APPENDIX B NEW JERSEY ADMINISTRATIVE CODE

APPENDIX B NEW JERSEY ADMINISTRATIVE CODE Current Through N.J. Register Volume 47, Number 16 (47 N.J.R. 2196) Includes Adopted Rules Filed Through July 24, 2015 SUBCHAPTER 3. BASIC AUTOMOBILE INSURANCE POLICY Source and Effective Date. R. 1998 d. 592, effective December 21, 1998 (operative March 22, 1999). Section 11:3-3.1. Purpose and scope. 11:3-3.2. Definitions. 11:3-3.3. General provisions. 11:3-3.4. Coverages; mandatory and optional. 11:3-3.5. Election of basic automobile insurance policy coverage and reporting. 11:3-3.6. Filing requirements. 11:3-3.1. Purpose and scope. (a) This subchapter provides rules to be utilized by insurers in developing the policy forms and rates for basic automobile insurance policies to be filed with and approved by the Department in accordance with the provisions of N.J.S.A. 39:6A-3.1. (b) This subchapter shall apply to all insurers writing private passenger automobile insurance on personal lines policy forms, including the New Jersey Personal Automobile Insurance Plan established by N.J.A.C. 11:3-2. 11:3-3.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Basic automobile insurance policy or basic policy means that automobile insurance policy offered pursuant to N.J.S.A. 39:6A-3.1 and this subchapter. Basic policy servicing carrier means a limited assignment distribution carrier that is a participating insurer that agrees to accept assignments of basic policies pursuant to this subchapter and the procedures set forth in the PAIP plan of operation. Commissioner means the Commissioner of the Department of Banking and Insurance. Department means the Department of Banking and Insurance. Insurer means any person or persons, corporation, association, partnership, company, reciprocal exchange, or other legal entity authorized or admitted to transact private passenger automobile insurance in this State, or any one member of a group of affiliated companies that transacts business in accordance with a common rating system. Medically necessary is as defined in N.J.A.C. 11:3-4.2. PAIP means the New Jersey Personal Automobile Insurance Plan established pursuant to N.J.S.A. 17:29D-1 and N.J.A.C. 11:3-2. Personal injury protection or PIP means the benefits and coverages set forth at N.J.S.A. 39:6A-4 and 39:6A-3.1 and N.J.A.C. 11:3-4. Significant disfigurement means the result and/or manifestation of a serious traumatic injury that is observable as a permanent and substantial defect in the appearance and functional ability of the person injured. Significant disfigurement is a serious outward change that substantially detracts from the appearance and functional ability of the person injured.

11:3-3.3 APPENDIX B - REGULATIONS Standard automobile insurance policy or standard policy means that policy form filed by private passenger automobile insurers and approved by the Commissioner that contains the coverages and options pursuant to N.J.S.A. 39:6A-4. Amended. R.2000 d.454, effective November 6, 2000; R.2007 d.151, effective May 7, 2007. 11:3-3.3. General provisions. (a) All insurers writing private passenger automobile insurance and the Personal Automobile Insurance Plan shall file for approval with the Department their rates, rules and policy forms for a basic automobile insurance policy to be issued in accordance with N.J.S.A. 39:6A-3.1 and this subchapter. (b) An insurer shall make available the basic policy at either a single tier rate or at multiple tier rates, consistent with its tier rating system filed and approved pursuant to N.J.A.C. 11:3-19A. If more than one basic policy rate is offered, each shall be identified as part of a standard, non-standard or preferred tier. (c) If a named insured has elected basic automobile insurance coverage and other immediate family members or resident relatives of the named insured have higher policy limits under a standard policy, the provisions of N.J.S.A. 39:6A-4.2 shall apply and the named insured shall only be entitled to the coverages provided under his or her basic policy. (d) Basic policies shall provide the tort option provided under N.J.S.A. 39:6A-8a. (e) Initial rates by coverage for basic policies filed in accordance with this subchapter shall demonstrate consistency with the rates in the insurer's standard policy, adjusted for reduced coverage limits. (f) Insurers shall file for approval an initial basic policy rating system by January 20, 1999. (g) An insurer may write basic policies through a basic policy servicing carrier. Amended. R.2007 d.151, effective May 7, 2007. 11:3-3.4. Coverages; mandatory and optional. (a) The following coverages shall be included in all basic policies: 1. Personal injury protection medical expense benefits coverage in an amount not to exceed $15,000 per person, per accident; except that all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requiring critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician shall be covered in an amount not to exceed $250,000, including the $15,000 above. The medical expense benefits provided herein shall be in accordance with N.J.A.C. 11:3-4; and 2. Liability insurance coverage insuring against loss resulting from liability imposed by law for property damage sustained by any person arising out of the ownership, maintenance, operation or use of an automobile in an amount or limit of $5,000, exclusive of interest and costs, for damage to property in any one accident. (b) Insurers shall also make available in the basic policy, at the option of the insured, liability insurance coverage for bodily injury or death in an amount or limit of $10,000, exclusive of interest and costs, on account of the injury or death of one or more persons in any one accident. (c) Insurers may make available with the basic policy, at the option of the insured, comprehensive and collision coverage with deductibles filed and approved pursuant to N.J.A.C. 11:3-13. (d) Basic policies shall not contain any other coverages, options, limits or deductibles other than those which are set forth in (a) through (c) above. Increased policy limits, the health insurance primary option for automobile medical expense

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.1 coverage and uninsured/under-insured motorist coverages shall not be provided in basic policies. 11:3-3.5. Election of basic automobile insurance policy coverage and reporting. No insurer shall issue a basic automobile insurance policy unless the named insured has signed a written document entitled basic automobile insurance policy coverage selection form set forth in N.J.A.C. 11:3-15.7. Amended. R.2003 d.95, effective March 3, 2003; R.2006 d.243, effective July 3, 2006. 11:3-3.6. Filing requirements. (a) Insurers initially filing basic policy rating systems shall include the following: 1. A complete set of policy forms and endorsements that provide the mandatory and optional coverages as set forth in this subchapter; 2. Rates and rules as necessary; 3. An actuarial memorandum that supports the rate differentials from the insurer's standard policy rates; 4. The declaration page; 5. The rating information form; and 6. The personal lines filing forms as set forth in N.J.A.C. 11:3-16.3(f) and (g). (b) Subsequent amendments to the rating systems shall be filed pursuant to N.J.A.C. 11:3-16 and other applicable statutes and rules. SUBCHAPTER 4. PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS Source and Effective Date: R.1998 d.597, effective December 21, 1998 (operative March 22, 1999). Section 11:3-4.1. Scope and purpose. 11:3-4.2. Definitions. 11:3-4.3. Personal injury protection benefits applicable to basic and standard policies. 11:3-4.4. Deductibles and co-pays. 11:3-4.5. Diagnostic tests. 11:3-4.6. Medical protocols. 11:3-4.7. Decision point review plans. 11:3-4.7A PIP vendor registration requirements 11:3-4.8. Voluntary networks. 11:3-4.9. Assignment of benefits; public information. 11:3-4.10. 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 11:3-4.1. Scope and purpose. (a) This subchapter implements the provisions of N.J.S.A. 39:6A-3.1, 39:6A-4 and 39:6A-4.3 by identifying the personal injury

11:3-4.2 APPENDIX B - REGULATIONS protection medical expense benefits and emergency personal injury protection coverage for which reimbursement of eligible charges will be made by automobile insurers under basic, standard and special automobile insurance policies and by motor bus insurers under medical expense benefits coverage. (b) This subchapter applies to all insurers that issue policies of automobile insurance containing PIP coverage, emergency personal injury protection coverage and policies of motor bus insurance containing medical expense benefits coverage. (c) This subchapter shall apply to those policies that are issued or renewed on or after March 22, 1999. Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). 11:3-4.2. Definitions. The following words, phrases and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. Ambulatory surgery facility or ambulatory surgical center (ASC) means: 1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are performed and which is separate and apart from any other facility license. (The ambulatory surgery facility may be physically connected to another licensed facility, such as a hospital, but is corporately, financially and administratively distinct, for example, it uses a separate tax-id number); or 2. A physician-owned single operating room in an office setting that is certified by Medicare. Basic automobile insurance policy or basic policy means those private passenger automobile insurance policies issued in accordance with N.J.S.A. 39:6A- 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.

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

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

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.4 11:3-4.3. Personal injury protection benefits applicable to basic and standard policies. (a) Personal injury protection coverage shall provide reimbursement for all medically necessary expenses for the diagnosis and treatment of injuries sustained from a covered automobile accident up to the limits set forth in the policy and in accordance with this subchapter. (b) Personal injury protection coverage shall only provide reimbursement for clinically supported necessary non-medical expenses that are prescribed by a treating medical provider for a permanent or significant brain, spinal cord or disfiguring injuries. 11:3-4.4. Deductibles and co-pays. (a) Each insurer shall offer a standard $250.00 deductible and 20 percent copayment on medical expense benefits payable between $250.00 and $5,000. (b) Each insurer shall also offer, at appropriately reduced premiums, the option to select medical expense benefit deductibles of $500.00, $1,000, $2,000 and $2,500 in accordance with the following provisions: 1. Any medical expense deductible elected by the named insured shall apply only to the named insured and any resident relative in the named insured's household, who is not a named insured under another automobile policy and not to any other person eligible for personal injury protection benefits required to be provided in accordance with N.J.S.A. 39:6A-3.1 and 39:6A-4; 2. Premium credits calculated and represented as a percentage of the applicable premium shall be provided for each deductible. The premium percentage shall be uniform by filer on a statewide basis; and 3. The deductible option elected by the named insured shall continue in force as to subsequent renewal or replacement policies until the insurer or its authorized representative receives a properly executed coverage selection form to eliminate or change the deductible. (c) All deductibles and co-pays in (a) and (b) above shall apply on a per accident basis. (d) An insurer may file policy language that waives the co-payment and deductible in (a) and (b) above when the insured receives medical treatment from a provider that is part of an ODS that has contracted with the insurer or its PIP vendor. The insured shall not be required to elect to use the providers or facilities in such an ODS either at issuance of the policy or when the claim is made. 1. Upon receipt of notification of a claim, the insurer or its PIP vendor shall make available to the insured information about physicians and facilities in any ODS with which it has a contract. i. The information shall include a notice that the insured is not required to use the providers or facilities of an ODS with which the insurer or its PIP vendor has contracted and indicate that if the insured chooses to receive covered services from such providers or facilities, the deductible and copayments in (a) and (b) above would not apply. ii. The information shall also indicate that the insured may seek treatment from providers and facilities that are not part of an ODS with which the insurer or its PIP vendor has contracted, in which case the deductible and copayments in (a) and (b) above would apply. 2. The actual ODS access fee or 25 percent of the reduction in charges resulting from the use of the ODS provider, whichever is less, may be included within the policy limits for any single bill from an in-network provider in the ODS with billed charges of $ 10,000 or more. Example: A $10,000 charge is reduced by the ODS contract with the insurer by 45 percent to $5,500. The insurer could include the ODS access fee or $1,125 (25 percent of the $4,500 reduction), whichever is less, within the policy limits.

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

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

11:3-4.5 APPENDIX B - REGULATIONS of nerve root compression and/or motor loss. MRI is not normally performed within five days of the insured event. However, clinically supported indication of neurological gross motor deficits, incontinence or acute nerve root compression with neurologic symptoms may justify MRI testing during the acute phase immediately post injury. In the case of TMJ/D where there are clinical signs of internal derangement such as nonself-induced clicking, deviation, limited opening, and pain with a history of trauma to the lower jaw, an MRI is allowable to show displacement of the condylar disc, such procedure following a panographic or transcranial x-ray and six or eight weeks of conservative treatment. This TMJ/D diagnostic test may be repeated post surgery and/or post appliance therapy. 6. Computer assisted tomographic studies (CT, CAT Scan) when used to evaluate injuries in numerous aspects of the body. With the exception of suspected brain injuries, CAT Scan is not normally administered immediately post injury, but may become appropriate within five days of the insured event. Repeat CAT Scans should not be undertaken unless there is clinically supported indication of an adverse change in the patient's condition. In the case of TMJ/D where there are clinical signs of degenerative joint disease as a result of traumatic injury of the temporomandibular joint, tomograms may not be performed sooner than 12 months following traumatic injury. 7. Dynatron/cyber station/cybex when used to evaluate muscle deterioration or atrophy. These tests should not be performed within 21 days of the insured event and should not be repeated if results are negative. Repeat tests are not appropriate at less than six months intervals. 8. Sonograms/ultrasound when used in the acute phase to evaluate the abdomen and pelvis for intra-abdominal bleeding. These tests are not normally used to assess joints (knee and elbow) because other tests are more appropriate. Where MRI is performed, sonograms/ultrasound are not necessary. However, echocardiogram is appropriate in the evaluation of possible cardiac injuries when clinically supported. 9. Thermography/thermograms only when used to evaluate pain associated with reflex sympathetic dystrophy ( RSD ), in a controlled setting by a physician experienced in such use and properly trained. 10. Brain mapping, when done in conjunction with appropriate neurodiagnostic testing. (c) The terms normal, normally, appropriate and indicated as used in (b) above, are intended to recognize that no single rule can replace the good faith educated judgment of a health care provider. Thus, normal, normally, appropriate and indicated pertain to the usual, routine, customary or common experience and conclusion, which may in unusual circumstances differ from the actual judgment of course of treatment. The unusual circumstances shall be based on clinically supported findings of a health care provider. The use of these terms is intended to indicate some flexibility and avoid rigidity in the application of these rules in the decision point review required in (d) below. (d) Except as provided in (e) below, a determination to administer any of the tests in (b) above shall be subject to decision point review pursuant to N.J.A.C. 11:3-4.7. (e) The requirements of (b) and (d) above shall not apply to diagnostic tests administered during emergency care. (f) Pursuant to N.J.A.C. 13:30-8.22(b), the personal injury protection medical expense coverage shall not provide reimbursement for the following diagnostic tests which have been identified by the New Jersey State Board of Dentistry as failing to yield data of sufficient volume to alter or influence the diagnosis or treatment plan employed to treat TMJ/D:

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.7 1. Mandibular tracking; 2. Surface EMG; 3. Sonography; 4. Doppler ultrasound; 5. Needle EMG; 6. Electroencephalogram (EEG); 7. Thermograms/thermographs; 8. Video fluoroscopy; and 9. Reflexology. Amended. R.2000 d.454, effective November 6, 2000. 11:3-4.6. Medical protocols. (a) Pursuant to N.J.S.A. 39:6A-3.1 and 39:6A-4, the Commissioner designates the care paths, set forth in the subchapter Appendix incorporated herein by reference, as the standard course of medically necessary treatment, including diagnostic tests, for the identified injuries. (b) Where the care path indicates a decision point either by a hexagon in the care path itself or by reference in the text to a second opinion, referral for a second independent consultative medical opinion, development of a treatment plan or mandatory case management, the policy shall provide for a decision point review in accordance with N.J.A.C. 11:3-4.7. (c) Treatments that vary from the care paths shall be reimbursable only when warranted by reason of medical necessity. (d) The care paths do not apply to treatment administered during emergency care. 11:3-4.7. Decision point review plans. (a) No insurer shall impose the co-payments permitted in N.J.A.C. 11:3-4.4(e), (f) and (g) unless it has an approved decision point review plan. 1. Initial decision point review plan filings and amendments to approved plans shall be submitted to the Department through the use of the NAIC electronic filing system SERFF (System for Electronic Rate and Form Filing). (b) No decision point or precertification requirements shall apply within 10 days of the insured event or to emergency care. This provision should not be construed so as to require reimbursement of tests and treatment that are not medically necessary. (c) A decision point review plan filing shall include the following information: 1. Identification of any PIP vendor with which the insurer has contracted and a copy of the contract between the insurer and the PIP vendor. No insurer shall contract with a PIP vendor unless the vendor is registered with the Department pursuant to N.J.A.C. 11:3-4.7A; 2. Identification of any specific medical procedures, treatments, diagnoses, diagnostic tests, other services or durable medical equipment that are subject to precertification. The inclusion of precertification requirements in a decision point review plan is optional. The medical procedures, treatments, diagnoses, diagnostic tests or durable medical equipment required to be precertified shall be those that the insurer has determined may be subject to overutiliztion and that are not already subject to decision point review. The insurer shall not require the precertification of a new-patient evaluation and management visit that is necessary for the provider to develop the plan of care that is incorporated into a precertification request for treatment or diagnostic testing; 3. Copies of the informational materials described in (d) below and an explanation of how the insurer will distribute information to policyholders, injured persons and providers at policy issuance, renewal and upon notification of claim. 4. Procedures for the prompt review, not to exceed three business days, of decision point review and precertification requests by insureds or providers. All de-

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

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

11:3-4.7A APPENDIX B - REGULATIONS 11:3-4.7A PIP vendor registration requirements (a) No company shall perform utilization management services for an insurer unless registered as a PIP vendor pursuant to this section. (b) Any PIP vendor working for an insurer prior to November 5, 2012 shall file for registration by February 3, 2013. (c) Application for registration shall be made on a form prescribed by the Commissioner, which can be found on the Department's website at http:// www.state.nj.us/dobi/pipinfo/aicrapg.htm. (d) The application shall be accompanied by the applicant s business plan, which shall include the following information: 1. A statement generally describing the applicant, its facilities, personnel, and the services to be offered by the PIP vendor; 2. The name of its medical director(s) licensed to practice as physician(s) in New Jersey and a detailed explanation about how the medical director(s) provide(s) oversight of determinations of medical necessity; 3. The name and contact information of a person at the vendor who is designated to receive and handle complaints and inquiries from the Department; 4. Information on activities undertaken or to be undertaken in New Jersey by the company; 5. A demonstration of the applicant's capability to provide a sufficient number of experienced and qualified personnel in the areas of PIP utilization management, and information on staffing levels, including, but not limited to, training, hiring requirements, experience of staff in general and with PIP utilization management in particular; 6. A statement about whether the applicant is licensed or certified as an entity that has networks as that term is defined in N.J.A.C. 11:3-4.8(a) or accredited by nationally recognized accrediting agencies such as URAC (http://www.urac.org/) in Health Utilization Management; and 7. A copy of the applicant's certificate of incorporation. (e) The application shall also be accompanied by the following information concerning how the applicant will handle PIP utilization management: 1. The vendor s clinical review criteria and protocols. The information shall include a descriptive flow chart of its processes used in decision-making, which shall be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers, and be based upon generally accepted medical standards and standard professional treatment protocols; 2. A copy of the vendor s policies and procedures that demonstrate that the vendor is handling utilization management in accordance with N.J.A.C. 11:3-4, 5 and 29; and 3. The mechanisms it uses to detect underutilization and overutilization of services. (f) A PIP vendor that arranges the physical examinations of injured parties pursuant to N.J.A.C. 11:3-4.7(e) shall submit the criteria it uses to select providers to be on the vendor s panel of examining providers, how it evaluates the quality of an examining provider s examination report and how it avoids conflicts of interest when examinations are ordered and scheduled. (g) Two copies of the information in (a) through (f) above shall be submitted to the Department at the following address:

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.7A New Jersey Department of Banking and Insurance Office of Property and Casualty P.O. Box 325 Trenton, NJ 08625-0325 (h) The Department shall advise the applicant if the application is incomplete not later than 60 days after receipt of the application. Notice to the applicant that the application is incomplete shall specify the missing items or information. The Department shall disapprove an incomplete application if the requested information is not provided within 30 days of the notification to the applicant. If the Department does not notify the applicant of missing items or information within 60 days of receipt, the application shall be deemed complete. (i) The Commissioner shall approve an application for registration if he or she finds that the applicant has demonstrated the ability to perform services in a manner that meets the requirements of this subchapter. (j) The Commissioner may deny an application for registration as a PIP vendor if he or she finds that any of standards established by this subchapter have not been met or for any other reasonable grounds. 1. If the application for registration is denied, the Commissioner shall notify the applicant in writing of the reasons for the denial. 2. When the Department denies an application for registration, the applicant may request a hearing within 30 days of receipt of the denial by submitting a request in writing to the address in (g) above setting forth, with specificity, the reasons that the applicant disputes the Department's denial notice. (k) Registration shall be effective for a period of two years. Registered PIP vendors shall reapply for registration 90 days prior to expiration by submitting the information in (d) through (f) above showing changes to the items previously submitted. (l) All data or information in the PIP vendor's application for registration and the vendor s contract with the insurer required to be submitted pursuant to N.J.A.C. 11:3-4.7(c)1 shall be confidential and shall not be disclosed to the public, except as follows: 1. The PIP vendor s certificate of incorporation; 2. The PIP vendor s address; 3. The names of the PIP vendor's officers and directors, or the individuals in the organization responsible for the administration of utilization management including the medical director(s); and 4. The date of registration of the PIP vendor and date that registration expires. (m) The Commissioner may suspend or revoke the registration of a PIP vendor upon finding that the PIP vendor no longer meets the standards set forth in this subchapter; that PIP utilization review services are not being provided in accordance with the requirements of this subchapter; or that the registration was granted based on false or misleading information. 1. Proceedings to revoke or suspend the registration shall be conducted pursuant to N.J.A.C. 11:17D. 2. Upon request of the PIP vendor for a hearing, the matter shall be transferred to the Office of Administrative Law for a hearing conducted pursuant to the Administratve Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1. New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

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

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10 11:3-4.9. Assignment of benefits; public information. (a) Pursuant to N.J.S.A. 39:6A-4, an insured may only assign benefits and duties under the policy to a provider of service benefits. Insurers may file for approval policy forms that include reasonable procedures for restrictions on the assignment of personal injury protection benefits and duties under the policy, consistent with the efficient administration of the coverage and the prevention of fraud. Insurers may not prohibit the assignment of benefits to providers. Reasonable restrictions may include, but are not limited to: 1. A requirement that as a condition of assignment, the provider agrees to follow the requirements of the insurer's decision point review plan for making decision point review and precertification requests; 2. A requirement that as a condition of assignment, the provider shall hold the insured harmless for penalty co-payments imposed by the insurer based on the provider's failure to follow the requirements of the insurer's decision point review plan; and/or 3. A requirement that as a condition of assignment, the provider agrees to submit disputes to alternate dispute resolution pursuant to N.J.A.C. 11:3-5. (b) Insurers shall file policy language requiring that providers who are assigned benefits by the insured or have a power of attorney from the insured make an internal appeal pursuant to N.J.A.C. 11:3-4.7B prior to making a request for dispute resolution in accordance with N.J.A.C. 11:3-5. (c) An insurer shall identify documents containing proprietary information in its decision point review plan submission. Documents containing proprietary information shall be confidential and shall not be subject to public inspection and copying pursuant to the "Right-to-Know" law, N.J.S.A. 47:1A-1 et seq. The Department shall notify the insurer prior to responding to any public record request for proprietary information. Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-4.10. (Reserved). Repealed. R.2004 d.218, effective June 7, 2004. APPENDIX - TREATMENT OF ACCIDENTAL INJURY TO THE SPINE AND BACK CARE PATHS Exhibit 1 Glossary of Terms Acute Disease--a disease with rapid onset and short course to recovery. Not chronic. Care Path--a recommended extensive course of care based on professionally recognized standards. Case Management--a method of coordinating the provision of healthcare to persons injured in automobile accidents, with the goal of ensuring continuity and quality of care and cost effective outcomes. The Case Manager may be a nurse, social worker, or physician, preferably with certification in case management. Cauda Equina--a collection of spinal roots that descend from the lower part of the spinal cord. They exist in the lower part of the vertebral canal. Chronis Disease--a disease with long duration that changes little and progresses slowly. The apposite of acute. Clinical Evaluation--the evaluation of the symptoms and signs of an injured person by a treating practitioner.

11:3-4.10 APPENDIX B - REGULATIONS Conservative Therapy--treatment which is not considered aggressive; avoiding the administration of medicine or utilization of invasive procedures until such procedures are clearly indicated. Contusion--an injury to underlying soft tissues when the skin is not broken. A bruise. Diagnostic Evaluation--the process of differentiating between two or more diseases with similar signs and symptoms through the use of evaluative procedures such as imaging, laboratory, and physical tests. Herniation--the protrusion or projection of an organ or other body structure through a defect or natural opening in a covering membrane, muscle, or bone. Independent Consultative Opinion--physical examination by a physician of similar specialty to the injured person's treating practitioner to provide a second medical opinion. The independent physician may support, refute, or provide alternatives to the current diagnosis and treatment plans. Non-Compliant--a patient who wilfully chooses not to participate in the treatment plan agreed upon by the patient and his/her healthcare provider and does not have secondary issues such as lack of transportation, pre-existing conditions or comorbidities. PT--Physical Therapy--the therapeutic use of heat, light, water, electricity, massage, exercise, and non-ionizing radiation in treatment of injuries to the soft tissue and muscles/skeleton. PT rendered to persons injured in automobile accidents must be provided by a person whose scope of licensure includes physical therapy. Radicular--pertaining to a root (such as a nerve root) disorder. Radiculopathy--a disorder of a nerve root. Sign--an objective manifestation, usually indicative of a disease or disorder. Signs can be observed by the clinician, as opposed to symptoms, which are perceived only by the affected individual. Soft Tissue Injury--injuries sustained to the muscle, skin, connective tissue. Spine--the vertebral column. Spinal Shock--an acute condition resulting from spinal cord severance. Characterized by a total sensory loss and loss of reflexes below the level of injury and flaccid paralysis. Sprain--an injury at a joint where a ligament is stretched or torn. Strain--an injury caused by the over-stretching or tearing of a muscle or tendon. In its most severe form, the muscle ruptures. Symptom--a subjective manifestation, usually indicative of a disease or disorder. Symptoms are experienced only by the affected individual, as opposed to signs, which can be observed by others. Treatment Plan--specific medical, surgical, chiropractic, acupuncture, or psychiatric procedures used to improve the signs or symptoms associated with injuries sustained in automobile accidents, e.g., physical therapy, surgery, administration of medications, etc.

. PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10 NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

11:3-4.10 APPENDIX B - REGULATIONS 1, 2, 3, 4 See Addendum to Care Paths

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10 NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

11:3-4.10 APPENDIX B - REGULATIONS 4 See Addendum to Care Paths ICD-9 CODES 728.0 728.85 739.0 739.1 847.0 847.9 922.3 922.31 953.0 CARE PATH 1

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10 NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

11:3-4.10 APPENDIX B - REGULATIONS 1, 2, 4 See Addendum to Care Paths ICD-9 CODES 722.0 722.2 722.70 722.71 728.0 739.0 953.0

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10 1, 2, 3, 4 See Addendum to Care Paths NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

11:3-4.10 APPENDIX B - REGULATIONS ICD-9 CODES 728.0 728.85 739.0 739.7 739.8 847.1 847.9 922.3 922.33 953.2 4 See Addendum to Care Paths 1,3 See Addendum to Care Paths CARE PATH 3

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10

11:3-4.10 APPENDIX B - REGULATIONS NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10 NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier. ICD-9 CODES

11:3-4.10 APPENDIX B - REGULATIONS 728.0 846.8 728.85 846.9 739.0 847.2 739.3 847.3 739.4 847.4 846 847.9 846.0 922.3 846.1 922.31 846.2 953.2 846.3 953.3 4 See Addendum to Care Paths CARE PATH 5

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10

11:3-4.10 APPENDIX B - REGULATIONS NOTE: These Care Paths identify typical courses of intervention. There may be patients who require more or less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatments must be based on patient need and professional judgment. Deviations may be justified by individual circumstances, such as pre-existing conditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by a motor vehicle accident (MVA). If at any point in the decision making process the healthcare provider finds evidence that the injury was not caused by a MVA, the provider must contact the patient s PIP carrier and medical insurance carrier.

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.10 EXHIBIT 9 TREATMENT OF ACCIDENTAL INJURY TO THE SPINE AND BACK CARE PATH DIAGNOSIS CODING The following International Classification of Diseases, 9th Revision Clinical Modification--fifth edition ICD-9-CM diagnostic codes are associated with Care Path 1 through Care Path 6 for treatment of Accidental Injury to the Spine and Back and are included on each appropriate Care Path. The ICD9 codes referenced do not include codes for multiple diagnoses or co-morbidity. Care Path 1 728.0 Disorders of muscle, ligament and fascia 728.85 Spasm of muscle 739.0 Non allopathic lesions--not elsewhere classified 739.1 Somatic dysfunction of cervical region 847.0 Sprains and strains of neck 847.9 Sprains and strains of back, unspecified site 922.3 Contusion of back 922.31 Contusion of back, excludes interscapular region 953.0 Injury to cervical root Care Path 2 722.0 Displacement of cervical intervertebral disc without myelopathy 722.2 Displacement of intervertebral disc, site unspecified, without myelopathy 722.70 Intervertebral disc disorder with myelopathy, unspecified region 722.71 Intervertebral disc disorder with myelopathy, cervical region 728.0 Disorders of muscle, ligament and fascia 739.0 Non allopathic lesions--not elsewhere classified 953.0 Injury to cervical root Care Path 3 728.0 Disorders of muscle, ligament and fascia 728.85 Spasm of muscle 739.0 Non allopathic lesions--not elsewhere classified 739.2 Somatic dysfunction of thoracic region 739.8 Somatic dysfunction of rib cage 847.1 Sprains and strains, thoracic 847.9 Sprains and strains of back, unspecified site 922.3 Contusion of back 922.33 Contusion of back, interscapular region Care Path 4 722.0 Displacement of cervical intervertebral disc without myelopathy 722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy 722.11 Displacement of thoracic intervertebral disc without myelopathy 722.2 Displacement of intervertebral disc, site unspecified, without myelopathy 722.70 Intervertebral disc disorder with myelopathy, unspecified region 722.72 Intervertebral disc disorder with myelopathy, thoracic region 728.0 Disorders of muscle, ligament and fascia

11:3-4.10 APPENDIX B - REGULATIONS 739.0 Non allopathic lesions--not elsewhere classified Care Path 5 728.0 Disorders of muscle, ligament and fascia 728.85 Spasm of muscle 739.0 Non allopathic lesions--not elsewhere classified 739.3 Somatic dysfunction of lumbar region 739.4 Somatic dysfunction of sacral region 846 Sprains and strains of sacroiliac region 846.0 Sprains and strains of lumbosacral (joint) (ligament) 846.1 Sprains and strains of sacroiliac ligament 846.2 Sprains and strains of sacrospinatus (ligament) 846.3 Sprains and strains of sacrotuberous (ligament) 846.8 Sprains and strains of other specified sites of sacroiliac region 846.9 Sprains and strains, unspecified site of sacroiliac region 847.2 Sprains and strains, lumbar 847.3 Sprains and strains, sacrum 847.4 Sprains and strains, coccyx 847.9 Sprains and strains, unspecified site of back 922.3 Contusion of back 922.31 Contusion of back, excludes interscapular region 953.2 Injury to lumbar root 953.3 Injury to sacral root Care Path 6 722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy 722.10 Displacement of lumbar intervertebral disc without myelopathy 722.2 Displacement of intervertebral disc, site unspecified, without myelopathy 722.70 Intervertebral disc disorder with myelopathy, unspecified region 722.73 Intervertebral disc disorder with myelopathy, lumbar region 728.0 Disorders of muscle, ligament and fascia 739.0 Non allopathic lesions--not elsewhere classified 953.3 Injury to sacral root The following ICD-9-CM supplemental classification of external causes of injury may be used in addition to the specific diagnostic codes noted above and on each Care Path: E 810 through E 819, selected E 820 series codes. These codes may be used to indicate cause of injury as motor vehicle accident but should not be used without an associated diagnostic code. EXHIBIT 10 ADDENDUM TO CARE PATHS 1. Medications Muscle Relaxants Muscle relaxants are an option in the treatment of patients with acute neck, thoracic, and low back problems. While probably more effective than placebo, muscle relaxants have not been shown to be more effective than NSAIDs. No additional benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone.

PIP DISPUTE RESOLUTION 11:3-5 Muscle relaxants have potential side effects in 30 percent of patients. When considering the option of using relaxants, the clinician should balance the potential patient's intolerance of other agents. Opioid Analgesics When used for a time-limited course, opioid analgesics are an option in the management of patients with acute neck, thoracic, and low back problems. The decision to use opioids should be guided by consideration of their potential complications relative to other options. Opioids appear to be more effective in relieving neck, thoracic, and low back symptoms than safer analgesics, such as acetaminophen or aspirin or other NSAIDs. Clinicians should be aware of the side effects of opioids, such as decreased reaction time, clouded judgment, and drowsiness, which lead to early discontinuation by as many as 35 percent of patients. Patients should be warned about dependence and the danger of opioids while operating heavy machinery. Oral Steroids Oral steroids are not recommended for the treatment of acute neck, thoracic, or low back problems. A potential for severe side effects is associated with the extended use of oral steroids or steroids in high doses. 2. Who May Perform Spinal Manipulation: Spinal manipulation may be performed by those providers licensed or certified to perform this procedure within their scope of practice. 3. Spinal Manipulation A course of spinal manipulation/chiropractic care may be considered as conservative therapy on all Care Paths. If there is no improvement within one month, then immediate reevaluation is indicated to determine appropriate further treatment and treatment options, including referral to other health care providers and/ or modification of conservative therapy. When findings suggest progressive or severe neurologic deficits, an appropriate diagnostic assessment to rule out serious neurologic conditions is indicated in any conservative therapy. 4. Mental Health/Rehabilitation Assessment Option If Patient Has Not Responded To Treatment A mental health/rehabilitation assessment can be obtained if psychological/ psychosocial or psychiatric distress is obvious from the history, i.e., presence of non-organic physical signs, repetitive back injuries, failed previous treatments, litigation or disability compensation claims, family or financial problems, apparent secondary gain, boredom and dissatisfaction with job, frequent bouts of pain, depression, alcohol and substance abuse, extreme obesity, and apparent psychiatric behavior. SUBCHAPTER 5. PERSONAL INJURY PROTECTION DISPUTE RESOLUTION Source and Effective Date.R. 1998 d. 592, effective December 21, 1998 (operative March 22, 1999). Section 11:3-5.1. Purpose and scope.

11:3-5.2 APPENDIX B - REGULATIONS 11:3-5.2. Definitions. 11:3-5.3. Designation of the administrator. 11:3-5.4. Dispute resolution organizations. 11:3-5.5. Dispute resolution professionals. 11:3-5.6. Conduct of PIP dispute resolution proceedings. 11:3-5.7. Recordkeeping. 11:3-5.8. Medical review organizations. 11:3-5.9. Standards for medical review organizations. 11:3-5.10. Medical review organization certification process. 11:3-5.11. Fees. 11:3-5.12. Prohibition of conflicts of interest. 11:3-5.1. Purpose and scope. (a) The purpose of this subchapter is to establish procedures for the resolution of disputes concerning the payment of medical expense and other benefits provided by the personal injury protection coverage in policies of automobile insurance. This subchapter implements N.J.S.A. 39:6A-5.1 and 5.2, which provide that PIP disputes shall be resolved by binding alternate dispute resolution as provided in the policy form approved by the Commissioner. This subchapter also implements provisions of N.J.S.A. 2A:23A-1 et seq., as applicable to PIP dispute resolution. (b) This subchapter shall apply to disputes arising under policies of private passenger automobile insurance, on either a personal lines or commercial lines policy form, that provide medical expense benefits and other benefits under personal injury protection coverage, as follows: 1. PIP benefits under a standard automobile insurance policy pursuant to N.J.S.A. 39:6A-4; 2. PIP benefits under a basic automobile insurance policy pursuant to N.J.S.A. 39:6A-3.1; 3. PIP benefits provided by the UCJF pursuant to N.J.S.A. 39:6-86.1; and 4. Additional PIP benefits provided pursuant to N.J.S.A. 39:6A-10. (c) This subchapter shall apply to policies issued or renewed on or after March 22, 1999 in accordance with the approved policy terms. 11:3-5.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Administrator means the dispute resolution organization designated by the Commissioner pursuant to N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.3. Basic policy means an automobile insurance policy issued pursuant to N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3. Commissioner means the Commissioner of the New Jersey Department of Banking and Insurance. Control or controlled means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds the power to vote, or holds proxies representing, 10 percent or more of the voting securities of any other person, provided that no such presumption of control shall of itself relieve any person so presumed to have control from any require-

PIP DISPUTE RESOLUTION 11:3-5.2 ment of P.L. 1970, c.22 (N.J.S.A. 17:27A-1 et seq.). This presumption may be rebutted by a showing made in the manner provided by N.J.S.A. 17:27A-3j that control does not exist in fact. The Commissioner may determine, after furnishing all persons in interest notice and an opportunity to be heard, and making specific findings of fact to support such determination, that control exists in fact, notwithstanding the absence of a presumption to that effect. Department means the New Jersey Department of Banking and Insurance. Dispute resolution organization or DRO means an organization that meets the standards set forth in N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.4. Dispute resolution professional or DRP means a natural person who meets the standards set forth in N.J.A.C. 11:3-5.5. "In-person proceeding" or "in-person case" means a PIP dispute where the parties or their representatives appear in person or telephonically before the DRP to present their cases in accordance with the rules of the dispute resolution organization. Medical review organization or MRO means an organization of health care professionals who are licensed in New Jersey, which is certified by the Commissioner to engage in unbiased medical review of the medical care provided to persons injured in automobile accidents in accordance with N.J.S.A. 39:6A-5.2 and this subchapter. The term includes either; 1. Any peer review organization with which the Federal Health Care Financing Administration or the State contracts for medical review of Medicare or medical assistance services; or 2. Any independent health care review company. "On-the-papers proceeding" or "on-the-papers case" means a PIP dispute where the parties or their representatives submit written documentation supporting their case and the DRP decides the case based solely upon the documentation without any in person or telephonic appearances by the parties or their representatives in accordance with the rules of the dispute resolution organization. On-thepapers proceedings are only permitted where all parties consent or where there is no further treatment at issue and the amount at issue in the dispute is less than $ 1,000. Personal Automobile Insurance Plan or PAIP means the personal lines automobile insurance residual market mechanism established pursuant to N.J.S.A. 17:29D-1 by N.J.A.C. 11:3-2. Personal injury protection or PIP means the coverage provided by a policy of automobile insurance pursuant to N.J.S.A. 39:6A-3.1, 39:6A-4 or the emergency personal injury protection coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89. PIP dispute includes, but is not limited to, matters concerning: 1. Interpretation of the insurance contract's PIP provisions; 2. Whether the medical treatment or diagnostic tests are in accordance with the provisions of applicable statutes and rules for the basic and standard policies and in compliance with the terms of the policy; 3. Eligibility of the treatment or service for compensation or reimbursement, including whether the injury is causally related to the accident and the application of deductible and copayment provisions; 4. Eligibility of the provider performing the service to be compensated or reimbursed under the terms of the policy and the provisions of N.J.A.C. 11:3-4, and

11:3-5.3 APPENDIX B - REGULATIONS including whether the provider is licensed or certified to perform the treatment or service; 5. Whether the treatment was actually performed; 6. Whether the diagnostic tests performed are recognized by the Professional Boards in the Division of Consumer Affairs, Department of Law and Public Safety, administered in accordance with their standards, and approved by the Commissioner at N.J.A.C. 11:3-4; 7. The necessity and appropriateness of consultation with other health care providers; 8. Disputes involving the application of, or adherence to, the automobile insurance medical fee schedule at N.J.A.C. 11:3-29; 9. Whether the treatment or service is reasonable, necessary and in accordance with medical protocols adopted by the Commissioner at N.J.A.C. 11:3-4; or 10. Amounts claimed for PIP income continuation benefits, essential services benefits, death benefits and funeral expense benefits. Provider or health care provider is as defined at N.J.A.C. 11:3-4.2. Standard policy means an automobile insurance policy including PIP coverage as provided in N.J.S.A. 39:6A-4. UCJF means the Unsatisfied Claim and Judgement Fund created pursuant to N.J.S.A. 39:6-61 et seq. Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-5.3. Designation of the administrator. (a) The Commissioner shall designate a dispute resolution organization as the administrator of the PIP alternate dispute resolution system by entering into a contract with a dispute resolution organization. (b) The contract designating the administrator shall be for a term not to exceed five years, but may be extended according to its terms until a new administrator is designated and substituted. Nothing in this subsection shall prohibit an administrator from succeeding itself, if so designated in accordance with N.J.S.A. 39:6A- 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;

PIP DISPUTE RESOLUTION 11:3-5.4 6. Such other information as may be provided by law, and that the Commissioner or the Treasurer may request in order to understand and evaluate the applicant's proposal. 11:3-5.4. Dispute resolution organizations. (a) In order to be eligible for designation as administrator, a dispute resolution organization shall meet the following criteria: 1. The dispute resolution organization shall not be owned or controlled by an insurer or affiliate of an insurer; 2. The dispute resolution organization shall utilize full-time dispute resolution professionals that meet the standards set forth in N.J.A.C. 11:3-5.5. For the purpose of this paragraph, full-time shall be construed to include persons who work fewer than five days per week, but who do not engage in other, conflicting employment; 3. The dispute resolution organization shall utilize an advisory council composed of parties who are users of the dispute resolution mechanism in connection with the selection of dispute resolution professionals and the periodic review of the organization's rules and processes; 4. The dispute resolution organization shall utilize procedures to avoid conflicts of interests as prohibited at N.J.A.C. 11:3-5.12; 5. The dispute resolution organization shall arrange for proceedings in locations reasonably convenient to the parties; 6. The dispute resolution organization shall maintain published rules for the conduct of the proceedings, and shall make them available to the parties and the public upon request; 7. The dispute resolution organization shall perform its functions in a prompt and efficient manner, giving due regard to the nature of the proceeding and the need for special attention when required by the exigencies of a particular matter; and 8. The dispute resolution organization shall provide sufficient oversight and training of its dispute resolution professionals so as to promote fair, efficient and consistent determinations consistent with substantive law and with rules adopted by the Commissioner. (b) The dispute resolution organization shall develop and maintain a dispute resolution plan approved by the Commissioner that sets forth its procedures and rules. The dispute resolution plan shall be reviewed at least annually and revisions made upon approval by the Commissioner. The plan shall include the following elements: 1. The plan shall provide that PIP dispute resolution be initiated by written notice to the administrator and to all other parties of the party's demand for dispute resolution, which notice shall set forth concisely the claims, and where appropriate the defenses, in dispute and the relief sought. Where the arbitration is filed by a provider acting as an assignee of benefits or with a power of attorney from the insured, the notice shall include proof of compliance with the internal appeal process required by N.J.A.C. 11:3-4.7B. All notices shall also include such other information as may be required for administrative purposes; 2. The plan shall provide for consolidation of claims into a single proceeding where appropriate in order to promote prompt, efficient resolution of PIP disputes consistent with fairness and due process of law; 3. The plan shall provide the assigned dispute resolution professional with sufficient authority to provide all relief and to determine all claims arising under PIP

11:3-5.5 APPENDIX B - REGULATIONS coverage, but may provide for limited, procedural or emergent matters to be determined by one or more specially designated dispute resolution professionals; i. Emergent or expedited relief shall be granted upon demonstration that immediate and irreparable loss or damage will result in the absence of such relief; 4. The plan shall provide for the assignment of a medical review organization to review the case and report its determination when requested pursuant to N.J.S.A. 39:6A-5.2 and this subchapter; 5. The plan shall provide for the prompt, fair and efficient resolution of PIP disputes, including in-person and on-the-papers proceedings in accordance with the rules of the dispute resolution organization. The plan shall also provide that alternate procedures may be utilized when appropriate, which may include mediation, conferences to promote consensual resolution and expedited hearings upon receipt of a medical review organization report, consistent with principles of substantive law and rules adopted by the Commissioner; 6. The plan shall provide for a procedure whereby a demand for arbitration based on an insurer's denial of a decision point review or precertification request as not medically necessary, as defined in N.J.A.C. 11:3-4.2, may be submitted directly to an MRO for an expedited determination of medical necessity. No DRP will be assigned and no attorney fees may be charged. The administrator shall set a fee for handling such requests in addition to the MRO fee. The plan shall provide that if the expedited MRO review does not resolve the dispute, the claimant/insured may continue with the standard arbitration procedure before a DRP; and 7. The plan shall provide for the fair and efficient conduct of adversarial proceedings when other methods of dispute resolution are either unsuccessful or inappropriate, consistent with traditional notions of due process and fundamental fairness. It shall address, at least, the following procedural issues; i. Discovery; ii. Receipt of evidence by the dispute resolution professional; iii. Submission of briefs or memoranda of law and fact; iv. Provision for decisions without testimony on consent of parties; v. Notice and place of hearing; vi. Methods to request adjournments; vii. Presentation of testimony and evidence at a hearing; and viii. Supplementation of the record. (c) If consistent with its dispute resolution plan, a dispute resolution organization may utilize one or more dispute resolution professionals specifically to handle preliminary matters on actions including motions to disqualify an appointed DRP. Amended. R.2010 d.142, effective July 6, 2004; R.2010 d.142, effective July 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-5.5. Dispute resolution professionals. (a) A dispute resolution professional employed by the dispute resolution organization shall be either: 1. An attorney licensed to practice in New Jersey with at least 10 years of experience in cases involving personal injury or workers' compensation; 2. A former judge of the Superior Court or the Workers' Compensation Court, or a former Administrative Law Judge; or 3. Any other person, qualified by education and at least 10 years' experience, with sufficient understanding of automobile insurance claims and practices, contract law, and judicial or alternate dispute resolution practices nd procedures. (b) Dispute resolution professionals shall avoid conflicts of interest as prohibited at N.J.A.C. 11:3-5.12 in any matter assigned to them for determination.

PIP DISPUTE RESOLUTION 11:3-5.6 1. Dispute resolution professionals shall complete and file with the dispute resolution organization a conflict of interest questionnaire that shall provide sufficient detail about financial interests of themselves and their immediate family so as to avoid any assignment to a particular case where there is a conflict of interest. Conflict of interest questionnaires shall remain confidential with the dispute resolution organization, and the information set forth therein shall only be disclosed as necessary to individuals responsible for assigning cases to dispute resolution professionals, or reviewing motions to disqualify an assigned dispute resolution professional. 2. If during the course of an assignment a dispute resolution professional determines that he or she has conflict of interest, based upon facts determined in the course of the proceedings, then the DRP shall promptly advise the administrator of the circumstances, who shall assign another DRP. 3. A party may challenge the assignment of a particular DRP by submitting the specific grounds for challenge in accordance with the rules of the dispute resolution organization approved by the Commissioner. The rules of the dispute resolution organization approved by the Commissioner shall provide that a party may challenge the assignment of the DRP as follows: i. When the party receives notification of the assignment of the DRP for an inperson case; or ii. As part of the appeal process provided in the rules for on-the-papers cases. (c) Dispute resolution professionals shall be compensated by the administrator in accordance with the terms of the contract designating the administrator. Compensation shall not be contingent in any way upon the decision or determination of the DRP. (d) Dispute resolution professionals shall create and maintain such records as may be necessary to carry out their responsibilities and provide such records to the administrator as required in the contract designating the administrator. Amended. R.2006 d.243, effective July 3, 2006; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-5.6. Conduct of PIP dispute resolution proceedings. (a) A request for dispute resolution of a PIP dispute may be made by the injured party, the insured, a provider who is an assignee of PIP benefits pursuant to N.J.A.C. 11:3-4.9 or the insurer, in accordance with the terms of the policy as approved by the Commissioner. The request for dispute resolution may include a request for review by a medical review organization. The request shall be made to the administrator and copies sent to other parties. 1. Every insurer shall establish a single address where requests for dispute resolution shall be sent. Insurers shall notify the administrator of the address and any changes thereto. The administrator shall make the list of insurer addresses available to the user community on a web page and any other available means of communication. 2. Providers who are the assignee of benefits by the insured or have a power of attorney from the insured shall follow the insurer's internal appeal process mandated by N.J.A.C. 11:3-4.7B before making a request for dispute resolution in accordance with (a) above. The dispute resolution organization's plan shall include a procedure for how the provider shall demonstrate that this requirement has been satisfied. (b) Upon receipt of the request, the administrator shall promptly assign the matter to a dispute resolution professional. For in-person proceedings, the administrator shall notify all parties of the DRP assigned at the time the assignment is

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

PIP DISPUTE RESOLUTION 11:3-5.6 1. If the DRP finds that the determination of a medical review organization is overcome by a preponderance of the evidence, the reasons supporting that finding shall be set forth in the written determination. 2. The award shall apportion the costs of the proceedings, regardless of who initiated the proceedings, in a reasonable and equitable manner consistent with the resolution of the issues in dispute. (e) Pursuant to N.J.S.A. 39:6A-5.2(g), the costs of the proceedings shall be apportioned by the DRP and the award may include reasonable attorney's fees for a successful claimant in an amount consonant with the award. Where attorney's fees for a successful claimant are requested, the DRP shall make the following analysis consistent with the jurisprudence of this State to determine reasonable attorney's fees, and shall address each item below in the award: 1. Calculate the "lodestar," which is the number of hours reasonably expended by the successful claimant's counsel in the arbitration multiplied by a reasonable hourly rate in accordance with the standards in Rule 1.5 of the Supreme Court's Rules of Professional Conduct (http://www.judiciary.state.nj.us/rules/appendices/ rpc.htm#p65_6482). i. The "lodestar" calculation shall exclude hours not reasonably expended; ii. If the DRP determines that the hours expended exceed those that competent counsel reasonably would have expended to achieve a comparable result, in the context of the damages prospectively recoverable, the interests vindicated, and the underlying statutory objectives, then the DRP shall reduce the hours expended in the "lodestar" calculation accordingly; and iii. The "lodestar" total calculation may also be reduced if the claimant has only achieved partial or limited success and the DRP determines that the "lodestar" total calculation is therefore an excessive amount. If the same evidence adduced to support a successful claim was also offered on an unsuccessful claim, the DRP should consider whether it is nevertheless reasonable to award legal fees for the time expended on the unsuccessful claim. 2. DRPs, in cases when the amount actually recovered is less than the attorney's fee request, shall also analyze whether the attorney's fees are consonant with the amount of the award. This analysis will focus on whether the amount of the attorney's fee request is compatible and/or consistent with the amount of the arbitration award. Additionally, where a request for attorney's fees is grossly disproportionate to the amount of the award, the DRP's review must make a heightened review of the "lodestar" calculation described in (e)1 above. (f) The award shall be signed by the dispute resolution professional. The original shall be filed with the administrator, and copies provided to each party. If the award requires payment by the insurer for a treatment or test, payment shall be made together with any accrued interest ordered in the award pursuant to N.J.S.A. 39:6A-5, within 45 days of the insurer's receipt of a copy of the determination, unless one of the actions permitted in (g) below has been filed. Where the arbitration has been filed by a provider who is the assignee of benefits pursuant to N.J.A.C. 11:3-4.9, the payment shall be made payable to the provider. (g) The final determination of the dispute resolution professional shall be binding upon the parties, but subject to clarification/modification and/or appeal as provided by the rules of the dispute resolution organization, and/or vacation, modification or correction by the Superior Court in an action filed pursuant to N.J.S.A. 2A:23A-13 for review of the award. Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). Administrative correction. See: 45 N.J.R. 214(a).

11:3-5.7 APPENDIX B - REGULATIONS 11:3-5.7. Recordkeeping. (a) The administrator shall maintain records of all determinations for a period of five years. (b) The administrator shall file a copy of each determination, except consent determinations, with the Department in either hard copy or electronic form, as provided in the contract designating the administrator. 1. Any determination filed with the Department shall be indexed and coded so as to facilitate retrieval. 2. The name of any injured party, except when appearing in the caption of the matter or used as identification of the particular case, shall be redacted in the copy filed with the Department so as to protect the privacy of the injured person. (c) The administrator shall keep such other records as may be required by the Commissioner and as set forth in the contract designating the administrator. 11:3-5.8. Medical review organizations. (a) Medical review organizations shall be authorized to determine in connection with the PIP dispute resolution process set forth in this subchapter: 1. Whether the medical treatment or diagnostic test is medically necessary; 2. Whether the treatment is in accordance with medically recognized standard protocols including those protocols approved by the Commissioner and set forth in N.J.A.C. 11:3-4; 3. Whether the treatment is consistent with symptoms or diagnosis of the injury; 4. Whether the injury is causally related to the accident; 5. Whether the treatment is of a palliative rather than a restorative nature; and 6. Whether medical procedures and tests that have been repeated are medically necessary. (b) The findings of a medical review organization shall be presumed to be correct, but may be rebutted by a preponderance of the evidence submitted to the dispute resolution professional. 11:3-5.9. Standards for medical review organizations. (a) Medical review organizations shall be capable of performing medical reviews for all primary specialties and disciplines. (b) Medical review organizations shall employ a medical director to actively participate in the review of cases to assure quality and consistency. (c) Medical review organizations shall utilize health care providers in the same discipline as the treating provider to perform the reviews who meet the following standards: 1. Reviewing health care providers shall be active practitioners who obtain a minimum of one-half of their income from practice in their area of specialty; 2. Reviewing health care providers shall be licensed in New Jersey and board certified in their specialty; 3. Reviewing health care providers shall have at least two years' experience in medical review, or be certified as a medical review physician; and 4. Reviewing health care providers shall have completed an orientation with the MRO, including medical review instruction and report writing. (d) A medical review organization shall have adequate procedures in place to assure confidentiality of patient records. 1. All MRO files shall be indexed and referred to by reference number rather than patient name. 2. Medical files shall be maintained in a secure area of the MRO s offices. 3. Only the MRO shall request additional documents relating to the injured person's medical condition, or direct that the injured person be physically examined.

PIP DISPUTE RESOLUTION 11:3-5.10 (e) A medical review organization shall utilize procedures to provide for the fair and open exchange of information and records related to the review between the treating health care provider, any provider that has reviewed the case on behalf of the insurer, and the MRO's reviewing health care provider. (f) A medical review organization shall complete its review and submit its report to the dispute resolution professional in accordance with the medical exigencies of the case, but in no event in excess of 20 business days from receipt of medical records from the treating health care provider. (g) A medical review organization shall have a procedure for obtaining mental or physical examinations of injured persons that may be required in the course of its review. (h) A medical review organization shall utilize written review procedures. In reaching its determinations, the MRO shall consider all information submitted by the parties and information deemed appropriate by the MRO, including: pertinent medical records, consulting physician reports and other documents submitted by the parties; applicable commonly accepted protocols, professional standards and practices by national standard setting organizations, and protocols and diagnostic tests approved by the Commissioner and set forth in N.J.A.C. 11:3-4. (i) A medical review organization shall utilize audit procedures to ensure compliance with statutory and regulatory requirements. (j) A medical review organization shall retain records of its determinations for five years. 11:3-5.10. Medical review organization certification process. (a) The Commissioner shall certify a medical review organization to provide medical review services in connection with the resolutions of PIP disputes if the Commissioner determines that the MRO complies with the standards set forth in N.J.A.C. 11:3-5.9 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 08625-0325 (c) The MRO application shall include the following: 1. A list of the names, addresses and specialties of the individual health care providers that will provide the medical review services. If the MRO will be limited in its service area, the application shall provide a map of the service area, including the providers by specialty; 2. A copy of the MRO's certificate of incorporation and by-laws; 3. A diagram of the MRO's organizational structure; 4. The location of the MRO's place of business where it administers its services and maintains its records;

11:3-5.10 APPENDIX B - REGULATIONS 5. A listing and biography of the MRO's officers and directors, or the individuals in the organization responsible for administration of medical reviews, including the medical director; 6. A detailed description of the MRO's experience in the review of medical care; 7. A description of its procedures for review of medical treatments, diagnostic tests and items of durable medical equipment in conjunction with PIP medical expense benefits; 8. A current list identifying all property/casualty insurers, health insurers, health maintenance organizations and health care providers with whom the MRO maintains any health related business arrangement. The list shall include a brief description of the nature of the arrangement, so as to permit the administrator to avoid assignments that may create a conflict of interest; 9. The fee(s) for determination by the MRO; 10. Such other information as the Commissioner may specifically request in connection with the certification of a particular applicant; and 11. A fee in the amount of $1,000 payable to the Department of Banking and Insurance. (d) The materials specified in (c) above shall be retained by the Department and may be referred to the Department of Health and Senior Services for consultation as necessary. Any significant changes in the materials filed with the Department shall be reported as an amendment to the materials filed within 30 days of the change. (e) The Department, in consultation with the Department of Health and Senior Services, shall review the materials and grant or deny certification within 45 days of receipt of a complete filing. The Commissioner may extend the time an additional 30 days for good cause shown, and shall notify the applicant of any extension. A decision to deny certification shall be in writing and include an explanation of the reason for the denial. (f) Initial certification shall be effective for a period of two years. Certified MROs shall reapply for certification 90 days prior to expiration by submitting the items set forth in (b)1, 6, 7, 8, 9 and 10 above and any changes to items previously submitted in (b)2, 3, 4 and 5 above. Renewal certification may be effective for a period of up to five years. (g) All data or information in the MRO's application for certification shall be confidential and shall not be disclosed to the public, except as follows: 1. The MRO's certificate of incorporation; 2. The MRO's address; 3. The names of the MRO's officers and directors, or the individuals in the organization responsible for the administration of medical reviews including the medical director; and 4. The date of certification of the MRO and date that certification expires. (h) Upon certification, the Department shall advise the administrator of the name and address of the MRO, any limitations on its geographical service area and information about persons with whom it maintains health related business arrangements. (i) The Commissioner may suspend or revoke the certification of an MRO upon finding that the MRO no longer meets the standards set forth in N.J.A.C. 11:3-5.9; that medical review services are not being provided in accordance with the re-

AUTOMOBILE REPARATION REFORM 11:3-5.12 quirements of this subchapter; or that the certification was granted based on false or misleading information. 1. Proceedings to revoke or suspend the certification shall be conducted pursuant to N.J.A.C. 11:17D. 2. Upon request of the MRO for a hearing, the matter shall be transferred to the Office of Administrative Law for a hearing conducted pursuant to the Uniform Administrative Procedure Rules, N.J.A.C. 1:1. Amended. R.2006 d.243, effective July 3, 2006; R.2010 d.142, effective July 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a). 11:3-5.11. Fees. When a mental or physical examination is performed in connection with the medical review organization's services, the health care provider performing the examination shall be paid the fee provided for that service set forth on the Department's medical fee schedule, N.J.A.C. 11:3-29. Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2010 d.142, effective July 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a). 11:3-5.12. Prohibition of conflicts of interest. (a) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall have any personal or financial interest, direct or indirect, or engage in any business or transaction which is in conflict with the proper conduct of his or her duties under this subchapter. (b) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall act in such capacity in any matter wherein he or she has a direct or indirect personal or financial interest that might reasonably be expected to impair his or her objectivity or independence of judgment. (c) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall accept any gift, favor, service or other thing of value under circumstances from which it might be reasonably inferred that such gift, service or other thing of value was given or offered for the purpose of influencing him or her in the conduct of duties under this subchapter. (d) No dispute resolution professional shall accept from any person, whether directly or indirectly and whether by him or herself or through a spouse or any family member or through any partner or associate or controlled business, any gift, favor, service, employment or offer of employment or any other thing of value which he or she knows or has reason to believe is offered with the intent to influence the performance of his or her duties as a dispute resolution professional. (e) No dispute resolution professional shall make any determination in any PIP dispute in which he or she directly or indirectly or through a spouse, family member or by partner or associate or controlled business has any personal or financial interest. SUBCHAPTER 7. AUTOMOBILE REPARATION REFORM ACT Section 11:3-7.1. Purpose. 11:3-7.2. General requirements applicable to additional personal injury protection benefits. 11:3-7.3. Personal injury protection policy forms or endorsements. 11:3-7.4. Minimum schedule of additional personal injury protection coverage benefits.

11:3-7.1 APPENDIX B - REGULATIONS 11:3-7.5. Notice requirements. 11:3-7.6. Cancellation of automobile coverage for nonpayment of premium. 11:3-7.1. Purpose. This subchapter implements certain provisions of the Automobile Reparation Reform Act, N.J.S.A. 39:6A-1 et seq., including the Commissioner s authority to establish the amounts and terms of additional personal injury protection benefits that must be made available to insureds electing a standard automobile insurance policy pursuant to N.J.S.A. 39:6A-4. Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999). 11:3-7.2. General requirements applicable to additional personal injury protection benefits. (a) In addition to the personal injury protection benefits that insurers must provide pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, insurers shall make available to the named insured, and, at his or her option, to any resident relatives in the named insured s household who are not named insureds on another standard or basic policy, additional income continuation benefits, essential services benefits, death benefits and funeral expense benefits pursuant to N.J.S.A. 39:6A-10 and this subchapter. (b) The additional benefit indicated in each option that an insurer may offer for income continuation benefits and essential services benefits represents the aggregate of the basic and additional personal injury protection benefits. (c) Any additional income continuation benefits that an insurer may offer shall be limited to 75 percent of the insured s weekly income. (d) The limits which are applicable to any additional personal injury protection benefits that an insurer may offer shall apply on a per person, per accident basis. (e) Each insurer shall make available as an option additional income continuation benefits for as long as the disability persists. 1. Each insurer shall furnish rates for such benefits upon the request of the insured. (f) Any additional death benefits which an insurer may offer shall be payable without regard to the period of time elapsing between the date of the accident and the date of death provided death occurs within two years of the accident and results from bodily injury from that accident. 1. The requirements of (f) above shall apply to any claim for additional death benefits where death occurs on or after April 21, 1986. i. With respect to any claim presented on or after the effective date of this subchapter, each insurer shall disclose the availability of additional death benefits in conformance with the applicable provisions of N.J.A.C. 11:2-17.1 et seq. ii. With respect to any claim initiated prior to the effective date of this subchapter, each insurer shall take appropriate steps to determine whether additional death benefits are payable, pursuant to (fl above. These steps shall include, but need not be limited to, review of claims closed on or after April 21, 1986 for the purpose of ascertaining the applicability of additional death benefits. Upon determining that such benefits are payable, each insurer shall provide written notice to eligible beneficiaries and process the claim in accord with N.J.S.A. 39:6A-5 and the applicable provisions of N.J.A.C. 11:2-17.1 et seq. (g) In addition to the minimum schedule of additional personal injury protection benefits set forth at N.J.A.C. 11:3-7.4(b), any insurer may provide other additional personal injury protection benefit options subject to review and approval of its filing by the Department of Insurance. Any additional options offered by the

AUTOMOBILE REPARATION REFORM 11:3-7.4 insurer must be in compliance with the standards and requirements set forth in this subchapter. (h) Insurers may also make available to named insureds covered under N.J.S.A. 39:6A-4, and at their option, to resident relatives in the household of the named insured or to other persons provided medical expense coverage pursuant to this statutory provision, or both, additional first party medical expense benefit coverage pursuant to N.J.S.A. 39:6A-l0. Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999); R. 2001 d. 44, effective February 5, 2001. 11:3-7.3. Personal injury protection policy forms or endorsements. (a) All policy forms or endorsements that provide personal injury protection benefits required by N.J.S.A. 39:6A-4 shall specify that such benefits shall be afforded by the insurer of the injured person subject to any deductibles or exclusions elected by the policyholder pursuant to N.J.S.A. 39:6A-4.3. The required personal injury protection benefits are set forth below: 1. Medical expense benefits; 2. Income continuation benefits; 3. Essential services benefits; 4. Death benefits; and 5. Funeral expense benefits. (b) Each policy form or endorsement covering an automobile as defined at N.J.S.A. 39:6A-2 shall include excess medical payments coverage, corresponding to Section II, Extended Medical Expense Benefits Coverage of the personal automobile policy. Insurers must include a minimum coverage of $1,000 and may offer coverage of $10,000. (c) Each policy form or endorsement providing additional personal injury protection benefits shall specify that, pursuant to N.J.S.A. 39:6A-10, additional death benefits under the policy shall be payable without regard to the period of time elapsing between the date of the accident and the date of death provided death occurs within two years of the accident and results from bodily injury from that accident Amended. R. 1996 d. 58, effective February 5, 1996. 11:3-7.4. Minimum schedule of additional personal injury protection coverage benefits. (a) Every rate filer s schedule of rates for additional personal injury protection benefits, other than medical expense benefits, shall provide at least the benefit schedules set forth in Table 1 in (b) below. (b) The additional personal injury protection coverage table follows: Table 1 Income Essential Services Funeral Option Weekly Total Per Day Total Death Expense 1 $100 $10,400 $12 $8,760 $10,000 $2,000 2 125 13,000 20 14,600 10,000 2,000 3 175 18,200 20 14,600 10,000 2,000 4 250 26,000 20 14,600 10,000 2,000 5 400 41,600 20 14,600 10,000 2,000 6 500 52,000 20 14,600 10,000 2,000 7 600 62,400 20 14,600 10,000 2,000 8 700 72,800 20 14,600 10,000 2,000

11:3-7.5 APPENDIX B - REGULATIONS 9 100 unlimited 12 8,760 10,000 2,000 10 125 unlimited 20 14,600 10,000 2,000 11 175 unlimited 20 14,600 10,000 2,000 12 250 unlimited 20 14,600 10,000 2,000 13 400 unlimited 20 14,600 10,000 2,000 14 500 unlimited 20 14,600 10,000 2,000 15 600 unlimited 20 14,600 10,000 2,000 16 700 unlimited 20 14,600 10,000 2,000 Amended. R. 1990, d. 580, effective November 19, 1990 (operative January 1, 1991). 11:3-7.5. Notice requirement. (a) Additional personal injury protection benefits that are required to be offered by an insurer shall be offered by the insurer at least annually as part of the Coverage Selection Form required pursuant to N.J.S.A. 39:6A-23 and N.J.A.C. 11:3-15. 1. The buyer s guide and coverage selection form specified at N.J.S.A. 39:6A- 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. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); Amended. R. 1996 d. 58, effective February 5, 1996. 11:3-7.6. Cancellation of automobile coverage for nonpayment of premium. (a) This rule applies to all automobile policies delivered or issued for delivery in this State, insuring a single individual or husband and wife resident of the same household, as named insured, and under which the insured vehicles therein designated are of the following types only: 1. A motor vehicle of the private passenger or station wagon type that is not used as a public or livery conveyance for passengers, not rented to others; or 2. Any other four-wheel motor vehicle with a load capacity of 1,500 pounds or less which is not customarily used in the occupation, profession or business of insured, other than farming or ranching, provided, however, that this rule shall not apply to any policy insuring more than four automobiles, or to any policy covering garage, automobile sales agency, repair shop, service station or public parking place operation hazards. (b) The effective date of the cancellation of a policy for nonpayment of premium shall not be earlier than 10 days prior to the last full day of which premium received by the company prior to the date of preparation of the cancellation notice, would pay for coverage on a pro rata basis. In calculating the effective date of the cancellation as provided in this section, the premium applicable to the coverage provided by the policy and the premium received by the company at or prior to the time cancellation notice was prepared shall be the premium used for the calculation and determination of such effective date. (c) Cancellation for nonpayment of premium does not include cancellation at the request of a premium finance company or of a producer of record under N.J.A.C. 11:17C-2.2(d). (d) No cancellation notice shall be mailed prior to 30 days in advance of its effective date. (e) The rule shall not apply to deposits accompanying New Jersey Automobile Personal Insurance Plan or Commercial Automobile Insurance Plan applications

MOPED INSURANCE 11:3-11.1 which are insufficient under Plan rules or those of any succeeding residual market availability plan. Amended. R. 1996 d. 58, effective February 5, 1996. Administrative correction. 40 N.J.R. 5043. SUBCHAPTER 11. MOPED INSURANCE Section 11:3-11.1. Required coverages for mopeds. 11:3-11.1. Required coverages for mopeds. (a) No policy insuring against loss resulting from liability imposed by law for bodily injury, death and property damage sustained by any person arising out of the ownership, operation or use of a motorized bicycle as defined in N.J.S.A. 39:1-1, as amended, shall be issued in the State to the owner (or parent or guardian of an owner under 18 years of age) of any motorized bicycle principally garaged or operated in this State unless it includes coverage for the owner and operator in the following minimum amounts or limits. 1. Bodily injury; i. An amount or limit of $15,000, exclusive of interest and costs, on account of injury to, or death of, one person, in any one accident; and ii. An amount or limit, subject to such limit for any one person so injured or killed, of $30,000, exclusive of interest and costs, On account of injury to or death of more than one person, in any one accident. 2. Property damage: An amount or limit of $5,000 in the aggregate or damage to property of others resulting from one accident. (b) Every liability insurance policy as described in (a) above, issued or renewed on or after April 22, 1985, shall provide personal injury protection coverage benefits, in accordance with N.J.S.A. 39:6A-4, to pedestrians who sustain bodily injury in this State caused by the named insured s motorized bicycle or caused by being struck by or from the motorized bicycle. 1. Every rating organization and insurer making its own rates for policies covering motorized bicycles shall submit to the Commissioner of insurance filings of rules, rates and forms within 30 days of the effective date of this subsection. (c) Every business entity or individual owner who rents motorized bicycles shall maintain liability insurance coverage pursuant to N.J.S.A. 39:4-14.3e in the minimum amounts or limits set forth in subsection (a) of his section. (d) Any such coverages as described in subsections (a), (b) and (c) above shall describe the make and model, piston displacement, and serial number (VIN) of each motorized bicycle insured. This information shall also constitute the description of vehicle required on insurance identification cards, and N.J.A.C. 11:3-5.1 through 6.4 shall apply to moped coverage except where the language is clearly inappropriate. (e) The policy period for the coverages described is subsection (a) of this section shall commence at 12:01 A.M. of the effective date shown in the policy declaration page, unless expressly set forth in the policy or in a binder or other contracts for temporary insurance. (f) Any insurer authorized to write motor vehicle coverage may write moped coverage. Adopted. R. 1978 d. 12, eff. January 19, 1978. Amended. R. 1985 d. 72, effective February 19, 1985 (operative April 22, 1985); R. 2001 d. 44, effective February 5, 2001.

11:3-14 APPENDIX B - REGULATIONS SUBCHAPTER 14. PERSONAL INJURY PROTECTION OPTIONS Section 11:3-14.1. Purpose. 11:3-14.2. Scope. 11:3-14.3. Optional medical expense benefit deductibles for personal injury protection coverage. 11:3-14.4. Optional exclusion of income continuation benefits, essential services benefits, death benefits and funeral expense benefits. 11:3-14.5. Option to choose health care insurance coverage as primary coverage. 11:3-14.6. Refund or credit of unearned premium. 11:3-14.7. Filing requirements. 11:3-14.8. Application of the option to choose health care insurance coverage as the primary insurer. 11:3-14.1. Purpose. This subchapter establishes rules for the provision of optional deductibles and benefits for personal injury protection offered under standard private passenger automobile insurance policies pursuant to N.J.S.A. 39:6A- 4. Amended. R. 1989 d. 117, effective February 21, 1989; R. 1996 d. 58, effective February 5, 1996; R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999). 11:3-14.2. Scope. This subchapter applies to every insurer, including any residual market mechanism created by any New Jersey statute, authorized to transact the business of automobile insurance in this State. Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991) 11:3-14.3. Optional medical expense benefits for standard policies. (a) With respect to personal injury protection under standard automobile insurance policies, issued pursuant to N.J.S.A. 39:6A-4, each insurer shall make available as an option, at appropriately reduced premiums, medical expense benefits in amounts of $150,000, $75,000, $50,000, and $15,000. If none of these options is affirmatively chosen in writing, the policy shall provide medical expense benefits in an amount not to exceed $250,000 per person per accident. (b) Notwithstanding (a) above, if an optional medical expense benefit option is chosen, the policy shall provide that medical expense benefits shall be paid in an amount not to exceed $250,000, inclusive of any limit of medical expense benefits pursuant to (a) above, for all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requires critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician. (c) Significant disfigurement as used in (b) above means the result and/or manifestation of a serious traumatic injury that is observable as a permanent and substantial defect in the appearance and functional ability of the person injured. Significant disfigurement is a serious outward change that substantially detracts from the appearance and functional ability of the person injured. Amended. R. 1984 d. 480, eff. November 5, 1984; R. 1989 d. 117, effective February 21, 1989; R. 1996 d. 58, effective February 5, 1996; R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999); R.2000 d.454, effective November 6, 2000.

PIP OPTIONS 11:3-14.5 11:3-14.4. Optional exclusion of income continuation benefits, essential services benefits, death benefits and funeral expense benefits. (a) Automobile insurers offering personal injury protection coverage pursuant to N.J.S.A. 39:6A- 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. 1996 d. 58, effective February 5, 1996; R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999). 11:3-14.5. Option to choose health care insurance coverage as primary coverage. (a) Pursuant to N.J.S.A. 39:6A-4.3, for policies issued or renewed on or after January 1, 1991, an insurer shall provide the option that other health insurance coverage or benefits of the insured, including health care services provided by a health maintenance organization and any coverage or benefits provided under any Federal or State program, are the primary coverage for medical expense benefits for personal injury protection coverage; provided, however, that this op-

11:3-14.6 APPENDIX B - REGULATIONS tion shall not apply to any coverage or benefits provided pursuant to Medicare or Medicaid. (b) The Coverage Selection Form (see N.J.A.C. 11:3-15.7) shall require insureds or prospective insureds to identify the health insurer(s) providing primary personal injury protection medical expense benefits. This identification shall fulfill the requirement in N.J.S.A. 39:6A-4.3 that named insureds provide proof that they and members of their family residing in the household are covered by health insurance coverage or benefits. Amended. R.1984 d.480, eff. November 5, 1984. Repealed. R. 1989 d. 117,effective February 21, 1989. Adopted. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991). 11:3-14.6. Refund or credit of unearned premium. Every automobile insurer offering personal injury protection coverage shall establish a fair, practicable and non-discriminatory plan for the refund or application of credit of any unearned premium resulting from the selection of any deductible and/or exclusion option pursuant to this subchapter. Amended. R. 1989 d. 117, effective February 21, 1989. 11:3-14.7. Filing requirements. (a) Every automobile filer shall submit to the Commissioner for approval filings of rates or manual rules which provide the optional medical expense benefit deductibles for personal injury protection coverage. (b) Within 30 days of the effective date of this subchapter, every automobile filer shall submit to the Commissioner for approval filings of rates or manual rules which provide the optional exclusion from personal injury protection coverage of income continuation benefits, essential service benefits, death benefits, and funeral expense benefits. (c) All filings submitted for approval pursuant to this subchapter, and all changes and amendments thereto, shall be prepared in accordance with insurance laws and regulations, including the applicable provisions of N.J.S.A. 17:29A-1 et seq. and N.J.A.C. 11:1-2 and the Department s existing filing procedures. (d) The filing of a rating organization shall be applicable to the members and subscribers of the organization who have authorized the organization to file on their behalf. Amended. R. 1989 d. 117, effective February 21, 1989. 11:3-14.8. Application of the option to choose health care insurance coverage as the primary insurer. When an insured or prospective insured elects to have a health insurer provide primary personal injury protection medical expenses benefits, the medical expenses benefits available to the insured under his or her automobile policy s personal injury protection provisions shall become a secondary benefits provider. The order of benefit determination shall be in accordance with N.J.A.C. 11:3-37. Adopted. R. 1991 d. 90, effective January 25, 1991. SUBCHAPTER 15. BUYER S GUIDE, COVERAGE SELECTION FORM, AND AUTOMOBILE INSURANCE CONSUMER BILL OF RIGHTS FOR STANDARD AND BASIC POLICIES Section 11:3-15.1. Purpose. 11:3-15.2. Scope. 11:3-15.3. Definitions.

BUYER S GUIDE; COVERAGE SELECTION FORM 11:3-15.3 11:3-15.4. Compliance. 11:3-15.5. New Jersey Auto Insurance Buyer's Guide. 11:3-15.6. Minimum standards for Coverage Selection Forms. 11:3-15.7. Use of Coverage Selection Form; availability. 11:3-15.8. New Jersey Automobile Insurance Consumer Bill of Rights. 11:3-15.9. Penalties. 11:3-15.10. (Reserved). 11:3-15.11. (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 11:3-15.1. Purpose. (a) N.J.S.A. 39:6A-23 requires the Commissioner of the Department of Banking and Insurance to promulgate standards for the written notice to be provided to applicants for private passenger automobile insurance and to policyholders offered renewal of coverage. This written notice includes one of two versions of the Buyer's Guide and one of two versions of the Coverage Selection Form. (b) N.J.S.A. 17:29A-52a requires every insurer writing private passenger automobile insurance in this State to provide each insured at least annually and each applicant for insurance with an Automobile Insurance Consumer Bill of Rights. The Automobile Insurance Consumer Bill of Rights shall contain the information necessary, relevant or appropriate to improve the understanding of the rights and responsibilities of consumers and insurers regarding automobile insurance. (c) This subchapter implements the statutory requirements in (a) and (b) above and establishes the necessary minimum standards insurers shall use in giving notice of available coverages, options and rate credits and of the rights and responsibilities of consumers and insurers regarding automobile insurance. Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1990 d.580, effective November 19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011. 11:3-15.2. Scope. (a) This subchapter applies to every insurer authorized to transact the business of private passenger automobile insurance in this State and to any automobile residual market mechanism created by any New Jersey statute. (b) This subchapter applies to every personal lines private passenger automobile insurance policies and individually-owned private passenger automobiles written on commercial insurance policies. Adopted. R.1989 d.117, effective February 21, 1989. Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effective March 15, 2004. 11:3-15.3. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Basic automobile insurance policy or basic policy means those private passenger automobile insurance policies issued in accordance with N.J.S.A. 39:6A- 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.

11:3-15.4 APPENDIX B - REGULATIONS Insurer means any person, corporation, association, partnership, company, reciprocal exchange and any other legal entity issuing a contract of private passenger automobile insurance, including any residual market mechanism established pursuant to any New Jersey statute. As appropriate, insurer shall also mean a servicing carrier for a residual market mechanism. Private passenger automobile insurance policy means a Standard policy as defined in N.J.S.A. 39:6a-3 or a Basic policy as defined in N.J.S.A. 39:6A-3.1 providing direct insurance on an automobile as defined in N.J.S.A. 39:6A-2. Standard automobile insurance policy or standard policy means a private passenger automobile insurance policy issued in accordance with N.J.S.A. 39:6A- 3 that includes the personal injury protection coverage described in N.J.S.A. 39:6A-4. Adopted. R. 1989 d. 117, effective February 21, 1989. Amended. R. 1989 d. 624, effective December 18, 1989 (operative January 1, 1990); R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d. 117, effective March 15, 2004. 11:3-15.4. Compliance. (a) No new private passenger automobile insurance policy or renewal shall be issued unless the application for the policy or renewal offer is accompanied by a Buyer's Guide, a Coverage Selection Form and an Automobile Insurance Consumer Bill of Rights that meet the minimum standards prescribed in this subchapter. 1. The renewal offer shall include the appropriate Buyer s Guide and Coverage Selection Form for the policy being renewed. 2. Where application for or renewal of an insurance policy is made via the Internet, compliance with (a) above shall be satisfied by having the Buyer s Guide, Coverage Selection Form and Automobile Insurance Consumer Bill of Rights readily available to the applicant/insured on the insurer s website. In addition to being readily available on the insurer s website, this information also may be placed on the producer s website, if provided or authorized by the insurer. 3. Where application for or renewal of an insurance policy is made via the telephone and coverage is bound during the telephonic transaction, compliance with (a) above shall be satisfied if the insurer, with the agreement of the applicant or insured, sends the insured the Buyer s Guide, a completed Coverage Selection Form showing the coverage choices made by the insured, and an Automobile Insurance Consumer Bill of Rights within five business days after the telephonic transaction is completed. Insureds may alter coverages based on their review of such documents by returning a signed Coverage Selection Form with the changes noted therein, or electronically, provided that the requirements of N.J.S.A. 12A:12-1 et seq. are satisfied and that such process is made available by the insurer. Such alterations shall be effective in accordance with N.J.A.C. 11:3-15.7(d)2. (b) The Buyer's Guide, Coverage Selection Form and Automobile Insurance Consumer Bill of Rights incorporate and therefore satisfy any and all other notice requirements previously set forth for the coverage options required by the New Jersey Automobile Reparation Reform Act, the New Jersey Automobile Insurance Reform Act of 1982, the New Jersey Automobile Insurance Freedom of Choice and Cost Containment Act of 1984, the Automobile Insurance Cost Reduction Act of 1998 and P.L. 2003, c.89. (c) As of June 6, 2011, each insurer that becomes authorized to write private passenger automobile insurance shall make a filing pursuant to N.J.A.C. 11:1-2. The filing shall consist of a certification in the form set forth in Exhibit 2 in the

BUYER S GUIDE; COVERAGE SELECTION FORM 11:3-15.5 subchapter Appendix, incorporated herein by reference, that the Lawsuit Option rate differentials in its Standard Policy Coverage Selection Form were calculated in accordance with N.J.A.C. 11:3-15.6(g)4. (d) An insurer may change the Lawsuit Option rate differentials in its approved Standard Policy Coverage Selection Forms by making a filing pursuant to N.J.A.C. 11:1-2 that specifies the effective date of the revised rate differentials that will be used and that includes the certification required by (c) above. Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1996 d.58, effective February 5, 1996; R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effective March 15, 2004; R.2005 d.83, effective March 7, 2005; R.2011 d.166, effective June 6, 2011. 11:3-15.5. New Jersey Auto Insurance Buyer's Guide. (a) There are established two Buyer s Guides for use by insurers: a personal lines Buyer s Guide and a commercial lines Buyer s Guide for individually owned vehicles written on commercial policies. The Buyer s Guides shall be available on the Department s website. 1. The personal lines Buyer s Guide can be found at http://www.state.nj.us/ dobi/division_insurance/byguide.doc. 2. The commercial Buyer s Guide can be found at http://www.state.nj.us/dobi/ division_insurance/commbyguide.doc. (b) The Buyer s Guide shall be reproduced in the format presented on the website, duplicating the information provided therein and, to the extent practicable, the layout, fonts, type-point sizes, colors and illustrations. Notwithstanding the foregoing, consistent with the requirements of N.J.A.C. 11:2-18.4, all text in the Buyer s Guide shall be printed on at least 10-point type on paper of a quality sufficient to assure that the printing does not bleed form one side to the other. (c) The Department shall notify insurers of any changes to the Buyer s Guides by Bulletin. Insurers shall provide the Buyer s Guide, as revised, for new and renewal business as soon as practicable, but no later than 90 days after the date of the Bulletin. The Buyer s Guide shall provide general descriptions of: 1. How to begin to shop for auto insurance; 2. The types of policies available and the basic differences between them; 3. Various insurance coverages such as Personal Injury Protection (PIP), Liability (including bodily injury and property damage liability coverage), Uninsured/Underinsured Motorists, Collision and Comprehensive; 4. Policy terms such as limits, deductibles, producer and direct writer; 5. PIP options such as deductibles and health care primary and PIP package coverage such as income continuation, essential services, death benefit and funeral expense benefit; 6. Comprehensive and Collision options such as limits, deductibles and named driver exclusions; 7. A Lawsuit Limitation Selection Guide that explains the tort threshold options with a warning that insurance companies and their producers shall not be held liable for the consumer s choice of right to sue options; and 8. Information on how the consumer can contact the Department of Banking and Insurance. (d) In addition, the Buyer s Guide may include company-specific information, such as its name and/or company logo, contact information and company-specific coverage options, provided that the information is consistent with the purposes of this subchapter.

11:3-15.6 APPENDIX B - REGULATIONS (e) The Buyer s Guide shall contain a statement advising the insured or applicant that additional information concerning coverages or premiums is available by contacting the insurer or the producer. Insurers that write at least two percent of the New Jersey private passenger automobile market shall provide a toll-free telephone number for this purpose. (f) As required by N.J.S.A. 17:29E-11, the Buyer s Guide shall contain a notice describing the functions of the Insurance Claims Ombudsman, the mailing address of the Ombudsman and a toll-free information telephone number. Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1989 d. 624, effective December 18, 1989 (operative January 1, 1990); R.1990 d.580, effective November 19, 1990 (operative January 1, 1991). Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended. R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011. 11:3-15.6. Minimum standards for Coverage Selection Forms. (a) Each insurer shall have a separate Coverage Selection Form for the Standard Policy and for the Basic Policy using the text found in the Appendix, Exhibits 1 and 3 incorporated herein by reference. (b) The Coverage Selection Forms shall contain a statement advising the insured or applicant that additional information concerning coverages or premiums is available by contacting the insurer or the producer. Insurers that write at least two percent of the New Jersey private passenger automobile market shall provide a toll-free telephone number for this purpose. (c) Except as otherwise provided in the text, each Coverage Selection Form shall be printed in at least 10-point type on a paper size that is easily readable. (d) In addition to the required text, each Coverage Selection Form shall include space at the top for the consumer's name and any other necessary information such as policy number, etc. The bottom of each Coverage Selection Form shall have space for the consumer's signature and date. 1. Text in the Appendix, Exhibits 1 and 3 in italics, thus, is instructions or options for the insurer and should not be printed in the Coverage Selection Form. 2. Text in uppercase letters denotes section headings, defined terms or is for emphasis. Insurers are not restricted to uppercase for these purposes in formatting the Coverage Selection Forms. (e) An insurer may expand the form to solicit additional relevant information, including, but not limited to, the names of resident relatives eligible for PIP benefits. (f) Each Coverage Selection Form shall include the range of premium rate differences as indicated by the text in the Exhibits. Each insurer shall determine the range of premium rate differences for use in these sections. Premium rate differences for the Lawsuit Options in the Standard Policy Coverage Selection Form, Appendix, Exhibit 1 shall be calculated according to (g) below. When the range of premium rate differences on a Coverage Selection Form changes for any reason, including, but not limited to, rate changes, a new Coverage Selection Form with the current numbers shall be filed with the Department in accordance with N.J.A.C. 11:3-15.4(d). (g) Each insurer shall calculate the percentage and dollar change in premium (or rate) from the selection of the No Limitation on Lawsuit Option in accordance with (g)1 through 4 below. In these calculations, premium (or rate) shall include any expense fee.

