunk/hip suppor E0956 RR KE IN $10.36 W/c lateral trunk/hip suppor E0956 UE IN $66.91 W/c lateral trunk/hip suppor E0956 UE KE IN $77.63 W/c lateral trunk/hip suppor E0957 NU IN $ W/c medial thigh support E0957 NU KE IN $ W/c medial thigh support E0957 RR IN $12.48 W/c medial thigh support E0957 RR KE IN $14.48 W/c medial thigh support E0957 UE IN $93.62 W/c medial thigh support E0957 UE KE TN $ W/c medial thigh support E0958 RR CR $44.53 Whlchr att- cony 1 arm drive E0959 NU IN $46.42 Amputee adapter E0959 RR IN $4.67 Amputee adapter E0959 UE IN $35.13 Amputee adapter E0960 NU IN $82.34 W/c shoulder harness/straps E0960 NU KE IN $95.53 W/c shoulder harness/straps E0960 RR IN $8.24 W/c shoulder harness/straps E0960 RR KE IN $9.56 W/c shoulder harness/straps E0960 UE IN $61.76 W/c shoulder harness/straps E0960 UE KE IN $71.65 W/c shoulder harness/straps E0961 NU IN $26.55 Wheelchair brake extension E0961 RR IN $2.77 Wheelchair brake extension E0961 UE IN $13.26 Wheelchair brake extension E0966 NU IN $67.97 Wheelchair head rest extensi E0966 RR IN $6.79 Wheelchair head rest extensi E0966 UE IN $50.98 Wheelchair head rest extensi E0967 NU IN $68.94 Manual we hand rim w project E0967 RR IN $6.89 Manual we hand rim w project E0967 UE IN $51.71 Manual we hand rim w project E0968 RR CR $18.83 Wheelchair commode seat E0969 NU IN $ Wheelchair narrowing device E0969 RR IN $15.36 Wheelchair narrowing device E0969 UE IN $ Wheelchair narrowing device E0971 NU IN $45.56 Wheelchair anti-tipping devi E0971 RR IN $4.56 Wheelchair anti-tipping devi E0971 UE TN $34.19 Wheelchair anti-tipping devi E0973 NU IN $ W/Ch access det adj armrest E0973 NU KE IN $ W/Ch access det adj armrest E0973 RR IN $9.91 W/Ch access det adj armrest E0973 RR KE TN $11.50 W/Ch access det adj armrest E0973 UE IN $78.04 W/Ch access det adj armrest E0973 UE KE IN $90.54 W/Ch access det adj armrest E0974 NU IN $82.33 W/Ch access anti-rollback E0974 RR IN $8.73 W/Ch access anti-rollback E0974 UE IN $62.21 W/Ch access anti-rollback E0978 NU IN $38.64 W/C acc,saf belt pelv strap E0978 NU KE IN $44.84 W/C acc,saf belt pelv strap E0978 RR IN $3.87 W/C acc,saf belt pelv strap E0978 RR KE IN $4.49 W/C acc,saf belt pelv strap

165 MEDICAL FEE SCHEDULES 11: E0978 UE IN $28.65 W/C acc,saf belt pelv strap E0978 UE IN $33.24 W/C acc,saf belt pelv strap E0980 NU IN $34.71 Wheelchair safety vest E0980 RR IN $3.47 Wheelchair safety vest B0980 UE I N $25.89 Wheelchair safety vest E0981 NU IN $42.67 Seat upholstery, replacement E0981 NU KE IN $49.51 Seat upholstery, replacement E0981 RR IN $4.34 Seat upholstery, replacement E0981 RR KE IN $5.04 Seat upholstery, replacement E0981 UE IN $32.31 Seat upholstery, replacement E0981 UE KE IN $37.49 Seat upholstery, replacement E0982 NU IN $46.63 Back upholstery, replacement E0982 NU KE IN $54.11 Back upholstery, replacement E0982 RR IN $4.66 Back upholstery, replacement E0982 RR KE IN $5.41 Back upholstery, replacement B0982 UE IN $34.97 Back upholstery, replacement E0982 UE KE IN $40.57 Back upholstery, replacement E0983 RR CR $ Add pwr joystick E0984 NU IN $1, Add pwr tiller E0984 RR IN $ Add pwr tiller E0984 UE IN $1, Add pwr tiller E0985 NU IN $ W/c seat lift mechanism E0985 RR IN $21.32 W/c seat lift mechanism E0985 UE IN $ W/c seat lift mechanism E0986 NU IN $5, Man w/c push-rim pow assist E0986 RR IN $ Man w/c push-rim pow assist E0986 UE IN $3, Man w/c push-rim pow assist E0990 NU IN $90.33 Wheelchair elevating leg res E0990 NU KE IN $ Wheelchair elevating leg res E0990 RR IN $11.96 Wheelchair elevating leg res E0990 RR KE IN $13.88 Wheelchair elevating leg res E0990 UE IN $70.58 Wheelchair elevating leg res E0990 UE KE IN $81.89 Wheelchair elevating leg res E0992 NU IN $84.92 Wheelchair. solid seat insert E0992 RR IN $8.25 Wheelchair solid seat insert E0992 UE IN $63.70 Wheelchair solid seat insert E0994 NU IN $17.65 Wheelchair arm rest E0994 RR IN $1.76 Wheelchair arm rest E0994 UE IN $13.25 Wheelchair arm rest E0995 NU IN $23.92 Wheelchair calf rest E0995 NU KE IN $27.75 Wheelchair calf rest E0995 RR IN $2.40 Wheelchair calf rest E0995 RR KE IN $2.78 Wheelchair calf rest E0995 UE IN $17.96 Wheelchair calf rest E0995 UE KE IN $20.84 Wheelchair calf rest E1002 NU IN $3, Pwr seat tilt E1002 NU KE IN $4, Pwr seat tilt E1002 RR IN $ Pwr seat tilt E1002 RR KE IN $ Pwr seat tilt E1002 UE IN $2, Pwr seat tilt E1002 UE KE IN $3, Pwr seat tilt E1003 NU IN $3, Pwr seat recline E1003 NU KE IN $4, Pwr seat recline E1003 RR IN $ Pwr seat recline E1003 RR KE IN $ Pwr seat recline E1003 UE IN $2, Pwr seat recline E1003 UE KE IN $3, Pwr seat recline E1004 NU IN $4, Pwr seat recline mech E1004 NU KE IN $5, Pwr seat recline mech E1004 RR IN $ Pwr seat recline mech E1004 RR KE IN $ Pwr seat recline mech E1004 UE IN $3, Pwr seat recline mech E1004 UE KE IN $3, Pwr seat recline mech E1005 NU IN $4, Pwr seat recline pwr E1005 NU KE IN $5, Pwr seat recline pwr E1005 RR IN $ Pwr seat recline pwr E1005 RR KE IN $ Pwr seat recline pwr E1005 UE IN $3, Pwr seat recline pwr

166 11: APPENDIX B - REGULATIONS E1005 UE KE IN $4, Pwr seat recline pwr E1006 NU IN $5, Pwr seat combo w/o shear E1006 NU KE IN $6, Pwr seat combo w/o shear E1006 RR IN $ Pwr seat combo w/o shear E1006 RR KE IN $ Pwr seat combo w/o shear E1006 UE IN $4, Pwr seat combo w/o shear E1006 UE KE IN $5, Pwr seat combo w/o shear B1007 NU IN $7, Pwr seat combo w/shear E1007 NU KE IN $9, Pwr seat combo w/shear E1007 RR IN $ Pwr seat combo w/shear E1007 RR IN $ Pwr seat combo w/shear E1007 UE IN $5, Pwr seat combo w/shear E1007 UE KE IN $6, Pwr seat combo w/shear E1008 NU IN $7, Pwr seat combo pwr shear E1008 NU KE IN $9, Pwr seat combo pwr shear E1008 RR IN $ Pwr seat combo pwr shear E1008 RR KE IN $ Pwr seat combo pwr shear E1008 UE IN $5, Pwr seat combo pwr shear E1008 UE KE IN $6, Pwr seat combo pwr shear E1009 NU IN $0.00 Add mech leg elevation E1009 RR IN $0.00 Add mech leg elevation E1009 UE IN $0.00 Add mech leg elevation E1010 NU IN $1, Add pwr leg elevation E1010 NU KE IN $1, Add pwr leg elevation E1010 RR IN $ Add pwr leg elevation E1010 RR KE IN $ Add pwr leg elevation E1010 UE IN $ Add pwr leg elevation E1010 UE KE IN $ Add pwr leg elevation E1011 NU IN $0.00 Ped wc modify width adjustm E101 l RR IN $0.00 Ped wc modify width adjustm E1011 UE IN $0.00 Ped wc modify width adjust E1014 NU IN $ Reclining back add ped w/c E1014 RR IN $38.35 Reclining back add ped w/c E1014 UE IN $ Reclining back add ped w/c E1015 NU IN $ Shock absorber for man w/c E1015 RR IN $12.03 Shock absorber for man w/c E1015 UE IN $90.32 Shock absorber for man w/c E1016 NU IN $ Shock absorber for power w/c E1016 NU KE IN $ Shock absorber for power w/c E1016 RR IN $11.89 Shock absorber for power w/c E1016 RR KE IN $13.80 Shock absorber for power w/c E1016 UE IN $89.12 Shock absorber for power w/c E1016 UE KE IN $ Shock absorber for power w/c E1017 NU IN $0.00 HD shck absrbr for hd man wc E1017 RR IN $0.00 HD shck absrbr for hd man wc E1017 UE IN $0.00 HD shck absrbr for hd man wc E1018 NU IN $0.00 HD slick absrber for hd powwc E1018 RR IN $0.00 HD shck absrber for hd powwc E1018 UE IN $0.00 HD sgck absrber for hd powwc E1020 NU IN $ Residual limb support system E1020 NU KE IN $ Residual limb support system E1020 RR IN $22.01 Residual limb support system E1020 RR KB IN $25.54 Residual limb support system E1020 UE IN $ Residual limb support system E1020 UE KE IN $ Residual limb support system E1028 NU IN $ W/c manual swingaway E1028 NU KE IN $ W/c manual swingaway E1028 RR IN $18.69 W/c manual swingaway E1028 RR KE IN $21.68 W/c manual swingaway E1028 UE IN $ W/c manual swingaway E1028 UE KE IN $ W/c manual swingaway B1029 NU IN $ W/c vent tray fixed E1029 NU KE IN $ W/c vent tray fixed E1029 RR IN $33.44 W/c vent tray fixed E1029 RR KE IN $38.80 W/c vent tray fixed E1029 UE IN $ W/c vent tray fixed E1029 UE KE IN $ W/c vent tray fixed E1030 NU IN $1, W/c vent tray gimbaled

167 MEDICAL FEE SCHEDULES 11: E1030 NU KE IN $1, W/o vent tray gimbaled E1030 RR IN $ W/c vent tray gimbaled E1030 RR KE IN $ W/c vent tray gimbaled E1030 UE IN $ W/c vent tray gimbaled E1030 UE KE IN $ W/c vent tray gimbaled E1031 RR CR $53.04 Rollabout chair with casters E1035 RR CR $ Patient transfer system <300 E1036 RR CR $ Patient transfer system >300 E1037 RR CR $ Transport chair, ped size E1038 RR CR $18.93 Transport chair pt wt<=3001b E1039 RR CR $35.91 Transport chair pt wt >3001b E1050 RR CR $ Whelchr fxd full length arms E1060 RR CR $ Wheelchair detachable arms E1070 RR CR $ Wheelchair detachable foot r E1083 RR CR $75.78 Hemi-wheelchair fixed arms E1084 RR CR $ Hemi-wheelchair detachable a E1087 RR CR $ Wheelchair lightwt fixed arm E1088 RR CR $ Wheelchair lightweight det a E1092 RR CR $ Wheelchair wide w/ leg rests E1093 RR CR $ Wheelchair wide w/ foot rest E1100 RR CR $ Whchr s-recl fxd arm leg res E1110 RR CR $ Wheelchair semi-reel detach E1150 RR CR $82.07 Wheelchair standard w/ leg r E1160 RR CR $64.53 Wheelchair fixed arms E1161 NU IN $2, Manual adult we w tiltinspac E1161 RR IN $ Manual adult we w tiltinspac E1161 UE IN $1, Manual adult we w tiltinspac E1170 RR CR $90.63 Whlchr ampu fxd arm leg rest E1171 RR CR $72.10 Wheelchair amputee w/o leg r E1172 RR CR $92.72 Wheelchair amputee detach ar E1180 RR CR $99.11 Wheelchair amputee w/ foot r E1190 RR CR $ Wheelchair amputee w/ leg re E1195 RR CR $ Wheelchair amputee heavy dut E1200 RR CR $85.27 Wheelchair amputee fixed arm E1221 RR CR $44.02 Wheelchair spec size w foot E1222 RR CR $71.18 Wheelchair spec size w/ leg E1223 RR CR $77.72 Wheelchair spec size w foot E1224 RR CR $85.21 Wheelchair spec size w/ leg E1225 RR CR $47.46 Manual semi-reclining back E1226 NU IN $ Manual fully reclining back E1226 RR IN $58.97 Manual fully reclining back E1226 UE IN $ Manual fully reclining back E1227 NU IN $ Wheelchair spec sz spec ht a E1227 RR IN $28.67 Wheelchair spec sz spec ht a E1227 UE IN $ Wheelchair spec sz spec ht a E1228 RR CR $25.01 Wheelchair spec sz spec ht b E1230 NU IN $2, Power operated vehicle E1230 RR IN $ Power operated vehicle E1230 UE IN $1, Power operated vehicle E1231 NU IN $0.00 Rigid ped w/c tilt-in-space E1231 RR IN $0.00 Rigid ped w/c tilt-in-space E1231 UE IN $0.00 Rigid ped w/c tilt-in-space E1232 NU IN $2, Folding ped wc tilt-in-space E1232 RR IN $ Folding ped wc tilt-in-space E1232 UE IN $1, Folding ped wc tilt-in-space E1233 NU IN $2, Rig ped wc tltnspc w/o seat E1233 RR IN $ Rig ped wc tltnspc w/o seat E1233 UE IN $1, Rig ped wc tltnspc w/o seat E1234 NU IN $2, Fld ped wc tltnspc w/o seat E1234 RR IN $ Fld ped wc tltnspc w/o seat E1234 UE IN $1, Fld ped wc tltnspc w/o seat E1235 NU IN $1, Rigid ped wc adjustable E1235 RR IN $ Rigid ped wc adjustable E1235 UE IN $1, Rigid ped wc adjustable E1236 NU IN $1, Folding ped wc adjustable E1236 RR IN $ Folding ped wc adjustable E1236 UE IN $1, Folding ped wc adjustable E1237 NU IN $1, Rgd ped wc adjstabl w/o seat

168 11: APPENDIX B - REGULATIONS E1237 RR IN $ Rgd ped wc adjstabl w/o seat E1237 UE IN $1, Rgd ped wc adjstabl w/o seat E1238 NU IN $1, Fld ped wc adjstabl w/o seat E1238 RR IN $ Fld ped wc adjstabl w/o seat E1238 UE IN $1, Fld ped wc adjstabl w/o seat E1240 RR CR $ Whchr litwt det arm leg rest E1270 RR CR $80.68 Wheelchair lightweight leg r E1280 RR CR $ Whchr h-duty det arm leg res E1295 RR CR $ Wheelchair heavy duty fixed E1296 NU IN $ Wheelchair special seat heig E1296 RR IN $44.57 Wheelchair special seat heig E1296 UE IN $ Wheelchair special seat heig E1297 NU IN $93.36 Wheelchair special seat dept E1297 RR IN $10.37 Wheelchair special seat dept E1297 UE IN $70.01 Wheelchair special seat dept E1298 NU IN $ Wheelchair spec seat depth/w E1298 RR IN $40.11 Wheelchair spec seat depth/w E1298 UE IN $ Wheelchair spec seat depth/w E1310 NU IN $2, Whirlpool non-portable E1310 RR IN $ Whirlpool non-portable E1310 UE IN $1, Whirlpool non-portable E1353 OX $29.75 Oxygen supplies regulator E1355 OX $22.40 Oxygen supplies stand/rack E1372 NU IN $ Oxy suppl heater for nebuliz E1372 RR IN $24.87 Oxy suppl heater for nebuliz E1372 UE IN $ Oxy suppl heater for nebuliz E1390 RR OX $ Oxygen concentrator E1391 RR OX $ Oxygen concentrator, dual E1392 RR OX $51.63 Portable oxygen concentrator E1405 RR OX $ O2/water vapor enrich wheat E1406 RR OX $ O2/water vapor enrich w/o he E1700 NU IN $ Jaw motion rehab system E1700 RR IN $30.18 Jaw motion rehab system E1700 UE IN $ Jaw motion rehab system E1701 SU $10.89 Repl cushions for jaw motion E1702 SU $21.85 Repl measr scales jaw motion E1800 RR CR $ Adjust elbow ext/flex device E1801 RR CR $ SPS elbow device E1802 RR CR $ Adjst forearm pro/sup device E1805 RR CR $ Adjust wrist ext/flex device E1806 RR CR $ SPS wrist device E1810 RR CR $ Adjust knee ext/flex device E1811 RR CR $ SPS knee device E1812 RR CR $90.29 Knee ext/flex w act res ctrl E1815 RR CR $ Adjust ankle ext/flex device E1816 RR CR $ SPS ankle device E1818 RR CR $ SPS forearm device E1820 NU IN $85.83 Soft interface material E1820 RR IN $8.58 Soft interface material E1820 UE IN $64.38 Soft interface material E1821 NU IN $ Replacement interface SPSD E1821 RR IN $11.04 Replacement interface SPSD E1821 UE IN $82.90 Replacement interface SPSD E1825 RR CR $ Adjust finger ext/flex devc E1830 RR CR $ Adjust toe ext/flex device E1840 RR CR $ Adj shoulder ext/flex device E1841 RR CR $ Static str shldr dev rom adj E2000 RR CR $51.05 Gastric suction pump hme mdl E2100 NU IN $ Bld glucose monitor w voice E2100 RR IN $66.60 Bld glucose monitor w voice E2100 UE IN $ Bld glucose monitor w voice E2101 NU IN $ Bld glucose monitor w lance E2101 RR IN $19.80 Bld glucose monitor w lance E2101 UE IN $ Bld glucose monitor w lance E2120 RR CR $ Pulse gen sys tx endolymp fl E2201 NU IN $ Man w/ch acc seat w>=20"<24" E2201 RR IN $39.18 Man w/ch ace seat w>=20"<24" E2201 UE IN $ Man w/ch ace seat w>=20"<24"

169 MEDICAL FEE SCHEDULES 11: E2202 NU IN $ Seat width in E2202 RR IN $49.77 Seat width in E2202 UE IN $ Seat width in E2203 NU IN $ F rame depth less than 22 in E2203 RR IN $50.28 Frame depth less than 22 in E2203 UE IN $ Frame depth less than 22 in E2204 NU IN $ Frame depth 22 to 25 in E2204 RR IN $85.42 Frame depth 22 to 25 in E2204 UE IN $ Frame depth 22 to 25 in E2205 NU IN $34.30 Manual we accessory, handrim E2205 RR IN $3.41 Manual we accessory, handrim E2205 UE IN $25.73 Manual we accessory, handrim E2206 NU IN $42.71 Complete wheel lock assembly E2206 RR IN $4.26 Complete wheel lock assembly E2206 UE IN $32.03 Complete wheel lock assembly E2207 NU IN $45.52 Crutch and cane holder E2207 RR IN $4.56 Crutch and cane holder E2207 UE IN $34.14 Crutch and cane holder E2208 NU IN $ Cylinder tank carrier E2208 NU KE IN $ Cylinder tank carrier E2208 RR IN $10.74 Cylinder tank carrier E2208 RR KE IN $12.46 Cylinder tank carrier E2208 UE IN $80.63 Cylinder tank carrier E2208 UE KE IN $93.54 Cylinder tank carrier E2209 NU IN $96.98 Arm trough each E2209 NU KE IN $ Arm trough each E2209 RR IN $9.72 Arm trough each E2209 RR KE IN $11.28 Arm trough each E2209 UE IN $72.74 Arm trough each E2209 UE KE IN $84.40 Arm trough each E2210 NU IN $5.93 Wheelchair bearings E2210 NU KE IN $6.88 Wheelchair bearings E2210 RR IN $0.51 Wheelchair bearings E2210 RR KE IN $0.59 Wheelchair bearings E2210 UE IN $4.45 Wheelchair bearings E2210 UE KE IN $5.17 Wheelchair bearings E2211 NU IN $42.96 Pneumatic propulsion tire E2211 RR IN $4.21 Pneumatic propulsion tire E2211 UE IN $30.77 Pneumatic propulsion tire E2212 NU IN $6.17 Pneumatic prop tire tube E2212 RR IN $0.64 Pneumatic prop tire tube E2212 UE IN $4.64 Pneumatic prop tire tube E2213 NU IN $31.92 Pneumatic prop tire insert E2213 RR IN $3.20 Pneumatic prop tire insert E2213 UE IN $23.92 Pneumatic prop tire insert E2214 NU IN $37.80 Pneumatic caster tire each E2214 RR IN $4.16 Pneumatic caster tire each E2214 UE IN $28.34 Pneumatic caster tire each E2215 NU IN $10.08 Pneumatic caster tire tube E2215 RR IN $1.00 Pneumatic caster tire tube E2215 UE IN $7.54 Pneumatic caster tire tube E2216 NU IN $0.00 Foam filled propulsion tire E2216 RR IN $0.00 Foam filled propulsion tire E2216 UE IN $0.00 Foam filled propulsion tire E2217 NU IN $0.00 Foam filled caster tire each E2217 RR IN $0.00 Foam filled caster tire each E2217 UE IN $0.00 Foam filled caster tire each E2218 NU IN $0.00 Foam propulsion tire each E2218 RR IN $0.00 Foam propulsion tire each E2218 UE IN $0.00 Foam propulsion tire each E2219 NU IN $43.94 Foam caster tire any size ea E2219 RR IN $4.96 Foam caster tire any size ea E2219 UE IN $32.96 Foam caster tire any size ea E2220 NU IN $29.95 Solid propulsion tire each E2220 RR IN $2.89 Solid propulsion tire each E2220 UE IN $22.80 Solid propulsion tire each E2221 NU IN $26.83 Solid caster tire each E2221 RR IN $2.71 Solid caster tire each

170 11: APPENDIX B - REGULATIONS E2221 UE IN $20.14 Solid caster tire each E2222 NU IN $22.11 Solid caster integrated whl E2222 RR IN $2.19 Solid caster integrated whl E2222 UE IN $16.60 Solid caster integrated whl E2224 NU IN $ Propulsion whl excludes tire E2224 RR IN $10.80 Propulsion whl excludes tire E2224 UE IN $77.23 Propulsion whl excludes tire E2225 NU IN $18.27 Caster wheel excludes tire E2225 RR IN $1.83 Caster wheel excludes tire E2225 UE IN $13.69 Caster wheel excludes tire E2226 NU IN $39.84 Caster fork replacement only E2226 RR IN $3.98 Caster fork replacement only E2226 UE IN $29.88 Caster fork replacement only E2227 NU IN $1, Gear reduction drive wheel E2227 RR IN $ Gear reduction drive wheel E2227 UE IN $1, Gear reduction drive wheel E2228 NU IN $ Mwc acc, wheelchair brake E2228 RR IN $98.30 Mwc acc, wheelchair brake E2228 UE IN $ Mwc acc, wheelchair brake E2231 NU IN $ Solid seat support base E2231 RR IN $16.14 Solid seat support base E2231 UE IN $ Solid seat support base E2310 NU IN $1, Electro connect btvv control E2310 NU KE IN $1, Electro connect btw control E2310 RR IN $ Electro connect btw control E2310 RR KE IN $ Electro connect btw control E2310 UE IN $ Electro connect btw control E2310 UE KE IN $ Electro connect btw control E2311 NU IN $2, Electro connect btw 2 sys E2311 NU KE IN $2, Electro connect btw 2 sys E2311 RR IN $ Electro connect btw 2 sys E2311 RR KE IN $ Electro connect btw 2 sys E2311 UE IN $1, Electro connect btw 2 sys E2311 UE KE IN $1, Electro connect btw 2 sys E2312 NU IN $2, Mini-prop remote joystick E2312 NU KC IN $2, Mini-prop remote joystick E2312 RR IN $ Mini-prop remote joystick E2312 RR KC IN $ Mini-prop remote joystick E2312 UE IN $1, Mini-prop remote joystick E2312 UE KC IN $1, Mini-prop remote joystick E2313 NU IN $ PWC harness, expand control E2313 RR IN $32.35 PWC harness, expand control E23 13 UE IN $ PWC harness, expand control E2321 NU IN $1, Hand interface joystick E2321 NU KC IN $2, Hand interface joystick E2321 NU KE IN $1, Hand interface joystick E2321 RR IN $ Hand interface joystick E2321 RR KC IN $ Hand interface joystick E2321 RR KE IN $ Hand interface joystick E2321 UE IN $1, Hand interface joystick E2321 UE KC IN $1, Hand interface joystick E2321 UE KE IN $1, Hand interface joystick E2322 NU IN $1, Mult mech switches E2322 NU KC IN $2, Mult mech switches E2322 NU KE IN $1, Mult mech switches E2322 RR IN $ Mult mech switches E2322 RR KC IN $ Mult mech switches E2322 RR KE IN $ Mult mech switches B2322 UE IN $ Mult mech switches E2322 UE KC IN $1, Mult mech switches E2322 UE KE IN $1, Mult mech switches E2323 NU IN $62.59 Special joystick handle E2323 NU KE IN $72.62 Special joystick handle E2323 RR IN $6.26 Special joystick handle E2323 RR KE IN $7.27 Special joystick handle E2323 UE IN $46.94 Special joystick handle E2323 UE KE IN $54.46 Special joystick handle E2324 NU IN $39.66 Chin cup interface

171 MEDICAL FEE SCHEDULES 11: E2324 NU KE IN $46.01 Chin cup interface E2324 RR IN $3.95 Chin cup interface E2324 RR KE IN $4.59 Chin cup interface E2324 UE IN $29.75 Chin cup interface E2324 UE KE IN $34.51 Chin cup interface E2325 NU IN $1, Sip and puff interface E2325 NU KE IN $1, Sip and puff interface E2325 RR IN $ Sip and puff interface E2325 RR KE IN $ Sip and puff interface E2325 UE IN $ Sip and puff interface E2325 UE KE IN $1, Sip and puff interface E2326 NU IN $ Breath tube kit E2326 NU KE IN $ Breath tube kit E2326 RR IN $31.43 Breath tube kit E2326 RR KE IN $36.47 Breath tube kit E2326 UE IN $ Breath tube kit E2326 UE KE IN $ Breath tube kit E2327 NU IN $2, Head control interface mech E2327 NU KC IN $3, Head control interface mech E2327 NU KE IN $2, Head control interface mech E2327 RR IN $ Head control interface mech E2327 RR KC IN $ Head control interface mech E2327 RR KE IN $ Head control interface mech E2327 UE IN $1, Head control interface mech E2327 UE KC IN $2, Head control interface mech E2327 UE KE IN $2, Head control interface mech E2328 NU IN $4, Head/extremity control inter E2328 NU KE IN $5, Head/extremity control inter E2328 RR IN $ Head/extremity control inter E2328 RR KE IN $ Head/extremity control inter E2328 UE IN $3, Head/extremity control inter E2328 UE KE IN $3, Head/extremity control inter E2329 NU IN $1, Head control nonproportional E2329 NU KE IN $1, Head control nonproportional E2329 RR IN $ Head control nonproportional E2329 RR KE IN $ Head control nonproportional E2329 UE IN $1, Head control nonproportional E2329 UE KE IN $1, Head control nonproportional E2330 NU IN $3, Head control proximity switc E2330 NU KE IN $3, Head control proximity switc E2330 RR IN $ Head control proximity switc E2330 RR KE IN $ Head control proximity switc E2330 UE IN $2, Head control proximity switc E2330 UE KE IN $2, Head control proximity switc E2340 NU IN $ W/c wdth in seat frame E2340 RR IN $37.64 W/c wdth in seat frame E2340 UE IN $ W/c wdth in seat frame E2341 NU IN $ W/o wdth in seat frame E2341 RR IN $56.45 W/c wdth in seat frame E2341 UE IN $ W/c wdth in seat frame E2342 NU IN $ W/c dpth in seat frame E2342 RR IN $47.04 W/c dpth in seat frame E2342 UE IN $ W/c dpth in seat frame E2343 NU IN $ W/c dpth in seat frame E2343 RR IN $75.25 W/c dpth in seat frame E2343 UE IN $ W/c dpth in seat frame E2351 NU IN $ Electronic SGD interface E2351 NU KE IN $ Electronic SGD interface E2351 RR IN $63.24 Electronic SGD interface E2351 RR KE IN $73.37 Electronic SGD interface E2351 UE IN $ Electronic SGD interface E2351 UE KE IN $ Electronic SGD interface E2360 NU IN $ nf nonsealed leadacid E2360 RR IN $ nf nonsealed leadacid E2360 UE IN $ nf nonsealed leadacid E2361 NU IN $ nf sealed leadacid battery E2361 NU KE IN $ nf sealed leadacid battery E2361 RR IN $ nf sealed leadacid battery