BUYER S GUIDE; COVERAGE SELECTION FORM 11:3-15.6 1. The Percentage Change Calculation: The range of percentage increase in the bodily injury liability premium arising from the selection of the No Limitation on Lawsuit Option shall be calculated as follows: i. The low end of the percentage range shall be produced by calculating the percentage increase in the bodily injury liability premium of a policy with a $250,000/$500,000 split limit or a $500,000 single limit for a change from the Limitation on Lawsuit Option to the No Limitation on Lawsuit Option. This calculation shall be made for the territory with the lowest basic limit Limitation on Lawsuit Option rate, and shall assume standard tier, pleasure usage by an age 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 $310.00 on its Coverage Selection Form. 3. Premium Basis for Single Limit Liability Coverage: i. For single limit liability coverage, the percentage range calculation that is described in (g)1 above shall be based upon the applicable liability rate. This calculation shall be made on the basis of a combined rate containing a charge for bodily injury liability, and property damage liability. ii. For single limit liability coverage, the dollar range calculation that is described in (g)2 above shall be based upon the applicable liability rate. In contrast to the procedure in (g)3i above, the dollar change calculation shall be made on the basis of a complete rate containing a charge for bodily injury liability, personal injury protection (PIP), and property damage liability. 4. Insurers shall prepare: i. An example showing the calculation of the high and low values for the percentage and dollar change ranges; ii. Data about the insurer's territorial rates to confirm that the highest and lowest basic limit Limitation on Lawsuit Option rates have been used in the example. A rating page showing a list of Standard tier, basic limit rates by territory shall be sufficient;

11:3-15.7 APPENDIX B - REGULATIONS iii. Data about the insurer's increased limits liability rating, vehicle usage, and type of driver factors to confirm that the proper relativities have been used in the example. The appropriate rating pages shall be sufficient; and iv. For those insurers offering only single limit liability coverage, an explanation of the procedure used to develop the bodily injury liability rate from which the percentage and dollar change amounts have been determined. This explanation shall include an example of the calculation methodology. Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2011 d.166, effective June 6, 2011. 11:3-15.7. Use of Coverage Selection Form; availability. (a) For all new policies, an insurer or an insurance producer shall receive a Coverage Selection Form signed by the named insured and indicating the prospective insured's coverage choices. Coverage shall not become effective until the signed Coverage Selection Form is received from the named insured, unless otherwise authorized by law. (b) For the mid-term policy changes set forth in (b)1 through 5 below, the insurer shall receive a Coverage Selection Form signed by the named insured prior to making the change. 1. Change of policy type to Standard or Basic; 2. Change of Lawsuit Option (Standard Policy only): 3. Change of primary coverage for PIP medical expense benefits coverage (from or to Health Insurer Primary) (Standard Policy only); 4. Change in PIP Medical Expense Coverage Limit (Standard Policy only); and 5. Addition or deletion of Liability Coverage (Basic Policy only). (c) An insurer may require that other policy changes be made by signed Coverage Selection Form. (d) All coverage changes that are required to be made by a signed Coverage Selection Form, either by this subchapter or by the insurer, shall become effective in the following manner, except when coverage for comprehensive or collision is effected by a required inspection pursuant to N.J.A.C. 11:3-36. 1. For new policies, the choices on the Coverage Selection Form shall be effective on the policy effective date; 2. For mid-term policy changes, the choices on the Coverage Selection Form shall be effective the day following the date of postmark or, when personal delivery is made or if the postmark is illegible, the day following receipt of the signed Coverage Selection Form by the insurer or an insurance producer. If the change is made electronically, the change shall be effective the day following date of receipt as determined in accordance with N.J.S.A. 12A:12-15; 3. For changes upon renewal, the changes shall be effective on the date of the next policy renewal if postmarked or received by the insurer or by an insurance producer prior to the renewal date. New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended. R. 2001 d. 44, effective February 5, 2001; R.2004 d.117, effective March 15, 2004; R.2005 d.83, effective March 7, 2005. 11:3-15.8. New Jersey Automobile Insurance Consumer Bill of Rights. (a) The insurer shall produce a Consumer Bill of Rights by reproducing the New Jersey Automobile Insurance Consumer Bill of Rights available on the Department s website at http:www.state.nj.us/dobi/autorights.pdf. The Department shall notify insurers of any changes to the Consumer Bill of Rights by Bulletin. Insurers shall

BUYER S GUIDE; COVERAGE SELECTION FORM11:3-15.11 provide the Consumer Bill of Rights, as revised, with new and renewal business 60 days after the date of the Bulletin. (b) The Consumer Bill of Rights shall be reproduced in the format as presented on the website, duplicating the language provided therein, and to the extent practicable, the layout, fonts, type-point sizes, colors and illustrations. Notwithstanding the foregoing, all language bolded on the Consumer Bill of Rights as depicted on the Department s website shall be bolded and no type-point sizes less than 10 point shall be used. (c) The Consumer Bill of Rights shall contain: 1. An overview containing the purpose of the Bill of Rights; 2. The consumer s obligations with regard to their insurance; 3. The duties of the insurer concerning the application process; 4. The consumer s general insurance rights regarding denials and right to purchase; 5. The consumer s right to appeal a cancellation of insurance; 6. Instructions on how to be an educated insurance consumer; and 7. A statement advising the insured or applicant that additional information concerning the Coverage Selection Form and Buyer s Guide is available by contacting the insurer or the producer. Amended. R.2006 d.243, effective July 3, 2006. 11:3-15.9. Penalties. Failure to comply with the provisions of this subchapter may result in the imposition of penalties as prescribed by law. Recodified from N.J.A.C. 11:3-15.11 by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); Re-recodified from 11:3-15.8 by R.2004 d.117, effective March 15, 2004. 11:3-15.10. (Reserved). Repealed by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). 11:3-15.11. (Reserved). Recodified to N.J.A.C. 11:3-15.11 by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). EXHIBIT 1 STANDARD POLICY COVERAGE SELECTION FORM Name: This Coverage Selection Form is for a STANDARD POLICY, see Buyer's Guide, page insert page # here. A BASIC POLICY with the minimum of required coverages is also available for a lower premium. A SPECIAL POLICY with a very low premium is also available for persons enrolled in Medicaid. Contact your insurer or producer for more information. BODILY INJURY LIABILITY--Buyer's Guide page insert page # here Choose the Bodily Injury Liability Limits that you want: At least four of the most popular coverage limits shall be listed, including the lowest limit offered. If a complete list is not provided, state that other coverage limits are available. PROPERTY DAMAGE LIABILITY--Buyer's Guide page insert page # here Choose the Property Damage Limits you want:

11:3-15.11 APPENDIX B - REGULATIONS At least four of the most popular coverage limits shall be listed, including the lowest limit offered. If a complete list is not provided, state that other coverage limits are available. For insurers offering combined single limits, substitute at least four of the most popular combined single limits, including the lowest offered. PERSONAL INJURY PROTECTION (PIP)--Buyer's Guide insert page # here [ ] I choose the standard PIP Medical Expense Limit of $250,000. Include higher limit if offered [ ] I choose one of the lower PIP Medical Expense Limits below. WARNING: Prior to insert effective date of P.L. 1998, c.21, all auto insurance policies had PIP Medical Expense Benefit limits of $250,000. The limits below provide you with less coverage. Warning must be in at least 12 point type. [ ] $150,000* for a % to % reduction in the PIP premium [ ] $75,000* for a % to % reduction in the PIP premium [ ] $50,000* for a % to % reduction in the PIP premium [ ] $15,000* for a % to % reduction in the PIP premium * Even if you choose one of the amounts above, all medically necessary treatment over the policy limit up to $250,000 will be paid for permanent or significant brain injury, spinal cord injury or disfigurement or treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until a doctor says that you no longer require critical care. Choose the PIP Medical Expenses Deductible you want: [ ] $250 deductible, minimum required by law. [ ] $500 deductible, for a % to % reduction in the PIP premium. [ ] $1,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,500 deductible, for a % to % reduction in the PIP premium. Health Insurer for PIP Option [ ] I choose the health insurer for PIP option--buyer's Guide, page insert page # here. The name of my health insurer(s) is (are): 1. Policy/Group #/Certificate # 2. Policy/Group #/Certificate # Extra PIP Package Coverage Options The Extra PIP Package benefits include income continuation, essential services, death benefits and funeral expense benefits--buyer's Guide page insert page # here You may choose not to have the Extra PIP Package benefits for a % to % savings in the PIP premium. Include the range of percentage savings and the base PIP premium I choose PIP Medical Expense Only You may choose to have higher limits for the Extra PIP Package of Income Continuation, Essential Services, Death and Funeral Benefits. Buyer's Guide page insert page # here Insert a chart listing options and choices

BUYER S GUIDE; COVERAGE SELECTION FORM11:3-15.11 UNINSURED/UNDERINSURED MOTORIST COVERAGE--Buyer's Guide, Page insert page # here You may choose one of the following higher limits of Uninsured/Underinsured Motorist Coverage, up to your Bodily Injury Liability Insurance Limit. List the same options available for bodily injury liability coverage above. Other options may also be listed. COLLISION COVERAGE--Buyer's Guide, page insert page # here [ ] No, I choose not to be covered for collision damage. [ ] Yes, I choose to be covered for collision damage with the default $750 deductible. [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from company or insurance producer (i.e., agent or broker). [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available COMPREHENSIVE COVERAGE Buyer s Guide page insert page # here. If appropriate, use the term other than collision coverage throughout this section [ ] No, I choose not to be covered for comprehensive damage. [ ] Yes, I choose to be covered for comprehensive damage with the default $750 deductible. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance producer. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available For both collision and comprehensive, if either the $200 deductible or $250 deductible is not offered, that option may be deleted from this form. Also, all other available collision and comprehensive deductibles shall be listed where appropriate. WARNING: Insurers or their producers or representatives shall not be held liable for choices you make for insurance coverages or limits as long as your choices provide at least the minimum coverage required by law. Insurers or their producers or representatives also shall not be held liable if you choose not to purchase higher limits of PIP medical expense coverage, higher limits of uninsured/underinsured motorists coverage, collision coverage or comprehensive coverage. Insurers, their producers and representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17:28-1.9 for more information. Warning must be in at least 12 point type.

11:3-15.11 APPENDIX B - REGULATIONS LAWSUIT OPTIONS, Buyer's Guide, page insert page # here [ ] I want the Limitation on Lawsuit Option. [ ] I want the No Limitation on Lawsuit Option. My bodily injury liability premium will be % to % higher if I select the No Limitation on Lawsuit option instead of the Limitation on Lawsuit option, depending upon where my car is garaged, my bodily injury liability coverage limit, and other factors. Per vehicle, my bodily injury liability premium at current rates will be $ to $ higher on each renewal of my policy if I select the No Limitation on Lawsuit option instead of the Lawsuit option. I understand that I can contact my insurer or my insurance producer for specific details. Insurance companies writing six month policies should insert the word semiannual in the blank space above. Companies writing 12 month policies should insert the word annual. Insurance companies writing single limit liability coverage may add a footnote to inform insureds that the policy declaration page will not include a specific premium for bodily injury liability coverage. WARNING: Insurance companies or their producers or representatives shall not be held liable for your choice of lawsuit option (limitation on lawsuit option or no limitation on lawsuit option). Insurers or their producers or representatives also shall not be liable if the limitation on lawsuit option is imposed by law because no choice was made on the coverage selection form. Insurers, their producers or representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17:28-1.9 for more information. Warning must be in at least 12 point type. STATEMENT OF INSURED or APPLICANT: I have read the Buyer's Guide outlining the coverage options available to me. The limits available for PIP medical expense coverage and uninsured and underinsured motorists coverage have been explained to me. My choices are shown above. I agree that each of these choices will apply for all vehicles insured by my policy and to each subsequent renewal, continuation, replacement or amendment until the insurer or its insurance producer receives my request that a change be made. For new policyholders, I understand that: (a) If I do not make a choice to have the No Limitation on Lawsuit Option, I will receive the Limitation on Lawsuit option; (b) If I carry collision and/or comprehensive coverage without making a written choice of deductible, I will receive the default $750 deductible; (c) If I do not choose to have my health insurer provide PIP medical expense benefits, my auto insurer will provide PIP medical expense benefits; and (d) If I do not choose a lower PIP medical expense limit, I will receive the $250,000 limit. I understand that if this is a policy renewal and if I do not complete choices, I will receive the same coverage as in my previous policy except when changes are required by a law becoming effective during the term of my previous policy. I understand that these choices take effect in the following manner: (1) For new policies, on the effective date of the policy; (2) For mid-term policy changes, on the day following the date of postmark or, when personal delivery is made or the postmark is illegible, the day following receipt of this form by the insurer or producer; and

BUYER S GUIDE; COVERAGE SELECTION FORM11:3-15.11 (3) For changes upon renewal, on the date of the next policy renewal if postmarked or received by the insurance company or by an insurance producer prior to the renewal date. ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY 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

11:3-15.11 APPENDIX B - REGULATIONS basic policy instead of a standard policy, or if you choose not to purchase bodily injury liability coverage, collision coverage or comprehensive coverage. Insurers, their producers and representatives can lose this limitation on liability for failing to act in accordance with the law. See N.J.S.A. 17:28-1.9 for more information. PERSONAL INJURY PROTECTION--Buyer's Guide, page insert page # here WARNING: For a BASIC POLICY, the limit on PIP Medical Expense Coverage is $15,000 but includes up to $250,000 for emergency care of certain catastrophic injuries (See Buyer's Guide page insert page # here). Prior to insert effective date of P.L. 1998, c.21, all automobile insurance policies had PIP Medical Expense limits of $250,000. The PIP Medical Expense Coverage for a BASIC POLICY is significantly less than previously required by law. Warning must be in at least 12 point type. Choose the PIP Medical Expenses Deductible you want: [ ] $250 deductible, minimum required by law. [ ] $500 deductible, for a % to % reduction in the PIP premium. [ ] $1,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,000 deductible, for a % to % reduction in the PIP premium. [ ] $2,500 deductible, for a % to % reduction in the PIP premium. COLLISION COVERAGE--Buyer's Guide, page insert page # here [ ] No, I choose not to be covered for collision damage. [ ] Yes, I choose to be covered for collision damage with the basic deductible. [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance producer. [ ] Yes, I choose to be covered for collision damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the default $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available COMPREHENSIVE COVERAGE Buyer's Guide page insert page # here. If appropriate, use the term other than collision coverage throughout this section [ ] No, I choose not to be covered for comprehensive damage. [ ] Yes, I choose to be covered for comprehensive damage with the default $750 deductible. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $1,000, $1,500 or $2,000. This premium will be less than the premium with the default $750 deductible. Details available from insurer or insurance producer. [ ] Yes, I choose to be covered for comprehensive damage with the deductible circled here: $100, $150, $200, $250 or $500. This premium will be more than the premium with the $750 deductible. Details available from insurer or insurance producer. Insert provision for coverage/no coverage per car if available. These sections should be omitted by insurers that do not offer collision and comprehensive coverage in the Basic Policy. For both collision and comprehensive, if either the $200 deductible or $250 deductible is not offered, that option may be deleted from this form. Also, all other available collision and comprehensive deductibles shall be listed where appropriate. STATEMENT OF INSURED or APPLICANT:

NOTIFICATION BY MEDICAL PROVIDERS 11:3-15 I have read the Buyer's Guide outlining the coverage options available to me. I understand that this is a BASIC POLICY with the minimum coverages required by law and that a Standard Policy with higher limits and additional coverages is available. The option to buy Bodily Liability Coverage has been explained to me. My choices are shown above. I agree that each of these choices will apply for all vehicles insured by my policy and to each subsequent renewal, continuation, replacement or amendment until the insurer or its insurance producer receives my request that a change be made. For new policyholders, I understand that: (a) Unless I choose to have the $10,000 Bodily Injury Liability Coverage, I will not receive any Bodily Injury Liability Coverage; (b) If I choose collision or comprehensive coverage without making a written choice of deductible, I will receive the $750 deductible; I understand that if this is a policy renewal and if I do not complete choices, I will receive the same coverage as in my previous policy except when changes are required by a law becoming effective during the term of my previous policy. I understand that these choices take effect in the following manner: (1) For new policies, on the effective date of the policy; (2) For mid-term policy changes, on the date of postmark or, when personal delivery is made or if the postmark is illegible, the day following receipt of this Form by the insurers or by a producer; and (3) For changes upon renewal, on the date of the next policy renewal if postmarked or received by the insurance company or by an insurance producer prior to the renewal date. ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY 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, 2011. SUBCHAPTER 25. PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS Source and Effective Date. R.1997 d.14, effective January 6, 1997. Section 11:3-25.1. Purpose and scope. 11:3-25.2. Definitions. 11:3-25.3. Notification of commencement of treatment. 11:3-25.4. Content of notice and proof of receipt. 11:3-25.5. Late notification. 11:3-25.6. Standards for adjustment of reduction. 11:3-25.7. Payment from insurers only.

11:3-25.1 APPENDIX B - REGULATIONS 11:3-25.8. Procedure for appeals. 11:3-25.9. Reporting requirement. 11:3-25.10. Compliance. APPENDIX A Notification of Commencement of Medical Treatment APPENDIX B Address for Notification of Commencement of Medical Treatment 11:3-25.1 Purpose and scope. (a) The purpose of this subchapter is to implement N.J.S.A. 39:6A-5, as amended by P.L. 1995, c.407, by establishing procedures to be followed by treating medical providers to give timely notification of the commencement of medical treatment for injuries sustained in automobile accidents. The subchapter sets forth: 1. Time limits for the filing of notification of the commencement of treatment for PIP claims; 2. The actions to be taken upon failure to comply with the notification time limits, including reduction or denial of claim payments; 3. The factors to be considered in evaluation of a late notification; and 4. The rights of providers when payment is reduced or denied for failure to comply with the notification requirements. (b) This subchapter shall apply to every insurer authorized to transact the business of automobile insurance in this State. The subchapter applies to treatment for injuries resulting from automobile accidents that occur after July 8, 1996. 11:3-25.2 Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Coverage status means the status of PIP coverage for an injured party pursuant to N.J.S.A. 39:6A-5. Department means the Department of Banking and Insurance of the State of New Jersey. Eligible charge means the treating medical provider's usual, customary and reasonable charge or the upper limit on the medical fee schedule as found in N.J.A.C. 11:3-29.6, whichever is lower subject to provisions of N.J.A.C. 11:3-29.4. Emergency care means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Such emergency care shall include all necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospital care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency care extends during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Multiple treating medical provider means a treating health care provider as defined herein that provides emergency care, in association with one or more other treating medical providers. Notification or notice means a written communication, transmitted by mail, facsimile or electronic message ( E-mail ).

NOTIFICATION BY MEDICAL PROVIDERS 11:3-25.2 Personal injury protection or PIP means the coverage set forth at N.J.S.A. 39:6A-4, 39:6A-3.1, or the emergency personal injury protection coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89. PIP information means: the name and address of the insured and the name and address of the injured party, if different; the name of the PIP insurer and the address established by the insurer for notification of commencement of medical treatment pursuant to N.J.A.C. 11:3-25.3(c); the policy number of the insurance policy providing PIP benefits; and the date of the accident/injury. A treating medical provider may obtain this information from the insured, the injured party, the hospital, a police report or any other reasonably available source. Secondary medical providers means those health care providers who provide medical products, care and services to a person injured in an automobile accident only after having received a prescription from a treating health care provider. Secondary medical providers shall include, but are not limited to, pharmacists, visiting nurses, prosthetics fabricators and providers of durable medical equipment products. Notwithstanding the existence of a prescription of a treating medical provider, physical therapists, chiropractors and any secondary medical provider who seeks payment of an eligible charge in excess of $500.00 for individual services or products provided on one occasion or in the course of 30 days shall not be considered secondary medical providers. Treating health care provider means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to: 1. A hospital or health care facility which is maintained by a state or any of its political subdivisions; 2. A hospital or health care facility licensed by the Department of Health and Senior Services; 3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency clinics or offices, and private treatment centers; 4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital; 5. Hospitals or other health care facilities or treatment centers located in other states or nations; 6. Physicians licensed to practice medicine and surgery; 7. Licensed chiropractors; 8. Licensed dentists; 9. Licensed optometrists; 10. Licensed pharmacists; 11. Licensed chiropodists (podiatrists); 12. Registered bio-analytical laboratories; 13. Licensed psychologists; 14. Licensed physical therapists; 15. Certified nurse-midwives; 16. Certified nurse-practitioners/clinical nurse-specialists 17. Licensed health maintenance organizations; 18. Licensed orthotists and prosthetists; 19. Licensed professional nurses; 20. Licensed occupational therapists; 21. Licensed speech-language pathologists; 22. Licensed audiologists;

11:3-25.3 APPENDIX B - REGULATIONS 23. Licensed physician assistants; 24. Licensed physical therapists assistants; 25. Licensed occupational therapy assistants; and 26. Providers of other health care services or supplies, including durable medical goods. Amended. R 1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, effective June 7, 2004. 11:3-25.3 Notification of commencement of treatment (a) When medical treatment is rendered for which a claim for payment will be made pursuant to the PIP coverage of a private passenger automobile insurance policy, a treating health care provider shall provide notice to the PIP insurer no later than 21 days following the date of the commencement of such treatment. (b) In accordance with the PIP information provided by the injured party or the insured, notice shall be sent by the treating health care provider to the insurer at the address established by the insurer for the receipt of such notice. (c) Insurers shall establish one address where notice must be sent by treating health care providers pursuant to these rules. Insurers shall provide this address, and may provide a facsimile transmission number, and E-mail address if any, on all insurance identification cards issued by the insurer after January 6, 1997. (d) In accordance with the provisions of N.J.A.C. 11:3-25.10, insurers shall file with the Department the address, and may provide a facsimile transmission number, and E-mail address, if any, where notice of commencement of treatment should be sent. Insurers shall also include the name and telephone number of a contact person at the insurer for this purpose. Such information shall be added to a list of insurer addresses maintained by the Department. (e) Notice sent to the address printed on a valid insurance identification card or on the Department's current list of addresses shall be presumed to have been sent to the proper address. (f) Within 14 days after receiving notice of the commencement of treatment, the insurer shall notify the treating health care provider of the coverage status of the person receiving treatment. If the notice from the insurer states that the coverage status of the person receiving treatment is unknown, the insurer shall make a determination of coverage and provide written confirmation to the treating health care provider no later than 60 days from receipt of notice of commencement of treatment. Examples where the coverage status may not be known are when the injured person is not a named insured, principal or occasional operator, or is not otherwise listed as a resident of the insured household on the most recent information provided to the insurer by the named insured. (g) The notice requirements set forth in (a) through (c) above and the eligible charge reductions contained in N.J.A.C. 11:3-25.5 shall not apply to secondary medical providers, except as noted in the definition of that term found in N.J.A.C. 11:3-25.2. (h) In calculating the time for notice in (a) and (f) above, the day treatment begins or the day the insurer receives notice from the treating health care provider is not to be included. If the last day for providing notice falls on a Saturday, Sunday or legal holiday, the time runs to the next business day. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999). 11:3-25.4 Content of notice and proof of receipt (a) The treating health care provider shall send the written notice required by N.J.A.C. 11:3-25.3(a) to the PIP insurer on either:

NOTIFICATION BY MEDICAL PROVIDERS 11:3-25.5 1.The Notification of Commencement of Medical Treatment Form found in Appendix A, appended to and incorporated by reference in this subchapter; or 2.A bill or invoice rendered by the treating health care provider that includes the information required in the Notification of Commencement of Medical Treatment Form in Appendix A. (b) When any notice required by this subchapter is mailed, the postmark shall be the proof of mailing. The insurer shall retain evidence of untimely mailing of the notice whenever it denies or reduces payment pursuant to N.J.A.C. 11:3-25.5. (c) If facsimile or E-mail notice is authorized by the insurer, and any notice required by this subchapter is sent by facsimile or by E-mail, the proof of notice shall be the facsimile transmission receipt generated by the sender's facsimile machine, a copy of the E-mail message showing the date and time of transmittal or an acknowledgment of receipt generated by the receiving system. Nothing in this section shall prohibit treating health care providers and insurers from mutually agreeing to accept other proofs of notice for electronic transmissions. It shall be the responsibility of the treating health care provider to retain proof of notice of commencement of treatment transmitted by facsimile or other electronic means. (d) Any notice given pursuant to this subchapter shall be deemed to have been made on the date of postmark or the date of transmission in the case of facsimile transmission and E-mail. (e) When a bill or invoice is used to provide notice of the commencement of treatment in accordance with this subchapter, it shall not be deemed to constitute notice unless the following message appears on the first page of the bill or invoice: 21 DAY NOTICE or FIRST BILL 21 DAY NOTICE. this message shall be in contrasting color ink and be in at least 12 point capital letters. Use of a rubber stamp or affixed label is acceptable for purposes of complying with this subsection. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999). 11:3-25.5 Late notification (a) In the event notice of commencement of medical treatment is made after 21 days, the insurer shall advise the treating health care provider in writing of the late notification and may reserve the right to deny or reduce payment in accordance with (b) below. (b) Where notice of the commencement of medical treatment is not timely provided in accordance with this subchapter, an insurer may apply the following reductions to the eligible charges: 1. 22 to 30 days after the commencement of treatment: 10 percent reduction. 2. 31 to 60 days after the commencement of treatment: 25 percent reduction. 3. 61 to 120 days after the commencement of treatment: 50 percent reduction. 4. 121 to 160 days after the commencement of treatment: 75 percent reduction. 5. 161 or more days from the commencement of treatment: 100 percent reduction. (c) If notice is not provided as required by this subchapter, the reduction formula set forth in (b) above shall apply to all eligible charges for which the treating health care provider seeks payment through such late notice. (d) Insurers shall not reduce an eligible charge under the following circumstances: 1. When the provider is a multiple treating health care provider giving emergency care as defined in N.J.A.C. 11:3-25.2; 2. When the provider is a secondary medical provider as defined in N.J.A.C. 11:3-25.2;

11:3-25.6 APPENDIX B - REGULATIONS 3. When the medical condition of the injured party made it impossible to comply with the notice requirement; or 4. When the provider has submitted a request for decision point review or precertification of treatment, diagnostic testing or durable medical equipment in accordance with an insurer s decision point review plan approved in accordance with N.J.A.C. 11:3-4.7 Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, effective June 7, 2004. 11:3-25.6 Standards for adjustment of reduction (a) Notwithstanding the reductions set forth in N.J.A.C. 11:3-25.5(b), insurers may choose to pay the full or a less reduced amount of an eligible charge based upon consideration of the following factors: 1. Whether the treating health care provider has previously provided untimely notice under this subchapter or has established a pattern of untimely notice; 2. The cost of medical treatment provided by the treating health care provider between the time treatment commenced, when notice was due and when it was provided; 3. The injured party was a pedestrian who did not have PIP coverage as the named insured or resident relative under another policy and the circumstances are such that additional time is necessary to identity the policy under which coverage is being provided; 4. Any potential adverse impact on the public and 5. Such other factors as the insurer may determine. (b) Within 60 days of receipt of notice, or such additional time as may be afforded under N.J.S.A. 39:6A-5g, the insurer shall give the treating health care provider notice of its final determination as to payment, reduction or denial of payment of an eligible charge. Such notice shall be clearly labeled Final Determination, and it shall refer clearly to the injured party, the insured, the claim number, the date of accident, the date of first treatment, the date notice of the commencement of treatment was made and the acceptance or rejection of any of the standards of adjustment of the reduction in (a) above and N.J.A.C. 11:3-25.5(b). Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999). 11:3-25.7 Responsibility for payment Whenever an eligible charge has been reduced or denied pursuant to N.J.A.C. 11:3-25.5(b), the treating health care provider shall not seek to obtain payment directly from the insured or the person receiving treatment. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999). 11:3-25.8 Procedure for appeals A treating health care provider who fails to notify the insurer within 21 days and whose claim has been reduced or denied by the insurer pursuant to N.J.A.C. 11:3-25.5(b) may, in the discretion of a judge of Superior Court, be permitted to refile such claim provided that the insurer has not been substantially prejudiced thereby. Application to the court for permission to refile a claim shall be made within 14 days of the receipt of the insurer's final determination of reduction or denial of payment and shall be made upon motion based upon affidavits showing sufficient reasons for the failure to notify the insurer within 21 days of the commencement of treatment. Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).

NOTIFICATION BY MEDICAL PROVIDERS 11:3-25.10 11:3-25.9 Reporting requirement (a) By February 5, 1997, every insurer shall file with the Department the address, facsimile number (if notice by facsimile is permitted) and E-mail address, if any, of the designated location for the filing of notice required under this subchapter. Insurers shall use Appendix B, appended to and incorporated by reference in this subchapter, to report the information required by this subsection. (b) Insurers shall complete and file the information in Appendix B by January 1 of each year. (c) Completed copies of Appendix B shall be submitted to: Department of Banking and Insurance Director of Public Affairs PO Box 325 Trenton, New Jersey 08625-0325 11:3-25.10. Compliance. For treatments rendered between January 6, 1997 and July 6, 1997, all eligible charge reductions set forth in N.J.A.C. 11:3-25.5(b) shall be reduced by 50 percent (for example, a 10 percent reduction shall be five percent, a 25 percent reduction shall be 12.5 percent, etc.). APPENDIX A Notification of Commencement of Medical Treatment (to be filed with insurer) Name, address and phone No. of Treating Health Care Provider: Fax No. (optional) Name and address of patient: Name and address of insured: (if different) Insurer Name: Insurer Address: Policy No. Date of accident/injury: Date of first treatment: APPENDIX B Address for Notification of Commencement of Medical Treatment Insurance Co. Name:

11:3-26.1 APPENDIX B - REGULATIONS NAIC Group #: NAIC Company #: Address established by insurer for the filing of the notification of the commencement of PIP treatment by Treating Health Care Providers Address: Facsimile No: E-mail: Contact Person: Phone: To be filed with: Department of Banking and Insurance Division of Public Affairs PO Box 325 Trenton, New Jersey 08625-0325 Attn: Notification of Treatment List SUBCHAPTER 26. UNSATISFIED CLAIM AND JUDGMENT FUND: NOTICE OF INTENT Section 11:3-26.1. Claim information. 11:3-26.2. Claim filing; form. 11:3-26.1. Claim information. (a) Notice of intention to make a claim under N.J.S.A. 39:6-65 shall contain the following information: 1. The claimant s name, address, date of birth and social security number; 2. The time, date, location, municipality and county in which the loss occurred; 3. The identity of the operators and vehicles involved in the accident, including the name and address of the owner and operator and the license plate number of the vehicle; 4. Such witnesses to said accident as are then known; 5. A short description of the accident, including the claimant s role or position therein; 6. A description of the injuries then known, and attached thereto a medical certificate if then available. In any event the medical certificate shall be filed as soon as available; 7. A description of the damage sustained to property, and attached thereto an estimate of the cost of repairs if then available; and 8. The policy number of any insurance applicable to the accident, including the name and address of all insurance companies involved. Amended. R. 1991 d. 45, effective February 4, 1991; Amended. R. 1996 d. 58, effective February 5, 1996. 11:3-26.2. Claim filing; form. (a) A Notice of Intention to Make Claim under N.J.S.A. 39:6-65 may be filed on the form designated by the Unsatisfied Claim

UCJF 11:3-28 and Judgment Fund Board identified as a Notice of Intention to Make Claim, incorporated herein by reference as Appendix A [See Appendix C-20] (b) A written notice to the Board in any other form that contains the information required by this section shall be acceptable. (c) A notice of intention to make a claim that does not contain the items identified in N.J.A.C. 11:3-26.1(a)1 through 8 shall be returned to the sender and deemed to be not filed with the Unsatisfied Claim and Judgment Fund (UCJF) for the purpose of complying with N.J.S.A. 39:6-65 and shall not toll the statute of limitations. Amended. R.1991 d.45, effective February 4, 1991; R.1996 d.58, effective February 5, 1996; R.1997 d.85, effective February 18, 1997; R.2006 d.243, effective July 3, 2006. SUBCHAPTER 27. UNSATISFIED CLAIM AND JUDGMENT FUND BOARD Section 11:3-27.1. Uninsured s Current Financial Status. 11:3-27.1. Uninsured s Current Financial Status. (a) Upon review of a case by the Unsatisfied Claim and Judgment Fund Board s designee, if the designee does not have sufficient current information to determine whether or not the uninsured s installment payment is reasonable, a request will be addressed to the uninsured asking for a statement of current financial status. (b) If the uninsured fails to furnish a completed statement of current financial status within a time period to be established by the executive director, the Unsatisfied Claim and Judgment Fund Board s designee will request the Director of Motor Vehicles to suspend the license and all registrations of the uninsured pursuant to N.J.S.A. 39:5-30 and 39:5-87, for failure to furnish this information. Amended. R.2006 d.243, effective July 3, 2006. SUBCHAPTER 28. UNSATISFIED CLAIM AND JUDGMENT FUND S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS Section 11:3-28.1. Purpose and scope. 11:3-28.2. Definitions. 11:3-28.3. Report of such claims when the carrier has paid at least $50,000 for medical expense benefits. 11:3-28.4. Notice of change in the amount of reserves. 11:3-28.5. Supplemental form to be submitted to the Fund. 11:3-28.6. Insurer's continuing obligation to investigate claims. 11:3-28.7. Reimbursement of excess medical expense benefits paid by insurers. 11:3-28.8. Audits. 11:3-28.9. Reporting of losses for personal injury protection payments in excess of $75,000. 11:3-28.10. Insurers' obligations to investigate and audit bills for medical benefits. 11:3-28.11. Modifications to vehicles. 11:3-28.12. Modifications to a claimant's residence. 11:3-28.13. Insurer's obligation to obtain recovery of payments for paid medical expense benefit claims.

11:3-28.1 APPENDIX B - REGULATIONS 11:3-28.14. Insurer s responsibility upon assignment of an uninsured motorist claim. 11:3-28.15. Reserved. 11:3-28.16. Reserved. 11:3-28.17. Reserved. 11:3-28.1 Purpose and scope (a) The purpose of this subchapter is to establish procedures to ensure that only appropriate, reimbursable claims are submitted to the Fund by insurers by requiring investigation of the medical necessity for certain claims; requiring the audit of claims of $10,000 or more submitted by licensed providers of health care services or claims of $25,000 or more by health care facilities; and requiring prior approval of claims for alterations to vehicles and residences. This subchapter also requires insurers to pursue the proper, alternative sources for reimbursement where such other sources of funds are available. (b) This subchapter applies to all insurers authorized in this State to write the kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1. In accordance with N.J.S.A. 39:6-73.1, reimbursement for medical expense benefits may be sought from the Fund on account of personal injury to any one person in any one accident occurring on or after February 19, 1978. (c) N.J.A.C. 11:3-28.13 establishes standards for insurers to demonstrate diligent pursuit of any potentially responsible tortfeasor for the purpose of recovering PIP medical expense benefits paid on behalf of the injured party by the Fund. Insurers shall obtain reimbursement from the Fund for excess medical expense benefit payments once they comply with the standards established herein. The purpose of these provisions are to contain costs for automobile insurance in this State. Accordingly, consistent with this purpose and N.J.S.A. 39:6A-9.1, for accidents occurring outside this State, insurers are expected to assert appropriate legal remedies to pursue recovery actions against potentially responsible tortfeasors, consistent with the legal rights and remedies asserted by the injured party. Repeal and New Rule, R.1993 d.583, effective November 15, 1993. See:25 N.J.R. 2636(b), 25 N.J.R. 5219(a). Amended. R. 2001 d. 151, effective May 7, 2001. 11:3-28.2 Definitions The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Board means the Board of the New Jersey Property-Liability Insurance Guaranty Association created in accordance with N.J.S.A. 17:30A-1 et seq. Diagnosis related groups or DRG means a patient classification scheme in which cases are grouped by shared characteristics of principal diagnosis, secondary diagnosis, age, surgical procedure, and other complications. Each DRG exhibits a consistent amount of resource consumption as measured by some unit (for example, length of stay or dollars). Excess medical expense benefits means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 that are in excess of $75,000 resulting from personal injury to any one person in any one accident. Fund means the Unsatisfied Claim and Judgment Fund established pursuant to N.J.S.A. 39:6-61 et seq. Health care facility means a health care provider that is a facility or institution, whether public or private, engaged principally in providing services for diagnosis of treatment of pain, injury, deformity or physical condition, including, but not limited to, a general hospital, special hospital, public health center, diag-

UCJF 11:3-28.2 nostic center, treatment center, rehabilitation center, extended care facility, skilled nursing home, nursing home, intermediate care facility, outpatient clinic, dispensary or residential health care facility. Health care provider or provider means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to: 1. A hospital or health care facility which is maintained by a state or any of its political subdivisions; 2. A hospital or health care facility licensed by the Department of Health and Senior Services; 3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency clinics or offices, and private treatment centers; 4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital; 5. Hospitals or other health care facilities or treatment centers located in other states or nations; 6. Physicians licensed to practice medicine and surgery; 7. Licensed chiropractors; 8. Licensed dentists; 9. Licensed optometrists; 10. Licensed pharmacists; 11. Licensed chiropodists (podiatrists); 12. Registered bio-analytical laboratories; 13. Licensed psychologists; 14. Licensed physical therapists; 15. Certified nurse-midwives; 16. Certified nurse-practitioners/clinical nurse-specialists 17. Licensed health maintenance organizations; 18. Licensed orthotists and prosthetists; 19. Licensed professional nurses; 20. Licensed occupational therapists; 21. Licensed speech-language pathologists; 22. Licensed audiologists; 23. Licensed physician assistants; 24. Licensed physical therapists assistants; 25. Licensed occupational therapy assistants; and 26. Providers of other health care services or supplies, including durable medical goods. Health care service means the preadmission, outpatient, inpatient and postdischarge care provided in or by a health care facility, and such other items or services as are necessary for such care, which are provided by or under the supervision of a physician for the purpose of diagnosis or treatment of pain, injury, disability, deformity or physical condition, including, but not limited to, nursing service, home care nursing and other paramedical service, ambulance service, service provided by an intern, resident in training or physician whose compensation is provided through agreement with a health care facility, laboratory service, medical social service, drugs, biologicals, supplies, appliances, equipment, bed and board. Insurer means any person authorized or admitted in this State to write the kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1, pursuant

11:3-28.3 APPENDIX B - REGULATIONS to N.J.S.A. 17:17-1et seq. or 17:32-1 et seq., as applicable. Insurer shall not include a surplus lines insurer eligible to write business pursuant to N.J.S.A. 17:22-6.40 et seq. Licensed nursing personnel or licensed nurse means a nurse licensed by the New Jersey State Board of Nursing or the equivalent from another jurisdiction. Medical expense benefits means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 and N.J.A.C. 11:3-4. Medically necessary is as defined in N.J.A.C. 11:3-4.2. Per diem means a daily fixed charge which includes room and board and other fees for services and supplies. PIP coverage means personal injury protection coverage as described at N.J.S.A. 39:6A-4 or 39:6A-3.1. Person means any individual, association, company, corporation, insurer, joint stock company, organization, partnership, society, syndicate, trust, any combination of the foregoing acting in concert or any other entity. Pre-screen means an off-site review of the billings from a health care facility to determine whether the care given and amounts charged are appropriate. Provider means any person that furnishes services or equipment for medical expense benefits for which payment is required to be made under PIP coverage in automobile insurance policies, but does not include health care facilities. Reimbursement refers to reimbursement to insurers by the Fund as provided at N.J.S.A. 39:6-73.1. Uninsured motorist claims means claims submitted against operators of uninsured vehicles and hit and run claims submitted pursuant to N.J.S. 39:6-61. New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.1994 d.597, effective December 5, 1994; R.1997 d.535, effective December 15, 1997; R.1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2006 d.243, effective July 3, 2006. 11:3-28.3 Report of such claims when the carrier has paid at least $50,000 for medical expense benefits In cases where the potential exposure to the automobile liability insurer exceeds $75,000, the insurer shall report on form UCJF Form 1(321) (incorporated herein by reference as Form 1 in Appendix A) [Publishers note: not included herein] whenever medical expense benefits in a total amount of $50,000 have been paid on account of personal injury to any one person in any one accident. Recodified from 11:3-28.2 and amended by R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, 1997. 11:3-28.4 Notice of change in the amount of reserves Whenever an automobile liability insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount of $50,000, said insurer shall notify the Fund of any changes in the amount of reserves established for payment of the claim or closing of the file. Recodified from 11:3-28.3 and amended by R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11:3-28.5 Supplemental form to be submitted to the Fund (a) UCJF Form 2(RR) (incorporated herein by reference as Form 2 in Appendix A), shall be filed with the Fund within 90 days after an automobile insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount in excess of $75,000. Such form together with UCJF Form 3(323) (incorporated herein by reference as Form 3 in Appendix A) [Publishers note: not included herein] shall be filed each quarter thereafter that the insurer seeks reimbursement.

UCJF 11:3-28.7 (b) Any office of an insurer seeking reimbursement of funds from the UCJF for personal injury protection medical expense must also complete and file with the UCJF a New Jersey Information Questionnaire, UCJF Form 4(W-9) (incorporated herein by reference as Form 4 in Appendix A) [Publishers note: not included herein]. Recodified from 11:3-28.4 and amended by R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, 1997. 11:3-28.6 Insurer's continuing obligation to investigate claims (a) An automobile liability insurer shall be required to discharge its duty of investigating claims where the potential exposure to the insurer exceeds $75,000. Said insurer's duty and obligation with regard to claim handling shall exist and continue to exist notwithstanding this rule. The Executive Director may direct such investigations as often as he or she deems necessary. All expenses relating to the investigation of claims, including expenses for medical examinations, file maintenance and cost containment measures, are the responsibility of the automobile liability insurer. (b) The failure to properly discharge the duty of investigating a claim may result in the imposition of a penalty, to be determined by the Board s designee, against the insurer's request for reimbursement. Amended. R.1991 d.45, effective February 4, 1991. Recodified from 11:3-28.5 and amended by R.1993 d.583, effective November 15, 1993. Amended. R.2006 d.243, effective July 3, 2006. 11:3-28.7 Reimbursement of excess medical benefits paid by insurers (a) Insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefit claim payments as soon as practicable after the close of the quarter for which reimbursement is sought for claim payments of $20,000 or more. For claim payments of less than $20,000, insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefits either quarterly or at the close of the calendar year in which such expenses are incurred. Insurers shall not be reimbursed for interest, attorney fees or punitive damages. 1. Regardless of the size of a claim payment for excess medical expense benefits, an insurer shall submit to the Fund a request for reimbursement within a period of two years from the date of payment by the insurer of the excess medical expense benefit for which reimbursement is sought. 2. Failure to comply with the requirements set forth in (a) 1 above shall result in a denial by the Fund of the reimbursement request which was omitted from the quarterly submission. (b) The Fund shall not reimburse an insurer for excess medical expense benefits if it is determined that there are multiple insurance policies applicable to a claim unless an insurer has expended medical benefits in an amount exceeding $75,000 on account of personal injury to any one person in any one accident. Where there are two or more different primary insurers liable, the Fund shall not reimburse such an insurer for excess medical expense benefits unless each primary insurer has expended medical benefits in an amount exceeding $75,000 on account of personal injury to any one person in any one accident. (c) Where the Fund has reimbursed an insurer for excess medical expense benefits and thereafter determines that there were or are multiple insurance policies applicable to the underlying claim, the insurer shall return all moneys paid from the Fund. The insurer(s) shall apportion the medical benefits payment and make individual application to the Fund where the potential exposure to the insur-

11:3-28.8 APPENDIX B - REGULATIONS er(s) exceeds $75,000 on account of personal injury to any one person in any one accident. (d) Whenever an insurer recovers amounts expended by it for medical benefits, it shall not be reimbursed for excess medical expense benefits unless it has fully repaid the amount previously reimbursed by the Fund. Recodified from 11:3-28.6 and amended by R.1993 d.583, effective November 15, 1993. Amended. R.2006 d.243, effective July 3, 2006; R.2007 d.61, effective February 20, 2007. 11:3-28.8 Audits Upon request of the Fund, the insurer(s) shall present for audit at the direction of the Executive Director at a New Jersey location all policy and claim records on which notice of potential for payment of excess medical expense benefits have been submitted. Recodified from 11:3-28.7 and amended by R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11:3-28.9 Reporting of losses for personal injury protection payments in excess of $75,000 (a) For purposes of completing page 14, Exhibit of Premiums and Losses, of the annual statement filed pursuant to N.J.S.A. 17:23-1, the insurer shall include the total amount of losses for private passenger automobile and commercial automobile personal injury protection payments (lines 19.1 and 19.3), including those in excess of $75,000. Insurers shall also provide a footnote on page 14 that indicates the amount of losses reported, excluding losses from payments of private passenger automobile and commercial automobile personal injury protection payments in excess of $75,000. (b) For purposes of completing Schedule F of the annual statement, insurers shall consider the assumption and reimbursement by the Fund of private passenger automobile and commercial automobile personal injury protection payments in excess of $75,000 as a reinsurance transaction. Insurers shall consider assessments paid to the UCJF pursuant to N.J.S.A. 39:6-63 based on the insurer's premiums for private passenger automobile liability insurance (including PIP) and commercial automobile liability insurance (including PIP) as ceded premium, pro rated for the appropriate line of business on which the assessment was based. (c) Insurers shall comply with the provisions of this section beginning with the annual statement due March 1, 1994 (covering the calendar year ended December 31, 1993). For purposes of completing the annual statement due March 1, 1993 (covering the calendar year ended December 31, 1992), insurers shall file by no later than July 1, 1993 a supplemental page 14 and schedule F of the annual statement in accordance with the provisions of this section. New Rule, R.1993 d.178, effective April 19, 1993. See:24 N.J.R. 3215(a), 24 N.J.R. 1769(a). Recodified from 11:3-28.8 and amended by R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11:3-28.10 Insurers' obligations to investigate and audit bills for medical benefits (a) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by health care facilities where such claims are equal to or in excess of $25,000 and an on-site audit where such claims are equal to or in excess of $50,000. 1. Failure of an insurer to complete an audit in accordance with these rules shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill.

UCJF 11:3-28.11 2. Per diem billings for health care facilities are not subject to the audit requirements set forth in this subchapter. 3. An insurer shall conduct any such audit to determine whether the level of care, need and charges are appropriate. 4. An insurer may pay 80 percent of the provider's bill prior to completion of the initial on-site audit. The remaining amount due, if any, shall be paid following completion of the insurer's audit. 5. Annual on-site audits shall be completed in 12-month intervals, from the initial on-site audit and shall be filed with the Fund within 90 days of completion of the audit; and 6. Whenever a change in services occurs such as, but not limited to, the level of care, the daily boom rate or additional charges, an insurer shall conduct an onsite audit and shall provide the audit and auditor's statement to the Fund with the next reimbursement request. 7. All other audits shall be conducted prior to payment to the health care facility and may be performed on a pre-screen basis as set forth in (e) below. (b) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by providers other than health care facilities where such claims are equal to or in excess of $10,000. 1. Failure of an insurer to complete an audit in accordance with this subchapter shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill. (c) The thresholds in (a) and (b) above are cumulative for each confinement associated with damages resulting from bodily injuries arising out of the ownership, maintenance or use of a motor vehicle in this State and shall incorporate all claims submitted per confinement by the provider. (d) To be eligible for reimbursement by the Fund, insurers shall audit, prior to payment, bills submitted for continuous treatment from any provider which exceed or may exceed the applicable threshold. (e) Audits of all providers conducted pursuant to this subchapter, including the audit of DRG bills and any successor pricing, shall be performed by: 1. Licensed nursing personnel with two years experience or training in required auditing and hospital practices; or 2. An outside auditing firm retained by the insurer for such purposes. (f) Audits performed shall include, but not be limited to, confirmation of compliance with the medical fee schedule set forth at N.J.A.C. 11:3-29 including those situations where the insurer does not provide the primary coverage to the claimant. (g) An insurer is not required to conduct a separate, independent audit, if it has obtained a true copy of an audit conducted by the primary insurer or health insurer. (h) Insurers shall append copies of audits conducted, including those conducted by the primary insurer or health insurer, and the auditor's statements with the reimbursement request filed with the Fund in accordance with N.J.A.C. 11:3-28.7. New Rule. R.1993 d.583, effective November 15, 1993. Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999); R.2006 d.243, effective July 3, 2006. 11:3-28.11 Modifications to vehicles. (a) An insurer shall obtain prior approval from the Fund for modifications to a claimant's vehicle, or vehicle to be used for the benefit of the claimant, the cost of which may be reimbursed by the Fund. (b) An insurer shall submit a written request to the Fund, including a Van Purchase and Modification Agreement seeking approval of modifications which

11:3-28.12 APPENDIX B - REGULATIONS are equal to or in excess of $1,000, within 30 days of a claimant's request for modifications. (c) A request to obtain prior approval from the Fund shall include the following: 1. A written recommendation for the modification by the claimant's primary care physician including: i. Where the claimant is the operator of the vehicle, current findings on the claimant's physical ability to drive and a copy of the claimant's current driver's license ii.a brief analysis of the medical necessity and medical purpose for the requested modifications iii. A description of the purpose for which the vehicle will be used and iv.verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident 2. A cost benefit analysis, supported by appropriate documentation, comparing the cost of modifying the claimant's vehicle to the cost of alternate methods of transporting the claimant. This analysis shall incorporate an evaluation of the anticipated miles to be driven per year for medically necessary health care services, including a breakdown reflecting the number of miles to be driven to obtain health care service and the frequency of such services, the cost per mile of alternate means of such transportation, as well as the useful life of the vehicle 3.An agreement between the insurer and the claimant setting forth, but not limited to: i. The claimant's responsibility to maintain insurance on the vehicle; and ii. The claimant's responsibility to repair and maintain the vehicle; and 4.Any additional information specifically requested by the Fund with regard to a particular application for approval. (d) The insurer may independently evaluate, or be required by the Fund to evaluate, the claimant by a physician chosen by the insurer and approved by the Fund, at the insurer's cost, to determine whether a medical necessity and medical purpose exist for modifications to the vehicle. The evaluation shall include a review of the elements considered in the primary evaluation as set forth at (c) above. (e) The Fund shall not approve modifications to a vehicle unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident, are required for a medical purpose and the modifications are shown to be cost effective or as the Fund may otherwise determine. (f) A request for modifications may be denied for failure to fulfill any of the above conditions. New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.2006 d.243, effective July 3, 2006. 11:3-28.12 Modifications to a claimant's residence (a) An insurer shall obtain prior approval from the Fund for any modifications to a claimant's primary residence the cost of which may be reimbursed by the Fund. (b) An insurer shall submit a written request to the Fund, seeking approval of modifications which are equal to or in excess of $10,000, within 30 days of a claimant's request for modifications. (c) A request to obtain prior approval from the Fund shall include the following: 1. A written recommendation for the modification by the claimant's primary care physician including:

UCJF 11:3-28.12 i. A brief analysis of the medical necessity for the requested modifications and ii. Verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident; 2. Medical documentation estimating the claimant's life expectancy; 3. A cost benefit analysis, supported by appropriate documentation, which establishes that the proposed modifications are more cost effective than long term residential care services. The analysis shall include, in accordance with Appendix B incorporated herein by reference [Publishers note: not included herein], an evaluation based on the life expectancy of the claimant and a comparison between the costs of the modifications and home care to be provided, to the costs of other residential care alternatives; 4. An evaluation prepared by an independent consultant experienced in barrier free designs that sets forth the type of modifications required and the costs of such modifications. 5. An agreement setting forth the responsibilities regarding the obligations of the claimant, the owner of the property or both and the insurer for, but not limited to: i. The claimant's or property owner's responsibility for: 1) The expenses for upkeep of the residence 2) Maintenance of insurance on the property; and 3) Repayment to the insurer in the event of the claimant's relocation, death or upon the sale of the modified premises; and ii. The insurer's obligation to remove nonessential equipment; 6. A repayment agreement with an amortization provision which provides an amortization term and amount, once a modification is determined to be cost effective, calculated in accordance with the formula provided in Appendix B to this subchapter; and 7. Any other additional information specifically requested by the Fund with regard to a particular application for approval. (d) The insurer may independently evaluate, or be required by the Fund to evaluate, the claimant by a physician chosen by the insurer and approved by the Fund, at the insurer's cost, to determine whether a medical necessity for the modifications exist. The evaluation shall include a review of the elements considered in the primary evaluation as set forth at (c) above. (e) The Fund shall not approve modifications to a residence unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident and the modifications are shown to be cost effective or as the Fund may otherwise determine. (f) A request for modification may be denied for failure to fulfill any of the above requirements. (g) Where a request for modifications is approved, the insurer shall record a lien against the modified property in the county in which the property is located and shall file a copy of the recorded lien with the Fund within 30 days. 1. This provision shall not apply to rental property. (h) Where a claimant seeks to modify rental property, the insurer shall obtain: 1. A written consent from the owner of the property which permits the modifications and indemnifies the insurer and the Fund from any other liabilities relating thereto and

11:3-28.13 APPENDIX B - REGULATIONS 2. A written agreement between the claimant and the insurer in which the claimant agrees to reimburse the insurer for the unamortized costs of the improvements in the event of the claimant's relocation or death. (i) Upon the claimant's relocation or death, the claimant, the claimant's estate or the owner of the property against which the lien is recorded, shall reimburse the insurer for the unamortized cost of the modifications to the claimant's residence. (j) The claimant, the claimant's estate or the owner of the property against which the lien was recorded, shall have a reasonable period in which to reimburse the insurer. (k) Where repayment by the claimant or the claimant's estate is required pursuant to this section, interest shall accrue at the prevailing rate of post judgment interest as set forth in the rules governing civil practice in the New Jersey Court Rules in effect at the time of execution of the repayment agreement, until the amount owed is paid in full. (l) Within 30 days from the date of the claimant's relocation or death, the insurer shall so notify the Fund in writing and shall include the terms of repayment by the claimant to the insurer. The insurer shall repay the Fund for such reimbursement. 1.The insurer shall be required to repay the Fund within 60 days from receipt of any and all partial payments or from the receipt of a payment made in full by the claimant. (m) A warrant discharging the lien shall be filed by the insurer when the full amount owed to the insurer, in accordance with the amortization agreement, is satisfied. New Rule, R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a). 11:3-28.13 Insurer's obligation to obtain recovery of payments for paid medical expense benefit claims (a) The Fund shall reimburse insurers for paid medical expense benefit claims if an insurer demonstrates that it has diligently pursued all potentially responsible tortfeasors within the time prescribed at N.J.S.A. 39:6A-9.1, or any other applicable limitation period. 1. An insurer shall demonstrate, in accordance with (c) below, that it has diligently pursued any potentially responsible tortfeasor to obtain reimbursement of PIP medical expense benefit claim payments made by the insurer from the Fund. 2. Where the insurer has failed to diligently pursue any potentially responsible tortfeasor as set forth in (c) below, the Fund shall be entitled to discontinue reimbursements on that claim. The Fund shall also be entitled to recover from the insurer any reimbursement payments already made to the insurer on that claim, after notice and opportunity for a hearing in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and Uniform Administrative Procedure Rules, N.J.A.C. 1:1. 3. An insurer shall obtain prior approval from the Fund before settling or compromising a claim against a potentially responsible tortfeasor or a tortfeasor. (b) Any and all expenses and fees incurred by the insurer as a result of the pursuit of a potentially responsible tortfeasor, shall be borne by the insurer. (c) For purposes of this section, diligently pursue means that the insurer has either prosecuted or is prosecuting an action, including by agreement or arbitration, in matters subject to N.J.S.A. 39:6A-9.1, against all potentially responsible tortfeasors, or determined not to do so after: 1. Examining or reviewing the following documents, where applicable:

UCJF 11:3-28.14 i. Police accident reports, including fatal accident reports and supplemental reports; ii. Statements of the parties involved; iii. Witness statements; iv. Central Index Bureau return results; v. Information about the assets of uninsured tortfeasors; vi. Scene photographs and diagrams; vii. Reports of blood alcohol content; viii. Relevant court records and information on any related suits, arbitrations, settlements or judgments, either within or outside the State, including, but not limited to: (1) Pleadings; (2) Transcripts of depositions and other related discovery materials; and (3) Amounts of settlements or judgments; and ix. Information about the amount of any potentially responsible tortfeasor's insurance liability limits, including, but not limited to, umbrella and excess insurance policies; and 2. Considering the following factors in determining whether to prosecute an action against potentially responsible tortfeasors: i. The liability of the parties involved; ii. Relevant law regarding right of recovery actions; and iii. The basis for denial of coverage by the insurer of the potentially responsible tortfeasor. (d) Insurers shall file a certification, in the form of Appendix C incorporated herein by reference, that they have diligently pursued recovery of medical expense benefits, and that the insurer has not received from any source reimbursement, contribution, or indemnification of the excess medical benefits paid by the insurer for which reimbursement from the Fund is sought. This certification shall be signed by an officer of the insurer or other person authorized to sign the certification on behalf of the insurer, and shall be filed no later than two years from the date of the accident, prior to expiration of any applicable statute of limitations, or at the time filing for reimbursement is made, whichever occurs first. Failure to file the certification shall result in denial of reimbursement to the insurer by the Fund. (e) All recovery amounts obtained or that should have been obtained from the tortfeasor will be deducted from the reimbursement claim. New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.2001 d.151, effective May 7, 2001; R.2006 d.243, effective July 3, 2006. 11:3-28.14 Insurer's responsibility upon assignment of an uninsured motorist claim. (a) An insurer shall, within 10 business days of receipt of a claim assignment and accompanying instruction sheet (see Appendix B, Item 1, incorporated herein by reference) from the Fund, submit a letter to the Fund which: 1. Acknowledges receipt of the assignment and the accompanying instruction sheet; and 2. Provides the names and telephone numbers of the case handler or manager, the claim investigator and the claim adjuster. (b) An insurer shall, within 10 business days from the date it assigns the claim to defense counsel, provide the Fund with the name, address and telephone number of defense counsel.

11:3-28.15 APPENDIX B - REGULATIONS (c) An insurer shall, within 10 business days, provide written notice to the Fund of any changes, substitutions or replacements which occur with respect to any of the persons identified pursuant to (a)2 or (b) above. New Rule, R.1994 d.597, effective December 5, 1994. See: 26 N.J.R. 2190(a), 26 N.J.R. 4772(a). 11:3-28.15 (Reserved) Repealed. R.2006 d.243, effective July 3, 2006. 11:3-28.16 (Reserved) 11:3-28.17 (Reserved) Repealed. R.2006 d.243, effective July 3, 2006. SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE Section 11:3-29.1. Purpose and scope. 11:3-29.2. Definitions. 11:3-29.3. Regions. 11:3-29.4. Application of Medical Fee Schedules. 11:3-29.5. ASC facility fees; hospital outpatient surgical facility fees. 11:3-29.6. Balance billing prohibited APPENDIX 11:3-29.1. Purpose and scope. (a) Every policy of automobile insurance and motor bus insurance issued in this State shall provide that the automobile insurer's limit of liability for medically necessary expenses payable under PIP coverage, and the motor bus insurer's limit of liability for medically necessary expenses payable under medical expense benefits coverage, is the fee set forth in this subchapter or the usual, customary and reasonable fee, whichever is less. (b) This subchapter implements the provisions of N.J.S.A. 39:6A-4.6 to establish medical fee schedules on a regional basis for the reimbursement of health care providers providing services or equipment for medical expense benefits for which payment is required to be made by automobile insurers under PIP coverage and by motor bus insurers under medical expense benefits coverage. (c) This subchapter applies to all insurers who issue policies of automobile insurance containing PIP coverage and policies of motor bus insurance containing medical expense benefits coverage. (d) This subchapter does not apply to the following: 1. Other coverages contained in an automobile or motor bus insurance policy such as coverage for bodily injury liability; 2. Any other kind of insurance including health insurance, even when the health insurer may be required pursuant to its health insurance contract to pay benefits to, or on behalf of, a person who sustained bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile or motor bus, or as a pedestrian, caused by an automobile or motor bus or an object propelled by or from an automobile or motor bus; 3. Medical services or equipment provided outside of the geographic boundaries of New Jersey except as set forth in N.J.A.C. 11:3-29.4(d)2; and

MEDICAL FEE SCHEDULES 11:3-29.2 4. Inpatient services provided by acute care hospitals, trauma centers, rehabilitation facilities, other specialized hospitals, residential alcohol treatment facilities and nursing homes, except as specifically set forth in this subchapter. Amended: R.1993 d. 25, effective January 4, 1993; R.2001 d.158, effective May 21, 2001; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-29.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: Ambulatory surgery facility or ASC means: 1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are performed and which is separate and apart from any other facility license. (The ambulatory surgery facility may be physically connected to another licensed facility, such as a hospital, but is corporately, financially and administratively distinct, for example, it uses a separate tax-id number); or 2. A physician-owned single operating room in an office setting that is certified by Medicare. Basic Life Support ( BLS ) means volunteer ambulance services, whose personnel are not required to be Emergency Medical Technicians, and municipal and proprietary ambulance services whose personnel are required to be Emergency Medical Technicians. Bilateral surgery means identical procedures (requiring use of the same CPT code) performed on the same anatomic site but on opposite sides of the body. Furthermore, each procedure is performed through its own separate incision. "CDT" means the American Dental Association's Current Dental Terminology 2011-2012, copyright 2010. Co-surgery means two surgeons (each in a different specialty) are required to perform a specific procedure. Co-surgery also refers to surgical procedures involving two surgeons performing the parts of one procedure simultaneously. "CPT" means the American Medical Association's Current Procedural Terminology, Fourth Edition, Version 2011, coding system. Current Procedural Terminology (CPT) is copyright 2011 American Medical Association (AMA), all rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained in the CPT. Applicable Federal Acquisition Regulation and Defense Federal Acquisition Regulation Supplement (FARS/DFARS), 48 CFR, restrictions apply to government use. CPT<(R)> is a trademark of the American Medical Association. "Eligible charge or expense" means the usual, customary and reasonable charge as determined pursuant to N.J.A.C. 11:3-29.4(e)1 or the upper limit in the fee schedule, whichever is lower. Emergency care means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Such emergency care shall include all medically necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency care extends

11:3-29.2 APPENDIX B - REGULATIONS during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Global service means the sum of the technical and professional components. HCPCS means the Federal Center for Medicare and Medicaid Services (CMS) Common Procedure Code System. Health care provider or provider is as defined in N.J.A.C. 11:3-4. Health insurance means a contract or agreement whereby an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the bodily injury, disability, sickness, death by accident or accidental means of a human being, or because of any expense relating thereto, or because of any expense incurred in prevention of sickness, and includes every risk pertaining to any of the enumerated risks. As used in this subchapter, health insurance includes workers' compensation coverage but does not include any PIP coverage. Health insurer includes any insurer issuing a policy of health insurance as defined in this subchapter. "Hospital" means a general acute care hospital, a long-term acute care hospital or a comprehensive rehabilitation hospital. "Hospital outpatient" means a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital. When a patient with a known diagnosis enters a hospital for a specific surgical procedure or other treatment that is expected to keep him or her in the hospital for only a few hours (less than 24), he or she is considered an outpatient for coverage purposes regardless of the hour he or she came to the hospital; whether he or she used a bed; or whether he or she remained in the hospital past midnight. "Hospital outpatient surgical facility" or "HOSF" means a facility where hospital outpatients are treated. Medically necessary or medical necessity means that: 1. The medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person; 2. The treatment is the most appropriate level of service that is in accordance with the standards of good practice and the provisions of N.J.A.C. 11:3-4, as applicable; 3. The treatment is not primarily for the convenience of the injured person or provider; 4. The treatment is not unnecessary; and 5. The treatment does not include unnecessary testing. Modifier means an addition to the five-digit CPT code of either two letters or numbers that indicates that a service or procedure was performed that has been altered by some specific circumstance but not changed in its definition or code. Motor bus means motor bus as defined in N.J.S.A. 17:28-1.5. Motor bus insurer includes any insurer issuing a policy of insurance on a motor bus the owner, registered owner, or operator of which is required to maintain medical expense benefits coverage pursuant to N.J.S.A. 17:28-1.6. Multiple surgeries means additional procedures, unrelated to the major procedure and adding significant time or complexity, performed on the same patient at the same operative session or on the same day. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.

MEDICAL FEE SCHEDULES 11:3-29.4 PIP coverage means personal injury protection coverage described in N.J.S.A. 39:6A-3.1(a), 39:6A-4a and 39:6A-10 as amended. PIP insurer includes any insurer issuing a policy of automobile insurance on any vehicle that contains PIP coverage. Powered traction device means VAX-D, DRX or similar devices determined by the Federal Food and Drug Administration to provide traction services. Three-digit zip code refers to the first three digits of the U.S. postal code. "Trauma services" means the care provided in the Level I or Level II trauma hospital to patients whose arrival requires trauma center activation. It does not include transportation to the hospital, treatment of patients whose arrival at the hospital does not require trauma activiation or outpatient visits after a patient who has received trauma care is discharged from acute care. Amended. R 1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993 d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1, 1995); R.2001, d.158, effective May 21, 2001; R.2003 d.143, effective April 7, 2003; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-29.3. Regions. (a) The Regions in Appendix, Exhibit 1, Physicians' Fee Schedule, Exhibit 2, Dental Fee Schedule and Exhibit 4, Ambulance Services, are as follows: 1. South Region consists of Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 077, 080, 081, 082, 083, 084, 086 and 087. The South Region also includes: 08501, 08505, 08510, 08511, 08514 through 08527, 08533 through 08535, 08540 through 08550, 08554, 08555 and 08560 through 08562. 2. North Region consists of Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union and Warren counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 070, 071, 072, 073, 074, 075, 076, 078, 079, 088 and 089. The North Region also includes: 08502, 08504, 08512, 08528, 08530, 08536, 08551, 08553, 08556 through 08559 and 08570. Amended. R.2001 d.253, effective July 16, 2001; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-29.4. Application of Medical Fee Schedules. (a) Nothing in this subchapter shall compel the PIP insurer or a motor bus insurer to pay more for any service or equipment than the usual, customary and reasonable fee, even if such fee is well below the automobile insurer's or motor bus insurer's limit of liability as set forth in the fee schedules. Insurers are not required to pay for services or equipment that are not medically necessary. 1. The fees for physicians' services in subchapter Appendix, Exhibit 1, the provisions in (f)1 through 7 below and the non-physician facility fees in subchapter Appendix, Exhibit 7 shall not apply to trauma services at Level I and Level II trauma hospitals. Bills for services subject to the trauma services exemption shall use the modifier "-TS". 2. The non-physician facility fees in subchapter Appendix, Exhibit 7 shall not apply to services provided in hospital emergency rooms. The bills for these services shall use the modifier "-ER". 3. The physician fees for surgical services (CPT 10000 though 69999) provided in emergency care in acute care hospitals that are not subject to the trauma care exemption shall be reimbursed at 150 percent of the physicians' fees in subchapter Appendix, Exhibit 1. The bills for these services shall use the modifier "-ER".

11:3-29.4 APPENDIX B - REGULATIONS 4. Except as provided in (a)1 through 3 above, the fees in Appendix, Exhibits 1 through 7 apply regardless of the site of service. (b) The region used to determine the proper fee set forth in the schedules shall be determined by the region in which the services were rendered or the equipment was provided or, in the case of elective services or equipment provided to New Jersey residents outside the State, by the region in which the insured resides. (c) The fees set forth in the schedule for durable medical equipment, subchapter Appendix, Exhibit 5, are retail prices, which may include purchase prices for both new and used equipment, and/or monthly rentals. New equipment shall be distinguished with the use of modifier-nu, used equipment with modifier-ue and rental equipment with modifier-rr. 1. The insurer's total limit of liability for the rental of a single item of durable medical equipment set forth in the schedule is 15 times the monthly rental fee or the purchase price of the item, whichever is less. 2. For the provision and billing of durable medical equipment, payors shall follow the relevant provisions of Chapter 20 of the Medicare Claims Processing Manual, updated periodically by CMS and incorporated by reference, that were in effect at the time the service was provided (http://www.cms.gov/manuals/downloads/clm104c20.pdf). (d) The insurer's limit of liability for any medical expense benefit for service or equipment provided outside the State of New Jersey shall be as follows: 1. When the service or equipment is provided by reason of emergency or medical necessity, the reasonable and necessary costs shall not exceed fees that are usual, customary and reasonable for that provider in the geographic location where the service or equipment is provided. 2. When the service or equipment is provided by reason of the election by the insured to receive treatment outside the State of New Jersey, the reasonable and necessary costs shall not exceed fees set forth in the fee schedules for the geographic region in which the insured resides. (e) Except as noted in (e)1 through 3 below, the insurer's limit of liability for any medical expense benefit for any service or equipment not set forth in or not covered by the fee schedules shall be a reasonable amount considering the fee schedule amount for similar services or equipment in the region where the service or equipment was provided or, in the case of elective services or equipment provided outside the State, the region in which the insured resides. When a CPT, CDT, or HCPCS code for the service performed has been changed since the fee schedule rule was last amended, the provider shall always bill the actual and correct code found in the most recent version of the American Medical Association's Current Procedural Terminology or the American Dental Association's Current Dental Terminology. The amount that the insurer pays for the service shall be in accordance with this subsection. Where the fee schedule does not contain a reference to similar services or equipment as set forth in the preceding sentence, the insurer's limit of liability for any medical expense benefit for any service or equipment not set forth in the fee schedules shall not exceed the usual, customary and reasonable fee. 1. For the purposes of this subchapter, determination of the usual, reasonable and customary fee means that the provider submits to the insurer his or her usual and customary fee by means of explanations of benefits from payors showing the provider's billed and paid fee(s). The insurer determines the reasonableness of the provider's fee by comparison of its experience with that provider and with other providers in the region. National databases of fees, such as those published by FAIR Health (www.fairhealthus.org) or Wasserman (http://www.medfees.com/),

MEDICAL FEE SCHEDULES 11:3-29.4 for example, are evidence of the reasonableness of fees for the provider's geographic region or ZIP code. The use of national databases of fees is not limited to the above examples. When using a database as evidence of the reasonableness of a fee, the insurer shall identify the database used, the edition date, the geozip, and the percentile. 2. All applicable provisions of this section concerning billing and payment apply to fees for services provided outside of New Jersey and to fees that are not on the fee schedule. 3. Codes in Appendix, Exhibit 1 that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC and are not subject to the provision in (e) above concerning services not set forth in or covered by the fee schedules. (f) Except as specifically stated to the contrary, the following shall apply to physician charges for multiple and bilateral surgeries (CPT 10000 through 69999), co-surgeries and assistant surgeons: 1. For multiple surgeries, rank the surgical procedures in descending order by the fee amount, using the fee schedule or UCR amount, as appropriate. The highest valued procedure is reimbursed at 100 percent of the eligible charge. Additional procedures are reported with the modifier "-51" and are reimbursed at 50 percent of the eligible charge. If any of the multiple surgeries are bilateral surgeries using the modifier "-50," consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions. 2. There are two types of procedures that are exempt from the multiple procedure reduction. Codes in CPT that have the note, "Modifier -51 exempt" shall be reimbursed at 100 percent of the eligible charge. In addition, some related procedures are commonly carried out in addition to the primary procedure. These procedure codes contain a specific descriptor that includes the words, "each additional" or "list separately in addition to the primary procedure." These add-on codes cannot be reported as stand-alone codes but when reported with the primary procedure are not subject to the 50 percent multiple procedure reduction. 3. The terminology for some procedure codes includes the terms "bilateral" or "unilateral or bilateral." The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT as "bilateral" or "unilateral or bilateral" since the fee schedule reflects any additional work required for bilateral surgeries. If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral) and is performed bilaterally, providers must report the procedure with modifier "-50" as a single line item. Reimbursement for bilateral surgeries reported with the modifier "-50" shall be 150 percent of the eligible charge. 4. For co-surgeries, each surgeon bills for the procedure with a modifier "-62". For co-surgeries (modifier 62), the fee schedule amount applicable to the payment for each co-surgeon is 62.5 percent of the eligible charge. 5. The eligible charge for medically necessary assistant surgeon expenses shall be 20 percent of the primary physician's allowable fee determined pursuant to the fee schedule and rules. Assistant surgeon expenses shall be reported using modifier -80, -81 or -82 as designated in CPT. When the assistant surgeon is someone other than a physician surgeon, the reimbursement shall not exceed 85 percent of the amount that would have been reimbursed had a physician surgeon provided the service. Non-physician assistant surgeon services shall be reported using modifier-as. 6. The necessity for co-surgeons and assistant surgeons for an operation shall be determined by reference to authorities such as the Medicare physician fee

11:3-29.4 APPENDIX B - REGULATIONS schedule database (www.cms.gov). Fees for assistant surgeons and co-surgeons are not rendered eligible for reimbursement simply because it is the policy of a provider or an outpatient surgical facility that one be present. 7. It is the responsibility of providers that are acting as co-surgeons or assistant surgeons to include the correct modifier in their bills, especially as they may not be submitted to the insurer at the same time. If a surgeon submits a bill without a modifier and is paid 100 percent of the eligible charge and the insurer subsequently receives a bill from a co-surgeon or assistant surgeon for the same procedure, the insurer shall notify both providers that it has already paid 100 percent of the eligible charge and that it cannot reimburse the co-surgeon or assistant surgeon until the overpayment has been offset or refunded. 8. Prosthetic and other devices, including neuro-stimulators, internal/external fixators, single use spine wands and spine probes, tissue grafts, plates, screws, anchors and wires, whether implanted, inserted, or otherwise applied by covered surgical procedures shall be reimbursed at no more than the invoice for the device plus 20 percent. This provision applies regardless of where the procedure is performed, including trauma centers, hospital emergency rooms, inpatient surgeries and outpatient surgical facilities. (g) Except as specifically stated to the contrary in this subchapter, the fee schedules shall be interpreted in accordance with the following, incorporated hererin by reference, as amended and supplemented: the relevant chapters of the Medicare Claims Processing Manual, updated periodically by CMS, that were in effect at the time the service was provided. The Medicare Claims Processing Manual is available at https: //www.cms.gov/manuals/iom/itemdetail.asp?itemid=cms018912; the NCCI Policy Manual for Medicare Services, as updated periodically by CMS and available at http://www.cms.gov/nationalcorrectcodinited/downloads/ncci_policy_manual.zip; Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service, available from CMS at https:// www.cms.gov/nationalcorrectcodinited/downloads/modifier59.pdf; and the CPT Assistant available from the American Medical Association (www.amabookstore.com). 1. Artificially separating or partitioning what is inherently one total procedure into subparts that are integral to the whole for the purpose of increasing medical fees is prohibited. Such practice is commonly referred to as "unbundling" or "fragmented" billing. Providers and payors shall use the National Correct Coding Initiative (NCCI) Edits, incorporated herein by reference, as updated quarterly by CMS and available at http://www.cms.hhs.gov/nationalcorrectcodinited/. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used. For more information on the criteria for the use of modifiers, see the NCCI Policy Manual and Modifier 59 Article referenced in (g) above. 2. CPT 97010 (application of hot/cold packs) is bundled into the payment for other services and shall not be reimbursed separately. 3. X-ray digitization or computer aided radiographic mensuration reported under CPT 76499 or any other code are not reimbursable under PIP. 4. Kinesio taping or other taping is not reimbursable under PIP. Kinesio taping shall not be billed using the strapping codes, CPT 29200 through 29280 and 29520 through 29590. 5. Platelet Rich Plasma (PRP) injections are only reimbursable for treatment of chronically injured tendons that have failed to improve despite appropriate con-

MEDICAL FEE SCHEDULES 11:3-29.4 servative treatments. PRP injections shall be billed under code 0232T in subchapter Appendix, Exhibit 1. 6. Leads, pads, batteries and any other supplies for use of TENS or EMS devices are included in the fee for the rental of the unit and are not separately reimbursable when rented. For purchase of the unit, the first month's supply of leads, pads, batteries and any other supplies for TENS or EMS units are included. 7. The eligible charge for an office visit includes reviewing the report of an imaging study when the provider of the imaging study has billed for the technical and professional component of the service. In these circumstances, it is not appropriate for the provider to bill for an office visit, CPT 76140 or for the physician component of the imaging study. CPT 76140 is not reimbursable. Where a provider in a different practice or facility performs a medically necessary review of an imaging study and produces a written report as part of a consultation, the provider shall bill the professional component (modifier -26) for each specific radiology service. 8. When CPT 77003, fluoroscopic guidance, can be billed separately and is not included as part of another procedure, it is reimbursable only per spinal region, not per level. 9. HCPCS code G0289 is an add-on code and should be added to the knee arthroscopy code for the major procedure being performed. This code is only to be reported once per extra compartment, even if chondroplasty, loose body removal and foreign body removal are all performed. The code may be reported twice if the physician performs these procedures in two compartments in addition to the compartment where the main procedure was performed. i. This code shall be reported only when the physician spends at least 15 minutes in the additional compartment performing the procedure. It shall not be reported if the reason for performing the procedure is due to a problem caused by the arthroscopic procedure itself. This code is to be used when a procedure is performed in the lateral, medial, or patellar compartments in addition to the main procedure. The billing of CPT codes 29874 and 29877 is not permitted with other arthroscopic procedures on the same knee and CPT code 29874 shall not be used to report the services described by code G0289. 10. Appendix J of the CPT manual, Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves may be used as a reference for the appropriate reimbursement of this type of Electrodiagnostic testing. 11. Moderate (conscious) sedation performed by the physician who also furnishes the medical or surgical service cannot be reimbursed separately for the procedures listed in Appendix G of the CPT manual. In that case, payment for the sedation is bundled into the payment for the medical or surgical service. As a result, CPT codes 99143 through 99145 are not reimbursable for the procedures in Appendix G of the CPT manual. 12. CPT codes 99148 through 99150 are only reimburseable when a second physician other than the provider performing the diagnostic or therapeutic services provides moderate sedation in a facility setting (for example, hospital, outpatient hospital/ambulatory surgery center or skilled nursing facility). CPT codes 99148 through 99150 are not reimburseable for services performed by a second physician in a physician office, freestanding imaging center or for any procedure code identified in CPT as including moderate (conscious) sedation. 13. CPT 22505, "Manipulation of spine requiring anesthesia, any region," if medically necessary, can only be reported once for any and all regions manipulated on that date. (h) To be reimbursable, nerve conduction studies (NCS) (CPT 95900-95904) must be interpreted by a provider who was on site and directly supervised or per-

11:3-29.4 APPENDIX B - REGULATIONS formed the nerve conduction study in accordance with N.J.A.C. 13:35-2.6(n)3. Needle Electromyography (EMG) interpretation must be performed in the same facility on the same day by the same physician who performed and/or supervised the needle EMG. (i) The reporting of nerve conduction studies and needle electromyography (EMG) (CPT 95860 through 95872) results should be integrated into a unified diagnostic impression. Separate reports for needle EMG and NCS are not reimbursable under the codes above in this subsection. (j) For surgery and many other procedures, it is established practice to include follow-up care and visits as part of the basic procedure charge. Such charges shall not be subject to additional billings. The existence of a CPT code, per se, does not imply the right to receive separate compensation for the procedure/sub-procedure so described. If a procedure is judged to be part of the primary procedure, only the charges for the primary procedure are eligible. As identified in CPT, separate procedures are commonly carried out as an integral part of another procedure. They shall not be billed in conjunction with the other procedure, but may be billed when performed independently of the other procedure. (k) CPT codes for procedures described in CPT as "unlisted procedure" or "unlisted service" (example: 64999 Unlisted procedure nervous system) are not reimbursable without documentation from the provider describing the procedure or service performed, demonstrating its medical appropriateness and indicating why it is not duplicative of a code for a listed procedure or service. Documentation may include the existence of temporary or AMA Category III or HCPCS codes for the procedure or information in the AMA CPT Assistant publication. In submitting bills for unlisted codes, the provider should base the fee on a comparable procedure. It is never appropriate for the provider to bill an unlisted code for a list of services that have CPT codes. Providers that intend to use unlisted codes in nonemergency situations are encouraged to notify the insurer in advance through the precertification process. Based on the information submitted by the provider, the insurer shall determine whether the CPT coding is appropriate. (l) Certain CPT codes are listed in the fee schedule with three entries. There is a global fee with no modifier, a technical component with modifier "TC" and a physician component with modifier "-26". Services with physician component amounts of zero in the fee schedule are considered to be 100 percent technical. A provider shall not bill the global fee and a technical or physician component. The technical or physician component shall be billed when only that part of the service is being provided. (m) The daily maximum allowable fee shall be $ 105.00 for the Physical Medicine and Rehabilitation CPT codes listed in subchapter Appendix, Exhibit 6, incorporated herein by reference, that are commonly provided together. The daily maximum applies when such services are performed for the same patient on the same date. In determining whether a provider has reached the daily maximum, the insurer shall apply the NCCI edits. The daily maximum applies to all providers, including dentists. However, when the provider can demonstrate that the severity or extent of the injury is such that extraordinary time and effort is needed for effective treatment, the insurer shall reimburse in excess of the daily maximum. Such injuries could include, but are not limited to, severe brain injury and nonsoft-tissue injuries to more than one part of the body. Such injuries would not include diagnoses for which there are care paths in N.J.A.C. 11:3-4. Treatment that the provider believes should not be subject to the daily maximum shall be billed using modifier -22 as designated in CPT for unusual procedural services. Unless already provided to the insurer as part of a decision point review or precertifica-

MEDICAL FEE SCHEDULES 11:3-29.5 tion request, the billing shall be accompanied by documentation of why the extraordinary time and effort for treatment was needed. 1. Supervised modalities and those therapeutic procedures that do not list a specific time increment in their description shall be limited to one unit per day. 2. CPT 97012 is the appropriate code for billing powered traction therapy. 3. CPT 97026 is the appropriate code for billing cold or low-powered laser therapy. 4. HPCPS code G0283 is the appropriate code for billing unattended electrical stimulation. 5. Pursuant to N.J.S.A. 39:6A-4, physical therapy, as defined in N.J.S.A. 45:9-37.13, shall not be reimbursable under PIP unless rendered by a licensed physical therapist pursuant to a referral from a licensed physician, dentist, podiatrist or chiropractor within the scope of the respective practices. (n) Follow-up evaluation and management services for the re-examination of an established patient shall be reimbursed in addition to physical medicine and rehabilitation procedures only when any of the circumstances set forth in (n)1 through 4 below is present and not more than twice in any 30-day period. Modifier -25 shall be added to an evaluation and management service when a significant separately identifiable evaluation and management service is provided and documented as medically necessary as follows: 1. There is a definite measurable change in the patient's condition requiring significant change in the treatment plan; 2. The patient fails to respond to treatment, requiring a change in the treatment plan; 3. The patient's condition becomes permanent and stationary, or the patient is ready for discharge; or 4. It is medically necessary to provide evaluation services over and above those normally provided during the therapeutic services. (o) Regardless of the specific codes that are included in a DPR/Precertification request, the insurer's reimbursement for those services shall be consistent with the rules contained in this subchapter, including the NCCI edits and the CPT Manual current at the time the services were provided. (p) The ANES code on the Physicians' Fee Schedule is the conversion factor for anesthesia units. Payors shall follow the Medicare Claims Processing Manual and other guidelines for calculating the number of units for the various CPT codes for the administration of anesthesia and other billing situations, such as directing or supervising Certified Nurse Anesthetists and other non-physician anesthesia providers. These can be found at: www.cms.hhs.gov/center/anesth.asp. Amended. R.1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993 d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1, 1995); R.2001 d.158, effective May 21, 2001; R.2001 d.253, effective July 16, 2001; R.2003 d.143, effective April 7, 2003; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013); R.2014 d.004, effective January 6, 2014. 11:3-29.5 ASC facility fees; hospital outpatient surgical facility fees. (a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including: 1. Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;

11:3-29.6 APPENDIX B - REGULATIONS 2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient's care; 3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment; 4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: www.cms.gov/ascpayment/ ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare (see: https://www.cms.gov/hospitaloutpatientpps/downloads/ CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgical procedures and are not permitted to be reimbursed separately in a HOSF; 5. Administrative, recordkeeping, and housekeeping items and services; 6. Blood, blood plasma, platelets, etc.; 7. Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and 8. Implantable DME and prosthetics. (b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The hospital outpatient surgical facility fee is the maximum that can be reimbursed for outpatient procedures performed in an HOSF. The hospital outpatient facility fees in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through 8 above. (c) The sale, lease or rental of durable medical equipment (DME) to patients for use in their homes are not included in the ASC or HOSF fee. If the ASC or HOSF furnishes items of DME to patients, billing for such items should be made in accordance with subchapter Appendix, Exhibit 5. (d) When multiple procedures are performed in an ASC or in an HOSF in the same operative session, the ASC facility fee or the HOSF fee, as applicable, for the procedure with the highest payment amount is reimbursed at 100 percent and reimbursement of any additional procedures furnished in the same session is 50 percent of the applicable facility fee. 1. A procedure performed bilaterally in one operative session is reported as two procedures and is subject to the multiple procedure reduction formula. 2. Subchapter Appendices, Exhibit 1, the Physicians and ASC Facility Fee Schedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, according to Medicare (see: www.cms.gov/ascpayment/ascrn/list.asp and http:/ /www.cms.gov/hospitaloutpatientpps/) are exempt from the multiple procedure reduction formula. New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-29.6 ASC facility fees; hospital outpatient surgical facility fees (a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including: 1. Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;