172 11: APPENDIX B - REGULATIONS E2361 RR KE IN $ nf sealed leadacid battery E2361 UE IN $ nf sealed leadacid battery E2361 UE KE IN $ nf sealed leadacid battery E2362 NU IN $96.58 Gr24 nonsealed leadacid E2362 RR IN $9.66 Gr24 nonsealed leadacid E2362 UE IN $72.43 Gr24 nonsealed leadacid E2363 NU IN $ Gr24 sealed leadacid battery E2363 NU KE IN $ Gr24 sealed leadacid battery E2363 RR IN $16.84 Gr24 sealed leadacid battery E2363 RR KE IN $19.54 Gr24 sealed leadacid battery E2363 UE IN $ Gr24 sealed leadacid battery E2363 UE KE IN $ Gr24 sealed leadacid battery E2364 NU IN $ Ulnonsealed leadacid battery E2364 RR IN $11.85 U1 nonsealed leadacid battery E2364 UE IN $88.47 U1 nonsealed leadacid battery E2365 NU IN $ U1 sealed leadacid battery E2365 NU KE IN $ U 1 sealed leadacid battery E2365 RR IN $10.15 U1 sealed leadacid battery E2365 RR KE IN $11.78 Ul sealed leadacid battery E2365 UE IN $76.16 U1 sealed leadacid battery E2365 UE KE IN $88.36 U1 sealed leadacid battery E2366 NU IN $ Battery charger, single mode E2366 NU KE IN $ Battery charger, single mode E2366 RR IN $23.92 Battery charger, single mode E2366 RR KE IN $27.75 Battery charger, single mode E2366 UE IN $ Battery charger, single mode E2366 UE KE IN $ Battery charger, single mode E2367 NU IN $ Battery charger, dual mode E2367 NU KE IN $ Battery charger, dual mode E2367 RR IN $37.93 Battery charger, dual mode E2367 RR KE IN $44.01 Battery charger, dual mode E2367 UE IN $$ Battery charger, dual mode E2367 UE KE IN $ Battery charger, dual mode E2368 NU IN $ Power we motor replacement E2368 NU KE IN $ Power we motor replacement E2368 RR IN $46.76 Power we motor replacement E2368 RR KE IN $54.25 Power we motor replacement E2368 UE IN $ Power we motor replacement E2368 UE KE IN $ Power we motor replacement E2369 NU IN $ Pwr we gear box replacement E2369 NU KE IN $ Pwr we gear box replacement E2369 RR IN $40.73 Pwr we gear box replacement E2369 RR KE IN $47.25 Pwr we gear box replacement E2369 UE IN $ Pwr we gear box replacement E2369 UE KE IN $ Pwr we gear box replacement E2370 NU IN $ Pwr we motor/gear box combo E2370 NU KE IN $ Pwr we motor/gear box combo E2370 RR IN $72.66 Pwr we motor/gear box combo E2370 RR KE IN $84.30 Pwr we motor/gear box combo E2370 UE IN $ Pwr we motor/gear box combo E2370 UE KE IN $ Pwr we motor/gear box combo E2371 NU IN $ Gr27 sealed leadacid battery E2371 NU KE IN $ Gr27 sealed leadacid battery E2371 RR IN $13.65 Gr27 sealed leadacid battery E2371 RR KE IN $15.83 Gr27 sealed leadacid battery E2371 UE IN $ Gr27 sealed leadacid battery E2371 UE KE IN $ Gr27 sealed leadacid battery E2372 NU IN $0.00 Gr27 non-sealed leadacid E2372 RR IN $0.00 Gr27 non-sealed leadacid E2372 UE IN $0.00 Gr27 non-sealed leadacid E2373 NU IN $ Hand/chin ctrl spec joystick E2373 NU KC IN $1, Hand/chin ctrl spec joystick E2373 NU KE IN $ Hand/chin ctrl spec joystick E2373 RR IN $70.99 Hand/chin ctrl spec joystick E2373 RR KC IN $ Hand/chin ctrl spec joystick E2373 RR KE IN $70.99 Hand/chin ctrl spec joystick E2373 UE IN $ Hand/chin ctrl spec joystick E2373 UE KC IN $ Hand/chin ctrl spec joystick

173 MEDICAL FEE SCHEDULES 11: E2373 UE KE IN $ Hand/chin ctrl spec joystick E2374 NU IN $ Hand/chin ctrl std j oystick E2374 NU KE IN $ Hand/chin ctrl std joystick E2374 RR IN $48.33 Hand/chin ctrl std joystick E2374 RR KE IN $56.07 Hand/chin ctrl std joystick E2374 UE IN $ Hand/chin ctrl std joystick E2374 UE KE IN $ Hand/chin ctrl std joystick E2375 NU IN $ Non-expandable controller E2375 NU KE IN $ Non-expandable controller E2375 RR IN $77.51 Non-expandable controller E2375 RR KE IN $89.93 Non-expandable controller E2375 UE IN $ Non-expandable controller E2375 UE KE IN $ Non-expandable controller E2376 NU IN $1, Expandable controller, repl E2376 NU KE IN $1, Expandable controller, repl E2376 RR IN $ Expandable controller, repl E2376 RR KE IN $ Expandable controller, repl E2376 UE IN $ Expandable controller, repl E2376 UE KE IN $1, Expandable controller, repl E2377 NU IN $ Expandable controller, initl E2377 NU KE IN $ Expandable controller, initl E2377 RR IN $43.95 Expandable controller, initl E2377 RR KE IN $50.99 Expandable controller, initl E2377 UE IN $ Expandable controller, initl E2377 UE KE IN $ Expandable controller, initl E2381 NU IN $68.94 Pneum drive wheel tire E2381 NU KE IN $79.99 Pneum drive wheel tire E2381 RR IN $6.91 Pneurn drive wheel tire E2381 RR KE IN $8.01 Pneum drive wheel tire E2381 UE IN $51.71 Pneum drive wheel tire E2381 UE KE IN $60.00 Pneuin drive wheel tire E2382 NU IN $18.80 Tube, pneurn wheel drive tire E2382 NU KE IN $21.81 Tube, pneum wheel drive tire E2382 RR IN $1.87 Tube, pneum wheel drive tire E2382 RR KE IN $2.17 Tube, pneum wheel drive tire E2382 UE IN $14.09 Tube, pneum wheel drive tire E2382 UE KE IN $16.35 Tube, pneum wheel drive tire E2383 NU IN $ Insert, pneum wheel drive E2383 NU KE IN $ Insert, pneum wheel drive E2383 RR IN $13.75 I nsert, pneum wheel drive E2383 RR KE IN $15.95 Insert, pneum wheel drive E2383 UE IN $ Insert, pneum wheel drive E2383 UE KE IN $ Insert, pneum wheel drive E2384 NU IN $73.22 Pneumatic caster tire E2384 NU KE IN $84.96 Pneumatic caster tire E2384 RR IN $7.34 Pneumatic caster tire E2384 RR KE IN $8.52 Pneumatic caster tire E2384 UE IN $54.92 Pneumatic caster tire E2384 UE KE IN $63.71 Pneumatic caster tire E2385 NU IN $44.80 Tube, pneumatic caster tire E2385 NU KE IN $51.98 Tube, pneumatic caster tire E2385 RR IN $4.49 Tube, pneumatic caster tire E2385 RR KE IN $5.21 Tube, pneumatic caster tire E2385 UE IN $33.58 Tube, pneumatic caster tire E2385 UE KE IN $38.97 Tube, pneumatic caster tire E2386 NU IN $ Foam filled drive wheel tire E2386 NU KE IN $ Foam filled drive wheel tire E2386 RR IN $13.62 Foam filled drive wheel tire E2386 RR KE IN $15.80 Foam filled drive wheel tire E2386 UE IN $ Foam filled drive wheel tire E2386 UE KE IN $ Foam filled drive wheel tire E2387 NU IN $61.08 Foam filled caster tire E2387 NU KE IN $70.86 Foam filled caster tire E2387 RR IN $6.11 Foam filled caster tire E2387 RR KE IN $7.09 Foam filled caster tire E2387 UE IN $45.84 Foam filled caster tire E2387 UE KE IN $53.18 Foam filled caster tire E2388 NU IN $45.60 Foam drive wheel tire

174 11: APPENDIX B - REGULATIONS E2388 NU KE IN $52.91 Foam drive wheel tire E2388 RR IN $4.56 Foam drive wheel tire E2388 RR KE IN $5.29 Foam drive wheel tire E2388 UE IN $34.21 Foam drive wheel tire E2388 UE KE IN $39.69 Foam drive wheel tire E2389 NU IN $24.76 Foam caster tire E2389 NU KE IN $28.73 Foam caster tire E2389 RR IN $2.48 Foam caster tire E2389 RR KE IN $2.88 Foam caster tire E2389 UE IN $18.56 Foam caster tire E2389 UE KE IN $21.54 Foam caster tire E2390 NU IN $38.72 Solid drive wheel tire E2390 NU KE IN $44.93 Solid drive wheel tire E2390 RR IN $3.87 Solid drive wheel tire E2390 RR KE IN $4.49 Solid drive wheel tire E2390 UE IN $29.02 Solid drive wheel tire E2390 UE KE IN $33.67 Solid drive wheel tire E2391 NU IN $18.55 Solid caster tire E2391 NU KE IN $21.53 Solid caster tire E2391 RR IN $1.86 Solid caster tire E2391 RR KE IN $2.15 Solid caster tire E2391 UE IN $13.92 Solid caster tire E2391 UE KE IN $16.15 Solid caster tire E2392 NU IN $48.76 Solid caster tire, integrate E2392 NU KE IN $56.57 Solid caster tire, integrate E2392 RR IN $4.89 Solid caster tire, integrate E2392 RR KE IN $5.67 Solid caster tire, integrate E2392 UE IN $36.57 Solid caster tire, integrate E2392 UE KE IN $42.43 Solid caster tire, integrate E2394 NU IN $69.46 Drive wheel excludes tire E2394 NU KE IN $80.59 Drive wheel excludes tire E2394 RR IN $6.96 Drive wheel excludes tire E2394 RR KE IN $8.07 Drive wheel excludes tire E2394 UE IN $52.10 Drive wheel excludes tire E2394 UE KE IN $60.45 Drive wheel excludes tire E2395 NU IN $49.37 Caster wheel excludes tire E2395 NU KE IN $57.28 Caster wheel excludes tire E2395 RR IN $4.94 Caster wheel excludes tire E2395 RR KE IN $5,73 Caster wheel excludes tire E2395 UE IN $37.04 Caster wheel excludes tire E2395 UE KE IN $42.98 Caster wheel excludes tire E2396 NU IN $60.19 Caster fork E2396 NU KE IN $69.84 Caster fork E2396 RR IN $6.45 Caster fork E2396 RR KE IN $7.49 Caster fork E2396 UE IN $45.15 Caster fork E2396 UE KE IN $52.38 Caster fork E2397 NU IN $ Pwc ace, lith-based battery E2397 RR IN $43.48 Pwc ace, lith-based battery E2397 UE IN $ Pwc ace, lith-based battery E2402 RR CR $1, Neg press wound therapy pump E2500 NU IN $ SGD digitized pre-rec <=8min E2500 RR IN $41.07 SGD digitized pre-rec <=8min E2500 UE IN $ SGD digitized pre-rec <=8min E2502 NU IN $1, SGD prerec msg >8min <=20min E2502 RR IN $ SGD prerec msg >8min <=20min E2502 UE IN $ SGD prerec msg >8min <=20min E2504 NU IN $1, SGD prerec msg>20min <=40min E2504 RR IN $ SGD prerec msg>20min <=40min E2504 UE IN $1, SGD prerec msg>20min <=40min E2506 NU IN $2, SGD prerec msg > 40 min E2506 RR IN $ SGD prerec msg > 40 min E2506 UE IN $1, SGD prerec msg > 40 min B2508 NU IN $3, SGD spelling phys contact E2508 RR IN $ SGD spelling phys contact E2508 UE IN $2, SGD spelling phys contact E2510 NU IN $7, SGD w multi methods msg/accs E2510 RR IN $ SGD w multi methods msg/accs

175 MEDICAL FEE SCHEDULES 11: E2510 UE IN $5, OD w multi methods msg/accs E2511 NU IN $0.00 SGD sftwre prgrm for PC/PDA E2511 RR IN $0.00 SGD sftwre prgrm for PC/PDA E2511 UE IN $0.00 SGD sftwre prgrm for PC/PDA E2512 NU IN $0.00 SGD accessory, mounting sys E2512 RR IN $0.00 SGD accessory, mounting sys E2512 UE IN $0.00 SGD accessory, mounting sys E2601 NU IN $55,35 Gen w/c cushion wdth < 22 in E2601 NU KE IN $64.22 Gen w/c cushion wdth < 22 in E2601 RR IN $5.55 Gen w/c cushion wdth < 22 in E2601 RR KE IN $6.44 Gen w/c cushion wdth < 22 in E2601 UE IN $41.51 Gen w/c cushion wdth < 22 in E2601 TIE KE IN $48.16 Gen w/c cushion wdth < 22 in E2602 NU IN $ Gen w/c cushion wdth >=22 in E2602 NU KE IN $ Gen w/c cushion wdth >=22 in E2602 RR IN $10.81 Gen w/c cushion wdth >=22 in E2602 RR KE IN $12.54 Gen w/c cushion wdth >=22 in E2602 UE IN $81.04 Gen w/c cushion wdth >=22 in E2602 UE KE IN $94.03 Gen w/c cushion wdth >=22 in E2603 NU IN $ Skin protect we cus wd <22in E2603 NU KE IN $ Skin protect we cus wd <22in E2603 RR IN $13.73 Skin protect wc cus wd <22in E2603 RR KE IN $15.93 Skin protect wc cus wd <22in E2603 UE IN $ Skin protect wc cus wd <22in E2603 UE KE IN $ Skin protect wc cus wd <22in E2604 NU IN $ Skin protect wc cus wd>=22in E2604 NU KE IN $ Skin protect wc cus wd>=22in E2604 RR IN $17.04 Skin protect wc cus wd>=22in E2604 RR KE IN $19.77 Skin protect wc cus wd>=22in E2604 UE IN $ Skin protect wc cus wd>=22in E2604 UE KE IN $ Skin protect wc cus wd>=22in E2605 NU IN $ Position wc cush wdth <22 in E2605 NU KE IN $ Position wc cush wdth <22 in E2605 RR IN $24.37 Position wc cush wdth <22 in E2605 RR KE IN $28.28 Position wc cush wdth <22 in E2605 UE IN $ Position wc cush wdth <22 in E2605 UE KE IN $ Position wc cush wdth <22 in E2606 NU IN $ Position wc cush wdth>=22 in E2606 NU KE IN $ Position wc cush wdth>=22 in E2606 RR IN $38.02 Position wc cush wdth>=22 in E2606 RR KE IN $44.11 Position wc cush wdth>=22 in E2606 UE IN $ Position wc cush wdth>=22 in E2606 UE KE IN $ Position wc cush wdth>=22 in E2607 NU IN $ Skin pro/pos wc cus wd <22in E2607 NU KE IN $ Skin pro/pos wc cus wd <22in E2607 RR IN $26.24 Skin pro/pos wc cus wd <22in E2607 RR KE IN $30.44 Skin pro/pos wc cus wd <22in E2607 UE IN $ Skin pro/pos wc cus wd <22in E2607 UE KE IN $ Skin pro/pos wc cus wd <22in E2608 NU IN $ Skin pro/pos wc cus wd>=22in E2608 NU KE IN $ Skin pro/pos wc cus wd>=22in E2608 RR IN $31.49 Skin pro/pos wc cus wd>=22in E2608 RR KE IN $36.54 Skin pro/pos wc cus wd>=22in E2608 UE IN $ Skin pro/pos wc cus wd>=22in E2608 UE KE IN $ Skin pro/pos wc cus wd>=22in E2611 NU IN $ Gen use back cush wdth <22in E2611 NU KE IN $ Gen use back cush wdth <22in E2611 RR IN $28.26 Gen use back cush wdth <22in E2611 RR KE IN $32.79 Gen use back cush wdth <22in E2611 UE IN $ Gen use back cush wdth <22in E2611 UE KE IN $ Gen use back cush wdth <22in E2612 NU IN $ Gen use back cush wdth>=22in E2612 NU KE IN $ Gen use back cush wdth>=22in E2612 RR IN $38.24 Gen use back cush wdth>=22in E2612 RR KE IN $44.36 Gen use back cush wdth>=22in E2612 UE IN $ Gen use back cush wdth>=22in E2612 UE KE IN $ Gen use back cush wdth>=22in E2613 NU IN $ Position back cush wd <22in

176 11: APPENDIX B - REGULATIONS E2613 NU KE IN $ Position back cush wd <22in E2613 RR IN $35.58 Position back cush wd <22in E2613 RR KE IN $41.28 Position back cush wd <22in E2613 UE IN $ Position back cush wd <22in E2613 UE KE IN $ Position back cush wd <22in E2614 NU IN $ Position back cush wd>=22in E2614 NU KE IN $ Position back cush wd>=22in E2614 RR IN $49.23 Position back cush wd>=22in E2614 RR KE IN $57.12 Position back cush wd>=22in E2614 UE IN $ Position back cush wd>=22in E2614 UE KE IN $ Position back cush wd>=22in E2615 NU IN $ Pos back post/lat wdth <22in E2615 NU KE IN $ Pos back post/lat wdth <22in E2615 RR IN $40.94 Pos back post/lat wdth <22in E2615 RR KE IN $47.50 Pos back post/lat wdth <22in E2615 UE IN $ Pos back post/lat wdth <22in E2615 UE KE IN $ Pos back post/lat wdth <22in E2616 NU IN $ Pos back post/lat wdth>=22in E2616 NU KE IN $ Pos back post/lat wdth>=22in E2616 RR IN $55.08 Pos back post/lat wdth>=22in E2616 RR KE IN $63.90 Pos back post/lat wdth>=22in E2616 UE IN $ Pos back post/lat wdth>=22in E2616 UE KE IN $ Pos back post/lat wdth>=22in E2619 NU IN $46.44 Replace cover w/c seat cush E2619 NU KE IN $53.89 Replace cover w/c seat cush E2619 RR IN $4.64 Replace cover w/c seat cush E2619 RR KE IN $5.39 Replace cover w/c seat cush E2619 UE IN $34.85 Replace cover w/c seat cush E2619 UE KE IN $40.44 Replace cover w/c seat cush E2620 NU IN $ WC planar back cush wd <22in E2620 NU KE IN $ WC planar back cush wd <22in E2620 RR IN $49.57 WC planar back cush wd <22in E2620 RR KE IN $57.51 WC planar back cush wd <22in E2620 UE IN $ WC planar back cush wd <22in E2620 UE KE IN $ WC planar back cush wd <22in E2621 NU IN $ WC planar back cush wd>=22in E2621 NU KE IN $ WC planar back cush wd>=22in E2621 RR IN $52.01 WC planar back cush wd>=22in E2621 RR KE IN $60.34 WC planar back cush wd>=22in E2621 UE IN $ WC planar back cush wd>=22in E2621 UE KE IN $ WC planar back cush wd>=22in K0001 RR CR $55.10 Standard wheelchair K0002 RR CR $85.92 Stnd hemi (low seat) whlchr K0003 RR CR $94.07 Lightweight wheelchair K0004 RR CR $ High strength ltwt whlchr K0005 NU IN $1, Ultralightweight wheelchair K0005 RR IN $ Ultralightweight wheelchair K0005 UE IN $1, Ultralightweight wheelchair K0006 RR CR $ Heavy duty wheelchair K0007 RR CR $ Extra heavy duty wheelchair K0010 RR CR $ Stnd wt frame power whlchr K0011 RR CR $ Stnd wt pwr whlchr w control K0011 RR KF CR $ Stnd wt pwr whlchr w control K0012 RR CR $ Ltwt portbl power whlchr K0015 NU IN $ Detach non-adjus hght armrst K0015 NU KE IN $ Detach non-adjus hght armrst K0015 RR IN $16.45 Detach non-adjus hght armrst K0015 RR KE IN $19.09 Detach non-adjus hght armrst K0015 UE IN $ Detach non-adjus hght armrst K0015 UE KE IN $ Detach non-adjus hght armrest K0017 NU IN $46.25 Detach adjust armrest base K0017 NU KE IN $53.67 Detach adjust armrest base K0017 RR IN $4.62 Detach adjust armrest base K0017 RR KE IN $5.37 Detach adjust armrest base K0017 UE IN $34.69 Detach adjust armrest base K0017 UE KE IN $40.25 Detach adjust armrest base K0018 NU IN $25.84 Detach adjust armrst upper K0018 NU KE IN $29.98 Detach adjust armrst upper

177 MEDICAL FEE SCHEDULES 11: K0018 RR IN $2.57 Detach adjust armrst upper K0018 RR KE IN $2.98 Detach adjust armrst upper K0018 UE IN $19.39 Detach adjust armrst upper K0018 UE KE IN $22.50 Detach adjust armrst upper K0019 NU IN $14.80 Arm pad each K0019 NU KE IN $17.17 Arm pad each K0019 RR IN $1.48 Arm pad each K0019 RR KE IN $1.72 Arm pad each K0019 UE IN $11.09 Arm pad each K0019 UE KE IN $12.86 Arm pad each K0020 NU IN $42.05 Fixed adjust armrest pair K0020 NU KE IN $48.78 Fixed adjust armrest pair K0020 RR IN $4.21 Fixed adjust armrest pair K0020 RR KE IN $4.88 Fixed adjust armrest pair K0020 UE IN $31.52 Fixed adjust armrest pair K0020 UE KE IN $36.57 Fixed adjust armrest pair K0037 NU IN $43.58 High mount flip-up footrest K0037 NU KE IN $50.57 High mount flip-up footrest K0037 RR IN $3.89 High mount flip-up footrest K0037 RR KE IN $4.52 High mount flip-up footrest K0037 UE IN $32.70 High mount flip-up footrest K0037 UE KE IN $37.94 High mount flip-up footrest K0038 NU IN $21.96 Leg strap each K0038 NU KE IN $25.47 Leg strap each K0038 RR IN $2.20 Leg strap each K0038 RR KE IN $2.55 Leg strap each K0038 UE IN $16.47 Leg strap each K0038 UE KE IN $19.11 Leg strap each K0039 NU IN $48.76 Leg strap h style each K0039 NU KE IN $56.57 Leg strap h style each K0039 RR IN $4.89 Leg strap h style each K0039 RR KE IN $5.67 Leg strap h style each K0039 UE IN $36.57 Leg strap h style each K0039 UE KE IN $42.43 Leg strap h style each K0040 NU IN $67.58 Adjustable angle footplate K0040 NU KE IN $78.40 Adjustable angle footplate K0040 RR IN $6.74 Adjustable angle footplate K0040 RR KE IN $7.82 Adjustable angle footplate K0040 UE IN $50.67 Adjustable angle footplate K0040 UE KE IN $58.79 Adjustable angle footplate K0041 NU IN $47.89 Large size footplate each K0041 NU KE IN $55.57 Large size footplate each K0041 RR IN $4.81 Large size footplate each K0041 RR KE IN $5.58 Large size footplate each K0041 UE IN $35.92 Large size footplate each K0041 UE KE IN $41.67 Large size footplate each K0042 NU IN $32.97 Standard size footplate each K0042 NU KE IN $38.25 Standard size footplate each K0042 RR IN $3.29 Standard size footplate each K0042 RR KE IN $3.81 Standard size footplate each K0042 UE IN $24.72 Standard size footplate each K0042 UE KE IN $28.69 Standard size footplate each K0043 NU IN $17.67 Ftrst lower extension tube K0043 NU KE IN $20.51 Ftrst lower extension tube K0043 RR IN $1.76 Ftrst lower extension tube K0043 RR KE IN $2.05 Ftrst lower extension tube K0043 UE IN $13.27 Ftrst lower extension tube K0043 UE KE IN $15.39 Ftrst lower extension tube K0044 NU IN $15.06 Ftrst upper hanger bracket K0044 NU KE IN $17.47 Ftrst upper hanger bracket K0044 RR IN $1.51 Ftrst upper hanger bracket K0044 RR KE IN $1.75 Ftrst upper hanger bracket K0044 UE IN $11.29 Ftrst upper hanger bracket K0044 UE KE IN $13.10 Ftrst upper hanger bracket K0045 NU IN $51.24 Footrest complete assembly K0045 NU KE IN $59.45 Footrest complete assembly K0045 RR IN $5.13 Footrest complete assembly K0045 RR KE IN $5.95 Footrest complete assembly

178 11: APPENDIX B - REGULATIONS K0045 UE IN $38.44 Footrest complete assembly K0045 UE KE IN $44.59 Footrest complete assembly K0046 NU IN $17.67 Elevat legrst low extension K0046 NU KE IN $20.51 Elevat legrst low extension K0046 RR IN $1.76 Elevat legrst low extension K0046 RR KE IN $2.05 Elevat legrst low extension K0046 UE IN $13.27 Elevat legrst low extension K0046 UE KE IN $15.39 Elevat legrst low extension K0047 NU IN $69.21 Elevat legrst up hangr brack K0047 NU KE IN $80.30 Elevat legrst up hangr brack K0047 RR IN $6.94 Elevat legrst up hangr brack K0047 RR KE IN $8.05 Elevat legrst up hangr brack K0047 UE IN $51.89 Elevat legrst up hangr brack K0047 UE KE IN $60.21 Elevat legrst up hangr brack K0050 NU IN $29.41 Ratchet assembly K0050 NU KE IN $34.13 Ratchet assembly K0050 RR IN $2.93 Ratchet assembly K0050 RR KE IN $3.40 Ratchet assembly K0050 UE IN $22.07 Ratchet assembly K0050 UE KE IN $25.61 Ratchet assembly K0051 NU IN $47.61 Cam relese assem ftrst/lgrst K0051 NU KE IN $55.24 Cam relese assem ftrst/lgrst K0051 RR IN $4.79 Cam relese assem ftrst/lgrst K0051 RR KE IN $5.55 Cam relese assem ftrst/lgrst K0051 UE IN $35.69 Cam relese assem ftrst/lgrst K0051 UE KE IN $41.41 Cam relese assem ftrst/lgrst K0052 NU IN $83.66 Swingaway detach footrest K0052 NU KE IN $97.06 Swingaway detach footrest K0052 RR IN $8.36 Swingaway detach footrest K0052 RR KE IN $9.70 Swingaway detach footrest K0052 UE IN $62.73 Swingaway detach footrest K0052 UE KE IN $72.79 Swingaway detach footrest K0053 NU IN $92.32 Elevate footrest articulate K0053 NU KE IN $ Elevate footrest articulate K0053 RR IN $9.22 Elevate footrest articulate K0053 RR KE IN $10.70 Elevate footrest articulate K0053 UE IN $69.24 Elevate footrest articulate K0053 UE KE IN $80.34 Elevate footrest articulate K0056 NU IN $99.86 Seat ht <17 or >=21 ltwt wc K0056 RR IN $9.99 Seat ht <17 or >=21 ltwt wc K0056 UE IN $74.91 Seat ht <17 or >=21 ltwt wc K0065 NU IN $46.68 Spoke protectors K0065 RR IN $4.67 Spoke protectors K0065 UE IN $35.01 Spoke protectors K0069 NU IN $ Rear whl complete solid tire K0069 RR IN $10.49 Rear whl complete solid tire K0069 UE IN $78.69 Rear whl complete solid tire K0070 NU IN $ Rear whl compl pneum tire K0070 RR IN $19.25 Rear whl compl pneum tire K0070 UE IN $ Rear whl compl pneum tire K0071 NU IN $ Front castr compl pneum tire K0071 RR IN $11.48 Front castr compl pneum tire K0071 UE IN $86.02 Front castr compl pneum tire K0072 NU IN $69.05 Frnt cstr cmpl sem-pneum tir K0072 RR IN $6.90 Frnt cstr cmpl sem-pneum tir K0072 UE IN $51.79 Frnt cstr cmpl sem-pneum tir K0073 NU IN $36.54 Caster pin lock each K0073 RR IN $3.65 Caster pin lock each K0073 UE IN $27.41 Caster pin lock each K0077 NU IN $61.79 Front caster assem complete K0077 RR IN $6.17 Front caster assem complete K0077 UE IN $46.34 Front caster assem complete K0098 NU IN $24.63 Drive belt power wheelchair K0098 NU KE IN $28.57 Drive belt power wheelchair K0098 RR IN $2.46 Drive belt power wheelchair K0098 RR KE IN $2.86 Drive belt power wheelchair K0098 UE IN $18.45 Drive belt power wheelchair K0098 UE KE IN $21.41 Drive belt power wheelchair

179 MEDICAL FEE SCHEDULES 11: K0105 NU IN $ Iv hanger K0105 RR IN $10.43 Iv hanger K0105 UE IN $78.30 Iv hanger K0195 RR CR $16.21 Elevating whlchair leg rests K0195 RR KE CR $18.80 Elevating whlchair leg rests K0455 RR FS $ Pump uninterrupted infusion K0552 SU $2.78 Supply/ext inf pump syr type K0601 NU IN $1.16 Repl batt silver oxide 1.5 v K0602 NU IN $6.68 Repl batt silver oxide 3 v K0603 NU IN $0.60 Repl batt alkaline 1.5 v K0604 NU IN $6.39 Repl batt lithium 3.6 v K0605 NU IN $15.33 Repl batt lithium 4.5 v K0606 RR KF CR $2, AED garment w elec analysis K0607 NU IN $ Repl batt for AED K0607 NU KF IN $ Repl batt for AED K0607 RR IN $20.40 Repl batt for AED K0607 RR KF IN $22.65 Repl batt for AED K0607 UE IN $ Repl batt for AED K0607 UE KF IN $ Repl batt for AED K0608 NU IN $ Repl garment for AED K0608 NU KF IN $ Repl garment for AED K0608 RR IN $12.75 Repl garment for AED K0608 RR KF IN $14.14 Repl garment for AED K0608 UE IN $95.46 Repl garment for AED K0608 UE KF IN $ Repl garment for AED K0609 SU $ Repl electrode for AED K0609 KF SU $ Repl electrode for AED K0672 PO $74.92 Removable soft interface LE K0730 NU IN $1, Ctrl dose inh drug deliv sys K0730 RR IN $ Ctrl dose inh drug deliv sys K0730 UE IN $1, Ctrl dose inh drug deliv sys K0733 NU IN $ hr sealed lead acid K0733 NU KE IN $ hr sealed lead acid K0733 RR IN $ hr sealed lead acid K0733 RR KE IN $ hr sealed lead acid K0733 UE IN $ hr sealed lead acid K0733 UE KE IN $ hr sealed lead acid K0734 NU IN $ Adj skin pro w/c cus wd<22in K0734 NU KE IN $ Adj skin pro w/c cus wd<22in K0734 RR IN $30.00 Adj skin pro w/c cus wd<22in K0734 RR KE IN $34.81 Adj skin pro w/c cus wd<22in K0734 UE IN $ Adj skin pro w/c cus wd<22in K0734 UE KE IN $ Adj skin pro w/c cus wd<22in K0735 NU IN $ Adj skin pro wc cus wd>=22in K0735 NU KE IN $ Adj skin pro wc cus wd>=22in K0735 RR IN $38.18 Adj skin pro wc cus wd>=22in K0735 RR KE IN $44.30 Adj skin pro wc cus wd>=22in K0735 UE IN $ Adj skin pro wc cus wd>=22in K0735 UE KE IN $ Adj skin pro wc cus wd>=22in K0736 NU IN $ Adj skin pro/pos wc cus<22in K0736 NU KE IN $ Adj skin pro/pos wc cus<22in K0736 RR IN $30.25 Adj skin pro/pos wc cus<22in K0736 RR KE IN $35.09 Adj skin pro/pos wc cus<22in K0736 UE IN $ Adj skin pro/pos wc cus<22in K0736 UE KE IN $ Adj skin pro/pos wc cus<22in K0737 NU IN $ Adj skin pro/pos wc cus>=22 K0737 NU KE IN $ Adj skin pro/pos wc cus>=22 K0737 RR IN $38.28 Adj skin pro/pos wc cus>=22 K0737 RR KE IN $44.42 Adj skin pro/pos wc cus>=22 K0737 UE IN $ Adj skin pro/pos wc cus>=22 K0737 UE KE IN $ Adj skin pro/pos wc cus>=22 K0738 RR OX $51.63 Portable gas oxygen system K0800 NU IN $1, POV group 1 std up to 300lbs K0800 RR IN $ POV group 1 std up to 300lbs K0800 UE IN $ POV group 1 std up to 300lbs K0801 NU IN $1, POV group 1 hd lbs K0801 RR IN $ POV group 1 hd lbs K0801 UE IN $1, POV group 1 hd lbs

180 11: APPENDIX B - REGULATIONS K0802 NU IN $2, POV group 1 vhd lbs K0802 RR IN $ POV group 1 vhd lbs K0802 UE IN $1, POV group 1 vhd lbs K0806 NU IN $1, POV group 2 std up to 300lbs K0806 RR IN $ POV group 2 std up to 300lbs K0806 UE IN $1, POV group 2 std up to 300lbs K0807 NU IN $2, POV group 2 hd lbs K0807 RR IN $ POV group 2 hd lbs K0807 UE IN $1, POV group 2 hd lbs K0808 NU IN $3, POV group 2 vhd lbs K0808 RR IN $ POV group 2 vhd lbs K0808 UE IN $2, POV group 2 vhd lbs K0813 RR CR $ PWC gp 1 std port seat/back K0814 RR CR $ PWC gp 1 std port cap chair K0815 RR CR $ PWC gp 1 std seat/back K0816 RR CR $ PWC gp 1 std cap chair K0820 RR CR $ PWC gp 2 std port seat/back K0821 RR CR $ PWC gp 2 std port cap chair K0822 RR CR $ PWC gp 2 std seat/back K0823 RR CR $ PWC gp 2 std cap chair K0824 RR CR $ PWC gp 2 hd seat/back K0825 RR CR $ PWC gp 2 hd cap chair K0826 RR CR $ PWC gp 2 vhd seat/back K0827 RR CR $ PWC gp vhd cap chair K0828 RR CR $ PWC gp 2 xtra hd seat/back K0829 RR CR $ PWC gp 2 xtra hd cap chair K0835 RR CR $ PWC gp2 std sing pow opt s/b K0836 RR CR $ PWC gp2 std sing pow opt cap K0837 RR CR $ PWC gp 2 hd sing pow opt s/b K0838 RR CR $ PWC gp 2 hd sing pow opt cap K0839 RR CR $ PWC gp2 vhd sing pow opt s/b K0840 RR CR $ PWC gp2 xhd sing pow opt s/b K0841 RR CR $ PWC gp2 std mult pow opt s/b K0842 RR CR $ PWC gp2 std mult pow opt cap K0843 RR CR $ PWC gp2 hd mult pow opt s/b K0848 RR CR $ PWC gp 3 std seat/back K0849 RR CR $ PWC gp 3 std cap chair K0850 RR CR $ PWC gp 3 hd seat/back K0851 RR CR $ PWC gp 3 hd cap chair K0852 RR CR $ PWC gp 3 vhd seat/back K0853 RR CR $ PWC gp 3 vhd cap chair K0854 RR CR $ PWC gp 3 xhd seat/back K0855 RR CR $ PWC gp 3 xhd cap chair K0856 RR CR $ PWC gp3 std sing pow opt s/b K0857 RR CR $ PWC gp3 std sing pow opt cap K0858 RR CR $ PWC gp3 hd sing pow opt s/b K0859 RR CR $ PWC gp3 hd sing pow opt cap K0860 RR CR $ PWC gp3 vhd sing pow opt s/b K0861 RR CR $ PWC gp3 std mult pow opt s/b K0861 RR KF CR $ PWC gp3 std mult pow opt s/b K0862 RR CR $ PWC gp3 hd mult pow opt s/b K0863 RR CR $ PWC gp3 vhd mult pow opt s/b K0864 RR CR $1, PWC gp3 xhd mult pow opt s/b L0112 PO $1, Cranial cervical orthosis L0113 PO $ Cranial cervical torticollis L0120 PO $22.46 Cerv flexible non-adjustable L0130 PO $ Flex thermoplastic collar mo L0140 PO $54.20 Cervical semi-rigid adjustab L0150 PO $ Cerv semi-rig adj molded chn L0160 PO $ Cerv semi-rig wire occ/mand L0170 PO $ Cervical collar molded to pt L0172 PO $ Cerv col thermplas foam 2 pi L0174 PO $ Cerv col foam 2 piece w thor L0180 PO $ Cer post col occ/man sup adj L0190 PO $ Cerv collar supp adj cerv ba L0200 PO $ Cerv col supp adj bar & thor L0220 PO $ Thor rib belt custom fabrica L0430 PO $1, Dewall posture protector

181 MEDICAL FEE SCHEDULES 11: L0450 PO $ TLSO flex prefab thoracic L0452 PO $0.00 tlso flex custom fab thoraci L0454 PO $ TLSO flex prefab sacrococ-t9 L0456 PO $ TLSO flex prefab L0458 PO $ TLSO 2Mod symphis-xipho pre L0460 PO $ TLSO2Mod symphysis-stern pre L0462 PO $1, TLSO 3Mod sacro-scap pre L0464 PO $1, TLSO 4Mod sacro-scap pre L0466 PO $ TLSO rigid frame pre soft ap L0468 PO $ TLSO rigid frame prefab pelv L0470 PO $ TLSO rigid frame pre subclav L0472 PO $ TLSO rigid frame hyperex pre L0480 PO $1, TLSO rigid plastic custom fa L0482 PO $1, TLSO rigid lined custom fab L0484 PO $1, TLSO rigid plastic cust fab L0486 PO $1, TLSO rigidlined cust fab two L0488 PO $ TLSO rigid lined pre one pie L0490 PO $ TLSO rigid plastic pre one L0491 PO $ TLSO 2 piece rigid shell L0492 PO $ TLSO 3 piece rigid shell L0621 PO $81.90 SIO flex pelvisacral prefab L0622 PO $ SIO flex pelvisacral custom L0623 PO $0.00 SIO panel prefab L0624 PO $0.00 SIO panel custom L0625 PO $48.67 LO flexibl L1-below L5 pre L0626 PO $68.88 LO sag stays/panels pre-fab L0627 PO $ LO sagitt rigid panel prefab L0628 PO $74.14 LO flex w/o rigid stays pre L0629 PO $0.00 LSO flex w/rigid stays cust L0630 PO $ LSO post rigid panel pre L0631 PO $ LSO sag-coro rigid frame pre L0632 PO $0.00 LSO sag rigid frame cust L0633 PO $ LSO flexion control prefab L0634 PO $0.00 LSO flexion control custom L0635 PO $ LSO sagit rigid panel prefab L0636 PO $1, LSO sagittal rigid panel cus L0637 PO $ LSO sag-coronal panel prefab L0638 PO $1, LSO sag-coronal panel custom L0639 PO $ LSO s/c shell/panel prefab L0640 PO $ LSO s/c shell/panel custom L0700 PO $1, Ctlso a-p-l control molded L0710 PO $1, Ctlso a-p-l control w/ inter L0810 PO $2, Halo cervical into jckt vest L0820 PO $1, Halo cervical into body jack L0830 PO $2, Halo cerv into milwaukee typ L0859 PO $1, MRI compatible system L0861 PO $ Halo repl liner/interface L0970 PO $ Tlso corset front L0972 PO $96.54 Lso corset front L0974 PO $ Tlso full corset L0976 PO $ Lso full corset L0978 PO $ Axillary crutch extension L0980 PO $14.78 Peroneal straps pair L0982 PO $13.78 Stocking supp grips set of f L0984 PO $55.43 Protective body sock each L1000 PO $1, Ctlso milwauke initial model L1001 PO $0.00 CTLSO infant immobilizer L1005 PO $2, Tension based scoliosis orth L1010 PO $56.82 Ctlso axilla sling L1020 PO $73.18 Kyphosis pad L1025 PO $ Kyphosis pad floating L1030 PO $53.86 Lumbar bolster pad L1040 PO $66.05 Lumbar or lumbar rib pad L1050 PO $70.49 Sternal pad L1060 PO $80.97 Thoracic pad L1070 PO $76.18 Trapezius sling L1080 PO $46.86 Outrigger L1085 PO $ Outrigger bil w/ vert extens

182 11: APPENDIX B - REGULATIONS L1090 PO $85.17 Lumbar L1100 PO $ Ring flange plastic/leather L1110 PO $ Ring flange plas/leather mol L1120 PO $33.62 Covers for upright each L1200 PO $1, Furnsh initial orthosis only L1210 PO $ Lateral thoracic extension L1220 PO $ Anterior thoracic extension L1230 PO $ Milwaukee type superstructur L1240 PO $66.35 Lumbar derotation pad L1250 PO $61.17 Anterior asis pad L1260 PO $64.05 Anterior thoracic derotation L1270 PO $65.60 Abdominal pad L1280 PO $78.46 Rib gusset (elastic) each L1290 PO $66.54 Lateral trochanteric pad L1300 PO $1, Body jacket mold to patient L1310 PO $1, Post-operative body jacket L1500 PO $1, Thkao mobility frame L1510 PO $1, Thkao standing frame L1520 PO $2, Thkao swivel walker L1600 PO $ Abduct hip flex frejka w cvr L1610 PO $40.61 Abduct hip flex frejka covr L1620 PO $ Abduct hip flex pavlik harne L1630 PO $ Abduct control hip semi-flex L1640 PO $ Pelv band/spread bar thigh c L1650 PO $ HO abduction hip adjustable L1652 PO $ HO bi thighcuffs w sprdr bar L1660 PO $ HO abduction static plastic L1680 PO $1, Pelvic & hip control thigh c L1685 PO $1, Post-op hip abduct custom fa L1686 PO $1, HO post-op hip abduction L1690 PO $1, Combination bilateral HO L1700 PO $1, Leg perthes orth toronto typ L1710 PO $1, Legg perthes orth newington L1720 PO $1, Legg perthes orthosis trilat L1730 PO $ Legg perthes orth scottish r L1755 PO $1, Legg perthes patten bottom t L1810 PO $90.95 Ko elastic with joints L1820 PO $ Ko elas w/ condyle pads & jo L1830 PO $87.80 Ko immobilizer canvas longit L1831 PO $ Knee orth pos locking join L1832 PO $ KO adj jnt pos rigid support L1834 PO $ Ko w/0 joint rigid molded to L1836 PO $ Rigid KO wo joints L1840 PO $ Ko derot ant cruciate custom L1843 PO $ KO single upright custom fit L1844 PO $1, Ko w/adj jt rot cntrl molded L1845 PO $ Ko w/ adj flex/ext rotat cus L1846 PO $1, Ko w adj flex/ext rotat mold L1847 PO $ KO adjustable w air chambers L1850 PO $ Ko swedish type L1860 PO $1, Ko supracondylar socket mold L1900 PO $ Afo sprng wir drsflx calf bd L1902 PO $88.45 Afo ankle gauntlet L1904 PO $ Afo molded ankle gauntlet L1906 PO $ Afo multiligamentus ankle su L1907 PO $ AFO supramalleolar custom L1910 PO $ Afo sing bar clasp attach sh L1920 PO $ Afo sing upright w/ adjust s L1930 PO $ Afo plastic L1932 PO $ Afo rig ant tib prefab TCF/= L1940 PO $ Afo molded to patient plasti L1945 PO $ Afo molded plas rig ant tib L1950 PO $ Afo spiral molded to pt plas L1951 PO $ AFO spiral prefabricated L1960 PO $ Afo pos solid ank plastic mo L1970 PO $ Afo plastic molded w/ankle j L1971 PO $ AFO w/ankle joint, prefab L1980 PO $ Afo sing solid stirrup calf

183 MEDICAL FEE SCHEDULES 11: L1990 PO $ Afo doub solid stirrup calf L2000 PO $ Kafo sing fre stirr thi/calf L2005 PO $3, KAFO sng/dbl mechanical act L2010 PO $1, Kafo sng solid stirrup w/o j L2020 PO $1, Kafo dbl solid stirrup band/ L2030 PO $1, Kafo dbl solid stirrup w/o j L2034 PO $1, KAFO pla sin up w/wo k/a cus L2035 PO $ KAFO plastic pediatric size L2036 PO $2, Kafo plas doub free knee mol L2037 PO $1, Kafo plas sing free knee mol L2038 PO $1, Kafo w/o joint multi-axis an L2040 PO $ Hkafo torsion bil rot straps L2050 PO $ Hkafo torsion cable hip pelv L2060 PO $ Hkafo torsion ball bearing j L2070 PO $ Hkafo torsion unilat rot str L2080 PO $ Hkafo unilat torsion cable L2090 PO $ Hkafo unilat torsion ball br L2106 PO $ Afo tib fx cast plaster mold L2108 PO $1, Afo tib fx cast molded to pt L2112 PO $ Afo tibial fracture soft L2114 PO $ Afo tib fx semi-rigid L2116 PO $ Afo tibial fracture rigid L2126 PO $1, Kafo fem fx cast thermoplas L2128 PO $1, Kafo fem fx cast molded to p L2132 PO $ Kafo femoral fx cast soft L2134 PO $1, Kafo fem fx cast semi-rigid L2136 PO $1, Kafo femoral fx cast rigid L2180 PO $99.15 Plas shoe insert w ank joint L2182 PO $77.60 Drop lock knee L2184 PO $ Limited motion knee joint L2186 PO $ Adj motion knee jnt lerman t L2188 PO $ Quadrilateral brim L2190 PO $79.61 Waist belt L2192 PO $ Pelvic band & belt thigh fla L2200 PO $41.70 Limited ankle motion ea jnt L2210 PO $62.19 Dorsiflexion assist each joi L2220 PO $78.65 Dorsi & plantar flex ass/res L2230 PO $64.96 Split flat caliper stirr & p L2232 PO $87.95 Rocker bottom, contact AFO L2240 PO $70.80 Round caliper and plate atta L2250 PO $ Foot plate molded stirrup at L2260 PO $ Reinforced solid stirrup L2265 PO $99.70 Long tongue stirrup L2270 PO $46.48 Varus/valgus strap padded/li L2275 PO $ Plastic mod low ext pad/line L2280 PO $ Molded inner boot L2300 PO $ Abduction bar jointed adjust L2310 PO $ Abduction bar-straight L2320 PO $ Non-molded lacer L2330 PO $ Lacer molded to patient mode L2335 PO $ Anterior swing band L2340 PO $ Pre-tibial shell molded to p L2350 PO $1, Prosthetic type socket molde L2360 PO $58.41 Extended steel shank L2370 PO $ Patten bottom L2375 PO $95.66 Torsion ank & half solid sti L2380 PO $ Torsion straight knee joint L2385 PO $ Straight knee joint heavy du L2387 PO $ Add LE poly knee custom KAFO L2390 PO $98.79 Offset knee joint each L2395 PO $ Offset knee joint heavy duty L2397 PO $99.93 Suspension sleeve lower ext L2405 PO $77.05 Knee joint drop lock ea jnt L2415 PO $ Knee joint cam lock each joi L2425 PO $ Knee disc/dial lock/adj flex L2430 PO $ Knee jnt ratchet lock ea jnt L2492 PO $98.36 Knee lift loop drop lock rin L2500 PO $ Thi/glut/ischia wgt bearing

184 11: APPENDIX B - REGULATIONS L2510 PO $ Th/wght bear quad-lat brim m L2520 PO $ Th/wght bear quad-lat brim c L2525 PO $1, Th/wght bear nar m-l brim mo L2526 PO $ Th/wght bear nar m-l brim cu L2530 PO $ Thigh/wght bear lacer non-mo L2540 PO $ Thigh/wght bear lacer molded L2550 PO $ Thigh/wght bear high roll cu L2570 PO $ Hip clevis type 2 posit jnt L2580 PO $ Pelvic control pelvic sling L2600 PO $ Hip clevis/thrust bearing fr L2610 PO $ Hip clevis/thrust bearing lo L2620 PO $ Pelvic control hip heavy dut L2622 PO $ Hip joint adjustable flexion L2624 PO $ Hip adj flex ext abduct cont L2627 PO $1, Plastic mold recipro hip & c L2628 PO $1, Metal frame recipro hip & ca L2630 PO $ Pelvic control band & belt u L2640 PO $ Pelvic control band & belt b L2650 PO $ Pelv & thor control gluteal L2660 PO $ Thoracic control thoracic ba L2670 PO $ Thorac cont paraspinal uprig L2680 PO $ Thorac cont lat support upri L2750 PO $83.30 Plating chrome/nickel pr bar L2755 PO $ Carbon graphite lamination L2760 PO $63.27 Extension per extension per L2768 PO $ Ortho sidebar disconnect L2780 PO $68.99 Non-corrosive finish L2785 PO $31.59 Drop lock retainer each L2795 PO $80.83 Knee control full kneecap L2800 PO $90.31 Knee cap medial or lateral p L2810 PO $66.13 Knee control condylar pad L2820 PO $84.45 Soft interface below knee se L2830 PO $97.94 Soft interface above knee se L2840 PO $43.76 Tibial length sock fx or equ L2850 PO $56.28 Femoral lgth sock fx or equa L3000 PO $ Ft insert ucb berkeley shell L3001 PO $ Foot insert remov molded spe L3002 PO $ Foot insert plastazote or eq L3003 PO $ Foot insert silicone gel eac L3010 PO $ Foot longitudinal arch suppo L3020 PO $ Foot longitud/metatarsal sup L3030 PO $67.45 Foot arch support remov prem L3031 PO $0.00 Foot lamin/prepreg composite L3040 PO $41.58 Ft arch suprt premold longit L3050 PO $41.58 Foot arch supp premold metat L3060 PO $65.19 Foot arch supp longitud/meta L3070 PO $28.07 Arch suprt att to sho longit L3080 PO $28.07 Arch supp att to shoe metata L3090 PO $35.98 Arch supp att to shoe long/m L3100 PO $38.21 Hallus-valgus nght dynamic s L3140 PO $78.69 Abduction rotation bar shoe L3150 PO $71.94 Abduct rotation bar w/o shoe L3170 PO $44.98 Foot plastic heel stabilizer L3224 PO $54.83 Woman s shoe oxford brace L3225 PO $61.58 Man s shoe oxford brace L3300 PO $46.07 Sho lift taper to metatarsal L3310 PO $71.94 Shoe lift elev heel/sole neo L3330 PO $ Lifts elevation metal extens L3332 PO $65.19 Shoe lifts tapered to one-ha L3334 PO $33.72 Shoe lifts elevation heel /i L3340 PO $75.32 Shoe wedge sach L3350 PO $20.24 Shoe heel wedge L3360 PO $31.47 Shoe sole wedge outside sole L3370 PO $43.81 Shoe sole wedge between sole L3380 PO $43.81 Shoe clubfoot wedge L3390 PO $43.81 Shoe outflare wedge L3400 PO $35.98 Shoe metatarsal bar wedge ro L3410 PO $82.04 Shoe metatarsal bar between

185 MEDICAL FEE SCHEDULES 11: L3420 PO $48.33 Full sole/heel wedge between L3430 PO $ Sho heel count plast reinfor L3440 PO $67.45 Heel leather reinforced L3450 PO $93.29 Shoe heel sach cushion type L3455 PO $35.98 Shoe heel new leather standa L3460 PO $30.33 Shoe heel new rubber standar L3465 PO $51.71 Shoe heel thomas with wedge L3470 PO $55.07 Shoe heel thomas extend to b L3480 PO $55.07 Shoe heel pad & depress for L3500 PO $25.85 Ortho shoe add leather insol L3510 PO $25.85 Orthopedic shoe add rub insl L3520 PO $28.07 O shoe add felt w leath insl L3530 PO $28.07 Ortho shoe add half sole L3540 PO $44.98 Ortho shoe add full sole L3550 PO $7.85 O shoe add standard toe tap L3560 PO $20.24 O shoe add horseshoe toe tap L3570 PO $75.32 O shoe add instep extension L3580 PO $57.32 O shoe add instep velcro clo L3590 PO $47.20 O shoe convert to sof counte L3595 PO $37.09 Ortho shoe add march bar L3600 PO $67.45 Trans shoe calip plate exist L3610 PO $88.78 Trans shoe caliper plate new L3620 PO $67.45 Trans shoe solid stirrup exi L3630 PO $88.78 Trans shoe solid stirrup new L3640 PO $38.21 Shoe dennis browne splint bo L3650 PO $56.44 Shlder fig 8 abduct restrain L3660 PO $87.15 Abduct restrainer canvas&web L3670 PO $ Acromio/clavicular canvas&we L3671 PO $ SO cap design w/o jnts CF L3672 PO $ SO airplane w/o jnts CF L3673 PO $ SO airplane w/joint CF L3675 PO $ Canvas vest SO L3702 PO $ EO w/o joints CF L3710 PO $ Elbow elastic with metal joi L3720 PO $ Forearm/arm cuffs free motio L3730 PO $ Forearm/arm cuffs ext/flex a L3740 PO $1, Cuffs adj lock w/ active con L3760 PO $ EO withjoint, Prefabricated L3762 PO $86.49 Rigid EO wo joints L3763 PO $ EWHO rigid w/o jnts CF L3764 PO $ EWHO w/joint(s) CF L3765 PO $1, EWHFO rigid w/o jnts CF L3766 PO $1, EWHFO w/joint(s) CF L3806 PO $ WHFO w/joint(s) custom fab L3807 PO $ WHFO,no joint, prefabricated L3808 PO $ WHFO, rigid w/o joints L3900 PO $1, Hinge extension/flex wrist/f L3901 PO $1, Hinge ext/flex wrist finger L3904 PO $2, Whfo electric custom fitted L3905 PO $ WHO w/nontorsion jnt(s) CF L3906 PO $ WHO w/o joints CF L3908 PO $66.19 Wrist cock-up non-molded L3912 PO $78.57 Flex glove w/elastic finger L3913 PO $ HFO w/o joints CF L3915 PO $ WHO w nontor jnt(s) prefab L3917 PO $84.97 Prefab metacarpl fx orthosis L3919 PO $ HO w/o joints CF L3921 PO $ HFO w/joint(s) CF L3923 PO $72.07 HFO w/o joints PF L3925 PO $40.89 FO pip/dip with joint/spring L3927 PO $28.10 FO pip/dip w/o joint/spring L3929 PO $64.76 HFO nontorsion joint, prefab L3931 PO $ WHFO nontorsion joint prefab L3933 PO $ FO w/o joints CF L3935 PO $ FO nontorsion joint CF L3956 PO $0.00 Add joint upper ext orthosis L3960 PO $ Sewho airplan desig abdu pos L3961 PO $1, SEWHO cap design w/o jnts CF

186 11: APPENDIX B - REGULATIONS L3962 PO $ Sewho erbs palsey design abd L3964 NU IN $ Seo mobile arm sup att to wc L3964 RR IN $65.21 Seo mobile arm sup att to wc L3964 UE IN $ Seo mobile arm sup att to wc L3965 NU IN $1, Arm supp att to wc rancho ty L3965 RR IN $ Arm supp att to wc rancho ty L3965 UE IN $ Arm supp att to wc rancho ty L3966 NU IN $ Mobile arm supports reclining L3966 RR IN $78.40 Mobile arm supports reclining L3966 UE IN $ Mobile arm supports reclinin L3967 PO $1, SEWHO airplane w/o jnts CF L3968 NU IN $ Friction dampening arm supp L3968 RR IN $99.20 Friction dampening arm supp L3968 UE IN $ Friction dampening arm sup L3969 NU IN $ Monosuspension arm/hand supp L3969 RR IN $67.52 Monosuspension arm/hand supp L3969 UE IN $ Monosuspension arm/hand supp L3970 NU IN $ Elevat proximal arm support L3970 RR IN $27.75 Elevat proximal arm support L3970 UE IN $ Elevat proximal arm support L3971 PO $1, SEWHO cap design w/jnt(s) CF L3972 NU IN $ Offset/lat rocker arm w/ ela L3972 RR IN $17.65 Offset/lat rocker arm w/ ela L3972 UE IN $ Offset/lat rocker arm w/ ela L3973 PO $1, SEWHO airplane w/jnt(s) CF L3974 NU IN $ Mobile arm support supinator L3974 RR IN $14.98 Mobile arm support supinator L3974 UE IN $ Mobile arm support supinator L3975 PO $1, SEWHFO cap design w/o jnt CF L3976 PO $1, SEWHFO airplane w/o jnts CF L3977 PO $1, SEWHFO cap desgn w/jnt(s) CF L3978 PO $1, SEWHFO airplane w/jnt(s) CF L3980 PO $ Upp ext fx orthosis humeral L3982 PO $ Upper ext fx orthosis rad/ul L3984 PO $ Upper ext fx orthosis wrist L3995 PO $36.12 Sock fracture or equal each L4000 PO $1, Repl girdle milwaukee orth L4002 PO $0.00 Replace strap, any orthosis L4010 PO $ Replace trilateral socket br L4020 PO $ Replace quadlat socket brim L4030 PO $ Replace socket brim cust fit L4040 PO $ Replace molded thigh lacer L4045 PO $ Replace non-molded thigh lac L4050 PO $ Replace molded calf lacer L4055 PO $ Replace non-molded calf lace L4060 PO $ Replace high roll cuff L4070 PO $ Replace prox & dist upright L4080 PO $87.52 Repl met band kafo-afo prox L4090 PO $91.00 Repl met band kafo-afo calf/ L4100 PO $ Repl leath cuff kafo prox th L4110 PO $94.65 Repl leath cuff kafo-afo cal L4130 PO $ Replace pretibial shell L4350 PO $75.68 Ankle control orthosi prefab L4360 PO $ Pneumati walking boot prefab L4370 PO $ Pneumatic full leg splint L4380 PO $ Pneumatic knee splint L4386 PO $ Non-pneum walk boot prefab L4392 PO $20.80 Replace AFO soft interface L4394 PO $15.17 Replace foot drop spint L4396 PO $ Static AFO L4398 PO $68.28 Foot drop splint recumbent L5000 PO $ Sho insert w arch toe filler L5010 PO $1, Mold socket ank hgt w/ toe f L5020 PO $1, Tibial tubercle hgt w/ toe f L5050 PO $2, Ank symes mold sckt sach ft L5060 PO $3, Symes met fr leath socket ar L5100 PO $2, Molded socket shin sach foot L5105 PO $3, Plast socket jts/thgh lacer