MEDICAL FEE SCHEDULES 11:3-29.6 2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient s care; 3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment; 4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: www.cms.gov/ascpayment/ ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare (see: https://www.cms.gov/hospitaloutpatientpps/downloads/ CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgical procedures and are not permitted to be reimbursed separately in a HOSF; 5. Administrative, recordkeeping, and housekeeping items and services; 6. Blood, blood plasma, platelets, etc.; 7. Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and 8. Implantable DME and prosthetics. (b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The hospital outpatient surgical facility fee is the maximum that can be reimbursed for outpatient procedures performed in an HOSF. The hospital outpatient facility fees in Appendix Exhibit 7 include services that would be covered if furnished in a hospital on an inpatient basis, including those set forth in (a)1 through 8 above. (c) The sale, lease or rental of durable medical equipment (DME) to patients for use in their homes are not included in the ASC or HOSF fee. If the ASC or HOSF furnishes items of DME to patients, billing for such items should be made in accordance with subchapter Appendix, Exhibit 5. (d) When multiple procedures are performed in an ASC or in an HOSF in the same operative session, the ASC facility fee or the HOSF fee, as applicable, for the procedure with the highest payment amount is reimbursed at 100 percent and reimbursement of any additional procedures furnished in the same session is 50 percent of the applicable facility fee. 1. A procedure performed bilaterally in one operative session is reported as two procedures and is subject to the multiple procedure reduction formula. 2. Subchapter Appendices, Exhibit 1, the Physicians and ASC Facility Fee Schedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, according to Medicare (see: www.cms.gov/ascpayment/ascrn/list.asp and http:/ /www.cms.gov/hospitaloutpatientpps/) are exempt from the multiple procedure reduction formula. New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). 11:3-29.6. Balance billing prohibited. No health care provider may demand or request any payment from any person in excess of those permitted by the medical fee schedules and this subchapter, nor shall any person be liable to any health care provider for any amount of money that results from the charging of fees in excess of those permitted by the medical fee schedules and this subchapter. Amended. R. 2001, d. 158, effective May 21, 2001. Recodified from N.J.A.C. 11:3-29.5 by R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

11:3-29.6 APPENDIX B - REGULATIONS APPENDIX: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE Exhibit 1 Physicians & Ambulatory Surgical Center (ASC) Facility Fee Schedule Payment Indi cator (See 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 86.47 84.36 0232T NJX PLATELET PLASMA 63.95 63.95 89.55 82.44 X G0283 ELECTRICAL STIMULATION, 20.14 19.26 (UNATTENDED), TO ONE OR MORE AREAS 00289 ARTHRO, LOOSE BODY + CHONDRO 483.50 467.0 X, N1 10060 DRAIN SKIN ABSCESS 176.46 168.00 198.84 183.03 10061 DRAIN SKIN ABSCESS 290.74 278.25 198.84 183.03 10120 REMOVE FOREIGN BODY 219.66 208.52 297.15 273.51 10121 REMOVE FOREIGN BODY 423.57 403.23 2,411.70 2,219.85 10140 DRAIN HEMATOMA/FLUID 250.71 238.43 321.75 296.13 10160 PUNCTURE DRAIN LESION 203.36 193.31 198.84 183.03 10180 COMPLEX DRAIN WOUND 381.01 362.70 2,694.69 2,480.34 11000 DEBRIDE INFECTED SKIN 84.28 80.26 102.96 94.77 11001 DEBRIDE INFECTED SKIN, ADDED 33.67 32.24 3.93 31.23 11010 DEBRIDE SKIN, FX 770.97 732.08 678.84 624.84 11011 DEBRIDE SKIN/MUSCLE, FX 842.60 801.49 678.84 624.84 11012 DEBRIDE SKIN/MUSCLEBONE, FX 1,128.89 1,074.42 678.84 624.84 11042 DEBRIDE SKIN/TISSUE 141.88 134.65 364.44 335.43 11043 DEBRIDE TISSUE/MUSCLE 309.64 294.89 364.44 335.43 11044 DEBRIDETISSUE/MUSCLE/BONE 467.58 447.17 1,132.98 1,042.83 11045 DEBRIDE SUBQ TISSUE ADD-ON 50.08 47.78 364.44 335.43 11046 DEBRIDE MUSCLE/FASCIA ADD-ON 86.02 82.37 364.44 335.43 11047 DEBRIDE BONE ADD-ON 141.04 135.27 1,132.98 1,042.83 11055 TRIM SKIN LESION 78.70 74.56 111.15 102.30 11056 TRIM SKIN LESIONS, 2 TO 4 93.59 88.93 121.44 111.78 11057 TRIM SKIN LESIONS, OVER 4 110.23 104.93 121.44 111.78 11100 BIOPSY SKIN LESION 168.53 159.57 199.77 183.90 11101 BIOPSY SKIN, ADDED 52.52 50.16 58.50 53.85 11200 REMOVE SKIN TAGS 136.42 129.65 121.44 111.78 11300 SHAVE SKIN LESION 111.63 105.61 121.44 111.78 11301 SHAVE SKIN LESION 150.18 142.55 121.44 111.78 11302 SHAVE SKIN LESION 179.35 170.36 121.44 111.78 11305 SHAVE SKIN LESION 110.55 104.93 121.44 111.78 11306 SHAVE SKIN LESION 152.62 145.18 121.44 111.78 11310 SHAVE SKIN LESION 137.16 130.09 121.44 111.78 11311 SHAVE SKIN LESION 171.78 163.30 121.44 111.78 11400 EXCISE TRT-EXT BENIGN+MARG 0.5 < CM 192.83 182.50 283.11 260.58 11401 EXCISE TRT-EXT BENIGN+MARG 0.6-1 CM 234.32 222.41 319.41 294.00 11402 EXCISE TRT-EXT BENIGN+MARG 1.1-2 CM 260.75 247.62 350.97 323.04 11403 EXCISE TRT-EXT BENIGN+MARG 2.1-3 CM 298.16 283.70 379.02 348.87 11404 EXCISE TRT-EXT BENIGN+MARG 3.1-4 CM 338.86 322.54 2,411.70 2,219.85 11406 EXCISE TRT-EXT BENIGN+MARG

MEDICAL FEE SCHEDULES 11:3-29.6 > 4.0 CM 457.22 457.22 2,411.70 2,219.85 11420 EXCISE H-F-NECK-SP BENIGN+MARG 0.5 < 191.28 181.36 266.76 245.52 11421 EXCISE H-F-NECK-SP BENIGN+MARG 0.6-1 247.34 235.08 324.03 298.26 11422 EXCISE H-F-NECK-SP BENIGN+MARG 1.1-2 275.21 261.73 354.48 326.28 11423 EXCISE H-F-NECK-SP BENIGN+MARG 2.1-3 317.92 302.76 394.26 362.88 11424 EXCISE H-F-NECK-SP BENIGN+MARG 3.1-4 364.37 347.38 2,411.70 2,219.85 11426 EXCISE H-F-NECK-SP BENIGN+MARG > 4 CM 516.41 494.20 3,188.13 2,934.54 11440 EXCISE FACE-MM BENIGN+MARG 0.5 < CM 211.84 200.73 301.83 277.83 11441 EXCISE FACE-MM BENIGN+MARG 0.6-1 CM 264.80 251.60 350.97 323.04 11442 EXCISE FACE-MM BENIGN+MARG 1.1-2 CM 298.23 283.53 388.41 357.51 11443 EXCISE FACE-MM BENIGN+MARG 2.1-3 CM 353.37 336.68 431.67 397.35 11444 EXCISE FACE-MM BENIGN+MARG 3.1-4 CM 442.21 422.12 1,132.98 1,042.83 11719 TRIM NAIL(S) 34.77 32.88 51.48 47.37 11720 DEBRIDE NAIL, 1-5 49.82 47.36 64.35 59.25 11721 DEBRIDE NAIL, 6 OR MORE 67.33 64.26 76.02 69.99 11730 REMOVE NAIL PLATE 151.98 144.74 121.44 111.78 11732 REMOVE NAIL PLATE, ADDED 68.85 65.77 76.02 69.99 11740 DRAIN BLOOD UNDER NAIL 75.08 71.04 57.72 53.13 11750 REMOVE NAIL BED 343.28 327.09 411.81 379.05 11752 REMOVE NAIL BED/FINGER TIP 494.47 471.49 582.60 536.25 11760 REPAIR NAIL BED 346.62 328.23 177.81 163.68 11762 RECONSTRUCT NAIL BED 429.68 409.09 531.12 488.88 11765 EXCISE NAIL FOLD, TOE 223.00 209.99 121.44 111.78 11900 INJECTION INTO SKIN LESIONS 90.58 86.02 121.44 111.78 11901 ADDED SKIN LESIONS INJECTION 113.27 108.02 121.44 111.78 11950 THERAPY FOR CONTOUR DEFECTS 113.05 107.85 131.01 120.60 11951 THERAPY FOR CONTOUR DEFECTS 160.21 153.19 175.47 161.52 11960 INSERT TISSUE EXPANDER(S) 1,436.90 1,374.88 2,972.49 2,736.03 11981 INSERT DRUG IMPLANT DEVICE 216.27 206.20 89.55 82.44 X 11982 REMOVE DRUG IMPLANT DEVICE 240.23 229.28 89.55 82.44 X 12001 REPAIR SUPERFICIAL WOUND(S) 156.46 148.50 177.81 163.68 12002 REPAIR SUPERFICIAL WOUND(S) 182.44 173.64 177.81 163.68 12004 REPAIR SUPERFICIAL WOUND(S) 215.99 205.84 177.81 163.68 12005 REPAIR SUPERFICIAL WOUND(S) 277.27 264.61 177.81 163.68 12006 REPAIR SUPERFICIAL WOUND(S) 334.76 319.54 177.81 163.68 12011 REPAIR SUPERFICIAL WOUND(S) 187.04 177.76 177.81 163.68 12013 REPAIR SUPERFICIAL WOUND(S) 200.42 190.64 177.81 163.68 12014 REPAIR SUPERFICIAL WOUND(S) 236.44 225.30 177.81 163.68 12015 REPAIR SUPERFICIAL WOUND(S) 289.42 275.96 177.81 163.68 12016 REPAIR SUPERFICIAL WOUND(S) 360.23 344.19 177.81 163.68 12017 REPAIR SUPERFICIAL WOUND(S) 268.51 260.21 177.81 163.68 12018 REPAIR SUPERFICIAL WOUND(S) 319.54 309.13 177.81 1 63.68 12020 CLOSE SPLIT WOUND 431.60 410.59 619.29 570.03 12021 CLOSE SPLIT WOUND 254.10 242.74 421.80 388.26 12031 INTERMED WOUND REPAIR S/TRT/EXT 392.46 372.69 177.81 163.68 12032 INTERMED WOUND REPAIR S/TRT/EXT 496.44 470.58 421.80 388.26 12034 INTERMED WOUND REPAIR S/TRT/EXT 491.15 467.17 177.81 163.68 12035 INTERMED WOUND REPAIR S/TRT/EXT 596.60 567.24 177.81 163.68 12036 INTERMED WOUND REPAIR S/TRT/EXT 649.31 618.41 421.80 388.26 12037 INTERMED WOUND REPAIR S/TRT/EXT 726.61 692.45 421.80 388.26 12041 INTERMED WOUND REPAIR N-HF/GENITAL 408.73 388.48 177.81 163.68 12042 INTERMED WOUND REPAIR N-HG/GENITAL 468.02 444.84 177.81 163.68 12044 INTERMED WOUND REPAIR

11:3-29.6 APPENDIX B - REGULATIONS N-HG/GENITAL 555.19 527.51 177.81 163.68 12045 INTERMED WOUND REPAIR N-HG/GENITAL 592.76 564.13 421.80 388.26 12046 INTERMED WOUND REPAIR N-HG/GENITAL 703.34 669.51 421.80 388.26 12047 INTERMED WOUND REPAIR N-HG/GENITAL 763.38 726.74 421.80 388.26 12051 INTERMED WOUND REPAIR FACE/MM 432.90 411.35 421.80 388.26 12052 INTERMED WOUND REPAIR FACE/MM 494.15 469.44 177.81 163.68 12053 INTERMED WOUND REPAIR FACE/MM 545.55 518.41 177.81 163.68 12054 INTERMED WOUND REPAIR FACE/MM 577.47 549.29 177.81 163.68 12055 INTERMED WOUND REPAIR FACE/MM 691.03 658.09 421.80 388.26 12056 INTERMED WOUND REPAIR FACE/MM 826.26 786.00 421.80 388.26 12057 INTERMED WOUND REPAIR FACE/MM 942.59 896.60 421.80 388.26 13100 REPAIR WOUND OR LESION 503.63 479.30 619.29 570.03 13101 REPAIR WOUND OR LESION 640.87 609.63 619.29 570.03 13102 REPAIR WOUND/LESION, ADDED 172.70 164.94 619.29 570.03 13120 REPAIR WOUND OR LESION 523.71 498.53 421.80 388.26 13121 REPAIR WOUND OR LESION 714.49 679.65 421.80 388.26 13122 REPAIR WOUND/LESION, ADDED 190.24 181.88 177.81 163.68 13131 REPAIR WOUND OR LESION 577.33 549.97 421.80 388.26 13132 REPAIR WOUND OR LESION 932.23 889.11 619.29 570.03 13133 REPAIR WOUND/LESION, ADDED 267.99 256.52 421.80 388.26 13150 REPAIR WOUND OR LESION 573.56 546.58 619.29 570.03 13151 REPAIR WOUND OR LESION 652.83 622.29 619.29 570.03 13152 REPAIR WOUND OR LESION 901.38 859.71 619.29 570.03 13153 REPAIR WOUND/LESION, ADDED 294.26 281.64 421.80 388.26 13160 LATE CLOSE WOUND 1,274.88 1,226.45 2,972.49 2,736.03 14000 SKIN TISSUE REARRANGEMENT 1,001.58 953.82 2,296.11 2,113.44 14001 SKIN TISSUE REARRANGEMENT 1,289.02 1,229.26 2,296.11 2,113.44 14020 SKIN TISSUE REARRANGEMENT 1,124.57 1,070.90 2,296.11 2,113.44 14021 SKIN TISSUE REARRANGEMENT 1,408.28 1,342.85 2,296.11 2,113.44 14040 SKIN TISSUE REARRANGEMENT 1,235.25 1,177.91 2,296.11 2,113.44 14041 SKIN TISSUE REARRANGEMENT 1,529.97 1,459.32 2,296.11 2,113.44 14060 SKIN TISSUE REARRANGEMENT 1,251.46 1,194.92 2,296.11 2,113.44 14061 SKIN TISSUE REARRANGEMENT 1,643.34 1,566.97 2,296.11 2,113.44 14301 SKIN TISSUE REARRANGEMENT 1,770.48 1,689.95 2,972.49 2,736.03 14302 SKIN TISSUE REARRANGE ADDED 369.95 356.41 2,972.49 2,736.03 15002 WOUND PREP, TRUNK/ARM/LEG 538.12 513.17 619.29 570.03 15003 WOUND PREP, ADDED 100 CM 117.04 111.70 619.29 570.03 15004 WOUND PREP, F/N/HF/G 631.19 602.33 619.29 570.03 15005 WOUND PREP, F/N/HF/G, ADDED CM 191.65 183.76 619.29 570.03 15050 SKIN PINCH GRAFT 898.35 854.77 619.29 570.03 15100 SKIN SPLIT GRAFT, TRUNK/ARM/LEG 1,374.74 1,313.41 2,972.49 2,736.03 15101 SKIN SPLIT GRAFT T/A/L, ADDED 300.62 285.81 2,972.49 2,736.03 15120 SKIN SPLIT A-GRAFT FAC/NEC/HF/G 1,518.58 1,450.58 2,972.49 2,736.03 15121 SKIN SPLIT A-GRAFT F/N/HF/G ADDED 428.19 407.69 2,972.49 2,736.03 15130 DERM AUTOGRAFT, TRUNK/ARM/LEG 1,077.48 1,028.66 2,296.11 2,113.44 15170 ACELLULAR GRAFT TRUNK/ARMS/LEGS 684.41 656.88 619.29 570.03 15171 ACELLULAR GRAFT T/ARM/LEG, ADDED 147.18 142.17 421.80 388.26 15175 ACELLULAR GRAFT, F/N/HF/G 810.60 779.34 619.29 570.03 15220 SKIN FULL GRAFT SCALP/ARM/LEG1,237.46 1,178.97 2,296.11 2,113.44 15221 SKIN FULL GRAFT, ADDED 222.58 211.34 619.29 570.03 15240 SKIN FULL GRAFT FACE/GENITAL/HF 1,491.27 1,422.47 2,296.11 2,113.44 15241 SKIN FULL GRAFT, ADDED 297.89 283.58 619.29 570.03 15260 SKIN FULL GRAFT EEN & LIPS 1,614.97 1,541.12 2,296.11 2,113.44 15330 APPLY ACELLULAR ALLOGRAFT T/ARM/LEG 513.93 491.81 619.29 570.03

MEDICAL FEE SCHEDULES 11:3-29.6 15331 APPLY ACELLULAR GRAFT T/A/L, ADDED 100.16 96.58 619.29 570.03 15340 APPLY CULT SKIN SUBSTITUTE 497.48 475.21 421.80 388.26 15341 APPLY CULT SKIN SUB, ADDED 75.02 71.44 421.80 388.26 15365 APPLY CULT DERM SUB F/N/HF/G 542.33 517.83 421.80 388.26 15366 APPLY CULT DERM F/KF/G ADDED 126.15 121.79 421.80 388.26 15430 APPLY ACELLULAR XENOGRAFT 861.84 822.78 619.29 570.03 15431 APPLY ACELLULAR XENOGRAFT ADDED 328.03 316.57 619.29 570.03 15570 FORM SKIN PEDICLE FLAP 1,424.66 1,361.15 2,972.49 2,736.03 15572 FORM SKIN PEDICLE FLAP 1,388.47 1,326.28 2,972.49 2,736.03 15574 FORM SKIN PEDICLE FLAP 1,451.66 1,386.66 2,972.49 2,736.03 15576 FORM SKIN PEDICLE FLAP 1,291.01 1,232.56 2,972.49 2,736.03 15620 SKIN GRAFT 709.40 673.04 2,972.49 2,736.03 15732 MUSCLE-SKIN GRAFT, HEAD/NECK 2,390.54 2,290.95 2,972.49 2,736.03 15734 MUSCLE-SKIN GRAFT, TRUNK 2,429.96 2,329.20 2,972.49 2,736.03 15736 MUSCLE-SKIN GRAFT, ARM 2,142.30 2,051.77 2,972.49 2,736.03 15738 MUSCLE-SKIN GRAFT, LEG 2,272.44 2,179.61 2,972.49 2,736.03 15756 FREE MYO/SKIN FLAP MICROVASC 3,749.52 3,610.13 15770 DERMA-FAT-FASCIA GRAFT 1,066.42 1,022.37 2,972.49 2,736.03 15780 ABRASION TREAT SKIN 1,322.37 1,259.08 1,641.36 1,510.80 15781 ABRASION TREAT SKIN 879.47 835.31 678.84 624.84 15782 ABRASION TREAT SKIN 900.92 853.46 678.84 624.84 15786 ABRASION, LESION, SING 391.74 371.66 121.44 111.78 15787 ABRASION, LESIONS, ADDED 78.22 7 3.91 119.34 109.86 15823 REVISE UPPER EYELID 979.35 934.65 2,972.49 2,736.03 15830 EXCISE SKIN ABD 979.35 934.65 3,188.13 2,934.54 15832 EXCISE EXCESSIVE SKIN TISSUE 979.35 934.65 3,188.13 2,934.54 15851 REMOVE SUTURES 152.95 145.19 207.09 190.59 15852 DRESSING CHANGE NOT FOR BURN 73.04 70.73 89.55 82.44 X 15940 REMOVE HIP PRESSURE SORE 1,088.76 1,047.78 3,188.13 2,934.54 15941 REMOVE HIP PRESSURE SORE 1,419.04 1,362.70 3,188.13 2,934.54 15944 REMOVE HIP PRESSURE SORE 1,410.54 1,354.92 2,972.49 2,736.03 15945 REMOVE HIP PRESSURE SORE 1,566.36 1,504.31 2,972.49 2,736.03 15946 REMOVE HIP PRESSURE SORE 2,593.22 2,494.79 2,972.49 2,736.03 15950 REMOVE THIGH PRESSURE SORE 898.37 863.19 3,188.13 2,934.54 15951 REMOVE THIGH PRESSURE SORE 1,357.84 1,302.86 3,188.13 2,934.54 15952 REMOVE THIGH PRESSURE SORE 1,316.96 1,267.76 2,296.11 2,113.44 15953 REMOVE THIGH PRESSURE SORE 1,445.87 1,391.23 2,296.11 2,113.44 15956 REMOVE THIGH PRESSURE SORE 1,823.53 1,754.01 2,296.11 2,113.44 15958 REMOVE THIGH PRESSURE SORE 1,864.20 1,791.74 2,296.11 2,113.44 16000 INITIAL TREAT BURN(S) 107.89 103.23 113.49 104.46 16020 DRESS/DEBRIDE P-THICK BURN, S 132.50 125.94 173.16 159.39 16025 DRESS/DEBRIDE P-THICK BURN, M 234.02 223.91 199.77 183.90 16030 DRESS/DEBRIDE P-THICK BURN, L 282.60 269.99 199.77 183.90 17000 DESTROY PREMALIG LESION 130.90 123.98 121.44 111.78 17003 DESTROY PREMALIG LES, 2-14 11.64 11.07 15.21 14.01 17004 DESTROY PREMALIG LESIONS 15+ 279.11 265.83 343.95 316.59 17106 DESTROY SKIN LESIONS 550.21 524.12 364.44 335.43 17107 DESTROY SKIN LESIONS 713.68 679.99 364.44 335.43 17108 DESTROY SKIN LESIONS 1,013.03 967.87 364.44 335.43 17110 DESTROY B9 LESION, 1-14 180.01 169.92 121.44 111.78 17111 DSTRJ B9 SK TGS/CUTAN VASC 15/> 213.26 201.74 199.77 183.90 17250 CHEM CAUT GRANLTJ TISS PROUD 123.93 117.07 190.68 175.53 FLESH SINUS/FSTL 17261 DESTROY SKIN LESIONS 32.56 220.55 199.77 183.90 17262 DESTROY SKIN LESIONS 281.00 266.92 199.77 183.90 19000 DRAIN BREAST LESION 179.37 169.75 263.25 242.31 19120 REMOVE BREAST LESION 750.90 719.29 3,413.91 3,142.35 19125 EXCISE BREAST LESION 832.58 797.97 3,413.91 3,142.35 19290 PLACE NEEDLE WIRE, BREAST 262.84 248.72 X, N1 20100 EXPLORE WOUND, NECK 927.38 897.30 20101 EXPLORE WOUND, CHEST 648.74 615.47 20102 EXPLORE WOUND, ABDOMEN 764.14 725.33 20103 EXPLORE WOUND, EXTREMITY 914.65 8 69.73 1,735.95 1,597.86 20520 REMOVE FOREIGN BODY 311.74 296.49 401.28 369.36 20525 REMOVE FOREIGN BODY 763.77 723.36 3,188.13 2,934.54 20526 THERAPEUTIC INJECTION, CARP TUNNEL 118.45 113.27 127.50 117.36 20550 INJECT TENDON SHEATH/LIGAMENT 89.97 86.03 95.94 88.29 20551 INJECT TENDON ORIGIN/INSERT 91.72 87.67 99.45 91.53 20552 INJECT TRIGGER POINT, 1/2 MUSCLE 129.69 123.83 94.77 87.21

11:3-29.6 APPENDIX B - REGULATIONS 20553 INJECT TRIGGER POINTS, =/> 3 256.49 244.86 107.64 99.06 20600 DRAIN/INJ, JOINTBURSA 85.46 81.58 97.11 89.37 20605 DRAIN/INJ, JOINTBURSA 93.41 89.07 109.98 101.22 20610 DRAIN/INJ, JOINTBURSA 168.19 160.06 157.95 145.38 20612 ASPIRATE/INJECT GANGLION CYST 92.67 88.43 106.47 98.01 20615 TREAT BONE CYST 347.60 330.96 430.50 396.27 20650 INSERT & REMOVE BONE PIN 313.04 298.60 3,064.83 2,821.05 20662 APPLY PELVIS BRACE 680.98 652.96 3,064.83 2,821.05 20663 APPLY THIGH BRACE 724.98 694.28 3,064.83 2,821.05 20665 REMOVE FIXATION DEVICE 89.55 82.44 X 20670 REMOVE SUPPORT IMPLANT 2,411.70 2,219.85 20680 REMOVE SUPPORT IMPLANT 976.54 929.22 3,188.13 2,934.54 20690 APPLY BONE FIXATION DEVICE 2,428.13 2,338.02 4,301.40 3,959.25 20692 APPLY BONE FIXATION DEVICE 4,571.37 4,397.67 4,301.40 3,959.25 20693 ADJUST BONE FIXATION DEVICE 1,941.73 1,861.31 3,064.83 2,821.05 20694 REMOVE BONE FIXATION DEVICE 1,824.61 1,737.34 3,064.83 2,821.05 20696 COMP MULTIPLANE EXT FIXATION 4,555.72 4,376.97 4,301.40 3,959.25 20697 COMP EXT FIXATE STRUT CHANGE 7,725.55 7,206.79 2,779.53 2,558.43 20900 REMOVE BONE FOR GRAFT 673.98 637.99 4,301.40 3,959.25 20902 REMOVE BONE FOR GRAFT 519.31 498.66 4,301.40 3,959.25 20910 REMOVE CARTILAGE FOR GRAFT 1,037.67 992.57 2,972.49 2,736.03 20912 REMOVE CARTILAGE FOR GRAFT 1,198.06 1,147.49 2,972.49 2,736.03 20920 REMOVE FASCIA FOR GRAFT 985.25 943.49 2,296.11 2,113.44 20922 REMOVE FASCIA FOR GRAFT 1,471.19 1,405.30 2,296.11 2,113.44 20924 REMOVE TENDON FOR GRAFT 800.25 767.01 4,301.40 3,959.25 20926 REMOVE TISSUE FOR GRAFT 692.39 664.11 619.29 570.03 20931 SP BONE ALLOGRAFT STRUCT, ADDED 480.89 465.78 20950 FLUID PRESSURE, MUSCLE 1,090.10 1,027.35 198.84 183.03 20955 FIBULA BONE GRAFT, MICROVASC10,896.00 10,491.67 20974 ELECTRICAL BONE STIMULATION 388.51 369.13 20975 ELECTRICAL BONE STIMULATION 968.04 932.18 X, N1 20979 US BONE STIMULATION 288.61 275.42 89.55 82.44 X 20985 COMPUTER-ASSIST DIR MS PX 233.28 225.44 X, N1 21060 REMOVE JAW JOINT CARTILAGE 1,303.59 1,251.23 5,961.75 5,487.51 21070 REMOVE CORONOID PROCESS 2,683.05 2,569.88 5,961.75 5,487.51 21073 MANIPULATE TMJ W/ANESTH 625.03 593.86 832.95 766.71 21085 PREPARE FACE/ORAL PROSTHESIS 1,453.19 1,375.54 1,265.82 1,165.11 21110 INTERDENTAL FIXATION 1,453.19 1,375.54 1,056.45 972.42 X, N1 21116 INJECTION, JAW JOINT X-RAY 242.27 228.15 21209 REDUCE FACIAL BONES 1,356.76 1,290.12 5,961.75 5,487.51 21210 FACE BONE GRAFT 3,584.38 3,377.47 5,961.75 5,487.51 21240 RECONSTRUCT JAW JOINT 3,361.24 3,224.68 5,961.75 5,487.51 21242 RECONSTRUCT JAW JOINT 3,085.47 2,959.40 5,961.75 5,487.51 21243 RECONSTRUCT JAW JOINT 5,070.37 4,866.28 5,961.75 5,487.51 21244 RECONSTRUCT LOWER JAW 1,701.06 1,626.83 5,961.75 5,487.51 21245 RECONSTRUCT JAW 1,819.98 1,735.61 5,961.75 5,487.51 21246 RECONSTRUCT JAW 1,327.80 1,275.95 5,961.75 5,487.51 21247 RECONSTRUCT LOWER JAW BONE 2,579.70 2,482.80 5,961.75 5,487.51 21248 RECONSTRUCT JAW 1,730.48 1,651.07 5,961.75 5,487.51 21249 RECONSTRUCT JAW 2,370.58 2,265.59 5,961.75 5,487.51 21310 TREAT NOSE FX 185.45 174.76 151.17 139.14 21315 TREAT NOSE FX 443.93 419.60 2,313.03 2,129.04 21320 TREAT NOSE FX 417.47 394.98 2,313.03 2,129.04 21325 TREAT NOSE FX 772.19 732.88 3,421.41 3,149.25 21330 TREAT NOSE FX 926.89 881.33 3,421.41 3,149.25 21335 TREAT NOSE FX 1,181.49 1,128.42 3,421.41 3,149.25 21356 TREAT CHEEK BONE FX 2,159.27 2,052.68 3,421.41 3,149.25 21360 TREAT CHEEK BONE FX 2,285.49 2,187.85 3,421.41 3,149.25 21365 TREAT CHEEK BONE FX 4,774.53 4,590.46 21366 TREAT CHEEK BONE FX 5,417.56 5,210.50 21385 TREAT EYE SOCKET FX 3,005.24 2,877.79 21386 TREAT EYE SOCKET FX 2,849.94 2,739.14 21390 TREAT EYE SOCKET FX 3,399.51 3,262.80 5,961.75 5,487.51 21395 TREAT EYE SOCKET FX 4,165.36 3,999.96 21400 TREAT EYE SOCKET FX 807.13 765.31 1,056.45 972.42 21401 TREAT EYE SOCKET FX 2,088.19 1,978.92 2,313.03 2,129.04 21406 TREAT EYE SOCKET FX 2,367.98 2,266.67 5,961.75 5,487.51 21407 TREAT EYE SOCKET FX 2,782.80 2,670.16 5,961.75 5,487.51 21408 TREAT EYE SOCKET FX 3,870.37 3,718.17 21450 TREAT LOWER JAW FX 954.01 901.26 474.09 436.38 21451 TREAT LOWER JAW FX 1,231.95 1,165.53 1,056.45 972.42

MEDICAL FEE SCHEDULES 11:3-29.6 21452 TREAT LOWER JAW FX 969.53 911.95 2,313.03 2,129.04 21453 TREAT LOWER JAW FX 1,437.35 1,360.70 5,961.75 5,487.51 21454 TREAT LOWER JAW FX 889.43 850.92 3,421.41 3,149.25 21461 TREAT LOWER JAW FX 3,370.55 3,171.80 5,961.75 5,487.51 21462 TREAT LOWER JAW FX 3,567.33 3,359.58 5,961.75 5,487.51 21465 TREAT LOWER JAW FX 1,514.36 1,453.74 5,961.75 5,487.51 21470 TREAT LOWER JAW FX 1,919.57 1,843.61 21800 TREAT RIB FX 164.26 156.32 210.60 193.83 21820 TREAT STERNUM FX 217.62 207.24 210.60 193.83 21825 TREAT STERNUM FX 900.11 864.97 22305 TREAT SPINE PROCESS FX 210.60 193.83 22310 TREAT SPINE FX 734.37 675.96 22315 TREAT SPINE FX 3,738.68 3,578.03 2,779.53 2,558.43 22505 MANIPULATE SPINE 214.24 206.29 2,074.56 1,909.53 22520 PERCUT VERTEBROPLASTY THORACIC 4,301.40 3,959.25 22521 PERCUT VERTEBROPLASTY LUMBAR 4,301.40 3,959.25 22522 PERCUT VERTEBROPLASTY ADDED 4,301.40 3,959.25 22554 NECK SPINE FUSION 6,185.12 5,961.42 22585 ADDED SPINAL FUSION 1,650.20 1,597.95 22845 INSERT SPINE FIXATION DEVICE 4,518.17 4,376.06 22851 APPLY SPINE PROSTH DEVICE 2,507.61 2,427.54 23120 PARTIAL REMOVE COLLAR BONE 3,521.55 3,374.09 4,301.40 3,959.25 23125 REMOVE COLLAR BONE 4,270.68 4,099.77 4,301.40 3,959.25 23130 REMOVE SHOULDER BONE, PART 3,681.64 3,527.78 6,312.78 5,810.61 23331 REMOVE SHOULDER FOREIGN BODY 3,576.37 3,428.03 3,188.13 2,934.54 23332 REMOVE SHOULDER FOREIGN BODY 5,348.95 5,138.14 23350 INJECTION FOR SHOULDER X-RAY 245.78 232.06 X, N1 23405 TX SHO AREA 1 TDN 989.02 949.25 4,301.40 3,959.25 23406 TX SHO AREA MLT TDN THRU SM INC 1,228.87 1,180.78 4,301.40 3,959.25 23410 OPEN REPAIR OF ROTATOR CUFF, RECENT 3,500.51 3,361.17 6,312.78 5,810.61 23412 OPEN REPAIR OF ROTATOR CUFF, OLD 3,640.20 3,495.88 6,312.78 5,810.61 23415 CORACOACROMIAL LIGM RLS +-ACROMP 1,096.46 1,051.70 6,312.78 5,810.61 23420 RECONSTRUCTION ROTATOR CUFF, OLD 4,128.82 3,965.45 6,312.78 5,810.61 23430 TENODIS LONG TDN BICEPS 1,169.96 1,123.11 6,312.78 5,810.61 23440 RESCJ/TRNSPLJ LONG TDN BICEPS 1,192.02 1,145.18 6,312.78 5,810.61 23470 RECONSTRUCT SHOULDER JOINT 5,149.21 4,954.04 23472 RECONSTRUCT SHOULDER JOINT 6,369.05 6,131.80 23480 REVISE COLLAR BONE 3,481.15 3,344.49 6,312.78 5,810.61 23485 REVISE COLLAR BONE 4,080.99 3,923.94 11,871.09 10,926.78 23500 TREAT CLAVICLE FX 517.10 320.37 210.60 193.83 23505 TREAT CLAVICLE FX 836.78 519.25 2,779.53 2,558.43 23515 TREAT CLAVICLE FX 2,182.75 2,094.37 8,925.39 8,215.41 23520 TREAT CLAVICLE DISLOCATION 543.64 518.10 734.37 675.96 23525 TREAT CLAVICLE DISLOCATION 889.99 848.39 734.37 675.96 23530 TREAT CLAVICLE DISLOCATION 1,683.11 1,615.14 6,420.90 5,910.15 23540 TREAT CLAVICLE DISLOCATION 526.02 501.82 210.60 193.83 23545 TREAT CLAVICLE DISLOCATION 963.58 919.00 734.37 675.96 23550 TREAT CLAVICLE DISLOCATION 1,729.78 1,659.14 6,420.90 5,910.15 23552 TREAT CLAVICLE DISLOCATION 1,992.63 1,911.66 6,420.90 5,910.15 23570 TREAT SHOULDER BLADE FX 550.00 524.31 210.60 193.83 23600 TREAT HUMERUS FX 774.56 479.33 210.60 193.83 23605 TREAT HUMERUS FX 1,118.44 693.94 2,779.53 2,558.43 23615 TREAT HUMERUS FX 3,210.58 1,336.23 8,925.39 8,215.41 23616 TREAT HUMERUS FX 4,569.61 1,904.53 8,925.39 8,215.41 23620 TREAT HUMERUS FX 640.51 609.71 210.60 193.83 23625 TREAT HUMERUS FX 910.15 868.61 2,779.53 2,558.43 23630 TREAT HUMERUS FX 2,340.39 2,246.76 8,925.39 8,215.41 23650 TREAT SHOULDER DISLOCATION 713.19 443.19 210.60 193.83 23655 TREAT SHOULDER DISLOCATION 941.00 585.27 2,074.56 1,909.53 23700 FIXATE SHOULDER 470.07 338.09 2,074.56 1,909.53 24220 INJECTION FOR ELBOW X-RAY 265.46 251.25 X, N1 24300 MANIPULATE ELBOW W/ANESTH 640.74 610.08 2,074.56 1,909.53 24305 ARM TENDON LENGTHENING 912.18 874.28 4,301.40 3,959.25 24340 REPAIR BICEPS TENDON 2,601.25 2,494.51 6,312.78 5,810.61 24341 REPAIR ARM TENDON/MUSCLE 3,143.66 3,012.32 6,312.78 5,810.61

11:3-29.6 APPENDIX B - REGULATIONS 24342 REPAIR RUPTURED TENDON 3,306.76 3,175.53 6,312.78 5,810.61 24343 REPAIR ELBOW LAT LIGAMENT W/TISS 2,987.14 2,862.45 4,301.40 3,959.25 24500 TREAT HUMERUS FX 549.29 522.97 210.60 193.83 24505 TREAT HUMERUS FX 780.56 744.97 210.60 193.83 24515 TREAT HUMERUS FX 1,381.32 1,326.32 8,925.39 8,215.41 24516 TREAT HUMERUS FX 1,358.43 1,305.28 8,925.39 8,215.41 24530 TREAT HUMERUS FX 588.23 560.15 210.60 193.83 24535 TREAT HUMERUS FX 965.43 922.74 734.37 675.96 24545 TREAT HUMERUS FX 1,456.68 1,399.91 8,925.39 8,215.41 24546 TREAT RUS FX 1,648.10 1,583.95 8,925.39 8,215.41 24560 TREAT HUMERUS FX 494.20 470.24 210.60 193.83 24565 TREAT HUMERUS FX 817.85 781.01 210.60 193.83 24575 TREAT RUS FX 1,155.33 1,108.02 8,925.39 8,215.41 24576 TREAT HUMERUS FX 524.86 499.14 210.60 193.83 24577 TREAT HUMERUS FX 846.15 808.13 210.60 193.83 24579 TREAT RUS FX 1,314.50 1,261.84 8,925.39 8,215.41 25000 INCISE TENDON SHEATH 547.09 521.24 3,064.83 2,821.05 25001 INCISE FLEXOR CARPI RADIALIS 536.36 511.94 3,064.83 2,821.05 25020 DECOMPRESS FOREARM 1 SPACE 1,767.91 1,684.75 4,301.40 3,959.25 25023 DECOMPRESS FOREARM 1 SPACE 3,363.81 3,221.26,301.40 3,959.25 25024 DECOMPRESS FOREARM 2 SPACES 2,353.42 2,260.29 4,301.40 3,959.25 25025 DECOMPRESS FOREARM 2 SPACES 3,669.10 3,530.71 4,301.40 3,959.25 25118 EXCISE WRIST TENDON SHEATH 607.03 580.07 4,301.40 3,959.25 25215 REMOVE WRIST BONES 1,898.51 1,818.66 4,301.40 3,959.25 25246 INJECTION FOR WRIST X-RAY 268.94 254.91 X, N1 25259 MANIPULATE WRIST W/ANESTH 644.82 613.89 2,779.53 2,558.43 25260 REPAIR FOREARM TENDON/MUSCLE2,008.73 1,921.52 4,301.40 3,959.25 25263 REPAIR FOREARM TENDON/MUSCLE1,999.71 1,913.76 4,301.40 3,959.25 25265 REPAIR FOREARM TENDON/MUSCLE2,368.51 2,270.10 4,301.40 3,959.25 25270 REPAIR FOREARM TENDON/MUSCLE1,592.68 1,522.50 4,301.40 3,959.25 25272 REPAIR FOREARM TENDON/MUSCLE1,784.09 1,706.99 4,301.40 3,959.25 25274 REPAIR FOREARM TENDON/MUSCLE2,130.04 2,040.87 4,301.40 3,959.25 25295 RELEASE WRIST/FOREARM TENDON 876.95 838.58 3,064.83 2,821.05 25500 TREAT FX RADIUS 413.29 393.45 210.60 193.83 25505 TREAT FX RADIUS 781.41 745.83 734.37 675.96 25515 TREAT FX RADIUS 1,050.48 1,007.25 6,420.90 5,910.15 25525 TREAT FX RADIUS 1,246.06 1,195.16 6,420.90 5,910.15 25526 TREAT FX RADIUS 1,533.29 1,471.52 6,420.90 5,910.15 25530 TREAT FX ULNA 402.85 382.70 210.60 193.83 25535 TREAT FX ULNA 760.01 725.62 210.60 193.83 25545 TREAT FX ULNA 981.64 940.37 6,420.90 5,910.15 25560 TREAT FX RADIUS & ULNA 808.02 769.13 210.60 193.83 25565 TREAT FX RADIUS & ULNA 1,566.66 1,496.29 734.37 675.96 25574 TREAT FX RADIUS & ULNA 2,025.40 1,942.13 8,925.39 8,215.41 25575 TREAT FX RADIUS/ULNA 2,717.76 2,608.67 8,925.39 8,215.41 25600 TREAT FX RADIUSIULNA 869.76 827.89 210.60 193.83 25605 TREAT FX RADIUS/ULNA 1,865.53 1,783.62 734.37 675.96 25606 TREAT FX DISTAL RADIAL 2,018.97 1,933.22 3,542.43 3,260.64 25607 TREAT FX RADIAL EXTRA-ARTICULAR 2,204.51 2,113.59 8,925.39 8,215.41 25608 TREAT FX RADIAL INTRA-ARTICULAR 2,472.05 2,371.92 8,925.39 8,215.41 25609 TREAT FX RADIAL 3+ FRAG 3,148.22 3,022.40 8,925.39 8,215.41 25622 TREAT WRIST BONE FX 900.97 857.05 210.60 193.83 25624 TREAT WRIST BONE FX 1,384.38 1,319.72 734.37 675.96 25628 TREAT WRIST BONE FX 2,177.02 2,087.90 6,420.90 5,910.15 25630 TREAT WRIST BONE FX 909.36 866.26 210.60 193.83 25635 TREAT WRIST BONE FX 1,342.79 1,280.29 210.60 193.83 25645 TREAT WRIST BONE FX 1,718.80 1,648.07 6,420.90 5,910.15 25650 TREAT WRIST BONE FX 953.03 908.21 210.60 193.83 25652 TREAT FX ULNAR STYLOID 1,879.79 1,801.28 6,420.90 5,910.15 25670 TREAT FX ULNAR STYLOID 1,831.97 1,757.00 3,542.43 3,260.64 25671 TREAT FX ULNAR STYLOID 1,598.39 1,529.90 3,542.43 3,260.64 25676 TREAT WRIST DISLOCATION 1,911.46 1,832.38 3,542.43 3,260.64 25680 TREAT WRIST FX 1,383.37 1,326.99 210.60 193.83 25685 TREAT WRIST FX 2,218.61 2,130.23 3,542.43 3,260.64 26055 INCISE FINGER TENDON SHEATH 910.15 858.58 2,289.75 2,107.62 26116 EXCISE HAND TUMOR DEEP < 1.5 CM 1,590.71 1,523.59 2,411.70 2,219.85 26140 REVISE FINGER JOINT, EACH 1,527.77 1,462.59 2,289.75 2,107.62 26145 TENDON EXCISE PALM/FINGER 2,479.64 2,374.52 2,289.75 2,107.62

MEDICAL FEE SCHEDULES 11:3-29.6 26340 MANIPULATE FINGER W/ANESTH 521.42 495.05 734.37 675.96 26410 REPAIR HAND TENDON 1,739.49 1,650.91 2,289.75 2,107.62 26418 REPAIR FINGER TENDON 2,125.52 2,014.58 2,289.75 2,107.62 26445 RELEASE HAND/FINGER TENDON 1,786.60 1,692.75 2,289.75 2,107.62 26480 TRANSPLANT HAND TENDON 2,307.21 2,192.78 3,971.19 3,655.32 26525 RELEASE FINGER CONTRACTURE 2,010.20 1,907.42 2,289.75 2,107.62 26540 REPAIR HAND JOINT 2,010.67 1,914.55 2,289.75 2,107.62 26600 TREAT METACARPAL FX 447.47 425.44 210.60 193.83 26605 TREAT METACARPAL FX 499.07 474.91 210.60 193.83 26607 TREAT METACARPAL FX 702.97 672.84 2,779.53 2,558.43 26608 TREAT METACARPAL FX 1,155.32 1,104.12 3,542.43 3,260.64 26615 TREAT METACARPAL FX 1,371.83 1,313.19 6,420.90 5,910.15 26720 TREAT FINGER FX, EACH 303.29 288.37 210.60 193.83 26725 TREAT FINGER FX, EACH 526.64 502.01 210.60 193.83 26727 TREAT FINGER FX, EACH 739.96 706.95 3,542.43 3,260.64 26735 TREAT FINGER FX, EACH 925.25 886.02 3,542.43 3,260.64 26740 TREAT FINGER FX, EACH 352.67 335.26 210.60 193.83 26742 TREAT FINGER FX, EACH 571.25 545.14 210.60 193.83 26746 TREAT FINGER FX, EACH 1,143.63 1,096.98 3,542.43 3,260.64 26750 TREAT FINGER FX, EACH 280.86 267.55 210.60 193.83 26755 TREAT FINGER FX, EACH 484.57 461.98 210.60 193.83 27036 EXCISE HIP JOINT/MUSCLE 3,050.71 2,932.10 27093 INJECTION FOR HIP X-RAY 313.73 296.32 X, N1 27095 INJECTION FOR HIP X-RAY 384.77 363.23 X, N1 27096 INJECT SACROILIAC JOINT 586.47 554.47 1,012.32 931.80 27130 TOTAL HIP ARTHROPLASTY 5,258.22 5,062.44 27132 TOTAL HIP ARTHROPLASTY 6,133.86 5,907.48 27193 TREAT PELVIC RING FX 1,417.56 1,359.02 210.60 193.83 27194 TREAT PELVIC RING FX 2,095.30 2,013.65 2,074.56 1,909.53 27227 TREAT HIP FX(S) 5,066.90 4,879.61 27228 TREAT HIP FX(S) 5,779.51 5,567.94 27236 TREAT THIGH FX 3,627.64 3,490.04 27245 TREAT THIGH FX 3,775.02 3,630.86 27275 MANIPULATE HIP JOINT 323.19 309.59 2,074.56 1,909.53 27403 REPAIR KNEE CARTILAGE 3,103.82 2,978.06 4,301.40 3,959.25 27405 REPAIR KNEE LIGAMENT 3,282.44 3,149.55 6,312.78 5,810.61 27420 REVISE UNSTABLE KNEECAP 2,261.71 2,171.44 6,312.78 5,810.61 27422 REVISE UNSTABLE KNEECAP 2,252.47 2,162.50 6,312.78 5,810.61 27424 REVISION/REMOVE KNEECAP 2,255.28 2,165.35 6,312.78 5,810.61 27447 TOTAL KNEE ARTHROPLASTY 4,684.46 4,509.75 27487 REVISE/REPLACE KNEE JOINT 4,295.95 4,137.99 27500 TREAT THIGH FX 2,180.66 2,087.12 34.37 675.96 27501 TREAT THIGH FX 2,131.34 2,042.54 210.60 193.83 27502 TREAT THIGH FX 3,311.93 3,184.79 2,779.53 2,558.43 27503 TREAT THIGH FX 3,407.62 3,273.56 210.60 193.83 27506 TREAT THIGH FX 5,689.32 5,472.85 27507 TREAT THIGH FX 4,156.52 3,999.46 27508 TREAT THIGH FX 2,209.66 2,113.32 210.60 193.83 27509 TREAT THIGH FX 2,744.11 2,628.26 3,542.43 3,260.64 27510 TREAT THIGH FX 2,936.26 2,821.17 734.37 675.96 27511 TREAT THIGH FX 4,295.44 4,134.33 27513 TREAT THIGH FX 5,359.94 5,162.29 27514 TREAT THIGH FX 4,219.76 4,059.34 27520 TREAT KNEECAP FX 1,349.20 1,284.12 210.60 193.83 27524 TREAT KNEECAP FX 3,198.15 3,070.62 27530 TREAT KNEE FX 1,671.35 1,593.30 210.60 193.83 27532 TREAT KNEE FX 2,604.20 2,492.86 2,779.53 2,558.43 27535 TREAT KNEE FX 3,857.40 3,711.25 27536 TREAT KNEE FX 5,066.57 4,872.90 27538 TREAT KNEE FX(S) 1,987.87 1,897.12 210.60 193.83 27540 TREAT KNEE FX 3,478.82 3,340.36 27570 FIXATE KNEE JOINT 235.46 225.20 2,074.56 1,909.53 27685 REVISE LOWER LEG TENDON 2,767.45 2,634.16 4,301.40 3,959.25 27686 REVISE LOWER LEG TENDONS 2,372.88 2,276.62 4,301.40 3,959.25 27690 REVISE LOWER LEG TENDON 2,704.36 2,595.44 6,312.78 5,810.61 27691 REVISE LOWER LEG TENDON 3,202.39 3,073.42 6,312.78 5,810.61 27692 REVISE ADDEDITIONAL LEG TENDON461.41 445.92 6,312.78 5,810.61 27695 REPAIR ANKLE LIGAMENT 1,477.41 1,416.90 4,301.40 3,959.25 27696 REPAIR ANKLE LIGAMENTS 1,723.72 1,656.05 4,301.40 3,959.25 27698 REPAIR ANKLE LIGAMENT 1,965.63 1,888.89 4,301.40 3,959.25 27750 TREAT TIBIA FX 1,446.76 1,377.78 210.60 193.83 27752 TREAT TIBIA FX 2,273.94 2,173.81 2,779.53 2,558.43

11:3-29.6 APPENDIX B - REGULATIONS 27758 TREAT TIBIA FX 3,785.47 3,636.72 6,420.90 5,910.15 27759 TREAT TIBIA FX 4,257.79 4,093.54 8,925.39 8,215.41 27760 CLOSED TREAT MEDIAL ANKLE FX 999.35 951.28 210.60 193.83 27762 CLOSED TREAT MED ANKLE FX W/MANIP 1,452.26 1,387.19 2,779.53 2,558.43 27766 OPEN TREAT MEDIAL ANKLE FX 1,856.02 1,778.54 6,420.90 5,910.15 27786 TREAT ANKLE FX 491.69 467.93 210.60 193.83 27788 TREAT ANKLE FX 662.30 632.08 210.60 193.83 27792 TREAT ANKLE FX 1,121.80 1,076.61 6,420.90 5,910.15 27808 TREAT ANKLE FX 518.87 493.37 210.60 193.83 27810 TREAT ANKLE FX 739.42 706.28 210.60 193.83 27814 TREAT ANKLE FX 1,223.81 1,174.68 6,420.90 5,910.15 27816 TREAT ANKLE FX 491.32 467.71 210.60 193.83 27818 TREAT ANKLE FX 756.19 722.98 734.37 675.96 27822 TREAT ANKLE FX 1,342.67 1,287.42 6,420.90 5,910.15 27823 TREAT ANKLE FX 1,523.63 1,462.35 8,925.39 8,215.41 27824 TREAT LOWER LEG FX 936.08 892.85 210.60 193.83 27825 TREAT LOWER LEG FX 1,653.18 1,582.18 2,779.53 2,558.43 27826 TREAT LOWER LEG FX 2,537.97 2,434.01 6,420.90 5,910.15 27827 TREAT LOWER LEG FX 3,313.36 3,179.78 8,925.39 8,215.41 27828 TREAT LOWER LEG FX 3,955.96 3,800.93 8,925.39 8,215.41 27829 TREAT LOWER LEG JOINT 2,062.48 1,976.64 6,420.90 5,910.15 27840 TREAT ANKLE DISLOCATION 1,072.56 1,028.51 210.60 193.83 27842 TREAT ANKLE DISLOCATION 1,488.26 1,426.77 2,074.56 1,909.53 27846 TREAT ANKLE DISLOCATION 2,235.14 2,146.41 6,420.90 5,910.15 27848 TREAT ANKLE DISLOCATION 2,511.52 2,412.81 6,420.90 5,910.15 27860 FIXATE ANKLE JOINT 276.66 265.27 2,074.56 1,909.53 28120 PART REMOVE ANKLE/HEEL 1,107.25 1,057.06 3,014.25 2,774.49 28122 PARTIAL REMOVE FOOT BONE 1,028.92 981.54 3,014.25 2,774.49 28400 TREAT HEEL FX 389.18 369.98 210.60 193.83 28405 TREAT HEEL FX 613.23 585.90 2,779.53 2,558.43 28415 TREAT HEEL FX 1,782.79 1,712.47 8,925.39 8,215.41 28420 TREAT/GRAFT HEEL FX 2,997.32 2,880.42 6,420.90 5,910.15 28430 TREAT ANKLE FX 563.23 535.64 210.60 193.83 28435 TREAT ANKLE FX 827.86 789.27 210.60 193.83 28436 TREAT ANKLE FX 1,073.70 1,025.26 3,542.43 3,260.64 28445 TREAT ANKLE FX 2,583.35 2,483.99 6,420.90,910.15 28470 TREAT METATARSAL FX 511.87 486.88 210.60 193.83 28475 TREAT METATARSAL FX 622.83 594.36 210.60 193.83 28476 TREAT METATARSAL FX 843.05 802.80 3,542.43 3,260.64 28485 TREAT METATARSAL FX 1,291.11 1,237.46 6,420.90 5,910.15 28725 FUSE FOOT BONES 1,926.38 1,852.85 7,371.54 6,785.16 28730 FUSE FOOT BONES 2,050.42 1,969.71 7,371.54 6,785.16 28740 FUSE FOOT BONES 2,079.28 1,981.86 7,371.54 6,785.16 28750 FUSE BIG TOE JOINT 2,027.14 1,930.24 7,371.54 6,785.16 29065 APPLY LONG ARM CAST 149.13 141.80 194.19 178.74 X 29075 APPLY FOREARM CAST 139.52 132.52 187.17 172.29 X 29085 APPLY HANDIWRIST CAST 147.51 140.22 149.40 137.52 X 29086 APPLY FINGER CAST 117.72 111.61 149.40 137.52 X 29105 APPLY LONG ARM SPLINT 155.41 148.00 149.40 137.52 X 29125 APPLY FOREARM SPLINT 125.21 118.86 147.42 135.69 X 29126 APPLY FOREARM SPLINT 141.72 134.82 149.40 137.52 X 29130 APPLY FINGER SPLINT 72.44 69.28 67.86 62.46 X 29131 APPLY FINGER SPLINT 92.77 88.41 97.11 89.37 X 29200 STRAP CHEST 82.75 78.96 94.77 87.21 X 29240 STRAP SHOULDER 89.29 85.21 101.79 93.69 X 29260 STRAP ELBOW OR WRIST 80.59 76.70 100.62 92.61 X 29280 STRAP HAND OR FINGER 78.61 74.72 101.79 93.69 X 29345 APPLY LONG LEG CAST 212.03 202.15 255.03 234.75 X 29355 APPLY LONG LEG CAST 219.66 209.65 255.03 234.75 X 29365 APPLY LONG LEG CAST 191.79 182.59 240.99 221.82 X 29405 APPLY SHORT LEG CAST 138.97 132.16 178.98 164.73 X 29425 APPLY SHORT LEG CAST 147.75 140.72 181.32 166.89 X 29450 APPLY LEG CAST 226.46 217.10 149.40 137.52 X 29505 APPLY LONG LEG SPLINT 121.67 115.58 149.40 137.52 X 29515 APPLY LOWER LEG SPLINT 112.71 107.26 141.54 130.29 X 29520 STRAP HIP 77.82 74.05 97.11 89.37 X 29530 STRAP KNEE 81.60 77.69 100.62 92.61 X 29540 STRAP ANKLE AND/OR FT 53.90 51.17 72.54 66.78 X 29550 STRAP TOES 44.24 41.67 72.54 66.78 X 29580 APPLY PASTE BOOT 82.79 78.81 102.96 94.77 X 29581 APPLY MULTILAY COMPRESS LWR

MEDICAL FEE SCHEDULES 11:3-29.6 LEG 152.30 143.77 149.40 137.52 X 29590 APPLY FOOT SPLINT 82.51 79.00 83.04 76.44 X 29700 REMOVE/REVISE CAST 103.41 98.21 139.20 128.13 X 29705 REMOVE/REVISE CAST 104.21 99.48 119.34 109.86 X 29710 REMOVE/REVISE CAST 190.34 181.78 217.62 200.31 29740 WEDGE CAST 141.31 135.19 149.40 137.52 X 29800 JAW ARTHROSCOPY/SURG 2,870.02 2,751.17 3,997.71 3,679.71 29804 JAW ARTHROSCOPY/SURG 3,578.52 3,434.24 3,997.71 3,679.71 29805 SHOULDER ARTHROSCOPY, DIAG 2,575.75 2,467.98 3,997.71 3,679.71 29806 SHOULDER ARTHROSCOPY/SURG 5,808.16 5,582.08 6,462.39 5,948.34 29807 SHOULDER ARTHROSCOPY/SURG 5,671.51 5,449.31 6,462.39 5,948.34 29819 SHOULDER ARTHROSCOPY/SURG 3,210.18 3,078.79 6,462.39 5,948.34 29820 SHOULDER ARTHROSCOPY/SURG 2,953.64 2,833.12 6,462.39 5,948.34 29821 SHOULDER ARTHROSCOPY/SURG 3,233.10 3,101.41 6,462.39 5,948.34 29822 SHOULDER ARTHROSCOPY/SURG 3,144.95 3,016.12 3,997.71 3,679.71 29823 SHOULDER ARTHROSCOPY/SURG 3,430.85 3,290.80 6,462.39 5,948.34 29824 SHOULDER ARTHROSCOPY/SURG 3,689.94 3,539.41 3,997.71 3,679.71 29825 SHOULDER ARTHROSCOPY/SURG 3,202.11 3,071.26 6,462.39 5,948.34 29826 SHOULDER ARTHROSCOPY/SURG3,650,34 3,504.39 6,462.39 5,948.34 29827 ARTHROSCOPY ROTATOR CUFF REPAIR 4,596.05 4,418.87 6,462.39 5,948.34 29828 ARTHROSCOPY BICEPS TENODESIS3,899.18 3,748.17 6,462.39 5,948.34 29830 ELBOW ARTHROSCOPY 1,932.85 1,852.70 3,997.71 3,679.71 29834 ELBOW ARTHROSCOPY/SURG 2,095.15 2,008.15 3,997.71 3,679.71 29835 ELBOW ARTHROSCOPY/SURG 2,154.22 2,065.19 3,997.71 3,679.71 29837 ELBOW ARTHROSCOPY/SURG 2,251.82 2,159.47 3,997.71 3,679.71 29840 WRIST ARTHROSCOPY 1,918.73 1,837.85 3,997.71 3,679.71 29844 WRIST ARTHROSCOPY/SURG 2,115.96 2,027.77 3,997.71 3,679.71 29845 WRIST ARTHROSCOPY/SURG 2,440.18 2,339.75 3,997.7 3,679.71 29846 WRIST ARTHROSCOPY/SURG 2,218.96 2,126.68 3,997.71 3,679.71 29847 WRIST ARTHROSCOPY/SURG 2,310.86 2,216.47 6,462.39 5,948.34 29848 WRIST ENDOSCOPY/SURG 2,159.31 2,067.30 3,997.71 3,679.71 29850 KNEE ARTHROSCOPY/SURG 2,540.30 2,439.30 3,997.71 3,679.71 29855 TIBIAL ARTHROSCOPY/SURG 3,347.13 3,213.03 6,462.39 5,948.34 29860 HIP ARTHROSCOPY, DIAG 2,809.81 2,697.02 6,462.39 5,948.34 29861 HIP ARTHROSCOPY/SURG 3,088.61 2,966.10 6,462.39 5,948.34 29862 HIP ARTHROSCOPY/SURG 3,469.37 3,330.41 6,462.39 5,948.34 29863 HIP ARTHROSCOPY/SURG 3,458.24 3,320.12 6,462.39 5,948.34 29870 KNEE ARTHROSCOPY, DIAG 2,543.44 2,416.34 3,997.71 3,679.71 29871 KNEE ARTHROSCOPY/DRAIN 2,182.27 2,092.01 3,997.71 3,679.71 29873 KNEE ARTHROSCOPY/SURG 2,221.06 2,124.42 3,997.71 3,679.71 29874 KNEE ARTHROSCOPY/SURG 2,291.42 2,197.95 3,997.71 3,679.71 29875 KNEE ARTHROSCOPY/SURG 2,712.06 2,599.81 3,997.71 3,679.71 29876 KNEE ARTHROSCOPY/SURG 3,584.57 3,439.85 3,997.71 3,679.71 29879 KNEE ARTHROSCOPY/SURG 2,818.03 2,704.52 3,997.71 3,679.71 29880 KNEE ARTHROSCOPY/SURG 3,774.79 3,623.53 3,997.71 3,679.71 29881 KNEE ARTHROSCOPY/SURG 3,531.15 3,388.20 3,997.71 3,679.71 29882 KNEE ARTHROSCOPY/SURG 3,812.37 3,660.32 3,997.71 3,679.71 29883 KNEE ARTHROSCOPY/SURG 3,576.15 3,435.01 3,997.71 3,679.71 29884 KNEE ARTHROSCOPY/SURG 2,635.72 2,528.41 3,997.71 3,679.71 29886 KNEE ARTHROSCOPY/SURG 2,695.10 2,585.53 3,997.71 3,679.71 29887 KNEE ARTHROSCOPY/SURG 3,168.57 3,041.28 3,997.71 3,679.71 29888 KNEE ARTHROSCOPY/SURG 4,211.31 4,048.82 11,871.09 10,926.78 29889 KNEE ARTHROSCOPY/SURG 5,187.05 4,985.30 11,871.09 10,926.78 29891 ANKLE ARTHROSCOPY/SURG 2,944.29 2,825.65 6,462.39 5,948.34 29894 ANKLE ARTHROSCOPY/SURG 2,194.01 2,106.44 3,997.71 3,679.71 29895 ANKLE ARTHROSCOPY/SURG 2,096.49 2,013.20 3,997.71 3,679.71 29897 ANKLE ARTHROSCOPY/SURG 2,198.99 2,111.07 3,997.71 3,679.71 29898 ANKLE ARTHROSCOPY/SURG 2,437.92 2,342.16 3,997.71 3,679.71 29899 ANKLE ARTHROSCOPY/SURG 4,454.29 4,283.43 6,462.39 5,948.34 30100 INTRANASAL BIOPSY 231.61 218.73 357.99 329.52 30130 EXCISE INFERIOR TURBINATE 616.48 585.09 2,313.03 2,129.04 30140 RESECT INFERIOR TURBINATE 714.07 676.41 3,421.41 3,149.25 30200 INJECTION TREAT NOSE 185.69 175.48 283.11 260.58 30300 REMOVE NASAL FOREIGN BODY 377.61 355.40 89.55 82.44 X 30310 REMOVE NASAL FOREIGN BODY 333.88 317.27 2,313.03 2,129.04 30520 REPAIR NASAL SEPTUM 1,533.94 1,462.07 3,421.41 3,149.25 30802 ABLATE INF TURBINATE SUBMUCOSAL 475.96 450.01 2;313.03 2,129.04 30901 CONTROL NOSEBLEED 154.98 147.82 151.17 139.14 30903 CONTROL NOSEBLEED 323.03 305.90 151.17 139.14 30905 CONTROL NOSEBLEED 400.32 379.29 151.17 139.14

11:3-29.6 APPENDIX B - REGULATIONS 30930 THERAPEUTIC FX, NASAL INF TURB 199.28 189.73 2,313.03 2,129.04 31000 IRRIGATE MAXILLARY SINUS 295.86 279.40 457.44 421.05 31020 EXPLORE MAXILLARY SINUS 793.30 748.88 3,421.41 3,149.25 31231 NASAL ENDOSCOPY, DIAG 316.52 298.37 268.32 246.99 31237 NASAL/SINUS ENDOSCOPY, SURG 533.18 505.96 2,927.49 2,694.60 31238 NASAL/SINUS ENDOSCOPY, SURG 547.19 519.83 2,927.49 2,694.60 31255 REMOVE ETHMOID SINUS 1,735.89 1,673.26 4,128.33 3,799.92 31256 EXPLORE MAXILLARY SINUS 1,228.03 1,181.96 4,128.33 3,799.92 31267 ENDOSCOPY, MAXILLARY SINUS 983.83 947.97 4,128.33 3,799.92 31500 INSERT EMERGENCY AIRWAY 169.29 164.70 315.78 290.67 X 31505 DIAGNOSTIC LARYNGOSCOPY 137.08 129.60 124.02 114.15 31515 LARYNGOSCOPY FOR ASPIRATION 342.57 324.79 2,927.49 2,694.60 31525 DIAG LARYNGOSCOPY EXCL NB 409.68 389.77 2,927.49 2,694.60 31575 DIAGNOSTIC LARYNGOSCOPY 188.42 178.87 253.86 233.67 31579 DIAGNOSTIC LARYNGOSCOPY 352.14 335.06 445.74 410.28 31600 INCISE WINDPIPE 629.61 609.27 31605 INCISE WINDPIPE 287.29 278.92 1,056.45 972.42 31622 DIAG BRONCHOSCOPE/WASH 515.11 488.50 1,400.82 1,289.40 31624 DIAG BRONCHOSCOPE/LAVAGE 516.04 489.32 1,400.82 1,289.40 31645 BRONCHOSCOPY, CLEAR AIRWAYS 493.95 469.51 1,400.82 1,289.40 31646 BRONCHOSCOPY, RECLEAR AIRWAY451.44 428.67 1,400.82 1,289.40 32405 BIOPSY LUNG OR MEDIASTINUM 154.47 149.43 1,298.73 1,195.41 29877 KNEE ARTHROSCOPY/SURG 3,398.38 3,259.86 3,997.71 3,679.71 32551 INSERT CHEST TUBE 523.12 506.94 32601 THORACOSCOPY, DIAGNOSTIC 499.24 483.47 32651 THORACOSCOPY, SURGICAL 1,750.69 1,694.03 32653 THORACOSCOPY, SURGICAL 1,686.57 1,632.06 33210 INSERT HEART ELECTRODE 297.55 288.11 3,763.15 3,209.05 33212 INSERT PULSE GENERATOR 564.31 544.12 11,119.83 9,530.10 36000 PLACE NEEDLE IN VEIN 41.55 39.31 X, N1 36005 INJECTION EXT VENOGRAPHY 590.62 553.75 X, N1 36010 PLACE CATHETER IN VEIN 952.65 895.82 X, N1 36011 PLACE CATHETER IN VEIN 1,569.24 1,473.07 X, N1 36013 PLACE CATHETER IN ARTERY 1,386.90 1,301.48 X, N1 36014 PLACE CATHETER IN ARTERY 1,452.05 1,363.05 X, N1 36140 ESTABLISH ACCESS TO ARTERY 818.12 769.44 X, N1 36200 PLACE CATHETER IN AORTA 1,104.48 1,039.78 X, N1 36215 PLACE CATHETER IN ARTERY 1,968.28 1,850.35 X, N1 36216 PLACE CATHETER IN ARTERY 2,164.58 2,035.32 X, N1 36217 PLACE CATHETER IN ARTERY 3,554.81 3,335.12 X, N1 36218 PLACE CATHETER IN ARTERY 325.68 306.84 X, N1 36245 PLACE CATHETER IN ARTERY 2,078.60 1,953.45 X, N1 36246 PLACE CATHETER IN ARTERY 2,094.97 1,970.56 X, N1 36247 PLACE CATHETER IN ARTERY 3,310.67 3,107.79 X, N1 36248 PLACE CATHETER IN ARTERY 272.11 256.86 X, N1 36400 BLOOD DRAW < 3 YRS FEM/JUGULAR 46.92 44.88 X, N1 36406 BLOOD DRAW < 3 YRS OTHER VEIN 28.17 26.82 X, N1 36410 NON-ROUTINE BL DRAW > 3 YRS 29.91 28.45 X, N1 36425 VEIN ACCESS CUTDOWN > 1 YR 62.34 60.40 35.67 32.82 X 36430 BLOOD TRANSFUSION SERVICE 59.91 55.92 119.34 109.86 X 36471 INJECTION THERAPY VEINS 290.72 276.37 121.44 111.78 36513 APHERESIS PLATELETS 158.96 153.73 1,652.49 1,521.03 X 36514 APHERESIS PLASMA 878.54 824.72 1,652.49 1,521.03 X 36515 APHERESIS, ADSORP/REINFUSE 3,313.31 3,095.86 4,195.89 3,862.11 X 36555 INSERT NON-TUNNEL CV CATH 442.67 420.24 1,516.71 1,396.08 36556 INSERT NON-TUNNEL CV CATH 383.48 364.91 1,516.71 1,396.08 36558 INSERT TUNNELED CV CATH 1,353.89 1,277.30 2,289.41 2,017.01 36569 INSERT PICC CATH 430.72 406.86 1,516.71 1,396.08 36571 INSERT PICVAD CATH 2,151.26 2,023.38 2,289.41 2,017.01 36576 REPAIR TUNNELED CV CATH 619.78 588.02 1,516.71 1,396.08 36578 REPLACE TUNNELED CV CATH 855.29 808.35 2,289.41 2,017.01 36580 REPLACE CVAD CATH 375.27 353.82 1,516.71 1,396.08 36584 REPLACE PICC CATH 360.67 339.77 1,516.71 1,396.08 36589 REMOVE TUNNELED CV CATH 271.78 260.38 844.41 777.24 36592 COLLECT BLOOD PICC 44.20 41.25 X, N1 36593 DECLOT VASCULAR DEVICE 49.44 46.14 98.28 90.45 36598 INJECT W/FLUOR, EVAL CV DEVICE 189.67 178.99 298.32 274.59 36600 WITHDRAW ARTERIAL BLOOD 50.41 47.90 X, N1 36620 INSERT CATHETER, ARTERY 210.31 204.69 X, N1 36625 INSERT CATHETER, ARTERY 169.68 164.90 X, N1 36800 INSERT CANNULA 261.61 251.45 4,009.88 3,637.55 36810 INSERT CANNULA 340.24 329.61 4,009.88 3,637.55

MEDICAL FEE SCHEDULES 11:3-29.6 36815 INSERT CANNULA 244.77 236.68 4,009.88 3,637.55 36818 AV FUSE, UPPER ARM, CEPHALIC 1,105.69 1,069.72 5,565.66 5,122.95 36833 AV FISTULA REVISION 1,079.72 1,045.86 5,565.66 5,122.95 36860 EXTERNAL CANNULA DECLOTTING 331.55 315.10 313.14 288.21 37140 REVISE CIRCULATION 2,310.08 2,235.33 37609 TEMPORAL ARTERY PROCEDURE 503.08 478.98 2,411.70 2,219.85 37620 REVISE MAJOR VEIN 2,029.20 1,958.69 37650 REVISE MAJOR VEIN 1,545.07 1,493.80 3,662.31 3,370.98 38100 REMOVE SPLEEN, TOTAL 1,765.00 1,708.45 37204 TRANSCATHETER OCCLUSION 1,460.69 1,414.57 8,466.97 7,482.97 38115 REPAIR RUPTURED SPLEEN 1,947.72 1,885.34 38200 INJECTION FOR SPLEEN X-RAY 234.86 227.73 X, N1 38206 HARVEST AUTO STEM CELLS 292.33 282.03 1,652.49 1,521.03 X 38220 BONE MARROW ASPIRATION 250.35 236.57 381.36 351.03 38221 BONE MARROW BIOPSY 269.34 254.87 393.09 361.80 38230 BONE MARROW COLLECTION 838.42 806.23 4,195.89 3,862.11 X 39501 REPAIR DIAPHRAGM LACERATION 1,328.67 1,283.88 43235 UPPER GI ENDOSCOPY, DIAGNOSIS 490.49 464.67 1,184.82 1,090.56 43236 UPPER GI SCOPE W/SUBMUCOSA INJECT 608.49 576.22 1,184.82 1,090.56 43239 UPPER GI ENDOSCOPY, BIOPSY 567.52 537.88 1,184.82 1,090.56 43246 PLACE GASTROSTOMY TUBE 403.59 389.45 1,184.82 1,090.56 43248 UPPER GI ENDOSCOPY/GUIDE WIRE 303.20 292.10 1,184.82 1,090.56 43249 ESOPH ENDOSCOPY, DILATION 279.64 269.41 1,184.82 1,090.56 43255 OPERATIVE UPPER GI ENDOSCOPY 453.95 437.69 1,184.82 1,090.56 43259 ENDOSCOPIC ULTRASOUND EXAM 488.13 470.63 1,184.82 1,090.56 43260 ENDO CHOLANGIOPANCREATOGRAPHY 556.81 536.98 3,099.69 2,853.12 43450 DILATE ESOPHAGUS 258.48 245.26 875.61 805.98 43760 CHANGE GASTROSTOMY TUBE 684.75 641.43 313.14 288.21 43830 PLACE GASTROSTOMY TUBE 1,076.48 1,038.48 44139 MOBILIZATION COLON 187.28 181.69 44500 INTRODUCE GASTROINTESTINAL TUBE 38.60 37.33 844.41 777.24 45300 PROCTOSIGMOIDOSCOPY DIAG 187.75 177.52 283.11 260.58 45330 DIAGNOSTIC SIGMOIDOSCOPY 227.77 215.31 345.12 317.67 45355 SURGICAL COLONOSCOPY 324.09 312.96 1,246.23 1,147.08 45378 DIAGNOSTIC COLONOSCOPY 647.09 614.70 1,246.23 1,147.08 46040 INCISE RECTAL ABSCESS 811.58 773.85 3,247.68 2,989.32 46600 DIAGNOSTIC ANOSCOPY 136.30 128.76 89.55 82.44 X 47000 NEEDLE BIOPSY LIVER 575.57 542.24 1,298.73 1,195.41 49080 PUNCTURE, PERITONEAL CAVITY 269.24 254.87 742.11 683.10 49320 DIAG LAP SEPARATE PROC 508.88 490.86 5,156.19 4,746.03 49421 INSERT ABDOM DRAIN, PERM 425.09 409.71 3,521.06 3,192.08 49505 PART RPR I/HERNIA INIT REDUCT >5 YR 799.46 771.01 4,412.82 4,061.82 50392 INSERT KIDNEY DRAIN 289.62 279.48 2,344.41 2,157.93 50394 INJECTION FOR KIDNEY X-RAY 173.81 164.23 X, N1 51600 INJECTION FOR BLADDER X-RAY 328.90 309.24 X, N1 51610 INJECTION FOR BLADDER X-RAY 184.26 174.79 X, N1 51700 IRRIGATION BLADDER 143.15 135.97 189.51 174.45 51701 INSERT BLADDER CATHETER 98.42 93.21 89.55 82.44 X 51702 INSERT TEMP BLADDER CATH 128.12 120.92 89.55 82.44 X 51703 INSERT BLADDER CATH, COMPLEX 227.44 216.26 148.20 136.41 51705 CHANGE BLADDER TUBE 186.01 176.43 256.20 235.83 51720 TREAT BLADDER LESION 185.88 177.55 205.92 189.54 51725 SIMPLE CYSTOMETROGRAM 349.50 330.16 51725 TC SIMPLE CYSTOMETROGRAM 228.20 212.91 428.43 394.35 51725 26 SIMPLE CYSTOMETROGRAM 121.30 117.25 51726 COMPLEX CYSTOMETROGRAM 514.29 484.52 51726 TC COMPLEX CYSTOMETROGRAMI 375.98 350.82 428.43 394.35 51726 26 COMPLEX CYSTOMETROGRAM 138.31 133.68 51741 ELECTRO-UROFLOWMETRY, FIRST 72.56 68.17 51741 TC ELECTRO-UROFLOWMETRY, FIRST 45.36 42.35 90.09 82.92 51741 26 ELECTRO-UROFLOWMETRY, FIRST 27.20 25.82 51784 ANAL/URINARY MUSCLE STUDY 340.60 321,93 51784 TC ANAL/URINARY MUSCLE STUDY 217.71. 203.13 148.20 136.41 51784 26 ANAL/URINARY MUSCLE STUDY 122.90 118.80 51797 INTRAABDOMINAL PRESSURE TEST 225.40 212.42 51797 TC INTRAABDOMINAL PRESSURE TEST 159.49 148.82 271.74 250.14 51797 26 INTRAABDOMINAL PRESSURE TEST 65.91 63.61 51798 US URINE CAPACITY MEASURE 33.71 31.48 66.69 61.38 X

11:3-29.6 APPENDIX B - REGULATIONS 52000 CYSTOSCOPY 348.14 331.01 992.58 913.62 52005 CYSTOSCOPY & URETER CATHETER 482.13 456.37 3,512.94 3,233.49 52204 CYSTOSCOPY W/BIOPSY(S) 706.29 666.08 3,512.94 3,233.49 52281 CYSTOSCOPY & TREAT 481.96 456.89 2,344.41 2,157.93 52310 CYSTOSCOPY & TREAT 412.14 392.33 2,344.41 2,157.93 52332 CYSTOSCOPY & TREAT 837.81 788.80 3,512.94 3,233.49 52351 CYSTOURETERO & OR PYELOSCOPE 511.15 493.07 3,512.94 3,233.49 53600 DILATE URETHRA STRICTURE 139.91 133.85 146.22 134.61 53601 DILATE URETHRA STRICTURE 137.75 131.17 148.20 136.41 53660 DILATE URETHRA 121.77 115.58 148.20 136.41 53661 DILATE URETHRA 120.54 114.44 148.20 136.41 54235 PENILE INJECTION 149.95 143.17 168.48 155.07 57452 EXAM CERVIX W/SCOPE 174.20 167.01 171.99 158.31 57500 BIOPSY CERVIX 213.96 203.21 286.62 263.82 57511 CRYOCAUTERY CERVIX 234.32 224.50 218.10 200.76 58340 CATHETER FOR HYSTERORRHAPHY 203.46 192.36 X, N1 58558 HYSTEROSCOPY, BIOPSY 576.77 552.42 3,079.32 2,834.37 59000 AMNIOCENTESIS, DIAGNOSTIC 208.66 199.11 248.01 228.30 59025 FETAL NON-STRESS TEST 117.18 112.00 59025 TC FETAL NON-STRESS TEST 45,58 42.59 58.50 53.85 59025 26 FETAL NON-STRESS TEST 71.58 69.41 59841 ABORTION 611.45 589.83 2,758.50 2,539.05 61107 DRILL SKULL FOR IMPLANTATION 1,155.41 1,120.28 61790 TREAT TRIGEMINAL NERVE 2,552.34 2,349.30 62263 EPIDURAL LYSIS MULT SESSIONS 1,788.44 1,102.21 1,012.32 931.80 62264 EPIDURAL LYSIS ON SINGLE DAY 1,033.30 638.56 1,706.88 1,571.10 62270 SPINAL FLUID TAP, DIAGNOSTIC 391.43 371.51 517.89 476.70 62273 INJECT EPIDURAL PATCH 414.98 396.26 1,012.32 931.80 62280 TREAT SPINAL CORD LESION 817.78 775.41 1,012.32 931.80 62281 TREAT SPINAL CORD LESION 650.31 618.08 1,012.32 931.80 62282 TREAT SPINAL CANAL LESION 743.51 703.87 1,012.32 931.80 62284 INJECTION FOR MYELOGRAM 544.03 514.23 X, N1 62287 PERCUTANEOUS DISKECTOMY 5,347.03 5,141.26 4,972.53 4,576.98 62290 INJECT FOR SPINE DISK X-RAY 1,256.74 1,191.64 X, N1 62291 INJECT FOR SPINE DISK X-RAY 1,184.82 1,123.82 X, N1 62292 INJECTION INTO DISK LESION 1,982.34 1,907.34 1,012.32 931.80 62310 INJECT SPINE C/T 1,021.73 967.17 1,012.32 931.80 62311 INJECT SPINE L/S (CD) 879.37 831.58 1,012.32 931.80 62318 INJECT SPINE W/CATH, C/T 749.21 709.56 1,012.32 931.80 62319 INJECT SPINE W/CATH L/S (CD) 475.01 451.01 1,706.88 1,571.10 62350 IMPLANT SPINAL CANAL CATH 5,591.79 5,146.98 62355 REMOVE SPINAL CANAL CATHETER 1,706.88 1,571.10 62360 INSERT SPINE INFUSION DEVICE 5,591.79 5,146.98 62362 IMPLANT SPINE INFUSION PUMP 22,241.41 18,893.98 62365 REMOVE SPINE INFUSION DEVICE 4,972.53 4,576.98 62367 ANALYZE SPINE INFUSION PUMP 76.02 69.99 X 62368 ANALYZE SPINE INFUSION PUMP 102.96 94.77 X 63075 NECK SPINE DISK SURG 10,012.99 9,659.93 63076 NECK SPINE DISK SURG 1,837.46 1,779.74 63650 IMPLANT NEUROELECTRODES 7,941.86 6,926.39 X 63655 IMPLANT NEUROELECTRODES 10,702.41 9,271.65 X 63685 INSERT/REDO SPINE N GENERATOR 24,642.86 20,858.66 X 63688 REVISE/REMOVE NEURORECEIVER 3,880.14 3,571.47 64400 NERVE BLOCK INJ, TRIGEMINAL 237.48 218.58 64402 NERVE BLOCK INJ, FACIAL 280.41 267.23 219.96 202.47 64405 NERVE BLOCK INJ, OCCIPITAL 278.84 266.46 202.38 186.30 64412 NERVE BLOCK INJ, SPINAL ACCESSORY 352.14 324.12 64413 NERVE BLOCK INJ, CERV PLEXUS 294.62 281.16 221.13 203.55 64415 NERVE BLOCK INJ, BRACHIAL PLEXUS 304.42 290.12 51.7.89 476.70 64416 NERVE BLOCK CONT INFUSE, B PLEX 191.93 186.58 1,012.32 931.80 64417 NERVE BLOCK INJ, AXILLARY 320.99 305.45 517.89 476.70 64418 NERVE BLOCK INJ, SUPRASCAPULAR 344.67 327.13 303.00 278.91 64420 NERVE BLOCK INJ, INTERCOSTAL, SING 343.60 325.60 517.89 476.70 64421 NERVE BLOCK INJ, INTERCOSTAL, MULT 493.86 468.06 1,012.32 931.80 64425 NERVE BLOCK INJ, ILIO-ING/HYPOGI321.93 307.96 221.13 203.55 64430 NERVE BLOCK INJ, PUDENDAL 1,012.32 931.80 64435 NERVE BLOCK INJ, PARACERV 352.78 335.81 287.79 264.90

MEDICAL FEE SCHEDULES 11:3-29.6 64445 NERVE BLOCK INJ, SCIATIC, SING 333.50 317.51 267.93 246.60 64446 NERVE BLOCK INJ, SCIATIC, CONT INF 1,012.32 931.80 64447 NERVE BLOCK INJ, FEM, SING 295.21 281.61 221.13 203.55 64448 NERVE BLOCK INJ, FEM, CONT INF 1,012.32 931.80 64449 NERVE BLOCK INJ, LUMBAR PLEXUS199.08 193.27 1,012.32 931.80 64450 NERVE BLOCK, OTHER PERIPHERAL 253.98 242.28 190.68 175.53 64455 NERVE BLOCK INJ, PLANTAR DIGIT 71.37 65.70 64479 INJECT FORAMEN EPIDURAL C/T 670.71 635.70 1,012.32 931.80 64480 INJECT FORAMEN EPIDURAL, ADDED397.14 377.32 517.89 476.70 64483 INJECT FORAMEN EPIDURAL L/S 611.76 578.07 1,012.32 931.80 64484 INJECT FORAMEN EPIDURAL, ADDED268.13 254.31 517.89 476.70 64490 INJECT PARAVERT F JNT C/T 1 LEV 494.93 469.59 1,012.32 931.80 64491 INJECT PARAVERT F JNT C/T 2 LEV 241.80 230.50 355.95 327.66 64492 INJECT PARAVERT F JNT C/T 3 LEV 244.49 233.01 355.95 327.66 64493 INJECT PARAVERT F JNT L/S 1 LEV 442.52 419.26 1,012.32 931.80 64494 INJECT PARAVERT F JNT L/S 2 LEV 218.85 208.33 355.95 327.66 64495 INJECT PARAVERT F JNT L/S 3 LEV 222.43 211.68 355.95 327.66 64505 NERVE BLOCK SPHENOPALATINE GANGLIA 241.39 230.83 166.14 152.91 64510 NERVE BLOCK STELLATE GANGLION340.64 322.89 1,012.32 931.80 64517 NERVE BLOCK INJ, HYPOGAS PLXS 429.82 410.19 1,012.32 931.80 64520 NERVE BLOCK LUMBAR/THORACIC 486.86 459.82 1,012.32 931.80 64550 APPLY NEUROSTIMULATOR 25.38 24.14 64555 IMPLANT NEUROELECTRODES 7,941.86 6,926.39 X 64561 IMPLANT NEUROELECTRODES 7,941.86 6,926.39 X 64565 IMPLANT NEUROELECTRODES 286.59 272.61 7,941.86 6,926.39 X 64600 INJECTION TREAT NERVE 673.41 638.56 1,706.88 1,571.10 64605 INJECTION TREAT NERVE 1,063.67 1,007.56 2,552.34 2,349.30 64610 INJECTION TREAT NERVE 1,180.01 1,125.84 2,552.34 2,349.30 64612 DESTROY NERVE, FACE MUSCLE 316.60 303.63 278.43 256.26 64613 DESTROY NERVE, NECK MUSCLE 302.92 290.62 260.91 240.15 64614 DESTROY NERVE, EXTREMITY MUSC324.01 310.13 295.98 272.43 64620 INJECTION TREAT NERVE 385.92 368.07 1,012.32 931.80 64622 DESTROY PARAVERTEBRAL NERVE L/S 634.27 601.31 1,706.88 1,571.10 64623 DESTROY PARAVERT NERVE, ADDED317.51 300.33 1,012.32 931.80 64626 DESTROY PARAVERTEBRAL NERVE C/T 751.82 713.75 1,012.32 931.80 64627 DESTROY PARAVERT NERVE, ADDED 436.29 411.90 355.95 327.66 64640 INJECTION TREAT NERVE 404.68 386.40 393.09 361.80 64680 INJECTION TREAT NERVE 594.94 563.72 1,012.32 931.80 64702 REVISE FINGER/TOE NERVE 2,552.34 2,349.30 64704 REVISE HAND/FOOT NERVE 2,552.34 2,349.30 64708 REVISE ARM/LEG NERVE 2,552.34 2,349.30 64712 REVISE SCIATIC NERVE 2,552.34 2,349.30 64713 REVISE ARM NERVE(S) 2,552.34 2,349.30 64714 REVISE LOW BACK NERVE(S) 2,552.34 2,349.30 64716 REVISE CRANIAL NERVE 2,552.34 2,349.30 64718 REVISE ULNAR NERVE AT ELBOW 2,552.34 2,349.30 64719 REVISE ULNAR NERVE AT WRIST 2,552.34 2,349.30 64721 CARPAL TUNNEL SURG 2,074.12 1,982.69 2,552.34 2,349.30 64818 REMOVE SYMPATHETIC NERVES 1,606.35 1,552.19 65205 REMOVE FOREIGN BODY EYE 132.40 126.72 90.09 82.92 X 65210 REMOVE FOREIGN BODY EYE 164.76 157.50 117.00 107.70 X 65220 REMOVE FOREIGN BODY EYE 136.80 130.87 129.36 119.07 X 65222 REMOVE FOREIGN BODY EYE 181.46 173.50 127.50 117.36 X 65265 REMOVE FOREIGN BODY EYE 2,640.72 2,533.79 3,125.70 2,877.06 67412 EXPLORE/TREAT EYE SOCKET 2,070.04 1,979.70 2,669.28 2,456.94 69210 REMOVE IMPACTED EAR WAX 80.59 76.92 89.55 82.44 X 69310 REBUILD OUTER EAR CANAL 1,786.26 1,698.11 5,961.75 5,487.51 69320 REBUILD OUTER EAR CANAL 2,511.83 2,392.78 5,961.75 5,487.51 69666 REPAIR MIDDLE EAR STRUCTURES3,035.82 2,897.99 5,961.75 5,487.51 69667 REPAIR MIDDLE EAR STRUCTURES3,041.01 2,902.91 5,961.75 5,487.51 69990 MICROSURG, ADDED 529.56 513.23 X, N1 70030 X-RAY EYE FOR FOREIGN BODY 48.10 45.35 70030 TC X-RAY EYE FOR FOREIGN BODY 34.87 32.57 69.03 63.54 70030 26 X-RAY EYE FOR FOREIGN BODY 13.22 12.79 70100 X-RAY JAW < 4 VIEWS 55.59 52.37 70100 TC X-RAY JAW < 4 VIEWS 41.28 38.54 81.87 75.36 70110 X-RAY JAW MINIMUM 4 VIEWS 66.14 62.37 70100 26 X-RAY JAW < 4 VIEWS 14.31 13.83

11:3-29.6 APPENDIX B - REGULATIONS 70110 TC X-RAY JAW MINIMUM 4 VIEWS 47.11 43.97 87.24 80.31 70110 26 X-RAY JAW MINIMUM 4 VIEWS 19.03 18.40 70120 X-RAY MASTOIDS < 3 VIEWS/SIDE 59.09 55.62 70120 TC X-RAY MASTOIDS < 3 VIEWS/SIDE 44.78 41.81 87.24 80.31 70120 26 X-RAY MASTOIDS < 3 VIEWS/SIDE 14.31 13.83 70130 X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE 93.99 88.58 70130 TC X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE 68.07 63.54 87.24 80.31 70130 26 X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE 25.92 25.05 70140 X-RAY FACIAL BONES < 3 VIEWS 50.86 47.98 70140 TC X-RAY FACIAL BONES < 3 VIEWS 35.46 33.11 70.20 64.62 70140 26 X-RAY FACIAL BONES < 3 VIEWS 15.40 14.86 70150 X-RAY FACIAL BONES MINIMUM 3 VIEWS 71.88 67.76 70150 TC X-RAY FACIAL BONES MINIMUM 3 VIEWS 51.76 48.32 87.24 80.31 70150 26 X-RAY FACIAL BONES MINIMUM 3 VIEWS 20.12 19.44 70160 X-RAY NASAL BONES MINIMUM 3 VIEWS 55.66 52.41 70160 TC X-RAY NASAL BONES M 3 VIEWS 42.45 39.63 84.21 77.52 70160 26 X-RAY NASAL BONES MINIMUM 3 VIEWS 13.22 12.79 70190 X-RAY OPTIC FORAMINA 60.03 56.57 70190 TC X-RAY OPTIC FORAMINA 43.61 40.71 86.55 79.68 70190 26 X-RAY OPTIC FORAMINA 16.41 15.86 70200 X-RAY ORBITS, MINIMUM 4 VIEWS 74.07 69.85 70200 TC X-RAY ORBITS, MINIMUM 4 VIEWS 52.34 48.86 87.24 80.31 70200 26 X-RAY ORBITS, MINIMUM 4 VIEWS 21.71 20.98 70210 X-RAY SINUSES < 3 VIEWS 52.17 49.16 70210 TC X-RAY SINUSES < 3 VIEWS 38.37 35.83 76.02 69.99 70210 26 X-RAY SINUSES < 3 VIEWS 13.80 13.33 70220 X-RAY SINUSES MINIMUM 3 VIEWS 64.97 61.29 70220 TC X-RAY SINUSES MINIMUM 3 VIEWS 45.94 42.89 87.24 80.31 70220 26 X-RAY SINUSES MINIMUM 3 VIEWS 19.03 18.40 70250 X-RAY SKULL < 4 VIEWS 62.13 58.62 70250 TC X-RAY SKULL < 4 VIEWS 43.03 40.17 85.38 78.60 70250 26 X-RAY SKULL < 4 VIEWS 19.10 18.45 70260 X-RAY SKULL MINIMUM 4 VIEWS 78.86 74.45 70260 TC X-RAY SKULL MIN 4 VIEWS 52.92 49.41 105.30 96.93 70260 26 X-RAY SKULL MINIMUM 4 VIEWS 25.92 25.05 70300 X-RAY TEETH SINGLE VIEW 24.17 22.85 70300 TC X-RAY TEETH SINGLE VIEW 15.08 14.10 29.22 26.91 70300 26 X-RAY TEETH SINGLE VIEW 9.09 8.75 70310 X-RAY TEETH < FULL MOUTH 63.31 59.51 70310 TC X-RAY TEETH < FULL MOUTH 49.44 46.14 59.04 54.36 70310 26 X-RAY TEETH < FULL MOUTH 13.88 13.37 70320 X-RAY TEETH FULL MOUTH 83.72 79.89 70320 TC X-RAY TEETH FULL MOUTH 66.90 62.44 59.04 54.36 70320 26 X-RAY TEETH FULL MOUTH 18.09 17.45 70328 X-RAY TMJ UNILATERAL 52.10 49.11 70328 TC X-RAY TMJ UNILATERAL 37.79 35.29 74.85 68.91 70328 26 X-RAY TMJ UNILATERAL 14.31 13.83 70330 X-RAY TMJ BILATERAL 81.34 76.54 70330 TC X-RAY TMJ BILATERAL 62.24 58.09 87.24 80.31 70330 26 X-RAY TMJ BILATERAL 19.10 18.45 70332 TMJ ARTHOGRAPHY; RAD SUPER & INTERP 143.03 134.89 N1 70332 TC TMJ ARTHOGRAPHY; RAD SUPER & INTERP 98.34 91.77 N1 70332 26 TMJ ARTHOGRAPHY; RAD SUPER & INTERP 44.68 43.10 N1 70336 MRI TMJ 763.99 716.59 70336 TC MRI TMJ 649.78 606.18 664.20 611.37 70336 26 MRI TMJ 114.20 110.43 70350 CEPHALOORAM, ORTHODONTIC 35.29 33.41 70350 TC CEPHALOGRAM, ORTHODONTIC 20.32 18.99 39.78 36.60 70350 26 CEPHALOGRAM, ORTHODONTIC 14.96 14.41 70355 ORTHOPANTOGRAM 35.64 33.81 70355 TC ORTHOPANTOGRAM 19.16 17.91 37.44 34.44

MEDICAL FEE SCHEDULES 11:3-29.6 70355 26 ORTHOPANTOGRAM 16.50 15.90 70360 X-RAY NECK SOFT TISSUE 46.36 43.73 70360 TC X-RAY NECK SOFT TISSUE 33.13 30.94 65.52 60.30 70360 26 X-RAY NECK SOFT TISSUE 13.22 12.79 70450 CT HEAD/BRAIN W/O DYE 426.03 400.31 70450 TC CT HEAD/BRAIN W/O DYE 341.76 318.85 375.45 345.60 70450 26 CT HEAD/BRAIN W/O DYE 84.27 81.46 70460 CT HEAD/BRAIN W/DYE 431.97 405.92 70460 TC CT HEAD/BRAIN W/DYE 344.66 321.55 580.71 534.51 70460 26 CT HEAD/BRAIN W/DYE 87.31 84.38 70470 CT HEAD/BRAIN W/O & W/DYE 523.38 491.61 70470 TC CT HEAD/BRAIN W/O & W/DYE 424.43 395.96 647.37 595.86 70470 26 CT HEAD/BRAIN W/O & W/DYE 98.95 95.65 70480 CT ORBIT/EAR/FOSSA W/O DYE 531.46 499.17 70480 TC CT ORBIT/EAR/FOSSA W/O DYE 431.99 403.02 375.45 345.60 70480 26 CT ORBITBAR/FOSSA W/O DYE 99.46 96.15 70481 CT ORBIT/EAR/FOSSA W/DYE 617.99 580.17 70481 TC CT ORBIT/EAR/FOSSA W/DYE 510.61 476.35 580.71 534.51 70481 26 CT ORBITBAR/FOSSA W/DYE 107.38 103.82 70482 CT ORBIT/EAR/FOSSA W/O & W/DYE 698.40 655.36 70482 TC CT ORBIT/EAR/FOSSA W/O & W/DYE 586.31 546.96 647.37 595.86 70482 26 CT ORBIT/EAR/FOSSA W/O & W/DYE 112.09 108.39 70486 CT MAXILLOFACIAL W/O DYE 442.37 415.65 70486 TC CT MAXILLOFACIAL W/O DYE 353.98 330.23 375.45 345.60 70486 26 CT MAXILLOFACIAL W/O DYE 88.41 85.42 70487 CT MAXILLOFACIAL W/DYE 533.63 501.24 70487 TC CT MAXILLOFACIAL W/DYE 432.58 403.56 580.71 534.51 70487 26 CT MAXILLOFACIAL W/DYE 101.05 97.69 70488 CT MAXILLOFACIAL W/O & W/DYE 649.72 609.86 70488 TC CT MAXILLOFACIAL W/O & W/DYE 539.73 503.52 647.37 595.86 70488 26 CT MAXILLOFACIAL W/O &W/DYE 109.99 106.35 70490 CT SOFT TISSUE NECK W/O DYE 432.46 406.83 70490 TC CT SOFT TISSUE NECK W/O DYE 333.02 310.68 375.45 345.60 70490 26 CT SOFT TISSUE NECK W/O DYE 99.46 96.15 70491 CT SOFT TISSUE NECK W/DYE 521.98 490.57 70491 TC CT SOFT TISSUE NECK W/DYE 415.11 387.27 580.71 534.51 70491 26 CT SOFT TISSUE NECK W/DYE 106.87 103.30 70492 CT SOFT TISSUE NECK W/O & W/DYE632.03 593.43 70492 TC CT SOFT TISSUE NECK W/O & W/DYE519.93 485.04 647.37 595.86 70492 26 CT SOFT TISSUE NECK W/O & W/DYE112.09 108.39 70496 CT ANGIOGRAPHY, HEAD 1,008.14 945.09 70496 TC CT ANGIOGRAPHY, HEAD 871.63 813.13 655.71 603.54 70496 26 CT ANGIOGRAPHY, HEAD 136.51 131.96 70498 CT ANGIOGRAPHY, NECK 1,025.62 961.39 70498 TC CT ANGIOGRAPHY, NECK 889.10 829.43 655.71 603.54 70498 26 CT ANGIOGRAPHY, NECK 136.51 131.96 70540 MRI ORBIT/FACE/NECK W/O DYE 849.38 795.95 70540 TC MRI ORBIT/FACE/NECK W/O DYE 744.69 694.71 664.20 611.37 70540 26 MRI ORBIT/FACE/NECK W/O DYE 104.69 101.24 70542 MRI ORBIT/FACE/NECK W/DYE 948.56 889.20 70542 TC MRI ORBIT/FACE/NECK W/DYE 822.72 767.50 846.36 779.04 70542 26 MRI ORBIT/FACE/NECK W/DYE 125.84 121.69 70543 MRI ORBIT/FACE/NECK W/O & W/DYE 1,239.11 1,161.59 70543 TC MRI ORBIT/FACE/NECK W/O & W/DYE 1,073.12 1,001.07 1,033.50 951.27 70543 26 MRI ORBIT/FACE/NECK W/O & W/DYE 166.00 160.53 70544 MR ANGIOGRAPHY HEAD W/O DYE 930.92 871.62 70544 TC MR ANGIOGRAPHY HEAD W/O DYE 837.86 781.62 664.20 611.37 70544 26 MR ANGIOGRAPHY HEAD W/O DYE 93.07 90.00 70545 MR ANGIOGRAPHY HEAD W/DYE 925.11 866.18 70545 TC MR ANGIOGRAPHY HEAD W/DYE 832.04 776.19 846.36 779.04 70545 26 MR ANGIOGRAPHY HEAD W/DYE 93.07 90.00 70546 MR ANGIOGRAPH HEAD W/O & W/DYE 1,457.83 1,364.72 70546 TC MR ANGIOGRAPH HEAD W/O & W/DYE 1,317.67 1,229.21 1,033.50 951.27 70546 26 MR ANGIOGRAPH HEAD W/O & W/DYE 140.15 135.51 70547 MR ANGIOGRAPHY NECK W/O DYE 929.19 869.99 70547 TC MR ANGIOGRAPHY NECK W/O DYE 836.11 779.99 664.20 611.37

11:3-29.6 APPENDIX B - REGULATIONS 70547 26 MR ANGIOGRAPHY NECK W/O DYE 93.07 90.00 70548 MR ANGIOGRAPHY NECK W/DYE 975.77 913.44 70548 TC MR ANGIOGRAPHY NECK W/DYE 882.71 823.45 846.36 779.04 70548 26 MR ANGIOGRAPHY NECK W/DYE 93.07 90.00 70549 MR ANGIOGRAPH NECK W/O & W/DYE 1,458.47 1,365.29 70549 TC MR ANGIOGRAPH NECK W/O & W/DYE 1,318.84 1,230.29 1,033.50 951.27 70549 26 MR ANGIOGRAPH NECK W/O & W/DYE 139.64 135.00 70551 MRI BRAIN W/O DYE 878.11 823.06 70551 TC MRI BRAIN W/O DYE 763.33 712.09 664.20 611.37 70551 26 MRI BRAIN W/0 DYE 114.78 110.97 70552 MRI BRAIN W/DYE 978.74 917.78 70552 TC MRI BRAIN W/DYE 839.60 783.26 846.36 779.04 70552 26 MRI BRAIN W/DYE 139.14 134.52 70553 MRI BRAIN W/O & W/DYE 1,228.68 1,152.44 70553 TC MRI BRAIN W/O & W/DYE 1,045.16 974.99 1,033.50 951.27 70553 26 MRI BRAIN W/O & W/DYE 183.52 177.45 70554 FMRI BRAIN BY TECH 964.57 905.39 70554 TC FMRI BRAIN BY TECH 799.43 745.77 664.20 611.37 70554 26 FMRI BRAIN BY TECH 165.14 159.62 70555 26 FMRI BRAIN BY PHYS/PSYCH 203.10 196.49 71010 CHEST X-RAY SINGLE VIEW FRONTAL46.85 44.31 71010 TC CHEST X-RAY SINGLE VIEW FRONTAL30.48 28.47 50.31 46.29 71010 26 CHEST X-RAY SINGLE VIEW FRONTAL16.37 15.84 71020 CHEST X-RAY 2 VIEWS FRONTAL & LATERAL 55.78 52.69 71020 TC CHEST X-RAY 2 VIEWS FRONTAL & LATERAL 37.56 35.08 69.03 63.54 71020 26 CHEST X-RAY 2 VIEWS FRONTAL & LATERAL 18.23 17.61 71021 CHEST X-RAY 2 VIEWS W/APICAL LORD PROC 63.65 60.11 71021 TC CHEST X-RAY 2 VIEWS W/APICAL LORD PROC 43.03 40.17 85.38 78.60 71021 26 CHEST X-RAY 2 VIEWS W/APICAL LORD PROC 20.62 19.94 71022 CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ 77.92 73.51 71022 TC CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ 54.09 50.49 87.24 80.31 71022 26 CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ 23.82 23.01 71030 CHEST X-RAY MINIMUM 4 VIEWS 77.34 72.96 71030 TC CHEST X-RAY MINIMUM 4 VIEWS 53.50 49.95 87.24 80.31 '71030 26 CHEST X-RAY MINIMUM 4 VIEWS 23.82 23.01 71035 CHEST X-RAY SPECIAL VIEWS 59.67 56.18 71035 TC CHEST X-RAY SPECIAL VIEWS 45.36 42.35 87.24 80.31 71035 26 CHEST X-RAY SPECIAL VIEWS 14.31 13.83 71040 CONTRAST X-RAY BRONCHI UNILATERAL 162.07 152.67 N1 71040 TC CONTRAST X-RAY BRONCHI UNILATERAL 118.73 110.79 N1 71040 26 CONTRAST X-RAY BRONCHI UNILATERAL 43.34 41.88 N1 71090 X-RAY & PACEMAKER INSERT 169.62 163.54 N1 71090 TC X-RAY & PACEMAKER INSERT 123.65 119.31 N1 71090 26 X-RAY & PACEMAKER INSERT 44.62 43.09 N1 71100 X-RAY RIBS 2 VIEWS 54.13 51.10 71100 TC X-RAY RIBS 2 VIEWS 37.20 34.75 73.71 67.86 71100 26 X-RAY RIBS 2 VIEWS 16.93 16.36 71101 X-RAY RIBS/CHEST MINIMUM 3 VIEWS 82.73 78.10 71101 TC X-RAY RIBS/CHEST MINIMUM 3 VIEWS 56.88 53.10 87.24 80.31 71101 26 X-RAY RIBS/CHEST MINIMUM 3 VIEWS 25.85 25.00 71110 X-RAY RIBS BILATERAL 3 VIEWS 68.31 64.46 71110 TC X-RAY RIBS BILATERAL 3 VIEWS 47.69 44.52 87.24 80.31 71110 26 X-RAY RIBS BILATERAL 3 VIEWS 20.62 19.94 71111 X-RAY RIBS/CHEST MINIMUM 4 VIEWS88.32 83.23

MEDICAL FEE SCHEDULES 11:3-29.6 71111 TC X-RAY RIBS/CHEST MINIMUM 4 VIEWS63.99 59.73 127.50 117.36 71111 26 X-RAY RIBS/CHEST 4 VIEWS 24.33 23.50 71120 X-RAY STE MINIMUM 2 VIEWS 53.70 50.65 71120 TC X-RAY STERNUM MINIMUM 2 VIEWS 38.37 35.83 76.02 69.99 71120 26 X-RAY STERNUM MINIMUM 2 VIEWS 15.33 14.82 71130 X-RAY STERNOCLAV JOINT MINIMUM62.87 59.24 3 VIEWS 71130 TC X-RAY STERNOCLAV JOINT MINIMUM45.94 42.89 87.24 80.31 3 VIEWS 71130 26 X-RAY STERNOCLAV JOINT MINIMUM16.93 16.36 3 VIEWS 71250 CT THORAX W/O DYE 423.62 397.82 71250 TC CT THORAX W/O DYE 344.07 320.99 375.45 345.60 71250 26 CT THORAX W/O DYE 79.55 76.82 71260 CT THORAX W/DYE 525.35 493.37 71260 TC CT THORAX W/DYE 428.51 399.76 580.71 534.51 71260 26 CT THORAX W/DYE 96.85 93.61 71270 CT THORAX W/O &W/DYE 646.01 606.26 71270 TC CT THORAX W/O & W/DYE 539.14 502.96 647.37 595.86 71270 26 CT THORAX W/O & W/DYE 106.87 103.30 71275 CT ANGIOGRAPHY, CHEST 802.43 753.64 71275 TC CT ANGIOGRAPHY, CHEST 652.69 608.89 655.71 603.54 71275 26 CT ANGIOGRAPHY, CHEST 149.74 144.75 71550 MRI CHEST W/O DYE 960.37 899.74 71550 TC MRI CHEST W/O DYE 847.76 790.86 664.20 611.37 71550 26 MRI CHEST W/O DYE 112.61 108.88 71552 MRI CHEST W/O & W/DYE 1,425.20 1,335.46 71552 TC MRI CHEST W/O & W/DYE 1,249.54 1,165.66 1,033.50 951.27 71552 26 MRI CHEST W/O & W/DYE 175.66 169.81 71555 MRI ANGIO CHEST W OR W/O DYE 940.15 881.81 71555 TC MRI ANGIO CHEST W OR W/O DYE 798.85 745.23 71555 26 MRI ANGIO CHEST W OR W/O DYE 141.30 136.58 72010 X-RAY SPINE ANTEROPOST & LATERAL 124.49 117.37 72010 TC X-RAY SPINE ANTEROPOST & LATERAL 89.03 83.09 146.91 135.24 72010 26 X-RAY SPINE ANTEROPOST & LATERAL 35.46 34.28 72020 X-RAY SPINE SINGLE VIEW SPECIFY LEVEL 40.10 37.84 72020 TC X-RAY SPINE SINGLE VIEW SPECIFY LEVEL 27.88 26.05 54.99 50.61 72020 26 X-RAY SPINE SINGLE VIEW SPECIFY LEVEL 12.21 11.79 72040 X-RAY NECK SPINE CERV 2/3 VIEWS 102.52 96.69 72040 TC X-RAY NECK SPINE CERV 2/3 VIEWS 73.56 68.66 87.24 80.31 72040 26 X-RAY NECK SPINE CERV 2/3 VIEWS 28.96 28.03 72050 X-RAY NECK SPINE CERV MINIMUM 4 VIEWS 119.60 112.79 72050 TC X-RAY NECK SPINE CERV MINIMUM 4 VIEWS 86.14 80.40 127.50 117.36 72050 26 X-RAY NECK SPINE CERV MINIMUM 4 VIEWS 33.46 32.39 72052 X-RAY NECK SPINE COMPLETE 147.68 139.10 72052 TC X-RAY NECK SPINE COMPLETE 110.33 102.97 146.91 135.24 72052 26 X-RAY NECK SPINE COMPLETE 37.35 36.13 72069 X-RAY TRUNK SPINE STANDING 62.74 59.20 72069 TC X-RAY TRUNK SPINE STANDING 44.20 41.25 87.24 80.31 72069 26 X-RAY TRUNK SPINE STANDING 18.55 17.95 72070 X-RAY THORACIC SPINE 2 VIEWS 80.74 76.17 72070 TC X-RAY THORACIC SPINE 2 VIEWS 55.96 52.26 78.36 72.12 72070 26 X-RAY THORACIC SPINE 2 VIEWS 24.78 23.92 72072 X-RAY THORACIC SPINE 3 VIEWS 63.45 59.80 72072 TC X-RAY THORACIC SPINE 3 VIEWS 46.53 43.43 87.24 80.31 72072 26 X-RAY THORACIC SPINE 3 VIEWS 16.93 16.36 72074 X-RAY THORACIC SPINE MINIMUM 4 VIEWS 75.09 70.66 72074 TC X-RAY THORACIC SPINE MINIMUM 4 VIEWS 58.16 54.30 87.24 80.31 72074 26 X-RAY THORACIC SPINE MINIMUM 4 VIEWS 16.93 16.36 72080 X-RAY TRUNK SPINE 2 VIEWS 61.58 58.12

11:3-29.6 APPENDIX B - REGULATIONS 72080 TC X-RAY TRUNK SPINE 2 VIEWS 43.03 40.17 85.38 78.60 72080 26 X-RAY TRUNK SPINE 2 VIEWS 18.55 17.95 72090 X-RAY TRUNK SPINE SCOLIOSIS STUDY 83.19 78.46 72090 TC X-RAY TRUNK SPINE SCOLIOSIS STUDY 59.33 55.38 118.17 108.78 72090 26 X-RAY TRUNK SPINE SCOLIOSIS STUDY 23.86 23.08 72100 X-RAY LOWER SPINE 2/3 VIEWS 68.57 64.63 72100 TC X-RAY LOWER SPINE 2/3 VIEWS 50.02 46.70 87.24 80.31 72100 26 X-RAY LOWER SPINE 2/3 VIEWS 18.55 17.95 72110 X-RAY LOWER SPINE MINIMUM 4 VIEWS 129.47 122.01 72110 TC X-RAY LOWER SPINE MINIMUM 4 VIEWS 95.06 88.72 136.86 125.97 72110 26 X-RAY LOWER SPINE MINIMUM 4 VIEWS 34.41 33.31 72114 X-RAY LOWER SPINE COMPLETE 125.68 118.29 72114 TC X-RAY LOWER SPINE COMPLETE 96.02 89.60 146.91 135.24 72114 26 X-RAY LOWER SPINE COMPLETE 29.67 28.69 72120 X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS 87.20 82.01 72120 TC X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS 68.65 64.08 87.24 80.31 72120 26 X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS 18.55 17.95 72125 CT NECK SPINE W/O DYE 425.96 399.99 72125 TC CT NECK SPINE W/O DYE 346.40 323.17 375.45 345.60 72125 26 CT NECK SPINE W/O DYE 79.55 76.82 72126 CT NECK SPINE W/DYE 524.34 492.38 72126 TC CT NECK SPINE W/DYE 429.68 400.84 580.71 534.51 72126 26 CT NECK SPINE W/DYE 94.66 91.53 72127 CT NECK SPINE W/O & W/DYE 636.93 597.54 72127 TC CT NECK SPINE W/O & W/DYE 538.56 502.42 647.37 595.86 72127 26 CT NECK SPINE W/O &W/DYE 98.37 95.11 72128 CT CHEST SPINE W/O DYE 425.37 399.45 72128 TC CT CHEST SPINE W/O DYE 345.82 322.63 375.45 345.60 72128 26 CT CHEST SPINE W/O DYE 79.55 76.82 72129 CT CHEST SPINE W/DYE 525.50 493.47 72129 TC CT CHEST SPINE W/DYE 430.26 401.38 580.71 534.51 72129 26 CT CHEST SPINE W/DYE 95.24 92.07 72130 CT CHEST SPINE W/O & W/DYE 637.51 598.08 72130 TC CT CHEST SPINE W/O & W/DYE 539.14 502.96 647.37 595.86 72130 26 CT CHEST SPINE W/O & W/DYE 98.37 95.11 72131 CT LUMBAR SPINE W/O DYE 424.21 398.37 72131 TC CT LUMBAR SPINE W/O DYE 344.66 321.55 375.45 345.60 72131 26 CT LUMBAR SPINE W/O DYE 79.55 76.82 72132 CT LUMBAR SPINE W/DYE 524.34 492.38 72132 TC CT LUMBAR SPINE W/DYE 429.10 400.30 580.71 534.51 72132 26 CT LUMBAR SPINE W/DYE 95.24 92.07 72133 CT LUMBAR SPINE W/O & W/DYE 636.93 597.54 72133 TC CT LUMBAR SPINE W/O & W/DYE 538.56 502.42 647.37 595.86 72133 26 CT LUMBAR SPINE W/O & W/DYE 98.37 95.11 72141 MRI NECK SPINE W/O DYE 936.23 878.43 72141 TC MRI NECK SPINE W/O DYE 788.37 735.46 664.20 611.37 72141 26 MRI NECK SPINE W/O DYE 147.87 142.97 72142 MRI NECK SPINE W/DYE 989.34 928.01 72142 TC MRI NECK SPINE W/DYE 840.19 783.80 846.36 779.04 72142 26 MRI NECK SPINE W/DYE 149.16 144.21 72146 MRI CHEST SPINE W/O DYE 801.97 752.41 72146 TC MRI CHEST SPINE W/O DYE 677.15 631.70 664.20 611,37 72146 26 MRI CHEST SPINE W/O DYE 124.83 120.69 72147 MRI CHEST SPINE W/DYE 890.93 836.21 72147 TC MRI CHEST SPINE W/DYE 741.19 691.46 846.36 779.04 72147 26 MRI CHEST SPINE W/DYE 149.74 144.75 72148 MRI LUMBAR SPINE W/O DYE 901.45 845.45 72148 TC MRI LUMBAR SPINE W/O DYE 769.58 717.94 664.20 611.37 72148 26 MRI LUMBAR SPINE W/O DYE 131.85 127.52 72149 MRI LUMBAR SPINE W/DYE 887.91 833.04 72149 TC MRI LUMBAR SPINE W/DYE 748.77 698.52 846.36 779.04 72149 26 MRI LUMBAR SPINE W/DYE 139.14 134.52 72156 MRI NECK SPINE W/O & W/DYE 1,227.571,151,99

MEDICAL FEE SCHEDULES 11:3-29.6 72156 TC MRI NECK SPINE W/O &W/DYE 1,027.10 958.16 1,033.50 951.27 72156 26 MRI NECK SPINE W/O & W/DYE 200.46 193.84 72157 MRI CHEST SPINE W/O & W/DYE 1,153.62 1,083.01 72157 TC MRI CHEST SPINE W/O & W/DYE 953.16 889.17 1,033.50 951.27 72157 26 MRI CHEST SPINE W/O & W/DYE 200.46 193.84 72158 MRI LUMBAR SPINE W/O & W/DYE 1,209.34 1,134.48 72158 TC MRI LUMBAR SPINE W/O & W/DYE 1,024.78 955.99 1,033.50 951.27 72158 26 MRI LUMBAR SPINE W/O & W/DYE 184.56 178.49 72170 X-RAY PELVIS 1/2 VIEWS 68.47 64.69 72170 TC X-RAY PELVIS 1/2 VIEWS 46.19 43.14 60.84 56.01 72170 26 X-RAY PELVIS 1/2 VIEWS 22.28 21.55 72190 X-RAY PELVIS MINIMUM 3 VIEWS 70.97 66.85 72190 TC X-RAY PELVIS MINIMUM 3 VIEWS 52.92 49.41 87.24 80.31 72190 26 X-RAY PELVIS MINIMUM 3 VIEWS 18.03 17.45 72191 CT ANGIOGRAPH PELVIS W/O & W/DYE 769.42 722.61 72191 TC CT ANGIOGRAPH PELVIS W/O & W/DYE 627.65 585.53 655.71 603.54 72191 26 CT ANGIOGRAPH PELVIS W/O & W/DYE 141.77 137.08 72192 CT PELVIS W/O DYE 409.56 384.93 72192 TC CT PELVIS W/O DYE 325.44 303.61 375.45 345.60 72192 26 CT PELVIS W/O DYE 84.11 81.30 72193 CT PELVIS W/DYE 497.42 467.12 72193 TC CT PELVIS W/DYE 406.97 379.67 580.71 534.51 72193 26 CT PELVIS W/DYE 90.45 87.45 72194 CT PELVIS W/O & W/DYE 639.05 599.38 72194 TC CT PELVIS W/O & W/DYE 544.39 507.85 647.37 595.86 72194 26 CT PELVIS W/O & W/DYE 94.66 91.53 72195 MRI PELVIS W/O DYE 873.48 818.76 72195 TC MRI PELVIS W/O DYE 759.26 708.30 664.20 611.37 72195 26 MRI PELVIS W/0 DYE 114.23 110.47 72196 MRI PELVIS W/DYE 966.38 906.08 72196 TC MRI PELVIS W/DYE 831.46 775.64 846.36 779.04 72196 26 MRI PELVIS W/DYE 134.92 130.43 72197 MRI PELVIS W/O & W/DYE 1,259.25 1,180.65 72197 TC MRI PELVIS W/O & W/DYE 1,084.17 1,011.38 1,033.50 951.27 72197 26 MRI PELVIS W/O & W/DYE 175.08 169.27 72198 MR ANGIO PELVIS W/O & W/DYE 936.15 878.06 72198 TC MR ANGIO PELVIS W/O & W/DYE 796.52 743.06 72198 26 MR ANGIO PELVIS W/O & W/DYE 139.64 135.00 72200 X-RAY EXAM SACROILIAC JOINTS 49.85 46.98 72200 TC X-RAY EXAM SACROILIAC JOINTS 36.62 34.19 72.54 66.78 72200 26 X-RAY EXAM SACROILIAC JOINTS 13.22 12.79 72202 X-RAY EXAM SACROILIAC JOINTS 58.43 55.04 72202 TC X-RAY EXAM SACROILIAC JOINTS 43.61 40.71 86.55 79.68 72202 26 X-RAY EXAM SACROILIAC JOINTS 14.82 14.32 72220 X-RAY TAILBONE 49.27 46.44 72220 TC X-RAY TAILBONE 36.04 33.65 71.37 65.70 72220 26 X-RAY TAILBONE 13.22 12.79 72240 CONTRAST X-RAY NECK SPINE 372.37 351.09 N1 72240 TC CONTRAST X-RAY NECK SPINE 263.27 245.65 N1 72240 26 CONTRAST X-RAY NECK SPINE 109.10 105.44 N1 72255 CONTRAST X-RAY THORAX SPINE 349.17 329.41 N1 72255 TC CONTRAST X-RAY THORAX SPINE 241.78 225.60 N1 72255 26 CONTRAST X-RAY THORAX SPINE 107.39 103.80 N1 72265 CONTRAST X-RAY LOWER SPINE 355.47 334.98 N1 72265 TC CONTRAST X-RAY LOWER SPINE 256.12 238.96 N1 72265 26 CONTRAST X-RAY LOWER SPINE 99.34 96.02 N1 72270 CONTRAST X-RAY SPINE 552.78 521.08 N1 72270 TC CONTRAST X-RAY SPINE 394.08 367.67 N1 72270 26 CONTRAST X-RAY SPINE 158.70 153.41 N1 72275 EPIDUROGRAPHY 572.81 540.58 N1 72275 TC EPIDUROGRAPHY 390.38 364.28 N1 72275 26 EPIDUROGRAPHY 182.38 176.30 N1 72285 X-RAY C/T SPINE DISK 376.65 356.04 N1 72285 TC X-RAY C/T SPINE DISK 236.40 220.57 N1 72285 26 X-RAY C/T SPINE DISK 140.25 135.46 N1 72291 PERCUT VERT/SACROPLASTY, FLUOR 267.82 258.54 N1 72291 TC PERCUT VERT/SACROPLASTY, FLUOR 161.82 156.18 N1

11:3-29.6 APPENDIX B - REGULATIONS 72291 26 PERCUT VERT/SACROPLASTY, FLUOR 113.43 109.79 N1 72295 X-RAY LOWER SPINE DISK 217.08 204.71 N1 72295 TC X-RAY LOWER SPINE DISK 151.33 141.20 N1 72295 26 X-RAY LOWER SPINE DISK 65.74 63.49 N1 73000 X-RAY COLLAR BONE 48.17 45.40 73000 TC X-RAY COLLAR BONE 35.46 33.11 70.20 64.62 73000 26 X-RAY COLLAR BONE 12.72 12.29 73010 X-RAY SHOULDER BLADE 51.47 48.57 73010 TC X-RAY SHOULDER BLADE 36.62 34.19 72.54 66.78 73010 26 X-RAY SHOULDER BLADE 14.85 14.37 73020 X-RAY SHOULDER 1 VIEW 39.52 37.29 73020 TC X-RAY SHOULDER 1 VIEW 27.88 26.05 54.99 50.61 73020 26 X-RAY SHOULDER 1 VIEW 11.62 11.24 73030 X-RAY SHOULDER MINIMUM 2 VIEWS74.36 70.21 73030 TC X-RAY SHOULDER MINIMUM 2 VIEWS51.56 48.15 71.37 65.70 73030 26 X-RAY SHOULDER MINIMUM 2 VIEWS22.79 22.04 73040 CONTRAST X-RAY SHOULDER 181.40 170.71 N1 73040 TC CONTRAST X-RAY SHOULDER 138.53 129.26 N1 73040 26 CONTRAST X-RAY SHOULDER 42.87 41.45 N1 73060 X-RAY HUMERUS MINIMUM 2 VIEWS 49.27 46.44 73060 TC X-RAY HUMERUS MINIMUM 2 VIEWS 35.46 33.11 70.20 64.62 73060 26 X-RAY HUMERUS MINIMUM 2 VIEWS 13.80 13.33 73070 X-RAY ELBOW 2 VIEWS 47.66 44.91 73070 TC X-RAY ELBOW 2 VIEWS 35.46 33.11 70.20 64.62 73070 26 X-RAY ELBOW 2 VIEWS 12.21 11.79 73080 X-RAY ELBOW MINIMUM 3 VIEWS 57.41 54.04 73080 TC X-RAY ELBOW MINIMUM 3 VIEWS 44.20 41.25 87.24 80.31 73080 26 X-RAY ELBOW MINIMUM 3 VIEWS 13.22 12.79 73090 X-RAY FOREARM 47.01 44.31 73090 TC X-RAY FOREARM 34.29 32.03 67.86 62.46 73090 26 X-RAY FOREARM 12.72 12.29 73092 X-RAY ARM, INFANT 51.67 48.66 73092 TC X-RAY ARM, INFANT 38.95 36.37 77.19 71.07 73050 X-RAY SHOULDERS 64.63 60.92 73050 TC X-RAY SHOULDERS 47.11 43.97 87.24 80.31 73050 26 X-RAY SHOULDERS 17.54 16.95 73092 26 X-RAY ARM, INFANT 12.72 12.29 73100 X-RAY WRIST 2 VIEWS 52.13 49.16 73100 TC X-RAY WRIST 2 VIEWS 37.79 35.29 74.85 68.91 73100 26 X-RAY WRIST 2 VIEWS 14.34 13.87 73110 X-RAY WRIST MIN 3 VIEWS 70.95 66.75 73110 TC X-RAY WRIST M 3 VIEWS 55.03 51.37 87.24 80.31 73110 26 X-RAY WRIST MINIMUM 3 VIEWS 15.92 15.38 73115 CONTRAST X-RAY WRIST 183.73 172.89 N1 73115 TC CONTRAST X-RAY WRIST 139.69 130.34 N1 73115 26 CONTRAST X-RAY WRIST 44.04 42.55 N1 73120 X-RAY HAND 2 VIEWS 46.43 43.77 73120 TC X-RAY HAND 2 VIEWS 33.71 31.48 66.69 61.38 73120 26 X-RAY HAND 2 VIEWS 12.72 12.29 73130 X-RAY HAND MINIMUM 3 VIEWS 62.21 58.60 73130 TC X-RAY HAND MINIMUM 3 VIEWS 46.96 43.85 80.70 74.28 73130 26 X-RAY HAND MINIMUM 3 VIEWS 15.25 14.76 73140 X-RAY FINGER(S) M 2 VIEWS 53.05 49.88 73140 TC X-RAY FINGER(S) MINIMUM 2 VIEWS 42.45 39.63 84.21 77.52 73140 26 X-RAY FINGER(S) MINIMUM 2 VIEWS 10.62 10.25 73200 CT UPPER EXTREMITY W/O DYE 414.19 389.09 73200 TC CT UPPER EXTREMITY W/O DYE 334.76 312.31 375.45 345.60 73200 26 CT UPPER EXTREMITY W/O DYE 79.42 76.78 73201 CT UPPER EXTREMITY W/DYE 506.15 475.27 73201 TC CT UPPER EXTREMITY W/DYE 415.69 387.81 580.71 534.51 73201 26 CT UPPER EXTREMITY W/DYE 90.45 87.45 73202 CT UPPER EXTREMITY W/O & W/DYE649.53 609.16 73202 TC CT UPPER EXTREMITY W/O & W/DYE554.86 517.63 647.37 595.86 73202 26 CT UPPER EXTREMITY W/O & W/DYE 94.66 91.53 73206 CT ANGIO UPR EXTREMITY W/O & W/DYE 732.98 688.49 73206 TC CT ANGIO UPR EXTREMITY W/O & W/DYE 592.72 552.94 655.71 603.54 73206 26 CT ANGIO UPR EXTREMITY W/O & W/DYE 140.26 135.54 73218 MRI UPPER EXTREMITY W/O DYE 879.74 824.21

MEDICAL FEE SCHEDULES 11:3-29.6 73218 TC MRI UPPER EXTREMITY W/O DYE 774.97 722.96 664.20 611.37 73218 26 MRI UPPER EXTREMITY W/O DYE 104.76 101.27 73219 MRI UPPER EXTREMITY W/DYE 950.89 891.36 73219 TC MRI UPPER EXTREMITY W/DYE 824.47 769.13 846.36 779.04 73219 26 MRI UPPER EXTREMITY W/DYE 126.42 122.24 73220 MRI UPPER EXTREMITY W/O & W/DYE 1,255.99 1,177.35 73220 TC MRI UPPER EXTREMITY W/O & W/DYE 1,088.83 1,015.73 1,033.50 951.27 73220 26 MRI UPPER EXTREMITY W/O & W/DYE 167.16 161.61 73221 MRI JOINT UPPER EXTREMITY W/O DYE 828.31 776.35 73221 TC MRI JOINT UPPER EXTREMITY W/O DYE 721.40 672.98 664.20 611.37 73221 26 MRI JOINT UPPER EXTREMITY W/O DYE 106.89 103.37 73222 MRI JOINT UPPER EXTREMITY W/DYE 901.39 845.19 73222 TC MRI JOINT UPPER EXTREMITY W/DYE 774.97 722.96 846.36 779.04 73222 26 MRI JOINT UPPER EXTREMITY W/DYE 126.42 122.24 73223 MRI JOINT UPPER EXTREMITY W/O & W/DYE 1,191.36 1,117.06 73223 TC MRI JOINT UPPER EXTREMITY W/O & W/DYE 1,024.78 955.99 1,033.50 951.27 73223 26 MRI JOINT UPPER EXTREMITY W/O & W/DYE 166.58 161.07 73225 MR ANGIO UPPER EXTREMITY W/O & W/DYE 1,024.20 959.93 73225 TC MR ANGIO UPPER EXTREMITY W/O & W/DYE 889.10 829.43 73225 26 MR ANGIO UPPER EXTREMITY W/O & W/DYE 135.10 130.50 73500 X-RAY HIP UNILATERAL 1 VIEW 45.06 42.59 73500 TC X-RAY HIP UNILATERAL 1 VIEW 30.21 28,22 59.67 54.93 73500 26 X-RAY HIP UNILATERAL 1 VIEW 14.85 14.37 73510 X-RAY HIP COMPLETE MINIMUM 2 VIEWS 71.16 67.09 73510 TC X-RAY HIP COMPLETE 2 VIEWS 51.46 48.03 87.24 80.31 73510 26 X-RAY HIP COMPLETE MINIMUM 2 VIEWS 19.70 19.06 73520 X-RAY HIPS MINIMUM 2 VIEWS 68.27 64.45 73520 TC X-RAY HIPS MINIMUM 2 VIEWS 47.11 43.97 87.24 80.31 73520 26 X-RAY HIPS MINIMUM 2 VIEWS 21.16 20.48 73525 X-RAY HIP ARTHROGRAPHY 168.58 158.76 N1 73525 TC X-RAY HIP ARTHROGRAPHY 124.54 116.22 N1 73525 26 X-RAY HIP ARTHROGRAPHY 44.04 42.55 N1 73530 X-RAY HIP DURING OPERATIVE PROCEDURE 60.32 58.24 N1 73530 TC X-RAY HIP DURING OPERATIVE PROCEDURE 37.53 36.22 N1 73530 26 X-RAY HIP DURING OPERATIVE PROCEDURE 23.26 22.51 N1 73540 X-RAY PELVIS & HIPS MINIMUM 2 VIEWS 68.71 64.73 73540 TC X-RAY PELVIS & HIPS MINIMUM 2 VIEWS 51.76 48.32 87.24 80.31 73540 26 X-RAY PELVIS & HIPS MINIMUM 2 VIEWS 16.95 16.40 73542 X-RAY EXAM, SACROILIAC JOINT 137.42 129.77 N1 73542 TC X-RAY EXAM, SACROILIAC JOINT 91.36 85.25 N1 73542 26 X-RAY EXAM, SACROILIAC JOINT 46.06 44.51 N1 73550 X-RAY THIGH 2 VIEWS 53.51 50.53 73550 TC X-RAY THIGH 2 VIEWS 37.60 35.11 66.69 61.38 73550 26 X-RAY THIGH 2 VIEWS 15.91 15.42 73560 X-RAY KNEE 1/2 VIEWS 57.41 54.18 73560 TC X-RAY KNEE 1/2 VIEWS 40.85 38.14 72.54 66.78 73560 26 X-RAY KNEE 1/2 VIEWS 16.56 16.02 73562 X-RAY KNEE 3 VIEWS 74.25 69.95 73562 TC X-RAY KNEE 3 VIEWS 55.13 51.47 87.24 80.31

11:3-29.6 APPENDIX B - REGULATIONS 73562 26 X-RAY KNEE 3 VIEWS 19.12 18.49 73564 X-RAY KNEE, COMPLETE 4/MORE VIEWS 85.62 80.68 73564 TC X-RAY KNEE, COMPLETE 4/MORE VIEWS 63.21 59.00 87.24 80.31 73564 26 X-RAY KNEE, COMPLETE 4/MORE VIEWS 22.40 21.68 73565 X-RAY KNEES STANDING ANTEROPOST 57.28 54.00 73565 TC X-RAY KNEES STANDING ANTEROPOST 41.87 39.08 83.04 76.44 73565 26 X-RAY KNEES STANDING ANTEROPOST 15.43 14.91 73580 X-RAY KNEE ARTHOGRAPHY 222.68 209.25 N1 73580 TC X-RAY KNEE ARTHOGRAPHY 176.95 165.10 N1 73580 26 X-RAY KNEE ARTHOGRAPHY 45.73 44.15 N1 73590 X-RAY TIBIA & FIBULA 2 VIEWS 56.34 53.14 73590 TC X-RAY TIBIA & FIBULA 2 VIEWS 40.26 37.60 65.52 60.30 73590 26 X-RAY TIBIA & FIBULA 2 VIEWS 16.06 15.54 73592 X-RAY LEG, INFANT MINIMUM 2 VIEWS 52.25 49.20 73592 TC X-RAY LEG, INFANT MINIMUM 2 VIEWS 39.53 36.92 78.36 72.12 73592 26 X-RAY LEG, INFANT MINIMUM 2 VIEWS 12.72 12.29 73600 X-RAY ANKLE 2 VIEWS 47.59 44.85 73600 TC X-RAY ANKLE 2 VIEWS 34.87 32.57 69.03 63.54 73600 26 X-RAY ANKLE 2 VIEWS 12.72 12.29 73610 X-RAY ANKLE MINIMUM 3 VIEWS 62.88 59.23 73610 TC X-RAY ANKLE MINIMUM 3 VIEWS 47.63 44.47 81.87 75.36 73610 26 X-RAY ANKLE MINIMUM 3 VIEWS 15.25 14.76 73615 CONTRAST X-RAY ANKLE 174.99 164.73 N1 73615 TC CONTRAST X-RAY ANKLE 130.95 122.20 N1 73615 26 CONTRAST X-RAY ANKLE 44.04 42.55 N1 73620 X-RAY FOOT 2 VIEWS 45.84 43.23 73620 TC X-RAY FOOT 2 VIEWS 33.71 31.48 66.69 61.38 73620 26 X-RAY FOOT 2 VIEWS 12.14 11.74 73630 X-RAY FOOT MINIMUM 3 VIEWS 61.95 58.35 73630 TC X-RAY FOOT MINIMUM 3 VIEWS 46.60 43.51 79.53 73.20 73630 26 X-RAY FOOT MINIMUM 3 VIEWS 15.35 14.86 73650 X-RAY HEEL 47.01 44.31 73650 TC X-RAY HEEL 34.29 32.03 67.86 62.46 73650 26 X-RAY HEEL 12.72 12.29 73660 X-RAY TOE(S) 49.57 46.63 73660 TC X-RAY TOE(S) 39.53 36.92 78.36 72.12 73660 26 X-RAY TOE(S) 10.03 9.71 73700 CT LOWER EXTREMITY W/O DYE 414.77 389.63 73700 TC CT LOWER EXTREMITY W/O DYE 335.35 312.85 375.45 345.60 73700 26 CT LOWER EXTREMITY W/O DYE 79.42 76.78 73701 CT LOWER EXTREMITY W/DYE 510.81 479.62 73701 TC CT LOWER EXTREMITY W/DYE 420.36 392.16 580.71 534.51 73701 26 CT LOWER EXTREMITY W/DYE 90.45 87.45 73706 CT ANGIO LWR EXTREMITY W/O & W/DYE 807.23 758.08 73706 TC CT ANGIO LWR EXTREMITY W/O & W/DYE 658.52 614.32 655.71 603.54 73706 26 CT ANGIO LWR EXTREMITY W/O & W/DYE 148.72 143.76 73718 MRI LOWER EXTREMITY W/O DYE 861.62 807.36 73718 TC MRI LOWER EXTREMITY W/O DYE 756.93 706.12 664.20 611.37 73718 26 MRI LOWER EXTREMITY W/O DYE 104.69 101.24 73719 MRI LOWER EXTREMITY W/DYE 947.98 888.65 73719 TC MRI LOWER EXTREMITY W/DYE 822.14 766.96 846.36 779.04 73719 26 MRI LOWER EXTREMITY W/DYE 125.84 121.69 73720 MRI LOWER EXTREMITY W/O & W/DYE 1,257.16 1,178.43 73720 TC MRI LOWER EXTREMITY W/O & W/DYE 1,090.58 1,017.37 1,033.50 951.27 73720 26 MRI LOWER EXTREMITY W/O & W/DYE 166.58 161.07 73721 MRI JOINT LOWER EXTREMITY W/O DYE 844.02 791.02

MEDICAL FEE SCHEDULES 11:3-29.6 73721 TC MRI JOINT LOWER EXTREMITY W/O DYE 737.71 688.19 664.20 611.37 73721 26 MRI JOINT LOWER EXTREMITY W/O DYE 106.31 102.82 73722 MRI JOINT LOWER EXTREMITY W/DYE 916.47 859.30 73722 TC MRI JOINT LOWER EXTREMITY W/DYE 788.94 735.99 846.36 779.04 73722 26 MRI JOINT LOWER EXTREMITY W/DYE 127.53 123.31 73723 MRI JOINT LWR EXTREMITY W/O & W/DYE 1,189.03 1,114.88 73723 TC MRI JOINT LWR EXTREMITY W/O & W/DYE 1,022.45 953.82 1,033.50 951.27 73723 26 MRI JOINT LWR EXTREMITY W/O & W/DYE 166.58 161.07 73725 MR ANGIO LOWER EXT W OR W/O DYE 938.33 880.13 73725 TC MR ANGIO LOWER EXT W OR W/O DYE 797.10 743.60 73725 26 MR ANGIO LOWER EXT W OR W/O DYE 141.23 136.54 74000 X-RAY ABDOMEN SINGLE ANTEROPOST 41.62 39.34 74000 TC X-RAY ABDOMEN SINGLE ANTEROPOST 27.88 26.05 54.99 50.61 74000 26 X-RAY ABDOMEN SINGLE ANTEROPOST 13.73 13.29 74010 X-RAY ABDOMEN ANTEROPOST & ADDED VW 63.95 60.30 74010 TC X-RAY ABDOMEN ANTEROPOST & ADDED VW 46.53 43.43 87.24 80.31 74010 26 X-RAY ABDOMEN ANTEROPOST & ADDED VW 17.44 16.85 74020 X-RAY ABDOMEN COMPLETE 67.15 63,37 74020 TC X-RAY ABDOMEN COMPLETE 46.53 43.43 87.24 80.31 74020 26 X-RAY ABDOMEN COMPLETE 20.62 19.94 74022 X-RAY EXAM SERIES, ABDOMEN 80.75 76.17 74022 TC X-RAY EXAM SERIES, ABDOMEN 56.42 52.67 112.32 103.38 74022 26 X-RAY EXAM SERIES, ABDOMEN 24.33 23.50 74150 CT ABDOMEN W/O DYE 415.67 390.94 74150 TC CT ABDOMEN W/O DYE 323.11 301.44 375.45 345.60 74150 26 CT ABDOMEN W/O DYE 92.56 89.50 74160 CT ABDOMEN W/DYE 621.20 583.19 74160 TC CT ABDOMEN W/DYE 512.35 477.98 580.71 534.51 74160 26 CT ABDOMEN W/DYE 108.84 105.22 74170 CT ABDOMEN W/O & W/DYE 748.27 701.76 74170 TC CT ABDOMEN W/O & W/DYE 639.30 596.40 647.37 595.86 74170 26 CT ABDOMEN W/O & W/DYE 108.98 105.36 74175 CT ANGIO ABDOM W/O & W/DYE 817.07 767.28 74175 TC CT ANGIO ABDOM W/O & W/DYE 668.42 623.56 655.71 603.54 74175 26 CT ANGIO ABDOM W/O & W/DYE 148.66 143.73 74176 CT ANGIO ABDOM & PELVIS 357.22 337.86 74176 TC CT ANGIO ABDOM & PELVIS 225.87 210.73 375.45 345.60 74176 26 CT ANGIO ABDOM & PELVIS 131.35 127.13 74177 CT ANGIO ABDOM & PELVIS W/CONTRAST 568.57 535.21 74177 TC CT ANGIO ABDOM & PELVIS W/CONTRAST 430.84 401.94 580.71 534.51 74177 26 CT ANGIO ABDOM & PELVIS W/CONTRAST 137.73 133.28 74178 CT ANGIO ABDOM & PELVIS 1+ REGNS 721.91 678.79 74178 TC CT ANGIO ABDOM & PELVIS 1+ REGNS 569.43 531.21 647.37 595.86 74178 26 CT ANGIO ABDOM & PELVIS 1+ REGNS 152.50 147.58 74181 MRI ABDOMEN W/O DYE 780.43 731.90 74181 TC MRI ABDOMEN W/O DYE 667.25 622.46 664.20 611.37 74181 26 MRI ABDOMEN W/O DYE 113.19 109.42 74183 MRI ABDOMEN W/O & W/DYE 1,261.00 1,182.28 74183 TC MRI ABDOMEN W/O & W/DYE 1,086.50 1,013.56 1,033.50 951.27

11:3-29.6 APPENDIX B - REGULATIONS 74183 26 MRI ABDOMEN W/O & W/DYE 174.49 168.71 74220 CONTRAST X-RAY, ESOPHAGUS 151.79 142.85 74220 TC CONTRAST X-RAY, ESOPHAGUS 115.82 108.07 167.97 154.59 74220 26 CONTRAST X-RAY, ESOPHAGUS 35.97 34.77 74230 CINE/VIDEO X-RAY, THROAT/ESOPH 153.59 144.71 74230 TC CINE/VIDEO X-RAY, THROAT/ESOPH 112.32 104.80 167.97 154.59 74230 26 CINE/VIDEO X-RAY, THROAT/ESOPH 41.27 39.89 74241 X-RAY EXAM, UPPER GI TRACT W/KUB 198.98 187.44 74241 TC X-RAY EXAM, UPPER GI TRACT W/KUB 146.09 136.31 167.97 154.59 74241 26 X-RAY EXAM, UPPER GI TRACT W/KUB 52.88 51.12 74246 CONTRAST X-RAY UGI TRACT W/O KUB 213.47 200.98 74246 TC CONTRAST X-RAY UGI TRACT W/O KUB 159.49 148.82 167.97 154.59 74246 26 CONTRAST X-RAY UGI TRACT W/O KUB 53.99 52.18 74280 CONTRAST X-RAY COLON W/WO GLUCOGEN 357.90 336.48 74280 TC CONTRAST X-RAY COLON W/WO GLUCOGEN 281.19 262.33 274.98 253.11 74280 26 CONTRAST X-RAY COLON W/WO GLUCOGEN 76.71 74.15 74290 CONTRAST X-RAY, GALLBLADDER 115.11 108.23 74290 TC CONTRAST X-RAY, GALLBLADDER 90.78 84.71 167.97 154.59 74290 26 CONTRAST X-RAY, GALLBLADDER 24.33 23.50 74330 X-RAY BILE/PANCREAS ENDOSCOPY300.56 290.09 N1 74330 TC X-RAY BILE/PANCREAS ENDOSCOPY230.31 222.27 N1 74330 26 X-RAY BILE/PANCREAS ENDOSCOPY 72.02 69.63 N1 74400 CONTRAST X-RAY URINARY TRACT 188.82 177.48 74400 TC CONTRAST X-RAY URINARY TRACT 150.75 140.66 301.83 277.83 74400 26 CONTRAST X-RAY URINARY TRACT 38.07 36.82 74410 CONTRAST X-RAY URINARY TRACT 194.65 182.91 74410 TC CONTRAST X-RAY URINARY TRACT 155.99 145.55 312.36 287.52 74410 26 CONTRAST X-RAY URINARY TRACT 38.65 37.36 74415 CONTRAST X-RAY URINARY TRACT 230.76 216.59 74415 TC CONTRAST X-RAY URINARY TRACT 192.68 179.77 341.13 313.98 74415 26 CONTRAST X-RAY URINARY TRACT 38.07 36.82 74420 CONTRAST X-RAY URINARY TRACT 219.86 212.18 74420 TC CONTRAST X-RAY URINARY TRACT 190.87 184.20 341.13 313.98 74420 26 CONTRAST X-RAY URINARY TRACT 28.56 27.63 74425 CONTRAST X-RAY URINARY TRACT 124.29 119.97 N1 74425 TC CONTRAST X-RAY URINARY TRACT 95.30 91.97 N1 74425 26 CONTRAST X-RAY URINARY TRACT 28.56 27.63 N1 74430 CONTRAST X-RAY BLADDER 102.29 96.28 N1 74430 TC CONTRAST X-RAY BLADDER 77.96 72.76 N1 74430 26 CONTRAST X-RAY BLADDER 24.33 23.50 N1 74450 X-RAY URETHRA/BLADDER 132.84 128.21 N1 74450 TC X-RAY URETHRA/BLADDER 106.33 102.60 N1 74450 26 X-RAY URETHRA/BLADDER 26.46 25.59 N1 74455 X-RAY URETHRA/BLADDER 151.71 142.41 N1 74455 TC X-RAY URETHRA/BLADDER 126.29 117.85 N1 74455 26 X-RAY URETHRA/BLADDER 25.42 24.56 N1 74475 X-RAY CONTROL, CATH INSERT 188.45 177.25 N1 74475 TC X-RAY CONTROL, OATH INSERT 146.09 136.31 N1 74475 26 X-RAY CONTROL, OATH INSERT 42.36 40.94 N1 74480 X-RAY CONTROL, OATH INSERT 189.03 177.79 N1 74480 TC X-RAY CONTROL, OATH INSERT 146.67 136.86 N1 74480 26 X-RAY CONTROL, OATH INSERT 42.36 40.94 N1 74485 X-RAY GUIDE, GU DILATION 186.12 175.08 N1 74485 TC X-RAY GUIDE, GU DILATION 143.77 134.15 N1 74485 26 X-RAY GUIDE, GU DILATION 42.36 40.94 N1 75561 CARDIAC MRI FOR MORPH W/DYE 1,022.10 960.23 75561 TC CARDIAC MRI FOR MORPH W/DYE 816.31 761.53 1,033.50 951.27 75561 26 CARDIAC MRI FOR MORPH W/DYE 205.79 198.70 75572 CT HEART W/3D IMAGE 489.05 460.69 75572 TC CT HEART W/3D IMAGE 358.64 334.58 497.49 457.92 75572 26 CT HEART NV/3D IMAGE 130.41 126.11 75574 CT ANGIO HEART W/3D IMAGE 745.46 701.56 75574 TC CT ANGIO HEART W/3D IMAGE 565.93 527.96 497.49 457.92

MEDICAL FEE SCHEDULES 11:3-29.6 75574 26 CT ANGIO HEART W/3D IMAGE 179.53 173.60 75605 CONTRAST X-RAY AORTA 360.73 339.57 N1 75605 TC CONTRAST X-RAY AORTA 270.12 252.01 N1 75605 26 CONTRAST X-RAY AORTA 90.61 87.55 N1 75625 CONTRAST X-RAY AORTA 361.13 340.04 N1 75625 TC CONTRAST X-RAY AORTA 270.70 252.55 N1 75625 26 CONTRAST X-RAY AORTA 90.42 87.48 N1 75630 X-RAY AORTA, LEG ARTERIES 417.40 394.12 N1 75630 TC X-RAY AORTA, LEG ARTERIES 277.11 258.54 N1 75630 26 X-RAY AORTA, LEG ARTERIES 140.29 135.59 N1 75635 CT ANGIO ABDOMINAL ARTERIES 913.36 858.40 N1 75635 TC CT ANGIO ABDOMINAL ARTERIES 725.35 676.75 N1 75635 26 CT ANGIO ABDOMINAL ARTERIES 188.01 181.66 N1 75650 ARTERY X-RAYS HEAD & NECK 389.94 367.78 N1 75650 TC ARTERY X-RAYS HEAD & NECK 272.45 254.19 N1 75650 26 ARTERY X-RAYS HEAD & NECK 117.50 113.59 N1 75665 ARTERY X-RAYS HEAD & NECK 425.00 400.08 N1 75665 TC ARTERY X-RAYS HEAD & NECK 319.62 298.19 N1 75665 26 ARTERY X-RAYS HEAD & NECK 105.39 101.89 N1 75671 ARTERY X-RAYS HEAD & NECK 494.52 465.82 N1 75671 TC ARTERY X-RAYS HEAD & NECK 363.17 338.89 N1 75671 26 ARTERY X-RAYS HEAD & NECK 131.36 126.95 N1 75676 ARTERY X-RAYS NECK UNILATERAL407.54 383.78 N1 75676 TC ARTERY X-RAYS NECK UNILATERAL302.73 282.44 N1 75676 26 ARTERY X-RAYS NECK UNILATERAL104.80 101.35 N1 75680 ARTERY X-RAYS NECK BILATERAL 460.30 433.83 N1 75680 TC ARTERY X-RAYS NECK BILATERAL 328.94 306.88 N1 75680 26 ARTERY X-RAYS NECK BILATERAL 131.36 126.95 N1 75685 ARTERY X-RAYS SPINE 409.47 385.48 N1 75685 TC ARTERY X-RAYS SPINE 305.65 285.15 N1 75685 26 ARTERY X-RAYS SPINE 103.82 100.33 N1 75705 ARTERY X-RAYS SPINE 472.31 446.19 N1 75705 TC ARTERY X-RAYS SPINE 303.32 282.98 N1 75705 26 ARTERY X-RAYS SPINE 169.00 163.23 N1 75710 ARTERY X-RAYS ARM/LEG 392.29 368.94 N1 75710 TC ARTERY X-RAYS ARM/LEG 304.48 284.06 N1 75710 26 ARTERY X-RAYS ARM/LEG 87.82 84.88 N1 75716 ARTERY X-RAYS ARMS/LEGS 453.48 426.68 N1 75716 TC ARTERY X-RAYS ARMS/LEGS 350.35 326.93 N1 75716 26 ARTERY X-RAYS ARMS/LEGS 103.13 99.75 N1 75722 ARTERY X-RAYS KIDNEY 379.94 357.49 N1 75722 TC ARTERY X-RAYS KIDNEY 289.33 269.93 N1 75722 26 ARTERY X-RAYS KIDNEY 90.61 87.55 N1 75724 ARTERY X-RAYS KIDNEYS 449.53 423.26 N1 75724 TC ARTERY X-RAYS KIDNEYS 329.39 307.38 N1 75724 26 ARTERY X-RAYS KIDNEYS 120.14 115.88 N1 75726 ARTERY X-RAYS ABDOMEN 389.19 366.16 N1 75726 TC ARTERY X-RAYS ABDOMEN 299.82 '279.71 N1 75726 26 ARTERY X-RAYS ABDOMEN 89.37 86.44 N1 75736 ARTERY X-RAYS PELVIS 387.64 364.59 N1 75736 TC ARTERY X-RAYS PELVIS 299.24 279.17 N1 75736 26 ARTERY X-RAYS PELVIS 88.41 85.42 N1 75743 ARTERY X-RAYS LUNGS 408.48 385.48 N1 75743 TC ARTERY X-RAYS LUNGS 278.28 259.62 N1 75743 26 ARTERY X-RAYS LUNGS 130.20 125.85 N1 75774 ARTERY X-RAY, EACH VESSEL 270.73 253.58 N1 75774 TC ARTERY X-RAY, EACH VESSEL 242.17 225.94 N1 75774 26 ARTERY X-RAY, EACH VESSEL 28.56 27.63 N1 75809 NONVASCULAR SHUNT, X-RAY 164.52 154.76 N1 75809 TC NONVASCULAR SHUNT, X-RAY 127.46 118.93 N1 75809 26 NONVASCULAR SHUNT, X-RAY 37.06 35.83 N1 75820 VEIN X-RAY ARM/LEG 210.48 198.23 N1 75820 TC VEIN X-RAY ARM/LEG 155.41 145.01 N1 75820 26 VEIN X-RAY ARM/LEG 55.07 53.22 N1 75822 VEIN X-RAY ARMS/LEGS 256.52 242.15 N1 75822 TC VEIN X-RAY ARMS/LEGS 174.04 162.39 N1 75822 26 VEIN X-RAY ARMS/LEGS 82.47 79.77 N1 75825 VEIN X-RAY TRUNK 345.52 325.41 N1 75825 TC VEIN X-RAY TRUNK 257.32 240.06 N1 75825 26 VEIN X-RAY TRUNK 88.21 85.35 N1 75894 X-RAYS, TRANSCATH THERAPY 1,855.82 1,791.12 N1 75894 TC X-RAYS, TRANSCATH THERAPY 1,753.06 1,691.80 N1

11:3-29.6 APPENDIX B - REGULATIONS 75894 26 X-RAYS, TRANSCATH THERAPY 106.24 102.86 N1 75898 F/U ANGIOGRAPHY 209.00 201.67 N1 75898 TC F/U ANGIOGRAPHY 78.78 76.03 N1 75898 26 F/U ANGIOGRAPHY 135.47 131.11 N1 75940 X-RAY PLACE VEIN FILTER 957.35 924.02 N1 75940 TC X-RAY PLACE VEIN FILTER 914.34 882.41 N1 75940 26 X-RAY PLACE VEIN FILTER 43.27 41.92 N1 75954 26 ILIAC ANEURYSM ENDOVASC REPAIR 183.83 178.42 75957 26 X-RAY, ENDOVASC THOR AO REPAIR494.34 480.01 75960 TRANSCATH IV STENT RS & I 326.56 306.84 N1 75960 TC TRANSCATH IV STENT RS & I 262.56 244.95 N1 75960 26 TRANSCATH IV STENT RS & I 64.01 61.89 N1 75961 RETRIEVE BROKEN CATHETER 601.23 572.18 N1 75961 TC RETRIEVE BROKEN CATHETER 271.28 253.09 N1 75961 26 RETRIEVE BROKEN CATHETER 329.93 319.08 N1 75962 REPAIR ARTERIAL BLOCKAGE 360.81 338.03 N1 75962 TC REPAIR ARTERIAL BLOCKAGE 319.03 297.65 N1 75962 26 REPAIR ARTERIAL BLOCKAGE 41.78 40.39 N1 75964 REPAIR ARTERY BLOCKAGE, EACH 224.67 210.63 N1 75964 TC REPAIR ARTERY BLOCKAGE, EACH 196.17 183.04 N1 75964 26 REPAIR ARTERY BLOCKAGE, EACH 28.51 27.61 N1 75978 REPAIR VENOUS BLOCKAGE 361.40 338.57 N1 75978 TC REPAIR VENOUS BLOCKAGE 320.20 298.73 N1 75978 26 REPAIR VENOUS BLOCKAGE 41.20 39.85 N1 75984 X-RAY CONTROL CATHETER CHANGE 192.29 181.30 N1 75984 TC X-RAY CONTROL CATHETER CHANGE 136.20 127.09 N1 75984 26 X-RAY CONTROL CATHETER CHANGE 56.09 54.21 N1 75989 ABSCESS DRAIN UNDER X-RAY 224.22 212.28 N1 75989 TC ABSCESS DRAIN UNDER X-RAY 132.70 123.82 N1 75989 26 ABSCESS DRAIN UNDER X-RAY 91.52 88.45 N1 76000 FLUOROSCOPE EXAM 304.49 285.18 N1 76000 TC FLUOROSCOPE EXAM 274.00 255.66 N1 76000 26 FLUOROSCOPE EXAM 30.50 29.51 N1 76001 FLUOROSCOPE EXAM, EXTENSIVE 576.95 556.98 N1 76001 TC FLUOROSCOPE EXAM, EXTENSIVE 453.41 437.54 N1 76001 26 FLUOROSCOPE EXAM, EXTENSIVE 128.39 124.16 N1 76010 X-RAY NOSE TO RECTUM 46.27 43.68 76010 TC X-RAY NOSE TO RECTUM 31.96 29.86 63.18 58.17 76010 26 X-RAY NOSE TO RECTUM 14.31 13.83 76080 X-RAY FISTULA 103.44 97.94 N1 76080 TC X-RAY FISTULA 61.08 57.01 N1 76080 26 X-RAY FISTULA 42.36 40.94 N1 76098 X-RAY EXAM, BREAST SPECIMEN 31.87 30.18 N1 76098 TC X-RAY EXAM, BREAST SPECIMEN 19.16 17.91 N1 76098 26 X-RAY EXAM, BREAST SPECIMEN 12.72 12.29 N1 76100 X-RAY BODY SECTION 206.65 194.40 76100 TC X-RAY BODY SECTION 158.32 147.72 146.91 135.24 76100 26 X-RAY BODY SECTION 48.33 46.68 76102 COMPLEX BODY SECTION X-RAYS 403.16 377.88 76102 TC COMPLEX BODY SECTION X-RAYS 349.32 325.88 445.38 409.95 76102 26 COMPLEX BODY SECTION X-RAYS 53.84 52.00 76120 CINEIVIDEO X-RAYS 129.09 121.49 76120 TC CINE/VIDEO X-RAYS 99.50 92.87 161.73 148.86 76120 26 CINE/VIDEO X-RAYS 29.57 28.62 76125 26 CINEIVIDEO X-RAYS, ADDED 22.84 22.06 N1 76376 3D RENDER W/O POST PROCESS 234.29 219.61 N1 76376 TC 3D RENDER W/O POST PROCESS 203.68 190.07 N1 76376 26 3D RENDER W/O POST PROCESS 30.61 29.54 N1 76377 3D RENDERING W/POST PROCESS 297.09 281.18 N1 76377 TC 3D RENDERING W/POST PROCESS 179.06 167.09 N1 76377 26 3D RENDERING W/POST PROCESS 118.06 114.10 N1 76380 CAT SCAN F/U STUDY 318.44 299.62 76380 TC CAT SCAN F/U STUDY 242.75 226.49 219.81 202.32 76380 26 CAT SCAN F/U STUDY 75.69 73.13 76506 ECHO EXAM HEAD 202.86 190.94 76506 TC ECHO EXAM HEAD 153.66 143.37 120.54 110.97 76506 26 ECHO EXAM HEAD 49.18 47.56 76510 OPHTHALMIC US, B & QUANT A 273.79 260.13

MEDICAL FEE SCHEDULES 11:3-29.6 76510 TC OPHTHALMIC US, B & QUANT A 127.46 118.93 255.03 234.75 76510 26 OPHTHALMIC US, B &QUANT A 146.33 141.20 76511 OPHTHALMIC US, QUANT A ONLY 163.45 154.84 76511 TC OPHTHALMIC US, QUANT A ONLY 83.20 77.65 166.14 152.91 76511 26 OPHTHALMIC US, QUANT A ONLY 80.25 77.19 76512 OPHTHALMIC US, B W/NON-QUANT A151.03 143.36 76512 TC OPHTHALMIC US, B W/NON-QUANT A 69.24 64.62 138.03 127.05 76512 26 OPHTHALMIC US, B W/NON-QUANT A 81.81 78.74 76514 ECHO EXAM EYE, THICKNESS 22.48 21.46 76514 TC ECHO EXAM EYE, THICKNESS 7.50 7.03 14.04 12.93 76514 26 ECHO EXAM EYE, THICKNESS 14.96 14.41 76516 ECHO EXAM EYE 119.29 112.66 76516 TC ECHO EXAM EYE 73.31 68.43 120.54 110.97 76516 26 ECHO EXAM EYE 45.97 44.24 76519 ECHO EXAM EYE 129.63 122.38 76519 TC ECHO EXAM EYE 82.04 76.57 163.80 150.78 76519 26 ECHO EXAM EYE 47.59 45.83 76536 US EXAM HEAD & NECK 199.36 187.48 76536 TC US EXAM HEAD & NECK 155.99 145,55 186.48 171.66 76536 26 US EXAM HEAD & NECK 43.37 41.94 76604 US EXAM, CHEST 147.03 138.64 76604 TC US EXAM, CHEST 104.75 97.76 120.54 110.97 76604 26 US EXAM, CHEST 42.28 40.88 76645 US EXAM, BREAST(S) 161.02 151.70 76645 TC US EXAM, BREAST(S) 118.73 110.79 120.54 110.97 76645 26 US EXAM, BREAST(S) 42.29 40.91 76700 US EXAM, ABDOM, COMPLETE 235.86 222.17 76700 TC US EXAM, ABDOM, COMPLETE 167.06 161.85 186.48 171.66 76700 26 US EXAM, ABDOM, COMPLETE 62.40 60.32 76705 ECHO EXAM ABDOMEN 179.34 168.88 76705 TC ECHO EXAM ABDOMEN 133.87 124.91 186.48 171.66 76705 26 ECHO EXAM ABDOMEN 45.47 43.97 76770 US EXAM ABDOM BACK WALL, COMP224.16 211.09 76770 TC US EXAM ABDOM BACK WALL, COMP167.06 155.86 186.48 171.66 76770 26 US EXAM ABDOM BACK WALL, COMP57.10 55.21 76775 US EXAM ABDOM BACK WALL, LIM 187.57 176.53 76775 TC US EXAM ABDOM BACK WALL, LIM 142.02 132.52 186.48 171.66 76775 26 US EXAM ABDOM BACK WALL, LIM 45.55 44.01 76776 US EXAM K TRANSPLANT W/DOPPLER254.87 239.78 76776 TC US EXAM K TRANSPLANT W/DOPPLER196.17 183.04 186.48 171.66 76776 26 US EXAM K TRANSPLANT W/DOPPLER58.70 56.76 76800 US EXAM, SPINAL CANAL 220.65 208.77 76800 TC US EXAM, SPINAL CANAL 135.03 125.99 186.48 171.66 76800 26 US EXAM, SPINAL CANAL 85.62 82.78 76801 OBSTET US < 14 WKS, SINGLE FETUS 216.53 204.54 76801 TC OBSTET US < 14 WKS, SINGLE FETUS 140.28 130.88 186.48 171.66 76801 26 OBSTET US < 14 WKS, SINGLE FETUS 76.26 73.65 76805 OBSTET US >/= 14 WKS, SINGLE FETUS 249.13 234.96 76805 TC OBSTET US >/= 14 WKS, SINGLE FETUS 172.87 161.31 186.48 171.66 76805 26 OBSTET US >/= 14 WKS, SINGLE FETUS 76.26 73.65 76810 OBSTET US >/= 14 WKS, ADDED FETUS 160.70 152.44 76810 TC OBSTET US >/= 14 WKS, ADDED FETUS 85.53 79.82 170.82 157.23 76810 26 OBSTET US >/= 14 WKS, ADDED FETUS 75.16 72.62 76811 OBSTET US, DETAILED, SINGLE FETUS 317.90 301.40 76811 TC OBSTET US, DETAILED, SINGLE FETUS 171.71 160.21 296.28 272.73 76811 26 OBSTET US, DETAILED, SINGLE FETUS 146.19 141.18 76814 OBSTET US NUCHAL MEAS, ADDED 131.51 125.24 76814 TC OBSTET US NUCHAL MEAS, ADDED 55.83 52.13 111.15 102.30 76814 26 OBSTET US NUCHAL MEAS, ADDED 75.67 73.11 76815 OBSTET US, LIMITED, FETUS(S) 152.23 143.66 76815 TC OBSTET US, LIMITED, FETUS(S) 103.00 96.12 120.54 110.97 76815 26 OBSTET US, LIMITED, FETUS(S) 49.23 47.55 76816 OBSTET US, F/U, PER FETUS 194.86 183.99

11:3-29.6 APPENDIX B - REGULATIONS 76816 TC OBSTET US, F/U, PER FETUS 129.20 120.56 120.54 110.97 76816 26 OBSTET US, F/U, PER FETUS 65.65 63.42 76817 TRANSVAGINAL US, OBSTETRIC 172.32 162.71 76817 TC TRANSVAGINAL US, OBSTETRIC 114.65 106.98 120.54 110.97 76817 26 TRANSVAGINAL US, OBSTETRIC 57.67 55.73 76818 FETAL BIOPHYS PROFILE W/NST 202.69 191.78 76818 TC FETAL BIOPHYS PROFILE W/NST 121.64 113.50 186.48 171.66 76818 26 FETAL BIOPHYS PROFILE W/NST 81.04 78.27 76819 FETAL BIOPHYS PROFILE W/O NST 152.37 144.15 76819 TC FETAL BIOPHYS PROFILE W/O NST 92.53 86.34 184.83 170.13 76819 26 FETAL BIOPHYS PROFILE W/O NST 59.86 57.81 76820 UMBILICAL ARTERY ECHO 76.50 72.65 76820 TC UMBILICAL ARTERY ECHO 38.37 35.83 76.02 69.99 76820 26 UMBILICAL ARTERY ECHO 38.13 36.82 76821 MIDDLE CEREBRAL ARTERY ECHO 162.22 153.16 76821 TC MIDDLE CEREBRAL ARTERY ECHO 107.66 100.47 120.54 110.97 76821 26 MIDDLE CEREBRAL ARTERY ECHO 54.56 52.71 76826 ECHO EXAM FETAL HEART 208.98 197.12 76826 TC ECHO EXAM FETAL HEART 145.52 135.77 291.30 268.14 76826 26 ECHO EXAM FETAL HEART 63.48 61.35 76827 ECHO EXAM FETAL HEART 109.66 103.78 76827 TC ECHO EXAM FETAL HEART 65.74 61.36 120.54 110.97 76827 26 ECHO EXAM FETAL HEART 43.93 42.43 76828 ECHO EXAM FETAL HEART 79.54 75.63 76828 TC ECHO EXAM FETAL HEART 36.62 34.19 72.54 66.78 76828 26 ECHO EXAM FETAL HEART 42.92 41.44 76830 TRANSVAGINAL US, NON-OB 210.04 197.76 76830 TC TRANSVAGINAL US, NON-OB 156.57 146.09 186.48 171.66 76830 26 TRANSVAGINAL US, NON-0B 53.46 51.66 76856 US EXAM, PELVIC, COMPLETE 209.45 197.22 76856 TC US EXAM, PELVIC, COMPLETE 155.99 145.55 186.48 171.66 76856 26 US EXAM, PELVIC, COMPLETE 53.46 51.66 76857 US EXAM, PELVIC, LIMITED 171.60 161.14 76857 TC US EXAM, PELVIC, LIMITED 140.86 131.42 120.54 110.97 76857 26 US EXAM, PELVIC, LIMITED 30.74 29.71 76870 US EXAM, SCROTUM 208.60 196.32 76870 TC US EXAM, SCROTUM 158.32 147.72 186.48 171.66 76870 26 US EXAM, SCROTUM 50.28 48.60 76872 US, TRANSRECTAL 236.77 222.71 76872 TC US, TRANSRECTAL 181.61 169.45 186.48 171.66 76872 26 US, TRANSRECTAL 55.15 53.26 76881 US XTR NON-VASC COMPLETE 192.67 181.34 76881 TC US XTR NON-VASC COMPLETE 147.84 137.94 186.48 171.66 76881 26 US XTR NON-VASC COMPLETE 44.84 43.40 76882 US XTR NON-VASC LMTD 48.50 46.38 76882 TC US XTR NON-VASC LMTD 17.41 16.27 33.93 31.23 76882 26 US XTR NON-VASC LMTD 31.09 30.11 76937 US GUIDE VASCULAR ACCESS 57.48 54.50 N1 76937 TC US GUIDE VASCULAR ACCESS 33.71 31.48 N1 76937 26 US GUIDE VASCULAR ACCESS 23.77 23.01 N1 76942 ECHO GUIDE FOR BIOPSY 334.15 313.52 N1 76942 TC ECHO GUIDE FOR BIOPSY 281.77 262.89 N1 76942 26 ECHO GUIDE FOR BIOPSY 52.38 50.65 N1 76998 US GUIDE, INTRAOP 293.61 283.70 N1 76998 TC US GUIDE, INTRAOP 197.37 190.50 N1 76998 26 US GUIDE, INTRAOP 101.78 98.78 N1 77001 FLUOROGUIDE FOR VEIN DEVICE 193.72 181.78 N1 77001 TC FLUOROGUIDE FOR VEIN DEVICE 163.57 152.61 N1 77001 26 FLUOROGUIDE FOR VEIN DEVICE 30.16 29.16 N1 77002 NEEDLE LOCALIZATION BY X-RAY 289.77 273.67 N1 77002 TC NEEDLE LOCALIZATION BY X-RAY 190.67 177.94 N1 77002 26 NEEDLE LOCALIZATION BY X-RAY 99.07 95.73 N1 77003 FLUOROGUIDE FOR SPINE INJECT 236.32 224.15 N1 77003 TC FLUOROGUIDE FOR SPINE INJECT 130.19 121.54 N1 77003 26 FLUOROGUIDE FOR SPINE INJECT 106.12 102.61 N1 77011 CT SCAN FOR LOCALIZATION 819.82 767.90 N1 77011 TC CT SCAN FOR LOCALIZATION 724.89 676.25 N1 77011 26 CT SCAN FOR LOCALIZATION 94.93 91.65 N1 77012 CT SCAN FOR NEEDLE BIOPSY 271.67 256.43 N1 77012 TC CT SCAN FOR NEEDLE BIOPSY 182.78 170.54 N1 77012 26 CT SCAN FOR NEEDLE BIOPSY 88.89 85.90 N1 77032 GUIDANCE FOR NEEDLE, BREAST 91.65 86.98 N1

MEDICAL FEE SCHEDULES 11:3-29.6 77032 TC GUIDANCE FOR NEEDLE, BREAST 48.27 45.06 N1 77032 26 GUIDANCE FOR NEEDLE, BREAST 43.37 41.94 N1 77051 COMPUTER DIAG MAMMOGRAM, ADDED 19.23 18.15 77051 TC COMPUTER DIAG MAMMOGRAM, ADDED 14.50 13.56 77051 26 COMPUTER DIAG MAMMOGRAM, ADDED 4.73 4.59 77052 COMP SCREEN MAMMOGRAM, ADDED19.23 18.15 77052 TC COMP SCREEN MAMMOGRAM, ADDED14.50 13.56 77052 26 COMP SCREEN MAMMOGRAM, ADDED 4.73 4.59 77055 MAMMOGRAM, ONE BREAST 142.93 135.22 77055 TC MAMMOGRAM, ONE BREAST 88.45 82.54 77055 26 MAMMOGRAM, ONE BREAST 54.48 52.68 77056 MAMMOGRAM, BOTH BREASTS 182.95 172.99 77056 TC MAMMOGRAM, BOTH BREASTS 115.24 107.53 77056 26 MAMMOGRAM, BOTH BREASTS 67.71 65.47 77057 MAMMOGRAM, SCREENING 133.62 126.53 77057 TC MAMMOGRAM, SCREENING 79.13 73.85 77057 26 MAMMOGRAM, SCREENING 54.48 52.68 77058 MRI ONE BREAST 1,287.39 1,205.28 77058 TC MRI ONE BREAST 1,160.46 1,082.55 77058 26 MRI ONE BREAST 126.93 122.74 77059 MRI BOTH BREASTS 1,336.30 1,250.91 77059 TC MRI BOTH BREASTS 1,209.37 1,128.17 77059 26 MRI BOTH BREASTS 126.93 122.74 77072 X-RAYS FOR BONE AGE 39.21 37.12 77072 TC X-RAYS FOR BONE AGE 24.40 22.79 47.97 44.16 77072 26 X-RAYS FOR BONE AGE 14.82 14.32 77073 X-RAYS, BONE LENGTH STUDIES 65.21 61.67 77073 TC X-RAYS, BONE LENGTH STUDIES 41.87 39.08 83.04 76.44 77073 26 X-RAYS, BONE LENGTH STUDIES 23.35 22.58 77074 X-RAYS, BONE SURVEY, LIMITED 116.91 110.30 77074 TC X-RAYS, BONE SURVEY, LIMITED 81.46 76.03 146.91 135.24 77074 26 X-RAYS, BONE SURVEY, LIMITED 35.46 34.28 77075 X-RAYS, BONE SURVEY COMPLETE 172.73 162.59 77075 TC X-RAYS, BONE SURVEY COMPLETE 130.95 122.20 146.91 135.24 77075 26 X-RAYS, BONE SURVEY COMPLETE 41.78 40.39 77076 X-RAYS, BONE SURVEY, INFANT 167.39 158.04 77076 TC X-RAYS, BONE SURVEY, INFANT 114.07 106.44 146.91 135.24 77076 26 X-RAYS, BONE SURVEY, INFANT 53.32 51.59 77077 JOINT SURVEY, SINGLE VIEW 70.16 66.38 77077 TC JOINT SURVEY, SINGLE VIEW 44.20 41.25 87.24 80.31 77077 26 JOINT SURVEY, SINGLE VIEW 25.96 25.11 77080 DIAG BONE DENSITY, AXIAL 164.52 154.53 77080 TC DIAG BONE DENSITY, AXIAL 147.68 138.21 136.59 125.73 77080 26 DIAG BONE DENSITY, AXIAL 16.85 16.31 77081 DIAG BONE DENSITY/PERIPHERAL 47.72 45.12 77081 TC DIAG BONE DENSITY/PERIPHERAL 32.54 30.40 62.19 57.24 77081 26 DIAG BONE DENSITY/PERIPHERAL 15.18 14.74 77082 DIAG BONE DENSITY, VERTEBRAL FX46.47 43.84 77082 TC DIAG BONE DENSITY, VERTEBRAL FX36.44 34.13 69.03 63.54 77082 26 DIAG BONE DENSITY, VERTEBRAL FX10.03 9.71 77261 RADIATION THERAPY PLANNING 113.00 109.15 77262 RADIATION THERAPY PLANNING 170.00 164.36 77263 RADIATION THERAPY PLANNING 252.06 243.70 77280 SET RADIATION THERAPY FIELD 318.27 298.74 77280 TC SET RADIATION THERAPY FIELD 263.72 246.05 202.35 186.27 77280 26 SET RADIATION THERAPY FIELD 54.56 52.71 77285 SET RADIATION THERAPY FIELD 559.51 524.71 77285 TC SET RADIATION THERAPY FIELD 477.43 445.40 526.05 484.20 77285 26 SET RADIATION THERAPY FIELD 82.08 79.31 77290 SET RADIATION THERAPY FIELD 896.21 840.10 77290 TC SET RADIATION THERAPY FIELD 774.39 722.42 526.05 484.20 77290 26 SET RADIATION THERAPY FIELD 121.82 117.69 77295 SET RADIATION THERAPY FIELD 931.90 881.43 77295 TC SET RADIATION THERAPY FIELD 574.47 536.03 1,150.02 1,058.52 77295 26 SET RADIATION THERAPY FIELD 357.43 345.39 77300 RADIATION THERAPY DOSE PLAN 115.07 108.98 77300 TC RADIATION THERAPY DOSE PLAN 66.32 61.90 132.18 121.68 77300 26 RADIATION THERAPY DOSE PLAN 48.74 47.09 77305 TELETX ISODOSE PLAN SIMPLE 108.64 103.20