187 MEDICAL FEE SCHEDULES 11: L5150 PO $3, Mold sckt ext knee shin sach L5160 PO $3, Mold socket bent knee shin s L5200 PO $2, Kne sing axis fric shin sach L5210 PO $2, No knee/ankle joints w/ ft b L5220 PO $2, No knee joint with artic ali L5230 PO $3, Fem focal defic constant fri L5250 PO $4, Hip canad sing axi cons fric L5270 PO $4, Tilt table locking hip sing L5280 PO $4, Hemipelvect canad sing axis L5301 PO $2, BK mold socket SACH ft endo L5311 PO $3, Knee disart, SACH ft, endo L5321 PO $2, AK open end SACH L5331 PO $4, Hip disart canadian SACH ft L5341 PO $4, Hemipelvectomy canadian SACH L5400 PO $1, Postop dress & 1 cast chg bk L5410 PO $ Postop dsg bk ea add cast ch L5420 PO $1, Postop dsg & 1 cast chg ak/d L5430 PO $ Postop dsg ak ea add cast ch L5450 PO $ Postop app non-wgt bear dsg L5460 PO $ Postop app non-wgt bear dsg L5500 PO $1, Init bk ptb plaster direct L5505 PO $1, Init ak ischal plstr direct L5510 PO $1, Prep BK ptb plaster molded L5520 PO $1, Perp BK ptb thermopls direct L5530 PO $1, Prep BK ptb thermopls molded L5535 PO $1, Prep BK ptb open end socket L5540 PO $1, Prep BK ptb laminated socket L5560 PO $2, Prep AK ischial plast molded L5570 PO $2, Prep AK ischial direct form L5580 PO $2, Prep AK ischial thermo mold L5585 PO $2, Prep AK ischial open end L5590 PO $2, Prep AK ischial laminated L5595 PO $4, Hip disartic sach thermopls L5600 PO $4, Hip disart sach laminat mold L5610 PO $1, Above knee hydracadence L5611 PO $1, Ak 4 bar link w/fric swing L5613 PO $2, Ak 4 bar ling w/hydraul swig L5614 PO $1, bar link above knee w/swng L5616 PO $1, Ak univ multiplex sys frict L5617 PO $ AK/BK self-aligning unit ea L5618 PO $ Test socket symes L5620 PO $ Test socket below knee L5622 PO $ Test socket knee disarticula L5624 PO $ Test socket above knee L5626 PO $ Test socket hip disarticulate L5628 PO $ Test socket hemipelvectomy L5629 PO $ Below knee acrylic socket L5630 PO $ Syme typ expandabl wall sckt L5631 PO $ Ak/knee disartic acrylic soc L5632 PO $ Symes type ptb brim design s L5634 PO $ Symes type poster opening so L5636 PO $ Symes type medial opening so L5637 PO $ Below knee total contact L5638 PO $ Below knee leather socket L5639 PO $1, Below knee wood socket L5640 PO $ Knee disarticulat leather so L5642 PO $ Above knee leather socket L5643 PO $1, Hip flex inner socket ext fr L5644 PO $ Above knee wood socket L5645 PO $ Bk flex inner socket ext fra L5646 PO $ Below knee cushion socket L5647 PO $ Below knee suction socket L5648 PO $ Above knee cushion socket L5649 PO $1, Isch containmt/narrow m-l so L5650 PO $ Tot contact ak/knee disart s L5651 PO $1, Ak flex inner socket ext fra L5652 PO $ Suction susp ak/knee disart L5653 PO $ Knee disart expand wall sock

188 11: APPENDIX B - REGULATIONS L5654 PO $ Socket insert symes L5655 PO $ Socket insert below knee L5656 PO $ Socket insert knee articulat L5658 PO $ Socket insert above knee L5661 PO $ Multi-durometer symes L5665 PO $ Multi-durometer below knee L5666 PO $70.93 Below knee cuff suspension L5668 PO $94.93 Socket insert w/o lock lower L5670 PO $ Bk molded supracondylar susp L5671 PO $ BK/AK locking mechanism L5672 PO $ Bk removable medial brim sus L5673 PO $ Socket insert w lock mech L5676 PO $ Bk knee joints single axis p L5677 PO $ Bk knee joints polycentric p L5678 PO $35.81 Bk joint covers pair L5679 PO $ Socket insert w/o lock mech L5680 PO $ Bk thigh lacer non-molded L5681 PO $1, Intl custm cong/latyp insert L5682 PO $ Bk thigh lacer glut/ischia m L5683 PO $1, Initial custom socket insert L5684 PO $44.57 Bk fork strap L5685 PO $ Below knee sus/seal sleeve L5686 PO $61.44 Bk back check L5688 PO $73.46 Bk waist belt webbing L5690 PO $93.38 Bk waist belt padded and lin L5692 PO $ Ak pelvic control belt light L5694 PO $ Ak pelvic control belt pad/l L5695 PO $ Ak sleeve susp neoprene/equa L5696 PO $ Ak/knee disartic pelvic join L5697 PO $72.41 Ak/knee disartic pelvic band L5698 PO $ Ak/knee disartic silesian ba L5699 PO $ Shoulder harness L5700 PO $2, Replace socket below knee L5701 PO $3, Replace socket above knee L5702 PO $3, Replace socket hip L5703 PO $2, Symes ankle w/o (SACH) foot L5704 PO $ Custom shape cover BK L5705 PO $ Custom shape cover AK L5706 PO $ Custom shape cvr knee disart L5707 PO $1, Custom shape cvr hip disart L5710 PO $ Kne-shin exo sng axi mnl loc L5711 PO $ Knee-shin exo mnl lock ultra L5712 PO $ Knee-shin exo frict swg & st L5714 PO $ Knee-shin exo variable frict L5716 PO $ Knee-shin exo mech stance ph L5718 PO $ Knee-shin exo frct swg & sta L5722 PO $ Knee-shin pneum swg frct exo L5724 PO $1, Knee-shin exo fluid swing ph L5726 PO $1, Knee-shin ext jnts fld swg e L5728 PO $2, Knee-shin fluid swg & stance L5780 PO $1, Knee-shin pneum/hydra pneum L5781 PO $3, Lower limb pros vacuum pump L5782 PO $3, HD low limb pros vacuum pump L5785 PO $ Exoskeletal bk ultralt mater L5790 PO $ Exoskeletal ak ultra-light m L5795 PO $ Exoskel hip ultra-light mate L5810 PO $ Endoskel knee-shin mnl lock L5811 PO $ Endo knee-shin mnl lck ultra L5812 PO $ Endo knee-shin frct swg & st L5814 PO $3, Endo knee-shin hydral swg ph L5816 PO $ Endo knee-shin polyc mch sta L5818 PO $ Endo knee-shin frct swg & st L5822 PO $1, Endo knee-shin pneum swg frc L5824 PO $1, Endo knee-shin fluid swing p L5826 PO $2, Miniature knee joint L5828 PO $3, Endo knee-shin fluid swg/sta L5830 PO $1, Endo knee-shin pneum/swg pha L5840 PO $3, Multi-axial knee/shin system

189 MEDICAL FEE SCHEDULES 11: L5845 PO $1, Knee-shin sys stance flexion L5848 PO $ Knee-shin sys hydraul stance L5850 PO $ Endo ak/hip knee extens assi L5855 PO $ Mech hip extension assist L5856 PO $21, Elec knee-shin swing/stance L5857 PO $7, Elec knee-shin swing only L5858 PO $16, Stance phase only L5910 PO $ Endo below knee alignable sy L5920 PO $ Endo ak/hip alignable system L5925 PO $ Above knee manual lock L5930 PO $3, High activity knee frame L5940 PO $ Endo bk ultra-light material L5950 PO $ Endo ak ultra-light material L5960 PO $1, Endo hip ultra-light material L5962 PO $ Below knee flex cover system L5964 PO $ Above knee flex cover system L5966 PO $1, Hip flexible cover system L5968 PO $3, Multiaxial ankle w dorsiflex L5970 PO $ Foot external keel sach foot L5971 PO $ SACH foot, replacement L5972 PO $ Flexible keel foot L5973 PO $15, Ank-foot sys dors-plant flex L5974 PO $ Foot single axis ankle/foot L5975 PO $ Combo ankle/foot prosthesis L5976 PO $ Energy storing foot L5978 PO $ Ft prosth multiaxial ankl/ft L5979 PO $2, Multi-axial ankle/ft prosth L5980 PO $4, Flex foot system L5981 PO $2, Flex-walk sys low ext prosth L5982 PO $ Exoskeletal axial rotation u L5984 PO $ Endoskeletal axial rotation L5985 PO $ Lwr ext dynamic prosth pylon L5986 PO $ Multi-axial rotation unit L5987 PO $6, Shank ft w vert load pylon L5988 PO $1, Vertical shock reducing pylo L5990 PO $1, User adjustable heel height L6000 PO $1, Par hand robin-aids thum rem L6010 PO $1, Hand robin-aids little/ring L6020 PO $1, Part hand robin-aids no fing L6025 PO $7, Part hand disart myoelectric L6050 PO $1, Wrst MLd sck flx hng tri pad L6055 PO $2, Wrst mold sock w/exp interfa L6100 PO $2, Elb mold sock flex hinge pad L6110 PO $2, Elbow mold sock suspension t L6120 PO $2, Elbow mold doub splt soc ste L6130 PO $2, Elbow stump activated lock h L6200 PO $2, Elbow mold outsid lock hinge L6205 PO $3, Elbow molded w/ expand inter L6250 PO $2, Elbow inter loc elbow forarm L6300 PO $4, Shlder disart int lock elbow L6310 PO $2, Shoulder passive restor comp L6320 PO $1, Shoulder passive restor cap L6350 PO $4, Thoracic intern lock elbow L6360 PO $2, Thoracic passive restor comp L6370 PO $2, Thoracic passive restor cap L6380 PO $1, Postop dsg cast chg wrst/elb L6382 PO $1, Postop dsg cast chg elb dis/ L6384 PO $2, Postop dsg cast chg shlder/t L6386 PO $ Postop ea cast chg & realign L6388 PO $ Postop applicat rigid dsg on L6400 PO $2, Below elbow prosth tiss shap L6450 PO $2, Elb disart prosth tiss shap L6500 PO $2, Above elbow prosth tiss shap L6550 PO $3, Shldr disar prosth tiss shap L6570 PO $4, Scap thorac prosth tiss shap L6580 PO $1, Wrist/elbow bowden cable mol L6582 PO $1, Wrist/elbow bowden cbl dir f L6584 PO $1, Elbow fair lead cable molded

190 11: APPENDIX B - REGULATIONS L6586 PO $1, Elbow fair lead cable dir fo L6588 PO $2, Shdr fair lead cable molded L6590 PO $2, Shdr fair lead cable direct L6600 PO $ Polycentric hinge pair L6605 PO $ Single pivot hinge pair L6610 PO $ Flexible metal hinge pair L6611 PO $ Additional switch, ext power L6615 PO $ Disconnect locking wrist uni L6616 PO $68.22 Disconnect insert locking wr L6620 PO $ Flexion/extension wrist unit L6621 PO $2, Flex/ext wrist w/wo friction L6623 PO $ Spring-ass rot wrst w/ latch L6624 PO $3, Flex/ext/rotation wrist unit L6625 PO $ Rotation wrst w/ cable lock L6628 PO $ Quick disconn hook adapter o L6629 PO $ Lamination collar w/ couplin L6630 PO $ Stainless steel any wrist L6632 PO $58.60 Latex suspension sleeve each L6635 PO $ Lift assist for elbow L6637 PO $ Nudge control elbow lock L6638 PO $2, Elec lock on manual pw elbow L6640 PO $ Shoulder abduction joint pai L6641 PO $ Excursion amplifier pulley t L6642 PO $ Excursion amplifier lever ty L6645 PO $ Shoulder flexion-abduction j L6646 PO $2, Multipo locking shoulder jnt L6647 PO $ Shoulder lock actuator L6648 PO $2, Ext pwrd shlder lock/unlock L6650 PO $ Shoulder universal joint L6655 PO $72.10 Standard control cable extra L6660 PO $82.79 Heavy duty control cable L6665 PO $48.11 Teflon or equal cable lining L6670 PO $53.31 Hook to hand cable adapter L6672 PO $ Harness chest/shlder saddle L6675 PO $ Harness figure of 8 sing con L6676 PO $ Harness figure of 8 dual con L6677 PO $ UE triple control harness L6680 PO $ Test sock wrist disart/bel e L6682 PO $ Test sock elbw disart/above L6684 PO $ Test socket shldr disart/tho L6686 PO $ Suction socket L6687 PO $ Frame typ socket bel elbow/w L6688 PO $ Frame typ sock above elb/dis L6689 PO $ Frame typ socket shoulder di L6690 PO $ Frame typ sock interscap-tho L6691 PO $ Removable insert each L6692 PO $ Silicone gel insert or equal L6693 PO $2, Lockingelbow forearm cntrbal L6694 PO $ Elbow socket ins use w/lock L6695 PO $ Elbow socket ins use w/o lck L6696 PO $1, Cus elbo skt in for con/atyp L6697 PO $1, Cus elbo skt in not con/atyp L6698 PO $ Below/above elbow lock mech L6703 PO $ Term dev, passive hand mitt L6704 PO $ Term dev, sport/rec/work att L6706 PO $ Term dev mech hook vol open L6707 PO $1, Term dev mech hook vol close L6708 PO $ Term dev mech hand vol open L6709 PO $1, Term dev mech hand vol close L6711 PO $ Ped term dev, hook, vol open L6712 PO $1, Ped term dev, hook, vol clos L6713 PO $1, Ped term dev, hand, vol open L6714 PO $1, Ped term dev, hand, vol clos L6721 PO $2, Hook/hand, hvy dty, vol open L6722 PO $1, Hook/hand, hvy dty, vol clos L6805 PO $ Term dev modifier wrist unit L6810 PO $ Term dev precision pinch dev L6881 PO $3, Term dev auto grasp feature

191 MEDICAL FEE SCHEDULES 11: L6882 PO $2, Microprocessor control uplmb L6883 PO $1, Replc sockt below e/w disa L6884 PO $2, Replc sockt above elbow disa L6885 PO $2, Replc sockt shldr dis/interc L6890 PO $ Prefab glove for term device L6895 PO $ Custom glove for term device L6900 PO $1, Hand restorat thumb/1 finger L6905 PO $1, Hand restoration multiple fi L6910 PO $1, Hand restoration no fingers L6915 PO $ Hand restoration replacmnt g L6920 PO $6, Wrist disarticul switch ctrl L6925 PO $6, Wrist disart myoelectronic c L6930 PO $6, Below elbow switch control L6935 PO $7, Below elbow myoelectronic ct L6940 PO $8, Elbow disarticulation switch L6945 PO $9, Elbow disart myoelectronic c L6950 PO $8, Above elbow switch control L6955 PO $10, Above elbow myoelectronic ct L6960 PO $10, Shldr disartic switch contro L6965 PO $12, Shldr disartic myoelectronic L6970 PO $13, Interscapular-thor switch ct L6975 PO $14, Interscap-thor myoelectronic L7007 PO $3, Adult electric hand L7008 PO $5, Pediatric electric hand L7009 PO $3, Adult electric hook L7040 PO $2, Prehensile actuator L7045 PO $1, Pediatric electric hook L7170 PO $5, Electronic elbow hosmer swit L7180 PO $32, Electronic elbow sequential L7181 PO $35, Electronic elbo simultaneous L7185 PO $6, Electron elbow adolescent sw L7186 PO $9, Electron elbow child switch L7190 PO $9, Elbow adolescent myoelectron L7191 PO $10, Elbow child myoelectronic ct L7260 PO $1, Electron wrist rotator otto L7261 PO $3, Electron wrist rotator utah L7266 PO $ Servo control steeper or equ L7272 PO $2, Analogue control unb or equa L7274 PO $5, Proportional ctl 12 volt uta L7360 PO $ Six volt bat otto bock/eq ea L7362 PO $ Battery chrgr six volt otto L7364 PO $ Twelve volt battery utah/equ L7366 PO $ Battery chrgr 12 volt utah/e L7367 PO $ Replacemnt lithium ionbatter L7368 PO $ Lithium ion battery charger L7400 PO $ Add UE prost be/wd, ultlite L7401 PO $ Add UE prost a/e ultlite mat L7402 PO $ Add UE prost s/d ultlite mat L7403 PO $ Add UE prost b/e acrylic L7404 PO $ Add UE prost a/e acrylic L7405 PO $ Add UE prost s/d acrylic L7900 PO $ Male vacuum erection system L8000 PO $33.23 Mastectomy bra L8001 PO $ Breast prosthesis bra & form L8002 PO $ Brst prsth bra & bilat form L8015 PO $53.08 Ext breastprosthesis garment L8020 PO $ Mastectomy form L8030 PO $ Breast prosthes w/o adhesive L8031 PO $ Breast prosthesis w adhesive L8032 PO $34.69 Reusable nipple prosthesis L8035 PO $3, Custom breast prosthesis L8040 PO $2, Nasal prosthesis L8040 KM PO $2, Nasal prosthesis L8040 KN PO $ Nasal prosthesis L8041 PO $2, Midfacial prosthesis L8041 KM PO $2, Midfacial prosthesis L8041 KN PO $1, Midfacial prosthesis L8042 PO $3, Orbital prosthesis

192 11: APPENDIX B - REGULATIONS L8042 KM PO $3, Orbital prosthesis L8042 KN PO $1, Orbital prosthesis L8043 PO $3, Upper facial prosthesis L8043 KM PO $3, Upper facial prosthesis L8043 KN PO $1, Upper facial prosthesis L8044 PO $4, Hemi-facial prosthesis L8044 KM PO $3, Hemi-facial prosthesis L8044 KN PO $1, Hemi-facial prosthesis L8045 PO $2, Auricular prosthesis L8045 KM PO $2, Auricular prosthesis L8045 KN PO $1, Auricular prosthesis L8046 PO $2, Partial facial prosthesis L8046 KM PO $2, Partial facial prosthesis L8046 KN PO $1, Partial facial prosthesis L8047 PO $1, Nasal septal prosthesis L8047 KM PO $1, Nasal septal prosthesis L8047 KN PO $ Nasal septal prosthesis L8300 PO $76.08 Truss single w/ standard pad L8310 PO $ Truss double w/ standard pad L8320 PO $48.22 Truss addition to std pad wa L8330 PO $44.53 Truss add to std pad scrotal L8400 PO $18.93 Sheath below knee L8410 PO $22.92 Sheath above knee L8415 PO $21.68 Sheath upper limb L8417 PO $66.49 Pros sheath/sock w gel cushn L8420 PO $20.33 Prosthetic sock multi ply BK L8430 PO $23.50 Prosthetic sock multi ply AK L8435 PO $19.82 Pros sock multi ply upper lm L8440 PO $48.81 Shrinker below knee L8460 PO $60.12 Shrinker above knee L8465 PO $44.00 Shrinker upper limb L8470 PO $6.02 Pros sock single ply BK L8480 PO $8.30 Pros sock single ply AK L8485 PO $10.08 Pros sock single ply upper l L8500 PO $ Artificial larynx L8501 PO $ Tracheostomy speaking valve L8507 PO $37.10 Trach-esoph voice pros pt in L8509 PO $96.71 Trach-esoph voice pros md in L8510 PO $ Voice amplifier L8511 PO $64.40 Indwelling trach insert L8512 PO $1.91 Gel cap for trach voice pros L8513 PO $4.60 Trach pros cleaning device L8514 PO $83.50 Repl trach puncture dilator L8515 PO $55.89 Gel cap app device for trach L8600 PO $ Implant breast silicone/eq L8603 PO $ Collagen imp urinary 2.5 ml L8606 PO $ Synthetic implnt urinary 1ml L8609 PO $5, Artificial cornea L8610 PO $ Ocular implant L8612 PO $ Aqueous shunt prosthesis L8613 PO $ Ossicular implant L8614 PO $17, Cochlear device L8615 PO $ Coch implant headset replace L8616 PO $93.02 Coch implant microphone repl L8617 PO $81.24 Coch implant trans coil repl L8618 PO $23.22 Coch implant tran cable repl L8619 PO $7, Coch imp ext proc/contr rplc L8621 PO $0.55 Repl zinc air battery L8622 PO $0.29 Repl alkaline battery L8623 PO $57.28 Lith ion batt CID,non-earlvl L8624 PO $ Lith ion batt CID, ear level L8627 PO $6, CID ext speech process repl L8628 PO $1, CID ext controller repl L8629 PO $ CID transmit coil and cable L8630 PO $ Metacarpophalangeal implant L8631 PO $1, MCP joint repl 2 pc or more L8641 PO $ Metatarsal joint implant L8642 PO $ Hallux implant

193 MEDICAL FEE SCHEDULES 11: L8658 PO $ Interphalangeal joint spacer L8659 PO $1, Interphalangeal joint repl L8670 PO $ Vascular graft, synthetic L8680 PO $ Implt neurostim elctr each L8681 PO $1, Pt prgrm for implt neurostim L8682 PO $5, Implt neurostim radiofq rec L8683 PO $4, Radiofq trsmtr for implt neu L8684 PO $ Radiof trsmtr implt scrl neu L8685 PO $11, Implt nrostm pls gen sng rec L8686 PO $7, Implt nrostm pls gen sng non L8687 PO $15, Implt nrostm pls gen dua rec L8688 PO $9, Implt nrostm pls gen dua non L8689 PO $1, External recharg sys intern L8690 PO $4, Aud osseo dev, int/ext comp L8691 PO $2, Osseointegrated snd proc rpl L8695 PO $14.74 External recharg sys extern Q0480 PO $79, Driver pneumatic vad, rep Q0481 PO $12, Microprcsr cu elec vad, rep Q0482 PO $4, Microprcsr cu combo vad, rep Q0483 PO $16, Monitor elec vad, rep Q0484 PO $3, Monitor elec or comb vad rep Q0485 PO $ Monitor cable elec vad, rep Q0486 PO $ Mon cable elec/pneum vad rep Q0487 PO $ Leads any type vad, rep only Q0489 PO $14, Pwr pck base combo vad, rep Q0490 PO $ Emr pwr source elec vad, rep Q0491 PO $ Emr pwr source combo vad rep Q0492 PO $78.84 Emr pwr cbl elec vad, rep Q0493 PO $ Emr pwr cbl combo vad, rep Q0494 PO $ Emr hd pmp elec/combo, rep Q0495 PO $3, Charger elec/combo vad, rep Q0496 PO $1, Battery elec/combo vad, rep Q0497 PO $ Bat clps elec/comb vad, rep Q0498 PO $ Holster elec/combo vad, rep Q0499 PO $ Belt/vest elec/combo vad rep Q0500 PO $27.04 Filters elec/combo vad, rep Q0501 PO $ Shwr cov elec/combo vad, rep Q0502 PO $ Mobility cart pneum vad, rep Q0503 PO $1, Battery pneum vad replacemnt Q0504 PO $ Pwr adpt pneum vad, rep veh Q0506 PO $ Lith-ion batt elec/pneum VAD V2020 PO $56.55 Vision svcs frames purchases V2100 PO $47.11 Lens spher single plano 4.00 V2101 PO $49.64 Single visn sphere V2102 PO $57.49 Singl visn sphere V2103 PO $40.91 Spherocylindr 4.00d/ d V2104 PO $45.30 Spherocylindr 4.00d/2.12-4d V2105 PO $49.32 Spherocylinder 4.00d/4.25-6d V2106 PO $54.46 Spherocylinder 4.00d/>6.00d V2107 PO $52.05 Spherocylinder 4.25d/12-2d V2108 PO $51.82 Spherocylinder 4.25d/2.12-4d V2109 PO $57.62 Spherocylinder 4.25d/4.25-6d V2110 PO $58.84 Spherocylinder 4.25d/over 6d V2111 PO $61.34 Spherocylindr 7.25d/ V2112 PO $66.96 Spherocylindr 7.25d/2.25-4d V2113 PO $73.58 Spherocylindr 7.25d/4.25-6d V2114 PO $81.74 Spherocylinder over 12.00d V2115 PO $68.90 Lens lenticular bifocal V2118 PO $75.59 Lens aniseikonic single V2121 PO $76.05 Lenticular lens, single V2200 PO $61.66 Lens spher bifoc plano 4.00d V2201 PO $66.76 Lens sphere bifocal V2202 PO $75.75 Lens sphere bifocal V2203 PO $62.20 Lens sphcyl bifocal 4.00d/.1 V2204 PO $63.86 Lens sphcy bifocal 4.00d/2.1 V2205 PO $69.62 Lens sphcy bifocal 4.00d/4.2 V2206 PO $70.32 Lens sphcy bifocal 4.00d/ove V2207 PO $64.74 Lens sphcy bifocal d/.