11:3-29.6 APPENDIX B - REGULATIONS 77305 TC TELETX ISODOSE PLAN SIMPLE 54.09 50.49 107.64 99.06 77305 26 TELETX ISODOSE PLAN SIMPLE 54.56 52.71 77310 TELETX ISODOSE PLAN INTERMED 153.06 145.56 77310 TC TELETX ISODOSE PLAN INTERMED 70.98 66.25 141.54 130.29 77310 26 TELETX ISODOSE PLAN INTERMED 82.08 79.31 77315 TELETX ISODOSE PLAN COMPLEX 232.39 220.88 77315 TC TELETX ISODOSE PLAN COMPLEX 110.57 103.18 221.13 203.55 77315 26 TELETX ISODOSE PLAN COMPLEX 121.82 117.69 77321 SPECIAL TELETX PORT PLAN 176.00 166.68 77321 TC SPECIAL TELETX PORT PLAN 102.42 95.58 204.75 188.46 77321 26 SPECIAL TELETX PORT PLAN 73.58 71.10 77331 SPECIAL RADIATION DOSIMETRY 101.48 96.97 77331 TC SPECIAL RADIATION DOSIMETRY 33.13 30.94 65.52 60.30 77331 26 SPECIAL RADIATION DOSIMETRY 68.35 66.02 77332 RADIATION TREAT AID(S) 130.80 123.48 77332 TC RADIATION TREAT AID(S) 88.45 82.54 176.64 162.60 77332 26 RADIATION TREAT AID(S) 42.36 40.94 77333 RADIATION TREAT AID(S) 95.88 91.67 77333 TC RADIATION TREAT AID(S) 30.21 28.22 59.67 54.93 77333 26 RADIATION TREAT AID(S) 65.67 63.45 77334 RADIATION TREAT AID(S) 253.55 239.75 77334 TC RADIATION TREAT AID(S) 157.16 146.64 314.70 289.68 77334 26 RADIATION TREAT AID(S) 96.39 93.11 77336 RADIATION PHYSICS CONSULT 89.61 83.63 178.98 164.73 77371 SRS, MULTISOURCE 2,070.29 1,900.21 14,838.51 13,658.16 77403 RADIATION TX SING AREA 6-10MEV 224.70 209.65 189.45 174.39 77413 RADIATION TX 3/MORE AREA 6-10MEV 401.73 374.78 310.95 286.23 77414 RADIATION TX 3/MORE AREA 11-19MEV 449.47 419.32 310.95 286.23 77417 RADIOLOGY PORT FILM(S) 25.57 23.87 N1 77427 RADIATION TX MANAGEMENT, X5 282.30 272.51 77431 RADIATION THERAPY MANAGEMENT155.03 149.53 77470 SPECIAL RADIATION TREAT 330.15 313.46 77470 TC SPECIAL RADIATION TREAT 166.48 155.32 333.42 306.90 77470 26 SPECIAL RADIATION TREAT 163.67 158.12 78006 THYROID IMAGING W/UPTAKE 400.08 374.61 78006 TC THYROID IMAGING W/UPTAKE 362.01 337.79 425.13 391.32 78006 26 THYROID IMAGING W/UPTAKE 38.07 36.82 78007 THYROID IMAGE, MULT UPTAKES 330.70 309.92 78007 TC THYROID IMAGE, MULT UPTAKES 292.13 272.61 425.13 391.32 78007 26 THYROID IMAGE, MULT UPTAKES 38.58 37.32 78102 BONE MARROW IMAGING, LTD 280.83 263.53 78102 TC BONE MARROW IMAGING, LTD 239.14 223.18 497.82 458.22 78102 26 BONE MARROW IMAGING, LTD 41.69 40.34 78103 BONE MARROW IMAGING, MULT 370.12 347.33 78103 TC BONE MARROW IMAGING, MULT 313.68 292.71 497.82 458.22 78103 26 BONE MARROW IMAGING, MULT 56.45 54.63 78215 LIVER & SPLEEN IMAGING 325.54 305.08 78215 TC LIVER & SPLEEN IMAGING 287.47 268.26 513.54 472.68 78215 26 LIVER & SPLEEN IMAGING 38.07 36.82 78220 LIVER FUNCTION STUDY 230.17 216.05 78220 TC LIVER FUNCTION STUDY 193.72 180.82 513.54 472.68 78220 26 LIVER FUNCTION STUDY 36.45 35.23 78223 HEPATOBILIARY IMAGING 560.43 525.09 78223 TC HEPATOBILIARY IMAGING 495.93 462.72 513.54 472.68 78223 26 HEPATOBILIARY IMAGING 64.50 62.36 78232 SALIVARY GLAND FUNCTION EXAM197.59 185.66 78232 TC SALIVARY GLAND FUNCTION EXAM163.44 152.57 463.50 426.63 78232 26 SALIVARY GLAND FUNCTION EXAM 34.15 33.11 78300 BONE IMAGING, LIMITED AREA 297.19 278.96 78300 TC BONE IMAGING, LIMITED AREA 249.03 232.42 473.94 436.23 78300 26 BONE IMAGING, LIMITED AREA 48.16 46.54 78305 BONE IMAGING, MULTIPLE AREAS 392.22 368.16 78305 TC BONE IMAGING, MULTIPLE AREAS 328.81 306.83 473.94 436.23 78305 26 BONE IMAGING, MULTIPLE AREAS 63.41 61.32 78306 BONE IMAGING, WHOLE BODY 427.52 401.16 78306 TC BONE IMAGING, WHOLE BODY 361.42 337.25 473.94 436.23 78306 26 BONE IMAGING, WHOLE BODY 66.11 63.91 78315 BONE IMAGING, 3 PHASE 583.48 547.06 78315 26 BONE IMAGING, 3 PHASE 78.23 75.64 78320 BONE IMAGING (3D) 410.39 385.64

MEDICAL FEE SCHEDULES 11:3-29.6 78320 TC BONE IMAGING (3D) 331.14 309.00 473.94 436.23 78320 26 BONE IMAGING (3D) 79.25 76.64 78445 VASCULAR FLOW IMAGING 289.56 271.46 78445 TC VASCULAR FLOW IMAGING 253.11 236.21 388.05 357.18 78445 26 VASCULAR FLOW IMAGING 36.45 35.23 78451 HEART MUSCLE IMAGE SPECT, SING 573.80 538.92 78451 TC HEART MUSCLE IMAGE SPECT, SING 471.47 439.91 1,471.83 1,354.74 78451 26 HEART MUSCLE IMAGE SPECT, SING 102.33 98.99 78452 HEART MUSCLE IMAGE SPECT, MULT806.02 756.16 78452 TC HEART MUSCLE IMAGE SPECT, MULT685.12 639.23 1,471.83 1,354.74 78452 26 HEART MUSCLE IMAGE SPECT, MULT120.91 116.93 78469 HEART INFARCT IMAGE (3D) 434.71 407.96 78469 TC HEART INFARCT IMAGE (3D) 360.26 336.16 564.39 519.48 78469 26 HEART INFARCT IMAGE (3D) 74.45 71.81 78472 GATED HEART, PLANAR, SING 424.29 398.43 78472 TC GATED HEART, PLANAR, SING 347.44 324.22 564.39 519.48 78472 26 GATED HEART, PLANAR, SING 76.85 74.22 78481 HEART FIRST PASS, SING 352.85 331.69 78481 TC HEART FIRST PASS, SING 273.62 255.27 564.39 519.48 78481 26 HEART FIRST PASS, SING 79.24 76.41 78494 HEART IMAGE, SPECT 450.67 423.55 78494 TC HEART IMAGE, SPECT 356.18 332.36 564.39 519.48 78494 26 HEART IMAGE, SPECT 94.49 91.19 78580 LUNG PERFUSION IMAGING 358.61 336.54 78580 TC LUNG PERFUSION IMAGING 302.02 281.84 381.24 350.91 78580 26 LUNG PERFUSION IMAGING 56.59 54.70 78584 LUNG V/Q IMAGE SINGLE BREATH 254.13 239.75 78584 TC LUNG V/Q IMAGE SINGLE BREATH 177.41 165.60 619.65 570.36 78584 26 LUNG V/Q IMAGE SINGLE BREATH 76.71 74.15 78585 LUNG V/Q IMAGING 596.93 559.78 78585 TC LUNG V/Q IMAGING 513.39 479.02 619.65 570.36 78585 26 LUNG V/Q IMAGING 83.53 80.76 78588 PERFUSION LUNG IMAGE 578.30 542.40 78588 TC PERFUSION LUNG IMAGE 494.76 461.64 619.65 570.36 78588 26 PERFUSION LUNG IMAGE 83.53 80.76 78594 VENT IMAGE, MULT PROD, GAS 367.16 344.02 78594 TC VENT IMAGE, MULT PROJ, GAS 327.06 305.21 381.24 350.91 78594 26 VENT IMAGE, MULT PROJ, GAS 40.10 38.81 78596 LUNG DIFFERENTIAL FUNCTION 628.84 589.95 78596 TC LUNG DIFFERENTIAL FUNCTION 534.36 498.57 619.65 570.36 78596 26 LUNG DIFFERENTIAL FUNCTION 94.47 91.38 78607 BRAIN IMAGING (3D) 612.19 574.36 78607 TC BRAIN IMAGING (3D) 519.80 485.00 1,154.88 1,062.99 78607 26 BRAIN IMAGING (3D) 92.38 89.36 78707 KID FLOW/FUNCT IMAGE W/O DRUG 399.99 375.71 78707 TC KID FLOW/FUNCT IMAGE W/O DRUG 327.06 305.21 622.62 573.09 78707 26 KID FLOW/FUNCT IMAGE W/O DRUG 72.93 70.51 78708 KID FLOW/FUNCT IMAGE W/DRUG 300.23 283.29 78315 TC BONE IMAGING, 3 PHASE 505.25 471.42 473.94 436.23 78708 TC KID FLOW/FUNCT IMAGE W/DRUG 207.69 193.85 622.62 573.09 78708 26 KID FLOW/FUNCT IMAGE W/DRUG 92.54 89.46 78709 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 617.12 579.46 78709 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 509.32 475.22 622.62 573.09 78709 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 107.80 104.25 78802 TUMOR IMAGING, WHOLE BODY 553.30 518.48 78802 TC TUMOR IMAGING, WHOLE BODY 487.77 455.12 919.98 846.78 78802 26 TUMOR IMAGING, WHOLE BODY 65.53 63.37 78803 TUMOR IMAGING (3D) 593.44 556.52 78803 TC TUMOR IMAGING (3D) 511.06 476.84 919.98 846.78 78803 26 TUMOR IMAGING (3D) 82.37 79.68 78805 ABSCESS IMAGING, LID AREA 310.29 291.48 78805 TC ABSCESS IMAGING, LTD AREA 254.27 237.31 919.98 846.78 78805 26 ABSCESS IMAGING, LTD AREA 56.00 54.17 78806 ABSCESS IMAGING, WHOLE BODY 573.09 536.94 78806 TC ABSCESS IMAGING, WHOLE BODY 507.58 473.59 919.98 846.78 78806 26 ABSCESS IMAGING, WHOLE BODY 65.53 63.37 78815 PET IMAGE W/CT, SKULL-THIGH 1,978.16 1,852.07 78815 TC PET IMAGE W/CT, SKULL-THIGH 1,785.85 1,665.93 2,018.19 1,857.66 78815 26 PET IMAGE W/CT, SKULL-THIGH 192.33 186.13

11:3-29.6 APPENDIX B - REGULATIONS 79101 NUCLEAR RX, IV ADMIN 261.42 248.93 79101 TC NUCLEAR RX, IV ADMIN 101.83 95.03 203.55 187.38 79101 26 NUCLEAR RX, IV ADMIN 159.59 153.90 80500 LAB PATHOLOGY CONSULTATION 32.57 31.39 83020 26 ASSAY HEMOGLOBIN ELECTROPHORESIS 30.24 29.22 83912 26 ASSAY GENETIC EXAM 28.49 27.58 84165 26 ASSAY PROTEIN E-PHORESIS, SERUM 29.66 28.66 84166 26 ASSAY PROTEIN E-PHORESIS/URINE/CSF 29.66 28.66 84182 26 ASSAY PROTEIN, WESTERN BLOT TEST 29.66 28.66 85060 BLOOD SMEAR INTERPRETATION 36.04 34.83 85097 BONE MARROW INTERPRETATION 139.39 132.50 85576 26 BLOOD PLATELET AGGREGATION 30.24 29.22 86255 26 FLUORESCENT ANTIBODY, SCREEN 30.24 29.22 86256 26 FLUORESCENT ANTIBODY, TITER 29.19 28.17 86334 26 IMMUNOFLX E-PHORESIS, SERUM 30.24 29.22 86335 26 IMMUNOFIX E-PHORESIS/URINE/CSF 29.66 28.66 86510 HISTOPLASMOSIS SKIN TEST 11.00 10.30 86580 TB INTRADERMAL TEST 12.75 11.92 88104 CYTOPATH FL NONGYN, SMEARS 107.49 101.71 88104 TC CYTOPATH FL NONGYN, SMEARS 64.57 60.27 88104 26 CYTOPATH FL NONGYN, SMEARS 42.92 41.44 88106 CYTOPATH FL NONGYN, FILTER 132.53 125.06 88106 TC CYTOPATH FL NONGYN, FILTER 90.20 84.17 88106 26 CYTOPATH FL NONGYN, FILTER 42.33 40.88 88108 CYTOPATH, CONCENTRATE TECH 124.96 117.99 88108 TC CYTOPATH, CONCENTRATE TECH 82.62 77.11 88108 26 CYTOPATH, CONCENTRATE TECH 42.33 40.88 88112 CYTOPATH, CELL ENHANCE TECH 166.71 158.56 88112 TC CYTOPATH, CELL ENHANCE TECH 79.13 73.85 88112 26 CYTOPATH, CELL ENHANCE TECH 87.58 84.72 88120 CYTOPATH, URINE 3-5 PROBES EA SPEC 772.67 723.91 88120 TC CYTOPATH, URINE 3-5 PROBES EA SPEC 692.17 645.78 88120 26 CYTOPATH, URINE 3-5 PROBES EA SPEC 80.50 78.13 88121 CYTOPATH, URINE 3-5 PROBES COMPUTER 652.59 611.34 88121 TC CYTOPATH, URINE 3-5 PROBES COMPUTER 580.48 541.53 88121 26 CYTOPATH, URINE 3-5 PROBES COMPUTER 72.11 69.80 88141 CYTOPATH, C/V, INTERPRET 46.17 44.20 88172 CYTOPATH FNA; 1ST EVAL, EACH SITE 82.15 78.16 88172 TC CYTOPATH FNA; 1ST EVAL, EACH SITE 35.46 33.11 88172 26 CYTOPATH FNA; 1 ST EVAL, EACH SITE 46.68 45.05 88173 CYTOPATH FNA; INTERPRET & REPORT 225.11 213.56 88173 TC CYTOPATH FNA; INTERPRET & REPORT 118.73 110.79 88173 26 CYTOPATH FNA; INTERPRET & REPORT 106.40 102.77 88177 CYTOPATH FNA; ADDED EVAL, SAME SITE 44.48 42.59 88177 TC CYTOPATH FNA; ADDED EVAL, SAME SITE 11.00 10.30 88177 26 CYTOPATH FNA; ADDED EVAL, SAME SITE 33.48 32.29 88184 FLOW CYTOMETRY/ TC, 1 MARKER 143.77 134.15 88185 FLOW CYTOMETRY/TC, ADDED 86.12 80.36 88187 FLOW CYTOMETRY/READ, 2-8 105.20 101.74 88300 SURGICAL PATH, GROSS 45.28 42.50 88300 TC SURGICAL PATH, GROSS 38.37 35.83 88300 26 SURGICAL PATH, GROSS 6.91 6.68 88302 TISSUE EXAM BY PATHOLOGIST 90.32 84.64 88302 TC TISSUE EXAM BY PATHOLOGIST 80.29 74.93

MEDICAL FEE SCHEDULES 11:3-29.6 88302 26 TISSUE EXAM BY PATHOLOGIST 10.03 9.71 88304 TISSUE EXAM BY PATHOLOGIST 105.37 98.91 88304 TC TISSUE EXAM BY PATHOLOGIST 88.45 82.54 88304 26 TISSUE EXAM BY PATHOLOGIST 16.93 16.36 88305 TISSUE EXAM BY PATHOLOGIST 175.94 166.03 88305 TC TISSUE EXAM BY PATHOLOGIST 119.31 111.33 88305 26 TISSUE EXAM BY PATHOLOGIST 56.63 54.70 88307 TISSUE EXAM BY PATHOLOGIST 375.59 354.43 88307 TC TISSUE EXAM BY PATHOLOGIST 251.49 234.63 88307 26 TISSUE EXAM BY PATHOLOGIST 124.10 119.80 88309 TISSUE EXAM BY PATHOLOGIST 565.90 535.11 88309 TC TISSUE EXAM BY PATHOLOGIST 349.19 325.84 88309 26 TISSUE EXAM BY PATHOLOGIST 216.70 209.27 88311 DECALCIFY TISSUE 30.10 28.73 88311 TC DECALCIFY TISSUE 11.58 10.84 88311 26 DECALCIFY TISSUE 18.52 17.91 88312 SPECIAL STAINS GROUP 1 178.67 168.06 88312 TC SPECIAL STAINS GROUP 1 137.94 128.71 88312 26 SPECIAL STAINS GROUP 1 40.73 39.35 88313 SPECIAL STAINS GROUP 2 131.42 123.25 88313 TC SPECIAL STAINS GROUP 2 113.49 105.90 88313 26 SPECIAL STAINS GROUP 2 17.93 17.35 88331 PATH CONSULT INTRAOP, 1 BLOC 147.61 140.67 88331 TC PATH CONSULT INTRAOP, 1 BLOC 54.67 51.03 88331 26 PATH CONSULT INTRAOP, 1 BLOC 92.94 89.63 88332 PATH CONSULT INTRAOP, ADDED 64.76 61.92 88332 TC PATH CONSULT INTRAOP, ADDED 19.16 17.91 88332 26 PATH CONSULT INTRAOP, ADDED 45.60 44.01 88334 INTRAOP CYTO PATH CONSULT, 2 95.03 90.57 88334 TC INTRAOP CYTO PATH CONSULT, 2 37.79 35.29 88334 26 INTRAOP CYTO PATH CONSULT, 2 57.24 55.28 88342 OHISTOCHEMISTRY 171.57 162.26 88342 TC OHISTOCHEMISTRY 107.66 100.47 88342 26 IMMUNOHISTOCHEMISTRY 63.91 61.80 88346 IMMUNOFLUORESCENT STUDY 168.13 159.00 88346 TC IMMUNOFLUORESCENT STUDY 104.17 97.20 88346 26 IMMUNOFLUORESCENT STUDY 63.96 61.80 88360 TUMOR OHISTOCHEM/MANUAL 202.89 192.09 88360 TC TUMOR IMMUNOHISTOCHEM/MANUAL 121.64 113.50 88360 26 TUMOR IMMUNOHISTOCHEM/MANUAL 81.26 78.59 88363 EXAM ARCHIVAL TISSUE MOLECULAR ANAL 62.26 59.09 88367 INSITU HYBRIDIZATION, AUTO 428.95 403.53 88367 TC INSITU HYBRIDIZATION, AUTO 334.76 312.31 88367 26 INSITU HYBRIDIZATION, AUTO 94.19 91.22 88368 INSITU HYBRIDIZATION, MANUAL 365.96 344.97 88368 TC INSITU HYBRIDIZATION, MANUAL 270.12 252.01 88368 26 INSITU HYBRIDIZATION, MANUAL 95.84 92.95 88372 26 PROTEIN ANALYSIS W/PROBE 30.24 29.22 90461 IMM ADMIN 0-18 ANY ROUTE, EA ADDED 18.62 17.76 90471 IMMUNIZATION ADMIN 38.26 36.14 90472 IMMUNIZATION ADMIN, EACH ADDED18.62 17.76 90801 PSYCH DIAG INTERVIEW 242.14 233.10 90802 INTERACT PSYCH DIAG INTERVIEW 263.21 253.31 90804 PSYCH, OFF, 20-30 MIN 103.95 100.23 90805 PSYCH, OFF, 20-30 MINIMUM W/E & M 118.52 114.27 90806 PSYCH, OFF, 45-50 MIN 137.79 133.55 90807 PSYCH, OFF, 45-50 MINIMUM W/E & M 163.35 157.87 90808 PSYCH, OFF, 75-80 MIN 202.42 196.35 90809 PSYCH, OFF, 75-80, W/E & M 228.55 221.21 90810 INTERACT PSYCH, OFF, 20-30 MIN 106.69 103.09 90811 INTERACT PSYCH, 20-30, W/E & M 134.04 129.09 90812 INTERACT PSYCH, OFF, 45-50 MIN 151.59 146.73 90813 INTERACT PSYCH, 45-50 MINIMUM W/E & M 177.78 171.60 90814 INTERACT PSYCH, OFF, 75-80 MIN 218.01 211.20 90816 PSYCH, HOSP, 20-30 MTN 84.68 82.35

11:3-29.6 APPENDIX B - REGULATIONS 90817 PSYCH, HOSP, 20-30 MINIMUM W/E & M 102.93 99.80 90818 PSYCH, HOSP, 45-50 MIN 125.31 122.00 90819 PSYCH, HOSP, 45-50 MINIMUM W/E & M 147.22 142.89 90826 INTERACT PSYCH, HOSP, 45-50 MIN 134.16 130.57 90846 FAMILY PSYCH W/O PATIENT 130.28 126.25 90847 FAMILY PSYCH W/PATIENT 162.90 157.63 90853 GROUP PSYCHOTHERAPY 77.13 74.33 90857 INTERACT GROUP PSYCH 57.98 55.73 90862 MEDICATION MANAGEMENT 105.73 101.47 90880 HYPNOTHERAPY 155.47 150.66 90901 BIOFEEDBACK TRAIN, ANY METHOD114.92 109.20 90911 BIOFEEDBACK PERI/URO/RECTAL 142.55 135.40 90935 HEMODIALYSIS, ONE EVAL 116.53 112.59 90945 DIALYSIS, ONE EVAL 166.37 160.72 90961 ESRD SERVICE, 2-3 VISITS P MO, 20+ 129.32 124.73 90962 ESRD SERVICE, 1 VISIT P MO, 20+ 275.65 265.53 91010 ESOPHAGUS MOTILITY STUDY 311.34 293.84 91010 TC ESOPHAGUS MOTILITY STUDY 203.16 189.54 91010 26 ESOPHAGUS MOTILITY STUDY 108.19 104.29 91013 ESOPH MOTILITY STUDY W/STIM/PERFUS 38.13 36.07 91013 TC ESOPH MOTILITY STUDY W/STIM/PERFUS 22.65 21.16 91013 26 ESOPH MOTILITY STUDY W/STIM/PERFUS 15.48 14.91 92002 EYE EXAM, NEW PATIENT 122.24 116.43 92004 EYE EXAM, NEW PATIENT 225.54 215.25 92012 EYE EXAM ESTABLISHED PAT 129.52 123.31 92014 EYE EXAM & TREAT 187.31 178.54 92020 SPECIAL EYE EVAL 41.88 40.07 92025 CORNEAL TOPOGRAPHY 57.23 54.31 92025 TC CORNEAL TOPOGRAPHY 27.30 25.51 92025 26 CORNEAL TOPOGRAPHY 29.93 28.81 92060 SPECIAL EYE EVAL 98.24 93.46 92060 TC SPECIAL EYE EVAL 39.53 36.92 92060 26 SPECIAL EYE EVAL 58.70 56.54 92065 ORTHOPTIC/PLEOPTIC TRAINING 123.66 116.86 92065 TC ORTHOPTIC/PLEOPTIC TRAINING 81.42 76.02 92065 26 ORTHOPTIC/PLEOPTIC TRAINING 42.22 40.84 92070 FIT CONTACT LENS 109.22 103.74 92081 VISUAL FIELD EXAM(S) LIMITED 80.77 76.23 92081 TC VISUAL FIELD EXAM(S) LIMITED 54.67 51.03 92081 26 VISUAL FIELD EXAM(S) LIMITED 26.11 25.18 92082 VISUAL FIELD EXAM(S) INTERMEDIATE 112.58 106.17 92082 TC VISUAL FIELD EXAM(S) INTERMEDIATE 77.96 72.76 92082 26 VISUAL FIELD EXAM(S) INTERMEDIATE 34.60 33.40 92083 VISUAL FIELD EXAM(S) EXTENDED 140.42 132.35 92083 TC VISUAL FIELD EXAM(S) EXTENDED 97.19 90.69 92083 26 VISUAL FIELD EXAM(S) EXTENDED 43.24 41.67 92132 SCAN COMP OPTH DX IMAGING, ANT SEG 59.44 56.45 92132 TC SCAN COMP OPTH DX IMAGING, ANT SEG 26.15 24.41 92132 26 SCAN COMP OPTH DX IMAGING, ANT SEG 33.30 32.02 92133 SCAN COMP OPTH DX IMAGING, POST SEG 72.29 68.79 92133 TC SCAN COMP OPTH DX IMAGING, POST SEG 26.15 24.41 92133 26 SCAN COMP OPTH DX IMAGING, POST SEG 46.14 44.38 92134 SCAN COMP OPTH DX IMAGING, RETINA 72.29 68.79 92134 TC SCAN COMP OPTH DX IMAGING, RETINA 26.15 24.41 92134 26 SCAN COMP OPTH DX IMAGING, RETINA 46.14 44.38

MEDICAL FEE SCHEDULES 11:3-29.6 92136 OPHTHALMIC BIOMETRY 137.92 130.04 92136 TC OPHTHALMIC BIOMETRY 91.36 85.25 92136 26 OPHTHALMIC BIOMETRY 46.55 44.78 92225 SPECIAL EYE EXAM, INITIAL 40.64 38.95 92226 SPECIAL EYE EXAM, SUBSEQUENT 36.48 34.87 92227 REMOTE IMAGING RETINAL DISEASE 19.74 18.45 92228 REMOTE IMAGING MONITOR RETINAL DIS 48.87 46.40 92228 TC REMOTE IMAGING MONITOR RETINAL DIS 21.49 20.08 92228 26 REMOTE IMAGING MONITOR RETINAL DIS 27.38 26.32 92230 26 FLUORESCEIN ANGIOSCOPY 93.66 88.99 92235 FLUORESCEIN ANGIOGRAPHY 217.30 204.82 92235 TC FLUORESCEIN ANGIOGRAPHY 146.09 136.31 92235 26 FLUORESCEIN ANGIOGRAPHY 71.20 68.50 92250 EYE EXAM W/PHOTOS 122.36 115.28 92250 TC EYE EXAM W/PHOTOS 86.12 80.36 92250 26 EYE EXAM W/PHOTOS 36.24 34.92 92275 ELECTRORETINOGRAPHY 234.95 221.80 92275 TC ELECTRORETINOGRAPHY 147.25 137.40 92275 26 ELECTRORETINOGRAPHY 87.69 84.41 92285 EYE PHOTOGRAPHY 47.25 44.27 92285 TC EYE PHOTOGRAPHY 40.70 38.00 92285 26 EYE PHOTOGRAPHY 6.55 6.27 92286 INTERNAL EYE PHOTOGRAPHY 198.16 186.53 92286 TC INTERNAL EYE PHOTOGRAPHY 143.19 133.60 92286 26 INTERNAL EYE PHOTOGRAPHY 54.98 52.94 92311 CONTACT LENS FITTING APHAKIA ONE EYE 156.21 148.63 92326 REPLACE CONTACT LENS 61.08 57.01 92371 EXT PAT/AUTO ECG TO 30 DAYS, DOWNLOAD 359.22 335.12 92504 EAR MICROSCOPY EXAM 154.22 147.79 92506 SPEECH/HEARING EVAL 50.42 47.51 92507 SPEECH/HEARING THERAPY 279.74 263.23 92508 SPEECH/HEARING THERAPY 130.75 125.38 92511 NASOPHARYNGOSCOPY 43.47 41.40 92526 ORAL FUNCTION THERAPY 267.73 251.93 92540 BASIC VESTIBULAR EVALUATION 155.00 148.43 92540 TC BASIC VESTIBULAR EVALUATION 31.96 29.86 92540 26 BASIC VESTIBULAR EVALUATION 123.04 118.58 92541 SPONTANEOUS NYSTAGMUS TEST 74.91 70.93 92541 TC SPONTANEOUS NYSTAGMUS TEST 43.03 40.17 92541 26 SPONTANEOUS NYSTAGMUS TEST 31.87 30.75 92542 POSITIONAL NYSTAGMUS TEST 74.85 70.70 92542 TC POSITIONAL NYSTAGMUS TEST 48.27 45.06 92542 26 POSITIONAL NYSTAGMUS TEST 26.59 25.64 92543 CALORIC VESTIBULAR TEST 37.56 35.36 92543 TC CALORIC VESTIBULAR TEST 29.05 27.14 92543 26 CALORIC VESTIBULAR TEST 8.51 8.21 92544 OPTOKINETIC NYSTAGMUS TEST 61.40 57.98 92544 TC OPTOKINETIC NYSTAGMUS TEST 40.70 38.00 92544 26 OPTOKINETIC NYSTAGMUS TEST 20.71 19.98 92545 OSCILLATING TRACKING TEST 57.55 54.31 92545 TC OSCILLATING TRACKING TEST 38.95 36.37 92545 26 OSCILLATING TRACKING TEST 18.60 17.95 92546 SINUSOIDAL ROTATIONAL TEST 159.00 149.10 92546 TC SINUSOIDAL ROTATIONAL TEST 136.20 127.09 92546 26 SINUSOIDAL ROTATIONAL TEST 22.81 22.01 92547 SUPPLEMENTAL ELECTRICAL TEST 8.67 8.13 92548 POSTUROGRAPHY 171.41 161.18 92548 TC POSTUROGRAPHY 131.54 122.74 92548 26 POSTUROGRAPHY 39.86 38.44 92550 TYMPANOMETRY & REFLEX THRESH 32.84 31.52 92552 PURE TONE AUDIOMETRY, AIR 43.61 40.71 92553 AUDIOMETRY, AIR & BONE 55.25 51.59 92556 SPEECH AUDIOMETRY, COMPLETE 49.44 46.14 92557 COMPREHENSIVE HEARING TEST 64.62 61.85 92563 TONE DECAY HEARING TEST 42.45 39.63 92564 SISI HEARING TEST 38.37 35.83 92565 STENGER TEST, PURE TONE 22.07 20.62

11:3-29.6 APPENDIX B - REGULATIONS 92567 TYMPANOMETRY 24.64 23.52 92568 ACOUSTIC REFLEX THRESHOLD TEST26.30 25.28 92570 ACOUSTIC IMMITTANCE TESTING 50.43 48.49 92582 CONDITIONING PLAY AUDIOMETRY 87.87 82.00 92584 ELECTROCOCHLEOGRAPHY 114.07 106.44 92585 AUDITOR EVOKE POTENT, COMPRE 292.37 274.71 92585 TC AUDITOR EVOKE POTENT, COMPRE 231.02 215.57 92585 26 AUDITOR EVOKE POTENT, COMPRE 61.33 59.14 92586 AUDITOR EVOKE POTENT, LIMIT 120.48 112.42 92587 EVOKED AUDITORY TEST 62.37 58.58 92587 TC EVOKED AUDITORY TEST 51.17 47.78 92587 26 EVOKED AUDITORY TEST 11.20 10.80 92588 EVOKED AUDITORY TEST 110.73 104.24 92588 TC EVOKED AUDITORY TEST 81.46 76.03 92588 26 EVOKED AUDITORY TEST 29.27 28.22 92607 EXCISE FOR SPEECH DEVICE RX, 1HR287.74 273.29 92611 MOTION FLUOROSCOPY/SWALLOW 183.96 175.16 92612 ENDOSCOPY SWALLOW TEST (FEES) 275.96 260.78 92613 ENDOSCOPY SWALLOW TEST (FEES) 60.24 58.07 92620 AUDITORY FUNCTION, 60 MIN 129.83 125.03 92621 AUDITORY FUNCTION, + 15 MIN 29.93 28.81 92625 TINNITUS ASSESS 99.39 95.70 92626 EVAL AUDITORY REHAB STATUS 132.91 127.66 92950 HEART/LUNG RESUSCITATION CPR 451.32 431.31 92960 CARDIOVERSION ELECTRIC, EXT 395.13 374.58 92971 CARDIOASSIST, EXTERNAL 156.11 150.32 92975 DISSOLVE CLOT, HEART VESSEL 660.35 639.20 92982 CORONARY ARTERY DILATION 1,011.84 978.97 93000 ELECTROCARDIOGRAM, COMPLETE 37.35 35.40 93005 ELECTROCARDIOGRAM, TRACING 28.57 26.72 93010 ELECTROCARDIOGRAM REPORT 19.11 18.46 93015 CARDIOVASCULAR STRESS TEST 152.58 144.27 93016 CARDIOVASCULAR STRESS TEST 36.17 34.87 93017 CARDIOVASCULAR STRESS TEST 92.53 86.34 93018 CARDIOVASCULAR STRESS TEST 23.90 23.06 93040 RHYTHM ECG W/R.EPORT 21.46 20.46 93042 RHYTHM ECG, REPORT 26.83 25.94 93224 ECG MONITOR/REPORT, 24 HRS 161.88 152.38 93225 ECG MONITOR/RECORD, 24 HRS 48.27 45.06 93226 ECG MONITOR/REPORT, 24 HRS 70.98 66.25 93227 ECG MONITOR/REVIEW, 24 HRS 42.63 41.07 93228 REMOTE 30 DAY ECG REV/REPORT 40.17 38.85 93229 REMOTE 30 DAY ECG TECH SUPP 1,167.45 1,089.06 93268 EXT PAT/AUTO ECG TO 30 DAYS, COMPLETE 425.66 398.44 93270 EXT PAT/AUTO ECG TO 30 DAYS, RECORDING 26.15 24.41 93272 EXT PAT/AUTO ECG TO 30 DAYS, REPORT 40.30 38.90 93280 PM DEVICE PROGRAM EVAL, DUAL 100.54 95.81 93280 TC PM DEVICE PROGRAM EVAL, DUAL 36.62 34.19 93280 26 PM DEVICE PROGRAM EVAL, DUAL 63.92 61.62 93281 PM DEVICE PROGRAM EVAL, MULTI 117.04 111.53 93281 TC PM DEVICE PROGRAM EVAL, MULTI 42.45 39.63 93281 26 PM DEVICE PROGRAM EVAL, MULTI 74.59 71.89 93282 ICD DEVICE PROGRAM EVAL, 1 SINGLE 107.52 102.52 93282 TC ICD DEVICE PROGRAM EVAL, 1 SINGLE 37.79 35.29 93282 26 ICD DEVICE PROGRAM EVAL, 1 SINGLE 69.73 67.23 93283 ICD DEVICE PROGRAM EVAL, DUAL 137.23 131.01 93283 TC ICD DEVICE PROGRAM EVAL, DUAL 43.61 40.71 93283 26 ICD DEVICE PROGRAM EVAL, DUAL 93.64 90.30 93284 ICD DEVICE PROGRAM EVAL, MULT 152.79 145.76 93284 TC ICD DEVICE PROGRAM EVAL, MULT 49.44 46.14 93284 26 ICD DEVICE PROGRAM EVAL, MULT 103.36 99.62 93285 ILR DEVICE EVAL PROGRAM 71.68 68.21 93285 TC ILR DEVICE EVAL PROGRAM 29.05 27.14 93285 26 ILR DEVICE EVAL PROGRAM 42.63 41.07 93288 PM DEVICE EVAL IN PERSON 64.79 61.56 93288 TC PM DEVICE EVAL IN PERSON 29.63 27.68

MEDICAL FEE SCHEDULES 11:3-29.6 93288 26 PM DEVICE EVAL IN PERSON 35.16 33.88 93289 ICD DEVICE INTERROGATE 109.91 104.92 93289 TC ICD DEVICE INTERROGATE 36.62 34.19 93289 26 ICD DEVICE INTERROGATE 73.29 70.71 93290 ICM DEVICE EVAL 49.07 46.90 93290 TC ICM DEVICE EVAL 16.83 15.73 93290 26 ICM DEVICE EVAL 32.24 31.16 93293 PM PHONE R-STRIP DEVICE EVAL 93.56 88.12 93293 TC PM PHONE R-STRIP DEVICE EVAL 68.65 64.08 93293 26 PM PHONE R-STRIP DEVICE EVAL 24.91 24.06 93294 PM DEVICE INTERROGATE REMOTE 54.29 52.37 93295 ICD DEVICE INTERROGATE REMOTE 106.89 103.14 93296 PM/ICD REMOTE TECH SERV 55.83 52.13 93297 ICM DEVICE INTERROGATE REMOTE 40.17 38.85 93299 ICM/ILR REMOTE TECH SERV 73.04 68.85 93303 ECHO TRANSTHORACIC 350.40 330.22 93303 TC ECHO TRANSTHORACIC 246.83 230.29 93303 26 ECHO TRANSTHORACIC 103.57 99.93 93306 TTE W/DOPPLER, COMPLETE 388.84 366.07 93306 TC TTE W/DOPPLER, COMPLETE 282.94 263.97 93306 26 TTE W/DOPPLER, COMPLETE 105.90 102.10 93307 TTE W/O DOPPLER, COMPLETE 246.74 232.56 93307 TC TTE W/O DOPPLER, COMPLETE 172.29 160.77 93307 26 TTE W/O DOPPLER, COMPLETE 74.45 71.81 93308 TTE, F-UP OR LIMITED 176.43 165.94 93308 TC TTE, F-UP OR LIMITED 133.87 124.91 93308 26 TTE, F-UP OR LIMITED 42.56 41.03 93312 ECHO TRANSESOPHAGEAL 537.84 507.44 93312 TC ECHO TRANSESOPHAGEAL 366.07 341.60 93312 26 ECHO TRANSESOPHAGEAL 171.77 165.84 93313 ECHO TRANSESOPHAGEAL 63.49 61.79 93314 ECHO TRANSESOPHAGEAL 479.33 450.44 93314 TC ECHO TRANSESOPHAGEAL 381.22 355.71 93314 26 ECHO TRANSESOPHAGEAL 98.13 94.73 93320 DOPPLER ECHO EXAM, HEART 104.18 98.17 93320 TC DOPPLER ECHO EXAM, HEART 73.90 68.97 93320 26 DOPPLER ECHO EXAM,. HEART 30.28 29.22 93321 DOPPLER ECHO EXAM, HEART 48.83 45.99 93321 TC DOPPLER ECHO EXAM, HEART 36.62 34.19 93321 26 DOPPLER ECHO EXAM, HEART 12.21 11.79 93325 DOPPLER COLOR FLOW, ADDED 60.50 56.67 93325 TC DOPPLER COLOR FLOW, ADDED 54.67 51.03 93325 26 DOPPLER COLOR FLOW, ADDED 5.81 5.63 93350 STRESS TTE ONLY 349.1.5 329.46 93350 TC STRESS TTE ONLY 229.95 214.54 93350 26 STRESS TTE ONLY 119.20 114.94 93351 STRESS TTE COMPLETE 410.89 387.86 93351 TC STRESS TTE COMPLETE 267.09 249.26 93351 26 STRESS TTE COMPLETE 143.81 138.60 93451 RIGHT HEART CATH 1,284.20 1,206.75 93451 TC RIGHT HEART CATH 1,053.77 983.10 93451 26 RIGHT HEART CATH 230.43 223.66 93452 LEFT HEART CATH W/VENTRCLGRPHY 1,410.49 1,331.17 93452 TC LEFT HEART CATH W/VENTRCLGRPHY 1,006.61 939.09 93452 26 LEFT HEART CATH W/VENTRCLGRPHY403.89 392.06 93453 R&L HEART CATH W/VENTRICLGRPHY 1,845.72 1,741.92 93453 TC R&L HEART CATH W/VENTRICLGRPHY 1,316.32 1,228.06 93453 26 R&L HEART CATH W/VENTRICLGRPHY 529.40 513.86 93454 CATH PLACE CORONARY ANGIO 1,455.61 1,373.35 93454 TC CATH PLACE CORONARY ANGIO 1,048.53 978.22 93454 26 CATH PLACE CORONARY ANGIO 407.08 395.15 93455 CATH PLACE BYPASS GRAFTS 1,698.80 1,602.61 93455 TC CATH PLACE BYPASS GRAFTS 1,228.98 1,146.57 93455 26 CATH PLACE BYPASS GRAFTS 469.82 456.03 93456 CATH PLACE WITH R HEART CATH 1,820.43 1,717.97 93456 TC CATH PLACE WITH R HEART CATH 1,299.44 1,212.30

11:3-29.6 APPENDIX B - REGULATIONS 93456 26 CATH PLACE WITH R HEART CATH 521.00 505.68 93457 R HEART ART/GRAFT ANGIO 2,063.64 1,947.25 93457 TC R HEART ART/GRAFT ANGIO 1,479.36 1,380.14 93457 26 R HEART ART/GRAFT ANGIO 584.28 567.10 93458 L HEART ARTERY/VENTRICLE ANGIO 1,755.96 1,656.97 93458 TC L HEART ARTERY/VENTRICLE ANGIO 1,259.26 1,174.82 93458 26 L HEART ARTERY/VENTRICLE ANGIO 496.71 482.14 93459 L HEART ART/GRAFT ANGIO 1,938.14 1,829.23 93459 TC L HEART ART/GRAFT ANGIO 1,379.22 1,286.72 93459 26 L HEART ART/GRAFT ANGIO 558.94 542.51 93460 R & L HEART ART/VENTRICLE ANGIO 2,071.87 1,956.36 93460 TC R & L HEART ART/VENTRICLE ANGIO 1,449.09 1,351.90 93460 26 R & L HEART ART/VENTRICLE ANGIO 622.77 604.46 93461 R & L HEART ART/VENTRICLE ANGIO 2,376.60 2,243.12 93461 TC R & L HEART ART/VENTRICLE ANGIO 1,689.51 1,576.21 93461 26 R & L HEART ART/VENTRICLE ANGIO 687.09 666.91 93462 L HEART CATH TRANSPLANT PUNCTURE 316.47 307.12 93463 DRUG ADMIN & HEMODYNMIC MEAS 167.77 162.76 93464 EXERCISE W/HEMODYNAMIC MEAS 416.35 394.04 93464 TC EXERCISE W/HEMODYNAMIC MEAS 268.95 250.93 93464 26 EXERCISE W/HEMODYNAMIC MEAS 147.39 143.12 93503 INSERT/PLACE HEART CATHETER 206.54 200.73 93563 INJECT CONGENITAL CARD CATH 87.15 84.36 93564 INJECT HEART CONGNTL ART/GRAFT 88.69 85.88 93565 INJECT L VENTR/ATRIAL ANGIO 67.02 64.90 93566 INJECT R VENTR/ATRIAL ANGIO 283.05 266.42 93567 INJECT SUPRVLV AORTOGRAPHY 231.57 218.66 93568 INJECT PULM ART HEART CATH 254.94 240.25 93609 26 MAP TACHYCARDIA, ADDED 453.72 439.26 93610 26 INTRA-ATRIAL PACING 271.48 262.90 93612 26 INTRAVENTRICULAR PACING 270.32 261.81 93620 ELECTROPHYSIOLOGY EVAL 1,831.99 1,764.36 93620 TC ELECTROPHYSIOLOGY EVAL 809.16 780.90 93620 26 ELECTROPHYSIOLOGY EVAL 1,055.32 1,021.50 93623 26 STIMULATION, PACING HEART 259.49 251.22 93641 ELECTROPHYSIOLOGY EVAL 800.92 770.31 93641 TC ELECTROPHYSIOLOGY EVAL 260.71 250.41 93641 26 ELECTROPHYSIOLOGY EVAL 538.69 521.48 93642 ELECTROPHYSIOLOGY EVAL 695.28 661.24 93642 TC ELECTROPHYSIOLOGY EVAL 293.87 274.24 93642 26 ELECTROPHYSIOLOGY EVAL 401.41 387.00 93660 TILT TABLE EVAL 267.19 254.13 93660 TC TILT TABLE EVAL 112.90 105.36 93660 26 TILT TABLE EVAL 154.29 148.79 93701 BIOIMPD TIIRC ELEC 45.94 42.89 93720 BIOIMPEDANCE, CV ANALYSIS 82.45 77.41 93722 TOTAL BODY PLETHYSMOGRAPHY 12.65 12.24 93784 AMBULATORY BP MONITORING 103.53 97.61 93798 CARDIAC REHAB/MONITOR 41.51 39.45 93875 EXTRACRANIAL STUDY 179.33 167.89 93875 TC EXTRACRANIAL STUDY 162.40 151.53 93875 26 EXTRACRANIAL STUDY 16.93 16.36 93880 EXTRACRANIAL STUDY 424.35 397.49 93880 TC EXTRACRANIAL STUDY 377.27 351.96 93880 26 EXTRACRANIAL STUDY 47.08 45.53 93882 EXTRACRANIAL STUDY 294.19 275.62 93882 TC EXTRACRANIAL STUDY 262.56 244.95 93882 26 EXTRACRANIAL STUDY 31.63 30.67 93886 INTRACRANIAL STUDY 560.39 525.22 93886 TC INTRACRANIAL STUDY 487.32 454.62 93886 26 INTRACRANIAL STUDY 73.07 70.60

MEDICAL FEE SCHEDULES 11:3-29.6 93922 EXTREMITY STUDY 187.26 175.36 93922 TC EXTREMITY STUDY 168.23 156.96 93922 26 EXTREMITY STUDY 19.03 18.40 93923 EXTREMITY STUDY 289.22 271.07 93923 TC EXTREMITY STUDY 253.82 236.81 93923 26 EXTREMITY STUDY 35.40 34.26 93924 EXTREMITY STUDY 361.62 338.73 93924 TC EXTREMITY STUDY 322.53 300.90 93924 26 EXTREMITY STUDY 39.09 37.83 93925 LOWER EXTREMITY STUDY 537.92 503.46 93925 TC LOWER EXTREMITY STUDY 493.02 460.00 93925 26 LOWER EXTREMITY STUDY 44.91 43.44 93926 LOWER EXTREMITY STUDY 349.57 327.26 93926 TC LOWER EXTREMITY STUDY 318.45 297.11 93926 26 LOWER EXTREMITY STUDY 31.12 30.16 93930 UPPER EXTREMITY STUDY 423.65 396.50 93930 TC UPPER EXTREMITY STUDY 387.74 361.74 93930 26 UPPER EXTREMITY STUDY 35.91 34.76 93931 UPPER EXTREMITY STUDY 283.34 265.20 93931 TC UPPER EXTREMITY STUDY 259.06 241.70 93931 26 UPPER EXTREMITY STUDY 24.27 23.50 93965 EXTREMITY STUDY 214.33 200.93 93965 TC EXTREMITY STUDY 186.86 174.34 93965 26 EXTREMITY STUDY 27.47 26.59 93970 EXTREMITY STUDY 436.95 409.56 93970 TC EXTREMITY STUDY 383.10 357.39 93970 26 EXTREMITY STUDY 53.87 52.15 93971 EXTREMITY STUDY 286.89 268.90 93971 TC EXTREMITY STUDY 251.49 234.63 93971 26 EXTREMITY STUDY 35.40 34.26 93975 VASCULAR STUDY 637.06 599.26 93975 TC VASCULAR STUDY 495.93 462.72 93975 26 VASCULAR STUDY 141.13 136.54 93976 VASCULAR STUDY 363.64 342.48 93976 TC VASCULAR STUDY 268.95 250.93 93976 26 VASCULAR STUDY 94.67 91.56 93978 VASCULAR STUDY 410.98 385.24 93978 TC VASCULAR STUDY 359.22 335.12 93978 26 VASCULAR STUDY 51.77 50.12 93979 VASCULAR STUDY 284.63 266.77 93979 TC VASCULAR STUDY 250.32 233.54 93979 26 VASCULAR STUDY 34.30 33.21 94002 VENT MGMT INPATIENT, INIT DAY 139.58 135.63 94003 VENT MGMT INPATIENT, SUBCUT DAY 100.93 97,84 94010 BREATHING CAPACITY TEST 59.16 55.68 94010 TC BREATHING CAPACITY TEST 45.94 42.89 94010 26 BREATHING CAPACITY TEST 13.22 12.79 94060 EVALUATE WHEEZING 101.79 95.78 94060 TC EVALUATE WHEEZING 79.13 73.85 94060 26 EVALUATE WHEEZING 22.65 21.93 94070 EVALUATE WHEEZING 97.74 92.78 94070 TC EVALUATE WHEEZING 53.50 49.95 94070 26 EVALUATE WHEEZING 44.24 42.83 94200 LUNG FUNCTION TEST (MBC/MVV) 40.40 38.01 94200 TC LUNG FUNCTION TEST (MBC/IvIVV) 31.96 29.86 94200 26 LUNG FUNCTION TEST (MBC/MVV) 8.43 8.17 94240 RESIDUAL LUNG CAPACITY 66.63 62.87 94240 TC RESIDUAL LUNG CAPACITY 47.69 44.52 94240 26 RESIDUAL LUNG CAPACITY 18.96 18.35 94250 EXPIRED GAS COLLECTION 42.72 40.19 94250 TC EXPIRED GAS COLLECTION 34.29 32.03 94250 26 EXPIRED GAS COLLECTION 8.43 8.17 94260 THORACIC GAS VOLUME 54.80 51.51 94260 TC THORACIC GAS VOLUME 45.36 42.35 94260 26 THORACIC GAS VOLUME 9.45 9.17 94350 LUNG NITROGEN WASHOUT CURVE 57.33 54.17 94350 TC LUNG NITROGEN WASHOUT CURVE 38.37 35.83 94350 26 LUNG NITROGEN WASHOUT CURVE 18.96 18.35 94360 MEASURE AIRFLOW RESISTANCE 74.21 69.93 94360 TC MEASURE AIRFLOW RESISTANCE 55.25 51.59 94360 26 MEASURE AIRFLOW RESISTANCE 18.96 18.35

11:3-29.6 APPENDIX B - REGULATIONS 94370 BREATH AIRWAY CLOSING VOLUME 56.74 53.63 94370 TC BREATH AIRWAY CLOSING VOLUME37,79 35.29 94370 26 BREATH AIRWAY CLOSING VOLUME 18.96 18.35 94375 RESPIRATORY FLOW VOLUME LOOP 63.35 59.93 94375 TC RESPIRATORY FLOW VOLUME LOOP 40.70 38.00 94375 26 RESPIRATORY FLOW VOLUME LOOP 22.65 21.93 94620 PULMONARY STRESS TEST/SIMPLE 103.85 98.58 94620 TC PULMONARY STRESS TEST/SIMPLE 56.42 52.67 94620 26 PULMONARY STRESS TEST/SIMPLE 47.44 45.92 94640 AIRWAY INHALATION TREAT 27.30 25.51 94660 POS AIRWAY PRESSURE, CPAP 95.91 91.49 94664 EVALUATE PAT USE INHALER 27.30 25.51 94667 CHEST WALL MANIPULATION 38.37 35.83 94720 MONOXIDE DIFFUSING CAPACITY 87.61 82.42 94720 TC MONOXIDE DIFFUSING CAPACITY 68.65 64.08 94720 26 MONOXIDE DIFFUSING CAPACITY 18.96 18.35 94750 PULMONARY COMPLIANCE STUDY 131.51 123.29 94750 TC PULMONARY COMPLIANCE STUDY114,65 106.98 94750 26 PULMONARY COMPLIANCE STUDY 16.85 16.31 94760 MEASURE BLOOD OXYGEN LEVEL 28.25 26.59 94761 MEASURE BLOOD OXYGEN LEVEL 46.17 43.29 94762 MEASURE BLOOD OXYGEN LEVEL 59.35 55.44 94770 EXHALED CARBON DIOXIDE TEST 38.28 36.18 95004 PERCUT ALLERGY SKIN TESTS 10.93 10.25 95015 ID ALLERGY TITRATE-DRUG/BUG 23.28 22.11 95024 ID ALLERGY TEST, DRUG/BUG 12.68 11.88 95027 ID ALLERGY TITRATE-AIRBORNE 8.01 7.53 95028 ID ALLERGY TEST-DELAYED TYPE 21.49 20.08 95044 ALLERGY PATCH TESTS 10.42 9.75 95115 OTHERAPY, ONE INJECTION 17.41 16.27 95117 IMMUNOTHERAPY INJECTIONS 21.49 20.08 95144 ANTIGEN THERAPY SERVICES 21.03 19.80 95800 SLEEP STUDY UNATT; COMP W/SLEEP TIME 344.12 323.75 95800 TC SLEEP STUDY UNATT; COMP W/SLEEP TIME 252.65 235.71 95800 26 SLEEP STUDY UNATT; COMP W/SLEEP TIME 91.46 88.02 95801 SLEEP STUDY UNATT; COMP W/O SLEEP TIME 158.15 150.15 95801 TC SLEEP STUDY UNATT; COMP W/O SLEEP TIME 77.96 72.76 95801 26 SLEEP STUDY UNATT; COMP W/O SLEEP TIME 80.19 77.39 95803 ACTIGRAPHY TESTING 271.28 255.44 95803 TC ACTIGRAPHY TESTING 197.91 184.66 95803 26 ACTIGRAPHY TESTING 73.37 70.78 95805 MULTIPLE SLEEP LATENCY TEST 693.93 650.54 95805 TC MULTIPLE SLEEP LATENCY TEST 597.18 557.22 95805 26 MULTIPLE SLEEP LATENCY TEST 96.75 93.32 95810 POLYSOMNOGRAPHY, 4 OR MORE 1,169.61 1,097.90 95810 TC POLYSOMNOGRAPHY, 4 OR MORE 974.08 909.04 95810 26 POLYSOMNOGRAPHY, 4 OR MORE 195.54 188.86 95811 POLYSOMNOGRAPHY W/CPAP 1,263.07 1,185.40 95811 TC POLYSOMNOGRAPHY W/CPAP 1,058.45 987.78 95811 26 POLYSOMNOGRAPHY W/CPAP 204.62 197.62 95812 EEG, 41-60 MINUTES 531.27 498.47 95812 TC EEG, 41-60 MINUTES 447.02 417.10 95812 26 EEG, 41-60 MINUTES 84.26 81.37 95813 EEG, OVER 1 HOUR 594.86 559.52 95813 TC EEG, OVER 1 HOUR 460.35 429.56 95813 26 EEG, OVER 1 HOUR 134.52 129.96 95816 EEG, AWAKE & DROWSY 378.16 355.01 95816 TC EEG, AWAKE & DROWSY 312.51 291.60 95816 26 EEG, AWAKE & DROWSY 65.65 63.41 95819 EEG, AWAKE & ASLEEP 549.32 515.31 95819 TC EEG, AWAKE & ASLEEP 464.48 433.39 95819 26 EEG, AWAKE & ASLEEP 84.84 81.91 95822 EEG, COMA OR SLEEP ONLY 513.22 481.63 95822 TC EEG, COMA OR SLEEP ONLY 428.39 399.72 95822 26 EEG, COMA OR SLEEP ONLY 84.84 81.91 95831 LIMB MUSCLE TESTING, MANUAL 47.21 44.84

MEDICAL FEE SCHEDULES 11:3-29.6 95832 HAND MUSCLE TESTING, MANUAL 52.37 49.80 95833 BODY MUSCLE TESTING, MANUAL 68.43 65.19 95834 BODY MUSCLE TESTING, MANUAL 85.99 82.02 95851 RANGE MOTION MEASUREMENTS 43.75 41.47 95852 RANGE MOTION MEASUREMENTS 24.16 22.84 95857 TENSILON TEST 76.14 72.46 95860 MUSCLE TEST, ONE LIMB 226.85 215.44 95860 TC MUSCLE TEST, ONE LIMB 107.41 100.24 95860 26 MUSCLE TEST, ONE LIMB 119.46 115.20 95861 MUSCLE TEST, 2 LIMBS 327.48 311.61 95861 TC MUSCLE TEST, 2 LIMBS 136.97 127.83 95861 26 MUSCLE TEST, 2 LIMBS 190.51 183.78 95863 MUSCLE TEST, 3 LIMBS 395.17 376.08 95863 TC MUSCLE TEST, 3 LIMBS 166.53 155.40 95863 26 MUSCLE TEST, 3 LIMBS 228.64 220.68 95864 MUSCLE TEST, 4 LIMBS 434.98 413.69 95864 TC MUSCLE TEST, 4 LIMBS 190.71 177.96 95864 26 MUSCLE TEST, 4 LIMBS 244.27 235.72 95865 MUSCLE TEST, LARYNX 296.79 283.01 95865 TC MUSCLE TEST, LARYNX 101.14 94.40 95865 26 MUSCLE TEST, LARYNX 195.65 188.61 95867 MUSCLE TEST CRANIAL NERVE UNILAT 201.95 191.56 95867 TC MUSCLE TEST CRANIAL NERVE UNILAT 103.83 96.90 95867 26 MUSCLE TEST CRANIAL NERVE UNILAT 98.12 94.67 95868 MUSCLE TEST CRANIAL NERVE BILAT 272.61 258.99 95868 TC MUSCLE TEST CRANIAL NERVE BILAT 128.01 119.46 95868 26 MUSCLE TEST CRANIAL NERVE BILAT 144.60 139.53 95869 MUSCLE TEST, THOR PARASPINAL 149.63 141.08 95869 TC MUSCLE TEST, THOR PARASPTNAL 103.83 96.90 95869 26 MUSCLE TEST, THOR PARASPINAL 45.80 44.18 95870 MUSCLE TEST, NONPARASPINAL 146.04 137.74 95870 TC MUSCLE TEST, NONPARASPINAL 101.14 94.40 95870 26 MUSCLE TEST, NONPARASPINAL 44.91 43.33 95873 GUIDE NERVE DESTROY, ELECT STIM 148.73 140.25 95873 TC GUIDE NERVE DESTROY, ELECT STIM 101.14 94.40 95873 26 GUIDE NERVE DESTROY, ELECT STIM 47.60 45.85 95874 GUIDE NERVE DESTROY, NEEDLE EMG 141.56 133.56 95874 TC GUIDE NERVE DESTROY, NEEDLE EMG 95.76 89.38 95874 26 GUIDE NERVE DESTROY, NEEDLE EMG 45.80 44.18 95900 MOTOR NERVE CONDUCTION TEST 153.54 144.91 95900 TC MOTOR NERVE CONDUCTION TEST 102.03 95.23 95900 26 MOTOR NERVE CONDUCTION TEST 51.51 49.67 95903 MOTOR NERVE CONDUCTION TEST 176.35 166.99 95903 TC MOTOR NERVE CONDUCTION TEST 102.93 96.07 95903 26 MOTOR NERVE CONDUCTION TEST 73.44 70.92 95904 SENSE NERVE CONDUCTION TEST 135.64 127.92 95904 TC SENSE NERVE CONDUCTION TEST 93.97 87.71 95904 26 SENSE NERVE CONDUCTION TEST 41.67 40.21 95920 INTRAOP NERVE TEST, ADDED 392.31 374.38 95920 TC INTRAOP NERVE TEST, ADDED 136.07 126.98 95920 26 INTRAOP NERVE TEST, ADDED 256.23 247.38 95921 AUTONOMIC NERVE FUNCTION TEST129.86 123.48 95921 TC AUTONOMIC NERVE FUNCTION TEST 60.50 56.47 95921 26 AUTONOMIC NERVE FUNCTION TEST 69.36 67.00 95922 AUTONOMIC NERVE FUNCTION TEST161.43 153.08 95922 TC AUTONOMIC NERVE FUNCTION TEST 87.28 81.46 95922 26 AUTONOMIC NERVE FUNCTION TEST 74.15 71.62 95923 AUTONOMIC NERVE FUNCTION TEST241.02 227.20 95923 TC AUTONOMIC NERVE FUNCTION TEST169.96 158.59 95923 26 AUTONOMIC NERVE FUNCTION TEST 71.04 68.61

11:3-29.6 APPENDIX B - REGULATIONS 95925 SOMATOSENSORY TESTING 640.37 600.70 95925 TC SOMATOSENSORY TESTING 538.82 502.74 95925 26 SOMATOSENSORY TESTING 101.51 98.00 95926 SOMATOSENSORY TESTING 393.84 369.63 95926 TC SOMATOSENSORY TESTING 327.79 305.82 95926 26 SOMATOSENSORY TESTING 66.05 63.82 95927 SOMATOSENSORY TESTING 368.96 346.31 95927 TC SOMATOSENSORY TESTING 303.59 283.25 95927 26 SOMATOSENSORY TESTING 65.35 63.05 95928 C MOTOR EVOKED, UPPER LIMBS 388.77 366.67 95928 TC C MOTOR EVOKED, UPPER LIMBS 270.57 252.51 95928 26 C MOTOR EVOKED, UPPER LIMBS 118.19 114.16 95929 C MOTOR EVOKED, LOWER LIMBS 412.64 388.95 95929 TC C MOTOR EVOKED, LOWER LIMBS 293.87 274.24 95929 26 C MOTOR EVOKED, LOWER LIMBS 118.77 114.71 95930 VISUAL EVOKED POTENTIAL TEST 225.51 211.30 95930 TC VISUAL EVOKED POTENTIAL TEST 197.91 184.66 95930 26 VISUAL EVOKED POTENTIAL TEST 27.60 26.63 95933 BLINK REFLEX TEST 122.27 115.65 95933 TC BLINK REFLEX TEST 75.05 70.05 95933 26 BLINK REFLEX TEST 47.22 45.60 95934 H-REFLEX TEST 155.93 147.69 95934 TC H-REFLEX TEST 87.59 81.77 95934 26 H-REFLEX TEST 68.32 65.89 95936 H-REFLEX TEST 126.83 120.70 95936 TC H-REFLEX TEST 54.09 50.53 95936 26 H-REFLEX TEST 72.75 70.20 95937 NEUROMUSCULAR JUNCTION TEST 105.46 100.14 95937 TC NEUROMUSCULAR JUNCTION TEST 53.50 49.95 95937 26 NEUROMUSCULAR JUNCTION TEST 51.95 50.19 95950 AMBULATORY EEG MONITORING 451.58 425.29 95950 TC AMBULATORY EEG MONITORING 332.89 310.63 95950 26 AMBULATORY EEG MONITORING 118.70 114.65 95951 EEG MONITORING/VIDEO RECORD 3,074.98 2,967.76 95951 TC EEG MONITORING/VIDEO RECORD 2,599.66 2,508.81 95951 26 EEG MONITORING/VIDEO RECORD 483.24 467.08 95953 EEG MONITORING/COMPUTER 683.31 645.57 95953 TC EEG MONITORING/COMPUTER 438.28 408.94 95953 26 EEG MONITORING/COMPUTER 245.04 236.62 95955 EEG DURING SURG 279.78 263.64 95955 TC EEG DURING SURG 201.41 187.92 95955 26 EEG DURING SURG 78.37 75.72 95956 EEG MONITORING, CABLE/RADIO 1,700.99 1,596.69 95956 TC EEG MONITORING, CABLE/RADIO 1,425.05 1,329.89 95956 26 EEG MONITORING, CABLE/RADIO 275.95 266.79 95957 EEG DIGITAL ANALYSIS 565.05 532.31 95957 TC EEG DIGITAL ANALYSIS 408.70 381.29 95957 26 EEG DIGITAL ANALYSIS 156.33 151.02 95961 ELECTRODE STIMULATION, BRAIN 407.15 387.59 95961 TC ELECTRODE STIMULATION, BRAIN 169.96 158.59 95961 26 ELECTRODE STIMULATION, BRAIN 237.19 228.99 95962 ELECTRODE STIM, BRAIN, ADDED 362.26 346.30 95962 TC ELECTRODE STIM, BRAIN, ADDED 108.83 101.55 95962 26 ELECTRODE STIM, BRAIN, ADDED 253.44 244.75 95970 ANALYZE NEUROSTIM, NO PROG 97.12 91.83 95971 ANALYZE NEUROSTIM, SIMPLE 92.71 88.63 95972 ANALYZE NEUROSTIM, COMPLEX 170.16 162.88 95973 ANALYZE NEUROSTIM, COMPLEX 95.10 91.23 95981 IO ANAL GAST N-STIM SUBSEQ 49.98 47.45 95991 SPIN/BRAIN PUMP REFILL & MAIN 174.44 164.77 95992 CANALITH REPOSITIONING PROC 66.86 64.38 96000 MOTION ANALYSIS, VIDEO/3D 141.90 137.15 96002 DYNAMIC SURFACE EMG 32.84 31.75 96004 PHYS REVIEW MOTION TESTS 174.11 168.13 96101 PSYCHO TESTING BY PSYCH/PHYS 171.94 166.83 96102 PSYCHO TESTING BY TECHNICIAN 110.20 104.12 96103 PSYCHO TESTING ADMIN BY COMP 92.07 87.24 96105 ASSESS APHASIA 169.49 162.53 96111 DEVELOPMENTAL TEST, EXTEND 194.42 188.26 96116 NEUROBEHAVIORAL STATUS EXAM 163.28 157.97 96118 NEUROPSYCH TEST BY PSYCH/PHYS 175.60 169.32 96119 NEUROPSYCH TESTING BY TEC 116.36 109.92

MEDICAL FEE SCHEDULES 11:3-29.6 96120 NEUROPSYCH TEST ADMIN W/COMP 136.91 129.06 96125 COGNITIVE TEST BY HC PRO 147.55 142.04 96150 ASSESS HEALTH/BEHAVE, INIT 32.30 31.39 96151 ASSESS HEALTH/BEHAVE, SUBSEQ 31.28 30.38 96152 INTERVENE HEALTH/BEHAVE, INDIV 29.69 28.85 96153 INTERVENE HEALTH/BEHAVE, GROUP 7.35 7.13 96154 INTERVENE HEALTH/BEHAVE, FAM W/PT 29.17 28.35 96360 HYDRATION IV INFUSION, INIT 96.36 90.41 96361 HYDRATE IV INFUSION, ADDED 25.47 24.02 96365 THER/PROPHY/DIAG IV INF, INIT 119.94 112.51 96366 THER/PROPHY/DIAG IV INF ADDED 35.85 33.92 96367 THER/PROPHY/DIAG ADDED SEQ IV INF 55.00 51.80 96368 THER/DIAG CONCURRENT INF 31.86 30.17 96370 SC THER INFUSION, ADDED HR 24.80 23.60 96372 THER/PROPHY/DIAG INJ, SC/IM 38.26 36.14 96373 THER/PROPHY/DIAG INJ, IA 31.28 29.63 96374 THER/PROPHY/DIAG INJ, IV PUSH 93.96 88.19 96375 TX/PRO/DIAG INJECT NEW DRUG ADDED 38.20 35.91 96409 CHEMO IV PUSH, SINGLE DRUG 191.22 179.13 96446 CHEMOTHERAPY ADM PERITONEAL CAV 300.18 281.16 96523 IRRIG DRUG DELIVERY DEVICE 43.31 40.53 96900 ULTRAVIOLET LIGHT THERAPY 35.46 33.11 96912 PHOTOCHEMOTHERAPY W/UV-A 152.50 142.29 97001 PHYSICAL THERAPY EVAL 114.74 110.13 97002 PHYSICAL THERAPY RE-EVAL 64.03 61.31 97003 OT EVAL 127.54 122.09 97004 OT RE-EVAL 78.59 74.88 97010 APPLIC MODAL 1/> AREAS; HOT/COLD PACKS 0.00 0.00 97012 MECHANICAL TRACTION THERAPY 28.01 26.87 97016 VASOPNEUMATIC DEVICE THERAPY 28.29 26.86 97014 APPLICATION MODALITY TO 1 OR MORE AREAS; E-STIM 0.00 0.00 97018 PARAFFIN BATH THERAPY 15.79 14.91 97022 WHIRLPOOL THERAPY 33.61 31.79 97024 DIATHERMY EG, MICROWAVE 9.98 9.48 97026 INFRARED THERAPY 8.81 8.40 97028 ULTRAVIOLET THERAPY 10.98 10.47 97032 ELECTRICAL STIMULATION 28.35 27.09 97033 ELECTRIC CURRENT THERAPY 46.33 43.88 97034 CONTRAST BATH THERAPY 26.32 25.10 97035 ULTRASOUND THERAPY 27.40 26.36 97036 HYDROTHERAPY 47.92 45.42 97039 PHYSICAL THERAPY TREAT 20.42 19.71 97110 THERAPEUTIC EXERCISES 50.87 48.67 97112 NEUROMUSCULAR REEDUCATION 53.36 51.01 97113 AQUATIC THERAPY/EXERCISES 67.87 64.51 97116 GAIT TRAINING THERAPY 48.21 46.14 97124 MASSAGE THERAPY 38.67 36.95 97139 PHYSICAL MEDICINE PROCEDURE 27.64 26.67 97140 MANUAL THERAPY 44.47 42.56 97150 GROUP THERAPEUTIC PROCEDURES 30.52 29.17 97530 THERAPEUTIC ACTIVITIES 59.96 57.21 97532 COGNITIVE SKILLS DEVELOPMENT 61.13 58.72 97533 SENSORY INTEGRATION 43.81 41.98 97535 SELF CARE MANAGEMENT TRAINING51.88 49.54 97537 COMMUNITY/WORK REINTEGRATION44.91 43.02 97542 WHEELCHAIR MANAGEMENT TRAINING 45.49 43.56 97597 ACTIVE WOUND CARE/20 CM OR < 119.31 112.72 97598 ACTIVE WOUND CARE > 20 CM 39.36 37.40 97605 NEG PRESS WOUND TX, < 50 CM 62.93 60.32 97606 NEG PRESS WOUND TX, > 50 CM 67.09 64.40 97750 PHYSICAL PERFORMANCE TEST 55.79 53.38 97755 ASSISTIVE TECHNOLOGY ASSESS 53.99 51.98 97760 ORTHOTIC MGMT & TRAINING 56.42 53.83 97761 PROSTHETIC TRAINING 49.44 47.32 97762 C/O FOR ORTHOTIC/PROSTH USE 67.36 63.48

11:3-29.6 APPENDIX B - REGULATIONS 97802 MEDICAL NUTRITION, INDIV, IN 50.58 48.59 97810 ACUPUNCT 1/> NDLES W/O E-STIM; INIT 15 MIN 1-1 43.74 32.07 97811 ACUPUNCT 1 /> NDLES W/O E-STIM; EA ADD 15 MIN 1-1 37.49 27.49 97813 ACUPUNCT 1/> NDLES WITH E-STIM; INIT 15 MIN 1-1 47.91 35.12 97814 ACUPUNCT 1/> NDLES WITH E-STIM; EA ADD 15 MIN 1-1 41.66 30.54 98925 OSTEOPATHIC MANIPULATION 1-2 REGIONS 55.70 53.34 98926 OSTEOPATHIC MANIPULATION 3-4 REGIONS 74.13 71.10 98927 OSTEOPATHIC MANIPULATION 5-6 REGIONS 96.35 92.48 98928 OSTEOPATHIC MANIPULATION 7-8 REGIONS 97.37 93.52 98940 CHIROPRACTIC MANIPULATION 1-2 REGIONS 39.44 37.90 98941 CHIROPRACTIC MANIPULATION 3-4 REGIONS 54.40 52.41 98942 CHIROPRACTIC MANIPULATION 5 REGIONS 69.90 67.39 98943 CHIROPRACTIC MANIP TX; XTRASPINAL 1/MORE REGIONS 37.14 36.01 99070 SUPPLIES & MATERIALS: ADDL TO USUAL FOR OFFICE VISIT 0.00 0.00 99071 EDUCATION SUPPLIES; S/A BOOKS, TAPES & PAMPHLETS FOR PATIENT EDUCATION 0.00 0.00 99080 SPECIAL REPORTS 0.00 0.00 99082 UNUSUAL PHYSICIAN TRAVEL 0.00 0.00 99143 MOD SEDATION SAME PHYS, < 5 YRS 44.74 43.70 99144 MOD SEDATION BY SAME PHYS, 5 YRS + 64.49 62.24 99145 MOD SEDATION BY SAME PHYS, ADDED 22.24 21.44 99148 MOD SEDATION DIFF PHYS < 5 YRS 125.97 121.58 99149 MOD SEDATION DIFF PHYS 5 YRS + 125.97 121.58 99150 MOD SEDATION DIFF PHYS, ADDED 47.38 45.69 99175 INDUCTION VOMITING 41.87 39.08 99183 HYPERBARIC OXYGEN THERAPY 518.83 494.16 99195 PHLEBOTOMY 227.07 212.09 99201 OFFICE/OUTPAT VISIT, NEW PAT 10 MINS 51.25 48.81 99202 OFFICE/OUTPAT VISIT, NEW PAT 20 MINS 87.92 83.95 99203 OFFICE/OUTPAT VISIT, NEW PAT 30 MINS 126.87 121.39 99204 OFFICE/OUTPAT VISIT, NEW PAT 45 MINS 193.64 185.82 99205 OFFICE/OUTPAT VISIT, NEW PAT 60 MINS 240.25 230.79 99211 OFFICE/OUTPAT VISIT, EST PAT 5 MINS 32.36 30.67 99212 OFFICE/OUTPAT VISIT, EST PAT 10 MINS 51.69 49.22 99213 OFFICE/OUTPAT VISIT, EST PAT 15 MINS 85.01 81.31 99214 OFFICE/OUTPAT VISIT, EST PAT 25 MINS 125.71 120.35 99215 OFFICE/OUTPAT VISIT, EST PAT 40 MINS 168.59 161.61 99217 OBSERVATION CARE DISCHARGE 108.71 104.82 99218 OBSERVATION CARE LOW SEVERITY 99.97 96.66 99219 OBSERVATION CARE MODERATE SEVERITY 167.12 161.61 99220 OBSERVATION CARE HIGH SEVERITY 233.75 226.05 99221 INITIAL HOSPITAL CARE 30 MINS 151.05 146.22 99222 INITIAL HOSPITAL CARE 50 MINS 205.62 198.94 99223 INITIAL HOSPITAL CARE 70 MINS 301.80 291.96

MEDICAL FEE SCHEDULES 11:3-29.6 99224 SUBSEQ OBSERVATION CARE 15 MINS 43.46 41.99 99225 SUBSEQ OBSERVATION CARE 25 MINS 76.94 74.29 99226 SUBSEQ OBSERVATION CARE 35 MINS 115.08 111.16 99231 SUBSEQUENT HOSPITAL CARE 15 MINS 69.00 66.70 99232 SUBSEQUENT HOSPITAL CARE 25 MINS 107.89 104.32 99233 SUBSEQUENT HOSPITAL CARE 35 MINS 154.90 149.80 99234 OBSERVE/HOSP SAME DATE LOW SEVERITY 204.82 198.08 99235 OBSERVE/HOSP SAME DATE MOD SEVERITY 268.27 259.39 99236 OBSERVE/HOSP SAME DATE HIGH SEVERITY 333.16 322.20 99238 HOSPITAL DISCHARGE DAY 30 MINS/LESS 108.19 104.29 99239 HOSPITAL DISCHARGE DAY > 30 MINS 158.62 152.99 99241 OFFICE CONSULTATION 15 MINS 94.26 81.72 99242 OFFICE CONSULTATION 30 MINS 120.18 104.19 99243 OFFICE CONSULTATION 40 MINS 153.17 132.79 99244 OFFICE CONSULTATION 60 MINS 200.30 173.66 99245 OFFICE CONSULTATION 80 MINS 252.93 219.28 99251 INPATIENT CONSULTATION 20 MINS 94.26 81.72 99252 INPATIENT CONSULTATION 40 MINS 142.96 123.94 99253 INPATIENT CONSULTATION 55 MINS 175.95 152.54 99254 INPATIENT CONSULTATION 80 MINS 219.94 190.88 99255 INPATIENT CONSULTATION 110 MINS276.50 239.71 99281 EMERGENCY DEPT VISIT SELF LIMIT/MINOR 122.92 119.32 99282 EMERGENCY DEPT VISIT LOW/MODERATE 203.58 197.73 99283 EMERGENCY DEPT VISIT MODERATE206.43 200.51 99284 EMERGENCY DEPT VISIT HIGH SEVERITY 375.38 365.00 99285 EMERGENCY DEPT VISIT HIGH SEVERITY 519.35 505.14 99291 CRITICAL CARE, FIRST HOUR 417.23 401.38 99292 CRITICAL CARE, ADDED 30 MIN 185.85 179.48 99304 NURSING FACILITY CARE, INIT 137.67 132.91 99305 NURSING FACILITY CARE, INIT 193.13 186.59 99306 NURSING FACILITY CARE, INIT 245.26 237.08 99307 NURSING FACILITY CARE, SUBSEQ 66.27 63.81 99308 NURSING FACILITY CARE, SUBSEQ 102.10 98.32 99309 NURSING FACILITY CARE, SUBSEQ 134.06 129.12 99310 NURSING FACILITY CARE, SUBSEQ 198.16 191.08 99315 NURSING FACILITY DISCHARGE DAY 96.51 93.02 99316 NURSING FACILITY DISCHARGE DAY125.11 120.65 99334 DOMICILE/REST HOME VISIT EST PAT 91.72 88.41 99341 HOME VISIT, NEW PATIENT 20 MINS 85.75 82.71 99342 HOME VISIT, NEW PATIENT-30 MINS 124.20 119.95 99343 HOME VISIT, NEW PATIENT 45 MINS 202.38 195.60 99344 HOME VISIT, NEW PATIENT 60 MINS 272.05 262.80 99345 HOME VISIT, NEW PATIENT 75 MINS 326.47 315.44 99347 HOME VISIT, EST PATIENT 15 MINS 85.25 82.21 99348 HOME VISIT, EST PATIENT 25 MINS 128.62 124.15 99349 HOME VISIT, EST PATIENT 40 MINS 190.15 183.56 99350 HOME VISIT, EST PATIENT 60 MINS 264.65 255.65 99354 PROLONGED SERVICE, OFFICE 149.70 144.35 99355 PROLONGED SERVICE, OFFICE 147.95 142.72 99356 PROLONGED SERVICE, INPATIENT 136.17 131.58 99357 PROLONGED SERVICE, INPATIENT 136.75 132.13 99406 BEHAVIOR CHANGE SMOKING 3-10 MIN 21.43 20.62 99407 BEHAVIOR CHANGE SMOKING > 10 MIN 41.50 40.03 99471 PEDIATRIC CRITICAL CARE, INITIAL1,202.04 1,163.38 99472 PEDIATRIC CRITICAL CARE, SUBSEQ605.11 585.66

11:3-29.6 APPENDIX B - REGULATIONS 99475 PEDIATRIC CRIT CARE AGE 2-5, INIT 848.53 822.02 99476 PEDIATRIC CRIT CARE AGE 2-5, SUBSEQ 514.56 498.30 99478 IC, LBW INF < 1500 GM SUBSEQ 213.55 206.55 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 59 52 D0140 limited oral evaluation - problem focused 91 80 D0150 comprehensive oral evaluation - new or established patient 104 92 D0160 detailed and extensive oral evaluation - problem focused, by report 190 168 D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) 85 75 D0180 comprehensive periodontal evaluation - new or established patient 113 100 D0210 intraoral - complete series (including bitewings) 153 135 D0220 intraoral - periapical first film 34 30 D0230 intraoral - periapical each additional film 28 25 D0240 intraoral - occlusal film 51 45 D0250 extraoral - first film 80 71 D0260 extraoral - each additional film 68 60 D0270 bitewing - single film 34 30 D0272 bitewings - two films 53 47 D0273 bitewings - three films 67 59 D0274 bitewings - four films 78 69 D0277 vertical bitewings - 7 to 8 films 119 105 D0290 posterior-anterior or lateral skull and facial bone survey film 164 145 D0320 temporomandibular joint arthrogram, including injection 714 632 D0321 other temporomandibular joint films, by report 248 219 D0330 panoramic film 130 115 D0340 cephalometric film 147 130 D0350 oral/facial photographic images 88 78 D0360 cone beam ct - craniofacial data capture 691 611 D0362 D0363 cone beam - two-dimensional image reconstruction using existing data, includes multiple images 448 397 cone beam - three-dimensional image reconstruction using existing data, includes multiple images 482 427 D0460 pulp vitality tests 67 59 D0470 diagnostic casts 135 119 D1110 prophylaxis - adult 108 95 D1120 prophylaxis - child 79 70 D1351 sealant - per tooth 65 57 D1510 space maintainer - fixed-unilateral 374 330 D1515 space maintainer - fixed - bilateral 509 451 D1520 space maintainer - removable - unilateral 457 405 D1525 space maintainer - removable - bilateral 578 512 D1550 re-cementation of space maintainer 101 89 D1555 removal of fixed space maintainer 93 82 D2140 amalgam - one surface, primary or permanent 169 149 D2150 amalgam - two surfaces, primary or permanent 213 188 D2160 amalgam - three surfaces, primary or permanent 256 226 D2161 amalgam - four or more surfaces, primary or permanent 305 269 D2330 resin-based composite - one surface, anterior 190 168 D2331 resin-based composite - two surfaces, anterior 238 210 D2332 resin-based composite - three surfaces, anterior 298 263 D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) 374 330 D2390 resin-based composite crown, anterior 549 486

MEDICAL FEE SCHEDULES 11:3-29.6 D2391 resin-based composite - one surface, posterior 209 185 D2392 resin-based composite - two surfaces, posterior 276 244 D2393 resin-based composite - three surfaces, posterior 338 299 D2394 resin-based composite - four or more surfaces, posterior 408 361 D2410 gold foil - one surface 772 683 D2420 gold foil - two surfaces 860 761 D2430 gold foil - three surfaces 938 830 D2510 inlay - metallic - one surface 1019 901 D2520 inlay - metallic - two surfaces 1073 949 D2530 inlay - metallic - three or more surfaces 1135 1005 D2542 onlay - metallic-two surfaces 1183 1047 D2543 onlay - metallic-three surfaces 1200 1062 D2544 onlay - metallic-four or more surfaces 1224 1083 D2610 inlay - porcelain/ceramic - one surface 1070 946 D2620 inlay - porcelain/ceramic - two surfaces 1142 1011 D2630 inlay - porcelain/ceramic - three or more surfaces 1189 1052 D2642 onlay - porcelain/ceramic - two surfaces 1193 1056 D2643 onlay - porcelain/ceramic - three surfaces 1245 1102 D2644 onlay - porcelain/ceramic - four or more surfaces 1302 1152 D2650 inlay - resin-based composite - one surface 1041 921 D2651 inlay - resin-based composite - two surfaces 1070 946 D2652 inlay - resin-based composite - three or more surfaces 1108 980 D2662 onlay - resin-based composite - two surfaces 1121 991 D2663 onlay - resin-based composite - three surfaces 1168 1034 D2664 onlay - resin-based composite - four or more surfaces 1223 1082 D2710 crown - resin-based composite (indirect) 1123 993 D2712 crown - 3/4 resin-based composite (indirect) 1197 1059 D2720 crown - resin with high noble metal 1245 1102 D2721 crown - resin with predominantly base metal 1189 1052 D2722 crown - resin with noble metal 1201 1063 D2740 crown - porcelain/ceramic substrate 1358 1202 D2750 crown - porcelain fused to high noble metal 1302 1152 D2751 crown - porcelain fused to predominantly base metal 1245 1102 D2752 crown - porcelain fused to noble metal 1247 1104 D2780 crown - 3/4 cast high noble metal 1250 1106 D2781 crown - 3/4 cast predominantly base metal 1215 1075 D2782 crown - 3/4 cast noble metal 1202 1064 D2783 crown - 3/4 porcelain/ceramic 1297 1148 D2790 crown - full cast high noble metal 1305 1155 D2791 crown - full cast predominantly base metal 1189 1052 D2792 crown - full cast noble metal 1238 1096 D2794 crown-titanium 1280 1133 D2799 provisional crown 526 466 D2910 recement inlay, onlay, or partial coverage restoration 130 115 D2915 recement cast or prefabricated post and core 135 119 D2920 recement crown 130 115 D2930 prefabricated stainless steel crown - primary tooth 321 284 D2931 prefabricated stainless steel crown - pennanent tooth 386 342 D2932 prefabricated resin crown 417 369 D2933 prefabricated stainless steel crown with resin window 440 390 D2934 prefabricated esthetic coated stainless steel crown - primary tooth 432 383 D2940 protective restoration 146 129 D2950 core buildup, including any pins 323 285 D2951 pin retention - per tooth, in addition to restoration 89 79 D2952 post and core in addition to crown, indirectly fabricated 504 446 D2953 each additional indirectly fabricated post - same tooth 374 330 D2954 prefabricated post and core in addition to crown 396 351 D2955 post removal (not in conjunction with endodontic therapy) 350 309 D2957 each additional prefabricated post - same tooth 243 215