194 11: APPENDIX B - REGULATIONS V2208 PO $66.85 Lens sphcy bifocal /2. V2209 PO $67.97 Lens sphcy bifocal /4. V2210 PO $72.61 Lens sphcy bifocal /ov V2211 PO $75.41 Lens sphcy bifo /.25- V2212 PO $76.61 Lens sphcyl bifo /2.2 V2213 PO $79.47 Lens sphcyl bifo /4.2 V2214 PO $96.83 Lens sphcyl bifocal over 12. V2215 PO $90.00 Lens lenticular bifocal V2218 PO $ Lens aniseikonic bifocal V2219 PO $50.39 Lens bifocal seg width over V2220 PO $43.43 Lens bifocal add over 3.25d V2221 PO $87.23 Lenticular lens, bifocal V2300 PO $76.06 Lens sphere trifocal 4.00d V2301 PO $73.45 Lens sphere trifocal V2302 PO $74.50 Lens sphere trifocal V2303 PO $72.61 Lens sphcy trifocal 4.0/.12- V2304 PO $78.29 Lens sphcy trifocal 4.0/2.25 V2305 PO $80.77 Lens sphcy trifocal 4.0/4.25 V2306 PO $82.90 Lens sphcyl trifocal 4.00/>6 V2307 PO $79.89 Lens sphcy trifocal /. V2308 PO $80.01 Lens sphc trifocal /2. V2309 PO $82.31 Lens sphc trifocal /4. V2310 PO $83.69 Lens sphc trifocal />6 V2311 PO $80.66 Lens sphc trifo /.25- V2312 PO $81.17 Lens sphc trifo /2.25 V2313 PO $91.43 Lens sphc trifo /4.25 V2314 PO $ Lens sphcyl trifocal over 12 V2315 PO $ Lens lenticular trifocal V2318 PO $ Lens aniseikonic trifocal V2319 PO $51.33 Lens trifocal seg width > 28 V2320 PO $63.01 Lens trifocal add over 3.25d V2321 PO $ Lenticular lens, trifocal V2410 PO $99.73 Lens variab asphericity sing V2430 PO $ Lens variable asphericity bi V2500 PO $97.75 Contact lens pmma spherical V2501 PO $ Cntct lens pmma-toric/prism V2502 PO $ Contact lens pmma bifocal V2503 PO $ Cntct lens pmma color vision V2510 PO $ Cntct gas permeable sphericl V2511 PO $ Cntct toric prism ballast V2512 PO $ Cntct lens gas permbl bifocl V2513 PO $ Contact lens extended wear V2520 PO $ Contact lens hydrophilic V2521 PO $ Cntct lens hydrophilic toric V2522 PO $ Cntct lens hydrophil bifocl V2523 PO $ Cntct lens hydrophil extend V2530 PO $ Contact lens gas impermeable V2531 PO $ Contact lens gas permeable V2623 PO $1, Plastic eye prosth custom V2624 PO $54.91 Polishing artifical eye V2625 PO $ Enlargemnt of eye prosthesis V2626 PO $ Reduction of eye prosthesis V2627 PO $1, Scleral cover shell V2628 PO $ Fabrication & fitting V2700 PO $45.54 Balance lens V2710 PO $77.11 Glass/plastic slab off prism V2715 PO $13.98 Prism lens/es V2718 PO $31.89 Fresnell prism press-on lens V2730 PO $19.02 Special base curve V2744 PO $14.98 Tint photochromatic lens/es V2745 PO $12.02 Tint, any color/solid/grad V2750 PO $18.47 Anti-reflective coating V2755 PO $14.99 UV lens/es V2760 PO $15.31 Scratch resistant coating V2762 PO $52.77 Polarization, any lens V2770 PO $22.59 Occluder lens/es V2780 PO $11.30 Oversize lens/es V2782 PO $57.00 Lens, p/ g

195 MEDICAL FEE SCHEDULES 11: V2783 PO $64.27 Lens, >= 1.66 p/>=1.80 g V2784 PO $41.80 Lens polycarb or equal V2786 PO $0.00 Occupational multifocal lens Modifiers: NU Purchased, New (MOD) RR Rented UE Purchased, Used KM Replacement of Facial Prosthesis including new impression/moulage KN Replacement of Facial Prosthesis using previous master mold AU Urological, ostomy or trach item AV Item with prosthetic/orthotic device AW Item with a surgical dressing KE Bid Under Round I of the DMEPOS Competitive Bid Program ForUse With NonCompetitive Bid Base Equipment KF--Class III device KL DMEPOS Item Delivered Via Mail KC Replacement of Special Power Wheelchair Interface Categories: IN Inexpensive and Other Routinely Purchased Items (CATG) FS Frequently Serviced Items CR Capped Rental Items OX Oxygen and Oxygen Equipment OS Ostomy, Tracheostomy & Urological Items SD Surgical Dressings PO Prosthetics & Orthotics SU Supplies TE Transcutaneous Electrical Nerve Stimulators TS Therapeutic Shoes Exhibit 6 Codes Subject to the Daily Maximum CPT*/HCPSC Description *Current Procedural Terminology (CPT) is copyright 2010 American Medical Association (AIvIA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. the AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association STRAP CHEST STRAP SHOULDER STRAP ELBOW OR WRIST STRAP HAND OR FINGER STRAP HIP STRAP KNEE STRAP ANKLE AND/OR FT STRAP TOES APPLY PASTE BOOT APPLY MULTILAY COMPRESS LWR LEG APPLY FOOT SPLINT CAST/STRAP PROCEDURE MECHANICAL TRACTION THERAPY SUPERVISED includes treatment MODALITY with VAX-D, DRX and similar machines G0283 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS VASOPNEUMATIC DEVICE THERAPY SUPERVISED MODALITY PARAFFIN BATH THERAPY SUPERVISED MODALITY WHIRLPOOL THERAPY SUPERVISED MODALITY DIATHERMY EG, MICROWAVE SUPERVISED MODALITY INFRARED THERAPY SUPERVISED MODALITY ULTRAVIOLET THERAPY SUPERVISED

196 11: APPENDIX B - REGULATIONS MODALITY APPLICATION OF A MODALITY TO DIRECT ONE- ONE OR MORE AREAS; ELECTRICAL ON-ONE STIMULATION (MANUAL), EACH 15 PATIENT MINUTES CONTACT REQUIRED IONTOPHORESIS, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED CONTRAST BATHS, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED ULTRASOUND, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED HUBBARD TANK, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED UNLISTED PHYSICAL MEDICINE & REHAB MODALITY THERAPEUTIC PROCEDURE, 1 OR DIRECT ONE- MORE AREAS, EACH 15 MINUTES; ON-ONE THERAPEUTIC EXERCISES TO PATIENT DEVELOP STRENGTH AND ENDURANCE, CONTACT RANGE OF MOTION AND FLEXIBILITY REQUIRED NEUROMUSCULAR REEDUCATION OF DIRECT ONE- MOVEMENT, BALANCE COORDINATION, ON-ONE KINESTHETIC SENSE, POSTURE, AND/OR PATIENT PROPRIOCEPTION FOR SITTING OR CONTACT STANDING ACTIVITIES REQUIRED AQUATIC THERAPY WITH THERAPEUTIC EXERCISES MASSAGE THERAPY DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED UNLISTED PHYSICAL MEDICINE PROCEDURE MANUAL THERAPY TECHNIQUES (eg DIRECT ONE- MOBILIZATION/IvIANIPULATION, ON-ONE MANUAL LYMPHATIC DRAINAGE, PATIENT MANUAL TRACTION, 1 OR CONTACT MORE REGIONS, EACH 15 MINUTES REQUIRED GROUP THERAPEUTIC PROCEDURES, CONSTANT (2 OR MORE INDIVIDUALS) ATTENDANCE OF PROVIDER REQUIRED THERAPEUTIC ACTIVITIES, (USE OF DIRECT ONE- DYNAMIC ACTIVITIES TO IMPROVE ON-ONE FUNCTIONAL PERFORMANCE) PATIENT CONTACT REQUIRED SELF CARE MANAGEMENT TRAINING DIRECT ONE-

197 MEDICAL FEE SCHEDULES 11: ACUPUNCTURE, 1 OR MORE NEEDLES, ON-ONE WITHOUT ELECTRICAL STIMULATION, PATIENT INITIAL 15 MINUTES CONTACT REQUIRED ACUPUNCTURE, 1 OR MORE NEEDLES, DIRECT ONE- WITHOUT ELECTRICAL STIMULATION, ON-ONE EACH ADDITIONAL 15 MINUTES, PATIENT WITH REINSERTION OF NEEDLES CONTACT REQUIRED ACUPUNCTURE, 1 OR MORE NEEDLES, DIRECT ONE- WITH ELECTRICAL STIMULATION, ON-ONE INITIAL 15 MINUTES PATIENT CONTACT REQUIRED ACUPUNCTURE, 1 OR MORE NEEDLES, DIRECT ONE- WITH ELECTRICAL STIMULATION, ON-ONE EACH ADDITIONAL 15 MINUTES, WITH PATIENT REINSERTION OF NEEDLES CONTACT REQUIRED OSTEOPATHIC MANIPULATION 1-2 REGIONS OSTEOPATHIC MANIPULATION 3-4 REGIONS OSTEOPATHIC MANIPULATION 5-6 REGIONS OSTEOPATHIC MANIPULATION 7-8 REGIONS OSTEOPATHIC MANIPULATION 9-10 REGIONS CHIROPRACTIC MANIPULATION 1-2 REGIONS CHIROPRACTIC MANIPULATION 3-4 REGIONS CHIROPRACTIC MANIPULATION 5 REGIONS CHIROPRACTIC MANIPULATION EXTRASPINAL, 1 OR MORE REGIONS NOTE: FOR CHIROPRACTIC MANIPULATIVE TREATMENT, THE 5 SPINAL REGIONS RE- FERRED TO ARE: CERVICAL REGION (INCLUDES ATLANTO-OCCIPITAL JOINT); THO- RACIC REGION (INCLUDES COSTOVERTEBRAL AND COSTOTRANSVERSE JOINTS); LUMBAR REGION; SACRAL REGION; AND PELVIC (SACRO-ILIAC JOINT) REGION. THE FIVE EXTRA-SPINAL REGIONS REFERRED TO ARE: HEAD (INCLUDING TEMPOROMAN- DIBULAR JOINT, EXCLUDING ATLANTO-OCCIPITAL) (EXCLUDING COSTOTRANSVERSE AND COSTOVERTEBRAL JOINTS AND ABDOMEN) NOTE: FOR OSTEOMANIPULATIVE TREATMENT, THE BODY REGIONS REFERRED TO ARE: HEAD REGION; CERVICAL REGION; THORACIC REGION; LUMBAR REGION; SAC- RAL REGION; PELVIC REGION; LOWER EXTREMITIES; UPPER EXTREMITIES; RIB CAGE REGION; ABDOMEN AND VISCERA REGION NOTE: FOR STRAPPING, THIS IS A REPLACEMENT PROCEDURE USED DURING OR AF- TER THE PERIOD OF FOLLOW-UP CARE OR WHEN THE APPLICATION IS AN INITIAL SER- VICE PERFORMED WITHOUT A RESTORATIVE TREATMENT TO STABILIZE OR PROTECT A FRACTURE, INJURY OR DISLOCATION AND/OR TO AFFORD COMFORT TO A PATIENT. Exhibit 7 Hospital Outpatient Surgical Facility (HOSF) Fees Ancillary Serv- CPT* DESCRIPTION Hospital Hospital Not ices Outpatient Outpatient Subject Packaged Separ- Surgical Surgical to Multiple Item; No ate Facility Facility Procedure Separate Pay- Fees North Fees South Reductions Payment ment 0232T NJX PLATELET PLASMA AS

198 11: APPENDIX B - REGULATIONS G0289 ARTHRO, LOOSE BODY + CHONDRO X N DRAIN SKIN ABSCESS DRAIN SKIN ABSCESS REMOVE FOREIGN BODY REMOVE FOREIGN BODY 4, , DRAIN HEMATOMA/FLUID 3, , PUNCTURE DRAIN LESION COMPLEX DRAIN WOUND 5, , DEBRIDE INFECTED SKIN DEBRIDE INFECTED SKIN, ADDED DEBRIDE SKIN, FX 1, , DEBRIDE SKIN/MUSCLE, FX 1, , DEBRIDE SKIN/MUSCLE/BONE, FX 1, , DEBRIDE SKIN/TISSUE DEBRIDE TISSUE/MUSCLE DEBRIDE TISSUE/MUSCLE BONE 2, , DEBRIDE SUBQ TISSUE ADD-ON DEBRIDE MUSCLE/FASCIA ADD-ON DEBRIDE BONE ADD-ON 2, , TRIM SKIN LESION TRIM SKIN LESIONS, 2 TO TRIM SKIN LESIONS, OVER BIOPSY SKIN LESION BIOPSY SKIN, ADDED REMOVE SKIN TAGS SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION SHAVE SKIN LESION EXCISE TRT-EXT BENIGN+ MARG 0.5 < CM 1, , EXCISE TRT-EXT BENIGN+ MARG CM 1, , EXCISE TRT-EXT BENIGN+ MARG CM 1, , EXCISE TRT-EXT BENIGN+ MARG CM 2, , EXCISE TRT-EXT BENIGN+ MARG CM 4, , EXCISE TRT-EXT BENIGN+ MARG > 4.0 CM 4, , EXCISE H-F-NECK-SP BENIGN+MARG 0.5 < 2, , EXCISE H-F-NECK-SP BENIGN+MARG , , EXCISE H-F-NECK-SP BENIGN+MARG , , EXCISE H-F-NECK-SP BENIGN+MARG , , EXCISE H-F-NECK-SP BENIGN+MARG , , EXCISE H-F-NECK-SP BENIGN+MARG > 4 CM 6, ,562.30

199 MEDICAL FEE SCHEDULES 11: EXCISE FACE-MM BENIGN+MARG 0.5 < CM 1, , EXCISE FACE-MM BENIGN+MARG CM 1, , EXCISE FACE-MM BENIGN+MARG CM 2, , EXCISE FACE-MM BENIGN+MARG CM 2, , EXCISE FACE-MM BENIGN+MARG CM 2, , TRIM NAIL(S) DEBRIDE NAIL, DEBRIDE NAIL, 6 OR MORE REMOVE NAIL PLATE REMOVE NAIL PLATE, ADDED DRAIN BLOOD UNDER NAIL REMOVE NAIL BED 1, , REMOVE NAIL BED/FINGER TIP 6, , REPAIR NAIL BED RECONSTRUCT NAIL BED 4, , EXCISE NAIL FOLD, TOE INJECTION INTO SKIN LESIONS ADDED SKIN LESIONS INJECTION THERAPY FOR CONTOUR DEFECTS THERAPY FOR CONTOUR DEFECTS INSERT TISSUE EXPANDER(S) 6, , INSERT DRUG IMPLANT DEVICE AS REMOVE DRUG IMPLANT DEVICE AS REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) REPAIR SUPERFICIAL WOUND(S) CLOSE SPLIT WOUND 1, , CLOSE SPLIT WOUND

200 11: APPENDIX B - REGULATIONS INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR S/TRT/EXT INTERMED WOUND REPAIR N-HF/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR N-HG/GENITAL INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM INTERMED WOUND REPAIR FACE/MM REPAIR WOUND OR LESION 1, , REPAIR WOUND OR LESION 1, , REPAIR WOUND/LESION, ADDED 1, , REPAIR WOUND OR LESION REPAIR WOUND OR LESION REPAIR WOUND/LESION, ADDED REPAIR WOUND OR LESION REPAIR WOUND OR LESION 1, , REPAIR WOUND/LESION, ADDED REPAIR WOUND OR LESION 1, , REPAIR WOUND OR LESION 1, , REPAIR WOUND OR LESION 1, , REPAIR WOUND/LESION, ADDED LATE CLOSE WOUND 6, , SKIN TISSUE REARRANGEMENT 4, , SKIN TISSUE REARRANGEMENT 4, , SKIN TISSUE REARRANGEMENT 4, ,005.94

201 MEDICAL FEE SCHEDULES 11: SKIN TISSUE REARRANGEMENT 4, , SKIN TISSUE REARRANGEMENT 4, , SKIN TISSUE REARRANGEMENT 4, , SKIN TISSUE REARRANGEMENT 4, , SKIN TISSUE REARRANGEMENT 4, , SKIN TISSUE REARRANGEMENT 6, , SKIN TISSUE REARRANGE ADDED 6, , WOUND PREP, TRUNK/ARM/LEG 1, , WOUND PREP, ADDED 100 CM 1, , WOUND PREP, F/N/HF/G 1, , WOUND PREP, F/N/HF/G, ADDED CM 1, , SKIN PINCH GRAFT 1, , SKIN SPLIT GRAFT, TRUNK/ARM/LEG 6, , SKIN SPLIT GRAFT T/A/L, ADDED 6, , SKIN SPLIT A-GRAFT FAC/NECK/HF/G 6, , SKIN SPLIT A-GRAFT F/N/HF/G ADDED 6, , DERM AUTOGRAFT, TRUNK/ARM/LEG 4, , ACELLULAR GRAFT TRUNK/ARMS/LEGS 1, , ACELLULAR GRAFT T/ARM/LEG, ADDED ACELLULAR GRAFT, F/N/HF/G1, , SKIN FULL GRAFT SCALP/ARM/LEG 4, , SKIN FULL GRAFT, ADDED 1, , SKIN FULL GRAFT FACE/GENITAL/HF 4, , SKIN FULL GRAFT, ADDED 1, , SKIN FULL GRAFT EEN & LIPS 4, , APPLY ACELLULAR ALLOGRAFT T/ARM/LEG 1, , APPLY ACELLULAR GRAFT T/A/L, ADDED 1, , APPLY CULT SKIN SUBSTITUTE APPLY CULT SKIN SUB, ADDED APPLY CULT DERM SUB F/N/HF/G APPLY CULT DERM F/HF/G ADDED APPLY ACELLULAR XENOGRAFT 1, , APPLY ACELLULAR XENOGRAFT ADDED 1, , FORM SKIN PEDICLE FLAP 6, ,186.06

202 11: APPENDIX B - REGULATIONS FORM SKIN PEDICLE FLAP 6, , FORM SKIN PEDICLE FLAP 6, , FORM SKIN PEDICLE FLAP 6, , SKIN GRAFT 6, , MUSCLE-SKIN GRAFT, HEAD/NECK 6, , MUSCLE-SKIN GRAFT, TRUNK 6, , MUSCLE-SKIN GRAFT, ARM 6, , MUSCLE-SKIN GRAFT, LEG 6, , DERMA-FAT-FASCIA GRAFT 6, , ABRASION TREAT SKIN 6, , ABRASION TREAT SKIN 1, , ABRASION TREAT SKIN 1, , ABRASION, LESION, SING ABRASION, LESIONS, ADDED REVISE UPPER EYELID 6, , EXCISE SKIN ABD 6, , EXCISE EXCESSIVE SKIN TISSUE 6, , REMOVE SUTURES DRESSING CHANGE NOT FOR BURN AS REMOVE HIP PRESSURE SORE6, , REMOVE HIP PRESSURE SORE6, , REMOVE HIP PRESSURE SORE6, , REMOVE HIP PRESSURE SORE6, , REMOVE HIP PRESSURE SORE6, , REMOVE THIGH PRESSURE SORE 6, , REMOVE THIGH PRESSURE SORE 6, , REMOVE THIGH PRESSURE SORE 4, , REMOVE THIGH PRESSURE SORE 4, , REMOVE THIGH PRESSURE SORE 4, , REMOVE THIGH PRESSURE SORE 4, , INITIAL TREAT BURN(S) DRESS/DEBRIDE P-THICK BURN, S DRESS/DEBRIDE P-THICK BURN, M DRESS/DEBRIDE P-THICK BURN, L DESTROY PREMALIG LESION DESTROY PREMALIG LES, DESTROY PREMALIG LESIONS DESTROY SKIN LESIONS DESTROY SKIN LESIONS DESTROY SKIN LESIONS DESTROY B9 LESION, DSTRJ B9 SK TGS/CUTAN VASC 15/> CHEM CAUT GRANLTJ TISS PROUD FLESH SINUS/FSTL DESTROY SKIN LESIONS DESTROY SKIN LESIONS DRAIN BREAST LESION 1, ,066.98

203 MEDICAL FEE SCHEDULES 11: REMOVE BREAST LESION 6, , EXCISE BREAST LESION 6, , PLACE NEEDLE WIRE, BREAST N EXPLORE WOUND, NECK 2, , EXPLORE WOUND, CHEST 6, , EXPLORE WOUND, ABDOMEN 6, , EXPLORE WOUND, EXTREMITY 3, , REMOVE FOREIGN BODY 6, , REMOVE FOREIGN BODY 6, , THERAPEUTIC INJECTION, CARP TUNNEL INJECT TENDON SHEATH/LIGAMENT INJECT TENDON ORIGIN/INSERT INJECT TRIGGER POINT, 1/2 MUSCLE INJECT TRIGGER POINTS, =/> DRAIN/INJ, JOINT/BURSA DRAIN/INJ, JOINT/BURSA DRAIN/INJ, JOINT/BURSA ASPIRATE/INJECT GANGLION CYST TREAT BONE CYST 1, , INSERT & REMOVE BONE PIN 6, , APPLY, REM FIXATION DEVICE 1, , APPLY PELVIS BRACE 6, , APPLY THIGH BRACE 6, , REMOVE FIXATION DEVICE AS REMOVE SUPPORT IMPLANT 4, , REMOVE SUPPORT IMPLANT 6, , APPLY BONE FIXATION DEVICE 8, , APPLY BONE FIXATION DEVICE 8, , ADJUST BONE FIXATION DEVICE 6, , REMOVE BONE FIXATION DEVICE 6, , COMP MULTIPLANE EXT FIXATION 8, , COMP EXT FIXATE STRUT CHANGE 5, , REMOVE BONE FOR GRAFT 8, , REMOVE BONE FOR GRAFT 8, , REMOVE CARTILAGE FOR GRAFT 6, , REMOVE CARTILAGE FOR GRAFT 6, , REMOVE FASCIA FOR GRAFT 4, , REMOVE FASCIA FOR GRAFT 4, , REMOVE TENDON FOR GRAFT 8, , REMOVE TISSUE FOR GRAFT 1, , FLUID PRESSURE, MUSCLE ELECTRICAL BONE

204 11: APPENDIX B - REGULATIONS STIMULATION N US BONE STIMULATION AS COMPUTER-ASSIST DIR MS PX N REMOVE JAW JOINT CARTILAGE 12, , REMOVE CORONOID PROCESS 12, , MANIPULATE TMJ W/ANESTH 2, , PREPARE FACE/ORAL PROSTHESIS 4, , INTERDENTAL FIXATION 2, , INJECTION, JAW JOINT X-RAY N REDUCE FACIAL BONES 12, , FACE BONE GRAFT 12, , RECONSTRUCT JAW JOINT 12, , RECONSTRUCT JAW JOINT 12, , RECONSTRUCT JAW JOINT 12, , RECONSTRUCT LOWER JAW 12, , RECONSTRUCT JAW 12, , RECONSTRUCT JAW 12, , RECONSTRUCT JAW 12, , RECONSTRUCT JAW 12, , TREAT NOSE FX TREAT NOSE FX 4, , TREAT NOSE FX 4, , TREAT NOSE FX 6, , TREAT NOSE FX 6, , TREAT NOSE FX 6, , TREAT CHEEK BONE FX 6, , TREAT CHEEK BONE FX 6, , TREAT CHEEK BONE FX 12, , TREAT EYE SOCKET FX 12, , TREAT EYE SOCKET FX 12, , TREAT EYE SOCKET FX 12, , TREAT EYE SOCKET FX 12, , TREAT EYE SOCKET FX 2, , TREAT EYE SOCKET FX 4, , TREAT EYE SOCKET FX 12, , TREAT EYE SOCKET FX 12, , TREAT EYE SOCKET FX 12, , TREAT LOWER JAW FX TREAT LOWER JAW FX 2, , TREAT LOWER JAW FX 4, , TREAT LOWER JAW FX 12, , TREAT LOWER JAW FX 6, , TREAT LOWER JAW FX 12, , TREAT LOWER JAW FX 12, , TREAT LOWER JAW FX 12, , TREAT LOWER JAW FX 12, , TREAT RIB FX TREAT STERNUM FX REVISE THORAX SPINE 13, , TREAT SPINE PROCESS FX TREAT SPINE FX 1, , TREAT SPINE FX 5, , MANIPULATE SPINE 4, , PERCUT VERTEBROPLASTY THORACIC 8, , PERCUT VERTEBROPLASTY

205 MEDICAL FEE SCHEDULES 11: LUMBAR 8, , PERCUT VERTEBROPLASTY ADDED 8, , LUMBAR SPINE FUSION 13, , SPINE FUSION, EXTRA SEGMENT 13, , APPLY SPINE PROSTH DEVICE 6, , PARTIAL REMOVE COLLAR BONE 8, , REMOVE COLLAR BONE 8, , REMOVE SHOULDER BONE, PART 12, , REMOVE SHOULDER FOREIGN BODY 6, , INJECTION FOR SHOULDER X-RAY TX SHO AREA 1 TDN 8, , TX SHO AREA MLT TDN THRU SM INC 8, , OPEN REPAIR OF ROTATOR CUFF, RECENT 12, , OPEN REPAIR OF ROTATOR CUFF, OLD 12, , CORACOACROMIAL LIGM RLS +-ACROMP 12, , RECONSTRUCTION ROTATOR CUFF, OLD 12, , TENODIS LONG TDN BICEPS 12, , RESCJ/TRNSPLJ LONG TDN BICEPS 12, , RECONSTRUCT SHOULDER JOINT 19, , REVISE COLLAR BONE 12, , REVISE COLLAR BONE 24, , TREAT CLAVICLE FX TREAT CLAVICLE FX 5, , TREAT CLAVICLE FX 18, , TREAT CLAVICLE DISLOCATION 1, , TREAT CLAVICLE DISLOCATION 1, , TREAT CLAVICLE DISLOCATION 13, , TREAT CLAVICLE DISLOCATION TREAT CLAVICLE DISLOCATION 1, , TREAT CLAVICLE DISLOCATION 13, , TREAT CLAVICLE DISLOCATION 13, , TREAT SHOULDER BLADE FX TREAT HUMERUS FX TREAT HUMERUS FX 5, , TREAT HUMERUS FX 18, , TREAT HUMERUS FX 18, , TREAT HUMERUS FX TREAT HUMERUS FX 5, , TREAT HUMERUS FX 18, , TREAT SHOULDER N1

206 11: APPENDIX B - REGULATIONS DISLOCATION TREAT SHOULDER DISLOCATION 4, , FIXATE SHOULDER 4, , INJECTION FOR ELBOW X-RAY MANIPULATE ELBOW W/ANESTH 4, , ARM TENDON LENGTHENING 8, , REPAIR BICEPS TENDON 12, , REPAIR ARM TENDON/MUSCLE 12, , REPAIR RUPTURED TENDON 12, , REPAIR ELBOW LAT LIGAMENT W/TISS 8, , TREAT HUMERUS FX TREAT HUMERUS FX TREAT HUMERUS FX 18, , TREAT HUMERUS FX 18, , TREAT HUMERUS FX TREAT HUMERUS FX 1, , TREAT HUMERUS FX 18, , TREAT HUMERUS FX 18, , TREAT HUMERUS FX TREAT HUMERUS FX TREAT HUMERUS FX 18, , TREAT HUMERUS FX TREAT HUMERUS FX TREAT HUMERUS FX 18, , INCISE TENDON SHEATH 6, , INCISE FLEXOR CARPI RADIALIS 6, , DECOMPRESS FOREARM 1 SPACE 8, , DECOMPRESS FOREARM 1 SPACE 8, , DECOMPRESS FOREARM 2 SPACES 8, , DECOMPRESS FOREARM 2 SPACES 8, , EXCISE WRIST TENDON SHEATH 8, , REMOVE WRIST BONES 8, , INJECTION FOR WRIST X-RAY MANIPULATE WRIST W/ANESTH 5, , REPAIR FOREARM TENDON/MUSCLE 8, , REPAIR FOREARM TENDON/MUSCLE 8, , REPAIR FOREARM TENDON/MUSCLE 8, , REPAIR FOREARM TENDON/MUSCLE 8, , REPAIR FOREARM TENDON/MUSCLE 8, , REPAIR FOREARM TENDON/MUSCLE 8, , RELEASE WRIST/FOREARM N1 N1

207 MEDICAL FEE SCHEDULES 11: TENDON 6, , TREAT FX RADIUS TREAT FX RADIUS 1, , TREAT FX RADIUS 13, , TREAT FX RADIUS 13, , TREAT FX RADIUS 13, , TREAT FX ULNA TREAT FX ULNA TREAT FX ULNA 13, , TREAT FX RADIUS & ULNA TREAT FX RADIUS & ULNA 1, , TREAT FX RADIUS & ULNA 18, , TREAT FX RADIUS/ULNA 18, , TREAT FX RADIUS/ULNA TREAT FX RADIUS/ULNA 1, , TREAT FX DISTAL RADIAL 7, , TREAT FX RADIAL EXTRA-ARTICULAR 18, , TREAT FX RADIAL INTRA-ARTICULAR 18, , TREAT FX RADIAL 3+ FRAG 18, , TREAT WRIST BONE FX TREAT WRIST BONE FX 1, , TREAT WRIST BONE FX 13, , TREAT WRIST BONE FX TREAT WRIST BONE FX TREAT WRIST BONE FX 13, , TREAT WRIST BONE FX TREAT FX ULNAR STYLOID 13, , TREAT FX ULNAR STYLOID 7, , TREAT FX ULNAR STYLOID 7, , TREAT WRIST DISLOCATION 7, , TREAT WRIST FX TREAT WRIST FX 7, , INCISE FINGER TENDON SHEATH 4, , EXCISE HAND TUMOR DEEP < 1.5 CM 4, , REVISE FINGER JOINT, EACH 4, , TENDON EXCISE PALM/FINGER 4, , MANIPULATE FINGER W/ANESTH 1, , REPAIR HAND TENDON 4, , REPAIR FINGER TENDON 4, , RELEASE HAND/FINGER TENDON 4, , TRANSPLANT HAND TENDON 8, , RELEASE FINGER CONTRACTURE 4, , REPAIR HAND JOINT 4, , TREAT METACARPAL FX TREAT METACARPAL FX TREAT METACARPAL FX 5, , TREAT METACARPAL FX 7, , TREAT METACARPAL FX 13, , TREAT FINGER FX, EACH TREAT FINGER FX, EACH TREAT FINGER FX, EACH 7, , TREAT FINGER FX, EACH 7, , TREAT FINGER FX, EACH

208 11: APPENDIX B - REGULATIONS TREAT FINGER FX, EACH TREAT FINGER FX, EACH 7, , TREAT FINGER FX, EACH TREAT FINGER FX, EACH INJECTION FOR HIP X-RAY N INJECTION FOR HIP X-RAY N TREAT PELVIC RING FX TREAT PELVIC RING FX 4, , MANIPULATE HIP JOINT 4, , REPAIR KNEE CARTILAGE 8, , REPAIR KNEE LIGAMENT 12, , REVISE UNSTABLE KNEECAP 12, , REVISE UNSTABLE KNEECAP 12, , REVISION/REMOVE KNEECAP 12, , TREAT THIGH FX 1, , TREAT THIGH FX TREAT THIGH FX 5, , TREAT THIGH FX TREAT THIGH FX TREAT THIGH FX 7, , TREAT THIGH FX 1, , TREAT KNEECAP FX TREAT KNEECAP FX 13, , TREAT KNEE FX TREAT KNEE FX 5, , TREAT KNEE FX(S) FIXATE KNEE JOINT 4, , REVISE LOWER LEG TENDON 8, , REVISE LOWER LEG TENDONS 8, , REVISE LOWER LEG TENDON 12, , REVISE LOWER LEG TENDON 12, , REVISE ADDEDITIONAL LEG TENDON 12, , REPAIR ANKLE LIGAMENT 8, , REPAIR ANKLE LIGAMENTS 8, , REPAIR ANKLE LIGAMENT 8, , TREAT TIBIA FX TREAT TIBIA FX 5, , TREAT TIBIA FX 13, , TREAT TIBIA FX 18, , CLOSED TREAT MEDIAL ANKLE FX CLOSED TREAT MED ANKLE FX W/MANIP 5, , OPEN TREAT MEDIAL ANKLE FX 13, , TREAT ANKLE FX TREAT ANKLE FX TREAT ANKLE FX 13, , TREAT ANKLE FX TREAT ANKLE FX TREAT ANKLE FX 13, , TREAT ANKLE FX TREAT ANKLE FX 1, , TREAT ANKLE FX 13, ,202.49