11:3-29.6 APPENDIX B - REGULATIONS D2960 labial veneer (resin laminate) - chairside 797 705 D2961 labial veneer (resin laminate) - laboratory 1160 1027 D2962 labial veneer (porcelain laminate) - laboratory 1360 1203 D2970 temporary crown (fractured tooth) 453 401 D2971 additional procedures to construct new crown under existing partial denture framework 246 217 D2975 coping 717 634 D2980 crown repair, by report 351 310 D3310 endodontic therapy, anterior tooth (excluding final restoration) 865 765 D3320 endodontic therapy, bicuspid tooth (excluding final restoration) 996 881 D3330 endodontic therapy, molar (excluding final restoration) 1198 1060 D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant 764 676 D4249 clinical crown lengthening - hard tissue 912 807 D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant 1272 1126 D4261 osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant 1075 951 D4263 bone replacement graft - first site in quadrant 851 753 D4341 periodontal scaling and root planing - four or more teeth per quadrant 300 265 D4355 full mouth debridement to enable comprehensive evaluation and diagnosis 217 192 D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report 180 159 D4910 periodontal maintenance 166 147 D5110 complete denture-maxillary 2038 1803 D5120 complete denture - mandibular 2042 1807 D5130 immediate denture-maxillary 2207 1953 D5140 immediate denture-mandibular 2207 1953 D5211 D5212 D5213 D5214 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1613 1427 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) 1613 1427 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 2126 1881 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 2126 1881 D5510 repair broken complete denture base 252 223 D5520 replace missing or broken teeth - complete denture (each tooth) 223 197 D5610 repair resin denture base 242 214 D5620 repair cast framework 345 305 D5630 repair or replace broken clasp 316 279 D5640 replace broken teeth - per tooth 218 193 D5650 add tooth to existing partial denture 267 236 D5660 add clasp to existing partial denture 323 285 D5670 replace all teeth and acrylic on cast metal framework (maxillary) 890 787 D5671 replace all teeth and acrylic on cast metal framework (mandibular) 901 797 D5710 rebase complete maxillary denture 692 612 D5711 rebase complete mandibular denture 686 607 D5720 rebase maxillary partial denture 668 591 D5721 rebase mandibular partial denture 668 591 D5730 reline complete maxillary denture (chairside) 441 391 D5731 reline complete mandibular denture (chairside) 440 390 D5740 reline maxillary partial denture (chairside) 432 383 D5741 reline mandibular partial denture (chairside) 440 390 D5750 reline complete maxillary denture (laboratory) 565 500 D5751 reline complete mandibular denture (laboratory) 566 501 D5760 reline maxillary partial denture (laboratory) 560 496 D5761 reline mandibular partial denture (laboratory) 560 496

MEDICAL FEE SCHEDULES 11:3-29.6 D5810 interim complete denture (maxillary) 1029 910 D5811 interim complete denture (mandibular) 1043 922 D5820 interim partial denture (maxillary) 834 738 D5821 interim partial denture (mandibular) 834 738 D5850 tissue conditioning, maxillary 249 220 D5851 tissue conditioning, mandibular 249 220 D5860 overdenture - complete, by report 2537 2244 D5861 overdenture - partial, by report 2477 2191 D5862 precision attachment, by report 849 751 D5867 replacement of replaceable part of semi-precision or precision attachment (male or female component) 462 409 D5875 modification of removable prosthesis following implant surgery 466 413 D5937 trismus appliance (not for TMD treatment) 882 780 D5951 feeding aid 1031 912 D5982 surgical stent 529 468 D5988 surgical splint 902 799 D6010 surgical placement of implant body: endosteal implant 2377 2103 D6012 surgical placement of interim implant body for transitional prosthesis: endosteal implant 1872 1656 D6040 surgical placement: eposteal implant 9819 8687 D6050 surgical placement: transosteal implant 6885 6091 D6053 implant/abutment supported removable denture for completely edentulous arch 3386 2995 D6054 implant/abutment supported removable denture for partially edentulous arch 3321 2938 D6055 connecting bar - implant supported or abutment supported 3506 3102 D6056 prefabricated abutment - includes placement 962 851 D6057 custom abutment - includes placement 1132 1002 D6058 abutment supported porcelain/ceramic crown 1727 1528 D6059 abutment supported porcelain fused to metal crown (high noble metal)1734 1534 D6060 abutment supported porcelain fused to metal crown (predominantly base metal) 1626 1438 D6061 abutment supported porcelain fused to metal crown (noble metal) 1622 1435 D6062 abutment supported cast metal crown (high noble metal) 1698 1502 D6063 abutment supported cast metal crown (predominantly base metal) 1586 1403 D6064 abutment supported cast metal crown (noble metal) 1623 1436 D6065 implant supported porcelain/ceramic crown 1824 1613 D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 1838 1626 D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) 1855 1641 D6068 abutment supported retainer for porcelain/ceramic FPD 1731 1531 D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1729 1529 D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) 1641 1452 D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) 1643 1453 D6072 abutment supported retainer for cast metal FPD (high noble metal) 1741 1540 D6073 abutment supported retainer for cast metal FPD (predominantly base metal) 1635 1446 D6074 abutment supported retainer for cast metal FPD (noble metal) 1603 1418 D6075 implant supported retainer for ceramic FPD 1813 1604 D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 1854 1640 D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) 1870 1654 D6078 implant/abutment supported fixed denture for completely edentulous arch 6621 5858

11:3-29.6 APPENDIX B - REGULATIONS D6079 implantlabutment supported fixed denture for partially edentulous arch 4784 4232 D6080 implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis 375 331 D6090 repair implant supported prosthesis, by report 889 786 D6091 replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment 752 665 D6092 recement implant/abutment supported crown 189 167 D6093 recement implant/abutment supported fixed partial denture 216 191 D6094 abutment supported crown - (titanium) 1590 1407 D6095 repair implant abutment, by report 863 763 D6100 implant removal, by report 904 800 D6190 radiographic/surgical implant index, by report 509 451 D6194 abutment supported retainer crown for FPD - (titanium) 1721 1522 D6205 pontic - indirect resin based composite 1156 1023 D6210 pontic - cast high noble metal 1296 1147 D6211 pontic - cast predominantly base metal 1201 1063 D6212 pontic - cast noble metal 1233 1091 D6214 pontic-titanium 1292 1143 D6240 pontic - porcelain fused to high noble metal 1319 1167 D6241 pontic - porcelain fused to predominantly base metal 1215 1075 D6242 pontic - porcelain fused to noble metal 1245 1102 D6245 pontic - porcelain/ceramic 1358 1202 D6250 pontic - resin with high noble metal 1255 1111 D6251 pontic - resin with predominantly base metal 1244 1101 D6252 pontic - resin with noble metal 1228 1087 D6253 provisional pontic 910 805 D6545 retainer - cast metal for resin bonded fixed prosthesis 1019 901 D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis 1122 992 D6710 crown - indirect resin based composite 1192 1055 D6720 crown - resin with high noble metal 1253 1109 D6721 crown - resin with predominantly base metal 1242 1099 D6722 crown - resin with noble metal 1245 1102 D6740 crown - porcelain/ceramic 1364 1207 D6750 crown - porcelain fused to high noble metal 1330 1177 D6751 crown - porcelain fused to predominantly base metal 1217 1077 D6752 crown - porcelain fused to noble metal 1245 1102 D6780 crown - 3/4 cast high noble metal 1271 1125 D6781 crown - 3/4 cast predominantly base metal 1218 1078 D6782 crown - 3/4 cast noble metal 1245 1102 D6783 crown - 3/4 porcelain/ceramic 1296 1147 D6790 crown - full cast high noble metal 1298 1149 D6791 crown - full cast predominantly base metal 1201 1063 D6792 crown - full cast noble metal 1233 1091 D6793 provisional retainer crown 661 585 D6794 crown - titanium 1250 1106 D6920 connector bar 1182 1046 D6930 recement fixed partial denture 205 181 D6940 stress breaker 528 467 D6950 precision attachment 789 698 D6970 post and core in addition to fixed partial denture retainer, indirectly fabricated 517 458 D6972 prefabricated post and core in addition to fixed partial denture retainer406 360 D6973 core build up for retainer, including any pins 323 285 D6975 coping-metal 832 736 D6976 each additional indirectly fabricated post - same tooth 343 303 D6977 each additional prefabricated post - same tooth 246 217

MEDICAL FEE SCHEDULES 11:3-29.6 D6980 fixed partial denture repair, by report 455 403 D6985 pediatric partial denture, fixed 1073 949 D7110 single tooth (extraction) n/a n/a D7111 extraction, coronal remnants - deciduous tooth 161 142 D7120 each add tooth (extraction) n/a n/a D7140 extraction, erupted tooth or exposed root (elevation and/or forceps D7210 removal) 209 185 surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 328 290 D7250 surgical removal of residual tooth roots (cutting procedure) 370 327 D7290 surgical repositioning of teeth 625 553 D7560 maxillary sinusotomy for removal of tooth fragment or foreign body 1681 1487 D7610 maxilla - open reduction (teeth immobilized, if present) 5162 4567 D7620 maxilla - closed reduction (teeth immobilized, if present) 4180 3699 D7630 mandible - open reduction (teeth immobilized, if present) 5349 4732 D7640 mandible - closed reduction (teeth immobilized, if present) 4157 3678 D7650 malar and/or zygomatic arch - open reduction 4631 4097 D7660 malar and/or zygomatic arch - closed reduction 3862 3417 D7670 alveolus closed reduction may include stabilization of teeth 2257 1997 D7671 alveolus, open reduction may include stabilization of teeth 1512 1338 D7680 facial bones - complicated reduction with fixation and multiple surgical approaches 7759 6864 D7710 maxilla open reduction 5260 4654 D7720 maxilla - closed reduction 4133 3656 D7730 mandible - open reduction 5746 5084 D7740 mandible - closed reduction 4273 3781 D7750 malar and/or zygomatic arch - open reduction 5014 4436 D7760 malar and/or zygomatic arch - closed reduction 7186 6358 D7770 alveolus - open reduction stabilization of teeth 3294 2914 D7771 alveolus, closed reduction stabilization of teeth 2287 2023 D7780 facial bones - complicated reduction with fixation and multiple surgical approaches 10128 8960 D7810 open reduction of dislocation 5014 4436 D7820 closed reduction of dislocation 763 675 D7830 manipulation under anesthesia 1166 1032 D7840 condylectomy 6424 5684 D7850 surgical discectomy, with/without implant 6210 5494 D7852 disc repair 6609 5847 D7854 synovectomy 6140 5432 D7856 myotomy 4188 3706 D7880 occlusal orthotic device, by report 1453 1376 D7910 suture of recent small wounds up to 5 cm 368 325 D7911 complicated suture - up to 5 cm 610 540 D7912 complicated suture - greater than 5 cm 961 850 D7920 skin graft (identify defect covered, location and type of graft) 3110 2751 D7955 repair of maxillofacial soft and/or hard tissue defect 4554 3941 D7960 frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure 538 476 D7990 emergency tracheotomy 1715 1517 D8210 removable appliance therapy 1034 914 D8220 fixed appliance therapy 1174 1039 D8691 repair of orthodontic appliance 255 225 D8692 replacement of lost or broken retainer 405 359 D8693 rebonding or recementing; and/or repair, as required, of fixed retainers 408 361 D9110 palliative (emergency) treatment of dental pain - minor procedure 154 136 D9210 local anesthesia not in conjunction with operative or surgical procedures 91 80

11:3-29.6 APPENDIX B - REGULATIONS D9211 regional block anesthesia 113 100 D9212 trigeminal division block anesthesia 317 280 D9215 local anesthesia in conjunction with operative or surgical procedures 79 70 D9220 deep sedation/general anesthesia - first 30 minutes 480 425 D9221 deep sedation/general anesthesia - each additional 15 minutes 205 181 D9230 inhalation of nitrous oxide / anxiolysis, analgesia 96 85 D9241 intravenous conscious sedation/analgesia - first 30 minutes 509 451 D9242 intravenous conscious sedation/analgesia - each additional 15 minutes200 177 D9248 non-intravenous conscious sedation 400 354 D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 158 140 D9410 house/extended care facility call 301 266 D9420 hospital or ambulatory surgical center call 357 315 D9430 office visit for observation (during regularly scheduled hours) - no other services performed 94 83 D9610 therapeutic parenteral drug, single administration 131 116 D9612 therapeutic parenteral drugs, two or more administrations, different medications 226 200 D9630 other drugs and/or medicaments, by report 63 56 D9940 occlusal guard, by report 727 643 D9950 occlusion analysis - mounted case 418 370 D9951 occlusal adjus ment - limited 223 197 D9952 occlusal adjustment - complete 846 748 Exhibit 3 Home Care Fees Service PRIVATE NURSING CARE (PER HOUR) HSPCS CODE FEE Registered nurse S9123 70.00 Licensed practical nurse S9124 65.00 Home health aide S9122 24.00 Live-in attendant (per 24-hr shift) S5126 180.00 HOME HEALTH VISITS (PER VISIT) HSPCS CODE FEE Registered nurse T1030 125.00 Physical therapist S9131 135.00 Speech therapist S9128 145.00 Occupational therapist S9129 135.00 Medical social worker S9127 195.00 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 1 8.93 8.93 AMBULANCE SERVICE, ALS, EMERGENCY TRANSPORT, LEVEL I 386.84 363.02 A0428 AMBULANCE SERVICE, BLS, NON-EMERGENCY TRANSPORT 612.49 574.78 A0429 AMBULANCE SERVICE, BLS, EMERGENCY TRANSPORT 322.36 302.52 A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES 515.78 484.02 TRANSPORT ONE WAY (ROTARY WING) 4,790.49 4,571.17 A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) 886.50 831.92 A0434 SPECIALTY CARE TRANSPORT (SCT) 1,047.68 983.17 A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE 27.99 27.99

MEDICAL FEE SCHEDULES 11:3-29.6 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

11:3-29.6 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 $5.78 2 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

MEDICAL FEE SCHEDULES 11:3-29.6 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 $206.27 Heavy duty battery A4611 RR IN $21.39 Heavy duty battery A4611 UE IN $154.71 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 $151.42 Battery charger A4613 RR IN $15.15 Battery charger A4613 UE IN $109.50 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 $301.57 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

11:3-29.6 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 $200.25 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 $199.82 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

MEDICAL FEE SCHEDULES 11:3-29.6 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

11:3-29.6 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 $140.74 Nebulizer not used w oxygen A7017 RR IN $14.07 Nebulizer not used w oxygen A7017 UE IN $105.55 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 $188.32 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 $170.72 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 $106.46 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 $173.36 Implanted pleural catheter A7043 PO $29.52 Vacuum drainagebottle/tubing A7044 NU IN $109.42 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 $110.28 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 $161.02 Soft protect helmet prefab A8000 RR IN $16.10 Soft protect helmet prefab A8000 UE IN $120.78 Soft protect helmet prefab A8001 NU IN $161.02 Hard protect helmet prefab A8001 RR IN $16.10 Hard protect helmet prefab A8001 UE IN $120.78 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

MEDICAL FEE SCHEDULES 11:3-29.6 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 $202.35 Underarm springassist crutch E0117 RR IN $20.22 Underarm springassist crutch E0117 UE IN $151.78 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 $326.44 Walker w trunk support E0140 RR IN $32.65 Walker w trunk support E0140 UE IN $244.84 Walker w trunk support E0141 NU IN $104.34 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 $108.81 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 $288.20 Enclosed walker w rear seat E0144 RR IN $24.51 Enclosed walker w rear seat E0144 UE IN $183.72 Enclosed walker w rear seat E0147 NU IN $520.20 Walker variable wheel resist E0147 RR IN $52.02 Walker variable wheel resist E0147 UE IN $390.17 Walker variable wheel resist E0148 NU IN $114.98 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 $202.00 Heavy duty wheeled walker E0149 RR IN $20.20 Heavy duty wheeled walker E0149 UE IN $151.49 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

11:3-29.6 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 $152.99 Sitz bath chair E0162 RR IN $16.05 Sitz bath chair E0162 UE IN $118.65 Sitz bath chair E0163 NU IN $115.80 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 $158.47 Heavyduty/wide commode chair E0168 RR IN $15.93 Heavyduty/wide commode chair E0168 UE IN $118.84 Heavyduty/wide commode chair E0170 RR CR $168.76 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 $173.77 Dry pressure mattress E0184 RR IN $25.80 Dry pressure mattress E0184 UE IN $133.27 Dry pressure mattress E0185 NU IIN $285.47 Gel pressure mattress pad E0185 RR IN $47.19 Gel pressure mattress pad E0185 UE IN $219.09 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 $786.82 Powered air flotation bed E0194 RR CR $3,307.35 Air fluidized bed E0196 RR CR $28.99 Gel pressure mattress E0197 NU IN $197.76 Air pressure pad for mattres E0197 RR IN $32.10 Air pressure pad for mattres E0197 UE IN $173.71 Air pressure pad for mattres E0198 NU IN $197.76 Water pressure pad for mattr E0198 RR IN $24.10 Water pressure pad for mattr E0198 UE IN $150.07 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 $173.20 Heat lamp with stand E0205 RR IN $20.84 Heat lamp with stand E0205 UE IN $129.90 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

MEDICAL FEE SCHEDULES 11:3-29.6 E0215 UE IN $47.43 Electric heat pad moist E0217 NU IN $443.10 Water circ heat pad w pump E0217 RR IN $49.33 Water circ heat pad w pump E0217 UE IN $332.30 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 $346.87 Hydrocollator unit E0225 RR IN $34.20 Hydrocollator unit E0225 UE IN $260.14 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 $472.32 Hydrocollator unit portable E0239 RR IN $47.24 Hydrocollator unit portable E0239 UE IN $354.26 Hydrocollator unit portable E0249 NU IN $104.58 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 $127.12 Hosp bed semi-electr w/ matt E0261 RR CR $105.34 Hosp bed semi-electr w/o mat E0265 RR CR $173.87 Hosp bed total electr w/ mat E0266 RR CR $160.72 Hosp bed total elec w/o matt E0271 NU IN $191.13 Mattress innerspring E0271 RR IN $20.87 Mattress innerspring E0271 UE IN $143.32 Mattress innerspring E0272 NU IN $176.39 Mattress foam rubber E0272 RR IN $19.12 Mattress foam rubber E0272 UE IN $132.29 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 $584.14 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 $100.88 Hosp bed semi-elect w/ matt E0295 RR CR $100.88 Hosp bed semi-elect w/o matt E0296 RR CR $127.56 Hosp bed total elect w/ matt E0297 RR CR $127.31 Hosp bed total elect w/o mat E0300 NU IN $2,568.95 Enclosed ped crib hosp grade E0300 RR IN $256.89 Enclosed ped crib hosp grade E0300 UE IN $1,926.71 Enclosed ped crib hosp grade E0301 RR CR $228.58 HD hosp bed, 350-600 lbs E0302 RR CR $647.47 Ex hd hosp bed > 600 lbs E0303 RR CR $258.68 Hosp bed hvy dty xtra wide E0304 RR CR $697.46 Hosp bed xtra hvy dty x wide E0305 RR CR $13.69 Rails bed side half length E0310 NU IN $175.70 Rails bed side full length E0310 RR IN $20.60 Rails bed side full length E0310 UE IN $132.95 Rails bed side full length E0316 RR CR $191.21 Bed safety enclosure

11:3-29.6 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 $377.47 Nonpower mattress overlay E0372 RR CR $458.01 Powered air mattress overlay E0373 RR CR $524.67 Nonpowered pressure mattress E0424 RR OX $173.17 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 $173.17 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 $1,002.25 Vol control vent invasiv int E0457 NU IN $645.24 Chest shell E0457 RR IN $64.52 Chest shell E0457 UE IN $483.89 Chest shell E0459 RR CR $53.43 Chest wrap E0460 RR FS $654.71 Neg press vent portabl/statn E0461 RR FS $1,002.25 Vol control vent noninv int E0462 RR CR $305.97 Rocking bed w/ or w/o side r E0463 RR FS $1,476.70 Press supp vent invasive int E0464 RR FS $1,476.70 Press supp vent noninv int E0470 RR CR $197.39 RAD w/o backup non-inv intfc E0471 RR CR $493.99 RAD w/backup non inv mine E0472 RR CR $493.99 RAD w backup invasive intrfc E0480 RR CR $46.14 Percussor elect/pneum home m E0482 RR CR $423.71 Cough stimulating device E0483 RR CR $1,116.29 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 $115.26 Ippb all types E0550 RR CR $52.64 Humidif extens supple w ippb E0560 NU IN $131.95 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 $272.60 Humidifier heated used w PAP E0562 RR IN $27.25 Humidifier heated used w PAP E0562 UE IN $204.45 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 $107.92 Nebulizer ultrasonic E0580 NU IN $121.31 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

MEDICAL FEE SCHEDULES 11:3-29.6 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 $249.75 Pacemaker monitr audible/vis E0610 RR IN $26.34 Pacemaker monitr audible/vis E0610 UE IN $187.34 Pacemaker monitr audible/vis E0615 NU IN $442.62 Pacemaker monitr digital/vis E0615 RR IN $61.43 Pacemaker monitr digital/vis E0615 UE IN $331.97 Pacemaker monitr digital/vis E0617 RR CR $319.25 Automatic ext defibrillator E0617 RR KF CR $354.45 Automatic ext defibrillator E0618 RR CR $257.49 Apnea monitor E0619 RR CR $0.00 Apnea monitor w recorder E0620 NU IN $918.11 Cap bld skin piercing laser E0620 RR IN $91.80 Cap bld skin piercing laser E0620 UE IN $688.58 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 $347.25 Seat lift incorp lift-chair E0627 RR IN $34.73 Seat lift incorp lift-chair E0627 UE IN $260.41 Seat lift incorp lift-chair E0628 NU IN $347.25 Seat lift for pt furn-electr E0628 RR IN $34.73 Seat lift for pt furn-electr E0628 UE IN $260.41 Seat lift for pt furn-electr E0629 NU IN $347.25 Seat lift for pt furn-non-el E0629 RR IN $34.73 Seat lift for pt furn-non-el E0629 UE IN $260.41 Seat lift for pt furn-non-el E0630 RR CR $101.67 Patient lift hydraulic E0635 RR CR $109.21 Patient lift electric E0636 RR CR $1,107.29 PT support & positioning sys E0650 NU IN $686.85 Pneuma compresor non-segment E0650 RR IN $93.31 Pneuma compresor non-segment E0650 UE IN $515.15 Pneuma compresor non-segment E0651 NU IN $964.34 Pneum compressor segmental E0651 RR IN $96.44 Pneum compressor segmental E0651 UE IN $723.26 Pneum compressor segmental E0652 NU IN $4,731.54 Pneum compres w/cal pressure E0652 RR IN $467.63 Pneum compres w/cal pressure E0652 UE IN $4,126.23 Pneum compres w/cal pressure E0655 NU IN $109.78 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 $606.60 Segmental pneumatic trunk E0656 RR IN $60.59 Segmental pneumatic trunk E0656 UE IN $455.01 Segmental pneumatic trunk E0657 NU IN $569.88 Segmental pneumatic chest E0657 RR IN $56.89 Segmental pneumatic chest E0657 UE IN $427.44 Segmental pneumatic chest E0660 NU IN $167.74 Pneumatic appliance full leg E0660 RR IN $17.46 Pneumatic appliance full leg E0660 UE IN $115.91 Pneumatic appliance full leg E0665 NU IN $122.26 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 $144.98 Pneumatic appliance half leg E0666 RR IN $14.94 Pneumatic appliance half leg E0666 UE IN $108.77 Pneumatic appliance half leg E0667 NU IN $339.96 Seg pneumatic appl full leg E0667 RR IN $34.00 Seg pneumatic appl full leg E0667 UE IN $254.96 Seg pneumatic appl full leg E0668 NU IN $394.37 Seg pneumatic appl full arm E0668 RR IN $38.92 Seg pneumatic appl full arm

11:3-29.6 APPENDIX B - REGULATIONS E0668 UE IN $295.79 Seg pneumatic appl full arm E0669 NU IN $182.76 Seg pneumatic appli half leg E0669 RR IN $18.28 Seg pneumatic appli half leg E0669 UE IN '$137.09 Seg pneumatic appli half leg E0671 NU IN $436.12 Pressure pneum appl full leg E0671 RR IN $43.62 Pressure pneum appl full leg E0671 UE IN $327.08 Pressure pneum appl full leg E0672 NU IN $338.87 Pressure pneum appl full arm E0672 RR IN $33.89 Pressure pneum appl full arm E0672 UE IN $254.16 Pressure pneum appl full arm E0673 NU IN $281.58 Pressure pneum appl half leg E0673 RR IN $28.16 Pressure pneum appl half leg E0673 UE IN $211.21 Pressure pnelun appl half leg E0675 RR CR $403.78 Pneumatic compression device E0691 NU IN $943.52 Uvl pnl 2 sq ft or less E0691 RR IN $94.35 Uvl pnl 2 sq ft or less E0691 UE IN $707.64 Uvl pnl 2 sq ft or less E0692 NU IN $1,184.79 Uvl sys panel 4 ft E0692 RR IN $118.47 Uvl sys panel 4 ft E0692 UE IN $888.60 Uv1 sys panel 4 ft E0693 NU IN $1,460.53 Uvl sys panel 6 ft E0693 RR IN $146.06 Uvl sys panel 6 ft E0693 UE IN $1,095.40 Uvl sys panel 6 ft E0694 NU IN $4,648.71 Uvl and cabinet sys 6 ft E0694 RR IN $464.87 Uvl and cabinet sys 6 ft E0694 UE IN $3,486.56 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 $100.00 Tens four lead E0731 NU IN $374.52 Conductive garment for tens/ E0740 NU IN $549.01 Incontinence treatment systm E0740 RR IN $54.90 Incontinence treatment systm E0740 UE IN $411.79 Incontinence treatment systm E0744 RR CR $96.15 Neuromuscular stim for scoli E0745 NU IN $200.00 Neuromuscular stim for shock E0745 RR CR $20.00 Neuromuscular stim for shock E0747 NU KF IN $3,963.48 Elec osteogen stim not spine E0747 RR KF IN $396.32 Elec osteogen stim not spine E0747 UE KF IN $2,972.60 Elec osteogen stim not spine E0748 NU KF IN $4,085.24 Elec osteogen stim spinal E0748 RR KF IN $408.52 Elec osteogen stim spinal E0748 UE KF IN $3,063.94 Elec osteogen stim spinal E0749 RR KF CR $298.59 Elec osteogen stim implanted E0760 NU KF IN $3,394.76 Osteogen ultrasound stimltor E0760 RR KF IN $339.49 Osteogen ultrasound stimltor E0760 UE KF IN $2,546.07 Osteogen ultrasound stimltor E0762 NU IN $1,154.54 Trans elec jt stim dev sys E0762 RR IN $115.46 Trans elec jt stim dev sys E0762 UE IN $865.88 Trans elec jt stim dev sys E0764 NU KF IN $11,620.16 Functional neuromuscularstim.e0764 RR KF IN $1,162.00 Functional neuromuscularstim E0764 UE KF IN $8,715.13 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 $127.77 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 $236.39 External ambulatory infus pu E0782 NU KF IN $4,508.08 Non-programble infusion pump E0782 RR KF IN $450.83 Non-programble infusion pump E0782 UE KF IN $3,381.07 Non-programble infusion pump E0783 NU KF IN $8,202.34 Programmable infusion pump E0783 RR KF IN $820.25 Programmable infusion pump

MEDICAL FEE SCHEDULES 11:3-29.6 E0783 UE KF IN $6,151.77 Programmable infusion pump E0784 RR CR $438.45 Ext amb infusn pump insulin E0785 KF IN $421.71 Replacement impl pump cachet E0786 NU KF IN $8,082.48 Implantable pump replacement E0786 RR KF IN $808.25 Implantable pump replacement E0786 UE KF IN $6,061.88 Implantable pump replacement E0791 RR CR $282.21 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 $541.08 Cervical pneum trac equip E0849 RR IN $54.11 Cervical pneurn trac equip E0849 UE IN $405.78 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 $527.76 Cervical traction equipment E0855 RR IN $52.77 Cervical traction equipment E0855 UE IN $395.81 Cervical traction equipment E0856 NU IN $161.73 Cervic collar w air bladder E0856 RR IN $16.19 Cervic collar w air bladder E0856 UE IN $121.31 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 $110.31 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 $112.05 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 $107.47 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 $114.35 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 $103.60 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 $636.78 Fracture frame attachmnts pe E0947 RR IN $66.03 Fracture frame attachmnts pe E0947 UE IN $477.58 Fracture frame attachmnts pe E0948 NU IN $615.92 Fracture frame attachmnts cc E0948 RR IN $61.57 Fracture frame attachmnts cc E0948 UE IN $434.39 Fracture frame attachmnts cc E0950 NU IN $94.07 Tray E0950 NU KE IN $109.15 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

11:3-29.6 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 $182.97 Cushioned headrest E0955 NIT KE IN $212.29 Cushioned headrest E0955 RR IN $18.31 Cushioned headrest E0955 RR KE IN $21.24 Cushioned headrest E0955 UE IN $137.23 Cushioned headrest E0955 UE KE IN $159.21 Cushioned headrest E0956 NU IN $89.21 W/c lateral trunk/hip suppor E0956 NU KE IN $103.51 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 $124.83 W/c medial thigh support E0957 NU KE IN $144.83 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 $108.62 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 $153.50 Wheelchair narrowing device E0969 RR IN $15.36 Wheelchair narrowing device E0969 UE IN $115.12 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 $104.05 W/Ch access det adj armrest E0973 NU KE IN $120.72 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

MEDICAL FEE SCHEDULES 11:3-29.6 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 $246.77 Add pwr joystick E0984 NU IN $1,705.19 Add pwr tiller E0984 RR IN $158.56 Add pwr tiller E0984 UE IN $1,315.78 Add pwr tiller E0985 NU IN $212.99 W/c seat lift mechanism E0985 RR IN $21.32 W/c seat lift mechanism E0985 UE IN $159.73 W/c seat lift mechanism E0986 NU IN $5,107.45 Man w/c push-rim pow assist E0986 RR IN $510.75 Man w/c push-rim pow assist E0986 UE IN $3,830.61 Man w/c push-rim pow assist E0990 NU IN $90.33 Wheelchair elevating leg res E0990 NU KE IN $104.81 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 $3,668.16 Pwr seat tilt E1002 NU KE IN $4,255.87 Pwr seat tilt E1002 RR IN $366.81 Pwr seat tilt E1002 RR KE IN $425.59 Pwr seat tilt E1002 UE IN $2,751.11 Pwr seat tilt E1002 UE KE IN $3,191.90 Pwr seat tilt E1003 NU IN $3,974.13 Pwr seat recline E1003 NU KE IN $4,610.87 Pwr seat recline E1003 RR IN $397.42 Pwr seat recline E1003 RR KE IN $461.10 Pwr seat recline E1003 UE IN $2,980.60 Pwr seat recline E1003 UE KE IN $3,458.15 Pwr seat recline E1004 NU IN $4,406.49 Pwr seat recline mech E1004 NU KE IN $5,112.50 Pwr seat recline mech E1004 RR IN $440.64 Pwr seat recline mech E1004 RR KE IN $511.25 Pwr seat recline mech E1004 UE IN $3,304.85 Pwr seat recline mech E1004 UE KE IN $3,834.36 Pwr seat recline mech E1005 NU IN $4,769.68 Pwr seat recline pwr E1005 NU KE IN $5,533.88 Pwr seat recline pwr E1005 RR IN $476.96 Pwr seat recline pwr E1005 RR KE IN $553.38 Pwr seat recline pwr E1005 UE IN $3,577.27 Pwr seat recline pwr

11:3-29.6 APPENDIX B - REGULATIONS E1005 UE KE IN $4,150.42 Pwr seat recline pwr E1006 NU IN $5,842.41 Pwr seat combo w/o shear E1006 NU KE IN $6,778.49 Pwr seat combo w/o shear E1006 RR IN $584.22 Pwr seat combo w/o shear E1006 RR KE IN $677.83 Pwr seat combo w/o shear E1006 UE IN $4,381.81 Pwr seat combo w/o shear E1006 UE KE IN $5,083.87 Pwr seat combo w/o shear B1007 NU IN $7,910.85 Pwr seat combo w/shear E1007 NU KE IN $9,178.33 Pwr seat combo w/shear E1007 RR IN $791.09 Pwr seat combo w/shear E1007 RR IN $917.84 Pwr seat combo w/shear E1007 UE IN $5,933.13 Pwr seat combo w/shear E1007 UE KE IN $6,883.74 Pwr seat combo w/shear E1008 NU IN $7,911.56 Pwr seat combo pwr shear E1008 NU KE IN $9,179.15 Pwr seat combo pwr shear E1008 RR IN $791.15 Pwr seat combo pwr shear E1008 RR KE IN $917.91 Pwr seat combo pwr shear E1008 UE IN $5,933.68 Pwr seat combo pwr shear E1008 UE KE IN $6,884.38 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 $1,035.13 Add pwr leg elevation E1010 NU KE IN $1,200.98 Add pwr leg elevation E1010 RR IN $103.51 Add pwr leg elevation E1010 RR KE IN $120.10 Add pwr leg elevation E1010 UE IN $776.36 Add pwr leg elevation E1010 UE KE IN $900.75 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 $383.40 Reclining back add ped w/c E1014 RR IN $38.35 Reclining back add ped w/c E1014 UE IN $287.54 Reclining back add ped w/c E1015 NU IN $120.44 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 $118.84 Shock absorber for power w/c E1016 NU KE IN $137.88 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 $103.40 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 $220.29 Residual limb support system E1020 NU KE IN $255.58 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 $165.21 Residual limb support system E1020 UE KE IN $191.68 Residual limb support system E1028 NU IN $186.92 W/c manual swingaway E1028 NU KE IN $216.87 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 $140.18 W/c manual swingaway E1028 UE KE IN $162.63 W/c manual swingaway B1029 NU IN $334.43 W/c vent tray fixed E1029 NU KE IN $388.02 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 $250.82 W/c vent tray fixed E1029 UE KE IN $291.01 W/c vent tray fixed E1030 NU IN $1,054.57 W/c vent tray gimbaled

MEDICAL FEE SCHEDULES 11:3-29.6 E1030 NU KE IN $1,223.53 W/o vent tray gimbaled E1030 RR IN $105.46 W/c vent tray gimbaled E1030 RR KE IN $122.36 W/c vent tray gimbaled E1030 UE IN $790.93 W/c vent tray gimbaled E1030 UE KE IN $917.66 W/c vent tray gimbaled E1031 RR CR $53.04 Rollabout chair with casters E1035 RR CR $643.86 Patient transfer system <300 E1036 RR CR $902.63 Patient transfer system >300 E1037 RR CR $113.91 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 $106.93 Whelchr fxd full length arms E1060 RR CR $118.97 Wheelchair detachable arms E1070 RR CR $115.01 Wheelchair detachable foot r E1083 RR CR $75.78 Hemi-wheelchair fixed arms E1084 RR CR $103.01 Hemi-wheelchair detachable a E1087 RR CR $121.80 Wheelchair lightwt fixed arm E1088 RR CR $158.31 Wheelchair lightweight det a E1092 RR CR $134.94 Wheelchair wide w/ leg rests E1093 RR CR $116.05 Wheelchair wide w/ foot rest E1100 RR CR $109.00 Whchr s-recl fxd arm leg res E1110 RR CR $106.74 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 $2,484.39 Manual adult we w tiltinspac E1161 RR IN $248.44 Manual adult we w tiltinspac E1161 UE IN $1,863.30 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 $114.51 Wheelchair amputee w/ leg re E1195 RR CR $112.12 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 $572.93 Manual fully reclining back E1226 RR IN $58.97 Manual fully reclining back E1226 UE IN $429.66 Manual fully reclining back E1227 NU IN $291.38 Wheelchair spec sz spec ht a E1227 RR IN $28.67 Wheelchair spec sz spec ht a E1227 UE IN $218.56 Wheelchair spec sz spec ht a E1228 RR CR $25.01 Wheelchair spec sz spec ht b E1230 NU IN $2,136.81 Power operated vehicle E1230 RR IN $233.57 Power operated vehicle E1230 UE IN $1,596.51 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 $2,245.33 Folding ped wc tilt-in-space E1232 RR IN $224.54 Folding ped wc tilt-in-space E1232 UE IN $1,684.01 Folding ped wc tilt-in-space E1233 NU IN $2,326.52 Rig ped wc tltnspc w/o seat E1233 RR IN $232.65 Rig ped wc tltnspc w/o seat E1233 UE IN $1,744.88 Rig ped wc tltnspc w/o seat E1234 NU IN $2,025.40 Fld ped wc tltnspc w/o seat E1234 RR IN $202.56 Fld ped wc tltnspc w/o seat E1234 UE IN $1,519.04 Fld ped wc tltnspc w/o seat E1235 NU IN $1,950.30 Rigid ped wc adjustable E1235 RR IN $195.04 Rigid ped wc adjustable E1235 UE IN $1,462.72 Rigid ped wc adjustable E1236 NU IN $1,720.67 Folding ped wc adjustable E1236 RR IN $172.06 Folding ped wc adjustable E1236 UE IN $1,290.50 Folding ped wc adjustable E1237 NU IN $1,735.70 Rgd ped wc adjstabl w/o seat

11:3-29.6 APPENDIX B - REGULATIONS E1237 RR IN $173.57 Rgd ped wc adjstabl w/o seat E1237 UE IN $1,301.79 Rgd ped wc adjstabl w/o seat E1238 NU IN $1,720.67 Fld ped wc adjstabl w/o seat E1238 RR IN $172.06 Fld ped wc adjstabl w/o seat E1238 UE IN $1,290.50 Fld ped wc adjstabl w/o seat E1240 RR CR $108.17 Whchr litwt det arm leg rest E1270 RR CR $80.68 Wheelchair lightweight leg r E1280 RR CR $128.96 Whchr h-duty det arm leg res E1295 RR CR $124.10 Wheelchair heavy duty fixed E1296 NU IN $438.81 Wheelchair special seat heig E1296 RR IN $44.57 Wheelchair special seat heig E1296 UE IN $329.11 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 $401.01 Wheelchair spec seat depth/w E1298 RR IN $40.11 Wheelchair spec seat depth/w E1298 UE IN $300.75 Wheelchair spec seat depth/w E1310 NU IN $2,254.77 Whirlpool non-portable E1310 RR IN $192.85 Whirlpool non-portable E1310 UE IN $1,691.08 Whirlpool non-portable E1353 OX $29.75 Oxygen supplies regulator E1355 OX $22.40 Oxygen supplies stand/rack E1372 NU IN $171.18 Oxy suppl heater for nebuliz E1372 RR IN $24.87 Oxy suppl heater for nebuliz E1372 UE IN $107.70 Oxy suppl heater for nebuliz E1390 RR OX $173.17 Oxygen concentrator E1391 RR OX $173.17 Oxygen concentrator, dual E1392 RR OX $51.63 Portable oxygen concentrator E1405 RR OX $209.99 O2/water vapor enrich wheat E1406 RR OX $190.08 O2/water vapor enrich w/o he E1700 NU IN $307.77 Jaw motion rehab system E1700 RR IN $30.18 Jaw motion rehab system E1700 UE IN $230.83 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 $109.34 Adjust elbow ext/flex device E1801 RR CR $127.14 SPS elbow device E1802 RR CR $343.14 Adjst forearm pro/sup device E1805 RR CR $118.01 Adjust wrist ext/flex device E1806 RR CR $104.34 SPS wrist device E1810 RR CR $118.01 Adjust knee ext/flex device E1811 RR CR $132.16 SPS knee device E1812 RR CR $90.29 Knee ext/flex w act res ctrl E1815 RR CR $118.01 Adjust ankle ext/flex device E1816 RR CR $134.24 SPS ankle device E1818 RR CR $137.05 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 $110.51 Replacement interface SPSD E1821 RR IN $11.04 Replacement interface SPSD E1821 UE IN $82.90 Replacement interface SPSD E1825 RR CR $118.01 Adjust finger ext/flex devc E1830 RR CR $118.01 Adjust toe ext/flex device E1840 RR CR $390.41 Adj shoulder ext/flex device E1841 RR CR $475.65 Static str shldr dev rom adj E2000 RR CR $51.05 Gastric suction pump hme mdl E2100 NU IN $666.03 Bld glucose monitor w voice E2100 RR IN $66.60 Bld glucose monitor w voice E2100 UE IN $499.54 Bld glucose monitor w voice E2101 NU IN $197.99 Bld glucose monitor w lance E2101 RR IN $19.80 Bld glucose monitor w lance E2101 UE IN $148.49 Bld glucose monitor w lance E2120 RR CR $297.70 Pulse gen sys tx endolymp fl E2201 NU IN $391.76 Man w/ch acc seat w>=20"<24" E2201 RR IN $39.18 Man w/ch ace seat w>=20"<24" E2201 UE IN $293.82 Man w/ch ace seat w>=20"<24"

MEDICAL FEE SCHEDULES 11:3-29.6 E2202 NU IN $497.68 Seat width 24-27 in E2202 RR IN $49.77 Seat width 24-27 in E2202 UE IN $373.28 Seat width 24-27 in E2203 NU IN $503.00 F rame depth less than 22 in E2203 RR IN $50.28 Frame depth less than 22 in E2203 UE IN $377.24 Frame depth less than 22 in E2204 NU IN $854.07 Frame depth 22 to 25 in E2204 RR IN $85.42 Frame depth 22 to 25 in E2204 UE IN $640.55 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 $107.50 Cylinder tank carrier E2208 NU KE IN $124.72 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 $112.52 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

11:3-29.6 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 $102.96 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 $1,888.65 Gear reduction drive wheel E2227 RR IN $188.85 Gear reduction drive wheel E2227 UE IN $1,416.48 Gear reduction drive wheel E2228 NU IN $983.07 Mwc acc, wheelchair brake E2228 RR IN $98.30 Mwc acc, wheelchair brake E2228 UE IN $737.33 Mwc acc, wheelchair brake E2231 NU IN $161.36 Solid seat support base E2231 RR IN $16.14 Solid seat support base E2231 UE IN $121.01 Solid seat support base E2310 NU IN $1,059.07 Electro connect btvv control E2310 NU KE IN $1,228.75 Electro connect btw control E2310 RR IN $105.90 Electro connect btw control E2310 RR KE IN $122.87 Electro connect btw control E2310 UE IN $794.30 Electro connect btw control E2310 UE KE IN $921.56 Electro connect btw control E2311 NU IN $2,144.13 Electro connect btw 2 sys E2311 NU KE IN $2,487.66 Electro connect btw 2 sys E2311 RR IN $214.42 Electro connect btw 2 sys E2311 RR KE IN $248.78 Electro connect btw 2 sys E2311 UE IN $1,608.09 Electro connect btw 2 sys E2311 UE KE IN $1,865.75 Electro connect btw 2 sys E2312 NU IN $2,036.14 Mini-prop remote joystick E2312 NU KC IN $2,596.84 Mini-prop remote joystick E2312 RR IN $203.62 Mini-prop remote joystick E2312 RR KC IN $259.69 Mini-prop remote joystick E2312 UE IN $1,527.08 Mini-prop remote joystick E2312 UE KC IN $1,947.62 Mini-prop remote joystick E2313 NU IN $323.33 PWC harness, expand control E2313 RR IN $32.35 PWC harness, expand control E23 13 UE IN $242.50 PWC harness, expand control E2321 NU IN $1,438.14 Hand interface joystick E2321 NU KC IN $2,342.55 Hand interface joystick E2321 NU KE IN $1,668.56 Hand interface joystick E2321 RR IN $143.82 Hand interface joystick E2321 RR KC IN $234.26 Hand interface joystick E2321 RR KE IN $166.87 Hand interface joystick E2321 UE IN $1,078.62 Hand interface joystick E2321 UE KC IN $1,756.91 Hand interface joystick E2321 UE KE IN $1,251.43 Hand interface joystick E2322 NU IN $1,276.38 Mult mech switches E2322 NU KC IN $2,480.72 Mult mech switches E2322 NU KE IN $1,480.88 Mult mech switches E2322 RR IN $127.63 Mult mech switches E2322 RR KC IN $248.07 Mult mech switches E2322 RR KE IN $148.08 Mult mech switches B2322 UE IN $957.29 Mult mech switches E2322 UE KC IN $1,860.54 Mult mech switches E2322 UE KE IN $1,110.67 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

MEDICAL FEE SCHEDULES 11:3-29.6 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 $1,218.88 Sip and puff interface E2325 NU KE IN $1,414.17 Sip and puff interface E2325 RR IN $121.90 Sip and puff interface E2325 RR KE IN $141.44 Sip and puff interface E2325 UE IN $914.17 Sip and puff interface E2325 UE KE IN $1,060.64 Sip and puff interface E2326 NU IN $314.16 Breath tube kit E2326 NU KE IN $364.50 Breath tube kit E2326 RR IN $31.43 Breath tube kit E2326 RR KE IN $36.47 Breath tube kit E2326 UE IN $235.61 Breath tube kit E2326 UE KE IN $273.36 Breath tube kit E2327 NU IN $2,364.20 Head control interface mech E2327 NU KC IN $3,591.81 Head control interface mech E2327 NU KE IN $2,743.00 Head control interface mech E2327 RR IN $236.42 Head control interface mech E2327 RR KC IN $359.18 Head control interface mech E2327 RR KE IN $274.30 Head control interface mech E2327 UE IN $1,773.15 Head control interface mech E2327 UE KC IN $2,693.85 Head control interface mech E2327 UE KE IN $2,057.24 Head control interface mech E2328 NU IN $4,484.56 Head/extremity control inter E2328 NU KE IN $5,203.09 Head/extremity control inter E2328 RR IN $448.45 Head/extremity control inter E2328 RR KE IN $520.30 Head/extremity control inter E2328 UE IN $3,363.43 Head/extremity control inter E2328 UE KE IN $3,902.33 Head/extremity control inter E2329 NU IN $1,598.35 Head control nonproportional E2329 NU KE IN $1,854.44 Head control nonproportional E2329 RR IN $159.83 Head control nonproportional E2329 RR KE IN $185.44 Head control nonproportional E2329 UE IN $1,198.76 Head control nonproportional E2329 UE KE IN $1,390.83 Head control nonproportional E2330 NU IN $3,096.99 Head control proximity switc E2330 NU KE IN $3,593.19 Head control proximity switc E2330 RR IN $309.69 Head control proximity switc E2330 RR KE IN $359.31 Head control proximity switc E2330 UE IN $2,322.75 Head control proximity switc E2330 UE KE IN $2,694.91 Head control proximity switc E2340 NU IN $376.28 W/c wdth 20-23 in seat frame E2340 RR IN $37.64 W/c wdth 20-23 in seat frame E2340 UE IN $282.23 W/c wdth 20-23 in seat frame E2341 NU IN $564.46 W/o wdth 24-27 in seat frame E2341 RR IN $56.45 W/c wdth 24-27 in seat frame E2341 UE IN $423.35 W/c wdth 24-27 in seat frame E2342 NU IN $470.38 W/c dpth 20-21 in seat frame E2342 RR IN $47.04 W/c dpth 20-21 in seat frame E2342 UE IN $352.79 W/c dpth 20-21 in seat frame E2343 NU IN $752.62 W/c dpth 22-25 in seat frame E2343 RR IN $75.25 W/c dpth 22-25 in seat frame E2343 UE IN $564.46 W/c dpth 22-25 in seat frame E2351 NU IN $632.26 Electronic SGD interface E2351 NU KE IN $733.56 Electronic SGD interface E2351 RR IN $63.24 Electronic SGD interface E2351 RR KE IN $73.37 Electronic SGD interface E2351 UE IN $474.18 Electronic SGD interface E2351 UE KE IN $550.16 Electronic SGD interface E2360 NU IN $117.96 22nf nonsealed leadacid E2360 RR IN $11.85 22nf nonsealed leadacid E2360 UE IN $88.47 22nf nonsealed leadacid E2361 NU IN $126.22 22nf sealed leadacid battery E2361 NU KE IN $146.44 22nf sealed leadacid battery E2361 RR IN $12.62 22nf sealed leadacid battery

11:3-29.6 APPENDIX B - REGULATIONS E2361 RR KE IN $14.65 22nf sealed leadacid battery E2361 UE IN $94.68 22nf sealed leadacid battery E2361 UE KE IN $109.85 22nf 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 $168.33 Gr24 sealed leadacid battery E2363 NU KE IN $195.30 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 $126.25 Gr24 sealed leadacid battery E2363 UE KE IN $146.48 Gr24 sealed leadacid battery E2364 NU IN $117.96 Ulnonsealed leadacid battery E2364 RR IN $11.85 U1 nonsealed leadacid battery E2364 UE IN $88.47 U1 nonsealed leadacid battery E2365 NU IN $101.51 U1 sealed leadacid battery E2365 NU KE IN $117.78 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 $238.58 Battery charger, single mode E2366 NU KE IN $276.80 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 $178.94 Battery charger, single mode E2366 UE KE IN $207.61 Battery charger, single mode E2367 NU IN $379.27 Battery charger, dual mode E2367 NU KE IN $440.03 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 $$284.45 Battery charger, dual mode E2367 UE KE IN $330.03 Battery charger, dual mode E2368 NU IN $467.50 Power we motor replacement E2368 NU KE IN $542.40 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 $350.63 Power we motor replacement E2368 UE KE IN $406.81 Power we motor replacement E2369 NU IN $407.20 Pwr we gear box replacement E2369 NU KE IN $472.44 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 $305.39 Pwr we gear box replacement E2369 UE KE IN $354.32 Pwr we gear box replacement E2370 NU IN $726.57 Pwr we motor/gear box combo E2370 NU KE IN $842.98 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 $544.92 Pwr we motor/gear box combo E2370 UE KE IN $632.23 Pwr we motor/gear box combo E2371 NU IN $136.42 Gr27 sealed leadacid battery E2371 NU KE IN $158.28 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 $102.32 Gr27 sealed leadacid battery E2371 UE KE IN $118.71 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 $709.72 Hand/chin ctrl spec joystick E2373 NU KC IN $1,094.99 Hand/chin ctrl spec joystick E2373 NU KE IN $709.72 Hand/chin ctrl spec joystick E2373 RR IN $70.99 Hand/chin ctrl spec joystick E2373 RR KC IN $109.51 Hand/chin ctrl spec joystick E2373 RR KE IN $70.99 Hand/chin ctrl spec joystick E2373 UE IN $532.31 Hand/chin ctrl spec joystick E2373 UE KC IN $821.26 Hand/chin ctrl spec joystick

MEDICAL FEE SCHEDULES 11:3-29.6 E2373 UE KE IN $532.31 Hand/chin ctrl spec joystick E2374 NU IN $483.29 Hand/chin ctrl std j oystick E2374 NU KE IN $560.72 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 $362.48 Hand/chin ctrl std joystick E2374 UE KE IN $420.56 Hand/chin ctrl std joystick E2375 NU IN $775.19 Non-expandable controller E2375 NU KE IN $899.39 Non-expandable controller E2375 RR IN $77.51 Non-expandable controller E2375 RR KE IN $89.93 Non-expandable controller E2375 UE IN $581.37 Non-expandable controller E2375 UE KE IN $674.52 Non-expandable controller E2376 NU IN $1,214.75 Expandable controller, repl E2376 NU KE IN $1,409.38 Expandable controller, repl E2376 RR IN $121.48 Expandable controller, repl E2376 RR KE IN $140.94 Expandable controller, repl E2376 UE IN $911.08 Expandable controller, repl E2376 UE KE IN $1,057.06 Expandable controller, repl E2377 NU IN $439.57 Expandable controller, initl E2377 NU KE IN $510.00 Expandable controller, initl E2377 RR IN $43.95 Expandable controller, initl E2377 RR KE IN $50.99 Expandable controller, initl E2377 UE IN $329.69 Expandable controller, initl E2377 UE KE IN $382.52 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 $137.45 Insert, pneum wheel drive E2383 NU KE IN $159.47 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 $103.09 Insert, pneum wheel drive E2383 UE KE IN $119.61 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 $136.21 Foam filled drive wheel tire E2386 NU KE IN $158.04 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 $102.15 Foam filled drive wheel tire E2386 UE KE IN $118.51 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

11:3-29.6 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 $434.84 Pwc ace, lith-based battery E2397 RR IN $43.48 Pwc ace, lith-based battery E2397 UE IN $326.12 Pwc ace, lith-based battery E2402 RR CR $1,553.40 Neg press wound therapy pump E2500 NU IN $410.61 SGD digitized pre-rec <=8min E2500 RR IN $41.07 SGD digitized pre-rec <=8min E2500 UE IN $307.95 SGD digitized pre-rec <=8min E2502 NU IN $1,255.59 SGD prerec msg >8min <=20min E2502 RR IN $125.57 SGD prerec msg >8min <=20min E2502 UE IN $941.70 SGD prerec msg >8min <=20min E2504 NU IN $1,656.29 SGD prerec msg>20min <=40min E2504 RR IN $165.65 SGD prerec msg>20min <=40min E2504 UE IN $1,242.20 SGD prerec msg>20min <=40min E2506 NU IN $2,428.61 SGD prerec msg > 40 min E2506 RR IN $242.85 SGD prerec msg > 40 min E2506 UE IN $1,821.42 SGD prerec msg > 40 min B2508 NU IN $3,755.44 SGD spelling phys contact E2508 RR IN $375.55 SGD spelling phys contact E2508 UE IN $2,816.59 SGD spelling phys contact E2510 NU IN $7,106.66 SGD w multi methods msg/accs E2510 RR IN $710.66 SGD w multi methods msg/accs

MEDICAL FEE SCHEDULES 11:3-29.6 E2510 UE IN $5,329.99 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 $108.06 Gen w/c cushion wdth >=22 in E2602 NU KE IN $125.37 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 $137.19 Skin protect we cus wd <22in E2603 NU KE IN $159.17 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 $102.89 Skin protect wc cus wd <22in E2603 UE KE IN $119.37 Skin protect wc cus wd <22in E2604 NU IN $170.51 Skin protect wc cus wd>=22in E2604 NU KE IN $197.83 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 $127.90 Skin protect wc cus wd>=22in E2604 UE KE IN $148.40 Skin protect wc cus wd>=22in E2605 NU IN $243.60 Position wc cush wdth <22 in E2605 NU KE IN $282.63 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 $182.73 Position wc cush wdth <22 in E2605 UE KE IN $212.01 Position wc cush wdth <22 in E2606 NU IN $380.04 Position wc cush wdth>=22 in E2606 NU KE IN $440.93 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 $285.02 Position wc cush wdth>=22 in E2606 UE KE IN $330.69 Position wc cush wdth>=22 in E2607 NU IN $262.31 Skin pro/pos wc cus wd <22in E2607 NU KE IN $304.34 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 $196.74 Skin pro/pos wc cus wd <22in E2607 UE KE IN $228.26 Skin pro/pos wc cus wd <22in E2608 NU IN $315.02 Skin pro/pos wc cus wd>=22in E2608 NU KE IN $365.49 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 $236.27 Skin pro/pos wc cus wd>=22in E2608 UE KE IN $274.12 Skin pro/pos wc cus wd>=22in E2611 NU IN $282.68 Gen use back cush wdth <22in E2611 NU KE IN $327.97 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 $212.03 Gen use back cush wdth <22in E2611 UE KE IN $246.00 Gen use back cush wdth <22in E2612 NU IN $382.40 Gen use back cush wdth>=22in E2612 NU KE IN $443.67 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 $286.79 Gen use back cush wdth>=22in E2612 UE KE IN $332.73 Gen use back cush wdth>=22in E2613 NU IN $355.70 Position back cush wd <22in

11:3-29.6 APPENDIX B - REGULATIONS E2613 NU KE IN $412.69 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 $266.78 Position back cush wd <22in E2613 UE KE IN $309.52 Position back cush wd <22in E2614 NU IN $492.26 Position back cush wd>=22in E2614 NU KE IN $571.13 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 $369.21 Position back cush wd>=22in E2614 UE KE IN $428.37 Position back cush wd>=22in E2615 NU IN $409.35 Pos back post/lat wdth <22in E2615 NU KE IN $474.94 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 $307.00 Pos back post/lat wdth <22in E2615 UE KE IN $356.19 Pos back post/lat wdth <22in E2616 NU IN $550.76 Pos back post/lat wdth>=22in E2616 NU KE IN $639.01 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 $413.09 Pos back post/lat wdth>=22in E2616 UE KE IN $479.27 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 $495.67 WC planar back cush wd <22in E2620 NU KE IN $575.09 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 $371.76 WC planar back cush wd <22in E2620 UE KE IN $431.33 WC planar back cush wd <22in E2621 NU IN $520.16 WC planar back cush wd>=22in E2621 NU KE IN $603.50 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 $390.13 WC planar back cush wd>=22in E2621 UE KE IN $452.63 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 $119.83 High strength ltwt whlchr K0005 NU IN $1,941.20 Ultralightweight wheelchair K0005 RR IN $194.10 Ultralightweight wheelchair K0005 UE IN $1,455.88 Ultralightweight wheelchair K0006 RR CR $128.51 Heavy duty wheelchair K0007 RR CR $178.30 Extra heavy duty wheelchair K0010 RR CR $380.20 Stnd wt frame power whlchr K0011 RR CR $521.87 Stnd wt pwr whlchr w control K0011 RR KF CR $579.42 Stnd wt pwr whlchr w control K0012 RR CR $320.12 Ltwt portbl power whlchr K0015 NU IN $164.44 Detach non-adjus hght armrst K0015 NU KE IN $190.79 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 $123.32 Detach non-adjus hght armrst K0015 UE KE IN $143.08 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

MEDICAL FEE SCHEDULES 11:3-29.6 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

11:3-29.6 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 $107.11 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 $104.92 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 $192.32 Rear whl compl pneum tire K0070 RR IN $19.25 Rear whl compl pneum tire K0070 UE IN $144.24 Rear whl compl pneum tire K0071 NU IN $114.71 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

MEDICAL FEE SCHEDULES 11:3-29.6 K0105 NU IN $104.40 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 $236.39 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 $2,644.18 AED garment w elec analysis K0607 NU IN $203.94 Repl batt for AED K0607 NU KF IN $226.42 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 $152.95 Repl batt for AED K0607 UE KF IN $169.82 Repl batt for AED K0608 NU IN $127.27 Repl garment for AED K0608 NU KF IN $141.31 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 $105.98 Repl garment for AED K0609 SU $846.39 Repl electrode for AED K0609 KF SU $939.71 Repl electrode for AED K0672 PO $74.92 Removable soft interface LE K0730 NU IN $1,810.22 Ctrl dose inh drug deliv sys K0730 RR IN $181.02 Ctrl dose inh drug deliv sys K0730 UE IN $1,357.66 Ctrl dose inh drug deliv sys K0733 NU IN $27.34 12-24hr sealed lead acid K0733 NU KE IN $31.72 12-24hr sealed lead acid K0733 RR IN $2.75 12-24hr sealed lead acid K0733 RR KE IN $3.19 12-24hr sealed lead acid K0733 UE IN $20.52 12-24hr sealed lead acid K0733 UE KE IN $23.80 12-24hr sealed lead acid K0734 NU IN $299.98 Adj skin pro w/c cus wd<22in K0734 NU KE IN $348.04 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 $224.98 Adj skin pro w/c cus wd<22in K0734 UE KE IN $261.03 Adj skin pro w/c cus wd<22in K0735 NU IN $381.71 Adj skin pro wc cus wd>=22in K0735 NU KE IN $442.87 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 $286.28 Adj skin pro wc cus wd>=22in K0735 UE KE IN $332.15 Adj skin pro wc cus wd>=22in K0736 NU IN $302.44 Adj skin pro/pos wc cus<22in K0736 NU KE IN $350.90 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 $226.85 Adj skin pro/pos wc cus<22in K0736 UE KE IN $263.19 Adj skin pro/pos wc cus<22in K0737 NU IN $382.87 Adj skin pro/pos wc cus>=22 K0737 NU KE IN $444.21 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 $287.15 Adj skin pro/pos wc cus>=22 K0737 UE KE IN $333.15 Adj skin pro/pos wc cus>=22 K0738 RR OX $51.63 Portable gas oxygen system K0800 NU IN $1,169.96 POV group 1 std up to 300lbs K0800 RR IN $117.00 POV group 1 std up to 300lbs K0800 UE IN $877.47 POV group 1 std up to 300lbs K0801 NU IN $1,886.22 POV group 1 hd 301-450 lbs K0801 RR IN $188.60 POV group 1 hd 301-450 lbs K0801 UE IN $1,414.65 POV group 1 hd 301-450 lbs

11:3-29.6 APPENDIX B - REGULATIONS K0802 NU IN $2,134.59 POV group 1 vhd 451-600 lbs K0802 RR IN $213.45 POV group 1 vhd 451-600 lbs K0802 UE IN $1,600.95 POV group 1 vhd 451-600 lbs K0806 NU IN $1,415.34 POV group 2 std up to 300lbs K0806 RR IN $141.53 POV group 2 std up to 300lbs K0806 UE IN $1,061.50 POV group 2 std up to 300lbs K0807 NU IN $2,147.61 POV group 2 hd 301-450 lbs K0807 RR IN $214.76 POV group 2 hd 301-450 lbs K0807 UE IN $1,610.72 POV group 2 hd 301-450 lbs K0808 NU IN $3,322.80 POV group 2 vhd 451-600 lbs K0808 RR IN $332.27 POV group 2 vhd 451-600 lbs K0808 UE IN $2,492.09 POV group 2 vhd 451-600 lbs K0813 RR CR $218.32 PWC gp 1 std port seat/back K0814 RR CR $279.45 PWC gp 1 std port cap chair K0815 RR CR $318.23 PWC gp 1 std seat/back K0816 RR CR $304.75 PWC gp 1 std cap chair K0820 RR CR $233.18 PWC gp 2 std port seat/back K0821 RR CR $299.35 PWC gp 2 std port cap chair K0822 RR CR $361.77 PWC gp 2 std seat/back K0823 RR CR $364.14 PWC gp 2 std cap chair K0824 RR CR $438.26 PWC gp 2 hd seat/back K0825 RR CR $401.20 PWC gp 2 hd cap chair K0826 RR CR $567.37 PWC gp 2 vhd seat/back K0827 RR CR $482.45 PWC gp vhd cap chair K0828 RR CR $625.19 PWC gp 2 xtra hd seat/back K0829 RR CR $574.10 PWC gp 2 xtra hd cap chair K0835 RR CR $367.19 PWC gp2 std sing pow opt s/b K0836 RR CR $380.78 PWC gp2 std sing pow opt cap K0837 RR CR $438.26 PWC gp 2 hd sing pow opt s/b K0838 RR CR $392.07 PWC gp 2 hd sing pow opt cap K0839 RR CR $567.37 PWC gp2 vhd sing pow opt s/b K0840 RR CR $859.60 PWC gp2 xhd sing pow opt s/b K0841 RR CR $390.83 PWC gp2 std mult pow opt s/b K0842 RR CR $390.83 PWC gp2 std mult pow opt cap K0843 RR CR $470.56 PWC gp2 hd mult pow opt s/b K0848 RR CR $478.24 PWC gp 3 std seat/back K0849 RR CR $459.80 PWC gp 3 std cap chair K0850 RR CR $554.75 PWC gp 3 hd seat/back K0851 RR CR $533.38 PWC gp 3 hd cap chair K0852 RR CR $640.98 PWC gp 3 vhd seat/back K0853 RR CR $658.44 PWC gp 3 vhd cap chair K0854 RR CR $872.29 PWC gp 3 xhd seat/back K0855 RR CR $824.01 PWC gp 3 xhd cap chair K0856 RR CR $513.34 PWC gp3 std sing pow opt s/b K0857 RR CR $523.63 PWC gp3 std sing pow opt cap K0858 RR CR $636.90 PWC gp3 hd sing pow opt s/b K0859 RR CR $607.41 PWC gp3 hd sing pow opt cap K0860 RR CR $909.90 PWC gp3 vhd sing pow opt s/b K0861 RR CR $514.17 PWC gp3 std mult pow opt s/b K0861 RR KF CR $662.31 PWC gp3 std mult pow opt s/b K0862 RR CR $636.90 PWC gp3 hd mult pow opt s/b K0863 RR CR $909.90 PWC gp3 vhd mult pow opt s/b K0864 RR CR $1,082.79 PWC gp3 xhd mult pow opt s/b L0112 PO $1,236.93 Cranial cervical orthosis L0113 PO $252.02 Cranial cervical torticollis L0120 PO $22.46 Cerv flexible non-adjustable L0130 PO $184.17 Flex thermoplastic collar mo L0140 PO $54.20 Cervical semi-rigid adjustab L0150 PO $104.69 Cerv semi-rig adj molded chn L0160 PO $141.88 Cerv semi-rig wire occ/mand L0170 PO $546.01 Cervical collar molded to pt L0172 PO $123.90 Cerv col thermplas foam 2 pi L0174 PO $232.58 Cerv col foam 2 piece w thor L0180 PO $343.37 Cer post col occ/man sup adj L0190 PO $459.91 Cerv collar supp adj cerv ba L0200 PO $442.87 Cerv col supp adj bar & thor L0220 PO $130.69 Thor rib belt custom fabrica L0430 PO $1,258.46 Dewall posture protector

MEDICAL FEE SCHEDULES 11:3-29.6 L0450 PO $172.35 TLSO flex prefab thoracic L0452 PO $0.00 tlso flex custom fab thoraci L0454 PO $306.51 TLSO flex prefab sacrococ-t9 L0456 PO $878.98 TLSO flex prefab L0458 PO $788.16 TLSO 2Mod symphis-xipho pre L0460 PO $887.12 TLSO2Mod symphysis-stern pre L0462 PO $1,103.45 TLSO 3Mod sacro-scap pre L0464 PO $1,313.63 TLSO 4Mod sacro-scap pre L0466 PO $316.31 TLSO rigid frame pre soft ap L0468 PO $388.08 TLSO rigid frame prefab pelv L0470 PO $629.34 TLSO rigid frame pre subclav L0472 PO $409.96 TLSO rigid frame hyperex pre L0480 PO $1,455.56 TLSO rigid plastic custom fa L0482 PO $1,622.12 TLSO rigid lined custom fab L0484 PO $1,611.53 TLSO rigid plastic cust fab L0486 PO $1,713.40 TLSO rigidlined cust fab two L0488 PO $887.12 TLSO rigid lined pre one pie L0490 PO $250.01 TLSO rigid plastic pre one L0491 PO $678.74 TLSO 2 piece rigid shell L0492 PO $445.87 TLSO 3 piece rigid shell L0621 PO $81.90 SIO flex pelvisacral prefab L0622 PO $218.72 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 $363.27 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 $143.13 LSO post rigid panel pre L0631 PO $907.25 LSO sag-coro rigid frame pre L0632 PO $0.00 LSO sag rigid frame cust L0633 PO $253.42 LSO flexion control prefab L0634 PO $0.00 LSO flexion control custom L0635 PO $861.51 LSO sagit rigid panel prefab L0636 PO $1,277.69 LSO sagittal rigid panel cus L0637 PO $949.40 LSO sag-coronal panel prefab L0638 PO $1,165.59 LSO sag-coronal panel custom L0639 PO $949.40 LSO s/c shell/panel prefab L0640 PO $924.76 LSO s/c shell/panel custom L0700 PO $1,711.65 Ctlso a-p-l control molded L0710 PO $1,776.81 Ctlso a-p-l control w/ inter L0810 PO $2,217.73 Halo cervical into jckt vest L0820 PO $1,828.81 Halo cervical into body jack L0830 PO $2,654.88 Halo cerv into milwaukee typ L0859 PO $1,031.40 MRI compatible system L0861 PO $190.48 Halo repl liner/interface L0970 PO $100.15 Tlso corset front L0972 PO $96.54 Lso corset front L0974 PO $151.58 Tlso full corset L0976 PO $135.38 Lso full corset L0978 PO $162.97 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 $1,718.88 Ctlso milwauke initial model L1001 PO $0.00 CTLSO infant immobilizer L1005 PO $2,828.58 Tension based scoliosis orth L1010 PO $56.82 Ctlso axilla sling L1020 PO $73.18 Kyphosis pad L1025 PO $140.77 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 $130.32 Outrigger bil w/ vert extens

11:3-29.6 APPENDIX B - REGULATIONS L1090 PO $85.17 Lumbar L1100 PO $138.22 Ring flange plastic/leather L1110 PO $216.23 Ring flange plas/leather mol L1120 PO $33.62 Covers for upright each L1200 PO $1,326.54 Furnsh initial orthosis only L1210 PO $295.37 Lateral thoracic extension L1220 PO $250.09 Anterior thoracic extension L1230 PO $641.70 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 $1,885.67 Body jacket mold to patient L1310 PO $1,878.10 Post-operative body jacket L1500 PO $1,608.16 Thkao mobility frame L1510 PO $1,356.53 Thkao standing frame L1520 PO $2,516.64 Thkao swivel walker L1600 PO $109.10 Abduct hip flex frejka w cvr L1610 PO $40.61 Abduct hip flex frejka covr L1620 PO $125.53 Abduct hip flex pavlik harne L1630 PO $143.46 Abduct control hip semi-flex L1640 PO $456.47 Pelv band/spread bar thigh c L1650 PO $196.02 HO abduction hip adjustable L1652 PO $315.03 HO bi thighcuffs w sprdr bar L1660 PO $144.89 HO abduction static plastic L1680 PO $1,031.57 Pelvic & hip control thigh c L1685 PO $1,007.06 Post-op hip abduct custom fa L1686 PO $1,029.73 HO post-op hip abduction L1690 PO $1,708.96 Combination bilateral HO L1700 PO $1,292.91 Leg perthes orth toronto typ L1710 PO $1,513.50 Legg perthes orth newington L1720 PO $1,115.63 Legg perthes orthosis trilat L1730 PO $983.88 Legg perthes orth scottish r L1755 PO $1,379.70 Legg perthes patten bottom t L1810 PO $90.95 Ko elastic with joints L1820 PO $124.61 Ko elas w/ condyle pads & jo L1830 PO $87.80 Ko immobilizer canvas longit L1831 PO $260.10 Knee orth pos locking join L1832 PO $686.31 KO adj jnt pos rigid support L1834 PO $744.08 Ko w/0 joint rigid molded to L1836 PO $117.92 Rigid KO wo joints L1840 PO $876.12 Ko derot ant cruciate custom L1843 PO $792.96 KO single upright custom fit L1844 PO $1,384.28 Ko w/adj jt rot cntrl molded L1845 PO $869.76 Ko w/ adj flex/ext rotat cus L1846 PO $1,141.23 Ko w adj flex/ext rotat mold L1847 PO $508.31 KO adjustable w air chambers L1850 PO $267.60 Ko swedish type L1860 PO $1,106.55 Ko supracondylar socket mold L1900 PO $228.40 Afo sprng wir drsflx calf bd L1902 PO $88.45 Afo ankle gauntlet L1904 PO $411.73 Afo molded ankle gauntlet L1906 PO $102.82 Afo multiligamentus ankle su L1907 PO $497.28 AFO supramalleolar custom L1910 PO $281.66 Afo sing bar clasp attach sh L1920 PO $316.64 Afo sing upright w/ adjust s L1930 PO $200.28 Afo plastic L1932 PO $788.63 Afo rig ant tib prefab TCF/= L1940 PO $531.48 Afo molded to patient plasti L1945 PO $783.73 Afo molded plas rig ant tib L1950 PO $840.82 Afo spiral molded to pt plas L1951 PO $742.21 AFO spiral prefabricated L1960 PO $625.71 Afo pos solid ank plastic mo L1970 PO $799.03 Afo plastic molded w/ankle j L1971 PO $414.24 AFO w/ankle joint, prefab L1980 PO $348.77 Afo sing solid stirrup calf

MEDICAL FEE SCHEDULES 11:3-29.6 L1990 PO $450.06 Afo doub solid stirrup calf L2000 PO $968.33 Kafo sing fre stirr thi/calf L2005 PO $3,621.39 KAFO sng/dbl mechanical act L2010 PO $1,043.76 Kafo sng solid stirrup w/o j L2020 PO $1,074.01 Kafo dbl solid stirrup band/ L2030 PO $1,101.22 Kafo dbl solid stirrup w/o j L2034 PO $1,842.24 KAFO pla sin up w/wo k/a cus L2035 PO $155.72 KAFO plastic pediatric size L2036 PO $2,094.38 Kafo plas doub free knee mol L2037 PO $1,853.19 Kafo plas sing free knee mol L2038 PO $1,590.19 Kafo w/o joint multi-axis an L2040 PO $150.31 Hkafo torsion bil rot straps L2050 PO $413.47 Hkafo torsion cable hip pelv L2060 PO $520.42 Hkafo torsion ball bearing j L2070 PO $114.59 Hkafo torsion unilat rot str L2080 PO $323.11 Hkafo unilat torsion cable L2090 PO $371.24 Hkafo unilat torsion ball br L2106 PO $738.57 Afo tib fx cast plaster mold L2108 PO $1,097.86 Afo tib fx cast molded to pt L2112 PO $501.71 Afo tibial fracture soft L2114 PO $654.70 Afo tib fx semi-rigid L2116 PO $720.29 Afo tibial fracture rigid L2126 PO $1,351.75 Kafo fem fx cast thermoplas L2128 PO $1,749.02 Kafo fem fx cast molded to p L2132 PO $910.62 Kafo femoral fx cast soft L2134 PO $1,091.80 Kafo fem fx cast semi-rigid L2136 PO $1,334.99 Kafo femoral fx cast rigid L2180 PO $99.15 Plas shoe insert w ank joint L2182 PO $77.60 Drop lock knee L2184 PO $104.88 Limited motion knee joint L2186 PO $140.15 Adj motion knee jnt lerman t L2188 PO $338.08 Quadrilateral brim L2190 PO $79.61 Waist belt L2192 PO $385.26 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 $300.84 Foot plate molded stirrup at L2260 PO $226.29 Reinforced solid stirrup L2265 PO $99.70 Long tongue stirrup L2270 PO $46.48 Varus/valgus strap padded/li L2275 PO $106.72 Plastic mod low ext pad/line L2280 PO $442.02 Molded inner boot L2300 PO $303.93 Abduction bar jointed adjust L2310 PO $104.15 Abduction bar-straight L2320 PO $208.49 Non-molded lacer L2330 PO $443.25 Lacer molded to patient mode L2335 PO $192.33 Anterior swing band L2340 PO $411.27 Pre-tibial shell molded to p L2350 PO $1,002.62 Prosthetic type socket molde L2360 PO $58.41 Extended steel shank L2370 PO $289.79 Patten bottom L2375 PO $95.66 Torsion ank & half solid sti L2380 PO $104.23 Torsion straight knee joint L2385 PO $113.40 Straight knee joint heavy du L2387 PO $140.12 Add LE poly knee custom KAFO L2390 PO $98.79 Offset knee joint each L2395 PO $132.46 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 $107.33 Knee joint cam lock each joi L2425 PO $126.68 Knee disc/dial lock/adj flex L2430 PO $126.68 Knee jnt ratchet lock ea jnt L2492 PO $98.36 Knee lift loop drop lock rin L2500 PO $267.09 Thi/glut/ischia wgt bearing

11:3-29.6 APPENDIX B - REGULATIONS L2510 PO $715.81 Th/wght bear quad-lat brim m L2520 PO $480.56 Th/wght bear quad-lat brim c L2525 PO $1,187.84 Th/wght bear nar m-l brim mo L2526 PO $579.90 Th/wght bear nar m-l brim cu L2530 PO $259.22 Thigh/wght bear lacer non-mo L2540 PO $365.67 Thigh/wght bear lacer molded L2550 PO $295.50 Thigh/wght bear high roll cu L2570 PO $403.26 Hip clevis type 2 posit jnt L2580 PO $450.84 Pelvic control pelvic sling L2600 PO $173.88 Hip clevis/thrust bearing fr L2610 PO $239.94 Hip clevis/thrust bearing lo L2620 PO $301.83 Pelvic control hip heavy dut L2622 PO $259.63 Hip joint adjustable flexion L2624 PO $300.21 Hip adj flex ext abduct cont L2627 PO $1,765.80 Plastic mold recipro hip & c L2628 PO $1,823.23 Metal frame recipro hip & ca L2630 PO $255.33 Pelvic control band & belt u L2640 PO $379.36 Pelvic control band & belt b L2650 PO $104.32 Pelv & thor control gluteal L2660 PO $157.80 Thoracic control thoracic ba L2670 PO $178.37 Thorac cont paraspinal uprig L2680 PO $165.80 Thorac cont lat support upri L2750 PO $83.30 Plating chrome/nickel pr bar L2755 PO $115.44 Carbon graphite lamination L2760 PO $63.27 Extension per extension per L2768 PO $115.14 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 $277.61 Ft insert ucb berkeley shell L3001 PO $116.89 Foot insert remov molded spe L3002 PO $142.73 Foot insert plastazote or eq L3003 PO $154.00 Foot insert silicone gel eac L3010 PO $154.00 Foot longitudinal arch suppo L3020 PO $175.35 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 $500.16 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

MEDICAL FEE SCHEDULES 11:3-29.6 L3420 PO $48.33 Full sole/heel wedge between L3430 PO $141.62 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 $111.07 Acromio/clavicular canvas&we L3671 PO $724.74 SO cap design w/o jnts CF L3672 PO $901.26 SO airplane w/o jnts CF L3673 PO $982.26 SO airplane w/joint CF L3675 PO $141.14 Canvas vest SO L3702 PO $232.24 EO w/o joints CF L3710 PO $106.90 Elbow elastic with metal joi L3720 PO $722.52 Forearm/arm cuffs free motio L3730 PO $974.00 Forearm/arm cuffs ext/flex a L3740 PO $1,092.33 Cuffs adj lock w/ active con L3760 PO $402.22 EO withjoint, Prefabricated L3762 PO $86.49 Rigid EO wo joints L3763 PO $619.76 EWHO rigid w/o jnts CF L3764 PO $779.98 EWHO w/joint(s) CF L3765 PO $1,031.30 EWHFO rigid w/o jnts CF L3766 PO $1,092.07 EWHFO w/joint(s) CF L3806 PO $365.35 WHFO w/joint(s) custom fab L3807 PO $201.12 WHFO,no joint, prefabricated L3808 PO $326.34 WHFO, rigid w/o joints L3900 PO $1,072.01 Hinge extension/flex wrist/f L3901 PO $1,472.96 Hinge ext/flex wrist finger L3904 PO $2,426.16 Whfo electric custom fitted L3905 PO $797.64 WHO w/nontorsion jnt(s) CF L3906 PO $338.28 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 $217.84 HFO w/o joints CF L3915 PO $427.53 WHO w nontor jnt(s) prefab L3917 PO $84.97 Prefab metacarpl fx orthosis L3919 PO $217.84 HO w/o joints CF L3921 PO $258.36 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 $158.21 WHFO nontorsion joint prefab L3933 PO $171.61 FO w/o joints CF L3935 PO $177.68 FO nontorsion joint CF L3956 PO $0.00 Add joint upper ext orthosis L3960 PO $624.54 Sewho airplan desig abdu pos L3961 PO $1,351.31 SEWHO cap design w/o jnts CF

11:3-29.6 APPENDIX B - REGULATIONS L3962 PO $594.43 Sewho erbs palsey design abd L3964 NU IN $652.17 Seo mobile arm sup att to wc L3964 RR IN $65.21 Seo mobile arm sup att to wc L3964 UE IN $489.09 Seo mobile arm sup att to wc L3965 NU IN $1,040.67 Arm supp att to wc rancho ty L3965 RR IN $104.09 Arm supp att to wc rancho ty L3965 UE IN $780.50 Arm supp att to wc rancho ty L3966 NU IN $783.97 Mobile arm supports reclining L3966 RR IN $78.40 Mobile arm supports reclining L3966 UE IN $587.98 Mobile arm supports reclinin L3967 PO $1,595.45 SEWHO airplane w/o jnts CF L3968 NU IN $992.10 Friction dampening arm supp L3968 RR IN $99.20 Friction dampening arm supp L3968 UE IN $744.08 Friction dampening arm sup L3969 NU IN $675.03 Monosuspension arm/hand supp L3969 RR IN $67.52 Monosuspension arm/hand supp L3969 UE IN $506.29 Monosuspension arm/hand supp L3970 NU IN $277.53 Elevat proximal arm support L3970 RR IN $27.75 Elevat proximal arm support L3970 UE IN $208.14 Elevat proximal arm support L3971 PO $1,514.45 SEWHO cap design w/jnt(s) CF L3972 NU IN $176.47 Offset/lat rocker arm w/ ela L3972 RR IN $17.65 Offset/lat rocker arm w/ ela L3972 UE IN $132.35 Offset/lat rocker arm w/ ela L3973 PO $1,595.45 SEWHO airplane w/jnt(s) CF L3974 NU IN $149.68 Mobile arm support supinator L3974 RR IN $14.98 Mobile arm support supinator L3974 UE IN $112.26 Mobile arm support supinator L3975 PO $1,351.31 SEWHFO cap design w/o jnt CF L3976 PO $1,351.31 SEWHFO airplane w/o jnts CF L3977 PO $1,514.45 SEWHFO cap desgn w/jnt(s) CF L3978 PO $1,595.45 SEWHFO airplane w/jnt(s) CF L3980 PO $292.85 Upp ext fx orthosis humeral L3982 PO $412.38 Upper ext fx orthosis rad/ul L3984 PO $305.04 Upper ext fx orthosis wrist L3995 PO $36.12 Sock fracture or equal each L4000 PO $1,079.50 Repl girdle milwaukee orth L4002 PO $0.00 Replace strap, any orthosis L4010 PO $670.03 Replace trilateral socket br L4020 PO $930.03 Replace quadlat socket brim L4030 PO $569.94 Replace socket brim cust fit L4040 PO $408.64 Replace molded thigh lacer L4045 PO $277.72 Replace non-molded thigh lac L4050 PO $466.04 Replace molded calf lacer L4055 PO $226.33 Replace non-molded calf lace L4060 PO $269.06 Replace high roll cuff L4070 PO $238.27 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 $109.71 Repl leath cuff kafo prox th L4110 PO $94.65 Repl leath cuff kafo-afo cal L4130 PO $420.05 Replace pretibial shell L4350 PO $75.68 Ankle control orthosi prefab L4360 PO $243.20 Pneumati walking boot prefab L4370 PO $159.83 Pneumatic full leg splint L4380 PO $112.46 Pneumatic knee splint L4386 PO $140.12 Non-pneum walk boot prefab L4392 PO $20.80 Replace AFO soft interface L4394 PO $15.17 Replace foot drop spint L4396 PO $148.29 Static AFO L4398 PO $68.28 Foot drop splint recumbent L5000 PO $455.74 Sho insert w arch toe filler L5010 PO $1,393.98 Mold socket ank hgt w/ toe f L5020 PO $1,787.52 Tibial tubercle hgt w/ toe f L5050 PO $2,206.49 Ank symes mold sckt sach ft L5060 PO $3,321.74 Symes met fr leath socket ar L5100 PO $2,286.02 Molded socket shin sach foot L5105 PO $3,818.81 Plast socket jts/thgh lacer