209 MEDICAL FEE SCHEDULES 11: TREAT ANKLE FX 18, , TREAT LOWER LEG FX TREAT LOWER LEG FX 5, , TREAT LOWER LEG FX 13, , TREAT LOWER LEG FX 18, , TREAT LOWER LEG FX 18, , TREAT LOWER LEG JOINT 13, , TREAT ANKLE DISLOCATION TREAT ANKLE DISLOCATION 4, , TREAT ANKLE DISLOCATION 13, , TREAT ANKLE DISLOCATION 13, , FIXATE ANKLE JOINT 4, , PART REMOVE ANKLE/HEEL 6, , PARTIAL REMOVE FOOT BONE 6, , TREAT HEEL FX TREAT HEEL FX 5, , TREAT HEEL FX 18, , TREAT/GRAFT HEEL FX 13, , TREAT ANKLE FX TREAT ANKLE FX TREAT ANKLE FX 7, , TREAT ANKLE FX 13, , TREAT METATARSAL FX TREAT METATARSAL FX TREAT METATARSAL FX 7, , TREAT METATARSAL FX 13, , FUSE FOOT BONES 15, , FUSE FOOT BONES 15, , FUSE FOOT BONES 15, , FUSE BIG TOE JOINT 15, , APPLY LONG ARM CAST X APPLY FOREARM CAST X APPLY HAND/WRIST CAST X APPLY FINGER CAST X APPLY LONG ARM SPLINT X APPLY FOREARM SPLINT X APPLY FOREARM SPLINT X APPLY FINGER SPLINT X APPLY FINGER SPLINT X STRAP CHEST X STRAP SHOULDER X STRAP ELBOW OR WRIST X STRAP HAND OR FINGER X APPLY LONG LEG CAST X APPLY LONG LEG CAST X APPLY LONG LEG CAST X APPLY SHORT LEG CAST X APPLY SHORT LEG CAST X APPLY LEG CAST X APPLY LONG LEG SPLINT X APPLY LOWER LEG SPLINT X STRAP HIP X STRAP KNEE X STRAP ANKLE AND/OR FT X STRAP TOES X APPLY PASTE BOOT X APPLY MULTILAY COMPRESS

210 11: APPENDIX B - REGULATIONS LWR LEG X APPLY FOOT SPLINT X REMOVE/REVISE CAST X REMOVE/REVISE CAST X REMOVE/REVISE CAST X WEDGE CAST X JAW ARTHROSCOPY/SURG 8, , JAW ARTHROSCOPY/SURG 8, , SHOULDER ARTHROSCOPY, DIAG 8, , SHOULDER ARTHROSCOPY/SURG 13, , SHOULDER ARTHROSCOPY/SURG 13, , SHOULDER ARTHROSCOPY/SURG 13, , SHOULDER ARTHROSCOPY/SURG 13, , SHOULDER ARTHROSCOPY/SURG 13, , SHOULDER ARTHROSCOPY/SURG 8, , SHOULDER ARTHROSCOPY/SURG 13, , SHOULDER ARTHROSCOPY/SURG 8, , SHOULDER ARTHROSCOPY/SURG 13, , SHOULDER ARTHROSCOPY/SURG 13, , ARTHROSCOPY ROTATOR CUFF REPAIR 13, , ARTHROSCOPY BICEPS TENODESIS 13, , ELBOW ARTHROSCOPY 8, , ELBOW ARTHROSCOPY/SURG 8, , ELBOW ARTHROSCOPY/SURG 8, , ELBOW ARTHROSCOPY/SURG 8, , WRIST ARTHROSCOPY 8, , WRIST ARTHROSCOPY/SURG 8, , WRIST ARTHROSCOPY/SURG 8, , WRIST ARTHROSCOPY/SURG 8, , WRIST ARTHROSCOPY/SURG13, , WRIST ENDOSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , TIBIAL ARTHROSCOPY/SURG13, , HIP ARTHROSCOPY, DIAG 13, , HIP ARTHROSCOPY/SURG 13, , HIP ARTHROSCOPY/SURG 13, , HIP ARTHROSCOPY/SURG 13, , KNEE ARTHROSCOPY, DIAG 8, , KNEE ARTHROSCOPY/DRAIN 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, ,974.74

211 MEDICAL FEE SCHEDULES 11: KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 8, , KNEE ARTHROSCOPY/SURG 24, , KNEE ARTHROSCOPY/SURG 24, , ANKLE ARTHROSCOPY/SURG 13, , ANKLE ARTHROSCOPY/SURG8, , ANKLE ARTHROSCOPY/SURG8, , ANKLE ARTHROSCOPY/SURG8, , ANKLE ARTHROSCOPY/SURG8, , ANKLE ARTHROSCOPY/SURG13, , INTRANASAL BIOPSY 2, , EXCISE INFERIOR TURBINATE 4, , RESECT INFERIOR TURBINATE 6, , INJECTION TREAT NOSE 2, , REMOVE NASAL FOREIGN BODY AS REMOVE NASAL FOREIGN BODY 4, , REPAIR NASAL SEPTUM 6, , ABLATE INF TURBINATE SUBMUCOSAL 4, , CONTROL NOSEBLEED CONTROL NOSEBLEED CONTROL NOSEBLEED THERAPEUTIC FX, NASAL INF TURB 4, , IRRIGATE MAXILLARY SINUS EXPLORE MAXILLARY SINUS6, , NASAL ENDOSCOPY, DIAG NASAL/SINUS ENDOSCOPY, SURG 5, , NASAL/SINUS ENDOSCOPY, SURG 5, , REMOVE ETHMOID SINUS 8, , EXPLORE MAXILLARY SINUS8, , ENDOSCOPY, MAXILLARY SINUS 8, , INSERT EMERGENCY AIRWAY X DIAGNOSTIC LARYNGOSCOPY LARYNGOSCOPY FOR ASPIRATION 5, , DIAG LARYNGOSCOPY EXCL NB 5, , DIAGNOSTIC LARYNGOSCOPY DIAGNOSTIC LARYNGOSCOPY1, INCISE WINDPIPE 6, , INCISE WINDPIPE 2, , DIAG BRONCHOSCOPE/WASH2, , DIAG BRONCHOSCOPE/LAVAGE2, , BRONCHOSCOPY, CLEAR AIRWAYS 2, , BRONCHOSCOPY, RECLEAR AIRWAY 2, ,443.97

212 11: APPENDIX B - REGULATIONS BIOPSY LUNG OR MEDIASTINUM 2, , INSERT CHEST TUBE 1, , THORACOSCOPY, DIAGNOSTIC 9, , INSERT HEART ELECTRODE 9, , INSERT PULSE GENERATOR 12, , PLACE NEEDLE IN VEIN N INJECTION EXT VENOGRAPHY N PLACE CATHETER IN VEIN N PLACE CATHETER IN VEIN N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N ESTABLISH ACCESS TO ARTERY N PLACE CATHETER IN AORTA N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N PLACE CATHETER IN ARTERY N BLOOD DRAW < 3 YRS FEM/JUGULAR N BLOOD DRAW < 3 YRS OTHER VEIN N NON-ROUTINE BL DRAW > 3 YRS N VEIN ACCESS CUTDOWN > 1 YR AS BLOOD TRANSFUSION SERVICE X INJECTION THERAPY VEINS APHERESIS PLATELETS 3, , X APHERESIS PLASMA 3, , X APHERESIS, ADSORP/REINFUSE 8, , X INSERT NON-TUNNEL CV CATH 3, , INSERT NON-TUNNEL CV CATH 3, , INSERT TUNNELED CV CATH 5, , INSERT PICC CATH 3, , INSERT PICVAD CATH 5, , REPAIR TUNNELED CV CATH 3, , REPLACE TUNNELED CV CATH 5, , REPLACE CVAD CATH 3, , REPLACE PICC CATH 3, , REMOVE TUNNELED CV CATH 1, , COLLECT BLOOD PICC DECLOT VASCULAR DEVICE INJECT W/FLUOR, EVAL CV DEVICE WITHDRAW ARTERIAL BLOOD

213 MEDICAL FEE SCHEDULES 11: INSERT CATHETER, ARTERY N INSERT CATHETER, ARTERY N INSERT CANNULA 8, , INSERT CANNULA 8, , INSERT CANNULA 8, , AV FUSE, UPPER ARM, CEPHALIC 11, , AV FISTULA REVISION 11, , EXTERNAL CANNULA DECLOTTING TRANSCATHETER OCCLUSION 19, , TEMPORAL ARTERY PROCEDURE 4, , REVISE MAJOR VEIN 11, , REVISE MAJOR VEIN 7, , INJECTION FOR SPLEEN X-RAY N UPPER GI ENDOSCOPY, DIAGNOSIS 2, , UPPER GI SCOPE W/SUBMUCOSA INJECT 2, , UPPER GI ENDOSCOPY, BIOPSY 2, , PLACE GASTROSTOMY TUBE 2, , UPPER GI ENDOSCOPY/GUIDE WIRE 2, , ESOPH ENDOSCOPY, DILATION 2, , OPERATIVE UPPER GI ENDOSCOPY 2, , ENDOSCOPIC ULTRASOUND EXAM 2, , ENDO CHOLANGIOPANCRE- ATOGRAPHY 6, , DILATE ESOPHAGUS 1, , CHANGE GASTROSTOMY TUBE PLACE GASTROSTOMY TUBE 4, , INTRODUCE GASTROINTESTINAL TUBE 1, , INCISE RECTAL ABSCESS 6, , DIAGNOSTIC ANOSCOPY AS NEEDLE BIOPSY LIVER 2, , PUNCTURE, PERITONEAL CAVITY 1, , DIAG LAP SEPARATE PROC 10, , INSERT ABDOM DRAIN, PERM 7, , PART RPR I/HERNIA INIT REDUCE >5 YR 8, , INSERT KIDNEY DRAIN 4, , INJECTION FOR KIDNEY X-RAY N INJECTION FOR BLADDER X-RAY N INJECTION FOR BLADDER X-RAY N IRRIGATION BLADDER INSERT BLADDER CATHETER AS

214 11: APPENDIX B - REGULATIONS INSERT TEMP BLADDER CATH AS INSERT BLADDER CATH, COMPLEX CHANGE BLADDER TUBE TREAT BLADDER LESION SIMPLE CYSTOMETROGRAM COMPLEX CYSTOMETROGRAM ELECTRO-UROFLOWMETRY, FIRST ANAL/URINARY MUSCLE STUDY INTRAABDOMINAL PRESSURE TEST US URINE CAPACITY MEASURE AS CYSTOSCOPY 2, , CYSTOSCOPY & URETER CATHETER 7, , CYSTOSCOPY W/BIOPSY(S) 7, , CYSTOSCOPY & TREAT 4, , CYSTOSCOPY & TREAT 4, , CYSTOSCOPY & TREAT 7, , CYSTOURETERO & OR PYELOSCOPE 7, , DILATE URETHRA STRICTURE DILATE URETHRA STRICTURE DILATE URETHRA DILATE URETHRA PENILE INJECTION EXAM CERVIX W/SCOPE BIOPSY CERVIX 1, , CRYOCAUTERY CERVIX CATHETER FOR HYSTERORRHAPHY N HYSTEROSCOPY, BIOPSY 6, , AMNIOCENTESIS, DIAGNOSTIC FETAL NON-STRESS TEST ABORTION 5, , TREAT TRIGEMINAL NERVE 5, , EPIDURAL LYSIS MULT SESSIONS 2, , EPIDURAL LYSIS ON SINGLE DAY 3, , SPINAL FLUID TAP, DIAGNOSTIC 1, INJECT EPIDURAL PATCH 2, , TREAT SPINAL CORD L ESION 2, , TREAT SPINAL CORD LESION 2, , TREAT SPINAL CANAL LESION 2, , INJECTION FOR MYELOGRAM N PERCUTANEOUS DISKECTOMY 10, , INJECT FOR SPINE DISK

215 MEDICAL FEE SCHEDULES 11: X-RAY N INJECT FOR SPINE DISK X-RAY N INJECTION INTO DISK LESION 2, , INJECT SPINE C/T 2, , INJECT SPINE L/S (CD) 2, , INJECT SPINE W/CATH, C/T 2, , INJECT SPINE W/CATH L/S (CD) 3, , IMPLANT SPINAL CANAL CATH 11, , REMOVE SPINAL CANAL CATHETER 3, , INSERT SPINE INFUSION DEVICE 11, , IMPLANT SPINE INFUSION PUMP 22, , REMOVE SPINE INFUSION DEVICE 10, , ANALYZE SPINE INFUSION PUMP X ANALYZE SPINE INFUSION PUMP X NECK SPINE DISK SURG 13, , LOW BACK DISK SURG 13, , SPINAL DISK SURG, ADDED 13, , LAMINOTOMY, SINGLE CERV 13, , LAMINOTOMY, SINGLE LUMBAR 13, , REMOVE SPINAL LAMINA 13, , REMOVE SPINAL LAMINA 13, , REMOVE SPINAL LAMINA 13, , REMOVE SPINAL LAMINA, ADDED 13, , DECOMPRESS SPINAL CORD13, , DECOMPRESS SPINE CORD, ADDED 13, , NECK SPINE DISK SURG 13, , NECK SPINE DISK SURG 13, , IMPLANT NEUROELECTRODES 17, , X IMPLANT NEUROELECTRODES 13, , X INSERT/REDO SPINE N GENERATOR 23, , X REVISE/REMOVE NEURORECEIVER 7, , NERVE BLOCK INJ, TRIGEMINAL NERVE BLOCK INJ, FACIAL NERVE BLOCK INJ, OCCIPITAL1, NERVE BLOCK INJ, SPINAL ACCESSORY 2, , NERVE BLOCK INJ, CERV PLEXUS 1, NERVE BLOCK INJ, BRACHIAL PLEXUS 1, NERVE BLOCK CONT INFUSE, B PLEX 2, , NERVE BLOCK INJ,

216 11: APPENDIX B - REGULATIONS AXILLARY 1, NERVE BLOCK INJ, SUPRASCAPULAR 1, NERVE BLOCK INJ, INTERCOSTAL, SING 1, NERVE BLOCK INJ, INTERCOSTAL, MULT 2, , NERVE BLOCK INJ, ILIO-ING/HYPOGI 1, NERVE BLOCK INJ, PUDENDAL 2, , NERVE BLOCK INJ, PARACERV 1, NERVE BLOCK INJ, SCIATIC, SING 2, , NERVE BLOCK INJ, SCIATIC, CONT INF 2, , NERVE BLOCK INJ, FEM, SING1, NERVE BLOCK INJ, FEM, CONT INF 2, , NERVE BLOCK INJ, LUMBAR PLEXUS 2, , NERVE BLOCK, OTHER PERIPHERAL 1, NERVE BLOCK INJ, PLANTAR DIGIT INJECT FORAMEN EPIDURAL C/T 2, , INJECT FORAMEN EPIDURAL, ADDED 1, INJECT FORAMEN EPIDURAL L/S 2, , INJECT FORAMEN EPIDURAL, ADDED 1, INJECT PARAVERT F JNT C/T 1 LEV 2, , INJECT PARAVERT F JNT C/T 2 LEV INJECT PARAVERT F JNT C/T 3 LEV INJECT PARAVERT F JNT L/S 1 LEV 2, , INJECT PARAVERT F JNT L/S 2 LEV INJECT PARAVERT F JNT L/S 3 LEV NERVE BLOCK SPHENOPALATINE GANGLIA NERVE BLOCK STELLATE GANGLION 2, , NERVE BLOCK INJ, HYPOGAS PLXS 2, , NERVE BLOCK LUMBAR/THORACIC 2, , IMPLANT NEUROELECTRODES 10, , X IMPLANT NEUROELECTRODES 10, , X IMPLANT NEUROELECTRODES 10, , X INJECTION TREAT NERVE 3, , INJECTION TREAT NERVE 5, ,453.01

217 MEDICAL FEE SCHEDULES 11: INJECTION TREAT NERVE 5, , DESTROY NERVE, FACE MUSCLE DESTROY NERVE, NECK MUSCLE 1, DESTROY NERVE, EXTREMITY MUSC 1, INJECTION TREAT NERVE 2, , DESTROY PARAVERTEBRAL NERVE L/S 3, , DESTROY PARAVERT NERVE, ADDED 2, , DESTROY PARAVERTEBRAL NERVE C/T 2, , DESTROY PARAVERT NERVE, ADDED INJECTION TREAT NERVE 2, , INJECTION TREAT NERVE 2, , REVISE FINGER/TOE NERVE 5, , REVISE HAND/FOOT NERVE 5, , REVISE ARM/LEG NERVE 5, , REVISE SCIATIC NERVE 5, , REVISE ARM NERVE(S) 5, , REVISE LOW BACK NERVE(S) 5, , REVISE CRANIAL NERVE 5, , REVISE ULNAR NERVE AT ELBOW 5, , REVISE ULNAR NERVE AT WRIST 5, , CARPAL TUNNEL SURG 5, , REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE X REMOVE FOREIGN BODY EYE6, , EXPLORE/TREAT EYE SOCKET 5, , REMOVE IMPACTED EAR WAX AS REBUILD OUTER EAR CANAL 12, , REBUILD OUTER EAR CANAL 12, , REPAIR MIDDLE EAR STRUCTURES 12, , REPAIR MIDDLE EAR STRUCTURES 12, , MICROSURG, ADDED N X-RAY EYE FOR FOREIGN BODY AS X-RAY JAW < 4 VIEWS AS X-RAY JAW MINIMUM 4 VIEWS AS X-RAY MASTOIDS < 3 VIEWS/SIDE AS X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE AS X-RAY FACIAL BONES < 3 VIEWS AS X-RAY FACIAL BONES MINIMUM 3 VIEWS AS X-RAY NASAL BONES

218 11: APPENDIX B - REGULATIONS MINIMUM 3 VIEWS AS X-RAY OPTIC FORAMINA AS X-RAY ORBITS, MINIMUM 4 VIEWS AS X-RAY SINUSES < 3 VIEWS AS X-RAY SINUSES MINIMUM 3 VIEWS AS X-RAY SKULL < 4 VIEWS AS X-RAY SKULL MINIMUM 4 VIEWS AS X-RAY TEETH SINGLE VIEW AS X-RAY TEETH < FULL MOUTH AS X-RAY TEETH FULL MOUTH AS X-RAY TMJ UNILATERAL AS X-RAY TMJ BILATERAL AS TMJ ARTHOGRAPHY; RAD SUPER & INTERP 1, MRI TMJ 1, , CEPHALOGRAM, ORTHODONTIC AS ORTHOPANTOGRAM AS X-RAY NECK SOFT TISSUE AS CT HEAD/BRAIN W/O DYE CT HEAD/BRAIN W/DYE 1, , CT HEAD/BRAIN W/O & W/DYE 1, , CT ORBIT/EAR/FOSSA W/O DYE CT ORBIT/EAR/FOSSA W/DYE 1, , CT ORBIT/EAR/FOSSA W/O & W/DYE 1, , CT MAXILLOFACIAL W/O DYE CT MAXILLOFACIAL W/DYE 1, , CT MAXILLOFACIAL W/O & W/DYE 1, , CT SOFT TISSUE NECK W/O DYE CT SOFT TISSUE NECK W/DYE 1, , CT SOFT TISSUE NECK W/O & W/DYE 1, , CT ANGIOGRAPHY, HEAD 1, , CT ANGIOGRAPHY, NECK 1, , MRI ORBIT/FACE/NECK W/O DYE 1, , MRI ORBIT/FACE/NECK W/DYE 1, , MRI ORBIT/FACE/NECK W/O & W/DYE 2, , MR ANGIOGRAPHY HEAD W/O DYE 1, , MR ANGIOGRAPHY HEAD W/DYE 1, , MR ANGIOGRAPH HEAD W/O & W/DYE 2, , MR ANGIOGRAPHY NECK W/O DYE 1, , MR ANGIOGRAPHY NECK W/DYE 1, , MR ANGIOGRAPH NECK W/O & W/DYE 2, ,803.14

219 MEDICAL FEE SCHEDULES 11: MRI BRAIN W/O DYE 1, , MRI BRAIN W/DYE 1, , MRI BRAIN W/O & W/DYE 2, , FMRI BRAIN BY TECH 1, , FMRI BRAIN BY PHYS/PSYCH 1, , X CHEST X-RAY SINGLE VIEW FRONTAL CHEST X-RAY 2 VIEWS FRONTAL & LATERAL CHEST X-RAY 2 VIEWS W/APICAL LORD PROC AS CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ AS CHEST X-RAY MINIMUM 4 VIEWS AS CHEST X-RAY SPECIAL VIEWS AS CONTRAST X-RAY BRONCHI UNILATERAL X-RAY & PACEMAKER INSERT N X-RAY RIBS 2 VIEWS AS X-RAY RIBS/CHEST MINIMUM 3 VIEWS AS X-RAY RIBS BILATERAL 3 VIEWS AS X-RAY RIBS/CHEST MINIMUM 4 VIEWS AS X-RAY STERNUM MINIMUM 2 VIEWS AS X-RAY STERNOCLAV JOINT MINIMUM 3 VIEWS AS CT THORAX W/O DYE CT THORAX W/DYE 1, , CT THORAX W/O & W/DYE 1, , CT ANGIOGRAPHY, CHEST 1, , MRI CHEST W/O DYE 1, , MRI CHEST W/O & W/DYE 2, , X-RAY SPINE ANTEROPOST & LATERAL AS X-RAY SPINE SINGLE VIEW SPECIFY LEVEL AS X-RAY NECK SPINE CERV 2/3 VIEWS AS X-RAY NECK SPINE CERV MINIMUM 4 VIEWS AS X-RAY NECK SPINE COMPLETE AS X-RAY TRUNK SPINE STANDING AS X-RAY THORACIC SPINE 2 VIEWS AS X-RAY THORACIC SPINE 3 VIEWS AS X-RAY THORACIC SPINE MINIMUM 4 VIEWS AS X-RAY TRUNK SPINE 2 VIEWS AS X-RAY TRUNK SPINE SCOLIOSIS STUDY AS X-RAY LOWER SPINE 2/3 VIEWS AS X-RAY LOWER SPINE MINIMUM 4 VIEWS AS X-RAY LOWER SPINE

220 11: APPENDIX B - REGULATIONS COMPLETE AS X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS AS CT NECK SPINE W/O DYE CT NECK SPINE W/DYE 1, , CT NECK SPINE W/O & W/DYE 1, , CT CHEST SPINE W/O DYE CT CHEST SPINE W/DYE 1, , CT CHEST SPINE W/O & W/DYE 1, , CT LUMBAR SPINE W/O DYE CT LUMBAR SPINE W/DYE 1, , CT LUMBAR SPINE W/O & W/DYE 1, , MRI NECK SPINE W/O DYE 1, , MRI NECK SPINE W/DYE 1, , MRI CHEST SPINE W/O DYE 1, , MRI CHEST SPINE W/DYE 1, , MRI LUMBAR SPINE W/O DYE 1, , MRI LUMBAR SPINE W/DYE 1, , MRI NECK SPINE W/O & W/DYE 2, , MRI CHEST SPINE W/O & W/DYE 2, , MRI LUMBAR SPINE W/O & W/DYE 2, , X-RAY PELVIS 1/2 VIEWS AS X-RAY PELVIS MINIMUM 3 VIEWS AS CT ANGIOGRAPH PELVIS W/O & W/DYE 1, , CT PELVIS W/O DYE CT PELVIS W/DYE 1, , CT PELVIS W/O & W/DYE 1, , MRI PELVIS W/O DYE 1, , MRI PELVIS W/DYE 1, , MRI PELVIS W/O & W/DYE 2, , X-RAY EXAM SACROILIAC JOINTS AS X-RAY EXAM SACROILIAC JOINTS AS X-RAY TAILBONE AS CONTRAST X-RAY NECK SPINE 1, , CONTRAST X-RAY THORAX SPINE 1, , CONTRAST X-RAY LOWER SPINE 1, , CONTRAST X-RAY SPINE 1, , EPIDUROGRAPHY N X-RAY C/T SPINE DISK 6, , PERCUT VERT/SACROPLASTY, FLUOR N X-RAY LOWER SPINE DISK 6, , X-RAY COLLAR BONE AS X-RAY SHOULDER BLADE AS X-RAY SHOULDER 1 VIEW AS X-RAY SHOULDER MINIMUM 2 VIEWS AS CONTRAST X-RAY

221 MEDICAL FEE SCHEDULES 11: SHOULDER 1, X-RAY SHOULDERS AS X-RAY HUMERUS MINIMUM 2 VIEWS AS X-RAY ELBOW 2 VIEWS AS X-RAY ELBOW MINIMUM 3 VIEWS AS X-RAY FOREARM AS X-RAY ARM, INFANT AS X-RAY WRIST 2 VIEWS AS X-RAY WRIST MINIMUM 3 VIEWS AS CONTRAST X-RAY WRIST 1, X-RAY HAND 2 VIEWS AS X-RAY HAND MINIMUM 3 VIEWS AS X-RAY FINGER(S) MINIMUM 2 VIEWS AS CT UPPER EXTREMITY W/O DYE CT UPPER EXTREMITY W/DYE 1, , CT UPPER EXTREMITY W/O & W/DYE 1, , CT ANGIO UPR EXTREMITY W/O & W/DYE 1, , MRI UPPER EXTREMITY W/O DYE 1, , MRI UPPER EXTREMITY W/DYE 1, , MRI UPPER EXTREMITY W/O & W/DYE 2, , MRI JOINT UPPER EXTREMITY W/O DYE 1, , MRI JOINT UPPER EXTREMITY W/DYE 1, , MRI JOINT UPPER EXTREMITY W/O & W/DYE 2, , X-RAY HIP UNILATERAL 1 VIEW AS X-RAY HIP COMPLETE MINIMUM 2 VIEWS AS X-RAY HIPS MINIMUM 2 VIEWS AS X-RAY HIP ARTHROGRAPHY 1, X-RAY HIP DURING OPERATIVE PROCEDURE N X-RAY PELVIS & HIPS MINIMUM 2 VIEWS AS X-RAY EXAM, SACROILIAC JOINT 1, X-RAY THIGH 2 VIEWS AS X-RAY KNEE 1/2 VIEWS AS X-RAY KNEE 3 VIEWS AS X-RAY KNEE, COMPLETE 4/MORE VIEWS AS X-RAY KNEES STANDING ANTEROPOST AS X-RAY KNEE ARTHOGRAPHY 1, X-RAY TIBIA & FIBULA 2 VIEWS AS X-RAY LEG, INFANT MINIMUM

222 11: APPENDIX B - REGULATIONS 2 VIEWS AS X-RAY ANKLE 2 VIEWS AS X-RAY ANKLE MINIMUM 3 VIEWS AS CONTRAST X-RAY ANKLE 1, X-RAY FOOT 2 VIEWS AS X-RAY FOOT MINIMUM 3 VIEWS AS X-RAY HEEL AS X-RAY TOE(S) AS CT LOWER EXTREMITY W/O DYE CT LOWER EXTREMITY W/DYE 1, , CT ANGIO LWR EXTREMITY W/O & W/DYE 1, , MRI LOWER EXTREMITY W/O DYE 1, , MRI LOWER EXTREMITY W/DYE 1, , MRI LOWER EXTREMITY W/O & W/DYE 2, , MRI JOINT LOWER EXTREMITY W/O DYE 1, , MRI JOINT LOWER EXTREMITY W/DYE 1, , MRI JOINT LWR EXTREMITY W/O & W/DYE 2, , X-RAY ABDOMEN SINGLE ANTEROPOST AS X-RAY ABDOMEN ANTEROPOST & ADDED VW AS X-RAY ABDOMEN COMPLETE AS X-RAY EXAM SERIES, ABDOMEN AS CT ABDOMEN W/O DYE CT ABDOMEN W/DYE 1, , CT ABDOMEN W/O & W/DYE 1, , CT ANGIO ABDOM W/O & W/DYE 1, , CT ANGIO ABDOM & PELVIS CT ANGIO ABDOM & PELVIS W/CONTRAST 1, , CT ANGIO ABDOM & PELVIS 1+ REGNS 1, , MRI ABDOMEN W/O DYE 1, , MRI ABDOMEN W/O & W/DYE2, , CONTRAST X-RAY, ESOPHAGUS X CINE/VIDEO X-RAY, THROAT/ESOPH X X-RAY EXAM, UPPER GI TRACT W/KUB X CONTRAST X-RAY UGI TRACT W/O KUB X CONTRAST X-RAY COLON W/WO GLUCOGEN X CONTRAST X-RAY, GALLBLADDER X X-RAY BILE/PANCREAS ENDOSCOPY N CONTRAST X-RAY URINARY