MEDICAL FEE SCHEDULES 11:3-29.6 L5150 PO $3,518.16 Mold sckt ext knee shin sach L5160 PO $3,445.23 Mold socket bent knee shin s L5200 PO $2,981.01 Kne sing axis fric shin sach L5210 PO $2,918.33 No knee/ankle joints w/ ft b L5220 PO $2,663.70 No knee joint with artic ali L5230 PO $3,431.32 Fem focal defic constant fri L5250 PO $4,998.89 Hip canad sing axi cons fric L5270 PO $4,639.02 Tilt table locking hip sing L5280 PO $4,592.63 Hemipelvect canad sing axis L5301 PO $2,071.00 BK mold socket SACH ft endo L5311 PO $3,026.74 Knee disart, SACH ft, endo L5321 PO $2,964.57 AK open end SACH L5331 PO $4,194.98 Hip disart canadian SACH ft L5341 PO $4,592.78 Hemipelvectomy canadian SACH L5400 PO $1,085.58 Postop dress & 1 cast chg bk L5410 PO $376.87 Postop dsg bk ea add cast ch L5420 PO $1,371.04 Postop dsg & 1 cast chg ak/d L5430 PO $605.19 Postop dsg ak ea add cast ch L5450 PO $408.79 Postop app non-wgt bear dsg L5460 PO $491.84 Postop app non-wgt bear dsg L5500 PO $1,158.45 Init bk ptb plaster direct L5505 PO $1,568.85 Init ak ischal plstr direct L5510 PO $1,313.18 Prep BK ptb plaster molded L5520 PO $1,584.72 Perp BK ptb thermopls direct L5530 PO $1,557.95 Prep BK ptb thermopls molded L5535 PO $1,710.89 Prep BK ptb open end socket L5540 PO $1,632.56 Prep BK ptb laminated socket L5560 PO $2,048.48 Prep AK ischial plast molded L5570 PO $2,063.30 Prep AK ischial direct form L5580 PO $2,338.67 Prep AK ischial thermo mold L5585 PO $2,307.80 Prep AK ischial open end L5590 PO $2,406.26 Prep AK ischial laminated L5595 PO $4,009.37 Hip disartic sach thermopls L5600 PO $4,435.46 Hip disart sach laminat mold L5610 PO $1,867.47 Above knee hydracadence L5611 PO $1,453.26 Ak 4 bar link w/fric swing L5613 PO $2,210.50 Ak 4 bar ling w/hydraul swig L5614 PO $1,494.20 4-bar link above knee w/swng L5616 PO $1,225.04 Ak univ multiplex sys frict L5617 PO $505.39 AK/BK self-aligning unit ea L5618 PO $267.34 Test socket symes L5620 PO $296.69 Test socket below knee L5622 PO $435.99 Test socket knee disarticula L5624 PO $378.87 Test socket above knee L5626 PO $430.06 Test socket hip disarticulate L5628 PO $449.66 Test socket hemipelvectomy L5629 PO $382.20 Below knee acrylic socket L5630 PO $408.92 Syme typ expandabl wall sckt L5631 PO $528.42 Ak/knee disartic acrylic soc L5632 PO $218.16 Symes type ptb brim design s L5634 PO $321.65 Symes type poster opening so L5636 PO $306.44 Symes type medial opening so L5637 PO $332.45 Below knee total contact L5638 PO $528.12 Below knee leather socket L5639 PO $1,288.34 Below knee wood socket L5640 PO $769.02 Knee disarticulat leather so L5642 PO $666.91 Above knee leather socket L5643 PO $1,403.89 Hip flex inner socket ext fr L5644 PO $532.75 Above knee wood socket L5645 PO $719.69 Bk flex inner socket ext fra L5646 PO $523.31 Below knee cushion socket L5647 PO $751.02 Below knee suction socket L5648 PO $659.98 Above knee cushion socket L5649 PO $1,717.33 Isch containmt/narrow m-l so L5650 PO $587.11 Tot contact ak/knee disart s L5651 PO $1,083.21 Ak flex inner socket ext fra L5652 PO $393.25 Suction susp ak/knee disart L5653 PO $524.95 Knee disart expand wall sock

11:3-29.6 APPENDIX B - REGULATIONS L5654 PO $316.80 Socket insert symes L5655 PO $307.80 Socket insert below knee L5656 PO $437.29 Socket insert knee articulat L5658 PO $353.07 Socket insert above knee L5661 PO $550.50 Multi-durometer symes L5665 PO $461.84 Multi-durometer below knee L5666 PO $70.93 Below knee cuff suspension L5668 PO $94.93 Socket insert w/o lock lower L5670 PO $253.22 Bk molded supracondylar susp L5671 PO $448.66 BK/AK locking mechanism L5672 PO $268.96 Bk removable medial brim sus L5673 PO $602.72 Socket insert w lock mech L5676 PO $326.85 Bk knee joints single axis p L5677 PO $444.73 Bk knee joints polycentric p L5678 PO $35.81 Bk joint covers pair L5679 PO $502.25 Socket insert w/o lock mech L5680 PO $351.57 Bk thigh lacer non-molded L5681 PO $1,164.74 Intl custm cong/latyp insert L5682 PO $588.04 Bk thigh lacer glut/ischia m L5683 PO $1,164.74 Initial custom socket insert L5684 PO $44.57 Bk fork strap L5685 PO $113.41 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 $119.86 Ak pelvic control belt light L5694 PO $163.63 Ak pelvic control belt pad/l L5695 PO $171.09 Ak sleeve susp neoprene/equa L5696 PO $181.28 Ak/knee disartic pelvic join L5697 PO $72.41 Ak/knee disartic pelvic band L5698 PO $118.13 Ak/knee disartic silesian ba L5699 PO $171.57 Shoulder harness L5700 PO $2,516.16 Replace socket below knee L5701 PO $3,121.51 Replace socket above knee L5702 PO $3,934.19 Replace socket hip L5703 PO $2,098.10 Symes ankle w/o (SACH) foot L5704 PO $513.04 Custom shape cover BK L5705 PO $940.57 Custom shape cover AK L5706 PO $917.40 Custom shape cvr knee disart L5707 PO $1,232.53 Custom shape cvr hip disart L5710 PO $341.39 Kne-shin exo sng axi mnl loc L5711 PO $512.58 Knee-shin exo mnl lock ultra L5712 PO $444.22 Knee-shin exo frict swg & st L5714 PO $391.36 Knee-shin exo variable frict L5716 PO $657.41 Knee-shin exo mech stance ph L5718 PO $821.69 Knee-shin exo frct swg & sta L5722 PO $814.38 Knee-shin pneum swg frct exo L5724 PO $1,695.67 Knee-shin exo fluid swing ph L5726 PO $1,569.07 Knee-shin ext jnts fld swg e L5728 PO $2,388.06 Knee-shin fluid swg & stance L5780 PO $1,032.69 Knee-shin pneum/hydra pneum L5781 PO $3,542.95 Lower limb pros vacuum pump L5782 PO $3,735.08 HD low limb pros vacuum pump L5785 PO $468.63 Exoskeletal bk ultralt mater L5790 PO $648.55 Exoskeletal ak ultra-light m L5795 PO $968.46 Exoskel hip ultra-light mate L5810 PO $453.75 Endoskel knee-shin mnl lock L5811 PO $657.83 Endo knee-shin mnl lck ultra L5812 PO $509.89 Endo knee-shin frct swg & st L5814 PO $3,288.54 Endo knee-shin hydral swg ph L5816 PO $767.09 Endo knee-shin polyc mch sta L5818 PO $928.33 Endo knee-shin frct swg & st L5822 PO $1,904.52 Endo knee-shin pneum swg frc L5824 PO $1,712.64 Endo knee-shin fluid swing p L5826 PO $2,812.31 Miniature knee joint L5828 PO $3,112.56 Endo knee-shin fluid swg/sta L5830 PO $1,836.77 Endo knee-shin pneum/swg pha L5840 PO $3,198.98 Multi-axial knee/shin system

MEDICAL FEE SCHEDULES 11:3-29.6 L5845 PO $1,587.11 Knee-shin sys stance flexion L5848 PO $952.18 Knee-shin sys hydraul stance L5850 PO $120.91 Endo ak/hip knee extens assi L5855 PO $278.56 Mech hip extension assist L5856 PO $21,353.09 Elec knee-shin swing/stance L5857 PO $7,639.05 Elec knee-shin swing only L5858 PO $16,456.85 Stance phase only L5910 PO $357.37 Endo below knee alignable sy L5920 PO $478.58 Endo ak/hip alignable system L5925 PO $303.07 Above knee manual lock L5930 PO $3,040.28 High activity knee frame L5940 PO $491.52 Endo bk ultra-light material L5950 PO $796.83 Endo ak ultra-light material L5960 PO $1,154.32 Endo hip ultra-light material L5962 PO $530.18 Below knee flex cover system L5964 PO $919.55 Above knee flex cover system L5966 PO $1,184.53 Hip flexible cover system L5968 PO $3,217.78 Multiaxial ankle w dorsiflex L5970 PO $183.19 Foot external keel sach foot L5971 PO $183.19 SACH foot, replacement L5972 PO $317.89 Flexible keel foot L5973 PO $15,410.73 Ank-foot sys dors-plant flex L5974 PO $210.19 Foot single axis ankle/foot L5975 PO $410.50 Combo ankle/foot prosthesis L5976 PO $637.40 Energy storing foot L5978 PO $263.23 Ft prosth multiaxial ankl/ft L5979 PO $2,058.12 Multi-axial ankle/ft prosth L5980 PO $4,391.63 Flex foot system L5981 PO $2,799.03 Flex-walk sys low ext prosth L5982 PO $521.45 Exoskeletal axial rotation u L5984 PO $513.84 Endoskeletal axial rotation L5985 PO $255.06 Lwr ext dynamic prosth pylon L5986 PO $571.58 Multi-axial rotation unit L5987 PO $6,369.90 Shank ft w vert load pylon L5988 PO $1,768.94 Vertical shock reducing pylo L5990 PO $1,606.45 User adjustable heel height L6000 PO $1,225.74 Par hand robin-aids thum rem L6010 PO $1,400.35 Hand robin-aids little/ring L6020 PO $1,243.46 Part hand robin-aids no fing L6025 PO $7,085.97 Part hand disart myoelectric L6050 PO $1,998.97 Wrst MLd sck flx hng tri pad L6055 PO $2,604.97 Wrst mold sock w/exp interfa L6100 PO $2,314.64 Elb mold sock flex hinge pad L6110 PO $2,455.06 Elbow mold sock suspension t L6120 PO $2,667.06 Elbow mold doub splt soc ste L6130 PO $2,886.40 Elbow stump activated lock h L6200 PO $2,460.70 Elbow mold outsid lock hinge L6205 PO $3,692.89 Elbow molded w/ expand inter L6250 PO $2,552.59 Elbow inter loc elbow forarm L6300 PO $4,078.78 Shlder disart int lock elbow L6310 PO $2,912.39 Shoulder passive restor comp L6320 PO $1,541.44 Shoulder passive restor cap L6350 PO $4,710.70 Thoracic intern lock elbow L6360 PO $2,873.00 Thoracic passive restor comp L6370 PO $2,442.68 Thoracic passive restor cap L6380 PO $1,248.88 Postop dsg cast chg wrst/elb L6382 PO $1,780.73 Postop dsg cast chg elb dis/ L6384 PO $2,292.98 Postop dsg cast chg shlder/t L6386 PO $482.97 Postop ea cast chg & realign L6388 PO $396.54 Postop applicat rigid dsg on L6400 PO $2,436.00 Below elbow prosth tiss shap L6450 PO $2,798.60 Elb disart prosth tiss shap L6500 PO $2,883.85 Above elbow prosth tiss shap L6550 PO $3,439.51 Shldr disar prosth tiss shap L6570 PO $4,204.05 Scap thorac prosth tiss shap L6580 PO $1,413.43 Wrist/elbow bowden cable mol L6582 PO $1,248.88 Wrist/elbow bowden cbl dir f L6584 PO $1,895.51 Elbow fair lead cable molded

11:3-29.6 APPENDIX B - REGULATIONS L6586 PO $1,698.83 Elbow fair lead cable dir fo L6588 PO $2,602.47 Shdr fair lead cable molded L6590 PO $2,423.98 Shdr fair lead cable direct L6600 PO $225.59 Polycentric hinge pair L6605 PO $222.75 Single pivot hinge pair L6610 PO $150.17 Flexible metal hinge pair L6611 PO $364.58 Additional switch, ext power L6615 PO $165.77 Disconnect locking wrist uni L6616 PO $68.22 Disconnect insert locking wr L6620 PO $273.49 Flexion/extension wrist unit L6621 PO $2,025.37 Flex/ext wrist w/wo friction L6623 PO $578.59 Spring-ass rot wrst w/ latch L6624 PO $3,334.81 Flex/ext/rotation wrist unit L6625 PO $479.73 Rotation wrst w/ cable lock L6628 PO $432.10 Quick disconn hook adapter o L6629 PO $158.07 Lamination collar w/ couplin L6630 PO $194.40 Stainless steel any wrist L6632 PO $58.60 Latex suspension sleeve each L6635 PO $182.27 Lift assist for elbow L6637 PO $331.20 Nudge control elbow lock L6638 PO $2,214.36 Elec lock on manual pw elbow L6640 PO $336.88 Shoulder abduction joint pai L6641 PO $192.94 Excursion amplifier pulley t L6642 PO $261.51 Excursion amplifier lever ty L6645 PO $291.09 Shoulder flexion-abduction j L6646 PO $2,792.80 Multipo locking shoulder jnt L6647 PO $459.77 Shoulder lock actuator L6648 PO $2,880.38 Ext pwrd shlder lock/unlock L6650 PO $349.67 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 $184.88 Harness chest/shlder saddle L6675 PO $122.61 Harness figure of 8 sing con L6676 PO $131.59 Harness figure of 8 dual con L6677 PO $262.67 UE triple control harness L6680 PO $263.73 Test sock wrist disart/bel e L6682 PO $282.84 Test sock elbw disart/above L6684 PO $401.49 Test socket shldr disart/tho L6686 PO $540.30 Suction socket L6687 PO $529.49 Frame typ socket bel elbow/w L6688 PO $491.68 Frame typ sock above elb/dis L6689 PO $810.35 Frame typ socket shoulder di L6690 PO $697.00 Frame typ sock interscap-tho L6691 PO $332.43 Removable insert each L6692 PO $511.61 Silicone gel insert or equal L6693 PO $2,513.89 Lockingelbow forearm cntrbal L6694 PO $602.72 Elbow socket ins use w/lock L6695 PO $502.25 Elbow socket ins use w/o lck L6696 PO $1,164.74 Cus elbo skt in for con/atyp L6697 PO $1,164.74 Cus elbo skt in not con/atyp L6698 PO $448.66 Below/above elbow lock mech L6703 PO $390.97 Term dev, passive hand mitt L6704 PO $529.24 Term dev, sport/rec/work att L6706 PO $314.73 Term dev mech hook vol open L6707 PO $1,236.49 Term dev mech hook vol close L6708 PO $828.61 Term dev mech hand vol open L6709 PO $1,109.29 Term dev mech hand vol close L6711 PO $595.31 Ped term dev, hook, vol open L6712 PO $1,096.10 Ped term dev, hook, vol clos L6713 PO $1,383.40 Ped term dev, hand, vol open L6714 PO $1,171.72 Ped term dev, hand, vol clos L6721 PO $2,082.62 Hook/hand, hvy dty, vol open L6722 PO $1,795.38 Hook/hand, hvy dty, vol clos L6805 PO $360.23 Term dev modifier wrist unit L6810 PO $168.25 Term dev precision pinch dev L6881 PO $3,620.07 Term dev auto grasp feature

MEDICAL FEE SCHEDULES 11:3-29.6 L6882 PO $2,745.98 Microprocessor control uplmb L6883 PO $1,908.47 Replc sockt below e/w disa L6884 PO $2,098.76 Replc sockt above elbow disa L6885 PO $2,873.00 Replc sockt shldr dis/interc L6890 PO $204.56 Prefab glove for term device L6895 PO $503.66 Custom glove for term device L6900 PO $1,601.01 Hand restorat thumb/1 finger L6905 PO $1,581.91 Hand restoration multiple fi L6910 PO $1,644.79 Hand restoration no fingers L6915 PO $564.67 Hand restoration replacmnt g L6920 PO $6,019.63 Wrist disarticul switch ctrl L6925 PO $6,949.58 Wrist disart myoelectronic c L6930 PO $6,056.96 Below elbow switch control L6935 PO $7,079.68 Below elbow myoelectronic ct L6940 PO $8,389.82 Elbow disarticulation switch L6945 PO $9,406.38 Elbow disart myoelectronic c L6950 PO $8,995.16 Above elbow switch control L6955 PO $10,772.93 Above elbow myoelectronic ct L6960 PO $10,865.31 Shldr disartic switch contro L6965 PO $12,783.55 Shldr disartic myoelectronic L6970 PO $13,155.45 Interscapular-thor switch ct L6975 PO $14,414.20 Interscap-thor myoelectronic L7007 PO $3,535.52 Adult electric hand L7008 PO $5,543.02 Pediatric electric hand L7009 PO $3,354.86 Adult electric hook L7040 PO $2,752.06 Prehensile actuator L7045 PO $1,457.92 Pediatric electric hook L7170 PO $5,288.82 Electronic elbow hosmer swit L7180 PO $32,424.45 Electronic elbow sequential L7181 PO $35,479.56 Electronic elbo simultaneous L7185 PO $6,467.88 Electron elbow adolescent sw L7186 PO $9,853.56 Electron elbow child switch L7190 PO $9,085.38 Elbow adolescent myoelectron L7191 PO $10,187.64 Elbow child myoelectronic ct L7260 PO $1,775.14 Electron wrist rotator otto L7261 PO $3,231.43 Electron wrist rotator utah L7266 PO $893.04 Servo control steeper or equ L7272 PO $2,007.51 Analogue control unb or equa L7274 PO $5,662.80 Proportional ctl 12 volt uta L7360 PO $273.48 Six volt bat otto bock/eq ea L7362 PO $252.04 Battery chrgr six volt otto L7364 PO $479.23 Twelve volt battery utah/equ L7366 PO $645.54 Battery chrgr 12 volt utah/e L7367 PO $344.74 Replacemnt lithium ionbatter L7368 PO $446.90 Lithium ion battery charger L7400 PO $271.39 Add UE prost be/wd, ultlite L7401 PO $303.82 Add UE prost a/e ultlite mat L7402 PO $328.10 Add UE prost s/d ultlite mat L7403 PO $326.09 Add UE prost b/e acrylic L7404 PO $492.16 Add UE prost a/e acrylic L7405 PO $643.68 Add UE prost s/d acrylic L7900 PO $465.26 Male vacuum erection system L8000 PO $33.23 Mastectomy bra L8001 PO $111.06 Breast prosthesis bra & form L8002 PO $146.08 Brst prsth bra & bilat form L8015 PO $53.08 Ext breastprosthesis garment L8020 PO $216.32 Mastectomy form L8030 PO $291.72 Breast prosthes w/o adhesive L8031 PO $291.72 Breast prosthesis w adhesive L8032 PO $34.69 Reusable nipple prosthesis L8035 PO $3,244.08 Custom breast prosthesis L8040 PO $2,461.37 Nasal prosthesis L8040 KM PO $2,338.31 Nasal prosthesis L8040 KN PO $984.54 Nasal prosthesis L8041 PO $2,966.74 Midfacial prosthesis L8041 KM PO $2,818.41 Midfacial prosthesis L8041 KN PO $1,186.69 Midfacial prosthesis L8042 PO $3,333.44 Orbital prosthesis

11:3-29.6 APPENDIX B - REGULATIONS L8042 KM PO $3,166.75 Orbital prosthesis L8042 KN PO $1,333.37 Orbital prosthesis L8043 PO $3,733.45 Upper facial prosthesis L8043 KM PO $3,546.76 Upper facial prosthesis L8043 KN PO $1,493.37 Upper facial prosthesis L8044 PO $4,133.46 Hemi-facial prosthesis L8044 KM PO $3,926.79 Hemi-facial prosthesis L8044 KN PO $1,653.38 Hemi-facial prosthesis L8045 PO $2,598.34 Auricular prosthesis L8045 KM PO $2,468.43 Auricular prosthesis L8045 KN PO $1,039.33 Auricular prosthesis L8046 PO $2,666.74 Partial facial prosthesis L8046 KM PO $2,533.42 Partial facial prosthesis L8046 KN PO $1,066.70 Partial facial prosthesis L8047 PO $1,366.71 Nasal septal prosthesis L8047 KM PO $1,298.39 Nasal septal prosthesis L8047 KN PO $546.68 Nasal septal prosthesis L8300 PO $76.08 Truss single w/ standard pad L8310 PO $159.29 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 $685.49 Artificial larynx L8501 PO $108.96 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 $223.74 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 $563.24 Implant breast silicone/eq L8603 PO $393.90 Collagen imp urinary 2.5 ml L8606 PO $193.99 Synthetic implnt urinary 1ml L8609 PO $5,769.31 Artificial cornea L8610 PO $625.30 Ocular implant L8612 PO $597.23 Aqueous shunt prosthesis L8613 PO $302.32 Ossicular implant L8614 PO $17,284.73 Cochlear device L8615 PO $399.36 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 $7,420.22 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 $142.80 Lith ion batt CID, ear level L8627 PO $6,324.80 CID ext speech process repl L8628 PO $1,095.43 CID ext controller repl L8629 PO $158.55 CID transmit coil and cable L8630 PO $303.88 Metacarpophalangeal implant L8631 PO $1,957.77 MCP joint repl 2 pc or more L8641 PO $315.74 Metatarsal joint implant L8642 PO $276.79 Hallux implant

MEDICAL FEE SCHEDULES 11:3-29.6 L8658 PO $275.29 Interphalangeal joint spacer L8659 PO $1,708.71 Interphalangeal joint repl L8670 PO $502.09 Vascular graft, synthetic L8680 PO $406.73 Implt neurostim elctr each L8681 PO $1,297.42 Pt prgrm for implt neurostim L8682 PO $5,278.95 Implt neurostim radiofq rec L8683 PO $4,646.68 Radiofq trsmtr for implt neu L8684 PO $614.20 Radiof trsmtr implt scrl neu L8685 PO $11,579.27 Implt nrostm pls gen sng rec L8686 PO $7,388.47 Implt nrostm pls gen sng non L8687 PO $15,069.25 Implt nrostm pls gen dua rec L8688 PO $9,615.40 Implt nrostm pls gen dua non L8689 PO $1,527.41 External recharg sys intern L8690 PO $4,212.39 Aud osseo dev, int/ext comp L8691 PO $2,361.18 Osseointegrated snd proc rpl L8695 PO $14.74 External recharg sys extern Q0480 PO $79,750.51 Driver pneumatic vad, rep Q0481 PO $12,866.81 Microprcsr cu elec vad, rep Q0482 PO $4,030.13 Microprcsr cu combo vad, rep Q0483 PO $16,602.32 Monitor elec vad, rep Q0484 PO $3,224.12 Monitor elec or comb vad rep Q0485 PO $311.28 Monitor cable elec vad, rep Q0486 PO $259.09 Mon cable elec/pneum vad rep Q0487 PO $302.26 Leads any type vad, rep only Q0489 PO $14,393.32 Pwr pck base combo vad, rep Q0490 PO $622.58 Emr pwr source elec vad, rep Q0491 PO $978.78 Emr pwr source combo vad rep Q0492 PO $78.84 Emr pwr cbl elec vad, rep Q0493 PO $224.53 Emr pwr cbl combo vad, rep Q0494 PO $190.00 Emr hd pmp elec/combo, rep Q0495 PO $3,698.71 Charger elec/combo vad, rep Q0496 PO $1,327.53 Battery elec/combo vad, rep Q0497 PO $414.53 Bat clps elec/comb vad, rep Q0498 PO $454.83 Holster elec/combo vad, rep Q0499 PO $147.78 Belt/vest elec/combo vad rep Q0500 PO $27.04 Filters elec/combo vad, rep Q0501 PO $452.21 Shwr cov elec/combo vad, rep Q0502 PO $575.73 Mobility cart pneum vad, rep Q0503 PO $1,151.46 Battery pneum vad replacemnt Q0504 PO $607.60 Pwr adpt pneum vad, rep veh Q0506 PO $756.33 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 4.12-7.00 V2102 PO $57.49 Singl visn sphere 7.12-20.00 V2103 PO $40.91 Spherocylindr 4.00d/12-2.00d 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/.25-2.25 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 4.12-7.0 V2202 PO $75.75 Lens sphere bifocal 7.12-20. 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 4.25-7d/.

11:3-29.6 APPENDIX B - REGULATIONS V2208 PO $66.85 Lens sphcy bifocal 4.25-7/2. V2209 PO $67.97 Lens sphcy bifocal 4.25-7/4. V2210 PO $72.61 Lens sphcy bifocal 4.25-7/ov V2211 PO $75.41 Lens sphcy bifo 7.25-12/.25- V2212 PO $76.61 Lens sphcyl bifo 7.25-12/2.2 V2213 PO $79.47 Lens sphcyl bifo 7.25-12/4.2 V2214 PO $96.83 Lens sphcyl bifocal over 12. V2215 PO $90.00 Lens lenticular bifocal V2218 PO $117.06 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 4.12-7. V2302 PO $74.50 Lens sphere trifocal 7.12-20 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 4.25-7/. V2308 PO $80.01 Lens sphc trifocal 4.25-7/2. V2309 PO $82.31 Lens sphc trifocal 4.25-7/4. V2310 PO $83.69 Lens sphc trifocal 4.25-7/>6 V2311 PO $80.66 Lens sphc trifo 7.25-12/.25- V2312 PO $81.17 Lens sphc trifo 7.25-12/2.25 V2313 PO $91.43 Lens sphc trifo 7.25-12/4.25 V2314 PO $104.24 Lens sphcyl trifocal over 12 V2315 PO $129.87 Lens lenticular trifocal V2318 PO $176.41 Lens aniseikonic trifocal V2319 PO $51.33 Lens trifocal seg width > 28 V2320 PO $63.01 Lens trifocal add over 3.25d V2321 PO $128.30 Lenticular lens, trifocal V2410 PO $99.73 Lens variab asphericity sing V2430 PO $129.96 Lens variable asphericity bi V2500 PO $97.75 Contact lens pmma spherical V2501 PO $148.90 Cntct lens pmma-toric/prism V2502 PO $183.43 Contact lens pmma bifocal V2503 PO $168.94 Cntct lens pmma color vision V2510 PO $113.95 Cntct gas permeable sphericl V2511 PO $191.73 Cntct toric prism ballast V2512 PO $226.56 Cntct lens gas permbl bifocl V2513 PO $190.21 Contact lens extended wear V2520 PO $125.43 Contact lens hydrophilic V2521 PO $218.37 Cntct lens hydrophilic toric V2522 PO $212.51 Cntct lens hydrophil bifocl V2523 PO $169.30 Cntct lens hydrophil extend V2530 PO $201.17 Contact lens gas impermeable V2531 PO $489.09 Contact lens gas permeable V2623 PO $1,045.38 Plastic eye prosth custom V2624 PO $54.91 Polishing artifical eye V2625 PO $333.85 Enlargemnt of eye prosthesis V2626 PO $179.96 Reduction of eye prosthesis V2627 PO $1,426.01 Scleral cover shell V2628 PO $278.76 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, 1.54-1.65 p/1.60-1.79g

MEDICAL FEE SCHEDULES 11:3-29.6 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. 29200 STRAP CHEST 29240 STRAP SHOULDER 29260 STRAP ELBOW OR WRIST 29280 STRAP HAND OR FINGER 29520 STRAP HIP 29530 STRAP KNEE 29540 STRAP ANKLE AND/OR FT 29550 STRAP TOES 29580 APPLY PASTE BOOT 29581 APPLY MULTILAY COMPRESS LWR LEG 29590 APPLY FOOT SPLINT 29799 CAST/STRAP PROCEDURE 97012 MECHANICAL TRACTION THERAPY SUPERVISED includes treatment MODALITY with VAX-D, DRX and similar machines G0283 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS 97016 VASOPNEUMATIC DEVICE THERAPY SUPERVISED MODALITY 97018 PARAFFIN BATH THERAPY SUPERVISED MODALITY 97022 WHIRLPOOL THERAPY SUPERVISED MODALITY 97024 DIATHERMY EG, MICROWAVE SUPERVISED MODALITY 97026 INFRARED THERAPY SUPERVISED MODALITY 97028 ULTRAVIOLET THERAPY SUPERVISED

11:3-29.6 APPENDIX B - REGULATIONS MODALITY 97032 APPLICATION OF A MODALITY TO DIRECT ONE- ONE OR MORE AREAS; ELECTRICAL ON-ONE STIMULATION (MANUAL), EACH 15 PATIENT MINUTES CONTACT REQUIRED 97033 IONTOPHORESIS, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED 97034 CONTRAST BATHS, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED 97035 ULTRASOUND, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED 97036 HUBBARD TANK, EACH 15 MINUTES DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED 97039 UNLISTED PHYSICAL MEDICINE & REHAB MODALITY 97110 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 97112 NEUROMUSCULAR REEDUCATION OF DIRECT ONE- MOVEMENT, BALANCE COORDINATION, ON-ONE KINESTHETIC SENSE, POSTURE, AND/OR PATIENT PROPRIOCEPTION FOR SITTING OR CONTACT STANDING ACTIVITIES REQUIRED 97113 AQUATIC THERAPY WITH THERAPEUTIC EXERCISES 97124 MASSAGE THERAPY DIRECT ONE- ON-ONE PATIENT CONTACT REQUIRED 97139 UNLISTED PHYSICAL MEDICINE PROCEDURE 97140 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 97150 GROUP THERAPEUTIC PROCEDURES, CONSTANT (2 OR MORE INDIVIDUALS) ATTENDANCE OF PROVIDER REQUIRED 97530 THERAPEUTIC ACTIVITIES, (USE OF DIRECT ONE- DYNAMIC ACTIVITIES TO IMPROVE ON-ONE FUNCTIONAL PERFORMANCE) PATIENT CONTACT REQUIRED 97535 SELF CARE MANAGEMENT TRAINING DIRECT ONE-

MEDICAL FEE SCHEDULES 11:3-29.6 97810 ACUPUNCTURE, 1 OR MORE NEEDLES, ON-ONE WITHOUT ELECTRICAL STIMULATION, PATIENT INITIAL 15 MINUTES CONTACT REQUIRED 97811 ACUPUNCTURE, 1 OR MORE NEEDLES, DIRECT ONE- WITHOUT ELECTRICAL STIMULATION, ON-ONE EACH ADDITIONAL 15 MINUTES, PATIENT WITH REINSERTION OF NEEDLES CONTACT REQUIRED 97813 ACUPUNCTURE, 1 OR MORE NEEDLES, DIRECT ONE- WITH ELECTRICAL STIMULATION, ON-ONE INITIAL 15 MINUTES PATIENT CONTACT REQUIRED 97814 ACUPUNCTURE, 1 OR MORE NEEDLES, DIRECT ONE- WITH ELECTRICAL STIMULATION, ON-ONE EACH ADDITIONAL 15 MINUTES, WITH PATIENT REINSERTION OF NEEDLES CONTACT REQUIRED 98925 OSTEOPATHIC MANIPULATION 1-2 REGIONS 98926 OSTEOPATHIC MANIPULATION 3-4 REGIONS 98927 OSTEOPATHIC MANIPULATION 5-6 REGIONS 98928 OSTEOPATHIC MANIPULATION 7-8 REGIONS 98929 OSTEOPATHIC MANIPULATION 9-10 REGIONS 98940 CHIROPRACTIC MANIPULATION 1-2 REGIONS 98941 CHIROPRACTIC MANIPULATION 3-4 REGIONS 98942 CHIROPRACTIC MANIPULATION 5 REGIONS 98943 CHIROPRACTIC MANIPULATION EXTRASPINAL, 1 OR MORE REGIONS NOTE: FOR CHIROPRACTIC MANIPULATIVE TREATMENT, THE 5 SPINAL REGIONS 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 182.27 156.22 AS

11:3-29.6 APPENDIX B - REGULATIONS G0289 ARTHRO, LOOSE BODY + CHONDRO X N1 10060 DRAIN SKIN ABSCESS 404.79 346.94 10061 DRAIN SKIN ABSCESS 404.79 346.94 10120 REMOVE FOREIGN BODY 741.84 635.83 10121 REMOVE FOREIGN BODY 4,909.21 4,207.68 10140 DRAIN HEMATOMA/FLUID 3,533.67 3,028.71 10160 PUNCTURE DRAIN LESION 404.79 346.94 10180 COMPLEX DRAIN WOUND 5,485.22 4,701.38 11000 DEBRIDE INFECTED SKIN 741.84 635.83 11001 DEBRIDE INFECTED SKIN, ADDED 247.20 211.88 11010 DEBRIDE SKIN, FX 1,381.84 1,184.38 11011 DEBRIDE SKIN/MUSCLE, FX 1,381.84 1,184.38 11012 DEBRIDE SKIN/MUSCLE/BONE, FX 1,381.84 1,184.38 11042 DEBRIDE SKIN/TISSUE 741.84 635.83 11043 DEBRIDE TISSUE/MUSCLE 741.84 635.83 11044 DEBRIDE TISSUE/MUSCLE BONE 2,306.26 1,976.70 11045 DEBRIDE SUBQ TISSUE ADD-ON 741.84 635.83 11046 DEBRIDE MUSCLE/FASCIA ADD-ON 741.84 635.83 11047 DEBRIDE BONE ADD-ON 2,306.26 1,976.70 11055 TRIM SKIN LESION 247.20 211.88 11056 TRIM SKIN LESIONS, 2 TO 4 247.20 211.88 11057 TRIM SKIN LESIONS, OVER 4 247.20 211.88 11100 BIOPSY SKIN LESION 406.64 348.53 11101 BIOPSY SKIN, ADDED 247.20 211.88 11200 REMOVE SKIN TAGS 247.20 211.88 11300 SHAVE SKIN LESION 247.20 211.88 11301 SHAVE SKIN LESION 247.20 211.88 11302 SHAVE SKIN LESION 247.20 211.88 11305 SHAVE SKIN LESION 247.20 211.88 11306 SHAVE SKIN LESION 247.20 211.88 11310 SHAVE SKIN LESION 247.20 211.88 11311 SHAVE SKIN LESION 247.20 211.88 11400 EXCISE TRT-EXT BENIGN+ MARG 0.5 < CM 1,381.84 1,184.38 11401 EXCISE TRT-EXT BENIGN+ MARG 0.6-1 CM 1,381.84 1,184.38 11402 EXCISE TRT-EXT BENIGN+ MARG 1.1-2 CM 1,381.84 1,184.38 11403 EXCISE TRT-EXT BENIGN+ MARG 2.1-3 CM 2,306.26 1,976.70 11404 EXCISE TRT-EXT BENIGN+ MARG 3.1-4 CM 4,909.21 4,042.57 11406 EXCISE TRT-EXT BENIGN+ MARG > 4.0 CM 4,909.21 4,042.57 11420 EXCISE H-F-NECK-SP BENIGN+MARG 0.5 < 2,306.26 1,976.70 11421 EXCISE H-F-NECK-SP BENIGN+MARG 0.6-1 2,306.26 1,976.70 11422 EXCISE H-F-NECK-SP BENIGN+MARG 1.1-2 2,306.26 1,976.70 11423 EXCISE H-F-NECK-SP BENIGN+MARG 2.1-3 4,909.21 4,207.68 11424 EXCISE H-F-NECK-SP BENIGN+MARG 3.1-4 4,909.21 4,207.68 11426 EXCISE H-F-NECK-SP BENIGN+MARG > 4 CM 6,489.68 5,562.30

MEDICAL FEE SCHEDULES 11:3-29.6 11440 EXCISE FACE-MM BENIGN+MARG 0.5 < CM 1,381.84 1,184.38 11441 EXCISE FACE-MM BENIGN+MARG 0.6-1 CM 1,381.84 1,184.38 11442 EXCISE FACE-MM BENIGN+MARG 1.1-2 CM 2,306.26 1,976.70 11443 EXCISE FACE-MM BENIGN+MARG 2.1-3 CM 2,306.26 1,976.70 11444 EXCISE FACE-MM BENIGN+MARG 3.1-4 CM 2,306.26 1,976.70 11719 TRIM NAIL(S) 117.49 100.70 11720 DEBRIDE NAIL, 1-5 247.20 211.88 11721 DEBRIDE NAIL, 6 OR MORE 247.20 211.88 11730 REMOVE NAIL PLATE 247.20 211.88 11732 REMOVE NAIL PLATE, ADDED 247.20 211.88 11740 DRAIN BLOOD UNDER NAIL 117.49 100.70 11750 REMOVE NAIL BED 1,381.84 1,184.38 11752 REMOVE NAIL BED/FINGER TIP 6,489.68 5,562.30 11760 REPAIR NAIL BED 361.97 310.24 11762 RECONSTRUCT NAIL BED 4,673.83 4,005.94 11765 EXCISE NAIL FOLD, TOE 247.20 211.88 11900 INJECTION INTO SKIN LESIONS 247.20 211.88 11901 ADDED SKIN LESIONS INJECTION 247.20 211.88 11950 THERAPY FOR CONTOUR DEFECTS 361.97 310.24 11951 THERAPY FOR CONTOUR DEFECTS 361.97 310.24 11960 INSERT TISSUE EXPANDER(S) 6,050.71 5,186.06 11981 INSERT DRUG IMPLANT DEVICE 182.27 156.22 AS 11982 REMOVE DRUG IMPLANT DEVICE 182.27 156.22 AS 12001 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12002 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12004 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12005 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12006 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12011 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12013 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12014 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12015 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12016 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12017 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12018 REPAIR SUPERFICIAL WOUND(S) 361.97 310.24 12020 CLOSE SPLIT WOUND 1,260.61 1,080.47 12021 CLOSE SPLIT WOUND 858.58 735.89

11:3-29.6 APPENDIX B - REGULATIONS 12031 INTERMED WOUND REPAIR S/TRT/EXT 361.97 310.24 12032 INTERMED WOUND REPAIR S/TRT/EXT 858.58 735.89 12034 INTERMED WOUND REPAIR S/TRT/EXT 361.97 310.24 12035 INTERMED WOUND REPAIR S/TRT/EXT 361.97 310.24 12036 INTERMED WOUND REPAIR S/TRT/EXT 858.58 735.89 12037 INTERMED WOUND REPAIR S/TRT/EXT 858.58 735.89 12041 INTERMED WOUND REPAIR N-HF/GENITAL 361.97 310.24 12042 INTERMED WOUND REPAIR N-HG/GENITAL 361.97 310.24 12044 INTERMED WOUND REPAIR N-HG/GENITAL 361.97 310.24 12045 INTERMED WOUND REPAIR N-HG/GENITAL 858.58 735.89 12046 INTERMED WOUND REPAIR N-HG/GENITAL 858.58 735.89 12047 INTERMED WOUND REPAIR N-HG/GENITAL 858.58 735.89 12051 INTERMED WOUND REPAIR FACE/MM 858.58 735.89 12052 INTERMED WOUND REPAIR FACE/MM 361.97 310.24 12053 INTERMED WOUND REPAIR FACE/MM 361.97 310.24 12054 INTERMED WOUND REPAIR FACE/MM 361.97 310.24 12055 INTERMED WOUND REPAIR FACE/MM 858.58 735.89 12056 INTERMED WOUND REPAIR FACE/MM 858.58 735.89 12057 INTERMED WOUND REPAIR FACE/MM 858.58 735.89 13100 REPAIR WOUND OR LESION 1,260.61 1,080.47 13101 REPAIR WOUND OR LESION 1,260.61 1,080.47 13102 REPAIR WOUND/LESION, ADDED 1,260.61 1,080.47 13120 REPAIR WOUND OR LESION 858.58 735.89 13121 REPAIR WOUND OR LESION 858.58 735.89 13122 REPAIR WOUND/LESION, ADDED 361.97 310.24 13131 REPAIR WOUND OR LESION 858.58 735.89 13132 REPAIR WOUND OR LESION 1,260.61 1,080.47 13133 REPAIR WOUND/LESION, ADDED 858.58 735.89 13150 REPAIR WOUND OR LESION 1,260.61 1,080.47 13151 REPAIR WOUND OR LESION 1,260.61 1,080.47 13152 REPAIR WOUND OR LESION 1,260.61 1,080.47 13153 REPAIR WOUND/LESION, ADDED 858.58 735.89 13160 LATE CLOSE WOUND 6,050.71 5,186.06 14000 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94 14001 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94 14020 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94

MEDICAL FEE SCHEDULES 11:3-29.6 14021 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94 14040 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94 14041 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94 14060 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94 14061 SKIN TISSUE REARRANGEMENT 4,673.83 4,005.94 14301 SKIN TISSUE REARRANGEMENT 6,050.71 5,186.06 14302 SKIN TISSUE REARRANGE ADDED 6,050.71 5,186.06 15002 WOUND PREP, TRUNK/ARM/LEG 1,260.61 1,080.47 15003 WOUND PREP, ADDED 100 CM 1,260.61 1,080.47 15004 WOUND PREP, F/N/HF/G 1,260.61 1,080.47 15005 WOUND PREP, F/N/HF/G, ADDED CM 1,260.61 1,080.47 15050 SKIN PINCH GRAFT 1,260.61 1,080.47 15100 SKIN SPLIT GRAFT, TRUNK/ARM/LEG 6,050.71 5,186.06 15101 SKIN SPLIT GRAFT T/A/L, ADDED 6,050.71 5,186.06 15120 SKIN SPLIT A-GRAFT FAC/NECK/HF/G 6,050.71 5,186.06 15121 SKIN SPLIT A-GRAFT F/N/HF/G ADDED 6,050.71 5,186.06 15130 DERM AUTOGRAFT, TRUNK/ARM/LEG 4,673.83 4,005.94 15170 ACELLULAR GRAFT TRUNK/ARMS/LEGS 1,260.61 1,080.47 15171 ACELLULAR GRAFT T/ARM/LEG, ADDED 858.58 735.89 15175 ACELLULAR GRAFT, F/N/HF/G1,260.61 1,080.47 15220 SKIN FULL GRAFT SCALP/ARM/LEG 4,673.83 4,005.94 15221 SKIN FULL GRAFT, ADDED 1,260.61 1,080.47 15240 SKIN FULL GRAFT FACE/GENITAL/HF 4,673.83 4,005.94 15241 SKIN FULL GRAFT, ADDED 1,260.61 1,080.47 15260 SKIN FULL GRAFT EEN & LIPS 4,673.83 4,005.94 15330 APPLY ACELLULAR ALLOGRAFT T/ARM/LEG 1,260.61 1,080.47 15331 APPLY ACELLULAR GRAFT T/A/L, ADDED 1,260.61 1,080.47 15340 APPLY CULT SKIN SUBSTITUTE 858.58 735.89 15341 APPLY CULT SKIN SUB, ADDED 858.58 735.89 15365 APPLY CULT DERM SUB F/N/HF/G 858.58 735.89 15366 APPLY CULT DERM F/HF/G ADDED 858.58 735.89 15430 APPLY ACELLULAR XENOGRAFT 1,260.61 1,080.47 15431 APPLY ACELLULAR XENOGRAFT ADDED 1,260.61 1,080.47 15570 FORM SKIN PEDICLE FLAP 6,050.71 5,186.06

11:3-29.6 APPENDIX B - REGULATIONS 15572 FORM SKIN PEDICLE FLAP 6,050.71 5,186.06 15574 FORM SKIN PEDICLE FLAP 6,050.71 5,186.06 15576 FORM SKIN PEDICLE FLAP 6,050.71 5,186.06 15620 SKIN GRAFT 6,050.71 5,186.06 15732 MUSCLE-SKIN GRAFT, HEAD/NECK 6,050.71 5,186.06 15734 MUSCLE-SKIN GRAFT, TRUNK 6,050.71 5,186.06 15736 MUSCLE-SKIN GRAFT, ARM 6,050.71 5,186.06 15738 MUSCLE-SKIN GRAFT, LEG 6,050.71 5,186.06 15770 DERMA-FAT-FASCIA GRAFT 6,050.71 5,186.06 15780 ABRASION TREAT SKIN 6,489.68 5,562.30 15781 ABRASION TREAT SKIN 1,381.84 1,184.38 15782 ABRASION TREAT SKIN 1,381.84 1,184.38 15786 ABRASION, LESION, SING 247.20 211.88 15787 ABRASION, LESIONS, ADDED 247.20 211.88 15823 REVISE UPPER EYELID 6,050.71 5,186.06 15830 EXCISE SKIN ABD 6,489.68 5,562.30 15832 EXCISE EXCESSIVE SKIN TISSUE 6,489.68 5,562.30 15851 REMOVE SUTURES 741.84 635.83 15852 DRESSING CHANGE NOT FOR BURN 182.27 156.22 AS 15940 REMOVE HIP PRESSURE SORE6,489.68 5,562.30 15941 REMOVE HIP PRESSURE SORE6,489.68 5,562.30 15944 REMOVE HIP PRESSURE SORE6,050.71 5,186.06 15945 REMOVE HIP PRESSURE SORE6,050.71 5,186.06 15946 REMOVE HIP PRESSURE SORE6,050.71 5,186.06 15950 REMOVE THIGH PRESSURE SORE 6,489.68 5,562.30 15951 REMOVE THIGH PRESSURE SORE 6,489.68 5,562.30 15952 REMOVE THIGH PRESSURE SORE 4,673.83 4,005.94 15953 REMOVE THIGH PRESSURE SORE 4,673.83 4,005.94 15956 REMOVE THIGH PRESSURE SORE 4,673.83 4,005.94 15958 REMOVE THIGH PRESSURE SORE 4,673.83 4,005.94 16000 INITIAL TREAT BURN(S) 247.20 211.88 16020 DRESS/DEBRIDE P-THICK BURN, S 406.64 348.53 16025 DRESS/DEBRIDE P-THICK BURN, M 406.64 348.53 16030 DRESS/DEBRIDE P-THICK BURN, L 406.64 348.53 17000 DESTROY PREMALIG LESION 247.20 211.88 17003 DESTROY PREMALIG LES, 2-14 117.49 100.70 17004 DESTROY PREMALIG LESIONS 15+ 741.84 635.83 17106 DESTROY SKIN LESIONS 741.84 635.83 17107 DESTROY SKIN LESIONS 741.84 635.83 17108 DESTROY SKIN LESIONS 741.84 635.83 17110 DESTROY B9 LESION, 1-14 247.20 211.88 17111 DSTRJ B9 SK TGS/CUTAN VASC 15/> 406.64 348.53 17250 CHEM CAUT GRANLTJ TISS PROUD FLESH SINUS/FSTL 406.64 348.53 17261 DESTROY SKIN LESIONS 406.64 348.53 17262 DESTROY SKIN LESIONS 406.64 348.53 19000 DRAIN BREAST LESION 1,244.88 1,066.98

MEDICAL FEE SCHEDULES 11:3-29.6 19120 REMOVE BREAST LESION 6,949.27 5,956.21 19125 EXCISE BREAST LESION 6,949.27 5,956.21 19290 PLACE NEEDLE WIRE, BREAST N1 20100 EXPLORE WOUND, NECK 2,150.53 1,843.22 20101 EXPLORE WOUND, CHEST 6,050.71 5,186.06 20102 EXPLORE WOUND, ABDOMEN 6,050.71 5,186.06 20103 EXPLORE WOUND, EXTREMITY 3,533.67 3,028.71 20520 REMOVE FOREIGN BODY 6,238.69 5,347.18 20525 REMOVE FOREIGN BODY 6,489.68 5,562.30 20526 THERAPEUTIC INJECTION, CARP TUNNEL 724.57 621.03 20550 INJECT TENDON SHEATH/LIGAMENT 724.57 621.03 20551 INJECT TENDON ORIGIN/INSERT 724.57 621.03 20552 INJECT TRIGGER POINT, 1/2 MUSCLE 724.57 621.03 20553 INJECT TRIGGER POINTS, =/> 3 724.57 621.03 20600 DRAIN/INJ, JOINT/BURSA 724.57 621.03 20605 DRAIN/INJ, JOINT/BURSA 724.57 621.03 20610 DRAIN/INJ, JOINT/BURSA 724.57 621.03 20612 ASPIRATE/INJECT GANGLION CYST 724.57 621.03 20615 TREAT BONE CYST 1,244.88 1,066.98 20650 INSERT & REMOVE BONE PIN 6,238.69 5,347.18 20660 APPLY, REM FIXATION DEVICE 1,494.88 1,281.26 20662 APPLY PELVIS BRACE 6,238.69 5,347.18 20663 APPLY THIGH BRACE 6,238.69 5,347.18 20665 REMOVE FIXATION DEVICE 182.27 156.22 AS 20670 REMOVE SUPPORT IMPLANT 4,909.21 4,207.68 20680 REMOVE SUPPORT IMPLANT 6,489.68 5,562.30 20690 APPLY BONE FIXATION DEVICE 8,755.84 7,504.63 20692 APPLY BONE FIXATION DEVICE 8,755.84 7,504.63 20693 ADJUST BONE FIXATION DEVICE 6,238.69 5,347.18 20694 REMOVE BONE FIXATION DEVICE 6,238.69 5,347.18 20696 COMP MULTIPLANE EXT FIXATION 8,755.84 7,504.63 20697 COMP EXT FIXATE STRUT CHANGE 5,657.91 4,849.39 20900 REMOVE BONE FOR GRAFT 8,755.84 7,504.63 20902 REMOVE BONE FOR GRAFT 8,755.84 7,504.63 20910 REMOVE CARTILAGE FOR GRAFT 6,050.71 5,186.06 20912 REMOVE CARTILAGE FOR GRAFT 6,050.71 5,186.06 20920 REMOVE FASCIA FOR GRAFT 4,673.83 4,005.94 20922 REMOVE FASCIA FOR GRAFT 4,673.83 4,005.94 20924 REMOVE TENDON FOR GRAFT 8,755.84 7,504.63 20926 REMOVE TISSUE FOR GRAFT 1,260.61 1,080.47 20950 FLUID PRESSURE, MUSCLE 404.79 346.94 20975 ELECTRICAL BONE

11:3-29.6 APPENDIX B - REGULATIONS STIMULATION N1 20979 US BONE STIMULATION 182.27 156.22 AS 20985 COMPUTER-ASSIST DIR MS PX N1 21060 REMOVE JAW JOINT CARTILAGE 12,135.56 10,401.38 21070 REMOVE CORONOID PROCESS 12,135.56 10,401.38 21073 MANIPULATE TMJ W/ANESTH 2,150.53 1,843.22 21085 PREPARE FACE/ORAL PROSTHESIS 4,708.37 4,035.54 21110 INTERDENTAL FIXATION 2,150.53 1,843.22 21116 INJECTION, JAW JOINT X-RAY N1 21209 REDUCE FACIAL BONES 12,135.56 10,401.38 21210 FACE BONE GRAFT 12,135.56 10,401.38 21240 RECONSTRUCT JAW JOINT 12,135.56 10,401.38 21242 RECONSTRUCT JAW JOINT 12,135.56 10,401.38 21243 RECONSTRUCT JAW JOINT 12,135.56 10,401.38 21244 RECONSTRUCT LOWER JAW 12,135.56 10,401.38 21245 RECONSTRUCT JAW 12,135.56 10,401.38 21246 RECONSTRUCT JAW 12,135.56 10,401.38 21248 RECONSTRUCT JAW 12,135.56 10,401.38 21249 RECONSTRUCT JAW 12,135.56 10,401.38 21310 TREAT NOSE FX 307.68 263.71 21315 TREAT NOSE FX 4,708.37 4,035.54 21320 TREAT NOSE FX 4,708.37 4,035.54 21325 TREAT NOSE FX 6,964.52 5,969.29 21330 TREAT NOSE FX 6,964.52 5,969.29 21335 TREAT NOSE FX 6,964.52 5,969.29 21356 TREAT CHEEK BONE FX 6,964.52 5,969.29 21360 TREAT CHEEK BONE FX 6,964.52 5,969.29 21365 TREAT CHEEK BONE FX 12,135.56 10,401.38 21385 TREAT EYE SOCKET FX 12,135.56 10,401.38 21386 TREAT EYE SOCKET FX 12,135.56 10,401.38 21390 TREAT EYE SOCKET FX 12,135.56 10,401.38 21395 TREAT EYE SOCKET FX 12,135.56 10,401.38 21400 TREAT EYE SOCKET FX 2,150.53 1,843.22 21401 TREAT EYE SOCKET FX 4,708.37 4,035.54 21406 TREAT EYE SOCKET FX 12,135.56 10,401.38 21407 TREAT EYE SOCKET FX 12,135.56 10,401.38 21408 TREAT EYE SOCKET FX 12,135.56 10,401.38 21450 TREAT LOWER JAW FX 965.03 827.13 21451 TREAT LOWER JAW FX 2,150.53 1,843.22 21452 TREAT LOWER JAW FX 4,708.37 4,035.54 21453 TREAT LOWER JAW FX 12,135.56 10,401.38 21454 TREAT LOWER JAW FX 6,964.52 5,969.29 21461 TREAT LOWER JAW FX 12,135.56 10,401.38 21462 TREAT LOWER JAW FX 12,135.56 10,401.38 21465 TREAT LOWER JAW FX 12,135.56 10,401.38 21470 TREAT LOWER JAW FX 12,135.56 10,401.38 21800 TREAT RIB FX 428.68 367.42 21820 TREAT STERNUM FX 428.68 367.42 22222 REVISE THORAX SPINE 13,940.72 11,948.58 22305 TREAT SPINE PROCESS FX 428.68 367.42 22310 TREAT SPINE FX 1,494.88 1,281.26 22315 TREAT SPINE FX 5,657.91 4,849.39 22505 MANIPULATE SPINE 4,222.92 3,619.46 22520 PERCUT VERTEBROPLASTY THORACIC 8,755.84 7,504.63 22521 PERCUT VERTEBROPLASTY

MEDICAL FEE SCHEDULES 11:3-29.6 LUMBAR 8,755.84 7,504.63 22522 PERCUT VERTEBROPLASTY ADDED 8,755.84 7,504.63 22612 LUMBAR SPINE FUSION 13,940.72 11,948.58 22614 SPINE FUSION, EXTRA SEGMENT 13,940.72 11,948.58 22851 APPLY SPINE PROSTH DEVICE 6,238.69 5,347.18 23120 PARTIAL REMOVE COLLAR BONE 8,755.84 7,504.63 23125 REMOVE COLLAR BONE 8,755.84 7,504.63 23130 REMOVE SHOULDER BONE, PART 12,850.12 11,013.83 23331 REMOVE SHOULDER FOREIGN BODY 6,489.68 5,562.30 23350 INJECTION FOR SHOULDER X-RAY 23405 TX SHO AREA 1 TDN 8,755.84 7,504.63 23406 TX SHO AREA MLT TDN THRU SM INC 8,755.84 7,504.63 23410 OPEN REPAIR OF ROTATOR CUFF, RECENT 12,850.12 11,013.83 23412 OPEN REPAIR OF ROTATOR CUFF, OLD 12,850.12 11,013.83 23415 CORACOACROMIAL LIGM RLS +-ACROMP 12,850.12 11,013.83 23420 RECONSTRUCTION ROTATOR CUFF, OLD 12,850.12 11,013.83 23430 TENODIS LONG TDN BICEPS 12,850.12 11,013.83 23440 RESCJ/TRNSPLJ LONG TDN BICEPS 12,850.12 11,013.83 23470 RECONSTRUCT SHOULDER JOINT 19,460.64 17,581.99 23480 REVISE COLLAR BONE 12,850.12 11,013.83 23485 REVISE COLLAR BONE 24,164.43 20,711.32 23500 TREAT CLAVICLE FX 428.68 367.42 23505 TREAT CLAVICLE FX 5,657.91 4,849.39 23515 TREAT CLAVICLE FX 18,168.29 15,572.03 23520 TREAT CLAVICLE DISLOCATION 1,494.88 1,281.26 23525 TREAT CLAVICLE DISLOCATION 1,494.88 1,281.26 23530 TREAT CLAVICLE DISLOCATION 13,070.23 11,202.49 23540 TREAT CLAVICLE DISLOCATION 428.68 367.42 23545 TREAT CLAVICLE DISLOCATION 1,494.88 1,281.26 23550 TREAT CLAVICLE DISLOCATION 13,070.23 11,202.49 23552 TREAT CLAVICLE DISLOCATION 13,070.23 11,202.49 23570 TREAT SHOULDER BLADE FX 428.68 367.42 23600 TREAT HUMERUS FX 428.68 367.42 23605 TREAT HUMERUS FX 5,657.91 4,849.39 23615 TREAT HUMERUS FX 18,168.29 15,572.03 23616 TREAT HUMERUS FX 18,168.29 15,572.03 23620 TREAT HUMERUS FX 428.68 367.42 23625 TREAT HUMERUS FX 5,657.91 4,849.39 23630 TREAT HUMERUS FX 18,168.29 15,572.03 23650 TREAT SHOULDER N1

11:3-29.6 APPENDIX B - REGULATIONS DISLOCATION 428.68 367.42 23655 TREAT SHOULDER DISLOCATION 4,222.92 3,619.46 23700 FIXATE SHOULDER 4,222.92 3,619.46 24220 INJECTION FOR ELBOW X-RAY 24300 MANIPULATE ELBOW W/ANESTH 4,222.92 3,619.46 24305 ARM TENDON LENGTHENING 8,755.84 7,504.63 24340 REPAIR BICEPS TENDON 12,850.12 11,013.83 24341 REPAIR ARM TENDON/MUSCLE 12,850.12 11,013.83 24342 REPAIR RUPTURED TENDON 12,850.12 11,013.83 24343 REPAIR ELBOW LAT LIGAMENT W/TISS 8,755.84 7,504.63 24500 TREAT HUMERUS FX 428.68 367.42 24505 TREAT HUMERUS FX 428.68 367.42 24515 TREAT HUMERUS FX 18,168.29 15,572.03 24516 TREAT HUMERUS FX 18,168.29 15,572.03 24530 TREAT HUMERUS FX 428.68 367.42 24535 TREAT HUMERUS FX 1,494.88 1,281.26 24545 TREAT HUMERUS FX 18,168.29 15,572.03 24546 TREAT HUMERUS FX 18,168.29 15,572.03 24560 TREAT HUMERUS FX 428.68 367.42 24565 TREAT HUMERUS FX 428.68 367.42 24575 TREAT HUMERUS FX 18,168.29 15,572.03 24576 TREAT HUMERUS FX 428.68 367.42 24577 TREAT HUMERUS FX 428.68 367.42 24579 TREAT HUMERUS FX 18,168.29 15,572.03 25000 INCISE TENDON SHEATH 6,238.69 5,347.18 25001 INCISE FLEXOR CARPI RADIALIS 6,238.69 5,347.18 25020 DECOMPRESS FOREARM 1 SPACE 8,755.84 7,504.63 25023 DECOMPRESS FOREARM 1 SPACE 8,755.84 7,504.63 25024 DECOMPRESS FOREARM 2 SPACES 8,755.84 7,504.63 25025 DECOMPRESS FOREARM 2 SPACES 8,755.84 7,504.63 25118 EXCISE WRIST TENDON SHEATH 8,755.84 7,504.63 25215 REMOVE WRIST BONES 8,755.84 7,504.63 25246 INJECTION FOR WRIST X-RAY 25259 MANIPULATE WRIST W/ANESTH 5,657.91 4,849.39 25260 REPAIR FOREARM TENDON/MUSCLE 8,755.84 7,504.63 25263 REPAIR FOREARM TENDON/MUSCLE 8,755.84 7,504.63 25265 REPAIR FOREARM TENDON/MUSCLE 8,755.84 7,504.63 25270 REPAIR FOREARM TENDON/MUSCLE 8,755.84 7,504.63 25272 REPAIR FOREARM TENDON/MUSCLE 8,755.84 7,504.63 25274 REPAIR FOREARM TENDON/MUSCLE 8,755.84 7,504.63 25295 RELEASE WRIST/FOREARM N1 N1

MEDICAL FEE SCHEDULES 11:3-29.6 TENDON 6,238.69 5,347.18 25500 TREAT FX RADIUS 428.68 367.42 25505 TREAT FX RADIUS 1,494.88 1,281.26 25515 TREAT FX RADIUS 13,070.23 11,202.49 25525 TREAT FX RADIUS 13,070.23 11,202.49 25526 TREAT FX RADIUS 13,070.23 11,202.49 25530 TREAT FX ULNA 428.68 367.42 25535 TREAT FX ULNA 428.68 367.42 25545 TREAT FX ULNA 13,070.23 11,202.49 25560 TREAT FX RADIUS & ULNA 428.68 367.42 25565 TREAT FX RADIUS & ULNA 1,494.88 1,281.26 25574 TREAT FX RADIUS & ULNA 18,168.29 15,572.03 25575 TREAT FX RADIUS/ULNA 18,168.29 15,572.03 25600 TREAT FX RADIUS/ULNA 428.68 367.42 25605 TREAT FX RADIUS/ULNA 1,494.88 1,281.26 25606 TREAT FX DISTAL RADIAL 7,210.82 6,180.39 25607 TREAT FX RADIAL EXTRA-ARTICULAR 18,168.29 15,572.03 25608 TREAT FX RADIAL INTRA-ARTICULAR 18,168.29 15,572.03 25609 TREAT FX RADIAL 3+ FRAG 18,168.29 15,572.03 25622 TREAT WRIST BONE FX 428.68 367.42 25624 TREAT WRIST BONE FX 1,494.88 1,281.26 25628 TREAT WRIST BONE FX 13,070.23 11,202.49 25630 TREAT WRIST BONE FX 428.68 367.42 25635 TREAT WRIST BONE FX 428.68 367.42 25645 TREAT WRIST BONE FX 13,070.23 11,202.49 25650 TREAT WRIST BONE FX 428.68 367.42 25652 TREAT FX ULNAR STYLOID 13,070.23 11,202.49 25670 TREAT FX ULNAR STYLOID 7,210.82 6,180.39 25671 TREAT FX ULNAR STYLOID 7,210.82 6,180.39 25676 TREAT WRIST DISLOCATION 7,210.82 6,180.39 25680 TREAT WRIST FX 428.68 367.42 25685 TREAT WRIST FX 7,210.82 6,180.39 26055 INCISE FINGER TENDON SHEATH 4,660.94 3,994.89 26116 EXCISE HAND TUMOR DEEP < 1.5 CM 4,909.21 4,207.68 26140 REVISE FINGER JOINT, EACH 4,660.94 3,994.89 26145 TENDON EXCISE PALM/FINGER 4,660.94 3,994.89 26340 MANIPULATE FINGER W/ANESTH 1,494.88 1,281.26 26410 REPAIR HAND TENDON 4,660.94 3,994.89 26418 REPAIR FINGER TENDON 4,660.94 3,994.89 26445 RELEASE HAND/FINGER TENDON 4,660.94 3,994.89 26480 TRANSPLANT HAND TENDON 8,083.67 6,928.51 26525 RELEASE FINGER CONTRACTURE 4,660.94 3,994.89 26540 REPAIR HAND JOINT 4,660.94 3,994.89 26600 TREAT METACARPAL FX 428.68 367.42 26605 TREAT METACARPAL FX 428.68 367.42 26607 TREAT METACARPAL FX 5,657.91 4,849.39 26608 TREAT METACARPAL FX 7,210.82 6,180.39 26615 TREAT METACARPAL FX 13,070.23 11,202.49 26720 TREAT FINGER FX, EACH 428.68 367.42 26725 TREAT FINGER FX, EACH 428.68 367.42 26727 TREAT FINGER FX, EACH 7,210.82 6,180.39 26735 TREAT FINGER FX, EACH 7,210.82 6,180.39 26740 TREAT FINGER FX, EACH 428.68 367.42

11:3-29.6 APPENDIX B - REGULATIONS 26742 TREAT FINGER FX, EACH 428.68 367.42 26746 TREAT FINGER FX, EACH 7,210.82 6,180.39 26750 TREAT FINGER FX, EACH 428.68 367.42 26755 TREAT FINGER FX, EACH 428.68 367.42 27093 INJECTION FOR HIP X-RAY N1 27095 INJECTION FOR HIP X-RAY N1 27193 TREAT PELVIC RING FX 428.68 367.42 27194 TREAT PELVIC RING FX 4,222.92 3,619.46 27275 MANIPULATE HIP JOINT 4,222.92 3,619.46 27403 REPAIR KNEE CARTILAGE 8,755.84 7,504.63 27405 REPAIR KNEE LIGAMENT 12,850.12 11,013.83 27420 REVISE UNSTABLE KNEECAP 12,850.12 11,013.83 27422 REVISE UNSTABLE KNEECAP 12,850.12 11,013.83 27424 REVISION/REMOVE KNEECAP 12,850.12 11,013.83 27500 TREAT THIGH FX 1,494.88 1,281.26 27501 TREAT THIGH FX 428.68 367.42 27502 TREAT THIGH FX 5,657.91 4,849.39 27503 TREAT THIGH FX 428.68 367.42 27508 TREAT THIGH FX 428.68 367.42 27509 TREAT THIGH FX 7,210.82 6,180.39 27510 TREAT THIGH FX 1,494.88 1,281.26 27520 TREAT KNEECAP FX 428.68 367.42 27524 TREAT KNEECAP FX 13,070.23 11,202.49 27530 TREAT KNEE FX 428.68 367.42 27532 TREAT KNEE FX 5,657.91 4,849.39 27538 TREAT KNEE FX(S) 428.68 367.42 27570 FIXATE KNEE JOINT 4,222.92 3,619.46 27685 REVISE LOWER LEG TENDON 8,755.84 7,504.63 27686 REVISE LOWER LEG TENDONS 8,755.84 7,504.63 27690 REVISE LOWER LEG TENDON 12,850.12 11,013.83 27691 REVISE LOWER LEG TENDON 12,850.12 11,013.83 27692 REVISE ADDEDITIONAL LEG TENDON 12,850.12 11,013.83 27695 REPAIR ANKLE LIGAMENT 8,755.84 7,504.63 27696 REPAIR ANKLE LIGAMENTS 8,755.84 7,504.63 27698 REPAIR ANKLE LIGAMENT 8,755.84 7,504.63 27750 TREAT TIBIA FX 428.68 367.42 27752 TREAT TIBIA FX 5,657.91 4,849.39 27758 TREAT TIBIA FX 13,070.23 11,202.49 27759 TREAT TIBIA FX 18,168.29 15,572.03 27760 CLOSED TREAT MEDIAL ANKLE FX 428.68 367.42 27762 CLOSED TREAT MED ANKLE FX W/MANIP 5,657.91 4,849.39 27766 OPEN TREAT MEDIAL ANKLE FX 13,070.23 11,202.49 27786 TREAT ANKLE FX 428.68 367.42 27788 TREAT ANKLE FX 428.68 367.42 27792 TREAT ANKLE FX 13,070.23 11,202.49 27808 TREAT ANKLE FX 428.68 367.42 27810 TREAT ANKLE FX 428.68 367.42 27814 TREAT ANKLE FX 13,070.23 11,202.49 27816 TREAT ANKLE FX 428.68 367.42 27818 TREAT ANKLE FX 1,494.88 1,281.26 27822 TREAT ANKLE FX 13,070.23 11,202.49

MEDICAL FEE SCHEDULES 11:3-29.6 27823 TREAT ANKLE FX 18,168.29 15,572.03 27824 TREAT LOWER LEG FX 428.68 367.42 27825 TREAT LOWER LEG FX 5,657.91 4,849.39 27826 TREAT LOWER LEG FX 13,070.23 11,202.49 27827 TREAT LOWER LEG FX 18,168.29 15,572.03 27828 TREAT LOWER LEG FX 18,168.29 15,572.03 27829 TREAT LOWER LEG JOINT 13,070.23 11,202.49 27840 TREAT ANKLE DISLOCATION 428.68 367.42 27842 TREAT ANKLE DISLOCATION 4,222.92 3,619.46 27846 TREAT ANKLE DISLOCATION 13,070.23 11,202.49 27848 TREAT ANKLE DISLOCATION 13,070.23 11,202.49 27860 FIXATE ANKLE JOINT 4,222.92 3,619.46 28120 PART REMOVE ANKLE/HEEL 6,135.71 5,258.91 28122 PARTIAL REMOVE FOOT BONE 6,135.71 5,258.91 28400 TREAT HEEL FX 428.68 367.42 28405 TREAT HEEL FX 5,657.91 4,849.39 28415 TREAT HEEL FX 18,168.29 15,572.03 28420 TREAT/GRAFT HEEL FX 13,070.23 11,202.49 28430 TREAT ANKLE FX 428.68 367.42 28435 TREAT ANKLE FX 428.68 367.42 28436 TREAT ANKLE FX 7,210.82 6,180.39 28445 TREAT ANKLE FX 13,070.23 11,202.49 28470 TREAT METATARSAL FX 428.68 367.42 28475 TREAT METATARSAL FX 428.68 367.42 28476 TREAT METATARSAL FX 7,210.82 6,180.39 28485 TREAT METATARSAL FX 13,070.23 11,202.49 28725 FUSE FOOT BONES 15,005.30 12,861.03 28730 FUSE FOOT BONES 15,005.30 12,861.03 28740 FUSE FOOT BONES 15,005.30 12,861.03 28750 FUSE BIG TOE JOINT 15,005.30 12,861.03 29065 APPLY LONG ARM CAST 691.49 592.68 X 29075 APPLY FOREARM CAST 691.49 592.68 X 29085 APPLY HAND/WRIST CAST 304.17 260.71 X 29086 APPLY FINGER CAST 304.17 260.71 X 29105 APPLY LONG ARM SPLINT 304.17 260.71 X 29125 APPLY FOREARM SPLINT 304.17 260.71 X 29126 APPLY FOREARM SPLINT 304.17 260.71 X 29130 APPLY FINGER SPLINT 304.17 260.71 X 29131 APPLY FINGER SPLINT 304.17 260.71 X 29200 STRAP CHEST 304.17 260.71 X 29240 STRAP SHOULDER 304.17 260.71 X 29260 STRAP ELBOW OR WRIST 304.17 260.71 X 29280 STRAP HAND OR FINGER 304.17 260.71 X 29345 APPLY LONG LEG CAST 691.49 592.68 X 29355 APPLY LONG LEG CAST 691.49 592.68 X 29365 APPLY LONG LEG CAST 691.49 592.68 X 29405 APPLY SHORT LEG CAST 691.49 592.68 X 29425 APPLY SHORT LEG CAST 691.49 592.68 X 29450 APPLY LEG CAST 304.17 260.71 X 29505 APPLY LONG LEG SPLINT 304.17 260.71 X 29515 APPLY LOWER LEG SPLINT 304.17 260.71 X 29520 STRAP HIP 304.17 260.71 X 29530 STRAP KNEE 304.17 260.71 X 29540 STRAP ANKLE AND/OR FT 304.17 260.71 X 29550 STRAP TOES 304.17 260.71 X 29580 APPLY PASTE BOOT 304.17 260.71 X 29581 APPLY MULTILAY COMPRESS

11:3-29.6 APPENDIX B - REGULATIONS LWR LEG 304.17 260.71 X 29590 APPLY FOOT SPLINT 304.17 260.71 X 29700 REMOVE/REVISE CAST 304.17 260.71 X 29705 REMOVE/REVISE CAST 304.17 260.71 X 29710 REMOVE/REVISE CAST 691.49 592.68 X 29740 WEDGE CAST 304.17 260.71 X 29800 JAW ARTHROSCOPY/SURG 8,137.61 6,974.74 29804 JAW ARTHROSCOPY/SURG 8,137.61 6,974.74 29805 SHOULDER ARTHROSCOPY, DIAG 8,137.61 6,974.74 29806 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29807 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29819 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29820 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29821 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29822 SHOULDER ARTHROSCOPY/SURG 8,137.61 6,974.74 29823 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29824 SHOULDER ARTHROSCOPY/SURG 8,137.61 6,974.74 29825 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29826 SHOULDER ARTHROSCOPY/SURG 13,154.68 11,274.87 29827 ARTHROSCOPY ROTATOR CUFF REPAIR 13,154.68 11,274.87 29828 ARTHROSCOPY BICEPS TENODESIS 13,154.68 11,274.87 29830 ELBOW ARTHROSCOPY 8,137.61 6,974.74 29834 ELBOW ARTHROSCOPY/SURG 8,137.61 6,974.74 29835 ELBOW ARTHROSCOPY/SURG 8,137.61 6,974.74 29837 ELBOW ARTHROSCOPY/SURG 8,137.61 6,974.74 29840 WRIST ARTHROSCOPY 8,137.61 6,974.74 29844 WRIST ARTHROSCOPY/SURG 8,137.61 6,974.74 29845 WRIST ARTHROSCOPY/SURG 8,137.61 6,974.74 29846 WRIST ARTHROSCOPY/SURG 8,137.61 6,974.74 29847 WRIST ARTHROSCOPY/SURG13,154.68 11,274.87 29848 WRIST ENDOSCOPY/SURG 8,137.61 6,974.74 29850 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29855 TIBIAL ARTHROSCOPY/SURG13,154.68 11,274.87 29860 HIP ARTHROSCOPY, DIAG 13,154.68 11,274.87 29861 HIP ARTHROSCOPY/SURG 13,154.68 11,274.87 29862 HIP ARTHROSCOPY/SURG 13,154.68 11,274.87 29863 HIP ARTHROSCOPY/SURG 13,154.68 11,274.87 29870 KNEE ARTHROSCOPY, DIAG 8,137.61 6,974.74 29871 KNEE ARTHROSCOPY/DRAIN 8,137.61 6,974.74 29873 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29874 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29875 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29876 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29877 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29879 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74

MEDICAL FEE SCHEDULES 11:3-29.6 29880 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29881 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29882 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29883 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29884 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29886 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29887 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74 29888 KNEE ARTHROSCOPY/SURG 24,164.43 20,711.32 29889 KNEE ARTHROSCOPY/SURG 24,164.43 20,711.32 29891 ANKLE ARTHROSCOPY/SURG 13,154.68 11,274.87 29894 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.74 29895 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.74 29897 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.74 29898 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.74 29899 ANKLE ARTHROSCOPY/SURG13,154.68 11,274.87 30100 INTRANASAL BIOPSY 2,150.53 1,843.22 30130 EXCISE INFERIOR TURBINATE 4,708.37 4,035.54 30140 RESECT INFERIOR TURBINATE 6,964.52 5,969.29 30200 INJECTION TREAT NOSE 2,150.53 1,843.22 30300 REMOVE NASAL FOREIGN BODY 182.27 156.22 AS 30310 REMOVE NASAL FOREIGN BODY 4,708.37 4,035.54 30520 REPAIR NASAL SEPTUM 6,964.52 5,969.29 30802 ABLATE INF TURBINATE SUBMUCOSAL 4,708.37 4,035.54 30901 CONTROL NOSEBLEED 307.68 263.71 30903 CONTROL NOSEBLEED 307.68 263.71 30905 CONTROL NOSEBLEED 307.68 263.71 30930 THERAPEUTIC FX, NASAL INF TURB 4,708.37 4,035.54 31000 IRRIGATE MAXILLARY SINUS 965.03 827.13 31020 EXPLORE MAXILLARY SINUS6,964.52 5,969.29 31231 NASAL ENDOSCOPY, DIAG 546.21 468.15 31237 NASAL/SINUS ENDOSCOPY, SURG 5,959.12 5,107.56 31238 NASAL/SINUS ENDOSCOPY, SURG 5,959.12 5,107.56 31255 REMOVE ETHMOID SINUS 8,403.49 7,202.63 31256 EXPLORE MAXILLARY SINUS8,403.49 7,202.63 31267 ENDOSCOPY, MAXILLARY SINUS 8,403.49 7,202.63 31500 INSERT EMERGENCY AIRWAY 642.80 550.94 X 31505 DIAGNOSTIC LARYNGOSCOPY 252.44 216.37 31515 LARYNGOSCOPY FOR ASPIRATION 5,959.12 5,107.56 31525 DIAG LARYNGOSCOPY EXCL NB 5,959.12 5,107.56 31575 DIAGNOSTIC LARYNGOSCOPY 546.21 468.15 31579 DIAGNOSTIC LARYNGOSCOPY1,147.30 983.35 31600 INCISE WINDPIPE 6,964.52 5,969.29 31605 INCISE WINDPIPE 2,150.53 1,843.22 31622 DIAG BRONCHOSCOPE/WASH2,851.45 2,443.97 31624 DIAG BRONCHOSCOPE/LAVAGE2,851.45 2,443.97 31645 BRONCHOSCOPY, CLEAR AIRWAYS 2,851.45 2,443.97 31646 BRONCHOSCOPY, RECLEAR AIRWAY 2,851.45 2,443.97

11:3-29.6 APPENDIX B - REGULATIONS 32405 BIOPSY LUNG OR MEDIASTINUM 2,643.63 2,265.85 32551 INSERT CHEST TUBE 1,510.65 1,294.77 32601 THORACOSCOPY, DIAGNOSTIC 9,461.41 8,109.37 33210 INSERT HEART ELECTRODE 9,299.39 8,275.58 33212 INSERT PULSE GENERATOR 12,451.20 11,516.42 36000 PLACE NEEDLE IN VEIN N1 36005 INJECTION EXT VENOGRAPHY N1 36010 PLACE CATHETER IN VEIN N1 36011 PLACE CATHETER IN VEIN N1 36013 PLACE CATHETER IN ARTERY N1 36014 PLACE CATHETER IN ARTERY N1 36140 ESTABLISH ACCESS TO ARTERY N1 36200 PLACE CATHETER IN AORTA N1 36215 PLACE CATHETER IN ARTERY N1 36216 PLACE CATHETER IN ARTERY N1 36217 PLACE CATHETER IN ARTERY N1 36218 PLACE CATHETER IN ARTERY N1 36245 PLACE CATHETER IN ARTERY N1 36246 PLACE CATHETER IN ARTERY N1 36247 PLACE CATHETER IN ARTERY N1 36248 PLACE CATHETER IN ARTERY N1 36400 BLOOD DRAW < 3 YRS FEM/JUGULAR N1 36406 BLOOD DRAW < 3 YRS OTHER VEIN N1 36410 NON-ROUTINE BL DRAW > 3 YRS N1 36425 VEIN ACCESS CUTDOWN > 1 YR 72.62 62.24 AS 36430 BLOOD TRANSFUSION SERVICE 921.03 789.41 X 36471 INJECTION THERAPY VEINS 247.20 211.88 36513 APHERESIS PLATELETS 3,363.75 2,883.07 X 36514 APHERESIS PLASMA 3,363.75 2,883.07 X 36515 APHERESIS, ADSORP/REINFUSE 8,540.97 7,320.46 X 36555 INSERT NON-TUNNEL CV CATH 3,087.37 2,646.18 36556 INSERT NON-TUNNEL CV CATH 3,087.37 2,646.18 36558 INSERT TUNNELED CV CATH 5,241.41 4,907.68 36569 INSERT PICC CATH 3,087.37 2,646.18 36571 INSERT PICVAD CATH 5,241.41 4,907.68 36576 REPAIR TUNNELED CV CATH 3,087.37 2,646.18 36578 REPLACE TUNNELED CV CATH 5,241.41 4,907.68 36580 REPLACE CVAD CATH 3,087.37 2,646.18 36584 REPLACE PICC CATH 3,087.37 2,646.18 36589 REMOVE TUNNELED CV CATH 1,718.86 1,473.23 36592 COLLECT BLOOD PICC 171.82 147.27 36593 DECLOT VASCULAR DEVICE 637.44 546.35 36598 INJECT W/FLUOR, EVAL CV DEVICE 637.44 546.35 36600 WITHDRAW ARTERIAL BLOOD 72.62 62.24

MEDICAL FEE SCHEDULES 11:3-29.6 36620 INSERT CATHETER, ARTERY N1 36625 INSERT CATHETER, ARTERY N1 36800 INSERT CANNULA 8,505.69 7,354.12 36810 INSERT CANNULA 8,505.69 7,354.12 36815 INSERT CANNULA 8,505.69 7,354.12 36818 AV FUSE, UPPER ARM, CEPHALIC 11,329.30 9,710.33 36833 AV FISTULA REVISION 11,329.30 9,710.33 36860 EXTERNAL CANNULA DECLOTTING 637.44 546.35 37204 TRANSCATHETER OCCLUSION 19,232.98 16,856.39 37609 TEMPORAL ARTERY PROCEDURE 4,909.21 4,207.68 37620 REVISE MAJOR VEIN 11,946.47 10,239.31 37650 REVISE MAJOR VEIN 7,454.87 6,389.56 38200 INJECTION FOR SPLEEN X-RAY N1 43235 UPPER GI ENDOSCOPY, DIAGNOSIS 2,411.81 2,067.16 43236 UPPER GI SCOPE W/SUBMUCOSA INJECT 2,411.81 2,067.16 43239 UPPER GI ENDOSCOPY, BIOPSY 2,411.81 2,067.16 43246 PLACE GASTROSTOMY TUBE 2,411.81 2,067.16 43248 UPPER GI ENDOSCOPY/GUIDE WIRE 2,411.81 2,067.16 43249 ESOPH ENDOSCOPY, DILATION 2,411.81 2,067.16 43255 OPERATIVE UPPER GI ENDOSCOPY 2,411.81 2,067.16 43259 ENDOSCOPIC ULTRASOUND EXAM 2,411.81 2,067.16 43260 ENDO CHOLANGIOPANCRE- ATOGRAPHY 6,309.66 5,408.00 43450 DILATE ESOPHAGUS 1,782.37 1,527.67 43760 CHANGE GASTROSTOMY TUBE 637.44 546.35 43830 PLACE GASTROSTOMY TUBE 4,529.06 3,881.86 44500 INTRODUCE GASTROINTESTINAL TUBE 1,718.86 1,473.23 46040 INCISE RECTAL ABSCESS 6,610.91 5,666.21 46600 DIAGNOSTIC ANOSCOPY 182.27 156.22 AS 47000 NEEDLE BIOPSY LIVER 2,643.63 2,265.85 49080 PUNCTURE, PERITONEAL CAVITY 1,510.65 1,294.77 49320 DIAG LAP SEPARATE PROC 10,495.79 8,995.94 49421 INSERT ABDOM DRAIN, PERM 7,481.94 6,471.31 49505 PART RPR I/HERNIA INIT REDUCE >5 YR 8,982.66 7,699.03 50392 INSERT KIDNEY DRAIN 4,772.16 4,090.22 50394 INJECTION FOR KIDNEY X-RAY N1 51600 INJECTION FOR BLADDER X-RAY N1 51610 INJECTION FOR BLADDER X-RAY N1 51700 IRRIGATION BLADDER 553.11 474.07 51701 INSERT BLADDER CATHETER 182.27 156.22 AS

11:3-29.6 APPENDIX B - REGULATIONS 51702 INSERT TEMP BLADDER CATH 182.27 156.22 AS 51703 INSERT BLADDER CATH, COMPLEX 301.69 258.58 51705 CHANGE BLADDER TUBE 553.11 474.07 51720 TREAT BLADDER LESION 872.10 747.48 51725 SIMPLE CYSTOMETROGRAM 872.10 747.48 51726 COMPLEX CYSTOMETROGRAM 872.10 747.48 51741 ELECTRO-UROFLOWMETRY, FIRST 301.69 258.58 51784 ANAL/URINARY MUSCLE STUDY 301.69 258.58 51797 INTRAABDOMINAL PRESSURE TEST 553.11 474.07 51798 US URINE CAPACITY MEASURE 182.27 156.22 AS 52000 CYSTOSCOPY 2,020.50 1,731.77 52005 CYSTOSCOPY & URETER CATHETER 7,150.85 6,128.99 52204 CYSTOSCOPY W/BIOPSY(S) 7,150.85 6,128.99 52281 CYSTOSCOPY & TREAT 4,772.16 4,090.22 52310 CYSTOSCOPY & TREAT 4,772.16 4,090.22 52332 CYSTOSCOPY & TREAT 7,150.85 6,128.99 52351 CYSTOURETERO & OR PYELOSCOPE 7,150.85 6,128.99 53600 DILATE URETHRA STRICTURE 874.07 749.17 53601 DILATE URETHRA STRICTURE 301.69 258.58 53660 DILATE URETHRA 301.69 258.58 53661 DILATE URETHRA 301.69 258.58 54235 PENILE INJECTION 872.10 747.48 57452 EXAM CERVIX W/SCOPE 443.98 380.53 57500 BIOPSY CERVIX 1,783.00 1,528.21 57511 CRYOCAUTERY CERVIX 443.98 380.53 58340 CATHETER FOR HYSTERORRHAPHY N1 58558 HYSTEROSCOPY, BIOPSY 6,268.18 5,372.45 59000 AMNIOCENTESIS, DIAGNOSTIC 983.13 842.64 59025 FETAL NON-STRESS TEST 443.98 380.53 59841 ABORTION 5,615.09 4,812.69 61790 TREAT TRIGEMINAL NERVE 5,195.44 4,453.01 62263 EPIDURAL LYSIS MULT SESSIONS 2,060.68 1,766.21 62264 EPIDURAL LYSIS ON SINGLE DAY 3,474.53 2,978.02 62270 SPINAL FLUID TAP, DIAGNOSTIC 1,054.25 903.60 62273 INJECT EPIDURAL PATCH 2,060.68 1,766.21 62280 TREAT SPINAL CORD L ESION 2,060.68 1,766.21 62281 TREAT SPINAL CORD LESION 2,060.68 1,766.21 62282 TREAT SPINAL CANAL LESION 2,060.68 1,766.21 62284 INJECTION FOR MYELOGRAM N1 62287 PERCUTANEOUS DISKECTOMY 10,121.96 8,675.52 62290 INJECT FOR SPINE DISK