223 MEDICAL FEE SCHEDULES 11: TRACT X CONTRAST X-RAY URINARY TRACT X CONTRAST X-RAY URINARY TRACT X CONTRAST X-RAY URINARY TRACT X CONTRAST X-RAY URINARY TRACT CONTRAST X-RAY BLADDER X-RAY URETHRA/BLADDER X-RAY URETHRA/BLADDER X-RAY CONTROL, CATH INSERT 4, , X-RAY CONTROL, CATH INSERT 4, , X-RAY GUIDE, GU DILATION 4, , CARDIAC MRI FOR MORPH W/DYE 2, , CT HEART W/3D IMAGE 1, X CT ANGIO HEART W/3D IMAGE 1, X CONTRAST X-RAY AORTA 7, , CONTRAST X-RAY AORTA 7, , X-RAY AORTA, LEG ARTERIES 7, , CT ANGIO ABDOMINAL ARTERIES 1, , ARTERY X-RAYS HEAD & NECK 12, , ARTERY X-RAYS HEAD & NECK 7, , ARTERY X-RAYS HEAD & NECK 12, , ARTERY X-RAYS NECK UNILATERAL 7, , ARTERY X-RAYS NECK BILATERAL 7, , ARTERY X-RAYS SPINE 7, , ARTERY X-RAYS SPINE 7, , ARTERY X-RAYS ARM/LEG 7, , ARTERY X-RAYS ARMS/LEGS 7, , ARTERY X-RAYS KIDNEY 7, , ARTERY X-RAYS KIDNEYS 7, , ARTERY X-RAYS ABDOMEN 7, , ARTERY X-RAYS PELVIS 7, , ARTERY X-RAYS LUNGS 7, , ARTERY X-RAY, EACH VESSEL N NONVASCULAR SHUNT, X-RAY VEIN X-RAY ARM/LEG 2, , VEIN X-RAY ARMS/LEGS 2, , VEIN X-RAY TRUNK 7, , X-RAYS, TRANSCATH THERAPY N F/U ANGIOGRAPHY X-RAY PLACE VEIN FILTER N TRANSCATH IV STENT RS & I N RETRIEVE BROKEN CATHETER N REPAIR ARTERIAL BLOCKAGE12, , REPAIR ARTERY BLOCKAGE, EACH N REPAIR VENOUS BLOCKAGE 8, , X-RAY CONTROL CATHETER CHANGE N1

224 11: APPENDIX B - REGULATIONS ABSCESS DRAIN UNDER X-RAY N FLUOROSCOPE EXAM FLUOROSCOPE EXAM, EXTENSIVE N X-RAY NOSE TO RECTUM AS X-RAY FISTULA X-RAY EXAM, BREAST SPECIMEN 1, , X-RAY BODY SECTION AS COMPLEX BODY SECTION X-RAYS AS CINE/VIDEO X-RAYS AS CINE/VIDEO X-RAYS, ADDED N D RENDER W/O POST PROCESS N D RENDERING W/POST PROCESS N CAT SCAN F/U STUDY X ECHO EXAM HEAD X OPHTHALMIC US, B & QUANT A OPHTHALMIC US, QUANT A ONLY X OPHTHALMIC US, B W/NON-QUANT A X ECHO EXAM EYE, THICKNESS AS ECHO EXAM EYE X ECHO EXAM EYE X US EXAM HEAD & NECK X US EXAM, CHEST US EXAM, BREAST(S) X US EXAM, ABDOM, COMPLETE ECHO EXAM ABDOMEN US EXAM ABDOM BACK WALL, COMP US EXAM ABDOM BACK WALL, LIM US EXAM K TRANSPLANT W/DOPPLER US EXAM, SPINAL CANAL X OBSTET US < 14 WKS, SINGLE FETUS X OBSTET US >/= 14 WKS, SINGLE FETUS X OBSTET US >/= 14 WKS, ADDED FETUS X OBSTET US, DETAILED, SINGLE FETUS X OBSTET US NUCHAL MEAS, ADDED X OBSTET US, LIMITED, FETUS(S) X OBSTET US, F/U, PER FETUS X TRANSVAGINAL US, OBSTETRIC X FETAL BIOPHYS PROFILE W/NST X FETAL BIOPHYS PROFILE W/O NST X UMBILICAL ARTERY ECHO X MIDDLE CEREBRAL ARTERY ECHO X ECHO EXAM FETAL HEART 1, , X ECHO EXAM FETAL HEART X

225 MEDICAL FEE SCHEDULES 11: ECHO EXAM FETAL HEART X TRANSVAGINAL US, NON-OB X US EXAM, PELVIC, COMPLETE US EXAM, PELVIC, LIMITED US EXAM, SCROTUM US, TRANSRECTAL X US XTR NON-VASC COMPLETE X US XTR NON-VASC LMTD X US GUIDE VASCULAR ACCESS N ECHO GUIDE FOR BIOPSY N US GUIDE, INTRAOP N FLUOROGUIDE FOR VEIN DEVICE N NEEDLE LOCALIZATION BY X-RAY N FLUOROGUIDE FOR SPINE INJECT N CT SCAN FOR LOCALIZATION N CT SCAN FOR NEEDLE BIOPSY N GUIDANCE FOR NEEDLE, BREAST N X-RAYS FOR BONE AGE AS X-RAYS, BONE LENGTH STUDIES AS X-RAYS, BONE SURVEY, LIMITED AS X-RAYS, BONE SURVEY COMPLETE AS X-RAYS, BONE SURVEY, INFANT AS JOINT SURVEY, SINGLE VIEW AS DIAG BONE DENSITY, AXIAL X DIAG BONE DENSITY/PERIPHERAL X DIAG BONE DENSITY, VERTEBRAL FX X SET RADIATION THERAPY FIELD AS SET RADIATION THERAPY FIELD 1, AS SET RADIATION THERAPY FIELD 1, AS SET RADIATION THERAPY FIELD 3, , AS RADIATION THERAPY DOSE PLAN AS TELETX ISODOSE PLAN SIMPLE AS TELETX ISODOSE PLAN INTERMED AS TELETX ISODOSE PLAN COMPLEX 1, AS SPECIAL TELETX PORT PLAN 1, AS SPECIAL RADIATION DOSIMETRY AS RADIATION TREAT AID(S) AS RADIATION TREAT AID(S) AS RADIATION TREAT AID(S) AS RADIATION PHYSICS CONSULT AS SRS, MULTISOURCE 30, , X

226 11: APPENDIX B - REGULATIONS RADIATION TX SING AREA 6-10MEV X RADIATION TX 3/MORE AREA 6-10MEV X RADIATION TX 3/MORE AREA 11-19MEV X RADIOLOGY PORT FILM(S) N SPECIAL RADIATION TREAT 1, , X THYROID IMAGING W/UPTAKE X THYROID IMAGE, MULT UPTAKES X BONE MARROW IMAGING, LTD 1, X BONE MARROW IMAGING, MULT 1, X LIVER & SPLEEN IMAGING 1, X LIVER FUNCTION STUDY 1, X HEPATOBILIARY IMAGING 1, X SALIVARY GLAND FUNCTION EXAM X BONE IMAGING, LIMITED AREA X BONE IMAGING, MULTIPLE AREAS X BONE IMAGING, WHOLE BODY X BONE IMAGING, 3 PHASE X BONE IMAGING (3D) X VASCULAR FLOW IMAGING X HEART MUSCLE IMAGE SPECT, SING 2, , X HEART MUSCLE IMAGE SPECT, MULT 2, , X HEART INFARCT IMAGE (3D) 1, X GATED HEART, PLANAR, SING 1, X HEART FIRST PASS, SING 1, X HEART IMAGE, SPECT 1, X LUNG PERFUSION IMAGING X LUNG V/Q IMAGE SINGLE BREATH 1, , X LUNG V/Q IMAGING 1, , X PERFUSION LUNG IMAGE 1, , X VENT IMAGE, MULT PROJ, GAS X LUNG DIFFERENTIAL FUNCTION 1, , X BRAIN IMAGING (3D) 2, , X KID FLOW/FUNCT IMAGE W/O DRUG 1, , X KID FLOW/FUNCT IMAGE W/DRUG 1, , X KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 1, , X TUMOR IMAGING, WHOLE BODY 1, , X TUMOR IMAGING (3D) 1, , X ABSCESS IMAGING, LTD AREA 1, , X ABSCESS IMAGING, WHOLE BODY 1, , X PET IMAGE W/CT,

227 MEDICAL FEE SCHEDULES 11: SKULL-THIGH 4, , X NUCLEAR RX, IV ADMIN X CYTOPATH, C/V, INTERPRET N FIT CONTACT LENS N EAR MICROSCOPY EXAM N SUPPLEMENTAL ELECTRICAL TEST N AUDITORY FUNCTION, + 15 MIN N ECHO TRANSESOPHAGEAL N DOPPLER ECHO EXAM, HEART N DOPPLER ECHO EXAM, HEART N DOPPLER COLOR FLOW, ADDED N DRUG ADMIN & HEMODYNMIC MEAS N EXERCISE W/HEMODYNAMIC MEAS N INJECT CONGENITAL CARD CATH N INJECT HEART CONGNTL ART/GRAFT N INJECT L VENTR/ATRIAL ANGIO N INJECT R VENTR/ATRIAL ANGIO N INJECT SUPRVLV AORTOGRAPHY N INJECT PULM ART HEART CATH N MAP TACHYCARDIA, ADDED N STIMULATION, PACING HEART N ELECTROPHYSIOLOGY EVAL N MEASURE BLOOD OXYGEN LEVEL N MEASURE BLOOD OXYGEN LEVEL N GUIDE NERVE DESTROY, ELECT STIM N GUIDE NERVE DESTROY, NEEDLE EMG N INTRAOP NERVE TEST, ADDED N EEG DURING SURG N EEG DIGITAL ANALYSIS N THER/DIAG CONCURRENT INF N MOD SEDATION SAME PHYS, < 5 YRS N MOD SEDATION BY SAME PHYS, 5 YRS + N MOD SEDATION BY SAME PHYS, ADDED N MOD SEDATION DIFF PHYS < 5 YRS N MOD SEDATION DIFF PHYS 5 YRS + N MOD SEDATION DIFF PHYS, ADDED N INDUCTION VOMITING N CRITICAL CARE, ADDED 30 MIN N PROLONGED SERVICE, OFFICE N PROLONGED SERVICE, OFFICE N1 New Rule. R.2001 d.253, effective July 16, 2001; R.2002 d.59, effective March 4, 2002; R.2003 d.143, effective April 7, 2003; R.2004 d.481, effective December 20, 2004; R.2007 d.305, effective October 1, 2007; R.2009 d.194, effective June 15, 2009; R.2009 d.209, effective July 6, Repeal and New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). Amended. R.2014 d.004, effective January 6, 2014.

228 11:3-30 APPENDIX B - REGULATIONS SUBCHAPTER 30. MOTOR VEHICLE SELF-INSURANCE Section 11: Purpose. 11: Scope. 11: Definitions. 11: General requirements. 11: Certificate of self-insurance. 11: Renewals. 11: Surety bond requirement. 11: Audits and examinations. 11: Public entities. 11: Cancellation of certificate of self-insurance. 11: Purpose. This subchapter sets forth the filing requirements for motor vehicle self-insurers pursuant to N.J.S.A. 39:6-50.1, and 39:6-52 to 39: : Scope. The provisions of this subchapter apply to any person seeking to qualify as a motor vehicle self-insurer in New Jersey, except public entities pursuant to N.J.S.A. 39: : Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Applicant means a person applying for a certificate of self-insurance who does not currently possess a valid certificate. Association means the New Jersey Automobile Full Insurance Underwriting Association created pursuant to N.J.S.A. 17:30E-1 et seq. Certificate means certificate of self-insurance. Certificate holder means a person who currently possesses a valid certificate of self-insurance. Certified public accountant means an independent certified public accountant or accounting firm in good standing with the American Institute of Certified Public Accountants and in all states in which they are licensed to do business. Commissioner means the Commissioner of Banking and Insurance. Motorized bicycle means a pedal bicycle having a helper motor characterized in that either the maximum piston displacement is less than 50 cubic centimeters (cc.) or said motor is rated at no more than 1.5 brake horsepower and said bicycle is capable of a maximum speed of no more than 25 miles per hour on a flat surface. Motor vehicle means all vehicles propelled otherwise than by muscular power, excepting such vehicles as run upon rails or tracks and motorized bicycles. Person means a natural person, firm, co-partnership, association or corporation. Public entity means this State, any political subdivision of this State or any municipality therein. Amended. R d. 44, effective February 5, : General requirements. (a) Any person in whose name more than 25 motor vehicles are registered or in whose name more than 25 motor vehicles

229 MOTOR VEHICLE SELF-INSURANCE 11: are leased may qualify as a self-insurer by obtaining a certificate of self-insurance issued at the discretion of the Commissioner as provided in this subchapter. (b) All filings for certificates of self-insurance, renewals, and any other filings deemed necessary by the Commissioner pursuant to this subchapter shall be sent to: New Jersey Department of Banking and Insurance Financial Exams Division 20 West State Street PO Box 325 Trenton, New Jersey Attention: Self-insurers Amended. R d. 44, effective February 5, : Certificate of self-insurance. (a) Any person applying for a certificate of self-insurance shall submit the following to the Commissioner: 1. A completed application form on forms to be provided by the Commissioner; 2. The most current financial statement and financial statements for the two years immediately preceding the date of such current financial statement: i. All financial statements shall be certified by a Certified Public Accountant: ii. If the applicant is a subsidiary of a corporation, the applicant shall also submit the financial statements of the subsidiary s ultimate parent corporation; iii. If the applicant is a corporation, the Commissioner may also include the name of any subsidiary corporation under the control of that corporation in the certificate of self-insurance if the ultimate parent corporation guarantees that it will discharge the subsidiary s liability as evidenced by the filing of an indemnity agreement. If the ultimate parent corporation does not provide such a guarantee, the subsidiary shall make a separate application and receive independent qualification as a self-insurer. If the name of the subsidiary is included in the certificate of self-insurance of the ultimate parent corporation and ownership of the ultimate parent or subsidiary corporation changes, the ultimate parent or subsidiary shall reapply for a certificate of self-insurance within 30 days of the ownership change; and 3. A 51,000 filing fee. (b) After the submission of an application, the Commissioner may require an additional fee to cover the costs of further examinations which may include a credit report to be prepared by a credit agency acceptable to the Commissioner. (c) If an application is approved and the Commissioner receives notification from the Association that the applicant has paid any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively, the Commissioner shall issue a certificate of self-insurance to the applicant. (d) All certificates of self-insurance are valid from the date of issuance until June 30 immediately following and may be renewed thereafter, pursuant to N.J.A.C. 11:3-30.6, for a one year period beginning July 1 and ending June 30 the following year. 11: Renewals. (a) Any certificate holder applying for renewal shall submit the following so that it is received by the Commissioner not later than June l of the year of the expiration date of such certificate: 1. An accident and claim activity report on forms to be provided by the Commissioner; 2. A financial statement for the calendar year immediately preceding the expiration date of the certificate of self-insurance certified by a Certified Public Accountant;

230 11: APPENDIX B - REGULATIONS 3. An updated vehicle listing which shall include a listing of the vehicles subject to any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively; 4. A $1,000 renewal fee; and 5. Any other information that is substantially different from the information provided in the original application form or from the information provided in the last renewal period. (b) After the submission of an application for renewal, the Commissioner may require an additional fee to cover the costs of further examinations which may include a credit report to be prepared by a credit agency acceptable to the Commissioner. (c) If an application for renewal is approved and the Commissioner receives notification from the Association that the certificate holder has paid any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively, the Commissioner shall issue a new certificate of self-insurance. 11: Surety bond requirement. (a) The Commissioner may require the furnishing of a surety bond and for evidence of excess insurance. (b) If the applicant or certificate holder is required to furnish a surety bond, the surety bond shall be in an amount of not less than , with an additional 510,000 for each vehicle registered or leased in the applicant s or certificate holder s name over the minimum required to qualify as self-insurer under this subchapter. up to a maximum amount of 51,000, : Audits and examinations. (a) The Commissioner may make or cause to be made audits or examinations as may be necessary to determine the ability of the applicant or the certificate holder to discharge its financial obligations as a self-insurer. (b) The applicant or certificate holder shall pay the reasonable expenses of the audit or examination. 11: Public entities. (a) This subchapter does not apply to any motor vehicle owned by the United States, this State, any political subdivision of this State or any municipality therein; nor to any motor vehicle which is subject to the requirements of law requiring insurance or other security on certain types of vehicles, other than the requirements of N.J.S.A. 39:6A-1 et seq. or N.J.S.A. 39:6B-1 et seq. (b) Notwithstanding the provisions in (a) to the contrary, any public entity that currently has or will establish in the future a self-insurance program or plans to discontinue a self-insurance program currently in effect, shall notify the Commissioner in writing that it currently has, will establish or discontinue such a program. 11: Cancellation of certificate of self-insurance. After a hearing conducted pursuant to the Administrative Procedure Act, N.J.S.A. 52:148-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1, upon not less than five days notice, the Commissioner may cancel a certificate of self-insurance upon reasonable grounds including, but not limited to, failure to pay any judgment within 30 days after such judgment has become final. SUBCHAPTER 34. ELIGIBLE PERSONS QUALIFICATIONS AND AUTOMOBILE INSURANCE ELIGIBILITY POINTS SCHEDULE Section 11: Purpose. 11: Scope.

231 INSURANCE ELIGIBILITY 11: : Definitions. 11: Eligible person qualifications. 11: Automobile insurance eligibility points. APPENDIX Schedule of Automobile Insurance Eligibility Points 11: Purpose. The purpose of this subchapter is to set forth the requirements for determining who can qualify as an eligible person, and to provide the schedule for automobile insurance eligibility points pursuant to N.J.S.A. 17:33B-13 and 14. Amended. R d. 58, effective February 5, : Scope. (a) The provisions of this subchapter apply to all insurers which write personal private passenger automobile insurance and all persons who are required to procure automobile insurance coverage in this State. (b) Except to the extent that the definition of eligible and ineligible persons at N.J.A.C. 11: is utilized for nonrenewals pursuant to N.J.A.C. 11:3-8, this subchapter shall become inoperative on and after January 1, 2009, unless and until the Commissioner by Order makes the requirements of N.J.S.A. 17:33B-15a and b operative pursuant to the limited circumstances set forth in N.J.S.A. 17:33B- 15d(3), upon a determination made after a hearing conducted pursuant to the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq., and Uniform Administrative Procedure Rules, N.J.A.C. 1:1, that a competitive market does not exist among insurers authorized to write private passenger automobile insurance in this State, or the Commissioner certifies by Order that the Personal Automobile Insurance Plan is insuring 10 percent or more of the aggregate number of private passenger automobile non-fleet exposures being written in this State. A notice of the issuance by the Commissioner of such an Order shall be published in the New Jersey Register. Amended. R d. 380, effective December 15, 2008 (operative January 1, 2009); R.2011 d.242, effective September 19, : Definitions. The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. At-fault accident is any accident involving a driver insured under the policy: 1. Where a driver is proportionately responsible based on the number of vehicles involved. A driver is proportionately responsible if 50 percent responsible for an accident involving two drivers; if 33 1/3 percent responsible for an accident involving three drivers, etc.; and 2. Which results in a total payment by the insurer of at least $ for an accident occurring before June 9, 2003; or at least $1,000 for an accident occurring on or after June 9, The $1,000 dollar amount may be adjusted in $ or $ increments by Order of the Commissioner not more frequently than every 36 months. The Order shall reflect the cumulative increases or decreases in the components of the Consumer Price Index, All Urban Consumers (CPI-U) for the Northeast Region, and the adjusted amount shall apply to automobile accidents occurring at least 120 days after the effective date of the adjustment. The adjustment shall be reflected in this definition through a notice of administrative change published in the New Jersey Register. An at-fault accident shall not include the following: 1. Involvement in an accident in which the motor vehicle owned or operated by the insured or other driver insured under the policy was lawfully parked;

232 11: APPENDIX B - REGULATIONS 2. Involvement in an accident in which the motor vehicle was struck by a hit and run driver, if such accident was reported to the proper authorities within 24 hours; 3. Involvement in an accident in connection with which neither the named insured nor any other driver insured under the policy was convicted of a moving traffic violation and the owner or operator of another vehicle involved in such accident was so convicted; 4. For physical damage losses other than collision; 5. For an accident in which the motor vehicle was struck in the rear by another vehicle and a driver insured under the policy has not been convicted of a moving violation in connection with the accident; or 6. For an accident occurring as a result of operation of any motor vehicle in response to an emergency if the operator at the time of the accident was responding to the call to duty as a paid or volunteer member of any police or fire department, first aid squad or any law enforcement agency. Automobile means an automobile as defined in N.J.S.A. 39:6A-2. Automobile insurance means insurance for an automobile including any or all of the following coverages: bodily injury liability, and property damage liability, comprehensive and collision coverages, uninsured and underinsured motorist coverage, personal injury protection coverage, additional personal injury protection coverage and any other automobile insurance required by law. Automobile insurance eligibility points means points calculated under the schedule promulgated by the Commissioner pursuant to this subchapter. Commissioner means the Commissioner of Banking and Insurance of the State of New Jersey. Department means the Department of Banking and Insurance of the State of New Jersey. State means the State of New Jersey. Amended. R d. 44, effective February 5, 2001; R d.469, effective December 1, : Eligible person qualifications. (a) An eligible person is a person who is an owner or registrant of an automobile registered and principally garaged in this State or who is a resident and holds a valid New Jersey driver's license to operate an automobile, but does not include any person: 1. Who, during the three-year period immediately preceding application for, or renewal of, an automobile insurance policy has been convicted pursuant to N.J.S.A. 39:4-50 or N.J.S.A. 39:4-50.4a or for an offense of a substantially similar nature committed in another jurisdiction; 2. Who has been convicted of a crime of the first, second or third degree resulting from the use of a motor vehicle; or has been convicted of theft of a motor vehicle; 3. Whose driver's license to operate an automobile is under suspension or revocation; 4. Who has been convicted, within the five-year period immediately preceding application for or renewal of a policy of automobile insurance, of fraud or intent to defraud involving an insurance claim or an application for insurance; 5. Who has been successfully denied, with the immediately preceding five years' payment by an insurer of a claim in excess of $1,000 under an automobile insurance policy, if there was evidence of fraud or intent to defraud involving the automobile insurance claim or application. For the purpose of this section: i. If the claim has been subject to litigation between the insurer and the insured in which the insurer defended against payment of the claim in whole or in part on

233 INSURANCE ELIGIBILITY 11: grounds of fraud, it shall be conclusively presumed that the claim was successfully denied if judgment was entered for the insurer in the litigation; and conclusively presumed that the claim was not successfully denied if judgment was entered for the insured; ii. If the claim has not been subject to litigation between the insurer and the insured, but the insurer denied the claim without payment by reason of fraud, it shall be presumed that the claim was successfully denied. This presumption may be overcome in an administrative proceeding pursuant to N.J.A.C. 11:3-33; iii. If the incident was not reported to the New Jersey Office of Insurance Fraud Prosecutor pursuant to N.J.S.A. 17:33A-9 it shall be presumed that there was no evidence of fraud or intent to defraud; 6. Whose automobile insurance policy has been cancelled for nonpayment of premiums or financed premium with a lapse of coverage of at least 30 days, within the immediately preceding two-year period, unless the premium due on a policy for which application has been made is paid in full before issuance or renewal of the policy. For the purpose of this section, paid in full shall not include any transaction in which a lender obtains authority from an insured to cancel the policy and receive a refund from the insurer in the event the insured defaults on a loan used to pay the premium; 7. Who fails to obtain or maintain membership or qualification for membership in a club, group, or organization, if membership is a uniform requirement of the insurer as a condition of providing insurance, and if the dues or charges, if any, or other conditions for membership or qualifications for membership are applied uniformly throughout this State, are not expressed as a percentage of the insurance premium, and do not vary with respect to the rating classification of the member or potential member except for the purpose of offering a membership fee to family units. Membership fees, if applicable, may vary in accordance with the amount or type of coverage if the purchase of additional coverage, either as to type or amount, is not a condition for reduction of dues or fees; 8. Whose driving record for the three year period immediately preceding the application for or renewal of a policy of automobile insurance has an accumulation of seven or more automobile insurance eligibility points as determined in N.J.A.C. 11:3-34.5; 9. Who, during the three-year period immediately preceding application for, or renewal of, an automobile insurance policy, has knowingly provided materially false or misleading information in connection with an application for insurance, renewal of insurance or claim for benefits under an insurance policy; 10. Who is a named insured or who is insured under the same policy as a person whose driver's license is suspended or revoked and either: i. The suspended or revoked driver has been convicted of a violation of N.J.S.A. 39:6B-2 within the previous three years; or ii. With the exception of a conviction for violating N.J.S.A. 39:3-40i, other evidence exists indicating that the suspended or revoked driver has been operating a vehicle during the period of suspension or revocation;or 11. Who, for the purposes of nonrenewals under N.J.A.C. 11:3-8 only, does not satisfy the insurer s acceptance criteria as set forth in N.J.A.C. 11: (b) An eligible person includes a person who is an owner or registrant of an automobile registered in this State or who holds a valid New Jersey driver's license to operate an automobile and is domiciled in this State who is temporarily residing out-of-state and whose car may be principally garaged in another state while the

234 11: APPENDIX B - REGULATIONS person either is a full time student or is in the military service and is stationed outof-state. Amended: R. 1992, d. 481; R d.246, effective June 3, 1996; R d. 44, effective February 5, 2001; R d. 469, effective December 1, 2003; R.2007 d.373, effective December 3, 2007; R.2011 d.242, effective September 19, : Automobile insurance eligibility points. (a) Automobile insurance eligibility points shall be accumulated as a result of convictions, suspensions, revocations and determinations of responsibility for civil infractions in accordance with the schedule set forth in the Appendix to this subchapter herein incorporated by reference. (b) Automobile eligibility points are cumulative and accrue for all violations and occurrences set forth on Schedules 1 and 2. Automobile insurance eligibility points shall be deemed to accrue as follows: 1. Points for an at-fault accident shall accrue on the date that total payment by the insurer equals or exceeds $1,000 or such other amount as may be prescribed by Order of the Commissioner issued pursuant to N.J.S.A. 17:33B-14. The amount under such Order shall be reflected in this paragraph through a notice of administrative change published in the New Jersey Register. An insurer may, at its option, use the date of the accident or date of first payment provided, however, that the insurer shall not underwrite or rate any policy based on the accident until total payment by the insurer equals or exceeds $1,00; and further provided that the insurer shall use the optional date consistently in all cases. 2. Points for conviction of motor vehicle violations and other events that are set forth on an abstract of drivers license records available from the New Jersey Motor Vehicle Commission, or a comparable agency of another state, shall accrue when the event is recorded in the agency's records as evidenced by an abstract. 3. When an eligible person is involved in an at-fault accident and has not accrued any eligibility points during the three-year period immediately preceding the date of that accident, no eligibility points for a two- or three-point violation, as set forth in Schedule 2 of the Appendix, shall accrue along with the points assessed in accordance with Schedule 1 for the at-fault accident, when the violation arises out of the same incident which results in 1the assessment of points for the at-fault accident. However, violations that arise out of the same incident may be considered by insurers for purposes of tier placement pursuant to N.J.A.C. 11:3-19A. 4. Points for each full year of court-imposed driver's license suspension within the preceding three years and points for each full year within the immediately preceding three years that a person has not held a driver's license shall accrue on the date of application for insurance. However, in accordance with Schedule 1, eligibility points assessed for failure to hold a drivers license in the previous three years are not cumulative to points assessed for the suspension of a drivers license. (c) Automobile insurance eligibility points set forth on Schedule 2 of the Appendix represent motor vehicle points established by the New Jersey Motor Vehicle Commission by rule, N.J.A.C. 13: , which is hereby incorporated by reference. Any additions, deletions or modifications to N.J.A.C. 13: shall likewise be incorporated as of the effective date of amendment. Schedule 2 is included in the Appendix for convenience. (d) The reference in Appendix Schedule 1 and Schedule 2 to provisions of the New Jersey Statutes Annotated is meant for convenience to assist in the quick identification of the nature of the event. If the event takes place in a state or prov-

235 INSURANCE ELIGIBILITY 11: ince other than New Jersey, Schedule 1 and 2 should be consulted for identification of the specific misconduct committed and the assessment of the appropriate number of insurance eligibility points to be assessed. (e) In addition to the motor vehicle violation and insurance eligibility points specifically enumerated on Schedule 2 of the Appendix pertaining to the New Jersey Turnpike, Atlantic City Expressway, and the Garden State Parkway, for any other motor vehicle violations that occur on the New Jersey Turnpike (N.J.A.C. 19:9), the Atlantic City Expressway (N.J.A.C. 19:2-2.1), the Garden State Parkway (N.J.A.C. 19:8) or for any other moving violation at any location, Schedules 1 and 2 shall be consulted for identification of the specific misconduct committed and the determination of the appropriate number of insurance eligibility points to be assessed. Amended. R.2001 d.44, effective February 5, 2001; R.2002 d.330, effective October 7, 2002; R.2003 d.469, effective December 1, 2003; R.2006 d.243, effective July 3, 2006; R.2007 d.373, effective December 3, APPENDIX Schedule of Automobile Insurance Eligibility Points Schedule 1 N.J.S.A. DMV Section Event Number Event Identifier(s) If applicabledescription If applicable Points 39:4-50 Operating a motor vehicle under the influence of alcohol or drugs 0450; : Refusal to submit to a chemical test C:11-2 Vehicular homicide C :3-40 Operating a motor vehicle while driving a through privilege is suspended h and j 39:6B-2 Operating a motor vehicle without liability insurance06b2 9 39:6A-15 Misrepresentation of insurance coverage 6A15 9 Each at fault accident 5 *For each full year of a court imposed driver s license suspension within the preceding 3 years 3 *For each full year within the immediately preceding 3 years that a person has not held a driver s license 1 Involved in a fatal accident EFTL 4 NFTL 2 39:3-37 Obtaining a driver s license or registration through deception 0337; 0312; 05D5; 1312; MSNJ; MSOS 5 39:3-38 Make or use counterfeit plate or plates other than issued : Make, alter or counterfeit driver s license or registration Failure to verify insurance involved in an automobile accident FVIA 2 * Points for failure to hold a driver s license in the previous three years are not cumulative to points for driver s license suspension.