MEDICAL FEE SCHEDULES 11:3-29.6 X-RAY N1 62291 INJECT FOR SPINE DISK X-RAY N1 62292 INJECTION INTO DISK LESION 2,060.68 1,766.21 62310 INJECT SPINE C/T 2,060.68 1,766.21 62311 INJECT SPINE L/S (CD) 2,060.68 1,766.21 62318 INJECT SPINE W/CATH, C/T 2,060.68 1,766.21 62319 INJECT SPINE W/CATH L/S (CD) 3,474.53 2,978.02 62350 IMPLANT SPINAL CANAL CATH 11,382.48 9,755.92 62355 REMOVE SPINAL CANAL CATHETER 3,474.53 2,978.02 62360 INSERT SPINE INFUSION DEVICE 11,382.48 9,755.92 62362 IMPLANT SPINE INFUSION PUMP 22,227.97 20,941.63 62365 REMOVE SPINE INFUSION DEVICE 10,121.96 8,675.52 62367 ANALYZE SPINE INFUSION PUMP 657.70 563.72 X 62368 ANALYZE SPINE INFUSION PUMP 657.70 563.72 X 63020 NECK SPINE DISK SURG 13,940.72 11,948.58 63030 LOW BACK DISK SURG 13,940.72 11,948.58 63035 SPINAL DISK SURG, ADDED 13,940.72 11,948.58 63040 LAMINOTOMY, SINGLE CERV 13,940.72 11,948.58 63042 LAMINOTOMY, SINGLE LUMBAR 13,940.72 11,948.58 63045 REMOVE SPINAL LAMINA 13,940.72 11,948.58 63046 REMOVE SPINAL LAMINA 13,940.72 11,948.58 63047 REMOVE SPINAL LAMINA 13,940.72 11,948.58 63048 REMOVE SPINAL LAMINA, ADDED 13,940.72 11,948.58 63056 DECOMPRESS SPINAL CORD13,940.72 11,948.58 63057 DECOMPRESS SPINE CORD, ADDED 13,940.72 11,948.58 63075 NECK SPINE DISK SURG 13,940.72 11,948.58 63076 NECK SPINE DISK SURG 13,940.72 11,948.58 63650 IMPLANT NEUROELECTRODES 17,950.74 9,545.51 X 63655 IMPLANT NEUROELECTRODES 13,352.79 12,138.59 X 63685 INSERT/REDO SPINE N GENERATOR 23,191.56 22,061.87 X 63688 REVISE/REMOVE NEURORECEIVER 7,898.33 6,769.65 64400 NERVE BLOCK INJ, TRIGEMINAL 724.57 621.03 64402 NERVE BLOCK INJ, FACIAL 724.57 621.03 64405 NERVE BLOCK INJ, OCCIPITAL1,054.25 903.60 64412 NERVE BLOCK INJ, SPINAL ACCESSORY 2,060.68 1,766.21 64413 NERVE BLOCK INJ, CERV PLEXUS 1,054.25 903.60 64415 NERVE BLOCK INJ, BRACHIAL PLEXUS 1,054.25 903.60 64416 NERVE BLOCK CONT INFUSE, B PLEX 2,060.68 1,766.21 64417 NERVE BLOCK INJ,

11:3-29.6 APPENDIX B - REGULATIONS AXILLARY 1,054.25 903.60 64418 NERVE BLOCK INJ, SUPRASCAPULAR 1,054.25 903.60 64420 NERVE BLOCK INJ, INTERCOSTAL, SING 1,054.25 903.60 64421 NERVE BLOCK INJ, INTERCOSTAL, MULT 2,060.68 1,766.21 64425 NERVE BLOCK INJ, ILIO-ING/HYPOGI 1,054.25 903.60 64430 NERVE BLOCK INJ, PUDENDAL 2,060.68 1,766.21 64435 NERVE BLOCK INJ, PARACERV 1,054.25 903.60 64445 NERVE BLOCK INJ, SCIATIC, SING 2,060.68 1,766.21 64446 NERVE BLOCK INJ, SCIATIC, CONT INF 2,060.68 1,766.21 64447 NERVE BLOCK INJ, FEM, SING1,054.25 903.60 64448 NERVE BLOCK INJ, FEM, CONT INF 2,060.68 1,766.21 64449 NERVE BLOCK INJ, LUMBAR PLEXUS 2,060.68 1,766.21 64450 NERVE BLOCK, OTHER PERIPHERAL 1,054.25 903.60 64455 NERVE BLOCK INJ, PLANTAR DIGIT 724.57 621.03 64479 INJECT FORAMEN EPIDURAL C/T 2,060.68 1,766.21 64480 INJECT FORAMEN EPIDURAL, ADDED 1,054.25 903.60 64483 INJECT FORAMEN EPIDURAL L/S 2,060.68 1,766.21 64484 INJECT FORAMEN EPIDURAL, ADDED 1,054.25 903.60 64490 INJECT PARAVERT F JNT C/T 1 LEV 2,060.68 1,766.21 64491 INJECT PARAVERT F JNT C/T 2 LEV 724.57 621.03 64492 INJECT PARAVERT F JNT C/T 3 LEV 724.57 621.03 64493 INJECT PARAVERT F JNT L/S 1 LEV 2,060.68 1,766.21 64494 INJECT PARAVERT F JNT L/S 2 LEV 724.57 621.03 64495 INJECT PARAVERT F JNT L/S 3 LEV 724.57 621.03 64505 NERVE BLOCK SPHENOPALATINE GANGLIA 724.57 621.03 64510 NERVE BLOCK STELLATE GANGLION 2,060.68 1,766.21 64517 NERVE BLOCK INJ, HYPOGAS PLXS 2,060.68 1,766.21 64520 NERVE BLOCK LUMBAR/THORACIC 2,060.68 1,766.21 64555 IMPLANT NEUROELECTRODES 10,600.82 9,545.51 X 64561 IMPLANT NEUROELECTRODES 10,600.82 9,545.51 X 64565 IMPLANT NEUROELECTRODES 10,600.82 9,545.51 X 64600 INJECTION TREAT NERVE 3,474.53 2,978.02 64605 INJECTION TREAT NERVE 5,195.44 4,453.01

MEDICAL FEE SCHEDULES 11:3-29.6 64610 INJECTION TREAT NERVE 5,195.44 4,453.01 64612 DESTROY NERVE, FACE MUSCLE 724.57 621.03 64613 DESTROY NERVE, NECK MUSCLE 1,054.25 903.60 64614 DESTROY NERVE, EXTREMITY MUSC 1,054.25 903.60 64620 INJECTION TREAT NERVE 2,060.68 1,766.21 64622 DESTROY PARAVERTEBRAL NERVE L/S 3,474.53 2,978.02 64623 DESTROY PARAVERT NERVE, ADDED 2,060.68 1,766.21 64626 DESTROY PARAVERTEBRAL NERVE C/T 2,060.68 1,766.21 64627 DESTROY PARAVERT NERVE, ADDED 724.57 621.03 64640 INJECTION TREAT NERVE 2,060.68 1,766.21 64680 INJECTION TREAT NERVE 2,060.68 1,766.21 64702 REVISE FINGER/TOE NERVE 5,195.44 4,453.01 64704 REVISE HAND/FOOT NERVE 5,195.44 4,453.01 64708 REVISE ARM/LEG NERVE 5,195.44 4,453.01 64712 REVISE SCIATIC NERVE 5,195.44 4,453.01 64713 REVISE ARM NERVE(S) 5,195.44 4,453.01 64714 REVISE LOW BACK NERVE(S) 5,195.44 4,453.01 64716 REVISE CRANIAL NERVE 5,195.44 4,453.01 64718 REVISE ULNAR NERVE AT ELBOW 5,195.44 4,453.01 64719 REVISE ULNAR NERVE AT WRIST 5,195.44 4,453.01 64721 CARPAL TUNNEL SURG 5,195.44 4,453.01 65205 REMOVE FOREIGN BODY EYE 263.33 225.70 X 65210 REMOVE FOREIGN BODY EYE 263.33 225.70 X 65220 REMOVE FOREIGN BODY EYE 263.33 225.70 X 65222 REMOVE FOREIGN BODY EYE 263.33 225.70 X 65265 REMOVE FOREIGN BODY EYE6,362.61 5,453.39 67412 EXPLORE/TREAT EYE SOCKET 5,433.49 4,657.04 69210 REMOVE IMPACTED EAR WAX 182.27 156.22 AS 69310 REBUILD OUTER EAR CANAL 12,135.56 10,401.38 69320 REBUILD OUTER EAR CANAL 12,135.56 10,401.38 69666 REPAIR MIDDLE EAR STRUCTURES 12,135.56 10,401.38 69667 REPAIR MIDDLE EAR STRUCTURES 12,135.56 10,401.38 69990 MICROSURG, ADDED N1 70030 X-RAY EYE FOR FOREIGN BODY 177.57 152.20 AS 70100 X-RAY JAW < 4 VIEWS 177.57 152.20 AS 70110 X-RAY JAW MINIMUM 4 VIEWS 177.57 152.20 AS 70120 X-RAY MASTOIDS < 3 VIEWS/SIDE 177.57 152.20 AS 70130 X-RAY MASTOIDS MINIMUM 3 VIEWS/SIDE 177.57 152.20 AS 70140 X-RAY FACIAL BONES < 3 VIEWS 177.57 152.20 AS 70150 X-RAY FACIAL BONES MINIMUM 3 VIEWS 177.57 152.20 AS 70160 X-RAY NASAL BONES

11:3-29.6 APPENDIX B - REGULATIONS MINIMUM 3 VIEWS 177.57 152.20 AS 70190 X-RAY OPTIC FORAMINA 177.57 152.20 AS 70200 X-RAY ORBITS, MINIMUM 4 VIEWS 177.57 152.20 AS 70210 X-RAY SINUSES < 3 VIEWS 177.57 152.20 AS 70220 X-RAY SINUSES MINIMUM 3 VIEWS 177.57 152.20 AS 70250 X-RAY SKULL < 4 VIEWS 177.57 152.20 AS 70260 X-RAY SKULL MINIMUM 4 VIEWS 299.09 256.35 AS 70300 X-RAY TEETH SINGLE VIEW 120.17 103.00 AS 70310 X-RAY TEETH < FULL MOUTH 120.17 103.00 AS 70320 X-RAY TEETH FULL MOUTH 120.17 103.00 AS 70328 X-RAY TMJ UNILATERAL 177.57 152.20 AS 70330 X-RAY TMJ BILATERAL 177.57 152.20 AS 70332 TMJ ARTHOGRAPHY; RAD SUPER & INTERP 1,084.37 929.42 70336 MRI TMJ 1,352.04 1,158.83 70350 CEPHALOGRAM, ORTHODONTIC 177.57 152.20 AS 70355 ORTHOPANTOGRAM 120.17 103.00 AS 70360 X-RAY NECK SOFT TISSUE 177.57 152.20 AS 70450 CT HEAD/BRAIN W/O DYE 764.27 655.06 70460 CT HEAD/BRAIN W/DYE 1,182.03 1,013.12 70470 CT HEAD/BRAIN W/O & W/DYE 1,317.77 1,129.46 70480 CT ORBIT/EAR/FOSSA W/O DYE 764.27 655.06 70481 CT ORBIT/EAR/FOSSA W/DYE 1,182.03 1,013.12 70482 CT ORBIT/EAR/FOSSA W/O & W/DYE 1,317.77 1,129.46 70486 CT MAXILLOFACIAL W/O DYE 764.27 655.06 70487 CT MAXILLOFACIAL W/DYE 1,182.03 1,013.12 70488 CT MAXILLOFACIAL W/O & W/DYE 1,317.77 1,129.46 70490 CT SOFT TISSUE NECK W/O DYE 764.27 655.06 70491 CT SOFT TISSUE NECK W/DYE 1,182.03 1,013.12 70492 CT SOFT TISSUE NECK W/O & W/DYE 1,317.77 1,129.46 70496 CT ANGIOGRAPHY, HEAD 1,334.69 1,143.96 70498 CT ANGIOGRAPHY, NECK 1,334.69 1,143.96 70540 MRI ORBIT/FACE/NECK W/O DYE 1,352.04 1,158.83 70542 MRI ORBIT/FACE/NECK W/DYE 1,722.84 1,476.64 70543 MRI ORBIT/FACE/NECK W/O & W/DYE 2,103.77 1,803.14 70544 MR ANGIOGRAPHY HEAD W/O DYE 1,352.04 1,158.83 70545 MR ANGIOGRAPHY HEAD W/DYE 1,722.84 1,476.64 70546 MR ANGIOGRAPH HEAD W/O & W/DYE 2,103.77 1,803.14 70547 MR ANGIOGRAPHY NECK W/O DYE 1,352.04 1,158.83 70548 MR ANGIOGRAPHY NECK W/DYE 1,722.84 1,476.64 70549 MR ANGIOGRAPH NECK W/O & W/DYE 2,103.77 1,803.14

MEDICAL FEE SCHEDULES 11:3-29.6 70551 MRI BRAIN W/O DYE 1,352.04 1,158.83 70552 MRI BRAIN W/DYE 1,722.84 1,476.64 70553 MRI BRAIN W/O & W/DYE 2,103.77 1,803.14 70554 FMRI BRAIN BY TECH 1,352.04 1,158.83 70555 FMRI BRAIN BY PHYS/PSYCH 1,352.04 1,158.83 X 71010 CHEST X-RAY SINGLE VIEW FRONTAL 177.57 152.20 71020 CHEST X-RAY 2 VIEWS FRONTAL & LATERAL 177.57 152.20 71021 CHEST X-RAY 2 VIEWS W/APICAL LORD PROC 177.57 152.20 AS 71022 CHEST X-RAY 2 VIEWS W/OBLIQUE PROJ 177.57 152.20 AS 71030 CHEST X-RAY MINIMUM 4 VIEWS 177.57 152.20 AS 71035 CHEST X-RAY SPECIAL VIEWS 177.57 152.20 AS 71040 CONTRAST X-RAY BRONCHI UNILATERAL 906.64 777.08 71090 X-RAY & PACEMAKER INSERT N1 71100 X-RAY RIBS 2 VIEWS 177.57 152.20 AS 71101 X-RAY RIBS/CHEST MINIMUM 3 VIEWS 177.57 152.20 AS 71110 X-RAY RIBS BILATERAL 3 VIEWS 177.57 152.20 AS 71111 X-RAY RIBS/CHEST MINIMUM 4 VIEWS 299.09 256.35 AS 71120 X-RAY STERNUM MINIMUM 2 VIEWS 177.57 152.20 AS 71130 X-RAY STERNOCLAV JOINT MINIMUM 3 VIEWS 177.57 152.20 AS 71250 CT THORAX W/O DYE 764.27 655.06 71260 CT THORAX W/DYE 1,182.03 1,013.12 71270 CT THORAX W/O & W/DYE 1,317.77 1,129.46 71275 CT ANGIOGRAPHY, CHEST 1,334.69 1,143.96 71550 MRI CHEST W/O DYE 1,352.04 1,158.83 71552 MRI CHEST W/O & W/DYE 2,103.77 1,803.14 72010 X-RAY SPINE ANTEROPOST & LATERAL 299.09 256.35 AS 72020 X-RAY SPINE SINGLE VIEW SPECIFY LEVEL 177.57 152.20 AS 72040 X-RAY NECK SPINE CERV 2/3 VIEWS 177.57 152.20 AS 72050 X-RAY NECK SPINE CERV MINIMUM 4 VIEWS 299.09 256.35 AS 72052 X-RAY NECK SPINE COMPLETE 299.09 256.35 AS 72069 X-RAY TRUNK SPINE STANDING 177.57 152.20 AS 72070 X-RAY THORACIC SPINE 2 VIEWS 177.57 152.20 AS 72072 X-RAY THORACIC SPINE 3 VIEWS 177.57 152.20 AS 72074 X-RAY THORACIC SPINE MINIMUM 4 VIEWS 177.57 152.20 AS 72080 X-RAY TRUNK SPINE 2 VIEWS 177.57 152.20 AS 72090 X-RAY TRUNK SPINE SCOLIOSIS STUDY 299.09 256.35 AS 72100 X-RAY LOWER SPINE 2/3 VIEWS 177.57 152.20 AS 72110 X-RAY LOWER SPINE MINIMUM 4 VIEWS 299.09 256.35 AS 72114 X-RAY LOWER SPINE

11:3-29.6 APPENDIX B - REGULATIONS COMPLETE 299.09 256.35 AS 72120 X-RAY LOWER SPINE BENDING MINIMUM 4 VIEWS 177.57 152.20 AS 72125 CT NECK SPINE W/O DYE 764.27 655.06 72126 CT NECK SPINE W/DYE 1,182.03 1,013.12 72127 CT NECK SPINE W/O & W/DYE 1,317.77 1,129.46 72128 CT CHEST SPINE W/O DYE 764.27 655.06 72129 CT CHEST SPINE W/DYE 1,182.03 1,013.12 72130 CT CHEST SPINE W/O & W/DYE 1,317.77 1,129.46 72131 CT LUMBAR SPINE W/O DYE 764.27 655.06 72132 CT LUMBAR SPINE W/DYE 1,182.03 1,013.12 72133 CT LUMBAR SPINE W/O & W/DYE 1,317.77 1,129.46 72141 MRI NECK SPINE W/O DYE 1,352.04 1,158.83 72142 MRI NECK SPINE W/DYE 1,722.84 1,476.64 72146 MRI CHEST SPINE W/O DYE 1,352.04 1,158.83 72147 MRI CHEST SPINE W/DYE 1,722.84 1,476.64 72148 MRI LUMBAR SPINE W/O DYE 1,352.04 1,158.83 72149 MRI LUMBAR SPINE W/DYE 1,722.84 1,476.64 72156 MRI NECK SPINE W/O & W/DYE 2,103.77 1,803.14 72157 MRI CHEST SPINE W/O & W/DYE 2,103.77 1,803.14 72158 MRI LUMBAR SPINE W/O & W/DYE 2,103.77 1,803.14 72170 X-RAY PELVIS 1/2 VIEWS 177.57 152.20 AS 72190 X-RAY PELVIS MINIMUM 3 VIEWS 177.57 152.20 AS 72191 CT ANGIOGRAPH PELVIS W/O & W/DYE 1,334.69 1,143.96 72192 CT PELVIS W/O DYE 764.27 655.06 72193 CT PELVIS W/DYE 1,182.03 1,013.12 72194 CT PELVIS W/O & W/DYE 1,317.77 1,129.46 72195 MRI PELVIS W/O DYE 1,352.04 1,158.83 72196 MRI PELVIS W/DYE 1,722.84 1,476.64 72197 MRI PELVIS W/O & W/DYE 2,103.77 1,803.14 72200 X-RAY EXAM SACROILIAC JOINTS 177.57 152.20 AS 72202 X-RAY EXAM SACROILIAC JOINTS 177.57 152.20 AS 72220 X-RAY TAILBONE 177.57 152.20 AS 72240 CONTRAST X-RAY NECK SPINE 1,967.75 1,686.56 72255 CONTRAST X-RAY THORAX SPINE 1,967.75 1,686.56 72265 CONTRAST X-RAY LOWER SPINE 1,967.75 1,686.56 72270 CONTRAST X-RAY SPINE 1,967.75 1,686.56 72275 EPIDUROGRAPHY N1 72285 X-RAY C/T SPINE DISK 6,593.09 5,650.93 72291 PERCUT VERT/SACROPLASTY, FLUOR N1 72295 X-RAY LOWER SPINE DISK 6,593.09 5,650.93 73000 X-RAY COLLAR BONE 177.57 152.20 AS 73010 X-RAY SHOULDER BLADE 177.57 152.20 AS 73020 X-RAY SHOULDER 1 VIEW 177.57 152.20 AS 73030 X-RAY SHOULDER MINIMUM 2 VIEWS 177.57 152.20 AS 73040 CONTRAST X-RAY

MEDICAL FEE SCHEDULES 11:3-29.6 SHOULDER 1,084.37 929.42 73050 X-RAY SHOULDERS 177.57 152.20 AS 73060 X-RAY HUMERUS MINIMUM 2 VIEWS 177.57 152.20 AS 73070 X-RAY ELBOW 2 VIEWS 177.57 152.20 AS 73080 X-RAY ELBOW MINIMUM 3 VIEWS 177.57 152.20 AS 73090 X-RAY FOREARM 177.57 152.20 AS 73092 X-RAY ARM, INFANT 177.57 152.20 AS 73100 X-RAY WRIST 2 VIEWS 177.57 152.20 AS 73110 X-RAY WRIST MINIMUM 3 VIEWS 177.57 152.20 AS 73115 CONTRAST X-RAY WRIST 1,084.37 929.42 73120 X-RAY HAND 2 VIEWS 177.57 152.20 AS 73130 X-RAY HAND MINIMUM 3 VIEWS 177.57 152.20 AS 73140 X-RAY FINGER(S) MINIMUM 2 VIEWS 177.57 152.20 AS 73200 CT UPPER EXTREMITY W/O DYE 764.27 655.06 73201 CT UPPER EXTREMITY W/DYE 1,182.03 1,013.12 73202 CT UPPER EXTREMITY W/O & W/DYE 1,317.77 1,129.46 73206 CT ANGIO UPR EXTREMITY W/O & W/DYE 1,334.69 1,143.96 73218 MRI UPPER EXTREMITY W/O DYE 1,352.04 1,158.83 73219 MRI UPPER EXTREMITY W/DYE 1,722.84 1,476.64 73220 MRI UPPER EXTREMITY W/O & W/DYE 2,103.77 1,803.14 73221 MRI JOINT UPPER EXTREMITY W/O DYE 1,352.04 1,158.83 73222 MRI JOINT UPPER EXTREMITY W/DYE 1,722.84 1,476.64 73223 MRI JOINT UPPER EXTREMITY W/O & W/DYE 2,103.77 1,803.14 73500 X-RAY HIP UNILATERAL 1 VIEW 177.57 152.20 AS 73510 X-RAY HIP COMPLETE MINIMUM 2 VIEWS 177.57 152.20 AS 73520 X-RAY HIPS MINIMUM 2 VIEWS 177.57 152.20 AS 73525 X-RAY HIP ARTHROGRAPHY 1,084.37 929.42 73530 X-RAY HIP DURING OPERATIVE PROCEDURE N1 73540 X-RAY PELVIS & HIPS MINIMUM 2 VIEWS 177.57 152.20 AS 73542 X-RAY EXAM, SACROILIAC JOINT 1,084.37 929.42 73550 X-RAY THIGH 2 VIEWS 177.57 152.20 AS 73560 X-RAY KNEE 1/2 VIEWS 177.57 152.20 AS 73562 X-RAY KNEE 3 VIEWS 177.57 152.20 AS 73564 X-RAY KNEE, COMPLETE 4/MORE VIEWS 177.57 152.20 AS 73565 X-RAY KNEES STANDING ANTEROPOST 177.57 152.20 AS 73580 X-RAY KNEE ARTHOGRAPHY 1,084.37 929.42 73590 X-RAY TIBIA & FIBULA 2 VIEWS 177.57 152.20 AS 73592 X-RAY LEG, INFANT MINIMUM

11:3-29.6 APPENDIX B - REGULATIONS 2 VIEWS 177.57 152.20 AS 73600 X-RAY ANKLE 2 VIEWS 177.57 152.20 AS 73610 X-RAY ANKLE MINIMUM 3 VIEWS 177.57 152.20 AS 73615 CONTRAST X-RAY ANKLE 1,084.37 929.42 73620 X-RAY FOOT 2 VIEWS 177.57 152.20 AS 73630 X-RAY FOOT MINIMUM 3 VIEWS 177.57 152.20 AS 73650 X-RAY HEEL 177.57 152.20 AS 73660 X-RAY TOE(S) 177.57 152.20 AS 73700 CT LOWER EXTREMITY W/O DYE 764.27 655.06 73701 CT LOWER EXTREMITY W/DYE 1,182.03 1,013.12 73706 CT ANGIO LWR EXTREMITY W/O & W/DYE 1,334.69 1,143.96 73718 MRI LOWER EXTREMITY W/O DYE 1,352.04 1,158.83 73719 MRI LOWER EXTREMITY W/DYE 1,722.84 1,476.64 73720 MRI LOWER EXTREMITY W/O & W/DYE 2,103.77 1,803.14 73721 MRI JOINT LOWER EXTREMITY W/O DYE 1,352.04 1,158.83 73722 MRI JOINT LOWER EXTREMITY W/DYE 1,722.84 1,476.64 73723 MRI JOINT LWR EXTREMITY W/O & W/DYE 2,103.77 1,803.14 74000 X-RAY ABDOMEN SINGLE ANTEROPOST 177.57 152.20 AS 74010 X-RAY ABDOMEN ANTEROPOST & ADDED VW 177.57 152.20 AS 74020 X-RAY ABDOMEN COMPLETE 177.57 152.20 AS 74022 X-RAY EXAM SERIES, ABDOMEN 299.09 256.35 AS 74150 CT ABDOMEN W/O DYE 764.27 655.06 74160 CT ABDOMEN W/DYE 1,182.03 1,013.12 74170 CT ABDOMEN W/O & W/DYE 1,317.77 1,129.46 74175 CT ANGIO ABDOM W/O & W/DYE 1,334.69 1,143.96 74176 CT ANGIO ABDOM & PELVIS 764.27 655.06 74177 CT ANGIO ABDOM & PELVIS W/CONTRAST 1,182.03 1,013.12 74178 CT ANGIO ABDOM & PELVIS 1+ REGNS 1,317.77 1,129.46 74181 MRI ABDOMEN W/O DYE 1,352.04 1,158.83 74183 MRI ABDOMEN W/O & W/DYE2,103.77 1,803.14 74220 CONTRAST X-RAY, ESOPHAGUS 341.90 293.04 X 74230 CINE/VIDEO X-RAY, THROAT/ESOPH 341.90 293.04 X 74241 X-RAY EXAM, UPPER GI TRACT W/KUB 341.90 293.04 X 74246 CONTRAST X-RAY UGI TRACT W/O KUB 341.90 293.04 X 74280 CONTRAST X-RAY COLON W/WO GLUCOGEN 559.77 479.78 X 74290 CONTRAST X-RAY, GALLBLADDER 341.90 293.04 X 74330 X-RAY BILE/PANCREAS ENDOSCOPY N1 74400 CONTRAST X-RAY URINARY

MEDICAL FEE SCHEDULES 11:3-29.6 TRACT 694.37 595.14 X 74410 CONTRAST X-RAY URINARY TRACT 694.37 595.14 X 74415 CONTRAST X-RAY URINARY TRACT 694.37 595.14 X 74420 CONTRAST X-RAY URINARY TRACT 694.37 595.14 X 74425 CONTRAST X-RAY URINARY TRACT 694.37 595.14 74430 CONTRAST X-RAY BLADDER 694.37 595.14 74450 X-RAY URETHRA/BLADDER 694.37 595.14 74455 X-RAY URETHRA/BLADDER 694.37 595.14 74475 X-RAY CONTROL, CATH INSERT 4,772.16 4,090.22 74480 X-RAY CONTROL, CATH INSERT 4,772.16 4,090.22 74485 X-RAY GUIDE, GU DILATION 4,772.16 4,090.22 75561 CARDIAC MRI FOR MORPH W/DYE 2,103.77 1,803.14 75572 CT HEART W/3D IMAGE 1,012.70 867.98 X 75574 CT ANGIO HEART W/3D IMAGE 1,012.70 867.98 X 75605 CONTRAST X-RAY AORTA 7,990.03 6,848.25 75625 CONTRAST X-RAY AORTA 7,990.03 6,848.25 75630 X-RAY AORTA, LEG ARTERIES 7,990.03 6,848.25 75635 CT ANGIO ABDOMINAL ARTERIES 1,334.69 1,143.96 75650 ARTERY X-RAYS HEAD & NECK 12,970.25 11,116.79 75665 ARTERY X-RAYS HEAD & NECK 7,990.03 6,848.25 75671 ARTERY X-RAYS HEAD & NECK 12,970.25 11,116.79 75676 ARTERY X-RAYS NECK UNILATERAL 7,990.03 6,848.25 75680 ARTERY X-RAYS NECK BILATERAL 7,990.03 6,848.25 75685 ARTERY X-RAYS SPINE 7,990.03 6,848.25 75705 ARTERY X-RAYS SPINE 7,990.03 6,848.25 75710 ARTERY X-RAYS ARM/LEG 7,990.03 6,848.25 75716 ARTERY X-RAYS ARMS/LEGS 7,990.03 6,848.25 75722 ARTERY X-RAYS KIDNEY 7,990.03 6,848.25 75724 ARTERY X-RAYS KIDNEYS 7,990.03 6,848.25 75726 ARTERY X-RAYS ABDOMEN 7,990.03 6,848.25 75736 ARTERY X-RAYS PELVIS 7,990.03 6,848.25 75743 ARTERY X-RAYS LUNGS 7,990.03 6,848.25 75774 ARTERY X-RAY, EACH VESSEL N1 75809 NONVASCULAR SHUNT, X-RAY 299.09 256.35 75820 VEIN X-RAY ARM/LEG 2,833.55 2,428.63 75822 VEIN X-RAY ARMS/LEGS 2,833.55 2,428.63 75825 VEIN X-RAY TRUNK 7,990.03 6,848.25 75894 X-RAYS, TRANSCATH THERAPY N1 75898 F/U ANGIOGRAPHY 299.09 256.35 75940 X-RAY PLACE VEIN FILTER N1 75960 TRANSCATH IV STENT RS & I N1 75961 RETRIEVE BROKEN CATHETER N1 75962 REPAIR ARTERIAL BLOCKAGE12,095.18 10,542.37 75964 REPAIR ARTERY BLOCKAGE, EACH N1 75978 REPAIR VENOUS BLOCKAGE 8,317.24 7,228.17 75984 X-RAY CONTROL CATHETER CHANGE N1

11:3-29.6 APPENDIX B - REGULATIONS 75989 ABSCESS DRAIN UNDER X-RAY N1 76000 FLUOROSCOPE EXAM 329.21 282.16 76001 FLUOROSCOPE EXAM, EXTENSIVE N1 76010 X-RAY NOSE TO RECTUM 177.57 152.20 AS 76080 X-RAY FISTULA 906.64 777.08 76098 X-RAY EXAM, BREAST SPECIMEN 1,605.07 1,375.71 76100 X-RAY BODY SECTION 299.09 256.35 AS 76102 COMPLEX BODY SECTION X-RAYS 906.64 777.08 AS 76120 CINE/VIDEO X-RAYS 329.21 282.16 AS 76125 CINE/VIDEO X-RAYS, ADDED N1 76376 3D RENDER W/O POST PROCESS N1 76377 3D RENDERING W/POST PROCESS N1 76380 CAT SCAN F/U STUDY 447.45 383.51 X 76506 ECHO EXAM HEAD 245.43 210.36 X 76510 OPHTHALMIC US, B & QUANT A 691.93 593.05 76511 OPHTHALMIC US, QUANT A ONLY 379.59 325.35 X 76512 OPHTHALMIC US, B W/NON-QUANT A 379.59 325.35 X 76514 ECHO EXAM EYE, THICKNESS 72.62 62.24 AS 76516 ECHO EXAM EYE 245.43 210.36 X 76519 ECHO EXAM EYE 379.59 325.35 X 76536 US EXAM HEAD & NECK 379.59 325.35 X 76604 US EXAM, CHEST 245.43 210.36 76645 US EXAM, BREAST(S) 245.43 210.36 X 76700 US EXAM, ABDOM, COMPLETE 379.59 325.35 76705 ECHO EXAM ABDOMEN 379.59 325.35 76770 US EXAM ABDOM BACK WALL, COMP 379.59 325.35 76775 US EXAM ABDOM BACK WALL, LIM 379.59 325.35 76776 US EXAM K TRANSPLANT W/DOPPLER 379.59 325.35 76800 US EXAM, SPINAL CANAL 379.59 325.35 X 76801 OBSTET US < 14 WKS, SINGLE FETUS 379.59 325.35 X 76805 OBSTET US >/= 14 WKS, SINGLE FETUS 379.59 325.35 X 76810 OBSTET US >/= 14 WKS, ADDED FETUS 379.59 325.35 X 76811 OBSTET US, DETAILED, SINGLE FETUS 603.18 516.98 X 76814 OBSTET US NUCHAL MEAS, ADDED 245.43 210.36 X 76815 OBSTET US, LIMITED, FETUS(S) 245.43 210.36 X 76816 OBSTET US, F/U, PER FETUS 245.43 210.36 X 76817 TRANSVAGINAL US, OBSTETRIC 245.43 210.36 X 76818 FETAL BIOPHYS PROFILE W/NST 379.59 325.35 X 76819 FETAL BIOPHYS PROFILE W/O NST 379.59 325.35 X 76820 UMBILICAL ARTERY ECHO 245.43 210.36 X 76821 MIDDLE CEREBRAL ARTERY ECHO 245.43 210.36 X 76826 ECHO EXAM FETAL HEART 1,586.46 1,359.76 X 76827 ECHO EXAM FETAL HEART 245.43 210.36 X

MEDICAL FEE SCHEDULES 11:3-29.6 76828 ECHO EXAM FETAL HEART 245.43 210.36 X 76830 TRANSVAGINAL US, NON-OB 379.59 325.35 X 76856 US EXAM, PELVIC, COMPLETE 379.59 325.35 76857 US EXAM, PELVIC, LIMITED 245.43 210.36 76870 US EXAM, SCROTUM 379.59 325.35 76872 US, TRANSRECTAL 379.59 325.35 X 76881 US XTR NON-VASC COMPLETE 379.59 325.35 X 76882 US XTR NON-VASC LMTD 245.43 210.36 X 76937 US GUIDE VASCULAR ACCESS N1 76942 ECHO GUIDE FOR BIOPSY N1 76998 US GUIDE, INTRAOP N1 77001 FLUOROGUIDE FOR VEIN DEVICE N1 77002 NEEDLE LOCALIZATION BY X-RAY N1 77003 FLUOROGUIDE FOR SPINE INJECT N1 77011 CT SCAN FOR LOCALIZATION N1 77012 CT SCAN FOR NEEDLE BIOPSY N1 77032 GUIDANCE FOR NEEDLE, BREAST N1 77072 X-RAYS FOR BONE AGE 177.57 152.20 AS 77073 X-RAYS, BONE LENGTH STUDIES 177.57 152.20 AS 77074 X-RAYS, BONE SURVEY, LIMITED 299.09 256.35 AS 77075 X-RAYS, BONE SURVEY COMPLETE 299.09 256.35 AS 77076 X-RAYS, BONE SURVEY, INFANT 299.09 256.35 AS 77077 JOINT SURVEY, SINGLE VIEW 177.57 152.20 AS 77080 DIAG BONE DENSITY, AXIAL 278.03 238.30 X 77081 DIAG BONE DENSITY/PERIPHERAL 126.60 108.51 X 77082 DIAG BONE DENSITY, VERTEBRAL FX 177.57 152.20 X 77280 SET RADIATION THERAPY FIELD 411.92 353.06 AS 77285 SET RADIATION THERAPY FIELD 1,070.85 917.82 AS 77290 SET RADIATION THERAPY FIELD 1,070.85 917.82 AS 77295 SET RADIATION THERAPY FIELD 3,653.77 3,131.64 AS 77300 RADIATION THERAPY DOSE PLAN 411.92 353.06 AS 77305 TELETX ISODOSE PLAN SIMPLE 411.92 353.06 AS 77310 TELETX ISODOSE PLAN INTERMED 411.92 353.06 AS 77315 TELETX ISODOSE PLAN COMPLEX 1,070.85 917.82 AS 77321 SPECIAL TELETX PORT PLAN 1,070.85 917.82 AS 77331 SPECIAL RADIATION DOSIMETRY 411.92 353.06 AS 77332 RADIATION TREAT AID(S) 787.38 674.86 AS 77333 RADIATION TREAT AID(S) 787.38 674.86 AS 77334 RADIATION TREAT AID(S) 787.38 674.86 AS 77336 RADIATION PHYSICS CONSULT 411.92 353.06 AS 77371 SRS, MULTISOURCE 30,204.85 25,888.56 X

11:3-29.6 APPENDIX B - REGULATIONS 77403 RADIATION TX SING AREA 6-10MEV 385.67 330.55 X 77413 RADIATION TX 3/MORE AREA 6-10MEV 632.95 542.50 X 77414 RADIATION TX 3/MORE AREA 11-19MEV 632.95 542.50 X 77417 RADIOLOGY PORT FILM(S) N1 77470 SPECIAL RADIATION TREAT 1,532.02 1,313.09 X 78006 THYROID IMAGING W/UPTAKE 865.36 741.70 X 78007 THYROID IMAGE, MULT UPTAKES 865.36 741.70 X 78102 BONE MARROW IMAGING, LTD 1,013.33 868.52 X 78103 BONE MARROW IMAGING, MULT 1,013.33 868.52 X 78215 LIVER & SPLEEN IMAGING 1,045.30 895.93 X 78220 LIVER FUNCTION STUDY 1,045.30 895.93 X 78223 HEPATOBILIARY IMAGING 1,045.30 895.93 X 78232 SALIVARY GLAND FUNCTION EXAM 943.46 808.64 X 78300 BONE IMAGING, LIMITED AREA 964.75 826.89 X 78305 BONE IMAGING, MULTIPLE AREAS 964.75 826.89 X 78306 BONE IMAGING, WHOLE BODY 964.75 826.89 X 78315 BONE IMAGING, 3 PHASE 964.75 826.89 X 78320 BONE IMAGING (3D) 964.75 826.89 X 78445 VASCULAR FLOW IMAGING 789.90 677.02 X 78451 HEART MUSCLE IMAGE SPECT, SING 2,995.98 2,567.85 X 78452 HEART MUSCLE IMAGE SPECT, MULT 2,995.98 2,567.85 X 78469 HEART INFARCT IMAGE (3D) 1,148.83 984.67 X 78472 GATED HEART, PLANAR, SING 1,148.83 984.67 X 78481 HEART FIRST PASS, SING 1,148.83 984.67 X 78494 HEART IMAGE, SPECT 1,148.83 984.67 X 78580 LUNG PERFUSION IMAGING 776.02 665.13 X 78584 LUNG V/Q IMAGE SINGLE BREATH 1,261.32 1,081.07 X 78585 LUNG V/Q IMAGING 1,261.32 1,081.07 X 78588 PERFUSION LUNG IMAGE 1,261.32 1,081.07 X 78594 VENT IMAGE, MULT PROJ, GAS 776.02 665.13 X 78596 LUNG DIFFERENTIAL FUNCTION 1,261.32 1,081.07 X 78607 BRAIN IMAGING (3D) 2,350.85 2,014.92 X 78707 KID FLOW/FUNCT IMAGE W/O DRUG 1,267.39 1,086.28 X 78708 KID FLOW/FUNCT IMAGE W/DRUG 1,267.39 1,086.28 X 78709 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE 1,267.39 1,086.28 X 78802 TUMOR IMAGING, WHOLE BODY 1,872.66 1,605.05 X 78803 TUMOR IMAGING (3D) 1,872.66 1,605.05 X 78805 ABSCESS IMAGING, LTD AREA 1,872.66 1,605.05 X 78806 ABSCESS IMAGING, WHOLE BODY 1,872.66 1,605.05 X 78815 PET IMAGE W/CT,

MEDICAL FEE SCHEDULES 11:3-29.6 SKULL-THIGH 4,108.15 3,521.09 X 79101 NUCLEAR RX, IV ADMIN 883.62 757.35 X 88141 CYTOPATH, C/V, INTERPRET N1 92070 FIT CONTACT LENS N1 92504 EAR MICROSCOPY EXAM N1 92547 SUPPLEMENTAL ELECTRICAL TEST N1 92621 AUDITORY FUNCTION, + 15 MIN N1 93314 ECHO TRANSESOPHAGEAL N1 93320 DOPPLER ECHO EXAM, HEART N1 93321 DOPPLER ECHO EXAM, HEART N1 93325 DOPPLER COLOR FLOW, ADDED N1 93463 DRUG ADMIN & HEMODYNMIC MEAS N1 93464 EXERCISE W/HEMODYNAMIC MEAS N1 93563 INJECT CONGENITAL CARD CATH N1 93564 INJECT HEART CONGNTL ART/GRAFT N1 93565 INJECT L VENTR/ATRIAL ANGIO N1 93566 INJECT R VENTR/ATRIAL ANGIO N1 93567 INJECT SUPRVLV AORTOGRAPHY N1 93568 INJECT PULM ART HEART CATH N1 93609 MAP TACHYCARDIA, ADDED N1 93623 STIMULATION, PACING HEART N1 93641 ELECTROPHYSIOLOGY EVAL N1 94760 MEASURE BLOOD OXYGEN LEVEL N1 94761 MEASURE BLOOD OXYGEN LEVEL N1 95873 GUIDE NERVE DESTROY, ELECT STIM N1 95874 GUIDE NERVE DESTROY, NEEDLE EMG N1 95920 INTRAOP NERVE TEST, ADDED N1 95955 EEG DURING SURG N1 95957 EEG DIGITAL ANALYSIS N1 96368 THER/DIAG CONCURRENT INF N1 99143 MOD SEDATION SAME PHYS, < 5 YRS N1 99144 MOD SEDATION BY SAME PHYS, 5 YRS + N1 99145 MOD SEDATION BY SAME PHYS, ADDED N1 99148 MOD SEDATION DIFF PHYS < 5 YRS N1 99149 MOD SEDATION DIFF PHYS 5 YRS + N1 99150 MOD SEDATION DIFF PHYS, ADDED N1 99175 INDUCTION VOMITING N1 99292 CRITICAL CARE, ADDED 30 MIN N1 99354 PROLONGED SERVICE, OFFICE N1 99355 PROLONGED SERVICE, OFFICE N1 New Rule. R.2001 d.253, effective July 16, 2001; R.2002 d.59, effective March 4, 2002; R.2003 d.143, effective April 7, 2003; R.2004 d.481, effective December 20, 2004; R.2007 d.305, effective October 1, 2007; R.2009 d.194, effective June 15, 2009; R.2009 d.209, effective July 6, 2009. Repeal and New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). Amended. R.2014 d.004, effective January 6, 2014.

11:3-30 APPENDIX B - REGULATIONS SUBCHAPTER 30. MOTOR VEHICLE SELF-INSURANCE Section 11:3-30.1. Purpose. 11:3-30.2. Scope. 11:3-30.3. Definitions. 11:3-30.4. General requirements. 11:3-30.5. Certificate of self-insurance. 11:3-30.6. Renewals. 11:3-30.7. Surety bond requirement. 11:3-30.8. Audits and examinations. 11:3-30.9. Public entities. 11:3-30.10. Cancellation of certificate of self-insurance. 11:3-30.1. Purpose. This subchapter sets forth the filing requirements for motor vehicle self-insurers pursuant to N.J.S.A. 39:6-50.1, and 39:6-52 to 39:6-54. 11:3-30.2. Scope. The provisions of this subchapter apply to any person seeking to qualify as a motor vehicle self-insurer in New Jersey, except public entities pursuant to N.J.S.A. 39:6-54. 11:3-30.3. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Applicant means a person applying for a certificate of self-insurance who does not currently possess a valid certificate. Association means the New Jersey Automobile Full Insurance Underwriting Association created pursuant to N.J.S.A. 17:30E-1 et seq. Certificate means certificate of self-insurance. Certificate holder means a person who currently possesses a valid certificate of self-insurance. Certified public accountant means an independent certified public accountant or accounting firm in good standing with the American Institute of Certified Public Accountants and in all states in which they are licensed to do business. Commissioner means the Commissioner of Banking and Insurance. Motorized bicycle means a pedal bicycle having a helper motor characterized in that either the maximum piston displacement is less than 50 cubic centimeters (cc.) or said motor is rated at no more than 1.5 brake horsepower and said bicycle is capable of a maximum speed of no more than 25 miles per hour on a flat surface. Motor vehicle means all vehicles propelled otherwise than by muscular power, excepting such vehicles as run upon rails or tracks and motorized bicycles. Person means a natural person, firm, co-partnership, association or corporation. Public entity means this State, any political subdivision of this State or any municipality therein. Amended. R. 2001 d. 44, effective February 5, 2001. 11:3-30.4. General requirements. (a) Any person in whose name more than 25 motor vehicles are registered or in whose name more than 25 motor vehicles

MOTOR VEHICLE SELF-INSURANCE 11:3-30.6 are leased may qualify as a self-insurer by obtaining a certificate of self-insurance issued at the discretion of the Commissioner as provided in this subchapter. (b) All filings for certificates of self-insurance, renewals, and any other filings deemed necessary by the Commissioner pursuant to this subchapter shall be sent to: New Jersey Department of Banking and Insurance Financial Exams Division 20 West State Street PO Box 325 Trenton, New Jersey 08625-0325 Attention: Self-insurers Amended. R. 2001 d. 44, effective February 5, 2001. 11:3-30.5. Certificate of self-insurance. (a) Any person applying for a certificate of self-insurance shall submit the following to the Commissioner: 1. A completed application form on forms to be provided by the Commissioner; 2. The most current financial statement and financial statements for the two years immediately preceding the date of such current financial statement: i. All financial statements shall be certified by a Certified Public Accountant: ii. If the applicant is a subsidiary of a corporation, the applicant shall also submit the financial statements of the subsidiary s ultimate parent corporation; iii. If the applicant is a corporation, the Commissioner may also include the name of any subsidiary corporation under the control of that corporation in the certificate of self-insurance if the ultimate parent corporation guarantees that it will discharge the subsidiary s liability as evidenced by the filing of an indemnity agreement. If the ultimate parent corporation does not provide such a guarantee, the subsidiary shall make a separate application and receive independent qualification as a self-insurer. If the name of the subsidiary is included in the certificate of self-insurance of the ultimate parent corporation and ownership of the ultimate parent or subsidiary corporation changes, the ultimate parent or subsidiary shall reapply for a certificate of self-insurance within 30 days of the ownership change; and 3. A 51,000 filing fee. (b) After the submission of an application, the Commissioner may require an additional fee to cover the costs of further examinations which may include a credit report to be prepared by a credit agency acceptable to the Commissioner. (c) If an application is approved and the Commissioner receives notification from the Association that the applicant has paid any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively, the Commissioner shall issue a certificate of self-insurance to the applicant. (d) All certificates of self-insurance are valid from the date of issuance until June 30 immediately following and may be renewed thereafter, pursuant to N.J.A.C. 11:3-30.6, for a one year period beginning July 1 and ending June 30 the following year. 11:3-30.6. Renewals. (a) Any certificate holder applying for renewal shall submit the following so that it is received by the Commissioner not later than June l of the year of the expiration date of such certificate: 1. An accident and claim activity report on forms to be provided by the Commissioner; 2. A financial statement for the calendar year immediately preceding the expiration date of the certificate of self-insurance certified by a Certified Public Accountant;

11:3-30.7 APPENDIX B - REGULATIONS 3. An updated vehicle listing which shall include a listing of the vehicles subject to any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively; 4. A $1,000 renewal fee; and 5. Any other information that is substantially different from the information provided in the original application form or from the information provided in the last renewal period. (b) After the submission of an application for renewal, the Commissioner may require an additional fee to cover the costs of further examinations which may include a credit report to be prepared by a credit agency acceptable to the Commissioner. (c) If an application for renewal is approved and the Commissioner receives notification from the Association that the certificate holder has paid any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively, the Commissioner shall issue a new certificate of self-insurance. 11:3-30.7. Surety bond requirement. (a) The Commissioner may require the furnishing of a surety bond and for evidence of excess insurance. (b) If the applicant or certificate holder is required to furnish a surety bond, the surety bond shall be in an amount of not less than 5300.000, with an additional 510,000 for each vehicle registered or leased in the applicant s or certificate holder s name over the minimum required to qualify as self-insurer under this subchapter. up to a maximum amount of 51,000,000. 11:3-30.8. Audits and examinations. (a) The Commissioner may make or cause to be made audits or examinations as may be necessary to determine the ability of the applicant or the certificate holder to discharge its financial obligations as a self-insurer. (b) The applicant or certificate holder shall pay the reasonable expenses of the audit or examination. 11:3-30.9. Public entities. (a) This subchapter does not apply to any motor vehicle owned by the United States, this State, any political subdivision of this State or any municipality therein; nor to any motor vehicle which is subject to the requirements of law requiring insurance or other security on certain types of vehicles, other than the requirements of N.J.S.A. 39:6A-1 et seq. or N.J.S.A. 39:6B-1 et seq. (b) Notwithstanding the provisions in (a) to the contrary, any public entity that currently has or will establish in the future a self-insurance program or plans to discontinue a self-insurance program currently in effect, shall notify the Commissioner in writing that it currently has, will establish or discontinue such a program. 11:3-30.10. Cancellation of certificate of self-insurance. After a hearing conducted pursuant to the Administrative Procedure Act, N.J.S.A. 52:148-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1, upon not less than five days notice, the Commissioner may cancel a certificate of self-insurance upon reasonable grounds including, but not limited to, failure to pay any judgment within 30 days after such judgment has become final. SUBCHAPTER 34. ELIGIBLE PERSONS QUALIFICATIONS AND AUTOMOBILE INSURANCE ELIGIBILITY POINTS SCHEDULE Section 11:3-34.1. Purpose. 11:3-34.2. Scope.

INSURANCE ELIGIBILITY 11:3-34.3 11:3-34.3. Definitions. 11:3-34.4. Eligible person qualifications. 11:3-34.5. Automobile insurance eligibility points. APPENDIX Schedule of Automobile Insurance Eligibility Points 11:3-34.1. Purpose. The purpose of this subchapter is to set forth the requirements for determining who can qualify as an eligible person, and to provide the schedule for automobile insurance eligibility points pursuant to N.J.S.A. 17:33B-13 and 14. Amended. R. 1996 d. 58, effective February 5, 1996. 11:3-34.2. Scope. (a) The provisions of this subchapter apply to all insurers which write personal private passenger automobile insurance and all persons who are required to procure automobile insurance coverage in this State. (b) Except to the extent that the definition of eligible and ineligible persons at N.J.A.C. 11:3-34.4 is utilized for nonrenewals pursuant to N.J.A.C. 11:3-8, this subchapter shall become inoperative on and after January 1, 2009, unless and until the Commissioner by Order makes the requirements of N.J.S.A. 17:33B-15a and b operative pursuant to the limited circumstances set forth in N.J.S.A. 17:33B- 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. 2008 d. 380, effective December 15, 2008 (operative January 1, 2009); R.2011 d.242, effective September 19, 2011. 11:3-34.3. Definitions. The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. At-fault accident is any accident involving a driver insured under the policy: 1. Where a driver is proportionately responsible based on the number of vehicles involved. A driver is proportionately responsible if 50 percent responsible for an accident involving two drivers; if 33 1/3 percent responsible for an accident involving three drivers, etc.; and 2. Which results in a total payment by the insurer of at least $500.00 for an accident occurring before June 9, 2003; or at least $1,000 for an accident occurring on or after June 9, 2003. The $1,000 dollar amount may be adjusted in $100.00 or $250.00 increments by Order of the Commissioner not more frequently than every 36 months. The Order shall reflect the cumulative increases or decreases in the components of the Consumer Price Index, All Urban Consumers (CPI-U) for the Northeast Region, and the adjusted amount shall apply to automobile accidents occurring at least 120 days after the effective date of the adjustment. The adjustment shall be reflected in this definition through a notice of administrative change published in the New Jersey Register. An at-fault accident shall not include the following: 1. Involvement in an accident in which the motor vehicle owned or operated by the insured or other driver insured under the policy was lawfully parked;

11:3-34.4 APPENDIX B - REGULATIONS 2. Involvement in an accident in which the motor vehicle was struck by a hit and run driver, if such accident was reported to the proper authorities within 24 hours; 3. Involvement in an accident in connection with which neither the named insured nor any other driver insured under the policy was convicted of a moving traffic violation and the owner or operator of another vehicle involved in such accident was so convicted; 4. For physical damage losses other than collision; 5. For an accident in which the motor vehicle was struck in the rear by another vehicle and a driver insured under the policy has not been convicted of a moving violation in connection with the accident; or 6. For an accident occurring as a result of operation of any motor vehicle in response to an emergency if the operator at the time of the accident was responding to the call to duty as a paid or volunteer member of any police or fire department, first aid squad or any law enforcement agency. Automobile means an automobile as defined in N.J.S.A. 39:6A-2. Automobile insurance means insurance for an automobile including any or all of the following coverages: bodily injury liability, and property damage liability, comprehensive and collision coverages, uninsured and underinsured motorist coverage, personal injury protection coverage, additional personal injury protection coverage and any other automobile insurance required by law. Automobile insurance eligibility points means points calculated under the schedule promulgated by the Commissioner pursuant to this subchapter. Commissioner means the Commissioner of Banking and Insurance of the State of New Jersey. Department means the Department of Banking and Insurance of the State of New Jersey. State means the State of New Jersey. Amended. R. 2001 d. 44, effective February 5, 2001; R. 2003 d.469, effective December 1, 2003. 11:3-34.4. Eligible person qualifications. (a) An eligible person is a person who is an owner or registrant of an automobile registered and principally garaged in this State or who is a resident and holds a valid New Jersey driver's license to operate an automobile, but does not include any person: 1. Who, during the three-year period immediately preceding application for, or renewal of, an automobile insurance policy has been convicted pursuant to N.J.S.A. 39:4-50 or N.J.S.A. 39:4-50.4a or for an offense of a substantially similar nature committed in another jurisdiction; 2. Who has been convicted of a crime of the first, second or third degree resulting from the use of a motor vehicle; or has been convicted of theft of a motor vehicle; 3. Whose driver's license to operate an automobile is under suspension or revocation; 4. Who has been convicted, within the five-year period immediately preceding application for or renewal of a policy of automobile insurance, of fraud or intent to defraud involving an insurance claim or an application for insurance; 5. Who has been successfully denied, with the immediately preceding five years' payment by an insurer of a claim in excess of $1,000 under an automobile insurance policy, if there was evidence of fraud or intent to defraud involving the automobile insurance claim or application. For the purpose of this section: i. If the claim has been subject to litigation between the insurer and the insured in which the insurer defended against payment of the claim in whole or in part on

INSURANCE ELIGIBILITY 11:3-34.4 grounds of fraud, it shall be conclusively presumed that the claim was successfully denied if judgment was entered for the insurer in the litigation; and conclusively presumed that the claim was not successfully denied if judgment was entered for the insured; ii. If the claim has not been subject to litigation between the insurer and the insured, but the insurer denied the claim without payment by reason of fraud, it shall be presumed that the claim was successfully denied. This presumption may be overcome in an administrative proceeding pursuant to N.J.A.C. 11:3-33; iii. If the incident was not reported to the New Jersey Office of Insurance Fraud Prosecutor pursuant to N.J.S.A. 17:33A-9 it shall be presumed that there was no evidence of fraud or intent to defraud; 6. Whose automobile insurance policy has been cancelled for nonpayment of premiums or financed premium with a lapse of coverage of at least 30 days, within the immediately preceding two-year period, unless the premium due on a policy for which application has been made is paid in full before issuance or renewal of the policy. For the purpose of this section, paid in full shall not include any transaction in which a lender obtains authority from an insured to cancel the policy and receive a refund from the insurer in the event the insured defaults on a loan used to pay the premium; 7. Who fails to obtain or maintain membership or qualification for membership in a club, group, or organization, if membership is a uniform requirement of the insurer as a condition of providing insurance, and if the dues or charges, if any, or other conditions for membership or qualifications for membership are applied uniformly throughout this State, are not expressed as a percentage of the insurance premium, and do not vary with respect to the rating classification of the member or potential member except for the purpose of offering a membership fee to family units. Membership fees, if applicable, may vary in accordance with the amount or type of coverage if the purchase of additional coverage, either as to type or amount, is not a condition for reduction of dues or fees; 8. Whose driving record for the three year period immediately preceding the application for or renewal of a policy of automobile insurance has an accumulation of seven or more automobile insurance eligibility points as determined in N.J.A.C. 11:3-34.5; 9. Who, during the three-year period immediately preceding application for, or renewal of, an automobile insurance policy, has knowingly provided materially false or misleading information in connection with an application for insurance, renewal of insurance or claim for benefits under an insurance policy; 10. Who is a named insured or who is insured under the same policy as a person whose driver's license is suspended or revoked and either: i. The suspended or revoked driver has been convicted of a violation of N.J.S.A. 39:6B-2 within the previous three years; or ii. With the exception of a conviction for violating N.J.S.A. 39:3-40i, other evidence exists indicating that the suspended or revoked driver has been operating a vehicle during the period of suspension or revocation;or 11. Who, for the purposes of nonrenewals under N.J.A.C. 11:3-8 only, does not satisfy the insurer s acceptance criteria as set forth in N.J.A.C. 11:3-8.12. (b) An eligible person includes a person who is an owner or registrant of an automobile registered in this State or who holds a valid New Jersey driver's license to operate an automobile and is domiciled in this State who is temporarily residing out-of-state and whose car may be principally garaged in another state while the

11:3-34.5 APPENDIX B - REGULATIONS person either is a full time student or is in the military service and is stationed outof-state. Amended: R. 1992, d. 481; R. 1996 d.246, effective June 3, 1996; R. 2001 d. 44, effective February 5, 2001; R. 2003 d. 469, effective December 1, 2003; R.2007 d.373, effective December 3, 2007; R.2011 d.242, effective September 19, 2011. 11:3-34.5. Automobile insurance eligibility points. (a) Automobile insurance eligibility points shall be accumulated as a result of convictions, suspensions, revocations and determinations of responsibility for civil infractions in accordance with the schedule set forth in the Appendix to this subchapter herein incorporated by reference. (b) Automobile eligibility points are cumulative and accrue for all violations and occurrences set forth on Schedules 1 and 2. Automobile insurance eligibility points shall be deemed to accrue as follows: 1. Points for an at-fault accident shall accrue on the date that total payment by the insurer equals or exceeds $1,000 or such other amount as may be prescribed by Order of the Commissioner issued pursuant to N.J.S.A. 17:33B-14. The amount under such Order shall be reflected in this paragraph through a notice of administrative change published in the New Jersey Register. An insurer may, at its option, use the date of the accident or date of first payment provided, however, that the insurer shall not underwrite or rate any policy based on the accident until total payment by the insurer equals or exceeds $1,00; and further provided that the insurer shall use the optional date consistently in all cases. 2. Points for conviction of motor vehicle violations and other events that are set forth on an abstract of drivers license records available from the New Jersey Motor Vehicle Commission, or a comparable agency of another state, shall accrue when the event is recorded in the agency's records as evidenced by an abstract. 3. When an eligible person is involved in an at-fault accident and has not accrued any eligibility points during the three-year period immediately preceding the date of that accident, no eligibility points for a two- or three-point violation, as set forth in Schedule 2 of the Appendix, shall accrue along with the points assessed in accordance with Schedule 1 for the at-fault accident, when the violation arises out of the same incident which results in 1the assessment of points for the at-fault accident. However, violations that arise out of the same incident may be considered by insurers for purposes of tier placement pursuant to N.J.A.C. 11:3-19A. 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. 13:19-10.1, which is hereby incorporated by reference. Any additions, deletions or modifications to N.J.A.C. 13:19-10.1 shall likewise be incorporated as of the effective date of amendment. Schedule 2 is included in the Appendix for convenience. (d) The reference in Appendix Schedule 1 and Schedule 2 to provisions of the New Jersey Statutes Annotated is meant for convenience to assist in the quick identification of the nature of the event. If the event takes place in a state or prov-

INSURANCE ELIGIBILITY 11:3-34.5 ince other than New Jersey, Schedule 1 and 2 should be consulted for identification of the specific misconduct committed and the assessment of the appropriate number of insurance eligibility points to be assessed. (e) In addition to the motor vehicle violation and insurance eligibility points specifically enumerated on Schedule 2 of the Appendix pertaining to the New Jersey Turnpike, Atlantic City Expressway, and the Garden State Parkway, for any other motor vehicle violations that occur on the New Jersey Turnpike (N.J.A.C. 19:9), the Atlantic City Expressway (N.J.A.C. 19:2-2.1), the Garden State Parkway (N.J.A.C. 19:8) or for any other moving violation at any location, Schedules 1 and 2 shall be consulted for identification of the specific misconduct committed and the determination of the appropriate number of insurance eligibility points to be assessed. Amended. R.2001 d.44, effective February 5, 2001; R.2002 d.330, effective October 7, 2002; R.2003 d.469, effective December 1, 2003; R.2006 d.243, effective July 3, 2006; R.2007 d.373, effective December 3, 2007. APPENDIX Schedule of Automobile Insurance Eligibility Points Schedule 1 N.J.S.A. DMV Section Event Number Event Identifier(s) If applicabledescription If applicable Points 39:4-50 Operating a motor vehicle under the influence of alcohol or drugs 0450; 3261 9 39:4-50.4 Refusal to submit to a chemical test 4504 9 2C:11-2 Vehicular homicide C115 9 39:3-40 Operating a motor vehicle while driving a through privilege is suspended 0340 9 h and j 39:6B-2 Operating a motor vehicle without liability insurance06b2 9 39:6A-15 Misrepresentation of insurance coverage 6A15 9 Each at fault accident 5 *For each full year of a court imposed driver s license suspension within the preceding 3 years 3 *For each full year within the immediately preceding 3 years that a person has not held a driver s license 1 Involved in a fatal accident EFTL 4 NFTL 2 39:3-37 Obtaining a driver s license or registration through deception 0337; 0312; 05D5; 1312; MSNJ; MSOS 5 39:3-38 Make or use counterfeit plate or plates other than issued 0338 5 39:3-38.1 Make, alter or counterfeit driver s license or registration 3381 5 Failure to verify insurance involved in an automobile accident FVIA 2 * Points for failure to hold a driver s license in the previous three years are not cumulative to points for driver s license suspension.

11:3-34.5 APPENDIX B - REGULATIONS Schedule 2 N.J.S.A. Section Number 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 39:4-14.3 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 39:4-66.1 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 39:4-82.1 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 39:4-85.1 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 39:4-90.1 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 39:4-97.1 Slow speed blocking traffic 2 39:4-98 & 39:4-99 Exceeding maximum speed 1-14 mph over limit 2 Exceeding maximum speed 15-29 mph over limit 4 Exceeding maximum speed 30 mph or more over limit 5

BENEFIT DETERMINATION: PIP - HEALTH 11:3-37.2 39:4-105 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 39:4-127.1 Improper crossing of railroad grade crossing 2 39:4-127.2 Improper crossing of bridge 2 39:4-128 Improper crossing of railroad grade crossing by certain vehicles 2 39:4-128.1 Improper passing of school bus 5 39:4-128.4 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. 1996 d. 58, effective February 5, 1996; R.2007 d.373, effective December 3, 2007. SUBCHAPTER 37. ORDER OF BENEFIT DETERMINATION BETWEEN AUTOMOBILE PERSONAL INJURY PROTECTION AND HEALTH INSURANCE Section 11:3-37.1. Purpose and scope. 11:3-37.2. Definitions. 11:3-37.3. Health benefits providers. 11:3-37.4. Application of the PIP-as-secondary coverage option. 11:3-37.5. Health benefit plan standards and the PIP premium reduction. 11:3-37.6. Order of benefits determination when PIP is secondary coverage. 11:3-37.7. Determination of PIP medical benefits payable when PIP is secondary coverage. 11:3-37.8. Health benefits plan coverage ineligibility. 11:3-37.9. Determination of benefits when PIP is primary coverage. 11:3-37.10. Explanation of benefits. 11:3-37.11. Dispute as to primacy of coverage. 11:3-37.12. Eligibility under two or more automobile policies. 11:3-37.13. Penalties. 11:3-37.14. Severability. 11:3-37.1. Purpose and scope. The purpose of this subchapter is to establish guidelines for the order of benefit determination between a plan of health insurance and personal injury protection provided through an automobile policy pursuant to N.J.S.A. 39:6A-4, when a named insured elects to have his or her personal injury protection become secondary coverage for the provision of benefits for medical expenses incurred due to injuries sustained in an automobile accident. This subchapter also sets forth the requirements for the order of benefit determination between a plan of health insurance and personal injury protection provided pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, when personal injury protection is primary coverage. The provisions of this subchapter shall apply to all automobile

11:3-37.2 APPENDIX B - REGULATIONS policies, as that term is defined at N.J.S.A. 39:6A-2a, issued to New Jersey residents, or renewed on or after January 1. 1991, and to all health benefits plans which have been or will be delivered or issued for delivery in this State. Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999). 11:3-37.2. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. Actual benefits means those benefits determined to be payable for allowable expenses. Allowable expense means a medically necessary, reasonable and customary item of expense covered by an insured's health benefits plan(s) or PIP plan as an eligible expense, at least in part. When a plan provides benefits in the form of services, the reasonable monetary value of each such service shall be considered as both an allowable expense and a paid benefit. Benefits means the provision of the following in consideration of payment of premiums or fees on a prepaid or postpaid basis: 1. Services, including supplies; 2. Payment of expenses incurred; 3. A combination of 1 and 2 above; or 4. An indemnification. Eligible expense means: 1. In the case of health benefits plans, that portion of the medical expenses incurred for treatment of an injury which is covered under the terms and conditions of the plan, without application of the deductible(s) and copayment(s), if any. 2. In the case of PIP plans, that portion of the medical expenses incurred for treatment of an injury which, without considering any deductible and copayment, shall not exceed: i. The percent or dollar amounts specified on the medical fee schedules, or the actual billed expense, whichever is less; or ii. The reasonable amount, as determined by the automobile insurer, considering the medical fee schedules for similar services or equipment in the region where the service or equipment was provided, when an incurred medical expense is not included on the medical fee schedules. Health benefits provider means any person, whether subject to the regulation of the New Jersey Department of Banking and Insurance, Department of Health and Senior Services, or both, or not otherwise subject to such regulation, who contracts to provide health services, provide reimbursement for the cost of health services in whole or in part, or to provide for indemnity in the event health services are used, in return for a prepaid or postpaid premium or fee or other consideration, including, but not limited to: 1. Insurers, as defined at N.J.S.A. 17B:17-2; 2. Hospital service corporations, as defined at N.J.S.A. 17:48-1; 3. Medical service corporations, as defined at N.J.S.A. 17:48A-1; 4. Health service corporations, as defined at N.J.S.A. 17:48E-1; 5. Health maintenance organizations, as defined at N.J.S.A. 26:2J-2; 6. Dental service corporations, as defined at N.J.S.A. 17:48C-2; 7. Dental plan organizations, as defined at N.J.S.A. 17:48D-2; 8. Medicare; 9. Medicaid; 10. State Employees Health Benefits Plan; 11. CHAMPUS; 12. Self-insured programs; and

BENEFIT DETERMINATION: PIP - HEALTH 11:3-37.2 13. An entity organized under the laws of any other state or jurisdiction which delivers certificates to residents of New Jersey evidencing coverage under a contract issued and delivered in a state or jurisdiction other than New Jersey. Hospital expenses, when used by the automobile insurance PIP plan, means those expenses defined at N.J.S.A. 39:6A-2f. Injury means bodily injury sustained by an insured as a result of an accident while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an object propelled by or from an automobile. Insured means a person eligible for coverage, at least in part, for medical expenses incurred for treatment of injuries, under an automobile policy PIP medical expense provision, and who meets the definition of a named insured or family member. 1. Named insured means the person or persons identified as the insured in the automobile policy and if an individual, that person's spouse, if the spouse is a resident of the same household, except that if the spouse ceases to be a resident of the household of the named insured, coverage for that spouse shall continue until the expiration of full term of any policy period in effect at the time of the cessation of residency. 2. Family member means any relative of the named insured or the named insured's spouse who: i. Is related to the named insured or named insured's spouse by blood, marriage, adoption or guardianship; ii. Resides in the household of the named insured or spouse of the named insured; and iii. Is not a named insured under another automobile policy. Medical expenses is as defined in N.J.A.C. 11:3-4.2. Medical fee schedule means that list of services, procedures and supplies to which have been assigned a maximum fee or percentage of a fee payable by an automobile insurer for expenses incurred as a result of the rendering to an insured any of those specific services, procedures or supplies for injuries, which list is set forth at N.J.A.C. 11:3-29. Out-of-State automobile insurance coverage or OSAIC means any coverage for medical expenses under an automobile insurance policy other than PIP, as PIP is defined herein, including automobile insurance policies issued in another state or jurisdiction. PIP means personal injury protection coverage provided as part of an automobile insurance policy pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, issued in New Jersey, specifically those provisions for medical expenses coverage. Plan means any policy, contract, certificate, booklet, evidence of enrollment, program, or other such term which evidences the existence of a relationship between a health benefits provider or PIP carrier and an insured with respect to the provisions of hospital, medical, surgical, dental and/or other health care related benefits, at least in part. Primary coverage means coverage by any plan which determines its actual benefits payable on allowable expenses incurred by an insured for treatment of injuries without taking into consideration the existence of any coverage for which the insured may be eligible provided secondary in accordance with this subchapter. There may be more than one plan providing the insured primary coverage.

11:3-37.3 APPENDIX B - REGULATIONS Secondary coverage means coverage by any plan which determines its actual benefits payable on all allowable expenses incurred by an insured for treatment of injuries after all plans providing primary coverage have considered expenses incurred and paid actual benefits. Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999); R. 2001 d. 44, effective February 5, 2001. 11:3-37.3. Health benefits providers. (a) Nothing in this subchapter shall be construed as requiring any health benefits provider to offer, provide, or continue coverage to or for any individual or group, except as may be set forth by other laws of this State, or of the Federal government. (b) Nothing in this subchapter shall be construed as requiring any health benefits provider to provide coverage for any treatment or service not otherwise covered under the terms of the applicable health benefits plan. (c) No health benefits contract or policy delivered or issued for delivery in this State, or renewed, continued or converted on or after January 1. 1991, shall contain any provision, rider, waiver of endorsement or other instrument which restricts, limits or excludes coverage, directly or indirectly, of services or expenses otherwise eligible under the policy or contract on the grounds that such expenses or services would be covered under an automobile policy PIP provision for which the insured would be eligible had the named insured on the automobile policy not selected the PIP-as-secondary coverage option. (d) No health benefits contract or policy delivered or issued for delivery in this State, or renewed, continued or converted on or after January 1. 1991, shall contain any provision, rider, waiver or endorsement, or other instrument which restricts, limits or excludes coverage, directly or indirectly, of services or expenses otherwise eligible under the policy or contract on the grounds that: 1. Such expenses arise from an automobile-related injury; 2. Such expenses are covered or paid by PIP; or 3. Such expenses are covered or paid by OSAIC except for reductions in benefits when the health benefits contract provides secondary coverage as defined in and permitted by this rule. (e) A health benefits contract or policy may provide that it is always primary to OSAIC, or may provide that it will determine its benefits as if it were secondary to any OSAIC. If the health benefits contract or policy provides that it will determine its benefits as if it were secondary to OSAIC and the OSAIC either contains a provision that it is always excess or secondary, or refuses to cooperate in determining the amount of benefits payable by the health benefits plan as secondary coverage provider, the health benefits plan shall provide primary coverage. 11:3-37.4. Application of the PIP-as-secondary coverage option. (a) When a named insured elects the PIP option, whereby the named insured intends that medical expenses incurred for treatment of an injury are to be covered by a health benefits provider or providers, as evidenced on the Coverage Selection Form, then the medical expense provisions of the PIP coverage shall be considered to be secondary coverage for the purposes of the order of benefit determination, and all health benefits plans of an insured subject to the PIP option elected shall be considered to be primary coverage. (b) The election by the named insured to make PIP medical expense provisions secondary coverage shall apply to only the named insured and family members of the named insured who reside in the named insured s household and are not named insureds under other automobile policies. (c) The election by the named insured to make PIP medical expense provisions secondary coverage shall continue in force as to subsequent renewal or replace-

BENEFIT DETERMINATION: PIP - HEALTH 11:3-37.5 ment policies until the automobile policy insurer or its authorized representative receives a properly executed written request revoking the selection of this option. (d) In the event that an insured is ineligible for health plan coverage of medical expenses, or is eligible for coverage under a dental expense or dental service plan only when an injury occurs, despite the selection of the PIP-as-secondary coverage option by the named insured, benefits shall be provided to the insured through PIP coverage in accordance with N.J.A.C. 11:3-37.8. 11:3-37.5. Health benefit plan standards and the PIP premium reduction. (a) An automobile insurer may eliminate the premium reduction on the base rate applicable to the amount of medical expense benefit chosen in conjunction with the PIP-as-secondary coverage option election if the automobile insurer complies with (b) below, and verifies that the coverage specified by the named insured: 1. Excludes the provision of benefits for treatment of injuries of an eligible insured when expenses incurred in relation to treatment of those injures are eligible expenses under an automobile policy s PIP provisions; or 2. Provides that it is always secondary, or otherwise will not be a primary provider of benefits; 3. Provides benefits only for dental expenses or dental services; or 4. Provides benefits only for prescription drugs. (b) An automobile carrier shall notify a named insured if the automobile insurer determines that the health benefits plan(s) specified by the named insured contain exclusionary or restrictive coverage provisions as set forth in (a) above, or if the automobile insurer determines that one or more of the insureds covered under the automobile insurance policy is not provided coverage by at least one of the health benefit plan(s) specified by the named insured, and, therefore, the named insured s premium reduction for PIP medical expense benefits will be eliminated. 1. The notice shall be in writing and shall specify the reasons why the automobile insurer believes the named insured s health plan coverage is not in compliance with this subchapter. 2. The automobile insurer may include in the notice a demand for payment of the premium reduction difference with an explanation that failure to pay the indicated premium reduction difference may result in early cancellation of the automobile policy in accordance with (c) below. 3. The notice shall be sent no later than 30 days prior to the date of cancellation as calculated in accordance with (c) below. A notice which is sent 30 days prior to the date of cancellation shall either contain a statement that it is a notice of cancellation, or be attached to a notice of cancellation, setting forth the effective date of cancellation. (c) The effective date of the cancellation of a policy for nonpayment of premium shall not be earlier than 10 days prior to the last full day of which premium received by the company, prior to the date of preparation of the cancellation notice, would pay for coverage on a pro rata basis. In calculating the effective date of the cancellation, the premium applicable to the coverage provided by the policy and the premium received by the company at or prior to the time the cancellation notice was prepared shall be the premium used for the calculation and determination of such effective date. 1. No cancellation in accordance with (c) above shall be effective unless prior thereto, the automobile insurer shall have notified the named insured that the premium reduction difference had to be paid to avoid cancellation, as specified in (b)2 above. 2. No cancellation notice shall be mailed prior to 30 days in advance of its effective date. (d) If the insured provides payment of the full premium amount and subsequently provides proof that coverage is not restricted in the manner set forth in ac-

11:3-37.6 APPENDIX B - REGULATIONS cordance with (a) above, or that all insureds under the automobile policy were provided coverage by a health benefits plan at the time notification of noncoverage was sent, and that such coverage continues and is not restricted in the manner set forth in accordance with (a) above, the automobile insurer shall refund the monies paid in excess of the full reduction, or shall credit any excess paid on the reduced premium to the extent any premium payment is still unpaid on the policy. 11:3-37.6. Order of benefits determination when PIP is secondary coverage. (a) When the named insured of an automobile policy has selected the PIP-assecondary coverage option, all health benefits plans for which the insured is eligible shall provide coverage for the allowable expenses incurred by the insured due to an automobile-related injury prior to any benefits for medical expenses being paid by a PIP plan. (b) If the insured is eligible for coverage under more than one group health benefits plan, the group health benefits plans shall coordinate benefits with one another in accordance with the rules set forth for such plans at N.J.A.C. 11:4-28. (c) The PIP plan shall provide benefits for allowable expenses remaining uncovered after all health benefits plans for which the insured is eligible have paid benefits towards those allowable expenses. (d) The PIP plan shall continue to be liable for expenses related to the same occurrence as the expenses are incurred, whether or not the health benefits plan(s) in force at the time of the accident terminate(s) coverage, or benefits provided under the health benefits plan(s) are exhausted subsequent to the occurrence of the accident, up to the maximum PIP benefits available to the insured under the terms of the automobile policy. (e) Total benefits paid by an insured s health benefits and PIP plans shall not exceed the amount of total allowable expenses. 11:3-37.7. Determination of PIP medical benefits payable when PIP is secondary coverage. (a) In calculating the actual benefits to be paid by the automobile insurer when the PIP-as-secondary coverage option has been selected, the automobile insurer shall first determine the amount of eligible expenses which would have been paid after application of the deductible and copayment limitations had the PIP-as-secondary coverage option not been selected. 1. In the event the remaining allowable expenses are less than the benefits calculated pursuant to (a) above, the automobile insurer shall pay actual benefits equal to the remaining allowable expenses, without reducing the remaining allowable expenses by its deductible or copayments. 2. In the event the remaining allowable expenses are greater than the benefits calculated pursuant to (a) above, the actual benefits paid by the automobile insurer shall be the benefits calculated pursuant to (a) above, without reducing the remaining allowable expenses by its deductible or copayments. (b) In paying actual benefits, the automobile insurer shall not: 1. Reduce its actual benefits payable on account of any deductibles or copayments of the health benefits plans which have provided benefits ahead of the PIP plan due to the selection of the PIP-as-secondary coverage option: or 2. Reduce its actual benefits payable for any allowable expense remaining uncovered which item of expense otherwise would not be an eligible expense under the PIP plan, except as set forth by (c) below. (c) In determining remaining uncovered allowable expenses, the automobile insurer shall not consider any amount for items of expense which exceed the dollar or percent amounts recognized by the medical fee schedules promulgated pursuant to N.J.S.A. 39:6A-4.6.

BENEFIT DETERMINATION: PIP - HEALTH 11:3-37.9 (d) The total amount of benefits to be provided through the PIP medical expense provisions for each insured per accident or occurrence shall not exceed the maximum PIP benefits as provided for by the terms of the policy. 11:3-37.8. Health benefits plan coverage ineligibility. (a) When, subsequent to the selection of the PIP-as-secondary coverage option by a named insured, it is determined that an insured did not have health coverage in effect at the time of an injury, or had health coverage in effect at the time of any injury which is such that the PIP-as-secondary coverage option selection could have been invalidated by the automobile insurer and elimination of the premium reduction amount effected in accordance with N.J.A.C. 11:3-37.5(a), but was not, then the insured shall be provided benefits for incurred medical expenses through the PIP medical expense provision. 1. Benefits payable shall be subject to a per accident deductible equalling the total of $750.00 plus the PIP deductible selected by the named insured of the policy. 2. Benefits payable shall be subject to a 20 percent copayment for amounts less than $5,000 after the deductible has been satisfied. 3. Determination of the amount of benefits payable shall be made in accordance with medical fee schedules promulgated pursuant to N.J.S.A. 39:6A-4.6 and set forth at N.J.A.C. 11:3-29, or on a reasonable basis, as determined by the automobile insurer, considering the medical fee schedules for similar services or equipment in the region where the service or equipment was provided, when an item of expense is not included on the medical fee schedules. 4. Total benefits paid for each insured eligible for benefits in any one accident shall not exceed the maximum PIP benefits provided for by the terms of the policy. (b) All items of medical expense incurred by the insured for treatment of an injury shall be eligible expense to the extent the treatment or procedure from which the expenses arose is recognized on the medical fee schedules, or are reasonable medical expenses in accordance with N.J.S.A. 39:6A-4. (c) The automobile insurer shall be entitled to recover, for the contract period in which the automobile-related injury occurred, the difference between the reduced premiums paid on the policy and the amount of premium which would have been due on the policy had the named insured not selected the PIP-as-secondary coverage option, and no premium reduction shall be provided on that policy for the PIP-as-secondary coverage option during the remainder of that current contract period. 11:3-37.9. Determination of benefits when PIP is primary coverage. (a) When no election has been made by a named insured to make his or her health benefits plan(s) primary coverage provider(s), so that the PIP plan will provide primary coverage for medical expenses incurred for treatment of injuries, the PIP plan shall provide benefits to the insured without consideration of any benefits for which the insured may be eligible under any health benefits plan. (b) Actual benefits paid by the PIP plan shall be medical expenses, subject to the policy limits and supplication of any deductible and copayment provided for by the terms of the automobile policy, approved by the Commissioner pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, and any rules promulgated thereunder. (c) Actual benefits payable by a health benefits plan, when the PIP plan is providing primary coverage for medical expenses incurred for treatment of injuries, shall be the lesser of the remaining uncovered allowable expenses or the actual benefits that would have been payable had the health benefits plan been providing coverage primary to the PIP plan. 1. Actual benefits payable may be reduced by the deductible(s) and copayment requirements applicable by the terms of the health benefits plan, and shall not ex-

11:3-37.10 APPENDIX B - REGULATIONS ceed the amount of actual benefits that would have been payable had the health benefits plan been providing coverage primary to the PIP plan. 2. Allowable expenses remaining uncovered, which the health benefits plan(s) shall consider when the PIP plan is providing primary coverage, include: i. Any PIP deductible(s); ii. Any PIP copayment amounts; iii. Any expenses which exceed the medical expense coverage limits of the PIP plan per person per accident, as set forth by the terms of the automobile policy; and iv. Any expenses not covered by the PIP plan when such expense was determined to be in excess of the reasonable charge for an item of expense not listed on the medical fee schedules, but for which the automobile insurer determined a reasonable charge based on the medical fee schedule for a similar item of expense in the region where the service or equipment was provided. (d) When a health benefits plan provides hospital expense or service benefits only, or medical expense or service benefits only, and is not otherwise a part of a basic health benefits package, all allowable expenses remaining uncovered shall be considered by that health benefits plan for the provision of benefits, without regard as to whether the expenses are hospital-related or medical-related expenses. Actual benefits paid by that health benefits plan for the allowable expenses remaining uncovered shall not exceed the total actual benefits which would have been payable had the health benefits plan been providing coverage primary to the PIP plan. (e) When there is one health benefits plan providing insureds hospital expense or service benefits and another health benefits plan providing insureds medical expense or service benefits as two separate parts of one basic health benefits plan package, the hospital benefits plan and the medical benefits plan shall both consider all allowable expenses remaining uncovered and shall apportion such allowable expenses between the two plans on a pro-rata basis without regard as to whether the expenses are hospital-related or medical-related expenses. Actual benefits paid by each plan of the health benefits plan package shall not exceed the total actual benefits which would have been payable by each plan had the health benefits plan package been providing primary coverage. (f) No insured shall be liable to a health care provider for any fees for services or supplies which exceed the dollar or percentage amounts recognized for those services or supplies on the medical fee schedules. (g) No health benefits plan shall seek repayment from or withhold payment to an insured for amounts paid to the insured in consideration of charges which were in excess of the amounts set forth in the medical fee schedules. (h) If there is more than one group health benefits plan providing secondary coverage to an insured, these plans may coordinate their benefits with one another in accordance with N.J.A.C. 11:4-28. Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999). 11:3-37.10. Explanation of benefits. (a) Automobile insurers shall develop and utilize an explanation of benefits form to be provided with the payment of benefits for expenses incurred for treatment of injuries which clearly identifies and explains the following: 1. Each procedure for which a claim has been made; 2. Eligible expense related to each procedure with an indication of whether the eligible expense is based on the medical fee schedules or is the reasonable charge as determined by the automobile insurer; 3. Actual benefits paid; 4. Any deductible or copayment applied;

BENEFIT DETERMINATION: PIP - HEALTH 11:3-37.12 5. A concise explanation why any item of expense is considered an ineligible expense, when this occurs; and 6. A statement to insureds that no health care provider may demand or request any payment from any person in excess of those permitted by N.J.A.C. 11:3-29, and that no person is liable to any health care provider for any amount of money which results from the charging of fees in excess of those permitted by N.J.A.C. 11:3-29, pursuant to N.J.S.A. 39:6A-4.6. Amended by R. 1994 d. 564, effective November 21, 1994 (operative January 1, 1995). 11:3-37.11. Dispute as to primacy of coverage. (a) If, subsequent to the selection of the PIP-as-secondary coverage option by the named insured, injuries are sustained by an insured eligible for health benefits plan coverage, but a dispute exists between the health benefits provider and the automobile insurer, then the health benefits provider shall provide benefit as if it were the primary coverage provider and no PIP benefits were available to the insured. In no event shall the provision of benefits be unreasonably delayed by either a health benefits provider or an automobile insurer. (b) If the health benefits provider asserts that it is not subject to N.J.A.C. 11:3-37.3, 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. 11:3-37.8. The automobile insurer shall be entitled to recover premium reductions in accordance with N.J.A.C. 11:3-37.8(c). 11:3-37.12. Eligibility under two or more automobile policies. (a) If an insured is eligible for coverage of medical expenses under more than one automobile policy, the determination as to which automobile policy will assume coverage responsibility for that insured shall be as follows: 1. A named insured shall receive benefits for medical expenses under the terms of the automobile policy on which he or she, or his or her spouse, is identified as the named insured. 2. A family member who is a child of a named insured or the named insured s spouse shall receive benefits for medical expenses under the automobile policy of the named insured, subject to the following: i. If the child is a child of more than one named insured or of more than one spouse of a named insured, the child shall receive benefits under the terms of the automobile policy of the named insured who has legal custody of that child or whose spouse has legal custody of that child. ii. If the child is a child of more than one named insured or of more than one named insured s spouse, and legal custody of that child has either never been awarded, or has been awarded jointly, then the child shall receive benefits under the terms of the automobile policy of the named insured whose birthday occurs earliest in the calendar year. iii. If the child is a named insured or the spouse of a named insured, (a)1 above shall apply. 3. If neither (a)1 nor (a)2 above apply to an adult or child family member, then that family member shall receive benefits for medical expenses under the terms of the automobile policy of the named insured whose birthday occurs earliest in the calendar year. 4. If an automobile policy identifies more than one person as a named insured on the automobile policy, the birthday of the named insured whose birthday occurs earliest in the calendar year shall be considered the determinant birthday on that automobile policy. (b) An insured shall not receive benefits for medical expenses under more than one automobile policy.

11:3-37.13 APPENDIX B - REGULATIONS (c) If an automobile policy PIP plan provides benefits for medical expenses for an insured who is eligible for medical expense benefits under more than one automobile policy PIP plan, the automobile insurer of the paying PIP plan may seek equitable pro rata contributions from the other automobile policy PIP plan(s) for the benefits actually paid by the paying PIP plan. 11:3-37.13. Penalties. Each automobile policy or health benefits plan subject to the terms of this subchapter which fails to comply with the terms herein shall be in violation of this subchapter. Failure to comply with the terms of this subchapter may result in the assessment of any and all penalties in accordance with the laws of this State. 11:3-37.14. Severability. If any provision of this subchapter or application thereof to any person or circumstance is held invalid, the remainder of the subchapter and the application of such provision to other persons or circumstances shall not be affected thereby.