236 11: APPENDIX B - REGULATIONS Schedule 2 N.J.S.A. Section Number Offense Points 27:23-29 Moving against traffic-new Jersey Turnpike, Garden State Parkway, and Atlantic City Expressway 2 27:23-29 Improper passing-new Jersey Turnpike, Garden State Parkway, and Atlantic City Expressway 4 27:23-29 Unlawful use of median strip-new Jersey Turnpike, Garden State Parkway, and Atlantic City Expressway 2 39:3-20 Operating constructor vehicle in excess of 30 mph 3 39: Operating motorized bicycle on a restricted highway 2 39:4-14.3d More than one person on a motorized bike 2 39:4-35 Failure to yield to pedestrian in crosswalk 2 39:4-36 Failure to yield to pedestrian in crosswalk; passing a vehicle yielding to pedestrian in crosswalk 2 39:4-41 Driving through a safety zone 2 39:4-52 & 39:5C-1 Racing on highway 5 39:4-55 Improper action or omission on grades and curves 2 39:4-57 Failure to observe direction of officer 2 39:4-66 Failure to stop vehicle before crossing sidewalk 2 39: Failure to yield to pedestrians or vehicles while entering or leaving highway 2 39:4-71 Operating a motor vehicle on a sidewalk 2 39:4-80 Failure to obey direction of officer 2 39:4-81 Failure to observe traffic signals 2 39:4-82 Failure to keep right 2 39: Improper operating of vehicle on divided highway or divider 2 39:4-83 Failure to keep right at intersection 2 39:4-84 Failure to pass to right of vehicle proceeding in opposite direction 5 39:4-85 Improper passing on right or off roadway 4 39: Wrong way on a one-way street 2 39:4-86 Improper passing in no passing zone 4 39:4-87 Failure to yield to overtaking vehicle 2 39:4-88 Failure to observe traffic lanes 2 39:4-89 Tailgating 5 39:4-90 Failure to yield at intersection 2 39: Failure to use proper entrances to limited access highways 2 39:4-91 & 39:4-92 Failure to yield to emergency vehicles 2 39:4-96 Reckless driving 5 39:4-97 Careless driving 2 39:4-97a Destruction of agricultural or recreational property 2 39: Slow speed blocking traffic 2 39:4-98 & 39:4-99 Exceeding maximum speed 1-14 mph over limit 2 Exceeding maximum speed mph over limit 4 Exceeding maximum speed 30 mph or more over limit 5

237 BENEFIT DETERMINATION: PIP - HEALTH 11: :4-105 Failure to stop for traffic light 2 39:4-115 Improper turn at traffic light 3 39:4-119 Failure to stop at flashing red signal 2 39:4-122 Failure to stop for police whistle 2 39:4-123 Improper right or left turn 3 39:4-124 Improper turn from approved turning course 3 39:4-125 Improper U turn 3 39:4-126 Failure to give proper signal 2 39:4-127 Improper backing or turning in street 2 39: Improper crossing of railroad grade crossing 2 39: Improper crossing of bridge 2 39:4-128 Improper crossing of railroad grade crossing by certain vehicles 2 39: Improper passing of school bus 5 39: Improper passing of a frozen -dessert truck 4 39:4-129 Leaving the scene of an accident No personal injury 2 Personal injury 8 39:4-144 Failure to observe stop or yield signs 2 39:5D-4 Moving violation out-of-state 2 Amended. R d. 58, effective February 5, 1996; R.2007 d.373, effective December 3, SUBCHAPTER 37. ORDER OF BENEFIT DETERMINATION BETWEEN AUTOMOBILE PERSONAL INJURY PROTECTION AND HEALTH INSURANCE Section 11: Purpose and scope. 11: Definitions. 11: Health benefits providers. 11: Application of the PIP-as-secondary coverage option. 11: Health benefit plan standards and the PIP premium reduction. 11: Order of benefits determination when PIP is secondary coverage. 11: Determination of PIP medical benefits payable when PIP is secondary coverage. 11: Health benefits plan coverage ineligibility. 11: Determination of benefits when PIP is primary coverage. 11: Explanation of benefits. 11: Dispute as to primacy of coverage. 11: Eligibility under two or more automobile policies. 11: Penalties. 11: Severability. 11: Purpose and scope. The purpose of this subchapter is to establish guidelines for the order of benefit determination between a plan of health insurance and personal injury protection provided through an automobile policy pursuant to N.J.S.A. 39:6A-4, when a named insured elects to have his or her personal injury protection become secondary coverage for the provision of benefits for medical expenses incurred due to injuries sustained in an automobile accident. This subchapter also sets forth the requirements for the order of benefit determination between a plan of health insurance and personal injury protection provided pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, when personal injury protection is primary coverage. The provisions of this subchapter shall apply to all automobile

238 11: APPENDIX B - REGULATIONS policies, as that term is defined at N.J.S.A. 39:6A-2a, issued to New Jersey residents, or renewed on or after January , and to all health benefits plans which have been or will be delivered or issued for delivery in this State. Amended. R d. 591, effective December 21, 1998 (operative March 22, 1999). 11: Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Actual benefits means those benefits determined to be payable for allowable expenses. Allowable expense means a medically necessary, reasonable and customary item of expense covered by an insured's health benefits plan(s) or PIP plan as an eligible expense, at least in part. When a plan provides benefits in the form of services, the reasonable monetary value of each such service shall be considered as both an allowable expense and a paid benefit. Benefits means the provision of the following in consideration of payment of premiums or fees on a prepaid or postpaid basis: 1. Services, including supplies; 2. Payment of expenses incurred; 3. A combination of 1 and 2 above; or 4. An indemnification. Eligible expense means: 1. In the case of health benefits plans, that portion of the medical expenses incurred for treatment of an injury which is covered under the terms and conditions of the plan, without application of the deductible(s) and copayment(s), if any. 2. In the case of PIP plans, that portion of the medical expenses incurred for treatment of an injury which, without considering any deductible and copayment, shall not exceed: i. The percent or dollar amounts specified on the medical fee schedules, or the actual billed expense, whichever is less; or ii. The reasonable amount, as determined by the automobile insurer, considering the medical fee schedules for similar services or equipment in the region where the service or equipment was provided, when an incurred medical expense is not included on the medical fee schedules. Health benefits provider means any person, whether subject to the regulation of the New Jersey Department of Banking and Insurance, Department of Health and Senior Services, or both, or not otherwise subject to such regulation, who contracts to provide health services, provide reimbursement for the cost of health services in whole or in part, or to provide for indemnity in the event health services are used, in return for a prepaid or postpaid premium or fee or other consideration, including, but not limited to: 1. Insurers, as defined at N.J.S.A. 17B:17-2; 2. Hospital service corporations, as defined at N.J.S.A. 17:48-1; 3. Medical service corporations, as defined at N.J.S.A. 17:48A-1; 4. Health service corporations, as defined at N.J.S.A. 17:48E-1; 5. Health maintenance organizations, as defined at N.J.S.A. 26:2J-2; 6. Dental service corporations, as defined at N.J.S.A. 17:48C-2; 7. Dental plan organizations, as defined at N.J.S.A. 17:48D-2; 8. Medicare; 9. Medicaid; 10. State Employees Health Benefits Plan; 11. CHAMPUS; 12. Self-insured programs; and

239 BENEFIT DETERMINATION: PIP - HEALTH 11: An entity organized under the laws of any other state or jurisdiction which delivers certificates to residents of New Jersey evidencing coverage under a contract issued and delivered in a state or jurisdiction other than New Jersey. Hospital expenses, when used by the automobile insurance PIP plan, means those expenses defined at N.J.S.A. 39:6A-2f. Injury means bodily injury sustained by an insured as a result of an accident while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an object propelled by or from an automobile. Insured means a person eligible for coverage, at least in part, for medical expenses incurred for treatment of injuries, under an automobile policy PIP medical expense provision, and who meets the definition of a named insured or family member. 1. Named insured means the person or persons identified as the insured in the automobile policy and if an individual, that person's spouse, if the spouse is a resident of the same household, except that if the spouse ceases to be a resident of the household of the named insured, coverage for that spouse shall continue until the expiration of full term of any policy period in effect at the time of the cessation of residency. 2. Family member means any relative of the named insured or the named insured's spouse who: i. Is related to the named insured or named insured's spouse by blood, marriage, adoption or guardianship; ii. Resides in the household of the named insured or spouse of the named insured; and iii. Is not a named insured under another automobile policy. Medical expenses is as defined in N.J.A.C. 11: Medical fee schedule means that list of services, procedures and supplies to which have been assigned a maximum fee or percentage of a fee payable by an automobile insurer for expenses incurred as a result of the rendering to an insured any of those specific services, procedures or supplies for injuries, which list is set forth at N.J.A.C. 11:3-29. Out-of-State automobile insurance coverage or OSAIC means any coverage for medical expenses under an automobile insurance policy other than PIP, as PIP is defined herein, including automobile insurance policies issued in another state or jurisdiction. PIP means personal injury protection coverage provided as part of an automobile insurance policy pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, issued in New Jersey, specifically those provisions for medical expenses coverage. Plan means any policy, contract, certificate, booklet, evidence of enrollment, program, or other such term which evidences the existence of a relationship between a health benefits provider or PIP carrier and an insured with respect to the provisions of hospital, medical, surgical, dental and/or other health care related benefits, at least in part. Primary coverage means coverage by any plan which determines its actual benefits payable on allowable expenses incurred by an insured for treatment of injuries without taking into consideration the existence of any coverage for which the insured may be eligible provided secondary in accordance with this subchapter. There may be more than one plan providing the insured primary coverage.

240 11: APPENDIX B - REGULATIONS Secondary coverage means coverage by any plan which determines its actual benefits payable on all allowable expenses incurred by an insured for treatment of injuries after all plans providing primary coverage have considered expenses incurred and paid actual benefits. Amended. R d. 591, effective December 21, 1998 (operative March 22, 1999); R d. 44, effective February 5, : Health benefits providers. (a) Nothing in this subchapter shall be construed as requiring any health benefits provider to offer, provide, or continue coverage to or for any individual or group, except as may be set forth by other laws of this State, or of the Federal government. (b) Nothing in this subchapter shall be construed as requiring any health benefits provider to provide coverage for any treatment or service not otherwise covered under the terms of the applicable health benefits plan. (c) No health benefits contract or policy delivered or issued for delivery in this State, or renewed, continued or converted on or after January , shall contain any provision, rider, waiver of endorsement or other instrument which restricts, limits or excludes coverage, directly or indirectly, of services or expenses otherwise eligible under the policy or contract on the grounds that such expenses or services would be covered under an automobile policy PIP provision for which the insured would be eligible had the named insured on the automobile policy not selected the PIP-as-secondary coverage option. (d) No health benefits contract or policy delivered or issued for delivery in this State, or renewed, continued or converted on or after January , shall contain any provision, rider, waiver or endorsement, or other instrument which restricts, limits or excludes coverage, directly or indirectly, of services or expenses otherwise eligible under the policy or contract on the grounds that: 1. Such expenses arise from an automobile-related injury; 2. Such expenses are covered or paid by PIP; or 3. Such expenses are covered or paid by OSAIC except for reductions in benefits when the health benefits contract provides secondary coverage as defined in and permitted by this rule. (e) A health benefits contract or policy may provide that it is always primary to OSAIC, or may provide that it will determine its benefits as if it were secondary to any OSAIC. If the health benefits contract or policy provides that it will determine its benefits as if it were secondary to OSAIC and the OSAIC either contains a provision that it is always excess or secondary, or refuses to cooperate in determining the amount of benefits payable by the health benefits plan as secondary coverage provider, the health benefits plan shall provide primary coverage. 11: Application of the PIP-as-secondary coverage option. (a) When a named insured elects the PIP option, whereby the named insured intends that medical expenses incurred for treatment of an injury are to be covered by a health benefits provider or providers, as evidenced on the Coverage Selection Form, then the medical expense provisions of the PIP coverage shall be considered to be secondary coverage for the purposes of the order of benefit determination, and all health benefits plans of an insured subject to the PIP option elected shall be considered to be primary coverage. (b) The election by the named insured to make PIP medical expense provisions secondary coverage shall apply to only the named insured and family members of the named insured who reside in the named insured s household and are not named insureds under other automobile policies. (c) The election by the named insured to make PIP medical expense provisions secondary coverage shall continue in force as to subsequent renewal or replace-

241 BENEFIT DETERMINATION: PIP - HEALTH 11: ment policies until the automobile policy insurer or its authorized representative receives a properly executed written request revoking the selection of this option. (d) In the event that an insured is ineligible for health plan coverage of medical expenses, or is eligible for coverage under a dental expense or dental service plan only when an injury occurs, despite the selection of the PIP-as-secondary coverage option by the named insured, benefits shall be provided to the insured through PIP coverage in accordance with N.J.A.C. 11: : Health benefit plan standards and the PIP premium reduction. (a) An automobile insurer may eliminate the premium reduction on the base rate applicable to the amount of medical expense benefit chosen in conjunction with the PIP-as-secondary coverage option election if the automobile insurer complies with (b) below, and verifies that the coverage specified by the named insured: 1. Excludes the provision of benefits for treatment of injuries of an eligible insured when expenses incurred in relation to treatment of those injures are eligible expenses under an automobile policy s PIP provisions; or 2. Provides that it is always secondary, or otherwise will not be a primary provider of benefits; 3. Provides benefits only for dental expenses or dental services; or 4. Provides benefits only for prescription drugs. (b) An automobile carrier shall notify a named insured if the automobile insurer determines that the health benefits plan(s) specified by the named insured contain exclusionary or restrictive coverage provisions as set forth in (a) above, or if the automobile insurer determines that one or more of the insureds covered under the automobile insurance policy is not provided coverage by at least one of the health benefit plan(s) specified by the named insured, and, therefore, the named insured s premium reduction for PIP medical expense benefits will be eliminated. 1. The notice shall be in writing and shall specify the reasons why the automobile insurer believes the named insured s health plan coverage is not in compliance with this subchapter. 2. The automobile insurer may include in the notice a demand for payment of the premium reduction difference with an explanation that failure to pay the indicated premium reduction difference may result in early cancellation of the automobile policy in accordance with (c) below. 3. The notice shall be sent no later than 30 days prior to the date of cancellation as calculated in accordance with (c) below. A notice which is sent 30 days prior to the date of cancellation shall either contain a statement that it is a notice of cancellation, or be attached to a notice of cancellation, setting forth the effective date of cancellation. (c) The effective date of the cancellation of a policy for nonpayment of premium shall not be earlier than 10 days prior to the last full day of which premium received by the company, prior to the date of preparation of the cancellation notice, would pay for coverage on a pro rata basis. In calculating the effective date of the cancellation, the premium applicable to the coverage provided by the policy and the premium received by the company at or prior to the time the cancellation notice was prepared shall be the premium used for the calculation and determination of such effective date. 1. No cancellation in accordance with (c) above shall be effective unless prior thereto, the automobile insurer shall have notified the named insured that the premium reduction difference had to be paid to avoid cancellation, as specified in (b)2 above. 2. No cancellation notice shall be mailed prior to 30 days in advance of its effective date. (d) If the insured provides payment of the full premium amount and subsequently provides proof that coverage is not restricted in the manner set forth in ac-

242 11: APPENDIX B - REGULATIONS cordance with (a) above, or that all insureds under the automobile policy were provided coverage by a health benefits plan at the time notification of noncoverage was sent, and that such coverage continues and is not restricted in the manner set forth in accordance with (a) above, the automobile insurer shall refund the monies paid in excess of the full reduction, or shall credit any excess paid on the reduced premium to the extent any premium payment is still unpaid on the policy. 11: Order of benefits determination when PIP is secondary coverage. (a) When the named insured of an automobile policy has selected the PIP-assecondary coverage option, all health benefits plans for which the insured is eligible shall provide coverage for the allowable expenses incurred by the insured due to an automobile-related injury prior to any benefits for medical expenses being paid by a PIP plan. (b) If the insured is eligible for coverage under more than one group health benefits plan, the group health benefits plans shall coordinate benefits with one another in accordance with the rules set forth for such plans at N.J.A.C. 11:4-28. (c) The PIP plan shall provide benefits for allowable expenses remaining uncovered after all health benefits plans for which the insured is eligible have paid benefits towards those allowable expenses. (d) The PIP plan shall continue to be liable for expenses related to the same occurrence as the expenses are incurred, whether or not the health benefits plan(s) in force at the time of the accident terminate(s) coverage, or benefits provided under the health benefits plan(s) are exhausted subsequent to the occurrence of the accident, up to the maximum PIP benefits available to the insured under the terms of the automobile policy. (e) Total benefits paid by an insured s health benefits and PIP plans shall not exceed the amount of total allowable expenses. 11: Determination of PIP medical benefits payable when PIP is secondary coverage. (a) In calculating the actual benefits to be paid by the automobile insurer when the PIP-as-secondary coverage option has been selected, the automobile insurer shall first determine the amount of eligible expenses which would have been paid after application of the deductible and copayment limitations had the PIP-as-secondary coverage option not been selected. 1. In the event the remaining allowable expenses are less than the benefits calculated pursuant to (a) above, the automobile insurer shall pay actual benefits equal to the remaining allowable expenses, without reducing the remaining allowable expenses by its deductible or copayments. 2. In the event the remaining allowable expenses are greater than the benefits calculated pursuant to (a) above, the actual benefits paid by the automobile insurer shall be the benefits calculated pursuant to (a) above, without reducing the remaining allowable expenses by its deductible or copayments. (b) In paying actual benefits, the automobile insurer shall not: 1. Reduce its actual benefits payable on account of any deductibles or copayments of the health benefits plans which have provided benefits ahead of the PIP plan due to the selection of the PIP-as-secondary coverage option: or 2. Reduce its actual benefits payable for any allowable expense remaining uncovered which item of expense otherwise would not be an eligible expense under the PIP plan, except as set forth by (c) below. (c) In determining remaining uncovered allowable expenses, the automobile insurer shall not consider any amount for items of expense which exceed the dollar or percent amounts recognized by the medical fee schedules promulgated pursuant to N.J.S.A. 39:6A-4.6.

243 BENEFIT DETERMINATION: PIP - HEALTH 11: (d) The total amount of benefits to be provided through the PIP medical expense provisions for each insured per accident or occurrence shall not exceed the maximum PIP benefits as provided for by the terms of the policy. 11: Health benefits plan coverage ineligibility. (a) When, subsequent to the selection of the PIP-as-secondary coverage option by a named insured, it is determined that an insured did not have health coverage in effect at the time of an injury, or had health coverage in effect at the time of any injury which is such that the PIP-as-secondary coverage option selection could have been invalidated by the automobile insurer and elimination of the premium reduction amount effected in accordance with N.J.A.C. 11:3-37.5(a), but was not, then the insured shall be provided benefits for incurred medical expenses through the PIP medical expense provision. 1. Benefits payable shall be subject to a per accident deductible equalling the total of $ plus the PIP deductible selected by the named insured of the policy. 2. Benefits payable shall be subject to a 20 percent copayment for amounts less than $5,000 after the deductible has been satisfied. 3. Determination of the amount of benefits payable shall be made in accordance with medical fee schedules promulgated pursuant to N.J.S.A. 39:6A-4.6 and set forth at N.J.A.C. 11:3-29, or on a reasonable basis, as determined by the automobile insurer, considering the medical fee schedules for similar services or equipment in the region where the service or equipment was provided, when an item of expense is not included on the medical fee schedules. 4. Total benefits paid for each insured eligible for benefits in any one accident shall not exceed the maximum PIP benefits provided for by the terms of the policy. (b) All items of medical expense incurred by the insured for treatment of an injury shall be eligible expense to the extent the treatment or procedure from which the expenses arose is recognized on the medical fee schedules, or are reasonable medical expenses in accordance with N.J.S.A. 39:6A-4. (c) The automobile insurer shall be entitled to recover, for the contract period in which the automobile-related injury occurred, the difference between the reduced premiums paid on the policy and the amount of premium which would have been due on the policy had the named insured not selected the PIP-as-secondary coverage option, and no premium reduction shall be provided on that policy for the PIP-as-secondary coverage option during the remainder of that current contract period. 11: Determination of benefits when PIP is primary coverage. (a) When no election has been made by a named insured to make his or her health benefits plan(s) primary coverage provider(s), so that the PIP plan will provide primary coverage for medical expenses incurred for treatment of injuries, the PIP plan shall provide benefits to the insured without consideration of any benefits for which the insured may be eligible under any health benefits plan. (b) Actual benefits paid by the PIP plan shall be medical expenses, subject to the policy limits and supplication of any deductible and copayment provided for by the terms of the automobile policy, approved by the Commissioner pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, and any rules promulgated thereunder. (c) Actual benefits payable by a health benefits plan, when the PIP plan is providing primary coverage for medical expenses incurred for treatment of injuries, shall be the lesser of the remaining uncovered allowable expenses or the actual benefits that would have been payable had the health benefits plan been providing coverage primary to the PIP plan. 1. Actual benefits payable may be reduced by the deductible(s) and copayment requirements applicable by the terms of the health benefits plan, and shall not ex-

244 11: APPENDIX B - REGULATIONS ceed the amount of actual benefits that would have been payable had the health benefits plan been providing coverage primary to the PIP plan. 2. Allowable expenses remaining uncovered, which the health benefits plan(s) shall consider when the PIP plan is providing primary coverage, include: i. Any PIP deductible(s); ii. Any PIP copayment amounts; iii. Any expenses which exceed the medical expense coverage limits of the PIP plan per person per accident, as set forth by the terms of the automobile policy; and iv. Any expenses not covered by the PIP plan when such expense was determined to be in excess of the reasonable charge for an item of expense not listed on the medical fee schedules, but for which the automobile insurer determined a reasonable charge based on the medical fee schedule for a similar item of expense in the region where the service or equipment was provided. (d) When a health benefits plan provides hospital expense or service benefits only, or medical expense or service benefits only, and is not otherwise a part of a basic health benefits package, all allowable expenses remaining uncovered shall be considered by that health benefits plan for the provision of benefits, without regard as to whether the expenses are hospital-related or medical-related expenses. Actual benefits paid by that health benefits plan for the allowable expenses remaining uncovered shall not exceed the total actual benefits which would have been payable had the health benefits plan been providing coverage primary to the PIP plan. (e) When there is one health benefits plan providing insureds hospital expense or service benefits and another health benefits plan providing insureds medical expense or service benefits as two separate parts of one basic health benefits plan package, the hospital benefits plan and the medical benefits plan shall both consider all allowable expenses remaining uncovered and shall apportion such allowable expenses between the two plans on a pro-rata basis without regard as to whether the expenses are hospital-related or medical-related expenses. Actual benefits paid by each plan of the health benefits plan package shall not exceed the total actual benefits which would have been payable by each plan had the health benefits plan package been providing primary coverage. (f) No insured shall be liable to a health care provider for any fees for services or supplies which exceed the dollar or percentage amounts recognized for those services or supplies on the medical fee schedules. (g) No health benefits plan shall seek repayment from or withhold payment to an insured for amounts paid to the insured in consideration of charges which were in excess of the amounts set forth in the medical fee schedules. (h) If there is more than one group health benefits plan providing secondary coverage to an insured, these plans may coordinate their benefits with one another in accordance with N.J.A.C. 11:4-28. Amended. R d. 591, effective December 21, 1998 (operative March 22, 1999). 11: Explanation of benefits. (a) Automobile insurers shall develop and utilize an explanation of benefits form to be provided with the payment of benefits for expenses incurred for treatment of injuries which clearly identifies and explains the following: 1. Each procedure for which a claim has been made; 2. Eligible expense related to each procedure with an indication of whether the eligible expense is based on the medical fee schedules or is the reasonable charge as determined by the automobile insurer; 3. Actual benefits paid; 4. Any deductible or copayment applied;

245 BENEFIT DETERMINATION: PIP - HEALTH 11: A concise explanation why any item of expense is considered an ineligible expense, when this occurs; and 6. A statement to insureds that no health care provider may demand or request any payment from any person in excess of those permitted by N.J.A.C. 11:3-29, and that no person is liable to any health care provider for any amount of money which results from the charging of fees in excess of those permitted by N.J.A.C. 11:3-29, pursuant to N.J.S.A. 39:6A-4.6. Amended by R d. 564, effective November 21, 1994 (operative January 1, 1995). 11: Dispute as to primacy of coverage. (a) If, subsequent to the selection of the PIP-as-secondary coverage option by the named insured, injuries are sustained by an insured eligible for health benefits plan coverage, but a dispute exists between the health benefits provider and the automobile insurer, then the health benefits provider shall provide benefit as if it were the primary coverage provider and no PIP benefits were available to the insured. In no event shall the provision of benefits be unreasonably delayed by either a health benefits provider or an automobile insurer. (b) If the health benefits provider asserts that it is not subject to N.J.A.C. 11:3-37.3, and thus, will not act as the primary coverage provider then the automobile insurer shall assume the role of primary coverage provider, and provide its benefits in accordance with N.J.A.C. 11: The automobile insurer shall be entitled to recover premium reductions in accordance with N.J.A.C. 11:3-37.8(c). 11: Eligibility under two or more automobile policies. (a) If an insured is eligible for coverage of medical expenses under more than one automobile policy, the determination as to which automobile policy will assume coverage responsibility for that insured shall be as follows: 1. A named insured shall receive benefits for medical expenses under the terms of the automobile policy on which he or she, or his or her spouse, is identified as the named insured. 2. A family member who is a child of a named insured or the named insured s spouse shall receive benefits for medical expenses under the automobile policy of the named insured, subject to the following: i. If the child is a child of more than one named insured or of more than one spouse of a named insured, the child shall receive benefits under the terms of the automobile policy of the named insured who has legal custody of that child or whose spouse has legal custody of that child. ii. If the child is a child of more than one named insured or of more than one named insured s spouse, and legal custody of that child has either never been awarded, or has been awarded jointly, then the child shall receive benefits under the terms of the automobile policy of the named insured whose birthday occurs earliest in the calendar year. iii. If the child is a named insured or the spouse of a named insured, (a)1 above shall apply. 3. If neither (a)1 nor (a)2 above apply to an adult or child family member, then that family member shall receive benefits for medical expenses under the terms of the automobile policy of the named insured whose birthday occurs earliest in the calendar year. 4. If an automobile policy identifies more than one person as a named insured on the automobile policy, the birthday of the named insured whose birthday occurs earliest in the calendar year shall be considered the determinant birthday on that automobile policy. (b) An insured shall not receive benefits for medical expenses under more than one automobile policy.

246 11: APPENDIX B - REGULATIONS (c) If an automobile policy PIP plan provides benefits for medical expenses for an insured who is eligible for medical expense benefits under more than one automobile policy PIP plan, the automobile insurer of the paying PIP plan may seek equitable pro rata contributions from the other automobile policy PIP plan(s) for the benefits actually paid by the paying PIP plan. 11: Penalties. Each automobile policy or health benefits plan subject to the terms of this subchapter which fails to comply with the terms herein shall be in violation of this subchapter. Failure to comply with the terms of this subchapter may result in the assessment of any and all penalties in accordance with the laws of this State. 11: Severability. If any provision of this subchapter or application thereof to any person or circumstance is held invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby.