2009 Medicare Part B ASC fee schedule - FCSO
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1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,149.97 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,458.37 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.34 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,506.93 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,506.93 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 217.63 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 217.63 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 109.89 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 232.24 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 69.82 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 625.16 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,425.58 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,115.87 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,115.87 0.00 0.00<br />

C8900 A 241.62 0.00 0.00 0123T S 892.36 0.00 0.00<br />

C8901 A 196.75 0.00 0.00 0124T S 174.42 0.00 0.00<br />

C8902 A 304.52 0.00 0.00 0144T TC A 59.36 0.00 0.00<br />

C8903 A 241.62 0.00 0.00 0145T TC A 159.80 0.00 0.00<br />

C8904 A 196.75 0.00 0.00 0146T TC A 159.80 0.00 0.00<br />

C8905 A 304.52 0.00 0.00 0147T TC A 159.80 0.00 0.00<br />

C8906 A 241.62 0.00 0.00 0148T TC A 159.80 0.00 0.00<br />

C8907 A 196.75 0.00 0.00 0149T TC A 159.80 0.00 0.00<br />

C8908 A 304.52 0.00 0.00 0150T TC A 159.80 0.00 0.00<br />

C8909 A 241.62 0.00 0.00 0151T TC A 59.36 0.00 0.00<br />

C8910 A 196.75 0.00 0.00 0170T S 1,159.13 0.00 0.00<br />

C8911 A 304.52 0.00 0.00 0176T S 1,368.67 0.00 0.00<br />

C8912 A 241.62 0.00 0.00 0177T S 1,368.67 0.00 0.00<br />

C8913 A 196.75 0.00 0.00 0182T A 989.28 0.00 0.00<br />

C8914 A 304.52 0.00 0.00 0186T S 833.76 0.00 0.00<br />

C8918 A 241.62 0.00 0.00 0190T S 833.76 0.00 0.00<br />

C8919 A 196.75 0.00 0.00 0191T S 892.36 0.00 0.00<br />

C8920 A 304.52 0.00 0.00 0192T S 1,529.34 0.00 0.00<br />

C9716 S 1,159.13 0.00 0.00 10021 S 53.49 0.00 0.00<br />

C9724 S 947.72 0.00 0.00 10022 S 167.03 0.00 0.00<br />

C9725 S 218.54 0.00 0.00 10040 S 30.92 0.00 0.00<br />

C9726 S 802.32 0.00 0.00 10060 S 47.05 0.00 0.00<br />

C9727 S 281.31 0.00 0.00 10061 S 52.75 0.00 0.00<br />

C9728 S 504.75 0.00 0.00 10080 S 52.75 0.00 0.00<br />

G0104 S 81.08 0.00 0.00 10081 S 121.46 0.00 0.00<br />

G0105 S 350.45 0.00 0.00 10120 S 66.07 0.00 0.00<br />

G0121 S 350.45 0.00 0.00 10121 S 498.01 0.00 0.00<br />

G0127 S 11.34 0.00 0.00 10140 S 70.07 0.00 0.00<br />

G0130 TC A 18.69 0.00 0.00 10160 S 52.75 0.00 0.00<br />

G0173 A 2,149.97 0.00 0.00 10180 S 563.18 0.00 0.00<br />

G0186 S 217.63 0.00 0.00 11000 S 22.70 0.00 0.00<br />

G0247 S 20.69 0.00 0.00 11001 S 7.68 0.00 0.00<br />

G0251 A 538.38 0.00 0.00 11010 S 197.03 0.00 0.00<br />

G0260 S 284.12 0.00 0.00 11011 S 197.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 197.03 0.00 0.00 11601 S 108.79 0.00 0.00<br />

11040 S 20.69 0.00 0.00 11602 S 119.79 0.00 0.00<br />

11041 S 23.03 0.00 0.00 11603 S 127.13 0.00 0.00<br />

11042 S 125.11 0.00 0.00 11604 S 342.93 0.00 0.00<br />

11043 S 125.11 0.00 0.00 11606 S 498.01 0.00 0.00<br />

11044 S 325.78 0.00 0.00 11620 S 92.77 0.00 0.00<br />

11055 S 24.36 0.00 0.00 11621 S 110.12 0.00 0.00<br />

11056 S 26.69 0.00 0.00 11622 S 122.46 0.00 0.00<br />

11057 S 30.92 0.00 0.00 11623 S 131.80 0.00 0.00<br />

11100 S 56.65 0.00 0.00 11624 S 498.01 0.00 0.00<br />

11101 S 13.35 0.00 0.00 11626 S 609.02 0.00 0.00<br />

11200 S 30.92 0.00 0.00 11640 S 98.11 0.00 0.00<br />

11201 S 5.34 0.00 0.00 11641 S 115.79 0.00 0.00<br />

11300 S 30.92 0.00 0.00 11642 S 129.14 0.00 0.00<br />

11301 S 30.92 0.00 0.00 11643 S 139.15 0.00 0.00<br />

11302 S 30.92 0.00 0.00 11644 S 498.01 0.00 0.00<br />

11303 S 56.65 0.00 0.00 11646 S 609.02 0.00 0.00<br />

11305 S 30.92 0.00 0.00 11719 S 11.34 0.00 0.00<br />

11306 S 30.92 0.00 0.00 11720 S 14.02 0.00 0.00<br />

11307 S 30.92 0.00 0.00 11721 S 17.01 0.00 0.00<br />

11308 S 30.92 0.00 0.00 11730 S 30.92 0.00 0.00<br />

11310 S 30.92 0.00 0.00 11732 S 17.01 0.00 0.00<br />

11311 S 30.92 0.00 0.00 11740 S 15.62 0.00 0.00<br />

11312 S 30.92 0.00 0.00 11750 S 90.10 0.00 0.00<br />

11313 S 30.92 0.00 0.00 11752 S 125.13 0.00 0.00<br />

11400 S 63.74 0.00 0.00 11755 S 62.40 0.00 0.00<br />

11401 S 71.74 0.00 0.00 11760 S 128.51 0.00 0.00<br />

11402 S 78.75 0.00 0.00 11762 S 114.79 0.00 0.00<br />

11403 S 84.09 0.00 0.00 11765 S 30.92 0.00 0.00<br />

11404 S 447.04 0.00 0.00 11770 S 637.90 0.00 0.00<br />

11406 S 498.01 0.00 0.00 11771 S 637.90 0.00 0.00<br />

11420 S 59.73 0.00 0.00 11772 S 637.90 0.00 0.00<br />

11421 S 72.41 0.00 0.00 11900 S 28.37 0.00 0.00<br />

11422 S 79.09 0.00 0.00 11901 S 30.92 0.00 0.00<br />

11423 S 88.10 0.00 0.00 11920 S 89.76 0.00 0.00<br />

11424 S 498.01 0.00 0.00 11921 S 98.77 0.00 0.00<br />

11426 S 609.02 0.00 0.00 11922 S 32.03 0.00 0.00<br />

11440 S 68.41 0.00 0.00 11950 S 32.71 0.00 0.00<br />

11441 S 79.09 0.00 0.00 11951 S 40.71 0.00 0.00<br />

11442 S 87.09 0.00 0.00 11952 S 49.01 0.00 0.00<br />

11443 S 96.43 0.00 0.00 11954 S 49.01 0.00 0.00<br />

11444 S 304.37 0.00 0.00 11960 S 594.52 0.00 0.00<br />

11446 S 609.02 0.00 0.00 11970 S 1,076.87 0.00 0.00<br />

11450 S 609.02 0.00 0.00 11971 S 558.05 0.00 0.00<br />

11451 S 609.02 0.00 0.00 11976 S 59.73 0.00 0.00<br />

11462 S 609.02 0.00 0.00 11980 S 24.13 0.00 0.00<br />

11463 S 609.02 0.00 0.00 11981 S 24.13 0.00 0.00<br />

11470 S 609.02 0.00 0.00 11982 S 24.13 0.00 0.00<br />

11471 S 609.02 0.00 0.00 11983 S 24.13 0.00 0.00<br />

11600 S 89.76 0.00 0.00 12001 S 49.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 49.01 0.00 0.00 14021 S 528.33 0.00 0.00<br />

12004 S 49.01 0.00 0.00 14040 S 499.46 0.00 0.00<br />

12005 S 65.66 0.00 0.00 14041 S 528.33 0.00 0.00<br />

12006 S 65.66 0.00 0.00 14060 S 528.33 0.00 0.00<br />

12007 S 65.66 0.00 0.00 14061 S 528.33 0.00 0.00<br />

12011 S 49.01 0.00 0.00 14300 S 677.51 0.00 0.00<br />

12013 S 49.01 0.00 0.00 14350 S 623.38 0.00 0.00<br />

12014 S 49.01 0.00 0.00 15002 S 228.55 0.00 0.00<br />

12015 S 49.01 0.00 0.00 15003 S 228.55 0.00 0.00<br />

12016 S 65.66 0.00 0.00 15004 S 228.55 0.00 0.00<br />

12017 S 65.66 0.00 0.00 15005 S 228.55 0.00 0.00<br />

12018 S 65.66 0.00 0.00 15040 S 105.41 0.00 0.00<br />

12020 S 123.88 0.00 0.00 15050 S 228.55 0.00 0.00<br />

12021 S 105.41 0.00 0.00 15100 S 594.52 0.00 0.00<br />

12031 S 49.01 0.00 0.00 15101 S 623.38 0.00 0.00<br />

12032 S 128.51 0.00 0.00 15110 S 283.91 0.00 0.00<br />

12034 S 65.66 0.00 0.00 15111 S 232.94 0.00 0.00<br />

12035 S 65.66 0.00 0.00 15115 S 283.91 0.00 0.00<br />

12036 S 105.41 0.00 0.00 15116 S 232.94 0.00 0.00<br />

12037 S 210.09 0.00 0.00 15120 S 594.52 0.00 0.00<br />

12041 S 49.01 0.00 0.00 15121 S 623.38 0.00 0.00<br />

12042 S 49.01 0.00 0.00 15130 S 499.46 0.00 0.00<br />

12044 S 65.66 0.00 0.00 15131 S 448.48 0.00 0.00<br />

12045 S 105.41 0.00 0.00 15135 S 499.46 0.00 0.00<br />

12046 S 105.41 0.00 0.00 15136 S 448.48 0.00 0.00<br />

12047 S 210.09 0.00 0.00 15150 S 283.91 0.00 0.00<br />

12051 S 49.01 0.00 0.00 15151 S 232.94 0.00 0.00<br />

12052 S 49.01 0.00 0.00 15152 S 232.94 0.00 0.00<br />

12053 S 49.01 0.00 0.00 15155 S 283.91 0.00 0.00<br />

12054 S 65.66 0.00 0.00 15156 S 232.94 0.00 0.00<br />

12055 S 105.41 0.00 0.00 15157 S 232.94 0.00 0.00<br />

12056 S 105.41 0.00 0.00 15170 S 128.51 0.00 0.00<br />

12057 S 210.09 0.00 0.00 15171 S 128.51 0.00 0.00<br />

13100 S 228.55 0.00 0.00 15175 S 165.45 0.00 0.00<br />

13101 S 228.55 0.00 0.00 15176 S 165.45 0.00 0.00<br />

13102 S 123.88 0.00 0.00 15200 S 528.33 0.00 0.00<br />

13120 S 105.41 0.00 0.00 15201 S 444.11 0.00 0.00<br />

13121 S 105.41 0.00 0.00 15220 S 499.46 0.00 0.00<br />

13122 S 105.41 0.00 0.00 15221 S 228.55 0.00 0.00<br />

13131 S 105.41 0.00 0.00 15240 S 528.33 0.00 0.00<br />

13132 S 105.41 0.00 0.00 15241 S 228.55 0.00 0.00<br />

13133 S 105.41 0.00 0.00 15260 S 499.46 0.00 0.00<br />

13150 S 228.55 0.00 0.00 15261 S 444.11 0.00 0.00<br />

13151 S 228.55 0.00 0.00 15300 S 228.55 0.00 0.00<br />

13152 S 228.55 0.00 0.00 15301 S 228.55 0.00 0.00<br />

13153 S 105.41 0.00 0.00 15320 S 228.55 0.00 0.00<br />

13160 S 594.52 0.00 0.00 15321 S 228.55 0.00 0.00<br />

14000 S 499.46 0.00 0.00 15330 S 228.55 0.00 0.00<br />

14001 S 528.33 0.00 0.00 15331 S 228.55 0.00 0.00<br />

14020 S 528.33 0.00 0.00 15335 S 228.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 228.55 0.00 0.00 15826 S 623.38 0.00 0.00<br />

15340 S 128.51 0.00 0.00 15828 S 623.38 0.00 0.00<br />

15341 S 128.51 0.00 0.00 15829 S 716.75 0.00 0.00<br />

15360 S 128.51 0.00 0.00 15830 S 637.90 0.00 0.00<br />

15361 S 128.51 0.00 0.00 15832 S 637.90 0.00 0.00<br />

15365 S 128.51 0.00 0.00 15833 S 637.90 0.00 0.00<br />

15366 S 128.51 0.00 0.00 15834 S 637.90 0.00 0.00<br />

15400 S 228.55 0.00 0.00 15835 S 553.67 0.00 0.00<br />

15401 S 228.55 0.00 0.00 15836 S 526.88 0.00 0.00<br />

15420 S 228.55 0.00 0.00 15837 S 593.66 0.00 0.00<br />

15421 S 228.55 0.00 0.00 15838 S 593.66 0.00 0.00<br />

15430 S 228.55 0.00 0.00 15839 S 526.88 0.00 0.00<br />

15431 S 228.55 0.00 0.00 15840 S 677.51 0.00 0.00<br />

15570 S 623.38 0.00 0.00 15841 S 677.51 0.00 0.00<br />

15572 S 623.38 0.00 0.00 15842 S 786.66 0.00 0.00<br />

15574 S 623.38 0.00 0.00 15845 S 677.51 0.00 0.00<br />

15576 S 623.38 0.00 0.00 15847 S 637.90 0.00 0.00<br />

15600 S 623.38 0.00 0.00 15850 S 101.90 0.00 0.00<br />

15610 S 623.38 0.00 0.00 15851 S 46.38 0.00 0.00<br />

15620 S 677.51 0.00 0.00 15852 S 24.13 0.00 0.00<br />

15630 S 623.38 0.00 0.00 15860 S 24.13 0.00 0.00<br />

15650 S 716.75 0.00 0.00 15876 S 623.38 0.00 0.00<br />

15731 S 623.38 0.00 0.00 15877 S 623.38 0.00 0.00<br />

15732 S 623.38 0.00 0.00 15878 S 623.38 0.00 0.00<br />

15734 S 623.38 0.00 0.00 15879 S 623.38 0.00 0.00<br />

15736 S 623.38 0.00 0.00 15920 S 197.03 0.00 0.00<br />

15738 S 623.38 0.00 0.00 15922 S 677.51 0.00 0.00<br />

15740 S 499.46 0.00 0.00 15931 S 637.90 0.00 0.00<br />

15750 S 594.52 0.00 0.00 15933 S 637.90 0.00 0.00<br />

15760 S 594.52 0.00 0.00 15934 S 623.38 0.00 0.00<br />

15770 S 623.38 0.00 0.00 15935 S 677.51 0.00 0.00<br />

15775 S 170.33 0.00 0.00 15936 S 582.46 0.00 0.00<br />

15776 S 170.33 0.00 0.00 15937 S 677.51 0.00 0.00<br />

15780 S 379.74 0.00 0.00 15940 S 637.90 0.00 0.00<br />

15781 S 167.15 0.00 0.00 15941 S 637.90 0.00 0.00<br />

15782 S 167.15 0.00 0.00 15944 S 623.38 0.00 0.00<br />

15783 S 101.90 0.00 0.00 15945 S 677.51 0.00 0.00<br />

15786 S 30.92 0.00 0.00 15946 S 677.51 0.00 0.00<br />

15787 S 28.03 0.00 0.00 15950 S 637.90 0.00 0.00<br />

15788 S 30.92 0.00 0.00 15951 S 692.02 0.00 0.00<br />

15789 S 56.65 0.00 0.00 15952 S 528.33 0.00 0.00<br />

15792 S 56.65 0.00 0.00 15953 S 582.46 0.00 0.00<br />

15793 S 30.92 0.00 0.00 15956 S 528.33 0.00 0.00<br />

15819 S 128.51 0.00 0.00 15958 S 582.46 0.00 0.00<br />

15820 S 623.38 0.00 0.00 16000 S 25.03 0.00 0.00<br />

15821 S 623.38 0.00 0.00 16020 S 38.04 0.00 0.00<br />

15822 S 623.38 0.00 0.00 16025 S 58.59 0.00 0.00<br />

15823 S 716.75 0.00 0.00 16030 S 73.36 0.00 0.00<br />

15824 S 623.38 0.00 0.00 16035 S 56.65 0.00 0.00<br />

15825 S 623.38 0.00 0.00 17000 S 30.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.67 0.00 0.00 19300 S 685.34 0.00 0.00<br />

17004 S 80.75 0.00 0.00 19301 S 631.22 0.00 0.00<br />

17106 S 101.90 0.00 0.00 19302 S 1,205.55 0.00 0.00<br />

17107 S 101.90 0.00 0.00 19303 S 911.07 0.00 0.00<br />

17108 S 101.90 0.00 0.00 19304 S 911.07 0.00 0.00<br />

17110 S 30.92 0.00 0.00 19316 S 911.07 0.00 0.00<br />

17111 S 56.65 0.00 0.00 19318 S 1,040.91 0.00 0.00<br />

17250 S 42.72 0.00 0.00 19324 S 1,040.91 0.00 0.00<br />

17260 S 45.71 0.00 0.00 19325 S 1,726.47 0.00 0.00<br />

17261 S 56.65 0.00 0.00 19328 S 777.10 0.00 0.00<br />

17262 S 56.65 0.00 0.00 19330 S 777.10 0.00 0.00<br />

17263 S 56.65 0.00 0.00 19340 S 957.91 0.00 0.00<br />

17264 S 56.65 0.00 0.00 19342 S 1,352.52 0.00 0.00<br />

17266 S 101.90 0.00 0.00 19350 S 685.34 0.00 0.00<br />

17270 S 56.65 0.00 0.00 19355 S 911.07 0.00 0.00<br />

17271 S 56.65 0.00 0.00 19357 S 1,445.89 0.00 0.00<br />

17272 S 56.65 0.00 0.00 19366 S 950.32 0.00 0.00<br />

17273 S 101.90 0.00 0.00 19370 S 911.07 0.00 0.00<br />

17274 S 101.90 0.00 0.00 19371 S 911.07 0.00 0.00<br />

17276 S 101.90 0.00 0.00 19380 S 1,080.15 0.00 0.00<br />

17280 S 56.65 0.00 0.00 19396 S 1,253.78 0.00 0.00<br />

17281 S 84.42 0.00 0.00 20000 S 52.75 0.00 0.00<br />

17282 S 96.43 0.00 0.00 20005 S 607.87 0.00 0.00<br />

17283 S 101.90 0.00 0.00 20103 S 596.56 0.00 0.00<br />

17284 S 101.90 0.00 0.00 20150 S 1,693.64 0.00 0.00<br />

17286 S 101.90 0.00 0.00 20200 S 498.01 0.00 0.00<br />

17311 S 168.22 0.00 0.00 20205 S 526.88 0.00 0.00<br />

17312 S 168.22 0.00 0.00 20206 S 246.20 0.00 0.00<br />

17313 S 168.22 0.00 0.00 20220 S 267.62 0.00 0.00<br />

17314 S 168.22 0.00 0.00 20225 S 485.60 0.00 0.00<br />

17315 S 38.04 0.00 0.00 20240 S 609.02 0.00 0.00<br />

17340 S 13.68 0.00 0.00 20245 S 637.90 0.00 0.00<br />

17360 S 30.92 0.00 0.00 20250 S 636.74 0.00 0.00<br />

17380 S 30.92 0.00 0.00 20251 S 636.74 0.00 0.00<br />

19000 S 64.40 0.00 0.00 20500 S 52.73 0.00 0.00<br />

19001 S 8.68 0.00 0.00 20520 S 88.76 0.00 0.00<br />

19020 S 563.18 0.00 0.00 20525 S 637.90 0.00 0.00<br />

19100 S 191.78 0.00 0.00 20526 S 28.70 0.00 0.00<br />

19101 S 602.34 0.00 0.00 20550 S 21.69 0.00 0.00<br />

19102 S 246.20 0.00 0.00 20551 S 21.35 0.00 0.00<br />

19103 S 430.92 0.00 0.00 20552 S 20.69 0.00 0.00<br />

19105 S 1,253.78 0.00 0.00 20553 S 23.03 0.00 0.00<br />

19110 S 602.34 0.00 0.00 20555 S 1,115.87 0.00 0.00<br />

19112 S 631.22 0.00 0.00 20600 S 22.02 0.00 0.00<br />

19120 S 631.22 0.00 0.00 20605 S 24.69 0.00 0.00<br />

19125 S 631.22 0.00 0.00 20610 S 34.70 0.00 0.00<br />

19126 S 631.22 0.00 0.00 20612 S 23.36 0.00 0.00<br />

19296 S 1,726.47 0.00 0.00 20615 S 97.78 0.00 0.00<br />

19297 S 1,726.47 0.00 0.00 20650 S 636.74 0.00 0.00<br />

19298 S 1,726.47 0.00 0.00 20662 S 813.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 813.37 0.00 0.00 21085 S 244.93 0.00 0.00<br />

20665 S 24.13 0.00 0.00 21086 S 533.23 0.00 0.00<br />

20670 S 447.04 0.00 0.00 21087 S 533.91 0.00 0.00<br />

20680 S 637.90 0.00 0.00 21088 S 1,563.71 0.00 0.00<br />

20690 S 759.12 0.00 0.00 21100 S 983.03 0.00 0.00<br />

20692 S 787.99 0.00 0.00 21110 S 281.31 0.00 0.00<br />

20693 S 636.74 0.00 0.00 21120 S 911.05 0.00 0.00<br />

20694 S 556.90 0.00 0.00 21121 S 911.05 0.00 0.00<br />

20696 S 1,115.87 0.00 0.00 21122 S 911.05 0.00 0.00<br />

20697 S 742.10 0.00 0.00 21123 S 911.05 0.00 0.00<br />

20822 S 1,045.59 0.00 0.00 21125 S 911.05 0.00 0.00<br />

20900 S 787.99 0.00 0.00 21127 S 1,385.85 0.00 0.00<br />

20902 S 842.12 0.00 0.00 21137 S 924.46 0.00 0.00<br />

20910 S 623.38 0.00 0.00 21138 S 1,563.71 0.00 0.00<br />

20912 S 623.38 0.00 0.00 21139 S 1,563.71 0.00 0.00<br />

20920 S 582.46 0.00 0.00 21150 S 1,563.71 0.00 0.00<br />

20922 S 528.33 0.00 0.00 21181 S 911.05 0.00 0.00<br />

20924 S 842.12 0.00 0.00 21198 S 1,563.71 0.00 0.00<br />

20926 S 366.91 0.00 0.00 21199 S 1,563.71 0.00 0.00<br />

20950 S 52.75 0.00 0.00 21206 S 1,105.28 0.00 0.00<br />

20972 S 1,766.02 0.00 0.00 21208 S 1,230.68 0.00 0.00<br />

20973 S 1,766.02 0.00 0.00 21209 S 1,105.28 0.00 0.00<br />

20979 S 21.69 0.00 0.00 21210 S 1,230.68 0.00 0.00<br />

20982 S 1,693.64 0.00 0.00 21215 S 1,230.68 0.00 0.00<br />

21010 S 663.41 0.00 0.00 21230 S 1,230.68 0.00 0.00<br />

21015 S 551.96 0.00 0.00 21235 S 911.05 0.00 0.00<br />

21025 S 983.03 0.00 0.00 21240 S 1,066.03 0.00 0.00<br />

21026 S 983.03 0.00 0.00 21242 S 1,105.28 0.00 0.00<br />

21029 S 983.03 0.00 0.00 21243 S 1,105.28 0.00 0.00<br />

21030 S 231.91 0.00 0.00 21244 S 1,230.68 0.00 0.00<br />

21031 S 191.87 0.00 0.00 21245 S 1,230.68 0.00 0.00<br />

21032 S 195.54 0.00 0.00 21246 S 1,230.68 0.00 0.00<br />

21034 S 1,011.91 0.00 0.00 21248 S 1,230.68 0.00 0.00<br />

21040 S 663.41 0.00 0.00 21249 S 1,230.68 0.00 0.00<br />

21044 S 983.03 0.00 0.00 21260 S 1,563.71 0.00 0.00<br />

21046 S 983.03 0.00 0.00 21267 S 1,230.68 0.00 0.00<br />

21047 S 983.03 0.00 0.00 21270 S 1,105.28 0.00 0.00<br />

21048 S 1,563.71 0.00 0.00 21275 S 1,230.68 0.00 0.00<br />

21050 S 1,011.91 0.00 0.00 21280 S 1,105.28 0.00 0.00<br />

21060 S 983.03 0.00 0.00 21282 S 645.33 0.00 0.00<br />

21070 S 1,011.91 0.00 0.00 21295 S 290.86 0.00 0.00<br />

21073 S 180.19 0.00 0.00 21296 S 612.44 0.00 0.00<br />

21076 S 312.66 0.00 0.00 21310 S 88.73 0.00 0.00<br />

21077 S 755.81 0.00 0.00 21315 S 389.89 0.00 0.00<br />

21079 S 541.24 0.00 0.00 21320 S 523.08 0.00 0.00<br />

21080 S 620.66 0.00 0.00 21325 S 746.41 0.00 0.00<br />

21081 S 571.94 0.00 0.00 21330 S 785.65 0.00 0.00<br />

21082 S 544.25 0.00 0.00 21335 S 911.05 0.00 0.00<br />

21083 S 536.24 0.00 0.00 21336 S 759.27 0.00 0.00<br />

21084 S 616.99 0.00 0.00 21337 S 523.08 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 746.41 0.00 0.00 22310 S 161.53 0.00 0.00<br />

21339 S 785.65 0.00 0.00 22315 S 417.79 0.00 0.00<br />

21340 S 1,066.03 0.00 0.00 22505 S 491.85 0.00 0.00<br />

21345 S 911.05 0.00 0.00 22520 S 1,161.93 0.00 0.00<br />

21355 S 1,011.91 0.00 0.00 22521 S 1,161.93 0.00 0.00<br />

21356 S 692.28 0.00 0.00 22522 S 1,161.93 0.00 0.00<br />

21360 S 924.46 0.00 0.00 22523 S 3,233.77 0.00 0.00<br />

21390 S 1,563.71 0.00 0.00 22524 S 3,233.77 0.00 0.00<br />

21400 S 341.83 0.00 0.00 22525 S 3,233.77 0.00 0.00<br />

21401 S 551.96 0.00 0.00 22900 S 692.02 0.00 0.00<br />

21406 S 1,563.71 0.00 0.00 23000 S 498.01 0.00 0.00<br />

21407 S 1,563.71 0.00 0.00 23020 S 1,048.00 0.00 0.00<br />

21421 S 746.41 0.00 0.00 23030 S 512.20 0.00 0.00<br />

21440 S 314.34 0.00 0.00 23031 S 592.04 0.00 0.00<br />

21445 S 746.41 0.00 0.00 23035 S 636.74 0.00 0.00<br />

21450 S 129.73 0.00 0.00 23040 S 787.99 0.00 0.00<br />

21451 S 350.02 0.00 0.00 23044 S 842.12 0.00 0.00<br />

21452 S 523.08 0.00 0.00 23065 S 94.10 0.00 0.00<br />

21453 S 1,011.91 0.00 0.00 23066 S 609.02 0.00 0.00<br />

21454 S 785.65 0.00 0.00 23075 S 498.01 0.00 0.00<br />

21461 S 1,066.03 0.00 0.00 23076 S 609.02 0.00 0.00<br />

21462 S 1,105.28 0.00 0.00 23077 S 637.90 0.00 0.00<br />

21465 S 1,066.03 0.00 0.00 23100 S 607.87 0.00 0.00<br />

21480 S 88.73 0.00 0.00 23101 S 1,006.77 0.00 0.00<br />

21485 S 523.08 0.00 0.00 23105 S 842.12 0.00 0.00<br />

21490 S 1,011.91 0.00 0.00 23106 S 842.12 0.00 0.00<br />

21495 S 643.80 0.00 0.00 23107 S 842.12 0.00 0.00<br />

21497 S 523.08 0.00 0.00 23120 S 881.36 0.00 0.00<br />

21501 S 563.18 0.00 0.00 23125 S 881.36 0.00 0.00<br />

21502 S 607.87 0.00 0.00 23130 S 1,170.24 0.00 0.00<br />

21550 S 593.66 0.00 0.00 23140 S 690.87 0.00 0.00<br />

21555 S 609.02 0.00 0.00 23145 S 881.36 0.00 0.00<br />

21556 S 609.02 0.00 0.00 23146 S 881.36 0.00 0.00<br />

21557 S 815.68 0.00 0.00 23150 S 842.12 0.00 0.00<br />

21600 S 759.12 0.00 0.00 23155 S 881.36 0.00 0.00<br />

21610 S 759.12 0.00 0.00 23156 S 881.36 0.00 0.00<br />

21685 S 281.31 0.00 0.00 23170 S 759.12 0.00 0.00<br />

21700 S 607.87 0.00 0.00 23172 S 759.12 0.00 0.00<br />

21720 S 636.74 0.00 0.00 23174 S 759.12 0.00 0.00<br />

21725 S 66.28 0.00 0.00 23180 S 842.12 0.00 0.00<br />

21800 S 76.57 0.00 0.00 23182 S 842.12 0.00 0.00<br />

21805 S 676.27 0.00 0.00 23184 S 842.12 0.00 0.00<br />

21820 S 76.57 0.00 0.00 23190 S 842.12 0.00 0.00<br />

21920 S 136.14 0.00 0.00 23195 S 881.36 0.00 0.00<br />

21925 S 609.02 0.00 0.00 23330 S 304.37 0.00 0.00<br />

21930 S 609.02 0.00 0.00 23331 S 558.05 0.00 0.00<br />

21935 S 637.90 0.00 0.00 23395 S 1,170.24 0.00 0.00<br />

22102 S 1,815.14 0.00 0.00 23397 S 2,065.71 0.00 0.00<br />

22103 S 1,815.14 0.00 0.00 23400 S 1,006.77 0.00 0.00<br />

22305 S 76.57 0.00 0.00 23405 S 759.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 759.12 0.00 0.00 23931 S 563.18 0.00 0.00<br />

23410 S 1,170.24 0.00 0.00 23935 S 607.87 0.00 0.00<br />

23412 S 1,295.64 0.00 0.00 24000 S 842.12 0.00 0.00<br />

23415 S 1,170.24 0.00 0.00 24006 S 842.12 0.00 0.00<br />

23420 S 1,295.64 0.00 0.00 24065 S 130.47 0.00 0.00<br />

23430 S 1,131.00 0.00 0.00 24066 S 498.01 0.00 0.00<br />

23440 S 1,131.00 0.00 0.00 24075 S 498.01 0.00 0.00<br />

23450 S 1,940.31 0.00 0.00 24076 S 609.02 0.00 0.00<br />

23455 S 2,065.71 0.00 0.00 24077 S 637.90 0.00 0.00<br />

23460 S 1,940.31 0.00 0.00 24100 S 556.90 0.00 0.00<br />

23462 S 1,295.64 0.00 0.00 24101 S 842.12 0.00 0.00<br />

23465 S 1,940.31 0.00 0.00 24102 S 842.12 0.00 0.00<br />

23466 S 1,295.64 0.00 0.00 24105 S 636.74 0.00 0.00<br />

23480 S 1,131.00 0.00 0.00 24110 S 607.87 0.00 0.00<br />

23485 S 2,065.71 0.00 0.00 24115 S 787.99 0.00 0.00<br />

23490 S 1,076.87 0.00 0.00 24116 S 787.99 0.00 0.00<br />

23491 S 1,846.94 0.00 0.00 24120 S 636.74 0.00 0.00<br />

23500 S 76.57 0.00 0.00 24125 S 787.99 0.00 0.00<br />

23505 S 417.79 0.00 0.00 24126 S 787.99 0.00 0.00<br />

23515 S 1,398.32 0.00 0.00 24130 S 787.99 0.00 0.00<br />

23520 S 161.53 0.00 0.00 24134 S 759.12 0.00 0.00<br />

23525 S 161.53 0.00 0.00 24136 S 759.12 0.00 0.00<br />

23530 S 1,030.42 0.00 0.00 24138 S 759.12 0.00 0.00<br />

23532 S 759.27 0.00 0.00 24140 S 787.99 0.00 0.00<br />

23540 S 76.57 0.00 0.00 24145 S 787.99 0.00 0.00<br />

23545 S 161.53 0.00 0.00 24147 S 759.12 0.00 0.00<br />

23550 S 1,030.42 0.00 0.00 24149 S 1,115.87 0.00 0.00<br />

23552 S 1,084.56 0.00 0.00 24152 S 1,693.64 0.00 0.00<br />

23570 S 76.57 0.00 0.00 24153 S 3,233.77 0.00 0.00<br />

23575 S 161.53 0.00 0.00 24155 S 1,076.87 0.00 0.00<br />

23585 S 1,398.32 0.00 0.00 24160 S 759.12 0.00 0.00<br />

23600 S 59.67 0.00 0.00 24164 S 787.99 0.00 0.00<br />

23605 S 417.79 0.00 0.00 24200 S 95.43 0.00 0.00<br />

23615 S 1,452.44 0.00 0.00 24201 S 498.01 0.00 0.00<br />

23616 S 1,452.44 0.00 0.00 24300 S 581.33 0.00 0.00<br />

23620 S 59.67 0.00 0.00 24301 S 842.12 0.00 0.00<br />

23625 S 417.79 0.00 0.00 24305 S 842.12 0.00 0.00<br />

23630 S 1,491.69 0.00 0.00 24310 S 636.74 0.00 0.00<br />

23650 S 76.57 0.00 0.00 24320 S 1,076.87 0.00 0.00<br />

23655 S 440.88 0.00 0.00 24330 S 1,846.94 0.00 0.00<br />

23660 S 1,030.42 0.00 0.00 24331 S 1,076.87 0.00 0.00<br />

23665 S 161.53 0.00 0.00 24332 S 813.37 0.00 0.00<br />

23670 S 1,398.32 0.00 0.00 24340 S 1,076.87 0.00 0.00<br />

23675 S 76.57 0.00 0.00 24341 S 1,076.87 0.00 0.00<br />

23680 S 1,030.42 0.00 0.00 24342 S 1,076.87 0.00 0.00<br />

23700 S 440.88 0.00 0.00 24343 S 1,115.87 0.00 0.00<br />

23800 S 1,901.06 0.00 0.00 24344 S 3,233.77 0.00 0.00<br />

23802 S 1,295.64 0.00 0.00 24345 S 759.12 0.00 0.00<br />

23921 S 444.11 0.00 0.00 24346 S 1,693.64 0.00 0.00<br />

23930 S 512.20 0.00 0.00 24357 S 1,115.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,115.87 0.00 0.00 24925 S 636.74 0.00 0.00<br />

24359 S 1,115.87 0.00 0.00 25000 S 636.74 0.00 0.00<br />

24360 S 1,029.79 0.00 0.00 25001 S 813.37 0.00 0.00<br />

24361 S 5,630.42 3,446.53 1,262.64 25020 S 636.74 0.00 0.00<br />

24362 S 1,316.07 0.00 0.00 25023 S 787.99 0.00 0.00<br />

24363 S 5,755.82 3,571.93 1,388.04 25024 S 787.99 0.00 0.00<br />

24365 S 1,029.79 0.00 0.00 25025 S 787.99 0.00 0.00<br />

24366 S 5,630.42 3,446.53 1,262.64 25028 S 556.90 0.00 0.00<br />

24400 S 842.12 0.00 0.00 25031 S 607.87 0.00 0.00<br />

24410 S 842.12 0.00 0.00 25035 S 607.87 0.00 0.00<br />

24420 S 1,076.87 0.00 0.00 25040 S 881.36 0.00 0.00<br />

24430 S 1,846.94 0.00 0.00 25065 S 132.47 0.00 0.00<br />

24435 S 1,901.06 0.00 0.00 25066 S 609.02 0.00 0.00<br />

24470 S 1,076.87 0.00 0.00 25075 S 498.01 0.00 0.00<br />

24495 S 759.12 0.00 0.00 25076 S 637.90 0.00 0.00<br />

24498 S 1,846.94 0.00 0.00 25077 S 637.90 0.00 0.00<br />

24500 S 76.57 0.00 0.00 25085 S 636.74 0.00 0.00<br />

24505 S 76.57 0.00 0.00 25100 S 607.87 0.00 0.00<br />

24515 S 1,452.44 0.00 0.00 25101 S 787.99 0.00 0.00<br />

24516 S 1,452.44 0.00 0.00 25105 S 842.12 0.00 0.00<br />

24530 S 76.57 0.00 0.00 25107 S 787.99 0.00 0.00<br />

24535 S 161.53 0.00 0.00 25109 S 813.37 0.00 0.00<br />

24538 S 676.27 0.00 0.00 25110 S 636.74 0.00 0.00<br />

24545 S 1,452.44 0.00 0.00 25111 S 636.74 0.00 0.00<br />

24546 S 1,491.69 0.00 0.00 25112 S 690.87 0.00 0.00<br />

24560 S 76.57 0.00 0.00 25115 S 690.87 0.00 0.00<br />

24565 S 76.57 0.00 0.00 25116 S 690.87 0.00 0.00<br />

24566 S 676.27 0.00 0.00 25118 S 759.12 0.00 0.00<br />

24575 S 1,398.32 0.00 0.00 25119 S 787.99 0.00 0.00<br />

24576 S 76.57 0.00 0.00 25120 S 787.99 0.00 0.00<br />

24577 S 161.53 0.00 0.00 25125 S 787.99 0.00 0.00<br />

24579 S 1,398.32 0.00 0.00 25126 S 787.99 0.00 0.00<br />

24582 S 676.27 0.00 0.00 25130 S 787.99 0.00 0.00<br />

24586 S 1,452.44 0.00 0.00 25135 S 787.99 0.00 0.00<br />

24587 S 1,491.69 0.00 0.00 25136 S 787.99 0.00 0.00<br />

24600 S 76.57 0.00 0.00 25145 S 759.12 0.00 0.00<br />

24605 S 491.85 0.00 0.00 25150 S 759.12 0.00 0.00<br />

24615 S 1,398.32 0.00 0.00 25151 S 759.12 0.00 0.00<br />

24620 S 417.79 0.00 0.00 25210 S 787.99 0.00 0.00<br />

24635 S 1,398.32 0.00 0.00 25215 S 842.12 0.00 0.00<br />

24640 S 51.72 0.00 0.00 25230 S 842.12 0.00 0.00<br />

24650 S 59.67 0.00 0.00 25240 S 842.12 0.00 0.00<br />

24655 S 161.53 0.00 0.00 25248 S 607.87 0.00 0.00<br />

24665 S 1,084.56 0.00 0.00 25250 S 708.15 0.00 0.00<br />

24666 S 1,452.44 0.00 0.00 25251 S 708.15 0.00 0.00<br />

24670 S 76.57 0.00 0.00 25259 S 742.10 0.00 0.00<br />

24675 S 76.57 0.00 0.00 25260 S 842.12 0.00 0.00<br />

24685 S 1,030.42 0.00 0.00 25263 S 759.12 0.00 0.00<br />

24800 S 1,131.00 0.00 0.00 25265 S 787.99 0.00 0.00<br />

24802 S 1,170.24 0.00 0.00 25270 S 842.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 787.99 0.00 0.00 25505 S 161.53 0.00 0.00<br />

25274 S 842.12 0.00 0.00 25515 S 1,030.42 0.00 0.00<br />

25275 S 842.12 0.00 0.00 25520 S 161.53 0.00 0.00<br />

25280 S 842.12 0.00 0.00 25525 S 1,084.56 0.00 0.00<br />

25290 S 787.99 0.00 0.00 25526 S 1,123.79 0.00 0.00<br />

25295 S 636.74 0.00 0.00 25530 S 59.67 0.00 0.00<br />

25300 S 787.99 0.00 0.00 25535 S 76.57 0.00 0.00<br />

25301 S 787.99 0.00 0.00 25545 S 1,030.42 0.00 0.00<br />

25310 S 1,076.87 0.00 0.00 25560 S 59.67 0.00 0.00<br />

25312 S 1,131.00 0.00 0.00 25565 S 161.53 0.00 0.00<br />

25315 S 1,076.87 0.00 0.00 25574 S 1,398.32 0.00 0.00<br />

25316 S 1,846.94 0.00 0.00 25575 S 1,398.32 0.00 0.00<br />

25320 S 1,076.87 0.00 0.00 25600 S 59.67 0.00 0.00<br />

25332 S 1,029.79 0.00 0.00 25605 S 161.53 0.00 0.00<br />

25335 S 1,076.87 0.00 0.00 25606 S 705.14 0.00 0.00<br />

25337 S 1,170.24 0.00 0.00 25607 S 1,491.69 0.00 0.00<br />

25350 S 1,846.94 0.00 0.00 25608 S 1,491.69 0.00 0.00<br />

25355 S 1,076.87 0.00 0.00 25609 S 1,491.69 0.00 0.00<br />

25360 S 787.99 0.00 0.00 25622 S 59.67 0.00 0.00<br />

25365 S 787.99 0.00 0.00 25624 S 161.53 0.00 0.00<br />

25370 S 1,076.87 0.00 0.00 25628 S 1,030.42 0.00 0.00<br />

25375 S 1,131.00 0.00 0.00 25630 S 59.67 0.00 0.00<br />

25390 S 787.99 0.00 0.00 25635 S 161.53 0.00 0.00<br />

25391 S 1,131.00 0.00 0.00 25645 S 1,030.42 0.00 0.00<br />

25392 S 787.99 0.00 0.00 25650 S 59.67 0.00 0.00<br />

25393 S 1,131.00 0.00 0.00 25651 S 950.17 0.00 0.00<br />

25394 S 1,693.64 0.00 0.00 25652 S 1,600.73 0.00 0.00<br />

25400 S 1,076.87 0.00 0.00 25660 S 76.57 0.00 0.00<br />

25405 S 1,901.06 0.00 0.00 25670 S 705.14 0.00 0.00<br />

25415 S 1,846.94 0.00 0.00 25671 S 625.30 0.00 0.00<br />

25420 S 1,901.06 0.00 0.00 25675 S 76.57 0.00 0.00<br />

25425 S 1,076.87 0.00 0.00 25676 S 676.27 0.00 0.00<br />

25426 S 1,131.00 0.00 0.00 25680 S 76.57 0.00 0.00<br />

25430 S 1,693.64 0.00 0.00 25685 S 705.14 0.00 0.00<br />

25431 S 1,693.64 0.00 0.00 25690 S 417.79 0.00 0.00<br />

25440 S 1,901.06 0.00 0.00 25695 S 676.27 0.00 0.00<br />

25441 S 5,630.42 3,446.53 1,262.64 25800 S 1,901.06 0.00 0.00<br />

25442 S 5,630.42 3,446.53 1,262.64 25805 S 1,170.24 0.00 0.00<br />

25443 S 1,316.07 0.00 0.00 25810 S 1,940.31 0.00 0.00<br />

25444 S 1,316.07 0.00 0.00 25820 S 1,131.00 0.00 0.00<br />

25445 S 1,316.07 0.00 0.00 25825 S 1,940.31 0.00 0.00<br />

25446 S 5,755.82 3,571.93 1,388.04 25830 S 1,940.31 0.00 0.00<br />

25447 S 1,029.79 0.00 0.00 25907 S 636.74 0.00 0.00<br />

25449 S 1,029.79 0.00 0.00 25922 S 636.74 0.00 0.00<br />

25450 S 1,076.87 0.00 0.00 25929 S 528.33 0.00 0.00<br />

25455 S 1,076.87 0.00 0.00 25931 S 813.37 0.00 0.00<br />

25490 S 1,076.87 0.00 0.00 26010 S 52.75 0.00 0.00<br />

25491 S 1,076.87 0.00 0.00 26011 S 385.38 0.00 0.00<br />

25492 S 1,076.87 0.00 0.00 26020 S 511.36 0.00 0.00<br />

25500 S 59.67 0.00 0.00 26025 S 460.38 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 511.36 0.00 0.00 26392 S 752.84 0.00 0.00<br />

26034 S 511.36 0.00 0.00 26410 S 540.22 0.00 0.00<br />

26035 S 620.35 0.00 0.00 26412 S 752.84 0.00 0.00<br />

26040 S 806.98 0.00 0.00 26415 S 806.98 0.00 0.00<br />

26045 S 752.84 0.00 0.00 26416 S 752.84 0.00 0.00<br />

26055 S 511.36 0.00 0.00 26418 S 594.36 0.00 0.00<br />

26060 S 511.36 0.00 0.00 26420 S 806.98 0.00 0.00<br />

26070 S 511.36 0.00 0.00 26426 S 752.84 0.00 0.00<br />

26075 S 594.36 0.00 0.00 26428 S 752.84 0.00 0.00<br />

26080 S 594.36 0.00 0.00 26432 S 540.22 0.00 0.00<br />

26100 S 511.36 0.00 0.00 26433 S 540.22 0.00 0.00<br />

26105 S 460.38 0.00 0.00 26434 S 752.84 0.00 0.00<br />

26110 S 460.38 0.00 0.00 26437 S 540.22 0.00 0.00<br />

26115 S 609.02 0.00 0.00 26440 S 540.22 0.00 0.00<br />

26116 S 609.02 0.00 0.00 26442 S 752.84 0.00 0.00<br />

26117 S 637.90 0.00 0.00 26445 S 540.22 0.00 0.00<br />

26121 S 806.98 0.00 0.00 26449 S 752.84 0.00 0.00<br />

26123 S 806.98 0.00 0.00 26450 S 540.22 0.00 0.00<br />

26125 S 594.36 0.00 0.00 26455 S 540.22 0.00 0.00<br />

26130 S 540.22 0.00 0.00 26460 S 540.22 0.00 0.00<br />

26135 S 806.98 0.00 0.00 26471 S 511.36 0.00 0.00<br />

26140 S 511.36 0.00 0.00 26474 S 511.36 0.00 0.00<br />

26145 S 540.22 0.00 0.00 26476 S 460.38 0.00 0.00<br />

26160 S 540.22 0.00 0.00 26477 S 460.38 0.00 0.00<br />

26170 S 540.22 0.00 0.00 26478 S 460.38 0.00 0.00<br />

26180 S 540.22 0.00 0.00 26479 S 460.38 0.00 0.00<br />

26185 S 594.36 0.00 0.00 26480 S 752.84 0.00 0.00<br />

26200 S 511.36 0.00 0.00 26483 S 752.84 0.00 0.00<br />

26205 S 752.84 0.00 0.00 26485 S 723.98 0.00 0.00<br />

26210 S 511.36 0.00 0.00 26489 S 752.84 0.00 0.00<br />

26215 S 540.22 0.00 0.00 26490 S 752.84 0.00 0.00<br />

26230 S 758.07 0.00 0.00 26492 S 752.84 0.00 0.00<br />

26235 S 540.22 0.00 0.00 26494 S 752.84 0.00 0.00<br />

26236 S 540.22 0.00 0.00 26496 S 752.84 0.00 0.00<br />

26250 S 540.22 0.00 0.00 26497 S 752.84 0.00 0.00<br />

26255 S 752.84 0.00 0.00 26498 S 806.98 0.00 0.00<br />

26260 S 540.22 0.00 0.00 26499 S 752.84 0.00 0.00<br />

26261 S 540.22 0.00 0.00 26500 S 594.36 0.00 0.00<br />

26262 S 511.36 0.00 0.00 26502 S 806.98 0.00 0.00<br />

26320 S 498.01 0.00 0.00 26508 S 540.22 0.00 0.00<br />

26340 S 229.58 0.00 0.00 26510 S 752.84 0.00 0.00<br />

26350 S 673.00 0.00 0.00 26516 S 673.00 0.00 0.00<br />

26352 S 806.98 0.00 0.00 26517 S 752.84 0.00 0.00<br />

26356 S 806.98 0.00 0.00 26518 S 752.84 0.00 0.00<br />

26357 S 806.98 0.00 0.00 26520 S 540.22 0.00 0.00<br />

26358 S 806.98 0.00 0.00 26525 S 540.22 0.00 0.00<br />

26370 S 806.98 0.00 0.00 26530 S 936.42 0.00 0.00<br />

26372 S 806.98 0.00 0.00 26531 S 1,441.47 0.00 0.00<br />

26373 S 752.84 0.00 0.00 26535 S 1,029.79 0.00 0.00<br />

26390 S 806.98 0.00 0.00 26536 S 1,316.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 594.36 0.00 0.00 26775 S 159.50 0.00 0.00<br />

26541 S 971.62 0.00 0.00 26776 S 676.27 0.00 0.00<br />

26542 S 594.36 0.00 0.00 26785 S 676.27 0.00 0.00<br />

26545 S 806.98 0.00 0.00 26820 S 846.22 0.00 0.00<br />

26546 S 806.98 0.00 0.00 26841 S 806.98 0.00 0.00<br />

26548 S 806.98 0.00 0.00 26842 S 806.98 0.00 0.00<br />

26550 S 723.98 0.00 0.00 26843 S 752.84 0.00 0.00<br />

26555 S 752.84 0.00 0.00 26844 S 752.84 0.00 0.00<br />

26560 S 511.36 0.00 0.00 26850 S 806.98 0.00 0.00<br />

26561 S 752.84 0.00 0.00 26852 S 806.98 0.00 0.00<br />

26562 S 806.98 0.00 0.00 26860 S 752.84 0.00 0.00<br />

26565 S 846.22 0.00 0.00 26861 S 723.98 0.00 0.00<br />

26567 S 846.22 0.00 0.00 26862 S 806.98 0.00 0.00<br />

26568 S 752.84 0.00 0.00 26863 S 752.84 0.00 0.00<br />

26580 S 633.60 0.00 0.00 26910 S 752.84 0.00 0.00<br />

26587 S 633.60 0.00 0.00 26951 S 511.36 0.00 0.00<br />

26590 S 633.60 0.00 0.00 26952 S 594.36 0.00 0.00<br />

26591 S 752.84 0.00 0.00 26990 S 556.90 0.00 0.00<br />

26593 S 540.22 0.00 0.00 26991 S 556.90 0.00 0.00<br />

26596 S 511.36 0.00 0.00 27000 S 607.87 0.00 0.00<br />

26600 S 59.67 0.00 0.00 27001 S 787.99 0.00 0.00<br />

26605 S 76.57 0.00 0.00 27003 S 787.99 0.00 0.00<br />

26607 S 417.79 0.00 0.00 27033 S 1,076.87 0.00 0.00<br />

26608 S 759.27 0.00 0.00 27035 S 1,131.00 0.00 0.00<br />

26615 S 1,084.56 0.00 0.00 27040 S 304.37 0.00 0.00<br />

26641 S 59.67 0.00 0.00 27041 S 342.93 0.00 0.00<br />

26645 S 161.53 0.00 0.00 27047 S 609.02 0.00 0.00<br />

26650 S 676.27 0.00 0.00 27048 S 637.90 0.00 0.00<br />

26665 S 1,084.56 0.00 0.00 27049 S 637.90 0.00 0.00<br />

26670 S 59.67 0.00 0.00 27050 S 636.74 0.00 0.00<br />

26675 S 161.53 0.00 0.00 27052 S 636.74 0.00 0.00<br />

26676 S 676.27 0.00 0.00 27060 S 730.11 0.00 0.00<br />

26685 S 705.14 0.00 0.00 27062 S 730.11 0.00 0.00<br />

26686 S 1,398.32 0.00 0.00 27065 S 730.11 0.00 0.00<br />

26700 S 59.67 0.00 0.00 27066 S 881.36 0.00 0.00<br />

26705 S 76.57 0.00 0.00 27067 S 881.36 0.00 0.00<br />

26706 S 417.79 0.00 0.00 27080 S 759.12 0.00 0.00<br />

26715 S 759.27 0.00 0.00 27086 S 304.37 0.00 0.00<br />

26720 S 59.67 0.00 0.00 27087 S 636.74 0.00 0.00<br />

26725 S 59.67 0.00 0.00 27097 S 787.99 0.00 0.00<br />

26727 S 923.91 0.00 0.00 27098 S 787.99 0.00 0.00<br />

26735 S 759.27 0.00 0.00 27100 S 1,131.00 0.00 0.00<br />

26740 S 59.67 0.00 0.00 27105 S 1,131.00 0.00 0.00<br />

26742 S 76.57 0.00 0.00 27110 S 1,131.00 0.00 0.00<br />

26746 S 798.51 0.00 0.00 27111 S 1,131.00 0.00 0.00<br />

26750 S 59.67 0.00 0.00 27193 S 76.57 0.00 0.00<br />

26755 S 59.67 0.00 0.00 27194 S 491.85 0.00 0.00<br />

26756 S 676.27 0.00 0.00 27200 S 59.67 0.00 0.00<br />

26765 S 759.27 0.00 0.00 27202 S 1,001.56 0.00 0.00<br />

26770 S 59.67 0.00 0.00 27220 S 59.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 76.57 0.00 0.00 27397 S 1,076.87 0.00 0.00<br />

27238 S 161.53 0.00 0.00 27400 S 1,076.87 0.00 0.00<br />

27246 S 161.53 0.00 0.00 27403 S 842.12 0.00 0.00<br />

27250 S 76.57 0.00 0.00 27405 S 1,131.00 0.00 0.00<br />

27252 S 491.85 0.00 0.00 27407 S 1,901.06 0.00 0.00<br />

27256 S 59.67 0.00 0.00 27409 S 1,131.00 0.00 0.00<br />

27257 S 520.72 0.00 0.00 27416 S 1,693.64 0.00 0.00<br />

27265 S 76.57 0.00 0.00 27418 S 1,076.87 0.00 0.00<br />

27266 S 491.85 0.00 0.00 27420 S 1,076.87 0.00 0.00<br />

27267 S 59.67 0.00 0.00 27422 S 1,295.64 0.00 0.00<br />

27275 S 491.85 0.00 0.00 27424 S 1,076.87 0.00 0.00<br />

27301 S 592.04 0.00 0.00 27425 S 1,006.77 0.00 0.00<br />

27305 S 607.87 0.00 0.00 27427 S 1,076.87 0.00 0.00<br />

27306 S 636.74 0.00 0.00 27428 S 1,901.06 0.00 0.00<br />

27307 S 636.74 0.00 0.00 27429 S 1,901.06 0.00 0.00<br />

27310 S 842.12 0.00 0.00 27430 S 1,131.00 0.00 0.00<br />

27323 S 304.37 0.00 0.00 27435 S 1,131.00 0.00 0.00<br />

27324 S 558.05 0.00 0.00 27437 S 990.55 0.00 0.00<br />

27325 S 546.81 0.00 0.00 27438 S 1,316.07 0.00 0.00<br />

27326 S 546.81 0.00 0.00 27440 S 1,412.73 0.00 0.00<br />

27327 S 609.02 0.00 0.00 27441 S 1,029.79 0.00 0.00<br />

27328 S 637.90 0.00 0.00 27442 S 1,029.79 0.00 0.00<br />

27329 S 692.02 0.00 0.00 27443 S 1,029.79 0.00 0.00<br />

27330 S 842.12 0.00 0.00 27446 S 10,104.27 6,070.18 2,036.10<br />

27331 S 842.12 0.00 0.00 27496 S 730.11 0.00 0.00<br />

27332 S 842.12 0.00 0.00 27497 S 636.74 0.00 0.00<br />

27333 S 842.12 0.00 0.00 27498 S 636.74 0.00 0.00<br />

27334 S 842.12 0.00 0.00 27499 S 636.74 0.00 0.00<br />

27335 S 842.12 0.00 0.00 27500 S 161.53 0.00 0.00<br />

27340 S 636.74 0.00 0.00 27501 S 76.57 0.00 0.00<br />

27345 S 690.87 0.00 0.00 27502 S 417.79 0.00 0.00<br />

27347 S 690.87 0.00 0.00 27503 S 76.57 0.00 0.00<br />

27350 S 842.12 0.00 0.00 27508 S 76.57 0.00 0.00<br />

27355 S 787.99 0.00 0.00 27509 S 705.14 0.00 0.00<br />

27356 S 842.12 0.00 0.00 27510 S 161.53 0.00 0.00<br />

27357 S 881.36 0.00 0.00 27516 S 76.57 0.00 0.00<br />

27358 S 881.36 0.00 0.00 27517 S 76.57 0.00 0.00<br />

27360 S 881.36 0.00 0.00 27520 S 76.57 0.00 0.00<br />

27372 S 856.67 0.00 0.00 27530 S 76.57 0.00 0.00<br />

27380 S 556.90 0.00 0.00 27532 S 417.79 0.00 0.00<br />

27381 S 636.74 0.00 0.00 27538 S 76.57 0.00 0.00<br />

27385 S 636.74 0.00 0.00 27550 S 76.57 0.00 0.00<br />

27386 S 636.74 0.00 0.00 27552 S 440.88 0.00 0.00<br />

27390 S 556.90 0.00 0.00 27560 S 76.57 0.00 0.00<br />

27391 S 607.87 0.00 0.00 27562 S 440.88 0.00 0.00<br />

27392 S 636.74 0.00 0.00 27566 S 1,001.56 0.00 0.00<br />

27393 S 759.12 0.00 0.00 27570 S 440.88 0.00 0.00<br />

27394 S 787.99 0.00 0.00 27594 S 636.74 0.00 0.00<br />

27395 S 1,076.87 0.00 0.00 27600 S 636.74 0.00 0.00<br />

27396 S 787.99 0.00 0.00 27601 S 636.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 636.74 0.00 0.00 27730 S 759.12 0.00 0.00<br />

27603 S 563.18 0.00 0.00 27732 S 759.12 0.00 0.00<br />

27604 S 607.87 0.00 0.00 27734 S 759.12 0.00 0.00<br />

27605 S 553.91 0.00 0.00 27740 S 759.12 0.00 0.00<br />

27606 S 556.90 0.00 0.00 27742 S 1,048.00 0.00 0.00<br />

27607 S 607.87 0.00 0.00 27745 S 1,846.94 0.00 0.00<br />

27610 S 759.12 0.00 0.00 27750 S 76.57 0.00 0.00<br />

27612 S 787.99 0.00 0.00 27752 S 417.79 0.00 0.00<br />

27613 S 125.13 0.00 0.00 27756 S 705.14 0.00 0.00<br />

27614 S 609.02 0.00 0.00 27758 S 1,084.56 0.00 0.00<br />

27615 S 787.99 0.00 0.00 27759 S 1,452.44 0.00 0.00<br />

27618 S 498.01 0.00 0.00 27760 S 76.57 0.00 0.00<br />

27619 S 637.90 0.00 0.00 27762 S 417.79 0.00 0.00<br />

27620 S 842.12 0.00 0.00 27766 S 1,030.42 0.00 0.00<br />

27625 S 842.12 0.00 0.00 27767 S 59.67 0.00 0.00<br />

27626 S 842.12 0.00 0.00 27768 S 59.67 0.00 0.00<br />

27630 S 636.74 0.00 0.00 27769 S 1,600.73 0.00 0.00<br />

27635 S 787.99 0.00 0.00 27780 S 76.57 0.00 0.00<br />

27637 S 787.99 0.00 0.00 27781 S 417.79 0.00 0.00<br />

27638 S 787.99 0.00 0.00 27784 S 1,030.42 0.00 0.00<br />

27640 S 1,048.00 0.00 0.00 27786 S 76.57 0.00 0.00<br />

27641 S 759.12 0.00 0.00 27788 S 76.57 0.00 0.00<br />

27647 S 1,076.87 0.00 0.00 27792 S 1,030.42 0.00 0.00<br />

27650 S 1,076.87 0.00 0.00 27808 S 76.57 0.00 0.00<br />

27652 S 1,846.94 0.00 0.00 27810 S 161.53 0.00 0.00<br />

27654 S 1,076.87 0.00 0.00 27814 S 1,030.42 0.00 0.00<br />

27656 S 607.87 0.00 0.00 27816 S 76.57 0.00 0.00<br />

27658 S 556.90 0.00 0.00 27818 S 161.53 0.00 0.00<br />

27659 S 607.87 0.00 0.00 27822 S 1,030.42 0.00 0.00<br />

27664 S 607.87 0.00 0.00 27823 S 1,398.32 0.00 0.00<br />

27665 S 759.12 0.00 0.00 27824 S 76.57 0.00 0.00<br />

27675 S 607.87 0.00 0.00 27825 S 417.79 0.00 0.00<br />

27676 S 787.99 0.00 0.00 27826 S 1,030.42 0.00 0.00<br />

27680 S 787.99 0.00 0.00 27827 S 1,398.32 0.00 0.00<br />

27681 S 759.12 0.00 0.00 27828 S 1,452.44 0.00 0.00<br />

27685 S 787.99 0.00 0.00 27829 S 1,001.56 0.00 0.00<br />

27686 S 787.99 0.00 0.00 27830 S 76.57 0.00 0.00<br />

27687 S 787.99 0.00 0.00 27831 S 417.79 0.00 0.00<br />

27690 S 1,131.00 0.00 0.00 27832 S 1,001.56 0.00 0.00<br />

27691 S 1,131.00 0.00 0.00 27840 S 161.53 0.00 0.00<br />

27692 S 1,076.87 0.00 0.00 27842 S 440.88 0.00 0.00<br />

27695 S 759.12 0.00 0.00 27846 S 1,030.42 0.00 0.00<br />

27696 S 759.12 0.00 0.00 27848 S 1,030.42 0.00 0.00<br />

27698 S 759.12 0.00 0.00 27860 S 440.88 0.00 0.00<br />

27700 S 1,029.79 0.00 0.00 27870 S 1,901.06 0.00 0.00<br />

27704 S 607.87 0.00 0.00 27871 S 1,901.06 0.00 0.00<br />

27705 S 1,048.00 0.00 0.00 27884 S 636.74 0.00 0.00<br />

27707 S 607.87 0.00 0.00 27889 S 787.99 0.00 0.00<br />

27709 S 759.12 0.00 0.00 27892 S 636.74 0.00 0.00<br />

27726 S 950.17 0.00 0.00 27893 S 636.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 636.74 0.00 0.00 28153 S 633.75 0.00 0.00<br />

28001 S 122.13 0.00 0.00 28160 S 633.75 0.00 0.00<br />

28002 S 636.74 0.00 0.00 28171 S 633.75 0.00 0.00<br />

28003 S 636.74 0.00 0.00 28173 S 633.75 0.00 0.00<br />

28005 S 633.75 0.00 0.00 28175 S 633.75 0.00 0.00<br />

28008 S 633.75 0.00 0.00 28190 S 126.13 0.00 0.00<br />

28010 S 89.76 0.00 0.00 28192 S 498.01 0.00 0.00<br />

28011 S 633.75 0.00 0.00 28193 S 342.93 0.00 0.00<br />

28020 S 604.88 0.00 0.00 28200 S 633.75 0.00 0.00<br />

28022 S 604.88 0.00 0.00 28202 S 633.75 0.00 0.00<br />

28024 S 604.88 0.00 0.00 28208 S 633.75 0.00 0.00<br />

28035 S 629.81 0.00 0.00 28210 S 1,113.06 0.00 0.00<br />

28043 S 609.02 0.00 0.00 28220 S 194.54 0.00 0.00<br />

28045 S 633.75 0.00 0.00 28222 S 553.91 0.00 0.00<br />

28046 S 633.75 0.00 0.00 28225 S 553.91 0.00 0.00<br />

28050 S 604.88 0.00 0.00 28226 S 553.91 0.00 0.00<br />

28052 S 604.88 0.00 0.00 28230 S 190.87 0.00 0.00<br />

28054 S 604.88 0.00 0.00 28232 S 182.52 0.00 0.00<br />

28055 S 629.81 0.00 0.00 28234 S 604.88 0.00 0.00<br />

28060 S 604.88 0.00 0.00 28238 S 1,113.06 0.00 0.00<br />

28062 S 633.75 0.00 0.00 28240 S 604.88 0.00 0.00<br />

28070 S 633.75 0.00 0.00 28250 S 633.75 0.00 0.00<br />

28072 S 633.75 0.00 0.00 28260 S 633.75 0.00 0.00<br />

28080 S 633.75 0.00 0.00 28261 S 633.75 0.00 0.00<br />

28086 S 604.88 0.00 0.00 28262 S 687.88 0.00 0.00<br />

28088 S 604.88 0.00 0.00 28264 S 1,033.22 0.00 0.00<br />

28090 S 633.75 0.00 0.00 28270 S 633.75 0.00 0.00<br />

28092 S 633.75 0.00 0.00 28272 S 176.19 0.00 0.00<br />

28100 S 604.88 0.00 0.00 28280 S 604.88 0.00 0.00<br />

28102 S 1,113.06 0.00 0.00 28285 S 633.75 0.00 0.00<br />

28103 S 1,113.06 0.00 0.00 28286 S 687.88 0.00 0.00<br />

28104 S 604.88 0.00 0.00 28288 S 633.75 0.00 0.00<br />

28106 S 1,113.06 0.00 0.00 28289 S 633.75 0.00 0.00<br />

28107 S 1,113.06 0.00 0.00 28290 S 781.18 0.00 0.00<br />

28108 S 604.88 0.00 0.00 28292 S 781.18 0.00 0.00<br />

28110 S 633.75 0.00 0.00 28293 S 810.05 0.00 0.00<br />

28111 S 633.75 0.00 0.00 28294 S 810.05 0.00 0.00<br />

28112 S 633.75 0.00 0.00 28296 S 810.05 0.00 0.00<br />

28113 S 633.75 0.00 0.00 28297 S 810.05 0.00 0.00<br />

28114 S 633.75 0.00 0.00 28298 S 810.05 0.00 0.00<br />

28116 S 633.75 0.00 0.00 28299 S 903.42 0.00 0.00<br />

28118 S 687.88 0.00 0.00 28300 S 1,084.20 0.00 0.00<br />

28119 S 687.88 0.00 0.00 28302 S 604.88 0.00 0.00<br />

28120 S 852.53 0.00 0.00 28304 S 1,084.20 0.00 0.00<br />

28122 S 633.75 0.00 0.00 28305 S 1,113.06 0.00 0.00<br />

28124 S 206.55 0.00 0.00 28306 S 687.88 0.00 0.00<br />

28126 S 633.75 0.00 0.00 28307 S 687.88 0.00 0.00<br />

28130 S 633.75 0.00 0.00 28308 S 604.88 0.00 0.00<br />

28140 S 633.75 0.00 0.00 28309 S 1,167.20 0.00 0.00<br />

28150 S 633.75 0.00 0.00 28310 S 633.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 633.75 0.00 0.00 28636 S 705.14 0.00 0.00<br />

28313 S 604.88 0.00 0.00 28645 S 705.14 0.00 0.00<br />

28315 S 687.88 0.00 0.00 28660 S 42.72 0.00 0.00<br />

28320 S 1,167.20 0.00 0.00 28665 S 440.88 0.00 0.00<br />

28322 S 1,167.20 0.00 0.00 28666 S 705.14 0.00 0.00<br />

28340 S 687.88 0.00 0.00 28675 S 705.14 0.00 0.00<br />

28341 S 687.88 0.00 0.00 28705 S 1,167.20 0.00 0.00<br />

28344 S 687.88 0.00 0.00 28715 S 1,901.06 0.00 0.00<br />

28345 S 687.88 0.00 0.00 28725 S 1,167.20 0.00 0.00<br />

28400 S 76.57 0.00 0.00 28730 S 1,167.20 0.00 0.00<br />

28405 S 417.79 0.00 0.00 28735 S 1,167.20 0.00 0.00<br />

28406 S 676.27 0.00 0.00 28737 S 1,206.43 0.00 0.00<br />

28415 S 1,398.32 0.00 0.00 28740 S 1,167.20 0.00 0.00<br />

28420 S 1,084.56 0.00 0.00 28750 S 1,167.20 0.00 0.00<br />

28430 S 59.67 0.00 0.00 28755 S 687.88 0.00 0.00<br />

28435 S 76.57 0.00 0.00 28760 S 1,167.20 0.00 0.00<br />

28436 S 676.27 0.00 0.00 28810 S 604.88 0.00 0.00<br />

28445 S 1,030.42 0.00 0.00 28820 S 604.88 0.00 0.00<br />

28446 S 1,766.02 0.00 0.00 28825 S 604.88 0.00 0.00<br />

28450 S 59.67 0.00 0.00 28890 S 159.84 0.00 0.00<br />

28455 S 59.67 0.00 0.00 29000 S 40.50 0.00 0.00<br />

28456 S 676.27 0.00 0.00 29010 S 90.76 0.00 0.00<br />

28465 S 1,030.42 0.00 0.00 29015 S 90.76 0.00 0.00<br />

28470 S 59.67 0.00 0.00 29020 S 40.50 0.00 0.00<br />

28475 S 59.67 0.00 0.00 29025 S 40.50 0.00 0.00<br />

28476 S 676.27 0.00 0.00 29035 S 90.76 0.00 0.00<br />

28485 S 1,084.56 0.00 0.00 29040 S 40.50 0.00 0.00<br />

28490 S 59.67 0.00 0.00 29044 S 90.76 0.00 0.00<br />

28495 S 59.67 0.00 0.00 29046 S 90.76 0.00 0.00<br />

28496 S 676.27 0.00 0.00 29049 S 36.70 0.00 0.00<br />

28505 S 705.14 0.00 0.00 29055 S 90.76 0.00 0.00<br />

28510 S 53.73 0.00 0.00 29058 S 40.50 0.00 0.00<br />

28515 S 59.67 0.00 0.00 29065 S 43.05 0.00 0.00<br />

28525 S 705.14 0.00 0.00 29075 S 41.37 0.00 0.00<br />

28530 S 51.72 0.00 0.00 29085 S 40.50 0.00 0.00<br />

28531 S 705.14 0.00 0.00 29086 S 34.70 0.00 0.00<br />

28540 S 59.67 0.00 0.00 29105 S 37.37 0.00 0.00<br />

28545 S 625.30 0.00 0.00 29125 S 32.36 0.00 0.00<br />

28546 S 676.27 0.00 0.00 29126 S 34.37 0.00 0.00<br />

28555 S 1,001.56 0.00 0.00 29130 S 14.68 0.00 0.00<br />

28570 S 77.41 0.00 0.00 29131 S 21.35 0.00 0.00<br />

28575 S 417.79 0.00 0.00 29200 S 20.69 0.00 0.00<br />

28576 S 705.14 0.00 0.00 29220 S 22.35 0.00 0.00<br />

28585 S 705.14 0.00 0.00 29240 S 23.36 0.00 0.00<br />

28600 S 59.67 0.00 0.00 29260 S 22.35 0.00 0.00<br />

28605 S 76.57 0.00 0.00 29280 S 22.70 0.00 0.00<br />

28606 S 676.27 0.00 0.00 29305 S 90.76 0.00 0.00<br />

28615 S 1,030.42 0.00 0.00 29325 S 90.76 0.00 0.00<br />

28630 S 59.67 0.00 0.00 29345 S 56.39 0.00 0.00<br />

28635 S 440.88 0.00 0.00 29355 S 55.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 68.74 0.00 0.00 29847 S 1,148.98 0.00 0.00<br />

29365 S 53.39 0.00 0.00 29848 S 1,153.22 0.00 0.00<br />

29405 S 39.71 0.00 0.00 29850 S 833.40 0.00 0.00<br />

29425 S 40.38 0.00 0.00 29851 S 1,203.11 0.00 0.00<br />

29435 S 51.05 0.00 0.00 29855 S 1,203.11 0.00 0.00<br />

29440 S 21.69 0.00 0.00 29856 S 1,203.11 0.00 0.00<br />

29445 S 53.73 0.00 0.00 29860 S 1,203.11 0.00 0.00<br />

29450 S 40.50 0.00 0.00 29861 S 1,203.11 0.00 0.00<br />

29505 S 36.04 0.00 0.00 29862 S 1,522.93 0.00 0.00<br />

29515 S 30.70 0.00 0.00 29863 S 1,203.11 0.00 0.00<br />

29520 S 22.02 0.00 0.00 29866 S 1,837.85 0.00 0.00<br />

29530 S 22.35 0.00 0.00 29870 S 779.28 0.00 0.00<br />

29540 S 16.68 0.00 0.00 29871 S 779.28 0.00 0.00<br />

29550 S 17.01 0.00 0.00 29873 S 779.28 0.00 0.00<br />

29580 S 23.03 0.00 0.00 29874 S 779.28 0.00 0.00<br />

29590 S 18.69 0.00 0.00 29875 S 833.40 0.00 0.00<br />

29700 S 31.03 0.00 0.00 29876 S 833.40 0.00 0.00<br />

29705 S 26.36 0.00 0.00 29877 S 833.40 0.00 0.00<br />

29710 S 46.38 0.00 0.00 29879 S 779.28 0.00 0.00<br />

29715 S 40.50 0.00 0.00 29880 S 833.40 0.00 0.00<br />

29720 S 38.71 0.00 0.00 29881 S 833.40 0.00 0.00<br />

29730 S 25.36 0.00 0.00 29882 S 779.28 0.00 0.00<br />

29740 S 34.70 0.00 0.00 29883 S 779.28 0.00 0.00<br />

29750 S 36.37 0.00 0.00 29884 S 779.28 0.00 0.00<br />

29800 S 779.28 0.00 0.00 29885 S 1,148.98 0.00 0.00<br />

29804 S 779.28 0.00 0.00 29886 S 779.28 0.00 0.00<br />

29805 S 779.28 0.00 0.00 29887 S 779.28 0.00 0.00<br />

29806 S 1,148.98 0.00 0.00 29888 S 1,148.98 0.00 0.00<br />

29807 S 1,148.98 0.00 0.00 29889 S 1,148.98 0.00 0.00<br />

29819 S 1,148.98 0.00 0.00 29891 S 1,148.98 0.00 0.00<br />

29820 S 1,148.98 0.00 0.00 29892 S 1,148.98 0.00 0.00<br />

29821 S 1,148.98 0.00 0.00 29893 S 970.05 0.00 0.00<br />

29822 S 779.28 0.00 0.00 29894 S 779.28 0.00 0.00<br />

29823 S 1,148.98 0.00 0.00 29895 S 779.28 0.00 0.00<br />

29824 S 872.65 0.00 0.00 29897 S 779.28 0.00 0.00<br />

29825 S 1,148.98 0.00 0.00 29898 S 779.28 0.00 0.00<br />

29826 S 1,148.98 0.00 0.00 29899 S 1,148.98 0.00 0.00<br />

29827 S 1,242.35 0.00 0.00 29900 S 779.28 0.00 0.00<br />

29828 S 1,837.85 0.00 0.00 29901 S 779.28 0.00 0.00<br />

29830 S 779.28 0.00 0.00 29902 S 779.28 0.00 0.00<br />

29834 S 779.28 0.00 0.00 29904 S 1,098.44 0.00 0.00<br />

29835 S 779.28 0.00 0.00 29905 S 1,098.44 0.00 0.00<br />

29836 S 779.28 0.00 0.00 29906 S 1,098.44 0.00 0.00<br />

29837 S 779.28 0.00 0.00 29907 S 1,837.85 0.00 0.00<br />

29838 S 779.28 0.00 0.00 30000 S 123.50 0.00 0.00<br />

29840 S 779.28 0.00 0.00 30020 S 123.50 0.00 0.00<br />

29843 S 779.28 0.00 0.00 30100 S 80.09 0.00 0.00<br />

29844 S 779.28 0.00 0.00 30110 S 123.80 0.00 0.00<br />

29845 S 779.28 0.00 0.00 30115 S 523.08 0.00 0.00<br />

29846 S 779.28 0.00 0.00 30117 S 551.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 692.28 0.00 0.00 31080 S 1,066.03 0.00 0.00<br />

30120 S 472.11 0.00 0.00 31081 S 1,066.03 0.00 0.00<br />

30124 S 281.31 0.00 0.00 31084 S 1,066.03 0.00 0.00<br />

30125 S 983.03 0.00 0.00 31085 S 1,066.03 0.00 0.00<br />

30130 S 551.96 0.00 0.00 31086 S 1,066.03 0.00 0.00<br />

30140 S 663.41 0.00 0.00 31087 S 1,066.03 0.00 0.00<br />

30150 S 1,011.91 0.00 0.00 31090 S 1,105.28 0.00 0.00<br />

30160 S 1,066.03 0.00 0.00 31200 S 983.03 0.00 0.00<br />

30200 S 63.07 0.00 0.00 31201 S 1,105.28 0.00 0.00<br />

30210 S 80.09 0.00 0.00 31205 S 1,011.91 0.00 0.00<br />

30220 S 350.02 0.00 0.00 31231 S 67.51 0.00 0.00<br />

30300 S 24.13 0.00 0.00 31233 S 72.72 0.00 0.00<br />

30310 S 472.11 0.00 0.00 31235 S 494.07 0.00 0.00<br />

30320 S 523.08 0.00 0.00 31237 S 545.04 0.00 0.00<br />

30400 S 1,066.03 0.00 0.00 31238 S 494.07 0.00 0.00<br />

30410 S 1,105.28 0.00 0.00 31239 S 721.18 0.00 0.00<br />

30420 S 1,105.28 0.00 0.00 31240 S 545.04 0.00 0.00<br />

30430 S 692.28 0.00 0.00 31254 S 667.05 0.00 0.00<br />

30435 S 1,105.28 0.00 0.00 31255 S 760.42 0.00 0.00<br />

30450 S 1,230.68 0.00 0.00 31256 S 667.05 0.00 0.00<br />

30460 S 1,230.68 0.00 0.00 31267 S 667.05 0.00 0.00<br />

30462 S 1,385.85 0.00 0.00 31276 S 667.05 0.00 0.00<br />

30465 S 1,385.85 0.00 0.00 31287 S 667.05 0.00 0.00<br />

30520 S 746.41 0.00 0.00 31288 S 667.05 0.00 0.00<br />

30540 S 1,105.28 0.00 0.00 31300 S 785.65 0.00 0.00<br />

30545 S 1,105.28 0.00 0.00 31320 S 983.03 0.00 0.00<br />

30560 S 129.73 0.00 0.00 31400 S 983.03 0.00 0.00<br />

30580 S 1,066.03 0.00 0.00 31420 S 983.03 0.00 0.00<br />

30600 S 1,066.03 0.00 0.00 31500 S 90.30 0.00 0.00<br />

30620 S 1,230.68 0.00 0.00 31502 S 51.92 0.00 0.00<br />

30630 S 911.05 0.00 0.00 31505 S 30.68 0.00 0.00<br />

30801 S 290.86 0.00 0.00 31510 S 545.04 0.00 0.00<br />

30802 S 290.86 0.00 0.00 31511 S 72.72 0.00 0.00<br />

30901 S 41.49 0.00 0.00 31512 S 545.04 0.00 0.00<br />

30903 S 53.44 0.00 0.00 31513 S 72.72 0.00 0.00<br />

30905 S 53.44 0.00 0.00 31515 S 494.07 0.00 0.00<br />

30906 S 53.44 0.00 0.00 31520 S 67.51 0.00 0.00<br />

30915 S 712.06 0.00 0.00 31525 S 494.07 0.00 0.00<br />

30920 S 740.94 0.00 0.00 31526 S 638.18 0.00 0.00<br />

30930 S 606.08 0.00 0.00 31527 S 587.21 0.00 0.00<br />

31000 S 103.11 0.00 0.00 31528 S 545.04 0.00 0.00<br />

31002 S 281.31 0.00 0.00 31529 S 545.04 0.00 0.00<br />

31020 S 663.41 0.00 0.00 31530 S 638.18 0.00 0.00<br />

31030 S 1,011.91 0.00 0.00 31531 S 667.05 0.00 0.00<br />

31032 S 1,066.03 0.00 0.00 31535 S 638.18 0.00 0.00<br />

31040 S 924.46 0.00 0.00 31536 S 667.05 0.00 0.00<br />

31050 S 983.03 0.00 0.00 31540 S 667.05 0.00 0.00<br />

31051 S 1,066.03 0.00 0.00 31541 S 721.18 0.00 0.00<br />

31070 S 663.41 0.00 0.00 31545 S 721.18 0.00 0.00<br />

31075 S 1,066.03 0.00 0.00 31546 S 721.18 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 760.42 0.00 0.00 32405 S 329.06 0.00 0.00<br />

31561 S 760.42 0.00 0.00 32420 S 200.09 0.00 0.00<br />

31570 S 545.04 0.00 0.00 32421 S 200.09 0.00 0.00<br />

31571 S 638.18 0.00 0.00 32422 S 199.20 0.00 0.00<br />

31575 S 58.07 0.00 0.00 32550 S 1,115.33 0.00 0.00<br />

31576 S 638.18 0.00 0.00 32960 S 199.20 0.00 0.00<br />

31577 S 188.52 0.00 0.00 32998 S 1,736.51 0.00 0.00<br />

31578 S 638.18 0.00 0.00 33010 S 200.09 0.00 0.00<br />

31579 S 103.45 0.00 0.00 33011 S 200.09 0.00 0.00<br />

31580 S 1,105.28 0.00 0.00 33206 S 6,419.74 3,819.73 1,219.72<br />

31582 S 1,105.28 0.00 0.00 33207 S 6,419.74 3,819.73 1,219.72<br />

31588 S 1,105.28 0.00 0.00 33208 S 7,962.30 4,639.59 1,316.89<br />

31590 S 1,105.28 0.00 0.00 33210 S 1,885.18 0.00 0.00<br />

31595 S 983.03 0.00 0.00 33211 S 1,885.18 0.00 0.00<br />

31603 S 290.86 0.00 0.00 33212 S 5,041.78 2,872.09 702.39<br />

31605 S 281.31 0.00 0.00 33213 S 5,819.30 3,260.43 701.56<br />

31611 S 692.28 0.00 0.00 33214 S 7,962.30 4,639.59 1,316.89<br />

31612 S 612.44 0.00 0.00 33215 S 826.30 0.00 0.00<br />

31613 S 663.41 0.00 0.00 33216 S 1,885.18 0.00 0.00<br />

31614 S 983.03 0.00 0.00 33217 S 1,885.18 0.00 0.00<br />

31615 S 290.86 0.00 0.00 33218 S 826.30 0.00 0.00<br />

31622 S 340.65 0.00 0.00 33220 S 826.30 0.00 0.00<br />

31623 S 391.62 0.00 0.00 33222 S 499.46 0.00 0.00<br />

31624 S 391.62 0.00 0.00 33223 S 499.46 0.00 0.00<br />

31625 S 391.62 0.00 0.00 33224 S 7,515.67 4,499.61 1,483.56<br />

31628 S 391.62 0.00 0.00 33225 S 7,515.67 4,499.61 1,483.56<br />

31629 S 391.62 0.00 0.00 33226 S 826.30 0.00 0.00<br />

31630 S 671.08 0.00 0.00 33233 S 614.33 0.00 0.00<br />

31631 S 671.08 0.00 0.00 33234 S 826.30 0.00 0.00<br />

31632 S 380.88 0.00 0.00 33235 S 826.30 0.00 0.00<br />

31633 S 380.88 0.00 0.00 33240 S 18,734.64 10,014.43 1,294.23<br />

31635 S 391.62 0.00 0.00 33241 S 826.30 0.00 0.00<br />

31636 S 671.08 0.00 0.00 33249 S 25,002.81 13,392.54 1,782.27<br />

31637 S 340.65 0.00 0.00 33282 S 3,953.10 2,366.56 780.02<br />

31638 S 671.08 0.00 0.00 33284 S 308.33 0.00 0.00<br />

31640 S 671.08 0.00 0.00 34490 S 1,505.37 0.00 0.00<br />

31641 S 671.08 0.00 0.00 35188 S 1,036.86 0.00 0.00<br />

31643 S 391.62 0.00 0.00 35207 S 1,036.86 0.00 0.00<br />

31645 S 340.65 0.00 0.00 35473 S 1,805.86 0.00 0.00<br />

31646 S 340.65 0.00 0.00 35476 S 1,805.86 0.00 0.00<br />

31656 S 340.65 0.00 0.00 35492 S 3,370.46 0.00 0.00<br />

31717 S 188.52 0.00 0.00 35761 S 1,084.23 0.00 0.00<br />

31720 S 28.87 0.00 0.00 35875 S 1,356.68 0.00 0.00<br />

31730 S 188.52 0.00 0.00 35876 S 1,356.68 0.00 0.00<br />

31750 S 1,105.28 0.00 0.00 36002 S 86.59 0.00 0.00<br />

31755 S 983.03 0.00 0.00 36260 S 785.49 0.00 0.00<br />

31820 S 472.11 0.00 0.00 36261 S 614.33 0.00 0.00<br />

31825 S 663.41 0.00 0.00 36262 S 563.35 0.00 0.00<br />

31830 S 663.41 0.00 0.00 36420 S 8.16 0.00 0.00<br />

32400 S 329.06 0.00 0.00 36425 S 8.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 31.36 0.00 0.00 36800 S 845.58 0.00 0.00<br />

36440 S 125.26 0.00 0.00 36810 S 845.58 0.00 0.00<br />

36450 S 125.26 0.00 0.00 36815 S 845.58 0.00 0.00<br />

36455 S 125.26 0.00 0.00 36818 S 982.74 0.00 0.00<br />

36468 S 30.92 0.00 0.00 36819 S 982.74 0.00 0.00<br />

36469 S 30.92 0.00 0.00 36820 S 982.74 0.00 0.00<br />

36470 S 30.92 0.00 0.00 36821 S 982.74 0.00 0.00<br />

36471 S 30.92 0.00 0.00 36825 S 1,036.86 0.00 0.00<br />

36475 S 1,421.66 0.00 0.00 36830 S 1,036.86 0.00 0.00<br />

36476 S 1,114.88 0.00 0.00 36831 S 1,356.68 0.00 0.00<br />

36478 S 1,114.88 0.00 0.00 36832 S 1,036.86 0.00 0.00<br />

36479 S 1,114.88 0.00 0.00 36833 S 1,036.86 0.00 0.00<br />

36511 S 429.46 0.00 0.00 36834 S 982.74 0.00 0.00<br />

36512 S 429.46 0.00 0.00 36835 S 899.71 0.00 0.00<br />

36513 S 429.46 0.00 0.00 36860 S 103.26 0.00 0.00<br />

36514 S 429.46 0.00 0.00 36861 S 845.58 0.00 0.00<br />

36515 S 1,149.66 0.00 0.00 36870 S 1,478.78 0.00 0.00<br />

36516 S 1,149.66 0.00 0.00 37184 S 1,505.37 0.00 0.00<br />

36522 S 1,149.66 0.00 0.00 37185 S 1,505.37 0.00 0.00<br />

36555 S 356.82 0.00 0.00 37186 S 1,505.37 0.00 0.00<br />

36556 S 356.82 0.00 0.00 37187 S 1,505.37 0.00 0.00<br />

36557 S 666.39 0.00 0.00 37188 S 1,505.37 0.00 0.00<br />

36558 S 666.39 0.00 0.00 37200 S 1,110.87 0.00 0.00<br />

36560 S 785.49 0.00 0.00 37203 S 1,110.87 0.00 0.00<br />

36561 S 785.49 0.00 0.00 37500 S 1,047.72 0.00 0.00<br />

36563 S 785.49 0.00 0.00 37607 S 740.94 0.00 0.00<br />

36565 S 785.49 0.00 0.00 37609 S 498.01 0.00 0.00<br />

36566 S 785.49 0.00 0.00 37650 S 712.06 0.00 0.00<br />

36568 S 356.82 0.00 0.00 37700 S 712.06 0.00 0.00<br />

36569 S 356.82 0.00 0.00 37718 S 740.94 0.00 0.00<br />

36570 S 695.26 0.00 0.00 37722 S 1,047.72 0.00 0.00<br />

36571 S 695.26 0.00 0.00 37735 S 1,047.72 0.00 0.00<br />

36575 S 286.99 0.00 0.00 37760 S 740.94 0.00 0.00<br />

36576 S 407.79 0.00 0.00 37765 S 1,021.76 0.00 0.00<br />

36578 S 666.39 0.00 0.00 37766 S 1,021.76 0.00 0.00<br />

36580 S 356.82 0.00 0.00 37780 S 740.94 0.00 0.00<br />

36581 S 666.39 0.00 0.00 37785 S 740.94 0.00 0.00<br />

36582 S 785.49 0.00 0.00 37790 S 894.09 0.00 0.00<br />

36583 S 785.49 0.00 0.00 38205 S 429.46 0.00 0.00<br />

36584 S 356.82 0.00 0.00 38206 S 429.46 0.00 0.00<br />

36585 S 695.26 0.00 0.00 38220 S 98.44 0.00 0.00<br />

36589 S 236.02 0.00 0.00 38221 S 103.11 0.00 0.00<br />

36590 S 356.82 0.00 0.00 38230 S 1,149.66 0.00 0.00<br />

36593 S 23.69 0.00 0.00 38241 S 1,149.66 0.00 0.00<br />

36595 S 930.42 0.00 0.00 38242 S 429.46 0.00 0.00<br />

36596 S 413.21 0.00 0.00 38300 S 385.38 0.00 0.00<br />

36597 S 413.21 0.00 0.00 38305 S 563.18 0.00 0.00<br />

36598 S 76.41 0.00 0.00 38308 S 643.50 0.00 0.00<br />

36640 S 705.64 0.00 0.00 38500 S 643.50 0.00 0.00<br />

36680 S 53.49 0.00 0.00 38505 S 246.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 643.50 0.00 0.00 41005 S 129.73 0.00 0.00<br />

38520 S 643.50 0.00 0.00 41006 S 612.44 0.00 0.00<br />

38525 S 643.50 0.00 0.00 41007 S 472.11 0.00 0.00<br />

38530 S 643.50 0.00 0.00 41008 S 472.11 0.00 0.00<br />

38542 S 1,082.60 0.00 0.00 41009 S 129.73 0.00 0.00<br />

38550 S 672.38 0.00 0.00 41010 S 290.86 0.00 0.00<br />

38555 S 726.50 0.00 0.00 41015 S 129.73 0.00 0.00<br />

38570 S 1,468.93 0.00 0.00 41016 S 290.86 0.00 0.00<br />

38571 S 1,909.58 0.00 0.00 41017 S 290.86 0.00 0.00<br />

38572 S 1,468.93 0.00 0.00 41018 S 290.86 0.00 0.00<br />

38700 S 884.65 0.00 0.00 41019 S 924.46 0.00 0.00<br />

38740 S 1,082.60 0.00 0.00 41100 S 87.09 0.00 0.00<br />

38745 S 1,165.60 0.00 0.00 41105 S 86.09 0.00 0.00<br />

38760 S 643.50 0.00 0.00 41108 S 79.75 0.00 0.00<br />

40490 S 65.74 0.00 0.00 41110 S 115.46 0.00 0.00<br />

40500 S 523.08 0.00 0.00 41112 S 523.08 0.00 0.00<br />

40510 S 663.41 0.00 0.00 41113 S 523.08 0.00 0.00<br />

40520 S 523.08 0.00 0.00 41114 S 663.41 0.00 0.00<br />

40525 S 663.41 0.00 0.00 41115 S 134.48 0.00 0.00<br />

40527 S 663.41 0.00 0.00 41116 S 472.11 0.00 0.00<br />

40530 S 663.41 0.00 0.00 41120 S 785.65 0.00 0.00<br />

40650 S 350.02 0.00 0.00 41250 S 88.73 0.00 0.00<br />

40652 S 350.02 0.00 0.00 41251 S 129.73 0.00 0.00<br />

40654 S 350.02 0.00 0.00 41252 S 341.83 0.00 0.00<br />

40700 S 1,230.68 0.00 0.00 41500 S 612.44 0.00 0.00<br />

40701 S 1,230.68 0.00 0.00 41510 S 472.11 0.00 0.00<br />

40702 S 1,563.71 0.00 0.00 41520 S 341.83 0.00 0.00<br />

40720 S 1,230.68 0.00 0.00 41530 S 643.80 0.00 0.00<br />

40761 S 1,011.91 0.00 0.00 41800 S 66.28 0.00 0.00<br />

40800 S 52.75 0.00 0.00 41805 S 143.49 0.00 0.00<br />

40801 S 341.83 0.00 0.00 41806 S 176.85 0.00 0.00<br />

40804 S 24.13 0.00 0.00 41820 S 281.31 0.00 0.00<br />

40805 S 163.18 0.00 0.00 41821 S 281.31 0.00 0.00<br />

40806 S 75.08 0.00 0.00 41822 S 146.49 0.00 0.00<br />

40808 S 111.45 0.00 0.00 41823 S 213.56 0.00 0.00<br />

40810 S 115.46 0.00 0.00 41825 S 117.45 0.00 0.00<br />

40812 S 144.82 0.00 0.00 41826 S 147.83 0.00 0.00<br />

40814 S 523.08 0.00 0.00 41827 S 663.41 0.00 0.00<br />

40816 S 663.41 0.00 0.00 41828 S 133.48 0.00 0.00<br />

40818 S 129.73 0.00 0.00 41830 S 189.54 0.00 0.00<br />

40819 S 290.86 0.00 0.00 41850 S 643.80 0.00 0.00<br />

40820 S 166.51 0.00 0.00 41870 S 924.46 0.00 0.00<br />

40830 S 123.50 0.00 0.00 41872 S 189.54 0.00 0.00<br />

40831 S 290.86 0.00 0.00 41874 S 182.86 0.00 0.00<br />

40840 S 663.41 0.00 0.00 42000 S 129.73 0.00 0.00<br />

40842 S 692.28 0.00 0.00 42100 S 74.08 0.00 0.00<br />

40843 S 692.28 0.00 0.00 42104 S 110.12 0.00 0.00<br />

40844 S 1,105.28 0.00 0.00 42106 S 138.15 0.00 0.00<br />

40845 S 1,105.28 0.00 0.00 42107 S 663.41 0.00 0.00<br />

41000 S 82.76 0.00 0.00 42120 S 1,066.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 341.83 0.00 0.00 42809 S 24.13 0.00 0.00<br />

42145 S 785.65 0.00 0.00 42810 S 692.28 0.00 0.00<br />

42160 S 130.80 0.00 0.00 42815 S 1,105.28 0.00 0.00<br />

42180 S 129.73 0.00 0.00 42820 S 692.28 0.00 0.00<br />

42182 S 983.03 0.00 0.00 42821 S 785.65 0.00 0.00<br />

42200 S 1,105.28 0.00 0.00 42825 S 746.41 0.00 0.00<br />

42205 S 1,105.28 0.00 0.00 42826 S 746.41 0.00 0.00<br />

42210 S 1,105.28 0.00 0.00 42830 S 746.41 0.00 0.00<br />

42215 S 1,230.68 0.00 0.00 42831 S 746.41 0.00 0.00<br />

42220 S 1,105.28 0.00 0.00 42835 S 746.41 0.00 0.00<br />

42226 S 1,105.28 0.00 0.00 42836 S 746.41 0.00 0.00<br />

42235 S 645.33 0.00 0.00 42860 S 692.28 0.00 0.00<br />

42260 S 746.41 0.00 0.00 42870 S 692.28 0.00 0.00<br />

42280 S 72.07 0.00 0.00 42890 S 1,230.68 0.00 0.00<br />

42281 S 643.80 0.00 0.00 42892 S 1,230.68 0.00 0.00<br />

42300 S 472.11 0.00 0.00 42900 S 290.86 0.00 0.00<br />

42305 S 523.08 0.00 0.00 42950 S 663.41 0.00 0.00<br />

42310 S 129.73 0.00 0.00 42955 S 663.41 0.00 0.00<br />

42320 S 129.73 0.00 0.00 42960 S 53.44 0.00 0.00<br />

42330 S 111.45 0.00 0.00 42962 S 983.03 0.00 0.00<br />

42335 S 184.86 0.00 0.00 42970 S 41.49 0.00 0.00<br />

42340 S 523.08 0.00 0.00 42972 S 551.96 0.00 0.00<br />

42400 S 62.74 0.00 0.00 43030 S 643.80 0.00 0.00<br />

42405 S 523.08 0.00 0.00 43200 S 311.76 0.00 0.00<br />

42408 S 551.96 0.00 0.00 43201 S 311.76 0.00 0.00<br />

42409 S 551.96 0.00 0.00 43202 S 311.76 0.00 0.00<br />

42410 S 1,011.91 0.00 0.00 43204 S 311.76 0.00 0.00<br />

42415 S 1,230.68 0.00 0.00 43205 S 311.76 0.00 0.00<br />

42420 S 1,230.68 0.00 0.00 43215 S 311.76 0.00 0.00<br />

42425 S 1,230.68 0.00 0.00 43216 S 311.76 0.00 0.00<br />

42440 S 1,011.91 0.00 0.00 43217 S 311.76 0.00 0.00<br />

42450 S 663.41 0.00 0.00 43219 S 630.08 0.00 0.00<br />

42500 S 692.28 0.00 0.00 43220 S 311.76 0.00 0.00<br />

42505 S 1,066.03 0.00 0.00 43226 S 311.76 0.00 0.00<br />

42507 S 1,011.91 0.00 0.00 43227 S 362.74 0.00 0.00<br />

42508 S 1,066.03 0.00 0.00 43228 S 675.04 0.00 0.00<br />

42509 S 1,066.03 0.00 0.00 43231 S 362.74 0.00 0.00<br />

42510 S 1,066.03 0.00 0.00 43232 S 362.74 0.00 0.00<br />

42600 S 472.11 0.00 0.00 43234 S 311.76 0.00 0.00<br />

42650 S 41.04 0.00 0.00 43235 S 311.76 0.00 0.00<br />

42660 S 48.05 0.00 0.00 43236 S 362.74 0.00 0.00<br />

42665 S 911.05 0.00 0.00 43237 S 362.74 0.00 0.00<br />

42700 S 129.73 0.00 0.00 43238 S 362.74 0.00 0.00<br />

42720 S 472.11 0.00 0.00 43239 S 362.74 0.00 0.00<br />

42725 S 983.03 0.00 0.00 43240 S 362.74 0.00 0.00<br />

42800 S 79.42 0.00 0.00 43241 S 362.74 0.00 0.00<br />

42802 S 472.11 0.00 0.00 43242 S 362.74 0.00 0.00<br />

42804 S 472.11 0.00 0.00 43243 S 362.74 0.00 0.00<br />

42806 S 663.41 0.00 0.00 43244 S 362.74 0.00 0.00<br />

42808 S 523.08 0.00 0.00 43245 S 362.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 362.74 0.00 0.00 44378 S 379.91 0.00 0.00<br />

43247 S 362.74 0.00 0.00 44379 S 1,083.87 0.00 0.00<br />

43248 S 362.74 0.00 0.00 44380 S 328.94 0.00 0.00<br />

43249 S 362.74 0.00 0.00 44382 S 328.94 0.00 0.00<br />

43250 S 362.74 0.00 0.00 44383 S 1,083.87 0.00 0.00<br />

43251 S 362.74 0.00 0.00 44385 S 318.04 0.00 0.00<br />

43255 S 362.74 0.00 0.00 44386 S 318.04 0.00 0.00<br />

43256 S 709.92 0.00 0.00 44388 S 318.04 0.00 0.00<br />

43257 S 703.91 0.00 0.00 44389 S 318.04 0.00 0.00<br />

43258 S 391.61 0.00 0.00 44390 S 318.04 0.00 0.00<br />

43259 S 391.61 0.00 0.00 44391 S 318.04 0.00 0.00<br />

43260 S 610.68 0.00 0.00 44392 S 318.04 0.00 0.00<br />

43261 S 610.68 0.00 0.00 44393 S 318.04 0.00 0.00<br />

43262 S 610.68 0.00 0.00 44394 S 318.04 0.00 0.00<br />

43263 S 610.68 0.00 0.00 44397 S 630.08 0.00 0.00<br />

43264 S 610.68 0.00 0.00 44500 S 171.62 0.00 0.00<br />

43265 S 610.68 0.00 0.00 45000 S 368.82 0.00 0.00<br />

43267 S 610.68 0.00 0.00 45005 S 429.24 0.00 0.00<br />

43268 S 681.06 0.00 0.00 45020 S 429.24 0.00 0.00<br />

43269 S 681.06 0.00 0.00 45100 S 583.16 0.00 0.00<br />

43271 S 610.68 0.00 0.00 45108 S 634.13 0.00 0.00<br />

43272 S 610.68 0.00 0.00 45150 S 634.13 0.00 0.00<br />

43273 S 819.00 0.00 0.00 45160 S 634.13 0.00 0.00<br />

43450 S 272.66 0.00 0.00 45170 S 634.13 0.00 0.00<br />

43453 S 272.66 0.00 0.00 45190 S 1,036.95 0.00 0.00<br />

43456 S 273.74 0.00 0.00 45300 S 61.40 0.00 0.00<br />

43458 S 312.86 0.00 0.00 45303 S 341.04 0.00 0.00<br />

43600 S 311.76 0.00 0.00 45305 S 320.73 0.00 0.00<br />

43653 S 1,468.93 0.00 0.00 45307 S 592.41 0.00 0.00<br />

43760 S 151.21 0.00 0.00 45308 S 320.73 0.00 0.00<br />

43761 S 311.76 0.00 0.00 45309 S 320.73 0.00 0.00<br />

43870 S 311.76 0.00 0.00 45315 S 320.73 0.00 0.00<br />

43886 S 786.66 0.00 0.00 45317 S 320.73 0.00 0.00<br />

43887 S 165.45 0.00 0.00 45320 S 592.41 0.00 0.00<br />

43888 S 786.66 0.00 0.00 45321 S 592.41 0.00 0.00<br />

44100 S 311.76 0.00 0.00 45327 S 630.08 0.00 0.00<br />

44312 S 543.54 0.00 0.00 45330 S 81.08 0.00 0.00<br />

44340 S 623.38 0.00 0.00 45331 S 239.78 0.00 0.00<br />

44360 S 379.91 0.00 0.00 45332 S 239.78 0.00 0.00<br />

44361 S 379.91 0.00 0.00 45333 S 320.73 0.00 0.00<br />

44363 S 379.91 0.00 0.00 45334 S 320.73 0.00 0.00<br />

44364 S 379.91 0.00 0.00 45335 S 239.78 0.00 0.00<br />

44365 S 379.91 0.00 0.00 45337 S 239.78 0.00 0.00<br />

44366 S 379.91 0.00 0.00 45338 S 320.73 0.00 0.00<br />

44369 S 379.91 0.00 0.00 45339 S 320.73 0.00 0.00<br />

44370 S 1,083.87 0.00 0.00 45340 S 320.73 0.00 0.00<br />

44372 S 379.91 0.00 0.00 45341 S 320.73 0.00 0.00<br />

44373 S 379.91 0.00 0.00 45342 S 320.73 0.00 0.00<br />

44376 S 379.91 0.00 0.00 45345 S 630.08 0.00 0.00<br />

44377 S 379.91 0.00 0.00 45355 S 318.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 369.02 0.00 0.00 46505 S 456.11 0.00 0.00<br />

45379 S 369.02 0.00 0.00 46600 S 24.13 0.00 0.00<br />

45380 S 369.02 0.00 0.00 46604 S 341.04 0.00 0.00<br />

45381 S 369.02 0.00 0.00 46606 S 128.14 0.00 0.00<br />

45382 S 369.02 0.00 0.00 46608 S 320.73 0.00 0.00<br />

45383 S 369.02 0.00 0.00 46610 S 592.41 0.00 0.00<br />

45384 S 369.02 0.00 0.00 46611 S 320.73 0.00 0.00<br />

45385 S 369.02 0.00 0.00 46612 S 592.41 0.00 0.00<br />

45386 S 369.02 0.00 0.00 46614 S 67.40 0.00 0.00<br />

45387 S 630.08 0.00 0.00 46615 S 643.37 0.00 0.00<br />

45391 S 369.02 0.00 0.00 46700 S 663.01 0.00 0.00<br />

45392 S 369.02 0.00 0.00 46706 S 729.77 0.00 0.00<br />

45500 S 634.13 0.00 0.00 46750 S 809.61 0.00 0.00<br />

45505 S 780.75 0.00 0.00 46753 S 663.01 0.00 0.00<br />

45520 S 30.92 0.00 0.00 46754 S 634.13 0.00 0.00<br />

45560 S 780.75 0.00 0.00 46760 S 780.75 0.00 0.00<br />

45900 S 250.04 0.00 0.00 46761 S 809.61 0.00 0.00<br />

45905 S 583.16 0.00 0.00 46762 S 1,028.39 0.00 0.00<br />

45910 S 583.16 0.00 0.00 46900 S 101.90 0.00 0.00<br />

45915 S 368.82 0.00 0.00 46910 S 121.79 0.00 0.00<br />

45990 S 573.72 0.00 0.00 46916 S 56.65 0.00 0.00<br />

46020 S 663.01 0.00 0.00 46917 S 528.46 0.00 0.00<br />

46030 S 250.04 0.00 0.00 46922 S 528.46 0.00 0.00<br />

46040 S 663.01 0.00 0.00 46924 S 528.46 0.00 0.00<br />

46045 S 634.13 0.00 0.00 46930 S 118.13 0.00 0.00<br />

46050 S 368.82 0.00 0.00 46937 S 634.13 0.00 0.00<br />

46060 S 634.13 0.00 0.00 46938 S 780.75 0.00 0.00<br />

46070 S 456.11 0.00 0.00 46940 S 87.42 0.00 0.00<br />

46080 S 663.01 0.00 0.00 46942 S 85.09 0.00 0.00<br />

46083 S 69.82 0.00 0.00 46945 S 144.82 0.00 0.00<br />

46200 S 634.13 0.00 0.00 46946 S 378.26 0.00 0.00<br />

46210 S 634.13 0.00 0.00 46947 S 1,028.39 0.00 0.00<br />

46211 S 634.13 0.00 0.00 47000 S 329.06 0.00 0.00<br />

46220 S 583.16 0.00 0.00 47382 S 1,736.51 0.00 0.00<br />

46221 S 114.79 0.00 0.00 47510 S 769.03 0.00 0.00<br />

46230 S 583.16 0.00 0.00 47511 S 1,129.82 0.00 0.00<br />

46250 S 663.01 0.00 0.00 47525 S 441.48 0.00 0.00<br />

46255 S 663.01 0.00 0.00 47530 S 441.48 0.00 0.00<br />

46257 S 663.01 0.00 0.00 47552 S 769.03 0.00 0.00<br />

46258 S 663.01 0.00 0.00 47553 S 797.89 0.00 0.00<br />

46260 S 663.01 0.00 0.00 47554 S 797.89 0.00 0.00<br />

46261 S 717.13 0.00 0.00 47555 S 797.89 0.00 0.00<br />

46262 S 717.13 0.00 0.00 47556 S 1,129.82 0.00 0.00<br />

46270 S 663.01 0.00 0.00 47560 S 937.50 0.00 0.00<br />

46275 S 663.01 0.00 0.00 47561 S 937.50 0.00 0.00<br />

46280 S 717.13 0.00 0.00 47562 S 1,729.87 0.00 0.00<br />

46285 S 583.16 0.00 0.00 47563 S 1,729.87 0.00 0.00<br />

46288 S 717.13 0.00 0.00 47564 S 1,729.87 0.00 0.00<br />

46320 S 77.75 0.00 0.00 47630 S 797.89 0.00 0.00<br />

46500 S 107.11 0.00 0.00 48102 S 329.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 200.09 0.00 0.00 49590 S 821.25 0.00 0.00<br />

49081 S 200.09 0.00 0.00 49600 S 875.38 0.00 0.00<br />

49180 S 329.06 0.00 0.00 49650 S 1,149.12 0.00 0.00<br />

49250 S 721.30 0.00 0.00 49651 S 1,313.77 0.00 0.00<br />

49320 S 937.50 0.00 0.00 49652 S 1,414.89 0.00 0.00<br />

49321 S 991.63 0.00 0.00 49653 S 1,414.89 0.00 0.00<br />

49322 S 991.63 0.00 0.00 49654 S 1,414.89 0.00 0.00<br />

49324 S 1,414.89 0.00 0.00 49655 S 1,414.89 0.00 0.00<br />

49325 S 1,414.89 0.00 0.00 49656 S 1,414.89 0.00 0.00<br />

49326 S 1,414.89 0.00 0.00 49657 S 1,414.89 0.00 0.00<br />

49402 S 638.30 0.00 0.00 50200 S 329.06 0.00 0.00<br />

49419 S 765.73 0.00 0.00 50382 S 955.51 0.00 0.00<br />

49420 S 707.87 0.00 0.00 50384 S 701.80 0.00 0.00<br />

49421 S 707.87 0.00 0.00 50385 S 701.80 0.00 0.00<br />

49422 S 563.35 0.00 0.00 50386 S 269.26 0.00 0.00<br />

49423 S 582.53 0.00 0.00 50387 S 582.53 0.00 0.00<br />

49426 S 638.30 0.00 0.00 50389 S 269.26 0.00 0.00<br />

49429 S 826.30 0.00 0.00 50390 S 329.06 0.00 0.00<br />

49440 S 323.12 0.00 0.00 50391 S 38.97 0.00 0.00<br />

49441 S 323.12 0.00 0.00 50392 S 501.11 0.00 0.00<br />

49446 S 323.12 0.00 0.00 50393 S 627.96 0.00 0.00<br />

49450 S 171.62 0.00 0.00 50395 S 501.11 0.00 0.00<br />

49451 S 171.62 0.00 0.00 50396 S 94.22 0.00 0.00<br />

49452 S 171.62 0.00 0.00 50398 S 441.48 0.00 0.00<br />

49460 S 171.62 0.00 0.00 50551 S 284.84 0.00 0.00<br />

49495 S 875.38 0.00 0.00 50553 S 627.96 0.00 0.00<br />

49496 S 875.38 0.00 0.00 50555 S 284.84 0.00 0.00<br />

49500 S 875.38 0.00 0.00 50557 S 627.96 0.00 0.00<br />

49501 S 1,195.19 0.00 0.00 50561 S 627.96 0.00 0.00<br />

49505 S 875.38 0.00 0.00 50562 S 269.26 0.00 0.00<br />

49507 S 1,195.19 0.00 0.00 50570 S 269.26 0.00 0.00<br />

49520 S 1,040.03 0.00 0.00 50572 S 269.26 0.00 0.00<br />

49521 S 1,195.19 0.00 0.00 50574 S 269.26 0.00 0.00<br />

49525 S 875.38 0.00 0.00 50575 S 1,339.36 0.00 0.00<br />

49540 S 792.38 0.00 0.00 50576 S 701.80 0.00 0.00<br />

49550 S 914.62 0.00 0.00 50580 S 701.80 0.00 0.00<br />

49553 S 1,195.19 0.00 0.00 50590 S 1,564.68 0.00 0.00<br />

49555 S 914.62 0.00 0.00 50592 S 1,736.51 0.00 0.00<br />

49557 S 1,195.19 0.00 0.00 50686 S 38.97 0.00 0.00<br />

49560 S 875.38 0.00 0.00 50688 S 441.48 0.00 0.00<br />

49561 S 1,195.19 0.00 0.00 50947 S 1,468.93 0.00 0.00<br />

49565 S 875.38 0.00 0.00 50948 S 1,468.93 0.00 0.00<br />

49566 S 1,195.19 0.00 0.00 50951 S 284.84 0.00 0.00<br />

49568 S 1,040.03 0.00 0.00 50953 S 284.84 0.00 0.00<br />

49570 S 875.38 0.00 0.00 50955 S 627.96 0.00 0.00<br />

49572 S 1,195.19 0.00 0.00 50957 S 627.96 0.00 0.00<br />

49580 S 875.38 0.00 0.00 50961 S 627.96 0.00 0.00<br />

49582 S 1,195.19 0.00 0.00 50970 S 284.84 0.00 0.00<br />

49585 S 875.38 0.00 0.00 50972 S 284.84 0.00 0.00<br />

49587 S 1,195.19 0.00 0.00 50974 S 501.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 501.11 0.00 0.00 52275 S 678.94 0.00 0.00<br />

50980 S 627.96 0.00 0.00 52276 S 707.81 0.00 0.00<br />

51020 S 761.94 0.00 0.00 52277 S 678.94 0.00 0.00<br />

51030 S 761.94 0.00 0.00 52281 S 552.08 0.00 0.00<br />

51040 S 761.94 0.00 0.00 52282 S 1,273.68 0.00 0.00<br />

51045 S 314.72 0.00 0.00 52283 S 678.94 0.00 0.00<br />

51050 S 761.94 0.00 0.00 52285 S 552.08 0.00 0.00<br />

51065 S 761.94 0.00 0.00 52290 S 552.08 0.00 0.00<br />

51080 S 512.20 0.00 0.00 52300 S 678.94 0.00 0.00<br />

51100 S 29.70 0.00 0.00 52301 S 707.81 0.00 0.00<br />

51101 S 38.97 0.00 0.00 52305 S 678.94 0.00 0.00<br />

51102 S 524.28 0.00 0.00 52310 S 530.98 0.00 0.00<br />

51500 S 875.38 0.00 0.00 52315 S 678.94 0.00 0.00<br />

51520 S 761.94 0.00 0.00 52317 S 627.96 0.00 0.00<br />

51700 S 50.72 0.00 0.00 52318 S 678.94 0.00 0.00<br />

51701 S 24.13 0.00 0.00 52320 S 801.18 0.00 0.00<br />

51702 S 24.13 0.00 0.00 52325 S 761.94 0.00 0.00<br />

51703 S 38.97 0.00 0.00 52327 S 870.86 0.00 0.00<br />

51705 S 69.82 0.00 0.00 52330 S 678.94 0.00 0.00<br />

51710 S 441.48 0.00 0.00 52332 S 678.94 0.00 0.00<br />

51715 S 801.59 0.00 0.00 52334 S 707.81 0.00 0.00<br />

51720 S 56.06 0.00 0.00 52341 S 707.81 0.00 0.00<br />

51725 TC S 107.69 0.00 0.00 52342 S 707.81 0.00 0.00<br />

51726 TC S 148.34 0.00 0.00 52343 S 707.81 0.00 0.00<br />

51736 TC S 20.35 0.00 0.00 52344 S 707.81 0.00 0.00<br />

51741 TC S 23.69 0.00 0.00 52345 S 707.81 0.00 0.00<br />

51772 TC S 94.22 0.00 0.00 52346 S 707.81 0.00 0.00<br />

51784 TC S 38.97 0.00 0.00 52351 S 707.81 0.00 0.00<br />

51785 TC S 65.10 0.00 0.00 52352 S 761.94 0.00 0.00<br />

51792 TC S 38.97 0.00 0.00 52353 S 953.86 0.00 0.00<br />

51795 TC S 69.82 0.00 0.00 52354 S 761.94 0.00 0.00<br />

51797 TC S 69.82 0.00 0.00 52355 S 761.94 0.00 0.00<br />

51798 S 17.35 0.00 0.00 52400 S 707.81 0.00 0.00<br />

51880 S 627.96 0.00 0.00 52402 S 707.81 0.00 0.00<br />

51992 S 1,188.36 0.00 0.00 52450 S 707.81 0.00 0.00<br />

52000 S 284.84 0.00 0.00 52500 S 707.81 0.00 0.00<br />

52001 S 530.98 0.00 0.00 52601 S 953.86 0.00 0.00<br />

52005 S 552.08 0.00 0.00 52630 S 870.86 0.00 0.00<br />

52007 S 678.94 0.00 0.00 52640 S 678.94 0.00 0.00<br />

52010 S 314.72 0.00 0.00 52647 S 1,459.32 0.00 0.00<br />

52204 S 552.08 0.00 0.00 52648 S 1,459.32 0.00 0.00<br />

52214 S 678.94 0.00 0.00 52700 S 678.94 0.00 0.00<br />

52224 S 678.94 0.00 0.00 53000 S 521.08 0.00 0.00<br />

52234 S 678.94 0.00 0.00 53010 S 521.08 0.00 0.00<br />

52235 S 707.81 0.00 0.00 53020 S 521.08 0.00 0.00<br />

52240 S 707.81 0.00 0.00 53025 S 741.74 0.00 0.00<br />

52250 S 761.94 0.00 0.00 53040 S 572.06 0.00 0.00<br />

52260 S 552.08 0.00 0.00 53060 S 67.74 0.00 0.00<br />

52265 S 269.26 0.00 0.00 53080 S 600.93 0.00 0.00<br />

52270 S 552.08 0.00 0.00 53085 S 741.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 521.08 0.00 0.00 54060 S 528.46 0.00 0.00<br />

53210 S 894.96 0.00 0.00 54065 S 528.46 0.00 0.00<br />

53215 S 694.30 0.00 0.00 54100 S 447.04 0.00 0.00<br />

53220 S 772.72 0.00 0.00 54105 S 558.05 0.00 0.00<br />

53230 S 772.72 0.00 0.00 54110 S 865.22 0.00 0.00<br />

53235 S 600.93 0.00 0.00 54111 S 865.22 0.00 0.00<br />

53240 S 772.72 0.00 0.00 54112 S 865.22 0.00 0.00<br />

53250 S 572.06 0.00 0.00 54115 S 512.20 0.00 0.00<br />

53260 S 572.06 0.00 0.00 54120 S 865.22 0.00 0.00<br />

53265 S 572.06 0.00 0.00 54150 S 576.62 0.00 0.00<br />

53270 S 572.06 0.00 0.00 54160 S 627.60 0.00 0.00<br />

53275 S 572.06 0.00 0.00 54161 S 627.60 0.00 0.00<br />

53400 S 801.59 0.00 0.00 54162 S 627.60 0.00 0.00<br />

53405 S 772.72 0.00 0.00 54163 S 627.60 0.00 0.00<br />

53410 S 772.72 0.00 0.00 54164 S 627.60 0.00 0.00<br />

53420 S 801.59 0.00 0.00 54200 S 65.74 0.00 0.00<br />

53425 S 772.72 0.00 0.00 54205 S 948.22 0.00 0.00<br />

53430 S 772.72 0.00 0.00 54220 S 94.22 0.00 0.00<br />

53431 S 772.72 0.00 0.00 54231 S 61.73 0.00 0.00<br />

53440 S 4,451.16 2,703.40 955.63 54235 S 43.72 0.00 0.00<br />

53442 S 721.75 0.00 0.00 54240 TC S 31.03 0.00 0.00<br />

53444 S 4,451.16 2,703.40 955.63 54250 TC S 11.01 0.00 0.00<br />

53445 S 7,476.83 4,258.00 1,039.18 54300 S 894.09 0.00 0.00<br />

53446 S 721.75 0.00 0.00 54304 S 894.09 0.00 0.00<br />

53447 S 7,476.83 4,258.00 1,039.18 54308 S 894.09 0.00 0.00<br />

53449 S 721.75 0.00 0.00 54312 S 894.09 0.00 0.00<br />

53450 S 721.75 0.00 0.00 54316 S 894.09 0.00 0.00<br />

53460 S 521.08 0.00 0.00 54318 S 894.09 0.00 0.00<br />

53502 S 572.06 0.00 0.00 54322 S 894.09 0.00 0.00<br />

53505 S 772.72 0.00 0.00 54324 S 894.09 0.00 0.00<br />

53510 S 572.06 0.00 0.00 54326 S 894.09 0.00 0.00<br />

53515 S 772.72 0.00 0.00 54328 S 894.09 0.00 0.00<br />

53520 S 772.72 0.00 0.00 54340 S 894.09 0.00 0.00<br />

53600 S 39.04 0.00 0.00 54344 S 894.09 0.00 0.00<br />

53601 S 38.97 0.00 0.00 54348 S 894.09 0.00 0.00<br />

53605 S 552.08 0.00 0.00 54352 S 894.09 0.00 0.00<br />

53620 S 60.06 0.00 0.00 54360 S 894.09 0.00 0.00<br />

53621 S 63.07 0.00 0.00 54380 S 894.09 0.00 0.00<br />

53660 S 38.97 0.00 0.00 54385 S 894.09 0.00 0.00<br />

53661 S 38.97 0.00 0.00 54400 S 4,480.04 2,732.27 984.51<br />

53665 S 521.08 0.00 0.00 54401 S 7,556.67 4,337.85 1,119.03<br />

53850 S 1,710.65 0.00 0.00 54405 S 7,556.67 4,337.85 1,119.03<br />

53852 S 1,710.65 0.00 0.00 54406 S 894.09 0.00 0.00<br />

54000 S 572.06 0.00 0.00 54408 S 894.09 0.00 0.00<br />

54001 S 572.06 0.00 0.00 54410 S 7,556.67 4,337.85 1,119.03<br />

54015 S 646.18 0.00 0.00 54415 S 894.09 0.00 0.00<br />

54050 S 30.92 0.00 0.00 54416 S 7,556.67 4,337.85 1,119.03<br />

54055 S 63.07 0.00 0.00 54420 S 948.22 0.00 0.00<br />

54056 S 30.92 0.00 0.00 54435 S 948.22 0.00 0.00<br />

54057 S 528.46 0.00 0.00 54440 S 948.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 148.34 0.00 0.00 55706 S 431.23 0.00 0.00<br />

54500 S 402.60 0.00 0.00 55720 S 627.96 0.00 0.00<br />

54505 S 576.62 0.00 0.00 55725 S 678.94 0.00 0.00<br />

54512 S 627.60 0.00 0.00 55860 S 748.15 0.00 0.00<br />

54520 S 656.47 0.00 0.00 55870 S 76.08 0.00 0.00<br />

54522 S 656.47 0.00 0.00 55873 S 5,919.68 0.00 0.00<br />

54530 S 875.38 0.00 0.00 55875 S 1,273.68 0.00 0.00<br />

54550 S 875.38 0.00 0.00 55876 S 69.74 0.00 0.00<br />

54560 S 852.83 0.00 0.00 55920 S 874.26 0.00 0.00<br />

54600 S 710.60 0.00 0.00 56405 S 40.71 0.00 0.00<br />

54620 S 656.47 0.00 0.00 56420 S 53.13 0.00 0.00<br />

54640 S 875.38 0.00 0.00 56440 S 570.58 0.00 0.00<br />

54660 S 627.60 0.00 0.00 56441 S 519.60 0.00 0.00<br />

54670 S 656.47 0.00 0.00 56442 S 519.60 0.00 0.00<br />

54680 S 656.47 0.00 0.00 56501 S 56.06 0.00 0.00<br />

54690 S 1,468.93 0.00 0.00 56515 S 608.30 0.00 0.00<br />

54692 S 2,611.16 0.00 0.00 56605 S 32.36 0.00 0.00<br />

54700 S 627.60 0.00 0.00 56606 S 13.35 0.00 0.00<br />

54800 S 140.87 0.00 0.00 56620 S 692.82 0.00 0.00<br />

54830 S 656.47 0.00 0.00 56625 S 818.22 0.00 0.00<br />

54840 S 710.60 0.00 0.00 56700 S 519.60 0.00 0.00<br />

54860 S 656.47 0.00 0.00 56740 S 599.45 0.00 0.00<br />

54861 S 710.60 0.00 0.00 56800 S 599.45 0.00 0.00<br />

54865 S 576.62 0.00 0.00 56805 S 738.79 0.00 0.00<br />

54900 S 710.60 0.00 0.00 56810 S 692.82 0.00 0.00<br />

54901 S 710.60 0.00 0.00 56820 S 41.37 0.00 0.00<br />

55000 S 64.07 0.00 0.00 56821 S 53.13 0.00 0.00<br />

55040 S 821.25 0.00 0.00 57000 S 519.60 0.00 0.00<br />

55041 S 914.62 0.00 0.00 57010 S 570.58 0.00 0.00<br />

55060 S 710.60 0.00 0.00 57020 S 299.24 0.00 0.00<br />

55100 S 385.38 0.00 0.00 57022 S 470.35 0.00 0.00<br />

55110 S 627.60 0.00 0.00 57023 S 512.20 0.00 0.00<br />

55120 S 627.60 0.00 0.00 57061 S 51.72 0.00 0.00<br />

55150 S 576.62 0.00 0.00 57065 S 519.60 0.00 0.00<br />

55175 S 576.62 0.00 0.00 57100 S 33.04 0.00 0.00<br />

55180 S 627.60 0.00 0.00 57105 S 570.58 0.00 0.00<br />

55200 S 627.60 0.00 0.00 57130 S 570.58 0.00 0.00<br />

55250 S 627.60 0.00 0.00 57135 S 570.58 0.00 0.00<br />

55400 S 576.62 0.00 0.00 57150 S 24.03 0.00 0.00<br />

55450 S 206.22 0.00 0.00 57155 S 299.24 0.00 0.00<br />

55500 S 656.47 0.00 0.00 57160 S 34.70 0.00 0.00<br />

55520 S 710.60 0.00 0.00 57170 S 5.69 0.00 0.00<br />

55530 S 710.60 0.00 0.00 57180 S 106.88 0.00 0.00<br />

55535 S 875.38 0.00 0.00 57200 S 519.60 0.00 0.00<br />

55540 S 914.62 0.00 0.00 57210 S 570.58 0.00 0.00<br />

55550 S 1,468.93 0.00 0.00 57220 S 1,046.36 0.00 0.00<br />

55600 S 852.83 0.00 0.00 57230 S 859.16 0.00 0.00<br />

55680 S 576.62 0.00 0.00 57240 S 952.53 0.00 0.00<br />

55700 S 371.61 0.00 0.00 57250 S 952.53 0.00 0.00<br />

55705 S 371.61 0.00 0.00 57260 S 952.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,265.14 0.00 0.00 58555 S 561.40 0.00 0.00<br />

57267 S 1,077.93 0.00 0.00 58558 S 641.25 0.00 0.00<br />

57268 S 859.16 0.00 0.00 58559 S 612.38 0.00 0.00<br />

57287 S 1,258.22 0.00 0.00 58560 S 914.33 0.00 0.00<br />

57288 S 1,139.74 0.00 0.00 58561 S 914.33 0.00 0.00<br />

57289 S 952.53 0.00 0.00 58562 S 641.25 0.00 0.00<br />

57291 S 952.53 0.00 0.00 58563 S 1,288.27 0.00 0.00<br />

57300 S 859.16 0.00 0.00 58565 S 1,420.31 0.00 0.00<br />

57320 S 1,258.22 0.00 0.00 58600 S 1,258.22 0.00 0.00<br />

57400 S 570.58 0.00 0.00 58615 S 738.79 0.00 0.00<br />

57410 S 570.58 0.00 0.00 58660 S 1,188.36 0.00 0.00<br />

57415 S 570.58 0.00 0.00 58661 S 1,188.36 0.00 0.00<br />

57420 S 42.72 0.00 0.00 58662 S 1,188.36 0.00 0.00<br />

57421 S 55.72 0.00 0.00 58670 S 1,094.99 0.00 0.00<br />

57452 S 40.38 0.00 0.00 58671 S 1,094.99 0.00 0.00<br />

57454 S 49.39 0.00 0.00 58672 S 1,188.36 0.00 0.00<br />

57455 S 52.38 0.00 0.00 58673 S 1,188.36 0.00 0.00<br />

57456 S 50.72 0.00 0.00 58800 S 599.45 0.00 0.00<br />

57460 S 155.83 0.00 0.00 58805 S 1,258.22 0.00 0.00<br />

57461 S 165.51 0.00 0.00 58820 S 859.16 0.00 0.00<br />

57500 S 71.41 0.00 0.00 58900 S 599.45 0.00 0.00<br />

57505 S 45.38 0.00 0.00 58970 S 166.97 0.00 0.00<br />

57510 S 46.05 0.00 0.00 58974 S 166.97 0.00 0.00<br />

57511 S 53.13 0.00 0.00 58976 S 166.97 0.00 0.00<br />

57513 S 570.58 0.00 0.00 59000 S 61.06 0.00 0.00<br />

57520 S 570.58 0.00 0.00 59001 S 229.21 0.00 0.00<br />

57522 S 570.58 0.00 0.00 59012 S 112.08 0.00 0.00<br />

57530 S 859.16 0.00 0.00 59015 S 49.39 0.00 0.00<br />

57550 S 859.16 0.00 0.00 59020 TC S 26.03 0.00 0.00<br />

57556 S 1,139.74 0.00 0.00 59025 TC S 13.68 0.00 0.00<br />

57558 S 599.45 0.00 0.00 59070 S 112.08 0.00 0.00<br />

57700 S 519.60 0.00 0.00 59072 S 112.08 0.00 0.00<br />

57720 S 599.45 0.00 0.00 59076 S 112.08 0.00 0.00<br />

57800 S 24.36 0.00 0.00 59100 S 1,258.22 0.00 0.00<br />

58100 S 40.04 0.00 0.00 59150 S 1,729.87 0.00 0.00<br />

58120 S 570.58 0.00 0.00 59151 S 1,729.87 0.00 0.00<br />

58145 S 952.53 0.00 0.00 59160 S 599.45 0.00 0.00<br />

58301 S 37.37 0.00 0.00 59200 S 33.37 0.00 0.00<br />

58321 S 35.04 0.00 0.00 59300 S 72.07 0.00 0.00<br />

58322 S 36.04 0.00 0.00 59320 S 519.60 0.00 0.00<br />

58323 S 8.35 0.00 0.00 59412 S 738.79 0.00 0.00<br />

58345 S 738.79 0.00 0.00 59414 S 738.79 0.00 0.00<br />

58346 S 570.58 0.00 0.00 59812 S 692.82 0.00 0.00<br />

58350 S 859.16 0.00 0.00 59820 S 692.82 0.00 0.00<br />

58353 S 1,077.93 0.00 0.00 59821 S 692.82 0.00 0.00<br />

58356 S 1,632.63 0.00 0.00 59840 S 692.82 0.00 0.00<br />

58545 S 1,311.44 0.00 0.00 59841 S 692.82 0.00 0.00<br />

58546 S 1,468.93 0.00 0.00 59866 S 112.08 0.00 0.00<br />

58550 S 1,909.58 0.00 0.00 59870 S 692.82 0.00 0.00<br />

58552 S 1,729.87 0.00 0.00 59871 S 692.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 290.86 0.00 0.00 62367 S 16.02 0.00 0.00<br />

60100 S 45.71 0.00 0.00 62368 S 20.35 0.00 0.00<br />

60200 S 1,082.60 0.00 0.00 63600 S 546.81 0.00 0.00<br />

60280 S 1,165.60 0.00 0.00 63610 S 495.83 0.00 0.00<br />

60281 S 1,165.60 0.00 0.00 63615 S 691.25 0.00 0.00<br />

60300 S 60.06 0.00 0.00 63650 S 2,943.20 1,825.08 706.96<br />

61000 S 267.83 0.00 0.00 63655 S 4,311.07 2,749.18 1,187.29<br />

61001 S 267.83 0.00 0.00 63660 S 516.88 0.00 0.00<br />

61020 S 216.84 0.00 0.00 63685 S 13,085.09 6,977.09 869.10<br />

61026 S 216.84 0.00 0.00 63688 S 701.88 0.00 0.00<br />

61050 S 216.84 0.00 0.00 63744 S 1,015.03 0.00 0.00<br />

61055 S 216.84 0.00 0.00 63746 S 469.53 0.00 0.00<br />

61070 S 168.73 0.00 0.00 64400 S 51.39 0.00 0.00<br />

61215 S 1,015.03 0.00 0.00 64402 S 48.39 0.00 0.00<br />

61330 S 1,563.71 0.00 0.00 64405 S 41.04 0.00 0.00<br />

61334 S 1,563.71 0.00 0.00 64408 S 51.05 0.00 0.00<br />

61790 S 575.68 0.00 0.00 64410 S 284.12 0.00 0.00<br />

61791 S 427.09 0.00 0.00 64412 S 75.08 0.00 0.00<br />

61880 S 733.34 0.00 0.00 64413 S 48.05 0.00 0.00<br />

61885 S 10,552.91 5,653.09 753.28 64415 S 130.85 0.00 0.00<br />

61886 S 15,758.06 8,305.41 852.77 64416 S 267.83 0.00 0.00<br />

61888 S 701.88 0.00 0.00 64417 S 130.85 0.00 0.00<br />

62194 S 284.12 0.00 0.00 64418 S 67.40 0.00 0.00<br />

62225 S 441.48 0.00 0.00 64420 S 130.85 0.00 0.00<br />

62230 S 986.15 0.00 0.00 64421 S 284.12 0.00 0.00<br />

62252 TC S 44.71 0.00 0.00 64425 S 46.71 0.00 0.00<br />

62263 S 284.12 0.00 0.00 64430 S 196.61 0.00 0.00<br />

62264 S 418.55 0.00 0.00 64435 S 70.41 0.00 0.00<br />

62267 S 167.03 0.00 0.00 64445 S 62.40 0.00 0.00<br />

62268 S 216.84 0.00 0.00 64446 S 536.69 0.00 0.00<br />

62269 S 329.06 0.00 0.00 64447 S 136.30 0.00 0.00<br />

62270 S 130.85 0.00 0.00 64448 S 136.30 0.00 0.00<br />

62272 S 130.85 0.00 0.00 64449 S 267.83 0.00 0.00<br />

62273 S 218.36 0.00 0.00 64450 S 41.71 0.00 0.00<br />

62280 S 284.12 0.00 0.00 64455 S 17.35 0.00 0.00<br />

62281 S 284.12 0.00 0.00 64470 S 284.12 0.00 0.00<br />

62282 S 284.12 0.00 0.00 64472 S 218.36 0.00 0.00<br />

62287 S 1,275.43 0.00 0.00 64475 S 284.12 0.00 0.00<br />

62292 S 267.83 0.00 0.00 64476 S 196.65 0.00 0.00<br />

62294 S 216.84 0.00 0.00 64479 S 284.12 0.00 0.00<br />

62310 S 284.12 0.00 0.00 64480 S 218.36 0.00 0.00<br />

62311 S 284.12 0.00 0.00 64483 S 284.12 0.00 0.00<br />

62318 S 284.12 0.00 0.00 64484 S 218.36 0.00 0.00<br />

62319 S 284.12 0.00 0.00 64505 S 38.04 0.00 0.00<br />

62350 S 986.15 0.00 0.00 64508 S 80.75 0.00 0.00<br />

62355 S 469.53 0.00 0.00 64510 S 284.12 0.00 0.00<br />

62360 S 986.15 0.00 0.00 64517 S 196.61 0.00 0.00<br />

62361 S 10,122.98 5,479.21 835.45 64520 S 284.12 0.00 0.00<br />

62362 S 10,122.98 5,479.21 835.45 64530 S 284.12 0.00 0.00<br />

62365 S 872.62 0.00 0.00 64553 S 2,892.22 1,774.10 655.99<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,247.79 2,129.67 1,011.56 64746 S 546.81 0.00 0.00<br />

64560 S 3,247.79 2,129.67 1,011.56 64761 S 691.25 0.00 0.00<br />

64561 S 2,972.07 1,853.94 735.83 64763 S 691.25 0.00 0.00<br />

64565 S 3,247.79 2,129.67 1,011.56 64766 S 1,342.87 0.00 0.00<br />

64573 S 5,059.58 2,997.31 935.03 64771 S 546.81 0.00 0.00<br />

64575 S 3,867.63 2,305.74 743.85 64772 S 546.81 0.00 0.00<br />

64577 S 3,867.63 2,305.74 743.85 64774 S 546.81 0.00 0.00<br />

64580 S 3,867.63 2,305.74 743.85 64776 S 575.68 0.00 0.00<br />

64581 S 3,947.48 2,385.58 823.70 64778 S 546.81 0.00 0.00<br />

64585 S 516.88 0.00 0.00 64782 S 575.68 0.00 0.00<br />

64590 S 10,552.91 5,653.09 753.28 64783 S 546.81 0.00 0.00<br />

64595 S 701.88 0.00 0.00 64784 S 575.68 0.00 0.00<br />

64600 S 418.55 0.00 0.00 64786 S 901.49 0.00 0.00<br />

64605 S 418.55 0.00 0.00 64787 S 546.81 0.00 0.00<br />

64610 S 418.55 0.00 0.00 64788 S 575.68 0.00 0.00<br />

64612 S 61.06 0.00 0.00 64790 S 575.68 0.00 0.00<br />

64613 S 59.06 0.00 0.00 64792 S 901.49 0.00 0.00<br />

64614 S 67.40 0.00 0.00 64795 S 546.81 0.00 0.00<br />

64620 S 284.12 0.00 0.00 64802 S 546.81 0.00 0.00<br />

64622 S 418.55 0.00 0.00 64820 S 691.25 0.00 0.00<br />

64623 S 284.12 0.00 0.00 64821 S 806.98 0.00 0.00<br />

64626 S 418.55 0.00 0.00 64822 S 1,045.59 0.00 0.00<br />

64627 S 196.65 0.00 0.00 64823 S 1,045.59 0.00 0.00<br />

64630 S 292.66 0.00 0.00 64831 S 955.62 0.00 0.00<br />

64632 S 31.70 0.00 0.00 64832 S 821.64 0.00 0.00<br />

64640 S 94.44 0.00 0.00 64834 S 872.62 0.00 0.00<br />

64650 S 31.70 0.00 0.00 64835 S 901.49 0.00 0.00<br />

64653 S 34.37 0.00 0.00 64836 S 901.49 0.00 0.00<br />

64680 S 444.70 0.00 0.00 64837 S 821.64 0.00 0.00<br />

64681 S 469.53 0.00 0.00 64840 S 872.62 0.00 0.00<br />

64702 S 495.83 0.00 0.00 64856 S 872.62 0.00 0.00<br />

64704 S 495.83 0.00 0.00 64857 S 872.62 0.00 0.00<br />

64708 S 546.81 0.00 0.00 64858 S 872.62 0.00 0.00<br />

64712 S 546.81 0.00 0.00 64859 S 821.64 0.00 0.00<br />

64713 S 546.81 0.00 0.00 64861 S 901.49 0.00 0.00<br />

64714 S 546.81 0.00 0.00 64862 S 901.49 0.00 0.00<br />

64716 S 575.68 0.00 0.00 64864 S 901.49 0.00 0.00<br />

64718 S 546.81 0.00 0.00 64865 S 955.62 0.00 0.00<br />

64719 S 546.81 0.00 0.00 64870 S 955.62 0.00 0.00<br />

64721 S 546.81 0.00 0.00 64872 S 872.62 0.00 0.00<br />

64722 S 495.83 0.00 0.00 64874 S 901.49 0.00 0.00<br />

64726 S 495.83 0.00 0.00 64876 S 901.49 0.00 0.00<br />

64727 S 495.83 0.00 0.00 64885 S 872.62 0.00 0.00<br />

64732 S 546.81 0.00 0.00 64886 S 872.62 0.00 0.00<br />

64734 S 546.81 0.00 0.00 64890 S 872.62 0.00 0.00<br />

64736 S 546.81 0.00 0.00 64891 S 872.62 0.00 0.00<br />

64738 S 546.81 0.00 0.00 64892 S 872.62 0.00 0.00<br />

64740 S 546.81 0.00 0.00 64893 S 872.62 0.00 0.00<br />

64742 S 546.81 0.00 0.00 64895 S 901.49 0.00 0.00<br />

64744 S 546.81 0.00 0.00 64896 S 901.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 901.49 0.00 0.00 65770 S 5,304.95 0.00 0.00<br />

64898 S 901.49 0.00 0.00 65772 S 596.76 0.00 0.00<br />

64901 S 872.62 0.00 0.00 65775 S 596.76 0.00 0.00<br />

64902 S 872.62 0.00 0.00 65780 S 1,032.32 0.00 0.00<br />

64905 S 872.62 0.00 0.00 65781 S 1,032.32 0.00 0.00<br />

64907 S 821.64 0.00 0.00 65782 S 1,032.32 0.00 0.00<br />

64910 S 1,342.87 0.00 0.00 65800 S 462.79 0.00 0.00<br />

65091 S 949.22 0.00 0.00 65805 S 462.79 0.00 0.00<br />

65093 S 949.22 0.00 0.00 65810 S 676.24 0.00 0.00<br />

65101 S 949.22 0.00 0.00 65815 S 647.36 0.00 0.00<br />

65103 S 949.22 0.00 0.00 65820 S 237.42 0.00 0.00<br />

65105 S 1,003.35 0.00 0.00 65850 S 730.36 0.00 0.00<br />

65110 S 1,042.59 0.00 0.00 65855 S 126.13 0.00 0.00<br />

65112 S 1,167.99 0.00 0.00 65860 S 117.80 0.00 0.00<br />

65114 S 1,167.99 0.00 0.00 65865 S 462.79 0.00 0.00<br />

65125 S 972.05 0.00 0.00 65870 S 730.36 0.00 0.00<br />

65130 S 716.08 0.00 0.00 65875 S 730.36 0.00 0.00<br />

65135 S 687.21 0.00 0.00 65880 S 596.76 0.00 0.00<br />

65140 S 949.22 0.00 0.00 65900 S 636.01 0.00 0.00<br />

65150 S 687.21 0.00 0.00 65920 S 895.01 0.00 0.00<br />

65155 S 949.22 0.00 0.00 65930 S 769.61 0.00 0.00<br />

65175 S 510.83 0.00 0.00 66020 S 462.79 0.00 0.00<br />

65205 S 19.69 0.00 0.00 66030 S 237.42 0.00 0.00<br />

65210 S 25.03 0.00 0.00 66130 S 895.01 0.00 0.00<br />

65220 S 34.87 0.00 0.00 66150 S 730.36 0.00 0.00<br />

65222 S 27.36 0.00 0.00 66155 S 730.36 0.00 0.00<br />

65235 S 513.76 0.00 0.00 66160 S 647.36 0.00 0.00<br />

65260 S 338.86 0.00 0.00 66165 S 730.36 0.00 0.00<br />

65265 S 701.06 0.00 0.00 66170 S 730.36 0.00 0.00<br />

65270 S 561.80 0.00 0.00 66172 S 730.36 0.00 0.00<br />

65272 S 647.36 0.00 0.00 66180 S 1,088.09 0.00 0.00<br />

65275 S 730.36 0.00 0.00 66185 S 965.85 0.00 0.00<br />

65280 S 701.06 0.00 0.00 66220 S 942.84 0.00 0.00<br />

65285 S 996.97 0.00 0.00 66225 S 1,048.85 0.00 0.00<br />

65286 S 174.42 0.00 0.00 66250 S 513.76 0.00 0.00<br />

65290 S 690.41 0.00 0.00 66500 S 237.42 0.00 0.00<br />

65400 S 462.79 0.00 0.00 66505 S 237.42 0.00 0.00<br />

65410 S 513.76 0.00 0.00 66600 S 676.24 0.00 0.00<br />

65420 S 513.76 0.00 0.00 66605 S 676.24 0.00 0.00<br />

65426 S 769.61 0.00 0.00 66625 S 480.81 0.00 0.00<br />

65430 S 34.87 0.00 0.00 66630 S 676.24 0.00 0.00<br />

65435 S 30.37 0.00 0.00 66635 S 676.24 0.00 0.00<br />

65436 S 131.80 0.00 0.00 66680 S 676.24 0.00 0.00<br />

65450 S 80.46 0.00 0.00 66682 S 647.36 0.00 0.00<br />

65600 S 155.50 0.00 0.00 66700 S 513.76 0.00 0.00<br />

65710 S 1,157.72 0.00 0.00 66710 S 513.76 0.00 0.00<br />

65730 S 1,157.72 0.00 0.00 66711 S 513.76 0.00 0.00<br />

65750 S 1,157.72 0.00 0.00 66720 S 513.76 0.00 0.00<br />

65755 S 1,157.72 0.00 0.00 66740 S 647.36 0.00 0.00<br />

65756 S 1,417.79 0.00 0.00 66761 S 175.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 178.53 0.00 0.00 67228 S 196.61 0.00 0.00<br />

66770 S 196.61 0.00 0.00 67229 S 196.61 0.00 0.00<br />

66820 S 174.42 0.00 0.00 67250 S 590.68 0.00 0.00<br />

66821 S 239.26 0.00 0.00 67255 S 646.94 0.00 0.00<br />

66825 S 730.36 0.00 0.00 67311 S 690.41 0.00 0.00<br />

66830 S 255.44 0.00 0.00 67312 S 744.55 0.00 0.00<br />

66840 S 549.10 0.00 0.00 67314 S 744.55 0.00 0.00<br />

66850 S 1,033.82 0.00 0.00 67316 S 744.55 0.00 0.00<br />

66852 S 869.17 0.00 0.00 67318 S 744.55 0.00 0.00<br />

66920 S 869.17 0.00 0.00 67320 S 744.55 0.00 0.00<br />

66930 S 908.42 0.00 0.00 67331 S 744.55 0.00 0.00<br />

66940 S 588.34 0.00 0.00 67332 S 744.55 0.00 0.00<br />

66982 S 892.54 0.00 0.00 67334 S 744.55 0.00 0.00<br />

66983 S 892.54 0.00 0.00 67335 S 744.55 0.00 0.00<br />

66984 S 892.54 0.00 0.00 67340 S 744.55 0.00 0.00<br />

66985 S 826.23 0.00 0.00 67343 S 909.18 0.00 0.00<br />

66986 S 826.23 0.00 0.00 67345 S 77.75 0.00 0.00<br />

67005 S 701.06 0.00 0.00 67346 S 420.54 0.00 0.00<br />

67010 S 701.06 0.00 0.00 67400 S 590.68 0.00 0.00<br />

67015 S 863.00 0.00 0.00 67405 S 770.21 0.00 0.00<br />

67025 S 567.09 0.00 0.00 67412 S 684.05 0.00 0.00<br />

67027 S 996.97 0.00 0.00 67413 S 809.45 0.00 0.00<br />

67028 S 78.42 0.00 0.00 67414 S 1,438.33 0.00 0.00<br />

67030 S 567.09 0.00 0.00 67415 S 510.83 0.00 0.00<br />

67031 S 239.26 0.00 0.00 67420 S 1,042.59 0.00 0.00<br />

67036 S 996.97 0.00 0.00 67430 S 1,042.59 0.00 0.00<br />

67039 S 1,161.62 0.00 0.00 67440 S 1,042.59 0.00 0.00<br />

67040 S 1,161.62 0.00 0.00 67445 S 1,042.59 0.00 0.00<br />

67041 S 1,425.58 0.00 0.00 67450 S 1,042.59 0.00 0.00<br />

67042 S 1,425.58 0.00 0.00 67500 S 80.46 0.00 0.00<br />

67043 S 1,425.58 0.00 0.00 67505 S 25.03 0.00 0.00<br />

67101 S 217.63 0.00 0.00 67515 S 25.36 0.00 0.00<br />

67105 S 196.61 0.00 0.00 67550 S 1,003.35 0.00 0.00<br />

67107 S 1,036.21 0.00 0.00 67560 S 687.21 0.00 0.00<br />

67108 S 1,161.62 0.00 0.00 67570 S 1,003.35 0.00 0.00<br />

67110 S 316.34 0.00 0.00 67700 S 117.72 0.00 0.00<br />

67112 S 1,161.62 0.00 0.00 67710 S 137.48 0.00 0.00<br />

67113 S 1,425.58 0.00 0.00 67715 S 510.83 0.00 0.00<br />

67115 S 618.06 0.00 0.00 67800 S 49.39 0.00 0.00<br />

67120 S 618.06 0.00 0.00 67801 S 59.73 0.00 0.00<br />

67121 S 618.06 0.00 0.00 67805 S 77.41 0.00 0.00<br />

67141 S 217.87 0.00 0.00 67808 S 561.80 0.00 0.00<br />

67145 S 185.86 0.00 0.00 67810 S 117.72 0.00 0.00<br />

67208 S 198.21 0.00 0.00 67820 S 16.35 0.00 0.00<br />

67210 S 196.61 0.00 0.00 67825 S 50.39 0.00 0.00<br />

67218 S 740.31 0.00 0.00 67830 S 344.91 0.00 0.00<br />

67220 S 217.63 0.00 0.00 67835 S 561.80 0.00 0.00<br />

67221 S 111.78 0.00 0.00 67840 S 144.16 0.00 0.00<br />

67225 S 7.68 0.00 0.00 67850 S 114.46 0.00 0.00<br />

67227 S 567.09 0.00 0.00 67875 S 287.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 542.64 0.00 0.00 68440 S 49.05 0.00 0.00<br />

67882 S 590.68 0.00 0.00 68500 S 716.08 0.00 0.00<br />

67900 S 770.21 0.00 0.00 68505 S 716.08 0.00 0.00<br />

67901 S 684.05 0.00 0.00 68510 S 510.83 0.00 0.00<br />

67902 S 809.45 0.00 0.00 68520 S 716.08 0.00 0.00<br />

67903 S 644.80 0.00 0.00 68525 S 510.83 0.00 0.00<br />

67904 S 644.80 0.00 0.00 68530 S 117.72 0.00 0.00<br />

67906 S 684.05 0.00 0.00 68540 S 590.68 0.00 0.00<br />

67908 S 644.80 0.00 0.00 68550 S 716.08 0.00 0.00<br />

67909 S 644.80 0.00 0.00 68700 S 561.80 0.00 0.00<br />

67911 S 590.68 0.00 0.00 68705 S 111.78 0.00 0.00<br />

67912 S 590.68 0.00 0.00 68720 S 770.21 0.00 0.00<br />

67914 S 590.68 0.00 0.00 68745 S 770.21 0.00 0.00<br />

67915 S 159.50 0.00 0.00 68750 S 770.21 0.00 0.00<br />

67916 S 644.80 0.00 0.00 68760 S 95.10 0.00 0.00<br />

67917 S 644.80 0.00 0.00 68761 S 65.74 0.00 0.00<br />

67921 S 590.68 0.00 0.00 68770 S 770.21 0.00 0.00<br />

67922 S 155.17 0.00 0.00 68801 S 34.87 0.00 0.00<br />

67923 S 644.80 0.00 0.00 68810 S 99.72 0.00 0.00<br />

67924 S 644.80 0.00 0.00 68811 S 561.80 0.00 0.00<br />

67930 S 159.50 0.00 0.00 68815 S 561.80 0.00 0.00<br />

67935 S 561.80 0.00 0.00 68816 S 721.24 0.00 0.00<br />

67938 S 80.46 0.00 0.00 68840 S 51.72 0.00 0.00<br />

67950 S 561.80 0.00 0.00 69000 S 52.75 0.00 0.00<br />

67961 S 590.68 0.00 0.00 69005 S 99.77 0.00 0.00<br />

67966 S 590.68 0.00 0.00 69020 S 52.75 0.00 0.00<br />

67971 S 590.68 0.00 0.00 69100 S 60.06 0.00 0.00<br />

67973 S 716.08 0.00 0.00 69105 S 85.09 0.00 0.00<br />

67974 S 590.68 0.00 0.00 69110 S 447.04 0.00 0.00<br />

67975 S 590.68 0.00 0.00 69120 S 663.41 0.00 0.00<br />

68020 S 43.72 0.00 0.00 69140 S 663.41 0.00 0.00<br />

68040 S 21.69 0.00 0.00 69145 S 498.01 0.00 0.00<br />

68100 S 86.76 0.00 0.00 69150 S 350.02 0.00 0.00<br />

68110 S 111.78 0.00 0.00 69200 S 24.13 0.00 0.00<br />

68115 S 561.80 0.00 0.00 69205 S 558.05 0.00 0.00<br />

68130 S 513.76 0.00 0.00 69210 S 19.69 0.00 0.00<br />

68135 S 56.06 0.00 0.00 69220 S 30.92 0.00 0.00<br />

68200 S 16.02 0.00 0.00 69222 S 130.14 0.00 0.00<br />

68320 S 770.21 0.00 0.00 69300 S 692.28 0.00 0.00<br />

68325 S 770.21 0.00 0.00 69310 S 1,011.91 0.00 0.00<br />

68326 S 644.80 0.00 0.00 69320 S 1,230.68 0.00 0.00<br />

68328 S 770.21 0.00 0.00 69400 S 87.42 0.00 0.00<br />

68330 S 730.36 0.00 0.00 69401 S 46.05 0.00 0.00<br />

68335 S 770.21 0.00 0.00 69405 S 120.79 0.00 0.00<br />

68340 S 644.80 0.00 0.00 69420 S 108.45 0.00 0.00<br />

68360 S 647.36 0.00 0.00 69421 S 551.96 0.00 0.00<br />

68362 S 647.36 0.00 0.00 69424 S 76.08 0.00 0.00<br />

68371 S 513.76 0.00 0.00 69433 S 108.12 0.00 0.00<br />

68400 S 117.72 0.00 0.00 69436 S 551.96 0.00 0.00<br />

68420 S 167.51 0.00 0.00 69440 S 692.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 932.06 0.00 0.00 69840 S 1,105.28 0.00 0.00<br />

69501 S 1,230.68 0.00 0.00 69905 S 1,230.68 0.00 0.00<br />

69502 S 911.05 0.00 0.00 69910 S 1,230.68 0.00 0.00<br />

69505 S 1,230.68 0.00 0.00 69915 S 1,230.68 0.00 0.00<br />

69511 S 1,230.68 0.00 0.00 69930 S 22,249.06 11,946.24 1,643.42<br />

69530 S 1,230.68 0.00 0.00 70030 TC A 17.01 0.00 0.00<br />

69540 S 127.13 0.00 0.00 70100 TC A 18.69 0.00 0.00<br />

69550 S 1,105.28 0.00 0.00 70110 TC A 23.03 0.00 0.00<br />

69552 S 1,230.68 0.00 0.00 70120 TC A 20.69 0.00 0.00<br />

69601 S 1,230.68 0.00 0.00 70130 TC A 25.28 0.00 0.00<br />

69602 S 1,230.68 0.00 0.00 70134 TC A 25.36 0.00 0.00<br />

69603 S 1,230.68 0.00 0.00 70140 TC A 17.35 0.00 0.00<br />

69604 S 1,230.68 0.00 0.00 70150 TC A 25.28 0.00 0.00<br />

69605 S 1,230.68 0.00 0.00 70160 TC A 20.35 0.00 0.00<br />

69610 S 170.18 0.00 0.00 70190 TC A 21.35 0.00 0.00<br />

69620 S 663.41 0.00 0.00 70200 TC A 25.28 0.00 0.00<br />

69631 S 1,105.28 0.00 0.00 70210 TC A 18.02 0.00 0.00<br />

69632 S 1,105.28 0.00 0.00 70220 TC A 22.70 0.00 0.00<br />

69633 S 1,105.28 0.00 0.00 70240 TC A 17.01 0.00 0.00<br />

69635 S 1,230.68 0.00 0.00 70250 TC A 20.69 0.00 0.00<br />

69636 S 1,230.68 0.00 0.00 70260 TC A 26.36 0.00 0.00<br />

69637 S 1,230.68 0.00 0.00 70300 TC A 7.34 0.00 0.00<br />

69641 S 1,230.68 0.00 0.00 70310 TC A 18.13 0.00 0.00<br />

69642 S 1,230.68 0.00 0.00 70320 TC A 18.13 0.00 0.00<br />

69643 S 1,230.68 0.00 0.00 70328 TC A 18.02 0.00 0.00<br />

69644 S 1,230.68 0.00 0.00 70330 TC A 25.28 0.00 0.00<br />

69645 S 1,230.68 0.00 0.00 70336 TC A 196.75 0.00 0.00<br />

69646 S 1,230.68 0.00 0.00 70350 TC A 10.01 0.00 0.00<br />

69650 S 911.05 0.00 0.00 70355 TC A 10.34 0.00 0.00<br />

69660 S 1,105.28 0.00 0.00 70360 TC A 16.02 0.00 0.00<br />

69661 S 1,105.28 0.00 0.00 70370 TC A 47.04 0.00 0.00<br />

69662 S 1,105.28 0.00 0.00 70371 TC A 47.04 0.00 0.00<br />

69666 S 1,066.03 0.00 0.00 70380 TC A 24.36 0.00 0.00<br />

69667 S 1,066.03 0.00 0.00 70450 TC A 109.89 0.00 0.00<br />

69670 S 1,011.91 0.00 0.00 70460 TC A 174.00 0.00 0.00<br />

69676 S 1,011.91 0.00 0.00 70470 TC A 192.75 0.00 0.00<br />

69700 S 1,011.91 0.00 0.00 70480 TC A 109.89 0.00 0.00<br />

69711 S 932.06 0.00 0.00 70481 TC A 174.00 0.00 0.00<br />

69714 S 5,910.99 3,727.10 1,543.22 70482 TC A 192.75 0.00 0.00<br />

69715 S 5,910.99 3,727.10 1,543.22 70486 TC A 109.89 0.00 0.00<br />

69717 S 5,910.99 3,727.10 1,543.22 70487 TC A 174.00 0.00 0.00<br />

69718 S 5,910.99 3,727.10 1,543.22 70488 TC A 192.75 0.00 0.00<br />

69720 S 1,105.28 0.00 0.00 70490 TC A 109.89 0.00 0.00<br />

69740 S 1,105.28 0.00 0.00 70491 TC A 174.00 0.00 0.00<br />

69745 S 1,105.28 0.00 0.00 70492 TC A 192.75 0.00 0.00<br />

69801 S 1,105.28 0.00 0.00 70496 TC A 198.91 0.00 0.00<br />

69802 S 1,230.68 0.00 0.00 70498 TC A 198.91 0.00 0.00<br />

69805 S 1,230.68 0.00 0.00 70540 TC A 196.75 0.00 0.00<br />

69806 S 1,230.68 0.00 0.00 70542 TC A 241.62 0.00 0.00<br />

69820 S 1,105.28 0.00 0.00 70543 TC A 304.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 196.75 0.00 0.00 72120 TC A 32.03 0.00 0.00<br />

70545 TC A 241.62 0.00 0.00 72125 TC A 109.89 0.00 0.00<br />

70546 TC A 304.52 0.00 0.00 72126 TC A 174.00 0.00 0.00<br />

70547 TC A 196.75 0.00 0.00 72127 TC A 192.75 0.00 0.00<br />

70548 TC A 241.62 0.00 0.00 72128 TC A 109.89 0.00 0.00<br />

70549 TC A 304.52 0.00 0.00 72129 TC A 174.00 0.00 0.00<br />

70551 TC A 196.75 0.00 0.00 72130 TC A 192.75 0.00 0.00<br />

70552 TC A 241.62 0.00 0.00 72131 TC A 109.89 0.00 0.00<br />

70553 TC A 304.52 0.00 0.00 72132 TC A 174.00 0.00 0.00<br />

70554 TC A 196.75 0.00 0.00 72133 TC A 192.75 0.00 0.00<br />

70555 TC A 196.75 0.00 0.00 72141 TC A 196.75 0.00 0.00<br />

70557 TC A 196.75 0.00 0.00 72142 TC A 241.62 0.00 0.00<br />

70558 TC A 241.62 0.00 0.00 72146 TC A 196.75 0.00 0.00<br />

70559 TC A 304.52 0.00 0.00 72147 TC A 241.62 0.00 0.00<br />

71010 TC A 13.02 0.00 0.00 72148 TC A 196.75 0.00 0.00<br />

71015 TC A 16.68 0.00 0.00 72149 TC A 241.62 0.00 0.00<br />

71020 TC A 17.69 0.00 0.00 72156 TC A 304.52 0.00 0.00<br />

71021 TC A 21.35 0.00 0.00 72157 TC A 304.52 0.00 0.00<br />

71022 TC A 25.28 0.00 0.00 72158 TC A 304.52 0.00 0.00<br />

71023 TC A 41.37 0.00 0.00 72170 TC A 15.02 0.00 0.00<br />

71030 TC A 25.28 0.00 0.00 72190 TC A 25.28 0.00 0.00<br />

71034 TC A 47.04 0.00 0.00 72191 TC A 198.91 0.00 0.00<br />

71035 TC A 22.02 0.00 0.00 72192 TC A 109.89 0.00 0.00<br />

71100 TC A 18.36 0.00 0.00 72193 TC A 174.00 0.00 0.00<br />

71101 TC A 22.35 0.00 0.00 72194 TC A 192.75 0.00 0.00<br />

71110 TC A 23.36 0.00 0.00 72195 TC A 196.75 0.00 0.00<br />

71111 TC A 31.03 0.00 0.00 72196 TC A 241.62 0.00 0.00<br />

71120 TC A 19.36 0.00 0.00 72197 TC A 304.52 0.00 0.00<br />

71130 TC A 22.70 0.00 0.00 72200 TC A 17.69 0.00 0.00<br />

71250 TC A 109.89 0.00 0.00 72202 TC A 21.69 0.00 0.00<br />

71260 TC A 174.00 0.00 0.00 72220 TC A 17.69 0.00 0.00<br />

71270 TC A 192.75 0.00 0.00 73000 TC A 16.68 0.00 0.00<br />

71275 TC A 198.91 0.00 0.00 73010 TC A 17.01 0.00 0.00<br />

71550 TC A 196.75 0.00 0.00 73020 TC A 13.68 0.00 0.00<br />

71551 TC A 241.62 0.00 0.00 73030 TC A 17.35 0.00 0.00<br />

71552 TC A 304.52 0.00 0.00 73050 TC A 21.69 0.00 0.00<br />

72010 TC A 42.08 0.00 0.00 73060 TC A 17.35 0.00 0.00<br />

72020 TC A 13.68 0.00 0.00 73070 TC A 16.68 0.00 0.00<br />

72040 TC A 22.02 0.00 0.00 73080 TC A 22.02 0.00 0.00<br />

72050 TC A 31.36 0.00 0.00 73090 TC A 16.68 0.00 0.00<br />

72052 TC A 42.08 0.00 0.00 73092 TC A 17.35 0.00 0.00<br />

72069 TC A 20.69 0.00 0.00 73100 TC A 17.35 0.00 0.00<br />

72070 TC A 19.36 0.00 0.00 73110 TC A 22.02 0.00 0.00<br />

72072 TC A 23.36 0.00 0.00 73120 TC A 16.35 0.00 0.00<br />

72074 TC A 25.28 0.00 0.00 73130 TC A 19.36 0.00 0.00<br />

72080 TC A 20.69 0.00 0.00 73140 TC A 19.02 0.00 0.00<br />

72090 TC A 27.70 0.00 0.00 73200 TC A 109.89 0.00 0.00<br />

72100 TC A 23.69 0.00 0.00 73201 TC A 174.00 0.00 0.00<br />

72110 TC A 33.04 0.00 0.00 73202 TC A 192.75 0.00 0.00<br />

72114 TC A 42.08 0.00 0.00 73206 TC A 198.91 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 196.75 0.00 0.00 74246 TC A 49.66 0.00 0.00<br />

73219 TC A 241.62 0.00 0.00 74247 TC A 49.66 0.00 0.00<br />

73220 TC A 304.52 0.00 0.00 74249 TC A 80.74 0.00 0.00<br />

73221 TC A 196.75 0.00 0.00 74250 TC A 49.66 0.00 0.00<br />

73222 TC A 241.62 0.00 0.00 74251 TC A 80.74 0.00 0.00<br />

73223 TC A 304.52 0.00 0.00 74260 TC A 49.66 0.00 0.00<br />

73500 TC A 14.35 0.00 0.00 74270 TC A 49.66 0.00 0.00<br />

73510 TC A 22.02 0.00 0.00 74280 TC A 80.74 0.00 0.00<br />

73520 TC A 22.70 0.00 0.00 74283 TC A 49.66 0.00 0.00<br />

73540 TC A 22.70 0.00 0.00 74290 TC A 42.37 0.00 0.00<br />

73550 TC A 16.68 0.00 0.00 74291 TC A 40.71 0.00 0.00<br />

73560 TC A 17.01 0.00 0.00 74400 TC A 73.75 0.00 0.00<br />

73562 TC A 21.02 0.00 0.00 74410 TC A 78.75 0.00 0.00<br />

73564 TC A 24.36 0.00 0.00 74415 TC A 94.10 0.00 0.00<br />

73565 TC A 18.36 0.00 0.00 74420 TC A 98.36 0.00 0.00<br />

73590 TC A 16.02 0.00 0.00 74710 TC A 22.02 0.00 0.00<br />

73592 TC A 17.35 0.00 0.00 74775 TC A 98.36 0.00 0.00<br />

73600 TC A 16.35 0.00 0.00 75557 TC A 196.75 0.00 0.00<br />

73610 TC A 19.36 0.00 0.00 75559 TC A 196.75 0.00 0.00<br />

73620 TC A 15.68 0.00 0.00 75561 TC A 304.52 0.00 0.00<br />

73630 TC A 19.02 0.00 0.00 75563 TC A 304.52 0.00 0.00<br />

73650 TC A 16.02 0.00 0.00 76010 TC A 16.35 0.00 0.00<br />

73660 TC A 18.02 0.00 0.00 76098 TC A 10.01 0.00 0.00<br />

73700 TC A 109.89 0.00 0.00 76100 TC A 42.08 0.00 0.00<br />

73701 TC A 174.00 0.00 0.00 76101 TC A 112.78 0.00 0.00<br />

73702 TC A 192.75 0.00 0.00 76102 TC A 112.78 0.00 0.00<br />

73706 TC A 198.91 0.00 0.00 76120 TC A 47.04 0.00 0.00<br />

73718 TC A 196.75 0.00 0.00 76150 A 16.35 0.00 0.00<br />

73719 TC A 241.62 0.00 0.00 76380 TC A 59.36 0.00 0.00<br />

73720 TC A 304.52 0.00 0.00 76496 TC A 47.04 0.00 0.00<br />

73721 TC A 196.75 0.00 0.00 76497 TC A 59.36 0.00 0.00<br />

73722 TC A 241.62 0.00 0.00 76498 TC A 196.75 0.00 0.00<br />

73723 TC A 304.52 0.00 0.00 76499 TC A 25.28 0.00 0.00<br />

74000 TC A 14.35 0.00 0.00 76506 TC A 35.33 0.00 0.00<br />

74010 TC A 22.35 0.00 0.00 76510 TC A 60.06 0.00 0.00<br />

74020 TC A 22.70 0.00 0.00 76511 TC A 42.04 0.00 0.00<br />

74022 TC A 27.70 0.00 0.00 76512 TC A 35.70 0.00 0.00<br />

74150 TC A 109.89 0.00 0.00 76513 TC A 43.38 0.00 0.00<br />

74160 TC A 174.00 0.00 0.00 76514 TC A 3.01 0.00 0.00<br />

74170 TC A 192.75 0.00 0.00 76516 TC A 34.04 0.00 0.00<br />

74175 TC A 198.91 0.00 0.00 76519 TC A 38.04 0.00 0.00<br />

74181 TC A 196.75 0.00 0.00 76529 TC A 33.04 0.00 0.00<br />

74182 TC A 241.62 0.00 0.00 76536 TC A 55.27 0.00 0.00<br />

74183 TC A 304.52 0.00 0.00 76604 TC A 35.33 0.00 0.00<br />

74210 TC A 49.66 0.00 0.00 76645 TC A 35.33 0.00 0.00<br />

74220 TC A 49.66 0.00 0.00 76700 TC A 55.27 0.00 0.00<br />

74230 TC A 49.66 0.00 0.00 76705 TC A 55.27 0.00 0.00<br />

74240 TC A 49.66 0.00 0.00 76770 TC A 55.27 0.00 0.00<br />

74241 TC A 49.66 0.00 0.00 76775 TC A 55.27 0.00 0.00<br />

74245 TC A 80.74 0.00 0.00 76776 TC A 55.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 55.27 0.00 0.00 77290 TC A 144.54 0.00 0.00<br />

76801 TC A 55.27 0.00 0.00 77295 TC A 378.74 0.00 0.00<br />

76802 TC A 26.36 0.00 0.00 77299 TC A 64.85 0.00 0.00<br />

76805 TC A 55.27 0.00 0.00 77300 TC A 35.04 0.00 0.00<br />

76810 TC A 41.71 0.00 0.00 77301 TC A 504.75 0.00 0.00<br />

76811 TC A 86.59 0.00 0.00 77305 TC A 32.03 0.00 0.00<br />

76812 TC A 35.33 0.00 0.00 77310 TC A 41.71 0.00 0.00<br />

76813 TC A 35.33 0.00 0.00 77315 TC A 60.73 0.00 0.00<br />

76814 TC A 28.03 0.00 0.00 77321 TC A 63.07 0.00 0.00<br />

76815 TC A 35.33 0.00 0.00 77326 TC A 64.85 0.00 0.00<br />

76816 TC A 35.33 0.00 0.00 77327 TC A 117.80 0.00 0.00<br />

76817 TC A 35.33 0.00 0.00 77328 TC A 144.54 0.00 0.00<br />

76818 TC A 55.27 0.00 0.00 77331 TC A 16.68 0.00 0.00<br />

76819 TC A 47.72 0.00 0.00 77332 TC A 44.71 0.00 0.00<br />

76820 TC A 23.69 0.00 0.00 77333 TC A 21.69 0.00 0.00<br />

76821 TC A 53.50 0.00 0.00 77334 TC A 83.76 0.00 0.00<br />

76825 TC A 111.45 0.00 0.00 77336 A 52.73 0.00 0.00<br />

76826 TC A 66.40 0.00 0.00 77370 A 64.85 0.00 0.00<br />

76827 TC A 35.33 0.00 0.00 77371 A 4,319.85 0.00 0.00<br />

76828 TC A 21.02 0.00 0.00 77399 TC A 64.85 0.00 0.00<br />

76830 TC A 55.27 0.00 0.00 77401 A 26.36 0.00 0.00<br />

76831 TC A 74.41 0.00 0.00 77402 A 53.07 0.00 0.00<br />

76856 TC A 55.27 0.00 0.00 77403 A 53.07 0.00 0.00<br />

76857 TC A 35.33 0.00 0.00 77404 A 53.07 0.00 0.00<br />

76870 TC A 55.27 0.00 0.00 77406 A 85.96 0.00 0.00<br />

76872 TC A 55.27 0.00 0.00 77407 A 53.07 0.00 0.00<br />

76873 TC A 55.27 0.00 0.00 77408 A 53.07 0.00 0.00<br />

76880 TC A 55.27 0.00 0.00 77409 A 53.07 0.00 0.00<br />

76885 TC A 35.33 0.00 0.00 77411 A 85.96 0.00 0.00<br />

76886 TC A 35.33 0.00 0.00 77412 A 85.96 0.00 0.00<br />

76936 TC A 53.50 0.00 0.00 77413 A 85.96 0.00 0.00<br />

76970 TC A 35.33 0.00 0.00 77414 A 85.96 0.00 0.00<br />

76977 TC A 9.01 0.00 0.00 77416 A 85.96 0.00 0.00<br />

76999 TC A 35.33 0.00 0.00 77418 A 232.24 0.00 0.00<br />

77071 A 20.69 0.00 0.00 77422 A 85.96 0.00 0.00<br />

77072 TC A 12.01 0.00 0.00 77423 A 85.96 0.00 0.00<br />

77073 TC A 20.35 0.00 0.00 77470 TC A 123.47 0.00 0.00<br />

77074 TC A 40.04 0.00 0.00 77520 A 397.62 0.00 0.00<br />

77075 TC A 42.08 0.00 0.00 77522 A 397.62 0.00 0.00<br />

77076 TC A 42.08 0.00 0.00 77523 A 475.17 0.00 0.00<br />

77077 TC A 22.70 0.00 0.00 77525 A 475.17 0.00 0.00<br />

77078 TC A 40.65 0.00 0.00 77600 TC A 210.97 0.00 0.00<br />

77079 TC A 41.71 0.00 0.00 77605 TC A 210.97 0.00 0.00<br />

77080 TC A 40.65 0.00 0.00 77610 TC A 210.97 0.00 0.00<br />

77081 TC A 16.35 0.00 0.00 77615 TC A 210.97 0.00 0.00<br />

77082 TC A 17.69 0.00 0.00 77620 TC A 210.97 0.00 0.00<br />

77083 TC A 14.02 0.00 0.00 77750 TC A 82.08 0.00 0.00<br />

77084 TC A 196.75 0.00 0.00 77761 TC A 144.49 0.00 0.00<br />

77280 TC A 64.85 0.00 0.00 77762 TC A 171.18 0.00 0.00<br />

77285 TC A 144.54 0.00 0.00 77763 TC A 220.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 156.50 0.00 0.00 78262 TC A 137.44 0.00 0.00<br />

77777 TC A 171.85 0.00 0.00 78264 TC A 137.44 0.00 0.00<br />

77778 TC A 228.91 0.00 0.00 78270 TC A 60.06 0.00 0.00<br />

77785 TC A 101.77 0.00 0.00 78271 TC A 61.06 0.00 0.00<br />

77786 TC A 357.71 0.00 0.00 78272 TC A 67.07 0.00 0.00<br />

77787 TC A 414.51 0.00 0.00 78278 TC A 137.44 0.00 0.00<br />

77789 TC A 42.72 0.00 0.00 78282 TC A 137.44 0.00 0.00<br />

77799 TC A 243.46 0.00 0.00 78290 TC A 137.44 0.00 0.00<br />

78000 TC A 52.38 0.00 0.00 78291 TC A 137.44 0.00 0.00<br />

78001 TC A 66.39 0.00 0.00 78299 TC A 137.44 0.00 0.00<br />

78003 TC A 52.73 0.00 0.00 78300 TC A 119.79 0.00 0.00<br />

78006 TC A 125.45 0.00 0.00 78305 TC A 138.94 0.00 0.00<br />

78007 TC A 92.77 0.00 0.00 78306 TC A 138.94 0.00 0.00<br />

78010 TC A 77.08 0.00 0.00 78315 TC A 138.94 0.00 0.00<br />

78011 TC A 77.08 0.00 0.00 78320 TC A 138.94 0.00 0.00<br />

78015 TC A 149.83 0.00 0.00 78399 TC A 138.94 0.00 0.00<br />

78016 TC A 169.12 0.00 0.00 78414 TC A 176.60 0.00 0.00<br />

78018 TC A 169.12 0.00 0.00 78428 TC A 135.48 0.00 0.00<br />

78070 TC A 115.12 0.00 0.00 78445 TC A 105.68 0.00 0.00<br />

78075 TC A 326.01 0.00 0.00 78456 TC A 105.68 0.00 0.00<br />

78099 TC A 77.08 0.00 0.00 78457 TC A 105.68 0.00 0.00<br />

78102 TC A 116.45 0.00 0.00 78458 TC A 105.68 0.00 0.00<br />

78103 TC A 148.45 0.00 0.00 78459 TC A 653.98 0.00 0.00<br />

78104 TC A 148.45 0.00 0.00 78460 TC A 126.80 0.00 0.00<br />

78110 TC A 59.06 0.00 0.00 78461 TC A 127.81 0.00 0.00<br />

78111 TC A 74.75 0.00 0.00 78464 TC A 187.53 0.00 0.00<br />

78120 TC A 65.40 0.00 0.00 78465 TC A 355.05 0.00 0.00<br />

78121 TC A 77.41 0.00 0.00 78466 TC A 125.80 0.00 0.00<br />

78122 TC A 91.76 0.00 0.00 78468 TC A 160.84 0.00 0.00<br />

78130 TC A 106.44 0.00 0.00 78469 TC A 176.60 0.00 0.00<br />

78135 TC A 226.23 0.00 0.00 78472 TC A 176.60 0.00 0.00<br />

78140 TC A 100.44 0.00 0.00 78473 TC A 176.60 0.00 0.00<br />

78185 TC A 148.45 0.00 0.00 78481 TC A 152.49 0.00 0.00<br />

78190 TC A 93.15 0.00 0.00 78483 TC A 176.60 0.00 0.00<br />

78191 TC A 93.15 0.00 0.00 78491 TC A 653.98 0.00 0.00<br />

78195 TC A 148.45 0.00 0.00 78492 TC A 653.98 0.00 0.00<br />

78199 TC A 148.45 0.00 0.00 78494 TC A 176.60 0.00 0.00<br />

78201 TC A 132.14 0.00 0.00 78499 TC A 176.60 0.00 0.00<br />

78202 TC A 155.44 0.00 0.00 78580 TC A 119.65 0.00 0.00<br />

78205 TC A 155.44 0.00 0.00 78584 TC A 92.43 0.00 0.00<br />

78206 TC A 155.44 0.00 0.00 78585 TC A 183.59 0.00 0.00<br />

78215 TC A 139.82 0.00 0.00 78586 TC A 119.65 0.00 0.00<br />

78216 TC A 94.77 0.00 0.00 78587 TC A 119.65 0.00 0.00<br />

78220 TC A 103.45 0.00 0.00 78588 TC A 183.59 0.00 0.00<br />

78223 TC A 155.44 0.00 0.00 78591 TC A 119.65 0.00 0.00<br />

78230 TC A 117.45 0.00 0.00 78593 TC A 119.65 0.00 0.00<br />

78231 TC A 92.43 0.00 0.00 78594 TC A 119.65 0.00 0.00<br />

78232 TC A 96.43 0.00 0.00 78596 TC A 183.59 0.00 0.00<br />

78258 TC A 137.44 0.00 0.00 78599 TC A 119.65 0.00 0.00<br />

78261 TC A 137.44 0.00 0.00 78600 TC A 105.45 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 10 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 105.45 0.00 0.00<br />

78605 TC A 105.45 0.00 0.00<br />

78606 TC A 236.92 0.00 0.00<br />

78607 TC A 260.28 0.00 0.00<br />

78608 TC A 586.17 0.00 0.00<br />

78610 TC A 140.48 0.00 0.00<br />

78630 TC A 250.27 0.00 0.00<br />

78635 TC A 230.58 0.00 0.00<br />

78645 TC A 105.45 0.00 0.00<br />

78647 TC A 255.27 0.00 0.00<br />

78650 TC A 247.26 0.00 0.00<br />

78660 TC A 105.45 0.00 0.00<br />

78699 TC A 105.45 0.00 0.00<br />

78700 TC A 129.81 0.00 0.00<br />

78701 TC A 158.17 0.00 0.00<br />

78707 TC A 165.18 0.00 0.00<br />

78708 TC A 113.12 0.00 0.00<br />

78709 TC A 185.98 0.00 0.00<br />

78710 TC A 174.52 0.00 0.00<br />

78725 TC A 69.74 0.00 0.00<br />

78730 TC A 59.06 0.00 0.00<br />

78740 TC A 154.17 0.00 0.00<br />

78761 TC A 147.15 0.00 0.00<br />

78799 TC A 185.98 0.00 0.00<br />

78800 TC A 130.14 0.00 0.00<br />

78801 TC A 178.53 0.00 0.00<br />

78802 TC A 241.92 0.00 0.00<br />

78803 TC A 259.28 0.00 0.00<br />

78804 TC A 452.48 0.00 0.00<br />

78805 TC A 127.13 0.00 0.00<br />

78806 TC A 254.27 0.00 0.00<br />

78807 TC A 259.61 0.00 0.00<br />

78811 TC A 586.17 0.00 0.00<br />

78812 TC A 586.17 0.00 0.00<br />

78813 TC A 586.17 0.00 0.00<br />

78814 TC A 586.17 0.00 0.00<br />

78815 TC A 586.17 0.00 0.00<br />

78816 TC A 586.17 0.00 0.00<br />

78999 TC A 66.39 0.00 0.00<br />

79005 TC A 53.39 0.00 0.00<br />

79101 TC A 58.40 0.00 0.00<br />

79200 TC A 63.07 0.00 0.00<br />

79300 TC A 121.68 0.00 0.00<br />

79403 TC A 90.43 0.00 0.00<br />

79440 TC A 51.05 0.00 0.00<br />

79445 TC A 121.68 0.00 0.00<br />

79999 TC A 121.68 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,312.17 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,568.40 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.74 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,620.62 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,620.62 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 234.04 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 234.04 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 118.18 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 249.76 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 75.08 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 672.32 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,533.13 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,200.06 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,200.06 0.00 0.00<br />

C8900 A 259.84 0.00 0.00 0123T S 959.69 0.00 0.00<br />

C8901 A 211.60 0.00 0.00 0124T S 187.58 0.00 0.00<br />

C8902 A 327.49 0.00 0.00 0144T TC A 63.84 0.00 0.00<br />

C8903 A 259.84 0.00 0.00 0145T TC A 171.86 0.00 0.00<br />

C8904 A 211.60 0.00 0.00 0146T TC A 171.86 0.00 0.00<br />

C8905 A 327.49 0.00 0.00 0147T TC A 171.86 0.00 0.00<br />

C8906 A 259.84 0.00 0.00 0148T TC A 171.86 0.00 0.00<br />

C8907 A 211.60 0.00 0.00 0149T TC A 171.86 0.00 0.00<br />

C8908 A 327.49 0.00 0.00 0150T TC A 171.86 0.00 0.00<br />

C8909 A 259.84 0.00 0.00 0151T TC A 63.84 0.00 0.00<br />

C8910 A 211.60 0.00 0.00 0170T S 1,246.58 0.00 0.00<br />

C8911 A 327.49 0.00 0.00 0176T S 1,471.92 0.00 0.00<br />

C8912 A 259.84 0.00 0.00 0177T S 1,471.92 0.00 0.00<br />

C8913 A 211.60 0.00 0.00 0182T A 1,063.91 0.00 0.00<br />

C8914 A 327.49 0.00 0.00 0186T S 896.66 0.00 0.00<br />

C8918 A 259.84 0.00 0.00 0190T S 896.66 0.00 0.00<br />

C8919 A 211.60 0.00 0.00 0191T S 959.69 0.00 0.00<br />

C8920 A 327.49 0.00 0.00 0192T S 1,644.72 0.00 0.00<br />

C9716 S 1,246.58 0.00 0.00 10021 S 57.52 0.00 0.00<br />

C9724 S 1,019.22 0.00 0.00 10022 S 179.63 0.00 0.00<br />

C9725 S 235.03 0.00 0.00 10040 S 33.25 0.00 0.00<br />

C9726 S 862.85 0.00 0.00 10060 S 50.60 0.00 0.00<br />

C9727 S 302.53 0.00 0.00 10061 S 56.73 0.00 0.00<br />

C9728 S 542.83 0.00 0.00 10080 S 56.73 0.00 0.00<br />

G0104 S 87.20 0.00 0.00 10081 S 130.62 0.00 0.00<br />

G0105 S 376.89 0.00 0.00 10120 S 71.05 0.00 0.00<br />

G0121 S 376.89 0.00 0.00 10121 S 535.58 0.00 0.00<br />

G0127 S 12.20 0.00 0.00 10140 S 75.36 0.00 0.00<br />

G0130 TC A 20.10 0.00 0.00 10160 S 56.73 0.00 0.00<br />

G0173 A 2,312.17 0.00 0.00 10180 S 605.67 0.00 0.00<br />

G0186 S 234.04 0.00 0.00 11000 S 24.41 0.00 0.00<br />

G0247 S 22.25 0.00 0.00 11001 S 8.26 0.00 0.00<br />

G0251 A 579.00 0.00 0.00 11010 S 211.90 0.00 0.00<br />

G0260 S 305.55 0.00 0.00 11011 S 211.90 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 211.90 0.00 0.00 11601 S 116.99 0.00 0.00<br />

11040 S 22.25 0.00 0.00 11602 S 128.83 0.00 0.00<br />

11041 S 24.77 0.00 0.00 11603 S 136.72 0.00 0.00<br />

11042 S 134.55 0.00 0.00 11604 S 368.81 0.00 0.00<br />

11043 S 134.55 0.00 0.00 11606 S 535.58 0.00 0.00<br />

11044 S 350.36 0.00 0.00 11620 S 99.77 0.00 0.00<br />

11055 S 26.20 0.00 0.00 11621 S 118.42 0.00 0.00<br />

11056 S 28.71 0.00 0.00 11622 S 131.70 0.00 0.00<br />

11057 S 33.25 0.00 0.00 11623 S 141.75 0.00 0.00<br />

11100 S 60.92 0.00 0.00 11624 S 535.58 0.00 0.00<br />

11101 S 14.36 0.00 0.00 11626 S 654.97 0.00 0.00<br />

11200 S 33.25 0.00 0.00 11640 S 105.51 0.00 0.00<br />

11201 S 5.74 0.00 0.00 11641 S 124.52 0.00 0.00<br />

11300 S 33.25 0.00 0.00 11642 S 138.88 0.00 0.00<br />

11301 S 33.25 0.00 0.00 11643 S 149.65 0.00 0.00<br />

11302 S 33.25 0.00 0.00 11644 S 535.58 0.00 0.00<br />

11303 S 60.92 0.00 0.00 11646 S 654.97 0.00 0.00<br />

11305 S 33.25 0.00 0.00 11719 S 12.20 0.00 0.00<br />

11306 S 33.25 0.00 0.00 11720 S 15.07 0.00 0.00<br />

11307 S 33.25 0.00 0.00 11721 S 18.30 0.00 0.00<br />

11308 S 33.25 0.00 0.00 11730 S 33.25 0.00 0.00<br />

11310 S 33.25 0.00 0.00 11732 S 18.30 0.00 0.00<br />

11311 S 33.25 0.00 0.00 11740 S 16.80 0.00 0.00<br />

11312 S 33.25 0.00 0.00 11750 S 96.89 0.00 0.00<br />

11313 S 33.25 0.00 0.00 11752 S 134.57 0.00 0.00<br />

11400 S 68.55 0.00 0.00 11755 S 67.10 0.00 0.00<br />

11401 S 77.15 0.00 0.00 11760 S 138.21 0.00 0.00<br />

11402 S 84.69 0.00 0.00 11762 S 123.45 0.00 0.00<br />

11403 S 90.44 0.00 0.00 11765 S 33.25 0.00 0.00<br />

11404 S 480.76 0.00 0.00 11770 S 686.02 0.00 0.00<br />

11406 S 535.58 0.00 0.00 11771 S 686.02 0.00 0.00<br />

11420 S 64.24 0.00 0.00 11772 S 686.02 0.00 0.00<br />

11421 S 77.87 0.00 0.00 11900 S 30.51 0.00 0.00<br />

11422 S 85.05 0.00 0.00 11901 S 33.25 0.00 0.00<br />

11423 S 94.74 0.00 0.00 11920 S 96.53 0.00 0.00<br />

11424 S 535.58 0.00 0.00 11921 S 106.23 0.00 0.00<br />

11426 S 654.97 0.00 0.00 11922 S 34.45 0.00 0.00<br />

11440 S 73.57 0.00 0.00 11950 S 35.17 0.00 0.00<br />

11441 S 85.05 0.00 0.00 11951 S 43.78 0.00 0.00<br />

11442 S 93.66 0.00 0.00 11952 S 52.71 0.00 0.00<br />

11443 S 103.71 0.00 0.00 11954 S 52.71 0.00 0.00<br />

11444 S 327.34 0.00 0.00 11960 S 639.37 0.00 0.00<br />

11446 S 654.97 0.00 0.00 11970 S 1,158.11 0.00 0.00<br />

11450 S 654.97 0.00 0.00 11971 S 600.15 0.00 0.00<br />

11451 S 654.97 0.00 0.00 11976 S 64.24 0.00 0.00<br />

11462 S 654.97 0.00 0.00 11980 S 25.95 0.00 0.00<br />

11463 S 654.97 0.00 0.00 11981 S 25.95 0.00 0.00<br />

11470 S 654.97 0.00 0.00 11982 S 25.95 0.00 0.00<br />

11471 S 654.97 0.00 0.00 11983 S 25.95 0.00 0.00<br />

11600 S 96.53 0.00 0.00 12001 S 52.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 52.71 0.00 0.00 14021 S 568.18 0.00 0.00<br />

12004 S 52.71 0.00 0.00 14040 S 537.14 0.00 0.00<br />

12005 S 70.62 0.00 0.00 14041 S 568.18 0.00 0.00<br />

12006 S 70.62 0.00 0.00 14060 S 568.18 0.00 0.00<br />

12007 S 70.62 0.00 0.00 14061 S 568.18 0.00 0.00<br />

12011 S 52.71 0.00 0.00 14300 S 728.63 0.00 0.00<br />

12013 S 52.71 0.00 0.00 14350 S 670.41 0.00 0.00<br />

12014 S 52.71 0.00 0.00 15002 S 245.79 0.00 0.00<br />

12015 S 52.71 0.00 0.00 15003 S 245.79 0.00 0.00<br />

12016 S 70.62 0.00 0.00 15004 S 245.79 0.00 0.00<br />

12017 S 70.62 0.00 0.00 15005 S 245.79 0.00 0.00<br />

12018 S 70.62 0.00 0.00 15040 S 113.36 0.00 0.00<br />

12020 S 133.23 0.00 0.00 15050 S 245.79 0.00 0.00<br />

12021 S 113.36 0.00 0.00 15100 S 639.37 0.00 0.00<br />

12031 S 52.71 0.00 0.00 15101 S 670.41 0.00 0.00<br />

12032 S 138.21 0.00 0.00 15110 S 305.33 0.00 0.00<br />

12034 S 70.62 0.00 0.00 15111 S 250.51 0.00 0.00<br />

12035 S 70.62 0.00 0.00 15115 S 305.33 0.00 0.00<br />

12036 S 113.36 0.00 0.00 15116 S 250.51 0.00 0.00<br />

12037 S 225.93 0.00 0.00 15120 S 639.37 0.00 0.00<br />

12041 S 52.71 0.00 0.00 15121 S 670.41 0.00 0.00<br />

12042 S 52.71 0.00 0.00 15130 S 537.14 0.00 0.00<br />

12044 S 70.62 0.00 0.00 15131 S 482.32 0.00 0.00<br />

12045 S 113.36 0.00 0.00 15135 S 537.14 0.00 0.00<br />

12046 S 113.36 0.00 0.00 15136 S 482.32 0.00 0.00<br />

12047 S 225.93 0.00 0.00 15150 S 305.33 0.00 0.00<br />

12051 S 52.71 0.00 0.00 15151 S 250.51 0.00 0.00<br />

12052 S 52.71 0.00 0.00 15152 S 250.51 0.00 0.00<br />

12053 S 52.71 0.00 0.00 15155 S 305.33 0.00 0.00<br />

12054 S 70.62 0.00 0.00 15156 S 250.51 0.00 0.00<br />

12055 S 113.36 0.00 0.00 15157 S 250.51 0.00 0.00<br />

12056 S 113.36 0.00 0.00 15170 S 138.21 0.00 0.00<br />

12057 S 225.93 0.00 0.00 15171 S 138.21 0.00 0.00<br />

13100 S 245.79 0.00 0.00 15175 S 177.94 0.00 0.00<br />

13101 S 245.79 0.00 0.00 15176 S 177.94 0.00 0.00<br />

13102 S 133.23 0.00 0.00 15200 S 568.18 0.00 0.00<br />

13120 S 113.36 0.00 0.00 15201 S 477.61 0.00 0.00<br />

13121 S 113.36 0.00 0.00 15220 S 537.14 0.00 0.00<br />

13122 S 113.36 0.00 0.00 15221 S 245.79 0.00 0.00<br />

13131 S 113.36 0.00 0.00 15240 S 568.18 0.00 0.00<br />

13132 S 113.36 0.00 0.00 15241 S 245.79 0.00 0.00<br />

13133 S 113.36 0.00 0.00 15260 S 537.14 0.00 0.00<br />

13150 S 245.79 0.00 0.00 15261 S 477.61 0.00 0.00<br />

13151 S 245.79 0.00 0.00 15300 S 245.79 0.00 0.00<br />

13152 S 245.79 0.00 0.00 15301 S 245.79 0.00 0.00<br />

13153 S 113.36 0.00 0.00 15320 S 245.79 0.00 0.00<br />

13160 S 639.37 0.00 0.00 15321 S 245.79 0.00 0.00<br />

14000 S 537.14 0.00 0.00 15330 S 245.79 0.00 0.00<br />

14001 S 568.18 0.00 0.00 15331 S 245.79 0.00 0.00<br />

14020 S 568.18 0.00 0.00 15335 S 245.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 245.79 0.00 0.00 15826 S 670.41 0.00 0.00<br />

15340 S 138.21 0.00 0.00 15828 S 670.41 0.00 0.00<br />

15341 S 138.21 0.00 0.00 15829 S 770.83 0.00 0.00<br />

15360 S 138.21 0.00 0.00 15830 S 686.02 0.00 0.00<br />

15361 S 138.21 0.00 0.00 15832 S 686.02 0.00 0.00<br />

15365 S 138.21 0.00 0.00 15833 S 686.02 0.00 0.00<br />

15366 S 138.21 0.00 0.00 15834 S 686.02 0.00 0.00<br />

15400 S 245.79 0.00 0.00 15835 S 595.44 0.00 0.00<br />

15401 S 245.79 0.00 0.00 15836 S 566.63 0.00 0.00<br />

15420 S 245.79 0.00 0.00 15837 S 638.45 0.00 0.00<br />

15421 S 245.79 0.00 0.00 15838 S 638.45 0.00 0.00<br />

15430 S 245.79 0.00 0.00 15839 S 566.63 0.00 0.00<br />

15431 S 245.79 0.00 0.00 15840 S 728.63 0.00 0.00<br />

15570 S 670.41 0.00 0.00 15841 S 728.63 0.00 0.00<br />

15572 S 670.41 0.00 0.00 15842 S 846.01 0.00 0.00<br />

15574 S 670.41 0.00 0.00 15845 S 728.63 0.00 0.00<br />

15576 S 670.41 0.00 0.00 15847 S 686.02 0.00 0.00<br />

15600 S 670.41 0.00 0.00 15850 S 109.59 0.00 0.00<br />

15610 S 670.41 0.00 0.00 15851 S 49.88 0.00 0.00<br />

15620 S 728.63 0.00 0.00 15852 S 25.95 0.00 0.00<br />

15630 S 670.41 0.00 0.00 15860 S 25.95 0.00 0.00<br />

15650 S 770.83 0.00 0.00 15876 S 670.41 0.00 0.00<br />

15731 S 670.41 0.00 0.00 15877 S 670.41 0.00 0.00<br />

15732 S 670.41 0.00 0.00 15878 S 670.41 0.00 0.00<br />

15734 S 670.41 0.00 0.00 15879 S 670.41 0.00 0.00<br />

15736 S 670.41 0.00 0.00 15920 S 211.90 0.00 0.00<br />

15738 S 670.41 0.00 0.00 15922 S 728.63 0.00 0.00<br />

15740 S 537.14 0.00 0.00 15931 S 686.02 0.00 0.00<br />

15750 S 639.37 0.00 0.00 15933 S 686.02 0.00 0.00<br />

15760 S 639.37 0.00 0.00 15934 S 670.41 0.00 0.00<br />

15770 S 670.41 0.00 0.00 15935 S 728.63 0.00 0.00<br />

15775 S 183.18 0.00 0.00 15936 S 626.40 0.00 0.00<br />

15776 S 183.18 0.00 0.00 15937 S 728.63 0.00 0.00<br />

15780 S 408.39 0.00 0.00 15940 S 686.02 0.00 0.00<br />

15781 S 179.76 0.00 0.00 15941 S 686.02 0.00 0.00<br />

15782 S 179.76 0.00 0.00 15944 S 670.41 0.00 0.00<br />

15783 S 109.59 0.00 0.00 15945 S 728.63 0.00 0.00<br />

15786 S 33.25 0.00 0.00 15946 S 728.63 0.00 0.00<br />

15787 S 30.15 0.00 0.00 15950 S 686.02 0.00 0.00<br />

15788 S 33.25 0.00 0.00 15951 S 744.23 0.00 0.00<br />

15789 S 60.92 0.00 0.00 15952 S 568.18 0.00 0.00<br />

15792 S 60.92 0.00 0.00 15953 S 626.40 0.00 0.00<br />

15793 S 33.25 0.00 0.00 15956 S 568.18 0.00 0.00<br />

15819 S 138.21 0.00 0.00 15958 S 626.40 0.00 0.00<br />

15820 S 670.41 0.00 0.00 16000 S 26.91 0.00 0.00<br />

15821 S 670.41 0.00 0.00 16020 S 40.91 0.00 0.00<br />

15822 S 670.41 0.00 0.00 16025 S 63.01 0.00 0.00<br />

15823 S 770.83 0.00 0.00 16030 S 78.89 0.00 0.00<br />

15824 S 670.41 0.00 0.00 16035 S 60.92 0.00 0.00<br />

15825 S 670.41 0.00 0.00 17000 S 33.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.95 0.00 0.00 19300 S 737.05 0.00 0.00<br />

17004 S 86.84 0.00 0.00 19301 S 678.84 0.00 0.00<br />

17106 S 109.59 0.00 0.00 19302 S 1,296.50 0.00 0.00<br />

17107 S 109.59 0.00 0.00 19303 S 979.81 0.00 0.00<br />

17108 S 109.59 0.00 0.00 19304 S 979.81 0.00 0.00<br />

17110 S 33.25 0.00 0.00 19316 S 979.81 0.00 0.00<br />

17111 S 60.92 0.00 0.00 19318 S 1,119.43 0.00 0.00<br />

17250 S 45.94 0.00 0.00 19324 S 1,119.43 0.00 0.00<br />

17260 S 49.16 0.00 0.00 19325 S 1,856.72 0.00 0.00<br />

17261 S 60.92 0.00 0.00 19328 S 835.73 0.00 0.00<br />

17262 S 60.92 0.00 0.00 19330 S 835.73 0.00 0.00<br />

17263 S 60.92 0.00 0.00 19340 S 1,030.17 0.00 0.00<br />

17264 S 60.92 0.00 0.00 19342 S 1,454.56 0.00 0.00<br />

17266 S 109.59 0.00 0.00 19350 S 737.05 0.00 0.00<br />

17270 S 60.92 0.00 0.00 19355 S 979.81 0.00 0.00<br />

17271 S 60.92 0.00 0.00 19357 S 1,554.98 0.00 0.00<br />

17272 S 60.92 0.00 0.00 19366 S 1,022.01 0.00 0.00<br />

17273 S 109.59 0.00 0.00 19370 S 979.81 0.00 0.00<br />

17274 S 109.59 0.00 0.00 19371 S 979.81 0.00 0.00<br />

17276 S 109.59 0.00 0.00 19380 S 1,161.64 0.00 0.00<br />

17280 S 60.92 0.00 0.00 19396 S 1,348.36 0.00 0.00<br />

17281 S 90.79 0.00 0.00 20000 S 56.73 0.00 0.00<br />

17282 S 103.71 0.00 0.00 20005 S 653.72 0.00 0.00<br />

17283 S 109.59 0.00 0.00 20103 S 641.57 0.00 0.00<br />

17284 S 109.59 0.00 0.00 20150 S 1,821.42 0.00 0.00<br />

17286 S 109.59 0.00 0.00 20200 S 535.58 0.00 0.00<br />

17311 S 180.91 0.00 0.00 20205 S 566.63 0.00 0.00<br />

17312 S 180.91 0.00 0.00 20206 S 264.78 0.00 0.00<br />

17313 S 180.91 0.00 0.00 20220 S 287.81 0.00 0.00<br />

17314 S 180.91 0.00 0.00 20225 S 522.24 0.00 0.00<br />

17315 S 40.91 0.00 0.00 20240 S 654.97 0.00 0.00<br />

17340 S 14.72 0.00 0.00 20245 S 686.02 0.00 0.00<br />

17360 S 33.25 0.00 0.00 20250 S 684.78 0.00 0.00<br />

17380 S 33.25 0.00 0.00 20251 S 684.78 0.00 0.00<br />

19000 S 69.26 0.00 0.00 20500 S 56.71 0.00 0.00<br />

19001 S 9.33 0.00 0.00 20520 S 95.46 0.00 0.00<br />

19020 S 605.67 0.00 0.00 20525 S 686.02 0.00 0.00<br />

19100 S 206.24 0.00 0.00 20526 S 30.86 0.00 0.00<br />

19101 S 647.78 0.00 0.00 20550 S 23.32 0.00 0.00<br />

19102 S 264.78 0.00 0.00 20551 S 22.96 0.00 0.00<br />

19103 S 463.43 0.00 0.00 20552 S 22.25 0.00 0.00<br />

19105 S 1,348.36 0.00 0.00 20553 S 24.77 0.00 0.00<br />

19110 S 647.78 0.00 0.00 20555 S 1,200.06 0.00 0.00<br />

19112 S 678.84 0.00 0.00 20600 S 23.68 0.00 0.00<br />

19120 S 678.84 0.00 0.00 20605 S 26.56 0.00 0.00<br />

19125 S 678.84 0.00 0.00 20610 S 37.32 0.00 0.00<br />

19126 S 678.84 0.00 0.00 20612 S 25.12 0.00 0.00<br />

19296 S 1,856.72 0.00 0.00 20615 S 105.15 0.00 0.00<br />

19297 S 1,856.72 0.00 0.00 20650 S 684.78 0.00 0.00<br />

19298 S 1,856.72 0.00 0.00 20662 S 874.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 874.73 0.00 0.00 21085 S 263.41 0.00 0.00<br />

20665 S 25.95 0.00 0.00 21086 S 573.46 0.00 0.00<br />

20670 S 480.76 0.00 0.00 21087 S 574.18 0.00 0.00<br />

20680 S 686.02 0.00 0.00 21088 S 1,681.68 0.00 0.00<br />

20690 S 816.39 0.00 0.00 21100 S 1,057.20 0.00 0.00<br />

20692 S 847.44 0.00 0.00 21110 S 302.53 0.00 0.00<br />

20693 S 684.78 0.00 0.00 21120 S 979.79 0.00 0.00<br />

20694 S 598.91 0.00 0.00 21121 S 979.79 0.00 0.00<br />

20696 S 1,200.06 0.00 0.00 21122 S 979.79 0.00 0.00<br />

20697 S 798.09 0.00 0.00 21123 S 979.79 0.00 0.00<br />

20822 S 1,124.47 0.00 0.00 21125 S 979.79 0.00 0.00<br />

20900 S 847.44 0.00 0.00 21127 S 1,490.40 0.00 0.00<br />

20902 S 905.65 0.00 0.00 21137 S 994.20 0.00 0.00<br />

20910 S 670.41 0.00 0.00 21138 S 1,681.68 0.00 0.00<br />

20912 S 670.41 0.00 0.00 21139 S 1,681.68 0.00 0.00<br />

20920 S 626.40 0.00 0.00 21150 S 1,681.68 0.00 0.00<br />

20922 S 568.18 0.00 0.00 21181 S 979.79 0.00 0.00<br />

20924 S 905.65 0.00 0.00 21198 S 1,681.68 0.00 0.00<br />

20926 S 394.59 0.00 0.00 21199 S 1,681.68 0.00 0.00<br />

20950 S 56.73 0.00 0.00 21206 S 1,188.67 0.00 0.00<br />

20972 S 1,899.26 0.00 0.00 21208 S 1,323.53 0.00 0.00<br />

20973 S 1,899.26 0.00 0.00 21209 S 1,188.67 0.00 0.00<br />

20979 S 23.32 0.00 0.00 21210 S 1,323.53 0.00 0.00<br />

20982 S 1,821.42 0.00 0.00 21215 S 1,323.53 0.00 0.00<br />

21010 S 713.45 0.00 0.00 21230 S 1,323.53 0.00 0.00<br />

21015 S 593.60 0.00 0.00 21235 S 979.79 0.00 0.00<br />

21025 S 1,057.20 0.00 0.00 21240 S 1,146.46 0.00 0.00<br />

21026 S 1,057.20 0.00 0.00 21242 S 1,188.67 0.00 0.00<br />

21029 S 1,057.20 0.00 0.00 21243 S 1,188.67 0.00 0.00<br />

21030 S 249.41 0.00 0.00 21244 S 1,323.53 0.00 0.00<br />

21031 S 206.34 0.00 0.00 21245 S 1,323.53 0.00 0.00<br />

21032 S 210.29 0.00 0.00 21246 S 1,323.53 0.00 0.00<br />

21034 S 1,088.25 0.00 0.00 21248 S 1,323.53 0.00 0.00<br />

21040 S 713.45 0.00 0.00 21249 S 1,323.53 0.00 0.00<br />

21044 S 1,057.20 0.00 0.00 21260 S 1,681.68 0.00 0.00<br />

21046 S 1,057.20 0.00 0.00 21267 S 1,323.53 0.00 0.00<br />

21047 S 1,057.20 0.00 0.00 21270 S 1,188.67 0.00 0.00<br />

21048 S 1,681.68 0.00 0.00 21275 S 1,323.53 0.00 0.00<br />

21050 S 1,088.25 0.00 0.00 21280 S 1,188.67 0.00 0.00<br />

21060 S 1,057.20 0.00 0.00 21282 S 694.01 0.00 0.00<br />

21070 S 1,088.25 0.00 0.00 21295 S 312.81 0.00 0.00<br />

21073 S 193.79 0.00 0.00 21296 S 658.64 0.00 0.00<br />

21076 S 336.25 0.00 0.00 21310 S 95.42 0.00 0.00<br />

21077 S 812.83 0.00 0.00 21315 S 419.30 0.00 0.00<br />

21079 S 582.08 0.00 0.00 21320 S 562.54 0.00 0.00<br />

21080 S 667.49 0.00 0.00 21325 S 802.72 0.00 0.00<br />

21081 S 615.09 0.00 0.00 21330 S 844.92 0.00 0.00<br />

21082 S 585.31 0.00 0.00 21335 S 979.79 0.00 0.00<br />

21083 S 576.69 0.00 0.00 21336 S 816.55 0.00 0.00<br />

21084 S 663.54 0.00 0.00 21337 S 562.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 802.72 0.00 0.00 22310 S 173.72 0.00 0.00<br />

21339 S 844.92 0.00 0.00 22315 S 449.31 0.00 0.00<br />

21340 S 1,146.46 0.00 0.00 22505 S 528.95 0.00 0.00<br />

21345 S 979.79 0.00 0.00 22520 S 1,249.59 0.00 0.00<br />

21355 S 1,088.25 0.00 0.00 22521 S 1,249.59 0.00 0.00<br />

21356 S 744.51 0.00 0.00 22522 S 1,249.59 0.00 0.00<br />

21360 S 994.20 0.00 0.00 22523 S 3,477.73 0.00 0.00<br />

21390 S 1,681.68 0.00 0.00 22524 S 3,477.73 0.00 0.00<br />

21400 S 367.62 0.00 0.00 22525 S 3,477.73 0.00 0.00<br />

21401 S 593.60 0.00 0.00 22900 S 744.23 0.00 0.00<br />

21406 S 1,681.68 0.00 0.00 23000 S 535.58 0.00 0.00<br />

21407 S 1,681.68 0.00 0.00 23020 S 1,127.07 0.00 0.00<br />

21421 S 802.72 0.00 0.00 23030 S 550.84 0.00 0.00<br />

21440 S 338.05 0.00 0.00 23031 S 636.71 0.00 0.00<br />

21445 S 802.72 0.00 0.00 23035 S 684.78 0.00 0.00<br />

21450 S 139.52 0.00 0.00 23040 S 847.44 0.00 0.00<br />

21451 S 376.43 0.00 0.00 23044 S 905.65 0.00 0.00<br />

21452 S 562.54 0.00 0.00 23065 S 101.20 0.00 0.00<br />

21453 S 1,088.25 0.00 0.00 23066 S 654.97 0.00 0.00<br />

21454 S 844.92 0.00 0.00 23075 S 535.58 0.00 0.00<br />

21461 S 1,146.46 0.00 0.00 23076 S 654.97 0.00 0.00<br />

21462 S 1,188.67 0.00 0.00 23077 S 686.02 0.00 0.00<br />

21465 S 1,146.46 0.00 0.00 23100 S 653.72 0.00 0.00<br />

21480 S 95.42 0.00 0.00 23101 S 1,082.72 0.00 0.00<br />

21485 S 562.54 0.00 0.00 23105 S 905.65 0.00 0.00<br />

21490 S 1,088.25 0.00 0.00 23106 S 905.65 0.00 0.00<br />

21495 S 692.37 0.00 0.00 23107 S 905.65 0.00 0.00<br />

21497 S 562.54 0.00 0.00 23120 S 947.86 0.00 0.00<br />

21501 S 605.67 0.00 0.00 23125 S 947.86 0.00 0.00<br />

21502 S 653.72 0.00 0.00 23130 S 1,258.53 0.00 0.00<br />

21550 S 638.45 0.00 0.00 23140 S 742.99 0.00 0.00<br />

21555 S 654.97 0.00 0.00 23145 S 947.86 0.00 0.00<br />

21556 S 654.97 0.00 0.00 23146 S 947.86 0.00 0.00<br />

21557 S 877.22 0.00 0.00 23150 S 905.65 0.00 0.00<br />

21600 S 816.39 0.00 0.00 23155 S 947.86 0.00 0.00<br />

21610 S 816.39 0.00 0.00 23156 S 947.86 0.00 0.00<br />

21685 S 302.53 0.00 0.00 23170 S 816.39 0.00 0.00<br />

21700 S 653.72 0.00 0.00 23172 S 816.39 0.00 0.00<br />

21720 S 684.78 0.00 0.00 23174 S 816.39 0.00 0.00<br />

21725 S 71.28 0.00 0.00 23180 S 905.65 0.00 0.00<br />

21800 S 82.35 0.00 0.00 23182 S 905.65 0.00 0.00<br />

21805 S 727.29 0.00 0.00 23184 S 905.65 0.00 0.00<br />

21820 S 82.35 0.00 0.00 23190 S 905.65 0.00 0.00<br />

21920 S 146.41 0.00 0.00 23195 S 947.86 0.00 0.00<br />

21925 S 654.97 0.00 0.00 23330 S 327.34 0.00 0.00<br />

21930 S 654.97 0.00 0.00 23331 S 600.15 0.00 0.00<br />

21935 S 686.02 0.00 0.00 23395 S 1,258.53 0.00 0.00<br />

22102 S 1,952.08 0.00 0.00 23397 S 2,221.56 0.00 0.00<br />

22103 S 1,952.08 0.00 0.00 23400 S 1,082.72 0.00 0.00<br />

22305 S 82.35 0.00 0.00 23405 S 816.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 816.39 0.00 0.00 23931 S 605.67 0.00 0.00<br />

23410 S 1,258.53 0.00 0.00 23935 S 653.72 0.00 0.00<br />

23412 S 1,393.39 0.00 0.00 24000 S 905.65 0.00 0.00<br />

23415 S 1,258.53 0.00 0.00 24006 S 905.65 0.00 0.00<br />

23420 S 1,393.39 0.00 0.00 24065 S 140.31 0.00 0.00<br />

23430 S 1,216.33 0.00 0.00 24066 S 535.58 0.00 0.00<br />

23440 S 1,216.33 0.00 0.00 24075 S 535.58 0.00 0.00<br />

23450 S 2,086.69 0.00 0.00 24076 S 654.97 0.00 0.00<br />

23455 S 2,221.56 0.00 0.00 24077 S 686.02 0.00 0.00<br />

23460 S 2,086.69 0.00 0.00 24100 S 598.91 0.00 0.00<br />

23462 S 1,393.39 0.00 0.00 24101 S 905.65 0.00 0.00<br />

23465 S 2,086.69 0.00 0.00 24102 S 905.65 0.00 0.00<br />

23466 S 1,393.39 0.00 0.00 24105 S 684.78 0.00 0.00<br />

23480 S 1,216.33 0.00 0.00 24110 S 653.72 0.00 0.00<br />

23485 S 2,221.56 0.00 0.00 24115 S 847.44 0.00 0.00<br />

23490 S 1,158.11 0.00 0.00 24116 S 847.44 0.00 0.00<br />

23491 S 1,986.28 0.00 0.00 24120 S 684.78 0.00 0.00<br />

23500 S 82.35 0.00 0.00 24125 S 847.44 0.00 0.00<br />

23505 S 449.31 0.00 0.00 24126 S 847.44 0.00 0.00<br />

23515 S 1,503.81 0.00 0.00 24130 S 847.44 0.00 0.00<br />

23520 S 173.72 0.00 0.00 24134 S 816.39 0.00 0.00<br />

23525 S 173.72 0.00 0.00 24136 S 816.39 0.00 0.00<br />

23530 S 1,108.16 0.00 0.00 24138 S 816.39 0.00 0.00<br />

23532 S 816.55 0.00 0.00 24140 S 847.44 0.00 0.00<br />

23540 S 82.35 0.00 0.00 24145 S 847.44 0.00 0.00<br />

23545 S 173.72 0.00 0.00 24147 S 816.39 0.00 0.00<br />

23550 S 1,108.16 0.00 0.00 24149 S 1,200.06 0.00 0.00<br />

23552 S 1,166.38 0.00 0.00 24152 S 1,821.42 0.00 0.00<br />

23570 S 82.35 0.00 0.00 24153 S 3,477.73 0.00 0.00<br />

23575 S 173.72 0.00 0.00 24155 S 1,158.11 0.00 0.00<br />

23585 S 1,503.81 0.00 0.00 24160 S 816.39 0.00 0.00<br />

23600 S 64.17 0.00 0.00 24164 S 847.44 0.00 0.00<br />

23605 S 449.31 0.00 0.00 24200 S 102.63 0.00 0.00<br />

23615 S 1,562.02 0.00 0.00 24201 S 535.58 0.00 0.00<br />

23616 S 1,562.02 0.00 0.00 24300 S 625.19 0.00 0.00<br />

23620 S 64.17 0.00 0.00 24301 S 905.65 0.00 0.00<br />

23625 S 449.31 0.00 0.00 24305 S 905.65 0.00 0.00<br />

23630 S 1,604.23 0.00 0.00 24310 S 684.78 0.00 0.00<br />

23650 S 82.35 0.00 0.00 24320 S 1,158.11 0.00 0.00<br />

23655 S 474.14 0.00 0.00 24330 S 1,986.28 0.00 0.00<br />

23660 S 1,108.16 0.00 0.00 24331 S 1,158.11 0.00 0.00<br />

23665 S 173.72 0.00 0.00 24332 S 874.73 0.00 0.00<br />

23670 S 1,503.81 0.00 0.00 24340 S 1,158.11 0.00 0.00<br />

23675 S 82.35 0.00 0.00 24341 S 1,158.11 0.00 0.00<br />

23680 S 1,108.16 0.00 0.00 24342 S 1,158.11 0.00 0.00<br />

23700 S 474.14 0.00 0.00 24343 S 1,200.06 0.00 0.00<br />

23800 S 2,044.49 0.00 0.00 24344 S 3,477.73 0.00 0.00<br />

23802 S 1,393.39 0.00 0.00 24345 S 816.39 0.00 0.00<br />

23921 S 477.61 0.00 0.00 24346 S 1,821.42 0.00 0.00<br />

23930 S 550.84 0.00 0.00 24357 S 1,200.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,200.06 0.00 0.00 24925 S 684.78 0.00 0.00<br />

24359 S 1,200.06 0.00 0.00 25000 S 684.78 0.00 0.00<br />

24360 S 1,107.48 0.00 0.00 25001 S 874.73 0.00 0.00<br />

24361 S 6,055.19 3,706.54 1,357.90 25020 S 684.78 0.00 0.00<br />

24362 S 1,415.36 0.00 0.00 25023 S 847.44 0.00 0.00<br />

24363 S 6,190.05 3,841.41 1,492.76 25024 S 847.44 0.00 0.00<br />

24365 S 1,107.48 0.00 0.00 25025 S 847.44 0.00 0.00<br />

24366 S 6,055.19 3,706.54 1,357.90 25028 S 598.91 0.00 0.00<br />

24400 S 905.65 0.00 0.00 25031 S 653.72 0.00 0.00<br />

24410 S 905.65 0.00 0.00 25035 S 653.72 0.00 0.00<br />

24420 S 1,158.11 0.00 0.00 25040 S 947.86 0.00 0.00<br />

24430 S 1,986.28 0.00 0.00 25065 S 142.46 0.00 0.00<br />

24435 S 2,044.49 0.00 0.00 25066 S 654.97 0.00 0.00<br />

24470 S 1,158.11 0.00 0.00 25075 S 535.58 0.00 0.00<br />

24495 S 816.39 0.00 0.00 25076 S 686.02 0.00 0.00<br />

24498 S 1,986.28 0.00 0.00 25077 S 686.02 0.00 0.00<br />

24500 S 82.35 0.00 0.00 25085 S 684.78 0.00 0.00<br />

24505 S 82.35 0.00 0.00 25100 S 653.72 0.00 0.00<br />

24515 S 1,562.02 0.00 0.00 25101 S 847.44 0.00 0.00<br />

24516 S 1,562.02 0.00 0.00 25105 S 905.65 0.00 0.00<br />

24530 S 82.35 0.00 0.00 25107 S 847.44 0.00 0.00<br />

24535 S 173.72 0.00 0.00 25109 S 874.73 0.00 0.00<br />

24538 S 727.29 0.00 0.00 25110 S 684.78 0.00 0.00<br />

24545 S 1,562.02 0.00 0.00 25111 S 684.78 0.00 0.00<br />

24546 S 1,604.23 0.00 0.00 25112 S 742.99 0.00 0.00<br />

24560 S 82.35 0.00 0.00 25115 S 742.99 0.00 0.00<br />

24565 S 82.35 0.00 0.00 25116 S 742.99 0.00 0.00<br />

24566 S 727.29 0.00 0.00 25118 S 816.39 0.00 0.00<br />

24575 S 1,503.81 0.00 0.00 25119 S 847.44 0.00 0.00<br />

24576 S 82.35 0.00 0.00 25120 S 847.44 0.00 0.00<br />

24577 S 173.72 0.00 0.00 25125 S 847.44 0.00 0.00<br />

24579 S 1,503.81 0.00 0.00 25126 S 847.44 0.00 0.00<br />

24582 S 727.29 0.00 0.00 25130 S 847.44 0.00 0.00<br />

24586 S 1,562.02 0.00 0.00 25135 S 847.44 0.00 0.00<br />

24587 S 1,604.23 0.00 0.00 25136 S 847.44 0.00 0.00<br />

24600 S 82.35 0.00 0.00 25145 S 816.39 0.00 0.00<br />

24605 S 528.95 0.00 0.00 25150 S 816.39 0.00 0.00<br />

24615 S 1,503.81 0.00 0.00 25151 S 816.39 0.00 0.00<br />

24620 S 449.31 0.00 0.00 25210 S 847.44 0.00 0.00<br />

24635 S 1,503.81 0.00 0.00 25215 S 905.65 0.00 0.00<br />

24640 S 55.62 0.00 0.00 25230 S 905.65 0.00 0.00<br />

24650 S 64.17 0.00 0.00 25240 S 905.65 0.00 0.00<br />

24655 S 173.72 0.00 0.00 25248 S 653.72 0.00 0.00<br />

24665 S 1,166.38 0.00 0.00 25250 S 761.57 0.00 0.00<br />

24666 S 1,562.02 0.00 0.00 25251 S 761.57 0.00 0.00<br />

24670 S 82.35 0.00 0.00 25259 S 798.09 0.00 0.00<br />

24675 S 82.35 0.00 0.00 25260 S 905.65 0.00 0.00<br />

24685 S 1,108.16 0.00 0.00 25263 S 816.39 0.00 0.00<br />

24800 S 1,216.33 0.00 0.00 25265 S 847.44 0.00 0.00<br />

24802 S 1,258.53 0.00 0.00 25270 S 905.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 847.44 0.00 0.00 25505 S 173.72 0.00 0.00<br />

25274 S 905.65 0.00 0.00 25515 S 1,108.16 0.00 0.00<br />

25275 S 905.65 0.00 0.00 25520 S 173.72 0.00 0.00<br />

25280 S 905.65 0.00 0.00 25525 S 1,166.38 0.00 0.00<br />

25290 S 847.44 0.00 0.00 25526 S 1,208.58 0.00 0.00<br />

25295 S 684.78 0.00 0.00 25530 S 64.17 0.00 0.00<br />

25300 S 847.44 0.00 0.00 25535 S 82.35 0.00 0.00<br />

25301 S 847.44 0.00 0.00 25545 S 1,108.16 0.00 0.00<br />

25310 S 1,158.11 0.00 0.00 25560 S 64.17 0.00 0.00<br />

25312 S 1,216.33 0.00 0.00 25565 S 173.72 0.00 0.00<br />

25315 S 1,158.11 0.00 0.00 25574 S 1,503.81 0.00 0.00<br />

25316 S 1,986.28 0.00 0.00 25575 S 1,503.81 0.00 0.00<br />

25320 S 1,158.11 0.00 0.00 25600 S 64.17 0.00 0.00<br />

25332 S 1,107.48 0.00 0.00 25605 S 173.72 0.00 0.00<br />

25335 S 1,158.11 0.00 0.00 25606 S 758.34 0.00 0.00<br />

25337 S 1,258.53 0.00 0.00 25607 S 1,604.23 0.00 0.00<br />

25350 S 1,986.28 0.00 0.00 25608 S 1,604.23 0.00 0.00<br />

25355 S 1,158.11 0.00 0.00 25609 S 1,604.23 0.00 0.00<br />

25360 S 847.44 0.00 0.00 25622 S 64.17 0.00 0.00<br />

25365 S 847.44 0.00 0.00 25624 S 173.72 0.00 0.00<br />

25370 S 1,158.11 0.00 0.00 25628 S 1,108.16 0.00 0.00<br />

25375 S 1,216.33 0.00 0.00 25630 S 64.17 0.00 0.00<br />

25390 S 847.44 0.00 0.00 25635 S 173.72 0.00 0.00<br />

25391 S 1,216.33 0.00 0.00 25645 S 1,108.16 0.00 0.00<br />

25392 S 847.44 0.00 0.00 25650 S 64.17 0.00 0.00<br />

25393 S 1,216.33 0.00 0.00 25651 S 1,021.86 0.00 0.00<br />

25394 S 1,821.42 0.00 0.00 25652 S 1,721.50 0.00 0.00<br />

25400 S 1,158.11 0.00 0.00 25660 S 82.35 0.00 0.00<br />

25405 S 2,044.49 0.00 0.00 25670 S 758.34 0.00 0.00<br />

25415 S 1,986.28 0.00 0.00 25671 S 672.47 0.00 0.00<br />

25420 S 2,044.49 0.00 0.00 25675 S 82.35 0.00 0.00<br />

25425 S 1,158.11 0.00 0.00 25676 S 727.29 0.00 0.00<br />

25426 S 1,216.33 0.00 0.00 25680 S 82.35 0.00 0.00<br />

25430 S 1,821.42 0.00 0.00 25685 S 758.34 0.00 0.00<br />

25431 S 1,821.42 0.00 0.00 25690 S 449.31 0.00 0.00<br />

25440 S 2,044.49 0.00 0.00 25695 S 727.29 0.00 0.00<br />

25441 S 6,055.19 3,706.54 1,357.90 25800 S 2,044.49 0.00 0.00<br />

25442 S 6,055.19 3,706.54 1,357.90 25805 S 1,258.53 0.00 0.00<br />

25443 S 1,415.36 0.00 0.00 25810 S 2,086.69 0.00 0.00<br />

25444 S 1,415.36 0.00 0.00 25820 S 1,216.33 0.00 0.00<br />

25445 S 1,415.36 0.00 0.00 25825 S 2,086.69 0.00 0.00<br />

25446 S 6,190.05 3,841.41 1,492.76 25830 S 2,086.69 0.00 0.00<br />

25447 S 1,107.48 0.00 0.00 25907 S 684.78 0.00 0.00<br />

25449 S 1,107.48 0.00 0.00 25922 S 684.78 0.00 0.00<br />

25450 S 1,158.11 0.00 0.00 25929 S 568.18 0.00 0.00<br />

25455 S 1,158.11 0.00 0.00 25931 S 874.73 0.00 0.00<br />

25490 S 1,158.11 0.00 0.00 26010 S 56.73 0.00 0.00<br />

25491 S 1,158.11 0.00 0.00 26011 S 414.46 0.00 0.00<br />

25492 S 1,158.11 0.00 0.00 26020 S 549.94 0.00 0.00<br />

25500 S 64.17 0.00 0.00 26025 S 495.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 549.94 0.00 0.00 26392 S 809.64 0.00 0.00<br />

26034 S 549.94 0.00 0.00 26410 S 580.98 0.00 0.00<br />

26035 S 667.15 0.00 0.00 26412 S 809.64 0.00 0.00<br />

26040 S 867.86 0.00 0.00 26415 S 867.86 0.00 0.00<br />

26045 S 809.64 0.00 0.00 26416 S 809.64 0.00 0.00<br />

26055 S 549.94 0.00 0.00 26418 S 639.20 0.00 0.00<br />

26060 S 549.94 0.00 0.00 26420 S 867.86 0.00 0.00<br />

26070 S 549.94 0.00 0.00 26426 S 809.64 0.00 0.00<br />

26075 S 639.20 0.00 0.00 26428 S 809.64 0.00 0.00<br />

26080 S 639.20 0.00 0.00 26432 S 580.98 0.00 0.00<br />

26100 S 549.94 0.00 0.00 26433 S 580.98 0.00 0.00<br />

26105 S 495.11 0.00 0.00 26434 S 809.64 0.00 0.00<br />

26110 S 495.11 0.00 0.00 26437 S 580.98 0.00 0.00<br />

26115 S 654.97 0.00 0.00 26440 S 580.98 0.00 0.00<br />

26116 S 654.97 0.00 0.00 26442 S 809.64 0.00 0.00<br />

26117 S 686.02 0.00 0.00 26445 S 580.98 0.00 0.00<br />

26121 S 867.86 0.00 0.00 26449 S 809.64 0.00 0.00<br />

26123 S 867.86 0.00 0.00 26450 S 580.98 0.00 0.00<br />

26125 S 639.20 0.00 0.00 26455 S 580.98 0.00 0.00<br />

26130 S 580.98 0.00 0.00 26460 S 580.98 0.00 0.00<br />

26135 S 867.86 0.00 0.00 26471 S 549.94 0.00 0.00<br />

26140 S 549.94 0.00 0.00 26474 S 549.94 0.00 0.00<br />

26145 S 580.98 0.00 0.00 26476 S 495.11 0.00 0.00<br />

26160 S 580.98 0.00 0.00 26477 S 495.11 0.00 0.00<br />

26170 S 580.98 0.00 0.00 26478 S 495.11 0.00 0.00<br />

26180 S 580.98 0.00 0.00 26479 S 495.11 0.00 0.00<br />

26185 S 639.20 0.00 0.00 26480 S 809.64 0.00 0.00<br />

26200 S 549.94 0.00 0.00 26483 S 809.64 0.00 0.00<br />

26205 S 809.64 0.00 0.00 26485 S 778.60 0.00 0.00<br />

26210 S 549.94 0.00 0.00 26489 S 809.64 0.00 0.00<br />

26215 S 580.98 0.00 0.00 26490 S 809.64 0.00 0.00<br />

26230 S 815.26 0.00 0.00 26492 S 809.64 0.00 0.00<br />

26235 S 580.98 0.00 0.00 26494 S 809.64 0.00 0.00<br />

26236 S 580.98 0.00 0.00 26496 S 809.64 0.00 0.00<br />

26250 S 580.98 0.00 0.00 26497 S 809.64 0.00 0.00<br />

26255 S 809.64 0.00 0.00 26498 S 867.86 0.00 0.00<br />

26260 S 580.98 0.00 0.00 26499 S 809.64 0.00 0.00<br />

26261 S 580.98 0.00 0.00 26500 S 639.20 0.00 0.00<br />

26262 S 549.94 0.00 0.00 26502 S 867.86 0.00 0.00<br />

26320 S 535.58 0.00 0.00 26508 S 580.98 0.00 0.00<br />

26340 S 246.90 0.00 0.00 26510 S 809.64 0.00 0.00<br />

26350 S 723.77 0.00 0.00 26516 S 723.77 0.00 0.00<br />

26352 S 867.86 0.00 0.00 26517 S 809.64 0.00 0.00<br />

26356 S 867.86 0.00 0.00 26518 S 809.64 0.00 0.00<br />

26357 S 867.86 0.00 0.00 26520 S 580.98 0.00 0.00<br />

26358 S 867.86 0.00 0.00 26525 S 580.98 0.00 0.00<br />

26370 S 867.86 0.00 0.00 26530 S 1,007.07 0.00 0.00<br />

26372 S 867.86 0.00 0.00 26531 S 1,550.22 0.00 0.00<br />

26373 S 809.64 0.00 0.00 26535 S 1,107.48 0.00 0.00<br />

26390 S 867.86 0.00 0.00 26536 S 1,415.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 639.20 0.00 0.00 26775 S 171.54 0.00 0.00<br />

26541 S 1,044.92 0.00 0.00 26776 S 727.29 0.00 0.00<br />

26542 S 639.20 0.00 0.00 26785 S 727.29 0.00 0.00<br />

26545 S 867.86 0.00 0.00 26820 S 910.06 0.00 0.00<br />

26546 S 867.86 0.00 0.00 26841 S 867.86 0.00 0.00<br />

26548 S 867.86 0.00 0.00 26842 S 867.86 0.00 0.00<br />

26550 S 778.60 0.00 0.00 26843 S 809.64 0.00 0.00<br />

26555 S 809.64 0.00 0.00 26844 S 809.64 0.00 0.00<br />

26560 S 549.94 0.00 0.00 26850 S 867.86 0.00 0.00<br />

26561 S 809.64 0.00 0.00 26852 S 867.86 0.00 0.00<br />

26562 S 867.86 0.00 0.00 26860 S 809.64 0.00 0.00<br />

26565 S 910.06 0.00 0.00 26861 S 778.60 0.00 0.00<br />

26567 S 910.06 0.00 0.00 26862 S 867.86 0.00 0.00<br />

26568 S 809.64 0.00 0.00 26863 S 809.64 0.00 0.00<br />

26580 S 681.40 0.00 0.00 26910 S 809.64 0.00 0.00<br />

26587 S 681.40 0.00 0.00 26951 S 549.94 0.00 0.00<br />

26590 S 681.40 0.00 0.00 26952 S 639.20 0.00 0.00<br />

26591 S 809.64 0.00 0.00 26990 S 598.91 0.00 0.00<br />

26593 S 580.98 0.00 0.00 26991 S 598.91 0.00 0.00<br />

26596 S 549.94 0.00 0.00 27000 S 653.72 0.00 0.00<br />

26600 S 64.17 0.00 0.00 27001 S 847.44 0.00 0.00<br />

26605 S 82.35 0.00 0.00 27003 S 847.44 0.00 0.00<br />

26607 S 449.31 0.00 0.00 27033 S 1,158.11 0.00 0.00<br />

26608 S 816.55 0.00 0.00 27035 S 1,216.33 0.00 0.00<br />

26615 S 1,166.38 0.00 0.00 27040 S 327.34 0.00 0.00<br />

26641 S 64.17 0.00 0.00 27041 S 368.81 0.00 0.00<br />

26645 S 173.72 0.00 0.00 27047 S 654.97 0.00 0.00<br />

26650 S 727.29 0.00 0.00 27048 S 686.02 0.00 0.00<br />

26665 S 1,166.38 0.00 0.00 27049 S 686.02 0.00 0.00<br />

26670 S 64.17 0.00 0.00 27050 S 684.78 0.00 0.00<br />

26675 S 173.72 0.00 0.00 27052 S 684.78 0.00 0.00<br />

26676 S 727.29 0.00 0.00 27060 S 785.19 0.00 0.00<br />

26685 S 758.34 0.00 0.00 27062 S 785.19 0.00 0.00<br />

26686 S 1,503.81 0.00 0.00 27065 S 785.19 0.00 0.00<br />

26700 S 64.17 0.00 0.00 27066 S 947.86 0.00 0.00<br />

26705 S 82.35 0.00 0.00 27067 S 947.86 0.00 0.00<br />

26706 S 449.31 0.00 0.00 27080 S 816.39 0.00 0.00<br />

26715 S 816.55 0.00 0.00 27086 S 327.34 0.00 0.00<br />

26720 S 64.17 0.00 0.00 27087 S 684.78 0.00 0.00<br />

26725 S 64.17 0.00 0.00 27097 S 847.44 0.00 0.00<br />

26727 S 993.62 0.00 0.00 27098 S 847.44 0.00 0.00<br />

26735 S 816.55 0.00 0.00 27100 S 1,216.33 0.00 0.00<br />

26740 S 64.17 0.00 0.00 27105 S 1,216.33 0.00 0.00<br />

26742 S 82.35 0.00 0.00 27110 S 1,216.33 0.00 0.00<br />

26746 S 858.75 0.00 0.00 27111 S 1,216.33 0.00 0.00<br />

26750 S 64.17 0.00 0.00 27193 S 82.35 0.00 0.00<br />

26755 S 64.17 0.00 0.00 27194 S 528.95 0.00 0.00<br />

26756 S 727.29 0.00 0.00 27200 S 64.17 0.00 0.00<br />

26765 S 816.55 0.00 0.00 27202 S 1,077.12 0.00 0.00<br />

26770 S 64.17 0.00 0.00 27220 S 64.17 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 82.35 0.00 0.00 27397 S 1,158.11 0.00 0.00<br />

27238 S 173.72 0.00 0.00 27400 S 1,158.11 0.00 0.00<br />

27246 S 173.72 0.00 0.00 27403 S 905.65 0.00 0.00<br />

27250 S 82.35 0.00 0.00 27405 S 1,216.33 0.00 0.00<br />

27252 S 528.95 0.00 0.00 27407 S 2,044.49 0.00 0.00<br />

27256 S 64.17 0.00 0.00 27409 S 1,216.33 0.00 0.00<br />

27257 S 560.01 0.00 0.00 27416 S 1,821.42 0.00 0.00<br />

27265 S 82.35 0.00 0.00 27418 S 1,158.11 0.00 0.00<br />

27266 S 528.95 0.00 0.00 27420 S 1,158.11 0.00 0.00<br />

27267 S 64.17 0.00 0.00 27422 S 1,393.39 0.00 0.00<br />

27275 S 528.95 0.00 0.00 27424 S 1,158.11 0.00 0.00<br />

27301 S 636.71 0.00 0.00 27425 S 1,082.72 0.00 0.00<br />

27305 S 653.72 0.00 0.00 27427 S 1,158.11 0.00 0.00<br />

27306 S 684.78 0.00 0.00 27428 S 2,044.49 0.00 0.00<br />

27307 S 684.78 0.00 0.00 27429 S 2,044.49 0.00 0.00<br />

27310 S 905.65 0.00 0.00 27430 S 1,216.33 0.00 0.00<br />

27323 S 327.34 0.00 0.00 27435 S 1,216.33 0.00 0.00<br />

27324 S 600.15 0.00 0.00 27437 S 1,065.28 0.00 0.00<br />

27325 S 588.06 0.00 0.00 27438 S 1,415.36 0.00 0.00<br />

27326 S 588.06 0.00 0.00 27440 S 1,519.32 0.00 0.00<br />

27327 S 654.97 0.00 0.00 27441 S 1,107.48 0.00 0.00<br />

27328 S 686.02 0.00 0.00 27442 S 1,107.48 0.00 0.00<br />

27329 S 744.23 0.00 0.00 27443 S 1,107.48 0.00 0.00<br />

27330 S 905.65 0.00 0.00 27446 S 10,866.56 6,528.14 2,189.71<br />

27331 S 905.65 0.00 0.00 27496 S 785.19 0.00 0.00<br />

27332 S 905.65 0.00 0.00 27497 S 684.78 0.00 0.00<br />

27333 S 905.65 0.00 0.00 27498 S 684.78 0.00 0.00<br />

27334 S 905.65 0.00 0.00 27499 S 684.78 0.00 0.00<br />

27335 S 905.65 0.00 0.00 27500 S 173.72 0.00 0.00<br />

27340 S 684.78 0.00 0.00 27501 S 82.35 0.00 0.00<br />

27345 S 742.99 0.00 0.00 27502 S 449.31 0.00 0.00<br />

27347 S 742.99 0.00 0.00 27503 S 82.35 0.00 0.00<br />

27350 S 905.65 0.00 0.00 27508 S 82.35 0.00 0.00<br />

27355 S 847.44 0.00 0.00 27509 S 758.34 0.00 0.00<br />

27356 S 905.65 0.00 0.00 27510 S 173.72 0.00 0.00<br />

27357 S 947.86 0.00 0.00 27516 S 82.35 0.00 0.00<br />

27358 S 947.86 0.00 0.00 27517 S 82.35 0.00 0.00<br />

27360 S 947.86 0.00 0.00 27520 S 82.35 0.00 0.00<br />

27372 S 921.30 0.00 0.00 27530 S 82.35 0.00 0.00<br />

27380 S 598.91 0.00 0.00 27532 S 449.31 0.00 0.00<br />

27381 S 684.78 0.00 0.00 27538 S 82.35 0.00 0.00<br />

27385 S 684.78 0.00 0.00 27550 S 82.35 0.00 0.00<br />

27386 S 684.78 0.00 0.00 27552 S 474.14 0.00 0.00<br />

27390 S 598.91 0.00 0.00 27560 S 82.35 0.00 0.00<br />

27391 S 653.72 0.00 0.00 27562 S 474.14 0.00 0.00<br />

27392 S 684.78 0.00 0.00 27566 S 1,077.12 0.00 0.00<br />

27393 S 816.39 0.00 0.00 27570 S 474.14 0.00 0.00<br />

27394 S 847.44 0.00 0.00 27594 S 684.78 0.00 0.00<br />

27395 S 1,158.11 0.00 0.00 27600 S 684.78 0.00 0.00<br />

27396 S 847.44 0.00 0.00 27601 S 684.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 684.78 0.00 0.00 27730 S 816.39 0.00 0.00<br />

27603 S 605.67 0.00 0.00 27732 S 816.39 0.00 0.00<br />

27604 S 653.72 0.00 0.00 27734 S 816.39 0.00 0.00<br />

27605 S 595.70 0.00 0.00 27740 S 816.39 0.00 0.00<br />

27606 S 598.91 0.00 0.00 27742 S 1,127.07 0.00 0.00<br />

27607 S 653.72 0.00 0.00 27745 S 1,986.28 0.00 0.00<br />

27610 S 816.39 0.00 0.00 27750 S 82.35 0.00 0.00<br />

27612 S 847.44 0.00 0.00 27752 S 449.31 0.00 0.00<br />

27613 S 134.57 0.00 0.00 27756 S 758.34 0.00 0.00<br />

27614 S 654.97 0.00 0.00 27758 S 1,166.38 0.00 0.00<br />

27615 S 847.44 0.00 0.00 27759 S 1,562.02 0.00 0.00<br />

27618 S 535.58 0.00 0.00 27760 S 82.35 0.00 0.00<br />

27619 S 686.02 0.00 0.00 27762 S 449.31 0.00 0.00<br />

27620 S 905.65 0.00 0.00 27766 S 1,108.16 0.00 0.00<br />

27625 S 905.65 0.00 0.00 27767 S 64.17 0.00 0.00<br />

27626 S 905.65 0.00 0.00 27768 S 64.17 0.00 0.00<br />

27630 S 684.78 0.00 0.00 27769 S 1,721.50 0.00 0.00<br />

27635 S 847.44 0.00 0.00 27780 S 82.35 0.00 0.00<br />

27637 S 847.44 0.00 0.00 27781 S 449.31 0.00 0.00<br />

27638 S 847.44 0.00 0.00 27784 S 1,108.16 0.00 0.00<br />

27640 S 1,127.07 0.00 0.00 27786 S 82.35 0.00 0.00<br />

27641 S 816.39 0.00 0.00 27788 S 82.35 0.00 0.00<br />

27647 S 1,158.11 0.00 0.00 27792 S 1,108.16 0.00 0.00<br />

27650 S 1,158.11 0.00 0.00 27808 S 82.35 0.00 0.00<br />

27652 S 1,986.28 0.00 0.00 27810 S 173.72 0.00 0.00<br />

27654 S 1,158.11 0.00 0.00 27814 S 1,108.16 0.00 0.00<br />

27656 S 653.72 0.00 0.00 27816 S 82.35 0.00 0.00<br />

27658 S 598.91 0.00 0.00 27818 S 173.72 0.00 0.00<br />

27659 S 653.72 0.00 0.00 27822 S 1,108.16 0.00 0.00<br />

27664 S 653.72 0.00 0.00 27823 S 1,503.81 0.00 0.00<br />

27665 S 816.39 0.00 0.00 27824 S 82.35 0.00 0.00<br />

27675 S 653.72 0.00 0.00 27825 S 449.31 0.00 0.00<br />

27676 S 847.44 0.00 0.00 27826 S 1,108.16 0.00 0.00<br />

27680 S 847.44 0.00 0.00 27827 S 1,503.81 0.00 0.00<br />

27681 S 816.39 0.00 0.00 27828 S 1,562.02 0.00 0.00<br />

27685 S 847.44 0.00 0.00 27829 S 1,077.12 0.00 0.00<br />

27686 S 847.44 0.00 0.00 27830 S 82.35 0.00 0.00<br />

27687 S 847.44 0.00 0.00 27831 S 449.31 0.00 0.00<br />

27690 S 1,216.33 0.00 0.00 27832 S 1,077.12 0.00 0.00<br />

27691 S 1,216.33 0.00 0.00 27840 S 173.72 0.00 0.00<br />

27692 S 1,158.11 0.00 0.00 27842 S 474.14 0.00 0.00<br />

27695 S 816.39 0.00 0.00 27846 S 1,108.16 0.00 0.00<br />

27696 S 816.39 0.00 0.00 27848 S 1,108.16 0.00 0.00<br />

27698 S 816.39 0.00 0.00 27860 S 474.14 0.00 0.00<br />

27700 S 1,107.48 0.00 0.00 27870 S 2,044.49 0.00 0.00<br />

27704 S 653.72 0.00 0.00 27871 S 2,044.49 0.00 0.00<br />

27705 S 1,127.07 0.00 0.00 27884 S 684.78 0.00 0.00<br />

27707 S 653.72 0.00 0.00 27889 S 847.44 0.00 0.00<br />

27709 S 816.39 0.00 0.00 27892 S 684.78 0.00 0.00<br />

27726 S 1,021.86 0.00 0.00 27893 S 684.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 684.78 0.00 0.00 28153 S 681.57 0.00 0.00<br />

28001 S 131.34 0.00 0.00 28160 S 681.57 0.00 0.00<br />

28002 S 684.78 0.00 0.00 28171 S 681.57 0.00 0.00<br />

28003 S 684.78 0.00 0.00 28173 S 681.57 0.00 0.00<br />

28005 S 681.57 0.00 0.00 28175 S 681.57 0.00 0.00<br />

28008 S 681.57 0.00 0.00 28190 S 135.65 0.00 0.00<br />

28010 S 96.53 0.00 0.00 28192 S 535.58 0.00 0.00<br />

28011 S 681.57 0.00 0.00 28193 S 368.81 0.00 0.00<br />

28020 S 650.51 0.00 0.00 28200 S 681.57 0.00 0.00<br />

28022 S 650.51 0.00 0.00 28202 S 681.57 0.00 0.00<br />

28024 S 650.51 0.00 0.00 28208 S 681.57 0.00 0.00<br />

28035 S 677.33 0.00 0.00 28210 S 1,197.03 0.00 0.00<br />

28043 S 654.97 0.00 0.00 28220 S 209.22 0.00 0.00<br />

28045 S 681.57 0.00 0.00 28222 S 595.70 0.00 0.00<br />

28046 S 681.57 0.00 0.00 28225 S 595.70 0.00 0.00<br />

28050 S 650.51 0.00 0.00 28226 S 595.70 0.00 0.00<br />

28052 S 650.51 0.00 0.00 28230 S 205.27 0.00 0.00<br />

28054 S 650.51 0.00 0.00 28232 S 196.29 0.00 0.00<br />

28055 S 677.33 0.00 0.00 28234 S 650.51 0.00 0.00<br />

28060 S 650.51 0.00 0.00 28238 S 1,197.03 0.00 0.00<br />

28062 S 681.57 0.00 0.00 28240 S 650.51 0.00 0.00<br />

28070 S 681.57 0.00 0.00 28250 S 681.57 0.00 0.00<br />

28072 S 681.57 0.00 0.00 28260 S 681.57 0.00 0.00<br />

28080 S 681.57 0.00 0.00 28261 S 681.57 0.00 0.00<br />

28086 S 650.51 0.00 0.00 28262 S 739.77 0.00 0.00<br />

28088 S 650.51 0.00 0.00 28264 S 1,111.17 0.00 0.00<br />

28090 S 681.57 0.00 0.00 28270 S 681.57 0.00 0.00<br />

28092 S 681.57 0.00 0.00 28272 S 189.48 0.00 0.00<br />

28100 S 650.51 0.00 0.00 28280 S 650.51 0.00 0.00<br />

28102 S 1,197.03 0.00 0.00 28285 S 681.57 0.00 0.00<br />

28103 S 1,197.03 0.00 0.00 28286 S 739.77 0.00 0.00<br />

28104 S 650.51 0.00 0.00 28288 S 681.57 0.00 0.00<br />

28106 S 1,197.03 0.00 0.00 28289 S 681.57 0.00 0.00<br />

28107 S 1,197.03 0.00 0.00 28290 S 840.12 0.00 0.00<br />

28108 S 650.51 0.00 0.00 28292 S 840.12 0.00 0.00<br />

28110 S 681.57 0.00 0.00 28293 S 871.16 0.00 0.00<br />

28111 S 681.57 0.00 0.00 28294 S 871.16 0.00 0.00<br />

28112 S 681.57 0.00 0.00 28296 S 871.16 0.00 0.00<br />

28113 S 681.57 0.00 0.00 28297 S 871.16 0.00 0.00<br />

28114 S 681.57 0.00 0.00 28298 S 871.16 0.00 0.00<br />

28116 S 681.57 0.00 0.00 28299 S 971.58 0.00 0.00<br />

28118 S 739.77 0.00 0.00 28300 S 1,165.99 0.00 0.00<br />

28119 S 739.77 0.00 0.00 28302 S 650.51 0.00 0.00<br />

28120 S 916.84 0.00 0.00 28304 S 1,165.99 0.00 0.00<br />

28122 S 681.57 0.00 0.00 28305 S 1,197.03 0.00 0.00<br />

28124 S 222.13 0.00 0.00 28306 S 739.77 0.00 0.00<br />

28126 S 681.57 0.00 0.00 28307 S 739.77 0.00 0.00<br />

28130 S 681.57 0.00 0.00 28308 S 650.51 0.00 0.00<br />

28140 S 681.57 0.00 0.00 28309 S 1,255.25 0.00 0.00<br />

28150 S 681.57 0.00 0.00 28310 S 681.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 681.57 0.00 0.00 28636 S 758.34 0.00 0.00<br />

28313 S 650.51 0.00 0.00 28645 S 758.34 0.00 0.00<br />

28315 S 739.77 0.00 0.00 28660 S 45.94 0.00 0.00<br />

28320 S 1,255.25 0.00 0.00 28665 S 474.14 0.00 0.00<br />

28322 S 1,255.25 0.00 0.00 28666 S 758.34 0.00 0.00<br />

28340 S 739.77 0.00 0.00 28675 S 758.34 0.00 0.00<br />

28341 S 739.77 0.00 0.00 28705 S 1,255.25 0.00 0.00<br />

28344 S 739.77 0.00 0.00 28715 S 2,044.49 0.00 0.00<br />

28345 S 739.77 0.00 0.00 28725 S 1,255.25 0.00 0.00<br />

28400 S 82.35 0.00 0.00 28730 S 1,255.25 0.00 0.00<br />

28405 S 449.31 0.00 0.00 28735 S 1,255.25 0.00 0.00<br />

28406 S 727.29 0.00 0.00 28737 S 1,297.45 0.00 0.00<br />

28415 S 1,503.81 0.00 0.00 28740 S 1,255.25 0.00 0.00<br />

28420 S 1,166.38 0.00 0.00 28750 S 1,255.25 0.00 0.00<br />

28430 S 64.17 0.00 0.00 28755 S 739.77 0.00 0.00<br />

28435 S 82.35 0.00 0.00 28760 S 1,255.25 0.00 0.00<br />

28436 S 727.29 0.00 0.00 28810 S 650.51 0.00 0.00<br />

28445 S 1,108.16 0.00 0.00 28820 S 650.51 0.00 0.00<br />

28446 S 1,899.26 0.00 0.00 28825 S 650.51 0.00 0.00<br />

28450 S 64.17 0.00 0.00 28890 S 171.90 0.00 0.00<br />

28455 S 64.17 0.00 0.00 29000 S 43.55 0.00 0.00<br />

28456 S 727.29 0.00 0.00 29010 S 97.61 0.00 0.00<br />

28465 S 1,108.16 0.00 0.00 29015 S 97.61 0.00 0.00<br />

28470 S 64.17 0.00 0.00 29020 S 43.55 0.00 0.00<br />

28475 S 64.17 0.00 0.00 29025 S 43.55 0.00 0.00<br />

28476 S 727.29 0.00 0.00 29035 S 97.61 0.00 0.00<br />

28485 S 1,166.38 0.00 0.00 29040 S 43.55 0.00 0.00<br />

28490 S 64.17 0.00 0.00 29044 S 97.61 0.00 0.00<br />

28495 S 64.17 0.00 0.00 29046 S 97.61 0.00 0.00<br />

28496 S 727.29 0.00 0.00 29049 S 39.47 0.00 0.00<br />

28505 S 758.34 0.00 0.00 29055 S 97.61 0.00 0.00<br />

28510 S 57.78 0.00 0.00 29058 S 43.55 0.00 0.00<br />

28515 S 64.17 0.00 0.00 29065 S 46.30 0.00 0.00<br />

28525 S 758.34 0.00 0.00 29075 S 44.50 0.00 0.00<br />

28530 S 55.62 0.00 0.00 29085 S 43.55 0.00 0.00<br />

28531 S 758.34 0.00 0.00 29086 S 37.32 0.00 0.00<br />

28540 S 64.17 0.00 0.00 29105 S 40.19 0.00 0.00<br />

28545 S 672.47 0.00 0.00 29125 S 34.81 0.00 0.00<br />

28546 S 727.29 0.00 0.00 29126 S 36.96 0.00 0.00<br />

28555 S 1,077.12 0.00 0.00 29130 S 15.79 0.00 0.00<br />

28570 S 83.25 0.00 0.00 29131 S 22.96 0.00 0.00<br />

28575 S 449.31 0.00 0.00 29200 S 22.25 0.00 0.00<br />

28576 S 758.34 0.00 0.00 29220 S 24.04 0.00 0.00<br />

28585 S 758.34 0.00 0.00 29240 S 25.12 0.00 0.00<br />

28600 S 64.17 0.00 0.00 29260 S 24.04 0.00 0.00<br />

28605 S 82.35 0.00 0.00 29280 S 24.41 0.00 0.00<br />

28606 S 727.29 0.00 0.00 29305 S 97.61 0.00 0.00<br />

28615 S 1,108.16 0.00 0.00 29325 S 97.61 0.00 0.00<br />

28630 S 64.17 0.00 0.00 29345 S 60.65 0.00 0.00<br />

28635 S 474.14 0.00 0.00 29355 S 59.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 73.93 0.00 0.00 29847 S 1,235.66 0.00 0.00<br />

29365 S 57.42 0.00 0.00 29848 S 1,240.22 0.00 0.00<br />

29405 S 42.71 0.00 0.00 29850 S 896.28 0.00 0.00<br />

29425 S 43.42 0.00 0.00 29851 S 1,293.88 0.00 0.00<br />

29435 S 54.90 0.00 0.00 29855 S 1,293.88 0.00 0.00<br />

29440 S 23.32 0.00 0.00 29856 S 1,293.88 0.00 0.00<br />

29445 S 57.78 0.00 0.00 29860 S 1,293.88 0.00 0.00<br />

29450 S 43.55 0.00 0.00 29861 S 1,293.88 0.00 0.00<br />

29505 S 38.76 0.00 0.00 29862 S 1,637.82 0.00 0.00<br />

29515 S 33.01 0.00 0.00 29863 S 1,293.88 0.00 0.00<br />

29520 S 23.68 0.00 0.00 29866 S 1,976.51 0.00 0.00<br />

29530 S 24.04 0.00 0.00 29870 S 838.07 0.00 0.00<br />

29540 S 17.94 0.00 0.00 29871 S 838.07 0.00 0.00<br />

29550 S 18.30 0.00 0.00 29873 S 838.07 0.00 0.00<br />

29580 S 24.77 0.00 0.00 29874 S 838.07 0.00 0.00<br />

29590 S 20.10 0.00 0.00 29875 S 896.28 0.00 0.00<br />

29700 S 33.37 0.00 0.00 29876 S 896.28 0.00 0.00<br />

29705 S 28.35 0.00 0.00 29877 S 896.28 0.00 0.00<br />

29710 S 49.88 0.00 0.00 29879 S 838.07 0.00 0.00<br />

29715 S 43.55 0.00 0.00 29880 S 896.28 0.00 0.00<br />

29720 S 41.63 0.00 0.00 29881 S 896.28 0.00 0.00<br />

29730 S 27.27 0.00 0.00 29882 S 838.07 0.00 0.00<br />

29740 S 37.32 0.00 0.00 29883 S 838.07 0.00 0.00<br />

29750 S 39.11 0.00 0.00 29884 S 838.07 0.00 0.00<br />

29800 S 838.07 0.00 0.00 29885 S 1,235.66 0.00 0.00<br />

29804 S 838.07 0.00 0.00 29886 S 838.07 0.00 0.00<br />

29805 S 838.07 0.00 0.00 29887 S 838.07 0.00 0.00<br />

29806 S 1,235.66 0.00 0.00 29888 S 1,235.66 0.00 0.00<br />

29807 S 1,235.66 0.00 0.00 29889 S 1,235.66 0.00 0.00<br />

29819 S 1,235.66 0.00 0.00 29891 S 1,235.66 0.00 0.00<br />

29820 S 1,235.66 0.00 0.00 29892 S 1,235.66 0.00 0.00<br />

29821 S 1,235.66 0.00 0.00 29893 S 1,043.24 0.00 0.00<br />

29822 S 838.07 0.00 0.00 29894 S 838.07 0.00 0.00<br />

29823 S 1,235.66 0.00 0.00 29895 S 838.07 0.00 0.00<br />

29824 S 938.48 0.00 0.00 29897 S 838.07 0.00 0.00<br />

29825 S 1,235.66 0.00 0.00 29898 S 838.07 0.00 0.00<br />

29826 S 1,235.66 0.00 0.00 29899 S 1,235.66 0.00 0.00<br />

29827 S 1,336.08 0.00 0.00 29900 S 838.07 0.00 0.00<br />

29828 S 1,976.51 0.00 0.00 29901 S 838.07 0.00 0.00<br />

29830 S 838.07 0.00 0.00 29902 S 838.07 0.00 0.00<br />

29834 S 838.07 0.00 0.00 29904 S 1,181.31 0.00 0.00<br />

29835 S 838.07 0.00 0.00 29905 S 1,181.31 0.00 0.00<br />

29836 S 838.07 0.00 0.00 29906 S 1,181.31 0.00 0.00<br />

29837 S 838.07 0.00 0.00 29907 S 1,976.51 0.00 0.00<br />

29838 S 838.07 0.00 0.00 30000 S 132.81 0.00 0.00<br />

29840 S 838.07 0.00 0.00 30020 S 132.81 0.00 0.00<br />

29843 S 838.07 0.00 0.00 30100 S 86.13 0.00 0.00<br />

29844 S 838.07 0.00 0.00 30110 S 133.14 0.00 0.00<br />

29845 S 838.07 0.00 0.00 30115 S 562.54 0.00 0.00<br />

29846 S 838.07 0.00 0.00 30117 S 593.60 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 744.51 0.00 0.00 31080 S 1,146.46 0.00 0.00<br />

30120 S 507.73 0.00 0.00 31081 S 1,146.46 0.00 0.00<br />

30124 S 302.53 0.00 0.00 31084 S 1,146.46 0.00 0.00<br />

30125 S 1,057.20 0.00 0.00 31085 S 1,146.46 0.00 0.00<br />

30130 S 593.60 0.00 0.00 31086 S 1,146.46 0.00 0.00<br />

30140 S 713.45 0.00 0.00 31087 S 1,146.46 0.00 0.00<br />

30150 S 1,088.25 0.00 0.00 31090 S 1,188.67 0.00 0.00<br />

30160 S 1,146.46 0.00 0.00 31200 S 1,057.20 0.00 0.00<br />

30200 S 67.83 0.00 0.00 31201 S 1,188.67 0.00 0.00<br />

30210 S 86.13 0.00 0.00 31205 S 1,088.25 0.00 0.00<br />

30220 S 376.43 0.00 0.00 31231 S 72.61 0.00 0.00<br />

30300 S 25.95 0.00 0.00 31233 S 78.21 0.00 0.00<br />

30310 S 507.73 0.00 0.00 31235 S 531.34 0.00 0.00<br />

30320 S 562.54 0.00 0.00 31237 S 586.15 0.00 0.00<br />

30400 S 1,146.46 0.00 0.00 31238 S 531.34 0.00 0.00<br />

30410 S 1,188.67 0.00 0.00 31239 S 775.59 0.00 0.00<br />

30420 S 1,188.67 0.00 0.00 31240 S 586.15 0.00 0.00<br />

30430 S 744.51 0.00 0.00 31254 S 717.38 0.00 0.00<br />

30435 S 1,188.67 0.00 0.00 31255 S 817.79 0.00 0.00<br />

30450 S 1,323.53 0.00 0.00 31256 S 717.38 0.00 0.00<br />

30460 S 1,323.53 0.00 0.00 31267 S 717.38 0.00 0.00<br />

30462 S 1,490.40 0.00 0.00 31276 S 717.38 0.00 0.00<br />

30465 S 1,490.40 0.00 0.00 31287 S 717.38 0.00 0.00<br />

30520 S 802.72 0.00 0.00 31288 S 717.38 0.00 0.00<br />

30540 S 1,188.67 0.00 0.00 31300 S 844.92 0.00 0.00<br />

30545 S 1,188.67 0.00 0.00 31320 S 1,057.20 0.00 0.00<br />

30560 S 139.52 0.00 0.00 31400 S 1,057.20 0.00 0.00<br />

30580 S 1,146.46 0.00 0.00 31420 S 1,057.20 0.00 0.00<br />

30600 S 1,146.46 0.00 0.00 31500 S 97.11 0.00 0.00<br />

30620 S 1,323.53 0.00 0.00 31502 S 55.84 0.00 0.00<br />

30630 S 979.79 0.00 0.00 31505 S 32.99 0.00 0.00<br />

30801 S 312.81 0.00 0.00 31510 S 586.15 0.00 0.00<br />

30802 S 312.81 0.00 0.00 31511 S 78.21 0.00 0.00<br />

30901 S 44.62 0.00 0.00 31512 S 586.15 0.00 0.00<br />

30903 S 57.47 0.00 0.00 31513 S 78.21 0.00 0.00<br />

30905 S 57.47 0.00 0.00 31515 S 531.34 0.00 0.00<br />

30906 S 57.47 0.00 0.00 31520 S 72.61 0.00 0.00<br />

30915 S 765.78 0.00 0.00 31525 S 531.34 0.00 0.00<br />

30920 S 796.84 0.00 0.00 31526 S 686.33 0.00 0.00<br />

30930 S 651.80 0.00 0.00 31527 S 631.51 0.00 0.00<br />

31000 S 110.89 0.00 0.00 31528 S 586.15 0.00 0.00<br />

31002 S 302.53 0.00 0.00 31529 S 586.15 0.00 0.00<br />

31020 S 713.45 0.00 0.00 31530 S 686.33 0.00 0.00<br />

31030 S 1,088.25 0.00 0.00 31531 S 717.38 0.00 0.00<br />

31032 S 1,146.46 0.00 0.00 31535 S 686.33 0.00 0.00<br />

31040 S 994.20 0.00 0.00 31536 S 717.38 0.00 0.00<br />

31050 S 1,057.20 0.00 0.00 31540 S 717.38 0.00 0.00<br />

31051 S 1,146.46 0.00 0.00 31541 S 775.59 0.00 0.00<br />

31070 S 713.45 0.00 0.00 31545 S 775.59 0.00 0.00<br />

31075 S 1,146.46 0.00 0.00 31546 S 775.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 817.79 0.00 0.00 32405 S 353.88 0.00 0.00<br />

31561 S 817.79 0.00 0.00 32420 S 215.19 0.00 0.00<br />

31570 S 586.15 0.00 0.00 32421 S 215.19 0.00 0.00<br />

31571 S 686.33 0.00 0.00 32422 S 214.23 0.00 0.00<br />

31575 S 62.45 0.00 0.00 32550 S 1,199.47 0.00 0.00<br />

31576 S 686.33 0.00 0.00 32960 S 214.23 0.00 0.00<br />

31577 S 202.74 0.00 0.00 32998 S 1,867.52 0.00 0.00<br />

31578 S 686.33 0.00 0.00 33010 S 215.19 0.00 0.00<br />

31579 S 111.25 0.00 0.00 33011 S 215.19 0.00 0.00<br />

31580 S 1,188.67 0.00 0.00 33206 S 6,904.07 4,107.90 1,311.74<br />

31582 S 1,188.67 0.00 0.00 33207 S 6,904.07 4,107.90 1,311.74<br />

31588 S 1,188.67 0.00 0.00 33208 S 8,563.00 4,989.62 1,416.24<br />

31590 S 1,188.67 0.00 0.00 33210 S 2,027.40 0.00 0.00<br />

31595 S 1,057.20 0.00 0.00 33211 S 2,027.40 0.00 0.00<br />

31603 S 312.81 0.00 0.00 33212 S 5,422.15 3,088.77 755.38<br />

31605 S 302.53 0.00 0.00 33213 S 6,258.33 3,506.41 754.49<br />

31611 S 744.51 0.00 0.00 33214 S 8,563.00 4,989.62 1,416.24<br />

31612 S 658.64 0.00 0.00 33215 S 888.63 0.00 0.00<br />

31613 S 713.45 0.00 0.00 33216 S 2,027.40 0.00 0.00<br />

31614 S 1,057.20 0.00 0.00 33217 S 2,027.40 0.00 0.00<br />

31615 S 312.81 0.00 0.00 33218 S 888.63 0.00 0.00<br />

31622 S 366.35 0.00 0.00 33220 S 888.63 0.00 0.00<br />

31623 S 421.16 0.00 0.00 33222 S 537.14 0.00 0.00<br />

31624 S 421.16 0.00 0.00 33223 S 537.14 0.00 0.00<br />

31625 S 421.16 0.00 0.00 33224 S 8,082.67 4,839.07 1,595.48<br />

31628 S 421.16 0.00 0.00 33225 S 8,082.67 4,839.07 1,595.48<br />

31629 S 421.16 0.00 0.00 33226 S 888.63 0.00 0.00<br />

31630 S 721.70 0.00 0.00 33233 S 660.68 0.00 0.00<br />

31631 S 721.70 0.00 0.00 33234 S 888.63 0.00 0.00<br />

31632 S 409.61 0.00 0.00 33235 S 888.63 0.00 0.00<br />

31633 S 409.61 0.00 0.00 33240 S 20,148.04 10,769.95 1,391.87<br />

31635 S 421.16 0.00 0.00 33241 S 888.63 0.00 0.00<br />

31636 S 721.70 0.00 0.00 33249 S 26,889.10 14,402.91 1,916.73<br />

31637 S 366.35 0.00 0.00 33282 S 4,251.34 2,545.10 838.86<br />

31638 S 721.70 0.00 0.00 33284 S 331.59 0.00 0.00<br />

31640 S 721.70 0.00 0.00 34490 S 1,618.93 0.00 0.00<br />

31641 S 721.70 0.00 0.00 35188 S 1,115.09 0.00 0.00<br />

31643 S 421.16 0.00 0.00 35207 S 1,115.09 0.00 0.00<br />

31645 S 366.35 0.00 0.00 35473 S 1,942.10 0.00 0.00<br />

31646 S 366.35 0.00 0.00 35476 S 1,942.10 0.00 0.00<br />

31656 S 366.35 0.00 0.00 35492 S 3,624.74 0.00 0.00<br />

31717 S 202.74 0.00 0.00 35761 S 1,166.03 0.00 0.00<br />

31720 S 31.04 0.00 0.00 35875 S 1,459.03 0.00 0.00<br />

31730 S 202.74 0.00 0.00 35876 S 1,459.03 0.00 0.00<br />

31750 S 1,188.67 0.00 0.00 36002 S 93.12 0.00 0.00<br />

31755 S 1,057.20 0.00 0.00 36260 S 844.75 0.00 0.00<br />

31820 S 507.73 0.00 0.00 36261 S 660.68 0.00 0.00<br />

31825 S 713.45 0.00 0.00 36262 S 605.86 0.00 0.00<br />

31830 S 713.45 0.00 0.00 36420 S 8.78 0.00 0.00<br />

32400 S 353.88 0.00 0.00 36425 S 8.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 33.73 0.00 0.00 36800 S 909.37 0.00 0.00<br />

36440 S 134.71 0.00 0.00 36810 S 909.37 0.00 0.00<br />

36450 S 134.71 0.00 0.00 36815 S 909.37 0.00 0.00<br />

36455 S 134.71 0.00 0.00 36818 S 1,056.88 0.00 0.00<br />

36468 S 33.25 0.00 0.00 36819 S 1,056.88 0.00 0.00<br />

36469 S 33.25 0.00 0.00 36820 S 1,056.88 0.00 0.00<br />

36470 S 33.25 0.00 0.00 36821 S 1,056.88 0.00 0.00<br />

36471 S 33.25 0.00 0.00 36825 S 1,115.09 0.00 0.00<br />

36475 S 1,528.92 0.00 0.00 36830 S 1,115.09 0.00 0.00<br />

36476 S 1,198.98 0.00 0.00 36831 S 1,459.03 0.00 0.00<br />

36478 S 1,198.98 0.00 0.00 36832 S 1,115.09 0.00 0.00<br />

36479 S 1,198.98 0.00 0.00 36833 S 1,115.09 0.00 0.00<br />

36511 S 461.86 0.00 0.00 36834 S 1,056.88 0.00 0.00<br />

36512 S 461.86 0.00 0.00 36835 S 967.59 0.00 0.00<br />

36513 S 461.86 0.00 0.00 36860 S 111.05 0.00 0.00<br />

36514 S 461.86 0.00 0.00 36861 S 909.37 0.00 0.00<br />

36515 S 1,236.40 0.00 0.00 36870 S 1,590.35 0.00 0.00<br />

36516 S 1,236.40 0.00 0.00 37184 S 1,618.93 0.00 0.00<br />

36522 S 1,236.40 0.00 0.00 37185 S 1,618.93 0.00 0.00<br />

36555 S 383.74 0.00 0.00 37186 S 1,618.93 0.00 0.00<br />

36556 S 383.74 0.00 0.00 37187 S 1,618.93 0.00 0.00<br />

36557 S 716.67 0.00 0.00 37188 S 1,618.93 0.00 0.00<br />

36558 S 716.67 0.00 0.00 37200 S 1,194.68 0.00 0.00<br />

36560 S 844.75 0.00 0.00 37203 S 1,194.68 0.00 0.00<br />

36561 S 844.75 0.00 0.00 37500 S 1,126.77 0.00 0.00<br />

36563 S 844.75 0.00 0.00 37607 S 796.84 0.00 0.00<br />

36565 S 844.75 0.00 0.00 37609 S 535.58 0.00 0.00<br />

36566 S 844.75 0.00 0.00 37650 S 765.78 0.00 0.00<br />

36568 S 383.74 0.00 0.00 37700 S 765.78 0.00 0.00<br />

36569 S 383.74 0.00 0.00 37718 S 796.84 0.00 0.00<br />

36570 S 747.71 0.00 0.00 37722 S 1,126.77 0.00 0.00<br />

36571 S 747.71 0.00 0.00 37735 S 1,126.77 0.00 0.00<br />

36575 S 308.64 0.00 0.00 37760 S 796.84 0.00 0.00<br />

36576 S 438.56 0.00 0.00 37765 S 1,098.85 0.00 0.00<br />

36578 S 716.67 0.00 0.00 37766 S 1,098.85 0.00 0.00<br />

36580 S 383.74 0.00 0.00 37780 S 796.84 0.00 0.00<br />

36581 S 716.67 0.00 0.00 37785 S 796.84 0.00 0.00<br />

36582 S 844.75 0.00 0.00 37790 S 961.54 0.00 0.00<br />

36583 S 844.75 0.00 0.00 38205 S 461.86 0.00 0.00<br />

36584 S 383.74 0.00 0.00 38206 S 461.86 0.00 0.00<br />

36585 S 747.71 0.00 0.00 38220 S 105.87 0.00 0.00<br />

36589 S 253.82 0.00 0.00 38221 S 110.89 0.00 0.00<br />

36590 S 383.74 0.00 0.00 38230 S 1,236.40 0.00 0.00<br />

36593 S 25.48 0.00 0.00 38241 S 1,236.40 0.00 0.00<br />

36595 S 1,000.61 0.00 0.00 38242 S 461.86 0.00 0.00<br />

36596 S 444.39 0.00 0.00 38300 S 414.46 0.00 0.00<br />

36597 S 444.39 0.00 0.00 38305 S 605.67 0.00 0.00<br />

36598 S 82.18 0.00 0.00 38308 S 692.05 0.00 0.00<br />

36640 S 758.88 0.00 0.00 38500 S 692.05 0.00 0.00<br />

36680 S 57.52 0.00 0.00 38505 S 264.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 692.05 0.00 0.00 41005 S 139.52 0.00 0.00<br />

38520 S 692.05 0.00 0.00 41006 S 658.64 0.00 0.00<br />

38525 S 692.05 0.00 0.00 41007 S 507.73 0.00 0.00<br />

38530 S 692.05 0.00 0.00 41008 S 507.73 0.00 0.00<br />

38542 S 1,164.28 0.00 0.00 41009 S 139.52 0.00 0.00<br />

38550 S 723.11 0.00 0.00 41010 S 312.81 0.00 0.00<br />

38555 S 781.31 0.00 0.00 41015 S 139.52 0.00 0.00<br />

38570 S 1,579.75 0.00 0.00 41016 S 312.81 0.00 0.00<br />

38571 S 2,053.64 0.00 0.00 41017 S 312.81 0.00 0.00<br />

38572 S 1,579.75 0.00 0.00 41018 S 312.81 0.00 0.00<br />

38700 S 951.39 0.00 0.00 41019 S 994.20 0.00 0.00<br />

38740 S 1,164.28 0.00 0.00 41100 S 93.66 0.00 0.00<br />

38745 S 1,253.54 0.00 0.00 41105 S 92.58 0.00 0.00<br />

38760 S 692.05 0.00 0.00 41108 S 85.77 0.00 0.00<br />

40490 S 70.69 0.00 0.00 41110 S 124.17 0.00 0.00<br />

40500 S 562.54 0.00 0.00 41112 S 562.54 0.00 0.00<br />

40510 S 713.45 0.00 0.00 41113 S 562.54 0.00 0.00<br />

40520 S 562.54 0.00 0.00 41114 S 713.45 0.00 0.00<br />

40525 S 713.45 0.00 0.00 41115 S 144.62 0.00 0.00<br />

40527 S 713.45 0.00 0.00 41116 S 507.73 0.00 0.00<br />

40530 S 713.45 0.00 0.00 41120 S 844.92 0.00 0.00<br />

40650 S 376.43 0.00 0.00 41250 S 95.42 0.00 0.00<br />

40652 S 376.43 0.00 0.00 41251 S 139.52 0.00 0.00<br />

40654 S 376.43 0.00 0.00 41252 S 367.62 0.00 0.00<br />

40700 S 1,323.53 0.00 0.00 41500 S 658.64 0.00 0.00<br />

40701 S 1,323.53 0.00 0.00 41510 S 507.73 0.00 0.00<br />

40702 S 1,681.68 0.00 0.00 41520 S 367.62 0.00 0.00<br />

40720 S 1,323.53 0.00 0.00 41530 S 692.37 0.00 0.00<br />

40761 S 1,088.25 0.00 0.00 41800 S 71.28 0.00 0.00<br />

40800 S 56.73 0.00 0.00 41805 S 154.31 0.00 0.00<br />

40801 S 367.62 0.00 0.00 41806 S 190.19 0.00 0.00<br />

40804 S 25.95 0.00 0.00 41820 S 302.53 0.00 0.00<br />

40805 S 175.49 0.00 0.00 41821 S 302.53 0.00 0.00<br />

40806 S 80.74 0.00 0.00 41822 S 157.54 0.00 0.00<br />

40808 S 119.86 0.00 0.00 41823 S 229.68 0.00 0.00<br />

40810 S 124.17 0.00 0.00 41825 S 126.32 0.00 0.00<br />

40812 S 155.75 0.00 0.00 41826 S 158.98 0.00 0.00<br />

40814 S 562.54 0.00 0.00 41827 S 713.45 0.00 0.00<br />

40816 S 713.45 0.00 0.00 41828 S 143.55 0.00 0.00<br />

40818 S 139.52 0.00 0.00 41830 S 203.84 0.00 0.00<br />

40819 S 312.81 0.00 0.00 41850 S 692.37 0.00 0.00<br />

40820 S 179.07 0.00 0.00 41870 S 994.20 0.00 0.00<br />

40830 S 132.81 0.00 0.00 41872 S 203.84 0.00 0.00<br />

40831 S 312.81 0.00 0.00 41874 S 196.65 0.00 0.00<br />

40840 S 713.45 0.00 0.00 42000 S 139.52 0.00 0.00<br />

40842 S 744.51 0.00 0.00 42100 S 79.67 0.00 0.00<br />

40843 S 744.51 0.00 0.00 42104 S 118.42 0.00 0.00<br />

40844 S 1,188.67 0.00 0.00 42106 S 148.57 0.00 0.00<br />

40845 S 1,188.67 0.00 0.00 42107 S 713.45 0.00 0.00<br />

41000 S 89.00 0.00 0.00 42120 S 1,146.46 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 367.62 0.00 0.00 42809 S 25.95 0.00 0.00<br />

42145 S 844.92 0.00 0.00 42810 S 744.51 0.00 0.00<br />

42160 S 140.67 0.00 0.00 42815 S 1,188.67 0.00 0.00<br />

42180 S 139.52 0.00 0.00 42820 S 744.51 0.00 0.00<br />

42182 S 1,057.20 0.00 0.00 42821 S 844.92 0.00 0.00<br />

42200 S 1,188.67 0.00 0.00 42825 S 802.72 0.00 0.00<br />

42205 S 1,188.67 0.00 0.00 42826 S 802.72 0.00 0.00<br />

42210 S 1,188.67 0.00 0.00 42830 S 802.72 0.00 0.00<br />

42215 S 1,323.53 0.00 0.00 42831 S 802.72 0.00 0.00<br />

42220 S 1,188.67 0.00 0.00 42835 S 802.72 0.00 0.00<br />

42226 S 1,188.67 0.00 0.00 42836 S 802.72 0.00 0.00<br />

42235 S 694.01 0.00 0.00 42860 S 744.51 0.00 0.00<br />

42260 S 802.72 0.00 0.00 42870 S 744.51 0.00 0.00<br />

42280 S 77.51 0.00 0.00 42890 S 1,323.53 0.00 0.00<br />

42281 S 692.37 0.00 0.00 42892 S 1,323.53 0.00 0.00<br />

42300 S 507.73 0.00 0.00 42900 S 312.81 0.00 0.00<br />

42305 S 562.54 0.00 0.00 42950 S 713.45 0.00 0.00<br />

42310 S 139.52 0.00 0.00 42955 S 713.45 0.00 0.00<br />

42320 S 139.52 0.00 0.00 42960 S 57.47 0.00 0.00<br />

42330 S 119.86 0.00 0.00 42962 S 1,057.20 0.00 0.00<br />

42335 S 198.81 0.00 0.00 42970 S 44.62 0.00 0.00<br />

42340 S 562.54 0.00 0.00 42972 S 593.60 0.00 0.00<br />

42400 S 67.47 0.00 0.00 43030 S 692.37 0.00 0.00<br />

42405 S 562.54 0.00 0.00 43200 S 335.29 0.00 0.00<br />

42408 S 593.60 0.00 0.00 43201 S 335.29 0.00 0.00<br />

42409 S 593.60 0.00 0.00 43202 S 335.29 0.00 0.00<br />

42410 S 1,088.25 0.00 0.00 43204 S 335.29 0.00 0.00<br />

42415 S 1,323.53 0.00 0.00 43205 S 335.29 0.00 0.00<br />

42420 S 1,323.53 0.00 0.00 43215 S 335.29 0.00 0.00<br />

42425 S 1,323.53 0.00 0.00 43216 S 335.29 0.00 0.00<br />

42440 S 1,088.25 0.00 0.00 43217 S 335.29 0.00 0.00<br />

42450 S 713.45 0.00 0.00 43219 S 677.61 0.00 0.00<br />

42500 S 744.51 0.00 0.00 43220 S 335.29 0.00 0.00<br />

42505 S 1,146.46 0.00 0.00 43226 S 335.29 0.00 0.00<br />

42507 S 1,088.25 0.00 0.00 43227 S 390.11 0.00 0.00<br />

42508 S 1,146.46 0.00 0.00 43228 S 725.96 0.00 0.00<br />

42509 S 1,146.46 0.00 0.00 43231 S 390.11 0.00 0.00<br />

42510 S 1,146.46 0.00 0.00 43232 S 390.11 0.00 0.00<br />

42600 S 507.73 0.00 0.00 43234 S 335.29 0.00 0.00<br />

42650 S 44.14 0.00 0.00 43235 S 335.29 0.00 0.00<br />

42660 S 51.68 0.00 0.00 43236 S 390.11 0.00 0.00<br />

42665 S 979.79 0.00 0.00 43237 S 390.11 0.00 0.00<br />

42700 S 139.52 0.00 0.00 43238 S 390.11 0.00 0.00<br />

42720 S 507.73 0.00 0.00 43239 S 390.11 0.00 0.00<br />

42725 S 1,057.20 0.00 0.00 43240 S 390.11 0.00 0.00<br />

42800 S 85.41 0.00 0.00 43241 S 390.11 0.00 0.00<br />

42802 S 507.73 0.00 0.00 43242 S 390.11 0.00 0.00<br />

42804 S 507.73 0.00 0.00 43243 S 390.11 0.00 0.00<br />

42806 S 713.45 0.00 0.00 43244 S 390.11 0.00 0.00<br />

42808 S 562.54 0.00 0.00 43245 S 390.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 390.11 0.00 0.00 44378 S 408.58 0.00 0.00<br />

43247 S 390.11 0.00 0.00 44379 S 1,165.64 0.00 0.00<br />

43248 S 390.11 0.00 0.00 44380 S 353.75 0.00 0.00<br />

43249 S 390.11 0.00 0.00 44382 S 353.75 0.00 0.00<br />

43250 S 390.11 0.00 0.00 44383 S 1,165.64 0.00 0.00<br />

43251 S 390.11 0.00 0.00 44385 S 342.03 0.00 0.00<br />

43255 S 390.11 0.00 0.00 44386 S 342.03 0.00 0.00<br />

43256 S 763.48 0.00 0.00 44388 S 342.03 0.00 0.00<br />

43257 S 757.02 0.00 0.00 44389 S 342.03 0.00 0.00<br />

43258 S 421.15 0.00 0.00 44390 S 342.03 0.00 0.00<br />

43259 S 421.15 0.00 0.00 44391 S 342.03 0.00 0.00<br />

43260 S 656.75 0.00 0.00 44392 S 342.03 0.00 0.00<br />

43261 S 656.75 0.00 0.00 44393 S 342.03 0.00 0.00<br />

43262 S 656.75 0.00 0.00 44394 S 342.03 0.00 0.00<br />

43263 S 656.75 0.00 0.00 44397 S 677.61 0.00 0.00<br />

43264 S 656.75 0.00 0.00 44500 S 184.57 0.00 0.00<br />

43265 S 656.75 0.00 0.00 45000 S 396.65 0.00 0.00<br />

43267 S 656.75 0.00 0.00 45005 S 461.62 0.00 0.00<br />

43268 S 732.44 0.00 0.00 45020 S 461.62 0.00 0.00<br />

43269 S 732.44 0.00 0.00 45100 S 627.16 0.00 0.00<br />

43271 S 656.75 0.00 0.00 45108 S 681.97 0.00 0.00<br />

43272 S 656.75 0.00 0.00 45150 S 681.97 0.00 0.00<br />

43273 S 880.78 0.00 0.00 45160 S 681.97 0.00 0.00<br />

43450 S 293.23 0.00 0.00 45170 S 681.97 0.00 0.00<br />

43453 S 293.23 0.00 0.00 45190 S 1,115.18 0.00 0.00<br />

43456 S 294.39 0.00 0.00 45300 S 66.03 0.00 0.00<br />

43458 S 336.46 0.00 0.00 45303 S 366.77 0.00 0.00<br />

43600 S 335.29 0.00 0.00 45305 S 344.93 0.00 0.00<br />

43653 S 1,579.75 0.00 0.00 45307 S 637.10 0.00 0.00<br />

43760 S 162.61 0.00 0.00 45308 S 344.93 0.00 0.00<br />

43761 S 335.29 0.00 0.00 45309 S 344.93 0.00 0.00<br />

43870 S 335.29 0.00 0.00 45315 S 344.93 0.00 0.00<br />

43886 S 846.01 0.00 0.00 45317 S 344.93 0.00 0.00<br />

43887 S 177.94 0.00 0.00 45320 S 637.10 0.00 0.00<br />

43888 S 846.01 0.00 0.00 45321 S 637.10 0.00 0.00<br />

44100 S 335.29 0.00 0.00 45327 S 677.61 0.00 0.00<br />

44312 S 584.54 0.00 0.00 45330 S 87.20 0.00 0.00<br />

44340 S 670.41 0.00 0.00 45331 S 257.87 0.00 0.00<br />

44360 S 408.58 0.00 0.00 45332 S 257.87 0.00 0.00<br />

44361 S 408.58 0.00 0.00 45333 S 344.93 0.00 0.00<br />

44363 S 408.58 0.00 0.00 45334 S 344.93 0.00 0.00<br />

44364 S 408.58 0.00 0.00 45335 S 257.87 0.00 0.00<br />

44365 S 408.58 0.00 0.00 45337 S 257.87 0.00 0.00<br />

44366 S 408.58 0.00 0.00 45338 S 344.93 0.00 0.00<br />

44369 S 408.58 0.00 0.00 45339 S 344.93 0.00 0.00<br />

44370 S 1,165.64 0.00 0.00 45340 S 344.93 0.00 0.00<br />

44372 S 408.58 0.00 0.00 45341 S 344.93 0.00 0.00<br />

44373 S 408.58 0.00 0.00 45342 S 344.93 0.00 0.00<br />

44376 S 408.58 0.00 0.00 45345 S 677.61 0.00 0.00<br />

44377 S 408.58 0.00 0.00 45355 S 342.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 396.86 0.00 0.00 46505 S 490.52 0.00 0.00<br />

45379 S 396.86 0.00 0.00 46600 S 25.95 0.00 0.00<br />

45380 S 396.86 0.00 0.00 46604 S 366.77 0.00 0.00<br />

45381 S 396.86 0.00 0.00 46606 S 137.81 0.00 0.00<br />

45382 S 396.86 0.00 0.00 46608 S 344.93 0.00 0.00<br />

45383 S 396.86 0.00 0.00 46610 S 637.10 0.00 0.00<br />

45384 S 396.86 0.00 0.00 46611 S 344.93 0.00 0.00<br />

45385 S 396.86 0.00 0.00 46612 S 637.10 0.00 0.00<br />

45386 S 396.86 0.00 0.00 46614 S 72.49 0.00 0.00<br />

45387 S 677.61 0.00 0.00 46615 S 691.91 0.00 0.00<br />

45391 S 396.86 0.00 0.00 46700 S 713.03 0.00 0.00<br />

45392 S 396.86 0.00 0.00 46706 S 784.83 0.00 0.00<br />

45500 S 681.97 0.00 0.00 46750 S 870.69 0.00 0.00<br />

45505 S 839.65 0.00 0.00 46753 S 713.03 0.00 0.00<br />

45520 S 33.25 0.00 0.00 46754 S 681.97 0.00 0.00<br />

45560 S 839.65 0.00 0.00 46760 S 839.65 0.00 0.00<br />

45900 S 268.90 0.00 0.00 46761 S 870.69 0.00 0.00<br />

45905 S 627.16 0.00 0.00 46762 S 1,105.97 0.00 0.00<br />

45910 S 627.16 0.00 0.00 46900 S 109.59 0.00 0.00<br />

45915 S 396.65 0.00 0.00 46910 S 130.98 0.00 0.00<br />

45990 S 617.00 0.00 0.00 46916 S 60.92 0.00 0.00<br />

46020 S 713.03 0.00 0.00 46917 S 568.32 0.00 0.00<br />

46030 S 268.90 0.00 0.00 46922 S 568.32 0.00 0.00<br />

46040 S 713.03 0.00 0.00 46924 S 568.32 0.00 0.00<br />

46045 S 681.97 0.00 0.00 46930 S 127.04 0.00 0.00<br />

46050 S 396.65 0.00 0.00 46937 S 681.97 0.00 0.00<br />

46060 S 681.97 0.00 0.00 46938 S 839.65 0.00 0.00<br />

46070 S 490.52 0.00 0.00 46940 S 94.02 0.00 0.00<br />

46080 S 713.03 0.00 0.00 46942 S 91.51 0.00 0.00<br />

46083 S 75.08 0.00 0.00 46945 S 155.75 0.00 0.00<br />

46200 S 681.97 0.00 0.00 46946 S 406.80 0.00 0.00<br />

46210 S 681.97 0.00 0.00 46947 S 1,105.97 0.00 0.00<br />

46211 S 681.97 0.00 0.00 47000 S 353.88 0.00 0.00<br />

46220 S 627.16 0.00 0.00 47382 S 1,867.52 0.00 0.00<br />

46221 S 123.45 0.00 0.00 47510 S 827.04 0.00 0.00<br />

46230 S 627.16 0.00 0.00 47511 S 1,215.05 0.00 0.00<br />

46250 S 713.03 0.00 0.00 47525 S 474.78 0.00 0.00<br />

46255 S 713.03 0.00 0.00 47530 S 474.78 0.00 0.00<br />

46257 S 713.03 0.00 0.00 47552 S 827.04 0.00 0.00<br />

46258 S 713.03 0.00 0.00 47553 S 858.09 0.00 0.00<br />

46260 S 713.03 0.00 0.00 47554 S 858.09 0.00 0.00<br />

46261 S 771.23 0.00 0.00 47555 S 858.09 0.00 0.00<br />

46262 S 771.23 0.00 0.00 47556 S 1,215.05 0.00 0.00<br />

46270 S 713.03 0.00 0.00 47560 S 1,008.22 0.00 0.00<br />

46275 S 713.03 0.00 0.00 47561 S 1,008.22 0.00 0.00<br />

46280 S 771.23 0.00 0.00 47562 S 1,860.38 0.00 0.00<br />

46285 S 627.16 0.00 0.00 47563 S 1,860.38 0.00 0.00<br />

46288 S 771.23 0.00 0.00 47564 S 1,860.38 0.00 0.00<br />

46320 S 83.62 0.00 0.00 47630 S 858.09 0.00 0.00<br />

46500 S 115.19 0.00 0.00 48102 S 353.88 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 215.19 0.00 0.00 49590 S 883.21 0.00 0.00<br />

49081 S 215.19 0.00 0.00 49600 S 941.42 0.00 0.00<br />

49180 S 353.88 0.00 0.00 49650 S 1,235.81 0.00 0.00<br />

49250 S 775.72 0.00 0.00 49651 S 1,412.88 0.00 0.00<br />

49320 S 1,008.22 0.00 0.00 49652 S 1,521.63 0.00 0.00<br />

49321 S 1,066.44 0.00 0.00 49653 S 1,521.63 0.00 0.00<br />

49322 S 1,066.44 0.00 0.00 49654 S 1,521.63 0.00 0.00<br />

49324 S 1,521.63 0.00 0.00 49655 S 1,521.63 0.00 0.00<br />

49325 S 1,521.63 0.00 0.00 49656 S 1,521.63 0.00 0.00<br />

49326 S 1,521.63 0.00 0.00 49657 S 1,521.63 0.00 0.00<br />

49402 S 686.46 0.00 0.00 50200 S 353.88 0.00 0.00<br />

49419 S 823.50 0.00 0.00 50382 S 1,027.60 0.00 0.00<br />

49420 S 761.27 0.00 0.00 50384 S 754.75 0.00 0.00<br />

49421 S 761.27 0.00 0.00 50385 S 754.75 0.00 0.00<br />

49422 S 605.86 0.00 0.00 50386 S 289.57 0.00 0.00<br />

49423 S 626.48 0.00 0.00 50387 S 626.48 0.00 0.00<br />

49426 S 686.46 0.00 0.00 50389 S 289.57 0.00 0.00<br />

49429 S 888.63 0.00 0.00 50390 S 353.88 0.00 0.00<br />

49440 S 347.49 0.00 0.00 50391 S 41.91 0.00 0.00<br />

49441 S 347.49 0.00 0.00 50392 S 538.91 0.00 0.00<br />

49446 S 347.49 0.00 0.00 50393 S 675.34 0.00 0.00<br />

49450 S 184.57 0.00 0.00 50395 S 538.91 0.00 0.00<br />

49451 S 184.57 0.00 0.00 50396 S 101.33 0.00 0.00<br />

49452 S 184.57 0.00 0.00 50398 S 474.78 0.00 0.00<br />

49460 S 184.57 0.00 0.00 50551 S 306.33 0.00 0.00<br />

49495 S 941.42 0.00 0.00 50553 S 675.34 0.00 0.00<br />

49496 S 941.42 0.00 0.00 50555 S 306.33 0.00 0.00<br />

49500 S 941.42 0.00 0.00 50557 S 675.34 0.00 0.00<br />

49501 S 1,285.36 0.00 0.00 50561 S 675.34 0.00 0.00<br />

49505 S 941.42 0.00 0.00 50562 S 289.57 0.00 0.00<br />

49507 S 1,285.36 0.00 0.00 50570 S 289.57 0.00 0.00<br />

49520 S 1,118.49 0.00 0.00 50572 S 289.57 0.00 0.00<br />

49521 S 1,285.36 0.00 0.00 50574 S 289.57 0.00 0.00<br />

49525 S 941.42 0.00 0.00 50575 S 1,440.40 0.00 0.00<br />

49540 S 852.16 0.00 0.00 50576 S 754.75 0.00 0.00<br />

49550 S 983.63 0.00 0.00 50580 S 754.75 0.00 0.00<br />

49553 S 1,285.36 0.00 0.00 50590 S 1,682.72 0.00 0.00<br />

49555 S 983.63 0.00 0.00 50592 S 1,867.52 0.00 0.00<br />

49557 S 1,285.36 0.00 0.00 50686 S 41.91 0.00 0.00<br />

49560 S 941.42 0.00 0.00 50688 S 474.78 0.00 0.00<br />

49561 S 1,285.36 0.00 0.00 50947 S 1,579.75 0.00 0.00<br />

49565 S 941.42 0.00 0.00 50948 S 1,579.75 0.00 0.00<br />

49566 S 1,285.36 0.00 0.00 50951 S 306.33 0.00 0.00<br />

49568 S 1,118.49 0.00 0.00 50953 S 306.33 0.00 0.00<br />

49570 S 941.42 0.00 0.00 50955 S 675.34 0.00 0.00<br />

49572 S 1,285.36 0.00 0.00 50957 S 675.34 0.00 0.00<br />

49580 S 941.42 0.00 0.00 50961 S 675.34 0.00 0.00<br />

49582 S 1,285.36 0.00 0.00 50970 S 306.33 0.00 0.00<br />

49585 S 941.42 0.00 0.00 50972 S 306.33 0.00 0.00<br />

49587 S 1,285.36 0.00 0.00 50974 S 538.91 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 538.91 0.00 0.00 52275 S 730.16 0.00 0.00<br />

50980 S 675.34 0.00 0.00 52276 S 761.20 0.00 0.00<br />

51020 S 819.42 0.00 0.00 52277 S 730.16 0.00 0.00<br />

51030 S 819.42 0.00 0.00 52281 S 593.73 0.00 0.00<br />

51040 S 819.42 0.00 0.00 52282 S 1,369.77 0.00 0.00<br />

51045 S 338.46 0.00 0.00 52283 S 730.16 0.00 0.00<br />

51050 S 819.42 0.00 0.00 52285 S 593.73 0.00 0.00<br />

51065 S 819.42 0.00 0.00 52290 S 593.73 0.00 0.00<br />

51080 S 550.84 0.00 0.00 52300 S 730.16 0.00 0.00<br />

51100 S 31.94 0.00 0.00 52301 S 761.20 0.00 0.00<br />

51101 S 41.91 0.00 0.00 52305 S 730.16 0.00 0.00<br />

51102 S 563.84 0.00 0.00 52310 S 571.04 0.00 0.00<br />

51500 S 941.42 0.00 0.00 52315 S 730.16 0.00 0.00<br />

51520 S 819.42 0.00 0.00 52317 S 675.34 0.00 0.00<br />

51700 S 54.55 0.00 0.00 52318 S 730.16 0.00 0.00<br />

51701 S 25.95 0.00 0.00 52320 S 861.62 0.00 0.00<br />

51702 S 25.95 0.00 0.00 52325 S 819.42 0.00 0.00<br />

51703 S 41.91 0.00 0.00 52327 S 936.56 0.00 0.00<br />

51705 S 75.08 0.00 0.00 52330 S 730.16 0.00 0.00<br />

51710 S 474.78 0.00 0.00 52332 S 730.16 0.00 0.00<br />

51715 S 862.07 0.00 0.00 52334 S 761.20 0.00 0.00<br />

51720 S 60.29 0.00 0.00 52341 S 761.20 0.00 0.00<br />

51725 TC S 115.82 0.00 0.00 52342 S 761.20 0.00 0.00<br />

51726 TC S 159.53 0.00 0.00 52343 S 761.20 0.00 0.00<br />

51736 TC S 21.89 0.00 0.00 52344 S 761.20 0.00 0.00<br />

51741 TC S 25.48 0.00 0.00 52345 S 761.20 0.00 0.00<br />

51772 TC S 101.33 0.00 0.00 52346 S 761.20 0.00 0.00<br />

51784 TC S 41.91 0.00 0.00 52351 S 761.20 0.00 0.00<br />

51785 TC S 70.01 0.00 0.00 52352 S 819.42 0.00 0.00<br />

51792 TC S 41.91 0.00 0.00 52353 S 1,025.83 0.00 0.00<br />

51795 TC S 75.08 0.00 0.00 52354 S 819.42 0.00 0.00<br />

51797 TC S 75.08 0.00 0.00 52355 S 819.42 0.00 0.00<br />

51798 S 18.66 0.00 0.00 52400 S 761.20 0.00 0.00<br />

51880 S 675.34 0.00 0.00 52402 S 761.20 0.00 0.00<br />

51992 S 1,278.02 0.00 0.00 52450 S 761.20 0.00 0.00<br />

52000 S 306.33 0.00 0.00 52500 S 761.20 0.00 0.00<br />

52001 S 571.04 0.00 0.00 52601 S 1,025.83 0.00 0.00<br />

52005 S 593.73 0.00 0.00 52630 S 936.56 0.00 0.00<br />

52007 S 730.16 0.00 0.00 52640 S 730.16 0.00 0.00<br />

52010 S 338.46 0.00 0.00 52647 S 1,569.41 0.00 0.00<br />

52204 S 593.73 0.00 0.00 52648 S 1,569.41 0.00 0.00<br />

52214 S 730.16 0.00 0.00 52700 S 730.16 0.00 0.00<br />

52224 S 730.16 0.00 0.00 53000 S 560.39 0.00 0.00<br />

52234 S 730.16 0.00 0.00 53010 S 560.39 0.00 0.00<br />

52235 S 761.20 0.00 0.00 53020 S 560.39 0.00 0.00<br />

52240 S 761.20 0.00 0.00 53025 S 797.70 0.00 0.00<br />

52250 S 819.42 0.00 0.00 53040 S 615.22 0.00 0.00<br />

52260 S 593.73 0.00 0.00 53060 S 72.85 0.00 0.00<br />

52265 S 289.57 0.00 0.00 53080 S 646.26 0.00 0.00<br />

52270 S 593.73 0.00 0.00 53085 S 797.70 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 560.39 0.00 0.00 54060 S 568.32 0.00 0.00<br />

53210 S 962.48 0.00 0.00 54065 S 568.32 0.00 0.00<br />

53215 S 746.68 0.00 0.00 54100 S 480.76 0.00 0.00<br />

53220 S 831.01 0.00 0.00 54105 S 600.15 0.00 0.00<br />

53230 S 831.01 0.00 0.00 54110 S 930.49 0.00 0.00<br />

53235 S 646.26 0.00 0.00 54111 S 930.49 0.00 0.00<br />

53240 S 831.01 0.00 0.00 54112 S 930.49 0.00 0.00<br />

53250 S 615.22 0.00 0.00 54115 S 550.84 0.00 0.00<br />

53260 S 615.22 0.00 0.00 54120 S 930.49 0.00 0.00<br />

53265 S 615.22 0.00 0.00 54150 S 620.12 0.00 0.00<br />

53270 S 615.22 0.00 0.00 54160 S 674.95 0.00 0.00<br />

53275 S 615.22 0.00 0.00 54161 S 674.95 0.00 0.00<br />

53400 S 862.07 0.00 0.00 54162 S 674.95 0.00 0.00<br />

53405 S 831.01 0.00 0.00 54163 S 674.95 0.00 0.00<br />

53410 S 831.01 0.00 0.00 54164 S 674.95 0.00 0.00<br />

53420 S 862.07 0.00 0.00 54200 S 70.69 0.00 0.00<br />

53425 S 831.01 0.00 0.00 54205 S 1,019.76 0.00 0.00<br />

53430 S 831.01 0.00 0.00 54220 S 101.33 0.00 0.00<br />

53431 S 831.01 0.00 0.00 54231 S 66.39 0.00 0.00<br />

53440 S 4,786.97 2,907.35 1,027.73 54235 S 47.01 0.00 0.00<br />

53442 S 776.20 0.00 0.00 54240 TC S 33.37 0.00 0.00<br />

53444 S 4,786.97 2,907.35 1,027.73 54250 TC S 11.84 0.00 0.00<br />

53445 S 8,040.90 4,579.24 1,117.58 54300 S 961.54 0.00 0.00<br />

53446 S 776.20 0.00 0.00 54304 S 961.54 0.00 0.00<br />

53447 S 8,040.90 4,579.24 1,117.58 54308 S 961.54 0.00 0.00<br />

53449 S 776.20 0.00 0.00 54312 S 961.54 0.00 0.00<br />

53450 S 776.20 0.00 0.00 54316 S 961.54 0.00 0.00<br />

53460 S 560.39 0.00 0.00 54318 S 961.54 0.00 0.00<br />

53502 S 615.22 0.00 0.00 54322 S 961.54 0.00 0.00<br />

53505 S 831.01 0.00 0.00 54324 S 961.54 0.00 0.00<br />

53510 S 615.22 0.00 0.00 54326 S 961.54 0.00 0.00<br />

53515 S 831.01 0.00 0.00 54328 S 961.54 0.00 0.00<br />

53520 S 831.01 0.00 0.00 54340 S 961.54 0.00 0.00<br />

53600 S 41.99 0.00 0.00 54344 S 961.54 0.00 0.00<br />

53601 S 41.91 0.00 0.00 54348 S 961.54 0.00 0.00<br />

53605 S 593.73 0.00 0.00 54352 S 961.54 0.00 0.00<br />

53620 S 64.60 0.00 0.00 54360 S 961.54 0.00 0.00<br />

53621 S 67.83 0.00 0.00 54380 S 961.54 0.00 0.00<br />

53660 S 41.91 0.00 0.00 54385 S 961.54 0.00 0.00<br />

53661 S 41.91 0.00 0.00 54400 S 4,818.03 2,938.40 1,058.78<br />

53665 S 560.39 0.00 0.00 54401 S 8,126.77 4,665.11 1,203.45<br />

53850 S 1,839.71 0.00 0.00 54405 S 8,126.77 4,665.11 1,203.45<br />

53852 S 1,839.71 0.00 0.00 54406 S 961.54 0.00 0.00<br />

54000 S 615.22 0.00 0.00 54408 S 961.54 0.00 0.00<br />

54001 S 615.22 0.00 0.00 54410 S 8,126.77 4,665.11 1,203.45<br />

54015 S 694.93 0.00 0.00 54415 S 961.54 0.00 0.00<br />

54050 S 33.25 0.00 0.00 54416 S 8,126.77 4,665.11 1,203.45<br />

54055 S 67.83 0.00 0.00 54420 S 1,019.76 0.00 0.00<br />

54056 S 33.25 0.00 0.00 54435 S 1,019.76 0.00 0.00<br />

54057 S 568.32 0.00 0.00 54440 S 1,019.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 159.53 0.00 0.00 55706 S 463.76 0.00 0.00<br />

54500 S 432.97 0.00 0.00 55720 S 675.34 0.00 0.00<br />

54505 S 620.12 0.00 0.00 55725 S 730.16 0.00 0.00<br />

54512 S 674.95 0.00 0.00 55860 S 804.60 0.00 0.00<br />

54520 S 705.99 0.00 0.00 55870 S 81.82 0.00 0.00<br />

54522 S 705.99 0.00 0.00 55873 S 6,366.28 0.00 0.00<br />

54530 S 941.42 0.00 0.00 55875 S 1,369.77 0.00 0.00<br />

54550 S 941.42 0.00 0.00 55876 S 75.00 0.00 0.00<br />

54560 S 917.17 0.00 0.00 55920 S 940.22 0.00 0.00<br />

54600 S 764.21 0.00 0.00 56405 S 43.78 0.00 0.00<br />

54620 S 705.99 0.00 0.00 56420 S 57.14 0.00 0.00<br />

54640 S 941.42 0.00 0.00 56440 S 613.63 0.00 0.00<br />

54660 S 674.95 0.00 0.00 56441 S 558.80 0.00 0.00<br />

54670 S 705.99 0.00 0.00 56442 S 558.80 0.00 0.00<br />

54680 S 705.99 0.00 0.00 56501 S 60.29 0.00 0.00<br />

54690 S 1,579.75 0.00 0.00 56515 S 654.19 0.00 0.00<br />

54692 S 2,808.16 0.00 0.00 56605 S 34.81 0.00 0.00<br />

54700 S 674.95 0.00 0.00 56606 S 14.36 0.00 0.00<br />

54800 S 151.50 0.00 0.00 56620 S 745.09 0.00 0.00<br />

54830 S 705.99 0.00 0.00 56625 S 879.95 0.00 0.00<br />

54840 S 764.21 0.00 0.00 56700 S 558.80 0.00 0.00<br />

54860 S 705.99 0.00 0.00 56740 S 644.67 0.00 0.00<br />

54861 S 764.21 0.00 0.00 56800 S 644.67 0.00 0.00<br />

54865 S 620.12 0.00 0.00 56805 S 794.53 0.00 0.00<br />

54900 S 764.21 0.00 0.00 56810 S 745.09 0.00 0.00<br />

54901 S 764.21 0.00 0.00 56820 S 44.50 0.00 0.00<br />

55000 S 68.90 0.00 0.00 56821 S 57.14 0.00 0.00<br />

55040 S 883.21 0.00 0.00 57000 S 558.80 0.00 0.00<br />

55041 S 983.63 0.00 0.00 57010 S 613.63 0.00 0.00<br />

55060 S 764.21 0.00 0.00 57020 S 321.81 0.00 0.00<br />

55100 S 414.46 0.00 0.00 57022 S 505.84 0.00 0.00<br />

55110 S 674.95 0.00 0.00 57023 S 550.84 0.00 0.00<br />

55120 S 674.95 0.00 0.00 57061 S 55.62 0.00 0.00<br />

55150 S 620.12 0.00 0.00 57065 S 558.80 0.00 0.00<br />

55175 S 620.12 0.00 0.00 57100 S 35.53 0.00 0.00<br />

55180 S 674.95 0.00 0.00 57105 S 613.63 0.00 0.00<br />

55200 S 674.95 0.00 0.00 57130 S 613.63 0.00 0.00<br />

55250 S 674.95 0.00 0.00 57135 S 613.63 0.00 0.00<br />

55400 S 620.12 0.00 0.00 57150 S 25.84 0.00 0.00<br />

55450 S 221.78 0.00 0.00 57155 S 321.81 0.00 0.00<br />

55500 S 705.99 0.00 0.00 57160 S 37.32 0.00 0.00<br />

55520 S 764.21 0.00 0.00 57170 S 6.12 0.00 0.00<br />

55530 S 764.21 0.00 0.00 57180 S 114.94 0.00 0.00<br />

55535 S 941.42 0.00 0.00 57200 S 558.80 0.00 0.00<br />

55540 S 983.63 0.00 0.00 57210 S 613.63 0.00 0.00<br />

55550 S 1,579.75 0.00 0.00 57220 S 1,125.31 0.00 0.00<br />

55600 S 917.17 0.00 0.00 57230 S 923.98 0.00 0.00<br />

55680 S 620.12 0.00 0.00 57240 S 1,024.39 0.00 0.00<br />

55700 S 399.64 0.00 0.00 57250 S 1,024.39 0.00 0.00<br />

55705 S 399.64 0.00 0.00 57260 S 1,024.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,360.58 0.00 0.00 58555 S 603.76 0.00 0.00<br />

57267 S 1,159.25 0.00 0.00 58558 S 689.62 0.00 0.00<br />

57268 S 923.98 0.00 0.00 58559 S 658.58 0.00 0.00<br />

57287 S 1,353.14 0.00 0.00 58560 S 983.31 0.00 0.00<br />

57288 S 1,225.72 0.00 0.00 58561 S 983.31 0.00 0.00<br />

57289 S 1,024.39 0.00 0.00 58562 S 689.62 0.00 0.00<br />

57291 S 1,024.39 0.00 0.00 58563 S 1,385.46 0.00 0.00<br />

57300 S 923.98 0.00 0.00 58565 S 1,527.46 0.00 0.00<br />

57320 S 1,353.14 0.00 0.00 58600 S 1,353.14 0.00 0.00<br />

57400 S 613.63 0.00 0.00 58615 S 794.53 0.00 0.00<br />

57410 S 613.63 0.00 0.00 58660 S 1,278.02 0.00 0.00<br />

57415 S 613.63 0.00 0.00 58661 S 1,278.02 0.00 0.00<br />

57420 S 45.94 0.00 0.00 58662 S 1,278.02 0.00 0.00<br />

57421 S 59.93 0.00 0.00 58670 S 1,177.60 0.00 0.00<br />

57452 S 43.42 0.00 0.00 58671 S 1,177.60 0.00 0.00<br />

57454 S 53.11 0.00 0.00 58672 S 1,278.02 0.00 0.00<br />

57455 S 56.34 0.00 0.00 58673 S 1,278.02 0.00 0.00<br />

57456 S 54.55 0.00 0.00 58800 S 644.67 0.00 0.00<br />

57460 S 167.59 0.00 0.00 58805 S 1,353.14 0.00 0.00<br />

57461 S 178.00 0.00 0.00 58820 S 923.98 0.00 0.00<br />

57500 S 76.79 0.00 0.00 58900 S 644.67 0.00 0.00<br />

57505 S 48.80 0.00 0.00 58970 S 179.57 0.00 0.00<br />

57510 S 49.52 0.00 0.00 58974 S 179.57 0.00 0.00<br />

57511 S 57.14 0.00 0.00 58976 S 179.57 0.00 0.00<br />

57513 S 613.63 0.00 0.00 59000 S 65.67 0.00 0.00<br />

57520 S 613.63 0.00 0.00 59001 S 246.50 0.00 0.00<br />

57522 S 613.63 0.00 0.00 59012 S 120.53 0.00 0.00<br />

57530 S 923.98 0.00 0.00 59015 S 53.11 0.00 0.00<br />

57550 S 923.98 0.00 0.00 59020 TC S 27.99 0.00 0.00<br />

57556 S 1,225.72 0.00 0.00 59025 TC S 14.72 0.00 0.00<br />

57558 S 644.67 0.00 0.00 59070 S 120.53 0.00 0.00<br />

57700 S 558.80 0.00 0.00 59072 S 120.53 0.00 0.00<br />

57720 S 644.67 0.00 0.00 59076 S 120.53 0.00 0.00<br />

57800 S 26.20 0.00 0.00 59100 S 1,353.14 0.00 0.00<br />

58100 S 43.06 0.00 0.00 59150 S 1,860.38 0.00 0.00<br />

58120 S 613.63 0.00 0.00 59151 S 1,860.38 0.00 0.00<br />

58145 S 1,024.39 0.00 0.00 59160 S 644.67 0.00 0.00<br />

58301 S 40.19 0.00 0.00 59200 S 35.89 0.00 0.00<br />

58321 S 37.68 0.00 0.00 59300 S 77.51 0.00 0.00<br />

58322 S 38.76 0.00 0.00 59320 S 558.80 0.00 0.00<br />

58323 S 8.97 0.00 0.00 59412 S 794.53 0.00 0.00<br />

58345 S 794.53 0.00 0.00 59414 S 794.53 0.00 0.00<br />

58346 S 613.63 0.00 0.00 59812 S 745.09 0.00 0.00<br />

58350 S 923.98 0.00 0.00 59820 S 745.09 0.00 0.00<br />

58353 S 1,159.25 0.00 0.00 59821 S 745.09 0.00 0.00<br />

58356 S 1,755.80 0.00 0.00 59840 S 745.09 0.00 0.00<br />

58545 S 1,410.38 0.00 0.00 59841 S 745.09 0.00 0.00<br />

58546 S 1,579.75 0.00 0.00 59866 S 120.53 0.00 0.00<br />

58550 S 2,053.64 0.00 0.00 59870 S 745.09 0.00 0.00<br />

58552 S 1,860.38 0.00 0.00 59871 S 745.09 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 312.81 0.00 0.00 62367 S 17.22 0.00 0.00<br />

60100 S 49.16 0.00 0.00 62368 S 21.89 0.00 0.00<br />

60200 S 1,164.28 0.00 0.00 63600 S 588.06 0.00 0.00<br />

60280 S 1,253.54 0.00 0.00 63610 S 533.24 0.00 0.00<br />

60281 S 1,253.54 0.00 0.00 63615 S 743.40 0.00 0.00<br />

60300 S 64.60 0.00 0.00 63650 S 3,165.24 1,962.77 760.30<br />

61000 S 288.03 0.00 0.00 63655 S 4,636.31 2,956.58 1,276.86<br />

61001 S 288.03 0.00 0.00 63660 S 555.88 0.00 0.00<br />

61020 S 233.20 0.00 0.00 63685 S 14,072.28 7,503.46 934.66<br />

61026 S 233.20 0.00 0.00 63688 S 754.84 0.00 0.00<br />

61050 S 233.20 0.00 0.00 63744 S 1,091.60 0.00 0.00<br />

61055 S 233.20 0.00 0.00 63746 S 504.95 0.00 0.00<br />

61070 S 181.46 0.00 0.00 64400 S 55.26 0.00 0.00<br />

61215 S 1,091.60 0.00 0.00 64402 S 52.04 0.00 0.00<br />

61330 S 1,681.68 0.00 0.00 64405 S 44.14 0.00 0.00<br />

61334 S 1,681.68 0.00 0.00 64408 S 54.90 0.00 0.00<br />

61790 S 619.11 0.00 0.00 64410 S 305.55 0.00 0.00<br />

61791 S 459.31 0.00 0.00 64412 S 80.74 0.00 0.00<br />

61880 S 788.67 0.00 0.00 64413 S 51.68 0.00 0.00<br />

61885 S 11,349.05 6,079.58 810.11 64415 S 140.72 0.00 0.00<br />

61886 S 16,946.90 8,932.00 917.10 64416 S 288.03 0.00 0.00<br />

61888 S 754.84 0.00 0.00 64417 S 140.72 0.00 0.00<br />

62194 S 305.55 0.00 0.00 64418 S 72.49 0.00 0.00<br />

62225 S 474.78 0.00 0.00 64420 S 140.72 0.00 0.00<br />

62230 S 1,060.55 0.00 0.00 64421 S 305.55 0.00 0.00<br />

62252 TC S 48.09 0.00 0.00 64425 S 50.24 0.00 0.00<br />

62263 S 305.55 0.00 0.00 64430 S 211.45 0.00 0.00<br />

62264 S 450.13 0.00 0.00 64435 S 75.72 0.00 0.00<br />

62267 S 179.63 0.00 0.00 64445 S 67.10 0.00 0.00<br />

62268 S 233.20 0.00 0.00 64446 S 577.18 0.00 0.00<br />

62269 S 353.88 0.00 0.00 64447 S 146.58 0.00 0.00<br />

62270 S 140.72 0.00 0.00 64448 S 146.58 0.00 0.00<br />

62272 S 140.72 0.00 0.00 64449 S 288.03 0.00 0.00<br />

62273 S 234.83 0.00 0.00 64450 S 44.85 0.00 0.00<br />

62280 S 305.55 0.00 0.00 64455 S 18.66 0.00 0.00<br />

62281 S 305.55 0.00 0.00 64470 S 305.55 0.00 0.00<br />

62282 S 305.55 0.00 0.00 64472 S 234.83 0.00 0.00<br />

62287 S 1,371.66 0.00 0.00 64475 S 305.55 0.00 0.00<br />

62292 S 288.03 0.00 0.00 64476 S 211.49 0.00 0.00<br />

62294 S 233.20 0.00 0.00 64479 S 305.55 0.00 0.00<br />

62310 S 305.55 0.00 0.00 64480 S 234.83 0.00 0.00<br />

62311 S 305.55 0.00 0.00 64483 S 305.55 0.00 0.00<br />

62318 S 305.55 0.00 0.00 64484 S 234.83 0.00 0.00<br />

62319 S 305.55 0.00 0.00 64505 S 40.91 0.00 0.00<br />

62350 S 1,060.55 0.00 0.00 64508 S 86.84 0.00 0.00<br />

62355 S 504.95 0.00 0.00 64510 S 305.55 0.00 0.00<br />

62360 S 1,060.55 0.00 0.00 64517 S 211.45 0.00 0.00<br />

62361 S 10,886.69 5,892.58 898.48 64520 S 305.55 0.00 0.00<br />

62362 S 10,886.69 5,892.58 898.48 64530 S 305.55 0.00 0.00<br />

62365 S 938.45 0.00 0.00 64553 S 3,110.42 1,907.94 705.47<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,492.82 2,290.34 1,087.87 64746 S 588.06 0.00 0.00<br />

64560 S 3,492.82 2,290.34 1,087.87 64761 S 743.40 0.00 0.00<br />

64561 S 3,196.29 1,993.81 791.34 64763 S 743.40 0.00 0.00<br />

64565 S 3,492.82 2,290.34 1,087.87 64766 S 1,444.18 0.00 0.00<br />

64573 S 5,441.29 3,223.43 1,005.58 64771 S 588.06 0.00 0.00<br />

64575 S 4,159.42 2,479.69 799.97 64772 S 588.06 0.00 0.00<br />

64577 S 4,159.42 2,479.69 799.97 64774 S 588.06 0.00 0.00<br />

64580 S 4,159.42 2,479.69 799.97 64776 S 619.11 0.00 0.00<br />

64581 S 4,245.29 2,565.56 885.84 64778 S 588.06 0.00 0.00<br />

64585 S 555.88 0.00 0.00 64782 S 619.11 0.00 0.00<br />

64590 S 11,349.05 6,079.58 810.11 64783 S 588.06 0.00 0.00<br />

64595 S 754.84 0.00 0.00 64784 S 619.11 0.00 0.00<br />

64600 S 450.13 0.00 0.00 64786 S 969.50 0.00 0.00<br />

64605 S 450.13 0.00 0.00 64787 S 588.06 0.00 0.00<br />

64610 S 450.13 0.00 0.00 64788 S 619.11 0.00 0.00<br />

64612 S 65.67 0.00 0.00 64790 S 619.11 0.00 0.00<br />

64613 S 63.52 0.00 0.00 64792 S 969.50 0.00 0.00<br />

64614 S 72.49 0.00 0.00 64795 S 588.06 0.00 0.00<br />

64620 S 305.55 0.00 0.00 64802 S 588.06 0.00 0.00<br />

64622 S 450.13 0.00 0.00 64820 S 743.40 0.00 0.00<br />

64623 S 305.55 0.00 0.00 64821 S 867.86 0.00 0.00<br />

64626 S 450.13 0.00 0.00 64822 S 1,124.47 0.00 0.00<br />

64627 S 211.49 0.00 0.00 64823 S 1,124.47 0.00 0.00<br />

64630 S 314.74 0.00 0.00 64831 S 1,027.72 0.00 0.00<br />

64632 S 34.09 0.00 0.00 64832 S 883.63 0.00 0.00<br />

64640 S 101.56 0.00 0.00 64834 S 938.45 0.00 0.00<br />

64650 S 34.09 0.00 0.00 64835 S 969.50 0.00 0.00<br />

64653 S 36.96 0.00 0.00 64836 S 969.50 0.00 0.00<br />

64680 S 478.25 0.00 0.00 64837 S 883.63 0.00 0.00<br />

64681 S 504.95 0.00 0.00 64840 S 938.45 0.00 0.00<br />

64702 S 533.24 0.00 0.00 64856 S 938.45 0.00 0.00<br />

64704 S 533.24 0.00 0.00 64857 S 938.45 0.00 0.00<br />

64708 S 588.06 0.00 0.00 64858 S 938.45 0.00 0.00<br />

64712 S 588.06 0.00 0.00 64859 S 883.63 0.00 0.00<br />

64713 S 588.06 0.00 0.00 64861 S 969.50 0.00 0.00<br />

64714 S 588.06 0.00 0.00 64862 S 969.50 0.00 0.00<br />

64716 S 619.11 0.00 0.00 64864 S 969.50 0.00 0.00<br />

64718 S 588.06 0.00 0.00 64865 S 1,027.72 0.00 0.00<br />

64719 S 588.06 0.00 0.00 64870 S 1,027.72 0.00 0.00<br />

64721 S 588.06 0.00 0.00 64872 S 938.45 0.00 0.00<br />

64722 S 533.24 0.00 0.00 64874 S 969.50 0.00 0.00<br />

64726 S 533.24 0.00 0.00 64876 S 969.50 0.00 0.00<br />

64727 S 533.24 0.00 0.00 64885 S 938.45 0.00 0.00<br />

64732 S 588.06 0.00 0.00 64886 S 938.45 0.00 0.00<br />

64734 S 588.06 0.00 0.00 64890 S 938.45 0.00 0.00<br />

64736 S 588.06 0.00 0.00 64891 S 938.45 0.00 0.00<br />

64738 S 588.06 0.00 0.00 64892 S 938.45 0.00 0.00<br />

64740 S 588.06 0.00 0.00 64893 S 938.45 0.00 0.00<br />

64742 S 588.06 0.00 0.00 64895 S 969.50 0.00 0.00<br />

64744 S 588.06 0.00 0.00 64896 S 969.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 969.50 0.00 0.00 65770 S 5,705.17 0.00 0.00<br />

64898 S 969.50 0.00 0.00 65772 S 641.78 0.00 0.00<br />

64901 S 938.45 0.00 0.00 65775 S 641.78 0.00 0.00<br />

64902 S 938.45 0.00 0.00 65780 S 1,110.20 0.00 0.00<br />

64905 S 938.45 0.00 0.00 65781 S 1,110.20 0.00 0.00<br />

64907 S 883.63 0.00 0.00 65782 S 1,110.20 0.00 0.00<br />

64910 S 1,444.18 0.00 0.00 65800 S 497.71 0.00 0.00<br />

65091 S 1,020.83 0.00 0.00 65805 S 497.71 0.00 0.00<br />

65093 S 1,020.83 0.00 0.00 65810 S 727.26 0.00 0.00<br />

65101 S 1,020.83 0.00 0.00 65815 S 696.20 0.00 0.00<br />

65103 S 1,020.83 0.00 0.00 65820 S 255.34 0.00 0.00<br />

65105 S 1,079.05 0.00 0.00 65850 S 785.46 0.00 0.00<br />

65110 S 1,121.25 0.00 0.00 65855 S 135.65 0.00 0.00<br />

65112 S 1,256.11 0.00 0.00 65860 S 126.68 0.00 0.00<br />

65114 S 1,256.11 0.00 0.00 65865 S 497.71 0.00 0.00<br />

65125 S 1,045.39 0.00 0.00 65870 S 785.46 0.00 0.00<br />

65130 S 770.10 0.00 0.00 65875 S 785.46 0.00 0.00<br />

65135 S 739.06 0.00 0.00 65880 S 641.78 0.00 0.00<br />

65140 S 1,020.83 0.00 0.00 65900 S 683.99 0.00 0.00<br />

65150 S 739.06 0.00 0.00 65920 S 962.53 0.00 0.00<br />

65155 S 1,020.83 0.00 0.00 65930 S 827.67 0.00 0.00<br />

65175 S 549.37 0.00 0.00 66020 S 497.71 0.00 0.00<br />

65205 S 21.17 0.00 0.00 66030 S 255.34 0.00 0.00<br />

65210 S 26.91 0.00 0.00 66130 S 962.53 0.00 0.00<br />

65220 S 37.50 0.00 0.00 66150 S 785.46 0.00 0.00<br />

65222 S 29.42 0.00 0.00 66155 S 785.46 0.00 0.00<br />

65235 S 552.52 0.00 0.00 66160 S 696.20 0.00 0.00<br />

65260 S 364.43 0.00 0.00 66165 S 785.46 0.00 0.00<br />

65265 S 753.95 0.00 0.00 66170 S 785.46 0.00 0.00<br />

65270 S 604.18 0.00 0.00 66172 S 785.46 0.00 0.00<br />

65272 S 696.20 0.00 0.00 66180 S 1,170.18 0.00 0.00<br />

65275 S 785.46 0.00 0.00 66185 S 1,038.72 0.00 0.00<br />

65280 S 753.95 0.00 0.00 66220 S 1,013.97 0.00 0.00<br />

65285 S 1,072.18 0.00 0.00 66225 S 1,127.98 0.00 0.00<br />

65286 S 187.58 0.00 0.00 66250 S 552.52 0.00 0.00<br />

65290 S 742.50 0.00 0.00 66500 S 255.34 0.00 0.00<br />

65400 S 497.71 0.00 0.00 66505 S 255.34 0.00 0.00<br />

65410 S 552.52 0.00 0.00 66600 S 727.26 0.00 0.00<br />

65420 S 552.52 0.00 0.00 66605 S 727.26 0.00 0.00<br />

65426 S 827.67 0.00 0.00 66625 S 517.08 0.00 0.00<br />

65430 S 37.50 0.00 0.00 66630 S 727.26 0.00 0.00<br />

65435 S 32.66 0.00 0.00 66635 S 727.26 0.00 0.00<br />

65436 S 141.75 0.00 0.00 66680 S 727.26 0.00 0.00<br />

65450 S 86.54 0.00 0.00 66682 S 696.20 0.00 0.00<br />

65600 S 167.23 0.00 0.00 66700 S 552.52 0.00 0.00<br />

65710 S 1,245.06 0.00 0.00 66710 S 552.52 0.00 0.00<br />

65730 S 1,245.06 0.00 0.00 66711 S 552.52 0.00 0.00<br />

65750 S 1,245.06 0.00 0.00 66720 S 552.52 0.00 0.00<br />

65755 S 1,245.06 0.00 0.00 66740 S 696.20 0.00 0.00<br />

65756 S 1,524.75 0.00 0.00 66761 S 188.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 192.00 0.00 0.00 67228 S 211.44 0.00 0.00<br />

66770 S 211.44 0.00 0.00 67229 S 211.44 0.00 0.00<br />

66820 S 187.58 0.00 0.00 67250 S 635.24 0.00 0.00<br />

66821 S 257.31 0.00 0.00 67255 S 695.74 0.00 0.00<br />

66825 S 785.46 0.00 0.00 67311 S 742.50 0.00 0.00<br />

66830 S 274.71 0.00 0.00 67312 S 800.72 0.00 0.00<br />

66840 S 590.52 0.00 0.00 67314 S 800.72 0.00 0.00<br />

66850 S 1,111.81 0.00 0.00 67316 S 800.72 0.00 0.00<br />

66852 S 934.74 0.00 0.00 67318 S 800.72 0.00 0.00<br />

66920 S 934.74 0.00 0.00 67320 S 800.72 0.00 0.00<br />

66930 S 976.95 0.00 0.00 67331 S 800.72 0.00 0.00<br />

66940 S 632.73 0.00 0.00 67332 S 800.72 0.00 0.00<br />

66982 S 959.88 0.00 0.00 67334 S 800.72 0.00 0.00<br />

66983 S 959.88 0.00 0.00 67335 S 800.72 0.00 0.00<br />

66984 S 959.88 0.00 0.00 67340 S 800.72 0.00 0.00<br />

66985 S 888.56 0.00 0.00 67343 S 977.78 0.00 0.00<br />

66986 S 888.56 0.00 0.00 67345 S 83.62 0.00 0.00<br />

67005 S 753.95 0.00 0.00 67346 S 452.27 0.00 0.00<br />

67010 S 753.95 0.00 0.00 67400 S 635.24 0.00 0.00<br />

67015 S 928.11 0.00 0.00 67405 S 828.32 0.00 0.00<br />

67025 S 609.88 0.00 0.00 67412 S 735.65 0.00 0.00<br />

67027 S 1,072.18 0.00 0.00 67413 S 870.52 0.00 0.00<br />

67028 S 84.34 0.00 0.00 67414 S 1,546.85 0.00 0.00<br />

67030 S 609.88 0.00 0.00 67415 S 549.37 0.00 0.00<br />

67031 S 257.31 0.00 0.00 67420 S 1,121.25 0.00 0.00<br />

67036 S 1,072.18 0.00 0.00 67430 S 1,121.25 0.00 0.00<br />

67039 S 1,249.25 0.00 0.00 67440 S 1,121.25 0.00 0.00<br />

67040 S 1,249.25 0.00 0.00 67445 S 1,121.25 0.00 0.00<br />

67041 S 1,533.13 0.00 0.00 67450 S 1,121.25 0.00 0.00<br />

67042 S 1,533.13 0.00 0.00 67500 S 86.54 0.00 0.00<br />

67043 S 1,533.13 0.00 0.00 67505 S 26.91 0.00 0.00<br />

67101 S 234.04 0.00 0.00 67515 S 27.27 0.00 0.00<br />

67105 S 211.44 0.00 0.00 67550 S 1,079.05 0.00 0.00<br />

67107 S 1,114.39 0.00 0.00 67560 S 739.06 0.00 0.00<br />

67108 S 1,249.25 0.00 0.00 67570 S 1,079.05 0.00 0.00<br />

67110 S 340.20 0.00 0.00 67700 S 126.60 0.00 0.00<br />

67112 S 1,249.25 0.00 0.00 67710 S 147.85 0.00 0.00<br />

67113 S 1,533.13 0.00 0.00 67715 S 549.37 0.00 0.00<br />

67115 S 664.69 0.00 0.00 67800 S 53.11 0.00 0.00<br />

67120 S 664.69 0.00 0.00 67801 S 64.24 0.00 0.00<br />

67121 S 664.69 0.00 0.00 67805 S 83.25 0.00 0.00<br />

67141 S 234.30 0.00 0.00 67808 S 604.18 0.00 0.00<br />

67145 S 199.89 0.00 0.00 67810 S 126.60 0.00 0.00<br />

67208 S 213.17 0.00 0.00 67820 S 17.58 0.00 0.00<br />

67210 S 211.44 0.00 0.00 67825 S 54.19 0.00 0.00<br />

67218 S 796.16 0.00 0.00 67830 S 370.93 0.00 0.00<br />

67220 S 234.04 0.00 0.00 67835 S 604.18 0.00 0.00<br />

67221 S 120.22 0.00 0.00 67840 S 155.03 0.00 0.00<br />

67225 S 8.26 0.00 0.00 67850 S 123.09 0.00 0.00<br />

67227 S 609.88 0.00 0.00 67875 S 309.13 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 583.58 0.00 0.00 68440 S 52.75 0.00 0.00<br />

67882 S 635.24 0.00 0.00 68500 S 770.10 0.00 0.00<br />

67900 S 828.32 0.00 0.00 68505 S 770.10 0.00 0.00<br />

67901 S 735.65 0.00 0.00 68510 S 549.37 0.00 0.00<br />

67902 S 870.52 0.00 0.00 68520 S 770.10 0.00 0.00<br />

67903 S 693.45 0.00 0.00 68525 S 549.37 0.00 0.00<br />

67904 S 693.45 0.00 0.00 68530 S 126.60 0.00 0.00<br />

67906 S 735.65 0.00 0.00 68540 S 635.24 0.00 0.00<br />

67908 S 693.45 0.00 0.00 68550 S 770.10 0.00 0.00<br />

67909 S 693.45 0.00 0.00 68700 S 604.18 0.00 0.00<br />

67911 S 635.24 0.00 0.00 68705 S 120.22 0.00 0.00<br />

67912 S 635.24 0.00 0.00 68720 S 828.32 0.00 0.00<br />

67914 S 635.24 0.00 0.00 68745 S 828.32 0.00 0.00<br />

67915 S 171.54 0.00 0.00 68750 S 828.32 0.00 0.00<br />

67916 S 693.45 0.00 0.00 68760 S 102.28 0.00 0.00<br />

67917 S 693.45 0.00 0.00 68761 S 70.69 0.00 0.00<br />

67921 S 635.24 0.00 0.00 68770 S 828.32 0.00 0.00<br />

67922 S 166.87 0.00 0.00 68801 S 37.50 0.00 0.00<br />

67923 S 693.45 0.00 0.00 68810 S 107.24 0.00 0.00<br />

67924 S 693.45 0.00 0.00 68811 S 604.18 0.00 0.00<br />

67930 S 171.54 0.00 0.00 68815 S 604.18 0.00 0.00<br />

67935 S 604.18 0.00 0.00 68816 S 775.65 0.00 0.00<br />

67938 S 86.54 0.00 0.00 68840 S 55.62 0.00 0.00<br />

67950 S 604.18 0.00 0.00 69000 S 56.73 0.00 0.00<br />

67961 S 635.24 0.00 0.00 69005 S 107.30 0.00 0.00<br />

67966 S 635.24 0.00 0.00 69020 S 56.73 0.00 0.00<br />

67971 S 635.24 0.00 0.00 69100 S 64.60 0.00 0.00<br />

67973 S 770.10 0.00 0.00 69105 S 91.51 0.00 0.00<br />

67974 S 635.24 0.00 0.00 69110 S 480.76 0.00 0.00<br />

67975 S 635.24 0.00 0.00 69120 S 713.45 0.00 0.00<br />

68020 S 47.01 0.00 0.00 69140 S 713.45 0.00 0.00<br />

68040 S 23.32 0.00 0.00 69145 S 535.58 0.00 0.00<br />

68100 S 93.30 0.00 0.00 69150 S 376.43 0.00 0.00<br />

68110 S 120.22 0.00 0.00 69200 S 25.95 0.00 0.00<br />

68115 S 604.18 0.00 0.00 69205 S 600.15 0.00 0.00<br />

68130 S 552.52 0.00 0.00 69210 S 21.17 0.00 0.00<br />

68135 S 60.29 0.00 0.00 69220 S 33.25 0.00 0.00<br />

68200 S 17.22 0.00 0.00 69222 S 139.96 0.00 0.00<br />

68320 S 828.32 0.00 0.00 69300 S 744.51 0.00 0.00<br />

68325 S 828.32 0.00 0.00 69310 S 1,088.25 0.00 0.00<br />

68326 S 693.45 0.00 0.00 69320 S 1,323.53 0.00 0.00<br />

68328 S 828.32 0.00 0.00 69400 S 94.02 0.00 0.00<br />

68330 S 785.46 0.00 0.00 69401 S 49.52 0.00 0.00<br />

68335 S 828.32 0.00 0.00 69405 S 129.91 0.00 0.00<br />

68340 S 693.45 0.00 0.00 69420 S 116.63 0.00 0.00<br />

68360 S 696.20 0.00 0.00 69421 S 593.60 0.00 0.00<br />

68362 S 696.20 0.00 0.00 69424 S 81.82 0.00 0.00<br />

68371 S 552.52 0.00 0.00 69433 S 116.28 0.00 0.00<br />

68400 S 126.60 0.00 0.00 69436 S 593.60 0.00 0.00<br />

68420 S 180.14 0.00 0.00 69440 S 744.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 1,002.38 0.00 0.00 69840 S 1,188.67 0.00 0.00<br />

69501 S 1,323.53 0.00 0.00 69905 S 1,323.53 0.00 0.00<br />

69502 S 979.79 0.00 0.00 69910 S 1,323.53 0.00 0.00<br />

69505 S 1,323.53 0.00 0.00 69915 S 1,323.53 0.00 0.00<br />

69511 S 1,323.53 0.00 0.00 69930 S 23,927.60 12,847.50 1,767.41<br />

69530 S 1,323.53 0.00 0.00 70030 TC A 18.30 0.00 0.00<br />

69540 S 136.72 0.00 0.00 70100 TC A 20.10 0.00 0.00<br />

69550 S 1,188.67 0.00 0.00 70110 TC A 24.77 0.00 0.00<br />

69552 S 1,323.53 0.00 0.00 70120 TC A 22.25 0.00 0.00<br />

69601 S 1,323.53 0.00 0.00 70130 TC A 27.18 0.00 0.00<br />

69602 S 1,323.53 0.00 0.00 70134 TC A 27.27 0.00 0.00<br />

69603 S 1,323.53 0.00 0.00 70140 TC A 18.66 0.00 0.00<br />

69604 S 1,323.53 0.00 0.00 70150 TC A 27.18 0.00 0.00<br />

69605 S 1,323.53 0.00 0.00 70160 TC A 21.89 0.00 0.00<br />

69610 S 183.02 0.00 0.00 70190 TC A 22.96 0.00 0.00<br />

69620 S 713.45 0.00 0.00 70200 TC A 27.18 0.00 0.00<br />

69631 S 1,188.67 0.00 0.00 70210 TC A 19.38 0.00 0.00<br />

69632 S 1,188.67 0.00 0.00 70220 TC A 24.41 0.00 0.00<br />

69633 S 1,188.67 0.00 0.00 70240 TC A 18.30 0.00 0.00<br />

69635 S 1,323.53 0.00 0.00 70250 TC A 22.25 0.00 0.00<br />

69636 S 1,323.53 0.00 0.00 70260 TC A 28.35 0.00 0.00<br />

69637 S 1,323.53 0.00 0.00 70300 TC A 7.89 0.00 0.00<br />

69641 S 1,323.53 0.00 0.00 70310 TC A 19.50 0.00 0.00<br />

69642 S 1,323.53 0.00 0.00 70320 TC A 19.50 0.00 0.00<br />

69643 S 1,323.53 0.00 0.00 70328 TC A 19.38 0.00 0.00<br />

69644 S 1,323.53 0.00 0.00 70330 TC A 27.18 0.00 0.00<br />

69645 S 1,323.53 0.00 0.00 70336 TC A 211.60 0.00 0.00<br />

69646 S 1,323.53 0.00 0.00 70350 TC A 10.77 0.00 0.00<br />

69650 S 979.79 0.00 0.00 70355 TC A 11.12 0.00 0.00<br />

69660 S 1,188.67 0.00 0.00 70360 TC A 17.22 0.00 0.00<br />

69661 S 1,188.67 0.00 0.00 70370 TC A 50.59 0.00 0.00<br />

69662 S 1,188.67 0.00 0.00 70371 TC A 50.59 0.00 0.00<br />

69666 S 1,146.46 0.00 0.00 70380 TC A 26.20 0.00 0.00<br />

69667 S 1,146.46 0.00 0.00 70450 TC A 118.18 0.00 0.00<br />

69670 S 1,088.25 0.00 0.00 70460 TC A 187.13 0.00 0.00<br />

69676 S 1,088.25 0.00 0.00 70470 TC A 207.29 0.00 0.00<br />

69700 S 1,088.25 0.00 0.00 70480 TC A 118.18 0.00 0.00<br />

69711 S 1,002.38 0.00 0.00 70481 TC A 187.13 0.00 0.00<br />

69714 S 6,356.94 4,008.29 1,659.64 70482 TC A 207.29 0.00 0.00<br />

69715 S 6,356.94 4,008.29 1,659.64 70486 TC A 118.18 0.00 0.00<br />

69717 S 6,356.94 4,008.29 1,659.64 70487 TC A 187.13 0.00 0.00<br />

69718 S 6,356.94 4,008.29 1,659.64 70488 TC A 207.29 0.00 0.00<br />

69720 S 1,188.67 0.00 0.00 70490 TC A 118.18 0.00 0.00<br />

69740 S 1,188.67 0.00 0.00 70491 TC A 187.13 0.00 0.00<br />

69745 S 1,188.67 0.00 0.00 70492 TC A 207.29 0.00 0.00<br />

69801 S 1,188.67 0.00 0.00 70496 TC A 213.92 0.00 0.00<br />

69802 S 1,323.53 0.00 0.00 70498 TC A 213.92 0.00 0.00<br />

69805 S 1,323.53 0.00 0.00 70540 TC A 211.60 0.00 0.00<br />

69806 S 1,323.53 0.00 0.00 70542 TC A 259.84 0.00 0.00<br />

69820 S 1,188.67 0.00 0.00 70543 TC A 327.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 211.60 0.00 0.00 72120 TC A 34.45 0.00 0.00<br />

70545 TC A 259.84 0.00 0.00 72125 TC A 118.18 0.00 0.00<br />

70546 TC A 327.49 0.00 0.00 72126 TC A 187.13 0.00 0.00<br />

70547 TC A 211.60 0.00 0.00 72127 TC A 207.29 0.00 0.00<br />

70548 TC A 259.84 0.00 0.00 72128 TC A 118.18 0.00 0.00<br />

70549 TC A 327.49 0.00 0.00 72129 TC A 187.13 0.00 0.00<br />

70551 TC A 211.60 0.00 0.00 72130 TC A 207.29 0.00 0.00<br />

70552 TC A 259.84 0.00 0.00 72131 TC A 118.18 0.00 0.00<br />

70553 TC A 327.49 0.00 0.00 72132 TC A 187.13 0.00 0.00<br />

70554 TC A 211.60 0.00 0.00 72133 TC A 207.29 0.00 0.00<br />

70555 TC A 211.60 0.00 0.00 72141 TC A 211.60 0.00 0.00<br />

70557 TC A 211.60 0.00 0.00 72142 TC A 259.84 0.00 0.00<br />

70558 TC A 259.84 0.00 0.00 72146 TC A 211.60 0.00 0.00<br />

70559 TC A 327.49 0.00 0.00 72147 TC A 259.84 0.00 0.00<br />

71010 TC A 14.00 0.00 0.00 72148 TC A 211.60 0.00 0.00<br />

71015 TC A 17.94 0.00 0.00 72149 TC A 259.84 0.00 0.00<br />

71020 TC A 19.02 0.00 0.00 72156 TC A 327.49 0.00 0.00<br />

71021 TC A 22.96 0.00 0.00 72157 TC A 327.49 0.00 0.00<br />

71022 TC A 27.18 0.00 0.00 72158 TC A 327.49 0.00 0.00<br />

71023 TC A 44.50 0.00 0.00 72170 TC A 16.15 0.00 0.00<br />

71030 TC A 27.18 0.00 0.00 72190 TC A 27.18 0.00 0.00<br />

71034 TC A 50.59 0.00 0.00 72191 TC A 213.92 0.00 0.00<br />

71035 TC A 23.68 0.00 0.00 72192 TC A 118.18 0.00 0.00<br />

71100 TC A 19.74 0.00 0.00 72193 TC A 187.13 0.00 0.00<br />

71101 TC A 24.04 0.00 0.00 72194 TC A 207.29 0.00 0.00<br />

71110 TC A 25.12 0.00 0.00 72195 TC A 211.60 0.00 0.00<br />

71111 TC A 33.37 0.00 0.00 72196 TC A 259.84 0.00 0.00<br />

71120 TC A 20.82 0.00 0.00 72197 TC A 327.49 0.00 0.00<br />

71130 TC A 24.41 0.00 0.00 72200 TC A 19.02 0.00 0.00<br />

71250 TC A 118.18 0.00 0.00 72202 TC A 23.32 0.00 0.00<br />

71260 TC A 187.13 0.00 0.00 72220 TC A 19.02 0.00 0.00<br />

71270 TC A 207.29 0.00 0.00 73000 TC A 17.94 0.00 0.00<br />

71275 TC A 213.92 0.00 0.00 73010 TC A 18.30 0.00 0.00<br />

71550 TC A 211.60 0.00 0.00 73020 TC A 14.72 0.00 0.00<br />

71551 TC A 259.84 0.00 0.00 73030 TC A 18.66 0.00 0.00<br />

71552 TC A 327.49 0.00 0.00 73050 TC A 23.32 0.00 0.00<br />

72010 TC A 45.25 0.00 0.00 73060 TC A 18.66 0.00 0.00<br />

72020 TC A 14.72 0.00 0.00 73070 TC A 17.94 0.00 0.00<br />

72040 TC A 23.68 0.00 0.00 73080 TC A 23.68 0.00 0.00<br />

72050 TC A 33.73 0.00 0.00 73090 TC A 17.94 0.00 0.00<br />

72052 TC A 45.25 0.00 0.00 73092 TC A 18.66 0.00 0.00<br />

72069 TC A 22.25 0.00 0.00 73100 TC A 18.66 0.00 0.00<br />

72070 TC A 20.82 0.00 0.00 73110 TC A 23.68 0.00 0.00<br />

72072 TC A 25.12 0.00 0.00 73120 TC A 17.58 0.00 0.00<br />

72074 TC A 27.18 0.00 0.00 73130 TC A 20.82 0.00 0.00<br />

72080 TC A 22.25 0.00 0.00 73140 TC A 20.46 0.00 0.00<br />

72090 TC A 29.79 0.00 0.00 73200 TC A 118.18 0.00 0.00<br />

72100 TC A 25.48 0.00 0.00 73201 TC A 187.13 0.00 0.00<br />

72110 TC A 35.53 0.00 0.00 73202 TC A 207.29 0.00 0.00<br />

72114 TC A 45.25 0.00 0.00 73206 TC A 213.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 211.60 0.00 0.00 74246 TC A 53.40 0.00 0.00<br />

73219 TC A 259.84 0.00 0.00 74247 TC A 53.40 0.00 0.00<br />

73220 TC A 327.49 0.00 0.00 74249 TC A 86.83 0.00 0.00<br />

73221 TC A 211.60 0.00 0.00 74250 TC A 53.40 0.00 0.00<br />

73222 TC A 259.84 0.00 0.00 74251 TC A 86.83 0.00 0.00<br />

73223 TC A 327.49 0.00 0.00 74260 TC A 53.40 0.00 0.00<br />

73500 TC A 15.43 0.00 0.00 74270 TC A 53.40 0.00 0.00<br />

73510 TC A 23.68 0.00 0.00 74280 TC A 86.83 0.00 0.00<br />

73520 TC A 24.41 0.00 0.00 74283 TC A 53.40 0.00 0.00<br />

73540 TC A 24.41 0.00 0.00 74290 TC A 45.57 0.00 0.00<br />

73550 TC A 17.94 0.00 0.00 74291 TC A 43.78 0.00 0.00<br />

73560 TC A 18.30 0.00 0.00 74400 TC A 79.31 0.00 0.00<br />

73562 TC A 22.61 0.00 0.00 74410 TC A 84.69 0.00 0.00<br />

73564 TC A 26.20 0.00 0.00 74415 TC A 101.20 0.00 0.00<br />

73565 TC A 19.74 0.00 0.00 74420 TC A 105.78 0.00 0.00<br />

73590 TC A 17.22 0.00 0.00 74710 TC A 23.68 0.00 0.00<br />

73592 TC A 18.66 0.00 0.00 74775 TC A 105.78 0.00 0.00<br />

73600 TC A 17.58 0.00 0.00 75557 TC A 211.60 0.00 0.00<br />

73610 TC A 20.82 0.00 0.00 75559 TC A 211.60 0.00 0.00<br />

73620 TC A 16.87 0.00 0.00 75561 TC A 327.49 0.00 0.00<br />

73630 TC A 20.46 0.00 0.00 75563 TC A 327.49 0.00 0.00<br />

73650 TC A 17.22 0.00 0.00 76010 TC A 17.58 0.00 0.00<br />

73660 TC A 19.38 0.00 0.00 76098 TC A 10.77 0.00 0.00<br />

73700 TC A 118.18 0.00 0.00 76100 TC A 45.25 0.00 0.00<br />

73701 TC A 187.13 0.00 0.00 76101 TC A 121.29 0.00 0.00<br />

73702 TC A 207.29 0.00 0.00 76102 TC A 121.29 0.00 0.00<br />

73706 TC A 213.92 0.00 0.00 76120 TC A 50.59 0.00 0.00<br />

73718 TC A 211.60 0.00 0.00 76150 A 17.58 0.00 0.00<br />

73719 TC A 259.84 0.00 0.00 76380 TC A 63.84 0.00 0.00<br />

73720 TC A 327.49 0.00 0.00 76496 TC A 50.59 0.00 0.00<br />

73721 TC A 211.60 0.00 0.00 76497 TC A 63.84 0.00 0.00<br />

73722 TC A 259.84 0.00 0.00 76498 TC A 211.60 0.00 0.00<br />

73723 TC A 327.49 0.00 0.00 76499 TC A 27.18 0.00 0.00<br />

74000 TC A 15.43 0.00 0.00 76506 TC A 38.00 0.00 0.00<br />

74010 TC A 24.04 0.00 0.00 76510 TC A 64.60 0.00 0.00<br />

74020 TC A 24.41 0.00 0.00 76511 TC A 45.21 0.00 0.00<br />

74022 TC A 29.79 0.00 0.00 76512 TC A 38.40 0.00 0.00<br />

74150 TC A 118.18 0.00 0.00 76513 TC A 46.66 0.00 0.00<br />

74160 TC A 187.13 0.00 0.00 76514 TC A 3.23 0.00 0.00<br />

74170 TC A 207.29 0.00 0.00 76516 TC A 36.61 0.00 0.00<br />

74175 TC A 213.92 0.00 0.00 76519 TC A 40.91 0.00 0.00<br />

74181 TC A 211.60 0.00 0.00 76529 TC A 35.53 0.00 0.00<br />

74182 TC A 259.84 0.00 0.00 76536 TC A 59.44 0.00 0.00<br />

74183 TC A 327.49 0.00 0.00 76604 TC A 38.00 0.00 0.00<br />

74210 TC A 53.40 0.00 0.00 76645 TC A 38.00 0.00 0.00<br />

74220 TC A 53.40 0.00 0.00 76700 TC A 59.44 0.00 0.00<br />

74230 TC A 53.40 0.00 0.00 76705 TC A 59.44 0.00 0.00<br />

74240 TC A 53.40 0.00 0.00 76770 TC A 59.44 0.00 0.00<br />

74241 TC A 53.40 0.00 0.00 76775 TC A 59.44 0.00 0.00<br />

74245 TC A 86.83 0.00 0.00 76776 TC A 59.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 59.44 0.00 0.00 77290 TC A 155.45 0.00 0.00<br />

76801 TC A 59.44 0.00 0.00 77295 TC A 407.31 0.00 0.00<br />

76802 TC A 28.35 0.00 0.00 77299 TC A 69.74 0.00 0.00<br />

76805 TC A 59.44 0.00 0.00 77300 TC A 37.68 0.00 0.00<br />

76810 TC A 44.85 0.00 0.00 77301 TC A 542.83 0.00 0.00<br />

76811 TC A 93.12 0.00 0.00 77305 TC A 34.45 0.00 0.00<br />

76812 TC A 38.00 0.00 0.00 77310 TC A 44.85 0.00 0.00<br />

76813 TC A 38.00 0.00 0.00 77315 TC A 65.31 0.00 0.00<br />

76814 TC A 30.15 0.00 0.00 77321 TC A 67.83 0.00 0.00<br />

76815 TC A 38.00 0.00 0.00 77326 TC A 69.74 0.00 0.00<br />

76816 TC A 38.00 0.00 0.00 77327 TC A 126.68 0.00 0.00<br />

76817 TC A 38.00 0.00 0.00 77328 TC A 155.45 0.00 0.00<br />

76818 TC A 59.44 0.00 0.00 77331 TC A 17.94 0.00 0.00<br />

76819 TC A 51.32 0.00 0.00 77332 TC A 48.09 0.00 0.00<br />

76820 TC A 25.48 0.00 0.00 77333 TC A 23.32 0.00 0.00<br />

76821 TC A 57.54 0.00 0.00 77334 TC A 90.08 0.00 0.00<br />

76825 TC A 119.86 0.00 0.00 77336 A 56.71 0.00 0.00<br />

76826 TC A 71.41 0.00 0.00 77370 A 69.74 0.00 0.00<br />

76827 TC A 38.00 0.00 0.00 77371 A 4,645.75 0.00 0.00<br />

76828 TC A 22.61 0.00 0.00 77399 TC A 69.74 0.00 0.00<br />

76830 TC A 59.44 0.00 0.00 77401 A 28.35 0.00 0.00<br />

76831 TC A 80.03 0.00 0.00 77402 A 57.07 0.00 0.00<br />

76856 TC A 59.44 0.00 0.00 77403 A 57.07 0.00 0.00<br />

76857 TC A 38.00 0.00 0.00 77404 A 57.07 0.00 0.00<br />

76870 TC A 59.44 0.00 0.00 77406 A 92.45 0.00 0.00<br />

76872 TC A 59.44 0.00 0.00 77407 A 57.07 0.00 0.00<br />

76873 TC A 59.44 0.00 0.00 77408 A 57.07 0.00 0.00<br />

76880 TC A 59.44 0.00 0.00 77409 A 57.07 0.00 0.00<br />

76885 TC A 38.00 0.00 0.00 77411 A 92.45 0.00 0.00<br />

76886 TC A 38.00 0.00 0.00 77412 A 92.45 0.00 0.00<br />

76936 TC A 57.54 0.00 0.00 77413 A 92.45 0.00 0.00<br />

76970 TC A 38.00 0.00 0.00 77414 A 92.45 0.00 0.00<br />

76977 TC A 9.69 0.00 0.00 77416 A 92.45 0.00 0.00<br />

76999 TC A 38.00 0.00 0.00 77418 A 249.76 0.00 0.00<br />

77071 A 22.25 0.00 0.00 77422 A 92.45 0.00 0.00<br />

77072 TC A 12.92 0.00 0.00 77423 A 92.45 0.00 0.00<br />

77073 TC A 21.89 0.00 0.00 77470 TC A 132.78 0.00 0.00<br />

77074 TC A 43.06 0.00 0.00 77520 A 427.62 0.00 0.00<br />

77075 TC A 45.25 0.00 0.00 77522 A 427.62 0.00 0.00<br />

77076 TC A 45.25 0.00 0.00 77523 A 511.02 0.00 0.00<br />

77077 TC A 24.41 0.00 0.00 77525 A 511.02 0.00 0.00<br />

77078 TC A 43.72 0.00 0.00 77600 TC A 226.89 0.00 0.00<br />

77079 TC A 44.85 0.00 0.00 77605 TC A 226.89 0.00 0.00<br />

77080 TC A 43.72 0.00 0.00 77610 TC A 226.89 0.00 0.00<br />

77081 TC A 17.58 0.00 0.00 77615 TC A 226.89 0.00 0.00<br />

77082 TC A 19.02 0.00 0.00 77620 TC A 226.89 0.00 0.00<br />

77083 TC A 15.07 0.00 0.00 77750 TC A 88.28 0.00 0.00<br />

77084 TC A 211.60 0.00 0.00 77761 TC A 155.39 0.00 0.00<br />

77280 TC A 69.74 0.00 0.00 77762 TC A 184.09 0.00 0.00<br />

77285 TC A 155.45 0.00 0.00 77763 TC A 237.21 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 168.30 0.00 0.00 78262 TC A 147.81 0.00 0.00<br />

77777 TC A 184.81 0.00 0.00 78264 TC A 147.81 0.00 0.00<br />

77778 TC A 246.18 0.00 0.00 78270 TC A 64.60 0.00 0.00<br />

77785 TC A 109.45 0.00 0.00 78271 TC A 65.67 0.00 0.00<br />

77786 TC A 384.70 0.00 0.00 78272 TC A 72.13 0.00 0.00<br />

77787 TC A 445.78 0.00 0.00 78278 TC A 147.81 0.00 0.00<br />

77789 TC A 45.94 0.00 0.00 78282 TC A 147.81 0.00 0.00<br />

77799 TC A 261.82 0.00 0.00 78290 TC A 147.81 0.00 0.00<br />

78000 TC A 56.34 0.00 0.00 78291 TC A 147.81 0.00 0.00<br />

78001 TC A 71.40 0.00 0.00 78299 TC A 147.81 0.00 0.00<br />

78003 TC A 56.71 0.00 0.00 78300 TC A 128.83 0.00 0.00<br />

78006 TC A 134.91 0.00 0.00 78305 TC A 149.42 0.00 0.00<br />

78007 TC A 99.77 0.00 0.00 78306 TC A 149.42 0.00 0.00<br />

78010 TC A 82.89 0.00 0.00 78315 TC A 149.42 0.00 0.00<br />

78011 TC A 82.89 0.00 0.00 78320 TC A 149.42 0.00 0.00<br />

78015 TC A 161.13 0.00 0.00 78399 TC A 149.42 0.00 0.00<br />

78016 TC A 181.88 0.00 0.00 78414 TC A 189.93 0.00 0.00<br />

78018 TC A 181.88 0.00 0.00 78428 TC A 145.70 0.00 0.00<br />

78070 TC A 123.81 0.00 0.00 78445 TC A 113.65 0.00 0.00<br />

78075 TC A 350.61 0.00 0.00 78456 TC A 113.65 0.00 0.00<br />

78099 TC A 82.89 0.00 0.00 78457 TC A 113.65 0.00 0.00<br />

78102 TC A 125.24 0.00 0.00 78458 TC A 113.65 0.00 0.00<br />

78103 TC A 159.65 0.00 0.00 78459 TC A 703.32 0.00 0.00<br />

78104 TC A 159.65 0.00 0.00 78460 TC A 136.36 0.00 0.00<br />

78110 TC A 63.52 0.00 0.00 78461 TC A 137.45 0.00 0.00<br />

78111 TC A 80.39 0.00 0.00 78464 TC A 201.68 0.00 0.00<br />

78120 TC A 70.34 0.00 0.00 78465 TC A 381.83 0.00 0.00<br />

78121 TC A 83.25 0.00 0.00 78466 TC A 135.29 0.00 0.00<br />

78122 TC A 98.68 0.00 0.00 78468 TC A 172.97 0.00 0.00<br />

78130 TC A 114.47 0.00 0.00 78469 TC A 189.93 0.00 0.00<br />

78135 TC A 243.30 0.00 0.00 78472 TC A 189.93 0.00 0.00<br />

78140 TC A 108.02 0.00 0.00 78473 TC A 189.93 0.00 0.00<br />

78185 TC A 159.65 0.00 0.00 78481 TC A 164.00 0.00 0.00<br />

78190 TC A 100.18 0.00 0.00 78483 TC A 189.93 0.00 0.00<br />

78191 TC A 100.18 0.00 0.00 78491 TC A 703.32 0.00 0.00<br />

78195 TC A 159.65 0.00 0.00 78492 TC A 703.32 0.00 0.00<br />

78199 TC A 159.65 0.00 0.00 78494 TC A 189.93 0.00 0.00<br />

78201 TC A 142.11 0.00 0.00 78499 TC A 189.93 0.00 0.00<br />

78202 TC A 167.17 0.00 0.00 78580 TC A 128.67 0.00 0.00<br />

78205 TC A 167.17 0.00 0.00 78584 TC A 99.40 0.00 0.00<br />

78206 TC A 167.17 0.00 0.00 78585 TC A 197.44 0.00 0.00<br />

78215 TC A 150.36 0.00 0.00 78586 TC A 128.67 0.00 0.00<br />

78216 TC A 101.92 0.00 0.00 78587 TC A 128.67 0.00 0.00<br />

78220 TC A 111.25 0.00 0.00 78588 TC A 197.44 0.00 0.00<br />

78223 TC A 167.17 0.00 0.00 78591 TC A 128.67 0.00 0.00<br />

78230 TC A 126.32 0.00 0.00 78593 TC A 128.67 0.00 0.00<br />

78231 TC A 99.40 0.00 0.00 78594 TC A 128.67 0.00 0.00<br />

78232 TC A 103.71 0.00 0.00 78596 TC A 197.44 0.00 0.00<br />

78258 TC A 147.81 0.00 0.00 78599 TC A 128.67 0.00 0.00<br />

78261 TC A 147.81 0.00 0.00 78600 TC A 113.40 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 14600 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 113.40 0.00 0.00<br />

78605 TC A 113.40 0.00 0.00<br />

78606 TC A 254.79 0.00 0.00<br />

78607 TC A 279.91 0.00 0.00<br />

78608 TC A 630.39 0.00 0.00<br />

78610 TC A 151.08 0.00 0.00<br />

78630 TC A 269.15 0.00 0.00<br />

78635 TC A 247.97 0.00 0.00<br />

78645 TC A 113.40 0.00 0.00<br />

78647 TC A 274.53 0.00 0.00<br />

78650 TC A 265.91 0.00 0.00<br />

78660 TC A 113.40 0.00 0.00<br />

78699 TC A 113.40 0.00 0.00<br />

78700 TC A 139.60 0.00 0.00<br />

78701 TC A 170.11 0.00 0.00<br />

78707 TC A 177.64 0.00 0.00<br />

78708 TC A 121.66 0.00 0.00<br />

78709 TC A 200.01 0.00 0.00<br />

78710 TC A 187.69 0.00 0.00<br />

78725 TC A 75.00 0.00 0.00<br />

78730 TC A 63.52 0.00 0.00<br />

78740 TC A 165.80 0.00 0.00<br />

78761 TC A 158.25 0.00 0.00<br />

78799 TC A 200.01 0.00 0.00<br />

78800 TC A 139.96 0.00 0.00<br />

78801 TC A 192.00 0.00 0.00<br />

78802 TC A 260.17 0.00 0.00<br />

78803 TC A 278.84 0.00 0.00<br />

78804 TC A 486.61 0.00 0.00<br />

78805 TC A 136.72 0.00 0.00<br />

78806 TC A 273.46 0.00 0.00<br />

78807 TC A 279.20 0.00 0.00<br />

78811 TC A 630.39 0.00 0.00<br />

78812 TC A 630.39 0.00 0.00<br />

78813 TC A 630.39 0.00 0.00<br />

78814 TC A 630.39 0.00 0.00<br />

78815 TC A 630.39 0.00 0.00<br />

78816 TC A 630.39 0.00 0.00<br />

78999 TC A 71.40 0.00 0.00<br />

79005 TC A 57.42 0.00 0.00<br />

79101 TC A 62.80 0.00 0.00<br />

79200 TC A 67.83 0.00 0.00<br />

79300 TC A 130.86 0.00 0.00<br />

79403 TC A 97.25 0.00 0.00<br />

79440 TC A 54.90 0.00 0.00<br />

79445 TC A 130.86 0.00 0.00<br />

79999 TC A 130.86 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,253.61 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,528.68 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.60 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,579.57 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,579.57 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 228.12 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 228.12 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 115.18 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 243.44 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 73.18 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 655.29 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,494.30 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,169.67 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,169.67 0.00 0.00<br />

C8900 A 253.26 0.00 0.00 0123T S 935.38 0.00 0.00<br />

C8901 A 206.24 0.00 0.00 0124T S 182.83 0.00 0.00<br />

C8902 A 319.20 0.00 0.00 0144T TC A 62.22 0.00 0.00<br />

C8903 A 253.26 0.00 0.00 0145T TC A 167.50 0.00 0.00<br />

C8904 A 206.24 0.00 0.00 0146T TC A 167.50 0.00 0.00<br />

C8905 A 319.20 0.00 0.00 0147T TC A 167.50 0.00 0.00<br />

C8906 A 253.26 0.00 0.00 0148T TC A 167.50 0.00 0.00<br />

C8907 A 206.24 0.00 0.00 0149T TC A 167.50 0.00 0.00<br />

C8908 A 319.20 0.00 0.00 0150T TC A 167.50 0.00 0.00<br />

C8909 A 253.26 0.00 0.00 0151T TC A 62.22 0.00 0.00<br />

C8910 A 206.24 0.00 0.00 0170T S 1,215.00 0.00 0.00<br />

C8911 A 319.20 0.00 0.00 0176T S 1,434.64 0.00 0.00<br />

C8912 A 253.26 0.00 0.00 0177T S 1,434.64 0.00 0.00<br />

C8913 A 206.24 0.00 0.00 0182T A 1,036.97 0.00 0.00<br />

C8914 A 319.20 0.00 0.00 0186T S 873.95 0.00 0.00<br />

C8918 A 253.26 0.00 0.00 0190T S 873.95 0.00 0.00<br />

C8919 A 206.24 0.00 0.00 0191T S 935.38 0.00 0.00<br />

C8920 A 319.20 0.00 0.00 0192T S 1,603.06 0.00 0.00<br />

C9716 S 1,215.00 0.00 0.00 10021 S 56.06 0.00 0.00<br />

C9724 S 993.40 0.00 0.00 10022 S 175.08 0.00 0.00<br />

C9725 S 229.08 0.00 0.00 10040 S 32.41 0.00 0.00<br />

C9726 S 841.00 0.00 0.00 10060 S 49.31 0.00 0.00<br />

C9727 S 294.87 0.00 0.00 10061 S 55.30 0.00 0.00<br />

C9728 S 529.08 0.00 0.00 10080 S 55.30 0.00 0.00<br />

G0104 S 84.99 0.00 0.00 10081 S 127.32 0.00 0.00<br />

G0105 S 367.34 0.00 0.00 10120 S 69.25 0.00 0.00<br />

G0121 S 367.34 0.00 0.00 10121 S 522.01 0.00 0.00<br />

G0127 S 11.89 0.00 0.00 10140 S 73.45 0.00 0.00<br />

G0130 TC A 19.59 0.00 0.00 10160 S 55.30 0.00 0.00<br />

G0173 A 2,253.61 0.00 0.00 10180 S 590.33 0.00 0.00<br />

G0186 S 228.12 0.00 0.00 11000 S 23.79 0.00 0.00<br />

G0247 S 21.68 0.00 0.00 11001 S 8.05 0.00 0.00<br />

G0251 A 564.34 0.00 0.00 11010 S 206.53 0.00 0.00<br />

G0260 S 297.82 0.00 0.00 11011 S 206.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 206.53 0.00 0.00 11601 S 114.03 0.00 0.00<br />

11040 S 21.68 0.00 0.00 11602 S 125.57 0.00 0.00<br />

11041 S 24.14 0.00 0.00 11603 S 133.26 0.00 0.00<br />

11042 S 131.15 0.00 0.00 11604 S 359.47 0.00 0.00<br />

11043 S 131.15 0.00 0.00 11606 S 522.01 0.00 0.00<br />

11044 S 341.49 0.00 0.00 11620 S 97.24 0.00 0.00<br />

11055 S 25.53 0.00 0.00 11621 S 115.43 0.00 0.00<br />

11056 S 27.98 0.00 0.00 11622 S 128.36 0.00 0.00<br />

11057 S 32.41 0.00 0.00 11623 S 138.16 0.00 0.00<br />

11100 S 59.38 0.00 0.00 11624 S 522.01 0.00 0.00<br />

11101 S 13.99 0.00 0.00 11626 S 638.38 0.00 0.00<br />

11200 S 32.41 0.00 0.00 11640 S 102.84 0.00 0.00<br />

11201 S 5.60 0.00 0.00 11641 S 121.37 0.00 0.00<br />

11300 S 32.41 0.00 0.00 11642 S 135.36 0.00 0.00<br />

11301 S 32.41 0.00 0.00 11643 S 145.86 0.00 0.00<br />

11302 S 32.41 0.00 0.00 11644 S 522.01 0.00 0.00<br />

11303 S 59.38 0.00 0.00 11646 S 638.38 0.00 0.00<br />

11305 S 32.41 0.00 0.00 11719 S 11.89 0.00 0.00<br />

11306 S 32.41 0.00 0.00 11720 S 14.69 0.00 0.00<br />

11307 S 32.41 0.00 0.00 11721 S 17.83 0.00 0.00<br />

11308 S 32.41 0.00 0.00 11730 S 32.41 0.00 0.00<br />

11310 S 32.41 0.00 0.00 11732 S 17.83 0.00 0.00<br />

11311 S 32.41 0.00 0.00 11740 S 16.37 0.00 0.00<br />

11312 S 32.41 0.00 0.00 11750 S 94.44 0.00 0.00<br />

11313 S 32.41 0.00 0.00 11752 S 131.17 0.00 0.00<br />

11400 S 66.81 0.00 0.00 11755 S 65.40 0.00 0.00<br />

11401 S 75.20 0.00 0.00 11760 S 134.71 0.00 0.00<br />

11402 S 82.55 0.00 0.00 11762 S 120.32 0.00 0.00<br />

11403 S 88.15 0.00 0.00 11765 S 32.41 0.00 0.00<br />

11404 S 468.59 0.00 0.00 11770 S 668.65 0.00 0.00<br />

11406 S 522.01 0.00 0.00 11771 S 668.65 0.00 0.00<br />

11420 S 62.61 0.00 0.00 11772 S 668.65 0.00 0.00<br />

11421 S 75.90 0.00 0.00 11900 S 29.73 0.00 0.00<br />

11422 S 82.90 0.00 0.00 11901 S 32.41 0.00 0.00<br />

11423 S 92.34 0.00 0.00 11920 S 94.09 0.00 0.00<br />

11424 S 522.01 0.00 0.00 11921 S 103.54 0.00 0.00<br />

11426 S 638.38 0.00 0.00 11922 S 33.57 0.00 0.00<br />

11440 S 71.71 0.00 0.00 11950 S 34.28 0.00 0.00<br />

11441 S 82.90 0.00 0.00 11951 S 42.67 0.00 0.00<br />

11442 S 91.29 0.00 0.00 11952 S 51.37 0.00 0.00<br />

11443 S 101.08 0.00 0.00 11954 S 51.37 0.00 0.00<br />

11444 S 319.04 0.00 0.00 11960 S 623.17 0.00 0.00<br />

11446 S 638.38 0.00 0.00 11970 S 1,128.78 0.00 0.00<br />

11450 S 638.38 0.00 0.00 11971 S 584.95 0.00 0.00<br />

11451 S 638.38 0.00 0.00 11976 S 62.61 0.00 0.00<br />

11462 S 638.38 0.00 0.00 11980 S 25.29 0.00 0.00<br />

11463 S 638.38 0.00 0.00 11981 S 25.29 0.00 0.00<br />

11470 S 638.38 0.00 0.00 11982 S 25.29 0.00 0.00<br />

11471 S 638.38 0.00 0.00 11983 S 25.29 0.00 0.00<br />

11600 S 94.09 0.00 0.00 12001 S 51.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 51.37 0.00 0.00 14021 S 553.79 0.00 0.00<br />

12004 S 51.37 0.00 0.00 14040 S 523.54 0.00 0.00<br />

12005 S 68.83 0.00 0.00 14041 S 553.79 0.00 0.00<br />

12006 S 68.83 0.00 0.00 14060 S 553.79 0.00 0.00<br />

12007 S 68.83 0.00 0.00 14061 S 553.79 0.00 0.00<br />

12011 S 51.37 0.00 0.00 14300 S 710.17 0.00 0.00<br />

12013 S 51.37 0.00 0.00 14350 S 653.43 0.00 0.00<br />

12014 S 51.37 0.00 0.00 15002 S 239.57 0.00 0.00<br />

12015 S 51.37 0.00 0.00 15003 S 239.57 0.00 0.00<br />

12016 S 68.83 0.00 0.00 15004 S 239.57 0.00 0.00<br />

12017 S 68.83 0.00 0.00 15005 S 239.57 0.00 0.00<br />

12018 S 68.83 0.00 0.00 15040 S 110.49 0.00 0.00<br />

12020 S 129.86 0.00 0.00 15050 S 239.57 0.00 0.00<br />

12021 S 110.49 0.00 0.00 15100 S 623.17 0.00 0.00<br />

12031 S 51.37 0.00 0.00 15101 S 653.43 0.00 0.00<br />

12032 S 134.71 0.00 0.00 15110 S 297.59 0.00 0.00<br />

12034 S 68.83 0.00 0.00 15111 S 244.17 0.00 0.00<br />

12035 S 68.83 0.00 0.00 15115 S 297.59 0.00 0.00<br />

12036 S 110.49 0.00 0.00 15116 S 244.17 0.00 0.00<br />

12037 S 220.21 0.00 0.00 15120 S 623.17 0.00 0.00<br />

12041 S 51.37 0.00 0.00 15121 S 653.43 0.00 0.00<br />

12042 S 51.37 0.00 0.00 15130 S 523.54 0.00 0.00<br />

12044 S 68.83 0.00 0.00 15131 S 470.10 0.00 0.00<br />

12045 S 110.49 0.00 0.00 15135 S 523.54 0.00 0.00<br />

12046 S 110.49 0.00 0.00 15136 S 470.10 0.00 0.00<br />

12047 S 220.21 0.00 0.00 15150 S 297.59 0.00 0.00<br />

12051 S 51.37 0.00 0.00 15151 S 244.17 0.00 0.00<br />

12052 S 51.37 0.00 0.00 15152 S 244.17 0.00 0.00<br />

12053 S 51.37 0.00 0.00 15155 S 297.59 0.00 0.00<br />

12054 S 68.83 0.00 0.00 15156 S 244.17 0.00 0.00<br />

12055 S 110.49 0.00 0.00 15157 S 244.17 0.00 0.00<br />

12056 S 110.49 0.00 0.00 15170 S 134.71 0.00 0.00<br />

12057 S 220.21 0.00 0.00 15171 S 134.71 0.00 0.00<br />

13100 S 239.57 0.00 0.00 15175 S 173.43 0.00 0.00<br />

13101 S 239.57 0.00 0.00 15176 S 173.43 0.00 0.00<br />

13102 S 129.86 0.00 0.00 15200 S 553.79 0.00 0.00<br />

13120 S 110.49 0.00 0.00 15201 S 465.51 0.00 0.00<br />

13121 S 110.49 0.00 0.00 15220 S 523.54 0.00 0.00<br />

13122 S 110.49 0.00 0.00 15221 S 239.57 0.00 0.00<br />

13131 S 110.49 0.00 0.00 15240 S 553.79 0.00 0.00<br />

13132 S 110.49 0.00 0.00 15241 S 239.57 0.00 0.00<br />

13133 S 110.49 0.00 0.00 15260 S 523.54 0.00 0.00<br />

13150 S 239.57 0.00 0.00 15261 S 465.51 0.00 0.00<br />

13151 S 239.57 0.00 0.00 15300 S 239.57 0.00 0.00<br />

13152 S 239.57 0.00 0.00 15301 S 239.57 0.00 0.00<br />

13153 S 110.49 0.00 0.00 15320 S 239.57 0.00 0.00<br />

13160 S 623.17 0.00 0.00 15321 S 239.57 0.00 0.00<br />

14000 S 523.54 0.00 0.00 15330 S 239.57 0.00 0.00<br />

14001 S 553.79 0.00 0.00 15331 S 239.57 0.00 0.00<br />

14020 S 553.79 0.00 0.00 15335 S 239.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 239.57 0.00 0.00 15826 S 653.43 0.00 0.00<br />

15340 S 134.71 0.00 0.00 15828 S 653.43 0.00 0.00<br />

15341 S 134.71 0.00 0.00 15829 S 751.30 0.00 0.00<br />

15360 S 134.71 0.00 0.00 15830 S 668.65 0.00 0.00<br />

15361 S 134.71 0.00 0.00 15832 S 668.65 0.00 0.00<br />

15365 S 134.71 0.00 0.00 15833 S 668.65 0.00 0.00<br />

15366 S 134.71 0.00 0.00 15834 S 668.65 0.00 0.00<br />

15400 S 239.57 0.00 0.00 15835 S 580.36 0.00 0.00<br />

15401 S 239.57 0.00 0.00 15836 S 552.28 0.00 0.00<br />

15420 S 239.57 0.00 0.00 15837 S 622.28 0.00 0.00<br />

15421 S 239.57 0.00 0.00 15838 S 622.28 0.00 0.00<br />

15430 S 239.57 0.00 0.00 15839 S 552.28 0.00 0.00<br />

15431 S 239.57 0.00 0.00 15840 S 710.17 0.00 0.00<br />

15570 S 653.43 0.00 0.00 15841 S 710.17 0.00 0.00<br />

15572 S 653.43 0.00 0.00 15842 S 824.58 0.00 0.00<br />

15574 S 653.43 0.00 0.00 15845 S 710.17 0.00 0.00<br />

15576 S 653.43 0.00 0.00 15847 S 668.65 0.00 0.00<br />

15600 S 653.43 0.00 0.00 15850 S 106.81 0.00 0.00<br />

15610 S 653.43 0.00 0.00 15851 S 48.62 0.00 0.00<br />

15620 S 710.17 0.00 0.00 15852 S 25.29 0.00 0.00<br />

15630 S 653.43 0.00 0.00 15860 S 25.29 0.00 0.00<br />

15650 S 751.30 0.00 0.00 15876 S 653.43 0.00 0.00<br />

15731 S 653.43 0.00 0.00 15877 S 653.43 0.00 0.00<br />

15732 S 653.43 0.00 0.00 15878 S 653.43 0.00 0.00<br />

15734 S 653.43 0.00 0.00 15879 S 653.43 0.00 0.00<br />

15736 S 653.43 0.00 0.00 15920 S 206.53 0.00 0.00<br />

15738 S 653.43 0.00 0.00 15922 S 710.17 0.00 0.00<br />

15740 S 523.54 0.00 0.00 15931 S 668.65 0.00 0.00<br />

15750 S 623.17 0.00 0.00 15933 S 668.65 0.00 0.00<br />

15760 S 623.17 0.00 0.00 15934 S 653.43 0.00 0.00<br />

15770 S 653.43 0.00 0.00 15935 S 710.17 0.00 0.00<br />

15775 S 178.54 0.00 0.00 15936 S 610.54 0.00 0.00<br />

15776 S 178.54 0.00 0.00 15937 S 710.17 0.00 0.00<br />

15780 S 398.04 0.00 0.00 15940 S 668.65 0.00 0.00<br />

15781 S 175.20 0.00 0.00 15941 S 668.65 0.00 0.00<br />

15782 S 175.20 0.00 0.00 15944 S 653.43 0.00 0.00<br />

15783 S 106.81 0.00 0.00 15945 S 710.17 0.00 0.00<br />

15786 S 32.41 0.00 0.00 15946 S 710.17 0.00 0.00<br />

15787 S 29.38 0.00 0.00 15950 S 668.65 0.00 0.00<br />

15788 S 32.41 0.00 0.00 15951 S 725.38 0.00 0.00<br />

15789 S 59.38 0.00 0.00 15952 S 553.79 0.00 0.00<br />

15792 S 59.38 0.00 0.00 15953 S 610.54 0.00 0.00<br />

15793 S 32.41 0.00 0.00 15956 S 553.79 0.00 0.00<br />

15819 S 134.71 0.00 0.00 15958 S 610.54 0.00 0.00<br />

15820 S 653.43 0.00 0.00 16000 S 26.23 0.00 0.00<br />

15821 S 653.43 0.00 0.00 16020 S 39.88 0.00 0.00<br />

15822 S 653.43 0.00 0.00 16025 S 61.42 0.00 0.00<br />

15823 S 751.30 0.00 0.00 16030 S 76.90 0.00 0.00<br />

15824 S 653.43 0.00 0.00 16035 S 59.38 0.00 0.00<br />

15825 S 653.43 0.00 0.00 17000 S 32.41 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.85 0.00 0.00 19300 S 718.38 0.00 0.00<br />

17004 S 84.64 0.00 0.00 19301 S 661.65 0.00 0.00<br />

17106 S 106.81 0.00 0.00 19302 S 1,263.67 0.00 0.00<br />

17107 S 106.81 0.00 0.00 19303 S 954.99 0.00 0.00<br />

17108 S 106.81 0.00 0.00 19304 S 954.99 0.00 0.00<br />

17110 S 32.41 0.00 0.00 19316 S 954.99 0.00 0.00<br />

17111 S 59.38 0.00 0.00 19318 S 1,091.08 0.00 0.00<br />

17250 S 44.78 0.00 0.00 19324 S 1,091.08 0.00 0.00<br />

17260 S 47.92 0.00 0.00 19325 S 1,809.70 0.00 0.00<br />

17261 S 59.38 0.00 0.00 19328 S 814.56 0.00 0.00<br />

17262 S 59.38 0.00 0.00 19330 S 814.56 0.00 0.00<br />

17263 S 59.38 0.00 0.00 19340 S 1,004.08 0.00 0.00<br />

17264 S 59.38 0.00 0.00 19342 S 1,417.72 0.00 0.00<br />

17266 S 106.81 0.00 0.00 19350 S 718.38 0.00 0.00<br />

17270 S 59.38 0.00 0.00 19355 S 954.99 0.00 0.00<br />

17271 S 59.38 0.00 0.00 19357 S 1,515.59 0.00 0.00<br />

17272 S 59.38 0.00 0.00 19366 S 996.13 0.00 0.00<br />

17273 S 106.81 0.00 0.00 19370 S 954.99 0.00 0.00<br />

17274 S 106.81 0.00 0.00 19371 S 954.99 0.00 0.00<br />

17276 S 106.81 0.00 0.00 19380 S 1,132.22 0.00 0.00<br />

17280 S 59.38 0.00 0.00 19396 S 1,314.21 0.00 0.00<br />

17281 S 88.49 0.00 0.00 20000 S 55.30 0.00 0.00<br />

17282 S 101.08 0.00 0.00 20005 S 637.17 0.00 0.00<br />

17283 S 106.81 0.00 0.00 20103 S 625.32 0.00 0.00<br />

17284 S 106.81 0.00 0.00 20150 S 1,775.29 0.00 0.00<br />

17286 S 106.81 0.00 0.00 20200 S 522.01 0.00 0.00<br />

17311 S 176.33 0.00 0.00 20205 S 552.28 0.00 0.00<br />

17312 S 176.33 0.00 0.00 20206 S 258.07 0.00 0.00<br />

17313 S 176.33 0.00 0.00 20220 S 280.52 0.00 0.00<br />

17314 S 176.33 0.00 0.00 20225 S 509.01 0.00 0.00<br />

17315 S 39.88 0.00 0.00 20240 S 638.38 0.00 0.00<br />

17340 S 14.34 0.00 0.00 20245 S 668.65 0.00 0.00<br />

17360 S 32.41 0.00 0.00 20250 S 667.44 0.00 0.00<br />

17380 S 32.41 0.00 0.00 20251 S 667.44 0.00 0.00<br />

19000 S 67.51 0.00 0.00 20500 S 55.27 0.00 0.00<br />

19001 S 9.10 0.00 0.00 20520 S 93.04 0.00 0.00<br />

19020 S 590.33 0.00 0.00 20525 S 668.65 0.00 0.00<br />

19100 S 201.02 0.00 0.00 20526 S 30.08 0.00 0.00<br />

19101 S 631.38 0.00 0.00 20550 S 22.73 0.00 0.00<br />

19102 S 258.07 0.00 0.00 20551 S 22.38 0.00 0.00<br />

19103 S 451.69 0.00 0.00 20552 S 21.68 0.00 0.00<br />

19105 S 1,314.21 0.00 0.00 20553 S 24.14 0.00 0.00<br />

19110 S 631.38 0.00 0.00 20555 S 1,169.67 0.00 0.00<br />

19112 S 661.65 0.00 0.00 20600 S 23.08 0.00 0.00<br />

19120 S 661.65 0.00 0.00 20605 S 25.88 0.00 0.00<br />

19125 S 661.65 0.00 0.00 20610 S 36.38 0.00 0.00<br />

19126 S 661.65 0.00 0.00 20612 S 24.49 0.00 0.00<br />

19296 S 1,809.70 0.00 0.00 20615 S 102.49 0.00 0.00<br />

19297 S 1,809.70 0.00 0.00 20650 S 667.44 0.00 0.00<br />

19298 S 1,809.70 0.00 0.00 20662 S 852.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 852.58 0.00 0.00 21085 S 256.74 0.00 0.00<br />

20665 S 25.29 0.00 0.00 21086 S 558.93 0.00 0.00<br />

20670 S 468.59 0.00 0.00 21087 S 559.64 0.00 0.00<br />

20680 S 668.65 0.00 0.00 21088 S 1,639.09 0.00 0.00<br />

20690 S 795.71 0.00 0.00 21100 S 1,030.42 0.00 0.00<br />

20692 S 825.98 0.00 0.00 21110 S 294.87 0.00 0.00<br />

20693 S 667.44 0.00 0.00 21120 S 954.97 0.00 0.00<br />

20694 S 583.74 0.00 0.00 21121 S 954.97 0.00 0.00<br />

20696 S 1,169.67 0.00 0.00 21122 S 954.97 0.00 0.00<br />

20697 S 777.88 0.00 0.00 21123 S 954.97 0.00 0.00<br />

20822 S 1,095.99 0.00 0.00 21125 S 954.97 0.00 0.00<br />

20900 S 825.98 0.00 0.00 21127 S 1,452.65 0.00 0.00<br />

20902 S 882.71 0.00 0.00 21137 S 969.02 0.00 0.00<br />

20910 S 653.43 0.00 0.00 21138 S 1,639.09 0.00 0.00<br />

20912 S 653.43 0.00 0.00 21139 S 1,639.09 0.00 0.00<br />

20920 S 610.54 0.00 0.00 21150 S 1,639.09 0.00 0.00<br />

20922 S 553.79 0.00 0.00 21181 S 954.97 0.00 0.00<br />

20924 S 882.71 0.00 0.00 21198 S 1,639.09 0.00 0.00<br />

20926 S 384.59 0.00 0.00 21199 S 1,639.09 0.00 0.00<br />

20950 S 55.30 0.00 0.00 21206 S 1,158.56 0.00 0.00<br />

20972 S 1,851.15 0.00 0.00 21208 S 1,290.01 0.00 0.00<br />

20973 S 1,851.15 0.00 0.00 21209 S 1,158.56 0.00 0.00<br />

20979 S 22.73 0.00 0.00 21210 S 1,290.01 0.00 0.00<br />

20982 S 1,775.29 0.00 0.00 21215 S 1,290.01 0.00 0.00<br />

21010 S 695.39 0.00 0.00 21230 S 1,290.01 0.00 0.00<br />

21015 S 578.56 0.00 0.00 21235 S 954.97 0.00 0.00<br />

21025 S 1,030.42 0.00 0.00 21240 S 1,117.42 0.00 0.00<br />

21026 S 1,030.42 0.00 0.00 21242 S 1,158.56 0.00 0.00<br />

21029 S 1,030.42 0.00 0.00 21243 S 1,158.56 0.00 0.00<br />

21030 S 243.09 0.00 0.00 21244 S 1,290.01 0.00 0.00<br />

21031 S 201.12 0.00 0.00 21245 S 1,290.01 0.00 0.00<br />

21032 S 204.97 0.00 0.00 21246 S 1,290.01 0.00 0.00<br />

21034 S 1,060.69 0.00 0.00 21248 S 1,290.01 0.00 0.00<br />

21040 S 695.39 0.00 0.00 21249 S 1,290.01 0.00 0.00<br />

21044 S 1,030.42 0.00 0.00 21260 S 1,639.09 0.00 0.00<br />

21046 S 1,030.42 0.00 0.00 21267 S 1,290.01 0.00 0.00<br />

21047 S 1,030.42 0.00 0.00 21270 S 1,158.56 0.00 0.00<br />

21048 S 1,639.09 0.00 0.00 21275 S 1,290.01 0.00 0.00<br />

21050 S 1,060.69 0.00 0.00 21280 S 1,158.56 0.00 0.00<br />

21060 S 1,030.42 0.00 0.00 21282 S 676.44 0.00 0.00<br />

21070 S 1,060.69 0.00 0.00 21295 S 304.89 0.00 0.00<br />

21073 S 188.88 0.00 0.00 21296 S 641.96 0.00 0.00<br />

21076 S 327.73 0.00 0.00 21310 S 93.00 0.00 0.00<br />

21077 S 792.24 0.00 0.00 21315 S 408.68 0.00 0.00<br />

21079 S 567.33 0.00 0.00 21320 S 548.30 0.00 0.00<br />

21080 S 650.58 0.00 0.00 21325 S 782.39 0.00 0.00<br />

21081 S 599.51 0.00 0.00 21330 S 823.53 0.00 0.00<br />

21082 S 570.48 0.00 0.00 21335 S 954.97 0.00 0.00<br />

21083 S 562.09 0.00 0.00 21336 S 795.87 0.00 0.00<br />

21084 S 646.73 0.00 0.00 21337 S 548.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 782.39 0.00 0.00 22310 S 169.32 0.00 0.00<br />

21339 S 823.53 0.00 0.00 22315 S 437.93 0.00 0.00<br />

21340 S 1,117.42 0.00 0.00 22505 S 515.56 0.00 0.00<br />

21345 S 954.97 0.00 0.00 22520 S 1,217.94 0.00 0.00<br />

21355 S 1,060.69 0.00 0.00 22521 S 1,217.94 0.00 0.00<br />

21356 S 725.65 0.00 0.00 22522 S 1,217.94 0.00 0.00<br />

21360 S 969.02 0.00 0.00 22523 S 3,389.65 0.00 0.00<br />

21390 S 1,639.09 0.00 0.00 22524 S 3,389.65 0.00 0.00<br />

21400 S 358.31 0.00 0.00 22525 S 3,389.65 0.00 0.00<br />

21401 S 578.56 0.00 0.00 22900 S 725.38 0.00 0.00<br />

21406 S 1,639.09 0.00 0.00 23000 S 522.01 0.00 0.00<br />

21407 S 1,639.09 0.00 0.00 23020 S 1,098.52 0.00 0.00<br />

21421 S 782.39 0.00 0.00 23030 S 536.89 0.00 0.00<br />

21440 S 329.49 0.00 0.00 23031 S 620.58 0.00 0.00<br />

21445 S 782.39 0.00 0.00 23035 S 667.44 0.00 0.00<br />

21450 S 135.99 0.00 0.00 23040 S 825.98 0.00 0.00<br />

21451 S 366.89 0.00 0.00 23044 S 882.71 0.00 0.00<br />

21452 S 548.30 0.00 0.00 23065 S 98.64 0.00 0.00<br />

21453 S 1,060.69 0.00 0.00 23066 S 638.38 0.00 0.00<br />

21454 S 823.53 0.00 0.00 23075 S 522.01 0.00 0.00<br />

21461 S 1,117.42 0.00 0.00 23076 S 638.38 0.00 0.00<br />

21462 S 1,158.56 0.00 0.00 23077 S 668.65 0.00 0.00<br />

21465 S 1,117.42 0.00 0.00 23100 S 637.17 0.00 0.00<br />

21480 S 93.00 0.00 0.00 23101 S 1,055.30 0.00 0.00<br />

21485 S 548.30 0.00 0.00 23105 S 882.71 0.00 0.00<br />

21490 S 1,060.69 0.00 0.00 23106 S 882.71 0.00 0.00<br />

21495 S 674.84 0.00 0.00 23107 S 882.71 0.00 0.00<br />

21497 S 548.30 0.00 0.00 23120 S 923.85 0.00 0.00<br />

21501 S 590.33 0.00 0.00 23125 S 923.85 0.00 0.00<br />

21502 S 637.17 0.00 0.00 23130 S 1,226.65 0.00 0.00<br />

21550 S 622.28 0.00 0.00 23140 S 724.17 0.00 0.00<br />

21555 S 638.38 0.00 0.00 23145 S 923.85 0.00 0.00<br />

21556 S 638.38 0.00 0.00 23146 S 923.85 0.00 0.00<br />

21557 S 855.00 0.00 0.00 23150 S 882.71 0.00 0.00<br />

21600 S 795.71 0.00 0.00 23155 S 923.85 0.00 0.00<br />

21610 S 795.71 0.00 0.00 23156 S 923.85 0.00 0.00<br />

21685 S 294.87 0.00 0.00 23170 S 795.71 0.00 0.00<br />

21700 S 637.17 0.00 0.00 23172 S 795.71 0.00 0.00<br />

21720 S 667.44 0.00 0.00 23174 S 795.71 0.00 0.00<br />

21725 S 69.48 0.00 0.00 23180 S 882.71 0.00 0.00<br />

21800 S 80.26 0.00 0.00 23182 S 882.71 0.00 0.00<br />

21805 S 708.87 0.00 0.00 23184 S 882.71 0.00 0.00<br />

21820 S 80.26 0.00 0.00 23190 S 882.71 0.00 0.00<br />

21920 S 142.71 0.00 0.00 23195 S 923.85 0.00 0.00<br />

21925 S 638.38 0.00 0.00 23330 S 319.04 0.00 0.00<br />

21930 S 638.38 0.00 0.00 23331 S 584.95 0.00 0.00<br />

21935 S 668.65 0.00 0.00 23395 S 1,226.65 0.00 0.00<br />

22102 S 1,902.64 0.00 0.00 23397 S 2,165.29 0.00 0.00<br />

22103 S 1,902.64 0.00 0.00 23400 S 1,055.30 0.00 0.00<br />

22305 S 80.26 0.00 0.00 23405 S 795.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 795.71 0.00 0.00 23931 S 590.33 0.00 0.00<br />

23410 S 1,226.65 0.00 0.00 23935 S 637.17 0.00 0.00<br />

23412 S 1,358.10 0.00 0.00 24000 S 882.71 0.00 0.00<br />

23415 S 1,226.65 0.00 0.00 24006 S 882.71 0.00 0.00<br />

23420 S 1,358.10 0.00 0.00 24065 S 136.76 0.00 0.00<br />

23430 S 1,185.52 0.00 0.00 24066 S 522.01 0.00 0.00<br />

23440 S 1,185.52 0.00 0.00 24075 S 522.01 0.00 0.00<br />

23450 S 2,033.85 0.00 0.00 24076 S 638.38 0.00 0.00<br />

23455 S 2,165.29 0.00 0.00 24077 S 668.65 0.00 0.00<br />

23460 S 2,033.85 0.00 0.00 24100 S 583.74 0.00 0.00<br />

23462 S 1,358.10 0.00 0.00 24101 S 882.71 0.00 0.00<br />

23465 S 2,033.85 0.00 0.00 24102 S 882.71 0.00 0.00<br />

23466 S 1,358.10 0.00 0.00 24105 S 667.44 0.00 0.00<br />

23480 S 1,185.52 0.00 0.00 24110 S 637.17 0.00 0.00<br />

23485 S 2,165.29 0.00 0.00 24115 S 825.98 0.00 0.00<br />

23490 S 1,128.78 0.00 0.00 24116 S 825.98 0.00 0.00<br />

23491 S 1,935.97 0.00 0.00 24120 S 667.44 0.00 0.00<br />

23500 S 80.26 0.00 0.00 24125 S 825.98 0.00 0.00<br />

23505 S 437.93 0.00 0.00 24126 S 825.98 0.00 0.00<br />

23515 S 1,465.73 0.00 0.00 24130 S 825.98 0.00 0.00<br />

23520 S 169.32 0.00 0.00 24134 S 795.71 0.00 0.00<br />

23525 S 169.32 0.00 0.00 24136 S 795.71 0.00 0.00<br />

23530 S 1,080.10 0.00 0.00 24138 S 795.71 0.00 0.00<br />

23532 S 795.87 0.00 0.00 24140 S 825.98 0.00 0.00<br />

23540 S 80.26 0.00 0.00 24145 S 825.98 0.00 0.00<br />

23545 S 169.32 0.00 0.00 24147 S 795.71 0.00 0.00<br />

23550 S 1,080.10 0.00 0.00 24149 S 1,169.67 0.00 0.00<br />

23552 S 1,136.84 0.00 0.00 24152 S 1,775.29 0.00 0.00<br />

23570 S 80.26 0.00 0.00 24153 S 3,389.65 0.00 0.00<br />

23575 S 169.32 0.00 0.00 24155 S 1,128.78 0.00 0.00<br />

23585 S 1,465.73 0.00 0.00 24160 S 795.71 0.00 0.00<br />

23600 S 62.54 0.00 0.00 24164 S 825.98 0.00 0.00<br />

23605 S 437.93 0.00 0.00 24200 S 100.03 0.00 0.00<br />

23615 S 1,522.46 0.00 0.00 24201 S 522.01 0.00 0.00<br />

23616 S 1,522.46 0.00 0.00 24300 S 609.35 0.00 0.00<br />

23620 S 62.54 0.00 0.00 24301 S 882.71 0.00 0.00<br />

23625 S 437.93 0.00 0.00 24305 S 882.71 0.00 0.00<br />

23630 S 1,563.60 0.00 0.00 24310 S 667.44 0.00 0.00<br />

23650 S 80.26 0.00 0.00 24320 S 1,128.78 0.00 0.00<br />

23655 S 462.13 0.00 0.00 24330 S 1,935.97 0.00 0.00<br />

23660 S 1,080.10 0.00 0.00 24331 S 1,128.78 0.00 0.00<br />

23665 S 169.32 0.00 0.00 24332 S 852.58 0.00 0.00<br />

23670 S 1,465.73 0.00 0.00 24340 S 1,128.78 0.00 0.00<br />

23675 S 80.26 0.00 0.00 24341 S 1,128.78 0.00 0.00<br />

23680 S 1,080.10 0.00 0.00 24342 S 1,128.78 0.00 0.00<br />

23700 S 462.13 0.00 0.00 24343 S 1,169.67 0.00 0.00<br />

23800 S 1,992.71 0.00 0.00 24344 S 3,389.65 0.00 0.00<br />

23802 S 1,358.10 0.00 0.00 24345 S 795.71 0.00 0.00<br />

23921 S 465.51 0.00 0.00 24346 S 1,775.29 0.00 0.00<br />

23930 S 536.89 0.00 0.00 24357 S 1,169.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,169.67 0.00 0.00 24925 S 667.44 0.00 0.00<br />

24359 S 1,169.67 0.00 0.00 25000 S 667.44 0.00 0.00<br />

24360 S 1,079.44 0.00 0.00 25001 S 852.58 0.00 0.00<br />

24361 S 5,901.83 3,612.67 1,323.51 25020 S 667.44 0.00 0.00<br />

24362 S 1,379.51 0.00 0.00 25023 S 825.98 0.00 0.00<br />

24363 S 6,033.28 3,744.12 1,454.95 25024 S 825.98 0.00 0.00<br />

24365 S 1,079.44 0.00 0.00 25025 S 825.98 0.00 0.00<br />

24366 S 5,901.83 3,612.67 1,323.51 25028 S 583.74 0.00 0.00<br />

24400 S 882.71 0.00 0.00 25031 S 637.17 0.00 0.00<br />

24410 S 882.71 0.00 0.00 25035 S 637.17 0.00 0.00<br />

24420 S 1,128.78 0.00 0.00 25040 S 923.85 0.00 0.00<br />

24430 S 1,935.97 0.00 0.00 25065 S 138.86 0.00 0.00<br />

24435 S 1,992.71 0.00 0.00 25066 S 638.38 0.00 0.00<br />

24470 S 1,128.78 0.00 0.00 25075 S 522.01 0.00 0.00<br />

24495 S 795.71 0.00 0.00 25076 S 668.65 0.00 0.00<br />

24498 S 1,935.97 0.00 0.00 25077 S 668.65 0.00 0.00<br />

24500 S 80.26 0.00 0.00 25085 S 667.44 0.00 0.00<br />

24505 S 80.26 0.00 0.00 25100 S 637.17 0.00 0.00<br />

24515 S 1,522.46 0.00 0.00 25101 S 825.98 0.00 0.00<br />

24516 S 1,522.46 0.00 0.00 25105 S 882.71 0.00 0.00<br />

24530 S 80.26 0.00 0.00 25107 S 825.98 0.00 0.00<br />

24535 S 169.32 0.00 0.00 25109 S 852.58 0.00 0.00<br />

24538 S 708.87 0.00 0.00 25110 S 667.44 0.00 0.00<br />

24545 S 1,522.46 0.00 0.00 25111 S 667.44 0.00 0.00<br />

24546 S 1,563.60 0.00 0.00 25112 S 724.17 0.00 0.00<br />

24560 S 80.26 0.00 0.00 25115 S 724.17 0.00 0.00<br />

24565 S 80.26 0.00 0.00 25116 S 724.17 0.00 0.00<br />

24566 S 708.87 0.00 0.00 25118 S 795.71 0.00 0.00<br />

24575 S 1,465.73 0.00 0.00 25119 S 825.98 0.00 0.00<br />

24576 S 80.26 0.00 0.00 25120 S 825.98 0.00 0.00<br />

24577 S 169.32 0.00 0.00 25125 S 825.98 0.00 0.00<br />

24579 S 1,465.73 0.00 0.00 25126 S 825.98 0.00 0.00<br />

24582 S 708.87 0.00 0.00 25130 S 825.98 0.00 0.00<br />

24586 S 1,522.46 0.00 0.00 25135 S 825.98 0.00 0.00<br />

24587 S 1,563.60 0.00 0.00 25136 S 825.98 0.00 0.00<br />

24600 S 80.26 0.00 0.00 25145 S 795.71 0.00 0.00<br />

24605 S 515.56 0.00 0.00 25150 S 795.71 0.00 0.00<br />

24615 S 1,465.73 0.00 0.00 25151 S 795.71 0.00 0.00<br />

24620 S 437.93 0.00 0.00 25210 S 825.98 0.00 0.00<br />

24635 S 1,465.73 0.00 0.00 25215 S 882.71 0.00 0.00<br />

24640 S 54.21 0.00 0.00 25230 S 882.71 0.00 0.00<br />

24650 S 62.54 0.00 0.00 25240 S 882.71 0.00 0.00<br />

24655 S 169.32 0.00 0.00 25248 S 637.17 0.00 0.00<br />

24665 S 1,136.84 0.00 0.00 25250 S 742.28 0.00 0.00<br />

24666 S 1,522.46 0.00 0.00 25251 S 742.28 0.00 0.00<br />

24670 S 80.26 0.00 0.00 25259 S 777.88 0.00 0.00<br />

24675 S 80.26 0.00 0.00 25260 S 882.71 0.00 0.00<br />

24685 S 1,080.10 0.00 0.00 25263 S 795.71 0.00 0.00<br />

24800 S 1,185.52 0.00 0.00 25265 S 825.98 0.00 0.00<br />

24802 S 1,226.65 0.00 0.00 25270 S 882.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 825.98 0.00 0.00 25505 S 169.32 0.00 0.00<br />

25274 S 882.71 0.00 0.00 25515 S 1,080.10 0.00 0.00<br />

25275 S 882.71 0.00 0.00 25520 S 169.32 0.00 0.00<br />

25280 S 882.71 0.00 0.00 25525 S 1,136.84 0.00 0.00<br />

25290 S 825.98 0.00 0.00 25526 S 1,177.97 0.00 0.00<br />

25295 S 667.44 0.00 0.00 25530 S 62.54 0.00 0.00<br />

25300 S 825.98 0.00 0.00 25535 S 80.26 0.00 0.00<br />

25301 S 825.98 0.00 0.00 25545 S 1,080.10 0.00 0.00<br />

25310 S 1,128.78 0.00 0.00 25560 S 62.54 0.00 0.00<br />

25312 S 1,185.52 0.00 0.00 25565 S 169.32 0.00 0.00<br />

25315 S 1,128.78 0.00 0.00 25574 S 1,465.73 0.00 0.00<br />

25316 S 1,935.97 0.00 0.00 25575 S 1,465.73 0.00 0.00<br />

25320 S 1,128.78 0.00 0.00 25600 S 62.54 0.00 0.00<br />

25332 S 1,079.44 0.00 0.00 25605 S 169.32 0.00 0.00<br />

25335 S 1,128.78 0.00 0.00 25606 S 739.13 0.00 0.00<br />

25337 S 1,226.65 0.00 0.00 25607 S 1,563.60 0.00 0.00<br />

25350 S 1,935.97 0.00 0.00 25608 S 1,563.60 0.00 0.00<br />

25355 S 1,128.78 0.00 0.00 25609 S 1,563.60 0.00 0.00<br />

25360 S 825.98 0.00 0.00 25622 S 62.54 0.00 0.00<br />

25365 S 825.98 0.00 0.00 25624 S 169.32 0.00 0.00<br />

25370 S 1,128.78 0.00 0.00 25628 S 1,080.10 0.00 0.00<br />

25375 S 1,185.52 0.00 0.00 25630 S 62.54 0.00 0.00<br />

25390 S 825.98 0.00 0.00 25635 S 169.32 0.00 0.00<br />

25391 S 1,185.52 0.00 0.00 25645 S 1,080.10 0.00 0.00<br />

25392 S 825.98 0.00 0.00 25650 S 62.54 0.00 0.00<br />

25393 S 1,185.52 0.00 0.00 25651 S 995.97 0.00 0.00<br />

25394 S 1,775.29 0.00 0.00 25652 S 1,677.90 0.00 0.00<br />

25400 S 1,128.78 0.00 0.00 25660 S 80.26 0.00 0.00<br />

25405 S 1,992.71 0.00 0.00 25670 S 739.13 0.00 0.00<br />

25415 S 1,935.97 0.00 0.00 25671 S 655.44 0.00 0.00<br />

25420 S 1,992.71 0.00 0.00 25675 S 80.26 0.00 0.00<br />

25425 S 1,128.78 0.00 0.00 25676 S 708.87 0.00 0.00<br />

25426 S 1,185.52 0.00 0.00 25680 S 80.26 0.00 0.00<br />

25430 S 1,775.29 0.00 0.00 25685 S 739.13 0.00 0.00<br />

25431 S 1,775.29 0.00 0.00 25690 S 437.93 0.00 0.00<br />

25440 S 1,992.71 0.00 0.00 25695 S 708.87 0.00 0.00<br />

25441 S 5,901.83 3,612.67 1,323.51 25800 S 1,992.71 0.00 0.00<br />

25442 S 5,901.83 3,612.67 1,323.51 25805 S 1,226.65 0.00 0.00<br />

25443 S 1,379.51 0.00 0.00 25810 S 2,033.85 0.00 0.00<br />

25444 S 1,379.51 0.00 0.00 25820 S 1,185.52 0.00 0.00<br />

25445 S 1,379.51 0.00 0.00 25825 S 2,033.85 0.00 0.00<br />

25446 S 6,033.28 3,744.12 1,454.95 25830 S 2,033.85 0.00 0.00<br />

25447 S 1,079.44 0.00 0.00 25907 S 667.44 0.00 0.00<br />

25449 S 1,079.44 0.00 0.00 25922 S 667.44 0.00 0.00<br />

25450 S 1,128.78 0.00 0.00 25929 S 553.79 0.00 0.00<br />

25455 S 1,128.78 0.00 0.00 25931 S 852.58 0.00 0.00<br />

25490 S 1,128.78 0.00 0.00 26010 S 55.30 0.00 0.00<br />

25491 S 1,128.78 0.00 0.00 26011 S 403.96 0.00 0.00<br />

25492 S 1,128.78 0.00 0.00 26020 S 536.01 0.00 0.00<br />

25500 S 62.54 0.00 0.00 26025 S 482.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 536.01 0.00 0.00 26392 S 789.14 0.00 0.00<br />

26034 S 536.01 0.00 0.00 26410 S 566.27 0.00 0.00<br />

26035 S 650.25 0.00 0.00 26412 S 789.14 0.00 0.00<br />

26040 S 845.88 0.00 0.00 26415 S 845.88 0.00 0.00<br />

26045 S 789.14 0.00 0.00 26416 S 789.14 0.00 0.00<br />

26055 S 536.01 0.00 0.00 26418 S 623.01 0.00 0.00<br />

26060 S 536.01 0.00 0.00 26420 S 845.88 0.00 0.00<br />

26070 S 536.01 0.00 0.00 26426 S 789.14 0.00 0.00<br />

26075 S 623.01 0.00 0.00 26428 S 789.14 0.00 0.00<br />

26080 S 623.01 0.00 0.00 26432 S 566.27 0.00 0.00<br />

26100 S 536.01 0.00 0.00 26433 S 566.27 0.00 0.00<br />

26105 S 482.57 0.00 0.00 26434 S 789.14 0.00 0.00<br />

26110 S 482.57 0.00 0.00 26437 S 566.27 0.00 0.00<br />

26115 S 638.38 0.00 0.00 26440 S 566.27 0.00 0.00<br />

26116 S 638.38 0.00 0.00 26442 S 789.14 0.00 0.00<br />

26117 S 668.65 0.00 0.00 26445 S 566.27 0.00 0.00<br />

26121 S 845.88 0.00 0.00 26449 S 789.14 0.00 0.00<br />

26123 S 845.88 0.00 0.00 26450 S 566.27 0.00 0.00<br />

26125 S 623.01 0.00 0.00 26455 S 566.27 0.00 0.00<br />

26130 S 566.27 0.00 0.00 26460 S 566.27 0.00 0.00<br />

26135 S 845.88 0.00 0.00 26471 S 536.01 0.00 0.00<br />

26140 S 536.01 0.00 0.00 26474 S 536.01 0.00 0.00<br />

26145 S 566.27 0.00 0.00 26476 S 482.57 0.00 0.00<br />

26160 S 566.27 0.00 0.00 26477 S 482.57 0.00 0.00<br />

26170 S 566.27 0.00 0.00 26478 S 482.57 0.00 0.00<br />

26180 S 566.27 0.00 0.00 26479 S 482.57 0.00 0.00<br />

26185 S 623.01 0.00 0.00 26480 S 789.14 0.00 0.00<br />

26200 S 536.01 0.00 0.00 26483 S 789.14 0.00 0.00<br />

26205 S 789.14 0.00 0.00 26485 S 758.88 0.00 0.00<br />

26210 S 536.01 0.00 0.00 26489 S 789.14 0.00 0.00<br />

26215 S 566.27 0.00 0.00 26490 S 789.14 0.00 0.00<br />

26230 S 794.62 0.00 0.00 26492 S 789.14 0.00 0.00<br />

26235 S 566.27 0.00 0.00 26494 S 789.14 0.00 0.00<br />

26236 S 566.27 0.00 0.00 26496 S 789.14 0.00 0.00<br />

26250 S 566.27 0.00 0.00 26497 S 789.14 0.00 0.00<br />

26255 S 789.14 0.00 0.00 26498 S 845.88 0.00 0.00<br />

26260 S 566.27 0.00 0.00 26499 S 789.14 0.00 0.00<br />

26261 S 566.27 0.00 0.00 26500 S 623.01 0.00 0.00<br />

26262 S 536.01 0.00 0.00 26502 S 845.88 0.00 0.00<br />

26320 S 522.01 0.00 0.00 26508 S 566.27 0.00 0.00<br />

26340 S 240.65 0.00 0.00 26510 S 789.14 0.00 0.00<br />

26350 S 705.44 0.00 0.00 26516 S 705.44 0.00 0.00<br />

26352 S 845.88 0.00 0.00 26517 S 789.14 0.00 0.00<br />

26356 S 845.88 0.00 0.00 26518 S 789.14 0.00 0.00<br />

26357 S 845.88 0.00 0.00 26520 S 566.27 0.00 0.00<br />

26358 S 845.88 0.00 0.00 26525 S 566.27 0.00 0.00<br />

26370 S 845.88 0.00 0.00 26530 S 981.56 0.00 0.00<br />

26372 S 845.88 0.00 0.00 26531 S 1,510.96 0.00 0.00<br />

26373 S 789.14 0.00 0.00 26535 S 1,079.44 0.00 0.00<br />

26390 S 845.88 0.00 0.00 26536 S 1,379.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 623.01 0.00 0.00 26775 S 167.19 0.00 0.00<br />

26541 S 1,018.45 0.00 0.00 26776 S 708.87 0.00 0.00<br />

26542 S 623.01 0.00 0.00 26785 S 708.87 0.00 0.00<br />

26545 S 845.88 0.00 0.00 26820 S 887.01 0.00 0.00<br />

26546 S 845.88 0.00 0.00 26841 S 845.88 0.00 0.00<br />

26548 S 845.88 0.00 0.00 26842 S 845.88 0.00 0.00<br />

26550 S 758.88 0.00 0.00 26843 S 789.14 0.00 0.00<br />

26555 S 789.14 0.00 0.00 26844 S 789.14 0.00 0.00<br />

26560 S 536.01 0.00 0.00 26850 S 845.88 0.00 0.00<br />

26561 S 789.14 0.00 0.00 26852 S 845.88 0.00 0.00<br />

26562 S 845.88 0.00 0.00 26860 S 789.14 0.00 0.00<br />

26565 S 887.01 0.00 0.00 26861 S 758.88 0.00 0.00<br />

26567 S 887.01 0.00 0.00 26862 S 845.88 0.00 0.00<br />

26568 S 789.14 0.00 0.00 26863 S 789.14 0.00 0.00<br />

26580 S 664.14 0.00 0.00 26910 S 789.14 0.00 0.00<br />

26587 S 664.14 0.00 0.00 26951 S 536.01 0.00 0.00<br />

26590 S 664.14 0.00 0.00 26952 S 623.01 0.00 0.00<br />

26591 S 789.14 0.00 0.00 26990 S 583.74 0.00 0.00<br />

26593 S 566.27 0.00 0.00 26991 S 583.74 0.00 0.00<br />

26596 S 536.01 0.00 0.00 27000 S 637.17 0.00 0.00<br />

26600 S 62.54 0.00 0.00 27001 S 825.98 0.00 0.00<br />

26605 S 80.26 0.00 0.00 27003 S 825.98 0.00 0.00<br />

26607 S 437.93 0.00 0.00 27033 S 1,128.78 0.00 0.00<br />

26608 S 795.87 0.00 0.00 27035 S 1,185.52 0.00 0.00<br />

26615 S 1,136.84 0.00 0.00 27040 S 319.04 0.00 0.00<br />

26641 S 62.54 0.00 0.00 27041 S 359.47 0.00 0.00<br />

26645 S 169.32 0.00 0.00 27047 S 638.38 0.00 0.00<br />

26650 S 708.87 0.00 0.00 27048 S 668.65 0.00 0.00<br />

26665 S 1,136.84 0.00 0.00 27049 S 668.65 0.00 0.00<br />

26670 S 62.54 0.00 0.00 27050 S 667.44 0.00 0.00<br />

26675 S 169.32 0.00 0.00 27052 S 667.44 0.00 0.00<br />

26676 S 708.87 0.00 0.00 27060 S 765.31 0.00 0.00<br />

26685 S 739.13 0.00 0.00 27062 S 765.31 0.00 0.00<br />

26686 S 1,465.73 0.00 0.00 27065 S 765.31 0.00 0.00<br />

26700 S 62.54 0.00 0.00 27066 S 923.85 0.00 0.00<br />

26705 S 80.26 0.00 0.00 27067 S 923.85 0.00 0.00<br />

26706 S 437.93 0.00 0.00 27080 S 795.71 0.00 0.00<br />

26715 S 795.87 0.00 0.00 27086 S 319.04 0.00 0.00<br />

26720 S 62.54 0.00 0.00 27087 S 667.44 0.00 0.00<br />

26725 S 62.54 0.00 0.00 27097 S 825.98 0.00 0.00<br />

26727 S 968.45 0.00 0.00 27098 S 825.98 0.00 0.00<br />

26735 S 795.87 0.00 0.00 27100 S 1,185.52 0.00 0.00<br />

26740 S 62.54 0.00 0.00 27105 S 1,185.52 0.00 0.00<br />

26742 S 80.26 0.00 0.00 27110 S 1,185.52 0.00 0.00<br />

26746 S 837.01 0.00 0.00 27111 S 1,185.52 0.00 0.00<br />

26750 S 62.54 0.00 0.00 27193 S 80.26 0.00 0.00<br />

26755 S 62.54 0.00 0.00 27194 S 515.56 0.00 0.00<br />

26756 S 708.87 0.00 0.00 27200 S 62.54 0.00 0.00<br />

26765 S 795.87 0.00 0.00 27202 S 1,049.84 0.00 0.00<br />

26770 S 62.54 0.00 0.00 27220 S 62.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 80.26 0.00 0.00 27397 S 1,128.78 0.00 0.00<br />

27238 S 169.32 0.00 0.00 27400 S 1,128.78 0.00 0.00<br />

27246 S 169.32 0.00 0.00 27403 S 882.71 0.00 0.00<br />

27250 S 80.26 0.00 0.00 27405 S 1,185.52 0.00 0.00<br />

27252 S 515.56 0.00 0.00 27407 S 1,992.71 0.00 0.00<br />

27256 S 62.54 0.00 0.00 27409 S 1,185.52 0.00 0.00<br />

27257 S 545.82 0.00 0.00 27416 S 1,775.29 0.00 0.00<br />

27265 S 80.26 0.00 0.00 27418 S 1,128.78 0.00 0.00<br />

27266 S 515.56 0.00 0.00 27420 S 1,128.78 0.00 0.00<br />

27267 S 62.54 0.00 0.00 27422 S 1,358.10 0.00 0.00<br />

27275 S 515.56 0.00 0.00 27424 S 1,128.78 0.00 0.00<br />

27301 S 620.58 0.00 0.00 27425 S 1,055.30 0.00 0.00<br />

27305 S 637.17 0.00 0.00 27427 S 1,128.78 0.00 0.00<br />

27306 S 667.44 0.00 0.00 27428 S 1,992.71 0.00 0.00<br />

27307 S 667.44 0.00 0.00 27429 S 1,992.71 0.00 0.00<br />

27310 S 882.71 0.00 0.00 27430 S 1,185.52 0.00 0.00<br />

27323 S 319.04 0.00 0.00 27435 S 1,185.52 0.00 0.00<br />

27324 S 584.95 0.00 0.00 27437 S 1,038.30 0.00 0.00<br />

27325 S 573.17 0.00 0.00 27438 S 1,379.51 0.00 0.00<br />

27326 S 573.17 0.00 0.00 27440 S 1,480.84 0.00 0.00<br />

27327 S 638.38 0.00 0.00 27441 S 1,079.44 0.00 0.00<br />

27328 S 668.65 0.00 0.00 27442 S 1,079.44 0.00 0.00<br />

27329 S 725.38 0.00 0.00 27443 S 1,079.44 0.00 0.00<br />

27330 S 882.71 0.00 0.00 27446 S 10,591.35 6,362.80 2,134.25<br />

27331 S 882.71 0.00 0.00 27496 S 765.31 0.00 0.00<br />

27332 S 882.71 0.00 0.00 27497 S 667.44 0.00 0.00<br />

27333 S 882.71 0.00 0.00 27498 S 667.44 0.00 0.00<br />

27334 S 882.71 0.00 0.00 27499 S 667.44 0.00 0.00<br />

27335 S 882.71 0.00 0.00 27500 S 169.32 0.00 0.00<br />

27340 S 667.44 0.00 0.00 27501 S 80.26 0.00 0.00<br />

27345 S 724.17 0.00 0.00 27502 S 437.93 0.00 0.00<br />

27347 S 724.17 0.00 0.00 27503 S 80.26 0.00 0.00<br />

27350 S 882.71 0.00 0.00 27508 S 80.26 0.00 0.00<br />

27355 S 825.98 0.00 0.00 27509 S 739.13 0.00 0.00<br />

27356 S 882.71 0.00 0.00 27510 S 169.32 0.00 0.00<br />

27357 S 923.85 0.00 0.00 27516 S 80.26 0.00 0.00<br />

27358 S 923.85 0.00 0.00 27517 S 80.26 0.00 0.00<br />

27360 S 923.85 0.00 0.00 27520 S 80.26 0.00 0.00<br />

27372 S 897.97 0.00 0.00 27530 S 80.26 0.00 0.00<br />

27380 S 583.74 0.00 0.00 27532 S 437.93 0.00 0.00<br />

27381 S 667.44 0.00 0.00 27538 S 80.26 0.00 0.00<br />

27385 S 667.44 0.00 0.00 27550 S 80.26 0.00 0.00<br />

27386 S 667.44 0.00 0.00 27552 S 462.13 0.00 0.00<br />

27390 S 583.74 0.00 0.00 27560 S 80.26 0.00 0.00<br />

27391 S 637.17 0.00 0.00 27562 S 462.13 0.00 0.00<br />

27392 S 667.44 0.00 0.00 27566 S 1,049.84 0.00 0.00<br />

27393 S 795.71 0.00 0.00 27570 S 462.13 0.00 0.00<br />

27394 S 825.98 0.00 0.00 27594 S 667.44 0.00 0.00<br />

27395 S 1,128.78 0.00 0.00 27600 S 667.44 0.00 0.00<br />

27396 S 825.98 0.00 0.00 27601 S 667.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 667.44 0.00 0.00 27730 S 795.71 0.00 0.00<br />

27603 S 590.33 0.00 0.00 27732 S 795.71 0.00 0.00<br />

27604 S 637.17 0.00 0.00 27734 S 795.71 0.00 0.00<br />

27605 S 580.61 0.00 0.00 27740 S 795.71 0.00 0.00<br />

27606 S 583.74 0.00 0.00 27742 S 1,098.52 0.00 0.00<br />

27607 S 637.17 0.00 0.00 27745 S 1,935.97 0.00 0.00<br />

27610 S 795.71 0.00 0.00 27750 S 80.26 0.00 0.00<br />

27612 S 825.98 0.00 0.00 27752 S 437.93 0.00 0.00<br />

27613 S 131.17 0.00 0.00 27756 S 739.13 0.00 0.00<br />

27614 S 638.38 0.00 0.00 27758 S 1,136.84 0.00 0.00<br />

27615 S 825.98 0.00 0.00 27759 S 1,522.46 0.00 0.00<br />

27618 S 522.01 0.00 0.00 27760 S 80.26 0.00 0.00<br />

27619 S 668.65 0.00 0.00 27762 S 437.93 0.00 0.00<br />

27620 S 882.71 0.00 0.00 27766 S 1,080.10 0.00 0.00<br />

27625 S 882.71 0.00 0.00 27767 S 62.54 0.00 0.00<br />

27626 S 882.71 0.00 0.00 27768 S 62.54 0.00 0.00<br />

27630 S 667.44 0.00 0.00 27769 S 1,677.90 0.00 0.00<br />

27635 S 825.98 0.00 0.00 27780 S 80.26 0.00 0.00<br />

27637 S 825.98 0.00 0.00 27781 S 437.93 0.00 0.00<br />

27638 S 825.98 0.00 0.00 27784 S 1,080.10 0.00 0.00<br />

27640 S 1,098.52 0.00 0.00 27786 S 80.26 0.00 0.00<br />

27641 S 795.71 0.00 0.00 27788 S 80.26 0.00 0.00<br />

27647 S 1,128.78 0.00 0.00 27792 S 1,080.10 0.00 0.00<br />

27650 S 1,128.78 0.00 0.00 27808 S 80.26 0.00 0.00<br />

27652 S 1,935.97 0.00 0.00 27810 S 169.32 0.00 0.00<br />

27654 S 1,128.78 0.00 0.00 27814 S 1,080.10 0.00 0.00<br />

27656 S 637.17 0.00 0.00 27816 S 80.26 0.00 0.00<br />

27658 S 583.74 0.00 0.00 27818 S 169.32 0.00 0.00<br />

27659 S 637.17 0.00 0.00 27822 S 1,080.10 0.00 0.00<br />

27664 S 637.17 0.00 0.00 27823 S 1,465.73 0.00 0.00<br />

27665 S 795.71 0.00 0.00 27824 S 80.26 0.00 0.00<br />

27675 S 637.17 0.00 0.00 27825 S 437.93 0.00 0.00<br />

27676 S 825.98 0.00 0.00 27826 S 1,080.10 0.00 0.00<br />

27680 S 825.98 0.00 0.00 27827 S 1,465.73 0.00 0.00<br />

27681 S 795.71 0.00 0.00 27828 S 1,522.46 0.00 0.00<br />

27685 S 825.98 0.00 0.00 27829 S 1,049.84 0.00 0.00<br />

27686 S 825.98 0.00 0.00 27830 S 80.26 0.00 0.00<br />

27687 S 825.98 0.00 0.00 27831 S 437.93 0.00 0.00<br />

27690 S 1,185.52 0.00 0.00 27832 S 1,049.84 0.00 0.00<br />

27691 S 1,185.52 0.00 0.00 27840 S 169.32 0.00 0.00<br />

27692 S 1,128.78 0.00 0.00 27842 S 462.13 0.00 0.00<br />

27695 S 795.71 0.00 0.00 27846 S 1,080.10 0.00 0.00<br />

27696 S 795.71 0.00 0.00 27848 S 1,080.10 0.00 0.00<br />

27698 S 795.71 0.00 0.00 27860 S 462.13 0.00 0.00<br />

27700 S 1,079.44 0.00 0.00 27870 S 1,992.71 0.00 0.00<br />

27704 S 637.17 0.00 0.00 27871 S 1,992.71 0.00 0.00<br />

27705 S 1,098.52 0.00 0.00 27884 S 667.44 0.00 0.00<br />

27707 S 637.17 0.00 0.00 27889 S 825.98 0.00 0.00<br />

27709 S 795.71 0.00 0.00 27892 S 667.44 0.00 0.00<br />

27726 S 995.97 0.00 0.00 27893 S 667.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 667.44 0.00 0.00 28153 S 664.30 0.00 0.00<br />

28001 S 128.01 0.00 0.00 28160 S 664.30 0.00 0.00<br />

28002 S 667.44 0.00 0.00 28171 S 664.30 0.00 0.00<br />

28003 S 667.44 0.00 0.00 28173 S 664.30 0.00 0.00<br />

28005 S 664.30 0.00 0.00 28175 S 664.30 0.00 0.00<br />

28008 S 664.30 0.00 0.00 28190 S 132.21 0.00 0.00<br />

28010 S 94.09 0.00 0.00 28192 S 522.01 0.00 0.00<br />

28011 S 664.30 0.00 0.00 28193 S 359.47 0.00 0.00<br />

28020 S 634.04 0.00 0.00 28200 S 664.30 0.00 0.00<br />

28022 S 634.04 0.00 0.00 28202 S 664.30 0.00 0.00<br />

28024 S 634.04 0.00 0.00 28208 S 664.30 0.00 0.00<br />

28035 S 660.17 0.00 0.00 28210 S 1,166.72 0.00 0.00<br />

28043 S 638.38 0.00 0.00 28220 S 203.92 0.00 0.00<br />

28045 S 664.30 0.00 0.00 28222 S 580.61 0.00 0.00<br />

28046 S 664.30 0.00 0.00 28225 S 580.61 0.00 0.00<br />

28050 S 634.04 0.00 0.00 28226 S 580.61 0.00 0.00<br />

28052 S 634.04 0.00 0.00 28230 S 200.07 0.00 0.00<br />

28054 S 634.04 0.00 0.00 28232 S 191.32 0.00 0.00<br />

28055 S 660.17 0.00 0.00 28234 S 634.04 0.00 0.00<br />

28060 S 634.04 0.00 0.00 28238 S 1,166.72 0.00 0.00<br />

28062 S 664.30 0.00 0.00 28240 S 634.04 0.00 0.00<br />

28070 S 664.30 0.00 0.00 28250 S 664.30 0.00 0.00<br />

28072 S 664.30 0.00 0.00 28260 S 664.30 0.00 0.00<br />

28080 S 664.30 0.00 0.00 28261 S 664.30 0.00 0.00<br />

28086 S 634.04 0.00 0.00 28262 S 721.04 0.00 0.00<br />

28088 S 634.04 0.00 0.00 28264 S 1,083.02 0.00 0.00<br />

28090 S 664.30 0.00 0.00 28270 S 664.30 0.00 0.00<br />

28092 S 664.30 0.00 0.00 28272 S 184.68 0.00 0.00<br />

28100 S 634.04 0.00 0.00 28280 S 634.04 0.00 0.00<br />

28102 S 1,166.72 0.00 0.00 28285 S 664.30 0.00 0.00<br />

28103 S 1,166.72 0.00 0.00 28286 S 721.04 0.00 0.00<br />

28104 S 634.04 0.00 0.00 28288 S 664.30 0.00 0.00<br />

28106 S 1,166.72 0.00 0.00 28289 S 664.30 0.00 0.00<br />

28107 S 1,166.72 0.00 0.00 28290 S 818.84 0.00 0.00<br />

28108 S 634.04 0.00 0.00 28292 S 818.84 0.00 0.00<br />

28110 S 664.30 0.00 0.00 28293 S 849.10 0.00 0.00<br />

28111 S 664.30 0.00 0.00 28294 S 849.10 0.00 0.00<br />

28112 S 664.30 0.00 0.00 28296 S 849.10 0.00 0.00<br />

28113 S 664.30 0.00 0.00 28297 S 849.10 0.00 0.00<br />

28114 S 664.30 0.00 0.00 28298 S 849.10 0.00 0.00<br />

28116 S 664.30 0.00 0.00 28299 S 946.97 0.00 0.00<br />

28118 S 721.04 0.00 0.00 28300 S 1,136.46 0.00 0.00<br />

28119 S 721.04 0.00 0.00 28302 S 634.04 0.00 0.00<br />

28120 S 893.62 0.00 0.00 28304 S 1,136.46 0.00 0.00<br />

28122 S 664.30 0.00 0.00 28305 S 1,166.72 0.00 0.00<br />

28124 S 216.51 0.00 0.00 28306 S 721.04 0.00 0.00<br />

28126 S 664.30 0.00 0.00 28307 S 721.04 0.00 0.00<br />

28130 S 664.30 0.00 0.00 28308 S 634.04 0.00 0.00<br />

28140 S 664.30 0.00 0.00 28309 S 1,223.46 0.00 0.00<br />

28150 S 664.30 0.00 0.00 28310 S 664.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 664.30 0.00 0.00 28636 S 739.13 0.00 0.00<br />

28313 S 634.04 0.00 0.00 28645 S 739.13 0.00 0.00<br />

28315 S 721.04 0.00 0.00 28660 S 44.78 0.00 0.00<br />

28320 S 1,223.46 0.00 0.00 28665 S 462.13 0.00 0.00<br />

28322 S 1,223.46 0.00 0.00 28666 S 739.13 0.00 0.00<br />

28340 S 721.04 0.00 0.00 28675 S 739.13 0.00 0.00<br />

28341 S 721.04 0.00 0.00 28705 S 1,223.46 0.00 0.00<br />

28344 S 721.04 0.00 0.00 28715 S 1,992.71 0.00 0.00<br />

28345 S 721.04 0.00 0.00 28725 S 1,223.46 0.00 0.00<br />

28400 S 80.26 0.00 0.00 28730 S 1,223.46 0.00 0.00<br />

28405 S 437.93 0.00 0.00 28735 S 1,223.46 0.00 0.00<br />

28406 S 708.87 0.00 0.00 28737 S 1,264.59 0.00 0.00<br />

28415 S 1,465.73 0.00 0.00 28740 S 1,223.46 0.00 0.00<br />

28420 S 1,136.84 0.00 0.00 28750 S 1,223.46 0.00 0.00<br />

28430 S 62.54 0.00 0.00 28755 S 721.04 0.00 0.00<br />

28435 S 80.26 0.00 0.00 28760 S 1,223.46 0.00 0.00<br />

28436 S 708.87 0.00 0.00 28810 S 634.04 0.00 0.00<br />

28445 S 1,080.10 0.00 0.00 28820 S 634.04 0.00 0.00<br />

28446 S 1,851.15 0.00 0.00 28825 S 634.04 0.00 0.00<br />

28450 S 62.54 0.00 0.00 28890 S 167.54 0.00 0.00<br />

28455 S 62.54 0.00 0.00 29000 S 42.45 0.00 0.00<br />

28456 S 708.87 0.00 0.00 29010 S 95.14 0.00 0.00<br />

28465 S 1,080.10 0.00 0.00 29015 S 95.14 0.00 0.00<br />

28470 S 62.54 0.00 0.00 29020 S 42.45 0.00 0.00<br />

28475 S 62.54 0.00 0.00 29025 S 42.45 0.00 0.00<br />

28476 S 708.87 0.00 0.00 29035 S 95.14 0.00 0.00<br />

28485 S 1,136.84 0.00 0.00 29040 S 42.45 0.00 0.00<br />

28490 S 62.54 0.00 0.00 29044 S 95.14 0.00 0.00<br />

28495 S 62.54 0.00 0.00 29046 S 95.14 0.00 0.00<br />

28496 S 708.87 0.00 0.00 29049 S 38.47 0.00 0.00<br />

28505 S 739.13 0.00 0.00 29055 S 95.14 0.00 0.00<br />

28510 S 56.32 0.00 0.00 29058 S 42.45 0.00 0.00<br />

28515 S 62.54 0.00 0.00 29065 S 45.12 0.00 0.00<br />

28525 S 739.13 0.00 0.00 29075 S 43.37 0.00 0.00<br />

28530 S 54.21 0.00 0.00 29085 S 42.45 0.00 0.00<br />

28531 S 739.13 0.00 0.00 29086 S 36.38 0.00 0.00<br />

28540 S 62.54 0.00 0.00 29105 S 39.17 0.00 0.00<br />

28545 S 655.44 0.00 0.00 29125 S 33.92 0.00 0.00<br />

28546 S 708.87 0.00 0.00 29126 S 36.03 0.00 0.00<br />

28555 S 1,049.84 0.00 0.00 29130 S 15.39 0.00 0.00<br />

28570 S 81.14 0.00 0.00 29131 S 22.38 0.00 0.00<br />

28575 S 437.93 0.00 0.00 29200 S 21.68 0.00 0.00<br />

28576 S 739.13 0.00 0.00 29220 S 23.43 0.00 0.00<br />

28585 S 739.13 0.00 0.00 29240 S 24.49 0.00 0.00<br />

28600 S 62.54 0.00 0.00 29260 S 23.43 0.00 0.00<br />

28605 S 80.26 0.00 0.00 29280 S 23.79 0.00 0.00<br />

28606 S 708.87 0.00 0.00 29305 S 95.14 0.00 0.00<br />

28615 S 1,080.10 0.00 0.00 29325 S 95.14 0.00 0.00<br />

28630 S 62.54 0.00 0.00 29345 S 59.11 0.00 0.00<br />

28635 S 462.13 0.00 0.00 29355 S 58.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 72.06 0.00 0.00 29847 S 1,204.37 0.00 0.00<br />

29365 S 55.97 0.00 0.00 29848 S 1,208.81 0.00 0.00<br />

29405 S 41.62 0.00 0.00 29850 S 873.58 0.00 0.00<br />

29425 S 42.32 0.00 0.00 29851 S 1,261.11 0.00 0.00<br />

29435 S 53.51 0.00 0.00 29855 S 1,261.11 0.00 0.00<br />

29440 S 22.73 0.00 0.00 29856 S 1,261.11 0.00 0.00<br />

29445 S 56.32 0.00 0.00 29860 S 1,261.11 0.00 0.00<br />

29450 S 42.45 0.00 0.00 29861 S 1,261.11 0.00 0.00<br />

29505 S 37.77 0.00 0.00 29862 S 1,596.34 0.00 0.00<br />

29515 S 32.18 0.00 0.00 29863 S 1,261.11 0.00 0.00<br />

29520 S 23.08 0.00 0.00 29866 S 1,926.45 0.00 0.00<br />

29530 S 23.43 0.00 0.00 29870 S 816.84 0.00 0.00<br />

29540 S 17.49 0.00 0.00 29871 S 816.84 0.00 0.00<br />

29550 S 17.83 0.00 0.00 29873 S 816.84 0.00 0.00<br />

29580 S 24.14 0.00 0.00 29874 S 816.84 0.00 0.00<br />

29590 S 19.59 0.00 0.00 29875 S 873.58 0.00 0.00<br />

29700 S 32.53 0.00 0.00 29876 S 873.58 0.00 0.00<br />

29705 S 27.63 0.00 0.00 29877 S 873.58 0.00 0.00<br />

29710 S 48.62 0.00 0.00 29879 S 816.84 0.00 0.00<br />

29715 S 42.45 0.00 0.00 29880 S 873.58 0.00 0.00<br />

29720 S 40.58 0.00 0.00 29881 S 873.58 0.00 0.00<br />

29730 S 26.58 0.00 0.00 29882 S 816.84 0.00 0.00<br />

29740 S 36.38 0.00 0.00 29883 S 816.84 0.00 0.00<br />

29750 S 38.12 0.00 0.00 29884 S 816.84 0.00 0.00<br />

29800 S 816.84 0.00 0.00 29885 S 1,204.37 0.00 0.00<br />

29804 S 816.84 0.00 0.00 29886 S 816.84 0.00 0.00<br />

29805 S 816.84 0.00 0.00 29887 S 816.84 0.00 0.00<br />

29806 S 1,204.37 0.00 0.00 29888 S 1,204.37 0.00 0.00<br />

29807 S 1,204.37 0.00 0.00 29889 S 1,204.37 0.00 0.00<br />

29819 S 1,204.37 0.00 0.00 29891 S 1,204.37 0.00 0.00<br />

29820 S 1,204.37 0.00 0.00 29892 S 1,204.37 0.00 0.00<br />

29821 S 1,204.37 0.00 0.00 29893 S 1,016.82 0.00 0.00<br />

29822 S 816.84 0.00 0.00 29894 S 816.84 0.00 0.00<br />

29823 S 1,204.37 0.00 0.00 29895 S 816.84 0.00 0.00<br />

29824 S 914.72 0.00 0.00 29897 S 816.84 0.00 0.00<br />

29825 S 1,204.37 0.00 0.00 29898 S 816.84 0.00 0.00<br />

29826 S 1,204.37 0.00 0.00 29899 S 1,204.37 0.00 0.00<br />

29827 S 1,302.24 0.00 0.00 29900 S 816.84 0.00 0.00<br />

29828 S 1,926.45 0.00 0.00 29901 S 816.84 0.00 0.00<br />

29830 S 816.84 0.00 0.00 29902 S 816.84 0.00 0.00<br />

29834 S 816.84 0.00 0.00 29904 S 1,151.40 0.00 0.00<br />

29835 S 816.84 0.00 0.00 29905 S 1,151.40 0.00 0.00<br />

29836 S 816.84 0.00 0.00 29906 S 1,151.40 0.00 0.00<br />

29837 S 816.84 0.00 0.00 29907 S 1,926.45 0.00 0.00<br />

29838 S 816.84 0.00 0.00 30000 S 129.45 0.00 0.00<br />

29840 S 816.84 0.00 0.00 30020 S 129.45 0.00 0.00<br />

29843 S 816.84 0.00 0.00 30100 S 83.95 0.00 0.00<br />

29844 S 816.84 0.00 0.00 30110 S 129.77 0.00 0.00<br />

29845 S 816.84 0.00 0.00 30115 S 548.30 0.00 0.00<br />

29846 S 816.84 0.00 0.00 30117 S 578.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 725.65 0.00 0.00 31080 S 1,117.42 0.00 0.00<br />

30120 S 494.87 0.00 0.00 31081 S 1,117.42 0.00 0.00<br />

30124 S 294.87 0.00 0.00 31084 S 1,117.42 0.00 0.00<br />

30125 S 1,030.42 0.00 0.00 31085 S 1,117.42 0.00 0.00<br />

30130 S 578.56 0.00 0.00 31086 S 1,117.42 0.00 0.00<br />

30140 S 695.39 0.00 0.00 31087 S 1,117.42 0.00 0.00<br />

30150 S 1,060.69 0.00 0.00 31090 S 1,158.56 0.00 0.00<br />

30160 S 1,117.42 0.00 0.00 31200 S 1,030.42 0.00 0.00<br />

30200 S 66.11 0.00 0.00 31201 S 1,158.56 0.00 0.00<br />

30210 S 83.95 0.00 0.00 31205 S 1,060.69 0.00 0.00<br />

30220 S 366.89 0.00 0.00 31231 S 70.77 0.00 0.00<br />

30300 S 25.29 0.00 0.00 31233 S 76.23 0.00 0.00<br />

30310 S 494.87 0.00 0.00 31235 S 517.88 0.00 0.00<br />

30320 S 548.30 0.00 0.00 31237 S 571.31 0.00 0.00<br />

30400 S 1,117.42 0.00 0.00 31238 S 517.88 0.00 0.00<br />

30410 S 1,158.56 0.00 0.00 31239 S 755.95 0.00 0.00<br />

30420 S 1,158.56 0.00 0.00 31240 S 571.31 0.00 0.00<br />

30430 S 725.65 0.00 0.00 31254 S 699.21 0.00 0.00<br />

30435 S 1,158.56 0.00 0.00 31255 S 797.08 0.00 0.00<br />

30450 S 1,290.01 0.00 0.00 31256 S 699.21 0.00 0.00<br />

30460 S 1,290.01 0.00 0.00 31267 S 699.21 0.00 0.00<br />

30462 S 1,452.65 0.00 0.00 31276 S 699.21 0.00 0.00<br />

30465 S 1,452.65 0.00 0.00 31287 S 699.21 0.00 0.00<br />

30520 S 782.39 0.00 0.00 31288 S 699.21 0.00 0.00<br />

30540 S 1,158.56 0.00 0.00 31300 S 823.53 0.00 0.00<br />

30545 S 1,158.56 0.00 0.00 31320 S 1,030.42 0.00 0.00<br />

30560 S 135.99 0.00 0.00 31400 S 1,030.42 0.00 0.00<br />

30580 S 1,117.42 0.00 0.00 31420 S 1,030.42 0.00 0.00<br />

30600 S 1,117.42 0.00 0.00 31500 S 94.65 0.00 0.00<br />

30620 S 1,290.01 0.00 0.00 31502 S 54.43 0.00 0.00<br />

30630 S 954.97 0.00 0.00 31505 S 32.16 0.00 0.00<br />

30801 S 304.89 0.00 0.00 31510 S 571.31 0.00 0.00<br />

30802 S 304.89 0.00 0.00 31511 S 76.23 0.00 0.00<br />

30901 S 43.49 0.00 0.00 31512 S 571.31 0.00 0.00<br />

30903 S 56.02 0.00 0.00 31513 S 76.23 0.00 0.00<br />

30905 S 56.02 0.00 0.00 31515 S 517.88 0.00 0.00<br />

30906 S 56.02 0.00 0.00 31520 S 70.77 0.00 0.00<br />

30915 S 746.39 0.00 0.00 31525 S 517.88 0.00 0.00<br />

30920 S 776.65 0.00 0.00 31526 S 668.95 0.00 0.00<br />

30930 S 635.30 0.00 0.00 31527 S 615.51 0.00 0.00<br />

31000 S 108.08 0.00 0.00 31528 S 571.31 0.00 0.00<br />

31002 S 294.87 0.00 0.00 31529 S 571.31 0.00 0.00<br />

31020 S 695.39 0.00 0.00 31530 S 668.95 0.00 0.00<br />

31030 S 1,060.69 0.00 0.00 31531 S 699.21 0.00 0.00<br />

31032 S 1,117.42 0.00 0.00 31535 S 668.95 0.00 0.00<br />

31040 S 969.02 0.00 0.00 31536 S 699.21 0.00 0.00<br />

31050 S 1,030.42 0.00 0.00 31540 S 699.21 0.00 0.00<br />

31051 S 1,117.42 0.00 0.00 31541 S 755.95 0.00 0.00<br />

31070 S 695.39 0.00 0.00 31545 S 755.95 0.00 0.00<br />

31075 S 1,117.42 0.00 0.00 31546 S 755.95 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 797.08 0.00 0.00 32405 S 344.92 0.00 0.00<br />

31561 S 797.08 0.00 0.00 32420 S 209.74 0.00 0.00<br />

31570 S 571.31 0.00 0.00 32421 S 209.74 0.00 0.00<br />

31571 S 668.95 0.00 0.00 32422 S 208.81 0.00 0.00<br />

31575 S 60.86 0.00 0.00 32550 S 1,169.09 0.00 0.00<br />

31576 S 668.95 0.00 0.00 32960 S 208.81 0.00 0.00<br />

31577 S 197.61 0.00 0.00 32998 S 1,820.22 0.00 0.00<br />

31578 S 668.95 0.00 0.00 33010 S 209.74 0.00 0.00<br />

31579 S 108.43 0.00 0.00 33011 S 209.74 0.00 0.00<br />

31580 S 1,158.56 0.00 0.00 33206 S 6,729.21 4,003.86 1,278.52<br />

31582 S 1,158.56 0.00 0.00 33207 S 6,729.21 4,003.86 1,278.52<br />

31588 S 1,158.56 0.00 0.00 33208 S 8,346.13 4,863.25 1,380.37<br />

31590 S 1,158.56 0.00 0.00 33210 S 1,976.05 0.00 0.00<br />

31595 S 1,030.42 0.00 0.00 33211 S 1,976.05 0.00 0.00<br />

31603 S 304.89 0.00 0.00 33212 S 5,284.83 3,010.54 736.25<br />

31605 S 294.87 0.00 0.00 33213 S 6,099.83 3,417.60 735.38<br />

31611 S 725.65 0.00 0.00 33214 S 8,346.13 4,863.25 1,380.37<br />

31612 S 641.96 0.00 0.00 33215 S 866.13 0.00 0.00<br />

31613 S 695.39 0.00 0.00 33216 S 1,976.05 0.00 0.00<br />

31614 S 1,030.42 0.00 0.00 33217 S 1,976.05 0.00 0.00<br />

31615 S 304.89 0.00 0.00 33218 S 866.13 0.00 0.00<br />

31622 S 357.07 0.00 0.00 33220 S 866.13 0.00 0.00<br />

31623 S 410.50 0.00 0.00 33222 S 523.54 0.00 0.00<br />

31624 S 410.50 0.00 0.00 33223 S 523.54 0.00 0.00<br />

31625 S 410.50 0.00 0.00 33224 S 7,877.97 4,716.52 1,555.07<br />

31628 S 410.50 0.00 0.00 33225 S 7,877.97 4,716.52 1,555.07<br />

31629 S 410.50 0.00 0.00 33226 S 866.13 0.00 0.00<br />

31630 S 703.43 0.00 0.00 33233 S 643.95 0.00 0.00<br />

31631 S 703.43 0.00 0.00 33234 S 866.13 0.00 0.00<br />

31632 S 399.24 0.00 0.00 33235 S 866.13 0.00 0.00<br />

31633 S 399.24 0.00 0.00 33240 S 19,637.76 10,497.18 1,356.61<br />

31635 S 410.50 0.00 0.00 33241 S 866.13 0.00 0.00<br />

31636 S 703.43 0.00 0.00 33249 S 26,208.09 14,038.14 1,868.18<br />

31637 S 357.07 0.00 0.00 33282 S 4,143.66 2,480.64 817.62<br />

31638 S 703.43 0.00 0.00 33284 S 323.20 0.00 0.00<br />

31640 S 703.43 0.00 0.00 34490 S 1,577.93 0.00 0.00<br />

31641 S 703.43 0.00 0.00 35188 S 1,086.85 0.00 0.00<br />

31643 S 410.50 0.00 0.00 35207 S 1,086.85 0.00 0.00<br />

31645 S 357.07 0.00 0.00 35473 S 1,892.91 0.00 0.00<br />

31646 S 357.07 0.00 0.00 35476 S 1,892.91 0.00 0.00<br />

31656 S 357.07 0.00 0.00 35492 S 3,532.93 0.00 0.00<br />

31717 S 197.61 0.00 0.00 35761 S 1,136.50 0.00 0.00<br />

31720 S 30.26 0.00 0.00 35875 S 1,422.08 0.00 0.00<br />

31730 S 197.61 0.00 0.00 35876 S 1,422.08 0.00 0.00<br />

31750 S 1,158.56 0.00 0.00 36002 S 90.76 0.00 0.00<br />

31755 S 1,030.42 0.00 0.00 36260 S 823.35 0.00 0.00<br />

31820 S 494.87 0.00 0.00 36261 S 643.95 0.00 0.00<br />

31825 S 695.39 0.00 0.00 36262 S 590.51 0.00 0.00<br />

31830 S 695.39 0.00 0.00 36420 S 8.55 0.00 0.00<br />

32400 S 344.92 0.00 0.00 36425 S 8.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.88 0.00 0.00 36800 S 886.34 0.00 0.00<br />

36440 S 131.30 0.00 0.00 36810 S 886.34 0.00 0.00<br />

36450 S 131.30 0.00 0.00 36815 S 886.34 0.00 0.00<br />

36455 S 131.30 0.00 0.00 36818 S 1,030.11 0.00 0.00<br />

36468 S 32.41 0.00 0.00 36819 S 1,030.11 0.00 0.00<br />

36469 S 32.41 0.00 0.00 36820 S 1,030.11 0.00 0.00<br />

36470 S 32.41 0.00 0.00 36821 S 1,030.11 0.00 0.00<br />

36471 S 32.41 0.00 0.00 36825 S 1,086.85 0.00 0.00<br />

36475 S 1,490.19 0.00 0.00 36830 S 1,086.85 0.00 0.00<br />

36476 S 1,168.62 0.00 0.00 36831 S 1,422.08 0.00 0.00<br />

36478 S 1,168.62 0.00 0.00 36832 S 1,086.85 0.00 0.00<br />

36479 S 1,168.62 0.00 0.00 36833 S 1,086.85 0.00 0.00<br />

36511 S 450.16 0.00 0.00 36834 S 1,030.11 0.00 0.00<br />

36512 S 450.16 0.00 0.00 36835 S 943.08 0.00 0.00<br />

36513 S 450.16 0.00 0.00 36860 S 108.24 0.00 0.00<br />

36514 S 450.16 0.00 0.00 36861 S 886.34 0.00 0.00<br />

36515 S 1,205.08 0.00 0.00 36870 S 1,550.07 0.00 0.00<br />

36516 S 1,205.08 0.00 0.00 37184 S 1,577.93 0.00 0.00<br />

36522 S 1,205.08 0.00 0.00 37185 S 1,577.93 0.00 0.00<br />

36555 S 374.02 0.00 0.00 37186 S 1,577.93 0.00 0.00<br />

36556 S 374.02 0.00 0.00 37187 S 1,577.93 0.00 0.00<br />

36557 S 698.52 0.00 0.00 37188 S 1,577.93 0.00 0.00<br />

36558 S 698.52 0.00 0.00 37200 S 1,164.42 0.00 0.00<br />

36560 S 823.35 0.00 0.00 37203 S 1,164.42 0.00 0.00<br />

36561 S 823.35 0.00 0.00 37500 S 1,098.23 0.00 0.00<br />

36563 S 823.35 0.00 0.00 37607 S 776.65 0.00 0.00<br />

36565 S 823.35 0.00 0.00 37609 S 522.01 0.00 0.00<br />

36566 S 823.35 0.00 0.00 37650 S 746.39 0.00 0.00<br />

36568 S 374.02 0.00 0.00 37700 S 746.39 0.00 0.00<br />

36569 S 374.02 0.00 0.00 37718 S 776.65 0.00 0.00<br />

36570 S 728.78 0.00 0.00 37722 S 1,098.23 0.00 0.00<br />

36571 S 728.78 0.00 0.00 37735 S 1,098.23 0.00 0.00<br />

36575 S 300.82 0.00 0.00 37760 S 776.65 0.00 0.00<br />

36576 S 427.45 0.00 0.00 37765 S 1,071.02 0.00 0.00<br />

36578 S 698.52 0.00 0.00 37766 S 1,071.02 0.00 0.00<br />

36580 S 374.02 0.00 0.00 37780 S 776.65 0.00 0.00<br />

36581 S 698.52 0.00 0.00 37785 S 776.65 0.00 0.00<br />

36582 S 823.35 0.00 0.00 37790 S 937.19 0.00 0.00<br />

36583 S 823.35 0.00 0.00 38205 S 450.16 0.00 0.00<br />

36584 S 374.02 0.00 0.00 38206 S 450.16 0.00 0.00<br />

36585 S 728.78 0.00 0.00 38220 S 103.19 0.00 0.00<br />

36589 S 247.40 0.00 0.00 38221 S 108.08 0.00 0.00<br />

36590 S 374.02 0.00 0.00 38230 S 1,205.08 0.00 0.00<br />

36593 S 24.84 0.00 0.00 38241 S 1,205.08 0.00 0.00<br />

36595 S 975.27 0.00 0.00 38242 S 450.16 0.00 0.00<br />

36596 S 433.13 0.00 0.00 38300 S 403.96 0.00 0.00<br />

36597 S 433.13 0.00 0.00 38305 S 590.33 0.00 0.00<br />

36598 S 80.10 0.00 0.00 38308 S 674.52 0.00 0.00<br />

36640 S 739.66 0.00 0.00 38500 S 674.52 0.00 0.00<br />

36680 S 56.06 0.00 0.00 38505 S 258.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 674.52 0.00 0.00 41005 S 135.99 0.00 0.00<br />

38520 S 674.52 0.00 0.00 41006 S 641.96 0.00 0.00<br />

38525 S 674.52 0.00 0.00 41007 S 494.87 0.00 0.00<br />

38530 S 674.52 0.00 0.00 41008 S 494.87 0.00 0.00<br />

38542 S 1,134.79 0.00 0.00 41009 S 135.99 0.00 0.00<br />

38550 S 704.79 0.00 0.00 41010 S 304.89 0.00 0.00<br />

38555 S 761.53 0.00 0.00 41015 S 135.99 0.00 0.00<br />

38570 S 1,539.74 0.00 0.00 41016 S 304.89 0.00 0.00<br />

38571 S 2,001.63 0.00 0.00 41017 S 304.89 0.00 0.00<br />

38572 S 1,539.74 0.00 0.00 41018 S 304.89 0.00 0.00<br />

38700 S 927.29 0.00 0.00 41019 S 969.02 0.00 0.00<br />

38740 S 1,134.79 0.00 0.00 41100 S 91.29 0.00 0.00<br />

38745 S 1,221.79 0.00 0.00 41105 S 90.24 0.00 0.00<br />

38760 S 674.52 0.00 0.00 41108 S 83.60 0.00 0.00<br />

40490 S 68.90 0.00 0.00 41110 S 121.02 0.00 0.00<br />

40500 S 548.30 0.00 0.00 41112 S 548.30 0.00 0.00<br />

40510 S 695.39 0.00 0.00 41113 S 548.30 0.00 0.00<br />

40520 S 548.30 0.00 0.00 41114 S 695.39 0.00 0.00<br />

40525 S 695.39 0.00 0.00 41115 S 140.96 0.00 0.00<br />

40527 S 695.39 0.00 0.00 41116 S 494.87 0.00 0.00<br />

40530 S 695.39 0.00 0.00 41120 S 823.53 0.00 0.00<br />

40650 S 366.89 0.00 0.00 41250 S 93.00 0.00 0.00<br />

40652 S 366.89 0.00 0.00 41251 S 135.99 0.00 0.00<br />

40654 S 366.89 0.00 0.00 41252 S 358.31 0.00 0.00<br />

40700 S 1,290.01 0.00 0.00 41500 S 641.96 0.00 0.00<br />

40701 S 1,290.01 0.00 0.00 41510 S 494.87 0.00 0.00<br />

40702 S 1,639.09 0.00 0.00 41520 S 358.31 0.00 0.00<br />

40720 S 1,290.01 0.00 0.00 41530 S 674.84 0.00 0.00<br />

40761 S 1,060.69 0.00 0.00 41800 S 69.48 0.00 0.00<br />

40800 S 55.30 0.00 0.00 41805 S 150.41 0.00 0.00<br />

40801 S 358.31 0.00 0.00 41806 S 185.38 0.00 0.00<br />

40804 S 25.29 0.00 0.00 41820 S 294.87 0.00 0.00<br />

40805 S 171.04 0.00 0.00 41821 S 294.87 0.00 0.00<br />

40806 S 78.70 0.00 0.00 41822 S 153.55 0.00 0.00<br />

40808 S 116.82 0.00 0.00 41823 S 223.86 0.00 0.00<br />

40810 S 121.02 0.00 0.00 41825 S 123.12 0.00 0.00<br />

40812 S 151.80 0.00 0.00 41826 S 154.95 0.00 0.00<br />

40814 S 548.30 0.00 0.00 41827 S 695.39 0.00 0.00<br />

40816 S 695.39 0.00 0.00 41828 S 139.91 0.00 0.00<br />

40818 S 135.99 0.00 0.00 41830 S 198.67 0.00 0.00<br />

40819 S 304.89 0.00 0.00 41850 S 674.84 0.00 0.00<br />

40820 S 174.53 0.00 0.00 41870 S 969.02 0.00 0.00<br />

40830 S 129.45 0.00 0.00 41872 S 198.67 0.00 0.00<br />

40831 S 304.89 0.00 0.00 41874 S 191.67 0.00 0.00<br />

40840 S 695.39 0.00 0.00 42000 S 135.99 0.00 0.00<br />

40842 S 725.65 0.00 0.00 42100 S 77.65 0.00 0.00<br />

40843 S 725.65 0.00 0.00 42104 S 115.43 0.00 0.00<br />

40844 S 1,158.56 0.00 0.00 42106 S 144.81 0.00 0.00<br />

40845 S 1,158.56 0.00 0.00 42107 S 695.39 0.00 0.00<br />

41000 S 86.75 0.00 0.00 42120 S 1,117.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 358.31 0.00 0.00 42809 S 25.29 0.00 0.00<br />

42145 S 823.53 0.00 0.00 42810 S 725.65 0.00 0.00<br />

42160 S 137.11 0.00 0.00 42815 S 1,158.56 0.00 0.00<br />

42180 S 135.99 0.00 0.00 42820 S 725.65 0.00 0.00<br />

42182 S 1,030.42 0.00 0.00 42821 S 823.53 0.00 0.00<br />

42200 S 1,158.56 0.00 0.00 42825 S 782.39 0.00 0.00<br />

42205 S 1,158.56 0.00 0.00 42826 S 782.39 0.00 0.00<br />

42210 S 1,158.56 0.00 0.00 42830 S 782.39 0.00 0.00<br />

42215 S 1,290.01 0.00 0.00 42831 S 782.39 0.00 0.00<br />

42220 S 1,158.56 0.00 0.00 42835 S 782.39 0.00 0.00<br />

42226 S 1,158.56 0.00 0.00 42836 S 782.39 0.00 0.00<br />

42235 S 676.44 0.00 0.00 42860 S 725.65 0.00 0.00<br />

42260 S 782.39 0.00 0.00 42870 S 725.65 0.00 0.00<br />

42280 S 75.55 0.00 0.00 42890 S 1,290.01 0.00 0.00<br />

42281 S 674.84 0.00 0.00 42892 S 1,290.01 0.00 0.00<br />

42300 S 494.87 0.00 0.00 42900 S 304.89 0.00 0.00<br />

42305 S 548.30 0.00 0.00 42950 S 695.39 0.00 0.00<br />

42310 S 135.99 0.00 0.00 42955 S 695.39 0.00 0.00<br />

42320 S 135.99 0.00 0.00 42960 S 56.02 0.00 0.00<br />

42330 S 116.82 0.00 0.00 42962 S 1,030.42 0.00 0.00<br />

42335 S 193.78 0.00 0.00 42970 S 43.49 0.00 0.00<br />

42340 S 548.30 0.00 0.00 42972 S 578.56 0.00 0.00<br />

42400 S 65.76 0.00 0.00 43030 S 674.84 0.00 0.00<br />

42405 S 548.30 0.00 0.00 43200 S 326.79 0.00 0.00<br />

42408 S 578.56 0.00 0.00 43201 S 326.79 0.00 0.00<br />

42409 S 578.56 0.00 0.00 43202 S 326.79 0.00 0.00<br />

42410 S 1,060.69 0.00 0.00 43204 S 326.79 0.00 0.00<br />

42415 S 1,290.01 0.00 0.00 43205 S 326.79 0.00 0.00<br />

42420 S 1,290.01 0.00 0.00 43215 S 326.79 0.00 0.00<br />

42425 S 1,290.01 0.00 0.00 43216 S 326.79 0.00 0.00<br />

42440 S 1,060.69 0.00 0.00 43217 S 326.79 0.00 0.00<br />

42450 S 695.39 0.00 0.00 43219 S 660.45 0.00 0.00<br />

42500 S 725.65 0.00 0.00 43220 S 326.79 0.00 0.00<br />

42505 S 1,117.42 0.00 0.00 43226 S 326.79 0.00 0.00<br />

42507 S 1,060.69 0.00 0.00 43227 S 380.23 0.00 0.00<br />

42508 S 1,117.42 0.00 0.00 43228 S 707.58 0.00 0.00<br />

42509 S 1,117.42 0.00 0.00 43231 S 380.23 0.00 0.00<br />

42510 S 1,117.42 0.00 0.00 43232 S 380.23 0.00 0.00<br />

42600 S 494.87 0.00 0.00 43234 S 326.79 0.00 0.00<br />

42650 S 43.02 0.00 0.00 43235 S 326.79 0.00 0.00<br />

42660 S 50.37 0.00 0.00 43236 S 380.23 0.00 0.00<br />

42665 S 954.97 0.00 0.00 43237 S 380.23 0.00 0.00<br />

42700 S 135.99 0.00 0.00 43238 S 380.23 0.00 0.00<br />

42720 S 494.87 0.00 0.00 43239 S 380.23 0.00 0.00<br />

42725 S 1,030.42 0.00 0.00 43240 S 380.23 0.00 0.00<br />

42800 S 83.25 0.00 0.00 43241 S 380.23 0.00 0.00<br />

42802 S 494.87 0.00 0.00 43242 S 380.23 0.00 0.00<br />

42804 S 494.87 0.00 0.00 43243 S 380.23 0.00 0.00<br />

42806 S 695.39 0.00 0.00 43244 S 380.23 0.00 0.00<br />

42808 S 548.30 0.00 0.00 43245 S 380.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 380.23 0.00 0.00 44378 S 398.23 0.00 0.00<br />

43247 S 380.23 0.00 0.00 44379 S 1,136.12 0.00 0.00<br />

43248 S 380.23 0.00 0.00 44380 S 344.79 0.00 0.00<br />

43249 S 380.23 0.00 0.00 44382 S 344.79 0.00 0.00<br />

43250 S 380.23 0.00 0.00 44383 S 1,136.12 0.00 0.00<br />

43251 S 380.23 0.00 0.00 44385 S 333.37 0.00 0.00<br />

43255 S 380.23 0.00 0.00 44386 S 333.37 0.00 0.00<br />

43256 S 744.15 0.00 0.00 44388 S 333.37 0.00 0.00<br />

43257 S 737.84 0.00 0.00 44389 S 333.37 0.00 0.00<br />

43258 S 410.49 0.00 0.00 44390 S 333.37 0.00 0.00<br />

43259 S 410.49 0.00 0.00 44391 S 333.37 0.00 0.00<br />

43260 S 640.12 0.00 0.00 44392 S 333.37 0.00 0.00<br />

43261 S 640.12 0.00 0.00 44393 S 333.37 0.00 0.00<br />

43262 S 640.12 0.00 0.00 44394 S 333.37 0.00 0.00<br />

43263 S 640.12 0.00 0.00 44397 S 660.45 0.00 0.00<br />

43264 S 640.12 0.00 0.00 44500 S 179.90 0.00 0.00<br />

43265 S 640.12 0.00 0.00 45000 S 386.60 0.00 0.00<br />

43267 S 640.12 0.00 0.00 45005 S 449.93 0.00 0.00<br />

43268 S 713.89 0.00 0.00 45020 S 449.93 0.00 0.00<br />

43269 S 713.89 0.00 0.00 45100 S 611.27 0.00 0.00<br />

43271 S 640.12 0.00 0.00 45108 S 664.70 0.00 0.00<br />

43272 S 640.12 0.00 0.00 45150 S 664.70 0.00 0.00<br />

43273 S 858.48 0.00 0.00 45160 S 664.70 0.00 0.00<br />

43450 S 285.80 0.00 0.00 45170 S 664.70 0.00 0.00<br />

43453 S 285.80 0.00 0.00 45190 S 1,086.93 0.00 0.00<br />

43456 S 286.93 0.00 0.00 45300 S 64.36 0.00 0.00<br />

43458 S 327.94 0.00 0.00 45303 S 357.48 0.00 0.00<br />

43600 S 326.79 0.00 0.00 45305 S 336.19 0.00 0.00<br />

43653 S 1,539.74 0.00 0.00 45307 S 620.96 0.00 0.00<br />

43760 S 158.49 0.00 0.00 45308 S 336.19 0.00 0.00<br />

43761 S 326.79 0.00 0.00 45309 S 336.19 0.00 0.00<br />

43870 S 326.79 0.00 0.00 45315 S 336.19 0.00 0.00<br />

43886 S 824.58 0.00 0.00 45317 S 336.19 0.00 0.00<br />

43887 S 173.43 0.00 0.00 45320 S 620.96 0.00 0.00<br />

43888 S 824.58 0.00 0.00 45321 S 620.96 0.00 0.00<br />

44100 S 326.79 0.00 0.00 45327 S 660.45 0.00 0.00<br />

44312 S 569.74 0.00 0.00 45330 S 84.99 0.00 0.00<br />

44340 S 653.43 0.00 0.00 45331 S 251.34 0.00 0.00<br />

44360 S 398.23 0.00 0.00 45332 S 251.34 0.00 0.00<br />

44361 S 398.23 0.00 0.00 45333 S 336.19 0.00 0.00<br />

44363 S 398.23 0.00 0.00 45334 S 336.19 0.00 0.00<br />

44364 S 398.23 0.00 0.00 45335 S 251.34 0.00 0.00<br />

44365 S 398.23 0.00 0.00 45337 S 251.34 0.00 0.00<br />

44366 S 398.23 0.00 0.00 45338 S 336.19 0.00 0.00<br />

44369 S 398.23 0.00 0.00 45339 S 336.19 0.00 0.00<br />

44370 S 1,136.12 0.00 0.00 45340 S 336.19 0.00 0.00<br />

44372 S 398.23 0.00 0.00 45341 S 336.19 0.00 0.00<br />

44373 S 398.23 0.00 0.00 45342 S 336.19 0.00 0.00<br />

44376 S 398.23 0.00 0.00 45345 S 660.45 0.00 0.00<br />

44377 S 398.23 0.00 0.00 45355 S 333.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 386.80 0.00 0.00 46505 S 478.09 0.00 0.00<br />

45379 S 386.80 0.00 0.00 46600 S 25.29 0.00 0.00<br />

45380 S 386.80 0.00 0.00 46604 S 357.48 0.00 0.00<br />

45381 S 386.80 0.00 0.00 46606 S 134.32 0.00 0.00<br />

45382 S 386.80 0.00 0.00 46608 S 336.19 0.00 0.00<br />

45383 S 386.80 0.00 0.00 46610 S 620.96 0.00 0.00<br />

45384 S 386.80 0.00 0.00 46611 S 336.19 0.00 0.00<br />

45385 S 386.80 0.00 0.00 46612 S 620.96 0.00 0.00<br />

45386 S 386.80 0.00 0.00 46614 S 70.65 0.00 0.00<br />

45387 S 660.45 0.00 0.00 46615 S 674.39 0.00 0.00<br />

45391 S 386.80 0.00 0.00 46700 S 694.97 0.00 0.00<br />

45392 S 386.80 0.00 0.00 46706 S 764.95 0.00 0.00<br />

45500 S 664.70 0.00 0.00 46750 S 848.64 0.00 0.00<br />

45505 S 818.39 0.00 0.00 46753 S 694.97 0.00 0.00<br />

45520 S 32.41 0.00 0.00 46754 S 664.70 0.00 0.00<br />

45560 S 818.39 0.00 0.00 46760 S 818.39 0.00 0.00<br />

45900 S 262.09 0.00 0.00 46761 S 848.64 0.00 0.00<br />

45905 S 611.27 0.00 0.00 46762 S 1,077.96 0.00 0.00<br />

45910 S 611.27 0.00 0.00 46900 S 106.81 0.00 0.00<br />

45915 S 386.60 0.00 0.00 46910 S 127.66 0.00 0.00<br />

45990 S 601.37 0.00 0.00 46916 S 59.38 0.00 0.00<br />

46020 S 694.97 0.00 0.00 46917 S 553.93 0.00 0.00<br />

46030 S 262.09 0.00 0.00 46922 S 553.93 0.00 0.00<br />

46040 S 694.97 0.00 0.00 46924 S 553.93 0.00 0.00<br />

46045 S 664.70 0.00 0.00 46930 S 123.82 0.00 0.00<br />

46050 S 386.60 0.00 0.00 46937 S 664.70 0.00 0.00<br />

46060 S 664.70 0.00 0.00 46938 S 818.39 0.00 0.00<br />

46070 S 478.09 0.00 0.00 46940 S 91.64 0.00 0.00<br />

46080 S 694.97 0.00 0.00 46942 S 89.19 0.00 0.00<br />

46083 S 73.18 0.00 0.00 46945 S 151.80 0.00 0.00<br />

46200 S 664.70 0.00 0.00 46946 S 396.49 0.00 0.00<br />

46210 S 664.70 0.00 0.00 46947 S 1,077.96 0.00 0.00<br />

46211 S 664.70 0.00 0.00 47000 S 344.92 0.00 0.00<br />

46220 S 611.27 0.00 0.00 47382 S 1,820.22 0.00 0.00<br />

46221 S 120.32 0.00 0.00 47510 S 806.10 0.00 0.00<br />

46230 S 611.27 0.00 0.00 47511 S 1,184.28 0.00 0.00<br />

46250 S 694.97 0.00 0.00 47525 S 462.76 0.00 0.00<br />

46255 S 694.97 0.00 0.00 47530 S 462.76 0.00 0.00<br />

46257 S 694.97 0.00 0.00 47552 S 806.10 0.00 0.00<br />

46258 S 694.97 0.00 0.00 47553 S 836.36 0.00 0.00<br />

46260 S 694.97 0.00 0.00 47554 S 836.36 0.00 0.00<br />

46261 S 751.70 0.00 0.00 47555 S 836.36 0.00 0.00<br />

46262 S 751.70 0.00 0.00 47556 S 1,184.28 0.00 0.00<br />

46270 S 694.97 0.00 0.00 47560 S 982.69 0.00 0.00<br />

46275 S 694.97 0.00 0.00 47561 S 982.69 0.00 0.00<br />

46280 S 751.70 0.00 0.00 47562 S 1,813.26 0.00 0.00<br />

46285 S 611.27 0.00 0.00 47563 S 1,813.26 0.00 0.00<br />

46288 S 751.70 0.00 0.00 47564 S 1,813.26 0.00 0.00<br />

46320 S 81.50 0.00 0.00 47630 S 836.36 0.00 0.00<br />

46500 S 112.27 0.00 0.00 48102 S 344.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 209.74 0.00 0.00 49590 S 860.84 0.00 0.00<br />

49081 S 209.74 0.00 0.00 49600 S 917.58 0.00 0.00<br />

49180 S 344.92 0.00 0.00 49650 S 1,204.51 0.00 0.00<br />

49250 S 756.08 0.00 0.00 49651 S 1,377.10 0.00 0.00<br />

49320 S 982.69 0.00 0.00 49652 S 1,483.10 0.00 0.00<br />

49321 S 1,039.43 0.00 0.00 49653 S 1,483.10 0.00 0.00<br />

49322 S 1,039.43 0.00 0.00 49654 S 1,483.10 0.00 0.00<br />

49324 S 1,483.10 0.00 0.00 49655 S 1,483.10 0.00 0.00<br />

49325 S 1,483.10 0.00 0.00 49656 S 1,483.10 0.00 0.00<br />

49326 S 1,483.10 0.00 0.00 49657 S 1,483.10 0.00 0.00<br />

49402 S 669.07 0.00 0.00 50200 S 344.92 0.00 0.00<br />

49419 S 802.65 0.00 0.00 50382 S 1,001.57 0.00 0.00<br />

49420 S 741.99 0.00 0.00 50384 S 735.63 0.00 0.00<br />

49421 S 741.99 0.00 0.00 50385 S 735.63 0.00 0.00<br />

49422 S 590.51 0.00 0.00 50386 S 282.24 0.00 0.00<br />

49423 S 610.62 0.00 0.00 50387 S 610.62 0.00 0.00<br />

49426 S 669.07 0.00 0.00 50389 S 282.24 0.00 0.00<br />

49429 S 866.13 0.00 0.00 50390 S 344.92 0.00 0.00<br />

49440 S 338.69 0.00 0.00 50391 S 40.85 0.00 0.00<br />

49441 S 338.69 0.00 0.00 50392 S 525.26 0.00 0.00<br />

49446 S 338.69 0.00 0.00 50393 S 658.23 0.00 0.00<br />

49450 S 179.90 0.00 0.00 50395 S 525.26 0.00 0.00<br />

49451 S 179.90 0.00 0.00 50396 S 98.76 0.00 0.00<br />

49452 S 179.90 0.00 0.00 50398 S 462.76 0.00 0.00<br />

49460 S 179.90 0.00 0.00 50551 S 298.57 0.00 0.00<br />

49495 S 917.58 0.00 0.00 50553 S 658.23 0.00 0.00<br />

49496 S 917.58 0.00 0.00 50555 S 298.57 0.00 0.00<br />

49500 S 917.58 0.00 0.00 50557 S 658.23 0.00 0.00<br />

49501 S 1,252.81 0.00 0.00 50561 S 658.23 0.00 0.00<br />

49505 S 917.58 0.00 0.00 50562 S 282.24 0.00 0.00<br />

49507 S 1,252.81 0.00 0.00 50570 S 282.24 0.00 0.00<br />

49520 S 1,090.16 0.00 0.00 50572 S 282.24 0.00 0.00<br />

49521 S 1,252.81 0.00 0.00 50574 S 282.24 0.00 0.00<br />

49525 S 917.58 0.00 0.00 50575 S 1,403.92 0.00 0.00<br />

49540 S 830.58 0.00 0.00 50576 S 735.63 0.00 0.00<br />

49550 S 958.72 0.00 0.00 50580 S 735.63 0.00 0.00<br />

49553 S 1,252.81 0.00 0.00 50590 S 1,640.11 0.00 0.00<br />

49555 S 958.72 0.00 0.00 50592 S 1,820.22 0.00 0.00<br />

49557 S 1,252.81 0.00 0.00 50686 S 40.85 0.00 0.00<br />

49560 S 917.58 0.00 0.00 50688 S 462.76 0.00 0.00<br />

49561 S 1,252.81 0.00 0.00 50947 S 1,539.74 0.00 0.00<br />

49565 S 917.58 0.00 0.00 50948 S 1,539.74 0.00 0.00<br />

49566 S 1,252.81 0.00 0.00 50951 S 298.57 0.00 0.00<br />

49568 S 1,090.16 0.00 0.00 50953 S 298.57 0.00 0.00<br />

49570 S 917.58 0.00 0.00 50955 S 658.23 0.00 0.00<br />

49572 S 1,252.81 0.00 0.00 50957 S 658.23 0.00 0.00<br />

49580 S 917.58 0.00 0.00 50961 S 658.23 0.00 0.00<br />

49582 S 1,252.81 0.00 0.00 50970 S 298.57 0.00 0.00<br />

49585 S 917.58 0.00 0.00 50972 S 298.57 0.00 0.00<br />

49587 S 1,252.81 0.00 0.00 50974 S 525.26 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 525.26 0.00 0.00 52275 S 711.67 0.00 0.00<br />

50980 S 658.23 0.00 0.00 52276 S 741.93 0.00 0.00<br />

51020 S 798.67 0.00 0.00 52277 S 711.67 0.00 0.00<br />

51030 S 798.67 0.00 0.00 52281 S 578.69 0.00 0.00<br />

51040 S 798.67 0.00 0.00 52282 S 1,335.08 0.00 0.00<br />

51045 S 329.89 0.00 0.00 52283 S 711.67 0.00 0.00<br />

51050 S 798.67 0.00 0.00 52285 S 578.69 0.00 0.00<br />

51065 S 798.67 0.00 0.00 52290 S 578.69 0.00 0.00<br />

51080 S 536.89 0.00 0.00 52300 S 711.67 0.00 0.00<br />

51100 S 31.13 0.00 0.00 52301 S 741.93 0.00 0.00<br />

51101 S 40.85 0.00 0.00 52305 S 711.67 0.00 0.00<br />

51102 S 549.56 0.00 0.00 52310 S 556.58 0.00 0.00<br />

51500 S 917.58 0.00 0.00 52315 S 711.67 0.00 0.00<br />

51520 S 798.67 0.00 0.00 52317 S 658.23 0.00 0.00<br />

51700 S 53.16 0.00 0.00 52318 S 711.67 0.00 0.00<br />

51701 S 25.29 0.00 0.00 52320 S 839.80 0.00 0.00<br />

51702 S 25.29 0.00 0.00 52325 S 798.67 0.00 0.00<br />

51703 S 40.85 0.00 0.00 52327 S 912.84 0.00 0.00<br />

51705 S 73.18 0.00 0.00 52330 S 711.67 0.00 0.00<br />

51710 S 462.76 0.00 0.00 52332 S 711.67 0.00 0.00<br />

51715 S 840.23 0.00 0.00 52334 S 741.93 0.00 0.00<br />

51720 S 58.76 0.00 0.00 52341 S 741.93 0.00 0.00<br />

51725 TC S 112.88 0.00 0.00 52342 S 741.93 0.00 0.00<br />

51726 TC S 155.49 0.00 0.00 52343 S 741.93 0.00 0.00<br />

51736 TC S 21.34 0.00 0.00 52344 S 741.93 0.00 0.00<br />

51741 TC S 24.84 0.00 0.00 52345 S 741.93 0.00 0.00<br />

51772 TC S 98.76 0.00 0.00 52346 S 741.93 0.00 0.00<br />

51784 TC S 40.85 0.00 0.00 52351 S 741.93 0.00 0.00<br />

51785 TC S 68.24 0.00 0.00 52352 S 798.67 0.00 0.00<br />

51792 TC S 40.85 0.00 0.00 52353 S 999.84 0.00 0.00<br />

51795 TC S 73.18 0.00 0.00 52354 S 798.67 0.00 0.00<br />

51797 TC S 73.18 0.00 0.00 52355 S 798.67 0.00 0.00<br />

51798 S 18.18 0.00 0.00 52400 S 741.93 0.00 0.00<br />

51880 S 658.23 0.00 0.00 52402 S 741.93 0.00 0.00<br />

51992 S 1,245.65 0.00 0.00 52450 S 741.93 0.00 0.00<br />

52000 S 298.57 0.00 0.00 52500 S 741.93 0.00 0.00<br />

52001 S 556.58 0.00 0.00 52601 S 999.84 0.00 0.00<br />

52005 S 578.69 0.00 0.00 52630 S 912.84 0.00 0.00<br />

52007 S 711.67 0.00 0.00 52640 S 711.67 0.00 0.00<br />

52010 S 329.89 0.00 0.00 52647 S 1,529.67 0.00 0.00<br />

52204 S 578.69 0.00 0.00 52648 S 1,529.67 0.00 0.00<br />

52214 S 711.67 0.00 0.00 52700 S 711.67 0.00 0.00<br />

52224 S 711.67 0.00 0.00 53000 S 546.20 0.00 0.00<br />

52234 S 711.67 0.00 0.00 53010 S 546.20 0.00 0.00<br />

52235 S 741.93 0.00 0.00 53020 S 546.20 0.00 0.00<br />

52240 S 741.93 0.00 0.00 53025 S 777.50 0.00 0.00<br />

52250 S 798.67 0.00 0.00 53040 S 599.64 0.00 0.00<br />

52260 S 578.69 0.00 0.00 53060 S 71.01 0.00 0.00<br />

52265 S 282.24 0.00 0.00 53080 S 629.89 0.00 0.00<br />

52270 S 578.69 0.00 0.00 53085 S 777.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 546.20 0.00 0.00 54060 S 553.93 0.00 0.00<br />

53210 S 938.11 0.00 0.00 54065 S 553.93 0.00 0.00<br />

53215 S 727.77 0.00 0.00 54100 S 468.59 0.00 0.00<br />

53220 S 809.97 0.00 0.00 54105 S 584.95 0.00 0.00<br />

53230 S 809.97 0.00 0.00 54110 S 906.93 0.00 0.00<br />

53235 S 629.89 0.00 0.00 54111 S 906.93 0.00 0.00<br />

53240 S 809.97 0.00 0.00 54112 S 906.93 0.00 0.00<br />

53250 S 599.64 0.00 0.00 54115 S 536.89 0.00 0.00<br />

53260 S 599.64 0.00 0.00 54120 S 906.93 0.00 0.00<br />

53265 S 599.64 0.00 0.00 54150 S 604.42 0.00 0.00<br />

53270 S 599.64 0.00 0.00 54160 S 657.85 0.00 0.00<br />

53275 S 599.64 0.00 0.00 54161 S 657.85 0.00 0.00<br />

53400 S 840.23 0.00 0.00 54162 S 657.85 0.00 0.00<br />

53405 S 809.97 0.00 0.00 54163 S 657.85 0.00 0.00<br />

53410 S 809.97 0.00 0.00 54164 S 657.85 0.00 0.00<br />

53420 S 840.23 0.00 0.00 54200 S 68.90 0.00 0.00<br />

53425 S 809.97 0.00 0.00 54205 S 993.93 0.00 0.00<br />

53430 S 809.97 0.00 0.00 54220 S 98.76 0.00 0.00<br />

53431 S 809.97 0.00 0.00 54231 S 64.71 0.00 0.00<br />

53440 S 4,665.74 2,833.72 1,001.70 54235 S 45.82 0.00 0.00<br />

53442 S 756.54 0.00 0.00 54240 TC S 32.53 0.00 0.00<br />

53444 S 4,665.74 2,833.72 1,001.70 54250 TC S 11.54 0.00 0.00<br />

53445 S 7,837.25 4,463.26 1,089.28 54300 S 937.19 0.00 0.00<br />

53446 S 756.54 0.00 0.00 54304 S 937.19 0.00 0.00<br />

53447 S 7,837.25 4,463.26 1,089.28 54308 S 937.19 0.00 0.00<br />

53449 S 756.54 0.00 0.00 54312 S 937.19 0.00 0.00<br />

53450 S 756.54 0.00 0.00 54316 S 937.19 0.00 0.00<br />

53460 S 546.20 0.00 0.00 54318 S 937.19 0.00 0.00<br />

53502 S 599.64 0.00 0.00 54322 S 937.19 0.00 0.00<br />

53505 S 809.97 0.00 0.00 54324 S 937.19 0.00 0.00<br />

53510 S 599.64 0.00 0.00 54326 S 937.19 0.00 0.00<br />

53515 S 809.97 0.00 0.00 54328 S 937.19 0.00 0.00<br />

53520 S 809.97 0.00 0.00 54340 S 937.19 0.00 0.00<br />

53600 S 40.93 0.00 0.00 54344 S 937.19 0.00 0.00<br />

53601 S 40.85 0.00 0.00 54348 S 937.19 0.00 0.00<br />

53605 S 578.69 0.00 0.00 54352 S 937.19 0.00 0.00<br />

53620 S 62.96 0.00 0.00 54360 S 937.19 0.00 0.00<br />

53621 S 66.11 0.00 0.00 54380 S 937.19 0.00 0.00<br />

53660 S 40.85 0.00 0.00 54385 S 937.19 0.00 0.00<br />

53661 S 40.85 0.00 0.00 54400 S 4,696.00 2,863.98 1,031.96<br />

53665 S 546.20 0.00 0.00 54401 S 7,920.95 4,546.96 1,172.97<br />

53850 S 1,793.11 0.00 0.00 54405 S 7,920.95 4,546.96 1,172.97<br />

53852 S 1,793.11 0.00 0.00 54406 S 937.19 0.00 0.00<br />

54000 S 599.64 0.00 0.00 54408 S 937.19 0.00 0.00<br />

54001 S 599.64 0.00 0.00 54410 S 7,920.95 4,546.96 1,172.97<br />

54015 S 677.33 0.00 0.00 54415 S 937.19 0.00 0.00<br />

54050 S 32.41 0.00 0.00 54416 S 7,920.95 4,546.96 1,172.97<br />

54055 S 66.11 0.00 0.00 54420 S 993.93 0.00 0.00<br />

54056 S 32.41 0.00 0.00 54435 S 993.93 0.00 0.00<br />

54057 S 553.93 0.00 0.00 54440 S 993.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 155.49 0.00 0.00 55706 S 452.01 0.00 0.00<br />

54500 S 422.01 0.00 0.00 55720 S 658.23 0.00 0.00<br />

54505 S 604.42 0.00 0.00 55725 S 711.67 0.00 0.00<br />

54512 S 657.85 0.00 0.00 55860 S 784.22 0.00 0.00<br />

54520 S 688.11 0.00 0.00 55870 S 79.75 0.00 0.00<br />

54522 S 688.11 0.00 0.00 55873 S 6,205.04 0.00 0.00<br />

54530 S 917.58 0.00 0.00 55875 S 1,335.08 0.00 0.00<br />

54550 S 917.58 0.00 0.00 55876 S 73.10 0.00 0.00<br />

54560 S 893.94 0.00 0.00 55920 S 916.40 0.00 0.00<br />

54600 S 744.85 0.00 0.00 56405 S 42.67 0.00 0.00<br />

54620 S 688.11 0.00 0.00 56420 S 55.70 0.00 0.00<br />

54640 S 917.58 0.00 0.00 56440 S 598.09 0.00 0.00<br />

54660 S 657.85 0.00 0.00 56441 S 544.65 0.00 0.00<br />

54670 S 688.11 0.00 0.00 56442 S 544.65 0.00 0.00<br />

54680 S 688.11 0.00 0.00 56501 S 58.76 0.00 0.00<br />

54690 S 1,539.74 0.00 0.00 56515 S 637.62 0.00 0.00<br />

54692 S 2,737.04 0.00 0.00 56605 S 33.92 0.00 0.00<br />

54700 S 657.85 0.00 0.00 56606 S 13.99 0.00 0.00<br />

54800 S 147.66 0.00 0.00 56620 S 726.22 0.00 0.00<br />

54830 S 688.11 0.00 0.00 56625 S 857.66 0.00 0.00<br />

54840 S 744.85 0.00 0.00 56700 S 544.65 0.00 0.00<br />

54860 S 688.11 0.00 0.00 56740 S 628.34 0.00 0.00<br />

54861 S 744.85 0.00 0.00 56800 S 628.34 0.00 0.00<br />

54865 S 604.42 0.00 0.00 56805 S 774.40 0.00 0.00<br />

54900 S 744.85 0.00 0.00 56810 S 726.22 0.00 0.00<br />

54901 S 744.85 0.00 0.00 56820 S 43.37 0.00 0.00<br />

55000 S 67.16 0.00 0.00 56821 S 55.70 0.00 0.00<br />

55040 S 860.84 0.00 0.00 57000 S 544.65 0.00 0.00<br />

55041 S 958.72 0.00 0.00 57010 S 598.09 0.00 0.00<br />

55060 S 744.85 0.00 0.00 57020 S 313.66 0.00 0.00<br />

55100 S 403.96 0.00 0.00 57022 S 493.03 0.00 0.00<br />

55110 S 657.85 0.00 0.00 57023 S 536.89 0.00 0.00<br />

55120 S 657.85 0.00 0.00 57061 S 54.21 0.00 0.00<br />

55150 S 604.42 0.00 0.00 57065 S 544.65 0.00 0.00<br />

55175 S 604.42 0.00 0.00 57100 S 34.63 0.00 0.00<br />

55180 S 657.85 0.00 0.00 57105 S 598.09 0.00 0.00<br />

55200 S 657.85 0.00 0.00 57130 S 598.09 0.00 0.00<br />

55250 S 657.85 0.00 0.00 57135 S 598.09 0.00 0.00<br />

55400 S 604.42 0.00 0.00 57150 S 25.19 0.00 0.00<br />

55450 S 216.16 0.00 0.00 57155 S 313.66 0.00 0.00<br />

55500 S 688.11 0.00 0.00 57160 S 36.38 0.00 0.00<br />

55520 S 744.85 0.00 0.00 57170 S 5.96 0.00 0.00<br />

55530 S 744.85 0.00 0.00 57180 S 112.03 0.00 0.00<br />

55535 S 917.58 0.00 0.00 57200 S 544.65 0.00 0.00<br />

55540 S 958.72 0.00 0.00 57210 S 598.09 0.00 0.00<br />

55550 S 1,539.74 0.00 0.00 57220 S 1,096.81 0.00 0.00<br />

55600 S 893.94 0.00 0.00 57230 S 900.58 0.00 0.00<br />

55680 S 604.42 0.00 0.00 57240 S 998.45 0.00 0.00<br />

55700 S 389.52 0.00 0.00 57250 S 998.45 0.00 0.00<br />

55705 S 389.52 0.00 0.00 57260 S 998.45 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,326.12 0.00 0.00 58555 S 588.46 0.00 0.00<br />

57267 S 1,129.89 0.00 0.00 58558 S 672.16 0.00 0.00<br />

57268 S 900.58 0.00 0.00 58559 S 641.90 0.00 0.00<br />

57287 S 1,318.87 0.00 0.00 58560 S 958.40 0.00 0.00<br />

57288 S 1,194.68 0.00 0.00 58561 S 958.40 0.00 0.00<br />

57289 S 998.45 0.00 0.00 58562 S 672.16 0.00 0.00<br />

57291 S 998.45 0.00 0.00 58563 S 1,350.37 0.00 0.00<br />

57300 S 900.58 0.00 0.00 58565 S 1,488.78 0.00 0.00<br />

57320 S 1,318.87 0.00 0.00 58600 S 1,318.87 0.00 0.00<br />

57400 S 598.09 0.00 0.00 58615 S 774.40 0.00 0.00<br />

57410 S 598.09 0.00 0.00 58660 S 1,245.65 0.00 0.00<br />

57415 S 598.09 0.00 0.00 58661 S 1,245.65 0.00 0.00<br />

57420 S 44.78 0.00 0.00 58662 S 1,245.65 0.00 0.00<br />

57421 S 58.41 0.00 0.00 58670 S 1,147.78 0.00 0.00<br />

57452 S 42.32 0.00 0.00 58671 S 1,147.78 0.00 0.00<br />

57454 S 51.77 0.00 0.00 58672 S 1,245.65 0.00 0.00<br />

57455 S 54.91 0.00 0.00 58673 S 1,245.65 0.00 0.00<br />

57456 S 53.16 0.00 0.00 58800 S 628.34 0.00 0.00<br />

57460 S 163.34 0.00 0.00 58805 S 1,318.87 0.00 0.00<br />

57461 S 173.49 0.00 0.00 58820 S 900.58 0.00 0.00<br />

57500 S 74.85 0.00 0.00 58900 S 628.34 0.00 0.00<br />

57505 S 47.57 0.00 0.00 58970 S 175.02 0.00 0.00<br />

57510 S 48.27 0.00 0.00 58974 S 175.02 0.00 0.00<br />

57511 S 55.70 0.00 0.00 58976 S 175.02 0.00 0.00<br />

57513 S 598.09 0.00 0.00 59000 S 64.01 0.00 0.00<br />

57520 S 598.09 0.00 0.00 59001 S 240.26 0.00 0.00<br />

57522 S 598.09 0.00 0.00 59012 S 117.48 0.00 0.00<br />

57530 S 900.58 0.00 0.00 59015 S 51.77 0.00 0.00<br />

57550 S 900.58 0.00 0.00 59020 TC S 27.28 0.00 0.00<br />

57556 S 1,194.68 0.00 0.00 59025 TC S 14.34 0.00 0.00<br />

57558 S 628.34 0.00 0.00 59070 S 117.48 0.00 0.00<br />

57700 S 544.65 0.00 0.00 59072 S 117.48 0.00 0.00<br />

57720 S 628.34 0.00 0.00 59076 S 117.48 0.00 0.00<br />

57800 S 25.53 0.00 0.00 59100 S 1,318.87 0.00 0.00<br />

58100 S 41.97 0.00 0.00 59150 S 1,813.26 0.00 0.00<br />

58120 S 598.09 0.00 0.00 59151 S 1,813.26 0.00 0.00<br />

58145 S 998.45 0.00 0.00 59160 S 628.34 0.00 0.00<br />

58301 S 39.17 0.00 0.00 59200 S 34.98 0.00 0.00<br />

58321 S 36.73 0.00 0.00 59300 S 75.55 0.00 0.00<br />

58322 S 37.77 0.00 0.00 59320 S 544.65 0.00 0.00<br />

58323 S 8.75 0.00 0.00 59412 S 774.40 0.00 0.00<br />

58345 S 774.40 0.00 0.00 59414 S 774.40 0.00 0.00<br />

58346 S 598.09 0.00 0.00 59812 S 726.22 0.00 0.00<br />

58350 S 900.58 0.00 0.00 59820 S 726.22 0.00 0.00<br />

58353 S 1,129.89 0.00 0.00 59821 S 726.22 0.00 0.00<br />

58356 S 1,711.33 0.00 0.00 59840 S 726.22 0.00 0.00<br />

58545 S 1,374.66 0.00 0.00 59841 S 726.22 0.00 0.00<br />

58546 S 1,539.74 0.00 0.00 59866 S 117.48 0.00 0.00<br />

58550 S 2,001.63 0.00 0.00 59870 S 726.22 0.00 0.00<br />

58552 S 1,813.26 0.00 0.00 59871 S 726.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 304.89 0.00 0.00 62367 S 16.79 0.00 0.00<br />

60100 S 47.92 0.00 0.00 62368 S 21.34 0.00 0.00<br />

60200 S 1,134.79 0.00 0.00 63600 S 573.17 0.00 0.00<br />

60280 S 1,221.79 0.00 0.00 63610 S 519.74 0.00 0.00<br />

60281 S 1,221.79 0.00 0.00 63615 S 724.58 0.00 0.00<br />

60300 S 62.96 0.00 0.00 63650 S 3,085.08 1,913.06 741.04<br />

61000 S 280.74 0.00 0.00 63655 S 4,518.89 2,881.70 1,244.52<br />

61001 S 280.74 0.00 0.00 63660 S 541.80 0.00 0.00<br />

61020 S 227.29 0.00 0.00 63685 S 13,715.87 7,313.43 910.99<br />

61026 S 227.29 0.00 0.00 63688 S 735.72 0.00 0.00<br />

61050 S 227.29 0.00 0.00 63744 S 1,063.96 0.00 0.00<br />

61055 S 227.29 0.00 0.00 63746 S 492.16 0.00 0.00<br />

61070 S 176.86 0.00 0.00 64400 S 53.86 0.00 0.00<br />

61215 S 1,063.96 0.00 0.00 64402 S 50.72 0.00 0.00<br />

61330 S 1,639.09 0.00 0.00 64405 S 43.02 0.00 0.00<br />

61334 S 1,639.09 0.00 0.00 64408 S 53.51 0.00 0.00<br />

61790 S 603.43 0.00 0.00 64410 S 297.82 0.00 0.00<br />

61791 S 447.68 0.00 0.00 64412 S 78.70 0.00 0.00<br />

61880 S 768.69 0.00 0.00 64413 S 50.37 0.00 0.00<br />

61885 S 11,061.62 5,925.60 789.59 64415 S 137.16 0.00 0.00<br />

61886 S 16,517.69 8,705.78 893.87 64416 S 280.74 0.00 0.00<br />

61888 S 735.72 0.00 0.00 64417 S 137.16 0.00 0.00<br />

62194 S 297.82 0.00 0.00 64418 S 70.65 0.00 0.00<br />

62225 S 462.76 0.00 0.00 64420 S 137.16 0.00 0.00<br />

62230 S 1,033.69 0.00 0.00 64421 S 297.82 0.00 0.00<br />

62252 TC S 46.87 0.00 0.00 64425 S 48.97 0.00 0.00<br />

62263 S 297.82 0.00 0.00 64430 S 206.09 0.00 0.00<br />

62264 S 438.73 0.00 0.00 64435 S 73.80 0.00 0.00<br />

62267 S 175.08 0.00 0.00 64445 S 65.40 0.00 0.00<br />

62268 S 227.29 0.00 0.00 64446 S 562.56 0.00 0.00<br />

62269 S 344.92 0.00 0.00 64447 S 142.87 0.00 0.00<br />

62270 S 137.16 0.00 0.00 64448 S 142.87 0.00 0.00<br />

62272 S 137.16 0.00 0.00 64449 S 280.74 0.00 0.00<br />

62273 S 228.88 0.00 0.00 64450 S 43.72 0.00 0.00<br />

62280 S 297.82 0.00 0.00 64455 S 18.18 0.00 0.00<br />

62281 S 297.82 0.00 0.00 64470 S 297.82 0.00 0.00<br />

62282 S 297.82 0.00 0.00 64472 S 228.88 0.00 0.00<br />

62287 S 1,336.92 0.00 0.00 64475 S 297.82 0.00 0.00<br />

62292 S 280.74 0.00 0.00 64476 S 206.13 0.00 0.00<br />

62294 S 227.29 0.00 0.00 64479 S 297.82 0.00 0.00<br />

62310 S 297.82 0.00 0.00 64480 S 228.88 0.00 0.00<br />

62311 S 297.82 0.00 0.00 64483 S 297.82 0.00 0.00<br />

62318 S 297.82 0.00 0.00 64484 S 228.88 0.00 0.00<br />

62319 S 297.82 0.00 0.00 64505 S 39.88 0.00 0.00<br />

62350 S 1,033.69 0.00 0.00 64508 S 84.64 0.00 0.00<br />

62355 S 492.16 0.00 0.00 64510 S 297.82 0.00 0.00<br />

62360 S 1,033.69 0.00 0.00 64517 S 206.09 0.00 0.00<br />

62361 S 10,610.97 5,743.34 875.72 64520 S 297.82 0.00 0.00<br />

62362 S 10,610.97 5,743.34 875.72 64530 S 297.82 0.00 0.00<br />

62365 S 914.69 0.00 0.00 64553 S 3,031.64 1,859.62 687.61<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,404.36 2,232.33 1,060.32 64746 S 573.17 0.00 0.00<br />

64560 S 3,404.36 2,232.33 1,060.32 64761 S 724.58 0.00 0.00<br />

64561 S 3,115.34 1,943.31 771.30 64763 S 724.58 0.00 0.00<br />

64565 S 3,404.36 2,232.33 1,060.32 64766 S 1,407.61 0.00 0.00<br />

64573 S 5,303.48 3,141.79 980.11 64771 S 573.17 0.00 0.00<br />

64575 S 4,054.07 2,416.89 779.71 64772 S 573.17 0.00 0.00<br />

64577 S 4,054.07 2,416.89 779.71 64774 S 573.17 0.00 0.00<br />

64580 S 4,054.07 2,416.89 779.71 64776 S 603.43 0.00 0.00<br />

64581 S 4,137.77 2,500.58 863.40 64778 S 573.17 0.00 0.00<br />

64585 S 541.80 0.00 0.00 64782 S 603.43 0.00 0.00<br />

64590 S 11,061.62 5,925.60 789.59 64783 S 573.17 0.00 0.00<br />

64595 S 735.72 0.00 0.00 64784 S 603.43 0.00 0.00<br />

64600 S 438.73 0.00 0.00 64786 S 944.94 0.00 0.00<br />

64605 S 438.73 0.00 0.00 64787 S 573.17 0.00 0.00<br />

64610 S 438.73 0.00 0.00 64788 S 603.43 0.00 0.00<br />

64612 S 64.01 0.00 0.00 64790 S 603.43 0.00 0.00<br />

64613 S 61.91 0.00 0.00 64792 S 944.94 0.00 0.00<br />

64614 S 70.65 0.00 0.00 64795 S 573.17 0.00 0.00<br />

64620 S 297.82 0.00 0.00 64802 S 573.17 0.00 0.00<br />

64622 S 438.73 0.00 0.00 64820 S 724.58 0.00 0.00<br />

64623 S 297.82 0.00 0.00 64821 S 845.88 0.00 0.00<br />

64626 S 438.73 0.00 0.00 64822 S 1,095.99 0.00 0.00<br />

64627 S 206.13 0.00 0.00 64823 S 1,095.99 0.00 0.00<br />

64630 S 306.77 0.00 0.00 64831 S 1,001.69 0.00 0.00<br />

64632 S 33.23 0.00 0.00 64832 S 861.25 0.00 0.00<br />

64640 S 98.99 0.00 0.00 64834 S 914.69 0.00 0.00<br />

64650 S 33.23 0.00 0.00 64835 S 944.94 0.00 0.00<br />

64653 S 36.03 0.00 0.00 64836 S 944.94 0.00 0.00<br />

64680 S 466.13 0.00 0.00 64837 S 861.25 0.00 0.00<br />

64681 S 492.16 0.00 0.00 64840 S 914.69 0.00 0.00<br />

64702 S 519.74 0.00 0.00 64856 S 914.69 0.00 0.00<br />

64704 S 519.74 0.00 0.00 64857 S 914.69 0.00 0.00<br />

64708 S 573.17 0.00 0.00 64858 S 914.69 0.00 0.00<br />

64712 S 573.17 0.00 0.00 64859 S 861.25 0.00 0.00<br />

64713 S 573.17 0.00 0.00 64861 S 944.94 0.00 0.00<br />

64714 S 573.17 0.00 0.00 64862 S 944.94 0.00 0.00<br />

64716 S 603.43 0.00 0.00 64864 S 944.94 0.00 0.00<br />

64718 S 573.17 0.00 0.00 64865 S 1,001.69 0.00 0.00<br />

64719 S 573.17 0.00 0.00 64870 S 1,001.69 0.00 0.00<br />

64721 S 573.17 0.00 0.00 64872 S 914.69 0.00 0.00<br />

64722 S 519.74 0.00 0.00 64874 S 944.94 0.00 0.00<br />

64726 S 519.74 0.00 0.00 64876 S 944.94 0.00 0.00<br />

64727 S 519.74 0.00 0.00 64885 S 914.69 0.00 0.00<br />

64732 S 573.17 0.00 0.00 64886 S 914.69 0.00 0.00<br />

64734 S 573.17 0.00 0.00 64890 S 914.69 0.00 0.00<br />

64736 S 573.17 0.00 0.00 64891 S 914.69 0.00 0.00<br />

64738 S 573.17 0.00 0.00 64892 S 914.69 0.00 0.00<br />

64740 S 573.17 0.00 0.00 64893 S 914.69 0.00 0.00<br />

64742 S 573.17 0.00 0.00 64895 S 944.94 0.00 0.00<br />

64744 S 573.17 0.00 0.00 64896 S 944.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 944.94 0.00 0.00 65770 S 5,560.68 0.00 0.00<br />

64898 S 944.94 0.00 0.00 65772 S 625.53 0.00 0.00<br />

64901 S 914.69 0.00 0.00 65775 S 625.53 0.00 0.00<br />

64902 S 914.69 0.00 0.00 65780 S 1,082.08 0.00 0.00<br />

64905 S 914.69 0.00 0.00 65781 S 1,082.08 0.00 0.00<br />

64907 S 861.25 0.00 0.00 65782 S 1,082.08 0.00 0.00<br />

64910 S 1,407.61 0.00 0.00 65800 S 485.10 0.00 0.00<br />

65091 S 994.98 0.00 0.00 65805 S 485.10 0.00 0.00<br />

65093 S 994.98 0.00 0.00 65810 S 708.84 0.00 0.00<br />

65101 S 994.98 0.00 0.00 65815 S 678.57 0.00 0.00<br />

65103 S 994.98 0.00 0.00 65820 S 248.87 0.00 0.00<br />

65105 S 1,051.72 0.00 0.00 65850 S 765.57 0.00 0.00<br />

65110 S 1,092.85 0.00 0.00 65855 S 132.21 0.00 0.00<br />

65112 S 1,224.29 0.00 0.00 65860 S 123.47 0.00 0.00<br />

65114 S 1,224.29 0.00 0.00 65865 S 485.10 0.00 0.00<br />

65125 S 1,018.91 0.00 0.00 65870 S 765.57 0.00 0.00<br />

65130 S 750.60 0.00 0.00 65875 S 765.57 0.00 0.00<br />

65135 S 720.34 0.00 0.00 65880 S 625.53 0.00 0.00<br />

65140 S 994.98 0.00 0.00 65900 S 666.67 0.00 0.00<br />

65150 S 720.34 0.00 0.00 65920 S 938.16 0.00 0.00<br />

65155 S 994.98 0.00 0.00 65930 S 806.71 0.00 0.00<br />

65175 S 535.46 0.00 0.00 66020 S 485.10 0.00 0.00<br />

65205 S 20.64 0.00 0.00 66030 S 248.87 0.00 0.00<br />

65210 S 26.23 0.00 0.00 66130 S 938.16 0.00 0.00<br />

65220 S 36.55 0.00 0.00 66150 S 765.57 0.00 0.00<br />

65222 S 28.68 0.00 0.00 66155 S 765.57 0.00 0.00<br />

65235 S 538.53 0.00 0.00 66160 S 678.57 0.00 0.00<br />

65260 S 355.20 0.00 0.00 66165 S 765.57 0.00 0.00<br />

65265 S 734.86 0.00 0.00 66170 S 765.57 0.00 0.00<br />

65270 S 588.88 0.00 0.00 66172 S 765.57 0.00 0.00<br />

65272 S 678.57 0.00 0.00 66180 S 1,140.54 0.00 0.00<br />

65275 S 765.57 0.00 0.00 66185 S 1,012.41 0.00 0.00<br />

65280 S 734.86 0.00 0.00 66220 S 988.29 0.00 0.00<br />

65285 S 1,045.03 0.00 0.00 66225 S 1,099.41 0.00 0.00<br />

65286 S 182.83 0.00 0.00 66250 S 538.53 0.00 0.00<br />

65290 S 723.69 0.00 0.00 66500 S 248.87 0.00 0.00<br />

65400 S 485.10 0.00 0.00 66505 S 248.87 0.00 0.00<br />

65410 S 538.53 0.00 0.00 66600 S 708.84 0.00 0.00<br />

65420 S 538.53 0.00 0.00 66605 S 708.84 0.00 0.00<br />

65426 S 806.71 0.00 0.00 66625 S 503.99 0.00 0.00<br />

65430 S 36.55 0.00 0.00 66630 S 708.84 0.00 0.00<br />

65435 S 31.83 0.00 0.00 66635 S 708.84 0.00 0.00<br />

65436 S 138.16 0.00 0.00 66680 S 708.84 0.00 0.00<br />

65450 S 84.34 0.00 0.00 66682 S 678.57 0.00 0.00<br />

65600 S 162.99 0.00 0.00 66700 S 538.53 0.00 0.00<br />

65710 S 1,213.53 0.00 0.00 66710 S 538.53 0.00 0.00<br />

65730 S 1,213.53 0.00 0.00 66711 S 538.53 0.00 0.00<br />

65750 S 1,213.53 0.00 0.00 66720 S 538.53 0.00 0.00<br />

65755 S 1,213.53 0.00 0.00 66740 S 678.57 0.00 0.00<br />

65756 S 1,486.13 0.00 0.00 66761 S 183.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 187.13 0.00 0.00 67228 S 206.08 0.00 0.00<br />

66770 S 206.08 0.00 0.00 67229 S 206.08 0.00 0.00<br />

66820 S 182.83 0.00 0.00 67250 S 619.15 0.00 0.00<br />

66821 S 250.79 0.00 0.00 67255 S 678.12 0.00 0.00<br />

66825 S 765.57 0.00 0.00 67311 S 723.69 0.00 0.00<br />

66830 S 267.75 0.00 0.00 67312 S 780.44 0.00 0.00<br />

66840 S 575.57 0.00 0.00 67314 S 780.44 0.00 0.00<br />

66850 S 1,083.65 0.00 0.00 67316 S 780.44 0.00 0.00<br />

66852 S 911.07 0.00 0.00 67318 S 780.44 0.00 0.00<br />

66920 S 911.07 0.00 0.00 67320 S 780.44 0.00 0.00<br />

66930 S 952.21 0.00 0.00 67331 S 780.44 0.00 0.00<br />

66940 S 616.71 0.00 0.00 67332 S 780.44 0.00 0.00<br />

66982 S 935.57 0.00 0.00 67334 S 780.44 0.00 0.00<br />

66983 S 935.57 0.00 0.00 67335 S 780.44 0.00 0.00<br />

66984 S 935.57 0.00 0.00 67340 S 780.44 0.00 0.00<br />

66985 S 866.06 0.00 0.00 67343 S 953.01 0.00 0.00<br />

66986 S 866.06 0.00 0.00 67345 S 81.50 0.00 0.00<br />

67005 S 734.86 0.00 0.00 67346 S 440.81 0.00 0.00<br />

67010 S 734.86 0.00 0.00 67400 S 619.15 0.00 0.00<br />

67015 S 904.60 0.00 0.00 67405 S 807.34 0.00 0.00<br />

67025 S 594.43 0.00 0.00 67412 S 717.02 0.00 0.00<br />

67027 S 1,045.03 0.00 0.00 67413 S 848.47 0.00 0.00<br />

67028 S 82.20 0.00 0.00 67414 S 1,507.67 0.00 0.00<br />

67030 S 594.43 0.00 0.00 67415 S 535.46 0.00 0.00<br />

67031 S 250.79 0.00 0.00 67420 S 1,092.85 0.00 0.00<br />

67036 S 1,045.03 0.00 0.00 67430 S 1,092.85 0.00 0.00<br />

67039 S 1,217.61 0.00 0.00 67440 S 1,092.85 0.00 0.00<br />

67040 S 1,217.61 0.00 0.00 67445 S 1,092.85 0.00 0.00<br />

67041 S 1,494.30 0.00 0.00 67450 S 1,092.85 0.00 0.00<br />

67042 S 1,494.30 0.00 0.00 67500 S 84.34 0.00 0.00<br />

67043 S 1,494.30 0.00 0.00 67505 S 26.23 0.00 0.00<br />

67101 S 228.12 0.00 0.00 67515 S 26.58 0.00 0.00<br />

67105 S 206.08 0.00 0.00 67550 S 1,051.72 0.00 0.00<br />

67107 S 1,086.17 0.00 0.00 67560 S 720.34 0.00 0.00<br />

67108 S 1,217.61 0.00 0.00 67570 S 1,051.72 0.00 0.00<br />

67110 S 331.58 0.00 0.00 67700 S 123.40 0.00 0.00<br />

67112 S 1,217.61 0.00 0.00 67710 S 144.10 0.00 0.00<br />

67113 S 1,494.30 0.00 0.00 67715 S 535.46 0.00 0.00<br />

67115 S 647.86 0.00 0.00 67800 S 51.77 0.00 0.00<br />

67120 S 647.86 0.00 0.00 67801 S 62.61 0.00 0.00<br />

67121 S 647.86 0.00 0.00 67805 S 81.14 0.00 0.00<br />

67141 S 228.37 0.00 0.00 67808 S 588.88 0.00 0.00<br />

67145 S 194.82 0.00 0.00 67810 S 123.40 0.00 0.00<br />

67208 S 207.77 0.00 0.00 67820 S 17.14 0.00 0.00<br />

67210 S 206.08 0.00 0.00 67825 S 52.82 0.00 0.00<br />

67218 S 776.00 0.00 0.00 67830 S 361.53 0.00 0.00<br />

67220 S 228.12 0.00 0.00 67835 S 588.88 0.00 0.00<br />

67221 S 117.17 0.00 0.00 67840 S 151.10 0.00 0.00<br />

67225 S 8.05 0.00 0.00 67850 S 119.97 0.00 0.00<br />

67227 S 594.43 0.00 0.00 67875 S 301.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 568.80 0.00 0.00 68440 S 51.42 0.00 0.00<br />

67882 S 619.15 0.00 0.00 68500 S 750.60 0.00 0.00<br />

67900 S 807.34 0.00 0.00 68505 S 750.60 0.00 0.00<br />

67901 S 717.02 0.00 0.00 68510 S 535.46 0.00 0.00<br />

67902 S 848.47 0.00 0.00 68520 S 750.60 0.00 0.00<br />

67903 S 675.88 0.00 0.00 68525 S 535.46 0.00 0.00<br />

67904 S 675.88 0.00 0.00 68530 S 123.40 0.00 0.00<br />

67906 S 717.02 0.00 0.00 68540 S 619.15 0.00 0.00<br />

67908 S 675.88 0.00 0.00 68550 S 750.60 0.00 0.00<br />

67909 S 675.88 0.00 0.00 68700 S 588.88 0.00 0.00<br />

67911 S 619.15 0.00 0.00 68705 S 117.17 0.00 0.00<br />

67912 S 619.15 0.00 0.00 68720 S 807.34 0.00 0.00<br />

67914 S 619.15 0.00 0.00 68745 S 807.34 0.00 0.00<br />

67915 S 167.19 0.00 0.00 68750 S 807.34 0.00 0.00<br />

67916 S 675.88 0.00 0.00 68760 S 99.69 0.00 0.00<br />

67917 S 675.88 0.00 0.00 68761 S 68.90 0.00 0.00<br />

67921 S 619.15 0.00 0.00 68770 S 807.34 0.00 0.00<br />

67922 S 162.65 0.00 0.00 68801 S 36.55 0.00 0.00<br />

67923 S 675.88 0.00 0.00 68810 S 104.53 0.00 0.00<br />

67924 S 675.88 0.00 0.00 68811 S 588.88 0.00 0.00<br />

67930 S 167.19 0.00 0.00 68815 S 588.88 0.00 0.00<br />

67935 S 588.88 0.00 0.00 68816 S 756.01 0.00 0.00<br />

67938 S 84.34 0.00 0.00 68840 S 54.21 0.00 0.00<br />

67950 S 588.88 0.00 0.00 69000 S 55.30 0.00 0.00<br />

67961 S 619.15 0.00 0.00 69005 S 104.58 0.00 0.00<br />

67966 S 619.15 0.00 0.00 69020 S 55.30 0.00 0.00<br />

67971 S 619.15 0.00 0.00 69100 S 62.96 0.00 0.00<br />

67973 S 750.60 0.00 0.00 69105 S 89.19 0.00 0.00<br />

67974 S 619.15 0.00 0.00 69110 S 468.59 0.00 0.00<br />

67975 S 619.15 0.00 0.00 69120 S 695.39 0.00 0.00<br />

68020 S 45.82 0.00 0.00 69140 S 695.39 0.00 0.00<br />

68040 S 22.73 0.00 0.00 69145 S 522.01 0.00 0.00<br />

68100 S 90.94 0.00 0.00 69150 S 366.89 0.00 0.00<br />

68110 S 117.17 0.00 0.00 69200 S 25.29 0.00 0.00<br />

68115 S 588.88 0.00 0.00 69205 S 584.95 0.00 0.00<br />

68130 S 538.53 0.00 0.00 69210 S 20.64 0.00 0.00<br />

68135 S 58.76 0.00 0.00 69220 S 32.41 0.00 0.00<br />

68200 S 16.79 0.00 0.00 69222 S 136.41 0.00 0.00<br />

68320 S 807.34 0.00 0.00 69300 S 725.65 0.00 0.00<br />

68325 S 807.34 0.00 0.00 69310 S 1,060.69 0.00 0.00<br />

68326 S 675.88 0.00 0.00 69320 S 1,290.01 0.00 0.00<br />

68328 S 807.34 0.00 0.00 69400 S 91.64 0.00 0.00<br />

68330 S 765.57 0.00 0.00 69401 S 48.27 0.00 0.00<br />

68335 S 807.34 0.00 0.00 69405 S 126.62 0.00 0.00<br />

68340 S 675.88 0.00 0.00 69420 S 113.68 0.00 0.00<br />

68360 S 678.57 0.00 0.00 69421 S 578.56 0.00 0.00<br />

68362 S 678.57 0.00 0.00 69424 S 79.75 0.00 0.00<br />

68371 S 538.53 0.00 0.00 69433 S 113.33 0.00 0.00<br />

68400 S 123.40 0.00 0.00 69436 S 578.56 0.00 0.00<br />

68420 S 175.58 0.00 0.00 69440 S 725.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 977.00 0.00 0.00 69840 S 1,158.56 0.00 0.00<br />

69501 S 1,290.01 0.00 0.00 69905 S 1,290.01 0.00 0.00<br />

69502 S 954.97 0.00 0.00 69910 S 1,290.01 0.00 0.00<br />

69505 S 1,290.01 0.00 0.00 69915 S 1,290.01 0.00 0.00<br />

69511 S 1,290.01 0.00 0.00 69930 S 23,321.60 12,522.12 1,722.65<br />

69530 S 1,290.01 0.00 0.00 70030 TC A 17.83 0.00 0.00<br />

69540 S 133.26 0.00 0.00 70100 TC A 19.59 0.00 0.00<br />

69550 S 1,158.56 0.00 0.00 70110 TC A 24.14 0.00 0.00<br />

69552 S 1,290.01 0.00 0.00 70120 TC A 21.68 0.00 0.00<br />

69601 S 1,290.01 0.00 0.00 70130 TC A 26.49 0.00 0.00<br />

69602 S 1,290.01 0.00 0.00 70134 TC A 26.58 0.00 0.00<br />

69603 S 1,290.01 0.00 0.00 70140 TC A 18.18 0.00 0.00<br />

69604 S 1,290.01 0.00 0.00 70150 TC A 26.49 0.00 0.00<br />

69605 S 1,290.01 0.00 0.00 70160 TC A 21.34 0.00 0.00<br />

69610 S 178.39 0.00 0.00 70190 TC A 22.38 0.00 0.00<br />

69620 S 695.39 0.00 0.00 70200 TC A 26.49 0.00 0.00<br />

69631 S 1,158.56 0.00 0.00 70210 TC A 18.89 0.00 0.00<br />

69632 S 1,158.56 0.00 0.00 70220 TC A 23.79 0.00 0.00<br />

69633 S 1,158.56 0.00 0.00 70240 TC A 17.83 0.00 0.00<br />

69635 S 1,290.01 0.00 0.00 70250 TC A 21.68 0.00 0.00<br />

69636 S 1,290.01 0.00 0.00 70260 TC A 27.63 0.00 0.00<br />

69637 S 1,290.01 0.00 0.00 70300 TC A 7.69 0.00 0.00<br />

69641 S 1,290.01 0.00 0.00 70310 TC A 19.01 0.00 0.00<br />

69642 S 1,290.01 0.00 0.00 70320 TC A 19.01 0.00 0.00<br />

69643 S 1,290.01 0.00 0.00 70328 TC A 18.89 0.00 0.00<br />

69644 S 1,290.01 0.00 0.00 70330 TC A 26.49 0.00 0.00<br />

69645 S 1,290.01 0.00 0.00 70336 TC A 206.24 0.00 0.00<br />

69646 S 1,290.01 0.00 0.00 70350 TC A 10.49 0.00 0.00<br />

69650 S 954.97 0.00 0.00 70355 TC A 10.84 0.00 0.00<br />

69660 S 1,158.56 0.00 0.00 70360 TC A 16.79 0.00 0.00<br />

69661 S 1,158.56 0.00 0.00 70370 TC A 49.30 0.00 0.00<br />

69662 S 1,158.56 0.00 0.00 70371 TC A 49.30 0.00 0.00<br />

69666 S 1,117.42 0.00 0.00 70380 TC A 25.53 0.00 0.00<br />

69667 S 1,117.42 0.00 0.00 70450 TC A 115.18 0.00 0.00<br />

69670 S 1,060.69 0.00 0.00 70460 TC A 182.39 0.00 0.00<br />

69676 S 1,060.69 0.00 0.00 70470 TC A 202.04 0.00 0.00<br />

69700 S 1,060.69 0.00 0.00 70480 TC A 115.18 0.00 0.00<br />

69711 S 977.00 0.00 0.00 70481 TC A 182.39 0.00 0.00<br />

69714 S 6,195.94 3,906.77 1,617.61 70482 TC A 202.04 0.00 0.00<br />

69715 S 6,195.94 3,906.77 1,617.61 70486 TC A 115.18 0.00 0.00<br />

69717 S 6,195.94 3,906.77 1,617.61 70487 TC A 182.39 0.00 0.00<br />

69718 S 6,195.94 3,906.77 1,617.61 70488 TC A 202.04 0.00 0.00<br />

69720 S 1,158.56 0.00 0.00 70490 TC A 115.18 0.00 0.00<br />

69740 S 1,158.56 0.00 0.00 70491 TC A 182.39 0.00 0.00<br />

69745 S 1,158.56 0.00 0.00 70492 TC A 202.04 0.00 0.00<br />

69801 S 1,158.56 0.00 0.00 70496 TC A 208.50 0.00 0.00<br />

69802 S 1,290.01 0.00 0.00 70498 TC A 208.50 0.00 0.00<br />

69805 S 1,290.01 0.00 0.00 70540 TC A 206.24 0.00 0.00<br />

69806 S 1,290.01 0.00 0.00 70542 TC A 253.26 0.00 0.00<br />

69820 S 1,158.56 0.00 0.00 70543 TC A 319.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 206.24 0.00 0.00 72120 TC A 33.57 0.00 0.00<br />

70545 TC A 253.26 0.00 0.00 72125 TC A 115.18 0.00 0.00<br />

70546 TC A 319.20 0.00 0.00 72126 TC A 182.39 0.00 0.00<br />

70547 TC A 206.24 0.00 0.00 72127 TC A 202.04 0.00 0.00<br />

70548 TC A 253.26 0.00 0.00 72128 TC A 115.18 0.00 0.00<br />

70549 TC A 319.20 0.00 0.00 72129 TC A 182.39 0.00 0.00<br />

70551 TC A 206.24 0.00 0.00 72130 TC A 202.04 0.00 0.00<br />

70552 TC A 253.26 0.00 0.00 72131 TC A 115.18 0.00 0.00<br />

70553 TC A 319.20 0.00 0.00 72132 TC A 182.39 0.00 0.00<br />

70554 TC A 206.24 0.00 0.00 72133 TC A 202.04 0.00 0.00<br />

70555 TC A 206.24 0.00 0.00 72141 TC A 206.24 0.00 0.00<br />

70557 TC A 206.24 0.00 0.00 72142 TC A 253.26 0.00 0.00<br />

70558 TC A 253.26 0.00 0.00 72146 TC A 206.24 0.00 0.00<br />

70559 TC A 319.20 0.00 0.00 72147 TC A 253.26 0.00 0.00<br />

71010 TC A 13.65 0.00 0.00 72148 TC A 206.24 0.00 0.00<br />

71015 TC A 17.49 0.00 0.00 72149 TC A 253.26 0.00 0.00<br />

71020 TC A 18.54 0.00 0.00 72156 TC A 319.20 0.00 0.00<br />

71021 TC A 22.38 0.00 0.00 72157 TC A 319.20 0.00 0.00<br />

71022 TC A 26.49 0.00 0.00 72158 TC A 319.20 0.00 0.00<br />

71023 TC A 43.37 0.00 0.00 72170 TC A 15.74 0.00 0.00<br />

71030 TC A 26.49 0.00 0.00 72190 TC A 26.49 0.00 0.00<br />

71034 TC A 49.30 0.00 0.00 72191 TC A 208.50 0.00 0.00<br />

71035 TC A 23.08 0.00 0.00 72192 TC A 115.18 0.00 0.00<br />

71100 TC A 19.24 0.00 0.00 72193 TC A 182.39 0.00 0.00<br />

71101 TC A 23.43 0.00 0.00 72194 TC A 202.04 0.00 0.00<br />

71110 TC A 24.49 0.00 0.00 72195 TC A 206.24 0.00 0.00<br />

71111 TC A 32.53 0.00 0.00 72196 TC A 253.26 0.00 0.00<br />

71120 TC A 20.29 0.00 0.00 72197 TC A 319.20 0.00 0.00<br />

71130 TC A 23.79 0.00 0.00 72200 TC A 18.54 0.00 0.00<br />

71250 TC A 115.18 0.00 0.00 72202 TC A 22.73 0.00 0.00<br />

71260 TC A 182.39 0.00 0.00 72220 TC A 18.54 0.00 0.00<br />

71270 TC A 202.04 0.00 0.00 73000 TC A 17.49 0.00 0.00<br />

71275 TC A 208.50 0.00 0.00 73010 TC A 17.83 0.00 0.00<br />

71550 TC A 206.24 0.00 0.00 73020 TC A 14.34 0.00 0.00<br />

71551 TC A 253.26 0.00 0.00 73030 TC A 18.18 0.00 0.00<br />

71552 TC A 319.20 0.00 0.00 73050 TC A 22.73 0.00 0.00<br />

72010 TC A 44.11 0.00 0.00 73060 TC A 18.18 0.00 0.00<br />

72020 TC A 14.34 0.00 0.00 73070 TC A 17.49 0.00 0.00<br />

72040 TC A 23.08 0.00 0.00 73080 TC A 23.08 0.00 0.00<br />

72050 TC A 32.88 0.00 0.00 73090 TC A 17.49 0.00 0.00<br />

72052 TC A 44.11 0.00 0.00 73092 TC A 18.18 0.00 0.00<br />

72069 TC A 21.68 0.00 0.00 73100 TC A 18.18 0.00 0.00<br />

72070 TC A 20.29 0.00 0.00 73110 TC A 23.08 0.00 0.00<br />

72072 TC A 24.49 0.00 0.00 73120 TC A 17.14 0.00 0.00<br />

72074 TC A 26.49 0.00 0.00 73130 TC A 20.29 0.00 0.00<br />

72080 TC A 21.68 0.00 0.00 73140 TC A 19.94 0.00 0.00<br />

72090 TC A 29.04 0.00 0.00 73200 TC A 115.18 0.00 0.00<br />

72100 TC A 24.84 0.00 0.00 73201 TC A 182.39 0.00 0.00<br />

72110 TC A 34.63 0.00 0.00 73202 TC A 202.04 0.00 0.00<br />

72114 TC A 44.11 0.00 0.00 73206 TC A 208.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 206.24 0.00 0.00 74246 TC A 52.05 0.00 0.00<br />

73219 TC A 253.26 0.00 0.00 74247 TC A 52.05 0.00 0.00<br />

73220 TC A 319.20 0.00 0.00 74249 TC A 84.63 0.00 0.00<br />

73221 TC A 206.24 0.00 0.00 74250 TC A 52.05 0.00 0.00<br />

73222 TC A 253.26 0.00 0.00 74251 TC A 84.63 0.00 0.00<br />

73223 TC A 319.20 0.00 0.00 74260 TC A 52.05 0.00 0.00<br />

73500 TC A 15.04 0.00 0.00 74270 TC A 52.05 0.00 0.00<br />

73510 TC A 23.08 0.00 0.00 74280 TC A 84.63 0.00 0.00<br />

73520 TC A 23.79 0.00 0.00 74283 TC A 52.05 0.00 0.00<br />

73540 TC A 23.79 0.00 0.00 74290 TC A 44.42 0.00 0.00<br />

73550 TC A 17.49 0.00 0.00 74291 TC A 42.67 0.00 0.00<br />

73560 TC A 17.83 0.00 0.00 74400 TC A 77.30 0.00 0.00<br />

73562 TC A 22.03 0.00 0.00 74410 TC A 82.55 0.00 0.00<br />

73564 TC A 25.53 0.00 0.00 74415 TC A 98.64 0.00 0.00<br />

73565 TC A 19.24 0.00 0.00 74420 TC A 103.10 0.00 0.00<br />

73590 TC A 16.79 0.00 0.00 74710 TC A 23.08 0.00 0.00<br />

73592 TC A 18.18 0.00 0.00 74775 TC A 103.10 0.00 0.00<br />

73600 TC A 17.14 0.00 0.00 75557 TC A 206.24 0.00 0.00<br />

73610 TC A 20.29 0.00 0.00 75559 TC A 206.24 0.00 0.00<br />

73620 TC A 16.44 0.00 0.00 75561 TC A 319.20 0.00 0.00<br />

73630 TC A 19.94 0.00 0.00 75563 TC A 319.20 0.00 0.00<br />

73650 TC A 16.79 0.00 0.00 76010 TC A 17.14 0.00 0.00<br />

73660 TC A 18.89 0.00 0.00 76098 TC A 10.49 0.00 0.00<br />

73700 TC A 115.18 0.00 0.00 76100 TC A 44.11 0.00 0.00<br />

73701 TC A 182.39 0.00 0.00 76101 TC A 118.22 0.00 0.00<br />

73702 TC A 202.04 0.00 0.00 76102 TC A 118.22 0.00 0.00<br />

73706 TC A 208.50 0.00 0.00 76120 TC A 49.30 0.00 0.00<br />

73718 TC A 206.24 0.00 0.00 76150 A 17.14 0.00 0.00<br />

73719 TC A 253.26 0.00 0.00 76380 TC A 62.22 0.00 0.00<br />

73720 TC A 319.20 0.00 0.00 76496 TC A 49.30 0.00 0.00<br />

73721 TC A 206.24 0.00 0.00 76497 TC A 62.22 0.00 0.00<br />

73722 TC A 253.26 0.00 0.00 76498 TC A 206.24 0.00 0.00<br />

73723 TC A 319.20 0.00 0.00 76499 TC A 26.49 0.00 0.00<br />

74000 TC A 15.04 0.00 0.00 76506 TC A 37.04 0.00 0.00<br />

74010 TC A 23.43 0.00 0.00 76510 TC A 62.96 0.00 0.00<br />

74020 TC A 23.79 0.00 0.00 76511 TC A 44.07 0.00 0.00<br />

74022 TC A 29.04 0.00 0.00 76512 TC A 37.42 0.00 0.00<br />

74150 TC A 115.18 0.00 0.00 76513 TC A 45.47 0.00 0.00<br />

74160 TC A 182.39 0.00 0.00 76514 TC A 3.15 0.00 0.00<br />

74170 TC A 202.04 0.00 0.00 76516 TC A 35.68 0.00 0.00<br />

74175 TC A 208.50 0.00 0.00 76519 TC A 39.88 0.00 0.00<br />

74181 TC A 206.24 0.00 0.00 76529 TC A 34.63 0.00 0.00<br />

74182 TC A 253.26 0.00 0.00 76536 TC A 57.94 0.00 0.00<br />

74183 TC A 319.20 0.00 0.00 76604 TC A 37.04 0.00 0.00<br />

74210 TC A 52.05 0.00 0.00 76645 TC A 37.04 0.00 0.00<br />

74220 TC A 52.05 0.00 0.00 76700 TC A 57.94 0.00 0.00<br />

74230 TC A 52.05 0.00 0.00 76705 TC A 57.94 0.00 0.00<br />

74240 TC A 52.05 0.00 0.00 76770 TC A 57.94 0.00 0.00<br />

74241 TC A 52.05 0.00 0.00 76775 TC A 57.94 0.00 0.00<br />

74245 TC A 84.63 0.00 0.00 76776 TC A 57.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 57.94 0.00 0.00 77290 TC A 151.51 0.00 0.00<br />

76801 TC A 57.94 0.00 0.00 77295 TC A 397.00 0.00 0.00<br />

76802 TC A 27.63 0.00 0.00 77299 TC A 67.97 0.00 0.00<br />

76805 TC A 57.94 0.00 0.00 77300 TC A 36.73 0.00 0.00<br />

76810 TC A 43.72 0.00 0.00 77301 TC A 529.08 0.00 0.00<br />

76811 TC A 90.76 0.00 0.00 77305 TC A 33.57 0.00 0.00<br />

76812 TC A 37.04 0.00 0.00 77310 TC A 43.72 0.00 0.00<br />

76813 TC A 37.04 0.00 0.00 77315 TC A 63.66 0.00 0.00<br />

76814 TC A 29.38 0.00 0.00 77321 TC A 66.11 0.00 0.00<br />

76815 TC A 37.04 0.00 0.00 77326 TC A 67.97 0.00 0.00<br />

76816 TC A 37.04 0.00 0.00 77327 TC A 123.47 0.00 0.00<br />

76817 TC A 37.04 0.00 0.00 77328 TC A 151.51 0.00 0.00<br />

76818 TC A 57.94 0.00 0.00 77331 TC A 17.49 0.00 0.00<br />

76819 TC A 50.02 0.00 0.00 77332 TC A 46.87 0.00 0.00<br />

76820 TC A 24.84 0.00 0.00 77333 TC A 22.73 0.00 0.00<br />

76821 TC A 56.08 0.00 0.00 77334 TC A 87.80 0.00 0.00<br />

76825 TC A 116.82 0.00 0.00 77336 A 55.27 0.00 0.00<br />

76826 TC A 69.60 0.00 0.00 77370 A 67.97 0.00 0.00<br />

76827 TC A 37.04 0.00 0.00 77371 A 4,528.09 0.00 0.00<br />

76828 TC A 22.03 0.00 0.00 77399 TC A 67.97 0.00 0.00<br />

76830 TC A 57.94 0.00 0.00 77401 A 27.63 0.00 0.00<br />

76831 TC A 78.00 0.00 0.00 77402 A 55.63 0.00 0.00<br />

76856 TC A 57.94 0.00 0.00 77403 A 55.63 0.00 0.00<br />

76857 TC A 37.04 0.00 0.00 77404 A 55.63 0.00 0.00<br />

76870 TC A 57.94 0.00 0.00 77406 A 90.10 0.00 0.00<br />

76872 TC A 57.94 0.00 0.00 77407 A 55.63 0.00 0.00<br />

76873 TC A 57.94 0.00 0.00 77408 A 55.63 0.00 0.00<br />

76880 TC A 57.94 0.00 0.00 77409 A 55.63 0.00 0.00<br />

76885 TC A 37.04 0.00 0.00 77411 A 90.10 0.00 0.00<br />

76886 TC A 37.04 0.00 0.00 77412 A 90.10 0.00 0.00<br />

76936 TC A 56.08 0.00 0.00 77413 A 90.10 0.00 0.00<br />

76970 TC A 37.04 0.00 0.00 77414 A 90.10 0.00 0.00<br />

76977 TC A 9.45 0.00 0.00 77416 A 90.10 0.00 0.00<br />

76999 TC A 37.04 0.00 0.00 77418 A 243.44 0.00 0.00<br />

77071 A 21.68 0.00 0.00 77422 A 90.10 0.00 0.00<br />

77072 TC A 12.59 0.00 0.00 77423 A 90.10 0.00 0.00<br />

77073 TC A 21.34 0.00 0.00 77470 TC A 129.42 0.00 0.00<br />

77074 TC A 41.97 0.00 0.00 77520 A 416.79 0.00 0.00<br />

77075 TC A 44.11 0.00 0.00 77522 A 416.79 0.00 0.00<br />

77076 TC A 44.11 0.00 0.00 77523 A 498.08 0.00 0.00<br />

77077 TC A 23.79 0.00 0.00 77525 A 498.08 0.00 0.00<br />

77078 TC A 42.61 0.00 0.00 77600 TC A 221.14 0.00 0.00<br />

77079 TC A 43.72 0.00 0.00 77605 TC A 221.14 0.00 0.00<br />

77080 TC A 42.61 0.00 0.00 77610 TC A 221.14 0.00 0.00<br />

77081 TC A 17.14 0.00 0.00 77615 TC A 221.14 0.00 0.00<br />

77082 TC A 18.54 0.00 0.00 77620 TC A 221.14 0.00 0.00<br />

77083 TC A 14.69 0.00 0.00 77750 TC A 86.04 0.00 0.00<br />

77084 TC A 206.24 0.00 0.00 77761 TC A 151.45 0.00 0.00<br />

77280 TC A 67.97 0.00 0.00 77762 TC A 179.43 0.00 0.00<br />

77285 TC A 151.51 0.00 0.00 77763 TC A 231.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 164.04 0.00 0.00 78262 TC A 144.06 0.00 0.00<br />

77777 TC A 180.13 0.00 0.00 78264 TC A 144.06 0.00 0.00<br />

77778 TC A 239.95 0.00 0.00 78270 TC A 62.96 0.00 0.00<br />

77785 TC A 106.68 0.00 0.00 78271 TC A 64.01 0.00 0.00<br />

77786 TC A 374.95 0.00 0.00 78272 TC A 70.30 0.00 0.00<br />

77787 TC A 434.49 0.00 0.00 78278 TC A 144.06 0.00 0.00<br />

77789 TC A 44.78 0.00 0.00 78282 TC A 144.06 0.00 0.00<br />

77799 TC A 255.19 0.00 0.00 78290 TC A 144.06 0.00 0.00<br />

78000 TC A 54.91 0.00 0.00 78291 TC A 144.06 0.00 0.00<br />

78001 TC A 69.59 0.00 0.00 78299 TC A 144.06 0.00 0.00<br />

78003 TC A 55.27 0.00 0.00 78300 TC A 125.57 0.00 0.00<br />

78006 TC A 131.50 0.00 0.00 78305 TC A 145.63 0.00 0.00<br />

78007 TC A 97.24 0.00 0.00 78306 TC A 145.63 0.00 0.00<br />

78010 TC A 80.79 0.00 0.00 78315 TC A 145.63 0.00 0.00<br />

78011 TC A 80.79 0.00 0.00 78320 TC A 145.63 0.00 0.00<br />

78015 TC A 157.05 0.00 0.00 78399 TC A 145.63 0.00 0.00<br />

78016 TC A 177.27 0.00 0.00 78414 TC A 185.12 0.00 0.00<br />

78018 TC A 177.27 0.00 0.00 78428 TC A 142.01 0.00 0.00<br />

78070 TC A 120.67 0.00 0.00 78445 TC A 110.77 0.00 0.00<br />

78075 TC A 341.73 0.00 0.00 78456 TC A 110.77 0.00 0.00<br />

78099 TC A 80.79 0.00 0.00 78457 TC A 110.77 0.00 0.00<br />

78102 TC A 122.07 0.00 0.00 78458 TC A 110.77 0.00 0.00<br />

78103 TC A 155.60 0.00 0.00 78459 TC A 685.50 0.00 0.00<br />

78104 TC A 155.60 0.00 0.00 78460 TC A 132.91 0.00 0.00<br />

78110 TC A 61.91 0.00 0.00 78461 TC A 133.97 0.00 0.00<br />

78111 TC A 78.35 0.00 0.00 78464 TC A 196.57 0.00 0.00<br />

78120 TC A 68.56 0.00 0.00 78465 TC A 372.16 0.00 0.00<br />

78121 TC A 81.14 0.00 0.00 78466 TC A 131.86 0.00 0.00<br />

78122 TC A 96.18 0.00 0.00 78468 TC A 168.59 0.00 0.00<br />

78130 TC A 111.58 0.00 0.00 78469 TC A 185.12 0.00 0.00<br />

78135 TC A 237.14 0.00 0.00 78472 TC A 185.12 0.00 0.00<br />

78140 TC A 105.28 0.00 0.00 78473 TC A 185.12 0.00 0.00<br />

78185 TC A 155.60 0.00 0.00 78481 TC A 159.84 0.00 0.00<br />

78190 TC A 97.64 0.00 0.00 78483 TC A 185.12 0.00 0.00<br />

78191 TC A 97.64 0.00 0.00 78491 TC A 685.50 0.00 0.00<br />

78195 TC A 155.60 0.00 0.00 78492 TC A 685.50 0.00 0.00<br />

78199 TC A 155.60 0.00 0.00 78494 TC A 185.12 0.00 0.00<br />

78201 TC A 138.51 0.00 0.00 78499 TC A 185.12 0.00 0.00<br />

78202 TC A 162.94 0.00 0.00 78580 TC A 125.41 0.00 0.00<br />

78205 TC A 162.94 0.00 0.00 78584 TC A 96.88 0.00 0.00<br />

78206 TC A 162.94 0.00 0.00 78585 TC A 192.44 0.00 0.00<br />

78215 TC A 146.56 0.00 0.00 78586 TC A 125.41 0.00 0.00<br />

78216 TC A 99.34 0.00 0.00 78587 TC A 125.41 0.00 0.00<br />

78220 TC A 108.43 0.00 0.00 78588 TC A 192.44 0.00 0.00<br />

78223 TC A 162.94 0.00 0.00 78591 TC A 125.41 0.00 0.00<br />

78230 TC A 123.12 0.00 0.00 78593 TC A 125.41 0.00 0.00<br />

78231 TC A 96.88 0.00 0.00 78594 TC A 125.41 0.00 0.00<br />

78232 TC A 101.08 0.00 0.00 78596 TC A 192.44 0.00 0.00<br />

78258 TC A 144.06 0.00 0.00 78599 TC A 125.41 0.00 0.00<br />

78261 TC A 144.06 0.00 0.00 78600 TC A 110.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 15980 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 110.53 0.00 0.00<br />

78605 TC A 110.53 0.00 0.00<br />

78606 TC A 248.34 0.00 0.00<br />

78607 TC A 272.82 0.00 0.00<br />

78608 TC A 614.43 0.00 0.00<br />

78610 TC A 147.25 0.00 0.00<br />

78630 TC A 262.33 0.00 0.00<br />

78635 TC A 241.69 0.00 0.00<br />

78645 TC A 110.53 0.00 0.00<br />

78647 TC A 267.58 0.00 0.00<br />

78650 TC A 259.18 0.00 0.00<br />

78660 TC A 110.53 0.00 0.00<br />

78699 TC A 110.53 0.00 0.00<br />

78700 TC A 136.06 0.00 0.00<br />

78701 TC A 165.80 0.00 0.00<br />

78707 TC A 173.14 0.00 0.00<br />

78708 TC A 118.58 0.00 0.00<br />

78709 TC A 194.95 0.00 0.00<br />

78710 TC A 182.93 0.00 0.00<br />

78725 TC A 73.10 0.00 0.00<br />

78730 TC A 61.91 0.00 0.00<br />

78740 TC A 161.60 0.00 0.00<br />

78761 TC A 154.25 0.00 0.00<br />

78799 TC A 194.95 0.00 0.00<br />

78800 TC A 136.41 0.00 0.00<br />

78801 TC A 187.13 0.00 0.00<br />

78802 TC A 253.58 0.00 0.00<br />

78803 TC A 271.78 0.00 0.00<br />

78804 TC A 474.29 0.00 0.00<br />

78805 TC A 133.26 0.00 0.00<br />

78806 TC A 266.53 0.00 0.00<br />

78807 TC A 272.13 0.00 0.00<br />

78811 TC A 614.43 0.00 0.00<br />

78812 TC A 614.43 0.00 0.00<br />

78813 TC A 614.43 0.00 0.00<br />

78814 TC A 614.43 0.00 0.00<br />

78815 TC A 614.43 0.00 0.00<br />

78816 TC A 614.43 0.00 0.00<br />

78999 TC A 69.59 0.00 0.00<br />

79005 TC A 55.97 0.00 0.00<br />

79101 TC A 61.21 0.00 0.00<br />

79200 TC A 66.11 0.00 0.00<br />

79300 TC A 127.55 0.00 0.00<br />

79403 TC A 94.79 0.00 0.00<br />

79440 TC A 53.51 0.00 0.00<br />

79445 TC A 127.55 0.00 0.00<br />

79999 TC A 127.55 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,194.82 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,488.80 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.45 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,538.36 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,538.36 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 222.17 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 222.17 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 112.18 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 237.09 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 71.27 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 638.20 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,455.31 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,139.15 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,139.15 0.00 0.00<br />

C8900 A 246.66 0.00 0.00 0123T S 910.98 0.00 0.00<br />

C8901 A 200.86 0.00 0.00 0124T S 178.06 0.00 0.00<br />

C8902 A 310.87 0.00 0.00 0144T TC A 60.60 0.00 0.00<br />

C8903 A 246.66 0.00 0.00 0145T TC A 163.13 0.00 0.00<br />

C8904 A 200.86 0.00 0.00 0146T TC A 163.13 0.00 0.00<br />

C8905 A 310.87 0.00 0.00 0147T TC A 163.13 0.00 0.00<br />

C8906 A 246.66 0.00 0.00 0148T TC A 163.13 0.00 0.00<br />

C8907 A 200.86 0.00 0.00 0149T TC A 163.13 0.00 0.00<br />

C8908 A 310.87 0.00 0.00 0150T TC A 163.13 0.00 0.00<br />

C8909 A 246.66 0.00 0.00 0151T TC A 60.60 0.00 0.00<br />

C8910 A 200.86 0.00 0.00 0170T S 1,183.31 0.00 0.00<br />

C8911 A 310.87 0.00 0.00 0176T S 1,397.22 0.00 0.00<br />

C8912 A 246.66 0.00 0.00 0177T S 1,397.22 0.00 0.00<br />

C8913 A 200.86 0.00 0.00 0182T A 1,009.92 0.00 0.00<br />

C8914 A 310.87 0.00 0.00 0186T S 851.16 0.00 0.00<br />

C8918 A 246.66 0.00 0.00 0190T S 851.16 0.00 0.00<br />

C8919 A 200.86 0.00 0.00 0191T S 910.98 0.00 0.00<br />

C8920 A 310.87 0.00 0.00 0192T S 1,561.24 0.00 0.00<br />

C9716 S 1,183.31 0.00 0.00 10021 S 54.60 0.00 0.00<br />

C9724 S 967.49 0.00 0.00 10022 S 170.51 0.00 0.00<br />

C9725 S 223.10 0.00 0.00 10040 S 31.57 0.00 0.00<br />

C9726 S 819.06 0.00 0.00 10060 S 48.03 0.00 0.00<br />

C9727 S 287.18 0.00 0.00 10061 S 53.86 0.00 0.00<br />

C9728 S 515.28 0.00 0.00 10080 S 53.86 0.00 0.00<br />

G0104 S 82.78 0.00 0.00 10081 S 123.99 0.00 0.00<br />

G0105 S 357.76 0.00 0.00 10120 S 67.45 0.00 0.00<br />

G0121 S 357.76 0.00 0.00 10121 S 508.40 0.00 0.00<br />

G0127 S 11.58 0.00 0.00 10140 S 71.54 0.00 0.00<br />

G0130 TC A 19.08 0.00 0.00 10160 S 53.86 0.00 0.00<br />

G0173 A 2,194.82 0.00 0.00 10180 S 574.93 0.00 0.00<br />

G0186 S 222.17 0.00 0.00 11000 S 23.17 0.00 0.00<br />

G0247 S 21.12 0.00 0.00 11001 S 7.84 0.00 0.00<br />

G0251 A 549.61 0.00 0.00 11010 S 201.14 0.00 0.00<br />

G0260 S 290.05 0.00 0.00 11011 S 201.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 201.14 0.00 0.00 11601 S 111.05 0.00 0.00<br />

11040 S 21.12 0.00 0.00 11602 S 122.29 0.00 0.00<br />

11041 S 23.51 0.00 0.00 11603 S 129.78 0.00 0.00<br />

11042 S 127.72 0.00 0.00 11604 S 350.09 0.00 0.00<br />

11043 S 127.72 0.00 0.00 11606 S 508.40 0.00 0.00<br />

11044 S 332.58 0.00 0.00 11620 S 94.71 0.00 0.00<br />

11055 S 24.87 0.00 0.00 11621 S 112.41 0.00 0.00<br />

11056 S 27.25 0.00 0.00 11622 S 125.01 0.00 0.00<br />

11057 S 31.57 0.00 0.00 11623 S 134.55 0.00 0.00<br />

11100 S 57.83 0.00 0.00 11624 S 508.40 0.00 0.00<br />

11101 S 13.63 0.00 0.00 11626 S 621.73 0.00 0.00<br />

11200 S 31.57 0.00 0.00 11640 S 100.15 0.00 0.00<br />

11201 S 5.45 0.00 0.00 11641 S 118.20 0.00 0.00<br />

11300 S 31.57 0.00 0.00 11642 S 131.83 0.00 0.00<br />

11301 S 31.57 0.00 0.00 11643 S 142.05 0.00 0.00<br />

11302 S 31.57 0.00 0.00 11644 S 508.40 0.00 0.00<br />

11303 S 57.83 0.00 0.00 11646 S 621.73 0.00 0.00<br />

11305 S 31.57 0.00 0.00 11719 S 11.58 0.00 0.00<br />

11306 S 31.57 0.00 0.00 11720 S 14.31 0.00 0.00<br />

11307 S 31.57 0.00 0.00 11721 S 17.37 0.00 0.00<br />

11308 S 31.57 0.00 0.00 11730 S 31.57 0.00 0.00<br />

11310 S 31.57 0.00 0.00 11732 S 17.37 0.00 0.00<br />

11311 S 31.57 0.00 0.00 11740 S 15.94 0.00 0.00<br />

11312 S 31.57 0.00 0.00 11750 S 91.98 0.00 0.00<br />

11313 S 31.57 0.00 0.00 11752 S 127.74 0.00 0.00<br />

11400 S 65.07 0.00 0.00 11755 S 63.70 0.00 0.00<br />

11401 S 73.24 0.00 0.00 11760 S 131.19 0.00 0.00<br />

11402 S 80.40 0.00 0.00 11762 S 117.18 0.00 0.00<br />

11403 S 85.85 0.00 0.00 11765 S 31.57 0.00 0.00<br />

11404 S 456.36 0.00 0.00 11770 S 651.20 0.00 0.00<br />

11406 S 508.40 0.00 0.00 11771 S 651.20 0.00 0.00<br />

11420 S 60.98 0.00 0.00 11772 S 651.20 0.00 0.00<br />

11421 S 73.92 0.00 0.00 11900 S 28.96 0.00 0.00<br />

11422 S 80.74 0.00 0.00 11901 S 31.57 0.00 0.00<br />

11423 S 89.94 0.00 0.00 11920 S 91.64 0.00 0.00<br />

11424 S 508.40 0.00 0.00 11921 S 100.83 0.00 0.00<br />

11426 S 621.73 0.00 0.00 11922 S 32.70 0.00 0.00<br />

11440 S 69.84 0.00 0.00 11950 S 33.39 0.00 0.00<br />

11441 S 80.74 0.00 0.00 11951 S 41.56 0.00 0.00<br />

11442 S 88.91 0.00 0.00 11952 S 50.03 0.00 0.00<br />

11443 S 98.45 0.00 0.00 11954 S 50.03 0.00 0.00<br />

11444 S 310.72 0.00 0.00 11960 S 606.92 0.00 0.00<br />

11446 S 621.73 0.00 0.00 11970 S 1,099.33 0.00 0.00<br />

11450 S 621.73 0.00 0.00 11971 S 569.69 0.00 0.00<br />

11451 S 621.73 0.00 0.00 11976 S 60.98 0.00 0.00<br />

11462 S 621.73 0.00 0.00 11980 S 24.63 0.00 0.00<br />

11463 S 621.73 0.00 0.00 11981 S 24.63 0.00 0.00<br />

11470 S 621.73 0.00 0.00 11982 S 24.63 0.00 0.00<br />

11471 S 621.73 0.00 0.00 11983 S 24.63 0.00 0.00<br />

11600 S 91.64 0.00 0.00 12001 S 50.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 50.03 0.00 0.00 14021 S 539.35 0.00 0.00<br />

12004 S 50.03 0.00 0.00 14040 S 509.88 0.00 0.00<br />

12005 S 67.03 0.00 0.00 14041 S 539.35 0.00 0.00<br />

12006 S 67.03 0.00 0.00 14060 S 539.35 0.00 0.00<br />

12007 S 67.03 0.00 0.00 14061 S 539.35 0.00 0.00<br />

12011 S 50.03 0.00 0.00 14300 S 691.65 0.00 0.00<br />

12013 S 50.03 0.00 0.00 14350 S 636.39 0.00 0.00<br />

12014 S 50.03 0.00 0.00 15002 S 233.32 0.00 0.00<br />

12015 S 50.03 0.00 0.00 15003 S 233.32 0.00 0.00<br />

12016 S 67.03 0.00 0.00 15004 S 233.32 0.00 0.00<br />

12017 S 67.03 0.00 0.00 15005 S 233.32 0.00 0.00<br />

12018 S 67.03 0.00 0.00 15040 S 107.61 0.00 0.00<br />

12020 S 126.47 0.00 0.00 15050 S 233.32 0.00 0.00<br />

12021 S 107.61 0.00 0.00 15100 S 606.92 0.00 0.00<br />

12031 S 50.03 0.00 0.00 15101 S 636.39 0.00 0.00<br />

12032 S 131.19 0.00 0.00 15110 S 289.83 0.00 0.00<br />

12034 S 67.03 0.00 0.00 15111 S 237.80 0.00 0.00<br />

12035 S 67.03 0.00 0.00 15115 S 289.83 0.00 0.00<br />

12036 S 107.61 0.00 0.00 15116 S 237.80 0.00 0.00<br />

12037 S 214.47 0.00 0.00 15120 S 606.92 0.00 0.00<br />

12041 S 50.03 0.00 0.00 15121 S 636.39 0.00 0.00<br />

12042 S 50.03 0.00 0.00 15130 S 509.88 0.00 0.00<br />

12044 S 67.03 0.00 0.00 15131 S 457.84 0.00 0.00<br />

12045 S 107.61 0.00 0.00 15135 S 509.88 0.00 0.00<br />

12046 S 107.61 0.00 0.00 15136 S 457.84 0.00 0.00<br />

12047 S 214.47 0.00 0.00 15150 S 289.83 0.00 0.00<br />

12051 S 50.03 0.00 0.00 15151 S 237.80 0.00 0.00<br />

12052 S 50.03 0.00 0.00 15152 S 237.80 0.00 0.00<br />

12053 S 50.03 0.00 0.00 15155 S 289.83 0.00 0.00<br />

12054 S 67.03 0.00 0.00 15156 S 237.80 0.00 0.00<br />

12055 S 107.61 0.00 0.00 15157 S 237.80 0.00 0.00<br />

12056 S 107.61 0.00 0.00 15170 S 131.19 0.00 0.00<br />

12057 S 214.47 0.00 0.00 15171 S 131.19 0.00 0.00<br />

13100 S 233.32 0.00 0.00 15175 S 168.90 0.00 0.00<br />

13101 S 233.32 0.00 0.00 15176 S 168.90 0.00 0.00<br />

13102 S 126.47 0.00 0.00 15200 S 539.35 0.00 0.00<br />

13120 S 107.61 0.00 0.00 15201 S 453.37 0.00 0.00<br />

13121 S 107.61 0.00 0.00 15220 S 509.88 0.00 0.00<br />

13122 S 107.61 0.00 0.00 15221 S 233.32 0.00 0.00<br />

13131 S 107.61 0.00 0.00 15240 S 539.35 0.00 0.00<br />

13132 S 107.61 0.00 0.00 15241 S 233.32 0.00 0.00<br />

13133 S 107.61 0.00 0.00 15260 S 509.88 0.00 0.00<br />

13150 S 233.32 0.00 0.00 15261 S 453.37 0.00 0.00<br />

13151 S 233.32 0.00 0.00 15300 S 233.32 0.00 0.00<br />

13152 S 233.32 0.00 0.00 15301 S 233.32 0.00 0.00<br />

13153 S 107.61 0.00 0.00 15320 S 233.32 0.00 0.00<br />

13160 S 606.92 0.00 0.00 15321 S 233.32 0.00 0.00<br />

14000 S 509.88 0.00 0.00 15330 S 233.32 0.00 0.00<br />

14001 S 539.35 0.00 0.00 15331 S 233.32 0.00 0.00<br />

14020 S 539.35 0.00 0.00 15335 S 233.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 233.32 0.00 0.00 15826 S 636.39 0.00 0.00<br />

15340 S 131.19 0.00 0.00 15828 S 636.39 0.00 0.00<br />

15341 S 131.19 0.00 0.00 15829 S 731.70 0.00 0.00<br />

15360 S 131.19 0.00 0.00 15830 S 651.20 0.00 0.00<br />

15361 S 131.19 0.00 0.00 15832 S 651.20 0.00 0.00<br />

15365 S 131.19 0.00 0.00 15833 S 651.20 0.00 0.00<br />

15366 S 131.19 0.00 0.00 15834 S 651.20 0.00 0.00<br />

15400 S 233.32 0.00 0.00 15835 S 565.22 0.00 0.00<br />

15401 S 233.32 0.00 0.00 15836 S 537.87 0.00 0.00<br />

15420 S 233.32 0.00 0.00 15837 S 606.05 0.00 0.00<br />

15421 S 233.32 0.00 0.00 15838 S 606.05 0.00 0.00<br />

15430 S 233.32 0.00 0.00 15839 S 537.87 0.00 0.00<br />

15431 S 233.32 0.00 0.00 15840 S 691.65 0.00 0.00<br />

15570 S 636.39 0.00 0.00 15841 S 691.65 0.00 0.00<br />

15572 S 636.39 0.00 0.00 15842 S 803.07 0.00 0.00<br />

15574 S 636.39 0.00 0.00 15845 S 691.65 0.00 0.00<br />

15576 S 636.39 0.00 0.00 15847 S 651.20 0.00 0.00<br />

15600 S 636.39 0.00 0.00 15850 S 104.03 0.00 0.00<br />

15610 S 636.39 0.00 0.00 15851 S 47.35 0.00 0.00<br />

15620 S 691.65 0.00 0.00 15852 S 24.63 0.00 0.00<br />

15630 S 636.39 0.00 0.00 15860 S 24.63 0.00 0.00<br />

15650 S 731.70 0.00 0.00 15876 S 636.39 0.00 0.00<br />

15731 S 636.39 0.00 0.00 15877 S 636.39 0.00 0.00<br />

15732 S 636.39 0.00 0.00 15878 S 636.39 0.00 0.00<br />

15734 S 636.39 0.00 0.00 15879 S 636.39 0.00 0.00<br />

15736 S 636.39 0.00 0.00 15920 S 201.14 0.00 0.00<br />

15738 S 636.39 0.00 0.00 15922 S 691.65 0.00 0.00<br />

15740 S 509.88 0.00 0.00 15931 S 651.20 0.00 0.00<br />

15750 S 606.92 0.00 0.00 15933 S 651.20 0.00 0.00<br />

15760 S 606.92 0.00 0.00 15934 S 636.39 0.00 0.00<br />

15770 S 636.39 0.00 0.00 15935 S 691.65 0.00 0.00<br />

15775 S 173.88 0.00 0.00 15936 S 594.61 0.00 0.00<br />

15776 S 173.88 0.00 0.00 15937 S 691.65 0.00 0.00<br />

15780 S 387.66 0.00 0.00 15940 S 651.20 0.00 0.00<br />

15781 S 170.63 0.00 0.00 15941 S 651.20 0.00 0.00<br />

15782 S 170.63 0.00 0.00 15944 S 636.39 0.00 0.00<br />

15783 S 104.03 0.00 0.00 15945 S 691.65 0.00 0.00<br />

15786 S 31.57 0.00 0.00 15946 S 691.65 0.00 0.00<br />

15787 S 28.62 0.00 0.00 15950 S 651.20 0.00 0.00<br />

15788 S 31.57 0.00 0.00 15951 S 706.46 0.00 0.00<br />

15789 S 57.83 0.00 0.00 15952 S 539.35 0.00 0.00<br />

15792 S 57.83 0.00 0.00 15953 S 594.61 0.00 0.00<br />

15793 S 31.57 0.00 0.00 15956 S 539.35 0.00 0.00<br />

15819 S 131.19 0.00 0.00 15958 S 594.61 0.00 0.00<br />

15820 S 636.39 0.00 0.00 16000 S 25.55 0.00 0.00<br />

15821 S 636.39 0.00 0.00 16020 S 38.84 0.00 0.00<br />

15822 S 636.39 0.00 0.00 16025 S 59.82 0.00 0.00<br />

15823 S 731.70 0.00 0.00 16030 S 74.89 0.00 0.00<br />

15824 S 636.39 0.00 0.00 16035 S 57.83 0.00 0.00<br />

15825 S 636.39 0.00 0.00 17000 S 31.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.75 0.00 0.00 19300 S 699.64 0.00 0.00<br />

17004 S 82.44 0.00 0.00 19301 S 644.39 0.00 0.00<br />

17106 S 104.03 0.00 0.00 19302 S 1,230.70 0.00 0.00<br />

17107 S 104.03 0.00 0.00 19303 S 930.08 0.00 0.00<br />

17108 S 104.03 0.00 0.00 19304 S 930.08 0.00 0.00<br />

17110 S 31.57 0.00 0.00 19316 S 930.08 0.00 0.00<br />

17111 S 57.83 0.00 0.00 19318 S 1,062.62 0.00 0.00<br />

17250 S 43.61 0.00 0.00 19324 S 1,062.62 0.00 0.00<br />

17260 S 46.67 0.00 0.00 19325 S 1,762.48 0.00 0.00<br />

17261 S 57.83 0.00 0.00 19328 S 793.31 0.00 0.00<br />

17262 S 57.83 0.00 0.00 19330 S 793.31 0.00 0.00<br />

17263 S 57.83 0.00 0.00 19340 S 977.89 0.00 0.00<br />

17264 S 57.83 0.00 0.00 19342 S 1,380.74 0.00 0.00<br />

17266 S 104.03 0.00 0.00 19350 S 699.64 0.00 0.00<br />

17270 S 57.83 0.00 0.00 19355 S 930.08 0.00 0.00<br />

17271 S 57.83 0.00 0.00 19357 S 1,476.06 0.00 0.00<br />

17272 S 57.83 0.00 0.00 19366 S 970.14 0.00 0.00<br />

17273 S 104.03 0.00 0.00 19370 S 930.08 0.00 0.00<br />

17274 S 104.03 0.00 0.00 19371 S 930.08 0.00 0.00<br />

17276 S 104.03 0.00 0.00 19380 S 1,102.68 0.00 0.00<br />

17280 S 57.83 0.00 0.00 19396 S 1,279.93 0.00 0.00<br />

17281 S 86.19 0.00 0.00 20000 S 53.86 0.00 0.00<br />

17282 S 98.45 0.00 0.00 20005 S 620.55 0.00 0.00<br />

17283 S 104.03 0.00 0.00 20103 S 609.00 0.00 0.00<br />

17284 S 104.03 0.00 0.00 20150 S 1,728.97 0.00 0.00<br />

17286 S 104.03 0.00 0.00 20200 S 508.40 0.00 0.00<br />

17311 S 171.73 0.00 0.00 20205 S 537.87 0.00 0.00<br />

17312 S 171.73 0.00 0.00 20206 S 251.34 0.00 0.00<br />

17313 S 171.73 0.00 0.00 20220 S 273.21 0.00 0.00<br />

17314 S 171.73 0.00 0.00 20225 S 495.73 0.00 0.00<br />

17315 S 38.84 0.00 0.00 20240 S 621.73 0.00 0.00<br />

17340 S 13.97 0.00 0.00 20245 S 651.20 0.00 0.00<br />

17360 S 31.57 0.00 0.00 20250 S 650.02 0.00 0.00<br />

17380 S 31.57 0.00 0.00 20251 S 650.02 0.00 0.00<br />

19000 S 65.75 0.00 0.00 20500 S 53.83 0.00 0.00<br />

19001 S 8.86 0.00 0.00 20520 S 90.62 0.00 0.00<br />

19020 S 574.93 0.00 0.00 20525 S 651.20 0.00 0.00<br />

19100 S 195.78 0.00 0.00 20526 S 29.30 0.00 0.00<br />

19101 S 614.91 0.00 0.00 20550 S 22.14 0.00 0.00<br />

19102 S 251.34 0.00 0.00 20551 S 21.80 0.00 0.00<br />

19103 S 439.91 0.00 0.00 20552 S 21.12 0.00 0.00<br />

19105 S 1,279.93 0.00 0.00 20553 S 23.51 0.00 0.00<br />

19110 S 614.91 0.00 0.00 20555 S 1,139.15 0.00 0.00<br />

19112 S 644.39 0.00 0.00 20600 S 22.48 0.00 0.00<br />

19120 S 644.39 0.00 0.00 20605 S 25.21 0.00 0.00<br />

19125 S 644.39 0.00 0.00 20610 S 35.43 0.00 0.00<br />

19126 S 644.39 0.00 0.00 20612 S 23.85 0.00 0.00<br />

19296 S 1,762.48 0.00 0.00 20615 S 99.81 0.00 0.00<br />

19297 S 1,762.48 0.00 0.00 20650 S 650.02 0.00 0.00<br />

19298 S 1,762.48 0.00 0.00 20662 S 830.34 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 830.34 0.00 0.00 21085 S 250.04 0.00 0.00<br />

20665 S 24.63 0.00 0.00 21086 S 544.35 0.00 0.00<br />

20670 S 456.36 0.00 0.00 21087 S 545.04 0.00 0.00<br />

20680 S 651.20 0.00 0.00 21088 S 1,596.33 0.00 0.00<br />

20690 S 774.95 0.00 0.00 21100 S 1,003.54 0.00 0.00<br />

20692 S 804.43 0.00 0.00 21110 S 287.18 0.00 0.00<br />

20693 S 650.02 0.00 0.00 21120 S 930.06 0.00 0.00<br />

20694 S 568.51 0.00 0.00 21121 S 930.06 0.00 0.00<br />

20696 S 1,139.15 0.00 0.00 21122 S 930.06 0.00 0.00<br />

20697 S 757.58 0.00 0.00 21123 S 930.06 0.00 0.00<br />

20822 S 1,067.40 0.00 0.00 21125 S 930.06 0.00 0.00<br />

20900 S 804.43 0.00 0.00 21127 S 1,414.76 0.00 0.00<br />

20902 S 859.68 0.00 0.00 21137 S 943.74 0.00 0.00<br />

20910 S 636.39 0.00 0.00 21138 S 1,596.33 0.00 0.00<br />

20912 S 636.39 0.00 0.00 21139 S 1,596.33 0.00 0.00<br />

20920 S 594.61 0.00 0.00 21150 S 1,596.33 0.00 0.00<br />

20922 S 539.35 0.00 0.00 21181 S 930.06 0.00 0.00<br />

20924 S 859.68 0.00 0.00 21198 S 1,596.33 0.00 0.00<br />

20926 S 374.56 0.00 0.00 21199 S 1,596.33 0.00 0.00<br />

20950 S 53.86 0.00 0.00 21206 S 1,128.34 0.00 0.00<br />

20972 S 1,802.86 0.00 0.00 21208 S 1,256.36 0.00 0.00<br />

20973 S 1,802.86 0.00 0.00 21209 S 1,128.34 0.00 0.00<br />

20979 S 22.14 0.00 0.00 21210 S 1,256.36 0.00 0.00<br />

20982 S 1,728.97 0.00 0.00 21215 S 1,256.36 0.00 0.00<br />

21010 S 677.24 0.00 0.00 21230 S 1,256.36 0.00 0.00<br />

21015 S 563.47 0.00 0.00 21235 S 930.06 0.00 0.00<br />

21025 S 1,003.54 0.00 0.00 21240 S 1,088.27 0.00 0.00<br />

21026 S 1,003.54 0.00 0.00 21242 S 1,128.34 0.00 0.00<br />

21029 S 1,003.54 0.00 0.00 21243 S 1,128.34 0.00 0.00<br />

21030 S 236.75 0.00 0.00 21244 S 1,256.36 0.00 0.00<br />

21031 S 195.87 0.00 0.00 21245 S 1,256.36 0.00 0.00<br />

21032 S 199.62 0.00 0.00 21246 S 1,256.36 0.00 0.00<br />

21034 S 1,033.02 0.00 0.00 21248 S 1,256.36 0.00 0.00<br />

21040 S 677.24 0.00 0.00 21249 S 1,256.36 0.00 0.00<br />

21044 S 1,003.54 0.00 0.00 21260 S 1,596.33 0.00 0.00<br />

21046 S 1,003.54 0.00 0.00 21267 S 1,256.36 0.00 0.00<br />

21047 S 1,003.54 0.00 0.00 21270 S 1,128.34 0.00 0.00<br />

21048 S 1,596.33 0.00 0.00 21275 S 1,256.36 0.00 0.00<br />

21050 S 1,033.02 0.00 0.00 21280 S 1,128.34 0.00 0.00<br />

21060 S 1,003.54 0.00 0.00 21282 S 658.79 0.00 0.00<br />

21070 S 1,033.02 0.00 0.00 21295 S 296.93 0.00 0.00<br />

21073 S 183.95 0.00 0.00 21296 S 625.21 0.00 0.00<br />

21076 S 319.18 0.00 0.00 21310 S 90.58 0.00 0.00<br />

21077 S 771.57 0.00 0.00 21315 S 398.02 0.00 0.00<br />

21079 S 552.53 0.00 0.00 21320 S 533.99 0.00 0.00<br />

21080 S 633.61 0.00 0.00 21325 S 761.98 0.00 0.00<br />

21081 S 583.87 0.00 0.00 21330 S 802.04 0.00 0.00<br />

21082 S 555.60 0.00 0.00 21335 S 930.06 0.00 0.00<br />

21083 S 547.42 0.00 0.00 21336 S 775.10 0.00 0.00<br />

21084 S 629.86 0.00 0.00 21337 S 533.99 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 761.98 0.00 0.00 22310 S 164.90 0.00 0.00<br />

21339 S 802.04 0.00 0.00 22315 S 426.51 0.00 0.00<br />

21340 S 1,088.27 0.00 0.00 22505 S 502.11 0.00 0.00<br />

21345 S 930.06 0.00 0.00 22520 S 1,186.17 0.00 0.00<br />

21355 S 1,033.02 0.00 0.00 22521 S 1,186.17 0.00 0.00<br />

21356 S 706.72 0.00 0.00 22522 S 1,186.17 0.00 0.00<br />

21360 S 943.74 0.00 0.00 22523 S 3,301.23 0.00 0.00<br />

21390 S 1,596.33 0.00 0.00 22524 S 3,301.23 0.00 0.00<br />

21400 S 348.96 0.00 0.00 22525 S 3,301.23 0.00 0.00<br />

21401 S 563.47 0.00 0.00 22900 S 706.46 0.00 0.00<br />

21406 S 1,596.33 0.00 0.00 23000 S 508.40 0.00 0.00<br />

21407 S 1,596.33 0.00 0.00 23020 S 1,069.86 0.00 0.00<br />

21421 S 761.98 0.00 0.00 23030 S 522.88 0.00 0.00<br />

21440 S 320.89 0.00 0.00 23031 S 604.39 0.00 0.00<br />

21445 S 761.98 0.00 0.00 23035 S 650.02 0.00 0.00<br />

21450 S 132.44 0.00 0.00 23040 S 804.43 0.00 0.00<br />

21451 S 357.32 0.00 0.00 23044 S 859.68 0.00 0.00<br />

21452 S 533.99 0.00 0.00 23065 S 96.07 0.00 0.00<br />

21453 S 1,033.02 0.00 0.00 23066 S 621.73 0.00 0.00<br />

21454 S 802.04 0.00 0.00 23075 S 508.40 0.00 0.00<br />

21461 S 1,088.27 0.00 0.00 23076 S 621.73 0.00 0.00<br />

21462 S 1,128.34 0.00 0.00 23077 S 651.20 0.00 0.00<br />

21465 S 1,088.27 0.00 0.00 23100 S 620.55 0.00 0.00<br />

21480 S 90.58 0.00 0.00 23101 S 1,027.77 0.00 0.00<br />

21485 S 533.99 0.00 0.00 23105 S 859.68 0.00 0.00<br />

21490 S 1,033.02 0.00 0.00 23106 S 859.68 0.00 0.00<br />

21495 S 657.23 0.00 0.00 23107 S 859.68 0.00 0.00<br />

21497 S 533.99 0.00 0.00 23120 S 899.75 0.00 0.00<br />

21501 S 574.93 0.00 0.00 23125 S 899.75 0.00 0.00<br />

21502 S 620.55 0.00 0.00 23130 S 1,194.65 0.00 0.00<br />

21550 S 606.05 0.00 0.00 23140 S 705.28 0.00 0.00<br />

21555 S 621.73 0.00 0.00 23145 S 899.75 0.00 0.00<br />

21556 S 621.73 0.00 0.00 23146 S 899.75 0.00 0.00<br />

21557 S 832.70 0.00 0.00 23150 S 859.68 0.00 0.00<br />

21600 S 774.95 0.00 0.00 23155 S 899.75 0.00 0.00<br />

21610 S 774.95 0.00 0.00 23156 S 899.75 0.00 0.00<br />

21685 S 287.18 0.00 0.00 23170 S 774.95 0.00 0.00<br />

21700 S 620.55 0.00 0.00 23172 S 774.95 0.00 0.00<br />

21720 S 650.02 0.00 0.00 23174 S 774.95 0.00 0.00<br />

21725 S 67.66 0.00 0.00 23180 S 859.68 0.00 0.00<br />

21800 S 78.17 0.00 0.00 23182 S 859.68 0.00 0.00<br />

21805 S 690.37 0.00 0.00 23184 S 859.68 0.00 0.00<br />

21820 S 78.17 0.00 0.00 23190 S 859.68 0.00 0.00<br />

21920 S 138.98 0.00 0.00 23195 S 899.75 0.00 0.00<br />

21925 S 621.73 0.00 0.00 23330 S 310.72 0.00 0.00<br />

21930 S 621.73 0.00 0.00 23331 S 569.69 0.00 0.00<br />

21935 S 651.20 0.00 0.00 23395 S 1,194.65 0.00 0.00<br />

22102 S 1,853.01 0.00 0.00 23397 S 2,108.80 0.00 0.00<br />

22103 S 1,853.01 0.00 0.00 23400 S 1,027.77 0.00 0.00<br />

22305 S 78.17 0.00 0.00 23405 S 774.95 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 774.95 0.00 0.00 23931 S 574.93 0.00 0.00<br />

23410 S 1,194.65 0.00 0.00 23935 S 620.55 0.00 0.00<br />

23412 S 1,322.67 0.00 0.00 24000 S 859.68 0.00 0.00<br />

23415 S 1,194.65 0.00 0.00 24006 S 859.68 0.00 0.00<br />

23420 S 1,322.67 0.00 0.00 24065 S 133.19 0.00 0.00<br />

23430 S 1,154.59 0.00 0.00 24066 S 508.40 0.00 0.00<br />

23440 S 1,154.59 0.00 0.00 24075 S 508.40 0.00 0.00<br />

23450 S 1,980.79 0.00 0.00 24076 S 621.73 0.00 0.00<br />

23455 S 2,108.80 0.00 0.00 24077 S 651.20 0.00 0.00<br />

23460 S 1,980.79 0.00 0.00 24100 S 568.51 0.00 0.00<br />

23462 S 1,322.67 0.00 0.00 24101 S 859.68 0.00 0.00<br />

23465 S 1,980.79 0.00 0.00 24102 S 859.68 0.00 0.00<br />

23466 S 1,322.67 0.00 0.00 24105 S 650.02 0.00 0.00<br />

23480 S 1,154.59 0.00 0.00 24110 S 620.55 0.00 0.00<br />

23485 S 2,108.80 0.00 0.00 24115 S 804.43 0.00 0.00<br />

23490 S 1,099.33 0.00 0.00 24116 S 804.43 0.00 0.00<br />

23491 S 1,885.47 0.00 0.00 24120 S 650.02 0.00 0.00<br />

23500 S 78.17 0.00 0.00 24125 S 804.43 0.00 0.00<br />

23505 S 426.51 0.00 0.00 24126 S 804.43 0.00 0.00<br />

23515 S 1,427.49 0.00 0.00 24130 S 804.43 0.00 0.00<br />

23520 S 164.90 0.00 0.00 24134 S 774.95 0.00 0.00<br />

23525 S 164.90 0.00 0.00 24136 S 774.95 0.00 0.00<br />

23530 S 1,051.92 0.00 0.00 24138 S 774.95 0.00 0.00<br />

23532 S 775.10 0.00 0.00 24140 S 804.43 0.00 0.00<br />

23540 S 78.17 0.00 0.00 24145 S 804.43 0.00 0.00<br />

23545 S 164.90 0.00 0.00 24147 S 774.95 0.00 0.00<br />

23550 S 1,051.92 0.00 0.00 24149 S 1,139.15 0.00 0.00<br />

23552 S 1,107.18 0.00 0.00 24152 S 1,728.97 0.00 0.00<br />

23570 S 78.17 0.00 0.00 24153 S 3,301.23 0.00 0.00<br />

23575 S 164.90 0.00 0.00 24155 S 1,099.33 0.00 0.00<br />

23585 S 1,427.49 0.00 0.00 24160 S 774.95 0.00 0.00<br />

23600 S 60.91 0.00 0.00 24164 S 804.43 0.00 0.00<br />

23605 S 426.51 0.00 0.00 24200 S 97.43 0.00 0.00<br />

23615 S 1,482.74 0.00 0.00 24201 S 508.40 0.00 0.00<br />

23616 S 1,482.74 0.00 0.00 24300 S 593.46 0.00 0.00<br />

23620 S 60.91 0.00 0.00 24301 S 859.68 0.00 0.00<br />

23625 S 426.51 0.00 0.00 24305 S 859.68 0.00 0.00<br />

23630 S 1,522.81 0.00 0.00 24310 S 650.02 0.00 0.00<br />

23650 S 78.17 0.00 0.00 24320 S 1,099.33 0.00 0.00<br />

23655 S 450.07 0.00 0.00 24330 S 1,885.47 0.00 0.00<br />

23660 S 1,051.92 0.00 0.00 24331 S 1,099.33 0.00 0.00<br />

23665 S 164.90 0.00 0.00 24332 S 830.34 0.00 0.00<br />

23670 S 1,427.49 0.00 0.00 24340 S 1,099.33 0.00 0.00<br />

23675 S 78.17 0.00 0.00 24341 S 1,099.33 0.00 0.00<br />

23680 S 1,051.92 0.00 0.00 24342 S 1,099.33 0.00 0.00<br />

23700 S 450.07 0.00 0.00 24343 S 1,139.15 0.00 0.00<br />

23800 S 1,940.72 0.00 0.00 24344 S 3,301.23 0.00 0.00<br />

23802 S 1,322.67 0.00 0.00 24345 S 774.95 0.00 0.00<br />

23921 S 453.37 0.00 0.00 24346 S 1,728.97 0.00 0.00<br />

23930 S 522.88 0.00 0.00 24357 S 1,139.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,139.15 0.00 0.00 24925 S 650.02 0.00 0.00<br />

24359 S 1,139.15 0.00 0.00 25000 S 650.02 0.00 0.00<br />

24360 S 1,051.28 0.00 0.00 25001 S 830.34 0.00 0.00<br />

24361 S 5,747.87 3,518.42 1,288.98 25020 S 650.02 0.00 0.00<br />

24362 S 1,343.52 0.00 0.00 25023 S 804.43 0.00 0.00<br />

24363 S 5,875.89 3,646.44 1,417.00 25024 S 804.43 0.00 0.00<br />

24365 S 1,051.28 0.00 0.00 25025 S 804.43 0.00 0.00<br />

24366 S 5,747.87 3,518.42 1,288.98 25028 S 568.51 0.00 0.00<br />

24400 S 859.68 0.00 0.00 25031 S 620.55 0.00 0.00<br />

24410 S 859.68 0.00 0.00 25035 S 620.55 0.00 0.00<br />

24420 S 1,099.33 0.00 0.00 25040 S 899.75 0.00 0.00<br />

24430 S 1,885.47 0.00 0.00 25065 S 135.23 0.00 0.00<br />

24435 S 1,940.72 0.00 0.00 25066 S 621.73 0.00 0.00<br />

24470 S 1,099.33 0.00 0.00 25075 S 508.40 0.00 0.00<br />

24495 S 774.95 0.00 0.00 25076 S 651.20 0.00 0.00<br />

24498 S 1,885.47 0.00 0.00 25077 S 651.20 0.00 0.00<br />

24500 S 78.17 0.00 0.00 25085 S 650.02 0.00 0.00<br />

24505 S 78.17 0.00 0.00 25100 S 620.55 0.00 0.00<br />

24515 S 1,482.74 0.00 0.00 25101 S 804.43 0.00 0.00<br />

24516 S 1,482.74 0.00 0.00 25105 S 859.68 0.00 0.00<br />

24530 S 78.17 0.00 0.00 25107 S 804.43 0.00 0.00<br />

24535 S 164.90 0.00 0.00 25109 S 830.34 0.00 0.00<br />

24538 S 690.37 0.00 0.00 25110 S 650.02 0.00 0.00<br />

24545 S 1,482.74 0.00 0.00 25111 S 650.02 0.00 0.00<br />

24546 S 1,522.81 0.00 0.00 25112 S 705.28 0.00 0.00<br />

24560 S 78.17 0.00 0.00 25115 S 705.28 0.00 0.00<br />

24565 S 78.17 0.00 0.00 25116 S 705.28 0.00 0.00<br />

24566 S 690.37 0.00 0.00 25118 S 774.95 0.00 0.00<br />

24575 S 1,427.49 0.00 0.00 25119 S 804.43 0.00 0.00<br />

24576 S 78.17 0.00 0.00 25120 S 804.43 0.00 0.00<br />

24577 S 164.90 0.00 0.00 25125 S 804.43 0.00 0.00<br />

24579 S 1,427.49 0.00 0.00 25126 S 804.43 0.00 0.00<br />

24582 S 690.37 0.00 0.00 25130 S 804.43 0.00 0.00<br />

24586 S 1,482.74 0.00 0.00 25135 S 804.43 0.00 0.00<br />

24587 S 1,522.81 0.00 0.00 25136 S 804.43 0.00 0.00<br />

24600 S 78.17 0.00 0.00 25145 S 774.95 0.00 0.00<br />

24605 S 502.11 0.00 0.00 25150 S 774.95 0.00 0.00<br />

24615 S 1,427.49 0.00 0.00 25151 S 774.95 0.00 0.00<br />

24620 S 426.51 0.00 0.00 25210 S 804.43 0.00 0.00<br />

24635 S 1,427.49 0.00 0.00 25215 S 859.68 0.00 0.00<br />

24640 S 52.80 0.00 0.00 25230 S 859.68 0.00 0.00<br />

24650 S 60.91 0.00 0.00 25240 S 859.68 0.00 0.00<br />

24655 S 164.90 0.00 0.00 25248 S 620.55 0.00 0.00<br />

24665 S 1,107.18 0.00 0.00 25250 S 722.92 0.00 0.00<br />

24666 S 1,482.74 0.00 0.00 25251 S 722.92 0.00 0.00<br />

24670 S 78.17 0.00 0.00 25259 S 757.58 0.00 0.00<br />

24675 S 78.17 0.00 0.00 25260 S 859.68 0.00 0.00<br />

24685 S 1,051.92 0.00 0.00 25263 S 774.95 0.00 0.00<br />

24800 S 1,154.59 0.00 0.00 25265 S 804.43 0.00 0.00<br />

24802 S 1,194.65 0.00 0.00 25270 S 859.68 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 804.43 0.00 0.00 25505 S 164.90 0.00 0.00<br />

25274 S 859.68 0.00 0.00 25515 S 1,051.92 0.00 0.00<br />

25275 S 859.68 0.00 0.00 25520 S 164.90 0.00 0.00<br />

25280 S 859.68 0.00 0.00 25525 S 1,107.18 0.00 0.00<br />

25290 S 804.43 0.00 0.00 25526 S 1,147.24 0.00 0.00<br />

25295 S 650.02 0.00 0.00 25530 S 60.91 0.00 0.00<br />

25300 S 804.43 0.00 0.00 25535 S 78.17 0.00 0.00<br />

25301 S 804.43 0.00 0.00 25545 S 1,051.92 0.00 0.00<br />

25310 S 1,099.33 0.00 0.00 25560 S 60.91 0.00 0.00<br />

25312 S 1,154.59 0.00 0.00 25565 S 164.90 0.00 0.00<br />

25315 S 1,099.33 0.00 0.00 25574 S 1,427.49 0.00 0.00<br />

25316 S 1,885.47 0.00 0.00 25575 S 1,427.49 0.00 0.00<br />

25320 S 1,099.33 0.00 0.00 25600 S 60.91 0.00 0.00<br />

25332 S 1,051.28 0.00 0.00 25605 S 164.90 0.00 0.00<br />

25335 S 1,099.33 0.00 0.00 25606 S 719.85 0.00 0.00<br />

25337 S 1,194.65 0.00 0.00 25607 S 1,522.81 0.00 0.00<br />

25350 S 1,885.47 0.00 0.00 25608 S 1,522.81 0.00 0.00<br />

25355 S 1,099.33 0.00 0.00 25609 S 1,522.81 0.00 0.00<br />

25360 S 804.43 0.00 0.00 25622 S 60.91 0.00 0.00<br />

25365 S 804.43 0.00 0.00 25624 S 164.90 0.00 0.00<br />

25370 S 1,099.33 0.00 0.00 25628 S 1,051.92 0.00 0.00<br />

25375 S 1,154.59 0.00 0.00 25630 S 60.91 0.00 0.00<br />

25390 S 804.43 0.00 0.00 25635 S 164.90 0.00 0.00<br />

25391 S 1,154.59 0.00 0.00 25645 S 1,051.92 0.00 0.00<br />

25392 S 804.43 0.00 0.00 25650 S 60.91 0.00 0.00<br />

25393 S 1,154.59 0.00 0.00 25651 S 969.99 0.00 0.00<br />

25394 S 1,728.97 0.00 0.00 25652 S 1,634.13 0.00 0.00<br />

25400 S 1,099.33 0.00 0.00 25660 S 78.17 0.00 0.00<br />

25405 S 1,940.72 0.00 0.00 25670 S 719.85 0.00 0.00<br />

25415 S 1,885.47 0.00 0.00 25671 S 638.34 0.00 0.00<br />

25420 S 1,940.72 0.00 0.00 25675 S 78.17 0.00 0.00<br />

25425 S 1,099.33 0.00 0.00 25676 S 690.37 0.00 0.00<br />

25426 S 1,154.59 0.00 0.00 25680 S 78.17 0.00 0.00<br />

25430 S 1,728.97 0.00 0.00 25685 S 719.85 0.00 0.00<br />

25431 S 1,728.97 0.00 0.00 25690 S 426.51 0.00 0.00<br />

25440 S 1,940.72 0.00 0.00 25695 S 690.37 0.00 0.00<br />

25441 S 5,747.87 3,518.42 1,288.98 25800 S 1,940.72 0.00 0.00<br />

25442 S 5,747.87 3,518.42 1,288.98 25805 S 1,194.65 0.00 0.00<br />

25443 S 1,343.52 0.00 0.00 25810 S 1,980.79 0.00 0.00<br />

25444 S 1,343.52 0.00 0.00 25820 S 1,154.59 0.00 0.00<br />

25445 S 1,343.52 0.00 0.00 25825 S 1,980.79 0.00 0.00<br />

25446 S 5,875.89 3,646.44 1,417.00 25830 S 1,980.79 0.00 0.00<br />

25447 S 1,051.28 0.00 0.00 25907 S 650.02 0.00 0.00<br />

25449 S 1,051.28 0.00 0.00 25922 S 650.02 0.00 0.00<br />

25450 S 1,099.33 0.00 0.00 25929 S 539.35 0.00 0.00<br />

25455 S 1,099.33 0.00 0.00 25931 S 830.34 0.00 0.00<br />

25490 S 1,099.33 0.00 0.00 26010 S 53.86 0.00 0.00<br />

25491 S 1,099.33 0.00 0.00 26011 S 393.42 0.00 0.00<br />

25492 S 1,099.33 0.00 0.00 26020 S 522.03 0.00 0.00<br />

25500 S 60.91 0.00 0.00 26025 S 469.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 522.03 0.00 0.00 26392 S 768.55 0.00 0.00<br />

26034 S 522.03 0.00 0.00 26410 S 551.49 0.00 0.00<br />

26035 S 633.29 0.00 0.00 26412 S 768.55 0.00 0.00<br />

26040 S 823.81 0.00 0.00 26415 S 823.81 0.00 0.00<br />

26045 S 768.55 0.00 0.00 26416 S 768.55 0.00 0.00<br />

26055 S 522.03 0.00 0.00 26418 S 606.76 0.00 0.00<br />

26060 S 522.03 0.00 0.00 26420 S 823.81 0.00 0.00<br />

26070 S 522.03 0.00 0.00 26426 S 768.55 0.00 0.00<br />

26075 S 606.76 0.00 0.00 26428 S 768.55 0.00 0.00<br />

26080 S 606.76 0.00 0.00 26432 S 551.49 0.00 0.00<br />

26100 S 522.03 0.00 0.00 26433 S 551.49 0.00 0.00<br />

26105 S 469.98 0.00 0.00 26434 S 768.55 0.00 0.00<br />

26110 S 469.98 0.00 0.00 26437 S 551.49 0.00 0.00<br />

26115 S 621.73 0.00 0.00 26440 S 551.49 0.00 0.00<br />

26116 S 621.73 0.00 0.00 26442 S 768.55 0.00 0.00<br />

26117 S 651.20 0.00 0.00 26445 S 551.49 0.00 0.00<br />

26121 S 823.81 0.00 0.00 26449 S 768.55 0.00 0.00<br />

26123 S 823.81 0.00 0.00 26450 S 551.49 0.00 0.00<br />

26125 S 606.76 0.00 0.00 26455 S 551.49 0.00 0.00<br />

26130 S 551.49 0.00 0.00 26460 S 551.49 0.00 0.00<br />

26135 S 823.81 0.00 0.00 26471 S 522.03 0.00 0.00<br />

26140 S 522.03 0.00 0.00 26474 S 522.03 0.00 0.00<br />

26145 S 551.49 0.00 0.00 26476 S 469.98 0.00 0.00<br />

26160 S 551.49 0.00 0.00 26477 S 469.98 0.00 0.00<br />

26170 S 551.49 0.00 0.00 26478 S 469.98 0.00 0.00<br />

26180 S 551.49 0.00 0.00 26479 S 469.98 0.00 0.00<br />

26185 S 606.76 0.00 0.00 26480 S 768.55 0.00 0.00<br />

26200 S 522.03 0.00 0.00 26483 S 768.55 0.00 0.00<br />

26205 S 768.55 0.00 0.00 26485 S 739.08 0.00 0.00<br />

26210 S 522.03 0.00 0.00 26489 S 768.55 0.00 0.00<br />

26215 S 551.49 0.00 0.00 26490 S 768.55 0.00 0.00<br />

26230 S 773.89 0.00 0.00 26492 S 768.55 0.00 0.00<br />

26235 S 551.49 0.00 0.00 26494 S 768.55 0.00 0.00<br />

26236 S 551.49 0.00 0.00 26496 S 768.55 0.00 0.00<br />

26250 S 551.49 0.00 0.00 26497 S 768.55 0.00 0.00<br />

26255 S 768.55 0.00 0.00 26498 S 823.81 0.00 0.00<br />

26260 S 551.49 0.00 0.00 26499 S 768.55 0.00 0.00<br />

26261 S 551.49 0.00 0.00 26500 S 606.76 0.00 0.00<br />

26262 S 522.03 0.00 0.00 26502 S 823.81 0.00 0.00<br />

26320 S 508.40 0.00 0.00 26508 S 551.49 0.00 0.00<br />

26340 S 234.37 0.00 0.00 26510 S 768.55 0.00 0.00<br />

26350 S 687.04 0.00 0.00 26516 S 687.04 0.00 0.00<br />

26352 S 823.81 0.00 0.00 26517 S 768.55 0.00 0.00<br />

26356 S 823.81 0.00 0.00 26518 S 768.55 0.00 0.00<br />

26357 S 823.81 0.00 0.00 26520 S 551.49 0.00 0.00<br />

26358 S 823.81 0.00 0.00 26525 S 551.49 0.00 0.00<br />

26370 S 823.81 0.00 0.00 26530 S 955.96 0.00 0.00<br />

26372 S 823.81 0.00 0.00 26531 S 1,471.54 0.00 0.00<br />

26373 S 768.55 0.00 0.00 26535 S 1,051.28 0.00 0.00<br />

26390 S 823.81 0.00 0.00 26536 S 1,343.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 606.76 0.00 0.00 26775 S 162.83 0.00 0.00<br />

26541 S 991.89 0.00 0.00 26776 S 690.37 0.00 0.00<br />

26542 S 606.76 0.00 0.00 26785 S 690.37 0.00 0.00<br />

26545 S 823.81 0.00 0.00 26820 S 863.87 0.00 0.00<br />

26546 S 823.81 0.00 0.00 26841 S 823.81 0.00 0.00<br />

26548 S 823.81 0.00 0.00 26842 S 823.81 0.00 0.00<br />

26550 S 739.08 0.00 0.00 26843 S 768.55 0.00 0.00<br />

26555 S 768.55 0.00 0.00 26844 S 768.55 0.00 0.00<br />

26560 S 522.03 0.00 0.00 26850 S 823.81 0.00 0.00<br />

26561 S 768.55 0.00 0.00 26852 S 823.81 0.00 0.00<br />

26562 S 823.81 0.00 0.00 26860 S 768.55 0.00 0.00<br />

26565 S 863.87 0.00 0.00 26861 S 739.08 0.00 0.00<br />

26567 S 863.87 0.00 0.00 26862 S 823.81 0.00 0.00<br />

26568 S 768.55 0.00 0.00 26863 S 768.55 0.00 0.00<br />

26580 S 646.81 0.00 0.00 26910 S 768.55 0.00 0.00<br />

26587 S 646.81 0.00 0.00 26951 S 522.03 0.00 0.00<br />

26590 S 646.81 0.00 0.00 26952 S 606.76 0.00 0.00<br />

26591 S 768.55 0.00 0.00 26990 S 568.51 0.00 0.00<br />

26593 S 551.49 0.00 0.00 26991 S 568.51 0.00 0.00<br />

26596 S 522.03 0.00 0.00 27000 S 620.55 0.00 0.00<br />

26600 S 60.91 0.00 0.00 27001 S 804.43 0.00 0.00<br />

26605 S 78.17 0.00 0.00 27003 S 804.43 0.00 0.00<br />

26607 S 426.51 0.00 0.00 27033 S 1,099.33 0.00 0.00<br />

26608 S 775.10 0.00 0.00 27035 S 1,154.59 0.00 0.00<br />

26615 S 1,107.18 0.00 0.00 27040 S 310.72 0.00 0.00<br />

26641 S 60.91 0.00 0.00 27041 S 350.09 0.00 0.00<br />

26645 S 164.90 0.00 0.00 27047 S 621.73 0.00 0.00<br />

26650 S 690.37 0.00 0.00 27048 S 651.20 0.00 0.00<br />

26665 S 1,107.18 0.00 0.00 27049 S 651.20 0.00 0.00<br />

26670 S 60.91 0.00 0.00 27050 S 650.02 0.00 0.00<br />

26675 S 164.90 0.00 0.00 27052 S 650.02 0.00 0.00<br />

26676 S 690.37 0.00 0.00 27060 S 745.34 0.00 0.00<br />

26685 S 719.85 0.00 0.00 27062 S 745.34 0.00 0.00<br />

26686 S 1,427.49 0.00 0.00 27065 S 745.34 0.00 0.00<br />

26700 S 60.91 0.00 0.00 27066 S 899.75 0.00 0.00<br />

26705 S 78.17 0.00 0.00 27067 S 899.75 0.00 0.00<br />

26706 S 426.51 0.00 0.00 27080 S 774.95 0.00 0.00<br />

26715 S 775.10 0.00 0.00 27086 S 310.72 0.00 0.00<br />

26720 S 60.91 0.00 0.00 27087 S 650.02 0.00 0.00<br />

26725 S 60.91 0.00 0.00 27097 S 804.43 0.00 0.00<br />

26727 S 943.19 0.00 0.00 27098 S 804.43 0.00 0.00<br />

26735 S 775.10 0.00 0.00 27100 S 1,154.59 0.00 0.00<br />

26740 S 60.91 0.00 0.00 27105 S 1,154.59 0.00 0.00<br />

26742 S 78.17 0.00 0.00 27110 S 1,154.59 0.00 0.00<br />

26746 S 815.17 0.00 0.00 27111 S 1,154.59 0.00 0.00<br />

26750 S 60.91 0.00 0.00 27193 S 78.17 0.00 0.00<br />

26755 S 60.91 0.00 0.00 27194 S 502.11 0.00 0.00<br />

26756 S 690.37 0.00 0.00 27200 S 60.91 0.00 0.00<br />

26765 S 775.10 0.00 0.00 27202 S 1,022.45 0.00 0.00<br />

26770 S 60.91 0.00 0.00 27220 S 60.91 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 78.17 0.00 0.00 27397 S 1,099.33 0.00 0.00<br />

27238 S 164.90 0.00 0.00 27400 S 1,099.33 0.00 0.00<br />

27246 S 164.90 0.00 0.00 27403 S 859.68 0.00 0.00<br />

27250 S 78.17 0.00 0.00 27405 S 1,154.59 0.00 0.00<br />

27252 S 502.11 0.00 0.00 27407 S 1,940.72 0.00 0.00<br />

27256 S 60.91 0.00 0.00 27409 S 1,154.59 0.00 0.00<br />

27257 S 531.58 0.00 0.00 27416 S 1,728.97 0.00 0.00<br />

27265 S 78.17 0.00 0.00 27418 S 1,099.33 0.00 0.00<br />

27266 S 502.11 0.00 0.00 27420 S 1,099.33 0.00 0.00<br />

27267 S 60.91 0.00 0.00 27422 S 1,322.67 0.00 0.00<br />

27275 S 502.11 0.00 0.00 27424 S 1,099.33 0.00 0.00<br />

27301 S 604.39 0.00 0.00 27425 S 1,027.77 0.00 0.00<br />

27305 S 620.55 0.00 0.00 27427 S 1,099.33 0.00 0.00<br />

27306 S 650.02 0.00 0.00 27428 S 1,940.72 0.00 0.00<br />

27307 S 650.02 0.00 0.00 27429 S 1,940.72 0.00 0.00<br />

27310 S 859.68 0.00 0.00 27430 S 1,154.59 0.00 0.00<br />

27323 S 310.72 0.00 0.00 27435 S 1,154.59 0.00 0.00<br />

27324 S 569.69 0.00 0.00 27437 S 1,011.21 0.00 0.00<br />

27325 S 558.22 0.00 0.00 27438 S 1,343.52 0.00 0.00<br />

27326 S 558.22 0.00 0.00 27440 S 1,442.20 0.00 0.00<br />

27327 S 621.73 0.00 0.00 27441 S 1,051.28 0.00 0.00<br />

27328 S 651.20 0.00 0.00 27442 S 1,051.28 0.00 0.00<br />

27329 S 706.46 0.00 0.00 27443 S 1,051.28 0.00 0.00<br />

27330 S 859.68 0.00 0.00 27446 S 10,315.05 6,196.81 2,078.57<br />

27331 S 859.68 0.00 0.00 27496 S 745.34 0.00 0.00<br />

27332 S 859.68 0.00 0.00 27497 S 650.02 0.00 0.00<br />

27333 S 859.68 0.00 0.00 27498 S 650.02 0.00 0.00<br />

27334 S 859.68 0.00 0.00 27499 S 650.02 0.00 0.00<br />

27335 S 859.68 0.00 0.00 27500 S 164.90 0.00 0.00<br />

27340 S 650.02 0.00 0.00 27501 S 78.17 0.00 0.00<br />

27345 S 705.28 0.00 0.00 27502 S 426.51 0.00 0.00<br />

27347 S 705.28 0.00 0.00 27503 S 78.17 0.00 0.00<br />

27350 S 859.68 0.00 0.00 27508 S 78.17 0.00 0.00<br />

27355 S 804.43 0.00 0.00 27509 S 719.85 0.00 0.00<br />

27356 S 859.68 0.00 0.00 27510 S 164.90 0.00 0.00<br />

27357 S 899.75 0.00 0.00 27516 S 78.17 0.00 0.00<br />

27358 S 899.75 0.00 0.00 27517 S 78.17 0.00 0.00<br />

27360 S 899.75 0.00 0.00 27520 S 78.17 0.00 0.00<br />

27372 S 874.54 0.00 0.00 27530 S 78.17 0.00 0.00<br />

27380 S 568.51 0.00 0.00 27532 S 426.51 0.00 0.00<br />

27381 S 650.02 0.00 0.00 27538 S 78.17 0.00 0.00<br />

27385 S 650.02 0.00 0.00 27550 S 78.17 0.00 0.00<br />

27386 S 650.02 0.00 0.00 27552 S 450.07 0.00 0.00<br />

27390 S 568.51 0.00 0.00 27560 S 78.17 0.00 0.00<br />

27391 S 620.55 0.00 0.00 27562 S 450.07 0.00 0.00<br />

27392 S 650.02 0.00 0.00 27566 S 1,022.45 0.00 0.00<br />

27393 S 774.95 0.00 0.00 27570 S 450.07 0.00 0.00<br />

27394 S 804.43 0.00 0.00 27594 S 650.02 0.00 0.00<br />

27395 S 1,099.33 0.00 0.00 27600 S 650.02 0.00 0.00<br />

27396 S 804.43 0.00 0.00 27601 S 650.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 650.02 0.00 0.00 27730 S 774.95 0.00 0.00<br />

27603 S 574.93 0.00 0.00 27732 S 774.95 0.00 0.00<br />

27604 S 620.55 0.00 0.00 27734 S 774.95 0.00 0.00<br />

27605 S 565.46 0.00 0.00 27740 S 774.95 0.00 0.00<br />

27606 S 568.51 0.00 0.00 27742 S 1,069.86 0.00 0.00<br />

27607 S 620.55 0.00 0.00 27745 S 1,885.47 0.00 0.00<br />

27610 S 774.95 0.00 0.00 27750 S 78.17 0.00 0.00<br />

27612 S 804.43 0.00 0.00 27752 S 426.51 0.00 0.00<br />

27613 S 127.74 0.00 0.00 27756 S 719.85 0.00 0.00<br />

27614 S 621.73 0.00 0.00 27758 S 1,107.18 0.00 0.00<br />

27615 S 804.43 0.00 0.00 27759 S 1,482.74 0.00 0.00<br />

27618 S 508.40 0.00 0.00 27760 S 78.17 0.00 0.00<br />

27619 S 651.20 0.00 0.00 27762 S 426.51 0.00 0.00<br />

27620 S 859.68 0.00 0.00 27766 S 1,051.92 0.00 0.00<br />

27625 S 859.68 0.00 0.00 27767 S 60.91 0.00 0.00<br />

27626 S 859.68 0.00 0.00 27768 S 60.91 0.00 0.00<br />

27630 S 650.02 0.00 0.00 27769 S 1,634.13 0.00 0.00<br />

27635 S 804.43 0.00 0.00 27780 S 78.17 0.00 0.00<br />

27637 S 804.43 0.00 0.00 27781 S 426.51 0.00 0.00<br />

27638 S 804.43 0.00 0.00 27784 S 1,051.92 0.00 0.00<br />

27640 S 1,069.86 0.00 0.00 27786 S 78.17 0.00 0.00<br />

27641 S 774.95 0.00 0.00 27788 S 78.17 0.00 0.00<br />

27647 S 1,099.33 0.00 0.00 27792 S 1,051.92 0.00 0.00<br />

27650 S 1,099.33 0.00 0.00 27808 S 78.17 0.00 0.00<br />

27652 S 1,885.47 0.00 0.00 27810 S 164.90 0.00 0.00<br />

27654 S 1,099.33 0.00 0.00 27814 S 1,051.92 0.00 0.00<br />

27656 S 620.55 0.00 0.00 27816 S 78.17 0.00 0.00<br />

27658 S 568.51 0.00 0.00 27818 S 164.90 0.00 0.00<br />

27659 S 620.55 0.00 0.00 27822 S 1,051.92 0.00 0.00<br />

27664 S 620.55 0.00 0.00 27823 S 1,427.49 0.00 0.00<br />

27665 S 774.95 0.00 0.00 27824 S 78.17 0.00 0.00<br />

27675 S 620.55 0.00 0.00 27825 S 426.51 0.00 0.00<br />

27676 S 804.43 0.00 0.00 27826 S 1,051.92 0.00 0.00<br />

27680 S 804.43 0.00 0.00 27827 S 1,427.49 0.00 0.00<br />

27681 S 774.95 0.00 0.00 27828 S 1,482.74 0.00 0.00<br />

27685 S 804.43 0.00 0.00 27829 S 1,022.45 0.00 0.00<br />

27686 S 804.43 0.00 0.00 27830 S 78.17 0.00 0.00<br />

27687 S 804.43 0.00 0.00 27831 S 426.51 0.00 0.00<br />

27690 S 1,154.59 0.00 0.00 27832 S 1,022.45 0.00 0.00<br />

27691 S 1,154.59 0.00 0.00 27840 S 164.90 0.00 0.00<br />

27692 S 1,099.33 0.00 0.00 27842 S 450.07 0.00 0.00<br />

27695 S 774.95 0.00 0.00 27846 S 1,051.92 0.00 0.00<br />

27696 S 774.95 0.00 0.00 27848 S 1,051.92 0.00 0.00<br />

27698 S 774.95 0.00 0.00 27860 S 450.07 0.00 0.00<br />

27700 S 1,051.28 0.00 0.00 27870 S 1,940.72 0.00 0.00<br />

27704 S 620.55 0.00 0.00 27871 S 1,940.72 0.00 0.00<br />

27705 S 1,069.86 0.00 0.00 27884 S 650.02 0.00 0.00<br />

27707 S 620.55 0.00 0.00 27889 S 804.43 0.00 0.00<br />

27709 S 774.95 0.00 0.00 27892 S 650.02 0.00 0.00<br />

27726 S 969.99 0.00 0.00 27893 S 650.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 650.02 0.00 0.00 28153 S 646.97 0.00 0.00<br />

28001 S 124.67 0.00 0.00 28160 S 646.97 0.00 0.00<br />

28002 S 650.02 0.00 0.00 28171 S 646.97 0.00 0.00<br />

28003 S 650.02 0.00 0.00 28173 S 646.97 0.00 0.00<br />

28005 S 646.97 0.00 0.00 28175 S 646.97 0.00 0.00<br />

28008 S 646.97 0.00 0.00 28190 S 128.76 0.00 0.00<br />

28010 S 91.64 0.00 0.00 28192 S 508.40 0.00 0.00<br />

28011 S 646.97 0.00 0.00 28193 S 350.09 0.00 0.00<br />

28020 S 617.50 0.00 0.00 28200 S 646.97 0.00 0.00<br />

28022 S 617.50 0.00 0.00 28202 S 646.97 0.00 0.00<br />

28024 S 617.50 0.00 0.00 28208 S 646.97 0.00 0.00<br />

28035 S 642.95 0.00 0.00 28210 S 1,136.28 0.00 0.00<br />

28043 S 621.73 0.00 0.00 28220 S 198.60 0.00 0.00<br />

28045 S 646.97 0.00 0.00 28222 S 565.46 0.00 0.00<br />

28046 S 646.97 0.00 0.00 28225 S 565.46 0.00 0.00<br />

28050 S 617.50 0.00 0.00 28226 S 565.46 0.00 0.00<br />

28052 S 617.50 0.00 0.00 28230 S 194.85 0.00 0.00<br />

28054 S 617.50 0.00 0.00 28232 S 186.33 0.00 0.00<br />

28055 S 642.95 0.00 0.00 28234 S 617.50 0.00 0.00<br />

28060 S 617.50 0.00 0.00 28238 S 1,136.28 0.00 0.00<br />

28062 S 646.97 0.00 0.00 28240 S 617.50 0.00 0.00<br />

28070 S 646.97 0.00 0.00 28250 S 646.97 0.00 0.00<br />

28072 S 646.97 0.00 0.00 28260 S 646.97 0.00 0.00<br />

28080 S 646.97 0.00 0.00 28261 S 646.97 0.00 0.00<br />

28086 S 617.50 0.00 0.00 28262 S 702.23 0.00 0.00<br />

28088 S 617.50 0.00 0.00 28264 S 1,054.77 0.00 0.00<br />

28090 S 646.97 0.00 0.00 28270 S 646.97 0.00 0.00<br />

28092 S 646.97 0.00 0.00 28272 S 179.86 0.00 0.00<br />

28100 S 617.50 0.00 0.00 28280 S 617.50 0.00 0.00<br />

28102 S 1,136.28 0.00 0.00 28285 S 646.97 0.00 0.00<br />

28103 S 1,136.28 0.00 0.00 28286 S 702.23 0.00 0.00<br />

28104 S 617.50 0.00 0.00 28288 S 646.97 0.00 0.00<br />

28106 S 1,136.28 0.00 0.00 28289 S 646.97 0.00 0.00<br />

28107 S 1,136.28 0.00 0.00 28290 S 797.48 0.00 0.00<br />

28108 S 617.50 0.00 0.00 28292 S 797.48 0.00 0.00<br />

28110 S 646.97 0.00 0.00 28293 S 826.95 0.00 0.00<br />

28111 S 646.97 0.00 0.00 28294 S 826.95 0.00 0.00<br />

28112 S 646.97 0.00 0.00 28296 S 826.95 0.00 0.00<br />

28113 S 646.97 0.00 0.00 28297 S 826.95 0.00 0.00<br />

28114 S 646.97 0.00 0.00 28298 S 826.95 0.00 0.00<br />

28116 S 646.97 0.00 0.00 28299 S 922.27 0.00 0.00<br />

28118 S 702.23 0.00 0.00 28300 S 1,106.81 0.00 0.00<br />

28119 S 702.23 0.00 0.00 28302 S 617.50 0.00 0.00<br />

28120 S 870.31 0.00 0.00 28304 S 1,106.81 0.00 0.00<br />

28122 S 646.97 0.00 0.00 28305 S 1,136.28 0.00 0.00<br />

28124 S 210.86 0.00 0.00 28306 S 702.23 0.00 0.00<br />

28126 S 646.97 0.00 0.00 28307 S 702.23 0.00 0.00<br />

28130 S 646.97 0.00 0.00 28308 S 617.50 0.00 0.00<br />

28140 S 646.97 0.00 0.00 28309 S 1,191.54 0.00 0.00<br />

28150 S 646.97 0.00 0.00 28310 S 646.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 646.97 0.00 0.00 28636 S 719.85 0.00 0.00<br />

28313 S 617.50 0.00 0.00 28645 S 719.85 0.00 0.00<br />

28315 S 702.23 0.00 0.00 28660 S 43.61 0.00 0.00<br />

28320 S 1,191.54 0.00 0.00 28665 S 450.07 0.00 0.00<br />

28322 S 1,191.54 0.00 0.00 28666 S 719.85 0.00 0.00<br />

28340 S 702.23 0.00 0.00 28675 S 719.85 0.00 0.00<br />

28341 S 702.23 0.00 0.00 28705 S 1,191.54 0.00 0.00<br />

28344 S 702.23 0.00 0.00 28715 S 1,940.72 0.00 0.00<br />

28345 S 702.23 0.00 0.00 28725 S 1,191.54 0.00 0.00<br />

28400 S 78.17 0.00 0.00 28730 S 1,191.54 0.00 0.00<br />

28405 S 426.51 0.00 0.00 28735 S 1,191.54 0.00 0.00<br />

28406 S 690.37 0.00 0.00 28737 S 1,231.60 0.00 0.00<br />

28415 S 1,427.49 0.00 0.00 28740 S 1,191.54 0.00 0.00<br />

28420 S 1,107.18 0.00 0.00 28750 S 1,191.54 0.00 0.00<br />

28430 S 60.91 0.00 0.00 28755 S 702.23 0.00 0.00<br />

28435 S 78.17 0.00 0.00 28760 S 1,191.54 0.00 0.00<br />

28436 S 690.37 0.00 0.00 28810 S 617.50 0.00 0.00<br />

28445 S 1,051.92 0.00 0.00 28820 S 617.50 0.00 0.00<br />

28446 S 1,802.86 0.00 0.00 28825 S 617.50 0.00 0.00<br />

28450 S 60.91 0.00 0.00 28890 S 163.17 0.00 0.00<br />

28455 S 60.91 0.00 0.00 29000 S 41.34 0.00 0.00<br />

28456 S 690.37 0.00 0.00 29010 S 92.66 0.00 0.00<br />

28465 S 1,051.92 0.00 0.00 29015 S 92.66 0.00 0.00<br />

28470 S 60.91 0.00 0.00 29020 S 41.34 0.00 0.00<br />

28475 S 60.91 0.00 0.00 29025 S 41.34 0.00 0.00<br />

28476 S 690.37 0.00 0.00 29035 S 92.66 0.00 0.00<br />

28485 S 1,107.18 0.00 0.00 29040 S 41.34 0.00 0.00<br />

28490 S 60.91 0.00 0.00 29044 S 92.66 0.00 0.00<br />

28495 S 60.91 0.00 0.00 29046 S 92.66 0.00 0.00<br />

28496 S 690.37 0.00 0.00 29049 S 37.47 0.00 0.00<br />

28505 S 719.85 0.00 0.00 29055 S 92.66 0.00 0.00<br />

28510 S 54.85 0.00 0.00 29058 S 41.34 0.00 0.00<br />

28515 S 60.91 0.00 0.00 29065 S 43.95 0.00 0.00<br />

28525 S 719.85 0.00 0.00 29075 S 42.24 0.00 0.00<br />

28530 S 52.80 0.00 0.00 29085 S 41.34 0.00 0.00<br />

28531 S 719.85 0.00 0.00 29086 S 35.43 0.00 0.00<br />

28540 S 60.91 0.00 0.00 29105 S 38.15 0.00 0.00<br />

28545 S 638.34 0.00 0.00 29125 S 33.04 0.00 0.00<br />

28546 S 690.37 0.00 0.00 29126 S 35.09 0.00 0.00<br />

28555 S 1,022.45 0.00 0.00 29130 S 14.99 0.00 0.00<br />

28570 S 79.03 0.00 0.00 29131 S 21.80 0.00 0.00<br />

28575 S 426.51 0.00 0.00 29200 S 21.12 0.00 0.00<br />

28576 S 719.85 0.00 0.00 29220 S 22.82 0.00 0.00<br />

28585 S 719.85 0.00 0.00 29240 S 23.85 0.00 0.00<br />

28600 S 60.91 0.00 0.00 29260 S 22.82 0.00 0.00<br />

28605 S 78.17 0.00 0.00 29280 S 23.17 0.00 0.00<br />

28606 S 690.37 0.00 0.00 29305 S 92.66 0.00 0.00<br />

28615 S 1,051.92 0.00 0.00 29325 S 92.66 0.00 0.00<br />

28630 S 60.91 0.00 0.00 29345 S 57.57 0.00 0.00<br />

28635 S 450.07 0.00 0.00 29355 S 56.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 70.18 0.00 0.00 29847 S 1,172.95 0.00 0.00<br />

29365 S 54.51 0.00 0.00 29848 S 1,177.27 0.00 0.00<br />

29405 S 40.54 0.00 0.00 29850 S 850.79 0.00 0.00<br />

29425 S 41.22 0.00 0.00 29851 S 1,228.21 0.00 0.00<br />

29435 S 52.12 0.00 0.00 29855 S 1,228.21 0.00 0.00<br />

29440 S 22.14 0.00 0.00 29856 S 1,228.21 0.00 0.00<br />

29445 S 54.85 0.00 0.00 29860 S 1,228.21 0.00 0.00<br />

29450 S 41.34 0.00 0.00 29861 S 1,228.21 0.00 0.00<br />

29505 S 36.79 0.00 0.00 29862 S 1,554.69 0.00 0.00<br />

29515 S 31.34 0.00 0.00 29863 S 1,228.21 0.00 0.00<br />

29520 S 22.48 0.00 0.00 29866 S 1,876.19 0.00 0.00<br />

29530 S 22.82 0.00 0.00 29870 S 795.53 0.00 0.00<br />

29540 S 17.03 0.00 0.00 29871 S 795.53 0.00 0.00<br />

29550 S 17.37 0.00 0.00 29873 S 795.53 0.00 0.00<br />

29580 S 23.51 0.00 0.00 29874 S 795.53 0.00 0.00<br />

29590 S 19.08 0.00 0.00 29875 S 850.79 0.00 0.00<br />

29700 S 31.68 0.00 0.00 29876 S 850.79 0.00 0.00<br />

29705 S 26.91 0.00 0.00 29877 S 850.79 0.00 0.00<br />

29710 S 47.35 0.00 0.00 29879 S 795.53 0.00 0.00<br />

29715 S 41.34 0.00 0.00 29880 S 850.79 0.00 0.00<br />

29720 S 39.52 0.00 0.00 29881 S 850.79 0.00 0.00<br />

29730 S 25.89 0.00 0.00 29882 S 795.53 0.00 0.00<br />

29740 S 35.43 0.00 0.00 29883 S 795.53 0.00 0.00<br />

29750 S 37.13 0.00 0.00 29884 S 795.53 0.00 0.00<br />

29800 S 795.53 0.00 0.00 29885 S 1,172.95 0.00 0.00<br />

29804 S 795.53 0.00 0.00 29886 S 795.53 0.00 0.00<br />

29805 S 795.53 0.00 0.00 29887 S 795.53 0.00 0.00<br />

29806 S 1,172.95 0.00 0.00 29888 S 1,172.95 0.00 0.00<br />

29807 S 1,172.95 0.00 0.00 29889 S 1,172.95 0.00 0.00<br />

29819 S 1,172.95 0.00 0.00 29891 S 1,172.95 0.00 0.00<br />

29820 S 1,172.95 0.00 0.00 29892 S 1,172.95 0.00 0.00<br />

29821 S 1,172.95 0.00 0.00 29893 S 990.29 0.00 0.00<br />

29822 S 795.53 0.00 0.00 29894 S 795.53 0.00 0.00<br />

29823 S 1,172.95 0.00 0.00 29895 S 795.53 0.00 0.00<br />

29824 S 890.85 0.00 0.00 29897 S 795.53 0.00 0.00<br />

29825 S 1,172.95 0.00 0.00 29898 S 795.53 0.00 0.00<br />

29826 S 1,172.95 0.00 0.00 29899 S 1,172.95 0.00 0.00<br />

29827 S 1,268.27 0.00 0.00 29900 S 795.53 0.00 0.00<br />

29828 S 1,876.19 0.00 0.00 29901 S 795.53 0.00 0.00<br />

29830 S 795.53 0.00 0.00 29902 S 795.53 0.00 0.00<br />

29834 S 795.53 0.00 0.00 29904 S 1,121.36 0.00 0.00<br />

29835 S 795.53 0.00 0.00 29905 S 1,121.36 0.00 0.00<br />

29836 S 795.53 0.00 0.00 29906 S 1,121.36 0.00 0.00<br />

29837 S 795.53 0.00 0.00 29907 S 1,876.19 0.00 0.00<br />

29838 S 795.53 0.00 0.00 30000 S 126.07 0.00 0.00<br />

29840 S 795.53 0.00 0.00 30020 S 126.07 0.00 0.00<br />

29843 S 795.53 0.00 0.00 30100 S 81.76 0.00 0.00<br />

29844 S 795.53 0.00 0.00 30110 S 126.38 0.00 0.00<br />

29845 S 795.53 0.00 0.00 30115 S 533.99 0.00 0.00<br />

29846 S 795.53 0.00 0.00 30117 S 563.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 706.72 0.00 0.00 31080 S 1,088.27 0.00 0.00<br />

30120 S 481.96 0.00 0.00 31081 S 1,088.27 0.00 0.00<br />

30124 S 287.18 0.00 0.00 31084 S 1,088.27 0.00 0.00<br />

30125 S 1,003.54 0.00 0.00 31085 S 1,088.27 0.00 0.00<br />

30130 S 563.47 0.00 0.00 31086 S 1,088.27 0.00 0.00<br />

30140 S 677.24 0.00 0.00 31087 S 1,088.27 0.00 0.00<br />

30150 S 1,033.02 0.00 0.00 31090 S 1,128.34 0.00 0.00<br />

30160 S 1,088.27 0.00 0.00 31200 S 1,003.54 0.00 0.00<br />

30200 S 64.39 0.00 0.00 31201 S 1,128.34 0.00 0.00<br />

30210 S 81.76 0.00 0.00 31205 S 1,033.02 0.00 0.00<br />

30220 S 357.32 0.00 0.00 31231 S 68.92 0.00 0.00<br />

30300 S 24.63 0.00 0.00 31233 S 74.24 0.00 0.00<br />

30310 S 481.96 0.00 0.00 31235 S 504.37 0.00 0.00<br />

30320 S 533.99 0.00 0.00 31237 S 556.40 0.00 0.00<br />

30400 S 1,088.27 0.00 0.00 31238 S 504.37 0.00 0.00<br />

30410 S 1,128.34 0.00 0.00 31239 S 736.23 0.00 0.00<br />

30420 S 1,128.34 0.00 0.00 31240 S 556.40 0.00 0.00<br />

30430 S 706.72 0.00 0.00 31254 S 680.97 0.00 0.00<br />

30435 S 1,128.34 0.00 0.00 31255 S 776.28 0.00 0.00<br />

30450 S 1,256.36 0.00 0.00 31256 S 680.97 0.00 0.00<br />

30460 S 1,256.36 0.00 0.00 31267 S 680.97 0.00 0.00<br />

30462 S 1,414.76 0.00 0.00 31276 S 680.97 0.00 0.00<br />

30465 S 1,414.76 0.00 0.00 31287 S 680.97 0.00 0.00<br />

30520 S 761.98 0.00 0.00 31288 S 680.97 0.00 0.00<br />

30540 S 1,128.34 0.00 0.00 31300 S 802.04 0.00 0.00<br />

30545 S 1,128.34 0.00 0.00 31320 S 1,003.54 0.00 0.00<br />

30560 S 132.44 0.00 0.00 31400 S 1,003.54 0.00 0.00<br />

30580 S 1,088.27 0.00 0.00 31420 S 1,003.54 0.00 0.00<br />

30600 S 1,088.27 0.00 0.00 31500 S 92.18 0.00 0.00<br />

30620 S 1,256.36 0.00 0.00 31502 S 53.01 0.00 0.00<br />

30630 S 930.06 0.00 0.00 31505 S 31.32 0.00 0.00<br />

30801 S 296.93 0.00 0.00 31510 S 556.40 0.00 0.00<br />

30802 S 296.93 0.00 0.00 31511 S 74.24 0.00 0.00<br />

30901 S 42.35 0.00 0.00 31512 S 556.40 0.00 0.00<br />

30903 S 54.55 0.00 0.00 31513 S 74.24 0.00 0.00<br />

30905 S 54.55 0.00 0.00 31515 S 504.37 0.00 0.00<br />

30906 S 54.55 0.00 0.00 31520 S 68.92 0.00 0.00<br />

30915 S 726.92 0.00 0.00 31525 S 504.37 0.00 0.00<br />

30920 S 756.39 0.00 0.00 31526 S 651.50 0.00 0.00<br />

30930 S 618.72 0.00 0.00 31527 S 599.46 0.00 0.00<br />

31000 S 105.26 0.00 0.00 31528 S 556.40 0.00 0.00<br />

31002 S 287.18 0.00 0.00 31529 S 556.40 0.00 0.00<br />

31020 S 677.24 0.00 0.00 31530 S 651.50 0.00 0.00<br />

31030 S 1,033.02 0.00 0.00 31531 S 680.97 0.00 0.00<br />

31032 S 1,088.27 0.00 0.00 31535 S 651.50 0.00 0.00<br />

31040 S 943.74 0.00 0.00 31536 S 680.97 0.00 0.00<br />

31050 S 1,003.54 0.00 0.00 31540 S 680.97 0.00 0.00<br />

31051 S 1,088.27 0.00 0.00 31541 S 736.23 0.00 0.00<br />

31070 S 677.24 0.00 0.00 31545 S 736.23 0.00 0.00<br />

31075 S 1,088.27 0.00 0.00 31546 S 736.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 776.28 0.00 0.00 32405 S 335.92 0.00 0.00<br />

31561 S 776.28 0.00 0.00 32420 S 204.27 0.00 0.00<br />

31570 S 556.40 0.00 0.00 32421 S 204.27 0.00 0.00<br />

31571 S 651.50 0.00 0.00 32422 S 203.36 0.00 0.00<br />

31575 S 59.28 0.00 0.00 32550 S 1,138.59 0.00 0.00<br />

31576 S 651.50 0.00 0.00 32960 S 203.36 0.00 0.00<br />

31577 S 192.45 0.00 0.00 32998 S 1,772.73 0.00 0.00<br />

31578 S 651.50 0.00 0.00 33010 S 204.27 0.00 0.00<br />

31579 S 105.60 0.00 0.00 33011 S 204.27 0.00 0.00<br />

31580 S 1,128.34 0.00 0.00 33206 S 6,553.66 3,899.41 1,245.16<br />

31582 S 1,128.34 0.00 0.00 33207 S 6,553.66 3,899.41 1,245.16<br />

31588 S 1,128.34 0.00 0.00 33208 S 8,128.40 4,736.37 1,344.36<br />

31590 S 1,128.34 0.00 0.00 33210 S 1,924.50 0.00 0.00<br />

31595 S 1,003.54 0.00 0.00 33211 S 1,924.50 0.00 0.00<br />

31603 S 296.93 0.00 0.00 33212 S 5,146.96 2,932.00 717.05<br />

31605 S 287.18 0.00 0.00 33213 S 5,940.70 3,328.45 716.20<br />

31611 S 706.72 0.00 0.00 33214 S 8,128.40 4,736.37 1,344.36<br />

31612 S 625.21 0.00 0.00 33215 S 843.53 0.00 0.00<br />

31613 S 677.24 0.00 0.00 33216 S 1,924.50 0.00 0.00<br />

31614 S 1,003.54 0.00 0.00 33217 S 1,924.50 0.00 0.00<br />

31615 S 296.93 0.00 0.00 33218 S 843.53 0.00 0.00<br />

31622 S 347.76 0.00 0.00 33220 S 843.53 0.00 0.00<br />

31623 S 399.79 0.00 0.00 33222 S 509.88 0.00 0.00<br />

31624 S 399.79 0.00 0.00 33223 S 509.88 0.00 0.00<br />

31625 S 399.79 0.00 0.00 33224 S 7,672.45 4,593.47 1,514.51<br />

31628 S 399.79 0.00 0.00 33225 S 7,672.45 4,593.47 1,514.51<br />

31629 S 399.79 0.00 0.00 33226 S 843.53 0.00 0.00<br />

31630 S 685.07 0.00 0.00 33233 S 627.15 0.00 0.00<br />

31631 S 685.07 0.00 0.00 33234 S 843.53 0.00 0.00<br />

31632 S 388.82 0.00 0.00 33235 S 843.53 0.00 0.00<br />

31633 S 388.82 0.00 0.00 33240 S 19,125.45 10,223.33 1,321.22<br />

31635 S 399.79 0.00 0.00 33241 S 843.53 0.00 0.00<br />

31636 S 685.07 0.00 0.00 33249 S 25,524.38 13,671.91 1,819.45<br />

31637 S 347.76 0.00 0.00 33282 S 4,035.57 2,415.93 796.29<br />

31638 S 685.07 0.00 0.00 33284 S 314.76 0.00 0.00<br />

31640 S 685.07 0.00 0.00 34490 S 1,536.77 0.00 0.00<br />

31641 S 685.07 0.00 0.00 35188 S 1,058.49 0.00 0.00<br />

31643 S 399.79 0.00 0.00 35207 S 1,058.49 0.00 0.00<br />

31645 S 347.76 0.00 0.00 35473 S 1,843.53 0.00 0.00<br />

31646 S 347.76 0.00 0.00 35476 S 1,843.53 0.00 0.00<br />

31656 S 347.76 0.00 0.00 35492 S 3,440.77 0.00 0.00<br />

31717 S 192.45 0.00 0.00 35761 S 1,106.85 0.00 0.00<br />

31720 S 29.47 0.00 0.00 35875 S 1,384.98 0.00 0.00<br />

31730 S 192.45 0.00 0.00 35876 S 1,384.98 0.00 0.00<br />

31750 S 1,128.34 0.00 0.00 36002 S 88.40 0.00 0.00<br />

31755 S 1,003.54 0.00 0.00 36260 S 801.87 0.00 0.00<br />

31820 S 481.96 0.00 0.00 36261 S 627.15 0.00 0.00<br />

31825 S 677.24 0.00 0.00 36262 S 575.11 0.00 0.00<br />

31830 S 677.24 0.00 0.00 36420 S 8.33 0.00 0.00<br />

32400 S 335.92 0.00 0.00 36425 S 8.33 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.02 0.00 0.00 36800 S 863.22 0.00 0.00<br />

36440 S 127.88 0.00 0.00 36810 S 863.22 0.00 0.00<br />

36450 S 127.88 0.00 0.00 36815 S 863.22 0.00 0.00<br />

36455 S 127.88 0.00 0.00 36818 S 1,003.24 0.00 0.00<br />

36468 S 31.57 0.00 0.00 36819 S 1,003.24 0.00 0.00<br />

36469 S 31.57 0.00 0.00 36820 S 1,003.24 0.00 0.00<br />

36470 S 31.57 0.00 0.00 36821 S 1,003.24 0.00 0.00<br />

36471 S 31.57 0.00 0.00 36825 S 1,058.49 0.00 0.00<br />

36475 S 1,451.32 0.00 0.00 36830 S 1,058.49 0.00 0.00<br />

36476 S 1,138.13 0.00 0.00 36831 S 1,384.98 0.00 0.00<br />

36478 S 1,138.13 0.00 0.00 36832 S 1,058.49 0.00 0.00<br />

36479 S 1,138.13 0.00 0.00 36833 S 1,058.49 0.00 0.00<br />

36511 S 438.42 0.00 0.00 36834 S 1,003.24 0.00 0.00<br />

36512 S 438.42 0.00 0.00 36835 S 918.48 0.00 0.00<br />

36513 S 438.42 0.00 0.00 36860 S 105.42 0.00 0.00<br />

36514 S 438.42 0.00 0.00 36861 S 863.22 0.00 0.00<br />

36515 S 1,173.65 0.00 0.00 36870 S 1,509.63 0.00 0.00<br />

36516 S 1,173.65 0.00 0.00 37184 S 1,536.77 0.00 0.00<br />

36522 S 1,173.65 0.00 0.00 37185 S 1,536.77 0.00 0.00<br />

36555 S 364.27 0.00 0.00 37186 S 1,536.77 0.00 0.00<br />

36556 S 364.27 0.00 0.00 37187 S 1,536.77 0.00 0.00<br />

36557 S 680.30 0.00 0.00 37188 S 1,536.77 0.00 0.00<br />

36558 S 680.30 0.00 0.00 37200 S 1,134.04 0.00 0.00<br />

36560 S 801.87 0.00 0.00 37203 S 1,134.04 0.00 0.00<br />

36561 S 801.87 0.00 0.00 37500 S 1,069.58 0.00 0.00<br />

36563 S 801.87 0.00 0.00 37607 S 756.39 0.00 0.00<br />

36565 S 801.87 0.00 0.00 37609 S 508.40 0.00 0.00<br />

36566 S 801.87 0.00 0.00 37650 S 726.92 0.00 0.00<br />

36568 S 364.27 0.00 0.00 37700 S 726.92 0.00 0.00<br />

36569 S 364.27 0.00 0.00 37718 S 756.39 0.00 0.00<br />

36570 S 709.76 0.00 0.00 37722 S 1,069.58 0.00 0.00<br />

36571 S 709.76 0.00 0.00 37735 S 1,069.58 0.00 0.00<br />

36575 S 292.97 0.00 0.00 37760 S 756.39 0.00 0.00<br />

36576 S 416.30 0.00 0.00 37765 S 1,043.08 0.00 0.00<br />

36578 S 680.30 0.00 0.00 37766 S 1,043.08 0.00 0.00<br />

36580 S 364.27 0.00 0.00 37780 S 756.39 0.00 0.00<br />

36581 S 680.30 0.00 0.00 37785 S 756.39 0.00 0.00<br />

36582 S 801.87 0.00 0.00 37790 S 912.74 0.00 0.00<br />

36583 S 801.87 0.00 0.00 38205 S 438.42 0.00 0.00<br />

36584 S 364.27 0.00 0.00 38206 S 438.42 0.00 0.00<br />

36585 S 709.76 0.00 0.00 38220 S 100.49 0.00 0.00<br />

36589 S 240.94 0.00 0.00 38221 S 105.26 0.00 0.00<br />

36590 S 364.27 0.00 0.00 38230 S 1,173.65 0.00 0.00<br />

36593 S 24.19 0.00 0.00 38241 S 1,173.65 0.00 0.00<br />

36595 S 949.83 0.00 0.00 38242 S 438.42 0.00 0.00<br />

36596 S 421.83 0.00 0.00 38300 S 393.42 0.00 0.00<br />

36597 S 421.83 0.00 0.00 38305 S 574.93 0.00 0.00<br />

36598 S 78.01 0.00 0.00 38308 S 656.93 0.00 0.00<br />

36640 S 720.36 0.00 0.00 38500 S 656.93 0.00 0.00<br />

36680 S 54.60 0.00 0.00 38505 S 251.34 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 656.93 0.00 0.00 41005 S 132.44 0.00 0.00<br />

38520 S 656.93 0.00 0.00 41006 S 625.21 0.00 0.00<br />

38525 S 656.93 0.00 0.00 41007 S 481.96 0.00 0.00<br />

38530 S 656.93 0.00 0.00 41008 S 481.96 0.00 0.00<br />

38542 S 1,105.19 0.00 0.00 41009 S 132.44 0.00 0.00<br />

38550 S 686.41 0.00 0.00 41010 S 296.93 0.00 0.00<br />

38555 S 741.66 0.00 0.00 41015 S 132.44 0.00 0.00<br />

38570 S 1,499.57 0.00 0.00 41016 S 296.93 0.00 0.00<br />

38571 S 1,949.41 0.00 0.00 41017 S 296.93 0.00 0.00<br />

38572 S 1,499.57 0.00 0.00 41018 S 296.93 0.00 0.00<br />

38700 S 903.10 0.00 0.00 41019 S 943.74 0.00 0.00<br />

38740 S 1,105.19 0.00 0.00 41100 S 88.91 0.00 0.00<br />

38745 S 1,189.92 0.00 0.00 41105 S 87.89 0.00 0.00<br />

38760 S 656.93 0.00 0.00 41108 S 81.42 0.00 0.00<br />

40490 S 67.11 0.00 0.00 41110 S 117.86 0.00 0.00<br />

40500 S 533.99 0.00 0.00 41112 S 533.99 0.00 0.00<br />

40510 S 677.24 0.00 0.00 41113 S 533.99 0.00 0.00<br />

40520 S 533.99 0.00 0.00 41114 S 677.24 0.00 0.00<br />

40525 S 677.24 0.00 0.00 41115 S 137.28 0.00 0.00<br />

40527 S 677.24 0.00 0.00 41116 S 481.96 0.00 0.00<br />

40530 S 677.24 0.00 0.00 41120 S 802.04 0.00 0.00<br />

40650 S 357.32 0.00 0.00 41250 S 90.58 0.00 0.00<br />

40652 S 357.32 0.00 0.00 41251 S 132.44 0.00 0.00<br />

40654 S 357.32 0.00 0.00 41252 S 348.96 0.00 0.00<br />

40700 S 1,256.36 0.00 0.00 41500 S 625.21 0.00 0.00<br />

40701 S 1,256.36 0.00 0.00 41510 S 481.96 0.00 0.00<br />

40702 S 1,596.33 0.00 0.00 41520 S 348.96 0.00 0.00<br />

40720 S 1,256.36 0.00 0.00 41530 S 657.23 0.00 0.00<br />

40761 S 1,033.02 0.00 0.00 41800 S 67.66 0.00 0.00<br />

40800 S 53.86 0.00 0.00 41805 S 146.48 0.00 0.00<br />

40801 S 348.96 0.00 0.00 41806 S 180.54 0.00 0.00<br />

40804 S 24.63 0.00 0.00 41820 S 287.18 0.00 0.00<br />

40805 S 166.58 0.00 0.00 41821 S 287.18 0.00 0.00<br />

40806 S 76.65 0.00 0.00 41822 S 149.54 0.00 0.00<br />

40808 S 113.77 0.00 0.00 41823 S 218.02 0.00 0.00<br />

40810 S 117.86 0.00 0.00 41825 S 119.90 0.00 0.00<br />

40812 S 147.84 0.00 0.00 41826 S 150.91 0.00 0.00<br />

40814 S 533.99 0.00 0.00 41827 S 677.24 0.00 0.00<br />

40816 S 677.24 0.00 0.00 41828 S 136.26 0.00 0.00<br />

40818 S 132.44 0.00 0.00 41830 S 193.49 0.00 0.00<br />

40819 S 296.93 0.00 0.00 41850 S 657.23 0.00 0.00<br />

40820 S 169.98 0.00 0.00 41870 S 943.74 0.00 0.00<br />

40830 S 126.07 0.00 0.00 41872 S 193.49 0.00 0.00<br />

40831 S 296.93 0.00 0.00 41874 S 186.67 0.00 0.00<br />

40840 S 677.24 0.00 0.00 42000 S 132.44 0.00 0.00<br />

40842 S 706.72 0.00 0.00 42100 S 75.63 0.00 0.00<br />

40843 S 706.72 0.00 0.00 42104 S 112.41 0.00 0.00<br />

40844 S 1,128.34 0.00 0.00 42106 S 141.03 0.00 0.00<br />

40845 S 1,128.34 0.00 0.00 42107 S 677.24 0.00 0.00<br />

41000 S 84.49 0.00 0.00 42120 S 1,088.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 348.96 0.00 0.00 42809 S 24.63 0.00 0.00<br />

42145 S 802.04 0.00 0.00 42810 S 706.72 0.00 0.00<br />

42160 S 133.53 0.00 0.00 42815 S 1,128.34 0.00 0.00<br />

42180 S 132.44 0.00 0.00 42820 S 706.72 0.00 0.00<br />

42182 S 1,003.54 0.00 0.00 42821 S 802.04 0.00 0.00<br />

42200 S 1,128.34 0.00 0.00 42825 S 761.98 0.00 0.00<br />

42205 S 1,128.34 0.00 0.00 42826 S 761.98 0.00 0.00<br />

42210 S 1,128.34 0.00 0.00 42830 S 761.98 0.00 0.00<br />

42215 S 1,256.36 0.00 0.00 42831 S 761.98 0.00 0.00<br />

42220 S 1,128.34 0.00 0.00 42835 S 761.98 0.00 0.00<br />

42226 S 1,128.34 0.00 0.00 42836 S 761.98 0.00 0.00<br />

42235 S 658.79 0.00 0.00 42860 S 706.72 0.00 0.00<br />

42260 S 761.98 0.00 0.00 42870 S 706.72 0.00 0.00<br />

42280 S 73.58 0.00 0.00 42890 S 1,256.36 0.00 0.00<br />

42281 S 657.23 0.00 0.00 42892 S 1,256.36 0.00 0.00<br />

42300 S 481.96 0.00 0.00 42900 S 296.93 0.00 0.00<br />

42305 S 533.99 0.00 0.00 42950 S 677.24 0.00 0.00<br />

42310 S 132.44 0.00 0.00 42955 S 677.24 0.00 0.00<br />

42320 S 132.44 0.00 0.00 42960 S 54.55 0.00 0.00<br />

42330 S 113.77 0.00 0.00 42962 S 1,003.54 0.00 0.00<br />

42335 S 188.72 0.00 0.00 42970 S 42.35 0.00 0.00<br />

42340 S 533.99 0.00 0.00 42972 S 563.47 0.00 0.00<br />

42400 S 64.05 0.00 0.00 43030 S 657.23 0.00 0.00<br />

42405 S 533.99 0.00 0.00 43200 S 318.27 0.00 0.00<br />

42408 S 563.47 0.00 0.00 43201 S 318.27 0.00 0.00<br />

42409 S 563.47 0.00 0.00 43202 S 318.27 0.00 0.00<br />

42410 S 1,033.02 0.00 0.00 43204 S 318.27 0.00 0.00<br />

42415 S 1,256.36 0.00 0.00 43205 S 318.27 0.00 0.00<br />

42420 S 1,256.36 0.00 0.00 43215 S 318.27 0.00 0.00<br />

42425 S 1,256.36 0.00 0.00 43216 S 318.27 0.00 0.00<br />

42440 S 1,033.02 0.00 0.00 43217 S 318.27 0.00 0.00<br />

42450 S 677.24 0.00 0.00 43219 S 643.22 0.00 0.00<br />

42500 S 706.72 0.00 0.00 43220 S 318.27 0.00 0.00<br />

42505 S 1,088.27 0.00 0.00 43226 S 318.27 0.00 0.00<br />

42507 S 1,033.02 0.00 0.00 43227 S 370.31 0.00 0.00<br />

42508 S 1,088.27 0.00 0.00 43228 S 689.12 0.00 0.00<br />

42509 S 1,088.27 0.00 0.00 43231 S 370.31 0.00 0.00<br />

42510 S 1,088.27 0.00 0.00 43232 S 370.31 0.00 0.00<br />

42600 S 481.96 0.00 0.00 43234 S 318.27 0.00 0.00<br />

42650 S 41.90 0.00 0.00 43235 S 318.27 0.00 0.00<br />

42660 S 49.06 0.00 0.00 43236 S 370.31 0.00 0.00<br />

42665 S 930.06 0.00 0.00 43237 S 370.31 0.00 0.00<br />

42700 S 132.44 0.00 0.00 43238 S 370.31 0.00 0.00<br />

42720 S 481.96 0.00 0.00 43239 S 370.31 0.00 0.00<br />

42725 S 1,003.54 0.00 0.00 43240 S 370.31 0.00 0.00<br />

42800 S 81.08 0.00 0.00 43241 S 370.31 0.00 0.00<br />

42802 S 481.96 0.00 0.00 43242 S 370.31 0.00 0.00<br />

42804 S 481.96 0.00 0.00 43243 S 370.31 0.00 0.00<br />

42806 S 677.24 0.00 0.00 43244 S 370.31 0.00 0.00<br />

42808 S 533.99 0.00 0.00 43245 S 370.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 370.31 0.00 0.00 44378 S 387.84 0.00 0.00<br />

43247 S 370.31 0.00 0.00 44379 S 1,106.48 0.00 0.00<br />

43248 S 370.31 0.00 0.00 44380 S 335.80 0.00 0.00<br />

43249 S 370.31 0.00 0.00 44382 S 335.80 0.00 0.00<br />

43250 S 370.31 0.00 0.00 44383 S 1,106.48 0.00 0.00<br />

43251 S 370.31 0.00 0.00 44385 S 324.67 0.00 0.00<br />

43255 S 370.31 0.00 0.00 44386 S 324.67 0.00 0.00<br />

43256 S 724.73 0.00 0.00 44388 S 324.67 0.00 0.00<br />

43257 S 718.59 0.00 0.00 44389 S 324.67 0.00 0.00<br />

43258 S 399.78 0.00 0.00 44390 S 324.67 0.00 0.00<br />

43259 S 399.78 0.00 0.00 44391 S 324.67 0.00 0.00<br />

43260 S 623.42 0.00 0.00 44392 S 324.67 0.00 0.00<br />

43261 S 623.42 0.00 0.00 44393 S 324.67 0.00 0.00<br />

43262 S 623.42 0.00 0.00 44394 S 324.67 0.00 0.00<br />

43263 S 623.42 0.00 0.00 44397 S 643.22 0.00 0.00<br />

43264 S 623.42 0.00 0.00 44500 S 175.20 0.00 0.00<br />

43265 S 623.42 0.00 0.00 45000 S 376.52 0.00 0.00<br />

43267 S 623.42 0.00 0.00 45005 S 438.19 0.00 0.00<br />

43268 S 695.27 0.00 0.00 45020 S 438.19 0.00 0.00<br />

43269 S 695.27 0.00 0.00 45100 S 595.33 0.00 0.00<br />

43271 S 623.42 0.00 0.00 45108 S 647.36 0.00 0.00<br />

43272 S 623.42 0.00 0.00 45150 S 647.36 0.00 0.00<br />

43273 S 836.08 0.00 0.00 45160 S 647.36 0.00 0.00<br />

43450 S 278.34 0.00 0.00 45170 S 647.36 0.00 0.00<br />

43453 S 278.34 0.00 0.00 45190 S 1,058.58 0.00 0.00<br />

43456 S 279.45 0.00 0.00 45300 S 62.68 0.00 0.00<br />

43458 S 319.38 0.00 0.00 45303 S 348.15 0.00 0.00<br />

43600 S 318.27 0.00 0.00 45305 S 327.42 0.00 0.00<br />

43653 S 1,499.57 0.00 0.00 45307 S 604.76 0.00 0.00<br />

43760 S 154.36 0.00 0.00 45308 S 327.42 0.00 0.00<br />

43761 S 318.27 0.00 0.00 45309 S 327.42 0.00 0.00<br />

43870 S 318.27 0.00 0.00 45315 S 327.42 0.00 0.00<br />

43886 S 803.07 0.00 0.00 45317 S 327.42 0.00 0.00<br />

43887 S 168.90 0.00 0.00 45320 S 604.76 0.00 0.00<br />

43888 S 803.07 0.00 0.00 45321 S 604.76 0.00 0.00<br />

44100 S 318.27 0.00 0.00 45327 S 643.22 0.00 0.00<br />

44312 S 554.87 0.00 0.00 45330 S 82.78 0.00 0.00<br />

44340 S 636.39 0.00 0.00 45331 S 244.79 0.00 0.00<br />

44360 S 387.84 0.00 0.00 45332 S 244.79 0.00 0.00<br />

44361 S 387.84 0.00 0.00 45333 S 327.42 0.00 0.00<br />

44363 S 387.84 0.00 0.00 45334 S 327.42 0.00 0.00<br />

44364 S 387.84 0.00 0.00 45335 S 244.79 0.00 0.00<br />

44365 S 387.84 0.00 0.00 45337 S 244.79 0.00 0.00<br />

44366 S 387.84 0.00 0.00 45338 S 327.42 0.00 0.00<br />

44369 S 387.84 0.00 0.00 45339 S 327.42 0.00 0.00<br />

44370 S 1,106.48 0.00 0.00 45340 S 327.42 0.00 0.00<br />

44372 S 387.84 0.00 0.00 45341 S 327.42 0.00 0.00<br />

44373 S 387.84 0.00 0.00 45342 S 327.42 0.00 0.00<br />

44376 S 387.84 0.00 0.00 45345 S 643.22 0.00 0.00<br />

44377 S 387.84 0.00 0.00 45355 S 324.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 376.71 0.00 0.00 46505 S 465.62 0.00 0.00<br />

45379 S 376.71 0.00 0.00 46600 S 24.63 0.00 0.00<br />

45380 S 376.71 0.00 0.00 46604 S 348.15 0.00 0.00<br />

45381 S 376.71 0.00 0.00 46606 S 130.81 0.00 0.00<br />

45382 S 376.71 0.00 0.00 46608 S 327.42 0.00 0.00<br />

45383 S 376.71 0.00 0.00 46610 S 604.76 0.00 0.00<br />

45384 S 376.71 0.00 0.00 46611 S 327.42 0.00 0.00<br />

45385 S 376.71 0.00 0.00 46612 S 604.76 0.00 0.00<br />

45386 S 376.71 0.00 0.00 46614 S 68.81 0.00 0.00<br />

45387 S 643.22 0.00 0.00 46615 S 656.80 0.00 0.00<br />

45391 S 376.71 0.00 0.00 46700 S 676.84 0.00 0.00<br />

45392 S 376.71 0.00 0.00 46706 S 744.99 0.00 0.00<br />

45500 S 647.36 0.00 0.00 46750 S 826.50 0.00 0.00<br />

45505 S 797.04 0.00 0.00 46753 S 676.84 0.00 0.00<br />

45520 S 31.57 0.00 0.00 46754 S 647.36 0.00 0.00<br />

45560 S 797.04 0.00 0.00 46760 S 797.04 0.00 0.00<br />

45900 S 255.25 0.00 0.00 46761 S 826.50 0.00 0.00<br />

45905 S 595.33 0.00 0.00 46762 S 1,049.84 0.00 0.00<br />

45910 S 595.33 0.00 0.00 46900 S 104.03 0.00 0.00<br />

45915 S 376.52 0.00 0.00 46910 S 124.33 0.00 0.00<br />

45990 S 585.68 0.00 0.00 46916 S 57.83 0.00 0.00<br />

46020 S 676.84 0.00 0.00 46917 S 539.48 0.00 0.00<br />

46030 S 255.25 0.00 0.00 46922 S 539.48 0.00 0.00<br />

46040 S 676.84 0.00 0.00 46924 S 539.48 0.00 0.00<br />

46045 S 647.36 0.00 0.00 46930 S 120.59 0.00 0.00<br />

46050 S 376.52 0.00 0.00 46937 S 647.36 0.00 0.00<br />

46060 S 647.36 0.00 0.00 46938 S 797.04 0.00 0.00<br />

46070 S 465.62 0.00 0.00 46940 S 89.25 0.00 0.00<br />

46080 S 676.84 0.00 0.00 46942 S 86.87 0.00 0.00<br />

46083 S 71.27 0.00 0.00 46945 S 147.84 0.00 0.00<br />

46200 S 647.36 0.00 0.00 46946 S 386.15 0.00 0.00<br />

46210 S 647.36 0.00 0.00 46947 S 1,049.84 0.00 0.00<br />

46211 S 647.36 0.00 0.00 47000 S 335.92 0.00 0.00<br />

46220 S 595.33 0.00 0.00 47382 S 1,772.73 0.00 0.00<br />

46221 S 117.18 0.00 0.00 47510 S 785.07 0.00 0.00<br />

46230 S 595.33 0.00 0.00 47511 S 1,153.39 0.00 0.00<br />

46250 S 676.84 0.00 0.00 47525 S 450.69 0.00 0.00<br />

46255 S 676.84 0.00 0.00 47530 S 450.69 0.00 0.00<br />

46257 S 676.84 0.00 0.00 47552 S 785.07 0.00 0.00<br />

46258 S 676.84 0.00 0.00 47553 S 814.54 0.00 0.00<br />

46260 S 676.84 0.00 0.00 47554 S 814.54 0.00 0.00<br />

46261 S 732.09 0.00 0.00 47555 S 814.54 0.00 0.00<br />

46262 S 732.09 0.00 0.00 47556 S 1,153.39 0.00 0.00<br />

46270 S 676.84 0.00 0.00 47560 S 957.05 0.00 0.00<br />

46275 S 676.84 0.00 0.00 47561 S 957.05 0.00 0.00<br />

46280 S 732.09 0.00 0.00 47562 S 1,765.96 0.00 0.00<br />

46285 S 595.33 0.00 0.00 47563 S 1,765.96 0.00 0.00<br />

46288 S 732.09 0.00 0.00 47564 S 1,765.96 0.00 0.00<br />

46320 S 79.38 0.00 0.00 47630 S 814.54 0.00 0.00<br />

46500 S 109.34 0.00 0.00 48102 S 335.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 204.27 0.00 0.00 49590 S 838.39 0.00 0.00<br />

49081 S 204.27 0.00 0.00 49600 S 893.64 0.00 0.00<br />

49180 S 335.92 0.00 0.00 49650 S 1,173.09 0.00 0.00<br />

49250 S 736.35 0.00 0.00 49651 S 1,341.17 0.00 0.00<br />

49320 S 957.05 0.00 0.00 49652 S 1,444.40 0.00 0.00<br />

49321 S 1,012.32 0.00 0.00 49653 S 1,444.40 0.00 0.00<br />

49322 S 1,012.32 0.00 0.00 49654 S 1,444.40 0.00 0.00<br />

49324 S 1,444.40 0.00 0.00 49655 S 1,444.40 0.00 0.00<br />

49325 S 1,444.40 0.00 0.00 49656 S 1,444.40 0.00 0.00<br />

49326 S 1,444.40 0.00 0.00 49657 S 1,444.40 0.00 0.00<br />

49402 S 651.62 0.00 0.00 50200 S 335.92 0.00 0.00<br />

49419 S 781.71 0.00 0.00 50382 S 975.44 0.00 0.00<br />

49420 S 722.64 0.00 0.00 50384 S 716.44 0.00 0.00<br />

49421 S 722.64 0.00 0.00 50385 S 716.44 0.00 0.00<br />

49422 S 575.11 0.00 0.00 50386 S 274.88 0.00 0.00<br />

49423 S 594.69 0.00 0.00 50387 S 594.69 0.00 0.00<br />

49426 S 651.62 0.00 0.00 50389 S 274.88 0.00 0.00<br />

49429 S 843.53 0.00 0.00 50390 S 335.92 0.00 0.00<br />

49440 S 329.86 0.00 0.00 50391 S 39.78 0.00 0.00<br />

49441 S 329.86 0.00 0.00 50392 S 511.56 0.00 0.00<br />

49446 S 329.86 0.00 0.00 50393 S 641.06 0.00 0.00<br />

49450 S 175.20 0.00 0.00 50395 S 511.56 0.00 0.00<br />

49451 S 175.20 0.00 0.00 50396 S 96.19 0.00 0.00<br />

49452 S 175.20 0.00 0.00 50398 S 450.69 0.00 0.00<br />

49460 S 175.20 0.00 0.00 50551 S 290.78 0.00 0.00<br />

49495 S 893.64 0.00 0.00 50553 S 641.06 0.00 0.00<br />

49496 S 893.64 0.00 0.00 50555 S 290.78 0.00 0.00<br />

49500 S 893.64 0.00 0.00 50557 S 641.06 0.00 0.00<br />

49501 S 1,220.12 0.00 0.00 50561 S 641.06 0.00 0.00<br />

49505 S 893.64 0.00 0.00 50562 S 274.88 0.00 0.00<br />

49507 S 1,220.12 0.00 0.00 50570 S 274.88 0.00 0.00<br />

49520 S 1,061.72 0.00 0.00 50572 S 274.88 0.00 0.00<br />

49521 S 1,220.12 0.00 0.00 50574 S 274.88 0.00 0.00<br />

49525 S 893.64 0.00 0.00 50575 S 1,367.30 0.00 0.00<br />

49540 S 808.91 0.00 0.00 50576 S 716.44 0.00 0.00<br />

49550 S 933.70 0.00 0.00 50580 S 716.44 0.00 0.00<br />

49553 S 1,220.12 0.00 0.00 50590 S 1,597.32 0.00 0.00<br />

49555 S 933.70 0.00 0.00 50592 S 1,772.73 0.00 0.00<br />

49557 S 1,220.12 0.00 0.00 50686 S 39.78 0.00 0.00<br />

49560 S 893.64 0.00 0.00 50688 S 450.69 0.00 0.00<br />

49561 S 1,220.12 0.00 0.00 50947 S 1,499.57 0.00 0.00<br />

49565 S 893.64 0.00 0.00 50948 S 1,499.57 0.00 0.00<br />

49566 S 1,220.12 0.00 0.00 50951 S 290.78 0.00 0.00<br />

49568 S 1,061.72 0.00 0.00 50953 S 290.78 0.00 0.00<br />

49570 S 893.64 0.00 0.00 50955 S 641.06 0.00 0.00<br />

49572 S 1,220.12 0.00 0.00 50957 S 641.06 0.00 0.00<br />

49580 S 893.64 0.00 0.00 50961 S 641.06 0.00 0.00<br />

49582 S 1,220.12 0.00 0.00 50970 S 290.78 0.00 0.00<br />

49585 S 893.64 0.00 0.00 50972 S 290.78 0.00 0.00<br />

49587 S 1,220.12 0.00 0.00 50974 S 511.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 511.56 0.00 0.00 52275 S 693.10 0.00 0.00<br />

50980 S 641.06 0.00 0.00 52276 S 722.57 0.00 0.00<br />

51020 S 777.83 0.00 0.00 52277 S 693.10 0.00 0.00<br />

51030 S 777.83 0.00 0.00 52281 S 563.59 0.00 0.00<br />

51040 S 777.83 0.00 0.00 52282 S 1,300.25 0.00 0.00<br />

51045 S 321.28 0.00 0.00 52283 S 693.10 0.00 0.00<br />

51050 S 777.83 0.00 0.00 52285 S 563.59 0.00 0.00<br />

51065 S 777.83 0.00 0.00 52290 S 563.59 0.00 0.00<br />

51080 S 522.88 0.00 0.00 52300 S 693.10 0.00 0.00<br />

51100 S 30.32 0.00 0.00 52301 S 722.57 0.00 0.00<br />

51101 S 39.78 0.00 0.00 52305 S 693.10 0.00 0.00<br />

51102 S 535.22 0.00 0.00 52310 S 542.06 0.00 0.00<br />

51500 S 893.64 0.00 0.00 52315 S 693.10 0.00 0.00<br />

51520 S 777.83 0.00 0.00 52317 S 641.06 0.00 0.00<br />

51700 S 51.78 0.00 0.00 52318 S 693.10 0.00 0.00<br />

51701 S 24.63 0.00 0.00 52320 S 817.89 0.00 0.00<br />

51702 S 24.63 0.00 0.00 52325 S 777.83 0.00 0.00<br />

51703 S 39.78 0.00 0.00 52327 S 889.03 0.00 0.00<br />

51705 S 71.27 0.00 0.00 52330 S 693.10 0.00 0.00<br />

51710 S 450.69 0.00 0.00 52332 S 693.10 0.00 0.00<br />

51715 S 818.31 0.00 0.00 52334 S 722.57 0.00 0.00<br />

51720 S 57.23 0.00 0.00 52341 S 722.57 0.00 0.00<br />

51725 TC S 109.94 0.00 0.00 52342 S 722.57 0.00 0.00<br />

51726 TC S 151.43 0.00 0.00 52343 S 722.57 0.00 0.00<br />

51736 TC S 20.78 0.00 0.00 52344 S 722.57 0.00 0.00<br />

51741 TC S 24.19 0.00 0.00 52345 S 722.57 0.00 0.00<br />

51772 TC S 96.19 0.00 0.00 52346 S 722.57 0.00 0.00<br />

51784 TC S 39.78 0.00 0.00 52351 S 722.57 0.00 0.00<br />

51785 TC S 66.46 0.00 0.00 52352 S 777.83 0.00 0.00<br />

51792 TC S 39.78 0.00 0.00 52353 S 973.76 0.00 0.00<br />

51795 TC S 71.27 0.00 0.00 52354 S 777.83 0.00 0.00<br />

51797 TC S 71.27 0.00 0.00 52355 S 777.83 0.00 0.00<br />

51798 S 17.71 0.00 0.00 52400 S 722.57 0.00 0.00<br />

51880 S 641.06 0.00 0.00 52402 S 722.57 0.00 0.00<br />

51992 S 1,213.15 0.00 0.00 52450 S 722.57 0.00 0.00<br />

52000 S 290.78 0.00 0.00 52500 S 722.57 0.00 0.00<br />

52001 S 542.06 0.00 0.00 52601 S 973.76 0.00 0.00<br />

52005 S 563.59 0.00 0.00 52630 S 889.03 0.00 0.00<br />

52007 S 693.10 0.00 0.00 52640 S 693.10 0.00 0.00<br />

52010 S 321.28 0.00 0.00 52647 S 1,489.76 0.00 0.00<br />

52204 S 563.59 0.00 0.00 52648 S 1,489.76 0.00 0.00<br />

52214 S 693.10 0.00 0.00 52700 S 693.10 0.00 0.00<br />

52224 S 693.10 0.00 0.00 53000 S 531.95 0.00 0.00<br />

52234 S 693.10 0.00 0.00 53010 S 531.95 0.00 0.00<br />

52235 S 722.57 0.00 0.00 53020 S 531.95 0.00 0.00<br />

52240 S 722.57 0.00 0.00 53025 S 757.22 0.00 0.00<br />

52250 S 777.83 0.00 0.00 53040 S 583.99 0.00 0.00<br />

52260 S 563.59 0.00 0.00 53060 S 69.16 0.00 0.00<br />

52265 S 274.88 0.00 0.00 53080 S 613.46 0.00 0.00<br />

52270 S 563.59 0.00 0.00 53085 S 757.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 531.95 0.00 0.00 54060 S 539.48 0.00 0.00<br />

53210 S 913.63 0.00 0.00 54065 S 539.48 0.00 0.00<br />

53215 S 708.78 0.00 0.00 54100 S 456.36 0.00 0.00<br />

53220 S 788.84 0.00 0.00 54105 S 569.69 0.00 0.00<br />

53230 S 788.84 0.00 0.00 54110 S 883.27 0.00 0.00<br />

53235 S 613.46 0.00 0.00 54111 S 883.27 0.00 0.00<br />

53240 S 788.84 0.00 0.00 54112 S 883.27 0.00 0.00<br />

53250 S 583.99 0.00 0.00 54115 S 522.88 0.00 0.00<br />

53260 S 583.99 0.00 0.00 54120 S 883.27 0.00 0.00<br />

53265 S 583.99 0.00 0.00 54150 S 588.65 0.00 0.00<br />

53270 S 583.99 0.00 0.00 54160 S 640.69 0.00 0.00<br />

53275 S 583.99 0.00 0.00 54161 S 640.69 0.00 0.00<br />

53400 S 818.31 0.00 0.00 54162 S 640.69 0.00 0.00<br />

53405 S 788.84 0.00 0.00 54163 S 640.69 0.00 0.00<br />

53410 S 788.84 0.00 0.00 54164 S 640.69 0.00 0.00<br />

53420 S 818.31 0.00 0.00 54200 S 67.11 0.00 0.00<br />

53425 S 788.84 0.00 0.00 54205 S 968.00 0.00 0.00<br />

53430 S 788.84 0.00 0.00 54220 S 96.19 0.00 0.00<br />

53431 S 788.84 0.00 0.00 54231 S 63.02 0.00 0.00<br />

53440 S 4,544.02 2,759.79 975.56 54235 S 44.63 0.00 0.00<br />

53442 S 736.80 0.00 0.00 54240 TC S 31.68 0.00 0.00<br />

53444 S 4,544.02 2,759.79 975.56 54250 TC S 11.24 0.00 0.00<br />

53445 S 7,632.80 4,346.83 1,060.86 54300 S 912.74 0.00 0.00<br />

53446 S 736.80 0.00 0.00 54304 S 912.74 0.00 0.00<br />

53447 S 7,632.80 4,346.83 1,060.86 54308 S 912.74 0.00 0.00<br />

53449 S 736.80 0.00 0.00 54312 S 912.74 0.00 0.00<br />

53450 S 736.80 0.00 0.00 54316 S 912.74 0.00 0.00<br />

53460 S 531.95 0.00 0.00 54318 S 912.74 0.00 0.00<br />

53502 S 583.99 0.00 0.00 54322 S 912.74 0.00 0.00<br />

53505 S 788.84 0.00 0.00 54324 S 912.74 0.00 0.00<br />

53510 S 583.99 0.00 0.00 54326 S 912.74 0.00 0.00<br />

53515 S 788.84 0.00 0.00 54328 S 912.74 0.00 0.00<br />

53520 S 788.84 0.00 0.00 54340 S 912.74 0.00 0.00<br />

53600 S 39.86 0.00 0.00 54344 S 912.74 0.00 0.00<br />

53601 S 39.78 0.00 0.00 54348 S 912.74 0.00 0.00<br />

53605 S 563.59 0.00 0.00 54352 S 912.74 0.00 0.00<br />

53620 S 61.32 0.00 0.00 54360 S 912.74 0.00 0.00<br />

53621 S 64.39 0.00 0.00 54380 S 912.74 0.00 0.00<br />

53660 S 39.78 0.00 0.00 54385 S 912.74 0.00 0.00<br />

53661 S 39.78 0.00 0.00 54400 S 4,573.50 2,789.27 1,005.04<br />

53665 S 531.95 0.00 0.00 54401 S 7,714.31 4,428.34 1,142.37<br />

53850 S 1,746.33 0.00 0.00 54405 S 7,714.31 4,428.34 1,142.37<br />

53852 S 1,746.33 0.00 0.00 54406 S 912.74 0.00 0.00<br />

54000 S 583.99 0.00 0.00 54408 S 912.74 0.00 0.00<br />

54001 S 583.99 0.00 0.00 54410 S 7,714.31 4,428.34 1,142.37<br />

54015 S 659.66 0.00 0.00 54415 S 912.74 0.00 0.00<br />

54050 S 31.57 0.00 0.00 54416 S 7,714.31 4,428.34 1,142.37<br />

54055 S 64.39 0.00 0.00 54420 S 968.00 0.00 0.00<br />

54056 S 31.57 0.00 0.00 54435 S 968.00 0.00 0.00<br />

54057 S 539.48 0.00 0.00 54440 S 968.00 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 151.43 0.00 0.00 55706 S 440.22 0.00 0.00<br />

54500 S 411.00 0.00 0.00 55720 S 641.06 0.00 0.00<br />

54505 S 588.65 0.00 0.00 55725 S 693.10 0.00 0.00<br />

54512 S 640.69 0.00 0.00 55860 S 763.76 0.00 0.00<br />

54520 S 670.16 0.00 0.00 55870 S 77.67 0.00 0.00<br />

54522 S 670.16 0.00 0.00 55873 S 6,043.17 0.00 0.00<br />

54530 S 893.64 0.00 0.00 55875 S 1,300.25 0.00 0.00<br />

54550 S 893.64 0.00 0.00 55876 S 71.20 0.00 0.00<br />

54560 S 870.62 0.00 0.00 55920 S 892.50 0.00 0.00<br />

54600 S 725.42 0.00 0.00 56405 S 41.56 0.00 0.00<br />

54620 S 670.16 0.00 0.00 56420 S 54.24 0.00 0.00<br />

54640 S 893.64 0.00 0.00 56440 S 582.48 0.00 0.00<br />

54660 S 640.69 0.00 0.00 56441 S 530.44 0.00 0.00<br />

54670 S 670.16 0.00 0.00 56442 S 530.44 0.00 0.00<br />

54680 S 670.16 0.00 0.00 56501 S 57.23 0.00 0.00<br />

54690 S 1,499.57 0.00 0.00 56515 S 620.99 0.00 0.00<br />

54692 S 2,665.63 0.00 0.00 56605 S 33.04 0.00 0.00<br />

54700 S 640.69 0.00 0.00 56606 S 13.63 0.00 0.00<br />

54800 S 143.81 0.00 0.00 56620 S 707.27 0.00 0.00<br />

54830 S 670.16 0.00 0.00 56625 S 835.29 0.00 0.00<br />

54840 S 725.42 0.00 0.00 56700 S 530.44 0.00 0.00<br />

54860 S 670.16 0.00 0.00 56740 S 611.95 0.00 0.00<br />

54861 S 725.42 0.00 0.00 56800 S 611.95 0.00 0.00<br />

54865 S 588.65 0.00 0.00 56805 S 754.20 0.00 0.00<br />

54900 S 725.42 0.00 0.00 56810 S 707.27 0.00 0.00<br />

54901 S 725.42 0.00 0.00 56820 S 42.24 0.00 0.00<br />

55000 S 65.41 0.00 0.00 56821 S 54.24 0.00 0.00<br />

55040 S 838.39 0.00 0.00 57000 S 530.44 0.00 0.00<br />

55041 S 933.70 0.00 0.00 57010 S 582.48 0.00 0.00<br />

55060 S 725.42 0.00 0.00 57020 S 305.48 0.00 0.00<br />

55100 S 393.42 0.00 0.00 57022 S 480.16 0.00 0.00<br />

55110 S 640.69 0.00 0.00 57023 S 522.88 0.00 0.00<br />

55120 S 640.69 0.00 0.00 57061 S 52.80 0.00 0.00<br />

55150 S 588.65 0.00 0.00 57065 S 530.44 0.00 0.00<br />

55175 S 588.65 0.00 0.00 57100 S 33.73 0.00 0.00<br />

55180 S 640.69 0.00 0.00 57105 S 582.48 0.00 0.00<br />

55200 S 640.69 0.00 0.00 57130 S 582.48 0.00 0.00<br />

55250 S 640.69 0.00 0.00 57135 S 582.48 0.00 0.00<br />

55400 S 588.65 0.00 0.00 57150 S 24.53 0.00 0.00<br />

55450 S 210.52 0.00 0.00 57155 S 305.48 0.00 0.00<br />

55500 S 670.16 0.00 0.00 57160 S 35.43 0.00 0.00<br />

55520 S 725.42 0.00 0.00 57170 S 5.81 0.00 0.00<br />

55530 S 725.42 0.00 0.00 57180 S 109.11 0.00 0.00<br />

55535 S 893.64 0.00 0.00 57200 S 530.44 0.00 0.00<br />

55540 S 933.70 0.00 0.00 57210 S 582.48 0.00 0.00<br />

55550 S 1,499.57 0.00 0.00 57220 S 1,068.19 0.00 0.00<br />

55600 S 870.62 0.00 0.00 57230 S 877.08 0.00 0.00<br />

55680 S 588.65 0.00 0.00 57240 S 972.40 0.00 0.00<br />

55700 S 379.36 0.00 0.00 57250 S 972.40 0.00 0.00<br />

55705 S 379.36 0.00 0.00 57260 S 972.40 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,291.53 0.00 0.00 58555 S 573.11 0.00 0.00<br />

57267 S 1,100.42 0.00 0.00 58558 S 654.62 0.00 0.00<br />

57268 S 877.08 0.00 0.00 58559 S 625.16 0.00 0.00<br />

57287 S 1,284.46 0.00 0.00 58560 S 933.40 0.00 0.00<br />

57288 S 1,163.51 0.00 0.00 58561 S 933.40 0.00 0.00<br />

57289 S 972.40 0.00 0.00 58562 S 654.62 0.00 0.00<br />

57291 S 972.40 0.00 0.00 58563 S 1,315.14 0.00 0.00<br />

57300 S 877.08 0.00 0.00 58565 S 1,449.94 0.00 0.00<br />

57320 S 1,284.46 0.00 0.00 58600 S 1,284.46 0.00 0.00<br />

57400 S 582.48 0.00 0.00 58615 S 754.20 0.00 0.00<br />

57410 S 582.48 0.00 0.00 58660 S 1,213.15 0.00 0.00<br />

57415 S 582.48 0.00 0.00 58661 S 1,213.15 0.00 0.00<br />

57420 S 43.61 0.00 0.00 58662 S 1,213.15 0.00 0.00<br />

57421 S 56.89 0.00 0.00 58670 S 1,117.83 0.00 0.00<br />

57452 S 41.22 0.00 0.00 58671 S 1,117.83 0.00 0.00<br />

57454 S 50.42 0.00 0.00 58672 S 1,213.15 0.00 0.00<br />

57455 S 53.48 0.00 0.00 58673 S 1,213.15 0.00 0.00<br />

57456 S 51.78 0.00 0.00 58800 S 611.95 0.00 0.00<br />

57460 S 159.08 0.00 0.00 58805 S 1,284.46 0.00 0.00<br />

57461 S 168.96 0.00 0.00 58820 S 877.08 0.00 0.00<br />

57500 S 72.90 0.00 0.00 58900 S 611.95 0.00 0.00<br />

57505 S 46.33 0.00 0.00 58970 S 170.45 0.00 0.00<br />

57510 S 47.01 0.00 0.00 58974 S 170.45 0.00 0.00<br />

57511 S 54.24 0.00 0.00 58976 S 170.45 0.00 0.00<br />

57513 S 582.48 0.00 0.00 59000 S 62.34 0.00 0.00<br />

57520 S 582.48 0.00 0.00 59001 S 233.99 0.00 0.00<br />

57522 S 582.48 0.00 0.00 59012 S 114.42 0.00 0.00<br />

57530 S 877.08 0.00 0.00 59015 S 50.42 0.00 0.00<br />

57550 S 877.08 0.00 0.00 59020 TC S 26.57 0.00 0.00<br />

57556 S 1,163.51 0.00 0.00 59025 TC S 13.97 0.00 0.00<br />

57558 S 611.95 0.00 0.00 59070 S 114.42 0.00 0.00<br />

57700 S 530.44 0.00 0.00 59072 S 114.42 0.00 0.00<br />

57720 S 611.95 0.00 0.00 59076 S 114.42 0.00 0.00<br />

57800 S 24.87 0.00 0.00 59100 S 1,284.46 0.00 0.00<br />

58100 S 40.88 0.00 0.00 59150 S 1,765.96 0.00 0.00<br />

58120 S 582.48 0.00 0.00 59151 S 1,765.96 0.00 0.00<br />

58145 S 972.40 0.00 0.00 59160 S 611.95 0.00 0.00<br />

58301 S 38.15 0.00 0.00 59200 S 34.07 0.00 0.00<br />

58321 S 35.77 0.00 0.00 59300 S 73.58 0.00 0.00<br />

58322 S 36.79 0.00 0.00 59320 S 530.44 0.00 0.00<br />

58323 S 8.52 0.00 0.00 59412 S 754.20 0.00 0.00<br />

58345 S 754.20 0.00 0.00 59414 S 754.20 0.00 0.00<br />

58346 S 582.48 0.00 0.00 59812 S 707.27 0.00 0.00<br />

58350 S 877.08 0.00 0.00 59820 S 707.27 0.00 0.00<br />

58353 S 1,100.42 0.00 0.00 59821 S 707.27 0.00 0.00<br />

58356 S 1,666.68 0.00 0.00 59840 S 707.27 0.00 0.00<br />

58545 S 1,338.80 0.00 0.00 59841 S 707.27 0.00 0.00<br />

58546 S 1,499.57 0.00 0.00 59866 S 114.42 0.00 0.00<br />

58550 S 1,949.41 0.00 0.00 59870 S 707.27 0.00 0.00<br />

58552 S 1,765.96 0.00 0.00 59871 S 707.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 296.93 0.00 0.00 62367 S 16.35 0.00 0.00<br />

60100 S 46.67 0.00 0.00 62368 S 20.78 0.00 0.00<br />

60200 S 1,105.19 0.00 0.00 63600 S 558.22 0.00 0.00<br />

60280 S 1,189.92 0.00 0.00 63610 S 506.18 0.00 0.00<br />

60281 S 1,189.92 0.00 0.00 63615 S 705.67 0.00 0.00<br />

60300 S 61.32 0.00 0.00 63650 S 3,004.60 1,863.15 721.71<br />

61000 S 273.41 0.00 0.00 63655 S 4,401.00 2,806.53 1,212.06<br />

61001 S 273.41 0.00 0.00 63660 S 527.66 0.00 0.00<br />

61020 S 221.36 0.00 0.00 63685 S 13,358.05 7,122.64 887.23<br />

61026 S 221.36 0.00 0.00 63688 S 716.53 0.00 0.00<br />

61050 S 221.36 0.00 0.00 63744 S 1,036.20 0.00 0.00<br />

61055 S 221.36 0.00 0.00 63746 S 479.32 0.00 0.00<br />

61070 S 172.25 0.00 0.00 64400 S 52.46 0.00 0.00<br />

61215 S 1,036.20 0.00 0.00 64402 S 49.40 0.00 0.00<br />

61330 S 1,596.33 0.00 0.00 64405 S 41.90 0.00 0.00<br />

61334 S 1,596.33 0.00 0.00 64408 S 52.12 0.00 0.00<br />

61790 S 587.69 0.00 0.00 64410 S 290.05 0.00 0.00<br />

61791 S 436.00 0.00 0.00 64412 S 76.65 0.00 0.00<br />

61880 S 748.64 0.00 0.00 64413 S 49.06 0.00 0.00<br />

61885 S 10,773.04 5,771.02 768.99 64415 S 133.58 0.00 0.00<br />

61886 S 16,086.78 8,478.66 870.56 64416 S 273.41 0.00 0.00<br />

61888 S 716.53 0.00 0.00 64417 S 133.58 0.00 0.00<br />

62194 S 290.05 0.00 0.00 64418 S 68.81 0.00 0.00<br />

62225 S 450.69 0.00 0.00 64420 S 133.58 0.00 0.00<br />

62230 S 1,006.72 0.00 0.00 64421 S 290.05 0.00 0.00<br />

62252 TC S 45.65 0.00 0.00 64425 S 47.69 0.00 0.00<br />

62263 S 290.05 0.00 0.00 64430 S 200.72 0.00 0.00<br />

62264 S 427.28 0.00 0.00 64435 S 71.88 0.00 0.00<br />

62267 S 170.51 0.00 0.00 64445 S 63.70 0.00 0.00<br />

62268 S 221.36 0.00 0.00 64446 S 547.89 0.00 0.00<br />

62269 S 335.92 0.00 0.00 64447 S 139.14 0.00 0.00<br />

62270 S 133.58 0.00 0.00 64448 S 139.14 0.00 0.00<br />

62272 S 133.58 0.00 0.00 64449 S 273.41 0.00 0.00<br />

62273 S 222.91 0.00 0.00 64450 S 42.58 0.00 0.00<br />

62280 S 290.05 0.00 0.00 64455 S 17.71 0.00 0.00<br />

62281 S 290.05 0.00 0.00 64470 S 290.05 0.00 0.00<br />

62282 S 290.05 0.00 0.00 64472 S 222.91 0.00 0.00<br />

62287 S 1,302.04 0.00 0.00 64475 S 290.05 0.00 0.00<br />

62292 S 273.41 0.00 0.00 64476 S 200.75 0.00 0.00<br />

62294 S 221.36 0.00 0.00 64479 S 290.05 0.00 0.00<br />

62310 S 290.05 0.00 0.00 64480 S 222.91 0.00 0.00<br />

62311 S 290.05 0.00 0.00 64483 S 290.05 0.00 0.00<br />

62318 S 290.05 0.00 0.00 64484 S 222.91 0.00 0.00<br />

62319 S 290.05 0.00 0.00 64505 S 38.84 0.00 0.00<br />

62350 S 1,006.72 0.00 0.00 64508 S 82.44 0.00 0.00<br />

62355 S 479.32 0.00 0.00 64510 S 290.05 0.00 0.00<br />

62360 S 1,006.72 0.00 0.00 64517 S 200.72 0.00 0.00<br />

62361 S 10,334.15 5,593.51 852.87 64520 S 290.05 0.00 0.00<br />

62362 S 10,334.15 5,593.51 852.87 64530 S 290.05 0.00 0.00<br />

62365 S 890.82 0.00 0.00 64553 S 2,952.55 1,811.11 669.67<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,315.54 2,174.10 1,032.66 64746 S 558.22 0.00 0.00<br />

64560 S 3,315.54 2,174.10 1,032.66 64761 S 705.67 0.00 0.00<br />

64561 S 3,034.06 1,892.62 751.18 64763 S 705.67 0.00 0.00<br />

64565 S 3,315.54 2,174.10 1,032.66 64766 S 1,370.89 0.00 0.00<br />

64573 S 5,165.12 3,059.83 954.54 64771 S 558.22 0.00 0.00<br />

64575 S 3,948.31 2,353.84 759.37 64772 S 558.22 0.00 0.00<br />

64577 S 3,948.31 2,353.84 759.37 64774 S 558.22 0.00 0.00<br />

64580 S 3,948.31 2,353.84 759.37 64776 S 587.69 0.00 0.00<br />

64581 S 4,029.82 2,435.35 840.88 64778 S 558.22 0.00 0.00<br />

64585 S 527.66 0.00 0.00 64782 S 587.69 0.00 0.00<br />

64590 S 10,773.04 5,771.02 768.99 64783 S 558.22 0.00 0.00<br />

64595 S 716.53 0.00 0.00 64784 S 587.69 0.00 0.00<br />

64600 S 427.28 0.00 0.00 64786 S 920.29 0.00 0.00<br />

64605 S 427.28 0.00 0.00 64787 S 558.22 0.00 0.00<br />

64610 S 427.28 0.00 0.00 64788 S 587.69 0.00 0.00<br />

64612 S 62.34 0.00 0.00 64790 S 587.69 0.00 0.00<br />

64613 S 60.30 0.00 0.00 64792 S 920.29 0.00 0.00<br />

64614 S 68.81 0.00 0.00 64795 S 558.22 0.00 0.00<br />

64620 S 290.05 0.00 0.00 64802 S 558.22 0.00 0.00<br />

64622 S 427.28 0.00 0.00 64820 S 705.67 0.00 0.00<br />

64623 S 290.05 0.00 0.00 64821 S 823.81 0.00 0.00<br />

64626 S 427.28 0.00 0.00 64822 S 1,067.40 0.00 0.00<br />

64627 S 200.75 0.00 0.00 64823 S 1,067.40 0.00 0.00<br />

64630 S 298.76 0.00 0.00 64831 S 975.56 0.00 0.00<br />

64632 S 32.36 0.00 0.00 64832 S 838.78 0.00 0.00<br />

64640 S 96.41 0.00 0.00 64834 S 890.82 0.00 0.00<br />

64650 S 32.36 0.00 0.00 64835 S 920.29 0.00 0.00<br />

64653 S 35.09 0.00 0.00 64836 S 920.29 0.00 0.00<br />

64680 S 453.97 0.00 0.00 64837 S 838.78 0.00 0.00<br />

64681 S 479.32 0.00 0.00 64840 S 890.82 0.00 0.00<br />

64702 S 506.18 0.00 0.00 64856 S 890.82 0.00 0.00<br />

64704 S 506.18 0.00 0.00 64857 S 890.82 0.00 0.00<br />

64708 S 558.22 0.00 0.00 64858 S 890.82 0.00 0.00<br />

64712 S 558.22 0.00 0.00 64859 S 838.78 0.00 0.00<br />

64713 S 558.22 0.00 0.00 64861 S 920.29 0.00 0.00<br />

64714 S 558.22 0.00 0.00 64862 S 920.29 0.00 0.00<br />

64716 S 587.69 0.00 0.00 64864 S 920.29 0.00 0.00<br />

64718 S 558.22 0.00 0.00 64865 S 975.56 0.00 0.00<br />

64719 S 558.22 0.00 0.00 64870 S 975.56 0.00 0.00<br />

64721 S 558.22 0.00 0.00 64872 S 890.82 0.00 0.00<br />

64722 S 506.18 0.00 0.00 64874 S 920.29 0.00 0.00<br />

64726 S 506.18 0.00 0.00 64876 S 920.29 0.00 0.00<br />

64727 S 506.18 0.00 0.00 64885 S 890.82 0.00 0.00<br />

64732 S 558.22 0.00 0.00 64886 S 890.82 0.00 0.00<br />

64734 S 558.22 0.00 0.00 64890 S 890.82 0.00 0.00<br />

64736 S 558.22 0.00 0.00 64891 S 890.82 0.00 0.00<br />

64738 S 558.22 0.00 0.00 64892 S 890.82 0.00 0.00<br />

64740 S 558.22 0.00 0.00 64893 S 890.82 0.00 0.00<br />

64742 S 558.22 0.00 0.00 64895 S 920.29 0.00 0.00<br />

64744 S 558.22 0.00 0.00 64896 S 920.29 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 920.29 0.00 0.00 65770 S 5,415.61 0.00 0.00<br />

64898 S 920.29 0.00 0.00 65772 S 609.21 0.00 0.00<br />

64901 S 890.82 0.00 0.00 65775 S 609.21 0.00 0.00<br />

64902 S 890.82 0.00 0.00 65780 S 1,053.85 0.00 0.00<br />

64905 S 890.82 0.00 0.00 65781 S 1,053.85 0.00 0.00<br />

64907 S 838.78 0.00 0.00 65782 S 1,053.85 0.00 0.00<br />

64910 S 1,370.89 0.00 0.00 65800 S 472.45 0.00 0.00<br />

65091 S 969.02 0.00 0.00 65805 S 472.45 0.00 0.00<br />

65093 S 969.02 0.00 0.00 65810 S 690.34 0.00 0.00<br />

65101 S 969.02 0.00 0.00 65815 S 660.87 0.00 0.00<br />

65103 S 969.02 0.00 0.00 65820 S 242.38 0.00 0.00<br />

65105 S 1,024.28 0.00 0.00 65850 S 745.60 0.00 0.00<br />

65110 S 1,064.34 0.00 0.00 65855 S 128.76 0.00 0.00<br />

65112 S 1,192.36 0.00 0.00 65860 S 120.25 0.00 0.00<br />

65114 S 1,192.36 0.00 0.00 65865 S 472.45 0.00 0.00<br />

65125 S 992.33 0.00 0.00 65870 S 745.60 0.00 0.00<br />

65130 S 731.01 0.00 0.00 65875 S 745.60 0.00 0.00<br />

65135 S 701.55 0.00 0.00 65880 S 609.21 0.00 0.00<br />

65140 S 969.02 0.00 0.00 65900 S 649.28 0.00 0.00<br />

65150 S 701.55 0.00 0.00 65920 S 913.68 0.00 0.00<br />

65155 S 969.02 0.00 0.00 65930 S 785.66 0.00 0.00<br />

65175 S 521.49 0.00 0.00 66020 S 472.45 0.00 0.00<br />

65205 S 20.10 0.00 0.00 66030 S 242.38 0.00 0.00<br />

65210 S 25.55 0.00 0.00 66130 S 913.68 0.00 0.00<br />

65220 S 35.60 0.00 0.00 66150 S 745.60 0.00 0.00<br />

65222 S 27.93 0.00 0.00 66155 S 745.60 0.00 0.00<br />

65235 S 524.48 0.00 0.00 66160 S 660.87 0.00 0.00<br />

65260 S 345.93 0.00 0.00 66165 S 745.60 0.00 0.00<br />

65265 S 715.69 0.00 0.00 66170 S 745.60 0.00 0.00<br />

65270 S 573.52 0.00 0.00 66172 S 745.60 0.00 0.00<br />

65272 S 660.87 0.00 0.00 66180 S 1,110.79 0.00 0.00<br />

65275 S 745.60 0.00 0.00 66185 S 986.00 0.00 0.00<br />

65280 S 715.69 0.00 0.00 66220 S 962.51 0.00 0.00<br />

65285 S 1,017.76 0.00 0.00 66225 S 1,070.73 0.00 0.00<br />

65286 S 178.06 0.00 0.00 66250 S 524.48 0.00 0.00<br />

65290 S 704.81 0.00 0.00 66500 S 242.38 0.00 0.00<br />

65400 S 472.45 0.00 0.00 66505 S 242.38 0.00 0.00<br />

65410 S 524.48 0.00 0.00 66600 S 690.34 0.00 0.00<br />

65420 S 524.48 0.00 0.00 66605 S 690.34 0.00 0.00<br />

65426 S 785.66 0.00 0.00 66625 S 490.84 0.00 0.00<br />

65430 S 35.60 0.00 0.00 66630 S 690.34 0.00 0.00<br />

65435 S 31.00 0.00 0.00 66635 S 690.34 0.00 0.00<br />

65436 S 134.55 0.00 0.00 66680 S 690.34 0.00 0.00<br />

65450 S 82.14 0.00 0.00 66682 S 660.87 0.00 0.00<br />

65600 S 158.74 0.00 0.00 66700 S 524.48 0.00 0.00<br />

65710 S 1,181.87 0.00 0.00 66710 S 524.48 0.00 0.00<br />

65730 S 1,181.87 0.00 0.00 66711 S 524.48 0.00 0.00<br />

65750 S 1,181.87 0.00 0.00 66720 S 524.48 0.00 0.00<br />

65755 S 1,181.87 0.00 0.00 66740 S 660.87 0.00 0.00<br />

65756 S 1,447.36 0.00 0.00 66761 S 179.18 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 182.25 0.00 0.00 67228 S 200.71 0.00 0.00<br />

66770 S 200.71 0.00 0.00 67229 S 200.71 0.00 0.00<br />

66820 S 178.06 0.00 0.00 67250 S 603.00 0.00 0.00<br />

66821 S 244.25 0.00 0.00 67255 S 660.43 0.00 0.00<br />

66825 S 745.60 0.00 0.00 67311 S 704.81 0.00 0.00<br />

66830 S 260.77 0.00 0.00 67312 S 760.08 0.00 0.00<br />

66840 S 560.55 0.00 0.00 67314 S 760.08 0.00 0.00<br />

66850 S 1,055.38 0.00 0.00 67316 S 760.08 0.00 0.00<br />

66852 S 887.30 0.00 0.00 67318 S 760.08 0.00 0.00<br />

66920 S 887.30 0.00 0.00 67320 S 760.08 0.00 0.00<br />

66930 S 927.37 0.00 0.00 67331 S 760.08 0.00 0.00<br />

66940 S 600.62 0.00 0.00 67332 S 760.08 0.00 0.00<br />

66982 S 911.16 0.00 0.00 67334 S 760.08 0.00 0.00<br />

66983 S 911.16 0.00 0.00 67335 S 760.08 0.00 0.00<br />

66984 S 911.16 0.00 0.00 67340 S 760.08 0.00 0.00<br />

66985 S 843.47 0.00 0.00 67343 S 928.15 0.00 0.00<br />

66986 S 843.47 0.00 0.00 67345 S 79.38 0.00 0.00<br />

67005 S 715.69 0.00 0.00 67346 S 429.31 0.00 0.00<br />

67010 S 715.69 0.00 0.00 67400 S 603.00 0.00 0.00<br />

67015 S 881.00 0.00 0.00 67405 S 786.28 0.00 0.00<br />

67025 S 578.92 0.00 0.00 67412 S 698.32 0.00 0.00<br />

67027 S 1,017.76 0.00 0.00 67413 S 826.33 0.00 0.00<br />

67028 S 80.06 0.00 0.00 67414 S 1,468.34 0.00 0.00<br />

67030 S 578.92 0.00 0.00 67415 S 521.49 0.00 0.00<br />

67031 S 244.25 0.00 0.00 67420 S 1,064.34 0.00 0.00<br />

67036 S 1,017.76 0.00 0.00 67430 S 1,064.34 0.00 0.00<br />

67039 S 1,185.85 0.00 0.00 67440 S 1,064.34 0.00 0.00<br />

67040 S 1,185.85 0.00 0.00 67445 S 1,064.34 0.00 0.00<br />

67041 S 1,455.31 0.00 0.00 67450 S 1,064.34 0.00 0.00<br />

67042 S 1,455.31 0.00 0.00 67500 S 82.14 0.00 0.00<br />

67043 S 1,455.31 0.00 0.00 67505 S 25.55 0.00 0.00<br />

67101 S 222.17 0.00 0.00 67515 S 25.89 0.00 0.00<br />

67105 S 200.71 0.00 0.00 67550 S 1,024.28 0.00 0.00<br />

67107 S 1,057.83 0.00 0.00 67560 S 701.55 0.00 0.00<br />

67108 S 1,185.85 0.00 0.00 67570 S 1,024.28 0.00 0.00<br />

67110 S 322.93 0.00 0.00 67700 S 120.18 0.00 0.00<br />

67112 S 1,185.85 0.00 0.00 67710 S 140.34 0.00 0.00<br />

67113 S 1,455.31 0.00 0.00 67715 S 521.49 0.00 0.00<br />

67115 S 630.95 0.00 0.00 67800 S 50.42 0.00 0.00<br />

67120 S 630.95 0.00 0.00 67801 S 60.98 0.00 0.00<br />

67121 S 630.95 0.00 0.00 67805 S 79.03 0.00 0.00<br />

67141 S 222.41 0.00 0.00 67808 S 573.52 0.00 0.00<br />

67145 S 189.74 0.00 0.00 67810 S 120.18 0.00 0.00<br />

67208 S 202.35 0.00 0.00 67820 S 16.69 0.00 0.00<br />

67210 S 200.71 0.00 0.00 67825 S 51.44 0.00 0.00<br />

67218 S 755.75 0.00 0.00 67830 S 352.10 0.00 0.00<br />

67220 S 222.17 0.00 0.00 67835 S 573.52 0.00 0.00<br />

67221 S 114.11 0.00 0.00 67840 S 147.16 0.00 0.00<br />

67225 S 7.84 0.00 0.00 67850 S 116.84 0.00 0.00<br />

67227 S 578.92 0.00 0.00 67875 S 293.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 553.96 0.00 0.00 68440 S 50.08 0.00 0.00<br />

67882 S 603.00 0.00 0.00 68500 S 731.01 0.00 0.00<br />

67900 S 786.28 0.00 0.00 68505 S 731.01 0.00 0.00<br />

67901 S 698.32 0.00 0.00 68510 S 521.49 0.00 0.00<br />

67902 S 826.33 0.00 0.00 68520 S 731.01 0.00 0.00<br />

67903 S 658.25 0.00 0.00 68525 S 521.49 0.00 0.00<br />

67904 S 658.25 0.00 0.00 68530 S 120.18 0.00 0.00<br />

67906 S 698.32 0.00 0.00 68540 S 603.00 0.00 0.00<br />

67908 S 658.25 0.00 0.00 68550 S 731.01 0.00 0.00<br />

67909 S 658.25 0.00 0.00 68700 S 573.52 0.00 0.00<br />

67911 S 603.00 0.00 0.00 68705 S 114.11 0.00 0.00<br />

67912 S 603.00 0.00 0.00 68720 S 786.28 0.00 0.00<br />

67914 S 603.00 0.00 0.00 68745 S 786.28 0.00 0.00<br />

67915 S 162.83 0.00 0.00 68750 S 786.28 0.00 0.00<br />

67916 S 658.25 0.00 0.00 68760 S 97.09 0.00 0.00<br />

67917 S 658.25 0.00 0.00 68761 S 67.11 0.00 0.00<br />

67921 S 603.00 0.00 0.00 68770 S 786.28 0.00 0.00<br />

67922 S 158.40 0.00 0.00 68801 S 35.60 0.00 0.00<br />

67923 S 658.25 0.00 0.00 68810 S 101.80 0.00 0.00<br />

67924 S 658.25 0.00 0.00 68811 S 573.52 0.00 0.00<br />

67930 S 162.83 0.00 0.00 68815 S 573.52 0.00 0.00<br />

67935 S 573.52 0.00 0.00 68816 S 736.28 0.00 0.00<br />

67938 S 82.14 0.00 0.00 68840 S 52.80 0.00 0.00<br />

67950 S 573.52 0.00 0.00 69000 S 53.86 0.00 0.00<br />

67961 S 603.00 0.00 0.00 69005 S 101.85 0.00 0.00<br />

67966 S 603.00 0.00 0.00 69020 S 53.86 0.00 0.00<br />

67971 S 603.00 0.00 0.00 69100 S 61.32 0.00 0.00<br />

67973 S 731.01 0.00 0.00 69105 S 86.87 0.00 0.00<br />

67974 S 603.00 0.00 0.00 69110 S 456.36 0.00 0.00<br />

67975 S 603.00 0.00 0.00 69120 S 677.24 0.00 0.00<br />

68020 S 44.63 0.00 0.00 69140 S 677.24 0.00 0.00<br />

68040 S 22.14 0.00 0.00 69145 S 508.40 0.00 0.00<br />

68100 S 88.57 0.00 0.00 69150 S 357.32 0.00 0.00<br />

68110 S 114.11 0.00 0.00 69200 S 24.63 0.00 0.00<br />

68115 S 573.52 0.00 0.00 69205 S 569.69 0.00 0.00<br />

68130 S 524.48 0.00 0.00 69210 S 20.10 0.00 0.00<br />

68135 S 57.23 0.00 0.00 69220 S 31.57 0.00 0.00<br />

68200 S 16.35 0.00 0.00 69222 S 132.85 0.00 0.00<br />

68320 S 786.28 0.00 0.00 69300 S 706.72 0.00 0.00<br />

68325 S 786.28 0.00 0.00 69310 S 1,033.02 0.00 0.00<br />

68326 S 658.25 0.00 0.00 69320 S 1,256.36 0.00 0.00<br />

68328 S 786.28 0.00 0.00 69400 S 89.25 0.00 0.00<br />

68330 S 745.60 0.00 0.00 69401 S 47.01 0.00 0.00<br />

68335 S 786.28 0.00 0.00 69405 S 123.31 0.00 0.00<br />

68340 S 658.25 0.00 0.00 69420 S 110.71 0.00 0.00<br />

68360 S 660.87 0.00 0.00 69421 S 563.47 0.00 0.00<br />

68362 S 660.87 0.00 0.00 69424 S 77.67 0.00 0.00<br />

68371 S 524.48 0.00 0.00 69433 S 110.37 0.00 0.00<br />

68400 S 120.18 0.00 0.00 69436 S 563.47 0.00 0.00<br />

68420 S 171.00 0.00 0.00 69440 S 706.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 951.51 0.00 0.00 69840 S 1,128.34 0.00 0.00<br />

69501 S 1,256.36 0.00 0.00 69905 S 1,256.36 0.00 0.00<br />

69502 S 930.06 0.00 0.00 69910 S 1,256.36 0.00 0.00<br />

69505 S 1,256.36 0.00 0.00 69915 S 1,256.36 0.00 0.00<br />

69511 S 1,256.36 0.00 0.00 69930 S 22,713.18 12,195.44 1,677.71<br />

69530 S 1,256.36 0.00 0.00 70030 TC A 17.37 0.00 0.00<br />

69540 S 129.78 0.00 0.00 70100 TC A 19.08 0.00 0.00<br />

69550 S 1,128.34 0.00 0.00 70110 TC A 23.51 0.00 0.00<br />

69552 S 1,256.36 0.00 0.00 70120 TC A 21.12 0.00 0.00<br />

69601 S 1,256.36 0.00 0.00 70130 TC A 25.80 0.00 0.00<br />

69602 S 1,256.36 0.00 0.00 70134 TC A 25.89 0.00 0.00<br />

69603 S 1,256.36 0.00 0.00 70140 TC A 17.71 0.00 0.00<br />

69604 S 1,256.36 0.00 0.00 70150 TC A 25.80 0.00 0.00<br />

69605 S 1,256.36 0.00 0.00 70160 TC A 20.78 0.00 0.00<br />

69610 S 173.73 0.00 0.00 70190 TC A 21.80 0.00 0.00<br />

69620 S 677.24 0.00 0.00 70200 TC A 25.80 0.00 0.00<br />

69631 S 1,128.34 0.00 0.00 70210 TC A 18.40 0.00 0.00<br />

69632 S 1,128.34 0.00 0.00 70220 TC A 23.17 0.00 0.00<br />

69633 S 1,128.34 0.00 0.00 70240 TC A 17.37 0.00 0.00<br />

69635 S 1,256.36 0.00 0.00 70250 TC A 21.12 0.00 0.00<br />

69636 S 1,256.36 0.00 0.00 70260 TC A 26.91 0.00 0.00<br />

69637 S 1,256.36 0.00 0.00 70300 TC A 7.49 0.00 0.00<br />

69641 S 1,256.36 0.00 0.00 70310 TC A 18.51 0.00 0.00<br />

69642 S 1,256.36 0.00 0.00 70320 TC A 18.51 0.00 0.00<br />

69643 S 1,256.36 0.00 0.00 70328 TC A 18.40 0.00 0.00<br />

69644 S 1,256.36 0.00 0.00 70330 TC A 25.80 0.00 0.00<br />

69645 S 1,256.36 0.00 0.00 70336 TC A 200.86 0.00 0.00<br />

69646 S 1,256.36 0.00 0.00 70350 TC A 10.22 0.00 0.00<br />

69650 S 930.06 0.00 0.00 70355 TC A 10.56 0.00 0.00<br />

69660 S 1,128.34 0.00 0.00 70360 TC A 16.35 0.00 0.00<br />

69661 S 1,128.34 0.00 0.00 70370 TC A 48.02 0.00 0.00<br />

69662 S 1,128.34 0.00 0.00 70371 TC A 48.02 0.00 0.00<br />

69666 S 1,088.27 0.00 0.00 70380 TC A 24.87 0.00 0.00<br />

69667 S 1,088.27 0.00 0.00 70450 TC A 112.18 0.00 0.00<br />

69670 S 1,033.02 0.00 0.00 70460 TC A 177.63 0.00 0.00<br />

69676 S 1,033.02 0.00 0.00 70470 TC A 196.77 0.00 0.00<br />

69700 S 1,033.02 0.00 0.00 70480 TC A 112.18 0.00 0.00<br />

69711 S 951.51 0.00 0.00 70481 TC A 177.63 0.00 0.00<br />

69714 S 6,034.30 3,804.85 1,575.41 70482 TC A 196.77 0.00 0.00<br />

69715 S 6,034.30 3,804.85 1,575.41 70486 TC A 112.18 0.00 0.00<br />

69717 S 6,034.30 3,804.85 1,575.41 70487 TC A 177.63 0.00 0.00<br />

69718 S 6,034.30 3,804.85 1,575.41 70488 TC A 196.77 0.00 0.00<br />

69720 S 1,128.34 0.00 0.00 70490 TC A 112.18 0.00 0.00<br />

69740 S 1,128.34 0.00 0.00 70491 TC A 177.63 0.00 0.00<br />

69745 S 1,128.34 0.00 0.00 70492 TC A 196.77 0.00 0.00<br />

69801 S 1,128.34 0.00 0.00 70496 TC A 203.06 0.00 0.00<br />

69802 S 1,256.36 0.00 0.00 70498 TC A 203.06 0.00 0.00<br />

69805 S 1,256.36 0.00 0.00 70540 TC A 200.86 0.00 0.00<br />

69806 S 1,256.36 0.00 0.00 70542 TC A 246.66 0.00 0.00<br />

69820 S 1,128.34 0.00 0.00 70543 TC A 310.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 200.86 0.00 0.00 72120 TC A 32.70 0.00 0.00<br />

70545 TC A 246.66 0.00 0.00 72125 TC A 112.18 0.00 0.00<br />

70546 TC A 310.87 0.00 0.00 72126 TC A 177.63 0.00 0.00<br />

70547 TC A 200.86 0.00 0.00 72127 TC A 196.77 0.00 0.00<br />

70548 TC A 246.66 0.00 0.00 72128 TC A 112.18 0.00 0.00<br />

70549 TC A 310.87 0.00 0.00 72129 TC A 177.63 0.00 0.00<br />

70551 TC A 200.86 0.00 0.00 72130 TC A 196.77 0.00 0.00<br />

70552 TC A 246.66 0.00 0.00 72131 TC A 112.18 0.00 0.00<br />

70553 TC A 310.87 0.00 0.00 72132 TC A 177.63 0.00 0.00<br />

70554 TC A 200.86 0.00 0.00 72133 TC A 196.77 0.00 0.00<br />

70555 TC A 200.86 0.00 0.00 72141 TC A 200.86 0.00 0.00<br />

70557 TC A 200.86 0.00 0.00 72142 TC A 246.66 0.00 0.00<br />

70558 TC A 246.66 0.00 0.00 72146 TC A 200.86 0.00 0.00<br />

70559 TC A 310.87 0.00 0.00 72147 TC A 246.66 0.00 0.00<br />

71010 TC A 13.29 0.00 0.00 72148 TC A 200.86 0.00 0.00<br />

71015 TC A 17.03 0.00 0.00 72149 TC A 246.66 0.00 0.00<br />

71020 TC A 18.06 0.00 0.00 72156 TC A 310.87 0.00 0.00<br />

71021 TC A 21.80 0.00 0.00 72157 TC A 310.87 0.00 0.00<br />

71022 TC A 25.80 0.00 0.00 72158 TC A 310.87 0.00 0.00<br />

71023 TC A 42.24 0.00 0.00 72170 TC A 15.33 0.00 0.00<br />

71030 TC A 25.80 0.00 0.00 72190 TC A 25.80 0.00 0.00<br />

71034 TC A 48.02 0.00 0.00 72191 TC A 203.06 0.00 0.00<br />

71035 TC A 22.48 0.00 0.00 72192 TC A 112.18 0.00 0.00<br />

71100 TC A 18.74 0.00 0.00 72193 TC A 177.63 0.00 0.00<br />

71101 TC A 22.82 0.00 0.00 72194 TC A 196.77 0.00 0.00<br />

71110 TC A 23.85 0.00 0.00 72195 TC A 200.86 0.00 0.00<br />

71111 TC A 31.68 0.00 0.00 72196 TC A 246.66 0.00 0.00<br />

71120 TC A 19.76 0.00 0.00 72197 TC A 310.87 0.00 0.00<br />

71130 TC A 23.17 0.00 0.00 72200 TC A 18.06 0.00 0.00<br />

71250 TC A 112.18 0.00 0.00 72202 TC A 22.14 0.00 0.00<br />

71260 TC A 177.63 0.00 0.00 72220 TC A 18.06 0.00 0.00<br />

71270 TC A 196.77 0.00 0.00 73000 TC A 17.03 0.00 0.00<br />

71275 TC A 203.06 0.00 0.00 73010 TC A 17.37 0.00 0.00<br />

71550 TC A 200.86 0.00 0.00 73020 TC A 13.97 0.00 0.00<br />

71551 TC A 246.66 0.00 0.00 73030 TC A 17.71 0.00 0.00<br />

71552 TC A 310.87 0.00 0.00 73050 TC A 22.14 0.00 0.00<br />

72010 TC A 42.96 0.00 0.00 73060 TC A 17.71 0.00 0.00<br />

72020 TC A 13.97 0.00 0.00 73070 TC A 17.03 0.00 0.00<br />

72040 TC A 22.48 0.00 0.00 73080 TC A 22.48 0.00 0.00<br />

72050 TC A 32.02 0.00 0.00 73090 TC A 17.03 0.00 0.00<br />

72052 TC A 42.96 0.00 0.00 73092 TC A 17.71 0.00 0.00<br />

72069 TC A 21.12 0.00 0.00 73100 TC A 17.71 0.00 0.00<br />

72070 TC A 19.76 0.00 0.00 73110 TC A 22.48 0.00 0.00<br />

72072 TC A 23.85 0.00 0.00 73120 TC A 16.69 0.00 0.00<br />

72074 TC A 25.80 0.00 0.00 73130 TC A 19.76 0.00 0.00<br />

72080 TC A 21.12 0.00 0.00 73140 TC A 19.42 0.00 0.00<br />

72090 TC A 28.28 0.00 0.00 73200 TC A 112.18 0.00 0.00<br />

72100 TC A 24.19 0.00 0.00 73201 TC A 177.63 0.00 0.00<br />

72110 TC A 33.73 0.00 0.00 73202 TC A 196.77 0.00 0.00<br />

72114 TC A 42.96 0.00 0.00 73206 TC A 203.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 200.86 0.00 0.00 74246 TC A 50.69 0.00 0.00<br />

73219 TC A 246.66 0.00 0.00 74247 TC A 50.69 0.00 0.00<br />

73220 TC A 310.87 0.00 0.00 74249 TC A 82.43 0.00 0.00<br />

73221 TC A 200.86 0.00 0.00 74250 TC A 50.69 0.00 0.00<br />

73222 TC A 246.66 0.00 0.00 74251 TC A 82.43 0.00 0.00<br />

73223 TC A 310.87 0.00 0.00 74260 TC A 50.69 0.00 0.00<br />

73500 TC A 14.65 0.00 0.00 74270 TC A 50.69 0.00 0.00<br />

73510 TC A 22.48 0.00 0.00 74280 TC A 82.43 0.00 0.00<br />

73520 TC A 23.17 0.00 0.00 74283 TC A 50.69 0.00 0.00<br />

73540 TC A 23.17 0.00 0.00 74290 TC A 43.26 0.00 0.00<br />

73550 TC A 17.03 0.00 0.00 74291 TC A 41.56 0.00 0.00<br />

73560 TC A 17.37 0.00 0.00 74400 TC A 75.29 0.00 0.00<br />

73562 TC A 21.46 0.00 0.00 74410 TC A 80.40 0.00 0.00<br />

73564 TC A 24.87 0.00 0.00 74415 TC A 96.07 0.00 0.00<br />

73565 TC A 18.74 0.00 0.00 74420 TC A 100.41 0.00 0.00<br />

73590 TC A 16.35 0.00 0.00 74710 TC A 22.48 0.00 0.00<br />

73592 TC A 17.71 0.00 0.00 74775 TC A 100.41 0.00 0.00<br />

73600 TC A 16.69 0.00 0.00 75557 TC A 200.86 0.00 0.00<br />

73610 TC A 19.76 0.00 0.00 75559 TC A 200.86 0.00 0.00<br />

73620 TC A 16.01 0.00 0.00 75561 TC A 310.87 0.00 0.00<br />

73630 TC A 19.42 0.00 0.00 75563 TC A 310.87 0.00 0.00<br />

73650 TC A 16.35 0.00 0.00 76010 TC A 16.69 0.00 0.00<br />

73660 TC A 18.40 0.00 0.00 76098 TC A 10.22 0.00 0.00<br />

73700 TC A 112.18 0.00 0.00 76100 TC A 42.96 0.00 0.00<br />

73701 TC A 177.63 0.00 0.00 76101 TC A 115.13 0.00 0.00<br />

73702 TC A 196.77 0.00 0.00 76102 TC A 115.13 0.00 0.00<br />

73706 TC A 203.06 0.00 0.00 76120 TC A 48.02 0.00 0.00<br />

73718 TC A 200.86 0.00 0.00 76150 A 16.69 0.00 0.00<br />

73719 TC A 246.66 0.00 0.00 76380 TC A 60.60 0.00 0.00<br />

73720 TC A 310.87 0.00 0.00 76496 TC A 48.02 0.00 0.00<br />

73721 TC A 200.86 0.00 0.00 76497 TC A 60.60 0.00 0.00<br />

73722 TC A 246.66 0.00 0.00 76498 TC A 200.86 0.00 0.00<br />

73723 TC A 310.87 0.00 0.00 76499 TC A 25.80 0.00 0.00<br />

74000 TC A 14.65 0.00 0.00 76506 TC A 36.07 0.00 0.00<br />

74010 TC A 22.82 0.00 0.00 76510 TC A 61.32 0.00 0.00<br />

74020 TC A 23.17 0.00 0.00 76511 TC A 42.92 0.00 0.00<br />

74022 TC A 28.28 0.00 0.00 76512 TC A 36.45 0.00 0.00<br />

74150 TC A 112.18 0.00 0.00 76513 TC A 44.29 0.00 0.00<br />

74160 TC A 177.63 0.00 0.00 76514 TC A 3.07 0.00 0.00<br />

74170 TC A 196.77 0.00 0.00 76516 TC A 34.75 0.00 0.00<br />

74175 TC A 203.06 0.00 0.00 76519 TC A 38.84 0.00 0.00<br />

74181 TC A 200.86 0.00 0.00 76529 TC A 33.73 0.00 0.00<br />

74182 TC A 246.66 0.00 0.00 76536 TC A 56.42 0.00 0.00<br />

74183 TC A 310.87 0.00 0.00 76604 TC A 36.07 0.00 0.00<br />

74210 TC A 50.69 0.00 0.00 76645 TC A 36.07 0.00 0.00<br />

74220 TC A 50.69 0.00 0.00 76700 TC A 56.42 0.00 0.00<br />

74230 TC A 50.69 0.00 0.00 76705 TC A 56.42 0.00 0.00<br />

74240 TC A 50.69 0.00 0.00 76770 TC A 56.42 0.00 0.00<br />

74241 TC A 50.69 0.00 0.00 76775 TC A 56.42 0.00 0.00<br />

74245 TC A 82.43 0.00 0.00 76776 TC A 56.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 56.42 0.00 0.00 77290 TC A 147.56 0.00 0.00<br />

76801 TC A 56.42 0.00 0.00 77295 TC A 386.64 0.00 0.00<br />

76802 TC A 26.91 0.00 0.00 77299 TC A 66.20 0.00 0.00<br />

76805 TC A 56.42 0.00 0.00 77300 TC A 35.77 0.00 0.00<br />

76810 TC A 42.58 0.00 0.00 77301 TC A 515.28 0.00 0.00<br />

76811 TC A 88.40 0.00 0.00 77305 TC A 32.70 0.00 0.00<br />

76812 TC A 36.07 0.00 0.00 77310 TC A 42.58 0.00 0.00<br />

76813 TC A 36.07 0.00 0.00 77315 TC A 62.00 0.00 0.00<br />

76814 TC A 28.62 0.00 0.00 77321 TC A 64.39 0.00 0.00<br />

76815 TC A 36.07 0.00 0.00 77326 TC A 66.20 0.00 0.00<br />

76816 TC A 36.07 0.00 0.00 77327 TC A 120.25 0.00 0.00<br />

76817 TC A 36.07 0.00 0.00 77328 TC A 147.56 0.00 0.00<br />

76818 TC A 56.42 0.00 0.00 77331 TC A 17.03 0.00 0.00<br />

76819 TC A 48.72 0.00 0.00 77332 TC A 45.65 0.00 0.00<br />

76820 TC A 24.19 0.00 0.00 77333 TC A 22.14 0.00 0.00<br />

76821 TC A 54.62 0.00 0.00 77334 TC A 85.51 0.00 0.00<br />

76825 TC A 113.77 0.00 0.00 77336 A 53.83 0.00 0.00<br />

76826 TC A 67.79 0.00 0.00 77370 A 66.20 0.00 0.00<br />

76827 TC A 36.07 0.00 0.00 77371 A 4,409.96 0.00 0.00<br />

76828 TC A 21.46 0.00 0.00 77399 TC A 66.20 0.00 0.00<br />

76830 TC A 56.42 0.00 0.00 77401 A 26.91 0.00 0.00<br />

76831 TC A 75.97 0.00 0.00 77402 A 54.18 0.00 0.00<br />

76856 TC A 56.42 0.00 0.00 77403 A 54.18 0.00 0.00<br />

76857 TC A 36.07 0.00 0.00 77404 A 54.18 0.00 0.00<br />

76870 TC A 56.42 0.00 0.00 77406 A 87.75 0.00 0.00<br />

76872 TC A 56.42 0.00 0.00 77407 A 54.18 0.00 0.00<br />

76873 TC A 56.42 0.00 0.00 77408 A 54.18 0.00 0.00<br />

76880 TC A 56.42 0.00 0.00 77409 A 54.18 0.00 0.00<br />

76885 TC A 36.07 0.00 0.00 77411 A 87.75 0.00 0.00<br />

76886 TC A 36.07 0.00 0.00 77412 A 87.75 0.00 0.00<br />

76936 TC A 54.62 0.00 0.00 77413 A 87.75 0.00 0.00<br />

76970 TC A 36.07 0.00 0.00 77414 A 87.75 0.00 0.00<br />

76977 TC A 9.20 0.00 0.00 77416 A 87.75 0.00 0.00<br />

76999 TC A 36.07 0.00 0.00 77418 A 237.09 0.00 0.00<br />

77071 A 21.12 0.00 0.00 77422 A 87.75 0.00 0.00<br />

77072 TC A 12.26 0.00 0.00 77423 A 87.75 0.00 0.00<br />

77073 TC A 20.78 0.00 0.00 77470 TC A 126.04 0.00 0.00<br />

77074 TC A 40.88 0.00 0.00 77520 A 405.92 0.00 0.00<br />

77075 TC A 42.96 0.00 0.00 77522 A 405.92 0.00 0.00<br />

77076 TC A 42.96 0.00 0.00 77523 A 485.09 0.00 0.00<br />

77077 TC A 23.17 0.00 0.00 77525 A 485.09 0.00 0.00<br />

77078 TC A 41.50 0.00 0.00 77600 TC A 215.37 0.00 0.00<br />

77079 TC A 42.58 0.00 0.00 77605 TC A 215.37 0.00 0.00<br />

77080 TC A 41.50 0.00 0.00 77610 TC A 215.37 0.00 0.00<br />

77081 TC A 16.69 0.00 0.00 77615 TC A 215.37 0.00 0.00<br />

77082 TC A 18.06 0.00 0.00 77620 TC A 215.37 0.00 0.00<br />

77083 TC A 14.31 0.00 0.00 77750 TC A 83.80 0.00 0.00<br />

77084 TC A 200.86 0.00 0.00 77761 TC A 147.50 0.00 0.00<br />

77280 TC A 66.20 0.00 0.00 77762 TC A 174.75 0.00 0.00<br />

77285 TC A 147.56 0.00 0.00 77763 TC A 225.17 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 159.76 0.00 0.00 78262 TC A 140.31 0.00 0.00<br />

77777 TC A 175.43 0.00 0.00 78264 TC A 140.31 0.00 0.00<br />

77778 TC A 233.69 0.00 0.00 78270 TC A 61.32 0.00 0.00<br />

77785 TC A 103.90 0.00 0.00 78271 TC A 62.34 0.00 0.00<br />

77786 TC A 365.17 0.00 0.00 78272 TC A 68.47 0.00 0.00<br />

77787 TC A 423.15 0.00 0.00 78278 TC A 140.31 0.00 0.00<br />

77789 TC A 43.61 0.00 0.00 78282 TC A 140.31 0.00 0.00<br />

77799 TC A 248.54 0.00 0.00 78290 TC A 140.31 0.00 0.00<br />

78000 TC A 53.48 0.00 0.00 78291 TC A 140.31 0.00 0.00<br />

78001 TC A 67.78 0.00 0.00 78299 TC A 140.31 0.00 0.00<br />

78003 TC A 53.83 0.00 0.00 78300 TC A 122.29 0.00 0.00<br />

78006 TC A 128.06 0.00 0.00 78305 TC A 141.84 0.00 0.00<br />

78007 TC A 94.71 0.00 0.00 78306 TC A 141.84 0.00 0.00<br />

78010 TC A 78.69 0.00 0.00 78315 TC A 141.84 0.00 0.00<br />

78011 TC A 78.69 0.00 0.00 78320 TC A 141.84 0.00 0.00<br />

78015 TC A 152.95 0.00 0.00 78399 TC A 141.84 0.00 0.00<br />

78016 TC A 172.65 0.00 0.00 78414 TC A 180.29 0.00 0.00<br />

78018 TC A 172.65 0.00 0.00 78428 TC A 138.30 0.00 0.00<br />

78070 TC A 117.52 0.00 0.00 78445 TC A 107.88 0.00 0.00<br />

78075 TC A 332.81 0.00 0.00 78456 TC A 107.88 0.00 0.00<br />

78099 TC A 78.69 0.00 0.00 78457 TC A 107.88 0.00 0.00<br />

78102 TC A 118.88 0.00 0.00 78458 TC A 107.88 0.00 0.00<br />

78103 TC A 151.55 0.00 0.00 78459 TC A 667.62 0.00 0.00<br />

78104 TC A 151.55 0.00 0.00 78460 TC A 129.44 0.00 0.00<br />

78110 TC A 60.30 0.00 0.00 78461 TC A 130.47 0.00 0.00<br />

78111 TC A 76.31 0.00 0.00 78464 TC A 191.44 0.00 0.00<br />

78120 TC A 66.77 0.00 0.00 78465 TC A 362.45 0.00 0.00<br />

78121 TC A 79.03 0.00 0.00 78466 TC A 128.42 0.00 0.00<br />

78122 TC A 93.68 0.00 0.00 78468 TC A 164.19 0.00 0.00<br />

78130 TC A 108.66 0.00 0.00 78469 TC A 180.29 0.00 0.00<br />

78135 TC A 230.95 0.00 0.00 78472 TC A 180.29 0.00 0.00<br />

78140 TC A 102.53 0.00 0.00 78473 TC A 180.29 0.00 0.00<br />

78185 TC A 151.55 0.00 0.00 78481 TC A 155.67 0.00 0.00<br />

78190 TC A 95.09 0.00 0.00 78483 TC A 180.29 0.00 0.00<br />

78191 TC A 95.09 0.00 0.00 78491 TC A 667.62 0.00 0.00<br />

78195 TC A 151.55 0.00 0.00 78492 TC A 667.62 0.00 0.00<br />

78199 TC A 151.55 0.00 0.00 78494 TC A 180.29 0.00 0.00<br />

78201 TC A 134.89 0.00 0.00 78499 TC A 180.29 0.00 0.00<br />

78202 TC A 158.69 0.00 0.00 78580 TC A 122.14 0.00 0.00<br />

78205 TC A 158.69 0.00 0.00 78584 TC A 94.36 0.00 0.00<br />

78206 TC A 158.69 0.00 0.00 78585 TC A 187.42 0.00 0.00<br />

78215 TC A 142.73 0.00 0.00 78586 TC A 122.14 0.00 0.00<br />

78216 TC A 96.75 0.00 0.00 78587 TC A 122.14 0.00 0.00<br />

78220 TC A 105.60 0.00 0.00 78588 TC A 187.42 0.00 0.00<br />

78223 TC A 158.69 0.00 0.00 78591 TC A 122.14 0.00 0.00<br />

78230 TC A 119.90 0.00 0.00 78593 TC A 122.14 0.00 0.00<br />

78231 TC A 94.36 0.00 0.00 78594 TC A 122.14 0.00 0.00<br />

78232 TC A 98.45 0.00 0.00 78596 TC A 187.42 0.00 0.00<br />

78258 TC A 140.31 0.00 0.00 78599 TC A 122.14 0.00 0.00<br />

78261 TC A 140.31 0.00 0.00 78600 TC A 107.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 19660 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 107.64 0.00 0.00<br />

78605 TC A 107.64 0.00 0.00<br />

78606 TC A 241.86 0.00 0.00<br />

78607 TC A 265.71 0.00 0.00<br />

78608 TC A 598.40 0.00 0.00<br />

78610 TC A 143.41 0.00 0.00<br />

78630 TC A 255.49 0.00 0.00<br />

78635 TC A 235.39 0.00 0.00<br />

78645 TC A 107.64 0.00 0.00<br />

78647 TC A 260.60 0.00 0.00<br />

78650 TC A 252.42 0.00 0.00<br />

78660 TC A 107.64 0.00 0.00<br />

78699 TC A 107.64 0.00 0.00<br />

78700 TC A 132.51 0.00 0.00<br />

78701 TC A 161.47 0.00 0.00<br />

78707 TC A 168.62 0.00 0.00<br />

78708 TC A 115.48 0.00 0.00<br />

78709 TC A 189.86 0.00 0.00<br />

78710 TC A 178.16 0.00 0.00<br />

78725 TC A 71.20 0.00 0.00<br />

78730 TC A 60.30 0.00 0.00<br />

78740 TC A 157.38 0.00 0.00<br />

78761 TC A 150.22 0.00 0.00<br />

78799 TC A 189.86 0.00 0.00<br />

78800 TC A 132.85 0.00 0.00<br />

78801 TC A 182.25 0.00 0.00<br />

78802 TC A 246.97 0.00 0.00<br />

78803 TC A 264.69 0.00 0.00<br />

78804 TC A 461.92 0.00 0.00<br />

78805 TC A 129.78 0.00 0.00<br />

78806 TC A 259.58 0.00 0.00<br />

78807 TC A 265.03 0.00 0.00<br />

78811 TC A 598.40 0.00 0.00<br />

78812 TC A 598.40 0.00 0.00<br />

78813 TC A 598.40 0.00 0.00<br />

78814 TC A 598.40 0.00 0.00<br />

78815 TC A 598.40 0.00 0.00<br />

78816 TC A 598.40 0.00 0.00<br />

78999 TC A 67.78 0.00 0.00<br />

79005 TC A 54.51 0.00 0.00<br />

79101 TC A 59.62 0.00 0.00<br />

79200 TC A 64.39 0.00 0.00<br />

79300 TC A 124.22 0.00 0.00<br />

79403 TC A 92.32 0.00 0.00<br />

79440 TC A 52.12 0.00 0.00<br />

79445 TC A 124.22 0.00 0.00<br />

79999 TC A 124.22 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,317.52 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,572.02 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.75 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,624.36 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,624.36 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 234.58 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 234.58 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 118.45 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 250.34 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 75.26 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 673.88 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,536.67 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,202.83 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,202.83 0.00 0.00<br />

C8900 A 260.44 0.00 0.00 0123T S 961.91 0.00 0.00<br />

C8901 A 212.09 0.00 0.00 0124T S 188.01 0.00 0.00<br />

C8902 A 328.25 0.00 0.00 0144T TC A 63.99 0.00 0.00<br />

C8903 A 260.44 0.00 0.00 0145T TC A 172.25 0.00 0.00<br />

C8904 A 212.09 0.00 0.00 0146T TC A 172.25 0.00 0.00<br />

C8905 A 328.25 0.00 0.00 0147T TC A 172.25 0.00 0.00<br />

C8906 A 260.44 0.00 0.00 0148T TC A 172.25 0.00 0.00<br />

C8907 A 212.09 0.00 0.00 0149T TC A 172.25 0.00 0.00<br />

C8908 A 328.25 0.00 0.00 0150T TC A 172.25 0.00 0.00<br />

C8909 A 260.44 0.00 0.00 0151T TC A 63.99 0.00 0.00<br />

C8910 A 212.09 0.00 0.00 0170T S 1,249.46 0.00 0.00<br />

C8911 A 328.25 0.00 0.00 0176T S 1,475.33 0.00 0.00<br />

C8912 A 260.44 0.00 0.00 0177T S 1,475.33 0.00 0.00<br />

C8913 A 212.09 0.00 0.00 0182T A 1,066.37 0.00 0.00<br />

C8914 A 328.25 0.00 0.00 0186T S 898.74 0.00 0.00<br />

C8918 A 260.44 0.00 0.00 0190T S 898.74 0.00 0.00<br />

C8919 A 212.09 0.00 0.00 0191T S 961.91 0.00 0.00<br />

C8920 A 328.25 0.00 0.00 0192T S 1,648.52 0.00 0.00<br />

C9716 S 1,249.46 0.00 0.00 10021 S 57.65 0.00 0.00<br />

C9724 S 1,021.57 0.00 0.00 10022 S 180.04 0.00 0.00<br />

C9725 S 235.57 0.00 0.00 10040 S 33.33 0.00 0.00<br />

C9726 S 864.85 0.00 0.00 10060 S 50.71 0.00 0.00<br />

C9727 S 303.23 0.00 0.00 10061 S 56.87 0.00 0.00<br />

C9728 S 544.09 0.00 0.00 10080 S 56.87 0.00 0.00<br />

G0104 S 87.40 0.00 0.00 10081 S 130.93 0.00 0.00<br />

G0105 S 377.76 0.00 0.00 10120 S 71.22 0.00 0.00<br />

G0121 S 377.76 0.00 0.00 10121 S 536.82 0.00 0.00<br />

G0127 S 12.23 0.00 0.00 10140 S 75.54 0.00 0.00<br />

G0130 TC A 20.15 0.00 0.00 10160 S 56.87 0.00 0.00<br />

G0173 A 2,317.52 0.00 0.00 10180 S 607.07 0.00 0.00<br />

G0186 S 234.58 0.00 0.00 11000 S 24.46 0.00 0.00<br />

G0247 S 22.30 0.00 0.00 11001 S 8.28 0.00 0.00<br />

G0251 A 580.34 0.00 0.00 11010 S 212.39 0.00 0.00<br />

G0260 S 306.26 0.00 0.00 11011 S 212.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 212.39 0.00 0.00 11601 S 117.26 0.00 0.00<br />

11040 S 22.30 0.00 0.00 11602 S 129.13 0.00 0.00<br />

11041 S 24.82 0.00 0.00 11603 S 137.04 0.00 0.00<br />

11042 S 134.86 0.00 0.00 11604 S 369.66 0.00 0.00<br />

11043 S 134.86 0.00 0.00 11606 S 536.82 0.00 0.00<br />

11044 S 351.17 0.00 0.00 11620 S 100.00 0.00 0.00<br />

11055 S 26.26 0.00 0.00 11621 S 118.70 0.00 0.00<br />

11056 S 28.77 0.00 0.00 11622 S 132.00 0.00 0.00<br />

11057 S 33.33 0.00 0.00 11623 S 142.08 0.00 0.00<br />

11100 S 61.06 0.00 0.00 11624 S 536.82 0.00 0.00<br />

11101 S 14.39 0.00 0.00 11626 S 656.48 0.00 0.00<br />

11200 S 33.33 0.00 0.00 11640 S 105.75 0.00 0.00<br />

11201 S 5.75 0.00 0.00 11641 S 124.81 0.00 0.00<br />

11300 S 33.33 0.00 0.00 11642 S 139.20 0.00 0.00<br />

11301 S 33.33 0.00 0.00 11643 S 149.99 0.00 0.00<br />

11302 S 33.33 0.00 0.00 11644 S 536.82 0.00 0.00<br />

11303 S 61.06 0.00 0.00 11646 S 656.48 0.00 0.00<br />

11305 S 33.33 0.00 0.00 11719 S 12.23 0.00 0.00<br />

11306 S 33.33 0.00 0.00 11720 S 15.11 0.00 0.00<br />

11307 S 33.33 0.00 0.00 11721 S 18.34 0.00 0.00<br />

11308 S 33.33 0.00 0.00 11730 S 33.33 0.00 0.00<br />

11310 S 33.33 0.00 0.00 11732 S 18.34 0.00 0.00<br />

11311 S 33.33 0.00 0.00 11740 S 16.83 0.00 0.00<br />

11312 S 33.33 0.00 0.00 11750 S 97.12 0.00 0.00<br />

11313 S 33.33 0.00 0.00 11752 S 134.88 0.00 0.00<br />

11400 S 68.70 0.00 0.00 11755 S 67.26 0.00 0.00<br />

11401 S 77.33 0.00 0.00 11760 S 138.52 0.00 0.00<br />

11402 S 84.89 0.00 0.00 11762 S 123.74 0.00 0.00<br />

11403 S 90.64 0.00 0.00 11765 S 33.33 0.00 0.00<br />

11404 S 481.88 0.00 0.00 11770 S 687.61 0.00 0.00<br />

11406 S 536.82 0.00 0.00 11771 S 687.61 0.00 0.00<br />

11420 S 64.39 0.00 0.00 11772 S 687.61 0.00 0.00<br />

11421 S 78.05 0.00 0.00 11900 S 30.58 0.00 0.00<br />

11422 S 85.25 0.00 0.00 11901 S 33.33 0.00 0.00<br />

11423 S 94.96 0.00 0.00 11920 S 96.76 0.00 0.00<br />

11424 S 536.82 0.00 0.00 11921 S 106.47 0.00 0.00<br />

11426 S 656.48 0.00 0.00 11922 S 34.53 0.00 0.00<br />

11440 S 73.74 0.00 0.00 11950 S 35.25 0.00 0.00<br />

11441 S 85.25 0.00 0.00 11951 S 43.88 0.00 0.00<br />

11442 S 93.88 0.00 0.00 11952 S 52.83 0.00 0.00<br />

11443 S 103.95 0.00 0.00 11954 S 52.83 0.00 0.00<br />

11444 S 328.09 0.00 0.00 11960 S 640.85 0.00 0.00<br />

11446 S 656.48 0.00 0.00 11970 S 1,160.79 0.00 0.00<br />

11450 S 656.48 0.00 0.00 11971 S 601.54 0.00 0.00<br />

11451 S 656.48 0.00 0.00 11976 S 64.39 0.00 0.00<br />

11462 S 656.48 0.00 0.00 11980 S 26.01 0.00 0.00<br />

11463 S 656.48 0.00 0.00 11981 S 26.01 0.00 0.00<br />

11470 S 656.48 0.00 0.00 11982 S 26.01 0.00 0.00<br />

11471 S 656.48 0.00 0.00 11983 S 26.01 0.00 0.00<br />

11600 S 96.76 0.00 0.00 12001 S 52.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 52.83 0.00 0.00 14021 S 569.50 0.00 0.00<br />

12004 S 52.83 0.00 0.00 14040 S 538.38 0.00 0.00<br />

12005 S 70.78 0.00 0.00 14041 S 569.50 0.00 0.00<br />

12006 S 70.78 0.00 0.00 14060 S 569.50 0.00 0.00<br />

12007 S 70.78 0.00 0.00 14061 S 569.50 0.00 0.00<br />

12011 S 52.83 0.00 0.00 14300 S 730.31 0.00 0.00<br />

12013 S 52.83 0.00 0.00 14350 S 671.96 0.00 0.00<br />

12014 S 52.83 0.00 0.00 15002 S 246.36 0.00 0.00<br />

12015 S 52.83 0.00 0.00 15003 S 246.36 0.00 0.00<br />

12016 S 70.78 0.00 0.00 15004 S 246.36 0.00 0.00<br />

12017 S 70.78 0.00 0.00 15005 S 246.36 0.00 0.00<br />

12018 S 70.78 0.00 0.00 15040 S 113.62 0.00 0.00<br />

12020 S 133.54 0.00 0.00 15050 S 246.36 0.00 0.00<br />

12021 S 113.62 0.00 0.00 15100 S 640.85 0.00 0.00<br />

12031 S 52.83 0.00 0.00 15101 S 671.96 0.00 0.00<br />

12032 S 138.52 0.00 0.00 15110 S 306.03 0.00 0.00<br />

12034 S 70.78 0.00 0.00 15111 S 251.09 0.00 0.00<br />

12035 S 70.78 0.00 0.00 15115 S 306.03 0.00 0.00<br />

12036 S 113.62 0.00 0.00 15116 S 251.09 0.00 0.00<br />

12037 S 226.46 0.00 0.00 15120 S 640.85 0.00 0.00<br />

12041 S 52.83 0.00 0.00 15121 S 671.96 0.00 0.00<br />

12042 S 52.83 0.00 0.00 15130 S 538.38 0.00 0.00<br />

12044 S 70.78 0.00 0.00 15131 S 483.43 0.00 0.00<br />

12045 S 113.62 0.00 0.00 15135 S 538.38 0.00 0.00<br />

12046 S 113.62 0.00 0.00 15136 S 483.43 0.00 0.00<br />

12047 S 226.46 0.00 0.00 15150 S 306.03 0.00 0.00<br />

12051 S 52.83 0.00 0.00 15151 S 251.09 0.00 0.00<br />

12052 S 52.83 0.00 0.00 15152 S 251.09 0.00 0.00<br />

12053 S 52.83 0.00 0.00 15155 S 306.03 0.00 0.00<br />

12054 S 70.78 0.00 0.00 15156 S 251.09 0.00 0.00<br />

12055 S 113.62 0.00 0.00 15157 S 251.09 0.00 0.00<br />

12056 S 113.62 0.00 0.00 15170 S 138.52 0.00 0.00<br />

12057 S 226.46 0.00 0.00 15171 S 138.52 0.00 0.00<br />

13100 S 246.36 0.00 0.00 15175 S 178.35 0.00 0.00<br />

13101 S 246.36 0.00 0.00 15176 S 178.35 0.00 0.00<br />

13102 S 133.54 0.00 0.00 15200 S 569.50 0.00 0.00<br />

13120 S 113.62 0.00 0.00 15201 S 478.71 0.00 0.00<br />

13121 S 113.62 0.00 0.00 15220 S 538.38 0.00 0.00<br />

13122 S 113.62 0.00 0.00 15221 S 246.36 0.00 0.00<br />

13131 S 113.62 0.00 0.00 15240 S 569.50 0.00 0.00<br />

13132 S 113.62 0.00 0.00 15241 S 246.36 0.00 0.00<br />

13133 S 113.62 0.00 0.00 15260 S 538.38 0.00 0.00<br />

13150 S 246.36 0.00 0.00 15261 S 478.71 0.00 0.00<br />

13151 S 246.36 0.00 0.00 15300 S 246.36 0.00 0.00<br />

13152 S 246.36 0.00 0.00 15301 S 246.36 0.00 0.00<br />

13153 S 113.62 0.00 0.00 15320 S 246.36 0.00 0.00<br />

13160 S 640.85 0.00 0.00 15321 S 246.36 0.00 0.00<br />

14000 S 538.38 0.00 0.00 15330 S 246.36 0.00 0.00<br />

14001 S 569.50 0.00 0.00 15331 S 246.36 0.00 0.00<br />

14020 S 569.50 0.00 0.00 15335 S 246.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 246.36 0.00 0.00 15826 S 671.96 0.00 0.00<br />

15340 S 138.52 0.00 0.00 15828 S 671.96 0.00 0.00<br />

15341 S 138.52 0.00 0.00 15829 S 772.61 0.00 0.00<br />

15360 S 138.52 0.00 0.00 15830 S 687.61 0.00 0.00<br />

15361 S 138.52 0.00 0.00 15832 S 687.61 0.00 0.00<br />

15365 S 138.52 0.00 0.00 15833 S 687.61 0.00 0.00<br />

15366 S 138.52 0.00 0.00 15834 S 687.61 0.00 0.00<br />

15400 S 246.36 0.00 0.00 15835 S 596.81 0.00 0.00<br />

15401 S 246.36 0.00 0.00 15836 S 567.94 0.00 0.00<br />

15420 S 246.36 0.00 0.00 15837 S 639.93 0.00 0.00<br />

15421 S 246.36 0.00 0.00 15838 S 639.93 0.00 0.00<br />

15430 S 246.36 0.00 0.00 15839 S 567.94 0.00 0.00<br />

15431 S 246.36 0.00 0.00 15840 S 730.31 0.00 0.00<br />

15570 S 671.96 0.00 0.00 15841 S 730.31 0.00 0.00<br />

15572 S 671.96 0.00 0.00 15842 S 847.96 0.00 0.00<br />

15574 S 671.96 0.00 0.00 15845 S 730.31 0.00 0.00<br />

15576 S 671.96 0.00 0.00 15847 S 687.61 0.00 0.00<br />

15600 S 671.96 0.00 0.00 15850 S 109.84 0.00 0.00<br />

15610 S 671.96 0.00 0.00 15851 S 49.99 0.00 0.00<br />

15620 S 730.31 0.00 0.00 15852 S 26.01 0.00 0.00<br />

15630 S 671.96 0.00 0.00 15860 S 26.01 0.00 0.00<br />

15650 S 772.61 0.00 0.00 15876 S 671.96 0.00 0.00<br />

15731 S 671.96 0.00 0.00 15877 S 671.96 0.00 0.00<br />

15732 S 671.96 0.00 0.00 15878 S 671.96 0.00 0.00<br />

15734 S 671.96 0.00 0.00 15879 S 671.96 0.00 0.00<br />

15736 S 671.96 0.00 0.00 15920 S 212.39 0.00 0.00<br />

15738 S 671.96 0.00 0.00 15922 S 730.31 0.00 0.00<br />

15740 S 538.38 0.00 0.00 15931 S 687.61 0.00 0.00<br />

15750 S 640.85 0.00 0.00 15933 S 687.61 0.00 0.00<br />

15760 S 640.85 0.00 0.00 15934 S 671.96 0.00 0.00<br />

15770 S 671.96 0.00 0.00 15935 S 730.31 0.00 0.00<br />

15775 S 183.60 0.00 0.00 15936 S 627.85 0.00 0.00<br />

15776 S 183.60 0.00 0.00 15937 S 730.31 0.00 0.00<br />

15780 S 409.33 0.00 0.00 15940 S 687.61 0.00 0.00<br />

15781 S 180.17 0.00 0.00 15941 S 687.61 0.00 0.00<br />

15782 S 180.17 0.00 0.00 15944 S 671.96 0.00 0.00<br />

15783 S 109.84 0.00 0.00 15945 S 730.31 0.00 0.00<br />

15786 S 33.33 0.00 0.00 15946 S 730.31 0.00 0.00<br />

15787 S 30.22 0.00 0.00 15950 S 687.61 0.00 0.00<br />

15788 S 33.33 0.00 0.00 15951 S 745.95 0.00 0.00<br />

15789 S 61.06 0.00 0.00 15952 S 569.50 0.00 0.00<br />

15792 S 61.06 0.00 0.00 15953 S 627.85 0.00 0.00<br />

15793 S 33.33 0.00 0.00 15956 S 569.50 0.00 0.00<br />

15819 S 138.52 0.00 0.00 15958 S 627.85 0.00 0.00<br />

15820 S 671.96 0.00 0.00 16000 S 26.98 0.00 0.00<br />

15821 S 671.96 0.00 0.00 16020 S 41.01 0.00 0.00<br />

15822 S 671.96 0.00 0.00 16025 S 63.16 0.00 0.00<br />

15823 S 772.61 0.00 0.00 16030 S 79.08 0.00 0.00<br />

15824 S 671.96 0.00 0.00 16035 S 61.06 0.00 0.00<br />

15825 S 671.96 0.00 0.00 17000 S 33.33 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.96 0.00 0.00 19300 S 738.75 0.00 0.00<br />

17004 S 87.04 0.00 0.00 19301 S 680.41 0.00 0.00<br />

17106 S 109.84 0.00 0.00 19302 S 1,299.50 0.00 0.00<br />

17107 S 109.84 0.00 0.00 19303 S 982.07 0.00 0.00<br />

17108 S 109.84 0.00 0.00 19304 S 982.07 0.00 0.00<br />

17110 S 33.33 0.00 0.00 19316 S 982.07 0.00 0.00<br />

17111 S 61.06 0.00 0.00 19318 S 1,122.02 0.00 0.00<br />

17250 S 46.05 0.00 0.00 19324 S 1,122.02 0.00 0.00<br />

17260 S 49.28 0.00 0.00 19325 S 1,861.01 0.00 0.00<br />

17261 S 61.06 0.00 0.00 19328 S 837.66 0.00 0.00<br />

17262 S 61.06 0.00 0.00 19330 S 837.66 0.00 0.00<br />

17263 S 61.06 0.00 0.00 19340 S 1,032.55 0.00 0.00<br />

17264 S 61.06 0.00 0.00 19342 S 1,457.92 0.00 0.00<br />

17266 S 109.84 0.00 0.00 19350 S 738.75 0.00 0.00<br />

17270 S 61.06 0.00 0.00 19355 S 982.07 0.00 0.00<br />

17271 S 61.06 0.00 0.00 19357 S 1,558.57 0.00 0.00<br />

17272 S 61.06 0.00 0.00 19366 S 1,024.38 0.00 0.00<br />

17273 S 109.84 0.00 0.00 19370 S 982.07 0.00 0.00<br />

17274 S 109.84 0.00 0.00 19371 S 982.07 0.00 0.00<br />

17276 S 109.84 0.00 0.00 19380 S 1,164.33 0.00 0.00<br />

17280 S 61.06 0.00 0.00 19396 S 1,351.48 0.00 0.00<br />

17281 S 91.00 0.00 0.00 20000 S 56.87 0.00 0.00<br />

17282 S 103.95 0.00 0.00 20005 S 655.24 0.00 0.00<br />

17283 S 109.84 0.00 0.00 20103 S 643.05 0.00 0.00<br />

17284 S 109.84 0.00 0.00 20150 S 1,825.63 0.00 0.00<br />

17286 S 109.84 0.00 0.00 20200 S 536.82 0.00 0.00<br />

17311 S 181.33 0.00 0.00 20205 S 567.94 0.00 0.00<br />

17312 S 181.33 0.00 0.00 20206 S 265.39 0.00 0.00<br />

17313 S 181.33 0.00 0.00 20220 S 288.48 0.00 0.00<br />

17314 S 181.33 0.00 0.00 20225 S 523.44 0.00 0.00<br />

17315 S 41.01 0.00 0.00 20240 S 656.48 0.00 0.00<br />

17340 S 14.75 0.00 0.00 20245 S 687.61 0.00 0.00<br />

17360 S 33.33 0.00 0.00 20250 S 686.36 0.00 0.00<br />

17380 S 33.33 0.00 0.00 20251 S 686.36 0.00 0.00<br />

19000 S 69.42 0.00 0.00 20500 S 56.84 0.00 0.00<br />

19001 S 9.35 0.00 0.00 20520 S 95.68 0.00 0.00<br />

19020 S 607.07 0.00 0.00 20525 S 687.61 0.00 0.00<br />

19100 S 206.72 0.00 0.00 20526 S 30.94 0.00 0.00<br />

19101 S 649.28 0.00 0.00 20550 S 23.38 0.00 0.00<br />

19102 S 265.39 0.00 0.00 20551 S 23.02 0.00 0.00<br />

19103 S 464.50 0.00 0.00 20552 S 22.30 0.00 0.00<br />

19105 S 1,351.48 0.00 0.00 20553 S 24.82 0.00 0.00<br />

19110 S 649.28 0.00 0.00 20555 S 1,202.83 0.00 0.00<br />

19112 S 680.41 0.00 0.00 20600 S 23.74 0.00 0.00<br />

19120 S 680.41 0.00 0.00 20605 S 26.62 0.00 0.00<br />

19125 S 680.41 0.00 0.00 20610 S 37.41 0.00 0.00<br />

19126 S 680.41 0.00 0.00 20612 S 25.18 0.00 0.00<br />

19296 S 1,861.01 0.00 0.00 20615 S 105.39 0.00 0.00<br />

19297 S 1,861.01 0.00 0.00 20650 S 686.36 0.00 0.00<br />

19298 S 1,861.01 0.00 0.00 20662 S 876.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 876.76 0.00 0.00 21085 S 264.02 0.00 0.00<br />

20665 S 26.01 0.00 0.00 21086 S 574.78 0.00 0.00<br />

20670 S 481.88 0.00 0.00 21087 S 575.51 0.00 0.00<br />

20680 S 687.61 0.00 0.00 21088 S 1,685.57 0.00 0.00<br />

20690 S 818.27 0.00 0.00 21100 S 1,059.64 0.00 0.00<br />

20692 S 849.40 0.00 0.00 21110 S 303.23 0.00 0.00<br />

20693 S 686.36 0.00 0.00 21120 S 982.05 0.00 0.00<br />

20694 S 600.29 0.00 0.00 21121 S 982.05 0.00 0.00<br />

20696 S 1,202.83 0.00 0.00 21122 S 982.05 0.00 0.00<br />

20697 S 799.93 0.00 0.00 21123 S 982.05 0.00 0.00<br />

20822 S 1,127.07 0.00 0.00 21125 S 982.05 0.00 0.00<br />

20900 S 849.40 0.00 0.00 21127 S 1,493.85 0.00 0.00<br />

20902 S 907.74 0.00 0.00 21137 S 996.50 0.00 0.00<br />

20910 S 671.96 0.00 0.00 21138 S 1,685.57 0.00 0.00<br />

20912 S 671.96 0.00 0.00 21139 S 1,685.57 0.00 0.00<br />

20920 S 627.85 0.00 0.00 21150 S 1,685.57 0.00 0.00<br />

20922 S 569.50 0.00 0.00 21181 S 982.05 0.00 0.00<br />

20924 S 907.74 0.00 0.00 21198 S 1,685.57 0.00 0.00<br />

20926 S 395.50 0.00 0.00 21199 S 1,685.57 0.00 0.00<br />

20950 S 56.87 0.00 0.00 21206 S 1,191.41 0.00 0.00<br />

20972 S 1,903.65 0.00 0.00 21208 S 1,326.59 0.00 0.00<br />

20973 S 1,903.65 0.00 0.00 21209 S 1,191.41 0.00 0.00<br />

20979 S 23.38 0.00 0.00 21210 S 1,326.59 0.00 0.00<br />

20982 S 1,825.63 0.00 0.00 21215 S 1,326.59 0.00 0.00<br />

21010 S 715.10 0.00 0.00 21230 S 1,326.59 0.00 0.00<br />

21015 S 594.97 0.00 0.00 21235 S 982.05 0.00 0.00<br />

21025 S 1,059.64 0.00 0.00 21240 S 1,149.11 0.00 0.00<br />

21026 S 1,059.64 0.00 0.00 21242 S 1,191.41 0.00 0.00<br />

21029 S 1,059.64 0.00 0.00 21243 S 1,191.41 0.00 0.00<br />

21030 S 249.98 0.00 0.00 21244 S 1,326.59 0.00 0.00<br />

21031 S 206.82 0.00 0.00 21245 S 1,326.59 0.00 0.00<br />

21032 S 210.78 0.00 0.00 21246 S 1,326.59 0.00 0.00<br />

21034 S 1,090.77 0.00 0.00 21248 S 1,326.59 0.00 0.00<br />

21040 S 715.10 0.00 0.00 21249 S 1,326.59 0.00 0.00<br />

21044 S 1,059.64 0.00 0.00 21260 S 1,685.57 0.00 0.00<br />

21046 S 1,059.64 0.00 0.00 21267 S 1,326.59 0.00 0.00<br />

21047 S 1,059.64 0.00 0.00 21270 S 1,191.41 0.00 0.00<br />

21048 S 1,685.57 0.00 0.00 21275 S 1,326.59 0.00 0.00<br />

21050 S 1,090.77 0.00 0.00 21280 S 1,191.41 0.00 0.00<br />

21060 S 1,059.64 0.00 0.00 21282 S 695.62 0.00 0.00<br />

21070 S 1,090.77 0.00 0.00 21295 S 313.53 0.00 0.00<br />

21073 S 194.23 0.00 0.00 21296 S 660.16 0.00 0.00<br />

21076 S 337.03 0.00 0.00 21310 S 95.64 0.00 0.00<br />

21077 S 814.70 0.00 0.00 21315 S 420.27 0.00 0.00<br />

21079 S 583.42 0.00 0.00 21320 S 563.84 0.00 0.00<br />

21080 S 669.03 0.00 0.00 21325 S 804.57 0.00 0.00<br />

21081 S 616.51 0.00 0.00 21330 S 846.88 0.00 0.00<br />

21082 S 586.66 0.00 0.00 21335 S 982.05 0.00 0.00<br />

21083 S 578.03 0.00 0.00 21336 S 818.43 0.00 0.00<br />

21084 S 665.07 0.00 0.00 21337 S 563.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 804.57 0.00 0.00 22310 S 174.12 0.00 0.00<br />

21339 S 846.88 0.00 0.00 22315 S 450.35 0.00 0.00<br />

21340 S 1,149.11 0.00 0.00 22505 S 530.17 0.00 0.00<br />

21345 S 982.05 0.00 0.00 22520 S 1,252.48 0.00 0.00<br />

21355 S 1,090.77 0.00 0.00 22521 S 1,252.48 0.00 0.00<br />

21356 S 746.23 0.00 0.00 22522 S 1,252.48 0.00 0.00<br />

21360 S 996.50 0.00 0.00 22523 S 3,485.77 0.00 0.00<br />

21390 S 1,685.57 0.00 0.00 22524 S 3,485.77 0.00 0.00<br />

21400 S 368.47 0.00 0.00 22525 S 3,485.77 0.00 0.00<br />

21401 S 594.97 0.00 0.00 22900 S 745.95 0.00 0.00<br />

21406 S 1,685.57 0.00 0.00 23000 S 536.82 0.00 0.00<br />

21407 S 1,685.57 0.00 0.00 23020 S 1,129.67 0.00 0.00<br />

21421 S 804.57 0.00 0.00 23030 S 552.12 0.00 0.00<br />

21440 S 338.83 0.00 0.00 23031 S 638.18 0.00 0.00<br />

21445 S 804.57 0.00 0.00 23035 S 686.36 0.00 0.00<br />

21450 S 139.84 0.00 0.00 23040 S 849.40 0.00 0.00<br />

21451 S 377.30 0.00 0.00 23044 S 907.74 0.00 0.00<br />

21452 S 563.84 0.00 0.00 23065 S 101.44 0.00 0.00<br />

21453 S 1,090.77 0.00 0.00 23066 S 656.48 0.00 0.00<br />

21454 S 846.88 0.00 0.00 23075 S 536.82 0.00 0.00<br />

21461 S 1,149.11 0.00 0.00 23076 S 656.48 0.00 0.00<br />

21462 S 1,191.41 0.00 0.00 23077 S 687.61 0.00 0.00<br />

21465 S 1,149.11 0.00 0.00 23100 S 655.24 0.00 0.00<br />

21480 S 95.64 0.00 0.00 23101 S 1,085.22 0.00 0.00<br />

21485 S 563.84 0.00 0.00 23105 S 907.74 0.00 0.00<br />

21490 S 1,090.77 0.00 0.00 23106 S 907.74 0.00 0.00<br />

21495 S 693.97 0.00 0.00 23107 S 907.74 0.00 0.00<br />

21497 S 563.84 0.00 0.00 23120 S 950.05 0.00 0.00<br />

21501 S 607.07 0.00 0.00 23125 S 950.05 0.00 0.00<br />

21502 S 655.24 0.00 0.00 23130 S 1,261.43 0.00 0.00<br />

21550 S 639.93 0.00 0.00 23140 S 744.70 0.00 0.00<br />

21555 S 656.48 0.00 0.00 23145 S 950.05 0.00 0.00<br />

21556 S 656.48 0.00 0.00 23146 S 950.05 0.00 0.00<br />

21557 S 879.25 0.00 0.00 23150 S 907.74 0.00 0.00<br />

21600 S 818.27 0.00 0.00 23155 S 950.05 0.00 0.00<br />

21610 S 818.27 0.00 0.00 23156 S 950.05 0.00 0.00<br />

21685 S 303.23 0.00 0.00 23170 S 818.27 0.00 0.00<br />

21700 S 655.24 0.00 0.00 23172 S 818.27 0.00 0.00<br />

21720 S 686.36 0.00 0.00 23174 S 818.27 0.00 0.00<br />

21725 S 71.45 0.00 0.00 23180 S 907.74 0.00 0.00<br />

21800 S 82.54 0.00 0.00 23182 S 907.74 0.00 0.00<br />

21805 S 728.97 0.00 0.00 23184 S 907.74 0.00 0.00<br />

21820 S 82.54 0.00 0.00 23190 S 907.74 0.00 0.00<br />

21920 S 146.75 0.00 0.00 23195 S 950.05 0.00 0.00<br />

21925 S 656.48 0.00 0.00 23330 S 328.09 0.00 0.00<br />

21930 S 656.48 0.00 0.00 23331 S 601.54 0.00 0.00<br />

21935 S 687.61 0.00 0.00 23395 S 1,261.43 0.00 0.00<br />

22102 S 1,956.59 0.00 0.00 23397 S 2,226.69 0.00 0.00<br />

22103 S 1,956.59 0.00 0.00 23400 S 1,085.22 0.00 0.00<br />

22305 S 82.54 0.00 0.00 23405 S 818.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 818.27 0.00 0.00 23931 S 607.07 0.00 0.00<br />

23410 S 1,261.43 0.00 0.00 23935 S 655.24 0.00 0.00<br />

23412 S 1,396.61 0.00 0.00 24000 S 907.74 0.00 0.00<br />

23415 S 1,261.43 0.00 0.00 24006 S 907.74 0.00 0.00<br />

23420 S 1,396.61 0.00 0.00 24065 S 140.64 0.00 0.00<br />

23430 S 1,219.14 0.00 0.00 24066 S 536.82 0.00 0.00<br />

23440 S 1,219.14 0.00 0.00 24075 S 536.82 0.00 0.00<br />

23450 S 2,091.52 0.00 0.00 24076 S 656.48 0.00 0.00<br />

23455 S 2,226.69 0.00 0.00 24077 S 687.61 0.00 0.00<br />

23460 S 2,091.52 0.00 0.00 24100 S 600.29 0.00 0.00<br />

23462 S 1,396.61 0.00 0.00 24101 S 907.74 0.00 0.00<br />

23465 S 2,091.52 0.00 0.00 24102 S 907.74 0.00 0.00<br />

23466 S 1,396.61 0.00 0.00 24105 S 686.36 0.00 0.00<br />

23480 S 1,219.14 0.00 0.00 24110 S 655.24 0.00 0.00<br />

23485 S 2,226.69 0.00 0.00 24115 S 849.40 0.00 0.00<br />

23490 S 1,160.79 0.00 0.00 24116 S 849.40 0.00 0.00<br />

23491 S 1,990.87 0.00 0.00 24120 S 686.36 0.00 0.00<br />

23500 S 82.54 0.00 0.00 24125 S 849.40 0.00 0.00<br />

23505 S 450.35 0.00 0.00 24126 S 849.40 0.00 0.00<br />

23515 S 1,507.29 0.00 0.00 24130 S 849.40 0.00 0.00<br />

23520 S 174.12 0.00 0.00 24134 S 818.27 0.00 0.00<br />

23525 S 174.12 0.00 0.00 24136 S 818.27 0.00 0.00<br />

23530 S 1,110.72 0.00 0.00 24138 S 818.27 0.00 0.00<br />

23532 S 818.43 0.00 0.00 24140 S 849.40 0.00 0.00<br />

23540 S 82.54 0.00 0.00 24145 S 849.40 0.00 0.00<br />

23545 S 174.12 0.00 0.00 24147 S 818.27 0.00 0.00<br />

23550 S 1,110.72 0.00 0.00 24149 S 1,202.83 0.00 0.00<br />

23552 S 1,169.07 0.00 0.00 24152 S 1,825.63 0.00 0.00<br />

23570 S 82.54 0.00 0.00 24153 S 3,485.77 0.00 0.00<br />

23575 S 174.12 0.00 0.00 24155 S 1,160.79 0.00 0.00<br />

23585 S 1,507.29 0.00 0.00 24160 S 818.27 0.00 0.00<br />

23600 S 64.32 0.00 0.00 24164 S 849.40 0.00 0.00<br />

23605 S 450.35 0.00 0.00 24200 S 102.87 0.00 0.00<br />

23615 S 1,565.63 0.00 0.00 24201 S 536.82 0.00 0.00<br />

23616 S 1,565.63 0.00 0.00 24300 S 626.63 0.00 0.00<br />

23620 S 64.32 0.00 0.00 24301 S 907.74 0.00 0.00<br />

23625 S 450.35 0.00 0.00 24305 S 907.74 0.00 0.00<br />

23630 S 1,607.94 0.00 0.00 24310 S 686.36 0.00 0.00<br />

23650 S 82.54 0.00 0.00 24320 S 1,160.79 0.00 0.00<br />

23655 S 475.23 0.00 0.00 24330 S 1,990.87 0.00 0.00<br />

23660 S 1,110.72 0.00 0.00 24331 S 1,160.79 0.00 0.00<br />

23665 S 174.12 0.00 0.00 24332 S 876.76 0.00 0.00<br />

23670 S 1,507.29 0.00 0.00 24340 S 1,160.79 0.00 0.00<br />

23675 S 82.54 0.00 0.00 24341 S 1,160.79 0.00 0.00<br />

23680 S 1,110.72 0.00 0.00 24342 S 1,160.79 0.00 0.00<br />

23700 S 475.23 0.00 0.00 24343 S 1,202.83 0.00 0.00<br />

23800 S 2,049.21 0.00 0.00 24344 S 3,485.77 0.00 0.00<br />

23802 S 1,396.61 0.00 0.00 24345 S 818.27 0.00 0.00<br />

23921 S 478.71 0.00 0.00 24346 S 1,825.63 0.00 0.00<br />

23930 S 552.12 0.00 0.00 24357 S 1,202.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,202.83 0.00 0.00 24925 S 686.36 0.00 0.00<br />

24359 S 1,202.83 0.00 0.00 25000 S 686.36 0.00 0.00<br />

24360 S 1,110.04 0.00 0.00 25001 S 876.76 0.00 0.00<br />

24361 S 6,069.19 3,715.11 1,361.04 25020 S 686.36 0.00 0.00<br />

24362 S 1,418.63 0.00 0.00 25023 S 849.40 0.00 0.00<br />

24363 S 6,204.36 3,850.29 1,496.21 25024 S 849.40 0.00 0.00<br />

24365 S 1,110.04 0.00 0.00 25025 S 849.40 0.00 0.00<br />

24366 S 6,069.19 3,715.11 1,361.04 25028 S 600.29 0.00 0.00<br />

24400 S 907.74 0.00 0.00 25031 S 655.24 0.00 0.00<br />

24410 S 907.74 0.00 0.00 25035 S 655.24 0.00 0.00<br />

24420 S 1,160.79 0.00 0.00 25040 S 950.05 0.00 0.00<br />

24430 S 1,990.87 0.00 0.00 25065 S 142.79 0.00 0.00<br />

24435 S 2,049.21 0.00 0.00 25066 S 656.48 0.00 0.00<br />

24470 S 1,160.79 0.00 0.00 25075 S 536.82 0.00 0.00<br />

24495 S 818.27 0.00 0.00 25076 S 687.61 0.00 0.00<br />

24498 S 1,990.87 0.00 0.00 25077 S 687.61 0.00 0.00<br />

24500 S 82.54 0.00 0.00 25085 S 686.36 0.00 0.00<br />

24505 S 82.54 0.00 0.00 25100 S 655.24 0.00 0.00<br />

24515 S 1,565.63 0.00 0.00 25101 S 849.40 0.00 0.00<br />

24516 S 1,565.63 0.00 0.00 25105 S 907.74 0.00 0.00<br />

24530 S 82.54 0.00 0.00 25107 S 849.40 0.00 0.00<br />

24535 S 174.12 0.00 0.00 25109 S 876.76 0.00 0.00<br />

24538 S 728.97 0.00 0.00 25110 S 686.36 0.00 0.00<br />

24545 S 1,565.63 0.00 0.00 25111 S 686.36 0.00 0.00<br />

24546 S 1,607.94 0.00 0.00 25112 S 744.70 0.00 0.00<br />

24560 S 82.54 0.00 0.00 25115 S 744.70 0.00 0.00<br />

24565 S 82.54 0.00 0.00 25116 S 744.70 0.00 0.00<br />

24566 S 728.97 0.00 0.00 25118 S 818.27 0.00 0.00<br />

24575 S 1,507.29 0.00 0.00 25119 S 849.40 0.00 0.00<br />

24576 S 82.54 0.00 0.00 25120 S 849.40 0.00 0.00<br />

24577 S 174.12 0.00 0.00 25125 S 849.40 0.00 0.00<br />

24579 S 1,507.29 0.00 0.00 25126 S 849.40 0.00 0.00<br />

24582 S 728.97 0.00 0.00 25130 S 849.40 0.00 0.00<br />

24586 S 1,565.63 0.00 0.00 25135 S 849.40 0.00 0.00<br />

24587 S 1,607.94 0.00 0.00 25136 S 849.40 0.00 0.00<br />

24600 S 82.54 0.00 0.00 25145 S 818.27 0.00 0.00<br />

24605 S 530.17 0.00 0.00 25150 S 818.27 0.00 0.00<br />

24615 S 1,507.29 0.00 0.00 25151 S 818.27 0.00 0.00<br />

24620 S 450.35 0.00 0.00 25210 S 849.40 0.00 0.00<br />

24635 S 1,507.29 0.00 0.00 25215 S 907.74 0.00 0.00<br />

24640 S 55.75 0.00 0.00 25230 S 907.74 0.00 0.00<br />

24650 S 64.32 0.00 0.00 25240 S 907.74 0.00 0.00<br />

24655 S 174.12 0.00 0.00 25248 S 655.24 0.00 0.00<br />

24665 S 1,169.07 0.00 0.00 25250 S 763.33 0.00 0.00<br />

24666 S 1,565.63 0.00 0.00 25251 S 763.33 0.00 0.00<br />

24670 S 82.54 0.00 0.00 25259 S 799.93 0.00 0.00<br />

24675 S 82.54 0.00 0.00 25260 S 907.74 0.00 0.00<br />

24685 S 1,110.72 0.00 0.00 25263 S 818.27 0.00 0.00<br />

24800 S 1,219.14 0.00 0.00 25265 S 849.40 0.00 0.00<br />

24802 S 1,261.43 0.00 0.00 25270 S 907.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 849.40 0.00 0.00 25505 S 174.12 0.00 0.00<br />

25274 S 907.74 0.00 0.00 25515 S 1,110.72 0.00 0.00<br />

25275 S 907.74 0.00 0.00 25520 S 174.12 0.00 0.00<br />

25280 S 907.74 0.00 0.00 25525 S 1,169.07 0.00 0.00<br />

25290 S 849.40 0.00 0.00 25526 S 1,211.37 0.00 0.00<br />

25295 S 686.36 0.00 0.00 25530 S 64.32 0.00 0.00<br />

25300 S 849.40 0.00 0.00 25535 S 82.54 0.00 0.00<br />

25301 S 849.40 0.00 0.00 25545 S 1,110.72 0.00 0.00<br />

25310 S 1,160.79 0.00 0.00 25560 S 64.32 0.00 0.00<br />

25312 S 1,219.14 0.00 0.00 25565 S 174.12 0.00 0.00<br />

25315 S 1,160.79 0.00 0.00 25574 S 1,507.29 0.00 0.00<br />

25316 S 1,990.87 0.00 0.00 25575 S 1,507.29 0.00 0.00<br />

25320 S 1,160.79 0.00 0.00 25600 S 64.32 0.00 0.00<br />

25332 S 1,110.04 0.00 0.00 25605 S 174.12 0.00 0.00<br />

25335 S 1,160.79 0.00 0.00 25606 S 760.09 0.00 0.00<br />

25337 S 1,261.43 0.00 0.00 25607 S 1,607.94 0.00 0.00<br />

25350 S 1,990.87 0.00 0.00 25608 S 1,607.94 0.00 0.00<br />

25355 S 1,160.79 0.00 0.00 25609 S 1,607.94 0.00 0.00<br />

25360 S 849.40 0.00 0.00 25622 S 64.32 0.00 0.00<br />

25365 S 849.40 0.00 0.00 25624 S 174.12 0.00 0.00<br />

25370 S 1,160.79 0.00 0.00 25628 S 1,110.72 0.00 0.00<br />

25375 S 1,219.14 0.00 0.00 25630 S 64.32 0.00 0.00<br />

25390 S 849.40 0.00 0.00 25635 S 174.12 0.00 0.00<br />

25391 S 1,219.14 0.00 0.00 25645 S 1,110.72 0.00 0.00<br />

25392 S 849.40 0.00 0.00 25650 S 64.32 0.00 0.00<br />

25393 S 1,219.14 0.00 0.00 25651 S 1,024.22 0.00 0.00<br />

25394 S 1,825.63 0.00 0.00 25652 S 1,725.48 0.00 0.00<br />

25400 S 1,160.79 0.00 0.00 25660 S 82.54 0.00 0.00<br />

25405 S 2,049.21 0.00 0.00 25670 S 760.09 0.00 0.00<br />

25415 S 1,990.87 0.00 0.00 25671 S 674.03 0.00 0.00<br />

25420 S 2,049.21 0.00 0.00 25675 S 82.54 0.00 0.00<br />

25425 S 1,160.79 0.00 0.00 25676 S 728.97 0.00 0.00<br />

25426 S 1,219.14 0.00 0.00 25680 S 82.54 0.00 0.00<br />

25430 S 1,825.63 0.00 0.00 25685 S 760.09 0.00 0.00<br />

25431 S 1,825.63 0.00 0.00 25690 S 450.35 0.00 0.00<br />

25440 S 2,049.21 0.00 0.00 25695 S 728.97 0.00 0.00<br />

25441 S 6,069.19 3,715.11 1,361.04 25800 S 2,049.21 0.00 0.00<br />

25442 S 6,069.19 3,715.11 1,361.04 25805 S 1,261.43 0.00 0.00<br />

25443 S 1,418.63 0.00 0.00 25810 S 2,091.52 0.00 0.00<br />

25444 S 1,418.63 0.00 0.00 25820 S 1,219.14 0.00 0.00<br />

25445 S 1,418.63 0.00 0.00 25825 S 2,091.52 0.00 0.00<br />

25446 S 6,204.36 3,850.29 1,496.21 25830 S 2,091.52 0.00 0.00<br />

25447 S 1,110.04 0.00 0.00 25907 S 686.36 0.00 0.00<br />

25449 S 1,110.04 0.00 0.00 25922 S 686.36 0.00 0.00<br />

25450 S 1,160.79 0.00 0.00 25929 S 569.50 0.00 0.00<br />

25455 S 1,160.79 0.00 0.00 25931 S 876.76 0.00 0.00<br />

25490 S 1,160.79 0.00 0.00 26010 S 56.87 0.00 0.00<br />

25491 S 1,160.79 0.00 0.00 26011 S 415.42 0.00 0.00<br />

25492 S 1,160.79 0.00 0.00 26020 S 551.21 0.00 0.00<br />

25500 S 64.32 0.00 0.00 26025 S 496.26 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 551.21 0.00 0.00 26392 S 811.51 0.00 0.00<br />

26034 S 551.21 0.00 0.00 26410 S 582.32 0.00 0.00<br />

26035 S 668.69 0.00 0.00 26412 S 811.51 0.00 0.00<br />

26040 S 869.87 0.00 0.00 26415 S 869.87 0.00 0.00<br />

26045 S 811.51 0.00 0.00 26416 S 811.51 0.00 0.00<br />

26055 S 551.21 0.00 0.00 26418 S 640.68 0.00 0.00<br />

26060 S 551.21 0.00 0.00 26420 S 869.87 0.00 0.00<br />

26070 S 551.21 0.00 0.00 26426 S 811.51 0.00 0.00<br />

26075 S 640.68 0.00 0.00 26428 S 811.51 0.00 0.00<br />

26080 S 640.68 0.00 0.00 26432 S 582.32 0.00 0.00<br />

26100 S 551.21 0.00 0.00 26433 S 582.32 0.00 0.00<br />

26105 S 496.26 0.00 0.00 26434 S 811.51 0.00 0.00<br />

26110 S 496.26 0.00 0.00 26437 S 582.32 0.00 0.00<br />

26115 S 656.48 0.00 0.00 26440 S 582.32 0.00 0.00<br />

26116 S 656.48 0.00 0.00 26442 S 811.51 0.00 0.00<br />

26117 S 687.61 0.00 0.00 26445 S 582.32 0.00 0.00<br />

26121 S 869.87 0.00 0.00 26449 S 811.51 0.00 0.00<br />

26123 S 869.87 0.00 0.00 26450 S 582.32 0.00 0.00<br />

26125 S 640.68 0.00 0.00 26455 S 582.32 0.00 0.00<br />

26130 S 582.32 0.00 0.00 26460 S 582.32 0.00 0.00<br />

26135 S 869.87 0.00 0.00 26471 S 551.21 0.00 0.00<br />

26140 S 551.21 0.00 0.00 26474 S 551.21 0.00 0.00<br />

26145 S 582.32 0.00 0.00 26476 S 496.26 0.00 0.00<br />

26160 S 582.32 0.00 0.00 26477 S 496.26 0.00 0.00<br />

26170 S 582.32 0.00 0.00 26478 S 496.26 0.00 0.00<br />

26180 S 582.32 0.00 0.00 26479 S 496.26 0.00 0.00<br />

26185 S 640.68 0.00 0.00 26480 S 811.51 0.00 0.00<br />

26200 S 551.21 0.00 0.00 26483 S 811.51 0.00 0.00<br />

26205 S 811.51 0.00 0.00 26485 S 780.40 0.00 0.00<br />

26210 S 551.21 0.00 0.00 26489 S 811.51 0.00 0.00<br />

26215 S 582.32 0.00 0.00 26490 S 811.51 0.00 0.00<br />

26230 S 817.15 0.00 0.00 26492 S 811.51 0.00 0.00<br />

26235 S 582.32 0.00 0.00 26494 S 811.51 0.00 0.00<br />

26236 S 582.32 0.00 0.00 26496 S 811.51 0.00 0.00<br />

26250 S 582.32 0.00 0.00 26497 S 811.51 0.00 0.00<br />

26255 S 811.51 0.00 0.00 26498 S 869.87 0.00 0.00<br />

26260 S 582.32 0.00 0.00 26499 S 811.51 0.00 0.00<br />

26261 S 582.32 0.00 0.00 26500 S 640.68 0.00 0.00<br />

26262 S 551.21 0.00 0.00 26502 S 869.87 0.00 0.00<br />

26320 S 536.82 0.00 0.00 26508 S 582.32 0.00 0.00<br />

26340 S 247.47 0.00 0.00 26510 S 811.51 0.00 0.00<br />

26350 S 725.45 0.00 0.00 26516 S 725.45 0.00 0.00<br />

26352 S 869.87 0.00 0.00 26517 S 811.51 0.00 0.00<br />

26356 S 869.87 0.00 0.00 26518 S 811.51 0.00 0.00<br />

26357 S 869.87 0.00 0.00 26520 S 582.32 0.00 0.00<br />

26358 S 869.87 0.00 0.00 26525 S 582.32 0.00 0.00<br />

26370 S 869.87 0.00 0.00 26530 S 1,009.40 0.00 0.00<br />

26372 S 869.87 0.00 0.00 26531 S 1,553.80 0.00 0.00<br />

26373 S 811.51 0.00 0.00 26535 S 1,110.04 0.00 0.00<br />

26390 S 869.87 0.00 0.00 26536 S 1,418.63 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 640.68 0.00 0.00 26775 S 171.93 0.00 0.00<br />

26541 S 1,047.33 0.00 0.00 26776 S 728.97 0.00 0.00<br />

26542 S 640.68 0.00 0.00 26785 S 728.97 0.00 0.00<br />

26545 S 869.87 0.00 0.00 26820 S 912.16 0.00 0.00<br />

26546 S 869.87 0.00 0.00 26841 S 869.87 0.00 0.00<br />

26548 S 869.87 0.00 0.00 26842 S 869.87 0.00 0.00<br />

26550 S 780.40 0.00 0.00 26843 S 811.51 0.00 0.00<br />

26555 S 811.51 0.00 0.00 26844 S 811.51 0.00 0.00<br />

26560 S 551.21 0.00 0.00 26850 S 869.87 0.00 0.00<br />

26561 S 811.51 0.00 0.00 26852 S 869.87 0.00 0.00<br />

26562 S 869.87 0.00 0.00 26860 S 811.51 0.00 0.00<br />

26565 S 912.16 0.00 0.00 26861 S 780.40 0.00 0.00<br />

26567 S 912.16 0.00 0.00 26862 S 869.87 0.00 0.00<br />

26568 S 811.51 0.00 0.00 26863 S 811.51 0.00 0.00<br />

26580 S 682.97 0.00 0.00 26910 S 811.51 0.00 0.00<br />

26587 S 682.97 0.00 0.00 26951 S 551.21 0.00 0.00<br />

26590 S 682.97 0.00 0.00 26952 S 640.68 0.00 0.00<br />

26591 S 811.51 0.00 0.00 26990 S 600.29 0.00 0.00<br />

26593 S 582.32 0.00 0.00 26991 S 600.29 0.00 0.00<br />

26596 S 551.21 0.00 0.00 27000 S 655.24 0.00 0.00<br />

26600 S 64.32 0.00 0.00 27001 S 849.40 0.00 0.00<br />

26605 S 82.54 0.00 0.00 27003 S 849.40 0.00 0.00<br />

26607 S 450.35 0.00 0.00 27033 S 1,160.79 0.00 0.00<br />

26608 S 818.43 0.00 0.00 27035 S 1,219.14 0.00 0.00<br />

26615 S 1,169.07 0.00 0.00 27040 S 328.09 0.00 0.00<br />

26641 S 64.32 0.00 0.00 27041 S 369.66 0.00 0.00<br />

26645 S 174.12 0.00 0.00 27047 S 656.48 0.00 0.00<br />

26650 S 728.97 0.00 0.00 27048 S 687.61 0.00 0.00<br />

26665 S 1,169.07 0.00 0.00 27049 S 687.61 0.00 0.00<br />

26670 S 64.32 0.00 0.00 27050 S 686.36 0.00 0.00<br />

26675 S 174.12 0.00 0.00 27052 S 686.36 0.00 0.00<br />

26676 S 728.97 0.00 0.00 27060 S 787.01 0.00 0.00<br />

26685 S 760.09 0.00 0.00 27062 S 787.01 0.00 0.00<br />

26686 S 1,507.29 0.00 0.00 27065 S 787.01 0.00 0.00<br />

26700 S 64.32 0.00 0.00 27066 S 950.05 0.00 0.00<br />

26705 S 82.54 0.00 0.00 27067 S 950.05 0.00 0.00<br />

26706 S 450.35 0.00 0.00 27080 S 818.27 0.00 0.00<br />

26715 S 818.43 0.00 0.00 27086 S 328.09 0.00 0.00<br />

26720 S 64.32 0.00 0.00 27087 S 686.36 0.00 0.00<br />

26725 S 64.32 0.00 0.00 27097 S 849.40 0.00 0.00<br />

26727 S 995.91 0.00 0.00 27098 S 849.40 0.00 0.00<br />

26735 S 818.43 0.00 0.00 27100 S 1,219.14 0.00 0.00<br />

26740 S 64.32 0.00 0.00 27105 S 1,219.14 0.00 0.00<br />

26742 S 82.54 0.00 0.00 27110 S 1,219.14 0.00 0.00<br />

26746 S 860.74 0.00 0.00 27111 S 1,219.14 0.00 0.00<br />

26750 S 64.32 0.00 0.00 27193 S 82.54 0.00 0.00<br />

26755 S 64.32 0.00 0.00 27194 S 530.17 0.00 0.00<br />

26756 S 728.97 0.00 0.00 27200 S 64.32 0.00 0.00<br />

26765 S 818.43 0.00 0.00 27202 S 1,079.61 0.00 0.00<br />

26770 S 64.32 0.00 0.00 27220 S 64.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 82.54 0.00 0.00 27397 S 1,160.79 0.00 0.00<br />

27238 S 174.12 0.00 0.00 27400 S 1,160.79 0.00 0.00<br />

27246 S 174.12 0.00 0.00 27403 S 907.74 0.00 0.00<br />

27250 S 82.54 0.00 0.00 27405 S 1,219.14 0.00 0.00<br />

27252 S 530.17 0.00 0.00 27407 S 2,049.21 0.00 0.00<br />

27256 S 64.32 0.00 0.00 27409 S 1,219.14 0.00 0.00<br />

27257 S 561.30 0.00 0.00 27416 S 1,825.63 0.00 0.00<br />

27265 S 82.54 0.00 0.00 27418 S 1,160.79 0.00 0.00<br />

27266 S 530.17 0.00 0.00 27420 S 1,160.79 0.00 0.00<br />

27267 S 64.32 0.00 0.00 27422 S 1,396.61 0.00 0.00<br />

27275 S 530.17 0.00 0.00 27424 S 1,160.79 0.00 0.00<br />

27301 S 638.18 0.00 0.00 27425 S 1,085.22 0.00 0.00<br />

27305 S 655.24 0.00 0.00 27427 S 1,160.79 0.00 0.00<br />

27306 S 686.36 0.00 0.00 27428 S 2,049.21 0.00 0.00<br />

27307 S 686.36 0.00 0.00 27429 S 2,049.21 0.00 0.00<br />

27310 S 907.74 0.00 0.00 27430 S 1,219.14 0.00 0.00<br />

27323 S 328.09 0.00 0.00 27435 S 1,219.14 0.00 0.00<br />

27324 S 601.54 0.00 0.00 27437 S 1,067.74 0.00 0.00<br />

27325 S 589.42 0.00 0.00 27438 S 1,418.63 0.00 0.00<br />

27326 S 589.42 0.00 0.00 27440 S 1,522.83 0.00 0.00<br />

27327 S 656.48 0.00 0.00 27441 S 1,110.04 0.00 0.00<br />

27328 S 687.61 0.00 0.00 27442 S 1,110.04 0.00 0.00<br />

27329 S 745.95 0.00 0.00 27443 S 1,110.04 0.00 0.00<br />

27330 S 907.74 0.00 0.00 27446 S 10,891.68 6,543.23 2,194.77<br />

27331 S 907.74 0.00 0.00 27496 S 787.01 0.00 0.00<br />

27332 S 907.74 0.00 0.00 27497 S 686.36 0.00 0.00<br />

27333 S 907.74 0.00 0.00 27498 S 686.36 0.00 0.00<br />

27334 S 907.74 0.00 0.00 27499 S 686.36 0.00 0.00<br />

27335 S 907.74 0.00 0.00 27500 S 174.12 0.00 0.00<br />

27340 S 686.36 0.00 0.00 27501 S 82.54 0.00 0.00<br />

27345 S 744.70 0.00 0.00 27502 S 450.35 0.00 0.00<br />

27347 S 744.70 0.00 0.00 27503 S 82.54 0.00 0.00<br />

27350 S 907.74 0.00 0.00 27508 S 82.54 0.00 0.00<br />

27355 S 849.40 0.00 0.00 27509 S 760.09 0.00 0.00<br />

27356 S 907.74 0.00 0.00 27510 S 174.12 0.00 0.00<br />

27357 S 950.05 0.00 0.00 27516 S 82.54 0.00 0.00<br />

27358 S 950.05 0.00 0.00 27517 S 82.54 0.00 0.00<br />

27360 S 950.05 0.00 0.00 27520 S 82.54 0.00 0.00<br />

27372 S 923.43 0.00 0.00 27530 S 82.54 0.00 0.00<br />

27380 S 600.29 0.00 0.00 27532 S 450.35 0.00 0.00<br />

27381 S 686.36 0.00 0.00 27538 S 82.54 0.00 0.00<br />

27385 S 686.36 0.00 0.00 27550 S 82.54 0.00 0.00<br />

27386 S 686.36 0.00 0.00 27552 S 475.23 0.00 0.00<br />

27390 S 600.29 0.00 0.00 27560 S 82.54 0.00 0.00<br />

27391 S 655.24 0.00 0.00 27562 S 475.23 0.00 0.00<br />

27392 S 686.36 0.00 0.00 27566 S 1,079.61 0.00 0.00<br />

27393 S 818.27 0.00 0.00 27570 S 475.23 0.00 0.00<br />

27394 S 849.40 0.00 0.00 27594 S 686.36 0.00 0.00<br />

27395 S 1,160.79 0.00 0.00 27600 S 686.36 0.00 0.00<br />

27396 S 849.40 0.00 0.00 27601 S 686.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 686.36 0.00 0.00 27730 S 818.27 0.00 0.00<br />

27603 S 607.07 0.00 0.00 27732 S 818.27 0.00 0.00<br />

27604 S 655.24 0.00 0.00 27734 S 818.27 0.00 0.00<br />

27605 S 597.07 0.00 0.00 27740 S 818.27 0.00 0.00<br />

27606 S 600.29 0.00 0.00 27742 S 1,129.67 0.00 0.00<br />

27607 S 655.24 0.00 0.00 27745 S 1,990.87 0.00 0.00<br />

27610 S 818.27 0.00 0.00 27750 S 82.54 0.00 0.00<br />

27612 S 849.40 0.00 0.00 27752 S 450.35 0.00 0.00<br />

27613 S 134.88 0.00 0.00 27756 S 760.09 0.00 0.00<br />

27614 S 656.48 0.00 0.00 27758 S 1,169.07 0.00 0.00<br />

27615 S 849.40 0.00 0.00 27759 S 1,565.63 0.00 0.00<br />

27618 S 536.82 0.00 0.00 27760 S 82.54 0.00 0.00<br />

27619 S 687.61 0.00 0.00 27762 S 450.35 0.00 0.00<br />

27620 S 907.74 0.00 0.00 27766 S 1,110.72 0.00 0.00<br />

27625 S 907.74 0.00 0.00 27767 S 64.32 0.00 0.00<br />

27626 S 907.74 0.00 0.00 27768 S 64.32 0.00 0.00<br />

27630 S 686.36 0.00 0.00 27769 S 1,725.48 0.00 0.00<br />

27635 S 849.40 0.00 0.00 27780 S 82.54 0.00 0.00<br />

27637 S 849.40 0.00 0.00 27781 S 450.35 0.00 0.00<br />

27638 S 849.40 0.00 0.00 27784 S 1,110.72 0.00 0.00<br />

27640 S 1,129.67 0.00 0.00 27786 S 82.54 0.00 0.00<br />

27641 S 818.27 0.00 0.00 27788 S 82.54 0.00 0.00<br />

27647 S 1,160.79 0.00 0.00 27792 S 1,110.72 0.00 0.00<br />

27650 S 1,160.79 0.00 0.00 27808 S 82.54 0.00 0.00<br />

27652 S 1,990.87 0.00 0.00 27810 S 174.12 0.00 0.00<br />

27654 S 1,160.79 0.00 0.00 27814 S 1,110.72 0.00 0.00<br />

27656 S 655.24 0.00 0.00 27816 S 82.54 0.00 0.00<br />

27658 S 600.29 0.00 0.00 27818 S 174.12 0.00 0.00<br />

27659 S 655.24 0.00 0.00 27822 S 1,110.72 0.00 0.00<br />

27664 S 655.24 0.00 0.00 27823 S 1,507.29 0.00 0.00<br />

27665 S 818.27 0.00 0.00 27824 S 82.54 0.00 0.00<br />

27675 S 655.24 0.00 0.00 27825 S 450.35 0.00 0.00<br />

27676 S 849.40 0.00 0.00 27826 S 1,110.72 0.00 0.00<br />

27680 S 849.40 0.00 0.00 27827 S 1,507.29 0.00 0.00<br />

27681 S 818.27 0.00 0.00 27828 S 1,565.63 0.00 0.00<br />

27685 S 849.40 0.00 0.00 27829 S 1,079.61 0.00 0.00<br />

27686 S 849.40 0.00 0.00 27830 S 82.54 0.00 0.00<br />

27687 S 849.40 0.00 0.00 27831 S 450.35 0.00 0.00<br />

27690 S 1,219.14 0.00 0.00 27832 S 1,079.61 0.00 0.00<br />

27691 S 1,219.14 0.00 0.00 27840 S 174.12 0.00 0.00<br />

27692 S 1,160.79 0.00 0.00 27842 S 475.23 0.00 0.00<br />

27695 S 818.27 0.00 0.00 27846 S 1,110.72 0.00 0.00<br />

27696 S 818.27 0.00 0.00 27848 S 1,110.72 0.00 0.00<br />

27698 S 818.27 0.00 0.00 27860 S 475.23 0.00 0.00<br />

27700 S 1,110.04 0.00 0.00 27870 S 2,049.21 0.00 0.00<br />

27704 S 655.24 0.00 0.00 27871 S 2,049.21 0.00 0.00<br />

27705 S 1,129.67 0.00 0.00 27884 S 686.36 0.00 0.00<br />

27707 S 655.24 0.00 0.00 27889 S 849.40 0.00 0.00<br />

27709 S 818.27 0.00 0.00 27892 S 686.36 0.00 0.00<br />

27726 S 1,024.22 0.00 0.00 27893 S 686.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 686.36 0.00 0.00 28153 S 683.14 0.00 0.00<br />

28001 S 131.64 0.00 0.00 28160 S 683.14 0.00 0.00<br />

28002 S 686.36 0.00 0.00 28171 S 683.14 0.00 0.00<br />

28003 S 686.36 0.00 0.00 28173 S 683.14 0.00 0.00<br />

28005 S 683.14 0.00 0.00 28175 S 683.14 0.00 0.00<br />

28008 S 683.14 0.00 0.00 28190 S 135.96 0.00 0.00<br />

28010 S 96.76 0.00 0.00 28192 S 536.82 0.00 0.00<br />

28011 S 683.14 0.00 0.00 28193 S 369.66 0.00 0.00<br />

28020 S 652.01 0.00 0.00 28200 S 683.14 0.00 0.00<br />

28022 S 652.01 0.00 0.00 28202 S 683.14 0.00 0.00<br />

28024 S 652.01 0.00 0.00 28208 S 683.14 0.00 0.00<br />

28035 S 678.89 0.00 0.00 28210 S 1,199.80 0.00 0.00<br />

28043 S 656.48 0.00 0.00 28220 S 209.70 0.00 0.00<br />

28045 S 683.14 0.00 0.00 28222 S 597.07 0.00 0.00<br />

28046 S 683.14 0.00 0.00 28225 S 597.07 0.00 0.00<br />

28050 S 652.01 0.00 0.00 28226 S 597.07 0.00 0.00<br />

28052 S 652.01 0.00 0.00 28230 S 205.74 0.00 0.00<br />

28054 S 652.01 0.00 0.00 28232 S 196.75 0.00 0.00<br />

28055 S 678.89 0.00 0.00 28234 S 652.01 0.00 0.00<br />

28060 S 652.01 0.00 0.00 28238 S 1,199.80 0.00 0.00<br />

28062 S 683.14 0.00 0.00 28240 S 652.01 0.00 0.00<br />

28070 S 683.14 0.00 0.00 28250 S 683.14 0.00 0.00<br />

28072 S 683.14 0.00 0.00 28260 S 683.14 0.00 0.00<br />

28080 S 683.14 0.00 0.00 28261 S 683.14 0.00 0.00<br />

28086 S 652.01 0.00 0.00 28262 S 741.48 0.00 0.00<br />

28088 S 652.01 0.00 0.00 28264 S 1,113.73 0.00 0.00<br />

28090 S 683.14 0.00 0.00 28270 S 683.14 0.00 0.00<br />

28092 S 683.14 0.00 0.00 28272 S 189.92 0.00 0.00<br />

28100 S 652.01 0.00 0.00 28280 S 652.01 0.00 0.00<br />

28102 S 1,199.80 0.00 0.00 28285 S 683.14 0.00 0.00<br />

28103 S 1,199.80 0.00 0.00 28286 S 741.48 0.00 0.00<br />

28104 S 652.01 0.00 0.00 28288 S 683.14 0.00 0.00<br />

28106 S 1,199.80 0.00 0.00 28289 S 683.14 0.00 0.00<br />

28107 S 1,199.80 0.00 0.00 28290 S 842.06 0.00 0.00<br />

28108 S 652.01 0.00 0.00 28292 S 842.06 0.00 0.00<br />

28110 S 683.14 0.00 0.00 28293 S 873.18 0.00 0.00<br />

28111 S 683.14 0.00 0.00 28294 S 873.18 0.00 0.00<br />

28112 S 683.14 0.00 0.00 28296 S 873.18 0.00 0.00<br />

28113 S 683.14 0.00 0.00 28297 S 873.18 0.00 0.00<br />

28114 S 683.14 0.00 0.00 28298 S 873.18 0.00 0.00<br />

28116 S 683.14 0.00 0.00 28299 S 973.82 0.00 0.00<br />

28118 S 741.48 0.00 0.00 28300 S 1,168.69 0.00 0.00<br />

28119 S 741.48 0.00 0.00 28302 S 652.01 0.00 0.00<br />

28120 S 918.96 0.00 0.00 28304 S 1,168.69 0.00 0.00<br />

28122 S 683.14 0.00 0.00 28305 S 1,199.80 0.00 0.00<br />

28124 S 222.65 0.00 0.00 28306 S 741.48 0.00 0.00<br />

28126 S 683.14 0.00 0.00 28307 S 741.48 0.00 0.00<br />

28130 S 683.14 0.00 0.00 28308 S 652.01 0.00 0.00<br />

28140 S 683.14 0.00 0.00 28309 S 1,258.15 0.00 0.00<br />

28150 S 683.14 0.00 0.00 28310 S 683.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 683.14 0.00 0.00 28636 S 760.09 0.00 0.00<br />

28313 S 652.01 0.00 0.00 28645 S 760.09 0.00 0.00<br />

28315 S 741.48 0.00 0.00 28660 S 46.05 0.00 0.00<br />

28320 S 1,258.15 0.00 0.00 28665 S 475.23 0.00 0.00<br />

28322 S 1,258.15 0.00 0.00 28666 S 760.09 0.00 0.00<br />

28340 S 741.48 0.00 0.00 28675 S 760.09 0.00 0.00<br />

28341 S 741.48 0.00 0.00 28705 S 1,258.15 0.00 0.00<br />

28344 S 741.48 0.00 0.00 28715 S 2,049.21 0.00 0.00<br />

28345 S 741.48 0.00 0.00 28725 S 1,258.15 0.00 0.00<br />

28400 S 82.54 0.00 0.00 28730 S 1,258.15 0.00 0.00<br />

28405 S 450.35 0.00 0.00 28735 S 1,258.15 0.00 0.00<br />

28406 S 728.97 0.00 0.00 28737 S 1,300.45 0.00 0.00<br />

28415 S 1,507.29 0.00 0.00 28740 S 1,258.15 0.00 0.00<br />

28420 S 1,169.07 0.00 0.00 28750 S 1,258.15 0.00 0.00<br />

28430 S 64.32 0.00 0.00 28755 S 741.48 0.00 0.00<br />

28435 S 82.54 0.00 0.00 28760 S 1,258.15 0.00 0.00<br />

28436 S 728.97 0.00 0.00 28810 S 652.01 0.00 0.00<br />

28445 S 1,110.72 0.00 0.00 28820 S 652.01 0.00 0.00<br />

28446 S 1,903.65 0.00 0.00 28825 S 652.01 0.00 0.00<br />

28450 S 64.32 0.00 0.00 28890 S 172.29 0.00 0.00<br />

28455 S 64.32 0.00 0.00 29000 S 43.65 0.00 0.00<br />

28456 S 728.97 0.00 0.00 29010 S 97.84 0.00 0.00<br />

28465 S 1,110.72 0.00 0.00 29015 S 97.84 0.00 0.00<br />

28470 S 64.32 0.00 0.00 29020 S 43.65 0.00 0.00<br />

28475 S 64.32 0.00 0.00 29025 S 43.65 0.00 0.00<br />

28476 S 728.97 0.00 0.00 29035 S 97.84 0.00 0.00<br />

28485 S 1,169.07 0.00 0.00 29040 S 43.65 0.00 0.00<br />

28490 S 64.32 0.00 0.00 29044 S 97.84 0.00 0.00<br />

28495 S 64.32 0.00 0.00 29046 S 97.84 0.00 0.00<br />

28496 S 728.97 0.00 0.00 29049 S 39.56 0.00 0.00<br />

28505 S 760.09 0.00 0.00 29055 S 97.84 0.00 0.00<br />

28510 S 57.91 0.00 0.00 29058 S 43.65 0.00 0.00<br />

28515 S 64.32 0.00 0.00 29065 S 46.40 0.00 0.00<br />

28525 S 760.09 0.00 0.00 29075 S 44.60 0.00 0.00<br />

28530 S 55.75 0.00 0.00 29085 S 43.65 0.00 0.00<br />

28531 S 760.09 0.00 0.00 29086 S 37.41 0.00 0.00<br />

28540 S 64.32 0.00 0.00 29105 S 40.28 0.00 0.00<br />

28545 S 674.03 0.00 0.00 29125 S 34.89 0.00 0.00<br />

28546 S 728.97 0.00 0.00 29126 S 37.05 0.00 0.00<br />

28555 S 1,079.61 0.00 0.00 29130 S 15.83 0.00 0.00<br />

28570 S 83.44 0.00 0.00 29131 S 23.02 0.00 0.00<br />

28575 S 450.35 0.00 0.00 29200 S 22.30 0.00 0.00<br />

28576 S 760.09 0.00 0.00 29220 S 24.09 0.00 0.00<br />

28585 S 760.09 0.00 0.00 29240 S 25.18 0.00 0.00<br />

28600 S 64.32 0.00 0.00 29260 S 24.09 0.00 0.00<br />

28605 S 82.54 0.00 0.00 29280 S 24.46 0.00 0.00<br />

28606 S 728.97 0.00 0.00 29305 S 97.84 0.00 0.00<br />

28615 S 1,110.72 0.00 0.00 29325 S 97.84 0.00 0.00<br />

28630 S 64.32 0.00 0.00 29345 S 60.79 0.00 0.00<br />

28635 S 475.23 0.00 0.00 29355 S 59.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 74.10 0.00 0.00 29847 S 1,238.52 0.00 0.00<br />

29365 S 57.55 0.00 0.00 29848 S 1,243.08 0.00 0.00<br />

29405 S 42.80 0.00 0.00 29850 S 898.35 0.00 0.00<br />

29425 S 43.52 0.00 0.00 29851 S 1,296.87 0.00 0.00<br />

29435 S 55.03 0.00 0.00 29855 S 1,296.87 0.00 0.00<br />

29440 S 23.38 0.00 0.00 29856 S 1,296.87 0.00 0.00<br />

29445 S 57.91 0.00 0.00 29860 S 1,296.87 0.00 0.00<br />

29450 S 43.65 0.00 0.00 29861 S 1,296.87 0.00 0.00<br />

29505 S 38.84 0.00 0.00 29862 S 1,641.61 0.00 0.00<br />

29515 S 33.09 0.00 0.00 29863 S 1,296.87 0.00 0.00<br />

29520 S 23.74 0.00 0.00 29866 S 1,981.08 0.00 0.00<br />

29530 S 24.09 0.00 0.00 29870 S 840.01 0.00 0.00<br />

29540 S 17.98 0.00 0.00 29871 S 840.01 0.00 0.00<br />

29550 S 18.34 0.00 0.00 29873 S 840.01 0.00 0.00<br />

29580 S 24.82 0.00 0.00 29874 S 840.01 0.00 0.00<br />

29590 S 20.15 0.00 0.00 29875 S 898.35 0.00 0.00<br />

29700 S 33.45 0.00 0.00 29876 S 898.35 0.00 0.00<br />

29705 S 28.41 0.00 0.00 29877 S 898.35 0.00 0.00<br />

29710 S 49.99 0.00 0.00 29879 S 840.01 0.00 0.00<br />

29715 S 43.65 0.00 0.00 29880 S 898.35 0.00 0.00<br />

29720 S 41.73 0.00 0.00 29881 S 898.35 0.00 0.00<br />

29730 S 27.34 0.00 0.00 29882 S 840.01 0.00 0.00<br />

29740 S 37.41 0.00 0.00 29883 S 840.01 0.00 0.00<br />

29750 S 39.20 0.00 0.00 29884 S 840.01 0.00 0.00<br />

29800 S 840.01 0.00 0.00 29885 S 1,238.52 0.00 0.00<br />

29804 S 840.01 0.00 0.00 29886 S 840.01 0.00 0.00<br />

29805 S 840.01 0.00 0.00 29887 S 840.01 0.00 0.00<br />

29806 S 1,238.52 0.00 0.00 29888 S 1,238.52 0.00 0.00<br />

29807 S 1,238.52 0.00 0.00 29889 S 1,238.52 0.00 0.00<br />

29819 S 1,238.52 0.00 0.00 29891 S 1,238.52 0.00 0.00<br />

29820 S 1,238.52 0.00 0.00 29892 S 1,238.52 0.00 0.00<br />

29821 S 1,238.52 0.00 0.00 29893 S 1,045.65 0.00 0.00<br />

29822 S 840.01 0.00 0.00 29894 S 840.01 0.00 0.00<br />

29823 S 1,238.52 0.00 0.00 29895 S 840.01 0.00 0.00<br />

29824 S 940.65 0.00 0.00 29897 S 840.01 0.00 0.00<br />

29825 S 1,238.52 0.00 0.00 29898 S 840.01 0.00 0.00<br />

29826 S 1,238.52 0.00 0.00 29899 S 1,238.52 0.00 0.00<br />

29827 S 1,339.16 0.00 0.00 29900 S 840.01 0.00 0.00<br />

29828 S 1,981.08 0.00 0.00 29901 S 840.01 0.00 0.00<br />

29830 S 840.01 0.00 0.00 29902 S 840.01 0.00 0.00<br />

29834 S 840.01 0.00 0.00 29904 S 1,184.04 0.00 0.00<br />

29835 S 840.01 0.00 0.00 29905 S 1,184.04 0.00 0.00<br />

29836 S 840.01 0.00 0.00 29906 S 1,184.04 0.00 0.00<br />

29837 S 840.01 0.00 0.00 29907 S 1,981.08 0.00 0.00<br />

29838 S 840.01 0.00 0.00 30000 S 133.12 0.00 0.00<br />

29840 S 840.01 0.00 0.00 30020 S 133.12 0.00 0.00<br />

29843 S 840.01 0.00 0.00 30100 S 86.33 0.00 0.00<br />

29844 S 840.01 0.00 0.00 30110 S 133.45 0.00 0.00<br />

29845 S 840.01 0.00 0.00 30115 S 563.84 0.00 0.00<br />

29846 S 840.01 0.00 0.00 30117 S 594.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 746.23 0.00 0.00 31080 S 1,149.11 0.00 0.00<br />

30120 S 508.90 0.00 0.00 31081 S 1,149.11 0.00 0.00<br />

30124 S 303.23 0.00 0.00 31084 S 1,149.11 0.00 0.00<br />

30125 S 1,059.64 0.00 0.00 31085 S 1,149.11 0.00 0.00<br />

30130 S 594.97 0.00 0.00 31086 S 1,149.11 0.00 0.00<br />

30140 S 715.10 0.00 0.00 31087 S 1,149.11 0.00 0.00<br />

30150 S 1,090.77 0.00 0.00 31090 S 1,191.41 0.00 0.00<br />

30160 S 1,149.11 0.00 0.00 31200 S 1,059.64 0.00 0.00<br />

30200 S 67.99 0.00 0.00 31201 S 1,191.41 0.00 0.00<br />

30210 S 86.33 0.00 0.00 31205 S 1,090.77 0.00 0.00<br />

30220 S 377.30 0.00 0.00 31231 S 72.77 0.00 0.00<br />

30300 S 26.01 0.00 0.00 31233 S 78.39 0.00 0.00<br />

30310 S 508.90 0.00 0.00 31235 S 532.57 0.00 0.00<br />

30320 S 563.84 0.00 0.00 31237 S 587.51 0.00 0.00<br />

30400 S 1,149.11 0.00 0.00 31238 S 532.57 0.00 0.00<br />

30410 S 1,191.41 0.00 0.00 31239 S 777.39 0.00 0.00<br />

30420 S 1,191.41 0.00 0.00 31240 S 587.51 0.00 0.00<br />

30430 S 746.23 0.00 0.00 31254 S 719.03 0.00 0.00<br />

30435 S 1,191.41 0.00 0.00 31255 S 819.68 0.00 0.00<br />

30450 S 1,326.59 0.00 0.00 31256 S 719.03 0.00 0.00<br />

30460 S 1,326.59 0.00 0.00 31267 S 719.03 0.00 0.00<br />

30462 S 1,493.85 0.00 0.00 31276 S 719.03 0.00 0.00<br />

30465 S 1,493.85 0.00 0.00 31287 S 719.03 0.00 0.00<br />

30520 S 804.57 0.00 0.00 31288 S 719.03 0.00 0.00<br />

30540 S 1,191.41 0.00 0.00 31300 S 846.88 0.00 0.00<br />

30545 S 1,191.41 0.00 0.00 31320 S 1,059.64 0.00 0.00<br />

30560 S 139.84 0.00 0.00 31400 S 1,059.64 0.00 0.00<br />

30580 S 1,149.11 0.00 0.00 31420 S 1,059.64 0.00 0.00<br />

30600 S 1,149.11 0.00 0.00 31500 S 97.34 0.00 0.00<br />

30620 S 1,326.59 0.00 0.00 31502 S 55.97 0.00 0.00<br />

30630 S 982.05 0.00 0.00 31505 S 33.07 0.00 0.00<br />

30801 S 313.53 0.00 0.00 31510 S 587.51 0.00 0.00<br />

30802 S 313.53 0.00 0.00 31511 S 78.39 0.00 0.00<br />

30901 S 44.72 0.00 0.00 31512 S 587.51 0.00 0.00<br />

30903 S 57.60 0.00 0.00 31513 S 78.39 0.00 0.00<br />

30905 S 57.60 0.00 0.00 31515 S 532.57 0.00 0.00<br />

30906 S 57.60 0.00 0.00 31520 S 72.77 0.00 0.00<br />

30915 S 767.55 0.00 0.00 31525 S 532.57 0.00 0.00<br />

30920 S 798.68 0.00 0.00 31526 S 687.92 0.00 0.00<br />

30930 S 653.31 0.00 0.00 31527 S 632.97 0.00 0.00<br />

31000 S 111.15 0.00 0.00 31528 S 587.51 0.00 0.00<br />

31002 S 303.23 0.00 0.00 31529 S 587.51 0.00 0.00<br />

31020 S 715.10 0.00 0.00 31530 S 687.92 0.00 0.00<br />

31030 S 1,090.77 0.00 0.00 31531 S 719.03 0.00 0.00<br />

31032 S 1,149.11 0.00 0.00 31535 S 687.92 0.00 0.00<br />

31040 S 996.50 0.00 0.00 31536 S 719.03 0.00 0.00<br />

31050 S 1,059.64 0.00 0.00 31540 S 719.03 0.00 0.00<br />

31051 S 1,149.11 0.00 0.00 31541 S 777.39 0.00 0.00<br />

31070 S 715.10 0.00 0.00 31545 S 777.39 0.00 0.00<br />

31075 S 1,149.11 0.00 0.00 31546 S 777.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 819.68 0.00 0.00 32405 S 354.70 0.00 0.00<br />

31561 S 819.68 0.00 0.00 32420 S 215.69 0.00 0.00<br />

31570 S 587.51 0.00 0.00 32421 S 215.69 0.00 0.00<br />

31571 S 687.92 0.00 0.00 32422 S 214.73 0.00 0.00<br />

31575 S 62.59 0.00 0.00 32550 S 1,202.25 0.00 0.00<br />

31576 S 687.92 0.00 0.00 32960 S 214.73 0.00 0.00<br />

31577 S 203.21 0.00 0.00 32998 S 1,871.83 0.00 0.00<br />

31578 S 687.92 0.00 0.00 33010 S 215.69 0.00 0.00<br />

31579 S 111.51 0.00 0.00 33011 S 215.69 0.00 0.00<br />

31580 S 1,191.41 0.00 0.00 33206 S 6,920.03 4,117.39 1,314.77<br />

31582 S 1,191.41 0.00 0.00 33207 S 6,920.03 4,117.39 1,314.77<br />

31588 S 1,191.41 0.00 0.00 33208 S 8,582.79 5,001.15 1,419.52<br />

31590 S 1,191.41 0.00 0.00 33210 S 2,032.09 0.00 0.00<br />

31595 S 1,059.64 0.00 0.00 33211 S 2,032.09 0.00 0.00<br />

31603 S 313.53 0.00 0.00 33212 S 5,434.69 3,095.91 757.13<br />

31605 S 303.23 0.00 0.00 33213 S 6,272.80 3,514.52 756.23<br />

31611 S 746.23 0.00 0.00 33214 S 8,582.79 5,001.15 1,419.52<br />

31612 S 660.16 0.00 0.00 33215 S 890.69 0.00 0.00<br />

31613 S 715.10 0.00 0.00 33216 S 2,032.09 0.00 0.00<br />

31614 S 1,059.64 0.00 0.00 33217 S 2,032.09 0.00 0.00<br />

31615 S 313.53 0.00 0.00 33218 S 890.69 0.00 0.00<br />

31622 S 367.20 0.00 0.00 33220 S 890.69 0.00 0.00<br />

31623 S 422.14 0.00 0.00 33222 S 538.38 0.00 0.00<br />

31624 S 422.14 0.00 0.00 33223 S 538.38 0.00 0.00<br />

31625 S 422.14 0.00 0.00 33224 S 8,101.36 4,850.26 1,599.17<br />

31628 S 422.14 0.00 0.00 33225 S 8,101.36 4,850.26 1,599.17<br />

31629 S 422.14 0.00 0.00 33226 S 890.69 0.00 0.00<br />

31630 S 723.37 0.00 0.00 33233 S 662.21 0.00 0.00<br />

31631 S 723.37 0.00 0.00 33234 S 890.69 0.00 0.00<br />

31632 S 410.56 0.00 0.00 33235 S 890.69 0.00 0.00<br />

31633 S 410.56 0.00 0.00 33240 S 20,194.62 10,794.85 1,395.08<br />

31635 S 422.14 0.00 0.00 33241 S 890.69 0.00 0.00<br />

31636 S 723.37 0.00 0.00 33249 S 26,951.25 14,436.21 1,921.16<br />

31637 S 367.20 0.00 0.00 33282 S 4,261.16 2,550.98 840.80<br />

31638 S 723.37 0.00 0.00 33284 S 332.36 0.00 0.00<br />

31640 S 723.37 0.00 0.00 34490 S 1,622.68 0.00 0.00<br />

31641 S 723.37 0.00 0.00 35188 S 1,117.66 0.00 0.00<br />

31643 S 422.14 0.00 0.00 35207 S 1,117.66 0.00 0.00<br />

31645 S 367.20 0.00 0.00 35473 S 1,946.59 0.00 0.00<br />

31646 S 367.20 0.00 0.00 35476 S 1,946.59 0.00 0.00<br />

31656 S 367.20 0.00 0.00 35492 S 3,633.11 0.00 0.00<br />

31717 S 203.21 0.00 0.00 35761 S 1,168.73 0.00 0.00<br />

31720 S 31.12 0.00 0.00 35875 S 1,462.40 0.00 0.00<br />

31730 S 203.21 0.00 0.00 35876 S 1,462.40 0.00 0.00<br />

31750 S 1,191.41 0.00 0.00 36002 S 93.34 0.00 0.00<br />

31755 S 1,059.64 0.00 0.00 36260 S 846.70 0.00 0.00<br />

31820 S 508.90 0.00 0.00 36261 S 662.21 0.00 0.00<br />

31825 S 715.10 0.00 0.00 36262 S 607.26 0.00 0.00<br />

31830 S 715.10 0.00 0.00 36420 S 8.80 0.00 0.00<br />

32400 S 354.70 0.00 0.00 36425 S 8.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 33.81 0.00 0.00 36800 S 911.47 0.00 0.00<br />

36440 S 135.02 0.00 0.00 36810 S 911.47 0.00 0.00<br />

36450 S 135.02 0.00 0.00 36815 S 911.47 0.00 0.00<br />

36455 S 135.02 0.00 0.00 36818 S 1,059.32 0.00 0.00<br />

36468 S 33.33 0.00 0.00 36819 S 1,059.32 0.00 0.00<br />

36469 S 33.33 0.00 0.00 36820 S 1,059.32 0.00 0.00<br />

36470 S 33.33 0.00 0.00 36821 S 1,059.32 0.00 0.00<br />

36471 S 33.33 0.00 0.00 36825 S 1,117.66 0.00 0.00<br />

36475 S 1,532.45 0.00 0.00 36830 S 1,117.66 0.00 0.00<br />

36476 S 1,201.76 0.00 0.00 36831 S 1,462.40 0.00 0.00<br />

36478 S 1,201.76 0.00 0.00 36832 S 1,117.66 0.00 0.00<br />

36479 S 1,201.76 0.00 0.00 36833 S 1,117.66 0.00 0.00<br />

36511 S 462.93 0.00 0.00 36834 S 1,059.32 0.00 0.00<br />

36512 S 462.93 0.00 0.00 36835 S 969.82 0.00 0.00<br />

36513 S 462.93 0.00 0.00 36860 S 111.31 0.00 0.00<br />

36514 S 462.93 0.00 0.00 36861 S 911.47 0.00 0.00<br />

36515 S 1,239.25 0.00 0.00 36870 S 1,594.02 0.00 0.00<br />

36516 S 1,239.25 0.00 0.00 37184 S 1,622.68 0.00 0.00<br />

36522 S 1,239.25 0.00 0.00 37185 S 1,622.68 0.00 0.00<br />

36555 S 384.63 0.00 0.00 37186 S 1,622.68 0.00 0.00<br />

36556 S 384.63 0.00 0.00 37187 S 1,622.68 0.00 0.00<br />

36557 S 718.33 0.00 0.00 37188 S 1,622.68 0.00 0.00<br />

36558 S 718.33 0.00 0.00 37200 S 1,197.44 0.00 0.00<br />

36560 S 846.70 0.00 0.00 37203 S 1,197.44 0.00 0.00<br />

36561 S 846.70 0.00 0.00 37500 S 1,129.37 0.00 0.00<br />

36563 S 846.70 0.00 0.00 37607 S 798.68 0.00 0.00<br />

36565 S 846.70 0.00 0.00 37609 S 536.82 0.00 0.00<br />

36566 S 846.70 0.00 0.00 37650 S 767.55 0.00 0.00<br />

36568 S 384.63 0.00 0.00 37700 S 767.55 0.00 0.00<br />

36569 S 384.63 0.00 0.00 37718 S 798.68 0.00 0.00<br />

36570 S 749.44 0.00 0.00 37722 S 1,129.37 0.00 0.00<br />

36571 S 749.44 0.00 0.00 37735 S 1,129.37 0.00 0.00<br />

36575 S 309.35 0.00 0.00 37760 S 798.68 0.00 0.00<br />

36576 S 439.57 0.00 0.00 37765 S 1,101.39 0.00 0.00<br />

36578 S 718.33 0.00 0.00 37766 S 1,101.39 0.00 0.00<br />

36580 S 384.63 0.00 0.00 37780 S 798.68 0.00 0.00<br />

36581 S 718.33 0.00 0.00 37785 S 798.68 0.00 0.00<br />

36582 S 846.70 0.00 0.00 37790 S 963.76 0.00 0.00<br />

36583 S 846.70 0.00 0.00 38205 S 462.93 0.00 0.00<br />

36584 S 384.63 0.00 0.00 38206 S 462.93 0.00 0.00<br />

36585 S 749.44 0.00 0.00 38220 S 106.11 0.00 0.00<br />

36589 S 254.41 0.00 0.00 38221 S 111.15 0.00 0.00<br />

36590 S 384.63 0.00 0.00 38230 S 1,239.25 0.00 0.00<br />

36593 S 25.54 0.00 0.00 38241 S 1,239.25 0.00 0.00<br />

36595 S 1,002.92 0.00 0.00 38242 S 462.93 0.00 0.00<br />

36596 S 445.41 0.00 0.00 38300 S 415.42 0.00 0.00<br />

36597 S 445.41 0.00 0.00 38305 S 607.07 0.00 0.00<br />

36598 S 82.37 0.00 0.00 38308 S 693.65 0.00 0.00<br />

36640 S 760.63 0.00 0.00 38500 S 693.65 0.00 0.00<br />

36680 S 57.65 0.00 0.00 38505 S 265.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 693.65 0.00 0.00 41005 S 139.84 0.00 0.00<br />

38520 S 693.65 0.00 0.00 41006 S 660.16 0.00 0.00<br />

38525 S 693.65 0.00 0.00 41007 S 508.90 0.00 0.00<br />

38530 S 693.65 0.00 0.00 41008 S 508.90 0.00 0.00<br />

38542 S 1,166.97 0.00 0.00 41009 S 139.84 0.00 0.00<br />

38550 S 724.78 0.00 0.00 41010 S 313.53 0.00 0.00<br />

38555 S 783.12 0.00 0.00 41015 S 139.84 0.00 0.00<br />

38570 S 1,583.40 0.00 0.00 41016 S 313.53 0.00 0.00<br />

38571 S 2,058.39 0.00 0.00 41017 S 313.53 0.00 0.00<br />

38572 S 1,583.40 0.00 0.00 41018 S 313.53 0.00 0.00<br />

38700 S 953.59 0.00 0.00 41019 S 996.50 0.00 0.00<br />

38740 S 1,166.97 0.00 0.00 41100 S 93.88 0.00 0.00<br />

38745 S 1,256.44 0.00 0.00 41105 S 92.80 0.00 0.00<br />

38760 S 693.65 0.00 0.00 41108 S 85.97 0.00 0.00<br />

40490 S 70.86 0.00 0.00 41110 S 124.45 0.00 0.00<br />

40500 S 563.84 0.00 0.00 41112 S 563.84 0.00 0.00<br />

40510 S 715.10 0.00 0.00 41113 S 563.84 0.00 0.00<br />

40520 S 563.84 0.00 0.00 41114 S 715.10 0.00 0.00<br />

40525 S 715.10 0.00 0.00 41115 S 144.96 0.00 0.00<br />

40527 S 715.10 0.00 0.00 41116 S 508.90 0.00 0.00<br />

40530 S 715.10 0.00 0.00 41120 S 846.88 0.00 0.00<br />

40650 S 377.30 0.00 0.00 41250 S 95.64 0.00 0.00<br />

40652 S 377.30 0.00 0.00 41251 S 139.84 0.00 0.00<br />

40654 S 377.30 0.00 0.00 41252 S 368.47 0.00 0.00<br />

40700 S 1,326.59 0.00 0.00 41500 S 660.16 0.00 0.00<br />

40701 S 1,326.59 0.00 0.00 41510 S 508.90 0.00 0.00<br />

40702 S 1,685.57 0.00 0.00 41520 S 368.47 0.00 0.00<br />

40720 S 1,326.59 0.00 0.00 41530 S 693.97 0.00 0.00<br />

40761 S 1,090.77 0.00 0.00 41800 S 71.45 0.00 0.00<br />

40800 S 56.87 0.00 0.00 41805 S 154.67 0.00 0.00<br />

40801 S 368.47 0.00 0.00 41806 S 190.63 0.00 0.00<br />

40804 S 26.01 0.00 0.00 41820 S 303.23 0.00 0.00<br />

40805 S 175.89 0.00 0.00 41821 S 303.23 0.00 0.00<br />

40806 S 80.93 0.00 0.00 41822 S 157.90 0.00 0.00<br />

40808 S 120.13 0.00 0.00 41823 S 230.21 0.00 0.00<br />

40810 S 124.45 0.00 0.00 41825 S 126.61 0.00 0.00<br />

40812 S 156.11 0.00 0.00 41826 S 159.35 0.00 0.00<br />

40814 S 563.84 0.00 0.00 41827 S 715.10 0.00 0.00<br />

40816 S 715.10 0.00 0.00 41828 S 143.88 0.00 0.00<br />

40818 S 139.84 0.00 0.00 41830 S 204.31 0.00 0.00<br />

40819 S 313.53 0.00 0.00 41850 S 693.97 0.00 0.00<br />

40820 S 179.48 0.00 0.00 41870 S 996.50 0.00 0.00<br />

40830 S 133.12 0.00 0.00 41872 S 204.31 0.00 0.00<br />

40831 S 313.53 0.00 0.00 41874 S 197.11 0.00 0.00<br />

40840 S 715.10 0.00 0.00 42000 S 139.84 0.00 0.00<br />

40842 S 746.23 0.00 0.00 42100 S 79.85 0.00 0.00<br />

40843 S 746.23 0.00 0.00 42104 S 118.70 0.00 0.00<br />

40844 S 1,191.41 0.00 0.00 42106 S 148.92 0.00 0.00<br />

40845 S 1,191.41 0.00 0.00 42107 S 715.10 0.00 0.00<br />

41000 S 89.21 0.00 0.00 42120 S 1,149.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 368.47 0.00 0.00 42809 S 26.01 0.00 0.00<br />

42145 S 846.88 0.00 0.00 42810 S 746.23 0.00 0.00<br />

42160 S 141.00 0.00 0.00 42815 S 1,191.41 0.00 0.00<br />

42180 S 139.84 0.00 0.00 42820 S 746.23 0.00 0.00<br />

42182 S 1,059.64 0.00 0.00 42821 S 846.88 0.00 0.00<br />

42200 S 1,191.41 0.00 0.00 42825 S 804.57 0.00 0.00<br />

42205 S 1,191.41 0.00 0.00 42826 S 804.57 0.00 0.00<br />

42210 S 1,191.41 0.00 0.00 42830 S 804.57 0.00 0.00<br />

42215 S 1,326.59 0.00 0.00 42831 S 804.57 0.00 0.00<br />

42220 S 1,191.41 0.00 0.00 42835 S 804.57 0.00 0.00<br />

42226 S 1,191.41 0.00 0.00 42836 S 804.57 0.00 0.00<br />

42235 S 695.62 0.00 0.00 42860 S 746.23 0.00 0.00<br />

42260 S 804.57 0.00 0.00 42870 S 746.23 0.00 0.00<br />

42280 S 77.69 0.00 0.00 42890 S 1,326.59 0.00 0.00<br />

42281 S 693.97 0.00 0.00 42892 S 1,326.59 0.00 0.00<br />

42300 S 508.90 0.00 0.00 42900 S 313.53 0.00 0.00<br />

42305 S 563.84 0.00 0.00 42950 S 715.10 0.00 0.00<br />

42310 S 139.84 0.00 0.00 42955 S 715.10 0.00 0.00<br />

42320 S 139.84 0.00 0.00 42960 S 57.60 0.00 0.00<br />

42330 S 120.13 0.00 0.00 42962 S 1,059.64 0.00 0.00<br />

42335 S 199.27 0.00 0.00 42970 S 44.72 0.00 0.00<br />

42340 S 563.84 0.00 0.00 42972 S 594.97 0.00 0.00<br />

42400 S 67.63 0.00 0.00 43030 S 693.97 0.00 0.00<br />

42405 S 563.84 0.00 0.00 43200 S 336.06 0.00 0.00<br />

42408 S 594.97 0.00 0.00 43201 S 336.06 0.00 0.00<br />

42409 S 594.97 0.00 0.00 43202 S 336.06 0.00 0.00<br />

42410 S 1,090.77 0.00 0.00 43204 S 336.06 0.00 0.00<br />

42415 S 1,326.59 0.00 0.00 43205 S 336.06 0.00 0.00<br />

42420 S 1,326.59 0.00 0.00 43215 S 336.06 0.00 0.00<br />

42425 S 1,326.59 0.00 0.00 43216 S 336.06 0.00 0.00<br />

42440 S 1,090.77 0.00 0.00 43217 S 336.06 0.00 0.00<br />

42450 S 715.10 0.00 0.00 43219 S 679.18 0.00 0.00<br />

42500 S 746.23 0.00 0.00 43220 S 336.06 0.00 0.00<br />

42505 S 1,149.11 0.00 0.00 43226 S 336.06 0.00 0.00<br />

42507 S 1,090.77 0.00 0.00 43227 S 391.01 0.00 0.00<br />

42508 S 1,149.11 0.00 0.00 43228 S 727.64 0.00 0.00<br />

42509 S 1,149.11 0.00 0.00 43231 S 391.01 0.00 0.00<br />

42510 S 1,149.11 0.00 0.00 43232 S 391.01 0.00 0.00<br />

42600 S 508.90 0.00 0.00 43234 S 336.06 0.00 0.00<br />

42650 S 44.24 0.00 0.00 43235 S 336.06 0.00 0.00<br />

42660 S 51.80 0.00 0.00 43236 S 391.01 0.00 0.00<br />

42665 S 982.05 0.00 0.00 43237 S 391.01 0.00 0.00<br />

42700 S 139.84 0.00 0.00 43238 S 391.01 0.00 0.00<br />

42720 S 508.90 0.00 0.00 43239 S 391.01 0.00 0.00<br />

42725 S 1,059.64 0.00 0.00 43240 S 391.01 0.00 0.00<br />

42800 S 85.61 0.00 0.00 43241 S 391.01 0.00 0.00<br />

42802 S 508.90 0.00 0.00 43242 S 391.01 0.00 0.00<br />

42804 S 508.90 0.00 0.00 43243 S 391.01 0.00 0.00<br />

42806 S 715.10 0.00 0.00 43244 S 391.01 0.00 0.00<br />

42808 S 563.84 0.00 0.00 43245 S 391.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 391.01 0.00 0.00 44378 S 409.52 0.00 0.00<br />

43247 S 391.01 0.00 0.00 44379 S 1,168.34 0.00 0.00<br />

43248 S 391.01 0.00 0.00 44380 S 354.57 0.00 0.00<br />

43249 S 391.01 0.00 0.00 44382 S 354.57 0.00 0.00<br />

43250 S 391.01 0.00 0.00 44383 S 1,168.34 0.00 0.00<br />

43251 S 391.01 0.00 0.00 44385 S 342.82 0.00 0.00<br />

43255 S 391.01 0.00 0.00 44386 S 342.82 0.00 0.00<br />

43256 S 765.25 0.00 0.00 44388 S 342.82 0.00 0.00<br />

43257 S 758.77 0.00 0.00 44389 S 342.82 0.00 0.00<br />

43258 S 422.13 0.00 0.00 44390 S 342.82 0.00 0.00<br />

43259 S 422.13 0.00 0.00 44391 S 342.82 0.00 0.00<br />

43260 S 658.27 0.00 0.00 44392 S 342.82 0.00 0.00<br />

43261 S 658.27 0.00 0.00 44393 S 342.82 0.00 0.00<br />

43262 S 658.27 0.00 0.00 44394 S 342.82 0.00 0.00<br />

43263 S 658.27 0.00 0.00 44397 S 679.18 0.00 0.00<br />

43264 S 658.27 0.00 0.00 44500 S 185.00 0.00 0.00<br />

43265 S 658.27 0.00 0.00 45000 S 397.56 0.00 0.00<br />

43267 S 658.27 0.00 0.00 45005 S 462.69 0.00 0.00<br />

43268 S 734.13 0.00 0.00 45020 S 462.69 0.00 0.00<br />

43269 S 734.13 0.00 0.00 45100 S 628.61 0.00 0.00<br />

43271 S 658.27 0.00 0.00 45108 S 683.55 0.00 0.00<br />

43272 S 658.27 0.00 0.00 45150 S 683.55 0.00 0.00<br />

43273 S 882.82 0.00 0.00 45160 S 683.55 0.00 0.00<br />

43450 S 293.90 0.00 0.00 45170 S 683.55 0.00 0.00<br />

43453 S 293.90 0.00 0.00 45190 S 1,117.75 0.00 0.00<br />

43456 S 295.07 0.00 0.00 45300 S 66.18 0.00 0.00<br />

43458 S 337.24 0.00 0.00 45303 S 367.61 0.00 0.00<br />

43600 S 336.06 0.00 0.00 45305 S 345.72 0.00 0.00<br />

43653 S 1,583.40 0.00 0.00 45307 S 638.57 0.00 0.00<br />

43760 S 162.99 0.00 0.00 45308 S 345.72 0.00 0.00<br />

43761 S 336.06 0.00 0.00 45309 S 345.72 0.00 0.00<br />

43870 S 336.06 0.00 0.00 45315 S 345.72 0.00 0.00<br />

43886 S 847.96 0.00 0.00 45317 S 345.72 0.00 0.00<br />

43887 S 178.35 0.00 0.00 45320 S 638.57 0.00 0.00<br />

43888 S 847.96 0.00 0.00 45321 S 638.57 0.00 0.00<br />

44100 S 336.06 0.00 0.00 45327 S 679.18 0.00 0.00<br />

44312 S 585.89 0.00 0.00 45330 S 87.40 0.00 0.00<br />

44340 S 671.96 0.00 0.00 45331 S 258.47 0.00 0.00<br />

44360 S 409.52 0.00 0.00 45332 S 258.47 0.00 0.00<br />

44361 S 409.52 0.00 0.00 45333 S 345.72 0.00 0.00<br />

44363 S 409.52 0.00 0.00 45334 S 345.72 0.00 0.00<br />

44364 S 409.52 0.00 0.00 45335 S 258.47 0.00 0.00<br />

44365 S 409.52 0.00 0.00 45337 S 258.47 0.00 0.00<br />

44366 S 409.52 0.00 0.00 45338 S 345.72 0.00 0.00<br />

44369 S 409.52 0.00 0.00 45339 S 345.72 0.00 0.00<br />

44370 S 1,168.34 0.00 0.00 45340 S 345.72 0.00 0.00<br />

44372 S 409.52 0.00 0.00 45341 S 345.72 0.00 0.00<br />

44373 S 409.52 0.00 0.00 45342 S 345.72 0.00 0.00<br />

44376 S 409.52 0.00 0.00 45345 S 679.18 0.00 0.00<br />

44377 S 409.52 0.00 0.00 45355 S 342.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 397.77 0.00 0.00 46505 S 491.65 0.00 0.00<br />

45379 S 397.77 0.00 0.00 46600 S 26.01 0.00 0.00<br />

45380 S 397.77 0.00 0.00 46604 S 367.61 0.00 0.00<br />

45381 S 397.77 0.00 0.00 46606 S 138.13 0.00 0.00<br />

45382 S 397.77 0.00 0.00 46608 S 345.72 0.00 0.00<br />

45383 S 397.77 0.00 0.00 46610 S 638.57 0.00 0.00<br />

45384 S 397.77 0.00 0.00 46611 S 345.72 0.00 0.00<br />

45385 S 397.77 0.00 0.00 46612 S 638.57 0.00 0.00<br />

45386 S 397.77 0.00 0.00 46614 S 72.65 0.00 0.00<br />

45387 S 679.18 0.00 0.00 46615 S 693.51 0.00 0.00<br />

45391 S 397.77 0.00 0.00 46700 S 714.68 0.00 0.00<br />

45392 S 397.77 0.00 0.00 46706 S 786.64 0.00 0.00<br />

45500 S 683.55 0.00 0.00 46750 S 872.71 0.00 0.00<br />

45505 S 841.59 0.00 0.00 46753 S 714.68 0.00 0.00<br />

45520 S 33.33 0.00 0.00 46754 S 683.55 0.00 0.00<br />

45560 S 841.59 0.00 0.00 46760 S 841.59 0.00 0.00<br />

45900 S 269.52 0.00 0.00 46761 S 872.71 0.00 0.00<br />

45905 S 628.61 0.00 0.00 46762 S 1,108.53 0.00 0.00<br />

45910 S 628.61 0.00 0.00 46900 S 109.84 0.00 0.00<br />

45915 S 397.56 0.00 0.00 46910 S 131.28 0.00 0.00<br />

45990 S 618.43 0.00 0.00 46916 S 61.06 0.00 0.00<br />

46020 S 714.68 0.00 0.00 46917 S 569.64 0.00 0.00<br />

46030 S 269.52 0.00 0.00 46922 S 569.64 0.00 0.00<br />

46040 S 714.68 0.00 0.00 46924 S 569.64 0.00 0.00<br />

46045 S 683.55 0.00 0.00 46930 S 127.34 0.00 0.00<br />

46050 S 397.56 0.00 0.00 46937 S 683.55 0.00 0.00<br />

46060 S 683.55 0.00 0.00 46938 S 841.59 0.00 0.00<br />

46070 S 491.65 0.00 0.00 46940 S 94.23 0.00 0.00<br />

46080 S 714.68 0.00 0.00 46942 S 91.72 0.00 0.00<br />

46083 S 75.26 0.00 0.00 46945 S 156.11 0.00 0.00<br />

46200 S 683.55 0.00 0.00 46946 S 407.74 0.00 0.00<br />

46210 S 683.55 0.00 0.00 46947 S 1,108.53 0.00 0.00<br />

46211 S 683.55 0.00 0.00 47000 S 354.70 0.00 0.00<br />

46220 S 628.61 0.00 0.00 47382 S 1,871.83 0.00 0.00<br />

46221 S 123.74 0.00 0.00 47510 S 828.96 0.00 0.00<br />

46230 S 628.61 0.00 0.00 47511 S 1,217.86 0.00 0.00<br />

46250 S 714.68 0.00 0.00 47525 S 475.88 0.00 0.00<br />

46255 S 714.68 0.00 0.00 47530 S 475.88 0.00 0.00<br />

46257 S 714.68 0.00 0.00 47552 S 828.96 0.00 0.00<br />

46258 S 714.68 0.00 0.00 47553 S 860.07 0.00 0.00<br />

46260 S 714.68 0.00 0.00 47554 S 860.07 0.00 0.00<br />

46261 S 773.02 0.00 0.00 47555 S 860.07 0.00 0.00<br />

46262 S 773.02 0.00 0.00 47556 S 1,217.86 0.00 0.00<br />

46270 S 714.68 0.00 0.00 47560 S 1,010.55 0.00 0.00<br />

46275 S 714.68 0.00 0.00 47561 S 1,010.55 0.00 0.00<br />

46280 S 773.02 0.00 0.00 47562 S 1,864.68 0.00 0.00<br />

46285 S 628.61 0.00 0.00 47563 S 1,864.68 0.00 0.00<br />

46288 S 773.02 0.00 0.00 47564 S 1,864.68 0.00 0.00<br />

46320 S 83.81 0.00 0.00 47630 S 860.07 0.00 0.00<br />

46500 S 115.46 0.00 0.00 48102 S 354.70 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 215.69 0.00 0.00 49590 S 885.25 0.00 0.00<br />

49081 S 215.69 0.00 0.00 49600 S 943.60 0.00 0.00<br />

49180 S 354.70 0.00 0.00 49650 S 1,238.67 0.00 0.00<br />

49250 S 777.52 0.00 0.00 49651 S 1,416.15 0.00 0.00<br />

49320 S 1,010.55 0.00 0.00 49652 S 1,525.15 0.00 0.00<br />

49321 S 1,068.91 0.00 0.00 49653 S 1,525.15 0.00 0.00<br />

49322 S 1,068.91 0.00 0.00 49654 S 1,525.15 0.00 0.00<br />

49324 S 1,525.15 0.00 0.00 49655 S 1,525.15 0.00 0.00<br />

49325 S 1,525.15 0.00 0.00 49656 S 1,525.15 0.00 0.00<br />

49326 S 1,525.15 0.00 0.00 49657 S 1,525.15 0.00 0.00<br />

49402 S 688.05 0.00 0.00 50200 S 354.70 0.00 0.00<br />

49419 S 825.41 0.00 0.00 50382 S 1,029.97 0.00 0.00<br />

49420 S 763.03 0.00 0.00 50384 S 756.49 0.00 0.00<br />

49421 S 763.03 0.00 0.00 50385 S 756.49 0.00 0.00<br />

49422 S 607.26 0.00 0.00 50386 S 290.24 0.00 0.00<br />

49423 S 627.93 0.00 0.00 50387 S 627.93 0.00 0.00<br />

49426 S 688.05 0.00 0.00 50389 S 290.24 0.00 0.00<br />

49429 S 890.69 0.00 0.00 50390 S 354.70 0.00 0.00<br />

49440 S 348.30 0.00 0.00 50391 S 42.01 0.00 0.00<br />

49441 S 348.30 0.00 0.00 50392 S 540.16 0.00 0.00<br />

49446 S 348.30 0.00 0.00 50393 S 676.90 0.00 0.00<br />

49450 S 185.00 0.00 0.00 50395 S 540.16 0.00 0.00<br />

49451 S 185.00 0.00 0.00 50396 S 101.57 0.00 0.00<br />

49452 S 185.00 0.00 0.00 50398 S 475.88 0.00 0.00<br />

49460 S 185.00 0.00 0.00 50551 S 307.04 0.00 0.00<br />

49495 S 943.60 0.00 0.00 50553 S 676.90 0.00 0.00<br />

49496 S 943.60 0.00 0.00 50555 S 307.04 0.00 0.00<br />

49500 S 943.60 0.00 0.00 50557 S 676.90 0.00 0.00<br />

49501 S 1,288.33 0.00 0.00 50561 S 676.90 0.00 0.00<br />

49505 S 943.60 0.00 0.00 50562 S 290.24 0.00 0.00<br />

49507 S 1,288.33 0.00 0.00 50570 S 290.24 0.00 0.00<br />

49520 S 1,121.07 0.00 0.00 50572 S 290.24 0.00 0.00<br />

49521 S 1,288.33 0.00 0.00 50574 S 290.24 0.00 0.00<br />

49525 S 943.60 0.00 0.00 50575 S 1,443.73 0.00 0.00<br />

49540 S 854.13 0.00 0.00 50576 S 756.49 0.00 0.00<br />

49550 S 985.90 0.00 0.00 50580 S 756.49 0.00 0.00<br />

49553 S 1,288.33 0.00 0.00 50590 S 1,686.61 0.00 0.00<br />

49555 S 985.90 0.00 0.00 50592 S 1,871.83 0.00 0.00<br />

49557 S 1,288.33 0.00 0.00 50686 S 42.01 0.00 0.00<br />

49560 S 943.60 0.00 0.00 50688 S 475.88 0.00 0.00<br />

49561 S 1,288.33 0.00 0.00 50947 S 1,583.40 0.00 0.00<br />

49565 S 943.60 0.00 0.00 50948 S 1,583.40 0.00 0.00<br />

49566 S 1,288.33 0.00 0.00 50951 S 307.04 0.00 0.00<br />

49568 S 1,121.07 0.00 0.00 50953 S 307.04 0.00 0.00<br />

49570 S 943.60 0.00 0.00 50955 S 676.90 0.00 0.00<br />

49572 S 1,288.33 0.00 0.00 50957 S 676.90 0.00 0.00<br />

49580 S 943.60 0.00 0.00 50961 S 676.90 0.00 0.00<br />

49582 S 1,288.33 0.00 0.00 50970 S 307.04 0.00 0.00<br />

49585 S 943.60 0.00 0.00 50972 S 307.04 0.00 0.00<br />

49587 S 1,288.33 0.00 0.00 50974 S 540.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 540.16 0.00 0.00 52275 S 731.85 0.00 0.00<br />

50980 S 676.90 0.00 0.00 52276 S 762.96 0.00 0.00<br />

51020 S 821.32 0.00 0.00 52277 S 731.85 0.00 0.00<br />

51030 S 821.32 0.00 0.00 52281 S 595.10 0.00 0.00<br />

51040 S 821.32 0.00 0.00 52282 S 1,372.93 0.00 0.00<br />

51045 S 339.24 0.00 0.00 52283 S 731.85 0.00 0.00<br />

51050 S 821.32 0.00 0.00 52285 S 595.10 0.00 0.00<br />

51065 S 821.32 0.00 0.00 52290 S 595.10 0.00 0.00<br />

51080 S 552.12 0.00 0.00 52300 S 731.85 0.00 0.00<br />

51100 S 32.01 0.00 0.00 52301 S 762.96 0.00 0.00<br />

51101 S 42.01 0.00 0.00 52305 S 731.85 0.00 0.00<br />

51102 S 565.14 0.00 0.00 52310 S 572.36 0.00 0.00<br />

51500 S 943.60 0.00 0.00 52315 S 731.85 0.00 0.00<br />

51520 S 821.32 0.00 0.00 52317 S 676.90 0.00 0.00<br />

51700 S 54.67 0.00 0.00 52318 S 731.85 0.00 0.00<br />

51701 S 26.01 0.00 0.00 52320 S 863.61 0.00 0.00<br />

51702 S 26.01 0.00 0.00 52325 S 821.32 0.00 0.00<br />

51703 S 42.01 0.00 0.00 52327 S 938.73 0.00 0.00<br />

51705 S 75.26 0.00 0.00 52330 S 731.85 0.00 0.00<br />

51710 S 475.88 0.00 0.00 52332 S 731.85 0.00 0.00<br />

51715 S 864.06 0.00 0.00 52334 S 762.96 0.00 0.00<br />

51720 S 60.43 0.00 0.00 52341 S 762.96 0.00 0.00<br />

51725 TC S 116.09 0.00 0.00 52342 S 762.96 0.00 0.00<br />

51726 TC S 159.90 0.00 0.00 52343 S 762.96 0.00 0.00<br />

51736 TC S 21.94 0.00 0.00 52344 S 762.96 0.00 0.00<br />

51741 TC S 25.54 0.00 0.00 52345 S 762.96 0.00 0.00<br />

51772 TC S 101.57 0.00 0.00 52346 S 762.96 0.00 0.00<br />

51784 TC S 42.01 0.00 0.00 52351 S 762.96 0.00 0.00<br />

51785 TC S 70.17 0.00 0.00 52352 S 821.32 0.00 0.00<br />

51792 TC S 42.01 0.00 0.00 52353 S 1,028.20 0.00 0.00<br />

51795 TC S 75.26 0.00 0.00 52354 S 821.32 0.00 0.00<br />

51797 TC S 75.26 0.00 0.00 52355 S 821.32 0.00 0.00<br />

51798 S 18.70 0.00 0.00 52400 S 762.96 0.00 0.00<br />

51880 S 676.90 0.00 0.00 52402 S 762.96 0.00 0.00<br />

51992 S 1,280.97 0.00 0.00 52450 S 762.96 0.00 0.00<br />

52000 S 307.04 0.00 0.00 52500 S 762.96 0.00 0.00<br />

52001 S 572.36 0.00 0.00 52601 S 1,028.20 0.00 0.00<br />

52005 S 595.10 0.00 0.00 52630 S 938.73 0.00 0.00<br />

52007 S 731.85 0.00 0.00 52640 S 731.85 0.00 0.00<br />

52010 S 339.24 0.00 0.00 52647 S 1,573.04 0.00 0.00<br />

52204 S 595.10 0.00 0.00 52648 S 1,573.04 0.00 0.00<br />

52214 S 731.85 0.00 0.00 52700 S 731.85 0.00 0.00<br />

52224 S 731.85 0.00 0.00 53000 S 561.69 0.00 0.00<br />

52234 S 731.85 0.00 0.00 53010 S 561.69 0.00 0.00<br />

52235 S 762.96 0.00 0.00 53020 S 561.69 0.00 0.00<br />

52240 S 762.96 0.00 0.00 53025 S 799.55 0.00 0.00<br />

52250 S 821.32 0.00 0.00 53040 S 616.64 0.00 0.00<br />

52260 S 595.10 0.00 0.00 53060 S 73.02 0.00 0.00<br />

52265 S 290.24 0.00 0.00 53080 S 647.76 0.00 0.00<br />

52270 S 595.10 0.00 0.00 53085 S 799.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 561.69 0.00 0.00 54060 S 569.64 0.00 0.00<br />

53210 S 964.71 0.00 0.00 54065 S 569.64 0.00 0.00<br />

53215 S 748.40 0.00 0.00 54100 S 481.88 0.00 0.00<br />

53220 S 832.93 0.00 0.00 54105 S 601.54 0.00 0.00<br />

53230 S 832.93 0.00 0.00 54110 S 932.65 0.00 0.00<br />

53235 S 647.76 0.00 0.00 54111 S 932.65 0.00 0.00<br />

53240 S 832.93 0.00 0.00 54112 S 932.65 0.00 0.00<br />

53250 S 616.64 0.00 0.00 54115 S 552.12 0.00 0.00<br />

53260 S 616.64 0.00 0.00 54120 S 932.65 0.00 0.00<br />

53265 S 616.64 0.00 0.00 54150 S 621.56 0.00 0.00<br />

53270 S 616.64 0.00 0.00 54160 S 676.51 0.00 0.00<br />

53275 S 616.64 0.00 0.00 54161 S 676.51 0.00 0.00<br />

53400 S 864.06 0.00 0.00 54162 S 676.51 0.00 0.00<br />

53405 S 832.93 0.00 0.00 54163 S 676.51 0.00 0.00<br />

53410 S 832.93 0.00 0.00 54164 S 676.51 0.00 0.00<br />

53420 S 864.06 0.00 0.00 54200 S 70.86 0.00 0.00<br />

53425 S 832.93 0.00 0.00 54205 S 1,022.11 0.00 0.00<br />

53430 S 832.93 0.00 0.00 54220 S 101.57 0.00 0.00<br />

53431 S 832.93 0.00 0.00 54231 S 66.54 0.00 0.00<br />

53440 S 4,798.04 2,914.07 1,030.10 54235 S 47.12 0.00 0.00<br />

53442 S 777.99 0.00 0.00 54240 TC S 33.45 0.00 0.00<br />

53444 S 4,798.04 2,914.07 1,030.10 54250 TC S 11.87 0.00 0.00<br />

53445 S 8,059.49 4,589.82 1,120.17 54300 S 963.76 0.00 0.00<br />

53446 S 777.99 0.00 0.00 54304 S 963.76 0.00 0.00<br />

53447 S 8,059.49 4,589.82 1,120.17 54308 S 963.76 0.00 0.00<br />

53449 S 777.99 0.00 0.00 54312 S 963.76 0.00 0.00<br />

53450 S 777.99 0.00 0.00 54316 S 963.76 0.00 0.00<br />

53460 S 561.69 0.00 0.00 54318 S 963.76 0.00 0.00<br />

53502 S 616.64 0.00 0.00 54322 S 963.76 0.00 0.00<br />

53505 S 832.93 0.00 0.00 54324 S 963.76 0.00 0.00<br />

53510 S 616.64 0.00 0.00 54326 S 963.76 0.00 0.00<br />

53515 S 832.93 0.00 0.00 54328 S 963.76 0.00 0.00<br />

53520 S 832.93 0.00 0.00 54340 S 963.76 0.00 0.00<br />

53600 S 42.09 0.00 0.00 54344 S 963.76 0.00 0.00<br />

53601 S 42.01 0.00 0.00 54348 S 963.76 0.00 0.00<br />

53605 S 595.10 0.00 0.00 54352 S 963.76 0.00 0.00<br />

53620 S 64.74 0.00 0.00 54360 S 963.76 0.00 0.00<br />

53621 S 67.99 0.00 0.00 54380 S 963.76 0.00 0.00<br />

53660 S 42.01 0.00 0.00 54385 S 963.76 0.00 0.00<br />

53661 S 42.01 0.00 0.00 54400 S 4,829.17 2,945.20 1,061.23<br />

53665 S 561.69 0.00 0.00 54401 S 8,145.56 4,675.89 1,206.23<br />

53850 S 1,843.96 0.00 0.00 54405 S 8,145.56 4,675.89 1,206.23<br />

53852 S 1,843.96 0.00 0.00 54406 S 963.76 0.00 0.00<br />

54000 S 616.64 0.00 0.00 54408 S 963.76 0.00 0.00<br />

54001 S 616.64 0.00 0.00 54410 S 8,145.56 4,675.89 1,206.23<br />

54015 S 696.53 0.00 0.00 54415 S 963.76 0.00 0.00<br />

54050 S 33.33 0.00 0.00 54416 S 8,145.56 4,675.89 1,206.23<br />

54055 S 67.99 0.00 0.00 54420 S 1,022.11 0.00 0.00<br />

54056 S 33.33 0.00 0.00 54435 S 1,022.11 0.00 0.00<br />

54057 S 569.64 0.00 0.00 54440 S 1,022.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 159.90 0.00 0.00 55706 S 464.83 0.00 0.00<br />

54500 S 433.98 0.00 0.00 55720 S 676.90 0.00 0.00<br />

54505 S 621.56 0.00 0.00 55725 S 731.85 0.00 0.00<br />

54512 S 676.51 0.00 0.00 55860 S 806.46 0.00 0.00<br />

54520 S 707.62 0.00 0.00 55870 S 82.01 0.00 0.00<br />

54522 S 707.62 0.00 0.00 55873 S 6,380.99 0.00 0.00<br />

54530 S 943.60 0.00 0.00 55875 S 1,372.93 0.00 0.00<br />

54550 S 943.60 0.00 0.00 55876 S 75.18 0.00 0.00<br />

54560 S 919.29 0.00 0.00 55920 S 942.39 0.00 0.00<br />

54600 S 765.98 0.00 0.00 56405 S 43.88 0.00 0.00<br />

54620 S 707.62 0.00 0.00 56420 S 57.27 0.00 0.00<br />

54640 S 943.60 0.00 0.00 56440 S 615.04 0.00 0.00<br />

54660 S 676.51 0.00 0.00 56441 S 560.09 0.00 0.00<br />

54670 S 707.62 0.00 0.00 56442 S 560.09 0.00 0.00<br />

54680 S 707.62 0.00 0.00 56501 S 60.43 0.00 0.00<br />

54690 S 1,583.40 0.00 0.00 56515 S 655.70 0.00 0.00<br />

54692 S 2,814.65 0.00 0.00 56605 S 34.89 0.00 0.00<br />

54700 S 676.51 0.00 0.00 56606 S 14.39 0.00 0.00<br />

54800 S 151.85 0.00 0.00 56620 S 746.81 0.00 0.00<br />

54830 S 707.62 0.00 0.00 56625 S 881.98 0.00 0.00<br />

54840 S 765.98 0.00 0.00 56700 S 560.09 0.00 0.00<br />

54860 S 707.62 0.00 0.00 56740 S 646.16 0.00 0.00<br />

54861 S 765.98 0.00 0.00 56800 S 646.16 0.00 0.00<br />

54865 S 621.56 0.00 0.00 56805 S 796.36 0.00 0.00<br />

54900 S 765.98 0.00 0.00 56810 S 746.81 0.00 0.00<br />

54901 S 765.98 0.00 0.00 56820 S 44.60 0.00 0.00<br />

55000 S 69.06 0.00 0.00 56821 S 57.27 0.00 0.00<br />

55040 S 885.25 0.00 0.00 57000 S 560.09 0.00 0.00<br />

55041 S 985.90 0.00 0.00 57010 S 615.04 0.00 0.00<br />

55060 S 765.98 0.00 0.00 57020 S 322.56 0.00 0.00<br />

55100 S 415.42 0.00 0.00 57022 S 507.01 0.00 0.00<br />

55110 S 676.51 0.00 0.00 57023 S 552.12 0.00 0.00<br />

55120 S 676.51 0.00 0.00 57061 S 55.75 0.00 0.00<br />

55150 S 621.56 0.00 0.00 57065 S 560.09 0.00 0.00<br />

55175 S 621.56 0.00 0.00 57100 S 35.61 0.00 0.00<br />

55180 S 676.51 0.00 0.00 57105 S 615.04 0.00 0.00<br />

55200 S 676.51 0.00 0.00 57130 S 615.04 0.00 0.00<br />

55250 S 676.51 0.00 0.00 57135 S 615.04 0.00 0.00<br />

55400 S 621.56 0.00 0.00 57150 S 25.90 0.00 0.00<br />

55450 S 222.29 0.00 0.00 57155 S 322.56 0.00 0.00<br />

55500 S 707.62 0.00 0.00 57160 S 37.41 0.00 0.00<br />

55520 S 765.98 0.00 0.00 57170 S 6.13 0.00 0.00<br />

55530 S 765.98 0.00 0.00 57180 S 115.21 0.00 0.00<br />

55535 S 943.60 0.00 0.00 57200 S 560.09 0.00 0.00<br />

55540 S 985.90 0.00 0.00 57210 S 615.04 0.00 0.00<br />

55550 S 1,583.40 0.00 0.00 57220 S 1,127.91 0.00 0.00<br />

55600 S 919.29 0.00 0.00 57230 S 926.11 0.00 0.00<br />

55680 S 621.56 0.00 0.00 57240 S 1,026.76 0.00 0.00<br />

55700 S 400.57 0.00 0.00 57250 S 1,026.76 0.00 0.00<br />

55705 S 400.57 0.00 0.00 57260 S 1,026.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,363.73 0.00 0.00 58555 S 605.15 0.00 0.00<br />

57267 S 1,161.93 0.00 0.00 58558 S 691.22 0.00 0.00<br />

57268 S 926.11 0.00 0.00 58559 S 660.10 0.00 0.00<br />

57287 S 1,356.27 0.00 0.00 58560 S 985.58 0.00 0.00<br />

57288 S 1,228.55 0.00 0.00 58561 S 985.58 0.00 0.00<br />

57289 S 1,026.76 0.00 0.00 58562 S 691.22 0.00 0.00<br />

57291 S 1,026.76 0.00 0.00 58563 S 1,388.66 0.00 0.00<br />

57300 S 926.11 0.00 0.00 58565 S 1,531.00 0.00 0.00<br />

57320 S 1,356.27 0.00 0.00 58600 S 1,356.27 0.00 0.00<br />

57400 S 615.04 0.00 0.00 58615 S 796.36 0.00 0.00<br />

57410 S 615.04 0.00 0.00 58660 S 1,280.97 0.00 0.00<br />

57415 S 615.04 0.00 0.00 58661 S 1,280.97 0.00 0.00<br />

57420 S 46.05 0.00 0.00 58662 S 1,280.97 0.00 0.00<br />

57421 S 60.07 0.00 0.00 58670 S 1,180.32 0.00 0.00<br />

57452 S 43.52 0.00 0.00 58671 S 1,180.32 0.00 0.00<br />

57454 S 53.24 0.00 0.00 58672 S 1,280.97 0.00 0.00<br />

57455 S 56.47 0.00 0.00 58673 S 1,280.97 0.00 0.00<br />

57456 S 54.67 0.00 0.00 58800 S 646.16 0.00 0.00<br />

57460 S 167.98 0.00 0.00 58805 S 1,356.27 0.00 0.00<br />

57461 S 178.41 0.00 0.00 58820 S 926.11 0.00 0.00<br />

57500 S 76.97 0.00 0.00 58900 S 646.16 0.00 0.00<br />

57505 S 48.92 0.00 0.00 58970 S 179.98 0.00 0.00<br />

57510 S 49.64 0.00 0.00 58974 S 179.98 0.00 0.00<br />

57511 S 57.27 0.00 0.00 58976 S 179.98 0.00 0.00<br />

57513 S 615.04 0.00 0.00 59000 S 65.82 0.00 0.00<br />

57520 S 615.04 0.00 0.00 59001 S 247.07 0.00 0.00<br />

57522 S 615.04 0.00 0.00 59012 S 120.81 0.00 0.00<br />

57530 S 926.11 0.00 0.00 59015 S 53.24 0.00 0.00<br />

57550 S 926.11 0.00 0.00 59020 TC S 28.05 0.00 0.00<br />

57556 S 1,228.55 0.00 0.00 59025 TC S 14.75 0.00 0.00<br />

57558 S 646.16 0.00 0.00 59070 S 120.81 0.00 0.00<br />

57700 S 560.09 0.00 0.00 59072 S 120.81 0.00 0.00<br />

57720 S 646.16 0.00 0.00 59076 S 120.81 0.00 0.00<br />

57800 S 26.26 0.00 0.00 59100 S 1,356.27 0.00 0.00<br />

58100 S 43.16 0.00 0.00 59150 S 1,864.68 0.00 0.00<br />

58120 S 615.04 0.00 0.00 59151 S 1,864.68 0.00 0.00<br />

58145 S 1,026.76 0.00 0.00 59160 S 646.16 0.00 0.00<br />

58301 S 40.28 0.00 0.00 59200 S 35.97 0.00 0.00<br />

58321 S 37.77 0.00 0.00 59300 S 77.69 0.00 0.00<br />

58322 S 38.84 0.00 0.00 59320 S 560.09 0.00 0.00<br />

58323 S 9.00 0.00 0.00 59412 S 796.36 0.00 0.00<br />

58345 S 796.36 0.00 0.00 59414 S 796.36 0.00 0.00<br />

58346 S 615.04 0.00 0.00 59812 S 746.81 0.00 0.00<br />

58350 S 926.11 0.00 0.00 59820 S 746.81 0.00 0.00<br />

58353 S 1,161.93 0.00 0.00 59821 S 746.81 0.00 0.00<br />

58356 S 1,759.86 0.00 0.00 59840 S 746.81 0.00 0.00<br />

58545 S 1,413.64 0.00 0.00 59841 S 746.81 0.00 0.00<br />

58546 S 1,583.40 0.00 0.00 59866 S 120.81 0.00 0.00<br />

58550 S 2,058.39 0.00 0.00 59870 S 746.81 0.00 0.00<br />

58552 S 1,864.68 0.00 0.00 59871 S 746.81 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 313.53 0.00 0.00 62367 S 17.26 0.00 0.00<br />

60100 S 49.28 0.00 0.00 62368 S 21.94 0.00 0.00<br />

60200 S 1,166.97 0.00 0.00 63600 S 589.42 0.00 0.00<br />

60280 S 1,256.44 0.00 0.00 63610 S 534.47 0.00 0.00<br />

60281 S 1,256.44 0.00 0.00 63615 S 745.12 0.00 0.00<br />

60300 S 64.74 0.00 0.00 63650 S 3,172.56 1,967.30 762.06<br />

61000 S 288.70 0.00 0.00 63655 S 4,647.03 2,963.42 1,279.82<br />

61001 S 288.70 0.00 0.00 63660 S 557.16 0.00 0.00<br />

61020 S 233.74 0.00 0.00 63685 S 14,104.80 7,520.81 936.82<br />

61026 S 233.74 0.00 0.00 63688 S 756.58 0.00 0.00<br />

61050 S 233.74 0.00 0.00 63744 S 1,094.13 0.00 0.00<br />

61055 S 233.74 0.00 0.00 63746 S 506.12 0.00 0.00<br />

61070 S 181.88 0.00 0.00 64400 S 55.39 0.00 0.00<br />

61215 S 1,094.13 0.00 0.00 64402 S 52.16 0.00 0.00<br />

61330 S 1,685.57 0.00 0.00 64405 S 44.24 0.00 0.00<br />

61334 S 1,685.57 0.00 0.00 64408 S 55.03 0.00 0.00<br />

61790 S 620.54 0.00 0.00 64410 S 306.26 0.00 0.00<br />

61791 S 460.37 0.00 0.00 64412 S 80.93 0.00 0.00<br />

61880 S 790.49 0.00 0.00 64413 S 51.80 0.00 0.00<br />

61885 S 11,375.28 6,093.63 811.98 64415 S 141.05 0.00 0.00<br />

61886 S 16,986.07 8,952.64 919.22 64416 S 288.70 0.00 0.00<br />

61888 S 756.58 0.00 0.00 64417 S 141.05 0.00 0.00<br />

62194 S 306.26 0.00 0.00 64418 S 72.65 0.00 0.00<br />

62225 S 475.88 0.00 0.00 64420 S 141.05 0.00 0.00<br />

62230 S 1,063.00 0.00 0.00 64421 S 306.26 0.00 0.00<br />

62252 TC S 48.20 0.00 0.00 64425 S 50.35 0.00 0.00<br />

62263 S 306.26 0.00 0.00 64430 S 211.94 0.00 0.00<br />

62264 S 451.17 0.00 0.00 64435 S 75.89 0.00 0.00<br />

62267 S 180.04 0.00 0.00 64445 S 67.26 0.00 0.00<br />

62268 S 233.74 0.00 0.00 64446 S 578.51 0.00 0.00<br />

62269 S 354.70 0.00 0.00 64447 S 146.92 0.00 0.00<br />

62270 S 141.05 0.00 0.00 64448 S 146.92 0.00 0.00<br />

62272 S 141.05 0.00 0.00 64449 S 288.70 0.00 0.00<br />

62273 S 235.37 0.00 0.00 64450 S 44.96 0.00 0.00<br />

62280 S 306.26 0.00 0.00 64455 S 18.70 0.00 0.00<br />

62281 S 306.26 0.00 0.00 64470 S 306.26 0.00 0.00<br />

62282 S 306.26 0.00 0.00 64472 S 235.37 0.00 0.00<br />

62287 S 1,374.83 0.00 0.00 64475 S 306.26 0.00 0.00<br />

62292 S 288.70 0.00 0.00 64476 S 211.98 0.00 0.00<br />

62294 S 233.74 0.00 0.00 64479 S 306.26 0.00 0.00<br />

62310 S 306.26 0.00 0.00 64480 S 235.37 0.00 0.00<br />

62311 S 306.26 0.00 0.00 64483 S 306.26 0.00 0.00<br />

62318 S 306.26 0.00 0.00 64484 S 235.37 0.00 0.00<br />

62319 S 306.26 0.00 0.00 64505 S 41.01 0.00 0.00<br />

62350 S 1,063.00 0.00 0.00 64508 S 87.04 0.00 0.00<br />

62355 S 506.12 0.00 0.00 64510 S 306.26 0.00 0.00<br />

62360 S 1,063.00 0.00 0.00 64517 S 211.94 0.00 0.00<br />

62361 S 10,911.86 5,906.20 900.55 64520 S 306.26 0.00 0.00<br />

62362 S 10,911.86 5,906.20 900.55 64530 S 306.26 0.00 0.00<br />

62365 S 940.62 0.00 0.00 64553 S 3,117.61 1,912.35 707.11<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,500.89 2,295.64 1,090.39 64746 S 589.42 0.00 0.00<br />

64560 S 3,500.89 2,295.64 1,090.39 64761 S 745.12 0.00 0.00<br />

64561 S 3,203.68 1,998.42 793.17 64763 S 745.12 0.00 0.00<br />

64565 S 3,500.89 2,295.64 1,090.39 64766 S 1,447.52 0.00 0.00<br />

64573 S 5,453.86 3,230.88 1,007.90 64771 S 589.42 0.00 0.00<br />

64575 S 4,169.03 2,485.42 801.82 64772 S 589.42 0.00 0.00<br />

64577 S 4,169.03 2,485.42 801.82 64774 S 589.42 0.00 0.00<br />

64580 S 4,169.03 2,485.42 801.82 64776 S 620.54 0.00 0.00<br />

64581 S 4,255.10 2,571.49 887.89 64778 S 589.42 0.00 0.00<br />

64585 S 557.16 0.00 0.00 64782 S 620.54 0.00 0.00<br />

64590 S 11,375.28 6,093.63 811.98 64783 S 589.42 0.00 0.00<br />

64595 S 756.58 0.00 0.00 64784 S 620.54 0.00 0.00<br />

64600 S 451.17 0.00 0.00 64786 S 971.74 0.00 0.00<br />

64605 S 451.17 0.00 0.00 64787 S 589.42 0.00 0.00<br />

64610 S 451.17 0.00 0.00 64788 S 620.54 0.00 0.00<br />

64612 S 65.82 0.00 0.00 64790 S 620.54 0.00 0.00<br />

64613 S 63.67 0.00 0.00 64792 S 971.74 0.00 0.00<br />

64614 S 72.65 0.00 0.00 64795 S 589.42 0.00 0.00<br />

64620 S 306.26 0.00 0.00 64802 S 589.42 0.00 0.00<br />

64622 S 451.17 0.00 0.00 64820 S 745.12 0.00 0.00<br />

64623 S 306.26 0.00 0.00 64821 S 869.87 0.00 0.00<br />

64626 S 451.17 0.00 0.00 64822 S 1,127.07 0.00 0.00<br />

64627 S 211.98 0.00 0.00 64823 S 1,127.07 0.00 0.00<br />

64630 S 315.47 0.00 0.00 64831 S 1,030.09 0.00 0.00<br />

64632 S 34.17 0.00 0.00 64832 S 885.67 0.00 0.00<br />

64640 S 101.79 0.00 0.00 64834 S 940.62 0.00 0.00<br />

64650 S 34.17 0.00 0.00 64835 S 971.74 0.00 0.00<br />

64653 S 37.05 0.00 0.00 64836 S 971.74 0.00 0.00<br />

64680 S 479.35 0.00 0.00 64837 S 885.67 0.00 0.00<br />

64681 S 506.12 0.00 0.00 64840 S 940.62 0.00 0.00<br />

64702 S 534.47 0.00 0.00 64856 S 940.62 0.00 0.00<br />

64704 S 534.47 0.00 0.00 64857 S 940.62 0.00 0.00<br />

64708 S 589.42 0.00 0.00 64858 S 940.62 0.00 0.00<br />

64712 S 589.42 0.00 0.00 64859 S 885.67 0.00 0.00<br />

64713 S 589.42 0.00 0.00 64861 S 971.74 0.00 0.00<br />

64714 S 589.42 0.00 0.00 64862 S 971.74 0.00 0.00<br />

64716 S 620.54 0.00 0.00 64864 S 971.74 0.00 0.00<br />

64718 S 589.42 0.00 0.00 64865 S 1,030.09 0.00 0.00<br />

64719 S 589.42 0.00 0.00 64870 S 1,030.09 0.00 0.00<br />

64721 S 589.42 0.00 0.00 64872 S 940.62 0.00 0.00<br />

64722 S 534.47 0.00 0.00 64874 S 971.74 0.00 0.00<br />

64726 S 534.47 0.00 0.00 64876 S 971.74 0.00 0.00<br />

64727 S 534.47 0.00 0.00 64885 S 940.62 0.00 0.00<br />

64732 S 589.42 0.00 0.00 64886 S 940.62 0.00 0.00<br />

64734 S 589.42 0.00 0.00 64890 S 940.62 0.00 0.00<br />

64736 S 589.42 0.00 0.00 64891 S 940.62 0.00 0.00<br />

64738 S 589.42 0.00 0.00 64892 S 940.62 0.00 0.00<br />

64740 S 589.42 0.00 0.00 64893 S 940.62 0.00 0.00<br />

64742 S 589.42 0.00 0.00 64895 S 971.74 0.00 0.00<br />

64744 S 589.42 0.00 0.00 64896 S 971.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 971.74 0.00 0.00 65770 S 5,718.36 0.00 0.00<br />

64898 S 971.74 0.00 0.00 65772 S 643.27 0.00 0.00<br />

64901 S 940.62 0.00 0.00 65775 S 643.27 0.00 0.00<br />

64902 S 940.62 0.00 0.00 65780 S 1,112.77 0.00 0.00<br />

64905 S 940.62 0.00 0.00 65781 S 1,112.77 0.00 0.00<br />

64907 S 885.67 0.00 0.00 65782 S 1,112.77 0.00 0.00<br />

64910 S 1,447.52 0.00 0.00 65800 S 498.86 0.00 0.00<br />

65091 S 1,023.19 0.00 0.00 65805 S 498.86 0.00 0.00<br />

65093 S 1,023.19 0.00 0.00 65810 S 728.94 0.00 0.00<br />

65101 S 1,023.19 0.00 0.00 65815 S 697.81 0.00 0.00<br />

65103 S 1,023.19 0.00 0.00 65820 S 255.93 0.00 0.00<br />

65105 S 1,081.54 0.00 0.00 65850 S 787.28 0.00 0.00<br />

65110 S 1,123.84 0.00 0.00 65855 S 135.96 0.00 0.00<br />

65112 S 1,259.01 0.00 0.00 65860 S 126.98 0.00 0.00<br />

65114 S 1,259.01 0.00 0.00 65865 S 498.86 0.00 0.00<br />

65125 S 1,047.80 0.00 0.00 65870 S 787.28 0.00 0.00<br />

65130 S 771.88 0.00 0.00 65875 S 787.28 0.00 0.00<br />

65135 S 740.76 0.00 0.00 65880 S 643.27 0.00 0.00<br />

65140 S 1,023.19 0.00 0.00 65900 S 685.57 0.00 0.00<br />

65150 S 740.76 0.00 0.00 65920 S 964.76 0.00 0.00<br />

65155 S 1,023.19 0.00 0.00 65930 S 829.58 0.00 0.00<br />

65175 S 550.64 0.00 0.00 66020 S 498.86 0.00 0.00<br />

65205 S 21.22 0.00 0.00 66030 S 255.93 0.00 0.00<br />

65210 S 26.98 0.00 0.00 66130 S 964.76 0.00 0.00<br />

65220 S 37.59 0.00 0.00 66150 S 787.28 0.00 0.00<br />

65222 S 29.49 0.00 0.00 66155 S 787.28 0.00 0.00<br />

65235 S 553.80 0.00 0.00 66160 S 697.81 0.00 0.00<br />

65260 S 365.27 0.00 0.00 66165 S 787.28 0.00 0.00<br />

65265 S 755.69 0.00 0.00 66170 S 787.28 0.00 0.00<br />

65270 S 605.58 0.00 0.00 66172 S 787.28 0.00 0.00<br />

65272 S 697.81 0.00 0.00 66180 S 1,172.88 0.00 0.00<br />

65275 S 787.28 0.00 0.00 66185 S 1,041.12 0.00 0.00<br />

65280 S 755.69 0.00 0.00 66220 S 1,016.32 0.00 0.00<br />

65285 S 1,074.66 0.00 0.00 66225 S 1,130.59 0.00 0.00<br />

65286 S 188.01 0.00 0.00 66250 S 553.80 0.00 0.00<br />

65290 S 744.22 0.00 0.00 66500 S 255.93 0.00 0.00<br />

65400 S 498.86 0.00 0.00 66505 S 255.93 0.00 0.00<br />

65410 S 553.80 0.00 0.00 66600 S 728.94 0.00 0.00<br />

65420 S 553.80 0.00 0.00 66605 S 728.94 0.00 0.00<br />

65426 S 829.58 0.00 0.00 66625 S 518.28 0.00 0.00<br />

65430 S 37.59 0.00 0.00 66630 S 728.94 0.00 0.00<br />

65435 S 32.73 0.00 0.00 66635 S 728.94 0.00 0.00<br />

65436 S 142.08 0.00 0.00 66680 S 728.94 0.00 0.00<br />

65450 S 86.74 0.00 0.00 66682 S 697.81 0.00 0.00<br />

65600 S 167.62 0.00 0.00 66700 S 553.80 0.00 0.00<br />

65710 S 1,247.94 0.00 0.00 66710 S 553.80 0.00 0.00<br />

65730 S 1,247.94 0.00 0.00 66711 S 553.80 0.00 0.00<br />

65750 S 1,247.94 0.00 0.00 66720 S 553.80 0.00 0.00<br />

65755 S 1,247.94 0.00 0.00 66740 S 697.81 0.00 0.00<br />

65756 S 1,528.27 0.00 0.00 66761 S 189.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 192.44 0.00 0.00 67228 S 211.93 0.00 0.00<br />

66770 S 211.93 0.00 0.00 67229 S 211.93 0.00 0.00<br />

66820 S 188.01 0.00 0.00 67250 S 636.71 0.00 0.00<br />

66821 S 257.90 0.00 0.00 67255 S 697.35 0.00 0.00<br />

66825 S 787.28 0.00 0.00 67311 S 744.22 0.00 0.00<br />

66830 S 275.34 0.00 0.00 67312 S 802.57 0.00 0.00<br />

66840 S 591.89 0.00 0.00 67314 S 802.57 0.00 0.00<br />

66850 S 1,114.38 0.00 0.00 67316 S 802.57 0.00 0.00<br />

66852 S 936.90 0.00 0.00 67318 S 802.57 0.00 0.00<br />

66920 S 936.90 0.00 0.00 67320 S 802.57 0.00 0.00<br />

66930 S 979.21 0.00 0.00 67331 S 802.57 0.00 0.00<br />

66940 S 634.19 0.00 0.00 67332 S 802.57 0.00 0.00<br />

66982 S 962.10 0.00 0.00 67334 S 802.57 0.00 0.00<br />

66983 S 962.10 0.00 0.00 67335 S 802.57 0.00 0.00<br />

66984 S 962.10 0.00 0.00 67340 S 802.57 0.00 0.00<br />

66985 S 890.62 0.00 0.00 67343 S 980.04 0.00 0.00<br />

66986 S 890.62 0.00 0.00 67345 S 83.81 0.00 0.00<br />

67005 S 755.69 0.00 0.00 67346 S 453.31 0.00 0.00<br />

67010 S 755.69 0.00 0.00 67400 S 636.71 0.00 0.00<br />

67015 S 930.25 0.00 0.00 67405 S 830.23 0.00 0.00<br />

67025 S 611.29 0.00 0.00 67412 S 737.35 0.00 0.00<br />

67027 S 1,074.66 0.00 0.00 67413 S 872.53 0.00 0.00<br />

67028 S 84.53 0.00 0.00 67414 S 1,550.42 0.00 0.00<br />

67030 S 611.29 0.00 0.00 67415 S 550.64 0.00 0.00<br />

67031 S 257.90 0.00 0.00 67420 S 1,123.84 0.00 0.00<br />

67036 S 1,074.66 0.00 0.00 67430 S 1,123.84 0.00 0.00<br />

67039 S 1,252.14 0.00 0.00 67440 S 1,123.84 0.00 0.00<br />

67040 S 1,252.14 0.00 0.00 67445 S 1,123.84 0.00 0.00<br />

67041 S 1,536.67 0.00 0.00 67450 S 1,123.84 0.00 0.00<br />

67042 S 1,536.67 0.00 0.00 67500 S 86.74 0.00 0.00<br />

67043 S 1,536.67 0.00 0.00 67505 S 26.98 0.00 0.00<br />

67101 S 234.58 0.00 0.00 67515 S 27.34 0.00 0.00<br />

67105 S 211.93 0.00 0.00 67550 S 1,081.54 0.00 0.00<br />

67107 S 1,116.97 0.00 0.00 67560 S 740.76 0.00 0.00<br />

67108 S 1,252.14 0.00 0.00 67570 S 1,081.54 0.00 0.00<br />

67110 S 340.99 0.00 0.00 67700 S 126.90 0.00 0.00<br />

67112 S 1,252.14 0.00 0.00 67710 S 148.19 0.00 0.00<br />

67113 S 1,536.67 0.00 0.00 67715 S 550.64 0.00 0.00<br />

67115 S 666.23 0.00 0.00 67800 S 53.24 0.00 0.00<br />

67120 S 666.23 0.00 0.00 67801 S 64.39 0.00 0.00<br />

67121 S 666.23 0.00 0.00 67805 S 83.44 0.00 0.00<br />

67141 S 234.84 0.00 0.00 67808 S 605.58 0.00 0.00<br />

67145 S 200.35 0.00 0.00 67810 S 126.90 0.00 0.00<br />

67208 S 213.66 0.00 0.00 67820 S 17.62 0.00 0.00<br />

67210 S 211.93 0.00 0.00 67825 S 54.31 0.00 0.00<br />

67218 S 798.00 0.00 0.00 67830 S 371.78 0.00 0.00<br />

67220 S 234.58 0.00 0.00 67835 S 605.58 0.00 0.00<br />

67221 S 120.49 0.00 0.00 67840 S 155.39 0.00 0.00<br />

67225 S 8.28 0.00 0.00 67850 S 123.38 0.00 0.00<br />

67227 S 611.29 0.00 0.00 67875 S 309.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 584.93 0.00 0.00 68440 S 52.88 0.00 0.00<br />

67882 S 636.71 0.00 0.00 68500 S 771.88 0.00 0.00<br />

67900 S 830.23 0.00 0.00 68505 S 771.88 0.00 0.00<br />

67901 S 737.35 0.00 0.00 68510 S 550.64 0.00 0.00<br />

67902 S 872.53 0.00 0.00 68520 S 771.88 0.00 0.00<br />

67903 S 695.05 0.00 0.00 68525 S 550.64 0.00 0.00<br />

67904 S 695.05 0.00 0.00 68530 S 126.90 0.00 0.00<br />

67906 S 737.35 0.00 0.00 68540 S 636.71 0.00 0.00<br />

67908 S 695.05 0.00 0.00 68550 S 771.88 0.00 0.00<br />

67909 S 695.05 0.00 0.00 68700 S 605.58 0.00 0.00<br />

67911 S 636.71 0.00 0.00 68705 S 120.49 0.00 0.00<br />

67912 S 636.71 0.00 0.00 68720 S 830.23 0.00 0.00<br />

67914 S 636.71 0.00 0.00 68745 S 830.23 0.00 0.00<br />

67915 S 171.93 0.00 0.00 68750 S 830.23 0.00 0.00<br />

67916 S 695.05 0.00 0.00 68760 S 102.51 0.00 0.00<br />

67917 S 695.05 0.00 0.00 68761 S 70.86 0.00 0.00<br />

67921 S 636.71 0.00 0.00 68770 S 830.23 0.00 0.00<br />

67922 S 167.26 0.00 0.00 68801 S 37.59 0.00 0.00<br />

67923 S 695.05 0.00 0.00 68810 S 107.49 0.00 0.00<br />

67924 S 695.05 0.00 0.00 68811 S 605.58 0.00 0.00<br />

67930 S 171.93 0.00 0.00 68815 S 605.58 0.00 0.00<br />

67935 S 605.58 0.00 0.00 68816 S 777.45 0.00 0.00<br />

67938 S 86.74 0.00 0.00 68840 S 55.75 0.00 0.00<br />

67950 S 605.58 0.00 0.00 69000 S 56.87 0.00 0.00<br />

67961 S 636.71 0.00 0.00 69005 S 107.55 0.00 0.00<br />

67966 S 636.71 0.00 0.00 69020 S 56.87 0.00 0.00<br />

67971 S 636.71 0.00 0.00 69100 S 64.74 0.00 0.00<br />

67973 S 771.88 0.00 0.00 69105 S 91.72 0.00 0.00<br />

67974 S 636.71 0.00 0.00 69110 S 481.88 0.00 0.00<br />

67975 S 636.71 0.00 0.00 69120 S 715.10 0.00 0.00<br />

68020 S 47.12 0.00 0.00 69140 S 715.10 0.00 0.00<br />

68040 S 23.38 0.00 0.00 69145 S 536.82 0.00 0.00<br />

68100 S 93.52 0.00 0.00 69150 S 377.30 0.00 0.00<br />

68110 S 120.49 0.00 0.00 69200 S 26.01 0.00 0.00<br />

68115 S 605.58 0.00 0.00 69205 S 601.54 0.00 0.00<br />

68130 S 553.80 0.00 0.00 69210 S 21.22 0.00 0.00<br />

68135 S 60.43 0.00 0.00 69220 S 33.33 0.00 0.00<br />

68200 S 17.26 0.00 0.00 69222 S 140.28 0.00 0.00<br />

68320 S 830.23 0.00 0.00 69300 S 746.23 0.00 0.00<br />

68325 S 830.23 0.00 0.00 69310 S 1,090.77 0.00 0.00<br />

68326 S 695.05 0.00 0.00 69320 S 1,326.59 0.00 0.00<br />

68328 S 830.23 0.00 0.00 69400 S 94.23 0.00 0.00<br />

68330 S 787.28 0.00 0.00 69401 S 49.64 0.00 0.00<br />

68335 S 830.23 0.00 0.00 69405 S 130.21 0.00 0.00<br />

68340 S 695.05 0.00 0.00 69420 S 116.90 0.00 0.00<br />

68360 S 697.81 0.00 0.00 69421 S 594.97 0.00 0.00<br />

68362 S 697.81 0.00 0.00 69424 S 82.01 0.00 0.00<br />

68371 S 553.80 0.00 0.00 69433 S 116.54 0.00 0.00<br />

68400 S 126.90 0.00 0.00 69436 S 594.97 0.00 0.00<br />

68420 S 180.56 0.00 0.00 69440 S 746.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 1,004.70 0.00 0.00 69840 S 1,191.41 0.00 0.00<br />

69501 S 1,326.59 0.00 0.00 69905 S 1,326.59 0.00 0.00<br />

69502 S 982.05 0.00 0.00 69910 S 1,326.59 0.00 0.00<br />

69505 S 1,326.59 0.00 0.00 69915 S 1,326.59 0.00 0.00<br />

69511 S 1,326.59 0.00 0.00 69930 S 23,982.91 12,877.20 1,771.49<br />

69530 S 1,326.59 0.00 0.00 70030 TC A 18.34 0.00 0.00<br />

69540 S 137.04 0.00 0.00 70100 TC A 20.15 0.00 0.00<br />

69550 S 1,191.41 0.00 0.00 70110 TC A 24.82 0.00 0.00<br />

69552 S 1,326.59 0.00 0.00 70120 TC A 22.30 0.00 0.00<br />

69601 S 1,326.59 0.00 0.00 70130 TC A 27.25 0.00 0.00<br />

69602 S 1,326.59 0.00 0.00 70134 TC A 27.34 0.00 0.00<br />

69603 S 1,326.59 0.00 0.00 70140 TC A 18.70 0.00 0.00<br />

69604 S 1,326.59 0.00 0.00 70150 TC A 27.25 0.00 0.00<br />

69605 S 1,326.59 0.00 0.00 70160 TC A 21.94 0.00 0.00<br />

69610 S 183.44 0.00 0.00 70190 TC A 23.02 0.00 0.00<br />

69620 S 715.10 0.00 0.00 70200 TC A 27.25 0.00 0.00<br />

69631 S 1,191.41 0.00 0.00 70210 TC A 19.43 0.00 0.00<br />

69632 S 1,191.41 0.00 0.00 70220 TC A 24.46 0.00 0.00<br />

69633 S 1,191.41 0.00 0.00 70240 TC A 18.34 0.00 0.00<br />

69635 S 1,326.59 0.00 0.00 70250 TC A 22.30 0.00 0.00<br />

69636 S 1,326.59 0.00 0.00 70260 TC A 28.41 0.00 0.00<br />

69637 S 1,326.59 0.00 0.00 70300 TC A 7.91 0.00 0.00<br />

69641 S 1,326.59 0.00 0.00 70310 TC A 19.55 0.00 0.00<br />

69642 S 1,326.59 0.00 0.00 70320 TC A 19.55 0.00 0.00<br />

69643 S 1,326.59 0.00 0.00 70328 TC A 19.43 0.00 0.00<br />

69644 S 1,326.59 0.00 0.00 70330 TC A 27.25 0.00 0.00<br />

69645 S 1,326.59 0.00 0.00 70336 TC A 212.09 0.00 0.00<br />

69646 S 1,326.59 0.00 0.00 70350 TC A 10.79 0.00 0.00<br />

69650 S 982.05 0.00 0.00 70355 TC A 11.15 0.00 0.00<br />

69660 S 1,191.41 0.00 0.00 70360 TC A 17.26 0.00 0.00<br />

69661 S 1,191.41 0.00 0.00 70370 TC A 50.70 0.00 0.00<br />

69662 S 1,191.41 0.00 0.00 70371 TC A 50.70 0.00 0.00<br />

69666 S 1,149.11 0.00 0.00 70380 TC A 26.26 0.00 0.00<br />

69667 S 1,149.11 0.00 0.00 70450 TC A 118.45 0.00 0.00<br />

69670 S 1,090.77 0.00 0.00 70460 TC A 187.56 0.00 0.00<br />

69676 S 1,090.77 0.00 0.00 70470 TC A 207.77 0.00 0.00<br />

69700 S 1,090.77 0.00 0.00 70480 TC A 118.45 0.00 0.00<br />

69711 S 1,004.70 0.00 0.00 70481 TC A 187.56 0.00 0.00<br />

69714 S 6,371.63 4,017.55 1,663.48 70482 TC A 207.77 0.00 0.00<br />

69715 S 6,371.63 4,017.55 1,663.48 70486 TC A 118.45 0.00 0.00<br />

69717 S 6,371.63 4,017.55 1,663.48 70487 TC A 187.56 0.00 0.00<br />

69718 S 6,371.63 4,017.55 1,663.48 70488 TC A 207.77 0.00 0.00<br />

69720 S 1,191.41 0.00 0.00 70490 TC A 118.45 0.00 0.00<br />

69740 S 1,191.41 0.00 0.00 70491 TC A 187.56 0.00 0.00<br />

69745 S 1,191.41 0.00 0.00 70492 TC A 207.77 0.00 0.00<br />

69801 S 1,191.41 0.00 0.00 70496 TC A 214.41 0.00 0.00<br />

69802 S 1,326.59 0.00 0.00 70498 TC A 214.41 0.00 0.00<br />

69805 S 1,326.59 0.00 0.00 70540 TC A 212.09 0.00 0.00<br />

69806 S 1,326.59 0.00 0.00 70542 TC A 260.44 0.00 0.00<br />

69820 S 1,191.41 0.00 0.00 70543 TC A 328.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 212.09 0.00 0.00 72120 TC A 34.53 0.00 0.00<br />

70545 TC A 260.44 0.00 0.00 72125 TC A 118.45 0.00 0.00<br />

70546 TC A 328.25 0.00 0.00 72126 TC A 187.56 0.00 0.00<br />

70547 TC A 212.09 0.00 0.00 72127 TC A 207.77 0.00 0.00<br />

70548 TC A 260.44 0.00 0.00 72128 TC A 118.45 0.00 0.00<br />

70549 TC A 328.25 0.00 0.00 72129 TC A 187.56 0.00 0.00<br />

70551 TC A 212.09 0.00 0.00 72130 TC A 207.77 0.00 0.00<br />

70552 TC A 260.44 0.00 0.00 72131 TC A 118.45 0.00 0.00<br />

70553 TC A 328.25 0.00 0.00 72132 TC A 187.56 0.00 0.00<br />

70554 TC A 212.09 0.00 0.00 72133 TC A 207.77 0.00 0.00<br />

70555 TC A 212.09 0.00 0.00 72141 TC A 212.09 0.00 0.00<br />

70557 TC A 212.09 0.00 0.00 72142 TC A 260.44 0.00 0.00<br />

70558 TC A 260.44 0.00 0.00 72146 TC A 212.09 0.00 0.00<br />

70559 TC A 328.25 0.00 0.00 72147 TC A 260.44 0.00 0.00<br />

71010 TC A 14.03 0.00 0.00 72148 TC A 212.09 0.00 0.00<br />

71015 TC A 17.98 0.00 0.00 72149 TC A 260.44 0.00 0.00<br />

71020 TC A 19.07 0.00 0.00 72156 TC A 328.25 0.00 0.00<br />

71021 TC A 23.02 0.00 0.00 72157 TC A 328.25 0.00 0.00<br />

71022 TC A 27.25 0.00 0.00 72158 TC A 328.25 0.00 0.00<br />

71023 TC A 44.60 0.00 0.00 72170 TC A 16.19 0.00 0.00<br />

71030 TC A 27.25 0.00 0.00 72190 TC A 27.25 0.00 0.00<br />

71034 TC A 50.70 0.00 0.00 72191 TC A 214.41 0.00 0.00<br />

71035 TC A 23.74 0.00 0.00 72192 TC A 118.45 0.00 0.00<br />

71100 TC A 19.79 0.00 0.00 72193 TC A 187.56 0.00 0.00<br />

71101 TC A 24.09 0.00 0.00 72194 TC A 207.77 0.00 0.00<br />

71110 TC A 25.18 0.00 0.00 72195 TC A 212.09 0.00 0.00<br />

71111 TC A 33.45 0.00 0.00 72196 TC A 260.44 0.00 0.00<br />

71120 TC A 20.86 0.00 0.00 72197 TC A 328.25 0.00 0.00<br />

71130 TC A 24.46 0.00 0.00 72200 TC A 19.07 0.00 0.00<br />

71250 TC A 118.45 0.00 0.00 72202 TC A 23.38 0.00 0.00<br />

71260 TC A 187.56 0.00 0.00 72220 TC A 19.07 0.00 0.00<br />

71270 TC A 207.77 0.00 0.00 73000 TC A 17.98 0.00 0.00<br />

71275 TC A 214.41 0.00 0.00 73010 TC A 18.34 0.00 0.00<br />

71550 TC A 212.09 0.00 0.00 73020 TC A 14.75 0.00 0.00<br />

71551 TC A 260.44 0.00 0.00 73030 TC A 18.70 0.00 0.00<br />

71552 TC A 328.25 0.00 0.00 73050 TC A 23.38 0.00 0.00<br />

72010 TC A 45.36 0.00 0.00 73060 TC A 18.70 0.00 0.00<br />

72020 TC A 14.75 0.00 0.00 73070 TC A 17.98 0.00 0.00<br />

72040 TC A 23.74 0.00 0.00 73080 TC A 23.74 0.00 0.00<br />

72050 TC A 33.81 0.00 0.00 73090 TC A 17.98 0.00 0.00<br />

72052 TC A 45.36 0.00 0.00 73092 TC A 18.70 0.00 0.00<br />

72069 TC A 22.30 0.00 0.00 73100 TC A 18.70 0.00 0.00<br />

72070 TC A 20.86 0.00 0.00 73110 TC A 23.74 0.00 0.00<br />

72072 TC A 25.18 0.00 0.00 73120 TC A 17.62 0.00 0.00<br />

72074 TC A 27.25 0.00 0.00 73130 TC A 20.86 0.00 0.00<br />

72080 TC A 22.30 0.00 0.00 73140 TC A 20.50 0.00 0.00<br />

72090 TC A 29.86 0.00 0.00 73200 TC A 118.45 0.00 0.00<br />

72100 TC A 25.54 0.00 0.00 73201 TC A 187.56 0.00 0.00<br />

72110 TC A 35.61 0.00 0.00 73202 TC A 207.77 0.00 0.00<br />

72114 TC A 45.36 0.00 0.00 73206 TC A 214.41 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 212.09 0.00 0.00 74246 TC A 53.53 0.00 0.00<br />

73219 TC A 260.44 0.00 0.00 74247 TC A 53.53 0.00 0.00<br />

73220 TC A 328.25 0.00 0.00 74249 TC A 87.03 0.00 0.00<br />

73221 TC A 212.09 0.00 0.00 74250 TC A 53.53 0.00 0.00<br />

73222 TC A 260.44 0.00 0.00 74251 TC A 87.03 0.00 0.00<br />

73223 TC A 328.25 0.00 0.00 74260 TC A 53.53 0.00 0.00<br />

73500 TC A 15.47 0.00 0.00 74270 TC A 53.53 0.00 0.00<br />

73510 TC A 23.74 0.00 0.00 74280 TC A 87.03 0.00 0.00<br />

73520 TC A 24.46 0.00 0.00 74283 TC A 53.53 0.00 0.00<br />

73540 TC A 24.46 0.00 0.00 74290 TC A 45.68 0.00 0.00<br />

73550 TC A 17.98 0.00 0.00 74291 TC A 43.88 0.00 0.00<br />

73560 TC A 18.34 0.00 0.00 74400 TC A 79.49 0.00 0.00<br />

73562 TC A 22.66 0.00 0.00 74410 TC A 84.89 0.00 0.00<br />

73564 TC A 26.26 0.00 0.00 74415 TC A 101.44 0.00 0.00<br />

73565 TC A 19.79 0.00 0.00 74420 TC A 106.02 0.00 0.00<br />

73590 TC A 17.26 0.00 0.00 74710 TC A 23.74 0.00 0.00<br />

73592 TC A 18.70 0.00 0.00 74775 TC A 106.02 0.00 0.00<br />

73600 TC A 17.62 0.00 0.00 75557 TC A 212.09 0.00 0.00<br />

73610 TC A 20.86 0.00 0.00 75559 TC A 212.09 0.00 0.00<br />

73620 TC A 16.90 0.00 0.00 75561 TC A 328.25 0.00 0.00<br />

73630 TC A 20.50 0.00 0.00 75563 TC A 328.25 0.00 0.00<br />

73650 TC A 17.26 0.00 0.00 76010 TC A 17.62 0.00 0.00<br />

73660 TC A 19.43 0.00 0.00 76098 TC A 10.79 0.00 0.00<br />

73700 TC A 118.45 0.00 0.00 76100 TC A 45.36 0.00 0.00<br />

73701 TC A 187.56 0.00 0.00 76101 TC A 121.57 0.00 0.00<br />

73702 TC A 207.77 0.00 0.00 76102 TC A 121.57 0.00 0.00<br />

73706 TC A 214.41 0.00 0.00 76120 TC A 50.70 0.00 0.00<br />

73718 TC A 212.09 0.00 0.00 76150 A 17.62 0.00 0.00<br />

73719 TC A 260.44 0.00 0.00 76380 TC A 63.99 0.00 0.00<br />

73720 TC A 328.25 0.00 0.00 76496 TC A 50.70 0.00 0.00<br />

73721 TC A 212.09 0.00 0.00 76497 TC A 63.99 0.00 0.00<br />

73722 TC A 260.44 0.00 0.00 76498 TC A 212.09 0.00 0.00<br />

73723 TC A 328.25 0.00 0.00 76499 TC A 27.25 0.00 0.00<br />

74000 TC A 15.47 0.00 0.00 76506 TC A 38.09 0.00 0.00<br />

74010 TC A 24.09 0.00 0.00 76510 TC A 64.74 0.00 0.00<br />

74020 TC A 24.46 0.00 0.00 76511 TC A 45.32 0.00 0.00<br />

74022 TC A 29.86 0.00 0.00 76512 TC A 38.49 0.00 0.00<br />

74150 TC A 118.45 0.00 0.00 76513 TC A 46.76 0.00 0.00<br />

74160 TC A 187.56 0.00 0.00 76514 TC A 3.24 0.00 0.00<br />

74170 TC A 207.77 0.00 0.00 76516 TC A 36.69 0.00 0.00<br />

74175 TC A 214.41 0.00 0.00 76519 TC A 41.01 0.00 0.00<br />

74181 TC A 212.09 0.00 0.00 76529 TC A 35.61 0.00 0.00<br />

74182 TC A 260.44 0.00 0.00 76536 TC A 59.58 0.00 0.00<br />

74183 TC A 328.25 0.00 0.00 76604 TC A 38.09 0.00 0.00<br />

74210 TC A 53.53 0.00 0.00 76645 TC A 38.09 0.00 0.00<br />

74220 TC A 53.53 0.00 0.00 76700 TC A 59.58 0.00 0.00<br />

74230 TC A 53.53 0.00 0.00 76705 TC A 59.58 0.00 0.00<br />

74240 TC A 53.53 0.00 0.00 76770 TC A 59.58 0.00 0.00<br />

74241 TC A 53.53 0.00 0.00 76775 TC A 59.58 0.00 0.00<br />

74245 TC A 87.03 0.00 0.00 76776 TC A 59.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 59.58 0.00 0.00 77290 TC A 155.81 0.00 0.00<br />

76801 TC A 59.58 0.00 0.00 77295 TC A 408.25 0.00 0.00<br />

76802 TC A 28.41 0.00 0.00 77299 TC A 69.90 0.00 0.00<br />

76805 TC A 59.58 0.00 0.00 77300 TC A 37.77 0.00 0.00<br />

76810 TC A 44.96 0.00 0.00 77301 TC A 544.09 0.00 0.00<br />

76811 TC A 93.34 0.00 0.00 77305 TC A 34.53 0.00 0.00<br />

76812 TC A 38.09 0.00 0.00 77310 TC A 44.96 0.00 0.00<br />

76813 TC A 38.09 0.00 0.00 77315 TC A 65.46 0.00 0.00<br />

76814 TC A 30.22 0.00 0.00 77321 TC A 67.99 0.00 0.00<br />

76815 TC A 38.09 0.00 0.00 77326 TC A 69.90 0.00 0.00<br />

76816 TC A 38.09 0.00 0.00 77327 TC A 126.98 0.00 0.00<br />

76817 TC A 38.09 0.00 0.00 77328 TC A 155.81 0.00 0.00<br />

76818 TC A 59.58 0.00 0.00 77331 TC A 17.98 0.00 0.00<br />

76819 TC A 51.44 0.00 0.00 77332 TC A 48.20 0.00 0.00<br />

76820 TC A 25.54 0.00 0.00 77333 TC A 23.38 0.00 0.00<br />

76821 TC A 57.67 0.00 0.00 77334 TC A 90.29 0.00 0.00<br />

76825 TC A 120.13 0.00 0.00 77336 A 56.84 0.00 0.00<br />

76826 TC A 71.58 0.00 0.00 77370 A 69.90 0.00 0.00<br />

76827 TC A 38.09 0.00 0.00 77371 A 4,656.49 0.00 0.00<br />

76828 TC A 22.66 0.00 0.00 77399 TC A 69.90 0.00 0.00<br />

76830 TC A 59.58 0.00 0.00 77401 A 28.41 0.00 0.00<br />

76831 TC A 80.21 0.00 0.00 77402 A 57.21 0.00 0.00<br />

76856 TC A 59.58 0.00 0.00 77403 A 57.21 0.00 0.00<br />

76857 TC A 38.09 0.00 0.00 77404 A 57.21 0.00 0.00<br />

76870 TC A 59.58 0.00 0.00 77406 A 92.66 0.00 0.00<br />

76872 TC A 59.58 0.00 0.00 77407 A 57.21 0.00 0.00<br />

76873 TC A 59.58 0.00 0.00 77408 A 57.21 0.00 0.00<br />

76880 TC A 59.58 0.00 0.00 77409 A 57.21 0.00 0.00<br />

76885 TC A 38.09 0.00 0.00 77411 A 92.66 0.00 0.00<br />

76886 TC A 38.09 0.00 0.00 77412 A 92.66 0.00 0.00<br />

76936 TC A 57.67 0.00 0.00 77413 A 92.66 0.00 0.00<br />

76970 TC A 38.09 0.00 0.00 77414 A 92.66 0.00 0.00<br />

76977 TC A 9.71 0.00 0.00 77416 A 92.66 0.00 0.00<br />

76999 TC A 38.09 0.00 0.00 77418 A 250.34 0.00 0.00<br />

77071 A 22.30 0.00 0.00 77422 A 92.66 0.00 0.00<br />

77072 TC A 12.94 0.00 0.00 77423 A 92.66 0.00 0.00<br />

77073 TC A 21.94 0.00 0.00 77470 TC A 133.09 0.00 0.00<br />

77074 TC A 43.16 0.00 0.00 77520 A 428.61 0.00 0.00<br />

77075 TC A 45.36 0.00 0.00 77522 A 428.61 0.00 0.00<br />

77076 TC A 45.36 0.00 0.00 77523 A 512.20 0.00 0.00<br />

77077 TC A 24.46 0.00 0.00 77525 A 512.20 0.00 0.00<br />

77078 TC A 43.82 0.00 0.00 77600 TC A 227.41 0.00 0.00<br />

77079 TC A 44.96 0.00 0.00 77605 TC A 227.41 0.00 0.00<br />

77080 TC A 43.82 0.00 0.00 77610 TC A 227.41 0.00 0.00<br />

77081 TC A 17.62 0.00 0.00 77615 TC A 227.41 0.00 0.00<br />

77082 TC A 19.07 0.00 0.00 77620 TC A 227.41 0.00 0.00<br />

77083 TC A 15.11 0.00 0.00 77750 TC A 88.48 0.00 0.00<br />

77084 TC A 212.09 0.00 0.00 77761 TC A 155.75 0.00 0.00<br />

77280 TC A 69.90 0.00 0.00 77762 TC A 184.52 0.00 0.00<br />

77285 TC A 155.81 0.00 0.00 77763 TC A 237.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 168.69 0.00 0.00 78262 TC A 148.15 0.00 0.00<br />

77777 TC A 185.24 0.00 0.00 78264 TC A 148.15 0.00 0.00<br />

77778 TC A 246.75 0.00 0.00 78270 TC A 64.74 0.00 0.00<br />

77785 TC A 109.70 0.00 0.00 78271 TC A 65.82 0.00 0.00<br />

77786 TC A 385.59 0.00 0.00 78272 TC A 72.29 0.00 0.00<br />

77787 TC A 446.81 0.00 0.00 78278 TC A 148.15 0.00 0.00<br />

77789 TC A 46.05 0.00 0.00 78282 TC A 148.15 0.00 0.00<br />

77799 TC A 262.43 0.00 0.00 78290 TC A 148.15 0.00 0.00<br />

78000 TC A 56.47 0.00 0.00 78291 TC A 148.15 0.00 0.00<br />

78001 TC A 71.57 0.00 0.00 78299 TC A 148.15 0.00 0.00<br />

78003 TC A 56.84 0.00 0.00 78300 TC A 129.13 0.00 0.00<br />

78006 TC A 135.22 0.00 0.00 78305 TC A 149.76 0.00 0.00<br />

78007 TC A 100.00 0.00 0.00 78306 TC A 149.76 0.00 0.00<br />

78010 TC A 83.09 0.00 0.00 78315 TC A 149.76 0.00 0.00<br />

78011 TC A 83.09 0.00 0.00 78320 TC A 149.76 0.00 0.00<br />

78015 TC A 161.50 0.00 0.00 78399 TC A 149.76 0.00 0.00<br />

78016 TC A 182.30 0.00 0.00 78414 TC A 190.36 0.00 0.00<br />

78018 TC A 182.30 0.00 0.00 78428 TC A 146.03 0.00 0.00<br />

78070 TC A 124.09 0.00 0.00 78445 TC A 113.91 0.00 0.00<br />

78075 TC A 351.42 0.00 0.00 78456 TC A 113.91 0.00 0.00<br />

78099 TC A 83.09 0.00 0.00 78457 TC A 113.91 0.00 0.00<br />

78102 TC A 125.53 0.00 0.00 78458 TC A 113.91 0.00 0.00<br />

78103 TC A 160.02 0.00 0.00 78459 TC A 704.94 0.00 0.00<br />

78104 TC A 160.02 0.00 0.00 78460 TC A 136.68 0.00 0.00<br />

78110 TC A 63.67 0.00 0.00 78461 TC A 137.77 0.00 0.00<br />

78111 TC A 80.57 0.00 0.00 78464 TC A 202.14 0.00 0.00<br />

78120 TC A 70.50 0.00 0.00 78465 TC A 382.71 0.00 0.00<br />

78121 TC A 83.44 0.00 0.00 78466 TC A 135.60 0.00 0.00<br />

78122 TC A 98.91 0.00 0.00 78468 TC A 173.37 0.00 0.00<br />

78130 TC A 114.74 0.00 0.00 78469 TC A 190.36 0.00 0.00<br />

78135 TC A 243.86 0.00 0.00 78472 TC A 190.36 0.00 0.00<br />

78140 TC A 108.27 0.00 0.00 78473 TC A 190.36 0.00 0.00<br />

78185 TC A 160.02 0.00 0.00 78481 TC A 164.37 0.00 0.00<br />

78190 TC A 100.41 0.00 0.00 78483 TC A 190.36 0.00 0.00<br />

78191 TC A 100.41 0.00 0.00 78491 TC A 704.94 0.00 0.00<br />

78195 TC A 160.02 0.00 0.00 78492 TC A 704.94 0.00 0.00<br />

78199 TC A 160.02 0.00 0.00 78494 TC A 190.36 0.00 0.00<br />

78201 TC A 142.43 0.00 0.00 78499 TC A 190.36 0.00 0.00<br />

78202 TC A 167.56 0.00 0.00 78580 TC A 128.97 0.00 0.00<br />

78205 TC A 167.56 0.00 0.00 78584 TC A 99.63 0.00 0.00<br />

78206 TC A 167.56 0.00 0.00 78585 TC A 197.89 0.00 0.00<br />

78215 TC A 150.71 0.00 0.00 78586 TC A 128.97 0.00 0.00<br />

78216 TC A 102.15 0.00 0.00 78587 TC A 128.97 0.00 0.00<br />

78220 TC A 111.51 0.00 0.00 78588 TC A 197.89 0.00 0.00<br />

78223 TC A 167.56 0.00 0.00 78591 TC A 128.97 0.00 0.00<br />

78230 TC A 126.61 0.00 0.00 78593 TC A 128.97 0.00 0.00<br />

78231 TC A 99.63 0.00 0.00 78594 TC A 128.97 0.00 0.00<br />

78232 TC A 103.95 0.00 0.00 78596 TC A 197.89 0.00 0.00<br />

78258 TC A 148.15 0.00 0.00 78599 TC A 128.97 0.00 0.00<br />

78261 TC A 148.15 0.00 0.00 78600 TC A 113.66 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 22744 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 113.66 0.00 0.00<br />

78605 TC A 113.66 0.00 0.00<br />

78606 TC A 255.38 0.00 0.00<br />

78607 TC A 280.56 0.00 0.00<br />

78608 TC A 631.85 0.00 0.00<br />

78610 TC A 151.43 0.00 0.00<br />

78630 TC A 269.77 0.00 0.00<br />

78635 TC A 248.55 0.00 0.00<br />

78645 TC A 113.66 0.00 0.00<br />

78647 TC A 275.17 0.00 0.00<br />

78650 TC A 266.53 0.00 0.00<br />

78660 TC A 113.66 0.00 0.00<br />

78699 TC A 113.66 0.00 0.00<br />

78700 TC A 139.92 0.00 0.00<br />

78701 TC A 170.50 0.00 0.00<br />

78707 TC A 178.05 0.00 0.00<br />

78708 TC A 121.94 0.00 0.00<br />

78709 TC A 200.48 0.00 0.00<br />

78710 TC A 188.12 0.00 0.00<br />

78725 TC A 75.18 0.00 0.00<br />

78730 TC A 63.67 0.00 0.00<br />

78740 TC A 166.18 0.00 0.00<br />

78761 TC A 158.62 0.00 0.00<br />

78799 TC A 200.48 0.00 0.00<br />

78800 TC A 140.28 0.00 0.00<br />

78801 TC A 192.44 0.00 0.00<br />

78802 TC A 260.77 0.00 0.00<br />

78803 TC A 279.48 0.00 0.00<br />

78804 TC A 487.74 0.00 0.00<br />

78805 TC A 137.04 0.00 0.00<br />

78806 TC A 274.09 0.00 0.00<br />

78807 TC A 279.84 0.00 0.00<br />

78811 TC A 631.85 0.00 0.00<br />

78812 TC A 631.85 0.00 0.00<br />

78813 TC A 631.85 0.00 0.00<br />

78814 TC A 631.85 0.00 0.00<br />

78815 TC A 631.85 0.00 0.00<br />

78816 TC A 631.85 0.00 0.00<br />

78999 TC A 71.57 0.00 0.00<br />

79005 TC A 57.55 0.00 0.00<br />

79101 TC A 62.95 0.00 0.00<br />

79200 TC A 67.99 0.00 0.00<br />

79300 TC A 131.16 0.00 0.00<br />

79403 TC A 97.48 0.00 0.00<br />

79440 TC A 55.03 0.00 0.00<br />

79445 TC A 131.16 0.00 0.00<br />

79999 TC A 131.16 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,180.76 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,479.26 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.41 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,528.51 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,528.51 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 220.74 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 220.74 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 111.46 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 235.57 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 70.82 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 634.11 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,445.99 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,131.86 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,131.86 0.00 0.00<br />

C8900 A 245.08 0.00 0.00 0123T S 905.14 0.00 0.00<br />

C8901 A 199.57 0.00 0.00 0124T S 176.92 0.00 0.00<br />

C8902 A 308.88 0.00 0.00 0144T TC A 60.21 0.00 0.00<br />

C8903 A 245.08 0.00 0.00 0145T TC A 162.09 0.00 0.00<br />

C8904 A 199.57 0.00 0.00 0146T TC A 162.09 0.00 0.00<br />

C8905 A 308.88 0.00 0.00 0147T TC A 162.09 0.00 0.00<br />

C8906 A 245.08 0.00 0.00 0148T TC A 162.09 0.00 0.00<br />

C8907 A 199.57 0.00 0.00 0149T TC A 162.09 0.00 0.00<br />

C8908 A 308.88 0.00 0.00 0150T TC A 162.09 0.00 0.00<br />

C8909 A 245.08 0.00 0.00 0151T TC A 60.21 0.00 0.00<br />

C8910 A 199.57 0.00 0.00 0170T S 1,175.73 0.00 0.00<br />

C8911 A 308.88 0.00 0.00 0176T S 1,388.27 0.00 0.00<br />

C8912 A 245.08 0.00 0.00 0177T S 1,388.27 0.00 0.00<br />

C8913 A 199.57 0.00 0.00 0182T A 1,003.45 0.00 0.00<br />

C8914 A 308.88 0.00 0.00 0186T S 845.70 0.00 0.00<br />

C8918 A 245.08 0.00 0.00 0190T S 845.70 0.00 0.00<br />

C8919 A 199.57 0.00 0.00 0191T S 905.14 0.00 0.00<br />

C8920 A 308.88 0.00 0.00 0192T S 1,551.24 0.00 0.00<br />

C9716 S 1,175.73 0.00 0.00 10021 S 54.25 0.00 0.00<br />

C9724 S 961.29 0.00 0.00 10022 S 169.42 0.00 0.00<br />

C9725 S 221.67 0.00 0.00 10040 S 31.36 0.00 0.00<br />

C9726 S 813.81 0.00 0.00 10060 S 47.72 0.00 0.00<br />

C9727 S 285.34 0.00 0.00 10061 S 53.51 0.00 0.00<br />

C9728 S 511.98 0.00 0.00 10080 S 53.51 0.00 0.00<br />

G0104 S 82.25 0.00 0.00 10081 S 123.20 0.00 0.00<br />

G0105 S 355.47 0.00 0.00 10120 S 67.01 0.00 0.00<br />

G0121 S 355.47 0.00 0.00 10121 S 505.14 0.00 0.00<br />

G0127 S 11.51 0.00 0.00 10140 S 71.08 0.00 0.00<br />

G0130 TC A 18.96 0.00 0.00 10160 S 53.51 0.00 0.00<br />

G0173 A 2,180.76 0.00 0.00 10180 S 571.24 0.00 0.00<br />

G0186 S 220.74 0.00 0.00 11000 S 23.02 0.00 0.00<br />

G0247 S 20.98 0.00 0.00 11001 S 7.79 0.00 0.00<br />

G0251 A 546.09 0.00 0.00 11010 S 199.85 0.00 0.00<br />

G0260 S 288.19 0.00 0.00 11011 S 199.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 199.85 0.00 0.00 11601 S 110.34 0.00 0.00<br />

11040 S 20.98 0.00 0.00 11602 S 121.51 0.00 0.00<br />

11041 S 23.36 0.00 0.00 11603 S 128.95 0.00 0.00<br />

11042 S 126.91 0.00 0.00 11604 S 347.85 0.00 0.00<br />

11043 S 126.91 0.00 0.00 11606 S 505.14 0.00 0.00<br />

11044 S 330.45 0.00 0.00 11620 S 94.10 0.00 0.00<br />

11055 S 24.71 0.00 0.00 11621 S 111.69 0.00 0.00<br />

11056 S 27.07 0.00 0.00 11622 S 124.21 0.00 0.00<br />

11057 S 31.36 0.00 0.00 11623 S 133.69 0.00 0.00<br />

11100 S 57.46 0.00 0.00 11624 S 505.14 0.00 0.00<br />

11101 S 13.54 0.00 0.00 11626 S 617.74 0.00 0.00<br />

11200 S 31.36 0.00 0.00 11640 S 99.51 0.00 0.00<br />

11201 S 5.41 0.00 0.00 11641 S 117.45 0.00 0.00<br />

11300 S 31.36 0.00 0.00 11642 S 130.99 0.00 0.00<br />

11301 S 31.36 0.00 0.00 11643 S 141.14 0.00 0.00<br />

11302 S 31.36 0.00 0.00 11644 S 505.14 0.00 0.00<br />

11303 S 57.46 0.00 0.00 11646 S 617.74 0.00 0.00<br />

11305 S 31.36 0.00 0.00 11719 S 11.51 0.00 0.00<br />

11306 S 31.36 0.00 0.00 11720 S 14.22 0.00 0.00<br />

11307 S 31.36 0.00 0.00 11721 S 17.26 0.00 0.00<br />

11308 S 31.36 0.00 0.00 11730 S 31.36 0.00 0.00<br />

11310 S 31.36 0.00 0.00 11732 S 17.26 0.00 0.00<br />

11311 S 31.36 0.00 0.00 11740 S 15.84 0.00 0.00<br />

11312 S 31.36 0.00 0.00 11750 S 91.39 0.00 0.00<br />

11313 S 31.36 0.00 0.00 11752 S 126.93 0.00 0.00<br />

11400 S 64.65 0.00 0.00 11755 S 63.29 0.00 0.00<br />

11401 S 72.77 0.00 0.00 11760 S 130.35 0.00 0.00<br />

11402 S 79.88 0.00 0.00 11762 S 116.43 0.00 0.00<br />

11403 S 85.30 0.00 0.00 11765 S 31.36 0.00 0.00<br />

11404 S 453.44 0.00 0.00 11770 S 647.03 0.00 0.00<br />

11406 S 505.14 0.00 0.00 11771 S 647.03 0.00 0.00<br />

11420 S 60.59 0.00 0.00 11772 S 647.03 0.00 0.00<br />

11421 S 73.44 0.00 0.00 11900 S 28.77 0.00 0.00<br />

11422 S 80.22 0.00 0.00 11901 S 31.36 0.00 0.00<br />

11423 S 89.36 0.00 0.00 11920 S 91.05 0.00 0.00<br />

11424 S 505.14 0.00 0.00 11921 S 100.19 0.00 0.00<br />

11426 S 617.74 0.00 0.00 11922 S 32.49 0.00 0.00<br />

11440 S 69.39 0.00 0.00 11950 S 33.17 0.00 0.00<br />

11441 S 80.22 0.00 0.00 11951 S 41.29 0.00 0.00<br />

11442 S 88.34 0.00 0.00 11952 S 49.71 0.00 0.00<br />

11443 S 97.81 0.00 0.00 11954 S 49.71 0.00 0.00<br />

11444 S 308.73 0.00 0.00 11960 S 603.03 0.00 0.00<br />

11446 S 617.74 0.00 0.00 11970 S 1,092.29 0.00 0.00<br />

11450 S 617.74 0.00 0.00 11971 S 566.04 0.00 0.00<br />

11451 S 617.74 0.00 0.00 11976 S 60.59 0.00 0.00<br />

11462 S 617.74 0.00 0.00 11980 S 24.47 0.00 0.00<br />

11463 S 617.74 0.00 0.00 11981 S 24.47 0.00 0.00<br />

11470 S 617.74 0.00 0.00 11982 S 24.47 0.00 0.00<br />

11471 S 617.74 0.00 0.00 11983 S 24.47 0.00 0.00<br />

11600 S 91.05 0.00 0.00 12001 S 49.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 49.71 0.00 0.00 14021 S 535.89 0.00 0.00<br />

12004 S 49.71 0.00 0.00 14040 S 506.61 0.00 0.00<br />

12005 S 66.60 0.00 0.00 14041 S 535.89 0.00 0.00<br />

12006 S 66.60 0.00 0.00 14060 S 535.89 0.00 0.00<br />

12007 S 66.60 0.00 0.00 14061 S 535.89 0.00 0.00<br />

12011 S 49.71 0.00 0.00 14300 S 687.22 0.00 0.00<br />

12013 S 49.71 0.00 0.00 14350 S 632.31 0.00 0.00<br />

12014 S 49.71 0.00 0.00 15002 S 231.83 0.00 0.00<br />

12015 S 49.71 0.00 0.00 15003 S 231.83 0.00 0.00<br />

12016 S 66.60 0.00 0.00 15004 S 231.83 0.00 0.00<br />

12017 S 66.60 0.00 0.00 15005 S 231.83 0.00 0.00<br />

12018 S 66.60 0.00 0.00 15040 S 106.92 0.00 0.00<br />

12020 S 125.66 0.00 0.00 15050 S 231.83 0.00 0.00<br />

12021 S 106.92 0.00 0.00 15100 S 603.03 0.00 0.00<br />

12031 S 49.71 0.00 0.00 15101 S 632.31 0.00 0.00<br />

12032 S 130.35 0.00 0.00 15110 S 287.97 0.00 0.00<br />

12034 S 66.60 0.00 0.00 15111 S 236.27 0.00 0.00<br />

12035 S 66.60 0.00 0.00 15115 S 287.97 0.00 0.00<br />

12036 S 106.92 0.00 0.00 15116 S 236.27 0.00 0.00<br />

12037 S 213.09 0.00 0.00 15120 S 603.03 0.00 0.00<br />

12041 S 49.71 0.00 0.00 15121 S 632.31 0.00 0.00<br />

12042 S 49.71 0.00 0.00 15130 S 506.61 0.00 0.00<br />

12044 S 66.60 0.00 0.00 15131 S 454.90 0.00 0.00<br />

12045 S 106.92 0.00 0.00 15135 S 506.61 0.00 0.00<br />

12046 S 106.92 0.00 0.00 15136 S 454.90 0.00 0.00<br />

12047 S 213.09 0.00 0.00 15150 S 287.97 0.00 0.00<br />

12051 S 49.71 0.00 0.00 15151 S 236.27 0.00 0.00<br />

12052 S 49.71 0.00 0.00 15152 S 236.27 0.00 0.00<br />

12053 S 49.71 0.00 0.00 15155 S 287.97 0.00 0.00<br />

12054 S 66.60 0.00 0.00 15156 S 236.27 0.00 0.00<br />

12055 S 106.92 0.00 0.00 15157 S 236.27 0.00 0.00<br />

12056 S 106.92 0.00 0.00 15170 S 130.35 0.00 0.00<br />

12057 S 213.09 0.00 0.00 15171 S 130.35 0.00 0.00<br />

13100 S 231.83 0.00 0.00 15175 S 167.82 0.00 0.00<br />

13101 S 231.83 0.00 0.00 15176 S 167.82 0.00 0.00<br />

13102 S 125.66 0.00 0.00 15200 S 535.89 0.00 0.00<br />

13120 S 106.92 0.00 0.00 15201 S 450.47 0.00 0.00<br />

13121 S 106.92 0.00 0.00 15220 S 506.61 0.00 0.00<br />

13122 S 106.92 0.00 0.00 15221 S 231.83 0.00 0.00<br />

13131 S 106.92 0.00 0.00 15240 S 535.89 0.00 0.00<br />

13132 S 106.92 0.00 0.00 15241 S 231.83 0.00 0.00<br />

13133 S 106.92 0.00 0.00 15260 S 506.61 0.00 0.00<br />

13150 S 231.83 0.00 0.00 15261 S 450.47 0.00 0.00<br />

13151 S 231.83 0.00 0.00 15300 S 231.83 0.00 0.00<br />

13152 S 231.83 0.00 0.00 15301 S 231.83 0.00 0.00<br />

13153 S 106.92 0.00 0.00 15320 S 231.83 0.00 0.00<br />

13160 S 603.03 0.00 0.00 15321 S 231.83 0.00 0.00<br />

14000 S 506.61 0.00 0.00 15330 S 231.83 0.00 0.00<br />

14001 S 535.89 0.00 0.00 15331 S 231.83 0.00 0.00<br />

14020 S 535.89 0.00 0.00 15335 S 231.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 231.83 0.00 0.00 15826 S 632.31 0.00 0.00<br />

15340 S 130.35 0.00 0.00 15828 S 632.31 0.00 0.00<br />

15341 S 130.35 0.00 0.00 15829 S 727.02 0.00 0.00<br />

15360 S 130.35 0.00 0.00 15830 S 647.03 0.00 0.00<br />

15361 S 130.35 0.00 0.00 15832 S 647.03 0.00 0.00<br />

15365 S 130.35 0.00 0.00 15833 S 647.03 0.00 0.00<br />

15366 S 130.35 0.00 0.00 15834 S 647.03 0.00 0.00<br />

15400 S 231.83 0.00 0.00 15835 S 561.60 0.00 0.00<br />

15401 S 231.83 0.00 0.00 15836 S 534.43 0.00 0.00<br />

15420 S 231.83 0.00 0.00 15837 S 602.17 0.00 0.00<br />

15421 S 231.83 0.00 0.00 15838 S 602.17 0.00 0.00<br />

15430 S 231.83 0.00 0.00 15839 S 534.43 0.00 0.00<br />

15431 S 231.83 0.00 0.00 15840 S 687.22 0.00 0.00<br />

15570 S 632.31 0.00 0.00 15841 S 687.22 0.00 0.00<br />

15572 S 632.31 0.00 0.00 15842 S 797.93 0.00 0.00<br />

15574 S 632.31 0.00 0.00 15845 S 687.22 0.00 0.00<br />

15576 S 632.31 0.00 0.00 15847 S 647.03 0.00 0.00<br />

15600 S 632.31 0.00 0.00 15850 S 103.36 0.00 0.00<br />

15610 S 632.31 0.00 0.00 15851 S 47.04 0.00 0.00<br />

15620 S 687.22 0.00 0.00 15852 S 24.47 0.00 0.00<br />

15630 S 632.31 0.00 0.00 15860 S 24.47 0.00 0.00<br />

15650 S 727.02 0.00 0.00 15876 S 632.31 0.00 0.00<br />

15731 S 632.31 0.00 0.00 15877 S 632.31 0.00 0.00<br />

15732 S 632.31 0.00 0.00 15878 S 632.31 0.00 0.00<br />

15734 S 632.31 0.00 0.00 15879 S 632.31 0.00 0.00<br />

15736 S 632.31 0.00 0.00 15920 S 199.85 0.00 0.00<br />

15738 S 632.31 0.00 0.00 15922 S 687.22 0.00 0.00<br />

15740 S 506.61 0.00 0.00 15931 S 647.03 0.00 0.00<br />

15750 S 603.03 0.00 0.00 15933 S 647.03 0.00 0.00<br />

15760 S 603.03 0.00 0.00 15934 S 632.31 0.00 0.00<br />

15770 S 632.31 0.00 0.00 15935 S 687.22 0.00 0.00<br />

15775 S 172.77 0.00 0.00 15936 S 590.80 0.00 0.00<br />

15776 S 172.77 0.00 0.00 15937 S 687.22 0.00 0.00<br />

15780 S 385.18 0.00 0.00 15940 S 647.03 0.00 0.00<br />

15781 S 169.54 0.00 0.00 15941 S 647.03 0.00 0.00<br />

15782 S 169.54 0.00 0.00 15944 S 632.31 0.00 0.00<br />

15783 S 103.36 0.00 0.00 15945 S 687.22 0.00 0.00<br />

15786 S 31.36 0.00 0.00 15946 S 687.22 0.00 0.00<br />

15787 S 28.44 0.00 0.00 15950 S 647.03 0.00 0.00<br />

15788 S 31.36 0.00 0.00 15951 S 701.93 0.00 0.00<br />

15789 S 57.46 0.00 0.00 15952 S 535.89 0.00 0.00<br />

15792 S 57.46 0.00 0.00 15953 S 590.80 0.00 0.00<br />

15793 S 31.36 0.00 0.00 15956 S 535.89 0.00 0.00<br />

15819 S 130.35 0.00 0.00 15958 S 590.80 0.00 0.00<br />

15820 S 632.31 0.00 0.00 16000 S 25.39 0.00 0.00<br />

15821 S 632.31 0.00 0.00 16020 S 38.59 0.00 0.00<br />

15822 S 632.31 0.00 0.00 16025 S 59.43 0.00 0.00<br />

15823 S 727.02 0.00 0.00 16030 S 74.41 0.00 0.00<br />

15824 S 632.31 0.00 0.00 16035 S 57.46 0.00 0.00<br />

15825 S 632.31 0.00 0.00 17000 S 31.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.73 0.00 0.00 19300 S 695.16 0.00 0.00<br />

17004 S 81.91 0.00 0.00 19301 S 640.26 0.00 0.00<br />

17106 S 103.36 0.00 0.00 19302 S 1,222.82 0.00 0.00<br />

17107 S 103.36 0.00 0.00 19303 S 924.12 0.00 0.00<br />

17108 S 103.36 0.00 0.00 19304 S 924.12 0.00 0.00<br />

17110 S 31.36 0.00 0.00 19316 S 924.12 0.00 0.00<br />

17111 S 57.46 0.00 0.00 19318 S 1,055.81 0.00 0.00<br />

17250 S 43.33 0.00 0.00 19324 S 1,055.81 0.00 0.00<br />

17260 S 46.37 0.00 0.00 19325 S 1,751.19 0.00 0.00<br />

17261 S 57.46 0.00 0.00 19328 S 788.23 0.00 0.00<br />

17262 S 57.46 0.00 0.00 19330 S 788.23 0.00 0.00<br />

17263 S 57.46 0.00 0.00 19340 S 971.62 0.00 0.00<br />

17264 S 57.46 0.00 0.00 19342 S 1,371.89 0.00 0.00<br />

17266 S 103.36 0.00 0.00 19350 S 695.16 0.00 0.00<br />

17270 S 57.46 0.00 0.00 19355 S 924.12 0.00 0.00<br />

17271 S 57.46 0.00 0.00 19357 S 1,466.60 0.00 0.00<br />

17272 S 57.46 0.00 0.00 19366 S 963.93 0.00 0.00<br />

17273 S 103.36 0.00 0.00 19370 S 924.12 0.00 0.00<br />

17274 S 103.36 0.00 0.00 19371 S 924.12 0.00 0.00<br />

17276 S 103.36 0.00 0.00 19380 S 1,095.62 0.00 0.00<br />

17280 S 57.46 0.00 0.00 19396 S 1,271.73 0.00 0.00<br />

17281 S 85.63 0.00 0.00 20000 S 53.51 0.00 0.00<br />

17282 S 97.81 0.00 0.00 20005 S 616.57 0.00 0.00<br />

17283 S 103.36 0.00 0.00 20103 S 605.10 0.00 0.00<br />

17284 S 103.36 0.00 0.00 20150 S 1,717.90 0.00 0.00<br />

17286 S 103.36 0.00 0.00 20200 S 505.14 0.00 0.00<br />

17311 S 170.63 0.00 0.00 20205 S 534.43 0.00 0.00<br />

17312 S 170.63 0.00 0.00 20206 S 249.73 0.00 0.00<br />

17313 S 170.63 0.00 0.00 20220 S 271.46 0.00 0.00<br />

17314 S 170.63 0.00 0.00 20225 S 492.55 0.00 0.00<br />

17315 S 38.59 0.00 0.00 20240 S 617.74 0.00 0.00<br />

17340 S 13.88 0.00 0.00 20245 S 647.03 0.00 0.00<br />

17360 S 31.36 0.00 0.00 20250 S 645.86 0.00 0.00<br />

17380 S 31.36 0.00 0.00 20251 S 645.86 0.00 0.00<br />

19000 S 65.33 0.00 0.00 20500 S 53.48 0.00 0.00<br />

19001 S 8.80 0.00 0.00 20520 S 90.03 0.00 0.00<br />

19020 S 571.24 0.00 0.00 20525 S 647.03 0.00 0.00<br />

19100 S 194.52 0.00 0.00 20526 S 29.11 0.00 0.00<br />

19101 S 610.97 0.00 0.00 20550 S 22.00 0.00 0.00<br />

19102 S 249.73 0.00 0.00 20551 S 21.66 0.00 0.00<br />

19103 S 437.09 0.00 0.00 20552 S 20.98 0.00 0.00<br />

19105 S 1,271.73 0.00 0.00 20553 S 23.36 0.00 0.00<br />

19110 S 610.97 0.00 0.00 20555 S 1,131.86 0.00 0.00<br />

19112 S 640.26 0.00 0.00 20600 S 22.34 0.00 0.00<br />

19120 S 640.26 0.00 0.00 20605 S 25.05 0.00 0.00<br />

19125 S 640.26 0.00 0.00 20610 S 35.20 0.00 0.00<br />

19126 S 640.26 0.00 0.00 20612 S 23.70 0.00 0.00<br />

19296 S 1,751.19 0.00 0.00 20615 S 99.18 0.00 0.00<br />

19297 S 1,751.19 0.00 0.00 20650 S 645.86 0.00 0.00<br />

19298 S 1,751.19 0.00 0.00 20662 S 825.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 825.02 0.00 0.00 21085 S 248.44 0.00 0.00<br />

20665 S 24.47 0.00 0.00 21086 S 540.87 0.00 0.00<br />

20670 S 453.44 0.00 0.00 21087 S 541.55 0.00 0.00<br />

20680 S 647.03 0.00 0.00 21088 S 1,586.10 0.00 0.00<br />

20690 S 769.99 0.00 0.00 21100 S 997.11 0.00 0.00<br />

20692 S 799.28 0.00 0.00 21110 S 285.34 0.00 0.00<br />

20693 S 645.86 0.00 0.00 21120 S 924.10 0.00 0.00<br />

20694 S 564.87 0.00 0.00 21121 S 924.10 0.00 0.00<br />

20696 S 1,131.86 0.00 0.00 21122 S 924.10 0.00 0.00<br />

20697 S 752.73 0.00 0.00 21123 S 924.10 0.00 0.00<br />

20822 S 1,060.56 0.00 0.00 21125 S 924.10 0.00 0.00<br />

20900 S 799.28 0.00 0.00 21127 S 1,405.69 0.00 0.00<br />

20902 S 854.18 0.00 0.00 21137 S 937.70 0.00 0.00<br />

20910 S 632.31 0.00 0.00 21138 S 1,586.10 0.00 0.00<br />

20912 S 632.31 0.00 0.00 21139 S 1,586.10 0.00 0.00<br />

20920 S 590.80 0.00 0.00 21150 S 1,586.10 0.00 0.00<br />

20922 S 535.89 0.00 0.00 21181 S 924.10 0.00 0.00<br />

20924 S 854.18 0.00 0.00 21198 S 1,586.10 0.00 0.00<br />

20926 S 372.16 0.00 0.00 21199 S 1,586.10 0.00 0.00<br />

20950 S 53.51 0.00 0.00 21206 S 1,121.11 0.00 0.00<br />

20972 S 1,791.31 0.00 0.00 21208 S 1,248.31 0.00 0.00<br />

20973 S 1,791.31 0.00 0.00 21209 S 1,121.11 0.00 0.00<br />

20979 S 22.00 0.00 0.00 21210 S 1,248.31 0.00 0.00<br />

20982 S 1,717.90 0.00 0.00 21215 S 1,248.31 0.00 0.00<br />

21010 S 672.91 0.00 0.00 21230 S 1,248.31 0.00 0.00<br />

21015 S 559.86 0.00 0.00 21235 S 924.10 0.00 0.00<br />

21025 S 997.11 0.00 0.00 21240 S 1,081.30 0.00 0.00<br />

21026 S 997.11 0.00 0.00 21242 S 1,121.11 0.00 0.00<br />

21029 S 997.11 0.00 0.00 21243 S 1,121.11 0.00 0.00<br />

21030 S 235.23 0.00 0.00 21244 S 1,248.31 0.00 0.00<br />

21031 S 194.62 0.00 0.00 21245 S 1,248.31 0.00 0.00<br />

21032 S 198.34 0.00 0.00 21246 S 1,248.31 0.00 0.00<br />

21034 S 1,026.40 0.00 0.00 21248 S 1,248.31 0.00 0.00<br />

21040 S 672.91 0.00 0.00 21249 S 1,248.31 0.00 0.00<br />

21044 S 997.11 0.00 0.00 21260 S 1,586.10 0.00 0.00<br />

21046 S 997.11 0.00 0.00 21267 S 1,248.31 0.00 0.00<br />

21047 S 997.11 0.00 0.00 21270 S 1,121.11 0.00 0.00<br />

21048 S 1,586.10 0.00 0.00 21275 S 1,248.31 0.00 0.00<br />

21050 S 1,026.40 0.00 0.00 21280 S 1,121.11 0.00 0.00<br />

21060 S 997.11 0.00 0.00 21282 S 654.57 0.00 0.00<br />

21070 S 1,026.40 0.00 0.00 21295 S 295.03 0.00 0.00<br />

21073 S 182.77 0.00 0.00 21296 S 621.21 0.00 0.00<br />

21076 S 317.14 0.00 0.00 21310 S 90.00 0.00 0.00<br />

21077 S 766.63 0.00 0.00 21315 S 395.47 0.00 0.00<br />

21079 S 548.99 0.00 0.00 21320 S 530.57 0.00 0.00<br />

21080 S 629.55 0.00 0.00 21325 S 757.09 0.00 0.00<br />

21081 S 580.13 0.00 0.00 21330 S 796.90 0.00 0.00<br />

21082 S 552.04 0.00 0.00 21335 S 924.10 0.00 0.00<br />

21083 S 543.92 0.00 0.00 21336 S 770.14 0.00 0.00<br />

21084 S 625.82 0.00 0.00 21337 S 530.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 757.09 0.00 0.00 22310 S 163.84 0.00 0.00<br />

21339 S 796.90 0.00 0.00 22315 S 423.78 0.00 0.00<br />

21340 S 1,081.30 0.00 0.00 22505 S 498.89 0.00 0.00<br />

21345 S 924.10 0.00 0.00 22520 S 1,178.57 0.00 0.00<br />

21355 S 1,026.40 0.00 0.00 22521 S 1,178.57 0.00 0.00<br />

21356 S 702.20 0.00 0.00 22522 S 1,178.57 0.00 0.00<br />

21360 S 937.70 0.00 0.00 22523 S 3,280.08 0.00 0.00<br />

21390 S 1,586.10 0.00 0.00 22524 S 3,280.08 0.00 0.00<br />

21400 S 346.73 0.00 0.00 22525 S 3,280.08 0.00 0.00<br />

21401 S 559.86 0.00 0.00 22900 S 701.93 0.00 0.00<br />

21406 S 1,586.10 0.00 0.00 23000 S 505.14 0.00 0.00<br />

21407 S 1,586.10 0.00 0.00 23020 S 1,063.01 0.00 0.00<br />

21421 S 757.09 0.00 0.00 23030 S 519.54 0.00 0.00<br />

21440 S 318.84 0.00 0.00 23031 S 600.52 0.00 0.00<br />

21445 S 757.09 0.00 0.00 23035 S 645.86 0.00 0.00<br />

21450 S 131.59 0.00 0.00 23040 S 799.28 0.00 0.00<br />

21451 S 355.03 0.00 0.00 23044 S 854.18 0.00 0.00<br />

21452 S 530.57 0.00 0.00 23065 S 95.45 0.00 0.00<br />

21453 S 1,026.40 0.00 0.00 23066 S 617.74 0.00 0.00<br />

21454 S 796.90 0.00 0.00 23075 S 505.14 0.00 0.00<br />

21461 S 1,081.30 0.00 0.00 23076 S 617.74 0.00 0.00<br />

21462 S 1,121.11 0.00 0.00 23077 S 647.03 0.00 0.00<br />

21465 S 1,081.30 0.00 0.00 23100 S 616.57 0.00 0.00<br />

21480 S 90.00 0.00 0.00 23101 S 1,021.18 0.00 0.00<br />

21485 S 530.57 0.00 0.00 23105 S 854.18 0.00 0.00<br />

21490 S 1,026.40 0.00 0.00 23106 S 854.18 0.00 0.00<br />

21495 S 653.02 0.00 0.00 23107 S 854.18 0.00 0.00<br />

21497 S 530.57 0.00 0.00 23120 S 893.99 0.00 0.00<br />

21501 S 571.24 0.00 0.00 23125 S 893.99 0.00 0.00<br />

21502 S 616.57 0.00 0.00 23130 S 1,187.00 0.00 0.00<br />

21550 S 602.17 0.00 0.00 23140 S 700.76 0.00 0.00<br />

21555 S 617.74 0.00 0.00 23145 S 893.99 0.00 0.00<br />

21556 S 617.74 0.00 0.00 23146 S 893.99 0.00 0.00<br />

21557 S 827.37 0.00 0.00 23150 S 854.18 0.00 0.00<br />

21600 S 769.99 0.00 0.00 23155 S 893.99 0.00 0.00<br />

21610 S 769.99 0.00 0.00 23156 S 893.99 0.00 0.00<br />

21685 S 285.34 0.00 0.00 23170 S 769.99 0.00 0.00<br />

21700 S 616.57 0.00 0.00 23172 S 769.99 0.00 0.00<br />

21720 S 645.86 0.00 0.00 23174 S 769.99 0.00 0.00<br />

21725 S 67.23 0.00 0.00 23180 S 854.18 0.00 0.00<br />

21800 S 77.67 0.00 0.00 23182 S 854.18 0.00 0.00<br />

21805 S 685.95 0.00 0.00 23184 S 854.18 0.00 0.00<br />

21820 S 77.67 0.00 0.00 23190 S 854.18 0.00 0.00<br />

21920 S 138.09 0.00 0.00 23195 S 893.99 0.00 0.00<br />

21925 S 617.74 0.00 0.00 23330 S 308.73 0.00 0.00<br />

21930 S 617.74 0.00 0.00 23331 S 566.04 0.00 0.00<br />

21935 S 647.03 0.00 0.00 23395 S 1,187.00 0.00 0.00<br />

22102 S 1,841.14 0.00 0.00 23397 S 2,095.30 0.00 0.00<br />

22103 S 1,841.14 0.00 0.00 23400 S 1,021.18 0.00 0.00<br />

22305 S 77.67 0.00 0.00 23405 S 769.99 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 769.99 0.00 0.00 23931 S 571.24 0.00 0.00<br />

23410 S 1,187.00 0.00 0.00 23935 S 616.57 0.00 0.00<br />

23412 S 1,314.20 0.00 0.00 24000 S 854.18 0.00 0.00<br />

23415 S 1,187.00 0.00 0.00 24006 S 854.18 0.00 0.00<br />

23420 S 1,314.20 0.00 0.00 24065 S 132.34 0.00 0.00<br />

23430 S 1,147.20 0.00 0.00 24066 S 505.14 0.00 0.00<br />

23440 S 1,147.20 0.00 0.00 24075 S 505.14 0.00 0.00<br />

23450 S 1,968.10 0.00 0.00 24076 S 617.74 0.00 0.00<br />

23455 S 2,095.30 0.00 0.00 24077 S 647.03 0.00 0.00<br />

23460 S 1,968.10 0.00 0.00 24100 S 564.87 0.00 0.00<br />

23462 S 1,314.20 0.00 0.00 24101 S 854.18 0.00 0.00<br />

23465 S 1,968.10 0.00 0.00 24102 S 854.18 0.00 0.00<br />

23466 S 1,314.20 0.00 0.00 24105 S 645.86 0.00 0.00<br />

23480 S 1,147.20 0.00 0.00 24110 S 616.57 0.00 0.00<br />

23485 S 2,095.30 0.00 0.00 24115 S 799.28 0.00 0.00<br />

23490 S 1,092.29 0.00 0.00 24116 S 799.28 0.00 0.00<br />

23491 S 1,873.39 0.00 0.00 24120 S 645.86 0.00 0.00<br />

23500 S 77.67 0.00 0.00 24125 S 799.28 0.00 0.00<br />

23505 S 423.78 0.00 0.00 24126 S 799.28 0.00 0.00<br />

23515 S 1,418.35 0.00 0.00 24130 S 799.28 0.00 0.00<br />

23520 S 163.84 0.00 0.00 24134 S 769.99 0.00 0.00<br />

23525 S 163.84 0.00 0.00 24136 S 769.99 0.00 0.00<br />

23530 S 1,045.18 0.00 0.00 24138 S 769.99 0.00 0.00<br />

23532 S 770.14 0.00 0.00 24140 S 799.28 0.00 0.00<br />

23540 S 77.67 0.00 0.00 24145 S 799.28 0.00 0.00<br />

23545 S 163.84 0.00 0.00 24147 S 769.99 0.00 0.00<br />

23550 S 1,045.18 0.00 0.00 24149 S 1,131.86 0.00 0.00<br />

23552 S 1,100.09 0.00 0.00 24152 S 1,717.90 0.00 0.00<br />

23570 S 77.67 0.00 0.00 24153 S 3,280.08 0.00 0.00<br />

23575 S 163.84 0.00 0.00 24155 S 1,092.29 0.00 0.00<br />

23585 S 1,418.35 0.00 0.00 24160 S 769.99 0.00 0.00<br />

23600 S 60.52 0.00 0.00 24164 S 799.28 0.00 0.00<br />

23605 S 423.78 0.00 0.00 24200 S 96.80 0.00 0.00<br />

23615 S 1,473.24 0.00 0.00 24201 S 505.14 0.00 0.00<br />

23616 S 1,473.24 0.00 0.00 24300 S 589.66 0.00 0.00<br />

23620 S 60.52 0.00 0.00 24301 S 854.18 0.00 0.00<br />

23625 S 423.78 0.00 0.00 24305 S 854.18 0.00 0.00<br />

23630 S 1,513.05 0.00 0.00 24310 S 645.86 0.00 0.00<br />

23650 S 77.67 0.00 0.00 24320 S 1,092.29 0.00 0.00<br />

23655 S 447.19 0.00 0.00 24330 S 1,873.39 0.00 0.00<br />

23660 S 1,045.18 0.00 0.00 24331 S 1,092.29 0.00 0.00<br />

23665 S 163.84 0.00 0.00 24332 S 825.02 0.00 0.00<br />

23670 S 1,418.35 0.00 0.00 24340 S 1,092.29 0.00 0.00<br />

23675 S 77.67 0.00 0.00 24341 S 1,092.29 0.00 0.00<br />

23680 S 1,045.18 0.00 0.00 24342 S 1,092.29 0.00 0.00<br />

23700 S 447.19 0.00 0.00 24343 S 1,131.86 0.00 0.00<br />

23800 S 1,928.29 0.00 0.00 24344 S 3,280.08 0.00 0.00<br />

23802 S 1,314.20 0.00 0.00 24345 S 769.99 0.00 0.00<br />

23921 S 450.47 0.00 0.00 24346 S 1,717.90 0.00 0.00<br />

23930 S 519.54 0.00 0.00 24357 S 1,131.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,131.86 0.00 0.00 24925 S 645.86 0.00 0.00<br />

24359 S 1,131.86 0.00 0.00 25000 S 645.86 0.00 0.00<br />

24360 S 1,044.54 0.00 0.00 25001 S 825.02 0.00 0.00<br />

24361 S 5,711.05 3,495.89 1,280.72 25020 S 645.86 0.00 0.00<br />

24362 S 1,334.92 0.00 0.00 25023 S 799.28 0.00 0.00<br />

24363 S 5,838.25 3,623.08 1,407.92 25024 S 799.28 0.00 0.00<br />

24365 S 1,044.54 0.00 0.00 25025 S 799.28 0.00 0.00<br />

24366 S 5,711.05 3,495.89 1,280.72 25028 S 564.87 0.00 0.00<br />

24400 S 854.18 0.00 0.00 25031 S 616.57 0.00 0.00<br />

24410 S 854.18 0.00 0.00 25035 S 616.57 0.00 0.00<br />

24420 S 1,092.29 0.00 0.00 25040 S 893.99 0.00 0.00<br />

24430 S 1,873.39 0.00 0.00 25065 S 134.37 0.00 0.00<br />

24435 S 1,928.29 0.00 0.00 25066 S 617.74 0.00 0.00<br />

24470 S 1,092.29 0.00 0.00 25075 S 505.14 0.00 0.00<br />

24495 S 769.99 0.00 0.00 25076 S 647.03 0.00 0.00<br />

24498 S 1,873.39 0.00 0.00 25077 S 647.03 0.00 0.00<br />

24500 S 77.67 0.00 0.00 25085 S 645.86 0.00 0.00<br />

24505 S 77.67 0.00 0.00 25100 S 616.57 0.00 0.00<br />

24515 S 1,473.24 0.00 0.00 25101 S 799.28 0.00 0.00<br />

24516 S 1,473.24 0.00 0.00 25105 S 854.18 0.00 0.00<br />

24530 S 77.67 0.00 0.00 25107 S 799.28 0.00 0.00<br />

24535 S 163.84 0.00 0.00 25109 S 825.02 0.00 0.00<br />

24538 S 685.95 0.00 0.00 25110 S 645.86 0.00 0.00<br />

24545 S 1,473.24 0.00 0.00 25111 S 645.86 0.00 0.00<br />

24546 S 1,513.05 0.00 0.00 25112 S 700.76 0.00 0.00<br />

24560 S 77.67 0.00 0.00 25115 S 700.76 0.00 0.00<br />

24565 S 77.67 0.00 0.00 25116 S 700.76 0.00 0.00<br />

24566 S 685.95 0.00 0.00 25118 S 769.99 0.00 0.00<br />

24575 S 1,418.35 0.00 0.00 25119 S 799.28 0.00 0.00<br />

24576 S 77.67 0.00 0.00 25120 S 799.28 0.00 0.00<br />

24577 S 163.84 0.00 0.00 25125 S 799.28 0.00 0.00<br />

24579 S 1,418.35 0.00 0.00 25126 S 799.28 0.00 0.00<br />

24582 S 685.95 0.00 0.00 25130 S 799.28 0.00 0.00<br />

24586 S 1,473.24 0.00 0.00 25135 S 799.28 0.00 0.00<br />

24587 S 1,513.05 0.00 0.00 25136 S 799.28 0.00 0.00<br />

24600 S 77.67 0.00 0.00 25145 S 769.99 0.00 0.00<br />

24605 S 498.89 0.00 0.00 25150 S 769.99 0.00 0.00<br />

24615 S 1,418.35 0.00 0.00 25151 S 769.99 0.00 0.00<br />

24620 S 423.78 0.00 0.00 25210 S 799.28 0.00 0.00<br />

24635 S 1,418.35 0.00 0.00 25215 S 854.18 0.00 0.00<br />

24640 S 52.46 0.00 0.00 25230 S 854.18 0.00 0.00<br />

24650 S 60.52 0.00 0.00 25240 S 854.18 0.00 0.00<br />

24655 S 163.84 0.00 0.00 25248 S 616.57 0.00 0.00<br />

24665 S 1,100.09 0.00 0.00 25250 S 718.29 0.00 0.00<br />

24666 S 1,473.24 0.00 0.00 25251 S 718.29 0.00 0.00<br />

24670 S 77.67 0.00 0.00 25259 S 752.73 0.00 0.00<br />

24675 S 77.67 0.00 0.00 25260 S 854.18 0.00 0.00<br />

24685 S 1,045.18 0.00 0.00 25263 S 769.99 0.00 0.00<br />

24800 S 1,147.20 0.00 0.00 25265 S 799.28 0.00 0.00<br />

24802 S 1,187.00 0.00 0.00 25270 S 854.18 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 799.28 0.00 0.00 25505 S 163.84 0.00 0.00<br />

25274 S 854.18 0.00 0.00 25515 S 1,045.18 0.00 0.00<br />

25275 S 854.18 0.00 0.00 25520 S 163.84 0.00 0.00<br />

25280 S 854.18 0.00 0.00 25525 S 1,100.09 0.00 0.00<br />

25290 S 799.28 0.00 0.00 25526 S 1,139.89 0.00 0.00<br />

25295 S 645.86 0.00 0.00 25530 S 60.52 0.00 0.00<br />

25300 S 799.28 0.00 0.00 25535 S 77.67 0.00 0.00<br />

25301 S 799.28 0.00 0.00 25545 S 1,045.18 0.00 0.00<br />

25310 S 1,092.29 0.00 0.00 25560 S 60.52 0.00 0.00<br />

25312 S 1,147.20 0.00 0.00 25565 S 163.84 0.00 0.00<br />

25315 S 1,092.29 0.00 0.00 25574 S 1,418.35 0.00 0.00<br />

25316 S 1,873.39 0.00 0.00 25575 S 1,418.35 0.00 0.00<br />

25320 S 1,092.29 0.00 0.00 25600 S 60.52 0.00 0.00<br />

25332 S 1,044.54 0.00 0.00 25605 S 163.84 0.00 0.00<br />

25335 S 1,092.29 0.00 0.00 25606 S 715.24 0.00 0.00<br />

25337 S 1,187.00 0.00 0.00 25607 S 1,513.05 0.00 0.00<br />

25350 S 1,873.39 0.00 0.00 25608 S 1,513.05 0.00 0.00<br />

25355 S 1,092.29 0.00 0.00 25609 S 1,513.05 0.00 0.00<br />

25360 S 799.28 0.00 0.00 25622 S 60.52 0.00 0.00<br />

25365 S 799.28 0.00 0.00 25624 S 163.84 0.00 0.00<br />

25370 S 1,092.29 0.00 0.00 25628 S 1,045.18 0.00 0.00<br />

25375 S 1,147.20 0.00 0.00 25630 S 60.52 0.00 0.00<br />

25390 S 799.28 0.00 0.00 25635 S 163.84 0.00 0.00<br />

25391 S 1,147.20 0.00 0.00 25645 S 1,045.18 0.00 0.00<br />

25392 S 799.28 0.00 0.00 25650 S 60.52 0.00 0.00<br />

25393 S 1,147.20 0.00 0.00 25651 S 963.78 0.00 0.00<br />

25394 S 1,717.90 0.00 0.00 25652 S 1,623.66 0.00 0.00<br />

25400 S 1,092.29 0.00 0.00 25660 S 77.67 0.00 0.00<br />

25405 S 1,928.29 0.00 0.00 25670 S 715.24 0.00 0.00<br />

25415 S 1,873.39 0.00 0.00 25671 S 634.25 0.00 0.00<br />

25420 S 1,928.29 0.00 0.00 25675 S 77.67 0.00 0.00<br />

25425 S 1,092.29 0.00 0.00 25676 S 685.95 0.00 0.00<br />

25426 S 1,147.20 0.00 0.00 25680 S 77.67 0.00 0.00<br />

25430 S 1,717.90 0.00 0.00 25685 S 715.24 0.00 0.00<br />

25431 S 1,717.90 0.00 0.00 25690 S 423.78 0.00 0.00<br />

25440 S 1,928.29 0.00 0.00 25695 S 685.95 0.00 0.00<br />

25441 S 5,711.05 3,495.89 1,280.72 25800 S 1,928.29 0.00 0.00<br />

25442 S 5,711.05 3,495.89 1,280.72 25805 S 1,187.00 0.00 0.00<br />

25443 S 1,334.92 0.00 0.00 25810 S 1,968.10 0.00 0.00<br />

25444 S 1,334.92 0.00 0.00 25820 S 1,147.20 0.00 0.00<br />

25445 S 1,334.92 0.00 0.00 25825 S 1,968.10 0.00 0.00<br />

25446 S 5,838.25 3,623.08 1,407.92 25830 S 1,968.10 0.00 0.00<br />

25447 S 1,044.54 0.00 0.00 25907 S 645.86 0.00 0.00<br />

25449 S 1,044.54 0.00 0.00 25922 S 645.86 0.00 0.00<br />

25450 S 1,092.29 0.00 0.00 25929 S 535.89 0.00 0.00<br />

25455 S 1,092.29 0.00 0.00 25931 S 825.02 0.00 0.00<br />

25490 S 1,092.29 0.00 0.00 26010 S 53.51 0.00 0.00<br />

25491 S 1,092.29 0.00 0.00 26011 S 390.90 0.00 0.00<br />

25492 S 1,092.29 0.00 0.00 26020 S 518.68 0.00 0.00<br />

25500 S 60.52 0.00 0.00 26025 S 466.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 518.68 0.00 0.00 26392 S 763.63 0.00 0.00<br />

26034 S 518.68 0.00 0.00 26410 S 547.96 0.00 0.00<br />

26035 S 629.23 0.00 0.00 26412 S 763.63 0.00 0.00<br />

26040 S 818.53 0.00 0.00 26415 S 818.53 0.00 0.00<br />

26045 S 763.63 0.00 0.00 26416 S 763.63 0.00 0.00<br />

26055 S 518.68 0.00 0.00 26418 S 602.87 0.00 0.00<br />

26060 S 518.68 0.00 0.00 26420 S 818.53 0.00 0.00<br />

26070 S 518.68 0.00 0.00 26426 S 763.63 0.00 0.00<br />

26075 S 602.87 0.00 0.00 26428 S 763.63 0.00 0.00<br />

26080 S 602.87 0.00 0.00 26432 S 547.96 0.00 0.00<br />

26100 S 518.68 0.00 0.00 26433 S 547.96 0.00 0.00<br />

26105 S 466.97 0.00 0.00 26434 S 763.63 0.00 0.00<br />

26110 S 466.97 0.00 0.00 26437 S 547.96 0.00 0.00<br />

26115 S 617.74 0.00 0.00 26440 S 547.96 0.00 0.00<br />

26116 S 617.74 0.00 0.00 26442 S 763.63 0.00 0.00<br />

26117 S 647.03 0.00 0.00 26445 S 547.96 0.00 0.00<br />

26121 S 818.53 0.00 0.00 26449 S 763.63 0.00 0.00<br />

26123 S 818.53 0.00 0.00 26450 S 547.96 0.00 0.00<br />

26125 S 602.87 0.00 0.00 26455 S 547.96 0.00 0.00<br />

26130 S 547.96 0.00 0.00 26460 S 547.96 0.00 0.00<br />

26135 S 818.53 0.00 0.00 26471 S 518.68 0.00 0.00<br />

26140 S 518.68 0.00 0.00 26474 S 518.68 0.00 0.00<br />

26145 S 547.96 0.00 0.00 26476 S 466.97 0.00 0.00<br />

26160 S 547.96 0.00 0.00 26477 S 466.97 0.00 0.00<br />

26170 S 547.96 0.00 0.00 26478 S 466.97 0.00 0.00<br />

26180 S 547.96 0.00 0.00 26479 S 466.97 0.00 0.00<br />

26185 S 602.87 0.00 0.00 26480 S 763.63 0.00 0.00<br />

26200 S 518.68 0.00 0.00 26483 S 763.63 0.00 0.00<br />

26205 S 763.63 0.00 0.00 26485 S 734.35 0.00 0.00<br />

26210 S 518.68 0.00 0.00 26489 S 763.63 0.00 0.00<br />

26215 S 547.96 0.00 0.00 26490 S 763.63 0.00 0.00<br />

26230 S 768.93 0.00 0.00 26492 S 763.63 0.00 0.00<br />

26235 S 547.96 0.00 0.00 26494 S 763.63 0.00 0.00<br />

26236 S 547.96 0.00 0.00 26496 S 763.63 0.00 0.00<br />

26250 S 547.96 0.00 0.00 26497 S 763.63 0.00 0.00<br />

26255 S 763.63 0.00 0.00 26498 S 818.53 0.00 0.00<br />

26260 S 547.96 0.00 0.00 26499 S 763.63 0.00 0.00<br />

26261 S 547.96 0.00 0.00 26500 S 602.87 0.00 0.00<br />

26262 S 518.68 0.00 0.00 26502 S 818.53 0.00 0.00<br />

26320 S 505.14 0.00 0.00 26508 S 547.96 0.00 0.00<br />

26340 S 232.87 0.00 0.00 26510 S 763.63 0.00 0.00<br />

26350 S 682.64 0.00 0.00 26516 S 682.64 0.00 0.00<br />

26352 S 818.53 0.00 0.00 26517 S 763.63 0.00 0.00<br />

26356 S 818.53 0.00 0.00 26518 S 763.63 0.00 0.00<br />

26357 S 818.53 0.00 0.00 26520 S 547.96 0.00 0.00<br />

26358 S 818.53 0.00 0.00 26525 S 547.96 0.00 0.00<br />

26370 S 818.53 0.00 0.00 26530 S 949.83 0.00 0.00<br />

26372 S 818.53 0.00 0.00 26531 S 1,462.11 0.00 0.00<br />

26373 S 763.63 0.00 0.00 26535 S 1,044.54 0.00 0.00<br />

26390 S 818.53 0.00 0.00 26536 S 1,334.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 602.87 0.00 0.00 26775 S 161.79 0.00 0.00<br />

26541 S 985.53 0.00 0.00 26776 S 685.95 0.00 0.00<br />

26542 S 602.87 0.00 0.00 26785 S 685.95 0.00 0.00<br />

26545 S 818.53 0.00 0.00 26820 S 858.33 0.00 0.00<br />

26546 S 818.53 0.00 0.00 26841 S 818.53 0.00 0.00<br />

26548 S 818.53 0.00 0.00 26842 S 818.53 0.00 0.00<br />

26550 S 734.35 0.00 0.00 26843 S 763.63 0.00 0.00<br />

26555 S 763.63 0.00 0.00 26844 S 763.63 0.00 0.00<br />

26560 S 518.68 0.00 0.00 26850 S 818.53 0.00 0.00<br />

26561 S 763.63 0.00 0.00 26852 S 818.53 0.00 0.00<br />

26562 S 818.53 0.00 0.00 26860 S 763.63 0.00 0.00<br />

26565 S 858.33 0.00 0.00 26861 S 734.35 0.00 0.00<br />

26567 S 858.33 0.00 0.00 26862 S 818.53 0.00 0.00<br />

26568 S 763.63 0.00 0.00 26863 S 763.63 0.00 0.00<br />

26580 S 642.67 0.00 0.00 26910 S 763.63 0.00 0.00<br />

26587 S 642.67 0.00 0.00 26951 S 518.68 0.00 0.00<br />

26590 S 642.67 0.00 0.00 26952 S 602.87 0.00 0.00<br />

26591 S 763.63 0.00 0.00 26990 S 564.87 0.00 0.00<br />

26593 S 547.96 0.00 0.00 26991 S 564.87 0.00 0.00<br />

26596 S 518.68 0.00 0.00 27000 S 616.57 0.00 0.00<br />

26600 S 60.52 0.00 0.00 27001 S 799.28 0.00 0.00<br />

26605 S 77.67 0.00 0.00 27003 S 799.28 0.00 0.00<br />

26607 S 423.78 0.00 0.00 27033 S 1,092.29 0.00 0.00<br />

26608 S 770.14 0.00 0.00 27035 S 1,147.20 0.00 0.00<br />

26615 S 1,100.09 0.00 0.00 27040 S 308.73 0.00 0.00<br />

26641 S 60.52 0.00 0.00 27041 S 347.85 0.00 0.00<br />

26645 S 163.84 0.00 0.00 27047 S 617.74 0.00 0.00<br />

26650 S 685.95 0.00 0.00 27048 S 647.03 0.00 0.00<br />

26665 S 1,100.09 0.00 0.00 27049 S 647.03 0.00 0.00<br />

26670 S 60.52 0.00 0.00 27050 S 645.86 0.00 0.00<br />

26675 S 163.84 0.00 0.00 27052 S 645.86 0.00 0.00<br />

26676 S 685.95 0.00 0.00 27060 S 740.57 0.00 0.00<br />

26685 S 715.24 0.00 0.00 27062 S 740.57 0.00 0.00<br />

26686 S 1,418.35 0.00 0.00 27065 S 740.57 0.00 0.00<br />

26700 S 60.52 0.00 0.00 27066 S 893.99 0.00 0.00<br />

26705 S 77.67 0.00 0.00 27067 S 893.99 0.00 0.00<br />

26706 S 423.78 0.00 0.00 27080 S 769.99 0.00 0.00<br />

26715 S 770.14 0.00 0.00 27086 S 308.73 0.00 0.00<br />

26720 S 60.52 0.00 0.00 27087 S 645.86 0.00 0.00<br />

26725 S 60.52 0.00 0.00 27097 S 799.28 0.00 0.00<br />

26727 S 937.15 0.00 0.00 27098 S 799.28 0.00 0.00<br />

26735 S 770.14 0.00 0.00 27100 S 1,147.20 0.00 0.00<br />

26740 S 60.52 0.00 0.00 27105 S 1,147.20 0.00 0.00<br />

26742 S 77.67 0.00 0.00 27110 S 1,147.20 0.00 0.00<br />

26746 S 809.95 0.00 0.00 27111 S 1,147.20 0.00 0.00<br />

26750 S 60.52 0.00 0.00 27193 S 77.67 0.00 0.00<br />

26755 S 60.52 0.00 0.00 27194 S 498.89 0.00 0.00<br />

26756 S 685.95 0.00 0.00 27200 S 60.52 0.00 0.00<br />

26765 S 770.14 0.00 0.00 27202 S 1,015.90 0.00 0.00<br />

26770 S 60.52 0.00 0.00 27220 S 60.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 77.67 0.00 0.00 27397 S 1,092.29 0.00 0.00<br />

27238 S 163.84 0.00 0.00 27400 S 1,092.29 0.00 0.00<br />

27246 S 163.84 0.00 0.00 27403 S 854.18 0.00 0.00<br />

27250 S 77.67 0.00 0.00 27405 S 1,147.20 0.00 0.00<br />

27252 S 498.89 0.00 0.00 27407 S 1,928.29 0.00 0.00<br />

27256 S 60.52 0.00 0.00 27409 S 1,147.20 0.00 0.00<br />

27257 S 528.18 0.00 0.00 27416 S 1,717.90 0.00 0.00<br />

27265 S 77.67 0.00 0.00 27418 S 1,092.29 0.00 0.00<br />

27266 S 498.89 0.00 0.00 27420 S 1,092.29 0.00 0.00<br />

27267 S 60.52 0.00 0.00 27422 S 1,314.20 0.00 0.00<br />

27275 S 498.89 0.00 0.00 27424 S 1,092.29 0.00 0.00<br />

27301 S 600.52 0.00 0.00 27425 S 1,021.18 0.00 0.00<br />

27305 S 616.57 0.00 0.00 27427 S 1,092.29 0.00 0.00<br />

27306 S 645.86 0.00 0.00 27428 S 1,928.29 0.00 0.00<br />

27307 S 645.86 0.00 0.00 27429 S 1,928.29 0.00 0.00<br />

27310 S 854.18 0.00 0.00 27430 S 1,147.20 0.00 0.00<br />

27323 S 308.73 0.00 0.00 27435 S 1,147.20 0.00 0.00<br />

27324 S 566.04 0.00 0.00 27437 S 1,004.73 0.00 0.00<br />

27325 S 554.64 0.00 0.00 27438 S 1,334.92 0.00 0.00<br />

27326 S 554.64 0.00 0.00 27440 S 1,432.97 0.00 0.00<br />

27327 S 617.74 0.00 0.00 27441 S 1,044.54 0.00 0.00<br />

27328 S 647.03 0.00 0.00 27442 S 1,044.54 0.00 0.00<br />

27329 S 701.93 0.00 0.00 27443 S 1,044.54 0.00 0.00<br />

27330 S 854.18 0.00 0.00 27446 S 10,248.97 6,157.11 2,065.26<br />

27331 S 854.18 0.00 0.00 27496 S 740.57 0.00 0.00<br />

27332 S 854.18 0.00 0.00 27497 S 645.86 0.00 0.00<br />

27333 S 854.18 0.00 0.00 27498 S 645.86 0.00 0.00<br />

27334 S 854.18 0.00 0.00 27499 S 645.86 0.00 0.00<br />

27335 S 854.18 0.00 0.00 27500 S 163.84 0.00 0.00<br />

27340 S 645.86 0.00 0.00 27501 S 77.67 0.00 0.00<br />

27345 S 700.76 0.00 0.00 27502 S 423.78 0.00 0.00<br />

27347 S 700.76 0.00 0.00 27503 S 77.67 0.00 0.00<br />

27350 S 854.18 0.00 0.00 27508 S 77.67 0.00 0.00<br />

27355 S 799.28 0.00 0.00 27509 S 715.24 0.00 0.00<br />

27356 S 854.18 0.00 0.00 27510 S 163.84 0.00 0.00<br />

27357 S 893.99 0.00 0.00 27516 S 77.67 0.00 0.00<br />

27358 S 893.99 0.00 0.00 27517 S 77.67 0.00 0.00<br />

27360 S 893.99 0.00 0.00 27520 S 77.67 0.00 0.00<br />

27372 S 868.94 0.00 0.00 27530 S 77.67 0.00 0.00<br />

27380 S 564.87 0.00 0.00 27532 S 423.78 0.00 0.00<br />

27381 S 645.86 0.00 0.00 27538 S 77.67 0.00 0.00<br />

27385 S 645.86 0.00 0.00 27550 S 77.67 0.00 0.00<br />

27386 S 645.86 0.00 0.00 27552 S 447.19 0.00 0.00<br />

27390 S 564.87 0.00 0.00 27560 S 77.67 0.00 0.00<br />

27391 S 616.57 0.00 0.00 27562 S 447.19 0.00 0.00<br />

27392 S 645.86 0.00 0.00 27566 S 1,015.90 0.00 0.00<br />

27393 S 769.99 0.00 0.00 27570 S 447.19 0.00 0.00<br />

27394 S 799.28 0.00 0.00 27594 S 645.86 0.00 0.00<br />

27395 S 1,092.29 0.00 0.00 27600 S 645.86 0.00 0.00<br />

27396 S 799.28 0.00 0.00 27601 S 645.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 645.86 0.00 0.00 27730 S 769.99 0.00 0.00<br />

27603 S 571.24 0.00 0.00 27732 S 769.99 0.00 0.00<br />

27604 S 616.57 0.00 0.00 27734 S 769.99 0.00 0.00<br />

27605 S 561.84 0.00 0.00 27740 S 769.99 0.00 0.00<br />

27606 S 564.87 0.00 0.00 27742 S 1,063.01 0.00 0.00<br />

27607 S 616.57 0.00 0.00 27745 S 1,873.39 0.00 0.00<br />

27610 S 769.99 0.00 0.00 27750 S 77.67 0.00 0.00<br />

27612 S 799.28 0.00 0.00 27752 S 423.78 0.00 0.00<br />

27613 S 126.93 0.00 0.00 27756 S 715.24 0.00 0.00<br />

27614 S 617.74 0.00 0.00 27758 S 1,100.09 0.00 0.00<br />

27615 S 799.28 0.00 0.00 27759 S 1,473.24 0.00 0.00<br />

27618 S 505.14 0.00 0.00 27760 S 77.67 0.00 0.00<br />

27619 S 647.03 0.00 0.00 27762 S 423.78 0.00 0.00<br />

27620 S 854.18 0.00 0.00 27766 S 1,045.18 0.00 0.00<br />

27625 S 854.18 0.00 0.00 27767 S 60.52 0.00 0.00<br />

27626 S 854.18 0.00 0.00 27768 S 60.52 0.00 0.00<br />

27630 S 645.86 0.00 0.00 27769 S 1,623.66 0.00 0.00<br />

27635 S 799.28 0.00 0.00 27780 S 77.67 0.00 0.00<br />

27637 S 799.28 0.00 0.00 27781 S 423.78 0.00 0.00<br />

27638 S 799.28 0.00 0.00 27784 S 1,045.18 0.00 0.00<br />

27640 S 1,063.01 0.00 0.00 27786 S 77.67 0.00 0.00<br />

27641 S 769.99 0.00 0.00 27788 S 77.67 0.00 0.00<br />

27647 S 1,092.29 0.00 0.00 27792 S 1,045.18 0.00 0.00<br />

27650 S 1,092.29 0.00 0.00 27808 S 77.67 0.00 0.00<br />

27652 S 1,873.39 0.00 0.00 27810 S 163.84 0.00 0.00<br />

27654 S 1,092.29 0.00 0.00 27814 S 1,045.18 0.00 0.00<br />

27656 S 616.57 0.00 0.00 27816 S 77.67 0.00 0.00<br />

27658 S 564.87 0.00 0.00 27818 S 163.84 0.00 0.00<br />

27659 S 616.57 0.00 0.00 27822 S 1,045.18 0.00 0.00<br />

27664 S 616.57 0.00 0.00 27823 S 1,418.35 0.00 0.00<br />

27665 S 769.99 0.00 0.00 27824 S 77.67 0.00 0.00<br />

27675 S 616.57 0.00 0.00 27825 S 423.78 0.00 0.00<br />

27676 S 799.28 0.00 0.00 27826 S 1,045.18 0.00 0.00<br />

27680 S 799.28 0.00 0.00 27827 S 1,418.35 0.00 0.00<br />

27681 S 769.99 0.00 0.00 27828 S 1,473.24 0.00 0.00<br />

27685 S 799.28 0.00 0.00 27829 S 1,015.90 0.00 0.00<br />

27686 S 799.28 0.00 0.00 27830 S 77.67 0.00 0.00<br />

27687 S 799.28 0.00 0.00 27831 S 423.78 0.00 0.00<br />

27690 S 1,147.20 0.00 0.00 27832 S 1,015.90 0.00 0.00<br />

27691 S 1,147.20 0.00 0.00 27840 S 163.84 0.00 0.00<br />

27692 S 1,092.29 0.00 0.00 27842 S 447.19 0.00 0.00<br />

27695 S 769.99 0.00 0.00 27846 S 1,045.18 0.00 0.00<br />

27696 S 769.99 0.00 0.00 27848 S 1,045.18 0.00 0.00<br />

27698 S 769.99 0.00 0.00 27860 S 447.19 0.00 0.00<br />

27700 S 1,044.54 0.00 0.00 27870 S 1,928.29 0.00 0.00<br />

27704 S 616.57 0.00 0.00 27871 S 1,928.29 0.00 0.00<br />

27705 S 1,063.01 0.00 0.00 27884 S 645.86 0.00 0.00<br />

27707 S 616.57 0.00 0.00 27889 S 799.28 0.00 0.00<br />

27709 S 769.99 0.00 0.00 27892 S 645.86 0.00 0.00<br />

27726 S 963.78 0.00 0.00 27893 S 645.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 645.86 0.00 0.00 28153 S 642.83 0.00 0.00<br />

28001 S 123.88 0.00 0.00 28160 S 642.83 0.00 0.00<br />

28002 S 645.86 0.00 0.00 28171 S 642.83 0.00 0.00<br />

28003 S 645.86 0.00 0.00 28173 S 642.83 0.00 0.00<br />

28005 S 642.83 0.00 0.00 28175 S 642.83 0.00 0.00<br />

28008 S 642.83 0.00 0.00 28190 S 127.94 0.00 0.00<br />

28010 S 91.05 0.00 0.00 28192 S 505.14 0.00 0.00<br />

28011 S 642.83 0.00 0.00 28193 S 347.85 0.00 0.00<br />

28020 S 613.54 0.00 0.00 28200 S 642.83 0.00 0.00<br />

28022 S 613.54 0.00 0.00 28202 S 642.83 0.00 0.00<br />

28024 S 613.54 0.00 0.00 28208 S 642.83 0.00 0.00<br />

28035 S 638.83 0.00 0.00 28210 S 1,129.00 0.00 0.00<br />

28043 S 617.74 0.00 0.00 28220 S 197.33 0.00 0.00<br />

28045 S 642.83 0.00 0.00 28222 S 561.84 0.00 0.00<br />

28046 S 642.83 0.00 0.00 28225 S 561.84 0.00 0.00<br />

28050 S 613.54 0.00 0.00 28226 S 561.84 0.00 0.00<br />

28052 S 613.54 0.00 0.00 28230 S 193.60 0.00 0.00<br />

28054 S 613.54 0.00 0.00 28232 S 185.14 0.00 0.00<br />

28055 S 638.83 0.00 0.00 28234 S 613.54 0.00 0.00<br />

28060 S 613.54 0.00 0.00 28238 S 1,129.00 0.00 0.00<br />

28062 S 642.83 0.00 0.00 28240 S 613.54 0.00 0.00<br />

28070 S 642.83 0.00 0.00 28250 S 642.83 0.00 0.00<br />

28072 S 642.83 0.00 0.00 28260 S 642.83 0.00 0.00<br />

28080 S 642.83 0.00 0.00 28261 S 642.83 0.00 0.00<br />

28086 S 613.54 0.00 0.00 28262 S 697.73 0.00 0.00<br />

28088 S 613.54 0.00 0.00 28264 S 1,048.01 0.00 0.00<br />

28090 S 642.83 0.00 0.00 28270 S 642.83 0.00 0.00<br />

28092 S 642.83 0.00 0.00 28272 S 178.71 0.00 0.00<br />

28100 S 613.54 0.00 0.00 28280 S 613.54 0.00 0.00<br />

28102 S 1,129.00 0.00 0.00 28285 S 642.83 0.00 0.00<br />

28103 S 1,129.00 0.00 0.00 28286 S 697.73 0.00 0.00<br />

28104 S 613.54 0.00 0.00 28288 S 642.83 0.00 0.00<br />

28106 S 1,129.00 0.00 0.00 28289 S 642.83 0.00 0.00<br />

28107 S 1,129.00 0.00 0.00 28290 S 792.37 0.00 0.00<br />

28108 S 613.54 0.00 0.00 28292 S 792.37 0.00 0.00<br />

28110 S 642.83 0.00 0.00 28293 S 821.65 0.00 0.00<br />

28111 S 642.83 0.00 0.00 28294 S 821.65 0.00 0.00<br />

28112 S 642.83 0.00 0.00 28296 S 821.65 0.00 0.00<br />

28113 S 642.83 0.00 0.00 28297 S 821.65 0.00 0.00<br />

28114 S 642.83 0.00 0.00 28298 S 821.65 0.00 0.00<br />

28116 S 642.83 0.00 0.00 28299 S 916.36 0.00 0.00<br />

28118 S 697.73 0.00 0.00 28300 S 1,099.72 0.00 0.00<br />

28119 S 697.73 0.00 0.00 28302 S 613.54 0.00 0.00<br />

28120 S 864.73 0.00 0.00 28304 S 1,099.72 0.00 0.00<br />

28122 S 642.83 0.00 0.00 28305 S 1,129.00 0.00 0.00<br />

28124 S 209.51 0.00 0.00 28306 S 697.73 0.00 0.00<br />

28126 S 642.83 0.00 0.00 28307 S 697.73 0.00 0.00<br />

28130 S 642.83 0.00 0.00 28308 S 613.54 0.00 0.00<br />

28140 S 642.83 0.00 0.00 28309 S 1,183.91 0.00 0.00<br />

28150 S 642.83 0.00 0.00 28310 S 642.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 642.83 0.00 0.00 28636 S 715.24 0.00 0.00<br />

28313 S 613.54 0.00 0.00 28645 S 715.24 0.00 0.00<br />

28315 S 697.73 0.00 0.00 28660 S 43.33 0.00 0.00<br />

28320 S 1,183.91 0.00 0.00 28665 S 447.19 0.00 0.00<br />

28322 S 1,183.91 0.00 0.00 28666 S 715.24 0.00 0.00<br />

28340 S 697.73 0.00 0.00 28675 S 715.24 0.00 0.00<br />

28341 S 697.73 0.00 0.00 28705 S 1,183.91 0.00 0.00<br />

28344 S 697.73 0.00 0.00 28715 S 1,928.29 0.00 0.00<br />

28345 S 697.73 0.00 0.00 28725 S 1,183.91 0.00 0.00<br />

28400 S 77.67 0.00 0.00 28730 S 1,183.91 0.00 0.00<br />

28405 S 423.78 0.00 0.00 28735 S 1,183.91 0.00 0.00<br />

28406 S 685.95 0.00 0.00 28737 S 1,223.71 0.00 0.00<br />

28415 S 1,418.35 0.00 0.00 28740 S 1,183.91 0.00 0.00<br />

28420 S 1,100.09 0.00 0.00 28750 S 1,183.91 0.00 0.00<br />

28430 S 60.52 0.00 0.00 28755 S 697.73 0.00 0.00<br />

28435 S 77.67 0.00 0.00 28760 S 1,183.91 0.00 0.00<br />

28436 S 685.95 0.00 0.00 28810 S 613.54 0.00 0.00<br />

28445 S 1,045.18 0.00 0.00 28820 S 613.54 0.00 0.00<br />

28446 S 1,791.31 0.00 0.00 28825 S 613.54 0.00 0.00<br />

28450 S 60.52 0.00 0.00 28890 S 162.13 0.00 0.00<br />

28455 S 60.52 0.00 0.00 29000 S 41.08 0.00 0.00<br />

28456 S 685.95 0.00 0.00 29010 S 92.06 0.00 0.00<br />

28465 S 1,045.18 0.00 0.00 29015 S 92.06 0.00 0.00<br />

28470 S 60.52 0.00 0.00 29020 S 41.08 0.00 0.00<br />

28475 S 60.52 0.00 0.00 29025 S 41.08 0.00 0.00<br />

28476 S 685.95 0.00 0.00 29035 S 92.06 0.00 0.00<br />

28485 S 1,100.09 0.00 0.00 29040 S 41.08 0.00 0.00<br />

28490 S 60.52 0.00 0.00 29044 S 92.06 0.00 0.00<br />

28495 S 60.52 0.00 0.00 29046 S 92.06 0.00 0.00<br />

28496 S 685.95 0.00 0.00 29049 S 37.23 0.00 0.00<br />

28505 S 715.24 0.00 0.00 29055 S 92.06 0.00 0.00<br />

28510 S 54.50 0.00 0.00 29058 S 41.08 0.00 0.00<br />

28515 S 60.52 0.00 0.00 29065 S 43.67 0.00 0.00<br />

28525 S 715.24 0.00 0.00 29075 S 41.97 0.00 0.00<br />

28530 S 52.46 0.00 0.00 29085 S 41.08 0.00 0.00<br />

28531 S 715.24 0.00 0.00 29086 S 35.20 0.00 0.00<br />

28540 S 60.52 0.00 0.00 29105 S 37.90 0.00 0.00<br />

28545 S 634.25 0.00 0.00 29125 S 32.83 0.00 0.00<br />

28546 S 685.95 0.00 0.00 29126 S 34.86 0.00 0.00<br />

28555 S 1,015.90 0.00 0.00 29130 S 14.89 0.00 0.00<br />

28570 S 78.52 0.00 0.00 29131 S 21.66 0.00 0.00<br />

28575 S 423.78 0.00 0.00 29200 S 20.98 0.00 0.00<br />

28576 S 715.24 0.00 0.00 29220 S 22.67 0.00 0.00<br />

28585 S 715.24 0.00 0.00 29240 S 23.70 0.00 0.00<br />

28600 S 60.52 0.00 0.00 29260 S 22.67 0.00 0.00<br />

28605 S 77.67 0.00 0.00 29280 S 23.02 0.00 0.00<br />

28606 S 685.95 0.00 0.00 29305 S 92.06 0.00 0.00<br />

28615 S 1,045.18 0.00 0.00 29325 S 92.06 0.00 0.00<br />

28630 S 60.52 0.00 0.00 29345 S 57.20 0.00 0.00<br />

28635 S 447.19 0.00 0.00 29355 S 56.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 69.73 0.00 0.00 29847 S 1,165.43 0.00 0.00<br />

29365 S 54.16 0.00 0.00 29848 S 1,169.73 0.00 0.00<br />

29405 S 40.28 0.00 0.00 29850 S 845.34 0.00 0.00<br />

29425 S 40.95 0.00 0.00 29851 S 1,220.34 0.00 0.00<br />

29435 S 51.78 0.00 0.00 29855 S 1,220.34 0.00 0.00<br />

29440 S 22.00 0.00 0.00 29856 S 1,220.34 0.00 0.00<br />

29445 S 54.50 0.00 0.00 29860 S 1,220.34 0.00 0.00<br />

29450 S 41.08 0.00 0.00 29861 S 1,220.34 0.00 0.00<br />

29505 S 36.55 0.00 0.00 29862 S 1,544.74 0.00 0.00<br />

29515 S 31.14 0.00 0.00 29863 S 1,220.34 0.00 0.00<br />

29520 S 22.34 0.00 0.00 29866 S 1,864.17 0.00 0.00<br />

29530 S 22.67 0.00 0.00 29870 S 790.44 0.00 0.00<br />

29540 S 16.92 0.00 0.00 29871 S 790.44 0.00 0.00<br />

29550 S 17.26 0.00 0.00 29873 S 790.44 0.00 0.00<br />

29580 S 23.36 0.00 0.00 29874 S 790.44 0.00 0.00<br />

29590 S 18.96 0.00 0.00 29875 S 845.34 0.00 0.00<br />

29700 S 31.48 0.00 0.00 29876 S 845.34 0.00 0.00<br />

29705 S 26.74 0.00 0.00 29877 S 845.34 0.00 0.00<br />

29710 S 47.04 0.00 0.00 29879 S 790.44 0.00 0.00<br />

29715 S 41.08 0.00 0.00 29880 S 845.34 0.00 0.00<br />

29720 S 39.26 0.00 0.00 29881 S 845.34 0.00 0.00<br />

29730 S 25.72 0.00 0.00 29882 S 790.44 0.00 0.00<br />

29740 S 35.20 0.00 0.00 29883 S 790.44 0.00 0.00<br />

29750 S 36.89 0.00 0.00 29884 S 790.44 0.00 0.00<br />

29800 S 790.44 0.00 0.00 29885 S 1,165.43 0.00 0.00<br />

29804 S 790.44 0.00 0.00 29886 S 790.44 0.00 0.00<br />

29805 S 790.44 0.00 0.00 29887 S 790.44 0.00 0.00<br />

29806 S 1,165.43 0.00 0.00 29888 S 1,165.43 0.00 0.00<br />

29807 S 1,165.43 0.00 0.00 29889 S 1,165.43 0.00 0.00<br />

29819 S 1,165.43 0.00 0.00 29891 S 1,165.43 0.00 0.00<br />

29820 S 1,165.43 0.00 0.00 29892 S 1,165.43 0.00 0.00<br />

29821 S 1,165.43 0.00 0.00 29893 S 983.95 0.00 0.00<br />

29822 S 790.44 0.00 0.00 29894 S 790.44 0.00 0.00<br />

29823 S 1,165.43 0.00 0.00 29895 S 790.44 0.00 0.00<br />

29824 S 885.15 0.00 0.00 29897 S 790.44 0.00 0.00<br />

29825 S 1,165.43 0.00 0.00 29898 S 790.44 0.00 0.00<br />

29826 S 1,165.43 0.00 0.00 29899 S 1,165.43 0.00 0.00<br />

29827 S 1,260.14 0.00 0.00 29900 S 790.44 0.00 0.00<br />

29828 S 1,864.17 0.00 0.00 29901 S 790.44 0.00 0.00<br />

29830 S 790.44 0.00 0.00 29902 S 790.44 0.00 0.00<br />

29834 S 790.44 0.00 0.00 29904 S 1,114.17 0.00 0.00<br />

29835 S 790.44 0.00 0.00 29905 S 1,114.17 0.00 0.00<br />

29836 S 790.44 0.00 0.00 29906 S 1,114.17 0.00 0.00<br />

29837 S 790.44 0.00 0.00 29907 S 1,864.17 0.00 0.00<br />

29838 S 790.44 0.00 0.00 30000 S 125.26 0.00 0.00<br />

29840 S 790.44 0.00 0.00 30020 S 125.26 0.00 0.00<br />

29843 S 790.44 0.00 0.00 30100 S 81.23 0.00 0.00<br />

29844 S 790.44 0.00 0.00 30110 S 125.57 0.00 0.00<br />

29845 S 790.44 0.00 0.00 30115 S 530.57 0.00 0.00<br />

29846 S 790.44 0.00 0.00 30117 S 559.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 702.20 0.00 0.00 31080 S 1,081.30 0.00 0.00<br />

30120 S 478.87 0.00 0.00 31081 S 1,081.30 0.00 0.00<br />

30124 S 285.34 0.00 0.00 31084 S 1,081.30 0.00 0.00<br />

30125 S 997.11 0.00 0.00 31085 S 1,081.30 0.00 0.00<br />

30130 S 559.86 0.00 0.00 31086 S 1,081.30 0.00 0.00<br />

30140 S 672.91 0.00 0.00 31087 S 1,081.30 0.00 0.00<br />

30150 S 1,026.40 0.00 0.00 31090 S 1,121.11 0.00 0.00<br />

30160 S 1,081.30 0.00 0.00 31200 S 997.11 0.00 0.00<br />

30200 S 63.97 0.00 0.00 31201 S 1,121.11 0.00 0.00<br />

30210 S 81.23 0.00 0.00 31205 S 1,026.40 0.00 0.00<br />

30220 S 355.03 0.00 0.00 31231 S 68.48 0.00 0.00<br />

30300 S 24.47 0.00 0.00 31233 S 73.76 0.00 0.00<br />

30310 S 478.87 0.00 0.00 31235 S 501.14 0.00 0.00<br />

30320 S 530.57 0.00 0.00 31237 S 552.84 0.00 0.00<br />

30400 S 1,081.30 0.00 0.00 31238 S 501.14 0.00 0.00<br />

30410 S 1,121.11 0.00 0.00 31239 S 731.51 0.00 0.00<br />

30420 S 1,121.11 0.00 0.00 31240 S 552.84 0.00 0.00<br />

30430 S 702.20 0.00 0.00 31254 S 676.60 0.00 0.00<br />

30435 S 1,121.11 0.00 0.00 31255 S 771.31 0.00 0.00<br />

30450 S 1,248.31 0.00 0.00 31256 S 676.60 0.00 0.00<br />

30460 S 1,248.31 0.00 0.00 31267 S 676.60 0.00 0.00<br />

30462 S 1,405.69 0.00 0.00 31276 S 676.60 0.00 0.00<br />

30465 S 1,405.69 0.00 0.00 31287 S 676.60 0.00 0.00<br />

30520 S 757.09 0.00 0.00 31288 S 676.60 0.00 0.00<br />

30540 S 1,121.11 0.00 0.00 31300 S 796.90 0.00 0.00<br />

30545 S 1,121.11 0.00 0.00 31320 S 997.11 0.00 0.00<br />

30560 S 131.59 0.00 0.00 31400 S 997.11 0.00 0.00<br />

30580 S 1,081.30 0.00 0.00 31420 S 997.11 0.00 0.00<br />

30600 S 1,081.30 0.00 0.00 31500 S 91.59 0.00 0.00<br />

30620 S 1,248.31 0.00 0.00 31502 S 52.67 0.00 0.00<br />

30630 S 924.10 0.00 0.00 31505 S 31.12 0.00 0.00<br />

30801 S 295.03 0.00 0.00 31510 S 552.84 0.00 0.00<br />

30802 S 295.03 0.00 0.00 31511 S 73.76 0.00 0.00<br />

30901 S 42.08 0.00 0.00 31512 S 552.84 0.00 0.00<br />

30903 S 54.20 0.00 0.00 31513 S 73.76 0.00 0.00<br />

30905 S 54.20 0.00 0.00 31515 S 501.14 0.00 0.00<br />

30906 S 54.20 0.00 0.00 31520 S 68.48 0.00 0.00<br />

30915 S 722.26 0.00 0.00 31525 S 501.14 0.00 0.00<br />

30920 S 751.55 0.00 0.00 31526 S 647.32 0.00 0.00<br />

30930 S 614.76 0.00 0.00 31527 S 595.62 0.00 0.00<br />

31000 S 104.59 0.00 0.00 31528 S 552.84 0.00 0.00<br />

31002 S 285.34 0.00 0.00 31529 S 552.84 0.00 0.00<br />

31020 S 672.91 0.00 0.00 31530 S 647.32 0.00 0.00<br />

31030 S 1,026.40 0.00 0.00 31531 S 676.60 0.00 0.00<br />

31032 S 1,081.30 0.00 0.00 31535 S 647.32 0.00 0.00<br />

31040 S 937.70 0.00 0.00 31536 S 676.60 0.00 0.00<br />

31050 S 997.11 0.00 0.00 31540 S 676.60 0.00 0.00<br />

31051 S 1,081.30 0.00 0.00 31541 S 731.51 0.00 0.00<br />

31070 S 672.91 0.00 0.00 31545 S 731.51 0.00 0.00<br />

31075 S 1,081.30 0.00 0.00 31546 S 731.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 771.31 0.00 0.00 32405 S 333.77 0.00 0.00<br />

31561 S 771.31 0.00 0.00 32420 S 202.96 0.00 0.00<br />

31570 S 552.84 0.00 0.00 32421 S 202.96 0.00 0.00<br />

31571 S 647.32 0.00 0.00 32422 S 202.06 0.00 0.00<br />

31575 S 58.90 0.00 0.00 32550 S 1,131.30 0.00 0.00<br />

31576 S 647.32 0.00 0.00 32960 S 202.06 0.00 0.00<br />

31577 S 191.22 0.00 0.00 32998 S 1,761.38 0.00 0.00<br />

31578 S 647.32 0.00 0.00 33010 S 202.96 0.00 0.00<br />

31579 S 104.93 0.00 0.00 33011 S 202.96 0.00 0.00<br />

31580 S 1,121.11 0.00 0.00 33206 S 6,511.68 3,874.43 1,237.19<br />

31582 S 1,121.11 0.00 0.00 33207 S 6,511.68 3,874.43 1,237.19<br />

31588 S 1,121.11 0.00 0.00 33208 S 8,076.33 4,706.04 1,335.75<br />

31590 S 1,121.11 0.00 0.00 33210 S 1,912.18 0.00 0.00<br />

31595 S 997.11 0.00 0.00 33211 S 1,912.18 0.00 0.00<br />

31603 S 295.03 0.00 0.00 33212 S 5,113.99 2,913.22 712.45<br />

31605 S 285.34 0.00 0.00 33213 S 5,902.64 3,307.13 711.61<br />

31611 S 702.20 0.00 0.00 33214 S 8,076.33 4,706.04 1,335.75<br />

31612 S 621.21 0.00 0.00 33215 S 838.13 0.00 0.00<br />

31613 S 672.91 0.00 0.00 33216 S 1,912.18 0.00 0.00<br />

31614 S 997.11 0.00 0.00 33217 S 1,912.18 0.00 0.00<br />

31615 S 295.03 0.00 0.00 33218 S 838.13 0.00 0.00<br />

31622 S 345.53 0.00 0.00 33220 S 838.13 0.00 0.00<br />

31623 S 397.23 0.00 0.00 33222 S 506.61 0.00 0.00<br />

31624 S 397.23 0.00 0.00 33223 S 506.61 0.00 0.00<br />

31625 S 397.23 0.00 0.00 33224 S 7,623.30 4,564.05 1,504.80<br />

31628 S 397.23 0.00 0.00 33225 S 7,623.30 4,564.05 1,504.80<br />

31629 S 397.23 0.00 0.00 33226 S 838.13 0.00 0.00<br />

31630 S 680.69 0.00 0.00 33233 S 623.13 0.00 0.00<br />

31631 S 680.69 0.00 0.00 33234 S 838.13 0.00 0.00<br />

31632 S 386.33 0.00 0.00 33235 S 838.13 0.00 0.00<br />

31633 S 386.33 0.00 0.00 33240 S 19,002.95 10,157.85 1,312.76<br />

31635 S 397.23 0.00 0.00 33241 S 838.13 0.00 0.00<br />

31636 S 680.69 0.00 0.00 33249 S 25,360.88 13,584.34 1,807.79<br />

31637 S 345.53 0.00 0.00 33282 S 4,009.72 2,400.45 791.19<br />

31638 S 680.69 0.00 0.00 33284 S 312.75 0.00 0.00<br />

31640 S 680.69 0.00 0.00 34490 S 1,526.92 0.00 0.00<br />

31641 S 680.69 0.00 0.00 35188 S 1,051.71 0.00 0.00<br />

31643 S 397.23 0.00 0.00 35207 S 1,051.71 0.00 0.00<br />

31645 S 345.53 0.00 0.00 35473 S 1,831.72 0.00 0.00<br />

31646 S 345.53 0.00 0.00 35476 S 1,831.72 0.00 0.00<br />

31656 S 345.53 0.00 0.00 35492 S 3,418.73 0.00 0.00<br />

31717 S 191.22 0.00 0.00 35761 S 1,099.76 0.00 0.00<br />

31720 S 29.28 0.00 0.00 35875 S 1,376.11 0.00 0.00<br />

31730 S 191.22 0.00 0.00 35876 S 1,376.11 0.00 0.00<br />

31750 S 1,121.11 0.00 0.00 36002 S 87.83 0.00 0.00<br />

31755 S 997.11 0.00 0.00 36260 S 796.73 0.00 0.00<br />

31820 S 478.87 0.00 0.00 36261 S 623.13 0.00 0.00<br />

31825 S 672.91 0.00 0.00 36262 S 571.42 0.00 0.00<br />

31830 S 672.91 0.00 0.00 36420 S 8.28 0.00 0.00<br />

32400 S 333.77 0.00 0.00 36425 S 8.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 31.81 0.00 0.00 36800 S 857.69 0.00 0.00<br />

36440 S 127.06 0.00 0.00 36810 S 857.69 0.00 0.00<br />

36450 S 127.06 0.00 0.00 36815 S 857.69 0.00 0.00<br />

36455 S 127.06 0.00 0.00 36818 S 996.81 0.00 0.00<br />

36468 S 31.36 0.00 0.00 36819 S 996.81 0.00 0.00<br />

36469 S 31.36 0.00 0.00 36820 S 996.81 0.00 0.00<br />

36470 S 31.36 0.00 0.00 36821 S 996.81 0.00 0.00<br />

36471 S 31.36 0.00 0.00 36825 S 1,051.71 0.00 0.00<br />

36475 S 1,442.02 0.00 0.00 36830 S 1,051.71 0.00 0.00<br />

36476 S 1,130.84 0.00 0.00 36831 S 1,376.11 0.00 0.00<br />

36478 S 1,130.84 0.00 0.00 36832 S 1,051.71 0.00 0.00<br />

36479 S 1,130.84 0.00 0.00 36833 S 1,051.71 0.00 0.00<br />

36511 S 435.61 0.00 0.00 36834 S 996.81 0.00 0.00<br />

36512 S 435.61 0.00 0.00 36835 S 912.60 0.00 0.00<br />

36513 S 435.61 0.00 0.00 36860 S 104.74 0.00 0.00<br />

36514 S 435.61 0.00 0.00 36861 S 857.69 0.00 0.00<br />

36515 S 1,166.13 0.00 0.00 36870 S 1,499.96 0.00 0.00<br />

36516 S 1,166.13 0.00 0.00 37184 S 1,526.92 0.00 0.00<br />

36522 S 1,166.13 0.00 0.00 37185 S 1,526.92 0.00 0.00<br />

36555 S 361.93 0.00 0.00 37186 S 1,526.92 0.00 0.00<br />

36556 S 361.93 0.00 0.00 37187 S 1,526.92 0.00 0.00<br />

36557 S 675.94 0.00 0.00 37188 S 1,526.92 0.00 0.00<br />

36558 S 675.94 0.00 0.00 37200 S 1,126.78 0.00 0.00<br />

36560 S 796.73 0.00 0.00 37203 S 1,126.78 0.00 0.00<br />

36561 S 796.73 0.00 0.00 37500 S 1,062.73 0.00 0.00<br />

36563 S 796.73 0.00 0.00 37607 S 751.55 0.00 0.00<br />

36565 S 796.73 0.00 0.00 37609 S 505.14 0.00 0.00<br />

36566 S 796.73 0.00 0.00 37650 S 722.26 0.00 0.00<br />

36568 S 361.93 0.00 0.00 37700 S 722.26 0.00 0.00<br />

36569 S 361.93 0.00 0.00 37718 S 751.55 0.00 0.00<br />

36570 S 705.22 0.00 0.00 37722 S 1,062.73 0.00 0.00<br />

36571 S 705.22 0.00 0.00 37735 S 1,062.73 0.00 0.00<br />

36575 S 291.10 0.00 0.00 37760 S 751.55 0.00 0.00<br />

36576 S 413.63 0.00 0.00 37765 S 1,036.40 0.00 0.00<br />

36578 S 675.94 0.00 0.00 37766 S 1,036.40 0.00 0.00<br />

36580 S 361.93 0.00 0.00 37780 S 751.55 0.00 0.00<br />

36581 S 675.94 0.00 0.00 37785 S 751.55 0.00 0.00<br />

36582 S 796.73 0.00 0.00 37790 S 906.89 0.00 0.00<br />

36583 S 796.73 0.00 0.00 38205 S 435.61 0.00 0.00<br />

36584 S 361.93 0.00 0.00 38206 S 435.61 0.00 0.00<br />

36585 S 705.22 0.00 0.00 38220 S 99.85 0.00 0.00<br />

36589 S 239.40 0.00 0.00 38221 S 104.59 0.00 0.00<br />

36590 S 361.93 0.00 0.00 38230 S 1,166.13 0.00 0.00<br />

36593 S 24.03 0.00 0.00 38241 S 1,166.13 0.00 0.00<br />

36595 S 943.74 0.00 0.00 38242 S 435.61 0.00 0.00<br />

36596 S 419.13 0.00 0.00 38300 S 390.90 0.00 0.00<br />

36597 S 419.13 0.00 0.00 38305 S 571.24 0.00 0.00<br />

36598 S 77.51 0.00 0.00 38308 S 652.72 0.00 0.00<br />

36640 S 715.75 0.00 0.00 38500 S 652.72 0.00 0.00<br />

36680 S 54.25 0.00 0.00 38505 S 249.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 652.72 0.00 0.00 41005 S 131.59 0.00 0.00<br />

38520 S 652.72 0.00 0.00 41006 S 621.21 0.00 0.00<br />

38525 S 652.72 0.00 0.00 41007 S 478.87 0.00 0.00<br />

38530 S 652.72 0.00 0.00 41008 S 478.87 0.00 0.00<br />

38542 S 1,098.11 0.00 0.00 41009 S 131.59 0.00 0.00<br />

38550 S 682.01 0.00 0.00 41010 S 295.03 0.00 0.00<br />

38555 S 736.91 0.00 0.00 41015 S 131.59 0.00 0.00<br />

38570 S 1,489.97 0.00 0.00 41016 S 295.03 0.00 0.00<br />

38571 S 1,936.92 0.00 0.00 41017 S 295.03 0.00 0.00<br />

38572 S 1,489.97 0.00 0.00 41018 S 295.03 0.00 0.00<br />

38700 S 897.32 0.00 0.00 41019 S 937.70 0.00 0.00<br />

38740 S 1,098.11 0.00 0.00 41100 S 88.34 0.00 0.00<br />

38745 S 1,182.30 0.00 0.00 41105 S 87.32 0.00 0.00<br />

38760 S 652.72 0.00 0.00 41108 S 80.89 0.00 0.00<br />

40490 S 66.68 0.00 0.00 41110 S 117.11 0.00 0.00<br />

40500 S 530.57 0.00 0.00 41112 S 530.57 0.00 0.00<br />

40510 S 672.91 0.00 0.00 41113 S 530.57 0.00 0.00<br />

40520 S 530.57 0.00 0.00 41114 S 672.91 0.00 0.00<br />

40525 S 672.91 0.00 0.00 41115 S 136.40 0.00 0.00<br />

40527 S 672.91 0.00 0.00 41116 S 478.87 0.00 0.00<br />

40530 S 672.91 0.00 0.00 41120 S 796.90 0.00 0.00<br />

40650 S 355.03 0.00 0.00 41250 S 90.00 0.00 0.00<br />

40652 S 355.03 0.00 0.00 41251 S 131.59 0.00 0.00<br />

40654 S 355.03 0.00 0.00 41252 S 346.73 0.00 0.00<br />

40700 S 1,248.31 0.00 0.00 41500 S 621.21 0.00 0.00<br />

40701 S 1,248.31 0.00 0.00 41510 S 478.87 0.00 0.00<br />

40702 S 1,586.10 0.00 0.00 41520 S 346.73 0.00 0.00<br />

40720 S 1,248.31 0.00 0.00 41530 S 653.02 0.00 0.00<br />

40761 S 1,026.40 0.00 0.00 41800 S 67.23 0.00 0.00<br />

40800 S 53.51 0.00 0.00 41805 S 145.54 0.00 0.00<br />

40801 S 346.73 0.00 0.00 41806 S 179.38 0.00 0.00<br />

40804 S 24.47 0.00 0.00 41820 S 285.34 0.00 0.00<br />

40805 S 165.51 0.00 0.00 41821 S 285.34 0.00 0.00<br />

40806 S 76.16 0.00 0.00 41822 S 148.58 0.00 0.00<br />

40808 S 113.05 0.00 0.00 41823 S 216.62 0.00 0.00<br />

40810 S 117.11 0.00 0.00 41825 S 119.14 0.00 0.00<br />

40812 S 146.90 0.00 0.00 41826 S 149.95 0.00 0.00<br />

40814 S 530.57 0.00 0.00 41827 S 672.91 0.00 0.00<br />

40816 S 672.91 0.00 0.00 41828 S 135.39 0.00 0.00<br />

40818 S 131.59 0.00 0.00 41830 S 192.25 0.00 0.00<br />

40819 S 295.03 0.00 0.00 41850 S 653.02 0.00 0.00<br />

40820 S 168.89 0.00 0.00 41870 S 937.70 0.00 0.00<br />

40830 S 125.26 0.00 0.00 41872 S 192.25 0.00 0.00<br />

40831 S 295.03 0.00 0.00 41874 S 185.48 0.00 0.00<br />

40840 S 672.91 0.00 0.00 42000 S 131.59 0.00 0.00<br />

40842 S 702.20 0.00 0.00 42100 S 75.14 0.00 0.00<br />

40843 S 702.20 0.00 0.00 42104 S 111.69 0.00 0.00<br />

40844 S 1,121.11 0.00 0.00 42106 S 140.13 0.00 0.00<br />

40845 S 1,121.11 0.00 0.00 42107 S 672.91 0.00 0.00<br />

41000 S 83.94 0.00 0.00 42120 S 1,081.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 346.73 0.00 0.00 42809 S 24.47 0.00 0.00<br />

42145 S 796.90 0.00 0.00 42810 S 702.20 0.00 0.00<br />

42160 S 132.68 0.00 0.00 42815 S 1,121.11 0.00 0.00<br />

42180 S 131.59 0.00 0.00 42820 S 702.20 0.00 0.00<br />

42182 S 997.11 0.00 0.00 42821 S 796.90 0.00 0.00<br />

42200 S 1,121.11 0.00 0.00 42825 S 757.09 0.00 0.00<br />

42205 S 1,121.11 0.00 0.00 42826 S 757.09 0.00 0.00<br />

42210 S 1,121.11 0.00 0.00 42830 S 757.09 0.00 0.00<br />

42215 S 1,248.31 0.00 0.00 42831 S 757.09 0.00 0.00<br />

42220 S 1,121.11 0.00 0.00 42835 S 757.09 0.00 0.00<br />

42226 S 1,121.11 0.00 0.00 42836 S 757.09 0.00 0.00<br />

42235 S 654.57 0.00 0.00 42860 S 702.20 0.00 0.00<br />

42260 S 757.09 0.00 0.00 42870 S 702.20 0.00 0.00<br />

42280 S 73.11 0.00 0.00 42890 S 1,248.31 0.00 0.00<br />

42281 S 653.02 0.00 0.00 42892 S 1,248.31 0.00 0.00<br />

42300 S 478.87 0.00 0.00 42900 S 295.03 0.00 0.00<br />

42305 S 530.57 0.00 0.00 42950 S 672.91 0.00 0.00<br />

42310 S 131.59 0.00 0.00 42955 S 672.91 0.00 0.00<br />

42320 S 131.59 0.00 0.00 42960 S 54.20 0.00 0.00<br />

42330 S 113.05 0.00 0.00 42962 S 997.11 0.00 0.00<br />

42335 S 187.51 0.00 0.00 42970 S 42.08 0.00 0.00<br />

42340 S 530.57 0.00 0.00 42972 S 559.86 0.00 0.00<br />

42400 S 63.64 0.00 0.00 43030 S 653.02 0.00 0.00<br />

42405 S 530.57 0.00 0.00 43200 S 316.23 0.00 0.00<br />

42408 S 559.86 0.00 0.00 43201 S 316.23 0.00 0.00<br />

42409 S 559.86 0.00 0.00 43202 S 316.23 0.00 0.00<br />

42410 S 1,026.40 0.00 0.00 43204 S 316.23 0.00 0.00<br />

42415 S 1,248.31 0.00 0.00 43205 S 316.23 0.00 0.00<br />

42420 S 1,248.31 0.00 0.00 43215 S 316.23 0.00 0.00<br />

42425 S 1,248.31 0.00 0.00 43216 S 316.23 0.00 0.00<br />

42440 S 1,026.40 0.00 0.00 43217 S 316.23 0.00 0.00<br />

42450 S 672.91 0.00 0.00 43219 S 639.10 0.00 0.00<br />

42500 S 702.20 0.00 0.00 43220 S 316.23 0.00 0.00<br />

42505 S 1,081.30 0.00 0.00 43226 S 316.23 0.00 0.00<br />

42507 S 1,026.40 0.00 0.00 43227 S 367.94 0.00 0.00<br />

42508 S 1,081.30 0.00 0.00 43228 S 684.70 0.00 0.00<br />

42509 S 1,081.30 0.00 0.00 43231 S 367.94 0.00 0.00<br />

42510 S 1,081.30 0.00 0.00 43232 S 367.94 0.00 0.00<br />

42600 S 478.87 0.00 0.00 43234 S 316.23 0.00 0.00<br />

42650 S 41.63 0.00 0.00 43235 S 316.23 0.00 0.00<br />

42660 S 48.74 0.00 0.00 43236 S 367.94 0.00 0.00<br />

42665 S 924.10 0.00 0.00 43237 S 367.94 0.00 0.00<br />

42700 S 131.59 0.00 0.00 43238 S 367.94 0.00 0.00<br />

42720 S 478.87 0.00 0.00 43239 S 367.94 0.00 0.00<br />

42725 S 997.11 0.00 0.00 43240 S 367.94 0.00 0.00<br />

42800 S 80.56 0.00 0.00 43241 S 367.94 0.00 0.00<br />

42802 S 478.87 0.00 0.00 43242 S 367.94 0.00 0.00<br />

42804 S 478.87 0.00 0.00 43243 S 367.94 0.00 0.00<br />

42806 S 672.91 0.00 0.00 43244 S 367.94 0.00 0.00<br />

42808 S 530.57 0.00 0.00 43245 S 367.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 367.94 0.00 0.00 44378 S 385.36 0.00 0.00<br />

43247 S 367.94 0.00 0.00 44379 S 1,099.39 0.00 0.00<br />

43248 S 367.94 0.00 0.00 44380 S 333.65 0.00 0.00<br />

43249 S 367.94 0.00 0.00 44382 S 333.65 0.00 0.00<br />

43250 S 367.94 0.00 0.00 44383 S 1,099.39 0.00 0.00<br />

43251 S 367.94 0.00 0.00 44385 S 322.59 0.00 0.00<br />

43255 S 367.94 0.00 0.00 44386 S 322.59 0.00 0.00<br />

43256 S 720.09 0.00 0.00 44388 S 322.59 0.00 0.00<br />

43257 S 713.99 0.00 0.00 44389 S 322.59 0.00 0.00<br />

43258 S 397.22 0.00 0.00 44390 S 322.59 0.00 0.00<br />

43259 S 397.22 0.00 0.00 44391 S 322.59 0.00 0.00<br />

43260 S 619.42 0.00 0.00 44392 S 322.59 0.00 0.00<br />

43261 S 619.42 0.00 0.00 44393 S 322.59 0.00 0.00<br />

43262 S 619.42 0.00 0.00 44394 S 322.59 0.00 0.00<br />

43263 S 619.42 0.00 0.00 44397 S 639.10 0.00 0.00<br />

43264 S 619.42 0.00 0.00 44500 S 174.08 0.00 0.00<br />

43265 S 619.42 0.00 0.00 45000 S 374.10 0.00 0.00<br />

43267 S 619.42 0.00 0.00 45005 S 435.38 0.00 0.00<br />

43268 S 690.81 0.00 0.00 45020 S 435.38 0.00 0.00<br />

43269 S 690.81 0.00 0.00 45100 S 591.51 0.00 0.00<br />

43271 S 619.42 0.00 0.00 45108 S 643.21 0.00 0.00<br />

43272 S 619.42 0.00 0.00 45150 S 643.21 0.00 0.00<br />

43273 S 830.73 0.00 0.00 45160 S 643.21 0.00 0.00<br />

43450 S 276.56 0.00 0.00 45170 S 643.21 0.00 0.00<br />

43453 S 276.56 0.00 0.00 45190 S 1,051.80 0.00 0.00<br />

43456 S 277.66 0.00 0.00 45300 S 62.28 0.00 0.00<br />

43458 S 317.34 0.00 0.00 45303 S 345.92 0.00 0.00<br />

43600 S 316.23 0.00 0.00 45305 S 325.32 0.00 0.00<br />

43653 S 1,489.97 0.00 0.00 45307 S 600.89 0.00 0.00<br />

43760 S 153.37 0.00 0.00 45308 S 325.32 0.00 0.00<br />

43761 S 316.23 0.00 0.00 45309 S 325.32 0.00 0.00<br />

43870 S 316.23 0.00 0.00 45315 S 325.32 0.00 0.00<br />

43886 S 797.93 0.00 0.00 45317 S 325.32 0.00 0.00<br />

43887 S 167.82 0.00 0.00 45320 S 600.89 0.00 0.00<br />

43888 S 797.93 0.00 0.00 45321 S 600.89 0.00 0.00<br />

44100 S 316.23 0.00 0.00 45327 S 639.10 0.00 0.00<br />

44312 S 551.32 0.00 0.00 45330 S 82.25 0.00 0.00<br />

44340 S 632.31 0.00 0.00 45331 S 243.22 0.00 0.00<br />

44360 S 385.36 0.00 0.00 45332 S 243.22 0.00 0.00<br />

44361 S 385.36 0.00 0.00 45333 S 325.32 0.00 0.00<br />

44363 S 385.36 0.00 0.00 45334 S 325.32 0.00 0.00<br />

44364 S 385.36 0.00 0.00 45335 S 243.22 0.00 0.00<br />

44365 S 385.36 0.00 0.00 45337 S 243.22 0.00 0.00<br />

44366 S 385.36 0.00 0.00 45338 S 325.32 0.00 0.00<br />

44369 S 385.36 0.00 0.00 45339 S 325.32 0.00 0.00<br />

44370 S 1,099.39 0.00 0.00 45340 S 325.32 0.00 0.00<br />

44372 S 385.36 0.00 0.00 45341 S 325.32 0.00 0.00<br />

44373 S 385.36 0.00 0.00 45342 S 325.32 0.00 0.00<br />

44376 S 385.36 0.00 0.00 45345 S 639.10 0.00 0.00<br />

44377 S 385.36 0.00 0.00 45355 S 322.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 374.30 0.00 0.00 46505 S 462.64 0.00 0.00<br />

45379 S 374.30 0.00 0.00 46600 S 24.47 0.00 0.00<br />

45380 S 374.30 0.00 0.00 46604 S 345.92 0.00 0.00<br />

45381 S 374.30 0.00 0.00 46606 S 129.98 0.00 0.00<br />

45382 S 374.30 0.00 0.00 46608 S 325.32 0.00 0.00<br />

45383 S 374.30 0.00 0.00 46610 S 600.89 0.00 0.00<br />

45384 S 374.30 0.00 0.00 46611 S 325.32 0.00 0.00<br />

45385 S 374.30 0.00 0.00 46612 S 600.89 0.00 0.00<br />

45386 S 374.30 0.00 0.00 46614 S 68.37 0.00 0.00<br />

45387 S 639.10 0.00 0.00 46615 S 652.59 0.00 0.00<br />

45391 S 374.30 0.00 0.00 46700 S 672.50 0.00 0.00<br />

45392 S 374.30 0.00 0.00 46706 S 740.22 0.00 0.00<br />

45500 S 643.21 0.00 0.00 46750 S 821.21 0.00 0.00<br />

45505 S 791.93 0.00 0.00 46753 S 672.50 0.00 0.00<br />

45520 S 31.36 0.00 0.00 46754 S 643.21 0.00 0.00<br />

45560 S 791.93 0.00 0.00 46760 S 791.93 0.00 0.00<br />

45900 S 253.62 0.00 0.00 46761 S 821.21 0.00 0.00<br />

45905 S 591.51 0.00 0.00 46762 S 1,043.12 0.00 0.00<br />

45910 S 591.51 0.00 0.00 46900 S 103.36 0.00 0.00<br />

45915 S 374.10 0.00 0.00 46910 S 123.54 0.00 0.00<br />

45990 S 581.93 0.00 0.00 46916 S 57.46 0.00 0.00<br />

46020 S 672.50 0.00 0.00 46917 S 536.02 0.00 0.00<br />

46030 S 253.62 0.00 0.00 46922 S 536.02 0.00 0.00<br />

46040 S 672.50 0.00 0.00 46924 S 536.02 0.00 0.00<br />

46045 S 643.21 0.00 0.00 46930 S 119.82 0.00 0.00<br />

46050 S 374.10 0.00 0.00 46937 S 643.21 0.00 0.00<br />

46060 S 643.21 0.00 0.00 46938 S 791.93 0.00 0.00<br />

46070 S 462.64 0.00 0.00 46940 S 88.67 0.00 0.00<br />

46080 S 672.50 0.00 0.00 46942 S 86.31 0.00 0.00<br />

46083 S 70.82 0.00 0.00 46945 S 146.90 0.00 0.00<br />

46200 S 643.21 0.00 0.00 46946 S 383.68 0.00 0.00<br />

46210 S 643.21 0.00 0.00 46947 S 1,043.12 0.00 0.00<br />

46211 S 643.21 0.00 0.00 47000 S 333.77 0.00 0.00<br />

46220 S 591.51 0.00 0.00 47382 S 1,761.38 0.00 0.00<br />

46221 S 116.43 0.00 0.00 47510 S 780.04 0.00 0.00<br />

46230 S 591.51 0.00 0.00 47511 S 1,146.00 0.00 0.00<br />

46250 S 672.50 0.00 0.00 47525 S 447.80 0.00 0.00<br />

46255 S 672.50 0.00 0.00 47530 S 447.80 0.00 0.00<br />

46257 S 672.50 0.00 0.00 47552 S 780.04 0.00 0.00<br />

46258 S 672.50 0.00 0.00 47553 S 809.32 0.00 0.00<br />

46260 S 672.50 0.00 0.00 47554 S 809.32 0.00 0.00<br />

46261 S 727.40 0.00 0.00 47555 S 809.32 0.00 0.00<br />

46262 S 727.40 0.00 0.00 47556 S 1,146.00 0.00 0.00<br />

46270 S 672.50 0.00 0.00 47560 S 950.92 0.00 0.00<br />

46275 S 672.50 0.00 0.00 47561 S 950.92 0.00 0.00<br />

46280 S 727.40 0.00 0.00 47562 S 1,754.65 0.00 0.00<br />

46285 S 591.51 0.00 0.00 47563 S 1,754.65 0.00 0.00<br />

46288 S 727.40 0.00 0.00 47564 S 1,754.65 0.00 0.00<br />

46320 S 78.87 0.00 0.00 47630 S 809.32 0.00 0.00<br />

46500 S 108.64 0.00 0.00 48102 S 333.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 202.96 0.00 0.00 49590 S 833.02 0.00 0.00<br />

49081 S 202.96 0.00 0.00 49600 S 887.91 0.00 0.00<br />

49180 S 333.77 0.00 0.00 49650 S 1,165.57 0.00 0.00<br />

49250 S 731.63 0.00 0.00 49651 S 1,332.58 0.00 0.00<br />

49320 S 950.92 0.00 0.00 49652 S 1,435.15 0.00 0.00<br />

49321 S 1,005.83 0.00 0.00 49653 S 1,435.15 0.00 0.00<br />

49322 S 1,005.83 0.00 0.00 49654 S 1,435.15 0.00 0.00<br />

49324 S 1,435.15 0.00 0.00 49655 S 1,435.15 0.00 0.00<br />

49325 S 1,435.15 0.00 0.00 49656 S 1,435.15 0.00 0.00<br />

49326 S 1,435.15 0.00 0.00 49657 S 1,435.15 0.00 0.00<br />

49402 S 647.45 0.00 0.00 50200 S 333.77 0.00 0.00<br />

49419 S 776.70 0.00 0.00 50382 S 969.19 0.00 0.00<br />

49420 S 718.01 0.00 0.00 50384 S 711.85 0.00 0.00<br />

49421 S 718.01 0.00 0.00 50385 S 711.85 0.00 0.00<br />

49422 S 571.42 0.00 0.00 50386 S 273.12 0.00 0.00<br />

49423 S 590.88 0.00 0.00 50387 S 590.88 0.00 0.00<br />

49426 S 647.45 0.00 0.00 50389 S 273.12 0.00 0.00<br />

49429 S 838.13 0.00 0.00 50390 S 333.77 0.00 0.00<br />

49440 S 327.74 0.00 0.00 50391 S 39.53 0.00 0.00<br />

49441 S 327.74 0.00 0.00 50392 S 508.28 0.00 0.00<br />

49446 S 327.74 0.00 0.00 50393 S 636.95 0.00 0.00<br />

49450 S 174.08 0.00 0.00 50395 S 508.28 0.00 0.00<br />

49451 S 174.08 0.00 0.00 50396 S 95.57 0.00 0.00<br />

49452 S 174.08 0.00 0.00 50398 S 447.80 0.00 0.00<br />

49460 S 174.08 0.00 0.00 50551 S 288.92 0.00 0.00<br />

49495 S 887.91 0.00 0.00 50553 S 636.95 0.00 0.00<br />

49496 S 887.91 0.00 0.00 50555 S 288.92 0.00 0.00<br />

49500 S 887.91 0.00 0.00 50557 S 636.95 0.00 0.00<br />

49501 S 1,212.31 0.00 0.00 50561 S 636.95 0.00 0.00<br />

49505 S 887.91 0.00 0.00 50562 S 273.12 0.00 0.00<br />

49507 S 1,212.31 0.00 0.00 50570 S 273.12 0.00 0.00<br />

49520 S 1,054.92 0.00 0.00 50572 S 273.12 0.00 0.00<br />

49521 S 1,212.31 0.00 0.00 50574 S 273.12 0.00 0.00<br />

49525 S 887.91 0.00 0.00 50575 S 1,358.54 0.00 0.00<br />

49540 S 803.73 0.00 0.00 50576 S 711.85 0.00 0.00<br />

49550 S 927.72 0.00 0.00 50580 S 711.85 0.00 0.00<br />

49553 S 1,212.31 0.00 0.00 50590 S 1,587.09 0.00 0.00<br />

49555 S 927.72 0.00 0.00 50592 S 1,761.38 0.00 0.00<br />

49557 S 1,212.31 0.00 0.00 50686 S 39.53 0.00 0.00<br />

49560 S 887.91 0.00 0.00 50688 S 447.80 0.00 0.00<br />

49561 S 1,212.31 0.00 0.00 50947 S 1,489.97 0.00 0.00<br />

49565 S 887.91 0.00 0.00 50948 S 1,489.97 0.00 0.00<br />

49566 S 1,212.31 0.00 0.00 50951 S 288.92 0.00 0.00<br />

49568 S 1,054.92 0.00 0.00 50953 S 288.92 0.00 0.00<br />

49570 S 887.91 0.00 0.00 50955 S 636.95 0.00 0.00<br />

49572 S 1,212.31 0.00 0.00 50957 S 636.95 0.00 0.00<br />

49580 S 887.91 0.00 0.00 50961 S 636.95 0.00 0.00<br />

49582 S 1,212.31 0.00 0.00 50970 S 288.92 0.00 0.00<br />

49585 S 887.91 0.00 0.00 50972 S 288.92 0.00 0.00<br />

49587 S 1,212.31 0.00 0.00 50974 S 508.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 508.28 0.00 0.00 52275 S 688.66 0.00 0.00<br />

50980 S 636.95 0.00 0.00 52276 S 717.94 0.00 0.00<br />

51020 S 772.85 0.00 0.00 52277 S 688.66 0.00 0.00<br />

51030 S 772.85 0.00 0.00 52281 S 559.98 0.00 0.00<br />

51040 S 772.85 0.00 0.00 52282 S 1,291.92 0.00 0.00<br />

51045 S 319.22 0.00 0.00 52283 S 688.66 0.00 0.00<br />

51050 S 772.85 0.00 0.00 52285 S 559.98 0.00 0.00<br />

51065 S 772.85 0.00 0.00 52290 S 559.98 0.00 0.00<br />

51080 S 519.54 0.00 0.00 52300 S 688.66 0.00 0.00<br />

51100 S 30.12 0.00 0.00 52301 S 717.94 0.00 0.00<br />

51101 S 39.53 0.00 0.00 52305 S 688.66 0.00 0.00<br />

51102 S 531.79 0.00 0.00 52310 S 538.59 0.00 0.00<br />

51500 S 887.91 0.00 0.00 52315 S 688.66 0.00 0.00<br />

51520 S 772.85 0.00 0.00 52317 S 636.95 0.00 0.00<br />

51700 S 51.45 0.00 0.00 52318 S 688.66 0.00 0.00<br />

51701 S 24.47 0.00 0.00 52320 S 812.65 0.00 0.00<br />

51702 S 24.47 0.00 0.00 52325 S 772.85 0.00 0.00<br />

51703 S 39.53 0.00 0.00 52327 S 883.33 0.00 0.00<br />

51705 S 70.82 0.00 0.00 52330 S 688.66 0.00 0.00<br />

51710 S 447.80 0.00 0.00 52332 S 688.66 0.00 0.00<br />

51715 S 813.07 0.00 0.00 52334 S 717.94 0.00 0.00<br />

51720 S 56.86 0.00 0.00 52341 S 717.94 0.00 0.00<br />

51725 TC S 109.24 0.00 0.00 52342 S 717.94 0.00 0.00<br />

51726 TC S 150.46 0.00 0.00 52343 S 717.94 0.00 0.00<br />

51736 TC S 20.65 0.00 0.00 52344 S 717.94 0.00 0.00<br />

51741 TC S 24.03 0.00 0.00 52345 S 717.94 0.00 0.00<br />

51772 TC S 95.57 0.00 0.00 52346 S 717.94 0.00 0.00<br />

51784 TC S 39.53 0.00 0.00 52351 S 717.94 0.00 0.00<br />

51785 TC S 66.03 0.00 0.00 52352 S 772.85 0.00 0.00<br />

51792 TC S 39.53 0.00 0.00 52353 S 967.52 0.00 0.00<br />

51795 TC S 70.82 0.00 0.00 52354 S 772.85 0.00 0.00<br />

51797 TC S 70.82 0.00 0.00 52355 S 772.85 0.00 0.00<br />

51798 S 17.60 0.00 0.00 52400 S 717.94 0.00 0.00<br />

51880 S 636.95 0.00 0.00 52402 S 717.94 0.00 0.00<br />

51992 S 1,205.38 0.00 0.00 52450 S 717.94 0.00 0.00<br />

52000 S 288.92 0.00 0.00 52500 S 717.94 0.00 0.00<br />

52001 S 538.59 0.00 0.00 52601 S 967.52 0.00 0.00<br />

52005 S 559.98 0.00 0.00 52630 S 883.33 0.00 0.00<br />

52007 S 688.66 0.00 0.00 52640 S 688.66 0.00 0.00<br />

52010 S 319.22 0.00 0.00 52647 S 1,480.22 0.00 0.00<br />

52204 S 559.98 0.00 0.00 52648 S 1,480.22 0.00 0.00<br />

52214 S 688.66 0.00 0.00 52700 S 688.66 0.00 0.00<br />

52224 S 688.66 0.00 0.00 53000 S 528.54 0.00 0.00<br />

52234 S 688.66 0.00 0.00 53010 S 528.54 0.00 0.00<br />

52235 S 717.94 0.00 0.00 53020 S 528.54 0.00 0.00<br />

52240 S 717.94 0.00 0.00 53025 S 752.36 0.00 0.00<br />

52250 S 772.85 0.00 0.00 53040 S 580.25 0.00 0.00<br />

52260 S 559.98 0.00 0.00 53060 S 68.71 0.00 0.00<br />

52265 S 273.12 0.00 0.00 53080 S 609.53 0.00 0.00<br />

52270 S 559.98 0.00 0.00 53085 S 752.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 528.54 0.00 0.00 54060 S 536.02 0.00 0.00<br />

53210 S 907.78 0.00 0.00 54065 S 536.02 0.00 0.00<br />

53215 S 704.24 0.00 0.00 54100 S 453.44 0.00 0.00<br />

53220 S 783.78 0.00 0.00 54105 S 566.04 0.00 0.00<br />

53230 S 783.78 0.00 0.00 54110 S 877.61 0.00 0.00<br />

53235 S 609.53 0.00 0.00 54111 S 877.61 0.00 0.00<br />

53240 S 783.78 0.00 0.00 54112 S 877.61 0.00 0.00<br />

53250 S 580.25 0.00 0.00 54115 S 519.54 0.00 0.00<br />

53260 S 580.25 0.00 0.00 54120 S 877.61 0.00 0.00<br />

53265 S 580.25 0.00 0.00 54150 S 584.88 0.00 0.00<br />

53270 S 580.25 0.00 0.00 54160 S 636.59 0.00 0.00<br />

53275 S 580.25 0.00 0.00 54161 S 636.59 0.00 0.00<br />

53400 S 813.07 0.00 0.00 54162 S 636.59 0.00 0.00<br />

53405 S 783.78 0.00 0.00 54163 S 636.59 0.00 0.00<br />

53410 S 783.78 0.00 0.00 54164 S 636.59 0.00 0.00<br />

53420 S 813.07 0.00 0.00 54200 S 66.68 0.00 0.00<br />

53425 S 783.78 0.00 0.00 54205 S 961.80 0.00 0.00<br />

53430 S 783.78 0.00 0.00 54220 S 95.57 0.00 0.00<br />

53431 S 783.78 0.00 0.00 54231 S 62.61 0.00 0.00<br />

53440 S 4,514.91 2,742.11 969.32 54235 S 44.34 0.00 0.00<br />

53442 S 732.08 0.00 0.00 54240 TC S 31.48 0.00 0.00<br />

53444 S 4,514.91 2,742.11 969.32 54250 TC S 11.17 0.00 0.00<br />

53445 S 7,583.91 4,318.98 1,054.07 54300 S 906.89 0.00 0.00<br />

53446 S 732.08 0.00 0.00 54304 S 906.89 0.00 0.00<br />

53447 S 7,583.91 4,318.98 1,054.07 54308 S 906.89 0.00 0.00<br />

53449 S 732.08 0.00 0.00 54312 S 906.89 0.00 0.00<br />

53450 S 732.08 0.00 0.00 54316 S 906.89 0.00 0.00<br />

53460 S 528.54 0.00 0.00 54318 S 906.89 0.00 0.00<br />

53502 S 580.25 0.00 0.00 54322 S 906.89 0.00 0.00<br />

53505 S 783.78 0.00 0.00 54324 S 906.89 0.00 0.00<br />

53510 S 580.25 0.00 0.00 54326 S 906.89 0.00 0.00<br />

53515 S 783.78 0.00 0.00 54328 S 906.89 0.00 0.00<br />

53520 S 783.78 0.00 0.00 54340 S 906.89 0.00 0.00<br />

53600 S 39.60 0.00 0.00 54344 S 906.89 0.00 0.00<br />

53601 S 39.53 0.00 0.00 54348 S 906.89 0.00 0.00<br />

53605 S 559.98 0.00 0.00 54352 S 906.89 0.00 0.00<br />

53620 S 60.92 0.00 0.00 54360 S 906.89 0.00 0.00<br />

53621 S 63.97 0.00 0.00 54380 S 906.89 0.00 0.00<br />

53660 S 39.53 0.00 0.00 54385 S 906.89 0.00 0.00<br />

53661 S 39.53 0.00 0.00 54400 S 4,544.20 2,771.40 998.60<br />

53665 S 528.54 0.00 0.00 54401 S 7,664.89 4,399.97 1,135.06<br />

53850 S 1,735.15 0.00 0.00 54405 S 7,664.89 4,399.97 1,135.06<br />

53852 S 1,735.15 0.00 0.00 54406 S 906.89 0.00 0.00<br />

54000 S 580.25 0.00 0.00 54408 S 906.89 0.00 0.00<br />

54001 S 580.25 0.00 0.00 54410 S 7,664.89 4,399.97 1,135.06<br />

54015 S 655.43 0.00 0.00 54415 S 906.89 0.00 0.00<br />

54050 S 31.36 0.00 0.00 54416 S 7,664.89 4,399.97 1,135.06<br />

54055 S 63.97 0.00 0.00 54420 S 961.80 0.00 0.00<br />

54056 S 31.36 0.00 0.00 54435 S 961.80 0.00 0.00<br />

54057 S 536.02 0.00 0.00 54440 S 961.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 150.46 0.00 0.00 55706 S 437.40 0.00 0.00<br />

54500 S 408.37 0.00 0.00 55720 S 636.95 0.00 0.00<br />

54505 S 584.88 0.00 0.00 55725 S 688.66 0.00 0.00<br />

54512 S 636.59 0.00 0.00 55860 S 758.87 0.00 0.00<br />

54520 S 665.87 0.00 0.00 55870 S 77.17 0.00 0.00<br />

54522 S 665.87 0.00 0.00 55873 S 6,004.46 0.00 0.00<br />

54530 S 887.91 0.00 0.00 55875 S 1,291.92 0.00 0.00<br />

54550 S 887.91 0.00 0.00 55876 S 70.74 0.00 0.00<br />

54560 S 865.04 0.00 0.00 55920 S 886.78 0.00 0.00<br />

54600 S 720.78 0.00 0.00 56405 S 41.29 0.00 0.00<br />

54620 S 665.87 0.00 0.00 56420 S 53.90 0.00 0.00<br />

54640 S 887.91 0.00 0.00 56440 S 578.75 0.00 0.00<br />

54660 S 636.59 0.00 0.00 56441 S 527.04 0.00 0.00<br />

54670 S 665.87 0.00 0.00 56442 S 527.04 0.00 0.00<br />

54680 S 665.87 0.00 0.00 56501 S 56.86 0.00 0.00<br />

54690 S 1,489.97 0.00 0.00 56515 S 617.01 0.00 0.00<br />

54692 S 2,648.56 0.00 0.00 56605 S 32.83 0.00 0.00<br />

54700 S 636.59 0.00 0.00 56606 S 13.54 0.00 0.00<br />

54800 S 142.89 0.00 0.00 56620 S 702.74 0.00 0.00<br />

54830 S 665.87 0.00 0.00 56625 S 829.94 0.00 0.00<br />

54840 S 720.78 0.00 0.00 56700 S 527.04 0.00 0.00<br />

54860 S 665.87 0.00 0.00 56740 S 608.03 0.00 0.00<br />

54861 S 720.78 0.00 0.00 56800 S 608.03 0.00 0.00<br />

54865 S 584.88 0.00 0.00 56805 S 749.37 0.00 0.00<br />

54900 S 720.78 0.00 0.00 56810 S 702.74 0.00 0.00<br />

54901 S 720.78 0.00 0.00 56820 S 41.97 0.00 0.00<br />

55000 S 64.99 0.00 0.00 56821 S 53.90 0.00 0.00<br />

55040 S 833.02 0.00 0.00 57000 S 527.04 0.00 0.00<br />

55041 S 927.72 0.00 0.00 57010 S 578.75 0.00 0.00<br />

55060 S 720.78 0.00 0.00 57020 S 303.52 0.00 0.00<br />

55100 S 390.90 0.00 0.00 57022 S 477.09 0.00 0.00<br />

55110 S 636.59 0.00 0.00 57023 S 519.54 0.00 0.00<br />

55120 S 636.59 0.00 0.00 57061 S 52.46 0.00 0.00<br />

55150 S 584.88 0.00 0.00 57065 S 527.04 0.00 0.00<br />

55175 S 584.88 0.00 0.00 57100 S 33.51 0.00 0.00<br />

55180 S 636.59 0.00 0.00 57105 S 578.75 0.00 0.00<br />

55200 S 636.59 0.00 0.00 57130 S 578.75 0.00 0.00<br />

55250 S 636.59 0.00 0.00 57135 S 578.75 0.00 0.00<br />

55400 S 584.88 0.00 0.00 57150 S 24.37 0.00 0.00<br />

55450 S 209.17 0.00 0.00 57155 S 303.52 0.00 0.00<br />

55500 S 665.87 0.00 0.00 57160 S 35.20 0.00 0.00<br />

55520 S 720.78 0.00 0.00 57170 S 5.77 0.00 0.00<br />

55530 S 720.78 0.00 0.00 57180 S 108.41 0.00 0.00<br />

55535 S 887.91 0.00 0.00 57200 S 527.04 0.00 0.00<br />

55540 S 927.72 0.00 0.00 57210 S 578.75 0.00 0.00<br />

55550 S 1,489.97 0.00 0.00 57220 S 1,061.35 0.00 0.00<br />

55600 S 865.04 0.00 0.00 57230 S 871.46 0.00 0.00<br />

55680 S 584.88 0.00 0.00 57240 S 966.17 0.00 0.00<br />

55700 S 376.93 0.00 0.00 57250 S 966.17 0.00 0.00<br />

55705 S 376.93 0.00 0.00 57260 S 966.17 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,283.26 0.00 0.00 58555 S 569.44 0.00 0.00<br />

57267 S 1,093.37 0.00 0.00 58558 S 650.43 0.00 0.00<br />

57268 S 871.46 0.00 0.00 58559 S 621.15 0.00 0.00<br />

57287 S 1,276.24 0.00 0.00 58560 S 927.42 0.00 0.00<br />

57288 S 1,156.06 0.00 0.00 58561 S 927.42 0.00 0.00<br />

57289 S 966.17 0.00 0.00 58562 S 650.43 0.00 0.00<br />

57291 S 966.17 0.00 0.00 58563 S 1,306.72 0.00 0.00<br />

57300 S 871.46 0.00 0.00 58565 S 1,440.65 0.00 0.00<br />

57320 S 1,276.24 0.00 0.00 58600 S 1,276.24 0.00 0.00<br />

57400 S 578.75 0.00 0.00 58615 S 749.37 0.00 0.00<br />

57410 S 578.75 0.00 0.00 58660 S 1,205.38 0.00 0.00<br />

57415 S 578.75 0.00 0.00 58661 S 1,205.38 0.00 0.00<br />

57420 S 43.33 0.00 0.00 58662 S 1,205.38 0.00 0.00<br />

57421 S 56.52 0.00 0.00 58670 S 1,110.67 0.00 0.00<br />

57452 S 40.95 0.00 0.00 58671 S 1,110.67 0.00 0.00<br />

57454 S 50.09 0.00 0.00 58672 S 1,205.38 0.00 0.00<br />

57455 S 53.14 0.00 0.00 58673 S 1,205.38 0.00 0.00<br />

57456 S 51.45 0.00 0.00 58800 S 608.03 0.00 0.00<br />

57460 S 158.06 0.00 0.00 58805 S 1,276.24 0.00 0.00<br />

57461 S 167.88 0.00 0.00 58820 S 871.46 0.00 0.00<br />

57500 S 72.43 0.00 0.00 58900 S 608.03 0.00 0.00<br />

57505 S 46.03 0.00 0.00 58970 S 169.36 0.00 0.00<br />

57510 S 46.71 0.00 0.00 58974 S 169.36 0.00 0.00<br />

57511 S 53.90 0.00 0.00 58976 S 169.36 0.00 0.00<br />

57513 S 578.75 0.00 0.00 59000 S 61.94 0.00 0.00<br />

57520 S 578.75 0.00 0.00 59001 S 232.49 0.00 0.00<br />

57522 S 578.75 0.00 0.00 59012 S 113.68 0.00 0.00<br />

57530 S 871.46 0.00 0.00 59015 S 50.09 0.00 0.00<br />

57550 S 871.46 0.00 0.00 59020 TC S 26.40 0.00 0.00<br />

57556 S 1,156.06 0.00 0.00 59025 TC S 13.88 0.00 0.00<br />

57558 S 608.03 0.00 0.00 59070 S 113.68 0.00 0.00<br />

57700 S 527.04 0.00 0.00 59072 S 113.68 0.00 0.00<br />

57720 S 608.03 0.00 0.00 59076 S 113.68 0.00 0.00<br />

57800 S 24.71 0.00 0.00 59100 S 1,276.24 0.00 0.00<br />

58100 S 40.62 0.00 0.00 59150 S 1,754.65 0.00 0.00<br />

58120 S 578.75 0.00 0.00 59151 S 1,754.65 0.00 0.00<br />

58145 S 966.17 0.00 0.00 59160 S 608.03 0.00 0.00<br />

58301 S 37.90 0.00 0.00 59200 S 33.85 0.00 0.00<br />

58321 S 35.54 0.00 0.00 59300 S 73.11 0.00 0.00<br />

58322 S 36.55 0.00 0.00 59320 S 527.04 0.00 0.00<br />

58323 S 8.46 0.00 0.00 59412 S 749.37 0.00 0.00<br />

58345 S 749.37 0.00 0.00 59414 S 749.37 0.00 0.00<br />

58346 S 578.75 0.00 0.00 59812 S 702.74 0.00 0.00<br />

58350 S 871.46 0.00 0.00 59820 S 702.74 0.00 0.00<br />

58353 S 1,093.37 0.00 0.00 59821 S 702.74 0.00 0.00<br />

58356 S 1,656.01 0.00 0.00 59840 S 702.74 0.00 0.00<br />

58545 S 1,330.22 0.00 0.00 59841 S 702.74 0.00 0.00<br />

58546 S 1,489.97 0.00 0.00 59866 S 113.68 0.00 0.00<br />

58550 S 1,936.92 0.00 0.00 59870 S 702.74 0.00 0.00<br />

58552 S 1,754.65 0.00 0.00 59871 S 702.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 295.03 0.00 0.00 62367 S 16.24 0.00 0.00<br />

60100 S 46.37 0.00 0.00 62368 S 20.65 0.00 0.00<br />

60200 S 1,098.11 0.00 0.00 63600 S 554.64 0.00 0.00<br />

60280 S 1,182.30 0.00 0.00 63610 S 502.93 0.00 0.00<br />

60281 S 1,182.30 0.00 0.00 63615 S 701.15 0.00 0.00<br />

60300 S 60.92 0.00 0.00 63650 S 2,985.35 1,851.21 717.09<br />

61000 S 271.66 0.00 0.00 63655 S 4,372.81 2,788.55 1,204.29<br />

61001 S 271.66 0.00 0.00 63660 S 524.28 0.00 0.00<br />

61020 S 219.94 0.00 0.00 63685 S 13,272.49 7,077.01 881.54<br />

61026 S 219.94 0.00 0.00 63688 S 711.94 0.00 0.00<br />

61050 S 219.94 0.00 0.00 63744 S 1,029.56 0.00 0.00<br />

61055 S 219.94 0.00 0.00 63746 S 476.25 0.00 0.00<br />

61070 S 171.15 0.00 0.00 64400 S 52.12 0.00 0.00<br />

61215 S 1,029.56 0.00 0.00 64402 S 49.08 0.00 0.00<br />

61330 S 1,586.10 0.00 0.00 64405 S 41.63 0.00 0.00<br />

61334 S 1,586.10 0.00 0.00 64408 S 51.78 0.00 0.00<br />

61790 S 583.92 0.00 0.00 64410 S 288.19 0.00 0.00<br />

61791 S 433.21 0.00 0.00 64412 S 76.16 0.00 0.00<br />

61880 S 743.84 0.00 0.00 64413 S 48.74 0.00 0.00<br />

61885 S 10,704.04 5,734.05 764.07 64415 S 132.72 0.00 0.00<br />

61886 S 15,983.74 8,424.35 864.98 64416 S 271.66 0.00 0.00<br />

61888 S 711.94 0.00 0.00 64417 S 132.72 0.00 0.00<br />

62194 S 288.19 0.00 0.00 64418 S 68.37 0.00 0.00<br />

62225 S 447.80 0.00 0.00 64420 S 132.72 0.00 0.00<br />

62230 S 1,000.28 0.00 0.00 64421 S 288.19 0.00 0.00<br />

62252 TC S 45.36 0.00 0.00 64425 S 47.38 0.00 0.00<br />

62263 S 288.19 0.00 0.00 64430 S 199.43 0.00 0.00<br />

62264 S 424.55 0.00 0.00 64435 S 71.42 0.00 0.00<br />

62267 S 169.42 0.00 0.00 64445 S 63.29 0.00 0.00<br />

62268 S 219.94 0.00 0.00 64446 S 544.38 0.00 0.00<br />

62269 S 333.77 0.00 0.00 64447 S 138.25 0.00 0.00<br />

62270 S 132.72 0.00 0.00 64448 S 138.25 0.00 0.00<br />

62272 S 132.72 0.00 0.00 64449 S 271.66 0.00 0.00<br />

62273 S 221.48 0.00 0.00 64450 S 42.31 0.00 0.00<br />

62280 S 288.19 0.00 0.00 64455 S 17.60 0.00 0.00<br />

62281 S 288.19 0.00 0.00 64470 S 288.19 0.00 0.00<br />

62282 S 288.19 0.00 0.00 64472 S 221.48 0.00 0.00<br />

62287 S 1,293.70 0.00 0.00 64475 S 288.19 0.00 0.00<br />

62292 S 271.66 0.00 0.00 64476 S 199.47 0.00 0.00<br />

62294 S 219.94 0.00 0.00 64479 S 288.19 0.00 0.00<br />

62310 S 288.19 0.00 0.00 64480 S 221.48 0.00 0.00<br />

62311 S 288.19 0.00 0.00 64483 S 288.19 0.00 0.00<br />

62318 S 288.19 0.00 0.00 64484 S 221.48 0.00 0.00<br />

62319 S 288.19 0.00 0.00 64505 S 38.59 0.00 0.00<br />

62350 S 1,000.28 0.00 0.00 64508 S 81.91 0.00 0.00<br />

62355 S 476.25 0.00 0.00 64510 S 288.19 0.00 0.00<br />

62360 S 1,000.28 0.00 0.00 64517 S 199.43 0.00 0.00<br />

62361 S 10,267.96 5,557.68 847.41 64520 S 288.19 0.00 0.00<br />

62362 S 10,267.96 5,557.68 847.41 64530 S 288.19 0.00 0.00<br />

62365 S 885.12 0.00 0.00 64553 S 2,933.64 1,799.51 665.38<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,294.31 2,160.17 1,026.04 64746 S 554.64 0.00 0.00<br />

64560 S 3,294.31 2,160.17 1,026.04 64761 S 701.15 0.00 0.00<br />

64561 S 3,014.63 1,880.49 746.37 64763 S 701.15 0.00 0.00<br />

64565 S 3,294.31 2,160.17 1,026.04 64766 S 1,362.10 0.00 0.00<br />

64573 S 5,132.04 3,040.23 948.43 64771 S 554.64 0.00 0.00<br />

64575 S 3,923.02 2,338.76 754.50 64772 S 554.64 0.00 0.00<br />

64577 S 3,923.02 2,338.76 754.50 64774 S 554.64 0.00 0.00<br />

64580 S 3,923.02 2,338.76 754.50 64776 S 583.92 0.00 0.00<br />

64581 S 4,004.01 2,419.75 835.49 64778 S 554.64 0.00 0.00<br />

64585 S 524.28 0.00 0.00 64782 S 583.92 0.00 0.00<br />

64590 S 10,704.04 5,734.05 764.07 64783 S 554.64 0.00 0.00<br />

64595 S 711.94 0.00 0.00 64784 S 583.92 0.00 0.00<br />

64600 S 424.55 0.00 0.00 64786 S 914.40 0.00 0.00<br />

64605 S 424.55 0.00 0.00 64787 S 554.64 0.00 0.00<br />

64610 S 424.55 0.00 0.00 64788 S 583.92 0.00 0.00<br />

64612 S 61.94 0.00 0.00 64790 S 583.92 0.00 0.00<br />

64613 S 59.91 0.00 0.00 64792 S 914.40 0.00 0.00<br />

64614 S 68.37 0.00 0.00 64795 S 554.64 0.00 0.00<br />

64620 S 288.19 0.00 0.00 64802 S 554.64 0.00 0.00<br />

64622 S 424.55 0.00 0.00 64820 S 701.15 0.00 0.00<br />

64623 S 288.19 0.00 0.00 64821 S 818.53 0.00 0.00<br />

64626 S 424.55 0.00 0.00 64822 S 1,060.56 0.00 0.00<br />

64627 S 199.47 0.00 0.00 64823 S 1,060.56 0.00 0.00<br />

64630 S 296.85 0.00 0.00 64831 S 969.31 0.00 0.00<br />

64632 S 32.15 0.00 0.00 64832 S 833.41 0.00 0.00<br />

64640 S 95.79 0.00 0.00 64834 S 885.12 0.00 0.00<br />

64650 S 32.15 0.00 0.00 64835 S 914.40 0.00 0.00<br />

64653 S 34.86 0.00 0.00 64836 S 914.40 0.00 0.00<br />

64680 S 451.07 0.00 0.00 64837 S 833.41 0.00 0.00<br />

64681 S 476.25 0.00 0.00 64840 S 885.12 0.00 0.00<br />

64702 S 502.93 0.00 0.00 64856 S 885.12 0.00 0.00<br />

64704 S 502.93 0.00 0.00 64857 S 885.12 0.00 0.00<br />

64708 S 554.64 0.00 0.00 64858 S 885.12 0.00 0.00<br />

64712 S 554.64 0.00 0.00 64859 S 833.41 0.00 0.00<br />

64713 S 554.64 0.00 0.00 64861 S 914.40 0.00 0.00<br />

64714 S 554.64 0.00 0.00 64862 S 914.40 0.00 0.00<br />

64716 S 583.92 0.00 0.00 64864 S 914.40 0.00 0.00<br />

64718 S 554.64 0.00 0.00 64865 S 969.31 0.00 0.00<br />

64719 S 554.64 0.00 0.00 64870 S 969.31 0.00 0.00<br />

64721 S 554.64 0.00 0.00 64872 S 885.12 0.00 0.00<br />

64722 S 502.93 0.00 0.00 64874 S 914.40 0.00 0.00<br />

64726 S 502.93 0.00 0.00 64876 S 914.40 0.00 0.00<br />

64727 S 502.93 0.00 0.00 64885 S 885.12 0.00 0.00<br />

64732 S 554.64 0.00 0.00 64886 S 885.12 0.00 0.00<br />

64734 S 554.64 0.00 0.00 64890 S 885.12 0.00 0.00<br />

64736 S 554.64 0.00 0.00 64891 S 885.12 0.00 0.00<br />

64738 S 554.64 0.00 0.00 64892 S 885.12 0.00 0.00<br />

64740 S 554.64 0.00 0.00 64893 S 885.12 0.00 0.00<br />

64742 S 554.64 0.00 0.00 64895 S 914.40 0.00 0.00<br />

64744 S 554.64 0.00 0.00 64896 S 914.40 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 914.40 0.00 0.00 65770 S 5,380.92 0.00 0.00<br />

64898 S 914.40 0.00 0.00 65772 S 605.31 0.00 0.00<br />

64901 S 885.12 0.00 0.00 65775 S 605.31 0.00 0.00<br />

64902 S 885.12 0.00 0.00 65780 S 1,047.10 0.00 0.00<br />

64905 S 885.12 0.00 0.00 65781 S 1,047.10 0.00 0.00<br />

64907 S 833.41 0.00 0.00 65782 S 1,047.10 0.00 0.00<br />

64910 S 1,362.10 0.00 0.00 65800 S 469.42 0.00 0.00<br />

65091 S 962.81 0.00 0.00 65805 S 469.42 0.00 0.00<br />

65093 S 962.81 0.00 0.00 65810 S 685.92 0.00 0.00<br />

65101 S 962.81 0.00 0.00 65815 S 656.63 0.00 0.00<br />

65103 S 962.81 0.00 0.00 65820 S 240.83 0.00 0.00<br />

65105 S 1,017.72 0.00 0.00 65850 S 740.82 0.00 0.00<br />

65110 S 1,057.52 0.00 0.00 65855 S 127.94 0.00 0.00<br />

65112 S 1,184.72 0.00 0.00 65860 S 119.48 0.00 0.00<br />

65114 S 1,184.72 0.00 0.00 65865 S 469.42 0.00 0.00<br />

65125 S 985.97 0.00 0.00 65870 S 740.82 0.00 0.00<br />

65130 S 726.33 0.00 0.00 65875 S 740.82 0.00 0.00<br />

65135 S 697.05 0.00 0.00 65880 S 605.31 0.00 0.00<br />

65140 S 962.81 0.00 0.00 65900 S 645.12 0.00 0.00<br />

65150 S 697.05 0.00 0.00 65920 S 907.83 0.00 0.00<br />

65155 S 962.81 0.00 0.00 65930 S 780.63 0.00 0.00<br />

65175 S 518.15 0.00 0.00 66020 S 469.42 0.00 0.00<br />

65205 S 19.97 0.00 0.00 66030 S 240.83 0.00 0.00<br />

65210 S 25.39 0.00 0.00 66130 S 907.83 0.00 0.00<br />

65220 S 35.37 0.00 0.00 66150 S 740.82 0.00 0.00<br />

65222 S 27.75 0.00 0.00 66155 S 740.82 0.00 0.00<br />

65235 S 521.12 0.00 0.00 66160 S 656.63 0.00 0.00<br />

65260 S 343.72 0.00 0.00 66165 S 740.82 0.00 0.00<br />

65265 S 711.10 0.00 0.00 66170 S 740.82 0.00 0.00<br />

65270 S 569.85 0.00 0.00 66172 S 740.82 0.00 0.00<br />

65272 S 656.63 0.00 0.00 66180 S 1,103.67 0.00 0.00<br />

65275 S 740.82 0.00 0.00 66185 S 979.69 0.00 0.00<br />

65280 S 711.10 0.00 0.00 66220 S 956.35 0.00 0.00<br />

65285 S 1,011.25 0.00 0.00 66225 S 1,063.87 0.00 0.00<br />

65286 S 176.92 0.00 0.00 66250 S 521.12 0.00 0.00<br />

65290 S 700.30 0.00 0.00 66500 S 240.83 0.00 0.00<br />

65400 S 469.42 0.00 0.00 66505 S 240.83 0.00 0.00<br />

65410 S 521.12 0.00 0.00 66600 S 685.92 0.00 0.00<br />

65420 S 521.12 0.00 0.00 66605 S 685.92 0.00 0.00<br />

65426 S 780.63 0.00 0.00 66625 S 487.69 0.00 0.00<br />

65430 S 35.37 0.00 0.00 66630 S 685.92 0.00 0.00<br />

65435 S 30.80 0.00 0.00 66635 S 685.92 0.00 0.00<br />

65436 S 133.69 0.00 0.00 66680 S 685.92 0.00 0.00<br />

65450 S 81.62 0.00 0.00 66682 S 656.63 0.00 0.00<br />

65600 S 157.73 0.00 0.00 66700 S 521.12 0.00 0.00<br />

65710 S 1,174.30 0.00 0.00 66710 S 521.12 0.00 0.00<br />

65730 S 1,174.30 0.00 0.00 66711 S 521.12 0.00 0.00<br />

65750 S 1,174.30 0.00 0.00 66720 S 521.12 0.00 0.00<br />

65755 S 1,174.30 0.00 0.00 66740 S 656.63 0.00 0.00<br />

65756 S 1,438.09 0.00 0.00 66761 S 178.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 181.08 0.00 0.00 67228 S 199.42 0.00 0.00<br />

66770 S 199.42 0.00 0.00 67229 S 199.42 0.00 0.00<br />

66820 S 176.92 0.00 0.00 67250 S 599.13 0.00 0.00<br />

66821 S 242.68 0.00 0.00 67255 S 656.20 0.00 0.00<br />

66825 S 740.82 0.00 0.00 67311 S 700.30 0.00 0.00<br />

66830 S 259.10 0.00 0.00 67312 S 755.21 0.00 0.00<br />

66840 S 556.96 0.00 0.00 67314 S 755.21 0.00 0.00<br />

66850 S 1,048.62 0.00 0.00 67316 S 755.21 0.00 0.00<br />

66852 S 881.62 0.00 0.00 67318 S 755.21 0.00 0.00<br />

66920 S 881.62 0.00 0.00 67320 S 755.21 0.00 0.00<br />

66930 S 921.43 0.00 0.00 67331 S 755.21 0.00 0.00<br />

66940 S 596.77 0.00 0.00 67332 S 755.21 0.00 0.00<br />

66982 S 905.32 0.00 0.00 67334 S 755.21 0.00 0.00<br />

66983 S 905.32 0.00 0.00 67335 S 755.21 0.00 0.00<br />

66984 S 905.32 0.00 0.00 67340 S 755.21 0.00 0.00<br />

66985 S 838.06 0.00 0.00 67343 S 922.21 0.00 0.00<br />

66986 S 838.06 0.00 0.00 67345 S 78.87 0.00 0.00<br />

67005 S 711.10 0.00 0.00 67346 S 426.56 0.00 0.00<br />

67010 S 711.10 0.00 0.00 67400 S 599.13 0.00 0.00<br />

67015 S 875.36 0.00 0.00 67405 S 781.24 0.00 0.00<br />

67025 S 575.21 0.00 0.00 67412 S 693.84 0.00 0.00<br />

67027 S 1,011.25 0.00 0.00 67413 S 821.04 0.00 0.00<br />

67028 S 79.54 0.00 0.00 67414 S 1,458.93 0.00 0.00<br />

67030 S 575.21 0.00 0.00 67415 S 518.15 0.00 0.00<br />

67031 S 242.68 0.00 0.00 67420 S 1,057.52 0.00 0.00<br />

67036 S 1,011.25 0.00 0.00 67430 S 1,057.52 0.00 0.00<br />

67039 S 1,178.25 0.00 0.00 67440 S 1,057.52 0.00 0.00<br />

67040 S 1,178.25 0.00 0.00 67445 S 1,057.52 0.00 0.00<br />

67041 S 1,445.99 0.00 0.00 67450 S 1,057.52 0.00 0.00<br />

67042 S 1,445.99 0.00 0.00 67500 S 81.62 0.00 0.00<br />

67043 S 1,445.99 0.00 0.00 67505 S 25.39 0.00 0.00<br />

67101 S 220.74 0.00 0.00 67515 S 25.72 0.00 0.00<br />

67105 S 199.42 0.00 0.00 67550 S 1,017.72 0.00 0.00<br />

67107 S 1,051.05 0.00 0.00 67560 S 697.05 0.00 0.00<br />

67108 S 1,178.25 0.00 0.00 67570 S 1,017.72 0.00 0.00<br />

67110 S 320.87 0.00 0.00 67700 S 119.41 0.00 0.00<br />

67112 S 1,178.25 0.00 0.00 67710 S 139.44 0.00 0.00<br />

67113 S 1,445.99 0.00 0.00 67715 S 518.15 0.00 0.00<br />

67115 S 626.91 0.00 0.00 67800 S 50.09 0.00 0.00<br />

67120 S 626.91 0.00 0.00 67801 S 60.59 0.00 0.00<br />

67121 S 626.91 0.00 0.00 67805 S 78.52 0.00 0.00<br />

67141 S 220.99 0.00 0.00 67808 S 569.85 0.00 0.00<br />

67145 S 188.53 0.00 0.00 67810 S 119.41 0.00 0.00<br />

67208 S 201.05 0.00 0.00 67820 S 16.58 0.00 0.00<br />

67210 S 199.42 0.00 0.00 67825 S 51.11 0.00 0.00<br />

67218 S 750.91 0.00 0.00 67830 S 349.84 0.00 0.00<br />

67220 S 220.74 0.00 0.00 67835 S 569.85 0.00 0.00<br />

67221 S 113.38 0.00 0.00 67840 S 146.22 0.00 0.00<br />

67225 S 7.79 0.00 0.00 67850 S 116.10 0.00 0.00<br />

67227 S 575.21 0.00 0.00 67875 S 291.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 550.41 0.00 0.00 68440 S 49.76 0.00 0.00<br />

67882 S 599.13 0.00 0.00 68500 S 726.33 0.00 0.00<br />

67900 S 781.24 0.00 0.00 68505 S 726.33 0.00 0.00<br />

67901 S 693.84 0.00 0.00 68510 S 518.15 0.00 0.00<br />

67902 S 821.04 0.00 0.00 68520 S 726.33 0.00 0.00<br />

67903 S 654.03 0.00 0.00 68525 S 518.15 0.00 0.00<br />

67904 S 654.03 0.00 0.00 68530 S 119.41 0.00 0.00<br />

67906 S 693.84 0.00 0.00 68540 S 599.13 0.00 0.00<br />

67908 S 654.03 0.00 0.00 68550 S 726.33 0.00 0.00<br />

67909 S 654.03 0.00 0.00 68700 S 569.85 0.00 0.00<br />

67911 S 599.13 0.00 0.00 68705 S 113.38 0.00 0.00<br />

67912 S 599.13 0.00 0.00 68720 S 781.24 0.00 0.00<br />

67914 S 599.13 0.00 0.00 68745 S 781.24 0.00 0.00<br />

67915 S 161.79 0.00 0.00 68750 S 781.24 0.00 0.00<br />

67916 S 654.03 0.00 0.00 68760 S 96.46 0.00 0.00<br />

67917 S 654.03 0.00 0.00 68761 S 66.68 0.00 0.00<br />

67921 S 599.13 0.00 0.00 68770 S 781.24 0.00 0.00<br />

67922 S 157.39 0.00 0.00 68801 S 35.37 0.00 0.00<br />

67923 S 654.03 0.00 0.00 68810 S 101.15 0.00 0.00<br />

67924 S 654.03 0.00 0.00 68811 S 569.85 0.00 0.00<br />

67930 S 161.79 0.00 0.00 68815 S 569.85 0.00 0.00<br />

67935 S 569.85 0.00 0.00 68816 S 731.57 0.00 0.00<br />

67938 S 81.62 0.00 0.00 68840 S 52.46 0.00 0.00<br />

67950 S 569.85 0.00 0.00 69000 S 53.51 0.00 0.00<br />

67961 S 599.13 0.00 0.00 69005 S 101.20 0.00 0.00<br />

67966 S 599.13 0.00 0.00 69020 S 53.51 0.00 0.00<br />

67971 S 599.13 0.00 0.00 69100 S 60.92 0.00 0.00<br />

67973 S 726.33 0.00 0.00 69105 S 86.31 0.00 0.00<br />

67974 S 599.13 0.00 0.00 69110 S 453.44 0.00 0.00<br />

67975 S 599.13 0.00 0.00 69120 S 672.91 0.00 0.00<br />

68020 S 44.34 0.00 0.00 69140 S 672.91 0.00 0.00<br />

68040 S 22.00 0.00 0.00 69145 S 505.14 0.00 0.00<br />

68100 S 88.00 0.00 0.00 69150 S 355.03 0.00 0.00<br />

68110 S 113.38 0.00 0.00 69200 S 24.47 0.00 0.00<br />

68115 S 569.85 0.00 0.00 69205 S 566.04 0.00 0.00<br />

68130 S 521.12 0.00 0.00 69210 S 19.97 0.00 0.00<br />

68135 S 56.86 0.00 0.00 69220 S 31.36 0.00 0.00<br />

68200 S 16.24 0.00 0.00 69222 S 132.00 0.00 0.00<br />

68320 S 781.24 0.00 0.00 69300 S 702.20 0.00 0.00<br />

68325 S 781.24 0.00 0.00 69310 S 1,026.40 0.00 0.00<br />

68326 S 654.03 0.00 0.00 69320 S 1,248.31 0.00 0.00<br />

68328 S 781.24 0.00 0.00 69400 S 88.67 0.00 0.00<br />

68330 S 740.82 0.00 0.00 69401 S 46.71 0.00 0.00<br />

68335 S 781.24 0.00 0.00 69405 S 122.52 0.00 0.00<br />

68340 S 654.03 0.00 0.00 69420 S 110.01 0.00 0.00<br />

68360 S 656.63 0.00 0.00 69421 S 559.86 0.00 0.00<br />

68362 S 656.63 0.00 0.00 69424 S 77.17 0.00 0.00<br />

68371 S 521.12 0.00 0.00 69433 S 109.67 0.00 0.00<br />

68400 S 119.41 0.00 0.00 69436 S 559.86 0.00 0.00<br />

68420 S 169.91 0.00 0.00 69440 S 702.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 945.41 0.00 0.00 69840 S 1,121.11 0.00 0.00<br />

69501 S 1,248.31 0.00 0.00 69905 S 1,248.31 0.00 0.00<br />

69502 S 924.10 0.00 0.00 69910 S 1,248.31 0.00 0.00<br />

69505 S 1,248.31 0.00 0.00 69915 S 1,248.31 0.00 0.00<br />

69511 S 1,248.31 0.00 0.00 69930 S 22,567.70 12,117.32 1,666.96<br />

69530 S 1,248.31 0.00 0.00 70030 TC A 17.26 0.00 0.00<br />

69540 S 128.95 0.00 0.00 70100 TC A 18.96 0.00 0.00<br />

69550 S 1,121.11 0.00 0.00 70110 TC A 23.36 0.00 0.00<br />

69552 S 1,248.31 0.00 0.00 70120 TC A 20.98 0.00 0.00<br />

69601 S 1,248.31 0.00 0.00 70130 TC A 25.64 0.00 0.00<br />

69602 S 1,248.31 0.00 0.00 70134 TC A 25.72 0.00 0.00<br />

69603 S 1,248.31 0.00 0.00 70140 TC A 17.60 0.00 0.00<br />

69604 S 1,248.31 0.00 0.00 70150 TC A 25.64 0.00 0.00<br />

69605 S 1,248.31 0.00 0.00 70160 TC A 20.65 0.00 0.00<br />

69610 S 172.62 0.00 0.00 70190 TC A 21.66 0.00 0.00<br />

69620 S 672.91 0.00 0.00 70200 TC A 25.64 0.00 0.00<br />

69631 S 1,121.11 0.00 0.00 70210 TC A 18.28 0.00 0.00<br />

69632 S 1,121.11 0.00 0.00 70220 TC A 23.02 0.00 0.00<br />

69633 S 1,121.11 0.00 0.00 70240 TC A 17.26 0.00 0.00<br />

69635 S 1,248.31 0.00 0.00 70250 TC A 20.98 0.00 0.00<br />

69636 S 1,248.31 0.00 0.00 70260 TC A 26.74 0.00 0.00<br />

69637 S 1,248.31 0.00 0.00 70300 TC A 7.44 0.00 0.00<br />

69641 S 1,248.31 0.00 0.00 70310 TC A 18.39 0.00 0.00<br />

69642 S 1,248.31 0.00 0.00 70320 TC A 18.39 0.00 0.00<br />

69643 S 1,248.31 0.00 0.00 70328 TC A 18.28 0.00 0.00<br />

69644 S 1,248.31 0.00 0.00 70330 TC A 25.64 0.00 0.00<br />

69645 S 1,248.31 0.00 0.00 70336 TC A 199.57 0.00 0.00<br />

69646 S 1,248.31 0.00 0.00 70350 TC A 10.15 0.00 0.00<br />

69650 S 924.10 0.00 0.00 70355 TC A 10.49 0.00 0.00<br />

69660 S 1,121.11 0.00 0.00 70360 TC A 16.24 0.00 0.00<br />

69661 S 1,121.11 0.00 0.00 70370 TC A 47.71 0.00 0.00<br />

69662 S 1,121.11 0.00 0.00 70371 TC A 47.71 0.00 0.00<br />

69666 S 1,081.30 0.00 0.00 70380 TC A 24.71 0.00 0.00<br />

69667 S 1,081.30 0.00 0.00 70450 TC A 111.46 0.00 0.00<br />

69670 S 1,026.40 0.00 0.00 70460 TC A 176.49 0.00 0.00<br />

69676 S 1,026.40 0.00 0.00 70470 TC A 195.51 0.00 0.00<br />

69700 S 1,026.40 0.00 0.00 70480 TC A 111.46 0.00 0.00<br />

69711 S 945.41 0.00 0.00 70481 TC A 176.49 0.00 0.00<br />

69714 S 5,995.64 3,780.48 1,565.32 70482 TC A 195.51 0.00 0.00<br />

69715 S 5,995.64 3,780.48 1,565.32 70486 TC A 111.46 0.00 0.00<br />

69717 S 5,995.64 3,780.48 1,565.32 70487 TC A 176.49 0.00 0.00<br />

69718 S 5,995.64 3,780.48 1,565.32 70488 TC A 195.51 0.00 0.00<br />

69720 S 1,121.11 0.00 0.00 70490 TC A 111.46 0.00 0.00<br />

69740 S 1,121.11 0.00 0.00 70491 TC A 176.49 0.00 0.00<br />

69745 S 1,121.11 0.00 0.00 70492 TC A 195.51 0.00 0.00<br />

69801 S 1,121.11 0.00 0.00 70496 TC A 201.76 0.00 0.00<br />

69802 S 1,248.31 0.00 0.00 70498 TC A 201.76 0.00 0.00<br />

69805 S 1,248.31 0.00 0.00 70540 TC A 199.57 0.00 0.00<br />

69806 S 1,248.31 0.00 0.00 70542 TC A 245.08 0.00 0.00<br />

69820 S 1,121.11 0.00 0.00 70543 TC A 308.88 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 199.57 0.00 0.00 72120 TC A 32.49 0.00 0.00<br />

70545 TC A 245.08 0.00 0.00 72125 TC A 111.46 0.00 0.00<br />

70546 TC A 308.88 0.00 0.00 72126 TC A 176.49 0.00 0.00<br />

70547 TC A 199.57 0.00 0.00 72127 TC A 195.51 0.00 0.00<br />

70548 TC A 245.08 0.00 0.00 72128 TC A 111.46 0.00 0.00<br />

70549 TC A 308.88 0.00 0.00 72129 TC A 176.49 0.00 0.00<br />

70551 TC A 199.57 0.00 0.00 72130 TC A 195.51 0.00 0.00<br />

70552 TC A 245.08 0.00 0.00 72131 TC A 111.46 0.00 0.00<br />

70553 TC A 308.88 0.00 0.00 72132 TC A 176.49 0.00 0.00<br />

70554 TC A 199.57 0.00 0.00 72133 TC A 195.51 0.00 0.00<br />

70555 TC A 199.57 0.00 0.00 72141 TC A 199.57 0.00 0.00<br />

70557 TC A 199.57 0.00 0.00 72142 TC A 245.08 0.00 0.00<br />

70558 TC A 245.08 0.00 0.00 72146 TC A 199.57 0.00 0.00<br />

70559 TC A 308.88 0.00 0.00 72147 TC A 245.08 0.00 0.00<br />

71010 TC A 13.20 0.00 0.00 72148 TC A 199.57 0.00 0.00<br />

71015 TC A 16.92 0.00 0.00 72149 TC A 245.08 0.00 0.00<br />

71020 TC A 17.94 0.00 0.00 72156 TC A 308.88 0.00 0.00<br />

71021 TC A 21.66 0.00 0.00 72157 TC A 308.88 0.00 0.00<br />

71022 TC A 25.64 0.00 0.00 72158 TC A 308.88 0.00 0.00<br />

71023 TC A 41.97 0.00 0.00 72170 TC A 15.23 0.00 0.00<br />

71030 TC A 25.64 0.00 0.00 72190 TC A 25.64 0.00 0.00<br />

71034 TC A 47.71 0.00 0.00 72191 TC A 201.76 0.00 0.00<br />

71035 TC A 22.34 0.00 0.00 72192 TC A 111.46 0.00 0.00<br />

71100 TC A 18.62 0.00 0.00 72193 TC A 176.49 0.00 0.00<br />

71101 TC A 22.67 0.00 0.00 72194 TC A 195.51 0.00 0.00<br />

71110 TC A 23.70 0.00 0.00 72195 TC A 199.57 0.00 0.00<br />

71111 TC A 31.48 0.00 0.00 72196 TC A 245.08 0.00 0.00<br />

71120 TC A 19.63 0.00 0.00 72197 TC A 308.88 0.00 0.00<br />

71130 TC A 23.02 0.00 0.00 72200 TC A 17.94 0.00 0.00<br />

71250 TC A 111.46 0.00 0.00 72202 TC A 22.00 0.00 0.00<br />

71260 TC A 176.49 0.00 0.00 72220 TC A 17.94 0.00 0.00<br />

71270 TC A 195.51 0.00 0.00 73000 TC A 16.92 0.00 0.00<br />

71275 TC A 201.76 0.00 0.00 73010 TC A 17.26 0.00 0.00<br />

71550 TC A 199.57 0.00 0.00 73020 TC A 13.88 0.00 0.00<br />

71551 TC A 245.08 0.00 0.00 73030 TC A 17.60 0.00 0.00<br />

71552 TC A 308.88 0.00 0.00 73050 TC A 22.00 0.00 0.00<br />

72010 TC A 42.68 0.00 0.00 73060 TC A 17.60 0.00 0.00<br />

72020 TC A 13.88 0.00 0.00 73070 TC A 16.92 0.00 0.00<br />

72040 TC A 22.34 0.00 0.00 73080 TC A 22.34 0.00 0.00<br />

72050 TC A 31.81 0.00 0.00 73090 TC A 16.92 0.00 0.00<br />

72052 TC A 42.68 0.00 0.00 73092 TC A 17.60 0.00 0.00<br />

72069 TC A 20.98 0.00 0.00 73100 TC A 17.60 0.00 0.00<br />

72070 TC A 19.63 0.00 0.00 73110 TC A 22.34 0.00 0.00<br />

72072 TC A 23.70 0.00 0.00 73120 TC A 16.58 0.00 0.00<br />

72074 TC A 25.64 0.00 0.00 73130 TC A 19.63 0.00 0.00<br />

72080 TC A 20.98 0.00 0.00 73140 TC A 19.29 0.00 0.00<br />

72090 TC A 28.10 0.00 0.00 73200 TC A 111.46 0.00 0.00<br />

72100 TC A 24.03 0.00 0.00 73201 TC A 176.49 0.00 0.00<br />

72110 TC A 33.51 0.00 0.00 73202 TC A 195.51 0.00 0.00<br />

72114 TC A 42.68 0.00 0.00 73206 TC A 201.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 199.57 0.00 0.00 74246 TC A 50.37 0.00 0.00<br />

73219 TC A 245.08 0.00 0.00 74247 TC A 50.37 0.00 0.00<br />

73220 TC A 308.88 0.00 0.00 74249 TC A 81.90 0.00 0.00<br />

73221 TC A 199.57 0.00 0.00 74250 TC A 50.37 0.00 0.00<br />

73222 TC A 245.08 0.00 0.00 74251 TC A 81.90 0.00 0.00<br />

73223 TC A 308.88 0.00 0.00 74260 TC A 50.37 0.00 0.00<br />

73500 TC A 14.56 0.00 0.00 74270 TC A 50.37 0.00 0.00<br />

73510 TC A 22.34 0.00 0.00 74280 TC A 81.90 0.00 0.00<br />

73520 TC A 23.02 0.00 0.00 74283 TC A 50.37 0.00 0.00<br />

73540 TC A 23.02 0.00 0.00 74290 TC A 42.98 0.00 0.00<br />

73550 TC A 16.92 0.00 0.00 74291 TC A 41.29 0.00 0.00<br />

73560 TC A 17.26 0.00 0.00 74400 TC A 74.80 0.00 0.00<br />

73562 TC A 21.32 0.00 0.00 74410 TC A 79.88 0.00 0.00<br />

73564 TC A 24.71 0.00 0.00 74415 TC A 95.45 0.00 0.00<br />

73565 TC A 18.62 0.00 0.00 74420 TC A 99.77 0.00 0.00<br />

73590 TC A 16.24 0.00 0.00 74710 TC A 22.34 0.00 0.00<br />

73592 TC A 17.60 0.00 0.00 74775 TC A 99.77 0.00 0.00<br />

73600 TC A 16.58 0.00 0.00 75557 TC A 199.57 0.00 0.00<br />

73610 TC A 19.63 0.00 0.00 75559 TC A 199.57 0.00 0.00<br />

73620 TC A 15.91 0.00 0.00 75561 TC A 308.88 0.00 0.00<br />

73630 TC A 19.29 0.00 0.00 75563 TC A 308.88 0.00 0.00<br />

73650 TC A 16.24 0.00 0.00 76010 TC A 16.58 0.00 0.00<br />

73660 TC A 18.28 0.00 0.00 76098 TC A 10.15 0.00 0.00<br />

73700 TC A 111.46 0.00 0.00 76100 TC A 42.68 0.00 0.00<br />

73701 TC A 176.49 0.00 0.00 76101 TC A 114.40 0.00 0.00<br />

73702 TC A 195.51 0.00 0.00 76102 TC A 114.40 0.00 0.00<br />

73706 TC A 201.76 0.00 0.00 76120 TC A 47.71 0.00 0.00<br />

73718 TC A 199.57 0.00 0.00 76150 A 16.58 0.00 0.00<br />

73719 TC A 245.08 0.00 0.00 76380 TC A 60.21 0.00 0.00<br />

73720 TC A 308.88 0.00 0.00 76496 TC A 47.71 0.00 0.00<br />

73721 TC A 199.57 0.00 0.00 76497 TC A 60.21 0.00 0.00<br />

73722 TC A 245.08 0.00 0.00 76498 TC A 199.57 0.00 0.00<br />

73723 TC A 308.88 0.00 0.00 76499 TC A 25.64 0.00 0.00<br />

74000 TC A 14.56 0.00 0.00 76506 TC A 35.84 0.00 0.00<br />

74010 TC A 22.67 0.00 0.00 76510 TC A 60.92 0.00 0.00<br />

74020 TC A 23.02 0.00 0.00 76511 TC A 42.64 0.00 0.00<br />

74022 TC A 28.10 0.00 0.00 76512 TC A 36.21 0.00 0.00<br />

74150 TC A 111.46 0.00 0.00 76513 TC A 44.00 0.00 0.00<br />

74160 TC A 176.49 0.00 0.00 76514 TC A 3.05 0.00 0.00<br />

74170 TC A 195.51 0.00 0.00 76516 TC A 34.53 0.00 0.00<br />

74175 TC A 201.76 0.00 0.00 76519 TC A 38.59 0.00 0.00<br />

74181 TC A 199.57 0.00 0.00 76529 TC A 33.51 0.00 0.00<br />

74182 TC A 245.08 0.00 0.00 76536 TC A 56.06 0.00 0.00<br />

74183 TC A 308.88 0.00 0.00 76604 TC A 35.84 0.00 0.00<br />

74210 TC A 50.37 0.00 0.00 76645 TC A 35.84 0.00 0.00<br />

74220 TC A 50.37 0.00 0.00 76700 TC A 56.06 0.00 0.00<br />

74230 TC A 50.37 0.00 0.00 76705 TC A 56.06 0.00 0.00<br />

74240 TC A 50.37 0.00 0.00 76770 TC A 56.06 0.00 0.00<br />

74241 TC A 50.37 0.00 0.00 76775 TC A 56.06 0.00 0.00<br />

74245 TC A 81.90 0.00 0.00 76776 TC A 56.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 56.06 0.00 0.00 77290 TC A 146.61 0.00 0.00<br />

76801 TC A 56.06 0.00 0.00 77295 TC A 384.16 0.00 0.00<br />

76802 TC A 26.74 0.00 0.00 77299 TC A 65.78 0.00 0.00<br />

76805 TC A 56.06 0.00 0.00 77300 TC A 35.54 0.00 0.00<br />

76810 TC A 42.31 0.00 0.00 77301 TC A 511.98 0.00 0.00<br />

76811 TC A 87.83 0.00 0.00 77305 TC A 32.49 0.00 0.00<br />

76812 TC A 35.84 0.00 0.00 77310 TC A 42.31 0.00 0.00<br />

76813 TC A 35.84 0.00 0.00 77315 TC A 61.60 0.00 0.00<br />

76814 TC A 28.44 0.00 0.00 77321 TC A 63.97 0.00 0.00<br />

76815 TC A 35.84 0.00 0.00 77326 TC A 65.78 0.00 0.00<br />

76816 TC A 35.84 0.00 0.00 77327 TC A 119.48 0.00 0.00<br />

76817 TC A 35.84 0.00 0.00 77328 TC A 146.61 0.00 0.00<br />

76818 TC A 56.06 0.00 0.00 77331 TC A 16.92 0.00 0.00<br />

76819 TC A 48.41 0.00 0.00 77332 TC A 45.36 0.00 0.00<br />

76820 TC A 24.03 0.00 0.00 77333 TC A 22.00 0.00 0.00<br />

76821 TC A 54.27 0.00 0.00 77334 TC A 84.96 0.00 0.00<br />

76825 TC A 113.05 0.00 0.00 77336 A 53.48 0.00 0.00<br />

76826 TC A 67.35 0.00 0.00 77370 A 65.78 0.00 0.00<br />

76827 TC A 35.84 0.00 0.00 77371 A 4,381.72 0.00 0.00<br />

76828 TC A 21.32 0.00 0.00 77399 TC A 65.78 0.00 0.00<br />

76830 TC A 56.06 0.00 0.00 77401 A 26.74 0.00 0.00<br />

76831 TC A 75.48 0.00 0.00 77402 A 53.83 0.00 0.00<br />

76856 TC A 56.06 0.00 0.00 77403 A 53.83 0.00 0.00<br />

76857 TC A 35.84 0.00 0.00 77404 A 53.83 0.00 0.00<br />

76870 TC A 56.06 0.00 0.00 77406 A 87.19 0.00 0.00<br />

76872 TC A 56.06 0.00 0.00 77407 A 53.83 0.00 0.00<br />

76873 TC A 56.06 0.00 0.00 77408 A 53.83 0.00 0.00<br />

76880 TC A 56.06 0.00 0.00 77409 A 53.83 0.00 0.00<br />

76885 TC A 35.84 0.00 0.00 77411 A 87.19 0.00 0.00<br />

76886 TC A 35.84 0.00 0.00 77412 A 87.19 0.00 0.00<br />

76936 TC A 54.27 0.00 0.00 77413 A 87.19 0.00 0.00<br />

76970 TC A 35.84 0.00 0.00 77414 A 87.19 0.00 0.00<br />

76977 TC A 9.14 0.00 0.00 77416 A 87.19 0.00 0.00<br />

76999 TC A 35.84 0.00 0.00 77418 A 235.57 0.00 0.00<br />

77071 A 20.98 0.00 0.00 77422 A 87.19 0.00 0.00<br />

77072 TC A 12.18 0.00 0.00 77423 A 87.19 0.00 0.00<br />

77073 TC A 20.65 0.00 0.00 77470 TC A 125.24 0.00 0.00<br />

77074 TC A 40.62 0.00 0.00 77520 A 403.32 0.00 0.00<br />

77075 TC A 42.68 0.00 0.00 77522 A 403.32 0.00 0.00<br />

77076 TC A 42.68 0.00 0.00 77523 A 481.98 0.00 0.00<br />

77077 TC A 23.02 0.00 0.00 77525 A 481.98 0.00 0.00<br />

77078 TC A 41.24 0.00 0.00 77600 TC A 213.99 0.00 0.00<br />

77079 TC A 42.31 0.00 0.00 77605 TC A 213.99 0.00 0.00<br />

77080 TC A 41.24 0.00 0.00 77610 TC A 213.99 0.00 0.00<br />

77081 TC A 16.58 0.00 0.00 77615 TC A 213.99 0.00 0.00<br />

77082 TC A 17.94 0.00 0.00 77620 TC A 213.99 0.00 0.00<br />

77083 TC A 14.22 0.00 0.00 77750 TC A 83.26 0.00 0.00<br />

77084 TC A 199.57 0.00 0.00 77761 TC A 146.56 0.00 0.00<br />

77280 TC A 65.78 0.00 0.00 77762 TC A 173.63 0.00 0.00<br />

77285 TC A 146.61 0.00 0.00 77763 TC A 223.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 158.74 0.00 0.00 78262 TC A 139.41 0.00 0.00<br />

77777 TC A 174.31 0.00 0.00 78264 TC A 139.41 0.00 0.00<br />

77778 TC A 232.19 0.00 0.00 78270 TC A 60.92 0.00 0.00<br />

77785 TC A 103.23 0.00 0.00 78271 TC A 61.94 0.00 0.00<br />

77786 TC A 362.83 0.00 0.00 78272 TC A 68.03 0.00 0.00<br />

77787 TC A 420.44 0.00 0.00 78278 TC A 139.41 0.00 0.00<br />

77789 TC A 43.33 0.00 0.00 78282 TC A 139.41 0.00 0.00<br />

77799 TC A 246.94 0.00 0.00 78290 TC A 139.41 0.00 0.00<br />

78000 TC A 53.14 0.00 0.00 78291 TC A 139.41 0.00 0.00<br />

78001 TC A 67.34 0.00 0.00 78299 TC A 139.41 0.00 0.00<br />

78003 TC A 53.48 0.00 0.00 78300 TC A 121.51 0.00 0.00<br />

78006 TC A 127.24 0.00 0.00 78305 TC A 140.93 0.00 0.00<br />

78007 TC A 94.10 0.00 0.00 78306 TC A 140.93 0.00 0.00<br />

78010 TC A 78.18 0.00 0.00 78315 TC A 140.93 0.00 0.00<br />

78011 TC A 78.18 0.00 0.00 78320 TC A 140.93 0.00 0.00<br />

78015 TC A 151.97 0.00 0.00 78399 TC A 140.93 0.00 0.00<br />

78016 TC A 171.54 0.00 0.00 78414 TC A 179.13 0.00 0.00<br />

78018 TC A 171.54 0.00 0.00 78428 TC A 137.42 0.00 0.00<br />

78070 TC A 116.77 0.00 0.00 78445 TC A 107.19 0.00 0.00<br />

78075 TC A 330.68 0.00 0.00 78456 TC A 107.19 0.00 0.00<br />

78099 TC A 78.18 0.00 0.00 78457 TC A 107.19 0.00 0.00<br />

78102 TC A 118.12 0.00 0.00 78458 TC A 107.19 0.00 0.00<br />

78103 TC A 150.57 0.00 0.00 78459 TC A 663.34 0.00 0.00<br />

78104 TC A 150.57 0.00 0.00 78460 TC A 128.61 0.00 0.00<br />

78110 TC A 59.91 0.00 0.00 78461 TC A 129.64 0.00 0.00<br />

78111 TC A 75.82 0.00 0.00 78464 TC A 190.21 0.00 0.00<br />

78120 TC A 66.34 0.00 0.00 78465 TC A 360.13 0.00 0.00<br />

78121 TC A 78.52 0.00 0.00 78466 TC A 127.60 0.00 0.00<br />

78122 TC A 93.08 0.00 0.00 78468 TC A 163.14 0.00 0.00<br />

78130 TC A 107.97 0.00 0.00 78469 TC A 179.13 0.00 0.00<br />

78135 TC A 229.47 0.00 0.00 78472 TC A 179.13 0.00 0.00<br />

78140 TC A 101.88 0.00 0.00 78473 TC A 179.13 0.00 0.00<br />

78185 TC A 150.57 0.00 0.00 78481 TC A 154.68 0.00 0.00<br />

78190 TC A 94.48 0.00 0.00 78483 TC A 179.13 0.00 0.00<br />

78191 TC A 94.48 0.00 0.00 78491 TC A 663.34 0.00 0.00<br />

78195 TC A 150.57 0.00 0.00 78492 TC A 663.34 0.00 0.00<br />

78199 TC A 150.57 0.00 0.00 78494 TC A 179.13 0.00 0.00<br />

78201 TC A 134.03 0.00 0.00 78499 TC A 179.13 0.00 0.00<br />

78202 TC A 157.67 0.00 0.00 78580 TC A 121.36 0.00 0.00<br />

78205 TC A 157.67 0.00 0.00 78584 TC A 93.75 0.00 0.00<br />

78206 TC A 157.67 0.00 0.00 78585 TC A 186.22 0.00 0.00<br />

78215 TC A 141.82 0.00 0.00 78586 TC A 121.36 0.00 0.00<br />

78216 TC A 96.13 0.00 0.00 78587 TC A 121.36 0.00 0.00<br />

78220 TC A 104.93 0.00 0.00 78588 TC A 186.22 0.00 0.00<br />

78223 TC A 157.67 0.00 0.00 78591 TC A 121.36 0.00 0.00<br />

78230 TC A 119.14 0.00 0.00 78593 TC A 121.36 0.00 0.00<br />

78231 TC A 93.75 0.00 0.00 78594 TC A 121.36 0.00 0.00<br />

78232 TC A 97.81 0.00 0.00 78596 TC A 186.22 0.00 0.00<br />

78258 TC A 139.41 0.00 0.00 78599 TC A 121.36 0.00 0.00<br />

78261 TC A 139.41 0.00 0.00 78600 TC A 106.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 23020 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 106.96 0.00 0.00<br />

78605 TC A 106.96 0.00 0.00<br />

78606 TC A 240.31 0.00 0.00<br />

78607 TC A 264.00 0.00 0.00<br />

78608 TC A 594.56 0.00 0.00<br />

78610 TC A 142.49 0.00 0.00<br />

78630 TC A 253.85 0.00 0.00<br />

78635 TC A 233.88 0.00 0.00<br />

78645 TC A 106.96 0.00 0.00<br />

78647 TC A 258.93 0.00 0.00<br />

78650 TC A 250.80 0.00 0.00<br />

78660 TC A 106.96 0.00 0.00<br />

78699 TC A 106.96 0.00 0.00<br />

78700 TC A 131.66 0.00 0.00<br />

78701 TC A 160.44 0.00 0.00<br />

78707 TC A 167.54 0.00 0.00<br />

78708 TC A 114.74 0.00 0.00<br />

78709 TC A 188.65 0.00 0.00<br />

78710 TC A 177.02 0.00 0.00<br />

78725 TC A 70.74 0.00 0.00<br />

78730 TC A 59.91 0.00 0.00<br />

78740 TC A 156.37 0.00 0.00<br />

78761 TC A 149.26 0.00 0.00<br />

78799 TC A 188.65 0.00 0.00<br />

78800 TC A 132.00 0.00 0.00<br />

78801 TC A 181.08 0.00 0.00<br />

78802 TC A 245.39 0.00 0.00<br />

78803 TC A 262.99 0.00 0.00<br />

78804 TC A 458.96 0.00 0.00<br />

78805 TC A 128.95 0.00 0.00<br />

78806 TC A 257.91 0.00 0.00<br />

78807 TC A 263.33 0.00 0.00<br />

78811 TC A 594.56 0.00 0.00<br />

78812 TC A 594.56 0.00 0.00<br />

78813 TC A 594.56 0.00 0.00<br />

78814 TC A 594.56 0.00 0.00<br />

78815 TC A 594.56 0.00 0.00<br />

78816 TC A 594.56 0.00 0.00<br />

78999 TC A 67.34 0.00 0.00<br />

79005 TC A 54.16 0.00 0.00<br />

79101 TC A 59.23 0.00 0.00<br />

79200 TC A 63.97 0.00 0.00<br />

79300 TC A 123.42 0.00 0.00<br />

79403 TC A 91.72 0.00 0.00<br />

79440 TC A 51.78 0.00 0.00<br />

79445 TC A 123.42 0.00 0.00<br />

79999 TC A 123.42 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,243.85 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,522.06 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.57 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,572.73 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,572.73 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 227.13 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 227.13 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 114.68 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 242.38 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 72.86 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 652.46 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,487.83 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,164.60 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,164.60 0.00 0.00<br />

C8900 A 252.17 0.00 0.00 0123T S 931.33 0.00 0.00<br />

C8901 A 205.34 0.00 0.00 0124T S 182.03 0.00 0.00<br />

C8902 A 317.82 0.00 0.00 0144T TC A 61.95 0.00 0.00<br />

C8903 A 252.17 0.00 0.00 0145T TC A 166.78 0.00 0.00<br />

C8904 A 205.34 0.00 0.00 0146T TC A 166.78 0.00 0.00<br />

C8905 A 317.82 0.00 0.00 0147T TC A 166.78 0.00 0.00<br />

C8906 A 252.17 0.00 0.00 0148T TC A 166.78 0.00 0.00<br />

C8907 A 205.34 0.00 0.00 0149T TC A 166.78 0.00 0.00<br />

C8908 A 317.82 0.00 0.00 0150T TC A 166.78 0.00 0.00<br />

C8909 A 252.17 0.00 0.00 0151T TC A 61.95 0.00 0.00<br />

C8910 A 205.34 0.00 0.00 0170T S 1,209.74 0.00 0.00<br />

C8911 A 317.82 0.00 0.00 0176T S 1,428.43 0.00 0.00<br />

C8912 A 252.17 0.00 0.00 0177T S 1,428.43 0.00 0.00<br />

C8913 A 205.34 0.00 0.00 0182T A 1,032.48 0.00 0.00<br />

C8914 A 317.82 0.00 0.00 0186T S 870.17 0.00 0.00<br />

C8918 A 252.17 0.00 0.00 0190T S 870.17 0.00 0.00<br />

C8919 A 205.34 0.00 0.00 0191T S 931.33 0.00 0.00<br />

C8920 A 317.82 0.00 0.00 0192T S 1,596.12 0.00 0.00<br />

C9716 S 1,209.74 0.00 0.00 10021 S 55.82 0.00 0.00<br />

C9724 S 989.10 0.00 0.00 10022 S 174.32 0.00 0.00<br />

C9725 S 228.08 0.00 0.00 10040 S 32.27 0.00 0.00<br />

C9726 S 837.36 0.00 0.00 10060 S 49.10 0.00 0.00<br />

C9727 S 293.59 0.00 0.00 10061 S 55.06 0.00 0.00<br />

C9728 S 526.79 0.00 0.00 10080 S 55.06 0.00 0.00<br />

G0104 S 84.63 0.00 0.00 10081 S 126.76 0.00 0.00<br />

G0105 S 365.75 0.00 0.00 10120 S 68.95 0.00 0.00<br />

G0121 S 365.75 0.00 0.00 10121 S 519.75 0.00 0.00<br />

G0127 S 11.84 0.00 0.00 10140 S 73.13 0.00 0.00<br />

G0130 TC A 19.51 0.00 0.00 10160 S 55.06 0.00 0.00<br />

G0173 A 2,243.85 0.00 0.00 10180 S 587.77 0.00 0.00<br />

G0186 S 227.13 0.00 0.00 11000 S 23.69 0.00 0.00<br />

G0247 S 21.59 0.00 0.00 11001 S 8.01 0.00 0.00<br />

G0251 A 561.89 0.00 0.00 11010 S 205.63 0.00 0.00<br />

G0260 S 296.53 0.00 0.00 11011 S 205.63 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 205.63 0.00 0.00 11601 S 113.54 0.00 0.00<br />

11040 S 21.59 0.00 0.00 11602 S 125.03 0.00 0.00<br />

11041 S 24.03 0.00 0.00 11603 S 132.68 0.00 0.00<br />

11042 S 130.58 0.00 0.00 11604 S 357.91 0.00 0.00<br />

11043 S 130.58 0.00 0.00 11606 S 519.75 0.00 0.00<br />

11044 S 340.01 0.00 0.00 11620 S 96.82 0.00 0.00<br />

11055 S 25.42 0.00 0.00 11621 S 114.93 0.00 0.00<br />

11056 S 27.86 0.00 0.00 11622 S 127.81 0.00 0.00<br />

11057 S 32.27 0.00 0.00 11623 S 137.56 0.00 0.00<br />

11100 S 59.12 0.00 0.00 11624 S 519.75 0.00 0.00<br />

11101 S 13.93 0.00 0.00 11626 S 635.62 0.00 0.00<br />

11200 S 32.27 0.00 0.00 11640 S 102.39 0.00 0.00<br />

11201 S 5.57 0.00 0.00 11641 S 120.84 0.00 0.00<br />

11300 S 32.27 0.00 0.00 11642 S 134.78 0.00 0.00<br />

11301 S 32.27 0.00 0.00 11643 S 145.23 0.00 0.00<br />

11302 S 32.27 0.00 0.00 11644 S 519.75 0.00 0.00<br />

11303 S 59.12 0.00 0.00 11646 S 635.62 0.00 0.00<br />

11305 S 32.27 0.00 0.00 11719 S 11.84 0.00 0.00<br />

11306 S 32.27 0.00 0.00 11720 S 14.63 0.00 0.00<br />

11307 S 32.27 0.00 0.00 11721 S 17.76 0.00 0.00<br />

11308 S 32.27 0.00 0.00 11730 S 32.27 0.00 0.00<br />

11310 S 32.27 0.00 0.00 11732 S 17.76 0.00 0.00<br />

11311 S 32.27 0.00 0.00 11740 S 16.30 0.00 0.00<br />

11312 S 32.27 0.00 0.00 11750 S 94.03 0.00 0.00<br />

11313 S 32.27 0.00 0.00 11752 S 130.60 0.00 0.00<br />

11400 S 66.52 0.00 0.00 11755 S 65.12 0.00 0.00<br />

11401 S 74.87 0.00 0.00 11760 S 134.12 0.00 0.00<br />

11402 S 82.19 0.00 0.00 11762 S 119.80 0.00 0.00<br />

11403 S 87.76 0.00 0.00 11765 S 32.27 0.00 0.00<br />

11404 S 466.56 0.00 0.00 11770 S 665.75 0.00 0.00<br />

11406 S 519.75 0.00 0.00 11771 S 665.75 0.00 0.00<br />

11420 S 62.34 0.00 0.00 11772 S 665.75 0.00 0.00<br />

11421 S 75.57 0.00 0.00 11900 S 29.61 0.00 0.00<br />

11422 S 82.54 0.00 0.00 11901 S 32.27 0.00 0.00<br />

11423 S 91.94 0.00 0.00 11920 S 93.68 0.00 0.00<br />

11424 S 519.75 0.00 0.00 11921 S 103.09 0.00 0.00<br />

11426 S 635.62 0.00 0.00 11922 S 33.43 0.00 0.00<br />

11440 S 71.40 0.00 0.00 11950 S 34.13 0.00 0.00<br />

11441 S 82.54 0.00 0.00 11951 S 42.49 0.00 0.00<br />

11442 S 90.89 0.00 0.00 11952 S 51.15 0.00 0.00<br />

11443 S 100.64 0.00 0.00 11954 S 51.15 0.00 0.00<br />

11444 S 317.66 0.00 0.00 11960 S 620.48 0.00 0.00<br />

11446 S 635.62 0.00 0.00 11970 S 1,123.89 0.00 0.00<br />

11450 S 635.62 0.00 0.00 11971 S 582.42 0.00 0.00<br />

11451 S 635.62 0.00 0.00 11976 S 62.34 0.00 0.00<br />

11462 S 635.62 0.00 0.00 11980 S 25.18 0.00 0.00<br />

11463 S 635.62 0.00 0.00 11981 S 25.18 0.00 0.00<br />

11470 S 635.62 0.00 0.00 11982 S 25.18 0.00 0.00<br />

11471 S 635.62 0.00 0.00 11983 S 25.18 0.00 0.00<br />

11600 S 93.68 0.00 0.00 12001 S 51.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 51.15 0.00 0.00 14021 S 551.40 0.00 0.00<br />

12004 S 51.15 0.00 0.00 14040 S 521.27 0.00 0.00<br />

12005 S 68.53 0.00 0.00 14041 S 551.40 0.00 0.00<br />

12006 S 68.53 0.00 0.00 14060 S 551.40 0.00 0.00<br />

12007 S 68.53 0.00 0.00 14061 S 551.40 0.00 0.00<br />

12011 S 51.15 0.00 0.00 14300 S 707.10 0.00 0.00<br />

12013 S 51.15 0.00 0.00 14350 S 650.60 0.00 0.00<br />

12014 S 51.15 0.00 0.00 15002 S 238.53 0.00 0.00<br />

12015 S 51.15 0.00 0.00 15003 S 238.53 0.00 0.00<br />

12016 S 68.53 0.00 0.00 15004 S 238.53 0.00 0.00<br />

12017 S 68.53 0.00 0.00 15005 S 238.53 0.00 0.00<br />

12018 S 68.53 0.00 0.00 15040 S 110.01 0.00 0.00<br />

12020 S 129.29 0.00 0.00 15050 S 238.53 0.00 0.00<br />

12021 S 110.01 0.00 0.00 15100 S 620.48 0.00 0.00<br />

12031 S 51.15 0.00 0.00 15101 S 650.60 0.00 0.00<br />

12032 S 134.12 0.00 0.00 15110 S 296.30 0.00 0.00<br />

12034 S 68.53 0.00 0.00 15111 S 243.11 0.00 0.00<br />

12035 S 68.53 0.00 0.00 15115 S 296.30 0.00 0.00<br />

12036 S 110.01 0.00 0.00 15116 S 243.11 0.00 0.00<br />

12037 S 219.26 0.00 0.00 15120 S 620.48 0.00 0.00<br />

12041 S 51.15 0.00 0.00 15121 S 650.60 0.00 0.00<br />

12042 S 51.15 0.00 0.00 15130 S 521.27 0.00 0.00<br />

12044 S 68.53 0.00 0.00 15131 S 468.06 0.00 0.00<br />

12045 S 110.01 0.00 0.00 15135 S 521.27 0.00 0.00<br />

12046 S 110.01 0.00 0.00 15136 S 468.06 0.00 0.00<br />

12047 S 219.26 0.00 0.00 15150 S 296.30 0.00 0.00<br />

12051 S 51.15 0.00 0.00 15151 S 243.11 0.00 0.00<br />

12052 S 51.15 0.00 0.00 15152 S 243.11 0.00 0.00<br />

12053 S 51.15 0.00 0.00 15155 S 296.30 0.00 0.00<br />

12054 S 68.53 0.00 0.00 15156 S 243.11 0.00 0.00<br />

12055 S 110.01 0.00 0.00 15157 S 243.11 0.00 0.00<br />

12056 S 110.01 0.00 0.00 15170 S 134.12 0.00 0.00<br />

12057 S 219.26 0.00 0.00 15171 S 134.12 0.00 0.00<br />

13100 S 238.53 0.00 0.00 15175 S 172.68 0.00 0.00<br />

13101 S 238.53 0.00 0.00 15176 S 172.68 0.00 0.00<br />

13102 S 129.29 0.00 0.00 15200 S 551.40 0.00 0.00<br />

13120 S 110.01 0.00 0.00 15201 S 463.50 0.00 0.00<br />

13121 S 110.01 0.00 0.00 15220 S 521.27 0.00 0.00<br />

13122 S 110.01 0.00 0.00 15221 S 238.53 0.00 0.00<br />

13131 S 110.01 0.00 0.00 15240 S 551.40 0.00 0.00<br />

13132 S 110.01 0.00 0.00 15241 S 238.53 0.00 0.00<br />

13133 S 110.01 0.00 0.00 15260 S 521.27 0.00 0.00<br />

13150 S 238.53 0.00 0.00 15261 S 463.50 0.00 0.00<br />

13151 S 238.53 0.00 0.00 15300 S 238.53 0.00 0.00<br />

13152 S 238.53 0.00 0.00 15301 S 238.53 0.00 0.00<br />

13153 S 110.01 0.00 0.00 15320 S 238.53 0.00 0.00<br />

13160 S 620.48 0.00 0.00 15321 S 238.53 0.00 0.00<br />

14000 S 521.27 0.00 0.00 15330 S 238.53 0.00 0.00<br />

14001 S 551.40 0.00 0.00 15331 S 238.53 0.00 0.00<br />

14020 S 551.40 0.00 0.00 15335 S 238.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 238.53 0.00 0.00 15826 S 650.60 0.00 0.00<br />

15340 S 134.12 0.00 0.00 15828 S 650.60 0.00 0.00<br />

15341 S 134.12 0.00 0.00 15829 S 748.05 0.00 0.00<br />

15360 S 134.12 0.00 0.00 15830 S 665.75 0.00 0.00<br />

15361 S 134.12 0.00 0.00 15832 S 665.75 0.00 0.00<br />

15365 S 134.12 0.00 0.00 15833 S 665.75 0.00 0.00<br />

15366 S 134.12 0.00 0.00 15834 S 665.75 0.00 0.00<br />

15400 S 238.53 0.00 0.00 15835 S 577.84 0.00 0.00<br />

15401 S 238.53 0.00 0.00 15836 S 549.89 0.00 0.00<br />

15420 S 238.53 0.00 0.00 15837 S 619.59 0.00 0.00<br />

15421 S 238.53 0.00 0.00 15838 S 619.59 0.00 0.00<br />

15430 S 238.53 0.00 0.00 15839 S 549.89 0.00 0.00<br />

15431 S 238.53 0.00 0.00 15840 S 707.10 0.00 0.00<br />

15570 S 650.60 0.00 0.00 15841 S 707.10 0.00 0.00<br />

15572 S 650.60 0.00 0.00 15842 S 821.01 0.00 0.00<br />

15574 S 650.60 0.00 0.00 15845 S 707.10 0.00 0.00<br />

15576 S 650.60 0.00 0.00 15847 S 665.75 0.00 0.00<br />

15600 S 650.60 0.00 0.00 15850 S 106.35 0.00 0.00<br />

15610 S 650.60 0.00 0.00 15851 S 48.41 0.00 0.00<br />

15620 S 707.10 0.00 0.00 15852 S 25.18 0.00 0.00<br />

15630 S 650.60 0.00 0.00 15860 S 25.18 0.00 0.00<br />

15650 S 748.05 0.00 0.00 15876 S 650.60 0.00 0.00<br />

15731 S 650.60 0.00 0.00 15877 S 650.60 0.00 0.00<br />

15732 S 650.60 0.00 0.00 15878 S 650.60 0.00 0.00<br />

15734 S 650.60 0.00 0.00 15879 S 650.60 0.00 0.00<br />

15736 S 650.60 0.00 0.00 15920 S 205.63 0.00 0.00<br />

15738 S 650.60 0.00 0.00 15922 S 707.10 0.00 0.00<br />

15740 S 521.27 0.00 0.00 15931 S 665.75 0.00 0.00<br />

15750 S 620.48 0.00 0.00 15933 S 665.75 0.00 0.00<br />

15760 S 620.48 0.00 0.00 15934 S 650.60 0.00 0.00<br />

15770 S 650.60 0.00 0.00 15935 S 707.10 0.00 0.00<br />

15775 S 177.77 0.00 0.00 15936 S 607.89 0.00 0.00<br />

15776 S 177.77 0.00 0.00 15937 S 707.10 0.00 0.00<br />

15780 S 396.32 0.00 0.00 15940 S 665.75 0.00 0.00<br />

15781 S 174.45 0.00 0.00 15941 S 665.75 0.00 0.00<br />

15782 S 174.45 0.00 0.00 15944 S 650.60 0.00 0.00<br />

15783 S 106.35 0.00 0.00 15945 S 707.10 0.00 0.00<br />

15786 S 32.27 0.00 0.00 15946 S 707.10 0.00 0.00<br />

15787 S 29.26 0.00 0.00 15950 S 665.75 0.00 0.00<br />

15788 S 32.27 0.00 0.00 15951 S 722.24 0.00 0.00<br />

15789 S 59.12 0.00 0.00 15952 S 551.40 0.00 0.00<br />

15792 S 59.12 0.00 0.00 15953 S 607.89 0.00 0.00<br />

15793 S 32.27 0.00 0.00 15956 S 551.40 0.00 0.00<br />

15819 S 134.12 0.00 0.00 15958 S 607.89 0.00 0.00<br />

15820 S 650.60 0.00 0.00 16000 S 26.12 0.00 0.00<br />

15821 S 650.60 0.00 0.00 16020 S 39.71 0.00 0.00<br />

15822 S 650.60 0.00 0.00 16025 S 61.15 0.00 0.00<br />

15823 S 748.05 0.00 0.00 16030 S 76.56 0.00 0.00<br />

15824 S 650.60 0.00 0.00 16035 S 59.12 0.00 0.00<br />

15825 S 650.60 0.00 0.00 17000 S 32.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.83 0.00 0.00 19300 S 715.27 0.00 0.00<br />

17004 S 84.28 0.00 0.00 19301 S 658.78 0.00 0.00<br />

17106 S 106.35 0.00 0.00 19302 S 1,258.20 0.00 0.00<br />

17107 S 106.35 0.00 0.00 19303 S 950.86 0.00 0.00<br />

17108 S 106.35 0.00 0.00 19304 S 950.86 0.00 0.00<br />

17110 S 32.27 0.00 0.00 19316 S 950.86 0.00 0.00<br />

17111 S 59.12 0.00 0.00 19318 S 1,086.36 0.00 0.00<br />

17250 S 44.58 0.00 0.00 19324 S 1,086.36 0.00 0.00<br />

17260 S 47.71 0.00 0.00 19325 S 1,801.86 0.00 0.00<br />

17261 S 59.12 0.00 0.00 19328 S 811.04 0.00 0.00<br />

17262 S 59.12 0.00 0.00 19330 S 811.04 0.00 0.00<br />

17263 S 59.12 0.00 0.00 19340 S 999.73 0.00 0.00<br />

17264 S 59.12 0.00 0.00 19342 S 1,411.58 0.00 0.00<br />

17266 S 106.35 0.00 0.00 19350 S 715.27 0.00 0.00<br />

17270 S 59.12 0.00 0.00 19355 S 950.86 0.00 0.00<br />

17271 S 59.12 0.00 0.00 19357 S 1,509.03 0.00 0.00<br />

17272 S 59.12 0.00 0.00 19366 S 991.82 0.00 0.00<br />

17273 S 106.35 0.00 0.00 19370 S 950.86 0.00 0.00<br />

17274 S 106.35 0.00 0.00 19371 S 950.86 0.00 0.00<br />

17276 S 106.35 0.00 0.00 19380 S 1,127.32 0.00 0.00<br />

17280 S 59.12 0.00 0.00 19396 S 1,308.52 0.00 0.00<br />

17281 S 88.11 0.00 0.00 20000 S 55.06 0.00 0.00<br />

17282 S 100.64 0.00 0.00 20005 S 634.41 0.00 0.00<br />

17283 S 106.35 0.00 0.00 20103 S 622.61 0.00 0.00<br />

17284 S 106.35 0.00 0.00 20150 S 1,767.60 0.00 0.00<br />

17286 S 106.35 0.00 0.00 20200 S 519.75 0.00 0.00<br />

17311 S 175.57 0.00 0.00 20205 S 549.89 0.00 0.00<br />

17312 S 175.57 0.00 0.00 20206 S 256.96 0.00 0.00<br />

17313 S 175.57 0.00 0.00 20220 S 279.31 0.00 0.00<br />

17314 S 175.57 0.00 0.00 20225 S 506.80 0.00 0.00<br />

17315 S 39.71 0.00 0.00 20240 S 635.62 0.00 0.00<br />

17340 S 14.28 0.00 0.00 20245 S 665.75 0.00 0.00<br />

17360 S 32.27 0.00 0.00 20250 S 664.55 0.00 0.00<br />

17380 S 32.27 0.00 0.00 20251 S 664.55 0.00 0.00<br />

19000 S 67.22 0.00 0.00 20500 S 55.03 0.00 0.00<br />

19001 S 9.06 0.00 0.00 20520 S 92.64 0.00 0.00<br />

19020 S 587.77 0.00 0.00 20525 S 665.75 0.00 0.00<br />

19100 S 200.15 0.00 0.00 20526 S 29.95 0.00 0.00<br />

19101 S 628.64 0.00 0.00 20550 S 22.63 0.00 0.00<br />

19102 S 256.96 0.00 0.00 20551 S 22.29 0.00 0.00<br />

19103 S 449.74 0.00 0.00 20552 S 21.59 0.00 0.00<br />

19105 S 1,308.52 0.00 0.00 20553 S 24.03 0.00 0.00<br />

19110 S 628.64 0.00 0.00 20555 S 1,164.60 0.00 0.00<br />

19112 S 658.78 0.00 0.00 20600 S 22.98 0.00 0.00<br />

19120 S 658.78 0.00 0.00 20605 S 25.77 0.00 0.00<br />

19125 S 658.78 0.00 0.00 20610 S 36.22 0.00 0.00<br />

19126 S 658.78 0.00 0.00 20612 S 24.38 0.00 0.00<br />

19296 S 1,801.86 0.00 0.00 20615 S 102.04 0.00 0.00<br />

19297 S 1,801.86 0.00 0.00 20650 S 664.55 0.00 0.00<br />

19298 S 1,801.86 0.00 0.00 20662 S 848.89 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 848.89 0.00 0.00 21085 S 255.62 0.00 0.00<br />

20665 S 25.18 0.00 0.00 21086 S 556.51 0.00 0.00<br />

20670 S 466.56 0.00 0.00 21087 S 557.22 0.00 0.00<br />

20680 S 665.75 0.00 0.00 21088 S 1,631.99 0.00 0.00<br />

20690 S 792.27 0.00 0.00 21100 S 1,025.96 0.00 0.00<br />

20692 S 822.40 0.00 0.00 21110 S 293.59 0.00 0.00<br />

20693 S 664.55 0.00 0.00 21120 S 950.84 0.00 0.00<br />

20694 S 581.21 0.00 0.00 21121 S 950.84 0.00 0.00<br />

20696 S 1,164.60 0.00 0.00 21122 S 950.84 0.00 0.00<br />

20697 S 774.51 0.00 0.00 21123 S 950.84 0.00 0.00<br />

20822 S 1,091.24 0.00 0.00 21125 S 950.84 0.00 0.00<br />

20900 S 822.40 0.00 0.00 21127 S 1,446.36 0.00 0.00<br />

20902 S 878.89 0.00 0.00 21137 S 964.83 0.00 0.00<br />

20910 S 650.60 0.00 0.00 21138 S 1,631.99 0.00 0.00<br />

20912 S 650.60 0.00 0.00 21139 S 1,631.99 0.00 0.00<br />

20920 S 607.89 0.00 0.00 21150 S 1,631.99 0.00 0.00<br />

20922 S 551.40 0.00 0.00 21181 S 950.84 0.00 0.00<br />

20924 S 878.89 0.00 0.00 21198 S 1,631.99 0.00 0.00<br />

20926 S 382.93 0.00 0.00 21199 S 1,631.99 0.00 0.00<br />

20950 S 55.06 0.00 0.00 21206 S 1,153.54 0.00 0.00<br />

20972 S 1,843.14 0.00 0.00 21208 S 1,284.42 0.00 0.00<br />

20973 S 1,843.14 0.00 0.00 21209 S 1,153.54 0.00 0.00<br />

20979 S 22.63 0.00 0.00 21210 S 1,284.42 0.00 0.00<br />

20982 S 1,767.60 0.00 0.00 21215 S 1,284.42 0.00 0.00<br />

21010 S 692.37 0.00 0.00 21230 S 1,284.42 0.00 0.00<br />

21015 S 576.06 0.00 0.00 21235 S 950.84 0.00 0.00<br />

21025 S 1,025.96 0.00 0.00 21240 S 1,112.58 0.00 0.00<br />

21026 S 1,025.96 0.00 0.00 21242 S 1,153.54 0.00 0.00<br />

21029 S 1,025.96 0.00 0.00 21243 S 1,153.54 0.00 0.00<br />

21030 S 242.04 0.00 0.00 21244 S 1,284.42 0.00 0.00<br />

21031 S 200.25 0.00 0.00 21245 S 1,284.42 0.00 0.00<br />

21032 S 204.08 0.00 0.00 21246 S 1,284.42 0.00 0.00<br />

21034 S 1,056.10 0.00 0.00 21248 S 1,284.42 0.00 0.00<br />

21040 S 692.37 0.00 0.00 21249 S 1,284.42 0.00 0.00<br />

21044 S 1,025.96 0.00 0.00 21260 S 1,631.99 0.00 0.00<br />

21046 S 1,025.96 0.00 0.00 21267 S 1,284.42 0.00 0.00<br />

21047 S 1,025.96 0.00 0.00 21270 S 1,153.54 0.00 0.00<br />

21048 S 1,631.99 0.00 0.00 21275 S 1,284.42 0.00 0.00<br />

21050 S 1,056.10 0.00 0.00 21280 S 1,153.54 0.00 0.00<br />

21060 S 1,025.96 0.00 0.00 21282 S 673.51 0.00 0.00<br />

21070 S 1,056.10 0.00 0.00 21295 S 303.57 0.00 0.00<br />

21073 S 188.06 0.00 0.00 21296 S 639.18 0.00 0.00<br />

21076 S 326.31 0.00 0.00 21310 S 92.60 0.00 0.00<br />

21077 S 788.81 0.00 0.00 21315 S 406.91 0.00 0.00<br />

21079 S 564.88 0.00 0.00 21320 S 545.92 0.00 0.00<br />

21080 S 647.76 0.00 0.00 21325 S 779.00 0.00 0.00<br />

21081 S 596.91 0.00 0.00 21330 S 819.96 0.00 0.00<br />

21082 S 568.01 0.00 0.00 21335 S 950.84 0.00 0.00<br />

21083 S 559.65 0.00 0.00 21336 S 792.42 0.00 0.00<br />

21084 S 643.93 0.00 0.00 21337 S 545.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 779.00 0.00 0.00 22310 S 168.58 0.00 0.00<br />

21339 S 819.96 0.00 0.00 22315 S 436.04 0.00 0.00<br />

21340 S 1,112.58 0.00 0.00 22505 S 513.32 0.00 0.00<br />

21345 S 950.84 0.00 0.00 22520 S 1,212.67 0.00 0.00<br />

21355 S 1,056.10 0.00 0.00 22521 S 1,212.67 0.00 0.00<br />

21356 S 722.51 0.00 0.00 22522 S 1,212.67 0.00 0.00<br />

21360 S 964.83 0.00 0.00 22523 S 3,374.97 0.00 0.00<br />

21390 S 1,631.99 0.00 0.00 22524 S 3,374.97 0.00 0.00<br />

21400 S 356.76 0.00 0.00 22525 S 3,374.97 0.00 0.00<br />

21401 S 576.06 0.00 0.00 22900 S 722.24 0.00 0.00<br />

21406 S 1,631.99 0.00 0.00 23000 S 519.75 0.00 0.00<br />

21407 S 1,631.99 0.00 0.00 23020 S 1,093.76 0.00 0.00<br />

21421 S 779.00 0.00 0.00 23030 S 534.57 0.00 0.00<br />

21440 S 328.06 0.00 0.00 23031 S 617.90 0.00 0.00<br />

21445 S 779.00 0.00 0.00 23035 S 664.55 0.00 0.00<br />

21450 S 135.40 0.00 0.00 23040 S 822.40 0.00 0.00<br />

21451 S 365.31 0.00 0.00 23044 S 878.89 0.00 0.00<br />

21452 S 545.92 0.00 0.00 23065 S 98.21 0.00 0.00<br />

21453 S 1,056.10 0.00 0.00 23066 S 635.62 0.00 0.00<br />

21454 S 819.96 0.00 0.00 23075 S 519.75 0.00 0.00<br />

21461 S 1,112.58 0.00 0.00 23076 S 635.62 0.00 0.00<br />

21462 S 1,153.54 0.00 0.00 23077 S 665.75 0.00 0.00<br />

21465 S 1,112.58 0.00 0.00 23100 S 634.41 0.00 0.00<br />

21480 S 92.60 0.00 0.00 23101 S 1,050.73 0.00 0.00<br />

21485 S 545.92 0.00 0.00 23105 S 878.89 0.00 0.00<br />

21490 S 1,056.10 0.00 0.00 23106 S 878.89 0.00 0.00<br />

21495 S 671.91 0.00 0.00 23107 S 878.89 0.00 0.00<br />

21497 S 545.92 0.00 0.00 23120 S 919.85 0.00 0.00<br />

21501 S 587.77 0.00 0.00 23125 S 919.85 0.00 0.00<br />

21502 S 634.41 0.00 0.00 23130 S 1,221.34 0.00 0.00<br />

21550 S 619.59 0.00 0.00 23140 S 721.03 0.00 0.00<br />

21555 S 635.62 0.00 0.00 23145 S 919.85 0.00 0.00<br />

21556 S 635.62 0.00 0.00 23146 S 919.85 0.00 0.00<br />

21557 S 851.30 0.00 0.00 23150 S 878.89 0.00 0.00<br />

21600 S 792.27 0.00 0.00 23155 S 919.85 0.00 0.00<br />

21610 S 792.27 0.00 0.00 23156 S 919.85 0.00 0.00<br />

21685 S 293.59 0.00 0.00 23170 S 792.27 0.00 0.00<br />

21700 S 634.41 0.00 0.00 23172 S 792.27 0.00 0.00<br />

21720 S 664.55 0.00 0.00 23174 S 792.27 0.00 0.00<br />

21725 S 69.18 0.00 0.00 23180 S 878.89 0.00 0.00<br />

21800 S 79.91 0.00 0.00 23182 S 878.89 0.00 0.00<br />

21805 S 705.80 0.00 0.00 23184 S 878.89 0.00 0.00<br />

21820 S 79.91 0.00 0.00 23190 S 878.89 0.00 0.00<br />

21920 S 142.09 0.00 0.00 23195 S 919.85 0.00 0.00<br />

21925 S 635.62 0.00 0.00 23330 S 317.66 0.00 0.00<br />

21930 S 635.62 0.00 0.00 23331 S 582.42 0.00 0.00<br />

21935 S 665.75 0.00 0.00 23395 S 1,221.34 0.00 0.00<br />

22102 S 1,894.40 0.00 0.00 23397 S 2,155.91 0.00 0.00<br />

22103 S 1,894.40 0.00 0.00 23400 S 1,050.73 0.00 0.00<br />

22305 S 79.91 0.00 0.00 23405 S 792.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 792.27 0.00 0.00 23931 S 587.77 0.00 0.00<br />

23410 S 1,221.34 0.00 0.00 23935 S 634.41 0.00 0.00<br />

23412 S 1,352.22 0.00 0.00 24000 S 878.89 0.00 0.00<br />

23415 S 1,221.34 0.00 0.00 24006 S 878.89 0.00 0.00<br />

23420 S 1,352.22 0.00 0.00 24065 S 136.17 0.00 0.00<br />

23430 S 1,180.39 0.00 0.00 24066 S 519.75 0.00 0.00<br />

23440 S 1,180.39 0.00 0.00 24075 S 519.75 0.00 0.00<br />

23450 S 2,025.04 0.00 0.00 24076 S 635.62 0.00 0.00<br />

23455 S 2,155.91 0.00 0.00 24077 S 665.75 0.00 0.00<br />

23460 S 2,025.04 0.00 0.00 24100 S 581.21 0.00 0.00<br />

23462 S 1,352.22 0.00 0.00 24101 S 878.89 0.00 0.00<br />

23465 S 2,025.04 0.00 0.00 24102 S 878.89 0.00 0.00<br />

23466 S 1,352.22 0.00 0.00 24105 S 664.55 0.00 0.00<br />

23480 S 1,180.39 0.00 0.00 24110 S 634.41 0.00 0.00<br />

23485 S 2,155.91 0.00 0.00 24115 S 822.40 0.00 0.00<br />

23490 S 1,123.89 0.00 0.00 24116 S 822.40 0.00 0.00<br />

23491 S 1,927.59 0.00 0.00 24120 S 664.55 0.00 0.00<br />

23500 S 79.91 0.00 0.00 24125 S 822.40 0.00 0.00<br />

23505 S 436.04 0.00 0.00 24126 S 822.40 0.00 0.00<br />

23515 S 1,459.38 0.00 0.00 24130 S 822.40 0.00 0.00<br />

23520 S 168.58 0.00 0.00 24134 S 792.27 0.00 0.00<br />

23525 S 168.58 0.00 0.00 24136 S 792.27 0.00 0.00<br />

23530 S 1,075.42 0.00 0.00 24138 S 792.27 0.00 0.00<br />

23532 S 792.42 0.00 0.00 24140 S 822.40 0.00 0.00<br />

23540 S 79.91 0.00 0.00 24145 S 822.40 0.00 0.00<br />

23545 S 168.58 0.00 0.00 24147 S 792.27 0.00 0.00<br />

23550 S 1,075.42 0.00 0.00 24149 S 1,164.60 0.00 0.00<br />

23552 S 1,131.91 0.00 0.00 24152 S 1,767.60 0.00 0.00<br />

23570 S 79.91 0.00 0.00 24153 S 3,374.97 0.00 0.00<br />

23575 S 168.58 0.00 0.00 24155 S 1,123.89 0.00 0.00<br />

23585 S 1,459.38 0.00 0.00 24160 S 792.27 0.00 0.00<br />

23600 S 62.27 0.00 0.00 24164 S 822.40 0.00 0.00<br />

23605 S 436.04 0.00 0.00 24200 S 99.60 0.00 0.00<br />

23615 S 1,515.87 0.00 0.00 24201 S 519.75 0.00 0.00<br />

23616 S 1,515.87 0.00 0.00 24300 S 606.72 0.00 0.00<br />

23620 S 62.27 0.00 0.00 24301 S 878.89 0.00 0.00<br />

23625 S 436.04 0.00 0.00 24305 S 878.89 0.00 0.00<br />

23630 S 1,556.83 0.00 0.00 24310 S 664.55 0.00 0.00<br />

23650 S 79.91 0.00 0.00 24320 S 1,123.89 0.00 0.00<br />

23655 S 460.13 0.00 0.00 24330 S 1,927.59 0.00 0.00<br />

23660 S 1,075.42 0.00 0.00 24331 S 1,123.89 0.00 0.00<br />

23665 S 168.58 0.00 0.00 24332 S 848.89 0.00 0.00<br />

23670 S 1,459.38 0.00 0.00 24340 S 1,123.89 0.00 0.00<br />

23675 S 79.91 0.00 0.00 24341 S 1,123.89 0.00 0.00<br />

23680 S 1,075.42 0.00 0.00 24342 S 1,123.89 0.00 0.00<br />

23700 S 460.13 0.00 0.00 24343 S 1,164.60 0.00 0.00<br />

23800 S 1,984.08 0.00 0.00 24344 S 3,374.97 0.00 0.00<br />

23802 S 1,352.22 0.00 0.00 24345 S 792.27 0.00 0.00<br />

23921 S 463.50 0.00 0.00 24346 S 1,767.60 0.00 0.00<br />

23930 S 534.57 0.00 0.00 24357 S 1,164.60 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,164.60 0.00 0.00 24925 S 664.55 0.00 0.00<br />

24359 S 1,164.60 0.00 0.00 25000 S 664.55 0.00 0.00<br />

24360 S 1,074.76 0.00 0.00 25001 S 848.89 0.00 0.00<br />

24361 S 5,876.27 3,597.02 1,317.77 25020 S 664.55 0.00 0.00<br />

24362 S 1,373.54 0.00 0.00 25023 S 822.40 0.00 0.00<br />

24363 S 6,007.15 3,727.90 1,448.65 25024 S 822.40 0.00 0.00<br />

24365 S 1,074.76 0.00 0.00 25025 S 822.40 0.00 0.00<br />

24366 S 5,876.27 3,597.02 1,317.77 25028 S 581.21 0.00 0.00<br />

24400 S 878.89 0.00 0.00 25031 S 634.41 0.00 0.00<br />

24410 S 878.89 0.00 0.00 25035 S 634.41 0.00 0.00<br />

24420 S 1,123.89 0.00 0.00 25040 S 919.85 0.00 0.00<br />

24430 S 1,927.59 0.00 0.00 25065 S 138.25 0.00 0.00<br />

24435 S 1,984.08 0.00 0.00 25066 S 635.62 0.00 0.00<br />

24470 S 1,123.89 0.00 0.00 25075 S 519.75 0.00 0.00<br />

24495 S 792.27 0.00 0.00 25076 S 665.75 0.00 0.00<br />

24498 S 1,927.59 0.00 0.00 25077 S 665.75 0.00 0.00<br />

24500 S 79.91 0.00 0.00 25085 S 664.55 0.00 0.00<br />

24505 S 79.91 0.00 0.00 25100 S 634.41 0.00 0.00<br />

24515 S 1,515.87 0.00 0.00 25101 S 822.40 0.00 0.00<br />

24516 S 1,515.87 0.00 0.00 25105 S 878.89 0.00 0.00<br />

24530 S 79.91 0.00 0.00 25107 S 822.40 0.00 0.00<br />

24535 S 168.58 0.00 0.00 25109 S 848.89 0.00 0.00<br />

24538 S 705.80 0.00 0.00 25110 S 664.55 0.00 0.00<br />

24545 S 1,515.87 0.00 0.00 25111 S 664.55 0.00 0.00<br />

24546 S 1,556.83 0.00 0.00 25112 S 721.03 0.00 0.00<br />

24560 S 79.91 0.00 0.00 25115 S 721.03 0.00 0.00<br />

24565 S 79.91 0.00 0.00 25116 S 721.03 0.00 0.00<br />

24566 S 705.80 0.00 0.00 25118 S 792.27 0.00 0.00<br />

24575 S 1,459.38 0.00 0.00 25119 S 822.40 0.00 0.00<br />

24576 S 79.91 0.00 0.00 25120 S 822.40 0.00 0.00<br />

24577 S 168.58 0.00 0.00 25125 S 822.40 0.00 0.00<br />

24579 S 1,459.38 0.00 0.00 25126 S 822.40 0.00 0.00<br />

24582 S 705.80 0.00 0.00 25130 S 822.40 0.00 0.00<br />

24586 S 1,515.87 0.00 0.00 25135 S 822.40 0.00 0.00<br />

24587 S 1,556.83 0.00 0.00 25136 S 822.40 0.00 0.00<br />

24600 S 79.91 0.00 0.00 25145 S 792.27 0.00 0.00<br />

24605 S 513.32 0.00 0.00 25150 S 792.27 0.00 0.00<br />

24615 S 1,459.38 0.00 0.00 25151 S 792.27 0.00 0.00<br />

24620 S 436.04 0.00 0.00 25210 S 822.40 0.00 0.00<br />

24635 S 1,459.38 0.00 0.00 25215 S 878.89 0.00 0.00<br />

24640 S 53.98 0.00 0.00 25230 S 878.89 0.00 0.00<br />

24650 S 62.27 0.00 0.00 25240 S 878.89 0.00 0.00<br />

24655 S 168.58 0.00 0.00 25248 S 634.41 0.00 0.00<br />

24665 S 1,131.91 0.00 0.00 25250 S 739.07 0.00 0.00<br />

24666 S 1,515.87 0.00 0.00 25251 S 739.07 0.00 0.00<br />

24670 S 79.91 0.00 0.00 25259 S 774.51 0.00 0.00<br />

24675 S 79.91 0.00 0.00 25260 S 878.89 0.00 0.00<br />

24685 S 1,075.42 0.00 0.00 25263 S 792.27 0.00 0.00<br />

24800 S 1,180.39 0.00 0.00 25265 S 822.40 0.00 0.00<br />

24802 S 1,221.34 0.00 0.00 25270 S 878.89 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 822.40 0.00 0.00 25505 S 168.58 0.00 0.00<br />

25274 S 878.89 0.00 0.00 25515 S 1,075.42 0.00 0.00<br />

25275 S 878.89 0.00 0.00 25520 S 168.58 0.00 0.00<br />

25280 S 878.89 0.00 0.00 25525 S 1,131.91 0.00 0.00<br />

25290 S 822.40 0.00 0.00 25526 S 1,172.87 0.00 0.00<br />

25295 S 664.55 0.00 0.00 25530 S 62.27 0.00 0.00<br />

25300 S 822.40 0.00 0.00 25535 S 79.91 0.00 0.00<br />

25301 S 822.40 0.00 0.00 25545 S 1,075.42 0.00 0.00<br />

25310 S 1,123.89 0.00 0.00 25560 S 62.27 0.00 0.00<br />

25312 S 1,180.39 0.00 0.00 25565 S 168.58 0.00 0.00<br />

25315 S 1,123.89 0.00 0.00 25574 S 1,459.38 0.00 0.00<br />

25316 S 1,927.59 0.00 0.00 25575 S 1,459.38 0.00 0.00<br />

25320 S 1,123.89 0.00 0.00 25600 S 62.27 0.00 0.00<br />

25332 S 1,074.76 0.00 0.00 25605 S 168.58 0.00 0.00<br />

25335 S 1,123.89 0.00 0.00 25606 S 735.93 0.00 0.00<br />

25337 S 1,221.34 0.00 0.00 25607 S 1,556.83 0.00 0.00<br />

25350 S 1,927.59 0.00 0.00 25608 S 1,556.83 0.00 0.00<br />

25355 S 1,123.89 0.00 0.00 25609 S 1,556.83 0.00 0.00<br />

25360 S 822.40 0.00 0.00 25622 S 62.27 0.00 0.00<br />

25365 S 822.40 0.00 0.00 25624 S 168.58 0.00 0.00<br />

25370 S 1,123.89 0.00 0.00 25628 S 1,075.42 0.00 0.00<br />

25375 S 1,180.39 0.00 0.00 25630 S 62.27 0.00 0.00<br />

25390 S 822.40 0.00 0.00 25635 S 168.58 0.00 0.00<br />

25391 S 1,180.39 0.00 0.00 25645 S 1,075.42 0.00 0.00<br />

25392 S 822.40 0.00 0.00 25650 S 62.27 0.00 0.00<br />

25393 S 1,180.39 0.00 0.00 25651 S 991.66 0.00 0.00<br />

25394 S 1,767.60 0.00 0.00 25652 S 1,670.63 0.00 0.00<br />

25400 S 1,123.89 0.00 0.00 25660 S 79.91 0.00 0.00<br />

25405 S 1,984.08 0.00 0.00 25670 S 735.93 0.00 0.00<br />

25415 S 1,927.59 0.00 0.00 25671 S 652.60 0.00 0.00<br />

25420 S 1,984.08 0.00 0.00 25675 S 79.91 0.00 0.00<br />

25425 S 1,123.89 0.00 0.00 25676 S 705.80 0.00 0.00<br />

25426 S 1,180.39 0.00 0.00 25680 S 79.91 0.00 0.00<br />

25430 S 1,767.60 0.00 0.00 25685 S 735.93 0.00 0.00<br />

25431 S 1,767.60 0.00 0.00 25690 S 436.04 0.00 0.00<br />

25440 S 1,984.08 0.00 0.00 25695 S 705.80 0.00 0.00<br />

25441 S 5,876.27 3,597.02 1,317.77 25800 S 1,984.08 0.00 0.00<br />

25442 S 5,876.27 3,597.02 1,317.77 25805 S 1,221.34 0.00 0.00<br />

25443 S 1,373.54 0.00 0.00 25810 S 2,025.04 0.00 0.00<br />

25444 S 1,373.54 0.00 0.00 25820 S 1,180.39 0.00 0.00<br />

25445 S 1,373.54 0.00 0.00 25825 S 2,025.04 0.00 0.00<br />

25446 S 6,007.15 3,727.90 1,448.65 25830 S 2,025.04 0.00 0.00<br />

25447 S 1,074.76 0.00 0.00 25907 S 664.55 0.00 0.00<br />

25449 S 1,074.76 0.00 0.00 25922 S 664.55 0.00 0.00<br />

25450 S 1,123.89 0.00 0.00 25929 S 551.40 0.00 0.00<br />

25455 S 1,123.89 0.00 0.00 25931 S 848.89 0.00 0.00<br />

25490 S 1,123.89 0.00 0.00 26010 S 55.06 0.00 0.00<br />

25491 S 1,123.89 0.00 0.00 26011 S 402.21 0.00 0.00<br />

25492 S 1,123.89 0.00 0.00 26020 S 533.69 0.00 0.00<br />

25500 S 62.27 0.00 0.00 26025 S 480.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 533.69 0.00 0.00 26392 S 785.72 0.00 0.00<br />

26034 S 533.69 0.00 0.00 26410 S 563.81 0.00 0.00<br />

26035 S 647.43 0.00 0.00 26412 S 785.72 0.00 0.00<br />

26040 S 842.22 0.00 0.00 26415 S 842.22 0.00 0.00<br />

26045 S 785.72 0.00 0.00 26416 S 785.72 0.00 0.00<br />

26055 S 533.69 0.00 0.00 26418 S 620.31 0.00 0.00<br />

26060 S 533.69 0.00 0.00 26420 S 842.22 0.00 0.00<br />

26070 S 533.69 0.00 0.00 26426 S 785.72 0.00 0.00<br />

26075 S 620.31 0.00 0.00 26428 S 785.72 0.00 0.00<br />

26080 S 620.31 0.00 0.00 26432 S 563.81 0.00 0.00<br />

26100 S 533.69 0.00 0.00 26433 S 563.81 0.00 0.00<br />

26105 S 480.48 0.00 0.00 26434 S 785.72 0.00 0.00<br />

26110 S 480.48 0.00 0.00 26437 S 563.81 0.00 0.00<br />

26115 S 635.62 0.00 0.00 26440 S 563.81 0.00 0.00<br />

26116 S 635.62 0.00 0.00 26442 S 785.72 0.00 0.00<br />

26117 S 665.75 0.00 0.00 26445 S 563.81 0.00 0.00<br />

26121 S 842.22 0.00 0.00 26449 S 785.72 0.00 0.00<br />

26123 S 842.22 0.00 0.00 26450 S 563.81 0.00 0.00<br />

26125 S 620.31 0.00 0.00 26455 S 563.81 0.00 0.00<br />

26130 S 563.81 0.00 0.00 26460 S 563.81 0.00 0.00<br />

26135 S 842.22 0.00 0.00 26471 S 533.69 0.00 0.00<br />

26140 S 533.69 0.00 0.00 26474 S 533.69 0.00 0.00<br />

26145 S 563.81 0.00 0.00 26476 S 480.48 0.00 0.00<br />

26160 S 563.81 0.00 0.00 26477 S 480.48 0.00 0.00<br />

26170 S 563.81 0.00 0.00 26478 S 480.48 0.00 0.00<br />

26180 S 563.81 0.00 0.00 26479 S 480.48 0.00 0.00<br />

26185 S 620.31 0.00 0.00 26480 S 785.72 0.00 0.00<br />

26200 S 533.69 0.00 0.00 26483 S 785.72 0.00 0.00<br />

26205 S 785.72 0.00 0.00 26485 S 755.59 0.00 0.00<br />

26210 S 533.69 0.00 0.00 26489 S 785.72 0.00 0.00<br />

26215 S 563.81 0.00 0.00 26490 S 785.72 0.00 0.00<br />

26230 S 791.17 0.00 0.00 26492 S 785.72 0.00 0.00<br />

26235 S 563.81 0.00 0.00 26494 S 785.72 0.00 0.00<br />

26236 S 563.81 0.00 0.00 26496 S 785.72 0.00 0.00<br />

26250 S 563.81 0.00 0.00 26497 S 785.72 0.00 0.00<br />

26255 S 785.72 0.00 0.00 26498 S 842.22 0.00 0.00<br />

26260 S 563.81 0.00 0.00 26499 S 785.72 0.00 0.00<br />

26261 S 563.81 0.00 0.00 26500 S 620.31 0.00 0.00<br />

26262 S 533.69 0.00 0.00 26502 S 842.22 0.00 0.00<br />

26320 S 519.75 0.00 0.00 26508 S 563.81 0.00 0.00<br />

26340 S 239.60 0.00 0.00 26510 S 785.72 0.00 0.00<br />

26350 S 702.39 0.00 0.00 26516 S 702.39 0.00 0.00<br />

26352 S 842.22 0.00 0.00 26517 S 785.72 0.00 0.00<br />

26356 S 842.22 0.00 0.00 26518 S 785.72 0.00 0.00<br />

26357 S 842.22 0.00 0.00 26520 S 563.81 0.00 0.00<br />

26358 S 842.22 0.00 0.00 26525 S 563.81 0.00 0.00<br />

26370 S 842.22 0.00 0.00 26530 S 977.31 0.00 0.00<br />

26372 S 842.22 0.00 0.00 26531 S 1,504.41 0.00 0.00<br />

26373 S 785.72 0.00 0.00 26535 S 1,074.76 0.00 0.00<br />

26390 S 842.22 0.00 0.00 26536 S 1,373.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 620.31 0.00 0.00 26775 S 166.47 0.00 0.00<br />

26541 S 1,014.04 0.00 0.00 26776 S 705.80 0.00 0.00<br />

26542 S 620.31 0.00 0.00 26785 S 705.80 0.00 0.00<br />

26545 S 842.22 0.00 0.00 26820 S 883.17 0.00 0.00<br />

26546 S 842.22 0.00 0.00 26841 S 842.22 0.00 0.00<br />

26548 S 842.22 0.00 0.00 26842 S 842.22 0.00 0.00<br />

26550 S 755.59 0.00 0.00 26843 S 785.72 0.00 0.00<br />

26555 S 785.72 0.00 0.00 26844 S 785.72 0.00 0.00<br />

26560 S 533.69 0.00 0.00 26850 S 842.22 0.00 0.00<br />

26561 S 785.72 0.00 0.00 26852 S 842.22 0.00 0.00<br />

26562 S 842.22 0.00 0.00 26860 S 785.72 0.00 0.00<br />

26565 S 883.17 0.00 0.00 26861 S 755.59 0.00 0.00<br />

26567 S 883.17 0.00 0.00 26862 S 842.22 0.00 0.00<br />

26568 S 785.72 0.00 0.00 26863 S 785.72 0.00 0.00<br />

26580 S 661.26 0.00 0.00 26910 S 785.72 0.00 0.00<br />

26587 S 661.26 0.00 0.00 26951 S 533.69 0.00 0.00<br />

26590 S 661.26 0.00 0.00 26952 S 620.31 0.00 0.00<br />

26591 S 785.72 0.00 0.00 26990 S 581.21 0.00 0.00<br />

26593 S 563.81 0.00 0.00 26991 S 581.21 0.00 0.00<br />

26596 S 533.69 0.00 0.00 27000 S 634.41 0.00 0.00<br />

26600 S 62.27 0.00 0.00 27001 S 822.40 0.00 0.00<br />

26605 S 79.91 0.00 0.00 27003 S 822.40 0.00 0.00<br />

26607 S 436.04 0.00 0.00 27033 S 1,123.89 0.00 0.00<br />

26608 S 792.42 0.00 0.00 27035 S 1,180.39 0.00 0.00<br />

26615 S 1,131.91 0.00 0.00 27040 S 317.66 0.00 0.00<br />

26641 S 62.27 0.00 0.00 27041 S 357.91 0.00 0.00<br />

26645 S 168.58 0.00 0.00 27047 S 635.62 0.00 0.00<br />

26650 S 705.80 0.00 0.00 27048 S 665.75 0.00 0.00<br />

26665 S 1,131.91 0.00 0.00 27049 S 665.75 0.00 0.00<br />

26670 S 62.27 0.00 0.00 27050 S 664.55 0.00 0.00<br />

26675 S 168.58 0.00 0.00 27052 S 664.55 0.00 0.00<br />

26676 S 705.80 0.00 0.00 27060 S 761.99 0.00 0.00<br />

26685 S 735.93 0.00 0.00 27062 S 761.99 0.00 0.00<br />

26686 S 1,459.38 0.00 0.00 27065 S 761.99 0.00 0.00<br />

26700 S 62.27 0.00 0.00 27066 S 919.85 0.00 0.00<br />

26705 S 79.91 0.00 0.00 27067 S 919.85 0.00 0.00<br />

26706 S 436.04 0.00 0.00 27080 S 792.27 0.00 0.00<br />

26715 S 792.42 0.00 0.00 27086 S 317.66 0.00 0.00<br />

26720 S 62.27 0.00 0.00 27087 S 664.55 0.00 0.00<br />

26725 S 62.27 0.00 0.00 27097 S 822.40 0.00 0.00<br />

26727 S 964.26 0.00 0.00 27098 S 822.40 0.00 0.00<br />

26735 S 792.42 0.00 0.00 27100 S 1,180.39 0.00 0.00<br />

26740 S 62.27 0.00 0.00 27105 S 1,180.39 0.00 0.00<br />

26742 S 79.91 0.00 0.00 27110 S 1,180.39 0.00 0.00<br />

26746 S 833.38 0.00 0.00 27111 S 1,180.39 0.00 0.00<br />

26750 S 62.27 0.00 0.00 27193 S 79.91 0.00 0.00<br />

26755 S 62.27 0.00 0.00 27194 S 513.32 0.00 0.00<br />

26756 S 705.80 0.00 0.00 27200 S 62.27 0.00 0.00<br />

26765 S 792.42 0.00 0.00 27202 S 1,045.29 0.00 0.00<br />

26770 S 62.27 0.00 0.00 27220 S 62.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 79.91 0.00 0.00 27397 S 1,123.89 0.00 0.00<br />

27238 S 168.58 0.00 0.00 27400 S 1,123.89 0.00 0.00<br />

27246 S 168.58 0.00 0.00 27403 S 878.89 0.00 0.00<br />

27250 S 79.91 0.00 0.00 27405 S 1,180.39 0.00 0.00<br />

27252 S 513.32 0.00 0.00 27407 S 1,984.08 0.00 0.00<br />

27256 S 62.27 0.00 0.00 27409 S 1,180.39 0.00 0.00<br />

27257 S 543.46 0.00 0.00 27416 S 1,767.60 0.00 0.00<br />

27265 S 79.91 0.00 0.00 27418 S 1,123.89 0.00 0.00<br />

27266 S 513.32 0.00 0.00 27420 S 1,123.89 0.00 0.00<br />

27267 S 62.27 0.00 0.00 27422 S 1,352.22 0.00 0.00<br />

27275 S 513.32 0.00 0.00 27424 S 1,123.89 0.00 0.00<br />

27301 S 617.90 0.00 0.00 27425 S 1,050.73 0.00 0.00<br />

27305 S 634.41 0.00 0.00 27427 S 1,123.89 0.00 0.00<br />

27306 S 664.55 0.00 0.00 27428 S 1,984.08 0.00 0.00<br />

27307 S 664.55 0.00 0.00 27429 S 1,984.08 0.00 0.00<br />

27310 S 878.89 0.00 0.00 27430 S 1,180.39 0.00 0.00<br />

27323 S 317.66 0.00 0.00 27435 S 1,180.39 0.00 0.00<br />

27324 S 582.42 0.00 0.00 27437 S 1,033.80 0.00 0.00<br />

27325 S 570.69 0.00 0.00 27438 S 1,373.54 0.00 0.00<br />

27326 S 570.69 0.00 0.00 27440 S 1,474.42 0.00 0.00<br />

27327 S 635.62 0.00 0.00 27441 S 1,074.76 0.00 0.00<br />

27328 S 665.75 0.00 0.00 27442 S 1,074.76 0.00 0.00<br />

27329 S 722.24 0.00 0.00 27443 S 1,074.76 0.00 0.00<br />

27330 S 878.89 0.00 0.00 27446 S 10,545.48 6,335.24 2,125.01<br />

27331 S 878.89 0.00 0.00 27496 S 761.99 0.00 0.00<br />

27332 S 878.89 0.00 0.00 27497 S 664.55 0.00 0.00<br />

27333 S 878.89 0.00 0.00 27498 S 664.55 0.00 0.00<br />

27334 S 878.89 0.00 0.00 27499 S 664.55 0.00 0.00<br />

27335 S 878.89 0.00 0.00 27500 S 168.58 0.00 0.00<br />

27340 S 664.55 0.00 0.00 27501 S 79.91 0.00 0.00<br />

27345 S 721.03 0.00 0.00 27502 S 436.04 0.00 0.00<br />

27347 S 721.03 0.00 0.00 27503 S 79.91 0.00 0.00<br />

27350 S 878.89 0.00 0.00 27508 S 79.91 0.00 0.00<br />

27355 S 822.40 0.00 0.00 27509 S 735.93 0.00 0.00<br />

27356 S 878.89 0.00 0.00 27510 S 168.58 0.00 0.00<br />

27357 S 919.85 0.00 0.00 27516 S 79.91 0.00 0.00<br />

27358 S 919.85 0.00 0.00 27517 S 79.91 0.00 0.00<br />

27360 S 919.85 0.00 0.00 27520 S 79.91 0.00 0.00<br />

27372 S 894.08 0.00 0.00 27530 S 79.91 0.00 0.00<br />

27380 S 581.21 0.00 0.00 27532 S 436.04 0.00 0.00<br />

27381 S 664.55 0.00 0.00 27538 S 79.91 0.00 0.00<br />

27385 S 664.55 0.00 0.00 27550 S 79.91 0.00 0.00<br />

27386 S 664.55 0.00 0.00 27552 S 460.13 0.00 0.00<br />

27390 S 581.21 0.00 0.00 27560 S 79.91 0.00 0.00<br />

27391 S 634.41 0.00 0.00 27562 S 460.13 0.00 0.00<br />

27392 S 664.55 0.00 0.00 27566 S 1,045.29 0.00 0.00<br />

27393 S 792.27 0.00 0.00 27570 S 460.13 0.00 0.00<br />

27394 S 822.40 0.00 0.00 27594 S 664.55 0.00 0.00<br />

27395 S 1,123.89 0.00 0.00 27600 S 664.55 0.00 0.00<br />

27396 S 822.40 0.00 0.00 27601 S 664.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 664.55 0.00 0.00 27730 S 792.27 0.00 0.00<br />

27603 S 587.77 0.00 0.00 27732 S 792.27 0.00 0.00<br />

27604 S 634.41 0.00 0.00 27734 S 792.27 0.00 0.00<br />

27605 S 578.10 0.00 0.00 27740 S 792.27 0.00 0.00<br />

27606 S 581.21 0.00 0.00 27742 S 1,093.76 0.00 0.00<br />

27607 S 634.41 0.00 0.00 27745 S 1,927.59 0.00 0.00<br />

27610 S 792.27 0.00 0.00 27750 S 79.91 0.00 0.00<br />

27612 S 822.40 0.00 0.00 27752 S 436.04 0.00 0.00<br />

27613 S 130.60 0.00 0.00 27756 S 735.93 0.00 0.00<br />

27614 S 635.62 0.00 0.00 27758 S 1,131.91 0.00 0.00<br />

27615 S 822.40 0.00 0.00 27759 S 1,515.87 0.00 0.00<br />

27618 S 519.75 0.00 0.00 27760 S 79.91 0.00 0.00<br />

27619 S 665.75 0.00 0.00 27762 S 436.04 0.00 0.00<br />

27620 S 878.89 0.00 0.00 27766 S 1,075.42 0.00 0.00<br />

27625 S 878.89 0.00 0.00 27767 S 62.27 0.00 0.00<br />

27626 S 878.89 0.00 0.00 27768 S 62.27 0.00 0.00<br />

27630 S 664.55 0.00 0.00 27769 S 1,670.63 0.00 0.00<br />

27635 S 822.40 0.00 0.00 27780 S 79.91 0.00 0.00<br />

27637 S 822.40 0.00 0.00 27781 S 436.04 0.00 0.00<br />

27638 S 822.40 0.00 0.00 27784 S 1,075.42 0.00 0.00<br />

27640 S 1,093.76 0.00 0.00 27786 S 79.91 0.00 0.00<br />

27641 S 792.27 0.00 0.00 27788 S 79.91 0.00 0.00<br />

27647 S 1,123.89 0.00 0.00 27792 S 1,075.42 0.00 0.00<br />

27650 S 1,123.89 0.00 0.00 27808 S 79.91 0.00 0.00<br />

27652 S 1,927.59 0.00 0.00 27810 S 168.58 0.00 0.00<br />

27654 S 1,123.89 0.00 0.00 27814 S 1,075.42 0.00 0.00<br />

27656 S 634.41 0.00 0.00 27816 S 79.91 0.00 0.00<br />

27658 S 581.21 0.00 0.00 27818 S 168.58 0.00 0.00<br />

27659 S 634.41 0.00 0.00 27822 S 1,075.42 0.00 0.00<br />

27664 S 634.41 0.00 0.00 27823 S 1,459.38 0.00 0.00<br />

27665 S 792.27 0.00 0.00 27824 S 79.91 0.00 0.00<br />

27675 S 634.41 0.00 0.00 27825 S 436.04 0.00 0.00<br />

27676 S 822.40 0.00 0.00 27826 S 1,075.42 0.00 0.00<br />

27680 S 822.40 0.00 0.00 27827 S 1,459.38 0.00 0.00<br />

27681 S 792.27 0.00 0.00 27828 S 1,515.87 0.00 0.00<br />

27685 S 822.40 0.00 0.00 27829 S 1,045.29 0.00 0.00<br />

27686 S 822.40 0.00 0.00 27830 S 79.91 0.00 0.00<br />

27687 S 822.40 0.00 0.00 27831 S 436.04 0.00 0.00<br />

27690 S 1,180.39 0.00 0.00 27832 S 1,045.29 0.00 0.00<br />

27691 S 1,180.39 0.00 0.00 27840 S 168.58 0.00 0.00<br />

27692 S 1,123.89 0.00 0.00 27842 S 460.13 0.00 0.00<br />

27695 S 792.27 0.00 0.00 27846 S 1,075.42 0.00 0.00<br />

27696 S 792.27 0.00 0.00 27848 S 1,075.42 0.00 0.00<br />

27698 S 792.27 0.00 0.00 27860 S 460.13 0.00 0.00<br />

27700 S 1,074.76 0.00 0.00 27870 S 1,984.08 0.00 0.00<br />

27704 S 634.41 0.00 0.00 27871 S 1,984.08 0.00 0.00<br />

27705 S 1,093.76 0.00 0.00 27884 S 664.55 0.00 0.00<br />

27707 S 634.41 0.00 0.00 27889 S 822.40 0.00 0.00<br />

27709 S 792.27 0.00 0.00 27892 S 664.55 0.00 0.00<br />

27726 S 991.66 0.00 0.00 27893 S 664.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 664.55 0.00 0.00 28153 S 661.43 0.00 0.00<br />

28001 S 127.46 0.00 0.00 28160 S 661.43 0.00 0.00<br />

28002 S 664.55 0.00 0.00 28171 S 661.43 0.00 0.00<br />

28003 S 664.55 0.00 0.00 28173 S 661.43 0.00 0.00<br />

28005 S 661.43 0.00 0.00 28175 S 661.43 0.00 0.00<br />

28008 S 661.43 0.00 0.00 28190 S 131.64 0.00 0.00<br />

28010 S 93.68 0.00 0.00 28192 S 519.75 0.00 0.00<br />

28011 S 661.43 0.00 0.00 28193 S 357.91 0.00 0.00<br />

28020 S 631.29 0.00 0.00 28200 S 661.43 0.00 0.00<br />

28022 S 631.29 0.00 0.00 28202 S 661.43 0.00 0.00<br />

28024 S 631.29 0.00 0.00 28208 S 661.43 0.00 0.00<br />

28035 S 657.31 0.00 0.00 28210 S 1,161.67 0.00 0.00<br />

28043 S 635.62 0.00 0.00 28220 S 203.04 0.00 0.00<br />

28045 S 661.43 0.00 0.00 28222 S 578.10 0.00 0.00<br />

28046 S 661.43 0.00 0.00 28225 S 578.10 0.00 0.00<br />

28050 S 631.29 0.00 0.00 28226 S 578.10 0.00 0.00<br />

28052 S 631.29 0.00 0.00 28230 S 199.20 0.00 0.00<br />

28054 S 631.29 0.00 0.00 28232 S 190.49 0.00 0.00<br />

28055 S 657.31 0.00 0.00 28234 S 631.29 0.00 0.00<br />

28060 S 631.29 0.00 0.00 28238 S 1,161.67 0.00 0.00<br />

28062 S 661.43 0.00 0.00 28240 S 631.29 0.00 0.00<br />

28070 S 661.43 0.00 0.00 28250 S 661.43 0.00 0.00<br />

28072 S 661.43 0.00 0.00 28260 S 661.43 0.00 0.00<br />

28080 S 661.43 0.00 0.00 28261 S 661.43 0.00 0.00<br />

28086 S 631.29 0.00 0.00 28262 S 717.91 0.00 0.00<br />

28088 S 631.29 0.00 0.00 28264 S 1,078.33 0.00 0.00<br />

28090 S 661.43 0.00 0.00 28270 S 661.43 0.00 0.00<br />

28092 S 661.43 0.00 0.00 28272 S 183.88 0.00 0.00<br />

28100 S 631.29 0.00 0.00 28280 S 631.29 0.00 0.00<br />

28102 S 1,161.67 0.00 0.00 28285 S 661.43 0.00 0.00<br />

28103 S 1,161.67 0.00 0.00 28286 S 717.91 0.00 0.00<br />

28104 S 631.29 0.00 0.00 28288 S 661.43 0.00 0.00<br />

28106 S 1,161.67 0.00 0.00 28289 S 661.43 0.00 0.00<br />

28107 S 1,161.67 0.00 0.00 28290 S 815.29 0.00 0.00<br />

28108 S 631.29 0.00 0.00 28292 S 815.29 0.00 0.00<br />

28110 S 661.43 0.00 0.00 28293 S 845.42 0.00 0.00<br />

28111 S 661.43 0.00 0.00 28294 S 845.42 0.00 0.00<br />

28112 S 661.43 0.00 0.00 28296 S 845.42 0.00 0.00<br />

28113 S 661.43 0.00 0.00 28297 S 845.42 0.00 0.00<br />

28114 S 661.43 0.00 0.00 28298 S 845.42 0.00 0.00<br />

28116 S 661.43 0.00 0.00 28299 S 942.87 0.00 0.00<br />

28118 S 717.91 0.00 0.00 28300 S 1,131.54 0.00 0.00<br />

28119 S 717.91 0.00 0.00 28302 S 631.29 0.00 0.00<br />

28120 S 889.75 0.00 0.00 28304 S 1,131.54 0.00 0.00<br />

28122 S 661.43 0.00 0.00 28305 S 1,161.67 0.00 0.00<br />

28124 S 215.57 0.00 0.00 28306 S 717.91 0.00 0.00<br />

28126 S 661.43 0.00 0.00 28307 S 717.91 0.00 0.00<br />

28130 S 661.43 0.00 0.00 28308 S 631.29 0.00 0.00<br />

28140 S 661.43 0.00 0.00 28309 S 1,218.16 0.00 0.00<br />

28150 S 661.43 0.00 0.00 28310 S 661.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 661.43 0.00 0.00 28636 S 735.93 0.00 0.00<br />

28313 S 631.29 0.00 0.00 28645 S 735.93 0.00 0.00<br />

28315 S 717.91 0.00 0.00 28660 S 44.58 0.00 0.00<br />

28320 S 1,218.16 0.00 0.00 28665 S 460.13 0.00 0.00<br />

28322 S 1,218.16 0.00 0.00 28666 S 735.93 0.00 0.00<br />

28340 S 717.91 0.00 0.00 28675 S 735.93 0.00 0.00<br />

28341 S 717.91 0.00 0.00 28705 S 1,218.16 0.00 0.00<br />

28344 S 717.91 0.00 0.00 28715 S 1,984.08 0.00 0.00<br />

28345 S 717.91 0.00 0.00 28725 S 1,218.16 0.00 0.00<br />

28400 S 79.91 0.00 0.00 28730 S 1,218.16 0.00 0.00<br />

28405 S 436.04 0.00 0.00 28735 S 1,218.16 0.00 0.00<br />

28406 S 705.80 0.00 0.00 28737 S 1,259.11 0.00 0.00<br />

28415 S 1,459.38 0.00 0.00 28740 S 1,218.16 0.00 0.00<br />

28420 S 1,131.91 0.00 0.00 28750 S 1,218.16 0.00 0.00<br />

28430 S 62.27 0.00 0.00 28755 S 717.91 0.00 0.00<br />

28435 S 79.91 0.00 0.00 28760 S 1,218.16 0.00 0.00<br />

28436 S 705.80 0.00 0.00 28810 S 631.29 0.00 0.00<br />

28445 S 1,075.42 0.00 0.00 28820 S 631.29 0.00 0.00<br />

28446 S 1,843.14 0.00 0.00 28825 S 631.29 0.00 0.00<br />

28450 S 62.27 0.00 0.00 28890 S 166.82 0.00 0.00<br />

28455 S 62.27 0.00 0.00 29000 S 42.26 0.00 0.00<br />

28456 S 705.80 0.00 0.00 29010 S 94.73 0.00 0.00<br />

28465 S 1,075.42 0.00 0.00 29015 S 94.73 0.00 0.00<br />

28470 S 62.27 0.00 0.00 29020 S 42.26 0.00 0.00<br />

28475 S 62.27 0.00 0.00 29025 S 42.26 0.00 0.00<br />

28476 S 705.80 0.00 0.00 29035 S 94.73 0.00 0.00<br />

28485 S 1,131.91 0.00 0.00 29040 S 42.26 0.00 0.00<br />

28490 S 62.27 0.00 0.00 29044 S 94.73 0.00 0.00<br />

28495 S 62.27 0.00 0.00 29046 S 94.73 0.00 0.00<br />

28496 S 705.80 0.00 0.00 29049 S 38.31 0.00 0.00<br />

28505 S 735.93 0.00 0.00 29055 S 94.73 0.00 0.00<br />

28510 S 56.07 0.00 0.00 29058 S 42.26 0.00 0.00<br />

28515 S 62.27 0.00 0.00 29065 S 44.93 0.00 0.00<br />

28525 S 735.93 0.00 0.00 29075 S 43.18 0.00 0.00<br />

28530 S 53.98 0.00 0.00 29085 S 42.26 0.00 0.00<br />

28531 S 735.93 0.00 0.00 29086 S 36.22 0.00 0.00<br />

28540 S 62.27 0.00 0.00 29105 S 39.00 0.00 0.00<br />

28545 S 652.60 0.00 0.00 29125 S 33.78 0.00 0.00<br />

28546 S 705.80 0.00 0.00 29126 S 35.87 0.00 0.00<br />

28555 S 1,045.29 0.00 0.00 29130 S 15.32 0.00 0.00<br />

28570 S 80.79 0.00 0.00 29131 S 22.29 0.00 0.00<br />

28575 S 436.04 0.00 0.00 29200 S 21.59 0.00 0.00<br />

28576 S 735.93 0.00 0.00 29220 S 23.33 0.00 0.00<br />

28585 S 735.93 0.00 0.00 29240 S 24.38 0.00 0.00<br />

28600 S 62.27 0.00 0.00 29260 S 23.33 0.00 0.00<br />

28605 S 79.91 0.00 0.00 29280 S 23.69 0.00 0.00<br />

28606 S 705.80 0.00 0.00 29305 S 94.73 0.00 0.00<br />

28615 S 1,075.42 0.00 0.00 29325 S 94.73 0.00 0.00<br />

28630 S 62.27 0.00 0.00 29345 S 58.85 0.00 0.00<br />

28635 S 460.13 0.00 0.00 29355 S 57.81 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 71.74 0.00 0.00 29847 S 1,199.15 0.00 0.00<br />

29365 S 55.72 0.00 0.00 29848 S 1,203.57 0.00 0.00<br />

29405 S 41.44 0.00 0.00 29850 S 869.79 0.00 0.00<br />

29425 S 42.14 0.00 0.00 29851 S 1,255.65 0.00 0.00<br />

29435 S 53.28 0.00 0.00 29855 S 1,255.65 0.00 0.00<br />

29440 S 22.63 0.00 0.00 29856 S 1,255.65 0.00 0.00<br />

29445 S 56.07 0.00 0.00 29860 S 1,255.65 0.00 0.00<br />

29450 S 42.26 0.00 0.00 29861 S 1,255.65 0.00 0.00<br />

29505 S 37.61 0.00 0.00 29862 S 1,589.43 0.00 0.00<br />

29515 S 32.04 0.00 0.00 29863 S 1,255.65 0.00 0.00<br />

29520 S 22.98 0.00 0.00 29866 S 1,918.11 0.00 0.00<br />

29530 S 23.33 0.00 0.00 29870 S 813.31 0.00 0.00<br />

29540 S 17.41 0.00 0.00 29871 S 813.31 0.00 0.00<br />

29550 S 17.76 0.00 0.00 29873 S 813.31 0.00 0.00<br />

29580 S 24.03 0.00 0.00 29874 S 813.31 0.00 0.00<br />

29590 S 19.51 0.00 0.00 29875 S 869.79 0.00 0.00<br />

29700 S 32.39 0.00 0.00 29876 S 869.79 0.00 0.00<br />

29705 S 27.51 0.00 0.00 29877 S 869.79 0.00 0.00<br />

29710 S 48.41 0.00 0.00 29879 S 813.31 0.00 0.00<br />

29715 S 42.26 0.00 0.00 29880 S 869.79 0.00 0.00<br />

29720 S 40.40 0.00 0.00 29881 S 869.79 0.00 0.00<br />

29730 S 26.47 0.00 0.00 29882 S 813.31 0.00 0.00<br />

29740 S 36.22 0.00 0.00 29883 S 813.31 0.00 0.00<br />

29750 S 37.96 0.00 0.00 29884 S 813.31 0.00 0.00<br />

29800 S 813.31 0.00 0.00 29885 S 1,199.15 0.00 0.00<br />

29804 S 813.31 0.00 0.00 29886 S 813.31 0.00 0.00<br />

29805 S 813.31 0.00 0.00 29887 S 813.31 0.00 0.00<br />

29806 S 1,199.15 0.00 0.00 29888 S 1,199.15 0.00 0.00<br />

29807 S 1,199.15 0.00 0.00 29889 S 1,199.15 0.00 0.00<br />

29819 S 1,199.15 0.00 0.00 29891 S 1,199.15 0.00 0.00<br />

29820 S 1,199.15 0.00 0.00 29892 S 1,199.15 0.00 0.00<br />

29821 S 1,199.15 0.00 0.00 29893 S 1,012.41 0.00 0.00<br />

29822 S 813.31 0.00 0.00 29894 S 813.31 0.00 0.00<br />

29823 S 1,199.15 0.00 0.00 29895 S 813.31 0.00 0.00<br />

29824 S 910.75 0.00 0.00 29897 S 813.31 0.00 0.00<br />

29825 S 1,199.15 0.00 0.00 29898 S 813.31 0.00 0.00<br />

29826 S 1,199.15 0.00 0.00 29899 S 1,199.15 0.00 0.00<br />

29827 S 1,296.60 0.00 0.00 29900 S 813.31 0.00 0.00<br />

29828 S 1,918.11 0.00 0.00 29901 S 813.31 0.00 0.00<br />

29830 S 813.31 0.00 0.00 29902 S 813.31 0.00 0.00<br />

29834 S 813.31 0.00 0.00 29904 S 1,146.41 0.00 0.00<br />

29835 S 813.31 0.00 0.00 29905 S 1,146.41 0.00 0.00<br />

29836 S 813.31 0.00 0.00 29906 S 1,146.41 0.00 0.00<br />

29837 S 813.31 0.00 0.00 29907 S 1,918.11 0.00 0.00<br />

29838 S 813.31 0.00 0.00 30000 S 128.89 0.00 0.00<br />

29840 S 813.31 0.00 0.00 30020 S 128.89 0.00 0.00<br />

29843 S 813.31 0.00 0.00 30100 S 83.58 0.00 0.00<br />

29844 S 813.31 0.00 0.00 30110 S 129.21 0.00 0.00<br />

29845 S 813.31 0.00 0.00 30115 S 545.92 0.00 0.00<br />

29846 S 813.31 0.00 0.00 30117 S 576.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 722.51 0.00 0.00 31080 S 1,112.58 0.00 0.00<br />

30120 S 492.73 0.00 0.00 31081 S 1,112.58 0.00 0.00<br />

30124 S 293.59 0.00 0.00 31084 S 1,112.58 0.00 0.00<br />

30125 S 1,025.96 0.00 0.00 31085 S 1,112.58 0.00 0.00<br />

30130 S 576.06 0.00 0.00 31086 S 1,112.58 0.00 0.00<br />

30140 S 692.37 0.00 0.00 31087 S 1,112.58 0.00 0.00<br />

30150 S 1,056.10 0.00 0.00 31090 S 1,153.54 0.00 0.00<br />

30160 S 1,112.58 0.00 0.00 31200 S 1,025.96 0.00 0.00<br />

30200 S 65.82 0.00 0.00 31201 S 1,153.54 0.00 0.00<br />

30210 S 83.58 0.00 0.00 31205 S 1,056.10 0.00 0.00<br />

30220 S 365.31 0.00 0.00 31231 S 70.46 0.00 0.00<br />

30300 S 25.18 0.00 0.00 31233 S 75.90 0.00 0.00<br />

30310 S 492.73 0.00 0.00 31235 S 515.64 0.00 0.00<br />

30320 S 545.92 0.00 0.00 31237 S 568.83 0.00 0.00<br />

30400 S 1,112.58 0.00 0.00 31238 S 515.64 0.00 0.00<br />

30410 S 1,153.54 0.00 0.00 31239 S 752.68 0.00 0.00<br />

30420 S 1,153.54 0.00 0.00 31240 S 568.83 0.00 0.00<br />

30430 S 722.51 0.00 0.00 31254 S 696.18 0.00 0.00<br />

30435 S 1,153.54 0.00 0.00 31255 S 793.63 0.00 0.00<br />

30450 S 1,284.42 0.00 0.00 31256 S 696.18 0.00 0.00<br />

30460 S 1,284.42 0.00 0.00 31267 S 696.18 0.00 0.00<br />

30462 S 1,446.36 0.00 0.00 31276 S 696.18 0.00 0.00<br />

30465 S 1,446.36 0.00 0.00 31287 S 696.18 0.00 0.00<br />

30520 S 779.00 0.00 0.00 31288 S 696.18 0.00 0.00<br />

30540 S 1,153.54 0.00 0.00 31300 S 819.96 0.00 0.00<br />

30545 S 1,153.54 0.00 0.00 31320 S 1,025.96 0.00 0.00<br />

30560 S 135.40 0.00 0.00 31400 S 1,025.96 0.00 0.00<br />

30580 S 1,112.58 0.00 0.00 31420 S 1,025.96 0.00 0.00<br />

30600 S 1,112.58 0.00 0.00 31500 S 94.24 0.00 0.00<br />

30620 S 1,284.42 0.00 0.00 31502 S 54.19 0.00 0.00<br />

30630 S 950.84 0.00 0.00 31505 S 32.02 0.00 0.00<br />

30801 S 303.57 0.00 0.00 31510 S 568.83 0.00 0.00<br />

30802 S 303.57 0.00 0.00 31511 S 75.90 0.00 0.00<br />

30901 S 43.30 0.00 0.00 31512 S 568.83 0.00 0.00<br />

30903 S 55.77 0.00 0.00 31513 S 75.90 0.00 0.00<br />

30905 S 55.77 0.00 0.00 31515 S 515.64 0.00 0.00<br />

30906 S 55.77 0.00 0.00 31520 S 70.46 0.00 0.00<br />

30915 S 743.15 0.00 0.00 31525 S 515.64 0.00 0.00<br />

30920 S 773.29 0.00 0.00 31526 S 666.05 0.00 0.00<br />

30930 S 632.55 0.00 0.00 31527 S 612.85 0.00 0.00<br />

31000 S 107.62 0.00 0.00 31528 S 568.83 0.00 0.00<br />

31002 S 293.59 0.00 0.00 31529 S 568.83 0.00 0.00<br />

31020 S 692.37 0.00 0.00 31530 S 666.05 0.00 0.00<br />

31030 S 1,056.10 0.00 0.00 31531 S 696.18 0.00 0.00<br />

31032 S 1,112.58 0.00 0.00 31535 S 666.05 0.00 0.00<br />

31040 S 964.83 0.00 0.00 31536 S 696.18 0.00 0.00<br />

31050 S 1,025.96 0.00 0.00 31540 S 696.18 0.00 0.00<br />

31051 S 1,112.58 0.00 0.00 31541 S 752.68 0.00 0.00<br />

31070 S 692.37 0.00 0.00 31545 S 752.68 0.00 0.00<br />

31075 S 1,112.58 0.00 0.00 31546 S 752.68 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 793.63 0.00 0.00 32405 S 343.43 0.00 0.00<br />

31561 S 793.63 0.00 0.00 32420 S 208.83 0.00 0.00<br />

31570 S 568.83 0.00 0.00 32421 S 208.83 0.00 0.00<br />

31571 S 666.05 0.00 0.00 32422 S 207.90 0.00 0.00<br />

31575 S 60.60 0.00 0.00 32550 S 1,164.03 0.00 0.00<br />

31576 S 666.05 0.00 0.00 32960 S 207.90 0.00 0.00<br />

31577 S 196.75 0.00 0.00 32998 S 1,812.33 0.00 0.00<br />

31578 S 666.05 0.00 0.00 33010 S 208.83 0.00 0.00<br />

31579 S 107.96 0.00 0.00 33011 S 208.83 0.00 0.00<br />

31580 S 1,153.54 0.00 0.00 33206 S 6,700.07 3,986.52 1,272.98<br />

31582 S 1,153.54 0.00 0.00 33207 S 6,700.07 3,986.52 1,272.98<br />

31588 S 1,153.54 0.00 0.00 33208 S 8,309.98 4,842.18 1,374.40<br />

31590 S 1,153.54 0.00 0.00 33210 S 1,967.50 0.00 0.00<br />

31595 S 1,025.96 0.00 0.00 33211 S 1,967.50 0.00 0.00<br />

31603 S 303.57 0.00 0.00 33212 S 5,261.94 2,997.50 733.06<br />

31605 S 293.59 0.00 0.00 33213 S 6,073.41 3,402.80 732.20<br />

31611 S 722.51 0.00 0.00 33214 S 8,309.98 4,842.18 1,374.40<br />

31612 S 639.18 0.00 0.00 33215 S 862.38 0.00 0.00<br />

31613 S 692.37 0.00 0.00 33216 S 1,967.50 0.00 0.00<br />

31614 S 1,025.96 0.00 0.00 33217 S 1,967.50 0.00 0.00<br />

31615 S 303.57 0.00 0.00 33218 S 862.38 0.00 0.00<br />

31622 S 355.52 0.00 0.00 33220 S 862.38 0.00 0.00<br />

31623 S 408.72 0.00 0.00 33222 S 521.27 0.00 0.00<br />

31624 S 408.72 0.00 0.00 33223 S 521.27 0.00 0.00<br />

31625 S 408.72 0.00 0.00 33224 S 7,843.85 4,696.09 1,548.34<br />

31628 S 408.72 0.00 0.00 33225 S 7,843.85 4,696.09 1,548.34<br />

31629 S 408.72 0.00 0.00 33226 S 862.38 0.00 0.00<br />

31630 S 700.38 0.00 0.00 33233 S 641.16 0.00 0.00<br />

31631 S 700.38 0.00 0.00 33234 S 862.38 0.00 0.00<br />

31632 S 397.51 0.00 0.00 33235 S 862.38 0.00 0.00<br />

31633 S 397.51 0.00 0.00 33240 S 19,552.71 10,451.72 1,350.74<br />

31635 S 408.72 0.00 0.00 33241 S 862.38 0.00 0.00<br />

31636 S 700.38 0.00 0.00 33249 S 26,094.59 13,977.34 1,860.09<br />

31637 S 355.52 0.00 0.00 33282 S 4,125.72 2,469.90 814.08<br />

31638 S 700.38 0.00 0.00 33284 S 321.80 0.00 0.00<br />

31640 S 700.38 0.00 0.00 34490 S 1,571.10 0.00 0.00<br />

31641 S 700.38 0.00 0.00 35188 S 1,082.14 0.00 0.00<br />

31643 S 408.72 0.00 0.00 35207 S 1,082.14 0.00 0.00<br />

31645 S 355.52 0.00 0.00 35473 S 1,884.72 0.00 0.00<br />

31646 S 355.52 0.00 0.00 35476 S 1,884.72 0.00 0.00<br />

31656 S 355.52 0.00 0.00 35492 S 3,517.63 0.00 0.00<br />

31717 S 196.75 0.00 0.00 35761 S 1,131.58 0.00 0.00<br />

31720 S 30.13 0.00 0.00 35875 S 1,415.92 0.00 0.00<br />

31730 S 196.75 0.00 0.00 35876 S 1,415.92 0.00 0.00<br />

31750 S 1,153.54 0.00 0.00 36002 S 90.37 0.00 0.00<br />

31755 S 1,025.96 0.00 0.00 36260 S 819.78 0.00 0.00<br />

31820 S 492.73 0.00 0.00 36261 S 641.16 0.00 0.00<br />

31825 S 692.37 0.00 0.00 36262 S 587.95 0.00 0.00<br />

31830 S 692.37 0.00 0.00 36420 S 8.52 0.00 0.00<br />

32400 S 343.43 0.00 0.00 36425 S 8.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.73 0.00 0.00 36800 S 882.50 0.00 0.00<br />

36440 S 130.73 0.00 0.00 36810 S 882.50 0.00 0.00<br />

36450 S 130.73 0.00 0.00 36815 S 882.50 0.00 0.00<br />

36455 S 130.73 0.00 0.00 36818 S 1,025.65 0.00 0.00<br />

36468 S 32.27 0.00 0.00 36819 S 1,025.65 0.00 0.00<br />

36469 S 32.27 0.00 0.00 36820 S 1,025.65 0.00 0.00<br />

36470 S 32.27 0.00 0.00 36821 S 1,025.65 0.00 0.00<br />

36471 S 32.27 0.00 0.00 36825 S 1,082.14 0.00 0.00<br />

36475 S 1,483.74 0.00 0.00 36830 S 1,082.14 0.00 0.00<br />

36476 S 1,163.56 0.00 0.00 36831 S 1,415.92 0.00 0.00<br />

36478 S 1,163.56 0.00 0.00 36832 S 1,082.14 0.00 0.00<br />

36479 S 1,163.56 0.00 0.00 36833 S 1,082.14 0.00 0.00<br />

36511 S 448.21 0.00 0.00 36834 S 1,025.65 0.00 0.00<br />

36512 S 448.21 0.00 0.00 36835 S 939.00 0.00 0.00<br />

36513 S 448.21 0.00 0.00 36860 S 107.77 0.00 0.00<br />

36514 S 448.21 0.00 0.00 36861 S 882.50 0.00 0.00<br />

36515 S 1,199.86 0.00 0.00 36870 S 1,543.36 0.00 0.00<br />

36516 S 1,199.86 0.00 0.00 37184 S 1,571.10 0.00 0.00<br />

36522 S 1,199.86 0.00 0.00 37185 S 1,571.10 0.00 0.00<br />

36555 S 372.40 0.00 0.00 37186 S 1,571.10 0.00 0.00<br />

36556 S 372.40 0.00 0.00 37187 S 1,571.10 0.00 0.00<br />

36557 S 695.49 0.00 0.00 37188 S 1,571.10 0.00 0.00<br />

36558 S 695.49 0.00 0.00 37200 S 1,159.38 0.00 0.00<br />

36560 S 819.78 0.00 0.00 37203 S 1,159.38 0.00 0.00<br />

36561 S 819.78 0.00 0.00 37500 S 1,093.47 0.00 0.00<br />

36563 S 819.78 0.00 0.00 37607 S 773.29 0.00 0.00<br />

36565 S 819.78 0.00 0.00 37609 S 519.75 0.00 0.00<br />

36566 S 819.78 0.00 0.00 37650 S 743.15 0.00 0.00<br />

36568 S 372.40 0.00 0.00 37700 S 743.15 0.00 0.00<br />

36569 S 372.40 0.00 0.00 37718 S 773.29 0.00 0.00<br />

36570 S 725.62 0.00 0.00 37722 S 1,093.47 0.00 0.00<br />

36571 S 725.62 0.00 0.00 37735 S 1,093.47 0.00 0.00<br />

36575 S 299.52 0.00 0.00 37760 S 773.29 0.00 0.00<br />

36576 S 425.60 0.00 0.00 37765 S 1,066.38 0.00 0.00<br />

36578 S 695.49 0.00 0.00 37766 S 1,066.38 0.00 0.00<br />

36580 S 372.40 0.00 0.00 37780 S 773.29 0.00 0.00<br />

36581 S 695.49 0.00 0.00 37785 S 773.29 0.00 0.00<br />

36582 S 819.78 0.00 0.00 37790 S 933.13 0.00 0.00<br />

36583 S 819.78 0.00 0.00 38205 S 448.21 0.00 0.00<br />

36584 S 372.40 0.00 0.00 38206 S 448.21 0.00 0.00<br />

36585 S 725.62 0.00 0.00 38220 S 102.74 0.00 0.00<br />

36589 S 246.32 0.00 0.00 38221 S 107.62 0.00 0.00<br />

36590 S 372.40 0.00 0.00 38230 S 1,199.86 0.00 0.00<br />

36593 S 24.73 0.00 0.00 38241 S 1,199.86 0.00 0.00<br />

36595 S 971.05 0.00 0.00 38242 S 448.21 0.00 0.00<br />

36596 S 431.26 0.00 0.00 38300 S 402.21 0.00 0.00<br />

36597 S 431.26 0.00 0.00 38305 S 587.77 0.00 0.00<br />

36598 S 79.75 0.00 0.00 38308 S 671.60 0.00 0.00<br />

36640 S 736.45 0.00 0.00 38500 S 671.60 0.00 0.00<br />

36680 S 55.82 0.00 0.00 38505 S 256.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 671.60 0.00 0.00 41005 S 135.40 0.00 0.00<br />

38520 S 671.60 0.00 0.00 41006 S 639.18 0.00 0.00<br />

38525 S 671.60 0.00 0.00 41007 S 492.73 0.00 0.00<br />

38530 S 671.60 0.00 0.00 41008 S 492.73 0.00 0.00<br />

38542 S 1,129.88 0.00 0.00 41009 S 135.40 0.00 0.00<br />

38550 S 701.74 0.00 0.00 41010 S 303.57 0.00 0.00<br />

38555 S 758.23 0.00 0.00 41015 S 135.40 0.00 0.00<br />

38570 S 1,533.07 0.00 0.00 41016 S 303.57 0.00 0.00<br />

38571 S 1,992.96 0.00 0.00 41017 S 303.57 0.00 0.00<br />

38572 S 1,533.07 0.00 0.00 41018 S 303.57 0.00 0.00<br />

38700 S 923.28 0.00 0.00 41019 S 964.83 0.00 0.00<br />

38740 S 1,129.88 0.00 0.00 41100 S 90.89 0.00 0.00<br />

38745 S 1,216.50 0.00 0.00 41105 S 89.85 0.00 0.00<br />

38760 S 671.60 0.00 0.00 41108 S 83.23 0.00 0.00<br />

40490 S 68.61 0.00 0.00 41110 S 120.50 0.00 0.00<br />

40500 S 545.92 0.00 0.00 41112 S 545.92 0.00 0.00<br />

40510 S 692.37 0.00 0.00 41113 S 545.92 0.00 0.00<br />

40520 S 545.92 0.00 0.00 41114 S 692.37 0.00 0.00<br />

40525 S 692.37 0.00 0.00 41115 S 140.35 0.00 0.00<br />

40527 S 692.37 0.00 0.00 41116 S 492.73 0.00 0.00<br />

40530 S 692.37 0.00 0.00 41120 S 819.96 0.00 0.00<br />

40650 S 365.31 0.00 0.00 41250 S 92.60 0.00 0.00<br />

40652 S 365.31 0.00 0.00 41251 S 135.40 0.00 0.00<br />

40654 S 365.31 0.00 0.00 41252 S 356.76 0.00 0.00<br />

40700 S 1,284.42 0.00 0.00 41500 S 639.18 0.00 0.00<br />

40701 S 1,284.42 0.00 0.00 41510 S 492.73 0.00 0.00<br />

40702 S 1,631.99 0.00 0.00 41520 S 356.76 0.00 0.00<br />

40720 S 1,284.42 0.00 0.00 41530 S 671.91 0.00 0.00<br />

40761 S 1,056.10 0.00 0.00 41800 S 69.18 0.00 0.00<br />

40800 S 55.06 0.00 0.00 41805 S 149.75 0.00 0.00<br />

40801 S 356.76 0.00 0.00 41806 S 184.57 0.00 0.00<br />

40804 S 25.18 0.00 0.00 41820 S 293.59 0.00 0.00<br />

40805 S 170.30 0.00 0.00 41821 S 293.59 0.00 0.00<br />

40806 S 78.36 0.00 0.00 41822 S 152.88 0.00 0.00<br />

40808 S 116.32 0.00 0.00 41823 S 222.89 0.00 0.00<br />

40810 S 120.50 0.00 0.00 41825 S 122.58 0.00 0.00<br />

40812 S 151.15 0.00 0.00 41826 S 154.28 0.00 0.00<br />

40814 S 545.92 0.00 0.00 41827 S 692.37 0.00 0.00<br />

40816 S 692.37 0.00 0.00 41828 S 139.31 0.00 0.00<br />

40818 S 135.40 0.00 0.00 41830 S 197.81 0.00 0.00<br />

40819 S 303.57 0.00 0.00 41850 S 671.91 0.00 0.00<br />

40820 S 173.78 0.00 0.00 41870 S 964.83 0.00 0.00<br />

40830 S 128.89 0.00 0.00 41872 S 197.81 0.00 0.00<br />

40831 S 303.57 0.00 0.00 41874 S 190.84 0.00 0.00<br />

40840 S 692.37 0.00 0.00 42000 S 135.40 0.00 0.00<br />

40842 S 722.51 0.00 0.00 42100 S 77.32 0.00 0.00<br />

40843 S 722.51 0.00 0.00 42104 S 114.93 0.00 0.00<br />

40844 S 1,153.54 0.00 0.00 42106 S 144.18 0.00 0.00<br />

40845 S 1,153.54 0.00 0.00 42107 S 692.37 0.00 0.00<br />

41000 S 86.37 0.00 0.00 42120 S 1,112.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 356.76 0.00 0.00 42809 S 25.18 0.00 0.00<br />

42145 S 819.96 0.00 0.00 42810 S 722.51 0.00 0.00<br />

42160 S 136.52 0.00 0.00 42815 S 1,153.54 0.00 0.00<br />

42180 S 135.40 0.00 0.00 42820 S 722.51 0.00 0.00<br />

42182 S 1,025.96 0.00 0.00 42821 S 819.96 0.00 0.00<br />

42200 S 1,153.54 0.00 0.00 42825 S 779.00 0.00 0.00<br />

42205 S 1,153.54 0.00 0.00 42826 S 779.00 0.00 0.00<br />

42210 S 1,153.54 0.00 0.00 42830 S 779.00 0.00 0.00<br />

42215 S 1,284.42 0.00 0.00 42831 S 779.00 0.00 0.00<br />

42220 S 1,153.54 0.00 0.00 42835 S 779.00 0.00 0.00<br />

42226 S 1,153.54 0.00 0.00 42836 S 779.00 0.00 0.00<br />

42235 S 673.51 0.00 0.00 42860 S 722.51 0.00 0.00<br />

42260 S 779.00 0.00 0.00 42870 S 722.51 0.00 0.00<br />

42280 S 75.22 0.00 0.00 42890 S 1,284.42 0.00 0.00<br />

42281 S 671.91 0.00 0.00 42892 S 1,284.42 0.00 0.00<br />

42300 S 492.73 0.00 0.00 42900 S 303.57 0.00 0.00<br />

42305 S 545.92 0.00 0.00 42950 S 692.37 0.00 0.00<br />

42310 S 135.40 0.00 0.00 42955 S 692.37 0.00 0.00<br />

42320 S 135.40 0.00 0.00 42960 S 55.77 0.00 0.00<br />

42330 S 116.32 0.00 0.00 42962 S 1,025.96 0.00 0.00<br />

42335 S 192.94 0.00 0.00 42970 S 43.30 0.00 0.00<br />

42340 S 545.92 0.00 0.00 42972 S 576.06 0.00 0.00<br />

42400 S 65.48 0.00 0.00 43030 S 671.91 0.00 0.00<br />

42405 S 545.92 0.00 0.00 43200 S 325.38 0.00 0.00<br />

42408 S 576.06 0.00 0.00 43201 S 325.38 0.00 0.00<br />

42409 S 576.06 0.00 0.00 43202 S 325.38 0.00 0.00<br />

42410 S 1,056.10 0.00 0.00 43204 S 325.38 0.00 0.00<br />

42415 S 1,284.42 0.00 0.00 43205 S 325.38 0.00 0.00<br />

42420 S 1,284.42 0.00 0.00 43215 S 325.38 0.00 0.00<br />

42425 S 1,284.42 0.00 0.00 43216 S 325.38 0.00 0.00<br />

42440 S 1,056.10 0.00 0.00 43217 S 325.38 0.00 0.00<br />

42450 S 692.37 0.00 0.00 43219 S 657.59 0.00 0.00<br />

42500 S 722.51 0.00 0.00 43220 S 325.38 0.00 0.00<br />

42505 S 1,112.58 0.00 0.00 43226 S 325.38 0.00 0.00<br />

42507 S 1,056.10 0.00 0.00 43227 S 378.58 0.00 0.00<br />

42508 S 1,112.58 0.00 0.00 43228 S 704.51 0.00 0.00<br />

42509 S 1,112.58 0.00 0.00 43231 S 378.58 0.00 0.00<br />

42510 S 1,112.58 0.00 0.00 43232 S 378.58 0.00 0.00<br />

42600 S 492.73 0.00 0.00 43234 S 325.38 0.00 0.00<br />

42650 S 42.83 0.00 0.00 43235 S 325.38 0.00 0.00<br />

42660 S 50.15 0.00 0.00 43236 S 378.58 0.00 0.00<br />

42665 S 950.84 0.00 0.00 43237 S 378.58 0.00 0.00<br />

42700 S 135.40 0.00 0.00 43238 S 378.58 0.00 0.00<br />

42720 S 492.73 0.00 0.00 43239 S 378.58 0.00 0.00<br />

42725 S 1,025.96 0.00 0.00 43240 S 378.58 0.00 0.00<br />

42800 S 82.89 0.00 0.00 43241 S 378.58 0.00 0.00<br />

42802 S 492.73 0.00 0.00 43242 S 378.58 0.00 0.00<br />

42804 S 492.73 0.00 0.00 43243 S 378.58 0.00 0.00<br />

42806 S 692.37 0.00 0.00 43244 S 378.58 0.00 0.00<br />

42808 S 545.92 0.00 0.00 43245 S 378.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 378.58 0.00 0.00 44378 S 396.50 0.00 0.00<br />

43247 S 378.58 0.00 0.00 44379 S 1,131.20 0.00 0.00<br />

43248 S 378.58 0.00 0.00 44380 S 343.30 0.00 0.00<br />

43249 S 378.58 0.00 0.00 44382 S 343.30 0.00 0.00<br />

43250 S 378.58 0.00 0.00 44383 S 1,131.20 0.00 0.00<br />

43251 S 378.58 0.00 0.00 44385 S 331.93 0.00 0.00<br />

43255 S 378.58 0.00 0.00 44386 S 331.93 0.00 0.00<br />

43256 S 740.92 0.00 0.00 44388 S 331.93 0.00 0.00<br />

43257 S 734.65 0.00 0.00 44389 S 331.93 0.00 0.00<br />

43258 S 408.71 0.00 0.00 44390 S 331.93 0.00 0.00<br />

43259 S 408.71 0.00 0.00 44391 S 331.93 0.00 0.00<br />

43260 S 637.34 0.00 0.00 44392 S 331.93 0.00 0.00<br />

43261 S 637.34 0.00 0.00 44393 S 331.93 0.00 0.00<br />

43262 S 637.34 0.00 0.00 44394 S 331.93 0.00 0.00<br />

43263 S 637.34 0.00 0.00 44397 S 657.59 0.00 0.00<br />

43264 S 637.34 0.00 0.00 44500 S 179.12 0.00 0.00<br />

43265 S 637.34 0.00 0.00 45000 S 384.93 0.00 0.00<br />

43267 S 637.34 0.00 0.00 45005 S 447.98 0.00 0.00<br />

43268 S 710.80 0.00 0.00 45020 S 447.98 0.00 0.00<br />

43269 S 710.80 0.00 0.00 45100 S 608.63 0.00 0.00<br />

43271 S 637.34 0.00 0.00 45108 S 661.82 0.00 0.00<br />

43272 S 637.34 0.00 0.00 45150 S 661.82 0.00 0.00<br />

43273 S 854.76 0.00 0.00 45160 S 661.82 0.00 0.00<br />

43450 S 284.56 0.00 0.00 45170 S 661.82 0.00 0.00<br />

43453 S 284.56 0.00 0.00 45190 S 1,082.23 0.00 0.00<br />

43456 S 285.69 0.00 0.00 45300 S 64.08 0.00 0.00<br />

43458 S 326.52 0.00 0.00 45303 S 355.93 0.00 0.00<br />

43600 S 325.38 0.00 0.00 45305 S 334.73 0.00 0.00<br />

43653 S 1,533.07 0.00 0.00 45307 S 618.27 0.00 0.00<br />

43760 S 157.81 0.00 0.00 45308 S 334.73 0.00 0.00<br />

43761 S 325.38 0.00 0.00 45309 S 334.73 0.00 0.00<br />

43870 S 325.38 0.00 0.00 45315 S 334.73 0.00 0.00<br />

43886 S 821.01 0.00 0.00 45317 S 334.73 0.00 0.00<br />

43887 S 172.68 0.00 0.00 45320 S 618.27 0.00 0.00<br />

43888 S 821.01 0.00 0.00 45321 S 618.27 0.00 0.00<br />

44100 S 325.38 0.00 0.00 45327 S 657.59 0.00 0.00<br />

44312 S 567.27 0.00 0.00 45330 S 84.63 0.00 0.00<br />

44340 S 650.60 0.00 0.00 45331 S 250.25 0.00 0.00<br />

44360 S 396.50 0.00 0.00 45332 S 250.25 0.00 0.00<br />

44361 S 396.50 0.00 0.00 45333 S 334.73 0.00 0.00<br />

44363 S 396.50 0.00 0.00 45334 S 334.73 0.00 0.00<br />

44364 S 396.50 0.00 0.00 45335 S 250.25 0.00 0.00<br />

44365 S 396.50 0.00 0.00 45337 S 250.25 0.00 0.00<br />

44366 S 396.50 0.00 0.00 45338 S 334.73 0.00 0.00<br />

44369 S 396.50 0.00 0.00 45339 S 334.73 0.00 0.00<br />

44370 S 1,131.20 0.00 0.00 45340 S 334.73 0.00 0.00<br />

44372 S 396.50 0.00 0.00 45341 S 334.73 0.00 0.00<br />

44373 S 396.50 0.00 0.00 45342 S 334.73 0.00 0.00<br />

44376 S 396.50 0.00 0.00 45345 S 657.59 0.00 0.00<br />

44377 S 396.50 0.00 0.00 45355 S 331.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 385.13 0.00 0.00 46505 S 476.02 0.00 0.00<br />

45379 S 385.13 0.00 0.00 46600 S 25.18 0.00 0.00<br />

45380 S 385.13 0.00 0.00 46604 S 355.93 0.00 0.00<br />

45381 S 385.13 0.00 0.00 46606 S 133.74 0.00 0.00<br />

45382 S 385.13 0.00 0.00 46608 S 334.73 0.00 0.00<br />

45383 S 385.13 0.00 0.00 46610 S 618.27 0.00 0.00<br />

45384 S 385.13 0.00 0.00 46611 S 334.73 0.00 0.00<br />

45385 S 385.13 0.00 0.00 46612 S 618.27 0.00 0.00<br />

45386 S 385.13 0.00 0.00 46614 S 70.34 0.00 0.00<br />

45387 S 657.59 0.00 0.00 46615 S 671.47 0.00 0.00<br />

45391 S 385.13 0.00 0.00 46700 S 691.96 0.00 0.00<br />

45392 S 385.13 0.00 0.00 46706 S 761.64 0.00 0.00<br />

45500 S 661.82 0.00 0.00 46750 S 844.97 0.00 0.00<br />

45505 S 814.84 0.00 0.00 46753 S 691.96 0.00 0.00<br />

45520 S 32.27 0.00 0.00 46754 S 661.82 0.00 0.00<br />

45560 S 814.84 0.00 0.00 46760 S 814.84 0.00 0.00<br />

45900 S 260.95 0.00 0.00 46761 S 844.97 0.00 0.00<br />

45905 S 608.63 0.00 0.00 46762 S 1,073.29 0.00 0.00<br />

45910 S 608.63 0.00 0.00 46900 S 106.35 0.00 0.00<br />

45915 S 384.93 0.00 0.00 46910 S 127.11 0.00 0.00<br />

45990 S 598.77 0.00 0.00 46916 S 59.12 0.00 0.00<br />

46020 S 691.96 0.00 0.00 46917 S 551.53 0.00 0.00<br />

46030 S 260.95 0.00 0.00 46922 S 551.53 0.00 0.00<br />

46040 S 691.96 0.00 0.00 46924 S 551.53 0.00 0.00<br />

46045 S 661.82 0.00 0.00 46930 S 123.29 0.00 0.00<br />

46050 S 384.93 0.00 0.00 46937 S 661.82 0.00 0.00<br />

46060 S 661.82 0.00 0.00 46938 S 814.84 0.00 0.00<br />

46070 S 476.02 0.00 0.00 46940 S 91.24 0.00 0.00<br />

46080 S 691.96 0.00 0.00 46942 S 88.81 0.00 0.00<br />

46083 S 72.86 0.00 0.00 46945 S 151.15 0.00 0.00<br />

46200 S 661.82 0.00 0.00 46946 S 394.78 0.00 0.00<br />

46210 S 661.82 0.00 0.00 46947 S 1,073.29 0.00 0.00<br />

46211 S 661.82 0.00 0.00 47000 S 343.43 0.00 0.00<br />

46220 S 608.63 0.00 0.00 47382 S 1,812.33 0.00 0.00<br />

46221 S 119.80 0.00 0.00 47510 S 802.61 0.00 0.00<br />

46230 S 608.63 0.00 0.00 47511 S 1,179.15 0.00 0.00<br />

46250 S 691.96 0.00 0.00 47525 S 460.76 0.00 0.00<br />

46255 S 691.96 0.00 0.00 47530 S 460.76 0.00 0.00<br />

46257 S 691.96 0.00 0.00 47552 S 802.61 0.00 0.00<br />

46258 S 691.96 0.00 0.00 47553 S 832.73 0.00 0.00<br />

46260 S 691.96 0.00 0.00 47554 S 832.73 0.00 0.00<br />

46261 S 748.45 0.00 0.00 47555 S 832.73 0.00 0.00<br />

46262 S 748.45 0.00 0.00 47556 S 1,179.15 0.00 0.00<br />

46270 S 691.96 0.00 0.00 47560 S 978.43 0.00 0.00<br />

46275 S 691.96 0.00 0.00 47561 S 978.43 0.00 0.00<br />

46280 S 748.45 0.00 0.00 47562 S 1,805.41 0.00 0.00<br />

46285 S 608.63 0.00 0.00 47563 S 1,805.41 0.00 0.00<br />

46288 S 748.45 0.00 0.00 47564 S 1,805.41 0.00 0.00<br />

46320 S 81.15 0.00 0.00 47630 S 832.73 0.00 0.00<br />

46500 S 111.79 0.00 0.00 48102 S 343.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 208.83 0.00 0.00 49590 S 857.11 0.00 0.00<br />

49081 S 208.83 0.00 0.00 49600 S 913.60 0.00 0.00<br />

49180 S 343.43 0.00 0.00 49650 S 1,199.29 0.00 0.00<br />

49250 S 752.80 0.00 0.00 49651 S 1,371.13 0.00 0.00<br />

49320 S 978.43 0.00 0.00 49652 S 1,476.67 0.00 0.00<br />

49321 S 1,034.93 0.00 0.00 49653 S 1,476.67 0.00 0.00<br />

49322 S 1,034.93 0.00 0.00 49654 S 1,476.67 0.00 0.00<br />

49324 S 1,476.67 0.00 0.00 49655 S 1,476.67 0.00 0.00<br />

49325 S 1,476.67 0.00 0.00 49656 S 1,476.67 0.00 0.00<br />

49326 S 1,476.67 0.00 0.00 49657 S 1,476.67 0.00 0.00<br />

49402 S 666.18 0.00 0.00 50200 S 343.43 0.00 0.00<br />

49419 S 799.17 0.00 0.00 50382 S 997.23 0.00 0.00<br />

49420 S 738.78 0.00 0.00 50384 S 732.45 0.00 0.00<br />

49421 S 738.78 0.00 0.00 50385 S 732.45 0.00 0.00<br />

49422 S 587.95 0.00 0.00 50386 S 281.02 0.00 0.00<br />

49423 S 607.97 0.00 0.00 50387 S 607.97 0.00 0.00<br />

49426 S 666.18 0.00 0.00 50389 S 281.02 0.00 0.00<br />

49429 S 862.38 0.00 0.00 50390 S 343.43 0.00 0.00<br />

49440 S 337.23 0.00 0.00 50391 S 40.67 0.00 0.00<br />

49441 S 337.23 0.00 0.00 50392 S 522.99 0.00 0.00<br />

49446 S 337.23 0.00 0.00 50393 S 655.38 0.00 0.00<br />

49450 S 179.12 0.00 0.00 50395 S 522.99 0.00 0.00<br />

49451 S 179.12 0.00 0.00 50396 S 98.34 0.00 0.00<br />

49452 S 179.12 0.00 0.00 50398 S 460.76 0.00 0.00<br />

49460 S 179.12 0.00 0.00 50551 S 297.28 0.00 0.00<br />

49495 S 913.60 0.00 0.00 50553 S 655.38 0.00 0.00<br />

49496 S 913.60 0.00 0.00 50555 S 297.28 0.00 0.00<br />

49500 S 913.60 0.00 0.00 50557 S 655.38 0.00 0.00<br />

49501 S 1,247.38 0.00 0.00 50561 S 655.38 0.00 0.00<br />

49505 S 913.60 0.00 0.00 50562 S 281.02 0.00 0.00<br />

49507 S 1,247.38 0.00 0.00 50570 S 281.02 0.00 0.00<br />

49520 S 1,085.44 0.00 0.00 50572 S 281.02 0.00 0.00<br />

49521 S 1,247.38 0.00 0.00 50574 S 281.02 0.00 0.00<br />

49525 S 913.60 0.00 0.00 50575 S 1,397.84 0.00 0.00<br />

49540 S 826.98 0.00 0.00 50576 S 732.45 0.00 0.00<br />

49550 S 954.56 0.00 0.00 50580 S 732.45 0.00 0.00<br />

49553 S 1,247.38 0.00 0.00 50590 S 1,633.00 0.00 0.00<br />

49555 S 954.56 0.00 0.00 50592 S 1,812.33 0.00 0.00<br />

49557 S 1,247.38 0.00 0.00 50686 S 40.67 0.00 0.00<br />

49560 S 913.60 0.00 0.00 50688 S 460.76 0.00 0.00<br />

49561 S 1,247.38 0.00 0.00 50947 S 1,533.07 0.00 0.00<br />

49565 S 913.60 0.00 0.00 50948 S 1,533.07 0.00 0.00<br />

49566 S 1,247.38 0.00 0.00 50951 S 297.28 0.00 0.00<br />

49568 S 1,085.44 0.00 0.00 50953 S 297.28 0.00 0.00<br />

49570 S 913.60 0.00 0.00 50955 S 655.38 0.00 0.00<br />

49572 S 1,247.38 0.00 0.00 50957 S 655.38 0.00 0.00<br />

49580 S 913.60 0.00 0.00 50961 S 655.38 0.00 0.00<br />

49582 S 1,247.38 0.00 0.00 50970 S 297.28 0.00 0.00<br />

49585 S 913.60 0.00 0.00 50972 S 297.28 0.00 0.00<br />

49587 S 1,247.38 0.00 0.00 50974 S 522.99 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 522.99 0.00 0.00 52275 S 708.59 0.00 0.00<br />

50980 S 655.38 0.00 0.00 52276 S 738.71 0.00 0.00<br />

51020 S 795.21 0.00 0.00 52277 S 708.59 0.00 0.00<br />

51030 S 795.21 0.00 0.00 52281 S 576.18 0.00 0.00<br />

51040 S 795.21 0.00 0.00 52282 S 1,329.29 0.00 0.00<br />

51045 S 328.46 0.00 0.00 52283 S 708.59 0.00 0.00<br />

51050 S 795.21 0.00 0.00 52285 S 576.18 0.00 0.00<br />

51065 S 795.21 0.00 0.00 52290 S 576.18 0.00 0.00<br />

51080 S 534.57 0.00 0.00 52300 S 708.59 0.00 0.00<br />

51100 S 31.00 0.00 0.00 52301 S 738.71 0.00 0.00<br />

51101 S 40.67 0.00 0.00 52305 S 708.59 0.00 0.00<br />

51102 S 547.18 0.00 0.00 52310 S 554.17 0.00 0.00<br />

51500 S 913.60 0.00 0.00 52315 S 708.59 0.00 0.00<br />

51520 S 795.21 0.00 0.00 52317 S 655.38 0.00 0.00<br />

51700 S 52.93 0.00 0.00 52318 S 708.59 0.00 0.00<br />

51701 S 25.18 0.00 0.00 52320 S 836.16 0.00 0.00<br />

51702 S 25.18 0.00 0.00 52325 S 795.21 0.00 0.00<br />

51703 S 40.67 0.00 0.00 52327 S 908.89 0.00 0.00<br />

51705 S 72.86 0.00 0.00 52330 S 708.59 0.00 0.00<br />

51710 S 460.76 0.00 0.00 52332 S 708.59 0.00 0.00<br />

51715 S 836.60 0.00 0.00 52334 S 738.71 0.00 0.00<br />

51720 S 58.51 0.00 0.00 52341 S 738.71 0.00 0.00<br />

51725 TC S 112.40 0.00 0.00 52342 S 738.71 0.00 0.00<br />

51726 TC S 154.81 0.00 0.00 52343 S 738.71 0.00 0.00<br />

51736 TC S 21.24 0.00 0.00 52344 S 738.71 0.00 0.00<br />

51741 TC S 24.73 0.00 0.00 52345 S 738.71 0.00 0.00<br />

51772 TC S 98.34 0.00 0.00 52346 S 738.71 0.00 0.00<br />

51784 TC S 40.67 0.00 0.00 52351 S 738.71 0.00 0.00<br />

51785 TC S 67.94 0.00 0.00 52352 S 795.21 0.00 0.00<br />

51792 TC S 40.67 0.00 0.00 52353 S 995.51 0.00 0.00<br />

51795 TC S 72.86 0.00 0.00 52354 S 795.21 0.00 0.00<br />

51797 TC S 72.86 0.00 0.00 52355 S 795.21 0.00 0.00<br />

51798 S 18.11 0.00 0.00 52400 S 738.71 0.00 0.00<br />

51880 S 655.38 0.00 0.00 52402 S 738.71 0.00 0.00<br />

51992 S 1,240.26 0.00 0.00 52450 S 738.71 0.00 0.00<br />

52000 S 297.28 0.00 0.00 52500 S 738.71 0.00 0.00<br />

52001 S 554.17 0.00 0.00 52601 S 995.51 0.00 0.00<br />

52005 S 576.18 0.00 0.00 52630 S 908.89 0.00 0.00<br />

52007 S 708.59 0.00 0.00 52640 S 708.59 0.00 0.00<br />

52010 S 328.46 0.00 0.00 52647 S 1,523.04 0.00 0.00<br />

52204 S 576.18 0.00 0.00 52648 S 1,523.04 0.00 0.00<br />

52214 S 708.59 0.00 0.00 52700 S 708.59 0.00 0.00<br />

52224 S 708.59 0.00 0.00 53000 S 543.84 0.00 0.00<br />

52234 S 708.59 0.00 0.00 53010 S 543.84 0.00 0.00<br />

52235 S 738.71 0.00 0.00 53020 S 543.84 0.00 0.00<br />

52240 S 738.71 0.00 0.00 53025 S 774.13 0.00 0.00<br />

52250 S 795.21 0.00 0.00 53040 S 597.04 0.00 0.00<br />

52260 S 576.18 0.00 0.00 53060 S 70.70 0.00 0.00<br />

52265 S 281.02 0.00 0.00 53080 S 627.17 0.00 0.00<br />

52270 S 576.18 0.00 0.00 53085 S 774.13 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 543.84 0.00 0.00 54060 S 551.53 0.00 0.00<br />

53210 S 934.04 0.00 0.00 54065 S 551.53 0.00 0.00<br />

53215 S 724.62 0.00 0.00 54100 S 466.56 0.00 0.00<br />

53220 S 806.46 0.00 0.00 54105 S 582.42 0.00 0.00<br />

53230 S 806.46 0.00 0.00 54110 S 903.00 0.00 0.00<br />

53235 S 627.17 0.00 0.00 54111 S 903.00 0.00 0.00<br />

53240 S 806.46 0.00 0.00 54112 S 903.00 0.00 0.00<br />

53250 S 597.04 0.00 0.00 54115 S 534.57 0.00 0.00<br />

53260 S 597.04 0.00 0.00 54120 S 903.00 0.00 0.00<br />

53265 S 597.04 0.00 0.00 54150 S 601.80 0.00 0.00<br />

53270 S 597.04 0.00 0.00 54160 S 655.01 0.00 0.00<br />

53275 S 597.04 0.00 0.00 54161 S 655.01 0.00 0.00<br />

53400 S 836.60 0.00 0.00 54162 S 655.01 0.00 0.00<br />

53405 S 806.46 0.00 0.00 54163 S 655.01 0.00 0.00<br />

53410 S 806.46 0.00 0.00 54164 S 655.01 0.00 0.00<br />

53420 S 836.60 0.00 0.00 54200 S 68.61 0.00 0.00<br />

53425 S 806.46 0.00 0.00 54205 S 989.62 0.00 0.00<br />

53430 S 806.46 0.00 0.00 54220 S 98.34 0.00 0.00<br />

53431 S 806.46 0.00 0.00 54231 S 64.42 0.00 0.00<br />

53440 S 4,645.53 2,821.44 997.36 54235 S 45.62 0.00 0.00<br />

53442 S 753.26 0.00 0.00 54240 TC S 32.39 0.00 0.00<br />

53444 S 4,645.53 2,821.44 997.36 54250 TC S 11.49 0.00 0.00<br />

53445 S 7,803.31 4,443.93 1,084.56 54300 S 933.13 0.00 0.00<br />

53446 S 753.26 0.00 0.00 54304 S 933.13 0.00 0.00<br />

53447 S 7,803.31 4,443.93 1,084.56 54308 S 933.13 0.00 0.00<br />

53449 S 753.26 0.00 0.00 54312 S 933.13 0.00 0.00<br />

53450 S 753.26 0.00 0.00 54316 S 933.13 0.00 0.00<br />

53460 S 543.84 0.00 0.00 54318 S 933.13 0.00 0.00<br />

53502 S 597.04 0.00 0.00 54322 S 933.13 0.00 0.00<br />

53505 S 806.46 0.00 0.00 54324 S 933.13 0.00 0.00<br />

53510 S 597.04 0.00 0.00 54326 S 933.13 0.00 0.00<br />

53515 S 806.46 0.00 0.00 54328 S 933.13 0.00 0.00<br />

53520 S 806.46 0.00 0.00 54340 S 933.13 0.00 0.00<br />

53600 S 40.75 0.00 0.00 54344 S 933.13 0.00 0.00<br />

53601 S 40.67 0.00 0.00 54348 S 933.13 0.00 0.00<br />

53605 S 576.18 0.00 0.00 54352 S 933.13 0.00 0.00<br />

53620 S 62.69 0.00 0.00 54360 S 933.13 0.00 0.00<br />

53621 S 65.82 0.00 0.00 54380 S 933.13 0.00 0.00<br />

53660 S 40.67 0.00 0.00 54385 S 933.13 0.00 0.00<br />

53661 S 40.67 0.00 0.00 54400 S 4,675.67 2,851.58 1,027.49<br />

53665 S 543.84 0.00 0.00 54401 S 7,886.64 4,527.26 1,167.89<br />

53850 S 1,785.35 0.00 0.00 54405 S 7,886.64 4,527.26 1,167.89<br />

53852 S 1,785.35 0.00 0.00 54406 S 933.13 0.00 0.00<br />

54000 S 597.04 0.00 0.00 54408 S 933.13 0.00 0.00<br />

54001 S 597.04 0.00 0.00 54410 S 7,886.64 4,527.26 1,167.89<br />

54015 S 674.39 0.00 0.00 54415 S 933.13 0.00 0.00<br />

54050 S 32.27 0.00 0.00 54416 S 7,886.64 4,527.26 1,167.89<br />

54055 S 65.82 0.00 0.00 54420 S 989.62 0.00 0.00<br />

54056 S 32.27 0.00 0.00 54435 S 989.62 0.00 0.00<br />

54057 S 551.53 0.00 0.00 54440 S 989.62 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 154.81 0.00 0.00 55706 S 450.06 0.00 0.00<br />

54500 S 420.18 0.00 0.00 55720 S 655.38 0.00 0.00<br />

54505 S 601.80 0.00 0.00 55725 S 708.59 0.00 0.00<br />

54512 S 655.01 0.00 0.00 55860 S 780.82 0.00 0.00<br />

54520 S 685.13 0.00 0.00 55870 S 79.40 0.00 0.00<br />

54522 S 685.13 0.00 0.00 55873 S 6,178.17 0.00 0.00<br />

54530 S 913.60 0.00 0.00 55875 S 1,329.29 0.00 0.00<br />

54550 S 913.60 0.00 0.00 55876 S 72.79 0.00 0.00<br />

54560 S 890.07 0.00 0.00 55920 S 912.43 0.00 0.00<br />

54600 S 741.63 0.00 0.00 56405 S 42.49 0.00 0.00<br />

54620 S 685.13 0.00 0.00 56420 S 55.45 0.00 0.00<br />

54640 S 913.60 0.00 0.00 56440 S 595.50 0.00 0.00<br />

54660 S 655.01 0.00 0.00 56441 S 542.29 0.00 0.00<br />

54670 S 685.13 0.00 0.00 56442 S 542.29 0.00 0.00<br />

54680 S 685.13 0.00 0.00 56501 S 58.51 0.00 0.00<br />

54690 S 1,533.07 0.00 0.00 56515 S 634.86 0.00 0.00<br />

54692 S 2,725.18 0.00 0.00 56605 S 33.78 0.00 0.00<br />

54700 S 655.01 0.00 0.00 56606 S 13.93 0.00 0.00<br />

54800 S 147.02 0.00 0.00 56620 S 723.07 0.00 0.00<br />

54830 S 685.13 0.00 0.00 56625 S 853.95 0.00 0.00<br />

54840 S 741.63 0.00 0.00 56700 S 542.29 0.00 0.00<br />

54860 S 685.13 0.00 0.00 56740 S 625.62 0.00 0.00<br />

54861 S 741.63 0.00 0.00 56800 S 625.62 0.00 0.00<br />

54865 S 601.80 0.00 0.00 56805 S 771.05 0.00 0.00<br />

54900 S 741.63 0.00 0.00 56810 S 723.07 0.00 0.00<br />

54901 S 741.63 0.00 0.00 56820 S 43.18 0.00 0.00<br />

55000 S 66.87 0.00 0.00 56821 S 55.45 0.00 0.00<br />

55040 S 857.11 0.00 0.00 57000 S 542.29 0.00 0.00<br />

55041 S 954.56 0.00 0.00 57010 S 595.50 0.00 0.00<br />

55060 S 741.63 0.00 0.00 57020 S 312.30 0.00 0.00<br />

55100 S 402.21 0.00 0.00 57022 S 490.89 0.00 0.00<br />

55110 S 655.01 0.00 0.00 57023 S 534.57 0.00 0.00<br />

55120 S 655.01 0.00 0.00 57061 S 53.98 0.00 0.00<br />

55150 S 601.80 0.00 0.00 57065 S 542.29 0.00 0.00<br />

55175 S 601.80 0.00 0.00 57100 S 34.48 0.00 0.00<br />

55180 S 655.01 0.00 0.00 57105 S 595.50 0.00 0.00<br />

55200 S 655.01 0.00 0.00 57130 S 595.50 0.00 0.00<br />

55250 S 655.01 0.00 0.00 57135 S 595.50 0.00 0.00<br />

55400 S 601.80 0.00 0.00 57150 S 25.08 0.00 0.00<br />

55450 S 215.22 0.00 0.00 57155 S 312.30 0.00 0.00<br />

55500 S 685.13 0.00 0.00 57160 S 36.22 0.00 0.00<br />

55520 S 741.63 0.00 0.00 57170 S 5.94 0.00 0.00<br />

55530 S 741.63 0.00 0.00 57180 S 111.55 0.00 0.00<br />

55535 S 913.60 0.00 0.00 57200 S 542.29 0.00 0.00<br />

55540 S 954.56 0.00 0.00 57210 S 595.50 0.00 0.00<br />

55550 S 1,533.07 0.00 0.00 57220 S 1,092.05 0.00 0.00<br />

55600 S 890.07 0.00 0.00 57230 S 896.68 0.00 0.00<br />

55680 S 601.80 0.00 0.00 57240 S 994.12 0.00 0.00<br />

55700 S 387.83 0.00 0.00 57250 S 994.12 0.00 0.00<br />

55705 S 387.83 0.00 0.00 57260 S 994.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,320.38 0.00 0.00 58555 S 585.92 0.00 0.00<br />

57267 S 1,125.00 0.00 0.00 58558 S 669.25 0.00 0.00<br />

57268 S 896.68 0.00 0.00 58559 S 639.12 0.00 0.00<br />

57287 S 1,313.16 0.00 0.00 58560 S 954.25 0.00 0.00<br />

57288 S 1,189.50 0.00 0.00 58561 S 954.25 0.00 0.00<br />

57289 S 994.12 0.00 0.00 58562 S 669.25 0.00 0.00<br />

57291 S 994.12 0.00 0.00 58563 S 1,344.52 0.00 0.00<br />

57300 S 896.68 0.00 0.00 58565 S 1,482.33 0.00 0.00<br />

57320 S 1,313.16 0.00 0.00 58600 S 1,313.16 0.00 0.00<br />

57400 S 595.50 0.00 0.00 58615 S 771.05 0.00 0.00<br />

57410 S 595.50 0.00 0.00 58660 S 1,240.26 0.00 0.00<br />

57415 S 595.50 0.00 0.00 58661 S 1,240.26 0.00 0.00<br />

57420 S 44.58 0.00 0.00 58662 S 1,240.26 0.00 0.00<br />

57421 S 58.16 0.00 0.00 58670 S 1,142.81 0.00 0.00<br />

57452 S 42.14 0.00 0.00 58671 S 1,142.81 0.00 0.00<br />

57454 S 51.54 0.00 0.00 58672 S 1,240.26 0.00 0.00<br />

57455 S 54.67 0.00 0.00 58673 S 1,240.26 0.00 0.00<br />

57456 S 52.93 0.00 0.00 58800 S 625.62 0.00 0.00<br />

57460 S 162.64 0.00 0.00 58805 S 1,313.16 0.00 0.00<br />

57461 S 172.74 0.00 0.00 58820 S 896.68 0.00 0.00<br />

57500 S 74.53 0.00 0.00 58900 S 625.62 0.00 0.00<br />

57505 S 47.36 0.00 0.00 58970 S 174.26 0.00 0.00<br />

57510 S 48.06 0.00 0.00 58974 S 174.26 0.00 0.00<br />

57511 S 55.45 0.00 0.00 58976 S 174.26 0.00 0.00<br />

57513 S 595.50 0.00 0.00 59000 S 63.73 0.00 0.00<br />

57520 S 595.50 0.00 0.00 59001 S 239.22 0.00 0.00<br />

57522 S 595.50 0.00 0.00 59012 S 116.97 0.00 0.00<br />

57530 S 896.68 0.00 0.00 59015 S 51.54 0.00 0.00<br />

57550 S 896.68 0.00 0.00 59020 TC S 27.16 0.00 0.00<br />

57556 S 1,189.50 0.00 0.00 59025 TC S 14.28 0.00 0.00<br />

57558 S 625.62 0.00 0.00 59070 S 116.97 0.00 0.00<br />

57700 S 542.29 0.00 0.00 59072 S 116.97 0.00 0.00<br />

57720 S 625.62 0.00 0.00 59076 S 116.97 0.00 0.00<br />

57800 S 25.42 0.00 0.00 59100 S 1,313.16 0.00 0.00<br />

58100 S 41.79 0.00 0.00 59150 S 1,805.41 0.00 0.00<br />

58120 S 595.50 0.00 0.00 59151 S 1,805.41 0.00 0.00<br />

58145 S 994.12 0.00 0.00 59160 S 625.62 0.00 0.00<br />

58301 S 39.00 0.00 0.00 59200 S 34.83 0.00 0.00<br />

58321 S 36.57 0.00 0.00 59300 S 75.22 0.00 0.00<br />

58322 S 37.61 0.00 0.00 59320 S 542.29 0.00 0.00<br />

58323 S 8.71 0.00 0.00 59412 S 771.05 0.00 0.00<br />

58345 S 771.05 0.00 0.00 59414 S 771.05 0.00 0.00<br />

58346 S 595.50 0.00 0.00 59812 S 723.07 0.00 0.00<br />

58350 S 896.68 0.00 0.00 59820 S 723.07 0.00 0.00<br />

58353 S 1,125.00 0.00 0.00 59821 S 723.07 0.00 0.00<br />

58356 S 1,703.92 0.00 0.00 59840 S 723.07 0.00 0.00<br />

58545 S 1,368.71 0.00 0.00 59841 S 723.07 0.00 0.00<br />

58546 S 1,533.07 0.00 0.00 59866 S 116.97 0.00 0.00<br />

58550 S 1,992.96 0.00 0.00 59870 S 723.07 0.00 0.00<br />

58552 S 1,805.41 0.00 0.00 59871 S 723.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 303.57 0.00 0.00 62367 S 16.71 0.00 0.00<br />

60100 S 47.71 0.00 0.00 62368 S 21.24 0.00 0.00<br />

60200 S 1,129.88 0.00 0.00 63600 S 570.69 0.00 0.00<br />

60280 S 1,216.50 0.00 0.00 63610 S 517.48 0.00 0.00<br />

60281 S 1,216.50 0.00 0.00 63615 S 721.44 0.00 0.00<br />

60300 S 62.69 0.00 0.00 63650 S 3,071.72 1,904.77 737.83<br />

61000 S 279.52 0.00 0.00 63655 S 4,499.32 2,869.22 1,239.14<br />

61001 S 279.52 0.00 0.00 63660 S 539.45 0.00 0.00<br />

61020 S 226.31 0.00 0.00 63685 S 13,656.47 7,281.75 907.05<br />

61026 S 226.31 0.00 0.00 63688 S 732.53 0.00 0.00<br />

61050 S 226.31 0.00 0.00 63744 S 1,059.35 0.00 0.00<br />

61055 S 226.31 0.00 0.00 63746 S 490.03 0.00 0.00<br />

61070 S 176.10 0.00 0.00 64400 S 53.63 0.00 0.00<br />

61215 S 1,059.35 0.00 0.00 64402 S 50.50 0.00 0.00<br />

61330 S 1,631.99 0.00 0.00 64405 S 42.83 0.00 0.00<br />

61334 S 1,631.99 0.00 0.00 64408 S 53.28 0.00 0.00<br />

61790 S 600.82 0.00 0.00 64410 S 296.53 0.00 0.00<br />

61791 S 445.74 0.00 0.00 64412 S 78.36 0.00 0.00<br />

61880 S 765.36 0.00 0.00 64413 S 50.15 0.00 0.00<br />

61885 S 11,013.71 5,899.94 786.17 64415 S 136.56 0.00 0.00<br />

61886 S 16,446.16 8,668.08 890.00 64416 S 279.52 0.00 0.00<br />

61888 S 732.53 0.00 0.00 64417 S 136.56 0.00 0.00<br />

62194 S 296.53 0.00 0.00 64418 S 70.34 0.00 0.00<br />

62225 S 460.76 0.00 0.00 64420 S 136.56 0.00 0.00<br />

62230 S 1,029.21 0.00 0.00 64421 S 296.53 0.00 0.00<br />

62252 TC S 46.67 0.00 0.00 64425 S 48.75 0.00 0.00<br />

62263 S 296.53 0.00 0.00 64430 S 205.20 0.00 0.00<br />

62264 S 436.83 0.00 0.00 64435 S 73.48 0.00 0.00<br />

62267 S 174.32 0.00 0.00 64445 S 65.12 0.00 0.00<br />

62268 S 226.31 0.00 0.00 64446 S 560.13 0.00 0.00<br />

62269 S 343.43 0.00 0.00 64447 S 142.25 0.00 0.00<br />

62270 S 136.56 0.00 0.00 64448 S 142.25 0.00 0.00<br />

62272 S 136.56 0.00 0.00 64449 S 279.52 0.00 0.00<br />

62273 S 227.89 0.00 0.00 64450 S 43.53 0.00 0.00<br />

62280 S 296.53 0.00 0.00 64455 S 18.11 0.00 0.00<br />

62281 S 296.53 0.00 0.00 64470 S 296.53 0.00 0.00<br />

62282 S 296.53 0.00 0.00 64472 S 227.89 0.00 0.00<br />

62287 S 1,331.13 0.00 0.00 64475 S 296.53 0.00 0.00<br />

62292 S 279.52 0.00 0.00 64476 S 205.24 0.00 0.00<br />

62294 S 226.31 0.00 0.00 64479 S 296.53 0.00 0.00<br />

62310 S 296.53 0.00 0.00 64480 S 227.89 0.00 0.00<br />

62311 S 296.53 0.00 0.00 64483 S 296.53 0.00 0.00<br />

62318 S 296.53 0.00 0.00 64484 S 227.89 0.00 0.00<br />

62319 S 296.53 0.00 0.00 64505 S 39.71 0.00 0.00<br />

62350 S 1,029.21 0.00 0.00 64508 S 84.28 0.00 0.00<br />

62355 S 490.03 0.00 0.00 64510 S 296.53 0.00 0.00<br />

62360 S 1,029.21 0.00 0.00 64517 S 205.20 0.00 0.00<br />

62361 S 10,565.02 5,718.47 871.93 64520 S 296.53 0.00 0.00<br />

62362 S 10,565.02 5,718.47 871.93 64530 S 296.53 0.00 0.00<br />

62365 S 910.72 0.00 0.00 64553 S 3,018.51 1,851.57 684.63<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,389.61 2,222.67 1,055.73 64746 S 570.69 0.00 0.00<br />

64560 S 3,389.61 2,222.67 1,055.73 64761 S 721.44 0.00 0.00<br />

64561 S 3,101.85 1,934.90 767.96 64763 S 721.44 0.00 0.00<br />

64565 S 3,389.61 2,222.67 1,055.73 64766 S 1,401.51 0.00 0.00<br />

64573 S 5,280.51 3,128.19 975.86 64771 S 570.69 0.00 0.00<br />

64575 S 4,036.52 2,406.42 776.33 64772 S 570.69 0.00 0.00<br />

64577 S 4,036.52 2,406.42 776.33 64774 S 570.69 0.00 0.00<br />

64580 S 4,036.52 2,406.42 776.33 64776 S 600.82 0.00 0.00<br />

64581 S 4,119.85 2,489.75 859.66 64778 S 570.69 0.00 0.00<br />

64585 S 539.45 0.00 0.00 64782 S 600.82 0.00 0.00<br />

64590 S 11,013.71 5,899.94 786.17 64783 S 570.69 0.00 0.00<br />

64595 S 732.53 0.00 0.00 64784 S 600.82 0.00 0.00<br />

64600 S 436.83 0.00 0.00 64786 S 940.85 0.00 0.00<br />

64605 S 436.83 0.00 0.00 64787 S 570.69 0.00 0.00<br />

64610 S 436.83 0.00 0.00 64788 S 600.82 0.00 0.00<br />

64612 S 63.73 0.00 0.00 64790 S 600.82 0.00 0.00<br />

64613 S 61.64 0.00 0.00 64792 S 940.85 0.00 0.00<br />

64614 S 70.34 0.00 0.00 64795 S 570.69 0.00 0.00<br />

64620 S 296.53 0.00 0.00 64802 S 570.69 0.00 0.00<br />

64622 S 436.83 0.00 0.00 64820 S 721.44 0.00 0.00<br />

64623 S 296.53 0.00 0.00 64821 S 842.22 0.00 0.00<br />

64626 S 436.83 0.00 0.00 64822 S 1,091.24 0.00 0.00<br />

64627 S 205.24 0.00 0.00 64823 S 1,091.24 0.00 0.00<br />

64630 S 305.44 0.00 0.00 64831 S 997.35 0.00 0.00<br />

64632 S 33.08 0.00 0.00 64832 S 857.52 0.00 0.00<br />

64640 S 98.56 0.00 0.00 64834 S 910.72 0.00 0.00<br />

64650 S 33.08 0.00 0.00 64835 S 940.85 0.00 0.00<br />

64653 S 35.87 0.00 0.00 64836 S 940.85 0.00 0.00<br />

64680 S 464.12 0.00 0.00 64837 S 857.52 0.00 0.00<br />

64681 S 490.03 0.00 0.00 64840 S 910.72 0.00 0.00<br />

64702 S 517.48 0.00 0.00 64856 S 910.72 0.00 0.00<br />

64704 S 517.48 0.00 0.00 64857 S 910.72 0.00 0.00<br />

64708 S 570.69 0.00 0.00 64858 S 910.72 0.00 0.00<br />

64712 S 570.69 0.00 0.00 64859 S 857.52 0.00 0.00<br />

64713 S 570.69 0.00 0.00 64861 S 940.85 0.00 0.00<br />

64714 S 570.69 0.00 0.00 64862 S 940.85 0.00 0.00<br />

64716 S 600.82 0.00 0.00 64864 S 940.85 0.00 0.00<br />

64718 S 570.69 0.00 0.00 64865 S 997.35 0.00 0.00<br />

64719 S 570.69 0.00 0.00 64870 S 997.35 0.00 0.00<br />

64721 S 570.69 0.00 0.00 64872 S 910.72 0.00 0.00<br />

64722 S 517.48 0.00 0.00 64874 S 940.85 0.00 0.00<br />

64726 S 517.48 0.00 0.00 64876 S 940.85 0.00 0.00<br />

64727 S 517.48 0.00 0.00 64885 S 910.72 0.00 0.00<br />

64732 S 570.69 0.00 0.00 64886 S 910.72 0.00 0.00<br />

64734 S 570.69 0.00 0.00 64890 S 910.72 0.00 0.00<br />

64736 S 570.69 0.00 0.00 64891 S 910.72 0.00 0.00<br />

64738 S 570.69 0.00 0.00 64892 S 910.72 0.00 0.00<br />

64740 S 570.69 0.00 0.00 64893 S 910.72 0.00 0.00<br />

64742 S 570.69 0.00 0.00 64895 S 940.85 0.00 0.00<br />

64744 S 570.69 0.00 0.00 64896 S 940.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 940.85 0.00 0.00 65770 S 5,536.60 0.00 0.00<br />

64898 S 940.85 0.00 0.00 65772 S 622.82 0.00 0.00<br />

64901 S 910.72 0.00 0.00 65775 S 622.82 0.00 0.00<br />

64902 S 910.72 0.00 0.00 65780 S 1,077.40 0.00 0.00<br />

64905 S 910.72 0.00 0.00 65781 S 1,077.40 0.00 0.00<br />

64907 S 857.52 0.00 0.00 65782 S 1,077.40 0.00 0.00<br />

64910 S 1,401.51 0.00 0.00 65800 S 483.00 0.00 0.00<br />

65091 S 990.67 0.00 0.00 65805 S 483.00 0.00 0.00<br />

65093 S 990.67 0.00 0.00 65810 S 705.77 0.00 0.00<br />

65101 S 990.67 0.00 0.00 65815 S 675.63 0.00 0.00<br />

65103 S 990.67 0.00 0.00 65820 S 247.79 0.00 0.00<br />

65105 S 1,047.16 0.00 0.00 65850 S 762.25 0.00 0.00<br />

65110 S 1,088.12 0.00 0.00 65855 S 131.64 0.00 0.00<br />

65112 S 1,218.99 0.00 0.00 65860 S 122.94 0.00 0.00<br />

65114 S 1,218.99 0.00 0.00 65865 S 483.00 0.00 0.00<br />

65125 S 1,014.50 0.00 0.00 65870 S 762.25 0.00 0.00<br />

65130 S 747.35 0.00 0.00 65875 S 762.25 0.00 0.00<br />

65135 S 717.22 0.00 0.00 65880 S 622.82 0.00 0.00<br />

65140 S 990.67 0.00 0.00 65900 S 663.78 0.00 0.00<br />

65150 S 717.22 0.00 0.00 65920 S 934.09 0.00 0.00<br />

65155 S 990.67 0.00 0.00 65930 S 803.22 0.00 0.00<br />

65175 S 533.14 0.00 0.00 66020 S 483.00 0.00 0.00<br />

65205 S 20.55 0.00 0.00 66030 S 247.79 0.00 0.00<br />

65210 S 26.12 0.00 0.00 66130 S 934.09 0.00 0.00<br />

65220 S 36.39 0.00 0.00 66150 S 762.25 0.00 0.00<br />

65222 S 28.55 0.00 0.00 66155 S 762.25 0.00 0.00<br />

65235 S 536.20 0.00 0.00 66160 S 675.63 0.00 0.00<br />

65260 S 353.66 0.00 0.00 66165 S 762.25 0.00 0.00<br />

65265 S 731.67 0.00 0.00 66170 S 762.25 0.00 0.00<br />

65270 S 586.33 0.00 0.00 66172 S 762.25 0.00 0.00<br />

65272 S 675.63 0.00 0.00 66180 S 1,135.60 0.00 0.00<br />

65275 S 762.25 0.00 0.00 66185 S 1,008.03 0.00 0.00<br />

65280 S 731.67 0.00 0.00 66220 S 984.01 0.00 0.00<br />

65285 S 1,040.50 0.00 0.00 66225 S 1,094.65 0.00 0.00<br />

65286 S 182.03 0.00 0.00 66250 S 536.20 0.00 0.00<br />

65290 S 720.56 0.00 0.00 66500 S 247.79 0.00 0.00<br />

65400 S 483.00 0.00 0.00 66505 S 247.79 0.00 0.00<br />

65410 S 536.20 0.00 0.00 66600 S 705.77 0.00 0.00<br />

65420 S 536.20 0.00 0.00 66605 S 705.77 0.00 0.00<br />

65426 S 803.22 0.00 0.00 66625 S 501.80 0.00 0.00<br />

65430 S 36.39 0.00 0.00 66630 S 705.77 0.00 0.00<br />

65435 S 31.69 0.00 0.00 66635 S 705.77 0.00 0.00<br />

65436 S 137.56 0.00 0.00 66680 S 705.77 0.00 0.00<br />

65450 S 83.98 0.00 0.00 66682 S 675.63 0.00 0.00<br />

65600 S 162.29 0.00 0.00 66700 S 536.20 0.00 0.00<br />

65710 S 1,208.27 0.00 0.00 66710 S 536.20 0.00 0.00<br />

65730 S 1,208.27 0.00 0.00 66711 S 536.20 0.00 0.00<br />

65750 S 1,208.27 0.00 0.00 66720 S 536.20 0.00 0.00<br />

65755 S 1,208.27 0.00 0.00 66740 S 675.63 0.00 0.00<br />

65756 S 1,479.70 0.00 0.00 66761 S 183.18 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 186.32 0.00 0.00 67228 S 205.19 0.00 0.00<br />

66770 S 205.19 0.00 0.00 67229 S 205.19 0.00 0.00<br />

66820 S 182.03 0.00 0.00 67250 S 616.47 0.00 0.00<br />

66821 S 249.70 0.00 0.00 67255 S 675.19 0.00 0.00<br />

66825 S 762.25 0.00 0.00 67311 S 720.56 0.00 0.00<br />

66830 S 266.59 0.00 0.00 67312 S 777.06 0.00 0.00<br />

66840 S 573.07 0.00 0.00 67314 S 777.06 0.00 0.00<br />

66850 S 1,078.96 0.00 0.00 67316 S 777.06 0.00 0.00<br />

66852 S 907.12 0.00 0.00 67318 S 777.06 0.00 0.00<br />

66920 S 907.12 0.00 0.00 67320 S 777.06 0.00 0.00<br />

66930 S 948.08 0.00 0.00 67331 S 777.06 0.00 0.00<br />

66940 S 614.03 0.00 0.00 67332 S 777.06 0.00 0.00<br />

66982 S 931.51 0.00 0.00 67334 S 777.06 0.00 0.00<br />

66983 S 931.51 0.00 0.00 67335 S 777.06 0.00 0.00<br />

66984 S 931.51 0.00 0.00 67340 S 777.06 0.00 0.00<br />

66985 S 862.31 0.00 0.00 67343 S 948.89 0.00 0.00<br />

66986 S 862.31 0.00 0.00 67345 S 81.15 0.00 0.00<br />

67005 S 731.67 0.00 0.00 67346 S 438.90 0.00 0.00<br />

67010 S 731.67 0.00 0.00 67400 S 616.47 0.00 0.00<br />

67015 S 900.68 0.00 0.00 67405 S 803.84 0.00 0.00<br />

67025 S 591.85 0.00 0.00 67412 S 713.92 0.00 0.00<br />

67027 S 1,040.50 0.00 0.00 67413 S 844.79 0.00 0.00<br />

67028 S 81.84 0.00 0.00 67414 S 1,501.14 0.00 0.00<br />

67030 S 591.85 0.00 0.00 67415 S 533.14 0.00 0.00<br />

67031 S 249.70 0.00 0.00 67420 S 1,088.12 0.00 0.00<br />

67036 S 1,040.50 0.00 0.00 67430 S 1,088.12 0.00 0.00<br />

67039 S 1,212.34 0.00 0.00 67440 S 1,088.12 0.00 0.00<br />

67040 S 1,212.34 0.00 0.00 67445 S 1,088.12 0.00 0.00<br />

67041 S 1,487.83 0.00 0.00 67450 S 1,088.12 0.00 0.00<br />

67042 S 1,487.83 0.00 0.00 67500 S 83.98 0.00 0.00<br />

67043 S 1,487.83 0.00 0.00 67505 S 26.12 0.00 0.00<br />

67101 S 227.13 0.00 0.00 67515 S 26.47 0.00 0.00<br />

67105 S 205.19 0.00 0.00 67550 S 1,047.16 0.00 0.00<br />

67107 S 1,081.46 0.00 0.00 67560 S 717.22 0.00 0.00<br />

67108 S 1,212.34 0.00 0.00 67570 S 1,047.16 0.00 0.00<br />

67110 S 330.15 0.00 0.00 67700 S 122.86 0.00 0.00<br />

67112 S 1,212.34 0.00 0.00 67710 S 143.48 0.00 0.00<br />

67113 S 1,487.83 0.00 0.00 67715 S 533.14 0.00 0.00<br />

67115 S 645.05 0.00 0.00 67800 S 51.54 0.00 0.00<br />

67120 S 645.05 0.00 0.00 67801 S 62.34 0.00 0.00<br />

67121 S 645.05 0.00 0.00 67805 S 80.79 0.00 0.00<br />

67141 S 227.38 0.00 0.00 67808 S 586.33 0.00 0.00<br />

67145 S 193.98 0.00 0.00 67810 S 122.86 0.00 0.00<br />

67208 S 206.87 0.00 0.00 67820 S 17.06 0.00 0.00<br />

67210 S 205.19 0.00 0.00 67825 S 52.59 0.00 0.00<br />

67218 S 772.63 0.00 0.00 67830 S 359.97 0.00 0.00<br />

67220 S 227.13 0.00 0.00 67835 S 586.33 0.00 0.00<br />

67221 S 116.66 0.00 0.00 67840 S 150.45 0.00 0.00<br />

67225 S 8.01 0.00 0.00 67850 S 119.45 0.00 0.00<br />

67227 S 591.85 0.00 0.00 67875 S 299.99 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 566.33 0.00 0.00 68440 S 51.20 0.00 0.00<br />

67882 S 616.47 0.00 0.00 68500 S 747.35 0.00 0.00<br />

67900 S 803.84 0.00 0.00 68505 S 747.35 0.00 0.00<br />

67901 S 713.92 0.00 0.00 68510 S 533.14 0.00 0.00<br />

67902 S 844.79 0.00 0.00 68520 S 747.35 0.00 0.00<br />

67903 S 672.96 0.00 0.00 68525 S 533.14 0.00 0.00<br />

67904 S 672.96 0.00 0.00 68530 S 122.86 0.00 0.00<br />

67906 S 713.92 0.00 0.00 68540 S 616.47 0.00 0.00<br />

67908 S 672.96 0.00 0.00 68550 S 747.35 0.00 0.00<br />

67909 S 672.96 0.00 0.00 68700 S 586.33 0.00 0.00<br />

67911 S 616.47 0.00 0.00 68705 S 116.66 0.00 0.00<br />

67912 S 616.47 0.00 0.00 68720 S 803.84 0.00 0.00<br />

67914 S 616.47 0.00 0.00 68745 S 803.84 0.00 0.00<br />

67915 S 166.47 0.00 0.00 68750 S 803.84 0.00 0.00<br />

67916 S 672.96 0.00 0.00 68760 S 99.25 0.00 0.00<br />

67917 S 672.96 0.00 0.00 68761 S 68.61 0.00 0.00<br />

67921 S 616.47 0.00 0.00 68770 S 803.84 0.00 0.00<br />

67922 S 161.94 0.00 0.00 68801 S 36.39 0.00 0.00<br />

67923 S 672.96 0.00 0.00 68810 S 104.07 0.00 0.00<br />

67924 S 672.96 0.00 0.00 68811 S 586.33 0.00 0.00<br />

67930 S 166.47 0.00 0.00 68815 S 586.33 0.00 0.00<br />

67935 S 586.33 0.00 0.00 68816 S 752.73 0.00 0.00<br />

67938 S 83.98 0.00 0.00 68840 S 53.98 0.00 0.00<br />

67950 S 586.33 0.00 0.00 69000 S 55.06 0.00 0.00<br />

67961 S 616.47 0.00 0.00 69005 S 104.13 0.00 0.00<br />

67966 S 616.47 0.00 0.00 69020 S 55.06 0.00 0.00<br />

67971 S 616.47 0.00 0.00 69100 S 62.69 0.00 0.00<br />

67973 S 747.35 0.00 0.00 69105 S 88.81 0.00 0.00<br />

67974 S 616.47 0.00 0.00 69110 S 466.56 0.00 0.00<br />

67975 S 616.47 0.00 0.00 69120 S 692.37 0.00 0.00<br />

68020 S 45.62 0.00 0.00 69140 S 692.37 0.00 0.00<br />

68040 S 22.63 0.00 0.00 69145 S 519.75 0.00 0.00<br />

68100 S 90.54 0.00 0.00 69150 S 365.31 0.00 0.00<br />

68110 S 116.66 0.00 0.00 69200 S 25.18 0.00 0.00<br />

68115 S 586.33 0.00 0.00 69205 S 582.42 0.00 0.00<br />

68130 S 536.20 0.00 0.00 69210 S 20.55 0.00 0.00<br />

68135 S 58.51 0.00 0.00 69220 S 32.27 0.00 0.00<br />

68200 S 16.71 0.00 0.00 69222 S 135.82 0.00 0.00<br />

68320 S 803.84 0.00 0.00 69300 S 722.51 0.00 0.00<br />

68325 S 803.84 0.00 0.00 69310 S 1,056.10 0.00 0.00<br />

68326 S 672.96 0.00 0.00 69320 S 1,284.42 0.00 0.00<br />

68328 S 803.84 0.00 0.00 69400 S 91.24 0.00 0.00<br />

68330 S 762.25 0.00 0.00 69401 S 48.06 0.00 0.00<br />

68335 S 803.84 0.00 0.00 69405 S 126.07 0.00 0.00<br />

68340 S 672.96 0.00 0.00 69420 S 113.19 0.00 0.00<br />

68360 S 675.63 0.00 0.00 69421 S 576.06 0.00 0.00<br />

68362 S 675.63 0.00 0.00 69424 S 79.40 0.00 0.00<br />

68371 S 536.20 0.00 0.00 69433 S 112.84 0.00 0.00<br />

68400 S 122.86 0.00 0.00 69436 S 576.06 0.00 0.00<br />

68420 S 174.82 0.00 0.00 69440 S 722.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 972.76 0.00 0.00 69840 S 1,153.54 0.00 0.00<br />

69501 S 1,284.42 0.00 0.00 69905 S 1,284.42 0.00 0.00<br />

69502 S 950.84 0.00 0.00 69910 S 1,284.42 0.00 0.00<br />

69505 S 1,284.42 0.00 0.00 69915 S 1,284.42 0.00 0.00<br />

69511 S 1,284.42 0.00 0.00 69930 S 23,220.59 12,467.89 1,715.19<br />

69530 S 1,284.42 0.00 0.00 70030 TC A 17.76 0.00 0.00<br />

69540 S 132.68 0.00 0.00 70100 TC A 19.51 0.00 0.00<br />

69550 S 1,153.54 0.00 0.00 70110 TC A 24.03 0.00 0.00<br />

69552 S 1,284.42 0.00 0.00 70120 TC A 21.59 0.00 0.00<br />

69601 S 1,284.42 0.00 0.00 70130 TC A 26.38 0.00 0.00<br />

69602 S 1,284.42 0.00 0.00 70134 TC A 26.47 0.00 0.00<br />

69603 S 1,284.42 0.00 0.00 70140 TC A 18.11 0.00 0.00<br />

69604 S 1,284.42 0.00 0.00 70150 TC A 26.38 0.00 0.00<br />

69605 S 1,284.42 0.00 0.00 70160 TC A 21.24 0.00 0.00<br />

69610 S 177.61 0.00 0.00 70190 TC A 22.29 0.00 0.00<br />

69620 S 692.37 0.00 0.00 70200 TC A 26.38 0.00 0.00<br />

69631 S 1,153.54 0.00 0.00 70210 TC A 18.81 0.00 0.00<br />

69632 S 1,153.54 0.00 0.00 70220 TC A 23.69 0.00 0.00<br />

69633 S 1,153.54 0.00 0.00 70240 TC A 17.76 0.00 0.00<br />

69635 S 1,284.42 0.00 0.00 70250 TC A 21.59 0.00 0.00<br />

69636 S 1,284.42 0.00 0.00 70260 TC A 27.51 0.00 0.00<br />

69637 S 1,284.42 0.00 0.00 70300 TC A 7.66 0.00 0.00<br />

69641 S 1,284.42 0.00 0.00 70310 TC A 18.93 0.00 0.00<br />

69642 S 1,284.42 0.00 0.00 70320 TC A 18.93 0.00 0.00<br />

69643 S 1,284.42 0.00 0.00 70328 TC A 18.81 0.00 0.00<br />

69644 S 1,284.42 0.00 0.00 70330 TC A 26.38 0.00 0.00<br />

69645 S 1,284.42 0.00 0.00 70336 TC A 205.34 0.00 0.00<br />

69646 S 1,284.42 0.00 0.00 70350 TC A 10.45 0.00 0.00<br />

69650 S 950.84 0.00 0.00 70355 TC A 10.80 0.00 0.00<br />

69660 S 1,153.54 0.00 0.00 70360 TC A 16.71 0.00 0.00<br />

69661 S 1,153.54 0.00 0.00 70370 TC A 49.09 0.00 0.00<br />

69662 S 1,153.54 0.00 0.00 70371 TC A 49.09 0.00 0.00<br />

69666 S 1,112.58 0.00 0.00 70380 TC A 25.42 0.00 0.00<br />

69667 S 1,112.58 0.00 0.00 70450 TC A 114.68 0.00 0.00<br />

69670 S 1,056.10 0.00 0.00 70460 TC A 181.60 0.00 0.00<br />

69676 S 1,056.10 0.00 0.00 70470 TC A 201.16 0.00 0.00<br />

69700 S 1,056.10 0.00 0.00 70480 TC A 114.68 0.00 0.00<br />

69711 S 972.76 0.00 0.00 70481 TC A 181.60 0.00 0.00<br />

69714 S 6,169.10 3,889.85 1,610.60 70482 TC A 201.16 0.00 0.00<br />

69715 S 6,169.10 3,889.85 1,610.60 70486 TC A 114.68 0.00 0.00<br />

69717 S 6,169.10 3,889.85 1,610.60 70487 TC A 181.60 0.00 0.00<br />

69718 S 6,169.10 3,889.85 1,610.60 70488 TC A 201.16 0.00 0.00<br />

69720 S 1,153.54 0.00 0.00 70490 TC A 114.68 0.00 0.00<br />

69740 S 1,153.54 0.00 0.00 70491 TC A 181.60 0.00 0.00<br />

69745 S 1,153.54 0.00 0.00 70492 TC A 201.16 0.00 0.00<br />

69801 S 1,153.54 0.00 0.00 70496 TC A 207.59 0.00 0.00<br />

69802 S 1,284.42 0.00 0.00 70498 TC A 207.59 0.00 0.00<br />

69805 S 1,284.42 0.00 0.00 70540 TC A 205.34 0.00 0.00<br />

69806 S 1,284.42 0.00 0.00 70542 TC A 252.17 0.00 0.00<br />

69820 S 1,153.54 0.00 0.00 70543 TC A 317.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 205.34 0.00 0.00 72120 TC A 33.43 0.00 0.00<br />

70545 TC A 252.17 0.00 0.00 72125 TC A 114.68 0.00 0.00<br />

70546 TC A 317.82 0.00 0.00 72126 TC A 181.60 0.00 0.00<br />

70547 TC A 205.34 0.00 0.00 72127 TC A 201.16 0.00 0.00<br />

70548 TC A 252.17 0.00 0.00 72128 TC A 114.68 0.00 0.00<br />

70549 TC A 317.82 0.00 0.00 72129 TC A 181.60 0.00 0.00<br />

70551 TC A 205.34 0.00 0.00 72130 TC A 201.16 0.00 0.00<br />

70552 TC A 252.17 0.00 0.00 72131 TC A 114.68 0.00 0.00<br />

70553 TC A 317.82 0.00 0.00 72132 TC A 181.60 0.00 0.00<br />

70554 TC A 205.34 0.00 0.00 72133 TC A 201.16 0.00 0.00<br />

70555 TC A 205.34 0.00 0.00 72141 TC A 205.34 0.00 0.00<br />

70557 TC A 205.34 0.00 0.00 72142 TC A 252.17 0.00 0.00<br />

70558 TC A 252.17 0.00 0.00 72146 TC A 205.34 0.00 0.00<br />

70559 TC A 317.82 0.00 0.00 72147 TC A 252.17 0.00 0.00<br />

71010 TC A 13.59 0.00 0.00 72148 TC A 205.34 0.00 0.00<br />

71015 TC A 17.41 0.00 0.00 72149 TC A 252.17 0.00 0.00<br />

71020 TC A 18.46 0.00 0.00 72156 TC A 317.82 0.00 0.00<br />

71021 TC A 22.29 0.00 0.00 72157 TC A 317.82 0.00 0.00<br />

71022 TC A 26.38 0.00 0.00 72158 TC A 317.82 0.00 0.00<br />

71023 TC A 43.18 0.00 0.00 72170 TC A 15.67 0.00 0.00<br />

71030 TC A 26.38 0.00 0.00 72190 TC A 26.38 0.00 0.00<br />

71034 TC A 49.09 0.00 0.00 72191 TC A 207.59 0.00 0.00<br />

71035 TC A 22.98 0.00 0.00 72192 TC A 114.68 0.00 0.00<br />

71100 TC A 19.16 0.00 0.00 72193 TC A 181.60 0.00 0.00<br />

71101 TC A 23.33 0.00 0.00 72194 TC A 201.16 0.00 0.00<br />

71110 TC A 24.38 0.00 0.00 72195 TC A 205.34 0.00 0.00<br />

71111 TC A 32.39 0.00 0.00 72196 TC A 252.17 0.00 0.00<br />

71120 TC A 20.20 0.00 0.00 72197 TC A 317.82 0.00 0.00<br />

71130 TC A 23.69 0.00 0.00 72200 TC A 18.46 0.00 0.00<br />

71250 TC A 114.68 0.00 0.00 72202 TC A 22.63 0.00 0.00<br />

71260 TC A 181.60 0.00 0.00 72220 TC A 18.46 0.00 0.00<br />

71270 TC A 201.16 0.00 0.00 73000 TC A 17.41 0.00 0.00<br />

71275 TC A 207.59 0.00 0.00 73010 TC A 17.76 0.00 0.00<br />

71550 TC A 205.34 0.00 0.00 73020 TC A 14.28 0.00 0.00<br />

71551 TC A 252.17 0.00 0.00 73030 TC A 18.11 0.00 0.00<br />

71552 TC A 317.82 0.00 0.00 73050 TC A 22.63 0.00 0.00<br />

72010 TC A 43.92 0.00 0.00 73060 TC A 18.11 0.00 0.00<br />

72020 TC A 14.28 0.00 0.00 73070 TC A 17.41 0.00 0.00<br />

72040 TC A 22.98 0.00 0.00 73080 TC A 22.98 0.00 0.00<br />

72050 TC A 32.73 0.00 0.00 73090 TC A 17.41 0.00 0.00<br />

72052 TC A 43.92 0.00 0.00 73092 TC A 18.11 0.00 0.00<br />

72069 TC A 21.59 0.00 0.00 73100 TC A 18.11 0.00 0.00<br />

72070 TC A 20.20 0.00 0.00 73110 TC A 22.98 0.00 0.00<br />

72072 TC A 24.38 0.00 0.00 73120 TC A 17.06 0.00 0.00<br />

72074 TC A 26.38 0.00 0.00 73130 TC A 20.20 0.00 0.00<br />

72080 TC A 21.59 0.00 0.00 73140 TC A 19.85 0.00 0.00<br />

72090 TC A 28.91 0.00 0.00 73200 TC A 114.68 0.00 0.00<br />

72100 TC A 24.73 0.00 0.00 73201 TC A 181.60 0.00 0.00<br />

72110 TC A 34.48 0.00 0.00 73202 TC A 201.16 0.00 0.00<br />

72114 TC A 43.92 0.00 0.00 73206 TC A 207.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 205.34 0.00 0.00 74246 TC A 51.82 0.00 0.00<br />

73219 TC A 252.17 0.00 0.00 74247 TC A 51.82 0.00 0.00<br />

73220 TC A 317.82 0.00 0.00 74249 TC A 84.27 0.00 0.00<br />

73221 TC A 205.34 0.00 0.00 74250 TC A 51.82 0.00 0.00<br />

73222 TC A 252.17 0.00 0.00 74251 TC A 84.27 0.00 0.00<br />

73223 TC A 317.82 0.00 0.00 74260 TC A 51.82 0.00 0.00<br />

73500 TC A 14.98 0.00 0.00 74270 TC A 51.82 0.00 0.00<br />

73510 TC A 22.98 0.00 0.00 74280 TC A 84.27 0.00 0.00<br />

73520 TC A 23.69 0.00 0.00 74283 TC A 51.82 0.00 0.00<br />

73540 TC A 23.69 0.00 0.00 74290 TC A 44.22 0.00 0.00<br />

73550 TC A 17.41 0.00 0.00 74291 TC A 42.49 0.00 0.00<br />

73560 TC A 17.76 0.00 0.00 74400 TC A 76.97 0.00 0.00<br />

73562 TC A 21.94 0.00 0.00 74410 TC A 82.19 0.00 0.00<br />

73564 TC A 25.42 0.00 0.00 74415 TC A 98.21 0.00 0.00<br />

73565 TC A 19.16 0.00 0.00 74420 TC A 102.65 0.00 0.00<br />

73590 TC A 16.71 0.00 0.00 74710 TC A 22.98 0.00 0.00<br />

73592 TC A 18.11 0.00 0.00 74775 TC A 102.65 0.00 0.00<br />

73600 TC A 17.06 0.00 0.00 75557 TC A 205.34 0.00 0.00<br />

73610 TC A 20.20 0.00 0.00 75559 TC A 205.34 0.00 0.00<br />

73620 TC A 16.37 0.00 0.00 75561 TC A 317.82 0.00 0.00<br />

73630 TC A 19.85 0.00 0.00 75563 TC A 317.82 0.00 0.00<br />

73650 TC A 16.71 0.00 0.00 76010 TC A 17.06 0.00 0.00<br />

73660 TC A 18.81 0.00 0.00 76098 TC A 10.45 0.00 0.00<br />

73700 TC A 114.68 0.00 0.00 76100 TC A 43.92 0.00 0.00<br />

73701 TC A 181.60 0.00 0.00 76101 TC A 117.71 0.00 0.00<br />

73702 TC A 201.16 0.00 0.00 76102 TC A 117.71 0.00 0.00<br />

73706 TC A 207.59 0.00 0.00 76120 TC A 49.09 0.00 0.00<br />

73718 TC A 205.34 0.00 0.00 76150 A 17.06 0.00 0.00<br />

73719 TC A 252.17 0.00 0.00 76380 TC A 61.95 0.00 0.00<br />

73720 TC A 317.82 0.00 0.00 76496 TC A 49.09 0.00 0.00<br />

73721 TC A 205.34 0.00 0.00 76497 TC A 61.95 0.00 0.00<br />

73722 TC A 252.17 0.00 0.00 76498 TC A 205.34 0.00 0.00<br />

73723 TC A 317.82 0.00 0.00 76499 TC A 26.38 0.00 0.00<br />

74000 TC A 14.98 0.00 0.00 76506 TC A 36.88 0.00 0.00<br />

74010 TC A 23.33 0.00 0.00 76510 TC A 62.69 0.00 0.00<br />

74020 TC A 23.69 0.00 0.00 76511 TC A 43.88 0.00 0.00<br />

74022 TC A 28.91 0.00 0.00 76512 TC A 37.26 0.00 0.00<br />

74150 TC A 114.68 0.00 0.00 76513 TC A 45.28 0.00 0.00<br />

74160 TC A 181.60 0.00 0.00 76514 TC A 3.14 0.00 0.00<br />

74170 TC A 201.16 0.00 0.00 76516 TC A 35.52 0.00 0.00<br />

74175 TC A 207.59 0.00 0.00 76519 TC A 39.71 0.00 0.00<br />

74181 TC A 205.34 0.00 0.00 76529 TC A 34.48 0.00 0.00<br />

74182 TC A 252.17 0.00 0.00 76536 TC A 57.68 0.00 0.00<br />

74183 TC A 317.82 0.00 0.00 76604 TC A 36.88 0.00 0.00<br />

74210 TC A 51.82 0.00 0.00 76645 TC A 36.88 0.00 0.00<br />

74220 TC A 51.82 0.00 0.00 76700 TC A 57.68 0.00 0.00<br />

74230 TC A 51.82 0.00 0.00 76705 TC A 57.68 0.00 0.00<br />

74240 TC A 51.82 0.00 0.00 76770 TC A 57.68 0.00 0.00<br />

74241 TC A 51.82 0.00 0.00 76775 TC A 57.68 0.00 0.00<br />

74245 TC A 84.27 0.00 0.00 76776 TC A 57.68 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 57.68 0.00 0.00 77290 TC A 150.86 0.00 0.00<br />

76801 TC A 57.68 0.00 0.00 77295 TC A 395.28 0.00 0.00<br />

76802 TC A 27.51 0.00 0.00 77299 TC A 67.68 0.00 0.00<br />

76805 TC A 57.68 0.00 0.00 77300 TC A 36.57 0.00 0.00<br />

76810 TC A 43.53 0.00 0.00 77301 TC A 526.79 0.00 0.00<br />

76811 TC A 90.37 0.00 0.00 77305 TC A 33.43 0.00 0.00<br />

76812 TC A 36.88 0.00 0.00 77310 TC A 43.53 0.00 0.00<br />

76813 TC A 36.88 0.00 0.00 77315 TC A 63.38 0.00 0.00<br />

76814 TC A 29.26 0.00 0.00 77321 TC A 65.82 0.00 0.00<br />

76815 TC A 36.88 0.00 0.00 77326 TC A 67.68 0.00 0.00<br />

76816 TC A 36.88 0.00 0.00 77327 TC A 122.94 0.00 0.00<br />

76817 TC A 36.88 0.00 0.00 77328 TC A 150.86 0.00 0.00<br />

76818 TC A 57.68 0.00 0.00 77331 TC A 17.41 0.00 0.00<br />

76819 TC A 49.81 0.00 0.00 77332 TC A 46.67 0.00 0.00<br />

76820 TC A 24.73 0.00 0.00 77333 TC A 22.63 0.00 0.00<br />

76821 TC A 55.84 0.00 0.00 77334 TC A 87.42 0.00 0.00<br />

76825 TC A 116.32 0.00 0.00 77336 A 55.03 0.00 0.00<br />

76826 TC A 69.30 0.00 0.00 77370 A 67.68 0.00 0.00<br />

76827 TC A 36.88 0.00 0.00 77371 A 4,508.48 0.00 0.00<br />

76828 TC A 21.94 0.00 0.00 77399 TC A 67.68 0.00 0.00<br />

76830 TC A 57.68 0.00 0.00 77401 A 27.51 0.00 0.00<br />

76831 TC A 77.66 0.00 0.00 77402 A 55.39 0.00 0.00<br />

76856 TC A 57.68 0.00 0.00 77403 A 55.39 0.00 0.00<br />

76857 TC A 36.88 0.00 0.00 77404 A 55.39 0.00 0.00<br />

76870 TC A 57.68 0.00 0.00 77406 A 89.71 0.00 0.00<br />

76872 TC A 57.68 0.00 0.00 77407 A 55.39 0.00 0.00<br />

76873 TC A 57.68 0.00 0.00 77408 A 55.39 0.00 0.00<br />

76880 TC A 57.68 0.00 0.00 77409 A 55.39 0.00 0.00<br />

76885 TC A 36.88 0.00 0.00 77411 A 89.71 0.00 0.00<br />

76886 TC A 36.88 0.00 0.00 77412 A 89.71 0.00 0.00<br />

76936 TC A 55.84 0.00 0.00 77413 A 89.71 0.00 0.00<br />

76970 TC A 36.88 0.00 0.00 77414 A 89.71 0.00 0.00<br />

76977 TC A 9.40 0.00 0.00 77416 A 89.71 0.00 0.00<br />

76999 TC A 36.88 0.00 0.00 77418 A 242.38 0.00 0.00<br />

77071 A 21.59 0.00 0.00 77422 A 89.71 0.00 0.00<br />

77072 TC A 12.53 0.00 0.00 77423 A 89.71 0.00 0.00<br />

77073 TC A 21.24 0.00 0.00 77470 TC A 128.86 0.00 0.00<br />

77074 TC A 41.79 0.00 0.00 77520 A 414.99 0.00 0.00<br />

77075 TC A 43.92 0.00 0.00 77522 A 414.99 0.00 0.00<br />

77076 TC A 43.92 0.00 0.00 77523 A 495.92 0.00 0.00<br />

77077 TC A 23.69 0.00 0.00 77525 A 495.92 0.00 0.00<br />

77078 TC A 42.43 0.00 0.00 77600 TC A 220.19 0.00 0.00<br />

77079 TC A 43.53 0.00 0.00 77605 TC A 220.19 0.00 0.00<br />

77080 TC A 42.43 0.00 0.00 77610 TC A 220.19 0.00 0.00<br />

77081 TC A 17.06 0.00 0.00 77615 TC A 220.19 0.00 0.00<br />

77082 TC A 18.46 0.00 0.00 77620 TC A 220.19 0.00 0.00<br />

77083 TC A 14.63 0.00 0.00 77750 TC A 85.67 0.00 0.00<br />

77084 TC A 205.34 0.00 0.00 77761 TC A 150.80 0.00 0.00<br />

77280 TC A 67.68 0.00 0.00 77762 TC A 178.66 0.00 0.00<br />

77285 TC A 150.86 0.00 0.00 77763 TC A 230.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 163.33 0.00 0.00 78262 TC A 143.44 0.00 0.00<br />

77777 TC A 179.35 0.00 0.00 78264 TC A 143.44 0.00 0.00<br />

77778 TC A 238.91 0.00 0.00 78270 TC A 62.69 0.00 0.00<br />

77785 TC A 106.22 0.00 0.00 78271 TC A 63.73 0.00 0.00<br />

77786 TC A 373.33 0.00 0.00 78272 TC A 70.00 0.00 0.00<br />

77787 TC A 432.61 0.00 0.00 78278 TC A 143.44 0.00 0.00<br />

77789 TC A 44.58 0.00 0.00 78282 TC A 143.44 0.00 0.00<br />

77799 TC A 254.09 0.00 0.00 78290 TC A 143.44 0.00 0.00<br />

78000 TC A 54.67 0.00 0.00 78291 TC A 143.44 0.00 0.00<br />

78001 TC A 69.29 0.00 0.00 78299 TC A 143.44 0.00 0.00<br />

78003 TC A 55.03 0.00 0.00 78300 TC A 125.03 0.00 0.00<br />

78006 TC A 130.93 0.00 0.00 78305 TC A 145.00 0.00 0.00<br />

78007 TC A 96.82 0.00 0.00 78306 TC A 145.00 0.00 0.00<br />

78010 TC A 80.44 0.00 0.00 78315 TC A 145.00 0.00 0.00<br />

78011 TC A 80.44 0.00 0.00 78320 TC A 145.00 0.00 0.00<br />

78015 TC A 156.37 0.00 0.00 78399 TC A 145.00 0.00 0.00<br />

78016 TC A 176.50 0.00 0.00 78414 TC A 184.31 0.00 0.00<br />

78018 TC A 176.50 0.00 0.00 78428 TC A 141.39 0.00 0.00<br />

78070 TC A 120.15 0.00 0.00 78445 TC A 110.29 0.00 0.00<br />

78075 TC A 340.25 0.00 0.00 78456 TC A 110.29 0.00 0.00<br />

78099 TC A 80.44 0.00 0.00 78457 TC A 110.29 0.00 0.00<br />

78102 TC A 121.54 0.00 0.00 78458 TC A 110.29 0.00 0.00<br />

78103 TC A 154.93 0.00 0.00 78459 TC A 682.53 0.00 0.00<br />

78104 TC A 154.93 0.00 0.00 78460 TC A 132.34 0.00 0.00<br />

78110 TC A 61.64 0.00 0.00 78461 TC A 133.39 0.00 0.00<br />

78111 TC A 78.01 0.00 0.00 78464 TC A 195.72 0.00 0.00<br />

78120 TC A 68.26 0.00 0.00 78465 TC A 370.55 0.00 0.00<br />

78121 TC A 80.79 0.00 0.00 78466 TC A 131.29 0.00 0.00<br />

78122 TC A 95.77 0.00 0.00 78468 TC A 167.86 0.00 0.00<br />

78130 TC A 111.09 0.00 0.00 78469 TC A 184.31 0.00 0.00<br />

78135 TC A 236.11 0.00 0.00 78472 TC A 184.31 0.00 0.00<br />

78140 TC A 104.83 0.00 0.00 78473 TC A 184.31 0.00 0.00<br />

78185 TC A 154.93 0.00 0.00 78481 TC A 159.15 0.00 0.00<br />

78190 TC A 97.22 0.00 0.00 78483 TC A 184.31 0.00 0.00<br />

78191 TC A 97.22 0.00 0.00 78491 TC A 682.53 0.00 0.00<br />

78195 TC A 154.93 0.00 0.00 78492 TC A 682.53 0.00 0.00<br />

78199 TC A 154.93 0.00 0.00 78494 TC A 184.31 0.00 0.00<br />

78201 TC A 137.91 0.00 0.00 78499 TC A 184.31 0.00 0.00<br />

78202 TC A 162.23 0.00 0.00 78580 TC A 124.87 0.00 0.00<br />

78205 TC A 162.23 0.00 0.00 78584 TC A 96.46 0.00 0.00<br />

78206 TC A 162.23 0.00 0.00 78585 TC A 191.60 0.00 0.00<br />

78215 TC A 145.92 0.00 0.00 78586 TC A 124.87 0.00 0.00<br />

78216 TC A 98.91 0.00 0.00 78587 TC A 124.87 0.00 0.00<br />

78220 TC A 107.96 0.00 0.00 78588 TC A 191.60 0.00 0.00<br />

78223 TC A 162.23 0.00 0.00 78591 TC A 124.87 0.00 0.00<br />

78230 TC A 122.58 0.00 0.00 78593 TC A 124.87 0.00 0.00<br />

78231 TC A 96.46 0.00 0.00 78594 TC A 124.87 0.00 0.00<br />

78232 TC A 100.64 0.00 0.00 78596 TC A 191.60 0.00 0.00<br />

78258 TC A 143.44 0.00 0.00 78599 TC A 124.87 0.00 0.00<br />

78261 TC A 143.44 0.00 0.00 78600 TC A 110.05 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 23540 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 110.05 0.00 0.00<br />

78605 TC A 110.05 0.00 0.00<br />

78606 TC A 247.26 0.00 0.00<br />

78607 TC A 271.64 0.00 0.00<br />

78608 TC A 611.77 0.00 0.00<br />

78610 TC A 146.62 0.00 0.00<br />

78630 TC A 261.19 0.00 0.00<br />

78635 TC A 240.65 0.00 0.00<br />

78645 TC A 110.05 0.00 0.00<br />

78647 TC A 266.42 0.00 0.00<br />

78650 TC A 258.06 0.00 0.00<br />

78660 TC A 110.05 0.00 0.00<br />

78699 TC A 110.05 0.00 0.00<br />

78700 TC A 135.47 0.00 0.00<br />

78701 TC A 165.08 0.00 0.00<br />

78707 TC A 172.39 0.00 0.00<br />

78708 TC A 118.06 0.00 0.00<br />

78709 TC A 194.10 0.00 0.00<br />

78710 TC A 182.14 0.00 0.00<br />

78725 TC A 72.79 0.00 0.00<br />

78730 TC A 61.64 0.00 0.00<br />

78740 TC A 160.90 0.00 0.00<br />

78761 TC A 153.58 0.00 0.00<br />

78799 TC A 194.10 0.00 0.00<br />

78800 TC A 135.82 0.00 0.00<br />

78801 TC A 186.32 0.00 0.00<br />

78802 TC A 252.49 0.00 0.00<br />

78803 TC A 270.60 0.00 0.00<br />

78804 TC A 472.24 0.00 0.00<br />

78805 TC A 132.68 0.00 0.00<br />

78806 TC A 265.38 0.00 0.00<br />

78807 TC A 270.95 0.00 0.00<br />

78811 TC A 611.77 0.00 0.00<br />

78812 TC A 611.77 0.00 0.00<br />

78813 TC A 611.77 0.00 0.00<br />

78814 TC A 611.77 0.00 0.00<br />

78815 TC A 611.77 0.00 0.00<br />

78816 TC A 611.77 0.00 0.00<br />

78999 TC A 69.29 0.00 0.00<br />

79005 TC A 55.72 0.00 0.00<br />

79101 TC A 60.95 0.00 0.00<br />

79200 TC A 65.82 0.00 0.00<br />

79300 TC A 127.00 0.00 0.00<br />

79403 TC A 94.38 0.00 0.00<br />

79440 TC A 53.28 0.00 0.00<br />

79445 TC A 127.00 0.00 0.00<br />

79999 TC A 127.00 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,207.48 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,497.39 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.48 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,547.24 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,547.24 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 223.45 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 223.45 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 112.83 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 238.46 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 71.68 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 641.88 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,463.71 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,145.73 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,145.73 0.00 0.00<br />

C8900 A 248.08 0.00 0.00 0123T S 916.24 0.00 0.00<br />

C8901 A 202.02 0.00 0.00 0124T S 179.08 0.00 0.00<br />

C8902 A 312.67 0.00 0.00 0144T TC A 60.95 0.00 0.00<br />

C8903 A 248.08 0.00 0.00 0145T TC A 164.08 0.00 0.00<br />

C8904 A 202.02 0.00 0.00 0146T TC A 164.08 0.00 0.00<br />

C8905 A 312.67 0.00 0.00 0147T TC A 164.08 0.00 0.00<br />

C8906 A 248.08 0.00 0.00 0148T TC A 164.08 0.00 0.00<br />

C8907 A 202.02 0.00 0.00 0149T TC A 164.08 0.00 0.00<br />

C8908 A 312.67 0.00 0.00 0150T TC A 164.08 0.00 0.00<br />

C8909 A 248.08 0.00 0.00 0151T TC A 60.95 0.00 0.00<br />

C8910 A 202.02 0.00 0.00 0170T S 1,190.14 0.00 0.00<br />

C8911 A 312.67 0.00 0.00 0176T S 1,405.28 0.00 0.00<br />

C8912 A 248.08 0.00 0.00 0177T S 1,405.28 0.00 0.00<br />

C8913 A 202.02 0.00 0.00 0182T A 1,015.74 0.00 0.00<br />

C8914 A 312.67 0.00 0.00 0186T S 856.07 0.00 0.00<br />

C8918 A 248.08 0.00 0.00 0190T S 856.07 0.00 0.00<br />

C8919 A 202.02 0.00 0.00 0191T S 916.24 0.00 0.00<br />

C8920 A 312.67 0.00 0.00 0192T S 1,570.25 0.00 0.00<br />

C9716 S 1,190.14 0.00 0.00 10021 S 54.92 0.00 0.00<br />

C9724 S 973.07 0.00 0.00 10022 S 171.49 0.00 0.00<br />

C9725 S 224.39 0.00 0.00 10040 S 31.75 0.00 0.00<br />

C9726 S 823.79 0.00 0.00 10060 S 48.30 0.00 0.00<br />

C9727 S 288.83 0.00 0.00 10061 S 54.17 0.00 0.00<br />

C9728 S 518.25 0.00 0.00 10080 S 54.17 0.00 0.00<br />

G0104 S 83.25 0.00 0.00 10081 S 124.71 0.00 0.00<br />

G0105 S 359.82 0.00 0.00 10120 S 67.84 0.00 0.00<br />

G0121 S 359.82 0.00 0.00 10121 S 511.33 0.00 0.00<br />

G0127 S 11.65 0.00 0.00 10140 S 71.95 0.00 0.00<br />

G0130 TC A 19.19 0.00 0.00 10160 S 54.17 0.00 0.00<br />

G0173 A 2,207.48 0.00 0.00 10180 S 578.24 0.00 0.00<br />

G0186 S 223.45 0.00 0.00 11000 S 23.30 0.00 0.00<br />

G0247 S 21.24 0.00 0.00 11001 S 7.88 0.00 0.00<br />

G0251 A 552.79 0.00 0.00 11010 S 202.30 0.00 0.00<br />

G0260 S 291.72 0.00 0.00 11011 S 202.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 202.30 0.00 0.00 11601 S 111.70 0.00 0.00<br />

11040 S 21.24 0.00 0.00 11602 S 123.00 0.00 0.00<br />

11041 S 23.64 0.00 0.00 11603 S 130.53 0.00 0.00<br />

11042 S 128.46 0.00 0.00 11604 S 352.11 0.00 0.00<br />

11043 S 128.46 0.00 0.00 11606 S 511.33 0.00 0.00<br />

11044 S 334.50 0.00 0.00 11620 S 95.25 0.00 0.00<br />

11055 S 25.01 0.00 0.00 11621 S 113.06 0.00 0.00<br />

11056 S 27.41 0.00 0.00 11622 S 125.74 0.00 0.00<br />

11057 S 31.75 0.00 0.00 11623 S 135.33 0.00 0.00<br />

11100 S 58.17 0.00 0.00 11624 S 511.33 0.00 0.00<br />

11101 S 13.71 0.00 0.00 11626 S 625.31 0.00 0.00<br />

11200 S 31.75 0.00 0.00 11640 S 100.73 0.00 0.00<br />

11201 S 5.48 0.00 0.00 11641 S 118.89 0.00 0.00<br />

11300 S 31.75 0.00 0.00 11642 S 132.59 0.00 0.00<br />

11301 S 31.75 0.00 0.00 11643 S 142.87 0.00 0.00<br />

11302 S 31.75 0.00 0.00 11644 S 511.33 0.00 0.00<br />

11303 S 58.17 0.00 0.00 11646 S 625.31 0.00 0.00<br />

11305 S 31.75 0.00 0.00 11719 S 11.65 0.00 0.00<br />

11306 S 31.75 0.00 0.00 11720 S 14.39 0.00 0.00<br />

11307 S 31.75 0.00 0.00 11721 S 17.47 0.00 0.00<br />

11308 S 31.75 0.00 0.00 11730 S 31.75 0.00 0.00<br />

11310 S 31.75 0.00 0.00 11732 S 17.47 0.00 0.00<br />

11311 S 31.75 0.00 0.00 11740 S 16.04 0.00 0.00<br />

11312 S 31.75 0.00 0.00 11750 S 92.51 0.00 0.00<br />

11313 S 31.75 0.00 0.00 11752 S 128.48 0.00 0.00<br />

11400 S 65.44 0.00 0.00 11755 S 64.06 0.00 0.00<br />

11401 S 73.66 0.00 0.00 11760 S 131.95 0.00 0.00<br />

11402 S 80.86 0.00 0.00 11762 S 117.86 0.00 0.00<br />

11403 S 86.34 0.00 0.00 11765 S 31.75 0.00 0.00<br />

11404 S 459.00 0.00 0.00 11770 S 654.96 0.00 0.00<br />

11406 S 511.33 0.00 0.00 11771 S 654.96 0.00 0.00<br />

11420 S 61.33 0.00 0.00 11772 S 654.96 0.00 0.00<br />

11421 S 74.34 0.00 0.00 11900 S 29.13 0.00 0.00<br />

11422 S 81.20 0.00 0.00 11901 S 31.75 0.00 0.00<br />

11423 S 90.45 0.00 0.00 11920 S 92.16 0.00 0.00<br />

11424 S 511.33 0.00 0.00 11921 S 101.42 0.00 0.00<br />

11426 S 625.31 0.00 0.00 11922 S 32.89 0.00 0.00<br />

11440 S 70.24 0.00 0.00 11950 S 33.58 0.00 0.00<br />

11441 S 81.20 0.00 0.00 11951 S 41.80 0.00 0.00<br />

11442 S 89.42 0.00 0.00 11952 S 50.32 0.00 0.00<br />

11443 S 99.01 0.00 0.00 11954 S 50.32 0.00 0.00<br />

11444 S 312.51 0.00 0.00 11960 S 610.42 0.00 0.00<br />

11446 S 625.31 0.00 0.00 11970 S 1,105.68 0.00 0.00<br />

11450 S 625.31 0.00 0.00 11971 S 572.98 0.00 0.00<br />

11451 S 625.31 0.00 0.00 11976 S 61.33 0.00 0.00<br />

11462 S 625.31 0.00 0.00 11980 S 24.77 0.00 0.00<br />

11463 S 625.31 0.00 0.00 11981 S 24.77 0.00 0.00<br />

11470 S 625.31 0.00 0.00 11982 S 24.77 0.00 0.00<br />

11471 S 625.31 0.00 0.00 11983 S 24.77 0.00 0.00<br />

11600 S 92.16 0.00 0.00 12001 S 50.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 50.32 0.00 0.00 14021 S 542.46 0.00 0.00<br />

12004 S 50.32 0.00 0.00 14040 S 512.82 0.00 0.00<br />

12005 S 67.42 0.00 0.00 14041 S 542.46 0.00 0.00<br />

12006 S 67.42 0.00 0.00 14060 S 542.46 0.00 0.00<br />

12007 S 67.42 0.00 0.00 14061 S 542.46 0.00 0.00<br />

12011 S 50.32 0.00 0.00 14300 S 695.64 0.00 0.00<br />

12013 S 50.32 0.00 0.00 14350 S 640.06 0.00 0.00<br />

12014 S 50.32 0.00 0.00 15002 S 234.67 0.00 0.00<br />

12015 S 50.32 0.00 0.00 15003 S 234.67 0.00 0.00<br />

12016 S 67.42 0.00 0.00 15004 S 234.67 0.00 0.00<br />

12017 S 67.42 0.00 0.00 15005 S 234.67 0.00 0.00<br />

12018 S 67.42 0.00 0.00 15040 S 108.23 0.00 0.00<br />

12020 S 127.20 0.00 0.00 15050 S 234.67 0.00 0.00<br />

12021 S 108.23 0.00 0.00 15100 S 610.42 0.00 0.00<br />

12031 S 50.32 0.00 0.00 15101 S 640.06 0.00 0.00<br />

12032 S 131.95 0.00 0.00 15110 S 291.50 0.00 0.00<br />

12034 S 67.42 0.00 0.00 15111 S 239.17 0.00 0.00<br />

12035 S 67.42 0.00 0.00 15115 S 291.50 0.00 0.00<br />

12036 S 108.23 0.00 0.00 15116 S 239.17 0.00 0.00<br />

12037 S 215.71 0.00 0.00 15120 S 610.42 0.00 0.00<br />

12041 S 50.32 0.00 0.00 15121 S 640.06 0.00 0.00<br />

12042 S 50.32 0.00 0.00 15130 S 512.82 0.00 0.00<br />

12044 S 67.42 0.00 0.00 15131 S 460.48 0.00 0.00<br />

12045 S 108.23 0.00 0.00 15135 S 512.82 0.00 0.00<br />

12046 S 108.23 0.00 0.00 15136 S 460.48 0.00 0.00<br />

12047 S 215.71 0.00 0.00 15150 S 291.50 0.00 0.00<br />

12051 S 50.32 0.00 0.00 15151 S 239.17 0.00 0.00<br />

12052 S 50.32 0.00 0.00 15152 S 239.17 0.00 0.00<br />

12053 S 50.32 0.00 0.00 15155 S 291.50 0.00 0.00<br />

12054 S 67.42 0.00 0.00 15156 S 239.17 0.00 0.00<br />

12055 S 108.23 0.00 0.00 15157 S 239.17 0.00 0.00<br />

12056 S 108.23 0.00 0.00 15170 S 131.95 0.00 0.00<br />

12057 S 215.71 0.00 0.00 15171 S 131.95 0.00 0.00<br />

13100 S 234.67 0.00 0.00 15175 S 169.88 0.00 0.00<br />

13101 S 234.67 0.00 0.00 15176 S 169.88 0.00 0.00<br />

13102 S 127.20 0.00 0.00 15200 S 542.46 0.00 0.00<br />

13120 S 108.23 0.00 0.00 15201 S 455.99 0.00 0.00<br />

13121 S 108.23 0.00 0.00 15220 S 512.82 0.00 0.00<br />

13122 S 108.23 0.00 0.00 15221 S 234.67 0.00 0.00<br />

13131 S 108.23 0.00 0.00 15240 S 542.46 0.00 0.00<br />

13132 S 108.23 0.00 0.00 15241 S 234.67 0.00 0.00<br />

13133 S 108.23 0.00 0.00 15260 S 512.82 0.00 0.00<br />

13150 S 234.67 0.00 0.00 15261 S 455.99 0.00 0.00<br />

13151 S 234.67 0.00 0.00 15300 S 234.67 0.00 0.00<br />

13152 S 234.67 0.00 0.00 15301 S 234.67 0.00 0.00<br />

13153 S 108.23 0.00 0.00 15320 S 234.67 0.00 0.00<br />

13160 S 610.42 0.00 0.00 15321 S 234.67 0.00 0.00<br />

14000 S 512.82 0.00 0.00 15330 S 234.67 0.00 0.00<br />

14001 S 542.46 0.00 0.00 15331 S 234.67 0.00 0.00<br />

14020 S 542.46 0.00 0.00 15335 S 234.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 234.67 0.00 0.00 15826 S 640.06 0.00 0.00<br />

15340 S 131.95 0.00 0.00 15828 S 640.06 0.00 0.00<br />

15341 S 131.95 0.00 0.00 15829 S 735.93 0.00 0.00<br />

15360 S 131.95 0.00 0.00 15830 S 654.96 0.00 0.00<br />

15361 S 131.95 0.00 0.00 15832 S 654.96 0.00 0.00<br />

15365 S 131.95 0.00 0.00 15833 S 654.96 0.00 0.00<br />

15366 S 131.95 0.00 0.00 15834 S 654.96 0.00 0.00<br />

15400 S 234.67 0.00 0.00 15835 S 568.48 0.00 0.00<br />

15401 S 234.67 0.00 0.00 15836 S 540.98 0.00 0.00<br />

15420 S 234.67 0.00 0.00 15837 S 609.54 0.00 0.00<br />

15421 S 234.67 0.00 0.00 15838 S 609.54 0.00 0.00<br />

15430 S 234.67 0.00 0.00 15839 S 540.98 0.00 0.00<br />

15431 S 234.67 0.00 0.00 15840 S 695.64 0.00 0.00<br />

15570 S 640.06 0.00 0.00 15841 S 695.64 0.00 0.00<br />

15572 S 640.06 0.00 0.00 15842 S 807.70 0.00 0.00<br />

15574 S 640.06 0.00 0.00 15845 S 695.64 0.00 0.00<br />

15576 S 640.06 0.00 0.00 15847 S 654.96 0.00 0.00<br />

15600 S 640.06 0.00 0.00 15850 S 104.63 0.00 0.00<br />

15610 S 640.06 0.00 0.00 15851 S 47.62 0.00 0.00<br />

15620 S 695.64 0.00 0.00 15852 S 24.77 0.00 0.00<br />

15630 S 640.06 0.00 0.00 15860 S 24.77 0.00 0.00<br />

15650 S 735.93 0.00 0.00 15876 S 640.06 0.00 0.00<br />

15731 S 640.06 0.00 0.00 15877 S 640.06 0.00 0.00<br />

15732 S 640.06 0.00 0.00 15878 S 640.06 0.00 0.00<br />

15734 S 640.06 0.00 0.00 15879 S 640.06 0.00 0.00<br />

15736 S 640.06 0.00 0.00 15920 S 202.30 0.00 0.00<br />

15738 S 640.06 0.00 0.00 15922 S 695.64 0.00 0.00<br />

15740 S 512.82 0.00 0.00 15931 S 654.96 0.00 0.00<br />

15750 S 610.42 0.00 0.00 15933 S 654.96 0.00 0.00<br />

15760 S 610.42 0.00 0.00 15934 S 640.06 0.00 0.00<br />

15770 S 640.06 0.00 0.00 15935 S 695.64 0.00 0.00<br />

15775 S 174.89 0.00 0.00 15936 S 598.04 0.00 0.00<br />

15776 S 174.89 0.00 0.00 15937 S 695.64 0.00 0.00<br />

15780 S 389.90 0.00 0.00 15940 S 654.96 0.00 0.00<br />

15781 S 171.62 0.00 0.00 15941 S 654.96 0.00 0.00<br />

15782 S 171.62 0.00 0.00 15944 S 640.06 0.00 0.00<br />

15783 S 104.63 0.00 0.00 15945 S 695.64 0.00 0.00<br />

15786 S 31.75 0.00 0.00 15946 S 695.64 0.00 0.00<br />

15787 S 28.78 0.00 0.00 15950 S 654.96 0.00 0.00<br />

15788 S 31.75 0.00 0.00 15951 S 710.53 0.00 0.00<br />

15789 S 58.17 0.00 0.00 15952 S 542.46 0.00 0.00<br />

15792 S 58.17 0.00 0.00 15953 S 598.04 0.00 0.00<br />

15793 S 31.75 0.00 0.00 15956 S 542.46 0.00 0.00<br />

15819 S 131.95 0.00 0.00 15958 S 598.04 0.00 0.00<br />

15820 S 640.06 0.00 0.00 16000 S 25.70 0.00 0.00<br />

15821 S 640.06 0.00 0.00 16020 S 39.06 0.00 0.00<br />

15822 S 640.06 0.00 0.00 16025 S 60.16 0.00 0.00<br />

15823 S 735.93 0.00 0.00 16030 S 75.32 0.00 0.00<br />

15824 S 640.06 0.00 0.00 16035 S 58.17 0.00 0.00<br />

15825 S 640.06 0.00 0.00 17000 S 31.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.77 0.00 0.00 19300 S 703.68 0.00 0.00<br />

17004 S 82.91 0.00 0.00 19301 S 648.10 0.00 0.00<br />

17106 S 104.63 0.00 0.00 19302 S 1,237.80 0.00 0.00<br />

17107 S 104.63 0.00 0.00 19303 S 935.44 0.00 0.00<br />

17108 S 104.63 0.00 0.00 19304 S 935.44 0.00 0.00<br />

17110 S 31.75 0.00 0.00 19316 S 935.44 0.00 0.00<br />

17111 S 58.17 0.00 0.00 19318 S 1,068.75 0.00 0.00<br />

17250 S 43.86 0.00 0.00 19324 S 1,068.75 0.00 0.00<br />

17260 S 46.94 0.00 0.00 19325 S 1,772.65 0.00 0.00<br />

17261 S 58.17 0.00 0.00 19328 S 797.89 0.00 0.00<br />

17262 S 58.17 0.00 0.00 19330 S 797.89 0.00 0.00<br />

17263 S 58.17 0.00 0.00 19340 S 983.53 0.00 0.00<br />

17264 S 58.17 0.00 0.00 19342 S 1,388.70 0.00 0.00<br />

17266 S 104.63 0.00 0.00 19350 S 703.68 0.00 0.00<br />

17270 S 58.17 0.00 0.00 19355 S 935.44 0.00 0.00<br />

17271 S 58.17 0.00 0.00 19357 S 1,484.57 0.00 0.00<br />

17272 S 58.17 0.00 0.00 19366 S 975.74 0.00 0.00<br />

17273 S 104.63 0.00 0.00 19370 S 935.44 0.00 0.00<br />

17274 S 104.63 0.00 0.00 19371 S 935.44 0.00 0.00<br />

17276 S 104.63 0.00 0.00 19380 S 1,109.05 0.00 0.00<br />

17280 S 58.17 0.00 0.00 19396 S 1,287.32 0.00 0.00<br />

17281 S 86.68 0.00 0.00 20000 S 54.17 0.00 0.00<br />

17282 S 99.01 0.00 0.00 20005 S 624.13 0.00 0.00<br />

17283 S 104.63 0.00 0.00 20103 S 612.52 0.00 0.00<br />

17284 S 104.63 0.00 0.00 20150 S 1,738.95 0.00 0.00<br />

17286 S 104.63 0.00 0.00 20200 S 511.33 0.00 0.00<br />

17311 S 172.72 0.00 0.00 20205 S 540.98 0.00 0.00<br />

17312 S 172.72 0.00 0.00 20206 S 252.79 0.00 0.00<br />

17313 S 172.72 0.00 0.00 20220 S 274.78 0.00 0.00<br />

17314 S 172.72 0.00 0.00 20225 S 498.59 0.00 0.00<br />

17315 S 39.06 0.00 0.00 20240 S 625.31 0.00 0.00<br />

17340 S 14.05 0.00 0.00 20245 S 654.96 0.00 0.00<br />

17360 S 31.75 0.00 0.00 20250 S 653.77 0.00 0.00<br />

17380 S 31.75 0.00 0.00 20251 S 653.77 0.00 0.00<br />

19000 S 66.13 0.00 0.00 20500 S 54.14 0.00 0.00<br />

19001 S 8.91 0.00 0.00 20520 S 91.14 0.00 0.00<br />

19020 S 578.24 0.00 0.00 20525 S 654.96 0.00 0.00<br />

19100 S 196.91 0.00 0.00 20526 S 29.47 0.00 0.00<br />

19101 S 618.46 0.00 0.00 20550 S 22.27 0.00 0.00<br />

19102 S 252.79 0.00 0.00 20551 S 21.92 0.00 0.00<br />

19103 S 442.45 0.00 0.00 20552 S 21.24 0.00 0.00<br />

19105 S 1,287.32 0.00 0.00 20553 S 23.64 0.00 0.00<br />

19110 S 618.46 0.00 0.00 20555 S 1,145.73 0.00 0.00<br />

19112 S 648.10 0.00 0.00 20600 S 22.61 0.00 0.00<br />

19120 S 648.10 0.00 0.00 20605 S 25.35 0.00 0.00<br />

19125 S 648.10 0.00 0.00 20610 S 35.63 0.00 0.00<br />

19126 S 648.10 0.00 0.00 20612 S 23.99 0.00 0.00<br />

19296 S 1,772.65 0.00 0.00 20615 S 100.39 0.00 0.00<br />

19297 S 1,772.65 0.00 0.00 20650 S 653.77 0.00 0.00<br />

19298 S 1,772.65 0.00 0.00 20662 S 835.13 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 835.13 0.00 0.00 21085 S 251.48 0.00 0.00<br />

20665 S 24.77 0.00 0.00 21086 S 547.49 0.00 0.00<br />

20670 S 459.00 0.00 0.00 21087 S 548.19 0.00 0.00<br />

20680 S 654.96 0.00 0.00 21088 S 1,605.54 0.00 0.00<br />

20690 S 779.42 0.00 0.00 21100 S 1,009.33 0.00 0.00<br />

20692 S 809.07 0.00 0.00 21110 S 288.83 0.00 0.00<br />

20693 S 653.77 0.00 0.00 21120 S 935.43 0.00 0.00<br />

20694 S 571.79 0.00 0.00 21121 S 935.43 0.00 0.00<br />

20696 S 1,145.73 0.00 0.00 21122 S 935.43 0.00 0.00<br />

20697 S 761.95 0.00 0.00 21123 S 935.43 0.00 0.00<br />

20822 S 1,073.56 0.00 0.00 21125 S 935.43 0.00 0.00<br />

20900 S 809.07 0.00 0.00 21127 S 1,422.92 0.00 0.00<br />

20902 S 864.64 0.00 0.00 21137 S 949.19 0.00 0.00<br />

20910 S 640.06 0.00 0.00 21138 S 1,605.54 0.00 0.00<br />

20912 S 640.06 0.00 0.00 21139 S 1,605.54 0.00 0.00<br />

20920 S 598.04 0.00 0.00 21150 S 1,605.54 0.00 0.00<br />

20922 S 542.46 0.00 0.00 21181 S 935.43 0.00 0.00<br />

20924 S 864.64 0.00 0.00 21198 S 1,605.54 0.00 0.00<br />

20926 S 376.72 0.00 0.00 21199 S 1,605.54 0.00 0.00<br />

20950 S 54.17 0.00 0.00 21206 S 1,134.85 0.00 0.00<br />

20972 S 1,813.26 0.00 0.00 21208 S 1,263.60 0.00 0.00<br />

20973 S 1,813.26 0.00 0.00 21209 S 1,134.85 0.00 0.00<br />

20979 S 22.27 0.00 0.00 21210 S 1,263.60 0.00 0.00<br />

20982 S 1,738.95 0.00 0.00 21215 S 1,263.60 0.00 0.00<br />

21010 S 681.15 0.00 0.00 21230 S 1,263.60 0.00 0.00<br />

21015 S 566.72 0.00 0.00 21235 S 935.43 0.00 0.00<br />

21025 S 1,009.33 0.00 0.00 21240 S 1,094.55 0.00 0.00<br />

21026 S 1,009.33 0.00 0.00 21242 S 1,134.85 0.00 0.00<br />

21029 S 1,009.33 0.00 0.00 21243 S 1,134.85 0.00 0.00<br />

21030 S 238.11 0.00 0.00 21244 S 1,263.60 0.00 0.00<br />

21031 S 197.00 0.00 0.00 21245 S 1,263.60 0.00 0.00<br />

21032 S 200.77 0.00 0.00 21246 S 1,263.60 0.00 0.00<br />

21034 S 1,038.98 0.00 0.00 21248 S 1,263.60 0.00 0.00<br />

21040 S 681.15 0.00 0.00 21249 S 1,263.60 0.00 0.00<br />

21044 S 1,009.33 0.00 0.00 21260 S 1,605.54 0.00 0.00<br />

21046 S 1,009.33 0.00 0.00 21267 S 1,263.60 0.00 0.00<br />

21047 S 1,009.33 0.00 0.00 21270 S 1,134.85 0.00 0.00<br />

21048 S 1,605.54 0.00 0.00 21275 S 1,263.60 0.00 0.00<br />

21050 S 1,038.98 0.00 0.00 21280 S 1,134.85 0.00 0.00<br />

21060 S 1,009.33 0.00 0.00 21282 S 662.59 0.00 0.00<br />

21070 S 1,038.98 0.00 0.00 21295 S 298.65 0.00 0.00<br />

21073 S 185.01 0.00 0.00 21296 S 628.82 0.00 0.00<br />

21076 S 321.03 0.00 0.00 21310 S 91.10 0.00 0.00<br />

21077 S 776.02 0.00 0.00 21315 S 400.32 0.00 0.00<br />

21079 S 555.72 0.00 0.00 21320 S 537.07 0.00 0.00<br />

21080 S 637.26 0.00 0.00 21325 S 766.37 0.00 0.00<br />

21081 S 587.24 0.00 0.00 21330 S 806.67 0.00 0.00<br />

21082 S 558.81 0.00 0.00 21335 S 935.43 0.00 0.00<br />

21083 S 550.58 0.00 0.00 21336 S 779.58 0.00 0.00<br />

21084 S 633.49 0.00 0.00 21337 S 537.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 766.37 0.00 0.00 22310 S 165.85 0.00 0.00<br />

21339 S 806.67 0.00 0.00 22315 S 428.97 0.00 0.00<br />

21340 S 1,094.55 0.00 0.00 22505 S 505.00 0.00 0.00<br />

21345 S 935.43 0.00 0.00 22520 S 1,193.01 0.00 0.00<br />

21355 S 1,038.98 0.00 0.00 22521 S 1,193.01 0.00 0.00<br />

21356 S 710.80 0.00 0.00 22522 S 1,193.01 0.00 0.00<br />

21360 S 949.19 0.00 0.00 22523 S 3,320.27 0.00 0.00<br />

21390 S 1,605.54 0.00 0.00 22524 S 3,320.27 0.00 0.00<br />

21400 S 350.98 0.00 0.00 22525 S 3,320.27 0.00 0.00<br />

21401 S 566.72 0.00 0.00 22900 S 710.53 0.00 0.00<br />

21406 S 1,605.54 0.00 0.00 23000 S 511.33 0.00 0.00<br />

21407 S 1,605.54 0.00 0.00 23020 S 1,076.04 0.00 0.00<br />

21421 S 766.37 0.00 0.00 23030 S 525.90 0.00 0.00<br />

21440 S 322.75 0.00 0.00 23031 S 607.88 0.00 0.00<br />

21445 S 766.37 0.00 0.00 23035 S 653.77 0.00 0.00<br />

21450 S 133.20 0.00 0.00 23040 S 809.07 0.00 0.00<br />

21451 S 359.39 0.00 0.00 23044 S 864.64 0.00 0.00<br />

21452 S 537.07 0.00 0.00 23065 S 96.62 0.00 0.00<br />

21453 S 1,038.98 0.00 0.00 23066 S 625.31 0.00 0.00<br />

21454 S 806.67 0.00 0.00 23075 S 511.33 0.00 0.00<br />

21461 S 1,094.55 0.00 0.00 23076 S 625.31 0.00 0.00<br />

21462 S 1,134.85 0.00 0.00 23077 S 654.96 0.00 0.00<br />

21465 S 1,094.55 0.00 0.00 23100 S 624.13 0.00 0.00<br />

21480 S 91.10 0.00 0.00 23101 S 1,033.70 0.00 0.00<br />

21485 S 537.07 0.00 0.00 23105 S 864.64 0.00 0.00<br />

21490 S 1,038.98 0.00 0.00 23106 S 864.64 0.00 0.00<br />

21495 S 661.02 0.00 0.00 23107 S 864.64 0.00 0.00<br />

21497 S 537.07 0.00 0.00 23120 S 904.94 0.00 0.00<br />

21501 S 578.24 0.00 0.00 23125 S 904.94 0.00 0.00<br />

21502 S 624.13 0.00 0.00 23130 S 1,201.54 0.00 0.00<br />

21550 S 609.54 0.00 0.00 23140 S 709.35 0.00 0.00<br />

21555 S 625.31 0.00 0.00 23145 S 904.94 0.00 0.00<br />

21556 S 625.31 0.00 0.00 23146 S 904.94 0.00 0.00<br />

21557 S 837.50 0.00 0.00 23150 S 864.64 0.00 0.00<br />

21600 S 779.42 0.00 0.00 23155 S 904.94 0.00 0.00<br />

21610 S 779.42 0.00 0.00 23156 S 904.94 0.00 0.00<br />

21685 S 288.83 0.00 0.00 23170 S 779.42 0.00 0.00<br />

21700 S 624.13 0.00 0.00 23172 S 779.42 0.00 0.00<br />

21720 S 653.77 0.00 0.00 23174 S 779.42 0.00 0.00<br />

21725 S 68.05 0.00 0.00 23180 S 864.64 0.00 0.00<br />

21800 S 78.62 0.00 0.00 23182 S 864.64 0.00 0.00<br />

21805 S 694.36 0.00 0.00 23184 S 864.64 0.00 0.00<br />

21820 S 78.62 0.00 0.00 23190 S 864.64 0.00 0.00<br />

21920 S 139.79 0.00 0.00 23195 S 904.94 0.00 0.00<br />

21925 S 625.31 0.00 0.00 23330 S 312.51 0.00 0.00<br />

21930 S 625.31 0.00 0.00 23331 S 572.98 0.00 0.00<br />

21935 S 654.96 0.00 0.00 23395 S 1,201.54 0.00 0.00<br />

22102 S 1,863.70 0.00 0.00 23397 S 2,120.97 0.00 0.00<br />

22103 S 1,863.70 0.00 0.00 23400 S 1,033.70 0.00 0.00<br />

22305 S 78.62 0.00 0.00 23405 S 779.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 779.42 0.00 0.00 23931 S 578.24 0.00 0.00<br />

23410 S 1,201.54 0.00 0.00 23935 S 624.13 0.00 0.00<br />

23412 S 1,330.30 0.00 0.00 24000 S 864.64 0.00 0.00<br />

23415 S 1,201.54 0.00 0.00 24006 S 864.64 0.00 0.00<br />

23420 S 1,330.30 0.00 0.00 24065 S 133.96 0.00 0.00<br />

23430 S 1,161.26 0.00 0.00 24066 S 511.33 0.00 0.00<br />

23440 S 1,161.26 0.00 0.00 24075 S 511.33 0.00 0.00<br />

23450 S 1,992.22 0.00 0.00 24076 S 625.31 0.00 0.00<br />

23455 S 2,120.97 0.00 0.00 24077 S 654.96 0.00 0.00<br />

23460 S 1,992.22 0.00 0.00 24100 S 571.79 0.00 0.00<br />

23462 S 1,330.30 0.00 0.00 24101 S 864.64 0.00 0.00<br />

23465 S 1,992.22 0.00 0.00 24102 S 864.64 0.00 0.00<br />

23466 S 1,330.30 0.00 0.00 24105 S 653.77 0.00 0.00<br />

23480 S 1,161.26 0.00 0.00 24110 S 624.13 0.00 0.00<br />

23485 S 2,120.97 0.00 0.00 24115 S 809.07 0.00 0.00<br />

23490 S 1,105.68 0.00 0.00 24116 S 809.07 0.00 0.00<br />

23491 S 1,896.35 0.00 0.00 24120 S 653.77 0.00 0.00<br />

23500 S 78.62 0.00 0.00 24125 S 809.07 0.00 0.00<br />

23505 S 428.97 0.00 0.00 24126 S 809.07 0.00 0.00<br />

23515 S 1,435.73 0.00 0.00 24130 S 809.07 0.00 0.00<br />

23520 S 165.85 0.00 0.00 24134 S 779.42 0.00 0.00<br />

23525 S 165.85 0.00 0.00 24136 S 779.42 0.00 0.00<br />

23530 S 1,057.99 0.00 0.00 24138 S 779.42 0.00 0.00<br />

23532 S 779.58 0.00 0.00 24140 S 809.07 0.00 0.00<br />

23540 S 78.62 0.00 0.00 24145 S 809.07 0.00 0.00<br />

23545 S 165.85 0.00 0.00 24147 S 779.42 0.00 0.00<br />

23550 S 1,057.99 0.00 0.00 24149 S 1,145.73 0.00 0.00<br />

23552 S 1,113.57 0.00 0.00 24152 S 1,738.95 0.00 0.00<br />

23570 S 78.62 0.00 0.00 24153 S 3,320.27 0.00 0.00<br />

23575 S 165.85 0.00 0.00 24155 S 1,105.68 0.00 0.00<br />

23585 S 1,435.73 0.00 0.00 24160 S 779.42 0.00 0.00<br />

23600 S 61.26 0.00 0.00 24164 S 809.07 0.00 0.00<br />

23605 S 428.97 0.00 0.00 24200 S 97.99 0.00 0.00<br />

23615 S 1,491.30 0.00 0.00 24201 S 511.33 0.00 0.00<br />

23616 S 1,491.30 0.00 0.00 24300 S 596.88 0.00 0.00<br />

23620 S 61.26 0.00 0.00 24301 S 864.64 0.00 0.00<br />

23625 S 428.97 0.00 0.00 24305 S 864.64 0.00 0.00<br />

23630 S 1,531.59 0.00 0.00 24310 S 653.77 0.00 0.00<br />

23650 S 78.62 0.00 0.00 24320 S 1,105.68 0.00 0.00<br />

23655 S 452.67 0.00 0.00 24330 S 1,896.35 0.00 0.00<br />

23660 S 1,057.99 0.00 0.00 24331 S 1,105.68 0.00 0.00<br />

23665 S 165.85 0.00 0.00 24332 S 835.13 0.00 0.00<br />

23670 S 1,435.73 0.00 0.00 24340 S 1,105.68 0.00 0.00<br />

23675 S 78.62 0.00 0.00 24341 S 1,105.68 0.00 0.00<br />

23680 S 1,057.99 0.00 0.00 24342 S 1,105.68 0.00 0.00<br />

23700 S 452.67 0.00 0.00 24343 S 1,145.73 0.00 0.00<br />

23800 S 1,951.92 0.00 0.00 24344 S 3,320.27 0.00 0.00<br />

23802 S 1,330.30 0.00 0.00 24345 S 779.42 0.00 0.00<br />

23921 S 455.99 0.00 0.00 24346 S 1,738.95 0.00 0.00<br />

23930 S 525.90 0.00 0.00 24357 S 1,145.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,145.73 0.00 0.00 24925 S 653.77 0.00 0.00<br />

24359 S 1,145.73 0.00 0.00 25000 S 653.77 0.00 0.00<br />

24360 S 1,057.34 0.00 0.00 25001 S 835.13 0.00 0.00<br />

24361 S 5,781.03 3,538.73 1,296.42 25020 S 653.77 0.00 0.00<br />

24362 S 1,351.28 0.00 0.00 25023 S 809.07 0.00 0.00<br />

24363 S 5,909.79 3,667.48 1,425.17 25024 S 809.07 0.00 0.00<br />

24365 S 1,057.34 0.00 0.00 25025 S 809.07 0.00 0.00<br />

24366 S 5,781.03 3,538.73 1,296.42 25028 S 571.79 0.00 0.00<br />

24400 S 864.64 0.00 0.00 25031 S 624.13 0.00 0.00<br />

24410 S 864.64 0.00 0.00 25035 S 624.13 0.00 0.00<br />

24420 S 1,105.68 0.00 0.00 25040 S 904.94 0.00 0.00<br />

24430 S 1,896.35 0.00 0.00 25065 S 136.01 0.00 0.00<br />

24435 S 1,951.92 0.00 0.00 25066 S 625.31 0.00 0.00<br />

24470 S 1,105.68 0.00 0.00 25075 S 511.33 0.00 0.00<br />

24495 S 779.42 0.00 0.00 25076 S 654.96 0.00 0.00<br />

24498 S 1,896.35 0.00 0.00 25077 S 654.96 0.00 0.00<br />

24500 S 78.62 0.00 0.00 25085 S 653.77 0.00 0.00<br />

24505 S 78.62 0.00 0.00 25100 S 624.13 0.00 0.00<br />

24515 S 1,491.30 0.00 0.00 25101 S 809.07 0.00 0.00<br />

24516 S 1,491.30 0.00 0.00 25105 S 864.64 0.00 0.00<br />

24530 S 78.62 0.00 0.00 25107 S 809.07 0.00 0.00<br />

24535 S 165.85 0.00 0.00 25109 S 835.13 0.00 0.00<br />

24538 S 694.36 0.00 0.00 25110 S 653.77 0.00 0.00<br />

24545 S 1,491.30 0.00 0.00 25111 S 653.77 0.00 0.00<br />

24546 S 1,531.59 0.00 0.00 25112 S 709.35 0.00 0.00<br />

24560 S 78.62 0.00 0.00 25115 S 709.35 0.00 0.00<br />

24565 S 78.62 0.00 0.00 25116 S 709.35 0.00 0.00<br />

24566 S 694.36 0.00 0.00 25118 S 779.42 0.00 0.00<br />

24575 S 1,435.73 0.00 0.00 25119 S 809.07 0.00 0.00<br />

24576 S 78.62 0.00 0.00 25120 S 809.07 0.00 0.00<br />

24577 S 165.85 0.00 0.00 25125 S 809.07 0.00 0.00<br />

24579 S 1,435.73 0.00 0.00 25126 S 809.07 0.00 0.00<br />

24582 S 694.36 0.00 0.00 25130 S 809.07 0.00 0.00<br />

24586 S 1,491.30 0.00 0.00 25135 S 809.07 0.00 0.00<br />

24587 S 1,531.59 0.00 0.00 25136 S 809.07 0.00 0.00<br />

24600 S 78.62 0.00 0.00 25145 S 779.42 0.00 0.00<br />

24605 S 505.00 0.00 0.00 25150 S 779.42 0.00 0.00<br />

24615 S 1,435.73 0.00 0.00 25151 S 779.42 0.00 0.00<br />

24620 S 428.97 0.00 0.00 25210 S 809.07 0.00 0.00<br />

24635 S 1,435.73 0.00 0.00 25215 S 864.64 0.00 0.00<br />

24640 S 53.10 0.00 0.00 25230 S 864.64 0.00 0.00<br />

24650 S 61.26 0.00 0.00 25240 S 864.64 0.00 0.00<br />

24655 S 165.85 0.00 0.00 25248 S 624.13 0.00 0.00<br />

24665 S 1,113.57 0.00 0.00 25250 S 727.09 0.00 0.00<br />

24666 S 1,491.30 0.00 0.00 25251 S 727.09 0.00 0.00<br />

24670 S 78.62 0.00 0.00 25259 S 761.95 0.00 0.00<br />

24675 S 78.62 0.00 0.00 25260 S 864.64 0.00 0.00<br />

24685 S 1,057.99 0.00 0.00 25263 S 779.42 0.00 0.00<br />

24800 S 1,161.26 0.00 0.00 25265 S 809.07 0.00 0.00<br />

24802 S 1,201.54 0.00 0.00 25270 S 864.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 809.07 0.00 0.00 25505 S 165.85 0.00 0.00<br />

25274 S 864.64 0.00 0.00 25515 S 1,057.99 0.00 0.00<br />

25275 S 864.64 0.00 0.00 25520 S 165.85 0.00 0.00<br />

25280 S 864.64 0.00 0.00 25525 S 1,113.57 0.00 0.00<br />

25290 S 809.07 0.00 0.00 25526 S 1,153.86 0.00 0.00<br />

25295 S 653.77 0.00 0.00 25530 S 61.26 0.00 0.00<br />

25300 S 809.07 0.00 0.00 25535 S 78.62 0.00 0.00<br />

25301 S 809.07 0.00 0.00 25545 S 1,057.99 0.00 0.00<br />

25310 S 1,105.68 0.00 0.00 25560 S 61.26 0.00 0.00<br />

25312 S 1,161.26 0.00 0.00 25565 S 165.85 0.00 0.00<br />

25315 S 1,105.68 0.00 0.00 25574 S 1,435.73 0.00 0.00<br />

25316 S 1,896.35 0.00 0.00 25575 S 1,435.73 0.00 0.00<br />

25320 S 1,105.68 0.00 0.00 25600 S 61.26 0.00 0.00<br />

25332 S 1,057.34 0.00 0.00 25605 S 165.85 0.00 0.00<br />

25335 S 1,105.68 0.00 0.00 25606 S 724.00 0.00 0.00<br />

25337 S 1,201.54 0.00 0.00 25607 S 1,531.59 0.00 0.00<br />

25350 S 1,896.35 0.00 0.00 25608 S 1,531.59 0.00 0.00<br />

25355 S 1,105.68 0.00 0.00 25609 S 1,531.59 0.00 0.00<br />

25360 S 809.07 0.00 0.00 25622 S 61.26 0.00 0.00<br />

25365 S 809.07 0.00 0.00 25624 S 165.85 0.00 0.00<br />

25370 S 1,105.68 0.00 0.00 25628 S 1,057.99 0.00 0.00<br />

25375 S 1,161.26 0.00 0.00 25630 S 61.26 0.00 0.00<br />

25390 S 809.07 0.00 0.00 25635 S 165.85 0.00 0.00<br />

25391 S 1,161.26 0.00 0.00 25645 S 1,057.99 0.00 0.00<br />

25392 S 809.07 0.00 0.00 25650 S 61.26 0.00 0.00<br />

25393 S 1,161.26 0.00 0.00 25651 S 975.59 0.00 0.00<br />

25394 S 1,738.95 0.00 0.00 25652 S 1,643.56 0.00 0.00<br />

25400 S 1,105.68 0.00 0.00 25660 S 78.62 0.00 0.00<br />

25405 S 1,951.92 0.00 0.00 25670 S 724.00 0.00 0.00<br />

25415 S 1,896.35 0.00 0.00 25671 S 642.02 0.00 0.00<br />

25420 S 1,951.92 0.00 0.00 25675 S 78.62 0.00 0.00<br />

25425 S 1,105.68 0.00 0.00 25676 S 694.36 0.00 0.00<br />

25426 S 1,161.26 0.00 0.00 25680 S 78.62 0.00 0.00<br />

25430 S 1,738.95 0.00 0.00 25685 S 724.00 0.00 0.00<br />

25431 S 1,738.95 0.00 0.00 25690 S 428.97 0.00 0.00<br />

25440 S 1,951.92 0.00 0.00 25695 S 694.36 0.00 0.00<br />

25441 S 5,781.03 3,538.73 1,296.42 25800 S 1,951.92 0.00 0.00<br />

25442 S 5,781.03 3,538.73 1,296.42 25805 S 1,201.54 0.00 0.00<br />

25443 S 1,351.28 0.00 0.00 25810 S 1,992.22 0.00 0.00<br />

25444 S 1,351.28 0.00 0.00 25820 S 1,161.26 0.00 0.00<br />

25445 S 1,351.28 0.00 0.00 25825 S 1,992.22 0.00 0.00<br />

25446 S 5,909.79 3,667.48 1,425.17 25830 S 1,992.22 0.00 0.00<br />

25447 S 1,057.34 0.00 0.00 25907 S 653.77 0.00 0.00<br />

25449 S 1,057.34 0.00 0.00 25922 S 653.77 0.00 0.00<br />

25450 S 1,105.68 0.00 0.00 25929 S 542.46 0.00 0.00<br />

25455 S 1,105.68 0.00 0.00 25931 S 835.13 0.00 0.00<br />

25490 S 1,105.68 0.00 0.00 26010 S 54.17 0.00 0.00<br />

25491 S 1,105.68 0.00 0.00 26011 S 395.69 0.00 0.00<br />

25492 S 1,105.68 0.00 0.00 26020 S 525.04 0.00 0.00<br />

25500 S 61.26 0.00 0.00 26025 S 472.70 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 525.04 0.00 0.00 26392 S 772.98 0.00 0.00<br />

26034 S 525.04 0.00 0.00 26410 S 554.68 0.00 0.00<br />

26035 S 636.94 0.00 0.00 26412 S 772.98 0.00 0.00<br />

26040 S 828.57 0.00 0.00 26415 S 828.57 0.00 0.00<br />

26045 S 772.98 0.00 0.00 26416 S 772.98 0.00 0.00<br />

26055 S 525.04 0.00 0.00 26418 S 610.26 0.00 0.00<br />

26060 S 525.04 0.00 0.00 26420 S 828.57 0.00 0.00<br />

26070 S 525.04 0.00 0.00 26426 S 772.98 0.00 0.00<br />

26075 S 610.26 0.00 0.00 26428 S 772.98 0.00 0.00<br />

26080 S 610.26 0.00 0.00 26432 S 554.68 0.00 0.00<br />

26100 S 525.04 0.00 0.00 26433 S 554.68 0.00 0.00<br />

26105 S 472.70 0.00 0.00 26434 S 772.98 0.00 0.00<br />

26110 S 472.70 0.00 0.00 26437 S 554.68 0.00 0.00<br />

26115 S 625.31 0.00 0.00 26440 S 554.68 0.00 0.00<br />

26116 S 625.31 0.00 0.00 26442 S 772.98 0.00 0.00<br />

26117 S 654.96 0.00 0.00 26445 S 554.68 0.00 0.00<br />

26121 S 828.57 0.00 0.00 26449 S 772.98 0.00 0.00<br />

26123 S 828.57 0.00 0.00 26450 S 554.68 0.00 0.00<br />

26125 S 610.26 0.00 0.00 26455 S 554.68 0.00 0.00<br />

26130 S 554.68 0.00 0.00 26460 S 554.68 0.00 0.00<br />

26135 S 828.57 0.00 0.00 26471 S 525.04 0.00 0.00<br />

26140 S 525.04 0.00 0.00 26474 S 525.04 0.00 0.00<br />

26145 S 554.68 0.00 0.00 26476 S 472.70 0.00 0.00<br />

26160 S 554.68 0.00 0.00 26477 S 472.70 0.00 0.00<br />

26170 S 554.68 0.00 0.00 26478 S 472.70 0.00 0.00<br />

26180 S 554.68 0.00 0.00 26479 S 472.70 0.00 0.00<br />

26185 S 610.26 0.00 0.00 26480 S 772.98 0.00 0.00<br />

26200 S 525.04 0.00 0.00 26483 S 772.98 0.00 0.00<br />

26205 S 772.98 0.00 0.00 26485 S 743.35 0.00 0.00<br />

26210 S 525.04 0.00 0.00 26489 S 772.98 0.00 0.00<br />

26215 S 554.68 0.00 0.00 26490 S 772.98 0.00 0.00<br />

26230 S 778.35 0.00 0.00 26492 S 772.98 0.00 0.00<br />

26235 S 554.68 0.00 0.00 26494 S 772.98 0.00 0.00<br />

26236 S 554.68 0.00 0.00 26496 S 772.98 0.00 0.00<br />

26250 S 554.68 0.00 0.00 26497 S 772.98 0.00 0.00<br />

26255 S 772.98 0.00 0.00 26498 S 828.57 0.00 0.00<br />

26260 S 554.68 0.00 0.00 26499 S 772.98 0.00 0.00<br />

26261 S 554.68 0.00 0.00 26500 S 610.26 0.00 0.00<br />

26262 S 525.04 0.00 0.00 26502 S 828.57 0.00 0.00<br />

26320 S 511.33 0.00 0.00 26508 S 554.68 0.00 0.00<br />

26340 S 235.72 0.00 0.00 26510 S 772.98 0.00 0.00<br />

26350 S 691.00 0.00 0.00 26516 S 691.00 0.00 0.00<br />

26352 S 828.57 0.00 0.00 26517 S 772.98 0.00 0.00<br />

26356 S 828.57 0.00 0.00 26518 S 772.98 0.00 0.00<br />

26357 S 828.57 0.00 0.00 26520 S 554.68 0.00 0.00<br />

26358 S 828.57 0.00 0.00 26525 S 554.68 0.00 0.00<br />

26370 S 828.57 0.00 0.00 26530 S 961.47 0.00 0.00<br />

26372 S 828.57 0.00 0.00 26531 S 1,480.03 0.00 0.00<br />

26373 S 772.98 0.00 0.00 26535 S 1,057.34 0.00 0.00<br />

26390 S 828.57 0.00 0.00 26536 S 1,351.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 610.26 0.00 0.00 26775 S 163.77 0.00 0.00<br />

26541 S 997.61 0.00 0.00 26776 S 694.36 0.00 0.00<br />

26542 S 610.26 0.00 0.00 26785 S 694.36 0.00 0.00<br />

26545 S 828.57 0.00 0.00 26820 S 868.85 0.00 0.00<br />

26546 S 828.57 0.00 0.00 26841 S 828.57 0.00 0.00<br />

26548 S 828.57 0.00 0.00 26842 S 828.57 0.00 0.00<br />

26550 S 743.35 0.00 0.00 26843 S 772.98 0.00 0.00<br />

26555 S 772.98 0.00 0.00 26844 S 772.98 0.00 0.00<br />

26560 S 525.04 0.00 0.00 26850 S 828.57 0.00 0.00<br />

26561 S 772.98 0.00 0.00 26852 S 828.57 0.00 0.00<br />

26562 S 828.57 0.00 0.00 26860 S 772.98 0.00 0.00<br />

26565 S 868.85 0.00 0.00 26861 S 743.35 0.00 0.00<br />

26567 S 868.85 0.00 0.00 26862 S 828.57 0.00 0.00<br />

26568 S 772.98 0.00 0.00 26863 S 772.98 0.00 0.00<br />

26580 S 650.54 0.00 0.00 26910 S 772.98 0.00 0.00<br />

26587 S 650.54 0.00 0.00 26951 S 525.04 0.00 0.00<br />

26590 S 650.54 0.00 0.00 26952 S 610.26 0.00 0.00<br />

26591 S 772.98 0.00 0.00 26990 S 571.79 0.00 0.00<br />

26593 S 554.68 0.00 0.00 26991 S 571.79 0.00 0.00<br />

26596 S 525.04 0.00 0.00 27000 S 624.13 0.00 0.00<br />

26600 S 61.26 0.00 0.00 27001 S 809.07 0.00 0.00<br />

26605 S 78.62 0.00 0.00 27003 S 809.07 0.00 0.00<br />

26607 S 428.97 0.00 0.00 27033 S 1,105.68 0.00 0.00<br />

26608 S 779.58 0.00 0.00 27035 S 1,161.26 0.00 0.00<br />

26615 S 1,113.57 0.00 0.00 27040 S 312.51 0.00 0.00<br />

26641 S 61.26 0.00 0.00 27041 S 352.11 0.00 0.00<br />

26645 S 165.85 0.00 0.00 27047 S 625.31 0.00 0.00<br />

26650 S 694.36 0.00 0.00 27048 S 654.96 0.00 0.00<br />

26665 S 1,113.57 0.00 0.00 27049 S 654.96 0.00 0.00<br />

26670 S 61.26 0.00 0.00 27050 S 653.77 0.00 0.00<br />

26675 S 165.85 0.00 0.00 27052 S 653.77 0.00 0.00<br />

26676 S 694.36 0.00 0.00 27060 S 749.64 0.00 0.00<br />

26685 S 724.00 0.00 0.00 27062 S 749.64 0.00 0.00<br />

26686 S 1,435.73 0.00 0.00 27065 S 749.64 0.00 0.00<br />

26700 S 61.26 0.00 0.00 27066 S 904.94 0.00 0.00<br />

26705 S 78.62 0.00 0.00 27067 S 904.94 0.00 0.00<br />

26706 S 428.97 0.00 0.00 27080 S 779.42 0.00 0.00<br />

26715 S 779.58 0.00 0.00 27086 S 312.51 0.00 0.00<br />

26720 S 61.26 0.00 0.00 27087 S 653.77 0.00 0.00<br />

26725 S 61.26 0.00 0.00 27097 S 809.07 0.00 0.00<br />

26727 S 948.63 0.00 0.00 27098 S 809.07 0.00 0.00<br />

26735 S 779.58 0.00 0.00 27100 S 1,161.26 0.00 0.00<br />

26740 S 61.26 0.00 0.00 27105 S 1,161.26 0.00 0.00<br />

26742 S 78.62 0.00 0.00 27110 S 1,161.26 0.00 0.00<br />

26746 S 819.87 0.00 0.00 27111 S 1,161.26 0.00 0.00<br />

26750 S 61.26 0.00 0.00 27193 S 78.62 0.00 0.00<br />

26755 S 61.26 0.00 0.00 27194 S 505.00 0.00 0.00<br />

26756 S 694.36 0.00 0.00 27200 S 61.26 0.00 0.00<br />

26765 S 779.58 0.00 0.00 27202 S 1,028.35 0.00 0.00<br />

26770 S 61.26 0.00 0.00 27220 S 61.26 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 78.62 0.00 0.00 27397 S 1,105.68 0.00 0.00<br />

27238 S 165.85 0.00 0.00 27400 S 1,105.68 0.00 0.00<br />

27246 S 165.85 0.00 0.00 27403 S 864.64 0.00 0.00<br />

27250 S 78.62 0.00 0.00 27405 S 1,161.26 0.00 0.00<br />

27252 S 505.00 0.00 0.00 27407 S 1,951.92 0.00 0.00<br />

27256 S 61.26 0.00 0.00 27409 S 1,161.26 0.00 0.00<br />

27257 S 534.65 0.00 0.00 27416 S 1,738.95 0.00 0.00<br />

27265 S 78.62 0.00 0.00 27418 S 1,105.68 0.00 0.00<br />

27266 S 505.00 0.00 0.00 27420 S 1,105.68 0.00 0.00<br />

27267 S 61.26 0.00 0.00 27422 S 1,330.30 0.00 0.00<br />

27275 S 505.00 0.00 0.00 27424 S 1,105.68 0.00 0.00<br />

27301 S 607.88 0.00 0.00 27425 S 1,033.70 0.00 0.00<br />

27305 S 624.13 0.00 0.00 27427 S 1,105.68 0.00 0.00<br />

27306 S 653.77 0.00 0.00 27428 S 1,951.92 0.00 0.00<br />

27307 S 653.77 0.00 0.00 27429 S 1,951.92 0.00 0.00<br />

27310 S 864.64 0.00 0.00 27430 S 1,161.26 0.00 0.00<br />

27323 S 312.51 0.00 0.00 27435 S 1,161.26 0.00 0.00<br />

27324 S 572.98 0.00 0.00 27437 S 1,017.04 0.00 0.00<br />

27325 S 561.44 0.00 0.00 27438 S 1,351.28 0.00 0.00<br />

27326 S 561.44 0.00 0.00 27440 S 1,450.53 0.00 0.00<br />

27327 S 625.31 0.00 0.00 27441 S 1,057.34 0.00 0.00<br />

27328 S 654.96 0.00 0.00 27442 S 1,057.34 0.00 0.00<br />

27329 S 710.53 0.00 0.00 27443 S 1,057.34 0.00 0.00<br />

27330 S 864.64 0.00 0.00 27446 S 10,374.57 6,232.56 2,090.56<br />

27331 S 864.64 0.00 0.00 27496 S 749.64 0.00 0.00<br />

27332 S 864.64 0.00 0.00 27497 S 653.77 0.00 0.00<br />

27333 S 864.64 0.00 0.00 27498 S 653.77 0.00 0.00<br />

27334 S 864.64 0.00 0.00 27499 S 653.77 0.00 0.00<br />

27335 S 864.64 0.00 0.00 27500 S 165.85 0.00 0.00<br />

27340 S 653.77 0.00 0.00 27501 S 78.62 0.00 0.00<br />

27345 S 709.35 0.00 0.00 27502 S 428.97 0.00 0.00<br />

27347 S 709.35 0.00 0.00 27503 S 78.62 0.00 0.00<br />

27350 S 864.64 0.00 0.00 27508 S 78.62 0.00 0.00<br />

27355 S 809.07 0.00 0.00 27509 S 724.00 0.00 0.00<br />

27356 S 864.64 0.00 0.00 27510 S 165.85 0.00 0.00<br />

27357 S 904.94 0.00 0.00 27516 S 78.62 0.00 0.00<br />

27358 S 904.94 0.00 0.00 27517 S 78.62 0.00 0.00<br />

27360 S 904.94 0.00 0.00 27520 S 78.62 0.00 0.00<br />

27372 S 879.59 0.00 0.00 27530 S 78.62 0.00 0.00<br />

27380 S 571.79 0.00 0.00 27532 S 428.97 0.00 0.00<br />

27381 S 653.77 0.00 0.00 27538 S 78.62 0.00 0.00<br />

27385 S 653.77 0.00 0.00 27550 S 78.62 0.00 0.00<br />

27386 S 653.77 0.00 0.00 27552 S 452.67 0.00 0.00<br />

27390 S 571.79 0.00 0.00 27560 S 78.62 0.00 0.00<br />

27391 S 624.13 0.00 0.00 27562 S 452.67 0.00 0.00<br />

27392 S 653.77 0.00 0.00 27566 S 1,028.35 0.00 0.00<br />

27393 S 779.42 0.00 0.00 27570 S 452.67 0.00 0.00<br />

27394 S 809.07 0.00 0.00 27594 S 653.77 0.00 0.00<br />

27395 S 1,105.68 0.00 0.00 27600 S 653.77 0.00 0.00<br />

27396 S 809.07 0.00 0.00 27601 S 653.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 653.77 0.00 0.00 27730 S 779.42 0.00 0.00<br />

27603 S 578.24 0.00 0.00 27732 S 779.42 0.00 0.00<br />

27604 S 624.13 0.00 0.00 27734 S 779.42 0.00 0.00<br />

27605 S 568.73 0.00 0.00 27740 S 779.42 0.00 0.00<br />

27606 S 571.79 0.00 0.00 27742 S 1,076.04 0.00 0.00<br />

27607 S 624.13 0.00 0.00 27745 S 1,896.35 0.00 0.00<br />

27610 S 779.42 0.00 0.00 27750 S 78.62 0.00 0.00<br />

27612 S 809.07 0.00 0.00 27752 S 428.97 0.00 0.00<br />

27613 S 128.48 0.00 0.00 27756 S 724.00 0.00 0.00<br />

27614 S 625.31 0.00 0.00 27758 S 1,113.57 0.00 0.00<br />

27615 S 809.07 0.00 0.00 27759 S 1,491.30 0.00 0.00<br />

27618 S 511.33 0.00 0.00 27760 S 78.62 0.00 0.00<br />

27619 S 654.96 0.00 0.00 27762 S 428.97 0.00 0.00<br />

27620 S 864.64 0.00 0.00 27766 S 1,057.99 0.00 0.00<br />

27625 S 864.64 0.00 0.00 27767 S 61.26 0.00 0.00<br />

27626 S 864.64 0.00 0.00 27768 S 61.26 0.00 0.00<br />

27630 S 653.77 0.00 0.00 27769 S 1,643.56 0.00 0.00<br />

27635 S 809.07 0.00 0.00 27780 S 78.62 0.00 0.00<br />

27637 S 809.07 0.00 0.00 27781 S 428.97 0.00 0.00<br />

27638 S 809.07 0.00 0.00 27784 S 1,057.99 0.00 0.00<br />

27640 S 1,076.04 0.00 0.00 27786 S 78.62 0.00 0.00<br />

27641 S 779.42 0.00 0.00 27788 S 78.62 0.00 0.00<br />

27647 S 1,105.68 0.00 0.00 27792 S 1,057.99 0.00 0.00<br />

27650 S 1,105.68 0.00 0.00 27808 S 78.62 0.00 0.00<br />

27652 S 1,896.35 0.00 0.00 27810 S 165.85 0.00 0.00<br />

27654 S 1,105.68 0.00 0.00 27814 S 1,057.99 0.00 0.00<br />

27656 S 624.13 0.00 0.00 27816 S 78.62 0.00 0.00<br />

27658 S 571.79 0.00 0.00 27818 S 165.85 0.00 0.00<br />

27659 S 624.13 0.00 0.00 27822 S 1,057.99 0.00 0.00<br />

27664 S 624.13 0.00 0.00 27823 S 1,435.73 0.00 0.00<br />

27665 S 779.42 0.00 0.00 27824 S 78.62 0.00 0.00<br />

27675 S 624.13 0.00 0.00 27825 S 428.97 0.00 0.00<br />

27676 S 809.07 0.00 0.00 27826 S 1,057.99 0.00 0.00<br />

27680 S 809.07 0.00 0.00 27827 S 1,435.73 0.00 0.00<br />

27681 S 779.42 0.00 0.00 27828 S 1,491.30 0.00 0.00<br />

27685 S 809.07 0.00 0.00 27829 S 1,028.35 0.00 0.00<br />

27686 S 809.07 0.00 0.00 27830 S 78.62 0.00 0.00<br />

27687 S 809.07 0.00 0.00 27831 S 428.97 0.00 0.00<br />

27690 S 1,161.26 0.00 0.00 27832 S 1,028.35 0.00 0.00<br />

27691 S 1,161.26 0.00 0.00 27840 S 165.85 0.00 0.00<br />

27692 S 1,105.68 0.00 0.00 27842 S 452.67 0.00 0.00<br />

27695 S 779.42 0.00 0.00 27846 S 1,057.99 0.00 0.00<br />

27696 S 779.42 0.00 0.00 27848 S 1,057.99 0.00 0.00<br />

27698 S 779.42 0.00 0.00 27860 S 452.67 0.00 0.00<br />

27700 S 1,057.34 0.00 0.00 27870 S 1,951.92 0.00 0.00<br />

27704 S 624.13 0.00 0.00 27871 S 1,951.92 0.00 0.00<br />

27705 S 1,076.04 0.00 0.00 27884 S 653.77 0.00 0.00<br />

27707 S 624.13 0.00 0.00 27889 S 809.07 0.00 0.00<br />

27709 S 779.42 0.00 0.00 27892 S 653.77 0.00 0.00<br />

27726 S 975.59 0.00 0.00 27893 S 653.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 653.77 0.00 0.00 28153 S 650.71 0.00 0.00<br />

28001 S 125.39 0.00 0.00 28160 S 650.71 0.00 0.00<br />

28002 S 653.77 0.00 0.00 28171 S 650.71 0.00 0.00<br />

28003 S 653.77 0.00 0.00 28173 S 650.71 0.00 0.00<br />

28005 S 650.71 0.00 0.00 28175 S 650.71 0.00 0.00<br />

28008 S 650.71 0.00 0.00 28190 S 129.51 0.00 0.00<br />

28010 S 92.16 0.00 0.00 28192 S 511.33 0.00 0.00<br />

28011 S 650.71 0.00 0.00 28193 S 352.11 0.00 0.00<br />

28020 S 621.06 0.00 0.00 28200 S 650.71 0.00 0.00<br />

28022 S 621.06 0.00 0.00 28202 S 650.71 0.00 0.00<br />

28024 S 621.06 0.00 0.00 28208 S 650.71 0.00 0.00<br />

28035 S 646.66 0.00 0.00 28210 S 1,142.84 0.00 0.00<br />

28043 S 625.31 0.00 0.00 28220 S 199.75 0.00 0.00<br />

28045 S 650.71 0.00 0.00 28222 S 568.73 0.00 0.00<br />

28046 S 650.71 0.00 0.00 28225 S 568.73 0.00 0.00<br />

28050 S 621.06 0.00 0.00 28226 S 568.73 0.00 0.00<br />

28052 S 621.06 0.00 0.00 28230 S 195.97 0.00 0.00<br />

28054 S 621.06 0.00 0.00 28232 S 187.41 0.00 0.00<br />

28055 S 646.66 0.00 0.00 28234 S 621.06 0.00 0.00<br />

28060 S 621.06 0.00 0.00 28238 S 1,142.84 0.00 0.00<br />

28062 S 650.71 0.00 0.00 28240 S 621.06 0.00 0.00<br />

28070 S 650.71 0.00 0.00 28250 S 650.71 0.00 0.00<br />

28072 S 650.71 0.00 0.00 28260 S 650.71 0.00 0.00<br />

28080 S 650.71 0.00 0.00 28261 S 650.71 0.00 0.00<br />

28086 S 621.06 0.00 0.00 28262 S 706.28 0.00 0.00<br />

28088 S 621.06 0.00 0.00 28264 S 1,060.86 0.00 0.00<br />

28090 S 650.71 0.00 0.00 28270 S 650.71 0.00 0.00<br />

28092 S 650.71 0.00 0.00 28272 S 180.90 0.00 0.00<br />

28100 S 621.06 0.00 0.00 28280 S 621.06 0.00 0.00<br />

28102 S 1,142.84 0.00 0.00 28285 S 650.71 0.00 0.00<br />

28103 S 1,142.84 0.00 0.00 28286 S 706.28 0.00 0.00<br />

28104 S 621.06 0.00 0.00 28288 S 650.71 0.00 0.00<br />

28106 S 1,142.84 0.00 0.00 28289 S 650.71 0.00 0.00<br />

28107 S 1,142.84 0.00 0.00 28290 S 802.08 0.00 0.00<br />

28108 S 621.06 0.00 0.00 28292 S 802.08 0.00 0.00<br />

28110 S 650.71 0.00 0.00 28293 S 831.72 0.00 0.00<br />

28111 S 650.71 0.00 0.00 28294 S 831.72 0.00 0.00<br />

28112 S 650.71 0.00 0.00 28296 S 831.72 0.00 0.00<br />

28113 S 650.71 0.00 0.00 28297 S 831.72 0.00 0.00<br />

28114 S 650.71 0.00 0.00 28298 S 831.72 0.00 0.00<br />

28116 S 650.71 0.00 0.00 28299 S 927.59 0.00 0.00<br />

28118 S 706.28 0.00 0.00 28300 S 1,113.20 0.00 0.00<br />

28119 S 706.28 0.00 0.00 28302 S 621.06 0.00 0.00<br />

28120 S 875.33 0.00 0.00 28304 S 1,113.20 0.00 0.00<br />

28122 S 650.71 0.00 0.00 28305 S 1,142.84 0.00 0.00<br />

28124 S 212.08 0.00 0.00 28306 S 706.28 0.00 0.00<br />

28126 S 650.71 0.00 0.00 28307 S 706.28 0.00 0.00<br />

28130 S 650.71 0.00 0.00 28308 S 621.06 0.00 0.00<br />

28140 S 650.71 0.00 0.00 28309 S 1,198.42 0.00 0.00<br />

28150 S 650.71 0.00 0.00 28310 S 650.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 650.71 0.00 0.00 28636 S 724.00 0.00 0.00<br />

28313 S 621.06 0.00 0.00 28645 S 724.00 0.00 0.00<br />

28315 S 706.28 0.00 0.00 28660 S 43.86 0.00 0.00<br />

28320 S 1,198.42 0.00 0.00 28665 S 452.67 0.00 0.00<br />

28322 S 1,198.42 0.00 0.00 28666 S 724.00 0.00 0.00<br />

28340 S 706.28 0.00 0.00 28675 S 724.00 0.00 0.00<br />

28341 S 706.28 0.00 0.00 28705 S 1,198.42 0.00 0.00<br />

28344 S 706.28 0.00 0.00 28715 S 1,951.92 0.00 0.00<br />

28345 S 706.28 0.00 0.00 28725 S 1,198.42 0.00 0.00<br />

28400 S 78.62 0.00 0.00 28730 S 1,198.42 0.00 0.00<br />

28405 S 428.97 0.00 0.00 28735 S 1,198.42 0.00 0.00<br />

28406 S 694.36 0.00 0.00 28737 S 1,238.71 0.00 0.00<br />

28415 S 1,435.73 0.00 0.00 28740 S 1,198.42 0.00 0.00<br />

28420 S 1,113.57 0.00 0.00 28750 S 1,198.42 0.00 0.00<br />

28430 S 61.26 0.00 0.00 28755 S 706.28 0.00 0.00<br />

28435 S 78.62 0.00 0.00 28760 S 1,198.42 0.00 0.00<br />

28436 S 694.36 0.00 0.00 28810 S 621.06 0.00 0.00<br />

28445 S 1,057.99 0.00 0.00 28820 S 621.06 0.00 0.00<br />

28446 S 1,813.26 0.00 0.00 28825 S 621.06 0.00 0.00<br />

28450 S 61.26 0.00 0.00 28890 S 164.11 0.00 0.00<br />

28455 S 61.26 0.00 0.00 29000 S 41.58 0.00 0.00<br />

28456 S 694.36 0.00 0.00 29010 S 93.19 0.00 0.00<br />

28465 S 1,057.99 0.00 0.00 29015 S 93.19 0.00 0.00<br />

28470 S 61.26 0.00 0.00 29020 S 41.58 0.00 0.00<br />

28475 S 61.26 0.00 0.00 29025 S 41.58 0.00 0.00<br />

28476 S 694.36 0.00 0.00 29035 S 93.19 0.00 0.00<br />

28485 S 1,113.57 0.00 0.00 29040 S 41.58 0.00 0.00<br />

28490 S 61.26 0.00 0.00 29044 S 93.19 0.00 0.00<br />

28495 S 61.26 0.00 0.00 29046 S 93.19 0.00 0.00<br />

28496 S 694.36 0.00 0.00 29049 S 37.68 0.00 0.00<br />

28505 S 724.00 0.00 0.00 29055 S 93.19 0.00 0.00<br />

28510 S 55.16 0.00 0.00 29058 S 41.58 0.00 0.00<br />

28515 S 61.26 0.00 0.00 29065 S 44.20 0.00 0.00<br />

28525 S 724.00 0.00 0.00 29075 S 42.48 0.00 0.00<br />

28530 S 53.10 0.00 0.00 29085 S 41.58 0.00 0.00<br />

28531 S 724.00 0.00 0.00 29086 S 35.63 0.00 0.00<br />

28540 S 61.26 0.00 0.00 29105 S 38.37 0.00 0.00<br />

28545 S 642.02 0.00 0.00 29125 S 33.23 0.00 0.00<br />

28546 S 694.36 0.00 0.00 29126 S 35.29 0.00 0.00<br />

28555 S 1,028.35 0.00 0.00 29130 S 15.08 0.00 0.00<br />

28570 S 79.48 0.00 0.00 29131 S 21.92 0.00 0.00<br />

28575 S 428.97 0.00 0.00 29200 S 21.24 0.00 0.00<br />

28576 S 724.00 0.00 0.00 29220 S 22.95 0.00 0.00<br />

28585 S 724.00 0.00 0.00 29240 S 23.99 0.00 0.00<br />

28600 S 61.26 0.00 0.00 29260 S 22.95 0.00 0.00<br />

28605 S 78.62 0.00 0.00 29280 S 23.30 0.00 0.00<br />

28606 S 694.36 0.00 0.00 29305 S 93.19 0.00 0.00<br />

28615 S 1,057.99 0.00 0.00 29325 S 93.19 0.00 0.00<br />

28630 S 61.26 0.00 0.00 29345 S 57.90 0.00 0.00<br />

28635 S 452.67 0.00 0.00 29355 S 56.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 70.58 0.00 0.00 29847 S 1,179.71 0.00 0.00<br />

29365 S 54.82 0.00 0.00 29848 S 1,184.07 0.00 0.00<br />

29405 S 40.77 0.00 0.00 29850 S 855.70 0.00 0.00<br />

29425 S 41.46 0.00 0.00 29851 S 1,235.30 0.00 0.00<br />

29435 S 52.42 0.00 0.00 29855 S 1,235.30 0.00 0.00<br />

29440 S 22.27 0.00 0.00 29856 S 1,235.30 0.00 0.00<br />

29445 S 55.16 0.00 0.00 29860 S 1,235.30 0.00 0.00<br />

29450 S 41.58 0.00 0.00 29861 S 1,235.30 0.00 0.00<br />

29505 S 37.00 0.00 0.00 29862 S 1,563.67 0.00 0.00<br />

29515 S 31.52 0.00 0.00 29863 S 1,235.30 0.00 0.00<br />

29520 S 22.61 0.00 0.00 29866 S 1,887.02 0.00 0.00<br />

29530 S 22.95 0.00 0.00 29870 S 800.12 0.00 0.00<br />

29540 S 17.13 0.00 0.00 29871 S 800.12 0.00 0.00<br />

29550 S 17.47 0.00 0.00 29873 S 800.12 0.00 0.00<br />

29580 S 23.64 0.00 0.00 29874 S 800.12 0.00 0.00<br />

29590 S 19.19 0.00 0.00 29875 S 855.70 0.00 0.00<br />

29700 S 31.86 0.00 0.00 29876 S 855.70 0.00 0.00<br />

29705 S 27.06 0.00 0.00 29877 S 855.70 0.00 0.00<br />

29710 S 47.62 0.00 0.00 29879 S 800.12 0.00 0.00<br />

29715 S 41.58 0.00 0.00 29880 S 855.70 0.00 0.00<br />

29720 S 39.75 0.00 0.00 29881 S 855.70 0.00 0.00<br />

29730 S 26.04 0.00 0.00 29882 S 800.12 0.00 0.00<br />

29740 S 35.63 0.00 0.00 29883 S 800.12 0.00 0.00<br />

29750 S 37.34 0.00 0.00 29884 S 800.12 0.00 0.00<br />

29800 S 800.12 0.00 0.00 29885 S 1,179.71 0.00 0.00<br />

29804 S 800.12 0.00 0.00 29886 S 800.12 0.00 0.00<br />

29805 S 800.12 0.00 0.00 29887 S 800.12 0.00 0.00<br />

29806 S 1,179.71 0.00 0.00 29888 S 1,179.71 0.00 0.00<br />

29807 S 1,179.71 0.00 0.00 29889 S 1,179.71 0.00 0.00<br />

29819 S 1,179.71 0.00 0.00 29891 S 1,179.71 0.00 0.00<br />

29820 S 1,179.71 0.00 0.00 29892 S 1,179.71 0.00 0.00<br />

29821 S 1,179.71 0.00 0.00 29893 S 996.00 0.00 0.00<br />

29822 S 800.12 0.00 0.00 29894 S 800.12 0.00 0.00<br />

29823 S 1,179.71 0.00 0.00 29895 S 800.12 0.00 0.00<br />

29824 S 895.99 0.00 0.00 29897 S 800.12 0.00 0.00<br />

29825 S 1,179.71 0.00 0.00 29898 S 800.12 0.00 0.00<br />

29826 S 1,179.71 0.00 0.00 29899 S 1,179.71 0.00 0.00<br />

29827 S 1,275.58 0.00 0.00 29900 S 800.12 0.00 0.00<br />

29828 S 1,887.02 0.00 0.00 29901 S 800.12 0.00 0.00<br />

29830 S 800.12 0.00 0.00 29902 S 800.12 0.00 0.00<br />

29834 S 800.12 0.00 0.00 29904 S 1,127.83 0.00 0.00<br />

29835 S 800.12 0.00 0.00 29905 S 1,127.83 0.00 0.00<br />

29836 S 800.12 0.00 0.00 29906 S 1,127.83 0.00 0.00<br />

29837 S 800.12 0.00 0.00 29907 S 1,887.02 0.00 0.00<br />

29838 S 800.12 0.00 0.00 30000 S 126.80 0.00 0.00<br />

29840 S 800.12 0.00 0.00 30020 S 126.80 0.00 0.00<br />

29843 S 800.12 0.00 0.00 30100 S 82.23 0.00 0.00<br />

29844 S 800.12 0.00 0.00 30110 S 127.11 0.00 0.00<br />

29845 S 800.12 0.00 0.00 30115 S 537.07 0.00 0.00<br />

29846 S 800.12 0.00 0.00 30117 S 566.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 710.80 0.00 0.00 31080 S 1,094.55 0.00 0.00<br />

30120 S 484.74 0.00 0.00 31081 S 1,094.55 0.00 0.00<br />

30124 S 288.83 0.00 0.00 31084 S 1,094.55 0.00 0.00<br />

30125 S 1,009.33 0.00 0.00 31085 S 1,094.55 0.00 0.00<br />

30130 S 566.72 0.00 0.00 31086 S 1,094.55 0.00 0.00<br />

30140 S 681.15 0.00 0.00 31087 S 1,094.55 0.00 0.00<br />

30150 S 1,038.98 0.00 0.00 31090 S 1,134.85 0.00 0.00<br />

30160 S 1,094.55 0.00 0.00 31200 S 1,009.33 0.00 0.00<br />

30200 S 64.76 0.00 0.00 31201 S 1,134.85 0.00 0.00<br />

30210 S 82.23 0.00 0.00 31205 S 1,038.98 0.00 0.00<br />

30220 S 359.39 0.00 0.00 31231 S 69.32 0.00 0.00<br />

30300 S 24.77 0.00 0.00 31233 S 74.67 0.00 0.00<br />

30310 S 484.74 0.00 0.00 31235 S 507.28 0.00 0.00<br />

30320 S 537.07 0.00 0.00 31237 S 559.62 0.00 0.00<br />

30400 S 1,094.55 0.00 0.00 31238 S 507.28 0.00 0.00<br />

30410 S 1,134.85 0.00 0.00 31239 S 740.48 0.00 0.00<br />

30420 S 1,134.85 0.00 0.00 31240 S 559.62 0.00 0.00<br />

30430 S 710.80 0.00 0.00 31254 S 684.89 0.00 0.00<br />

30435 S 1,134.85 0.00 0.00 31255 S 780.76 0.00 0.00<br />

30450 S 1,263.60 0.00 0.00 31256 S 684.89 0.00 0.00<br />

30460 S 1,263.60 0.00 0.00 31267 S 684.89 0.00 0.00<br />

30462 S 1,422.92 0.00 0.00 31276 S 684.89 0.00 0.00<br />

30465 S 1,422.92 0.00 0.00 31287 S 684.89 0.00 0.00<br />

30520 S 766.37 0.00 0.00 31288 S 684.89 0.00 0.00<br />

30540 S 1,134.85 0.00 0.00 31300 S 806.67 0.00 0.00<br />

30545 S 1,134.85 0.00 0.00 31320 S 1,009.33 0.00 0.00<br />

30560 S 133.20 0.00 0.00 31400 S 1,009.33 0.00 0.00<br />

30580 S 1,094.55 0.00 0.00 31420 S 1,009.33 0.00 0.00<br />

30600 S 1,094.55 0.00 0.00 31500 S 92.72 0.00 0.00<br />

30620 S 1,263.60 0.00 0.00 31502 S 53.31 0.00 0.00<br />

30630 S 935.43 0.00 0.00 31505 S 31.50 0.00 0.00<br />

30801 S 298.65 0.00 0.00 31510 S 559.62 0.00 0.00<br />

30802 S 298.65 0.00 0.00 31511 S 74.67 0.00 0.00<br />

30901 S 42.60 0.00 0.00 31512 S 559.62 0.00 0.00<br />

30903 S 54.87 0.00 0.00 31513 S 74.67 0.00 0.00<br />

30905 S 54.87 0.00 0.00 31515 S 507.28 0.00 0.00<br />

30906 S 54.87 0.00 0.00 31520 S 69.32 0.00 0.00<br />

30915 S 731.11 0.00 0.00 31525 S 507.28 0.00 0.00<br />

30920 S 760.76 0.00 0.00 31526 S 655.26 0.00 0.00<br />

30930 S 622.29 0.00 0.00 31527 S 602.91 0.00 0.00<br />

31000 S 105.87 0.00 0.00 31528 S 559.62 0.00 0.00<br />

31002 S 288.83 0.00 0.00 31529 S 559.62 0.00 0.00<br />

31020 S 681.15 0.00 0.00 31530 S 655.26 0.00 0.00<br />

31030 S 1,038.98 0.00 0.00 31531 S 684.89 0.00 0.00<br />

31032 S 1,094.55 0.00 0.00 31535 S 655.26 0.00 0.00<br />

31040 S 949.19 0.00 0.00 31536 S 684.89 0.00 0.00<br />

31050 S 1,009.33 0.00 0.00 31540 S 684.89 0.00 0.00<br />

31051 S 1,094.55 0.00 0.00 31541 S 740.48 0.00 0.00<br />

31070 S 681.15 0.00 0.00 31545 S 740.48 0.00 0.00<br />

31075 S 1,094.55 0.00 0.00 31546 S 740.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 780.76 0.00 0.00 32405 S 337.86 0.00 0.00<br />

31561 S 780.76 0.00 0.00 32420 S 205.45 0.00 0.00<br />

31570 S 559.62 0.00 0.00 32421 S 205.45 0.00 0.00<br />

31571 S 655.26 0.00 0.00 32422 S 204.53 0.00 0.00<br />

31575 S 59.62 0.00 0.00 32550 S 1,145.16 0.00 0.00<br />

31576 S 655.26 0.00 0.00 32960 S 204.53 0.00 0.00<br />

31577 S 193.56 0.00 0.00 32998 S 1,782.96 0.00 0.00<br />

31578 S 655.26 0.00 0.00 33010 S 205.45 0.00 0.00<br />

31579 S 106.21 0.00 0.00 33011 S 205.45 0.00 0.00<br />

31580 S 1,134.85 0.00 0.00 33206 S 6,591.48 3,921.91 1,252.35<br />

31582 S 1,134.85 0.00 0.00 33207 S 6,591.48 3,921.91 1,252.35<br />

31588 S 1,134.85 0.00 0.00 33208 S 8,175.30 4,763.70 1,352.12<br />

31590 S 1,134.85 0.00 0.00 33210 S 1,935.61 0.00 0.00<br />

31595 S 1,009.33 0.00 0.00 33211 S 1,935.61 0.00 0.00<br />

31603 S 298.65 0.00 0.00 33212 S 5,176.66 2,948.92 721.18<br />

31605 S 288.83 0.00 0.00 33213 S 5,974.98 3,347.65 720.33<br />

31611 S 710.80 0.00 0.00 33214 S 8,175.30 4,763.70 1,352.12<br />

31612 S 628.82 0.00 0.00 33215 S 848.40 0.00 0.00<br />

31613 S 681.15 0.00 0.00 33216 S 1,935.61 0.00 0.00<br />

31614 S 1,009.33 0.00 0.00 33217 S 1,935.61 0.00 0.00<br />

31615 S 298.65 0.00 0.00 33218 S 848.40 0.00 0.00<br />

31622 S 349.76 0.00 0.00 33220 S 848.40 0.00 0.00<br />

31623 S 402.09 0.00 0.00 33222 S 512.82 0.00 0.00<br />

31624 S 402.09 0.00 0.00 33223 S 512.82 0.00 0.00<br />

31625 S 402.09 0.00 0.00 33224 S 7,716.72 4,619.98 1,523.24<br />

31628 S 402.09 0.00 0.00 33225 S 7,716.72 4,619.98 1,523.24<br />

31629 S 402.09 0.00 0.00 33226 S 848.40 0.00 0.00<br />

31630 S 689.03 0.00 0.00 33233 S 630.77 0.00 0.00<br />

31631 S 689.03 0.00 0.00 33234 S 848.40 0.00 0.00<br />

31632 S 391.07 0.00 0.00 33235 S 848.40 0.00 0.00<br />

31633 S 391.07 0.00 0.00 33240 S 19,235.81 10,282.33 1,328.85<br />

31635 S 402.09 0.00 0.00 33241 S 848.40 0.00 0.00<br />

31636 S 689.03 0.00 0.00 33249 S 25,671.66 13,750.80 1,829.95<br />

31637 S 349.76 0.00 0.00 33282 S 4,058.85 2,429.87 800.88<br />

31638 S 689.03 0.00 0.00 33284 S 316.58 0.00 0.00<br />

31640 S 689.03 0.00 0.00 34490 S 1,545.64 0.00 0.00<br />

31641 S 689.03 0.00 0.00 35188 S 1,064.60 0.00 0.00<br />

31643 S 402.09 0.00 0.00 35207 S 1,064.60 0.00 0.00<br />

31645 S 349.76 0.00 0.00 35473 S 1,854.17 0.00 0.00<br />

31646 S 349.76 0.00 0.00 35476 S 1,854.17 0.00 0.00<br />

31656 S 349.76 0.00 0.00 35492 S 3,460.62 0.00 0.00<br />

31717 S 193.56 0.00 0.00 35761 S 1,113.24 0.00 0.00<br />

31720 S 29.64 0.00 0.00 35875 S 1,392.97 0.00 0.00<br />

31730 S 193.56 0.00 0.00 35876 S 1,392.97 0.00 0.00<br />

31750 S 1,134.85 0.00 0.00 36002 S 88.91 0.00 0.00<br />

31755 S 1,009.33 0.00 0.00 36260 S 806.50 0.00 0.00<br />

31820 S 484.74 0.00 0.00 36261 S 630.77 0.00 0.00<br />

31825 S 681.15 0.00 0.00 36262 S 578.42 0.00 0.00<br />

31830 S 681.15 0.00 0.00 36420 S 8.38 0.00 0.00<br />

32400 S 337.86 0.00 0.00 36425 S 8.38 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.20 0.00 0.00 36800 S 868.20 0.00 0.00<br />

36440 S 128.61 0.00 0.00 36810 S 868.20 0.00 0.00<br />

36450 S 128.61 0.00 0.00 36815 S 868.20 0.00 0.00<br />

36455 S 128.61 0.00 0.00 36818 S 1,009.03 0.00 0.00<br />

36468 S 31.75 0.00 0.00 36819 S 1,009.03 0.00 0.00<br />

36469 S 31.75 0.00 0.00 36820 S 1,009.03 0.00 0.00<br />

36470 S 31.75 0.00 0.00 36821 S 1,009.03 0.00 0.00<br />

36471 S 31.75 0.00 0.00 36825 S 1,064.60 0.00 0.00<br />

36475 S 1,459.69 0.00 0.00 36830 S 1,064.60 0.00 0.00<br />

36476 S 1,144.70 0.00 0.00 36831 S 1,392.97 0.00 0.00<br />

36478 S 1,144.70 0.00 0.00 36832 S 1,064.60 0.00 0.00<br />

36479 S 1,144.70 0.00 0.00 36833 S 1,064.60 0.00 0.00<br />

36511 S 440.95 0.00 0.00 36834 S 1,009.03 0.00 0.00<br />

36512 S 440.95 0.00 0.00 36835 S 923.78 0.00 0.00<br />

36513 S 440.95 0.00 0.00 36860 S 106.02 0.00 0.00<br />

36514 S 440.95 0.00 0.00 36861 S 868.20 0.00 0.00<br />

36515 S 1,180.42 0.00 0.00 36870 S 1,518.34 0.00 0.00<br />

36516 S 1,180.42 0.00 0.00 37184 S 1,545.64 0.00 0.00<br />

36522 S 1,180.42 0.00 0.00 37185 S 1,545.64 0.00 0.00<br />

36555 S 366.37 0.00 0.00 37186 S 1,545.64 0.00 0.00<br />

36556 S 366.37 0.00 0.00 37187 S 1,545.64 0.00 0.00<br />

36557 S 684.22 0.00 0.00 37188 S 1,545.64 0.00 0.00<br />

36558 S 684.22 0.00 0.00 37200 S 1,140.59 0.00 0.00<br />

36560 S 806.50 0.00 0.00 37203 S 1,140.59 0.00 0.00<br />

36561 S 806.50 0.00 0.00 37500 S 1,075.75 0.00 0.00<br />

36563 S 806.50 0.00 0.00 37607 S 760.76 0.00 0.00<br />

36565 S 806.50 0.00 0.00 37609 S 511.33 0.00 0.00<br />

36566 S 806.50 0.00 0.00 37650 S 731.11 0.00 0.00<br />

36568 S 366.37 0.00 0.00 37700 S 731.11 0.00 0.00<br />

36569 S 366.37 0.00 0.00 37718 S 760.76 0.00 0.00<br />

36570 S 713.86 0.00 0.00 37722 S 1,075.75 0.00 0.00<br />

36571 S 713.86 0.00 0.00 37735 S 1,075.75 0.00 0.00<br />

36575 S 294.66 0.00 0.00 37760 S 760.76 0.00 0.00<br />

36576 S 418.70 0.00 0.00 37765 S 1,049.10 0.00 0.00<br />

36578 S 684.22 0.00 0.00 37766 S 1,049.10 0.00 0.00<br />

36580 S 366.37 0.00 0.00 37780 S 760.76 0.00 0.00<br />

36581 S 684.22 0.00 0.00 37785 S 760.76 0.00 0.00<br />

36582 S 806.50 0.00 0.00 37790 S 918.00 0.00 0.00<br />

36583 S 806.50 0.00 0.00 38205 S 440.95 0.00 0.00<br />

36584 S 366.37 0.00 0.00 38206 S 440.95 0.00 0.00<br />

36585 S 713.86 0.00 0.00 38220 S 101.07 0.00 0.00<br />

36589 S 242.33 0.00 0.00 38221 S 105.87 0.00 0.00<br />

36590 S 366.37 0.00 0.00 38230 S 1,180.42 0.00 0.00<br />

36593 S 24.33 0.00 0.00 38241 S 1,180.42 0.00 0.00<br />

36595 S 955.31 0.00 0.00 38242 S 440.95 0.00 0.00<br />

36596 S 424.27 0.00 0.00 38300 S 395.69 0.00 0.00<br />

36597 S 424.27 0.00 0.00 38305 S 578.24 0.00 0.00<br />

36598 S 78.46 0.00 0.00 38308 S 660.72 0.00 0.00<br />

36640 S 724.52 0.00 0.00 38500 S 660.72 0.00 0.00<br />

36680 S 54.92 0.00 0.00 38505 S 252.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 660.72 0.00 0.00 41005 S 133.20 0.00 0.00<br />

38520 S 660.72 0.00 0.00 41006 S 628.82 0.00 0.00<br />

38525 S 660.72 0.00 0.00 41007 S 484.74 0.00 0.00<br />

38530 S 660.72 0.00 0.00 41008 S 484.74 0.00 0.00<br />

38542 S 1,111.56 0.00 0.00 41009 S 133.20 0.00 0.00<br />

38550 S 690.37 0.00 0.00 41010 S 298.65 0.00 0.00<br />

38555 S 745.94 0.00 0.00 41015 S 133.20 0.00 0.00<br />

38570 S 1,508.23 0.00 0.00 41016 S 298.65 0.00 0.00<br />

38571 S 1,960.66 0.00 0.00 41017 S 298.65 0.00 0.00<br />

38572 S 1,508.23 0.00 0.00 41018 S 298.65 0.00 0.00<br />

38700 S 908.31 0.00 0.00 41019 S 949.19 0.00 0.00<br />

38740 S 1,111.56 0.00 0.00 41100 S 89.42 0.00 0.00<br />

38745 S 1,196.79 0.00 0.00 41105 S 88.39 0.00 0.00<br />

38760 S 660.72 0.00 0.00 41108 S 81.89 0.00 0.00<br />

40490 S 67.49 0.00 0.00 41110 S 118.54 0.00 0.00<br />

40500 S 537.07 0.00 0.00 41112 S 537.07 0.00 0.00<br />

40510 S 681.15 0.00 0.00 41113 S 537.07 0.00 0.00<br />

40520 S 537.07 0.00 0.00 41114 S 681.15 0.00 0.00<br />

40525 S 681.15 0.00 0.00 41115 S 138.08 0.00 0.00<br />

40527 S 681.15 0.00 0.00 41116 S 484.74 0.00 0.00<br />

40530 S 681.15 0.00 0.00 41120 S 806.67 0.00 0.00<br />

40650 S 359.39 0.00 0.00 41250 S 91.10 0.00 0.00<br />

40652 S 359.39 0.00 0.00 41251 S 133.20 0.00 0.00<br />

40654 S 359.39 0.00 0.00 41252 S 350.98 0.00 0.00<br />

40700 S 1,263.60 0.00 0.00 41500 S 628.82 0.00 0.00<br />

40701 S 1,263.60 0.00 0.00 41510 S 484.74 0.00 0.00<br />

40702 S 1,605.54 0.00 0.00 41520 S 350.98 0.00 0.00<br />

40720 S 1,263.60 0.00 0.00 41530 S 661.02 0.00 0.00<br />

40761 S 1,038.98 0.00 0.00 41800 S 68.05 0.00 0.00<br />

40800 S 54.17 0.00 0.00 41805 S 147.33 0.00 0.00<br />

40801 S 350.98 0.00 0.00 41806 S 181.58 0.00 0.00<br />

40804 S 24.77 0.00 0.00 41820 S 288.83 0.00 0.00<br />

40805 S 167.54 0.00 0.00 41821 S 288.83 0.00 0.00<br />

40806 S 77.09 0.00 0.00 41822 S 150.41 0.00 0.00<br />

40808 S 114.43 0.00 0.00 41823 S 219.28 0.00 0.00<br />

40810 S 118.54 0.00 0.00 41825 S 120.60 0.00 0.00<br />

40812 S 148.70 0.00 0.00 41826 S 151.78 0.00 0.00<br />

40814 S 537.07 0.00 0.00 41827 S 681.15 0.00 0.00<br />

40816 S 681.15 0.00 0.00 41828 S 137.05 0.00 0.00<br />

40818 S 133.20 0.00 0.00 41830 S 194.61 0.00 0.00<br />

40819 S 298.65 0.00 0.00 41850 S 661.02 0.00 0.00<br />

40820 S 170.96 0.00 0.00 41870 S 949.19 0.00 0.00<br />

40830 S 126.80 0.00 0.00 41872 S 194.61 0.00 0.00<br />

40831 S 298.65 0.00 0.00 41874 S 187.75 0.00 0.00<br />

40840 S 681.15 0.00 0.00 42000 S 133.20 0.00 0.00<br />

40842 S 710.80 0.00 0.00 42100 S 76.06 0.00 0.00<br />

40843 S 710.80 0.00 0.00 42104 S 113.06 0.00 0.00<br />

40844 S 1,134.85 0.00 0.00 42106 S 141.85 0.00 0.00<br />

40845 S 1,134.85 0.00 0.00 42107 S 681.15 0.00 0.00<br />

41000 S 84.97 0.00 0.00 42120 S 1,094.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 350.98 0.00 0.00 42809 S 24.77 0.00 0.00<br />

42145 S 806.67 0.00 0.00 42810 S 710.80 0.00 0.00<br />

42160 S 134.30 0.00 0.00 42815 S 1,134.85 0.00 0.00<br />

42180 S 133.20 0.00 0.00 42820 S 710.80 0.00 0.00<br />

42182 S 1,009.33 0.00 0.00 42821 S 806.67 0.00 0.00<br />

42200 S 1,134.85 0.00 0.00 42825 S 766.37 0.00 0.00<br />

42205 S 1,134.85 0.00 0.00 42826 S 766.37 0.00 0.00<br />

42210 S 1,134.85 0.00 0.00 42830 S 766.37 0.00 0.00<br />

42215 S 1,263.60 0.00 0.00 42831 S 766.37 0.00 0.00<br />

42220 S 1,134.85 0.00 0.00 42835 S 766.37 0.00 0.00<br />

42226 S 1,134.85 0.00 0.00 42836 S 766.37 0.00 0.00<br />

42235 S 662.59 0.00 0.00 42860 S 710.80 0.00 0.00<br />

42260 S 766.37 0.00 0.00 42870 S 710.80 0.00 0.00<br />

42280 S 74.00 0.00 0.00 42890 S 1,263.60 0.00 0.00<br />

42281 S 661.02 0.00 0.00 42892 S 1,263.60 0.00 0.00<br />

42300 S 484.74 0.00 0.00 42900 S 298.65 0.00 0.00<br />

42305 S 537.07 0.00 0.00 42950 S 681.15 0.00 0.00<br />

42310 S 133.20 0.00 0.00 42955 S 681.15 0.00 0.00<br />

42320 S 133.20 0.00 0.00 42960 S 54.87 0.00 0.00<br />

42330 S 114.43 0.00 0.00 42962 S 1,009.33 0.00 0.00<br />

42335 S 189.81 0.00 0.00 42970 S 42.60 0.00 0.00<br />

42340 S 537.07 0.00 0.00 42972 S 566.72 0.00 0.00<br />

42400 S 64.42 0.00 0.00 43030 S 661.02 0.00 0.00<br />

42405 S 537.07 0.00 0.00 43200 S 320.10 0.00 0.00<br />

42408 S 566.72 0.00 0.00 43201 S 320.10 0.00 0.00<br />

42409 S 566.72 0.00 0.00 43202 S 320.10 0.00 0.00<br />

42410 S 1,038.98 0.00 0.00 43204 S 320.10 0.00 0.00<br />

42415 S 1,263.60 0.00 0.00 43205 S 320.10 0.00 0.00<br />

42420 S 1,263.60 0.00 0.00 43215 S 320.10 0.00 0.00<br />

42425 S 1,263.60 0.00 0.00 43216 S 320.10 0.00 0.00<br />

42440 S 1,038.98 0.00 0.00 43217 S 320.10 0.00 0.00<br />

42450 S 681.15 0.00 0.00 43219 S 646.93 0.00 0.00<br />

42500 S 710.80 0.00 0.00 43220 S 320.10 0.00 0.00<br />

42505 S 1,094.55 0.00 0.00 43226 S 320.10 0.00 0.00<br />

42507 S 1,038.98 0.00 0.00 43227 S 372.45 0.00 0.00<br />

42508 S 1,094.55 0.00 0.00 43228 S 693.09 0.00 0.00<br />

42509 S 1,094.55 0.00 0.00 43231 S 372.45 0.00 0.00<br />

42510 S 1,094.55 0.00 0.00 43232 S 372.45 0.00 0.00<br />

42600 S 484.74 0.00 0.00 43234 S 320.10 0.00 0.00<br />

42650 S 42.14 0.00 0.00 43235 S 320.10 0.00 0.00<br />

42660 S 49.34 0.00 0.00 43236 S 372.45 0.00 0.00<br />

42665 S 935.43 0.00 0.00 43237 S 372.45 0.00 0.00<br />

42700 S 133.20 0.00 0.00 43238 S 372.45 0.00 0.00<br />

42720 S 484.74 0.00 0.00 43239 S 372.45 0.00 0.00<br />

42725 S 1,009.33 0.00 0.00 43240 S 372.45 0.00 0.00<br />

42800 S 81.54 0.00 0.00 43241 S 372.45 0.00 0.00<br />

42802 S 484.74 0.00 0.00 43242 S 372.45 0.00 0.00<br />

42804 S 484.74 0.00 0.00 43243 S 372.45 0.00 0.00<br />

42806 S 681.15 0.00 0.00 43244 S 372.45 0.00 0.00<br />

42808 S 537.07 0.00 0.00 43245 S 372.45 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 372.45 0.00 0.00 44378 S 390.08 0.00 0.00<br />

43247 S 372.45 0.00 0.00 44379 S 1,112.87 0.00 0.00<br />

43248 S 372.45 0.00 0.00 44380 S 337.74 0.00 0.00<br />

43249 S 372.45 0.00 0.00 44382 S 337.74 0.00 0.00<br />

43250 S 372.45 0.00 0.00 44383 S 1,112.87 0.00 0.00<br />

43251 S 372.45 0.00 0.00 44385 S 326.55 0.00 0.00<br />

43255 S 372.45 0.00 0.00 44386 S 326.55 0.00 0.00<br />

43256 S 728.92 0.00 0.00 44388 S 326.55 0.00 0.00<br />

43257 S 722.74 0.00 0.00 44389 S 326.55 0.00 0.00<br />

43258 S 402.09 0.00 0.00 44390 S 326.55 0.00 0.00<br />

43259 S 402.09 0.00 0.00 44391 S 326.55 0.00 0.00<br />

43260 S 627.01 0.00 0.00 44392 S 326.55 0.00 0.00<br />

43261 S 627.01 0.00 0.00 44393 S 326.55 0.00 0.00<br />

43262 S 627.01 0.00 0.00 44394 S 326.55 0.00 0.00<br />

43263 S 627.01 0.00 0.00 44397 S 646.93 0.00 0.00<br />

43264 S 627.01 0.00 0.00 44500 S 176.22 0.00 0.00<br />

43265 S 627.01 0.00 0.00 45000 S 378.69 0.00 0.00<br />

43267 S 627.01 0.00 0.00 45005 S 440.72 0.00 0.00<br />

43268 S 699.28 0.00 0.00 45020 S 440.72 0.00 0.00<br />

43269 S 699.28 0.00 0.00 45100 S 598.76 0.00 0.00<br />

43271 S 627.01 0.00 0.00 45108 S 651.10 0.00 0.00<br />

43272 S 627.01 0.00 0.00 45150 S 651.10 0.00 0.00<br />

43273 S 840.91 0.00 0.00 45160 S 651.10 0.00 0.00<br />

43450 S 279.95 0.00 0.00 45170 S 651.10 0.00 0.00<br />

43453 S 279.95 0.00 0.00 45190 S 1,064.68 0.00 0.00<br />

43456 S 281.06 0.00 0.00 45300 S 63.04 0.00 0.00<br />

43458 S 321.23 0.00 0.00 45303 S 350.16 0.00 0.00<br />

43600 S 320.10 0.00 0.00 45305 S 329.31 0.00 0.00<br />

43653 S 1,508.23 0.00 0.00 45307 S 608.25 0.00 0.00<br />

43760 S 155.25 0.00 0.00 45308 S 329.31 0.00 0.00<br />

43761 S 320.10 0.00 0.00 45309 S 329.31 0.00 0.00<br />

43870 S 320.10 0.00 0.00 45315 S 329.31 0.00 0.00<br />

43886 S 807.70 0.00 0.00 45317 S 329.31 0.00 0.00<br />

43887 S 169.88 0.00 0.00 45320 S 608.25 0.00 0.00<br />

43888 S 807.70 0.00 0.00 45321 S 608.25 0.00 0.00<br />

44100 S 320.10 0.00 0.00 45327 S 646.93 0.00 0.00<br />

44312 S 558.08 0.00 0.00 45330 S 83.25 0.00 0.00<br />

44340 S 640.06 0.00 0.00 45331 S 246.20 0.00 0.00<br />

44360 S 390.08 0.00 0.00 45332 S 246.20 0.00 0.00<br />

44361 S 390.08 0.00 0.00 45333 S 329.31 0.00 0.00<br />

44363 S 390.08 0.00 0.00 45334 S 329.31 0.00 0.00<br />

44364 S 390.08 0.00 0.00 45335 S 246.20 0.00 0.00<br />

44365 S 390.08 0.00 0.00 45337 S 246.20 0.00 0.00<br />

44366 S 390.08 0.00 0.00 45338 S 329.31 0.00 0.00<br />

44369 S 390.08 0.00 0.00 45339 S 329.31 0.00 0.00<br />

44370 S 1,112.87 0.00 0.00 45340 S 329.31 0.00 0.00<br />

44372 S 390.08 0.00 0.00 45341 S 329.31 0.00 0.00<br />

44373 S 390.08 0.00 0.00 45342 S 329.31 0.00 0.00<br />

44376 S 390.08 0.00 0.00 45345 S 646.93 0.00 0.00<br />

44377 S 390.08 0.00 0.00 45355 S 326.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 378.89 0.00 0.00 46505 S 468.31 0.00 0.00<br />

45379 S 378.89 0.00 0.00 46600 S 24.77 0.00 0.00<br />

45380 S 378.89 0.00 0.00 46604 S 350.16 0.00 0.00<br />

45381 S 378.89 0.00 0.00 46606 S 131.57 0.00 0.00<br />

45382 S 378.89 0.00 0.00 46608 S 329.31 0.00 0.00<br />

45383 S 378.89 0.00 0.00 46610 S 608.25 0.00 0.00<br />

45384 S 378.89 0.00 0.00 46611 S 329.31 0.00 0.00<br />

45385 S 378.89 0.00 0.00 46612 S 608.25 0.00 0.00<br />

45386 S 378.89 0.00 0.00 46614 S 69.20 0.00 0.00<br />

45387 S 646.93 0.00 0.00 46615 S 660.59 0.00 0.00<br />

45391 S 378.89 0.00 0.00 46700 S 680.74 0.00 0.00<br />

45392 S 378.89 0.00 0.00 46706 S 749.29 0.00 0.00<br />

45500 S 651.10 0.00 0.00 46750 S 831.27 0.00 0.00<br />

45505 S 801.63 0.00 0.00 46753 S 680.74 0.00 0.00<br />

45520 S 31.75 0.00 0.00 46754 S 651.10 0.00 0.00<br />

45560 S 801.63 0.00 0.00 46760 S 801.63 0.00 0.00<br />

45900 S 256.72 0.00 0.00 46761 S 831.27 0.00 0.00<br />

45905 S 598.76 0.00 0.00 46762 S 1,055.90 0.00 0.00<br />

45910 S 598.76 0.00 0.00 46900 S 104.63 0.00 0.00<br />

45915 S 378.69 0.00 0.00 46910 S 125.05 0.00 0.00<br />

45990 S 589.06 0.00 0.00 46916 S 58.17 0.00 0.00<br />

46020 S 680.74 0.00 0.00 46917 S 542.59 0.00 0.00<br />

46030 S 256.72 0.00 0.00 46922 S 542.59 0.00 0.00<br />

46040 S 680.74 0.00 0.00 46924 S 542.59 0.00 0.00<br />

46045 S 651.10 0.00 0.00 46930 S 121.29 0.00 0.00<br />

46050 S 378.69 0.00 0.00 46937 S 651.10 0.00 0.00<br />

46060 S 651.10 0.00 0.00 46938 S 801.63 0.00 0.00<br />

46070 S 468.31 0.00 0.00 46940 S 89.76 0.00 0.00<br />

46080 S 680.74 0.00 0.00 46942 S 87.37 0.00 0.00<br />

46083 S 71.68 0.00 0.00 46945 S 148.70 0.00 0.00<br />

46200 S 651.10 0.00 0.00 46946 S 388.38 0.00 0.00<br />

46210 S 651.10 0.00 0.00 46947 S 1,055.90 0.00 0.00<br />

46211 S 651.10 0.00 0.00 47000 S 337.86 0.00 0.00<br />

46220 S 598.76 0.00 0.00 47382 S 1,782.96 0.00 0.00<br />

46221 S 117.86 0.00 0.00 47510 S 789.60 0.00 0.00<br />

46230 S 598.76 0.00 0.00 47511 S 1,160.04 0.00 0.00<br />

46250 S 680.74 0.00 0.00 47525 S 453.29 0.00 0.00<br />

46255 S 680.74 0.00 0.00 47530 S 453.29 0.00 0.00<br />

46257 S 680.74 0.00 0.00 47552 S 789.60 0.00 0.00<br />

46258 S 680.74 0.00 0.00 47553 S 819.24 0.00 0.00<br />

46260 S 680.74 0.00 0.00 47554 S 819.24 0.00 0.00<br />

46261 S 736.32 0.00 0.00 47555 S 819.24 0.00 0.00<br />

46262 S 736.32 0.00 0.00 47556 S 1,160.04 0.00 0.00<br />

46270 S 680.74 0.00 0.00 47560 S 962.57 0.00 0.00<br />

46275 S 680.74 0.00 0.00 47561 S 962.57 0.00 0.00<br />

46280 S 736.32 0.00 0.00 47562 S 1,776.15 0.00 0.00<br />

46285 S 598.76 0.00 0.00 47563 S 1,776.15 0.00 0.00<br />

46288 S 736.32 0.00 0.00 47564 S 1,776.15 0.00 0.00<br />

46320 S 79.83 0.00 0.00 47630 S 819.24 0.00 0.00<br />

46500 S 109.98 0.00 0.00 48102 S 337.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 205.45 0.00 0.00 49590 S 843.22 0.00 0.00<br />

49081 S 205.45 0.00 0.00 49600 S 898.80 0.00 0.00<br />

49180 S 337.86 0.00 0.00 49650 S 1,179.86 0.00 0.00<br />

49250 S 740.60 0.00 0.00 49651 S 1,348.91 0.00 0.00<br />

49320 S 962.57 0.00 0.00 49652 S 1,452.74 0.00 0.00<br />

49321 S 1,018.16 0.00 0.00 49653 S 1,452.74 0.00 0.00<br />

49322 S 1,018.16 0.00 0.00 49654 S 1,452.74 0.00 0.00<br />

49324 S 1,452.74 0.00 0.00 49655 S 1,452.74 0.00 0.00<br />

49325 S 1,452.74 0.00 0.00 49656 S 1,452.74 0.00 0.00<br />

49326 S 1,452.74 0.00 0.00 49657 S 1,452.74 0.00 0.00<br />

49402 S 655.38 0.00 0.00 50200 S 337.86 0.00 0.00<br />

49419 S 786.22 0.00 0.00 50382 S 981.07 0.00 0.00<br />

49420 S 726.81 0.00 0.00 50384 S 720.58 0.00 0.00<br />

49421 S 726.81 0.00 0.00 50385 S 720.58 0.00 0.00<br />

49422 S 578.42 0.00 0.00 50386 S 276.46 0.00 0.00<br />

49423 S 598.12 0.00 0.00 50387 S 598.12 0.00 0.00<br />

49426 S 655.38 0.00 0.00 50389 S 276.46 0.00 0.00<br />

49429 S 848.40 0.00 0.00 50390 S 337.86 0.00 0.00<br />

49440 S 331.76 0.00 0.00 50391 S 40.01 0.00 0.00<br />

49441 S 331.76 0.00 0.00 50392 S 514.51 0.00 0.00<br />

49446 S 331.76 0.00 0.00 50393 S 644.76 0.00 0.00<br />

49450 S 176.22 0.00 0.00 50395 S 514.51 0.00 0.00<br />

49451 S 176.22 0.00 0.00 50396 S 96.74 0.00 0.00<br />

49452 S 176.22 0.00 0.00 50398 S 453.29 0.00 0.00<br />

49460 S 176.22 0.00 0.00 50551 S 292.46 0.00 0.00<br />

49495 S 898.80 0.00 0.00 50553 S 644.76 0.00 0.00<br />

49496 S 898.80 0.00 0.00 50555 S 292.46 0.00 0.00<br />

49500 S 898.80 0.00 0.00 50557 S 644.76 0.00 0.00<br />

49501 S 1,227.16 0.00 0.00 50561 S 644.76 0.00 0.00<br />

49505 S 898.80 0.00 0.00 50562 S 276.46 0.00 0.00<br />

49507 S 1,227.16 0.00 0.00 50570 S 276.46 0.00 0.00<br />

49520 S 1,067.85 0.00 0.00 50572 S 276.46 0.00 0.00<br />

49521 S 1,227.16 0.00 0.00 50574 S 276.46 0.00 0.00<br />

49525 S 898.80 0.00 0.00 50575 S 1,375.19 0.00 0.00<br />

49540 S 813.58 0.00 0.00 50576 S 720.58 0.00 0.00<br />

49550 S 939.09 0.00 0.00 50580 S 720.58 0.00 0.00<br />

49553 S 1,227.16 0.00 0.00 50590 S 1,606.54 0.00 0.00<br />

49555 S 939.09 0.00 0.00 50592 S 1,782.96 0.00 0.00<br />

49557 S 1,227.16 0.00 0.00 50686 S 40.01 0.00 0.00<br />

49560 S 898.80 0.00 0.00 50688 S 453.29 0.00 0.00<br />

49561 S 1,227.16 0.00 0.00 50947 S 1,508.23 0.00 0.00<br />

49565 S 898.80 0.00 0.00 50948 S 1,508.23 0.00 0.00<br />

49566 S 1,227.16 0.00 0.00 50951 S 292.46 0.00 0.00<br />

49568 S 1,067.85 0.00 0.00 50953 S 292.46 0.00 0.00<br />

49570 S 898.80 0.00 0.00 50955 S 644.76 0.00 0.00<br />

49572 S 1,227.16 0.00 0.00 50957 S 644.76 0.00 0.00<br />

49580 S 898.80 0.00 0.00 50961 S 644.76 0.00 0.00<br />

49582 S 1,227.16 0.00 0.00 50970 S 292.46 0.00 0.00<br />

49585 S 898.80 0.00 0.00 50972 S 292.46 0.00 0.00<br />

49587 S 1,227.16 0.00 0.00 50974 S 514.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 514.51 0.00 0.00 52275 S 697.10 0.00 0.00<br />

50980 S 644.76 0.00 0.00 52276 S 726.74 0.00 0.00<br />

51020 S 782.32 0.00 0.00 52277 S 697.10 0.00 0.00<br />

51030 S 782.32 0.00 0.00 52281 S 566.84 0.00 0.00<br />

51040 S 782.32 0.00 0.00 52282 S 1,307.75 0.00 0.00<br />

51045 S 323.13 0.00 0.00 52283 S 697.10 0.00 0.00<br />

51050 S 782.32 0.00 0.00 52285 S 566.84 0.00 0.00<br />

51065 S 782.32 0.00 0.00 52290 S 566.84 0.00 0.00<br />

51080 S 525.90 0.00 0.00 52300 S 697.10 0.00 0.00<br />

51100 S 30.49 0.00 0.00 52301 S 726.74 0.00 0.00<br />

51101 S 40.01 0.00 0.00 52305 S 697.10 0.00 0.00<br />

51102 S 538.31 0.00 0.00 52310 S 545.19 0.00 0.00<br />

51500 S 898.80 0.00 0.00 52315 S 697.10 0.00 0.00<br />

51520 S 782.32 0.00 0.00 52317 S 644.76 0.00 0.00<br />

51700 S 52.08 0.00 0.00 52318 S 697.10 0.00 0.00<br />

51701 S 24.77 0.00 0.00 52320 S 822.61 0.00 0.00<br />

51702 S 24.77 0.00 0.00 52325 S 782.32 0.00 0.00<br />

51703 S 40.01 0.00 0.00 52327 S 894.16 0.00 0.00<br />

51705 S 71.68 0.00 0.00 52330 S 697.10 0.00 0.00<br />

51710 S 453.29 0.00 0.00 52332 S 697.10 0.00 0.00<br />

51715 S 823.04 0.00 0.00 52334 S 726.74 0.00 0.00<br />

51720 S 57.56 0.00 0.00 52341 S 726.74 0.00 0.00<br />

51725 TC S 110.57 0.00 0.00 52342 S 726.74 0.00 0.00<br />

51726 TC S 152.31 0.00 0.00 52343 S 726.74 0.00 0.00<br />

51736 TC S 20.90 0.00 0.00 52344 S 726.74 0.00 0.00<br />

51741 TC S 24.33 0.00 0.00 52345 S 726.74 0.00 0.00<br />

51772 TC S 96.74 0.00 0.00 52346 S 726.74 0.00 0.00<br />

51784 TC S 40.01 0.00 0.00 52351 S 726.74 0.00 0.00<br />

51785 TC S 66.84 0.00 0.00 52352 S 782.32 0.00 0.00<br />

51792 TC S 40.01 0.00 0.00 52353 S 979.38 0.00 0.00<br />

51795 TC S 71.68 0.00 0.00 52354 S 782.32 0.00 0.00<br />

51797 TC S 71.68 0.00 0.00 52355 S 782.32 0.00 0.00<br />

51798 S 17.81 0.00 0.00 52400 S 726.74 0.00 0.00<br />

51880 S 644.76 0.00 0.00 52402 S 726.74 0.00 0.00<br />

51992 S 1,220.15 0.00 0.00 52450 S 726.74 0.00 0.00<br />

52000 S 292.46 0.00 0.00 52500 S 726.74 0.00 0.00<br />

52001 S 545.19 0.00 0.00 52601 S 979.38 0.00 0.00<br />

52005 S 566.84 0.00 0.00 52630 S 894.16 0.00 0.00<br />

52007 S 697.10 0.00 0.00 52640 S 697.10 0.00 0.00<br />

52010 S 323.13 0.00 0.00 52647 S 1,498.36 0.00 0.00<br />

52204 S 566.84 0.00 0.00 52648 S 1,498.36 0.00 0.00<br />

52214 S 697.10 0.00 0.00 52700 S 697.10 0.00 0.00<br />

52224 S 697.10 0.00 0.00 53000 S 535.02 0.00 0.00<br />

52234 S 697.10 0.00 0.00 53010 S 535.02 0.00 0.00<br />

52235 S 726.74 0.00 0.00 53020 S 535.02 0.00 0.00<br />

52240 S 726.74 0.00 0.00 53025 S 761.58 0.00 0.00<br />

52250 S 782.32 0.00 0.00 53040 S 587.36 0.00 0.00<br />

52260 S 566.84 0.00 0.00 53060 S 69.56 0.00 0.00<br />

52265 S 276.46 0.00 0.00 53080 S 617.00 0.00 0.00<br />

52270 S 566.84 0.00 0.00 53085 S 761.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 535.02 0.00 0.00 54060 S 542.59 0.00 0.00<br />

53210 S 918.91 0.00 0.00 54065 S 542.59 0.00 0.00<br />

53215 S 712.87 0.00 0.00 54100 S 459.00 0.00 0.00<br />

53220 S 793.39 0.00 0.00 54105 S 572.98 0.00 0.00<br />

53230 S 793.39 0.00 0.00 54110 S 888.36 0.00 0.00<br />

53235 S 617.00 0.00 0.00 54111 S 888.36 0.00 0.00<br />

53240 S 793.39 0.00 0.00 54112 S 888.36 0.00 0.00<br />

53250 S 587.36 0.00 0.00 54115 S 525.90 0.00 0.00<br />

53260 S 587.36 0.00 0.00 54120 S 888.36 0.00 0.00<br />

53265 S 587.36 0.00 0.00 54150 S 592.05 0.00 0.00<br />

53270 S 587.36 0.00 0.00 54160 S 644.39 0.00 0.00<br />

53275 S 587.36 0.00 0.00 54161 S 644.39 0.00 0.00<br />

53400 S 823.04 0.00 0.00 54162 S 644.39 0.00 0.00<br />

53405 S 793.39 0.00 0.00 54163 S 644.39 0.00 0.00<br />

53410 S 793.39 0.00 0.00 54164 S 644.39 0.00 0.00<br />

53420 S 823.04 0.00 0.00 54200 S 67.49 0.00 0.00<br />

53425 S 793.39 0.00 0.00 54205 S 973.58 0.00 0.00<br />

53430 S 793.39 0.00 0.00 54220 S 96.74 0.00 0.00<br />

53431 S 793.39 0.00 0.00 54231 S 63.38 0.00 0.00<br />

53440 S 4,570.24 2,775.72 981.19 54235 S 44.89 0.00 0.00<br />

53442 S 741.06 0.00 0.00 54240 TC S 31.86 0.00 0.00<br />

53444 S 4,570.24 2,775.72 981.19 54250 TC S 11.30 0.00 0.00<br />

53445 S 7,676.84 4,371.91 1,066.98 54300 S 918.00 0.00 0.00<br />

53446 S 741.06 0.00 0.00 54304 S 918.00 0.00 0.00<br />

53447 S 7,676.84 4,371.91 1,066.98 54308 S 918.00 0.00 0.00<br />

53449 S 741.06 0.00 0.00 54312 S 918.00 0.00 0.00<br />

53450 S 741.06 0.00 0.00 54316 S 918.00 0.00 0.00<br />

53460 S 535.02 0.00 0.00 54318 S 918.00 0.00 0.00<br />

53502 S 587.36 0.00 0.00 54322 S 918.00 0.00 0.00<br />

53505 S 793.39 0.00 0.00 54324 S 918.00 0.00 0.00<br />

53510 S 587.36 0.00 0.00 54326 S 918.00 0.00 0.00<br />

53515 S 793.39 0.00 0.00 54328 S 918.00 0.00 0.00<br />

53520 S 793.39 0.00 0.00 54340 S 918.00 0.00 0.00<br />

53600 S 40.09 0.00 0.00 54344 S 918.00 0.00 0.00<br />

53601 S 40.01 0.00 0.00 54348 S 918.00 0.00 0.00<br />

53605 S 566.84 0.00 0.00 54352 S 918.00 0.00 0.00<br />

53620 S 61.67 0.00 0.00 54360 S 918.00 0.00 0.00<br />

53621 S 64.76 0.00 0.00 54380 S 918.00 0.00 0.00<br />

53660 S 40.01 0.00 0.00 54385 S 918.00 0.00 0.00<br />

53661 S 40.01 0.00 0.00 54400 S 4,599.89 2,805.36 1,010.84<br />

53665 S 535.02 0.00 0.00 54401 S 7,758.82 4,453.89 1,148.96<br />

53850 S 1,756.41 0.00 0.00 54405 S 7,758.82 4,453.89 1,148.96<br />

53852 S 1,756.41 0.00 0.00 54406 S 918.00 0.00 0.00<br />

54000 S 587.36 0.00 0.00 54408 S 918.00 0.00 0.00<br />

54001 S 587.36 0.00 0.00 54410 S 7,758.82 4,453.89 1,148.96<br />

54015 S 663.46 0.00 0.00 54415 S 918.00 0.00 0.00<br />

54050 S 31.75 0.00 0.00 54416 S 7,758.82 4,453.89 1,148.96<br />

54055 S 64.76 0.00 0.00 54420 S 973.58 0.00 0.00<br />

54056 S 31.75 0.00 0.00 54435 S 973.58 0.00 0.00<br />

54057 S 542.59 0.00 0.00 54440 S 973.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 152.31 0.00 0.00 55706 S 442.76 0.00 0.00<br />

54500 S 413.37 0.00 0.00 55720 S 644.76 0.00 0.00<br />

54505 S 592.05 0.00 0.00 55725 S 697.10 0.00 0.00<br />

54512 S 644.39 0.00 0.00 55860 S 768.17 0.00 0.00<br />

54520 S 674.03 0.00 0.00 55870 S 78.11 0.00 0.00<br />

54522 S 674.03 0.00 0.00 55873 S 6,078.04 0.00 0.00<br />

54530 S 898.80 0.00 0.00 55875 S 1,307.75 0.00 0.00<br />

54550 S 898.80 0.00 0.00 55876 S 71.61 0.00 0.00<br />

54560 S 875.64 0.00 0.00 55920 S 897.65 0.00 0.00<br />

54600 S 729.61 0.00 0.00 56405 S 41.80 0.00 0.00<br />

54620 S 674.03 0.00 0.00 56420 S 54.56 0.00 0.00<br />

54640 S 898.80 0.00 0.00 56440 S 585.84 0.00 0.00<br />

54660 S 644.39 0.00 0.00 56441 S 533.50 0.00 0.00<br />

54670 S 674.03 0.00 0.00 56442 S 533.50 0.00 0.00<br />

54680 S 674.03 0.00 0.00 56501 S 57.56 0.00 0.00<br />

54690 S 1,508.23 0.00 0.00 56515 S 624.57 0.00 0.00<br />

54692 S 2,681.02 0.00 0.00 56605 S 33.23 0.00 0.00<br />

54700 S 644.39 0.00 0.00 56606 S 13.71 0.00 0.00<br />

54800 S 144.64 0.00 0.00 56620 S 711.35 0.00 0.00<br />

54830 S 674.03 0.00 0.00 56625 S 840.11 0.00 0.00<br />

54840 S 729.61 0.00 0.00 56700 S 533.50 0.00 0.00<br />

54860 S 674.03 0.00 0.00 56740 S 615.48 0.00 0.00<br />

54861 S 729.61 0.00 0.00 56800 S 615.48 0.00 0.00<br />

54865 S 592.05 0.00 0.00 56805 S 758.55 0.00 0.00<br />

54900 S 729.61 0.00 0.00 56810 S 711.35 0.00 0.00<br />

54901 S 729.61 0.00 0.00 56820 S 42.48 0.00 0.00<br />

55000 S 65.78 0.00 0.00 56821 S 54.56 0.00 0.00<br />

55040 S 843.22 0.00 0.00 57000 S 533.50 0.00 0.00<br />

55041 S 939.09 0.00 0.00 57010 S 585.84 0.00 0.00<br />

55060 S 729.61 0.00 0.00 57020 S 307.24 0.00 0.00<br />

55100 S 395.69 0.00 0.00 57022 S 482.94 0.00 0.00<br />

55110 S 644.39 0.00 0.00 57023 S 525.90 0.00 0.00<br />

55120 S 644.39 0.00 0.00 57061 S 53.10 0.00 0.00<br />

55150 S 592.05 0.00 0.00 57065 S 533.50 0.00 0.00<br />

55175 S 592.05 0.00 0.00 57100 S 33.92 0.00 0.00<br />

55180 S 644.39 0.00 0.00 57105 S 585.84 0.00 0.00<br />

55200 S 644.39 0.00 0.00 57130 S 585.84 0.00 0.00<br />

55250 S 644.39 0.00 0.00 57135 S 585.84 0.00 0.00<br />

55400 S 592.05 0.00 0.00 57150 S 24.67 0.00 0.00<br />

55450 S 211.73 0.00 0.00 57155 S 307.24 0.00 0.00<br />

55500 S 674.03 0.00 0.00 57160 S 35.63 0.00 0.00<br />

55520 S 729.61 0.00 0.00 57170 S 5.84 0.00 0.00<br />

55530 S 729.61 0.00 0.00 57180 S 109.74 0.00 0.00<br />

55535 S 898.80 0.00 0.00 57200 S 533.50 0.00 0.00<br />

55540 S 939.09 0.00 0.00 57210 S 585.84 0.00 0.00<br />

55550 S 1,508.23 0.00 0.00 57220 S 1,074.36 0.00 0.00<br />

55600 S 875.64 0.00 0.00 57230 S 882.14 0.00 0.00<br />

55680 S 592.05 0.00 0.00 57240 S 978.01 0.00 0.00<br />

55700 S 381.55 0.00 0.00 57250 S 978.01 0.00 0.00<br />

55705 S 381.55 0.00 0.00 57260 S 978.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,298.98 0.00 0.00 58555 S 576.42 0.00 0.00<br />

57267 S 1,106.77 0.00 0.00 58558 S 658.40 0.00 0.00<br />

57268 S 882.14 0.00 0.00 58559 S 628.76 0.00 0.00<br />

57287 S 1,291.88 0.00 0.00 58560 S 938.79 0.00 0.00<br />

57288 S 1,170.22 0.00 0.00 58561 S 938.79 0.00 0.00<br />

57289 S 978.01 0.00 0.00 58562 S 658.40 0.00 0.00<br />

57291 S 978.01 0.00 0.00 58563 S 1,322.73 0.00 0.00<br />

57300 S 882.14 0.00 0.00 58565 S 1,458.31 0.00 0.00<br />

57320 S 1,291.88 0.00 0.00 58600 S 1,291.88 0.00 0.00<br />

57400 S 585.84 0.00 0.00 58615 S 758.55 0.00 0.00<br />

57410 S 585.84 0.00 0.00 58660 S 1,220.15 0.00 0.00<br />

57415 S 585.84 0.00 0.00 58661 S 1,220.15 0.00 0.00<br />

57420 S 43.86 0.00 0.00 58662 S 1,220.15 0.00 0.00<br />

57421 S 57.22 0.00 0.00 58670 S 1,124.28 0.00 0.00<br />

57452 S 41.46 0.00 0.00 58671 S 1,124.28 0.00 0.00<br />

57454 S 50.71 0.00 0.00 58672 S 1,220.15 0.00 0.00<br />

57455 S 53.79 0.00 0.00 58673 S 1,220.15 0.00 0.00<br />

57456 S 52.08 0.00 0.00 58800 S 615.48 0.00 0.00<br />

57460 S 160.00 0.00 0.00 58805 S 1,291.88 0.00 0.00<br />

57461 S 169.94 0.00 0.00 58820 S 882.14 0.00 0.00<br />

57500 S 73.32 0.00 0.00 58900 S 615.48 0.00 0.00<br />

57505 S 46.60 0.00 0.00 58970 S 171.44 0.00 0.00<br />

57510 S 47.28 0.00 0.00 58974 S 171.44 0.00 0.00<br />

57511 S 54.56 0.00 0.00 58976 S 171.44 0.00 0.00<br />

57513 S 585.84 0.00 0.00 59000 S 62.70 0.00 0.00<br />

57520 S 585.84 0.00 0.00 59001 S 235.34 0.00 0.00<br />

57522 S 585.84 0.00 0.00 59012 S 115.08 0.00 0.00<br />

57530 S 882.14 0.00 0.00 59015 S 50.71 0.00 0.00<br />

57550 S 882.14 0.00 0.00 59020 TC S 26.72 0.00 0.00<br />

57556 S 1,170.22 0.00 0.00 59025 TC S 14.05 0.00 0.00<br />

57558 S 615.48 0.00 0.00 59070 S 115.08 0.00 0.00<br />

57700 S 533.50 0.00 0.00 59072 S 115.08 0.00 0.00<br />

57720 S 615.48 0.00 0.00 59076 S 115.08 0.00 0.00<br />

57800 S 25.01 0.00 0.00 59100 S 1,291.88 0.00 0.00<br />

58100 S 41.11 0.00 0.00 59150 S 1,776.15 0.00 0.00<br />

58120 S 585.84 0.00 0.00 59151 S 1,776.15 0.00 0.00<br />

58145 S 978.01 0.00 0.00 59160 S 615.48 0.00 0.00<br />

58301 S 38.37 0.00 0.00 59200 S 34.26 0.00 0.00<br />

58321 S 35.97 0.00 0.00 59300 S 74.00 0.00 0.00<br />

58322 S 37.00 0.00 0.00 59320 S 533.50 0.00 0.00<br />

58323 S 8.57 0.00 0.00 59412 S 758.55 0.00 0.00<br />

58345 S 758.55 0.00 0.00 59414 S 758.55 0.00 0.00<br />

58346 S 585.84 0.00 0.00 59812 S 711.35 0.00 0.00<br />

58350 S 882.14 0.00 0.00 59820 S 711.35 0.00 0.00<br />

58353 S 1,106.77 0.00 0.00 59821 S 711.35 0.00 0.00<br />

58356 S 1,676.30 0.00 0.00 59840 S 711.35 0.00 0.00<br />

58545 S 1,346.53 0.00 0.00 59841 S 711.35 0.00 0.00<br />

58546 S 1,508.23 0.00 0.00 59866 S 115.08 0.00 0.00<br />

58550 S 1,960.66 0.00 0.00 59870 S 711.35 0.00 0.00<br />

58552 S 1,776.15 0.00 0.00 59871 S 711.35 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 298.65 0.00 0.00 62367 S 16.44 0.00 0.00<br />

60100 S 46.94 0.00 0.00 62368 S 20.90 0.00 0.00<br />

60200 S 1,111.56 0.00 0.00 63600 S 561.44 0.00 0.00<br />

60280 S 1,196.79 0.00 0.00 63610 S 509.10 0.00 0.00<br />

60281 S 1,196.79 0.00 0.00 63615 S 709.75 0.00 0.00<br />

60300 S 61.67 0.00 0.00 63650 S 3,021.93 1,873.90 725.88<br />

61000 S 274.99 0.00 0.00 63655 S 4,426.40 2,822.72 1,219.05<br />

61001 S 274.99 0.00 0.00 63660 S 530.71 0.00 0.00<br />

61020 S 222.64 0.00 0.00 63685 S 13,435.13 7,163.73 892.35<br />

61026 S 222.64 0.00 0.00 63688 S 720.66 0.00 0.00<br />

61050 S 222.64 0.00 0.00 63744 S 1,042.18 0.00 0.00<br />

61055 S 222.64 0.00 0.00 63746 S 482.09 0.00 0.00<br />

61070 S 173.24 0.00 0.00 64400 S 52.76 0.00 0.00<br />

61215 S 1,042.18 0.00 0.00 64402 S 49.68 0.00 0.00<br />

61330 S 1,605.54 0.00 0.00 64405 S 42.14 0.00 0.00<br />

61334 S 1,605.54 0.00 0.00 64408 S 52.42 0.00 0.00<br />

61790 S 591.08 0.00 0.00 64410 S 291.72 0.00 0.00<br />

61791 S 438.52 0.00 0.00 64412 S 77.09 0.00 0.00<br />

61880 S 752.96 0.00 0.00 64413 S 49.34 0.00 0.00<br />

61885 S 10,835.21 5,804.32 773.43 64415 S 134.35 0.00 0.00<br />

61886 S 16,179.61 8,527.59 875.58 64416 S 274.99 0.00 0.00<br />

61888 S 720.66 0.00 0.00 64417 S 134.35 0.00 0.00<br />

62194 S 291.72 0.00 0.00 64418 S 69.20 0.00 0.00<br />

62225 S 453.29 0.00 0.00 64420 S 134.35 0.00 0.00<br />

62230 S 1,012.53 0.00 0.00 64421 S 291.72 0.00 0.00<br />

62252 TC S 45.91 0.00 0.00 64425 S 47.96 0.00 0.00<br />

62263 S 291.72 0.00 0.00 64430 S 201.87 0.00 0.00<br />

62264 S 429.75 0.00 0.00 64435 S 72.29 0.00 0.00<br />

62267 S 171.49 0.00 0.00 64445 S 64.06 0.00 0.00<br />

62268 S 222.64 0.00 0.00 64446 S 551.05 0.00 0.00<br />

62269 S 337.86 0.00 0.00 64447 S 139.95 0.00 0.00<br />

62270 S 134.35 0.00 0.00 64448 S 139.95 0.00 0.00<br />

62272 S 134.35 0.00 0.00 64449 S 274.99 0.00 0.00<br />

62273 S 224.20 0.00 0.00 64450 S 42.82 0.00 0.00<br />

62280 S 291.72 0.00 0.00 64455 S 17.81 0.00 0.00<br />

62281 S 291.72 0.00 0.00 64470 S 291.72 0.00 0.00<br />

62282 S 291.72 0.00 0.00 64472 S 224.20 0.00 0.00<br />

62287 S 1,309.55 0.00 0.00 64475 S 291.72 0.00 0.00<br />

62292 S 274.99 0.00 0.00 64476 S 201.91 0.00 0.00<br />

62294 S 222.64 0.00 0.00 64479 S 291.72 0.00 0.00<br />

62310 S 291.72 0.00 0.00 64480 S 224.20 0.00 0.00<br />

62311 S 291.72 0.00 0.00 64483 S 291.72 0.00 0.00<br />

62318 S 291.72 0.00 0.00 64484 S 224.20 0.00 0.00<br />

62319 S 291.72 0.00 0.00 64505 S 39.06 0.00 0.00<br />

62350 S 1,012.53 0.00 0.00 64508 S 82.91 0.00 0.00<br />

62355 S 482.09 0.00 0.00 64510 S 291.72 0.00 0.00<br />

62360 S 1,012.53 0.00 0.00 64517 S 201.87 0.00 0.00<br />

62361 S 10,393.78 5,625.78 857.80 64520 S 291.72 0.00 0.00<br />

62362 S 10,393.78 5,625.78 857.80 64530 S 291.72 0.00 0.00<br />

62365 S 895.96 0.00 0.00 64553 S 2,969.59 1,821.56 673.53<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,334.68 2,186.64 1,038.62 64746 S 561.44 0.00 0.00<br />

64560 S 3,334.68 2,186.64 1,038.62 64761 S 709.75 0.00 0.00<br />

64561 S 3,051.57 1,903.54 755.51 64763 S 709.75 0.00 0.00<br />

64565 S 3,334.68 2,186.64 1,038.62 64766 S 1,378.80 0.00 0.00<br />

64573 S 5,194.93 3,077.49 960.05 64771 S 561.44 0.00 0.00<br />

64575 S 3,971.09 2,367.42 763.75 64772 S 561.44 0.00 0.00<br />

64577 S 3,971.09 2,367.42 763.75 64774 S 561.44 0.00 0.00<br />

64580 S 3,971.09 2,367.42 763.75 64776 S 591.08 0.00 0.00<br />

64581 S 4,053.08 2,449.40 845.73 64778 S 561.44 0.00 0.00<br />

64585 S 530.71 0.00 0.00 64782 S 591.08 0.00 0.00<br />

64590 S 10,835.21 5,804.32 773.43 64783 S 561.44 0.00 0.00<br />

64595 S 720.66 0.00 0.00 64784 S 591.08 0.00 0.00<br />

64600 S 429.75 0.00 0.00 64786 S 925.60 0.00 0.00<br />

64605 S 429.75 0.00 0.00 64787 S 561.44 0.00 0.00<br />

64610 S 429.75 0.00 0.00 64788 S 591.08 0.00 0.00<br />

64612 S 62.70 0.00 0.00 64790 S 591.08 0.00 0.00<br />

64613 S 60.64 0.00 0.00 64792 S 925.60 0.00 0.00<br />

64614 S 69.20 0.00 0.00 64795 S 561.44 0.00 0.00<br />

64620 S 291.72 0.00 0.00 64802 S 561.44 0.00 0.00<br />

64622 S 429.75 0.00 0.00 64820 S 709.75 0.00 0.00<br />

64623 S 291.72 0.00 0.00 64821 S 828.57 0.00 0.00<br />

64626 S 429.75 0.00 0.00 64822 S 1,073.56 0.00 0.00<br />

64627 S 201.91 0.00 0.00 64823 S 1,073.56 0.00 0.00<br />

64630 S 300.49 0.00 0.00 64831 S 981.18 0.00 0.00<br />

64632 S 32.55 0.00 0.00 64832 S 843.62 0.00 0.00<br />

64640 S 96.96 0.00 0.00 64834 S 895.96 0.00 0.00<br />

64650 S 32.55 0.00 0.00 64835 S 925.60 0.00 0.00<br />

64653 S 35.29 0.00 0.00 64836 S 925.60 0.00 0.00<br />

64680 S 456.59 0.00 0.00 64837 S 843.62 0.00 0.00<br />

64681 S 482.09 0.00 0.00 64840 S 895.96 0.00 0.00<br />

64702 S 509.10 0.00 0.00 64856 S 895.96 0.00 0.00<br />

64704 S 509.10 0.00 0.00 64857 S 895.96 0.00 0.00<br />

64708 S 561.44 0.00 0.00 64858 S 895.96 0.00 0.00<br />

64712 S 561.44 0.00 0.00 64859 S 843.62 0.00 0.00<br />

64713 S 561.44 0.00 0.00 64861 S 925.60 0.00 0.00<br />

64714 S 561.44 0.00 0.00 64862 S 925.60 0.00 0.00<br />

64716 S 591.08 0.00 0.00 64864 S 925.60 0.00 0.00<br />

64718 S 561.44 0.00 0.00 64865 S 981.18 0.00 0.00<br />

64719 S 561.44 0.00 0.00 64870 S 981.18 0.00 0.00<br />

64721 S 561.44 0.00 0.00 64872 S 895.96 0.00 0.00<br />

64722 S 509.10 0.00 0.00 64874 S 925.60 0.00 0.00<br />

64726 S 509.10 0.00 0.00 64876 S 925.60 0.00 0.00<br />

64727 S 509.10 0.00 0.00 64885 S 895.96 0.00 0.00<br />

64732 S 561.44 0.00 0.00 64886 S 895.96 0.00 0.00<br />

64734 S 561.44 0.00 0.00 64890 S 895.96 0.00 0.00<br />

64736 S 561.44 0.00 0.00 64891 S 895.96 0.00 0.00<br />

64738 S 561.44 0.00 0.00 64892 S 895.96 0.00 0.00<br />

64740 S 561.44 0.00 0.00 64893 S 895.96 0.00 0.00<br />

64742 S 561.44 0.00 0.00 64895 S 925.60 0.00 0.00<br />

64744 S 561.44 0.00 0.00 64896 S 925.60 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 925.60 0.00 0.00 65770 S 5,446.86 0.00 0.00<br />

64898 S 925.60 0.00 0.00 65772 S 612.73 0.00 0.00<br />

64901 S 895.96 0.00 0.00 65775 S 612.73 0.00 0.00<br />

64902 S 895.96 0.00 0.00 65780 S 1,059.94 0.00 0.00<br />

64905 S 895.96 0.00 0.00 65781 S 1,059.94 0.00 0.00<br />

64907 S 843.62 0.00 0.00 65782 S 1,059.94 0.00 0.00<br />

64910 S 1,378.80 0.00 0.00 65800 S 475.17 0.00 0.00<br />

65091 S 974.61 0.00 0.00 65805 S 475.17 0.00 0.00<br />

65093 S 974.61 0.00 0.00 65810 S 694.33 0.00 0.00<br />

65101 S 974.61 0.00 0.00 65815 S 664.68 0.00 0.00<br />

65103 S 974.61 0.00 0.00 65820 S 243.78 0.00 0.00<br />

65105 S 1,030.19 0.00 0.00 65850 S 749.90 0.00 0.00<br />

65110 S 1,070.48 0.00 0.00 65855 S 129.51 0.00 0.00<br />

65112 S 1,199.24 0.00 0.00 65860 S 120.95 0.00 0.00<br />

65114 S 1,199.24 0.00 0.00 65865 S 475.17 0.00 0.00<br />

65125 S 998.06 0.00 0.00 65870 S 749.90 0.00 0.00<br />

65130 S 735.23 0.00 0.00 65875 S 749.90 0.00 0.00<br />

65135 S 705.59 0.00 0.00 65880 S 612.73 0.00 0.00<br />

65140 S 974.61 0.00 0.00 65900 S 653.02 0.00 0.00<br />

65150 S 705.59 0.00 0.00 65920 S 918.95 0.00 0.00<br />

65155 S 974.61 0.00 0.00 65930 S 790.20 0.00 0.00<br />

65175 S 524.50 0.00 0.00 66020 S 475.17 0.00 0.00<br />

65205 S 20.21 0.00 0.00 66030 S 243.78 0.00 0.00<br />

65210 S 25.70 0.00 0.00 66130 S 918.95 0.00 0.00<br />

65220 S 35.80 0.00 0.00 66150 S 749.90 0.00 0.00<br />

65222 S 28.09 0.00 0.00 66155 S 749.90 0.00 0.00<br />

65235 S 527.51 0.00 0.00 66160 S 664.68 0.00 0.00<br />

65260 S 347.93 0.00 0.00 66165 S 749.90 0.00 0.00<br />

65265 S 719.82 0.00 0.00 66170 S 749.90 0.00 0.00<br />

65270 S 576.83 0.00 0.00 66172 S 749.90 0.00 0.00<br />

65272 S 664.68 0.00 0.00 66180 S 1,117.20 0.00 0.00<br />

65275 S 749.90 0.00 0.00 66185 S 991.69 0.00 0.00<br />

65280 S 719.82 0.00 0.00 66220 S 968.07 0.00 0.00<br />

65285 S 1,023.64 0.00 0.00 66225 S 1,076.91 0.00 0.00<br />

65286 S 179.08 0.00 0.00 66250 S 527.51 0.00 0.00<br />

65290 S 708.88 0.00 0.00 66500 S 243.78 0.00 0.00<br />

65400 S 475.17 0.00 0.00 66505 S 243.78 0.00 0.00<br />

65410 S 527.51 0.00 0.00 66600 S 694.33 0.00 0.00<br />

65420 S 527.51 0.00 0.00 66605 S 694.33 0.00 0.00<br />

65426 S 790.20 0.00 0.00 66625 S 493.67 0.00 0.00<br />

65430 S 35.80 0.00 0.00 66630 S 694.33 0.00 0.00<br />

65435 S 31.18 0.00 0.00 66635 S 694.33 0.00 0.00<br />

65436 S 135.33 0.00 0.00 66680 S 694.33 0.00 0.00<br />

65450 S 82.62 0.00 0.00 66682 S 664.68 0.00 0.00<br />

65600 S 159.66 0.00 0.00 66700 S 527.51 0.00 0.00<br />

65710 S 1,188.69 0.00 0.00 66710 S 527.51 0.00 0.00<br />

65730 S 1,188.69 0.00 0.00 66711 S 527.51 0.00 0.00<br />

65750 S 1,188.69 0.00 0.00 66720 S 527.51 0.00 0.00<br />

65755 S 1,188.69 0.00 0.00 66740 S 664.68 0.00 0.00<br />

65756 S 1,455.71 0.00 0.00 66761 S 180.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 183.30 0.00 0.00 67228 S 201.86 0.00 0.00<br />

66770 S 201.86 0.00 0.00 67229 S 201.86 0.00 0.00<br />

66820 S 179.08 0.00 0.00 67250 S 606.48 0.00 0.00<br />

66821 S 245.66 0.00 0.00 67255 S 664.24 0.00 0.00<br />

66825 S 749.90 0.00 0.00 67311 S 708.88 0.00 0.00<br />

66830 S 262.27 0.00 0.00 67312 S 764.46 0.00 0.00<br />

66840 S 563.79 0.00 0.00 67314 S 764.46 0.00 0.00<br />

66850 S 1,061.47 0.00 0.00 67316 S 764.46 0.00 0.00<br />

66852 S 892.42 0.00 0.00 67318 S 764.46 0.00 0.00<br />

66920 S 892.42 0.00 0.00 67320 S 764.46 0.00 0.00<br />

66930 S 932.72 0.00 0.00 67331 S 764.46 0.00 0.00<br />

66940 S 604.08 0.00 0.00 67332 S 764.46 0.00 0.00<br />

66982 S 916.42 0.00 0.00 67334 S 764.46 0.00 0.00<br />

66983 S 916.42 0.00 0.00 67335 S 764.46 0.00 0.00<br />

66984 S 916.42 0.00 0.00 67340 S 764.46 0.00 0.00<br />

66985 S 848.33 0.00 0.00 67343 S 933.51 0.00 0.00<br />

66986 S 848.33 0.00 0.00 67345 S 79.83 0.00 0.00<br />

67005 S 719.82 0.00 0.00 67346 S 431.79 0.00 0.00<br />

67010 S 719.82 0.00 0.00 67400 S 606.48 0.00 0.00<br />

67015 S 886.08 0.00 0.00 67405 S 790.81 0.00 0.00<br />

67025 S 582.26 0.00 0.00 67412 S 702.35 0.00 0.00<br />

67027 S 1,023.64 0.00 0.00 67413 S 831.10 0.00 0.00<br />

67028 S 80.52 0.00 0.00 67414 S 1,476.81 0.00 0.00<br />

67030 S 582.26 0.00 0.00 67415 S 524.50 0.00 0.00<br />

67031 S 245.66 0.00 0.00 67420 S 1,070.48 0.00 0.00<br />

67036 S 1,023.64 0.00 0.00 67430 S 1,070.48 0.00 0.00<br />

67039 S 1,192.69 0.00 0.00 67440 S 1,070.48 0.00 0.00<br />

67040 S 1,192.69 0.00 0.00 67445 S 1,070.48 0.00 0.00<br />

67041 S 1,463.71 0.00 0.00 67450 S 1,070.48 0.00 0.00<br />

67042 S 1,463.71 0.00 0.00 67500 S 82.62 0.00 0.00<br />

67043 S 1,463.71 0.00 0.00 67505 S 25.70 0.00 0.00<br />

67101 S 223.45 0.00 0.00 67515 S 26.04 0.00 0.00<br />

67105 S 201.86 0.00 0.00 67550 S 1,030.19 0.00 0.00<br />

67107 S 1,063.93 0.00 0.00 67560 S 705.59 0.00 0.00<br />

67108 S 1,192.69 0.00 0.00 67570 S 1,030.19 0.00 0.00<br />

67110 S 324.80 0.00 0.00 67700 S 120.87 0.00 0.00<br />

67112 S 1,192.69 0.00 0.00 67710 S 141.15 0.00 0.00<br />

67113 S 1,463.71 0.00 0.00 67715 S 524.50 0.00 0.00<br />

67115 S 634.60 0.00 0.00 67800 S 50.71 0.00 0.00<br />

67120 S 634.60 0.00 0.00 67801 S 61.33 0.00 0.00<br />

67121 S 634.60 0.00 0.00 67805 S 79.48 0.00 0.00<br />

67141 S 223.69 0.00 0.00 67808 S 576.83 0.00 0.00<br />

67145 S 190.84 0.00 0.00 67810 S 120.87 0.00 0.00<br />

67208 S 203.52 0.00 0.00 67820 S 16.79 0.00 0.00<br />

67210 S 201.86 0.00 0.00 67825 S 51.73 0.00 0.00<br />

67218 S 760.11 0.00 0.00 67830 S 354.13 0.00 0.00<br />

67220 S 223.45 0.00 0.00 67835 S 576.83 0.00 0.00<br />

67221 S 114.77 0.00 0.00 67840 S 148.01 0.00 0.00<br />

67225 S 7.88 0.00 0.00 67850 S 117.52 0.00 0.00<br />

67227 S 582.26 0.00 0.00 67875 S 295.13 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 557.16 0.00 0.00 68440 S 50.37 0.00 0.00<br />

67882 S 606.48 0.00 0.00 68500 S 735.23 0.00 0.00<br />

67900 S 790.81 0.00 0.00 68505 S 735.23 0.00 0.00<br />

67901 S 702.35 0.00 0.00 68510 S 524.50 0.00 0.00<br />

67902 S 831.10 0.00 0.00 68520 S 735.23 0.00 0.00<br />

67903 S 662.05 0.00 0.00 68525 S 524.50 0.00 0.00<br />

67904 S 662.05 0.00 0.00 68530 S 120.87 0.00 0.00<br />

67906 S 702.35 0.00 0.00 68540 S 606.48 0.00 0.00<br />

67908 S 662.05 0.00 0.00 68550 S 735.23 0.00 0.00<br />

67909 S 662.05 0.00 0.00 68700 S 576.83 0.00 0.00<br />

67911 S 606.48 0.00 0.00 68705 S 114.77 0.00 0.00<br />

67912 S 606.48 0.00 0.00 68720 S 790.81 0.00 0.00<br />

67914 S 606.48 0.00 0.00 68745 S 790.81 0.00 0.00<br />

67915 S 163.77 0.00 0.00 68750 S 790.81 0.00 0.00<br />

67916 S 662.05 0.00 0.00 68760 S 97.65 0.00 0.00<br />

67917 S 662.05 0.00 0.00 68761 S 67.49 0.00 0.00<br />

67921 S 606.48 0.00 0.00 68770 S 790.81 0.00 0.00<br />

67922 S 159.32 0.00 0.00 68801 S 35.80 0.00 0.00<br />

67923 S 662.05 0.00 0.00 68810 S 102.39 0.00 0.00<br />

67924 S 662.05 0.00 0.00 68811 S 576.83 0.00 0.00<br />

67930 S 163.77 0.00 0.00 68815 S 576.83 0.00 0.00<br />

67935 S 576.83 0.00 0.00 68816 S 740.53 0.00 0.00<br />

67938 S 82.62 0.00 0.00 68840 S 53.10 0.00 0.00<br />

67950 S 576.83 0.00 0.00 69000 S 54.17 0.00 0.00<br />

67961 S 606.48 0.00 0.00 69005 S 102.44 0.00 0.00<br />

67966 S 606.48 0.00 0.00 69020 S 54.17 0.00 0.00<br />

67971 S 606.48 0.00 0.00 69100 S 61.67 0.00 0.00<br />

67973 S 735.23 0.00 0.00 69105 S 87.37 0.00 0.00<br />

67974 S 606.48 0.00 0.00 69110 S 459.00 0.00 0.00<br />

67975 S 606.48 0.00 0.00 69120 S 681.15 0.00 0.00<br />

68020 S 44.89 0.00 0.00 69140 S 681.15 0.00 0.00<br />

68040 S 22.27 0.00 0.00 69145 S 511.33 0.00 0.00<br />

68100 S 89.08 0.00 0.00 69150 S 359.39 0.00 0.00<br />

68110 S 114.77 0.00 0.00 69200 S 24.77 0.00 0.00<br />

68115 S 576.83 0.00 0.00 69205 S 572.98 0.00 0.00<br />

68130 S 527.51 0.00 0.00 69210 S 20.21 0.00 0.00<br />

68135 S 57.56 0.00 0.00 69220 S 31.75 0.00 0.00<br />

68200 S 16.44 0.00 0.00 69222 S 133.62 0.00 0.00<br />

68320 S 790.81 0.00 0.00 69300 S 710.80 0.00 0.00<br />

68325 S 790.81 0.00 0.00 69310 S 1,038.98 0.00 0.00<br />

68326 S 662.05 0.00 0.00 69320 S 1,263.60 0.00 0.00<br />

68328 S 790.81 0.00 0.00 69400 S 89.76 0.00 0.00<br />

68330 S 749.90 0.00 0.00 69401 S 47.28 0.00 0.00<br />

68335 S 790.81 0.00 0.00 69405 S 124.03 0.00 0.00<br />

68340 S 662.05 0.00 0.00 69420 S 111.35 0.00 0.00<br />

68360 S 664.68 0.00 0.00 69421 S 566.72 0.00 0.00<br />

68362 S 664.68 0.00 0.00 69424 S 78.11 0.00 0.00<br />

68371 S 527.51 0.00 0.00 69433 S 111.01 0.00 0.00<br />

68400 S 120.87 0.00 0.00 69436 S 566.72 0.00 0.00<br />

68420 S 171.99 0.00 0.00 69440 S 710.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 957.00 0.00 0.00 69840 S 1,134.85 0.00 0.00<br />

69501 S 1,263.60 0.00 0.00 69905 S 1,263.60 0.00 0.00<br />

69502 S 935.43 0.00 0.00 69910 S 1,263.60 0.00 0.00<br />

69505 S 1,263.60 0.00 0.00 69915 S 1,263.60 0.00 0.00<br />

69511 S 1,263.60 0.00 0.00 69930 S 22,844.25 12,265.81 1,687.39<br />

69530 S 1,263.60 0.00 0.00 70030 TC A 17.47 0.00 0.00<br />

69540 S 130.53 0.00 0.00 70100 TC A 19.19 0.00 0.00<br />

69550 S 1,134.85 0.00 0.00 70110 TC A 23.64 0.00 0.00<br />

69552 S 1,263.60 0.00 0.00 70120 TC A 21.24 0.00 0.00<br />

69601 S 1,263.60 0.00 0.00 70130 TC A 25.95 0.00 0.00<br />

69602 S 1,263.60 0.00 0.00 70134 TC A 26.04 0.00 0.00<br />

69603 S 1,263.60 0.00 0.00 70140 TC A 17.81 0.00 0.00<br />

69604 S 1,263.60 0.00 0.00 70150 TC A 25.95 0.00 0.00<br />

69605 S 1,263.60 0.00 0.00 70160 TC A 20.90 0.00 0.00<br />

69610 S 174.73 0.00 0.00 70190 TC A 21.92 0.00 0.00<br />

69620 S 681.15 0.00 0.00 70200 TC A 25.95 0.00 0.00<br />

69631 S 1,134.85 0.00 0.00 70210 TC A 18.51 0.00 0.00<br />

69632 S 1,134.85 0.00 0.00 70220 TC A 23.30 0.00 0.00<br />

69633 S 1,134.85 0.00 0.00 70240 TC A 17.47 0.00 0.00<br />

69635 S 1,263.60 0.00 0.00 70250 TC A 21.24 0.00 0.00<br />

69636 S 1,263.60 0.00 0.00 70260 TC A 27.06 0.00 0.00<br />

69637 S 1,263.60 0.00 0.00 70300 TC A 7.53 0.00 0.00<br />

69641 S 1,263.60 0.00 0.00 70310 TC A 18.62 0.00 0.00<br />

69642 S 1,263.60 0.00 0.00 70320 TC A 18.62 0.00 0.00<br />

69643 S 1,263.60 0.00 0.00 70328 TC A 18.51 0.00 0.00<br />

69644 S 1,263.60 0.00 0.00 70330 TC A 25.95 0.00 0.00<br />

69645 S 1,263.60 0.00 0.00 70336 TC A 202.02 0.00 0.00<br />

69646 S 1,263.60 0.00 0.00 70350 TC A 10.28 0.00 0.00<br />

69650 S 935.43 0.00 0.00 70355 TC A 10.62 0.00 0.00<br />

69660 S 1,134.85 0.00 0.00 70360 TC A 16.44 0.00 0.00<br />

69661 S 1,134.85 0.00 0.00 70370 TC A 48.30 0.00 0.00<br />

69662 S 1,134.85 0.00 0.00 70371 TC A 48.30 0.00 0.00<br />

69666 S 1,094.55 0.00 0.00 70380 TC A 25.01 0.00 0.00<br />

69667 S 1,094.55 0.00 0.00 70450 TC A 112.83 0.00 0.00<br />

69670 S 1,038.98 0.00 0.00 70460 TC A 178.66 0.00 0.00<br />

69676 S 1,038.98 0.00 0.00 70470 TC A 197.90 0.00 0.00<br />

69700 S 1,038.98 0.00 0.00 70480 TC A 112.83 0.00 0.00<br />

69711 S 957.00 0.00 0.00 70481 TC A 178.66 0.00 0.00<br />

69714 S 6,069.12 3,826.81 1,584.50 70482 TC A 197.90 0.00 0.00<br />

69715 S 6,069.12 3,826.81 1,584.50 70486 TC A 112.83 0.00 0.00<br />

69717 S 6,069.12 3,826.81 1,584.50 70487 TC A 178.66 0.00 0.00<br />

69718 S 6,069.12 3,826.81 1,584.50 70488 TC A 197.90 0.00 0.00<br />

69720 S 1,134.85 0.00 0.00 70490 TC A 112.83 0.00 0.00<br />

69740 S 1,134.85 0.00 0.00 70491 TC A 178.66 0.00 0.00<br />

69745 S 1,134.85 0.00 0.00 70492 TC A 197.90 0.00 0.00<br />

69801 S 1,134.85 0.00 0.00 70496 TC A 204.23 0.00 0.00<br />

69802 S 1,263.60 0.00 0.00 70498 TC A 204.23 0.00 0.00<br />

69805 S 1,263.60 0.00 0.00 70540 TC A 202.02 0.00 0.00<br />

69806 S 1,263.60 0.00 0.00 70542 TC A 248.08 0.00 0.00<br />

69820 S 1,134.85 0.00 0.00 70543 TC A 312.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 202.02 0.00 0.00 72120 TC A 32.89 0.00 0.00<br />

70545 TC A 248.08 0.00 0.00 72125 TC A 112.83 0.00 0.00<br />

70546 TC A 312.67 0.00 0.00 72126 TC A 178.66 0.00 0.00<br />

70547 TC A 202.02 0.00 0.00 72127 TC A 197.90 0.00 0.00<br />

70548 TC A 248.08 0.00 0.00 72128 TC A 112.83 0.00 0.00<br />

70549 TC A 312.67 0.00 0.00 72129 TC A 178.66 0.00 0.00<br />

70551 TC A 202.02 0.00 0.00 72130 TC A 197.90 0.00 0.00<br />

70552 TC A 248.08 0.00 0.00 72131 TC A 112.83 0.00 0.00<br />

70553 TC A 312.67 0.00 0.00 72132 TC A 178.66 0.00 0.00<br />

70554 TC A 202.02 0.00 0.00 72133 TC A 197.90 0.00 0.00<br />

70555 TC A 202.02 0.00 0.00 72141 TC A 202.02 0.00 0.00<br />

70557 TC A 202.02 0.00 0.00 72142 TC A 248.08 0.00 0.00<br />

70558 TC A 248.08 0.00 0.00 72146 TC A 202.02 0.00 0.00<br />

70559 TC A 312.67 0.00 0.00 72147 TC A 248.08 0.00 0.00<br />

71010 TC A 13.37 0.00 0.00 72148 TC A 202.02 0.00 0.00<br />

71015 TC A 17.13 0.00 0.00 72149 TC A 248.08 0.00 0.00<br />

71020 TC A 18.16 0.00 0.00 72156 TC A 312.67 0.00 0.00<br />

71021 TC A 21.92 0.00 0.00 72157 TC A 312.67 0.00 0.00<br />

71022 TC A 25.95 0.00 0.00 72158 TC A 312.67 0.00 0.00<br />

71023 TC A 42.48 0.00 0.00 72170 TC A 15.42 0.00 0.00<br />

71030 TC A 25.95 0.00 0.00 72190 TC A 25.95 0.00 0.00<br />

71034 TC A 48.30 0.00 0.00 72191 TC A 204.23 0.00 0.00<br />

71035 TC A 22.61 0.00 0.00 72192 TC A 112.83 0.00 0.00<br />

71100 TC A 18.85 0.00 0.00 72193 TC A 178.66 0.00 0.00<br />

71101 TC A 22.95 0.00 0.00 72194 TC A 197.90 0.00 0.00<br />

71110 TC A 23.99 0.00 0.00 72195 TC A 202.02 0.00 0.00<br />

71111 TC A 31.86 0.00 0.00 72196 TC A 248.08 0.00 0.00<br />

71120 TC A 19.87 0.00 0.00 72197 TC A 312.67 0.00 0.00<br />

71130 TC A 23.30 0.00 0.00 72200 TC A 18.16 0.00 0.00<br />

71250 TC A 112.83 0.00 0.00 72202 TC A 22.27 0.00 0.00<br />

71260 TC A 178.66 0.00 0.00 72220 TC A 18.16 0.00 0.00<br />

71270 TC A 197.90 0.00 0.00 73000 TC A 17.13 0.00 0.00<br />

71275 TC A 204.23 0.00 0.00 73010 TC A 17.47 0.00 0.00<br />

71550 TC A 202.02 0.00 0.00 73020 TC A 14.05 0.00 0.00<br />

71551 TC A 248.08 0.00 0.00 73030 TC A 17.81 0.00 0.00<br />

71552 TC A 312.67 0.00 0.00 73050 TC A 22.27 0.00 0.00<br />

72010 TC A 43.20 0.00 0.00 73060 TC A 17.81 0.00 0.00<br />

72020 TC A 14.05 0.00 0.00 73070 TC A 17.13 0.00 0.00<br />

72040 TC A 22.61 0.00 0.00 73080 TC A 22.61 0.00 0.00<br />

72050 TC A 32.20 0.00 0.00 73090 TC A 17.13 0.00 0.00<br />

72052 TC A 43.20 0.00 0.00 73092 TC A 17.81 0.00 0.00<br />

72069 TC A 21.24 0.00 0.00 73100 TC A 17.81 0.00 0.00<br />

72070 TC A 19.87 0.00 0.00 73110 TC A 22.61 0.00 0.00<br />

72072 TC A 23.99 0.00 0.00 73120 TC A 16.79 0.00 0.00<br />

72074 TC A 25.95 0.00 0.00 73130 TC A 19.87 0.00 0.00<br />

72080 TC A 21.24 0.00 0.00 73140 TC A 19.53 0.00 0.00<br />

72090 TC A 28.44 0.00 0.00 73200 TC A 112.83 0.00 0.00<br />

72100 TC A 24.33 0.00 0.00 73201 TC A 178.66 0.00 0.00<br />

72110 TC A 33.92 0.00 0.00 73202 TC A 197.90 0.00 0.00<br />

72114 TC A 43.20 0.00 0.00 73206 TC A 204.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 202.02 0.00 0.00 74246 TC A 50.98 0.00 0.00<br />

73219 TC A 248.08 0.00 0.00 74247 TC A 50.98 0.00 0.00<br />

73220 TC A 312.67 0.00 0.00 74249 TC A 82.90 0.00 0.00<br />

73221 TC A 202.02 0.00 0.00 74250 TC A 50.98 0.00 0.00<br />

73222 TC A 248.08 0.00 0.00 74251 TC A 82.90 0.00 0.00<br />

73223 TC A 312.67 0.00 0.00 74260 TC A 50.98 0.00 0.00<br />

73500 TC A 14.73 0.00 0.00 74270 TC A 50.98 0.00 0.00<br />

73510 TC A 22.61 0.00 0.00 74280 TC A 82.90 0.00 0.00<br />

73520 TC A 23.30 0.00 0.00 74283 TC A 50.98 0.00 0.00<br />

73540 TC A 23.30 0.00 0.00 74290 TC A 43.51 0.00 0.00<br />

73550 TC A 17.13 0.00 0.00 74291 TC A 41.80 0.00 0.00<br />

73560 TC A 17.47 0.00 0.00 74400 TC A 75.72 0.00 0.00<br />

73562 TC A 21.58 0.00 0.00 74410 TC A 80.86 0.00 0.00<br />

73564 TC A 25.01 0.00 0.00 74415 TC A 96.62 0.00 0.00<br />

73565 TC A 18.85 0.00 0.00 74420 TC A 100.99 0.00 0.00<br />

73590 TC A 16.44 0.00 0.00 74710 TC A 22.61 0.00 0.00<br />

73592 TC A 17.81 0.00 0.00 74775 TC A 100.99 0.00 0.00<br />

73600 TC A 16.79 0.00 0.00 75557 TC A 202.02 0.00 0.00<br />

73610 TC A 19.87 0.00 0.00 75559 TC A 202.02 0.00 0.00<br />

73620 TC A 16.10 0.00 0.00 75561 TC A 312.67 0.00 0.00<br />

73630 TC A 19.53 0.00 0.00 75563 TC A 312.67 0.00 0.00<br />

73650 TC A 16.44 0.00 0.00 76010 TC A 16.79 0.00 0.00<br />

73660 TC A 18.51 0.00 0.00 76098 TC A 10.28 0.00 0.00<br />

73700 TC A 112.83 0.00 0.00 76100 TC A 43.20 0.00 0.00<br />

73701 TC A 178.66 0.00 0.00 76101 TC A 115.80 0.00 0.00<br />

73702 TC A 197.90 0.00 0.00 76102 TC A 115.80 0.00 0.00<br />

73706 TC A 204.23 0.00 0.00 76120 TC A 48.30 0.00 0.00<br />

73718 TC A 202.02 0.00 0.00 76150 A 16.79 0.00 0.00<br />

73719 TC A 248.08 0.00 0.00 76380 TC A 60.95 0.00 0.00<br />

73720 TC A 312.67 0.00 0.00 76496 TC A 48.30 0.00 0.00<br />

73721 TC A 202.02 0.00 0.00 76497 TC A 60.95 0.00 0.00<br />

73722 TC A 248.08 0.00 0.00 76498 TC A 202.02 0.00 0.00<br />

73723 TC A 312.67 0.00 0.00 76499 TC A 25.95 0.00 0.00<br />

74000 TC A 14.73 0.00 0.00 76506 TC A 36.28 0.00 0.00<br />

74010 TC A 22.95 0.00 0.00 76510 TC A 61.67 0.00 0.00<br />

74020 TC A 23.30 0.00 0.00 76511 TC A 43.17 0.00 0.00<br />

74022 TC A 28.44 0.00 0.00 76512 TC A 36.66 0.00 0.00<br />

74150 TC A 112.83 0.00 0.00 76513 TC A 44.54 0.00 0.00<br />

74160 TC A 178.66 0.00 0.00 76514 TC A 3.09 0.00 0.00<br />

74170 TC A 197.90 0.00 0.00 76516 TC A 34.95 0.00 0.00<br />

74175 TC A 204.23 0.00 0.00 76519 TC A 39.06 0.00 0.00<br />

74181 TC A 202.02 0.00 0.00 76529 TC A 33.92 0.00 0.00<br />

74182 TC A 248.08 0.00 0.00 76536 TC A 56.75 0.00 0.00<br />

74183 TC A 312.67 0.00 0.00 76604 TC A 36.28 0.00 0.00<br />

74210 TC A 50.98 0.00 0.00 76645 TC A 36.28 0.00 0.00<br />

74220 TC A 50.98 0.00 0.00 76700 TC A 56.75 0.00 0.00<br />

74230 TC A 50.98 0.00 0.00 76705 TC A 56.75 0.00 0.00<br />

74240 TC A 50.98 0.00 0.00 76770 TC A 56.75 0.00 0.00<br />

74241 TC A 50.98 0.00 0.00 76775 TC A 56.75 0.00 0.00<br />

74245 TC A 82.90 0.00 0.00 76776 TC A 56.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 56.75 0.00 0.00 77290 TC A 148.41 0.00 0.00<br />

76801 TC A 56.75 0.00 0.00 77295 TC A 388.87 0.00 0.00<br />

76802 TC A 27.06 0.00 0.00 77299 TC A 66.58 0.00 0.00<br />

76805 TC A 56.75 0.00 0.00 77300 TC A 35.97 0.00 0.00<br />

76810 TC A 42.82 0.00 0.00 77301 TC A 518.25 0.00 0.00<br />

76811 TC A 88.91 0.00 0.00 77305 TC A 32.89 0.00 0.00<br />

76812 TC A 36.28 0.00 0.00 77310 TC A 42.82 0.00 0.00<br />

76813 TC A 36.28 0.00 0.00 77315 TC A 62.35 0.00 0.00<br />

76814 TC A 28.78 0.00 0.00 77321 TC A 64.76 0.00 0.00<br />

76815 TC A 36.28 0.00 0.00 77326 TC A 66.58 0.00 0.00<br />

76816 TC A 36.28 0.00 0.00 77327 TC A 120.95 0.00 0.00<br />

76817 TC A 36.28 0.00 0.00 77328 TC A 148.41 0.00 0.00<br />

76818 TC A 56.75 0.00 0.00 77331 TC A 17.13 0.00 0.00<br />

76819 TC A 49.00 0.00 0.00 77332 TC A 45.91 0.00 0.00<br />

76820 TC A 24.33 0.00 0.00 77333 TC A 22.27 0.00 0.00<br />

76821 TC A 54.94 0.00 0.00 77334 TC A 86.00 0.00 0.00<br />

76825 TC A 114.43 0.00 0.00 77336 A 54.14 0.00 0.00<br />

76826 TC A 68.18 0.00 0.00 77370 A 66.58 0.00 0.00<br />

76827 TC A 36.28 0.00 0.00 77371 A 4,435.41 0.00 0.00<br />

76828 TC A 21.58 0.00 0.00 77399 TC A 66.58 0.00 0.00<br />

76830 TC A 56.75 0.00 0.00 77401 A 27.06 0.00 0.00<br />

76831 TC A 76.40 0.00 0.00 77402 A 54.49 0.00 0.00<br />

76856 TC A 56.75 0.00 0.00 77403 A 54.49 0.00 0.00<br />

76857 TC A 36.28 0.00 0.00 77404 A 54.49 0.00 0.00<br />

76870 TC A 56.75 0.00 0.00 77406 A 88.26 0.00 0.00<br />

76872 TC A 56.75 0.00 0.00 77407 A 54.49 0.00 0.00<br />

76873 TC A 56.75 0.00 0.00 77408 A 54.49 0.00 0.00<br />

76880 TC A 56.75 0.00 0.00 77409 A 54.49 0.00 0.00<br />

76885 TC A 36.28 0.00 0.00 77411 A 88.26 0.00 0.00<br />

76886 TC A 36.28 0.00 0.00 77412 A 88.26 0.00 0.00<br />

76936 TC A 54.94 0.00 0.00 77413 A 88.26 0.00 0.00<br />

76970 TC A 36.28 0.00 0.00 77414 A 88.26 0.00 0.00<br />

76977 TC A 9.25 0.00 0.00 77416 A 88.26 0.00 0.00<br />

76999 TC A 36.28 0.00 0.00 77418 A 238.46 0.00 0.00<br />

77071 A 21.24 0.00 0.00 77422 A 88.26 0.00 0.00<br />

77072 TC A 12.33 0.00 0.00 77423 A 88.26 0.00 0.00<br />

77073 TC A 20.90 0.00 0.00 77470 TC A 126.77 0.00 0.00<br />

77074 TC A 41.11 0.00 0.00 77520 A 408.26 0.00 0.00<br />

77075 TC A 43.20 0.00 0.00 77522 A 408.26 0.00 0.00<br />

77076 TC A 43.20 0.00 0.00 77523 A 487.88 0.00 0.00<br />

77077 TC A 23.30 0.00 0.00 77525 A 487.88 0.00 0.00<br />

77078 TC A 41.74 0.00 0.00 77600 TC A 216.62 0.00 0.00<br />

77079 TC A 42.82 0.00 0.00 77605 TC A 216.62 0.00 0.00<br />

77080 TC A 41.74 0.00 0.00 77610 TC A 216.62 0.00 0.00<br />

77081 TC A 16.79 0.00 0.00 77615 TC A 216.62 0.00 0.00<br />

77082 TC A 18.16 0.00 0.00 77620 TC A 216.62 0.00 0.00<br />

77083 TC A 14.39 0.00 0.00 77750 TC A 84.28 0.00 0.00<br />

77084 TC A 202.02 0.00 0.00 77761 TC A 148.35 0.00 0.00<br />

77280 TC A 66.58 0.00 0.00 77762 TC A 175.76 0.00 0.00<br />

77285 TC A 148.41 0.00 0.00 77763 TC A 226.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 160.68 0.00 0.00 78262 TC A 141.12 0.00 0.00<br />

77777 TC A 176.44 0.00 0.00 78264 TC A 141.12 0.00 0.00<br />

77778 TC A 235.04 0.00 0.00 78270 TC A 61.67 0.00 0.00<br />

77785 TC A 104.49 0.00 0.00 78271 TC A 62.70 0.00 0.00<br />

77786 TC A 367.28 0.00 0.00 78272 TC A 68.86 0.00 0.00<br />

77787 TC A 425.60 0.00 0.00 78278 TC A 141.12 0.00 0.00<br />

77789 TC A 43.86 0.00 0.00 78282 TC A 141.12 0.00 0.00<br />

77799 TC A 249.97 0.00 0.00 78290 TC A 141.12 0.00 0.00<br />

78000 TC A 53.79 0.00 0.00 78291 TC A 141.12 0.00 0.00<br />

78001 TC A 68.17 0.00 0.00 78299 TC A 141.12 0.00 0.00<br />

78003 TC A 54.14 0.00 0.00 78300 TC A 123.00 0.00 0.00<br />

78006 TC A 128.80 0.00 0.00 78305 TC A 142.65 0.00 0.00<br />

78007 TC A 95.25 0.00 0.00 78306 TC A 142.65 0.00 0.00<br />

78010 TC A 79.14 0.00 0.00 78315 TC A 142.65 0.00 0.00<br />

78011 TC A 79.14 0.00 0.00 78320 TC A 142.65 0.00 0.00<br />

78015 TC A 153.83 0.00 0.00 78399 TC A 142.65 0.00 0.00<br />

78016 TC A 173.64 0.00 0.00 78414 TC A 181.33 0.00 0.00<br />

78018 TC A 173.64 0.00 0.00 78428 TC A 139.10 0.00 0.00<br />

78070 TC A 118.20 0.00 0.00 78445 TC A 108.50 0.00 0.00<br />

78075 TC A 334.73 0.00 0.00 78456 TC A 108.50 0.00 0.00<br />

78099 TC A 79.14 0.00 0.00 78457 TC A 108.50 0.00 0.00<br />

78102 TC A 119.57 0.00 0.00 78458 TC A 108.50 0.00 0.00<br />

78103 TC A 152.42 0.00 0.00 78459 TC A 671.47 0.00 0.00<br />

78104 TC A 152.42 0.00 0.00 78460 TC A 130.19 0.00 0.00<br />

78110 TC A 60.64 0.00 0.00 78461 TC A 131.23 0.00 0.00<br />

78111 TC A 76.75 0.00 0.00 78464 TC A 192.55 0.00 0.00<br />

78120 TC A 67.15 0.00 0.00 78465 TC A 364.54 0.00 0.00<br />

78121 TC A 79.48 0.00 0.00 78466 TC A 129.16 0.00 0.00<br />

78122 TC A 94.22 0.00 0.00 78468 TC A 165.14 0.00 0.00<br />

78130 TC A 109.29 0.00 0.00 78469 TC A 181.33 0.00 0.00<br />

78135 TC A 232.28 0.00 0.00 78472 TC A 181.33 0.00 0.00<br />

78140 TC A 103.13 0.00 0.00 78473 TC A 181.33 0.00 0.00<br />

78185 TC A 152.42 0.00 0.00 78481 TC A 156.57 0.00 0.00<br />

78190 TC A 95.64 0.00 0.00 78483 TC A 181.33 0.00 0.00<br />

78191 TC A 95.64 0.00 0.00 78491 TC A 671.47 0.00 0.00<br />

78195 TC A 152.42 0.00 0.00 78492 TC A 671.47 0.00 0.00<br />

78199 TC A 152.42 0.00 0.00 78494 TC A 181.33 0.00 0.00<br />

78201 TC A 135.67 0.00 0.00 78499 TC A 181.33 0.00 0.00<br />

78202 TC A 159.60 0.00 0.00 78580 TC A 122.85 0.00 0.00<br />

78205 TC A 159.60 0.00 0.00 78584 TC A 94.90 0.00 0.00<br />

78206 TC A 159.60 0.00 0.00 78585 TC A 188.50 0.00 0.00<br />

78215 TC A 143.56 0.00 0.00 78586 TC A 122.85 0.00 0.00<br />

78216 TC A 97.30 0.00 0.00 78587 TC A 122.85 0.00 0.00<br />

78220 TC A 106.21 0.00 0.00 78588 TC A 188.50 0.00 0.00<br />

78223 TC A 159.60 0.00 0.00 78591 TC A 122.85 0.00 0.00<br />

78230 TC A 120.60 0.00 0.00 78593 TC A 122.85 0.00 0.00<br />

78231 TC A 94.90 0.00 0.00 78594 TC A 122.85 0.00 0.00<br />

78232 TC A 99.01 0.00 0.00 78596 TC A 188.50 0.00 0.00<br />

78258 TC A 141.12 0.00 0.00 78599 TC A 122.85 0.00 0.00<br />

78261 TC A 141.12 0.00 0.00 78600 TC A 108.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 27260 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 108.27 0.00 0.00<br />

78605 TC A 108.27 0.00 0.00<br />

78606 TC A 243.25 0.00 0.00<br />

78607 TC A 267.24 0.00 0.00<br />

78608 TC A 601.85 0.00 0.00<br />

78610 TC A 144.24 0.00 0.00<br />

78630 TC A 256.96 0.00 0.00<br />

78635 TC A 236.75 0.00 0.00<br />

78645 TC A 108.27 0.00 0.00<br />

78647 TC A 262.10 0.00 0.00<br />

78650 TC A 253.87 0.00 0.00<br />

78660 TC A 108.27 0.00 0.00<br />

78699 TC A 108.27 0.00 0.00<br />

78700 TC A 133.28 0.00 0.00<br />

78701 TC A 162.40 0.00 0.00<br />

78707 TC A 169.59 0.00 0.00<br />

78708 TC A 116.15 0.00 0.00<br />

78709 TC A 190.96 0.00 0.00<br />

78710 TC A 179.19 0.00 0.00<br />

78725 TC A 71.61 0.00 0.00<br />

78730 TC A 60.64 0.00 0.00<br />

78740 TC A 158.29 0.00 0.00<br />

78761 TC A 151.09 0.00 0.00<br />

78799 TC A 190.96 0.00 0.00<br />

78800 TC A 133.62 0.00 0.00<br />

78801 TC A 183.30 0.00 0.00<br />

78802 TC A 248.39 0.00 0.00<br />

78803 TC A 266.21 0.00 0.00<br />

78804 TC A 464.58 0.00 0.00<br />

78805 TC A 130.53 0.00 0.00<br />

78806 TC A 261.07 0.00 0.00<br />

78807 TC A 266.56 0.00 0.00<br />

78811 TC A 601.85 0.00 0.00<br />

78812 TC A 601.85 0.00 0.00<br />

78813 TC A 601.85 0.00 0.00<br />

78814 TC A 601.85 0.00 0.00<br />

78815 TC A 601.85 0.00 0.00<br />

78816 TC A 601.85 0.00 0.00<br />

78999 TC A 68.17 0.00 0.00<br />

79005 TC A 54.82 0.00 0.00<br />

79101 TC A 59.96 0.00 0.00<br />

79200 TC A 64.76 0.00 0.00<br />

79300 TC A 124.94 0.00 0.00<br />

79403 TC A 92.85 0.00 0.00<br />

79440 TC A 52.42 0.00 0.00<br />

79445 TC A 124.94 0.00 0.00<br />

79999 TC A 124.94 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,152.99 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,460.42 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.35 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,509.05 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,509.05 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 217.93 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 217.93 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 110.04 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 232.57 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 69.91 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 626.04 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,427.58 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,117.44 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,117.44 0.00 0.00<br />

C8900 A 241.96 0.00 0.00 0123T S 893.62 0.00 0.00<br />

C8901 A 197.03 0.00 0.00 0124T S 174.66 0.00 0.00<br />

C8902 A 304.95 0.00 0.00 0144T TC A 59.44 0.00 0.00<br />

C8903 A 241.96 0.00 0.00 0145T TC A 160.03 0.00 0.00<br />

C8904 A 197.03 0.00 0.00 0146T TC A 160.03 0.00 0.00<br />

C8905 A 304.95 0.00 0.00 0147T TC A 160.03 0.00 0.00<br />

C8906 A 241.96 0.00 0.00 0148T TC A 160.03 0.00 0.00<br />

C8907 A 197.03 0.00 0.00 0149T TC A 160.03 0.00 0.00<br />

C8908 A 304.95 0.00 0.00 0150T TC A 160.03 0.00 0.00<br />

C8909 A 241.96 0.00 0.00 0151T TC A 59.44 0.00 0.00<br />

C8910 A 197.03 0.00 0.00 0170T S 1,160.76 0.00 0.00<br />

C8911 A 304.95 0.00 0.00 0176T S 1,370.59 0.00 0.00<br />

C8912 A 241.96 0.00 0.00 0177T S 1,370.59 0.00 0.00<br />

C8913 A 197.03 0.00 0.00 0182T A 990.67 0.00 0.00<br />

C8914 A 304.95 0.00 0.00 0186T S 834.93 0.00 0.00<br />

C8918 A 241.96 0.00 0.00 0190T S 834.93 0.00 0.00<br />

C8919 A 197.03 0.00 0.00 0191T S 893.62 0.00 0.00<br />

C8920 A 304.95 0.00 0.00 0192T S 1,531.49 0.00 0.00<br />

C9716 S 1,160.76 0.00 0.00 10021 S 53.56 0.00 0.00<br />

C9724 S 949.05 0.00 0.00 10022 S 167.26 0.00 0.00<br />

C9725 S 218.85 0.00 0.00 10040 S 30.96 0.00 0.00<br />

C9726 S 803.45 0.00 0.00 10060 S 47.11 0.00 0.00<br />

C9727 S 281.70 0.00 0.00 10061 S 52.83 0.00 0.00<br />

C9728 S 505.46 0.00 0.00 10080 S 52.83 0.00 0.00<br />

G0104 S 81.20 0.00 0.00 10081 S 121.63 0.00 0.00<br />

G0105 S 350.94 0.00 0.00 10120 S 66.16 0.00 0.00<br />

G0121 S 350.94 0.00 0.00 10121 S 498.71 0.00 0.00<br />

G0127 S 11.36 0.00 0.00 10140 S 70.17 0.00 0.00<br />

G0130 TC A 18.72 0.00 0.00 10160 S 52.83 0.00 0.00<br />

G0173 A 2,152.99 0.00 0.00 10180 S 563.97 0.00 0.00<br />

G0186 S 217.93 0.00 0.00 11000 S 22.73 0.00 0.00<br />

G0247 S 20.72 0.00 0.00 11001 S 7.69 0.00 0.00<br />

G0251 A 539.14 0.00 0.00 11010 S 197.31 0.00 0.00<br />

G0260 S 284.52 0.00 0.00 11011 S 197.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 197.31 0.00 0.00 11601 S 108.94 0.00 0.00<br />

11040 S 20.72 0.00 0.00 11602 S 119.96 0.00 0.00<br />

11041 S 23.06 0.00 0.00 11603 S 127.31 0.00 0.00<br />

11042 S 125.29 0.00 0.00 11604 S 343.42 0.00 0.00<br />

11043 S 125.29 0.00 0.00 11606 S 498.71 0.00 0.00<br />

11044 S 326.24 0.00 0.00 11620 S 92.90 0.00 0.00<br />

11055 S 24.39 0.00 0.00 11621 S 110.27 0.00 0.00<br />

11056 S 26.73 0.00 0.00 11622 S 122.63 0.00 0.00<br />

11057 S 30.96 0.00 0.00 11623 S 131.99 0.00 0.00<br />

11100 S 56.73 0.00 0.00 11624 S 498.71 0.00 0.00<br />

11101 S 13.37 0.00 0.00 11626 S 609.88 0.00 0.00<br />

11200 S 30.96 0.00 0.00 11640 S 98.25 0.00 0.00<br />

11201 S 5.35 0.00 0.00 11641 S 115.95 0.00 0.00<br />

11300 S 30.96 0.00 0.00 11642 S 129.32 0.00 0.00<br />

11301 S 30.96 0.00 0.00 11643 S 139.35 0.00 0.00<br />

11302 S 30.96 0.00 0.00 11644 S 498.71 0.00 0.00<br />

11303 S 56.73 0.00 0.00 11646 S 609.88 0.00 0.00<br />

11305 S 30.96 0.00 0.00 11719 S 11.36 0.00 0.00<br />

11306 S 30.96 0.00 0.00 11720 S 14.04 0.00 0.00<br />

11307 S 30.96 0.00 0.00 11721 S 17.04 0.00 0.00<br />

11308 S 30.96 0.00 0.00 11730 S 30.96 0.00 0.00<br />

11310 S 30.96 0.00 0.00 11732 S 17.04 0.00 0.00<br />

11311 S 30.96 0.00 0.00 11740 S 15.64 0.00 0.00<br />

11312 S 30.96 0.00 0.00 11750 S 90.22 0.00 0.00<br />

11313 S 30.96 0.00 0.00 11752 S 125.31 0.00 0.00<br />

11400 S 63.83 0.00 0.00 11755 S 62.48 0.00 0.00<br />

11401 S 71.84 0.00 0.00 11760 S 128.69 0.00 0.00<br />

11402 S 78.86 0.00 0.00 11762 S 114.95 0.00 0.00<br />

11403 S 84.21 0.00 0.00 11765 S 30.96 0.00 0.00<br />

11404 S 447.67 0.00 0.00 11770 S 638.79 0.00 0.00<br />

11406 S 498.71 0.00 0.00 11771 S 638.79 0.00 0.00<br />

11420 S 59.81 0.00 0.00 11772 S 638.79 0.00 0.00<br />

11421 S 72.51 0.00 0.00 11900 S 28.41 0.00 0.00<br />

11422 S 79.20 0.00 0.00 11901 S 30.96 0.00 0.00<br />

11423 S 88.22 0.00 0.00 11920 S 89.89 0.00 0.00<br />

11424 S 498.71 0.00 0.00 11921 S 98.91 0.00 0.00<br />

11426 S 609.88 0.00 0.00 11922 S 32.08 0.00 0.00<br />

11440 S 68.51 0.00 0.00 11950 S 32.75 0.00 0.00<br />

11441 S 79.20 0.00 0.00 11951 S 40.77 0.00 0.00<br />

11442 S 87.21 0.00 0.00 11952 S 49.08 0.00 0.00<br />

11443 S 96.57 0.00 0.00 11954 S 49.08 0.00 0.00<br />

11444 S 304.80 0.00 0.00 11960 S 595.35 0.00 0.00<br />

11446 S 609.88 0.00 0.00 11970 S 1,078.38 0.00 0.00<br />

11450 S 609.88 0.00 0.00 11971 S 558.84 0.00 0.00<br />

11451 S 609.88 0.00 0.00 11976 S 59.81 0.00 0.00<br />

11462 S 609.88 0.00 0.00 11980 S 24.16 0.00 0.00<br />

11463 S 609.88 0.00 0.00 11981 S 24.16 0.00 0.00<br />

11470 S 609.88 0.00 0.00 11982 S 24.16 0.00 0.00<br />

11471 S 609.88 0.00 0.00 11983 S 24.16 0.00 0.00<br />

11600 S 89.89 0.00 0.00 12001 S 49.08 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 49.08 0.00 0.00 14021 S 529.07 0.00 0.00<br />

12004 S 49.08 0.00 0.00 14040 S 500.16 0.00 0.00<br />

12005 S 65.75 0.00 0.00 14041 S 529.07 0.00 0.00<br />

12006 S 65.75 0.00 0.00 14060 S 529.07 0.00 0.00<br />

12007 S 65.75 0.00 0.00 14061 S 529.07 0.00 0.00<br />

12011 S 49.08 0.00 0.00 14300 S 678.47 0.00 0.00<br />

12013 S 49.08 0.00 0.00 14350 S 624.26 0.00 0.00<br />

12014 S 49.08 0.00 0.00 15002 S 228.87 0.00 0.00<br />

12015 S 49.08 0.00 0.00 15003 S 228.87 0.00 0.00<br />

12016 S 65.75 0.00 0.00 15004 S 228.87 0.00 0.00<br />

12017 S 65.75 0.00 0.00 15005 S 228.87 0.00 0.00<br />

12018 S 65.75 0.00 0.00 15040 S 105.56 0.00 0.00<br />

12020 S 124.06 0.00 0.00 15050 S 228.87 0.00 0.00<br />

12021 S 105.56 0.00 0.00 15100 S 595.35 0.00 0.00<br />

12031 S 49.08 0.00 0.00 15101 S 624.26 0.00 0.00<br />

12032 S 128.69 0.00 0.00 15110 S 284.31 0.00 0.00<br />

12034 S 65.75 0.00 0.00 15111 S 233.26 0.00 0.00<br />

12035 S 65.75 0.00 0.00 15115 S 284.31 0.00 0.00<br />

12036 S 105.56 0.00 0.00 15116 S 233.26 0.00 0.00<br />

12037 S 210.38 0.00 0.00 15120 S 595.35 0.00 0.00<br />

12041 S 49.08 0.00 0.00 15121 S 624.26 0.00 0.00<br />

12042 S 49.08 0.00 0.00 15130 S 500.16 0.00 0.00<br />

12044 S 65.75 0.00 0.00 15131 S 449.11 0.00 0.00<br />

12045 S 105.56 0.00 0.00 15135 S 500.16 0.00 0.00<br />

12046 S 105.56 0.00 0.00 15136 S 449.11 0.00 0.00<br />

12047 S 210.38 0.00 0.00 15150 S 284.31 0.00 0.00<br />

12051 S 49.08 0.00 0.00 15151 S 233.26 0.00 0.00<br />

12052 S 49.08 0.00 0.00 15152 S 233.26 0.00 0.00<br />

12053 S 49.08 0.00 0.00 15155 S 284.31 0.00 0.00<br />

12054 S 65.75 0.00 0.00 15156 S 233.26 0.00 0.00<br />

12055 S 105.56 0.00 0.00 15157 S 233.26 0.00 0.00<br />

12056 S 105.56 0.00 0.00 15170 S 128.69 0.00 0.00<br />

12057 S 210.38 0.00 0.00 15171 S 128.69 0.00 0.00<br />

13100 S 228.87 0.00 0.00 15175 S 165.69 0.00 0.00<br />

13101 S 228.87 0.00 0.00 15176 S 165.69 0.00 0.00<br />

13102 S 124.06 0.00 0.00 15200 S 529.07 0.00 0.00<br />

13120 S 105.56 0.00 0.00 15201 S 444.73 0.00 0.00<br />

13121 S 105.56 0.00 0.00 15220 S 500.16 0.00 0.00<br />

13122 S 105.56 0.00 0.00 15221 S 228.87 0.00 0.00<br />

13131 S 105.56 0.00 0.00 15240 S 529.07 0.00 0.00<br />

13132 S 105.56 0.00 0.00 15241 S 228.87 0.00 0.00<br />

13133 S 105.56 0.00 0.00 15260 S 500.16 0.00 0.00<br />

13150 S 228.87 0.00 0.00 15261 S 444.73 0.00 0.00<br />

13151 S 228.87 0.00 0.00 15300 S 228.87 0.00 0.00<br />

13152 S 228.87 0.00 0.00 15301 S 228.87 0.00 0.00<br />

13153 S 105.56 0.00 0.00 15320 S 228.87 0.00 0.00<br />

13160 S 595.35 0.00 0.00 15321 S 228.87 0.00 0.00<br />

14000 S 500.16 0.00 0.00 15330 S 228.87 0.00 0.00<br />

14001 S 529.07 0.00 0.00 15331 S 228.87 0.00 0.00<br />

14020 S 529.07 0.00 0.00 15335 S 228.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 228.87 0.00 0.00 15826 S 624.26 0.00 0.00<br />

15340 S 128.69 0.00 0.00 15828 S 624.26 0.00 0.00<br />

15341 S 128.69 0.00 0.00 15829 S 717.76 0.00 0.00<br />

15360 S 128.69 0.00 0.00 15830 S 638.79 0.00 0.00<br />

15361 S 128.69 0.00 0.00 15832 S 638.79 0.00 0.00<br />

15365 S 128.69 0.00 0.00 15833 S 638.79 0.00 0.00<br />

15366 S 128.69 0.00 0.00 15834 S 638.79 0.00 0.00<br />

15400 S 228.87 0.00 0.00 15835 S 554.45 0.00 0.00<br />

15401 S 228.87 0.00 0.00 15836 S 527.62 0.00 0.00<br />

15420 S 228.87 0.00 0.00 15837 S 594.50 0.00 0.00<br />

15421 S 228.87 0.00 0.00 15838 S 594.50 0.00 0.00<br />

15430 S 228.87 0.00 0.00 15839 S 527.62 0.00 0.00<br />

15431 S 228.87 0.00 0.00 15840 S 678.47 0.00 0.00<br />

15570 S 624.26 0.00 0.00 15841 S 678.47 0.00 0.00<br />

15572 S 624.26 0.00 0.00 15842 S 787.77 0.00 0.00<br />

15574 S 624.26 0.00 0.00 15845 S 678.47 0.00 0.00<br />

15576 S 624.26 0.00 0.00 15847 S 638.79 0.00 0.00<br />

15600 S 624.26 0.00 0.00 15850 S 102.04 0.00 0.00<br />

15610 S 624.26 0.00 0.00 15851 S 46.45 0.00 0.00<br />

15620 S 678.47 0.00 0.00 15852 S 24.16 0.00 0.00<br />

15630 S 624.26 0.00 0.00 15860 S 24.16 0.00 0.00<br />

15650 S 717.76 0.00 0.00 15876 S 624.26 0.00 0.00<br />

15731 S 624.26 0.00 0.00 15877 S 624.26 0.00 0.00<br />

15732 S 624.26 0.00 0.00 15878 S 624.26 0.00 0.00<br />

15734 S 624.26 0.00 0.00 15879 S 624.26 0.00 0.00<br />

15736 S 624.26 0.00 0.00 15920 S 197.31 0.00 0.00<br />

15738 S 624.26 0.00 0.00 15922 S 678.47 0.00 0.00<br />

15740 S 500.16 0.00 0.00 15931 S 638.79 0.00 0.00<br />

15750 S 595.35 0.00 0.00 15933 S 638.79 0.00 0.00<br />

15760 S 595.35 0.00 0.00 15934 S 624.26 0.00 0.00<br />

15770 S 624.26 0.00 0.00 15935 S 678.47 0.00 0.00<br />

15775 S 170.57 0.00 0.00 15936 S 583.28 0.00 0.00<br />

15776 S 170.57 0.00 0.00 15937 S 678.47 0.00 0.00<br />

15780 S 380.27 0.00 0.00 15940 S 638.79 0.00 0.00<br />

15781 S 167.38 0.00 0.00 15941 S 638.79 0.00 0.00<br />

15782 S 167.38 0.00 0.00 15944 S 624.26 0.00 0.00<br />

15783 S 102.04 0.00 0.00 15945 S 678.47 0.00 0.00<br />

15786 S 30.96 0.00 0.00 15946 S 678.47 0.00 0.00<br />

15787 S 28.07 0.00 0.00 15950 S 638.79 0.00 0.00<br />

15788 S 30.96 0.00 0.00 15951 S 692.99 0.00 0.00<br />

15789 S 56.73 0.00 0.00 15952 S 529.07 0.00 0.00<br />

15792 S 56.73 0.00 0.00 15953 S 583.28 0.00 0.00<br />

15793 S 30.96 0.00 0.00 15956 S 529.07 0.00 0.00<br />

15819 S 128.69 0.00 0.00 15958 S 583.28 0.00 0.00<br />

15820 S 624.26 0.00 0.00 16000 S 25.06 0.00 0.00<br />

15821 S 624.26 0.00 0.00 16020 S 38.10 0.00 0.00<br />

15822 S 624.26 0.00 0.00 16025 S 58.68 0.00 0.00<br />

15823 S 717.76 0.00 0.00 16030 S 73.46 0.00 0.00<br />

15824 S 624.26 0.00 0.00 16035 S 56.73 0.00 0.00<br />

15825 S 624.26 0.00 0.00 17000 S 30.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.68 0.00 0.00 19300 S 686.30 0.00 0.00<br />

17004 S 80.86 0.00 0.00 19301 S 632.10 0.00 0.00<br />

17106 S 102.04 0.00 0.00 19302 S 1,207.25 0.00 0.00<br />

17107 S 102.04 0.00 0.00 19303 S 912.35 0.00 0.00<br />

17108 S 102.04 0.00 0.00 19304 S 912.35 0.00 0.00<br />

17110 S 30.96 0.00 0.00 19316 S 912.35 0.00 0.00<br />

17111 S 56.73 0.00 0.00 19318 S 1,042.37 0.00 0.00<br />

17250 S 42.78 0.00 0.00 19324 S 1,042.37 0.00 0.00<br />

17260 S 45.78 0.00 0.00 19325 S 1,728.90 0.00 0.00<br />

17261 S 56.73 0.00 0.00 19328 S 778.20 0.00 0.00<br />

17262 S 56.73 0.00 0.00 19330 S 778.20 0.00 0.00<br />

17263 S 56.73 0.00 0.00 19340 S 959.25 0.00 0.00<br />

17264 S 56.73 0.00 0.00 19342 S 1,354.42 0.00 0.00<br />

17266 S 102.04 0.00 0.00 19350 S 686.30 0.00 0.00<br />

17270 S 56.73 0.00 0.00 19355 S 912.35 0.00 0.00<br />

17271 S 56.73 0.00 0.00 19357 S 1,447.92 0.00 0.00<br />

17272 S 56.73 0.00 0.00 19366 S 951.65 0.00 0.00<br />

17273 S 102.04 0.00 0.00 19370 S 912.35 0.00 0.00<br />

17274 S 102.04 0.00 0.00 19371 S 912.35 0.00 0.00<br />

17276 S 102.04 0.00 0.00 19380 S 1,081.67 0.00 0.00<br />

17280 S 56.73 0.00 0.00 19396 S 1,255.54 0.00 0.00<br />

17281 S 84.54 0.00 0.00 20000 S 52.83 0.00 0.00<br />

17282 S 96.57 0.00 0.00 20005 S 608.72 0.00 0.00<br />

17283 S 102.04 0.00 0.00 20103 S 597.40 0.00 0.00<br />

17284 S 102.04 0.00 0.00 20150 S 1,696.02 0.00 0.00<br />

17286 S 102.04 0.00 0.00 20200 S 498.71 0.00 0.00<br />

17311 S 168.46 0.00 0.00 20205 S 527.62 0.00 0.00<br />

17312 S 168.46 0.00 0.00 20206 S 246.55 0.00 0.00<br />

17313 S 168.46 0.00 0.00 20220 S 268.00 0.00 0.00<br />

17314 S 168.46 0.00 0.00 20225 S 486.28 0.00 0.00<br />

17315 S 38.10 0.00 0.00 20240 S 609.88 0.00 0.00<br />

17340 S 13.70 0.00 0.00 20245 S 638.79 0.00 0.00<br />

17360 S 30.96 0.00 0.00 20250 S 637.64 0.00 0.00<br />

17380 S 30.96 0.00 0.00 20251 S 637.64 0.00 0.00<br />

19000 S 64.49 0.00 0.00 20500 S 52.80 0.00 0.00<br />

19001 S 8.69 0.00 0.00 20520 S 88.89 0.00 0.00<br />

19020 S 563.97 0.00 0.00 20525 S 638.79 0.00 0.00<br />

19100 S 192.04 0.00 0.00 20526 S 28.74 0.00 0.00<br />

19101 S 603.19 0.00 0.00 20550 S 21.72 0.00 0.00<br />

19102 S 246.55 0.00 0.00 20551 S 21.38 0.00 0.00<br />

19103 S 431.53 0.00 0.00 20552 S 20.72 0.00 0.00<br />

19105 S 1,255.54 0.00 0.00 20553 S 23.06 0.00 0.00<br />

19110 S 603.19 0.00 0.00 20555 S 1,117.44 0.00 0.00<br />

19112 S 632.10 0.00 0.00 20600 S 22.05 0.00 0.00<br />

19120 S 632.10 0.00 0.00 20605 S 24.73 0.00 0.00<br />

19125 S 632.10 0.00 0.00 20610 S 34.75 0.00 0.00<br />

19126 S 632.10 0.00 0.00 20612 S 23.39 0.00 0.00<br />

19296 S 1,728.90 0.00 0.00 20615 S 97.91 0.00 0.00<br />

19297 S 1,728.90 0.00 0.00 20650 S 637.64 0.00 0.00<br />

19298 S 1,728.90 0.00 0.00 20662 S 814.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 814.51 0.00 0.00 21085 S 245.27 0.00 0.00<br />

20665 S 24.16 0.00 0.00 21086 S 533.98 0.00 0.00<br />

20670 S 447.67 0.00 0.00 21087 S 534.66 0.00 0.00<br />

20680 S 638.79 0.00 0.00 21088 S 1,565.91 0.00 0.00<br />

20690 S 760.18 0.00 0.00 21100 S 984.42 0.00 0.00<br />

20692 S 789.10 0.00 0.00 21110 S 281.70 0.00 0.00<br />

20693 S 637.64 0.00 0.00 21120 S 912.33 0.00 0.00<br />

20694 S 557.68 0.00 0.00 21121 S 912.33 0.00 0.00<br />

20696 S 1,117.44 0.00 0.00 21122 S 912.33 0.00 0.00<br />

20697 S 743.15 0.00 0.00 21123 S 912.33 0.00 0.00<br />

20822 S 1,047.06 0.00 0.00 21125 S 912.33 0.00 0.00<br />

20900 S 789.10 0.00 0.00 21127 S 1,387.80 0.00 0.00<br />

20902 S 843.30 0.00 0.00 21137 S 925.76 0.00 0.00<br />

20910 S 624.26 0.00 0.00 21138 S 1,565.91 0.00 0.00<br />

20912 S 624.26 0.00 0.00 21139 S 1,565.91 0.00 0.00<br />

20920 S 583.28 0.00 0.00 21150 S 1,565.91 0.00 0.00<br />

20922 S 529.07 0.00 0.00 21181 S 912.33 0.00 0.00<br />

20924 S 843.30 0.00 0.00 21198 S 1,565.91 0.00 0.00<br />

20926 S 367.42 0.00 0.00 21199 S 1,565.91 0.00 0.00<br />

20950 S 52.83 0.00 0.00 21206 S 1,106.83 0.00 0.00<br />

20972 S 1,768.50 0.00 0.00 21208 S 1,232.41 0.00 0.00<br />

20973 S 1,768.50 0.00 0.00 21209 S 1,106.83 0.00 0.00<br />

20979 S 21.72 0.00 0.00 21210 S 1,232.41 0.00 0.00<br />

20982 S 1,696.02 0.00 0.00 21215 S 1,232.41 0.00 0.00<br />

21010 S 664.34 0.00 0.00 21230 S 1,232.41 0.00 0.00<br />

21015 S 552.73 0.00 0.00 21235 S 912.33 0.00 0.00<br />

21025 S 984.42 0.00 0.00 21240 S 1,067.53 0.00 0.00<br />

21026 S 984.42 0.00 0.00 21242 S 1,106.83 0.00 0.00<br />

21029 S 984.42 0.00 0.00 21243 S 1,106.83 0.00 0.00<br />

21030 S 232.24 0.00 0.00 21244 S 1,232.41 0.00 0.00<br />

21031 S 192.14 0.00 0.00 21245 S 1,232.41 0.00 0.00<br />

21032 S 195.82 0.00 0.00 21246 S 1,232.41 0.00 0.00<br />

21034 S 1,013.33 0.00 0.00 21248 S 1,232.41 0.00 0.00<br />

21040 S 664.34 0.00 0.00 21249 S 1,232.41 0.00 0.00<br />

21044 S 984.42 0.00 0.00 21260 S 1,565.91 0.00 0.00<br />

21046 S 984.42 0.00 0.00 21267 S 1,232.41 0.00 0.00<br />

21047 S 984.42 0.00 0.00 21270 S 1,106.83 0.00 0.00<br />

21048 S 1,565.91 0.00 0.00 21275 S 1,232.41 0.00 0.00<br />

21050 S 1,013.33 0.00 0.00 21280 S 1,106.83 0.00 0.00<br />

21060 S 984.42 0.00 0.00 21282 S 646.23 0.00 0.00<br />

21070 S 1,013.33 0.00 0.00 21295 S 291.27 0.00 0.00<br />

21073 S 180.45 0.00 0.00 21296 S 613.30 0.00 0.00<br />

21076 S 313.10 0.00 0.00 21310 S 88.85 0.00 0.00<br />

21077 S 756.87 0.00 0.00 21315 S 390.44 0.00 0.00<br />

21079 S 542.00 0.00 0.00 21320 S 523.82 0.00 0.00<br />

21080 S 621.53 0.00 0.00 21325 S 747.45 0.00 0.00<br />

21081 S 572.74 0.00 0.00 21330 S 786.76 0.00 0.00<br />

21082 S 545.01 0.00 0.00 21335 S 912.33 0.00 0.00<br />

21083 S 536.99 0.00 0.00 21336 S 760.33 0.00 0.00<br />

21084 S 617.86 0.00 0.00 21337 S 523.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 747.45 0.00 0.00 22310 S 161.76 0.00 0.00<br />

21339 S 786.76 0.00 0.00 22315 S 418.38 0.00 0.00<br />

21340 S 1,067.53 0.00 0.00 22505 S 492.54 0.00 0.00<br />

21345 S 912.33 0.00 0.00 22520 S 1,163.56 0.00 0.00<br />

21355 S 1,013.33 0.00 0.00 22521 S 1,163.56 0.00 0.00<br />

21356 S 693.25 0.00 0.00 22522 S 1,163.56 0.00 0.00<br />

21360 S 925.76 0.00 0.00 22523 S 3,238.31 0.00 0.00<br />

21390 S 1,565.91 0.00 0.00 22524 S 3,238.31 0.00 0.00<br />

21400 S 342.31 0.00 0.00 22525 S 3,238.31 0.00 0.00<br />

21401 S 552.73 0.00 0.00 22900 S 692.99 0.00 0.00<br />

21406 S 1,565.91 0.00 0.00 23000 S 498.71 0.00 0.00<br />

21407 S 1,565.91 0.00 0.00 23020 S 1,049.47 0.00 0.00<br />

21421 S 747.45 0.00 0.00 23030 S 512.92 0.00 0.00<br />

21440 S 314.78 0.00 0.00 23031 S 592.88 0.00 0.00<br />

21445 S 747.45 0.00 0.00 23035 S 637.64 0.00 0.00<br />

21450 S 129.91 0.00 0.00 23040 S 789.10 0.00 0.00<br />

21451 S 350.51 0.00 0.00 23044 S 843.30 0.00 0.00<br />

21452 S 523.82 0.00 0.00 23065 S 94.23 0.00 0.00<br />

21453 S 1,013.33 0.00 0.00 23066 S 609.88 0.00 0.00<br />

21454 S 786.76 0.00 0.00 23075 S 498.71 0.00 0.00<br />

21461 S 1,067.53 0.00 0.00 23076 S 609.88 0.00 0.00<br />

21462 S 1,106.83 0.00 0.00 23077 S 638.79 0.00 0.00<br />

21465 S 1,067.53 0.00 0.00 23100 S 608.72 0.00 0.00<br />

21480 S 88.85 0.00 0.00 23101 S 1,008.18 0.00 0.00<br />

21485 S 523.82 0.00 0.00 23105 S 843.30 0.00 0.00<br />

21490 S 1,013.33 0.00 0.00 23106 S 843.30 0.00 0.00<br />

21495 S 644.71 0.00 0.00 23107 S 843.30 0.00 0.00<br />

21497 S 523.82 0.00 0.00 23120 S 882.60 0.00 0.00<br />

21501 S 563.97 0.00 0.00 23125 S 882.60 0.00 0.00<br />

21502 S 608.72 0.00 0.00 23130 S 1,171.88 0.00 0.00<br />

21550 S 594.50 0.00 0.00 23140 S 691.84 0.00 0.00<br />

21555 S 609.88 0.00 0.00 23145 S 882.60 0.00 0.00<br />

21556 S 609.88 0.00 0.00 23146 S 882.60 0.00 0.00<br />

21557 S 816.83 0.00 0.00 23150 S 843.30 0.00 0.00<br />

21600 S 760.18 0.00 0.00 23155 S 882.60 0.00 0.00<br />

21610 S 760.18 0.00 0.00 23156 S 882.60 0.00 0.00<br />

21685 S 281.70 0.00 0.00 23170 S 760.18 0.00 0.00<br />

21700 S 608.72 0.00 0.00 23172 S 760.18 0.00 0.00<br />

21720 S 637.64 0.00 0.00 23174 S 760.18 0.00 0.00<br />

21725 S 66.37 0.00 0.00 23180 S 843.30 0.00 0.00<br />

21800 S 76.68 0.00 0.00 23182 S 843.30 0.00 0.00<br />

21805 S 677.22 0.00 0.00 23184 S 843.30 0.00 0.00<br />

21820 S 76.68 0.00 0.00 23190 S 843.30 0.00 0.00<br />

21920 S 136.33 0.00 0.00 23195 S 882.60 0.00 0.00<br />

21925 S 609.88 0.00 0.00 23330 S 304.80 0.00 0.00<br />

21930 S 609.88 0.00 0.00 23331 S 558.84 0.00 0.00<br />

21935 S 638.79 0.00 0.00 23395 S 1,171.88 0.00 0.00<br />

22102 S 1,817.69 0.00 0.00 23397 S 2,068.62 0.00 0.00<br />

22103 S 1,817.69 0.00 0.00 23400 S 1,008.18 0.00 0.00<br />

22305 S 76.68 0.00 0.00 23405 S 760.18 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 760.18 0.00 0.00 23931 S 563.97 0.00 0.00<br />

23410 S 1,171.88 0.00 0.00 23935 S 608.72 0.00 0.00<br />

23412 S 1,297.46 0.00 0.00 24000 S 843.30 0.00 0.00<br />

23415 S 1,171.88 0.00 0.00 24006 S 843.30 0.00 0.00<br />

23420 S 1,297.46 0.00 0.00 24065 S 130.66 0.00 0.00<br />

23430 S 1,132.59 0.00 0.00 24066 S 498.71 0.00 0.00<br />

23440 S 1,132.59 0.00 0.00 24075 S 498.71 0.00 0.00<br />

23450 S 1,943.04 0.00 0.00 24076 S 609.88 0.00 0.00<br />

23455 S 2,068.62 0.00 0.00 24077 S 638.79 0.00 0.00<br />

23460 S 1,943.04 0.00 0.00 24100 S 557.68 0.00 0.00<br />

23462 S 1,297.46 0.00 0.00 24101 S 843.30 0.00 0.00<br />

23465 S 1,943.04 0.00 0.00 24102 S 843.30 0.00 0.00<br />

23466 S 1,297.46 0.00 0.00 24105 S 637.64 0.00 0.00<br />

23480 S 1,132.59 0.00 0.00 24110 S 608.72 0.00 0.00<br />

23485 S 2,068.62 0.00 0.00 24115 S 789.10 0.00 0.00<br />

23490 S 1,078.38 0.00 0.00 24116 S 789.10 0.00 0.00<br />

23491 S 1,849.53 0.00 0.00 24120 S 637.64 0.00 0.00<br />

23500 S 76.68 0.00 0.00 24125 S 789.10 0.00 0.00<br />

23505 S 418.38 0.00 0.00 24126 S 789.10 0.00 0.00<br />

23515 S 1,400.28 0.00 0.00 24130 S 789.10 0.00 0.00<br />

23520 S 161.76 0.00 0.00 24134 S 760.18 0.00 0.00<br />

23525 S 161.76 0.00 0.00 24136 S 760.18 0.00 0.00<br />

23530 S 1,031.87 0.00 0.00 24138 S 760.18 0.00 0.00<br />

23532 S 760.33 0.00 0.00 24140 S 789.10 0.00 0.00<br />

23540 S 76.68 0.00 0.00 24145 S 789.10 0.00 0.00<br />

23545 S 161.76 0.00 0.00 24147 S 760.18 0.00 0.00<br />

23550 S 1,031.87 0.00 0.00 24149 S 1,117.44 0.00 0.00<br />

23552 S 1,086.08 0.00 0.00 24152 S 1,696.02 0.00 0.00<br />

23570 S 76.68 0.00 0.00 24153 S 3,238.31 0.00 0.00<br />

23575 S 161.76 0.00 0.00 24155 S 1,078.38 0.00 0.00<br />

23585 S 1,400.28 0.00 0.00 24160 S 760.18 0.00 0.00<br />

23600 S 59.75 0.00 0.00 24164 S 789.10 0.00 0.00<br />

23605 S 418.38 0.00 0.00 24200 S 95.57 0.00 0.00<br />

23615 S 1,454.48 0.00 0.00 24201 S 498.71 0.00 0.00<br />

23616 S 1,454.48 0.00 0.00 24300 S 582.15 0.00 0.00<br />

23620 S 59.75 0.00 0.00 24301 S 843.30 0.00 0.00<br />

23625 S 418.38 0.00 0.00 24305 S 843.30 0.00 0.00<br />

23630 S 1,493.79 0.00 0.00 24310 S 637.64 0.00 0.00<br />

23650 S 76.68 0.00 0.00 24320 S 1,078.38 0.00 0.00<br />

23655 S 441.50 0.00 0.00 24330 S 1,849.53 0.00 0.00<br />

23660 S 1,031.87 0.00 0.00 24331 S 1,078.38 0.00 0.00<br />

23665 S 161.76 0.00 0.00 24332 S 814.51 0.00 0.00<br />

23670 S 1,400.28 0.00 0.00 24340 S 1,078.38 0.00 0.00<br />

23675 S 76.68 0.00 0.00 24341 S 1,078.38 0.00 0.00<br />

23680 S 1,031.87 0.00 0.00 24342 S 1,078.38 0.00 0.00<br />

23700 S 441.50 0.00 0.00 24343 S 1,117.44 0.00 0.00<br />

23800 S 1,903.74 0.00 0.00 24344 S 3,238.31 0.00 0.00<br />

23802 S 1,297.46 0.00 0.00 24345 S 760.18 0.00 0.00<br />

23921 S 444.73 0.00 0.00 24346 S 1,696.02 0.00 0.00<br />

23930 S 512.92 0.00 0.00 24357 S 1,117.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,117.44 0.00 0.00 24925 S 637.64 0.00 0.00<br />

24359 S 1,117.44 0.00 0.00 25000 S 637.64 0.00 0.00<br />

24360 S 1,031.24 0.00 0.00 25001 S 814.51 0.00 0.00<br />

24361 S 5,638.33 3,451.37 1,264.41 25020 S 637.64 0.00 0.00<br />

24362 S 1,317.92 0.00 0.00 25023 S 789.10 0.00 0.00<br />

24363 S 5,763.90 3,576.95 1,389.99 25024 S 789.10 0.00 0.00<br />

24365 S 1,031.24 0.00 0.00 25025 S 789.10 0.00 0.00<br />

24366 S 5,638.33 3,451.37 1,264.41 25028 S 557.68 0.00 0.00<br />

24400 S 843.30 0.00 0.00 25031 S 608.72 0.00 0.00<br />

24410 S 843.30 0.00 0.00 25035 S 608.72 0.00 0.00<br />

24420 S 1,078.38 0.00 0.00 25040 S 882.60 0.00 0.00<br />

24430 S 1,849.53 0.00 0.00 25065 S 132.66 0.00 0.00<br />

24435 S 1,903.74 0.00 0.00 25066 S 609.88 0.00 0.00<br />

24470 S 1,078.38 0.00 0.00 25075 S 498.71 0.00 0.00<br />

24495 S 760.18 0.00 0.00 25076 S 638.79 0.00 0.00<br />

24498 S 1,849.53 0.00 0.00 25077 S 638.79 0.00 0.00<br />

24500 S 76.68 0.00 0.00 25085 S 637.64 0.00 0.00<br />

24505 S 76.68 0.00 0.00 25100 S 608.72 0.00 0.00<br />

24515 S 1,454.48 0.00 0.00 25101 S 789.10 0.00 0.00<br />

24516 S 1,454.48 0.00 0.00 25105 S 843.30 0.00 0.00<br />

24530 S 76.68 0.00 0.00 25107 S 789.10 0.00 0.00<br />

24535 S 161.76 0.00 0.00 25109 S 814.51 0.00 0.00<br />

24538 S 677.22 0.00 0.00 25110 S 637.64 0.00 0.00<br />

24545 S 1,454.48 0.00 0.00 25111 S 637.64 0.00 0.00<br />

24546 S 1,493.79 0.00 0.00 25112 S 691.84 0.00 0.00<br />

24560 S 76.68 0.00 0.00 25115 S 691.84 0.00 0.00<br />

24565 S 76.68 0.00 0.00 25116 S 691.84 0.00 0.00<br />

24566 S 677.22 0.00 0.00 25118 S 760.18 0.00 0.00<br />

24575 S 1,400.28 0.00 0.00 25119 S 789.10 0.00 0.00<br />

24576 S 76.68 0.00 0.00 25120 S 789.10 0.00 0.00<br />

24577 S 161.76 0.00 0.00 25125 S 789.10 0.00 0.00<br />

24579 S 1,400.28 0.00 0.00 25126 S 789.10 0.00 0.00<br />

24582 S 677.22 0.00 0.00 25130 S 789.10 0.00 0.00<br />

24586 S 1,454.48 0.00 0.00 25135 S 789.10 0.00 0.00<br />

24587 S 1,493.79 0.00 0.00 25136 S 789.10 0.00 0.00<br />

24600 S 76.68 0.00 0.00 25145 S 760.18 0.00 0.00<br />

24605 S 492.54 0.00 0.00 25150 S 760.18 0.00 0.00<br />

24615 S 1,400.28 0.00 0.00 25151 S 760.18 0.00 0.00<br />

24620 S 418.38 0.00 0.00 25210 S 789.10 0.00 0.00<br />

24635 S 1,400.28 0.00 0.00 25215 S 843.30 0.00 0.00<br />

24640 S 51.79 0.00 0.00 25230 S 843.30 0.00 0.00<br />

24650 S 59.75 0.00 0.00 25240 S 843.30 0.00 0.00<br />

24655 S 161.76 0.00 0.00 25248 S 608.72 0.00 0.00<br />

24665 S 1,086.08 0.00 0.00 25250 S 709.14 0.00 0.00<br />

24666 S 1,454.48 0.00 0.00 25251 S 709.14 0.00 0.00<br />

24670 S 76.68 0.00 0.00 25259 S 743.15 0.00 0.00<br />

24675 S 76.68 0.00 0.00 25260 S 843.30 0.00 0.00<br />

24685 S 1,031.87 0.00 0.00 25263 S 760.18 0.00 0.00<br />

24800 S 1,132.59 0.00 0.00 25265 S 789.10 0.00 0.00<br />

24802 S 1,171.88 0.00 0.00 25270 S 843.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 789.10 0.00 0.00 25505 S 161.76 0.00 0.00<br />

25274 S 843.30 0.00 0.00 25515 S 1,031.87 0.00 0.00<br />

25275 S 843.30 0.00 0.00 25520 S 161.76 0.00 0.00<br />

25280 S 843.30 0.00 0.00 25525 S 1,086.08 0.00 0.00<br />

25290 S 789.10 0.00 0.00 25526 S 1,125.37 0.00 0.00<br />

25295 S 637.64 0.00 0.00 25530 S 59.75 0.00 0.00<br />

25300 S 789.10 0.00 0.00 25535 S 76.68 0.00 0.00<br />

25301 S 789.10 0.00 0.00 25545 S 1,031.87 0.00 0.00<br />

25310 S 1,078.38 0.00 0.00 25560 S 59.75 0.00 0.00<br />

25312 S 1,132.59 0.00 0.00 25565 S 161.76 0.00 0.00<br />

25315 S 1,078.38 0.00 0.00 25574 S 1,400.28 0.00 0.00<br />

25316 S 1,849.53 0.00 0.00 25575 S 1,400.28 0.00 0.00<br />

25320 S 1,078.38 0.00 0.00 25600 S 59.75 0.00 0.00<br />

25332 S 1,031.24 0.00 0.00 25605 S 161.76 0.00 0.00<br />

25335 S 1,078.38 0.00 0.00 25606 S 706.13 0.00 0.00<br />

25337 S 1,171.88 0.00 0.00 25607 S 1,493.79 0.00 0.00<br />

25350 S 1,849.53 0.00 0.00 25608 S 1,493.79 0.00 0.00<br />

25355 S 1,078.38 0.00 0.00 25609 S 1,493.79 0.00 0.00<br />

25360 S 789.10 0.00 0.00 25622 S 59.75 0.00 0.00<br />

25365 S 789.10 0.00 0.00 25624 S 161.76 0.00 0.00<br />

25370 S 1,078.38 0.00 0.00 25628 S 1,031.87 0.00 0.00<br />

25375 S 1,132.59 0.00 0.00 25630 S 59.75 0.00 0.00<br />

25390 S 789.10 0.00 0.00 25635 S 161.76 0.00 0.00<br />

25391 S 1,132.59 0.00 0.00 25645 S 1,031.87 0.00 0.00<br />

25392 S 789.10 0.00 0.00 25650 S 59.75 0.00 0.00<br />

25393 S 1,132.59 0.00 0.00 25651 S 951.51 0.00 0.00<br />

25394 S 1,696.02 0.00 0.00 25652 S 1,602.98 0.00 0.00<br />

25400 S 1,078.38 0.00 0.00 25660 S 76.68 0.00 0.00<br />

25405 S 1,903.74 0.00 0.00 25670 S 706.13 0.00 0.00<br />

25415 S 1,849.53 0.00 0.00 25671 S 626.18 0.00 0.00<br />

25420 S 1,903.74 0.00 0.00 25675 S 76.68 0.00 0.00<br />

25425 S 1,078.38 0.00 0.00 25676 S 677.22 0.00 0.00<br />

25426 S 1,132.59 0.00 0.00 25680 S 76.68 0.00 0.00<br />

25430 S 1,696.02 0.00 0.00 25685 S 706.13 0.00 0.00<br />

25431 S 1,696.02 0.00 0.00 25690 S 418.38 0.00 0.00<br />

25440 S 1,903.74 0.00 0.00 25695 S 677.22 0.00 0.00<br />

25441 S 5,638.33 3,451.37 1,264.41 25800 S 1,903.74 0.00 0.00<br />

25442 S 5,638.33 3,451.37 1,264.41 25805 S 1,171.88 0.00 0.00<br />

25443 S 1,317.92 0.00 0.00 25810 S 1,943.04 0.00 0.00<br />

25444 S 1,317.92 0.00 0.00 25820 S 1,132.59 0.00 0.00<br />

25445 S 1,317.92 0.00 0.00 25825 S 1,943.04 0.00 0.00<br />

25446 S 5,763.90 3,576.95 1,389.99 25830 S 1,943.04 0.00 0.00<br />

25447 S 1,031.24 0.00 0.00 25907 S 637.64 0.00 0.00<br />

25449 S 1,031.24 0.00 0.00 25922 S 637.64 0.00 0.00<br />

25450 S 1,078.38 0.00 0.00 25929 S 529.07 0.00 0.00<br />

25455 S 1,078.38 0.00 0.00 25931 S 814.51 0.00 0.00<br />

25490 S 1,078.38 0.00 0.00 26010 S 52.83 0.00 0.00<br />

25491 S 1,078.38 0.00 0.00 26011 S 385.92 0.00 0.00<br />

25492 S 1,078.38 0.00 0.00 26020 S 512.08 0.00 0.00<br />

25500 S 59.75 0.00 0.00 26025 S 461.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 512.08 0.00 0.00 26392 S 753.90 0.00 0.00<br />

26034 S 512.08 0.00 0.00 26410 S 540.98 0.00 0.00<br />

26035 S 621.22 0.00 0.00 26412 S 753.90 0.00 0.00<br />

26040 S 808.11 0.00 0.00 26415 S 808.11 0.00 0.00<br />

26045 S 753.90 0.00 0.00 26416 S 753.90 0.00 0.00<br />

26055 S 512.08 0.00 0.00 26418 S 595.19 0.00 0.00<br />

26060 S 512.08 0.00 0.00 26420 S 808.11 0.00 0.00<br />

26070 S 512.08 0.00 0.00 26426 S 753.90 0.00 0.00<br />

26075 S 595.19 0.00 0.00 26428 S 753.90 0.00 0.00<br />

26080 S 595.19 0.00 0.00 26432 S 540.98 0.00 0.00<br />

26100 S 512.08 0.00 0.00 26433 S 540.98 0.00 0.00<br />

26105 S 461.03 0.00 0.00 26434 S 753.90 0.00 0.00<br />

26110 S 461.03 0.00 0.00 26437 S 540.98 0.00 0.00<br />

26115 S 609.88 0.00 0.00 26440 S 540.98 0.00 0.00<br />

26116 S 609.88 0.00 0.00 26442 S 753.90 0.00 0.00<br />

26117 S 638.79 0.00 0.00 26445 S 540.98 0.00 0.00<br />

26121 S 808.11 0.00 0.00 26449 S 753.90 0.00 0.00<br />

26123 S 808.11 0.00 0.00 26450 S 540.98 0.00 0.00<br />

26125 S 595.19 0.00 0.00 26455 S 540.98 0.00 0.00<br />

26130 S 540.98 0.00 0.00 26460 S 540.98 0.00 0.00<br />

26135 S 808.11 0.00 0.00 26471 S 512.08 0.00 0.00<br />

26140 S 512.08 0.00 0.00 26474 S 512.08 0.00 0.00<br />

26145 S 540.98 0.00 0.00 26476 S 461.03 0.00 0.00<br />

26160 S 540.98 0.00 0.00 26477 S 461.03 0.00 0.00<br />

26170 S 540.98 0.00 0.00 26478 S 461.03 0.00 0.00<br />

26180 S 540.98 0.00 0.00 26479 S 461.03 0.00 0.00<br />

26185 S 595.19 0.00 0.00 26480 S 753.90 0.00 0.00<br />

26200 S 512.08 0.00 0.00 26483 S 753.90 0.00 0.00<br />

26205 S 753.90 0.00 0.00 26485 S 725.00 0.00 0.00<br />

26210 S 512.08 0.00 0.00 26489 S 753.90 0.00 0.00<br />

26215 S 540.98 0.00 0.00 26490 S 753.90 0.00 0.00<br />

26230 S 759.14 0.00 0.00 26492 S 753.90 0.00 0.00<br />

26235 S 540.98 0.00 0.00 26494 S 753.90 0.00 0.00<br />

26236 S 540.98 0.00 0.00 26496 S 753.90 0.00 0.00<br />

26250 S 540.98 0.00 0.00 26497 S 753.90 0.00 0.00<br />

26255 S 753.90 0.00 0.00 26498 S 808.11 0.00 0.00<br />

26260 S 540.98 0.00 0.00 26499 S 753.90 0.00 0.00<br />

26261 S 540.98 0.00 0.00 26500 S 595.19 0.00 0.00<br />

26262 S 512.08 0.00 0.00 26502 S 808.11 0.00 0.00<br />

26320 S 498.71 0.00 0.00 26508 S 540.98 0.00 0.00<br />

26340 S 229.90 0.00 0.00 26510 S 753.90 0.00 0.00<br />

26350 S 673.95 0.00 0.00 26516 S 673.95 0.00 0.00<br />

26352 S 808.11 0.00 0.00 26517 S 753.90 0.00 0.00<br />

26356 S 808.11 0.00 0.00 26518 S 753.90 0.00 0.00<br />

26357 S 808.11 0.00 0.00 26520 S 540.98 0.00 0.00<br />

26358 S 808.11 0.00 0.00 26525 S 540.98 0.00 0.00<br />

26370 S 808.11 0.00 0.00 26530 S 937.74 0.00 0.00<br />

26372 S 808.11 0.00 0.00 26531 S 1,443.50 0.00 0.00<br />

26373 S 753.90 0.00 0.00 26535 S 1,031.24 0.00 0.00<br />

26390 S 808.11 0.00 0.00 26536 S 1,317.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 595.19 0.00 0.00 26775 S 159.73 0.00 0.00<br />

26541 S 972.98 0.00 0.00 26776 S 677.22 0.00 0.00<br />

26542 S 595.19 0.00 0.00 26785 S 677.22 0.00 0.00<br />

26545 S 808.11 0.00 0.00 26820 S 847.40 0.00 0.00<br />

26546 S 808.11 0.00 0.00 26841 S 808.11 0.00 0.00<br />

26548 S 808.11 0.00 0.00 26842 S 808.11 0.00 0.00<br />

26550 S 725.00 0.00 0.00 26843 S 753.90 0.00 0.00<br />

26555 S 753.90 0.00 0.00 26844 S 753.90 0.00 0.00<br />

26560 S 512.08 0.00 0.00 26850 S 808.11 0.00 0.00<br />

26561 S 753.90 0.00 0.00 26852 S 808.11 0.00 0.00<br />

26562 S 808.11 0.00 0.00 26860 S 753.90 0.00 0.00<br />

26565 S 847.40 0.00 0.00 26861 S 725.00 0.00 0.00<br />

26567 S 847.40 0.00 0.00 26862 S 808.11 0.00 0.00<br />

26568 S 753.90 0.00 0.00 26863 S 753.90 0.00 0.00<br />

26580 S 634.49 0.00 0.00 26910 S 753.90 0.00 0.00<br />

26587 S 634.49 0.00 0.00 26951 S 512.08 0.00 0.00<br />

26590 S 634.49 0.00 0.00 26952 S 595.19 0.00 0.00<br />

26591 S 753.90 0.00 0.00 26990 S 557.68 0.00 0.00<br />

26593 S 540.98 0.00 0.00 26991 S 557.68 0.00 0.00<br />

26596 S 512.08 0.00 0.00 27000 S 608.72 0.00 0.00<br />

26600 S 59.75 0.00 0.00 27001 S 789.10 0.00 0.00<br />

26605 S 76.68 0.00 0.00 27003 S 789.10 0.00 0.00<br />

26607 S 418.38 0.00 0.00 27033 S 1,078.38 0.00 0.00<br />

26608 S 760.33 0.00 0.00 27035 S 1,132.59 0.00 0.00<br />

26615 S 1,086.08 0.00 0.00 27040 S 304.80 0.00 0.00<br />

26641 S 59.75 0.00 0.00 27041 S 343.42 0.00 0.00<br />

26645 S 161.76 0.00 0.00 27047 S 609.88 0.00 0.00<br />

26650 S 677.22 0.00 0.00 27048 S 638.79 0.00 0.00<br />

26665 S 1,086.08 0.00 0.00 27049 S 638.79 0.00 0.00<br />

26670 S 59.75 0.00 0.00 27050 S 637.64 0.00 0.00<br />

26675 S 161.76 0.00 0.00 27052 S 637.64 0.00 0.00<br />

26676 S 677.22 0.00 0.00 27060 S 731.14 0.00 0.00<br />

26685 S 706.13 0.00 0.00 27062 S 731.14 0.00 0.00<br />

26686 S 1,400.28 0.00 0.00 27065 S 731.14 0.00 0.00<br />

26700 S 59.75 0.00 0.00 27066 S 882.60 0.00 0.00<br />

26705 S 76.68 0.00 0.00 27067 S 882.60 0.00 0.00<br />

26706 S 418.38 0.00 0.00 27080 S 760.18 0.00 0.00<br />

26715 S 760.33 0.00 0.00 27086 S 304.80 0.00 0.00<br />

26720 S 59.75 0.00 0.00 27087 S 637.64 0.00 0.00<br />

26725 S 59.75 0.00 0.00 27097 S 789.10 0.00 0.00<br />

26727 S 925.21 0.00 0.00 27098 S 789.10 0.00 0.00<br />

26735 S 760.33 0.00 0.00 27100 S 1,132.59 0.00 0.00<br />

26740 S 59.75 0.00 0.00 27105 S 1,132.59 0.00 0.00<br />

26742 S 76.68 0.00 0.00 27110 S 1,132.59 0.00 0.00<br />

26746 S 799.63 0.00 0.00 27111 S 1,132.59 0.00 0.00<br />

26750 S 59.75 0.00 0.00 27193 S 76.68 0.00 0.00<br />

26755 S 59.75 0.00 0.00 27194 S 492.54 0.00 0.00<br />

26756 S 677.22 0.00 0.00 27200 S 59.75 0.00 0.00<br />

26765 S 760.33 0.00 0.00 27202 S 1,002.96 0.00 0.00<br />

26770 S 59.75 0.00 0.00 27220 S 59.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 76.68 0.00 0.00 27397 S 1,078.38 0.00 0.00<br />

27238 S 161.76 0.00 0.00 27400 S 1,078.38 0.00 0.00<br />

27246 S 161.76 0.00 0.00 27403 S 843.30 0.00 0.00<br />

27250 S 76.68 0.00 0.00 27405 S 1,132.59 0.00 0.00<br />

27252 S 492.54 0.00 0.00 27407 S 1,903.74 0.00 0.00<br />

27256 S 59.75 0.00 0.00 27409 S 1,132.59 0.00 0.00<br />

27257 S 521.45 0.00 0.00 27416 S 1,696.02 0.00 0.00<br />

27265 S 76.68 0.00 0.00 27418 S 1,078.38 0.00 0.00<br />

27266 S 492.54 0.00 0.00 27420 S 1,078.38 0.00 0.00<br />

27267 S 59.75 0.00 0.00 27422 S 1,297.46 0.00 0.00<br />

27275 S 492.54 0.00 0.00 27424 S 1,078.38 0.00 0.00<br />

27301 S 592.88 0.00 0.00 27425 S 1,008.18 0.00 0.00<br />

27305 S 608.72 0.00 0.00 27427 S 1,078.38 0.00 0.00<br />

27306 S 637.64 0.00 0.00 27428 S 1,903.74 0.00 0.00<br />

27307 S 637.64 0.00 0.00 27429 S 1,903.74 0.00 0.00<br />

27310 S 843.30 0.00 0.00 27430 S 1,132.59 0.00 0.00<br />

27323 S 304.80 0.00 0.00 27435 S 1,132.59 0.00 0.00<br />

27324 S 558.84 0.00 0.00 27437 S 991.94 0.00 0.00<br />

27325 S 547.58 0.00 0.00 27438 S 1,317.92 0.00 0.00<br />

27326 S 547.58 0.00 0.00 27440 S 1,414.72 0.00 0.00<br />

27327 S 609.88 0.00 0.00 27441 S 1,031.24 0.00 0.00<br />

27328 S 638.79 0.00 0.00 27442 S 1,031.24 0.00 0.00<br />

27329 S 692.99 0.00 0.00 27443 S 1,031.24 0.00 0.00<br />

27330 S 843.30 0.00 0.00 27446 S 10,118.46 6,078.71 2,038.96<br />

27331 S 843.30 0.00 0.00 27496 S 731.14 0.00 0.00<br />

27332 S 843.30 0.00 0.00 27497 S 637.64 0.00 0.00<br />

27333 S 843.30 0.00 0.00 27498 S 637.64 0.00 0.00<br />

27334 S 843.30 0.00 0.00 27499 S 637.64 0.00 0.00<br />

27335 S 843.30 0.00 0.00 27500 S 161.76 0.00 0.00<br />

27340 S 637.64 0.00 0.00 27501 S 76.68 0.00 0.00<br />

27345 S 691.84 0.00 0.00 27502 S 418.38 0.00 0.00<br />

27347 S 691.84 0.00 0.00 27503 S 76.68 0.00 0.00<br />

27350 S 843.30 0.00 0.00 27508 S 76.68 0.00 0.00<br />

27355 S 789.10 0.00 0.00 27509 S 706.13 0.00 0.00<br />

27356 S 843.30 0.00 0.00 27510 S 161.76 0.00 0.00<br />

27357 S 882.60 0.00 0.00 27516 S 76.68 0.00 0.00<br />

27358 S 882.60 0.00 0.00 27517 S 76.68 0.00 0.00<br />

27360 S 882.60 0.00 0.00 27520 S 76.68 0.00 0.00<br />

27372 S 857.87 0.00 0.00 27530 S 76.68 0.00 0.00<br />

27380 S 557.68 0.00 0.00 27532 S 418.38 0.00 0.00<br />

27381 S 637.64 0.00 0.00 27538 S 76.68 0.00 0.00<br />

27385 S 637.64 0.00 0.00 27550 S 76.68 0.00 0.00<br />

27386 S 637.64 0.00 0.00 27552 S 441.50 0.00 0.00<br />

27390 S 557.68 0.00 0.00 27560 S 76.68 0.00 0.00<br />

27391 S 608.72 0.00 0.00 27562 S 441.50 0.00 0.00<br />

27392 S 637.64 0.00 0.00 27566 S 1,002.96 0.00 0.00<br />

27393 S 760.18 0.00 0.00 27570 S 441.50 0.00 0.00<br />

27394 S 789.10 0.00 0.00 27594 S 637.64 0.00 0.00<br />

27395 S 1,078.38 0.00 0.00 27600 S 637.64 0.00 0.00<br />

27396 S 789.10 0.00 0.00 27601 S 637.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 637.64 0.00 0.00 27730 S 760.18 0.00 0.00<br />

27603 S 563.97 0.00 0.00 27732 S 760.18 0.00 0.00<br />

27604 S 608.72 0.00 0.00 27734 S 760.18 0.00 0.00<br />

27605 S 554.69 0.00 0.00 27740 S 760.18 0.00 0.00<br />

27606 S 557.68 0.00 0.00 27742 S 1,049.47 0.00 0.00<br />

27607 S 608.72 0.00 0.00 27745 S 1,849.53 0.00 0.00<br />

27610 S 760.18 0.00 0.00 27750 S 76.68 0.00 0.00<br />

27612 S 789.10 0.00 0.00 27752 S 418.38 0.00 0.00<br />

27613 S 125.31 0.00 0.00 27756 S 706.13 0.00 0.00<br />

27614 S 609.88 0.00 0.00 27758 S 1,086.08 0.00 0.00<br />

27615 S 789.10 0.00 0.00 27759 S 1,454.48 0.00 0.00<br />

27618 S 498.71 0.00 0.00 27760 S 76.68 0.00 0.00<br />

27619 S 638.79 0.00 0.00 27762 S 418.38 0.00 0.00<br />

27620 S 843.30 0.00 0.00 27766 S 1,031.87 0.00 0.00<br />

27625 S 843.30 0.00 0.00 27767 S 59.75 0.00 0.00<br />

27626 S 843.30 0.00 0.00 27768 S 59.75 0.00 0.00<br />

27630 S 637.64 0.00 0.00 27769 S 1,602.98 0.00 0.00<br />

27635 S 789.10 0.00 0.00 27780 S 76.68 0.00 0.00<br />

27637 S 789.10 0.00 0.00 27781 S 418.38 0.00 0.00<br />

27638 S 789.10 0.00 0.00 27784 S 1,031.87 0.00 0.00<br />

27640 S 1,049.47 0.00 0.00 27786 S 76.68 0.00 0.00<br />

27641 S 760.18 0.00 0.00 27788 S 76.68 0.00 0.00<br />

27647 S 1,078.38 0.00 0.00 27792 S 1,031.87 0.00 0.00<br />

27650 S 1,078.38 0.00 0.00 27808 S 76.68 0.00 0.00<br />

27652 S 1,849.53 0.00 0.00 27810 S 161.76 0.00 0.00<br />

27654 S 1,078.38 0.00 0.00 27814 S 1,031.87 0.00 0.00<br />

27656 S 608.72 0.00 0.00 27816 S 76.68 0.00 0.00<br />

27658 S 557.68 0.00 0.00 27818 S 161.76 0.00 0.00<br />

27659 S 608.72 0.00 0.00 27822 S 1,031.87 0.00 0.00<br />

27664 S 608.72 0.00 0.00 27823 S 1,400.28 0.00 0.00<br />

27665 S 760.18 0.00 0.00 27824 S 76.68 0.00 0.00<br />

27675 S 608.72 0.00 0.00 27825 S 418.38 0.00 0.00<br />

27676 S 789.10 0.00 0.00 27826 S 1,031.87 0.00 0.00<br />

27680 S 789.10 0.00 0.00 27827 S 1,400.28 0.00 0.00<br />

27681 S 760.18 0.00 0.00 27828 S 1,454.48 0.00 0.00<br />

27685 S 789.10 0.00 0.00 27829 S 1,002.96 0.00 0.00<br />

27686 S 789.10 0.00 0.00 27830 S 76.68 0.00 0.00<br />

27687 S 789.10 0.00 0.00 27831 S 418.38 0.00 0.00<br />

27690 S 1,132.59 0.00 0.00 27832 S 1,002.96 0.00 0.00<br />

27691 S 1,132.59 0.00 0.00 27840 S 161.76 0.00 0.00<br />

27692 S 1,078.38 0.00 0.00 27842 S 441.50 0.00 0.00<br />

27695 S 760.18 0.00 0.00 27846 S 1,031.87 0.00 0.00<br />

27696 S 760.18 0.00 0.00 27848 S 1,031.87 0.00 0.00<br />

27698 S 760.18 0.00 0.00 27860 S 441.50 0.00 0.00<br />

27700 S 1,031.24 0.00 0.00 27870 S 1,903.74 0.00 0.00<br />

27704 S 608.72 0.00 0.00 27871 S 1,903.74 0.00 0.00<br />

27705 S 1,049.47 0.00 0.00 27884 S 637.64 0.00 0.00<br />

27707 S 608.72 0.00 0.00 27889 S 789.10 0.00 0.00<br />

27709 S 760.18 0.00 0.00 27892 S 637.64 0.00 0.00<br />

27726 S 951.51 0.00 0.00 27893 S 637.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 637.64 0.00 0.00 28153 S 634.64 0.00 0.00<br />

28001 S 122.30 0.00 0.00 28160 S 634.64 0.00 0.00<br />

28002 S 637.64 0.00 0.00 28171 S 634.64 0.00 0.00<br />

28003 S 637.64 0.00 0.00 28173 S 634.64 0.00 0.00<br />

28005 S 634.64 0.00 0.00 28175 S 634.64 0.00 0.00<br />

28008 S 634.64 0.00 0.00 28190 S 126.31 0.00 0.00<br />

28010 S 89.89 0.00 0.00 28192 S 498.71 0.00 0.00<br />

28011 S 634.64 0.00 0.00 28193 S 343.42 0.00 0.00<br />

28020 S 605.73 0.00 0.00 28200 S 634.64 0.00 0.00<br />

28022 S 605.73 0.00 0.00 28202 S 634.64 0.00 0.00<br />

28024 S 605.73 0.00 0.00 28208 S 634.64 0.00 0.00<br />

28035 S 630.70 0.00 0.00 28210 S 1,114.63 0.00 0.00<br />

28043 S 609.88 0.00 0.00 28220 S 194.82 0.00 0.00<br />

28045 S 634.64 0.00 0.00 28222 S 554.69 0.00 0.00<br />

28046 S 634.64 0.00 0.00 28225 S 554.69 0.00 0.00<br />

28050 S 605.73 0.00 0.00 28226 S 554.69 0.00 0.00<br />

28052 S 605.73 0.00 0.00 28230 S 191.14 0.00 0.00<br />

28054 S 605.73 0.00 0.00 28232 S 182.78 0.00 0.00<br />

28055 S 630.70 0.00 0.00 28234 S 605.73 0.00 0.00<br />

28060 S 605.73 0.00 0.00 28238 S 1,114.63 0.00 0.00<br />

28062 S 634.64 0.00 0.00 28240 S 605.73 0.00 0.00<br />

28070 S 634.64 0.00 0.00 28250 S 634.64 0.00 0.00<br />

28072 S 634.64 0.00 0.00 28260 S 634.64 0.00 0.00<br />

28080 S 634.64 0.00 0.00 28261 S 634.64 0.00 0.00<br />

28086 S 605.73 0.00 0.00 28262 S 688.84 0.00 0.00<br />

28088 S 605.73 0.00 0.00 28264 S 1,034.67 0.00 0.00<br />

28090 S 634.64 0.00 0.00 28270 S 634.64 0.00 0.00<br />

28092 S 634.64 0.00 0.00 28272 S 176.43 0.00 0.00<br />

28100 S 605.73 0.00 0.00 28280 S 605.73 0.00 0.00<br />

28102 S 1,114.63 0.00 0.00 28285 S 634.64 0.00 0.00<br />

28103 S 1,114.63 0.00 0.00 28286 S 688.84 0.00 0.00<br />

28104 S 605.73 0.00 0.00 28288 S 634.64 0.00 0.00<br />

28106 S 1,114.63 0.00 0.00 28289 S 634.64 0.00 0.00<br />

28107 S 1,114.63 0.00 0.00 28290 S 782.28 0.00 0.00<br />

28108 S 605.73 0.00 0.00 28292 S 782.28 0.00 0.00<br />

28110 S 634.64 0.00 0.00 28293 S 811.19 0.00 0.00<br />

28111 S 634.64 0.00 0.00 28294 S 811.19 0.00 0.00<br />

28112 S 634.64 0.00 0.00 28296 S 811.19 0.00 0.00<br />

28113 S 634.64 0.00 0.00 28297 S 811.19 0.00 0.00<br />

28114 S 634.64 0.00 0.00 28298 S 811.19 0.00 0.00<br />

28116 S 634.64 0.00 0.00 28299 S 904.69 0.00 0.00<br />

28118 S 688.84 0.00 0.00 28300 S 1,085.72 0.00 0.00<br />

28119 S 688.84 0.00 0.00 28302 S 605.73 0.00 0.00<br />

28120 S 853.72 0.00 0.00 28304 S 1,085.72 0.00 0.00<br />

28122 S 634.64 0.00 0.00 28305 S 1,114.63 0.00 0.00<br />

28124 S 206.84 0.00 0.00 28306 S 688.84 0.00 0.00<br />

28126 S 634.64 0.00 0.00 28307 S 688.84 0.00 0.00<br />

28130 S 634.64 0.00 0.00 28308 S 605.73 0.00 0.00<br />

28140 S 634.64 0.00 0.00 28309 S 1,168.84 0.00 0.00<br />

28150 S 634.64 0.00 0.00 28310 S 634.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 634.64 0.00 0.00 28636 S 706.13 0.00 0.00<br />

28313 S 605.73 0.00 0.00 28645 S 706.13 0.00 0.00<br />

28315 S 688.84 0.00 0.00 28660 S 42.78 0.00 0.00<br />

28320 S 1,168.84 0.00 0.00 28665 S 441.50 0.00 0.00<br />

28322 S 1,168.84 0.00 0.00 28666 S 706.13 0.00 0.00<br />

28340 S 688.84 0.00 0.00 28675 S 706.13 0.00 0.00<br />

28341 S 688.84 0.00 0.00 28705 S 1,168.84 0.00 0.00<br />

28344 S 688.84 0.00 0.00 28715 S 1,903.74 0.00 0.00<br />

28345 S 688.84 0.00 0.00 28725 S 1,168.84 0.00 0.00<br />

28400 S 76.68 0.00 0.00 28730 S 1,168.84 0.00 0.00<br />

28405 S 418.38 0.00 0.00 28735 S 1,168.84 0.00 0.00<br />

28406 S 677.22 0.00 0.00 28737 S 1,208.13 0.00 0.00<br />

28415 S 1,400.28 0.00 0.00 28740 S 1,168.84 0.00 0.00<br />

28420 S 1,086.08 0.00 0.00 28750 S 1,168.84 0.00 0.00<br />

28430 S 59.75 0.00 0.00 28755 S 688.84 0.00 0.00<br />

28435 S 76.68 0.00 0.00 28760 S 1,168.84 0.00 0.00<br />

28436 S 677.22 0.00 0.00 28810 S 605.73 0.00 0.00<br />

28445 S 1,031.87 0.00 0.00 28820 S 605.73 0.00 0.00<br />

28446 S 1,768.50 0.00 0.00 28825 S 605.73 0.00 0.00<br />

28450 S 59.75 0.00 0.00 28890 S 160.06 0.00 0.00<br />

28455 S 59.75 0.00 0.00 29000 S 40.55 0.00 0.00<br />

28456 S 677.22 0.00 0.00 29010 S 90.89 0.00 0.00<br />

28465 S 1,031.87 0.00 0.00 29015 S 90.89 0.00 0.00<br />

28470 S 59.75 0.00 0.00 29020 S 40.55 0.00 0.00<br />

28475 S 59.75 0.00 0.00 29025 S 40.55 0.00 0.00<br />

28476 S 677.22 0.00 0.00 29035 S 90.89 0.00 0.00<br />

28485 S 1,086.08 0.00 0.00 29040 S 40.55 0.00 0.00<br />

28490 S 59.75 0.00 0.00 29044 S 90.89 0.00 0.00<br />

28495 S 59.75 0.00 0.00 29046 S 90.89 0.00 0.00<br />

28496 S 677.22 0.00 0.00 29049 S 36.75 0.00 0.00<br />

28505 S 706.13 0.00 0.00 29055 S 90.89 0.00 0.00<br />

28510 S 53.80 0.00 0.00 29058 S 40.55 0.00 0.00<br />

28515 S 59.75 0.00 0.00 29065 S 43.11 0.00 0.00<br />

28525 S 706.13 0.00 0.00 29075 S 41.43 0.00 0.00<br />

28530 S 51.79 0.00 0.00 29085 S 40.55 0.00 0.00<br />

28531 S 706.13 0.00 0.00 29086 S 34.75 0.00 0.00<br />

28540 S 59.75 0.00 0.00 29105 S 37.42 0.00 0.00<br />

28545 S 626.18 0.00 0.00 29125 S 32.41 0.00 0.00<br />

28546 S 677.22 0.00 0.00 29126 S 34.42 0.00 0.00<br />

28555 S 1,002.96 0.00 0.00 29130 S 14.70 0.00 0.00<br />

28570 S 77.52 0.00 0.00 29131 S 21.38 0.00 0.00<br />

28575 S 418.38 0.00 0.00 29200 S 20.72 0.00 0.00<br />

28576 S 706.13 0.00 0.00 29220 S 22.38 0.00 0.00<br />

28585 S 706.13 0.00 0.00 29240 S 23.39 0.00 0.00<br />

28600 S 59.75 0.00 0.00 29260 S 22.38 0.00 0.00<br />

28605 S 76.68 0.00 0.00 29280 S 22.73 0.00 0.00<br />

28606 S 677.22 0.00 0.00 29305 S 90.89 0.00 0.00<br />

28615 S 1,031.87 0.00 0.00 29325 S 90.89 0.00 0.00<br />

28630 S 59.75 0.00 0.00 29345 S 56.47 0.00 0.00<br />

28635 S 441.50 0.00 0.00 29355 S 55.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 68.84 0.00 0.00 29847 S 1,150.59 0.00 0.00<br />

29365 S 53.47 0.00 0.00 29848 S 1,154.84 0.00 0.00<br />

29405 S 39.77 0.00 0.00 29850 S 834.57 0.00 0.00<br />

29425 S 40.43 0.00 0.00 29851 S 1,204.80 0.00 0.00<br />

29435 S 51.12 0.00 0.00 29855 S 1,204.80 0.00 0.00<br />

29440 S 21.72 0.00 0.00 29856 S 1,204.80 0.00 0.00<br />

29445 S 53.80 0.00 0.00 29860 S 1,204.80 0.00 0.00<br />

29450 S 40.55 0.00 0.00 29861 S 1,204.80 0.00 0.00<br />

29505 S 36.09 0.00 0.00 29862 S 1,525.07 0.00 0.00<br />

29515 S 30.74 0.00 0.00 29863 S 1,204.80 0.00 0.00<br />

29520 S 22.05 0.00 0.00 29866 S 1,840.44 0.00 0.00<br />

29530 S 22.38 0.00 0.00 29870 S 780.37 0.00 0.00<br />

29540 S 16.70 0.00 0.00 29871 S 780.37 0.00 0.00<br />

29550 S 17.04 0.00 0.00 29873 S 780.37 0.00 0.00<br />

29580 S 23.06 0.00 0.00 29874 S 780.37 0.00 0.00<br />

29590 S 18.72 0.00 0.00 29875 S 834.57 0.00 0.00<br />

29700 S 31.07 0.00 0.00 29876 S 834.57 0.00 0.00<br />

29705 S 26.40 0.00 0.00 29877 S 834.57 0.00 0.00<br />

29710 S 46.45 0.00 0.00 29879 S 780.37 0.00 0.00<br />

29715 S 40.55 0.00 0.00 29880 S 834.57 0.00 0.00<br />

29720 S 38.76 0.00 0.00 29881 S 834.57 0.00 0.00<br />

29730 S 25.40 0.00 0.00 29882 S 780.37 0.00 0.00<br />

29740 S 34.75 0.00 0.00 29883 S 780.37 0.00 0.00<br />

29750 S 36.42 0.00 0.00 29884 S 780.37 0.00 0.00<br />

29800 S 780.37 0.00 0.00 29885 S 1,150.59 0.00 0.00<br />

29804 S 780.37 0.00 0.00 29886 S 780.37 0.00 0.00<br />

29805 S 780.37 0.00 0.00 29887 S 780.37 0.00 0.00<br />

29806 S 1,150.59 0.00 0.00 29888 S 1,150.59 0.00 0.00<br />

29807 S 1,150.59 0.00 0.00 29889 S 1,150.59 0.00 0.00<br />

29819 S 1,150.59 0.00 0.00 29891 S 1,150.59 0.00 0.00<br />

29820 S 1,150.59 0.00 0.00 29892 S 1,150.59 0.00 0.00<br />

29821 S 1,150.59 0.00 0.00 29893 S 971.42 0.00 0.00<br />

29822 S 780.37 0.00 0.00 29894 S 780.37 0.00 0.00<br />

29823 S 1,150.59 0.00 0.00 29895 S 780.37 0.00 0.00<br />

29824 S 873.87 0.00 0.00 29897 S 780.37 0.00 0.00<br />

29825 S 1,150.59 0.00 0.00 29898 S 780.37 0.00 0.00<br />

29826 S 1,150.59 0.00 0.00 29899 S 1,150.59 0.00 0.00<br />

29827 S 1,244.09 0.00 0.00 29900 S 780.37 0.00 0.00<br />

29828 S 1,840.44 0.00 0.00 29901 S 780.37 0.00 0.00<br />

29830 S 780.37 0.00 0.00 29902 S 780.37 0.00 0.00<br />

29834 S 780.37 0.00 0.00 29904 S 1,099.99 0.00 0.00<br />

29835 S 780.37 0.00 0.00 29905 S 1,099.99 0.00 0.00<br />

29836 S 780.37 0.00 0.00 29906 S 1,099.99 0.00 0.00<br />

29837 S 780.37 0.00 0.00 29907 S 1,840.44 0.00 0.00<br />

29838 S 780.37 0.00 0.00 30000 S 123.67 0.00 0.00<br />

29840 S 780.37 0.00 0.00 30020 S 123.67 0.00 0.00<br />

29843 S 780.37 0.00 0.00 30100 S 80.20 0.00 0.00<br />

29844 S 780.37 0.00 0.00 30110 S 123.97 0.00 0.00<br />

29845 S 780.37 0.00 0.00 30115 S 523.82 0.00 0.00<br />

29846 S 780.37 0.00 0.00 30117 S 552.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 693.25 0.00 0.00 31080 S 1,067.53 0.00 0.00<br />

30120 S 472.77 0.00 0.00 31081 S 1,067.53 0.00 0.00<br />

30124 S 281.70 0.00 0.00 31084 S 1,067.53 0.00 0.00<br />

30125 S 984.42 0.00 0.00 31085 S 1,067.53 0.00 0.00<br />

30130 S 552.73 0.00 0.00 31086 S 1,067.53 0.00 0.00<br />

30140 S 664.34 0.00 0.00 31087 S 1,067.53 0.00 0.00<br />

30150 S 1,013.33 0.00 0.00 31090 S 1,106.83 0.00 0.00<br />

30160 S 1,067.53 0.00 0.00 31200 S 984.42 0.00 0.00<br />

30200 S 63.16 0.00 0.00 31201 S 1,106.83 0.00 0.00<br />

30210 S 80.20 0.00 0.00 31205 S 1,013.33 0.00 0.00<br />

30220 S 350.51 0.00 0.00 31231 S 67.61 0.00 0.00<br />

30300 S 24.16 0.00 0.00 31233 S 72.82 0.00 0.00<br />

30310 S 472.77 0.00 0.00 31235 S 494.76 0.00 0.00<br />

30320 S 523.82 0.00 0.00 31237 S 545.80 0.00 0.00<br />

30400 S 1,067.53 0.00 0.00 31238 S 494.76 0.00 0.00<br />

30410 S 1,106.83 0.00 0.00 31239 S 722.20 0.00 0.00<br />

30420 S 1,106.83 0.00 0.00 31240 S 545.80 0.00 0.00<br />

30430 S 693.25 0.00 0.00 31254 S 667.99 0.00 0.00<br />

30435 S 1,106.83 0.00 0.00 31255 S 761.49 0.00 0.00<br />

30450 S 1,232.41 0.00 0.00 31256 S 667.99 0.00 0.00<br />

30460 S 1,232.41 0.00 0.00 31267 S 667.99 0.00 0.00<br />

30462 S 1,387.80 0.00 0.00 31276 S 667.99 0.00 0.00<br />

30465 S 1,387.80 0.00 0.00 31287 S 667.99 0.00 0.00<br />

30520 S 747.45 0.00 0.00 31288 S 667.99 0.00 0.00<br />

30540 S 1,106.83 0.00 0.00 31300 S 786.76 0.00 0.00<br />

30545 S 1,106.83 0.00 0.00 31320 S 984.42 0.00 0.00<br />

30560 S 129.91 0.00 0.00 31400 S 984.42 0.00 0.00<br />

30580 S 1,067.53 0.00 0.00 31420 S 984.42 0.00 0.00<br />

30600 S 1,067.53 0.00 0.00 31500 S 90.43 0.00 0.00<br />

30620 S 1,232.41 0.00 0.00 31502 S 52.00 0.00 0.00<br />

30630 S 912.33 0.00 0.00 31505 S 30.72 0.00 0.00<br />

30801 S 291.27 0.00 0.00 31510 S 545.80 0.00 0.00<br />

30802 S 291.27 0.00 0.00 31511 S 72.82 0.00 0.00<br />

30901 S 41.54 0.00 0.00 31512 S 545.80 0.00 0.00<br />

30903 S 53.51 0.00 0.00 31513 S 72.82 0.00 0.00<br />

30905 S 53.51 0.00 0.00 31515 S 494.76 0.00 0.00<br />

30906 S 53.51 0.00 0.00 31520 S 67.61 0.00 0.00<br />

30915 S 713.06 0.00 0.00 31525 S 494.76 0.00 0.00<br />

30920 S 741.98 0.00 0.00 31526 S 639.08 0.00 0.00<br />

30930 S 606.93 0.00 0.00 31527 S 588.03 0.00 0.00<br />

31000 S 103.26 0.00 0.00 31528 S 545.80 0.00 0.00<br />

31002 S 281.70 0.00 0.00 31529 S 545.80 0.00 0.00<br />

31020 S 664.34 0.00 0.00 31530 S 639.08 0.00 0.00<br />

31030 S 1,013.33 0.00 0.00 31531 S 667.99 0.00 0.00<br />

31032 S 1,067.53 0.00 0.00 31535 S 639.08 0.00 0.00<br />

31040 S 925.76 0.00 0.00 31536 S 667.99 0.00 0.00<br />

31050 S 984.42 0.00 0.00 31540 S 667.99 0.00 0.00<br />

31051 S 1,067.53 0.00 0.00 31541 S 722.20 0.00 0.00<br />

31070 S 664.34 0.00 0.00 31545 S 722.20 0.00 0.00<br />

31075 S 1,067.53 0.00 0.00 31546 S 722.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 761.49 0.00 0.00 32405 S 329.52 0.00 0.00<br />

31561 S 761.49 0.00 0.00 32420 S 200.37 0.00 0.00<br />

31570 S 545.80 0.00 0.00 32421 S 200.37 0.00 0.00<br />

31571 S 639.08 0.00 0.00 32422 S 199.48 0.00 0.00<br />

31575 S 58.15 0.00 0.00 32550 S 1,116.90 0.00 0.00<br />

31576 S 639.08 0.00 0.00 32960 S 199.48 0.00 0.00<br />

31577 S 188.78 0.00 0.00 32998 S 1,738.95 0.00 0.00<br />

31578 S 639.08 0.00 0.00 33010 S 200.37 0.00 0.00<br />

31579 S 103.59 0.00 0.00 33011 S 200.37 0.00 0.00<br />

31580 S 1,106.83 0.00 0.00 33206 S 6,428.76 3,825.09 1,221.43<br />

31582 S 1,106.83 0.00 0.00 33207 S 6,428.76 3,825.09 1,221.43<br />

31588 S 1,106.83 0.00 0.00 33208 S 7,973.49 4,646.11 1,318.74<br />

31590 S 1,106.83 0.00 0.00 33210 S 1,887.83 0.00 0.00<br />

31595 S 984.42 0.00 0.00 33211 S 1,887.83 0.00 0.00<br />

31603 S 291.27 0.00 0.00 33212 S 5,048.87 2,876.12 703.38<br />

31605 S 281.70 0.00 0.00 33213 S 5,827.48 3,265.01 702.55<br />

31611 S 693.25 0.00 0.00 33214 S 7,973.49 4,646.11 1,318.74<br />

31612 S 613.30 0.00 0.00 33215 S 827.46 0.00 0.00<br />

31613 S 664.34 0.00 0.00 33216 S 1,887.83 0.00 0.00<br />

31614 S 984.42 0.00 0.00 33217 S 1,887.83 0.00 0.00<br />

31615 S 291.27 0.00 0.00 33218 S 827.46 0.00 0.00<br />

31622 S 341.13 0.00 0.00 33220 S 827.46 0.00 0.00<br />

31623 S 392.17 0.00 0.00 33222 S 500.16 0.00 0.00<br />

31624 S 392.17 0.00 0.00 33223 S 500.16 0.00 0.00<br />

31625 S 392.17 0.00 0.00 33224 S 7,526.23 4,505.93 1,485.64<br />

31628 S 392.17 0.00 0.00 33225 S 7,526.23 4,505.93 1,485.64<br />

31629 S 392.17 0.00 0.00 33226 S 827.46 0.00 0.00<br />

31630 S 672.02 0.00 0.00 33233 S 615.20 0.00 0.00<br />

31631 S 672.02 0.00 0.00 33234 S 827.46 0.00 0.00<br />

31632 S 381.41 0.00 0.00 33235 S 827.46 0.00 0.00<br />

31633 S 381.41 0.00 0.00 33240 S 18,760.97 10,028.50 1,296.04<br />

31635 S 392.17 0.00 0.00 33241 S 827.46 0.00 0.00<br />

31636 S 672.02 0.00 0.00 33249 S 25,037.94 13,411.36 1,784.77<br />

31637 S 341.13 0.00 0.00 33282 S 3,958.66 2,369.89 781.11<br />

31638 S 672.02 0.00 0.00 33284 S 308.77 0.00 0.00<br />

31640 S 672.02 0.00 0.00 34490 S 1,507.48 0.00 0.00<br />

31641 S 672.02 0.00 0.00 35188 S 1,038.32 0.00 0.00<br />

31643 S 392.17 0.00 0.00 35207 S 1,038.32 0.00 0.00<br />

31645 S 341.13 0.00 0.00 35473 S 1,808.40 0.00 0.00<br />

31646 S 341.13 0.00 0.00 35476 S 1,808.40 0.00 0.00<br />

31656 S 341.13 0.00 0.00 35492 S 3,375.19 0.00 0.00<br />

31717 S 188.78 0.00 0.00 35761 S 1,085.76 0.00 0.00<br />

31720 S 28.91 0.00 0.00 35875 S 1,358.58 0.00 0.00<br />

31730 S 188.78 0.00 0.00 35876 S 1,358.58 0.00 0.00<br />

31750 S 1,106.83 0.00 0.00 36002 S 86.71 0.00 0.00<br />

31755 S 984.42 0.00 0.00 36260 S 786.59 0.00 0.00<br />

31820 S 472.77 0.00 0.00 36261 S 615.20 0.00 0.00<br />

31825 S 664.34 0.00 0.00 36262 S 564.15 0.00 0.00<br />

31830 S 664.34 0.00 0.00 36420 S 8.17 0.00 0.00<br />

32400 S 329.52 0.00 0.00 36425 S 8.17 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 31.41 0.00 0.00 36800 S 846.77 0.00 0.00<br />

36440 S 125.44 0.00 0.00 36810 S 846.77 0.00 0.00<br />

36450 S 125.44 0.00 0.00 36815 S 846.77 0.00 0.00<br />

36455 S 125.44 0.00 0.00 36818 S 984.12 0.00 0.00<br />

36468 S 30.96 0.00 0.00 36819 S 984.12 0.00 0.00<br />

36469 S 30.96 0.00 0.00 36820 S 984.12 0.00 0.00<br />

36470 S 30.96 0.00 0.00 36821 S 984.12 0.00 0.00<br />

36471 S 30.96 0.00 0.00 36825 S 1,038.32 0.00 0.00<br />

36475 S 1,423.66 0.00 0.00 36830 S 1,038.32 0.00 0.00<br />

36476 S 1,116.44 0.00 0.00 36831 S 1,358.58 0.00 0.00<br />

36478 S 1,116.44 0.00 0.00 36832 S 1,038.32 0.00 0.00<br />

36479 S 1,116.44 0.00 0.00 36833 S 1,038.32 0.00 0.00<br />

36511 S 430.06 0.00 0.00 36834 S 984.12 0.00 0.00<br />

36512 S 430.06 0.00 0.00 36835 S 900.97 0.00 0.00<br />

36513 S 430.06 0.00 0.00 36860 S 103.41 0.00 0.00<br />

36514 S 430.06 0.00 0.00 36861 S 846.77 0.00 0.00<br />

36515 S 1,151.28 0.00 0.00 36870 S 1,480.86 0.00 0.00<br />

36516 S 1,151.28 0.00 0.00 37184 S 1,507.48 0.00 0.00<br />

36522 S 1,151.28 0.00 0.00 37185 S 1,507.48 0.00 0.00<br />

36555 S 357.32 0.00 0.00 37186 S 1,507.48 0.00 0.00<br />

36556 S 357.32 0.00 0.00 37187 S 1,507.48 0.00 0.00<br />

36557 S 667.33 0.00 0.00 37188 S 1,507.48 0.00 0.00<br />

36558 S 667.33 0.00 0.00 37200 S 1,112.43 0.00 0.00<br />

36560 S 786.59 0.00 0.00 37203 S 1,112.43 0.00 0.00<br />

36561 S 786.59 0.00 0.00 37500 S 1,049.20 0.00 0.00<br />

36563 S 786.59 0.00 0.00 37607 S 741.98 0.00 0.00<br />

36565 S 786.59 0.00 0.00 37609 S 498.71 0.00 0.00<br />

36566 S 786.59 0.00 0.00 37650 S 713.06 0.00 0.00<br />

36568 S 357.32 0.00 0.00 37700 S 713.06 0.00 0.00<br />

36569 S 357.32 0.00 0.00 37718 S 741.98 0.00 0.00<br />

36570 S 696.24 0.00 0.00 37722 S 1,049.20 0.00 0.00<br />

36571 S 696.24 0.00 0.00 37735 S 1,049.20 0.00 0.00<br />

36575 S 287.39 0.00 0.00 37760 S 741.98 0.00 0.00<br />

36576 S 408.36 0.00 0.00 37765 S 1,023.20 0.00 0.00<br />

36578 S 667.33 0.00 0.00 37766 S 1,023.20 0.00 0.00<br />

36580 S 357.32 0.00 0.00 37780 S 741.98 0.00 0.00<br />

36581 S 667.33 0.00 0.00 37785 S 741.98 0.00 0.00<br />

36582 S 786.59 0.00 0.00 37790 S 895.34 0.00 0.00<br />

36583 S 786.59 0.00 0.00 38205 S 430.06 0.00 0.00<br />

36584 S 357.32 0.00 0.00 38206 S 430.06 0.00 0.00<br />

36585 S 696.24 0.00 0.00 38220 S 98.58 0.00 0.00<br />

36589 S 236.35 0.00 0.00 38221 S 103.26 0.00 0.00<br />

36590 S 357.32 0.00 0.00 38230 S 1,151.28 0.00 0.00<br />

36593 S 23.73 0.00 0.00 38241 S 1,151.28 0.00 0.00<br />

36595 S 931.73 0.00 0.00 38242 S 430.06 0.00 0.00<br />

36596 S 413.79 0.00 0.00 38300 S 385.92 0.00 0.00<br />

36597 S 413.79 0.00 0.00 38305 S 563.97 0.00 0.00<br />

36598 S 76.52 0.00 0.00 38308 S 644.41 0.00 0.00<br />

36640 S 706.63 0.00 0.00 38500 S 644.41 0.00 0.00<br />

36680 S 53.56 0.00 0.00 38505 S 246.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 644.41 0.00 0.00 41005 S 129.91 0.00 0.00<br />

38520 S 644.41 0.00 0.00 41006 S 613.30 0.00 0.00<br />

38525 S 644.41 0.00 0.00 41007 S 472.77 0.00 0.00<br />

38530 S 644.41 0.00 0.00 41008 S 472.77 0.00 0.00<br />

38542 S 1,084.13 0.00 0.00 41009 S 129.91 0.00 0.00<br />

38550 S 673.32 0.00 0.00 41010 S 291.27 0.00 0.00<br />

38555 S 727.52 0.00 0.00 41015 S 129.91 0.00 0.00<br />

38570 S 1,470.99 0.00 0.00 41016 S 291.27 0.00 0.00<br />

38571 S 1,912.26 0.00 0.00 41017 S 291.27 0.00 0.00<br />

38572 S 1,470.99 0.00 0.00 41018 S 291.27 0.00 0.00<br />

38700 S 885.89 0.00 0.00 41019 S 925.76 0.00 0.00<br />

38740 S 1,084.13 0.00 0.00 41100 S 87.21 0.00 0.00<br />

38745 S 1,167.24 0.00 0.00 41105 S 86.21 0.00 0.00<br />

38760 S 644.41 0.00 0.00 41108 S 79.86 0.00 0.00<br />

40490 S 65.83 0.00 0.00 41110 S 115.62 0.00 0.00<br />

40500 S 523.82 0.00 0.00 41112 S 523.82 0.00 0.00<br />

40510 S 664.34 0.00 0.00 41113 S 523.82 0.00 0.00<br />

40520 S 523.82 0.00 0.00 41114 S 664.34 0.00 0.00<br />

40525 S 664.34 0.00 0.00 41115 S 134.67 0.00 0.00<br />

40527 S 664.34 0.00 0.00 41116 S 472.77 0.00 0.00<br />

40530 S 664.34 0.00 0.00 41120 S 786.76 0.00 0.00<br />

40650 S 350.51 0.00 0.00 41250 S 88.85 0.00 0.00<br />

40652 S 350.51 0.00 0.00 41251 S 129.91 0.00 0.00<br />

40654 S 350.51 0.00 0.00 41252 S 342.31 0.00 0.00<br />

40700 S 1,232.41 0.00 0.00 41500 S 613.30 0.00 0.00<br />

40701 S 1,232.41 0.00 0.00 41510 S 472.77 0.00 0.00<br />

40702 S 1,565.91 0.00 0.00 41520 S 342.31 0.00 0.00<br />

40720 S 1,232.41 0.00 0.00 41530 S 644.71 0.00 0.00<br />

40761 S 1,013.33 0.00 0.00 41800 S 66.37 0.00 0.00<br />

40800 S 52.83 0.00 0.00 41805 S 143.69 0.00 0.00<br />

40801 S 342.31 0.00 0.00 41806 S 177.10 0.00 0.00<br />

40804 S 24.16 0.00 0.00 41820 S 281.70 0.00 0.00<br />

40805 S 163.41 0.00 0.00 41821 S 281.70 0.00 0.00<br />

40806 S 75.19 0.00 0.00 41822 S 146.69 0.00 0.00<br />

40808 S 111.61 0.00 0.00 41823 S 213.86 0.00 0.00<br />

40810 S 115.62 0.00 0.00 41825 S 117.62 0.00 0.00<br />

40812 S 145.03 0.00 0.00 41826 S 148.04 0.00 0.00<br />

40814 S 523.82 0.00 0.00 41827 S 664.34 0.00 0.00<br />

40816 S 664.34 0.00 0.00 41828 S 133.67 0.00 0.00<br />

40818 S 129.91 0.00 0.00 41830 S 189.80 0.00 0.00<br />

40819 S 291.27 0.00 0.00 41850 S 644.71 0.00 0.00<br />

40820 S 166.74 0.00 0.00 41870 S 925.76 0.00 0.00<br />

40830 S 123.67 0.00 0.00 41872 S 189.80 0.00 0.00<br />

40831 S 291.27 0.00 0.00 41874 S 183.11 0.00 0.00<br />

40840 S 664.34 0.00 0.00 42000 S 129.91 0.00 0.00<br />

40842 S 693.25 0.00 0.00 42100 S 74.18 0.00 0.00<br />

40843 S 693.25 0.00 0.00 42104 S 110.27 0.00 0.00<br />

40844 S 1,106.83 0.00 0.00 42106 S 138.34 0.00 0.00<br />

40845 S 1,106.83 0.00 0.00 42107 S 664.34 0.00 0.00<br />

41000 S 82.88 0.00 0.00 42120 S 1,067.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 342.31 0.00 0.00 42809 S 24.16 0.00 0.00<br />

42145 S 786.76 0.00 0.00 42810 S 693.25 0.00 0.00<br />

42160 S 130.99 0.00 0.00 42815 S 1,106.83 0.00 0.00<br />

42180 S 129.91 0.00 0.00 42820 S 693.25 0.00 0.00<br />

42182 S 984.42 0.00 0.00 42821 S 786.76 0.00 0.00<br />

42200 S 1,106.83 0.00 0.00 42825 S 747.45 0.00 0.00<br />

42205 S 1,106.83 0.00 0.00 42826 S 747.45 0.00 0.00<br />

42210 S 1,106.83 0.00 0.00 42830 S 747.45 0.00 0.00<br />

42215 S 1,232.41 0.00 0.00 42831 S 747.45 0.00 0.00<br />

42220 S 1,106.83 0.00 0.00 42835 S 747.45 0.00 0.00<br />

42226 S 1,106.83 0.00 0.00 42836 S 747.45 0.00 0.00<br />

42235 S 646.23 0.00 0.00 42860 S 693.25 0.00 0.00<br />

42260 S 747.45 0.00 0.00 42870 S 693.25 0.00 0.00<br />

42280 S 72.17 0.00 0.00 42890 S 1,232.41 0.00 0.00<br />

42281 S 644.71 0.00 0.00 42892 S 1,232.41 0.00 0.00<br />

42300 S 472.77 0.00 0.00 42900 S 291.27 0.00 0.00<br />

42305 S 523.82 0.00 0.00 42950 S 664.34 0.00 0.00<br />

42310 S 129.91 0.00 0.00 42955 S 664.34 0.00 0.00<br />

42320 S 129.91 0.00 0.00 42960 S 53.51 0.00 0.00<br />

42330 S 111.61 0.00 0.00 42962 S 984.42 0.00 0.00<br />

42335 S 185.12 0.00 0.00 42970 S 41.54 0.00 0.00<br />

42340 S 523.82 0.00 0.00 42972 S 552.73 0.00 0.00<br />

42400 S 62.83 0.00 0.00 43030 S 644.71 0.00 0.00<br />

42405 S 523.82 0.00 0.00 43200 S 312.20 0.00 0.00<br />

42408 S 552.73 0.00 0.00 43201 S 312.20 0.00 0.00<br />

42409 S 552.73 0.00 0.00 43202 S 312.20 0.00 0.00<br />

42410 S 1,013.33 0.00 0.00 43204 S 312.20 0.00 0.00<br />

42415 S 1,232.41 0.00 0.00 43205 S 312.20 0.00 0.00<br />

42420 S 1,232.41 0.00 0.00 43215 S 312.20 0.00 0.00<br />

42425 S 1,232.41 0.00 0.00 43216 S 312.20 0.00 0.00<br />

42440 S 1,013.33 0.00 0.00 43217 S 312.20 0.00 0.00<br />

42450 S 664.34 0.00 0.00 43219 S 630.97 0.00 0.00<br />

42500 S 693.25 0.00 0.00 43220 S 312.20 0.00 0.00<br />

42505 S 1,067.53 0.00 0.00 43226 S 312.20 0.00 0.00<br />

42507 S 1,013.33 0.00 0.00 43227 S 363.25 0.00 0.00<br />

42508 S 1,067.53 0.00 0.00 43228 S 675.98 0.00 0.00<br />

42509 S 1,067.53 0.00 0.00 43231 S 363.25 0.00 0.00<br />

42510 S 1,067.53 0.00 0.00 43232 S 363.25 0.00 0.00<br />

42600 S 472.77 0.00 0.00 43234 S 312.20 0.00 0.00<br />

42650 S 41.10 0.00 0.00 43235 S 312.20 0.00 0.00<br />

42660 S 48.12 0.00 0.00 43236 S 363.25 0.00 0.00<br />

42665 S 912.33 0.00 0.00 43237 S 363.25 0.00 0.00<br />

42700 S 129.91 0.00 0.00 43238 S 363.25 0.00 0.00<br />

42720 S 472.77 0.00 0.00 43239 S 363.25 0.00 0.00<br />

42725 S 984.42 0.00 0.00 43240 S 363.25 0.00 0.00<br />

42800 S 79.53 0.00 0.00 43241 S 363.25 0.00 0.00<br />

42802 S 472.77 0.00 0.00 43242 S 363.25 0.00 0.00<br />

42804 S 472.77 0.00 0.00 43243 S 363.25 0.00 0.00<br />

42806 S 664.34 0.00 0.00 43244 S 363.25 0.00 0.00<br />

42808 S 523.82 0.00 0.00 43245 S 363.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 363.25 0.00 0.00 44378 S 380.45 0.00 0.00<br />

43247 S 363.25 0.00 0.00 44379 S 1,085.39 0.00 0.00<br />

43248 S 363.25 0.00 0.00 44380 S 329.40 0.00 0.00<br />

43249 S 363.25 0.00 0.00 44382 S 329.40 0.00 0.00<br />

43250 S 363.25 0.00 0.00 44383 S 1,085.39 0.00 0.00<br />

43251 S 363.25 0.00 0.00 44385 S 318.48 0.00 0.00<br />

43255 S 363.25 0.00 0.00 44386 S 318.48 0.00 0.00<br />

43256 S 710.92 0.00 0.00 44388 S 318.48 0.00 0.00<br />

43257 S 704.90 0.00 0.00 44389 S 318.48 0.00 0.00<br />

43258 S 392.16 0.00 0.00 44390 S 318.48 0.00 0.00<br />

43259 S 392.16 0.00 0.00 44391 S 318.48 0.00 0.00<br />

43260 S 611.54 0.00 0.00 44392 S 318.48 0.00 0.00<br />

43261 S 611.54 0.00 0.00 44393 S 318.48 0.00 0.00<br />

43262 S 611.54 0.00 0.00 44394 S 318.48 0.00 0.00<br />

43263 S 611.54 0.00 0.00 44397 S 630.97 0.00 0.00<br />

43264 S 611.54 0.00 0.00 44500 S 171.87 0.00 0.00<br />

43265 S 611.54 0.00 0.00 45000 S 369.34 0.00 0.00<br />

43267 S 611.54 0.00 0.00 45005 S 429.84 0.00 0.00<br />

43268 S 682.02 0.00 0.00 45020 S 429.84 0.00 0.00<br />

43269 S 682.02 0.00 0.00 45100 S 583.98 0.00 0.00<br />

43271 S 611.54 0.00 0.00 45108 S 635.02 0.00 0.00<br />

43272 S 611.54 0.00 0.00 45150 S 635.02 0.00 0.00<br />

43273 S 820.15 0.00 0.00 45160 S 635.02 0.00 0.00<br />

43450 S 273.04 0.00 0.00 45170 S 635.02 0.00 0.00<br />

43453 S 273.04 0.00 0.00 45190 S 1,038.40 0.00 0.00<br />

43456 S 274.12 0.00 0.00 45300 S 61.48 0.00 0.00<br />

43458 S 313.30 0.00 0.00 45303 S 341.52 0.00 0.00<br />

43600 S 312.20 0.00 0.00 45305 S 321.18 0.00 0.00<br />

43653 S 1,470.99 0.00 0.00 45307 S 593.24 0.00 0.00<br />

43760 S 151.42 0.00 0.00 45308 S 321.18 0.00 0.00<br />

43761 S 312.20 0.00 0.00 45309 S 321.18 0.00 0.00<br />

43870 S 312.20 0.00 0.00 45315 S 321.18 0.00 0.00<br />

43886 S 787.77 0.00 0.00 45317 S 321.18 0.00 0.00<br />

43887 S 165.69 0.00 0.00 45320 S 593.24 0.00 0.00<br />

43888 S 787.77 0.00 0.00 45321 S 593.24 0.00 0.00<br />

44100 S 312.20 0.00 0.00 45327 S 630.97 0.00 0.00<br />

44312 S 544.30 0.00 0.00 45330 S 81.20 0.00 0.00<br />

44340 S 624.26 0.00 0.00 45331 S 240.12 0.00 0.00<br />

44360 S 380.45 0.00 0.00 45332 S 240.12 0.00 0.00<br />

44361 S 380.45 0.00 0.00 45333 S 321.18 0.00 0.00<br />

44363 S 380.45 0.00 0.00 45334 S 321.18 0.00 0.00<br />

44364 S 380.45 0.00 0.00 45335 S 240.12 0.00 0.00<br />

44365 S 380.45 0.00 0.00 45337 S 240.12 0.00 0.00<br />

44366 S 380.45 0.00 0.00 45338 S 321.18 0.00 0.00<br />

44369 S 380.45 0.00 0.00 45339 S 321.18 0.00 0.00<br />

44370 S 1,085.39 0.00 0.00 45340 S 321.18 0.00 0.00<br />

44372 S 380.45 0.00 0.00 45341 S 321.18 0.00 0.00<br />

44373 S 380.45 0.00 0.00 45342 S 321.18 0.00 0.00<br />

44376 S 380.45 0.00 0.00 45345 S 630.97 0.00 0.00<br />

44377 S 380.45 0.00 0.00 45355 S 318.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 369.53 0.00 0.00 46505 S 456.75 0.00 0.00<br />

45379 S 369.53 0.00 0.00 46600 S 24.16 0.00 0.00<br />

45380 S 369.53 0.00 0.00 46604 S 341.52 0.00 0.00<br />

45381 S 369.53 0.00 0.00 46606 S 128.32 0.00 0.00<br />

45382 S 369.53 0.00 0.00 46608 S 321.18 0.00 0.00<br />

45383 S 369.53 0.00 0.00 46610 S 593.24 0.00 0.00<br />

45384 S 369.53 0.00 0.00 46611 S 321.18 0.00 0.00<br />

45385 S 369.53 0.00 0.00 46612 S 593.24 0.00 0.00<br />

45386 S 369.53 0.00 0.00 46614 S 67.50 0.00 0.00<br />

45387 S 630.97 0.00 0.00 46615 S 644.28 0.00 0.00<br />

45391 S 369.53 0.00 0.00 46700 S 663.94 0.00 0.00<br />

45392 S 369.53 0.00 0.00 46706 S 730.80 0.00 0.00<br />

45500 S 635.02 0.00 0.00 46750 S 810.75 0.00 0.00<br />

45505 S 781.85 0.00 0.00 46753 S 663.94 0.00 0.00<br />

45520 S 30.96 0.00 0.00 46754 S 635.02 0.00 0.00<br />

45560 S 781.85 0.00 0.00 46760 S 781.85 0.00 0.00<br />

45900 S 250.39 0.00 0.00 46761 S 810.75 0.00 0.00<br />

45905 S 583.98 0.00 0.00 46762 S 1,029.83 0.00 0.00<br />

45910 S 583.98 0.00 0.00 46900 S 102.04 0.00 0.00<br />

45915 S 369.34 0.00 0.00 46910 S 121.96 0.00 0.00<br />

45990 S 574.52 0.00 0.00 46916 S 56.73 0.00 0.00<br />

46020 S 663.94 0.00 0.00 46917 S 529.20 0.00 0.00<br />

46030 S 250.39 0.00 0.00 46922 S 529.20 0.00 0.00<br />

46040 S 663.94 0.00 0.00 46924 S 529.20 0.00 0.00<br />

46045 S 635.02 0.00 0.00 46930 S 118.30 0.00 0.00<br />

46050 S 369.34 0.00 0.00 46937 S 635.02 0.00 0.00<br />

46060 S 635.02 0.00 0.00 46938 S 781.85 0.00 0.00<br />

46070 S 456.75 0.00 0.00 46940 S 87.54 0.00 0.00<br />

46080 S 663.94 0.00 0.00 46942 S 85.21 0.00 0.00<br />

46083 S 69.91 0.00 0.00 46945 S 145.03 0.00 0.00<br />

46200 S 635.02 0.00 0.00 46946 S 378.79 0.00 0.00<br />

46210 S 635.02 0.00 0.00 46947 S 1,029.83 0.00 0.00<br />

46211 S 635.02 0.00 0.00 47000 S 329.52 0.00 0.00<br />

46220 S 583.98 0.00 0.00 47382 S 1,738.95 0.00 0.00<br />

46221 S 114.95 0.00 0.00 47510 S 770.11 0.00 0.00<br />

46230 S 583.98 0.00 0.00 47511 S 1,131.40 0.00 0.00<br />

46250 S 663.94 0.00 0.00 47525 S 442.10 0.00 0.00<br />

46255 S 663.94 0.00 0.00 47530 S 442.10 0.00 0.00<br />

46257 S 663.94 0.00 0.00 47552 S 770.11 0.00 0.00<br />

46258 S 663.94 0.00 0.00 47553 S 799.01 0.00 0.00<br />

46260 S 663.94 0.00 0.00 47554 S 799.01 0.00 0.00<br />

46261 S 718.14 0.00 0.00 47555 S 799.01 0.00 0.00<br />

46262 S 718.14 0.00 0.00 47556 S 1,131.40 0.00 0.00<br />

46270 S 663.94 0.00 0.00 47560 S 938.81 0.00 0.00<br />

46275 S 663.94 0.00 0.00 47561 S 938.81 0.00 0.00<br />

46280 S 718.14 0.00 0.00 47562 S 1,732.30 0.00 0.00<br />

46285 S 583.98 0.00 0.00 47563 S 1,732.30 0.00 0.00<br />

46288 S 718.14 0.00 0.00 47564 S 1,732.30 0.00 0.00<br />

46320 S 77.86 0.00 0.00 47630 S 799.01 0.00 0.00<br />

46500 S 107.26 0.00 0.00 48102 S 329.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 200.37 0.00 0.00 49590 S 822.41 0.00 0.00<br />

49081 S 200.37 0.00 0.00 49600 S 876.61 0.00 0.00<br />

49180 S 329.52 0.00 0.00 49650 S 1,150.73 0.00 0.00<br />

49250 S 722.32 0.00 0.00 49651 S 1,315.61 0.00 0.00<br />

49320 S 938.81 0.00 0.00 49652 S 1,416.88 0.00 0.00<br />

49321 S 993.02 0.00 0.00 49653 S 1,416.88 0.00 0.00<br />

49322 S 993.02 0.00 0.00 49654 S 1,416.88 0.00 0.00<br />

49324 S 1,416.88 0.00 0.00 49655 S 1,416.88 0.00 0.00<br />

49325 S 1,416.88 0.00 0.00 49656 S 1,416.88 0.00 0.00<br />

49326 S 1,416.88 0.00 0.00 49657 S 1,416.88 0.00 0.00<br />

49402 S 639.20 0.00 0.00 50200 S 329.52 0.00 0.00<br />

49419 S 766.81 0.00 0.00 50382 S 956.85 0.00 0.00<br />

49420 S 708.87 0.00 0.00 50384 S 702.79 0.00 0.00<br />

49421 S 708.87 0.00 0.00 50385 S 702.79 0.00 0.00<br />

49422 S 564.15 0.00 0.00 50386 S 269.64 0.00 0.00<br />

49423 S 583.35 0.00 0.00 50387 S 583.35 0.00 0.00<br />

49426 S 639.20 0.00 0.00 50389 S 269.64 0.00 0.00<br />

49429 S 827.46 0.00 0.00 50390 S 329.52 0.00 0.00<br />

49440 S 323.57 0.00 0.00 50391 S 39.02 0.00 0.00<br />

49441 S 323.57 0.00 0.00 50392 S 501.81 0.00 0.00<br />

49446 S 323.57 0.00 0.00 50393 S 628.84 0.00 0.00<br />

49450 S 171.87 0.00 0.00 50395 S 501.81 0.00 0.00<br />

49451 S 171.87 0.00 0.00 50396 S 94.35 0.00 0.00<br />

49452 S 171.87 0.00 0.00 50398 S 442.10 0.00 0.00<br />

49460 S 171.87 0.00 0.00 50551 S 285.24 0.00 0.00<br />

49495 S 876.61 0.00 0.00 50553 S 628.84 0.00 0.00<br />

49496 S 876.61 0.00 0.00 50555 S 285.24 0.00 0.00<br />

49500 S 876.61 0.00 0.00 50557 S 628.84 0.00 0.00<br />

49501 S 1,196.87 0.00 0.00 50561 S 628.84 0.00 0.00<br />

49505 S 876.61 0.00 0.00 50562 S 269.64 0.00 0.00<br />

49507 S 1,196.87 0.00 0.00 50570 S 269.64 0.00 0.00<br />

49520 S 1,041.49 0.00 0.00 50572 S 269.64 0.00 0.00<br />

49521 S 1,196.87 0.00 0.00 50574 S 269.64 0.00 0.00<br />

49525 S 876.61 0.00 0.00 50575 S 1,341.24 0.00 0.00<br />

49540 S 793.49 0.00 0.00 50576 S 702.79 0.00 0.00<br />

49550 S 915.91 0.00 0.00 50580 S 702.79 0.00 0.00<br />

49553 S 1,196.87 0.00 0.00 50590 S 1,566.88 0.00 0.00<br />

49555 S 915.91 0.00 0.00 50592 S 1,738.95 0.00 0.00<br />

49557 S 1,196.87 0.00 0.00 50686 S 39.02 0.00 0.00<br />

49560 S 876.61 0.00 0.00 50688 S 442.10 0.00 0.00<br />

49561 S 1,196.87 0.00 0.00 50947 S 1,470.99 0.00 0.00<br />

49565 S 876.61 0.00 0.00 50948 S 1,470.99 0.00 0.00<br />

49566 S 1,196.87 0.00 0.00 50951 S 285.24 0.00 0.00<br />

49568 S 1,041.49 0.00 0.00 50953 S 285.24 0.00 0.00<br />

49570 S 876.61 0.00 0.00 50955 S 628.84 0.00 0.00<br />

49572 S 1,196.87 0.00 0.00 50957 S 628.84 0.00 0.00<br />

49580 S 876.61 0.00 0.00 50961 S 628.84 0.00 0.00<br />

49582 S 1,196.87 0.00 0.00 50970 S 285.24 0.00 0.00<br />

49585 S 876.61 0.00 0.00 50972 S 285.24 0.00 0.00<br />

49587 S 1,196.87 0.00 0.00 50974 S 501.81 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 501.81 0.00 0.00 52275 S 679.89 0.00 0.00<br />

50980 S 628.84 0.00 0.00 52276 S 708.80 0.00 0.00<br />

51020 S 763.01 0.00 0.00 52277 S 679.89 0.00 0.00<br />

51030 S 763.01 0.00 0.00 52281 S 552.85 0.00 0.00<br />

51040 S 763.01 0.00 0.00 52282 S 1,275.47 0.00 0.00<br />

51045 S 315.16 0.00 0.00 52283 S 679.89 0.00 0.00<br />

51050 S 763.01 0.00 0.00 52285 S 552.85 0.00 0.00<br />

51065 S 763.01 0.00 0.00 52290 S 552.85 0.00 0.00<br />

51080 S 512.92 0.00 0.00 52300 S 679.89 0.00 0.00<br />

51100 S 29.74 0.00 0.00 52301 S 708.80 0.00 0.00<br />

51101 S 39.02 0.00 0.00 52305 S 679.89 0.00 0.00<br />

51102 S 525.02 0.00 0.00 52310 S 531.73 0.00 0.00<br />

51500 S 876.61 0.00 0.00 52315 S 679.89 0.00 0.00<br />

51520 S 763.01 0.00 0.00 52317 S 628.84 0.00 0.00<br />

51700 S 50.79 0.00 0.00 52318 S 679.89 0.00 0.00<br />

51701 S 24.16 0.00 0.00 52320 S 802.30 0.00 0.00<br />

51702 S 24.16 0.00 0.00 52325 S 763.01 0.00 0.00<br />

51703 S 39.02 0.00 0.00 52327 S 872.09 0.00 0.00<br />

51705 S 69.91 0.00 0.00 52330 S 679.89 0.00 0.00<br />

51710 S 442.10 0.00 0.00 52332 S 679.89 0.00 0.00<br />

51715 S 802.72 0.00 0.00 52334 S 708.80 0.00 0.00<br />

51720 S 56.14 0.00 0.00 52341 S 708.80 0.00 0.00<br />

51725 TC S 107.84 0.00 0.00 52342 S 708.80 0.00 0.00<br />

51726 TC S 148.55 0.00 0.00 52343 S 708.80 0.00 0.00<br />

51736 TC S 20.38 0.00 0.00 52344 S 708.80 0.00 0.00<br />

51741 TC S 23.73 0.00 0.00 52345 S 708.80 0.00 0.00<br />

51772 TC S 94.35 0.00 0.00 52346 S 708.80 0.00 0.00<br />

51784 TC S 39.02 0.00 0.00 52351 S 708.80 0.00 0.00<br />

51785 TC S 65.19 0.00 0.00 52352 S 763.01 0.00 0.00<br />

51792 TC S 39.02 0.00 0.00 52353 S 955.20 0.00 0.00<br />

51795 TC S 69.91 0.00 0.00 52354 S 763.01 0.00 0.00<br />

51797 TC S 69.91 0.00 0.00 52355 S 763.01 0.00 0.00<br />

51798 S 17.37 0.00 0.00 52400 S 708.80 0.00 0.00<br />

51880 S 628.84 0.00 0.00 52402 S 708.80 0.00 0.00<br />

51992 S 1,190.03 0.00 0.00 52450 S 708.80 0.00 0.00<br />

52000 S 285.24 0.00 0.00 52500 S 708.80 0.00 0.00<br />

52001 S 531.73 0.00 0.00 52601 S 955.20 0.00 0.00<br />

52005 S 552.85 0.00 0.00 52630 S 872.09 0.00 0.00<br />

52007 S 679.89 0.00 0.00 52640 S 679.89 0.00 0.00<br />

52010 S 315.16 0.00 0.00 52647 S 1,461.37 0.00 0.00<br />

52204 S 552.85 0.00 0.00 52648 S 1,461.37 0.00 0.00<br />

52214 S 679.89 0.00 0.00 52700 S 679.89 0.00 0.00<br />

52224 S 679.89 0.00 0.00 53000 S 521.81 0.00 0.00<br />

52234 S 679.89 0.00 0.00 53010 S 521.81 0.00 0.00<br />

52235 S 708.80 0.00 0.00 53020 S 521.81 0.00 0.00<br />

52240 S 708.80 0.00 0.00 53025 S 742.78 0.00 0.00<br />

52250 S 763.01 0.00 0.00 53040 S 572.86 0.00 0.00<br />

52260 S 552.85 0.00 0.00 53060 S 67.84 0.00 0.00<br />

52265 S 269.64 0.00 0.00 53080 S 601.77 0.00 0.00<br />

52270 S 552.85 0.00 0.00 53085 S 742.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 521.81 0.00 0.00 54060 S 529.20 0.00 0.00<br />

53210 S 896.22 0.00 0.00 54065 S 529.20 0.00 0.00<br />

53215 S 695.27 0.00 0.00 54100 S 447.67 0.00 0.00<br />

53220 S 773.80 0.00 0.00 54105 S 558.84 0.00 0.00<br />

53230 S 773.80 0.00 0.00 54110 S 866.44 0.00 0.00<br />

53235 S 601.77 0.00 0.00 54111 S 866.44 0.00 0.00<br />

53240 S 773.80 0.00 0.00 54112 S 866.44 0.00 0.00<br />

53250 S 572.86 0.00 0.00 54115 S 512.92 0.00 0.00<br />

53260 S 572.86 0.00 0.00 54120 S 866.44 0.00 0.00<br />

53265 S 572.86 0.00 0.00 54150 S 577.43 0.00 0.00<br />

53270 S 572.86 0.00 0.00 54160 S 628.48 0.00 0.00<br />

53275 S 572.86 0.00 0.00 54161 S 628.48 0.00 0.00<br />

53400 S 802.72 0.00 0.00 54162 S 628.48 0.00 0.00<br />

53405 S 773.80 0.00 0.00 54163 S 628.48 0.00 0.00<br />

53410 S 773.80 0.00 0.00 54164 S 628.48 0.00 0.00<br />

53420 S 802.72 0.00 0.00 54200 S 65.83 0.00 0.00<br />

53425 S 773.80 0.00 0.00 54205 S 949.55 0.00 0.00<br />

53430 S 773.80 0.00 0.00 54220 S 94.35 0.00 0.00<br />

53431 S 773.80 0.00 0.00 54231 S 61.82 0.00 0.00<br />

53440 S 4,457.42 2,707.20 956.97 54235 S 43.78 0.00 0.00<br />

53442 S 722.76 0.00 0.00 54240 TC S 31.07 0.00 0.00<br />

53444 S 4,457.42 2,707.20 956.97 54250 TC S 11.03 0.00 0.00<br />

53445 S 7,487.33 4,263.98 1,040.64 54300 S 895.34 0.00 0.00<br />

53446 S 722.76 0.00 0.00 54304 S 895.34 0.00 0.00<br />

53447 S 7,487.33 4,263.98 1,040.64 54308 S 895.34 0.00 0.00<br />

53449 S 722.76 0.00 0.00 54312 S 895.34 0.00 0.00<br />

53450 S 722.76 0.00 0.00 54316 S 895.34 0.00 0.00<br />

53460 S 521.81 0.00 0.00 54318 S 895.34 0.00 0.00<br />

53502 S 572.86 0.00 0.00 54322 S 895.34 0.00 0.00<br />

53505 S 773.80 0.00 0.00 54324 S 895.34 0.00 0.00<br />

53510 S 572.86 0.00 0.00 54326 S 895.34 0.00 0.00<br />

53515 S 773.80 0.00 0.00 54328 S 895.34 0.00 0.00<br />

53520 S 773.80 0.00 0.00 54340 S 895.34 0.00 0.00<br />

53600 S 39.10 0.00 0.00 54344 S 895.34 0.00 0.00<br />

53601 S 39.02 0.00 0.00 54348 S 895.34 0.00 0.00<br />

53605 S 552.85 0.00 0.00 54352 S 895.34 0.00 0.00<br />

53620 S 60.15 0.00 0.00 54360 S 895.34 0.00 0.00<br />

53621 S 63.16 0.00 0.00 54380 S 895.34 0.00 0.00<br />

53660 S 39.02 0.00 0.00 54385 S 895.34 0.00 0.00<br />

53661 S 39.02 0.00 0.00 54400 S 4,486.34 2,736.11 985.89<br />

53665 S 521.81 0.00 0.00 54401 S 7,567.29 4,343.94 1,120.60<br />

53850 S 1,713.05 0.00 0.00 54405 S 7,567.29 4,343.94 1,120.60<br />

53852 S 1,713.05 0.00 0.00 54406 S 895.34 0.00 0.00<br />

54000 S 572.86 0.00 0.00 54408 S 895.34 0.00 0.00<br />

54001 S 572.86 0.00 0.00 54410 S 7,567.29 4,343.94 1,120.60<br />

54015 S 647.09 0.00 0.00 54415 S 895.34 0.00 0.00<br />

54050 S 30.96 0.00 0.00 54416 S 7,567.29 4,343.94 1,120.60<br />

54055 S 63.16 0.00 0.00 54420 S 949.55 0.00 0.00<br />

54056 S 30.96 0.00 0.00 54435 S 949.55 0.00 0.00<br />

54057 S 529.20 0.00 0.00 54440 S 949.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 148.55 0.00 0.00 55706 S 431.83 0.00 0.00<br />

54500 S 403.17 0.00 0.00 55720 S 628.84 0.00 0.00<br />

54505 S 577.43 0.00 0.00 55725 S 679.89 0.00 0.00<br />

54512 S 628.48 0.00 0.00 55860 S 749.20 0.00 0.00<br />

54520 S 657.39 0.00 0.00 55870 S 76.19 0.00 0.00<br />

54522 S 657.39 0.00 0.00 55873 S 5,928.00 0.00 0.00<br />

54530 S 876.61 0.00 0.00 55875 S 1,275.47 0.00 0.00<br />

54550 S 876.61 0.00 0.00 55876 S 69.84 0.00 0.00<br />

54560 S 854.03 0.00 0.00 55920 S 875.49 0.00 0.00<br />

54600 S 711.60 0.00 0.00 56405 S 40.77 0.00 0.00<br />

54620 S 657.39 0.00 0.00 56420 S 53.21 0.00 0.00<br />

54640 S 876.61 0.00 0.00 56440 S 571.38 0.00 0.00<br />

54660 S 628.48 0.00 0.00 56441 S 520.33 0.00 0.00<br />

54670 S 657.39 0.00 0.00 56442 S 520.33 0.00 0.00<br />

54680 S 657.39 0.00 0.00 56501 S 56.14 0.00 0.00<br />

54690 S 1,470.99 0.00 0.00 56515 S 609.16 0.00 0.00<br />

54692 S 2,614.83 0.00 0.00 56605 S 32.41 0.00 0.00<br />

54700 S 628.48 0.00 0.00 56606 S 13.37 0.00 0.00<br />

54800 S 141.07 0.00 0.00 56620 S 693.79 0.00 0.00<br />

54830 S 657.39 0.00 0.00 56625 S 819.37 0.00 0.00<br />

54840 S 711.60 0.00 0.00 56700 S 520.33 0.00 0.00<br />

54860 S 657.39 0.00 0.00 56740 S 600.29 0.00 0.00<br />

54861 S 711.60 0.00 0.00 56800 S 600.29 0.00 0.00<br />

54865 S 577.43 0.00 0.00 56805 S 739.83 0.00 0.00<br />

54900 S 711.60 0.00 0.00 56810 S 693.79 0.00 0.00<br />

54901 S 711.60 0.00 0.00 56820 S 41.43 0.00 0.00<br />

55000 S 64.16 0.00 0.00 56821 S 53.21 0.00 0.00<br />

55040 S 822.41 0.00 0.00 57000 S 520.33 0.00 0.00<br />

55041 S 915.91 0.00 0.00 57010 S 571.38 0.00 0.00<br />

55060 S 711.60 0.00 0.00 57020 S 299.66 0.00 0.00<br />

55100 S 385.92 0.00 0.00 57022 S 471.01 0.00 0.00<br />

55110 S 628.48 0.00 0.00 57023 S 512.92 0.00 0.00<br />

55120 S 628.48 0.00 0.00 57061 S 51.79 0.00 0.00<br />

55150 S 577.43 0.00 0.00 57065 S 520.33 0.00 0.00<br />

55175 S 577.43 0.00 0.00 57100 S 33.09 0.00 0.00<br />

55180 S 628.48 0.00 0.00 57105 S 571.38 0.00 0.00<br />

55200 S 628.48 0.00 0.00 57130 S 571.38 0.00 0.00<br />

55250 S 628.48 0.00 0.00 57135 S 571.38 0.00 0.00<br />

55400 S 577.43 0.00 0.00 57150 S 24.06 0.00 0.00<br />

55450 S 206.51 0.00 0.00 57155 S 299.66 0.00 0.00<br />

55500 S 657.39 0.00 0.00 57160 S 34.75 0.00 0.00<br />

55520 S 711.60 0.00 0.00 57170 S 5.70 0.00 0.00<br />

55530 S 711.60 0.00 0.00 57180 S 107.03 0.00 0.00<br />

55535 S 876.61 0.00 0.00 57200 S 520.33 0.00 0.00<br />

55540 S 915.91 0.00 0.00 57210 S 571.38 0.00 0.00<br />

55550 S 1,470.99 0.00 0.00 57220 S 1,047.83 0.00 0.00<br />

55600 S 854.03 0.00 0.00 57230 S 860.37 0.00 0.00<br />

55680 S 577.43 0.00 0.00 57240 S 953.87 0.00 0.00<br />

55700 S 372.13 0.00 0.00 57250 S 953.87 0.00 0.00<br />

55705 S 372.13 0.00 0.00 57260 S 953.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,266.91 0.00 0.00 58555 S 562.19 0.00 0.00<br />

57267 S 1,079.45 0.00 0.00 58558 S 642.15 0.00 0.00<br />

57268 S 860.37 0.00 0.00 58559 S 613.24 0.00 0.00<br />

57287 S 1,259.98 0.00 0.00 58560 S 915.61 0.00 0.00<br />

57288 S 1,141.34 0.00 0.00 58561 S 915.61 0.00 0.00<br />

57289 S 953.87 0.00 0.00 58562 S 642.15 0.00 0.00<br />

57291 S 953.87 0.00 0.00 58563 S 1,290.08 0.00 0.00<br />

57300 S 860.37 0.00 0.00 58565 S 1,422.31 0.00 0.00<br />

57320 S 1,259.98 0.00 0.00 58600 S 1,259.98 0.00 0.00<br />

57400 S 571.38 0.00 0.00 58615 S 739.83 0.00 0.00<br />

57410 S 571.38 0.00 0.00 58660 S 1,190.03 0.00 0.00<br />

57415 S 571.38 0.00 0.00 58661 S 1,190.03 0.00 0.00<br />

57420 S 42.78 0.00 0.00 58662 S 1,190.03 0.00 0.00<br />

57421 S 55.80 0.00 0.00 58670 S 1,096.53 0.00 0.00<br />

57452 S 40.43 0.00 0.00 58671 S 1,096.53 0.00 0.00<br />

57454 S 49.46 0.00 0.00 58672 S 1,190.03 0.00 0.00<br />

57455 S 52.46 0.00 0.00 58673 S 1,190.03 0.00 0.00<br />

57456 S 50.79 0.00 0.00 58800 S 600.29 0.00 0.00<br />

57460 S 156.05 0.00 0.00 58805 S 1,259.98 0.00 0.00<br />

57461 S 165.74 0.00 0.00 58820 S 860.37 0.00 0.00<br />

57500 S 71.51 0.00 0.00 58900 S 600.29 0.00 0.00<br />

57505 S 45.44 0.00 0.00 58970 S 167.21 0.00 0.00<br />

57510 S 46.11 0.00 0.00 58974 S 167.21 0.00 0.00<br />

57511 S 53.21 0.00 0.00 58976 S 167.21 0.00 0.00<br />

57513 S 571.38 0.00 0.00 59000 S 61.15 0.00 0.00<br />

57520 S 571.38 0.00 0.00 59001 S 229.53 0.00 0.00<br />

57522 S 571.38 0.00 0.00 59012 S 112.24 0.00 0.00<br />

57530 S 860.37 0.00 0.00 59015 S 49.46 0.00 0.00<br />

57550 S 860.37 0.00 0.00 59020 TC S 26.06 0.00 0.00<br />

57556 S 1,141.34 0.00 0.00 59025 TC S 13.70 0.00 0.00<br />

57558 S 600.29 0.00 0.00 59070 S 112.24 0.00 0.00<br />

57700 S 520.33 0.00 0.00 59072 S 112.24 0.00 0.00<br />

57720 S 600.29 0.00 0.00 59076 S 112.24 0.00 0.00<br />

57800 S 24.39 0.00 0.00 59100 S 1,259.98 0.00 0.00<br />

58100 S 40.10 0.00 0.00 59150 S 1,732.30 0.00 0.00<br />

58120 S 571.38 0.00 0.00 59151 S 1,732.30 0.00 0.00<br />

58145 S 953.87 0.00 0.00 59160 S 600.29 0.00 0.00<br />

58301 S 37.42 0.00 0.00 59200 S 33.42 0.00 0.00<br />

58321 S 35.09 0.00 0.00 59300 S 72.17 0.00 0.00<br />

58322 S 36.09 0.00 0.00 59320 S 520.33 0.00 0.00<br />

58323 S 8.36 0.00 0.00 59412 S 739.83 0.00 0.00<br />

58345 S 739.83 0.00 0.00 59414 S 739.83 0.00 0.00<br />

58346 S 571.38 0.00 0.00 59812 S 693.79 0.00 0.00<br />

58350 S 860.37 0.00 0.00 59820 S 693.79 0.00 0.00<br />

58353 S 1,079.45 0.00 0.00 59821 S 693.79 0.00 0.00<br />

58356 S 1,634.92 0.00 0.00 59840 S 693.79 0.00 0.00<br />

58545 S 1,313.29 0.00 0.00 59841 S 693.79 0.00 0.00<br />

58546 S 1,470.99 0.00 0.00 59866 S 112.24 0.00 0.00<br />

58550 S 1,912.26 0.00 0.00 59870 S 693.79 0.00 0.00<br />

58552 S 1,732.30 0.00 0.00 59871 S 693.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 291.27 0.00 0.00 62367 S 16.04 0.00 0.00<br />

60100 S 45.78 0.00 0.00 62368 S 20.38 0.00 0.00<br />

60200 S 1,084.13 0.00 0.00 63600 S 547.58 0.00 0.00<br />

60280 S 1,167.24 0.00 0.00 63610 S 496.53 0.00 0.00<br />

60281 S 1,167.24 0.00 0.00 63615 S 692.23 0.00 0.00<br />

60300 S 60.15 0.00 0.00 63650 S 2,947.34 1,827.64 707.96<br />

61000 S 268.20 0.00 0.00 63655 S 4,317.13 2,753.04 1,188.96<br />

61001 S 268.20 0.00 0.00 63660 S 517.61 0.00 0.00<br />

61020 S 217.14 0.00 0.00 63685 S 13,103.48 6,986.89 870.32<br />

61026 S 217.14 0.00 0.00 63688 S 702.87 0.00 0.00<br />

61050 S 217.14 0.00 0.00 63744 S 1,016.45 0.00 0.00<br />

61055 S 217.14 0.00 0.00 63746 S 470.19 0.00 0.00<br />

61070 S 168.97 0.00 0.00 64400 S 51.46 0.00 0.00<br />

61215 S 1,016.45 0.00 0.00 64402 S 48.46 0.00 0.00<br />

61330 S 1,565.91 0.00 0.00 64405 S 41.10 0.00 0.00<br />

61334 S 1,565.91 0.00 0.00 64408 S 51.12 0.00 0.00<br />

61790 S 576.49 0.00 0.00 64410 S 284.52 0.00 0.00<br />

61791 S 427.69 0.00 0.00 64412 S 75.19 0.00 0.00<br />

61880 S 734.37 0.00 0.00 64413 S 48.12 0.00 0.00<br />

61885 S 10,567.73 5,661.04 754.34 64415 S 131.03 0.00 0.00<br />

61886 S 15,780.20 8,317.08 853.96 64416 S 268.20 0.00 0.00<br />

61888 S 702.87 0.00 0.00 64417 S 131.03 0.00 0.00<br />

62194 S 284.52 0.00 0.00 64418 S 67.50 0.00 0.00<br />

62225 S 442.10 0.00 0.00 64420 S 131.03 0.00 0.00<br />

62230 S 987.54 0.00 0.00 64421 S 284.52 0.00 0.00<br />

62252 TC S 44.78 0.00 0.00 64425 S 46.78 0.00 0.00<br />

62263 S 284.52 0.00 0.00 64430 S 196.89 0.00 0.00<br />

62264 S 419.14 0.00 0.00 64435 S 70.51 0.00 0.00<br />

62267 S 167.26 0.00 0.00 64445 S 62.48 0.00 0.00<br />

62268 S 217.14 0.00 0.00 64446 S 537.44 0.00 0.00<br />

62269 S 329.52 0.00 0.00 64447 S 136.49 0.00 0.00<br />

62270 S 131.03 0.00 0.00 64448 S 136.49 0.00 0.00<br />

62272 S 131.03 0.00 0.00 64449 S 268.20 0.00 0.00<br />

62273 S 218.66 0.00 0.00 64450 S 41.77 0.00 0.00<br />

62280 S 284.52 0.00 0.00 64455 S 17.37 0.00 0.00<br />

62281 S 284.52 0.00 0.00 64470 S 284.52 0.00 0.00<br />

62282 S 284.52 0.00 0.00 64472 S 218.66 0.00 0.00<br />

62287 S 1,277.23 0.00 0.00 64475 S 284.52 0.00 0.00<br />

62292 S 268.20 0.00 0.00 64476 S 196.93 0.00 0.00<br />

62294 S 217.14 0.00 0.00 64479 S 284.52 0.00 0.00<br />

62310 S 284.52 0.00 0.00 64480 S 218.66 0.00 0.00<br />

62311 S 284.52 0.00 0.00 64483 S 284.52 0.00 0.00<br />

62318 S 284.52 0.00 0.00 64484 S 218.66 0.00 0.00<br />

62319 S 284.52 0.00 0.00 64505 S 38.10 0.00 0.00<br />

62350 S 987.54 0.00 0.00 64508 S 80.86 0.00 0.00<br />

62355 S 470.19 0.00 0.00 64510 S 284.52 0.00 0.00<br />

62360 S 987.54 0.00 0.00 64517 S 196.89 0.00 0.00<br />

62361 S 10,137.21 5,486.91 836.62 64520 S 284.52 0.00 0.00<br />

62362 S 10,137.21 5,486.91 836.62 64530 S 284.52 0.00 0.00<br />

62365 S 873.85 0.00 0.00 64553 S 2,896.29 1,776.59 656.91<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,252.36 2,132.66 1,012.98 64746 S 547.58 0.00 0.00<br />

64560 S 3,252.36 2,132.66 1,012.98 64761 S 692.23 0.00 0.00<br />

64561 S 2,976.24 1,856.55 736.86 64763 S 692.23 0.00 0.00<br />

64565 S 3,252.36 2,132.66 1,012.98 64766 S 1,344.76 0.00 0.00<br />

64573 S 5,066.69 3,001.52 936.35 64771 S 547.58 0.00 0.00<br />

64575 S 3,873.07 2,308.98 744.90 64772 S 547.58 0.00 0.00<br />

64577 S 3,873.07 2,308.98 744.90 64774 S 547.58 0.00 0.00<br />

64580 S 3,873.07 2,308.98 744.90 64776 S 576.49 0.00 0.00<br />

64581 S 3,953.02 2,388.93 824.85 64778 S 547.58 0.00 0.00<br />

64585 S 517.61 0.00 0.00 64782 S 576.49 0.00 0.00<br />

64590 S 10,567.73 5,661.04 754.34 64783 S 547.58 0.00 0.00<br />

64595 S 702.87 0.00 0.00 64784 S 576.49 0.00 0.00<br />

64600 S 419.14 0.00 0.00 64786 S 902.75 0.00 0.00<br />

64605 S 419.14 0.00 0.00 64787 S 547.58 0.00 0.00<br />

64610 S 419.14 0.00 0.00 64788 S 576.49 0.00 0.00<br />

64612 S 61.15 0.00 0.00 64790 S 576.49 0.00 0.00<br />

64613 S 59.15 0.00 0.00 64792 S 902.75 0.00 0.00<br />

64614 S 67.50 0.00 0.00 64795 S 547.58 0.00 0.00<br />

64620 S 284.52 0.00 0.00 64802 S 547.58 0.00 0.00<br />

64622 S 419.14 0.00 0.00 64820 S 692.23 0.00 0.00<br />

64623 S 284.52 0.00 0.00 64821 S 808.11 0.00 0.00<br />

64626 S 419.14 0.00 0.00 64822 S 1,047.06 0.00 0.00<br />

64627 S 196.93 0.00 0.00 64823 S 1,047.06 0.00 0.00<br />

64630 S 293.07 0.00 0.00 64831 S 956.96 0.00 0.00<br />

64632 S 31.74 0.00 0.00 64832 S 822.80 0.00 0.00<br />

64640 S 94.57 0.00 0.00 64834 S 873.85 0.00 0.00<br />

64650 S 31.74 0.00 0.00 64835 S 902.75 0.00 0.00<br />

64653 S 34.42 0.00 0.00 64836 S 902.75 0.00 0.00<br />

64680 S 445.32 0.00 0.00 64837 S 822.80 0.00 0.00<br />

64681 S 470.19 0.00 0.00 64840 S 873.85 0.00 0.00<br />

64702 S 496.53 0.00 0.00 64856 S 873.85 0.00 0.00<br />

64704 S 496.53 0.00 0.00 64857 S 873.85 0.00 0.00<br />

64708 S 547.58 0.00 0.00 64858 S 873.85 0.00 0.00<br />

64712 S 547.58 0.00 0.00 64859 S 822.80 0.00 0.00<br />

64713 S 547.58 0.00 0.00 64861 S 902.75 0.00 0.00<br />

64714 S 547.58 0.00 0.00 64862 S 902.75 0.00 0.00<br />

64716 S 576.49 0.00 0.00 64864 S 902.75 0.00 0.00<br />

64718 S 547.58 0.00 0.00 64865 S 956.96 0.00 0.00<br />

64719 S 547.58 0.00 0.00 64870 S 956.96 0.00 0.00<br />

64721 S 547.58 0.00 0.00 64872 S 873.85 0.00 0.00<br />

64722 S 496.53 0.00 0.00 64874 S 902.75 0.00 0.00<br />

64726 S 496.53 0.00 0.00 64876 S 902.75 0.00 0.00<br />

64727 S 496.53 0.00 0.00 64885 S 873.85 0.00 0.00<br />

64732 S 547.58 0.00 0.00 64886 S 873.85 0.00 0.00<br />

64734 S 547.58 0.00 0.00 64890 S 873.85 0.00 0.00<br />

64736 S 547.58 0.00 0.00 64891 S 873.85 0.00 0.00<br />

64738 S 547.58 0.00 0.00 64892 S 873.85 0.00 0.00<br />

64740 S 547.58 0.00 0.00 64893 S 873.85 0.00 0.00<br />

64742 S 547.58 0.00 0.00 64895 S 902.75 0.00 0.00<br />

64744 S 547.58 0.00 0.00 64896 S 902.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 902.75 0.00 0.00 65770 S 5,312.40 0.00 0.00<br />

64898 S 902.75 0.00 0.00 65772 S 597.60 0.00 0.00<br />

64901 S 873.85 0.00 0.00 65775 S 597.60 0.00 0.00<br />

64902 S 873.85 0.00 0.00 65780 S 1,033.77 0.00 0.00<br />

64905 S 873.85 0.00 0.00 65781 S 1,033.77 0.00 0.00<br />

64907 S 822.80 0.00 0.00 65782 S 1,033.77 0.00 0.00<br />

64910 S 1,344.76 0.00 0.00 65800 S 463.44 0.00 0.00<br />

65091 S 950.55 0.00 0.00 65805 S 463.44 0.00 0.00<br />

65093 S 950.55 0.00 0.00 65810 S 677.19 0.00 0.00<br />

65101 S 950.55 0.00 0.00 65815 S 648.27 0.00 0.00<br />

65103 S 950.55 0.00 0.00 65820 S 237.76 0.00 0.00<br />

65105 S 1,004.76 0.00 0.00 65850 S 731.39 0.00 0.00<br />

65110 S 1,044.05 0.00 0.00 65855 S 126.31 0.00 0.00<br />

65112 S 1,169.63 0.00 0.00 65860 S 117.96 0.00 0.00<br />

65114 S 1,169.63 0.00 0.00 65865 S 463.44 0.00 0.00<br />

65125 S 973.42 0.00 0.00 65870 S 731.39 0.00 0.00<br />

65130 S 717.08 0.00 0.00 65875 S 731.39 0.00 0.00<br />

65135 S 688.18 0.00 0.00 65880 S 597.60 0.00 0.00<br />

65140 S 950.55 0.00 0.00 65900 S 636.90 0.00 0.00<br />

65150 S 688.18 0.00 0.00 65920 S 896.27 0.00 0.00<br />

65155 S 950.55 0.00 0.00 65930 S 770.69 0.00 0.00<br />

65175 S 511.55 0.00 0.00 66020 S 463.44 0.00 0.00<br />

65205 S 19.72 0.00 0.00 66030 S 237.76 0.00 0.00<br />

65210 S 25.06 0.00 0.00 66130 S 896.27 0.00 0.00<br />

65220 S 34.92 0.00 0.00 66150 S 731.39 0.00 0.00<br />

65222 S 27.40 0.00 0.00 66155 S 731.39 0.00 0.00<br />

65235 S 514.49 0.00 0.00 66160 S 648.27 0.00 0.00<br />

65260 S 339.34 0.00 0.00 66165 S 731.39 0.00 0.00<br />

65265 S 702.05 0.00 0.00 66170 S 731.39 0.00 0.00<br />

65270 S 562.59 0.00 0.00 66172 S 731.39 0.00 0.00<br />

65272 S 648.27 0.00 0.00 66180 S 1,089.62 0.00 0.00<br />

65275 S 731.39 0.00 0.00 66185 S 967.21 0.00 0.00<br />

65280 S 702.05 0.00 0.00 66220 S 944.17 0.00 0.00<br />

65285 S 998.37 0.00 0.00 66225 S 1,050.33 0.00 0.00<br />

65286 S 174.66 0.00 0.00 66250 S 514.49 0.00 0.00<br />

65290 S 691.38 0.00 0.00 66500 S 237.76 0.00 0.00<br />

65400 S 463.44 0.00 0.00 66505 S 237.76 0.00 0.00<br />

65410 S 514.49 0.00 0.00 66600 S 677.19 0.00 0.00<br />

65420 S 514.49 0.00 0.00 66605 S 677.19 0.00 0.00<br />

65426 S 770.69 0.00 0.00 66625 S 481.48 0.00 0.00<br />

65430 S 34.92 0.00 0.00 66630 S 677.19 0.00 0.00<br />

65435 S 30.41 0.00 0.00 66635 S 677.19 0.00 0.00<br />

65436 S 131.99 0.00 0.00 66680 S 677.19 0.00 0.00<br />

65450 S 80.58 0.00 0.00 66682 S 648.27 0.00 0.00<br />

65600 S 155.72 0.00 0.00 66700 S 514.49 0.00 0.00<br />

65710 S 1,159.35 0.00 0.00 66710 S 514.49 0.00 0.00<br />

65730 S 1,159.35 0.00 0.00 66711 S 514.49 0.00 0.00<br />

65750 S 1,159.35 0.00 0.00 66720 S 514.49 0.00 0.00<br />

65755 S 1,159.35 0.00 0.00 66740 S 648.27 0.00 0.00<br />

65756 S 1,419.78 0.00 0.00 66761 S 175.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 178.78 0.00 0.00 67228 S 196.88 0.00 0.00<br />

66770 S 196.88 0.00 0.00 67229 S 196.88 0.00 0.00<br />

66820 S 174.66 0.00 0.00 67250 S 591.51 0.00 0.00<br />

66821 S 239.59 0.00 0.00 67255 S 647.85 0.00 0.00<br />

66825 S 731.39 0.00 0.00 67311 S 691.38 0.00 0.00<br />

66830 S 255.80 0.00 0.00 67312 S 745.59 0.00 0.00<br />

66840 S 549.87 0.00 0.00 67314 S 745.59 0.00 0.00<br />

66850 S 1,035.27 0.00 0.00 67316 S 745.59 0.00 0.00<br />

66852 S 870.39 0.00 0.00 67318 S 745.59 0.00 0.00<br />

66920 S 870.39 0.00 0.00 67320 S 745.59 0.00 0.00<br />

66930 S 909.69 0.00 0.00 67331 S 745.59 0.00 0.00<br />

66940 S 589.17 0.00 0.00 67332 S 745.59 0.00 0.00<br />

66982 S 893.79 0.00 0.00 67334 S 745.59 0.00 0.00<br />

66983 S 893.79 0.00 0.00 67335 S 745.59 0.00 0.00<br />

66984 S 893.79 0.00 0.00 67340 S 745.59 0.00 0.00<br />

66985 S 827.39 0.00 0.00 67343 S 910.46 0.00 0.00<br />

66986 S 827.39 0.00 0.00 67345 S 77.86 0.00 0.00<br />

67005 S 702.05 0.00 0.00 67346 S 421.13 0.00 0.00<br />

67010 S 702.05 0.00 0.00 67400 S 591.51 0.00 0.00<br />

67015 S 864.21 0.00 0.00 67405 S 771.29 0.00 0.00<br />

67025 S 567.89 0.00 0.00 67412 S 685.01 0.00 0.00<br />

67027 S 998.37 0.00 0.00 67413 S 810.59 0.00 0.00<br />

67028 S 78.53 0.00 0.00 67414 S 1,440.36 0.00 0.00<br />

67030 S 567.89 0.00 0.00 67415 S 511.55 0.00 0.00<br />

67031 S 239.59 0.00 0.00 67420 S 1,044.05 0.00 0.00<br />

67036 S 998.37 0.00 0.00 67430 S 1,044.05 0.00 0.00<br />

67039 S 1,163.25 0.00 0.00 67440 S 1,044.05 0.00 0.00<br />

67040 S 1,163.25 0.00 0.00 67445 S 1,044.05 0.00 0.00<br />

67041 S 1,427.58 0.00 0.00 67450 S 1,044.05 0.00 0.00<br />

67042 S 1,427.58 0.00 0.00 67500 S 80.58 0.00 0.00<br />

67043 S 1,427.58 0.00 0.00 67505 S 25.06 0.00 0.00<br />

67101 S 217.93 0.00 0.00 67515 S 25.40 0.00 0.00<br />

67105 S 196.88 0.00 0.00 67550 S 1,004.76 0.00 0.00<br />

67107 S 1,037.67 0.00 0.00 67560 S 688.18 0.00 0.00<br />

67108 S 1,163.25 0.00 0.00 67570 S 1,004.76 0.00 0.00<br />

67110 S 316.78 0.00 0.00 67700 S 117.89 0.00 0.00<br />

67112 S 1,163.25 0.00 0.00 67710 S 137.67 0.00 0.00<br />

67113 S 1,427.58 0.00 0.00 67715 S 511.55 0.00 0.00<br />

67115 S 618.93 0.00 0.00 67800 S 49.46 0.00 0.00<br />

67120 S 618.93 0.00 0.00 67801 S 59.81 0.00 0.00<br />

67121 S 618.93 0.00 0.00 67805 S 77.52 0.00 0.00<br />

67141 S 218.17 0.00 0.00 67808 S 562.59 0.00 0.00<br />

67145 S 186.12 0.00 0.00 67810 S 117.89 0.00 0.00<br />

67208 S 198.49 0.00 0.00 67820 S 16.37 0.00 0.00<br />

67210 S 196.88 0.00 0.00 67825 S 50.46 0.00 0.00<br />

67218 S 741.35 0.00 0.00 67830 S 345.39 0.00 0.00<br />

67220 S 217.93 0.00 0.00 67835 S 562.59 0.00 0.00<br />

67221 S 111.94 0.00 0.00 67840 S 144.36 0.00 0.00<br />

67225 S 7.69 0.00 0.00 67850 S 114.62 0.00 0.00<br />

67227 S 567.89 0.00 0.00 67875 S 287.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 543.40 0.00 0.00 68440 S 49.12 0.00 0.00<br />

67882 S 591.51 0.00 0.00 68500 S 717.08 0.00 0.00<br />

67900 S 771.29 0.00 0.00 68505 S 717.08 0.00 0.00<br />

67901 S 685.01 0.00 0.00 68510 S 511.55 0.00 0.00<br />

67902 S 810.59 0.00 0.00 68520 S 717.08 0.00 0.00<br />

67903 S 645.71 0.00 0.00 68525 S 511.55 0.00 0.00<br />

67904 S 645.71 0.00 0.00 68530 S 117.89 0.00 0.00<br />

67906 S 685.01 0.00 0.00 68540 S 591.51 0.00 0.00<br />

67908 S 645.71 0.00 0.00 68550 S 717.08 0.00 0.00<br />

67909 S 645.71 0.00 0.00 68700 S 562.59 0.00 0.00<br />

67911 S 591.51 0.00 0.00 68705 S 111.94 0.00 0.00<br />

67912 S 591.51 0.00 0.00 68720 S 771.29 0.00 0.00<br />

67914 S 591.51 0.00 0.00 68745 S 771.29 0.00 0.00<br />

67915 S 159.73 0.00 0.00 68750 S 771.29 0.00 0.00<br />

67916 S 645.71 0.00 0.00 68760 S 95.23 0.00 0.00<br />

67917 S 645.71 0.00 0.00 68761 S 65.83 0.00 0.00<br />

67921 S 591.51 0.00 0.00 68770 S 771.29 0.00 0.00<br />

67922 S 155.38 0.00 0.00 68801 S 34.92 0.00 0.00<br />

67923 S 645.71 0.00 0.00 68810 S 99.86 0.00 0.00<br />

67924 S 645.71 0.00 0.00 68811 S 562.59 0.00 0.00<br />

67930 S 159.73 0.00 0.00 68815 S 562.59 0.00 0.00<br />

67935 S 562.59 0.00 0.00 68816 S 722.25 0.00 0.00<br />

67938 S 80.58 0.00 0.00 68840 S 51.79 0.00 0.00<br />

67950 S 562.59 0.00 0.00 69000 S 52.83 0.00 0.00<br />

67961 S 591.51 0.00 0.00 69005 S 99.91 0.00 0.00<br />

67966 S 591.51 0.00 0.00 69020 S 52.83 0.00 0.00<br />

67971 S 591.51 0.00 0.00 69100 S 60.15 0.00 0.00<br />

67973 S 717.08 0.00 0.00 69105 S 85.21 0.00 0.00<br />

67974 S 591.51 0.00 0.00 69110 S 447.67 0.00 0.00<br />

67975 S 591.51 0.00 0.00 69120 S 664.34 0.00 0.00<br />

68020 S 43.78 0.00 0.00 69140 S 664.34 0.00 0.00<br />

68040 S 21.72 0.00 0.00 69145 S 498.71 0.00 0.00<br />

68100 S 86.88 0.00 0.00 69150 S 350.51 0.00 0.00<br />

68110 S 111.94 0.00 0.00 69200 S 24.16 0.00 0.00<br />

68115 S 562.59 0.00 0.00 69205 S 558.84 0.00 0.00<br />

68130 S 514.49 0.00 0.00 69210 S 19.72 0.00 0.00<br />

68135 S 56.14 0.00 0.00 69220 S 30.96 0.00 0.00<br />

68200 S 16.04 0.00 0.00 69222 S 130.32 0.00 0.00<br />

68320 S 771.29 0.00 0.00 69300 S 693.25 0.00 0.00<br />

68325 S 771.29 0.00 0.00 69310 S 1,013.33 0.00 0.00<br />

68326 S 645.71 0.00 0.00 69320 S 1,232.41 0.00 0.00<br />

68328 S 771.29 0.00 0.00 69400 S 87.54 0.00 0.00<br />

68330 S 731.39 0.00 0.00 69401 S 46.11 0.00 0.00<br />

68335 S 771.29 0.00 0.00 69405 S 120.96 0.00 0.00<br />

68340 S 645.71 0.00 0.00 69420 S 108.60 0.00 0.00<br />

68360 S 648.27 0.00 0.00 69421 S 552.73 0.00 0.00<br />

68362 S 648.27 0.00 0.00 69424 S 76.19 0.00 0.00<br />

68371 S 514.49 0.00 0.00 69433 S 108.27 0.00 0.00<br />

68400 S 117.89 0.00 0.00 69436 S 552.73 0.00 0.00<br />

68420 S 167.74 0.00 0.00 69440 S 693.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 933.37 0.00 0.00 69840 S 1,106.83 0.00 0.00<br />

69501 S 1,232.41 0.00 0.00 69905 S 1,232.41 0.00 0.00<br />

69502 S 912.33 0.00 0.00 69910 S 1,232.41 0.00 0.00<br />

69505 S 1,232.41 0.00 0.00 69915 S 1,232.41 0.00 0.00<br />

69511 S 1,232.41 0.00 0.00 69930 S 22,280.32 11,963.02 1,645.73<br />

69530 S 1,232.41 0.00 0.00 70030 TC A 17.04 0.00 0.00<br />

69540 S 127.31 0.00 0.00 70100 TC A 18.72 0.00 0.00<br />

69550 S 1,106.83 0.00 0.00 70110 TC A 23.06 0.00 0.00<br />

69552 S 1,232.41 0.00 0.00 70120 TC A 20.72 0.00 0.00<br />

69601 S 1,232.41 0.00 0.00 70130 TC A 25.31 0.00 0.00<br />

69602 S 1,232.41 0.00 0.00 70134 TC A 25.40 0.00 0.00<br />

69603 S 1,232.41 0.00 0.00 70140 TC A 17.37 0.00 0.00<br />

69604 S 1,232.41 0.00 0.00 70150 TC A 25.31 0.00 0.00<br />

69605 S 1,232.41 0.00 0.00 70160 TC A 20.38 0.00 0.00<br />

69610 S 170.42 0.00 0.00 70190 TC A 21.38 0.00 0.00<br />

69620 S 664.34 0.00 0.00 70200 TC A 25.31 0.00 0.00<br />

69631 S 1,106.83 0.00 0.00 70210 TC A 18.05 0.00 0.00<br />

69632 S 1,106.83 0.00 0.00 70220 TC A 22.73 0.00 0.00<br />

69633 S 1,106.83 0.00 0.00 70240 TC A 17.04 0.00 0.00<br />

69635 S 1,232.41 0.00 0.00 70250 TC A 20.72 0.00 0.00<br />

69636 S 1,232.41 0.00 0.00 70260 TC A 26.40 0.00 0.00<br />

69637 S 1,232.41 0.00 0.00 70300 TC A 7.35 0.00 0.00<br />

69641 S 1,232.41 0.00 0.00 70310 TC A 18.16 0.00 0.00<br />

69642 S 1,232.41 0.00 0.00 70320 TC A 18.16 0.00 0.00<br />

69643 S 1,232.41 0.00 0.00 70328 TC A 18.05 0.00 0.00<br />

69644 S 1,232.41 0.00 0.00 70330 TC A 25.31 0.00 0.00<br />

69645 S 1,232.41 0.00 0.00 70336 TC A 197.03 0.00 0.00<br />

69646 S 1,232.41 0.00 0.00 70350 TC A 10.02 0.00 0.00<br />

69650 S 912.33 0.00 0.00 70355 TC A 10.36 0.00 0.00<br />

69660 S 1,106.83 0.00 0.00 70360 TC A 16.04 0.00 0.00<br />

69661 S 1,106.83 0.00 0.00 70370 TC A 47.10 0.00 0.00<br />

69662 S 1,106.83 0.00 0.00 70371 TC A 47.10 0.00 0.00<br />

69666 S 1,067.53 0.00 0.00 70380 TC A 24.39 0.00 0.00<br />

69667 S 1,067.53 0.00 0.00 70450 TC A 110.04 0.00 0.00<br />

69670 S 1,013.33 0.00 0.00 70460 TC A 174.25 0.00 0.00<br />

69676 S 1,013.33 0.00 0.00 70470 TC A 193.02 0.00 0.00<br />

69700 S 1,013.33 0.00 0.00 70480 TC A 110.04 0.00 0.00<br />

69711 S 933.37 0.00 0.00 70481 TC A 174.25 0.00 0.00<br />

69714 S 5,919.30 3,732.34 1,545.38 70482 TC A 193.02 0.00 0.00<br />

69715 S 5,919.30 3,732.34 1,545.38 70486 TC A 110.04 0.00 0.00<br />

69717 S 5,919.30 3,732.34 1,545.38 70487 TC A 174.25 0.00 0.00<br />

69718 S 5,919.30 3,732.34 1,545.38 70488 TC A 193.02 0.00 0.00<br />

69720 S 1,106.83 0.00 0.00 70490 TC A 110.04 0.00 0.00<br />

69740 S 1,106.83 0.00 0.00 70491 TC A 174.25 0.00 0.00<br />

69745 S 1,106.83 0.00 0.00 70492 TC A 193.02 0.00 0.00<br />

69801 S 1,106.83 0.00 0.00 70496 TC A 199.19 0.00 0.00<br />

69802 S 1,232.41 0.00 0.00 70498 TC A 199.19 0.00 0.00<br />

69805 S 1,232.41 0.00 0.00 70540 TC A 197.03 0.00 0.00<br />

69806 S 1,232.41 0.00 0.00 70542 TC A 241.96 0.00 0.00<br />

69820 S 1,106.83 0.00 0.00 70543 TC A 304.95 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 197.03 0.00 0.00 72120 TC A 32.08 0.00 0.00<br />

70545 TC A 241.96 0.00 0.00 72125 TC A 110.04 0.00 0.00<br />

70546 TC A 304.95 0.00 0.00 72126 TC A 174.25 0.00 0.00<br />

70547 TC A 197.03 0.00 0.00 72127 TC A 193.02 0.00 0.00<br />

70548 TC A 241.96 0.00 0.00 72128 TC A 110.04 0.00 0.00<br />

70549 TC A 304.95 0.00 0.00 72129 TC A 174.25 0.00 0.00<br />

70551 TC A 197.03 0.00 0.00 72130 TC A 193.02 0.00 0.00<br />

70552 TC A 241.96 0.00 0.00 72131 TC A 110.04 0.00 0.00<br />

70553 TC A 304.95 0.00 0.00 72132 TC A 174.25 0.00 0.00<br />

70554 TC A 197.03 0.00 0.00 72133 TC A 193.02 0.00 0.00<br />

70555 TC A 197.03 0.00 0.00 72141 TC A 197.03 0.00 0.00<br />

70557 TC A 197.03 0.00 0.00 72142 TC A 241.96 0.00 0.00<br />

70558 TC A 241.96 0.00 0.00 72146 TC A 197.03 0.00 0.00<br />

70559 TC A 304.95 0.00 0.00 72147 TC A 241.96 0.00 0.00<br />

71010 TC A 13.04 0.00 0.00 72148 TC A 197.03 0.00 0.00<br />

71015 TC A 16.70 0.00 0.00 72149 TC A 241.96 0.00 0.00<br />

71020 TC A 17.71 0.00 0.00 72156 TC A 304.95 0.00 0.00<br />

71021 TC A 21.38 0.00 0.00 72157 TC A 304.95 0.00 0.00<br />

71022 TC A 25.31 0.00 0.00 72158 TC A 304.95 0.00 0.00<br />

71023 TC A 41.43 0.00 0.00 72170 TC A 15.04 0.00 0.00<br />

71030 TC A 25.31 0.00 0.00 72190 TC A 25.31 0.00 0.00<br />

71034 TC A 47.10 0.00 0.00 72191 TC A 199.19 0.00 0.00<br />

71035 TC A 22.05 0.00 0.00 72192 TC A 110.04 0.00 0.00<br />

71100 TC A 18.38 0.00 0.00 72193 TC A 174.25 0.00 0.00<br />

71101 TC A 22.38 0.00 0.00 72194 TC A 193.02 0.00 0.00<br />

71110 TC A 23.39 0.00 0.00 72195 TC A 197.03 0.00 0.00<br />

71111 TC A 31.07 0.00 0.00 72196 TC A 241.96 0.00 0.00<br />

71120 TC A 19.38 0.00 0.00 72197 TC A 304.95 0.00 0.00<br />

71130 TC A 22.73 0.00 0.00 72200 TC A 17.71 0.00 0.00<br />

71250 TC A 110.04 0.00 0.00 72202 TC A 21.72 0.00 0.00<br />

71260 TC A 174.25 0.00 0.00 72220 TC A 17.71 0.00 0.00<br />

71270 TC A 193.02 0.00 0.00 73000 TC A 16.70 0.00 0.00<br />

71275 TC A 199.19 0.00 0.00 73010 TC A 17.04 0.00 0.00<br />

71550 TC A 197.03 0.00 0.00 73020 TC A 13.70 0.00 0.00<br />

71551 TC A 241.96 0.00 0.00 73030 TC A 17.37 0.00 0.00<br />

71552 TC A 304.95 0.00 0.00 73050 TC A 21.72 0.00 0.00<br />

72010 TC A 42.14 0.00 0.00 73060 TC A 17.37 0.00 0.00<br />

72020 TC A 13.70 0.00 0.00 73070 TC A 16.70 0.00 0.00<br />

72040 TC A 22.05 0.00 0.00 73080 TC A 22.05 0.00 0.00<br />

72050 TC A 31.41 0.00 0.00 73090 TC A 16.70 0.00 0.00<br />

72052 TC A 42.14 0.00 0.00 73092 TC A 17.37 0.00 0.00<br />

72069 TC A 20.72 0.00 0.00 73100 TC A 17.37 0.00 0.00<br />

72070 TC A 19.38 0.00 0.00 73110 TC A 22.05 0.00 0.00<br />

72072 TC A 23.39 0.00 0.00 73120 TC A 16.37 0.00 0.00<br />

72074 TC A 25.31 0.00 0.00 73130 TC A 19.38 0.00 0.00<br />

72080 TC A 20.72 0.00 0.00 73140 TC A 19.05 0.00 0.00<br />

72090 TC A 27.74 0.00 0.00 73200 TC A 110.04 0.00 0.00<br />

72100 TC A 23.73 0.00 0.00 73201 TC A 174.25 0.00 0.00<br />

72110 TC A 33.09 0.00 0.00 73202 TC A 193.02 0.00 0.00<br />

72114 TC A 42.14 0.00 0.00 73206 TC A 199.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 197.03 0.00 0.00 74246 TC A 49.73 0.00 0.00<br />

73219 TC A 241.96 0.00 0.00 74247 TC A 49.73 0.00 0.00<br />

73220 TC A 304.95 0.00 0.00 74249 TC A 80.86 0.00 0.00<br />

73221 TC A 197.03 0.00 0.00 74250 TC A 49.73 0.00 0.00<br />

73222 TC A 241.96 0.00 0.00 74251 TC A 80.86 0.00 0.00<br />

73223 TC A 304.95 0.00 0.00 74260 TC A 49.73 0.00 0.00<br />

73500 TC A 14.37 0.00 0.00 74270 TC A 49.73 0.00 0.00<br />

73510 TC A 22.05 0.00 0.00 74280 TC A 80.86 0.00 0.00<br />

73520 TC A 22.73 0.00 0.00 74283 TC A 49.73 0.00 0.00<br />

73540 TC A 22.73 0.00 0.00 74290 TC A 42.43 0.00 0.00<br />

73550 TC A 16.70 0.00 0.00 74291 TC A 40.77 0.00 0.00<br />

73560 TC A 17.04 0.00 0.00 74400 TC A 73.85 0.00 0.00<br />

73562 TC A 21.05 0.00 0.00 74410 TC A 78.86 0.00 0.00<br />

73564 TC A 24.39 0.00 0.00 74415 TC A 94.23 0.00 0.00<br />

73565 TC A 18.38 0.00 0.00 74420 TC A 98.50 0.00 0.00<br />

73590 TC A 16.04 0.00 0.00 74710 TC A 22.05 0.00 0.00<br />

73592 TC A 17.37 0.00 0.00 74775 TC A 98.50 0.00 0.00<br />

73600 TC A 16.37 0.00 0.00 75557 TC A 197.03 0.00 0.00<br />

73610 TC A 19.38 0.00 0.00 75559 TC A 197.03 0.00 0.00<br />

73620 TC A 15.70 0.00 0.00 75561 TC A 304.95 0.00 0.00<br />

73630 TC A 19.05 0.00 0.00 75563 TC A 304.95 0.00 0.00<br />

73650 TC A 16.04 0.00 0.00 76010 TC A 16.37 0.00 0.00<br />

73660 TC A 18.05 0.00 0.00 76098 TC A 10.02 0.00 0.00<br />

73700 TC A 110.04 0.00 0.00 76100 TC A 42.14 0.00 0.00<br />

73701 TC A 174.25 0.00 0.00 76101 TC A 112.94 0.00 0.00<br />

73702 TC A 193.02 0.00 0.00 76102 TC A 112.94 0.00 0.00<br />

73706 TC A 199.19 0.00 0.00 76120 TC A 47.10 0.00 0.00<br />

73718 TC A 197.03 0.00 0.00 76150 A 16.37 0.00 0.00<br />

73719 TC A 241.96 0.00 0.00 76380 TC A 59.44 0.00 0.00<br />

73720 TC A 304.95 0.00 0.00 76496 TC A 47.10 0.00 0.00<br />

73721 TC A 197.03 0.00 0.00 76497 TC A 59.44 0.00 0.00<br />

73722 TC A 241.96 0.00 0.00 76498 TC A 197.03 0.00 0.00<br />

73723 TC A 304.95 0.00 0.00 76499 TC A 25.31 0.00 0.00<br />

74000 TC A 14.37 0.00 0.00 76506 TC A 35.38 0.00 0.00<br />

74010 TC A 22.38 0.00 0.00 76510 TC A 60.15 0.00 0.00<br />

74020 TC A 22.73 0.00 0.00 76511 TC A 42.10 0.00 0.00<br />

74022 TC A 27.74 0.00 0.00 76512 TC A 35.75 0.00 0.00<br />

74150 TC A 110.04 0.00 0.00 76513 TC A 43.44 0.00 0.00<br />

74160 TC A 174.25 0.00 0.00 76514 TC A 3.01 0.00 0.00<br />

74170 TC A 193.02 0.00 0.00 76516 TC A 34.09 0.00 0.00<br />

74175 TC A 199.19 0.00 0.00 76519 TC A 38.10 0.00 0.00<br />

74181 TC A 197.03 0.00 0.00 76529 TC A 33.09 0.00 0.00<br />

74182 TC A 241.96 0.00 0.00 76536 TC A 55.35 0.00 0.00<br />

74183 TC A 304.95 0.00 0.00 76604 TC A 35.38 0.00 0.00<br />

74210 TC A 49.73 0.00 0.00 76645 TC A 35.38 0.00 0.00<br />

74220 TC A 49.73 0.00 0.00 76700 TC A 55.35 0.00 0.00<br />

74230 TC A 49.73 0.00 0.00 76705 TC A 55.35 0.00 0.00<br />

74240 TC A 49.73 0.00 0.00 76770 TC A 55.35 0.00 0.00<br />

74241 TC A 49.73 0.00 0.00 76775 TC A 55.35 0.00 0.00<br />

74245 TC A 80.86 0.00 0.00 76776 TC A 55.35 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 55.35 0.00 0.00 77290 TC A 144.75 0.00 0.00<br />

76801 TC A 55.35 0.00 0.00 77295 TC A 379.27 0.00 0.00<br />

76802 TC A 26.40 0.00 0.00 77299 TC A 64.94 0.00 0.00<br />

76805 TC A 55.35 0.00 0.00 77300 TC A 35.09 0.00 0.00<br />

76810 TC A 41.77 0.00 0.00 77301 TC A 505.46 0.00 0.00<br />

76811 TC A 86.71 0.00 0.00 77305 TC A 32.08 0.00 0.00<br />

76812 TC A 35.38 0.00 0.00 77310 TC A 41.77 0.00 0.00<br />

76813 TC A 35.38 0.00 0.00 77315 TC A 60.82 0.00 0.00<br />

76814 TC A 28.07 0.00 0.00 77321 TC A 63.16 0.00 0.00<br />

76815 TC A 35.38 0.00 0.00 77326 TC A 64.94 0.00 0.00<br />

76816 TC A 35.38 0.00 0.00 77327 TC A 117.96 0.00 0.00<br />

76817 TC A 35.38 0.00 0.00 77328 TC A 144.75 0.00 0.00<br />

76818 TC A 55.35 0.00 0.00 77331 TC A 16.70 0.00 0.00<br />

76819 TC A 47.79 0.00 0.00 77332 TC A 44.78 0.00 0.00<br />

76820 TC A 23.73 0.00 0.00 77333 TC A 21.72 0.00 0.00<br />

76821 TC A 53.58 0.00 0.00 77334 TC A 83.88 0.00 0.00<br />

76825 TC A 111.61 0.00 0.00 77336 A 52.80 0.00 0.00<br />

76826 TC A 66.49 0.00 0.00 77370 A 64.94 0.00 0.00<br />

76827 TC A 35.38 0.00 0.00 77371 A 4,325.92 0.00 0.00<br />

76828 TC A 21.05 0.00 0.00 77399 TC A 64.94 0.00 0.00<br />

76830 TC A 55.35 0.00 0.00 77401 A 26.40 0.00 0.00<br />

76831 TC A 74.52 0.00 0.00 77402 A 53.14 0.00 0.00<br />

76856 TC A 55.35 0.00 0.00 77403 A 53.14 0.00 0.00<br />

76857 TC A 35.38 0.00 0.00 77404 A 53.14 0.00 0.00<br />

76870 TC A 55.35 0.00 0.00 77406 A 86.08 0.00 0.00<br />

76872 TC A 55.35 0.00 0.00 77407 A 53.14 0.00 0.00<br />

76873 TC A 55.35 0.00 0.00 77408 A 53.14 0.00 0.00<br />

76880 TC A 55.35 0.00 0.00 77409 A 53.14 0.00 0.00<br />

76885 TC A 35.38 0.00 0.00 77411 A 86.08 0.00 0.00<br />

76886 TC A 35.38 0.00 0.00 77412 A 86.08 0.00 0.00<br />

76936 TC A 53.58 0.00 0.00 77413 A 86.08 0.00 0.00<br />

76970 TC A 35.38 0.00 0.00 77414 A 86.08 0.00 0.00<br />

76977 TC A 9.02 0.00 0.00 77416 A 86.08 0.00 0.00<br />

76999 TC A 35.38 0.00 0.00 77418 A 232.57 0.00 0.00<br />

77071 A 20.72 0.00 0.00 77422 A 86.08 0.00 0.00<br />

77072 TC A 12.03 0.00 0.00 77423 A 86.08 0.00 0.00<br />

77073 TC A 20.38 0.00 0.00 77470 TC A 123.64 0.00 0.00<br />

77074 TC A 40.10 0.00 0.00 77520 A 398.18 0.00 0.00<br />

77075 TC A 42.14 0.00 0.00 77522 A 398.18 0.00 0.00<br />

77076 TC A 42.14 0.00 0.00 77523 A 475.84 0.00 0.00<br />

77077 TC A 22.73 0.00 0.00 77525 A 475.84 0.00 0.00<br />

77078 TC A 40.71 0.00 0.00 77600 TC A 211.27 0.00 0.00<br />

77079 TC A 41.77 0.00 0.00 77605 TC A 211.27 0.00 0.00<br />

77080 TC A 40.71 0.00 0.00 77610 TC A 211.27 0.00 0.00<br />

77081 TC A 16.37 0.00 0.00 77615 TC A 211.27 0.00 0.00<br />

77082 TC A 17.71 0.00 0.00 77620 TC A 211.27 0.00 0.00<br />

77083 TC A 14.04 0.00 0.00 77750 TC A 82.20 0.00 0.00<br />

77084 TC A 197.03 0.00 0.00 77761 TC A 144.69 0.00 0.00<br />

77280 TC A 64.94 0.00 0.00 77762 TC A 171.42 0.00 0.00<br />

77285 TC A 144.75 0.00 0.00 77763 TC A 220.88 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 156.72 0.00 0.00 78262 TC A 137.63 0.00 0.00<br />

77777 TC A 172.09 0.00 0.00 78264 TC A 137.63 0.00 0.00<br />

77778 TC A 229.23 0.00 0.00 78270 TC A 60.15 0.00 0.00<br />

77785 TC A 101.92 0.00 0.00 78271 TC A 61.15 0.00 0.00<br />

77786 TC A 358.21 0.00 0.00 78272 TC A 67.16 0.00 0.00<br />

77787 TC A 415.09 0.00 0.00 78278 TC A 137.63 0.00 0.00<br />

77789 TC A 42.78 0.00 0.00 78282 TC A 137.63 0.00 0.00<br />

77799 TC A 243.80 0.00 0.00 78290 TC A 137.63 0.00 0.00<br />

78000 TC A 52.46 0.00 0.00 78291 TC A 137.63 0.00 0.00<br />

78001 TC A 66.49 0.00 0.00 78299 TC A 137.63 0.00 0.00<br />

78003 TC A 52.80 0.00 0.00 78300 TC A 119.96 0.00 0.00<br />

78006 TC A 125.62 0.00 0.00 78305 TC A 139.13 0.00 0.00<br />

78007 TC A 92.90 0.00 0.00 78306 TC A 139.13 0.00 0.00<br />

78010 TC A 77.19 0.00 0.00 78315 TC A 139.13 0.00 0.00<br />

78011 TC A 77.19 0.00 0.00 78320 TC A 139.13 0.00 0.00<br />

78015 TC A 150.04 0.00 0.00 78399 TC A 139.13 0.00 0.00<br />

78016 TC A 169.35 0.00 0.00 78414 TC A 176.85 0.00 0.00<br />

78018 TC A 169.35 0.00 0.00 78428 TC A 135.67 0.00 0.00<br />

78070 TC A 115.28 0.00 0.00 78445 TC A 105.82 0.00 0.00<br />

78075 TC A 326.47 0.00 0.00 78456 TC A 105.82 0.00 0.00<br />

78099 TC A 77.19 0.00 0.00 78457 TC A 105.82 0.00 0.00<br />

78102 TC A 116.62 0.00 0.00 78458 TC A 105.82 0.00 0.00<br />

78103 TC A 148.66 0.00 0.00 78459 TC A 654.90 0.00 0.00<br />

78104 TC A 148.66 0.00 0.00 78460 TC A 126.98 0.00 0.00<br />

78110 TC A 59.15 0.00 0.00 78461 TC A 127.99 0.00 0.00<br />

78111 TC A 74.85 0.00 0.00 78464 TC A 187.79 0.00 0.00<br />

78120 TC A 65.49 0.00 0.00 78465 TC A 355.54 0.00 0.00<br />

78121 TC A 77.52 0.00 0.00 78466 TC A 125.98 0.00 0.00<br />

78122 TC A 91.89 0.00 0.00 78468 TC A 161.06 0.00 0.00<br />

78130 TC A 106.59 0.00 0.00 78469 TC A 176.85 0.00 0.00<br />

78135 TC A 226.55 0.00 0.00 78472 TC A 176.85 0.00 0.00<br />

78140 TC A 100.58 0.00 0.00 78473 TC A 176.85 0.00 0.00<br />

78185 TC A 148.66 0.00 0.00 78481 TC A 152.71 0.00 0.00<br />

78190 TC A 93.28 0.00 0.00 78483 TC A 176.85 0.00 0.00<br />

78191 TC A 93.28 0.00 0.00 78491 TC A 654.90 0.00 0.00<br />

78195 TC A 148.66 0.00 0.00 78492 TC A 654.90 0.00 0.00<br />

78199 TC A 148.66 0.00 0.00 78494 TC A 176.85 0.00 0.00<br />

78201 TC A 132.32 0.00 0.00 78499 TC A 176.85 0.00 0.00<br />

78202 TC A 155.66 0.00 0.00 78580 TC A 119.81 0.00 0.00<br />

78205 TC A 155.66 0.00 0.00 78584 TC A 92.56 0.00 0.00<br />

78206 TC A 155.66 0.00 0.00 78585 TC A 183.85 0.00 0.00<br />

78215 TC A 140.01 0.00 0.00 78586 TC A 119.81 0.00 0.00<br />

78216 TC A 94.90 0.00 0.00 78587 TC A 119.81 0.00 0.00<br />

78220 TC A 103.59 0.00 0.00 78588 TC A 183.85 0.00 0.00<br />

78223 TC A 155.66 0.00 0.00 78591 TC A 119.81 0.00 0.00<br />

78230 TC A 117.62 0.00 0.00 78593 TC A 119.81 0.00 0.00<br />

78231 TC A 92.56 0.00 0.00 78594 TC A 119.81 0.00 0.00<br />

78232 TC A 96.57 0.00 0.00 78596 TC A 183.85 0.00 0.00<br />

78258 TC A 137.63 0.00 0.00 78599 TC A 119.81 0.00 0.00<br />

78261 TC A 137.63 0.00 0.00 78600 TC A 105.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 29460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 105.59 0.00 0.00<br />

78605 TC A 105.59 0.00 0.00<br />

78606 TC A 237.25 0.00 0.00<br />

78607 TC A 260.64 0.00 0.00<br />

78608 TC A 586.99 0.00 0.00<br />

78610 TC A 140.68 0.00 0.00<br />

78630 TC A 250.62 0.00 0.00<br />

78635 TC A 230.90 0.00 0.00<br />

78645 TC A 105.59 0.00 0.00<br />

78647 TC A 255.63 0.00 0.00<br />

78650 TC A 247.61 0.00 0.00<br />

78660 TC A 105.59 0.00 0.00<br />

78699 TC A 105.59 0.00 0.00<br />

78700 TC A 129.99 0.00 0.00<br />

78701 TC A 158.39 0.00 0.00<br />

78707 TC A 165.41 0.00 0.00<br />

78708 TC A 113.28 0.00 0.00<br />

78709 TC A 186.25 0.00 0.00<br />

78710 TC A 174.77 0.00 0.00<br />

78725 TC A 69.84 0.00 0.00<br />

78730 TC A 59.15 0.00 0.00<br />

78740 TC A 154.38 0.00 0.00<br />

78761 TC A 147.36 0.00 0.00<br />

78799 TC A 186.25 0.00 0.00<br />

78800 TC A 130.32 0.00 0.00<br />

78801 TC A 178.78 0.00 0.00<br />

78802 TC A 242.26 0.00 0.00<br />

78803 TC A 259.64 0.00 0.00<br />

78804 TC A 453.11 0.00 0.00<br />

78805 TC A 127.31 0.00 0.00<br />

78806 TC A 254.63 0.00 0.00<br />

78807 TC A 259.98 0.00 0.00<br />

78811 TC A 586.99 0.00 0.00<br />

78812 TC A 586.99 0.00 0.00<br />

78813 TC A 586.99 0.00 0.00<br />

78814 TC A 586.99 0.00 0.00<br />

78815 TC A 586.99 0.00 0.00<br />

78816 TC A 586.99 0.00 0.00<br />

78999 TC A 66.49 0.00 0.00<br />

79005 TC A 53.47 0.00 0.00<br />

79101 TC A 58.48 0.00 0.00<br />

79200 TC A 63.16 0.00 0.00<br />

79300 TC A 121.85 0.00 0.00<br />

79403 TC A 90.56 0.00 0.00<br />

79440 TC A 51.12 0.00 0.00<br />

79445 TC A 121.85 0.00 0.00<br />

79999 TC A 121.85 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,304.04 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,562.88 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.72 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,614.92 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,614.92 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 233.22 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 233.22 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 117.76 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 248.89 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 74.82 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 669.96 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,527.73 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,195.84 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,195.84 0.00 0.00<br />

C8900 A 258.93 0.00 0.00 0123T S 956.31 0.00 0.00<br />

C8901 A 210.85 0.00 0.00 0124T S 186.92 0.00 0.00<br />

C8902 A 326.34 0.00 0.00 0144T TC A 63.61 0.00 0.00<br />

C8903 A 258.93 0.00 0.00 0145T TC A 171.25 0.00 0.00<br />

C8904 A 210.85 0.00 0.00 0146T TC A 171.25 0.00 0.00<br />

C8905 A 326.34 0.00 0.00 0147T TC A 171.25 0.00 0.00<br />

C8906 A 258.93 0.00 0.00 0148T TC A 171.25 0.00 0.00<br />

C8907 A 210.85 0.00 0.00 0149T TC A 171.25 0.00 0.00<br />

C8908 A 326.34 0.00 0.00 0150T TC A 171.25 0.00 0.00<br />

C8909 A 258.93 0.00 0.00 0151T TC A 63.61 0.00 0.00<br />

C8910 A 210.85 0.00 0.00 0170T S 1,242.19 0.00 0.00<br />

C8911 A 326.34 0.00 0.00 0176T S 1,466.75 0.00 0.00<br />

C8912 A 258.93 0.00 0.00 0177T S 1,466.75 0.00 0.00<br />

C8913 A 210.85 0.00 0.00 0182T A 1,060.17 0.00 0.00<br />

C8914 A 326.34 0.00 0.00 0186T S 893.51 0.00 0.00<br />

C8918 A 258.93 0.00 0.00 0190T S 893.51 0.00 0.00<br />

C8919 A 210.85 0.00 0.00 0191T S 956.31 0.00 0.00<br />

C8920 A 326.34 0.00 0.00 0192T S 1,638.93 0.00 0.00<br />

C9716 S 1,242.19 0.00 0.00 10021 S 57.32 0.00 0.00<br />

C9724 S 1,015.63 0.00 0.00 10022 S 179.00 0.00 0.00<br />

C9725 S 234.20 0.00 0.00 10040 S 33.14 0.00 0.00<br />

C9726 S 859.82 0.00 0.00 10060 S 50.42 0.00 0.00<br />

C9727 S 301.47 0.00 0.00 10061 S 56.54 0.00 0.00<br />

C9728 S 540.92 0.00 0.00 10080 S 56.54 0.00 0.00<br />

G0104 S 86.90 0.00 0.00 10081 S 130.16 0.00 0.00<br />

G0105 S 375.56 0.00 0.00 10120 S 70.80 0.00 0.00<br />

G0121 S 375.56 0.00 0.00 10121 S 533.69 0.00 0.00<br />

G0127 S 12.16 0.00 0.00 10140 S 75.10 0.00 0.00<br />

G0130 TC A 20.03 0.00 0.00 10160 S 56.54 0.00 0.00<br />

G0173 A 2,304.04 0.00 0.00 10180 S 603.54 0.00 0.00<br />

G0186 S 233.22 0.00 0.00 11000 S 24.32 0.00 0.00<br />

G0247 S 22.17 0.00 0.00 11001 S 8.23 0.00 0.00<br />

G0251 A 576.96 0.00 0.00 11010 S 211.15 0.00 0.00<br />

G0260 S 304.48 0.00 0.00 11011 S 211.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 211.15 0.00 0.00 11601 S 116.58 0.00 0.00<br />

11040 S 22.17 0.00 0.00 11602 S 128.38 0.00 0.00<br />

11041 S 24.68 0.00 0.00 11603 S 136.24 0.00 0.00<br />

11042 S 134.08 0.00 0.00 11604 S 367.51 0.00 0.00<br />

11043 S 134.08 0.00 0.00 11606 S 533.69 0.00 0.00<br />

11044 S 349.13 0.00 0.00 11620 S 99.42 0.00 0.00<br />

11055 S 26.11 0.00 0.00 11621 S 118.01 0.00 0.00<br />

11056 S 28.60 0.00 0.00 11622 S 131.23 0.00 0.00<br />

11057 S 33.14 0.00 0.00 11623 S 141.25 0.00 0.00<br />

11100 S 60.71 0.00 0.00 11624 S 533.69 0.00 0.00<br />

11101 S 14.31 0.00 0.00 11626 S 652.66 0.00 0.00<br />

11200 S 33.14 0.00 0.00 11640 S 105.14 0.00 0.00<br />

11201 S 5.72 0.00 0.00 11641 S 124.09 0.00 0.00<br />

11300 S 33.14 0.00 0.00 11642 S 138.39 0.00 0.00<br />

11301 S 33.14 0.00 0.00 11643 S 149.12 0.00 0.00<br />

11302 S 33.14 0.00 0.00 11644 S 533.69 0.00 0.00<br />

11303 S 60.71 0.00 0.00 11646 S 652.66 0.00 0.00<br />

11305 S 33.14 0.00 0.00 11719 S 12.16 0.00 0.00<br />

11306 S 33.14 0.00 0.00 11720 S 15.02 0.00 0.00<br />

11307 S 33.14 0.00 0.00 11721 S 18.23 0.00 0.00<br />

11308 S 33.14 0.00 0.00 11730 S 33.14 0.00 0.00<br />

11310 S 33.14 0.00 0.00 11732 S 18.23 0.00 0.00<br />

11311 S 33.14 0.00 0.00 11740 S 16.74 0.00 0.00<br />

11312 S 33.14 0.00 0.00 11750 S 96.55 0.00 0.00<br />

11313 S 33.14 0.00 0.00 11752 S 134.10 0.00 0.00<br />

11400 S 68.30 0.00 0.00 11755 S 66.87 0.00 0.00<br />

11401 S 76.88 0.00 0.00 11760 S 137.72 0.00 0.00<br />

11402 S 84.40 0.00 0.00 11762 S 123.02 0.00 0.00<br />

11403 S 90.12 0.00 0.00 11765 S 33.14 0.00 0.00<br />

11404 S 479.07 0.00 0.00 11770 S 683.61 0.00 0.00<br />

11406 S 533.69 0.00 0.00 11771 S 683.61 0.00 0.00<br />

11420 S 64.01 0.00 0.00 11772 S 683.61 0.00 0.00<br />

11421 S 77.59 0.00 0.00 11900 S 30.40 0.00 0.00<br />

11422 S 84.75 0.00 0.00 11901 S 33.14 0.00 0.00<br />

11423 S 94.41 0.00 0.00 11920 S 96.20 0.00 0.00<br />

11424 S 533.69 0.00 0.00 11921 S 105.85 0.00 0.00<br />

11426 S 652.66 0.00 0.00 11922 S 34.33 0.00 0.00<br />

11440 S 73.31 0.00 0.00 11950 S 35.05 0.00 0.00<br />

11441 S 84.75 0.00 0.00 11951 S 43.63 0.00 0.00<br />

11442 S 93.33 0.00 0.00 11952 S 52.52 0.00 0.00<br />

11443 S 103.34 0.00 0.00 11954 S 52.52 0.00 0.00<br />

11444 S 326.18 0.00 0.00 11960 S 637.12 0.00 0.00<br />

11446 S 652.66 0.00 0.00 11970 S 1,154.04 0.00 0.00<br />

11450 S 652.66 0.00 0.00 11971 S 598.04 0.00 0.00<br />

11451 S 652.66 0.00 0.00 11976 S 64.01 0.00 0.00<br />

11462 S 652.66 0.00 0.00 11980 S 25.86 0.00 0.00<br />

11463 S 652.66 0.00 0.00 11981 S 25.86 0.00 0.00<br />

11470 S 652.66 0.00 0.00 11982 S 25.86 0.00 0.00<br />

11471 S 652.66 0.00 0.00 11983 S 25.86 0.00 0.00<br />

11600 S 96.20 0.00 0.00 12001 S 52.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 52.52 0.00 0.00 14021 S 566.19 0.00 0.00<br />

12004 S 52.52 0.00 0.00 14040 S 535.25 0.00 0.00<br />

12005 S 70.37 0.00 0.00 14041 S 566.19 0.00 0.00<br />

12006 S 70.37 0.00 0.00 14060 S 566.19 0.00 0.00<br />

12007 S 70.37 0.00 0.00 14061 S 566.19 0.00 0.00<br />

12011 S 52.52 0.00 0.00 14300 S 726.07 0.00 0.00<br />

12013 S 52.52 0.00 0.00 14350 S 668.05 0.00 0.00<br />

12014 S 52.52 0.00 0.00 15002 S 244.93 0.00 0.00<br />

12015 S 52.52 0.00 0.00 15003 S 244.93 0.00 0.00<br />

12016 S 70.37 0.00 0.00 15004 S 244.93 0.00 0.00<br />

12017 S 70.37 0.00 0.00 15005 S 244.93 0.00 0.00<br />

12018 S 70.37 0.00 0.00 15040 S 112.96 0.00 0.00<br />

12020 S 132.76 0.00 0.00 15050 S 244.93 0.00 0.00<br />

12021 S 112.96 0.00 0.00 15100 S 637.12 0.00 0.00<br />

12031 S 52.52 0.00 0.00 15101 S 668.05 0.00 0.00<br />

12032 S 137.72 0.00 0.00 15110 S 304.25 0.00 0.00<br />

12034 S 70.37 0.00 0.00 15111 S 249.63 0.00 0.00<br />

12035 S 70.37 0.00 0.00 15115 S 304.25 0.00 0.00<br />

12036 S 112.96 0.00 0.00 15116 S 249.63 0.00 0.00<br />

12037 S 225.14 0.00 0.00 15120 S 637.12 0.00 0.00<br />

12041 S 52.52 0.00 0.00 15121 S 668.05 0.00 0.00<br />

12042 S 52.52 0.00 0.00 15130 S 535.25 0.00 0.00<br />

12044 S 70.37 0.00 0.00 15131 S 480.62 0.00 0.00<br />

12045 S 112.96 0.00 0.00 15135 S 535.25 0.00 0.00<br />

12046 S 112.96 0.00 0.00 15136 S 480.62 0.00 0.00<br />

12047 S 225.14 0.00 0.00 15150 S 304.25 0.00 0.00<br />

12051 S 52.52 0.00 0.00 15151 S 249.63 0.00 0.00<br />

12052 S 52.52 0.00 0.00 15152 S 249.63 0.00 0.00<br />

12053 S 52.52 0.00 0.00 15155 S 304.25 0.00 0.00<br />

12054 S 70.37 0.00 0.00 15156 S 249.63 0.00 0.00<br />

12055 S 112.96 0.00 0.00 15157 S 249.63 0.00 0.00<br />

12056 S 112.96 0.00 0.00 15170 S 137.72 0.00 0.00<br />

12057 S 225.14 0.00 0.00 15171 S 137.72 0.00 0.00<br />

13100 S 244.93 0.00 0.00 15175 S 177.31 0.00 0.00<br />

13101 S 244.93 0.00 0.00 15176 S 177.31 0.00 0.00<br />

13102 S 132.76 0.00 0.00 15200 S 566.19 0.00 0.00<br />

13120 S 112.96 0.00 0.00 15201 S 475.93 0.00 0.00<br />

13121 S 112.96 0.00 0.00 15220 S 535.25 0.00 0.00<br />

13122 S 112.96 0.00 0.00 15221 S 244.93 0.00 0.00<br />

13131 S 112.96 0.00 0.00 15240 S 566.19 0.00 0.00<br />

13132 S 112.96 0.00 0.00 15241 S 244.93 0.00 0.00<br />

13133 S 112.96 0.00 0.00 15260 S 535.25 0.00 0.00<br />

13150 S 244.93 0.00 0.00 15261 S 475.93 0.00 0.00<br />

13151 S 244.93 0.00 0.00 15300 S 244.93 0.00 0.00<br />

13152 S 244.93 0.00 0.00 15301 S 244.93 0.00 0.00<br />

13153 S 112.96 0.00 0.00 15320 S 244.93 0.00 0.00<br />

13160 S 637.12 0.00 0.00 15321 S 244.93 0.00 0.00<br />

14000 S 535.25 0.00 0.00 15330 S 244.93 0.00 0.00<br />

14001 S 566.19 0.00 0.00 15331 S 244.93 0.00 0.00<br />

14020 S 566.19 0.00 0.00 15335 S 244.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 244.93 0.00 0.00 15826 S 668.05 0.00 0.00<br />

15340 S 137.72 0.00 0.00 15828 S 668.05 0.00 0.00<br />

15341 S 137.72 0.00 0.00 15829 S 768.12 0.00 0.00<br />

15360 S 137.72 0.00 0.00 15830 S 683.61 0.00 0.00<br />

15361 S 137.72 0.00 0.00 15832 S 683.61 0.00 0.00<br />

15365 S 137.72 0.00 0.00 15833 S 683.61 0.00 0.00<br />

15366 S 137.72 0.00 0.00 15834 S 683.61 0.00 0.00<br />

15400 S 244.93 0.00 0.00 15835 S 593.34 0.00 0.00<br />

15401 S 244.93 0.00 0.00 15836 S 564.64 0.00 0.00<br />

15420 S 244.93 0.00 0.00 15837 S 636.21 0.00 0.00<br />

15421 S 244.93 0.00 0.00 15838 S 636.21 0.00 0.00<br />

15430 S 244.93 0.00 0.00 15839 S 564.64 0.00 0.00<br />

15431 S 244.93 0.00 0.00 15840 S 726.07 0.00 0.00<br />

15570 S 668.05 0.00 0.00 15841 S 726.07 0.00 0.00<br />

15572 S 668.05 0.00 0.00 15842 S 843.03 0.00 0.00<br />

15574 S 668.05 0.00 0.00 15845 S 726.07 0.00 0.00<br />

15576 S 668.05 0.00 0.00 15847 S 683.61 0.00 0.00<br />

15600 S 668.05 0.00 0.00 15850 S 109.20 0.00 0.00<br />

15610 S 668.05 0.00 0.00 15851 S 49.70 0.00 0.00<br />

15620 S 726.07 0.00 0.00 15852 S 25.86 0.00 0.00<br />

15630 S 668.05 0.00 0.00 15860 S 25.86 0.00 0.00<br />

15650 S 768.12 0.00 0.00 15876 S 668.05 0.00 0.00<br />

15731 S 668.05 0.00 0.00 15877 S 668.05 0.00 0.00<br />

15732 S 668.05 0.00 0.00 15878 S 668.05 0.00 0.00<br />

15734 S 668.05 0.00 0.00 15879 S 668.05 0.00 0.00<br />

15736 S 668.05 0.00 0.00 15920 S 211.15 0.00 0.00<br />

15738 S 668.05 0.00 0.00 15922 S 726.07 0.00 0.00<br />

15740 S 535.25 0.00 0.00 15931 S 683.61 0.00 0.00<br />

15750 S 637.12 0.00 0.00 15933 S 683.61 0.00 0.00<br />

15760 S 637.12 0.00 0.00 15934 S 668.05 0.00 0.00<br />

15770 S 668.05 0.00 0.00 15935 S 726.07 0.00 0.00<br />

15775 S 182.54 0.00 0.00 15936 S 624.20 0.00 0.00<br />

15776 S 182.54 0.00 0.00 15937 S 726.07 0.00 0.00<br />

15780 S 406.95 0.00 0.00 15940 S 683.61 0.00 0.00<br />

15781 S 179.12 0.00 0.00 15941 S 683.61 0.00 0.00<br />

15782 S 179.12 0.00 0.00 15944 S 668.05 0.00 0.00<br />

15783 S 109.20 0.00 0.00 15945 S 726.07 0.00 0.00<br />

15786 S 33.14 0.00 0.00 15946 S 726.07 0.00 0.00<br />

15787 S 30.04 0.00 0.00 15950 S 683.61 0.00 0.00<br />

15788 S 33.14 0.00 0.00 15951 S 741.61 0.00 0.00<br />

15789 S 60.71 0.00 0.00 15952 S 566.19 0.00 0.00<br />

15792 S 60.71 0.00 0.00 15953 S 624.20 0.00 0.00<br />

15793 S 33.14 0.00 0.00 15956 S 566.19 0.00 0.00<br />

15819 S 137.72 0.00 0.00 15958 S 624.20 0.00 0.00<br />

15820 S 668.05 0.00 0.00 16000 S 26.82 0.00 0.00<br />

15821 S 668.05 0.00 0.00 16020 S 40.77 0.00 0.00<br />

15822 S 668.05 0.00 0.00 16025 S 62.79 0.00 0.00<br />

15823 S 768.12 0.00 0.00 16030 S 78.62 0.00 0.00<br />

15824 S 668.05 0.00 0.00 16035 S 60.71 0.00 0.00<br />

15825 S 668.05 0.00 0.00 17000 S 33.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.94 0.00 0.00 19300 S 734.45 0.00 0.00<br />

17004 S 86.54 0.00 0.00 19301 S 676.45 0.00 0.00<br />

17106 S 109.20 0.00 0.00 19302 S 1,291.94 0.00 0.00<br />

17107 S 109.20 0.00 0.00 19303 S 976.36 0.00 0.00<br />

17108 S 109.20 0.00 0.00 19304 S 976.36 0.00 0.00<br />

17110 S 33.14 0.00 0.00 19316 S 976.36 0.00 0.00<br />

17111 S 60.71 0.00 0.00 19318 S 1,115.50 0.00 0.00<br />

17250 S 45.78 0.00 0.00 19324 S 1,115.50 0.00 0.00<br />

17260 S 48.99 0.00 0.00 19325 S 1,850.19 0.00 0.00<br />

17261 S 60.71 0.00 0.00 19328 S 832.79 0.00 0.00<br />

17262 S 60.71 0.00 0.00 19330 S 832.79 0.00 0.00<br />

17263 S 60.71 0.00 0.00 19340 S 1,026.55 0.00 0.00<br />

17264 S 60.71 0.00 0.00 19342 S 1,449.44 0.00 0.00<br />

17266 S 109.20 0.00 0.00 19350 S 734.45 0.00 0.00<br />

17270 S 60.71 0.00 0.00 19355 S 976.36 0.00 0.00<br />

17271 S 60.71 0.00 0.00 19357 S 1,549.51 0.00 0.00<br />

17272 S 60.71 0.00 0.00 19366 S 1,018.42 0.00 0.00<br />

17273 S 109.20 0.00 0.00 19370 S 976.36 0.00 0.00<br />

17274 S 109.20 0.00 0.00 19371 S 976.36 0.00 0.00<br />

17276 S 109.20 0.00 0.00 19380 S 1,157.56 0.00 0.00<br />

17280 S 60.71 0.00 0.00 19396 S 1,343.62 0.00 0.00<br />

17281 S 90.47 0.00 0.00 20000 S 56.54 0.00 0.00<br />

17282 S 103.34 0.00 0.00 20005 S 651.43 0.00 0.00<br />

17283 S 109.20 0.00 0.00 20103 S 639.31 0.00 0.00<br />

17284 S 109.20 0.00 0.00 20150 S 1,815.01 0.00 0.00<br />

17286 S 109.20 0.00 0.00 20200 S 533.69 0.00 0.00<br />

17311 S 180.27 0.00 0.00 20205 S 564.64 0.00 0.00<br />

17312 S 180.27 0.00 0.00 20206 S 263.85 0.00 0.00<br />

17313 S 180.27 0.00 0.00 20220 S 286.80 0.00 0.00<br />

17314 S 180.27 0.00 0.00 20225 S 520.40 0.00 0.00<br />

17315 S 40.77 0.00 0.00 20240 S 652.66 0.00 0.00<br />

17340 S 14.66 0.00 0.00 20245 S 683.61 0.00 0.00<br />

17360 S 33.14 0.00 0.00 20250 S 682.37 0.00 0.00<br />

17380 S 33.14 0.00 0.00 20251 S 682.37 0.00 0.00<br />

19000 S 69.02 0.00 0.00 20500 S 56.51 0.00 0.00<br />

19001 S 9.30 0.00 0.00 20520 S 95.12 0.00 0.00<br />

19020 S 603.54 0.00 0.00 20525 S 683.61 0.00 0.00<br />

19100 S 205.52 0.00 0.00 20526 S 30.76 0.00 0.00<br />

19101 S 645.51 0.00 0.00 20550 S 23.24 0.00 0.00<br />

19102 S 263.85 0.00 0.00 20551 S 22.88 0.00 0.00<br />

19103 S 461.80 0.00 0.00 20552 S 22.17 0.00 0.00<br />

19105 S 1,343.62 0.00 0.00 20553 S 24.68 0.00 0.00<br />

19110 S 645.51 0.00 0.00 20555 S 1,195.84 0.00 0.00<br />

19112 S 676.45 0.00 0.00 20600 S 23.60 0.00 0.00<br />

19120 S 676.45 0.00 0.00 20605 S 26.46 0.00 0.00<br />

19125 S 676.45 0.00 0.00 20610 S 37.19 0.00 0.00<br />

19126 S 676.45 0.00 0.00 20612 S 25.04 0.00 0.00<br />

19296 S 1,850.19 0.00 0.00 20615 S 104.78 0.00 0.00<br />

19297 S 1,850.19 0.00 0.00 20650 S 682.37 0.00 0.00<br />

19298 S 1,850.19 0.00 0.00 20662 S 871.66 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 871.66 0.00 0.00 21085 S 262.48 0.00 0.00<br />

20665 S 25.86 0.00 0.00 21086 S 571.44 0.00 0.00<br />

20670 S 479.07 0.00 0.00 21087 S 572.16 0.00 0.00<br />

20680 S 683.61 0.00 0.00 21088 S 1,675.76 0.00 0.00<br />

20690 S 813.52 0.00 0.00 21100 S 1,053.48 0.00 0.00<br />

20692 S 844.46 0.00 0.00 21110 S 301.47 0.00 0.00<br />

20693 S 682.37 0.00 0.00 21120 S 976.34 0.00 0.00<br />

20694 S 596.80 0.00 0.00 21121 S 976.34 0.00 0.00<br />

20696 S 1,195.84 0.00 0.00 21122 S 976.34 0.00 0.00<br />

20697 S 795.28 0.00 0.00 21123 S 976.34 0.00 0.00<br />

20822 S 1,120.51 0.00 0.00 21125 S 976.34 0.00 0.00<br />

20900 S 844.46 0.00 0.00 21127 S 1,485.16 0.00 0.00<br />

20902 S 902.46 0.00 0.00 21137 S 990.71 0.00 0.00<br />

20910 S 668.05 0.00 0.00 21138 S 1,675.76 0.00 0.00<br />

20912 S 668.05 0.00 0.00 21139 S 1,675.76 0.00 0.00<br />

20920 S 624.20 0.00 0.00 21150 S 1,675.76 0.00 0.00<br />

20922 S 566.19 0.00 0.00 21181 S 976.34 0.00 0.00<br />

20924 S 902.46 0.00 0.00 21198 S 1,675.76 0.00 0.00<br />

20926 S 393.20 0.00 0.00 21199 S 1,675.76 0.00 0.00<br />

20950 S 56.54 0.00 0.00 21206 S 1,184.49 0.00 0.00<br />

20972 S 1,892.58 0.00 0.00 21208 S 1,318.87 0.00 0.00<br />

20973 S 1,892.58 0.00 0.00 21209 S 1,184.49 0.00 0.00<br />

20979 S 23.24 0.00 0.00 21210 S 1,318.87 0.00 0.00<br />

20982 S 1,815.01 0.00 0.00 21215 S 1,318.87 0.00 0.00<br />

21010 S 710.95 0.00 0.00 21230 S 1,318.87 0.00 0.00<br />

21015 S 591.51 0.00 0.00 21235 S 976.34 0.00 0.00<br />

21025 S 1,053.48 0.00 0.00 21240 S 1,142.43 0.00 0.00<br />

21026 S 1,053.48 0.00 0.00 21242 S 1,184.49 0.00 0.00<br />

21029 S 1,053.48 0.00 0.00 21243 S 1,184.49 0.00 0.00<br />

21030 S 248.53 0.00 0.00 21244 S 1,318.87 0.00 0.00<br />

21031 S 205.62 0.00 0.00 21245 S 1,318.87 0.00 0.00<br />

21032 S 209.55 0.00 0.00 21246 S 1,318.87 0.00 0.00<br />

21034 S 1,084.42 0.00 0.00 21248 S 1,318.87 0.00 0.00<br />

21040 S 710.95 0.00 0.00 21249 S 1,318.87 0.00 0.00<br />

21044 S 1,053.48 0.00 0.00 21260 S 1,675.76 0.00 0.00<br />

21046 S 1,053.48 0.00 0.00 21267 S 1,318.87 0.00 0.00<br />

21047 S 1,053.48 0.00 0.00 21270 S 1,184.49 0.00 0.00<br />

21048 S 1,675.76 0.00 0.00 21275 S 1,318.87 0.00 0.00<br />

21050 S 1,084.42 0.00 0.00 21280 S 1,184.49 0.00 0.00<br />

21060 S 1,053.48 0.00 0.00 21282 S 691.57 0.00 0.00<br />

21070 S 1,084.42 0.00 0.00 21295 S 311.71 0.00 0.00<br />

21073 S 193.10 0.00 0.00 21296 S 656.32 0.00 0.00<br />

21076 S 335.07 0.00 0.00 21310 S 95.08 0.00 0.00<br />

21077 S 809.97 0.00 0.00 21315 S 417.83 0.00 0.00<br />

21079 S 580.03 0.00 0.00 21320 S 560.56 0.00 0.00<br />

21080 S 665.14 0.00 0.00 21325 S 799.89 0.00 0.00<br />

21081 S 612.93 0.00 0.00 21330 S 841.95 0.00 0.00<br />

21082 S 583.25 0.00 0.00 21335 S 976.34 0.00 0.00<br />

21083 S 574.66 0.00 0.00 21336 S 813.67 0.00 0.00<br />

21084 S 661.20 0.00 0.00 21337 S 560.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 799.89 0.00 0.00 22310 S 173.11 0.00 0.00<br />

21339 S 841.95 0.00 0.00 22315 S 447.73 0.00 0.00<br />

21340 S 1,142.43 0.00 0.00 22505 S 527.09 0.00 0.00<br />

21345 S 976.34 0.00 0.00 22520 S 1,245.20 0.00 0.00<br />

21355 S 1,084.42 0.00 0.00 22521 S 1,245.20 0.00 0.00<br />

21356 S 741.89 0.00 0.00 22522 S 1,245.20 0.00 0.00<br />

21360 S 990.71 0.00 0.00 22523 S 3,465.50 0.00 0.00<br />

21390 S 1,675.76 0.00 0.00 22524 S 3,465.50 0.00 0.00<br />

21400 S 366.33 0.00 0.00 22525 S 3,465.50 0.00 0.00<br />

21401 S 591.51 0.00 0.00 22900 S 741.61 0.00 0.00<br />

21406 S 1,675.76 0.00 0.00 23000 S 533.69 0.00 0.00<br />

21407 S 1,675.76 0.00 0.00 23020 S 1,123.10 0.00 0.00<br />

21421 S 799.89 0.00 0.00 23030 S 548.90 0.00 0.00<br />

21440 S 336.86 0.00 0.00 23031 S 634.47 0.00 0.00<br />

21445 S 799.89 0.00 0.00 23035 S 682.37 0.00 0.00<br />

21450 S 139.03 0.00 0.00 23040 S 844.46 0.00 0.00<br />

21451 S 375.10 0.00 0.00 23044 S 902.46 0.00 0.00<br />

21452 S 560.56 0.00 0.00 23065 S 100.85 0.00 0.00<br />

21453 S 1,084.42 0.00 0.00 23066 S 652.66 0.00 0.00<br />

21454 S 841.95 0.00 0.00 23075 S 533.69 0.00 0.00<br />

21461 S 1,142.43 0.00 0.00 23076 S 652.66 0.00 0.00<br />

21462 S 1,184.49 0.00 0.00 23077 S 683.61 0.00 0.00<br />

21465 S 1,142.43 0.00 0.00 23100 S 651.43 0.00 0.00<br />

21480 S 95.08 0.00 0.00 23101 S 1,078.91 0.00 0.00<br />

21485 S 560.56 0.00 0.00 23105 S 902.46 0.00 0.00<br />

21490 S 1,084.42 0.00 0.00 23106 S 902.46 0.00 0.00<br />

21495 S 689.94 0.00 0.00 23107 S 902.46 0.00 0.00<br />

21497 S 560.56 0.00 0.00 23120 S 944.52 0.00 0.00<br />

21501 S 603.54 0.00 0.00 23125 S 944.52 0.00 0.00<br />

21502 S 651.43 0.00 0.00 23130 S 1,254.10 0.00 0.00<br />

21550 S 636.21 0.00 0.00 23140 S 740.37 0.00 0.00<br />

21555 S 652.66 0.00 0.00 23145 S 944.52 0.00 0.00<br />

21556 S 652.66 0.00 0.00 23146 S 944.52 0.00 0.00<br />

21557 S 874.14 0.00 0.00 23150 S 902.46 0.00 0.00<br />

21600 S 813.52 0.00 0.00 23155 S 944.52 0.00 0.00<br />

21610 S 813.52 0.00 0.00 23156 S 944.52 0.00 0.00<br />

21685 S 301.47 0.00 0.00 23170 S 813.52 0.00 0.00<br />

21700 S 651.43 0.00 0.00 23172 S 813.52 0.00 0.00<br />

21720 S 682.37 0.00 0.00 23174 S 813.52 0.00 0.00<br />

21725 S 71.03 0.00 0.00 23180 S 902.46 0.00 0.00<br />

21800 S 82.06 0.00 0.00 23182 S 902.46 0.00 0.00<br />

21805 S 724.73 0.00 0.00 23184 S 902.46 0.00 0.00<br />

21820 S 82.06 0.00 0.00 23190 S 902.46 0.00 0.00<br />

21920 S 145.90 0.00 0.00 23195 S 944.52 0.00 0.00<br />

21925 S 652.66 0.00 0.00 23330 S 326.18 0.00 0.00<br />

21930 S 652.66 0.00 0.00 23331 S 598.04 0.00 0.00<br />

21935 S 683.61 0.00 0.00 23395 S 1,254.10 0.00 0.00<br />

22102 S 1,945.21 0.00 0.00 23397 S 2,213.74 0.00 0.00<br />

22103 S 1,945.21 0.00 0.00 23400 S 1,078.91 0.00 0.00<br />

22305 S 82.06 0.00 0.00 23405 S 813.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 813.52 0.00 0.00 23931 S 603.54 0.00 0.00<br />

23410 S 1,254.10 0.00 0.00 23935 S 651.43 0.00 0.00<br />

23412 S 1,388.49 0.00 0.00 24000 S 902.46 0.00 0.00<br />

23415 S 1,254.10 0.00 0.00 24006 S 902.46 0.00 0.00<br />

23420 S 1,388.49 0.00 0.00 24065 S 139.82 0.00 0.00<br />

23430 S 1,212.05 0.00 0.00 24066 S 533.69 0.00 0.00<br />

23440 S 1,212.05 0.00 0.00 24075 S 533.69 0.00 0.00<br />

23450 S 2,079.35 0.00 0.00 24076 S 652.66 0.00 0.00<br />

23455 S 2,213.74 0.00 0.00 24077 S 683.61 0.00 0.00<br />

23460 S 2,079.35 0.00 0.00 24100 S 596.80 0.00 0.00<br />

23462 S 1,388.49 0.00 0.00 24101 S 902.46 0.00 0.00<br />

23465 S 2,079.35 0.00 0.00 24102 S 902.46 0.00 0.00<br />

23466 S 1,388.49 0.00 0.00 24105 S 682.37 0.00 0.00<br />

23480 S 1,212.05 0.00 0.00 24110 S 651.43 0.00 0.00<br />

23485 S 2,213.74 0.00 0.00 24115 S 844.46 0.00 0.00<br />

23490 S 1,154.04 0.00 0.00 24116 S 844.46 0.00 0.00<br />

23491 S 1,979.29 0.00 0.00 24120 S 682.37 0.00 0.00<br />

23500 S 82.06 0.00 0.00 24125 S 844.46 0.00 0.00<br />

23505 S 447.73 0.00 0.00 24126 S 844.46 0.00 0.00<br />

23515 S 1,498.52 0.00 0.00 24130 S 844.46 0.00 0.00<br />

23520 S 173.11 0.00 0.00 24134 S 813.52 0.00 0.00<br />

23525 S 173.11 0.00 0.00 24136 S 813.52 0.00 0.00<br />

23530 S 1,104.26 0.00 0.00 24138 S 813.52 0.00 0.00<br />

23532 S 813.67 0.00 0.00 24140 S 844.46 0.00 0.00<br />

23540 S 82.06 0.00 0.00 24145 S 844.46 0.00 0.00<br />

23545 S 173.11 0.00 0.00 24147 S 813.52 0.00 0.00<br />

23550 S 1,104.26 0.00 0.00 24149 S 1,195.84 0.00 0.00<br />

23552 S 1,162.28 0.00 0.00 24152 S 1,815.01 0.00 0.00<br />

23570 S 82.06 0.00 0.00 24153 S 3,465.50 0.00 0.00<br />

23575 S 173.11 0.00 0.00 24155 S 1,154.04 0.00 0.00<br />

23585 S 1,498.52 0.00 0.00 24160 S 813.52 0.00 0.00<br />

23600 S 63.94 0.00 0.00 24164 S 844.46 0.00 0.00<br />

23605 S 447.73 0.00 0.00 24200 S 102.27 0.00 0.00<br />

23615 S 1,556.53 0.00 0.00 24201 S 533.69 0.00 0.00<br />

23616 S 1,556.53 0.00 0.00 24300 S 622.99 0.00 0.00<br />

23620 S 63.94 0.00 0.00 24301 S 902.46 0.00 0.00<br />

23625 S 447.73 0.00 0.00 24305 S 902.46 0.00 0.00<br />

23630 S 1,598.59 0.00 0.00 24310 S 682.37 0.00 0.00<br />

23650 S 82.06 0.00 0.00 24320 S 1,154.04 0.00 0.00<br />

23655 S 472.47 0.00 0.00 24330 S 1,979.29 0.00 0.00<br />

23660 S 1,104.26 0.00 0.00 24331 S 1,154.04 0.00 0.00<br />

23665 S 173.11 0.00 0.00 24332 S 871.66 0.00 0.00<br />

23670 S 1,498.52 0.00 0.00 24340 S 1,154.04 0.00 0.00<br />

23675 S 82.06 0.00 0.00 24341 S 1,154.04 0.00 0.00<br />

23680 S 1,104.26 0.00 0.00 24342 S 1,154.04 0.00 0.00<br />

23700 S 472.47 0.00 0.00 24343 S 1,195.84 0.00 0.00<br />

23800 S 2,037.29 0.00 0.00 24344 S 3,465.50 0.00 0.00<br />

23802 S 1,388.49 0.00 0.00 24345 S 813.52 0.00 0.00<br />

23921 S 475.93 0.00 0.00 24346 S 1,815.01 0.00 0.00<br />

23930 S 548.90 0.00 0.00 24357 S 1,195.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,195.84 0.00 0.00 24925 S 682.37 0.00 0.00<br />

24359 S 1,195.84 0.00 0.00 25000 S 682.37 0.00 0.00<br />

24360 S 1,103.59 0.00 0.00 25001 S 871.66 0.00 0.00<br />

24361 S 6,033.89 3,693.51 1,353.12 25020 S 682.37 0.00 0.00<br />

24362 S 1,410.38 0.00 0.00 25023 S 844.46 0.00 0.00<br />

24363 S 6,168.28 3,827.89 1,487.51 25024 S 844.46 0.00 0.00<br />

24365 S 1,103.59 0.00 0.00 25025 S 844.46 0.00 0.00<br />

24366 S 6,033.89 3,693.51 1,353.12 25028 S 596.80 0.00 0.00<br />

24400 S 902.46 0.00 0.00 25031 S 651.43 0.00 0.00<br />

24410 S 902.46 0.00 0.00 25035 S 651.43 0.00 0.00<br />

24420 S 1,154.04 0.00 0.00 25040 S 944.52 0.00 0.00<br />

24430 S 1,979.29 0.00 0.00 25065 S 141.96 0.00 0.00<br />

24435 S 2,037.29 0.00 0.00 25066 S 652.66 0.00 0.00<br />

24470 S 1,154.04 0.00 0.00 25075 S 533.69 0.00 0.00<br />

24495 S 813.52 0.00 0.00 25076 S 683.61 0.00 0.00<br />

24498 S 1,979.29 0.00 0.00 25077 S 683.61 0.00 0.00<br />

24500 S 82.06 0.00 0.00 25085 S 682.37 0.00 0.00<br />

24505 S 82.06 0.00 0.00 25100 S 651.43 0.00 0.00<br />

24515 S 1,556.53 0.00 0.00 25101 S 844.46 0.00 0.00<br />

24516 S 1,556.53 0.00 0.00 25105 S 902.46 0.00 0.00<br />

24530 S 82.06 0.00 0.00 25107 S 844.46 0.00 0.00<br />

24535 S 173.11 0.00 0.00 25109 S 871.66 0.00 0.00<br />

24538 S 724.73 0.00 0.00 25110 S 682.37 0.00 0.00<br />

24545 S 1,556.53 0.00 0.00 25111 S 682.37 0.00 0.00<br />

24546 S 1,598.59 0.00 0.00 25112 S 740.37 0.00 0.00<br />

24560 S 82.06 0.00 0.00 25115 S 740.37 0.00 0.00<br />

24565 S 82.06 0.00 0.00 25116 S 740.37 0.00 0.00<br />

24566 S 724.73 0.00 0.00 25118 S 813.52 0.00 0.00<br />

24575 S 1,498.52 0.00 0.00 25119 S 844.46 0.00 0.00<br />

24576 S 82.06 0.00 0.00 25120 S 844.46 0.00 0.00<br />

24577 S 173.11 0.00 0.00 25125 S 844.46 0.00 0.00<br />

24579 S 1,498.52 0.00 0.00 25126 S 844.46 0.00 0.00<br />

24582 S 724.73 0.00 0.00 25130 S 844.46 0.00 0.00<br />

24586 S 1,556.53 0.00 0.00 25135 S 844.46 0.00 0.00<br />

24587 S 1,598.59 0.00 0.00 25136 S 844.46 0.00 0.00<br />

24600 S 82.06 0.00 0.00 25145 S 813.52 0.00 0.00<br />

24605 S 527.09 0.00 0.00 25150 S 813.52 0.00 0.00<br />

24615 S 1,498.52 0.00 0.00 25151 S 813.52 0.00 0.00<br />

24620 S 447.73 0.00 0.00 25210 S 844.46 0.00 0.00<br />

24635 S 1,498.52 0.00 0.00 25215 S 902.46 0.00 0.00<br />

24640 S 55.42 0.00 0.00 25230 S 902.46 0.00 0.00<br />

24650 S 63.94 0.00 0.00 25240 S 902.46 0.00 0.00<br />

24655 S 173.11 0.00 0.00 25248 S 651.43 0.00 0.00<br />

24665 S 1,162.28 0.00 0.00 25250 S 758.89 0.00 0.00<br />

24666 S 1,556.53 0.00 0.00 25251 S 758.89 0.00 0.00<br />

24670 S 82.06 0.00 0.00 25259 S 795.28 0.00 0.00<br />

24675 S 82.06 0.00 0.00 25260 S 902.46 0.00 0.00<br />

24685 S 1,104.26 0.00 0.00 25263 S 813.52 0.00 0.00<br />

24800 S 1,212.05 0.00 0.00 25265 S 844.46 0.00 0.00<br />

24802 S 1,254.10 0.00 0.00 25270 S 902.46 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 844.46 0.00 0.00 25505 S 173.11 0.00 0.00<br />

25274 S 902.46 0.00 0.00 25515 S 1,104.26 0.00 0.00<br />

25275 S 902.46 0.00 0.00 25520 S 173.11 0.00 0.00<br />

25280 S 902.46 0.00 0.00 25525 S 1,162.28 0.00 0.00<br />

25290 S 844.46 0.00 0.00 25526 S 1,204.33 0.00 0.00<br />

25295 S 682.37 0.00 0.00 25530 S 63.94 0.00 0.00<br />

25300 S 844.46 0.00 0.00 25535 S 82.06 0.00 0.00<br />

25301 S 844.46 0.00 0.00 25545 S 1,104.26 0.00 0.00<br />

25310 S 1,154.04 0.00 0.00 25560 S 63.94 0.00 0.00<br />

25312 S 1,212.05 0.00 0.00 25565 S 173.11 0.00 0.00<br />

25315 S 1,154.04 0.00 0.00 25574 S 1,498.52 0.00 0.00<br />

25316 S 1,979.29 0.00 0.00 25575 S 1,498.52 0.00 0.00<br />

25320 S 1,154.04 0.00 0.00 25600 S 63.94 0.00 0.00<br />

25332 S 1,103.59 0.00 0.00 25605 S 173.11 0.00 0.00<br />

25335 S 1,154.04 0.00 0.00 25606 S 755.67 0.00 0.00<br />

25337 S 1,254.10 0.00 0.00 25607 S 1,598.59 0.00 0.00<br />

25350 S 1,979.29 0.00 0.00 25608 S 1,598.59 0.00 0.00<br />

25355 S 1,154.04 0.00 0.00 25609 S 1,598.59 0.00 0.00<br />

25360 S 844.46 0.00 0.00 25622 S 63.94 0.00 0.00<br />

25365 S 844.46 0.00 0.00 25624 S 173.11 0.00 0.00<br />

25370 S 1,154.04 0.00 0.00 25628 S 1,104.26 0.00 0.00<br />

25375 S 1,212.05 0.00 0.00 25630 S 63.94 0.00 0.00<br />

25390 S 844.46 0.00 0.00 25635 S 173.11 0.00 0.00<br />

25391 S 1,212.05 0.00 0.00 25645 S 1,104.26 0.00 0.00<br />

25392 S 844.46 0.00 0.00 25650 S 63.94 0.00 0.00<br />

25393 S 1,212.05 0.00 0.00 25651 S 1,018.26 0.00 0.00<br />

25394 S 1,815.01 0.00 0.00 25652 S 1,715.44 0.00 0.00<br />

25400 S 1,154.04 0.00 0.00 25660 S 82.06 0.00 0.00<br />

25405 S 2,037.29 0.00 0.00 25670 S 755.67 0.00 0.00<br />

25415 S 1,979.29 0.00 0.00 25671 S 670.11 0.00 0.00<br />

25420 S 2,037.29 0.00 0.00 25675 S 82.06 0.00 0.00<br />

25425 S 1,154.04 0.00 0.00 25676 S 724.73 0.00 0.00<br />

25426 S 1,212.05 0.00 0.00 25680 S 82.06 0.00 0.00<br />

25430 S 1,815.01 0.00 0.00 25685 S 755.67 0.00 0.00<br />

25431 S 1,815.01 0.00 0.00 25690 S 447.73 0.00 0.00<br />

25440 S 2,037.29 0.00 0.00 25695 S 724.73 0.00 0.00<br />

25441 S 6,033.89 3,693.51 1,353.12 25800 S 2,037.29 0.00 0.00<br />

25442 S 6,033.89 3,693.51 1,353.12 25805 S 1,254.10 0.00 0.00<br />

25443 S 1,410.38 0.00 0.00 25810 S 2,079.35 0.00 0.00<br />

25444 S 1,410.38 0.00 0.00 25820 S 1,212.05 0.00 0.00<br />

25445 S 1,410.38 0.00 0.00 25825 S 2,079.35 0.00 0.00<br />

25446 S 6,168.28 3,827.89 1,487.51 25830 S 2,079.35 0.00 0.00<br />

25447 S 1,103.59 0.00 0.00 25907 S 682.37 0.00 0.00<br />

25449 S 1,103.59 0.00 0.00 25922 S 682.37 0.00 0.00<br />

25450 S 1,154.04 0.00 0.00 25929 S 566.19 0.00 0.00<br />

25455 S 1,154.04 0.00 0.00 25931 S 871.66 0.00 0.00<br />

25490 S 1,154.04 0.00 0.00 26010 S 56.54 0.00 0.00<br />

25491 S 1,154.04 0.00 0.00 26011 S 413.00 0.00 0.00<br />

25492 S 1,154.04 0.00 0.00 26020 S 548.00 0.00 0.00<br />

25500 S 63.94 0.00 0.00 26025 S 493.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 548.00 0.00 0.00 26392 S 806.79 0.00 0.00<br />

26034 S 548.00 0.00 0.00 26410 S 578.94 0.00 0.00<br />

26035 S 664.80 0.00 0.00 26412 S 806.79 0.00 0.00<br />

26040 S 864.81 0.00 0.00 26415 S 864.81 0.00 0.00<br />

26045 S 806.79 0.00 0.00 26416 S 806.79 0.00 0.00<br />

26055 S 548.00 0.00 0.00 26418 S 636.95 0.00 0.00<br />

26060 S 548.00 0.00 0.00 26420 S 864.81 0.00 0.00<br />

26070 S 548.00 0.00 0.00 26426 S 806.79 0.00 0.00<br />

26075 S 636.95 0.00 0.00 26428 S 806.79 0.00 0.00<br />

26080 S 636.95 0.00 0.00 26432 S 578.94 0.00 0.00<br />

26100 S 548.00 0.00 0.00 26433 S 578.94 0.00 0.00<br />

26105 S 493.37 0.00 0.00 26434 S 806.79 0.00 0.00<br />

26110 S 493.37 0.00 0.00 26437 S 578.94 0.00 0.00<br />

26115 S 652.66 0.00 0.00 26440 S 578.94 0.00 0.00<br />

26116 S 652.66 0.00 0.00 26442 S 806.79 0.00 0.00<br />

26117 S 683.61 0.00 0.00 26445 S 578.94 0.00 0.00<br />

26121 S 864.81 0.00 0.00 26449 S 806.79 0.00 0.00<br />

26123 S 864.81 0.00 0.00 26450 S 578.94 0.00 0.00<br />

26125 S 636.95 0.00 0.00 26455 S 578.94 0.00 0.00<br />

26130 S 578.94 0.00 0.00 26460 S 578.94 0.00 0.00<br />

26135 S 864.81 0.00 0.00 26471 S 548.00 0.00 0.00<br />

26140 S 548.00 0.00 0.00 26474 S 548.00 0.00 0.00<br />

26145 S 578.94 0.00 0.00 26476 S 493.37 0.00 0.00<br />

26160 S 578.94 0.00 0.00 26477 S 493.37 0.00 0.00<br />

26170 S 578.94 0.00 0.00 26478 S 493.37 0.00 0.00<br />

26180 S 578.94 0.00 0.00 26479 S 493.37 0.00 0.00<br />

26185 S 636.95 0.00 0.00 26480 S 806.79 0.00 0.00<br />

26200 S 548.00 0.00 0.00 26483 S 806.79 0.00 0.00<br />

26205 S 806.79 0.00 0.00 26485 S 775.86 0.00 0.00<br />

26210 S 548.00 0.00 0.00 26489 S 806.79 0.00 0.00<br />

26215 S 578.94 0.00 0.00 26490 S 806.79 0.00 0.00<br />

26230 S 812.40 0.00 0.00 26492 S 806.79 0.00 0.00<br />

26235 S 578.94 0.00 0.00 26494 S 806.79 0.00 0.00<br />

26236 S 578.94 0.00 0.00 26496 S 806.79 0.00 0.00<br />

26250 S 578.94 0.00 0.00 26497 S 806.79 0.00 0.00<br />

26255 S 806.79 0.00 0.00 26498 S 864.81 0.00 0.00<br />

26260 S 578.94 0.00 0.00 26499 S 806.79 0.00 0.00<br />

26261 S 578.94 0.00 0.00 26500 S 636.95 0.00 0.00<br />

26262 S 548.00 0.00 0.00 26502 S 864.81 0.00 0.00<br />

26320 S 533.69 0.00 0.00 26508 S 578.94 0.00 0.00<br />

26340 S 246.03 0.00 0.00 26510 S 806.79 0.00 0.00<br />

26350 S 721.23 0.00 0.00 26516 S 721.23 0.00 0.00<br />

26352 S 864.81 0.00 0.00 26517 S 806.79 0.00 0.00<br />

26356 S 864.81 0.00 0.00 26518 S 806.79 0.00 0.00<br />

26357 S 864.81 0.00 0.00 26520 S 578.94 0.00 0.00<br />

26358 S 864.81 0.00 0.00 26525 S 578.94 0.00 0.00<br />

26370 S 864.81 0.00 0.00 26530 S 1,003.53 0.00 0.00<br />

26372 S 864.81 0.00 0.00 26531 S 1,544.77 0.00 0.00<br />

26373 S 806.79 0.00 0.00 26535 S 1,103.59 0.00 0.00<br />

26390 S 864.81 0.00 0.00 26536 S 1,410.38 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 636.95 0.00 0.00 26775 S 170.93 0.00 0.00<br />

26541 S 1,041.24 0.00 0.00 26776 S 724.73 0.00 0.00<br />

26542 S 636.95 0.00 0.00 26785 S 724.73 0.00 0.00<br />

26545 S 864.81 0.00 0.00 26820 S 906.86 0.00 0.00<br />

26546 S 864.81 0.00 0.00 26841 S 864.81 0.00 0.00<br />

26548 S 864.81 0.00 0.00 26842 S 864.81 0.00 0.00<br />

26550 S 775.86 0.00 0.00 26843 S 806.79 0.00 0.00<br />

26555 S 806.79 0.00 0.00 26844 S 806.79 0.00 0.00<br />

26560 S 548.00 0.00 0.00 26850 S 864.81 0.00 0.00<br />

26561 S 806.79 0.00 0.00 26852 S 864.81 0.00 0.00<br />

26562 S 864.81 0.00 0.00 26860 S 806.79 0.00 0.00<br />

26565 S 906.86 0.00 0.00 26861 S 775.86 0.00 0.00<br />

26567 S 906.86 0.00 0.00 26862 S 864.81 0.00 0.00<br />

26568 S 806.79 0.00 0.00 26863 S 806.79 0.00 0.00<br />

26580 S 679.00 0.00 0.00 26910 S 806.79 0.00 0.00<br />

26587 S 679.00 0.00 0.00 26951 S 548.00 0.00 0.00<br />

26590 S 679.00 0.00 0.00 26952 S 636.95 0.00 0.00<br />

26591 S 806.79 0.00 0.00 26990 S 596.80 0.00 0.00<br />

26593 S 578.94 0.00 0.00 26991 S 596.80 0.00 0.00<br />

26596 S 548.00 0.00 0.00 27000 S 651.43 0.00 0.00<br />

26600 S 63.94 0.00 0.00 27001 S 844.46 0.00 0.00<br />

26605 S 82.06 0.00 0.00 27003 S 844.46 0.00 0.00<br />

26607 S 447.73 0.00 0.00 27033 S 1,154.04 0.00 0.00<br />

26608 S 813.67 0.00 0.00 27035 S 1,212.05 0.00 0.00<br />

26615 S 1,162.28 0.00 0.00 27040 S 326.18 0.00 0.00<br />

26641 S 63.94 0.00 0.00 27041 S 367.51 0.00 0.00<br />

26645 S 173.11 0.00 0.00 27047 S 652.66 0.00 0.00<br />

26650 S 724.73 0.00 0.00 27048 S 683.61 0.00 0.00<br />

26665 S 1,162.28 0.00 0.00 27049 S 683.61 0.00 0.00<br />

26670 S 63.94 0.00 0.00 27050 S 682.37 0.00 0.00<br />

26675 S 173.11 0.00 0.00 27052 S 682.37 0.00 0.00<br />

26676 S 724.73 0.00 0.00 27060 S 782.43 0.00 0.00<br />

26685 S 755.67 0.00 0.00 27062 S 782.43 0.00 0.00<br />

26686 S 1,498.52 0.00 0.00 27065 S 782.43 0.00 0.00<br />

26700 S 63.94 0.00 0.00 27066 S 944.52 0.00 0.00<br />

26705 S 82.06 0.00 0.00 27067 S 944.52 0.00 0.00<br />

26706 S 447.73 0.00 0.00 27080 S 813.52 0.00 0.00<br />

26715 S 813.67 0.00 0.00 27086 S 326.18 0.00 0.00<br />

26720 S 63.94 0.00 0.00 27087 S 682.37 0.00 0.00<br />

26725 S 63.94 0.00 0.00 27097 S 844.46 0.00 0.00<br />

26727 S 990.12 0.00 0.00 27098 S 844.46 0.00 0.00<br />

26735 S 813.67 0.00 0.00 27100 S 1,212.05 0.00 0.00<br />

26740 S 63.94 0.00 0.00 27105 S 1,212.05 0.00 0.00<br />

26742 S 82.06 0.00 0.00 27110 S 1,212.05 0.00 0.00<br />

26746 S 855.73 0.00 0.00 27111 S 1,212.05 0.00 0.00<br />

26750 S 63.94 0.00 0.00 27193 S 82.06 0.00 0.00<br />

26755 S 63.94 0.00 0.00 27194 S 527.09 0.00 0.00<br />

26756 S 724.73 0.00 0.00 27200 S 63.94 0.00 0.00<br />

26765 S 813.67 0.00 0.00 27202 S 1,073.33 0.00 0.00<br />

26770 S 63.94 0.00 0.00 27220 S 63.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 82.06 0.00 0.00 27397 S 1,154.04 0.00 0.00<br />

27238 S 173.11 0.00 0.00 27400 S 1,154.04 0.00 0.00<br />

27246 S 173.11 0.00 0.00 27403 S 902.46 0.00 0.00<br />

27250 S 82.06 0.00 0.00 27405 S 1,212.05 0.00 0.00<br />

27252 S 527.09 0.00 0.00 27407 S 2,037.29 0.00 0.00<br />

27256 S 63.94 0.00 0.00 27409 S 1,212.05 0.00 0.00<br />

27257 S 558.04 0.00 0.00 27416 S 1,815.01 0.00 0.00<br />

27265 S 82.06 0.00 0.00 27418 S 1,154.04 0.00 0.00<br />

27266 S 527.09 0.00 0.00 27420 S 1,154.04 0.00 0.00<br />

27267 S 63.94 0.00 0.00 27422 S 1,388.49 0.00 0.00<br />

27275 S 527.09 0.00 0.00 27424 S 1,154.04 0.00 0.00<br />

27301 S 634.47 0.00 0.00 27425 S 1,078.91 0.00 0.00<br />

27305 S 651.43 0.00 0.00 27427 S 1,154.04 0.00 0.00<br />

27306 S 682.37 0.00 0.00 27428 S 2,037.29 0.00 0.00<br />

27307 S 682.37 0.00 0.00 27429 S 2,037.29 0.00 0.00<br />

27310 S 902.46 0.00 0.00 27430 S 1,212.05 0.00 0.00<br />

27323 S 326.18 0.00 0.00 27435 S 1,212.05 0.00 0.00<br />

27324 S 598.04 0.00 0.00 27437 S 1,061.53 0.00 0.00<br />

27325 S 586.00 0.00 0.00 27438 S 1,410.38 0.00 0.00<br />

27326 S 586.00 0.00 0.00 27440 S 1,513.97 0.00 0.00<br />

27327 S 652.66 0.00 0.00 27441 S 1,103.59 0.00 0.00<br />

27328 S 683.61 0.00 0.00 27442 S 1,103.59 0.00 0.00<br />

27329 S 741.61 0.00 0.00 27443 S 1,103.59 0.00 0.00<br />

27330 S 902.46 0.00 0.00 27446 S 10,828.34 6,505.17 2,182.00<br />

27331 S 902.46 0.00 0.00 27496 S 782.43 0.00 0.00<br />

27332 S 902.46 0.00 0.00 27497 S 682.37 0.00 0.00<br />

27333 S 902.46 0.00 0.00 27498 S 682.37 0.00 0.00<br />

27334 S 902.46 0.00 0.00 27499 S 682.37 0.00 0.00<br />

27335 S 902.46 0.00 0.00 27500 S 173.11 0.00 0.00<br />

27340 S 682.37 0.00 0.00 27501 S 82.06 0.00 0.00<br />

27345 S 740.37 0.00 0.00 27502 S 447.73 0.00 0.00<br />

27347 S 740.37 0.00 0.00 27503 S 82.06 0.00 0.00<br />

27350 S 902.46 0.00 0.00 27508 S 82.06 0.00 0.00<br />

27355 S 844.46 0.00 0.00 27509 S 755.67 0.00 0.00<br />

27356 S 902.46 0.00 0.00 27510 S 173.11 0.00 0.00<br />

27357 S 944.52 0.00 0.00 27516 S 82.06 0.00 0.00<br />

27358 S 944.52 0.00 0.00 27517 S 82.06 0.00 0.00<br />

27360 S 944.52 0.00 0.00 27520 S 82.06 0.00 0.00<br />

27372 S 918.06 0.00 0.00 27530 S 82.06 0.00 0.00<br />

27380 S 596.80 0.00 0.00 27532 S 447.73 0.00 0.00<br />

27381 S 682.37 0.00 0.00 27538 S 82.06 0.00 0.00<br />

27385 S 682.37 0.00 0.00 27550 S 82.06 0.00 0.00<br />

27386 S 682.37 0.00 0.00 27552 S 472.47 0.00 0.00<br />

27390 S 596.80 0.00 0.00 27560 S 82.06 0.00 0.00<br />

27391 S 651.43 0.00 0.00 27562 S 472.47 0.00 0.00<br />

27392 S 682.37 0.00 0.00 27566 S 1,073.33 0.00 0.00<br />

27393 S 813.52 0.00 0.00 27570 S 472.47 0.00 0.00<br />

27394 S 844.46 0.00 0.00 27594 S 682.37 0.00 0.00<br />

27395 S 1,154.04 0.00 0.00 27600 S 682.37 0.00 0.00<br />

27396 S 844.46 0.00 0.00 27601 S 682.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 682.37 0.00 0.00 27730 S 813.52 0.00 0.00<br />

27603 S 603.54 0.00 0.00 27732 S 813.52 0.00 0.00<br />

27604 S 651.43 0.00 0.00 27734 S 813.52 0.00 0.00<br />

27605 S 593.60 0.00 0.00 27740 S 813.52 0.00 0.00<br />

27606 S 596.80 0.00 0.00 27742 S 1,123.10 0.00 0.00<br />

27607 S 651.43 0.00 0.00 27745 S 1,979.29 0.00 0.00<br />

27610 S 813.52 0.00 0.00 27750 S 82.06 0.00 0.00<br />

27612 S 844.46 0.00 0.00 27752 S 447.73 0.00 0.00<br />

27613 S 134.10 0.00 0.00 27756 S 755.67 0.00 0.00<br />

27614 S 652.66 0.00 0.00 27758 S 1,162.28 0.00 0.00<br />

27615 S 844.46 0.00 0.00 27759 S 1,556.53 0.00 0.00<br />

27618 S 533.69 0.00 0.00 27760 S 82.06 0.00 0.00<br />

27619 S 683.61 0.00 0.00 27762 S 447.73 0.00 0.00<br />

27620 S 902.46 0.00 0.00 27766 S 1,104.26 0.00 0.00<br />

27625 S 902.46 0.00 0.00 27767 S 63.94 0.00 0.00<br />

27626 S 902.46 0.00 0.00 27768 S 63.94 0.00 0.00<br />

27630 S 682.37 0.00 0.00 27769 S 1,715.44 0.00 0.00<br />

27635 S 844.46 0.00 0.00 27780 S 82.06 0.00 0.00<br />

27637 S 844.46 0.00 0.00 27781 S 447.73 0.00 0.00<br />

27638 S 844.46 0.00 0.00 27784 S 1,104.26 0.00 0.00<br />

27640 S 1,123.10 0.00 0.00 27786 S 82.06 0.00 0.00<br />

27641 S 813.52 0.00 0.00 27788 S 82.06 0.00 0.00<br />

27647 S 1,154.04 0.00 0.00 27792 S 1,104.26 0.00 0.00<br />

27650 S 1,154.04 0.00 0.00 27808 S 82.06 0.00 0.00<br />

27652 S 1,979.29 0.00 0.00 27810 S 173.11 0.00 0.00<br />

27654 S 1,154.04 0.00 0.00 27814 S 1,104.26 0.00 0.00<br />

27656 S 651.43 0.00 0.00 27816 S 82.06 0.00 0.00<br />

27658 S 596.80 0.00 0.00 27818 S 173.11 0.00 0.00<br />

27659 S 651.43 0.00 0.00 27822 S 1,104.26 0.00 0.00<br />

27664 S 651.43 0.00 0.00 27823 S 1,498.52 0.00 0.00<br />

27665 S 813.52 0.00 0.00 27824 S 82.06 0.00 0.00<br />

27675 S 651.43 0.00 0.00 27825 S 447.73 0.00 0.00<br />

27676 S 844.46 0.00 0.00 27826 S 1,104.26 0.00 0.00<br />

27680 S 844.46 0.00 0.00 27827 S 1,498.52 0.00 0.00<br />

27681 S 813.52 0.00 0.00 27828 S 1,556.53 0.00 0.00<br />

27685 S 844.46 0.00 0.00 27829 S 1,073.33 0.00 0.00<br />

27686 S 844.46 0.00 0.00 27830 S 82.06 0.00 0.00<br />

27687 S 844.46 0.00 0.00 27831 S 447.73 0.00 0.00<br />

27690 S 1,212.05 0.00 0.00 27832 S 1,073.33 0.00 0.00<br />

27691 S 1,212.05 0.00 0.00 27840 S 173.11 0.00 0.00<br />

27692 S 1,154.04 0.00 0.00 27842 S 472.47 0.00 0.00<br />

27695 S 813.52 0.00 0.00 27846 S 1,104.26 0.00 0.00<br />

27696 S 813.52 0.00 0.00 27848 S 1,104.26 0.00 0.00<br />

27698 S 813.52 0.00 0.00 27860 S 472.47 0.00 0.00<br />

27700 S 1,103.59 0.00 0.00 27870 S 2,037.29 0.00 0.00<br />

27704 S 651.43 0.00 0.00 27871 S 2,037.29 0.00 0.00<br />

27705 S 1,123.10 0.00 0.00 27884 S 682.37 0.00 0.00<br />

27707 S 651.43 0.00 0.00 27889 S 844.46 0.00 0.00<br />

27709 S 813.52 0.00 0.00 27892 S 682.37 0.00 0.00<br />

27726 S 1,018.26 0.00 0.00 27893 S 682.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 682.37 0.00 0.00 28153 S 679.17 0.00 0.00<br />

28001 S 130.88 0.00 0.00 28160 S 679.17 0.00 0.00<br />

28002 S 682.37 0.00 0.00 28171 S 679.17 0.00 0.00<br />

28003 S 682.37 0.00 0.00 28173 S 679.17 0.00 0.00<br />

28005 S 679.17 0.00 0.00 28175 S 679.17 0.00 0.00<br />

28008 S 679.17 0.00 0.00 28190 S 135.17 0.00 0.00<br />

28010 S 96.20 0.00 0.00 28192 S 533.69 0.00 0.00<br />

28011 S 679.17 0.00 0.00 28193 S 367.51 0.00 0.00<br />

28020 S 648.22 0.00 0.00 28200 S 679.17 0.00 0.00<br />

28022 S 648.22 0.00 0.00 28202 S 679.17 0.00 0.00<br />

28024 S 648.22 0.00 0.00 28208 S 679.17 0.00 0.00<br />

28035 S 674.94 0.00 0.00 28210 S 1,192.82 0.00 0.00<br />

28043 S 652.66 0.00 0.00 28220 S 208.48 0.00 0.00<br />

28045 S 679.17 0.00 0.00 28222 S 593.60 0.00 0.00<br />

28046 S 679.17 0.00 0.00 28225 S 593.60 0.00 0.00<br />

28050 S 648.22 0.00 0.00 28226 S 593.60 0.00 0.00<br />

28052 S 648.22 0.00 0.00 28230 S 204.55 0.00 0.00<br />

28054 S 648.22 0.00 0.00 28232 S 195.60 0.00 0.00<br />

28055 S 674.94 0.00 0.00 28234 S 648.22 0.00 0.00<br />

28060 S 648.22 0.00 0.00 28238 S 1,192.82 0.00 0.00<br />

28062 S 679.17 0.00 0.00 28240 S 648.22 0.00 0.00<br />

28070 S 679.17 0.00 0.00 28250 S 679.17 0.00 0.00<br />

28072 S 679.17 0.00 0.00 28260 S 679.17 0.00 0.00<br />

28080 S 679.17 0.00 0.00 28261 S 679.17 0.00 0.00<br />

28086 S 648.22 0.00 0.00 28262 S 737.17 0.00 0.00<br />

28088 S 648.22 0.00 0.00 28264 S 1,107.26 0.00 0.00<br />

28090 S 679.17 0.00 0.00 28270 S 679.17 0.00 0.00<br />

28092 S 679.17 0.00 0.00 28272 S 188.81 0.00 0.00<br />

28100 S 648.22 0.00 0.00 28280 S 648.22 0.00 0.00<br />

28102 S 1,192.82 0.00 0.00 28285 S 679.17 0.00 0.00<br />

28103 S 1,192.82 0.00 0.00 28286 S 737.17 0.00 0.00<br />

28104 S 648.22 0.00 0.00 28288 S 679.17 0.00 0.00<br />

28106 S 1,192.82 0.00 0.00 28289 S 679.17 0.00 0.00<br />

28107 S 1,192.82 0.00 0.00 28290 S 837.16 0.00 0.00<br />

28108 S 648.22 0.00 0.00 28292 S 837.16 0.00 0.00<br />

28110 S 679.17 0.00 0.00 28293 S 868.10 0.00 0.00<br />

28111 S 679.17 0.00 0.00 28294 S 868.10 0.00 0.00<br />

28112 S 679.17 0.00 0.00 28296 S 868.10 0.00 0.00<br />

28113 S 679.17 0.00 0.00 28297 S 868.10 0.00 0.00<br />

28114 S 679.17 0.00 0.00 28298 S 868.10 0.00 0.00<br />

28116 S 679.17 0.00 0.00 28299 S 968.16 0.00 0.00<br />

28118 S 737.17 0.00 0.00 28300 S 1,161.89 0.00 0.00<br />

28119 S 737.17 0.00 0.00 28302 S 648.22 0.00 0.00<br />

28120 S 913.62 0.00 0.00 28304 S 1,161.89 0.00 0.00<br />

28122 S 679.17 0.00 0.00 28305 S 1,192.82 0.00 0.00<br />

28124 S 221.35 0.00 0.00 28306 S 737.17 0.00 0.00<br />

28126 S 679.17 0.00 0.00 28307 S 737.17 0.00 0.00<br />

28130 S 679.17 0.00 0.00 28308 S 648.22 0.00 0.00<br />

28140 S 679.17 0.00 0.00 28309 S 1,250.84 0.00 0.00<br />

28150 S 679.17 0.00 0.00 28310 S 679.17 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 679.17 0.00 0.00 28636 S 755.67 0.00 0.00<br />

28313 S 648.22 0.00 0.00 28645 S 755.67 0.00 0.00<br />

28315 S 737.17 0.00 0.00 28660 S 45.78 0.00 0.00<br />

28320 S 1,250.84 0.00 0.00 28665 S 472.47 0.00 0.00<br />

28322 S 1,250.84 0.00 0.00 28666 S 755.67 0.00 0.00<br />

28340 S 737.17 0.00 0.00 28675 S 755.67 0.00 0.00<br />

28341 S 737.17 0.00 0.00 28705 S 1,250.84 0.00 0.00<br />

28344 S 737.17 0.00 0.00 28715 S 2,037.29 0.00 0.00<br />

28345 S 737.17 0.00 0.00 28725 S 1,250.84 0.00 0.00<br />

28400 S 82.06 0.00 0.00 28730 S 1,250.84 0.00 0.00<br />

28405 S 447.73 0.00 0.00 28735 S 1,250.84 0.00 0.00<br />

28406 S 724.73 0.00 0.00 28737 S 1,292.89 0.00 0.00<br />

28415 S 1,498.52 0.00 0.00 28740 S 1,250.84 0.00 0.00<br />

28420 S 1,162.28 0.00 0.00 28750 S 1,250.84 0.00 0.00<br />

28430 S 63.94 0.00 0.00 28755 S 737.17 0.00 0.00<br />

28435 S 82.06 0.00 0.00 28760 S 1,250.84 0.00 0.00<br />

28436 S 724.73 0.00 0.00 28810 S 648.22 0.00 0.00<br />

28445 S 1,104.26 0.00 0.00 28820 S 648.22 0.00 0.00<br />

28446 S 1,892.58 0.00 0.00 28825 S 648.22 0.00 0.00<br />

28450 S 63.94 0.00 0.00 28890 S 171.29 0.00 0.00<br />

28455 S 63.94 0.00 0.00 29000 S 43.40 0.00 0.00<br />

28456 S 724.73 0.00 0.00 29010 S 97.27 0.00 0.00<br />

28465 S 1,104.26 0.00 0.00 29015 S 97.27 0.00 0.00<br />

28470 S 63.94 0.00 0.00 29020 S 43.40 0.00 0.00<br />

28475 S 63.94 0.00 0.00 29025 S 43.40 0.00 0.00<br />

28476 S 724.73 0.00 0.00 29035 S 97.27 0.00 0.00<br />

28485 S 1,162.28 0.00 0.00 29040 S 43.40 0.00 0.00<br />

28490 S 63.94 0.00 0.00 29044 S 97.27 0.00 0.00<br />

28495 S 63.94 0.00 0.00 29046 S 97.27 0.00 0.00<br />

28496 S 724.73 0.00 0.00 29049 S 39.33 0.00 0.00<br />

28505 S 755.67 0.00 0.00 29055 S 97.27 0.00 0.00<br />

28510 S 57.58 0.00 0.00 29058 S 43.40 0.00 0.00<br />

28515 S 63.94 0.00 0.00 29065 S 46.13 0.00 0.00<br />

28525 S 755.67 0.00 0.00 29075 S 44.34 0.00 0.00<br />

28530 S 55.42 0.00 0.00 29085 S 43.40 0.00 0.00<br />

28531 S 755.67 0.00 0.00 29086 S 37.19 0.00 0.00<br />

28540 S 63.94 0.00 0.00 29105 S 40.05 0.00 0.00<br />

28545 S 670.11 0.00 0.00 29125 S 34.68 0.00 0.00<br />

28546 S 724.73 0.00 0.00 29126 S 36.83 0.00 0.00<br />

28555 S 1,073.33 0.00 0.00 29130 S 15.74 0.00 0.00<br />

28570 S 82.96 0.00 0.00 29131 S 22.88 0.00 0.00<br />

28575 S 447.73 0.00 0.00 29200 S 22.17 0.00 0.00<br />

28576 S 755.67 0.00 0.00 29220 S 23.95 0.00 0.00<br />

28585 S 755.67 0.00 0.00 29240 S 25.04 0.00 0.00<br />

28600 S 63.94 0.00 0.00 29260 S 23.95 0.00 0.00<br />

28605 S 82.06 0.00 0.00 29280 S 24.32 0.00 0.00<br />

28606 S 724.73 0.00 0.00 29305 S 97.27 0.00 0.00<br />

28615 S 1,104.26 0.00 0.00 29325 S 97.27 0.00 0.00<br />

28630 S 63.94 0.00 0.00 29345 S 60.43 0.00 0.00<br />

28635 S 472.47 0.00 0.00 29355 S 59.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 73.67 0.00 0.00 29847 S 1,231.31 0.00 0.00<br />

29365 S 57.22 0.00 0.00 29848 S 1,235.86 0.00 0.00<br />

29405 S 42.56 0.00 0.00 29850 S 893.12 0.00 0.00<br />

29425 S 43.27 0.00 0.00 29851 S 1,289.33 0.00 0.00<br />

29435 S 54.71 0.00 0.00 29855 S 1,289.33 0.00 0.00<br />

29440 S 23.24 0.00 0.00 29856 S 1,289.33 0.00 0.00<br />

29445 S 57.58 0.00 0.00 29860 S 1,289.33 0.00 0.00<br />

29450 S 43.40 0.00 0.00 29861 S 1,289.33 0.00 0.00<br />

29505 S 38.62 0.00 0.00 29862 S 1,632.06 0.00 0.00<br />

29515 S 32.90 0.00 0.00 29863 S 1,289.33 0.00 0.00<br />

29520 S 23.60 0.00 0.00 29866 S 1,969.56 0.00 0.00<br />

29530 S 23.95 0.00 0.00 29870 S 835.12 0.00 0.00<br />

29540 S 17.88 0.00 0.00 29871 S 835.12 0.00 0.00<br />

29550 S 18.23 0.00 0.00 29873 S 835.12 0.00 0.00<br />

29580 S 24.68 0.00 0.00 29874 S 835.12 0.00 0.00<br />

29590 S 20.03 0.00 0.00 29875 S 893.12 0.00 0.00<br />

29700 S 33.25 0.00 0.00 29876 S 893.12 0.00 0.00<br />

29705 S 28.25 0.00 0.00 29877 S 893.12 0.00 0.00<br />

29710 S 49.70 0.00 0.00 29879 S 835.12 0.00 0.00<br />

29715 S 43.40 0.00 0.00 29880 S 893.12 0.00 0.00<br />

29720 S 41.48 0.00 0.00 29881 S 893.12 0.00 0.00<br />

29730 S 27.18 0.00 0.00 29882 S 835.12 0.00 0.00<br />

29740 S 37.19 0.00 0.00 29883 S 835.12 0.00 0.00<br />

29750 S 38.98 0.00 0.00 29884 S 835.12 0.00 0.00<br />

29800 S 835.12 0.00 0.00 29885 S 1,231.31 0.00 0.00<br />

29804 S 835.12 0.00 0.00 29886 S 835.12 0.00 0.00<br />

29805 S 835.12 0.00 0.00 29887 S 835.12 0.00 0.00<br />

29806 S 1,231.31 0.00 0.00 29888 S 1,231.31 0.00 0.00<br />

29807 S 1,231.31 0.00 0.00 29889 S 1,231.31 0.00 0.00<br />

29819 S 1,231.31 0.00 0.00 29891 S 1,231.31 0.00 0.00<br />

29820 S 1,231.31 0.00 0.00 29892 S 1,231.31 0.00 0.00<br />

29821 S 1,231.31 0.00 0.00 29893 S 1,039.57 0.00 0.00<br />

29822 S 835.12 0.00 0.00 29894 S 835.12 0.00 0.00<br />

29823 S 1,231.31 0.00 0.00 29895 S 835.12 0.00 0.00<br />

29824 S 935.18 0.00 0.00 29897 S 835.12 0.00 0.00<br />

29825 S 1,231.31 0.00 0.00 29898 S 835.12 0.00 0.00<br />

29826 S 1,231.31 0.00 0.00 29899 S 1,231.31 0.00 0.00<br />

29827 S 1,331.38 0.00 0.00 29900 S 835.12 0.00 0.00<br />

29828 S 1,969.56 0.00 0.00 29901 S 835.12 0.00 0.00<br />

29830 S 835.12 0.00 0.00 29902 S 835.12 0.00 0.00<br />

29834 S 835.12 0.00 0.00 29904 S 1,177.16 0.00 0.00<br />

29835 S 835.12 0.00 0.00 29905 S 1,177.16 0.00 0.00<br />

29836 S 835.12 0.00 0.00 29906 S 1,177.16 0.00 0.00<br />

29837 S 835.12 0.00 0.00 29907 S 1,969.56 0.00 0.00<br />

29838 S 835.12 0.00 0.00 30000 S 132.35 0.00 0.00<br />

29840 S 835.12 0.00 0.00 30020 S 132.35 0.00 0.00<br />

29843 S 835.12 0.00 0.00 30100 S 85.82 0.00 0.00<br />

29844 S 835.12 0.00 0.00 30110 S 132.67 0.00 0.00<br />

29845 S 835.12 0.00 0.00 30115 S 560.56 0.00 0.00<br />

29846 S 835.12 0.00 0.00 30117 S 591.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 741.89 0.00 0.00 31080 S 1,142.43 0.00 0.00<br />

30120 S 505.94 0.00 0.00 31081 S 1,142.43 0.00 0.00<br />

30124 S 301.47 0.00 0.00 31084 S 1,142.43 0.00 0.00<br />

30125 S 1,053.48 0.00 0.00 31085 S 1,142.43 0.00 0.00<br />

30130 S 591.51 0.00 0.00 31086 S 1,142.43 0.00 0.00<br />

30140 S 710.95 0.00 0.00 31087 S 1,142.43 0.00 0.00<br />

30150 S 1,084.42 0.00 0.00 31090 S 1,184.49 0.00 0.00<br />

30160 S 1,142.43 0.00 0.00 31200 S 1,053.48 0.00 0.00<br />

30200 S 67.59 0.00 0.00 31201 S 1,184.49 0.00 0.00<br />

30210 S 85.82 0.00 0.00 31205 S 1,084.42 0.00 0.00<br />

30220 S 375.10 0.00 0.00 31231 S 72.35 0.00 0.00<br />

30300 S 25.86 0.00 0.00 31233 S 77.93 0.00 0.00<br />

30310 S 505.94 0.00 0.00 31235 S 529.47 0.00 0.00<br />

30320 S 560.56 0.00 0.00 31237 S 584.09 0.00 0.00<br />

30400 S 1,142.43 0.00 0.00 31238 S 529.47 0.00 0.00<br />

30410 S 1,184.49 0.00 0.00 31239 S 772.86 0.00 0.00<br />

30420 S 1,184.49 0.00 0.00 31240 S 584.09 0.00 0.00<br />

30430 S 741.89 0.00 0.00 31254 S 714.85 0.00 0.00<br />

30435 S 1,184.49 0.00 0.00 31255 S 814.91 0.00 0.00<br />

30450 S 1,318.87 0.00 0.00 31256 S 714.85 0.00 0.00<br />

30460 S 1,318.87 0.00 0.00 31267 S 714.85 0.00 0.00<br />

30462 S 1,485.16 0.00 0.00 31276 S 714.85 0.00 0.00<br />

30465 S 1,485.16 0.00 0.00 31287 S 714.85 0.00 0.00<br />

30520 S 799.89 0.00 0.00 31288 S 714.85 0.00 0.00<br />

30540 S 1,184.49 0.00 0.00 31300 S 841.95 0.00 0.00<br />

30545 S 1,184.49 0.00 0.00 31320 S 1,053.48 0.00 0.00<br />

30560 S 139.03 0.00 0.00 31400 S 1,053.48 0.00 0.00<br />

30580 S 1,142.43 0.00 0.00 31420 S 1,053.48 0.00 0.00<br />

30600 S 1,142.43 0.00 0.00 31500 S 96.77 0.00 0.00<br />

30620 S 1,318.87 0.00 0.00 31502 S 55.64 0.00 0.00<br />

30630 S 976.34 0.00 0.00 31505 S 32.88 0.00 0.00<br />

30801 S 311.71 0.00 0.00 31510 S 584.09 0.00 0.00<br />

30802 S 311.71 0.00 0.00 31511 S 77.93 0.00 0.00<br />

30901 S 44.46 0.00 0.00 31512 S 584.09 0.00 0.00<br />

30903 S 57.27 0.00 0.00 31513 S 77.93 0.00 0.00<br />

30905 S 57.27 0.00 0.00 31515 S 529.47 0.00 0.00<br />

30906 S 57.27 0.00 0.00 31520 S 72.35 0.00 0.00<br />

30915 S 763.09 0.00 0.00 31525 S 529.47 0.00 0.00<br />

30920 S 794.03 0.00 0.00 31526 S 683.92 0.00 0.00<br />

30930 S 649.51 0.00 0.00 31527 S 629.29 0.00 0.00<br />

31000 S 110.50 0.00 0.00 31528 S 584.09 0.00 0.00<br />

31002 S 301.47 0.00 0.00 31529 S 584.09 0.00 0.00<br />

31020 S 710.95 0.00 0.00 31530 S 683.92 0.00 0.00<br />

31030 S 1,084.42 0.00 0.00 31531 S 714.85 0.00 0.00<br />

31032 S 1,142.43 0.00 0.00 31535 S 683.92 0.00 0.00<br />

31040 S 990.71 0.00 0.00 31536 S 714.85 0.00 0.00<br />

31050 S 1,053.48 0.00 0.00 31540 S 714.85 0.00 0.00<br />

31051 S 1,142.43 0.00 0.00 31541 S 772.86 0.00 0.00<br />

31070 S 710.95 0.00 0.00 31545 S 772.86 0.00 0.00<br />

31075 S 1,142.43 0.00 0.00 31546 S 772.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 814.91 0.00 0.00 32405 S 352.64 0.00 0.00<br />

31561 S 814.91 0.00 0.00 32420 S 214.43 0.00 0.00<br />

31570 S 584.09 0.00 0.00 32421 S 214.43 0.00 0.00<br />

31571 S 683.92 0.00 0.00 32422 S 213.48 0.00 0.00<br />

31575 S 62.23 0.00 0.00 32550 S 1,195.25 0.00 0.00<br />

31576 S 683.92 0.00 0.00 32960 S 213.48 0.00 0.00<br />

31577 S 202.03 0.00 0.00 32998 S 1,860.95 0.00 0.00<br />

31578 S 683.92 0.00 0.00 33010 S 214.43 0.00 0.00<br />

31579 S 110.86 0.00 0.00 33011 S 214.43 0.00 0.00<br />

31580 S 1,184.49 0.00 0.00 33206 S 6,879.78 4,093.45 1,307.12<br />

31582 S 1,184.49 0.00 0.00 33207 S 6,879.78 4,093.45 1,307.12<br />

31588 S 1,184.49 0.00 0.00 33208 S 8,532.88 4,972.07 1,411.26<br />

31590 S 1,184.49 0.00 0.00 33210 S 2,020.27 0.00 0.00<br />

31595 S 1,053.48 0.00 0.00 33211 S 2,020.27 0.00 0.00<br />

31603 S 311.71 0.00 0.00 33212 S 5,403.08 3,077.90 752.73<br />

31605 S 301.47 0.00 0.00 33213 S 6,236.32 3,494.08 751.83<br />

31611 S 741.89 0.00 0.00 33214 S 8,532.88 4,972.07 1,411.26<br />

31612 S 656.32 0.00 0.00 33215 S 885.51 0.00 0.00<br />

31613 S 710.95 0.00 0.00 33216 S 2,020.27 0.00 0.00<br />

31614 S 1,053.48 0.00 0.00 33217 S 2,020.27 0.00 0.00<br />

31615 S 311.71 0.00 0.00 33218 S 885.51 0.00 0.00<br />

31622 S 365.06 0.00 0.00 33220 S 885.51 0.00 0.00<br />

31623 S 419.68 0.00 0.00 33222 S 535.25 0.00 0.00<br />

31624 S 419.68 0.00 0.00 33223 S 535.25 0.00 0.00<br />

31625 S 419.68 0.00 0.00 33224 S 8,054.24 4,822.05 1,589.87<br />

31628 S 419.68 0.00 0.00 33225 S 8,054.24 4,822.05 1,589.87<br />

31629 S 419.68 0.00 0.00 33226 S 885.51 0.00 0.00<br />

31630 S 719.16 0.00 0.00 33233 S 658.36 0.00 0.00<br />

31631 S 719.16 0.00 0.00 33234 S 885.51 0.00 0.00<br />

31632 S 408.17 0.00 0.00 33235 S 885.51 0.00 0.00<br />

31633 S 408.17 0.00 0.00 33240 S 20,077.17 10,732.07 1,386.97<br />

31635 S 419.68 0.00 0.00 33241 S 885.51 0.00 0.00<br />

31636 S 719.16 0.00 0.00 33249 S 26,794.51 14,352.25 1,909.99<br />

31637 S 365.06 0.00 0.00 33282 S 4,236.38 2,536.15 835.91<br />

31638 S 719.16 0.00 0.00 33284 S 330.43 0.00 0.00<br />

31640 S 719.16 0.00 0.00 34490 S 1,613.24 0.00 0.00<br />

31641 S 719.16 0.00 0.00 35188 S 1,111.16 0.00 0.00<br />

31643 S 419.68 0.00 0.00 35207 S 1,111.16 0.00 0.00<br />

31645 S 365.06 0.00 0.00 35473 S 1,935.27 0.00 0.00<br />

31646 S 365.06 0.00 0.00 35476 S 1,935.27 0.00 0.00<br />

31656 S 365.06 0.00 0.00 35492 S 3,611.98 0.00 0.00<br />

31717 S 202.03 0.00 0.00 35761 S 1,161.93 0.00 0.00<br />

31720 S 30.93 0.00 0.00 35875 S 1,453.90 0.00 0.00<br />

31730 S 202.03 0.00 0.00 35876 S 1,453.90 0.00 0.00<br />

31750 S 1,184.49 0.00 0.00 36002 S 92.79 0.00 0.00<br />

31755 S 1,053.48 0.00 0.00 36260 S 841.77 0.00 0.00<br />

31820 S 505.94 0.00 0.00 36261 S 658.36 0.00 0.00<br />

31825 S 710.95 0.00 0.00 36262 S 603.72 0.00 0.00<br />

31830 S 710.95 0.00 0.00 36420 S 8.75 0.00 0.00<br />

32400 S 352.64 0.00 0.00 36425 S 8.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 33.61 0.00 0.00 36800 S 906.17 0.00 0.00<br />

36440 S 134.24 0.00 0.00 36810 S 906.17 0.00 0.00<br />

36450 S 134.24 0.00 0.00 36815 S 906.17 0.00 0.00<br />

36455 S 134.24 0.00 0.00 36818 S 1,053.16 0.00 0.00<br />

36468 S 33.14 0.00 0.00 36819 S 1,053.16 0.00 0.00<br />

36469 S 33.14 0.00 0.00 36820 S 1,053.16 0.00 0.00<br />

36470 S 33.14 0.00 0.00 36821 S 1,053.16 0.00 0.00<br />

36471 S 33.14 0.00 0.00 36825 S 1,111.16 0.00 0.00<br />

36475 S 1,523.54 0.00 0.00 36830 S 1,111.16 0.00 0.00<br />

36476 S 1,194.77 0.00 0.00 36831 S 1,453.90 0.00 0.00<br />

36478 S 1,194.77 0.00 0.00 36832 S 1,111.16 0.00 0.00<br />

36479 S 1,194.77 0.00 0.00 36833 S 1,111.16 0.00 0.00<br />

36511 S 460.23 0.00 0.00 36834 S 1,053.16 0.00 0.00<br />

36512 S 460.23 0.00 0.00 36835 S 964.18 0.00 0.00<br />

36513 S 460.23 0.00 0.00 36860 S 110.66 0.00 0.00<br />

36514 S 460.23 0.00 0.00 36861 S 906.17 0.00 0.00<br />

36515 S 1,232.05 0.00 0.00 36870 S 1,584.75 0.00 0.00<br />

36516 S 1,232.05 0.00 0.00 37184 S 1,613.24 0.00 0.00<br />

36522 S 1,232.05 0.00 0.00 37185 S 1,613.24 0.00 0.00<br />

36555 S 382.39 0.00 0.00 37186 S 1,613.24 0.00 0.00<br />

36556 S 382.39 0.00 0.00 37187 S 1,613.24 0.00 0.00<br />

36557 S 714.15 0.00 0.00 37188 S 1,613.24 0.00 0.00<br />

36558 S 714.15 0.00 0.00 37200 S 1,190.47 0.00 0.00<br />

36560 S 841.77 0.00 0.00 37203 S 1,190.47 0.00 0.00<br />

36561 S 841.77 0.00 0.00 37500 S 1,122.80 0.00 0.00<br />

36563 S 841.77 0.00 0.00 37607 S 794.03 0.00 0.00<br />

36565 S 841.77 0.00 0.00 37609 S 533.69 0.00 0.00<br />

36566 S 841.77 0.00 0.00 37650 S 763.09 0.00 0.00<br />

36568 S 382.39 0.00 0.00 37700 S 763.09 0.00 0.00<br />

36569 S 382.39 0.00 0.00 37718 S 794.03 0.00 0.00<br />

36570 S 745.08 0.00 0.00 37722 S 1,122.80 0.00 0.00<br />

36571 S 745.08 0.00 0.00 37735 S 1,122.80 0.00 0.00<br />

36575 S 307.55 0.00 0.00 37760 S 794.03 0.00 0.00<br />

36576 S 437.01 0.00 0.00 37765 S 1,094.98 0.00 0.00<br />

36578 S 714.15 0.00 0.00 37766 S 1,094.98 0.00 0.00<br />

36580 S 382.39 0.00 0.00 37780 S 794.03 0.00 0.00<br />

36581 S 714.15 0.00 0.00 37785 S 794.03 0.00 0.00<br />

36582 S 841.77 0.00 0.00 37790 S 958.16 0.00 0.00<br />

36583 S 841.77 0.00 0.00 38205 S 460.23 0.00 0.00<br />

36584 S 382.39 0.00 0.00 38206 S 460.23 0.00 0.00<br />

36585 S 745.08 0.00 0.00 38220 S 105.50 0.00 0.00<br />

36589 S 252.93 0.00 0.00 38221 S 110.50 0.00 0.00<br />

36590 S 382.39 0.00 0.00 38230 S 1,232.05 0.00 0.00<br />

36593 S 25.39 0.00 0.00 38241 S 1,232.05 0.00 0.00<br />

36595 S 997.09 0.00 0.00 38242 S 460.23 0.00 0.00<br />

36596 S 442.82 0.00 0.00 38300 S 413.00 0.00 0.00<br />

36597 S 442.82 0.00 0.00 38305 S 603.54 0.00 0.00<br />

36598 S 81.89 0.00 0.00 38308 S 689.62 0.00 0.00<br />

36640 S 756.21 0.00 0.00 38500 S 689.62 0.00 0.00<br />

36680 S 57.32 0.00 0.00 38505 S 263.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 689.62 0.00 0.00 41005 S 139.03 0.00 0.00<br />

38520 S 689.62 0.00 0.00 41006 S 656.32 0.00 0.00<br />

38525 S 689.62 0.00 0.00 41007 S 505.94 0.00 0.00<br />

38530 S 689.62 0.00 0.00 41008 S 505.94 0.00 0.00<br />

38542 S 1,160.18 0.00 0.00 41009 S 139.03 0.00 0.00<br />

38550 S 720.56 0.00 0.00 41010 S 311.71 0.00 0.00<br />

38555 S 778.57 0.00 0.00 41015 S 139.03 0.00 0.00<br />

38570 S 1,574.19 0.00 0.00 41016 S 311.71 0.00 0.00<br />

38571 S 2,046.42 0.00 0.00 41017 S 311.71 0.00 0.00<br />

38572 S 1,574.19 0.00 0.00 41018 S 311.71 0.00 0.00<br />

38700 S 948.04 0.00 0.00 41019 S 990.71 0.00 0.00<br />

38740 S 1,160.18 0.00 0.00 41100 S 93.33 0.00 0.00<br />

38745 S 1,249.13 0.00 0.00 41105 S 92.26 0.00 0.00<br />

38760 S 689.62 0.00 0.00 41108 S 85.47 0.00 0.00<br />

40490 S 70.45 0.00 0.00 41110 S 123.73 0.00 0.00<br />

40500 S 560.56 0.00 0.00 41112 S 560.56 0.00 0.00<br />

40510 S 710.95 0.00 0.00 41113 S 560.56 0.00 0.00<br />

40520 S 560.56 0.00 0.00 41114 S 710.95 0.00 0.00<br />

40525 S 710.95 0.00 0.00 41115 S 144.11 0.00 0.00<br />

40527 S 710.95 0.00 0.00 41116 S 505.94 0.00 0.00<br />

40530 S 710.95 0.00 0.00 41120 S 841.95 0.00 0.00<br />

40650 S 375.10 0.00 0.00 41250 S 95.08 0.00 0.00<br />

40652 S 375.10 0.00 0.00 41251 S 139.03 0.00 0.00<br />

40654 S 375.10 0.00 0.00 41252 S 366.33 0.00 0.00<br />

40700 S 1,318.87 0.00 0.00 41500 S 656.32 0.00 0.00<br />

40701 S 1,318.87 0.00 0.00 41510 S 505.94 0.00 0.00<br />

40702 S 1,675.76 0.00 0.00 41520 S 366.33 0.00 0.00<br />

40720 S 1,318.87 0.00 0.00 41530 S 689.94 0.00 0.00<br />

40761 S 1,084.42 0.00 0.00 41800 S 71.03 0.00 0.00<br />

40800 S 56.54 0.00 0.00 41805 S 153.77 0.00 0.00<br />

40801 S 366.33 0.00 0.00 41806 S 189.53 0.00 0.00<br />

40804 S 25.86 0.00 0.00 41820 S 301.47 0.00 0.00<br />

40805 S 174.87 0.00 0.00 41821 S 301.47 0.00 0.00<br />

40806 S 80.46 0.00 0.00 41822 S 156.98 0.00 0.00<br />

40808 S 119.44 0.00 0.00 41823 S 228.87 0.00 0.00<br />

40810 S 123.73 0.00 0.00 41825 S 125.87 0.00 0.00<br />

40812 S 155.20 0.00 0.00 41826 S 158.42 0.00 0.00<br />

40814 S 560.56 0.00 0.00 41827 S 710.95 0.00 0.00<br />

40816 S 710.95 0.00 0.00 41828 S 143.04 0.00 0.00<br />

40818 S 139.03 0.00 0.00 41830 S 203.12 0.00 0.00<br />

40819 S 311.71 0.00 0.00 41850 S 689.94 0.00 0.00<br />

40820 S 178.44 0.00 0.00 41870 S 990.71 0.00 0.00<br />

40830 S 132.35 0.00 0.00 41872 S 203.12 0.00 0.00<br />

40831 S 311.71 0.00 0.00 41874 S 195.96 0.00 0.00<br />

40840 S 710.95 0.00 0.00 42000 S 139.03 0.00 0.00<br />

40842 S 741.89 0.00 0.00 42100 S 79.39 0.00 0.00<br />

40843 S 741.89 0.00 0.00 42104 S 118.01 0.00 0.00<br />

40844 S 1,184.49 0.00 0.00 42106 S 148.05 0.00 0.00<br />

40845 S 1,184.49 0.00 0.00 42107 S 710.95 0.00 0.00<br />

41000 S 88.69 0.00 0.00 42120 S 1,142.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 366.33 0.00 0.00 42809 S 25.86 0.00 0.00<br />

42145 S 841.95 0.00 0.00 42810 S 741.89 0.00 0.00<br />

42160 S 140.18 0.00 0.00 42815 S 1,184.49 0.00 0.00<br />

42180 S 139.03 0.00 0.00 42820 S 741.89 0.00 0.00<br />

42182 S 1,053.48 0.00 0.00 42821 S 841.95 0.00 0.00<br />

42200 S 1,184.49 0.00 0.00 42825 S 799.89 0.00 0.00<br />

42205 S 1,184.49 0.00 0.00 42826 S 799.89 0.00 0.00<br />

42210 S 1,184.49 0.00 0.00 42830 S 799.89 0.00 0.00<br />

42215 S 1,318.87 0.00 0.00 42831 S 799.89 0.00 0.00<br />

42220 S 1,184.49 0.00 0.00 42835 S 799.89 0.00 0.00<br />

42226 S 1,184.49 0.00 0.00 42836 S 799.89 0.00 0.00<br />

42235 S 691.57 0.00 0.00 42860 S 741.89 0.00 0.00<br />

42260 S 799.89 0.00 0.00 42870 S 741.89 0.00 0.00<br />

42280 S 77.24 0.00 0.00 42890 S 1,318.87 0.00 0.00<br />

42281 S 689.94 0.00 0.00 42892 S 1,318.87 0.00 0.00<br />

42300 S 505.94 0.00 0.00 42900 S 311.71 0.00 0.00<br />

42305 S 560.56 0.00 0.00 42950 S 710.95 0.00 0.00<br />

42310 S 139.03 0.00 0.00 42955 S 710.95 0.00 0.00<br />

42320 S 139.03 0.00 0.00 42960 S 57.27 0.00 0.00<br />

42330 S 119.44 0.00 0.00 42962 S 1,053.48 0.00 0.00<br />

42335 S 198.11 0.00 0.00 42970 S 44.46 0.00 0.00<br />

42340 S 560.56 0.00 0.00 42972 S 591.51 0.00 0.00<br />

42400 S 67.23 0.00 0.00 43030 S 689.94 0.00 0.00<br />

42405 S 560.56 0.00 0.00 43200 S 334.11 0.00 0.00<br />

42408 S 591.51 0.00 0.00 43201 S 334.11 0.00 0.00<br />

42409 S 591.51 0.00 0.00 43202 S 334.11 0.00 0.00<br />

42410 S 1,084.42 0.00 0.00 43204 S 334.11 0.00 0.00<br />

42415 S 1,318.87 0.00 0.00 43205 S 334.11 0.00 0.00<br />

42420 S 1,318.87 0.00 0.00 43215 S 334.11 0.00 0.00<br />

42425 S 1,318.87 0.00 0.00 43216 S 334.11 0.00 0.00<br />

42440 S 1,084.42 0.00 0.00 43217 S 334.11 0.00 0.00<br />

42450 S 710.95 0.00 0.00 43219 S 675.23 0.00 0.00<br />

42500 S 741.89 0.00 0.00 43220 S 334.11 0.00 0.00<br />

42505 S 1,142.43 0.00 0.00 43226 S 334.11 0.00 0.00<br />

42507 S 1,084.42 0.00 0.00 43227 S 388.74 0.00 0.00<br />

42508 S 1,142.43 0.00 0.00 43228 S 723.41 0.00 0.00<br />

42509 S 1,142.43 0.00 0.00 43231 S 388.74 0.00 0.00<br />

42510 S 1,142.43 0.00 0.00 43232 S 388.74 0.00 0.00<br />

42600 S 505.94 0.00 0.00 43234 S 334.11 0.00 0.00<br />

42650 S 43.98 0.00 0.00 43235 S 334.11 0.00 0.00<br />

42660 S 51.50 0.00 0.00 43236 S 388.74 0.00 0.00<br />

42665 S 976.34 0.00 0.00 43237 S 388.74 0.00 0.00<br />

42700 S 139.03 0.00 0.00 43238 S 388.74 0.00 0.00<br />

42720 S 505.94 0.00 0.00 43239 S 388.74 0.00 0.00<br />

42725 S 1,053.48 0.00 0.00 43240 S 388.74 0.00 0.00<br />

42800 S 85.11 0.00 0.00 43241 S 388.74 0.00 0.00<br />

42802 S 505.94 0.00 0.00 43242 S 388.74 0.00 0.00<br />

42804 S 505.94 0.00 0.00 43243 S 388.74 0.00 0.00<br />

42806 S 710.95 0.00 0.00 43244 S 388.74 0.00 0.00<br />

42808 S 560.56 0.00 0.00 43245 S 388.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 388.74 0.00 0.00 44378 S 407.14 0.00 0.00<br />

43247 S 388.74 0.00 0.00 44379 S 1,161.54 0.00 0.00<br />

43248 S 388.74 0.00 0.00 44380 S 352.51 0.00 0.00<br />

43249 S 388.74 0.00 0.00 44382 S 352.51 0.00 0.00<br />

43250 S 388.74 0.00 0.00 44383 S 1,161.54 0.00 0.00<br />

43251 S 388.74 0.00 0.00 44385 S 340.83 0.00 0.00<br />

43255 S 388.74 0.00 0.00 44386 S 340.83 0.00 0.00<br />

43256 S 760.80 0.00 0.00 44388 S 340.83 0.00 0.00<br />

43257 S 754.35 0.00 0.00 44389 S 340.83 0.00 0.00<br />

43258 S 419.67 0.00 0.00 44390 S 340.83 0.00 0.00<br />

43259 S 419.67 0.00 0.00 44391 S 340.83 0.00 0.00<br />

43260 S 654.44 0.00 0.00 44392 S 340.83 0.00 0.00<br />

43261 S 654.44 0.00 0.00 44393 S 340.83 0.00 0.00<br />

43262 S 654.44 0.00 0.00 44394 S 340.83 0.00 0.00<br />

43263 S 654.44 0.00 0.00 44397 S 675.23 0.00 0.00<br />

43264 S 654.44 0.00 0.00 44500 S 183.92 0.00 0.00<br />

43265 S 654.44 0.00 0.00 45000 S 395.25 0.00 0.00<br />

43267 S 654.44 0.00 0.00 45005 S 460.00 0.00 0.00<br />

43268 S 729.86 0.00 0.00 45020 S 460.00 0.00 0.00<br />

43269 S 729.86 0.00 0.00 45100 S 624.95 0.00 0.00<br />

43271 S 654.44 0.00 0.00 45108 S 679.57 0.00 0.00<br />

43272 S 654.44 0.00 0.00 45150 S 679.57 0.00 0.00<br />

43273 S 877.69 0.00 0.00 45160 S 679.57 0.00 0.00<br />

43450 S 292.20 0.00 0.00 45170 S 679.57 0.00 0.00<br />

43453 S 292.20 0.00 0.00 45190 S 1,111.25 0.00 0.00<br />

43456 S 293.36 0.00 0.00 45300 S 65.80 0.00 0.00<br />

43458 S 335.28 0.00 0.00 45303 S 365.48 0.00 0.00<br />

43600 S 334.11 0.00 0.00 45305 S 343.71 0.00 0.00<br />

43653 S 1,574.19 0.00 0.00 45307 S 634.86 0.00 0.00<br />

43760 S 162.04 0.00 0.00 45308 S 343.71 0.00 0.00<br />

43761 S 334.11 0.00 0.00 45309 S 343.71 0.00 0.00<br />

43870 S 334.11 0.00 0.00 45315 S 343.71 0.00 0.00<br />

43886 S 843.03 0.00 0.00 45317 S 343.71 0.00 0.00<br />

43887 S 177.31 0.00 0.00 45320 S 634.86 0.00 0.00<br />

43888 S 843.03 0.00 0.00 45321 S 634.86 0.00 0.00<br />

44100 S 334.11 0.00 0.00 45327 S 675.23 0.00 0.00<br />

44312 S 582.49 0.00 0.00 45330 S 86.90 0.00 0.00<br />

44340 S 668.05 0.00 0.00 45331 S 256.97 0.00 0.00<br />

44360 S 407.14 0.00 0.00 45332 S 256.97 0.00 0.00<br />

44361 S 407.14 0.00 0.00 45333 S 343.71 0.00 0.00<br />

44363 S 407.14 0.00 0.00 45334 S 343.71 0.00 0.00<br />

44364 S 407.14 0.00 0.00 45335 S 256.97 0.00 0.00<br />

44365 S 407.14 0.00 0.00 45337 S 256.97 0.00 0.00<br />

44366 S 407.14 0.00 0.00 45338 S 343.71 0.00 0.00<br />

44369 S 407.14 0.00 0.00 45339 S 343.71 0.00 0.00<br />

44370 S 1,161.54 0.00 0.00 45340 S 343.71 0.00 0.00<br />

44372 S 407.14 0.00 0.00 45341 S 343.71 0.00 0.00<br />

44373 S 407.14 0.00 0.00 45342 S 343.71 0.00 0.00<br />

44376 S 407.14 0.00 0.00 45345 S 675.23 0.00 0.00<br />

44377 S 407.14 0.00 0.00 45355 S 340.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 395.46 0.00 0.00 46505 S 488.79 0.00 0.00<br />

45379 S 395.46 0.00 0.00 46600 S 25.86 0.00 0.00<br />

45380 S 395.46 0.00 0.00 46604 S 365.48 0.00 0.00<br />

45381 S 395.46 0.00 0.00 46606 S 137.32 0.00 0.00<br />

45382 S 395.46 0.00 0.00 46608 S 343.71 0.00 0.00<br />

45383 S 395.46 0.00 0.00 46610 S 634.86 0.00 0.00<br />

45384 S 395.46 0.00 0.00 46611 S 343.71 0.00 0.00<br />

45385 S 395.46 0.00 0.00 46612 S 634.86 0.00 0.00<br />

45386 S 395.46 0.00 0.00 46614 S 72.23 0.00 0.00<br />

45387 S 675.23 0.00 0.00 46615 S 689.48 0.00 0.00<br />

45391 S 395.46 0.00 0.00 46700 S 710.52 0.00 0.00<br />

45392 S 395.46 0.00 0.00 46706 S 782.07 0.00 0.00<br />

45500 S 679.57 0.00 0.00 46750 S 867.63 0.00 0.00<br />

45505 S 836.70 0.00 0.00 46753 S 710.52 0.00 0.00<br />

45520 S 33.14 0.00 0.00 46754 S 679.57 0.00 0.00<br />

45560 S 836.70 0.00 0.00 46760 S 836.70 0.00 0.00<br />

45900 S 267.95 0.00 0.00 46761 S 867.63 0.00 0.00<br />

45905 S 624.95 0.00 0.00 46762 S 1,102.08 0.00 0.00<br />

45910 S 624.95 0.00 0.00 46900 S 109.20 0.00 0.00<br />

45915 S 395.25 0.00 0.00 46910 S 130.52 0.00 0.00<br />

45990 S 614.83 0.00 0.00 46916 S 60.71 0.00 0.00<br />

46020 S 710.52 0.00 0.00 46917 S 566.32 0.00 0.00<br />

46030 S 267.95 0.00 0.00 46922 S 566.32 0.00 0.00<br />

46040 S 710.52 0.00 0.00 46924 S 566.32 0.00 0.00<br />

46045 S 679.57 0.00 0.00 46930 S 126.59 0.00 0.00<br />

46050 S 395.25 0.00 0.00 46937 S 679.57 0.00 0.00<br />

46060 S 679.57 0.00 0.00 46938 S 836.70 0.00 0.00<br />

46070 S 488.79 0.00 0.00 46940 S 93.69 0.00 0.00<br />

46080 S 710.52 0.00 0.00 46942 S 91.19 0.00 0.00<br />

46083 S 74.82 0.00 0.00 46945 S 155.20 0.00 0.00<br />

46200 S 679.57 0.00 0.00 46946 S 405.36 0.00 0.00<br />

46210 S 679.57 0.00 0.00 46947 S 1,102.08 0.00 0.00<br />

46211 S 679.57 0.00 0.00 47000 S 352.64 0.00 0.00<br />

46220 S 624.95 0.00 0.00 47382 S 1,860.95 0.00 0.00<br />

46221 S 123.02 0.00 0.00 47510 S 824.13 0.00 0.00<br />

46230 S 624.95 0.00 0.00 47511 S 1,210.78 0.00 0.00<br />

46250 S 710.52 0.00 0.00 47525 S 473.11 0.00 0.00<br />

46255 S 710.52 0.00 0.00 47530 S 473.11 0.00 0.00<br />

46257 S 710.52 0.00 0.00 47552 S 824.13 0.00 0.00<br />

46258 S 710.52 0.00 0.00 47553 S 855.07 0.00 0.00<br />

46260 S 710.52 0.00 0.00 47554 S 855.07 0.00 0.00<br />

46261 S 768.52 0.00 0.00 47555 S 855.07 0.00 0.00<br />

46262 S 768.52 0.00 0.00 47556 S 1,210.78 0.00 0.00<br />

46270 S 710.52 0.00 0.00 47560 S 1,004.68 0.00 0.00<br />

46275 S 710.52 0.00 0.00 47561 S 1,004.68 0.00 0.00<br />

46280 S 768.52 0.00 0.00 47562 S 1,853.84 0.00 0.00<br />

46285 S 624.95 0.00 0.00 47563 S 1,853.84 0.00 0.00<br />

46288 S 768.52 0.00 0.00 47564 S 1,853.84 0.00 0.00<br />

46320 S 83.33 0.00 0.00 47630 S 855.07 0.00 0.00<br />

46500 S 114.79 0.00 0.00 48102 S 352.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 214.43 0.00 0.00 49590 S 880.10 0.00 0.00<br />

49081 S 214.43 0.00 0.00 49600 S 938.11 0.00 0.00<br />

49180 S 352.64 0.00 0.00 49650 S 1,231.46 0.00 0.00<br />

49250 S 772.99 0.00 0.00 49651 S 1,407.91 0.00 0.00<br />

49320 S 1,004.68 0.00 0.00 49652 S 1,516.28 0.00 0.00<br />

49321 S 1,062.69 0.00 0.00 49653 S 1,516.28 0.00 0.00<br />

49322 S 1,062.69 0.00 0.00 49654 S 1,516.28 0.00 0.00<br />

49324 S 1,516.28 0.00 0.00 49655 S 1,516.28 0.00 0.00<br />

49325 S 1,516.28 0.00 0.00 49656 S 1,516.28 0.00 0.00<br />

49326 S 1,516.28 0.00 0.00 49657 S 1,516.28 0.00 0.00<br />

49402 S 684.05 0.00 0.00 50200 S 352.64 0.00 0.00<br />

49419 S 820.61 0.00 0.00 50382 S 1,023.98 0.00 0.00<br />

49420 S 758.60 0.00 0.00 50384 S 752.09 0.00 0.00<br />

49421 S 758.60 0.00 0.00 50385 S 752.09 0.00 0.00<br />

49422 S 603.72 0.00 0.00 50386 S 288.56 0.00 0.00<br />

49423 S 624.28 0.00 0.00 50387 S 624.28 0.00 0.00<br />

49426 S 684.05 0.00 0.00 50389 S 288.56 0.00 0.00<br />

49429 S 885.51 0.00 0.00 50390 S 352.64 0.00 0.00<br />

49440 S 346.27 0.00 0.00 50391 S 41.76 0.00 0.00<br />

49441 S 346.27 0.00 0.00 50392 S 537.02 0.00 0.00<br />

49446 S 346.27 0.00 0.00 50393 S 672.96 0.00 0.00<br />

49450 S 183.92 0.00 0.00 50395 S 537.02 0.00 0.00<br />

49451 S 183.92 0.00 0.00 50396 S 100.97 0.00 0.00<br />

49452 S 183.92 0.00 0.00 50398 S 473.11 0.00 0.00<br />

49460 S 183.92 0.00 0.00 50551 S 305.25 0.00 0.00<br />

49495 S 938.11 0.00 0.00 50553 S 672.96 0.00 0.00<br />

49496 S 938.11 0.00 0.00 50555 S 305.25 0.00 0.00<br />

49500 S 938.11 0.00 0.00 50557 S 672.96 0.00 0.00<br />

49501 S 1,280.84 0.00 0.00 50561 S 672.96 0.00 0.00<br />

49505 S 938.11 0.00 0.00 50562 S 288.56 0.00 0.00<br />

49507 S 1,280.84 0.00 0.00 50570 S 288.56 0.00 0.00<br />

49520 S 1,114.56 0.00 0.00 50572 S 288.56 0.00 0.00<br />

49521 S 1,280.84 0.00 0.00 50574 S 288.56 0.00 0.00<br />

49525 S 938.11 0.00 0.00 50575 S 1,435.34 0.00 0.00<br />

49540 S 849.16 0.00 0.00 50576 S 752.09 0.00 0.00<br />

49550 S 980.17 0.00 0.00 50580 S 752.09 0.00 0.00<br />

49553 S 1,280.84 0.00 0.00 50590 S 1,676.80 0.00 0.00<br />

49555 S 980.17 0.00 0.00 50592 S 1,860.95 0.00 0.00<br />

49557 S 1,280.84 0.00 0.00 50686 S 41.76 0.00 0.00<br />

49560 S 938.11 0.00 0.00 50688 S 473.11 0.00 0.00<br />

49561 S 1,280.84 0.00 0.00 50947 S 1,574.19 0.00 0.00<br />

49565 S 938.11 0.00 0.00 50948 S 1,574.19 0.00 0.00<br />

49566 S 1,280.84 0.00 0.00 50951 S 305.25 0.00 0.00<br />

49568 S 1,114.56 0.00 0.00 50953 S 305.25 0.00 0.00<br />

49570 S 938.11 0.00 0.00 50955 S 672.96 0.00 0.00<br />

49572 S 1,280.84 0.00 0.00 50957 S 672.96 0.00 0.00<br />

49580 S 938.11 0.00 0.00 50961 S 672.96 0.00 0.00<br />

49582 S 1,280.84 0.00 0.00 50970 S 305.25 0.00 0.00<br />

49585 S 938.11 0.00 0.00 50972 S 305.25 0.00 0.00<br />

49587 S 1,280.84 0.00 0.00 50974 S 537.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 537.02 0.00 0.00 52275 S 727.59 0.00 0.00<br />

50980 S 672.96 0.00 0.00 52276 S 758.53 0.00 0.00<br />

51020 S 816.54 0.00 0.00 52277 S 727.59 0.00 0.00<br />

51030 S 816.54 0.00 0.00 52281 S 591.64 0.00 0.00<br />

51040 S 816.54 0.00 0.00 52282 S 1,364.95 0.00 0.00<br />

51045 S 337.27 0.00 0.00 52283 S 727.59 0.00 0.00<br />

51050 S 816.54 0.00 0.00 52285 S 591.64 0.00 0.00<br />

51065 S 816.54 0.00 0.00 52290 S 591.64 0.00 0.00<br />

51080 S 548.90 0.00 0.00 52300 S 727.59 0.00 0.00<br />

51100 S 31.83 0.00 0.00 52301 S 758.53 0.00 0.00<br />

51101 S 41.76 0.00 0.00 52305 S 727.59 0.00 0.00<br />

51102 S 561.85 0.00 0.00 52310 S 569.03 0.00 0.00<br />

51500 S 938.11 0.00 0.00 52315 S 727.59 0.00 0.00<br />

51520 S 816.54 0.00 0.00 52317 S 672.96 0.00 0.00<br />

51700 S 54.35 0.00 0.00 52318 S 727.59 0.00 0.00<br />

51701 S 25.86 0.00 0.00 52320 S 858.59 0.00 0.00<br />

51702 S 25.86 0.00 0.00 52325 S 816.54 0.00 0.00<br />

51703 S 41.76 0.00 0.00 52327 S 933.27 0.00 0.00<br />

51705 S 74.82 0.00 0.00 52330 S 727.59 0.00 0.00<br />

51710 S 473.11 0.00 0.00 52332 S 727.59 0.00 0.00<br />

51715 S 859.04 0.00 0.00 52334 S 758.53 0.00 0.00<br />

51720 S 60.07 0.00 0.00 52341 S 758.53 0.00 0.00<br />

51725 TC S 115.41 0.00 0.00 52342 S 758.53 0.00 0.00<br />

51726 TC S 158.97 0.00 0.00 52343 S 758.53 0.00 0.00<br />

51736 TC S 21.81 0.00 0.00 52344 S 758.53 0.00 0.00<br />

51741 TC S 25.39 0.00 0.00 52345 S 758.53 0.00 0.00<br />

51772 TC S 100.97 0.00 0.00 52346 S 758.53 0.00 0.00<br />

51784 TC S 41.76 0.00 0.00 52351 S 758.53 0.00 0.00<br />

51785 TC S 69.76 0.00 0.00 52352 S 816.54 0.00 0.00<br />

51792 TC S 41.76 0.00 0.00 52353 S 1,022.22 0.00 0.00<br />

51795 TC S 74.82 0.00 0.00 52354 S 816.54 0.00 0.00<br />

51797 TC S 74.82 0.00 0.00 52355 S 816.54 0.00 0.00<br />

51798 S 18.59 0.00 0.00 52400 S 758.53 0.00 0.00<br />

51880 S 672.96 0.00 0.00 52402 S 758.53 0.00 0.00<br />

51992 S 1,273.52 0.00 0.00 52450 S 758.53 0.00 0.00<br />

52000 S 305.25 0.00 0.00 52500 S 758.53 0.00 0.00<br />

52001 S 569.03 0.00 0.00 52601 S 1,022.22 0.00 0.00<br />

52005 S 591.64 0.00 0.00 52630 S 933.27 0.00 0.00<br />

52007 S 727.59 0.00 0.00 52640 S 727.59 0.00 0.00<br />

52010 S 337.27 0.00 0.00 52647 S 1,563.89 0.00 0.00<br />

52204 S 591.64 0.00 0.00 52648 S 1,563.89 0.00 0.00<br />

52214 S 727.59 0.00 0.00 52700 S 727.59 0.00 0.00<br />

52224 S 727.59 0.00 0.00 53000 S 558.42 0.00 0.00<br />

52234 S 727.59 0.00 0.00 53010 S 558.42 0.00 0.00<br />

52235 S 758.53 0.00 0.00 53020 S 558.42 0.00 0.00<br />

52240 S 758.53 0.00 0.00 53025 S 794.90 0.00 0.00<br />

52250 S 816.54 0.00 0.00 53040 S 613.05 0.00 0.00<br />

52260 S 591.64 0.00 0.00 53060 S 72.60 0.00 0.00<br />

52265 S 288.56 0.00 0.00 53080 S 643.99 0.00 0.00<br />

52270 S 591.64 0.00 0.00 53085 S 794.90 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 558.42 0.00 0.00 54060 S 566.32 0.00 0.00<br />

53210 S 959.10 0.00 0.00 54065 S 566.32 0.00 0.00<br />

53215 S 744.05 0.00 0.00 54100 S 479.07 0.00 0.00<br />

53220 S 828.09 0.00 0.00 54105 S 598.04 0.00 0.00<br />

53230 S 828.09 0.00 0.00 54110 S 927.22 0.00 0.00<br />

53235 S 643.99 0.00 0.00 54111 S 927.22 0.00 0.00<br />

53240 S 828.09 0.00 0.00 54112 S 927.22 0.00 0.00<br />

53250 S 613.05 0.00 0.00 54115 S 548.90 0.00 0.00<br />

53260 S 613.05 0.00 0.00 54120 S 927.22 0.00 0.00<br />

53265 S 613.05 0.00 0.00 54150 S 617.94 0.00 0.00<br />

53270 S 613.05 0.00 0.00 54160 S 672.57 0.00 0.00<br />

53275 S 613.05 0.00 0.00 54161 S 672.57 0.00 0.00<br />

53400 S 859.04 0.00 0.00 54162 S 672.57 0.00 0.00<br />

53405 S 828.09 0.00 0.00 54163 S 672.57 0.00 0.00<br />

53410 S 828.09 0.00 0.00 54164 S 672.57 0.00 0.00<br />

53420 S 859.04 0.00 0.00 54200 S 70.45 0.00 0.00<br />

53425 S 828.09 0.00 0.00 54205 S 1,016.17 0.00 0.00<br />

53430 S 828.09 0.00 0.00 54220 S 100.97 0.00 0.00<br />

53431 S 828.09 0.00 0.00 54231 S 66.15 0.00 0.00<br />

53440 S 4,770.14 2,897.12 1,024.11 54235 S 46.85 0.00 0.00<br />

53442 S 773.47 0.00 0.00 54240 TC S 33.25 0.00 0.00<br />

53444 S 4,770.14 2,897.12 1,024.11 54250 TC S 11.80 0.00 0.00<br />

53445 S 8,012.62 4,563.13 1,113.65 54300 S 958.16 0.00 0.00<br />

53446 S 773.47 0.00 0.00 54304 S 958.16 0.00 0.00<br />

53447 S 8,012.62 4,563.13 1,113.65 54308 S 958.16 0.00 0.00<br />

53449 S 773.47 0.00 0.00 54312 S 958.16 0.00 0.00<br />

53450 S 773.47 0.00 0.00 54316 S 958.16 0.00 0.00<br />

53460 S 558.42 0.00 0.00 54318 S 958.16 0.00 0.00<br />

53502 S 613.05 0.00 0.00 54322 S 958.16 0.00 0.00<br />

53505 S 828.09 0.00 0.00 54324 S 958.16 0.00 0.00<br />

53510 S 613.05 0.00 0.00 54326 S 958.16 0.00 0.00<br />

53515 S 828.09 0.00 0.00 54328 S 958.16 0.00 0.00<br />

53520 S 828.09 0.00 0.00 54340 S 958.16 0.00 0.00<br />

53600 S 41.84 0.00 0.00 54344 S 958.16 0.00 0.00<br />

53601 S 41.76 0.00 0.00 54348 S 958.16 0.00 0.00<br />

53605 S 591.64 0.00 0.00 54352 S 958.16 0.00 0.00<br />

53620 S 64.37 0.00 0.00 54360 S 958.16 0.00 0.00<br />

53621 S 67.59 0.00 0.00 54380 S 958.16 0.00 0.00<br />

53660 S 41.76 0.00 0.00 54385 S 958.16 0.00 0.00<br />

53661 S 41.76 0.00 0.00 54400 S 4,801.08 2,928.07 1,055.06<br />

53665 S 558.42 0.00 0.00 54401 S 8,098.19 4,648.70 1,199.22<br />

53850 S 1,833.23 0.00 0.00 54405 S 8,098.19 4,648.70 1,199.22<br />

53852 S 1,833.23 0.00 0.00 54406 S 958.16 0.00 0.00<br />

54000 S 613.05 0.00 0.00 54408 S 958.16 0.00 0.00<br />

54001 S 613.05 0.00 0.00 54410 S 8,098.19 4,648.70 1,199.22<br />

54015 S 692.48 0.00 0.00 54415 S 958.16 0.00 0.00<br />

54050 S 33.14 0.00 0.00 54416 S 8,098.19 4,648.70 1,199.22<br />

54055 S 67.59 0.00 0.00 54420 S 1,016.17 0.00 0.00<br />

54056 S 33.14 0.00 0.00 54435 S 1,016.17 0.00 0.00<br />

54057 S 566.32 0.00 0.00 54440 S 1,016.17 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 158.97 0.00 0.00 55706 S 462.13 0.00 0.00<br />

54500 S 431.45 0.00 0.00 55720 S 672.96 0.00 0.00<br />

54505 S 617.94 0.00 0.00 55725 S 727.59 0.00 0.00<br />

54512 S 672.57 0.00 0.00 55860 S 801.77 0.00 0.00<br />

54520 S 703.51 0.00 0.00 55870 S 81.53 0.00 0.00<br />

54522 S 703.51 0.00 0.00 55873 S 6,343.88 0.00 0.00<br />

54530 S 938.11 0.00 0.00 55875 S 1,364.95 0.00 0.00<br />

54550 S 938.11 0.00 0.00 55876 S 74.74 0.00 0.00<br />

54560 S 913.94 0.00 0.00 55920 S 936.91 0.00 0.00<br />

54600 S 761.52 0.00 0.00 56405 S 43.63 0.00 0.00<br />

54620 S 703.51 0.00 0.00 56420 S 56.94 0.00 0.00<br />

54640 S 938.11 0.00 0.00 56440 S 611.47 0.00 0.00<br />

54660 S 672.57 0.00 0.00 56441 S 556.84 0.00 0.00<br />

54670 S 703.51 0.00 0.00 56442 S 556.84 0.00 0.00<br />

54680 S 703.51 0.00 0.00 56501 S 60.07 0.00 0.00<br />

54690 S 1,574.19 0.00 0.00 56515 S 651.89 0.00 0.00<br />

54692 S 2,798.28 0.00 0.00 56605 S 34.68 0.00 0.00<br />

54700 S 672.57 0.00 0.00 56606 S 14.31 0.00 0.00<br />

54800 S 150.97 0.00 0.00 56620 S 742.46 0.00 0.00<br />

54830 S 703.51 0.00 0.00 56625 S 876.85 0.00 0.00<br />

54840 S 761.52 0.00 0.00 56700 S 556.84 0.00 0.00<br />

54860 S 703.51 0.00 0.00 56740 S 642.40 0.00 0.00<br />

54861 S 761.52 0.00 0.00 56800 S 642.40 0.00 0.00<br />

54865 S 617.94 0.00 0.00 56805 S 791.73 0.00 0.00<br />

54900 S 761.52 0.00 0.00 56810 S 742.46 0.00 0.00<br />

54901 S 761.52 0.00 0.00 56820 S 44.34 0.00 0.00<br />

55000 S 68.66 0.00 0.00 56821 S 56.94 0.00 0.00<br />

55040 S 880.10 0.00 0.00 57000 S 556.84 0.00 0.00<br />

55041 S 980.17 0.00 0.00 57010 S 611.47 0.00 0.00<br />

55060 S 761.52 0.00 0.00 57020 S 320.68 0.00 0.00<br />

55100 S 413.00 0.00 0.00 57022 S 504.06 0.00 0.00<br />

55110 S 672.57 0.00 0.00 57023 S 548.90 0.00 0.00<br />

55120 S 672.57 0.00 0.00 57061 S 55.42 0.00 0.00<br />

55150 S 617.94 0.00 0.00 57065 S 556.84 0.00 0.00<br />

55175 S 617.94 0.00 0.00 57100 S 35.41 0.00 0.00<br />

55180 S 672.57 0.00 0.00 57105 S 611.47 0.00 0.00<br />

55200 S 672.57 0.00 0.00 57130 S 611.47 0.00 0.00<br />

55250 S 672.57 0.00 0.00 57135 S 611.47 0.00 0.00<br />

55400 S 617.94 0.00 0.00 57150 S 25.75 0.00 0.00<br />

55450 S 221.00 0.00 0.00 57155 S 320.68 0.00 0.00<br />

55500 S 703.51 0.00 0.00 57160 S 37.19 0.00 0.00<br />

55520 S 761.52 0.00 0.00 57170 S 6.10 0.00 0.00<br />

55530 S 761.52 0.00 0.00 57180 S 114.54 0.00 0.00<br />

55535 S 938.11 0.00 0.00 57200 S 556.84 0.00 0.00<br />

55540 S 980.17 0.00 0.00 57210 S 611.47 0.00 0.00<br />

55550 S 1,574.19 0.00 0.00 57220 S 1,121.35 0.00 0.00<br />

55600 S 913.94 0.00 0.00 57230 S 920.73 0.00 0.00<br />

55680 S 617.94 0.00 0.00 57240 S 1,020.79 0.00 0.00<br />

55700 S 398.24 0.00 0.00 57250 S 1,020.79 0.00 0.00<br />

55705 S 398.24 0.00 0.00 57260 S 1,020.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,355.80 0.00 0.00 58555 S 601.63 0.00 0.00<br />

57267 S 1,155.18 0.00 0.00 58558 S 687.20 0.00 0.00<br />

57268 S 920.73 0.00 0.00 58559 S 656.26 0.00 0.00<br />

57287 S 1,348.38 0.00 0.00 58560 S 979.85 0.00 0.00<br />

57288 S 1,221.41 0.00 0.00 58561 S 979.85 0.00 0.00<br />

57289 S 1,020.79 0.00 0.00 58562 S 687.20 0.00 0.00<br />

57291 S 1,020.79 0.00 0.00 58563 S 1,380.58 0.00 0.00<br />

57300 S 920.73 0.00 0.00 58565 S 1,522.09 0.00 0.00<br />

57320 S 1,348.38 0.00 0.00 58600 S 1,348.38 0.00 0.00<br />

57400 S 611.47 0.00 0.00 58615 S 791.73 0.00 0.00<br />

57410 S 611.47 0.00 0.00 58660 S 1,273.52 0.00 0.00<br />

57415 S 611.47 0.00 0.00 58661 S 1,273.52 0.00 0.00<br />

57420 S 45.78 0.00 0.00 58662 S 1,273.52 0.00 0.00<br />

57421 S 59.72 0.00 0.00 58670 S 1,173.46 0.00 0.00<br />

57452 S 43.27 0.00 0.00 58671 S 1,173.46 0.00 0.00<br />

57454 S 52.93 0.00 0.00 58672 S 1,273.52 0.00 0.00<br />

57455 S 56.14 0.00 0.00 58673 S 1,273.52 0.00 0.00<br />

57456 S 54.35 0.00 0.00 58800 S 642.40 0.00 0.00<br />

57460 S 167.00 0.00 0.00 58805 S 1,348.38 0.00 0.00<br />

57461 S 177.37 0.00 0.00 58820 S 920.73 0.00 0.00<br />

57500 S 76.52 0.00 0.00 58900 S 642.40 0.00 0.00<br />

57505 S 48.63 0.00 0.00 58970 S 178.94 0.00 0.00<br />

57510 S 49.35 0.00 0.00 58974 S 178.94 0.00 0.00<br />

57511 S 56.94 0.00 0.00 58976 S 178.94 0.00 0.00<br />

57513 S 611.47 0.00 0.00 59000 S 65.44 0.00 0.00<br />

57520 S 611.47 0.00 0.00 59001 S 245.63 0.00 0.00<br />

57522 S 611.47 0.00 0.00 59012 S 120.11 0.00 0.00<br />

57530 S 920.73 0.00 0.00 59015 S 52.93 0.00 0.00<br />

57550 S 920.73 0.00 0.00 59020 TC S 27.89 0.00 0.00<br />

57556 S 1,221.41 0.00 0.00 59025 TC S 14.66 0.00 0.00<br />

57558 S 642.40 0.00 0.00 59070 S 120.11 0.00 0.00<br />

57700 S 556.84 0.00 0.00 59072 S 120.11 0.00 0.00<br />

57720 S 642.40 0.00 0.00 59076 S 120.11 0.00 0.00<br />

57800 S 26.11 0.00 0.00 59100 S 1,348.38 0.00 0.00<br />

58100 S 42.91 0.00 0.00 59150 S 1,853.84 0.00 0.00<br />

58120 S 611.47 0.00 0.00 59151 S 1,853.84 0.00 0.00<br />

58145 S 1,020.79 0.00 0.00 59160 S 642.40 0.00 0.00<br />

58301 S 40.05 0.00 0.00 59200 S 35.76 0.00 0.00<br />

58321 S 37.55 0.00 0.00 59300 S 77.24 0.00 0.00<br />

58322 S 38.62 0.00 0.00 59320 S 556.84 0.00 0.00<br />

58323 S 8.94 0.00 0.00 59412 S 791.73 0.00 0.00<br />

58345 S 791.73 0.00 0.00 59414 S 791.73 0.00 0.00<br />

58346 S 611.47 0.00 0.00 59812 S 742.46 0.00 0.00<br />

58350 S 920.73 0.00 0.00 59820 S 742.46 0.00 0.00<br />

58353 S 1,155.18 0.00 0.00 59821 S 742.46 0.00 0.00<br />

58356 S 1,749.62 0.00 0.00 59840 S 742.46 0.00 0.00<br />

58545 S 1,405.42 0.00 0.00 59841 S 742.46 0.00 0.00<br />

58546 S 1,574.19 0.00 0.00 59866 S 120.11 0.00 0.00<br />

58550 S 2,046.42 0.00 0.00 59870 S 742.46 0.00 0.00<br />

58552 S 1,853.84 0.00 0.00 59871 S 742.46 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 311.71 0.00 0.00 62367 S 17.16 0.00 0.00<br />

60100 S 48.99 0.00 0.00 62368 S 21.81 0.00 0.00<br />

60200 S 1,160.18 0.00 0.00 63600 S 586.00 0.00 0.00<br />

60280 S 1,249.13 0.00 0.00 63610 S 531.36 0.00 0.00<br />

60281 S 1,249.13 0.00 0.00 63615 S 740.79 0.00 0.00<br />

60300 S 64.37 0.00 0.00 63650 S 3,154.11 1,955.86 757.62<br />

61000 S 287.02 0.00 0.00 63655 S 4,620.00 2,946.18 1,272.37<br />

61001 S 287.02 0.00 0.00 63660 S 553.92 0.00 0.00<br />

61020 S 232.38 0.00 0.00 63685 S 14,022.77 7,477.07 931.38<br />

61026 S 232.38 0.00 0.00 63688 S 752.18 0.00 0.00<br />

61050 S 232.38 0.00 0.00 63744 S 1,087.76 0.00 0.00<br />

61055 S 232.38 0.00 0.00 63746 S 503.18 0.00 0.00<br />

61070 S 180.82 0.00 0.00 64400 S 55.07 0.00 0.00<br />

61215 S 1,087.76 0.00 0.00 64402 S 51.86 0.00 0.00<br />

61330 S 1,675.76 0.00 0.00 64405 S 43.98 0.00 0.00<br />

61334 S 1,675.76 0.00 0.00 64408 S 54.71 0.00 0.00<br />

61790 S 616.93 0.00 0.00 64410 S 304.48 0.00 0.00<br />

61791 S 457.70 0.00 0.00 64412 S 80.46 0.00 0.00<br />

61880 S 785.89 0.00 0.00 64413 S 51.50 0.00 0.00<br />

61885 S 11,309.13 6,058.19 807.26 64415 S 140.23 0.00 0.00<br />

61886 S 16,887.29 8,900.58 913.88 64416 S 287.02 0.00 0.00<br />

61888 S 752.18 0.00 0.00 64417 S 140.23 0.00 0.00<br />

62194 S 304.48 0.00 0.00 64418 S 72.23 0.00 0.00<br />

62225 S 473.11 0.00 0.00 64420 S 140.23 0.00 0.00<br />

62230 S 1,056.82 0.00 0.00 64421 S 304.48 0.00 0.00<br />

62252 TC S 47.92 0.00 0.00 64425 S 50.06 0.00 0.00<br />

62263 S 304.48 0.00 0.00 64430 S 210.70 0.00 0.00<br />

62264 S 448.54 0.00 0.00 64435 S 75.45 0.00 0.00<br />

62267 S 179.00 0.00 0.00 64445 S 66.87 0.00 0.00<br />

62268 S 232.38 0.00 0.00 64446 S 575.15 0.00 0.00<br />

62269 S 352.64 0.00 0.00 64447 S 146.07 0.00 0.00<br />

62270 S 140.23 0.00 0.00 64448 S 146.07 0.00 0.00<br />

62272 S 140.23 0.00 0.00 64449 S 287.02 0.00 0.00<br />

62273 S 234.00 0.00 0.00 64450 S 44.70 0.00 0.00<br />

62280 S 304.48 0.00 0.00 64455 S 18.59 0.00 0.00<br />

62281 S 304.48 0.00 0.00 64470 S 304.48 0.00 0.00<br />

62282 S 304.48 0.00 0.00 64472 S 234.00 0.00 0.00<br />

62287 S 1,366.83 0.00 0.00 64475 S 304.48 0.00 0.00<br />

62292 S 287.02 0.00 0.00 64476 S 210.74 0.00 0.00<br />

62294 S 232.38 0.00 0.00 64479 S 304.48 0.00 0.00<br />

62310 S 304.48 0.00 0.00 64480 S 234.00 0.00 0.00<br />

62311 S 304.48 0.00 0.00 64483 S 304.48 0.00 0.00<br />

62318 S 304.48 0.00 0.00 64484 S 234.00 0.00 0.00<br />

62319 S 304.48 0.00 0.00 64505 S 40.77 0.00 0.00<br />

62350 S 1,056.82 0.00 0.00 64508 S 86.54 0.00 0.00<br />

62355 S 503.18 0.00 0.00 64510 S 304.48 0.00 0.00<br />

62360 S 1,056.82 0.00 0.00 64517 S 210.70 0.00 0.00<br />

62361 S 10,848.40 5,871.85 895.31 64520 S 304.48 0.00 0.00<br />

62362 S 10,848.40 5,871.85 895.31 64530 S 304.48 0.00 0.00<br />

62365 S 935.15 0.00 0.00 64553 S 3,099.48 1,901.23 702.99<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,480.53 2,282.28 1,084.05 64746 S 586.00 0.00 0.00<br />

64560 S 3,480.53 2,282.28 1,084.05 64761 S 740.79 0.00 0.00<br />

64561 S 3,185.05 1,986.80 788.56 64763 S 740.79 0.00 0.00<br />

64565 S 3,480.53 2,282.28 1,084.05 64766 S 1,439.10 0.00 0.00<br />

64573 S 5,422.15 3,212.09 1,002.04 64771 S 586.00 0.00 0.00<br />

64575 S 4,144.79 2,470.97 797.16 64772 S 586.00 0.00 0.00<br />

64577 S 4,144.79 2,470.97 797.16 64774 S 586.00 0.00 0.00<br />

64580 S 4,144.79 2,470.97 797.16 64776 S 616.93 0.00 0.00<br />

64581 S 4,230.35 2,556.53 882.72 64778 S 586.00 0.00 0.00<br />

64585 S 553.92 0.00 0.00 64782 S 616.93 0.00 0.00<br />

64590 S 11,309.13 6,058.19 807.26 64783 S 586.00 0.00 0.00<br />

64595 S 752.18 0.00 0.00 64784 S 616.93 0.00 0.00<br />

64600 S 448.54 0.00 0.00 64786 S 966.09 0.00 0.00<br />

64605 S 448.54 0.00 0.00 64787 S 586.00 0.00 0.00<br />

64610 S 448.54 0.00 0.00 64788 S 616.93 0.00 0.00<br />

64612 S 65.44 0.00 0.00 64790 S 616.93 0.00 0.00<br />

64613 S 63.30 0.00 0.00 64792 S 966.09 0.00 0.00<br />

64614 S 72.23 0.00 0.00 64795 S 586.00 0.00 0.00<br />

64620 S 304.48 0.00 0.00 64802 S 586.00 0.00 0.00<br />

64622 S 448.54 0.00 0.00 64820 S 740.79 0.00 0.00<br />

64623 S 304.48 0.00 0.00 64821 S 864.81 0.00 0.00<br />

64626 S 448.54 0.00 0.00 64822 S 1,120.51 0.00 0.00<br />

64627 S 210.74 0.00 0.00 64823 S 1,120.51 0.00 0.00<br />

64630 S 313.63 0.00 0.00 64831 S 1,024.10 0.00 0.00<br />

64632 S 33.97 0.00 0.00 64832 S 880.52 0.00 0.00<br />

64640 S 101.20 0.00 0.00 64834 S 935.15 0.00 0.00<br />

64650 S 33.97 0.00 0.00 64835 S 966.09 0.00 0.00<br />

64653 S 36.83 0.00 0.00 64836 S 966.09 0.00 0.00<br />

64680 S 476.56 0.00 0.00 64837 S 880.52 0.00 0.00<br />

64681 S 503.18 0.00 0.00 64840 S 935.15 0.00 0.00<br />

64702 S 531.36 0.00 0.00 64856 S 935.15 0.00 0.00<br />

64704 S 531.36 0.00 0.00 64857 S 935.15 0.00 0.00<br />

64708 S 586.00 0.00 0.00 64858 S 935.15 0.00 0.00<br />

64712 S 586.00 0.00 0.00 64859 S 880.52 0.00 0.00<br />

64713 S 586.00 0.00 0.00 64861 S 966.09 0.00 0.00<br />

64714 S 586.00 0.00 0.00 64862 S 966.09 0.00 0.00<br />

64716 S 616.93 0.00 0.00 64864 S 966.09 0.00 0.00<br />

64718 S 586.00 0.00 0.00 64865 S 1,024.10 0.00 0.00<br />

64719 S 586.00 0.00 0.00 64870 S 1,024.10 0.00 0.00<br />

64721 S 586.00 0.00 0.00 64872 S 935.15 0.00 0.00<br />

64722 S 531.36 0.00 0.00 64874 S 966.09 0.00 0.00<br />

64726 S 531.36 0.00 0.00 64876 S 966.09 0.00 0.00<br />

64727 S 531.36 0.00 0.00 64885 S 935.15 0.00 0.00<br />

64732 S 586.00 0.00 0.00 64886 S 935.15 0.00 0.00<br />

64734 S 586.00 0.00 0.00 64890 S 935.15 0.00 0.00<br />

64736 S 586.00 0.00 0.00 64891 S 935.15 0.00 0.00<br />

64738 S 586.00 0.00 0.00 64892 S 935.15 0.00 0.00<br />

64740 S 586.00 0.00 0.00 64893 S 935.15 0.00 0.00<br />

64742 S 586.00 0.00 0.00 64895 S 966.09 0.00 0.00<br />

64744 S 586.00 0.00 0.00 64896 S 966.09 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 966.09 0.00 0.00 65770 S 5,685.10 0.00 0.00<br />

64898 S 966.09 0.00 0.00 65772 S 639.53 0.00 0.00<br />

64901 S 935.15 0.00 0.00 65775 S 639.53 0.00 0.00<br />

64902 S 935.15 0.00 0.00 65780 S 1,106.30 0.00 0.00<br />

64905 S 935.15 0.00 0.00 65781 S 1,106.30 0.00 0.00<br />

64907 S 880.52 0.00 0.00 65782 S 1,106.30 0.00 0.00<br />

64910 S 1,439.10 0.00 0.00 65800 S 495.96 0.00 0.00<br />

65091 S 1,017.24 0.00 0.00 65805 S 495.96 0.00 0.00<br />

65093 S 1,017.24 0.00 0.00 65810 S 724.70 0.00 0.00<br />

65101 S 1,017.24 0.00 0.00 65815 S 693.75 0.00 0.00<br />

65103 S 1,017.24 0.00 0.00 65820 S 254.44 0.00 0.00<br />

65105 S 1,075.25 0.00 0.00 65850 S 782.70 0.00 0.00<br />

65110 S 1,117.30 0.00 0.00 65855 S 135.17 0.00 0.00<br />

65112 S 1,251.69 0.00 0.00 65860 S 126.24 0.00 0.00<br />

65114 S 1,251.69 0.00 0.00 65865 S 495.96 0.00 0.00<br />

65125 S 1,041.71 0.00 0.00 65870 S 782.70 0.00 0.00<br />

65130 S 767.39 0.00 0.00 65875 S 782.70 0.00 0.00<br />

65135 S 736.46 0.00 0.00 65880 S 639.53 0.00 0.00<br />

65140 S 1,017.24 0.00 0.00 65900 S 681.59 0.00 0.00<br />

65150 S 736.46 0.00 0.00 65920 S 959.15 0.00 0.00<br />

65155 S 1,017.24 0.00 0.00 65930 S 824.76 0.00 0.00<br />

65175 S 547.44 0.00 0.00 66020 S 495.96 0.00 0.00<br />

65205 S 21.10 0.00 0.00 66030 S 254.44 0.00 0.00<br />

65210 S 26.82 0.00 0.00 66130 S 959.15 0.00 0.00<br />

65220 S 37.37 0.00 0.00 66150 S 782.70 0.00 0.00<br />

65222 S 29.32 0.00 0.00 66155 S 782.70 0.00 0.00<br />

65235 S 550.58 0.00 0.00 66160 S 693.75 0.00 0.00<br />

65260 S 363.15 0.00 0.00 66165 S 782.70 0.00 0.00<br />

65265 S 751.30 0.00 0.00 66170 S 782.70 0.00 0.00<br />

65270 S 602.06 0.00 0.00 66172 S 782.70 0.00 0.00<br />

65272 S 693.75 0.00 0.00 66180 S 1,166.06 0.00 0.00<br />

65275 S 782.70 0.00 0.00 66185 S 1,035.07 0.00 0.00<br />

65280 S 751.30 0.00 0.00 66220 S 1,010.41 0.00 0.00<br />

65285 S 1,068.41 0.00 0.00 66225 S 1,124.01 0.00 0.00<br />

65286 S 186.92 0.00 0.00 66250 S 550.58 0.00 0.00<br />

65290 S 739.89 0.00 0.00 66500 S 254.44 0.00 0.00<br />

65400 S 495.96 0.00 0.00 66505 S 254.44 0.00 0.00<br />

65410 S 550.58 0.00 0.00 66600 S 724.70 0.00 0.00<br />

65420 S 550.58 0.00 0.00 66605 S 724.70 0.00 0.00<br />

65426 S 824.76 0.00 0.00 66625 S 515.26 0.00 0.00<br />

65430 S 37.37 0.00 0.00 66630 S 724.70 0.00 0.00<br />

65435 S 32.54 0.00 0.00 66635 S 724.70 0.00 0.00<br />

65436 S 141.25 0.00 0.00 66680 S 724.70 0.00 0.00<br />

65450 S 86.23 0.00 0.00 66682 S 693.75 0.00 0.00<br />

65600 S 166.64 0.00 0.00 66700 S 550.58 0.00 0.00<br />

65710 S 1,240.68 0.00 0.00 66710 S 550.58 0.00 0.00<br />

65730 S 1,240.68 0.00 0.00 66711 S 550.58 0.00 0.00<br />

65750 S 1,240.68 0.00 0.00 66720 S 550.58 0.00 0.00<br />

65755 S 1,240.68 0.00 0.00 66740 S 693.75 0.00 0.00<br />

65756 S 1,519.38 0.00 0.00 66761 S 188.10 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 191.32 0.00 0.00 67228 S 210.69 0.00 0.00<br />

66770 S 210.69 0.00 0.00 67229 S 210.69 0.00 0.00<br />

66820 S 186.92 0.00 0.00 67250 S 633.00 0.00 0.00<br />

66821 S 256.40 0.00 0.00 67255 S 693.30 0.00 0.00<br />

66825 S 782.70 0.00 0.00 67311 S 739.89 0.00 0.00<br />

66830 S 273.74 0.00 0.00 67312 S 797.90 0.00 0.00<br />

66840 S 588.45 0.00 0.00 67314 S 797.90 0.00 0.00<br />

66850 S 1,107.90 0.00 0.00 67316 S 797.90 0.00 0.00<br />

66852 S 931.45 0.00 0.00 67318 S 797.90 0.00 0.00<br />

66920 S 931.45 0.00 0.00 67320 S 797.90 0.00 0.00<br />

66930 S 973.51 0.00 0.00 67331 S 797.90 0.00 0.00<br />

66940 S 630.50 0.00 0.00 67332 S 797.90 0.00 0.00<br />

66982 S 956.50 0.00 0.00 67334 S 797.90 0.00 0.00<br />

66983 S 956.50 0.00 0.00 67335 S 797.90 0.00 0.00<br />

66984 S 956.50 0.00 0.00 67340 S 797.90 0.00 0.00<br />

66985 S 885.44 0.00 0.00 67343 S 974.34 0.00 0.00<br />

66986 S 885.44 0.00 0.00 67345 S 83.33 0.00 0.00<br />

67005 S 751.30 0.00 0.00 67346 S 450.68 0.00 0.00<br />

67010 S 751.30 0.00 0.00 67400 S 633.00 0.00 0.00<br />

67015 S 924.84 0.00 0.00 67405 S 825.40 0.00 0.00<br />

67025 S 607.73 0.00 0.00 67412 S 733.07 0.00 0.00<br />

67027 S 1,068.41 0.00 0.00 67413 S 867.45 0.00 0.00<br />

67028 S 84.04 0.00 0.00 67414 S 1,541.41 0.00 0.00<br />

67030 S 607.73 0.00 0.00 67415 S 547.44 0.00 0.00<br />

67031 S 256.40 0.00 0.00 67420 S 1,117.30 0.00 0.00<br />

67036 S 1,068.41 0.00 0.00 67430 S 1,117.30 0.00 0.00<br />

67039 S 1,244.86 0.00 0.00 67440 S 1,117.30 0.00 0.00<br />

67040 S 1,244.86 0.00 0.00 67445 S 1,117.30 0.00 0.00<br />

67041 S 1,527.73 0.00 0.00 67450 S 1,117.30 0.00 0.00<br />

67042 S 1,527.73 0.00 0.00 67500 S 86.23 0.00 0.00<br />

67043 S 1,527.73 0.00 0.00 67505 S 26.82 0.00 0.00<br />

67101 S 233.22 0.00 0.00 67515 S 27.18 0.00 0.00<br />

67105 S 210.69 0.00 0.00 67550 S 1,075.25 0.00 0.00<br />

67107 S 1,110.47 0.00 0.00 67560 S 736.46 0.00 0.00<br />

67108 S 1,244.86 0.00 0.00 67570 S 1,075.25 0.00 0.00<br />

67110 S 339.00 0.00 0.00 67700 S 126.16 0.00 0.00<br />

67112 S 1,244.86 0.00 0.00 67710 S 147.33 0.00 0.00<br />

67113 S 1,527.73 0.00 0.00 67715 S 547.44 0.00 0.00<br />

67115 S 662.35 0.00 0.00 67800 S 52.93 0.00 0.00<br />

67120 S 662.35 0.00 0.00 67801 S 64.01 0.00 0.00<br />

67121 S 662.35 0.00 0.00 67805 S 82.96 0.00 0.00<br />

67141 S 233.48 0.00 0.00 67808 S 602.06 0.00 0.00<br />

67145 S 199.18 0.00 0.00 67810 S 126.16 0.00 0.00<br />

67208 S 212.42 0.00 0.00 67820 S 17.52 0.00 0.00<br />

67210 S 210.69 0.00 0.00 67825 S 54.00 0.00 0.00<br />

67218 S 793.36 0.00 0.00 67830 S 369.62 0.00 0.00<br />

67220 S 233.22 0.00 0.00 67835 S 602.06 0.00 0.00<br />

67221 S 119.79 0.00 0.00 67840 S 154.49 0.00 0.00<br />

67225 S 8.23 0.00 0.00 67850 S 122.66 0.00 0.00<br />

67227 S 607.73 0.00 0.00 67875 S 308.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 581.52 0.00 0.00 68440 S 52.57 0.00 0.00<br />

67882 S 633.00 0.00 0.00 68500 S 767.39 0.00 0.00<br />

67900 S 825.40 0.00 0.00 68505 S 767.39 0.00 0.00<br />

67901 S 733.07 0.00 0.00 68510 S 547.44 0.00 0.00<br />

67902 S 867.45 0.00 0.00 68520 S 767.39 0.00 0.00<br />

67903 S 691.01 0.00 0.00 68525 S 547.44 0.00 0.00<br />

67904 S 691.01 0.00 0.00 68530 S 126.16 0.00 0.00<br />

67906 S 733.07 0.00 0.00 68540 S 633.00 0.00 0.00<br />

67908 S 691.01 0.00 0.00 68550 S 767.39 0.00 0.00<br />

67909 S 691.01 0.00 0.00 68700 S 602.06 0.00 0.00<br />

67911 S 633.00 0.00 0.00 68705 S 119.79 0.00 0.00<br />

67912 S 633.00 0.00 0.00 68720 S 825.40 0.00 0.00<br />

67914 S 633.00 0.00 0.00 68745 S 825.40 0.00 0.00<br />

67915 S 170.93 0.00 0.00 68750 S 825.40 0.00 0.00<br />

67916 S 691.01 0.00 0.00 68760 S 101.92 0.00 0.00<br />

67917 S 691.01 0.00 0.00 68761 S 70.45 0.00 0.00<br />

67921 S 633.00 0.00 0.00 68770 S 825.40 0.00 0.00<br />

67922 S 166.28 0.00 0.00 68801 S 37.37 0.00 0.00<br />

67923 S 691.01 0.00 0.00 68810 S 106.86 0.00 0.00<br />

67924 S 691.01 0.00 0.00 68811 S 602.06 0.00 0.00<br />

67930 S 170.93 0.00 0.00 68815 S 602.06 0.00 0.00<br />

67935 S 602.06 0.00 0.00 68816 S 772.92 0.00 0.00<br />

67938 S 86.23 0.00 0.00 68840 S 55.42 0.00 0.00<br />

67950 S 602.06 0.00 0.00 69000 S 56.54 0.00 0.00<br />

67961 S 633.00 0.00 0.00 69005 S 106.92 0.00 0.00<br />

67966 S 633.00 0.00 0.00 69020 S 56.54 0.00 0.00<br />

67971 S 633.00 0.00 0.00 69100 S 64.37 0.00 0.00<br />

67973 S 767.39 0.00 0.00 69105 S 91.19 0.00 0.00<br />

67974 S 633.00 0.00 0.00 69110 S 479.07 0.00 0.00<br />

67975 S 633.00 0.00 0.00 69120 S 710.95 0.00 0.00<br />

68020 S 46.85 0.00 0.00 69140 S 710.95 0.00 0.00<br />

68040 S 23.24 0.00 0.00 69145 S 533.69 0.00 0.00<br />

68100 S 92.97 0.00 0.00 69150 S 375.10 0.00 0.00<br />

68110 S 119.79 0.00 0.00 69200 S 25.86 0.00 0.00<br />

68115 S 602.06 0.00 0.00 69205 S 598.04 0.00 0.00<br />

68130 S 550.58 0.00 0.00 69210 S 21.10 0.00 0.00<br />

68135 S 60.07 0.00 0.00 69220 S 33.14 0.00 0.00<br />

68200 S 17.16 0.00 0.00 69222 S 139.46 0.00 0.00<br />

68320 S 825.40 0.00 0.00 69300 S 741.89 0.00 0.00<br />

68325 S 825.40 0.00 0.00 69310 S 1,084.42 0.00 0.00<br />

68326 S 691.01 0.00 0.00 69320 S 1,318.87 0.00 0.00<br />

68328 S 825.40 0.00 0.00 69400 S 93.69 0.00 0.00<br />

68330 S 782.70 0.00 0.00 69401 S 49.35 0.00 0.00<br />

68335 S 825.40 0.00 0.00 69405 S 129.45 0.00 0.00<br />

68340 S 691.01 0.00 0.00 69420 S 116.22 0.00 0.00<br />

68360 S 693.75 0.00 0.00 69421 S 591.51 0.00 0.00<br />

68362 S 693.75 0.00 0.00 69424 S 81.53 0.00 0.00<br />

68371 S 550.58 0.00 0.00 69433 S 115.87 0.00 0.00<br />

68400 S 126.16 0.00 0.00 69436 S 591.51 0.00 0.00<br />

68420 S 179.51 0.00 0.00 69440 S 741.89 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 998.86 0.00 0.00 69840 S 1,184.49 0.00 0.00<br />

69501 S 1,318.87 0.00 0.00 69905 S 1,318.87 0.00 0.00<br />

69502 S 976.34 0.00 0.00 69910 S 1,318.87 0.00 0.00<br />

69505 S 1,318.87 0.00 0.00 69915 S 1,318.87 0.00 0.00<br />

69511 S 1,318.87 0.00 0.00 69930 S 23,843.43 12,802.31 1,761.19<br />

69530 S 1,318.87 0.00 0.00 70030 TC A 18.23 0.00 0.00<br />

69540 S 136.24 0.00 0.00 70100 TC A 20.03 0.00 0.00<br />

69550 S 1,184.49 0.00 0.00 70110 TC A 24.68 0.00 0.00<br />

69552 S 1,318.87 0.00 0.00 70120 TC A 22.17 0.00 0.00<br />

69601 S 1,318.87 0.00 0.00 70130 TC A 27.09 0.00 0.00<br />

69602 S 1,318.87 0.00 0.00 70134 TC A 27.18 0.00 0.00<br />

69603 S 1,318.87 0.00 0.00 70140 TC A 18.59 0.00 0.00<br />

69604 S 1,318.87 0.00 0.00 70150 TC A 27.09 0.00 0.00<br />

69605 S 1,318.87 0.00 0.00 70160 TC A 21.81 0.00 0.00<br />

69610 S 182.38 0.00 0.00 70190 TC A 22.88 0.00 0.00<br />

69620 S 710.95 0.00 0.00 70200 TC A 27.09 0.00 0.00<br />

69631 S 1,184.49 0.00 0.00 70210 TC A 19.31 0.00 0.00<br />

69632 S 1,184.49 0.00 0.00 70220 TC A 24.32 0.00 0.00<br />

69633 S 1,184.49 0.00 0.00 70240 TC A 18.23 0.00 0.00<br />

69635 S 1,318.87 0.00 0.00 70250 TC A 22.17 0.00 0.00<br />

69636 S 1,318.87 0.00 0.00 70260 TC A 28.25 0.00 0.00<br />

69637 S 1,318.87 0.00 0.00 70300 TC A 7.86 0.00 0.00<br />

69641 S 1,318.87 0.00 0.00 70310 TC A 19.43 0.00 0.00<br />

69642 S 1,318.87 0.00 0.00 70320 TC A 19.43 0.00 0.00<br />

69643 S 1,318.87 0.00 0.00 70328 TC A 19.31 0.00 0.00<br />

69644 S 1,318.87 0.00 0.00 70330 TC A 27.09 0.00 0.00<br />

69645 S 1,318.87 0.00 0.00 70336 TC A 210.85 0.00 0.00<br />

69646 S 1,318.87 0.00 0.00 70350 TC A 10.73 0.00 0.00<br />

69650 S 976.34 0.00 0.00 70355 TC A 11.08 0.00 0.00<br />

69660 S 1,184.49 0.00 0.00 70360 TC A 17.16 0.00 0.00<br />

69661 S 1,184.49 0.00 0.00 70370 TC A 50.41 0.00 0.00<br />

69662 S 1,184.49 0.00 0.00 70371 TC A 50.41 0.00 0.00<br />

69666 S 1,142.43 0.00 0.00 70380 TC A 26.11 0.00 0.00<br />

69667 S 1,142.43 0.00 0.00 70450 TC A 117.76 0.00 0.00<br />

69670 S 1,084.42 0.00 0.00 70460 TC A 186.47 0.00 0.00<br />

69676 S 1,084.42 0.00 0.00 70470 TC A 206.56 0.00 0.00<br />

69700 S 1,084.42 0.00 0.00 70480 TC A 117.76 0.00 0.00<br />

69711 S 998.86 0.00 0.00 70481 TC A 186.47 0.00 0.00<br />

69714 S 6,334.57 3,994.19 1,653.80 70482 TC A 206.56 0.00 0.00<br />

69715 S 6,334.57 3,994.19 1,653.80 70486 TC A 117.76 0.00 0.00<br />

69717 S 6,334.57 3,994.19 1,653.80 70487 TC A 186.47 0.00 0.00<br />

69718 S 6,334.57 3,994.19 1,653.80 70488 TC A 206.56 0.00 0.00<br />

69720 S 1,184.49 0.00 0.00 70490 TC A 117.76 0.00 0.00<br />

69740 S 1,184.49 0.00 0.00 70491 TC A 186.47 0.00 0.00<br />

69745 S 1,184.49 0.00 0.00 70492 TC A 206.56 0.00 0.00<br />

69801 S 1,184.49 0.00 0.00 70496 TC A 213.16 0.00 0.00<br />

69802 S 1,318.87 0.00 0.00 70498 TC A 213.16 0.00 0.00<br />

69805 S 1,318.87 0.00 0.00 70540 TC A 210.85 0.00 0.00<br />

69806 S 1,318.87 0.00 0.00 70542 TC A 258.93 0.00 0.00<br />

69820 S 1,184.49 0.00 0.00 70543 TC A 326.34 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 210.85 0.00 0.00 72120 TC A 34.33 0.00 0.00<br />

70545 TC A 258.93 0.00 0.00 72125 TC A 117.76 0.00 0.00<br />

70546 TC A 326.34 0.00 0.00 72126 TC A 186.47 0.00 0.00<br />

70547 TC A 210.85 0.00 0.00 72127 TC A 206.56 0.00 0.00<br />

70548 TC A 258.93 0.00 0.00 72128 TC A 117.76 0.00 0.00<br />

70549 TC A 326.34 0.00 0.00 72129 TC A 186.47 0.00 0.00<br />

70551 TC A 210.85 0.00 0.00 72130 TC A 206.56 0.00 0.00<br />

70552 TC A 258.93 0.00 0.00 72131 TC A 117.76 0.00 0.00<br />

70553 TC A 326.34 0.00 0.00 72132 TC A 186.47 0.00 0.00<br />

70554 TC A 210.85 0.00 0.00 72133 TC A 206.56 0.00 0.00<br />

70555 TC A 210.85 0.00 0.00 72141 TC A 210.85 0.00 0.00<br />

70557 TC A 210.85 0.00 0.00 72142 TC A 258.93 0.00 0.00<br />

70558 TC A 258.93 0.00 0.00 72146 TC A 210.85 0.00 0.00<br />

70559 TC A 326.34 0.00 0.00 72147 TC A 258.93 0.00 0.00<br />

71010 TC A 13.95 0.00 0.00 72148 TC A 210.85 0.00 0.00<br />

71015 TC A 17.88 0.00 0.00 72149 TC A 258.93 0.00 0.00<br />

71020 TC A 18.96 0.00 0.00 72156 TC A 326.34 0.00 0.00<br />

71021 TC A 22.88 0.00 0.00 72157 TC A 326.34 0.00 0.00<br />

71022 TC A 27.09 0.00 0.00 72158 TC A 326.34 0.00 0.00<br />

71023 TC A 44.34 0.00 0.00 72170 TC A 16.09 0.00 0.00<br />

71030 TC A 27.09 0.00 0.00 72190 TC A 27.09 0.00 0.00<br />

71034 TC A 50.41 0.00 0.00 72191 TC A 213.16 0.00 0.00<br />

71035 TC A 23.60 0.00 0.00 72192 TC A 117.76 0.00 0.00<br />

71100 TC A 19.67 0.00 0.00 72193 TC A 186.47 0.00 0.00<br />

71101 TC A 23.95 0.00 0.00 72194 TC A 206.56 0.00 0.00<br />

71110 TC A 25.04 0.00 0.00 72195 TC A 210.85 0.00 0.00<br />

71111 TC A 33.25 0.00 0.00 72196 TC A 258.93 0.00 0.00<br />

71120 TC A 20.74 0.00 0.00 72197 TC A 326.34 0.00 0.00<br />

71130 TC A 24.32 0.00 0.00 72200 TC A 18.96 0.00 0.00<br />

71250 TC A 117.76 0.00 0.00 72202 TC A 23.24 0.00 0.00<br />

71260 TC A 186.47 0.00 0.00 72220 TC A 18.96 0.00 0.00<br />

71270 TC A 206.56 0.00 0.00 73000 TC A 17.88 0.00 0.00<br />

71275 TC A 213.16 0.00 0.00 73010 TC A 18.23 0.00 0.00<br />

71550 TC A 210.85 0.00 0.00 73020 TC A 14.66 0.00 0.00<br />

71551 TC A 258.93 0.00 0.00 73030 TC A 18.59 0.00 0.00<br />

71552 TC A 326.34 0.00 0.00 73050 TC A 23.24 0.00 0.00<br />

72010 TC A 45.09 0.00 0.00 73060 TC A 18.59 0.00 0.00<br />

72020 TC A 14.66 0.00 0.00 73070 TC A 17.88 0.00 0.00<br />

72040 TC A 23.60 0.00 0.00 73080 TC A 23.60 0.00 0.00<br />

72050 TC A 33.61 0.00 0.00 73090 TC A 17.88 0.00 0.00<br />

72052 TC A 45.09 0.00 0.00 73092 TC A 18.59 0.00 0.00<br />

72069 TC A 22.17 0.00 0.00 73100 TC A 18.59 0.00 0.00<br />

72070 TC A 20.74 0.00 0.00 73110 TC A 23.60 0.00 0.00<br />

72072 TC A 25.04 0.00 0.00 73120 TC A 17.52 0.00 0.00<br />

72074 TC A 27.09 0.00 0.00 73130 TC A 20.74 0.00 0.00<br />

72080 TC A 22.17 0.00 0.00 73140 TC A 20.39 0.00 0.00<br />

72090 TC A 29.69 0.00 0.00 73200 TC A 117.76 0.00 0.00<br />

72100 TC A 25.39 0.00 0.00 73201 TC A 186.47 0.00 0.00<br />

72110 TC A 35.41 0.00 0.00 73202 TC A 206.56 0.00 0.00<br />

72114 TC A 45.09 0.00 0.00 73206 TC A 213.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 210.85 0.00 0.00 74246 TC A 53.21 0.00 0.00<br />

73219 TC A 258.93 0.00 0.00 74247 TC A 53.21 0.00 0.00<br />

73220 TC A 326.34 0.00 0.00 74249 TC A 86.53 0.00 0.00<br />

73221 TC A 210.85 0.00 0.00 74250 TC A 53.21 0.00 0.00<br />

73222 TC A 258.93 0.00 0.00 74251 TC A 86.53 0.00 0.00<br />

73223 TC A 326.34 0.00 0.00 74260 TC A 53.21 0.00 0.00<br />

73500 TC A 15.38 0.00 0.00 74270 TC A 53.21 0.00 0.00<br />

73510 TC A 23.60 0.00 0.00 74280 TC A 86.53 0.00 0.00<br />

73520 TC A 24.32 0.00 0.00 74283 TC A 53.21 0.00 0.00<br />

73540 TC A 24.32 0.00 0.00 74290 TC A 45.41 0.00 0.00<br />

73550 TC A 17.88 0.00 0.00 74291 TC A 43.63 0.00 0.00<br />

73560 TC A 18.23 0.00 0.00 74400 TC A 79.03 0.00 0.00<br />

73562 TC A 22.53 0.00 0.00 74410 TC A 84.40 0.00 0.00<br />

73564 TC A 26.11 0.00 0.00 74415 TC A 100.85 0.00 0.00<br />

73565 TC A 19.67 0.00 0.00 74420 TC A 105.41 0.00 0.00<br />

73590 TC A 17.16 0.00 0.00 74710 TC A 23.60 0.00 0.00<br />

73592 TC A 18.59 0.00 0.00 74775 TC A 105.41 0.00 0.00<br />

73600 TC A 17.52 0.00 0.00 75557 TC A 210.85 0.00 0.00<br />

73610 TC A 20.74 0.00 0.00 75559 TC A 210.85 0.00 0.00<br />

73620 TC A 16.81 0.00 0.00 75561 TC A 326.34 0.00 0.00<br />

73630 TC A 20.39 0.00 0.00 75563 TC A 326.34 0.00 0.00<br />

73650 TC A 17.16 0.00 0.00 76010 TC A 17.52 0.00 0.00<br />

73660 TC A 19.31 0.00 0.00 76098 TC A 10.73 0.00 0.00<br />

73700 TC A 117.76 0.00 0.00 76100 TC A 45.09 0.00 0.00<br />

73701 TC A 186.47 0.00 0.00 76101 TC A 120.86 0.00 0.00<br />

73702 TC A 206.56 0.00 0.00 76102 TC A 120.86 0.00 0.00<br />

73706 TC A 213.16 0.00 0.00 76120 TC A 50.41 0.00 0.00<br />

73718 TC A 210.85 0.00 0.00 76150 A 17.52 0.00 0.00<br />

73719 TC A 258.93 0.00 0.00 76380 TC A 63.61 0.00 0.00<br />

73720 TC A 326.34 0.00 0.00 76496 TC A 50.41 0.00 0.00<br />

73721 TC A 210.85 0.00 0.00 76497 TC A 63.61 0.00 0.00<br />

73722 TC A 258.93 0.00 0.00 76498 TC A 210.85 0.00 0.00<br />

73723 TC A 326.34 0.00 0.00 76499 TC A 27.09 0.00 0.00<br />

74000 TC A 15.38 0.00 0.00 76506 TC A 37.87 0.00 0.00<br />

74010 TC A 23.95 0.00 0.00 76510 TC A 64.37 0.00 0.00<br />

74020 TC A 24.32 0.00 0.00 76511 TC A 45.05 0.00 0.00<br />

74022 TC A 29.69 0.00 0.00 76512 TC A 38.26 0.00 0.00<br />

74150 TC A 117.76 0.00 0.00 76513 TC A 46.49 0.00 0.00<br />

74160 TC A 186.47 0.00 0.00 76514 TC A 3.22 0.00 0.00<br />

74170 TC A 206.56 0.00 0.00 76516 TC A 36.48 0.00 0.00<br />

74175 TC A 213.16 0.00 0.00 76519 TC A 40.77 0.00 0.00<br />

74181 TC A 210.85 0.00 0.00 76529 TC A 35.41 0.00 0.00<br />

74182 TC A 258.93 0.00 0.00 76536 TC A 59.23 0.00 0.00<br />

74183 TC A 326.34 0.00 0.00 76604 TC A 37.87 0.00 0.00<br />

74210 TC A 53.21 0.00 0.00 76645 TC A 37.87 0.00 0.00<br />

74220 TC A 53.21 0.00 0.00 76700 TC A 59.23 0.00 0.00<br />

74230 TC A 53.21 0.00 0.00 76705 TC A 59.23 0.00 0.00<br />

74240 TC A 53.21 0.00 0.00 76770 TC A 59.23 0.00 0.00<br />

74241 TC A 53.21 0.00 0.00 76775 TC A 59.23 0.00 0.00<br />

74245 TC A 86.53 0.00 0.00 76776 TC A 59.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 59.23 0.00 0.00 77290 TC A 154.90 0.00 0.00<br />

76801 TC A 59.23 0.00 0.00 77295 TC A 405.88 0.00 0.00<br />

76802 TC A 28.25 0.00 0.00 77299 TC A 69.49 0.00 0.00<br />

76805 TC A 59.23 0.00 0.00 77300 TC A 37.55 0.00 0.00<br />

76810 TC A 44.70 0.00 0.00 77301 TC A 540.92 0.00 0.00<br />

76811 TC A 92.79 0.00 0.00 77305 TC A 34.33 0.00 0.00<br />

76812 TC A 37.87 0.00 0.00 77310 TC A 44.70 0.00 0.00<br />

76813 TC A 37.87 0.00 0.00 77315 TC A 65.08 0.00 0.00<br />

76814 TC A 30.04 0.00 0.00 77321 TC A 67.59 0.00 0.00<br />

76815 TC A 37.87 0.00 0.00 77326 TC A 69.49 0.00 0.00<br />

76816 TC A 37.87 0.00 0.00 77327 TC A 126.24 0.00 0.00<br />

76817 TC A 37.87 0.00 0.00 77328 TC A 154.90 0.00 0.00<br />

76818 TC A 59.23 0.00 0.00 77331 TC A 17.88 0.00 0.00<br />

76819 TC A 51.14 0.00 0.00 77332 TC A 47.92 0.00 0.00<br />

76820 TC A 25.39 0.00 0.00 77333 TC A 23.24 0.00 0.00<br />

76821 TC A 57.34 0.00 0.00 77334 TC A 89.76 0.00 0.00<br />

76825 TC A 119.44 0.00 0.00 77336 A 56.51 0.00 0.00<br />

76826 TC A 71.16 0.00 0.00 77370 A 69.49 0.00 0.00<br />

76827 TC A 37.87 0.00 0.00 77371 A 4,629.41 0.00 0.00<br />

76828 TC A 22.53 0.00 0.00 77399 TC A 69.49 0.00 0.00<br />

76830 TC A 59.23 0.00 0.00 77401 A 28.25 0.00 0.00<br />

76831 TC A 79.75 0.00 0.00 77402 A 56.87 0.00 0.00<br />

76856 TC A 59.23 0.00 0.00 77403 A 56.87 0.00 0.00<br />

76857 TC A 37.87 0.00 0.00 77404 A 56.87 0.00 0.00<br />

76870 TC A 59.23 0.00 0.00 77406 A 92.12 0.00 0.00<br />

76872 TC A 59.23 0.00 0.00 77407 A 56.87 0.00 0.00<br />

76873 TC A 59.23 0.00 0.00 77408 A 56.87 0.00 0.00<br />

76880 TC A 59.23 0.00 0.00 77409 A 56.87 0.00 0.00<br />

76885 TC A 37.87 0.00 0.00 77411 A 92.12 0.00 0.00<br />

76886 TC A 37.87 0.00 0.00 77412 A 92.12 0.00 0.00<br />

76936 TC A 57.34 0.00 0.00 77413 A 92.12 0.00 0.00<br />

76970 TC A 37.87 0.00 0.00 77414 A 92.12 0.00 0.00<br />

76977 TC A 9.66 0.00 0.00 77416 A 92.12 0.00 0.00<br />

76999 TC A 37.87 0.00 0.00 77418 A 248.89 0.00 0.00<br />

77071 A 22.17 0.00 0.00 77422 A 92.12 0.00 0.00<br />

77072 TC A 12.87 0.00 0.00 77423 A 92.12 0.00 0.00<br />

77073 TC A 21.81 0.00 0.00 77470 TC A 132.32 0.00 0.00<br />

77074 TC A 42.91 0.00 0.00 77520 A 426.12 0.00 0.00<br />

77075 TC A 45.09 0.00 0.00 77522 A 426.12 0.00 0.00<br />

77076 TC A 45.09 0.00 0.00 77523 A 509.22 0.00 0.00<br />

77077 TC A 24.32 0.00 0.00 77525 A 509.22 0.00 0.00<br />

77078 TC A 43.57 0.00 0.00 77600 TC A 226.09 0.00 0.00<br />

77079 TC A 44.70 0.00 0.00 77605 TC A 226.09 0.00 0.00<br />

77080 TC A 43.57 0.00 0.00 77610 TC A 226.09 0.00 0.00<br />

77081 TC A 17.52 0.00 0.00 77615 TC A 226.09 0.00 0.00<br />

77082 TC A 18.96 0.00 0.00 77620 TC A 226.09 0.00 0.00<br />

77083 TC A 15.02 0.00 0.00 77750 TC A 87.97 0.00 0.00<br />

77084 TC A 210.85 0.00 0.00 77761 TC A 154.84 0.00 0.00<br />

77280 TC A 69.49 0.00 0.00 77762 TC A 183.45 0.00 0.00<br />

77285 TC A 154.90 0.00 0.00 77763 TC A 236.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 167.71 0.00 0.00 78262 TC A 147.29 0.00 0.00<br />

77777 TC A 184.16 0.00 0.00 78264 TC A 147.29 0.00 0.00<br />

77778 TC A 245.32 0.00 0.00 78270 TC A 64.37 0.00 0.00<br />

77785 TC A 109.07 0.00 0.00 78271 TC A 65.44 0.00 0.00<br />

77786 TC A 383.34 0.00 0.00 78272 TC A 71.87 0.00 0.00<br />

77787 TC A 444.21 0.00 0.00 78278 TC A 147.29 0.00 0.00<br />

77789 TC A 45.78 0.00 0.00 78282 TC A 147.29 0.00 0.00<br />

77799 TC A 260.90 0.00 0.00 78290 TC A 147.29 0.00 0.00<br />

78000 TC A 56.14 0.00 0.00 78291 TC A 147.29 0.00 0.00<br />

78001 TC A 71.15 0.00 0.00 78299 TC A 147.29 0.00 0.00<br />

78003 TC A 56.51 0.00 0.00 78300 TC A 128.38 0.00 0.00<br />

78006 TC A 134.44 0.00 0.00 78305 TC A 148.89 0.00 0.00<br />

78007 TC A 99.42 0.00 0.00 78306 TC A 148.89 0.00 0.00<br />

78010 TC A 82.60 0.00 0.00 78315 TC A 148.89 0.00 0.00<br />

78011 TC A 82.60 0.00 0.00 78320 TC A 148.89 0.00 0.00<br />

78015 TC A 160.56 0.00 0.00 78399 TC A 148.89 0.00 0.00<br />

78016 TC A 181.24 0.00 0.00 78414 TC A 189.26 0.00 0.00<br />

78018 TC A 181.24 0.00 0.00 78428 TC A 145.19 0.00 0.00<br />

78070 TC A 123.37 0.00 0.00 78445 TC A 113.25 0.00 0.00<br />

78075 TC A 349.37 0.00 0.00 78456 TC A 113.25 0.00 0.00<br />

78099 TC A 82.60 0.00 0.00 78457 TC A 113.25 0.00 0.00<br />

78102 TC A 124.80 0.00 0.00 78458 TC A 113.25 0.00 0.00<br />

78103 TC A 159.09 0.00 0.00 78459 TC A 700.84 0.00 0.00<br />

78104 TC A 159.09 0.00 0.00 78460 TC A 135.89 0.00 0.00<br />

78110 TC A 63.30 0.00 0.00 78461 TC A 136.97 0.00 0.00<br />

78111 TC A 80.10 0.00 0.00 78464 TC A 200.97 0.00 0.00<br />

78120 TC A 70.09 0.00 0.00 78465 TC A 380.49 0.00 0.00<br />

78121 TC A 82.96 0.00 0.00 78466 TC A 134.81 0.00 0.00<br />

78122 TC A 98.34 0.00 0.00 78468 TC A 172.36 0.00 0.00<br />

78130 TC A 114.07 0.00 0.00 78469 TC A 189.26 0.00 0.00<br />

78135 TC A 242.44 0.00 0.00 78472 TC A 189.26 0.00 0.00<br />

78140 TC A 107.64 0.00 0.00 78473 TC A 189.26 0.00 0.00<br />

78185 TC A 159.09 0.00 0.00 78481 TC A 163.42 0.00 0.00<br />

78190 TC A 99.82 0.00 0.00 78483 TC A 189.26 0.00 0.00<br />

78191 TC A 99.82 0.00 0.00 78491 TC A 700.84 0.00 0.00<br />

78195 TC A 159.09 0.00 0.00 78492 TC A 700.84 0.00 0.00<br />

78199 TC A 159.09 0.00 0.00 78494 TC A 189.26 0.00 0.00<br />

78201 TC A 141.61 0.00 0.00 78499 TC A 189.26 0.00 0.00<br />

78202 TC A 166.58 0.00 0.00 78580 TC A 128.22 0.00 0.00<br />

78205 TC A 166.58 0.00 0.00 78584 TC A 99.05 0.00 0.00<br />

78206 TC A 166.58 0.00 0.00 78585 TC A 196.74 0.00 0.00<br />

78215 TC A 149.84 0.00 0.00 78586 TC A 128.22 0.00 0.00<br />

78216 TC A 101.56 0.00 0.00 78587 TC A 128.22 0.00 0.00<br />

78220 TC A 110.86 0.00 0.00 78588 TC A 196.74 0.00 0.00<br />

78223 TC A 166.58 0.00 0.00 78591 TC A 128.22 0.00 0.00<br />

78230 TC A 125.87 0.00 0.00 78593 TC A 128.22 0.00 0.00<br />

78231 TC A 99.05 0.00 0.00 78594 TC A 128.22 0.00 0.00<br />

78232 TC A 103.34 0.00 0.00 78596 TC A 196.74 0.00 0.00<br />

78258 TC A 147.29 0.00 0.00 78599 TC A 128.22 0.00 0.00<br />

78261 TC A 147.29 0.00 0.00 78600 TC A 113.00 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 33124 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 113.00 0.00 0.00<br />

78605 TC A 113.00 0.00 0.00<br />

78606 TC A 253.89 0.00 0.00<br />

78607 TC A 278.93 0.00 0.00<br />

78608 TC A 628.17 0.00 0.00<br />

78610 TC A 150.55 0.00 0.00<br />

78630 TC A 268.20 0.00 0.00<br />

78635 TC A 247.10 0.00 0.00<br />

78645 TC A 113.00 0.00 0.00<br />

78647 TC A 273.56 0.00 0.00<br />

78650 TC A 264.98 0.00 0.00<br />

78660 TC A 113.00 0.00 0.00<br />

78699 TC A 113.00 0.00 0.00<br />

78700 TC A 139.11 0.00 0.00<br />

78701 TC A 169.51 0.00 0.00<br />

78707 TC A 177.01 0.00 0.00<br />

78708 TC A 121.23 0.00 0.00<br />

78709 TC A 199.31 0.00 0.00<br />

78710 TC A 187.03 0.00 0.00<br />

78725 TC A 74.74 0.00 0.00<br />

78730 TC A 63.30 0.00 0.00<br />

78740 TC A 165.21 0.00 0.00<br />

78761 TC A 157.70 0.00 0.00<br />

78799 TC A 199.31 0.00 0.00<br />

78800 TC A 139.46 0.00 0.00<br />

78801 TC A 191.32 0.00 0.00<br />

78802 TC A 259.26 0.00 0.00<br />

78803 TC A 277.86 0.00 0.00<br />

78804 TC A 484.90 0.00 0.00<br />

78805 TC A 136.24 0.00 0.00<br />

78806 TC A 272.49 0.00 0.00<br />

78807 TC A 278.21 0.00 0.00<br />

78811 TC A 628.17 0.00 0.00<br />

78812 TC A 628.17 0.00 0.00<br />

78813 TC A 628.17 0.00 0.00<br />

78814 TC A 628.17 0.00 0.00<br />

78815 TC A 628.17 0.00 0.00<br />

78816 TC A 628.17 0.00 0.00<br />

78999 TC A 71.15 0.00 0.00<br />

79005 TC A 57.22 0.00 0.00<br />

79101 TC A 62.58 0.00 0.00<br />

79200 TC A 67.59 0.00 0.00<br />

79300 TC A 130.40 0.00 0.00<br />

79403 TC A 96.91 0.00 0.00<br />

79440 TC A 54.71 0.00 0.00<br />

79445 TC A 130.40 0.00 0.00<br />

79999 TC A 130.40 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,285.68 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,550.43 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.68 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,602.05 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,602.05 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 231.36 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 231.36 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 116.82 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 246.90 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 74.22 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 664.62 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,515.56 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,186.31 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,186.31 0.00 0.00<br />

C8900 A 256.87 0.00 0.00 0123T S 948.69 0.00 0.00<br />

C8901 A 209.17 0.00 0.00 0124T S 185.43 0.00 0.00<br />

C8902 A 323.74 0.00 0.00 0144T TC A 63.11 0.00 0.00<br />

C8903 A 256.87 0.00 0.00 0145T TC A 169.89 0.00 0.00<br />

C8904 A 209.17 0.00 0.00 0146T TC A 169.89 0.00 0.00<br />

C8905 A 323.74 0.00 0.00 0147T TC A 169.89 0.00 0.00<br />

C8906 A 256.87 0.00 0.00 0148T TC A 169.89 0.00 0.00<br />

C8907 A 209.17 0.00 0.00 0149T TC A 169.89 0.00 0.00<br />

C8908 A 323.74 0.00 0.00 0150T TC A 169.89 0.00 0.00<br />

C8909 A 256.87 0.00 0.00 0151T TC A 63.11 0.00 0.00<br />

C8910 A 209.17 0.00 0.00 0170T S 1,232.29 0.00 0.00<br />

C8911 A 323.74 0.00 0.00 0176T S 1,455.06 0.00 0.00<br />

C8912 A 256.87 0.00 0.00 0177T S 1,455.06 0.00 0.00<br />

C8913 A 209.17 0.00 0.00 0182T A 1,051.72 0.00 0.00<br />

C8914 A 323.74 0.00 0.00 0186T S 886.39 0.00 0.00<br />

C8918 A 256.87 0.00 0.00 0190T S 886.39 0.00 0.00<br />

C8919 A 209.17 0.00 0.00 0191T S 948.69 0.00 0.00<br />

C8920 A 323.74 0.00 0.00 0192T S 1,625.87 0.00 0.00<br />

C9716 S 1,232.29 0.00 0.00 10021 S 56.86 0.00 0.00<br />

C9724 S 1,007.54 0.00 0.00 10022 S 177.57 0.00 0.00<br />

C9725 S 232.34 0.00 0.00 10040 S 32.87 0.00 0.00<br />

C9726 S 852.97 0.00 0.00 10060 S 50.02 0.00 0.00<br />

C9727 S 299.06 0.00 0.00 10061 S 56.08 0.00 0.00<br />

C9728 S 536.61 0.00 0.00 10080 S 56.08 0.00 0.00<br />

G0104 S 86.20 0.00 0.00 10081 S 129.13 0.00 0.00<br />

G0105 S 372.57 0.00 0.00 10120 S 70.24 0.00 0.00<br />

G0121 S 372.57 0.00 0.00 10121 S 529.44 0.00 0.00<br />

G0127 S 12.06 0.00 0.00 10140 S 74.50 0.00 0.00<br />

G0130 TC A 19.87 0.00 0.00 10160 S 56.08 0.00 0.00<br />

G0173 A 2,285.68 0.00 0.00 10180 S 598.73 0.00 0.00<br />

G0186 S 231.36 0.00 0.00 11000 S 24.13 0.00 0.00<br />

G0247 S 21.99 0.00 0.00 11001 S 8.16 0.00 0.00<br />

G0251 A 572.37 0.00 0.00 11010 S 209.47 0.00 0.00<br />

G0260 S 302.05 0.00 0.00 11011 S 209.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 209.47 0.00 0.00 11601 S 115.65 0.00 0.00<br />

11040 S 21.99 0.00 0.00 11602 S 127.36 0.00 0.00<br />

11041 S 24.48 0.00 0.00 11603 S 135.16 0.00 0.00<br />

11042 S 133.01 0.00 0.00 11604 S 364.58 0.00 0.00<br />

11043 S 133.01 0.00 0.00 11606 S 529.44 0.00 0.00<br />

11044 S 346.35 0.00 0.00 11620 S 98.63 0.00 0.00<br />

11055 S 25.90 0.00 0.00 11621 S 117.07 0.00 0.00<br />

11056 S 28.38 0.00 0.00 11622 S 130.19 0.00 0.00<br />

11057 S 32.87 0.00 0.00 11623 S 140.12 0.00 0.00<br />

11100 S 60.23 0.00 0.00 11624 S 529.44 0.00 0.00<br />

11101 S 14.19 0.00 0.00 11626 S 647.46 0.00 0.00<br />

11200 S 32.87 0.00 0.00 11640 S 104.30 0.00 0.00<br />

11201 S 5.68 0.00 0.00 11641 S 123.10 0.00 0.00<br />

11300 S 32.87 0.00 0.00 11642 S 137.29 0.00 0.00<br />

11301 S 32.87 0.00 0.00 11643 S 147.93 0.00 0.00<br />

11302 S 32.87 0.00 0.00 11644 S 529.44 0.00 0.00<br />

11303 S 60.23 0.00 0.00 11646 S 647.46 0.00 0.00<br />

11305 S 32.87 0.00 0.00 11719 S 12.06 0.00 0.00<br />

11306 S 32.87 0.00 0.00 11720 S 14.90 0.00 0.00<br />

11307 S 32.87 0.00 0.00 11721 S 18.09 0.00 0.00<br />

11308 S 32.87 0.00 0.00 11730 S 32.87 0.00 0.00<br />

11310 S 32.87 0.00 0.00 11732 S 18.09 0.00 0.00<br />

11311 S 32.87 0.00 0.00 11740 S 16.60 0.00 0.00<br />

11312 S 32.87 0.00 0.00 11750 S 95.78 0.00 0.00<br />

11313 S 32.87 0.00 0.00 11752 S 133.03 0.00 0.00<br />

11400 S 67.76 0.00 0.00 11755 S 66.33 0.00 0.00<br />

11401 S 76.27 0.00 0.00 11760 S 136.62 0.00 0.00<br />

11402 S 83.72 0.00 0.00 11762 S 122.04 0.00 0.00<br />

11403 S 89.40 0.00 0.00 11765 S 32.87 0.00 0.00<br />

11404 S 475.26 0.00 0.00 11770 S 678.16 0.00 0.00<br />

11406 S 529.44 0.00 0.00 11771 S 678.16 0.00 0.00<br />

11420 S 63.50 0.00 0.00 11772 S 678.16 0.00 0.00<br />

11421 S 76.98 0.00 0.00 11900 S 30.16 0.00 0.00<br />

11422 S 84.08 0.00 0.00 11901 S 32.87 0.00 0.00<br />

11423 S 93.66 0.00 0.00 11920 S 95.43 0.00 0.00<br />

11424 S 529.44 0.00 0.00 11921 S 105.01 0.00 0.00<br />

11426 S 647.46 0.00 0.00 11922 S 34.05 0.00 0.00<br />

11440 S 72.73 0.00 0.00 11950 S 34.77 0.00 0.00<br />

11441 S 84.08 0.00 0.00 11951 S 43.28 0.00 0.00<br />

11442 S 92.59 0.00 0.00 11952 S 52.10 0.00 0.00<br />

11443 S 102.52 0.00 0.00 11954 S 52.10 0.00 0.00<br />

11444 S 323.58 0.00 0.00 11960 S 632.04 0.00 0.00<br />

11446 S 647.46 0.00 0.00 11970 S 1,144.84 0.00 0.00<br />

11450 S 647.46 0.00 0.00 11971 S 593.28 0.00 0.00<br />

11451 S 647.46 0.00 0.00 11976 S 63.50 0.00 0.00<br />

11462 S 647.46 0.00 0.00 11980 S 25.65 0.00 0.00<br />

11463 S 647.46 0.00 0.00 11981 S 25.65 0.00 0.00<br />

11470 S 647.46 0.00 0.00 11982 S 25.65 0.00 0.00<br />

11471 S 647.46 0.00 0.00 11983 S 25.65 0.00 0.00<br />

11600 S 95.43 0.00 0.00 12001 S 52.10 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 52.10 0.00 0.00 14021 S 561.67 0.00 0.00<br />

12004 S 52.10 0.00 0.00 14040 S 530.99 0.00 0.00<br />

12005 S 69.81 0.00 0.00 14041 S 561.67 0.00 0.00<br />

12006 S 69.81 0.00 0.00 14060 S 561.67 0.00 0.00<br />

12007 S 69.81 0.00 0.00 14061 S 561.67 0.00 0.00<br />

12011 S 52.10 0.00 0.00 14300 S 720.28 0.00 0.00<br />

12013 S 52.10 0.00 0.00 14350 S 662.73 0.00 0.00<br />

12014 S 52.10 0.00 0.00 15002 S 242.98 0.00 0.00<br />

12015 S 52.10 0.00 0.00 15003 S 242.98 0.00 0.00<br />

12016 S 69.81 0.00 0.00 15004 S 242.98 0.00 0.00<br />

12017 S 69.81 0.00 0.00 15005 S 242.98 0.00 0.00<br />

12018 S 69.81 0.00 0.00 15040 S 112.06 0.00 0.00<br />

12020 S 131.70 0.00 0.00 15050 S 242.98 0.00 0.00<br />

12021 S 112.06 0.00 0.00 15100 S 632.04 0.00 0.00<br />

12031 S 52.10 0.00 0.00 15101 S 662.73 0.00 0.00<br />

12032 S 136.62 0.00 0.00 15110 S 301.83 0.00 0.00<br />

12034 S 69.81 0.00 0.00 15111 S 247.64 0.00 0.00<br />

12035 S 69.81 0.00 0.00 15115 S 301.83 0.00 0.00<br />

12036 S 112.06 0.00 0.00 15116 S 247.64 0.00 0.00<br />

12037 S 223.35 0.00 0.00 15120 S 632.04 0.00 0.00<br />

12041 S 52.10 0.00 0.00 15121 S 662.73 0.00 0.00<br />

12042 S 52.10 0.00 0.00 15130 S 530.99 0.00 0.00<br />

12044 S 69.81 0.00 0.00 15131 S 476.79 0.00 0.00<br />

12045 S 112.06 0.00 0.00 15135 S 530.99 0.00 0.00<br />

12046 S 112.06 0.00 0.00 15136 S 476.79 0.00 0.00<br />

12047 S 223.35 0.00 0.00 15150 S 301.83 0.00 0.00<br />

12051 S 52.10 0.00 0.00 15151 S 247.64 0.00 0.00<br />

12052 S 52.10 0.00 0.00 15152 S 247.64 0.00 0.00<br />

12053 S 52.10 0.00 0.00 15155 S 301.83 0.00 0.00<br />

12054 S 69.81 0.00 0.00 15156 S 247.64 0.00 0.00<br />

12055 S 112.06 0.00 0.00 15157 S 247.64 0.00 0.00<br />

12056 S 112.06 0.00 0.00 15170 S 136.62 0.00 0.00<br />

12057 S 223.35 0.00 0.00 15171 S 136.62 0.00 0.00<br />

13100 S 242.98 0.00 0.00 15175 S 175.90 0.00 0.00<br />

13101 S 242.98 0.00 0.00 15176 S 175.90 0.00 0.00<br />

13102 S 131.70 0.00 0.00 15200 S 561.67 0.00 0.00<br />

13120 S 112.06 0.00 0.00 15201 S 472.14 0.00 0.00<br />

13121 S 112.06 0.00 0.00 15220 S 530.99 0.00 0.00<br />

13122 S 112.06 0.00 0.00 15221 S 242.98 0.00 0.00<br />

13131 S 112.06 0.00 0.00 15240 S 561.67 0.00 0.00<br />

13132 S 112.06 0.00 0.00 15241 S 242.98 0.00 0.00<br />

13133 S 112.06 0.00 0.00 15260 S 530.99 0.00 0.00<br />

13150 S 242.98 0.00 0.00 15261 S 472.14 0.00 0.00<br />

13151 S 242.98 0.00 0.00 15300 S 242.98 0.00 0.00<br />

13152 S 242.98 0.00 0.00 15301 S 242.98 0.00 0.00<br />

13153 S 112.06 0.00 0.00 15320 S 242.98 0.00 0.00<br />

13160 S 632.04 0.00 0.00 15321 S 242.98 0.00 0.00<br />

14000 S 530.99 0.00 0.00 15330 S 242.98 0.00 0.00<br />

14001 S 561.67 0.00 0.00 15331 S 242.98 0.00 0.00<br />

14020 S 561.67 0.00 0.00 15335 S 242.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 242.98 0.00 0.00 15826 S 662.73 0.00 0.00<br />

15340 S 136.62 0.00 0.00 15828 S 662.73 0.00 0.00<br />

15341 S 136.62 0.00 0.00 15829 S 761.99 0.00 0.00<br />

15360 S 136.62 0.00 0.00 15830 S 678.16 0.00 0.00<br />

15361 S 136.62 0.00 0.00 15832 S 678.16 0.00 0.00<br />

15365 S 136.62 0.00 0.00 15833 S 678.16 0.00 0.00<br />

15366 S 136.62 0.00 0.00 15834 S 678.16 0.00 0.00<br />

15400 S 242.98 0.00 0.00 15835 S 588.62 0.00 0.00<br />

15401 S 242.98 0.00 0.00 15836 S 560.14 0.00 0.00<br />

15420 S 242.98 0.00 0.00 15837 S 631.14 0.00 0.00<br />

15421 S 242.98 0.00 0.00 15838 S 631.14 0.00 0.00<br />

15430 S 242.98 0.00 0.00 15839 S 560.14 0.00 0.00<br />

15431 S 242.98 0.00 0.00 15840 S 720.28 0.00 0.00<br />

15570 S 662.73 0.00 0.00 15841 S 720.28 0.00 0.00<br />

15572 S 662.73 0.00 0.00 15842 S 836.32 0.00 0.00<br />

15574 S 662.73 0.00 0.00 15845 S 720.28 0.00 0.00<br />

15576 S 662.73 0.00 0.00 15847 S 678.16 0.00 0.00<br />

15600 S 662.73 0.00 0.00 15850 S 108.33 0.00 0.00<br />

15610 S 662.73 0.00 0.00 15851 S 49.31 0.00 0.00<br />

15620 S 720.28 0.00 0.00 15852 S 25.65 0.00 0.00<br />

15630 S 662.73 0.00 0.00 15860 S 25.65 0.00 0.00<br />

15650 S 761.99 0.00 0.00 15876 S 662.73 0.00 0.00<br />

15731 S 662.73 0.00 0.00 15877 S 662.73 0.00 0.00<br />

15732 S 662.73 0.00 0.00 15878 S 662.73 0.00 0.00<br />

15734 S 662.73 0.00 0.00 15879 S 662.73 0.00 0.00<br />

15736 S 662.73 0.00 0.00 15920 S 209.47 0.00 0.00<br />

15738 S 662.73 0.00 0.00 15922 S 720.28 0.00 0.00<br />

15740 S 530.99 0.00 0.00 15931 S 678.16 0.00 0.00<br />

15750 S 632.04 0.00 0.00 15933 S 678.16 0.00 0.00<br />

15760 S 632.04 0.00 0.00 15934 S 662.73 0.00 0.00<br />

15770 S 662.73 0.00 0.00 15935 S 720.28 0.00 0.00<br />

15775 S 181.08 0.00 0.00 15936 S 619.23 0.00 0.00<br />

15776 S 181.08 0.00 0.00 15937 S 720.28 0.00 0.00<br />

15780 S 403.71 0.00 0.00 15940 S 678.16 0.00 0.00<br />

15781 S 177.70 0.00 0.00 15941 S 678.16 0.00 0.00<br />

15782 S 177.70 0.00 0.00 15944 S 662.73 0.00 0.00<br />

15783 S 108.33 0.00 0.00 15945 S 720.28 0.00 0.00<br />

15786 S 32.87 0.00 0.00 15946 S 720.28 0.00 0.00<br />

15787 S 29.80 0.00 0.00 15950 S 678.16 0.00 0.00<br />

15788 S 32.87 0.00 0.00 15951 S 735.70 0.00 0.00<br />

15789 S 60.23 0.00 0.00 15952 S 561.67 0.00 0.00<br />

15792 S 60.23 0.00 0.00 15953 S 619.23 0.00 0.00<br />

15793 S 32.87 0.00 0.00 15956 S 561.67 0.00 0.00<br />

15819 S 136.62 0.00 0.00 15958 S 619.23 0.00 0.00<br />

15820 S 662.73 0.00 0.00 16000 S 26.61 0.00 0.00<br />

15821 S 662.73 0.00 0.00 16020 S 40.45 0.00 0.00<br />

15822 S 662.73 0.00 0.00 16025 S 62.29 0.00 0.00<br />

15823 S 761.99 0.00 0.00 16030 S 77.99 0.00 0.00<br />

15824 S 662.73 0.00 0.00 16035 S 60.23 0.00 0.00<br />

15825 S 662.73 0.00 0.00 17000 S 32.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.90 0.00 0.00 19300 S 728.60 0.00 0.00<br />

17004 S 85.85 0.00 0.00 19301 S 671.06 0.00 0.00<br />

17106 S 108.33 0.00 0.00 19302 S 1,281.65 0.00 0.00<br />

17107 S 108.33 0.00 0.00 19303 S 968.58 0.00 0.00<br />

17108 S 108.33 0.00 0.00 19304 S 968.58 0.00 0.00<br />

17110 S 32.87 0.00 0.00 19316 S 968.58 0.00 0.00<br />

17111 S 60.23 0.00 0.00 19318 S 1,106.61 0.00 0.00<br />

17250 S 45.41 0.00 0.00 19324 S 1,106.61 0.00 0.00<br />

17260 S 48.60 0.00 0.00 19325 S 1,835.45 0.00 0.00<br />

17261 S 60.23 0.00 0.00 19328 S 826.16 0.00 0.00<br />

17262 S 60.23 0.00 0.00 19330 S 826.16 0.00 0.00<br />

17263 S 60.23 0.00 0.00 19340 S 1,018.37 0.00 0.00<br />

17264 S 60.23 0.00 0.00 19342 S 1,437.90 0.00 0.00<br />

17266 S 108.33 0.00 0.00 19350 S 728.60 0.00 0.00<br />

17270 S 60.23 0.00 0.00 19355 S 968.58 0.00 0.00<br />

17271 S 60.23 0.00 0.00 19357 S 1,537.16 0.00 0.00<br />

17272 S 60.23 0.00 0.00 19366 S 1,010.30 0.00 0.00<br />

17273 S 108.33 0.00 0.00 19370 S 968.58 0.00 0.00<br />

17274 S 108.33 0.00 0.00 19371 S 968.58 0.00 0.00<br />

17276 S 108.33 0.00 0.00 19380 S 1,148.33 0.00 0.00<br />

17280 S 60.23 0.00 0.00 19396 S 1,332.92 0.00 0.00<br />

17281 S 89.75 0.00 0.00 20000 S 56.08 0.00 0.00<br />

17282 S 102.52 0.00 0.00 20005 S 646.24 0.00 0.00<br />

17283 S 108.33 0.00 0.00 20103 S 634.22 0.00 0.00<br />

17284 S 108.33 0.00 0.00 20150 S 1,800.55 0.00 0.00<br />

17286 S 108.33 0.00 0.00 20200 S 529.44 0.00 0.00<br />

17311 S 178.84 0.00 0.00 20205 S 560.14 0.00 0.00<br />

17312 S 178.84 0.00 0.00 20206 S 261.75 0.00 0.00<br />

17313 S 178.84 0.00 0.00 20220 S 284.52 0.00 0.00<br />

17314 S 178.84 0.00 0.00 20225 S 516.25 0.00 0.00<br />

17315 S 40.45 0.00 0.00 20240 S 647.46 0.00 0.00<br />

17340 S 14.55 0.00 0.00 20245 S 678.16 0.00 0.00<br />

17360 S 32.87 0.00 0.00 20250 S 676.93 0.00 0.00<br />

17380 S 32.87 0.00 0.00 20251 S 676.93 0.00 0.00<br />

19000 S 68.47 0.00 0.00 20500 S 56.06 0.00 0.00<br />

19001 S 9.23 0.00 0.00 20520 S 94.37 0.00 0.00<br />

19020 S 598.73 0.00 0.00 20525 S 678.16 0.00 0.00<br />

19100 S 203.88 0.00 0.00 20526 S 30.51 0.00 0.00<br />

19101 S 640.36 0.00 0.00 20550 S 23.06 0.00 0.00<br />

19102 S 261.75 0.00 0.00 20551 S 22.70 0.00 0.00<br />

19103 S 458.12 0.00 0.00 20552 S 21.99 0.00 0.00<br />

19105 S 1,332.92 0.00 0.00 20553 S 24.48 0.00 0.00<br />

19110 S 640.36 0.00 0.00 20555 S 1,186.31 0.00 0.00<br />

19112 S 671.06 0.00 0.00 20600 S 23.41 0.00 0.00<br />

19120 S 671.06 0.00 0.00 20605 S 26.25 0.00 0.00<br />

19125 S 671.06 0.00 0.00 20610 S 36.89 0.00 0.00<br />

19126 S 671.06 0.00 0.00 20612 S 24.84 0.00 0.00<br />

19296 S 1,835.45 0.00 0.00 20615 S 103.95 0.00 0.00<br />

19297 S 1,835.45 0.00 0.00 20650 S 676.93 0.00 0.00<br />

19298 S 1,835.45 0.00 0.00 20662 S 864.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 864.71 0.00 0.00 21085 S 260.39 0.00 0.00<br />

20665 S 25.65 0.00 0.00 21086 S 566.89 0.00 0.00<br />

20670 S 475.26 0.00 0.00 21087 S 567.61 0.00 0.00<br />

20680 S 678.16 0.00 0.00 21088 S 1,662.41 0.00 0.00<br />

20690 S 807.03 0.00 0.00 21100 S 1,045.08 0.00 0.00<br />

20692 S 837.73 0.00 0.00 21110 S 299.06 0.00 0.00<br />

20693 S 676.93 0.00 0.00 21120 S 968.56 0.00 0.00<br />

20694 S 592.05 0.00 0.00 21121 S 968.56 0.00 0.00<br />

20696 S 1,186.31 0.00 0.00 21122 S 968.56 0.00 0.00<br />

20697 S 788.95 0.00 0.00 21123 S 968.56 0.00 0.00<br />

20822 S 1,111.59 0.00 0.00 21125 S 968.56 0.00 0.00<br />

20900 S 837.73 0.00 0.00 21127 S 1,473.32 0.00 0.00<br />

20902 S 895.27 0.00 0.00 21137 S 982.81 0.00 0.00<br />

20910 S 662.73 0.00 0.00 21138 S 1,662.41 0.00 0.00<br />

20912 S 662.73 0.00 0.00 21139 S 1,662.41 0.00 0.00<br />

20920 S 619.23 0.00 0.00 21150 S 1,662.41 0.00 0.00<br />

20922 S 561.67 0.00 0.00 21181 S 968.56 0.00 0.00<br />

20924 S 895.27 0.00 0.00 21198 S 1,662.41 0.00 0.00<br />

20926 S 390.07 0.00 0.00 21199 S 1,662.41 0.00 0.00<br />

20950 S 56.08 0.00 0.00 21206 S 1,175.05 0.00 0.00<br />

20972 S 1,877.50 0.00 0.00 21208 S 1,308.37 0.00 0.00<br />

20973 S 1,877.50 0.00 0.00 21209 S 1,175.05 0.00 0.00<br />

20979 S 23.06 0.00 0.00 21210 S 1,308.37 0.00 0.00<br />

20982 S 1,800.55 0.00 0.00 21215 S 1,308.37 0.00 0.00<br />

21010 S 705.28 0.00 0.00 21230 S 1,308.37 0.00 0.00<br />

21015 S 586.80 0.00 0.00 21235 S 968.56 0.00 0.00<br />

21025 S 1,045.08 0.00 0.00 21240 S 1,133.32 0.00 0.00<br />

21026 S 1,045.08 0.00 0.00 21242 S 1,175.05 0.00 0.00<br />

21029 S 1,045.08 0.00 0.00 21243 S 1,175.05 0.00 0.00<br />

21030 S 246.55 0.00 0.00 21244 S 1,308.37 0.00 0.00<br />

21031 S 203.98 0.00 0.00 21245 S 1,308.37 0.00 0.00<br />

21032 S 207.88 0.00 0.00 21246 S 1,308.37 0.00 0.00<br />

21034 S 1,075.78 0.00 0.00 21248 S 1,308.37 0.00 0.00<br />

21040 S 705.28 0.00 0.00 21249 S 1,308.37 0.00 0.00<br />

21044 S 1,045.08 0.00 0.00 21260 S 1,662.41 0.00 0.00<br />

21046 S 1,045.08 0.00 0.00 21267 S 1,308.37 0.00 0.00<br />

21047 S 1,045.08 0.00 0.00 21270 S 1,175.05 0.00 0.00<br />

21048 S 1,662.41 0.00 0.00 21275 S 1,308.37 0.00 0.00<br />

21050 S 1,075.78 0.00 0.00 21280 S 1,175.05 0.00 0.00<br />

21060 S 1,045.08 0.00 0.00 21282 S 686.06 0.00 0.00<br />

21070 S 1,075.78 0.00 0.00 21295 S 309.22 0.00 0.00<br />

21073 S 191.57 0.00 0.00 21296 S 651.09 0.00 0.00<br />

21076 S 332.40 0.00 0.00 21310 S 94.33 0.00 0.00<br />

21077 S 803.51 0.00 0.00 21315 S 414.50 0.00 0.00<br />

21079 S 575.41 0.00 0.00 21320 S 556.10 0.00 0.00<br />

21080 S 659.84 0.00 0.00 21325 S 793.52 0.00 0.00<br />

21081 S 608.04 0.00 0.00 21330 S 835.24 0.00 0.00<br />

21082 S 578.60 0.00 0.00 21335 S 968.56 0.00 0.00<br />

21083 S 570.08 0.00 0.00 21336 S 807.19 0.00 0.00<br />

21084 S 655.93 0.00 0.00 21337 S 556.10 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 793.52 0.00 0.00 22310 S 171.73 0.00 0.00<br />

21339 S 835.24 0.00 0.00 22315 S 444.16 0.00 0.00<br />

21340 S 1,133.32 0.00 0.00 22505 S 522.89 0.00 0.00<br />

21345 S 968.56 0.00 0.00 22520 S 1,235.27 0.00 0.00<br />

21355 S 1,075.78 0.00 0.00 22521 S 1,235.27 0.00 0.00<br />

21356 S 735.98 0.00 0.00 22522 S 1,235.27 0.00 0.00<br />

21360 S 982.81 0.00 0.00 22523 S 3,437.89 0.00 0.00<br />

21390 S 1,662.41 0.00 0.00 22524 S 3,437.89 0.00 0.00<br />

21400 S 363.41 0.00 0.00 22525 S 3,437.89 0.00 0.00<br />

21401 S 586.80 0.00 0.00 22900 S 735.70 0.00 0.00<br />

21406 S 1,662.41 0.00 0.00 23000 S 529.44 0.00 0.00<br />

21407 S 1,662.41 0.00 0.00 23020 S 1,114.15 0.00 0.00<br />

21421 S 793.52 0.00 0.00 23030 S 544.53 0.00 0.00<br />

21440 S 334.18 0.00 0.00 23031 S 629.42 0.00 0.00<br />

21445 S 793.52 0.00 0.00 23035 S 676.93 0.00 0.00<br />

21450 S 137.92 0.00 0.00 23040 S 837.73 0.00 0.00<br />

21451 S 372.12 0.00 0.00 23044 S 895.27 0.00 0.00<br />

21452 S 556.10 0.00 0.00 23065 S 100.04 0.00 0.00<br />

21453 S 1,075.78 0.00 0.00 23066 S 647.46 0.00 0.00<br />

21454 S 835.24 0.00 0.00 23075 S 529.44 0.00 0.00<br />

21461 S 1,133.32 0.00 0.00 23076 S 647.46 0.00 0.00<br />

21462 S 1,175.05 0.00 0.00 23077 S 678.16 0.00 0.00<br />

21465 S 1,133.32 0.00 0.00 23100 S 646.24 0.00 0.00<br />

21480 S 94.33 0.00 0.00 23101 S 1,070.31 0.00 0.00<br />

21485 S 556.10 0.00 0.00 23105 S 895.27 0.00 0.00<br />

21490 S 1,075.78 0.00 0.00 23106 S 895.27 0.00 0.00<br />

21495 S 684.44 0.00 0.00 23107 S 895.27 0.00 0.00<br />

21497 S 556.10 0.00 0.00 23120 S 937.00 0.00 0.00<br />

21501 S 598.73 0.00 0.00 23125 S 937.00 0.00 0.00<br />

21502 S 646.24 0.00 0.00 23130 S 1,244.11 0.00 0.00<br />

21550 S 631.14 0.00 0.00 23140 S 734.47 0.00 0.00<br />

21555 S 647.46 0.00 0.00 23145 S 937.00 0.00 0.00<br />

21556 S 647.46 0.00 0.00 23146 S 937.00 0.00 0.00<br />

21557 S 867.17 0.00 0.00 23150 S 895.27 0.00 0.00<br />

21600 S 807.03 0.00 0.00 23155 S 937.00 0.00 0.00<br />

21610 S 807.03 0.00 0.00 23156 S 937.00 0.00 0.00<br />

21685 S 299.06 0.00 0.00 23170 S 807.03 0.00 0.00<br />

21700 S 646.24 0.00 0.00 23172 S 807.03 0.00 0.00<br />

21720 S 676.93 0.00 0.00 23174 S 807.03 0.00 0.00<br />

21725 S 70.47 0.00 0.00 23180 S 895.27 0.00 0.00<br />

21800 S 81.40 0.00 0.00 23182 S 895.27 0.00 0.00<br />

21805 S 718.95 0.00 0.00 23184 S 895.27 0.00 0.00<br />

21820 S 81.40 0.00 0.00 23190 S 895.27 0.00 0.00<br />

21920 S 144.74 0.00 0.00 23195 S 937.00 0.00 0.00<br />

21925 S 647.46 0.00 0.00 23330 S 323.58 0.00 0.00<br />

21930 S 647.46 0.00 0.00 23331 S 593.28 0.00 0.00<br />

21935 S 678.16 0.00 0.00 23395 S 1,244.11 0.00 0.00<br />

22102 S 1,929.72 0.00 0.00 23397 S 2,196.10 0.00 0.00<br />

22103 S 1,929.72 0.00 0.00 23400 S 1,070.31 0.00 0.00<br />

22305 S 81.40 0.00 0.00 23405 S 807.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 807.03 0.00 0.00 23931 S 598.73 0.00 0.00<br />

23410 S 1,244.11 0.00 0.00 23935 S 646.24 0.00 0.00<br />

23412 S 1,377.42 0.00 0.00 24000 S 895.27 0.00 0.00<br />

23415 S 1,244.11 0.00 0.00 24006 S 895.27 0.00 0.00<br />

23420 S 1,377.42 0.00 0.00 24065 S 138.71 0.00 0.00<br />

23430 S 1,202.39 0.00 0.00 24066 S 529.44 0.00 0.00<br />

23440 S 1,202.39 0.00 0.00 24075 S 529.44 0.00 0.00<br />

23450 S 2,062.79 0.00 0.00 24076 S 647.46 0.00 0.00<br />

23455 S 2,196.10 0.00 0.00 24077 S 678.16 0.00 0.00<br />

23460 S 2,062.79 0.00 0.00 24100 S 592.05 0.00 0.00<br />

23462 S 1,377.42 0.00 0.00 24101 S 895.27 0.00 0.00<br />

23465 S 2,062.79 0.00 0.00 24102 S 895.27 0.00 0.00<br />

23466 S 1,377.42 0.00 0.00 24105 S 676.93 0.00 0.00<br />

23480 S 1,202.39 0.00 0.00 24110 S 646.24 0.00 0.00<br />

23485 S 2,196.10 0.00 0.00 24115 S 837.73 0.00 0.00<br />

23490 S 1,144.84 0.00 0.00 24116 S 837.73 0.00 0.00<br />

23491 S 1,963.52 0.00 0.00 24120 S 676.93 0.00 0.00<br />

23500 S 81.40 0.00 0.00 24125 S 837.73 0.00 0.00<br />

23505 S 444.16 0.00 0.00 24126 S 837.73 0.00 0.00<br />

23515 S 1,486.58 0.00 0.00 24130 S 837.73 0.00 0.00<br />

23520 S 171.73 0.00 0.00 24134 S 807.03 0.00 0.00<br />

23525 S 171.73 0.00 0.00 24136 S 807.03 0.00 0.00<br />

23530 S 1,095.46 0.00 0.00 24138 S 807.03 0.00 0.00<br />

23532 S 807.19 0.00 0.00 24140 S 837.73 0.00 0.00<br />

23540 S 81.40 0.00 0.00 24145 S 837.73 0.00 0.00<br />

23545 S 171.73 0.00 0.00 24147 S 807.03 0.00 0.00<br />

23550 S 1,095.46 0.00 0.00 24149 S 1,186.31 0.00 0.00<br />

23552 S 1,153.02 0.00 0.00 24152 S 1,800.55 0.00 0.00<br />

23570 S 81.40 0.00 0.00 24153 S 3,437.89 0.00 0.00<br />

23575 S 171.73 0.00 0.00 24155 S 1,144.84 0.00 0.00<br />

23585 S 1,486.58 0.00 0.00 24160 S 807.03 0.00 0.00<br />

23600 S 63.43 0.00 0.00 24164 S 837.73 0.00 0.00<br />

23605 S 444.16 0.00 0.00 24200 S 101.46 0.00 0.00<br />

23615 S 1,544.12 0.00 0.00 24201 S 529.44 0.00 0.00<br />

23616 S 1,544.12 0.00 0.00 24300 S 618.03 0.00 0.00<br />

23620 S 63.43 0.00 0.00 24301 S 895.27 0.00 0.00<br />

23625 S 444.16 0.00 0.00 24305 S 895.27 0.00 0.00<br />

23630 S 1,585.85 0.00 0.00 24310 S 676.93 0.00 0.00<br />

23650 S 81.40 0.00 0.00 24320 S 1,144.84 0.00 0.00<br />

23655 S 468.71 0.00 0.00 24330 S 1,963.52 0.00 0.00<br />

23660 S 1,095.46 0.00 0.00 24331 S 1,144.84 0.00 0.00<br />

23665 S 171.73 0.00 0.00 24332 S 864.71 0.00 0.00<br />

23670 S 1,486.58 0.00 0.00 24340 S 1,144.84 0.00 0.00<br />

23675 S 81.40 0.00 0.00 24341 S 1,144.84 0.00 0.00<br />

23680 S 1,095.46 0.00 0.00 24342 S 1,144.84 0.00 0.00<br />

23700 S 468.71 0.00 0.00 24343 S 1,186.31 0.00 0.00<br />

23800 S 2,021.06 0.00 0.00 24344 S 3,437.89 0.00 0.00<br />

23802 S 1,377.42 0.00 0.00 24345 S 807.03 0.00 0.00<br />

23921 S 472.14 0.00 0.00 24346 S 1,800.55 0.00 0.00<br />

23930 S 544.53 0.00 0.00 24357 S 1,186.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,186.31 0.00 0.00 24925 S 676.93 0.00 0.00<br />

24359 S 1,186.31 0.00 0.00 25000 S 676.93 0.00 0.00<br />

24360 S 1,094.80 0.00 0.00 25001 S 864.71 0.00 0.00<br />

24361 S 5,985.82 3,664.08 1,342.34 25020 S 676.93 0.00 0.00<br />

24362 S 1,399.14 0.00 0.00 25023 S 837.73 0.00 0.00<br />

24363 S 6,119.13 3,797.39 1,475.66 25024 S 837.73 0.00 0.00<br />

24365 S 1,094.80 0.00 0.00 25025 S 837.73 0.00 0.00<br />

24366 S 5,985.82 3,664.08 1,342.34 25028 S 592.05 0.00 0.00<br />

24400 S 895.27 0.00 0.00 25031 S 646.24 0.00 0.00<br />

24410 S 895.27 0.00 0.00 25035 S 646.24 0.00 0.00<br />

24420 S 1,144.84 0.00 0.00 25040 S 937.00 0.00 0.00<br />

24430 S 1,963.52 0.00 0.00 25065 S 140.83 0.00 0.00<br />

24435 S 2,021.06 0.00 0.00 25066 S 647.46 0.00 0.00<br />

24470 S 1,144.84 0.00 0.00 25075 S 529.44 0.00 0.00<br />

24495 S 807.03 0.00 0.00 25076 S 678.16 0.00 0.00<br />

24498 S 1,963.52 0.00 0.00 25077 S 678.16 0.00 0.00<br />

24500 S 81.40 0.00 0.00 25085 S 676.93 0.00 0.00<br />

24505 S 81.40 0.00 0.00 25100 S 646.24 0.00 0.00<br />

24515 S 1,544.12 0.00 0.00 25101 S 837.73 0.00 0.00<br />

24516 S 1,544.12 0.00 0.00 25105 S 895.27 0.00 0.00<br />

24530 S 81.40 0.00 0.00 25107 S 837.73 0.00 0.00<br />

24535 S 171.73 0.00 0.00 25109 S 864.71 0.00 0.00<br />

24538 S 718.95 0.00 0.00 25110 S 676.93 0.00 0.00<br />

24545 S 1,544.12 0.00 0.00 25111 S 676.93 0.00 0.00<br />

24546 S 1,585.85 0.00 0.00 25112 S 734.47 0.00 0.00<br />

24560 S 81.40 0.00 0.00 25115 S 734.47 0.00 0.00<br />

24565 S 81.40 0.00 0.00 25116 S 734.47 0.00 0.00<br />

24566 S 718.95 0.00 0.00 25118 S 807.03 0.00 0.00<br />

24575 S 1,486.58 0.00 0.00 25119 S 837.73 0.00 0.00<br />

24576 S 81.40 0.00 0.00 25120 S 837.73 0.00 0.00<br />

24577 S 171.73 0.00 0.00 25125 S 837.73 0.00 0.00<br />

24579 S 1,486.58 0.00 0.00 25126 S 837.73 0.00 0.00<br />

24582 S 718.95 0.00 0.00 25130 S 837.73 0.00 0.00<br />

24586 S 1,544.12 0.00 0.00 25135 S 837.73 0.00 0.00<br />

24587 S 1,585.85 0.00 0.00 25136 S 837.73 0.00 0.00<br />

24600 S 81.40 0.00 0.00 25145 S 807.03 0.00 0.00<br />

24605 S 522.89 0.00 0.00 25150 S 807.03 0.00 0.00<br />

24615 S 1,486.58 0.00 0.00 25151 S 807.03 0.00 0.00<br />

24620 S 444.16 0.00 0.00 25210 S 837.73 0.00 0.00<br />

24635 S 1,486.58 0.00 0.00 25215 S 895.27 0.00 0.00<br />

24640 S 54.98 0.00 0.00 25230 S 895.27 0.00 0.00<br />

24650 S 63.43 0.00 0.00 25240 S 895.27 0.00 0.00<br />

24655 S 171.73 0.00 0.00 25248 S 646.24 0.00 0.00<br />

24665 S 1,153.02 0.00 0.00 25250 S 752.85 0.00 0.00<br />

24666 S 1,544.12 0.00 0.00 25251 S 752.85 0.00 0.00<br />

24670 S 81.40 0.00 0.00 25259 S 788.95 0.00 0.00<br />

24675 S 81.40 0.00 0.00 25260 S 895.27 0.00 0.00<br />

24685 S 1,095.46 0.00 0.00 25263 S 807.03 0.00 0.00<br />

24800 S 1,202.39 0.00 0.00 25265 S 837.73 0.00 0.00<br />

24802 S 1,244.11 0.00 0.00 25270 S 895.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 837.73 0.00 0.00 25505 S 171.73 0.00 0.00<br />

25274 S 895.27 0.00 0.00 25515 S 1,095.46 0.00 0.00<br />

25275 S 895.27 0.00 0.00 25520 S 171.73 0.00 0.00<br />

25280 S 895.27 0.00 0.00 25525 S 1,153.02 0.00 0.00<br />

25290 S 837.73 0.00 0.00 25526 S 1,194.73 0.00 0.00<br />

25295 S 676.93 0.00 0.00 25530 S 63.43 0.00 0.00<br />

25300 S 837.73 0.00 0.00 25535 S 81.40 0.00 0.00<br />

25301 S 837.73 0.00 0.00 25545 S 1,095.46 0.00 0.00<br />

25310 S 1,144.84 0.00 0.00 25560 S 63.43 0.00 0.00<br />

25312 S 1,202.39 0.00 0.00 25565 S 171.73 0.00 0.00<br />

25315 S 1,144.84 0.00 0.00 25574 S 1,486.58 0.00 0.00<br />

25316 S 1,963.52 0.00 0.00 25575 S 1,486.58 0.00 0.00<br />

25320 S 1,144.84 0.00 0.00 25600 S 63.43 0.00 0.00<br />

25332 S 1,094.80 0.00 0.00 25605 S 171.73 0.00 0.00<br />

25335 S 1,144.84 0.00 0.00 25606 S 749.65 0.00 0.00<br />

25337 S 1,244.11 0.00 0.00 25607 S 1,585.85 0.00 0.00<br />

25350 S 1,963.52 0.00 0.00 25608 S 1,585.85 0.00 0.00<br />

25355 S 1,144.84 0.00 0.00 25609 S 1,585.85 0.00 0.00<br />

25360 S 837.73 0.00 0.00 25622 S 63.43 0.00 0.00<br />

25365 S 837.73 0.00 0.00 25624 S 171.73 0.00 0.00<br />

25370 S 1,144.84 0.00 0.00 25628 S 1,095.46 0.00 0.00<br />

25375 S 1,202.39 0.00 0.00 25630 S 63.43 0.00 0.00<br />

25390 S 837.73 0.00 0.00 25635 S 171.73 0.00 0.00<br />

25391 S 1,202.39 0.00 0.00 25645 S 1,095.46 0.00 0.00<br />

25392 S 837.73 0.00 0.00 25650 S 63.43 0.00 0.00<br />

25393 S 1,202.39 0.00 0.00 25651 S 1,010.15 0.00 0.00<br />

25394 S 1,800.55 0.00 0.00 25652 S 1,701.78 0.00 0.00<br />

25400 S 1,144.84 0.00 0.00 25660 S 81.40 0.00 0.00<br />

25405 S 2,021.06 0.00 0.00 25670 S 749.65 0.00 0.00<br />

25415 S 1,963.52 0.00 0.00 25671 S 664.77 0.00 0.00<br />

25420 S 2,021.06 0.00 0.00 25675 S 81.40 0.00 0.00<br />

25425 S 1,144.84 0.00 0.00 25676 S 718.95 0.00 0.00<br />

25426 S 1,202.39 0.00 0.00 25680 S 81.40 0.00 0.00<br />

25430 S 1,800.55 0.00 0.00 25685 S 749.65 0.00 0.00<br />

25431 S 1,800.55 0.00 0.00 25690 S 444.16 0.00 0.00<br />

25440 S 2,021.06 0.00 0.00 25695 S 718.95 0.00 0.00<br />

25441 S 5,985.82 3,664.08 1,342.34 25800 S 2,021.06 0.00 0.00<br />

25442 S 5,985.82 3,664.08 1,342.34 25805 S 1,244.11 0.00 0.00<br />

25443 S 1,399.14 0.00 0.00 25810 S 2,062.79 0.00 0.00<br />

25444 S 1,399.14 0.00 0.00 25820 S 1,202.39 0.00 0.00<br />

25445 S 1,399.14 0.00 0.00 25825 S 2,062.79 0.00 0.00<br />

25446 S 6,119.13 3,797.39 1,475.66 25830 S 2,062.79 0.00 0.00<br />

25447 S 1,094.80 0.00 0.00 25907 S 676.93 0.00 0.00<br />

25449 S 1,094.80 0.00 0.00 25922 S 676.93 0.00 0.00<br />

25450 S 1,144.84 0.00 0.00 25929 S 561.67 0.00 0.00<br />

25455 S 1,144.84 0.00 0.00 25931 S 864.71 0.00 0.00<br />

25490 S 1,144.84 0.00 0.00 26010 S 56.08 0.00 0.00<br />

25491 S 1,144.84 0.00 0.00 26011 S 409.71 0.00 0.00<br />

25492 S 1,144.84 0.00 0.00 26020 S 543.64 0.00 0.00<br />

25500 S 63.43 0.00 0.00 26025 S 489.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 543.64 0.00 0.00 26392 S 800.37 0.00 0.00<br />

26034 S 543.64 0.00 0.00 26410 S 574.32 0.00 0.00<br />

26035 S 659.50 0.00 0.00 26412 S 800.37 0.00 0.00<br />

26040 S 857.92 0.00 0.00 26415 S 857.92 0.00 0.00<br />

26045 S 800.37 0.00 0.00 26416 S 800.37 0.00 0.00<br />

26055 S 543.64 0.00 0.00 26418 S 631.87 0.00 0.00<br />

26060 S 543.64 0.00 0.00 26420 S 857.92 0.00 0.00<br />

26070 S 543.64 0.00 0.00 26426 S 800.37 0.00 0.00<br />

26075 S 631.87 0.00 0.00 26428 S 800.37 0.00 0.00<br />

26080 S 631.87 0.00 0.00 26432 S 574.32 0.00 0.00<br />

26100 S 543.64 0.00 0.00 26433 S 574.32 0.00 0.00<br />

26105 S 489.44 0.00 0.00 26434 S 800.37 0.00 0.00<br />

26110 S 489.44 0.00 0.00 26437 S 574.32 0.00 0.00<br />

26115 S 647.46 0.00 0.00 26440 S 574.32 0.00 0.00<br />

26116 S 647.46 0.00 0.00 26442 S 800.37 0.00 0.00<br />

26117 S 678.16 0.00 0.00 26445 S 574.32 0.00 0.00<br />

26121 S 857.92 0.00 0.00 26449 S 800.37 0.00 0.00<br />

26123 S 857.92 0.00 0.00 26450 S 574.32 0.00 0.00<br />

26125 S 631.87 0.00 0.00 26455 S 574.32 0.00 0.00<br />

26130 S 574.32 0.00 0.00 26460 S 574.32 0.00 0.00<br />

26135 S 857.92 0.00 0.00 26471 S 543.64 0.00 0.00<br />

26140 S 543.64 0.00 0.00 26474 S 543.64 0.00 0.00<br />

26145 S 574.32 0.00 0.00 26476 S 489.44 0.00 0.00<br />

26160 S 574.32 0.00 0.00 26477 S 489.44 0.00 0.00<br />

26170 S 574.32 0.00 0.00 26478 S 489.44 0.00 0.00<br />

26180 S 574.32 0.00 0.00 26479 S 489.44 0.00 0.00<br />

26185 S 631.87 0.00 0.00 26480 S 800.37 0.00 0.00<br />

26200 S 543.64 0.00 0.00 26483 S 800.37 0.00 0.00<br />

26205 S 800.37 0.00 0.00 26485 S 769.68 0.00 0.00<br />

26210 S 543.64 0.00 0.00 26489 S 800.37 0.00 0.00<br />

26215 S 574.32 0.00 0.00 26490 S 800.37 0.00 0.00<br />

26230 S 805.92 0.00 0.00 26492 S 800.37 0.00 0.00<br />

26235 S 574.32 0.00 0.00 26494 S 800.37 0.00 0.00<br />

26236 S 574.32 0.00 0.00 26496 S 800.37 0.00 0.00<br />

26250 S 574.32 0.00 0.00 26497 S 800.37 0.00 0.00<br />

26255 S 800.37 0.00 0.00 26498 S 857.92 0.00 0.00<br />

26260 S 574.32 0.00 0.00 26499 S 800.37 0.00 0.00<br />

26261 S 574.32 0.00 0.00 26500 S 631.87 0.00 0.00<br />

26262 S 543.64 0.00 0.00 26502 S 857.92 0.00 0.00<br />

26320 S 529.44 0.00 0.00 26508 S 574.32 0.00 0.00<br />

26340 S 244.07 0.00 0.00 26510 S 800.37 0.00 0.00<br />

26350 S 715.48 0.00 0.00 26516 S 715.48 0.00 0.00<br />

26352 S 857.92 0.00 0.00 26517 S 800.37 0.00 0.00<br />

26356 S 857.92 0.00 0.00 26518 S 800.37 0.00 0.00<br />

26357 S 857.92 0.00 0.00 26520 S 574.32 0.00 0.00<br />

26358 S 857.92 0.00 0.00 26525 S 574.32 0.00 0.00<br />

26370 S 857.92 0.00 0.00 26530 S 995.53 0.00 0.00<br />

26372 S 857.92 0.00 0.00 26531 S 1,532.46 0.00 0.00<br />

26373 S 800.37 0.00 0.00 26535 S 1,094.80 0.00 0.00<br />

26390 S 857.92 0.00 0.00 26536 S 1,399.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 631.87 0.00 0.00 26775 S 169.57 0.00 0.00<br />

26541 S 1,032.95 0.00 0.00 26776 S 718.95 0.00 0.00<br />

26542 S 631.87 0.00 0.00 26785 S 718.95 0.00 0.00<br />

26545 S 857.92 0.00 0.00 26820 S 899.63 0.00 0.00<br />

26546 S 857.92 0.00 0.00 26841 S 857.92 0.00 0.00<br />

26548 S 857.92 0.00 0.00 26842 S 857.92 0.00 0.00<br />

26550 S 769.68 0.00 0.00 26843 S 800.37 0.00 0.00<br />

26555 S 800.37 0.00 0.00 26844 S 800.37 0.00 0.00<br />

26560 S 543.64 0.00 0.00 26850 S 857.92 0.00 0.00<br />

26561 S 800.37 0.00 0.00 26852 S 857.92 0.00 0.00<br />

26562 S 857.92 0.00 0.00 26860 S 800.37 0.00 0.00<br />

26565 S 899.63 0.00 0.00 26861 S 769.68 0.00 0.00<br />

26567 S 899.63 0.00 0.00 26862 S 857.92 0.00 0.00<br />

26568 S 800.37 0.00 0.00 26863 S 800.37 0.00 0.00<br />

26580 S 673.59 0.00 0.00 26910 S 800.37 0.00 0.00<br />

26587 S 673.59 0.00 0.00 26951 S 543.64 0.00 0.00<br />

26590 S 673.59 0.00 0.00 26952 S 631.87 0.00 0.00<br />

26591 S 800.37 0.00 0.00 26990 S 592.05 0.00 0.00<br />

26593 S 574.32 0.00 0.00 26991 S 592.05 0.00 0.00<br />

26596 S 543.64 0.00 0.00 27000 S 646.24 0.00 0.00<br />

26600 S 63.43 0.00 0.00 27001 S 837.73 0.00 0.00<br />

26605 S 81.40 0.00 0.00 27003 S 837.73 0.00 0.00<br />

26607 S 444.16 0.00 0.00 27033 S 1,144.84 0.00 0.00<br />

26608 S 807.19 0.00 0.00 27035 S 1,202.39 0.00 0.00<br />

26615 S 1,153.02 0.00 0.00 27040 S 323.58 0.00 0.00<br />

26641 S 63.43 0.00 0.00 27041 S 364.58 0.00 0.00<br />

26645 S 171.73 0.00 0.00 27047 S 647.46 0.00 0.00<br />

26650 S 718.95 0.00 0.00 27048 S 678.16 0.00 0.00<br />

26665 S 1,153.02 0.00 0.00 27049 S 678.16 0.00 0.00<br />

26670 S 63.43 0.00 0.00 27050 S 676.93 0.00 0.00<br />

26675 S 171.73 0.00 0.00 27052 S 676.93 0.00 0.00<br />

26676 S 718.95 0.00 0.00 27060 S 776.20 0.00 0.00<br />

26685 S 749.65 0.00 0.00 27062 S 776.20 0.00 0.00<br />

26686 S 1,486.58 0.00 0.00 27065 S 776.20 0.00 0.00<br />

26700 S 63.43 0.00 0.00 27066 S 937.00 0.00 0.00<br />

26705 S 81.40 0.00 0.00 27067 S 937.00 0.00 0.00<br />

26706 S 444.16 0.00 0.00 27080 S 807.03 0.00 0.00<br />

26715 S 807.19 0.00 0.00 27086 S 323.58 0.00 0.00<br />

26720 S 63.43 0.00 0.00 27087 S 676.93 0.00 0.00<br />

26725 S 63.43 0.00 0.00 27097 S 837.73 0.00 0.00<br />

26727 S 982.23 0.00 0.00 27098 S 837.73 0.00 0.00<br />

26735 S 807.19 0.00 0.00 27100 S 1,202.39 0.00 0.00<br />

26740 S 63.43 0.00 0.00 27105 S 1,202.39 0.00 0.00<br />

26742 S 81.40 0.00 0.00 27110 S 1,202.39 0.00 0.00<br />

26746 S 848.92 0.00 0.00 27111 S 1,202.39 0.00 0.00<br />

26750 S 63.43 0.00 0.00 27193 S 81.40 0.00 0.00<br />

26755 S 63.43 0.00 0.00 27194 S 522.89 0.00 0.00<br />

26756 S 718.95 0.00 0.00 27200 S 63.43 0.00 0.00<br />

26765 S 807.19 0.00 0.00 27202 S 1,064.78 0.00 0.00<br />

26770 S 63.43 0.00 0.00 27220 S 63.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 81.40 0.00 0.00 27397 S 1,144.84 0.00 0.00<br />

27238 S 171.73 0.00 0.00 27400 S 1,144.84 0.00 0.00<br />

27246 S 171.73 0.00 0.00 27403 S 895.27 0.00 0.00<br />

27250 S 81.40 0.00 0.00 27405 S 1,202.39 0.00 0.00<br />

27252 S 522.89 0.00 0.00 27407 S 2,021.06 0.00 0.00<br />

27256 S 63.43 0.00 0.00 27409 S 1,202.39 0.00 0.00<br />

27257 S 553.59 0.00 0.00 27416 S 1,800.55 0.00 0.00<br />

27265 S 81.40 0.00 0.00 27418 S 1,144.84 0.00 0.00<br />

27266 S 522.89 0.00 0.00 27420 S 1,144.84 0.00 0.00<br />

27267 S 63.43 0.00 0.00 27422 S 1,377.42 0.00 0.00<br />

27275 S 522.89 0.00 0.00 27424 S 1,144.84 0.00 0.00<br />

27301 S 629.42 0.00 0.00 27425 S 1,070.31 0.00 0.00<br />

27305 S 646.24 0.00 0.00 27427 S 1,144.84 0.00 0.00<br />

27306 S 676.93 0.00 0.00 27428 S 2,021.06 0.00 0.00<br />

27307 S 676.93 0.00 0.00 27429 S 2,021.06 0.00 0.00<br />

27310 S 895.27 0.00 0.00 27430 S 1,202.39 0.00 0.00<br />

27323 S 323.58 0.00 0.00 27435 S 1,202.39 0.00 0.00<br />

27324 S 593.28 0.00 0.00 27437 S 1,053.07 0.00 0.00<br />

27325 S 581.33 0.00 0.00 27438 S 1,399.14 0.00 0.00<br />

27326 S 581.33 0.00 0.00 27440 S 1,501.91 0.00 0.00<br />

27327 S 647.46 0.00 0.00 27441 S 1,094.80 0.00 0.00<br />

27328 S 678.16 0.00 0.00 27442 S 1,094.80 0.00 0.00<br />

27329 S 735.70 0.00 0.00 27443 S 1,094.80 0.00 0.00<br />

27330 S 895.27 0.00 0.00 27446 S 10,742.06 6,453.34 2,164.62<br />

27331 S 895.27 0.00 0.00 27496 S 776.20 0.00 0.00<br />

27332 S 895.27 0.00 0.00 27497 S 676.93 0.00 0.00<br />

27333 S 895.27 0.00 0.00 27498 S 676.93 0.00 0.00<br />

27334 S 895.27 0.00 0.00 27499 S 676.93 0.00 0.00<br />

27335 S 895.27 0.00 0.00 27500 S 171.73 0.00 0.00<br />

27340 S 676.93 0.00 0.00 27501 S 81.40 0.00 0.00<br />

27345 S 734.47 0.00 0.00 27502 S 444.16 0.00 0.00<br />

27347 S 734.47 0.00 0.00 27503 S 81.40 0.00 0.00<br />

27350 S 895.27 0.00 0.00 27508 S 81.40 0.00 0.00<br />

27355 S 837.73 0.00 0.00 27509 S 749.65 0.00 0.00<br />

27356 S 895.27 0.00 0.00 27510 S 171.73 0.00 0.00<br />

27357 S 937.00 0.00 0.00 27516 S 81.40 0.00 0.00<br />

27358 S 937.00 0.00 0.00 27517 S 81.40 0.00 0.00<br />

27360 S 937.00 0.00 0.00 27520 S 81.40 0.00 0.00<br />

27372 S 910.74 0.00 0.00 27530 S 81.40 0.00 0.00<br />

27380 S 592.05 0.00 0.00 27532 S 444.16 0.00 0.00<br />

27381 S 676.93 0.00 0.00 27538 S 81.40 0.00 0.00<br />

27385 S 676.93 0.00 0.00 27550 S 81.40 0.00 0.00<br />

27386 S 676.93 0.00 0.00 27552 S 468.71 0.00 0.00<br />

27390 S 592.05 0.00 0.00 27560 S 81.40 0.00 0.00<br />

27391 S 646.24 0.00 0.00 27562 S 468.71 0.00 0.00<br />

27392 S 676.93 0.00 0.00 27566 S 1,064.78 0.00 0.00<br />

27393 S 807.03 0.00 0.00 27570 S 468.71 0.00 0.00<br />

27394 S 837.73 0.00 0.00 27594 S 676.93 0.00 0.00<br />

27395 S 1,144.84 0.00 0.00 27600 S 676.93 0.00 0.00<br />

27396 S 837.73 0.00 0.00 27601 S 676.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 676.93 0.00 0.00 27730 S 807.03 0.00 0.00<br />

27603 S 598.73 0.00 0.00 27732 S 807.03 0.00 0.00<br />

27604 S 646.24 0.00 0.00 27734 S 807.03 0.00 0.00<br />

27605 S 588.87 0.00 0.00 27740 S 807.03 0.00 0.00<br />

27606 S 592.05 0.00 0.00 27742 S 1,114.15 0.00 0.00<br />

27607 S 646.24 0.00 0.00 27745 S 1,963.52 0.00 0.00<br />

27610 S 807.03 0.00 0.00 27750 S 81.40 0.00 0.00<br />

27612 S 837.73 0.00 0.00 27752 S 444.16 0.00 0.00<br />

27613 S 133.03 0.00 0.00 27756 S 749.65 0.00 0.00<br />

27614 S 647.46 0.00 0.00 27758 S 1,153.02 0.00 0.00<br />

27615 S 837.73 0.00 0.00 27759 S 1,544.12 0.00 0.00<br />

27618 S 529.44 0.00 0.00 27760 S 81.40 0.00 0.00<br />

27619 S 678.16 0.00 0.00 27762 S 444.16 0.00 0.00<br />

27620 S 895.27 0.00 0.00 27766 S 1,095.46 0.00 0.00<br />

27625 S 895.27 0.00 0.00 27767 S 63.43 0.00 0.00<br />

27626 S 895.27 0.00 0.00 27768 S 63.43 0.00 0.00<br />

27630 S 676.93 0.00 0.00 27769 S 1,701.78 0.00 0.00<br />

27635 S 837.73 0.00 0.00 27780 S 81.40 0.00 0.00<br />

27637 S 837.73 0.00 0.00 27781 S 444.16 0.00 0.00<br />

27638 S 837.73 0.00 0.00 27784 S 1,095.46 0.00 0.00<br />

27640 S 1,114.15 0.00 0.00 27786 S 81.40 0.00 0.00<br />

27641 S 807.03 0.00 0.00 27788 S 81.40 0.00 0.00<br />

27647 S 1,144.84 0.00 0.00 27792 S 1,095.46 0.00 0.00<br />

27650 S 1,144.84 0.00 0.00 27808 S 81.40 0.00 0.00<br />

27652 S 1,963.52 0.00 0.00 27810 S 171.73 0.00 0.00<br />

27654 S 1,144.84 0.00 0.00 27814 S 1,095.46 0.00 0.00<br />

27656 S 646.24 0.00 0.00 27816 S 81.40 0.00 0.00<br />

27658 S 592.05 0.00 0.00 27818 S 171.73 0.00 0.00<br />

27659 S 646.24 0.00 0.00 27822 S 1,095.46 0.00 0.00<br />

27664 S 646.24 0.00 0.00 27823 S 1,486.58 0.00 0.00<br />

27665 S 807.03 0.00 0.00 27824 S 81.40 0.00 0.00<br />

27675 S 646.24 0.00 0.00 27825 S 444.16 0.00 0.00<br />

27676 S 837.73 0.00 0.00 27826 S 1,095.46 0.00 0.00<br />

27680 S 837.73 0.00 0.00 27827 S 1,486.58 0.00 0.00<br />

27681 S 807.03 0.00 0.00 27828 S 1,544.12 0.00 0.00<br />

27685 S 837.73 0.00 0.00 27829 S 1,064.78 0.00 0.00<br />

27686 S 837.73 0.00 0.00 27830 S 81.40 0.00 0.00<br />

27687 S 837.73 0.00 0.00 27831 S 444.16 0.00 0.00<br />

27690 S 1,202.39 0.00 0.00 27832 S 1,064.78 0.00 0.00<br />

27691 S 1,202.39 0.00 0.00 27840 S 171.73 0.00 0.00<br />

27692 S 1,144.84 0.00 0.00 27842 S 468.71 0.00 0.00<br />

27695 S 807.03 0.00 0.00 27846 S 1,095.46 0.00 0.00<br />

27696 S 807.03 0.00 0.00 27848 S 1,095.46 0.00 0.00<br />

27698 S 807.03 0.00 0.00 27860 S 468.71 0.00 0.00<br />

27700 S 1,094.80 0.00 0.00 27870 S 2,021.06 0.00 0.00<br />

27704 S 646.24 0.00 0.00 27871 S 2,021.06 0.00 0.00<br />

27705 S 1,114.15 0.00 0.00 27884 S 676.93 0.00 0.00<br />

27707 S 646.24 0.00 0.00 27889 S 837.73 0.00 0.00<br />

27709 S 807.03 0.00 0.00 27892 S 676.93 0.00 0.00<br />

27726 S 1,010.15 0.00 0.00 27893 S 676.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 676.93 0.00 0.00 28153 S 673.76 0.00 0.00<br />

28001 S 129.84 0.00 0.00 28160 S 673.76 0.00 0.00<br />

28002 S 676.93 0.00 0.00 28171 S 673.76 0.00 0.00<br />

28003 S 676.93 0.00 0.00 28173 S 673.76 0.00 0.00<br />

28005 S 673.76 0.00 0.00 28175 S 673.76 0.00 0.00<br />

28008 S 673.76 0.00 0.00 28190 S 134.09 0.00 0.00<br />

28010 S 95.43 0.00 0.00 28192 S 529.44 0.00 0.00<br />

28011 S 673.76 0.00 0.00 28193 S 364.58 0.00 0.00<br />

28020 S 643.06 0.00 0.00 28200 S 673.76 0.00 0.00<br />

28022 S 643.06 0.00 0.00 28202 S 673.76 0.00 0.00<br />

28024 S 643.06 0.00 0.00 28208 S 673.76 0.00 0.00<br />

28035 S 669.57 0.00 0.00 28210 S 1,183.32 0.00 0.00<br />

28043 S 647.46 0.00 0.00 28220 S 206.82 0.00 0.00<br />

28045 S 673.76 0.00 0.00 28222 S 588.87 0.00 0.00<br />

28046 S 673.76 0.00 0.00 28225 S 588.87 0.00 0.00<br />

28050 S 643.06 0.00 0.00 28226 S 588.87 0.00 0.00<br />

28052 S 643.06 0.00 0.00 28230 S 202.92 0.00 0.00<br />

28054 S 643.06 0.00 0.00 28232 S 194.04 0.00 0.00<br />

28055 S 669.57 0.00 0.00 28234 S 643.06 0.00 0.00<br />

28060 S 643.06 0.00 0.00 28238 S 1,183.32 0.00 0.00<br />

28062 S 673.76 0.00 0.00 28240 S 643.06 0.00 0.00<br />

28070 S 673.76 0.00 0.00 28250 S 673.76 0.00 0.00<br />

28072 S 673.76 0.00 0.00 28260 S 673.76 0.00 0.00<br />

28080 S 673.76 0.00 0.00 28261 S 673.76 0.00 0.00<br />

28086 S 643.06 0.00 0.00 28262 S 731.30 0.00 0.00<br />

28088 S 643.06 0.00 0.00 28264 S 1,098.44 0.00 0.00<br />

28090 S 673.76 0.00 0.00 28270 S 673.76 0.00 0.00<br />

28092 S 673.76 0.00 0.00 28272 S 187.31 0.00 0.00<br />

28100 S 643.06 0.00 0.00 28280 S 643.06 0.00 0.00<br />

28102 S 1,183.32 0.00 0.00 28285 S 673.76 0.00 0.00<br />

28103 S 1,183.32 0.00 0.00 28286 S 731.30 0.00 0.00<br />

28104 S 643.06 0.00 0.00 28288 S 673.76 0.00 0.00<br />

28106 S 1,183.32 0.00 0.00 28289 S 673.76 0.00 0.00<br />

28107 S 1,183.32 0.00 0.00 28290 S 830.49 0.00 0.00<br />

28108 S 643.06 0.00 0.00 28292 S 830.49 0.00 0.00<br />

28110 S 673.76 0.00 0.00 28293 S 861.18 0.00 0.00<br />

28111 S 673.76 0.00 0.00 28294 S 861.18 0.00 0.00<br />

28112 S 673.76 0.00 0.00 28296 S 861.18 0.00 0.00<br />

28113 S 673.76 0.00 0.00 28297 S 861.18 0.00 0.00<br />

28114 S 673.76 0.00 0.00 28298 S 861.18 0.00 0.00<br />

28116 S 673.76 0.00 0.00 28299 S 960.45 0.00 0.00<br />

28118 S 731.30 0.00 0.00 28300 S 1,152.63 0.00 0.00<br />

28119 S 731.30 0.00 0.00 28302 S 643.06 0.00 0.00<br />

28120 S 906.34 0.00 0.00 28304 S 1,152.63 0.00 0.00<br />

28122 S 673.76 0.00 0.00 28305 S 1,183.32 0.00 0.00<br />

28124 S 219.59 0.00 0.00 28306 S 731.30 0.00 0.00<br />

28126 S 673.76 0.00 0.00 28307 S 731.30 0.00 0.00<br />

28130 S 673.76 0.00 0.00 28308 S 643.06 0.00 0.00<br />

28140 S 673.76 0.00 0.00 28309 S 1,240.87 0.00 0.00<br />

28150 S 673.76 0.00 0.00 28310 S 673.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 673.76 0.00 0.00 28636 S 749.65 0.00 0.00<br />

28313 S 643.06 0.00 0.00 28645 S 749.65 0.00 0.00<br />

28315 S 731.30 0.00 0.00 28660 S 45.41 0.00 0.00<br />

28320 S 1,240.87 0.00 0.00 28665 S 468.71 0.00 0.00<br />

28322 S 1,240.87 0.00 0.00 28666 S 749.65 0.00 0.00<br />

28340 S 731.30 0.00 0.00 28675 S 749.65 0.00 0.00<br />

28341 S 731.30 0.00 0.00 28705 S 1,240.87 0.00 0.00<br />

28344 S 731.30 0.00 0.00 28715 S 2,021.06 0.00 0.00<br />

28345 S 731.30 0.00 0.00 28725 S 1,240.87 0.00 0.00<br />

28400 S 81.40 0.00 0.00 28730 S 1,240.87 0.00 0.00<br />

28405 S 444.16 0.00 0.00 28735 S 1,240.87 0.00 0.00<br />

28406 S 718.95 0.00 0.00 28737 S 1,282.58 0.00 0.00<br />

28415 S 1,486.58 0.00 0.00 28740 S 1,240.87 0.00 0.00<br />

28420 S 1,153.02 0.00 0.00 28750 S 1,240.87 0.00 0.00<br />

28430 S 63.43 0.00 0.00 28755 S 731.30 0.00 0.00<br />

28435 S 81.40 0.00 0.00 28760 S 1,240.87 0.00 0.00<br />

28436 S 718.95 0.00 0.00 28810 S 643.06 0.00 0.00<br />

28445 S 1,095.46 0.00 0.00 28820 S 643.06 0.00 0.00<br />

28446 S 1,877.50 0.00 0.00 28825 S 643.06 0.00 0.00<br />

28450 S 63.43 0.00 0.00 28890 S 169.93 0.00 0.00<br />

28455 S 63.43 0.00 0.00 29000 S 43.05 0.00 0.00<br />

28456 S 718.95 0.00 0.00 29010 S 96.49 0.00 0.00<br />

28465 S 1,095.46 0.00 0.00 29015 S 96.49 0.00 0.00<br />

28470 S 63.43 0.00 0.00 29020 S 43.05 0.00 0.00<br />

28475 S 63.43 0.00 0.00 29025 S 43.05 0.00 0.00<br />

28476 S 718.95 0.00 0.00 29035 S 96.49 0.00 0.00<br />

28485 S 1,153.02 0.00 0.00 29040 S 43.05 0.00 0.00<br />

28490 S 63.43 0.00 0.00 29044 S 96.49 0.00 0.00<br />

28495 S 63.43 0.00 0.00 29046 S 96.49 0.00 0.00<br />

28496 S 718.95 0.00 0.00 29049 S 39.02 0.00 0.00<br />

28505 S 749.65 0.00 0.00 29055 S 96.49 0.00 0.00<br />

28510 S 57.12 0.00 0.00 29058 S 43.05 0.00 0.00<br />

28515 S 63.43 0.00 0.00 29065 S 45.77 0.00 0.00<br />

28525 S 749.65 0.00 0.00 29075 S 43.99 0.00 0.00<br />

28530 S 54.98 0.00 0.00 29085 S 43.05 0.00 0.00<br />

28531 S 749.65 0.00 0.00 29086 S 36.89 0.00 0.00<br />

28540 S 63.43 0.00 0.00 29105 S 39.73 0.00 0.00<br />

28545 S 664.77 0.00 0.00 29125 S 34.41 0.00 0.00<br />

28546 S 718.95 0.00 0.00 29126 S 36.54 0.00 0.00<br />

28555 S 1,064.78 0.00 0.00 29130 S 15.61 0.00 0.00<br />

28570 S 82.30 0.00 0.00 29131 S 22.70 0.00 0.00<br />

28575 S 444.16 0.00 0.00 29200 S 21.99 0.00 0.00<br />

28576 S 749.65 0.00 0.00 29220 S 23.76 0.00 0.00<br />

28585 S 749.65 0.00 0.00 29240 S 24.84 0.00 0.00<br />

28600 S 63.43 0.00 0.00 29260 S 23.76 0.00 0.00<br />

28605 S 81.40 0.00 0.00 29280 S 24.13 0.00 0.00<br />

28606 S 718.95 0.00 0.00 29305 S 96.49 0.00 0.00<br />

28615 S 1,095.46 0.00 0.00 29325 S 96.49 0.00 0.00<br />

28630 S 63.43 0.00 0.00 29345 S 59.95 0.00 0.00<br />

28635 S 468.71 0.00 0.00 29355 S 58.89 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 73.08 0.00 0.00 29847 S 1,221.50 0.00 0.00<br />

29365 S 56.76 0.00 0.00 29848 S 1,226.01 0.00 0.00<br />

29405 S 42.22 0.00 0.00 29850 S 886.01 0.00 0.00<br />

29425 S 42.92 0.00 0.00 29851 S 1,279.05 0.00 0.00<br />

29435 S 54.28 0.00 0.00 29855 S 1,279.05 0.00 0.00<br />

29440 S 23.06 0.00 0.00 29856 S 1,279.05 0.00 0.00<br />

29445 S 57.12 0.00 0.00 29860 S 1,279.05 0.00 0.00<br />

29450 S 43.05 0.00 0.00 29861 S 1,279.05 0.00 0.00<br />

29505 S 38.31 0.00 0.00 29862 S 1,619.05 0.00 0.00<br />

29515 S 32.64 0.00 0.00 29863 S 1,279.05 0.00 0.00<br />

29520 S 23.41 0.00 0.00 29866 S 1,953.86 0.00 0.00<br />

29530 S 23.76 0.00 0.00 29870 S 828.47 0.00 0.00<br />

29540 S 17.73 0.00 0.00 29871 S 828.47 0.00 0.00<br />

29550 S 18.09 0.00 0.00 29873 S 828.47 0.00 0.00<br />

29580 S 24.48 0.00 0.00 29874 S 828.47 0.00 0.00<br />

29590 S 19.87 0.00 0.00 29875 S 886.01 0.00 0.00<br />

29700 S 32.99 0.00 0.00 29876 S 886.01 0.00 0.00<br />

29705 S 28.02 0.00 0.00 29877 S 886.01 0.00 0.00<br />

29710 S 49.31 0.00 0.00 29879 S 828.47 0.00 0.00<br />

29715 S 43.05 0.00 0.00 29880 S 886.01 0.00 0.00<br />

29720 S 41.15 0.00 0.00 29881 S 886.01 0.00 0.00<br />

29730 S 26.96 0.00 0.00 29882 S 828.47 0.00 0.00<br />

29740 S 36.89 0.00 0.00 29883 S 828.47 0.00 0.00<br />

29750 S 38.67 0.00 0.00 29884 S 828.47 0.00 0.00<br />

29800 S 828.47 0.00 0.00 29885 S 1,221.50 0.00 0.00<br />

29804 S 828.47 0.00 0.00 29886 S 828.47 0.00 0.00<br />

29805 S 828.47 0.00 0.00 29887 S 828.47 0.00 0.00<br />

29806 S 1,221.50 0.00 0.00 29888 S 1,221.50 0.00 0.00<br />

29807 S 1,221.50 0.00 0.00 29889 S 1,221.50 0.00 0.00<br />

29819 S 1,221.50 0.00 0.00 29891 S 1,221.50 0.00 0.00<br />

29820 S 1,221.50 0.00 0.00 29892 S 1,221.50 0.00 0.00<br />

29821 S 1,221.50 0.00 0.00 29893 S 1,031.28 0.00 0.00<br />

29822 S 828.47 0.00 0.00 29894 S 828.47 0.00 0.00<br />

29823 S 1,221.50 0.00 0.00 29895 S 828.47 0.00 0.00<br />

29824 S 927.73 0.00 0.00 29897 S 828.47 0.00 0.00<br />

29825 S 1,221.50 0.00 0.00 29898 S 828.47 0.00 0.00<br />

29826 S 1,221.50 0.00 0.00 29899 S 1,221.50 0.00 0.00<br />

29827 S 1,320.77 0.00 0.00 29900 S 828.47 0.00 0.00<br />

29828 S 1,953.86 0.00 0.00 29901 S 828.47 0.00 0.00<br />

29830 S 828.47 0.00 0.00 29902 S 828.47 0.00 0.00<br />

29834 S 828.47 0.00 0.00 29904 S 1,167.78 0.00 0.00<br />

29835 S 828.47 0.00 0.00 29905 S 1,167.78 0.00 0.00<br />

29836 S 828.47 0.00 0.00 29906 S 1,167.78 0.00 0.00<br />

29837 S 828.47 0.00 0.00 29907 S 1,953.86 0.00 0.00<br />

29838 S 828.47 0.00 0.00 30000 S 131.29 0.00 0.00<br />

29840 S 828.47 0.00 0.00 30020 S 131.29 0.00 0.00<br />

29843 S 828.47 0.00 0.00 30100 S 85.14 0.00 0.00<br />

29844 S 828.47 0.00 0.00 30110 S 131.62 0.00 0.00<br />

29845 S 828.47 0.00 0.00 30115 S 556.10 0.00 0.00<br />

29846 S 828.47 0.00 0.00 30117 S 586.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 735.98 0.00 0.00 31080 S 1,133.32 0.00 0.00<br />

30120 S 501.91 0.00 0.00 31081 S 1,133.32 0.00 0.00<br />

30124 S 299.06 0.00 0.00 31084 S 1,133.32 0.00 0.00<br />

30125 S 1,045.08 0.00 0.00 31085 S 1,133.32 0.00 0.00<br />

30130 S 586.80 0.00 0.00 31086 S 1,133.32 0.00 0.00<br />

30140 S 705.28 0.00 0.00 31087 S 1,133.32 0.00 0.00<br />

30150 S 1,075.78 0.00 0.00 31090 S 1,175.05 0.00 0.00<br />

30160 S 1,133.32 0.00 0.00 31200 S 1,045.08 0.00 0.00<br />

30200 S 67.05 0.00 0.00 31201 S 1,175.05 0.00 0.00<br />

30210 S 85.14 0.00 0.00 31205 S 1,075.78 0.00 0.00<br />

30220 S 372.12 0.00 0.00 31231 S 71.77 0.00 0.00<br />

30300 S 25.65 0.00 0.00 31233 S 77.31 0.00 0.00<br />

30310 S 501.91 0.00 0.00 31235 S 525.25 0.00 0.00<br />

30320 S 556.10 0.00 0.00 31237 S 579.44 0.00 0.00<br />

30400 S 1,133.32 0.00 0.00 31238 S 525.25 0.00 0.00<br />

30410 S 1,175.05 0.00 0.00 31239 S 766.71 0.00 0.00<br />

30420 S 1,175.05 0.00 0.00 31240 S 579.44 0.00 0.00<br />

30430 S 735.98 0.00 0.00 31254 S 709.16 0.00 0.00<br />

30435 S 1,175.05 0.00 0.00 31255 S 808.42 0.00 0.00<br />

30450 S 1,308.37 0.00 0.00 31256 S 709.16 0.00 0.00<br />

30460 S 1,308.37 0.00 0.00 31267 S 709.16 0.00 0.00<br />

30462 S 1,473.32 0.00 0.00 31276 S 709.16 0.00 0.00<br />

30465 S 1,473.32 0.00 0.00 31287 S 709.16 0.00 0.00<br />

30520 S 793.52 0.00 0.00 31288 S 709.16 0.00 0.00<br />

30540 S 1,175.05 0.00 0.00 31300 S 835.24 0.00 0.00<br />

30545 S 1,175.05 0.00 0.00 31320 S 1,045.08 0.00 0.00<br />

30560 S 137.92 0.00 0.00 31400 S 1,045.08 0.00 0.00<br />

30580 S 1,133.32 0.00 0.00 31420 S 1,045.08 0.00 0.00<br />

30600 S 1,133.32 0.00 0.00 31500 S 96.00 0.00 0.00<br />

30620 S 1,308.37 0.00 0.00 31502 S 55.20 0.00 0.00<br />

30630 S 968.56 0.00 0.00 31505 S 32.62 0.00 0.00<br />

30801 S 309.22 0.00 0.00 31510 S 579.44 0.00 0.00<br />

30802 S 309.22 0.00 0.00 31511 S 77.31 0.00 0.00<br />

30901 S 44.10 0.00 0.00 31512 S 579.44 0.00 0.00<br />

30903 S 56.81 0.00 0.00 31513 S 77.31 0.00 0.00<br />

30905 S 56.81 0.00 0.00 31515 S 525.25 0.00 0.00<br />

30906 S 56.81 0.00 0.00 31520 S 71.77 0.00 0.00<br />

30915 S 757.01 0.00 0.00 31525 S 525.25 0.00 0.00<br />

30920 S 787.71 0.00 0.00 31526 S 678.47 0.00 0.00<br />

30930 S 644.34 0.00 0.00 31527 S 624.27 0.00 0.00<br />

31000 S 109.62 0.00 0.00 31528 S 579.44 0.00 0.00<br />

31002 S 299.06 0.00 0.00 31529 S 579.44 0.00 0.00<br />

31020 S 705.28 0.00 0.00 31530 S 678.47 0.00 0.00<br />

31030 S 1,075.78 0.00 0.00 31531 S 709.16 0.00 0.00<br />

31032 S 1,133.32 0.00 0.00 31535 S 678.47 0.00 0.00<br />

31040 S 982.81 0.00 0.00 31536 S 709.16 0.00 0.00<br />

31050 S 1,045.08 0.00 0.00 31540 S 709.16 0.00 0.00<br />

31051 S 1,133.32 0.00 0.00 31541 S 766.71 0.00 0.00<br />

31070 S 705.28 0.00 0.00 31545 S 766.71 0.00 0.00<br />

31075 S 1,133.32 0.00 0.00 31546 S 766.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 808.42 0.00 0.00 32405 S 349.83 0.00 0.00<br />

31561 S 808.42 0.00 0.00 32420 S 212.72 0.00 0.00<br />

31570 S 579.44 0.00 0.00 32421 S 212.72 0.00 0.00<br />

31571 S 678.47 0.00 0.00 32422 S 211.78 0.00 0.00<br />

31575 S 61.73 0.00 0.00 32550 S 1,185.73 0.00 0.00<br />

31576 S 678.47 0.00 0.00 32960 S 211.78 0.00 0.00<br />

31577 S 200.42 0.00 0.00 32998 S 1,846.12 0.00 0.00<br />

31578 S 678.47 0.00 0.00 33010 S 212.72 0.00 0.00<br />

31579 S 109.98 0.00 0.00 33011 S 212.72 0.00 0.00<br />

31580 S 1,175.05 0.00 0.00 33206 S 6,824.96 4,060.83 1,296.71<br />

31582 S 1,175.05 0.00 0.00 33207 S 6,824.96 4,060.83 1,296.71<br />

31588 S 1,175.05 0.00 0.00 33208 S 8,464.89 4,932.45 1,400.02<br />

31590 S 1,175.05 0.00 0.00 33210 S 2,004.17 0.00 0.00<br />

31595 S 1,045.08 0.00 0.00 33211 S 2,004.17 0.00 0.00<br />

31603 S 309.22 0.00 0.00 33212 S 5,360.03 3,053.38 746.73<br />

31605 S 299.06 0.00 0.00 33213 S 6,186.63 3,466.24 745.84<br />

31611 S 735.98 0.00 0.00 33214 S 8,464.89 4,932.45 1,400.02<br />

31612 S 651.09 0.00 0.00 33215 S 878.45 0.00 0.00<br />

31613 S 705.28 0.00 0.00 33216 S 2,004.17 0.00 0.00<br />

31614 S 1,045.08 0.00 0.00 33217 S 2,004.17 0.00 0.00<br />

31615 S 309.22 0.00 0.00 33218 S 878.45 0.00 0.00<br />

31622 S 362.15 0.00 0.00 33220 S 878.45 0.00 0.00<br />

31623 S 416.34 0.00 0.00 33222 S 530.99 0.00 0.00<br />

31624 S 416.34 0.00 0.00 33223 S 530.99 0.00 0.00<br />

31625 S 416.34 0.00 0.00 33224 S 7,990.07 4,783.63 1,577.20<br />

31628 S 416.34 0.00 0.00 33225 S 7,990.07 4,783.63 1,577.20<br />

31629 S 416.34 0.00 0.00 33226 S 878.45 0.00 0.00<br />

31630 S 713.43 0.00 0.00 33233 S 653.11 0.00 0.00<br />

31631 S 713.43 0.00 0.00 33234 S 878.45 0.00 0.00<br />

31632 S 404.92 0.00 0.00 33235 S 878.45 0.00 0.00<br />

31633 S 404.92 0.00 0.00 33240 S 19,917.20 10,646.56 1,375.92<br />

31635 S 416.34 0.00 0.00 33241 S 878.45 0.00 0.00<br />

31636 S 713.43 0.00 0.00 33249 S 26,581.02 14,237.90 1,894.77<br />

31637 S 362.15 0.00 0.00 33282 S 4,202.63 2,515.94 829.25<br />

31638 S 713.43 0.00 0.00 33284 S 327.79 0.00 0.00<br />

31640 S 713.43 0.00 0.00 34490 S 1,600.39 0.00 0.00<br />

31641 S 713.43 0.00 0.00 35188 S 1,102.31 0.00 0.00<br />

31643 S 416.34 0.00 0.00 35207 S 1,102.31 0.00 0.00<br />

31645 S 362.15 0.00 0.00 35473 S 1,919.85 0.00 0.00<br />

31646 S 362.15 0.00 0.00 35476 S 1,919.85 0.00 0.00<br />

31656 S 362.15 0.00 0.00 35492 S 3,583.21 0.00 0.00<br />

31717 S 200.42 0.00 0.00 35761 S 1,152.67 0.00 0.00<br />

31720 S 30.69 0.00 0.00 35875 S 1,442.31 0.00 0.00<br />

31730 S 200.42 0.00 0.00 35876 S 1,442.31 0.00 0.00<br />

31750 S 1,175.05 0.00 0.00 36002 S 92.06 0.00 0.00<br />

31755 S 1,045.08 0.00 0.00 36260 S 835.07 0.00 0.00<br />

31820 S 501.91 0.00 0.00 36261 S 653.11 0.00 0.00<br />

31825 S 705.28 0.00 0.00 36262 S 598.91 0.00 0.00<br />

31830 S 705.28 0.00 0.00 36420 S 8.68 0.00 0.00<br />

32400 S 349.83 0.00 0.00 36425 S 8.68 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 33.34 0.00 0.00 36800 S 898.95 0.00 0.00<br />

36440 S 133.17 0.00 0.00 36810 S 898.95 0.00 0.00<br />

36450 S 133.17 0.00 0.00 36815 S 898.95 0.00 0.00<br />

36455 S 133.17 0.00 0.00 36818 S 1,044.77 0.00 0.00<br />

36468 S 32.87 0.00 0.00 36819 S 1,044.77 0.00 0.00<br />

36469 S 32.87 0.00 0.00 36820 S 1,044.77 0.00 0.00<br />

36470 S 32.87 0.00 0.00 36821 S 1,044.77 0.00 0.00<br />

36471 S 32.87 0.00 0.00 36825 S 1,102.31 0.00 0.00<br />

36475 S 1,511.40 0.00 0.00 36830 S 1,102.31 0.00 0.00<br />

36476 S 1,185.25 0.00 0.00 36831 S 1,442.31 0.00 0.00<br />

36478 S 1,185.25 0.00 0.00 36832 S 1,102.31 0.00 0.00<br />

36479 S 1,185.25 0.00 0.00 36833 S 1,102.31 0.00 0.00<br />

36511 S 456.57 0.00 0.00 36834 S 1,044.77 0.00 0.00<br />

36512 S 456.57 0.00 0.00 36835 S 956.50 0.00 0.00<br />

36513 S 456.57 0.00 0.00 36860 S 109.78 0.00 0.00<br />

36514 S 456.57 0.00 0.00 36861 S 898.95 0.00 0.00<br />

36515 S 1,222.23 0.00 0.00 36870 S 1,572.13 0.00 0.00<br />

36516 S 1,222.23 0.00 0.00 37184 S 1,600.39 0.00 0.00<br />

36522 S 1,222.23 0.00 0.00 37185 S 1,600.39 0.00 0.00<br />

36555 S 379.35 0.00 0.00 37186 S 1,600.39 0.00 0.00<br />

36556 S 379.35 0.00 0.00 37187 S 1,600.39 0.00 0.00<br />

36557 S 708.46 0.00 0.00 37188 S 1,600.39 0.00 0.00<br />

36558 S 708.46 0.00 0.00 37200 S 1,180.99 0.00 0.00<br />

36560 S 835.07 0.00 0.00 37203 S 1,180.99 0.00 0.00<br />

36561 S 835.07 0.00 0.00 37500 S 1,113.86 0.00 0.00<br />

36563 S 835.07 0.00 0.00 37607 S 787.71 0.00 0.00<br />

36565 S 835.07 0.00 0.00 37609 S 529.44 0.00 0.00<br />

36566 S 835.07 0.00 0.00 37650 S 757.01 0.00 0.00<br />

36568 S 379.35 0.00 0.00 37700 S 757.01 0.00 0.00<br />

36569 S 379.35 0.00 0.00 37718 S 787.71 0.00 0.00<br />

36570 S 739.15 0.00 0.00 37722 S 1,113.86 0.00 0.00<br />

36571 S 739.15 0.00 0.00 37735 S 1,113.86 0.00 0.00<br />

36575 S 305.10 0.00 0.00 37760 S 787.71 0.00 0.00<br />

36576 S 433.53 0.00 0.00 37765 S 1,086.26 0.00 0.00<br />

36578 S 708.46 0.00 0.00 37766 S 1,086.26 0.00 0.00<br />

36580 S 379.35 0.00 0.00 37780 S 787.71 0.00 0.00<br />

36581 S 708.46 0.00 0.00 37785 S 787.71 0.00 0.00<br />

36582 S 835.07 0.00 0.00 37790 S 950.52 0.00 0.00<br />

36583 S 835.07 0.00 0.00 38205 S 456.57 0.00 0.00<br />

36584 S 379.35 0.00 0.00 38206 S 456.57 0.00 0.00<br />

36585 S 739.15 0.00 0.00 38220 S 104.66 0.00 0.00<br />

36589 S 250.92 0.00 0.00 38221 S 109.62 0.00 0.00<br />

36590 S 379.35 0.00 0.00 38230 S 1,222.23 0.00 0.00<br />

36593 S 25.19 0.00 0.00 38241 S 1,222.23 0.00 0.00<br />

36595 S 989.15 0.00 0.00 38242 S 456.57 0.00 0.00<br />

36596 S 439.30 0.00 0.00 38300 S 409.71 0.00 0.00<br />

36597 S 439.30 0.00 0.00 38305 S 598.73 0.00 0.00<br />

36598 S 81.24 0.00 0.00 38308 S 684.12 0.00 0.00<br />

36640 S 750.18 0.00 0.00 38500 S 684.12 0.00 0.00<br />

36680 S 56.86 0.00 0.00 38505 S 261.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 684.12 0.00 0.00 41005 S 137.92 0.00 0.00<br />

38520 S 684.12 0.00 0.00 41006 S 651.09 0.00 0.00<br />

38525 S 684.12 0.00 0.00 41007 S 501.91 0.00 0.00<br />

38530 S 684.12 0.00 0.00 41008 S 501.91 0.00 0.00<br />

38542 S 1,150.94 0.00 0.00 41009 S 137.92 0.00 0.00<br />

38550 S 714.82 0.00 0.00 41010 S 309.22 0.00 0.00<br />

38555 S 772.36 0.00 0.00 41015 S 137.92 0.00 0.00<br />

38570 S 1,561.65 0.00 0.00 41016 S 309.22 0.00 0.00<br />

38571 S 2,030.11 0.00 0.00 41017 S 309.22 0.00 0.00<br />

38572 S 1,561.65 0.00 0.00 41018 S 309.22 0.00 0.00<br />

38700 S 940.49 0.00 0.00 41019 S 982.81 0.00 0.00<br />

38740 S 1,150.94 0.00 0.00 41100 S 92.59 0.00 0.00<br />

38745 S 1,239.18 0.00 0.00 41105 S 91.52 0.00 0.00<br />

38760 S 684.12 0.00 0.00 41108 S 84.79 0.00 0.00<br />

40490 S 69.88 0.00 0.00 41110 S 122.74 0.00 0.00<br />

40500 S 556.10 0.00 0.00 41112 S 556.10 0.00 0.00<br />

40510 S 705.28 0.00 0.00 41113 S 556.10 0.00 0.00<br />

40520 S 556.10 0.00 0.00 41114 S 705.28 0.00 0.00<br />

40525 S 705.28 0.00 0.00 41115 S 142.97 0.00 0.00<br />

40527 S 705.28 0.00 0.00 41116 S 501.91 0.00 0.00<br />

40530 S 705.28 0.00 0.00 41120 S 835.24 0.00 0.00<br />

40650 S 372.12 0.00 0.00 41250 S 94.33 0.00 0.00<br />

40652 S 372.12 0.00 0.00 41251 S 137.92 0.00 0.00<br />

40654 S 372.12 0.00 0.00 41252 S 363.41 0.00 0.00<br />

40700 S 1,308.37 0.00 0.00 41500 S 651.09 0.00 0.00<br />

40701 S 1,308.37 0.00 0.00 41510 S 501.91 0.00 0.00<br />

40702 S 1,662.41 0.00 0.00 41520 S 363.41 0.00 0.00<br />

40720 S 1,308.37 0.00 0.00 41530 S 684.44 0.00 0.00<br />

40761 S 1,075.78 0.00 0.00 41800 S 70.47 0.00 0.00<br />

40800 S 56.08 0.00 0.00 41805 S 152.55 0.00 0.00<br />

40801 S 363.41 0.00 0.00 41806 S 188.02 0.00 0.00<br />

40804 S 25.65 0.00 0.00 41820 S 299.06 0.00 0.00<br />

40805 S 173.48 0.00 0.00 41821 S 299.06 0.00 0.00<br />

40806 S 79.82 0.00 0.00 41822 S 155.73 0.00 0.00<br />

40808 S 118.48 0.00 0.00 41823 S 227.04 0.00 0.00<br />

40810 S 122.74 0.00 0.00 41825 S 124.87 0.00 0.00<br />

40812 S 153.96 0.00 0.00 41826 S 157.16 0.00 0.00<br />

40814 S 556.10 0.00 0.00 41827 S 705.28 0.00 0.00<br />

40816 S 705.28 0.00 0.00 41828 S 141.90 0.00 0.00<br />

40818 S 137.92 0.00 0.00 41830 S 201.50 0.00 0.00<br />

40819 S 309.22 0.00 0.00 41850 S 684.44 0.00 0.00<br />

40820 S 177.02 0.00 0.00 41870 S 982.81 0.00 0.00<br />

40830 S 131.29 0.00 0.00 41872 S 201.50 0.00 0.00<br />

40831 S 309.22 0.00 0.00 41874 S 194.40 0.00 0.00<br />

40840 S 705.28 0.00 0.00 42000 S 137.92 0.00 0.00<br />

40842 S 735.98 0.00 0.00 42100 S 78.76 0.00 0.00<br />

40843 S 735.98 0.00 0.00 42104 S 117.07 0.00 0.00<br />

40844 S 1,175.05 0.00 0.00 42106 S 146.87 0.00 0.00<br />

40845 S 1,175.05 0.00 0.00 42107 S 705.28 0.00 0.00<br />

41000 S 87.98 0.00 0.00 42120 S 1,133.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 363.41 0.00 0.00 42809 S 25.65 0.00 0.00<br />

42145 S 835.24 0.00 0.00 42810 S 735.98 0.00 0.00<br />

42160 S 139.06 0.00 0.00 42815 S 1,175.05 0.00 0.00<br />

42180 S 137.92 0.00 0.00 42820 S 735.98 0.00 0.00<br />

42182 S 1,045.08 0.00 0.00 42821 S 835.24 0.00 0.00<br />

42200 S 1,175.05 0.00 0.00 42825 S 793.52 0.00 0.00<br />

42205 S 1,175.05 0.00 0.00 42826 S 793.52 0.00 0.00<br />

42210 S 1,175.05 0.00 0.00 42830 S 793.52 0.00 0.00<br />

42215 S 1,308.37 0.00 0.00 42831 S 793.52 0.00 0.00<br />

42220 S 1,175.05 0.00 0.00 42835 S 793.52 0.00 0.00<br />

42226 S 1,175.05 0.00 0.00 42836 S 793.52 0.00 0.00<br />

42235 S 686.06 0.00 0.00 42860 S 735.98 0.00 0.00<br />

42260 S 793.52 0.00 0.00 42870 S 735.98 0.00 0.00<br />

42280 S 76.62 0.00 0.00 42890 S 1,308.37 0.00 0.00<br />

42281 S 684.44 0.00 0.00 42892 S 1,308.37 0.00 0.00<br />

42300 S 501.91 0.00 0.00 42900 S 309.22 0.00 0.00<br />

42305 S 556.10 0.00 0.00 42950 S 705.28 0.00 0.00<br />

42310 S 137.92 0.00 0.00 42955 S 705.28 0.00 0.00<br />

42320 S 137.92 0.00 0.00 42960 S 56.81 0.00 0.00<br />

42330 S 118.48 0.00 0.00 42962 S 1,045.08 0.00 0.00<br />

42335 S 196.53 0.00 0.00 42970 S 44.10 0.00 0.00<br />

42340 S 556.10 0.00 0.00 42972 S 586.80 0.00 0.00<br />

42400 S 66.70 0.00 0.00 43030 S 684.44 0.00 0.00<br />

42405 S 556.10 0.00 0.00 43200 S 331.44 0.00 0.00<br />

42408 S 586.80 0.00 0.00 43201 S 331.44 0.00 0.00<br />

42409 S 586.80 0.00 0.00 43202 S 331.44 0.00 0.00<br />

42410 S 1,075.78 0.00 0.00 43204 S 331.44 0.00 0.00<br />

42415 S 1,308.37 0.00 0.00 43205 S 331.44 0.00 0.00<br />

42420 S 1,308.37 0.00 0.00 43215 S 331.44 0.00 0.00<br />

42425 S 1,308.37 0.00 0.00 43216 S 331.44 0.00 0.00<br />

42440 S 1,075.78 0.00 0.00 43217 S 331.44 0.00 0.00<br />

42450 S 705.28 0.00 0.00 43219 S 669.85 0.00 0.00<br />

42500 S 735.98 0.00 0.00 43220 S 331.44 0.00 0.00<br />

42505 S 1,133.32 0.00 0.00 43226 S 331.44 0.00 0.00<br />

42507 S 1,075.78 0.00 0.00 43227 S 385.64 0.00 0.00<br />

42508 S 1,133.32 0.00 0.00 43228 S 717.64 0.00 0.00<br />

42509 S 1,133.32 0.00 0.00 43231 S 385.64 0.00 0.00<br />

42510 S 1,133.32 0.00 0.00 43232 S 385.64 0.00 0.00<br />

42600 S 501.91 0.00 0.00 43234 S 331.44 0.00 0.00<br />

42650 S 43.63 0.00 0.00 43235 S 331.44 0.00 0.00<br />

42660 S 51.09 0.00 0.00 43236 S 385.64 0.00 0.00<br />

42665 S 968.56 0.00 0.00 43237 S 385.64 0.00 0.00<br />

42700 S 137.92 0.00 0.00 43238 S 385.64 0.00 0.00<br />

42720 S 501.91 0.00 0.00 43239 S 385.64 0.00 0.00<br />

42725 S 1,045.08 0.00 0.00 43240 S 385.64 0.00 0.00<br />

42800 S 84.43 0.00 0.00 43241 S 385.64 0.00 0.00<br />

42802 S 501.91 0.00 0.00 43242 S 385.64 0.00 0.00<br />

42804 S 501.91 0.00 0.00 43243 S 385.64 0.00 0.00<br />

42806 S 705.28 0.00 0.00 43244 S 385.64 0.00 0.00<br />

42808 S 556.10 0.00 0.00 43245 S 385.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 385.64 0.00 0.00 44378 S 403.90 0.00 0.00<br />

43247 S 385.64 0.00 0.00 44379 S 1,152.29 0.00 0.00<br />

43248 S 385.64 0.00 0.00 44380 S 349.70 0.00 0.00<br />

43249 S 385.64 0.00 0.00 44382 S 349.70 0.00 0.00<br />

43250 S 385.64 0.00 0.00 44383 S 1,152.29 0.00 0.00<br />

43251 S 385.64 0.00 0.00 44385 S 338.11 0.00 0.00<br />

43255 S 385.64 0.00 0.00 44386 S 338.11 0.00 0.00<br />

43256 S 754.74 0.00 0.00 44388 S 338.11 0.00 0.00<br />

43257 S 748.34 0.00 0.00 44389 S 338.11 0.00 0.00<br />

43258 S 416.33 0.00 0.00 44390 S 338.11 0.00 0.00<br />

43259 S 416.33 0.00 0.00 44391 S 338.11 0.00 0.00<br />

43260 S 649.23 0.00 0.00 44392 S 338.11 0.00 0.00<br />

43261 S 649.23 0.00 0.00 44393 S 338.11 0.00 0.00<br />

43262 S 649.23 0.00 0.00 44394 S 338.11 0.00 0.00<br />

43263 S 649.23 0.00 0.00 44397 S 669.85 0.00 0.00<br />

43264 S 649.23 0.00 0.00 44500 S 182.46 0.00 0.00<br />

43265 S 649.23 0.00 0.00 45000 S 392.10 0.00 0.00<br />

43267 S 649.23 0.00 0.00 45005 S 456.33 0.00 0.00<br />

43268 S 724.05 0.00 0.00 45020 S 456.33 0.00 0.00<br />

43269 S 724.05 0.00 0.00 45100 S 619.97 0.00 0.00<br />

43271 S 649.23 0.00 0.00 45108 S 674.16 0.00 0.00<br />

43272 S 649.23 0.00 0.00 45150 S 674.16 0.00 0.00<br />

43273 S 870.69 0.00 0.00 45160 S 674.16 0.00 0.00<br />

43450 S 289.87 0.00 0.00 45170 S 674.16 0.00 0.00<br />

43453 S 289.87 0.00 0.00 45190 S 1,102.40 0.00 0.00<br />

43456 S 291.02 0.00 0.00 45300 S 65.27 0.00 0.00<br />

43458 S 332.60 0.00 0.00 45303 S 362.56 0.00 0.00<br />

43600 S 331.44 0.00 0.00 45305 S 340.97 0.00 0.00<br />

43653 S 1,561.65 0.00 0.00 45307 S 629.80 0.00 0.00<br />

43760 S 160.75 0.00 0.00 45308 S 340.97 0.00 0.00<br />

43761 S 331.44 0.00 0.00 45309 S 340.97 0.00 0.00<br />

43870 S 331.44 0.00 0.00 45315 S 340.97 0.00 0.00<br />

43886 S 836.32 0.00 0.00 45317 S 340.97 0.00 0.00<br />

43887 S 175.90 0.00 0.00 45320 S 629.80 0.00 0.00<br />

43888 S 836.32 0.00 0.00 45321 S 629.80 0.00 0.00<br />

44100 S 331.44 0.00 0.00 45327 S 669.85 0.00 0.00<br />

44312 S 577.85 0.00 0.00 45330 S 86.20 0.00 0.00<br />

44340 S 662.73 0.00 0.00 45331 S 254.92 0.00 0.00<br />

44360 S 403.90 0.00 0.00 45332 S 254.92 0.00 0.00<br />

44361 S 403.90 0.00 0.00 45333 S 340.97 0.00 0.00<br />

44363 S 403.90 0.00 0.00 45334 S 340.97 0.00 0.00<br />

44364 S 403.90 0.00 0.00 45335 S 254.92 0.00 0.00<br />

44365 S 403.90 0.00 0.00 45337 S 254.92 0.00 0.00<br />

44366 S 403.90 0.00 0.00 45338 S 340.97 0.00 0.00<br />

44369 S 403.90 0.00 0.00 45339 S 340.97 0.00 0.00<br />

44370 S 1,152.29 0.00 0.00 45340 S 340.97 0.00 0.00<br />

44372 S 403.90 0.00 0.00 45341 S 340.97 0.00 0.00<br />

44373 S 403.90 0.00 0.00 45342 S 340.97 0.00 0.00<br />

44376 S 403.90 0.00 0.00 45345 S 669.85 0.00 0.00<br />

44377 S 403.90 0.00 0.00 45355 S 338.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 392.31 0.00 0.00 46505 S 484.90 0.00 0.00<br />

45379 S 392.31 0.00 0.00 46600 S 25.65 0.00 0.00<br />

45380 S 392.31 0.00 0.00 46604 S 362.56 0.00 0.00<br />

45381 S 392.31 0.00 0.00 46606 S 136.23 0.00 0.00<br />

45382 S 392.31 0.00 0.00 46608 S 340.97 0.00 0.00<br />

45383 S 392.31 0.00 0.00 46610 S 629.80 0.00 0.00<br />

45384 S 392.31 0.00 0.00 46611 S 340.97 0.00 0.00<br />

45385 S 392.31 0.00 0.00 46612 S 629.80 0.00 0.00<br />

45386 S 392.31 0.00 0.00 46614 S 71.66 0.00 0.00<br />

45387 S 669.85 0.00 0.00 46615 S 683.99 0.00 0.00<br />

45391 S 392.31 0.00 0.00 46700 S 704.86 0.00 0.00<br />

45392 S 392.31 0.00 0.00 46706 S 775.83 0.00 0.00<br />

45500 S 674.16 0.00 0.00 46750 S 860.72 0.00 0.00<br />

45505 S 830.03 0.00 0.00 46753 S 704.86 0.00 0.00<br />

45520 S 32.87 0.00 0.00 46754 S 674.16 0.00 0.00<br />

45560 S 830.03 0.00 0.00 46760 S 830.03 0.00 0.00<br />

45900 S 265.82 0.00 0.00 46761 S 860.72 0.00 0.00<br />

45905 S 619.97 0.00 0.00 46762 S 1,093.30 0.00 0.00<br />

45910 S 619.97 0.00 0.00 46900 S 108.33 0.00 0.00<br />

45915 S 392.10 0.00 0.00 46910 S 129.48 0.00 0.00<br />

45990 S 609.93 0.00 0.00 46916 S 60.23 0.00 0.00<br />

46020 S 704.86 0.00 0.00 46917 S 561.81 0.00 0.00<br />

46030 S 265.82 0.00 0.00 46922 S 561.81 0.00 0.00<br />

46040 S 704.86 0.00 0.00 46924 S 561.81 0.00 0.00<br />

46045 S 674.16 0.00 0.00 46930 S 125.59 0.00 0.00<br />

46050 S 392.10 0.00 0.00 46937 S 674.16 0.00 0.00<br />

46060 S 674.16 0.00 0.00 46938 S 830.03 0.00 0.00<br />

46070 S 484.90 0.00 0.00 46940 S 92.94 0.00 0.00<br />

46080 S 704.86 0.00 0.00 46942 S 90.46 0.00 0.00<br />

46083 S 74.22 0.00 0.00 46945 S 153.96 0.00 0.00<br />

46200 S 674.16 0.00 0.00 46946 S 402.14 0.00 0.00<br />

46210 S 674.16 0.00 0.00 46947 S 1,093.30 0.00 0.00<br />

46211 S 674.16 0.00 0.00 47000 S 349.83 0.00 0.00<br />

46220 S 619.97 0.00 0.00 47382 S 1,846.12 0.00 0.00<br />

46221 S 122.04 0.00 0.00 47510 S 817.57 0.00 0.00<br />

46230 S 619.97 0.00 0.00 47511 S 1,201.13 0.00 0.00<br />

46250 S 704.86 0.00 0.00 47525 S 469.34 0.00 0.00<br />

46255 S 704.86 0.00 0.00 47530 S 469.34 0.00 0.00<br />

46257 S 704.86 0.00 0.00 47552 S 817.57 0.00 0.00<br />

46258 S 704.86 0.00 0.00 47553 S 848.26 0.00 0.00<br />

46260 S 704.86 0.00 0.00 47554 S 848.26 0.00 0.00<br />

46261 S 762.40 0.00 0.00 47555 S 848.26 0.00 0.00<br />

46262 S 762.40 0.00 0.00 47556 S 1,201.13 0.00 0.00<br />

46270 S 704.86 0.00 0.00 47560 S 996.67 0.00 0.00<br />

46275 S 704.86 0.00 0.00 47561 S 996.67 0.00 0.00<br />

46280 S 762.40 0.00 0.00 47562 S 1,839.07 0.00 0.00<br />

46285 S 619.97 0.00 0.00 47563 S 1,839.07 0.00 0.00<br />

46288 S 762.40 0.00 0.00 47564 S 1,839.07 0.00 0.00<br />

46320 S 82.66 0.00 0.00 47630 S 848.26 0.00 0.00<br />

46500 S 113.87 0.00 0.00 48102 S 349.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 212.72 0.00 0.00 49590 S 873.09 0.00 0.00<br />

49081 S 212.72 0.00 0.00 49600 S 930.63 0.00 0.00<br />

49180 S 349.83 0.00 0.00 49650 S 1,221.65 0.00 0.00<br />

49250 S 766.83 0.00 0.00 49651 S 1,396.69 0.00 0.00<br />

49320 S 996.67 0.00 0.00 49652 S 1,504.20 0.00 0.00<br />

49321 S 1,054.22 0.00 0.00 49653 S 1,504.20 0.00 0.00<br />

49322 S 1,054.22 0.00 0.00 49654 S 1,504.20 0.00 0.00<br />

49324 S 1,504.20 0.00 0.00 49655 S 1,504.20 0.00 0.00<br />

49325 S 1,504.20 0.00 0.00 49656 S 1,504.20 0.00 0.00<br />

49326 S 1,504.20 0.00 0.00 49657 S 1,504.20 0.00 0.00<br />

49402 S 678.60 0.00 0.00 50200 S 349.83 0.00 0.00<br />

49419 S 814.07 0.00 0.00 50382 S 1,015.82 0.00 0.00<br />

49420 S 752.55 0.00 0.00 50384 S 746.10 0.00 0.00<br />

49421 S 752.55 0.00 0.00 50385 S 746.10 0.00 0.00<br />

49422 S 598.91 0.00 0.00 50386 S 286.26 0.00 0.00<br />

49423 S 619.30 0.00 0.00 50387 S 619.30 0.00 0.00<br />

49426 S 678.60 0.00 0.00 50389 S 286.26 0.00 0.00<br />

49429 S 878.45 0.00 0.00 50390 S 349.83 0.00 0.00<br />

49440 S 343.51 0.00 0.00 50391 S 41.43 0.00 0.00<br />

49441 S 343.51 0.00 0.00 50392 S 532.74 0.00 0.00<br />

49446 S 343.51 0.00 0.00 50393 S 667.60 0.00 0.00<br />

49450 S 182.46 0.00 0.00 50395 S 532.74 0.00 0.00<br />

49451 S 182.46 0.00 0.00 50396 S 100.17 0.00 0.00<br />

49452 S 182.46 0.00 0.00 50398 S 469.34 0.00 0.00<br />

49460 S 182.46 0.00 0.00 50551 S 302.82 0.00 0.00<br />

49495 S 930.63 0.00 0.00 50553 S 667.60 0.00 0.00<br />

49496 S 930.63 0.00 0.00 50555 S 302.82 0.00 0.00<br />

49500 S 930.63 0.00 0.00 50557 S 667.60 0.00 0.00<br />

49501 S 1,270.63 0.00 0.00 50561 S 667.60 0.00 0.00<br />

49505 S 930.63 0.00 0.00 50562 S 286.26 0.00 0.00<br />

49507 S 1,270.63 0.00 0.00 50570 S 286.26 0.00 0.00<br />

49520 S 1,105.67 0.00 0.00 50572 S 286.26 0.00 0.00<br />

49521 S 1,270.63 0.00 0.00 50574 S 286.26 0.00 0.00<br />

49525 S 930.63 0.00 0.00 50575 S 1,423.90 0.00 0.00<br />

49540 S 842.39 0.00 0.00 50576 S 746.10 0.00 0.00<br />

49550 S 972.36 0.00 0.00 50580 S 746.10 0.00 0.00<br />

49553 S 1,270.63 0.00 0.00 50590 S 1,663.44 0.00 0.00<br />

49555 S 972.36 0.00 0.00 50592 S 1,846.12 0.00 0.00<br />

49557 S 1,270.63 0.00 0.00 50686 S 41.43 0.00 0.00<br />

49560 S 930.63 0.00 0.00 50688 S 469.34 0.00 0.00<br />

49561 S 1,270.63 0.00 0.00 50947 S 1,561.65 0.00 0.00<br />

49565 S 930.63 0.00 0.00 50948 S 1,561.65 0.00 0.00<br />

49566 S 1,270.63 0.00 0.00 50951 S 302.82 0.00 0.00<br />

49568 S 1,105.67 0.00 0.00 50953 S 302.82 0.00 0.00<br />

49570 S 930.63 0.00 0.00 50955 S 667.60 0.00 0.00<br />

49572 S 1,270.63 0.00 0.00 50957 S 667.60 0.00 0.00<br />

49580 S 930.63 0.00 0.00 50961 S 667.60 0.00 0.00<br />

49582 S 1,270.63 0.00 0.00 50970 S 302.82 0.00 0.00<br />

49585 S 930.63 0.00 0.00 50972 S 302.82 0.00 0.00<br />

49587 S 1,270.63 0.00 0.00 50974 S 532.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 532.74 0.00 0.00 52275 S 721.80 0.00 0.00<br />

50980 S 667.60 0.00 0.00 52276 S 752.48 0.00 0.00<br />

51020 S 810.03 0.00 0.00 52277 S 721.80 0.00 0.00<br />

51030 S 810.03 0.00 0.00 52281 S 586.92 0.00 0.00<br />

51040 S 810.03 0.00 0.00 52282 S 1,354.07 0.00 0.00<br />

51045 S 334.58 0.00 0.00 52283 S 721.80 0.00 0.00<br />

51050 S 810.03 0.00 0.00 52285 S 586.92 0.00 0.00<br />

51065 S 810.03 0.00 0.00 52290 S 586.92 0.00 0.00<br />

51080 S 544.53 0.00 0.00 52300 S 721.80 0.00 0.00<br />

51100 S 31.57 0.00 0.00 52301 S 752.48 0.00 0.00<br />

51101 S 41.43 0.00 0.00 52305 S 721.80 0.00 0.00<br />

51102 S 557.38 0.00 0.00 52310 S 564.50 0.00 0.00<br />

51500 S 930.63 0.00 0.00 52315 S 721.80 0.00 0.00<br />

51520 S 810.03 0.00 0.00 52317 S 667.60 0.00 0.00<br />

51700 S 53.92 0.00 0.00 52318 S 721.80 0.00 0.00<br />

51701 S 25.65 0.00 0.00 52320 S 851.75 0.00 0.00<br />

51702 S 25.65 0.00 0.00 52325 S 810.03 0.00 0.00<br />

51703 S 41.43 0.00 0.00 52327 S 925.83 0.00 0.00<br />

51705 S 74.22 0.00 0.00 52330 S 721.80 0.00 0.00<br />

51710 S 469.34 0.00 0.00 52332 S 721.80 0.00 0.00<br />

51715 S 852.19 0.00 0.00 52334 S 752.48 0.00 0.00<br />

51720 S 59.60 0.00 0.00 52341 S 752.48 0.00 0.00<br />

51725 TC S 114.49 0.00 0.00 52342 S 752.48 0.00 0.00<br />

51726 TC S 157.70 0.00 0.00 52343 S 752.48 0.00 0.00<br />

51736 TC S 21.64 0.00 0.00 52344 S 752.48 0.00 0.00<br />

51741 TC S 25.19 0.00 0.00 52345 S 752.48 0.00 0.00<br />

51772 TC S 100.17 0.00 0.00 52346 S 752.48 0.00 0.00<br />

51784 TC S 41.43 0.00 0.00 52351 S 752.48 0.00 0.00<br />

51785 TC S 69.21 0.00 0.00 52352 S 810.03 0.00 0.00<br />

51792 TC S 41.43 0.00 0.00 52353 S 1,014.07 0.00 0.00<br />

51795 TC S 74.22 0.00 0.00 52354 S 810.03 0.00 0.00<br />

51797 TC S 74.22 0.00 0.00 52355 S 810.03 0.00 0.00<br />

51798 S 18.44 0.00 0.00 52400 S 752.48 0.00 0.00<br />

51880 S 667.60 0.00 0.00 52402 S 752.48 0.00 0.00<br />

51992 S 1,263.38 0.00 0.00 52450 S 752.48 0.00 0.00<br />

52000 S 302.82 0.00 0.00 52500 S 752.48 0.00 0.00<br />

52001 S 564.50 0.00 0.00 52601 S 1,014.07 0.00 0.00<br />

52005 S 586.92 0.00 0.00 52630 S 925.83 0.00 0.00<br />

52007 S 721.80 0.00 0.00 52640 S 721.80 0.00 0.00<br />

52010 S 334.58 0.00 0.00 52647 S 1,551.43 0.00 0.00<br />

52204 S 586.92 0.00 0.00 52648 S 1,551.43 0.00 0.00<br />

52214 S 721.80 0.00 0.00 52700 S 721.80 0.00 0.00<br />

52224 S 721.80 0.00 0.00 53000 S 553.97 0.00 0.00<br />

52234 S 721.80 0.00 0.00 53010 S 553.97 0.00 0.00<br />

52235 S 752.48 0.00 0.00 53020 S 553.97 0.00 0.00<br />

52240 S 752.48 0.00 0.00 53025 S 788.56 0.00 0.00<br />

52250 S 810.03 0.00 0.00 53040 S 608.17 0.00 0.00<br />

52260 S 586.92 0.00 0.00 53060 S 72.02 0.00 0.00<br />

52265 S 286.26 0.00 0.00 53080 S 638.86 0.00 0.00<br />

52270 S 586.92 0.00 0.00 53085 S 788.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 553.97 0.00 0.00 54060 S 561.81 0.00 0.00<br />

53210 S 951.46 0.00 0.00 54065 S 561.81 0.00 0.00<br />

53215 S 738.12 0.00 0.00 54100 S 475.26 0.00 0.00<br />

53220 S 821.49 0.00 0.00 54105 S 593.28 0.00 0.00<br />

53230 S 821.49 0.00 0.00 54110 S 919.83 0.00 0.00<br />

53235 S 638.86 0.00 0.00 54111 S 919.83 0.00 0.00<br />

53240 S 821.49 0.00 0.00 54112 S 919.83 0.00 0.00<br />

53250 S 608.17 0.00 0.00 54115 S 544.53 0.00 0.00<br />

53260 S 608.17 0.00 0.00 54120 S 919.83 0.00 0.00<br />

53265 S 608.17 0.00 0.00 54150 S 613.02 0.00 0.00<br />

53270 S 608.17 0.00 0.00 54160 S 667.22 0.00 0.00<br />

53275 S 608.17 0.00 0.00 54161 S 667.22 0.00 0.00<br />

53400 S 852.19 0.00 0.00 54162 S 667.22 0.00 0.00<br />

53405 S 821.49 0.00 0.00 54163 S 667.22 0.00 0.00<br />

53410 S 821.49 0.00 0.00 54164 S 667.22 0.00 0.00<br />

53420 S 852.19 0.00 0.00 54200 S 69.88 0.00 0.00<br />

53425 S 821.49 0.00 0.00 54205 S 1,008.07 0.00 0.00<br />

53430 S 821.49 0.00 0.00 54220 S 100.17 0.00 0.00<br />

53431 S 821.49 0.00 0.00 54231 S 65.63 0.00 0.00<br />

53440 S 4,732.13 2,874.04 1,015.95 54235 S 46.48 0.00 0.00<br />

53442 S 767.31 0.00 0.00 54240 TC S 32.99 0.00 0.00<br />

53444 S 4,732.13 2,874.04 1,015.95 54250 TC S 11.70 0.00 0.00<br />

53445 S 7,948.78 4,526.77 1,104.78 54300 S 950.52 0.00 0.00<br />

53446 S 767.31 0.00 0.00 54304 S 950.52 0.00 0.00<br />

53447 S 7,948.78 4,526.77 1,104.78 54308 S 950.52 0.00 0.00<br />

53449 S 767.31 0.00 0.00 54312 S 950.52 0.00 0.00<br />

53450 S 767.31 0.00 0.00 54316 S 950.52 0.00 0.00<br />

53460 S 553.97 0.00 0.00 54318 S 950.52 0.00 0.00<br />

53502 S 608.17 0.00 0.00 54322 S 950.52 0.00 0.00<br />

53505 S 821.49 0.00 0.00 54324 S 950.52 0.00 0.00<br />

53510 S 608.17 0.00 0.00 54326 S 950.52 0.00 0.00<br />

53515 S 821.49 0.00 0.00 54328 S 950.52 0.00 0.00<br />

53520 S 821.49 0.00 0.00 54340 S 950.52 0.00 0.00<br />

53600 S 41.51 0.00 0.00 54344 S 950.52 0.00 0.00<br />

53601 S 41.43 0.00 0.00 54348 S 950.52 0.00 0.00<br />

53605 S 586.92 0.00 0.00 54352 S 950.52 0.00 0.00<br />

53620 S 63.86 0.00 0.00 54360 S 950.52 0.00 0.00<br />

53621 S 67.05 0.00 0.00 54380 S 950.52 0.00 0.00<br />

53660 S 41.43 0.00 0.00 54385 S 950.52 0.00 0.00<br />

53661 S 41.43 0.00 0.00 54400 S 4,762.83 2,904.74 1,046.65<br />

53665 S 553.97 0.00 0.00 54401 S 8,033.66 4,611.66 1,189.66<br />

53850 S 1,818.63 0.00 0.00 54405 S 8,033.66 4,611.66 1,189.66<br />

53852 S 1,818.63 0.00 0.00 54406 S 950.52 0.00 0.00<br />

54000 S 608.17 0.00 0.00 54408 S 950.52 0.00 0.00<br />

54001 S 608.17 0.00 0.00 54410 S 8,033.66 4,611.66 1,189.66<br />

54015 S 686.97 0.00 0.00 54415 S 950.52 0.00 0.00<br />

54050 S 32.87 0.00 0.00 54416 S 8,033.66 4,611.66 1,189.66<br />

54055 S 67.05 0.00 0.00 54420 S 1,008.07 0.00 0.00<br />

54056 S 32.87 0.00 0.00 54435 S 1,008.07 0.00 0.00<br />

54057 S 561.81 0.00 0.00 54440 S 1,008.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 157.70 0.00 0.00 55706 S 458.45 0.00 0.00<br />

54500 S 428.01 0.00 0.00 55720 S 667.60 0.00 0.00<br />

54505 S 613.02 0.00 0.00 55725 S 721.80 0.00 0.00<br />

54512 S 667.22 0.00 0.00 55860 S 795.38 0.00 0.00<br />

54520 S 697.90 0.00 0.00 55870 S 80.88 0.00 0.00<br />

54522 S 697.90 0.00 0.00 55873 S 6,293.34 0.00 0.00<br />

54530 S 930.63 0.00 0.00 55875 S 1,354.07 0.00 0.00<br />

54550 S 930.63 0.00 0.00 55876 S 74.14 0.00 0.00<br />

54560 S 906.66 0.00 0.00 55920 S 929.44 0.00 0.00<br />

54600 S 755.45 0.00 0.00 56405 S 43.28 0.00 0.00<br />

54620 S 697.90 0.00 0.00 56420 S 56.49 0.00 0.00<br />

54640 S 930.63 0.00 0.00 56440 S 606.60 0.00 0.00<br />

54660 S 667.22 0.00 0.00 56441 S 552.40 0.00 0.00<br />

54670 S 697.90 0.00 0.00 56442 S 552.40 0.00 0.00<br />

54680 S 697.90 0.00 0.00 56501 S 59.60 0.00 0.00<br />

54690 S 1,561.65 0.00 0.00 56515 S 646.70 0.00 0.00<br />

54692 S 2,775.98 0.00 0.00 56605 S 34.41 0.00 0.00<br />

54700 S 667.22 0.00 0.00 56606 S 14.19 0.00 0.00<br />

54800 S 149.76 0.00 0.00 56620 S 736.55 0.00 0.00<br />

54830 S 697.90 0.00 0.00 56625 S 869.87 0.00 0.00<br />

54840 S 755.45 0.00 0.00 56700 S 552.40 0.00 0.00<br />

54860 S 697.90 0.00 0.00 56740 S 637.28 0.00 0.00<br />

54861 S 755.45 0.00 0.00 56800 S 637.28 0.00 0.00<br />

54865 S 613.02 0.00 0.00 56805 S 785.42 0.00 0.00<br />

54900 S 755.45 0.00 0.00 56810 S 736.55 0.00 0.00<br />

54901 S 755.45 0.00 0.00 56820 S 43.99 0.00 0.00<br />

55000 S 68.11 0.00 0.00 56821 S 56.49 0.00 0.00<br />

55040 S 873.09 0.00 0.00 57000 S 552.40 0.00 0.00<br />

55041 S 972.36 0.00 0.00 57010 S 606.60 0.00 0.00<br />

55060 S 755.45 0.00 0.00 57020 S 318.13 0.00 0.00<br />

55100 S 409.71 0.00 0.00 57022 S 500.04 0.00 0.00<br />

55110 S 667.22 0.00 0.00 57023 S 544.53 0.00 0.00<br />

55120 S 667.22 0.00 0.00 57061 S 54.98 0.00 0.00<br />

55150 S 613.02 0.00 0.00 57065 S 552.40 0.00 0.00<br />

55175 S 613.02 0.00 0.00 57100 S 35.12 0.00 0.00<br />

55180 S 667.22 0.00 0.00 57105 S 606.60 0.00 0.00<br />

55200 S 667.22 0.00 0.00 57130 S 606.60 0.00 0.00<br />

55250 S 667.22 0.00 0.00 57135 S 606.60 0.00 0.00<br />

55400 S 613.02 0.00 0.00 57150 S 25.54 0.00 0.00<br />

55450 S 219.23 0.00 0.00 57155 S 318.13 0.00 0.00<br />

55500 S 697.90 0.00 0.00 57160 S 36.89 0.00 0.00<br />

55520 S 755.45 0.00 0.00 57170 S 6.05 0.00 0.00<br />

55530 S 755.45 0.00 0.00 57180 S 113.63 0.00 0.00<br />

55535 S 930.63 0.00 0.00 57200 S 552.40 0.00 0.00<br />

55540 S 972.36 0.00 0.00 57210 S 606.60 0.00 0.00<br />

55550 S 1,561.65 0.00 0.00 57220 S 1,112.41 0.00 0.00<br />

55600 S 906.66 0.00 0.00 57230 S 913.39 0.00 0.00<br />

55680 S 613.02 0.00 0.00 57240 S 1,012.66 0.00 0.00<br />

55700 S 395.06 0.00 0.00 57250 S 1,012.66 0.00 0.00<br />

55705 S 395.06 0.00 0.00 57260 S 1,012.66 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,344.99 0.00 0.00 58555 S 596.84 0.00 0.00<br />

57267 S 1,145.97 0.00 0.00 58558 S 681.72 0.00 0.00<br />

57268 S 913.39 0.00 0.00 58559 S 651.04 0.00 0.00<br />

57287 S 1,337.64 0.00 0.00 58560 S 972.04 0.00 0.00<br />

57288 S 1,211.68 0.00 0.00 58561 S 972.04 0.00 0.00<br />

57289 S 1,012.66 0.00 0.00 58562 S 681.72 0.00 0.00<br />

57291 S 1,012.66 0.00 0.00 58563 S 1,369.58 0.00 0.00<br />

57300 S 913.39 0.00 0.00 58565 S 1,509.96 0.00 0.00<br />

57320 S 1,337.64 0.00 0.00 58600 S 1,337.64 0.00 0.00<br />

57400 S 606.60 0.00 0.00 58615 S 785.42 0.00 0.00<br />

57410 S 606.60 0.00 0.00 58660 S 1,263.38 0.00 0.00<br />

57415 S 606.60 0.00 0.00 58661 S 1,263.38 0.00 0.00<br />

57420 S 45.41 0.00 0.00 58662 S 1,263.38 0.00 0.00<br />

57421 S 59.24 0.00 0.00 58670 S 1,164.11 0.00 0.00<br />

57452 S 42.92 0.00 0.00 58671 S 1,164.11 0.00 0.00<br />

57454 S 52.50 0.00 0.00 58672 S 1,263.38 0.00 0.00<br />

57455 S 55.69 0.00 0.00 58673 S 1,263.38 0.00 0.00<br />

57456 S 53.92 0.00 0.00 58800 S 637.28 0.00 0.00<br />

57460 S 165.67 0.00 0.00 58805 S 1,337.64 0.00 0.00<br />

57461 S 175.96 0.00 0.00 58820 S 913.39 0.00 0.00<br />

57500 S 75.91 0.00 0.00 58900 S 637.28 0.00 0.00<br />

57505 S 48.25 0.00 0.00 58970 S 177.51 0.00 0.00<br />

57510 S 48.95 0.00 0.00 58974 S 177.51 0.00 0.00<br />

57511 S 56.49 0.00 0.00 58976 S 177.51 0.00 0.00<br />

57513 S 606.60 0.00 0.00 59000 S 64.92 0.00 0.00<br />

57520 S 606.60 0.00 0.00 59001 S 243.68 0.00 0.00<br />

57522 S 606.60 0.00 0.00 59012 S 119.15 0.00 0.00<br />

57530 S 913.39 0.00 0.00 59015 S 52.50 0.00 0.00<br />

57550 S 913.39 0.00 0.00 59020 TC S 27.67 0.00 0.00<br />

57556 S 1,211.68 0.00 0.00 59025 TC S 14.55 0.00 0.00<br />

57558 S 637.28 0.00 0.00 59070 S 119.15 0.00 0.00<br />

57700 S 552.40 0.00 0.00 59072 S 119.15 0.00 0.00<br />

57720 S 637.28 0.00 0.00 59076 S 119.15 0.00 0.00<br />

57800 S 25.90 0.00 0.00 59100 S 1,337.64 0.00 0.00<br />

58100 S 42.57 0.00 0.00 59150 S 1,839.07 0.00 0.00<br />

58120 S 606.60 0.00 0.00 59151 S 1,839.07 0.00 0.00<br />

58145 S 1,012.66 0.00 0.00 59160 S 637.28 0.00 0.00<br />

58301 S 39.73 0.00 0.00 59200 S 35.48 0.00 0.00<br />

58321 S 37.25 0.00 0.00 59300 S 76.62 0.00 0.00<br />

58322 S 38.31 0.00 0.00 59320 S 552.40 0.00 0.00<br />

58323 S 8.87 0.00 0.00 59412 S 785.42 0.00 0.00<br />

58345 S 785.42 0.00 0.00 59414 S 785.42 0.00 0.00<br />

58346 S 606.60 0.00 0.00 59812 S 736.55 0.00 0.00<br />

58350 S 913.39 0.00 0.00 59820 S 736.55 0.00 0.00<br />

58353 S 1,145.97 0.00 0.00 59821 S 736.55 0.00 0.00<br />

58356 S 1,735.68 0.00 0.00 59840 S 736.55 0.00 0.00<br />

58545 S 1,394.22 0.00 0.00 59841 S 736.55 0.00 0.00<br />

58546 S 1,561.65 0.00 0.00 59866 S 119.15 0.00 0.00<br />

58550 S 2,030.11 0.00 0.00 59870 S 736.55 0.00 0.00<br />

58552 S 1,839.07 0.00 0.00 59871 S 736.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 309.22 0.00 0.00 62367 S 17.03 0.00 0.00<br />

60100 S 48.60 0.00 0.00 62368 S 21.64 0.00 0.00<br />

60200 S 1,150.94 0.00 0.00 63600 S 581.33 0.00 0.00<br />

60280 S 1,239.18 0.00 0.00 63610 S 527.13 0.00 0.00<br />

60281 S 1,239.18 0.00 0.00 63615 S 734.89 0.00 0.00<br />

60300 S 63.86 0.00 0.00 63650 S 3,128.98 1,940.28 751.59<br />

61000 S 284.73 0.00 0.00 63655 S 4,583.19 2,922.71 1,262.23<br />

61001 S 284.73 0.00 0.00 63660 S 549.51 0.00 0.00<br />

61020 S 230.53 0.00 0.00 63685 S 13,911.04 7,417.49 923.95<br />

61026 S 230.53 0.00 0.00 63688 S 746.19 0.00 0.00<br />

61050 S 230.53 0.00 0.00 63744 S 1,079.10 0.00 0.00<br />

61055 S 230.53 0.00 0.00 63746 S 499.17 0.00 0.00<br />

61070 S 179.38 0.00 0.00 64400 S 54.63 0.00 0.00<br />

61215 S 1,079.10 0.00 0.00 64402 S 51.44 0.00 0.00<br />

61330 S 1,662.41 0.00 0.00 64405 S 43.63 0.00 0.00<br />

61334 S 1,662.41 0.00 0.00 64408 S 54.28 0.00 0.00<br />

61790 S 612.02 0.00 0.00 64410 S 302.05 0.00 0.00<br />

61791 S 454.05 0.00 0.00 64412 S 79.82 0.00 0.00<br />

61880 S 779.63 0.00 0.00 64413 S 51.09 0.00 0.00<br />

61885 S 11,219.02 6,009.92 800.83 64415 S 139.11 0.00 0.00<br />

61886 S 16,752.73 8,829.66 906.59 64416 S 284.73 0.00 0.00<br />

61888 S 746.19 0.00 0.00 64417 S 139.11 0.00 0.00<br />

62194 S 302.05 0.00 0.00 64418 S 71.66 0.00 0.00<br />

62225 S 469.34 0.00 0.00 64420 S 139.11 0.00 0.00<br />

62230 S 1,048.40 0.00 0.00 64421 S 302.05 0.00 0.00<br />

62252 TC S 47.54 0.00 0.00 64425 S 49.66 0.00 0.00<br />

62263 S 302.05 0.00 0.00 64430 S 209.02 0.00 0.00<br />

62264 S 444.97 0.00 0.00 64435 S 74.85 0.00 0.00<br />

62267 S 177.57 0.00 0.00 64445 S 66.33 0.00 0.00<br />

62268 S 230.53 0.00 0.00 64446 S 570.57 0.00 0.00<br />

62269 S 349.83 0.00 0.00 64447 S 144.90 0.00 0.00<br />

62270 S 139.11 0.00 0.00 64448 S 144.90 0.00 0.00<br />

62272 S 139.11 0.00 0.00 64449 S 284.73 0.00 0.00<br />

62273 S 232.14 0.00 0.00 64450 S 44.34 0.00 0.00<br />

62280 S 302.05 0.00 0.00 64455 S 18.44 0.00 0.00<br />

62281 S 302.05 0.00 0.00 64470 S 302.05 0.00 0.00<br />

62282 S 302.05 0.00 0.00 64472 S 232.14 0.00 0.00<br />

62287 S 1,355.94 0.00 0.00 64475 S 302.05 0.00 0.00<br />

62292 S 284.73 0.00 0.00 64476 S 209.06 0.00 0.00<br />

62294 S 230.53 0.00 0.00 64479 S 302.05 0.00 0.00<br />

62310 S 302.05 0.00 0.00 64480 S 232.14 0.00 0.00<br />

62311 S 302.05 0.00 0.00 64483 S 302.05 0.00 0.00<br />

62318 S 302.05 0.00 0.00 64484 S 232.14 0.00 0.00<br />

62319 S 302.05 0.00 0.00 64505 S 40.45 0.00 0.00<br />

62350 S 1,048.40 0.00 0.00 64508 S 85.85 0.00 0.00<br />

62355 S 499.17 0.00 0.00 64510 S 302.05 0.00 0.00<br />

62360 S 1,048.40 0.00 0.00 64517 S 209.02 0.00 0.00<br />

62361 S 10,761.96 5,825.07 888.18 64520 S 302.05 0.00 0.00<br />

62362 S 10,761.96 5,825.07 888.18 64530 S 302.05 0.00 0.00<br />

62365 S 927.70 0.00 0.00 64553 S 3,074.78 1,886.08 697.39<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,452.80 2,264.10 1,075.41 64746 S 581.33 0.00 0.00<br />

64560 S 3,452.80 2,264.10 1,075.41 64761 S 734.89 0.00 0.00<br />

64561 S 3,159.67 1,970.97 782.28 64763 S 734.89 0.00 0.00<br />

64565 S 3,452.80 2,264.10 1,075.41 64766 S 1,427.64 0.00 0.00<br />

64573 S 5,378.94 3,186.50 994.06 64771 S 581.33 0.00 0.00<br />

64575 S 4,111.76 2,451.28 790.80 64772 S 581.33 0.00 0.00<br />

64577 S 4,111.76 2,451.28 790.80 64774 S 581.33 0.00 0.00<br />

64580 S 4,111.76 2,451.28 790.80 64776 S 612.02 0.00 0.00<br />

64581 S 4,196.65 2,536.16 875.69 64778 S 581.33 0.00 0.00<br />

64585 S 549.51 0.00 0.00 64782 S 612.02 0.00 0.00<br />

64590 S 11,219.02 6,009.92 800.83 64783 S 581.33 0.00 0.00<br />

64595 S 746.19 0.00 0.00 64784 S 612.02 0.00 0.00<br />

64600 S 444.97 0.00 0.00 64786 S 958.39 0.00 0.00<br />

64605 S 444.97 0.00 0.00 64787 S 581.33 0.00 0.00<br />

64610 S 444.97 0.00 0.00 64788 S 612.02 0.00 0.00<br />

64612 S 64.92 0.00 0.00 64790 S 612.02 0.00 0.00<br />

64613 S 62.79 0.00 0.00 64792 S 958.39 0.00 0.00<br />

64614 S 71.66 0.00 0.00 64795 S 581.33 0.00 0.00<br />

64620 S 302.05 0.00 0.00 64802 S 581.33 0.00 0.00<br />

64622 S 444.97 0.00 0.00 64820 S 734.89 0.00 0.00<br />

64623 S 302.05 0.00 0.00 64821 S 857.92 0.00 0.00<br />

64626 S 444.97 0.00 0.00 64822 S 1,111.59 0.00 0.00<br />

64627 S 209.06 0.00 0.00 64823 S 1,111.59 0.00 0.00<br />

64630 S 311.13 0.00 0.00 64831 S 1,015.94 0.00 0.00<br />

64632 S 33.70 0.00 0.00 64832 S 873.51 0.00 0.00<br />

64640 S 100.40 0.00 0.00 64834 S 927.70 0.00 0.00<br />

64650 S 33.70 0.00 0.00 64835 S 958.39 0.00 0.00<br />

64653 S 36.54 0.00 0.00 64836 S 958.39 0.00 0.00<br />

64680 S 472.77 0.00 0.00 64837 S 873.51 0.00 0.00<br />

64681 S 499.17 0.00 0.00 64840 S 927.70 0.00 0.00<br />

64702 S 527.13 0.00 0.00 64856 S 927.70 0.00 0.00<br />

64704 S 527.13 0.00 0.00 64857 S 927.70 0.00 0.00<br />

64708 S 581.33 0.00 0.00 64858 S 927.70 0.00 0.00<br />

64712 S 581.33 0.00 0.00 64859 S 873.51 0.00 0.00<br />

64713 S 581.33 0.00 0.00 64861 S 958.39 0.00 0.00<br />

64714 S 581.33 0.00 0.00 64862 S 958.39 0.00 0.00<br />

64716 S 612.02 0.00 0.00 64864 S 958.39 0.00 0.00<br />

64718 S 581.33 0.00 0.00 64865 S 1,015.94 0.00 0.00<br />

64719 S 581.33 0.00 0.00 64870 S 1,015.94 0.00 0.00<br />

64721 S 581.33 0.00 0.00 64872 S 927.70 0.00 0.00<br />

64722 S 527.13 0.00 0.00 64874 S 958.39 0.00 0.00<br />

64726 S 527.13 0.00 0.00 64876 S 958.39 0.00 0.00<br />

64727 S 527.13 0.00 0.00 64885 S 927.70 0.00 0.00<br />

64732 S 581.33 0.00 0.00 64886 S 927.70 0.00 0.00<br />

64734 S 581.33 0.00 0.00 64890 S 927.70 0.00 0.00<br />

64736 S 581.33 0.00 0.00 64891 S 927.70 0.00 0.00<br />

64738 S 581.33 0.00 0.00 64892 S 927.70 0.00 0.00<br />

64740 S 581.33 0.00 0.00 64893 S 927.70 0.00 0.00<br />

64742 S 581.33 0.00 0.00 64895 S 958.39 0.00 0.00<br />

64744 S 581.33 0.00 0.00 64896 S 958.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 958.39 0.00 0.00 65770 S 5,639.81 0.00 0.00<br />

64898 S 958.39 0.00 0.00 65772 S 634.43 0.00 0.00<br />

64901 S 927.70 0.00 0.00 65775 S 634.43 0.00 0.00<br />

64902 S 927.70 0.00 0.00 65780 S 1,097.48 0.00 0.00<br />

64905 S 927.70 0.00 0.00 65781 S 1,097.48 0.00 0.00<br />

64907 S 873.51 0.00 0.00 65782 S 1,097.48 0.00 0.00<br />

64910 S 1,427.64 0.00 0.00 65800 S 492.01 0.00 0.00<br />

65091 S 1,009.13 0.00 0.00 65805 S 492.01 0.00 0.00<br />

65093 S 1,009.13 0.00 0.00 65810 S 718.92 0.00 0.00<br />

65101 S 1,009.13 0.00 0.00 65815 S 688.22 0.00 0.00<br />

65103 S 1,009.13 0.00 0.00 65820 S 252.41 0.00 0.00<br />

65105 S 1,066.68 0.00 0.00 65850 S 776.46 0.00 0.00<br />

65110 S 1,108.40 0.00 0.00 65855 S 134.09 0.00 0.00<br />

65112 S 1,241.72 0.00 0.00 65860 S 125.23 0.00 0.00<br />

65114 S 1,241.72 0.00 0.00 65865 S 492.01 0.00 0.00<br />

65125 S 1,033.41 0.00 0.00 65870 S 776.46 0.00 0.00<br />

65130 S 761.28 0.00 0.00 65875 S 776.46 0.00 0.00<br />

65135 S 730.59 0.00 0.00 65880 S 634.43 0.00 0.00<br />

65140 S 1,009.13 0.00 0.00 65900 S 676.16 0.00 0.00<br />

65150 S 730.59 0.00 0.00 65920 S 951.51 0.00 0.00<br />

65155 S 1,009.13 0.00 0.00 65930 S 818.19 0.00 0.00<br />

65175 S 543.08 0.00 0.00 66020 S 492.01 0.00 0.00<br />

65205 S 20.93 0.00 0.00 66030 S 252.41 0.00 0.00<br />

65210 S 26.61 0.00 0.00 66130 S 951.51 0.00 0.00<br />

65220 S 37.07 0.00 0.00 66150 S 776.46 0.00 0.00<br />

65222 S 29.09 0.00 0.00 66155 S 776.46 0.00 0.00<br />

65235 S 546.19 0.00 0.00 66160 S 688.22 0.00 0.00<br />

65260 S 360.25 0.00 0.00 66165 S 776.46 0.00 0.00<br />

65265 S 745.31 0.00 0.00 66170 S 776.46 0.00 0.00<br />

65270 S 597.26 0.00 0.00 66172 S 776.46 0.00 0.00<br />

65272 S 688.22 0.00 0.00 66180 S 1,156.77 0.00 0.00<br />

65275 S 776.46 0.00 0.00 66185 S 1,026.82 0.00 0.00<br />

65280 S 745.31 0.00 0.00 66220 S 1,002.36 0.00 0.00<br />

65285 S 1,059.90 0.00 0.00 66225 S 1,115.06 0.00 0.00<br />

65286 S 185.43 0.00 0.00 66250 S 546.19 0.00 0.00<br />

65290 S 733.99 0.00 0.00 66500 S 252.41 0.00 0.00<br />

65400 S 492.01 0.00 0.00 66505 S 252.41 0.00 0.00<br />

65410 S 546.19 0.00 0.00 66600 S 718.92 0.00 0.00<br />

65420 S 546.19 0.00 0.00 66605 S 718.92 0.00 0.00<br />

65426 S 818.19 0.00 0.00 66625 S 511.16 0.00 0.00<br />

65430 S 37.07 0.00 0.00 66630 S 718.92 0.00 0.00<br />

65435 S 32.28 0.00 0.00 66635 S 718.92 0.00 0.00<br />

65436 S 140.12 0.00 0.00 66680 S 718.92 0.00 0.00<br />

65450 S 85.54 0.00 0.00 66682 S 688.22 0.00 0.00<br />

65600 S 165.31 0.00 0.00 66700 S 546.19 0.00 0.00<br />

65710 S 1,230.80 0.00 0.00 66710 S 546.19 0.00 0.00<br />

65730 S 1,230.80 0.00 0.00 66711 S 546.19 0.00 0.00<br />

65750 S 1,230.80 0.00 0.00 66720 S 546.19 0.00 0.00<br />

65755 S 1,230.80 0.00 0.00 66740 S 688.22 0.00 0.00<br />

65756 S 1,507.28 0.00 0.00 66761 S 186.60 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 189.80 0.00 0.00 67228 S 209.02 0.00 0.00<br />

66770 S 209.02 0.00 0.00 67229 S 209.02 0.00 0.00<br />

66820 S 185.43 0.00 0.00 67250 S 627.96 0.00 0.00<br />

66821 S 254.36 0.00 0.00 67255 S 687.77 0.00 0.00<br />

66825 S 776.46 0.00 0.00 67311 S 733.99 0.00 0.00<br />

66830 S 271.56 0.00 0.00 67312 S 791.54 0.00 0.00<br />

66840 S 583.76 0.00 0.00 67314 S 791.54 0.00 0.00<br />

66850 S 1,099.07 0.00 0.00 67316 S 791.54 0.00 0.00<br />

66852 S 924.03 0.00 0.00 67318 S 791.54 0.00 0.00<br />

66920 S 924.03 0.00 0.00 67320 S 791.54 0.00 0.00<br />

66930 S 965.76 0.00 0.00 67331 S 791.54 0.00 0.00<br />

66940 S 625.48 0.00 0.00 67332 S 791.54 0.00 0.00<br />

66982 S 948.88 0.00 0.00 67334 S 791.54 0.00 0.00<br />

66983 S 948.88 0.00 0.00 67335 S 791.54 0.00 0.00<br />

66984 S 948.88 0.00 0.00 67340 S 791.54 0.00 0.00<br />

66985 S 878.38 0.00 0.00 67343 S 966.57 0.00 0.00<br />

66986 S 878.38 0.00 0.00 67345 S 82.66 0.00 0.00<br />

67005 S 745.31 0.00 0.00 67346 S 447.09 0.00 0.00<br />

67010 S 745.31 0.00 0.00 67400 S 627.96 0.00 0.00<br />

67015 S 917.47 0.00 0.00 67405 S 818.83 0.00 0.00<br />

67025 S 602.89 0.00 0.00 67412 S 727.22 0.00 0.00<br />

67027 S 1,059.90 0.00 0.00 67413 S 860.54 0.00 0.00<br />

67028 S 83.37 0.00 0.00 67414 S 1,529.12 0.00 0.00<br />

67030 S 602.89 0.00 0.00 67415 S 543.08 0.00 0.00<br />

67031 S 254.36 0.00 0.00 67420 S 1,108.40 0.00 0.00<br />

67036 S 1,059.90 0.00 0.00 67430 S 1,108.40 0.00 0.00<br />

67039 S 1,234.94 0.00 0.00 67440 S 1,108.40 0.00 0.00<br />

67040 S 1,234.94 0.00 0.00 67445 S 1,108.40 0.00 0.00<br />

67041 S 1,515.56 0.00 0.00 67450 S 1,108.40 0.00 0.00<br />

67042 S 1,515.56 0.00 0.00 67500 S 85.54 0.00 0.00<br />

67043 S 1,515.56 0.00 0.00 67505 S 26.61 0.00 0.00<br />

67101 S 231.36 0.00 0.00 67515 S 26.96 0.00 0.00<br />

67105 S 209.02 0.00 0.00 67550 S 1,066.68 0.00 0.00<br />

67107 S 1,101.62 0.00 0.00 67560 S 730.59 0.00 0.00<br />

67108 S 1,234.94 0.00 0.00 67570 S 1,066.68 0.00 0.00<br />

67110 S 336.30 0.00 0.00 67700 S 125.15 0.00 0.00<br />

67112 S 1,234.94 0.00 0.00 67710 S 146.15 0.00 0.00<br />

67113 S 1,515.56 0.00 0.00 67715 S 543.08 0.00 0.00<br />

67115 S 657.07 0.00 0.00 67800 S 52.50 0.00 0.00<br />

67120 S 657.07 0.00 0.00 67801 S 63.50 0.00 0.00<br />

67121 S 657.07 0.00 0.00 67805 S 82.30 0.00 0.00<br />

67141 S 231.62 0.00 0.00 67808 S 597.26 0.00 0.00<br />

67145 S 197.60 0.00 0.00 67810 S 125.15 0.00 0.00<br />

67208 S 210.73 0.00 0.00 67820 S 17.38 0.00 0.00<br />

67210 S 209.02 0.00 0.00 67825 S 53.57 0.00 0.00<br />

67218 S 787.04 0.00 0.00 67830 S 366.68 0.00 0.00<br />

67220 S 231.36 0.00 0.00 67835 S 597.26 0.00 0.00<br />

67221 S 118.84 0.00 0.00 67840 S 153.25 0.00 0.00<br />

67225 S 8.16 0.00 0.00 67850 S 121.68 0.00 0.00<br />

67227 S 602.89 0.00 0.00 67875 S 305.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 576.89 0.00 0.00 68440 S 52.15 0.00 0.00<br />

67882 S 627.96 0.00 0.00 68500 S 761.28 0.00 0.00<br />

67900 S 818.83 0.00 0.00 68505 S 761.28 0.00 0.00<br />

67901 S 727.22 0.00 0.00 68510 S 543.08 0.00 0.00<br />

67902 S 860.54 0.00 0.00 68520 S 761.28 0.00 0.00<br />

67903 S 685.50 0.00 0.00 68525 S 543.08 0.00 0.00<br />

67904 S 685.50 0.00 0.00 68530 S 125.15 0.00 0.00<br />

67906 S 727.22 0.00 0.00 68540 S 627.96 0.00 0.00<br />

67908 S 685.50 0.00 0.00 68550 S 761.28 0.00 0.00<br />

67909 S 685.50 0.00 0.00 68700 S 597.26 0.00 0.00<br />

67911 S 627.96 0.00 0.00 68705 S 118.84 0.00 0.00<br />

67912 S 627.96 0.00 0.00 68720 S 818.83 0.00 0.00<br />

67914 S 627.96 0.00 0.00 68745 S 818.83 0.00 0.00<br />

67915 S 169.57 0.00 0.00 68750 S 818.83 0.00 0.00<br />

67916 S 685.50 0.00 0.00 68760 S 101.10 0.00 0.00<br />

67917 S 685.50 0.00 0.00 68761 S 69.88 0.00 0.00<br />

67921 S 627.96 0.00 0.00 68770 S 818.83 0.00 0.00<br />

67922 S 164.96 0.00 0.00 68801 S 37.07 0.00 0.00<br />

67923 S 685.50 0.00 0.00 68810 S 106.01 0.00 0.00<br />

67924 S 685.50 0.00 0.00 68811 S 597.26 0.00 0.00<br />

67930 S 169.57 0.00 0.00 68815 S 597.26 0.00 0.00<br />

67935 S 597.26 0.00 0.00 68816 S 766.77 0.00 0.00<br />

67938 S 85.54 0.00 0.00 68840 S 54.98 0.00 0.00<br />

67950 S 597.26 0.00 0.00 69000 S 56.08 0.00 0.00<br />

67961 S 627.96 0.00 0.00 69005 S 106.07 0.00 0.00<br />

67966 S 627.96 0.00 0.00 69020 S 56.08 0.00 0.00<br />

67971 S 627.96 0.00 0.00 69100 S 63.86 0.00 0.00<br />

67973 S 761.28 0.00 0.00 69105 S 90.46 0.00 0.00<br />

67974 S 627.96 0.00 0.00 69110 S 475.26 0.00 0.00<br />

67975 S 627.96 0.00 0.00 69120 S 705.28 0.00 0.00<br />

68020 S 46.48 0.00 0.00 69140 S 705.28 0.00 0.00<br />

68040 S 23.06 0.00 0.00 69145 S 529.44 0.00 0.00<br />

68100 S 92.23 0.00 0.00 69150 S 372.12 0.00 0.00<br />

68110 S 118.84 0.00 0.00 69200 S 25.65 0.00 0.00<br />

68115 S 597.26 0.00 0.00 69205 S 593.28 0.00 0.00<br />

68130 S 546.19 0.00 0.00 69210 S 20.93 0.00 0.00<br />

68135 S 59.60 0.00 0.00 69220 S 32.87 0.00 0.00<br />

68200 S 17.03 0.00 0.00 69222 S 138.35 0.00 0.00<br />

68320 S 818.83 0.00 0.00 69300 S 735.98 0.00 0.00<br />

68325 S 818.83 0.00 0.00 69310 S 1,075.78 0.00 0.00<br />

68326 S 685.50 0.00 0.00 69320 S 1,308.37 0.00 0.00<br />

68328 S 818.83 0.00 0.00 69400 S 92.94 0.00 0.00<br />

68330 S 776.46 0.00 0.00 69401 S 48.95 0.00 0.00<br />

68335 S 818.83 0.00 0.00 69405 S 128.42 0.00 0.00<br />

68340 S 685.50 0.00 0.00 69420 S 115.30 0.00 0.00<br />

68360 S 688.22 0.00 0.00 69421 S 586.80 0.00 0.00<br />

68362 S 688.22 0.00 0.00 69424 S 80.88 0.00 0.00<br />

68371 S 546.19 0.00 0.00 69433 S 114.94 0.00 0.00<br />

68400 S 125.15 0.00 0.00 69436 S 586.80 0.00 0.00<br />

68420 S 178.08 0.00 0.00 69440 S 735.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 990.90 0.00 0.00 69840 S 1,175.05 0.00 0.00<br />

69501 S 1,308.37 0.00 0.00 69905 S 1,308.37 0.00 0.00<br />

69502 S 968.56 0.00 0.00 69910 S 1,308.37 0.00 0.00<br />

69505 S 1,308.37 0.00 0.00 69915 S 1,308.37 0.00 0.00<br />

69511 S 1,308.37 0.00 0.00 69930 S 23,653.46 12,700.30 1,747.16<br />

69530 S 1,308.37 0.00 0.00 70030 TC A 18.09 0.00 0.00<br />

69540 S 135.16 0.00 0.00 70100 TC A 19.87 0.00 0.00<br />

69550 S 1,175.05 0.00 0.00 70110 TC A 24.48 0.00 0.00<br />

69552 S 1,308.37 0.00 0.00 70120 TC A 21.99 0.00 0.00<br />

69601 S 1,308.37 0.00 0.00 70130 TC A 26.87 0.00 0.00<br />

69602 S 1,308.37 0.00 0.00 70134 TC A 26.96 0.00 0.00<br />

69603 S 1,308.37 0.00 0.00 70140 TC A 18.44 0.00 0.00<br />

69604 S 1,308.37 0.00 0.00 70150 TC A 26.87 0.00 0.00<br />

69605 S 1,308.37 0.00 0.00 70160 TC A 21.64 0.00 0.00<br />

69610 S 180.92 0.00 0.00 70190 TC A 22.70 0.00 0.00<br />

69620 S 705.28 0.00 0.00 70200 TC A 26.87 0.00 0.00<br />

69631 S 1,175.05 0.00 0.00 70210 TC A 19.16 0.00 0.00<br />

69632 S 1,175.05 0.00 0.00 70220 TC A 24.13 0.00 0.00<br />

69633 S 1,175.05 0.00 0.00 70240 TC A 18.09 0.00 0.00<br />

69635 S 1,308.37 0.00 0.00 70250 TC A 21.99 0.00 0.00<br />

69636 S 1,308.37 0.00 0.00 70260 TC A 28.02 0.00 0.00<br />

69637 S 1,308.37 0.00 0.00 70300 TC A 7.80 0.00 0.00<br />

69641 S 1,308.37 0.00 0.00 70310 TC A 19.28 0.00 0.00<br />

69642 S 1,308.37 0.00 0.00 70320 TC A 19.28 0.00 0.00<br />

69643 S 1,308.37 0.00 0.00 70328 TC A 19.16 0.00 0.00<br />

69644 S 1,308.37 0.00 0.00 70330 TC A 26.87 0.00 0.00<br />

69645 S 1,308.37 0.00 0.00 70336 TC A 209.17 0.00 0.00<br />

69646 S 1,308.37 0.00 0.00 70350 TC A 10.64 0.00 0.00<br />

69650 S 968.56 0.00 0.00 70355 TC A 11.00 0.00 0.00<br />

69660 S 1,175.05 0.00 0.00 70360 TC A 17.03 0.00 0.00<br />

69661 S 1,175.05 0.00 0.00 70370 TC A 50.01 0.00 0.00<br />

69662 S 1,175.05 0.00 0.00 70371 TC A 50.01 0.00 0.00<br />

69666 S 1,133.32 0.00 0.00 70380 TC A 25.90 0.00 0.00<br />

69667 S 1,133.32 0.00 0.00 70450 TC A 116.82 0.00 0.00<br />

69670 S 1,075.78 0.00 0.00 70460 TC A 184.99 0.00 0.00<br />

69676 S 1,075.78 0.00 0.00 70470 TC A 204.91 0.00 0.00<br />

69700 S 1,075.78 0.00 0.00 70480 TC A 116.82 0.00 0.00<br />

69711 S 990.90 0.00 0.00 70481 TC A 184.99 0.00 0.00<br />

69714 S 6,284.10 3,962.36 1,640.63 70482 TC A 204.91 0.00 0.00<br />

69715 S 6,284.10 3,962.36 1,640.63 70486 TC A 116.82 0.00 0.00<br />

69717 S 6,284.10 3,962.36 1,640.63 70487 TC A 184.99 0.00 0.00<br />

69718 S 6,284.10 3,962.36 1,640.63 70488 TC A 204.91 0.00 0.00<br />

69720 S 1,175.05 0.00 0.00 70490 TC A 116.82 0.00 0.00<br />

69740 S 1,175.05 0.00 0.00 70491 TC A 184.99 0.00 0.00<br />

69745 S 1,175.05 0.00 0.00 70492 TC A 204.91 0.00 0.00<br />

69801 S 1,175.05 0.00 0.00 70496 TC A 211.46 0.00 0.00<br />

69802 S 1,308.37 0.00 0.00 70498 TC A 211.46 0.00 0.00<br />

69805 S 1,308.37 0.00 0.00 70540 TC A 209.17 0.00 0.00<br />

69806 S 1,308.37 0.00 0.00 70542 TC A 256.87 0.00 0.00<br />

69820 S 1,175.05 0.00 0.00 70543 TC A 323.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 209.17 0.00 0.00 72120 TC A 34.05 0.00 0.00<br />

70545 TC A 256.87 0.00 0.00 72125 TC A 116.82 0.00 0.00<br />

70546 TC A 323.74 0.00 0.00 72126 TC A 184.99 0.00 0.00<br />

70547 TC A 209.17 0.00 0.00 72127 TC A 204.91 0.00 0.00<br />

70548 TC A 256.87 0.00 0.00 72128 TC A 116.82 0.00 0.00<br />

70549 TC A 323.74 0.00 0.00 72129 TC A 184.99 0.00 0.00<br />

70551 TC A 209.17 0.00 0.00 72130 TC A 204.91 0.00 0.00<br />

70552 TC A 256.87 0.00 0.00 72131 TC A 116.82 0.00 0.00<br />

70553 TC A 323.74 0.00 0.00 72132 TC A 184.99 0.00 0.00<br />

70554 TC A 209.17 0.00 0.00 72133 TC A 204.91 0.00 0.00<br />

70555 TC A 209.17 0.00 0.00 72141 TC A 209.17 0.00 0.00<br />

70557 TC A 209.17 0.00 0.00 72142 TC A 256.87 0.00 0.00<br />

70558 TC A 256.87 0.00 0.00 72146 TC A 209.17 0.00 0.00<br />

70559 TC A 323.74 0.00 0.00 72147 TC A 256.87 0.00 0.00<br />

71010 TC A 13.84 0.00 0.00 72148 TC A 209.17 0.00 0.00<br />

71015 TC A 17.73 0.00 0.00 72149 TC A 256.87 0.00 0.00<br />

71020 TC A 18.81 0.00 0.00 72156 TC A 323.74 0.00 0.00<br />

71021 TC A 22.70 0.00 0.00 72157 TC A 323.74 0.00 0.00<br />

71022 TC A 26.87 0.00 0.00 72158 TC A 323.74 0.00 0.00<br />

71023 TC A 43.99 0.00 0.00 72170 TC A 15.96 0.00 0.00<br />

71030 TC A 26.87 0.00 0.00 72190 TC A 26.87 0.00 0.00<br />

71034 TC A 50.01 0.00 0.00 72191 TC A 211.46 0.00 0.00<br />

71035 TC A 23.41 0.00 0.00 72192 TC A 116.82 0.00 0.00<br />

71100 TC A 19.51 0.00 0.00 72193 TC A 184.99 0.00 0.00<br />

71101 TC A 23.76 0.00 0.00 72194 TC A 204.91 0.00 0.00<br />

71110 TC A 24.84 0.00 0.00 72195 TC A 209.17 0.00 0.00<br />

71111 TC A 32.99 0.00 0.00 72196 TC A 256.87 0.00 0.00<br />

71120 TC A 20.58 0.00 0.00 72197 TC A 323.74 0.00 0.00<br />

71130 TC A 24.13 0.00 0.00 72200 TC A 18.81 0.00 0.00<br />

71250 TC A 116.82 0.00 0.00 72202 TC A 23.06 0.00 0.00<br />

71260 TC A 184.99 0.00 0.00 72220 TC A 18.81 0.00 0.00<br />

71270 TC A 204.91 0.00 0.00 73000 TC A 17.73 0.00 0.00<br />

71275 TC A 211.46 0.00 0.00 73010 TC A 18.09 0.00 0.00<br />

71550 TC A 209.17 0.00 0.00 73020 TC A 14.55 0.00 0.00<br />

71551 TC A 256.87 0.00 0.00 73030 TC A 18.44 0.00 0.00<br />

71552 TC A 323.74 0.00 0.00 73050 TC A 23.06 0.00 0.00<br />

72010 TC A 44.73 0.00 0.00 73060 TC A 18.44 0.00 0.00<br />

72020 TC A 14.55 0.00 0.00 73070 TC A 17.73 0.00 0.00<br />

72040 TC A 23.41 0.00 0.00 73080 TC A 23.41 0.00 0.00<br />

72050 TC A 33.34 0.00 0.00 73090 TC A 17.73 0.00 0.00<br />

72052 TC A 44.73 0.00 0.00 73092 TC A 18.44 0.00 0.00<br />

72069 TC A 21.99 0.00 0.00 73100 TC A 18.44 0.00 0.00<br />

72070 TC A 20.58 0.00 0.00 73110 TC A 23.41 0.00 0.00<br />

72072 TC A 24.84 0.00 0.00 73120 TC A 17.38 0.00 0.00<br />

72074 TC A 26.87 0.00 0.00 73130 TC A 20.58 0.00 0.00<br />

72080 TC A 21.99 0.00 0.00 73140 TC A 20.22 0.00 0.00<br />

72090 TC A 29.45 0.00 0.00 73200 TC A 116.82 0.00 0.00<br />

72100 TC A 25.19 0.00 0.00 73201 TC A 184.99 0.00 0.00<br />

72110 TC A 35.12 0.00 0.00 73202 TC A 204.91 0.00 0.00<br />

72114 TC A 44.73 0.00 0.00 73206 TC A 211.46 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 209.17 0.00 0.00 74246 TC A 52.79 0.00 0.00<br />

73219 TC A 256.87 0.00 0.00 74247 TC A 52.79 0.00 0.00<br />

73220 TC A 323.74 0.00 0.00 74249 TC A 85.84 0.00 0.00<br />

73221 TC A 209.17 0.00 0.00 74250 TC A 52.79 0.00 0.00<br />

73222 TC A 256.87 0.00 0.00 74251 TC A 85.84 0.00 0.00<br />

73223 TC A 323.74 0.00 0.00 74260 TC A 52.79 0.00 0.00<br />

73500 TC A 15.26 0.00 0.00 74270 TC A 52.79 0.00 0.00<br />

73510 TC A 23.41 0.00 0.00 74280 TC A 85.84 0.00 0.00<br />

73520 TC A 24.13 0.00 0.00 74283 TC A 52.79 0.00 0.00<br />

73540 TC A 24.13 0.00 0.00 74290 TC A 45.05 0.00 0.00<br />

73550 TC A 17.73 0.00 0.00 74291 TC A 43.28 0.00 0.00<br />

73560 TC A 18.09 0.00 0.00 74400 TC A 78.40 0.00 0.00<br />

73562 TC A 22.35 0.00 0.00 74410 TC A 83.72 0.00 0.00<br />

73564 TC A 25.90 0.00 0.00 74415 TC A 100.04 0.00 0.00<br />

73565 TC A 19.51 0.00 0.00 74420 TC A 104.57 0.00 0.00<br />

73590 TC A 17.03 0.00 0.00 74710 TC A 23.41 0.00 0.00<br />

73592 TC A 18.44 0.00 0.00 74775 TC A 104.57 0.00 0.00<br />

73600 TC A 17.38 0.00 0.00 75557 TC A 209.17 0.00 0.00<br />

73610 TC A 20.58 0.00 0.00 75559 TC A 209.17 0.00 0.00<br />

73620 TC A 16.67 0.00 0.00 75561 TC A 323.74 0.00 0.00<br />

73630 TC A 20.22 0.00 0.00 75563 TC A 323.74 0.00 0.00<br />

73650 TC A 17.03 0.00 0.00 76010 TC A 17.38 0.00 0.00<br />

73660 TC A 19.16 0.00 0.00 76098 TC A 10.64 0.00 0.00<br />

73700 TC A 116.82 0.00 0.00 76100 TC A 44.73 0.00 0.00<br />

73701 TC A 184.99 0.00 0.00 76101 TC A 119.90 0.00 0.00<br />

73702 TC A 204.91 0.00 0.00 76102 TC A 119.90 0.00 0.00<br />

73706 TC A 211.46 0.00 0.00 76120 TC A 50.01 0.00 0.00<br />

73718 TC A 209.17 0.00 0.00 76150 A 17.38 0.00 0.00<br />

73719 TC A 256.87 0.00 0.00 76380 TC A 63.11 0.00 0.00<br />

73720 TC A 323.74 0.00 0.00 76496 TC A 50.01 0.00 0.00<br />

73721 TC A 209.17 0.00 0.00 76497 TC A 63.11 0.00 0.00<br />

73722 TC A 256.87 0.00 0.00 76498 TC A 209.17 0.00 0.00<br />

73723 TC A 323.74 0.00 0.00 76499 TC A 26.87 0.00 0.00<br />

74000 TC A 15.26 0.00 0.00 76506 TC A 37.56 0.00 0.00<br />

74010 TC A 23.76 0.00 0.00 76510 TC A 63.86 0.00 0.00<br />

74020 TC A 24.13 0.00 0.00 76511 TC A 44.69 0.00 0.00<br />

74022 TC A 29.45 0.00 0.00 76512 TC A 37.96 0.00 0.00<br />

74150 TC A 116.82 0.00 0.00 76513 TC A 46.12 0.00 0.00<br />

74160 TC A 184.99 0.00 0.00 76514 TC A 3.20 0.00 0.00<br />

74170 TC A 204.91 0.00 0.00 76516 TC A 36.19 0.00 0.00<br />

74175 TC A 211.46 0.00 0.00 76519 TC A 40.45 0.00 0.00<br />

74181 TC A 209.17 0.00 0.00 76529 TC A 35.12 0.00 0.00<br />

74182 TC A 256.87 0.00 0.00 76536 TC A 58.76 0.00 0.00<br />

74183 TC A 323.74 0.00 0.00 76604 TC A 37.56 0.00 0.00<br />

74210 TC A 52.79 0.00 0.00 76645 TC A 37.56 0.00 0.00<br />

74220 TC A 52.79 0.00 0.00 76700 TC A 58.76 0.00 0.00<br />

74230 TC A 52.79 0.00 0.00 76705 TC A 58.76 0.00 0.00<br />

74240 TC A 52.79 0.00 0.00 76770 TC A 58.76 0.00 0.00<br />

74241 TC A 52.79 0.00 0.00 76775 TC A 58.76 0.00 0.00<br />

74245 TC A 85.84 0.00 0.00 76776 TC A 58.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 58.76 0.00 0.00 77290 TC A 153.67 0.00 0.00<br />

76801 TC A 58.76 0.00 0.00 77295 TC A 402.65 0.00 0.00<br />

76802 TC A 28.02 0.00 0.00 77299 TC A 68.94 0.00 0.00<br />

76805 TC A 58.76 0.00 0.00 77300 TC A 37.25 0.00 0.00<br />

76810 TC A 44.34 0.00 0.00 77301 TC A 536.61 0.00 0.00<br />

76811 TC A 92.06 0.00 0.00 77305 TC A 34.05 0.00 0.00<br />

76812 TC A 37.56 0.00 0.00 77310 TC A 44.34 0.00 0.00<br />

76813 TC A 37.56 0.00 0.00 77315 TC A 64.56 0.00 0.00<br />

76814 TC A 29.80 0.00 0.00 77321 TC A 67.05 0.00 0.00<br />

76815 TC A 37.56 0.00 0.00 77326 TC A 68.94 0.00 0.00<br />

76816 TC A 37.56 0.00 0.00 77327 TC A 125.23 0.00 0.00<br />

76817 TC A 37.56 0.00 0.00 77328 TC A 153.67 0.00 0.00<br />

76818 TC A 58.76 0.00 0.00 77331 TC A 17.73 0.00 0.00<br />

76819 TC A 50.73 0.00 0.00 77332 TC A 47.54 0.00 0.00<br />

76820 TC A 25.19 0.00 0.00 77333 TC A 23.06 0.00 0.00<br />

76821 TC A 56.88 0.00 0.00 77334 TC A 89.05 0.00 0.00<br />

76825 TC A 118.48 0.00 0.00 77336 A 56.06 0.00 0.00<br />

76826 TC A 70.59 0.00 0.00 77370 A 68.94 0.00 0.00<br />

76827 TC A 37.56 0.00 0.00 77371 A 4,592.53 0.00 0.00<br />

76828 TC A 22.35 0.00 0.00 77399 TC A 68.94 0.00 0.00<br />

76830 TC A 58.76 0.00 0.00 77401 A 28.02 0.00 0.00<br />

76831 TC A 79.11 0.00 0.00 77402 A 56.42 0.00 0.00<br />

76856 TC A 58.76 0.00 0.00 77403 A 56.42 0.00 0.00<br />

76857 TC A 37.56 0.00 0.00 77404 A 56.42 0.00 0.00<br />

76870 TC A 58.76 0.00 0.00 77406 A 91.39 0.00 0.00<br />

76872 TC A 58.76 0.00 0.00 77407 A 56.42 0.00 0.00<br />

76873 TC A 58.76 0.00 0.00 77408 A 56.42 0.00 0.00<br />

76880 TC A 58.76 0.00 0.00 77409 A 56.42 0.00 0.00<br />

76885 TC A 37.56 0.00 0.00 77411 A 91.39 0.00 0.00<br />

76886 TC A 37.56 0.00 0.00 77412 A 91.39 0.00 0.00<br />

76936 TC A 56.88 0.00 0.00 77413 A 91.39 0.00 0.00<br />

76970 TC A 37.56 0.00 0.00 77414 A 91.39 0.00 0.00<br />

76977 TC A 9.58 0.00 0.00 77416 A 91.39 0.00 0.00<br />

76999 TC A 37.56 0.00 0.00 77418 A 246.90 0.00 0.00<br />

77071 A 21.99 0.00 0.00 77422 A 91.39 0.00 0.00<br />

77072 TC A 12.77 0.00 0.00 77423 A 91.39 0.00 0.00<br />

77073 TC A 21.64 0.00 0.00 77470 TC A 131.26 0.00 0.00<br />

77074 TC A 42.57 0.00 0.00 77520 A 422.72 0.00 0.00<br />

77075 TC A 44.73 0.00 0.00 77522 A 422.72 0.00 0.00<br />

77076 TC A 44.73 0.00 0.00 77523 A 505.17 0.00 0.00<br />

77077 TC A 24.13 0.00 0.00 77525 A 505.17 0.00 0.00<br />

77078 TC A 43.22 0.00 0.00 77600 TC A 224.29 0.00 0.00<br />

77079 TC A 44.34 0.00 0.00 77605 TC A 224.29 0.00 0.00<br />

77080 TC A 43.22 0.00 0.00 77610 TC A 224.29 0.00 0.00<br />

77081 TC A 17.38 0.00 0.00 77615 TC A 224.29 0.00 0.00<br />

77082 TC A 18.81 0.00 0.00 77620 TC A 224.29 0.00 0.00<br />

77083 TC A 14.90 0.00 0.00 77750 TC A 87.26 0.00 0.00<br />

77084 TC A 209.17 0.00 0.00 77761 TC A 153.61 0.00 0.00<br />

77280 TC A 68.94 0.00 0.00 77762 TC A 181.99 0.00 0.00<br />

77285 TC A 153.67 0.00 0.00 77763 TC A 234.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 166.38 0.00 0.00 78262 TC A 146.11 0.00 0.00<br />

77777 TC A 182.69 0.00 0.00 78264 TC A 146.11 0.00 0.00<br />

77778 TC A 243.36 0.00 0.00 78270 TC A 63.86 0.00 0.00<br />

77785 TC A 108.20 0.00 0.00 78271 TC A 64.92 0.00 0.00<br />

77786 TC A 380.29 0.00 0.00 78272 TC A 71.30 0.00 0.00<br />

77787 TC A 440.67 0.00 0.00 78278 TC A 146.11 0.00 0.00<br />

77789 TC A 45.41 0.00 0.00 78282 TC A 146.11 0.00 0.00<br />

77799 TC A 258.82 0.00 0.00 78290 TC A 146.11 0.00 0.00<br />

78000 TC A 55.69 0.00 0.00 78291 TC A 146.11 0.00 0.00<br />

78001 TC A 70.58 0.00 0.00 78299 TC A 146.11 0.00 0.00<br />

78003 TC A 56.06 0.00 0.00 78300 TC A 127.36 0.00 0.00<br />

78006 TC A 133.37 0.00 0.00 78305 TC A 147.71 0.00 0.00<br />

78007 TC A 98.63 0.00 0.00 78306 TC A 147.71 0.00 0.00<br />

78010 TC A 81.94 0.00 0.00 78315 TC A 147.71 0.00 0.00<br />

78011 TC A 81.94 0.00 0.00 78320 TC A 147.71 0.00 0.00<br />

78015 TC A 159.28 0.00 0.00 78399 TC A 147.71 0.00 0.00<br />

78016 TC A 179.79 0.00 0.00 78414 TC A 187.75 0.00 0.00<br />

78018 TC A 179.79 0.00 0.00 78428 TC A 144.03 0.00 0.00<br />

78070 TC A 122.39 0.00 0.00 78445 TC A 112.35 0.00 0.00<br />

78075 TC A 346.59 0.00 0.00 78456 TC A 112.35 0.00 0.00<br />

78099 TC A 81.94 0.00 0.00 78457 TC A 112.35 0.00 0.00<br />

78102 TC A 123.81 0.00 0.00 78458 TC A 112.35 0.00 0.00<br />

78103 TC A 157.82 0.00 0.00 78459 TC A 695.26 0.00 0.00<br />

78104 TC A 157.82 0.00 0.00 78460 TC A 134.80 0.00 0.00<br />

78110 TC A 62.79 0.00 0.00 78461 TC A 135.87 0.00 0.00<br />

78111 TC A 79.47 0.00 0.00 78464 TC A 199.37 0.00 0.00<br />

78120 TC A 69.53 0.00 0.00 78465 TC A 377.46 0.00 0.00<br />

78121 TC A 82.30 0.00 0.00 78466 TC A 133.74 0.00 0.00<br />

78122 TC A 97.55 0.00 0.00 78468 TC A 170.99 0.00 0.00<br />

78130 TC A 113.16 0.00 0.00 78469 TC A 187.75 0.00 0.00<br />

78135 TC A 240.51 0.00 0.00 78472 TC A 187.75 0.00 0.00<br />

78140 TC A 106.78 0.00 0.00 78473 TC A 187.75 0.00 0.00<br />

78185 TC A 157.82 0.00 0.00 78481 TC A 162.12 0.00 0.00<br />

78190 TC A 99.03 0.00 0.00 78483 TC A 187.75 0.00 0.00<br />

78191 TC A 99.03 0.00 0.00 78491 TC A 695.26 0.00 0.00<br />

78195 TC A 157.82 0.00 0.00 78492 TC A 695.26 0.00 0.00<br />

78199 TC A 157.82 0.00 0.00 78494 TC A 187.75 0.00 0.00<br />

78201 TC A 140.48 0.00 0.00 78499 TC A 187.75 0.00 0.00<br />

78202 TC A 165.25 0.00 0.00 78580 TC A 127.20 0.00 0.00<br />

78205 TC A 165.25 0.00 0.00 78584 TC A 98.26 0.00 0.00<br />

78206 TC A 165.25 0.00 0.00 78585 TC A 195.18 0.00 0.00<br />

78215 TC A 148.64 0.00 0.00 78586 TC A 127.20 0.00 0.00<br />

78216 TC A 100.75 0.00 0.00 78587 TC A 127.20 0.00 0.00<br />

78220 TC A 109.98 0.00 0.00 78588 TC A 195.18 0.00 0.00<br />

78223 TC A 165.25 0.00 0.00 78591 TC A 127.20 0.00 0.00<br />

78230 TC A 124.87 0.00 0.00 78593 TC A 127.20 0.00 0.00<br />

78231 TC A 98.26 0.00 0.00 78594 TC A 127.20 0.00 0.00<br />

78232 TC A 102.52 0.00 0.00 78596 TC A 195.18 0.00 0.00<br />

78258 TC A 146.11 0.00 0.00 78599 TC A 127.20 0.00 0.00<br />

78261 TC A 146.11 0.00 0.00 78600 TC A 112.10 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 34940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 112.10 0.00 0.00<br />

78605 TC A 112.10 0.00 0.00<br />

78606 TC A 251.87 0.00 0.00<br />

78607 TC A 276.71 0.00 0.00<br />

78608 TC A 623.17 0.00 0.00<br />

78610 TC A 149.35 0.00 0.00<br />

78630 TC A 266.06 0.00 0.00<br />

78635 TC A 245.13 0.00 0.00<br />

78645 TC A 112.10 0.00 0.00<br />

78647 TC A 271.39 0.00 0.00<br />

78650 TC A 262.87 0.00 0.00<br />

78660 TC A 112.10 0.00 0.00<br />

78699 TC A 112.10 0.00 0.00<br />

78700 TC A 138.00 0.00 0.00<br />

78701 TC A 168.16 0.00 0.00<br />

78707 TC A 175.60 0.00 0.00<br />

78708 TC A 120.26 0.00 0.00<br />

78709 TC A 197.72 0.00 0.00<br />

78710 TC A 185.54 0.00 0.00<br />

78725 TC A 74.14 0.00 0.00<br />

78730 TC A 62.79 0.00 0.00<br />

78740 TC A 163.90 0.00 0.00<br />

78761 TC A 156.44 0.00 0.00<br />

78799 TC A 197.72 0.00 0.00<br />

78800 TC A 138.35 0.00 0.00<br />

78801 TC A 189.80 0.00 0.00<br />

78802 TC A 257.19 0.00 0.00<br />

78803 TC A 275.64 0.00 0.00<br />

78804 TC A 481.04 0.00 0.00<br />

78805 TC A 135.16 0.00 0.00<br />

78806 TC A 270.32 0.00 0.00<br />

78807 TC A 276.00 0.00 0.00<br />

78811 TC A 623.17 0.00 0.00<br />

78812 TC A 623.17 0.00 0.00<br />

78813 TC A 623.17 0.00 0.00<br />

78814 TC A 623.17 0.00 0.00<br />

78815 TC A 623.17 0.00 0.00<br />

78816 TC A 623.17 0.00 0.00<br />

78999 TC A 70.58 0.00 0.00<br />

79005 TC A 56.76 0.00 0.00<br />

79101 TC A 62.08 0.00 0.00<br />

79200 TC A 67.05 0.00 0.00<br />

79300 TC A 129.36 0.00 0.00<br />

79403 TC A 96.14 0.00 0.00<br />

79440 TC A 54.28 0.00 0.00<br />

79445 TC A 129.36 0.00 0.00<br />

79999 TC A 129.36 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,150.90 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,459.00 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.34 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,507.58 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,507.58 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 217.72 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 217.72 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 109.93 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 232.34 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 69.85 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 625.43 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,426.19 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,116.36 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,116.36 0.00 0.00<br />

C8900 A 241.72 0.00 0.00 0123T S 892.75 0.00 0.00<br />

C8901 A 196.84 0.00 0.00 0124T S 174.49 0.00 0.00<br />

C8902 A 304.65 0.00 0.00 0144T TC A 59.39 0.00 0.00<br />

C8903 A 241.72 0.00 0.00 0145T TC A 159.87 0.00 0.00<br />

C8904 A 196.84 0.00 0.00 0146T TC A 159.87 0.00 0.00<br />

C8905 A 304.65 0.00 0.00 0147T TC A 159.87 0.00 0.00<br />

C8906 A 241.72 0.00 0.00 0148T TC A 159.87 0.00 0.00<br />

C8907 A 196.84 0.00 0.00 0149T TC A 159.87 0.00 0.00<br />

C8908 A 304.65 0.00 0.00 0150T TC A 159.87 0.00 0.00<br />

C8909 A 241.72 0.00 0.00 0151T TC A 59.39 0.00 0.00<br />

C8910 A 196.84 0.00 0.00 0170T S 1,159.63 0.00 0.00<br />

C8911 A 304.65 0.00 0.00 0176T S 1,369.26 0.00 0.00<br />

C8912 A 241.72 0.00 0.00 0177T S 1,369.26 0.00 0.00<br />

C8913 A 196.84 0.00 0.00 0182T A 989.71 0.00 0.00<br />

C8914 A 304.65 0.00 0.00 0186T S 834.12 0.00 0.00<br />

C8918 A 241.72 0.00 0.00 0190T S 834.12 0.00 0.00<br />

C8919 A 196.84 0.00 0.00 0191T S 892.75 0.00 0.00<br />

C8920 A 304.65 0.00 0.00 0192T S 1,530.00 0.00 0.00<br />

C9716 S 1,159.63 0.00 0.00 10021 S 53.51 0.00 0.00<br />

C9724 S 948.13 0.00 0.00 10022 S 167.10 0.00 0.00<br />

C9725 S 218.64 0.00 0.00 10040 S 30.93 0.00 0.00<br />

C9726 S 802.67 0.00 0.00 10060 S 47.07 0.00 0.00<br />

C9727 S 281.43 0.00 0.00 10061 S 52.78 0.00 0.00<br />

C9728 S 504.97 0.00 0.00 10080 S 52.78 0.00 0.00<br />

G0104 S 81.12 0.00 0.00 10081 S 121.51 0.00 0.00<br />

G0105 S 350.60 0.00 0.00 10120 S 66.10 0.00 0.00<br />

G0121 S 350.60 0.00 0.00 10121 S 498.22 0.00 0.00<br />

G0127 S 11.35 0.00 0.00 10140 S 70.10 0.00 0.00<br />

G0130 TC A 18.70 0.00 0.00 10160 S 52.78 0.00 0.00<br />

G0173 A 2,150.90 0.00 0.00 10180 S 563.42 0.00 0.00<br />

G0186 S 217.72 0.00 0.00 11000 S 22.70 0.00 0.00<br />

G0247 S 20.70 0.00 0.00 11001 S 7.68 0.00 0.00<br />

G0251 A 538.62 0.00 0.00 11010 S 197.12 0.00 0.00<br />

G0260 S 284.24 0.00 0.00 11011 S 197.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 197.12 0.00 0.00 11601 S 108.83 0.00 0.00<br />

11040 S 20.70 0.00 0.00 11602 S 119.85 0.00 0.00<br />

11041 S 23.04 0.00 0.00 11603 S 127.19 0.00 0.00<br />

11042 S 125.17 0.00 0.00 11604 S 343.08 0.00 0.00<br />

11043 S 125.17 0.00 0.00 11606 S 498.22 0.00 0.00<br />

11044 S 325.92 0.00 0.00 11620 S 92.81 0.00 0.00<br />

11055 S 24.37 0.00 0.00 11621 S 110.16 0.00 0.00<br />

11056 S 26.70 0.00 0.00 11622 S 122.51 0.00 0.00<br />

11057 S 30.93 0.00 0.00 11623 S 131.86 0.00 0.00<br />

11100 S 56.67 0.00 0.00 11624 S 498.22 0.00 0.00<br />

11101 S 13.36 0.00 0.00 11626 S 609.29 0.00 0.00<br />

11200 S 30.93 0.00 0.00 11640 S 98.15 0.00 0.00<br />

11201 S 5.34 0.00 0.00 11641 S 115.84 0.00 0.00<br />

11300 S 30.93 0.00 0.00 11642 S 129.20 0.00 0.00<br />

11301 S 30.93 0.00 0.00 11643 S 139.21 0.00 0.00<br />

11302 S 30.93 0.00 0.00 11644 S 498.22 0.00 0.00<br />

11303 S 56.67 0.00 0.00 11646 S 609.29 0.00 0.00<br />

11305 S 30.93 0.00 0.00 11719 S 11.35 0.00 0.00<br />

11306 S 30.93 0.00 0.00 11720 S 14.02 0.00 0.00<br />

11307 S 30.93 0.00 0.00 11721 S 17.02 0.00 0.00<br />

11308 S 30.93 0.00 0.00 11730 S 30.93 0.00 0.00<br />

11310 S 30.93 0.00 0.00 11732 S 17.02 0.00 0.00<br />

11311 S 30.93 0.00 0.00 11740 S 15.62 0.00 0.00<br />

11312 S 30.93 0.00 0.00 11750 S 90.13 0.00 0.00<br />

11313 S 30.93 0.00 0.00 11752 S 125.19 0.00 0.00<br />

11400 S 63.76 0.00 0.00 11755 S 62.42 0.00 0.00<br />

11401 S 71.77 0.00 0.00 11760 S 128.57 0.00 0.00<br />

11402 S 78.79 0.00 0.00 11762 S 114.84 0.00 0.00<br />

11403 S 84.13 0.00 0.00 11765 S 30.93 0.00 0.00<br />

11404 S 447.23 0.00 0.00 11770 S 638.17 0.00 0.00<br />

11406 S 498.22 0.00 0.00 11771 S 638.17 0.00 0.00<br />

11420 S 59.76 0.00 0.00 11772 S 638.17 0.00 0.00<br />

11421 S 72.44 0.00 0.00 11900 S 28.38 0.00 0.00<br />

11422 S 79.12 0.00 0.00 11901 S 30.93 0.00 0.00<br />

11423 S 88.14 0.00 0.00 11920 S 89.80 0.00 0.00<br />

11424 S 498.22 0.00 0.00 11921 S 98.82 0.00 0.00<br />

11426 S 609.29 0.00 0.00 11922 S 32.04 0.00 0.00<br />

11440 S 68.44 0.00 0.00 11950 S 32.72 0.00 0.00<br />

11441 S 79.12 0.00 0.00 11951 S 40.73 0.00 0.00<br />

11442 S 87.13 0.00 0.00 11952 S 49.03 0.00 0.00<br />

11443 S 96.48 0.00 0.00 11954 S 49.03 0.00 0.00<br />

11444 S 304.50 0.00 0.00 11960 S 594.77 0.00 0.00<br />

11446 S 609.29 0.00 0.00 11970 S 1,077.33 0.00 0.00<br />

11450 S 609.29 0.00 0.00 11971 S 558.29 0.00 0.00<br />

11451 S 609.29 0.00 0.00 11976 S 59.76 0.00 0.00<br />

11462 S 609.29 0.00 0.00 11980 S 24.14 0.00 0.00<br />

11463 S 609.29 0.00 0.00 11981 S 24.14 0.00 0.00<br />

11470 S 609.29 0.00 0.00 11982 S 24.14 0.00 0.00<br />

11471 S 609.29 0.00 0.00 11983 S 24.14 0.00 0.00<br />

11600 S 89.80 0.00 0.00 12001 S 49.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 49.03 0.00 0.00 14021 S 528.55 0.00 0.00<br />

12004 S 49.03 0.00 0.00 14040 S 499.68 0.00 0.00<br />

12005 S 65.69 0.00 0.00 14041 S 528.55 0.00 0.00<br />

12006 S 65.69 0.00 0.00 14060 S 528.55 0.00 0.00<br />

12007 S 65.69 0.00 0.00 14061 S 528.55 0.00 0.00<br />

12011 S 49.03 0.00 0.00 14300 S 677.81 0.00 0.00<br />

12013 S 49.03 0.00 0.00 14350 S 623.65 0.00 0.00<br />

12014 S 49.03 0.00 0.00 15002 S 228.65 0.00 0.00<br />

12015 S 49.03 0.00 0.00 15003 S 228.65 0.00 0.00<br />

12016 S 65.69 0.00 0.00 15004 S 228.65 0.00 0.00<br />

12017 S 65.69 0.00 0.00 15005 S 228.65 0.00 0.00<br />

12018 S 65.69 0.00 0.00 15040 S 105.45 0.00 0.00<br />

12020 S 123.94 0.00 0.00 15050 S 228.65 0.00 0.00<br />

12021 S 105.45 0.00 0.00 15100 S 594.77 0.00 0.00<br />

12031 S 49.03 0.00 0.00 15101 S 623.65 0.00 0.00<br />

12032 S 128.57 0.00 0.00 15110 S 284.03 0.00 0.00<br />

12034 S 65.69 0.00 0.00 15111 S 233.04 0.00 0.00<br />

12035 S 65.69 0.00 0.00 15115 S 284.03 0.00 0.00<br />

12036 S 105.45 0.00 0.00 15116 S 233.04 0.00 0.00<br />

12037 S 210.18 0.00 0.00 15120 S 594.77 0.00 0.00<br />

12041 S 49.03 0.00 0.00 15121 S 623.65 0.00 0.00<br />

12042 S 49.03 0.00 0.00 15130 S 499.68 0.00 0.00<br />

12044 S 65.69 0.00 0.00 15131 S 448.68 0.00 0.00<br />

12045 S 105.45 0.00 0.00 15135 S 499.68 0.00 0.00<br />

12046 S 105.45 0.00 0.00 15136 S 448.68 0.00 0.00<br />

12047 S 210.18 0.00 0.00 15150 S 284.03 0.00 0.00<br />

12051 S 49.03 0.00 0.00 15151 S 233.04 0.00 0.00<br />

12052 S 49.03 0.00 0.00 15152 S 233.04 0.00 0.00<br />

12053 S 49.03 0.00 0.00 15155 S 284.03 0.00 0.00<br />

12054 S 65.69 0.00 0.00 15156 S 233.04 0.00 0.00<br />

12055 S 105.45 0.00 0.00 15157 S 233.04 0.00 0.00<br />

12056 S 105.45 0.00 0.00 15170 S 128.57 0.00 0.00<br />

12057 S 210.18 0.00 0.00 15171 S 128.57 0.00 0.00<br />

13100 S 228.65 0.00 0.00 15175 S 165.53 0.00 0.00<br />

13101 S 228.65 0.00 0.00 15176 S 165.53 0.00 0.00<br />

13102 S 123.94 0.00 0.00 15200 S 528.55 0.00 0.00<br />

13120 S 105.45 0.00 0.00 15201 S 444.30 0.00 0.00<br />

13121 S 105.45 0.00 0.00 15220 S 499.68 0.00 0.00<br />

13122 S 105.45 0.00 0.00 15221 S 228.65 0.00 0.00<br />

13131 S 105.45 0.00 0.00 15240 S 528.55 0.00 0.00<br />

13132 S 105.45 0.00 0.00 15241 S 228.65 0.00 0.00<br />

13133 S 105.45 0.00 0.00 15260 S 499.68 0.00 0.00<br />

13150 S 228.65 0.00 0.00 15261 S 444.30 0.00 0.00<br />

13151 S 228.65 0.00 0.00 15300 S 228.65 0.00 0.00<br />

13152 S 228.65 0.00 0.00 15301 S 228.65 0.00 0.00<br />

13153 S 105.45 0.00 0.00 15320 S 228.65 0.00 0.00<br />

13160 S 594.77 0.00 0.00 15321 S 228.65 0.00 0.00<br />

14000 S 499.68 0.00 0.00 15330 S 228.65 0.00 0.00<br />

14001 S 528.55 0.00 0.00 15331 S 228.65 0.00 0.00<br />

14020 S 528.55 0.00 0.00 15335 S 228.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 228.65 0.00 0.00 15826 S 623.65 0.00 0.00<br />

15340 S 128.57 0.00 0.00 15828 S 623.65 0.00 0.00<br />

15341 S 128.57 0.00 0.00 15829 S 717.06 0.00 0.00<br />

15360 S 128.57 0.00 0.00 15830 S 638.17 0.00 0.00<br />

15361 S 128.57 0.00 0.00 15832 S 638.17 0.00 0.00<br />

15365 S 128.57 0.00 0.00 15833 S 638.17 0.00 0.00<br />

15366 S 128.57 0.00 0.00 15834 S 638.17 0.00 0.00<br />

15400 S 228.65 0.00 0.00 15835 S 553.91 0.00 0.00<br />

15401 S 228.65 0.00 0.00 15836 S 527.11 0.00 0.00<br />

15420 S 228.65 0.00 0.00 15837 S 593.92 0.00 0.00<br />

15421 S 228.65 0.00 0.00 15838 S 593.92 0.00 0.00<br />

15430 S 228.65 0.00 0.00 15839 S 527.11 0.00 0.00<br />

15431 S 228.65 0.00 0.00 15840 S 677.81 0.00 0.00<br />

15570 S 623.65 0.00 0.00 15841 S 677.81 0.00 0.00<br />

15572 S 623.65 0.00 0.00 15842 S 787.00 0.00 0.00<br />

15574 S 623.65 0.00 0.00 15845 S 677.81 0.00 0.00<br />

15576 S 623.65 0.00 0.00 15847 S 638.17 0.00 0.00<br />

15600 S 623.65 0.00 0.00 15850 S 101.95 0.00 0.00<br />

15610 S 623.65 0.00 0.00 15851 S 46.40 0.00 0.00<br />

15620 S 677.81 0.00 0.00 15852 S 24.14 0.00 0.00<br />

15630 S 623.65 0.00 0.00 15860 S 24.14 0.00 0.00<br />

15650 S 717.06 0.00 0.00 15876 S 623.65 0.00 0.00<br />

15731 S 623.65 0.00 0.00 15877 S 623.65 0.00 0.00<br />

15732 S 623.65 0.00 0.00 15878 S 623.65 0.00 0.00<br />

15734 S 623.65 0.00 0.00 15879 S 623.65 0.00 0.00<br />

15736 S 623.65 0.00 0.00 15920 S 197.12 0.00 0.00<br />

15738 S 623.65 0.00 0.00 15922 S 677.81 0.00 0.00<br />

15740 S 499.68 0.00 0.00 15931 S 638.17 0.00 0.00<br />

15750 S 594.77 0.00 0.00 15933 S 638.17 0.00 0.00<br />

15760 S 594.77 0.00 0.00 15934 S 623.65 0.00 0.00<br />

15770 S 623.65 0.00 0.00 15935 S 677.81 0.00 0.00<br />

15775 S 170.40 0.00 0.00 15936 S 582.71 0.00 0.00<br />

15776 S 170.40 0.00 0.00 15937 S 677.81 0.00 0.00<br />

15780 S 379.90 0.00 0.00 15940 S 638.17 0.00 0.00<br />

15781 S 167.22 0.00 0.00 15941 S 638.17 0.00 0.00<br />

15782 S 167.22 0.00 0.00 15944 S 623.65 0.00 0.00<br />

15783 S 101.95 0.00 0.00 15945 S 677.81 0.00 0.00<br />

15786 S 30.93 0.00 0.00 15946 S 677.81 0.00 0.00<br />

15787 S 28.05 0.00 0.00 15950 S 638.17 0.00 0.00<br />

15788 S 30.93 0.00 0.00 15951 S 692.32 0.00 0.00<br />

15789 S 56.67 0.00 0.00 15952 S 528.55 0.00 0.00<br />

15792 S 56.67 0.00 0.00 15953 S 582.71 0.00 0.00<br />

15793 S 30.93 0.00 0.00 15956 S 528.55 0.00 0.00<br />

15819 S 128.57 0.00 0.00 15958 S 582.71 0.00 0.00<br />

15820 S 623.65 0.00 0.00 16000 S 25.04 0.00 0.00<br />

15821 S 623.65 0.00 0.00 16020 S 38.06 0.00 0.00<br />

15822 S 623.65 0.00 0.00 16025 S 58.62 0.00 0.00<br />

15823 S 717.06 0.00 0.00 16030 S 73.39 0.00 0.00<br />

15824 S 623.65 0.00 0.00 16035 S 56.67 0.00 0.00<br />

15825 S 623.65 0.00 0.00 17000 S 30.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.67 0.00 0.00 19300 S 685.64 0.00 0.00<br />

17004 S 80.79 0.00 0.00 19301 S 631.49 0.00 0.00<br />

17106 S 101.95 0.00 0.00 19302 S 1,206.08 0.00 0.00<br />

17107 S 101.95 0.00 0.00 19303 S 911.47 0.00 0.00<br />

17108 S 101.95 0.00 0.00 19304 S 911.47 0.00 0.00<br />

17110 S 30.93 0.00 0.00 19316 S 911.47 0.00 0.00<br />

17111 S 56.67 0.00 0.00 19318 S 1,041.36 0.00 0.00<br />

17250 S 42.73 0.00 0.00 19324 S 1,041.36 0.00 0.00<br />

17260 S 45.73 0.00 0.00 19325 S 1,727.22 0.00 0.00<br />

17261 S 56.67 0.00 0.00 19328 S 777.44 0.00 0.00<br />

17262 S 56.67 0.00 0.00 19330 S 777.44 0.00 0.00<br />

17263 S 56.67 0.00 0.00 19340 S 958.32 0.00 0.00<br />

17264 S 56.67 0.00 0.00 19342 S 1,353.11 0.00 0.00<br />

17266 S 101.95 0.00 0.00 19350 S 685.64 0.00 0.00<br />

17270 S 56.67 0.00 0.00 19355 S 911.47 0.00 0.00<br />

17271 S 56.67 0.00 0.00 19357 S 1,446.52 0.00 0.00<br />

17272 S 56.67 0.00 0.00 19366 S 950.73 0.00 0.00<br />

17273 S 101.95 0.00 0.00 19370 S 911.47 0.00 0.00<br />

17274 S 101.95 0.00 0.00 19371 S 911.47 0.00 0.00<br />

17276 S 101.95 0.00 0.00 19380 S 1,080.62 0.00 0.00<br />

17280 S 56.67 0.00 0.00 19396 S 1,254.32 0.00 0.00<br />

17281 S 84.46 0.00 0.00 20000 S 52.78 0.00 0.00<br />

17282 S 96.48 0.00 0.00 20005 S 608.13 0.00 0.00<br />

17283 S 101.95 0.00 0.00 20103 S 596.82 0.00 0.00<br />

17284 S 101.95 0.00 0.00 20150 S 1,694.38 0.00 0.00<br />

17286 S 101.95 0.00 0.00 20200 S 498.22 0.00 0.00<br />

17311 S 168.29 0.00 0.00 20205 S 527.11 0.00 0.00<br />

17312 S 168.29 0.00 0.00 20206 S 246.31 0.00 0.00<br />

17313 S 168.29 0.00 0.00 20220 S 267.74 0.00 0.00<br />

17314 S 168.29 0.00 0.00 20225 S 485.81 0.00 0.00<br />

17315 S 38.06 0.00 0.00 20240 S 609.29 0.00 0.00<br />

17340 S 13.69 0.00 0.00 20245 S 638.17 0.00 0.00<br />

17360 S 30.93 0.00 0.00 20250 S 637.02 0.00 0.00<br />

17380 S 30.93 0.00 0.00 20251 S 637.02 0.00 0.00<br />

19000 S 64.43 0.00 0.00 20500 S 52.75 0.00 0.00<br />

19001 S 8.68 0.00 0.00 20520 S 88.80 0.00 0.00<br />

19020 S 563.42 0.00 0.00 20525 S 638.17 0.00 0.00<br />

19100 S 191.86 0.00 0.00 20526 S 28.71 0.00 0.00<br />

19101 S 602.60 0.00 0.00 20550 S 21.70 0.00 0.00<br />

19102 S 246.31 0.00 0.00 20551 S 21.36 0.00 0.00<br />

19103 S 431.11 0.00 0.00 20552 S 20.70 0.00 0.00<br />

19105 S 1,254.32 0.00 0.00 20553 S 23.04 0.00 0.00<br />

19110 S 602.60 0.00 0.00 20555 S 1,116.36 0.00 0.00<br />

19112 S 631.49 0.00 0.00 20600 S 22.03 0.00 0.00<br />

19120 S 631.49 0.00 0.00 20605 S 24.70 0.00 0.00<br />

19125 S 631.49 0.00 0.00 20610 S 34.72 0.00 0.00<br />

19126 S 631.49 0.00 0.00 20612 S 23.37 0.00 0.00<br />

19296 S 1,727.22 0.00 0.00 20615 S 97.82 0.00 0.00<br />

19297 S 1,727.22 0.00 0.00 20650 S 637.02 0.00 0.00<br />

19298 S 1,727.22 0.00 0.00 20662 S 813.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 813.72 0.00 0.00 21085 S 245.03 0.00 0.00<br />

20665 S 24.14 0.00 0.00 21086 S 533.46 0.00 0.00<br />

20670 S 447.23 0.00 0.00 21087 S 534.14 0.00 0.00<br />

20680 S 638.17 0.00 0.00 21088 S 1,564.38 0.00 0.00<br />

20690 S 759.45 0.00 0.00 21100 S 983.46 0.00 0.00<br />

20692 S 788.33 0.00 0.00 21110 S 281.43 0.00 0.00<br />

20693 S 637.02 0.00 0.00 21120 S 911.45 0.00 0.00<br />

20694 S 557.14 0.00 0.00 21121 S 911.45 0.00 0.00<br />

20696 S 1,116.36 0.00 0.00 21122 S 911.45 0.00 0.00<br />

20697 S 742.42 0.00 0.00 21123 S 911.45 0.00 0.00<br />

20822 S 1,046.04 0.00 0.00 21125 S 911.45 0.00 0.00<br />

20900 S 788.33 0.00 0.00 21127 S 1,386.45 0.00 0.00<br />

20902 S 842.48 0.00 0.00 21137 S 924.86 0.00 0.00<br />

20910 S 623.65 0.00 0.00 21138 S 1,564.38 0.00 0.00<br />

20912 S 623.65 0.00 0.00 21139 S 1,564.38 0.00 0.00<br />

20920 S 582.71 0.00 0.00 21150 S 1,564.38 0.00 0.00<br />

20922 S 528.55 0.00 0.00 21181 S 911.45 0.00 0.00<br />

20924 S 842.48 0.00 0.00 21198 S 1,564.38 0.00 0.00<br />

20926 S 367.07 0.00 0.00 21199 S 1,564.38 0.00 0.00<br />

20950 S 52.78 0.00 0.00 21206 S 1,105.76 0.00 0.00<br />

20972 S 1,766.79 0.00 0.00 21208 S 1,231.21 0.00 0.00<br />

20973 S 1,766.79 0.00 0.00 21209 S 1,105.76 0.00 0.00<br />

20979 S 21.70 0.00 0.00 21210 S 1,231.21 0.00 0.00<br />

20982 S 1,694.38 0.00 0.00 21215 S 1,231.21 0.00 0.00<br />

21010 S 663.69 0.00 0.00 21230 S 1,231.21 0.00 0.00<br />

21015 S 552.19 0.00 0.00 21235 S 911.45 0.00 0.00<br />

21025 S 983.46 0.00 0.00 21240 S 1,066.49 0.00 0.00<br />

21026 S 983.46 0.00 0.00 21242 S 1,105.76 0.00 0.00<br />

21029 S 983.46 0.00 0.00 21243 S 1,105.76 0.00 0.00<br />

21030 S 232.01 0.00 0.00 21244 S 1,231.21 0.00 0.00<br />

21031 S 191.95 0.00 0.00 21245 S 1,231.21 0.00 0.00<br />

21032 S 195.63 0.00 0.00 21246 S 1,231.21 0.00 0.00<br />

21034 S 1,012.35 0.00 0.00 21248 S 1,231.21 0.00 0.00<br />

21040 S 663.69 0.00 0.00 21249 S 1,231.21 0.00 0.00<br />

21044 S 983.46 0.00 0.00 21260 S 1,564.38 0.00 0.00<br />

21046 S 983.46 0.00 0.00 21267 S 1,231.21 0.00 0.00<br />

21047 S 983.46 0.00 0.00 21270 S 1,105.76 0.00 0.00<br />

21048 S 1,564.38 0.00 0.00 21275 S 1,231.21 0.00 0.00<br />

21050 S 1,012.35 0.00 0.00 21280 S 1,105.76 0.00 0.00<br />

21060 S 983.46 0.00 0.00 21282 S 645.61 0.00 0.00<br />

21070 S 1,012.35 0.00 0.00 21295 S 290.99 0.00 0.00<br />

21073 S 180.27 0.00 0.00 21296 S 612.70 0.00 0.00<br />

21076 S 312.80 0.00 0.00 21310 S 88.77 0.00 0.00<br />

21077 S 756.13 0.00 0.00 21315 S 390.06 0.00 0.00<br />

21079 S 541.48 0.00 0.00 21320 S 523.31 0.00 0.00<br />

21080 S 620.93 0.00 0.00 21325 S 746.73 0.00 0.00<br />

21081 S 572.19 0.00 0.00 21330 S 785.99 0.00 0.00<br />

21082 S 544.48 0.00 0.00 21335 S 911.45 0.00 0.00<br />

21083 S 536.47 0.00 0.00 21336 S 759.59 0.00 0.00<br />

21084 S 617.25 0.00 0.00 21337 S 523.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 746.73 0.00 0.00 22310 S 161.60 0.00 0.00<br />

21339 S 785.99 0.00 0.00 22315 S 417.97 0.00 0.00<br />

21340 S 1,066.49 0.00 0.00 22505 S 492.06 0.00 0.00<br />

21345 S 911.45 0.00 0.00 22520 S 1,162.43 0.00 0.00<br />

21355 S 1,012.35 0.00 0.00 22521 S 1,162.43 0.00 0.00<br />

21356 S 692.58 0.00 0.00 22522 S 1,162.43 0.00 0.00<br />

21360 S 924.86 0.00 0.00 22523 S 3,235.17 0.00 0.00<br />

21390 S 1,564.38 0.00 0.00 22524 S 3,235.17 0.00 0.00<br />

21400 S 341.98 0.00 0.00 22525 S 3,235.17 0.00 0.00<br />

21401 S 552.19 0.00 0.00 22900 S 692.32 0.00 0.00<br />

21406 S 1,564.38 0.00 0.00 23000 S 498.22 0.00 0.00<br />

21407 S 1,564.38 0.00 0.00 23020 S 1,048.45 0.00 0.00<br />

21421 S 746.73 0.00 0.00 23030 S 512.42 0.00 0.00<br />

21440 S 314.47 0.00 0.00 23031 S 592.30 0.00 0.00<br />

21445 S 746.73 0.00 0.00 23035 S 637.02 0.00 0.00<br />

21450 S 129.79 0.00 0.00 23040 S 788.33 0.00 0.00<br />

21451 S 350.17 0.00 0.00 23044 S 842.48 0.00 0.00<br />

21452 S 523.31 0.00 0.00 23065 S 94.14 0.00 0.00<br />

21453 S 1,012.35 0.00 0.00 23066 S 609.29 0.00 0.00<br />

21454 S 785.99 0.00 0.00 23075 S 498.22 0.00 0.00<br />

21461 S 1,066.49 0.00 0.00 23076 S 609.29 0.00 0.00<br />

21462 S 1,105.76 0.00 0.00 23077 S 638.17 0.00 0.00<br />

21465 S 1,066.49 0.00 0.00 23100 S 608.13 0.00 0.00<br />

21480 S 88.77 0.00 0.00 23101 S 1,007.20 0.00 0.00<br />

21485 S 523.31 0.00 0.00 23105 S 842.48 0.00 0.00<br />

21490 S 1,012.35 0.00 0.00 23106 S 842.48 0.00 0.00<br />

21495 S 644.08 0.00 0.00 23107 S 842.48 0.00 0.00<br />

21497 S 523.31 0.00 0.00 23120 S 881.75 0.00 0.00<br />

21501 S 563.42 0.00 0.00 23125 S 881.75 0.00 0.00<br />

21502 S 608.13 0.00 0.00 23130 S 1,170.75 0.00 0.00<br />

21550 S 593.92 0.00 0.00 23140 S 691.16 0.00 0.00<br />

21555 S 609.29 0.00 0.00 23145 S 881.75 0.00 0.00<br />

21556 S 609.29 0.00 0.00 23146 S 881.75 0.00 0.00<br />

21557 S 816.04 0.00 0.00 23150 S 842.48 0.00 0.00<br />

21600 S 759.45 0.00 0.00 23155 S 881.75 0.00 0.00<br />

21610 S 759.45 0.00 0.00 23156 S 881.75 0.00 0.00<br />

21685 S 281.43 0.00 0.00 23170 S 759.45 0.00 0.00<br />

21700 S 608.13 0.00 0.00 23172 S 759.45 0.00 0.00<br />

21720 S 637.02 0.00 0.00 23174 S 759.45 0.00 0.00<br />

21725 S 66.31 0.00 0.00 23180 S 842.48 0.00 0.00<br />

21800 S 76.60 0.00 0.00 23182 S 842.48 0.00 0.00<br />

21805 S 676.56 0.00 0.00 23184 S 842.48 0.00 0.00<br />

21820 S 76.60 0.00 0.00 23190 S 842.48 0.00 0.00<br />

21920 S 136.20 0.00 0.00 23195 S 881.75 0.00 0.00<br />

21925 S 609.29 0.00 0.00 23330 S 304.50 0.00 0.00<br />

21930 S 609.29 0.00 0.00 23331 S 558.29 0.00 0.00<br />

21935 S 638.17 0.00 0.00 23395 S 1,170.75 0.00 0.00<br />

22102 S 1,815.93 0.00 0.00 23397 S 2,066.61 0.00 0.00<br />

22103 S 1,815.93 0.00 0.00 23400 S 1,007.20 0.00 0.00<br />

22305 S 76.60 0.00 0.00 23405 S 759.45 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 759.45 0.00 0.00 23931 S 563.42 0.00 0.00<br />

23410 S 1,170.75 0.00 0.00 23935 S 608.13 0.00 0.00<br />

23412 S 1,296.20 0.00 0.00 24000 S 842.48 0.00 0.00<br />

23415 S 1,170.75 0.00 0.00 24006 S 842.48 0.00 0.00<br />

23420 S 1,296.20 0.00 0.00 24065 S 130.53 0.00 0.00<br />

23430 S 1,131.49 0.00 0.00 24066 S 498.22 0.00 0.00<br />

23440 S 1,131.49 0.00 0.00 24075 S 498.22 0.00 0.00<br />

23450 S 1,941.15 0.00 0.00 24076 S 609.29 0.00 0.00<br />

23455 S 2,066.61 0.00 0.00 24077 S 638.17 0.00 0.00<br />

23460 S 1,941.15 0.00 0.00 24100 S 557.14 0.00 0.00<br />

23462 S 1,296.20 0.00 0.00 24101 S 842.48 0.00 0.00<br />

23465 S 1,941.15 0.00 0.00 24102 S 842.48 0.00 0.00<br />

23466 S 1,296.20 0.00 0.00 24105 S 637.02 0.00 0.00<br />

23480 S 1,131.49 0.00 0.00 24110 S 608.13 0.00 0.00<br />

23485 S 2,066.61 0.00 0.00 24115 S 788.33 0.00 0.00<br />

23490 S 1,077.33 0.00 0.00 24116 S 788.33 0.00 0.00<br />

23491 S 1,847.74 0.00 0.00 24120 S 637.02 0.00 0.00<br />

23500 S 76.60 0.00 0.00 24125 S 788.33 0.00 0.00<br />

23505 S 417.97 0.00 0.00 24126 S 788.33 0.00 0.00<br />

23515 S 1,398.92 0.00 0.00 24130 S 788.33 0.00 0.00<br />

23520 S 161.60 0.00 0.00 24134 S 759.45 0.00 0.00<br />

23525 S 161.60 0.00 0.00 24136 S 759.45 0.00 0.00<br />

23530 S 1,030.87 0.00 0.00 24138 S 759.45 0.00 0.00<br />

23532 S 759.59 0.00 0.00 24140 S 788.33 0.00 0.00<br />

23540 S 76.60 0.00 0.00 24145 S 788.33 0.00 0.00<br />

23545 S 161.60 0.00 0.00 24147 S 759.45 0.00 0.00<br />

23550 S 1,030.87 0.00 0.00 24149 S 1,116.36 0.00 0.00<br />

23552 S 1,085.03 0.00 0.00 24152 S 1,694.38 0.00 0.00<br />

23570 S 76.60 0.00 0.00 24153 S 3,235.17 0.00 0.00<br />

23575 S 161.60 0.00 0.00 24155 S 1,077.33 0.00 0.00<br />

23585 S 1,398.92 0.00 0.00 24160 S 759.45 0.00 0.00<br />

23600 S 59.69 0.00 0.00 24164 S 788.33 0.00 0.00<br />

23605 S 417.97 0.00 0.00 24200 S 95.48 0.00 0.00<br />

23615 S 1,453.07 0.00 0.00 24201 S 498.22 0.00 0.00<br />

23616 S 1,453.07 0.00 0.00 24300 S 581.58 0.00 0.00<br />

23620 S 59.69 0.00 0.00 24301 S 842.48 0.00 0.00<br />

23625 S 417.97 0.00 0.00 24305 S 842.48 0.00 0.00<br />

23630 S 1,492.34 0.00 0.00 24310 S 637.02 0.00 0.00<br />

23650 S 76.60 0.00 0.00 24320 S 1,077.33 0.00 0.00<br />

23655 S 441.07 0.00 0.00 24330 S 1,847.74 0.00 0.00<br />

23660 S 1,030.87 0.00 0.00 24331 S 1,077.33 0.00 0.00<br />

23665 S 161.60 0.00 0.00 24332 S 813.72 0.00 0.00<br />

23670 S 1,398.92 0.00 0.00 24340 S 1,077.33 0.00 0.00<br />

23675 S 76.60 0.00 0.00 24341 S 1,077.33 0.00 0.00<br />

23680 S 1,030.87 0.00 0.00 24342 S 1,077.33 0.00 0.00<br />

23700 S 441.07 0.00 0.00 24343 S 1,116.36 0.00 0.00<br />

23800 S 1,901.89 0.00 0.00 24344 S 3,235.17 0.00 0.00<br />

23802 S 1,296.20 0.00 0.00 24345 S 759.45 0.00 0.00<br />

23921 S 444.30 0.00 0.00 24346 S 1,694.38 0.00 0.00<br />

23930 S 512.42 0.00 0.00 24357 S 1,116.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,116.36 0.00 0.00 24925 S 637.02 0.00 0.00<br />

24359 S 1,116.36 0.00 0.00 25000 S 637.02 0.00 0.00<br />

24360 S 1,030.24 0.00 0.00 25001 S 813.72 0.00 0.00<br />

24361 S 5,632.85 3,448.02 1,263.18 25020 S 637.02 0.00 0.00<br />

24362 S 1,316.64 0.00 0.00 25023 S 788.33 0.00 0.00<br />

24363 S 5,758.31 3,573.47 1,388.64 25024 S 788.33 0.00 0.00<br />

24365 S 1,030.24 0.00 0.00 25025 S 788.33 0.00 0.00<br />

24366 S 5,632.85 3,448.02 1,263.18 25028 S 557.14 0.00 0.00<br />

24400 S 842.48 0.00 0.00 25031 S 608.13 0.00 0.00<br />

24410 S 842.48 0.00 0.00 25035 S 608.13 0.00 0.00<br />

24420 S 1,077.33 0.00 0.00 25040 S 881.75 0.00 0.00<br />

24430 S 1,847.74 0.00 0.00 25065 S 132.53 0.00 0.00<br />

24435 S 1,901.89 0.00 0.00 25066 S 609.29 0.00 0.00<br />

24470 S 1,077.33 0.00 0.00 25075 S 498.22 0.00 0.00<br />

24495 S 759.45 0.00 0.00 25076 S 638.17 0.00 0.00<br />

24498 S 1,847.74 0.00 0.00 25077 S 638.17 0.00 0.00<br />

24500 S 76.60 0.00 0.00 25085 S 637.02 0.00 0.00<br />

24505 S 76.60 0.00 0.00 25100 S 608.13 0.00 0.00<br />

24515 S 1,453.07 0.00 0.00 25101 S 788.33 0.00 0.00<br />

24516 S 1,453.07 0.00 0.00 25105 S 842.48 0.00 0.00<br />

24530 S 76.60 0.00 0.00 25107 S 788.33 0.00 0.00<br />

24535 S 161.60 0.00 0.00 25109 S 813.72 0.00 0.00<br />

24538 S 676.56 0.00 0.00 25110 S 637.02 0.00 0.00<br />

24545 S 1,453.07 0.00 0.00 25111 S 637.02 0.00 0.00<br />

24546 S 1,492.34 0.00 0.00 25112 S 691.16 0.00 0.00<br />

24560 S 76.60 0.00 0.00 25115 S 691.16 0.00 0.00<br />

24565 S 76.60 0.00 0.00 25116 S 691.16 0.00 0.00<br />

24566 S 676.56 0.00 0.00 25118 S 759.45 0.00 0.00<br />

24575 S 1,398.92 0.00 0.00 25119 S 788.33 0.00 0.00<br />

24576 S 76.60 0.00 0.00 25120 S 788.33 0.00 0.00<br />

24577 S 161.60 0.00 0.00 25125 S 788.33 0.00 0.00<br />

24579 S 1,398.92 0.00 0.00 25126 S 788.33 0.00 0.00<br />

24582 S 676.56 0.00 0.00 25130 S 788.33 0.00 0.00<br />

24586 S 1,453.07 0.00 0.00 25135 S 788.33 0.00 0.00<br />

24587 S 1,492.34 0.00 0.00 25136 S 788.33 0.00 0.00<br />

24600 S 76.60 0.00 0.00 25145 S 759.45 0.00 0.00<br />

24605 S 492.06 0.00 0.00 25150 S 759.45 0.00 0.00<br />

24615 S 1,398.92 0.00 0.00 25151 S 759.45 0.00 0.00<br />

24620 S 417.97 0.00 0.00 25210 S 788.33 0.00 0.00<br />

24635 S 1,398.92 0.00 0.00 25215 S 842.48 0.00 0.00<br />

24640 S 51.74 0.00 0.00 25230 S 842.48 0.00 0.00<br />

24650 S 59.69 0.00 0.00 25240 S 842.48 0.00 0.00<br />

24655 S 161.60 0.00 0.00 25248 S 608.13 0.00 0.00<br />

24665 S 1,085.03 0.00 0.00 25250 S 708.45 0.00 0.00<br />

24666 S 1,453.07 0.00 0.00 25251 S 708.45 0.00 0.00<br />

24670 S 76.60 0.00 0.00 25259 S 742.42 0.00 0.00<br />

24675 S 76.60 0.00 0.00 25260 S 842.48 0.00 0.00<br />

24685 S 1,030.87 0.00 0.00 25263 S 759.45 0.00 0.00<br />

24800 S 1,131.49 0.00 0.00 25265 S 788.33 0.00 0.00<br />

24802 S 1,170.75 0.00 0.00 25270 S 842.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 788.33 0.00 0.00 25505 S 161.60 0.00 0.00<br />

25274 S 842.48 0.00 0.00 25515 S 1,030.87 0.00 0.00<br />

25275 S 842.48 0.00 0.00 25520 S 161.60 0.00 0.00<br />

25280 S 842.48 0.00 0.00 25525 S 1,085.03 0.00 0.00<br />

25290 S 788.33 0.00 0.00 25526 S 1,124.28 0.00 0.00<br />

25295 S 637.02 0.00 0.00 25530 S 59.69 0.00 0.00<br />

25300 S 788.33 0.00 0.00 25535 S 76.60 0.00 0.00<br />

25301 S 788.33 0.00 0.00 25545 S 1,030.87 0.00 0.00<br />

25310 S 1,077.33 0.00 0.00 25560 S 59.69 0.00 0.00<br />

25312 S 1,131.49 0.00 0.00 25565 S 161.60 0.00 0.00<br />

25315 S 1,077.33 0.00 0.00 25574 S 1,398.92 0.00 0.00<br />

25316 S 1,847.74 0.00 0.00 25575 S 1,398.92 0.00 0.00<br />

25320 S 1,077.33 0.00 0.00 25600 S 59.69 0.00 0.00<br />

25332 S 1,030.24 0.00 0.00 25605 S 161.60 0.00 0.00<br />

25335 S 1,077.33 0.00 0.00 25606 S 705.45 0.00 0.00<br />

25337 S 1,170.75 0.00 0.00 25607 S 1,492.34 0.00 0.00<br />

25350 S 1,847.74 0.00 0.00 25608 S 1,492.34 0.00 0.00<br />

25355 S 1,077.33 0.00 0.00 25609 S 1,492.34 0.00 0.00<br />

25360 S 788.33 0.00 0.00 25622 S 59.69 0.00 0.00<br />

25365 S 788.33 0.00 0.00 25624 S 161.60 0.00 0.00<br />

25370 S 1,077.33 0.00 0.00 25628 S 1,030.87 0.00 0.00<br />

25375 S 1,131.49 0.00 0.00 25630 S 59.69 0.00 0.00<br />

25390 S 788.33 0.00 0.00 25635 S 161.60 0.00 0.00<br />

25391 S 1,131.49 0.00 0.00 25645 S 1,030.87 0.00 0.00<br />

25392 S 788.33 0.00 0.00 25650 S 59.69 0.00 0.00<br />

25393 S 1,131.49 0.00 0.00 25651 S 950.58 0.00 0.00<br />

25394 S 1,694.38 0.00 0.00 25652 S 1,601.43 0.00 0.00<br />

25400 S 1,077.33 0.00 0.00 25660 S 76.60 0.00 0.00<br />

25405 S 1,901.89 0.00 0.00 25670 S 705.45 0.00 0.00<br />

25415 S 1,847.74 0.00 0.00 25671 S 625.57 0.00 0.00<br />

25420 S 1,901.89 0.00 0.00 25675 S 76.60 0.00 0.00<br />

25425 S 1,077.33 0.00 0.00 25676 S 676.56 0.00 0.00<br />

25426 S 1,131.49 0.00 0.00 25680 S 76.60 0.00 0.00<br />

25430 S 1,694.38 0.00 0.00 25685 S 705.45 0.00 0.00<br />

25431 S 1,694.38 0.00 0.00 25690 S 417.97 0.00 0.00<br />

25440 S 1,901.89 0.00 0.00 25695 S 676.56 0.00 0.00<br />

25441 S 5,632.85 3,448.02 1,263.18 25800 S 1,901.89 0.00 0.00<br />

25442 S 5,632.85 3,448.02 1,263.18 25805 S 1,170.75 0.00 0.00<br />

25443 S 1,316.64 0.00 0.00 25810 S 1,941.15 0.00 0.00<br />

25444 S 1,316.64 0.00 0.00 25820 S 1,131.49 0.00 0.00<br />

25445 S 1,316.64 0.00 0.00 25825 S 1,941.15 0.00 0.00<br />

25446 S 5,758.31 3,573.47 1,388.64 25830 S 1,941.15 0.00 0.00<br />

25447 S 1,030.24 0.00 0.00 25907 S 637.02 0.00 0.00<br />

25449 S 1,030.24 0.00 0.00 25922 S 637.02 0.00 0.00<br />

25450 S 1,077.33 0.00 0.00 25929 S 528.55 0.00 0.00<br />

25455 S 1,077.33 0.00 0.00 25931 S 813.72 0.00 0.00<br />

25490 S 1,077.33 0.00 0.00 26010 S 52.78 0.00 0.00<br />

25491 S 1,077.33 0.00 0.00 26011 S 385.55 0.00 0.00<br />

25492 S 1,077.33 0.00 0.00 26020 S 511.58 0.00 0.00<br />

25500 S 59.69 0.00 0.00 26025 S 460.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 511.58 0.00 0.00 26392 S 753.17 0.00 0.00<br />

26034 S 511.58 0.00 0.00 26410 S 540.46 0.00 0.00<br />

26035 S 620.61 0.00 0.00 26412 S 753.17 0.00 0.00<br />

26040 S 807.33 0.00 0.00 26415 S 807.33 0.00 0.00<br />

26045 S 753.17 0.00 0.00 26416 S 753.17 0.00 0.00<br />

26055 S 511.58 0.00 0.00 26418 S 594.61 0.00 0.00<br />

26060 S 511.58 0.00 0.00 26420 S 807.33 0.00 0.00<br />

26070 S 511.58 0.00 0.00 26426 S 753.17 0.00 0.00<br />

26075 S 594.61 0.00 0.00 26428 S 753.17 0.00 0.00<br />

26080 S 594.61 0.00 0.00 26432 S 540.46 0.00 0.00<br />

26100 S 511.58 0.00 0.00 26433 S 540.46 0.00 0.00<br />

26105 S 460.58 0.00 0.00 26434 S 753.17 0.00 0.00<br />

26110 S 460.58 0.00 0.00 26437 S 540.46 0.00 0.00<br />

26115 S 609.29 0.00 0.00 26440 S 540.46 0.00 0.00<br />

26116 S 609.29 0.00 0.00 26442 S 753.17 0.00 0.00<br />

26117 S 638.17 0.00 0.00 26445 S 540.46 0.00 0.00<br />

26121 S 807.33 0.00 0.00 26449 S 753.17 0.00 0.00<br />

26123 S 807.33 0.00 0.00 26450 S 540.46 0.00 0.00<br />

26125 S 594.61 0.00 0.00 26455 S 540.46 0.00 0.00<br />

26130 S 540.46 0.00 0.00 26460 S 540.46 0.00 0.00<br />

26135 S 807.33 0.00 0.00 26471 S 511.58 0.00 0.00<br />

26140 S 511.58 0.00 0.00 26474 S 511.58 0.00 0.00<br />

26145 S 540.46 0.00 0.00 26476 S 460.58 0.00 0.00<br />

26160 S 540.46 0.00 0.00 26477 S 460.58 0.00 0.00<br />

26170 S 540.46 0.00 0.00 26478 S 460.58 0.00 0.00<br />

26180 S 540.46 0.00 0.00 26479 S 460.58 0.00 0.00<br />

26185 S 594.61 0.00 0.00 26480 S 753.17 0.00 0.00<br />

26200 S 511.58 0.00 0.00 26483 S 753.17 0.00 0.00<br />

26205 S 753.17 0.00 0.00 26485 S 724.29 0.00 0.00<br />

26210 S 511.58 0.00 0.00 26489 S 753.17 0.00 0.00<br />

26215 S 540.46 0.00 0.00 26490 S 753.17 0.00 0.00<br />

26230 S 758.40 0.00 0.00 26492 S 753.17 0.00 0.00<br />

26235 S 540.46 0.00 0.00 26494 S 753.17 0.00 0.00<br />

26236 S 540.46 0.00 0.00 26496 S 753.17 0.00 0.00<br />

26250 S 540.46 0.00 0.00 26497 S 753.17 0.00 0.00<br />

26255 S 753.17 0.00 0.00 26498 S 807.33 0.00 0.00<br />

26260 S 540.46 0.00 0.00 26499 S 753.17 0.00 0.00<br />

26261 S 540.46 0.00 0.00 26500 S 594.61 0.00 0.00<br />

26262 S 511.58 0.00 0.00 26502 S 807.33 0.00 0.00<br />

26320 S 498.22 0.00 0.00 26508 S 540.46 0.00 0.00<br />

26340 S 229.68 0.00 0.00 26510 S 753.17 0.00 0.00<br />

26350 S 673.29 0.00 0.00 26516 S 673.29 0.00 0.00<br />

26352 S 807.33 0.00 0.00 26517 S 753.17 0.00 0.00<br />

26356 S 807.33 0.00 0.00 26518 S 753.17 0.00 0.00<br />

26357 S 807.33 0.00 0.00 26520 S 540.46 0.00 0.00<br />

26358 S 807.33 0.00 0.00 26525 S 540.46 0.00 0.00<br />

26370 S 807.33 0.00 0.00 26530 S 936.83 0.00 0.00<br />

26372 S 807.33 0.00 0.00 26531 S 1,442.09 0.00 0.00<br />

26373 S 753.17 0.00 0.00 26535 S 1,030.24 0.00 0.00<br />

26390 S 807.33 0.00 0.00 26536 S 1,316.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 594.61 0.00 0.00 26775 S 159.57 0.00 0.00<br />

26541 S 972.04 0.00 0.00 26776 S 676.56 0.00 0.00<br />

26542 S 594.61 0.00 0.00 26785 S 676.56 0.00 0.00<br />

26545 S 807.33 0.00 0.00 26820 S 846.58 0.00 0.00<br />

26546 S 807.33 0.00 0.00 26841 S 807.33 0.00 0.00<br />

26548 S 807.33 0.00 0.00 26842 S 807.33 0.00 0.00<br />

26550 S 724.29 0.00 0.00 26843 S 753.17 0.00 0.00<br />

26555 S 753.17 0.00 0.00 26844 S 753.17 0.00 0.00<br />

26560 S 511.58 0.00 0.00 26850 S 807.33 0.00 0.00<br />

26561 S 753.17 0.00 0.00 26852 S 807.33 0.00 0.00<br />

26562 S 807.33 0.00 0.00 26860 S 753.17 0.00 0.00<br />

26565 S 846.58 0.00 0.00 26861 S 724.29 0.00 0.00<br />

26567 S 846.58 0.00 0.00 26862 S 807.33 0.00 0.00<br />

26568 S 753.17 0.00 0.00 26863 S 753.17 0.00 0.00<br />

26580 S 633.87 0.00 0.00 26910 S 753.17 0.00 0.00<br />

26587 S 633.87 0.00 0.00 26951 S 511.58 0.00 0.00<br />

26590 S 633.87 0.00 0.00 26952 S 594.61 0.00 0.00<br />

26591 S 753.17 0.00 0.00 26990 S 557.14 0.00 0.00<br />

26593 S 540.46 0.00 0.00 26991 S 557.14 0.00 0.00<br />

26596 S 511.58 0.00 0.00 27000 S 608.13 0.00 0.00<br />

26600 S 59.69 0.00 0.00 27001 S 788.33 0.00 0.00<br />

26605 S 76.60 0.00 0.00 27003 S 788.33 0.00 0.00<br />

26607 S 417.97 0.00 0.00 27033 S 1,077.33 0.00 0.00<br />

26608 S 759.59 0.00 0.00 27035 S 1,131.49 0.00 0.00<br />

26615 S 1,085.03 0.00 0.00 27040 S 304.50 0.00 0.00<br />

26641 S 59.69 0.00 0.00 27041 S 343.08 0.00 0.00<br />

26645 S 161.60 0.00 0.00 27047 S 609.29 0.00 0.00<br />

26650 S 676.56 0.00 0.00 27048 S 638.17 0.00 0.00<br />

26665 S 1,085.03 0.00 0.00 27049 S 638.17 0.00 0.00<br />

26670 S 59.69 0.00 0.00 27050 S 637.02 0.00 0.00<br />

26675 S 161.60 0.00 0.00 27052 S 637.02 0.00 0.00<br />

26676 S 676.56 0.00 0.00 27060 S 730.43 0.00 0.00<br />

26685 S 705.45 0.00 0.00 27062 S 730.43 0.00 0.00<br />

26686 S 1,398.92 0.00 0.00 27065 S 730.43 0.00 0.00<br />

26700 S 59.69 0.00 0.00 27066 S 881.75 0.00 0.00<br />

26705 S 76.60 0.00 0.00 27067 S 881.75 0.00 0.00<br />

26706 S 417.97 0.00 0.00 27080 S 759.45 0.00 0.00<br />

26715 S 759.59 0.00 0.00 27086 S 304.50 0.00 0.00<br />

26720 S 59.69 0.00 0.00 27087 S 637.02 0.00 0.00<br />

26725 S 59.69 0.00 0.00 27097 S 788.33 0.00 0.00<br />

26727 S 924.31 0.00 0.00 27098 S 788.33 0.00 0.00<br />

26735 S 759.59 0.00 0.00 27100 S 1,131.49 0.00 0.00<br />

26740 S 59.69 0.00 0.00 27105 S 1,131.49 0.00 0.00<br />

26742 S 76.60 0.00 0.00 27110 S 1,131.49 0.00 0.00<br />

26746 S 798.86 0.00 0.00 27111 S 1,131.49 0.00 0.00<br />

26750 S 59.69 0.00 0.00 27193 S 76.60 0.00 0.00<br />

26755 S 59.69 0.00 0.00 27194 S 492.06 0.00 0.00<br />

26756 S 676.56 0.00 0.00 27200 S 59.69 0.00 0.00<br />

26765 S 759.59 0.00 0.00 27202 S 1,001.99 0.00 0.00<br />

26770 S 59.69 0.00 0.00 27220 S 59.69 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 76.60 0.00 0.00 27397 S 1,077.33 0.00 0.00<br />

27238 S 161.60 0.00 0.00 27400 S 1,077.33 0.00 0.00<br />

27246 S 161.60 0.00 0.00 27403 S 842.48 0.00 0.00<br />

27250 S 76.60 0.00 0.00 27405 S 1,131.49 0.00 0.00<br />

27252 S 492.06 0.00 0.00 27407 S 1,901.89 0.00 0.00<br />

27256 S 59.69 0.00 0.00 27409 S 1,131.49 0.00 0.00<br />

27257 S 520.95 0.00 0.00 27416 S 1,694.38 0.00 0.00<br />

27265 S 76.60 0.00 0.00 27418 S 1,077.33 0.00 0.00<br />

27266 S 492.06 0.00 0.00 27420 S 1,077.33 0.00 0.00<br />

27267 S 59.69 0.00 0.00 27422 S 1,296.20 0.00 0.00<br />

27275 S 492.06 0.00 0.00 27424 S 1,077.33 0.00 0.00<br />

27301 S 592.30 0.00 0.00 27425 S 1,007.20 0.00 0.00<br />

27305 S 608.13 0.00 0.00 27427 S 1,077.33 0.00 0.00<br />

27306 S 637.02 0.00 0.00 27428 S 1,901.89 0.00 0.00<br />

27307 S 637.02 0.00 0.00 27429 S 1,901.89 0.00 0.00<br />

27310 S 842.48 0.00 0.00 27430 S 1,131.49 0.00 0.00<br />

27323 S 304.50 0.00 0.00 27435 S 1,131.49 0.00 0.00<br />

27324 S 558.29 0.00 0.00 27437 S 990.98 0.00 0.00<br />

27325 S 547.05 0.00 0.00 27438 S 1,316.64 0.00 0.00<br />

27326 S 547.05 0.00 0.00 27440 S 1,413.34 0.00 0.00<br />

27327 S 609.29 0.00 0.00 27441 S 1,030.24 0.00 0.00<br />

27328 S 638.17 0.00 0.00 27442 S 1,030.24 0.00 0.00<br />

27329 S 692.32 0.00 0.00 27443 S 1,030.24 0.00 0.00<br />

27330 S 842.48 0.00 0.00 27446 S 10,108.63 6,072.81 2,036.98<br />

27331 S 842.48 0.00 0.00 27496 S 730.43 0.00 0.00<br />

27332 S 842.48 0.00 0.00 27497 S 637.02 0.00 0.00<br />

27333 S 842.48 0.00 0.00 27498 S 637.02 0.00 0.00<br />

27334 S 842.48 0.00 0.00 27499 S 637.02 0.00 0.00<br />

27335 S 842.48 0.00 0.00 27500 S 161.60 0.00 0.00<br />

27340 S 637.02 0.00 0.00 27501 S 76.60 0.00 0.00<br />

27345 S 691.16 0.00 0.00 27502 S 417.97 0.00 0.00<br />

27347 S 691.16 0.00 0.00 27503 S 76.60 0.00 0.00<br />

27350 S 842.48 0.00 0.00 27508 S 76.60 0.00 0.00<br />

27355 S 788.33 0.00 0.00 27509 S 705.45 0.00 0.00<br />

27356 S 842.48 0.00 0.00 27510 S 161.60 0.00 0.00<br />

27357 S 881.75 0.00 0.00 27516 S 76.60 0.00 0.00<br />

27358 S 881.75 0.00 0.00 27517 S 76.60 0.00 0.00<br />

27360 S 881.75 0.00 0.00 27520 S 76.60 0.00 0.00<br />

27372 S 857.04 0.00 0.00 27530 S 76.60 0.00 0.00<br />

27380 S 557.14 0.00 0.00 27532 S 417.97 0.00 0.00<br />

27381 S 637.02 0.00 0.00 27538 S 76.60 0.00 0.00<br />

27385 S 637.02 0.00 0.00 27550 S 76.60 0.00 0.00<br />

27386 S 637.02 0.00 0.00 27552 S 441.07 0.00 0.00<br />

27390 S 557.14 0.00 0.00 27560 S 76.60 0.00 0.00<br />

27391 S 608.13 0.00 0.00 27562 S 441.07 0.00 0.00<br />

27392 S 637.02 0.00 0.00 27566 S 1,001.99 0.00 0.00<br />

27393 S 759.45 0.00 0.00 27570 S 441.07 0.00 0.00<br />

27394 S 788.33 0.00 0.00 27594 S 637.02 0.00 0.00<br />

27395 S 1,077.33 0.00 0.00 27600 S 637.02 0.00 0.00<br />

27396 S 788.33 0.00 0.00 27601 S 637.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 637.02 0.00 0.00 27730 S 759.45 0.00 0.00<br />

27603 S 563.42 0.00 0.00 27732 S 759.45 0.00 0.00<br />

27604 S 608.13 0.00 0.00 27734 S 759.45 0.00 0.00<br />

27605 S 554.15 0.00 0.00 27740 S 759.45 0.00 0.00<br />

27606 S 557.14 0.00 0.00 27742 S 1,048.45 0.00 0.00<br />

27607 S 608.13 0.00 0.00 27745 S 1,847.74 0.00 0.00<br />

27610 S 759.45 0.00 0.00 27750 S 76.60 0.00 0.00<br />

27612 S 788.33 0.00 0.00 27752 S 417.97 0.00 0.00<br />

27613 S 125.19 0.00 0.00 27756 S 705.45 0.00 0.00<br />

27614 S 609.29 0.00 0.00 27758 S 1,085.03 0.00 0.00<br />

27615 S 788.33 0.00 0.00 27759 S 1,453.07 0.00 0.00<br />

27618 S 498.22 0.00 0.00 27760 S 76.60 0.00 0.00<br />

27619 S 638.17 0.00 0.00 27762 S 417.97 0.00 0.00<br />

27620 S 842.48 0.00 0.00 27766 S 1,030.87 0.00 0.00<br />

27625 S 842.48 0.00 0.00 27767 S 59.69 0.00 0.00<br />

27626 S 842.48 0.00 0.00 27768 S 59.69 0.00 0.00<br />

27630 S 637.02 0.00 0.00 27769 S 1,601.43 0.00 0.00<br />

27635 S 788.33 0.00 0.00 27780 S 76.60 0.00 0.00<br />

27637 S 788.33 0.00 0.00 27781 S 417.97 0.00 0.00<br />

27638 S 788.33 0.00 0.00 27784 S 1,030.87 0.00 0.00<br />

27640 S 1,048.45 0.00 0.00 27786 S 76.60 0.00 0.00<br />

27641 S 759.45 0.00 0.00 27788 S 76.60 0.00 0.00<br />

27647 S 1,077.33 0.00 0.00 27792 S 1,030.87 0.00 0.00<br />

27650 S 1,077.33 0.00 0.00 27808 S 76.60 0.00 0.00<br />

27652 S 1,847.74 0.00 0.00 27810 S 161.60 0.00 0.00<br />

27654 S 1,077.33 0.00 0.00 27814 S 1,030.87 0.00 0.00<br />

27656 S 608.13 0.00 0.00 27816 S 76.60 0.00 0.00<br />

27658 S 557.14 0.00 0.00 27818 S 161.60 0.00 0.00<br />

27659 S 608.13 0.00 0.00 27822 S 1,030.87 0.00 0.00<br />

27664 S 608.13 0.00 0.00 27823 S 1,398.92 0.00 0.00<br />

27665 S 759.45 0.00 0.00 27824 S 76.60 0.00 0.00<br />

27675 S 608.13 0.00 0.00 27825 S 417.97 0.00 0.00<br />

27676 S 788.33 0.00 0.00 27826 S 1,030.87 0.00 0.00<br />

27680 S 788.33 0.00 0.00 27827 S 1,398.92 0.00 0.00<br />

27681 S 759.45 0.00 0.00 27828 S 1,453.07 0.00 0.00<br />

27685 S 788.33 0.00 0.00 27829 S 1,001.99 0.00 0.00<br />

27686 S 788.33 0.00 0.00 27830 S 76.60 0.00 0.00<br />

27687 S 788.33 0.00 0.00 27831 S 417.97 0.00 0.00<br />

27690 S 1,131.49 0.00 0.00 27832 S 1,001.99 0.00 0.00<br />

27691 S 1,131.49 0.00 0.00 27840 S 161.60 0.00 0.00<br />

27692 S 1,077.33 0.00 0.00 27842 S 441.07 0.00 0.00<br />

27695 S 759.45 0.00 0.00 27846 S 1,030.87 0.00 0.00<br />

27696 S 759.45 0.00 0.00 27848 S 1,030.87 0.00 0.00<br />

27698 S 759.45 0.00 0.00 27860 S 441.07 0.00 0.00<br />

27700 S 1,030.24 0.00 0.00 27870 S 1,901.89 0.00 0.00<br />

27704 S 608.13 0.00 0.00 27871 S 1,901.89 0.00 0.00<br />

27705 S 1,048.45 0.00 0.00 27884 S 637.02 0.00 0.00<br />

27707 S 608.13 0.00 0.00 27889 S 788.33 0.00 0.00<br />

27709 S 759.45 0.00 0.00 27892 S 637.02 0.00 0.00<br />

27726 S 950.58 0.00 0.00 27893 S 637.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 637.02 0.00 0.00 28153 S 634.03 0.00 0.00<br />

28001 S 122.18 0.00 0.00 28160 S 634.03 0.00 0.00<br />

28002 S 637.02 0.00 0.00 28171 S 634.03 0.00 0.00<br />

28003 S 637.02 0.00 0.00 28173 S 634.03 0.00 0.00<br />

28005 S 634.03 0.00 0.00 28175 S 634.03 0.00 0.00<br />

28008 S 634.03 0.00 0.00 28190 S 126.19 0.00 0.00<br />

28010 S 89.80 0.00 0.00 28192 S 498.22 0.00 0.00<br />

28011 S 634.03 0.00 0.00 28193 S 343.08 0.00 0.00<br />

28020 S 605.14 0.00 0.00 28200 S 634.03 0.00 0.00<br />

28022 S 605.14 0.00 0.00 28202 S 634.03 0.00 0.00<br />

28024 S 605.14 0.00 0.00 28208 S 634.03 0.00 0.00<br />

28035 S 630.08 0.00 0.00 28210 S 1,113.54 0.00 0.00<br />

28043 S 609.29 0.00 0.00 28220 S 194.63 0.00 0.00<br />

28045 S 634.03 0.00 0.00 28222 S 554.15 0.00 0.00<br />

28046 S 634.03 0.00 0.00 28225 S 554.15 0.00 0.00<br />

28050 S 605.14 0.00 0.00 28226 S 554.15 0.00 0.00<br />

28052 S 605.14 0.00 0.00 28230 S 190.95 0.00 0.00<br />

28054 S 605.14 0.00 0.00 28232 S 182.60 0.00 0.00<br />

28055 S 630.08 0.00 0.00 28234 S 605.14 0.00 0.00<br />

28060 S 605.14 0.00 0.00 28238 S 1,113.54 0.00 0.00<br />

28062 S 634.03 0.00 0.00 28240 S 605.14 0.00 0.00<br />

28070 S 634.03 0.00 0.00 28250 S 634.03 0.00 0.00<br />

28072 S 634.03 0.00 0.00 28260 S 634.03 0.00 0.00<br />

28080 S 634.03 0.00 0.00 28261 S 634.03 0.00 0.00<br />

28086 S 605.14 0.00 0.00 28262 S 688.17 0.00 0.00<br />

28088 S 605.14 0.00 0.00 28264 S 1,033.66 0.00 0.00<br />

28090 S 634.03 0.00 0.00 28270 S 634.03 0.00 0.00<br />

28092 S 634.03 0.00 0.00 28272 S 176.26 0.00 0.00<br />

28100 S 605.14 0.00 0.00 28280 S 605.14 0.00 0.00<br />

28102 S 1,113.54 0.00 0.00 28285 S 634.03 0.00 0.00<br />

28103 S 1,113.54 0.00 0.00 28286 S 688.17 0.00 0.00<br />

28104 S 605.14 0.00 0.00 28288 S 634.03 0.00 0.00<br />

28106 S 1,113.54 0.00 0.00 28289 S 634.03 0.00 0.00<br />

28107 S 1,113.54 0.00 0.00 28290 S 781.52 0.00 0.00<br />

28108 S 605.14 0.00 0.00 28292 S 781.52 0.00 0.00<br />

28110 S 634.03 0.00 0.00 28293 S 810.40 0.00 0.00<br />

28111 S 634.03 0.00 0.00 28294 S 810.40 0.00 0.00<br />

28112 S 634.03 0.00 0.00 28296 S 810.40 0.00 0.00<br />

28113 S 634.03 0.00 0.00 28297 S 810.40 0.00 0.00<br />

28114 S 634.03 0.00 0.00 28298 S 810.40 0.00 0.00<br />

28116 S 634.03 0.00 0.00 28299 S 903.81 0.00 0.00<br />

28118 S 688.17 0.00 0.00 28300 S 1,084.66 0.00 0.00<br />

28119 S 688.17 0.00 0.00 28302 S 605.14 0.00 0.00<br />

28120 S 852.89 0.00 0.00 28304 S 1,084.66 0.00 0.00<br />

28122 S 634.03 0.00 0.00 28305 S 1,113.54 0.00 0.00<br />

28124 S 206.64 0.00 0.00 28306 S 688.17 0.00 0.00<br />

28126 S 634.03 0.00 0.00 28307 S 688.17 0.00 0.00<br />

28130 S 634.03 0.00 0.00 28308 S 605.14 0.00 0.00<br />

28140 S 634.03 0.00 0.00 28309 S 1,167.70 0.00 0.00<br />

28150 S 634.03 0.00 0.00 28310 S 634.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 634.03 0.00 0.00 28636 S 705.45 0.00 0.00<br />

28313 S 605.14 0.00 0.00 28645 S 705.45 0.00 0.00<br />

28315 S 688.17 0.00 0.00 28660 S 42.73 0.00 0.00<br />

28320 S 1,167.70 0.00 0.00 28665 S 441.07 0.00 0.00<br />

28322 S 1,167.70 0.00 0.00 28666 S 705.45 0.00 0.00<br />

28340 S 688.17 0.00 0.00 28675 S 705.45 0.00 0.00<br />

28341 S 688.17 0.00 0.00 28705 S 1,167.70 0.00 0.00<br />

28344 S 688.17 0.00 0.00 28715 S 1,901.89 0.00 0.00<br />

28345 S 688.17 0.00 0.00 28725 S 1,167.70 0.00 0.00<br />

28400 S 76.60 0.00 0.00 28730 S 1,167.70 0.00 0.00<br />

28405 S 417.97 0.00 0.00 28735 S 1,167.70 0.00 0.00<br />

28406 S 676.56 0.00 0.00 28737 S 1,206.95 0.00 0.00<br />

28415 S 1,398.92 0.00 0.00 28740 S 1,167.70 0.00 0.00<br />

28420 S 1,085.03 0.00 0.00 28750 S 1,167.70 0.00 0.00<br />

28430 S 59.69 0.00 0.00 28755 S 688.17 0.00 0.00<br />

28435 S 76.60 0.00 0.00 28760 S 1,167.70 0.00 0.00<br />

28436 S 676.56 0.00 0.00 28810 S 605.14 0.00 0.00<br />

28445 S 1,030.87 0.00 0.00 28820 S 605.14 0.00 0.00<br />

28446 S 1,766.79 0.00 0.00 28825 S 605.14 0.00 0.00<br />

28450 S 59.69 0.00 0.00 28890 S 159.91 0.00 0.00<br />

28455 S 59.69 0.00 0.00 29000 S 40.51 0.00 0.00<br />

28456 S 676.56 0.00 0.00 29010 S 90.80 0.00 0.00<br />

28465 S 1,030.87 0.00 0.00 29015 S 90.80 0.00 0.00<br />

28470 S 59.69 0.00 0.00 29020 S 40.51 0.00 0.00<br />

28475 S 59.69 0.00 0.00 29025 S 40.51 0.00 0.00<br />

28476 S 676.56 0.00 0.00 29035 S 90.80 0.00 0.00<br />

28485 S 1,085.03 0.00 0.00 29040 S 40.51 0.00 0.00<br />

28490 S 59.69 0.00 0.00 29044 S 90.80 0.00 0.00<br />

28495 S 59.69 0.00 0.00 29046 S 90.80 0.00 0.00<br />

28496 S 676.56 0.00 0.00 29049 S 36.72 0.00 0.00<br />

28505 S 705.45 0.00 0.00 29055 S 90.80 0.00 0.00<br />

28510 S 53.75 0.00 0.00 29058 S 40.51 0.00 0.00<br />

28515 S 59.69 0.00 0.00 29065 S 43.07 0.00 0.00<br />

28525 S 705.45 0.00 0.00 29075 S 41.39 0.00 0.00<br />

28530 S 51.74 0.00 0.00 29085 S 40.51 0.00 0.00<br />

28531 S 705.45 0.00 0.00 29086 S 34.72 0.00 0.00<br />

28540 S 59.69 0.00 0.00 29105 S 37.38 0.00 0.00<br />

28545 S 625.57 0.00 0.00 29125 S 32.38 0.00 0.00<br />

28546 S 676.56 0.00 0.00 29126 S 34.39 0.00 0.00<br />

28555 S 1,001.99 0.00 0.00 29130 S 14.69 0.00 0.00<br />

28570 S 77.44 0.00 0.00 29131 S 21.36 0.00 0.00<br />

28575 S 417.97 0.00 0.00 29200 S 20.70 0.00 0.00<br />

28576 S 705.45 0.00 0.00 29220 S 22.36 0.00 0.00<br />

28585 S 705.45 0.00 0.00 29240 S 23.37 0.00 0.00<br />

28600 S 59.69 0.00 0.00 29260 S 22.36 0.00 0.00<br />

28605 S 76.60 0.00 0.00 29280 S 22.70 0.00 0.00<br />

28606 S 676.56 0.00 0.00 29305 S 90.80 0.00 0.00<br />

28615 S 1,030.87 0.00 0.00 29325 S 90.80 0.00 0.00<br />

28630 S 59.69 0.00 0.00 29345 S 56.42 0.00 0.00<br />

28635 S 441.07 0.00 0.00 29355 S 55.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 68.77 0.00 0.00 29847 S 1,149.47 0.00 0.00<br />

29365 S 53.42 0.00 0.00 29848 S 1,153.71 0.00 0.00<br />

29405 S 39.73 0.00 0.00 29850 S 833.76 0.00 0.00<br />

29425 S 40.39 0.00 0.00 29851 S 1,203.63 0.00 0.00<br />

29435 S 51.07 0.00 0.00 29855 S 1,203.63 0.00 0.00<br />

29440 S 21.70 0.00 0.00 29856 S 1,203.63 0.00 0.00<br />

29445 S 53.75 0.00 0.00 29860 S 1,203.63 0.00 0.00<br />

29450 S 40.51 0.00 0.00 29861 S 1,203.63 0.00 0.00<br />

29505 S 36.05 0.00 0.00 29862 S 1,523.58 0.00 0.00<br />

29515 S 30.71 0.00 0.00 29863 S 1,203.63 0.00 0.00<br />

29520 S 22.03 0.00 0.00 29866 S 1,838.65 0.00 0.00<br />

29530 S 22.36 0.00 0.00 29870 S 779.61 0.00 0.00<br />

29540 S 16.69 0.00 0.00 29871 S 779.61 0.00 0.00<br />

29550 S 17.02 0.00 0.00 29873 S 779.61 0.00 0.00<br />

29580 S 23.04 0.00 0.00 29874 S 779.61 0.00 0.00<br />

29590 S 18.70 0.00 0.00 29875 S 833.76 0.00 0.00<br />

29700 S 31.04 0.00 0.00 29876 S 833.76 0.00 0.00<br />

29705 S 26.37 0.00 0.00 29877 S 833.76 0.00 0.00<br />

29710 S 46.40 0.00 0.00 29879 S 779.61 0.00 0.00<br />

29715 S 40.51 0.00 0.00 29880 S 833.76 0.00 0.00<br />

29720 S 38.73 0.00 0.00 29881 S 833.76 0.00 0.00<br />

29730 S 25.37 0.00 0.00 29882 S 779.61 0.00 0.00<br />

29740 S 34.72 0.00 0.00 29883 S 779.61 0.00 0.00<br />

29750 S 36.39 0.00 0.00 29884 S 779.61 0.00 0.00<br />

29800 S 779.61 0.00 0.00 29885 S 1,149.47 0.00 0.00<br />

29804 S 779.61 0.00 0.00 29886 S 779.61 0.00 0.00<br />

29805 S 779.61 0.00 0.00 29887 S 779.61 0.00 0.00<br />

29806 S 1,149.47 0.00 0.00 29888 S 1,149.47 0.00 0.00<br />

29807 S 1,149.47 0.00 0.00 29889 S 1,149.47 0.00 0.00<br />

29819 S 1,149.47 0.00 0.00 29891 S 1,149.47 0.00 0.00<br />

29820 S 1,149.47 0.00 0.00 29892 S 1,149.47 0.00 0.00<br />

29821 S 1,149.47 0.00 0.00 29893 S 970.47 0.00 0.00<br />

29822 S 779.61 0.00 0.00 29894 S 779.61 0.00 0.00<br />

29823 S 1,149.47 0.00 0.00 29895 S 779.61 0.00 0.00<br />

29824 S 873.03 0.00 0.00 29897 S 779.61 0.00 0.00<br />

29825 S 1,149.47 0.00 0.00 29898 S 779.61 0.00 0.00<br />

29826 S 1,149.47 0.00 0.00 29899 S 1,149.47 0.00 0.00<br />

29827 S 1,242.89 0.00 0.00 29900 S 779.61 0.00 0.00<br />

29828 S 1,838.65 0.00 0.00 29901 S 779.61 0.00 0.00<br />

29830 S 779.61 0.00 0.00 29902 S 779.61 0.00 0.00<br />

29834 S 779.61 0.00 0.00 29904 S 1,098.92 0.00 0.00<br />

29835 S 779.61 0.00 0.00 29905 S 1,098.92 0.00 0.00<br />

29836 S 779.61 0.00 0.00 29906 S 1,098.92 0.00 0.00<br />

29837 S 779.61 0.00 0.00 29907 S 1,838.65 0.00 0.00<br />

29838 S 779.61 0.00 0.00 30000 S 123.55 0.00 0.00<br />

29840 S 779.61 0.00 0.00 30020 S 123.55 0.00 0.00<br />

29843 S 779.61 0.00 0.00 30100 S 80.12 0.00 0.00<br />

29844 S 779.61 0.00 0.00 30110 S 123.85 0.00 0.00<br />

29845 S 779.61 0.00 0.00 30115 S 523.31 0.00 0.00<br />

29846 S 779.61 0.00 0.00 30117 S 552.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 692.58 0.00 0.00 31080 S 1,066.49 0.00 0.00<br />

30120 S 472.32 0.00 0.00 31081 S 1,066.49 0.00 0.00<br />

30124 S 281.43 0.00 0.00 31084 S 1,066.49 0.00 0.00<br />

30125 S 983.46 0.00 0.00 31085 S 1,066.49 0.00 0.00<br />

30130 S 552.19 0.00 0.00 31086 S 1,066.49 0.00 0.00<br />

30140 S 663.69 0.00 0.00 31087 S 1,066.49 0.00 0.00<br />

30150 S 1,012.35 0.00 0.00 31090 S 1,105.76 0.00 0.00<br />

30160 S 1,066.49 0.00 0.00 31200 S 983.46 0.00 0.00<br />

30200 S 63.10 0.00 0.00 31201 S 1,105.76 0.00 0.00<br />

30210 S 80.12 0.00 0.00 31205 S 1,012.35 0.00 0.00<br />

30220 S 350.17 0.00 0.00 31231 S 67.54 0.00 0.00<br />

30300 S 24.14 0.00 0.00 31233 S 72.75 0.00 0.00<br />

30310 S 472.32 0.00 0.00 31235 S 494.28 0.00 0.00<br />

30320 S 523.31 0.00 0.00 31237 S 545.27 0.00 0.00<br />

30400 S 1,066.49 0.00 0.00 31238 S 494.28 0.00 0.00<br />

30410 S 1,105.76 0.00 0.00 31239 S 721.50 0.00 0.00<br />

30420 S 1,105.76 0.00 0.00 31240 S 545.27 0.00 0.00<br />

30430 S 692.58 0.00 0.00 31254 S 667.34 0.00 0.00<br />

30435 S 1,105.76 0.00 0.00 31255 S 760.75 0.00 0.00<br />

30450 S 1,231.21 0.00 0.00 31256 S 667.34 0.00 0.00<br />

30460 S 1,231.21 0.00 0.00 31267 S 667.34 0.00 0.00<br />

30462 S 1,386.45 0.00 0.00 31276 S 667.34 0.00 0.00<br />

30465 S 1,386.45 0.00 0.00 31287 S 667.34 0.00 0.00<br />

30520 S 746.73 0.00 0.00 31288 S 667.34 0.00 0.00<br />

30540 S 1,105.76 0.00 0.00 31300 S 785.99 0.00 0.00<br />

30545 S 1,105.76 0.00 0.00 31320 S 983.46 0.00 0.00<br />

30560 S 129.79 0.00 0.00 31400 S 983.46 0.00 0.00<br />

30580 S 1,066.49 0.00 0.00 31420 S 983.46 0.00 0.00<br />

30600 S 1,066.49 0.00 0.00 31500 S 90.34 0.00 0.00<br />

30620 S 1,231.21 0.00 0.00 31502 S 51.94 0.00 0.00<br />

30630 S 911.45 0.00 0.00 31505 S 30.69 0.00 0.00<br />

30801 S 290.99 0.00 0.00 31510 S 545.27 0.00 0.00<br />

30802 S 290.99 0.00 0.00 31511 S 72.75 0.00 0.00<br />

30901 S 41.50 0.00 0.00 31512 S 545.27 0.00 0.00<br />

30903 S 53.46 0.00 0.00 31513 S 72.75 0.00 0.00<br />

30905 S 53.46 0.00 0.00 31515 S 494.28 0.00 0.00<br />

30906 S 53.46 0.00 0.00 31520 S 67.54 0.00 0.00<br />

30915 S 712.37 0.00 0.00 31525 S 494.28 0.00 0.00<br />

30920 S 741.26 0.00 0.00 31526 S 638.46 0.00 0.00<br />

30930 S 606.34 0.00 0.00 31527 S 587.46 0.00 0.00<br />

31000 S 103.16 0.00 0.00 31528 S 545.27 0.00 0.00<br />

31002 S 281.43 0.00 0.00 31529 S 545.27 0.00 0.00<br />

31020 S 663.69 0.00 0.00 31530 S 638.46 0.00 0.00<br />

31030 S 1,012.35 0.00 0.00 31531 S 667.34 0.00 0.00<br />

31032 S 1,066.49 0.00 0.00 31535 S 638.46 0.00 0.00<br />

31040 S 924.86 0.00 0.00 31536 S 667.34 0.00 0.00<br />

31050 S 983.46 0.00 0.00 31540 S 667.34 0.00 0.00<br />

31051 S 1,066.49 0.00 0.00 31541 S 721.50 0.00 0.00<br />

31070 S 663.69 0.00 0.00 31545 S 721.50 0.00 0.00<br />

31075 S 1,066.49 0.00 0.00 31546 S 721.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 760.75 0.00 0.00 32405 S 329.20 0.00 0.00<br />

31561 S 760.75 0.00 0.00 32420 S 200.18 0.00 0.00<br />

31570 S 545.27 0.00 0.00 32421 S 200.18 0.00 0.00<br />

31571 S 638.46 0.00 0.00 32422 S 199.29 0.00 0.00<br />

31575 S 58.09 0.00 0.00 32550 S 1,115.81 0.00 0.00<br />

31576 S 638.46 0.00 0.00 32960 S 199.29 0.00 0.00<br />

31577 S 188.60 0.00 0.00 32998 S 1,737.26 0.00 0.00<br />

31578 S 638.46 0.00 0.00 33010 S 200.18 0.00 0.00<br />

31579 S 103.49 0.00 0.00 33011 S 200.18 0.00 0.00<br />

31580 S 1,105.76 0.00 0.00 33206 S 6,422.52 3,821.38 1,220.25<br />

31582 S 1,105.76 0.00 0.00 33207 S 6,422.52 3,821.38 1,220.25<br />

31588 S 1,105.76 0.00 0.00 33208 S 7,965.74 4,641.60 1,317.46<br />

31590 S 1,105.76 0.00 0.00 33210 S 1,885.99 0.00 0.00<br />

31595 S 983.46 0.00 0.00 33211 S 1,885.99 0.00 0.00<br />

31603 S 290.99 0.00 0.00 33212 S 5,043.96 2,873.33 702.70<br />

31605 S 281.43 0.00 0.00 33213 S 5,821.82 3,261.84 701.86<br />

31611 S 692.58 0.00 0.00 33214 S 7,965.74 4,641.60 1,317.46<br />

31612 S 612.70 0.00 0.00 33215 S 826.65 0.00 0.00<br />

31613 S 663.69 0.00 0.00 33216 S 1,885.99 0.00 0.00<br />

31614 S 983.46 0.00 0.00 33217 S 1,885.99 0.00 0.00<br />

31615 S 290.99 0.00 0.00 33218 S 826.65 0.00 0.00<br />

31622 S 340.80 0.00 0.00 33220 S 826.65 0.00 0.00<br />

31623 S 391.79 0.00 0.00 33222 S 499.68 0.00 0.00<br />

31624 S 391.79 0.00 0.00 33223 S 499.68 0.00 0.00<br />

31625 S 391.79 0.00 0.00 33224 S 7,518.92 4,501.55 1,484.20<br />

31628 S 391.79 0.00 0.00 33225 S 7,518.92 4,501.55 1,484.20<br />

31629 S 391.79 0.00 0.00 33226 S 826.65 0.00 0.00<br />

31630 S 671.37 0.00 0.00 33233 S 614.60 0.00 0.00<br />

31631 S 671.37 0.00 0.00 33234 S 826.65 0.00 0.00<br />

31632 S 381.04 0.00 0.00 33235 S 826.65 0.00 0.00<br />

31633 S 381.04 0.00 0.00 33240 S 18,742.74 10,018.76 1,294.78<br />

31635 S 391.79 0.00 0.00 33241 S 826.65 0.00 0.00<br />

31636 S 671.37 0.00 0.00 33249 S 25,013.62 13,398.33 1,783.04<br />

31637 S 340.80 0.00 0.00 33282 S 3,954.81 2,367.58 780.35<br />

31638 S 671.37 0.00 0.00 33284 S 308.47 0.00 0.00<br />

31640 S 671.37 0.00 0.00 34490 S 1,506.02 0.00 0.00<br />

31641 S 671.37 0.00 0.00 35188 S 1,037.31 0.00 0.00<br />

31643 S 391.79 0.00 0.00 35207 S 1,037.31 0.00 0.00<br />

31645 S 340.80 0.00 0.00 35473 S 1,806.64 0.00 0.00<br />

31646 S 340.80 0.00 0.00 35476 S 1,806.64 0.00 0.00<br />

31656 S 340.80 0.00 0.00 35492 S 3,371.91 0.00 0.00<br />

31717 S 188.60 0.00 0.00 35761 S 1,084.70 0.00 0.00<br />

31720 S 28.88 0.00 0.00 35875 S 1,357.26 0.00 0.00<br />

31730 S 188.60 0.00 0.00 35876 S 1,357.26 0.00 0.00<br />

31750 S 1,105.76 0.00 0.00 36002 S 86.63 0.00 0.00<br />

31755 S 983.46 0.00 0.00 36260 S 785.83 0.00 0.00<br />

31820 S 472.32 0.00 0.00 36261 S 614.60 0.00 0.00<br />

31825 S 663.69 0.00 0.00 36262 S 563.60 0.00 0.00<br />

31830 S 663.69 0.00 0.00 36420 S 8.16 0.00 0.00<br />

32400 S 329.20 0.00 0.00 36425 S 8.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 31.38 0.00 0.00 36800 S 845.94 0.00 0.00<br />

36440 S 125.32 0.00 0.00 36810 S 845.94 0.00 0.00<br />

36450 S 125.32 0.00 0.00 36815 S 845.94 0.00 0.00<br />

36455 S 125.32 0.00 0.00 36818 S 983.16 0.00 0.00<br />

36468 S 30.93 0.00 0.00 36819 S 983.16 0.00 0.00<br />

36469 S 30.93 0.00 0.00 36820 S 983.16 0.00 0.00<br />

36470 S 30.93 0.00 0.00 36821 S 983.16 0.00 0.00<br />

36471 S 30.93 0.00 0.00 36825 S 1,037.31 0.00 0.00<br />

36475 S 1,422.28 0.00 0.00 36830 S 1,037.31 0.00 0.00<br />

36476 S 1,115.36 0.00 0.00 36831 S 1,357.26 0.00 0.00<br />

36478 S 1,115.36 0.00 0.00 36832 S 1,037.31 0.00 0.00<br />

36479 S 1,115.36 0.00 0.00 36833 S 1,037.31 0.00 0.00<br />

36511 S 429.65 0.00 0.00 36834 S 983.16 0.00 0.00<br />

36512 S 429.65 0.00 0.00 36835 S 900.10 0.00 0.00<br />

36513 S 429.65 0.00 0.00 36860 S 103.31 0.00 0.00<br />

36514 S 429.65 0.00 0.00 36861 S 845.94 0.00 0.00<br />

36515 S 1,150.16 0.00 0.00 36870 S 1,479.42 0.00 0.00<br />

36516 S 1,150.16 0.00 0.00 37184 S 1,506.02 0.00 0.00<br />

36522 S 1,150.16 0.00 0.00 37185 S 1,506.02 0.00 0.00<br />

36555 S 356.98 0.00 0.00 37186 S 1,506.02 0.00 0.00<br />

36556 S 356.98 0.00 0.00 37187 S 1,506.02 0.00 0.00<br />

36557 S 666.68 0.00 0.00 37188 S 1,506.02 0.00 0.00<br />

36558 S 666.68 0.00 0.00 37200 S 1,111.35 0.00 0.00<br />

36560 S 785.83 0.00 0.00 37203 S 1,111.35 0.00 0.00<br />

36561 S 785.83 0.00 0.00 37500 S 1,048.18 0.00 0.00<br />

36563 S 785.83 0.00 0.00 37607 S 741.26 0.00 0.00<br />

36565 S 785.83 0.00 0.00 37609 S 498.22 0.00 0.00<br />

36566 S 785.83 0.00 0.00 37650 S 712.37 0.00 0.00<br />

36568 S 356.98 0.00 0.00 37700 S 712.37 0.00 0.00<br />

36569 S 356.98 0.00 0.00 37718 S 741.26 0.00 0.00<br />

36570 S 695.56 0.00 0.00 37722 S 1,048.18 0.00 0.00<br />

36571 S 695.56 0.00 0.00 37735 S 1,048.18 0.00 0.00<br />

36575 S 287.11 0.00 0.00 37760 S 741.26 0.00 0.00<br />

36576 S 407.97 0.00 0.00 37765 S 1,022.20 0.00 0.00<br />

36578 S 666.68 0.00 0.00 37766 S 1,022.20 0.00 0.00<br />

36580 S 356.98 0.00 0.00 37780 S 741.26 0.00 0.00<br />

36581 S 666.68 0.00 0.00 37785 S 741.26 0.00 0.00<br />

36582 S 785.83 0.00 0.00 37790 S 894.47 0.00 0.00<br />

36583 S 785.83 0.00 0.00 38205 S 429.65 0.00 0.00<br />

36584 S 356.98 0.00 0.00 38206 S 429.65 0.00 0.00<br />

36585 S 695.56 0.00 0.00 38220 S 98.48 0.00 0.00<br />

36589 S 236.12 0.00 0.00 38221 S 103.16 0.00 0.00<br />

36590 S 356.98 0.00 0.00 38230 S 1,150.16 0.00 0.00<br />

36593 S 23.70 0.00 0.00 38241 S 1,150.16 0.00 0.00<br />

36595 S 930.82 0.00 0.00 38242 S 429.65 0.00 0.00<br />

36596 S 413.39 0.00 0.00 38300 S 385.55 0.00 0.00<br />

36597 S 413.39 0.00 0.00 38305 S 563.42 0.00 0.00<br />

36598 S 76.45 0.00 0.00 38308 S 643.78 0.00 0.00<br />

36640 S 705.95 0.00 0.00 38500 S 643.78 0.00 0.00<br />

36680 S 53.51 0.00 0.00 38505 S 246.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 643.78 0.00 0.00 41005 S 129.79 0.00 0.00<br />

38520 S 643.78 0.00 0.00 41006 S 612.70 0.00 0.00<br />

38525 S 643.78 0.00 0.00 41007 S 472.32 0.00 0.00<br />

38530 S 643.78 0.00 0.00 41008 S 472.32 0.00 0.00<br />

38542 S 1,083.07 0.00 0.00 41009 S 129.79 0.00 0.00<br />

38550 S 672.67 0.00 0.00 41010 S 290.99 0.00 0.00<br />

38555 S 726.82 0.00 0.00 41015 S 129.79 0.00 0.00<br />

38570 S 1,469.57 0.00 0.00 41016 S 290.99 0.00 0.00<br />

38571 S 1,910.40 0.00 0.00 41017 S 290.99 0.00 0.00<br />

38572 S 1,469.57 0.00 0.00 41018 S 290.99 0.00 0.00<br />

38700 S 885.03 0.00 0.00 41019 S 924.86 0.00 0.00<br />

38740 S 1,083.07 0.00 0.00 41100 S 87.13 0.00 0.00<br />

38745 S 1,166.11 0.00 0.00 41105 S 86.13 0.00 0.00<br />

38760 S 643.78 0.00 0.00 41108 S 79.79 0.00 0.00<br />

40490 S 65.76 0.00 0.00 41110 S 115.51 0.00 0.00<br />

40500 S 523.31 0.00 0.00 41112 S 523.31 0.00 0.00<br />

40510 S 663.69 0.00 0.00 41113 S 523.31 0.00 0.00<br />

40520 S 523.31 0.00 0.00 41114 S 663.69 0.00 0.00<br />

40525 S 663.69 0.00 0.00 41115 S 134.54 0.00 0.00<br />

40527 S 663.69 0.00 0.00 41116 S 472.32 0.00 0.00<br />

40530 S 663.69 0.00 0.00 41120 S 785.99 0.00 0.00<br />

40650 S 350.17 0.00 0.00 41250 S 88.77 0.00 0.00<br />

40652 S 350.17 0.00 0.00 41251 S 129.79 0.00 0.00<br />

40654 S 350.17 0.00 0.00 41252 S 341.98 0.00 0.00<br />

40700 S 1,231.21 0.00 0.00 41500 S 612.70 0.00 0.00<br />

40701 S 1,231.21 0.00 0.00 41510 S 472.32 0.00 0.00<br />

40702 S 1,564.38 0.00 0.00 41520 S 341.98 0.00 0.00<br />

40720 S 1,231.21 0.00 0.00 41530 S 644.08 0.00 0.00<br />

40761 S 1,012.35 0.00 0.00 41800 S 66.31 0.00 0.00<br />

40800 S 52.78 0.00 0.00 41805 S 143.55 0.00 0.00<br />

40801 S 341.98 0.00 0.00 41806 S 176.93 0.00 0.00<br />

40804 S 24.14 0.00 0.00 41820 S 281.43 0.00 0.00<br />

40805 S 163.25 0.00 0.00 41821 S 281.43 0.00 0.00<br />

40806 S 75.11 0.00 0.00 41822 S 146.55 0.00 0.00<br />

40808 S 111.50 0.00 0.00 41823 S 213.66 0.00 0.00<br />

40810 S 115.51 0.00 0.00 41825 S 117.50 0.00 0.00<br />

40812 S 144.88 0.00 0.00 41826 S 147.89 0.00 0.00<br />

40814 S 523.31 0.00 0.00 41827 S 663.69 0.00 0.00<br />

40816 S 663.69 0.00 0.00 41828 S 133.54 0.00 0.00<br />

40818 S 129.79 0.00 0.00 41830 S 189.62 0.00 0.00<br />

40819 S 290.99 0.00 0.00 41850 S 644.08 0.00 0.00<br />

40820 S 166.58 0.00 0.00 41870 S 924.86 0.00 0.00<br />

40830 S 123.55 0.00 0.00 41872 S 189.62 0.00 0.00<br />

40831 S 290.99 0.00 0.00 41874 S 182.94 0.00 0.00<br />

40840 S 663.69 0.00 0.00 42000 S 129.79 0.00 0.00<br />

40842 S 692.58 0.00 0.00 42100 S 74.11 0.00 0.00<br />

40843 S 692.58 0.00 0.00 42104 S 110.16 0.00 0.00<br />

40844 S 1,105.76 0.00 0.00 42106 S 138.21 0.00 0.00<br />

40845 S 1,105.76 0.00 0.00 42107 S 663.69 0.00 0.00<br />

41000 S 82.79 0.00 0.00 42120 S 1,066.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 341.98 0.00 0.00 42809 S 24.14 0.00 0.00<br />

42145 S 785.99 0.00 0.00 42810 S 692.58 0.00 0.00<br />

42160 S 130.86 0.00 0.00 42815 S 1,105.76 0.00 0.00<br />

42180 S 129.79 0.00 0.00 42820 S 692.58 0.00 0.00<br />

42182 S 983.46 0.00 0.00 42821 S 785.99 0.00 0.00<br />

42200 S 1,105.76 0.00 0.00 42825 S 746.73 0.00 0.00<br />

42205 S 1,105.76 0.00 0.00 42826 S 746.73 0.00 0.00<br />

42210 S 1,105.76 0.00 0.00 42830 S 746.73 0.00 0.00<br />

42215 S 1,231.21 0.00 0.00 42831 S 746.73 0.00 0.00<br />

42220 S 1,105.76 0.00 0.00 42835 S 746.73 0.00 0.00<br />

42226 S 1,105.76 0.00 0.00 42836 S 746.73 0.00 0.00<br />

42235 S 645.61 0.00 0.00 42860 S 692.58 0.00 0.00<br />

42260 S 746.73 0.00 0.00 42870 S 692.58 0.00 0.00<br />

42280 S 72.10 0.00 0.00 42890 S 1,231.21 0.00 0.00<br />

42281 S 644.08 0.00 0.00 42892 S 1,231.21 0.00 0.00<br />

42300 S 472.32 0.00 0.00 42900 S 290.99 0.00 0.00<br />

42305 S 523.31 0.00 0.00 42950 S 663.69 0.00 0.00<br />

42310 S 129.79 0.00 0.00 42955 S 663.69 0.00 0.00<br />

42320 S 129.79 0.00 0.00 42960 S 53.46 0.00 0.00<br />

42330 S 111.50 0.00 0.00 42962 S 983.46 0.00 0.00<br />

42335 S 184.94 0.00 0.00 42970 S 41.50 0.00 0.00<br />

42340 S 523.31 0.00 0.00 42972 S 552.19 0.00 0.00<br />

42400 S 62.76 0.00 0.00 43030 S 644.08 0.00 0.00<br />

42405 S 523.31 0.00 0.00 43200 S 311.90 0.00 0.00<br />

42408 S 552.19 0.00 0.00 43201 S 311.90 0.00 0.00<br />

42409 S 552.19 0.00 0.00 43202 S 311.90 0.00 0.00<br />

42410 S 1,012.35 0.00 0.00 43204 S 311.90 0.00 0.00<br />

42415 S 1,231.21 0.00 0.00 43205 S 311.90 0.00 0.00<br />

42420 S 1,231.21 0.00 0.00 43215 S 311.90 0.00 0.00<br />

42425 S 1,231.21 0.00 0.00 43216 S 311.90 0.00 0.00<br />

42440 S 1,012.35 0.00 0.00 43217 S 311.90 0.00 0.00<br />

42450 S 663.69 0.00 0.00 43219 S 630.35 0.00 0.00<br />

42500 S 692.58 0.00 0.00 43220 S 311.90 0.00 0.00<br />

42505 S 1,066.49 0.00 0.00 43226 S 311.90 0.00 0.00<br />

42507 S 1,012.35 0.00 0.00 43227 S 362.90 0.00 0.00<br />

42508 S 1,066.49 0.00 0.00 43228 S 675.33 0.00 0.00<br />

42509 S 1,066.49 0.00 0.00 43231 S 362.90 0.00 0.00<br />

42510 S 1,066.49 0.00 0.00 43232 S 362.90 0.00 0.00<br />

42600 S 472.32 0.00 0.00 43234 S 311.90 0.00 0.00<br />

42650 S 41.06 0.00 0.00 43235 S 311.90 0.00 0.00<br />

42660 S 48.08 0.00 0.00 43236 S 362.90 0.00 0.00<br />

42665 S 911.45 0.00 0.00 43237 S 362.90 0.00 0.00<br />

42700 S 129.79 0.00 0.00 43238 S 362.90 0.00 0.00<br />

42720 S 472.32 0.00 0.00 43239 S 362.90 0.00 0.00<br />

42725 S 983.46 0.00 0.00 43240 S 362.90 0.00 0.00<br />

42800 S 79.45 0.00 0.00 43241 S 362.90 0.00 0.00<br />

42802 S 472.32 0.00 0.00 43242 S 362.90 0.00 0.00<br />

42804 S 472.32 0.00 0.00 43243 S 362.90 0.00 0.00<br />

42806 S 663.69 0.00 0.00 43244 S 362.90 0.00 0.00<br />

42808 S 523.31 0.00 0.00 43245 S 362.90 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 362.90 0.00 0.00 44378 S 380.08 0.00 0.00<br />

43247 S 362.90 0.00 0.00 44379 S 1,084.34 0.00 0.00<br />

43248 S 362.90 0.00 0.00 44380 S 329.08 0.00 0.00<br />

43249 S 362.90 0.00 0.00 44382 S 329.08 0.00 0.00<br />

43250 S 362.90 0.00 0.00 44383 S 1,084.34 0.00 0.00<br />

43251 S 362.90 0.00 0.00 44385 S 318.18 0.00 0.00<br />

43255 S 362.90 0.00 0.00 44386 S 318.18 0.00 0.00<br />

43256 S 710.23 0.00 0.00 44388 S 318.18 0.00 0.00<br />

43257 S 704.21 0.00 0.00 44389 S 318.18 0.00 0.00<br />

43258 S 391.78 0.00 0.00 44390 S 318.18 0.00 0.00<br />

43259 S 391.78 0.00 0.00 44391 S 318.18 0.00 0.00<br />

43260 S 610.94 0.00 0.00 44392 S 318.18 0.00 0.00<br />

43261 S 610.94 0.00 0.00 44393 S 318.18 0.00 0.00<br />

43262 S 610.94 0.00 0.00 44394 S 318.18 0.00 0.00<br />

43263 S 610.94 0.00 0.00 44397 S 630.35 0.00 0.00<br />

43264 S 610.94 0.00 0.00 44500 S 171.70 0.00 0.00<br />

43265 S 610.94 0.00 0.00 45000 S 368.98 0.00 0.00<br />

43267 S 610.94 0.00 0.00 45005 S 429.42 0.00 0.00<br />

43268 S 681.35 0.00 0.00 45020 S 429.42 0.00 0.00<br />

43269 S 681.35 0.00 0.00 45100 S 583.41 0.00 0.00<br />

43271 S 610.94 0.00 0.00 45108 S 634.41 0.00 0.00<br />

43272 S 610.94 0.00 0.00 45150 S 634.41 0.00 0.00<br />

43273 S 819.35 0.00 0.00 45160 S 634.41 0.00 0.00<br />

43450 S 272.77 0.00 0.00 45170 S 634.41 0.00 0.00<br />

43453 S 272.77 0.00 0.00 45190 S 1,037.39 0.00 0.00<br />

43456 S 273.86 0.00 0.00 45300 S 61.42 0.00 0.00<br />

43458 S 312.99 0.00 0.00 45303 S 341.19 0.00 0.00<br />

43600 S 311.90 0.00 0.00 45305 S 320.87 0.00 0.00<br />

43653 S 1,469.57 0.00 0.00 45307 S 592.66 0.00 0.00<br />

43760 S 151.27 0.00 0.00 45308 S 320.87 0.00 0.00<br />

43761 S 311.90 0.00 0.00 45309 S 320.87 0.00 0.00<br />

43870 S 311.90 0.00 0.00 45315 S 320.87 0.00 0.00<br />

43886 S 787.00 0.00 0.00 45317 S 320.87 0.00 0.00<br />

43887 S 165.53 0.00 0.00 45320 S 592.66 0.00 0.00<br />

43888 S 787.00 0.00 0.00 45321 S 592.66 0.00 0.00<br />

44100 S 311.90 0.00 0.00 45327 S 630.35 0.00 0.00<br />

44312 S 543.77 0.00 0.00 45330 S 81.12 0.00 0.00<br />

44340 S 623.65 0.00 0.00 45331 S 239.89 0.00 0.00<br />

44360 S 380.08 0.00 0.00 45332 S 239.89 0.00 0.00<br />

44361 S 380.08 0.00 0.00 45333 S 320.87 0.00 0.00<br />

44363 S 380.08 0.00 0.00 45334 S 320.87 0.00 0.00<br />

44364 S 380.08 0.00 0.00 45335 S 239.89 0.00 0.00<br />

44365 S 380.08 0.00 0.00 45337 S 239.89 0.00 0.00<br />

44366 S 380.08 0.00 0.00 45338 S 320.87 0.00 0.00<br />

44369 S 380.08 0.00 0.00 45339 S 320.87 0.00 0.00<br />

44370 S 1,084.34 0.00 0.00 45340 S 320.87 0.00 0.00<br />

44372 S 380.08 0.00 0.00 45341 S 320.87 0.00 0.00<br />

44373 S 380.08 0.00 0.00 45342 S 320.87 0.00 0.00<br />

44376 S 380.08 0.00 0.00 45345 S 630.35 0.00 0.00<br />

44377 S 380.08 0.00 0.00 45355 S 318.18 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 369.18 0.00 0.00 46505 S 456.30 0.00 0.00<br />

45379 S 369.18 0.00 0.00 46600 S 24.14 0.00 0.00<br />

45380 S 369.18 0.00 0.00 46604 S 341.19 0.00 0.00<br />

45381 S 369.18 0.00 0.00 46606 S 128.20 0.00 0.00<br />

45382 S 369.18 0.00 0.00 46608 S 320.87 0.00 0.00<br />

45383 S 369.18 0.00 0.00 46610 S 592.66 0.00 0.00<br />

45384 S 369.18 0.00 0.00 46611 S 320.87 0.00 0.00<br />

45385 S 369.18 0.00 0.00 46612 S 592.66 0.00 0.00<br />

45386 S 369.18 0.00 0.00 46614 S 67.43 0.00 0.00<br />

45387 S 630.35 0.00 0.00 46615 S 643.65 0.00 0.00<br />

45391 S 369.18 0.00 0.00 46700 S 663.29 0.00 0.00<br />

45392 S 369.18 0.00 0.00 46706 S 730.09 0.00 0.00<br />

45500 S 634.41 0.00 0.00 46750 S 809.96 0.00 0.00<br />

45505 S 781.09 0.00 0.00 46753 S 663.29 0.00 0.00<br />

45520 S 30.93 0.00 0.00 46754 S 634.41 0.00 0.00<br />

45560 S 781.09 0.00 0.00 46760 S 781.09 0.00 0.00<br />

45900 S 250.14 0.00 0.00 46761 S 809.96 0.00 0.00<br />

45905 S 583.41 0.00 0.00 46762 S 1,028.83 0.00 0.00<br />

45910 S 583.41 0.00 0.00 46900 S 101.95 0.00 0.00<br />

45915 S 368.98 0.00 0.00 46910 S 121.85 0.00 0.00<br />

45990 S 573.96 0.00 0.00 46916 S 56.67 0.00 0.00<br />

46020 S 663.29 0.00 0.00 46917 S 528.68 0.00 0.00<br />

46030 S 250.14 0.00 0.00 46922 S 528.68 0.00 0.00<br />

46040 S 663.29 0.00 0.00 46924 S 528.68 0.00 0.00<br />

46045 S 634.41 0.00 0.00 46930 S 118.18 0.00 0.00<br />

46050 S 368.98 0.00 0.00 46937 S 634.41 0.00 0.00<br />

46060 S 634.41 0.00 0.00 46938 S 781.09 0.00 0.00<br />

46070 S 456.30 0.00 0.00 46940 S 87.46 0.00 0.00<br />

46080 S 663.29 0.00 0.00 46942 S 85.13 0.00 0.00<br />

46083 S 69.85 0.00 0.00 46945 S 144.88 0.00 0.00<br />

46200 S 634.41 0.00 0.00 46946 S 378.42 0.00 0.00<br />

46210 S 634.41 0.00 0.00 46947 S 1,028.83 0.00 0.00<br />

46211 S 634.41 0.00 0.00 47000 S 329.20 0.00 0.00<br />

46220 S 583.41 0.00 0.00 47382 S 1,737.26 0.00 0.00<br />

46221 S 114.84 0.00 0.00 47510 S 769.36 0.00 0.00<br />

46230 S 583.41 0.00 0.00 47511 S 1,130.31 0.00 0.00<br />

46250 S 663.29 0.00 0.00 47525 S 441.67 0.00 0.00<br />

46255 S 663.29 0.00 0.00 47530 S 441.67 0.00 0.00<br />

46257 S 663.29 0.00 0.00 47552 S 769.36 0.00 0.00<br />

46258 S 663.29 0.00 0.00 47553 S 798.24 0.00 0.00<br />

46260 S 663.29 0.00 0.00 47554 S 798.24 0.00 0.00<br />

46261 S 717.44 0.00 0.00 47555 S 798.24 0.00 0.00<br />

46262 S 717.44 0.00 0.00 47556 S 1,130.31 0.00 0.00<br />

46270 S 663.29 0.00 0.00 47560 S 937.90 0.00 0.00<br />

46275 S 663.29 0.00 0.00 47561 S 937.90 0.00 0.00<br />

46280 S 717.44 0.00 0.00 47562 S 1,730.62 0.00 0.00<br />

46285 S 583.41 0.00 0.00 47563 S 1,730.62 0.00 0.00<br />

46288 S 717.44 0.00 0.00 47564 S 1,730.62 0.00 0.00<br />

46320 S 77.79 0.00 0.00 47630 S 798.24 0.00 0.00<br />

46500 S 107.16 0.00 0.00 48102 S 329.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 200.18 0.00 0.00 49590 S 821.61 0.00 0.00<br />

49081 S 200.18 0.00 0.00 49600 S 875.76 0.00 0.00<br />

49180 S 329.20 0.00 0.00 49650 S 1,149.61 0.00 0.00<br />

49250 S 721.62 0.00 0.00 49651 S 1,314.33 0.00 0.00<br />

49320 S 937.90 0.00 0.00 49652 S 1,415.50 0.00 0.00<br />

49321 S 992.06 0.00 0.00 49653 S 1,415.50 0.00 0.00<br />

49322 S 992.06 0.00 0.00 49654 S 1,415.50 0.00 0.00<br />

49324 S 1,415.50 0.00 0.00 49655 S 1,415.50 0.00 0.00<br />

49325 S 1,415.50 0.00 0.00 49656 S 1,415.50 0.00 0.00<br />

49326 S 1,415.50 0.00 0.00 49657 S 1,415.50 0.00 0.00<br />

49402 S 638.58 0.00 0.00 50200 S 329.20 0.00 0.00<br />

49419 S 766.06 0.00 0.00 50382 S 955.92 0.00 0.00<br />

49420 S 708.18 0.00 0.00 50384 S 702.10 0.00 0.00<br />

49421 S 708.18 0.00 0.00 50385 S 702.10 0.00 0.00<br />

49422 S 563.60 0.00 0.00 50386 S 269.38 0.00 0.00<br />

49423 S 582.79 0.00 0.00 50387 S 582.79 0.00 0.00<br />

49426 S 638.58 0.00 0.00 50389 S 269.38 0.00 0.00<br />

49429 S 826.65 0.00 0.00 50390 S 329.20 0.00 0.00<br />

49440 S 323.26 0.00 0.00 50391 S 38.99 0.00 0.00<br />

49441 S 323.26 0.00 0.00 50392 S 501.32 0.00 0.00<br />

49446 S 323.26 0.00 0.00 50393 S 628.23 0.00 0.00<br />

49450 S 171.70 0.00 0.00 50395 S 501.32 0.00 0.00<br />

49451 S 171.70 0.00 0.00 50396 S 94.26 0.00 0.00<br />

49452 S 171.70 0.00 0.00 50398 S 441.67 0.00 0.00<br />

49460 S 171.70 0.00 0.00 50551 S 284.96 0.00 0.00<br />

49495 S 875.76 0.00 0.00 50553 S 628.23 0.00 0.00<br />

49496 S 875.76 0.00 0.00 50555 S 284.96 0.00 0.00<br />

49500 S 875.76 0.00 0.00 50557 S 628.23 0.00 0.00<br />

49501 S 1,195.71 0.00 0.00 50561 S 628.23 0.00 0.00<br />

49505 S 875.76 0.00 0.00 50562 S 269.38 0.00 0.00<br />

49507 S 1,195.71 0.00 0.00 50570 S 269.38 0.00 0.00<br />

49520 S 1,040.48 0.00 0.00 50572 S 269.38 0.00 0.00<br />

49521 S 1,195.71 0.00 0.00 50574 S 269.38 0.00 0.00<br />

49525 S 875.76 0.00 0.00 50575 S 1,339.94 0.00 0.00<br />

49540 S 792.72 0.00 0.00 50576 S 702.10 0.00 0.00<br />

49550 S 915.02 0.00 0.00 50580 S 702.10 0.00 0.00<br />

49553 S 1,195.71 0.00 0.00 50590 S 1,565.36 0.00 0.00<br />

49555 S 915.02 0.00 0.00 50592 S 1,737.26 0.00 0.00<br />

49557 S 1,195.71 0.00 0.00 50686 S 38.99 0.00 0.00<br />

49560 S 875.76 0.00 0.00 50688 S 441.67 0.00 0.00<br />

49561 S 1,195.71 0.00 0.00 50947 S 1,469.57 0.00 0.00<br />

49565 S 875.76 0.00 0.00 50948 S 1,469.57 0.00 0.00<br />

49566 S 1,195.71 0.00 0.00 50951 S 284.96 0.00 0.00<br />

49568 S 1,040.48 0.00 0.00 50953 S 284.96 0.00 0.00<br />

49570 S 875.76 0.00 0.00 50955 S 628.23 0.00 0.00<br />

49572 S 1,195.71 0.00 0.00 50957 S 628.23 0.00 0.00<br />

49580 S 875.76 0.00 0.00 50961 S 628.23 0.00 0.00<br />

49582 S 1,195.71 0.00 0.00 50970 S 284.96 0.00 0.00<br />

49585 S 875.76 0.00 0.00 50972 S 284.96 0.00 0.00<br />

49587 S 1,195.71 0.00 0.00 50974 S 501.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 501.32 0.00 0.00 52275 S 679.23 0.00 0.00<br />

50980 S 628.23 0.00 0.00 52276 S 708.11 0.00 0.00<br />

51020 S 762.27 0.00 0.00 52277 S 679.23 0.00 0.00<br />

51030 S 762.27 0.00 0.00 52281 S 552.31 0.00 0.00<br />

51040 S 762.27 0.00 0.00 52282 S 1,274.23 0.00 0.00<br />

51045 S 314.85 0.00 0.00 52283 S 679.23 0.00 0.00<br />

51050 S 762.27 0.00 0.00 52285 S 552.31 0.00 0.00<br />

51065 S 762.27 0.00 0.00 52290 S 552.31 0.00 0.00<br />

51080 S 512.42 0.00 0.00 52300 S 679.23 0.00 0.00<br />

51100 S 29.71 0.00 0.00 52301 S 708.11 0.00 0.00<br />

51101 S 38.99 0.00 0.00 52305 S 679.23 0.00 0.00<br />

51102 S 524.51 0.00 0.00 52310 S 531.21 0.00 0.00<br />

51500 S 875.76 0.00 0.00 52315 S 679.23 0.00 0.00<br />

51520 S 762.27 0.00 0.00 52317 S 628.23 0.00 0.00<br />

51700 S 50.74 0.00 0.00 52318 S 679.23 0.00 0.00<br />

51701 S 24.14 0.00 0.00 52320 S 801.52 0.00 0.00<br />

51702 S 24.14 0.00 0.00 52325 S 762.27 0.00 0.00<br />

51703 S 38.99 0.00 0.00 52327 S 871.24 0.00 0.00<br />

51705 S 69.85 0.00 0.00 52330 S 679.23 0.00 0.00<br />

51710 S 441.67 0.00 0.00 52332 S 679.23 0.00 0.00<br />

51715 S 801.94 0.00 0.00 52334 S 708.11 0.00 0.00<br />

51720 S 56.08 0.00 0.00 52341 S 708.11 0.00 0.00<br />

51725 TC S 107.74 0.00 0.00 52342 S 708.11 0.00 0.00<br />

51726 TC S 148.40 0.00 0.00 52343 S 708.11 0.00 0.00<br />

51736 TC S 20.36 0.00 0.00 52344 S 708.11 0.00 0.00<br />

51741 TC S 23.70 0.00 0.00 52345 S 708.11 0.00 0.00<br />

51772 TC S 94.26 0.00 0.00 52346 S 708.11 0.00 0.00<br />

51784 TC S 38.99 0.00 0.00 52351 S 708.11 0.00 0.00<br />

51785 TC S 65.13 0.00 0.00 52352 S 762.27 0.00 0.00<br />

51792 TC S 38.99 0.00 0.00 52353 S 954.28 0.00 0.00<br />

51795 TC S 69.85 0.00 0.00 52354 S 762.27 0.00 0.00<br />

51797 TC S 69.85 0.00 0.00 52355 S 762.27 0.00 0.00<br />

51798 S 17.36 0.00 0.00 52400 S 708.11 0.00 0.00<br />

51880 S 628.23 0.00 0.00 52402 S 708.11 0.00 0.00<br />

51992 S 1,188.88 0.00 0.00 52450 S 708.11 0.00 0.00<br />

52000 S 284.96 0.00 0.00 52500 S 708.11 0.00 0.00<br />

52001 S 531.21 0.00 0.00 52601 S 954.28 0.00 0.00<br />

52005 S 552.31 0.00 0.00 52630 S 871.24 0.00 0.00<br />

52007 S 679.23 0.00 0.00 52640 S 679.23 0.00 0.00<br />

52010 S 314.85 0.00 0.00 52647 S 1,459.95 0.00 0.00<br />

52204 S 552.31 0.00 0.00 52648 S 1,459.95 0.00 0.00<br />

52214 S 679.23 0.00 0.00 52700 S 679.23 0.00 0.00<br />

52224 S 679.23 0.00 0.00 53000 S 521.31 0.00 0.00<br />

52234 S 679.23 0.00 0.00 53010 S 521.31 0.00 0.00<br />

52235 S 708.11 0.00 0.00 53020 S 521.31 0.00 0.00<br />

52240 S 708.11 0.00 0.00 53025 S 742.06 0.00 0.00<br />

52250 S 762.27 0.00 0.00 53040 S 572.31 0.00 0.00<br />

52260 S 552.31 0.00 0.00 53060 S 67.77 0.00 0.00<br />

52265 S 269.38 0.00 0.00 53080 S 601.19 0.00 0.00<br />

52270 S 552.31 0.00 0.00 53085 S 742.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 521.31 0.00 0.00 54060 S 528.68 0.00 0.00<br />

53210 S 895.35 0.00 0.00 54065 S 528.68 0.00 0.00<br />

53215 S 694.60 0.00 0.00 54100 S 447.23 0.00 0.00<br />

53220 S 773.05 0.00 0.00 54105 S 558.29 0.00 0.00<br />

53230 S 773.05 0.00 0.00 54110 S 865.59 0.00 0.00<br />

53235 S 601.19 0.00 0.00 54111 S 865.59 0.00 0.00<br />

53240 S 773.05 0.00 0.00 54112 S 865.59 0.00 0.00<br />

53250 S 572.31 0.00 0.00 54115 S 512.42 0.00 0.00<br />

53260 S 572.31 0.00 0.00 54120 S 865.59 0.00 0.00<br />

53265 S 572.31 0.00 0.00 54150 S 576.87 0.00 0.00<br />

53270 S 572.31 0.00 0.00 54160 S 627.87 0.00 0.00<br />

53275 S 572.31 0.00 0.00 54161 S 627.87 0.00 0.00<br />

53400 S 801.94 0.00 0.00 54162 S 627.87 0.00 0.00<br />

53405 S 773.05 0.00 0.00 54163 S 627.87 0.00 0.00<br />

53410 S 773.05 0.00 0.00 54164 S 627.87 0.00 0.00<br />

53420 S 801.94 0.00 0.00 54200 S 65.76 0.00 0.00<br />

53425 S 773.05 0.00 0.00 54205 S 948.63 0.00 0.00<br />

53430 S 773.05 0.00 0.00 54220 S 94.26 0.00 0.00<br />

53431 S 773.05 0.00 0.00 54231 S 61.76 0.00 0.00<br />

53440 S 4,453.09 2,704.57 956.04 54235 S 43.73 0.00 0.00<br />

53442 S 722.06 0.00 0.00 54240 TC S 31.04 0.00 0.00<br />

53444 S 4,453.09 2,704.57 956.04 54250 TC S 11.01 0.00 0.00<br />

53445 S 7,480.06 4,259.84 1,039.63 54300 S 894.47 0.00 0.00<br />

53446 S 722.06 0.00 0.00 54304 S 894.47 0.00 0.00<br />

53447 S 7,480.06 4,259.84 1,039.63 54308 S 894.47 0.00 0.00<br />

53449 S 722.06 0.00 0.00 54312 S 894.47 0.00 0.00<br />

53450 S 722.06 0.00 0.00 54316 S 894.47 0.00 0.00<br />

53460 S 521.31 0.00 0.00 54318 S 894.47 0.00 0.00<br />

53502 S 572.31 0.00 0.00 54322 S 894.47 0.00 0.00<br />

53505 S 773.05 0.00 0.00 54324 S 894.47 0.00 0.00<br />

53510 S 572.31 0.00 0.00 54326 S 894.47 0.00 0.00<br />

53515 S 773.05 0.00 0.00 54328 S 894.47 0.00 0.00<br />

53520 S 773.05 0.00 0.00 54340 S 894.47 0.00 0.00<br />

53600 S 39.06 0.00 0.00 54344 S 894.47 0.00 0.00<br />

53601 S 38.99 0.00 0.00 54348 S 894.47 0.00 0.00<br />

53605 S 552.31 0.00 0.00 54352 S 894.47 0.00 0.00<br />

53620 S 60.09 0.00 0.00 54360 S 894.47 0.00 0.00<br />

53621 S 63.10 0.00 0.00 54380 S 894.47 0.00 0.00<br />

53660 S 38.99 0.00 0.00 54385 S 894.47 0.00 0.00<br />

53661 S 38.99 0.00 0.00 54400 S 4,481.98 2,733.45 984.93<br />

53665 S 521.31 0.00 0.00 54401 S 7,559.94 4,339.72 1,119.51<br />

53850 S 1,711.39 0.00 0.00 54405 S 7,559.94 4,339.72 1,119.51<br />

53852 S 1,711.39 0.00 0.00 54406 S 894.47 0.00 0.00<br />

54000 S 572.31 0.00 0.00 54408 S 894.47 0.00 0.00<br />

54001 S 572.31 0.00 0.00 54410 S 7,559.94 4,339.72 1,119.51<br />

54015 S 646.46 0.00 0.00 54415 S 894.47 0.00 0.00<br />

54050 S 30.93 0.00 0.00 54416 S 7,559.94 4,339.72 1,119.51<br />

54055 S 63.10 0.00 0.00 54420 S 948.63 0.00 0.00<br />

54056 S 30.93 0.00 0.00 54435 S 948.63 0.00 0.00<br />

54057 S 528.68 0.00 0.00 54440 S 948.63 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 148.40 0.00 0.00 55706 S 431.41 0.00 0.00<br />

54500 S 402.77 0.00 0.00 55720 S 628.23 0.00 0.00<br />

54505 S 576.87 0.00 0.00 55725 S 679.23 0.00 0.00<br />

54512 S 627.87 0.00 0.00 55860 S 748.48 0.00 0.00<br />

54520 S 656.75 0.00 0.00 55870 S 76.11 0.00 0.00<br />

54522 S 656.75 0.00 0.00 55873 S 5,922.24 0.00 0.00<br />

54530 S 875.76 0.00 0.00 55875 S 1,274.23 0.00 0.00<br />

54550 S 875.76 0.00 0.00 55876 S 69.77 0.00 0.00<br />

54560 S 853.20 0.00 0.00 55920 S 874.64 0.00 0.00<br />

54600 S 710.91 0.00 0.00 56405 S 40.73 0.00 0.00<br />

54620 S 656.75 0.00 0.00 56420 S 53.16 0.00 0.00<br />

54640 S 875.76 0.00 0.00 56440 S 570.83 0.00 0.00<br />

54660 S 627.87 0.00 0.00 56441 S 519.83 0.00 0.00<br />

54670 S 656.75 0.00 0.00 56442 S 519.83 0.00 0.00<br />

54680 S 656.75 0.00 0.00 56501 S 56.08 0.00 0.00<br />

54690 S 1,469.57 0.00 0.00 56515 S 608.56 0.00 0.00<br />

54692 S 2,612.29 0.00 0.00 56605 S 32.38 0.00 0.00<br />

54700 S 627.87 0.00 0.00 56606 S 13.36 0.00 0.00<br />

54800 S 140.93 0.00 0.00 56620 S 693.12 0.00 0.00<br />

54830 S 656.75 0.00 0.00 56625 S 818.57 0.00 0.00<br />

54840 S 710.91 0.00 0.00 56700 S 519.83 0.00 0.00<br />

54860 S 656.75 0.00 0.00 56740 S 599.71 0.00 0.00<br />

54861 S 710.91 0.00 0.00 56800 S 599.71 0.00 0.00<br />

54865 S 576.87 0.00 0.00 56805 S 739.11 0.00 0.00<br />

54900 S 710.91 0.00 0.00 56810 S 693.12 0.00 0.00<br />

54901 S 710.91 0.00 0.00 56820 S 41.39 0.00 0.00<br />

55000 S 64.10 0.00 0.00 56821 S 53.16 0.00 0.00<br />

55040 S 821.61 0.00 0.00 57000 S 519.83 0.00 0.00<br />

55041 S 915.02 0.00 0.00 57010 S 570.83 0.00 0.00<br />

55060 S 710.91 0.00 0.00 57020 S 299.37 0.00 0.00<br />

55100 S 385.55 0.00 0.00 57022 S 470.56 0.00 0.00<br />

55110 S 627.87 0.00 0.00 57023 S 512.42 0.00 0.00<br />

55120 S 627.87 0.00 0.00 57061 S 51.74 0.00 0.00<br />

55150 S 576.87 0.00 0.00 57065 S 519.83 0.00 0.00<br />

55175 S 576.87 0.00 0.00 57100 S 33.05 0.00 0.00<br />

55180 S 627.87 0.00 0.00 57105 S 570.83 0.00 0.00<br />

55200 S 627.87 0.00 0.00 57130 S 570.83 0.00 0.00<br />

55250 S 627.87 0.00 0.00 57135 S 570.83 0.00 0.00<br />

55400 S 576.87 0.00 0.00 57150 S 24.04 0.00 0.00<br />

55450 S 206.31 0.00 0.00 57155 S 299.37 0.00 0.00<br />

55500 S 656.75 0.00 0.00 57160 S 34.72 0.00 0.00<br />

55520 S 710.91 0.00 0.00 57170 S 5.69 0.00 0.00<br />

55530 S 710.91 0.00 0.00 57180 S 106.93 0.00 0.00<br />

55535 S 875.76 0.00 0.00 57200 S 519.83 0.00 0.00<br />

55540 S 915.02 0.00 0.00 57210 S 570.83 0.00 0.00<br />

55550 S 1,469.57 0.00 0.00 57220 S 1,046.82 0.00 0.00<br />

55600 S 853.20 0.00 0.00 57230 S 859.53 0.00 0.00<br />

55680 S 576.87 0.00 0.00 57240 S 952.94 0.00 0.00<br />

55700 S 371.77 0.00 0.00 57250 S 952.94 0.00 0.00<br />

55705 S 371.77 0.00 0.00 57260 S 952.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,265.68 0.00 0.00 58555 S 561.64 0.00 0.00<br />

57267 S 1,078.40 0.00 0.00 58558 S 641.52 0.00 0.00<br />

57268 S 859.53 0.00 0.00 58559 S 612.65 0.00 0.00<br />

57287 S 1,258.76 0.00 0.00 58560 S 914.72 0.00 0.00<br />

57288 S 1,140.23 0.00 0.00 58561 S 914.72 0.00 0.00<br />

57289 S 952.94 0.00 0.00 58562 S 641.52 0.00 0.00<br />

57291 S 952.94 0.00 0.00 58563 S 1,288.82 0.00 0.00<br />

57300 S 859.53 0.00 0.00 58565 S 1,420.93 0.00 0.00<br />

57320 S 1,258.76 0.00 0.00 58600 S 1,258.76 0.00 0.00<br />

57400 S 570.83 0.00 0.00 58615 S 739.11 0.00 0.00<br />

57410 S 570.83 0.00 0.00 58660 S 1,188.88 0.00 0.00<br />

57415 S 570.83 0.00 0.00 58661 S 1,188.88 0.00 0.00<br />

57420 S 42.73 0.00 0.00 58662 S 1,188.88 0.00 0.00<br />

57421 S 55.75 0.00 0.00 58670 S 1,095.47 0.00 0.00<br />

57452 S 40.39 0.00 0.00 58671 S 1,095.47 0.00 0.00<br />

57454 S 49.41 0.00 0.00 58672 S 1,188.88 0.00 0.00<br />

57455 S 52.41 0.00 0.00 58673 S 1,188.88 0.00 0.00<br />

57456 S 50.74 0.00 0.00 58800 S 599.71 0.00 0.00<br />

57460 S 155.90 0.00 0.00 58805 S 1,258.76 0.00 0.00<br />

57461 S 165.58 0.00 0.00 58820 S 859.53 0.00 0.00<br />

57500 S 71.44 0.00 0.00 58900 S 599.71 0.00 0.00<br />

57505 S 45.40 0.00 0.00 58970 S 167.04 0.00 0.00<br />

57510 S 46.07 0.00 0.00 58974 S 167.04 0.00 0.00<br />

57511 S 53.16 0.00 0.00 58976 S 167.04 0.00 0.00<br />

57513 S 570.83 0.00 0.00 59000 S 61.09 0.00 0.00<br />

57520 S 570.83 0.00 0.00 59001 S 229.31 0.00 0.00<br />

57522 S 570.83 0.00 0.00 59012 S 112.13 0.00 0.00<br />

57530 S 859.53 0.00 0.00 59015 S 49.41 0.00 0.00<br />

57550 S 859.53 0.00 0.00 59020 TC S 26.04 0.00 0.00<br />

57556 S 1,140.23 0.00 0.00 59025 TC S 13.69 0.00 0.00<br />

57558 S 599.71 0.00 0.00 59070 S 112.13 0.00 0.00<br />

57700 S 519.83 0.00 0.00 59072 S 112.13 0.00 0.00<br />

57720 S 599.71 0.00 0.00 59076 S 112.13 0.00 0.00<br />

57800 S 24.37 0.00 0.00 59100 S 1,258.76 0.00 0.00<br />

58100 S 40.06 0.00 0.00 59150 S 1,730.62 0.00 0.00<br />

58120 S 570.83 0.00 0.00 59151 S 1,730.62 0.00 0.00<br />

58145 S 952.94 0.00 0.00 59160 S 599.71 0.00 0.00<br />

58301 S 37.38 0.00 0.00 59200 S 33.39 0.00 0.00<br />

58321 S 35.05 0.00 0.00 59300 S 72.10 0.00 0.00<br />

58322 S 36.05 0.00 0.00 59320 S 519.83 0.00 0.00<br />

58323 S 8.35 0.00 0.00 59412 S 739.11 0.00 0.00<br />

58345 S 739.11 0.00 0.00 59414 S 739.11 0.00 0.00<br />

58346 S 570.83 0.00 0.00 59812 S 693.12 0.00 0.00<br />

58350 S 859.53 0.00 0.00 59820 S 693.12 0.00 0.00<br />

58353 S 1,078.40 0.00 0.00 59821 S 693.12 0.00 0.00<br />

58356 S 1,633.33 0.00 0.00 59840 S 693.12 0.00 0.00<br />

58545 S 1,312.01 0.00 0.00 59841 S 693.12 0.00 0.00<br />

58546 S 1,469.57 0.00 0.00 59866 S 112.13 0.00 0.00<br />

58550 S 1,910.40 0.00 0.00 59870 S 693.12 0.00 0.00<br />

58552 S 1,730.62 0.00 0.00 59871 S 693.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 290.99 0.00 0.00 62367 S 16.02 0.00 0.00<br />

60100 S 45.73 0.00 0.00 62368 S 20.36 0.00 0.00<br />

60200 S 1,083.07 0.00 0.00 63600 S 547.05 0.00 0.00<br />

60280 S 1,166.11 0.00 0.00 63610 S 496.05 0.00 0.00<br />

60281 S 1,166.11 0.00 0.00 63615 S 691.55 0.00 0.00<br />

60300 S 60.09 0.00 0.00 63650 S 2,944.47 1,825.87 707.27<br />

61000 S 267.94 0.00 0.00 63655 S 4,312.94 2,750.36 1,187.80<br />

61001 S 267.94 0.00 0.00 63660 S 517.10 0.00 0.00<br />

61020 S 216.93 0.00 0.00 63685 S 13,090.75 6,980.11 869.47<br />

61026 S 216.93 0.00 0.00 63688 S 702.19 0.00 0.00<br />

61050 S 216.93 0.00 0.00 63744 S 1,015.47 0.00 0.00<br />

61055 S 216.93 0.00 0.00 63746 S 469.73 0.00 0.00<br />

61070 S 168.80 0.00 0.00 64400 S 51.41 0.00 0.00<br />

61215 S 1,015.47 0.00 0.00 64402 S 48.41 0.00 0.00<br />

61330 S 1,564.38 0.00 0.00 64405 S 41.06 0.00 0.00<br />

61334 S 1,564.38 0.00 0.00 64408 S 51.07 0.00 0.00<br />

61790 S 575.93 0.00 0.00 64410 S 284.24 0.00 0.00<br />

61791 S 427.28 0.00 0.00 64412 S 75.11 0.00 0.00<br />

61880 S 733.66 0.00 0.00 64413 S 48.08 0.00 0.00<br />

61885 S 10,557.47 5,655.54 753.61 64415 S 130.91 0.00 0.00<br />

61886 S 15,764.87 8,309.00 853.13 64416 S 267.94 0.00 0.00<br />

61888 S 702.19 0.00 0.00 64417 S 130.91 0.00 0.00<br />

62194 S 284.24 0.00 0.00 64418 S 67.43 0.00 0.00<br />

62225 S 441.67 0.00 0.00 64420 S 130.91 0.00 0.00<br />

62230 S 986.58 0.00 0.00 64421 S 284.24 0.00 0.00<br />

62252 TC S 44.73 0.00 0.00 64425 S 46.73 0.00 0.00<br />

62263 S 284.24 0.00 0.00 64430 S 196.70 0.00 0.00<br />

62264 S 418.73 0.00 0.00 64435 S 70.44 0.00 0.00<br />

62267 S 167.10 0.00 0.00 64445 S 62.42 0.00 0.00<br />

62268 S 216.93 0.00 0.00 64446 S 536.92 0.00 0.00<br />

62269 S 329.20 0.00 0.00 64447 S 136.36 0.00 0.00<br />

62270 S 130.91 0.00 0.00 64448 S 136.36 0.00 0.00<br />

62272 S 130.91 0.00 0.00 64449 S 267.94 0.00 0.00<br />

62273 S 218.45 0.00 0.00 64450 S 41.73 0.00 0.00<br />

62280 S 284.24 0.00 0.00 64455 S 17.36 0.00 0.00<br />

62281 S 284.24 0.00 0.00 64470 S 284.24 0.00 0.00<br />

62282 S 284.24 0.00 0.00 64472 S 218.45 0.00 0.00<br />

62287 S 1,275.99 0.00 0.00 64475 S 284.24 0.00 0.00<br />

62292 S 267.94 0.00 0.00 64476 S 196.74 0.00 0.00<br />

62294 S 216.93 0.00 0.00 64479 S 284.24 0.00 0.00<br />

62310 S 284.24 0.00 0.00 64480 S 218.45 0.00 0.00<br />

62311 S 284.24 0.00 0.00 64483 S 284.24 0.00 0.00<br />

62318 S 284.24 0.00 0.00 64484 S 218.45 0.00 0.00<br />

62319 S 284.24 0.00 0.00 64505 S 38.06 0.00 0.00<br />

62350 S 986.58 0.00 0.00 64508 S 80.79 0.00 0.00<br />

62355 S 469.73 0.00 0.00 64510 S 284.24 0.00 0.00<br />

62360 S 986.58 0.00 0.00 64517 S 196.70 0.00 0.00<br />

62361 S 10,127.36 5,481.58 835.81 64520 S 284.24 0.00 0.00<br />

62362 S 10,127.36 5,481.58 835.81 64530 S 284.24 0.00 0.00<br />

62365 S 873.00 0.00 0.00 64553 S 2,893.47 1,774.87 656.27<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,249.20 2,130.59 1,012.00 64746 S 547.05 0.00 0.00<br />

64560 S 3,249.20 2,130.59 1,012.00 64761 S 691.55 0.00 0.00<br />

64561 S 2,973.35 1,854.75 736.15 64763 S 691.55 0.00 0.00<br />

64565 S 3,249.20 2,130.59 1,012.00 64766 S 1,343.45 0.00 0.00<br />

64573 S 5,061.76 2,998.60 935.44 64771 S 547.05 0.00 0.00<br />

64575 S 3,869.30 2,306.73 744.17 64772 S 547.05 0.00 0.00<br />

64577 S 3,869.30 2,306.73 744.17 64774 S 547.05 0.00 0.00<br />

64580 S 3,869.30 2,306.73 744.17 64776 S 575.93 0.00 0.00<br />

64581 S 3,949.18 2,386.61 824.05 64778 S 547.05 0.00 0.00<br />

64585 S 517.10 0.00 0.00 64782 S 575.93 0.00 0.00<br />

64590 S 10,557.47 5,655.54 753.61 64783 S 547.05 0.00 0.00<br />

64595 S 702.19 0.00 0.00 64784 S 575.93 0.00 0.00<br />

64600 S 418.73 0.00 0.00 64786 S 901.88 0.00 0.00<br />

64605 S 418.73 0.00 0.00 64787 S 547.05 0.00 0.00<br />

64610 S 418.73 0.00 0.00 64788 S 575.93 0.00 0.00<br />

64612 S 61.09 0.00 0.00 64790 S 575.93 0.00 0.00<br />

64613 S 59.09 0.00 0.00 64792 S 901.88 0.00 0.00<br />

64614 S 67.43 0.00 0.00 64795 S 547.05 0.00 0.00<br />

64620 S 284.24 0.00 0.00 64802 S 547.05 0.00 0.00<br />

64622 S 418.73 0.00 0.00 64820 S 691.55 0.00 0.00<br />

64623 S 284.24 0.00 0.00 64821 S 807.33 0.00 0.00<br />

64626 S 418.73 0.00 0.00 64822 S 1,046.04 0.00 0.00<br />

64627 S 196.74 0.00 0.00 64823 S 1,046.04 0.00 0.00<br />

64630 S 292.79 0.00 0.00 64831 S 956.03 0.00 0.00<br />

64632 S 31.71 0.00 0.00 64832 S 822.00 0.00 0.00<br />

64640 S 94.48 0.00 0.00 64834 S 873.00 0.00 0.00<br />

64650 S 31.71 0.00 0.00 64835 S 901.88 0.00 0.00<br />

64653 S 34.39 0.00 0.00 64836 S 901.88 0.00 0.00<br />

64680 S 444.89 0.00 0.00 64837 S 822.00 0.00 0.00<br />

64681 S 469.73 0.00 0.00 64840 S 873.00 0.00 0.00<br />

64702 S 496.05 0.00 0.00 64856 S 873.00 0.00 0.00<br />

64704 S 496.05 0.00 0.00 64857 S 873.00 0.00 0.00<br />

64708 S 547.05 0.00 0.00 64858 S 873.00 0.00 0.00<br />

64712 S 547.05 0.00 0.00 64859 S 822.00 0.00 0.00<br />

64713 S 547.05 0.00 0.00 64861 S 901.88 0.00 0.00<br />

64714 S 547.05 0.00 0.00 64862 S 901.88 0.00 0.00<br />

64716 S 575.93 0.00 0.00 64864 S 901.88 0.00 0.00<br />

64718 S 547.05 0.00 0.00 64865 S 956.03 0.00 0.00<br />

64719 S 547.05 0.00 0.00 64870 S 956.03 0.00 0.00<br />

64721 S 547.05 0.00 0.00 64872 S 873.00 0.00 0.00<br />

64722 S 496.05 0.00 0.00 64874 S 901.88 0.00 0.00<br />

64726 S 496.05 0.00 0.00 64876 S 901.88 0.00 0.00<br />

64727 S 496.05 0.00 0.00 64885 S 873.00 0.00 0.00<br />

64732 S 547.05 0.00 0.00 64886 S 873.00 0.00 0.00<br />

64734 S 547.05 0.00 0.00 64890 S 873.00 0.00 0.00<br />

64736 S 547.05 0.00 0.00 64891 S 873.00 0.00 0.00<br />

64738 S 547.05 0.00 0.00 64892 S 873.00 0.00 0.00<br />

64740 S 547.05 0.00 0.00 64893 S 873.00 0.00 0.00<br />

64742 S 547.05 0.00 0.00 64895 S 901.88 0.00 0.00<br />

64744 S 547.05 0.00 0.00 64896 S 901.88 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 901.88 0.00 0.00 65770 S 5,307.24 0.00 0.00<br />

64898 S 901.88 0.00 0.00 65772 S 597.02 0.00 0.00<br />

64901 S 873.00 0.00 0.00 65775 S 597.02 0.00 0.00<br />

64902 S 873.00 0.00 0.00 65780 S 1,032.77 0.00 0.00<br />

64905 S 873.00 0.00 0.00 65781 S 1,032.77 0.00 0.00<br />

64907 S 822.00 0.00 0.00 65782 S 1,032.77 0.00 0.00<br />

64910 S 1,343.45 0.00 0.00 65800 S 462.99 0.00 0.00<br />

65091 S 949.63 0.00 0.00 65805 S 462.99 0.00 0.00<br />

65093 S 949.63 0.00 0.00 65810 S 676.53 0.00 0.00<br />

65101 S 949.63 0.00 0.00 65815 S 647.64 0.00 0.00<br />

65103 S 949.63 0.00 0.00 65820 S 237.53 0.00 0.00<br />

65105 S 1,003.79 0.00 0.00 65850 S 730.68 0.00 0.00<br />

65110 S 1,043.04 0.00 0.00 65855 S 126.19 0.00 0.00<br />

65112 S 1,168.50 0.00 0.00 65860 S 117.85 0.00 0.00<br />

65114 S 1,168.50 0.00 0.00 65865 S 462.99 0.00 0.00<br />

65125 S 972.47 0.00 0.00 65870 S 730.68 0.00 0.00<br />

65130 S 716.39 0.00 0.00 65875 S 730.68 0.00 0.00<br />

65135 S 687.51 0.00 0.00 65880 S 597.02 0.00 0.00<br />

65140 S 949.63 0.00 0.00 65900 S 636.29 0.00 0.00<br />

65150 S 687.51 0.00 0.00 65920 S 895.40 0.00 0.00<br />

65155 S 949.63 0.00 0.00 65930 S 769.94 0.00 0.00<br />

65175 S 511.05 0.00 0.00 66020 S 462.99 0.00 0.00<br />

65205 S 19.70 0.00 0.00 66030 S 237.53 0.00 0.00<br />

65210 S 25.04 0.00 0.00 66130 S 895.40 0.00 0.00<br />

65220 S 34.89 0.00 0.00 66150 S 730.68 0.00 0.00<br />

65222 S 27.37 0.00 0.00 66155 S 730.68 0.00 0.00<br />

65235 S 513.99 0.00 0.00 66160 S 647.64 0.00 0.00<br />

65260 S 339.01 0.00 0.00 66165 S 730.68 0.00 0.00<br />

65265 S 701.36 0.00 0.00 66170 S 730.68 0.00 0.00<br />

65270 S 562.04 0.00 0.00 66172 S 730.68 0.00 0.00<br />

65272 S 647.64 0.00 0.00 66180 S 1,088.56 0.00 0.00<br />

65275 S 730.68 0.00 0.00 66185 S 966.27 0.00 0.00<br />

65280 S 701.36 0.00 0.00 66220 S 943.25 0.00 0.00<br />

65285 S 997.40 0.00 0.00 66225 S 1,049.31 0.00 0.00<br />

65286 S 174.49 0.00 0.00 66250 S 513.99 0.00 0.00<br />

65290 S 690.71 0.00 0.00 66500 S 237.53 0.00 0.00<br />

65400 S 462.99 0.00 0.00 66505 S 237.53 0.00 0.00<br />

65410 S 513.99 0.00 0.00 66600 S 676.53 0.00 0.00<br />

65420 S 513.99 0.00 0.00 66605 S 676.53 0.00 0.00<br />

65426 S 769.94 0.00 0.00 66625 S 481.02 0.00 0.00<br />

65430 S 34.89 0.00 0.00 66630 S 676.53 0.00 0.00<br />

65435 S 30.38 0.00 0.00 66635 S 676.53 0.00 0.00<br />

65436 S 131.86 0.00 0.00 66680 S 676.53 0.00 0.00<br />

65450 S 80.50 0.00 0.00 66682 S 647.64 0.00 0.00<br />

65600 S 155.57 0.00 0.00 66700 S 513.99 0.00 0.00<br />

65710 S 1,158.22 0.00 0.00 66710 S 513.99 0.00 0.00<br />

65730 S 1,158.22 0.00 0.00 66711 S 513.99 0.00 0.00<br />

65750 S 1,158.22 0.00 0.00 66720 S 513.99 0.00 0.00<br />

65755 S 1,158.22 0.00 0.00 66740 S 647.64 0.00 0.00<br />

65756 S 1,418.40 0.00 0.00 66761 S 175.60 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 178.60 0.00 0.00 67228 S 196.69 0.00 0.00<br />

66770 S 196.69 0.00 0.00 67229 S 196.69 0.00 0.00<br />

66820 S 174.49 0.00 0.00 67250 S 590.93 0.00 0.00<br />

66821 S 239.36 0.00 0.00 67255 S 647.22 0.00 0.00<br />

66825 S 730.68 0.00 0.00 67311 S 690.71 0.00 0.00<br />

66830 S 255.55 0.00 0.00 67312 S 744.87 0.00 0.00<br />

66840 S 549.33 0.00 0.00 67314 S 744.87 0.00 0.00<br />

66850 S 1,034.27 0.00 0.00 67316 S 744.87 0.00 0.00<br />

66852 S 869.55 0.00 0.00 67318 S 744.87 0.00 0.00<br />

66920 S 869.55 0.00 0.00 67320 S 744.87 0.00 0.00<br />

66930 S 908.81 0.00 0.00 67331 S 744.87 0.00 0.00<br />

66940 S 588.60 0.00 0.00 67332 S 744.87 0.00 0.00<br />

66982 S 892.93 0.00 0.00 67334 S 744.87 0.00 0.00<br />

66983 S 892.93 0.00 0.00 67335 S 744.87 0.00 0.00<br />

66984 S 892.93 0.00 0.00 67340 S 744.87 0.00 0.00<br />

66985 S 826.59 0.00 0.00 67343 S 909.58 0.00 0.00<br />

66986 S 826.59 0.00 0.00 67345 S 77.79 0.00 0.00<br />

67005 S 701.36 0.00 0.00 67346 S 420.72 0.00 0.00<br />

67010 S 701.36 0.00 0.00 67400 S 590.93 0.00 0.00<br />

67015 S 863.37 0.00 0.00 67405 S 770.54 0.00 0.00<br />

67025 S 567.34 0.00 0.00 67412 S 684.34 0.00 0.00<br />

67027 S 997.40 0.00 0.00 67413 S 809.80 0.00 0.00<br />

67028 S 78.45 0.00 0.00 67414 S 1,438.96 0.00 0.00<br />

67030 S 567.34 0.00 0.00 67415 S 511.05 0.00 0.00<br />

67031 S 239.36 0.00 0.00 67420 S 1,043.04 0.00 0.00<br />

67036 S 997.40 0.00 0.00 67430 S 1,043.04 0.00 0.00<br />

67039 S 1,162.12 0.00 0.00 67440 S 1,043.04 0.00 0.00<br />

67040 S 1,162.12 0.00 0.00 67445 S 1,043.04 0.00 0.00<br />

67041 S 1,426.19 0.00 0.00 67450 S 1,043.04 0.00 0.00<br />

67042 S 1,426.19 0.00 0.00 67500 S 80.50 0.00 0.00<br />

67043 S 1,426.19 0.00 0.00 67505 S 25.04 0.00 0.00<br />

67101 S 217.72 0.00 0.00 67515 S 25.37 0.00 0.00<br />

67105 S 196.69 0.00 0.00 67550 S 1,003.79 0.00 0.00<br />

67107 S 1,036.66 0.00 0.00 67560 S 687.51 0.00 0.00<br />

67108 S 1,162.12 0.00 0.00 67570 S 1,003.79 0.00 0.00<br />

67110 S 316.47 0.00 0.00 67700 S 117.77 0.00 0.00<br />

67112 S 1,162.12 0.00 0.00 67710 S 137.53 0.00 0.00<br />

67113 S 1,426.19 0.00 0.00 67715 S 511.05 0.00 0.00<br />

67115 S 618.33 0.00 0.00 67800 S 49.41 0.00 0.00<br />

67120 S 618.33 0.00 0.00 67801 S 59.76 0.00 0.00<br />

67121 S 618.33 0.00 0.00 67805 S 77.44 0.00 0.00<br />

67141 S 217.96 0.00 0.00 67808 S 562.04 0.00 0.00<br />

67145 S 185.94 0.00 0.00 67810 S 117.77 0.00 0.00<br />

67208 S 198.30 0.00 0.00 67820 S 16.36 0.00 0.00<br />

67210 S 196.69 0.00 0.00 67825 S 50.41 0.00 0.00<br />

67218 S 740.63 0.00 0.00 67830 S 345.05 0.00 0.00<br />

67220 S 217.72 0.00 0.00 67835 S 562.04 0.00 0.00<br />

67221 S 111.83 0.00 0.00 67840 S 144.22 0.00 0.00<br />

67225 S 7.68 0.00 0.00 67850 S 114.51 0.00 0.00<br />

67227 S 567.34 0.00 0.00 67875 S 287.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 542.87 0.00 0.00 68440 S 49.08 0.00 0.00<br />

67882 S 590.93 0.00 0.00 68500 S 716.39 0.00 0.00<br />

67900 S 770.54 0.00 0.00 68505 S 716.39 0.00 0.00<br />

67901 S 684.34 0.00 0.00 68510 S 511.05 0.00 0.00<br />

67902 S 809.80 0.00 0.00 68520 S 716.39 0.00 0.00<br />

67903 S 645.08 0.00 0.00 68525 S 511.05 0.00 0.00<br />

67904 S 645.08 0.00 0.00 68530 S 117.77 0.00 0.00<br />

67906 S 684.34 0.00 0.00 68540 S 590.93 0.00 0.00<br />

67908 S 645.08 0.00 0.00 68550 S 716.39 0.00 0.00<br />

67909 S 645.08 0.00 0.00 68700 S 562.04 0.00 0.00<br />

67911 S 590.93 0.00 0.00 68705 S 111.83 0.00 0.00<br />

67912 S 590.93 0.00 0.00 68720 S 770.54 0.00 0.00<br />

67914 S 590.93 0.00 0.00 68745 S 770.54 0.00 0.00<br />

67915 S 159.57 0.00 0.00 68750 S 770.54 0.00 0.00<br />

67916 S 645.08 0.00 0.00 68760 S 95.14 0.00 0.00<br />

67917 S 645.08 0.00 0.00 68761 S 65.76 0.00 0.00<br />

67921 S 590.93 0.00 0.00 68770 S 770.54 0.00 0.00<br />

67922 S 155.23 0.00 0.00 68801 S 34.89 0.00 0.00<br />

67923 S 645.08 0.00 0.00 68810 S 99.76 0.00 0.00<br />

67924 S 645.08 0.00 0.00 68811 S 562.04 0.00 0.00<br />

67930 S 159.57 0.00 0.00 68815 S 562.04 0.00 0.00<br />

67935 S 562.04 0.00 0.00 68816 S 721.55 0.00 0.00<br />

67938 S 80.50 0.00 0.00 68840 S 51.74 0.00 0.00<br />

67950 S 562.04 0.00 0.00 69000 S 52.78 0.00 0.00<br />

67961 S 590.93 0.00 0.00 69005 S 99.82 0.00 0.00<br />

67966 S 590.93 0.00 0.00 69020 S 52.78 0.00 0.00<br />

67971 S 590.93 0.00 0.00 69100 S 60.09 0.00 0.00<br />

67973 S 716.39 0.00 0.00 69105 S 85.13 0.00 0.00<br />

67974 S 590.93 0.00 0.00 69110 S 447.23 0.00 0.00<br />

67975 S 590.93 0.00 0.00 69120 S 663.69 0.00 0.00<br />

68020 S 43.73 0.00 0.00 69140 S 663.69 0.00 0.00<br />

68040 S 21.70 0.00 0.00 69145 S 498.22 0.00 0.00<br />

68100 S 86.79 0.00 0.00 69150 S 350.17 0.00 0.00<br />

68110 S 111.83 0.00 0.00 69200 S 24.14 0.00 0.00<br />

68115 S 562.04 0.00 0.00 69205 S 558.29 0.00 0.00<br />

68130 S 513.99 0.00 0.00 69210 S 19.70 0.00 0.00<br />

68135 S 56.08 0.00 0.00 69220 S 30.93 0.00 0.00<br />

68200 S 16.02 0.00 0.00 69222 S 130.19 0.00 0.00<br />

68320 S 770.54 0.00 0.00 69300 S 692.58 0.00 0.00<br />

68325 S 770.54 0.00 0.00 69310 S 1,012.35 0.00 0.00<br />

68326 S 645.08 0.00 0.00 69320 S 1,231.21 0.00 0.00<br />

68328 S 770.54 0.00 0.00 69400 S 87.46 0.00 0.00<br />

68330 S 730.68 0.00 0.00 69401 S 46.07 0.00 0.00<br />

68335 S 770.54 0.00 0.00 69405 S 120.85 0.00 0.00<br />

68340 S 645.08 0.00 0.00 69420 S 108.50 0.00 0.00<br />

68360 S 647.64 0.00 0.00 69421 S 552.19 0.00 0.00<br />

68362 S 647.64 0.00 0.00 69424 S 76.11 0.00 0.00<br />

68371 S 513.99 0.00 0.00 69433 S 108.17 0.00 0.00<br />

68400 S 117.77 0.00 0.00 69436 S 552.19 0.00 0.00<br />

68420 S 167.58 0.00 0.00 69440 S 692.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 932.47 0.00 0.00 69840 S 1,105.76 0.00 0.00<br />

69501 S 1,231.21 0.00 0.00 69905 S 1,231.21 0.00 0.00<br />

69502 S 911.45 0.00 0.00 69910 S 1,231.21 0.00 0.00<br />

69505 S 1,231.21 0.00 0.00 69915 S 1,231.21 0.00 0.00<br />

69511 S 1,231.21 0.00 0.00 69930 S 22,258.68 11,951.40 1,644.13<br />

69530 S 1,231.21 0.00 0.00 70030 TC A 17.02 0.00 0.00<br />

69540 S 127.19 0.00 0.00 70100 TC A 18.70 0.00 0.00<br />

69550 S 1,105.76 0.00 0.00 70110 TC A 23.04 0.00 0.00<br />

69552 S 1,231.21 0.00 0.00 70120 TC A 20.70 0.00 0.00<br />

69601 S 1,231.21 0.00 0.00 70130 TC A 25.29 0.00 0.00<br />

69602 S 1,231.21 0.00 0.00 70134 TC A 25.37 0.00 0.00<br />

69603 S 1,231.21 0.00 0.00 70140 TC A 17.36 0.00 0.00<br />

69604 S 1,231.21 0.00 0.00 70150 TC A 25.29 0.00 0.00<br />

69605 S 1,231.21 0.00 0.00 70160 TC A 20.36 0.00 0.00<br />

69610 S 170.25 0.00 0.00 70190 TC A 21.36 0.00 0.00<br />

69620 S 663.69 0.00 0.00 70200 TC A 25.29 0.00 0.00<br />

69631 S 1,105.76 0.00 0.00 70210 TC A 18.03 0.00 0.00<br />

69632 S 1,105.76 0.00 0.00 70220 TC A 22.70 0.00 0.00<br />

69633 S 1,105.76 0.00 0.00 70240 TC A 17.02 0.00 0.00<br />

69635 S 1,231.21 0.00 0.00 70250 TC A 20.70 0.00 0.00<br />

69636 S 1,231.21 0.00 0.00 70260 TC A 26.37 0.00 0.00<br />

69637 S 1,231.21 0.00 0.00 70300 TC A 7.34 0.00 0.00<br />

69641 S 1,231.21 0.00 0.00 70310 TC A 18.14 0.00 0.00<br />

69642 S 1,231.21 0.00 0.00 70320 TC A 18.14 0.00 0.00<br />

69643 S 1,231.21 0.00 0.00 70328 TC A 18.03 0.00 0.00<br />

69644 S 1,231.21 0.00 0.00 70330 TC A 25.29 0.00 0.00<br />

69645 S 1,231.21 0.00 0.00 70336 TC A 196.84 0.00 0.00<br />

69646 S 1,231.21 0.00 0.00 70350 TC A 10.01 0.00 0.00<br />

69650 S 911.45 0.00 0.00 70355 TC A 10.35 0.00 0.00<br />

69660 S 1,105.76 0.00 0.00 70360 TC A 16.02 0.00 0.00<br />

69661 S 1,105.76 0.00 0.00 70370 TC A 47.06 0.00 0.00<br />

69662 S 1,105.76 0.00 0.00 70371 TC A 47.06 0.00 0.00<br />

69666 S 1,066.49 0.00 0.00 70380 TC A 24.37 0.00 0.00<br />

69667 S 1,066.49 0.00 0.00 70450 TC A 109.93 0.00 0.00<br />

69670 S 1,012.35 0.00 0.00 70460 TC A 174.08 0.00 0.00<br />

69676 S 1,012.35 0.00 0.00 70470 TC A 192.83 0.00 0.00<br />

69700 S 1,012.35 0.00 0.00 70480 TC A 109.93 0.00 0.00<br />

69711 S 932.47 0.00 0.00 70481 TC A 174.08 0.00 0.00<br />

69714 S 5,913.55 3,728.71 1,543.88 70482 TC A 192.83 0.00 0.00<br />

69715 S 5,913.55 3,728.71 1,543.88 70486 TC A 109.93 0.00 0.00<br />

69717 S 5,913.55 3,728.71 1,543.88 70487 TC A 174.08 0.00 0.00<br />

69718 S 5,913.55 3,728.71 1,543.88 70488 TC A 192.83 0.00 0.00<br />

69720 S 1,105.76 0.00 0.00 70490 TC A 109.93 0.00 0.00<br />

69740 S 1,105.76 0.00 0.00 70491 TC A 174.08 0.00 0.00<br />

69745 S 1,105.76 0.00 0.00 70492 TC A 192.83 0.00 0.00<br />

69801 S 1,105.76 0.00 0.00 70496 TC A 198.99 0.00 0.00<br />

69802 S 1,231.21 0.00 0.00 70498 TC A 198.99 0.00 0.00<br />

69805 S 1,231.21 0.00 0.00 70540 TC A 196.84 0.00 0.00<br />

69806 S 1,231.21 0.00 0.00 70542 TC A 241.72 0.00 0.00<br />

69820 S 1,105.76 0.00 0.00 70543 TC A 304.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 196.84 0.00 0.00 72120 TC A 32.04 0.00 0.00<br />

70545 TC A 241.72 0.00 0.00 72125 TC A 109.93 0.00 0.00<br />

70546 TC A 304.65 0.00 0.00 72126 TC A 174.08 0.00 0.00<br />

70547 TC A 196.84 0.00 0.00 72127 TC A 192.83 0.00 0.00<br />

70548 TC A 241.72 0.00 0.00 72128 TC A 109.93 0.00 0.00<br />

70549 TC A 304.65 0.00 0.00 72129 TC A 174.08 0.00 0.00<br />

70551 TC A 196.84 0.00 0.00 72130 TC A 192.83 0.00 0.00<br />

70552 TC A 241.72 0.00 0.00 72131 TC A 109.93 0.00 0.00<br />

70553 TC A 304.65 0.00 0.00 72132 TC A 174.08 0.00 0.00<br />

70554 TC A 196.84 0.00 0.00 72133 TC A 192.83 0.00 0.00<br />

70555 TC A 196.84 0.00 0.00 72141 TC A 196.84 0.00 0.00<br />

70557 TC A 196.84 0.00 0.00 72142 TC A 241.72 0.00 0.00<br />

70558 TC A 241.72 0.00 0.00 72146 TC A 196.84 0.00 0.00<br />

70559 TC A 304.65 0.00 0.00 72147 TC A 241.72 0.00 0.00<br />

71010 TC A 13.02 0.00 0.00 72148 TC A 196.84 0.00 0.00<br />

71015 TC A 16.69 0.00 0.00 72149 TC A 241.72 0.00 0.00<br />

71020 TC A 17.70 0.00 0.00 72156 TC A 304.65 0.00 0.00<br />

71021 TC A 21.36 0.00 0.00 72157 TC A 304.65 0.00 0.00<br />

71022 TC A 25.29 0.00 0.00 72158 TC A 304.65 0.00 0.00<br />

71023 TC A 41.39 0.00 0.00 72170 TC A 15.02 0.00 0.00<br />

71030 TC A 25.29 0.00 0.00 72190 TC A 25.29 0.00 0.00<br />

71034 TC A 47.06 0.00 0.00 72191 TC A 198.99 0.00 0.00<br />

71035 TC A 22.03 0.00 0.00 72192 TC A 109.93 0.00 0.00<br />

71100 TC A 18.36 0.00 0.00 72193 TC A 174.08 0.00 0.00<br />

71101 TC A 22.36 0.00 0.00 72194 TC A 192.83 0.00 0.00<br />

71110 TC A 23.37 0.00 0.00 72195 TC A 196.84 0.00 0.00<br />

71111 TC A 31.04 0.00 0.00 72196 TC A 241.72 0.00 0.00<br />

71120 TC A 19.36 0.00 0.00 72197 TC A 304.65 0.00 0.00<br />

71130 TC A 22.70 0.00 0.00 72200 TC A 17.70 0.00 0.00<br />

71250 TC A 109.93 0.00 0.00 72202 TC A 21.70 0.00 0.00<br />

71260 TC A 174.08 0.00 0.00 72220 TC A 17.70 0.00 0.00<br />

71270 TC A 192.83 0.00 0.00 73000 TC A 16.69 0.00 0.00<br />

71275 TC A 198.99 0.00 0.00 73010 TC A 17.02 0.00 0.00<br />

71550 TC A 196.84 0.00 0.00 73020 TC A 13.69 0.00 0.00<br />

71551 TC A 241.72 0.00 0.00 73030 TC A 17.36 0.00 0.00<br />

71552 TC A 304.65 0.00 0.00 73050 TC A 21.70 0.00 0.00<br />

72010 TC A 42.10 0.00 0.00 73060 TC A 17.36 0.00 0.00<br />

72020 TC A 13.69 0.00 0.00 73070 TC A 16.69 0.00 0.00<br />

72040 TC A 22.03 0.00 0.00 73080 TC A 22.03 0.00 0.00<br />

72050 TC A 31.38 0.00 0.00 73090 TC A 16.69 0.00 0.00<br />

72052 TC A 42.10 0.00 0.00 73092 TC A 17.36 0.00 0.00<br />

72069 TC A 20.70 0.00 0.00 73100 TC A 17.36 0.00 0.00<br />

72070 TC A 19.36 0.00 0.00 73110 TC A 22.03 0.00 0.00<br />

72072 TC A 23.37 0.00 0.00 73120 TC A 16.36 0.00 0.00<br />

72074 TC A 25.29 0.00 0.00 73130 TC A 19.36 0.00 0.00<br />

72080 TC A 20.70 0.00 0.00 73140 TC A 19.03 0.00 0.00<br />

72090 TC A 27.71 0.00 0.00 73200 TC A 109.93 0.00 0.00<br />

72100 TC A 23.70 0.00 0.00 73201 TC A 174.08 0.00 0.00<br />

72110 TC A 33.05 0.00 0.00 73202 TC A 192.83 0.00 0.00<br />

72114 TC A 42.10 0.00 0.00 73206 TC A 198.99 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 196.84 0.00 0.00 74246 TC A 49.68 0.00 0.00<br />

73219 TC A 241.72 0.00 0.00 74247 TC A 49.68 0.00 0.00<br />

73220 TC A 304.65 0.00 0.00 74249 TC A 80.78 0.00 0.00<br />

73221 TC A 196.84 0.00 0.00 74250 TC A 49.68 0.00 0.00<br />

73222 TC A 241.72 0.00 0.00 74251 TC A 80.78 0.00 0.00<br />

73223 TC A 304.65 0.00 0.00 74260 TC A 49.68 0.00 0.00<br />

73500 TC A 14.36 0.00 0.00 74270 TC A 49.68 0.00 0.00<br />

73510 TC A 22.03 0.00 0.00 74280 TC A 80.78 0.00 0.00<br />

73520 TC A 22.70 0.00 0.00 74283 TC A 49.68 0.00 0.00<br />

73540 TC A 22.70 0.00 0.00 74290 TC A 42.39 0.00 0.00<br />

73550 TC A 16.69 0.00 0.00 74291 TC A 40.73 0.00 0.00<br />

73560 TC A 17.02 0.00 0.00 74400 TC A 73.78 0.00 0.00<br />

73562 TC A 21.03 0.00 0.00 74410 TC A 78.79 0.00 0.00<br />

73564 TC A 24.37 0.00 0.00 74415 TC A 94.14 0.00 0.00<br />

73565 TC A 18.36 0.00 0.00 74420 TC A 98.40 0.00 0.00<br />

73590 TC A 16.02 0.00 0.00 74710 TC A 22.03 0.00 0.00<br />

73592 TC A 17.36 0.00 0.00 74775 TC A 98.40 0.00 0.00<br />

73600 TC A 16.36 0.00 0.00 75557 TC A 196.84 0.00 0.00<br />

73610 TC A 19.36 0.00 0.00 75559 TC A 196.84 0.00 0.00<br />

73620 TC A 15.69 0.00 0.00 75561 TC A 304.65 0.00 0.00<br />

73630 TC A 19.03 0.00 0.00 75563 TC A 304.65 0.00 0.00<br />

73650 TC A 16.02 0.00 0.00 76010 TC A 16.36 0.00 0.00<br />

73660 TC A 18.03 0.00 0.00 76098 TC A 10.01 0.00 0.00<br />

73700 TC A 109.93 0.00 0.00 76100 TC A 42.10 0.00 0.00<br />

73701 TC A 174.08 0.00 0.00 76101 TC A 112.83 0.00 0.00<br />

73702 TC A 192.83 0.00 0.00 76102 TC A 112.83 0.00 0.00<br />

73706 TC A 198.99 0.00 0.00 76120 TC A 47.06 0.00 0.00<br />

73718 TC A 196.84 0.00 0.00 76150 A 16.36 0.00 0.00<br />

73719 TC A 241.72 0.00 0.00 76380 TC A 59.39 0.00 0.00<br />

73720 TC A 304.65 0.00 0.00 76496 TC A 47.06 0.00 0.00<br />

73721 TC A 196.84 0.00 0.00 76497 TC A 59.39 0.00 0.00<br />

73722 TC A 241.72 0.00 0.00 76498 TC A 196.84 0.00 0.00<br />

73723 TC A 304.65 0.00 0.00 76499 TC A 25.29 0.00 0.00<br />

74000 TC A 14.36 0.00 0.00 76506 TC A 35.35 0.00 0.00<br />

74010 TC A 22.36 0.00 0.00 76510 TC A 60.09 0.00 0.00<br />

74020 TC A 22.70 0.00 0.00 76511 TC A 42.06 0.00 0.00<br />

74022 TC A 27.71 0.00 0.00 76512 TC A 35.72 0.00 0.00<br />

74150 TC A 109.93 0.00 0.00 76513 TC A 43.40 0.00 0.00<br />

74160 TC A 174.08 0.00 0.00 76514 TC A 3.01 0.00 0.00<br />

74170 TC A 192.83 0.00 0.00 76516 TC A 34.05 0.00 0.00<br />

74175 TC A 198.99 0.00 0.00 76519 TC A 38.06 0.00 0.00<br />

74181 TC A 196.84 0.00 0.00 76529 TC A 33.05 0.00 0.00<br />

74182 TC A 241.72 0.00 0.00 76536 TC A 55.30 0.00 0.00<br />

74183 TC A 304.65 0.00 0.00 76604 TC A 35.35 0.00 0.00<br />

74210 TC A 49.68 0.00 0.00 76645 TC A 35.35 0.00 0.00<br />

74220 TC A 49.68 0.00 0.00 76700 TC A 55.30 0.00 0.00<br />

74230 TC A 49.68 0.00 0.00 76705 TC A 55.30 0.00 0.00<br />

74240 TC A 49.68 0.00 0.00 76770 TC A 55.30 0.00 0.00<br />

74241 TC A 49.68 0.00 0.00 76775 TC A 55.30 0.00 0.00<br />

74245 TC A 80.78 0.00 0.00 76776 TC A 55.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 55.30 0.00 0.00 77290 TC A 144.61 0.00 0.00<br />

76801 TC A 55.30 0.00 0.00 77295 TC A 378.90 0.00 0.00<br />

76802 TC A 26.37 0.00 0.00 77299 TC A 64.88 0.00 0.00<br />

76805 TC A 55.30 0.00 0.00 77300 TC A 35.05 0.00 0.00<br />

76810 TC A 41.73 0.00 0.00 77301 TC A 504.97 0.00 0.00<br />

76811 TC A 86.63 0.00 0.00 77305 TC A 32.04 0.00 0.00<br />

76812 TC A 35.35 0.00 0.00 77310 TC A 41.73 0.00 0.00<br />

76813 TC A 35.35 0.00 0.00 77315 TC A 60.76 0.00 0.00<br />

76814 TC A 28.05 0.00 0.00 77321 TC A 63.10 0.00 0.00<br />

76815 TC A 35.35 0.00 0.00 77326 TC A 64.88 0.00 0.00<br />

76816 TC A 35.35 0.00 0.00 77327 TC A 117.85 0.00 0.00<br />

76817 TC A 35.35 0.00 0.00 77328 TC A 144.61 0.00 0.00<br />

76818 TC A 55.30 0.00 0.00 77331 TC A 16.69 0.00 0.00<br />

76819 TC A 47.74 0.00 0.00 77332 TC A 44.73 0.00 0.00<br />

76820 TC A 23.70 0.00 0.00 77333 TC A 21.70 0.00 0.00<br />

76821 TC A 53.53 0.00 0.00 77334 TC A 83.79 0.00 0.00<br />

76825 TC A 111.50 0.00 0.00 77336 A 52.75 0.00 0.00<br />

76826 TC A 66.43 0.00 0.00 77370 A 64.88 0.00 0.00<br />

76827 TC A 35.35 0.00 0.00 77371 A 4,321.72 0.00 0.00<br />

76828 TC A 21.03 0.00 0.00 77399 TC A 64.88 0.00 0.00<br />

76830 TC A 55.30 0.00 0.00 77401 A 26.37 0.00 0.00<br />

76831 TC A 74.45 0.00 0.00 77402 A 53.09 0.00 0.00<br />

76856 TC A 55.30 0.00 0.00 77403 A 53.09 0.00 0.00<br />

76857 TC A 35.35 0.00 0.00 77404 A 53.09 0.00 0.00<br />

76870 TC A 55.30 0.00 0.00 77406 A 86.00 0.00 0.00<br />

76872 TC A 55.30 0.00 0.00 77407 A 53.09 0.00 0.00<br />

76873 TC A 55.30 0.00 0.00 77408 A 53.09 0.00 0.00<br />

76880 TC A 55.30 0.00 0.00 77409 A 53.09 0.00 0.00<br />

76885 TC A 35.35 0.00 0.00 77411 A 86.00 0.00 0.00<br />

76886 TC A 35.35 0.00 0.00 77412 A 86.00 0.00 0.00<br />

76936 TC A 53.53 0.00 0.00 77413 A 86.00 0.00 0.00<br />

76970 TC A 35.35 0.00 0.00 77414 A 86.00 0.00 0.00<br />

76977 TC A 9.02 0.00 0.00 77416 A 86.00 0.00 0.00<br />

76999 TC A 35.35 0.00 0.00 77418 A 232.34 0.00 0.00<br />

77071 A 20.70 0.00 0.00 77422 A 86.00 0.00 0.00<br />

77072 TC A 12.01 0.00 0.00 77423 A 86.00 0.00 0.00<br />

77073 TC A 20.36 0.00 0.00 77470 TC A 123.52 0.00 0.00<br />

77074 TC A 40.06 0.00 0.00 77520 A 397.80 0.00 0.00<br />

77075 TC A 42.10 0.00 0.00 77522 A 397.80 0.00 0.00<br />

77076 TC A 42.10 0.00 0.00 77523 A 475.38 0.00 0.00<br />

77077 TC A 22.70 0.00 0.00 77525 A 475.38 0.00 0.00<br />

77078 TC A 40.67 0.00 0.00 77600 TC A 211.06 0.00 0.00<br />

77079 TC A 41.73 0.00 0.00 77605 TC A 211.06 0.00 0.00<br />

77080 TC A 40.67 0.00 0.00 77610 TC A 211.06 0.00 0.00<br />

77081 TC A 16.36 0.00 0.00 77615 TC A 211.06 0.00 0.00<br />

77082 TC A 17.70 0.00 0.00 77620 TC A 211.06 0.00 0.00<br />

77083 TC A 14.02 0.00 0.00 77750 TC A 82.12 0.00 0.00<br />

77084 TC A 196.84 0.00 0.00 77761 TC A 144.55 0.00 0.00<br />

77280 TC A 64.88 0.00 0.00 77762 TC A 171.25 0.00 0.00<br />

77285 TC A 144.61 0.00 0.00 77763 TC A 220.66 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 156.57 0.00 0.00 78262 TC A 137.50 0.00 0.00<br />

77777 TC A 171.92 0.00 0.00 78264 TC A 137.50 0.00 0.00<br />

77778 TC A 229.01 0.00 0.00 78270 TC A 60.09 0.00 0.00<br />

77785 TC A 101.82 0.00 0.00 78271 TC A 61.09 0.00 0.00<br />

77786 TC A 357.86 0.00 0.00 78272 TC A 67.10 0.00 0.00<br />

77787 TC A 414.69 0.00 0.00 78278 TC A 137.50 0.00 0.00<br />

77789 TC A 42.73 0.00 0.00 78282 TC A 137.50 0.00 0.00<br />

77799 TC A 243.56 0.00 0.00 78290 TC A 137.50 0.00 0.00<br />

78000 TC A 52.41 0.00 0.00 78291 TC A 137.50 0.00 0.00<br />

78001 TC A 66.42 0.00 0.00 78299 TC A 137.50 0.00 0.00<br />

78003 TC A 52.75 0.00 0.00 78300 TC A 119.85 0.00 0.00<br />

78006 TC A 125.50 0.00 0.00 78305 TC A 139.00 0.00 0.00<br />

78007 TC A 92.81 0.00 0.00 78306 TC A 139.00 0.00 0.00<br />

78010 TC A 77.11 0.00 0.00 78315 TC A 139.00 0.00 0.00<br />

78011 TC A 77.11 0.00 0.00 78320 TC A 139.00 0.00 0.00<br />

78015 TC A 149.89 0.00 0.00 78399 TC A 139.00 0.00 0.00<br />

78016 TC A 169.19 0.00 0.00 78414 TC A 176.68 0.00 0.00<br />

78018 TC A 169.19 0.00 0.00 78428 TC A 135.54 0.00 0.00<br />

78070 TC A 115.17 0.00 0.00 78445 TC A 105.72 0.00 0.00<br />

78075 TC A 326.15 0.00 0.00 78456 TC A 105.72 0.00 0.00<br />

78099 TC A 77.11 0.00 0.00 78457 TC A 105.72 0.00 0.00<br />

78102 TC A 116.51 0.00 0.00 78458 TC A 105.72 0.00 0.00<br />

78103 TC A 148.51 0.00 0.00 78459 TC A 654.26 0.00 0.00<br />

78104 TC A 148.51 0.00 0.00 78460 TC A 126.85 0.00 0.00<br />

78110 TC A 59.09 0.00 0.00 78461 TC A 127.86 0.00 0.00<br />

78111 TC A 74.78 0.00 0.00 78464 TC A 187.61 0.00 0.00<br />

78120 TC A 65.43 0.00 0.00 78465 TC A 355.20 0.00 0.00<br />

78121 TC A 77.44 0.00 0.00 78466 TC A 125.85 0.00 0.00<br />

78122 TC A 91.80 0.00 0.00 78468 TC A 160.91 0.00 0.00<br />

78130 TC A 106.49 0.00 0.00 78469 TC A 176.68 0.00 0.00<br />

78135 TC A 226.33 0.00 0.00 78472 TC A 176.68 0.00 0.00<br />

78140 TC A 100.48 0.00 0.00 78473 TC A 176.68 0.00 0.00<br />

78185 TC A 148.51 0.00 0.00 78481 TC A 152.56 0.00 0.00<br />

78190 TC A 93.19 0.00 0.00 78483 TC A 176.68 0.00 0.00<br />

78191 TC A 93.19 0.00 0.00 78491 TC A 654.26 0.00 0.00<br />

78195 TC A 148.51 0.00 0.00 78492 TC A 654.26 0.00 0.00<br />

78199 TC A 148.51 0.00 0.00 78494 TC A 176.68 0.00 0.00<br />

78201 TC A 132.19 0.00 0.00 78499 TC A 176.68 0.00 0.00<br />

78202 TC A 155.51 0.00 0.00 78580 TC A 119.70 0.00 0.00<br />

78205 TC A 155.51 0.00 0.00 78584 TC A 92.47 0.00 0.00<br />

78206 TC A 155.51 0.00 0.00 78585 TC A 183.67 0.00 0.00<br />

78215 TC A 139.88 0.00 0.00 78586 TC A 119.70 0.00 0.00<br />

78216 TC A 94.81 0.00 0.00 78587 TC A 119.70 0.00 0.00<br />

78220 TC A 103.49 0.00 0.00 78588 TC A 183.67 0.00 0.00<br />

78223 TC A 155.51 0.00 0.00 78591 TC A 119.70 0.00 0.00<br />

78230 TC A 117.50 0.00 0.00 78593 TC A 119.70 0.00 0.00<br />

78231 TC A 92.47 0.00 0.00 78594 TC A 119.70 0.00 0.00<br />

78232 TC A 96.48 0.00 0.00 78596 TC A 183.67 0.00 0.00<br />

78258 TC A 137.50 0.00 0.00 78599 TC A 119.70 0.00 0.00<br />

78261 TC A 137.50 0.00 0.00 78600 TC A 105.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 36100 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 105.49 0.00 0.00<br />

78605 TC A 105.49 0.00 0.00<br />

78606 TC A 237.02 0.00 0.00<br />

78607 TC A 260.39 0.00 0.00<br />

78608 TC A 586.42 0.00 0.00<br />

78610 TC A 140.54 0.00 0.00<br />

78630 TC A 250.37 0.00 0.00<br />

78635 TC A 230.68 0.00 0.00<br />

78645 TC A 105.49 0.00 0.00<br />

78647 TC A 255.38 0.00 0.00<br />

78650 TC A 247.37 0.00 0.00<br />

78660 TC A 105.49 0.00 0.00<br />

78699 TC A 105.49 0.00 0.00<br />

78700 TC A 129.86 0.00 0.00<br />

78701 TC A 158.24 0.00 0.00<br />

78707 TC A 165.25 0.00 0.00<br />

78708 TC A 113.17 0.00 0.00<br />

78709 TC A 186.06 0.00 0.00<br />

78710 TC A 174.60 0.00 0.00<br />

78725 TC A 69.77 0.00 0.00<br />

78730 TC A 59.09 0.00 0.00<br />

78740 TC A 154.23 0.00 0.00<br />

78761 TC A 147.22 0.00 0.00<br />

78799 TC A 186.06 0.00 0.00<br />

78800 TC A 130.19 0.00 0.00<br />

78801 TC A 178.60 0.00 0.00<br />

78802 TC A 242.03 0.00 0.00<br />

78803 TC A 259.39 0.00 0.00<br />

78804 TC A 452.67 0.00 0.00<br />

78805 TC A 127.19 0.00 0.00<br />

78806 TC A 254.38 0.00 0.00<br />

78807 TC A 259.72 0.00 0.00<br />

78811 TC A 586.42 0.00 0.00<br />

78812 TC A 586.42 0.00 0.00<br />

78813 TC A 586.42 0.00 0.00<br />

78814 TC A 586.42 0.00 0.00<br />

78815 TC A 586.42 0.00 0.00<br />

78816 TC A 586.42 0.00 0.00<br />

78999 TC A 66.42 0.00 0.00<br />

79005 TC A 53.42 0.00 0.00<br />

79101 TC A 58.42 0.00 0.00<br />

79200 TC A 63.10 0.00 0.00<br />

79300 TC A 121.73 0.00 0.00<br />

79403 TC A 90.47 0.00 0.00<br />

79440 TC A 51.07 0.00 0.00<br />

79445 TC A 121.73 0.00 0.00<br />

79999 TC A 121.73 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,220.50 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,506.21 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.51 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,556.36 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,556.36 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 224.76 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 224.76 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 113.49 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 239.86 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 72.11 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 645.67 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,472.34 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,152.48 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,152.48 0.00 0.00<br />

C8900 A 249.54 0.00 0.00 0123T S 921.64 0.00 0.00<br />

C8901 A 203.21 0.00 0.00 0124T S 180.14 0.00 0.00<br />

C8902 A 314.51 0.00 0.00 0144T TC A 61.31 0.00 0.00<br />

C8903 A 249.54 0.00 0.00 0145T TC A 165.04 0.00 0.00<br />

C8904 A 203.21 0.00 0.00 0146T TC A 165.04 0.00 0.00<br />

C8905 A 314.51 0.00 0.00 0147T TC A 165.04 0.00 0.00<br />

C8906 A 249.54 0.00 0.00 0148T TC A 165.04 0.00 0.00<br />

C8907 A 203.21 0.00 0.00 0149T TC A 165.04 0.00 0.00<br />

C8908 A 314.51 0.00 0.00 0150T TC A 165.04 0.00 0.00<br />

C8909 A 249.54 0.00 0.00 0151T TC A 61.31 0.00 0.00<br />

C8910 A 203.21 0.00 0.00 0170T S 1,197.15 0.00 0.00<br />

C8911 A 314.51 0.00 0.00 0176T S 1,413.56 0.00 0.00<br />

C8912 A 249.54 0.00 0.00 0177T S 1,413.56 0.00 0.00<br />

C8913 A 203.21 0.00 0.00 0182T A 1,021.73 0.00 0.00<br />

C8914 A 314.51 0.00 0.00 0186T S 861.11 0.00 0.00<br />

C8918 A 249.54 0.00 0.00 0190T S 861.11 0.00 0.00<br />

C8919 A 203.21 0.00 0.00 0191T S 921.64 0.00 0.00<br />

C8920 A 314.51 0.00 0.00 0192T S 1,579.51 0.00 0.00<br />

C9716 S 1,197.15 0.00 0.00 10021 S 55.24 0.00 0.00<br />

C9724 S 978.81 0.00 0.00 10022 S 172.51 0.00 0.00<br />

C9725 S 225.71 0.00 0.00 10040 S 31.93 0.00 0.00<br />

C9726 S 828.64 0.00 0.00 10060 S 48.59 0.00 0.00<br />

C9727 S 290.53 0.00 0.00 10061 S 54.49 0.00 0.00<br />

C9728 S 521.31 0.00 0.00 10080 S 54.49 0.00 0.00<br />

G0104 S 83.74 0.00 0.00 10081 S 125.44 0.00 0.00<br />

G0105 S 361.94 0.00 0.00 10120 S 68.24 0.00 0.00<br />

G0121 S 361.94 0.00 0.00 10121 S 514.34 0.00 0.00<br />

G0127 S 11.72 0.00 0.00 10140 S 72.37 0.00 0.00<br />

G0130 TC A 19.30 0.00 0.00 10160 S 54.49 0.00 0.00<br />

G0173 A 2,220.50 0.00 0.00 10180 S 581.65 0.00 0.00<br />

G0186 S 224.76 0.00 0.00 11000 S 23.44 0.00 0.00<br />

G0247 S 21.37 0.00 0.00 11001 S 7.93 0.00 0.00<br />

G0251 A 556.04 0.00 0.00 11010 S 203.49 0.00 0.00<br />

G0260 S 293.44 0.00 0.00 11011 S 203.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 203.49 0.00 0.00 11601 S 112.35 0.00 0.00<br />

11040 S 21.37 0.00 0.00 11602 S 123.72 0.00 0.00<br />

11041 S 23.78 0.00 0.00 11603 S 131.30 0.00 0.00<br />

11042 S 129.22 0.00 0.00 11604 S 354.18 0.00 0.00<br />

11043 S 129.22 0.00 0.00 11606 S 514.34 0.00 0.00<br />

11044 S 336.47 0.00 0.00 11620 S 95.81 0.00 0.00<br />

11055 S 25.16 0.00 0.00 11621 S 113.73 0.00 0.00<br />

11056 S 27.57 0.00 0.00 11622 S 126.48 0.00 0.00<br />

11057 S 31.93 0.00 0.00 11623 S 136.13 0.00 0.00<br />

11100 S 58.51 0.00 0.00 11624 S 514.34 0.00 0.00<br />

11101 S 13.79 0.00 0.00 11626 S 629.00 0.00 0.00<br />

11200 S 31.93 0.00 0.00 11640 S 101.33 0.00 0.00<br />

11201 S 5.51 0.00 0.00 11641 S 119.59 0.00 0.00<br />

11300 S 31.93 0.00 0.00 11642 S 133.38 0.00 0.00<br />

11301 S 31.93 0.00 0.00 11643 S 143.71 0.00 0.00<br />

11302 S 31.93 0.00 0.00 11644 S 514.34 0.00 0.00<br />

11303 S 58.51 0.00 0.00 11646 S 629.00 0.00 0.00<br />

11305 S 31.93 0.00 0.00 11719 S 11.72 0.00 0.00<br />

11306 S 31.93 0.00 0.00 11720 S 14.48 0.00 0.00<br />

11307 S 31.93 0.00 0.00 11721 S 17.57 0.00 0.00<br />

11308 S 31.93 0.00 0.00 11730 S 31.93 0.00 0.00<br />

11310 S 31.93 0.00 0.00 11732 S 17.57 0.00 0.00<br />

11311 S 31.93 0.00 0.00 11740 S 16.13 0.00 0.00<br />

11312 S 31.93 0.00 0.00 11750 S 93.05 0.00 0.00<br />

11313 S 31.93 0.00 0.00 11752 S 129.24 0.00 0.00<br />

11400 S 65.83 0.00 0.00 11755 S 64.44 0.00 0.00<br />

11401 S 74.09 0.00 0.00 11760 S 132.73 0.00 0.00<br />

11402 S 81.34 0.00 0.00 11762 S 118.56 0.00 0.00<br />

11403 S 86.85 0.00 0.00 11765 S 31.93 0.00 0.00<br />

11404 S 461.70 0.00 0.00 11770 S 658.82 0.00 0.00<br />

11406 S 514.34 0.00 0.00 11771 S 658.82 0.00 0.00<br />

11420 S 61.69 0.00 0.00 11772 S 658.82 0.00 0.00<br />

11421 S 74.78 0.00 0.00 11900 S 29.30 0.00 0.00<br />

11422 S 81.68 0.00 0.00 11901 S 31.93 0.00 0.00<br />

11423 S 90.99 0.00 0.00 11920 S 92.71 0.00 0.00<br />

11424 S 514.34 0.00 0.00 11921 S 102.01 0.00 0.00<br />

11426 S 629.00 0.00 0.00 11922 S 33.08 0.00 0.00<br />

11440 S 70.65 0.00 0.00 11950 S 33.78 0.00 0.00<br />

11441 S 81.68 0.00 0.00 11951 S 42.04 0.00 0.00<br />

11442 S 89.95 0.00 0.00 11952 S 50.62 0.00 0.00<br />

11443 S 99.60 0.00 0.00 11954 S 50.62 0.00 0.00<br />

11444 S 314.36 0.00 0.00 11960 S 614.02 0.00 0.00<br />

11446 S 629.00 0.00 0.00 11970 S 1,112.19 0.00 0.00<br />

11450 S 629.00 0.00 0.00 11971 S 576.36 0.00 0.00<br />

11451 S 629.00 0.00 0.00 11976 S 61.69 0.00 0.00<br />

11462 S 629.00 0.00 0.00 11980 S 24.92 0.00 0.00<br />

11463 S 629.00 0.00 0.00 11981 S 24.92 0.00 0.00<br />

11470 S 629.00 0.00 0.00 11982 S 24.92 0.00 0.00<br />

11471 S 629.00 0.00 0.00 11983 S 24.92 0.00 0.00<br />

11600 S 92.71 0.00 0.00 12001 S 50.62 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 50.62 0.00 0.00 14021 S 545.66 0.00 0.00<br />

12004 S 50.62 0.00 0.00 14040 S 515.84 0.00 0.00<br />

12005 S 67.82 0.00 0.00 14041 S 545.66 0.00 0.00<br />

12006 S 67.82 0.00 0.00 14060 S 545.66 0.00 0.00<br />

12007 S 67.82 0.00 0.00 14061 S 545.66 0.00 0.00<br />

12011 S 50.62 0.00 0.00 14300 S 699.74 0.00 0.00<br />

12013 S 50.62 0.00 0.00 14350 S 643.83 0.00 0.00<br />

12014 S 50.62 0.00 0.00 15002 S 236.05 0.00 0.00<br />

12015 S 50.62 0.00 0.00 15003 S 236.05 0.00 0.00<br />

12016 S 67.82 0.00 0.00 15004 S 236.05 0.00 0.00<br />

12017 S 67.82 0.00 0.00 15005 S 236.05 0.00 0.00<br />

12018 S 67.82 0.00 0.00 15040 S 108.87 0.00 0.00<br />

12020 S 127.95 0.00 0.00 15050 S 236.05 0.00 0.00<br />

12021 S 108.87 0.00 0.00 15100 S 614.02 0.00 0.00<br />

12031 S 50.62 0.00 0.00 15101 S 643.83 0.00 0.00<br />

12032 S 132.73 0.00 0.00 15110 S 293.22 0.00 0.00<br />

12034 S 67.82 0.00 0.00 15111 S 240.58 0.00 0.00<br />

12035 S 67.82 0.00 0.00 15115 S 293.22 0.00 0.00<br />

12036 S 108.87 0.00 0.00 15116 S 240.58 0.00 0.00<br />

12037 S 216.98 0.00 0.00 15120 S 614.02 0.00 0.00<br />

12041 S 50.62 0.00 0.00 15121 S 643.83 0.00 0.00<br />

12042 S 50.62 0.00 0.00 15130 S 515.84 0.00 0.00<br />

12044 S 67.82 0.00 0.00 15131 S 463.19 0.00 0.00<br />

12045 S 108.87 0.00 0.00 15135 S 515.84 0.00 0.00<br />

12046 S 108.87 0.00 0.00 15136 S 463.19 0.00 0.00<br />

12047 S 216.98 0.00 0.00 15150 S 293.22 0.00 0.00<br />

12051 S 50.62 0.00 0.00 15151 S 240.58 0.00 0.00<br />

12052 S 50.62 0.00 0.00 15152 S 240.58 0.00 0.00<br />

12053 S 50.62 0.00 0.00 15155 S 293.22 0.00 0.00<br />

12054 S 67.82 0.00 0.00 15156 S 240.58 0.00 0.00<br />

12055 S 108.87 0.00 0.00 15157 S 240.58 0.00 0.00<br />

12056 S 108.87 0.00 0.00 15170 S 132.73 0.00 0.00<br />

12057 S 216.98 0.00 0.00 15171 S 132.73 0.00 0.00<br />

13100 S 236.05 0.00 0.00 15175 S 170.88 0.00 0.00<br />

13101 S 236.05 0.00 0.00 15176 S 170.88 0.00 0.00<br />

13102 S 127.95 0.00 0.00 15200 S 545.66 0.00 0.00<br />

13120 S 108.87 0.00 0.00 15201 S 458.67 0.00 0.00<br />

13121 S 108.87 0.00 0.00 15220 S 515.84 0.00 0.00<br />

13122 S 108.87 0.00 0.00 15221 S 236.05 0.00 0.00<br />

13131 S 108.87 0.00 0.00 15240 S 545.66 0.00 0.00<br />

13132 S 108.87 0.00 0.00 15241 S 236.05 0.00 0.00<br />

13133 S 108.87 0.00 0.00 15260 S 515.84 0.00 0.00<br />

13150 S 236.05 0.00 0.00 15261 S 458.67 0.00 0.00<br />

13151 S 236.05 0.00 0.00 15300 S 236.05 0.00 0.00<br />

13152 S 236.05 0.00 0.00 15301 S 236.05 0.00 0.00<br />

13153 S 108.87 0.00 0.00 15320 S 236.05 0.00 0.00<br />

13160 S 614.02 0.00 0.00 15321 S 236.05 0.00 0.00<br />

14000 S 515.84 0.00 0.00 15330 S 236.05 0.00 0.00<br />

14001 S 545.66 0.00 0.00 15331 S 236.05 0.00 0.00<br />

14020 S 545.66 0.00 0.00 15335 S 236.05 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 236.05 0.00 0.00 15826 S 643.83 0.00 0.00<br />

15340 S 132.73 0.00 0.00 15828 S 643.83 0.00 0.00<br />

15341 S 132.73 0.00 0.00 15829 S 740.26 0.00 0.00<br />

15360 S 132.73 0.00 0.00 15830 S 658.82 0.00 0.00<br />

15361 S 132.73 0.00 0.00 15832 S 658.82 0.00 0.00<br />

15365 S 132.73 0.00 0.00 15833 S 658.82 0.00 0.00<br />

15366 S 132.73 0.00 0.00 15834 S 658.82 0.00 0.00<br />

15400 S 236.05 0.00 0.00 15835 S 571.83 0.00 0.00<br />

15401 S 236.05 0.00 0.00 15836 S 544.17 0.00 0.00<br />

15420 S 236.05 0.00 0.00 15837 S 613.14 0.00 0.00<br />

15421 S 236.05 0.00 0.00 15838 S 613.14 0.00 0.00<br />

15430 S 236.05 0.00 0.00 15839 S 544.17 0.00 0.00<br />

15431 S 236.05 0.00 0.00 15840 S 699.74 0.00 0.00<br />

15570 S 643.83 0.00 0.00 15841 S 699.74 0.00 0.00<br />

15572 S 643.83 0.00 0.00 15842 S 812.47 0.00 0.00<br />

15574 S 643.83 0.00 0.00 15845 S 699.74 0.00 0.00<br />

15576 S 643.83 0.00 0.00 15847 S 658.82 0.00 0.00<br />

15600 S 643.83 0.00 0.00 15850 S 105.24 0.00 0.00<br />

15610 S 643.83 0.00 0.00 15851 S 47.90 0.00 0.00<br />

15620 S 699.74 0.00 0.00 15852 S 24.92 0.00 0.00<br />

15630 S 643.83 0.00 0.00 15860 S 24.92 0.00 0.00<br />

15650 S 740.26 0.00 0.00 15876 S 643.83 0.00 0.00<br />

15731 S 643.83 0.00 0.00 15877 S 643.83 0.00 0.00<br />

15732 S 643.83 0.00 0.00 15878 S 643.83 0.00 0.00<br />

15734 S 643.83 0.00 0.00 15879 S 643.83 0.00 0.00<br />

15736 S 643.83 0.00 0.00 15920 S 203.49 0.00 0.00<br />

15738 S 643.83 0.00 0.00 15922 S 699.74 0.00 0.00<br />

15740 S 515.84 0.00 0.00 15931 S 658.82 0.00 0.00<br />

15750 S 614.02 0.00 0.00 15933 S 658.82 0.00 0.00<br />

15760 S 614.02 0.00 0.00 15934 S 643.83 0.00 0.00<br />

15770 S 643.83 0.00 0.00 15935 S 699.74 0.00 0.00<br />

15775 S 175.92 0.00 0.00 15936 S 601.57 0.00 0.00<br />

15776 S 175.92 0.00 0.00 15937 S 699.74 0.00 0.00<br />

15780 S 392.20 0.00 0.00 15940 S 658.82 0.00 0.00<br />

15781 S 172.63 0.00 0.00 15941 S 658.82 0.00 0.00<br />

15782 S 172.63 0.00 0.00 15944 S 643.83 0.00 0.00<br />

15783 S 105.24 0.00 0.00 15945 S 699.74 0.00 0.00<br />

15786 S 31.93 0.00 0.00 15946 S 699.74 0.00 0.00<br />

15787 S 28.95 0.00 0.00 15950 S 658.82 0.00 0.00<br />

15788 S 31.93 0.00 0.00 15951 S 714.72 0.00 0.00<br />

15789 S 58.51 0.00 0.00 15952 S 545.66 0.00 0.00<br />

15792 S 58.51 0.00 0.00 15953 S 601.57 0.00 0.00<br />

15793 S 31.93 0.00 0.00 15956 S 545.66 0.00 0.00<br />

15819 S 132.73 0.00 0.00 15958 S 601.57 0.00 0.00<br />

15820 S 643.83 0.00 0.00 16000 S 25.85 0.00 0.00<br />

15821 S 643.83 0.00 0.00 16020 S 39.29 0.00 0.00<br />

15822 S 643.83 0.00 0.00 16025 S 60.51 0.00 0.00<br />

15823 S 740.26 0.00 0.00 16030 S 75.77 0.00 0.00<br />

15824 S 643.83 0.00 0.00 16035 S 58.51 0.00 0.00<br />

15825 S 643.83 0.00 0.00 17000 S 31.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.79 0.00 0.00 19300 S 707.82 0.00 0.00<br />

17004 S 83.40 0.00 0.00 19301 S 651.92 0.00 0.00<br />

17106 S 105.24 0.00 0.00 19302 S 1,245.10 0.00 0.00<br />

17107 S 105.24 0.00 0.00 19303 S 940.96 0.00 0.00<br />

17108 S 105.24 0.00 0.00 19304 S 940.96 0.00 0.00<br />

17110 S 31.93 0.00 0.00 19316 S 940.96 0.00 0.00<br />

17111 S 58.51 0.00 0.00 19318 S 1,075.05 0.00 0.00<br />

17250 S 44.12 0.00 0.00 19324 S 1,075.05 0.00 0.00<br />

17260 S 47.21 0.00 0.00 19325 S 1,783.10 0.00 0.00<br />

17261 S 58.51 0.00 0.00 19328 S 802.60 0.00 0.00<br />

17262 S 58.51 0.00 0.00 19330 S 802.60 0.00 0.00<br />

17263 S 58.51 0.00 0.00 19340 S 989.33 0.00 0.00<br />

17264 S 58.51 0.00 0.00 19342 S 1,396.89 0.00 0.00<br />

17266 S 105.24 0.00 0.00 19350 S 707.82 0.00 0.00<br />

17270 S 58.51 0.00 0.00 19355 S 940.96 0.00 0.00<br />

17271 S 58.51 0.00 0.00 19357 S 1,493.32 0.00 0.00<br />

17272 S 58.51 0.00 0.00 19366 S 981.49 0.00 0.00<br />

17273 S 105.24 0.00 0.00 19370 S 940.96 0.00 0.00<br />

17274 S 105.24 0.00 0.00 19371 S 940.96 0.00 0.00<br />

17276 S 105.24 0.00 0.00 19380 S 1,115.59 0.00 0.00<br />

17280 S 58.51 0.00 0.00 19396 S 1,294.90 0.00 0.00<br />

17281 S 87.19 0.00 0.00 20000 S 54.49 0.00 0.00<br />

17282 S 99.60 0.00 0.00 20005 S 627.81 0.00 0.00<br />

17283 S 105.24 0.00 0.00 20103 S 616.13 0.00 0.00<br />

17284 S 105.24 0.00 0.00 20150 S 1,749.20 0.00 0.00<br />

17286 S 105.24 0.00 0.00 20200 S 514.34 0.00 0.00<br />

17311 S 173.74 0.00 0.00 20205 S 544.17 0.00 0.00<br />

17312 S 173.74 0.00 0.00 20206 S 254.28 0.00 0.00<br />

17313 S 173.74 0.00 0.00 20220 S 276.40 0.00 0.00<br />

17314 S 173.74 0.00 0.00 20225 S 501.53 0.00 0.00<br />

17315 S 39.29 0.00 0.00 20240 S 629.00 0.00 0.00<br />

17340 S 14.13 0.00 0.00 20245 S 658.82 0.00 0.00<br />

17360 S 31.93 0.00 0.00 20250 S 657.63 0.00 0.00<br />

17380 S 31.93 0.00 0.00 20251 S 657.63 0.00 0.00<br />

19000 S 66.52 0.00 0.00 20500 S 54.46 0.00 0.00<br />

19001 S 8.96 0.00 0.00 20520 S 91.68 0.00 0.00<br />

19020 S 581.65 0.00 0.00 20525 S 658.82 0.00 0.00<br />

19100 S 198.07 0.00 0.00 20526 S 29.64 0.00 0.00<br />

19101 S 622.10 0.00 0.00 20550 S 22.40 0.00 0.00<br />

19102 S 254.28 0.00 0.00 20551 S 22.05 0.00 0.00<br />

19103 S 445.06 0.00 0.00 20552 S 21.37 0.00 0.00<br />

19105 S 1,294.90 0.00 0.00 20553 S 23.78 0.00 0.00<br />

19110 S 622.10 0.00 0.00 20555 S 1,152.48 0.00 0.00<br />

19112 S 651.92 0.00 0.00 20600 S 22.74 0.00 0.00<br />

19120 S 651.92 0.00 0.00 20605 S 25.50 0.00 0.00<br />

19125 S 651.92 0.00 0.00 20610 S 35.84 0.00 0.00<br />

19126 S 651.92 0.00 0.00 20612 S 24.13 0.00 0.00<br />

19296 S 1,783.10 0.00 0.00 20615 S 100.98 0.00 0.00<br />

19297 S 1,783.10 0.00 0.00 20650 S 657.63 0.00 0.00<br />

19298 S 1,783.10 0.00 0.00 20662 S 840.05 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 840.05 0.00 0.00 21085 S 252.96 0.00 0.00<br />

20665 S 24.92 0.00 0.00 21086 S 550.72 0.00 0.00<br />

20670 S 461.70 0.00 0.00 21087 S 551.42 0.00 0.00<br />

20680 S 658.82 0.00 0.00 21088 S 1,615.00 0.00 0.00<br />

20690 S 784.02 0.00 0.00 21100 S 1,015.28 0.00 0.00<br />

20692 S 813.84 0.00 0.00 21110 S 290.53 0.00 0.00<br />

20693 S 657.63 0.00 0.00 21120 S 940.94 0.00 0.00<br />

20694 S 575.16 0.00 0.00 21121 S 940.94 0.00 0.00<br />

20696 S 1,152.48 0.00 0.00 21122 S 940.94 0.00 0.00<br />

20697 S 766.45 0.00 0.00 21123 S 940.94 0.00 0.00<br />

20822 S 1,079.89 0.00 0.00 21125 S 940.94 0.00 0.00<br />

20900 S 813.84 0.00 0.00 21127 S 1,431.31 0.00 0.00<br />

20902 S 869.74 0.00 0.00 21137 S 954.79 0.00 0.00<br />

20910 S 643.83 0.00 0.00 21138 S 1,615.00 0.00 0.00<br />

20912 S 643.83 0.00 0.00 21139 S 1,615.00 0.00 0.00<br />

20920 S 601.57 0.00 0.00 21150 S 1,615.00 0.00 0.00<br />

20922 S 545.66 0.00 0.00 21181 S 940.94 0.00 0.00<br />

20924 S 869.74 0.00 0.00 21198 S 1,615.00 0.00 0.00<br />

20926 S 378.94 0.00 0.00 21199 S 1,615.00 0.00 0.00<br />

20950 S 54.49 0.00 0.00 21206 S 1,141.54 0.00 0.00<br />

20972 S 1,823.95 0.00 0.00 21208 S 1,271.05 0.00 0.00<br />

20973 S 1,823.95 0.00 0.00 21209 S 1,141.54 0.00 0.00<br />

20979 S 22.40 0.00 0.00 21210 S 1,271.05 0.00 0.00<br />

20982 S 1,749.20 0.00 0.00 21215 S 1,271.05 0.00 0.00<br />

21010 S 685.17 0.00 0.00 21230 S 1,271.05 0.00 0.00<br />

21015 S 570.06 0.00 0.00 21235 S 940.94 0.00 0.00<br />

21025 S 1,015.28 0.00 0.00 21240 S 1,101.00 0.00 0.00<br />

21026 S 1,015.28 0.00 0.00 21242 S 1,141.54 0.00 0.00<br />

21029 S 1,015.28 0.00 0.00 21243 S 1,141.54 0.00 0.00<br />

21030 S 239.52 0.00 0.00 21244 S 1,271.05 0.00 0.00<br />

21031 S 198.16 0.00 0.00 21245 S 1,271.05 0.00 0.00<br />

21032 S 201.96 0.00 0.00 21246 S 1,271.05 0.00 0.00<br />

21034 S 1,045.10 0.00 0.00 21248 S 1,271.05 0.00 0.00<br />

21040 S 685.17 0.00 0.00 21249 S 1,271.05 0.00 0.00<br />

21044 S 1,015.28 0.00 0.00 21260 S 1,615.00 0.00 0.00<br />

21046 S 1,015.28 0.00 0.00 21267 S 1,271.05 0.00 0.00<br />

21047 S 1,015.28 0.00 0.00 21270 S 1,141.54 0.00 0.00<br />

21048 S 1,615.00 0.00 0.00 21275 S 1,271.05 0.00 0.00<br />

21050 S 1,045.10 0.00 0.00 21280 S 1,141.54 0.00 0.00<br />

21060 S 1,015.28 0.00 0.00 21282 S 666.50 0.00 0.00<br />

21070 S 1,045.10 0.00 0.00 21295 S 300.41 0.00 0.00<br />

21073 S 186.10 0.00 0.00 21296 S 632.53 0.00 0.00<br />

21076 S 322.92 0.00 0.00 21310 S 91.64 0.00 0.00<br />

21077 S 780.60 0.00 0.00 21315 S 402.68 0.00 0.00<br />

21079 S 559.00 0.00 0.00 21320 S 540.24 0.00 0.00<br />

21080 S 641.02 0.00 0.00 21325 S 770.89 0.00 0.00<br />

21081 S 590.70 0.00 0.00 21330 S 811.42 0.00 0.00<br />

21082 S 562.10 0.00 0.00 21335 S 940.94 0.00 0.00<br />

21083 S 553.83 0.00 0.00 21336 S 784.17 0.00 0.00<br />

21084 S 637.23 0.00 0.00 21337 S 540.24 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 770.89 0.00 0.00 22310 S 166.83 0.00 0.00<br />

21339 S 811.42 0.00 0.00 22315 S 431.50 0.00 0.00<br />

21340 S 1,101.00 0.00 0.00 22505 S 507.98 0.00 0.00<br />

21345 S 940.94 0.00 0.00 22520 S 1,200.05 0.00 0.00<br />

21355 S 1,045.10 0.00 0.00 22521 S 1,200.05 0.00 0.00<br />

21356 S 714.99 0.00 0.00 22522 S 1,200.05 0.00 0.00<br />

21360 S 954.79 0.00 0.00 22523 S 3,339.85 0.00 0.00<br />

21390 S 1,615.00 0.00 0.00 22524 S 3,339.85 0.00 0.00<br />

21400 S 353.05 0.00 0.00 22525 S 3,339.85 0.00 0.00<br />

21401 S 570.06 0.00 0.00 22900 S 714.72 0.00 0.00<br />

21406 S 1,615.00 0.00 0.00 23000 S 514.34 0.00 0.00<br />

21407 S 1,615.00 0.00 0.00 23020 S 1,082.38 0.00 0.00<br />

21421 S 770.89 0.00 0.00 23030 S 529.00 0.00 0.00<br />

21440 S 324.65 0.00 0.00 23031 S 611.47 0.00 0.00<br />

21445 S 770.89 0.00 0.00 23035 S 657.63 0.00 0.00<br />

21450 S 133.99 0.00 0.00 23040 S 813.84 0.00 0.00<br />

21451 S 361.50 0.00 0.00 23044 S 869.74 0.00 0.00<br />

21452 S 540.24 0.00 0.00 23065 S 97.19 0.00 0.00<br />

21453 S 1,045.10 0.00 0.00 23066 S 629.00 0.00 0.00<br />

21454 S 811.42 0.00 0.00 23075 S 514.34 0.00 0.00<br />

21461 S 1,101.00 0.00 0.00 23076 S 629.00 0.00 0.00<br />

21462 S 1,141.54 0.00 0.00 23077 S 658.82 0.00 0.00<br />

21465 S 1,101.00 0.00 0.00 23100 S 627.81 0.00 0.00<br />

21480 S 91.64 0.00 0.00 23101 S 1,039.79 0.00 0.00<br />

21485 S 540.24 0.00 0.00 23105 S 869.74 0.00 0.00<br />

21490 S 1,045.10 0.00 0.00 23106 S 869.74 0.00 0.00<br />

21495 S 664.92 0.00 0.00 23107 S 869.74 0.00 0.00<br />

21497 S 540.24 0.00 0.00 23120 S 910.28 0.00 0.00<br />

21501 S 581.65 0.00 0.00 23125 S 910.28 0.00 0.00<br />

21502 S 627.81 0.00 0.00 23130 S 1,208.63 0.00 0.00<br />

21550 S 613.14 0.00 0.00 23140 S 713.53 0.00 0.00<br />

21555 S 629.00 0.00 0.00 23145 S 910.28 0.00 0.00<br />

21556 S 629.00 0.00 0.00 23146 S 910.28 0.00 0.00<br />

21557 S 842.44 0.00 0.00 23150 S 869.74 0.00 0.00<br />

21600 S 784.02 0.00 0.00 23155 S 910.28 0.00 0.00<br />

21610 S 784.02 0.00 0.00 23156 S 910.28 0.00 0.00<br />

21685 S 290.53 0.00 0.00 23170 S 784.02 0.00 0.00<br />

21700 S 627.81 0.00 0.00 23172 S 784.02 0.00 0.00<br />

21720 S 657.63 0.00 0.00 23174 S 784.02 0.00 0.00<br />

21725 S 68.46 0.00 0.00 23180 S 869.74 0.00 0.00<br />

21800 S 79.08 0.00 0.00 23182 S 869.74 0.00 0.00<br />

21805 S 698.45 0.00 0.00 23184 S 869.74 0.00 0.00<br />

21820 S 79.08 0.00 0.00 23190 S 869.74 0.00 0.00<br />

21920 S 140.61 0.00 0.00 23195 S 910.28 0.00 0.00<br />

21925 S 629.00 0.00 0.00 23330 S 314.36 0.00 0.00<br />

21930 S 629.00 0.00 0.00 23331 S 576.36 0.00 0.00<br />

21935 S 658.82 0.00 0.00 23395 S 1,208.63 0.00 0.00<br />

22102 S 1,874.68 0.00 0.00 23397 S 2,133.48 0.00 0.00<br />

22103 S 1,874.68 0.00 0.00 23400 S 1,039.79 0.00 0.00<br />

22305 S 79.08 0.00 0.00 23405 S 784.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 784.02 0.00 0.00 23931 S 581.65 0.00 0.00<br />

23410 S 1,208.63 0.00 0.00 23935 S 627.81 0.00 0.00<br />

23412 S 1,338.14 0.00 0.00 24000 S 869.74 0.00 0.00<br />

23415 S 1,208.63 0.00 0.00 24006 S 869.74 0.00 0.00<br />

23420 S 1,338.14 0.00 0.00 24065 S 134.75 0.00 0.00<br />

23430 S 1,168.10 0.00 0.00 24066 S 514.34 0.00 0.00<br />

23440 S 1,168.10 0.00 0.00 24075 S 514.34 0.00 0.00<br />

23450 S 2,003.96 0.00 0.00 24076 S 629.00 0.00 0.00<br />

23455 S 2,133.48 0.00 0.00 24077 S 658.82 0.00 0.00<br />

23460 S 2,003.96 0.00 0.00 24100 S 575.16 0.00 0.00<br />

23462 S 1,338.14 0.00 0.00 24101 S 869.74 0.00 0.00<br />

23465 S 2,003.96 0.00 0.00 24102 S 869.74 0.00 0.00<br />

23466 S 1,338.14 0.00 0.00 24105 S 657.63 0.00 0.00<br />

23480 S 1,168.10 0.00 0.00 24110 S 627.81 0.00 0.00<br />

23485 S 2,133.48 0.00 0.00 24115 S 813.84 0.00 0.00<br />

23490 S 1,112.19 0.00 0.00 24116 S 813.84 0.00 0.00<br />

23491 S 1,907.53 0.00 0.00 24120 S 657.63 0.00 0.00<br />

23500 S 79.08 0.00 0.00 24125 S 813.84 0.00 0.00<br />

23505 S 431.50 0.00 0.00 24126 S 813.84 0.00 0.00<br />

23515 S 1,444.19 0.00 0.00 24130 S 813.84 0.00 0.00<br />

23520 S 166.83 0.00 0.00 24134 S 784.02 0.00 0.00<br />

23525 S 166.83 0.00 0.00 24136 S 784.02 0.00 0.00<br />

23530 S 1,064.22 0.00 0.00 24138 S 784.02 0.00 0.00<br />

23532 S 784.17 0.00 0.00 24140 S 813.84 0.00 0.00<br />

23540 S 79.08 0.00 0.00 24145 S 813.84 0.00 0.00<br />

23545 S 166.83 0.00 0.00 24147 S 784.02 0.00 0.00<br />

23550 S 1,064.22 0.00 0.00 24149 S 1,152.48 0.00 0.00<br />

23552 S 1,120.13 0.00 0.00 24152 S 1,749.20 0.00 0.00<br />

23570 S 79.08 0.00 0.00 24153 S 3,339.85 0.00 0.00<br />

23575 S 166.83 0.00 0.00 24155 S 1,112.19 0.00 0.00<br />

23585 S 1,444.19 0.00 0.00 24160 S 784.02 0.00 0.00<br />

23600 S 61.62 0.00 0.00 24164 S 813.84 0.00 0.00<br />

23605 S 431.50 0.00 0.00 24200 S 98.56 0.00 0.00<br />

23615 S 1,500.09 0.00 0.00 24201 S 514.34 0.00 0.00<br />

23616 S 1,500.09 0.00 0.00 24300 S 600.40 0.00 0.00<br />

23620 S 61.62 0.00 0.00 24301 S 869.74 0.00 0.00<br />

23625 S 431.50 0.00 0.00 24305 S 869.74 0.00 0.00<br />

23630 S 1,540.62 0.00 0.00 24310 S 657.63 0.00 0.00<br />

23650 S 79.08 0.00 0.00 24320 S 1,112.19 0.00 0.00<br />

23655 S 455.34 0.00 0.00 24330 S 1,907.53 0.00 0.00<br />

23660 S 1,064.22 0.00 0.00 24331 S 1,112.19 0.00 0.00<br />

23665 S 166.83 0.00 0.00 24332 S 840.05 0.00 0.00<br />

23670 S 1,444.19 0.00 0.00 24340 S 1,112.19 0.00 0.00<br />

23675 S 79.08 0.00 0.00 24341 S 1,112.19 0.00 0.00<br />

23680 S 1,064.22 0.00 0.00 24342 S 1,112.19 0.00 0.00<br />

23700 S 455.34 0.00 0.00 24343 S 1,152.48 0.00 0.00<br />

23800 S 1,963.43 0.00 0.00 24344 S 3,339.85 0.00 0.00<br />

23802 S 1,338.14 0.00 0.00 24345 S 784.02 0.00 0.00<br />

23921 S 458.67 0.00 0.00 24346 S 1,749.20 0.00 0.00<br />

23930 S 529.00 0.00 0.00 24357 S 1,152.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,152.48 0.00 0.00 24925 S 657.63 0.00 0.00<br />

24359 S 1,152.48 0.00 0.00 25000 S 657.63 0.00 0.00<br />

24360 S 1,063.57 0.00 0.00 25001 S 840.05 0.00 0.00<br />

24361 S 5,815.11 3,559.59 1,304.06 25020 S 657.63 0.00 0.00<br />

24362 S 1,359.24 0.00 0.00 25023 S 813.84 0.00 0.00<br />

24363 S 5,944.63 3,689.10 1,433.57 25024 S 813.84 0.00 0.00<br />

24365 S 1,063.57 0.00 0.00 25025 S 813.84 0.00 0.00<br />

24366 S 5,815.11 3,559.59 1,304.06 25028 S 575.16 0.00 0.00<br />

24400 S 869.74 0.00 0.00 25031 S 627.81 0.00 0.00<br />

24410 S 869.74 0.00 0.00 25035 S 627.81 0.00 0.00<br />

24420 S 1,112.19 0.00 0.00 25040 S 910.28 0.00 0.00<br />

24430 S 1,907.53 0.00 0.00 25065 S 136.82 0.00 0.00<br />

24435 S 1,963.43 0.00 0.00 25066 S 629.00 0.00 0.00<br />

24470 S 1,112.19 0.00 0.00 25075 S 514.34 0.00 0.00<br />

24495 S 784.02 0.00 0.00 25076 S 658.82 0.00 0.00<br />

24498 S 1,907.53 0.00 0.00 25077 S 658.82 0.00 0.00<br />

24500 S 79.08 0.00 0.00 25085 S 657.63 0.00 0.00<br />

24505 S 79.08 0.00 0.00 25100 S 627.81 0.00 0.00<br />

24515 S 1,500.09 0.00 0.00 25101 S 813.84 0.00 0.00<br />

24516 S 1,500.09 0.00 0.00 25105 S 869.74 0.00 0.00<br />

24530 S 79.08 0.00 0.00 25107 S 813.84 0.00 0.00<br />

24535 S 166.83 0.00 0.00 25109 S 840.05 0.00 0.00<br />

24538 S 698.45 0.00 0.00 25110 S 657.63 0.00 0.00<br />

24545 S 1,500.09 0.00 0.00 25111 S 657.63 0.00 0.00<br />

24546 S 1,540.62 0.00 0.00 25112 S 713.53 0.00 0.00<br />

24560 S 79.08 0.00 0.00 25115 S 713.53 0.00 0.00<br />

24565 S 79.08 0.00 0.00 25116 S 713.53 0.00 0.00<br />

24566 S 698.45 0.00 0.00 25118 S 784.02 0.00 0.00<br />

24575 S 1,444.19 0.00 0.00 25119 S 813.84 0.00 0.00<br />

24576 S 79.08 0.00 0.00 25120 S 813.84 0.00 0.00<br />

24577 S 166.83 0.00 0.00 25125 S 813.84 0.00 0.00<br />

24579 S 1,444.19 0.00 0.00 25126 S 813.84 0.00 0.00<br />

24582 S 698.45 0.00 0.00 25130 S 813.84 0.00 0.00<br />

24586 S 1,500.09 0.00 0.00 25135 S 813.84 0.00 0.00<br />

24587 S 1,540.62 0.00 0.00 25136 S 813.84 0.00 0.00<br />

24600 S 79.08 0.00 0.00 25145 S 784.02 0.00 0.00<br />

24605 S 507.98 0.00 0.00 25150 S 784.02 0.00 0.00<br />

24615 S 1,444.19 0.00 0.00 25151 S 784.02 0.00 0.00<br />

24620 S 431.50 0.00 0.00 25210 S 813.84 0.00 0.00<br />

24635 S 1,444.19 0.00 0.00 25215 S 869.74 0.00 0.00<br />

24640 S 53.42 0.00 0.00 25230 S 869.74 0.00 0.00<br />

24650 S 61.62 0.00 0.00 25240 S 869.74 0.00 0.00<br />

24655 S 166.83 0.00 0.00 25248 S 627.81 0.00 0.00<br />

24665 S 1,120.13 0.00 0.00 25250 S 731.38 0.00 0.00<br />

24666 S 1,500.09 0.00 0.00 25251 S 731.38 0.00 0.00<br />

24670 S 79.08 0.00 0.00 25259 S 766.45 0.00 0.00<br />

24675 S 79.08 0.00 0.00 25260 S 869.74 0.00 0.00<br />

24685 S 1,064.22 0.00 0.00 25263 S 784.02 0.00 0.00<br />

24800 S 1,168.10 0.00 0.00 25265 S 813.84 0.00 0.00<br />

24802 S 1,208.63 0.00 0.00 25270 S 869.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 813.84 0.00 0.00 25505 S 166.83 0.00 0.00<br />

25274 S 869.74 0.00 0.00 25515 S 1,064.22 0.00 0.00<br />

25275 S 869.74 0.00 0.00 25520 S 166.83 0.00 0.00<br />

25280 S 869.74 0.00 0.00 25525 S 1,120.13 0.00 0.00<br />

25290 S 813.84 0.00 0.00 25526 S 1,160.66 0.00 0.00<br />

25295 S 657.63 0.00 0.00 25530 S 61.62 0.00 0.00<br />

25300 S 813.84 0.00 0.00 25535 S 79.08 0.00 0.00<br />

25301 S 813.84 0.00 0.00 25545 S 1,064.22 0.00 0.00<br />

25310 S 1,112.19 0.00 0.00 25560 S 61.62 0.00 0.00<br />

25312 S 1,168.10 0.00 0.00 25565 S 166.83 0.00 0.00<br />

25315 S 1,112.19 0.00 0.00 25574 S 1,444.19 0.00 0.00<br />

25316 S 1,907.53 0.00 0.00 25575 S 1,444.19 0.00 0.00<br />

25320 S 1,112.19 0.00 0.00 25600 S 61.62 0.00 0.00<br />

25332 S 1,063.57 0.00 0.00 25605 S 166.83 0.00 0.00<br />

25335 S 1,112.19 0.00 0.00 25606 S 728.27 0.00 0.00<br />

25337 S 1,208.63 0.00 0.00 25607 S 1,540.62 0.00 0.00<br />

25350 S 1,907.53 0.00 0.00 25608 S 1,540.62 0.00 0.00<br />

25355 S 1,112.19 0.00 0.00 25609 S 1,540.62 0.00 0.00<br />

25360 S 813.84 0.00 0.00 25622 S 61.62 0.00 0.00<br />

25365 S 813.84 0.00 0.00 25624 S 166.83 0.00 0.00<br />

25370 S 1,112.19 0.00 0.00 25628 S 1,064.22 0.00 0.00<br />

25375 S 1,168.10 0.00 0.00 25630 S 61.62 0.00 0.00<br />

25390 S 813.84 0.00 0.00 25635 S 166.83 0.00 0.00<br />

25391 S 1,168.10 0.00 0.00 25645 S 1,064.22 0.00 0.00<br />

25392 S 813.84 0.00 0.00 25650 S 61.62 0.00 0.00<br />

25393 S 1,168.10 0.00 0.00 25651 S 981.34 0.00 0.00<br />

25394 S 1,749.20 0.00 0.00 25652 S 1,653.24 0.00 0.00<br />

25400 S 1,112.19 0.00 0.00 25660 S 79.08 0.00 0.00<br />

25405 S 1,963.43 0.00 0.00 25670 S 728.27 0.00 0.00<br />

25415 S 1,907.53 0.00 0.00 25671 S 645.81 0.00 0.00<br />

25420 S 1,963.43 0.00 0.00 25675 S 79.08 0.00 0.00<br />

25425 S 1,112.19 0.00 0.00 25676 S 698.45 0.00 0.00<br />

25426 S 1,168.10 0.00 0.00 25680 S 79.08 0.00 0.00<br />

25430 S 1,749.20 0.00 0.00 25685 S 728.27 0.00 0.00<br />

25431 S 1,749.20 0.00 0.00 25690 S 431.50 0.00 0.00<br />

25440 S 1,963.43 0.00 0.00 25695 S 698.45 0.00 0.00<br />

25441 S 5,815.11 3,559.59 1,304.06 25800 S 1,963.43 0.00 0.00<br />

25442 S 5,815.11 3,559.59 1,304.06 25805 S 1,208.63 0.00 0.00<br />

25443 S 1,359.24 0.00 0.00 25810 S 2,003.96 0.00 0.00<br />

25444 S 1,359.24 0.00 0.00 25820 S 1,168.10 0.00 0.00<br />

25445 S 1,359.24 0.00 0.00 25825 S 2,003.96 0.00 0.00<br />

25446 S 5,944.63 3,689.10 1,433.57 25830 S 2,003.96 0.00 0.00<br />

25447 S 1,063.57 0.00 0.00 25907 S 657.63 0.00 0.00<br />

25449 S 1,063.57 0.00 0.00 25922 S 657.63 0.00 0.00<br />

25450 S 1,112.19 0.00 0.00 25929 S 545.66 0.00 0.00<br />

25455 S 1,112.19 0.00 0.00 25931 S 840.05 0.00 0.00<br />

25490 S 1,112.19 0.00 0.00 26010 S 54.49 0.00 0.00<br />

25491 S 1,112.19 0.00 0.00 26011 S 398.02 0.00 0.00<br />

25492 S 1,112.19 0.00 0.00 26020 S 528.13 0.00 0.00<br />

25500 S 61.62 0.00 0.00 26025 S 475.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 528.13 0.00 0.00 26392 S 777.54 0.00 0.00<br />

26034 S 528.13 0.00 0.00 26410 S 557.95 0.00 0.00<br />

26035 S 640.70 0.00 0.00 26412 S 777.54 0.00 0.00<br />

26040 S 833.45 0.00 0.00 26415 S 833.45 0.00 0.00<br />

26045 S 777.54 0.00 0.00 26416 S 777.54 0.00 0.00<br />

26055 S 528.13 0.00 0.00 26418 S 613.85 0.00 0.00<br />

26060 S 528.13 0.00 0.00 26420 S 833.45 0.00 0.00<br />

26070 S 528.13 0.00 0.00 26426 S 777.54 0.00 0.00<br />

26075 S 613.85 0.00 0.00 26428 S 777.54 0.00 0.00<br />

26080 S 613.85 0.00 0.00 26432 S 557.95 0.00 0.00<br />

26100 S 528.13 0.00 0.00 26433 S 557.95 0.00 0.00<br />

26105 S 475.48 0.00 0.00 26434 S 777.54 0.00 0.00<br />

26110 S 475.48 0.00 0.00 26437 S 557.95 0.00 0.00<br />

26115 S 629.00 0.00 0.00 26440 S 557.95 0.00 0.00<br />

26116 S 629.00 0.00 0.00 26442 S 777.54 0.00 0.00<br />

26117 S 658.82 0.00 0.00 26445 S 557.95 0.00 0.00<br />

26121 S 833.45 0.00 0.00 26449 S 777.54 0.00 0.00<br />

26123 S 833.45 0.00 0.00 26450 S 557.95 0.00 0.00<br />

26125 S 613.85 0.00 0.00 26455 S 557.95 0.00 0.00<br />

26130 S 557.95 0.00 0.00 26460 S 557.95 0.00 0.00<br />

26135 S 833.45 0.00 0.00 26471 S 528.13 0.00 0.00<br />

26140 S 528.13 0.00 0.00 26474 S 528.13 0.00 0.00<br />

26145 S 557.95 0.00 0.00 26476 S 475.48 0.00 0.00<br />

26160 S 557.95 0.00 0.00 26477 S 475.48 0.00 0.00<br />

26170 S 557.95 0.00 0.00 26478 S 475.48 0.00 0.00<br />

26180 S 557.95 0.00 0.00 26479 S 475.48 0.00 0.00<br />

26185 S 613.85 0.00 0.00 26480 S 777.54 0.00 0.00<br />

26200 S 528.13 0.00 0.00 26483 S 777.54 0.00 0.00<br />

26205 S 777.54 0.00 0.00 26485 S 747.73 0.00 0.00<br />

26210 S 528.13 0.00 0.00 26489 S 777.54 0.00 0.00<br />

26215 S 557.95 0.00 0.00 26490 S 777.54 0.00 0.00<br />

26230 S 782.94 0.00 0.00 26492 S 777.54 0.00 0.00<br />

26235 S 557.95 0.00 0.00 26494 S 777.54 0.00 0.00<br />

26236 S 557.95 0.00 0.00 26496 S 777.54 0.00 0.00<br />

26250 S 557.95 0.00 0.00 26497 S 777.54 0.00 0.00<br />

26255 S 777.54 0.00 0.00 26498 S 833.45 0.00 0.00<br />

26260 S 557.95 0.00 0.00 26499 S 777.54 0.00 0.00<br />

26261 S 557.95 0.00 0.00 26500 S 613.85 0.00 0.00<br />

26262 S 528.13 0.00 0.00 26502 S 833.45 0.00 0.00<br />

26320 S 514.34 0.00 0.00 26508 S 557.95 0.00 0.00<br />

26340 S 237.11 0.00 0.00 26510 S 777.54 0.00 0.00<br />

26350 S 695.08 0.00 0.00 26516 S 695.08 0.00 0.00<br />

26352 S 833.45 0.00 0.00 26517 S 777.54 0.00 0.00<br />

26356 S 833.45 0.00 0.00 26518 S 777.54 0.00 0.00<br />

26357 S 833.45 0.00 0.00 26520 S 557.95 0.00 0.00<br />

26358 S 833.45 0.00 0.00 26525 S 557.95 0.00 0.00<br />

26370 S 833.45 0.00 0.00 26530 S 967.14 0.00 0.00<br />

26372 S 833.45 0.00 0.00 26531 S 1,488.76 0.00 0.00<br />

26373 S 777.54 0.00 0.00 26535 S 1,063.57 0.00 0.00<br />

26390 S 833.45 0.00 0.00 26536 S 1,359.24 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 613.85 0.00 0.00 26775 S 164.74 0.00 0.00<br />

26541 S 1,003.49 0.00 0.00 26776 S 698.45 0.00 0.00<br />

26542 S 613.85 0.00 0.00 26785 S 698.45 0.00 0.00<br />

26545 S 833.45 0.00 0.00 26820 S 873.97 0.00 0.00<br />

26546 S 833.45 0.00 0.00 26841 S 833.45 0.00 0.00<br />

26548 S 833.45 0.00 0.00 26842 S 833.45 0.00 0.00<br />

26550 S 747.73 0.00 0.00 26843 S 777.54 0.00 0.00<br />

26555 S 777.54 0.00 0.00 26844 S 777.54 0.00 0.00<br />

26560 S 528.13 0.00 0.00 26850 S 833.45 0.00 0.00<br />

26561 S 777.54 0.00 0.00 26852 S 833.45 0.00 0.00<br />

26562 S 833.45 0.00 0.00 26860 S 777.54 0.00 0.00<br />

26565 S 873.97 0.00 0.00 26861 S 747.73 0.00 0.00<br />

26567 S 873.97 0.00 0.00 26862 S 833.45 0.00 0.00<br />

26568 S 777.54 0.00 0.00 26863 S 777.54 0.00 0.00<br />

26580 S 654.38 0.00 0.00 26910 S 777.54 0.00 0.00<br />

26587 S 654.38 0.00 0.00 26951 S 528.13 0.00 0.00<br />

26590 S 654.38 0.00 0.00 26952 S 613.85 0.00 0.00<br />

26591 S 777.54 0.00 0.00 26990 S 575.16 0.00 0.00<br />

26593 S 557.95 0.00 0.00 26991 S 575.16 0.00 0.00<br />

26596 S 528.13 0.00 0.00 27000 S 627.81 0.00 0.00<br />

26600 S 61.62 0.00 0.00 27001 S 813.84 0.00 0.00<br />

26605 S 79.08 0.00 0.00 27003 S 813.84 0.00 0.00<br />

26607 S 431.50 0.00 0.00 27033 S 1,112.19 0.00 0.00<br />

26608 S 784.17 0.00 0.00 27035 S 1,168.10 0.00 0.00<br />

26615 S 1,120.13 0.00 0.00 27040 S 314.36 0.00 0.00<br />

26641 S 61.62 0.00 0.00 27041 S 354.18 0.00 0.00<br />

26645 S 166.83 0.00 0.00 27047 S 629.00 0.00 0.00<br />

26650 S 698.45 0.00 0.00 27048 S 658.82 0.00 0.00<br />

26665 S 1,120.13 0.00 0.00 27049 S 658.82 0.00 0.00<br />

26670 S 61.62 0.00 0.00 27050 S 657.63 0.00 0.00<br />

26675 S 166.83 0.00 0.00 27052 S 657.63 0.00 0.00<br />

26676 S 698.45 0.00 0.00 27060 S 754.06 0.00 0.00<br />

26685 S 728.27 0.00 0.00 27062 S 754.06 0.00 0.00<br />

26686 S 1,444.19 0.00 0.00 27065 S 754.06 0.00 0.00<br />

26700 S 61.62 0.00 0.00 27066 S 910.28 0.00 0.00<br />

26705 S 79.08 0.00 0.00 27067 S 910.28 0.00 0.00<br />

26706 S 431.50 0.00 0.00 27080 S 784.02 0.00 0.00<br />

26715 S 784.17 0.00 0.00 27086 S 314.36 0.00 0.00<br />

26720 S 61.62 0.00 0.00 27087 S 657.63 0.00 0.00<br />

26725 S 61.62 0.00 0.00 27097 S 813.84 0.00 0.00<br />

26727 S 954.22 0.00 0.00 27098 S 813.84 0.00 0.00<br />

26735 S 784.17 0.00 0.00 27100 S 1,168.10 0.00 0.00<br />

26740 S 61.62 0.00 0.00 27105 S 1,168.10 0.00 0.00<br />

26742 S 79.08 0.00 0.00 27110 S 1,168.10 0.00 0.00<br />

26746 S 824.71 0.00 0.00 27111 S 1,168.10 0.00 0.00<br />

26750 S 61.62 0.00 0.00 27193 S 79.08 0.00 0.00<br />

26755 S 61.62 0.00 0.00 27194 S 507.98 0.00 0.00<br />

26756 S 698.45 0.00 0.00 27200 S 61.62 0.00 0.00<br />

26765 S 784.17 0.00 0.00 27202 S 1,034.41 0.00 0.00<br />

26770 S 61.62 0.00 0.00 27220 S 61.62 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 79.08 0.00 0.00 27397 S 1,112.19 0.00 0.00<br />

27238 S 166.83 0.00 0.00 27400 S 1,112.19 0.00 0.00<br />

27246 S 166.83 0.00 0.00 27403 S 869.74 0.00 0.00<br />

27250 S 79.08 0.00 0.00 27405 S 1,168.10 0.00 0.00<br />

27252 S 507.98 0.00 0.00 27407 S 1,963.43 0.00 0.00<br />

27256 S 61.62 0.00 0.00 27409 S 1,168.10 0.00 0.00<br />

27257 S 537.80 0.00 0.00 27416 S 1,749.20 0.00 0.00<br />

27265 S 79.08 0.00 0.00 27418 S 1,112.19 0.00 0.00<br />

27266 S 507.98 0.00 0.00 27420 S 1,112.19 0.00 0.00<br />

27267 S 61.62 0.00 0.00 27422 S 1,338.14 0.00 0.00<br />

27275 S 507.98 0.00 0.00 27424 S 1,112.19 0.00 0.00<br />

27301 S 611.47 0.00 0.00 27425 S 1,039.79 0.00 0.00<br />

27305 S 627.81 0.00 0.00 27427 S 1,112.19 0.00 0.00<br />

27306 S 657.63 0.00 0.00 27428 S 1,963.43 0.00 0.00<br />

27307 S 657.63 0.00 0.00 27429 S 1,963.43 0.00 0.00<br />

27310 S 869.74 0.00 0.00 27430 S 1,168.10 0.00 0.00<br />

27323 S 314.36 0.00 0.00 27435 S 1,168.10 0.00 0.00<br />

27324 S 576.36 0.00 0.00 27437 S 1,023.04 0.00 0.00<br />

27325 S 564.75 0.00 0.00 27438 S 1,359.24 0.00 0.00<br />

27326 S 564.75 0.00 0.00 27440 S 1,459.08 0.00 0.00<br />

27327 S 629.00 0.00 0.00 27441 S 1,063.57 0.00 0.00<br />

27328 S 658.82 0.00 0.00 27442 S 1,063.57 0.00 0.00<br />

27329 S 714.72 0.00 0.00 27443 S 1,063.57 0.00 0.00<br />

27330 S 869.74 0.00 0.00 27446 S 10,435.72 6,269.31 2,102.89<br />

27331 S 869.74 0.00 0.00 27496 S 754.06 0.00 0.00<br />

27332 S 869.74 0.00 0.00 27497 S 657.63 0.00 0.00<br />

27333 S 869.74 0.00 0.00 27498 S 657.63 0.00 0.00<br />

27334 S 869.74 0.00 0.00 27499 S 657.63 0.00 0.00<br />

27335 S 869.74 0.00 0.00 27500 S 166.83 0.00 0.00<br />

27340 S 657.63 0.00 0.00 27501 S 79.08 0.00 0.00<br />

27345 S 713.53 0.00 0.00 27502 S 431.50 0.00 0.00<br />

27347 S 713.53 0.00 0.00 27503 S 79.08 0.00 0.00<br />

27350 S 869.74 0.00 0.00 27508 S 79.08 0.00 0.00<br />

27355 S 813.84 0.00 0.00 27509 S 728.27 0.00 0.00<br />

27356 S 869.74 0.00 0.00 27510 S 166.83 0.00 0.00<br />

27357 S 910.28 0.00 0.00 27516 S 79.08 0.00 0.00<br />

27358 S 910.28 0.00 0.00 27517 S 79.08 0.00 0.00<br />

27360 S 910.28 0.00 0.00 27520 S 79.08 0.00 0.00<br />

27372 S 884.77 0.00 0.00 27530 S 79.08 0.00 0.00<br />

27380 S 575.16 0.00 0.00 27532 S 431.50 0.00 0.00<br />

27381 S 657.63 0.00 0.00 27538 S 79.08 0.00 0.00<br />

27385 S 657.63 0.00 0.00 27550 S 79.08 0.00 0.00<br />

27386 S 657.63 0.00 0.00 27552 S 455.34 0.00 0.00<br />

27390 S 575.16 0.00 0.00 27560 S 79.08 0.00 0.00<br />

27391 S 627.81 0.00 0.00 27562 S 455.34 0.00 0.00<br />

27392 S 657.63 0.00 0.00 27566 S 1,034.41 0.00 0.00<br />

27393 S 784.02 0.00 0.00 27570 S 455.34 0.00 0.00<br />

27394 S 813.84 0.00 0.00 27594 S 657.63 0.00 0.00<br />

27395 S 1,112.19 0.00 0.00 27600 S 657.63 0.00 0.00<br />

27396 S 813.84 0.00 0.00 27601 S 657.63 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 657.63 0.00 0.00 27730 S 784.02 0.00 0.00<br />

27603 S 581.65 0.00 0.00 27732 S 784.02 0.00 0.00<br />

27604 S 627.81 0.00 0.00 27734 S 784.02 0.00 0.00<br />

27605 S 572.08 0.00 0.00 27740 S 784.02 0.00 0.00<br />

27606 S 575.16 0.00 0.00 27742 S 1,082.38 0.00 0.00<br />

27607 S 627.81 0.00 0.00 27745 S 1,907.53 0.00 0.00<br />

27610 S 784.02 0.00 0.00 27750 S 79.08 0.00 0.00<br />

27612 S 813.84 0.00 0.00 27752 S 431.50 0.00 0.00<br />

27613 S 129.24 0.00 0.00 27756 S 728.27 0.00 0.00<br />

27614 S 629.00 0.00 0.00 27758 S 1,120.13 0.00 0.00<br />

27615 S 813.84 0.00 0.00 27759 S 1,500.09 0.00 0.00<br />

27618 S 514.34 0.00 0.00 27760 S 79.08 0.00 0.00<br />

27619 S 658.82 0.00 0.00 27762 S 431.50 0.00 0.00<br />

27620 S 869.74 0.00 0.00 27766 S 1,064.22 0.00 0.00<br />

27625 S 869.74 0.00 0.00 27767 S 61.62 0.00 0.00<br />

27626 S 869.74 0.00 0.00 27768 S 61.62 0.00 0.00<br />

27630 S 657.63 0.00 0.00 27769 S 1,653.24 0.00 0.00<br />

27635 S 813.84 0.00 0.00 27780 S 79.08 0.00 0.00<br />

27637 S 813.84 0.00 0.00 27781 S 431.50 0.00 0.00<br />

27638 S 813.84 0.00 0.00 27784 S 1,064.22 0.00 0.00<br />

27640 S 1,082.38 0.00 0.00 27786 S 79.08 0.00 0.00<br />

27641 S 784.02 0.00 0.00 27788 S 79.08 0.00 0.00<br />

27647 S 1,112.19 0.00 0.00 27792 S 1,064.22 0.00 0.00<br />

27650 S 1,112.19 0.00 0.00 27808 S 79.08 0.00 0.00<br />

27652 S 1,907.53 0.00 0.00 27810 S 166.83 0.00 0.00<br />

27654 S 1,112.19 0.00 0.00 27814 S 1,064.22 0.00 0.00<br />

27656 S 627.81 0.00 0.00 27816 S 79.08 0.00 0.00<br />

27658 S 575.16 0.00 0.00 27818 S 166.83 0.00 0.00<br />

27659 S 627.81 0.00 0.00 27822 S 1,064.22 0.00 0.00<br />

27664 S 627.81 0.00 0.00 27823 S 1,444.19 0.00 0.00<br />

27665 S 784.02 0.00 0.00 27824 S 79.08 0.00 0.00<br />

27675 S 627.81 0.00 0.00 27825 S 431.50 0.00 0.00<br />

27676 S 813.84 0.00 0.00 27826 S 1,064.22 0.00 0.00<br />

27680 S 813.84 0.00 0.00 27827 S 1,444.19 0.00 0.00<br />

27681 S 784.02 0.00 0.00 27828 S 1,500.09 0.00 0.00<br />

27685 S 813.84 0.00 0.00 27829 S 1,034.41 0.00 0.00<br />

27686 S 813.84 0.00 0.00 27830 S 79.08 0.00 0.00<br />

27687 S 813.84 0.00 0.00 27831 S 431.50 0.00 0.00<br />

27690 S 1,168.10 0.00 0.00 27832 S 1,034.41 0.00 0.00<br />

27691 S 1,168.10 0.00 0.00 27840 S 166.83 0.00 0.00<br />

27692 S 1,112.19 0.00 0.00 27842 S 455.34 0.00 0.00<br />

27695 S 784.02 0.00 0.00 27846 S 1,064.22 0.00 0.00<br />

27696 S 784.02 0.00 0.00 27848 S 1,064.22 0.00 0.00<br />

27698 S 784.02 0.00 0.00 27860 S 455.34 0.00 0.00<br />

27700 S 1,063.57 0.00 0.00 27870 S 1,963.43 0.00 0.00<br />

27704 S 627.81 0.00 0.00 27871 S 1,963.43 0.00 0.00<br />

27705 S 1,082.38 0.00 0.00 27884 S 657.63 0.00 0.00<br />

27707 S 627.81 0.00 0.00 27889 S 813.84 0.00 0.00<br />

27709 S 784.02 0.00 0.00 27892 S 657.63 0.00 0.00<br />

27726 S 981.34 0.00 0.00 27893 S 657.63 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 657.63 0.00 0.00 28153 S 654.54 0.00 0.00<br />

28001 S 126.13 0.00 0.00 28160 S 654.54 0.00 0.00<br />

28002 S 657.63 0.00 0.00 28171 S 654.54 0.00 0.00<br />

28003 S 657.63 0.00 0.00 28173 S 654.54 0.00 0.00<br />

28005 S 654.54 0.00 0.00 28175 S 654.54 0.00 0.00<br />

28008 S 654.54 0.00 0.00 28190 S 130.27 0.00 0.00<br />

28010 S 92.71 0.00 0.00 28192 S 514.34 0.00 0.00<br />

28011 S 654.54 0.00 0.00 28193 S 354.18 0.00 0.00<br />

28020 S 624.72 0.00 0.00 28200 S 654.54 0.00 0.00<br />

28022 S 624.72 0.00 0.00 28202 S 654.54 0.00 0.00<br />

28024 S 624.72 0.00 0.00 28208 S 654.54 0.00 0.00<br />

28035 S 650.47 0.00 0.00 28210 S 1,149.57 0.00 0.00<br />

28043 S 629.00 0.00 0.00 28220 S 200.92 0.00 0.00<br />

28045 S 654.54 0.00 0.00 28222 S 572.08 0.00 0.00<br />

28046 S 654.54 0.00 0.00 28225 S 572.08 0.00 0.00<br />

28050 S 624.72 0.00 0.00 28226 S 572.08 0.00 0.00<br />

28052 S 624.72 0.00 0.00 28230 S 197.13 0.00 0.00<br />

28054 S 624.72 0.00 0.00 28232 S 188.51 0.00 0.00<br />

28055 S 650.47 0.00 0.00 28234 S 624.72 0.00 0.00<br />

28060 S 624.72 0.00 0.00 28238 S 1,149.57 0.00 0.00<br />

28062 S 654.54 0.00 0.00 28240 S 624.72 0.00 0.00<br />

28070 S 654.54 0.00 0.00 28250 S 654.54 0.00 0.00<br />

28072 S 654.54 0.00 0.00 28260 S 654.54 0.00 0.00<br />

28080 S 654.54 0.00 0.00 28261 S 654.54 0.00 0.00<br />

28086 S 624.72 0.00 0.00 28262 S 710.44 0.00 0.00<br />

28088 S 624.72 0.00 0.00 28264 S 1,067.11 0.00 0.00<br />

28090 S 654.54 0.00 0.00 28270 S 654.54 0.00 0.00<br />

28092 S 654.54 0.00 0.00 28272 S 181.97 0.00 0.00<br />

28100 S 624.72 0.00 0.00 28280 S 624.72 0.00 0.00<br />

28102 S 1,149.57 0.00 0.00 28285 S 654.54 0.00 0.00<br />

28103 S 1,149.57 0.00 0.00 28286 S 710.44 0.00 0.00<br />

28104 S 624.72 0.00 0.00 28288 S 654.54 0.00 0.00<br />

28106 S 1,149.57 0.00 0.00 28289 S 654.54 0.00 0.00<br />

28107 S 1,149.57 0.00 0.00 28290 S 806.81 0.00 0.00<br />

28108 S 624.72 0.00 0.00 28292 S 806.81 0.00 0.00<br />

28110 S 654.54 0.00 0.00 28293 S 836.62 0.00 0.00<br />

28111 S 654.54 0.00 0.00 28294 S 836.62 0.00 0.00<br />

28112 S 654.54 0.00 0.00 28296 S 836.62 0.00 0.00<br />

28113 S 654.54 0.00 0.00 28297 S 836.62 0.00 0.00<br />

28114 S 654.54 0.00 0.00 28298 S 836.62 0.00 0.00<br />

28116 S 654.54 0.00 0.00 28299 S 933.06 0.00 0.00<br />

28118 S 710.44 0.00 0.00 28300 S 1,119.76 0.00 0.00<br />

28119 S 710.44 0.00 0.00 28302 S 624.72 0.00 0.00<br />

28120 S 880.49 0.00 0.00 28304 S 1,119.76 0.00 0.00<br />

28122 S 654.54 0.00 0.00 28305 S 1,149.57 0.00 0.00<br />

28124 S 213.33 0.00 0.00 28306 S 710.44 0.00 0.00<br />

28126 S 654.54 0.00 0.00 28307 S 710.44 0.00 0.00<br />

28130 S 654.54 0.00 0.00 28308 S 624.72 0.00 0.00<br />

28140 S 654.54 0.00 0.00 28309 S 1,205.48 0.00 0.00<br />

28150 S 654.54 0.00 0.00 28310 S 654.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 654.54 0.00 0.00 28636 S 728.27 0.00 0.00<br />

28313 S 624.72 0.00 0.00 28645 S 728.27 0.00 0.00<br />

28315 S 710.44 0.00 0.00 28660 S 44.12 0.00 0.00<br />

28320 S 1,205.48 0.00 0.00 28665 S 455.34 0.00 0.00<br />

28322 S 1,205.48 0.00 0.00 28666 S 728.27 0.00 0.00<br />

28340 S 710.44 0.00 0.00 28675 S 728.27 0.00 0.00<br />

28341 S 710.44 0.00 0.00 28705 S 1,205.48 0.00 0.00<br />

28344 S 710.44 0.00 0.00 28715 S 1,963.43 0.00 0.00<br />

28345 S 710.44 0.00 0.00 28725 S 1,205.48 0.00 0.00<br />

28400 S 79.08 0.00 0.00 28730 S 1,205.48 0.00 0.00<br />

28405 S 431.50 0.00 0.00 28735 S 1,205.48 0.00 0.00<br />

28406 S 698.45 0.00 0.00 28737 S 1,246.01 0.00 0.00<br />

28415 S 1,444.19 0.00 0.00 28740 S 1,205.48 0.00 0.00<br />

28420 S 1,120.13 0.00 0.00 28750 S 1,205.48 0.00 0.00<br />

28430 S 61.62 0.00 0.00 28755 S 710.44 0.00 0.00<br />

28435 S 79.08 0.00 0.00 28760 S 1,205.48 0.00 0.00<br />

28436 S 698.45 0.00 0.00 28810 S 624.72 0.00 0.00<br />

28445 S 1,064.22 0.00 0.00 28820 S 624.72 0.00 0.00<br />

28446 S 1,823.95 0.00 0.00 28825 S 624.72 0.00 0.00<br />

28450 S 61.62 0.00 0.00 28890 S 165.08 0.00 0.00<br />

28455 S 61.62 0.00 0.00 29000 S 41.82 0.00 0.00<br />

28456 S 698.45 0.00 0.00 29010 S 93.74 0.00 0.00<br />

28465 S 1,064.22 0.00 0.00 29015 S 93.74 0.00 0.00<br />

28470 S 61.62 0.00 0.00 29020 S 41.82 0.00 0.00<br />

28475 S 61.62 0.00 0.00 29025 S 41.82 0.00 0.00<br />

28476 S 698.45 0.00 0.00 29035 S 93.74 0.00 0.00<br />

28485 S 1,120.13 0.00 0.00 29040 S 41.82 0.00 0.00<br />

28490 S 61.62 0.00 0.00 29044 S 93.74 0.00 0.00<br />

28495 S 61.62 0.00 0.00 29046 S 93.74 0.00 0.00<br />

28496 S 698.45 0.00 0.00 29049 S 37.91 0.00 0.00<br />

28505 S 728.27 0.00 0.00 29055 S 93.74 0.00 0.00<br />

28510 S 55.49 0.00 0.00 29058 S 41.82 0.00 0.00<br />

28515 S 61.62 0.00 0.00 29065 S 44.46 0.00 0.00<br />

28525 S 728.27 0.00 0.00 29075 S 42.73 0.00 0.00<br />

28530 S 53.42 0.00 0.00 29085 S 41.82 0.00 0.00<br />

28531 S 728.27 0.00 0.00 29086 S 35.84 0.00 0.00<br />

28540 S 61.62 0.00 0.00 29105 S 38.59 0.00 0.00<br />

28545 S 645.81 0.00 0.00 29125 S 33.43 0.00 0.00<br />

28546 S 698.45 0.00 0.00 29126 S 35.50 0.00 0.00<br />

28555 S 1,034.41 0.00 0.00 29130 S 15.16 0.00 0.00<br />

28570 S 79.95 0.00 0.00 29131 S 22.05 0.00 0.00<br />

28575 S 431.50 0.00 0.00 29200 S 21.37 0.00 0.00<br />

28576 S 728.27 0.00 0.00 29220 S 23.09 0.00 0.00<br />

28585 S 728.27 0.00 0.00 29240 S 24.13 0.00 0.00<br />

28600 S 61.62 0.00 0.00 29260 S 23.09 0.00 0.00<br />

28605 S 79.08 0.00 0.00 29280 S 23.44 0.00 0.00<br />

28606 S 698.45 0.00 0.00 29305 S 93.74 0.00 0.00<br />

28615 S 1,064.22 0.00 0.00 29325 S 93.74 0.00 0.00<br />

28630 S 61.62 0.00 0.00 29345 S 58.24 0.00 0.00<br />

28635 S 455.34 0.00 0.00 29355 S 57.21 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 71.00 0.00 0.00 29847 S 1,186.67 0.00 0.00<br />

29365 S 55.14 0.00 0.00 29848 S 1,191.05 0.00 0.00<br />

29405 S 41.01 0.00 0.00 29850 S 860.74 0.00 0.00<br />

29425 S 41.70 0.00 0.00 29851 S 1,242.58 0.00 0.00<br />

29435 S 52.73 0.00 0.00 29855 S 1,242.58 0.00 0.00<br />

29440 S 22.40 0.00 0.00 29856 S 1,242.58 0.00 0.00<br />

29445 S 55.49 0.00 0.00 29860 S 1,242.58 0.00 0.00<br />

29450 S 41.82 0.00 0.00 29861 S 1,242.58 0.00 0.00<br />

29505 S 37.22 0.00 0.00 29862 S 1,572.88 0.00 0.00<br />

29515 S 31.71 0.00 0.00 29863 S 1,242.58 0.00 0.00<br />

29520 S 22.74 0.00 0.00 29866 S 1,898.14 0.00 0.00<br />

29530 S 23.09 0.00 0.00 29870 S 804.84 0.00 0.00<br />

29540 S 17.23 0.00 0.00 29871 S 804.84 0.00 0.00<br />

29550 S 17.57 0.00 0.00 29873 S 804.84 0.00 0.00<br />

29580 S 23.78 0.00 0.00 29874 S 804.84 0.00 0.00<br />

29590 S 19.30 0.00 0.00 29875 S 860.74 0.00 0.00<br />

29700 S 32.05 0.00 0.00 29876 S 860.74 0.00 0.00<br />

29705 S 27.22 0.00 0.00 29877 S 860.74 0.00 0.00<br />

29710 S 47.90 0.00 0.00 29879 S 804.84 0.00 0.00<br />

29715 S 41.82 0.00 0.00 29880 S 860.74 0.00 0.00<br />

29720 S 39.98 0.00 0.00 29881 S 860.74 0.00 0.00<br />

29730 S 26.19 0.00 0.00 29882 S 804.84 0.00 0.00<br />

29740 S 35.84 0.00 0.00 29883 S 804.84 0.00 0.00<br />

29750 S 37.56 0.00 0.00 29884 S 804.84 0.00 0.00<br />

29800 S 804.84 0.00 0.00 29885 S 1,186.67 0.00 0.00<br />

29804 S 804.84 0.00 0.00 29886 S 804.84 0.00 0.00<br />

29805 S 804.84 0.00 0.00 29887 S 804.84 0.00 0.00<br />

29806 S 1,186.67 0.00 0.00 29888 S 1,186.67 0.00 0.00<br />

29807 S 1,186.67 0.00 0.00 29889 S 1,186.67 0.00 0.00<br />

29819 S 1,186.67 0.00 0.00 29891 S 1,186.67 0.00 0.00<br />

29820 S 1,186.67 0.00 0.00 29892 S 1,186.67 0.00 0.00<br />

29821 S 1,186.67 0.00 0.00 29893 S 1,001.88 0.00 0.00<br />

29822 S 804.84 0.00 0.00 29894 S 804.84 0.00 0.00<br />

29823 S 1,186.67 0.00 0.00 29895 S 804.84 0.00 0.00<br />

29824 S 901.27 0.00 0.00 29897 S 804.84 0.00 0.00<br />

29825 S 1,186.67 0.00 0.00 29898 S 804.84 0.00 0.00<br />

29826 S 1,186.67 0.00 0.00 29899 S 1,186.67 0.00 0.00<br />

29827 S 1,283.10 0.00 0.00 29900 S 804.84 0.00 0.00<br />

29828 S 1,898.14 0.00 0.00 29901 S 804.84 0.00 0.00<br />

29830 S 804.84 0.00 0.00 29902 S 804.84 0.00 0.00<br />

29834 S 804.84 0.00 0.00 29904 S 1,134.48 0.00 0.00<br />

29835 S 804.84 0.00 0.00 29905 S 1,134.48 0.00 0.00<br />

29836 S 804.84 0.00 0.00 29906 S 1,134.48 0.00 0.00<br />

29837 S 804.84 0.00 0.00 29907 S 1,898.14 0.00 0.00<br />

29838 S 804.84 0.00 0.00 30000 S 127.55 0.00 0.00<br />

29840 S 804.84 0.00 0.00 30020 S 127.55 0.00 0.00<br />

29843 S 804.84 0.00 0.00 30100 S 82.71 0.00 0.00<br />

29844 S 804.84 0.00 0.00 30110 S 127.86 0.00 0.00<br />

29845 S 804.84 0.00 0.00 30115 S 540.24 0.00 0.00<br />

29846 S 804.84 0.00 0.00 30117 S 570.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 714.99 0.00 0.00 31080 S 1,101.00 0.00 0.00<br />

30120 S 487.60 0.00 0.00 31081 S 1,101.00 0.00 0.00<br />

30124 S 290.53 0.00 0.00 31084 S 1,101.00 0.00 0.00<br />

30125 S 1,015.28 0.00 0.00 31085 S 1,101.00 0.00 0.00<br />

30130 S 570.06 0.00 0.00 31086 S 1,101.00 0.00 0.00<br />

30140 S 685.17 0.00 0.00 31087 S 1,101.00 0.00 0.00<br />

30150 S 1,045.10 0.00 0.00 31090 S 1,141.54 0.00 0.00<br />

30160 S 1,101.00 0.00 0.00 31200 S 1,015.28 0.00 0.00<br />

30200 S 65.14 0.00 0.00 31201 S 1,141.54 0.00 0.00<br />

30210 S 82.71 0.00 0.00 31205 S 1,045.10 0.00 0.00<br />

30220 S 361.50 0.00 0.00 31231 S 69.73 0.00 0.00<br />

30300 S 24.92 0.00 0.00 31233 S 75.11 0.00 0.00<br />

30310 S 487.60 0.00 0.00 31235 S 510.27 0.00 0.00<br />

30320 S 540.24 0.00 0.00 31237 S 562.91 0.00 0.00<br />

30400 S 1,101.00 0.00 0.00 31238 S 510.27 0.00 0.00<br />

30410 S 1,141.54 0.00 0.00 31239 S 744.84 0.00 0.00<br />

30420 S 1,141.54 0.00 0.00 31240 S 562.91 0.00 0.00<br />

30430 S 714.99 0.00 0.00 31254 S 688.93 0.00 0.00<br />

30435 S 1,141.54 0.00 0.00 31255 S 785.37 0.00 0.00<br />

30450 S 1,271.05 0.00 0.00 31256 S 688.93 0.00 0.00<br />

30460 S 1,271.05 0.00 0.00 31267 S 688.93 0.00 0.00<br />

30462 S 1,431.31 0.00 0.00 31276 S 688.93 0.00 0.00<br />

30465 S 1,431.31 0.00 0.00 31287 S 688.93 0.00 0.00<br />

30520 S 770.89 0.00 0.00 31288 S 688.93 0.00 0.00<br />

30540 S 1,141.54 0.00 0.00 31300 S 811.42 0.00 0.00<br />

30545 S 1,141.54 0.00 0.00 31320 S 1,015.28 0.00 0.00<br />

30560 S 133.99 0.00 0.00 31400 S 1,015.28 0.00 0.00<br />

30580 S 1,101.00 0.00 0.00 31420 S 1,015.28 0.00 0.00<br />

30600 S 1,101.00 0.00 0.00 31500 S 93.26 0.00 0.00<br />

30620 S 1,271.05 0.00 0.00 31502 S 53.63 0.00 0.00<br />

30630 S 940.94 0.00 0.00 31505 S 31.69 0.00 0.00<br />

30801 S 300.41 0.00 0.00 31510 S 562.91 0.00 0.00<br />

30802 S 300.41 0.00 0.00 31511 S 75.11 0.00 0.00<br />

30901 S 42.85 0.00 0.00 31512 S 562.91 0.00 0.00<br />

30903 S 55.19 0.00 0.00 31513 S 75.11 0.00 0.00<br />

30905 S 55.19 0.00 0.00 31515 S 510.27 0.00 0.00<br />

30906 S 55.19 0.00 0.00 31520 S 69.73 0.00 0.00<br />

30915 S 735.42 0.00 0.00 31525 S 510.27 0.00 0.00<br />

30920 S 765.24 0.00 0.00 31526 S 659.12 0.00 0.00<br />

30930 S 625.96 0.00 0.00 31527 S 606.47 0.00 0.00<br />

31000 S 106.50 0.00 0.00 31528 S 562.91 0.00 0.00<br />

31002 S 290.53 0.00 0.00 31529 S 562.91 0.00 0.00<br />

31020 S 685.17 0.00 0.00 31530 S 659.12 0.00 0.00<br />

31030 S 1,045.10 0.00 0.00 31531 S 688.93 0.00 0.00<br />

31032 S 1,101.00 0.00 0.00 31535 S 659.12 0.00 0.00<br />

31040 S 954.79 0.00 0.00 31536 S 688.93 0.00 0.00<br />

31050 S 1,015.28 0.00 0.00 31540 S 688.93 0.00 0.00<br />

31051 S 1,101.00 0.00 0.00 31541 S 744.84 0.00 0.00<br />

31070 S 685.17 0.00 0.00 31545 S 744.84 0.00 0.00<br />

31075 S 1,101.00 0.00 0.00 31546 S 744.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 785.37 0.00 0.00 32405 S 339.85 0.00 0.00<br />

31561 S 785.37 0.00 0.00 32420 S 206.66 0.00 0.00<br />

31570 S 562.91 0.00 0.00 32421 S 206.66 0.00 0.00<br />

31571 S 659.12 0.00 0.00 32422 S 205.74 0.00 0.00<br />

31575 S 59.97 0.00 0.00 32550 S 1,151.92 0.00 0.00<br />

31576 S 659.12 0.00 0.00 32960 S 205.74 0.00 0.00<br />

31577 S 194.70 0.00 0.00 32998 S 1,793.47 0.00 0.00<br />

31578 S 659.12 0.00 0.00 33010 S 206.66 0.00 0.00<br />

31579 S 106.84 0.00 0.00 33011 S 206.66 0.00 0.00<br />

31580 S 1,141.54 0.00 0.00 33206 S 6,630.33 3,945.03 1,259.73<br />

31582 S 1,141.54 0.00 0.00 33207 S 6,630.33 3,945.03 1,259.73<br />

31588 S 1,141.54 0.00 0.00 33208 S 8,223.49 4,791.79 1,360.09<br />

31590 S 1,141.54 0.00 0.00 33210 S 1,947.02 0.00 0.00<br />

31595 S 1,015.28 0.00 0.00 33211 S 1,947.02 0.00 0.00<br />

31603 S 300.41 0.00 0.00 33212 S 5,207.17 2,966.30 725.43<br />

31605 S 290.53 0.00 0.00 33213 S 6,010.20 3,367.39 724.57<br />

31611 S 714.99 0.00 0.00 33214 S 8,223.49 4,791.79 1,360.09<br />

31612 S 632.53 0.00 0.00 33215 S 853.40 0.00 0.00<br />

31613 S 685.17 0.00 0.00 33216 S 1,947.02 0.00 0.00<br />

31614 S 1,015.28 0.00 0.00 33217 S 1,947.02 0.00 0.00<br />

31615 S 300.41 0.00 0.00 33218 S 853.40 0.00 0.00<br />

31622 S 351.82 0.00 0.00 33220 S 853.40 0.00 0.00<br />

31623 S 404.47 0.00 0.00 33222 S 515.84 0.00 0.00<br />

31624 S 404.47 0.00 0.00 33223 S 515.84 0.00 0.00<br />

31625 S 404.47 0.00 0.00 33224 S 7,762.21 4,647.21 1,532.22<br />

31628 S 404.47 0.00 0.00 33225 S 7,762.21 4,647.21 1,532.22<br />

31629 S 404.47 0.00 0.00 33226 S 853.40 0.00 0.00<br />

31630 S 693.09 0.00 0.00 33233 S 634.49 0.00 0.00<br />

31631 S 693.09 0.00 0.00 33234 S 853.40 0.00 0.00<br />

31632 S 393.37 0.00 0.00 33235 S 853.40 0.00 0.00<br />

31633 S 393.37 0.00 0.00 33240 S 19,349.21 10,342.94 1,336.68<br />

31635 S 404.47 0.00 0.00 33241 S 853.40 0.00 0.00<br />

31636 S 693.09 0.00 0.00 33249 S 25,822.99 13,831.86 1,840.73<br />

31637 S 351.82 0.00 0.00 33282 S 4,082.78 2,444.19 805.61<br />

31638 S 693.09 0.00 0.00 33284 S 318.45 0.00 0.00<br />

31640 S 693.09 0.00 0.00 34490 S 1,554.75 0.00 0.00<br />

31641 S 693.09 0.00 0.00 35188 S 1,070.88 0.00 0.00<br />

31643 S 404.47 0.00 0.00 35207 S 1,070.88 0.00 0.00<br />

31645 S 351.82 0.00 0.00 35473 S 1,865.10 0.00 0.00<br />

31646 S 351.82 0.00 0.00 35476 S 1,865.10 0.00 0.00<br />

31656 S 351.82 0.00 0.00 35492 S 3,481.02 0.00 0.00<br />

31717 S 194.70 0.00 0.00 35761 S 1,119.80 0.00 0.00<br />

31720 S 29.81 0.00 0.00 35875 S 1,401.18 0.00 0.00<br />

31730 S 194.70 0.00 0.00 35876 S 1,401.18 0.00 0.00<br />

31750 S 1,141.54 0.00 0.00 36002 S 89.43 0.00 0.00<br />

31755 S 1,015.28 0.00 0.00 36260 S 811.25 0.00 0.00<br />

31820 S 487.60 0.00 0.00 36261 S 634.49 0.00 0.00<br />

31825 S 685.17 0.00 0.00 36262 S 581.83 0.00 0.00<br />

31830 S 685.17 0.00 0.00 36420 S 8.43 0.00 0.00<br />

32400 S 339.85 0.00 0.00 36425 S 8.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.39 0.00 0.00 36800 S 873.32 0.00 0.00<br />

36440 S 129.37 0.00 0.00 36810 S 873.32 0.00 0.00<br />

36450 S 129.37 0.00 0.00 36815 S 873.32 0.00 0.00<br />

36455 S 129.37 0.00 0.00 36818 S 1,014.98 0.00 0.00<br />

36468 S 31.93 0.00 0.00 36819 S 1,014.98 0.00 0.00<br />

36469 S 31.93 0.00 0.00 36820 S 1,014.98 0.00 0.00<br />

36470 S 31.93 0.00 0.00 36821 S 1,014.98 0.00 0.00<br />

36471 S 31.93 0.00 0.00 36825 S 1,070.88 0.00 0.00<br />

36475 S 1,468.30 0.00 0.00 36830 S 1,070.88 0.00 0.00<br />

36476 S 1,151.45 0.00 0.00 36831 S 1,401.18 0.00 0.00<br />

36478 S 1,151.45 0.00 0.00 36832 S 1,070.88 0.00 0.00<br />

36479 S 1,151.45 0.00 0.00 36833 S 1,070.88 0.00 0.00<br />

36511 S 443.55 0.00 0.00 36834 S 1,014.98 0.00 0.00<br />

36512 S 443.55 0.00 0.00 36835 S 929.22 0.00 0.00<br />

36513 S 443.55 0.00 0.00 36860 S 106.65 0.00 0.00<br />

36514 S 443.55 0.00 0.00 36861 S 873.32 0.00 0.00<br />

36515 S 1,187.38 0.00 0.00 36870 S 1,527.29 0.00 0.00<br />

36516 S 1,187.38 0.00 0.00 37184 S 1,554.75 0.00 0.00<br />

36522 S 1,187.38 0.00 0.00 37185 S 1,554.75 0.00 0.00<br />

36555 S 368.53 0.00 0.00 37186 S 1,554.75 0.00 0.00<br />

36556 S 368.53 0.00 0.00 37187 S 1,554.75 0.00 0.00<br />

36557 S 688.25 0.00 0.00 37188 S 1,554.75 0.00 0.00<br />

36558 S 688.25 0.00 0.00 37200 S 1,147.31 0.00 0.00<br />

36560 S 811.25 0.00 0.00 37203 S 1,147.31 0.00 0.00<br />

36561 S 811.25 0.00 0.00 37500 S 1,082.09 0.00 0.00<br />

36563 S 811.25 0.00 0.00 37607 S 765.24 0.00 0.00<br />

36565 S 811.25 0.00 0.00 37609 S 514.34 0.00 0.00<br />

36566 S 811.25 0.00 0.00 37650 S 735.42 0.00 0.00<br />

36568 S 368.53 0.00 0.00 37700 S 735.42 0.00 0.00<br />

36569 S 368.53 0.00 0.00 37718 S 765.24 0.00 0.00<br />

36570 S 718.07 0.00 0.00 37722 S 1,082.09 0.00 0.00<br />

36571 S 718.07 0.00 0.00 37735 S 1,082.09 0.00 0.00<br />

36575 S 296.40 0.00 0.00 37760 S 765.24 0.00 0.00<br />

36576 S 421.17 0.00 0.00 37765 S 1,055.28 0.00 0.00<br />

36578 S 688.25 0.00 0.00 37766 S 1,055.28 0.00 0.00<br />

36580 S 368.53 0.00 0.00 37780 S 765.24 0.00 0.00<br />

36581 S 688.25 0.00 0.00 37785 S 765.24 0.00 0.00<br />

36582 S 811.25 0.00 0.00 37790 S 923.41 0.00 0.00<br />

36583 S 811.25 0.00 0.00 38205 S 443.55 0.00 0.00<br />

36584 S 368.53 0.00 0.00 38206 S 443.55 0.00 0.00<br />

36585 S 718.07 0.00 0.00 38220 S 101.67 0.00 0.00<br />

36589 S 243.76 0.00 0.00 38221 S 106.50 0.00 0.00<br />

36590 S 368.53 0.00 0.00 38230 S 1,187.38 0.00 0.00<br />

36593 S 24.47 0.00 0.00 38241 S 1,187.38 0.00 0.00<br />

36595 S 960.94 0.00 0.00 38242 S 443.55 0.00 0.00<br />

36596 S 426.77 0.00 0.00 38300 S 398.02 0.00 0.00<br />

36597 S 426.77 0.00 0.00 38305 S 581.65 0.00 0.00<br />

36598 S 78.92 0.00 0.00 38308 S 664.61 0.00 0.00<br />

36640 S 728.79 0.00 0.00 38500 S 664.61 0.00 0.00<br />

36680 S 55.24 0.00 0.00 38505 S 254.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 664.61 0.00 0.00 41005 S 133.99 0.00 0.00<br />

38520 S 664.61 0.00 0.00 41006 S 632.53 0.00 0.00<br />

38525 S 664.61 0.00 0.00 41007 S 487.60 0.00 0.00<br />

38530 S 664.61 0.00 0.00 41008 S 487.60 0.00 0.00<br />

38542 S 1,118.12 0.00 0.00 41009 S 133.99 0.00 0.00<br />

38550 S 694.44 0.00 0.00 41010 S 300.41 0.00 0.00<br />

38555 S 750.34 0.00 0.00 41015 S 133.99 0.00 0.00<br />

38570 S 1,517.12 0.00 0.00 41016 S 300.41 0.00 0.00<br />

38571 S 1,972.22 0.00 0.00 41017 S 300.41 0.00 0.00<br />

38572 S 1,517.12 0.00 0.00 41018 S 300.41 0.00 0.00<br />

38700 S 913.67 0.00 0.00 41019 S 954.79 0.00 0.00<br />

38740 S 1,118.12 0.00 0.00 41100 S 89.95 0.00 0.00<br />

38745 S 1,203.84 0.00 0.00 41105 S 88.91 0.00 0.00<br />

38760 S 664.61 0.00 0.00 41108 S 82.37 0.00 0.00<br />

40490 S 67.89 0.00 0.00 41110 S 119.24 0.00 0.00<br />

40500 S 540.24 0.00 0.00 41112 S 540.24 0.00 0.00<br />

40510 S 685.17 0.00 0.00 41113 S 540.24 0.00 0.00<br />

40520 S 540.24 0.00 0.00 41114 S 685.17 0.00 0.00<br />

40525 S 685.17 0.00 0.00 41115 S 138.89 0.00 0.00<br />

40527 S 685.17 0.00 0.00 41116 S 487.60 0.00 0.00<br />

40530 S 685.17 0.00 0.00 41120 S 811.42 0.00 0.00<br />

40650 S 361.50 0.00 0.00 41250 S 91.64 0.00 0.00<br />

40652 S 361.50 0.00 0.00 41251 S 133.99 0.00 0.00<br />

40654 S 361.50 0.00 0.00 41252 S 353.05 0.00 0.00<br />

40700 S 1,271.05 0.00 0.00 41500 S 632.53 0.00 0.00<br />

40701 S 1,271.05 0.00 0.00 41510 S 487.60 0.00 0.00<br />

40702 S 1,615.00 0.00 0.00 41520 S 353.05 0.00 0.00<br />

40720 S 1,271.05 0.00 0.00 41530 S 664.92 0.00 0.00<br />

40761 S 1,045.10 0.00 0.00 41800 S 68.46 0.00 0.00<br />

40800 S 54.49 0.00 0.00 41805 S 148.20 0.00 0.00<br />

40801 S 353.05 0.00 0.00 41806 S 182.65 0.00 0.00<br />

40804 S 24.92 0.00 0.00 41820 S 290.53 0.00 0.00<br />

40805 S 168.53 0.00 0.00 41821 S 290.53 0.00 0.00<br />

40806 S 77.54 0.00 0.00 41822 S 151.29 0.00 0.00<br />

40808 S 115.11 0.00 0.00 41823 S 220.57 0.00 0.00<br />

40810 S 119.24 0.00 0.00 41825 S 121.31 0.00 0.00<br />

40812 S 149.57 0.00 0.00 41826 S 152.68 0.00 0.00<br />

40814 S 540.24 0.00 0.00 41827 S 685.17 0.00 0.00<br />

40816 S 685.17 0.00 0.00 41828 S 137.86 0.00 0.00<br />

40818 S 133.99 0.00 0.00 41830 S 195.75 0.00 0.00<br />

40819 S 300.41 0.00 0.00 41850 S 664.92 0.00 0.00<br />

40820 S 171.97 0.00 0.00 41870 S 954.79 0.00 0.00<br />

40830 S 127.55 0.00 0.00 41872 S 195.75 0.00 0.00<br />

40831 S 300.41 0.00 0.00 41874 S 188.85 0.00 0.00<br />

40840 S 685.17 0.00 0.00 42000 S 133.99 0.00 0.00<br />

40842 S 714.99 0.00 0.00 42100 S 76.51 0.00 0.00<br />

40843 S 714.99 0.00 0.00 42104 S 113.73 0.00 0.00<br />

40844 S 1,141.54 0.00 0.00 42106 S 142.68 0.00 0.00<br />

40845 S 1,141.54 0.00 0.00 42107 S 685.17 0.00 0.00<br />

41000 S 85.47 0.00 0.00 42120 S 1,101.00 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 353.05 0.00 0.00 42809 S 24.92 0.00 0.00<br />

42145 S 811.42 0.00 0.00 42810 S 714.99 0.00 0.00<br />

42160 S 135.10 0.00 0.00 42815 S 1,141.54 0.00 0.00<br />

42180 S 133.99 0.00 0.00 42820 S 714.99 0.00 0.00<br />

42182 S 1,015.28 0.00 0.00 42821 S 811.42 0.00 0.00<br />

42200 S 1,141.54 0.00 0.00 42825 S 770.89 0.00 0.00<br />

42205 S 1,141.54 0.00 0.00 42826 S 770.89 0.00 0.00<br />

42210 S 1,141.54 0.00 0.00 42830 S 770.89 0.00 0.00<br />

42215 S 1,271.05 0.00 0.00 42831 S 770.89 0.00 0.00<br />

42220 S 1,141.54 0.00 0.00 42835 S 770.89 0.00 0.00<br />

42226 S 1,141.54 0.00 0.00 42836 S 770.89 0.00 0.00<br />

42235 S 666.50 0.00 0.00 42860 S 714.99 0.00 0.00<br />

42260 S 770.89 0.00 0.00 42870 S 714.99 0.00 0.00<br />

42280 S 74.44 0.00 0.00 42890 S 1,271.05 0.00 0.00<br />

42281 S 664.92 0.00 0.00 42892 S 1,271.05 0.00 0.00<br />

42300 S 487.60 0.00 0.00 42900 S 300.41 0.00 0.00<br />

42305 S 540.24 0.00 0.00 42950 S 685.17 0.00 0.00<br />

42310 S 133.99 0.00 0.00 42955 S 685.17 0.00 0.00<br />

42320 S 133.99 0.00 0.00 42960 S 55.19 0.00 0.00<br />

42330 S 115.11 0.00 0.00 42962 S 1,015.28 0.00 0.00<br />

42335 S 190.93 0.00 0.00 42970 S 42.85 0.00 0.00<br />

42340 S 540.24 0.00 0.00 42972 S 570.06 0.00 0.00<br />

42400 S 64.80 0.00 0.00 43030 S 664.92 0.00 0.00<br />

42405 S 540.24 0.00 0.00 43200 S 321.99 0.00 0.00<br />

42408 S 570.06 0.00 0.00 43201 S 321.99 0.00 0.00<br />

42409 S 570.06 0.00 0.00 43202 S 321.99 0.00 0.00<br />

42410 S 1,045.10 0.00 0.00 43204 S 321.99 0.00 0.00<br />

42415 S 1,271.05 0.00 0.00 43205 S 321.99 0.00 0.00<br />

42420 S 1,271.05 0.00 0.00 43215 S 321.99 0.00 0.00<br />

42425 S 1,271.05 0.00 0.00 43216 S 321.99 0.00 0.00<br />

42440 S 1,045.10 0.00 0.00 43217 S 321.99 0.00 0.00<br />

42450 S 685.17 0.00 0.00 43219 S 650.75 0.00 0.00<br />

42500 S 714.99 0.00 0.00 43220 S 321.99 0.00 0.00<br />

42505 S 1,101.00 0.00 0.00 43226 S 321.99 0.00 0.00<br />

42507 S 1,045.10 0.00 0.00 43227 S 374.64 0.00 0.00<br />

42508 S 1,101.00 0.00 0.00 43228 S 697.18 0.00 0.00<br />

42509 S 1,101.00 0.00 0.00 43231 S 374.64 0.00 0.00<br />

42510 S 1,101.00 0.00 0.00 43232 S 374.64 0.00 0.00<br />

42600 S 487.60 0.00 0.00 43234 S 321.99 0.00 0.00<br />

42650 S 42.39 0.00 0.00 43235 S 321.99 0.00 0.00<br />

42660 S 49.63 0.00 0.00 43236 S 374.64 0.00 0.00<br />

42665 S 940.94 0.00 0.00 43237 S 374.64 0.00 0.00<br />

42700 S 133.99 0.00 0.00 43238 S 374.64 0.00 0.00<br />

42720 S 487.60 0.00 0.00 43239 S 374.64 0.00 0.00<br />

42725 S 1,015.28 0.00 0.00 43240 S 374.64 0.00 0.00<br />

42800 S 82.02 0.00 0.00 43241 S 374.64 0.00 0.00<br />

42802 S 487.60 0.00 0.00 43242 S 374.64 0.00 0.00<br />

42804 S 487.60 0.00 0.00 43243 S 374.64 0.00 0.00<br />

42806 S 685.17 0.00 0.00 43244 S 374.64 0.00 0.00<br />

42808 S 540.24 0.00 0.00 43245 S 374.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 374.64 0.00 0.00 44378 S 392.38 0.00 0.00<br />

43247 S 374.64 0.00 0.00 44379 S 1,119.43 0.00 0.00<br />

43248 S 374.64 0.00 0.00 44380 S 339.73 0.00 0.00<br />

43249 S 374.64 0.00 0.00 44382 S 339.73 0.00 0.00<br />

43250 S 374.64 0.00 0.00 44383 S 1,119.43 0.00 0.00<br />

43251 S 374.64 0.00 0.00 44385 S 328.47 0.00 0.00<br />

43255 S 374.64 0.00 0.00 44386 S 328.47 0.00 0.00<br />

43256 S 733.21 0.00 0.00 44388 S 328.47 0.00 0.00<br />

43257 S 727.00 0.00 0.00 44389 S 328.47 0.00 0.00<br />

43258 S 404.46 0.00 0.00 44390 S 328.47 0.00 0.00<br />

43259 S 404.46 0.00 0.00 44391 S 328.47 0.00 0.00<br />

43260 S 630.71 0.00 0.00 44392 S 328.47 0.00 0.00<br />

43261 S 630.71 0.00 0.00 44393 S 328.47 0.00 0.00<br />

43262 S 630.71 0.00 0.00 44394 S 328.47 0.00 0.00<br />

43263 S 630.71 0.00 0.00 44397 S 650.75 0.00 0.00<br />

43264 S 630.71 0.00 0.00 44500 S 177.25 0.00 0.00<br />

43265 S 630.71 0.00 0.00 45000 S 380.92 0.00 0.00<br />

43267 S 630.71 0.00 0.00 45005 S 443.32 0.00 0.00<br />

43268 S 703.40 0.00 0.00 45020 S 443.32 0.00 0.00<br />

43269 S 703.40 0.00 0.00 45100 S 602.29 0.00 0.00<br />

43271 S 630.71 0.00 0.00 45108 S 654.93 0.00 0.00<br />

43272 S 630.71 0.00 0.00 45150 S 654.93 0.00 0.00<br />

43273 S 845.86 0.00 0.00 45160 S 654.93 0.00 0.00<br />

43450 S 281.60 0.00 0.00 45170 S 654.93 0.00 0.00<br />

43453 S 281.60 0.00 0.00 45190 S 1,070.96 0.00 0.00<br />

43456 S 282.72 0.00 0.00 45300 S 63.41 0.00 0.00<br />

43458 S 323.12 0.00 0.00 45303 S 352.23 0.00 0.00<br />

43600 S 321.99 0.00 0.00 45305 S 331.25 0.00 0.00<br />

43653 S 1,517.12 0.00 0.00 45307 S 611.84 0.00 0.00<br />

43760 S 156.17 0.00 0.00 45308 S 331.25 0.00 0.00<br />

43761 S 321.99 0.00 0.00 45309 S 331.25 0.00 0.00<br />

43870 S 321.99 0.00 0.00 45315 S 331.25 0.00 0.00<br />

43886 S 812.47 0.00 0.00 45317 S 331.25 0.00 0.00<br />

43887 S 170.88 0.00 0.00 45320 S 611.84 0.00 0.00<br />

43888 S 812.47 0.00 0.00 45321 S 611.84 0.00 0.00<br />

44100 S 321.99 0.00 0.00 45327 S 650.75 0.00 0.00<br />

44312 S 561.37 0.00 0.00 45330 S 83.74 0.00 0.00<br />

44340 S 643.83 0.00 0.00 45331 S 247.65 0.00 0.00<br />

44360 S 392.38 0.00 0.00 45332 S 247.65 0.00 0.00<br />

44361 S 392.38 0.00 0.00 45333 S 331.25 0.00 0.00<br />

44363 S 392.38 0.00 0.00 45334 S 331.25 0.00 0.00<br />

44364 S 392.38 0.00 0.00 45335 S 247.65 0.00 0.00<br />

44365 S 392.38 0.00 0.00 45337 S 247.65 0.00 0.00<br />

44366 S 392.38 0.00 0.00 45338 S 331.25 0.00 0.00<br />

44369 S 392.38 0.00 0.00 45339 S 331.25 0.00 0.00<br />

44370 S 1,119.43 0.00 0.00 45340 S 331.25 0.00 0.00<br />

44372 S 392.38 0.00 0.00 45341 S 331.25 0.00 0.00<br />

44373 S 392.38 0.00 0.00 45342 S 331.25 0.00 0.00<br />

44376 S 392.38 0.00 0.00 45345 S 650.75 0.00 0.00<br />

44377 S 392.38 0.00 0.00 45355 S 328.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 381.12 0.00 0.00 46505 S 471.07 0.00 0.00<br />

45379 S 381.12 0.00 0.00 46600 S 24.92 0.00 0.00<br />

45380 S 381.12 0.00 0.00 46604 S 352.23 0.00 0.00<br />

45381 S 381.12 0.00 0.00 46606 S 132.34 0.00 0.00<br />

45382 S 381.12 0.00 0.00 46608 S 331.25 0.00 0.00<br />

45383 S 381.12 0.00 0.00 46610 S 611.84 0.00 0.00<br />

45384 S 381.12 0.00 0.00 46611 S 331.25 0.00 0.00<br />

45385 S 381.12 0.00 0.00 46612 S 611.84 0.00 0.00<br />

45386 S 381.12 0.00 0.00 46614 S 69.61 0.00 0.00<br />

45387 S 650.75 0.00 0.00 46615 S 664.48 0.00 0.00<br />

45391 S 381.12 0.00 0.00 46700 S 684.76 0.00 0.00<br />

45392 S 381.12 0.00 0.00 46706 S 753.71 0.00 0.00<br />

45500 S 654.93 0.00 0.00 46750 S 836.17 0.00 0.00<br />

45505 S 806.36 0.00 0.00 46753 S 684.76 0.00 0.00<br />

45520 S 31.93 0.00 0.00 46754 S 654.93 0.00 0.00<br />

45560 S 806.36 0.00 0.00 46760 S 806.36 0.00 0.00<br />

45900 S 258.24 0.00 0.00 46761 S 836.17 0.00 0.00<br />

45905 S 602.29 0.00 0.00 46762 S 1,062.12 0.00 0.00<br />

45910 S 602.29 0.00 0.00 46900 S 105.24 0.00 0.00<br />

45915 S 380.92 0.00 0.00 46910 S 125.79 0.00 0.00<br />

45990 S 592.54 0.00 0.00 46916 S 58.51 0.00 0.00<br />

46020 S 684.76 0.00 0.00 46917 S 545.79 0.00 0.00<br />

46030 S 258.24 0.00 0.00 46922 S 545.79 0.00 0.00<br />

46040 S 684.76 0.00 0.00 46924 S 545.79 0.00 0.00<br />

46045 S 654.93 0.00 0.00 46930 S 122.00 0.00 0.00<br />

46050 S 380.92 0.00 0.00 46937 S 654.93 0.00 0.00<br />

46060 S 654.93 0.00 0.00 46938 S 806.36 0.00 0.00<br />

46070 S 471.07 0.00 0.00 46940 S 90.29 0.00 0.00<br />

46080 S 684.76 0.00 0.00 46942 S 87.88 0.00 0.00<br />

46083 S 72.11 0.00 0.00 46945 S 149.57 0.00 0.00<br />

46200 S 654.93 0.00 0.00 46946 S 390.67 0.00 0.00<br />

46210 S 654.93 0.00 0.00 46947 S 1,062.12 0.00 0.00<br />

46211 S 654.93 0.00 0.00 47000 S 339.85 0.00 0.00<br />

46220 S 602.29 0.00 0.00 47382 S 1,793.47 0.00 0.00<br />

46221 S 118.56 0.00 0.00 47510 S 794.25 0.00 0.00<br />

46230 S 602.29 0.00 0.00 47511 S 1,166.88 0.00 0.00<br />

46250 S 684.76 0.00 0.00 47525 S 455.96 0.00 0.00<br />

46255 S 684.76 0.00 0.00 47530 S 455.96 0.00 0.00<br />

46257 S 684.76 0.00 0.00 47552 S 794.25 0.00 0.00<br />

46258 S 684.76 0.00 0.00 47553 S 824.07 0.00 0.00<br />

46260 S 684.76 0.00 0.00 47554 S 824.07 0.00 0.00<br />

46261 S 740.66 0.00 0.00 47555 S 824.07 0.00 0.00<br />

46262 S 740.66 0.00 0.00 47556 S 1,166.88 0.00 0.00<br />

46270 S 684.76 0.00 0.00 47560 S 968.25 0.00 0.00<br />

46275 S 684.76 0.00 0.00 47561 S 968.25 0.00 0.00<br />

46280 S 740.66 0.00 0.00 47562 S 1,786.62 0.00 0.00<br />

46285 S 602.29 0.00 0.00 47563 S 1,786.62 0.00 0.00<br />

46288 S 740.66 0.00 0.00 47564 S 1,786.62 0.00 0.00<br />

46320 S 80.30 0.00 0.00 47630 S 824.07 0.00 0.00<br />

46500 S 110.62 0.00 0.00 48102 S 339.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 206.66 0.00 0.00 49590 S 848.19 0.00 0.00<br />

49081 S 206.66 0.00 0.00 49600 S 904.09 0.00 0.00<br />

49180 S 339.85 0.00 0.00 49650 S 1,186.81 0.00 0.00<br />

49250 S 744.97 0.00 0.00 49651 S 1,356.86 0.00 0.00<br />

49320 S 968.25 0.00 0.00 49652 S 1,461.30 0.00 0.00<br />

49321 S 1,024.16 0.00 0.00 49653 S 1,461.30 0.00 0.00<br />

49322 S 1,024.16 0.00 0.00 49654 S 1,461.30 0.00 0.00<br />

49324 S 1,461.30 0.00 0.00 49655 S 1,461.30 0.00 0.00<br />

49325 S 1,461.30 0.00 0.00 49656 S 1,461.30 0.00 0.00<br />

49326 S 1,461.30 0.00 0.00 49657 S 1,461.30 0.00 0.00<br />

49402 S 659.24 0.00 0.00 50200 S 339.85 0.00 0.00<br />

49419 S 790.85 0.00 0.00 50382 S 986.85 0.00 0.00<br />

49420 S 731.09 0.00 0.00 50384 S 724.82 0.00 0.00<br />

49421 S 731.09 0.00 0.00 50385 S 724.82 0.00 0.00<br />

49422 S 581.83 0.00 0.00 50386 S 278.09 0.00 0.00<br />

49423 S 601.64 0.00 0.00 50387 S 601.64 0.00 0.00<br />

49426 S 659.24 0.00 0.00 50389 S 278.09 0.00 0.00<br />

49429 S 853.40 0.00 0.00 50390 S 339.85 0.00 0.00<br />

49440 S 333.72 0.00 0.00 50391 S 40.25 0.00 0.00<br />

49441 S 333.72 0.00 0.00 50392 S 517.54 0.00 0.00<br />

49446 S 333.72 0.00 0.00 50393 S 648.56 0.00 0.00<br />

49450 S 177.25 0.00 0.00 50395 S 517.54 0.00 0.00<br />

49451 S 177.25 0.00 0.00 50396 S 97.31 0.00 0.00<br />

49452 S 177.25 0.00 0.00 50398 S 455.96 0.00 0.00<br />

49460 S 177.25 0.00 0.00 50551 S 294.19 0.00 0.00<br />

49495 S 904.09 0.00 0.00 50553 S 648.56 0.00 0.00<br />

49496 S 904.09 0.00 0.00 50555 S 294.19 0.00 0.00<br />

49500 S 904.09 0.00 0.00 50557 S 648.56 0.00 0.00<br />

49501 S 1,234.40 0.00 0.00 50561 S 648.56 0.00 0.00<br />

49505 S 904.09 0.00 0.00 50562 S 278.09 0.00 0.00<br />

49507 S 1,234.40 0.00 0.00 50570 S 278.09 0.00 0.00<br />

49520 S 1,074.14 0.00 0.00 50572 S 278.09 0.00 0.00<br />

49521 S 1,234.40 0.00 0.00 50574 S 278.09 0.00 0.00<br />

49525 S 904.09 0.00 0.00 50575 S 1,383.29 0.00 0.00<br />

49540 S 818.37 0.00 0.00 50576 S 724.82 0.00 0.00<br />

49550 S 944.63 0.00 0.00 50580 S 724.82 0.00 0.00<br />

49553 S 1,234.40 0.00 0.00 50590 S 1,616.01 0.00 0.00<br />

49555 S 944.63 0.00 0.00 50592 S 1,793.47 0.00 0.00<br />

49557 S 1,234.40 0.00 0.00 50686 S 40.25 0.00 0.00<br />

49560 S 904.09 0.00 0.00 50688 S 455.96 0.00 0.00<br />

49561 S 1,234.40 0.00 0.00 50947 S 1,517.12 0.00 0.00<br />

49565 S 904.09 0.00 0.00 50948 S 1,517.12 0.00 0.00<br />

49566 S 1,234.40 0.00 0.00 50951 S 294.19 0.00 0.00<br />

49568 S 1,074.14 0.00 0.00 50953 S 294.19 0.00 0.00<br />

49570 S 904.09 0.00 0.00 50955 S 648.56 0.00 0.00<br />

49572 S 1,234.40 0.00 0.00 50957 S 648.56 0.00 0.00<br />

49580 S 904.09 0.00 0.00 50961 S 648.56 0.00 0.00<br />

49582 S 1,234.40 0.00 0.00 50970 S 294.19 0.00 0.00<br />

49585 S 904.09 0.00 0.00 50972 S 294.19 0.00 0.00<br />

49587 S 1,234.40 0.00 0.00 50974 S 517.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 517.54 0.00 0.00 52275 S 701.21 0.00 0.00<br />

50980 S 648.56 0.00 0.00 52276 S 731.02 0.00 0.00<br />

51020 S 786.93 0.00 0.00 52277 S 701.21 0.00 0.00<br />

51030 S 786.93 0.00 0.00 52281 S 570.19 0.00 0.00<br />

51040 S 786.93 0.00 0.00 52282 S 1,315.46 0.00 0.00<br />

51045 S 325.04 0.00 0.00 52283 S 701.21 0.00 0.00<br />

51050 S 786.93 0.00 0.00 52285 S 570.19 0.00 0.00<br />

51065 S 786.93 0.00 0.00 52290 S 570.19 0.00 0.00<br />

51080 S 529.00 0.00 0.00 52300 S 701.21 0.00 0.00<br />

51100 S 30.67 0.00 0.00 52301 S 731.02 0.00 0.00<br />

51101 S 40.25 0.00 0.00 52305 S 701.21 0.00 0.00<br />

51102 S 541.48 0.00 0.00 52310 S 548.40 0.00 0.00<br />

51500 S 904.09 0.00 0.00 52315 S 701.21 0.00 0.00<br />

51520 S 786.93 0.00 0.00 52317 S 648.56 0.00 0.00<br />

51700 S 52.38 0.00 0.00 52318 S 701.21 0.00 0.00<br />

51701 S 24.92 0.00 0.00 52320 S 827.46 0.00 0.00<br />

51702 S 24.92 0.00 0.00 52325 S 786.93 0.00 0.00<br />

51703 S 40.25 0.00 0.00 52327 S 899.43 0.00 0.00<br />

51705 S 72.11 0.00 0.00 52330 S 701.21 0.00 0.00<br />

51710 S 455.96 0.00 0.00 52332 S 701.21 0.00 0.00<br />

51715 S 827.89 0.00 0.00 52334 S 731.02 0.00 0.00<br />

51720 S 57.90 0.00 0.00 52341 S 731.02 0.00 0.00<br />

51725 TC S 111.23 0.00 0.00 52342 S 731.02 0.00 0.00<br />

51726 TC S 153.20 0.00 0.00 52343 S 731.02 0.00 0.00<br />

51736 TC S 21.02 0.00 0.00 52344 S 731.02 0.00 0.00<br />

51741 TC S 24.47 0.00 0.00 52345 S 731.02 0.00 0.00<br />

51772 TC S 97.31 0.00 0.00 52346 S 731.02 0.00 0.00<br />

51784 TC S 40.25 0.00 0.00 52351 S 731.02 0.00 0.00<br />

51785 TC S 67.23 0.00 0.00 52352 S 786.93 0.00 0.00<br />

51792 TC S 40.25 0.00 0.00 52353 S 985.15 0.00 0.00<br />

51795 TC S 72.11 0.00 0.00 52354 S 786.93 0.00 0.00<br />

51797 TC S 72.11 0.00 0.00 52355 S 786.93 0.00 0.00<br />

51798 S 17.92 0.00 0.00 52400 S 731.02 0.00 0.00<br />

51880 S 648.56 0.00 0.00 52402 S 731.02 0.00 0.00<br />

51992 S 1,227.35 0.00 0.00 52450 S 731.02 0.00 0.00<br />

52000 S 294.19 0.00 0.00 52500 S 731.02 0.00 0.00<br />

52001 S 548.40 0.00 0.00 52601 S 985.15 0.00 0.00<br />

52005 S 570.19 0.00 0.00 52630 S 899.43 0.00 0.00<br />

52007 S 701.21 0.00 0.00 52640 S 701.21 0.00 0.00<br />

52010 S 325.04 0.00 0.00 52647 S 1,507.19 0.00 0.00<br />

52204 S 570.19 0.00 0.00 52648 S 1,507.19 0.00 0.00<br />

52214 S 701.21 0.00 0.00 52700 S 701.21 0.00 0.00<br />

52224 S 701.21 0.00 0.00 53000 S 538.18 0.00 0.00<br />

52234 S 701.21 0.00 0.00 53010 S 538.18 0.00 0.00<br />

52235 S 731.02 0.00 0.00 53020 S 538.18 0.00 0.00<br />

52240 S 731.02 0.00 0.00 53025 S 766.07 0.00 0.00<br />

52250 S 786.93 0.00 0.00 53040 S 590.83 0.00 0.00<br />

52260 S 570.19 0.00 0.00 53060 S 69.97 0.00 0.00<br />

52265 S 278.09 0.00 0.00 53080 S 620.64 0.00 0.00<br />

52270 S 570.19 0.00 0.00 53085 S 766.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 538.18 0.00 0.00 54060 S 545.79 0.00 0.00<br />

53210 S 924.32 0.00 0.00 54065 S 545.79 0.00 0.00<br />

53215 S 717.07 0.00 0.00 54100 S 461.70 0.00 0.00<br />

53220 S 798.07 0.00 0.00 54105 S 576.36 0.00 0.00<br />

53230 S 798.07 0.00 0.00 54110 S 893.60 0.00 0.00<br />

53235 S 620.64 0.00 0.00 54111 S 893.60 0.00 0.00<br />

53240 S 798.07 0.00 0.00 54112 S 893.60 0.00 0.00<br />

53250 S 590.83 0.00 0.00 54115 S 529.00 0.00 0.00<br />

53260 S 590.83 0.00 0.00 54120 S 893.60 0.00 0.00<br />

53265 S 590.83 0.00 0.00 54150 S 595.54 0.00 0.00<br />

53270 S 590.83 0.00 0.00 54160 S 648.19 0.00 0.00<br />

53275 S 590.83 0.00 0.00 54161 S 648.19 0.00 0.00<br />

53400 S 827.89 0.00 0.00 54162 S 648.19 0.00 0.00<br />

53405 S 798.07 0.00 0.00 54163 S 648.19 0.00 0.00<br />

53410 S 798.07 0.00 0.00 54164 S 648.19 0.00 0.00<br />

53420 S 827.89 0.00 0.00 54200 S 67.89 0.00 0.00<br />

53425 S 798.07 0.00 0.00 54205 S 979.32 0.00 0.00<br />

53430 S 798.07 0.00 0.00 54220 S 97.31 0.00 0.00<br />

53431 S 798.07 0.00 0.00 54231 S 63.75 0.00 0.00<br />

53440 S 4,597.18 2,792.08 986.98 54235 S 45.15 0.00 0.00<br />

53442 S 745.42 0.00 0.00 54240 TC S 32.05 0.00 0.00<br />

53444 S 4,597.18 2,792.08 986.98 54250 TC S 11.37 0.00 0.00<br />

53445 S 7,722.10 4,397.68 1,073.27 54300 S 923.41 0.00 0.00<br />

53446 S 745.42 0.00 0.00 54304 S 923.41 0.00 0.00<br />

53447 S 7,722.10 4,397.68 1,073.27 54308 S 923.41 0.00 0.00<br />

53449 S 745.42 0.00 0.00 54312 S 923.41 0.00 0.00<br />

53450 S 745.42 0.00 0.00 54316 S 923.41 0.00 0.00<br />

53460 S 538.18 0.00 0.00 54318 S 923.41 0.00 0.00<br />

53502 S 590.83 0.00 0.00 54322 S 923.41 0.00 0.00<br />

53505 S 798.07 0.00 0.00 54324 S 923.41 0.00 0.00<br />

53510 S 590.83 0.00 0.00 54326 S 923.41 0.00 0.00<br />

53515 S 798.07 0.00 0.00 54328 S 923.41 0.00 0.00<br />

53520 S 798.07 0.00 0.00 54340 S 923.41 0.00 0.00<br />

53600 S 40.32 0.00 0.00 54344 S 923.41 0.00 0.00<br />

53601 S 40.25 0.00 0.00 54348 S 923.41 0.00 0.00<br />

53605 S 570.19 0.00 0.00 54352 S 923.41 0.00 0.00<br />

53620 S 62.03 0.00 0.00 54360 S 923.41 0.00 0.00<br />

53621 S 65.14 0.00 0.00 54380 S 923.41 0.00 0.00<br />

53660 S 40.25 0.00 0.00 54385 S 923.41 0.00 0.00<br />

53661 S 40.25 0.00 0.00 54400 S 4,627.00 2,821.90 1,016.80<br />

53665 S 538.18 0.00 0.00 54401 S 7,804.56 4,480.14 1,155.74<br />

53850 S 1,766.76 0.00 0.00 54405 S 7,804.56 4,480.14 1,155.74<br />

53852 S 1,766.76 0.00 0.00 54406 S 923.41 0.00 0.00<br />

54000 S 590.83 0.00 0.00 54408 S 923.41 0.00 0.00<br />

54001 S 590.83 0.00 0.00 54410 S 7,804.56 4,480.14 1,155.74<br />

54015 S 667.38 0.00 0.00 54415 S 923.41 0.00 0.00<br />

54050 S 31.93 0.00 0.00 54416 S 7,804.56 4,480.14 1,155.74<br />

54055 S 65.14 0.00 0.00 54420 S 979.32 0.00 0.00<br />

54056 S 31.93 0.00 0.00 54435 S 979.32 0.00 0.00<br />

54057 S 545.79 0.00 0.00 54440 S 979.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 153.20 0.00 0.00 55706 S 445.37 0.00 0.00<br />

54500 S 415.81 0.00 0.00 55720 S 648.56 0.00 0.00<br />

54505 S 595.54 0.00 0.00 55725 S 701.21 0.00 0.00<br />

54512 S 648.19 0.00 0.00 55860 S 772.70 0.00 0.00<br />

54520 S 678.00 0.00 0.00 55870 S 78.57 0.00 0.00<br />

54522 S 678.00 0.00 0.00 55873 S 6,113.87 0.00 0.00<br />

54530 S 904.09 0.00 0.00 55875 S 1,315.46 0.00 0.00<br />

54550 S 904.09 0.00 0.00 55876 S 72.03 0.00 0.00<br />

54560 S 880.81 0.00 0.00 55920 S 902.94 0.00 0.00<br />

54600 S 733.91 0.00 0.00 56405 S 42.04 0.00 0.00<br />

54620 S 678.00 0.00 0.00 56420 S 54.88 0.00 0.00<br />

54640 S 904.09 0.00 0.00 56440 S 589.30 0.00 0.00<br />

54660 S 648.19 0.00 0.00 56441 S 536.65 0.00 0.00<br />

54670 S 678.00 0.00 0.00 56442 S 536.65 0.00 0.00<br />

54680 S 678.00 0.00 0.00 56501 S 57.90 0.00 0.00<br />

54690 S 1,517.12 0.00 0.00 56515 S 628.26 0.00 0.00<br />

54692 S 2,696.82 0.00 0.00 56605 S 33.43 0.00 0.00<br />

54700 S 648.19 0.00 0.00 56606 S 13.79 0.00 0.00<br />

54800 S 145.49 0.00 0.00 56620 S 715.54 0.00 0.00<br />

54830 S 678.00 0.00 0.00 56625 S 845.06 0.00 0.00<br />

54840 S 733.91 0.00 0.00 56700 S 536.65 0.00 0.00<br />

54860 S 678.00 0.00 0.00 56740 S 619.11 0.00 0.00<br />

54861 S 733.91 0.00 0.00 56800 S 619.11 0.00 0.00<br />

54865 S 595.54 0.00 0.00 56805 S 763.03 0.00 0.00<br />

54900 S 733.91 0.00 0.00 56810 S 715.54 0.00 0.00<br />

54901 S 733.91 0.00 0.00 56820 S 42.73 0.00 0.00<br />

55000 S 66.17 0.00 0.00 56821 S 54.88 0.00 0.00<br />

55040 S 848.19 0.00 0.00 57000 S 536.65 0.00 0.00<br />

55041 S 944.63 0.00 0.00 57010 S 589.30 0.00 0.00<br />

55060 S 733.91 0.00 0.00 57020 S 309.05 0.00 0.00<br />

55100 S 398.02 0.00 0.00 57022 S 485.78 0.00 0.00<br />

55110 S 648.19 0.00 0.00 57023 S 529.00 0.00 0.00<br />

55120 S 648.19 0.00 0.00 57061 S 53.42 0.00 0.00<br />

55150 S 595.54 0.00 0.00 57065 S 536.65 0.00 0.00<br />

55175 S 595.54 0.00 0.00 57100 S 34.12 0.00 0.00<br />

55180 S 648.19 0.00 0.00 57105 S 589.30 0.00 0.00<br />

55200 S 648.19 0.00 0.00 57130 S 589.30 0.00 0.00<br />

55250 S 648.19 0.00 0.00 57135 S 589.30 0.00 0.00<br />

55400 S 595.54 0.00 0.00 57150 S 24.82 0.00 0.00<br />

55450 S 212.98 0.00 0.00 57155 S 309.05 0.00 0.00<br />

55500 S 678.00 0.00 0.00 57160 S 35.84 0.00 0.00<br />

55520 S 733.91 0.00 0.00 57170 S 5.88 0.00 0.00<br />

55530 S 733.91 0.00 0.00 57180 S 110.39 0.00 0.00<br />

55535 S 904.09 0.00 0.00 57200 S 536.65 0.00 0.00<br />

55540 S 944.63 0.00 0.00 57210 S 589.30 0.00 0.00<br />

55550 S 1,517.12 0.00 0.00 57220 S 1,080.69 0.00 0.00<br />

55600 S 880.81 0.00 0.00 57230 S 887.34 0.00 0.00<br />

55680 S 595.54 0.00 0.00 57240 S 983.78 0.00 0.00<br />

55700 S 383.80 0.00 0.00 57250 S 983.78 0.00 0.00<br />

55705 S 383.80 0.00 0.00 57260 S 983.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,306.64 0.00 0.00 58555 S 579.82 0.00 0.00<br />

57267 S 1,113.29 0.00 0.00 58558 S 662.28 0.00 0.00<br />

57268 S 887.34 0.00 0.00 58559 S 632.47 0.00 0.00<br />

57287 S 1,299.49 0.00 0.00 58560 S 944.32 0.00 0.00<br />

57288 S 1,177.12 0.00 0.00 58561 S 944.32 0.00 0.00<br />

57289 S 983.78 0.00 0.00 58562 S 662.28 0.00 0.00<br />

57291 S 983.78 0.00 0.00 58563 S 1,330.53 0.00 0.00<br />

57300 S 887.34 0.00 0.00 58565 S 1,466.90 0.00 0.00<br />

57320 S 1,299.49 0.00 0.00 58600 S 1,299.49 0.00 0.00<br />

57400 S 589.30 0.00 0.00 58615 S 763.03 0.00 0.00<br />

57410 S 589.30 0.00 0.00 58660 S 1,227.35 0.00 0.00<br />

57415 S 589.30 0.00 0.00 58661 S 1,227.35 0.00 0.00<br />

57420 S 44.12 0.00 0.00 58662 S 1,227.35 0.00 0.00<br />

57421 S 57.55 0.00 0.00 58670 S 1,130.91 0.00 0.00<br />

57452 S 41.70 0.00 0.00 58671 S 1,130.91 0.00 0.00<br />

57454 S 51.01 0.00 0.00 58672 S 1,227.35 0.00 0.00<br />

57455 S 54.10 0.00 0.00 58673 S 1,227.35 0.00 0.00<br />

57456 S 52.38 0.00 0.00 58800 S 619.11 0.00 0.00<br />

57460 S 160.94 0.00 0.00 58805 S 1,299.49 0.00 0.00<br />

57461 S 170.94 0.00 0.00 58820 S 887.34 0.00 0.00<br />

57500 S 73.75 0.00 0.00 58900 S 619.11 0.00 0.00<br />

57505 S 46.87 0.00 0.00 58970 S 172.45 0.00 0.00<br />

57510 S 47.56 0.00 0.00 58974 S 172.45 0.00 0.00<br />

57511 S 54.88 0.00 0.00 58976 S 172.45 0.00 0.00<br />

57513 S 589.30 0.00 0.00 59000 S 63.07 0.00 0.00<br />

57520 S 589.30 0.00 0.00 59001 S 236.73 0.00 0.00<br />

57522 S 589.30 0.00 0.00 59012 S 115.76 0.00 0.00<br />

57530 S 887.34 0.00 0.00 59015 S 51.01 0.00 0.00<br />

57550 S 887.34 0.00 0.00 59020 TC S 26.88 0.00 0.00<br />

57556 S 1,177.12 0.00 0.00 59025 TC S 14.13 0.00 0.00<br />

57558 S 619.11 0.00 0.00 59070 S 115.76 0.00 0.00<br />

57700 S 536.65 0.00 0.00 59072 S 115.76 0.00 0.00<br />

57720 S 619.11 0.00 0.00 59076 S 115.76 0.00 0.00<br />

57800 S 25.16 0.00 0.00 59100 S 1,299.49 0.00 0.00<br />

58100 S 41.36 0.00 0.00 59150 S 1,786.62 0.00 0.00<br />

58120 S 589.30 0.00 0.00 59151 S 1,786.62 0.00 0.00<br />

58145 S 983.78 0.00 0.00 59160 S 619.11 0.00 0.00<br />

58301 S 38.59 0.00 0.00 59200 S 34.47 0.00 0.00<br />

58321 S 36.19 0.00 0.00 59300 S 74.44 0.00 0.00<br />

58322 S 37.22 0.00 0.00 59320 S 536.65 0.00 0.00<br />

58323 S 8.62 0.00 0.00 59412 S 763.03 0.00 0.00<br />

58345 S 763.03 0.00 0.00 59414 S 763.03 0.00 0.00<br />

58346 S 589.30 0.00 0.00 59812 S 715.54 0.00 0.00<br />

58350 S 887.34 0.00 0.00 59820 S 715.54 0.00 0.00<br />

58353 S 1,113.29 0.00 0.00 59821 S 715.54 0.00 0.00<br />

58356 S 1,686.18 0.00 0.00 59840 S 715.54 0.00 0.00<br />

58545 S 1,354.46 0.00 0.00 59841 S 715.54 0.00 0.00<br />

58546 S 1,517.12 0.00 0.00 59866 S 115.76 0.00 0.00<br />

58550 S 1,972.22 0.00 0.00 59870 S 715.54 0.00 0.00<br />

58552 S 1,786.62 0.00 0.00 59871 S 715.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 300.41 0.00 0.00 62367 S 16.54 0.00 0.00<br />

60100 S 47.21 0.00 0.00 62368 S 21.02 0.00 0.00<br />

60200 S 1,118.12 0.00 0.00 63600 S 564.75 0.00 0.00<br />

60280 S 1,203.84 0.00 0.00 63610 S 512.10 0.00 0.00<br />

60281 S 1,203.84 0.00 0.00 63615 S 713.93 0.00 0.00<br />

60300 S 62.03 0.00 0.00 63650 S 3,039.75 1,884.95 730.15<br />

61000 S 276.61 0.00 0.00 63655 S 4,452.49 2,839.36 1,226.24<br />

61001 S 276.61 0.00 0.00 63660 S 533.84 0.00 0.00<br />

61020 S 223.95 0.00 0.00 63685 S 13,514.33 7,205.96 897.61<br />

61026 S 223.95 0.00 0.00 63688 S 724.91 0.00 0.00<br />

61050 S 223.95 0.00 0.00 63744 S 1,048.32 0.00 0.00<br />

61055 S 223.95 0.00 0.00 63746 S 484.93 0.00 0.00<br />

61070 S 174.26 0.00 0.00 64400 S 53.07 0.00 0.00<br />

61215 S 1,048.32 0.00 0.00 64402 S 49.98 0.00 0.00<br />

61330 S 1,615.00 0.00 0.00 64405 S 42.39 0.00 0.00<br />

61334 S 1,615.00 0.00 0.00 64408 S 52.73 0.00 0.00<br />

61790 S 594.56 0.00 0.00 64410 S 293.44 0.00 0.00<br />

61791 S 441.10 0.00 0.00 64412 S 77.54 0.00 0.00<br />

61880 S 757.40 0.00 0.00 64413 S 49.63 0.00 0.00<br />

61885 S 10,899.08 5,838.53 777.99 64415 S 135.14 0.00 0.00<br />

61886 S 16,274.98 8,577.86 880.74 64416 S 276.61 0.00 0.00<br />

61888 S 724.91 0.00 0.00 64417 S 135.14 0.00 0.00<br />

62194 S 293.44 0.00 0.00 64418 S 69.61 0.00 0.00<br />

62225 S 455.96 0.00 0.00 64420 S 135.14 0.00 0.00<br />

62230 S 1,018.50 0.00 0.00 64421 S 293.44 0.00 0.00<br />

62252 TC S 46.18 0.00 0.00 64425 S 48.25 0.00 0.00<br />

62263 S 293.44 0.00 0.00 64430 S 203.06 0.00 0.00<br />

62264 S 432.28 0.00 0.00 64435 S 72.72 0.00 0.00<br />

62267 S 172.51 0.00 0.00 64445 S 64.44 0.00 0.00<br />

62268 S 223.95 0.00 0.00 64446 S 554.30 0.00 0.00<br />

62269 S 339.85 0.00 0.00 64447 S 140.77 0.00 0.00<br />

62270 S 135.14 0.00 0.00 64448 S 140.77 0.00 0.00<br />

62272 S 135.14 0.00 0.00 64449 S 276.61 0.00 0.00<br />

62273 S 225.52 0.00 0.00 64450 S 43.08 0.00 0.00<br />

62280 S 293.44 0.00 0.00 64455 S 17.92 0.00 0.00<br />

62281 S 293.44 0.00 0.00 64470 S 293.44 0.00 0.00<br />

62282 S 293.44 0.00 0.00 64472 S 225.52 0.00 0.00<br />

62287 S 1,317.27 0.00 0.00 64475 S 293.44 0.00 0.00<br />

62292 S 276.61 0.00 0.00 64476 S 203.10 0.00 0.00<br />

62294 S 223.95 0.00 0.00 64479 S 293.44 0.00 0.00<br />

62310 S 293.44 0.00 0.00 64480 S 225.52 0.00 0.00<br />

62311 S 293.44 0.00 0.00 64483 S 293.44 0.00 0.00<br />

62318 S 293.44 0.00 0.00 64484 S 225.52 0.00 0.00<br />

62319 S 293.44 0.00 0.00 64505 S 39.29 0.00 0.00<br />

62350 S 1,018.50 0.00 0.00 64508 S 83.40 0.00 0.00<br />

62355 S 484.93 0.00 0.00 64510 S 293.44 0.00 0.00<br />

62360 S 1,018.50 0.00 0.00 64517 S 203.06 0.00 0.00<br />

62361 S 10,455.05 5,658.95 862.85 64520 S 293.44 0.00 0.00<br />

62362 S 10,455.05 5,658.95 862.85 64530 S 293.44 0.00 0.00<br />

62365 S 901.25 0.00 0.00 64553 S 2,987.10 1,832.30 677.50<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,354.33 2,199.53 1,044.74 64746 S 564.75 0.00 0.00<br />

64560 S 3,354.33 2,199.53 1,044.74 64761 S 713.93 0.00 0.00<br />

64561 S 3,069.56 1,914.76 759.97 64763 S 713.93 0.00 0.00<br />

64565 S 3,354.33 2,199.53 1,044.74 64766 S 1,386.92 0.00 0.00<br />

64573 S 5,225.55 3,095.63 965.71 64771 S 564.75 0.00 0.00<br />

64575 S 3,994.50 2,381.37 768.25 64772 S 564.75 0.00 0.00<br />

64577 S 3,994.50 2,381.37 768.25 64774 S 564.75 0.00 0.00<br />

64580 S 3,994.50 2,381.37 768.25 64776 S 594.56 0.00 0.00<br />

64581 S 4,076.97 2,463.84 850.72 64778 S 564.75 0.00 0.00<br />

64585 S 533.84 0.00 0.00 64782 S 594.56 0.00 0.00<br />

64590 S 10,899.08 5,838.53 777.99 64783 S 564.75 0.00 0.00<br />

64595 S 724.91 0.00 0.00 64784 S 594.56 0.00 0.00<br />

64600 S 432.28 0.00 0.00 64786 S 931.06 0.00 0.00<br />

64605 S 432.28 0.00 0.00 64787 S 564.75 0.00 0.00<br />

64610 S 432.28 0.00 0.00 64788 S 594.56 0.00 0.00<br />

64612 S 63.07 0.00 0.00 64790 S 594.56 0.00 0.00<br />

64613 S 61.00 0.00 0.00 64792 S 931.06 0.00 0.00<br />

64614 S 69.61 0.00 0.00 64795 S 564.75 0.00 0.00<br />

64620 S 293.44 0.00 0.00 64802 S 564.75 0.00 0.00<br />

64622 S 432.28 0.00 0.00 64820 S 713.93 0.00 0.00<br />

64623 S 293.44 0.00 0.00 64821 S 833.45 0.00 0.00<br />

64626 S 432.28 0.00 0.00 64822 S 1,079.89 0.00 0.00<br />

64627 S 203.10 0.00 0.00 64823 S 1,079.89 0.00 0.00<br />

64630 S 302.26 0.00 0.00 64831 S 986.97 0.00 0.00<br />

64632 S 32.74 0.00 0.00 64832 S 848.60 0.00 0.00<br />

64640 S 97.53 0.00 0.00 64834 S 901.25 0.00 0.00<br />

64650 S 32.74 0.00 0.00 64835 S 931.06 0.00 0.00<br />

64653 S 35.50 0.00 0.00 64836 S 931.06 0.00 0.00<br />

64680 S 459.29 0.00 0.00 64837 S 848.60 0.00 0.00<br />

64681 S 484.93 0.00 0.00 64840 S 901.25 0.00 0.00<br />

64702 S 512.10 0.00 0.00 64856 S 901.25 0.00 0.00<br />

64704 S 512.10 0.00 0.00 64857 S 901.25 0.00 0.00<br />

64708 S 564.75 0.00 0.00 64858 S 901.25 0.00 0.00<br />

64712 S 564.75 0.00 0.00 64859 S 848.60 0.00 0.00<br />

64713 S 564.75 0.00 0.00 64861 S 931.06 0.00 0.00<br />

64714 S 564.75 0.00 0.00 64862 S 931.06 0.00 0.00<br />

64716 S 594.56 0.00 0.00 64864 S 931.06 0.00 0.00<br />

64718 S 564.75 0.00 0.00 64865 S 986.97 0.00 0.00<br />

64719 S 564.75 0.00 0.00 64870 S 986.97 0.00 0.00<br />

64721 S 564.75 0.00 0.00 64872 S 901.25 0.00 0.00<br />

64722 S 512.10 0.00 0.00 64874 S 931.06 0.00 0.00<br />

64726 S 512.10 0.00 0.00 64876 S 931.06 0.00 0.00<br />

64727 S 512.10 0.00 0.00 64885 S 901.25 0.00 0.00<br />

64732 S 564.75 0.00 0.00 64886 S 901.25 0.00 0.00<br />

64734 S 564.75 0.00 0.00 64890 S 901.25 0.00 0.00<br />

64736 S 564.75 0.00 0.00 64891 S 901.25 0.00 0.00<br />

64738 S 564.75 0.00 0.00 64892 S 901.25 0.00 0.00<br />

64740 S 564.75 0.00 0.00 64893 S 901.25 0.00 0.00<br />

64742 S 564.75 0.00 0.00 64895 S 931.06 0.00 0.00<br />

64744 S 564.75 0.00 0.00 64896 S 931.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 931.06 0.00 0.00 65770 S 5,478.97 0.00 0.00<br />

64898 S 931.06 0.00 0.00 65772 S 616.34 0.00 0.00<br />

64901 S 901.25 0.00 0.00 65775 S 616.34 0.00 0.00<br />

64902 S 901.25 0.00 0.00 65780 S 1,066.18 0.00 0.00<br />

64905 S 901.25 0.00 0.00 65781 S 1,066.18 0.00 0.00<br />

64907 S 848.60 0.00 0.00 65782 S 1,066.18 0.00 0.00<br />

64910 S 1,386.92 0.00 0.00 65800 S 477.98 0.00 0.00<br />

65091 S 980.36 0.00 0.00 65805 S 477.98 0.00 0.00<br />

65093 S 980.36 0.00 0.00 65810 S 698.42 0.00 0.00<br />

65101 S 980.36 0.00 0.00 65815 S 668.60 0.00 0.00<br />

65103 S 980.36 0.00 0.00 65820 S 245.21 0.00 0.00<br />

65105 S 1,036.27 0.00 0.00 65850 S 754.32 0.00 0.00<br />

65110 S 1,076.79 0.00 0.00 65855 S 130.27 0.00 0.00<br />

65112 S 1,206.31 0.00 0.00 65860 S 121.66 0.00 0.00<br />

65114 S 1,206.31 0.00 0.00 65865 S 477.98 0.00 0.00<br />

65125 S 1,003.94 0.00 0.00 65870 S 754.32 0.00 0.00<br />

65130 S 739.57 0.00 0.00 65875 S 754.32 0.00 0.00<br />

65135 S 709.75 0.00 0.00 65880 S 616.34 0.00 0.00<br />

65140 S 980.36 0.00 0.00 65900 S 656.87 0.00 0.00<br />

65150 S 709.75 0.00 0.00 65920 S 924.37 0.00 0.00<br />

65155 S 980.36 0.00 0.00 65930 S 794.86 0.00 0.00<br />

65175 S 527.59 0.00 0.00 66020 S 477.98 0.00 0.00<br />

65205 S 20.33 0.00 0.00 66030 S 245.21 0.00 0.00<br />

65210 S 25.85 0.00 0.00 66130 S 924.37 0.00 0.00<br />

65220 S 36.01 0.00 0.00 66150 S 754.32 0.00 0.00<br />

65222 S 28.26 0.00 0.00 66155 S 754.32 0.00 0.00<br />

65235 S 530.62 0.00 0.00 66160 S 668.60 0.00 0.00<br />

65260 S 349.98 0.00 0.00 66165 S 754.32 0.00 0.00<br />

65265 S 724.06 0.00 0.00 66170 S 754.32 0.00 0.00<br />

65270 S 580.23 0.00 0.00 66172 S 754.32 0.00 0.00<br />

65272 S 668.60 0.00 0.00 66180 S 1,123.78 0.00 0.00<br />

65275 S 754.32 0.00 0.00 66185 S 997.54 0.00 0.00<br />

65280 S 724.06 0.00 0.00 66220 S 973.77 0.00 0.00<br />

65285 S 1,029.67 0.00 0.00 66225 S 1,083.26 0.00 0.00<br />

65286 S 180.14 0.00 0.00 66250 S 530.62 0.00 0.00<br />

65290 S 713.06 0.00 0.00 66500 S 245.21 0.00 0.00<br />

65400 S 477.98 0.00 0.00 66505 S 245.21 0.00 0.00<br />

65410 S 530.62 0.00 0.00 66600 S 698.42 0.00 0.00<br />

65420 S 530.62 0.00 0.00 66605 S 698.42 0.00 0.00<br />

65426 S 794.86 0.00 0.00 66625 S 496.58 0.00 0.00<br />

65430 S 36.01 0.00 0.00 66630 S 698.42 0.00 0.00<br />

65435 S 31.36 0.00 0.00 66635 S 698.42 0.00 0.00<br />

65436 S 136.13 0.00 0.00 66680 S 698.42 0.00 0.00<br />

65450 S 83.10 0.00 0.00 66682 S 668.60 0.00 0.00<br />

65600 S 160.60 0.00 0.00 66700 S 530.62 0.00 0.00<br />

65710 S 1,195.70 0.00 0.00 66710 S 530.62 0.00 0.00<br />

65730 S 1,195.70 0.00 0.00 66711 S 530.62 0.00 0.00<br />

65750 S 1,195.70 0.00 0.00 66720 S 530.62 0.00 0.00<br />

65755 S 1,195.70 0.00 0.00 66740 S 668.60 0.00 0.00<br />

65756 S 1,464.29 0.00 0.00 66761 S 181.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 184.38 0.00 0.00 67228 S 203.05 0.00 0.00<br />

66770 S 203.05 0.00 0.00 67229 S 203.05 0.00 0.00<br />

66820 S 180.14 0.00 0.00 67250 S 610.05 0.00 0.00<br />

66821 S 247.11 0.00 0.00 67255 S 668.16 0.00 0.00<br />

66825 S 754.32 0.00 0.00 67311 S 713.06 0.00 0.00<br />

66830 S 263.82 0.00 0.00 67312 S 768.97 0.00 0.00<br />

66840 S 567.11 0.00 0.00 67314 S 768.97 0.00 0.00<br />

66850 S 1,067.73 0.00 0.00 67316 S 768.97 0.00 0.00<br />

66852 S 897.68 0.00 0.00 67318 S 768.97 0.00 0.00<br />

66920 S 897.68 0.00 0.00 67320 S 768.97 0.00 0.00<br />

66930 S 938.22 0.00 0.00 67331 S 768.97 0.00 0.00<br />

66940 S 607.64 0.00 0.00 67332 S 768.97 0.00 0.00<br />

66982 S 921.82 0.00 0.00 67334 S 768.97 0.00 0.00<br />

66983 S 921.82 0.00 0.00 67335 S 768.97 0.00 0.00<br />

66984 S 921.82 0.00 0.00 67340 S 768.97 0.00 0.00<br />

66985 S 853.33 0.00 0.00 67343 S 939.01 0.00 0.00<br />

66986 S 853.33 0.00 0.00 67345 S 80.30 0.00 0.00<br />

67005 S 724.06 0.00 0.00 67346 S 434.34 0.00 0.00<br />

67010 S 724.06 0.00 0.00 67400 S 610.05 0.00 0.00<br />

67015 S 891.31 0.00 0.00 67405 S 795.48 0.00 0.00<br />

67025 S 585.69 0.00 0.00 67412 S 706.49 0.00 0.00<br />

67027 S 1,029.67 0.00 0.00 67413 S 836.00 0.00 0.00<br />

67028 S 80.99 0.00 0.00 67414 S 1,485.52 0.00 0.00<br />

67030 S 585.69 0.00 0.00 67415 S 527.59 0.00 0.00<br />

67031 S 247.11 0.00 0.00 67420 S 1,076.79 0.00 0.00<br />

67036 S 1,029.67 0.00 0.00 67430 S 1,076.79 0.00 0.00<br />

67039 S 1,199.72 0.00 0.00 67440 S 1,076.79 0.00 0.00<br />

67040 S 1,199.72 0.00 0.00 67445 S 1,076.79 0.00 0.00<br />

67041 S 1,472.34 0.00 0.00 67450 S 1,076.79 0.00 0.00<br />

67042 S 1,472.34 0.00 0.00 67500 S 83.10 0.00 0.00<br />

67043 S 1,472.34 0.00 0.00 67505 S 25.85 0.00 0.00<br />

67101 S 224.76 0.00 0.00 67515 S 26.19 0.00 0.00<br />

67105 S 203.05 0.00 0.00 67550 S 1,036.27 0.00 0.00<br />

67107 S 1,070.21 0.00 0.00 67560 S 709.75 0.00 0.00<br />

67108 S 1,199.72 0.00 0.00 67570 S 1,036.27 0.00 0.00<br />

67110 S 326.71 0.00 0.00 67700 S 121.58 0.00 0.00<br />

67112 S 1,199.72 0.00 0.00 67710 S 141.99 0.00 0.00<br />

67113 S 1,472.34 0.00 0.00 67715 S 527.59 0.00 0.00<br />

67115 S 638.34 0.00 0.00 67800 S 51.01 0.00 0.00<br />

67120 S 638.34 0.00 0.00 67801 S 61.69 0.00 0.00<br />

67121 S 638.34 0.00 0.00 67805 S 79.95 0.00 0.00<br />

67141 S 225.01 0.00 0.00 67808 S 580.23 0.00 0.00<br />

67145 S 191.96 0.00 0.00 67810 S 121.58 0.00 0.00<br />

67208 S 204.72 0.00 0.00 67820 S 16.88 0.00 0.00<br />

67210 S 203.05 0.00 0.00 67825 S 52.04 0.00 0.00<br />

67218 S 764.59 0.00 0.00 67830 S 356.22 0.00 0.00<br />

67220 S 224.76 0.00 0.00 67835 S 580.23 0.00 0.00<br />

67221 S 115.45 0.00 0.00 67840 S 148.88 0.00 0.00<br />

67225 S 7.93 0.00 0.00 67850 S 118.21 0.00 0.00<br />

67227 S 585.69 0.00 0.00 67875 S 296.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 560.44 0.00 0.00 68440 S 50.66 0.00 0.00<br />

67882 S 610.05 0.00 0.00 68500 S 739.57 0.00 0.00<br />

67900 S 795.48 0.00 0.00 68505 S 739.57 0.00 0.00<br />

67901 S 706.49 0.00 0.00 68510 S 527.59 0.00 0.00<br />

67902 S 836.00 0.00 0.00 68520 S 739.57 0.00 0.00<br />

67903 S 665.95 0.00 0.00 68525 S 527.59 0.00 0.00<br />

67904 S 665.95 0.00 0.00 68530 S 121.58 0.00 0.00<br />

67906 S 706.49 0.00 0.00 68540 S 610.05 0.00 0.00<br />

67908 S 665.95 0.00 0.00 68550 S 739.57 0.00 0.00<br />

67909 S 665.95 0.00 0.00 68700 S 580.23 0.00 0.00<br />

67911 S 610.05 0.00 0.00 68705 S 115.45 0.00 0.00<br />

67912 S 610.05 0.00 0.00 68720 S 795.48 0.00 0.00<br />

67914 S 610.05 0.00 0.00 68745 S 795.48 0.00 0.00<br />

67915 S 164.74 0.00 0.00 68750 S 795.48 0.00 0.00<br />

67916 S 665.95 0.00 0.00 68760 S 98.22 0.00 0.00<br />

67917 S 665.95 0.00 0.00 68761 S 67.89 0.00 0.00<br />

67921 S 610.05 0.00 0.00 68770 S 795.48 0.00 0.00<br />

67922 S 160.26 0.00 0.00 68801 S 36.01 0.00 0.00<br />

67923 S 665.95 0.00 0.00 68810 S 102.99 0.00 0.00<br />

67924 S 665.95 0.00 0.00 68811 S 580.23 0.00 0.00<br />

67930 S 164.74 0.00 0.00 68815 S 580.23 0.00 0.00<br />

67935 S 580.23 0.00 0.00 68816 S 744.90 0.00 0.00<br />

67938 S 83.10 0.00 0.00 68840 S 53.42 0.00 0.00<br />

67950 S 580.23 0.00 0.00 69000 S 54.49 0.00 0.00<br />

67961 S 610.05 0.00 0.00 69005 S 103.05 0.00 0.00<br />

67966 S 610.05 0.00 0.00 69020 S 54.49 0.00 0.00<br />

67971 S 610.05 0.00 0.00 69100 S 62.03 0.00 0.00<br />

67973 S 739.57 0.00 0.00 69105 S 87.88 0.00 0.00<br />

67974 S 610.05 0.00 0.00 69110 S 461.70 0.00 0.00<br />

67975 S 610.05 0.00 0.00 69120 S 685.17 0.00 0.00<br />

68020 S 45.15 0.00 0.00 69140 S 685.17 0.00 0.00<br />

68040 S 22.40 0.00 0.00 69145 S 514.34 0.00 0.00<br />

68100 S 89.60 0.00 0.00 69150 S 361.50 0.00 0.00<br />

68110 S 115.45 0.00 0.00 69200 S 24.92 0.00 0.00<br />

68115 S 580.23 0.00 0.00 69205 S 576.36 0.00 0.00<br />

68130 S 530.62 0.00 0.00 69210 S 20.33 0.00 0.00<br />

68135 S 57.90 0.00 0.00 69220 S 31.93 0.00 0.00<br />

68200 S 16.54 0.00 0.00 69222 S 134.41 0.00 0.00<br />

68320 S 795.48 0.00 0.00 69300 S 714.99 0.00 0.00<br />

68325 S 795.48 0.00 0.00 69310 S 1,045.10 0.00 0.00<br />

68326 S 665.95 0.00 0.00 69320 S 1,271.05 0.00 0.00<br />

68328 S 795.48 0.00 0.00 69400 S 90.29 0.00 0.00<br />

68330 S 754.32 0.00 0.00 69401 S 47.56 0.00 0.00<br />

68335 S 795.48 0.00 0.00 69405 S 124.76 0.00 0.00<br />

68340 S 665.95 0.00 0.00 69420 S 112.01 0.00 0.00<br />

68360 S 668.60 0.00 0.00 69421 S 570.06 0.00 0.00<br />

68362 S 668.60 0.00 0.00 69424 S 78.57 0.00 0.00<br />

68371 S 530.62 0.00 0.00 69433 S 111.67 0.00 0.00<br />

68400 S 121.58 0.00 0.00 69436 S 570.06 0.00 0.00<br />

68420 S 173.00 0.00 0.00 69440 S 714.99 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 962.64 0.00 0.00 69840 S 1,141.54 0.00 0.00<br />

69501 S 1,271.05 0.00 0.00 69905 S 1,271.05 0.00 0.00<br />

69502 S 940.94 0.00 0.00 69910 S 1,271.05 0.00 0.00<br />

69505 S 1,271.05 0.00 0.00 69915 S 1,271.05 0.00 0.00<br />

69511 S 1,271.05 0.00 0.00 69930 S 22,978.91 12,338.12 1,697.33<br />

69530 S 1,271.05 0.00 0.00 70030 TC A 17.57 0.00 0.00<br />

69540 S 131.30 0.00 0.00 70100 TC A 19.30 0.00 0.00<br />

69550 S 1,141.54 0.00 0.00 70110 TC A 23.78 0.00 0.00<br />

69552 S 1,271.05 0.00 0.00 70120 TC A 21.37 0.00 0.00<br />

69601 S 1,271.05 0.00 0.00 70130 TC A 26.11 0.00 0.00<br />

69602 S 1,271.05 0.00 0.00 70134 TC A 26.19 0.00 0.00<br />

69603 S 1,271.05 0.00 0.00 70140 TC A 17.92 0.00 0.00<br />

69604 S 1,271.05 0.00 0.00 70150 TC A 26.11 0.00 0.00<br />

69605 S 1,271.05 0.00 0.00 70160 TC A 21.02 0.00 0.00<br />

69610 S 175.76 0.00 0.00 70190 TC A 22.05 0.00 0.00<br />

69620 S 685.17 0.00 0.00 70200 TC A 26.11 0.00 0.00<br />

69631 S 1,141.54 0.00 0.00 70210 TC A 18.61 0.00 0.00<br />

69632 S 1,141.54 0.00 0.00 70220 TC A 23.44 0.00 0.00<br />

69633 S 1,141.54 0.00 0.00 70240 TC A 17.57 0.00 0.00<br />

69635 S 1,271.05 0.00 0.00 70250 TC A 21.37 0.00 0.00<br />

69636 S 1,271.05 0.00 0.00 70260 TC A 27.22 0.00 0.00<br />

69637 S 1,271.05 0.00 0.00 70300 TC A 7.58 0.00 0.00<br />

69641 S 1,271.05 0.00 0.00 70310 TC A 18.73 0.00 0.00<br />

69642 S 1,271.05 0.00 0.00 70320 TC A 18.73 0.00 0.00<br />

69643 S 1,271.05 0.00 0.00 70328 TC A 18.61 0.00 0.00<br />

69644 S 1,271.05 0.00 0.00 70330 TC A 26.11 0.00 0.00<br />

69645 S 1,271.05 0.00 0.00 70336 TC A 203.21 0.00 0.00<br />

69646 S 1,271.05 0.00 0.00 70350 TC A 10.34 0.00 0.00<br />

69650 S 940.94 0.00 0.00 70355 TC A 10.68 0.00 0.00<br />

69660 S 1,141.54 0.00 0.00 70360 TC A 16.54 0.00 0.00<br />

69661 S 1,141.54 0.00 0.00 70370 TC A 48.58 0.00 0.00<br />

69662 S 1,141.54 0.00 0.00 70371 TC A 48.58 0.00 0.00<br />

69666 S 1,101.00 0.00 0.00 70380 TC A 25.16 0.00 0.00<br />

69667 S 1,101.00 0.00 0.00 70450 TC A 113.49 0.00 0.00<br />

69670 S 1,045.10 0.00 0.00 70460 TC A 179.71 0.00 0.00<br />

69676 S 1,045.10 0.00 0.00 70470 TC A 199.07 0.00 0.00<br />

69700 S 1,045.10 0.00 0.00 70480 TC A 113.49 0.00 0.00<br />

69711 S 962.64 0.00 0.00 70481 TC A 179.71 0.00 0.00<br />

69714 S 6,104.89 3,849.37 1,593.84 70482 TC A 199.07 0.00 0.00<br />

69715 S 6,104.89 3,849.37 1,593.84 70486 TC A 113.49 0.00 0.00<br />

69717 S 6,104.89 3,849.37 1,593.84 70487 TC A 179.71 0.00 0.00<br />

69718 S 6,104.89 3,849.37 1,593.84 70488 TC A 199.07 0.00 0.00<br />

69720 S 1,141.54 0.00 0.00 70490 TC A 113.49 0.00 0.00<br />

69740 S 1,141.54 0.00 0.00 70491 TC A 179.71 0.00 0.00<br />

69745 S 1,141.54 0.00 0.00 70492 TC A 199.07 0.00 0.00<br />

69801 S 1,141.54 0.00 0.00 70496 TC A 205.43 0.00 0.00<br />

69802 S 1,271.05 0.00 0.00 70498 TC A 205.43 0.00 0.00<br />

69805 S 1,271.05 0.00 0.00 70540 TC A 203.21 0.00 0.00<br />

69806 S 1,271.05 0.00 0.00 70542 TC A 249.54 0.00 0.00<br />

69820 S 1,141.54 0.00 0.00 70543 TC A 314.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 203.21 0.00 0.00 72120 TC A 33.08 0.00 0.00<br />

70545 TC A 249.54 0.00 0.00 72125 TC A 113.49 0.00 0.00<br />

70546 TC A 314.51 0.00 0.00 72126 TC A 179.71 0.00 0.00<br />

70547 TC A 203.21 0.00 0.00 72127 TC A 199.07 0.00 0.00<br />

70548 TC A 249.54 0.00 0.00 72128 TC A 113.49 0.00 0.00<br />

70549 TC A 314.51 0.00 0.00 72129 TC A 179.71 0.00 0.00<br />

70551 TC A 203.21 0.00 0.00 72130 TC A 199.07 0.00 0.00<br />

70552 TC A 249.54 0.00 0.00 72131 TC A 113.49 0.00 0.00<br />

70553 TC A 314.51 0.00 0.00 72132 TC A 179.71 0.00 0.00<br />

70554 TC A 203.21 0.00 0.00 72133 TC A 199.07 0.00 0.00<br />

70555 TC A 203.21 0.00 0.00 72141 TC A 203.21 0.00 0.00<br />

70557 TC A 203.21 0.00 0.00 72142 TC A 249.54 0.00 0.00<br />

70558 TC A 249.54 0.00 0.00 72146 TC A 203.21 0.00 0.00<br />

70559 TC A 314.51 0.00 0.00 72147 TC A 249.54 0.00 0.00<br />

71010 TC A 13.44 0.00 0.00 72148 TC A 203.21 0.00 0.00<br />

71015 TC A 17.23 0.00 0.00 72149 TC A 249.54 0.00 0.00<br />

71020 TC A 18.27 0.00 0.00 72156 TC A 314.51 0.00 0.00<br />

71021 TC A 22.05 0.00 0.00 72157 TC A 314.51 0.00 0.00<br />

71022 TC A 26.11 0.00 0.00 72158 TC A 314.51 0.00 0.00<br />

71023 TC A 42.73 0.00 0.00 72170 TC A 15.51 0.00 0.00<br />

71030 TC A 26.11 0.00 0.00 72190 TC A 26.11 0.00 0.00<br />

71034 TC A 48.58 0.00 0.00 72191 TC A 205.43 0.00 0.00<br />

71035 TC A 22.74 0.00 0.00 72192 TC A 113.49 0.00 0.00<br />

71100 TC A 18.96 0.00 0.00 72193 TC A 179.71 0.00 0.00<br />

71101 TC A 23.09 0.00 0.00 72194 TC A 199.07 0.00 0.00<br />

71110 TC A 24.13 0.00 0.00 72195 TC A 203.21 0.00 0.00<br />

71111 TC A 32.05 0.00 0.00 72196 TC A 249.54 0.00 0.00<br />

71120 TC A 19.99 0.00 0.00 72197 TC A 314.51 0.00 0.00<br />

71130 TC A 23.44 0.00 0.00 72200 TC A 18.27 0.00 0.00<br />

71250 TC A 113.49 0.00 0.00 72202 TC A 22.40 0.00 0.00<br />

71260 TC A 179.71 0.00 0.00 72220 TC A 18.27 0.00 0.00<br />

71270 TC A 199.07 0.00 0.00 73000 TC A 17.23 0.00 0.00<br />

71275 TC A 205.43 0.00 0.00 73010 TC A 17.57 0.00 0.00<br />

71550 TC A 203.21 0.00 0.00 73020 TC A 14.13 0.00 0.00<br />

71551 TC A 249.54 0.00 0.00 73030 TC A 17.92 0.00 0.00<br />

71552 TC A 314.51 0.00 0.00 73050 TC A 22.40 0.00 0.00<br />

72010 TC A 43.46 0.00 0.00 73060 TC A 17.92 0.00 0.00<br />

72020 TC A 14.13 0.00 0.00 73070 TC A 17.23 0.00 0.00<br />

72040 TC A 22.74 0.00 0.00 73080 TC A 22.74 0.00 0.00<br />

72050 TC A 32.39 0.00 0.00 73090 TC A 17.23 0.00 0.00<br />

72052 TC A 43.46 0.00 0.00 73092 TC A 17.92 0.00 0.00<br />

72069 TC A 21.37 0.00 0.00 73100 TC A 17.92 0.00 0.00<br />

72070 TC A 19.99 0.00 0.00 73110 TC A 22.74 0.00 0.00<br />

72072 TC A 24.13 0.00 0.00 73120 TC A 16.88 0.00 0.00<br />

72074 TC A 26.11 0.00 0.00 73130 TC A 19.99 0.00 0.00<br />

72080 TC A 21.37 0.00 0.00 73140 TC A 19.65 0.00 0.00<br />

72090 TC A 28.61 0.00 0.00 73200 TC A 113.49 0.00 0.00<br />

72100 TC A 24.47 0.00 0.00 73201 TC A 179.71 0.00 0.00<br />

72110 TC A 34.12 0.00 0.00 73202 TC A 199.07 0.00 0.00<br />

72114 TC A 43.46 0.00 0.00 73206 TC A 205.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 203.21 0.00 0.00 74246 TC A 51.28 0.00 0.00<br />

73219 TC A 249.54 0.00 0.00 74247 TC A 51.28 0.00 0.00<br />

73220 TC A 314.51 0.00 0.00 74249 TC A 83.39 0.00 0.00<br />

73221 TC A 203.21 0.00 0.00 74250 TC A 51.28 0.00 0.00<br />

73222 TC A 249.54 0.00 0.00 74251 TC A 83.39 0.00 0.00<br />

73223 TC A 314.51 0.00 0.00 74260 TC A 51.28 0.00 0.00<br />

73500 TC A 14.82 0.00 0.00 74270 TC A 51.28 0.00 0.00<br />

73510 TC A 22.74 0.00 0.00 74280 TC A 83.39 0.00 0.00<br />

73520 TC A 23.44 0.00 0.00 74283 TC A 51.28 0.00 0.00<br />

73540 TC A 23.44 0.00 0.00 74290 TC A 43.76 0.00 0.00<br />

73550 TC A 17.23 0.00 0.00 74291 TC A 42.04 0.00 0.00<br />

73560 TC A 17.57 0.00 0.00 74400 TC A 76.17 0.00 0.00<br />

73562 TC A 21.71 0.00 0.00 74410 TC A 81.34 0.00 0.00<br />

73564 TC A 25.16 0.00 0.00 74415 TC A 97.19 0.00 0.00<br />

73565 TC A 18.96 0.00 0.00 74420 TC A 101.58 0.00 0.00<br />

73590 TC A 16.54 0.00 0.00 74710 TC A 22.74 0.00 0.00<br />

73592 TC A 17.92 0.00 0.00 74775 TC A 101.58 0.00 0.00<br />

73600 TC A 16.88 0.00 0.00 75557 TC A 203.21 0.00 0.00<br />

73610 TC A 19.99 0.00 0.00 75559 TC A 203.21 0.00 0.00<br />

73620 TC A 16.20 0.00 0.00 75561 TC A 314.51 0.00 0.00<br />

73630 TC A 19.65 0.00 0.00 75563 TC A 314.51 0.00 0.00<br />

73650 TC A 16.54 0.00 0.00 76010 TC A 16.88 0.00 0.00<br />

73660 TC A 18.61 0.00 0.00 76098 TC A 10.34 0.00 0.00<br />

73700 TC A 113.49 0.00 0.00 76100 TC A 43.46 0.00 0.00<br />

73701 TC A 179.71 0.00 0.00 76101 TC A 116.48 0.00 0.00<br />

73702 TC A 199.07 0.00 0.00 76102 TC A 116.48 0.00 0.00<br />

73706 TC A 205.43 0.00 0.00 76120 TC A 48.58 0.00 0.00<br />

73718 TC A 203.21 0.00 0.00 76150 A 16.88 0.00 0.00<br />

73719 TC A 249.54 0.00 0.00 76380 TC A 61.31 0.00 0.00<br />

73720 TC A 314.51 0.00 0.00 76496 TC A 48.58 0.00 0.00<br />

73721 TC A 203.21 0.00 0.00 76497 TC A 61.31 0.00 0.00<br />

73722 TC A 249.54 0.00 0.00 76498 TC A 203.21 0.00 0.00<br />

73723 TC A 314.51 0.00 0.00 76499 TC A 26.11 0.00 0.00<br />

74000 TC A 14.82 0.00 0.00 76506 TC A 36.49 0.00 0.00<br />

74010 TC A 23.09 0.00 0.00 76510 TC A 62.03 0.00 0.00<br />

74020 TC A 23.44 0.00 0.00 76511 TC A 43.42 0.00 0.00<br />

74022 TC A 28.61 0.00 0.00 76512 TC A 36.87 0.00 0.00<br />

74150 TC A 113.49 0.00 0.00 76513 TC A 44.81 0.00 0.00<br />

74160 TC A 179.71 0.00 0.00 76514 TC A 3.11 0.00 0.00<br />

74170 TC A 199.07 0.00 0.00 76516 TC A 35.15 0.00 0.00<br />

74175 TC A 205.43 0.00 0.00 76519 TC A 39.29 0.00 0.00<br />

74181 TC A 203.21 0.00 0.00 76529 TC A 34.12 0.00 0.00<br />

74182 TC A 249.54 0.00 0.00 76536 TC A 57.08 0.00 0.00<br />

74183 TC A 314.51 0.00 0.00 76604 TC A 36.49 0.00 0.00<br />

74210 TC A 51.28 0.00 0.00 76645 TC A 36.49 0.00 0.00<br />

74220 TC A 51.28 0.00 0.00 76700 TC A 57.08 0.00 0.00<br />

74230 TC A 51.28 0.00 0.00 76705 TC A 57.08 0.00 0.00<br />

74240 TC A 51.28 0.00 0.00 76770 TC A 57.08 0.00 0.00<br />

74241 TC A 51.28 0.00 0.00 76775 TC A 57.08 0.00 0.00<br />

74245 TC A 83.39 0.00 0.00 76776 TC A 57.08 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 57.08 0.00 0.00 77290 TC A 149.29 0.00 0.00<br />

76801 TC A 57.08 0.00 0.00 77295 TC A 391.16 0.00 0.00<br />

76802 TC A 27.22 0.00 0.00 77299 TC A 66.97 0.00 0.00<br />

76805 TC A 57.08 0.00 0.00 77300 TC A 36.19 0.00 0.00<br />

76810 TC A 43.08 0.00 0.00 77301 TC A 521.31 0.00 0.00<br />

76811 TC A 89.43 0.00 0.00 77305 TC A 33.08 0.00 0.00<br />

76812 TC A 36.49 0.00 0.00 77310 TC A 43.08 0.00 0.00<br />

76813 TC A 36.49 0.00 0.00 77315 TC A 62.72 0.00 0.00<br />

76814 TC A 28.95 0.00 0.00 77321 TC A 65.14 0.00 0.00<br />

76815 TC A 36.49 0.00 0.00 77326 TC A 66.97 0.00 0.00<br />

76816 TC A 36.49 0.00 0.00 77327 TC A 121.66 0.00 0.00<br />

76817 TC A 36.49 0.00 0.00 77328 TC A 149.29 0.00 0.00<br />

76818 TC A 57.08 0.00 0.00 77331 TC A 17.23 0.00 0.00<br />

76819 TC A 49.29 0.00 0.00 77332 TC A 46.18 0.00 0.00<br />

76820 TC A 24.47 0.00 0.00 77333 TC A 22.40 0.00 0.00<br />

76821 TC A 55.26 0.00 0.00 77334 TC A 86.51 0.00 0.00<br />

76825 TC A 115.11 0.00 0.00 77336 A 54.46 0.00 0.00<br />

76826 TC A 68.58 0.00 0.00 77370 A 66.97 0.00 0.00<br />

76827 TC A 36.49 0.00 0.00 77371 A 4,461.56 0.00 0.00<br />

76828 TC A 21.71 0.00 0.00 77399 TC A 66.97 0.00 0.00<br />

76830 TC A 57.08 0.00 0.00 77401 A 27.22 0.00 0.00<br />

76831 TC A 76.85 0.00 0.00 77402 A 54.81 0.00 0.00<br />

76856 TC A 57.08 0.00 0.00 77403 A 54.81 0.00 0.00<br />

76857 TC A 36.49 0.00 0.00 77404 A 54.81 0.00 0.00<br />

76870 TC A 57.08 0.00 0.00 77406 A 88.78 0.00 0.00<br />

76872 TC A 57.08 0.00 0.00 77407 A 54.81 0.00 0.00<br />

76873 TC A 57.08 0.00 0.00 77408 A 54.81 0.00 0.00<br />

76880 TC A 57.08 0.00 0.00 77409 A 54.81 0.00 0.00<br />

76885 TC A 36.49 0.00 0.00 77411 A 88.78 0.00 0.00<br />

76886 TC A 36.49 0.00 0.00 77412 A 88.78 0.00 0.00<br />

76936 TC A 55.26 0.00 0.00 77413 A 88.78 0.00 0.00<br />

76970 TC A 36.49 0.00 0.00 77414 A 88.78 0.00 0.00<br />

76977 TC A 9.31 0.00 0.00 77416 A 88.78 0.00 0.00<br />

76999 TC A 36.49 0.00 0.00 77418 A 239.86 0.00 0.00<br />

77071 A 21.37 0.00 0.00 77422 A 88.78 0.00 0.00<br />

77072 TC A 12.40 0.00 0.00 77423 A 88.78 0.00 0.00<br />

77073 TC A 21.02 0.00 0.00 77470 TC A 127.52 0.00 0.00<br />

77074 TC A 41.36 0.00 0.00 77520 A 410.67 0.00 0.00<br />

77075 TC A 43.46 0.00 0.00 77522 A 410.67 0.00 0.00<br />

77076 TC A 43.46 0.00 0.00 77523 A 490.76 0.00 0.00<br />

77077 TC A 23.44 0.00 0.00 77525 A 490.76 0.00 0.00<br />

77078 TC A 41.99 0.00 0.00 77600 TC A 217.89 0.00 0.00<br />

77079 TC A 43.08 0.00 0.00 77605 TC A 217.89 0.00 0.00<br />

77080 TC A 41.99 0.00 0.00 77610 TC A 217.89 0.00 0.00<br />

77081 TC A 16.88 0.00 0.00 77615 TC A 217.89 0.00 0.00<br />

77082 TC A 18.27 0.00 0.00 77620 TC A 217.89 0.00 0.00<br />

77083 TC A 14.48 0.00 0.00 77750 TC A 84.78 0.00 0.00<br />

77084 TC A 203.21 0.00 0.00 77761 TC A 149.23 0.00 0.00<br />

77280 TC A 66.97 0.00 0.00 77762 TC A 176.80 0.00 0.00<br />

77285 TC A 149.29 0.00 0.00 77763 TC A 227.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 161.63 0.00 0.00 78262 TC A 141.95 0.00 0.00<br />

77777 TC A 177.48 0.00 0.00 78264 TC A 141.95 0.00 0.00<br />

77778 TC A 236.42 0.00 0.00 78270 TC A 62.03 0.00 0.00<br />

77785 TC A 105.11 0.00 0.00 78271 TC A 63.07 0.00 0.00<br />

77786 TC A 369.44 0.00 0.00 78272 TC A 69.27 0.00 0.00<br />

77787 TC A 428.11 0.00 0.00 78278 TC A 141.95 0.00 0.00<br />

77789 TC A 44.12 0.00 0.00 78282 TC A 141.95 0.00 0.00<br />

77799 TC A 251.44 0.00 0.00 78290 TC A 141.95 0.00 0.00<br />

78000 TC A 54.10 0.00 0.00 78291 TC A 141.95 0.00 0.00<br />

78001 TC A 68.57 0.00 0.00 78299 TC A 141.95 0.00 0.00<br />

78003 TC A 54.46 0.00 0.00 78300 TC A 123.72 0.00 0.00<br />

78006 TC A 129.56 0.00 0.00 78305 TC A 143.49 0.00 0.00<br />

78007 TC A 95.81 0.00 0.00 78306 TC A 143.49 0.00 0.00<br />

78010 TC A 79.61 0.00 0.00 78315 TC A 143.49 0.00 0.00<br />

78011 TC A 79.61 0.00 0.00 78320 TC A 143.49 0.00 0.00<br />

78015 TC A 154.74 0.00 0.00 78399 TC A 143.49 0.00 0.00<br />

78016 TC A 174.66 0.00 0.00 78414 TC A 182.40 0.00 0.00<br />

78018 TC A 174.66 0.00 0.00 78428 TC A 139.92 0.00 0.00<br />

78070 TC A 118.90 0.00 0.00 78445 TC A 109.14 0.00 0.00<br />

78075 TC A 336.71 0.00 0.00 78456 TC A 109.14 0.00 0.00<br />

78099 TC A 79.61 0.00 0.00 78457 TC A 109.14 0.00 0.00<br />

78102 TC A 120.28 0.00 0.00 78458 TC A 109.14 0.00 0.00<br />

78103 TC A 153.32 0.00 0.00 78459 TC A 675.43 0.00 0.00<br />

78104 TC A 153.32 0.00 0.00 78460 TC A 130.96 0.00 0.00<br />

78110 TC A 61.00 0.00 0.00 78461 TC A 132.00 0.00 0.00<br />

78111 TC A 77.20 0.00 0.00 78464 TC A 193.68 0.00 0.00<br />

78120 TC A 67.55 0.00 0.00 78465 TC A 366.69 0.00 0.00<br />

78121 TC A 79.95 0.00 0.00 78466 TC A 129.93 0.00 0.00<br />

78122 TC A 94.77 0.00 0.00 78468 TC A 166.11 0.00 0.00<br />

78130 TC A 109.94 0.00 0.00 78469 TC A 182.40 0.00 0.00<br />

78135 TC A 233.65 0.00 0.00 78472 TC A 182.40 0.00 0.00<br />

78140 TC A 103.73 0.00 0.00 78473 TC A 182.40 0.00 0.00<br />

78185 TC A 153.32 0.00 0.00 78481 TC A 157.49 0.00 0.00<br />

78190 TC A 96.20 0.00 0.00 78483 TC A 182.40 0.00 0.00<br />

78191 TC A 96.20 0.00 0.00 78491 TC A 675.43 0.00 0.00<br />

78195 TC A 153.32 0.00 0.00 78492 TC A 675.43 0.00 0.00<br />

78199 TC A 153.32 0.00 0.00 78494 TC A 182.40 0.00 0.00<br />

78201 TC A 136.47 0.00 0.00 78499 TC A 182.40 0.00 0.00<br />

78202 TC A 160.54 0.00 0.00 78580 TC A 123.57 0.00 0.00<br />

78205 TC A 160.54 0.00 0.00 78584 TC A 95.46 0.00 0.00<br />

78206 TC A 160.54 0.00 0.00 78585 TC A 189.61 0.00 0.00<br />

78215 TC A 144.40 0.00 0.00 78586 TC A 123.57 0.00 0.00<br />

78216 TC A 97.88 0.00 0.00 78587 TC A 123.57 0.00 0.00<br />

78220 TC A 106.84 0.00 0.00 78588 TC A 189.61 0.00 0.00<br />

78223 TC A 160.54 0.00 0.00 78591 TC A 123.57 0.00 0.00<br />

78230 TC A 121.31 0.00 0.00 78593 TC A 123.57 0.00 0.00<br />

78231 TC A 95.46 0.00 0.00 78594 TC A 123.57 0.00 0.00<br />

78232 TC A 99.60 0.00 0.00 78596 TC A 189.61 0.00 0.00<br />

78258 TC A 141.95 0.00 0.00 78599 TC A 123.57 0.00 0.00<br />

78261 TC A 141.95 0.00 0.00 78600 TC A 108.90 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 36740 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 108.90 0.00 0.00<br />

78605 TC A 108.90 0.00 0.00<br />

78606 TC A 244.69 0.00 0.00<br />

78607 TC A 268.82 0.00 0.00<br />

78608 TC A 605.40 0.00 0.00<br />

78610 TC A 145.09 0.00 0.00<br />

78630 TC A 258.48 0.00 0.00<br />

78635 TC A 238.14 0.00 0.00<br />

78645 TC A 108.90 0.00 0.00<br />

78647 TC A 263.65 0.00 0.00<br />

78650 TC A 255.37 0.00 0.00<br />

78660 TC A 108.90 0.00 0.00<br />

78699 TC A 108.90 0.00 0.00<br />

78700 TC A 134.06 0.00 0.00<br />

78701 TC A 163.36 0.00 0.00<br />

78707 TC A 170.59 0.00 0.00<br />

78708 TC A 116.84 0.00 0.00<br />

78709 TC A 192.08 0.00 0.00<br />

78710 TC A 180.25 0.00 0.00<br />

78725 TC A 72.03 0.00 0.00<br />

78730 TC A 61.00 0.00 0.00<br />

78740 TC A 159.22 0.00 0.00<br />

78761 TC A 151.98 0.00 0.00<br />

78799 TC A 192.08 0.00 0.00<br />

78800 TC A 134.41 0.00 0.00<br />

78801 TC A 184.38 0.00 0.00<br />

78802 TC A 249.86 0.00 0.00<br />

78803 TC A 267.78 0.00 0.00<br />

78804 TC A 467.32 0.00 0.00<br />

78805 TC A 131.30 0.00 0.00<br />

78806 TC A 262.61 0.00 0.00<br />

78807 TC A 268.13 0.00 0.00<br />

78811 TC A 605.40 0.00 0.00<br />

78812 TC A 605.40 0.00 0.00<br />

78813 TC A 605.40 0.00 0.00<br />

78814 TC A 605.40 0.00 0.00<br />

78815 TC A 605.40 0.00 0.00<br />

78816 TC A 605.40 0.00 0.00<br />

78999 TC A 68.57 0.00 0.00<br />

79005 TC A 55.14 0.00 0.00<br />

79101 TC A 60.31 0.00 0.00<br />

79200 TC A 65.14 0.00 0.00<br />

79300 TC A 125.67 0.00 0.00<br />

79403 TC A 93.40 0.00 0.00<br />

79440 TC A 52.73 0.00 0.00<br />

79445 TC A 125.67 0.00 0.00<br />

79999 TC A 125.67 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,246.18 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,523.63 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.58 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,574.36 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,574.36 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 227.36 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 227.36 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 114.80 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 242.64 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 72.94 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 653.13 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,489.37 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,165.81 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,165.81 0.00 0.00<br />

C8900 A 252.43 0.00 0.00 0123T S 932.30 0.00 0.00<br />

C8901 A 205.56 0.00 0.00 0124T S 182.22 0.00 0.00<br />

C8902 A 318.15 0.00 0.00 0144T TC A 62.02 0.00 0.00<br />

C8903 A 252.43 0.00 0.00 0145T TC A 166.95 0.00 0.00<br />

C8904 A 205.56 0.00 0.00 0146T TC A 166.95 0.00 0.00<br />

C8905 A 318.15 0.00 0.00 0147T TC A 166.95 0.00 0.00<br />

C8906 A 252.43 0.00 0.00 0148T TC A 166.95 0.00 0.00<br />

C8907 A 205.56 0.00 0.00 0149T TC A 166.95 0.00 0.00<br />

C8908 A 318.15 0.00 0.00 0150T TC A 166.95 0.00 0.00<br />

C8909 A 252.43 0.00 0.00 0151T TC A 62.02 0.00 0.00<br />

C8910 A 205.56 0.00 0.00 0170T S 1,211.00 0.00 0.00<br />

C8911 A 318.15 0.00 0.00 0176T S 1,429.91 0.00 0.00<br />

C8912 A 252.43 0.00 0.00 0177T S 1,429.91 0.00 0.00<br />

C8913 A 205.56 0.00 0.00 0182T A 1,033.55 0.00 0.00<br />

C8914 A 318.15 0.00 0.00 0186T S 871.07 0.00 0.00<br />

C8918 A 252.43 0.00 0.00 0190T S 871.07 0.00 0.00<br />

C8919 A 205.56 0.00 0.00 0191T S 932.30 0.00 0.00<br />

C8920 A 318.15 0.00 0.00 0192T S 1,597.77 0.00 0.00<br />

C9716 S 1,211.00 0.00 0.00 10021 S 55.88 0.00 0.00<br />

C9724 S 990.13 0.00 0.00 10022 S 174.50 0.00 0.00<br />

C9725 S 228.32 0.00 0.00 10040 S 32.30 0.00 0.00<br />

C9726 S 838.23 0.00 0.00 10060 S 49.15 0.00 0.00<br />

C9727 S 293.89 0.00 0.00 10061 S 55.12 0.00 0.00<br />

C9728 S 527.34 0.00 0.00 10080 S 55.12 0.00 0.00<br />

G0104 S 84.71 0.00 0.00 10081 S 126.90 0.00 0.00<br />

G0105 S 366.13 0.00 0.00 10120 S 69.02 0.00 0.00<br />

G0121 S 366.13 0.00 0.00 10121 S 520.29 0.00 0.00<br />

G0127 S 11.85 0.00 0.00 10140 S 73.21 0.00 0.00<br />

G0130 TC A 19.53 0.00 0.00 10160 S 55.12 0.00 0.00<br />

G0173 A 2,246.18 0.00 0.00 10180 S 588.38 0.00 0.00<br />

G0186 S 227.36 0.00 0.00 11000 S 23.71 0.00 0.00<br />

G0247 S 21.61 0.00 0.00 11001 S 8.02 0.00 0.00<br />

G0251 A 562.47 0.00 0.00 11010 S 205.85 0.00 0.00<br />

G0260 S 296.83 0.00 0.00 11011 S 205.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 205.85 0.00 0.00 11601 S 113.65 0.00 0.00<br />

11040 S 21.61 0.00 0.00 11602 S 125.16 0.00 0.00<br />

11041 S 24.06 0.00 0.00 11603 S 132.82 0.00 0.00<br />

11042 S 130.71 0.00 0.00 11604 S 358.28 0.00 0.00<br />

11043 S 130.71 0.00 0.00 11606 S 520.29 0.00 0.00<br />

11044 S 340.36 0.00 0.00 11620 S 96.92 0.00 0.00<br />

11055 S 25.45 0.00 0.00 11621 S 115.04 0.00 0.00<br />

11056 S 27.89 0.00 0.00 11622 S 127.94 0.00 0.00<br />

11057 S 32.30 0.00 0.00 11623 S 137.70 0.00 0.00<br />

11100 S 59.18 0.00 0.00 11624 S 520.29 0.00 0.00<br />

11101 S 13.95 0.00 0.00 11626 S 636.27 0.00 0.00<br />

11200 S 32.30 0.00 0.00 11640 S 102.50 0.00 0.00<br />

11201 S 5.58 0.00 0.00 11641 S 120.97 0.00 0.00<br />

11300 S 32.30 0.00 0.00 11642 S 134.92 0.00 0.00<br />

11301 S 32.30 0.00 0.00 11643 S 145.38 0.00 0.00<br />

11302 S 32.30 0.00 0.00 11644 S 520.29 0.00 0.00<br />

11303 S 59.18 0.00 0.00 11646 S 636.27 0.00 0.00<br />

11305 S 32.30 0.00 0.00 11719 S 11.85 0.00 0.00<br />

11306 S 32.30 0.00 0.00 11720 S 14.64 0.00 0.00<br />

11307 S 32.30 0.00 0.00 11721 S 17.78 0.00 0.00<br />

11308 S 32.30 0.00 0.00 11730 S 32.30 0.00 0.00<br />

11310 S 32.30 0.00 0.00 11732 S 17.78 0.00 0.00<br />

11311 S 32.30 0.00 0.00 11740 S 16.32 0.00 0.00<br />

11312 S 32.30 0.00 0.00 11750 S 94.13 0.00 0.00<br />

11313 S 32.30 0.00 0.00 11752 S 130.73 0.00 0.00<br />

11400 S 66.59 0.00 0.00 11755 S 65.19 0.00 0.00<br />

11401 S 74.95 0.00 0.00 11760 S 134.26 0.00 0.00<br />

11402 S 82.28 0.00 0.00 11762 S 119.93 0.00 0.00<br />

11403 S 87.85 0.00 0.00 11765 S 32.30 0.00 0.00<br />

11404 S 467.04 0.00 0.00 11770 S 666.44 0.00 0.00<br />

11406 S 520.29 0.00 0.00 11771 S 666.44 0.00 0.00<br />

11420 S 62.40 0.00 0.00 11772 S 666.44 0.00 0.00<br />

11421 S 75.65 0.00 0.00 11900 S 29.64 0.00 0.00<br />

11422 S 82.62 0.00 0.00 11901 S 32.30 0.00 0.00<br />

11423 S 92.04 0.00 0.00 11920 S 93.78 0.00 0.00<br />

11424 S 520.29 0.00 0.00 11921 S 103.19 0.00 0.00<br />

11426 S 636.27 0.00 0.00 11922 S 33.46 0.00 0.00<br />

11440 S 71.47 0.00 0.00 11950 S 34.17 0.00 0.00<br />

11441 S 82.62 0.00 0.00 11951 S 42.53 0.00 0.00<br />

11442 S 90.99 0.00 0.00 11952 S 51.20 0.00 0.00<br />

11443 S 100.75 0.00 0.00 11954 S 51.20 0.00 0.00<br />

11444 S 317.99 0.00 0.00 11960 S 621.12 0.00 0.00<br />

11446 S 636.27 0.00 0.00 11970 S 1,125.05 0.00 0.00<br />

11450 S 636.27 0.00 0.00 11971 S 583.02 0.00 0.00<br />

11451 S 636.27 0.00 0.00 11976 S 62.40 0.00 0.00<br />

11462 S 636.27 0.00 0.00 11980 S 25.21 0.00 0.00<br />

11463 S 636.27 0.00 0.00 11981 S 25.21 0.00 0.00<br />

11470 S 636.27 0.00 0.00 11982 S 25.21 0.00 0.00<br />

11471 S 636.27 0.00 0.00 11983 S 25.21 0.00 0.00<br />

11600 S 93.78 0.00 0.00 12001 S 51.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 51.20 0.00 0.00 14021 S 551.97 0.00 0.00<br />

12004 S 51.20 0.00 0.00 14040 S 521.81 0.00 0.00<br />

12005 S 68.60 0.00 0.00 14041 S 551.97 0.00 0.00<br />

12006 S 68.60 0.00 0.00 14060 S 551.97 0.00 0.00<br />

12007 S 68.60 0.00 0.00 14061 S 551.97 0.00 0.00<br />

12011 S 51.20 0.00 0.00 14300 S 707.83 0.00 0.00<br />

12013 S 51.20 0.00 0.00 14350 S 651.28 0.00 0.00<br />

12014 S 51.20 0.00 0.00 15002 S 238.78 0.00 0.00<br />

12015 S 51.20 0.00 0.00 15003 S 238.78 0.00 0.00<br />

12016 S 68.60 0.00 0.00 15004 S 238.78 0.00 0.00<br />

12017 S 68.60 0.00 0.00 15005 S 238.78 0.00 0.00<br />

12018 S 68.60 0.00 0.00 15040 S 110.12 0.00 0.00<br />

12020 S 129.43 0.00 0.00 15050 S 238.78 0.00 0.00<br />

12021 S 110.12 0.00 0.00 15100 S 621.12 0.00 0.00<br />

12031 S 51.20 0.00 0.00 15101 S 651.28 0.00 0.00<br />

12032 S 134.26 0.00 0.00 15110 S 296.61 0.00 0.00<br />

12034 S 68.60 0.00 0.00 15111 S 243.36 0.00 0.00<br />

12035 S 68.60 0.00 0.00 15115 S 296.61 0.00 0.00<br />

12036 S 110.12 0.00 0.00 15116 S 243.36 0.00 0.00<br />

12037 S 219.49 0.00 0.00 15120 S 621.12 0.00 0.00<br />

12041 S 51.20 0.00 0.00 15121 S 651.28 0.00 0.00<br />

12042 S 51.20 0.00 0.00 15130 S 521.81 0.00 0.00<br />

12044 S 68.60 0.00 0.00 15131 S 468.55 0.00 0.00<br />

12045 S 110.12 0.00 0.00 15135 S 521.81 0.00 0.00<br />

12046 S 110.12 0.00 0.00 15136 S 468.55 0.00 0.00<br />

12047 S 219.49 0.00 0.00 15150 S 296.61 0.00 0.00<br />

12051 S 51.20 0.00 0.00 15151 S 243.36 0.00 0.00<br />

12052 S 51.20 0.00 0.00 15152 S 243.36 0.00 0.00<br />

12053 S 51.20 0.00 0.00 15155 S 296.61 0.00 0.00<br />

12054 S 68.60 0.00 0.00 15156 S 243.36 0.00 0.00<br />

12055 S 110.12 0.00 0.00 15157 S 243.36 0.00 0.00<br />

12056 S 110.12 0.00 0.00 15170 S 134.26 0.00 0.00<br />

12057 S 219.49 0.00 0.00 15171 S 134.26 0.00 0.00<br />

13100 S 238.78 0.00 0.00 15175 S 172.86 0.00 0.00<br />

13101 S 238.78 0.00 0.00 15176 S 172.86 0.00 0.00<br />

13102 S 129.43 0.00 0.00 15200 S 551.97 0.00 0.00<br />

13120 S 110.12 0.00 0.00 15201 S 463.98 0.00 0.00<br />

13121 S 110.12 0.00 0.00 15220 S 521.81 0.00 0.00<br />

13122 S 110.12 0.00 0.00 15221 S 238.78 0.00 0.00<br />

13131 S 110.12 0.00 0.00 15240 S 551.97 0.00 0.00<br />

13132 S 110.12 0.00 0.00 15241 S 238.78 0.00 0.00<br />

13133 S 110.12 0.00 0.00 15260 S 521.81 0.00 0.00<br />

13150 S 238.78 0.00 0.00 15261 S 463.98 0.00 0.00<br />

13151 S 238.78 0.00 0.00 15300 S 238.78 0.00 0.00<br />

13152 S 238.78 0.00 0.00 15301 S 238.78 0.00 0.00<br />

13153 S 110.12 0.00 0.00 15320 S 238.78 0.00 0.00<br />

13160 S 621.12 0.00 0.00 15321 S 238.78 0.00 0.00<br />

14000 S 521.81 0.00 0.00 15330 S 238.78 0.00 0.00<br />

14001 S 551.97 0.00 0.00 15331 S 238.78 0.00 0.00<br />

14020 S 551.97 0.00 0.00 15335 S 238.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 238.78 0.00 0.00 15826 S 651.28 0.00 0.00<br />

15340 S 134.26 0.00 0.00 15828 S 651.28 0.00 0.00<br />

15341 S 134.26 0.00 0.00 15829 S 748.83 0.00 0.00<br />

15360 S 134.26 0.00 0.00 15830 S 666.44 0.00 0.00<br />

15361 S 134.26 0.00 0.00 15832 S 666.44 0.00 0.00<br />

15365 S 134.26 0.00 0.00 15833 S 666.44 0.00 0.00<br />

15366 S 134.26 0.00 0.00 15834 S 666.44 0.00 0.00<br />

15400 S 238.78 0.00 0.00 15835 S 578.44 0.00 0.00<br />

15401 S 238.78 0.00 0.00 15836 S 550.46 0.00 0.00<br />

15420 S 238.78 0.00 0.00 15837 S 620.23 0.00 0.00<br />

15421 S 238.78 0.00 0.00 15838 S 620.23 0.00 0.00<br />

15430 S 238.78 0.00 0.00 15839 S 550.46 0.00 0.00<br />

15431 S 238.78 0.00 0.00 15840 S 707.83 0.00 0.00<br />

15570 S 651.28 0.00 0.00 15841 S 707.83 0.00 0.00<br />

15572 S 651.28 0.00 0.00 15842 S 821.86 0.00 0.00<br />

15574 S 651.28 0.00 0.00 15845 S 707.83 0.00 0.00<br />

15576 S 651.28 0.00 0.00 15847 S 666.44 0.00 0.00<br />

15600 S 651.28 0.00 0.00 15850 S 106.46 0.00 0.00<br />

15610 S 651.28 0.00 0.00 15851 S 48.46 0.00 0.00<br />

15620 S 707.83 0.00 0.00 15852 S 25.21 0.00 0.00<br />

15630 S 651.28 0.00 0.00 15860 S 25.21 0.00 0.00<br />

15650 S 748.83 0.00 0.00 15876 S 651.28 0.00 0.00<br />

15731 S 651.28 0.00 0.00 15877 S 651.28 0.00 0.00<br />

15732 S 651.28 0.00 0.00 15878 S 651.28 0.00 0.00<br />

15734 S 651.28 0.00 0.00 15879 S 651.28 0.00 0.00<br />

15736 S 651.28 0.00 0.00 15920 S 205.85 0.00 0.00<br />

15738 S 651.28 0.00 0.00 15922 S 707.83 0.00 0.00<br />

15740 S 521.81 0.00 0.00 15931 S 666.44 0.00 0.00<br />

15750 S 621.12 0.00 0.00 15933 S 666.44 0.00 0.00<br />

15760 S 621.12 0.00 0.00 15934 S 651.28 0.00 0.00<br />

15770 S 651.28 0.00 0.00 15935 S 707.83 0.00 0.00<br />

15775 S 177.95 0.00 0.00 15936 S 608.52 0.00 0.00<br />

15776 S 177.95 0.00 0.00 15937 S 707.83 0.00 0.00<br />

15780 S 396.73 0.00 0.00 15940 S 666.44 0.00 0.00<br />

15781 S 174.63 0.00 0.00 15941 S 666.44 0.00 0.00<br />

15782 S 174.63 0.00 0.00 15944 S 651.28 0.00 0.00<br />

15783 S 106.46 0.00 0.00 15945 S 707.83 0.00 0.00<br />

15786 S 32.30 0.00 0.00 15946 S 707.83 0.00 0.00<br />

15787 S 29.29 0.00 0.00 15950 S 666.44 0.00 0.00<br />

15788 S 32.30 0.00 0.00 15951 S 722.99 0.00 0.00<br />

15789 S 59.18 0.00 0.00 15952 S 551.97 0.00 0.00<br />

15792 S 59.18 0.00 0.00 15953 S 608.52 0.00 0.00<br />

15793 S 32.30 0.00 0.00 15956 S 551.97 0.00 0.00<br />

15819 S 134.26 0.00 0.00 15958 S 608.52 0.00 0.00<br />

15820 S 651.28 0.00 0.00 16000 S 26.15 0.00 0.00<br />

15821 S 651.28 0.00 0.00 16020 S 39.75 0.00 0.00<br />

15822 S 651.28 0.00 0.00 16025 S 61.21 0.00 0.00<br />

15823 S 748.83 0.00 0.00 16030 S 76.64 0.00 0.00<br />

15824 S 651.28 0.00 0.00 16035 S 59.18 0.00 0.00<br />

15825 S 651.28 0.00 0.00 17000 S 32.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.84 0.00 0.00 19300 S 716.01 0.00 0.00<br />

17004 S 84.36 0.00 0.00 19301 S 659.46 0.00 0.00<br />

17106 S 106.46 0.00 0.00 19302 S 1,259.50 0.00 0.00<br />

17107 S 106.46 0.00 0.00 19303 S 951.84 0.00 0.00<br />

17108 S 106.46 0.00 0.00 19304 S 951.84 0.00 0.00<br />

17110 S 32.30 0.00 0.00 19316 S 951.84 0.00 0.00<br />

17111 S 59.18 0.00 0.00 19318 S 1,087.48 0.00 0.00<br />

17250 S 44.63 0.00 0.00 19324 S 1,087.48 0.00 0.00<br />

17260 S 47.76 0.00 0.00 19325 S 1,803.72 0.00 0.00<br />

17261 S 59.18 0.00 0.00 19328 S 811.88 0.00 0.00<br />

17262 S 59.18 0.00 0.00 19330 S 811.88 0.00 0.00<br />

17263 S 59.18 0.00 0.00 19340 S 1,000.77 0.00 0.00<br />

17264 S 59.18 0.00 0.00 19342 S 1,413.04 0.00 0.00<br />

17266 S 106.46 0.00 0.00 19350 S 716.01 0.00 0.00<br />

17270 S 59.18 0.00 0.00 19355 S 951.84 0.00 0.00<br />

17271 S 59.18 0.00 0.00 19357 S 1,510.59 0.00 0.00<br />

17272 S 59.18 0.00 0.00 19366 S 992.84 0.00 0.00<br />

17273 S 106.46 0.00 0.00 19370 S 951.84 0.00 0.00<br />

17274 S 106.46 0.00 0.00 19371 S 951.84 0.00 0.00<br />

17276 S 106.46 0.00 0.00 19380 S 1,128.49 0.00 0.00<br />

17280 S 59.18 0.00 0.00 19396 S 1,309.88 0.00 0.00<br />

17281 S 88.20 0.00 0.00 20000 S 55.12 0.00 0.00<br />

17282 S 100.75 0.00 0.00 20005 S 635.07 0.00 0.00<br />

17283 S 106.46 0.00 0.00 20103 S 623.25 0.00 0.00<br />

17284 S 106.46 0.00 0.00 20150 S 1,769.43 0.00 0.00<br />

17286 S 106.46 0.00 0.00 20200 S 520.29 0.00 0.00<br />

17311 S 175.75 0.00 0.00 20205 S 550.46 0.00 0.00<br />

17312 S 175.75 0.00 0.00 20206 S 257.22 0.00 0.00<br />

17313 S 175.75 0.00 0.00 20220 S 279.60 0.00 0.00<br />

17314 S 175.75 0.00 0.00 20225 S 507.33 0.00 0.00<br />

17315 S 39.75 0.00 0.00 20240 S 636.27 0.00 0.00<br />

17340 S 14.30 0.00 0.00 20245 S 666.44 0.00 0.00<br />

17360 S 32.30 0.00 0.00 20250 S 665.23 0.00 0.00<br />

17380 S 32.30 0.00 0.00 20251 S 665.23 0.00 0.00<br />

19000 S 67.29 0.00 0.00 20500 S 55.09 0.00 0.00<br />

19001 S 9.07 0.00 0.00 20520 S 92.74 0.00 0.00<br />

19020 S 588.38 0.00 0.00 20525 S 666.44 0.00 0.00<br />

19100 S 200.36 0.00 0.00 20526 S 29.98 0.00 0.00<br />

19101 S 629.30 0.00 0.00 20550 S 22.66 0.00 0.00<br />

19102 S 257.22 0.00 0.00 20551 S 22.31 0.00 0.00<br />

19103 S 450.20 0.00 0.00 20552 S 21.61 0.00 0.00<br />

19105 S 1,309.88 0.00 0.00 20553 S 24.06 0.00 0.00<br />

19110 S 629.30 0.00 0.00 20555 S 1,165.81 0.00 0.00<br />

19112 S 659.46 0.00 0.00 20600 S 23.01 0.00 0.00<br />

19120 S 659.46 0.00 0.00 20605 S 25.80 0.00 0.00<br />

19125 S 659.46 0.00 0.00 20610 S 36.26 0.00 0.00<br />

19126 S 659.46 0.00 0.00 20612 S 24.41 0.00 0.00<br />

19296 S 1,803.72 0.00 0.00 20615 S 102.15 0.00 0.00<br />

19297 S 1,803.72 0.00 0.00 20650 S 665.23 0.00 0.00<br />

19298 S 1,803.72 0.00 0.00 20662 S 849.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 849.77 0.00 0.00 21085 S 255.89 0.00 0.00<br />

20665 S 25.21 0.00 0.00 21086 S 557.09 0.00 0.00<br />

20670 S 467.04 0.00 0.00 21087 S 557.80 0.00 0.00<br />

20680 S 666.44 0.00 0.00 21088 S 1,633.68 0.00 0.00<br />

20690 S 793.09 0.00 0.00 21100 S 1,027.02 0.00 0.00<br />

20692 S 823.25 0.00 0.00 21110 S 293.89 0.00 0.00<br />

20693 S 665.23 0.00 0.00 21120 S 951.82 0.00 0.00<br />

20694 S 581.82 0.00 0.00 21121 S 951.82 0.00 0.00<br />

20696 S 1,165.81 0.00 0.00 21122 S 951.82 0.00 0.00<br />

20697 S 775.31 0.00 0.00 21123 S 951.82 0.00 0.00<br />

20822 S 1,092.37 0.00 0.00 21125 S 951.82 0.00 0.00<br />

20900 S 823.25 0.00 0.00 21127 S 1,447.86 0.00 0.00<br />

20902 S 879.80 0.00 0.00 21137 S 965.83 0.00 0.00<br />

20910 S 651.28 0.00 0.00 21138 S 1,633.68 0.00 0.00<br />

20912 S 651.28 0.00 0.00 21139 S 1,633.68 0.00 0.00<br />

20920 S 608.52 0.00 0.00 21150 S 1,633.68 0.00 0.00<br />

20922 S 551.97 0.00 0.00 21181 S 951.82 0.00 0.00<br />

20924 S 879.80 0.00 0.00 21198 S 1,633.68 0.00 0.00<br />

20926 S 383.32 0.00 0.00 21199 S 1,633.68 0.00 0.00<br />

20950 S 55.12 0.00 0.00 21206 S 1,154.74 0.00 0.00<br />

20972 S 1,845.05 0.00 0.00 21208 S 1,285.75 0.00 0.00<br />

20973 S 1,845.05 0.00 0.00 21209 S 1,154.74 0.00 0.00<br />

20979 S 22.66 0.00 0.00 21210 S 1,285.75 0.00 0.00<br />

20982 S 1,769.43 0.00 0.00 21215 S 1,285.75 0.00 0.00<br />

21010 S 693.09 0.00 0.00 21230 S 1,285.75 0.00 0.00<br />

21015 S 576.65 0.00 0.00 21235 S 951.82 0.00 0.00<br />

21025 S 1,027.02 0.00 0.00 21240 S 1,113.74 0.00 0.00<br />

21026 S 1,027.02 0.00 0.00 21242 S 1,154.74 0.00 0.00<br />

21029 S 1,027.02 0.00 0.00 21243 S 1,154.74 0.00 0.00<br />

21030 S 242.29 0.00 0.00 21244 S 1,285.75 0.00 0.00<br />

21031 S 200.45 0.00 0.00 21245 S 1,285.75 0.00 0.00<br />

21032 S 204.29 0.00 0.00 21246 S 1,285.75 0.00 0.00<br />

21034 S 1,057.19 0.00 0.00 21248 S 1,285.75 0.00 0.00<br />

21040 S 693.09 0.00 0.00 21249 S 1,285.75 0.00 0.00<br />

21044 S 1,027.02 0.00 0.00 21260 S 1,633.68 0.00 0.00<br />

21046 S 1,027.02 0.00 0.00 21267 S 1,285.75 0.00 0.00<br />

21047 S 1,027.02 0.00 0.00 21270 S 1,154.74 0.00 0.00<br />

21048 S 1,633.68 0.00 0.00 21275 S 1,285.75 0.00 0.00<br />

21050 S 1,057.19 0.00 0.00 21280 S 1,154.74 0.00 0.00<br />

21060 S 1,027.02 0.00 0.00 21282 S 674.20 0.00 0.00<br />

21070 S 1,057.19 0.00 0.00 21295 S 303.88 0.00 0.00<br />

21073 S 188.26 0.00 0.00 21296 S 639.84 0.00 0.00<br />

21076 S 326.65 0.00 0.00 21310 S 92.70 0.00 0.00<br />

21077 S 789.63 0.00 0.00 21315 S 407.33 0.00 0.00<br />

21079 S 565.46 0.00 0.00 21320 S 546.49 0.00 0.00<br />

21080 S 648.43 0.00 0.00 21325 S 779.80 0.00 0.00<br />

21081 S 597.53 0.00 0.00 21330 S 820.81 0.00 0.00<br />

21082 S 568.60 0.00 0.00 21335 S 951.82 0.00 0.00<br />

21083 S 560.23 0.00 0.00 21336 S 793.24 0.00 0.00<br />

21084 S 644.60 0.00 0.00 21337 S 546.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 779.80 0.00 0.00 22310 S 168.76 0.00 0.00<br />

21339 S 820.81 0.00 0.00 22315 S 436.49 0.00 0.00<br />

21340 S 1,113.74 0.00 0.00 22505 S 513.85 0.00 0.00<br />

21345 S 951.82 0.00 0.00 22520 S 1,213.92 0.00 0.00<br />

21355 S 1,057.19 0.00 0.00 22521 S 1,213.92 0.00 0.00<br />

21356 S 723.26 0.00 0.00 22522 S 1,213.92 0.00 0.00<br />

21360 S 965.83 0.00 0.00 22523 S 3,378.47 0.00 0.00<br />

21390 S 1,633.68 0.00 0.00 22524 S 3,378.47 0.00 0.00<br />

21400 S 357.13 0.00 0.00 22525 S 3,378.47 0.00 0.00<br />

21401 S 576.65 0.00 0.00 22900 S 722.99 0.00 0.00<br />

21406 S 1,633.68 0.00 0.00 23000 S 520.29 0.00 0.00<br />

21407 S 1,633.68 0.00 0.00 23020 S 1,094.90 0.00 0.00<br />

21421 S 779.80 0.00 0.00 23030 S 535.12 0.00 0.00<br />

21440 S 328.40 0.00 0.00 23031 S 618.54 0.00 0.00<br />

21445 S 779.80 0.00 0.00 23035 S 665.23 0.00 0.00<br />

21450 S 135.54 0.00 0.00 23040 S 823.25 0.00 0.00<br />

21451 S 365.68 0.00 0.00 23044 S 879.80 0.00 0.00<br />

21452 S 546.49 0.00 0.00 23065 S 98.31 0.00 0.00<br />

21453 S 1,057.19 0.00 0.00 23066 S 636.27 0.00 0.00<br />

21454 S 820.81 0.00 0.00 23075 S 520.29 0.00 0.00<br />

21461 S 1,113.74 0.00 0.00 23076 S 636.27 0.00 0.00<br />

21462 S 1,154.74 0.00 0.00 23077 S 666.44 0.00 0.00<br />

21465 S 1,113.74 0.00 0.00 23100 S 635.07 0.00 0.00<br />

21480 S 92.70 0.00 0.00 23101 S 1,051.82 0.00 0.00<br />

21485 S 546.49 0.00 0.00 23105 S 879.80 0.00 0.00<br />

21490 S 1,057.19 0.00 0.00 23106 S 879.80 0.00 0.00<br />

21495 S 672.61 0.00 0.00 23107 S 879.80 0.00 0.00<br />

21497 S 546.49 0.00 0.00 23120 S 920.80 0.00 0.00<br />

21501 S 588.38 0.00 0.00 23125 S 920.80 0.00 0.00<br />

21502 S 635.07 0.00 0.00 23130 S 1,222.60 0.00 0.00<br />

21550 S 620.23 0.00 0.00 23140 S 721.78 0.00 0.00<br />

21555 S 636.27 0.00 0.00 23145 S 920.80 0.00 0.00<br />

21556 S 636.27 0.00 0.00 23146 S 920.80 0.00 0.00<br />

21557 S 852.18 0.00 0.00 23150 S 879.80 0.00 0.00<br />

21600 S 793.09 0.00 0.00 23155 S 920.80 0.00 0.00<br />

21610 S 793.09 0.00 0.00 23156 S 920.80 0.00 0.00<br />

21685 S 293.89 0.00 0.00 23170 S 793.09 0.00 0.00<br />

21700 S 635.07 0.00 0.00 23172 S 793.09 0.00 0.00<br />

21720 S 665.23 0.00 0.00 23174 S 793.09 0.00 0.00<br />

21725 S 69.25 0.00 0.00 23180 S 879.80 0.00 0.00<br />

21800 S 80.00 0.00 0.00 23182 S 879.80 0.00 0.00<br />

21805 S 706.53 0.00 0.00 23184 S 879.80 0.00 0.00<br />

21820 S 80.00 0.00 0.00 23190 S 879.80 0.00 0.00<br />

21920 S 142.24 0.00 0.00 23195 S 920.80 0.00 0.00<br />

21925 S 636.27 0.00 0.00 23330 S 317.99 0.00 0.00<br />

21930 S 636.27 0.00 0.00 23331 S 583.02 0.00 0.00<br />

21935 S 666.44 0.00 0.00 23395 S 1,222.60 0.00 0.00<br />

22102 S 1,896.36 0.00 0.00 23397 S 2,158.15 0.00 0.00<br />

22103 S 1,896.36 0.00 0.00 23400 S 1,051.82 0.00 0.00<br />

22305 S 80.00 0.00 0.00 23405 S 793.09 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 793.09 0.00 0.00 23931 S 588.38 0.00 0.00<br />

23410 S 1,222.60 0.00 0.00 23935 S 635.07 0.00 0.00<br />

23412 S 1,353.62 0.00 0.00 24000 S 879.80 0.00 0.00<br />

23415 S 1,222.60 0.00 0.00 24006 S 879.80 0.00 0.00<br />

23420 S 1,353.62 0.00 0.00 24065 S 136.31 0.00 0.00<br />

23430 S 1,181.61 0.00 0.00 24066 S 520.29 0.00 0.00<br />

23440 S 1,181.61 0.00 0.00 24075 S 520.29 0.00 0.00<br />

23450 S 2,027.13 0.00 0.00 24076 S 636.27 0.00 0.00<br />

23455 S 2,158.15 0.00 0.00 24077 S 666.44 0.00 0.00<br />

23460 S 2,027.13 0.00 0.00 24100 S 581.82 0.00 0.00<br />

23462 S 1,353.62 0.00 0.00 24101 S 879.80 0.00 0.00<br />

23465 S 2,027.13 0.00 0.00 24102 S 879.80 0.00 0.00<br />

23466 S 1,353.62 0.00 0.00 24105 S 665.23 0.00 0.00<br />

23480 S 1,181.61 0.00 0.00 24110 S 635.07 0.00 0.00<br />

23485 S 2,158.15 0.00 0.00 24115 S 823.25 0.00 0.00<br />

23490 S 1,125.05 0.00 0.00 24116 S 823.25 0.00 0.00<br />

23491 S 1,929.58 0.00 0.00 24120 S 665.23 0.00 0.00<br />

23500 S 80.00 0.00 0.00 24125 S 823.25 0.00 0.00<br />

23505 S 436.49 0.00 0.00 24126 S 823.25 0.00 0.00<br />

23515 S 1,460.89 0.00 0.00 24130 S 823.25 0.00 0.00<br />

23520 S 168.76 0.00 0.00 24134 S 793.09 0.00 0.00<br />

23525 S 168.76 0.00 0.00 24136 S 793.09 0.00 0.00<br />

23530 S 1,076.53 0.00 0.00 24138 S 793.09 0.00 0.00<br />

23532 S 793.24 0.00 0.00 24140 S 823.25 0.00 0.00<br />

23540 S 80.00 0.00 0.00 24145 S 823.25 0.00 0.00<br />

23545 S 168.76 0.00 0.00 24147 S 793.09 0.00 0.00<br />

23550 S 1,076.53 0.00 0.00 24149 S 1,165.81 0.00 0.00<br />

23552 S 1,133.09 0.00 0.00 24152 S 1,769.43 0.00 0.00<br />

23570 S 80.00 0.00 0.00 24153 S 3,378.47 0.00 0.00<br />

23575 S 168.76 0.00 0.00 24155 S 1,125.05 0.00 0.00<br />

23585 S 1,460.89 0.00 0.00 24160 S 793.09 0.00 0.00<br />

23600 S 62.34 0.00 0.00 24164 S 823.25 0.00 0.00<br />

23605 S 436.49 0.00 0.00 24200 S 99.70 0.00 0.00<br />

23615 S 1,517.44 0.00 0.00 24201 S 520.29 0.00 0.00<br />

23616 S 1,517.44 0.00 0.00 24300 S 607.34 0.00 0.00<br />

23620 S 62.34 0.00 0.00 24301 S 879.80 0.00 0.00<br />

23625 S 436.49 0.00 0.00 24305 S 879.80 0.00 0.00<br />

23630 S 1,558.44 0.00 0.00 24310 S 665.23 0.00 0.00<br />

23650 S 80.00 0.00 0.00 24320 S 1,125.05 0.00 0.00<br />

23655 S 460.60 0.00 0.00 24330 S 1,929.58 0.00 0.00<br />

23660 S 1,076.53 0.00 0.00 24331 S 1,125.05 0.00 0.00<br />

23665 S 168.76 0.00 0.00 24332 S 849.77 0.00 0.00<br />

23670 S 1,460.89 0.00 0.00 24340 S 1,125.05 0.00 0.00<br />

23675 S 80.00 0.00 0.00 24341 S 1,125.05 0.00 0.00<br />

23680 S 1,076.53 0.00 0.00 24342 S 1,125.05 0.00 0.00<br />

23700 S 460.60 0.00 0.00 24343 S 1,165.81 0.00 0.00<br />

23800 S 1,986.13 0.00 0.00 24344 S 3,378.47 0.00 0.00<br />

23802 S 1,353.62 0.00 0.00 24345 S 793.09 0.00 0.00<br />

23921 S 463.98 0.00 0.00 24346 S 1,769.43 0.00 0.00<br />

23930 S 535.12 0.00 0.00 24357 S 1,165.81 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,165.81 0.00 0.00 24925 S 665.23 0.00 0.00<br />

24359 S 1,165.81 0.00 0.00 25000 S 665.23 0.00 0.00<br />

24360 S 1,075.87 0.00 0.00 25001 S 849.77 0.00 0.00<br />

24361 S 5,882.36 3,600.75 1,319.14 25020 S 665.23 0.00 0.00<br />

24362 S 1,374.96 0.00 0.00 25023 S 823.25 0.00 0.00<br />

24363 S 6,013.37 3,731.76 1,450.15 25024 S 823.25 0.00 0.00<br />

24365 S 1,075.87 0.00 0.00 25025 S 823.25 0.00 0.00<br />

24366 S 5,882.36 3,600.75 1,319.14 25028 S 581.82 0.00 0.00<br />

24400 S 879.80 0.00 0.00 25031 S 635.07 0.00 0.00<br />

24410 S 879.80 0.00 0.00 25035 S 635.07 0.00 0.00<br />

24420 S 1,125.05 0.00 0.00 25040 S 920.80 0.00 0.00<br />

24430 S 1,929.58 0.00 0.00 25065 S 138.40 0.00 0.00<br />

24435 S 1,986.13 0.00 0.00 25066 S 636.27 0.00 0.00<br />

24470 S 1,125.05 0.00 0.00 25075 S 520.29 0.00 0.00<br />

24495 S 793.09 0.00 0.00 25076 S 666.44 0.00 0.00<br />

24498 S 1,929.58 0.00 0.00 25077 S 666.44 0.00 0.00<br />

24500 S 80.00 0.00 0.00 25085 S 665.23 0.00 0.00<br />

24505 S 80.00 0.00 0.00 25100 S 635.07 0.00 0.00<br />

24515 S 1,517.44 0.00 0.00 25101 S 823.25 0.00 0.00<br />

24516 S 1,517.44 0.00 0.00 25105 S 879.80 0.00 0.00<br />

24530 S 80.00 0.00 0.00 25107 S 823.25 0.00 0.00<br />

24535 S 168.76 0.00 0.00 25109 S 849.77 0.00 0.00<br />

24538 S 706.53 0.00 0.00 25110 S 665.23 0.00 0.00<br />

24545 S 1,517.44 0.00 0.00 25111 S 665.23 0.00 0.00<br />

24546 S 1,558.44 0.00 0.00 25112 S 721.78 0.00 0.00<br />

24560 S 80.00 0.00 0.00 25115 S 721.78 0.00 0.00<br />

24565 S 80.00 0.00 0.00 25116 S 721.78 0.00 0.00<br />

24566 S 706.53 0.00 0.00 25118 S 793.09 0.00 0.00<br />

24575 S 1,460.89 0.00 0.00 25119 S 823.25 0.00 0.00<br />

24576 S 80.00 0.00 0.00 25120 S 823.25 0.00 0.00<br />

24577 S 168.76 0.00 0.00 25125 S 823.25 0.00 0.00<br />

24579 S 1,460.89 0.00 0.00 25126 S 823.25 0.00 0.00<br />

24582 S 706.53 0.00 0.00 25130 S 823.25 0.00 0.00<br />

24586 S 1,517.44 0.00 0.00 25135 S 823.25 0.00 0.00<br />

24587 S 1,558.44 0.00 0.00 25136 S 823.25 0.00 0.00<br />

24600 S 80.00 0.00 0.00 25145 S 793.09 0.00 0.00<br />

24605 S 513.85 0.00 0.00 25150 S 793.09 0.00 0.00<br />

24615 S 1,460.89 0.00 0.00 25151 S 793.09 0.00 0.00<br />

24620 S 436.49 0.00 0.00 25210 S 823.25 0.00 0.00<br />

24635 S 1,460.89 0.00 0.00 25215 S 879.80 0.00 0.00<br />

24640 S 54.03 0.00 0.00 25230 S 879.80 0.00 0.00<br />

24650 S 62.34 0.00 0.00 25240 S 879.80 0.00 0.00<br />

24655 S 168.76 0.00 0.00 25248 S 635.07 0.00 0.00<br />

24665 S 1,133.09 0.00 0.00 25250 S 739.84 0.00 0.00<br />

24666 S 1,517.44 0.00 0.00 25251 S 739.84 0.00 0.00<br />

24670 S 80.00 0.00 0.00 25259 S 775.31 0.00 0.00<br />

24675 S 80.00 0.00 0.00 25260 S 879.80 0.00 0.00<br />

24685 S 1,076.53 0.00 0.00 25263 S 793.09 0.00 0.00<br />

24800 S 1,181.61 0.00 0.00 25265 S 823.25 0.00 0.00<br />

24802 S 1,222.60 0.00 0.00 25270 S 879.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 823.25 0.00 0.00 25505 S 168.76 0.00 0.00<br />

25274 S 879.80 0.00 0.00 25515 S 1,076.53 0.00 0.00<br />

25275 S 879.80 0.00 0.00 25520 S 168.76 0.00 0.00<br />

25280 S 879.80 0.00 0.00 25525 S 1,133.09 0.00 0.00<br />

25290 S 823.25 0.00 0.00 25526 S 1,174.08 0.00 0.00<br />

25295 S 665.23 0.00 0.00 25530 S 62.34 0.00 0.00<br />

25300 S 823.25 0.00 0.00 25535 S 80.00 0.00 0.00<br />

25301 S 823.25 0.00 0.00 25545 S 1,076.53 0.00 0.00<br />

25310 S 1,125.05 0.00 0.00 25560 S 62.34 0.00 0.00<br />

25312 S 1,181.61 0.00 0.00 25565 S 168.76 0.00 0.00<br />

25315 S 1,125.05 0.00 0.00 25574 S 1,460.89 0.00 0.00<br />

25316 S 1,929.58 0.00 0.00 25575 S 1,460.89 0.00 0.00<br />

25320 S 1,125.05 0.00 0.00 25600 S 62.34 0.00 0.00<br />

25332 S 1,075.87 0.00 0.00 25605 S 168.76 0.00 0.00<br />

25335 S 1,125.05 0.00 0.00 25606 S 736.69 0.00 0.00<br />

25337 S 1,222.60 0.00 0.00 25607 S 1,558.44 0.00 0.00<br />

25350 S 1,929.58 0.00 0.00 25608 S 1,558.44 0.00 0.00<br />

25355 S 1,125.05 0.00 0.00 25609 S 1,558.44 0.00 0.00<br />

25360 S 823.25 0.00 0.00 25622 S 62.34 0.00 0.00<br />

25365 S 823.25 0.00 0.00 25624 S 168.76 0.00 0.00<br />

25370 S 1,125.05 0.00 0.00 25628 S 1,076.53 0.00 0.00<br />

25375 S 1,181.61 0.00 0.00 25630 S 62.34 0.00 0.00<br />

25390 S 823.25 0.00 0.00 25635 S 168.76 0.00 0.00<br />

25391 S 1,181.61 0.00 0.00 25645 S 1,076.53 0.00 0.00<br />

25392 S 823.25 0.00 0.00 25650 S 62.34 0.00 0.00<br />

25393 S 1,181.61 0.00 0.00 25651 S 992.69 0.00 0.00<br />

25394 S 1,769.43 0.00 0.00 25652 S 1,672.36 0.00 0.00<br />

25400 S 1,125.05 0.00 0.00 25660 S 80.00 0.00 0.00<br />

25405 S 1,986.13 0.00 0.00 25670 S 736.69 0.00 0.00<br />

25415 S 1,929.58 0.00 0.00 25671 S 653.28 0.00 0.00<br />

25420 S 1,986.13 0.00 0.00 25675 S 80.00 0.00 0.00<br />

25425 S 1,125.05 0.00 0.00 25676 S 706.53 0.00 0.00<br />

25426 S 1,181.61 0.00 0.00 25680 S 80.00 0.00 0.00<br />

25430 S 1,769.43 0.00 0.00 25685 S 736.69 0.00 0.00<br />

25431 S 1,769.43 0.00 0.00 25690 S 436.49 0.00 0.00<br />

25440 S 1,986.13 0.00 0.00 25695 S 706.53 0.00 0.00<br />

25441 S 5,882.36 3,600.75 1,319.14 25800 S 1,986.13 0.00 0.00<br />

25442 S 5,882.36 3,600.75 1,319.14 25805 S 1,222.60 0.00 0.00<br />

25443 S 1,374.96 0.00 0.00 25810 S 2,027.13 0.00 0.00<br />

25444 S 1,374.96 0.00 0.00 25820 S 1,181.61 0.00 0.00<br />

25445 S 1,374.96 0.00 0.00 25825 S 2,027.13 0.00 0.00<br />

25446 S 6,013.37 3,731.76 1,450.15 25830 S 2,027.13 0.00 0.00<br />

25447 S 1,075.87 0.00 0.00 25907 S 665.23 0.00 0.00<br />

25449 S 1,075.87 0.00 0.00 25922 S 665.23 0.00 0.00<br />

25450 S 1,125.05 0.00 0.00 25929 S 551.97 0.00 0.00<br />

25455 S 1,125.05 0.00 0.00 25931 S 849.77 0.00 0.00<br />

25490 S 1,125.05 0.00 0.00 26010 S 55.12 0.00 0.00<br />

25491 S 1,125.05 0.00 0.00 26011 S 402.63 0.00 0.00<br />

25492 S 1,125.05 0.00 0.00 26020 S 534.24 0.00 0.00<br />

25500 S 62.34 0.00 0.00 26025 S 480.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 534.24 0.00 0.00 26392 S 786.53 0.00 0.00<br />

26034 S 534.24 0.00 0.00 26410 S 564.40 0.00 0.00<br />

26035 S 648.11 0.00 0.00 26412 S 786.53 0.00 0.00<br />

26040 S 843.09 0.00 0.00 26415 S 843.09 0.00 0.00<br />

26045 S 786.53 0.00 0.00 26416 S 786.53 0.00 0.00<br />

26055 S 534.24 0.00 0.00 26418 S 620.95 0.00 0.00<br />

26060 S 534.24 0.00 0.00 26420 S 843.09 0.00 0.00<br />

26070 S 534.24 0.00 0.00 26426 S 786.53 0.00 0.00<br />

26075 S 620.95 0.00 0.00 26428 S 786.53 0.00 0.00<br />

26080 S 620.95 0.00 0.00 26432 S 564.40 0.00 0.00<br />

26100 S 534.24 0.00 0.00 26433 S 564.40 0.00 0.00<br />

26105 S 480.98 0.00 0.00 26434 S 786.53 0.00 0.00<br />

26110 S 480.98 0.00 0.00 26437 S 564.40 0.00 0.00<br />

26115 S 636.27 0.00 0.00 26440 S 564.40 0.00 0.00<br />

26116 S 636.27 0.00 0.00 26442 S 786.53 0.00 0.00<br />

26117 S 666.44 0.00 0.00 26445 S 564.40 0.00 0.00<br />

26121 S 843.09 0.00 0.00 26449 S 786.53 0.00 0.00<br />

26123 S 843.09 0.00 0.00 26450 S 564.40 0.00 0.00<br />

26125 S 620.95 0.00 0.00 26455 S 564.40 0.00 0.00<br />

26130 S 564.40 0.00 0.00 26460 S 564.40 0.00 0.00<br />

26135 S 843.09 0.00 0.00 26471 S 534.24 0.00 0.00<br />

26140 S 534.24 0.00 0.00 26474 S 534.24 0.00 0.00<br />

26145 S 564.40 0.00 0.00 26476 S 480.98 0.00 0.00<br />

26160 S 564.40 0.00 0.00 26477 S 480.98 0.00 0.00<br />

26170 S 564.40 0.00 0.00 26478 S 480.98 0.00 0.00<br />

26180 S 564.40 0.00 0.00 26479 S 480.98 0.00 0.00<br />

26185 S 620.95 0.00 0.00 26480 S 786.53 0.00 0.00<br />

26200 S 534.24 0.00 0.00 26483 S 786.53 0.00 0.00<br />

26205 S 786.53 0.00 0.00 26485 S 756.37 0.00 0.00<br />

26210 S 534.24 0.00 0.00 26489 S 786.53 0.00 0.00<br />

26215 S 564.40 0.00 0.00 26490 S 786.53 0.00 0.00<br />

26230 S 791.99 0.00 0.00 26492 S 786.53 0.00 0.00<br />

26235 S 564.40 0.00 0.00 26494 S 786.53 0.00 0.00<br />

26236 S 564.40 0.00 0.00 26496 S 786.53 0.00 0.00<br />

26250 S 564.40 0.00 0.00 26497 S 786.53 0.00 0.00<br />

26255 S 786.53 0.00 0.00 26498 S 843.09 0.00 0.00<br />

26260 S 564.40 0.00 0.00 26499 S 786.53 0.00 0.00<br />

26261 S 564.40 0.00 0.00 26500 S 620.95 0.00 0.00<br />

26262 S 534.24 0.00 0.00 26502 S 843.09 0.00 0.00<br />

26320 S 520.29 0.00 0.00 26508 S 564.40 0.00 0.00<br />

26340 S 239.85 0.00 0.00 26510 S 786.53 0.00 0.00<br />

26350 S 703.11 0.00 0.00 26516 S 703.11 0.00 0.00<br />

26352 S 843.09 0.00 0.00 26517 S 786.53 0.00 0.00<br />

26356 S 843.09 0.00 0.00 26518 S 786.53 0.00 0.00<br />

26357 S 843.09 0.00 0.00 26520 S 564.40 0.00 0.00<br />

26358 S 843.09 0.00 0.00 26525 S 564.40 0.00 0.00<br />

26370 S 843.09 0.00 0.00 26530 S 978.32 0.00 0.00<br />

26372 S 843.09 0.00 0.00 26531 S 1,505.97 0.00 0.00<br />

26373 S 786.53 0.00 0.00 26535 S 1,075.87 0.00 0.00<br />

26390 S 843.09 0.00 0.00 26536 S 1,374.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 620.95 0.00 0.00 26775 S 166.64 0.00 0.00<br />

26541 S 1,015.09 0.00 0.00 26776 S 706.53 0.00 0.00<br />

26542 S 620.95 0.00 0.00 26785 S 706.53 0.00 0.00<br />

26545 S 843.09 0.00 0.00 26820 S 884.08 0.00 0.00<br />

26546 S 843.09 0.00 0.00 26841 S 843.09 0.00 0.00<br />

26548 S 843.09 0.00 0.00 26842 S 843.09 0.00 0.00<br />

26550 S 756.37 0.00 0.00 26843 S 786.53 0.00 0.00<br />

26555 S 786.53 0.00 0.00 26844 S 786.53 0.00 0.00<br />

26560 S 534.24 0.00 0.00 26850 S 843.09 0.00 0.00<br />

26561 S 786.53 0.00 0.00 26852 S 843.09 0.00 0.00<br />

26562 S 843.09 0.00 0.00 26860 S 786.53 0.00 0.00<br />

26565 S 884.08 0.00 0.00 26861 S 756.37 0.00 0.00<br />

26567 S 884.08 0.00 0.00 26862 S 843.09 0.00 0.00<br />

26568 S 786.53 0.00 0.00 26863 S 786.53 0.00 0.00<br />

26580 S 661.95 0.00 0.00 26910 S 786.53 0.00 0.00<br />

26587 S 661.95 0.00 0.00 26951 S 534.24 0.00 0.00<br />

26590 S 661.95 0.00 0.00 26952 S 620.95 0.00 0.00<br />

26591 S 786.53 0.00 0.00 26990 S 581.82 0.00 0.00<br />

26593 S 564.40 0.00 0.00 26991 S 581.82 0.00 0.00<br />

26596 S 534.24 0.00 0.00 27000 S 635.07 0.00 0.00<br />

26600 S 62.34 0.00 0.00 27001 S 823.25 0.00 0.00<br />

26605 S 80.00 0.00 0.00 27003 S 823.25 0.00 0.00<br />

26607 S 436.49 0.00 0.00 27033 S 1,125.05 0.00 0.00<br />

26608 S 793.24 0.00 0.00 27035 S 1,181.61 0.00 0.00<br />

26615 S 1,133.09 0.00 0.00 27040 S 317.99 0.00 0.00<br />

26641 S 62.34 0.00 0.00 27041 S 358.28 0.00 0.00<br />

26645 S 168.76 0.00 0.00 27047 S 636.27 0.00 0.00<br />

26650 S 706.53 0.00 0.00 27048 S 666.44 0.00 0.00<br />

26665 S 1,133.09 0.00 0.00 27049 S 666.44 0.00 0.00<br />

26670 S 62.34 0.00 0.00 27050 S 665.23 0.00 0.00<br />

26675 S 168.76 0.00 0.00 27052 S 665.23 0.00 0.00<br />

26676 S 706.53 0.00 0.00 27060 S 762.78 0.00 0.00<br />

26685 S 736.69 0.00 0.00 27062 S 762.78 0.00 0.00<br />

26686 S 1,460.89 0.00 0.00 27065 S 762.78 0.00 0.00<br />

26700 S 62.34 0.00 0.00 27066 S 920.80 0.00 0.00<br />

26705 S 80.00 0.00 0.00 27067 S 920.80 0.00 0.00<br />

26706 S 436.49 0.00 0.00 27080 S 793.09 0.00 0.00<br />

26715 S 793.24 0.00 0.00 27086 S 317.99 0.00 0.00<br />

26720 S 62.34 0.00 0.00 27087 S 665.23 0.00 0.00<br />

26725 S 62.34 0.00 0.00 27097 S 823.25 0.00 0.00<br />

26727 S 965.26 0.00 0.00 27098 S 823.25 0.00 0.00<br />

26735 S 793.24 0.00 0.00 27100 S 1,181.61 0.00 0.00<br />

26740 S 62.34 0.00 0.00 27105 S 1,181.61 0.00 0.00<br />

26742 S 80.00 0.00 0.00 27110 S 1,181.61 0.00 0.00<br />

26746 S 834.24 0.00 0.00 27111 S 1,181.61 0.00 0.00<br />

26750 S 62.34 0.00 0.00 27193 S 80.00 0.00 0.00<br />

26755 S 62.34 0.00 0.00 27194 S 513.85 0.00 0.00<br />

26756 S 706.53 0.00 0.00 27200 S 62.34 0.00 0.00<br />

26765 S 793.24 0.00 0.00 27202 S 1,046.37 0.00 0.00<br />

26770 S 62.34 0.00 0.00 27220 S 62.34 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 80.00 0.00 0.00 27397 S 1,125.05 0.00 0.00<br />

27238 S 168.76 0.00 0.00 27400 S 1,125.05 0.00 0.00<br />

27246 S 168.76 0.00 0.00 27403 S 879.80 0.00 0.00<br />

27250 S 80.00 0.00 0.00 27405 S 1,181.61 0.00 0.00<br />

27252 S 513.85 0.00 0.00 27407 S 1,986.13 0.00 0.00<br />

27256 S 62.34 0.00 0.00 27409 S 1,181.61 0.00 0.00<br />

27257 S 544.02 0.00 0.00 27416 S 1,769.43 0.00 0.00<br />

27265 S 80.00 0.00 0.00 27418 S 1,125.05 0.00 0.00<br />

27266 S 513.85 0.00 0.00 27420 S 1,125.05 0.00 0.00<br />

27267 S 62.34 0.00 0.00 27422 S 1,353.62 0.00 0.00<br />

27275 S 513.85 0.00 0.00 27424 S 1,125.05 0.00 0.00<br />

27301 S 618.54 0.00 0.00 27425 S 1,051.82 0.00 0.00<br />

27305 S 635.07 0.00 0.00 27427 S 1,125.05 0.00 0.00<br />

27306 S 665.23 0.00 0.00 27428 S 1,986.13 0.00 0.00<br />

27307 S 665.23 0.00 0.00 27429 S 1,986.13 0.00 0.00<br />

27310 S 879.80 0.00 0.00 27430 S 1,181.61 0.00 0.00<br />

27323 S 317.99 0.00 0.00 27435 S 1,181.61 0.00 0.00<br />

27324 S 583.02 0.00 0.00 27437 S 1,034.87 0.00 0.00<br />

27325 S 571.28 0.00 0.00 27438 S 1,374.96 0.00 0.00<br />

27326 S 571.28 0.00 0.00 27440 S 1,475.95 0.00 0.00<br />

27327 S 636.27 0.00 0.00 27441 S 1,075.87 0.00 0.00<br />

27328 S 666.44 0.00 0.00 27442 S 1,075.87 0.00 0.00<br />

27329 S 722.99 0.00 0.00 27443 S 1,075.87 0.00 0.00<br />

27330 S 879.80 0.00 0.00 27446 S 10,556.40 6,341.80 2,127.21<br />

27331 S 879.80 0.00 0.00 27496 S 762.78 0.00 0.00<br />

27332 S 879.80 0.00 0.00 27497 S 665.23 0.00 0.00<br />

27333 S 879.80 0.00 0.00 27498 S 665.23 0.00 0.00<br />

27334 S 879.80 0.00 0.00 27499 S 665.23 0.00 0.00<br />

27335 S 879.80 0.00 0.00 27500 S 168.76 0.00 0.00<br />

27340 S 665.23 0.00 0.00 27501 S 80.00 0.00 0.00<br />

27345 S 721.78 0.00 0.00 27502 S 436.49 0.00 0.00<br />

27347 S 721.78 0.00 0.00 27503 S 80.00 0.00 0.00<br />

27350 S 879.80 0.00 0.00 27508 S 80.00 0.00 0.00<br />

27355 S 823.25 0.00 0.00 27509 S 736.69 0.00 0.00<br />

27356 S 879.80 0.00 0.00 27510 S 168.76 0.00 0.00<br />

27357 S 920.80 0.00 0.00 27516 S 80.00 0.00 0.00<br />

27358 S 920.80 0.00 0.00 27517 S 80.00 0.00 0.00<br />

27360 S 920.80 0.00 0.00 27520 S 80.00 0.00 0.00<br />

27372 S 895.00 0.00 0.00 27530 S 80.00 0.00 0.00<br />

27380 S 581.82 0.00 0.00 27532 S 436.49 0.00 0.00<br />

27381 S 665.23 0.00 0.00 27538 S 80.00 0.00 0.00<br />

27385 S 665.23 0.00 0.00 27550 S 80.00 0.00 0.00<br />

27386 S 665.23 0.00 0.00 27552 S 460.60 0.00 0.00<br />

27390 S 581.82 0.00 0.00 27560 S 80.00 0.00 0.00<br />

27391 S 635.07 0.00 0.00 27562 S 460.60 0.00 0.00<br />

27392 S 665.23 0.00 0.00 27566 S 1,046.37 0.00 0.00<br />

27393 S 793.09 0.00 0.00 27570 S 460.60 0.00 0.00<br />

27394 S 823.25 0.00 0.00 27594 S 665.23 0.00 0.00<br />

27395 S 1,125.05 0.00 0.00 27600 S 665.23 0.00 0.00<br />

27396 S 823.25 0.00 0.00 27601 S 665.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 665.23 0.00 0.00 27730 S 793.09 0.00 0.00<br />

27603 S 588.38 0.00 0.00 27732 S 793.09 0.00 0.00<br />

27604 S 635.07 0.00 0.00 27734 S 793.09 0.00 0.00<br />

27605 S 578.69 0.00 0.00 27740 S 793.09 0.00 0.00<br />

27606 S 581.82 0.00 0.00 27742 S 1,094.90 0.00 0.00<br />

27607 S 635.07 0.00 0.00 27745 S 1,929.58 0.00 0.00<br />

27610 S 793.09 0.00 0.00 27750 S 80.00 0.00 0.00<br />

27612 S 823.25 0.00 0.00 27752 S 436.49 0.00 0.00<br />

27613 S 130.73 0.00 0.00 27756 S 736.69 0.00 0.00<br />

27614 S 636.27 0.00 0.00 27758 S 1,133.09 0.00 0.00<br />

27615 S 823.25 0.00 0.00 27759 S 1,517.44 0.00 0.00<br />

27618 S 520.29 0.00 0.00 27760 S 80.00 0.00 0.00<br />

27619 S 666.44 0.00 0.00 27762 S 436.49 0.00 0.00<br />

27620 S 879.80 0.00 0.00 27766 S 1,076.53 0.00 0.00<br />

27625 S 879.80 0.00 0.00 27767 S 62.34 0.00 0.00<br />

27626 S 879.80 0.00 0.00 27768 S 62.34 0.00 0.00<br />

27630 S 665.23 0.00 0.00 27769 S 1,672.36 0.00 0.00<br />

27635 S 823.25 0.00 0.00 27780 S 80.00 0.00 0.00<br />

27637 S 823.25 0.00 0.00 27781 S 436.49 0.00 0.00<br />

27638 S 823.25 0.00 0.00 27784 S 1,076.53 0.00 0.00<br />

27640 S 1,094.90 0.00 0.00 27786 S 80.00 0.00 0.00<br />

27641 S 793.09 0.00 0.00 27788 S 80.00 0.00 0.00<br />

27647 S 1,125.05 0.00 0.00 27792 S 1,076.53 0.00 0.00<br />

27650 S 1,125.05 0.00 0.00 27808 S 80.00 0.00 0.00<br />

27652 S 1,929.58 0.00 0.00 27810 S 168.76 0.00 0.00<br />

27654 S 1,125.05 0.00 0.00 27814 S 1,076.53 0.00 0.00<br />

27656 S 635.07 0.00 0.00 27816 S 80.00 0.00 0.00<br />

27658 S 581.82 0.00 0.00 27818 S 168.76 0.00 0.00<br />

27659 S 635.07 0.00 0.00 27822 S 1,076.53 0.00 0.00<br />

27664 S 635.07 0.00 0.00 27823 S 1,460.89 0.00 0.00<br />

27665 S 793.09 0.00 0.00 27824 S 80.00 0.00 0.00<br />

27675 S 635.07 0.00 0.00 27825 S 436.49 0.00 0.00<br />

27676 S 823.25 0.00 0.00 27826 S 1,076.53 0.00 0.00<br />

27680 S 823.25 0.00 0.00 27827 S 1,460.89 0.00 0.00<br />

27681 S 793.09 0.00 0.00 27828 S 1,517.44 0.00 0.00<br />

27685 S 823.25 0.00 0.00 27829 S 1,046.37 0.00 0.00<br />

27686 S 823.25 0.00 0.00 27830 S 80.00 0.00 0.00<br />

27687 S 823.25 0.00 0.00 27831 S 436.49 0.00 0.00<br />

27690 S 1,181.61 0.00 0.00 27832 S 1,046.37 0.00 0.00<br />

27691 S 1,181.61 0.00 0.00 27840 S 168.76 0.00 0.00<br />

27692 S 1,125.05 0.00 0.00 27842 S 460.60 0.00 0.00<br />

27695 S 793.09 0.00 0.00 27846 S 1,076.53 0.00 0.00<br />

27696 S 793.09 0.00 0.00 27848 S 1,076.53 0.00 0.00<br />

27698 S 793.09 0.00 0.00 27860 S 460.60 0.00 0.00<br />

27700 S 1,075.87 0.00 0.00 27870 S 1,986.13 0.00 0.00<br />

27704 S 635.07 0.00 0.00 27871 S 1,986.13 0.00 0.00<br />

27705 S 1,094.90 0.00 0.00 27884 S 665.23 0.00 0.00<br />

27707 S 635.07 0.00 0.00 27889 S 823.25 0.00 0.00<br />

27709 S 793.09 0.00 0.00 27892 S 665.23 0.00 0.00<br />

27726 S 992.69 0.00 0.00 27893 S 665.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 665.23 0.00 0.00 28153 S 662.11 0.00 0.00<br />

28001 S 127.59 0.00 0.00 28160 S 662.11 0.00 0.00<br />

28002 S 665.23 0.00 0.00 28171 S 662.11 0.00 0.00<br />

28003 S 665.23 0.00 0.00 28173 S 662.11 0.00 0.00<br />

28005 S 662.11 0.00 0.00 28175 S 662.11 0.00 0.00<br />

28008 S 662.11 0.00 0.00 28190 S 131.78 0.00 0.00<br />

28010 S 93.78 0.00 0.00 28192 S 520.29 0.00 0.00<br />

28011 S 662.11 0.00 0.00 28193 S 358.28 0.00 0.00<br />

28020 S 631.94 0.00 0.00 28200 S 662.11 0.00 0.00<br />

28022 S 631.94 0.00 0.00 28202 S 662.11 0.00 0.00<br />

28024 S 631.94 0.00 0.00 28208 S 662.11 0.00 0.00<br />

28035 S 657.99 0.00 0.00 28210 S 1,162.87 0.00 0.00<br />

28043 S 636.27 0.00 0.00 28220 S 203.25 0.00 0.00<br />

28045 S 662.11 0.00 0.00 28222 S 578.69 0.00 0.00<br />

28046 S 662.11 0.00 0.00 28225 S 578.69 0.00 0.00<br />

28050 S 631.94 0.00 0.00 28226 S 578.69 0.00 0.00<br />

28052 S 631.94 0.00 0.00 28230 S 199.41 0.00 0.00<br />

28054 S 631.94 0.00 0.00 28232 S 190.69 0.00 0.00<br />

28055 S 657.99 0.00 0.00 28234 S 631.94 0.00 0.00<br />

28060 S 631.94 0.00 0.00 28238 S 1,162.87 0.00 0.00<br />

28062 S 662.11 0.00 0.00 28240 S 631.94 0.00 0.00<br />

28070 S 662.11 0.00 0.00 28250 S 662.11 0.00 0.00<br />

28072 S 662.11 0.00 0.00 28260 S 662.11 0.00 0.00<br />

28080 S 662.11 0.00 0.00 28261 S 662.11 0.00 0.00<br />

28086 S 631.94 0.00 0.00 28262 S 718.66 0.00 0.00<br />

28088 S 631.94 0.00 0.00 28264 S 1,079.45 0.00 0.00<br />

28090 S 662.11 0.00 0.00 28270 S 662.11 0.00 0.00<br />

28092 S 662.11 0.00 0.00 28272 S 184.07 0.00 0.00<br />

28100 S 631.94 0.00 0.00 28280 S 631.94 0.00 0.00<br />

28102 S 1,162.87 0.00 0.00 28285 S 662.11 0.00 0.00<br />

28103 S 1,162.87 0.00 0.00 28286 S 718.66 0.00 0.00<br />

28104 S 631.94 0.00 0.00 28288 S 662.11 0.00 0.00<br />

28106 S 1,162.87 0.00 0.00 28289 S 662.11 0.00 0.00<br />

28107 S 1,162.87 0.00 0.00 28290 S 816.14 0.00 0.00<br />

28108 S 631.94 0.00 0.00 28292 S 816.14 0.00 0.00<br />

28110 S 662.11 0.00 0.00 28293 S 846.30 0.00 0.00<br />

28111 S 662.11 0.00 0.00 28294 S 846.30 0.00 0.00<br />

28112 S 662.11 0.00 0.00 28296 S 846.30 0.00 0.00<br />

28113 S 662.11 0.00 0.00 28297 S 846.30 0.00 0.00<br />

28114 S 662.11 0.00 0.00 28298 S 846.30 0.00 0.00<br />

28116 S 662.11 0.00 0.00 28299 S 943.85 0.00 0.00<br />

28118 S 718.66 0.00 0.00 28300 S 1,132.71 0.00 0.00<br />

28119 S 718.66 0.00 0.00 28302 S 631.94 0.00 0.00<br />

28120 S 890.67 0.00 0.00 28304 S 1,132.71 0.00 0.00<br />

28122 S 662.11 0.00 0.00 28305 S 1,162.87 0.00 0.00<br />

28124 S 215.79 0.00 0.00 28306 S 718.66 0.00 0.00<br />

28126 S 662.11 0.00 0.00 28307 S 718.66 0.00 0.00<br />

28130 S 662.11 0.00 0.00 28308 S 631.94 0.00 0.00<br />

28140 S 662.11 0.00 0.00 28309 S 1,219.42 0.00 0.00<br />

28150 S 662.11 0.00 0.00 28310 S 662.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 662.11 0.00 0.00 28636 S 736.69 0.00 0.00<br />

28313 S 631.94 0.00 0.00 28645 S 736.69 0.00 0.00<br />

28315 S 718.66 0.00 0.00 28660 S 44.63 0.00 0.00<br />

28320 S 1,219.42 0.00 0.00 28665 S 460.60 0.00 0.00<br />

28322 S 1,219.42 0.00 0.00 28666 S 736.69 0.00 0.00<br />

28340 S 718.66 0.00 0.00 28675 S 736.69 0.00 0.00<br />

28341 S 718.66 0.00 0.00 28705 S 1,219.42 0.00 0.00<br />

28344 S 718.66 0.00 0.00 28715 S 1,986.13 0.00 0.00<br />

28345 S 718.66 0.00 0.00 28725 S 1,219.42 0.00 0.00<br />

28400 S 80.00 0.00 0.00 28730 S 1,219.42 0.00 0.00<br />

28405 S 436.49 0.00 0.00 28735 S 1,219.42 0.00 0.00<br />

28406 S 706.53 0.00 0.00 28737 S 1,260.42 0.00 0.00<br />

28415 S 1,460.89 0.00 0.00 28740 S 1,219.42 0.00 0.00<br />

28420 S 1,133.09 0.00 0.00 28750 S 1,219.42 0.00 0.00<br />

28430 S 62.34 0.00 0.00 28755 S 718.66 0.00 0.00<br />

28435 S 80.00 0.00 0.00 28760 S 1,219.42 0.00 0.00<br />

28436 S 706.53 0.00 0.00 28810 S 631.94 0.00 0.00<br />

28445 S 1,076.53 0.00 0.00 28820 S 631.94 0.00 0.00<br />

28446 S 1,845.05 0.00 0.00 28825 S 631.94 0.00 0.00<br />

28450 S 62.34 0.00 0.00 28890 S 166.99 0.00 0.00<br />

28455 S 62.34 0.00 0.00 29000 S 42.31 0.00 0.00<br />

28456 S 706.53 0.00 0.00 29010 S 94.82 0.00 0.00<br />

28465 S 1,076.53 0.00 0.00 29015 S 94.82 0.00 0.00<br />

28470 S 62.34 0.00 0.00 29020 S 42.31 0.00 0.00<br />

28475 S 62.34 0.00 0.00 29025 S 42.31 0.00 0.00<br />

28476 S 706.53 0.00 0.00 29035 S 94.82 0.00 0.00<br />

28485 S 1,133.09 0.00 0.00 29040 S 42.31 0.00 0.00<br />

28490 S 62.34 0.00 0.00 29044 S 94.82 0.00 0.00<br />

28495 S 62.34 0.00 0.00 29046 S 94.82 0.00 0.00<br />

28496 S 706.53 0.00 0.00 29049 S 38.35 0.00 0.00<br />

28505 S 736.69 0.00 0.00 29055 S 94.82 0.00 0.00<br />

28510 S 56.13 0.00 0.00 29058 S 42.31 0.00 0.00<br />

28515 S 62.34 0.00 0.00 29065 S 44.98 0.00 0.00<br />

28525 S 736.69 0.00 0.00 29075 S 43.23 0.00 0.00<br />

28530 S 54.03 0.00 0.00 29085 S 42.31 0.00 0.00<br />

28531 S 736.69 0.00 0.00 29086 S 36.26 0.00 0.00<br />

28540 S 62.34 0.00 0.00 29105 S 39.04 0.00 0.00<br />

28545 S 653.28 0.00 0.00 29125 S 33.81 0.00 0.00<br />

28546 S 706.53 0.00 0.00 29126 S 35.91 0.00 0.00<br />

28555 S 1,046.37 0.00 0.00 29130 S 15.34 0.00 0.00<br />

28570 S 80.88 0.00 0.00 29131 S 22.31 0.00 0.00<br />

28575 S 436.49 0.00 0.00 29200 S 21.61 0.00 0.00<br />

28576 S 736.69 0.00 0.00 29220 S 23.35 0.00 0.00<br />

28585 S 736.69 0.00 0.00 29240 S 24.41 0.00 0.00<br />

28600 S 62.34 0.00 0.00 29260 S 23.35 0.00 0.00<br />

28605 S 80.00 0.00 0.00 29280 S 23.71 0.00 0.00<br />

28606 S 706.53 0.00 0.00 29305 S 94.82 0.00 0.00<br />

28615 S 1,076.53 0.00 0.00 29325 S 94.82 0.00 0.00<br />

28630 S 62.34 0.00 0.00 29345 S 58.91 0.00 0.00<br />

28635 S 460.60 0.00 0.00 29355 S 57.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 71.82 0.00 0.00 29847 S 1,200.39 0.00 0.00<br />

29365 S 55.78 0.00 0.00 29848 S 1,204.82 0.00 0.00<br />

29405 S 41.49 0.00 0.00 29850 S 870.69 0.00 0.00<br />

29425 S 42.18 0.00 0.00 29851 S 1,256.95 0.00 0.00<br />

29435 S 53.34 0.00 0.00 29855 S 1,256.95 0.00 0.00<br />

29440 S 22.66 0.00 0.00 29856 S 1,256.95 0.00 0.00<br />

29445 S 56.13 0.00 0.00 29860 S 1,256.95 0.00 0.00<br />

29450 S 42.31 0.00 0.00 29861 S 1,256.95 0.00 0.00<br />

29505 S 37.65 0.00 0.00 29862 S 1,591.07 0.00 0.00<br />

29515 S 32.07 0.00 0.00 29863 S 1,256.95 0.00 0.00<br />

29520 S 23.01 0.00 0.00 29866 S 1,920.09 0.00 0.00<br />

29530 S 23.35 0.00 0.00 29870 S 814.15 0.00 0.00<br />

29540 S 17.43 0.00 0.00 29871 S 814.15 0.00 0.00<br />

29550 S 17.78 0.00 0.00 29873 S 814.15 0.00 0.00<br />

29580 S 24.06 0.00 0.00 29874 S 814.15 0.00 0.00<br />

29590 S 19.53 0.00 0.00 29875 S 870.69 0.00 0.00<br />

29700 S 32.42 0.00 0.00 29876 S 870.69 0.00 0.00<br />

29705 S 27.54 0.00 0.00 29877 S 870.69 0.00 0.00<br />

29710 S 48.46 0.00 0.00 29879 S 814.15 0.00 0.00<br />

29715 S 42.31 0.00 0.00 29880 S 870.69 0.00 0.00<br />

29720 S 40.44 0.00 0.00 29881 S 870.69 0.00 0.00<br />

29730 S 26.49 0.00 0.00 29882 S 814.15 0.00 0.00<br />

29740 S 36.26 0.00 0.00 29883 S 814.15 0.00 0.00<br />

29750 S 38.00 0.00 0.00 29884 S 814.15 0.00 0.00<br />

29800 S 814.15 0.00 0.00 29885 S 1,200.39 0.00 0.00<br />

29804 S 814.15 0.00 0.00 29886 S 814.15 0.00 0.00<br />

29805 S 814.15 0.00 0.00 29887 S 814.15 0.00 0.00<br />

29806 S 1,200.39 0.00 0.00 29888 S 1,200.39 0.00 0.00<br />

29807 S 1,200.39 0.00 0.00 29889 S 1,200.39 0.00 0.00<br />

29819 S 1,200.39 0.00 0.00 29891 S 1,200.39 0.00 0.00<br />

29820 S 1,200.39 0.00 0.00 29892 S 1,200.39 0.00 0.00<br />

29821 S 1,200.39 0.00 0.00 29893 S 1,013.46 0.00 0.00<br />

29822 S 814.15 0.00 0.00 29894 S 814.15 0.00 0.00<br />

29823 S 1,200.39 0.00 0.00 29895 S 814.15 0.00 0.00<br />

29824 S 911.70 0.00 0.00 29897 S 814.15 0.00 0.00<br />

29825 S 1,200.39 0.00 0.00 29898 S 814.15 0.00 0.00<br />

29826 S 1,200.39 0.00 0.00 29899 S 1,200.39 0.00 0.00<br />

29827 S 1,297.94 0.00 0.00 29900 S 814.15 0.00 0.00<br />

29828 S 1,920.09 0.00 0.00 29901 S 814.15 0.00 0.00<br />

29830 S 814.15 0.00 0.00 29902 S 814.15 0.00 0.00<br />

29834 S 814.15 0.00 0.00 29904 S 1,147.60 0.00 0.00<br />

29835 S 814.15 0.00 0.00 29905 S 1,147.60 0.00 0.00<br />

29836 S 814.15 0.00 0.00 29906 S 1,147.60 0.00 0.00<br />

29837 S 814.15 0.00 0.00 29907 S 1,920.09 0.00 0.00<br />

29838 S 814.15 0.00 0.00 30000 S 129.02 0.00 0.00<br />

29840 S 814.15 0.00 0.00 30020 S 129.02 0.00 0.00<br />

29843 S 814.15 0.00 0.00 30100 S 83.67 0.00 0.00<br />

29844 S 814.15 0.00 0.00 30110 S 129.34 0.00 0.00<br />

29845 S 814.15 0.00 0.00 30115 S 546.49 0.00 0.00<br />

29846 S 814.15 0.00 0.00 30117 S 576.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 723.26 0.00 0.00 31080 S 1,113.74 0.00 0.00<br />

30120 S 493.24 0.00 0.00 31081 S 1,113.74 0.00 0.00<br />

30124 S 293.89 0.00 0.00 31084 S 1,113.74 0.00 0.00<br />

30125 S 1,027.02 0.00 0.00 31085 S 1,113.74 0.00 0.00<br />

30130 S 576.65 0.00 0.00 31086 S 1,113.74 0.00 0.00<br />

30140 S 693.09 0.00 0.00 31087 S 1,113.74 0.00 0.00<br />

30150 S 1,057.19 0.00 0.00 31090 S 1,154.74 0.00 0.00<br />

30160 S 1,113.74 0.00 0.00 31200 S 1,027.02 0.00 0.00<br />

30200 S 65.89 0.00 0.00 31201 S 1,154.74 0.00 0.00<br />

30210 S 83.67 0.00 0.00 31205 S 1,057.19 0.00 0.00<br />

30220 S 365.68 0.00 0.00 31231 S 70.53 0.00 0.00<br />

30300 S 25.21 0.00 0.00 31233 S 75.97 0.00 0.00<br />

30310 S 493.24 0.00 0.00 31235 S 516.17 0.00 0.00<br />

30320 S 546.49 0.00 0.00 31237 S 569.42 0.00 0.00<br />

30400 S 1,113.74 0.00 0.00 31238 S 516.17 0.00 0.00<br />

30410 S 1,154.74 0.00 0.00 31239 S 753.46 0.00 0.00<br />

30420 S 1,154.74 0.00 0.00 31240 S 569.42 0.00 0.00<br />

30430 S 723.26 0.00 0.00 31254 S 696.90 0.00 0.00<br />

30435 S 1,154.74 0.00 0.00 31255 S 794.45 0.00 0.00<br />

30450 S 1,285.75 0.00 0.00 31256 S 696.90 0.00 0.00<br />

30460 S 1,285.75 0.00 0.00 31267 S 696.90 0.00 0.00<br />

30462 S 1,447.86 0.00 0.00 31276 S 696.90 0.00 0.00<br />

30465 S 1,447.86 0.00 0.00 31287 S 696.90 0.00 0.00<br />

30520 S 779.80 0.00 0.00 31288 S 696.90 0.00 0.00<br />

30540 S 1,154.74 0.00 0.00 31300 S 820.81 0.00 0.00<br />

30545 S 1,154.74 0.00 0.00 31320 S 1,027.02 0.00 0.00<br />

30560 S 135.54 0.00 0.00 31400 S 1,027.02 0.00 0.00<br />

30580 S 1,113.74 0.00 0.00 31420 S 1,027.02 0.00 0.00<br />

30600 S 1,113.74 0.00 0.00 31500 S 94.34 0.00 0.00<br />

30620 S 1,285.75 0.00 0.00 31502 S 54.25 0.00 0.00<br />

30630 S 951.82 0.00 0.00 31505 S 32.05 0.00 0.00<br />

30801 S 303.88 0.00 0.00 31510 S 569.42 0.00 0.00<br />

30802 S 303.88 0.00 0.00 31511 S 75.97 0.00 0.00<br />

30901 S 43.34 0.00 0.00 31512 S 569.42 0.00 0.00<br />

30903 S 55.83 0.00 0.00 31513 S 75.97 0.00 0.00<br />

30905 S 55.83 0.00 0.00 31515 S 516.17 0.00 0.00<br />

30906 S 55.83 0.00 0.00 31520 S 70.53 0.00 0.00<br />

30915 S 743.92 0.00 0.00 31525 S 516.17 0.00 0.00<br />

30920 S 774.09 0.00 0.00 31526 S 666.74 0.00 0.00<br />

30930 S 633.20 0.00 0.00 31527 S 613.48 0.00 0.00<br />

31000 S 107.73 0.00 0.00 31528 S 569.42 0.00 0.00<br />

31002 S 293.89 0.00 0.00 31529 S 569.42 0.00 0.00<br />

31020 S 693.09 0.00 0.00 31530 S 666.74 0.00 0.00<br />

31030 S 1,057.19 0.00 0.00 31531 S 696.90 0.00 0.00<br />

31032 S 1,113.74 0.00 0.00 31535 S 666.74 0.00 0.00<br />

31040 S 965.83 0.00 0.00 31536 S 696.90 0.00 0.00<br />

31050 S 1,027.02 0.00 0.00 31540 S 696.90 0.00 0.00<br />

31051 S 1,113.74 0.00 0.00 31541 S 753.46 0.00 0.00<br />

31070 S 693.09 0.00 0.00 31545 S 753.46 0.00 0.00<br />

31075 S 1,113.74 0.00 0.00 31546 S 753.46 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 794.45 0.00 0.00 32405 S 343.78 0.00 0.00<br />

31561 S 794.45 0.00 0.00 32420 S 209.05 0.00 0.00<br />

31570 S 569.42 0.00 0.00 32421 S 209.05 0.00 0.00<br />

31571 S 666.74 0.00 0.00 32422 S 208.12 0.00 0.00<br />

31575 S 60.66 0.00 0.00 32550 S 1,165.24 0.00 0.00<br />

31576 S 666.74 0.00 0.00 32960 S 208.12 0.00 0.00<br />

31577 S 196.95 0.00 0.00 32998 S 1,814.21 0.00 0.00<br />

31578 S 666.74 0.00 0.00 33010 S 209.05 0.00 0.00<br />

31579 S 108.08 0.00 0.00 33011 S 209.05 0.00 0.00<br />

31580 S 1,154.74 0.00 0.00 33206 S 6,707.01 3,990.65 1,274.30<br />

31582 S 1,154.74 0.00 0.00 33207 S 6,707.01 3,990.65 1,274.30<br />

31588 S 1,154.74 0.00 0.00 33208 S 8,318.59 4,847.20 1,375.82<br />

31590 S 1,154.74 0.00 0.00 33210 S 1,969.53 0.00 0.00<br />

31595 S 1,027.02 0.00 0.00 33211 S 1,969.53 0.00 0.00<br />

31603 S 303.88 0.00 0.00 33212 S 5,267.39 3,000.61 733.82<br />

31605 S 293.89 0.00 0.00 33213 S 6,079.70 3,406.33 732.95<br />

31611 S 723.26 0.00 0.00 33214 S 8,318.59 4,847.20 1,375.82<br />

31612 S 639.84 0.00 0.00 33215 S 863.27 0.00 0.00<br />

31613 S 693.09 0.00 0.00 33216 S 1,969.53 0.00 0.00<br />

31614 S 1,027.02 0.00 0.00 33217 S 1,969.53 0.00 0.00<br />

31615 S 303.88 0.00 0.00 33218 S 863.27 0.00 0.00<br />

31622 S 355.89 0.00 0.00 33220 S 863.27 0.00 0.00<br />

31623 S 409.14 0.00 0.00 33222 S 521.81 0.00 0.00<br />

31624 S 409.14 0.00 0.00 33223 S 521.81 0.00 0.00<br />

31625 S 409.14 0.00 0.00 33224 S 7,851.97 4,700.95 1,549.94<br />

31628 S 409.14 0.00 0.00 33225 S 7,851.97 4,700.95 1,549.94<br />

31629 S 409.14 0.00 0.00 33226 S 863.27 0.00 0.00<br />

31630 S 701.10 0.00 0.00 33233 S 641.82 0.00 0.00<br />

31631 S 701.10 0.00 0.00 33234 S 863.27 0.00 0.00<br />

31632 S 397.92 0.00 0.00 33235 S 863.27 0.00 0.00<br />

31633 S 397.92 0.00 0.00 33240 S 19,572.96 10,462.55 1,352.14<br />

31635 S 409.14 0.00 0.00 33241 S 863.27 0.00 0.00<br />

31636 S 701.10 0.00 0.00 33249 S 26,121.61 13,991.82 1,862.02<br />

31637 S 355.89 0.00 0.00 33282 S 4,129.99 2,472.46 814.92<br />

31638 S 701.10 0.00 0.00 33284 S 322.13 0.00 0.00<br />

31640 S 701.10 0.00 0.00 34490 S 1,572.73 0.00 0.00<br />

31641 S 701.10 0.00 0.00 35188 S 1,083.26 0.00 0.00<br />

31643 S 409.14 0.00 0.00 35207 S 1,083.26 0.00 0.00<br />

31645 S 355.89 0.00 0.00 35473 S 1,886.67 0.00 0.00<br />

31646 S 355.89 0.00 0.00 35476 S 1,886.67 0.00 0.00<br />

31656 S 355.89 0.00 0.00 35492 S 3,521.28 0.00 0.00<br />

31717 S 196.95 0.00 0.00 35761 S 1,132.75 0.00 0.00<br />

31720 S 30.16 0.00 0.00 35875 S 1,417.38 0.00 0.00<br />

31730 S 196.95 0.00 0.00 35876 S 1,417.38 0.00 0.00<br />

31750 S 1,154.74 0.00 0.00 36002 S 90.46 0.00 0.00<br />

31755 S 1,027.02 0.00 0.00 36260 S 820.63 0.00 0.00<br />

31820 S 493.24 0.00 0.00 36261 S 641.82 0.00 0.00<br />

31825 S 693.09 0.00 0.00 36262 S 588.56 0.00 0.00<br />

31830 S 693.09 0.00 0.00 36420 S 8.53 0.00 0.00<br />

32400 S 343.78 0.00 0.00 36425 S 8.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.77 0.00 0.00 36800 S 883.41 0.00 0.00<br />

36440 S 130.87 0.00 0.00 36810 S 883.41 0.00 0.00<br />

36450 S 130.87 0.00 0.00 36815 S 883.41 0.00 0.00<br />

36455 S 130.87 0.00 0.00 36818 S 1,026.71 0.00 0.00<br />

36468 S 32.30 0.00 0.00 36819 S 1,026.71 0.00 0.00<br />

36469 S 32.30 0.00 0.00 36820 S 1,026.71 0.00 0.00<br />

36470 S 32.30 0.00 0.00 36821 S 1,026.71 0.00 0.00<br />

36471 S 32.30 0.00 0.00 36825 S 1,083.26 0.00 0.00<br />

36475 S 1,485.28 0.00 0.00 36830 S 1,083.26 0.00 0.00<br />

36476 S 1,164.76 0.00 0.00 36831 S 1,417.38 0.00 0.00<br />

36478 S 1,164.76 0.00 0.00 36832 S 1,083.26 0.00 0.00<br />

36479 S 1,164.76 0.00 0.00 36833 S 1,083.26 0.00 0.00<br />

36511 S 448.68 0.00 0.00 36834 S 1,026.71 0.00 0.00<br />

36512 S 448.68 0.00 0.00 36835 S 939.97 0.00 0.00<br />

36513 S 448.68 0.00 0.00 36860 S 107.88 0.00 0.00<br />

36514 S 448.68 0.00 0.00 36861 S 883.41 0.00 0.00<br />

36515 S 1,201.11 0.00 0.00 36870 S 1,544.96 0.00 0.00<br />

36516 S 1,201.11 0.00 0.00 37184 S 1,572.73 0.00 0.00<br />

36522 S 1,201.11 0.00 0.00 37185 S 1,572.73 0.00 0.00<br />

36555 S 372.79 0.00 0.00 37186 S 1,572.73 0.00 0.00<br />

36556 S 372.79 0.00 0.00 37187 S 1,572.73 0.00 0.00<br />

36557 S 696.21 0.00 0.00 37188 S 1,572.73 0.00 0.00<br />

36558 S 696.21 0.00 0.00 37200 S 1,160.58 0.00 0.00<br />

36560 S 820.63 0.00 0.00 37203 S 1,160.58 0.00 0.00<br />

36561 S 820.63 0.00 0.00 37500 S 1,094.61 0.00 0.00<br />

36563 S 820.63 0.00 0.00 37607 S 774.09 0.00 0.00<br />

36565 S 820.63 0.00 0.00 37609 S 520.29 0.00 0.00<br />

36566 S 820.63 0.00 0.00 37650 S 743.92 0.00 0.00<br />

36568 S 372.79 0.00 0.00 37700 S 743.92 0.00 0.00<br />

36569 S 372.79 0.00 0.00 37718 S 774.09 0.00 0.00<br />

36570 S 726.37 0.00 0.00 37722 S 1,094.61 0.00 0.00<br />

36571 S 726.37 0.00 0.00 37735 S 1,094.61 0.00 0.00<br />

36575 S 299.83 0.00 0.00 37760 S 774.09 0.00 0.00<br />

36576 S 426.04 0.00 0.00 37765 S 1,067.48 0.00 0.00<br />

36578 S 696.21 0.00 0.00 37766 S 1,067.48 0.00 0.00<br />

36580 S 372.79 0.00 0.00 37780 S 774.09 0.00 0.00<br />

36581 S 696.21 0.00 0.00 37785 S 774.09 0.00 0.00<br />

36582 S 820.63 0.00 0.00 37790 S 934.09 0.00 0.00<br />

36583 S 820.63 0.00 0.00 38205 S 448.68 0.00 0.00<br />

36584 S 372.79 0.00 0.00 38206 S 448.68 0.00 0.00<br />

36585 S 726.37 0.00 0.00 38220 S 102.85 0.00 0.00<br />

36589 S 246.58 0.00 0.00 38221 S 107.73 0.00 0.00<br />

36590 S 372.79 0.00 0.00 38230 S 1,201.11 0.00 0.00<br />

36593 S 24.75 0.00 0.00 38241 S 1,201.11 0.00 0.00<br />

36595 S 972.05 0.00 0.00 38242 S 448.68 0.00 0.00<br />

36596 S 431.70 0.00 0.00 38300 S 402.63 0.00 0.00<br />

36597 S 431.70 0.00 0.00 38305 S 588.38 0.00 0.00<br />

36598 S 79.83 0.00 0.00 38308 S 672.30 0.00 0.00<br />

36640 S 737.22 0.00 0.00 38500 S 672.30 0.00 0.00<br />

36680 S 55.88 0.00 0.00 38505 S 257.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 672.30 0.00 0.00 41005 S 135.54 0.00 0.00<br />

38520 S 672.30 0.00 0.00 41006 S 639.84 0.00 0.00<br />

38525 S 672.30 0.00 0.00 41007 S 493.24 0.00 0.00<br />

38530 S 672.30 0.00 0.00 41008 S 493.24 0.00 0.00<br />

38542 S 1,131.05 0.00 0.00 41009 S 135.54 0.00 0.00<br />

38550 S 702.47 0.00 0.00 41010 S 303.88 0.00 0.00<br />

38555 S 759.01 0.00 0.00 41015 S 135.54 0.00 0.00<br />

38570 S 1,534.66 0.00 0.00 41016 S 303.88 0.00 0.00<br />

38571 S 1,995.02 0.00 0.00 41017 S 303.88 0.00 0.00<br />

38572 S 1,534.66 0.00 0.00 41018 S 303.88 0.00 0.00<br />

38700 S 924.23 0.00 0.00 41019 S 965.83 0.00 0.00<br />

38740 S 1,131.05 0.00 0.00 41100 S 90.99 0.00 0.00<br />

38745 S 1,217.76 0.00 0.00 41105 S 89.94 0.00 0.00<br />

38760 S 672.30 0.00 0.00 41108 S 83.32 0.00 0.00<br />

40490 S 68.68 0.00 0.00 41110 S 120.62 0.00 0.00<br />

40500 S 546.49 0.00 0.00 41112 S 546.49 0.00 0.00<br />

40510 S 693.09 0.00 0.00 41113 S 546.49 0.00 0.00<br />

40520 S 546.49 0.00 0.00 41114 S 693.09 0.00 0.00<br />

40525 S 693.09 0.00 0.00 41115 S 140.50 0.00 0.00<br />

40527 S 693.09 0.00 0.00 41116 S 493.24 0.00 0.00<br />

40530 S 693.09 0.00 0.00 41120 S 820.81 0.00 0.00<br />

40650 S 365.68 0.00 0.00 41250 S 92.70 0.00 0.00<br />

40652 S 365.68 0.00 0.00 41251 S 135.54 0.00 0.00<br />

40654 S 365.68 0.00 0.00 41252 S 357.13 0.00 0.00<br />

40700 S 1,285.75 0.00 0.00 41500 S 639.84 0.00 0.00<br />

40701 S 1,285.75 0.00 0.00 41510 S 493.24 0.00 0.00<br />

40702 S 1,633.68 0.00 0.00 41520 S 357.13 0.00 0.00<br />

40720 S 1,285.75 0.00 0.00 41530 S 672.61 0.00 0.00<br />

40761 S 1,057.19 0.00 0.00 41800 S 69.25 0.00 0.00<br />

40800 S 55.12 0.00 0.00 41805 S 149.91 0.00 0.00<br />

40801 S 357.13 0.00 0.00 41806 S 184.77 0.00 0.00<br />

40804 S 25.21 0.00 0.00 41820 S 293.89 0.00 0.00<br />

40805 S 170.48 0.00 0.00 41821 S 293.89 0.00 0.00<br />

40806 S 78.44 0.00 0.00 41822 S 153.04 0.00 0.00<br />

40808 S 116.44 0.00 0.00 41823 S 223.12 0.00 0.00<br />

40810 S 120.62 0.00 0.00 41825 S 122.71 0.00 0.00<br />

40812 S 151.30 0.00 0.00 41826 S 154.44 0.00 0.00<br />

40814 S 546.49 0.00 0.00 41827 S 693.09 0.00 0.00<br />

40816 S 693.09 0.00 0.00 41828 S 139.45 0.00 0.00<br />

40818 S 135.54 0.00 0.00 41830 S 198.02 0.00 0.00<br />

40819 S 303.88 0.00 0.00 41850 S 672.61 0.00 0.00<br />

40820 S 173.96 0.00 0.00 41870 S 965.83 0.00 0.00<br />

40830 S 129.02 0.00 0.00 41872 S 198.02 0.00 0.00<br />

40831 S 303.88 0.00 0.00 41874 S 191.04 0.00 0.00<br />

40840 S 693.09 0.00 0.00 42000 S 135.54 0.00 0.00<br />

40842 S 723.26 0.00 0.00 42100 S 77.40 0.00 0.00<br />

40843 S 723.26 0.00 0.00 42104 S 115.04 0.00 0.00<br />

40844 S 1,154.74 0.00 0.00 42106 S 144.33 0.00 0.00<br />

40845 S 1,154.74 0.00 0.00 42107 S 693.09 0.00 0.00<br />

41000 S 86.46 0.00 0.00 42120 S 1,113.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 357.13 0.00 0.00 42809 S 25.21 0.00 0.00<br />

42145 S 820.81 0.00 0.00 42810 S 723.26 0.00 0.00<br />

42160 S 136.66 0.00 0.00 42815 S 1,154.74 0.00 0.00<br />

42180 S 135.54 0.00 0.00 42820 S 723.26 0.00 0.00<br />

42182 S 1,027.02 0.00 0.00 42821 S 820.81 0.00 0.00<br />

42200 S 1,154.74 0.00 0.00 42825 S 779.80 0.00 0.00<br />

42205 S 1,154.74 0.00 0.00 42826 S 779.80 0.00 0.00<br />

42210 S 1,154.74 0.00 0.00 42830 S 779.80 0.00 0.00<br />

42215 S 1,285.75 0.00 0.00 42831 S 779.80 0.00 0.00<br />

42220 S 1,154.74 0.00 0.00 42835 S 779.80 0.00 0.00<br />

42226 S 1,154.74 0.00 0.00 42836 S 779.80 0.00 0.00<br />

42235 S 674.20 0.00 0.00 42860 S 723.26 0.00 0.00<br />

42260 S 779.80 0.00 0.00 42870 S 723.26 0.00 0.00<br />

42280 S 75.30 0.00 0.00 42890 S 1,285.75 0.00 0.00<br />

42281 S 672.61 0.00 0.00 42892 S 1,285.75 0.00 0.00<br />

42300 S 493.24 0.00 0.00 42900 S 303.88 0.00 0.00<br />

42305 S 546.49 0.00 0.00 42950 S 693.09 0.00 0.00<br />

42310 S 135.54 0.00 0.00 42955 S 693.09 0.00 0.00<br />

42320 S 135.54 0.00 0.00 42960 S 55.83 0.00 0.00<br />

42330 S 116.44 0.00 0.00 42962 S 1,027.02 0.00 0.00<br />

42335 S 193.14 0.00 0.00 42970 S 43.34 0.00 0.00<br />

42340 S 546.49 0.00 0.00 42972 S 576.65 0.00 0.00<br />

42400 S 65.55 0.00 0.00 43030 S 672.61 0.00 0.00<br />

42405 S 546.49 0.00 0.00 43200 S 325.72 0.00 0.00<br />

42408 S 576.65 0.00 0.00 43201 S 325.72 0.00 0.00<br />

42409 S 576.65 0.00 0.00 43202 S 325.72 0.00 0.00<br />

42410 S 1,057.19 0.00 0.00 43204 S 325.72 0.00 0.00<br />

42415 S 1,285.75 0.00 0.00 43205 S 325.72 0.00 0.00<br />

42420 S 1,285.75 0.00 0.00 43215 S 325.72 0.00 0.00<br />

42425 S 1,285.75 0.00 0.00 43216 S 325.72 0.00 0.00<br />

42440 S 1,057.19 0.00 0.00 43217 S 325.72 0.00 0.00<br />

42450 S 693.09 0.00 0.00 43219 S 658.27 0.00 0.00<br />

42500 S 723.26 0.00 0.00 43220 S 325.72 0.00 0.00<br />

42505 S 1,113.74 0.00 0.00 43226 S 325.72 0.00 0.00<br />

42507 S 1,057.19 0.00 0.00 43227 S 378.97 0.00 0.00<br />

42508 S 1,113.74 0.00 0.00 43228 S 705.24 0.00 0.00<br />

42509 S 1,113.74 0.00 0.00 43231 S 378.97 0.00 0.00<br />

42510 S 1,113.74 0.00 0.00 43232 S 378.97 0.00 0.00<br />

42600 S 493.24 0.00 0.00 43234 S 325.72 0.00 0.00<br />

42650 S 42.88 0.00 0.00 43235 S 325.72 0.00 0.00<br />

42660 S 50.21 0.00 0.00 43236 S 378.97 0.00 0.00<br />

42665 S 951.82 0.00 0.00 43237 S 378.97 0.00 0.00<br />

42700 S 135.54 0.00 0.00 43238 S 378.97 0.00 0.00<br />

42720 S 493.24 0.00 0.00 43239 S 378.97 0.00 0.00<br />

42725 S 1,027.02 0.00 0.00 43240 S 378.97 0.00 0.00<br />

42800 S 82.97 0.00 0.00 43241 S 378.97 0.00 0.00<br />

42802 S 493.24 0.00 0.00 43242 S 378.97 0.00 0.00<br />

42804 S 493.24 0.00 0.00 43243 S 378.97 0.00 0.00<br />

42806 S 693.09 0.00 0.00 43244 S 378.97 0.00 0.00<br />

42808 S 546.49 0.00 0.00 43245 S 378.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 378.97 0.00 0.00 44378 S 396.91 0.00 0.00<br />

43247 S 378.97 0.00 0.00 44379 S 1,132.37 0.00 0.00<br />

43248 S 378.97 0.00 0.00 44380 S 343.66 0.00 0.00<br />

43249 S 378.97 0.00 0.00 44382 S 343.66 0.00 0.00<br />

43250 S 378.97 0.00 0.00 44383 S 1,132.37 0.00 0.00<br />

43251 S 378.97 0.00 0.00 44385 S 332.27 0.00 0.00<br />

43255 S 378.97 0.00 0.00 44386 S 332.27 0.00 0.00<br />

43256 S 741.69 0.00 0.00 44388 S 332.27 0.00 0.00<br />

43257 S 735.41 0.00 0.00 44389 S 332.27 0.00 0.00<br />

43258 S 409.13 0.00 0.00 44390 S 332.27 0.00 0.00<br />

43259 S 409.13 0.00 0.00 44391 S 332.27 0.00 0.00<br />

43260 S 638.00 0.00 0.00 44392 S 332.27 0.00 0.00<br />

43261 S 638.00 0.00 0.00 44393 S 332.27 0.00 0.00<br />

43262 S 638.00 0.00 0.00 44394 S 332.27 0.00 0.00<br />

43263 S 638.00 0.00 0.00 44397 S 658.27 0.00 0.00<br />

43264 S 638.00 0.00 0.00 44500 S 179.30 0.00 0.00<br />

43265 S 638.00 0.00 0.00 45000 S 385.33 0.00 0.00<br />

43267 S 638.00 0.00 0.00 45005 S 448.44 0.00 0.00<br />

43268 S 711.53 0.00 0.00 45020 S 448.44 0.00 0.00<br />

43269 S 711.53 0.00 0.00 45100 S 609.26 0.00 0.00<br />

43271 S 638.00 0.00 0.00 45108 S 662.51 0.00 0.00<br />

43272 S 638.00 0.00 0.00 45150 S 662.51 0.00 0.00<br />

43273 S 855.64 0.00 0.00 45160 S 662.51 0.00 0.00<br />

43450 S 284.86 0.00 0.00 45170 S 662.51 0.00 0.00<br />

43453 S 284.86 0.00 0.00 45190 S 1,083.35 0.00 0.00<br />

43456 S 285.99 0.00 0.00 45300 S 64.14 0.00 0.00<br />

43458 S 326.86 0.00 0.00 45303 S 356.30 0.00 0.00<br />

43600 S 325.72 0.00 0.00 45305 S 335.08 0.00 0.00<br />

43653 S 1,534.66 0.00 0.00 45307 S 618.91 0.00 0.00<br />

43760 S 157.97 0.00 0.00 45308 S 335.08 0.00 0.00<br />

43761 S 325.72 0.00 0.00 45309 S 335.08 0.00 0.00<br />

43870 S 325.72 0.00 0.00 45315 S 335.08 0.00 0.00<br />

43886 S 821.86 0.00 0.00 45317 S 335.08 0.00 0.00<br />

43887 S 172.86 0.00 0.00 45320 S 618.91 0.00 0.00<br />

43888 S 821.86 0.00 0.00 45321 S 618.91 0.00 0.00<br />

44100 S 325.72 0.00 0.00 45327 S 658.27 0.00 0.00<br />

44312 S 567.86 0.00 0.00 45330 S 84.71 0.00 0.00<br />

44340 S 651.28 0.00 0.00 45331 S 250.51 0.00 0.00<br />

44360 S 396.91 0.00 0.00 45332 S 250.51 0.00 0.00<br />

44361 S 396.91 0.00 0.00 45333 S 335.08 0.00 0.00<br />

44363 S 396.91 0.00 0.00 45334 S 335.08 0.00 0.00<br />

44364 S 396.91 0.00 0.00 45335 S 250.51 0.00 0.00<br />

44365 S 396.91 0.00 0.00 45337 S 250.51 0.00 0.00<br />

44366 S 396.91 0.00 0.00 45338 S 335.08 0.00 0.00<br />

44369 S 396.91 0.00 0.00 45339 S 335.08 0.00 0.00<br />

44370 S 1,132.37 0.00 0.00 45340 S 335.08 0.00 0.00<br />

44372 S 396.91 0.00 0.00 45341 S 335.08 0.00 0.00<br />

44373 S 396.91 0.00 0.00 45342 S 335.08 0.00 0.00<br />

44376 S 396.91 0.00 0.00 45345 S 658.27 0.00 0.00<br />

44377 S 396.91 0.00 0.00 45355 S 332.27 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 385.53 0.00 0.00 46505 S 476.51 0.00 0.00<br />

45379 S 385.53 0.00 0.00 46600 S 25.21 0.00 0.00<br />

45380 S 385.53 0.00 0.00 46604 S 356.30 0.00 0.00<br />

45381 S 385.53 0.00 0.00 46606 S 133.87 0.00 0.00<br />

45382 S 385.53 0.00 0.00 46608 S 335.08 0.00 0.00<br />

45383 S 385.53 0.00 0.00 46610 S 618.91 0.00 0.00<br />

45384 S 385.53 0.00 0.00 46611 S 335.08 0.00 0.00<br />

45385 S 385.53 0.00 0.00 46612 S 618.91 0.00 0.00<br />

45386 S 385.53 0.00 0.00 46614 S 70.42 0.00 0.00<br />

45387 S 658.27 0.00 0.00 46615 S 672.16 0.00 0.00<br />

45391 S 385.53 0.00 0.00 46700 S 692.68 0.00 0.00<br />

45392 S 385.53 0.00 0.00 46706 S 762.43 0.00 0.00<br />

45500 S 662.51 0.00 0.00 46750 S 845.84 0.00 0.00<br />

45505 S 815.68 0.00 0.00 46753 S 692.68 0.00 0.00<br />

45520 S 32.30 0.00 0.00 46754 S 662.51 0.00 0.00<br />

45560 S 815.68 0.00 0.00 46760 S 815.68 0.00 0.00<br />

45900 S 261.22 0.00 0.00 46761 S 845.84 0.00 0.00<br />

45905 S 609.26 0.00 0.00 46762 S 1,074.40 0.00 0.00<br />

45910 S 609.26 0.00 0.00 46900 S 106.46 0.00 0.00<br />

45915 S 385.33 0.00 0.00 46910 S 127.24 0.00 0.00<br />

45990 S 599.39 0.00 0.00 46916 S 59.18 0.00 0.00<br />

46020 S 692.68 0.00 0.00 46917 S 552.10 0.00 0.00<br />

46030 S 261.22 0.00 0.00 46922 S 552.10 0.00 0.00<br />

46040 S 692.68 0.00 0.00 46924 S 552.10 0.00 0.00<br />

46045 S 662.51 0.00 0.00 46930 S 123.42 0.00 0.00<br />

46050 S 385.33 0.00 0.00 46937 S 662.51 0.00 0.00<br />

46060 S 662.51 0.00 0.00 46938 S 815.68 0.00 0.00<br />

46070 S 476.51 0.00 0.00 46940 S 91.33 0.00 0.00<br />

46080 S 692.68 0.00 0.00 46942 S 88.90 0.00 0.00<br />

46083 S 72.94 0.00 0.00 46945 S 151.30 0.00 0.00<br />

46200 S 662.51 0.00 0.00 46946 S 395.18 0.00 0.00<br />

46210 S 662.51 0.00 0.00 46947 S 1,074.40 0.00 0.00<br />

46211 S 662.51 0.00 0.00 47000 S 343.78 0.00 0.00<br />

46220 S 609.26 0.00 0.00 47382 S 1,814.21 0.00 0.00<br />

46221 S 119.93 0.00 0.00 47510 S 803.44 0.00 0.00<br />

46230 S 609.26 0.00 0.00 47511 S 1,180.37 0.00 0.00<br />

46250 S 692.68 0.00 0.00 47525 S 461.23 0.00 0.00<br />

46255 S 692.68 0.00 0.00 47530 S 461.23 0.00 0.00<br />

46257 S 692.68 0.00 0.00 47552 S 803.44 0.00 0.00<br />

46258 S 692.68 0.00 0.00 47553 S 833.60 0.00 0.00<br />

46260 S 692.68 0.00 0.00 47554 S 833.60 0.00 0.00<br />

46261 S 749.22 0.00 0.00 47555 S 833.60 0.00 0.00<br />

46262 S 749.22 0.00 0.00 47556 S 1,180.37 0.00 0.00<br />

46270 S 692.68 0.00 0.00 47560 S 979.45 0.00 0.00<br />

46275 S 692.68 0.00 0.00 47561 S 979.45 0.00 0.00<br />

46280 S 749.22 0.00 0.00 47562 S 1,807.28 0.00 0.00<br />

46285 S 609.26 0.00 0.00 47563 S 1,807.28 0.00 0.00<br />

46288 S 749.22 0.00 0.00 47564 S 1,807.28 0.00 0.00<br />

46320 S 81.23 0.00 0.00 47630 S 833.60 0.00 0.00<br />

46500 S 111.90 0.00 0.00 48102 S 343.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 209.05 0.00 0.00 49590 S 858.00 0.00 0.00<br />

49081 S 209.05 0.00 0.00 49600 S 914.55 0.00 0.00<br />

49180 S 343.78 0.00 0.00 49650 S 1,200.54 0.00 0.00<br />

49250 S 753.58 0.00 0.00 49651 S 1,372.55 0.00 0.00<br />

49320 S 979.45 0.00 0.00 49652 S 1,478.20 0.00 0.00<br />

49321 S 1,036.00 0.00 0.00 49653 S 1,478.20 0.00 0.00<br />

49322 S 1,036.00 0.00 0.00 49654 S 1,478.20 0.00 0.00<br />

49324 S 1,478.20 0.00 0.00 49655 S 1,478.20 0.00 0.00<br />

49325 S 1,478.20 0.00 0.00 49656 S 1,478.20 0.00 0.00<br />

49326 S 1,478.20 0.00 0.00 49657 S 1,478.20 0.00 0.00<br />

49402 S 666.87 0.00 0.00 50200 S 343.78 0.00 0.00<br />

49419 S 800.00 0.00 0.00 50382 S 998.27 0.00 0.00<br />

49420 S 739.55 0.00 0.00 50384 S 733.20 0.00 0.00<br />

49421 S 739.55 0.00 0.00 50385 S 733.20 0.00 0.00<br />

49422 S 588.56 0.00 0.00 50386 S 281.31 0.00 0.00<br />

49423 S 608.60 0.00 0.00 50387 S 608.60 0.00 0.00<br />

49426 S 666.87 0.00 0.00 50389 S 281.31 0.00 0.00<br />

49429 S 863.27 0.00 0.00 50390 S 343.78 0.00 0.00<br />

49440 S 337.58 0.00 0.00 50391 S 40.71 0.00 0.00<br />

49441 S 337.58 0.00 0.00 50392 S 523.53 0.00 0.00<br />

49446 S 337.58 0.00 0.00 50393 S 656.06 0.00 0.00<br />

49450 S 179.30 0.00 0.00 50395 S 523.53 0.00 0.00<br />

49451 S 179.30 0.00 0.00 50396 S 98.44 0.00 0.00<br />

49452 S 179.30 0.00 0.00 50398 S 461.23 0.00 0.00<br />

49460 S 179.30 0.00 0.00 50551 S 297.59 0.00 0.00<br />

49495 S 914.55 0.00 0.00 50553 S 656.06 0.00 0.00<br />

49496 S 914.55 0.00 0.00 50555 S 297.59 0.00 0.00<br />

49500 S 914.55 0.00 0.00 50557 S 656.06 0.00 0.00<br />

49501 S 1,248.67 0.00 0.00 50561 S 656.06 0.00 0.00<br />

49505 S 914.55 0.00 0.00 50562 S 281.31 0.00 0.00<br />

49507 S 1,248.67 0.00 0.00 50570 S 281.31 0.00 0.00<br />

49520 S 1,086.56 0.00 0.00 50572 S 281.31 0.00 0.00<br />

49521 S 1,248.67 0.00 0.00 50574 S 281.31 0.00 0.00<br />

49525 S 914.55 0.00 0.00 50575 S 1,399.29 0.00 0.00<br />

49540 S 827.83 0.00 0.00 50576 S 733.20 0.00 0.00<br />

49550 S 955.55 0.00 0.00 50580 S 733.20 0.00 0.00<br />

49553 S 1,248.67 0.00 0.00 50590 S 1,634.69 0.00 0.00<br />

49555 S 955.55 0.00 0.00 50592 S 1,814.21 0.00 0.00<br />

49557 S 1,248.67 0.00 0.00 50686 S 40.71 0.00 0.00<br />

49560 S 914.55 0.00 0.00 50688 S 461.23 0.00 0.00<br />

49561 S 1,248.67 0.00 0.00 50947 S 1,534.66 0.00 0.00<br />

49565 S 914.55 0.00 0.00 50948 S 1,534.66 0.00 0.00<br />

49566 S 1,248.67 0.00 0.00 50951 S 297.59 0.00 0.00<br />

49568 S 1,086.56 0.00 0.00 50953 S 297.59 0.00 0.00<br />

49570 S 914.55 0.00 0.00 50955 S 656.06 0.00 0.00<br />

49572 S 1,248.67 0.00 0.00 50957 S 656.06 0.00 0.00<br />

49580 S 914.55 0.00 0.00 50961 S 656.06 0.00 0.00<br />

49582 S 1,248.67 0.00 0.00 50970 S 297.59 0.00 0.00<br />

49585 S 914.55 0.00 0.00 50972 S 297.59 0.00 0.00<br />

49587 S 1,248.67 0.00 0.00 50974 S 523.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 523.53 0.00 0.00 52275 S 709.32 0.00 0.00<br />

50980 S 656.06 0.00 0.00 52276 S 739.48 0.00 0.00<br />

51020 S 796.03 0.00 0.00 52277 S 709.32 0.00 0.00<br />

51030 S 796.03 0.00 0.00 52281 S 576.78 0.00 0.00<br />

51040 S 796.03 0.00 0.00 52282 S 1,330.67 0.00 0.00<br />

51045 S 328.80 0.00 0.00 52283 S 709.32 0.00 0.00<br />

51050 S 796.03 0.00 0.00 52285 S 576.78 0.00 0.00<br />

51065 S 796.03 0.00 0.00 52290 S 576.78 0.00 0.00<br />

51080 S 535.12 0.00 0.00 52300 S 709.32 0.00 0.00<br />

51100 S 31.03 0.00 0.00 52301 S 739.48 0.00 0.00<br />

51101 S 40.71 0.00 0.00 52305 S 709.32 0.00 0.00<br />

51102 S 547.74 0.00 0.00 52310 S 554.74 0.00 0.00<br />

51500 S 914.55 0.00 0.00 52315 S 709.32 0.00 0.00<br />

51520 S 796.03 0.00 0.00 52317 S 656.06 0.00 0.00<br />

51700 S 52.99 0.00 0.00 52318 S 709.32 0.00 0.00<br />

51701 S 25.21 0.00 0.00 52320 S 837.03 0.00 0.00<br />

51702 S 25.21 0.00 0.00 52325 S 796.03 0.00 0.00<br />

51703 S 40.71 0.00 0.00 52327 S 909.83 0.00 0.00<br />

51705 S 72.94 0.00 0.00 52330 S 709.32 0.00 0.00<br />

51710 S 461.23 0.00 0.00 52332 S 709.32 0.00 0.00<br />

51715 S 837.46 0.00 0.00 52334 S 739.48 0.00 0.00<br />

51720 S 58.57 0.00 0.00 52341 S 739.48 0.00 0.00<br />

51725 TC S 112.51 0.00 0.00 52342 S 739.48 0.00 0.00<br />

51726 TC S 154.97 0.00 0.00 52343 S 739.48 0.00 0.00<br />

51736 TC S 21.27 0.00 0.00 52344 S 739.48 0.00 0.00<br />

51741 TC S 24.75 0.00 0.00 52345 S 739.48 0.00 0.00<br />

51772 TC S 98.44 0.00 0.00 52346 S 739.48 0.00 0.00<br />

51784 TC S 40.71 0.00 0.00 52351 S 739.48 0.00 0.00<br />

51785 TC S 68.01 0.00 0.00 52352 S 796.03 0.00 0.00<br />

51792 TC S 40.71 0.00 0.00 52353 S 996.55 0.00 0.00<br />

51795 TC S 72.94 0.00 0.00 52354 S 796.03 0.00 0.00<br />

51797 TC S 72.94 0.00 0.00 52355 S 796.03 0.00 0.00<br />

51798 S 18.12 0.00 0.00 52400 S 739.48 0.00 0.00<br />

51880 S 656.06 0.00 0.00 52402 S 739.48 0.00 0.00<br />

51992 S 1,241.54 0.00 0.00 52450 S 739.48 0.00 0.00<br />

52000 S 297.59 0.00 0.00 52500 S 739.48 0.00 0.00<br />

52001 S 554.74 0.00 0.00 52601 S 996.55 0.00 0.00<br />

52005 S 576.78 0.00 0.00 52630 S 909.83 0.00 0.00<br />

52007 S 709.32 0.00 0.00 52640 S 709.32 0.00 0.00<br />

52010 S 328.80 0.00 0.00 52647 S 1,524.62 0.00 0.00<br />

52204 S 576.78 0.00 0.00 52648 S 1,524.62 0.00 0.00<br />

52214 S 709.32 0.00 0.00 52700 S 709.32 0.00 0.00<br />

52224 S 709.32 0.00 0.00 53000 S 544.40 0.00 0.00<br />

52234 S 709.32 0.00 0.00 53010 S 544.40 0.00 0.00<br />

52235 S 739.48 0.00 0.00 53020 S 544.40 0.00 0.00<br />

52240 S 739.48 0.00 0.00 53025 S 774.93 0.00 0.00<br />

52250 S 796.03 0.00 0.00 53040 S 597.66 0.00 0.00<br />

52260 S 576.78 0.00 0.00 53060 S 70.77 0.00 0.00<br />

52265 S 281.31 0.00 0.00 53080 S 627.82 0.00 0.00<br />

52270 S 576.78 0.00 0.00 53085 S 774.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 544.40 0.00 0.00 54060 S 552.10 0.00 0.00<br />

53210 S 935.01 0.00 0.00 54065 S 552.10 0.00 0.00<br />

53215 S 725.37 0.00 0.00 54100 S 467.04 0.00 0.00<br />

53220 S 807.29 0.00 0.00 54105 S 583.02 0.00 0.00<br />

53230 S 807.29 0.00 0.00 54110 S 903.94 0.00 0.00<br />

53235 S 627.82 0.00 0.00 54111 S 903.94 0.00 0.00<br />

53240 S 807.29 0.00 0.00 54112 S 903.94 0.00 0.00<br />

53250 S 597.66 0.00 0.00 54115 S 535.12 0.00 0.00<br />

53260 S 597.66 0.00 0.00 54120 S 903.94 0.00 0.00<br />

53265 S 597.66 0.00 0.00 54150 S 602.42 0.00 0.00<br />

53270 S 597.66 0.00 0.00 54160 S 655.68 0.00 0.00<br />

53275 S 597.66 0.00 0.00 54161 S 655.68 0.00 0.00<br />

53400 S 837.46 0.00 0.00 54162 S 655.68 0.00 0.00<br />

53405 S 807.29 0.00 0.00 54163 S 655.68 0.00 0.00<br />

53410 S 807.29 0.00 0.00 54164 S 655.68 0.00 0.00<br />

53420 S 837.46 0.00 0.00 54200 S 68.68 0.00 0.00<br />

53425 S 807.29 0.00 0.00 54205 S 990.65 0.00 0.00<br />

53430 S 807.29 0.00 0.00 54220 S 98.44 0.00 0.00<br />

53431 S 807.29 0.00 0.00 54231 S 64.49 0.00 0.00<br />

53440 S 4,650.34 2,824.37 998.39 54235 S 45.67 0.00 0.00<br />

53442 S 754.04 0.00 0.00 54240 TC S 32.42 0.00 0.00<br />

53444 S 4,650.34 2,824.37 998.39 54250 TC S 11.50 0.00 0.00<br />

53445 S 7,811.39 4,448.53 1,085.69 54300 S 934.09 0.00 0.00<br />

53446 S 754.04 0.00 0.00 54304 S 934.09 0.00 0.00<br />

53447 S 7,811.39 4,448.53 1,085.69 54308 S 934.09 0.00 0.00<br />

53449 S 754.04 0.00 0.00 54312 S 934.09 0.00 0.00<br />

53450 S 754.04 0.00 0.00 54316 S 934.09 0.00 0.00<br />

53460 S 544.40 0.00 0.00 54318 S 934.09 0.00 0.00<br />

53502 S 597.66 0.00 0.00 54322 S 934.09 0.00 0.00<br />

53505 S 807.29 0.00 0.00 54324 S 934.09 0.00 0.00<br />

53510 S 597.66 0.00 0.00 54326 S 934.09 0.00 0.00<br />

53515 S 807.29 0.00 0.00 54328 S 934.09 0.00 0.00<br />

53520 S 807.29 0.00 0.00 54340 S 934.09 0.00 0.00<br />

53600 S 40.79 0.00 0.00 54344 S 934.09 0.00 0.00<br />

53601 S 40.71 0.00 0.00 54348 S 934.09 0.00 0.00<br />

53605 S 576.78 0.00 0.00 54352 S 934.09 0.00 0.00<br />

53620 S 62.75 0.00 0.00 54360 S 934.09 0.00 0.00<br />

53621 S 65.89 0.00 0.00 54380 S 934.09 0.00 0.00<br />

53660 S 40.71 0.00 0.00 54385 S 934.09 0.00 0.00<br />

53661 S 40.71 0.00 0.00 54400 S 4,680.51 2,854.53 1,028.56<br />

53665 S 544.40 0.00 0.00 54401 S 7,894.81 4,531.95 1,169.10<br />

53850 S 1,787.20 0.00 0.00 54405 S 7,894.81 4,531.95 1,169.10<br />

53852 S 1,787.20 0.00 0.00 54406 S 934.09 0.00 0.00<br />

54000 S 597.66 0.00 0.00 54408 S 934.09 0.00 0.00<br />

54001 S 597.66 0.00 0.00 54410 S 7,894.81 4,531.95 1,169.10<br />

54015 S 675.09 0.00 0.00 54415 S 934.09 0.00 0.00<br />

54050 S 32.30 0.00 0.00 54416 S 7,894.81 4,531.95 1,169.10<br />

54055 S 65.89 0.00 0.00 54420 S 990.65 0.00 0.00<br />

54056 S 32.30 0.00 0.00 54435 S 990.65 0.00 0.00<br />

54057 S 552.10 0.00 0.00 54440 S 990.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 154.97 0.00 0.00 55706 S 450.52 0.00 0.00<br />

54500 S 420.62 0.00 0.00 55720 S 656.06 0.00 0.00<br />

54505 S 602.42 0.00 0.00 55725 S 709.32 0.00 0.00<br />

54512 S 655.68 0.00 0.00 55860 S 781.63 0.00 0.00<br />

54520 S 685.84 0.00 0.00 55870 S 79.48 0.00 0.00<br />

54522 S 685.84 0.00 0.00 55873 S 6,184.57 0.00 0.00<br />

54530 S 914.55 0.00 0.00 55875 S 1,330.67 0.00 0.00<br />

54550 S 914.55 0.00 0.00 55876 S 72.86 0.00 0.00<br />

54560 S 890.99 0.00 0.00 55920 S 913.38 0.00 0.00<br />

54600 S 742.40 0.00 0.00 56405 S 42.53 0.00 0.00<br />

54620 S 685.84 0.00 0.00 56420 S 55.51 0.00 0.00<br />

54640 S 914.55 0.00 0.00 56440 S 596.11 0.00 0.00<br />

54660 S 655.68 0.00 0.00 56441 S 542.85 0.00 0.00<br />

54670 S 685.84 0.00 0.00 56442 S 542.85 0.00 0.00<br />

54680 S 685.84 0.00 0.00 56501 S 58.57 0.00 0.00<br />

54690 S 1,534.66 0.00 0.00 56515 S 635.52 0.00 0.00<br />

54692 S 2,728.01 0.00 0.00 56605 S 33.81 0.00 0.00<br />

54700 S 655.68 0.00 0.00 56606 S 13.95 0.00 0.00<br />

54800 S 147.17 0.00 0.00 56620 S 723.82 0.00 0.00<br />

54830 S 685.84 0.00 0.00 56625 S 854.83 0.00 0.00<br />

54840 S 742.40 0.00 0.00 56700 S 542.85 0.00 0.00<br />

54860 S 685.84 0.00 0.00 56740 S 626.27 0.00 0.00<br />

54861 S 742.40 0.00 0.00 56800 S 626.27 0.00 0.00<br />

54865 S 602.42 0.00 0.00 56805 S 771.85 0.00 0.00<br />

54900 S 742.40 0.00 0.00 56810 S 723.82 0.00 0.00<br />

54901 S 742.40 0.00 0.00 56820 S 43.23 0.00 0.00<br />

55000 S 66.94 0.00 0.00 56821 S 55.51 0.00 0.00<br />

55040 S 858.00 0.00 0.00 57000 S 542.85 0.00 0.00<br />

55041 S 955.55 0.00 0.00 57010 S 596.11 0.00 0.00<br />

55060 S 742.40 0.00 0.00 57020 S 312.63 0.00 0.00<br />

55100 S 402.63 0.00 0.00 57022 S 491.40 0.00 0.00<br />

55110 S 655.68 0.00 0.00 57023 S 535.12 0.00 0.00<br />

55120 S 655.68 0.00 0.00 57061 S 54.03 0.00 0.00<br />

55150 S 602.42 0.00 0.00 57065 S 542.85 0.00 0.00<br />

55175 S 602.42 0.00 0.00 57100 S 34.52 0.00 0.00<br />

55180 S 655.68 0.00 0.00 57105 S 596.11 0.00 0.00<br />

55200 S 655.68 0.00 0.00 57130 S 596.11 0.00 0.00<br />

55250 S 655.68 0.00 0.00 57135 S 596.11 0.00 0.00<br />

55400 S 602.42 0.00 0.00 57150 S 25.10 0.00 0.00<br />

55450 S 215.45 0.00 0.00 57155 S 312.63 0.00 0.00<br />

55500 S 685.84 0.00 0.00 57160 S 36.26 0.00 0.00<br />

55520 S 742.40 0.00 0.00 57170 S 5.94 0.00 0.00<br />

55530 S 742.40 0.00 0.00 57180 S 111.66 0.00 0.00<br />

55535 S 914.55 0.00 0.00 57200 S 542.85 0.00 0.00<br />

55540 S 955.55 0.00 0.00 57210 S 596.11 0.00 0.00<br />

55550 S 1,534.66 0.00 0.00 57220 S 1,093.19 0.00 0.00<br />

55600 S 890.99 0.00 0.00 57230 S 897.60 0.00 0.00<br />

55680 S 602.42 0.00 0.00 57240 S 995.15 0.00 0.00<br />

55700 S 388.23 0.00 0.00 57250 S 995.15 0.00 0.00<br />

55705 S 388.23 0.00 0.00 57260 S 995.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,321.75 0.00 0.00 58555 S 586.52 0.00 0.00<br />

57267 S 1,126.17 0.00 0.00 58558 S 669.94 0.00 0.00<br />

57268 S 897.60 0.00 0.00 58559 S 639.78 0.00 0.00<br />

57287 S 1,314.52 0.00 0.00 58560 S 955.24 0.00 0.00<br />

57288 S 1,190.74 0.00 0.00 58561 S 955.24 0.00 0.00<br />

57289 S 995.15 0.00 0.00 58562 S 669.94 0.00 0.00<br />

57291 S 995.15 0.00 0.00 58563 S 1,345.91 0.00 0.00<br />

57300 S 897.60 0.00 0.00 58565 S 1,483.87 0.00 0.00<br />

57320 S 1,314.52 0.00 0.00 58600 S 1,314.52 0.00 0.00<br />

57400 S 596.11 0.00 0.00 58615 S 771.85 0.00 0.00<br />

57410 S 596.11 0.00 0.00 58660 S 1,241.54 0.00 0.00<br />

57415 S 596.11 0.00 0.00 58661 S 1,241.54 0.00 0.00<br />

57420 S 44.63 0.00 0.00 58662 S 1,241.54 0.00 0.00<br />

57421 S 58.22 0.00 0.00 58670 S 1,143.99 0.00 0.00<br />

57452 S 42.18 0.00 0.00 58671 S 1,143.99 0.00 0.00<br />

57454 S 51.60 0.00 0.00 58672 S 1,241.54 0.00 0.00<br />

57455 S 54.73 0.00 0.00 58673 S 1,241.54 0.00 0.00<br />

57456 S 52.99 0.00 0.00 58800 S 626.27 0.00 0.00<br />

57460 S 162.80 0.00 0.00 58805 S 1,314.52 0.00 0.00<br />

57461 S 172.92 0.00 0.00 58820 S 897.60 0.00 0.00<br />

57500 S 74.60 0.00 0.00 58900 S 626.27 0.00 0.00<br />

57505 S 47.41 0.00 0.00 58970 S 174.44 0.00 0.00<br />

57510 S 48.11 0.00 0.00 58974 S 174.44 0.00 0.00<br />

57511 S 55.51 0.00 0.00 58976 S 174.44 0.00 0.00<br />

57513 S 596.11 0.00 0.00 59000 S 63.80 0.00 0.00<br />

57520 S 596.11 0.00 0.00 59001 S 239.47 0.00 0.00<br />

57522 S 596.11 0.00 0.00 59012 S 117.09 0.00 0.00<br />

57530 S 897.60 0.00 0.00 59015 S 51.60 0.00 0.00<br />

57550 S 897.60 0.00 0.00 59020 TC S 27.19 0.00 0.00<br />

57556 S 1,190.74 0.00 0.00 59025 TC S 14.30 0.00 0.00<br />

57558 S 626.27 0.00 0.00 59070 S 117.09 0.00 0.00<br />

57700 S 542.85 0.00 0.00 59072 S 117.09 0.00 0.00<br />

57720 S 626.27 0.00 0.00 59076 S 117.09 0.00 0.00<br />

57800 S 25.45 0.00 0.00 59100 S 1,314.52 0.00 0.00<br />

58100 S 41.83 0.00 0.00 59150 S 1,807.28 0.00 0.00<br />

58120 S 596.11 0.00 0.00 59151 S 1,807.28 0.00 0.00<br />

58145 S 995.15 0.00 0.00 59160 S 626.27 0.00 0.00<br />

58301 S 39.04 0.00 0.00 59200 S 34.87 0.00 0.00<br />

58321 S 36.61 0.00 0.00 59300 S 75.30 0.00 0.00<br />

58322 S 37.65 0.00 0.00 59320 S 542.85 0.00 0.00<br />

58323 S 8.72 0.00 0.00 59412 S 771.85 0.00 0.00<br />

58345 S 771.85 0.00 0.00 59414 S 771.85 0.00 0.00<br />

58346 S 596.11 0.00 0.00 59812 S 723.82 0.00 0.00<br />

58350 S 897.60 0.00 0.00 59820 S 723.82 0.00 0.00<br />

58353 S 1,126.17 0.00 0.00 59821 S 723.82 0.00 0.00<br />

58356 S 1,705.68 0.00 0.00 59840 S 723.82 0.00 0.00<br />

58545 S 1,370.13 0.00 0.00 59841 S 723.82 0.00 0.00<br />

58546 S 1,534.66 0.00 0.00 59866 S 117.09 0.00 0.00<br />

58550 S 1,995.02 0.00 0.00 59870 S 723.82 0.00 0.00<br />

58552 S 1,807.28 0.00 0.00 59871 S 723.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 303.88 0.00 0.00 62367 S 16.73 0.00 0.00<br />

60100 S 47.76 0.00 0.00 62368 S 21.27 0.00 0.00<br />

60200 S 1,131.05 0.00 0.00 63600 S 571.28 0.00 0.00<br />

60280 S 1,217.76 0.00 0.00 63610 S 518.02 0.00 0.00<br />

60281 S 1,217.76 0.00 0.00 63615 S 722.19 0.00 0.00<br />

60300 S 62.75 0.00 0.00 63650 S 3,074.90 1,906.74 738.60<br />

61000 S 279.81 0.00 0.00 63655 S 4,503.98 2,872.19 1,240.42<br />

61001 S 279.81 0.00 0.00 63660 S 540.01 0.00 0.00<br />

61020 S 226.54 0.00 0.00 63685 S 13,670.61 7,289.29 907.99<br />

61026 S 226.54 0.00 0.00 63688 S 733.29 0.00 0.00<br />

61050 S 226.54 0.00 0.00 63744 S 1,060.45 0.00 0.00<br />

61055 S 226.54 0.00 0.00 63746 S 490.54 0.00 0.00<br />

61070 S 176.28 0.00 0.00 64400 S 53.68 0.00 0.00<br />

61215 S 1,060.45 0.00 0.00 64402 S 50.55 0.00 0.00<br />

61330 S 1,633.68 0.00 0.00 64405 S 42.88 0.00 0.00<br />

61334 S 1,633.68 0.00 0.00 64408 S 53.34 0.00 0.00<br />

61790 S 601.44 0.00 0.00 64410 S 296.83 0.00 0.00<br />

61791 S 446.20 0.00 0.00 64412 S 78.44 0.00 0.00<br />

61880 S 766.16 0.00 0.00 64413 S 50.21 0.00 0.00<br />

61885 S 11,025.12 5,906.05 786.99 64415 S 136.71 0.00 0.00<br />

61886 S 16,463.19 8,677.05 890.92 64416 S 279.81 0.00 0.00<br />

61888 S 733.29 0.00 0.00 64417 S 136.71 0.00 0.00<br />

62194 S 296.83 0.00 0.00 64418 S 70.42 0.00 0.00<br />

62225 S 461.23 0.00 0.00 64420 S 136.71 0.00 0.00<br />

62230 S 1,030.28 0.00 0.00 64421 S 296.83 0.00 0.00<br />

62252 TC S 46.72 0.00 0.00 64425 S 48.80 0.00 0.00<br />

62263 S 296.83 0.00 0.00 64430 S 205.41 0.00 0.00<br />

62264 S 437.28 0.00 0.00 64435 S 73.56 0.00 0.00<br />

62267 S 174.50 0.00 0.00 64445 S 65.19 0.00 0.00<br />

62268 S 226.54 0.00 0.00 64446 S 560.71 0.00 0.00<br />

62269 S 343.78 0.00 0.00 64447 S 142.40 0.00 0.00<br />

62270 S 136.71 0.00 0.00 64448 S 142.40 0.00 0.00<br />

62272 S 136.71 0.00 0.00 64449 S 279.81 0.00 0.00<br />

62273 S 228.13 0.00 0.00 64450 S 43.57 0.00 0.00<br />

62280 S 296.83 0.00 0.00 64455 S 18.12 0.00 0.00<br />

62281 S 296.83 0.00 0.00 64470 S 296.83 0.00 0.00<br />

62282 S 296.83 0.00 0.00 64472 S 228.13 0.00 0.00<br />

62287 S 1,332.51 0.00 0.00 64475 S 296.83 0.00 0.00<br />

62292 S 279.81 0.00 0.00 64476 S 205.45 0.00 0.00<br />

62294 S 226.54 0.00 0.00 64479 S 296.83 0.00 0.00<br />

62310 S 296.83 0.00 0.00 64480 S 228.13 0.00 0.00<br />

62311 S 296.83 0.00 0.00 64483 S 296.83 0.00 0.00<br />

62318 S 296.83 0.00 0.00 64484 S 228.13 0.00 0.00<br />

62319 S 296.83 0.00 0.00 64505 S 39.75 0.00 0.00<br />

62350 S 1,030.28 0.00 0.00 64508 S 84.36 0.00 0.00<br />

62355 S 490.54 0.00 0.00 64510 S 296.83 0.00 0.00<br />

62360 S 1,030.28 0.00 0.00 64517 S 205.41 0.00 0.00<br />

62361 S 10,575.96 5,724.39 872.83 64520 S 296.83 0.00 0.00<br />

62362 S 10,575.96 5,724.39 872.83 64530 S 296.83 0.00 0.00<br />

62365 S 911.67 0.00 0.00 64553 S 3,021.64 1,853.48 685.34<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,393.12 2,224.97 1,056.82 64746 S 571.28 0.00 0.00<br />

64560 S 3,393.12 2,224.97 1,056.82 64761 S 722.19 0.00 0.00<br />

64561 S 3,105.06 1,936.90 768.76 64763 S 722.19 0.00 0.00<br />

64565 S 3,393.12 2,224.97 1,056.82 64766 S 1,402.96 0.00 0.00<br />

64573 S 5,285.98 3,131.43 976.87 64771 S 571.28 0.00 0.00<br />

64575 S 4,040.70 2,408.91 777.14 64772 S 571.28 0.00 0.00<br />

64577 S 4,040.70 2,408.91 777.14 64774 S 571.28 0.00 0.00<br />

64580 S 4,040.70 2,408.91 777.14 64776 S 601.44 0.00 0.00<br />

64581 S 4,124.11 2,492.33 860.55 64778 S 571.28 0.00 0.00<br />

64585 S 540.01 0.00 0.00 64782 S 601.44 0.00 0.00<br />

64590 S 11,025.12 5,906.05 786.99 64783 S 571.28 0.00 0.00<br />

64595 S 733.29 0.00 0.00 64784 S 601.44 0.00 0.00<br />

64600 S 437.28 0.00 0.00 64786 S 941.83 0.00 0.00<br />

64605 S 437.28 0.00 0.00 64787 S 571.28 0.00 0.00<br />

64610 S 437.28 0.00 0.00 64788 S 601.44 0.00 0.00<br />

64612 S 63.80 0.00 0.00 64790 S 601.44 0.00 0.00<br />

64613 S 61.71 0.00 0.00 64792 S 941.83 0.00 0.00<br />

64614 S 70.42 0.00 0.00 64795 S 571.28 0.00 0.00<br />

64620 S 296.83 0.00 0.00 64802 S 571.28 0.00 0.00<br />

64622 S 437.28 0.00 0.00 64820 S 722.19 0.00 0.00<br />

64623 S 296.83 0.00 0.00 64821 S 843.09 0.00 0.00<br />

64626 S 437.28 0.00 0.00 64822 S 1,092.37 0.00 0.00<br />

64627 S 205.45 0.00 0.00 64823 S 1,092.37 0.00 0.00<br />

64630 S 305.75 0.00 0.00 64831 S 998.38 0.00 0.00<br />

64632 S 33.12 0.00 0.00 64832 S 858.41 0.00 0.00<br />

64640 S 98.66 0.00 0.00 64834 S 911.67 0.00 0.00<br />

64650 S 33.12 0.00 0.00 64835 S 941.83 0.00 0.00<br />

64653 S 35.91 0.00 0.00 64836 S 941.83 0.00 0.00<br />

64680 S 464.60 0.00 0.00 64837 S 858.41 0.00 0.00<br />

64681 S 490.54 0.00 0.00 64840 S 911.67 0.00 0.00<br />

64702 S 518.02 0.00 0.00 64856 S 911.67 0.00 0.00<br />

64704 S 518.02 0.00 0.00 64857 S 911.67 0.00 0.00<br />

64708 S 571.28 0.00 0.00 64858 S 911.67 0.00 0.00<br />

64712 S 571.28 0.00 0.00 64859 S 858.41 0.00 0.00<br />

64713 S 571.28 0.00 0.00 64861 S 941.83 0.00 0.00<br />

64714 S 571.28 0.00 0.00 64862 S 941.83 0.00 0.00<br />

64716 S 601.44 0.00 0.00 64864 S 941.83 0.00 0.00<br />

64718 S 571.28 0.00 0.00 64865 S 998.38 0.00 0.00<br />

64719 S 571.28 0.00 0.00 64870 S 998.38 0.00 0.00<br />

64721 S 571.28 0.00 0.00 64872 S 911.67 0.00 0.00<br />

64722 S 518.02 0.00 0.00 64874 S 941.83 0.00 0.00<br />

64726 S 518.02 0.00 0.00 64876 S 941.83 0.00 0.00<br />

64727 S 518.02 0.00 0.00 64885 S 911.67 0.00 0.00<br />

64732 S 571.28 0.00 0.00 64886 S 911.67 0.00 0.00<br />

64734 S 571.28 0.00 0.00 64890 S 911.67 0.00 0.00<br />

64736 S 571.28 0.00 0.00 64891 S 911.67 0.00 0.00<br />

64738 S 571.28 0.00 0.00 64892 S 911.67 0.00 0.00<br />

64740 S 571.28 0.00 0.00 64893 S 911.67 0.00 0.00<br />

64742 S 571.28 0.00 0.00 64895 S 941.83 0.00 0.00<br />

64744 S 571.28 0.00 0.00 64896 S 941.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 941.83 0.00 0.00 65770 S 5,542.33 0.00 0.00<br />

64898 S 941.83 0.00 0.00 65772 S 623.47 0.00 0.00<br />

64901 S 911.67 0.00 0.00 65775 S 623.47 0.00 0.00<br />

64902 S 911.67 0.00 0.00 65780 S 1,078.51 0.00 0.00<br />

64905 S 911.67 0.00 0.00 65781 S 1,078.51 0.00 0.00<br />

64907 S 858.41 0.00 0.00 65782 S 1,078.51 0.00 0.00<br />

64910 S 1,402.96 0.00 0.00 65800 S 483.50 0.00 0.00<br />

65091 S 991.69 0.00 0.00 65805 S 483.50 0.00 0.00<br />

65093 S 991.69 0.00 0.00 65810 S 706.50 0.00 0.00<br />

65101 S 991.69 0.00 0.00 65815 S 676.33 0.00 0.00<br />

65103 S 991.69 0.00 0.00 65820 S 248.05 0.00 0.00<br />

65105 S 1,048.25 0.00 0.00 65850 S 763.04 0.00 0.00<br />

65110 S 1,089.24 0.00 0.00 65855 S 131.78 0.00 0.00<br />

65112 S 1,220.26 0.00 0.00 65860 S 123.07 0.00 0.00<br />

65114 S 1,220.26 0.00 0.00 65865 S 483.50 0.00 0.00<br />

65125 S 1,015.55 0.00 0.00 65870 S 763.04 0.00 0.00<br />

65130 S 748.12 0.00 0.00 65875 S 763.04 0.00 0.00<br />

65135 S 717.96 0.00 0.00 65880 S 623.47 0.00 0.00<br />

65140 S 991.69 0.00 0.00 65900 S 664.47 0.00 0.00<br />

65150 S 717.96 0.00 0.00 65920 S 935.06 0.00 0.00<br />

65155 S 991.69 0.00 0.00 65930 S 804.05 0.00 0.00<br />

65175 S 533.69 0.00 0.00 66020 S 483.50 0.00 0.00<br />

65205 S 20.57 0.00 0.00 66030 S 248.05 0.00 0.00<br />

65210 S 26.15 0.00 0.00 66130 S 935.06 0.00 0.00<br />

65220 S 36.43 0.00 0.00 66150 S 763.04 0.00 0.00<br />

65222 S 28.58 0.00 0.00 66155 S 763.04 0.00 0.00<br />

65235 S 536.75 0.00 0.00 66160 S 676.33 0.00 0.00<br />

65260 S 354.03 0.00 0.00 66165 S 763.04 0.00 0.00<br />

65265 S 732.43 0.00 0.00 66170 S 763.04 0.00 0.00<br />

65270 S 586.94 0.00 0.00 66172 S 763.04 0.00 0.00<br />

65272 S 676.33 0.00 0.00 66180 S 1,136.78 0.00 0.00<br />

65275 S 763.04 0.00 0.00 66185 S 1,009.07 0.00 0.00<br />

65280 S 732.43 0.00 0.00 66220 S 985.03 0.00 0.00<br />

65285 S 1,041.58 0.00 0.00 66225 S 1,095.79 0.00 0.00<br />

65286 S 182.22 0.00 0.00 66250 S 536.75 0.00 0.00<br />

65290 S 721.31 0.00 0.00 66500 S 248.05 0.00 0.00<br />

65400 S 483.50 0.00 0.00 66505 S 248.05 0.00 0.00<br />

65410 S 536.75 0.00 0.00 66600 S 706.50 0.00 0.00<br />

65420 S 536.75 0.00 0.00 66605 S 706.50 0.00 0.00<br />

65426 S 804.05 0.00 0.00 66625 S 502.32 0.00 0.00<br />

65430 S 36.43 0.00 0.00 66630 S 706.50 0.00 0.00<br />

65435 S 31.72 0.00 0.00 66635 S 706.50 0.00 0.00<br />

65436 S 137.70 0.00 0.00 66680 S 706.50 0.00 0.00<br />

65450 S 84.07 0.00 0.00 66682 S 676.33 0.00 0.00<br />

65600 S 162.46 0.00 0.00 66700 S 536.75 0.00 0.00<br />

65710 S 1,209.53 0.00 0.00 66710 S 536.75 0.00 0.00<br />

65730 S 1,209.53 0.00 0.00 66711 S 536.75 0.00 0.00<br />

65750 S 1,209.53 0.00 0.00 66720 S 536.75 0.00 0.00<br />

65755 S 1,209.53 0.00 0.00 66740 S 676.33 0.00 0.00<br />

65756 S 1,481.23 0.00 0.00 66761 S 183.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 186.52 0.00 0.00 67228 S 205.40 0.00 0.00<br />

66770 S 205.40 0.00 0.00 67229 S 205.40 0.00 0.00<br />

66820 S 182.22 0.00 0.00 67250 S 617.11 0.00 0.00<br />

66821 S 249.96 0.00 0.00 67255 S 675.89 0.00 0.00<br />

66825 S 763.04 0.00 0.00 67311 S 721.31 0.00 0.00<br />

66830 S 266.87 0.00 0.00 67312 S 777.86 0.00 0.00<br />

66840 S 573.67 0.00 0.00 67314 S 777.86 0.00 0.00<br />

66850 S 1,080.08 0.00 0.00 67316 S 777.86 0.00 0.00<br />

66852 S 908.06 0.00 0.00 67318 S 777.86 0.00 0.00<br />

66920 S 908.06 0.00 0.00 67320 S 777.86 0.00 0.00<br />

66930 S 949.07 0.00 0.00 67331 S 777.86 0.00 0.00<br />

66940 S 614.67 0.00 0.00 67332 S 777.86 0.00 0.00<br />

66982 S 932.48 0.00 0.00 67334 S 777.86 0.00 0.00<br />

66983 S 932.48 0.00 0.00 67335 S 777.86 0.00 0.00<br />

66984 S 932.48 0.00 0.00 67340 S 777.86 0.00 0.00<br />

66985 S 863.20 0.00 0.00 67343 S 949.87 0.00 0.00<br />

66986 S 863.20 0.00 0.00 67345 S 81.23 0.00 0.00<br />

67005 S 732.43 0.00 0.00 67346 S 439.36 0.00 0.00<br />

67010 S 732.43 0.00 0.00 67400 S 617.11 0.00 0.00<br />

67015 S 901.62 0.00 0.00 67405 S 804.68 0.00 0.00<br />

67025 S 592.47 0.00 0.00 67412 S 714.66 0.00 0.00<br />

67027 S 1,041.58 0.00 0.00 67413 S 845.67 0.00 0.00<br />

67028 S 81.93 0.00 0.00 67414 S 1,502.70 0.00 0.00<br />

67030 S 592.47 0.00 0.00 67415 S 533.69 0.00 0.00<br />

67031 S 249.96 0.00 0.00 67420 S 1,089.24 0.00 0.00<br />

67036 S 1,041.58 0.00 0.00 67430 S 1,089.24 0.00 0.00<br />

67039 S 1,213.60 0.00 0.00 67440 S 1,089.24 0.00 0.00<br />

67040 S 1,213.60 0.00 0.00 67445 S 1,089.24 0.00 0.00<br />

67041 S 1,489.37 0.00 0.00 67450 S 1,089.24 0.00 0.00<br />

67042 S 1,489.37 0.00 0.00 67500 S 84.07 0.00 0.00<br />

67043 S 1,489.37 0.00 0.00 67505 S 26.15 0.00 0.00<br />

67101 S 227.36 0.00 0.00 67515 S 26.49 0.00 0.00<br />

67105 S 205.40 0.00 0.00 67550 S 1,048.25 0.00 0.00<br />

67107 S 1,082.58 0.00 0.00 67560 S 717.96 0.00 0.00<br />

67108 S 1,213.60 0.00 0.00 67570 S 1,048.25 0.00 0.00<br />

67110 S 330.49 0.00 0.00 67700 S 122.99 0.00 0.00<br />

67112 S 1,213.60 0.00 0.00 67710 S 143.63 0.00 0.00<br />

67113 S 1,489.37 0.00 0.00 67715 S 533.69 0.00 0.00<br />

67115 S 645.72 0.00 0.00 67800 S 51.60 0.00 0.00<br />

67120 S 645.72 0.00 0.00 67801 S 62.40 0.00 0.00<br />

67121 S 645.72 0.00 0.00 67805 S 80.88 0.00 0.00<br />

67141 S 227.61 0.00 0.00 67808 S 586.94 0.00 0.00<br />

67145 S 194.18 0.00 0.00 67810 S 122.99 0.00 0.00<br />

67208 S 207.08 0.00 0.00 67820 S 17.08 0.00 0.00<br />

67210 S 205.40 0.00 0.00 67825 S 52.64 0.00 0.00<br />

67218 S 773.43 0.00 0.00 67830 S 360.34 0.00 0.00<br />

67220 S 227.36 0.00 0.00 67835 S 586.94 0.00 0.00<br />

67221 S 116.78 0.00 0.00 67840 S 150.61 0.00 0.00<br />

67225 S 8.02 0.00 0.00 67850 S 119.58 0.00 0.00<br />

67227 S 592.47 0.00 0.00 67875 S 300.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 566.92 0.00 0.00 68440 S 51.25 0.00 0.00<br />

67882 S 617.11 0.00 0.00 68500 S 748.12 0.00 0.00<br />

67900 S 804.68 0.00 0.00 68505 S 748.12 0.00 0.00<br />

67901 S 714.66 0.00 0.00 68510 S 533.69 0.00 0.00<br />

67902 S 845.67 0.00 0.00 68520 S 748.12 0.00 0.00<br />

67903 S 673.65 0.00 0.00 68525 S 533.69 0.00 0.00<br />

67904 S 673.65 0.00 0.00 68530 S 122.99 0.00 0.00<br />

67906 S 714.66 0.00 0.00 68540 S 617.11 0.00 0.00<br />

67908 S 673.65 0.00 0.00 68550 S 748.12 0.00 0.00<br />

67909 S 673.65 0.00 0.00 68700 S 586.94 0.00 0.00<br />

67911 S 617.11 0.00 0.00 68705 S 116.78 0.00 0.00<br />

67912 S 617.11 0.00 0.00 68720 S 804.68 0.00 0.00<br />

67914 S 617.11 0.00 0.00 68745 S 804.68 0.00 0.00<br />

67915 S 166.64 0.00 0.00 68750 S 804.68 0.00 0.00<br />

67916 S 673.65 0.00 0.00 68760 S 99.36 0.00 0.00<br />

67917 S 673.65 0.00 0.00 68761 S 68.68 0.00 0.00<br />

67921 S 617.11 0.00 0.00 68770 S 804.68 0.00 0.00<br />

67922 S 162.11 0.00 0.00 68801 S 36.43 0.00 0.00<br />

67923 S 673.65 0.00 0.00 68810 S 104.18 0.00 0.00<br />

67924 S 673.65 0.00 0.00 68811 S 586.94 0.00 0.00<br />

67930 S 166.64 0.00 0.00 68815 S 586.94 0.00 0.00<br />

67935 S 586.94 0.00 0.00 68816 S 753.51 0.00 0.00<br />

67938 S 84.07 0.00 0.00 68840 S 54.03 0.00 0.00<br />

67950 S 586.94 0.00 0.00 69000 S 55.12 0.00 0.00<br />

67961 S 617.11 0.00 0.00 69005 S 104.24 0.00 0.00<br />

67966 S 617.11 0.00 0.00 69020 S 55.12 0.00 0.00<br />

67971 S 617.11 0.00 0.00 69100 S 62.75 0.00 0.00<br />

67973 S 748.12 0.00 0.00 69105 S 88.90 0.00 0.00<br />

67974 S 617.11 0.00 0.00 69110 S 467.04 0.00 0.00<br />

67975 S 617.11 0.00 0.00 69120 S 693.09 0.00 0.00<br />

68020 S 45.67 0.00 0.00 69140 S 693.09 0.00 0.00<br />

68040 S 22.66 0.00 0.00 69145 S 520.29 0.00 0.00<br />

68100 S 90.64 0.00 0.00 69150 S 365.68 0.00 0.00<br />

68110 S 116.78 0.00 0.00 69200 S 25.21 0.00 0.00<br />

68115 S 586.94 0.00 0.00 69205 S 583.02 0.00 0.00<br />

68130 S 536.75 0.00 0.00 69210 S 20.57 0.00 0.00<br />

68135 S 58.57 0.00 0.00 69220 S 32.30 0.00 0.00<br />

68200 S 16.73 0.00 0.00 69222 S 135.96 0.00 0.00<br />

68320 S 804.68 0.00 0.00 69300 S 723.26 0.00 0.00<br />

68325 S 804.68 0.00 0.00 69310 S 1,057.19 0.00 0.00<br />

68326 S 673.65 0.00 0.00 69320 S 1,285.75 0.00 0.00<br />

68328 S 804.68 0.00 0.00 69400 S 91.33 0.00 0.00<br />

68330 S 763.04 0.00 0.00 69401 S 48.11 0.00 0.00<br />

68335 S 804.68 0.00 0.00 69405 S 126.20 0.00 0.00<br />

68340 S 673.65 0.00 0.00 69420 S 113.30 0.00 0.00<br />

68360 S 676.33 0.00 0.00 69421 S 576.65 0.00 0.00<br />

68362 S 676.33 0.00 0.00 69424 S 79.48 0.00 0.00<br />

68371 S 536.75 0.00 0.00 69433 S 112.96 0.00 0.00<br />

68400 S 122.99 0.00 0.00 69436 S 576.65 0.00 0.00<br />

68420 S 175.00 0.00 0.00 69440 S 723.26 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 973.77 0.00 0.00 69840 S 1,154.74 0.00 0.00<br />

69501 S 1,285.75 0.00 0.00 69905 S 1,285.75 0.00 0.00<br />

69502 S 951.82 0.00 0.00 69910 S 1,285.75 0.00 0.00<br />

69505 S 1,285.75 0.00 0.00 69915 S 1,285.75 0.00 0.00<br />

69511 S 1,285.75 0.00 0.00 69930 S 23,244.64 12,480.80 1,716.96<br />

69530 S 1,285.75 0.00 0.00 70030 TC A 17.78 0.00 0.00<br />

69540 S 132.82 0.00 0.00 70100 TC A 19.53 0.00 0.00<br />

69550 S 1,154.74 0.00 0.00 70110 TC A 24.06 0.00 0.00<br />

69552 S 1,285.75 0.00 0.00 70120 TC A 21.61 0.00 0.00<br />

69601 S 1,285.75 0.00 0.00 70130 TC A 26.41 0.00 0.00<br />

69602 S 1,285.75 0.00 0.00 70134 TC A 26.49 0.00 0.00<br />

69603 S 1,285.75 0.00 0.00 70140 TC A 18.12 0.00 0.00<br />

69604 S 1,285.75 0.00 0.00 70150 TC A 26.41 0.00 0.00<br />

69605 S 1,285.75 0.00 0.00 70160 TC A 21.27 0.00 0.00<br />

69610 S 177.80 0.00 0.00 70190 TC A 22.31 0.00 0.00<br />

69620 S 693.09 0.00 0.00 70200 TC A 26.41 0.00 0.00<br />

69631 S 1,154.74 0.00 0.00 70210 TC A 18.83 0.00 0.00<br />

69632 S 1,154.74 0.00 0.00 70220 TC A 23.71 0.00 0.00<br />

69633 S 1,154.74 0.00 0.00 70240 TC A 17.78 0.00 0.00<br />

69635 S 1,285.75 0.00 0.00 70250 TC A 21.61 0.00 0.00<br />

69636 S 1,285.75 0.00 0.00 70260 TC A 27.54 0.00 0.00<br />

69637 S 1,285.75 0.00 0.00 70300 TC A 7.67 0.00 0.00<br />

69641 S 1,285.75 0.00 0.00 70310 TC A 18.95 0.00 0.00<br />

69642 S 1,285.75 0.00 0.00 70320 TC A 18.95 0.00 0.00<br />

69643 S 1,285.75 0.00 0.00 70328 TC A 18.83 0.00 0.00<br />

69644 S 1,285.75 0.00 0.00 70330 TC A 26.41 0.00 0.00<br />

69645 S 1,285.75 0.00 0.00 70336 TC A 205.56 0.00 0.00<br />

69646 S 1,285.75 0.00 0.00 70350 TC A 10.46 0.00 0.00<br />

69650 S 951.82 0.00 0.00 70355 TC A 10.81 0.00 0.00<br />

69660 S 1,154.74 0.00 0.00 70360 TC A 16.73 0.00 0.00<br />

69661 S 1,154.74 0.00 0.00 70370 TC A 49.14 0.00 0.00<br />

69662 S 1,154.74 0.00 0.00 70371 TC A 49.14 0.00 0.00<br />

69666 S 1,113.74 0.00 0.00 70380 TC A 25.45 0.00 0.00<br />

69667 S 1,113.74 0.00 0.00 70450 TC A 114.80 0.00 0.00<br />

69670 S 1,057.19 0.00 0.00 70460 TC A 181.79 0.00 0.00<br />

69676 S 1,057.19 0.00 0.00 70470 TC A 201.37 0.00 0.00<br />

69700 S 1,057.19 0.00 0.00 70480 TC A 114.80 0.00 0.00<br />

69711 S 973.77 0.00 0.00 70481 TC A 181.79 0.00 0.00<br />

69714 S 6,175.49 3,893.88 1,612.27 70482 TC A 201.37 0.00 0.00<br />

69715 S 6,175.49 3,893.88 1,612.27 70486 TC A 114.80 0.00 0.00<br />

69717 S 6,175.49 3,893.88 1,612.27 70487 TC A 181.79 0.00 0.00<br />

69718 S 6,175.49 3,893.88 1,612.27 70488 TC A 201.37 0.00 0.00<br />

69720 S 1,154.74 0.00 0.00 70490 TC A 114.80 0.00 0.00<br />

69740 S 1,154.74 0.00 0.00 70491 TC A 181.79 0.00 0.00<br />

69745 S 1,154.74 0.00 0.00 70492 TC A 201.37 0.00 0.00<br />

69801 S 1,154.74 0.00 0.00 70496 TC A 207.81 0.00 0.00<br />

69802 S 1,285.75 0.00 0.00 70498 TC A 207.81 0.00 0.00<br />

69805 S 1,285.75 0.00 0.00 70540 TC A 205.56 0.00 0.00<br />

69806 S 1,285.75 0.00 0.00 70542 TC A 252.43 0.00 0.00<br />

69820 S 1,154.74 0.00 0.00 70543 TC A 318.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 205.56 0.00 0.00 72120 TC A 33.46 0.00 0.00<br />

70545 TC A 252.43 0.00 0.00 72125 TC A 114.80 0.00 0.00<br />

70546 TC A 318.15 0.00 0.00 72126 TC A 181.79 0.00 0.00<br />

70547 TC A 205.56 0.00 0.00 72127 TC A 201.37 0.00 0.00<br />

70548 TC A 252.43 0.00 0.00 72128 TC A 114.80 0.00 0.00<br />

70549 TC A 318.15 0.00 0.00 72129 TC A 181.79 0.00 0.00<br />

70551 TC A 205.56 0.00 0.00 72130 TC A 201.37 0.00 0.00<br />

70552 TC A 252.43 0.00 0.00 72131 TC A 114.80 0.00 0.00<br />

70553 TC A 318.15 0.00 0.00 72132 TC A 181.79 0.00 0.00<br />

70554 TC A 205.56 0.00 0.00 72133 TC A 201.37 0.00 0.00<br />

70555 TC A 205.56 0.00 0.00 72141 TC A 205.56 0.00 0.00<br />

70557 TC A 205.56 0.00 0.00 72142 TC A 252.43 0.00 0.00<br />

70558 TC A 252.43 0.00 0.00 72146 TC A 205.56 0.00 0.00<br />

70559 TC A 318.15 0.00 0.00 72147 TC A 252.43 0.00 0.00<br />

71010 TC A 13.60 0.00 0.00 72148 TC A 205.56 0.00 0.00<br />

71015 TC A 17.43 0.00 0.00 72149 TC A 252.43 0.00 0.00<br />

71020 TC A 18.48 0.00 0.00 72156 TC A 318.15 0.00 0.00<br />

71021 TC A 22.31 0.00 0.00 72157 TC A 318.15 0.00 0.00<br />

71022 TC A 26.41 0.00 0.00 72158 TC A 318.15 0.00 0.00<br />

71023 TC A 43.23 0.00 0.00 72170 TC A 15.69 0.00 0.00<br />

71030 TC A 26.41 0.00 0.00 72190 TC A 26.41 0.00 0.00<br />

71034 TC A 49.14 0.00 0.00 72191 TC A 207.81 0.00 0.00<br />

71035 TC A 23.01 0.00 0.00 72192 TC A 114.80 0.00 0.00<br />

71100 TC A 19.18 0.00 0.00 72193 TC A 181.79 0.00 0.00<br />

71101 TC A 23.35 0.00 0.00 72194 TC A 201.37 0.00 0.00<br />

71110 TC A 24.41 0.00 0.00 72195 TC A 205.56 0.00 0.00<br />

71111 TC A 32.42 0.00 0.00 72196 TC A 252.43 0.00 0.00<br />

71120 TC A 20.22 0.00 0.00 72197 TC A 318.15 0.00 0.00<br />

71130 TC A 23.71 0.00 0.00 72200 TC A 18.48 0.00 0.00<br />

71250 TC A 114.80 0.00 0.00 72202 TC A 22.66 0.00 0.00<br />

71260 TC A 181.79 0.00 0.00 72220 TC A 18.48 0.00 0.00<br />

71270 TC A 201.37 0.00 0.00 73000 TC A 17.43 0.00 0.00<br />

71275 TC A 207.81 0.00 0.00 73010 TC A 17.78 0.00 0.00<br />

71550 TC A 205.56 0.00 0.00 73020 TC A 14.30 0.00 0.00<br />

71551 TC A 252.43 0.00 0.00 73030 TC A 18.12 0.00 0.00<br />

71552 TC A 318.15 0.00 0.00 73050 TC A 22.66 0.00 0.00<br />

72010 TC A 43.96 0.00 0.00 73060 TC A 18.12 0.00 0.00<br />

72020 TC A 14.30 0.00 0.00 73070 TC A 17.43 0.00 0.00<br />

72040 TC A 23.01 0.00 0.00 73080 TC A 23.01 0.00 0.00<br />

72050 TC A 32.77 0.00 0.00 73090 TC A 17.43 0.00 0.00<br />

72052 TC A 43.96 0.00 0.00 73092 TC A 18.12 0.00 0.00<br />

72069 TC A 21.61 0.00 0.00 73100 TC A 18.12 0.00 0.00<br />

72070 TC A 20.22 0.00 0.00 73110 TC A 23.01 0.00 0.00<br />

72072 TC A 24.41 0.00 0.00 73120 TC A 17.08 0.00 0.00<br />

72074 TC A 26.41 0.00 0.00 73130 TC A 20.22 0.00 0.00<br />

72080 TC A 21.61 0.00 0.00 73140 TC A 19.87 0.00 0.00<br />

72090 TC A 28.94 0.00 0.00 73200 TC A 114.80 0.00 0.00<br />

72100 TC A 24.75 0.00 0.00 73201 TC A 181.79 0.00 0.00<br />

72110 TC A 34.52 0.00 0.00 73202 TC A 201.37 0.00 0.00<br />

72114 TC A 43.96 0.00 0.00 73206 TC A 207.81 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 205.56 0.00 0.00 74246 TC A 51.88 0.00 0.00<br />

73219 TC A 252.43 0.00 0.00 74247 TC A 51.88 0.00 0.00<br />

73220 TC A 318.15 0.00 0.00 74249 TC A 84.36 0.00 0.00<br />

73221 TC A 205.56 0.00 0.00 74250 TC A 51.88 0.00 0.00<br />

73222 TC A 252.43 0.00 0.00 74251 TC A 84.36 0.00 0.00<br />

73223 TC A 318.15 0.00 0.00 74260 TC A 51.88 0.00 0.00<br />

73500 TC A 14.99 0.00 0.00 74270 TC A 51.88 0.00 0.00<br />

73510 TC A 23.01 0.00 0.00 74280 TC A 84.36 0.00 0.00<br />

73520 TC A 23.71 0.00 0.00 74283 TC A 51.88 0.00 0.00<br />

73540 TC A 23.71 0.00 0.00 74290 TC A 44.27 0.00 0.00<br />

73550 TC A 17.43 0.00 0.00 74291 TC A 42.53 0.00 0.00<br />

73560 TC A 17.78 0.00 0.00 74400 TC A 77.05 0.00 0.00<br />

73562 TC A 21.96 0.00 0.00 74410 TC A 82.28 0.00 0.00<br />

73564 TC A 25.45 0.00 0.00 74415 TC A 98.31 0.00 0.00<br />

73565 TC A 19.18 0.00 0.00 74420 TC A 102.76 0.00 0.00<br />

73590 TC A 16.73 0.00 0.00 74710 TC A 23.01 0.00 0.00<br />

73592 TC A 18.12 0.00 0.00 74775 TC A 102.76 0.00 0.00<br />

73600 TC A 17.08 0.00 0.00 75557 TC A 205.56 0.00 0.00<br />

73610 TC A 20.22 0.00 0.00 75559 TC A 205.56 0.00 0.00<br />

73620 TC A 16.38 0.00 0.00 75561 TC A 318.15 0.00 0.00<br />

73630 TC A 19.87 0.00 0.00 75563 TC A 318.15 0.00 0.00<br />

73650 TC A 16.73 0.00 0.00 76010 TC A 17.08 0.00 0.00<br />

73660 TC A 18.83 0.00 0.00 76098 TC A 10.46 0.00 0.00<br />

73700 TC A 114.80 0.00 0.00 76100 TC A 43.96 0.00 0.00<br />

73701 TC A 181.79 0.00 0.00 76101 TC A 117.83 0.00 0.00<br />

73702 TC A 201.37 0.00 0.00 76102 TC A 117.83 0.00 0.00<br />

73706 TC A 207.81 0.00 0.00 76120 TC A 49.14 0.00 0.00<br />

73718 TC A 205.56 0.00 0.00 76150 A 17.08 0.00 0.00<br />

73719 TC A 252.43 0.00 0.00 76380 TC A 62.02 0.00 0.00<br />

73720 TC A 318.15 0.00 0.00 76496 TC A 49.14 0.00 0.00<br />

73721 TC A 205.56 0.00 0.00 76497 TC A 62.02 0.00 0.00<br />

73722 TC A 252.43 0.00 0.00 76498 TC A 205.56 0.00 0.00<br />

73723 TC A 318.15 0.00 0.00 76499 TC A 26.41 0.00 0.00<br />

74000 TC A 14.99 0.00 0.00 76506 TC A 36.91 0.00 0.00<br />

74010 TC A 23.35 0.00 0.00 76510 TC A 62.75 0.00 0.00<br />

74020 TC A 23.71 0.00 0.00 76511 TC A 43.92 0.00 0.00<br />

74022 TC A 28.94 0.00 0.00 76512 TC A 37.30 0.00 0.00<br />

74150 TC A 114.80 0.00 0.00 76513 TC A 45.32 0.00 0.00<br />

74160 TC A 181.79 0.00 0.00 76514 TC A 3.14 0.00 0.00<br />

74170 TC A 201.37 0.00 0.00 76516 TC A 35.56 0.00 0.00<br />

74175 TC A 207.81 0.00 0.00 76519 TC A 39.75 0.00 0.00<br />

74181 TC A 205.56 0.00 0.00 76529 TC A 34.52 0.00 0.00<br />

74182 TC A 252.43 0.00 0.00 76536 TC A 57.74 0.00 0.00<br />

74183 TC A 318.15 0.00 0.00 76604 TC A 36.91 0.00 0.00<br />

74210 TC A 51.88 0.00 0.00 76645 TC A 36.91 0.00 0.00<br />

74220 TC A 51.88 0.00 0.00 76700 TC A 57.74 0.00 0.00<br />

74230 TC A 51.88 0.00 0.00 76705 TC A 57.74 0.00 0.00<br />

74240 TC A 51.88 0.00 0.00 76770 TC A 57.74 0.00 0.00<br />

74241 TC A 51.88 0.00 0.00 76775 TC A 57.74 0.00 0.00<br />

74245 TC A 84.36 0.00 0.00 76776 TC A 57.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 57.74 0.00 0.00 77290 TC A 151.01 0.00 0.00<br />

76801 TC A 57.74 0.00 0.00 77295 TC A 395.69 0.00 0.00<br />

76802 TC A 27.54 0.00 0.00 77299 TC A 67.75 0.00 0.00<br />

76805 TC A 57.74 0.00 0.00 77300 TC A 36.61 0.00 0.00<br />

76810 TC A 43.57 0.00 0.00 77301 TC A 527.34 0.00 0.00<br />

76811 TC A 90.46 0.00 0.00 77305 TC A 33.46 0.00 0.00<br />

76812 TC A 36.91 0.00 0.00 77310 TC A 43.57 0.00 0.00<br />

76813 TC A 36.91 0.00 0.00 77315 TC A 63.45 0.00 0.00<br />

76814 TC A 29.29 0.00 0.00 77321 TC A 65.89 0.00 0.00<br />

76815 TC A 36.91 0.00 0.00 77326 TC A 67.75 0.00 0.00<br />

76816 TC A 36.91 0.00 0.00 77327 TC A 123.07 0.00 0.00<br />

76817 TC A 36.91 0.00 0.00 77328 TC A 151.01 0.00 0.00<br />

76818 TC A 57.74 0.00 0.00 77331 TC A 17.43 0.00 0.00<br />

76819 TC A 49.86 0.00 0.00 77332 TC A 46.72 0.00 0.00<br />

76820 TC A 24.75 0.00 0.00 77333 TC A 22.66 0.00 0.00<br />

76821 TC A 55.90 0.00 0.00 77334 TC A 87.51 0.00 0.00<br />

76825 TC A 116.44 0.00 0.00 77336 A 55.09 0.00 0.00<br />

76826 TC A 69.37 0.00 0.00 77370 A 67.75 0.00 0.00<br />

76827 TC A 36.91 0.00 0.00 77371 A 4,513.15 0.00 0.00<br />

76828 TC A 21.96 0.00 0.00 77399 TC A 67.75 0.00 0.00<br />

76830 TC A 57.74 0.00 0.00 77401 A 27.54 0.00 0.00<br />

76831 TC A 77.74 0.00 0.00 77402 A 55.44 0.00 0.00<br />

76856 TC A 57.74 0.00 0.00 77403 A 55.44 0.00 0.00<br />

76857 TC A 36.91 0.00 0.00 77404 A 55.44 0.00 0.00<br />

76870 TC A 57.74 0.00 0.00 77406 A 89.81 0.00 0.00<br />

76872 TC A 57.74 0.00 0.00 77407 A 55.44 0.00 0.00<br />

76873 TC A 57.74 0.00 0.00 77408 A 55.44 0.00 0.00<br />

76880 TC A 57.74 0.00 0.00 77409 A 55.44 0.00 0.00<br />

76885 TC A 36.91 0.00 0.00 77411 A 89.81 0.00 0.00<br />

76886 TC A 36.91 0.00 0.00 77412 A 89.81 0.00 0.00<br />

76936 TC A 55.90 0.00 0.00 77413 A 89.81 0.00 0.00<br />

76970 TC A 36.91 0.00 0.00 77414 A 89.81 0.00 0.00<br />

76977 TC A 9.41 0.00 0.00 77416 A 89.81 0.00 0.00<br />

76999 TC A 36.91 0.00 0.00 77418 A 242.64 0.00 0.00<br />

77071 A 21.61 0.00 0.00 77422 A 89.81 0.00 0.00<br />

77072 TC A 12.55 0.00 0.00 77423 A 89.81 0.00 0.00<br />

77073 TC A 21.27 0.00 0.00 77470 TC A 128.99 0.00 0.00<br />

77074 TC A 41.83 0.00 0.00 77520 A 415.42 0.00 0.00<br />

77075 TC A 43.96 0.00 0.00 77522 A 415.42 0.00 0.00<br />

77076 TC A 43.96 0.00 0.00 77523 A 496.44 0.00 0.00<br />

77077 TC A 23.71 0.00 0.00 77525 A 496.44 0.00 0.00<br />

77078 TC A 42.47 0.00 0.00 77600 TC A 220.41 0.00 0.00<br />

77079 TC A 43.57 0.00 0.00 77605 TC A 220.41 0.00 0.00<br />

77080 TC A 42.47 0.00 0.00 77610 TC A 220.41 0.00 0.00<br />

77081 TC A 17.08 0.00 0.00 77615 TC A 220.41 0.00 0.00<br />

77082 TC A 18.48 0.00 0.00 77620 TC A 220.41 0.00 0.00<br />

77083 TC A 14.64 0.00 0.00 77750 TC A 85.76 0.00 0.00<br />

77084 TC A 205.56 0.00 0.00 77761 TC A 150.95 0.00 0.00<br />

77280 TC A 67.75 0.00 0.00 77762 TC A 178.84 0.00 0.00<br />

77285 TC A 151.01 0.00 0.00 77763 TC A 230.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 163.50 0.00 0.00 78262 TC A 143.59 0.00 0.00<br />

77777 TC A 179.54 0.00 0.00 78264 TC A 143.59 0.00 0.00<br />

77778 TC A 239.16 0.00 0.00 78270 TC A 62.75 0.00 0.00<br />

77785 TC A 106.33 0.00 0.00 78271 TC A 63.80 0.00 0.00<br />

77786 TC A 373.72 0.00 0.00 78272 TC A 70.07 0.00 0.00<br />

77787 TC A 433.06 0.00 0.00 78278 TC A 143.59 0.00 0.00<br />

77789 TC A 44.63 0.00 0.00 78282 TC A 143.59 0.00 0.00<br />

77799 TC A 254.35 0.00 0.00 78290 TC A 143.59 0.00 0.00<br />

78000 TC A 54.73 0.00 0.00 78291 TC A 143.59 0.00 0.00<br />

78001 TC A 69.36 0.00 0.00 78299 TC A 143.59 0.00 0.00<br />

78003 TC A 55.09 0.00 0.00 78300 TC A 125.16 0.00 0.00<br />

78006 TC A 131.06 0.00 0.00 78305 TC A 145.15 0.00 0.00<br />

78007 TC A 96.92 0.00 0.00 78306 TC A 145.15 0.00 0.00<br />

78010 TC A 80.53 0.00 0.00 78315 TC A 145.15 0.00 0.00<br />

78011 TC A 80.53 0.00 0.00 78320 TC A 145.15 0.00 0.00<br />

78015 TC A 156.53 0.00 0.00 78399 TC A 145.15 0.00 0.00<br />

78016 TC A 176.68 0.00 0.00 78414 TC A 184.50 0.00 0.00<br />

78018 TC A 176.68 0.00 0.00 78428 TC A 141.54 0.00 0.00<br />

78070 TC A 120.27 0.00 0.00 78445 TC A 110.41 0.00 0.00<br />

78075 TC A 340.60 0.00 0.00 78456 TC A 110.41 0.00 0.00<br />

78099 TC A 80.53 0.00 0.00 78457 TC A 110.41 0.00 0.00<br />

78102 TC A 121.67 0.00 0.00 78458 TC A 110.41 0.00 0.00<br />

78103 TC A 155.09 0.00 0.00 78459 TC A 683.24 0.00 0.00<br />

78104 TC A 155.09 0.00 0.00 78460 TC A 132.47 0.00 0.00<br />

78110 TC A 61.71 0.00 0.00 78461 TC A 133.53 0.00 0.00<br />

78111 TC A 78.09 0.00 0.00 78464 TC A 195.92 0.00 0.00<br />

78120 TC A 68.33 0.00 0.00 78465 TC A 370.93 0.00 0.00<br />

78121 TC A 80.88 0.00 0.00 78466 TC A 131.43 0.00 0.00<br />

78122 TC A 95.87 0.00 0.00 78468 TC A 168.03 0.00 0.00<br />

78130 TC A 111.21 0.00 0.00 78469 TC A 184.50 0.00 0.00<br />

78135 TC A 236.35 0.00 0.00 78472 TC A 184.50 0.00 0.00<br />

78140 TC A 104.93 0.00 0.00 78473 TC A 184.50 0.00 0.00<br />

78185 TC A 155.09 0.00 0.00 78481 TC A 159.32 0.00 0.00<br />

78190 TC A 97.32 0.00 0.00 78483 TC A 184.50 0.00 0.00<br />

78191 TC A 97.32 0.00 0.00 78491 TC A 683.24 0.00 0.00<br />

78195 TC A 155.09 0.00 0.00 78492 TC A 683.24 0.00 0.00<br />

78199 TC A 155.09 0.00 0.00 78494 TC A 184.50 0.00 0.00<br />

78201 TC A 138.05 0.00 0.00 78499 TC A 184.50 0.00 0.00<br />

78202 TC A 162.40 0.00 0.00 78580 TC A 125.00 0.00 0.00<br />

78205 TC A 162.40 0.00 0.00 78584 TC A 96.56 0.00 0.00<br />

78206 TC A 162.40 0.00 0.00 78585 TC A 191.80 0.00 0.00<br />

78215 TC A 146.07 0.00 0.00 78586 TC A 125.00 0.00 0.00<br />

78216 TC A 99.01 0.00 0.00 78587 TC A 125.00 0.00 0.00<br />

78220 TC A 108.08 0.00 0.00 78588 TC A 191.80 0.00 0.00<br />

78223 TC A 162.40 0.00 0.00 78591 TC A 125.00 0.00 0.00<br />

78230 TC A 122.71 0.00 0.00 78593 TC A 125.00 0.00 0.00<br />

78231 TC A 96.56 0.00 0.00 78594 TC A 125.00 0.00 0.00<br />

78232 TC A 100.75 0.00 0.00 78596 TC A 191.80 0.00 0.00<br />

78258 TC A 143.59 0.00 0.00 78599 TC A 125.00 0.00 0.00<br />

78261 TC A 143.59 0.00 0.00 78600 TC A 110.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 37340 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 110.16 0.00 0.00<br />

78605 TC A 110.16 0.00 0.00<br />

78606 TC A 247.52 0.00 0.00<br />

78607 TC A 271.92 0.00 0.00<br />

78608 TC A 612.40 0.00 0.00<br />

78610 TC A 146.77 0.00 0.00<br />

78630 TC A 261.47 0.00 0.00<br />

78635 TC A 240.90 0.00 0.00<br />

78645 TC A 110.16 0.00 0.00<br />

78647 TC A 266.69 0.00 0.00<br />

78650 TC A 258.32 0.00 0.00<br />

78660 TC A 110.16 0.00 0.00<br />

78699 TC A 110.16 0.00 0.00<br />

78700 TC A 135.61 0.00 0.00<br />

78701 TC A 165.25 0.00 0.00<br />

78707 TC A 172.57 0.00 0.00<br />

78708 TC A 118.19 0.00 0.00<br />

78709 TC A 194.31 0.00 0.00<br />

78710 TC A 182.33 0.00 0.00<br />

78725 TC A 72.86 0.00 0.00<br />

78730 TC A 61.71 0.00 0.00<br />

78740 TC A 161.06 0.00 0.00<br />

78761 TC A 153.74 0.00 0.00<br />

78799 TC A 194.31 0.00 0.00<br />

78800 TC A 135.96 0.00 0.00<br />

78801 TC A 186.52 0.00 0.00<br />

78802 TC A 252.75 0.00 0.00<br />

78803 TC A 270.88 0.00 0.00<br />

78804 TC A 472.73 0.00 0.00<br />

78805 TC A 132.82 0.00 0.00<br />

78806 TC A 265.65 0.00 0.00<br />

78807 TC A 271.23 0.00 0.00<br />

78811 TC A 612.40 0.00 0.00<br />

78812 TC A 612.40 0.00 0.00<br />

78813 TC A 612.40 0.00 0.00<br />

78814 TC A 612.40 0.00 0.00<br />

78815 TC A 612.40 0.00 0.00<br />

78816 TC A 612.40 0.00 0.00<br />

78999 TC A 69.36 0.00 0.00<br />

79005 TC A 55.78 0.00 0.00<br />

79101 TC A 61.01 0.00 0.00<br />

79200 TC A 65.89 0.00 0.00<br />

79300 TC A 127.13 0.00 0.00<br />

79403 TC A 94.48 0.00 0.00<br />

79440 TC A 53.34 0.00 0.00<br />

79445 TC A 127.13 0.00 0.00<br />

79999 TC A 127.13 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,203.30 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,494.55 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.47 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,544.31 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,544.31 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 223.02 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 223.02 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 112.61 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 238.00 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 71.55 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 640.66 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,460.94 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,143.55 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,143.55 0.00 0.00<br />

C8900 A 247.61 0.00 0.00 0123T S 914.50 0.00 0.00<br />

C8901 A 201.63 0.00 0.00 0124T S 178.75 0.00 0.00<br />

C8902 A 312.07 0.00 0.00 0144T TC A 60.83 0.00 0.00<br />

C8903 A 247.61 0.00 0.00 0145T TC A 163.76 0.00 0.00<br />

C8904 A 201.63 0.00 0.00 0146T TC A 163.76 0.00 0.00<br />

C8905 A 312.07 0.00 0.00 0147T TC A 163.76 0.00 0.00<br />

C8906 A 247.61 0.00 0.00 0148T TC A 163.76 0.00 0.00<br />

C8907 A 201.63 0.00 0.00 0149T TC A 163.76 0.00 0.00<br />

C8908 A 312.07 0.00 0.00 0150T TC A 163.76 0.00 0.00<br />

C8909 A 247.61 0.00 0.00 0151T TC A 60.83 0.00 0.00<br />

C8910 A 201.63 0.00 0.00 0170T S 1,187.88 0.00 0.00<br />

C8911 A 312.07 0.00 0.00 0176T S 1,402.62 0.00 0.00<br />

C8912 A 247.61 0.00 0.00 0177T S 1,402.62 0.00 0.00<br />

C8913 A 201.63 0.00 0.00 0182T A 1,013.82 0.00 0.00<br />

C8914 A 312.07 0.00 0.00 0186T S 854.44 0.00 0.00<br />

C8918 A 247.61 0.00 0.00 0190T S 854.44 0.00 0.00<br />

C8919 A 201.63 0.00 0.00 0191T S 914.50 0.00 0.00<br />

C8920 A 312.07 0.00 0.00 0192T S 1,567.27 0.00 0.00<br />

C9716 S 1,187.88 0.00 0.00 10021 S 54.81 0.00 0.00<br />

C9724 S 971.23 0.00 0.00 10022 S 171.17 0.00 0.00<br />

C9725 S 223.96 0.00 0.00 10040 S 31.69 0.00 0.00<br />

C9726 S 822.23 0.00 0.00 10060 S 48.21 0.00 0.00<br />

C9727 S 288.29 0.00 0.00 10061 S 54.06 0.00 0.00<br />

C9728 S 517.27 0.00 0.00 10080 S 54.06 0.00 0.00<br />

G0104 S 83.10 0.00 0.00 10081 S 124.47 0.00 0.00<br />

G0105 S 359.14 0.00 0.00 10120 S 67.71 0.00 0.00<br />

G0121 S 359.14 0.00 0.00 10121 S 510.36 0.00 0.00<br />

G0127 S 11.62 0.00 0.00 10140 S 71.81 0.00 0.00<br />

G0130 TC A 19.15 0.00 0.00 10160 S 54.06 0.00 0.00<br />

G0173 A 2,203.30 0.00 0.00 10180 S 577.15 0.00 0.00<br />

G0186 S 223.02 0.00 0.00 11000 S 23.26 0.00 0.00<br />

G0247 S 21.20 0.00 0.00 11001 S 7.87 0.00 0.00<br />

G0251 A 551.74 0.00 0.00 11010 S 201.92 0.00 0.00<br />

G0260 S 291.17 0.00 0.00 11011 S 201.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 201.92 0.00 0.00 11601 S 111.48 0.00 0.00<br />

11040 S 21.20 0.00 0.00 11602 S 122.77 0.00 0.00<br />

11041 S 23.60 0.00 0.00 11603 S 130.29 0.00 0.00<br />

11042 S 128.22 0.00 0.00 11604 S 351.44 0.00 0.00<br />

11043 S 128.22 0.00 0.00 11606 S 510.36 0.00 0.00<br />

11044 S 333.86 0.00 0.00 11620 S 95.07 0.00 0.00<br />

11055 S 24.96 0.00 0.00 11621 S 112.85 0.00 0.00<br />

11056 S 27.35 0.00 0.00 11622 S 125.50 0.00 0.00<br />

11057 S 31.69 0.00 0.00 11623 S 135.07 0.00 0.00<br />

11100 S 58.06 0.00 0.00 11624 S 510.36 0.00 0.00<br />

11101 S 13.68 0.00 0.00 11626 S 624.13 0.00 0.00<br />

11200 S 31.69 0.00 0.00 11640 S 100.54 0.00 0.00<br />

11201 S 5.47 0.00 0.00 11641 S 118.66 0.00 0.00<br />

11300 S 31.69 0.00 0.00 11642 S 132.34 0.00 0.00<br />

11301 S 31.69 0.00 0.00 11643 S 142.60 0.00 0.00<br />

11302 S 31.69 0.00 0.00 11644 S 510.36 0.00 0.00<br />

11303 S 58.06 0.00 0.00 11646 S 624.13 0.00 0.00<br />

11305 S 31.69 0.00 0.00 11719 S 11.62 0.00 0.00<br />

11306 S 31.69 0.00 0.00 11720 S 14.36 0.00 0.00<br />

11307 S 31.69 0.00 0.00 11721 S 17.44 0.00 0.00<br />

11308 S 31.69 0.00 0.00 11730 S 31.69 0.00 0.00<br />

11310 S 31.69 0.00 0.00 11732 S 17.44 0.00 0.00<br />

11311 S 31.69 0.00 0.00 11740 S 16.00 0.00 0.00<br />

11312 S 31.69 0.00 0.00 11750 S 92.33 0.00 0.00<br />

11313 S 31.69 0.00 0.00 11752 S 128.24 0.00 0.00<br />

11400 S 65.32 0.00 0.00 11755 S 63.94 0.00 0.00<br />

11401 S 73.52 0.00 0.00 11760 S 131.70 0.00 0.00<br />

11402 S 80.71 0.00 0.00 11762 S 117.64 0.00 0.00<br />

11403 S 86.18 0.00 0.00 11765 S 31.69 0.00 0.00<br />

11404 S 458.13 0.00 0.00 11770 S 653.72 0.00 0.00<br />

11406 S 510.36 0.00 0.00 11771 S 653.72 0.00 0.00<br />

11420 S 61.21 0.00 0.00 11772 S 653.72 0.00 0.00<br />

11421 S 74.20 0.00 0.00 11900 S 29.07 0.00 0.00<br />

11422 S 81.05 0.00 0.00 11901 S 31.69 0.00 0.00<br />

11423 S 90.28 0.00 0.00 11920 S 91.99 0.00 0.00<br />

11424 S 510.36 0.00 0.00 11921 S 101.22 0.00 0.00<br />

11426 S 624.13 0.00 0.00 11922 S 32.82 0.00 0.00<br />

11440 S 70.11 0.00 0.00 11950 S 33.52 0.00 0.00<br />

11441 S 81.05 0.00 0.00 11951 S 41.72 0.00 0.00<br />

11442 S 89.25 0.00 0.00 11952 S 50.22 0.00 0.00<br />

11443 S 98.83 0.00 0.00 11954 S 50.22 0.00 0.00<br />

11444 S 311.92 0.00 0.00 11960 S 609.26 0.00 0.00<br />

11446 S 624.13 0.00 0.00 11970 S 1,103.58 0.00 0.00<br />

11450 S 624.13 0.00 0.00 11971 S 571.90 0.00 0.00<br />

11451 S 624.13 0.00 0.00 11976 S 61.21 0.00 0.00<br />

11462 S 624.13 0.00 0.00 11980 S 24.73 0.00 0.00<br />

11463 S 624.13 0.00 0.00 11981 S 24.73 0.00 0.00<br />

11470 S 624.13 0.00 0.00 11982 S 24.73 0.00 0.00<br />

11471 S 624.13 0.00 0.00 11983 S 24.73 0.00 0.00<br />

11600 S 91.99 0.00 0.00 12001 S 50.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 50.22 0.00 0.00 14021 S 541.43 0.00 0.00<br />

12004 S 50.22 0.00 0.00 14040 S 511.85 0.00 0.00<br />

12005 S 67.29 0.00 0.00 14041 S 541.43 0.00 0.00<br />

12006 S 67.29 0.00 0.00 14060 S 541.43 0.00 0.00<br />

12007 S 67.29 0.00 0.00 14061 S 541.43 0.00 0.00<br />

12011 S 50.22 0.00 0.00 14300 S 694.32 0.00 0.00<br />

12013 S 50.22 0.00 0.00 14350 S 638.84 0.00 0.00<br />

12014 S 50.22 0.00 0.00 15002 S 234.22 0.00 0.00<br />

12015 S 50.22 0.00 0.00 15003 S 234.22 0.00 0.00<br />

12016 S 67.29 0.00 0.00 15004 S 234.22 0.00 0.00<br />

12017 S 67.29 0.00 0.00 15005 S 234.22 0.00 0.00<br />

12018 S 67.29 0.00 0.00 15040 S 108.02 0.00 0.00<br />

12020 S 126.96 0.00 0.00 15050 S 234.22 0.00 0.00<br />

12021 S 108.02 0.00 0.00 15100 S 609.26 0.00 0.00<br />

12031 S 50.22 0.00 0.00 15101 S 638.84 0.00 0.00<br />

12032 S 131.70 0.00 0.00 15110 S 290.95 0.00 0.00<br />

12034 S 67.29 0.00 0.00 15111 S 238.72 0.00 0.00<br />

12035 S 67.29 0.00 0.00 15115 S 290.95 0.00 0.00<br />

12036 S 108.02 0.00 0.00 15116 S 238.72 0.00 0.00<br />

12037 S 215.30 0.00 0.00 15120 S 609.26 0.00 0.00<br />

12041 S 50.22 0.00 0.00 15121 S 638.84 0.00 0.00<br />

12042 S 50.22 0.00 0.00 15130 S 511.85 0.00 0.00<br />

12044 S 67.29 0.00 0.00 15131 S 459.61 0.00 0.00<br />

12045 S 108.02 0.00 0.00 15135 S 511.85 0.00 0.00<br />

12046 S 108.02 0.00 0.00 15136 S 459.61 0.00 0.00<br />

12047 S 215.30 0.00 0.00 15150 S 290.95 0.00 0.00<br />

12051 S 50.22 0.00 0.00 15151 S 238.72 0.00 0.00<br />

12052 S 50.22 0.00 0.00 15152 S 238.72 0.00 0.00<br />

12053 S 50.22 0.00 0.00 15155 S 290.95 0.00 0.00<br />

12054 S 67.29 0.00 0.00 15156 S 238.72 0.00 0.00<br />

12055 S 108.02 0.00 0.00 15157 S 238.72 0.00 0.00<br />

12056 S 108.02 0.00 0.00 15170 S 131.70 0.00 0.00<br />

12057 S 215.30 0.00 0.00 15171 S 131.70 0.00 0.00<br />

13100 S 234.22 0.00 0.00 15175 S 169.56 0.00 0.00<br />

13101 S 234.22 0.00 0.00 15176 S 169.56 0.00 0.00<br />

13102 S 126.96 0.00 0.00 15200 S 541.43 0.00 0.00<br />

13120 S 108.02 0.00 0.00 15201 S 455.12 0.00 0.00<br />

13121 S 108.02 0.00 0.00 15220 S 511.85 0.00 0.00<br />

13122 S 108.02 0.00 0.00 15221 S 234.22 0.00 0.00<br />

13131 S 108.02 0.00 0.00 15240 S 541.43 0.00 0.00<br />

13132 S 108.02 0.00 0.00 15241 S 234.22 0.00 0.00<br />

13133 S 108.02 0.00 0.00 15260 S 511.85 0.00 0.00<br />

13150 S 234.22 0.00 0.00 15261 S 455.12 0.00 0.00<br />

13151 S 234.22 0.00 0.00 15300 S 234.22 0.00 0.00<br />

13152 S 234.22 0.00 0.00 15301 S 234.22 0.00 0.00<br />

13153 S 108.02 0.00 0.00 15320 S 234.22 0.00 0.00<br />

13160 S 609.26 0.00 0.00 15321 S 234.22 0.00 0.00<br />

14000 S 511.85 0.00 0.00 15330 S 234.22 0.00 0.00<br />

14001 S 541.43 0.00 0.00 15331 S 234.22 0.00 0.00<br />

14020 S 541.43 0.00 0.00 15335 S 234.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 234.22 0.00 0.00 15826 S 638.84 0.00 0.00<br />

15340 S 131.70 0.00 0.00 15828 S 638.84 0.00 0.00<br />

15341 S 131.70 0.00 0.00 15829 S 734.53 0.00 0.00<br />

15360 S 131.70 0.00 0.00 15830 S 653.72 0.00 0.00<br />

15361 S 131.70 0.00 0.00 15832 S 653.72 0.00 0.00<br />

15365 S 131.70 0.00 0.00 15833 S 653.72 0.00 0.00<br />

15366 S 131.70 0.00 0.00 15834 S 653.72 0.00 0.00<br />

15400 S 234.22 0.00 0.00 15835 S 567.40 0.00 0.00<br />

15401 S 234.22 0.00 0.00 15836 S 539.95 0.00 0.00<br />

15420 S 234.22 0.00 0.00 15837 S 608.39 0.00 0.00<br />

15421 S 234.22 0.00 0.00 15838 S 608.39 0.00 0.00<br />

15430 S 234.22 0.00 0.00 15839 S 539.95 0.00 0.00<br />

15431 S 234.22 0.00 0.00 15840 S 694.32 0.00 0.00<br />

15570 S 638.84 0.00 0.00 15841 S 694.32 0.00 0.00<br />

15572 S 638.84 0.00 0.00 15842 S 806.17 0.00 0.00<br />

15574 S 638.84 0.00 0.00 15845 S 694.32 0.00 0.00<br />

15576 S 638.84 0.00 0.00 15847 S 653.72 0.00 0.00<br />

15600 S 638.84 0.00 0.00 15850 S 104.43 0.00 0.00<br />

15610 S 638.84 0.00 0.00 15851 S 47.53 0.00 0.00<br />

15620 S 694.32 0.00 0.00 15852 S 24.73 0.00 0.00<br />

15630 S 638.84 0.00 0.00 15860 S 24.73 0.00 0.00<br />

15650 S 734.53 0.00 0.00 15876 S 638.84 0.00 0.00<br />

15731 S 638.84 0.00 0.00 15877 S 638.84 0.00 0.00<br />

15732 S 638.84 0.00 0.00 15878 S 638.84 0.00 0.00<br />

15734 S 638.84 0.00 0.00 15879 S 638.84 0.00 0.00<br />

15736 S 638.84 0.00 0.00 15920 S 201.92 0.00 0.00<br />

15738 S 638.84 0.00 0.00 15922 S 694.32 0.00 0.00<br />

15740 S 511.85 0.00 0.00 15931 S 653.72 0.00 0.00<br />

15750 S 609.26 0.00 0.00 15933 S 653.72 0.00 0.00<br />

15760 S 609.26 0.00 0.00 15934 S 638.84 0.00 0.00<br />

15770 S 638.84 0.00 0.00 15935 S 694.32 0.00 0.00<br />

15775 S 174.55 0.00 0.00 15936 S 596.91 0.00 0.00<br />

15776 S 174.55 0.00 0.00 15937 S 694.32 0.00 0.00<br />

15780 S 389.16 0.00 0.00 15940 S 653.72 0.00 0.00<br />

15781 S 171.29 0.00 0.00 15941 S 653.72 0.00 0.00<br />

15782 S 171.29 0.00 0.00 15944 S 638.84 0.00 0.00<br />

15783 S 104.43 0.00 0.00 15945 S 694.32 0.00 0.00<br />

15786 S 31.69 0.00 0.00 15946 S 694.32 0.00 0.00<br />

15787 S 28.73 0.00 0.00 15950 S 653.72 0.00 0.00<br />

15788 S 31.69 0.00 0.00 15951 S 709.19 0.00 0.00<br />

15789 S 58.06 0.00 0.00 15952 S 541.43 0.00 0.00<br />

15792 S 58.06 0.00 0.00 15953 S 596.91 0.00 0.00<br />

15793 S 31.69 0.00 0.00 15956 S 541.43 0.00 0.00<br />

15819 S 131.70 0.00 0.00 15958 S 596.91 0.00 0.00<br />

15820 S 638.84 0.00 0.00 16000 S 25.65 0.00 0.00<br />

15821 S 638.84 0.00 0.00 16020 S 38.99 0.00 0.00<br />

15822 S 638.84 0.00 0.00 16025 S 60.05 0.00 0.00<br />

15823 S 734.53 0.00 0.00 16030 S 75.18 0.00 0.00<br />

15824 S 638.84 0.00 0.00 16035 S 58.06 0.00 0.00<br />

15825 S 638.84 0.00 0.00 17000 S 31.69 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.76 0.00 0.00 19300 S 702.34 0.00 0.00<br />

17004 S 82.75 0.00 0.00 19301 S 646.88 0.00 0.00<br />

17106 S 104.43 0.00 0.00 19302 S 1,235.46 0.00 0.00<br />

17107 S 104.43 0.00 0.00 19303 S 933.67 0.00 0.00<br />

17108 S 104.43 0.00 0.00 19304 S 933.67 0.00 0.00<br />

17110 S 31.69 0.00 0.00 19316 S 933.67 0.00 0.00<br />

17111 S 58.06 0.00 0.00 19318 S 1,066.73 0.00 0.00<br />

17250 S 43.78 0.00 0.00 19324 S 1,066.73 0.00 0.00<br />

17260 S 46.85 0.00 0.00 19325 S 1,769.30 0.00 0.00<br />

17261 S 58.06 0.00 0.00 19328 S 796.38 0.00 0.00<br />

17262 S 58.06 0.00 0.00 19330 S 796.38 0.00 0.00<br />

17263 S 58.06 0.00 0.00 19340 S 981.67 0.00 0.00<br />

17264 S 58.06 0.00 0.00 19342 S 1,386.07 0.00 0.00<br />

17266 S 104.43 0.00 0.00 19350 S 702.34 0.00 0.00<br />

17270 S 58.06 0.00 0.00 19355 S 933.67 0.00 0.00<br />

17271 S 58.06 0.00 0.00 19357 S 1,481.76 0.00 0.00<br />

17272 S 58.06 0.00 0.00 19366 S 973.89 0.00 0.00<br />

17273 S 104.43 0.00 0.00 19370 S 933.67 0.00 0.00<br />

17274 S 104.43 0.00 0.00 19371 S 933.67 0.00 0.00<br />

17276 S 104.43 0.00 0.00 19380 S 1,106.95 0.00 0.00<br />

17280 S 58.06 0.00 0.00 19396 S 1,284.88 0.00 0.00<br />

17281 S 86.52 0.00 0.00 20000 S 54.06 0.00 0.00<br />

17282 S 98.83 0.00 0.00 20005 S 622.94 0.00 0.00<br />

17283 S 104.43 0.00 0.00 20103 S 611.36 0.00 0.00<br />

17284 S 104.43 0.00 0.00 20150 S 1,735.65 0.00 0.00<br />

17286 S 104.43 0.00 0.00 20200 S 510.36 0.00 0.00<br />

17311 S 172.39 0.00 0.00 20205 S 539.95 0.00 0.00<br />

17312 S 172.39 0.00 0.00 20206 S 252.31 0.00 0.00<br />

17313 S 172.39 0.00 0.00 20220 S 274.26 0.00 0.00<br />

17314 S 172.39 0.00 0.00 20225 S 497.65 0.00 0.00<br />

17315 S 38.99 0.00 0.00 20240 S 624.13 0.00 0.00<br />

17340 S 14.02 0.00 0.00 20245 S 653.72 0.00 0.00<br />

17360 S 31.69 0.00 0.00 20250 S 652.54 0.00 0.00<br />

17380 S 31.69 0.00 0.00 20251 S 652.54 0.00 0.00<br />

19000 S 66.00 0.00 0.00 20500 S 54.04 0.00 0.00<br />

19001 S 8.89 0.00 0.00 20520 S 90.97 0.00 0.00<br />

19020 S 577.15 0.00 0.00 20525 S 653.72 0.00 0.00<br />

19100 S 196.53 0.00 0.00 20526 S 29.41 0.00 0.00<br />

19101 S 617.28 0.00 0.00 20550 S 22.22 0.00 0.00<br />

19102 S 252.31 0.00 0.00 20551 S 21.88 0.00 0.00<br />

19103 S 441.61 0.00 0.00 20552 S 21.20 0.00 0.00<br />

19105 S 1,284.88 0.00 0.00 20553 S 23.60 0.00 0.00<br />

19110 S 617.28 0.00 0.00 20555 S 1,143.55 0.00 0.00<br />

19112 S 646.88 0.00 0.00 20600 S 22.57 0.00 0.00<br />

19120 S 646.88 0.00 0.00 20605 S 25.31 0.00 0.00<br />

19125 S 646.88 0.00 0.00 20610 S 35.57 0.00 0.00<br />

19126 S 646.88 0.00 0.00 20612 S 23.94 0.00 0.00<br />

19296 S 1,769.30 0.00 0.00 20615 S 100.20 0.00 0.00<br />

19297 S 1,769.30 0.00 0.00 20650 S 652.54 0.00 0.00<br />

19298 S 1,769.30 0.00 0.00 20662 S 833.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 833.55 0.00 0.00 21085 S 251.00 0.00 0.00<br />

20665 S 24.73 0.00 0.00 21086 S 546.46 0.00 0.00<br />

20670 S 458.13 0.00 0.00 21087 S 547.15 0.00 0.00<br />

20680 S 653.72 0.00 0.00 21088 S 1,602.50 0.00 0.00<br />

20690 S 777.95 0.00 0.00 21100 S 1,007.42 0.00 0.00<br />

20692 S 807.54 0.00 0.00 21110 S 288.29 0.00 0.00<br />

20693 S 652.54 0.00 0.00 21120 S 933.65 0.00 0.00<br />

20694 S 570.71 0.00 0.00 21121 S 933.65 0.00 0.00<br />

20696 S 1,143.55 0.00 0.00 21122 S 933.65 0.00 0.00<br />

20697 S 760.51 0.00 0.00 21123 S 933.65 0.00 0.00<br />

20822 S 1,071.52 0.00 0.00 21125 S 933.65 0.00 0.00<br />

20900 S 807.54 0.00 0.00 21127 S 1,420.22 0.00 0.00<br />

20902 S 863.01 0.00 0.00 21137 S 947.39 0.00 0.00<br />

20910 S 638.84 0.00 0.00 21138 S 1,602.50 0.00 0.00<br />

20912 S 638.84 0.00 0.00 21139 S 1,602.50 0.00 0.00<br />

20920 S 596.91 0.00 0.00 21150 S 1,602.50 0.00 0.00<br />

20922 S 541.43 0.00 0.00 21181 S 933.65 0.00 0.00<br />

20924 S 863.01 0.00 0.00 21198 S 1,602.50 0.00 0.00<br />

20926 S 376.01 0.00 0.00 21199 S 1,602.50 0.00 0.00<br />

20950 S 54.06 0.00 0.00 21206 S 1,132.70 0.00 0.00<br />

20972 S 1,809.83 0.00 0.00 21208 S 1,261.21 0.00 0.00<br />

20973 S 1,809.83 0.00 0.00 21209 S 1,132.70 0.00 0.00<br />

20979 S 22.22 0.00 0.00 21210 S 1,261.21 0.00 0.00<br />

20982 S 1,735.65 0.00 0.00 21215 S 1,261.21 0.00 0.00<br />

21010 S 679.86 0.00 0.00 21230 S 1,261.21 0.00 0.00<br />

21015 S 565.65 0.00 0.00 21235 S 933.65 0.00 0.00<br />

21025 S 1,007.42 0.00 0.00 21240 S 1,092.48 0.00 0.00<br />

21026 S 1,007.42 0.00 0.00 21242 S 1,132.70 0.00 0.00<br />

21029 S 1,007.42 0.00 0.00 21243 S 1,132.70 0.00 0.00<br />

21030 S 237.66 0.00 0.00 21244 S 1,261.21 0.00 0.00<br />

21031 S 196.63 0.00 0.00 21245 S 1,261.21 0.00 0.00<br />

21032 S 200.39 0.00 0.00 21246 S 1,261.21 0.00 0.00<br />

21034 S 1,037.01 0.00 0.00 21248 S 1,261.21 0.00 0.00<br />

21040 S 679.86 0.00 0.00 21249 S 1,261.21 0.00 0.00<br />

21044 S 1,007.42 0.00 0.00 21260 S 1,602.50 0.00 0.00<br />

21046 S 1,007.42 0.00 0.00 21267 S 1,261.21 0.00 0.00<br />

21047 S 1,007.42 0.00 0.00 21270 S 1,132.70 0.00 0.00<br />

21048 S 1,602.50 0.00 0.00 21275 S 1,261.21 0.00 0.00<br />

21050 S 1,037.01 0.00 0.00 21280 S 1,132.70 0.00 0.00<br />

21060 S 1,007.42 0.00 0.00 21282 S 661.33 0.00 0.00<br />

21070 S 1,037.01 0.00 0.00 21295 S 298.08 0.00 0.00<br />

21073 S 184.66 0.00 0.00 21296 S 627.63 0.00 0.00<br />

21076 S 320.42 0.00 0.00 21310 S 90.93 0.00 0.00<br />

21077 S 774.55 0.00 0.00 21315 S 399.56 0.00 0.00<br />

21079 S 554.67 0.00 0.00 21320 S 536.06 0.00 0.00<br />

21080 S 636.06 0.00 0.00 21325 S 764.92 0.00 0.00<br />

21081 S 586.13 0.00 0.00 21330 S 805.14 0.00 0.00<br />

21082 S 557.75 0.00 0.00 21335 S 933.65 0.00 0.00<br />

21083 S 549.54 0.00 0.00 21336 S 778.10 0.00 0.00<br />

21084 S 632.29 0.00 0.00 21337 S 536.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 764.92 0.00 0.00 22310 S 165.54 0.00 0.00<br />

21339 S 805.14 0.00 0.00 22315 S 428.16 0.00 0.00<br />

21340 S 1,092.48 0.00 0.00 22505 S 504.05 0.00 0.00<br />

21345 S 933.65 0.00 0.00 22520 S 1,190.75 0.00 0.00<br />

21355 S 1,037.01 0.00 0.00 22521 S 1,190.75 0.00 0.00<br />

21356 S 709.45 0.00 0.00 22522 S 1,190.75 0.00 0.00<br />

21360 S 947.39 0.00 0.00 22523 S 3,313.98 0.00 0.00<br />

21390 S 1,602.50 0.00 0.00 22524 S 3,313.98 0.00 0.00<br />

21400 S 350.31 0.00 0.00 22525 S 3,313.98 0.00 0.00<br />

21401 S 565.65 0.00 0.00 22900 S 709.19 0.00 0.00<br />

21406 S 1,602.50 0.00 0.00 23000 S 510.36 0.00 0.00<br />

21407 S 1,602.50 0.00 0.00 23020 S 1,074.00 0.00 0.00<br />

21421 S 764.92 0.00 0.00 23030 S 524.91 0.00 0.00<br />

21440 S 322.13 0.00 0.00 23031 S 606.73 0.00 0.00<br />

21445 S 764.92 0.00 0.00 23035 S 652.54 0.00 0.00<br />

21450 S 132.95 0.00 0.00 23040 S 807.54 0.00 0.00<br />

21451 S 358.70 0.00 0.00 23044 S 863.01 0.00 0.00<br />

21452 S 536.06 0.00 0.00 23065 S 96.44 0.00 0.00<br />

21453 S 1,037.01 0.00 0.00 23066 S 624.13 0.00 0.00<br />

21454 S 805.14 0.00 0.00 23075 S 510.36 0.00 0.00<br />

21461 S 1,092.48 0.00 0.00 23076 S 624.13 0.00 0.00<br />

21462 S 1,132.70 0.00 0.00 23077 S 653.72 0.00 0.00<br />

21465 S 1,092.48 0.00 0.00 23100 S 622.94 0.00 0.00<br />

21480 S 90.93 0.00 0.00 23101 S 1,031.74 0.00 0.00<br />

21485 S 536.06 0.00 0.00 23105 S 863.01 0.00 0.00<br />

21490 S 1,037.01 0.00 0.00 23106 S 863.01 0.00 0.00<br />

21495 S 659.77 0.00 0.00 23107 S 863.01 0.00 0.00<br />

21497 S 536.06 0.00 0.00 23120 S 903.23 0.00 0.00<br />

21501 S 577.15 0.00 0.00 23125 S 903.23 0.00 0.00<br />

21502 S 622.94 0.00 0.00 23130 S 1,199.27 0.00 0.00<br />

21550 S 608.39 0.00 0.00 23140 S 708.00 0.00 0.00<br />

21555 S 624.13 0.00 0.00 23145 S 903.23 0.00 0.00<br />

21556 S 624.13 0.00 0.00 23146 S 903.23 0.00 0.00<br />

21557 S 835.92 0.00 0.00 23150 S 863.01 0.00 0.00<br />

21600 S 777.95 0.00 0.00 23155 S 903.23 0.00 0.00<br />

21610 S 777.95 0.00 0.00 23156 S 903.23 0.00 0.00<br />

21685 S 288.29 0.00 0.00 23170 S 777.95 0.00 0.00<br />

21700 S 622.94 0.00 0.00 23172 S 777.95 0.00 0.00<br />

21720 S 652.54 0.00 0.00 23174 S 777.95 0.00 0.00<br />

21725 S 67.93 0.00 0.00 23180 S 863.01 0.00 0.00<br />

21800 S 78.47 0.00 0.00 23182 S 863.01 0.00 0.00<br />

21805 S 693.04 0.00 0.00 23184 S 863.01 0.00 0.00<br />

21820 S 78.47 0.00 0.00 23190 S 863.01 0.00 0.00<br />

21920 S 139.52 0.00 0.00 23195 S 903.23 0.00 0.00<br />

21925 S 624.13 0.00 0.00 23330 S 311.92 0.00 0.00<br />

21930 S 624.13 0.00 0.00 23331 S 571.90 0.00 0.00<br />

21935 S 653.72 0.00 0.00 23395 S 1,199.27 0.00 0.00<br />

22102 S 1,860.17 0.00 0.00 23397 S 2,116.95 0.00 0.00<br />

22103 S 1,860.17 0.00 0.00 23400 S 1,031.74 0.00 0.00<br />

22305 S 78.47 0.00 0.00 23405 S 777.95 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 777.95 0.00 0.00 23931 S 577.15 0.00 0.00<br />

23410 S 1,199.27 0.00 0.00 23935 S 622.94 0.00 0.00<br />

23412 S 1,327.78 0.00 0.00 24000 S 863.01 0.00 0.00<br />

23415 S 1,199.27 0.00 0.00 24006 S 863.01 0.00 0.00<br />

23420 S 1,327.78 0.00 0.00 24065 S 133.71 0.00 0.00<br />

23430 S 1,159.06 0.00 0.00 24066 S 510.36 0.00 0.00<br />

23440 S 1,159.06 0.00 0.00 24075 S 510.36 0.00 0.00<br />

23450 S 1,988.44 0.00 0.00 24076 S 624.13 0.00 0.00<br />

23455 S 2,116.95 0.00 0.00 24077 S 653.72 0.00 0.00<br />

23460 S 1,988.44 0.00 0.00 24100 S 570.71 0.00 0.00<br />

23462 S 1,327.78 0.00 0.00 24101 S 863.01 0.00 0.00<br />

23465 S 1,988.44 0.00 0.00 24102 S 863.01 0.00 0.00<br />

23466 S 1,327.78 0.00 0.00 24105 S 652.54 0.00 0.00<br />

23480 S 1,159.06 0.00 0.00 24110 S 622.94 0.00 0.00<br />

23485 S 2,116.95 0.00 0.00 24115 S 807.54 0.00 0.00<br />

23490 S 1,103.58 0.00 0.00 24116 S 807.54 0.00 0.00<br />

23491 S 1,892.75 0.00 0.00 24120 S 652.54 0.00 0.00<br />

23500 S 78.47 0.00 0.00 24125 S 807.54 0.00 0.00<br />

23505 S 428.16 0.00 0.00 24126 S 807.54 0.00 0.00<br />

23515 S 1,433.01 0.00 0.00 24130 S 807.54 0.00 0.00<br />

23520 S 165.54 0.00 0.00 24134 S 777.95 0.00 0.00<br />

23525 S 165.54 0.00 0.00 24136 S 777.95 0.00 0.00<br />

23530 S 1,055.98 0.00 0.00 24138 S 777.95 0.00 0.00<br />

23532 S 778.10 0.00 0.00 24140 S 807.54 0.00 0.00<br />

23540 S 78.47 0.00 0.00 24145 S 807.54 0.00 0.00<br />

23545 S 165.54 0.00 0.00 24147 S 777.95 0.00 0.00<br />

23550 S 1,055.98 0.00 0.00 24149 S 1,143.55 0.00 0.00<br />

23552 S 1,111.46 0.00 0.00 24152 S 1,735.65 0.00 0.00<br />

23570 S 78.47 0.00 0.00 24153 S 3,313.98 0.00 0.00<br />

23575 S 165.54 0.00 0.00 24155 S 1,103.58 0.00 0.00<br />

23585 S 1,433.01 0.00 0.00 24160 S 777.95 0.00 0.00<br />

23600 S 61.15 0.00 0.00 24164 S 807.54 0.00 0.00<br />

23605 S 428.16 0.00 0.00 24200 S 97.80 0.00 0.00<br />

23615 S 1,488.47 0.00 0.00 24201 S 510.36 0.00 0.00<br />

23616 S 1,488.47 0.00 0.00 24300 S 595.75 0.00 0.00<br />

23620 S 61.15 0.00 0.00 24301 S 863.01 0.00 0.00<br />

23625 S 428.16 0.00 0.00 24305 S 863.01 0.00 0.00<br />

23630 S 1,528.69 0.00 0.00 24310 S 652.54 0.00 0.00<br />

23650 S 78.47 0.00 0.00 24320 S 1,103.58 0.00 0.00<br />

23655 S 451.81 0.00 0.00 24330 S 1,892.75 0.00 0.00<br />

23660 S 1,055.98 0.00 0.00 24331 S 1,103.58 0.00 0.00<br />

23665 S 165.54 0.00 0.00 24332 S 833.55 0.00 0.00<br />

23670 S 1,433.01 0.00 0.00 24340 S 1,103.58 0.00 0.00<br />

23675 S 78.47 0.00 0.00 24341 S 1,103.58 0.00 0.00<br />

23680 S 1,055.98 0.00 0.00 24342 S 1,103.58 0.00 0.00<br />

23700 S 451.81 0.00 0.00 24343 S 1,143.55 0.00 0.00<br />

23800 S 1,948.22 0.00 0.00 24344 S 3,313.98 0.00 0.00<br />

23802 S 1,327.78 0.00 0.00 24345 S 777.95 0.00 0.00<br />

23921 S 455.12 0.00 0.00 24346 S 1,735.65 0.00 0.00<br />

23930 S 524.91 0.00 0.00 24357 S 1,143.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,143.55 0.00 0.00 24925 S 652.54 0.00 0.00<br />

24359 S 1,143.55 0.00 0.00 25000 S 652.54 0.00 0.00<br />

24360 S 1,055.34 0.00 0.00 25001 S 833.55 0.00 0.00<br />

24361 S 5,770.08 3,532.02 1,293.96 25020 S 652.54 0.00 0.00<br />

24362 S 1,348.71 0.00 0.00 25023 S 807.54 0.00 0.00<br />

24363 S 5,898.59 3,660.53 1,422.47 25024 S 807.54 0.00 0.00<br />

24365 S 1,055.34 0.00 0.00 25025 S 807.54 0.00 0.00<br />

24366 S 5,770.08 3,532.02 1,293.96 25028 S 570.71 0.00 0.00<br />

24400 S 863.01 0.00 0.00 25031 S 622.94 0.00 0.00<br />

24410 S 863.01 0.00 0.00 25035 S 622.94 0.00 0.00<br />

24420 S 1,103.58 0.00 0.00 25040 S 903.23 0.00 0.00<br />

24430 S 1,892.75 0.00 0.00 25065 S 135.76 0.00 0.00<br />

24435 S 1,948.22 0.00 0.00 25066 S 624.13 0.00 0.00<br />

24470 S 1,103.58 0.00 0.00 25075 S 510.36 0.00 0.00<br />

24495 S 777.95 0.00 0.00 25076 S 653.72 0.00 0.00<br />

24498 S 1,892.75 0.00 0.00 25077 S 653.72 0.00 0.00<br />

24500 S 78.47 0.00 0.00 25085 S 652.54 0.00 0.00<br />

24505 S 78.47 0.00 0.00 25100 S 622.94 0.00 0.00<br />

24515 S 1,488.47 0.00 0.00 25101 S 807.54 0.00 0.00<br />

24516 S 1,488.47 0.00 0.00 25105 S 863.01 0.00 0.00<br />

24530 S 78.47 0.00 0.00 25107 S 807.54 0.00 0.00<br />

24535 S 165.54 0.00 0.00 25109 S 833.55 0.00 0.00<br />

24538 S 693.04 0.00 0.00 25110 S 652.54 0.00 0.00<br />

24545 S 1,488.47 0.00 0.00 25111 S 652.54 0.00 0.00<br />

24546 S 1,528.69 0.00 0.00 25112 S 708.00 0.00 0.00<br />

24560 S 78.47 0.00 0.00 25115 S 708.00 0.00 0.00<br />

24565 S 78.47 0.00 0.00 25116 S 708.00 0.00 0.00<br />

24566 S 693.04 0.00 0.00 25118 S 777.95 0.00 0.00<br />

24575 S 1,433.01 0.00 0.00 25119 S 807.54 0.00 0.00<br />

24576 S 78.47 0.00 0.00 25120 S 807.54 0.00 0.00<br />

24577 S 165.54 0.00 0.00 25125 S 807.54 0.00 0.00<br />

24579 S 1,433.01 0.00 0.00 25126 S 807.54 0.00 0.00<br />

24582 S 693.04 0.00 0.00 25130 S 807.54 0.00 0.00<br />

24586 S 1,488.47 0.00 0.00 25135 S 807.54 0.00 0.00<br />

24587 S 1,528.69 0.00 0.00 25136 S 807.54 0.00 0.00<br />

24600 S 78.47 0.00 0.00 25145 S 777.95 0.00 0.00<br />

24605 S 504.05 0.00 0.00 25150 S 777.95 0.00 0.00<br />

24615 S 1,433.01 0.00 0.00 25151 S 777.95 0.00 0.00<br />

24620 S 428.16 0.00 0.00 25210 S 807.54 0.00 0.00<br />

24635 S 1,433.01 0.00 0.00 25215 S 863.01 0.00 0.00<br />

24640 S 53.00 0.00 0.00 25230 S 863.01 0.00 0.00<br />

24650 S 61.15 0.00 0.00 25240 S 863.01 0.00 0.00<br />

24655 S 165.54 0.00 0.00 25248 S 622.94 0.00 0.00<br />

24665 S 1,111.46 0.00 0.00 25250 S 725.71 0.00 0.00<br />

24666 S 1,488.47 0.00 0.00 25251 S 725.71 0.00 0.00<br />

24670 S 78.47 0.00 0.00 25259 S 760.51 0.00 0.00<br />

24675 S 78.47 0.00 0.00 25260 S 863.01 0.00 0.00<br />

24685 S 1,055.98 0.00 0.00 25263 S 777.95 0.00 0.00<br />

24800 S 1,159.06 0.00 0.00 25265 S 807.54 0.00 0.00<br />

24802 S 1,199.27 0.00 0.00 25270 S 863.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 807.54 0.00 0.00 25505 S 165.54 0.00 0.00<br />

25274 S 863.01 0.00 0.00 25515 S 1,055.98 0.00 0.00<br />

25275 S 863.01 0.00 0.00 25520 S 165.54 0.00 0.00<br />

25280 S 863.01 0.00 0.00 25525 S 1,111.46 0.00 0.00<br />

25290 S 807.54 0.00 0.00 25526 S 1,151.67 0.00 0.00<br />

25295 S 652.54 0.00 0.00 25530 S 61.15 0.00 0.00<br />

25300 S 807.54 0.00 0.00 25535 S 78.47 0.00 0.00<br />

25301 S 807.54 0.00 0.00 25545 S 1,055.98 0.00 0.00<br />

25310 S 1,103.58 0.00 0.00 25560 S 61.15 0.00 0.00<br />

25312 S 1,159.06 0.00 0.00 25565 S 165.54 0.00 0.00<br />

25315 S 1,103.58 0.00 0.00 25574 S 1,433.01 0.00 0.00<br />

25316 S 1,892.75 0.00 0.00 25575 S 1,433.01 0.00 0.00<br />

25320 S 1,103.58 0.00 0.00 25600 S 61.15 0.00 0.00<br />

25332 S 1,055.34 0.00 0.00 25605 S 165.54 0.00 0.00<br />

25335 S 1,103.58 0.00 0.00 25606 S 722.63 0.00 0.00<br />

25337 S 1,199.27 0.00 0.00 25607 S 1,528.69 0.00 0.00<br />

25350 S 1,892.75 0.00 0.00 25608 S 1,528.69 0.00 0.00<br />

25355 S 1,103.58 0.00 0.00 25609 S 1,528.69 0.00 0.00<br />

25360 S 807.54 0.00 0.00 25622 S 61.15 0.00 0.00<br />

25365 S 807.54 0.00 0.00 25624 S 165.54 0.00 0.00<br />

25370 S 1,103.58 0.00 0.00 25628 S 1,055.98 0.00 0.00<br />

25375 S 1,159.06 0.00 0.00 25630 S 61.15 0.00 0.00<br />

25390 S 807.54 0.00 0.00 25635 S 165.54 0.00 0.00<br />

25391 S 1,159.06 0.00 0.00 25645 S 1,055.98 0.00 0.00<br />

25392 S 807.54 0.00 0.00 25650 S 61.15 0.00 0.00<br />

25393 S 1,159.06 0.00 0.00 25651 S 973.74 0.00 0.00<br />

25394 S 1,735.65 0.00 0.00 25652 S 1,640.44 0.00 0.00<br />

25400 S 1,103.58 0.00 0.00 25660 S 78.47 0.00 0.00<br />

25405 S 1,948.22 0.00 0.00 25670 S 722.63 0.00 0.00<br />

25415 S 1,892.75 0.00 0.00 25671 S 640.81 0.00 0.00<br />

25420 S 1,948.22 0.00 0.00 25675 S 78.47 0.00 0.00<br />

25425 S 1,103.58 0.00 0.00 25676 S 693.04 0.00 0.00<br />

25426 S 1,159.06 0.00 0.00 25680 S 78.47 0.00 0.00<br />

25430 S 1,735.65 0.00 0.00 25685 S 722.63 0.00 0.00<br />

25431 S 1,735.65 0.00 0.00 25690 S 428.16 0.00 0.00<br />

25440 S 1,948.22 0.00 0.00 25695 S 693.04 0.00 0.00<br />

25441 S 5,770.08 3,532.02 1,293.96 25800 S 1,948.22 0.00 0.00<br />

25442 S 5,770.08 3,532.02 1,293.96 25805 S 1,199.27 0.00 0.00<br />

25443 S 1,348.71 0.00 0.00 25810 S 1,988.44 0.00 0.00<br />

25444 S 1,348.71 0.00 0.00 25820 S 1,159.06 0.00 0.00<br />

25445 S 1,348.71 0.00 0.00 25825 S 1,988.44 0.00 0.00<br />

25446 S 5,898.59 3,660.53 1,422.47 25830 S 1,988.44 0.00 0.00<br />

25447 S 1,055.34 0.00 0.00 25907 S 652.54 0.00 0.00<br />

25449 S 1,055.34 0.00 0.00 25922 S 652.54 0.00 0.00<br />

25450 S 1,103.58 0.00 0.00 25929 S 541.43 0.00 0.00<br />

25455 S 1,103.58 0.00 0.00 25931 S 833.55 0.00 0.00<br />

25490 S 1,103.58 0.00 0.00 26010 S 54.06 0.00 0.00<br />

25491 S 1,103.58 0.00 0.00 26011 S 394.94 0.00 0.00<br />

25492 S 1,103.58 0.00 0.00 26020 S 524.04 0.00 0.00<br />

25500 S 61.15 0.00 0.00 26025 S 471.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 524.04 0.00 0.00 26392 S 771.52 0.00 0.00<br />

26034 S 524.04 0.00 0.00 26410 S 553.62 0.00 0.00<br />

26035 S 635.73 0.00 0.00 26412 S 771.52 0.00 0.00<br />

26040 S 827.00 0.00 0.00 26415 S 827.00 0.00 0.00<br />

26045 S 771.52 0.00 0.00 26416 S 771.52 0.00 0.00<br />

26055 S 524.04 0.00 0.00 26418 S 609.10 0.00 0.00<br />

26060 S 524.04 0.00 0.00 26420 S 827.00 0.00 0.00<br />

26070 S 524.04 0.00 0.00 26426 S 771.52 0.00 0.00<br />

26075 S 609.10 0.00 0.00 26428 S 771.52 0.00 0.00<br />

26080 S 609.10 0.00 0.00 26432 S 553.62 0.00 0.00<br />

26100 S 524.04 0.00 0.00 26433 S 553.62 0.00 0.00<br />

26105 S 471.80 0.00 0.00 26434 S 771.52 0.00 0.00<br />

26110 S 471.80 0.00 0.00 26437 S 553.62 0.00 0.00<br />

26115 S 624.13 0.00 0.00 26440 S 553.62 0.00 0.00<br />

26116 S 624.13 0.00 0.00 26442 S 771.52 0.00 0.00<br />

26117 S 653.72 0.00 0.00 26445 S 553.62 0.00 0.00<br />

26121 S 827.00 0.00 0.00 26449 S 771.52 0.00 0.00<br />

26123 S 827.00 0.00 0.00 26450 S 553.62 0.00 0.00<br />

26125 S 609.10 0.00 0.00 26455 S 553.62 0.00 0.00<br />

26130 S 553.62 0.00 0.00 26460 S 553.62 0.00 0.00<br />

26135 S 827.00 0.00 0.00 26471 S 524.04 0.00 0.00<br />

26140 S 524.04 0.00 0.00 26474 S 524.04 0.00 0.00<br />

26145 S 553.62 0.00 0.00 26476 S 471.80 0.00 0.00<br />

26160 S 553.62 0.00 0.00 26477 S 471.80 0.00 0.00<br />

26170 S 553.62 0.00 0.00 26478 S 471.80 0.00 0.00<br />

26180 S 553.62 0.00 0.00 26479 S 471.80 0.00 0.00<br />

26185 S 609.10 0.00 0.00 26480 S 771.52 0.00 0.00<br />

26200 S 524.04 0.00 0.00 26483 S 771.52 0.00 0.00<br />

26205 S 771.52 0.00 0.00 26485 S 741.94 0.00 0.00<br />

26210 S 524.04 0.00 0.00 26489 S 771.52 0.00 0.00<br />

26215 S 553.62 0.00 0.00 26490 S 771.52 0.00 0.00<br />

26230 S 776.88 0.00 0.00 26492 S 771.52 0.00 0.00<br />

26235 S 553.62 0.00 0.00 26494 S 771.52 0.00 0.00<br />

26236 S 553.62 0.00 0.00 26496 S 771.52 0.00 0.00<br />

26250 S 553.62 0.00 0.00 26497 S 771.52 0.00 0.00<br />

26255 S 771.52 0.00 0.00 26498 S 827.00 0.00 0.00<br />

26260 S 553.62 0.00 0.00 26499 S 771.52 0.00 0.00<br />

26261 S 553.62 0.00 0.00 26500 S 609.10 0.00 0.00<br />

26262 S 524.04 0.00 0.00 26502 S 827.00 0.00 0.00<br />

26320 S 510.36 0.00 0.00 26508 S 553.62 0.00 0.00<br />

26340 S 235.27 0.00 0.00 26510 S 771.52 0.00 0.00<br />

26350 S 689.69 0.00 0.00 26516 S 689.69 0.00 0.00<br />

26352 S 827.00 0.00 0.00 26517 S 771.52 0.00 0.00<br />

26356 S 827.00 0.00 0.00 26518 S 771.52 0.00 0.00<br />

26357 S 827.00 0.00 0.00 26520 S 553.62 0.00 0.00<br />

26358 S 827.00 0.00 0.00 26525 S 553.62 0.00 0.00<br />

26370 S 827.00 0.00 0.00 26530 S 959.65 0.00 0.00<br />

26372 S 827.00 0.00 0.00 26531 S 1,477.23 0.00 0.00<br />

26373 S 771.52 0.00 0.00 26535 S 1,055.34 0.00 0.00<br />

26390 S 827.00 0.00 0.00 26536 S 1,348.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 609.10 0.00 0.00 26775 S 163.46 0.00 0.00<br />

26541 S 995.72 0.00 0.00 26776 S 693.04 0.00 0.00<br />

26542 S 609.10 0.00 0.00 26785 S 693.04 0.00 0.00<br />

26545 S 827.00 0.00 0.00 26820 S 867.21 0.00 0.00<br />

26546 S 827.00 0.00 0.00 26841 S 827.00 0.00 0.00<br />

26548 S 827.00 0.00 0.00 26842 S 827.00 0.00 0.00<br />

26550 S 741.94 0.00 0.00 26843 S 771.52 0.00 0.00<br />

26555 S 771.52 0.00 0.00 26844 S 771.52 0.00 0.00<br />

26560 S 524.04 0.00 0.00 26850 S 827.00 0.00 0.00<br />

26561 S 771.52 0.00 0.00 26852 S 827.00 0.00 0.00<br />

26562 S 827.00 0.00 0.00 26860 S 771.52 0.00 0.00<br />

26565 S 867.21 0.00 0.00 26861 S 741.94 0.00 0.00<br />

26567 S 867.21 0.00 0.00 26862 S 827.00 0.00 0.00<br />

26568 S 771.52 0.00 0.00 26863 S 771.52 0.00 0.00<br />

26580 S 649.31 0.00 0.00 26910 S 771.52 0.00 0.00<br />

26587 S 649.31 0.00 0.00 26951 S 524.04 0.00 0.00<br />

26590 S 649.31 0.00 0.00 26952 S 609.10 0.00 0.00<br />

26591 S 771.52 0.00 0.00 26990 S 570.71 0.00 0.00<br />

26593 S 553.62 0.00 0.00 26991 S 570.71 0.00 0.00<br />

26596 S 524.04 0.00 0.00 27000 S 622.94 0.00 0.00<br />

26600 S 61.15 0.00 0.00 27001 S 807.54 0.00 0.00<br />

26605 S 78.47 0.00 0.00 27003 S 807.54 0.00 0.00<br />

26607 S 428.16 0.00 0.00 27033 S 1,103.58 0.00 0.00<br />

26608 S 778.10 0.00 0.00 27035 S 1,159.06 0.00 0.00<br />

26615 S 1,111.46 0.00 0.00 27040 S 311.92 0.00 0.00<br />

26641 S 61.15 0.00 0.00 27041 S 351.44 0.00 0.00<br />

26645 S 165.54 0.00 0.00 27047 S 624.13 0.00 0.00<br />

26650 S 693.04 0.00 0.00 27048 S 653.72 0.00 0.00<br />

26665 S 1,111.46 0.00 0.00 27049 S 653.72 0.00 0.00<br />

26670 S 61.15 0.00 0.00 27050 S 652.54 0.00 0.00<br />

26675 S 165.54 0.00 0.00 27052 S 652.54 0.00 0.00<br />

26676 S 693.04 0.00 0.00 27060 S 748.22 0.00 0.00<br />

26685 S 722.63 0.00 0.00 27062 S 748.22 0.00 0.00<br />

26686 S 1,433.01 0.00 0.00 27065 S 748.22 0.00 0.00<br />

26700 S 61.15 0.00 0.00 27066 S 903.23 0.00 0.00<br />

26705 S 78.47 0.00 0.00 27067 S 903.23 0.00 0.00<br />

26706 S 428.16 0.00 0.00 27080 S 777.95 0.00 0.00<br />

26715 S 778.10 0.00 0.00 27086 S 311.92 0.00 0.00<br />

26720 S 61.15 0.00 0.00 27087 S 652.54 0.00 0.00<br />

26725 S 61.15 0.00 0.00 27097 S 807.54 0.00 0.00<br />

26727 S 946.83 0.00 0.00 27098 S 807.54 0.00 0.00<br />

26735 S 778.10 0.00 0.00 27100 S 1,159.06 0.00 0.00<br />

26740 S 61.15 0.00 0.00 27105 S 1,159.06 0.00 0.00<br />

26742 S 78.47 0.00 0.00 27110 S 1,159.06 0.00 0.00<br />

26746 S 818.32 0.00 0.00 27111 S 1,159.06 0.00 0.00<br />

26750 S 61.15 0.00 0.00 27193 S 78.47 0.00 0.00<br />

26755 S 61.15 0.00 0.00 27194 S 504.05 0.00 0.00<br />

26756 S 693.04 0.00 0.00 27200 S 61.15 0.00 0.00<br />

26765 S 778.10 0.00 0.00 27202 S 1,026.40 0.00 0.00<br />

26770 S 61.15 0.00 0.00 27220 S 61.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 78.47 0.00 0.00 27397 S 1,103.58 0.00 0.00<br />

27238 S 165.54 0.00 0.00 27400 S 1,103.58 0.00 0.00<br />

27246 S 165.54 0.00 0.00 27403 S 863.01 0.00 0.00<br />

27250 S 78.47 0.00 0.00 27405 S 1,159.06 0.00 0.00<br />

27252 S 504.05 0.00 0.00 27407 S 1,948.22 0.00 0.00<br />

27256 S 61.15 0.00 0.00 27409 S 1,159.06 0.00 0.00<br />

27257 S 533.64 0.00 0.00 27416 S 1,735.65 0.00 0.00<br />

27265 S 78.47 0.00 0.00 27418 S 1,103.58 0.00 0.00<br />

27266 S 504.05 0.00 0.00 27420 S 1,103.58 0.00 0.00<br />

27267 S 61.15 0.00 0.00 27422 S 1,327.78 0.00 0.00<br />

27275 S 504.05 0.00 0.00 27424 S 1,103.58 0.00 0.00<br />

27301 S 606.73 0.00 0.00 27425 S 1,031.74 0.00 0.00<br />

27305 S 622.94 0.00 0.00 27427 S 1,103.58 0.00 0.00<br />

27306 S 652.54 0.00 0.00 27428 S 1,948.22 0.00 0.00<br />

27307 S 652.54 0.00 0.00 27429 S 1,948.22 0.00 0.00<br />

27310 S 863.01 0.00 0.00 27430 S 1,159.06 0.00 0.00<br />

27323 S 311.92 0.00 0.00 27435 S 1,159.06 0.00 0.00<br />

27324 S 571.90 0.00 0.00 27437 S 1,015.12 0.00 0.00<br />

27325 S 560.38 0.00 0.00 27438 S 1,348.71 0.00 0.00<br />

27326 S 560.38 0.00 0.00 27440 S 1,447.78 0.00 0.00<br />

27327 S 624.13 0.00 0.00 27441 S 1,055.34 0.00 0.00<br />

27328 S 653.72 0.00 0.00 27442 S 1,055.34 0.00 0.00<br />

27329 S 709.19 0.00 0.00 27443 S 1,055.34 0.00 0.00<br />

27330 S 863.01 0.00 0.00 27446 S 10,354.91 6,220.76 2,086.60<br />

27331 S 863.01 0.00 0.00 27496 S 748.22 0.00 0.00<br />

27332 S 863.01 0.00 0.00 27497 S 652.54 0.00 0.00<br />

27333 S 863.01 0.00 0.00 27498 S 652.54 0.00 0.00<br />

27334 S 863.01 0.00 0.00 27499 S 652.54 0.00 0.00<br />

27335 S 863.01 0.00 0.00 27500 S 165.54 0.00 0.00<br />

27340 S 652.54 0.00 0.00 27501 S 78.47 0.00 0.00<br />

27345 S 708.00 0.00 0.00 27502 S 428.16 0.00 0.00<br />

27347 S 708.00 0.00 0.00 27503 S 78.47 0.00 0.00<br />

27350 S 863.01 0.00 0.00 27508 S 78.47 0.00 0.00<br />

27355 S 807.54 0.00 0.00 27509 S 722.63 0.00 0.00<br />

27356 S 863.01 0.00 0.00 27510 S 165.54 0.00 0.00<br />

27357 S 903.23 0.00 0.00 27516 S 78.47 0.00 0.00<br />

27358 S 903.23 0.00 0.00 27517 S 78.47 0.00 0.00<br />

27360 S 903.23 0.00 0.00 27520 S 78.47 0.00 0.00<br />

27372 S 877.92 0.00 0.00 27530 S 78.47 0.00 0.00<br />

27380 S 570.71 0.00 0.00 27532 S 428.16 0.00 0.00<br />

27381 S 652.54 0.00 0.00 27538 S 78.47 0.00 0.00<br />

27385 S 652.54 0.00 0.00 27550 S 78.47 0.00 0.00<br />

27386 S 652.54 0.00 0.00 27552 S 451.81 0.00 0.00<br />

27390 S 570.71 0.00 0.00 27560 S 78.47 0.00 0.00<br />

27391 S 622.94 0.00 0.00 27562 S 451.81 0.00 0.00<br />

27392 S 652.54 0.00 0.00 27566 S 1,026.40 0.00 0.00<br />

27393 S 777.95 0.00 0.00 27570 S 451.81 0.00 0.00<br />

27394 S 807.54 0.00 0.00 27594 S 652.54 0.00 0.00<br />

27395 S 1,103.58 0.00 0.00 27600 S 652.54 0.00 0.00<br />

27396 S 807.54 0.00 0.00 27601 S 652.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 652.54 0.00 0.00 27730 S 777.95 0.00 0.00<br />

27603 S 577.15 0.00 0.00 27732 S 777.95 0.00 0.00<br />

27604 S 622.94 0.00 0.00 27734 S 777.95 0.00 0.00<br />

27605 S 567.65 0.00 0.00 27740 S 777.95 0.00 0.00<br />

27606 S 570.71 0.00 0.00 27742 S 1,074.00 0.00 0.00<br />

27607 S 622.94 0.00 0.00 27745 S 1,892.75 0.00 0.00<br />

27610 S 777.95 0.00 0.00 27750 S 78.47 0.00 0.00<br />

27612 S 807.54 0.00 0.00 27752 S 428.16 0.00 0.00<br />

27613 S 128.24 0.00 0.00 27756 S 722.63 0.00 0.00<br />

27614 S 624.13 0.00 0.00 27758 S 1,111.46 0.00 0.00<br />

27615 S 807.54 0.00 0.00 27759 S 1,488.47 0.00 0.00<br />

27618 S 510.36 0.00 0.00 27760 S 78.47 0.00 0.00<br />

27619 S 653.72 0.00 0.00 27762 S 428.16 0.00 0.00<br />

27620 S 863.01 0.00 0.00 27766 S 1,055.98 0.00 0.00<br />

27625 S 863.01 0.00 0.00 27767 S 61.15 0.00 0.00<br />

27626 S 863.01 0.00 0.00 27768 S 61.15 0.00 0.00<br />

27630 S 652.54 0.00 0.00 27769 S 1,640.44 0.00 0.00<br />

27635 S 807.54 0.00 0.00 27780 S 78.47 0.00 0.00<br />

27637 S 807.54 0.00 0.00 27781 S 428.16 0.00 0.00<br />

27638 S 807.54 0.00 0.00 27784 S 1,055.98 0.00 0.00<br />

27640 S 1,074.00 0.00 0.00 27786 S 78.47 0.00 0.00<br />

27641 S 777.95 0.00 0.00 27788 S 78.47 0.00 0.00<br />

27647 S 1,103.58 0.00 0.00 27792 S 1,055.98 0.00 0.00<br />

27650 S 1,103.58 0.00 0.00 27808 S 78.47 0.00 0.00<br />

27652 S 1,892.75 0.00 0.00 27810 S 165.54 0.00 0.00<br />

27654 S 1,103.58 0.00 0.00 27814 S 1,055.98 0.00 0.00<br />

27656 S 622.94 0.00 0.00 27816 S 78.47 0.00 0.00<br />

27658 S 570.71 0.00 0.00 27818 S 165.54 0.00 0.00<br />

27659 S 622.94 0.00 0.00 27822 S 1,055.98 0.00 0.00<br />

27664 S 622.94 0.00 0.00 27823 S 1,433.01 0.00 0.00<br />

27665 S 777.95 0.00 0.00 27824 S 78.47 0.00 0.00<br />

27675 S 622.94 0.00 0.00 27825 S 428.16 0.00 0.00<br />

27676 S 807.54 0.00 0.00 27826 S 1,055.98 0.00 0.00<br />

27680 S 807.54 0.00 0.00 27827 S 1,433.01 0.00 0.00<br />

27681 S 777.95 0.00 0.00 27828 S 1,488.47 0.00 0.00<br />

27685 S 807.54 0.00 0.00 27829 S 1,026.40 0.00 0.00<br />

27686 S 807.54 0.00 0.00 27830 S 78.47 0.00 0.00<br />

27687 S 807.54 0.00 0.00 27831 S 428.16 0.00 0.00<br />

27690 S 1,159.06 0.00 0.00 27832 S 1,026.40 0.00 0.00<br />

27691 S 1,159.06 0.00 0.00 27840 S 165.54 0.00 0.00<br />

27692 S 1,103.58 0.00 0.00 27842 S 451.81 0.00 0.00<br />

27695 S 777.95 0.00 0.00 27846 S 1,055.98 0.00 0.00<br />

27696 S 777.95 0.00 0.00 27848 S 1,055.98 0.00 0.00<br />

27698 S 777.95 0.00 0.00 27860 S 451.81 0.00 0.00<br />

27700 S 1,055.34 0.00 0.00 27870 S 1,948.22 0.00 0.00<br />

27704 S 622.94 0.00 0.00 27871 S 1,948.22 0.00 0.00<br />

27705 S 1,074.00 0.00 0.00 27884 S 652.54 0.00 0.00<br />

27707 S 622.94 0.00 0.00 27889 S 807.54 0.00 0.00<br />

27709 S 777.95 0.00 0.00 27892 S 652.54 0.00 0.00<br />

27726 S 973.74 0.00 0.00 27893 S 652.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 652.54 0.00 0.00 28153 S 649.47 0.00 0.00<br />

28001 S 125.16 0.00 0.00 28160 S 649.47 0.00 0.00<br />

28002 S 652.54 0.00 0.00 28171 S 649.47 0.00 0.00<br />

28003 S 652.54 0.00 0.00 28173 S 649.47 0.00 0.00<br />

28005 S 649.47 0.00 0.00 28175 S 649.47 0.00 0.00<br />

28008 S 649.47 0.00 0.00 28190 S 129.26 0.00 0.00<br />

28010 S 91.99 0.00 0.00 28192 S 510.36 0.00 0.00<br />

28011 S 649.47 0.00 0.00 28193 S 351.44 0.00 0.00<br />

28020 S 619.88 0.00 0.00 28200 S 649.47 0.00 0.00<br />

28022 S 619.88 0.00 0.00 28202 S 649.47 0.00 0.00<br />

28024 S 619.88 0.00 0.00 28208 S 649.47 0.00 0.00<br />

28035 S 645.43 0.00 0.00 28210 S 1,140.67 0.00 0.00<br />

28043 S 624.13 0.00 0.00 28220 S 199.37 0.00 0.00<br />

28045 S 649.47 0.00 0.00 28222 S 567.65 0.00 0.00<br />

28046 S 649.47 0.00 0.00 28225 S 567.65 0.00 0.00<br />

28050 S 619.88 0.00 0.00 28226 S 567.65 0.00 0.00<br />

28052 S 619.88 0.00 0.00 28230 S 195.60 0.00 0.00<br />

28054 S 619.88 0.00 0.00 28232 S 187.05 0.00 0.00<br />

28055 S 645.43 0.00 0.00 28234 S 619.88 0.00 0.00<br />

28060 S 619.88 0.00 0.00 28238 S 1,140.67 0.00 0.00<br />

28062 S 649.47 0.00 0.00 28240 S 619.88 0.00 0.00<br />

28070 S 649.47 0.00 0.00 28250 S 649.47 0.00 0.00<br />

28072 S 649.47 0.00 0.00 28260 S 649.47 0.00 0.00<br />

28080 S 649.47 0.00 0.00 28261 S 649.47 0.00 0.00<br />

28086 S 619.88 0.00 0.00 28262 S 704.94 0.00 0.00<br />

28088 S 619.88 0.00 0.00 28264 S 1,058.85 0.00 0.00<br />

28090 S 649.47 0.00 0.00 28270 S 649.47 0.00 0.00<br />

28092 S 649.47 0.00 0.00 28272 S 180.56 0.00 0.00<br />

28100 S 619.88 0.00 0.00 28280 S 619.88 0.00 0.00<br />

28102 S 1,140.67 0.00 0.00 28285 S 649.47 0.00 0.00<br />

28103 S 1,140.67 0.00 0.00 28286 S 704.94 0.00 0.00<br />

28104 S 619.88 0.00 0.00 28288 S 649.47 0.00 0.00<br />

28106 S 1,140.67 0.00 0.00 28289 S 649.47 0.00 0.00<br />

28107 S 1,140.67 0.00 0.00 28290 S 800.56 0.00 0.00<br />

28108 S 619.88 0.00 0.00 28292 S 800.56 0.00 0.00<br />

28110 S 649.47 0.00 0.00 28293 S 830.14 0.00 0.00<br />

28111 S 649.47 0.00 0.00 28294 S 830.14 0.00 0.00<br />

28112 S 649.47 0.00 0.00 28296 S 830.14 0.00 0.00<br />

28113 S 649.47 0.00 0.00 28297 S 830.14 0.00 0.00<br />

28114 S 649.47 0.00 0.00 28298 S 830.14 0.00 0.00<br />

28116 S 649.47 0.00 0.00 28299 S 925.83 0.00 0.00<br />

28118 S 704.94 0.00 0.00 28300 S 1,111.09 0.00 0.00<br />

28119 S 704.94 0.00 0.00 28302 S 619.88 0.00 0.00<br />

28120 S 873.67 0.00 0.00 28304 S 1,111.09 0.00 0.00<br />

28122 S 649.47 0.00 0.00 28305 S 1,140.67 0.00 0.00<br />

28124 S 211.67 0.00 0.00 28306 S 704.94 0.00 0.00<br />

28126 S 649.47 0.00 0.00 28307 S 704.94 0.00 0.00<br />

28130 S 649.47 0.00 0.00 28308 S 619.88 0.00 0.00<br />

28140 S 649.47 0.00 0.00 28309 S 1,196.15 0.00 0.00<br />

28150 S 649.47 0.00 0.00 28310 S 649.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 649.47 0.00 0.00 28636 S 722.63 0.00 0.00<br />

28313 S 619.88 0.00 0.00 28645 S 722.63 0.00 0.00<br />

28315 S 704.94 0.00 0.00 28660 S 43.78 0.00 0.00<br />

28320 S 1,196.15 0.00 0.00 28665 S 451.81 0.00 0.00<br />

28322 S 1,196.15 0.00 0.00 28666 S 722.63 0.00 0.00<br />

28340 S 704.94 0.00 0.00 28675 S 722.63 0.00 0.00<br />

28341 S 704.94 0.00 0.00 28705 S 1,196.15 0.00 0.00<br />

28344 S 704.94 0.00 0.00 28715 S 1,948.22 0.00 0.00<br />

28345 S 704.94 0.00 0.00 28725 S 1,196.15 0.00 0.00<br />

28400 S 78.47 0.00 0.00 28730 S 1,196.15 0.00 0.00<br />

28405 S 428.16 0.00 0.00 28735 S 1,196.15 0.00 0.00<br />

28406 S 693.04 0.00 0.00 28737 S 1,236.36 0.00 0.00<br />

28415 S 1,433.01 0.00 0.00 28740 S 1,196.15 0.00 0.00<br />

28420 S 1,111.46 0.00 0.00 28750 S 1,196.15 0.00 0.00<br />

28430 S 61.15 0.00 0.00 28755 S 704.94 0.00 0.00<br />

28435 S 78.47 0.00 0.00 28760 S 1,196.15 0.00 0.00<br />

28436 S 693.04 0.00 0.00 28810 S 619.88 0.00 0.00<br />

28445 S 1,055.98 0.00 0.00 28820 S 619.88 0.00 0.00<br />

28446 S 1,809.83 0.00 0.00 28825 S 619.88 0.00 0.00<br />

28450 S 61.15 0.00 0.00 28890 S 163.80 0.00 0.00<br />

28455 S 61.15 0.00 0.00 29000 S 41.50 0.00 0.00<br />

28456 S 693.04 0.00 0.00 29010 S 93.01 0.00 0.00<br />

28465 S 1,055.98 0.00 0.00 29015 S 93.01 0.00 0.00<br />

28470 S 61.15 0.00 0.00 29020 S 41.50 0.00 0.00<br />

28475 S 61.15 0.00 0.00 29025 S 41.50 0.00 0.00<br />

28476 S 693.04 0.00 0.00 29035 S 93.01 0.00 0.00<br />

28485 S 1,111.46 0.00 0.00 29040 S 41.50 0.00 0.00<br />

28490 S 61.15 0.00 0.00 29044 S 93.01 0.00 0.00<br />

28495 S 61.15 0.00 0.00 29046 S 93.01 0.00 0.00<br />

28496 S 693.04 0.00 0.00 29049 S 37.61 0.00 0.00<br />

28505 S 722.63 0.00 0.00 29055 S 93.01 0.00 0.00<br />

28510 S 55.06 0.00 0.00 29058 S 41.50 0.00 0.00<br />

28515 S 61.15 0.00 0.00 29065 S 44.12 0.00 0.00<br />

28525 S 722.63 0.00 0.00 29075 S 42.40 0.00 0.00<br />

28530 S 53.00 0.00 0.00 29085 S 41.50 0.00 0.00<br />

28531 S 722.63 0.00 0.00 29086 S 35.57 0.00 0.00<br />

28540 S 61.15 0.00 0.00 29105 S 38.30 0.00 0.00<br />

28545 S 640.81 0.00 0.00 29125 S 33.17 0.00 0.00<br />

28546 S 693.04 0.00 0.00 29126 S 35.22 0.00 0.00<br />

28555 S 1,026.40 0.00 0.00 29130 S 15.05 0.00 0.00<br />

28570 S 79.33 0.00 0.00 29131 S 21.88 0.00 0.00<br />

28575 S 428.16 0.00 0.00 29200 S 21.20 0.00 0.00<br />

28576 S 722.63 0.00 0.00 29220 S 22.91 0.00 0.00<br />

28585 S 722.63 0.00 0.00 29240 S 23.94 0.00 0.00<br />

28600 S 61.15 0.00 0.00 29260 S 22.91 0.00 0.00<br />

28605 S 78.47 0.00 0.00 29280 S 23.26 0.00 0.00<br />

28606 S 693.04 0.00 0.00 29305 S 93.01 0.00 0.00<br />

28615 S 1,055.98 0.00 0.00 29325 S 93.01 0.00 0.00<br />

28630 S 61.15 0.00 0.00 29345 S 57.79 0.00 0.00<br />

28635 S 451.81 0.00 0.00 29355 S 56.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 70.45 0.00 0.00 29847 S 1,177.48 0.00 0.00<br />

29365 S 54.72 0.00 0.00 29848 S 1,181.82 0.00 0.00<br />

29405 S 40.69 0.00 0.00 29850 S 854.07 0.00 0.00<br />

29425 S 41.38 0.00 0.00 29851 S 1,232.96 0.00 0.00<br />

29435 S 52.32 0.00 0.00 29855 S 1,232.96 0.00 0.00<br />

29440 S 22.22 0.00 0.00 29856 S 1,232.96 0.00 0.00<br />

29445 S 55.06 0.00 0.00 29860 S 1,232.96 0.00 0.00<br />

29450 S 41.50 0.00 0.00 29861 S 1,232.96 0.00 0.00<br />

29505 S 36.93 0.00 0.00 29862 S 1,560.70 0.00 0.00<br />

29515 S 31.46 0.00 0.00 29863 S 1,232.96 0.00 0.00<br />

29520 S 22.57 0.00 0.00 29866 S 1,883.44 0.00 0.00<br />

29530 S 22.91 0.00 0.00 29870 S 798.61 0.00 0.00<br />

29540 S 17.10 0.00 0.00 29871 S 798.61 0.00 0.00<br />

29550 S 17.44 0.00 0.00 29873 S 798.61 0.00 0.00<br />

29580 S 23.60 0.00 0.00 29874 S 798.61 0.00 0.00<br />

29590 S 19.15 0.00 0.00 29875 S 854.07 0.00 0.00<br />

29700 S 31.80 0.00 0.00 29876 S 854.07 0.00 0.00<br />

29705 S 27.01 0.00 0.00 29877 S 854.07 0.00 0.00<br />

29710 S 47.53 0.00 0.00 29879 S 798.61 0.00 0.00<br />

29715 S 41.50 0.00 0.00 29880 S 854.07 0.00 0.00<br />

29720 S 39.67 0.00 0.00 29881 S 854.07 0.00 0.00<br />

29730 S 25.99 0.00 0.00 29882 S 798.61 0.00 0.00<br />

29740 S 35.57 0.00 0.00 29883 S 798.61 0.00 0.00<br />

29750 S 37.27 0.00 0.00 29884 S 798.61 0.00 0.00<br />

29800 S 798.61 0.00 0.00 29885 S 1,177.48 0.00 0.00<br />

29804 S 798.61 0.00 0.00 29886 S 798.61 0.00 0.00<br />

29805 S 798.61 0.00 0.00 29887 S 798.61 0.00 0.00<br />

29806 S 1,177.48 0.00 0.00 29888 S 1,177.48 0.00 0.00<br />

29807 S 1,177.48 0.00 0.00 29889 S 1,177.48 0.00 0.00<br />

29819 S 1,177.48 0.00 0.00 29891 S 1,177.48 0.00 0.00<br />

29820 S 1,177.48 0.00 0.00 29892 S 1,177.48 0.00 0.00<br />

29821 S 1,177.48 0.00 0.00 29893 S 994.12 0.00 0.00<br />

29822 S 798.61 0.00 0.00 29894 S 798.61 0.00 0.00<br />

29823 S 1,177.48 0.00 0.00 29895 S 798.61 0.00 0.00<br />

29824 S 894.30 0.00 0.00 29897 S 798.61 0.00 0.00<br />

29825 S 1,177.48 0.00 0.00 29898 S 798.61 0.00 0.00<br />

29826 S 1,177.48 0.00 0.00 29899 S 1,177.48 0.00 0.00<br />

29827 S 1,273.17 0.00 0.00 29900 S 798.61 0.00 0.00<br />

29828 S 1,883.44 0.00 0.00 29901 S 798.61 0.00 0.00<br />

29830 S 798.61 0.00 0.00 29902 S 798.61 0.00 0.00<br />

29834 S 798.61 0.00 0.00 29904 S 1,125.69 0.00 0.00<br />

29835 S 798.61 0.00 0.00 29905 S 1,125.69 0.00 0.00<br />

29836 S 798.61 0.00 0.00 29906 S 1,125.69 0.00 0.00<br />

29837 S 798.61 0.00 0.00 29907 S 1,883.44 0.00 0.00<br />

29838 S 798.61 0.00 0.00 30000 S 126.56 0.00 0.00<br />

29840 S 798.61 0.00 0.00 30020 S 126.56 0.00 0.00<br />

29843 S 798.61 0.00 0.00 30100 S 82.07 0.00 0.00<br />

29844 S 798.61 0.00 0.00 30110 S 126.87 0.00 0.00<br />

29845 S 798.61 0.00 0.00 30115 S 536.06 0.00 0.00<br />

29846 S 798.61 0.00 0.00 30117 S 565.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 709.45 0.00 0.00 31080 S 1,092.48 0.00 0.00<br />

30120 S 483.82 0.00 0.00 31081 S 1,092.48 0.00 0.00<br />

30124 S 288.29 0.00 0.00 31084 S 1,092.48 0.00 0.00<br />

30125 S 1,007.42 0.00 0.00 31085 S 1,092.48 0.00 0.00<br />

30130 S 565.65 0.00 0.00 31086 S 1,092.48 0.00 0.00<br />

30140 S 679.86 0.00 0.00 31087 S 1,092.48 0.00 0.00<br />

30150 S 1,037.01 0.00 0.00 31090 S 1,132.70 0.00 0.00<br />

30160 S 1,092.48 0.00 0.00 31200 S 1,007.42 0.00 0.00<br />

30200 S 64.64 0.00 0.00 31201 S 1,132.70 0.00 0.00<br />

30210 S 82.07 0.00 0.00 31205 S 1,037.01 0.00 0.00<br />

30220 S 358.70 0.00 0.00 31231 S 69.19 0.00 0.00<br />

30300 S 24.73 0.00 0.00 31233 S 74.52 0.00 0.00<br />

30310 S 483.82 0.00 0.00 31235 S 506.32 0.00 0.00<br />

30320 S 536.06 0.00 0.00 31237 S 558.56 0.00 0.00<br />

30400 S 1,092.48 0.00 0.00 31238 S 506.32 0.00 0.00<br />

30410 S 1,132.70 0.00 0.00 31239 S 739.07 0.00 0.00<br />

30420 S 1,132.70 0.00 0.00 31240 S 558.56 0.00 0.00<br />

30430 S 709.45 0.00 0.00 31254 S 683.60 0.00 0.00<br />

30435 S 1,132.70 0.00 0.00 31255 S 779.28 0.00 0.00<br />

30450 S 1,261.21 0.00 0.00 31256 S 683.60 0.00 0.00<br />

30460 S 1,261.21 0.00 0.00 31267 S 683.60 0.00 0.00<br />

30462 S 1,420.22 0.00 0.00 31276 S 683.60 0.00 0.00<br />

30465 S 1,420.22 0.00 0.00 31287 S 683.60 0.00 0.00<br />

30520 S 764.92 0.00 0.00 31288 S 683.60 0.00 0.00<br />

30540 S 1,132.70 0.00 0.00 31300 S 805.14 0.00 0.00<br />

30545 S 1,132.70 0.00 0.00 31320 S 1,007.42 0.00 0.00<br />

30560 S 132.95 0.00 0.00 31400 S 1,007.42 0.00 0.00<br />

30580 S 1,092.48 0.00 0.00 31420 S 1,007.42 0.00 0.00<br />

30600 S 1,092.48 0.00 0.00 31500 S 92.54 0.00 0.00<br />

30620 S 1,261.21 0.00 0.00 31502 S 53.21 0.00 0.00<br />

30630 S 933.65 0.00 0.00 31505 S 31.44 0.00 0.00<br />

30801 S 298.08 0.00 0.00 31510 S 558.56 0.00 0.00<br />

30802 S 298.08 0.00 0.00 31511 S 74.52 0.00 0.00<br />

30901 S 42.52 0.00 0.00 31512 S 558.56 0.00 0.00<br />

30903 S 54.77 0.00 0.00 31513 S 74.52 0.00 0.00<br />

30905 S 54.77 0.00 0.00 31515 S 506.32 0.00 0.00<br />

30906 S 54.77 0.00 0.00 31520 S 69.19 0.00 0.00<br />

30915 S 729.72 0.00 0.00 31525 S 506.32 0.00 0.00<br />

30920 S 759.32 0.00 0.00 31526 S 654.01 0.00 0.00<br />

30930 S 621.11 0.00 0.00 31527 S 601.77 0.00 0.00<br />

31000 S 105.67 0.00 0.00 31528 S 558.56 0.00 0.00<br />

31002 S 288.29 0.00 0.00 31529 S 558.56 0.00 0.00<br />

31020 S 679.86 0.00 0.00 31530 S 654.01 0.00 0.00<br />

31030 S 1,037.01 0.00 0.00 31531 S 683.60 0.00 0.00<br />

31032 S 1,092.48 0.00 0.00 31535 S 654.01 0.00 0.00<br />

31040 S 947.39 0.00 0.00 31536 S 683.60 0.00 0.00<br />

31050 S 1,007.42 0.00 0.00 31540 S 683.60 0.00 0.00<br />

31051 S 1,092.48 0.00 0.00 31541 S 739.07 0.00 0.00<br />

31070 S 679.86 0.00 0.00 31545 S 739.07 0.00 0.00<br />

31075 S 1,092.48 0.00 0.00 31546 S 739.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 779.28 0.00 0.00 32405 S 337.22 0.00 0.00<br />

31561 S 779.28 0.00 0.00 32420 S 205.06 0.00 0.00<br />

31570 S 558.56 0.00 0.00 32421 S 205.06 0.00 0.00<br />

31571 S 654.01 0.00 0.00 32422 S 204.15 0.00 0.00<br />

31575 S 59.51 0.00 0.00 32550 S 1,142.99 0.00 0.00<br />

31576 S 654.01 0.00 0.00 32960 S 204.15 0.00 0.00<br />

31577 S 193.20 0.00 0.00 32998 S 1,779.58 0.00 0.00<br />

31578 S 654.01 0.00 0.00 33010 S 205.06 0.00 0.00<br />

31579 S 106.01 0.00 0.00 33011 S 205.06 0.00 0.00<br />

31580 S 1,132.70 0.00 0.00 33206 S 6,578.99 3,914.48 1,249.97<br />

31582 S 1,132.70 0.00 0.00 33207 S 6,578.99 3,914.48 1,249.97<br />

31588 S 1,132.70 0.00 0.00 33208 S 8,159.81 4,754.68 1,349.56<br />

31590 S 1,132.70 0.00 0.00 33210 S 1,931.94 0.00 0.00<br />

31595 S 1,007.42 0.00 0.00 33211 S 1,931.94 0.00 0.00<br />

31603 S 298.08 0.00 0.00 33212 S 5,166.85 2,943.33 719.82<br />

31605 S 288.29 0.00 0.00 33213 S 5,963.65 3,341.31 718.96<br />

31611 S 709.45 0.00 0.00 33214 S 8,159.81 4,754.68 1,349.56<br />

31612 S 627.63 0.00 0.00 33215 S 846.79 0.00 0.00<br />

31613 S 679.86 0.00 0.00 33216 S 1,931.94 0.00 0.00<br />

31614 S 1,007.42 0.00 0.00 33217 S 1,931.94 0.00 0.00<br />

31615 S 298.08 0.00 0.00 33218 S 846.79 0.00 0.00<br />

31622 S 349.10 0.00 0.00 33220 S 846.79 0.00 0.00<br />

31623 S 401.33 0.00 0.00 33222 S 511.85 0.00 0.00<br />

31624 S 401.33 0.00 0.00 33223 S 511.85 0.00 0.00<br />

31625 S 401.33 0.00 0.00 33224 S 7,702.10 4,611.22 1,520.36<br />

31628 S 401.33 0.00 0.00 33225 S 7,702.10 4,611.22 1,520.36<br />

31629 S 401.33 0.00 0.00 33226 S 846.79 0.00 0.00<br />

31630 S 687.72 0.00 0.00 33233 S 629.57 0.00 0.00<br />

31631 S 687.72 0.00 0.00 33234 S 846.79 0.00 0.00<br />

31632 S 390.32 0.00 0.00 33235 S 846.79 0.00 0.00<br />

31633 S 390.32 0.00 0.00 33240 S 19,199.36 10,262.84 1,326.33<br />

31635 S 401.33 0.00 0.00 33241 S 846.79 0.00 0.00<br />

31636 S 687.72 0.00 0.00 33249 S 25,623.01 13,724.75 1,826.48<br />

31637 S 349.10 0.00 0.00 33282 S 4,051.16 2,425.26 799.37<br />

31638 S 687.72 0.00 0.00 33284 S 315.98 0.00 0.00<br />

31640 S 687.72 0.00 0.00 34490 S 1,542.71 0.00 0.00<br />

31641 S 687.72 0.00 0.00 35188 S 1,062.58 0.00 0.00<br />

31643 S 401.33 0.00 0.00 35207 S 1,062.58 0.00 0.00<br />

31645 S 349.10 0.00 0.00 35473 S 1,850.66 0.00 0.00<br />

31646 S 349.10 0.00 0.00 35476 S 1,850.66 0.00 0.00<br />

31656 S 349.10 0.00 0.00 35492 S 3,454.06 0.00 0.00<br />

31717 S 193.20 0.00 0.00 35761 S 1,111.13 0.00 0.00<br />

31720 S 29.58 0.00 0.00 35875 S 1,390.33 0.00 0.00<br />

31730 S 193.20 0.00 0.00 35876 S 1,390.33 0.00 0.00<br />

31750 S 1,132.70 0.00 0.00 36002 S 88.74 0.00 0.00<br />

31755 S 1,007.42 0.00 0.00 36260 S 804.97 0.00 0.00<br />

31820 S 483.82 0.00 0.00 36261 S 629.57 0.00 0.00<br />

31825 S 679.86 0.00 0.00 36262 S 577.33 0.00 0.00<br />

31830 S 679.86 0.00 0.00 36420 S 8.36 0.00 0.00<br />

32400 S 337.22 0.00 0.00 36425 S 8.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.14 0.00 0.00 36800 S 866.55 0.00 0.00<br />

36440 S 128.37 0.00 0.00 36810 S 866.55 0.00 0.00<br />

36450 S 128.37 0.00 0.00 36815 S 866.55 0.00 0.00<br />

36455 S 128.37 0.00 0.00 36818 S 1,007.12 0.00 0.00<br />

36468 S 31.69 0.00 0.00 36819 S 1,007.12 0.00 0.00<br />

36469 S 31.69 0.00 0.00 36820 S 1,007.12 0.00 0.00<br />

36470 S 31.69 0.00 0.00 36821 S 1,007.12 0.00 0.00<br />

36471 S 31.69 0.00 0.00 36825 S 1,062.58 0.00 0.00<br />

36475 S 1,456.93 0.00 0.00 36830 S 1,062.58 0.00 0.00<br />

36476 S 1,142.53 0.00 0.00 36831 S 1,390.33 0.00 0.00<br />

36478 S 1,142.53 0.00 0.00 36832 S 1,062.58 0.00 0.00<br />

36479 S 1,142.53 0.00 0.00 36833 S 1,062.58 0.00 0.00<br />

36511 S 440.11 0.00 0.00 36834 S 1,007.12 0.00 0.00<br />

36512 S 440.11 0.00 0.00 36835 S 922.03 0.00 0.00<br />

36513 S 440.11 0.00 0.00 36860 S 105.82 0.00 0.00<br />

36514 S 440.11 0.00 0.00 36861 S 866.55 0.00 0.00<br />

36515 S 1,178.18 0.00 0.00 36870 S 1,515.47 0.00 0.00<br />

36516 S 1,178.18 0.00 0.00 37184 S 1,542.71 0.00 0.00<br />

36522 S 1,178.18 0.00 0.00 37185 S 1,542.71 0.00 0.00<br />

36555 S 365.67 0.00 0.00 37186 S 1,542.71 0.00 0.00<br />

36556 S 365.67 0.00 0.00 37187 S 1,542.71 0.00 0.00<br />

36557 S 682.92 0.00 0.00 37188 S 1,542.71 0.00 0.00<br />

36558 S 682.92 0.00 0.00 37200 S 1,138.42 0.00 0.00<br />

36560 S 804.97 0.00 0.00 37203 S 1,138.42 0.00 0.00<br />

36561 S 804.97 0.00 0.00 37500 S 1,073.71 0.00 0.00<br />

36563 S 804.97 0.00 0.00 37607 S 759.32 0.00 0.00<br />

36565 S 804.97 0.00 0.00 37609 S 510.36 0.00 0.00<br />

36566 S 804.97 0.00 0.00 37650 S 729.72 0.00 0.00<br />

36568 S 365.67 0.00 0.00 37700 S 729.72 0.00 0.00<br />

36569 S 365.67 0.00 0.00 37718 S 759.32 0.00 0.00<br />

36570 S 712.51 0.00 0.00 37722 S 1,073.71 0.00 0.00<br />

36571 S 712.51 0.00 0.00 37735 S 1,073.71 0.00 0.00<br />

36575 S 294.11 0.00 0.00 37760 S 759.32 0.00 0.00<br />

36576 S 417.91 0.00 0.00 37765 S 1,047.11 0.00 0.00<br />

36578 S 682.92 0.00 0.00 37766 S 1,047.11 0.00 0.00<br />

36580 S 365.67 0.00 0.00 37780 S 759.32 0.00 0.00<br />

36581 S 682.92 0.00 0.00 37785 S 759.32 0.00 0.00<br />

36582 S 804.97 0.00 0.00 37790 S 916.26 0.00 0.00<br />

36583 S 804.97 0.00 0.00 38205 S 440.11 0.00 0.00<br />

36584 S 365.67 0.00 0.00 38206 S 440.11 0.00 0.00<br />

36585 S 712.51 0.00 0.00 38220 S 100.88 0.00 0.00<br />

36589 S 241.87 0.00 0.00 38221 S 105.67 0.00 0.00<br />

36590 S 365.67 0.00 0.00 38230 S 1,178.18 0.00 0.00<br />

36593 S 24.28 0.00 0.00 38241 S 1,178.18 0.00 0.00<br />

36595 S 953.50 0.00 0.00 38242 S 440.11 0.00 0.00<br />

36596 S 423.46 0.00 0.00 38300 S 394.94 0.00 0.00<br />

36597 S 423.46 0.00 0.00 38305 S 577.15 0.00 0.00<br />

36598 S 78.31 0.00 0.00 38308 S 659.47 0.00 0.00<br />

36640 S 723.14 0.00 0.00 38500 S 659.47 0.00 0.00<br />

36680 S 54.81 0.00 0.00 38505 S 252.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 659.47 0.00 0.00 41005 S 132.95 0.00 0.00<br />

38520 S 659.47 0.00 0.00 41006 S 627.63 0.00 0.00<br />

38525 S 659.47 0.00 0.00 41007 S 483.82 0.00 0.00<br />

38530 S 659.47 0.00 0.00 41008 S 483.82 0.00 0.00<br />

38542 S 1,109.46 0.00 0.00 41009 S 132.95 0.00 0.00<br />

38550 S 689.06 0.00 0.00 41010 S 298.08 0.00 0.00<br />

38555 S 744.53 0.00 0.00 41015 S 132.95 0.00 0.00<br />

38570 S 1,505.37 0.00 0.00 41016 S 298.08 0.00 0.00<br />

38571 S 1,956.94 0.00 0.00 41017 S 298.08 0.00 0.00<br />

38572 S 1,505.37 0.00 0.00 41018 S 298.08 0.00 0.00<br />

38700 S 906.59 0.00 0.00 41019 S 947.39 0.00 0.00<br />

38740 S 1,109.46 0.00 0.00 41100 S 89.25 0.00 0.00<br />

38745 S 1,194.52 0.00 0.00 41105 S 88.23 0.00 0.00<br />

38760 S 659.47 0.00 0.00 41108 S 81.73 0.00 0.00<br />

40490 S 67.37 0.00 0.00 41110 S 118.32 0.00 0.00<br />

40500 S 536.06 0.00 0.00 41112 S 536.06 0.00 0.00<br />

40510 S 679.86 0.00 0.00 41113 S 536.06 0.00 0.00<br />

40520 S 536.06 0.00 0.00 41114 S 679.86 0.00 0.00<br />

40525 S 679.86 0.00 0.00 41115 S 137.81 0.00 0.00<br />

40527 S 679.86 0.00 0.00 41116 S 483.82 0.00 0.00<br />

40530 S 679.86 0.00 0.00 41120 S 805.14 0.00 0.00<br />

40650 S 358.70 0.00 0.00 41250 S 90.93 0.00 0.00<br />

40652 S 358.70 0.00 0.00 41251 S 132.95 0.00 0.00<br />

40654 S 358.70 0.00 0.00 41252 S 350.31 0.00 0.00<br />

40700 S 1,261.21 0.00 0.00 41500 S 627.63 0.00 0.00<br />

40701 S 1,261.21 0.00 0.00 41510 S 483.82 0.00 0.00<br />

40702 S 1,602.50 0.00 0.00 41520 S 350.31 0.00 0.00<br />

40720 S 1,261.21 0.00 0.00 41530 S 659.77 0.00 0.00<br />

40761 S 1,037.01 0.00 0.00 41800 S 67.93 0.00 0.00<br />

40800 S 54.06 0.00 0.00 41805 S 147.05 0.00 0.00<br />

40801 S 350.31 0.00 0.00 41806 S 181.24 0.00 0.00<br />

40804 S 24.73 0.00 0.00 41820 S 288.29 0.00 0.00<br />

40805 S 167.23 0.00 0.00 41821 S 288.29 0.00 0.00<br />

40806 S 76.94 0.00 0.00 41822 S 150.12 0.00 0.00<br />

40808 S 114.21 0.00 0.00 41823 S 218.86 0.00 0.00<br />

40810 S 118.32 0.00 0.00 41825 S 120.37 0.00 0.00<br />

40812 S 148.41 0.00 0.00 41826 S 151.50 0.00 0.00<br />

40814 S 536.06 0.00 0.00 41827 S 679.86 0.00 0.00<br />

40816 S 679.86 0.00 0.00 41828 S 136.79 0.00 0.00<br />

40818 S 132.95 0.00 0.00 41830 S 194.24 0.00 0.00<br />

40819 S 298.08 0.00 0.00 41850 S 659.77 0.00 0.00<br />

40820 S 170.64 0.00 0.00 41870 S 947.39 0.00 0.00<br />

40830 S 126.56 0.00 0.00 41872 S 194.24 0.00 0.00<br />

40831 S 298.08 0.00 0.00 41874 S 187.39 0.00 0.00<br />

40840 S 679.86 0.00 0.00 42000 S 132.95 0.00 0.00<br />

40842 S 709.45 0.00 0.00 42100 S 75.92 0.00 0.00<br />

40843 S 709.45 0.00 0.00 42104 S 112.85 0.00 0.00<br />

40844 S 1,132.70 0.00 0.00 42106 S 141.58 0.00 0.00<br />

40845 S 1,132.70 0.00 0.00 42107 S 679.86 0.00 0.00<br />

41000 S 84.81 0.00 0.00 42120 S 1,092.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 350.31 0.00 0.00 42809 S 24.73 0.00 0.00<br />

42145 S 805.14 0.00 0.00 42810 S 709.45 0.00 0.00<br />

42160 S 134.05 0.00 0.00 42815 S 1,132.70 0.00 0.00<br />

42180 S 132.95 0.00 0.00 42820 S 709.45 0.00 0.00<br />

42182 S 1,007.42 0.00 0.00 42821 S 805.14 0.00 0.00<br />

42200 S 1,132.70 0.00 0.00 42825 S 764.92 0.00 0.00<br />

42205 S 1,132.70 0.00 0.00 42826 S 764.92 0.00 0.00<br />

42210 S 1,132.70 0.00 0.00 42830 S 764.92 0.00 0.00<br />

42215 S 1,261.21 0.00 0.00 42831 S 764.92 0.00 0.00<br />

42220 S 1,132.70 0.00 0.00 42835 S 764.92 0.00 0.00<br />

42226 S 1,132.70 0.00 0.00 42836 S 764.92 0.00 0.00<br />

42235 S 661.33 0.00 0.00 42860 S 709.45 0.00 0.00<br />

42260 S 764.92 0.00 0.00 42870 S 709.45 0.00 0.00<br />

42280 S 73.86 0.00 0.00 42890 S 1,261.21 0.00 0.00<br />

42281 S 659.77 0.00 0.00 42892 S 1,261.21 0.00 0.00<br />

42300 S 483.82 0.00 0.00 42900 S 298.08 0.00 0.00<br />

42305 S 536.06 0.00 0.00 42950 S 679.86 0.00 0.00<br />

42310 S 132.95 0.00 0.00 42955 S 679.86 0.00 0.00<br />

42320 S 132.95 0.00 0.00 42960 S 54.77 0.00 0.00<br />

42330 S 114.21 0.00 0.00 42962 S 1,007.42 0.00 0.00<br />

42335 S 189.45 0.00 0.00 42970 S 42.52 0.00 0.00<br />

42340 S 536.06 0.00 0.00 42972 S 565.65 0.00 0.00<br />

42400 S 64.29 0.00 0.00 43030 S 659.77 0.00 0.00<br />

42405 S 536.06 0.00 0.00 43200 S 319.50 0.00 0.00<br />

42408 S 565.65 0.00 0.00 43201 S 319.50 0.00 0.00<br />

42409 S 565.65 0.00 0.00 43202 S 319.50 0.00 0.00<br />

42410 S 1,037.01 0.00 0.00 43204 S 319.50 0.00 0.00<br />

42415 S 1,261.21 0.00 0.00 43205 S 319.50 0.00 0.00<br />

42420 S 1,261.21 0.00 0.00 43215 S 319.50 0.00 0.00<br />

42425 S 1,261.21 0.00 0.00 43216 S 319.50 0.00 0.00<br />

42440 S 1,037.01 0.00 0.00 43217 S 319.50 0.00 0.00<br />

42450 S 679.86 0.00 0.00 43219 S 645.71 0.00 0.00<br />

42500 S 709.45 0.00 0.00 43220 S 319.50 0.00 0.00<br />

42505 S 1,092.48 0.00 0.00 43226 S 319.50 0.00 0.00<br />

42507 S 1,037.01 0.00 0.00 43227 S 371.74 0.00 0.00<br />

42508 S 1,092.48 0.00 0.00 43228 S 691.78 0.00 0.00<br />

42509 S 1,092.48 0.00 0.00 43231 S 371.74 0.00 0.00<br />

42510 S 1,092.48 0.00 0.00 43232 S 371.74 0.00 0.00<br />

42600 S 483.82 0.00 0.00 43234 S 319.50 0.00 0.00<br />

42650 S 42.06 0.00 0.00 43235 S 319.50 0.00 0.00<br />

42660 S 49.25 0.00 0.00 43236 S 371.74 0.00 0.00<br />

42665 S 933.65 0.00 0.00 43237 S 371.74 0.00 0.00<br />

42700 S 132.95 0.00 0.00 43238 S 371.74 0.00 0.00<br />

42720 S 483.82 0.00 0.00 43239 S 371.74 0.00 0.00<br />

42725 S 1,007.42 0.00 0.00 43240 S 371.74 0.00 0.00<br />

42800 S 81.39 0.00 0.00 43241 S 371.74 0.00 0.00<br />

42802 S 483.82 0.00 0.00 43242 S 371.74 0.00 0.00<br />

42804 S 483.82 0.00 0.00 43243 S 371.74 0.00 0.00<br />

42806 S 679.86 0.00 0.00 43244 S 371.74 0.00 0.00<br />

42808 S 536.06 0.00 0.00 43245 S 371.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 371.74 0.00 0.00 44378 S 389.34 0.00 0.00<br />

43247 S 371.74 0.00 0.00 44379 S 1,110.76 0.00 0.00<br />

43248 S 371.74 0.00 0.00 44380 S 337.10 0.00 0.00<br />

43249 S 371.74 0.00 0.00 44382 S 337.10 0.00 0.00<br />

43250 S 371.74 0.00 0.00 44383 S 1,110.76 0.00 0.00<br />

43251 S 371.74 0.00 0.00 44385 S 325.93 0.00 0.00<br />

43255 S 371.74 0.00 0.00 44386 S 325.93 0.00 0.00<br />

43256 S 727.53 0.00 0.00 44388 S 325.93 0.00 0.00<br />

43257 S 721.37 0.00 0.00 44389 S 325.93 0.00 0.00<br />

43258 S 401.32 0.00 0.00 44390 S 325.93 0.00 0.00<br />

43259 S 401.32 0.00 0.00 44391 S 325.93 0.00 0.00<br />

43260 S 625.83 0.00 0.00 44392 S 325.93 0.00 0.00<br />

43261 S 625.83 0.00 0.00 44393 S 325.93 0.00 0.00<br />

43262 S 625.83 0.00 0.00 44394 S 325.93 0.00 0.00<br />

43263 S 625.83 0.00 0.00 44397 S 645.71 0.00 0.00<br />

43264 S 625.83 0.00 0.00 44500 S 175.88 0.00 0.00<br />

43265 S 625.83 0.00 0.00 45000 S 377.97 0.00 0.00<br />

43267 S 625.83 0.00 0.00 45005 S 439.88 0.00 0.00<br />

43268 S 697.95 0.00 0.00 45020 S 439.88 0.00 0.00<br />

43269 S 697.95 0.00 0.00 45100 S 597.63 0.00 0.00<br />

43271 S 625.83 0.00 0.00 45108 S 649.86 0.00 0.00<br />

43272 S 625.83 0.00 0.00 45150 S 649.86 0.00 0.00<br />

43273 S 839.31 0.00 0.00 45160 S 649.86 0.00 0.00<br />

43450 S 279.42 0.00 0.00 45170 S 649.86 0.00 0.00<br />

43453 S 279.42 0.00 0.00 45190 S 1,062.67 0.00 0.00<br />

43456 S 280.53 0.00 0.00 45300 S 62.92 0.00 0.00<br />

43458 S 320.62 0.00 0.00 45303 S 349.50 0.00 0.00<br />

43600 S 319.50 0.00 0.00 45305 S 328.69 0.00 0.00<br />

43653 S 1,505.37 0.00 0.00 45307 S 607.10 0.00 0.00<br />

43760 S 154.96 0.00 0.00 45308 S 328.69 0.00 0.00<br />

43761 S 319.50 0.00 0.00 45309 S 328.69 0.00 0.00<br />

43870 S 319.50 0.00 0.00 45315 S 328.69 0.00 0.00<br />

43886 S 806.17 0.00 0.00 45317 S 328.69 0.00 0.00<br />

43887 S 169.56 0.00 0.00 45320 S 607.10 0.00 0.00<br />

43888 S 806.17 0.00 0.00 45321 S 607.10 0.00 0.00<br />

44100 S 319.50 0.00 0.00 45327 S 645.71 0.00 0.00<br />

44312 S 557.02 0.00 0.00 45330 S 83.10 0.00 0.00<br />

44340 S 638.84 0.00 0.00 45331 S 245.73 0.00 0.00<br />

44360 S 389.34 0.00 0.00 45332 S 245.73 0.00 0.00<br />

44361 S 389.34 0.00 0.00 45333 S 328.69 0.00 0.00<br />

44363 S 389.34 0.00 0.00 45334 S 328.69 0.00 0.00<br />

44364 S 389.34 0.00 0.00 45335 S 245.73 0.00 0.00<br />

44365 S 389.34 0.00 0.00 45337 S 245.73 0.00 0.00<br />

44366 S 389.34 0.00 0.00 45338 S 328.69 0.00 0.00<br />

44369 S 389.34 0.00 0.00 45339 S 328.69 0.00 0.00<br />

44370 S 1,110.76 0.00 0.00 45340 S 328.69 0.00 0.00<br />

44372 S 389.34 0.00 0.00 45341 S 328.69 0.00 0.00<br />

44373 S 389.34 0.00 0.00 45342 S 328.69 0.00 0.00<br />

44376 S 389.34 0.00 0.00 45345 S 645.71 0.00 0.00<br />

44377 S 389.34 0.00 0.00 45355 S 325.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 378.17 0.00 0.00 46505 S 467.42 0.00 0.00<br />

45379 S 378.17 0.00 0.00 46600 S 24.73 0.00 0.00<br />

45380 S 378.17 0.00 0.00 46604 S 349.50 0.00 0.00<br />

45381 S 378.17 0.00 0.00 46606 S 131.32 0.00 0.00<br />

45382 S 378.17 0.00 0.00 46608 S 328.69 0.00 0.00<br />

45383 S 378.17 0.00 0.00 46610 S 607.10 0.00 0.00<br />

45384 S 378.17 0.00 0.00 46611 S 328.69 0.00 0.00<br />

45385 S 378.17 0.00 0.00 46612 S 607.10 0.00 0.00<br />

45386 S 378.17 0.00 0.00 46614 S 69.07 0.00 0.00<br />

45387 S 645.71 0.00 0.00 46615 S 659.33 0.00 0.00<br />

45391 S 378.17 0.00 0.00 46700 S 679.45 0.00 0.00<br />

45392 S 378.17 0.00 0.00 46706 S 747.87 0.00 0.00<br />

45500 S 649.86 0.00 0.00 46750 S 829.70 0.00 0.00<br />

45505 S 800.12 0.00 0.00 46753 S 679.45 0.00 0.00<br />

45520 S 31.69 0.00 0.00 46754 S 649.86 0.00 0.00<br />

45560 S 800.12 0.00 0.00 46760 S 800.12 0.00 0.00<br />

45900 S 256.24 0.00 0.00 46761 S 829.70 0.00 0.00<br />

45905 S 597.63 0.00 0.00 46762 S 1,053.90 0.00 0.00<br />

45910 S 597.63 0.00 0.00 46900 S 104.43 0.00 0.00<br />

45915 S 377.97 0.00 0.00 46910 S 124.81 0.00 0.00<br />

45990 S 587.95 0.00 0.00 46916 S 58.06 0.00 0.00<br />

46020 S 679.45 0.00 0.00 46917 S 541.56 0.00 0.00<br />

46030 S 256.24 0.00 0.00 46922 S 541.56 0.00 0.00<br />

46040 S 679.45 0.00 0.00 46924 S 541.56 0.00 0.00<br />

46045 S 649.86 0.00 0.00 46930 S 121.06 0.00 0.00<br />

46050 S 377.97 0.00 0.00 46937 S 649.86 0.00 0.00<br />

46060 S 649.86 0.00 0.00 46938 S 800.12 0.00 0.00<br />

46070 S 467.42 0.00 0.00 46940 S 89.59 0.00 0.00<br />

46080 S 679.45 0.00 0.00 46942 S 87.20 0.00 0.00<br />

46083 S 71.55 0.00 0.00 46945 S 148.41 0.00 0.00<br />

46200 S 649.86 0.00 0.00 46946 S 387.64 0.00 0.00<br />

46210 S 649.86 0.00 0.00 46947 S 1,053.90 0.00 0.00<br />

46211 S 649.86 0.00 0.00 47000 S 337.22 0.00 0.00<br />

46220 S 597.63 0.00 0.00 47382 S 1,779.58 0.00 0.00<br />

46221 S 117.64 0.00 0.00 47510 S 788.10 0.00 0.00<br />

46230 S 597.63 0.00 0.00 47511 S 1,157.84 0.00 0.00<br />

46250 S 679.45 0.00 0.00 47525 S 452.43 0.00 0.00<br />

46255 S 679.45 0.00 0.00 47530 S 452.43 0.00 0.00<br />

46257 S 679.45 0.00 0.00 47552 S 788.10 0.00 0.00<br />

46258 S 679.45 0.00 0.00 47553 S 817.68 0.00 0.00<br />

46260 S 679.45 0.00 0.00 47554 S 817.68 0.00 0.00<br />

46261 S 734.92 0.00 0.00 47555 S 817.68 0.00 0.00<br />

46262 S 734.92 0.00 0.00 47556 S 1,157.84 0.00 0.00<br />

46270 S 679.45 0.00 0.00 47560 S 960.75 0.00 0.00<br />

46275 S 679.45 0.00 0.00 47561 S 960.75 0.00 0.00<br />

46280 S 734.92 0.00 0.00 47562 S 1,772.78 0.00 0.00<br />

46285 S 597.63 0.00 0.00 47563 S 1,772.78 0.00 0.00<br />

46288 S 734.92 0.00 0.00 47564 S 1,772.78 0.00 0.00<br />

46320 S 79.68 0.00 0.00 47630 S 817.68 0.00 0.00<br />

46500 S 109.77 0.00 0.00 48102 S 337.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 205.06 0.00 0.00 49590 S 841.63 0.00 0.00<br />

49081 S 205.06 0.00 0.00 49600 S 897.09 0.00 0.00<br />

49180 S 337.22 0.00 0.00 49650 S 1,177.62 0.00 0.00<br />

49250 S 739.20 0.00 0.00 49651 S 1,346.35 0.00 0.00<br />

49320 S 960.75 0.00 0.00 49652 S 1,449.99 0.00 0.00<br />

49321 S 1,016.23 0.00 0.00 49653 S 1,449.99 0.00 0.00<br />

49322 S 1,016.23 0.00 0.00 49654 S 1,449.99 0.00 0.00<br />

49324 S 1,449.99 0.00 0.00 49655 S 1,449.99 0.00 0.00<br />

49325 S 1,449.99 0.00 0.00 49656 S 1,449.99 0.00 0.00<br />

49326 S 1,449.99 0.00 0.00 49657 S 1,449.99 0.00 0.00<br />

49402 S 654.14 0.00 0.00 50200 S 337.22 0.00 0.00<br />

49419 S 784.73 0.00 0.00 50382 S 979.21 0.00 0.00<br />

49420 S 725.43 0.00 0.00 50384 S 719.21 0.00 0.00<br />

49421 S 725.43 0.00 0.00 50385 S 719.21 0.00 0.00<br />

49422 S 577.33 0.00 0.00 50386 S 275.94 0.00 0.00<br />

49423 S 596.98 0.00 0.00 50387 S 596.98 0.00 0.00<br />

49426 S 654.14 0.00 0.00 50389 S 275.94 0.00 0.00<br />

49429 S 846.79 0.00 0.00 50390 S 337.22 0.00 0.00<br />

49440 S 331.13 0.00 0.00 50391 S 39.94 0.00 0.00<br />

49441 S 331.13 0.00 0.00 50392 S 513.54 0.00 0.00<br />

49446 S 331.13 0.00 0.00 50393 S 643.54 0.00 0.00<br />

49450 S 175.88 0.00 0.00 50395 S 513.54 0.00 0.00<br />

49451 S 175.88 0.00 0.00 50396 S 96.56 0.00 0.00<br />

49452 S 175.88 0.00 0.00 50398 S 452.43 0.00 0.00<br />

49460 S 175.88 0.00 0.00 50551 S 291.91 0.00 0.00<br />

49495 S 897.09 0.00 0.00 50553 S 643.54 0.00 0.00<br />

49496 S 897.09 0.00 0.00 50555 S 291.91 0.00 0.00<br />

49500 S 897.09 0.00 0.00 50557 S 643.54 0.00 0.00<br />

49501 S 1,224.84 0.00 0.00 50561 S 643.54 0.00 0.00<br />

49505 S 897.09 0.00 0.00 50562 S 275.94 0.00 0.00<br />

49507 S 1,224.84 0.00 0.00 50570 S 275.94 0.00 0.00<br />

49520 S 1,065.82 0.00 0.00 50572 S 275.94 0.00 0.00<br />

49521 S 1,224.84 0.00 0.00 50574 S 275.94 0.00 0.00<br />

49525 S 897.09 0.00 0.00 50575 S 1,372.58 0.00 0.00<br />

49540 S 812.03 0.00 0.00 50576 S 719.21 0.00 0.00<br />

49550 S 937.31 0.00 0.00 50580 S 719.21 0.00 0.00<br />

49553 S 1,224.84 0.00 0.00 50590 S 1,603.49 0.00 0.00<br />

49555 S 937.31 0.00 0.00 50592 S 1,779.58 0.00 0.00<br />

49557 S 1,224.84 0.00 0.00 50686 S 39.94 0.00 0.00<br />

49560 S 897.09 0.00 0.00 50688 S 452.43 0.00 0.00<br />

49561 S 1,224.84 0.00 0.00 50947 S 1,505.37 0.00 0.00<br />

49565 S 897.09 0.00 0.00 50948 S 1,505.37 0.00 0.00<br />

49566 S 1,224.84 0.00 0.00 50951 S 291.91 0.00 0.00<br />

49568 S 1,065.82 0.00 0.00 50953 S 291.91 0.00 0.00<br />

49570 S 897.09 0.00 0.00 50955 S 643.54 0.00 0.00<br />

49572 S 1,224.84 0.00 0.00 50957 S 643.54 0.00 0.00<br />

49580 S 897.09 0.00 0.00 50961 S 643.54 0.00 0.00<br />

49582 S 1,224.84 0.00 0.00 50970 S 291.91 0.00 0.00<br />

49585 S 897.09 0.00 0.00 50972 S 291.91 0.00 0.00<br />

49587 S 1,224.84 0.00 0.00 50974 S 513.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 513.54 0.00 0.00 52275 S 695.78 0.00 0.00<br />

50980 S 643.54 0.00 0.00 52276 S 725.36 0.00 0.00<br />

51020 S 780.84 0.00 0.00 52277 S 695.78 0.00 0.00<br />

51030 S 780.84 0.00 0.00 52281 S 565.77 0.00 0.00<br />

51040 S 780.84 0.00 0.00 52282 S 1,305.27 0.00 0.00<br />

51045 S 322.52 0.00 0.00 52283 S 695.78 0.00 0.00<br />

51050 S 780.84 0.00 0.00 52285 S 565.77 0.00 0.00<br />

51065 S 780.84 0.00 0.00 52290 S 565.77 0.00 0.00<br />

51080 S 524.91 0.00 0.00 52300 S 695.78 0.00 0.00<br />

51100 S 30.44 0.00 0.00 52301 S 725.36 0.00 0.00<br />

51101 S 39.94 0.00 0.00 52305 S 695.78 0.00 0.00<br />

51102 S 537.29 0.00 0.00 52310 S 544.15 0.00 0.00<br />

51500 S 897.09 0.00 0.00 52315 S 695.78 0.00 0.00<br />

51520 S 780.84 0.00 0.00 52317 S 643.54 0.00 0.00<br />

51700 S 51.98 0.00 0.00 52318 S 695.78 0.00 0.00<br />

51701 S 24.73 0.00 0.00 52320 S 821.05 0.00 0.00<br />

51702 S 24.73 0.00 0.00 52325 S 780.84 0.00 0.00<br />

51703 S 39.94 0.00 0.00 52327 S 892.47 0.00 0.00<br />

51705 S 71.55 0.00 0.00 52330 S 695.78 0.00 0.00<br />

51710 S 452.43 0.00 0.00 52332 S 695.78 0.00 0.00<br />

51715 S 821.48 0.00 0.00 52334 S 725.36 0.00 0.00<br />

51720 S 57.45 0.00 0.00 52341 S 725.36 0.00 0.00<br />

51725 TC S 110.36 0.00 0.00 52342 S 725.36 0.00 0.00<br />

51726 TC S 152.02 0.00 0.00 52343 S 725.36 0.00 0.00<br />

51736 TC S 20.86 0.00 0.00 52344 S 725.36 0.00 0.00<br />

51741 TC S 24.28 0.00 0.00 52345 S 725.36 0.00 0.00<br />

51772 TC S 96.56 0.00 0.00 52346 S 725.36 0.00 0.00<br />

51784 TC S 39.94 0.00 0.00 52351 S 725.36 0.00 0.00<br />

51785 TC S 66.71 0.00 0.00 52352 S 780.84 0.00 0.00<br />

51792 TC S 39.94 0.00 0.00 52353 S 977.52 0.00 0.00<br />

51795 TC S 71.55 0.00 0.00 52354 S 780.84 0.00 0.00<br />

51797 TC S 71.55 0.00 0.00 52355 S 780.84 0.00 0.00<br />

51798 S 17.78 0.00 0.00 52400 S 725.36 0.00 0.00<br />

51880 S 643.54 0.00 0.00 52402 S 725.36 0.00 0.00<br />

51992 S 1,217.84 0.00 0.00 52450 S 725.36 0.00 0.00<br />

52000 S 291.91 0.00 0.00 52500 S 725.36 0.00 0.00<br />

52001 S 544.15 0.00 0.00 52601 S 977.52 0.00 0.00<br />

52005 S 565.77 0.00 0.00 52630 S 892.47 0.00 0.00<br />

52007 S 695.78 0.00 0.00 52640 S 695.78 0.00 0.00<br />

52010 S 322.52 0.00 0.00 52647 S 1,495.52 0.00 0.00<br />

52204 S 565.77 0.00 0.00 52648 S 1,495.52 0.00 0.00<br />

52214 S 695.78 0.00 0.00 52700 S 695.78 0.00 0.00<br />

52224 S 695.78 0.00 0.00 53000 S 534.01 0.00 0.00<br />

52234 S 695.78 0.00 0.00 53010 S 534.01 0.00 0.00<br />

52235 S 725.36 0.00 0.00 53020 S 534.01 0.00 0.00<br />

52240 S 725.36 0.00 0.00 53025 S 760.14 0.00 0.00<br />

52250 S 780.84 0.00 0.00 53040 S 586.25 0.00 0.00<br />

52260 S 565.77 0.00 0.00 53060 S 69.42 0.00 0.00<br />

52265 S 275.94 0.00 0.00 53080 S 615.83 0.00 0.00<br />

52270 S 565.77 0.00 0.00 53085 S 760.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 534.01 0.00 0.00 54060 S 541.56 0.00 0.00<br />

53210 S 917.16 0.00 0.00 54065 S 541.56 0.00 0.00<br />

53215 S 711.52 0.00 0.00 54100 S 458.13 0.00 0.00<br />

53220 S 791.89 0.00 0.00 54105 S 571.90 0.00 0.00<br />

53230 S 791.89 0.00 0.00 54110 S 886.68 0.00 0.00<br />

53235 S 615.83 0.00 0.00 54111 S 886.68 0.00 0.00<br />

53240 S 791.89 0.00 0.00 54112 S 886.68 0.00 0.00<br />

53250 S 586.25 0.00 0.00 54115 S 524.91 0.00 0.00<br />

53260 S 586.25 0.00 0.00 54120 S 886.68 0.00 0.00<br />

53265 S 586.25 0.00 0.00 54150 S 590.93 0.00 0.00<br />

53270 S 586.25 0.00 0.00 54160 S 643.17 0.00 0.00<br />

53275 S 586.25 0.00 0.00 54161 S 643.17 0.00 0.00<br />

53400 S 821.48 0.00 0.00 54162 S 643.17 0.00 0.00<br />

53405 S 791.89 0.00 0.00 54163 S 643.17 0.00 0.00<br />

53410 S 791.89 0.00 0.00 54164 S 643.17 0.00 0.00<br />

53420 S 821.48 0.00 0.00 54200 S 67.37 0.00 0.00<br />

53425 S 791.89 0.00 0.00 54205 S 971.74 0.00 0.00<br />

53430 S 791.89 0.00 0.00 54220 S 96.56 0.00 0.00<br />

53431 S 791.89 0.00 0.00 54231 S 63.26 0.00 0.00<br />

53440 S 4,561.58 2,770.46 979.33 54235 S 44.80 0.00 0.00<br />

53442 S 739.65 0.00 0.00 54240 TC S 31.80 0.00 0.00<br />

53444 S 4,561.58 2,770.46 979.33 54250 TC S 11.28 0.00 0.00<br />

53445 S 7,662.29 4,363.62 1,064.96 54300 S 916.26 0.00 0.00<br />

53446 S 739.65 0.00 0.00 54304 S 916.26 0.00 0.00<br />

53447 S 7,662.29 4,363.62 1,064.96 54308 S 916.26 0.00 0.00<br />

53449 S 739.65 0.00 0.00 54312 S 916.26 0.00 0.00<br />

53450 S 739.65 0.00 0.00 54316 S 916.26 0.00 0.00<br />

53460 S 534.01 0.00 0.00 54318 S 916.26 0.00 0.00<br />

53502 S 586.25 0.00 0.00 54322 S 916.26 0.00 0.00<br />

53505 S 791.89 0.00 0.00 54324 S 916.26 0.00 0.00<br />

53510 S 586.25 0.00 0.00 54326 S 916.26 0.00 0.00<br />

53515 S 791.89 0.00 0.00 54328 S 916.26 0.00 0.00<br />

53520 S 791.89 0.00 0.00 54340 S 916.26 0.00 0.00<br />

53600 S 40.01 0.00 0.00 54344 S 916.26 0.00 0.00<br />

53601 S 39.94 0.00 0.00 54348 S 916.26 0.00 0.00<br />

53605 S 565.77 0.00 0.00 54352 S 916.26 0.00 0.00<br />

53620 S 61.55 0.00 0.00 54360 S 916.26 0.00 0.00<br />

53621 S 64.64 0.00 0.00 54380 S 916.26 0.00 0.00<br />

53660 S 39.94 0.00 0.00 54385 S 916.26 0.00 0.00<br />

53661 S 39.94 0.00 0.00 54400 S 4,591.17 2,800.05 1,008.93<br />

53665 S 534.01 0.00 0.00 54401 S 7,744.12 4,445.45 1,146.79<br />

53850 S 1,753.08 0.00 0.00 54405 S 7,744.12 4,445.45 1,146.79<br />

53852 S 1,753.08 0.00 0.00 54406 S 916.26 0.00 0.00<br />

54000 S 586.25 0.00 0.00 54408 S 916.26 0.00 0.00<br />

54001 S 586.25 0.00 0.00 54410 S 7,744.12 4,445.45 1,146.79<br />

54015 S 662.21 0.00 0.00 54415 S 916.26 0.00 0.00<br />

54050 S 31.69 0.00 0.00 54416 S 7,744.12 4,445.45 1,146.79<br />

54055 S 64.64 0.00 0.00 54420 S 971.74 0.00 0.00<br />

54056 S 31.69 0.00 0.00 54435 S 971.74 0.00 0.00<br />

54057 S 541.56 0.00 0.00 54440 S 971.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 152.02 0.00 0.00 55706 S 441.92 0.00 0.00<br />

54500 S 412.59 0.00 0.00 55720 S 643.54 0.00 0.00<br />

54505 S 590.93 0.00 0.00 55725 S 695.78 0.00 0.00<br />

54512 S 643.17 0.00 0.00 55860 S 766.71 0.00 0.00<br />

54520 S 672.75 0.00 0.00 55870 S 77.97 0.00 0.00<br />

54522 S 672.75 0.00 0.00 55873 S 6,066.52 0.00 0.00<br />

54530 S 897.09 0.00 0.00 55875 S 1,305.27 0.00 0.00<br />

54550 S 897.09 0.00 0.00 55876 S 71.47 0.00 0.00<br />

54560 S 873.99 0.00 0.00 55920 S 895.94 0.00 0.00<br />

54600 S 728.23 0.00 0.00 56405 S 41.72 0.00 0.00<br />

54620 S 672.75 0.00 0.00 56420 S 54.45 0.00 0.00<br />

54640 S 897.09 0.00 0.00 56440 S 584.73 0.00 0.00<br />

54660 S 643.17 0.00 0.00 56441 S 532.49 0.00 0.00<br />

54670 S 672.75 0.00 0.00 56442 S 532.49 0.00 0.00<br />

54680 S 672.75 0.00 0.00 56501 S 57.45 0.00 0.00<br />

54690 S 1,505.37 0.00 0.00 56515 S 623.39 0.00 0.00<br />

54692 S 2,675.94 0.00 0.00 56605 S 33.17 0.00 0.00<br />

54700 S 643.17 0.00 0.00 56606 S 13.68 0.00 0.00<br />

54800 S 144.37 0.00 0.00 56620 S 710.00 0.00 0.00<br />

54830 S 672.75 0.00 0.00 56625 S 838.52 0.00 0.00<br />

54840 S 728.23 0.00 0.00 56700 S 532.49 0.00 0.00<br />

54860 S 672.75 0.00 0.00 56740 S 614.32 0.00 0.00<br />

54861 S 728.23 0.00 0.00 56800 S 614.32 0.00 0.00<br />

54865 S 590.93 0.00 0.00 56805 S 757.12 0.00 0.00<br />

54900 S 728.23 0.00 0.00 56810 S 710.00 0.00 0.00<br />

54901 S 728.23 0.00 0.00 56820 S 42.40 0.00 0.00<br />

55000 S 65.66 0.00 0.00 56821 S 54.45 0.00 0.00<br />

55040 S 841.63 0.00 0.00 57000 S 532.49 0.00 0.00<br />

55041 S 937.31 0.00 0.00 57010 S 584.73 0.00 0.00<br />

55060 S 728.23 0.00 0.00 57020 S 306.66 0.00 0.00<br />

55100 S 394.94 0.00 0.00 57022 S 482.02 0.00 0.00<br />

55110 S 643.17 0.00 0.00 57023 S 524.91 0.00 0.00<br />

55120 S 643.17 0.00 0.00 57061 S 53.00 0.00 0.00<br />

55150 S 590.93 0.00 0.00 57065 S 532.49 0.00 0.00<br />

55175 S 590.93 0.00 0.00 57100 S 33.86 0.00 0.00<br />

55180 S 643.17 0.00 0.00 57105 S 584.73 0.00 0.00<br />

55200 S 643.17 0.00 0.00 57130 S 584.73 0.00 0.00<br />

55250 S 643.17 0.00 0.00 57135 S 584.73 0.00 0.00<br />

55400 S 590.93 0.00 0.00 57150 S 24.62 0.00 0.00<br />

55450 S 211.33 0.00 0.00 57155 S 306.66 0.00 0.00<br />

55500 S 672.75 0.00 0.00 57160 S 35.57 0.00 0.00<br />

55520 S 728.23 0.00 0.00 57170 S 5.83 0.00 0.00<br />

55530 S 728.23 0.00 0.00 57180 S 109.53 0.00 0.00<br />

55535 S 897.09 0.00 0.00 57200 S 532.49 0.00 0.00<br />

55540 S 937.31 0.00 0.00 57210 S 584.73 0.00 0.00<br />

55550 S 1,505.37 0.00 0.00 57220 S 1,072.32 0.00 0.00<br />

55600 S 873.99 0.00 0.00 57230 S 880.47 0.00 0.00<br />

55680 S 590.93 0.00 0.00 57240 S 976.16 0.00 0.00<br />

55700 S 380.82 0.00 0.00 57250 S 976.16 0.00 0.00<br />

55705 S 380.82 0.00 0.00 57260 S 976.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,296.52 0.00 0.00 58555 S 575.33 0.00 0.00<br />

57267 S 1,104.67 0.00 0.00 58558 S 657.15 0.00 0.00<br />

57268 S 880.47 0.00 0.00 58559 S 627.57 0.00 0.00<br />

57287 S 1,289.43 0.00 0.00 58560 S 937.01 0.00 0.00<br />

57288 S 1,168.01 0.00 0.00 58561 S 937.01 0.00 0.00<br />

57289 S 976.16 0.00 0.00 58562 S 657.15 0.00 0.00<br />

57291 S 976.16 0.00 0.00 58563 S 1,320.22 0.00 0.00<br />

57300 S 880.47 0.00 0.00 58565 S 1,455.54 0.00 0.00<br />

57320 S 1,289.43 0.00 0.00 58600 S 1,289.43 0.00 0.00<br />

57400 S 584.73 0.00 0.00 58615 S 757.12 0.00 0.00<br />

57410 S 584.73 0.00 0.00 58660 S 1,217.84 0.00 0.00<br />

57415 S 584.73 0.00 0.00 58661 S 1,217.84 0.00 0.00<br />

57420 S 43.78 0.00 0.00 58662 S 1,217.84 0.00 0.00<br />

57421 S 57.11 0.00 0.00 58670 S 1,122.15 0.00 0.00<br />

57452 S 41.38 0.00 0.00 58671 S 1,122.15 0.00 0.00<br />

57454 S 50.61 0.00 0.00 58672 S 1,217.84 0.00 0.00<br />

57455 S 53.68 0.00 0.00 58673 S 1,217.84 0.00 0.00<br />

57456 S 51.98 0.00 0.00 58800 S 614.32 0.00 0.00<br />

57460 S 159.70 0.00 0.00 58805 S 1,289.43 0.00 0.00<br />

57461 S 169.61 0.00 0.00 58820 S 880.47 0.00 0.00<br />

57500 S 73.18 0.00 0.00 58900 S 614.32 0.00 0.00<br />

57505 S 46.51 0.00 0.00 58970 S 171.11 0.00 0.00<br />

57510 S 47.19 0.00 0.00 58974 S 171.11 0.00 0.00<br />

57511 S 54.45 0.00 0.00 58976 S 171.11 0.00 0.00<br />

57513 S 584.73 0.00 0.00 59000 S 62.58 0.00 0.00<br />

57520 S 584.73 0.00 0.00 59001 S 234.89 0.00 0.00<br />

57522 S 584.73 0.00 0.00 59012 S 114.86 0.00 0.00<br />

57530 S 880.47 0.00 0.00 59015 S 50.61 0.00 0.00<br />

57550 S 880.47 0.00 0.00 59020 TC S 26.67 0.00 0.00<br />

57556 S 1,168.01 0.00 0.00 59025 TC S 14.02 0.00 0.00<br />

57558 S 614.32 0.00 0.00 59070 S 114.86 0.00 0.00<br />

57700 S 532.49 0.00 0.00 59072 S 114.86 0.00 0.00<br />

57720 S 614.32 0.00 0.00 59076 S 114.86 0.00 0.00<br />

57800 S 24.96 0.00 0.00 59100 S 1,289.43 0.00 0.00<br />

58100 S 41.04 0.00 0.00 59150 S 1,772.78 0.00 0.00<br />

58120 S 584.73 0.00 0.00 59151 S 1,772.78 0.00 0.00<br />

58145 S 976.16 0.00 0.00 59160 S 614.32 0.00 0.00<br />

58301 S 38.30 0.00 0.00 59200 S 34.20 0.00 0.00<br />

58321 S 35.91 0.00 0.00 59300 S 73.86 0.00 0.00<br />

58322 S 36.93 0.00 0.00 59320 S 532.49 0.00 0.00<br />

58323 S 8.55 0.00 0.00 59412 S 757.12 0.00 0.00<br />

58345 S 757.12 0.00 0.00 59414 S 757.12 0.00 0.00<br />

58346 S 584.73 0.00 0.00 59812 S 710.00 0.00 0.00<br />

58350 S 880.47 0.00 0.00 59820 S 710.00 0.00 0.00<br />

58353 S 1,104.67 0.00 0.00 59821 S 710.00 0.00 0.00<br />

58356 S 1,673.12 0.00 0.00 59840 S 710.00 0.00 0.00<br />

58545 S 1,343.97 0.00 0.00 59841 S 710.00 0.00 0.00<br />

58546 S 1,505.37 0.00 0.00 59866 S 114.86 0.00 0.00<br />

58550 S 1,956.94 0.00 0.00 59870 S 710.00 0.00 0.00<br />

58552 S 1,772.78 0.00 0.00 59871 S 710.00 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 298.08 0.00 0.00 62367 S 16.41 0.00 0.00<br />

60100 S 46.85 0.00 0.00 62368 S 20.86 0.00 0.00<br />

60200 S 1,109.46 0.00 0.00 63600 S 560.38 0.00 0.00<br />

60280 S 1,194.52 0.00 0.00 63610 S 508.13 0.00 0.00<br />

60281 S 1,194.52 0.00 0.00 63615 S 708.40 0.00 0.00<br />

60300 S 61.55 0.00 0.00 63650 S 3,016.21 1,870.35 724.50<br />

61000 S 274.47 0.00 0.00 63655 S 4,418.01 2,817.37 1,216.74<br />

61001 S 274.47 0.00 0.00 63660 S 529.70 0.00 0.00<br />

61020 S 222.22 0.00 0.00 63685 S 13,409.68 7,150.16 890.65<br />

61026 S 222.22 0.00 0.00 63688 S 719.30 0.00 0.00<br />

61050 S 222.22 0.00 0.00 63744 S 1,040.21 0.00 0.00<br />

61055 S 222.22 0.00 0.00 63746 S 481.18 0.00 0.00<br />

61070 S 172.91 0.00 0.00 64400 S 52.66 0.00 0.00<br />

61215 S 1,040.21 0.00 0.00 64402 S 49.59 0.00 0.00<br />

61330 S 1,602.50 0.00 0.00 64405 S 42.06 0.00 0.00<br />

61334 S 1,602.50 0.00 0.00 64408 S 52.32 0.00 0.00<br />

61790 S 589.96 0.00 0.00 64410 S 291.17 0.00 0.00<br />

61791 S 437.69 0.00 0.00 64412 S 76.94 0.00 0.00<br />

61880 S 751.53 0.00 0.00 64413 S 49.25 0.00 0.00<br />

61885 S 10,814.67 5,793.32 771.96 64415 S 134.10 0.00 0.00<br />

61886 S 16,148.95 8,511.43 873.92 64416 S 274.47 0.00 0.00<br />

61888 S 719.30 0.00 0.00 64417 S 134.10 0.00 0.00<br />

62194 S 291.17 0.00 0.00 64418 S 69.07 0.00 0.00<br />

62225 S 452.43 0.00 0.00 64420 S 134.10 0.00 0.00<br />

62230 S 1,010.61 0.00 0.00 64421 S 291.17 0.00 0.00<br />

62252 TC S 45.82 0.00 0.00 64425 S 47.87 0.00 0.00<br />

62263 S 291.17 0.00 0.00 64430 S 201.49 0.00 0.00<br />

62264 S 428.93 0.00 0.00 64435 S 72.15 0.00 0.00<br />

62267 S 171.17 0.00 0.00 64445 S 63.94 0.00 0.00<br />

62268 S 222.22 0.00 0.00 64446 S 550.00 0.00 0.00<br />

62269 S 337.22 0.00 0.00 64447 S 139.68 0.00 0.00<br />

62270 S 134.10 0.00 0.00 64448 S 139.68 0.00 0.00<br />

62272 S 134.10 0.00 0.00 64449 S 274.47 0.00 0.00<br />

62273 S 223.77 0.00 0.00 64450 S 42.74 0.00 0.00<br />

62280 S 291.17 0.00 0.00 64455 S 17.78 0.00 0.00<br />

62281 S 291.17 0.00 0.00 64470 S 291.17 0.00 0.00<br />

62282 S 291.17 0.00 0.00 64472 S 223.77 0.00 0.00<br />

62287 S 1,307.07 0.00 0.00 64475 S 291.17 0.00 0.00<br />

62292 S 274.47 0.00 0.00 64476 S 201.53 0.00 0.00<br />

62294 S 222.22 0.00 0.00 64479 S 291.17 0.00 0.00<br />

62310 S 291.17 0.00 0.00 64480 S 223.77 0.00 0.00<br />

62311 S 291.17 0.00 0.00 64483 S 291.17 0.00 0.00<br />

62318 S 291.17 0.00 0.00 64484 S 223.77 0.00 0.00<br />

62319 S 291.17 0.00 0.00 64505 S 38.99 0.00 0.00<br />

62350 S 1,010.61 0.00 0.00 64508 S 82.75 0.00 0.00<br />

62355 S 481.18 0.00 0.00 64510 S 291.17 0.00 0.00<br />

62360 S 1,010.61 0.00 0.00 64517 S 201.49 0.00 0.00<br />

62361 S 10,374.09 5,615.12 856.17 64520 S 291.17 0.00 0.00<br />

62362 S 10,374.09 5,615.12 856.17 64530 S 291.17 0.00 0.00<br />

62365 S 894.27 0.00 0.00 64553 S 2,963.96 1,818.11 672.26<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,328.36 2,182.50 1,036.65 64746 S 560.38 0.00 0.00<br />

64560 S 3,328.36 2,182.50 1,036.65 64761 S 708.40 0.00 0.00<br />

64561 S 3,045.79 1,899.93 754.08 64763 S 708.40 0.00 0.00<br />

64565 S 3,328.36 2,182.50 1,036.65 64766 S 1,376.18 0.00 0.00<br />

64573 S 5,185.08 3,071.66 958.23 64771 S 560.38 0.00 0.00<br />

64575 S 3,963.57 2,362.93 762.30 64772 S 560.38 0.00 0.00<br />

64577 S 3,963.57 2,362.93 762.30 64774 S 560.38 0.00 0.00<br />

64580 S 3,963.57 2,362.93 762.30 64776 S 589.96 0.00 0.00<br />

64581 S 4,045.40 2,444.76 844.13 64778 S 560.38 0.00 0.00<br />

64585 S 529.70 0.00 0.00 64782 S 589.96 0.00 0.00<br />

64590 S 10,814.67 5,793.32 771.96 64783 S 560.38 0.00 0.00<br />

64595 S 719.30 0.00 0.00 64784 S 589.96 0.00 0.00<br />

64600 S 428.93 0.00 0.00 64786 S 923.85 0.00 0.00<br />

64605 S 428.93 0.00 0.00 64787 S 560.38 0.00 0.00<br />

64610 S 428.93 0.00 0.00 64788 S 589.96 0.00 0.00<br />

64612 S 62.58 0.00 0.00 64790 S 589.96 0.00 0.00<br />

64613 S 60.53 0.00 0.00 64792 S 923.85 0.00 0.00<br />

64614 S 69.07 0.00 0.00 64795 S 560.38 0.00 0.00<br />

64620 S 291.17 0.00 0.00 64802 S 560.38 0.00 0.00<br />

64622 S 428.93 0.00 0.00 64820 S 708.40 0.00 0.00<br />

64623 S 291.17 0.00 0.00 64821 S 827.00 0.00 0.00<br />

64626 S 428.93 0.00 0.00 64822 S 1,071.52 0.00 0.00<br />

64627 S 201.53 0.00 0.00 64823 S 1,071.52 0.00 0.00<br />

64630 S 299.92 0.00 0.00 64831 S 979.33 0.00 0.00<br />

64632 S 32.48 0.00 0.00 64832 S 842.02 0.00 0.00<br />

64640 S 96.78 0.00 0.00 64834 S 894.27 0.00 0.00<br />

64650 S 32.48 0.00 0.00 64835 S 923.85 0.00 0.00<br />

64653 S 35.22 0.00 0.00 64836 S 923.85 0.00 0.00<br />

64680 S 455.73 0.00 0.00 64837 S 842.02 0.00 0.00<br />

64681 S 481.18 0.00 0.00 64840 S 894.27 0.00 0.00<br />

64702 S 508.13 0.00 0.00 64856 S 894.27 0.00 0.00<br />

64704 S 508.13 0.00 0.00 64857 S 894.27 0.00 0.00<br />

64708 S 560.38 0.00 0.00 64858 S 894.27 0.00 0.00<br />

64712 S 560.38 0.00 0.00 64859 S 842.02 0.00 0.00<br />

64713 S 560.38 0.00 0.00 64861 S 923.85 0.00 0.00<br />

64714 S 560.38 0.00 0.00 64862 S 923.85 0.00 0.00<br />

64716 S 589.96 0.00 0.00 64864 S 923.85 0.00 0.00<br />

64718 S 560.38 0.00 0.00 64865 S 979.33 0.00 0.00<br />

64719 S 560.38 0.00 0.00 64870 S 979.33 0.00 0.00<br />

64721 S 560.38 0.00 0.00 64872 S 894.27 0.00 0.00<br />

64722 S 508.13 0.00 0.00 64874 S 923.85 0.00 0.00<br />

64726 S 508.13 0.00 0.00 64876 S 923.85 0.00 0.00<br />

64727 S 508.13 0.00 0.00 64885 S 894.27 0.00 0.00<br />

64732 S 560.38 0.00 0.00 64886 S 894.27 0.00 0.00<br />

64734 S 560.38 0.00 0.00 64890 S 894.27 0.00 0.00<br />

64736 S 560.38 0.00 0.00 64891 S 894.27 0.00 0.00<br />

64738 S 560.38 0.00 0.00 64892 S 894.27 0.00 0.00<br />

64740 S 560.38 0.00 0.00 64893 S 894.27 0.00 0.00<br />

64742 S 560.38 0.00 0.00 64895 S 923.85 0.00 0.00<br />

64744 S 560.38 0.00 0.00 64896 S 923.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 923.85 0.00 0.00 65770 S 5,436.54 0.00 0.00<br />

64898 S 923.85 0.00 0.00 65772 S 611.57 0.00 0.00<br />

64901 S 894.27 0.00 0.00 65775 S 611.57 0.00 0.00<br />

64902 S 894.27 0.00 0.00 65780 S 1,057.93 0.00 0.00<br />

64905 S 894.27 0.00 0.00 65781 S 1,057.93 0.00 0.00<br />

64907 S 842.02 0.00 0.00 65782 S 1,057.93 0.00 0.00<br />

64910 S 1,376.18 0.00 0.00 65800 S 474.27 0.00 0.00<br />

65091 S 972.76 0.00 0.00 65805 S 474.27 0.00 0.00<br />

65093 S 972.76 0.00 0.00 65810 S 693.01 0.00 0.00<br />

65101 S 972.76 0.00 0.00 65815 S 663.42 0.00 0.00<br />

65103 S 972.76 0.00 0.00 65820 S 243.31 0.00 0.00<br />

65105 S 1,028.24 0.00 0.00 65850 S 748.48 0.00 0.00<br />

65110 S 1,068.45 0.00 0.00 65855 S 129.26 0.00 0.00<br />

65112 S 1,196.96 0.00 0.00 65860 S 120.72 0.00 0.00<br />

65114 S 1,196.96 0.00 0.00 65865 S 474.27 0.00 0.00<br />

65125 S 996.16 0.00 0.00 65870 S 748.48 0.00 0.00<br />

65130 S 733.84 0.00 0.00 65875 S 748.48 0.00 0.00<br />

65135 S 704.26 0.00 0.00 65880 S 611.57 0.00 0.00<br />

65140 S 972.76 0.00 0.00 65900 S 651.79 0.00 0.00<br />

65150 S 704.26 0.00 0.00 65920 S 917.21 0.00 0.00<br />

65155 S 972.76 0.00 0.00 65930 S 788.70 0.00 0.00<br />

65175 S 523.50 0.00 0.00 66020 S 474.27 0.00 0.00<br />

65205 S 20.18 0.00 0.00 66030 S 243.31 0.00 0.00<br />

65210 S 25.65 0.00 0.00 66130 S 917.21 0.00 0.00<br />

65220 S 35.74 0.00 0.00 66150 S 748.48 0.00 0.00<br />

65222 S 28.04 0.00 0.00 66155 S 748.48 0.00 0.00<br />

65235 S 526.51 0.00 0.00 66160 S 663.42 0.00 0.00<br />

65260 S 347.27 0.00 0.00 66165 S 748.48 0.00 0.00<br />

65265 S 718.45 0.00 0.00 66170 S 748.48 0.00 0.00<br />

65270 S 575.74 0.00 0.00 66172 S 748.48 0.00 0.00<br />

65272 S 663.42 0.00 0.00 66180 S 1,115.08 0.00 0.00<br />

65275 S 748.48 0.00 0.00 66185 S 989.81 0.00 0.00<br />

65280 S 718.45 0.00 0.00 66220 S 966.23 0.00 0.00<br />

65285 S 1,021.70 0.00 0.00 66225 S 1,074.87 0.00 0.00<br />

65286 S 178.75 0.00 0.00 66250 S 526.51 0.00 0.00<br />

65290 S 707.54 0.00 0.00 66500 S 243.31 0.00 0.00<br />

65400 S 474.27 0.00 0.00 66505 S 243.31 0.00 0.00<br />

65410 S 526.51 0.00 0.00 66600 S 693.01 0.00 0.00<br />

65420 S 526.51 0.00 0.00 66605 S 693.01 0.00 0.00<br />

65426 S 788.70 0.00 0.00 66625 S 492.73 0.00 0.00<br />

65430 S 35.74 0.00 0.00 66630 S 693.01 0.00 0.00<br />

65435 S 31.12 0.00 0.00 66635 S 693.01 0.00 0.00<br />

65436 S 135.07 0.00 0.00 66680 S 693.01 0.00 0.00<br />

65450 S 82.46 0.00 0.00 66682 S 663.42 0.00 0.00<br />

65600 S 159.36 0.00 0.00 66700 S 526.51 0.00 0.00<br />

65710 S 1,186.44 0.00 0.00 66710 S 526.51 0.00 0.00<br />

65730 S 1,186.44 0.00 0.00 66711 S 526.51 0.00 0.00<br />

65750 S 1,186.44 0.00 0.00 66720 S 526.51 0.00 0.00<br />

65755 S 1,186.44 0.00 0.00 66740 S 663.42 0.00 0.00<br />

65756 S 1,452.95 0.00 0.00 66761 S 179.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 182.96 0.00 0.00 67228 S 201.48 0.00 0.00<br />

66770 S 201.48 0.00 0.00 67229 S 201.48 0.00 0.00<br />

66820 S 178.75 0.00 0.00 67250 S 605.33 0.00 0.00<br />

66821 S 245.19 0.00 0.00 67255 S 662.98 0.00 0.00<br />

66825 S 748.48 0.00 0.00 67311 S 707.54 0.00 0.00<br />

66830 S 261.77 0.00 0.00 67312 S 763.01 0.00 0.00<br />

66840 S 562.72 0.00 0.00 67314 S 763.01 0.00 0.00<br />

66850 S 1,059.46 0.00 0.00 67316 S 763.01 0.00 0.00<br />

66852 S 890.73 0.00 0.00 67318 S 763.01 0.00 0.00<br />

66920 S 890.73 0.00 0.00 67320 S 763.01 0.00 0.00<br />

66930 S 930.95 0.00 0.00 67331 S 763.01 0.00 0.00<br />

66940 S 602.94 0.00 0.00 67332 S 763.01 0.00 0.00<br />

66982 S 914.68 0.00 0.00 67334 S 763.01 0.00 0.00<br />

66983 S 914.68 0.00 0.00 67335 S 763.01 0.00 0.00<br />

66984 S 914.68 0.00 0.00 67340 S 763.01 0.00 0.00<br />

66985 S 846.73 0.00 0.00 67343 S 931.74 0.00 0.00<br />

66986 S 846.73 0.00 0.00 67345 S 79.68 0.00 0.00<br />

67005 S 718.45 0.00 0.00 67346 S 430.97 0.00 0.00<br />

67010 S 718.45 0.00 0.00 67400 S 605.33 0.00 0.00<br />

67015 S 884.41 0.00 0.00 67405 S 789.32 0.00 0.00<br />

67025 S 581.16 0.00 0.00 67412 S 701.01 0.00 0.00<br />

67027 S 1,021.70 0.00 0.00 67413 S 829.53 0.00 0.00<br />

67028 S 80.37 0.00 0.00 67414 S 1,474.01 0.00 0.00<br />

67030 S 581.16 0.00 0.00 67415 S 523.50 0.00 0.00<br />

67031 S 245.19 0.00 0.00 67420 S 1,068.45 0.00 0.00<br />

67036 S 1,021.70 0.00 0.00 67430 S 1,068.45 0.00 0.00<br />

67039 S 1,190.43 0.00 0.00 67440 S 1,068.45 0.00 0.00<br />

67040 S 1,190.43 0.00 0.00 67445 S 1,068.45 0.00 0.00<br />

67041 S 1,460.94 0.00 0.00 67450 S 1,068.45 0.00 0.00<br />

67042 S 1,460.94 0.00 0.00 67500 S 82.46 0.00 0.00<br />

67043 S 1,460.94 0.00 0.00 67505 S 25.65 0.00 0.00<br />

67101 S 223.02 0.00 0.00 67515 S 25.99 0.00 0.00<br />

67105 S 201.48 0.00 0.00 67550 S 1,028.24 0.00 0.00<br />

67107 S 1,061.92 0.00 0.00 67560 S 704.26 0.00 0.00<br />

67108 S 1,190.43 0.00 0.00 67570 S 1,028.24 0.00 0.00<br />

67110 S 324.18 0.00 0.00 67700 S 120.64 0.00 0.00<br />

67112 S 1,190.43 0.00 0.00 67710 S 140.89 0.00 0.00<br />

67113 S 1,460.94 0.00 0.00 67715 S 523.50 0.00 0.00<br />

67115 S 633.39 0.00 0.00 67800 S 50.61 0.00 0.00<br />

67120 S 633.39 0.00 0.00 67801 S 61.21 0.00 0.00<br />

67121 S 633.39 0.00 0.00 67805 S 79.33 0.00 0.00<br />

67141 S 223.27 0.00 0.00 67808 S 575.74 0.00 0.00<br />

67145 S 190.47 0.00 0.00 67810 S 120.64 0.00 0.00<br />

67208 S 203.13 0.00 0.00 67820 S 16.75 0.00 0.00<br />

67210 S 201.48 0.00 0.00 67825 S 51.64 0.00 0.00<br />

67218 S 758.67 0.00 0.00 67830 S 353.46 0.00 0.00<br />

67220 S 223.02 0.00 0.00 67835 S 575.74 0.00 0.00<br />

67221 S 114.56 0.00 0.00 67840 S 147.73 0.00 0.00<br />

67225 S 7.87 0.00 0.00 67850 S 117.30 0.00 0.00<br />

67227 S 581.16 0.00 0.00 67875 S 294.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 556.10 0.00 0.00 68440 S 50.27 0.00 0.00<br />

67882 S 605.33 0.00 0.00 68500 S 733.84 0.00 0.00<br />

67900 S 789.32 0.00 0.00 68505 S 733.84 0.00 0.00<br />

67901 S 701.01 0.00 0.00 68510 S 523.50 0.00 0.00<br />

67902 S 829.53 0.00 0.00 68520 S 733.84 0.00 0.00<br />

67903 S 660.79 0.00 0.00 68525 S 523.50 0.00 0.00<br />

67904 S 660.79 0.00 0.00 68530 S 120.64 0.00 0.00<br />

67906 S 701.01 0.00 0.00 68540 S 605.33 0.00 0.00<br />

67908 S 660.79 0.00 0.00 68550 S 733.84 0.00 0.00<br />

67909 S 660.79 0.00 0.00 68700 S 575.74 0.00 0.00<br />

67911 S 605.33 0.00 0.00 68705 S 114.56 0.00 0.00<br />

67912 S 605.33 0.00 0.00 68720 S 789.32 0.00 0.00<br />

67914 S 605.33 0.00 0.00 68745 S 789.32 0.00 0.00<br />

67915 S 163.46 0.00 0.00 68750 S 789.32 0.00 0.00<br />

67916 S 660.79 0.00 0.00 68760 S 97.46 0.00 0.00<br />

67917 S 660.79 0.00 0.00 68761 S 67.37 0.00 0.00<br />

67921 S 605.33 0.00 0.00 68770 S 789.32 0.00 0.00<br />

67922 S 159.01 0.00 0.00 68801 S 35.74 0.00 0.00<br />

67923 S 660.79 0.00 0.00 68810 S 102.19 0.00 0.00<br />

67924 S 660.79 0.00 0.00 68811 S 575.74 0.00 0.00<br />

67930 S 163.46 0.00 0.00 68815 S 575.74 0.00 0.00<br />

67935 S 575.74 0.00 0.00 68816 S 739.13 0.00 0.00<br />

67938 S 82.46 0.00 0.00 68840 S 53.00 0.00 0.00<br />

67950 S 575.74 0.00 0.00 69000 S 54.06 0.00 0.00<br />

67961 S 605.33 0.00 0.00 69005 S 102.25 0.00 0.00<br />

67966 S 605.33 0.00 0.00 69020 S 54.06 0.00 0.00<br />

67971 S 605.33 0.00 0.00 69100 S 61.55 0.00 0.00<br />

67973 S 733.84 0.00 0.00 69105 S 87.20 0.00 0.00<br />

67974 S 605.33 0.00 0.00 69110 S 458.13 0.00 0.00<br />

67975 S 605.33 0.00 0.00 69120 S 679.86 0.00 0.00<br />

68020 S 44.80 0.00 0.00 69140 S 679.86 0.00 0.00<br />

68040 S 22.22 0.00 0.00 69145 S 510.36 0.00 0.00<br />

68100 S 88.91 0.00 0.00 69150 S 358.70 0.00 0.00<br />

68110 S 114.56 0.00 0.00 69200 S 24.73 0.00 0.00<br />

68115 S 575.74 0.00 0.00 69205 S 571.90 0.00 0.00<br />

68130 S 526.51 0.00 0.00 69210 S 20.18 0.00 0.00<br />

68135 S 57.45 0.00 0.00 69220 S 31.69 0.00 0.00<br />

68200 S 16.41 0.00 0.00 69222 S 133.37 0.00 0.00<br />

68320 S 789.32 0.00 0.00 69300 S 709.45 0.00 0.00<br />

68325 S 789.32 0.00 0.00 69310 S 1,037.01 0.00 0.00<br />

68326 S 660.79 0.00 0.00 69320 S 1,261.21 0.00 0.00<br />

68328 S 789.32 0.00 0.00 69400 S 89.59 0.00 0.00<br />

68330 S 748.48 0.00 0.00 69401 S 47.19 0.00 0.00<br />

68335 S 789.32 0.00 0.00 69405 S 123.79 0.00 0.00<br />

68340 S 660.79 0.00 0.00 69420 S 111.14 0.00 0.00<br />

68360 S 663.42 0.00 0.00 69421 S 565.65 0.00 0.00<br />

68362 S 663.42 0.00 0.00 69424 S 77.97 0.00 0.00<br />

68371 S 526.51 0.00 0.00 69433 S 110.80 0.00 0.00<br />

68400 S 120.64 0.00 0.00 69436 S 565.65 0.00 0.00<br />

68420 S 171.66 0.00 0.00 69440 S 709.45 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 955.19 0.00 0.00 69840 S 1,132.70 0.00 0.00<br />

69501 S 1,261.21 0.00 0.00 69905 S 1,261.21 0.00 0.00<br />

69502 S 933.65 0.00 0.00 69910 S 1,261.21 0.00 0.00<br />

69505 S 1,261.21 0.00 0.00 69915 S 1,261.21 0.00 0.00<br />

69511 S 1,261.21 0.00 0.00 69930 S 22,800.96 12,242.57 1,684.19<br />

69530 S 1,261.21 0.00 0.00 70030 TC A 17.44 0.00 0.00<br />

69540 S 130.29 0.00 0.00 70100 TC A 19.15 0.00 0.00<br />

69550 S 1,132.70 0.00 0.00 70110 TC A 23.60 0.00 0.00<br />

69552 S 1,261.21 0.00 0.00 70120 TC A 21.20 0.00 0.00<br />

69601 S 1,261.21 0.00 0.00 70130 TC A 25.90 0.00 0.00<br />

69602 S 1,261.21 0.00 0.00 70134 TC A 25.99 0.00 0.00<br />

69603 S 1,261.21 0.00 0.00 70140 TC A 17.78 0.00 0.00<br />

69604 S 1,261.21 0.00 0.00 70150 TC A 25.90 0.00 0.00<br />

69605 S 1,261.21 0.00 0.00 70160 TC A 20.86 0.00 0.00<br />

69610 S 174.40 0.00 0.00 70190 TC A 21.88 0.00 0.00<br />

69620 S 679.86 0.00 0.00 70200 TC A 25.90 0.00 0.00<br />

69631 S 1,132.70 0.00 0.00 70210 TC A 18.47 0.00 0.00<br />

69632 S 1,132.70 0.00 0.00 70220 TC A 23.26 0.00 0.00<br />

69633 S 1,132.70 0.00 0.00 70240 TC A 17.44 0.00 0.00<br />

69635 S 1,261.21 0.00 0.00 70250 TC A 21.20 0.00 0.00<br />

69636 S 1,261.21 0.00 0.00 70260 TC A 27.01 0.00 0.00<br />

69637 S 1,261.21 0.00 0.00 70300 TC A 7.52 0.00 0.00<br />

69641 S 1,261.21 0.00 0.00 70310 TC A 18.58 0.00 0.00<br />

69642 S 1,261.21 0.00 0.00 70320 TC A 18.58 0.00 0.00<br />

69643 S 1,261.21 0.00 0.00 70328 TC A 18.47 0.00 0.00<br />

69644 S 1,261.21 0.00 0.00 70330 TC A 25.90 0.00 0.00<br />

69645 S 1,261.21 0.00 0.00 70336 TC A 201.63 0.00 0.00<br />

69646 S 1,261.21 0.00 0.00 70350 TC A 10.26 0.00 0.00<br />

69650 S 933.65 0.00 0.00 70355 TC A 10.60 0.00 0.00<br />

69660 S 1,132.70 0.00 0.00 70360 TC A 16.41 0.00 0.00<br />

69661 S 1,132.70 0.00 0.00 70370 TC A 48.20 0.00 0.00<br />

69662 S 1,132.70 0.00 0.00 70371 TC A 48.20 0.00 0.00<br />

69666 S 1,092.48 0.00 0.00 70380 TC A 24.96 0.00 0.00<br />

69667 S 1,092.48 0.00 0.00 70450 TC A 112.61 0.00 0.00<br />

69670 S 1,037.01 0.00 0.00 70460 TC A 178.32 0.00 0.00<br />

69676 S 1,037.01 0.00 0.00 70470 TC A 197.53 0.00 0.00<br />

69700 S 1,037.01 0.00 0.00 70480 TC A 112.61 0.00 0.00<br />

69711 S 955.19 0.00 0.00 70481 TC A 178.32 0.00 0.00<br />

69714 S 6,057.62 3,819.56 1,581.50 70482 TC A 197.53 0.00 0.00<br />

69715 S 6,057.62 3,819.56 1,581.50 70486 TC A 112.61 0.00 0.00<br />

69717 S 6,057.62 3,819.56 1,581.50 70487 TC A 178.32 0.00 0.00<br />

69718 S 6,057.62 3,819.56 1,581.50 70488 TC A 197.53 0.00 0.00<br />

69720 S 1,132.70 0.00 0.00 70490 TC A 112.61 0.00 0.00<br />

69740 S 1,132.70 0.00 0.00 70491 TC A 178.32 0.00 0.00<br />

69745 S 1,132.70 0.00 0.00 70492 TC A 197.53 0.00 0.00<br />

69801 S 1,132.70 0.00 0.00 70496 TC A 203.84 0.00 0.00<br />

69802 S 1,261.21 0.00 0.00 70498 TC A 203.84 0.00 0.00<br />

69805 S 1,261.21 0.00 0.00 70540 TC A 201.63 0.00 0.00<br />

69806 S 1,261.21 0.00 0.00 70542 TC A 247.61 0.00 0.00<br />

69820 S 1,132.70 0.00 0.00 70543 TC A 312.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 201.63 0.00 0.00 72120 TC A 32.82 0.00 0.00<br />

70545 TC A 247.61 0.00 0.00 72125 TC A 112.61 0.00 0.00<br />

70546 TC A 312.07 0.00 0.00 72126 TC A 178.32 0.00 0.00<br />

70547 TC A 201.63 0.00 0.00 72127 TC A 197.53 0.00 0.00<br />

70548 TC A 247.61 0.00 0.00 72128 TC A 112.61 0.00 0.00<br />

70549 TC A 312.07 0.00 0.00 72129 TC A 178.32 0.00 0.00<br />

70551 TC A 201.63 0.00 0.00 72130 TC A 197.53 0.00 0.00<br />

70552 TC A 247.61 0.00 0.00 72131 TC A 112.61 0.00 0.00<br />

70553 TC A 312.07 0.00 0.00 72132 TC A 178.32 0.00 0.00<br />

70554 TC A 201.63 0.00 0.00 72133 TC A 197.53 0.00 0.00<br />

70555 TC A 201.63 0.00 0.00 72141 TC A 201.63 0.00 0.00<br />

70557 TC A 201.63 0.00 0.00 72142 TC A 247.61 0.00 0.00<br />

70558 TC A 247.61 0.00 0.00 72146 TC A 201.63 0.00 0.00<br />

70559 TC A 312.07 0.00 0.00 72147 TC A 247.61 0.00 0.00<br />

71010 TC A 13.34 0.00 0.00 72148 TC A 201.63 0.00 0.00<br />

71015 TC A 17.10 0.00 0.00 72149 TC A 247.61 0.00 0.00<br />

71020 TC A 18.13 0.00 0.00 72156 TC A 312.07 0.00 0.00<br />

71021 TC A 21.88 0.00 0.00 72157 TC A 312.07 0.00 0.00<br />

71022 TC A 25.90 0.00 0.00 72158 TC A 312.07 0.00 0.00<br />

71023 TC A 42.40 0.00 0.00 72170 TC A 15.39 0.00 0.00<br />

71030 TC A 25.90 0.00 0.00 72190 TC A 25.90 0.00 0.00<br />

71034 TC A 48.20 0.00 0.00 72191 TC A 203.84 0.00 0.00<br />

71035 TC A 22.57 0.00 0.00 72192 TC A 112.61 0.00 0.00<br />

71100 TC A 18.81 0.00 0.00 72193 TC A 178.32 0.00 0.00<br />

71101 TC A 22.91 0.00 0.00 72194 TC A 197.53 0.00 0.00<br />

71110 TC A 23.94 0.00 0.00 72195 TC A 201.63 0.00 0.00<br />

71111 TC A 31.80 0.00 0.00 72196 TC A 247.61 0.00 0.00<br />

71120 TC A 19.84 0.00 0.00 72197 TC A 312.07 0.00 0.00<br />

71130 TC A 23.26 0.00 0.00 72200 TC A 18.13 0.00 0.00<br />

71250 TC A 112.61 0.00 0.00 72202 TC A 22.22 0.00 0.00<br />

71260 TC A 178.32 0.00 0.00 72220 TC A 18.13 0.00 0.00<br />

71270 TC A 197.53 0.00 0.00 73000 TC A 17.10 0.00 0.00<br />

71275 TC A 203.84 0.00 0.00 73010 TC A 17.44 0.00 0.00<br />

71550 TC A 201.63 0.00 0.00 73020 TC A 14.02 0.00 0.00<br />

71551 TC A 247.61 0.00 0.00 73030 TC A 17.78 0.00 0.00<br />

71552 TC A 312.07 0.00 0.00 73050 TC A 22.22 0.00 0.00<br />

72010 TC A 43.12 0.00 0.00 73060 TC A 17.78 0.00 0.00<br />

72020 TC A 14.02 0.00 0.00 73070 TC A 17.10 0.00 0.00<br />

72040 TC A 22.57 0.00 0.00 73080 TC A 22.57 0.00 0.00<br />

72050 TC A 32.14 0.00 0.00 73090 TC A 17.10 0.00 0.00<br />

72052 TC A 43.12 0.00 0.00 73092 TC A 17.78 0.00 0.00<br />

72069 TC A 21.20 0.00 0.00 73100 TC A 17.78 0.00 0.00<br />

72070 TC A 19.84 0.00 0.00 73110 TC A 22.57 0.00 0.00<br />

72072 TC A 23.94 0.00 0.00 73120 TC A 16.75 0.00 0.00<br />

72074 TC A 25.90 0.00 0.00 73130 TC A 19.84 0.00 0.00<br />

72080 TC A 21.20 0.00 0.00 73140 TC A 19.49 0.00 0.00<br />

72090 TC A 28.39 0.00 0.00 73200 TC A 112.61 0.00 0.00<br />

72100 TC A 24.28 0.00 0.00 73201 TC A 178.32 0.00 0.00<br />

72110 TC A 33.86 0.00 0.00 73202 TC A 197.53 0.00 0.00<br />

72114 TC A 43.12 0.00 0.00 73206 TC A 203.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 201.63 0.00 0.00 74246 TC A 50.89 0.00 0.00<br />

73219 TC A 247.61 0.00 0.00 74247 TC A 50.89 0.00 0.00<br />

73220 TC A 312.07 0.00 0.00 74249 TC A 82.75 0.00 0.00<br />

73221 TC A 201.63 0.00 0.00 74250 TC A 50.89 0.00 0.00<br />

73222 TC A 247.61 0.00 0.00 74251 TC A 82.75 0.00 0.00<br />

73223 TC A 312.07 0.00 0.00 74260 TC A 50.89 0.00 0.00<br />

73500 TC A 14.71 0.00 0.00 74270 TC A 50.89 0.00 0.00<br />

73510 TC A 22.57 0.00 0.00 74280 TC A 82.75 0.00 0.00<br />

73520 TC A 23.26 0.00 0.00 74283 TC A 50.89 0.00 0.00<br />

73540 TC A 23.26 0.00 0.00 74290 TC A 43.43 0.00 0.00<br />

73550 TC A 17.10 0.00 0.00 74291 TC A 41.72 0.00 0.00<br />

73560 TC A 17.44 0.00 0.00 74400 TC A 75.58 0.00 0.00<br />

73562 TC A 21.54 0.00 0.00 74410 TC A 80.71 0.00 0.00<br />

73564 TC A 24.96 0.00 0.00 74415 TC A 96.44 0.00 0.00<br />

73565 TC A 18.81 0.00 0.00 74420 TC A 100.80 0.00 0.00<br />

73590 TC A 16.41 0.00 0.00 74710 TC A 22.57 0.00 0.00<br />

73592 TC A 17.78 0.00 0.00 74775 TC A 100.80 0.00 0.00<br />

73600 TC A 16.75 0.00 0.00 75557 TC A 201.63 0.00 0.00<br />

73610 TC A 19.84 0.00 0.00 75559 TC A 201.63 0.00 0.00<br />

73620 TC A 16.07 0.00 0.00 75561 TC A 312.07 0.00 0.00<br />

73630 TC A 19.49 0.00 0.00 75563 TC A 312.07 0.00 0.00<br />

73650 TC A 16.41 0.00 0.00 76010 TC A 16.75 0.00 0.00<br />

73660 TC A 18.47 0.00 0.00 76098 TC A 10.26 0.00 0.00<br />

73700 TC A 112.61 0.00 0.00 76100 TC A 43.12 0.00 0.00<br />

73701 TC A 178.32 0.00 0.00 76101 TC A 115.58 0.00 0.00<br />

73702 TC A 197.53 0.00 0.00 76102 TC A 115.58 0.00 0.00<br />

73706 TC A 203.84 0.00 0.00 76120 TC A 48.20 0.00 0.00<br />

73718 TC A 201.63 0.00 0.00 76150 A 16.75 0.00 0.00<br />

73719 TC A 247.61 0.00 0.00 76380 TC A 60.83 0.00 0.00<br />

73720 TC A 312.07 0.00 0.00 76496 TC A 48.20 0.00 0.00<br />

73721 TC A 201.63 0.00 0.00 76497 TC A 60.83 0.00 0.00<br />

73722 TC A 247.61 0.00 0.00 76498 TC A 201.63 0.00 0.00<br />

73723 TC A 312.07 0.00 0.00 76499 TC A 25.90 0.00 0.00<br />

74000 TC A 14.71 0.00 0.00 76506 TC A 36.21 0.00 0.00<br />

74010 TC A 22.91 0.00 0.00 76510 TC A 61.55 0.00 0.00<br />

74020 TC A 23.26 0.00 0.00 76511 TC A 43.08 0.00 0.00<br />

74022 TC A 28.39 0.00 0.00 76512 TC A 36.59 0.00 0.00<br />

74150 TC A 112.61 0.00 0.00 76513 TC A 44.46 0.00 0.00<br />

74160 TC A 178.32 0.00 0.00 76514 TC A 3.08 0.00 0.00<br />

74170 TC A 197.53 0.00 0.00 76516 TC A 34.88 0.00 0.00<br />

74175 TC A 203.84 0.00 0.00 76519 TC A 38.99 0.00 0.00<br />

74181 TC A 201.63 0.00 0.00 76529 TC A 33.86 0.00 0.00<br />

74182 TC A 247.61 0.00 0.00 76536 TC A 56.64 0.00 0.00<br />

74183 TC A 312.07 0.00 0.00 76604 TC A 36.21 0.00 0.00<br />

74210 TC A 50.89 0.00 0.00 76645 TC A 36.21 0.00 0.00<br />

74220 TC A 50.89 0.00 0.00 76700 TC A 56.64 0.00 0.00<br />

74230 TC A 50.89 0.00 0.00 76705 TC A 56.64 0.00 0.00<br />

74240 TC A 50.89 0.00 0.00 76770 TC A 56.64 0.00 0.00<br />

74241 TC A 50.89 0.00 0.00 76775 TC A 56.64 0.00 0.00<br />

74245 TC A 82.75 0.00 0.00 76776 TC A 56.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 56.64 0.00 0.00 77290 TC A 148.13 0.00 0.00<br />

76801 TC A 56.64 0.00 0.00 77295 TC A 388.13 0.00 0.00<br />

76802 TC A 27.01 0.00 0.00 77299 TC A 66.46 0.00 0.00<br />

76805 TC A 56.64 0.00 0.00 77300 TC A 35.91 0.00 0.00<br />

76810 TC A 42.74 0.00 0.00 77301 TC A 517.27 0.00 0.00<br />

76811 TC A 88.74 0.00 0.00 77305 TC A 32.82 0.00 0.00<br />

76812 TC A 36.21 0.00 0.00 77310 TC A 42.74 0.00 0.00<br />

76813 TC A 36.21 0.00 0.00 77315 TC A 62.24 0.00 0.00<br />

76814 TC A 28.73 0.00 0.00 77321 TC A 64.64 0.00 0.00<br />

76815 TC A 36.21 0.00 0.00 77326 TC A 66.46 0.00 0.00<br />

76816 TC A 36.21 0.00 0.00 77327 TC A 120.72 0.00 0.00<br />

76817 TC A 36.21 0.00 0.00 77328 TC A 148.13 0.00 0.00<br />

76818 TC A 56.64 0.00 0.00 77331 TC A 17.10 0.00 0.00<br />

76819 TC A 48.91 0.00 0.00 77332 TC A 45.82 0.00 0.00<br />

76820 TC A 24.28 0.00 0.00 77333 TC A 22.22 0.00 0.00<br />

76821 TC A 54.83 0.00 0.00 77334 TC A 85.84 0.00 0.00<br />

76825 TC A 114.21 0.00 0.00 77336 A 54.04 0.00 0.00<br />

76826 TC A 68.05 0.00 0.00 77370 A 66.46 0.00 0.00<br />

76827 TC A 36.21 0.00 0.00 77371 A 4,427.01 0.00 0.00<br />

76828 TC A 21.54 0.00 0.00 77399 TC A 66.46 0.00 0.00<br />

76830 TC A 56.64 0.00 0.00 77401 A 27.01 0.00 0.00<br />

76831 TC A 76.26 0.00 0.00 77402 A 54.39 0.00 0.00<br />

76856 TC A 56.64 0.00 0.00 77403 A 54.39 0.00 0.00<br />

76857 TC A 36.21 0.00 0.00 77404 A 54.39 0.00 0.00<br />

76870 TC A 56.64 0.00 0.00 77406 A 88.09 0.00 0.00<br />

76872 TC A 56.64 0.00 0.00 77407 A 54.39 0.00 0.00<br />

76873 TC A 56.64 0.00 0.00 77408 A 54.39 0.00 0.00<br />

76880 TC A 56.64 0.00 0.00 77409 A 54.39 0.00 0.00<br />

76885 TC A 36.21 0.00 0.00 77411 A 88.09 0.00 0.00<br />

76886 TC A 36.21 0.00 0.00 77412 A 88.09 0.00 0.00<br />

76936 TC A 54.83 0.00 0.00 77413 A 88.09 0.00 0.00<br />

76970 TC A 36.21 0.00 0.00 77414 A 88.09 0.00 0.00<br />

76977 TC A 9.23 0.00 0.00 77416 A 88.09 0.00 0.00<br />

76999 TC A 36.21 0.00 0.00 77418 A 238.00 0.00 0.00<br />

77071 A 21.20 0.00 0.00 77422 A 88.09 0.00 0.00<br />

77072 TC A 12.31 0.00 0.00 77423 A 88.09 0.00 0.00<br />

77073 TC A 20.86 0.00 0.00 77470 TC A 126.53 0.00 0.00<br />

77074 TC A 41.04 0.00 0.00 77520 A 407.49 0.00 0.00<br />

77075 TC A 43.12 0.00 0.00 77522 A 407.49 0.00 0.00<br />

77076 TC A 43.12 0.00 0.00 77523 A 486.96 0.00 0.00<br />

77077 TC A 23.26 0.00 0.00 77525 A 486.96 0.00 0.00<br />

77078 TC A 41.66 0.00 0.00 77600 TC A 216.21 0.00 0.00<br />

77079 TC A 42.74 0.00 0.00 77605 TC A 216.21 0.00 0.00<br />

77080 TC A 41.66 0.00 0.00 77610 TC A 216.21 0.00 0.00<br />

77081 TC A 16.75 0.00 0.00 77615 TC A 216.21 0.00 0.00<br />

77082 TC A 18.13 0.00 0.00 77620 TC A 216.21 0.00 0.00<br />

77083 TC A 14.36 0.00 0.00 77750 TC A 84.12 0.00 0.00<br />

77084 TC A 201.63 0.00 0.00 77761 TC A 148.07 0.00 0.00<br />

77280 TC A 66.46 0.00 0.00 77762 TC A 175.43 0.00 0.00<br />

77285 TC A 148.13 0.00 0.00 77763 TC A 226.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 160.38 0.00 0.00 78262 TC A 140.85 0.00 0.00<br />

77777 TC A 176.11 0.00 0.00 78264 TC A 140.85 0.00 0.00<br />

77778 TC A 234.59 0.00 0.00 78270 TC A 61.55 0.00 0.00<br />

77785 TC A 104.30 0.00 0.00 78271 TC A 62.58 0.00 0.00<br />

77786 TC A 366.58 0.00 0.00 78272 TC A 68.73 0.00 0.00<br />

77787 TC A 424.79 0.00 0.00 78278 TC A 140.85 0.00 0.00<br />

77789 TC A 43.78 0.00 0.00 78282 TC A 140.85 0.00 0.00<br />

77799 TC A 249.50 0.00 0.00 78290 TC A 140.85 0.00 0.00<br />

78000 TC A 53.68 0.00 0.00 78291 TC A 140.85 0.00 0.00<br />

78001 TC A 68.04 0.00 0.00 78299 TC A 140.85 0.00 0.00<br />

78003 TC A 54.04 0.00 0.00 78300 TC A 122.77 0.00 0.00<br />

78006 TC A 128.56 0.00 0.00 78305 TC A 142.38 0.00 0.00<br />

78007 TC A 95.07 0.00 0.00 78306 TC A 142.38 0.00 0.00<br />

78010 TC A 78.99 0.00 0.00 78315 TC A 142.38 0.00 0.00<br />

78011 TC A 78.99 0.00 0.00 78320 TC A 142.38 0.00 0.00<br />

78015 TC A 153.54 0.00 0.00 78399 TC A 142.38 0.00 0.00<br />

78016 TC A 173.31 0.00 0.00 78414 TC A 180.98 0.00 0.00<br />

78018 TC A 173.31 0.00 0.00 78428 TC A 138.84 0.00 0.00<br />

78070 TC A 117.98 0.00 0.00 78445 TC A 108.30 0.00 0.00<br />

78075 TC A 334.10 0.00 0.00 78456 TC A 108.30 0.00 0.00<br />

78099 TC A 78.99 0.00 0.00 78457 TC A 108.30 0.00 0.00<br />

78102 TC A 119.34 0.00 0.00 78458 TC A 108.30 0.00 0.00<br />

78103 TC A 152.13 0.00 0.00 78459 TC A 670.20 0.00 0.00<br />

78104 TC A 152.13 0.00 0.00 78460 TC A 129.94 0.00 0.00<br />

78110 TC A 60.53 0.00 0.00 78461 TC A 130.98 0.00 0.00<br />

78111 TC A 76.60 0.00 0.00 78464 TC A 192.18 0.00 0.00<br />

78120 TC A 67.02 0.00 0.00 78465 TC A 363.85 0.00 0.00<br />

78121 TC A 79.33 0.00 0.00 78466 TC A 128.92 0.00 0.00<br />

78122 TC A 94.04 0.00 0.00 78468 TC A 164.83 0.00 0.00<br />

78130 TC A 109.08 0.00 0.00 78469 TC A 180.98 0.00 0.00<br />

78135 TC A 231.84 0.00 0.00 78472 TC A 180.98 0.00 0.00<br />

78140 TC A 102.93 0.00 0.00 78473 TC A 180.98 0.00 0.00<br />

78185 TC A 152.13 0.00 0.00 78481 TC A 156.27 0.00 0.00<br />

78190 TC A 95.46 0.00 0.00 78483 TC A 180.98 0.00 0.00<br />

78191 TC A 95.46 0.00 0.00 78491 TC A 670.20 0.00 0.00<br />

78195 TC A 152.13 0.00 0.00 78492 TC A 670.20 0.00 0.00<br />

78199 TC A 152.13 0.00 0.00 78494 TC A 180.98 0.00 0.00<br />

78201 TC A 135.41 0.00 0.00 78499 TC A 180.98 0.00 0.00<br />

78202 TC A 159.30 0.00 0.00 78580 TC A 122.61 0.00 0.00<br />

78205 TC A 159.30 0.00 0.00 78584 TC A 94.72 0.00 0.00<br />

78206 TC A 159.30 0.00 0.00 78585 TC A 188.14 0.00 0.00<br />

78215 TC A 143.28 0.00 0.00 78586 TC A 122.61 0.00 0.00<br />

78216 TC A 97.12 0.00 0.00 78587 TC A 122.61 0.00 0.00<br />

78220 TC A 106.01 0.00 0.00 78588 TC A 188.14 0.00 0.00<br />

78223 TC A 159.30 0.00 0.00 78591 TC A 122.61 0.00 0.00<br />

78230 TC A 120.37 0.00 0.00 78593 TC A 122.61 0.00 0.00<br />

78231 TC A 94.72 0.00 0.00 78594 TC A 122.61 0.00 0.00<br />

78232 TC A 98.83 0.00 0.00 78596 TC A 188.14 0.00 0.00<br />

78258 TC A 140.85 0.00 0.00 78599 TC A 122.61 0.00 0.00<br />

78261 TC A 140.85 0.00 0.00 78600 TC A 108.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 37380 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 108.06 0.00 0.00<br />

78605 TC A 108.06 0.00 0.00<br />

78606 TC A 242.79 0.00 0.00<br />

78607 TC A 266.73 0.00 0.00<br />

78608 TC A 600.71 0.00 0.00<br />

78610 TC A 143.97 0.00 0.00<br />

78630 TC A 256.47 0.00 0.00<br />

78635 TC A 236.30 0.00 0.00<br />

78645 TC A 108.06 0.00 0.00<br />

78647 TC A 261.60 0.00 0.00<br />

78650 TC A 253.39 0.00 0.00<br />

78660 TC A 108.06 0.00 0.00<br />

78699 TC A 108.06 0.00 0.00<br />

78700 TC A 133.03 0.00 0.00<br />

78701 TC A 162.10 0.00 0.00<br />

78707 TC A 169.27 0.00 0.00<br />

78708 TC A 115.93 0.00 0.00<br />

78709 TC A 190.60 0.00 0.00<br />

78710 TC A 178.85 0.00 0.00<br />

78725 TC A 71.47 0.00 0.00<br />

78730 TC A 60.53 0.00 0.00<br />

78740 TC A 157.99 0.00 0.00<br />

78761 TC A 150.80 0.00 0.00<br />

78799 TC A 190.60 0.00 0.00<br />

78800 TC A 133.37 0.00 0.00<br />

78801 TC A 182.96 0.00 0.00<br />

78802 TC A 247.92 0.00 0.00<br />

78803 TC A 265.71 0.00 0.00<br />

78804 TC A 463.70 0.00 0.00<br />

78805 TC A 130.29 0.00 0.00<br />

78806 TC A 260.58 0.00 0.00<br />

78807 TC A 266.05 0.00 0.00<br />

78811 TC A 600.71 0.00 0.00<br />

78812 TC A 600.71 0.00 0.00<br />

78813 TC A 600.71 0.00 0.00<br />

78814 TC A 600.71 0.00 0.00<br />

78815 TC A 600.71 0.00 0.00<br />

78816 TC A 600.71 0.00 0.00<br />

78999 TC A 68.04 0.00 0.00<br />

79005 TC A 54.72 0.00 0.00<br />

79101 TC A 59.85 0.00 0.00<br />

79200 TC A 64.64 0.00 0.00<br />

79300 TC A 124.70 0.00 0.00<br />

79403 TC A 92.67 0.00 0.00<br />

79440 TC A 52.32 0.00 0.00<br />

79445 TC A 124.70 0.00 0.00<br />

79999 TC A 124.70 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,133.24 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,447.03 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.30 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,495.20 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,495.20 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 215.93 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 215.93 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 109.03 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 230.44 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 69.27 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 620.29 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,414.48 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,107.19 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,107.19 0.00 0.00<br />

C8900 A 239.74 0.00 0.00 0123T S 885.42 0.00 0.00<br />

C8901 A 195.22 0.00 0.00 0124T S 173.06 0.00 0.00<br />

C8902 A 302.15 0.00 0.00 0144T TC A 58.90 0.00 0.00<br />

C8903 A 239.74 0.00 0.00 0145T TC A 158.56 0.00 0.00<br />

C8904 A 195.22 0.00 0.00 0146T TC A 158.56 0.00 0.00<br />

C8905 A 302.15 0.00 0.00 0147T TC A 158.56 0.00 0.00<br />

C8906 A 239.74 0.00 0.00 0148T TC A 158.56 0.00 0.00<br />

C8907 A 195.22 0.00 0.00 0149T TC A 158.56 0.00 0.00<br />

C8908 A 302.15 0.00 0.00 0150T TC A 158.56 0.00 0.00<br />

C8909 A 239.74 0.00 0.00 0151T TC A 58.90 0.00 0.00<br />

C8910 A 195.22 0.00 0.00 0170T S 1,150.11 0.00 0.00<br />

C8911 A 302.15 0.00 0.00 0176T S 1,358.02 0.00 0.00<br />

C8912 A 239.74 0.00 0.00 0177T S 1,358.02 0.00 0.00<br />

C8913 A 195.22 0.00 0.00 0182T A 981.58 0.00 0.00<br />

C8914 A 302.15 0.00 0.00 0186T S 827.27 0.00 0.00<br />

C8918 A 239.74 0.00 0.00 0190T S 827.27 0.00 0.00<br />

C8919 A 195.22 0.00 0.00 0191T S 885.42 0.00 0.00<br />

C8920 A 302.15 0.00 0.00 0192T S 1,517.44 0.00 0.00<br />

C9716 S 1,150.11 0.00 0.00 10021 S 53.07 0.00 0.00<br />

C9724 S 940.34 0.00 0.00 10022 S 165.73 0.00 0.00<br />

C9725 S 216.84 0.00 0.00 10040 S 30.68 0.00 0.00<br />

C9726 S 796.08 0.00 0.00 10060 S 46.68 0.00 0.00<br />

C9727 S 279.12 0.00 0.00 10061 S 52.34 0.00 0.00<br />

C9728 S 500.82 0.00 0.00 10080 S 52.34 0.00 0.00<br />

G0104 S 80.45 0.00 0.00 10081 S 120.52 0.00 0.00<br />

G0105 S 347.72 0.00 0.00 10120 S 65.55 0.00 0.00<br />

G0121 S 347.72 0.00 0.00 10121 S 494.13 0.00 0.00<br />

G0127 S 11.25 0.00 0.00 10140 S 69.53 0.00 0.00<br />

G0130 TC A 18.54 0.00 0.00 10160 S 52.34 0.00 0.00<br />

G0173 A 2,133.24 0.00 0.00 10180 S 558.80 0.00 0.00<br />

G0186 S 215.93 0.00 0.00 11000 S 22.52 0.00 0.00<br />

G0247 S 20.53 0.00 0.00 11001 S 7.62 0.00 0.00<br />

G0251 A 534.19 0.00 0.00 11010 S 195.50 0.00 0.00<br />

G0260 S 281.91 0.00 0.00 11011 S 195.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 195.50 0.00 0.00 11601 S 107.94 0.00 0.00<br />

11040 S 20.53 0.00 0.00 11602 S 118.86 0.00 0.00<br />

11041 S 22.85 0.00 0.00 11603 S 126.14 0.00 0.00<br />

11042 S 124.14 0.00 0.00 11604 S 340.27 0.00 0.00<br />

11043 S 124.14 0.00 0.00 11606 S 494.13 0.00 0.00<br />

11044 S 323.25 0.00 0.00 11620 S 92.05 0.00 0.00<br />

11055 S 24.17 0.00 0.00 11621 S 109.26 0.00 0.00<br />

11056 S 26.48 0.00 0.00 11622 S 121.51 0.00 0.00<br />

11057 S 30.68 0.00 0.00 11623 S 130.78 0.00 0.00<br />

11100 S 56.21 0.00 0.00 11624 S 494.13 0.00 0.00<br />

11101 S 13.25 0.00 0.00 11626 S 604.28 0.00 0.00<br />

11200 S 30.68 0.00 0.00 11640 S 97.34 0.00 0.00<br />

11201 S 5.30 0.00 0.00 11641 S 114.89 0.00 0.00<br />

11300 S 30.68 0.00 0.00 11642 S 128.13 0.00 0.00<br />

11301 S 30.68 0.00 0.00 11643 S 138.07 0.00 0.00<br />

11302 S 30.68 0.00 0.00 11644 S 494.13 0.00 0.00<br />

11303 S 56.21 0.00 0.00 11646 S 604.28 0.00 0.00<br />

11305 S 30.68 0.00 0.00 11719 S 11.25 0.00 0.00<br />

11306 S 30.68 0.00 0.00 11720 S 13.91 0.00 0.00<br />

11307 S 30.68 0.00 0.00 11721 S 16.88 0.00 0.00<br />

11308 S 30.68 0.00 0.00 11730 S 30.68 0.00 0.00<br />

11310 S 30.68 0.00 0.00 11732 S 16.88 0.00 0.00<br />

11311 S 30.68 0.00 0.00 11740 S 15.50 0.00 0.00<br />

11312 S 30.68 0.00 0.00 11750 S 89.39 0.00 0.00<br />

11313 S 30.68 0.00 0.00 11752 S 124.16 0.00 0.00<br />

11400 S 63.24 0.00 0.00 11755 S 61.91 0.00 0.00<br />

11401 S 71.18 0.00 0.00 11760 S 127.51 0.00 0.00<br />

11402 S 78.14 0.00 0.00 11762 S 113.90 0.00 0.00<br />

11403 S 83.44 0.00 0.00 11765 S 30.68 0.00 0.00<br />

11404 S 443.56 0.00 0.00 11770 S 632.93 0.00 0.00<br />

11406 S 494.13 0.00 0.00 11771 S 632.93 0.00 0.00<br />

11420 S 59.27 0.00 0.00 11772 S 632.93 0.00 0.00<br />

11421 S 71.84 0.00 0.00 11900 S 28.15 0.00 0.00<br />

11422 S 78.47 0.00 0.00 11901 S 30.68 0.00 0.00<br />

11423 S 87.41 0.00 0.00 11920 S 89.06 0.00 0.00<br />

11424 S 494.13 0.00 0.00 11921 S 98.01 0.00 0.00<br />

11426 S 604.28 0.00 0.00 11922 S 31.78 0.00 0.00<br />

11440 S 67.88 0.00 0.00 11950 S 32.45 0.00 0.00<br />

11441 S 78.47 0.00 0.00 11951 S 40.39 0.00 0.00<br />

11442 S 86.41 0.00 0.00 11952 S 48.63 0.00 0.00<br />

11443 S 95.68 0.00 0.00 11954 S 48.63 0.00 0.00<br />

11444 S 302.00 0.00 0.00 11960 S 589.89 0.00 0.00<br />

11446 S 604.28 0.00 0.00 11970 S 1,068.49 0.00 0.00<br />

11450 S 604.28 0.00 0.00 11971 S 553.71 0.00 0.00<br />

11451 S 604.28 0.00 0.00 11976 S 59.27 0.00 0.00<br />

11462 S 604.28 0.00 0.00 11980 S 23.94 0.00 0.00<br />

11463 S 604.28 0.00 0.00 11981 S 23.94 0.00 0.00<br />

11470 S 604.28 0.00 0.00 11982 S 23.94 0.00 0.00<br />

11471 S 604.28 0.00 0.00 11983 S 23.94 0.00 0.00<br />

11600 S 89.06 0.00 0.00 12001 S 48.63 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 48.63 0.00 0.00 14021 S 524.21 0.00 0.00<br />

12004 S 48.63 0.00 0.00 14040 S 495.57 0.00 0.00<br />

12005 S 65.15 0.00 0.00 14041 S 524.21 0.00 0.00<br />

12006 S 65.15 0.00 0.00 14060 S 524.21 0.00 0.00<br />

12007 S 65.15 0.00 0.00 14061 S 524.21 0.00 0.00<br />

12011 S 48.63 0.00 0.00 14300 S 672.24 0.00 0.00<br />

12013 S 48.63 0.00 0.00 14350 S 618.53 0.00 0.00<br />

12014 S 48.63 0.00 0.00 15002 S 226.77 0.00 0.00<br />

12015 S 48.63 0.00 0.00 15003 S 226.77 0.00 0.00<br />

12016 S 65.15 0.00 0.00 15004 S 226.77 0.00 0.00<br />

12017 S 65.15 0.00 0.00 15005 S 226.77 0.00 0.00<br />

12018 S 65.15 0.00 0.00 15040 S 104.59 0.00 0.00<br />

12020 S 122.92 0.00 0.00 15050 S 226.77 0.00 0.00<br />

12021 S 104.59 0.00 0.00 15100 S 589.89 0.00 0.00<br />

12031 S 48.63 0.00 0.00 15101 S 618.53 0.00 0.00<br />

12032 S 127.51 0.00 0.00 15110 S 281.70 0.00 0.00<br />

12034 S 65.15 0.00 0.00 15111 S 231.12 0.00 0.00<br />

12035 S 65.15 0.00 0.00 15115 S 281.70 0.00 0.00<br />

12036 S 104.59 0.00 0.00 15116 S 231.12 0.00 0.00<br />

12037 S 208.45 0.00 0.00 15120 S 589.89 0.00 0.00<br />

12041 S 48.63 0.00 0.00 15121 S 618.53 0.00 0.00<br />

12042 S 48.63 0.00 0.00 15130 S 495.57 0.00 0.00<br />

12044 S 65.15 0.00 0.00 15131 S 444.99 0.00 0.00<br />

12045 S 104.59 0.00 0.00 15135 S 495.57 0.00 0.00<br />

12046 S 104.59 0.00 0.00 15136 S 444.99 0.00 0.00<br />

12047 S 208.45 0.00 0.00 15150 S 281.70 0.00 0.00<br />

12051 S 48.63 0.00 0.00 15151 S 231.12 0.00 0.00<br />

12052 S 48.63 0.00 0.00 15152 S 231.12 0.00 0.00<br />

12053 S 48.63 0.00 0.00 15155 S 281.70 0.00 0.00<br />

12054 S 65.15 0.00 0.00 15156 S 231.12 0.00 0.00<br />

12055 S 104.59 0.00 0.00 15157 S 231.12 0.00 0.00<br />

12056 S 104.59 0.00 0.00 15170 S 127.51 0.00 0.00<br />

12057 S 208.45 0.00 0.00 15171 S 127.51 0.00 0.00<br />

13100 S 226.77 0.00 0.00 15175 S 164.17 0.00 0.00<br />

13101 S 226.77 0.00 0.00 15176 S 164.17 0.00 0.00<br />

13102 S 122.92 0.00 0.00 15200 S 524.21 0.00 0.00<br />

13120 S 104.59 0.00 0.00 15201 S 440.65 0.00 0.00<br />

13121 S 104.59 0.00 0.00 15220 S 495.57 0.00 0.00<br />

13122 S 104.59 0.00 0.00 15221 S 226.77 0.00 0.00<br />

13131 S 104.59 0.00 0.00 15240 S 524.21 0.00 0.00<br />

13132 S 104.59 0.00 0.00 15241 S 226.77 0.00 0.00<br />

13133 S 104.59 0.00 0.00 15260 S 495.57 0.00 0.00<br />

13150 S 226.77 0.00 0.00 15261 S 440.65 0.00 0.00<br />

13151 S 226.77 0.00 0.00 15300 S 226.77 0.00 0.00<br />

13152 S 226.77 0.00 0.00 15301 S 226.77 0.00 0.00<br />

13153 S 104.59 0.00 0.00 15320 S 226.77 0.00 0.00<br />

13160 S 589.89 0.00 0.00 15321 S 226.77 0.00 0.00<br />

14000 S 495.57 0.00 0.00 15330 S 226.77 0.00 0.00<br />

14001 S 524.21 0.00 0.00 15331 S 226.77 0.00 0.00<br />

14020 S 524.21 0.00 0.00 15335 S 226.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 226.77 0.00 0.00 15826 S 618.53 0.00 0.00<br />

15340 S 127.51 0.00 0.00 15828 S 618.53 0.00 0.00<br />

15341 S 127.51 0.00 0.00 15829 S 711.17 0.00 0.00<br />

15360 S 127.51 0.00 0.00 15830 S 632.93 0.00 0.00<br />

15361 S 127.51 0.00 0.00 15832 S 632.93 0.00 0.00<br />

15365 S 127.51 0.00 0.00 15833 S 632.93 0.00 0.00<br />

15366 S 127.51 0.00 0.00 15834 S 632.93 0.00 0.00<br />

15400 S 226.77 0.00 0.00 15835 S 549.36 0.00 0.00<br />

15401 S 226.77 0.00 0.00 15836 S 522.78 0.00 0.00<br />

15420 S 226.77 0.00 0.00 15837 S 589.04 0.00 0.00<br />

15421 S 226.77 0.00 0.00 15838 S 589.04 0.00 0.00<br />

15430 S 226.77 0.00 0.00 15839 S 522.78 0.00 0.00<br />

15431 S 226.77 0.00 0.00 15840 S 672.24 0.00 0.00<br />

15570 S 618.53 0.00 0.00 15841 S 672.24 0.00 0.00<br />

15572 S 618.53 0.00 0.00 15842 S 780.54 0.00 0.00<br />

15574 S 618.53 0.00 0.00 15845 S 672.24 0.00 0.00<br />

15576 S 618.53 0.00 0.00 15847 S 632.93 0.00 0.00<br />

15600 S 618.53 0.00 0.00 15850 S 101.11 0.00 0.00<br />

15610 S 618.53 0.00 0.00 15851 S 46.02 0.00 0.00<br />

15620 S 672.24 0.00 0.00 15852 S 23.94 0.00 0.00<br />

15630 S 618.53 0.00 0.00 15860 S 23.94 0.00 0.00<br />

15650 S 711.17 0.00 0.00 15876 S 618.53 0.00 0.00<br />

15731 S 618.53 0.00 0.00 15877 S 618.53 0.00 0.00<br />

15732 S 618.53 0.00 0.00 15878 S 618.53 0.00 0.00<br />

15734 S 618.53 0.00 0.00 15879 S 618.53 0.00 0.00<br />

15736 S 618.53 0.00 0.00 15920 S 195.50 0.00 0.00<br />

15738 S 618.53 0.00 0.00 15922 S 672.24 0.00 0.00<br />

15740 S 495.57 0.00 0.00 15931 S 632.93 0.00 0.00<br />

15750 S 589.89 0.00 0.00 15933 S 632.93 0.00 0.00<br />

15760 S 589.89 0.00 0.00 15934 S 618.53 0.00 0.00<br />

15770 S 618.53 0.00 0.00 15935 S 672.24 0.00 0.00<br />

15775 S 169.00 0.00 0.00 15936 S 577.93 0.00 0.00<br />

15776 S 169.00 0.00 0.00 15937 S 672.24 0.00 0.00<br />

15780 S 376.78 0.00 0.00 15940 S 632.93 0.00 0.00<br />

15781 S 165.85 0.00 0.00 15941 S 632.93 0.00 0.00<br />

15782 S 165.85 0.00 0.00 15944 S 618.53 0.00 0.00<br />

15783 S 101.11 0.00 0.00 15945 S 672.24 0.00 0.00<br />

15786 S 30.68 0.00 0.00 15946 S 672.24 0.00 0.00<br />

15787 S 27.82 0.00 0.00 15950 S 632.93 0.00 0.00<br />

15788 S 30.68 0.00 0.00 15951 S 686.64 0.00 0.00<br />

15789 S 56.21 0.00 0.00 15952 S 524.21 0.00 0.00<br />

15792 S 56.21 0.00 0.00 15953 S 577.93 0.00 0.00<br />

15793 S 30.68 0.00 0.00 15956 S 524.21 0.00 0.00<br />

15819 S 127.51 0.00 0.00 15958 S 577.93 0.00 0.00<br />

15820 S 618.53 0.00 0.00 16000 S 24.83 0.00 0.00<br />

15821 S 618.53 0.00 0.00 16020 S 37.75 0.00 0.00<br />

15822 S 618.53 0.00 0.00 16025 S 58.14 0.00 0.00<br />

15823 S 711.17 0.00 0.00 16030 S 72.79 0.00 0.00<br />

15824 S 618.53 0.00 0.00 16035 S 56.21 0.00 0.00<br />

15825 S 618.53 0.00 0.00 17000 S 30.68 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.64 0.00 0.00 19300 S 680.01 0.00 0.00<br />

17004 S 80.12 0.00 0.00 19301 S 626.31 0.00 0.00<br />

17106 S 101.11 0.00 0.00 19302 S 1,196.17 0.00 0.00<br />

17107 S 101.11 0.00 0.00 19303 S 903.98 0.00 0.00<br />

17108 S 101.11 0.00 0.00 19304 S 903.98 0.00 0.00<br />

17110 S 30.68 0.00 0.00 19316 S 903.98 0.00 0.00<br />

17111 S 56.21 0.00 0.00 19318 S 1,032.81 0.00 0.00<br />

17250 S 42.38 0.00 0.00 19324 S 1,032.81 0.00 0.00<br />

17260 S 45.36 0.00 0.00 19325 S 1,713.03 0.00 0.00<br />

17261 S 56.21 0.00 0.00 19328 S 771.06 0.00 0.00<br />

17262 S 56.21 0.00 0.00 19330 S 771.06 0.00 0.00<br />

17263 S 56.21 0.00 0.00 19340 S 950.45 0.00 0.00<br />

17264 S 56.21 0.00 0.00 19342 S 1,342.00 0.00 0.00<br />

17266 S 101.11 0.00 0.00 19350 S 680.01 0.00 0.00<br />

17270 S 56.21 0.00 0.00 19355 S 903.98 0.00 0.00<br />

17271 S 56.21 0.00 0.00 19357 S 1,434.64 0.00 0.00<br />

17272 S 56.21 0.00 0.00 19366 S 942.92 0.00 0.00<br />

17273 S 101.11 0.00 0.00 19370 S 903.98 0.00 0.00<br />

17274 S 101.11 0.00 0.00 19371 S 903.98 0.00 0.00<br />

17276 S 101.11 0.00 0.00 19380 S 1,071.75 0.00 0.00<br />

17280 S 56.21 0.00 0.00 19396 S 1,244.02 0.00 0.00<br />

17281 S 83.77 0.00 0.00 20000 S 52.34 0.00 0.00<br />

17282 S 95.68 0.00 0.00 20005 S 603.14 0.00 0.00<br />

17283 S 101.11 0.00 0.00 20103 S 591.92 0.00 0.00<br />

17284 S 101.11 0.00 0.00 20150 S 1,680.46 0.00 0.00<br />

17286 S 101.11 0.00 0.00 20200 S 494.13 0.00 0.00<br />

17311 S 166.91 0.00 0.00 20205 S 522.78 0.00 0.00<br />

17312 S 166.91 0.00 0.00 20206 S 244.29 0.00 0.00<br />

17313 S 166.91 0.00 0.00 20220 S 265.54 0.00 0.00<br />

17314 S 166.91 0.00 0.00 20225 S 481.82 0.00 0.00<br />

17315 S 37.75 0.00 0.00 20240 S 604.28 0.00 0.00<br />

17340 S 13.58 0.00 0.00 20245 S 632.93 0.00 0.00<br />

17360 S 30.68 0.00 0.00 20250 S 631.79 0.00 0.00<br />

17380 S 30.68 0.00 0.00 20251 S 631.79 0.00 0.00<br />

19000 S 63.90 0.00 0.00 20500 S 52.32 0.00 0.00<br />

19001 S 8.61 0.00 0.00 20520 S 88.07 0.00 0.00<br />

19020 S 558.80 0.00 0.00 20525 S 632.93 0.00 0.00<br />

19100 S 190.28 0.00 0.00 20526 S 28.48 0.00 0.00<br />

19101 S 597.65 0.00 0.00 20550 S 21.52 0.00 0.00<br />

19102 S 244.29 0.00 0.00 20551 S 21.19 0.00 0.00<br />

19103 S 427.57 0.00 0.00 20552 S 20.53 0.00 0.00<br />

19105 S 1,244.02 0.00 0.00 20553 S 22.85 0.00 0.00<br />

19110 S 597.65 0.00 0.00 20555 S 1,107.19 0.00 0.00<br />

19112 S 626.31 0.00 0.00 20600 S 21.85 0.00 0.00<br />

19120 S 626.31 0.00 0.00 20605 S 24.50 0.00 0.00<br />

19125 S 626.31 0.00 0.00 20610 S 34.43 0.00 0.00<br />

19126 S 626.31 0.00 0.00 20612 S 23.18 0.00 0.00<br />

19296 S 1,713.03 0.00 0.00 20615 S 97.01 0.00 0.00<br />

19297 S 1,713.03 0.00 0.00 20650 S 631.79 0.00 0.00<br />

19298 S 1,713.03 0.00 0.00 20662 S 807.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 807.04 0.00 0.00 21085 S 243.02 0.00 0.00<br />

20665 S 23.94 0.00 0.00 21086 S 529.08 0.00 0.00<br />

20670 S 443.56 0.00 0.00 21087 S 529.75 0.00 0.00<br />

20680 S 632.93 0.00 0.00 21088 S 1,551.54 0.00 0.00<br />

20690 S 753.21 0.00 0.00 21100 S 975.38 0.00 0.00<br />

20692 S 781.86 0.00 0.00 21110 S 279.12 0.00 0.00<br />

20693 S 631.79 0.00 0.00 21120 S 903.96 0.00 0.00<br />

20694 S 552.56 0.00 0.00 21121 S 903.96 0.00 0.00<br />

20696 S 1,107.19 0.00 0.00 21122 S 903.96 0.00 0.00<br />

20697 S 736.33 0.00 0.00 21123 S 903.96 0.00 0.00<br />

20822 S 1,037.45 0.00 0.00 21125 S 903.96 0.00 0.00<br />

20900 S 781.86 0.00 0.00 21127 S 1,375.06 0.00 0.00<br />

20902 S 835.56 0.00 0.00 21137 S 917.27 0.00 0.00<br />

20910 S 618.53 0.00 0.00 21138 S 1,551.54 0.00 0.00<br />

20912 S 618.53 0.00 0.00 21139 S 1,551.54 0.00 0.00<br />

20920 S 577.93 0.00 0.00 21150 S 1,551.54 0.00 0.00<br />

20922 S 524.21 0.00 0.00 21181 S 903.96 0.00 0.00<br />

20924 S 835.56 0.00 0.00 21198 S 1,551.54 0.00 0.00<br />

20926 S 364.05 0.00 0.00 21199 S 1,551.54 0.00 0.00<br />

20950 S 52.34 0.00 0.00 21206 S 1,096.68 0.00 0.00<br />

20972 S 1,752.28 0.00 0.00 21208 S 1,221.11 0.00 0.00<br />

20973 S 1,752.28 0.00 0.00 21209 S 1,096.68 0.00 0.00<br />

20979 S 21.52 0.00 0.00 21210 S 1,221.11 0.00 0.00<br />

20982 S 1,680.46 0.00 0.00 21215 S 1,221.11 0.00 0.00<br />

21010 S 658.24 0.00 0.00 21230 S 1,221.11 0.00 0.00<br />

21015 S 547.66 0.00 0.00 21235 S 903.96 0.00 0.00<br />

21025 S 975.38 0.00 0.00 21240 S 1,057.74 0.00 0.00<br />

21026 S 975.38 0.00 0.00 21242 S 1,096.68 0.00 0.00<br />

21029 S 975.38 0.00 0.00 21243 S 1,096.68 0.00 0.00<br />

21030 S 230.11 0.00 0.00 21244 S 1,221.11 0.00 0.00<br />

21031 S 190.37 0.00 0.00 21245 S 1,221.11 0.00 0.00<br />

21032 S 194.02 0.00 0.00 21246 S 1,221.11 0.00 0.00<br />

21034 S 1,004.03 0.00 0.00 21248 S 1,221.11 0.00 0.00<br />

21040 S 658.24 0.00 0.00 21249 S 1,221.11 0.00 0.00<br />

21044 S 975.38 0.00 0.00 21260 S 1,551.54 0.00 0.00<br />

21046 S 975.38 0.00 0.00 21267 S 1,221.11 0.00 0.00<br />

21047 S 975.38 0.00 0.00 21270 S 1,096.68 0.00 0.00<br />

21048 S 1,551.54 0.00 0.00 21275 S 1,221.11 0.00 0.00<br />

21050 S 1,004.03 0.00 0.00 21280 S 1,096.68 0.00 0.00<br />

21060 S 975.38 0.00 0.00 21282 S 640.31 0.00 0.00<br />

21070 S 1,004.03 0.00 0.00 21295 S 288.60 0.00 0.00<br />

21073 S 178.79 0.00 0.00 21296 S 607.67 0.00 0.00<br />

21076 S 310.23 0.00 0.00 21310 S 88.04 0.00 0.00<br />

21077 S 749.92 0.00 0.00 21315 S 386.85 0.00 0.00<br />

21079 S 537.03 0.00 0.00 21320 S 519.01 0.00 0.00<br />

21080 S 615.83 0.00 0.00 21325 S 740.60 0.00 0.00<br />

21081 S 567.49 0.00 0.00 21330 S 779.54 0.00 0.00<br />

21082 S 540.01 0.00 0.00 21335 S 903.96 0.00 0.00<br />

21083 S 532.06 0.00 0.00 21336 S 753.36 0.00 0.00<br />

21084 S 612.19 0.00 0.00 21337 S 519.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 740.60 0.00 0.00 22310 S 160.27 0.00 0.00<br />

21339 S 779.54 0.00 0.00 22315 S 414.54 0.00 0.00<br />

21340 S 1,057.74 0.00 0.00 22505 S 488.02 0.00 0.00<br />

21345 S 903.96 0.00 0.00 22520 S 1,152.89 0.00 0.00<br />

21355 S 1,004.03 0.00 0.00 22521 S 1,152.89 0.00 0.00<br />

21356 S 686.89 0.00 0.00 22522 S 1,152.89 0.00 0.00<br />

21360 S 917.27 0.00 0.00 22523 S 3,208.60 0.00 0.00<br />

21390 S 1,551.54 0.00 0.00 22524 S 3,208.60 0.00 0.00<br />

21400 S 339.17 0.00 0.00 22525 S 3,208.60 0.00 0.00<br />

21401 S 547.66 0.00 0.00 22900 S 686.64 0.00 0.00<br />

21406 S 1,551.54 0.00 0.00 23000 S 494.13 0.00 0.00<br />

21407 S 1,551.54 0.00 0.00 23020 S 1,039.85 0.00 0.00<br />

21421 S 740.60 0.00 0.00 23030 S 508.21 0.00 0.00<br />

21440 S 311.89 0.00 0.00 23031 S 587.44 0.00 0.00<br />

21445 S 740.60 0.00 0.00 23035 S 631.79 0.00 0.00<br />

21450 S 128.72 0.00 0.00 23040 S 781.86 0.00 0.00<br />

21451 S 347.30 0.00 0.00 23044 S 835.56 0.00 0.00<br />

21452 S 519.01 0.00 0.00 23065 S 93.37 0.00 0.00<br />

21453 S 1,004.03 0.00 0.00 23066 S 604.28 0.00 0.00<br />

21454 S 779.54 0.00 0.00 23075 S 494.13 0.00 0.00<br />

21461 S 1,057.74 0.00 0.00 23076 S 604.28 0.00 0.00<br />

21462 S 1,096.68 0.00 0.00 23077 S 632.93 0.00 0.00<br />

21465 S 1,057.74 0.00 0.00 23100 S 603.14 0.00 0.00<br />

21480 S 88.04 0.00 0.00 23101 S 998.93 0.00 0.00<br />

21485 S 519.01 0.00 0.00 23105 S 835.56 0.00 0.00<br />

21490 S 1,004.03 0.00 0.00 23106 S 835.56 0.00 0.00<br />

21495 S 638.79 0.00 0.00 23107 S 835.56 0.00 0.00<br />

21497 S 519.01 0.00 0.00 23120 S 874.51 0.00 0.00<br />

21501 S 558.80 0.00 0.00 23125 S 874.51 0.00 0.00<br />

21502 S 603.14 0.00 0.00 23130 S 1,161.13 0.00 0.00<br />

21550 S 589.04 0.00 0.00 23140 S 685.49 0.00 0.00<br />

21555 S 604.28 0.00 0.00 23145 S 874.51 0.00 0.00<br />

21556 S 604.28 0.00 0.00 23146 S 874.51 0.00 0.00<br />

21557 S 809.34 0.00 0.00 23150 S 835.56 0.00 0.00<br />

21600 S 753.21 0.00 0.00 23155 S 874.51 0.00 0.00<br />

21610 S 753.21 0.00 0.00 23156 S 874.51 0.00 0.00<br />

21685 S 279.12 0.00 0.00 23170 S 753.21 0.00 0.00<br />

21700 S 603.14 0.00 0.00 23172 S 753.21 0.00 0.00<br />

21720 S 631.79 0.00 0.00 23174 S 753.21 0.00 0.00<br />

21725 S 65.77 0.00 0.00 23180 S 835.56 0.00 0.00<br />

21800 S 75.97 0.00 0.00 23182 S 835.56 0.00 0.00<br />

21805 S 671.00 0.00 0.00 23184 S 835.56 0.00 0.00<br />

21820 S 75.97 0.00 0.00 23190 S 835.56 0.00 0.00<br />

21920 S 135.08 0.00 0.00 23195 S 874.51 0.00 0.00<br />

21925 S 604.28 0.00 0.00 23330 S 302.00 0.00 0.00<br />

21930 S 604.28 0.00 0.00 23331 S 553.71 0.00 0.00<br />

21935 S 632.93 0.00 0.00 23395 S 1,161.13 0.00 0.00<br />

22102 S 1,801.02 0.00 0.00 23397 S 2,049.64 0.00 0.00<br />

22103 S 1,801.02 0.00 0.00 23400 S 998.93 0.00 0.00<br />

22305 S 75.97 0.00 0.00 23405 S 753.21 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 753.21 0.00 0.00 23931 S 558.80 0.00 0.00<br />

23410 S 1,161.13 0.00 0.00 23935 S 603.14 0.00 0.00<br />

23412 S 1,285.56 0.00 0.00 24000 S 835.56 0.00 0.00<br />

23415 S 1,161.13 0.00 0.00 24006 S 835.56 0.00 0.00<br />

23420 S 1,285.56 0.00 0.00 24065 S 129.46 0.00 0.00<br />

23430 S 1,122.20 0.00 0.00 24066 S 494.13 0.00 0.00<br />

23440 S 1,122.20 0.00 0.00 24075 S 494.13 0.00 0.00<br />

23450 S 1,925.21 0.00 0.00 24076 S 604.28 0.00 0.00<br />

23455 S 2,049.64 0.00 0.00 24077 S 632.93 0.00 0.00<br />

23460 S 1,925.21 0.00 0.00 24100 S 552.56 0.00 0.00<br />

23462 S 1,285.56 0.00 0.00 24101 S 835.56 0.00 0.00<br />

23465 S 1,925.21 0.00 0.00 24102 S 835.56 0.00 0.00<br />

23466 S 1,285.56 0.00 0.00 24105 S 631.79 0.00 0.00<br />

23480 S 1,122.20 0.00 0.00 24110 S 603.14 0.00 0.00<br />

23485 S 2,049.64 0.00 0.00 24115 S 781.86 0.00 0.00<br />

23490 S 1,068.49 0.00 0.00 24116 S 781.86 0.00 0.00<br />

23491 S 1,832.57 0.00 0.00 24120 S 631.79 0.00 0.00<br />

23500 S 75.97 0.00 0.00 24125 S 781.86 0.00 0.00<br />

23505 S 414.54 0.00 0.00 24126 S 781.86 0.00 0.00<br />

23515 S 1,387.44 0.00 0.00 24130 S 781.86 0.00 0.00<br />

23520 S 160.27 0.00 0.00 24134 S 753.21 0.00 0.00<br />

23525 S 160.27 0.00 0.00 24136 S 753.21 0.00 0.00<br />

23530 S 1,022.40 0.00 0.00 24138 S 753.21 0.00 0.00<br />

23532 S 753.36 0.00 0.00 24140 S 781.86 0.00 0.00<br />

23540 S 75.97 0.00 0.00 24145 S 781.86 0.00 0.00<br />

23545 S 160.27 0.00 0.00 24147 S 753.21 0.00 0.00<br />

23550 S 1,022.40 0.00 0.00 24149 S 1,107.19 0.00 0.00<br />

23552 S 1,076.12 0.00 0.00 24152 S 1,680.46 0.00 0.00<br />

23570 S 75.97 0.00 0.00 24153 S 3,208.60 0.00 0.00<br />

23575 S 160.27 0.00 0.00 24155 S 1,068.49 0.00 0.00<br />

23585 S 1,387.44 0.00 0.00 24160 S 753.21 0.00 0.00<br />

23600 S 59.20 0.00 0.00 24164 S 781.86 0.00 0.00<br />

23605 S 414.54 0.00 0.00 24200 S 94.69 0.00 0.00<br />

23615 S 1,441.14 0.00 0.00 24201 S 494.13 0.00 0.00<br />

23616 S 1,441.14 0.00 0.00 24300 S 576.81 0.00 0.00<br />

23620 S 59.20 0.00 0.00 24301 S 835.56 0.00 0.00<br />

23625 S 414.54 0.00 0.00 24305 S 835.56 0.00 0.00<br />

23630 S 1,480.08 0.00 0.00 24310 S 631.79 0.00 0.00<br />

23650 S 75.97 0.00 0.00 24320 S 1,068.49 0.00 0.00<br />

23655 S 437.45 0.00 0.00 24330 S 1,832.57 0.00 0.00<br />

23660 S 1,022.40 0.00 0.00 24331 S 1,068.49 0.00 0.00<br />

23665 S 160.27 0.00 0.00 24332 S 807.04 0.00 0.00<br />

23670 S 1,387.44 0.00 0.00 24340 S 1,068.49 0.00 0.00<br />

23675 S 75.97 0.00 0.00 24341 S 1,068.49 0.00 0.00<br />

23680 S 1,022.40 0.00 0.00 24342 S 1,068.49 0.00 0.00<br />

23700 S 437.45 0.00 0.00 24343 S 1,107.19 0.00 0.00<br />

23800 S 1,886.27 0.00 0.00 24344 S 3,208.60 0.00 0.00<br />

23802 S 1,285.56 0.00 0.00 24345 S 753.21 0.00 0.00<br />

23921 S 440.65 0.00 0.00 24346 S 1,680.46 0.00 0.00<br />

23930 S 508.21 0.00 0.00 24357 S 1,107.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,107.19 0.00 0.00 24925 S 631.79 0.00 0.00<br />

24359 S 1,107.19 0.00 0.00 25000 S 631.79 0.00 0.00<br />

24360 S 1,021.78 0.00 0.00 25001 S 807.04 0.00 0.00<br />

24361 S 5,586.60 3,419.71 1,252.81 25020 S 631.79 0.00 0.00<br />

24362 S 1,305.83 0.00 0.00 25023 S 781.86 0.00 0.00<br />

24363 S 5,711.02 3,544.13 1,377.24 25024 S 781.86 0.00 0.00<br />

24365 S 1,021.78 0.00 0.00 25025 S 781.86 0.00 0.00<br />

24366 S 5,586.60 3,419.71 1,252.81 25028 S 552.56 0.00 0.00<br />

24400 S 835.56 0.00 0.00 25031 S 603.14 0.00 0.00<br />

24410 S 835.56 0.00 0.00 25035 S 603.14 0.00 0.00<br />

24420 S 1,068.49 0.00 0.00 25040 S 874.51 0.00 0.00<br />

24430 S 1,832.57 0.00 0.00 25065 S 131.44 0.00 0.00<br />

24435 S 1,886.27 0.00 0.00 25066 S 604.28 0.00 0.00<br />

24470 S 1,068.49 0.00 0.00 25075 S 494.13 0.00 0.00<br />

24495 S 753.21 0.00 0.00 25076 S 632.93 0.00 0.00<br />

24498 S 1,832.57 0.00 0.00 25077 S 632.93 0.00 0.00<br />

24500 S 75.97 0.00 0.00 25085 S 631.79 0.00 0.00<br />

24505 S 75.97 0.00 0.00 25100 S 603.14 0.00 0.00<br />

24515 S 1,441.14 0.00 0.00 25101 S 781.86 0.00 0.00<br />

24516 S 1,441.14 0.00 0.00 25105 S 835.56 0.00 0.00<br />

24530 S 75.97 0.00 0.00 25107 S 781.86 0.00 0.00<br />

24535 S 160.27 0.00 0.00 25109 S 807.04 0.00 0.00<br />

24538 S 671.00 0.00 0.00 25110 S 631.79 0.00 0.00<br />

24545 S 1,441.14 0.00 0.00 25111 S 631.79 0.00 0.00<br />

24546 S 1,480.08 0.00 0.00 25112 S 685.49 0.00 0.00<br />

24560 S 75.97 0.00 0.00 25115 S 685.49 0.00 0.00<br />

24565 S 75.97 0.00 0.00 25116 S 685.49 0.00 0.00<br />

24566 S 671.00 0.00 0.00 25118 S 753.21 0.00 0.00<br />

24575 S 1,387.44 0.00 0.00 25119 S 781.86 0.00 0.00<br />

24576 S 75.97 0.00 0.00 25120 S 781.86 0.00 0.00<br />

24577 S 160.27 0.00 0.00 25125 S 781.86 0.00 0.00<br />

24579 S 1,387.44 0.00 0.00 25126 S 781.86 0.00 0.00<br />

24582 S 671.00 0.00 0.00 25130 S 781.86 0.00 0.00<br />

24586 S 1,441.14 0.00 0.00 25135 S 781.86 0.00 0.00<br />

24587 S 1,480.08 0.00 0.00 25136 S 781.86 0.00 0.00<br />

24600 S 75.97 0.00 0.00 25145 S 753.21 0.00 0.00<br />

24605 S 488.02 0.00 0.00 25150 S 753.21 0.00 0.00<br />

24615 S 1,387.44 0.00 0.00 25151 S 753.21 0.00 0.00<br />

24620 S 414.54 0.00 0.00 25210 S 781.86 0.00 0.00<br />

24635 S 1,387.44 0.00 0.00 25215 S 835.56 0.00 0.00<br />

24640 S 51.32 0.00 0.00 25230 S 835.56 0.00 0.00<br />

24650 S 59.20 0.00 0.00 25240 S 835.56 0.00 0.00<br />

24655 S 160.27 0.00 0.00 25248 S 603.14 0.00 0.00<br />

24665 S 1,076.12 0.00 0.00 25250 S 702.64 0.00 0.00<br />

24666 S 1,441.14 0.00 0.00 25251 S 702.64 0.00 0.00<br />

24670 S 75.97 0.00 0.00 25259 S 736.33 0.00 0.00<br />

24675 S 75.97 0.00 0.00 25260 S 835.56 0.00 0.00<br />

24685 S 1,022.40 0.00 0.00 25263 S 753.21 0.00 0.00<br />

24800 S 1,122.20 0.00 0.00 25265 S 781.86 0.00 0.00<br />

24802 S 1,161.13 0.00 0.00 25270 S 835.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 781.86 0.00 0.00 25505 S 160.27 0.00 0.00<br />

25274 S 835.56 0.00 0.00 25515 S 1,022.40 0.00 0.00<br />

25275 S 835.56 0.00 0.00 25520 S 160.27 0.00 0.00<br />

25280 S 835.56 0.00 0.00 25525 S 1,076.12 0.00 0.00<br />

25290 S 781.86 0.00 0.00 25526 S 1,115.05 0.00 0.00<br />

25295 S 631.79 0.00 0.00 25530 S 59.20 0.00 0.00<br />

25300 S 781.86 0.00 0.00 25535 S 75.97 0.00 0.00<br />

25301 S 781.86 0.00 0.00 25545 S 1,022.40 0.00 0.00<br />

25310 S 1,068.49 0.00 0.00 25560 S 59.20 0.00 0.00<br />

25312 S 1,122.20 0.00 0.00 25565 S 160.27 0.00 0.00<br />

25315 S 1,068.49 0.00 0.00 25574 S 1,387.44 0.00 0.00<br />

25316 S 1,832.57 0.00 0.00 25575 S 1,387.44 0.00 0.00<br />

25320 S 1,068.49 0.00 0.00 25600 S 59.20 0.00 0.00<br />

25332 S 1,021.78 0.00 0.00 25605 S 160.27 0.00 0.00<br />

25335 S 1,068.49 0.00 0.00 25606 S 699.65 0.00 0.00<br />

25337 S 1,161.13 0.00 0.00 25607 S 1,480.08 0.00 0.00<br />

25350 S 1,832.57 0.00 0.00 25608 S 1,480.08 0.00 0.00<br />

25355 S 1,068.49 0.00 0.00 25609 S 1,480.08 0.00 0.00<br />

25360 S 781.86 0.00 0.00 25622 S 59.20 0.00 0.00<br />

25365 S 781.86 0.00 0.00 25624 S 160.27 0.00 0.00<br />

25370 S 1,068.49 0.00 0.00 25628 S 1,022.40 0.00 0.00<br />

25375 S 1,122.20 0.00 0.00 25630 S 59.20 0.00 0.00<br />

25390 S 781.86 0.00 0.00 25635 S 160.27 0.00 0.00<br />

25391 S 1,122.20 0.00 0.00 25645 S 1,022.40 0.00 0.00<br />

25392 S 781.86 0.00 0.00 25650 S 59.20 0.00 0.00<br />

25393 S 1,122.20 0.00 0.00 25651 S 942.78 0.00 0.00<br />

25394 S 1,680.46 0.00 0.00 25652 S 1,588.28 0.00 0.00<br />

25400 S 1,068.49 0.00 0.00 25660 S 75.97 0.00 0.00<br />

25405 S 1,886.27 0.00 0.00 25670 S 699.65 0.00 0.00<br />

25415 S 1,832.57 0.00 0.00 25671 S 620.43 0.00 0.00<br />

25420 S 1,886.27 0.00 0.00 25675 S 75.97 0.00 0.00<br />

25425 S 1,068.49 0.00 0.00 25676 S 671.00 0.00 0.00<br />

25426 S 1,122.20 0.00 0.00 25680 S 75.97 0.00 0.00<br />

25430 S 1,680.46 0.00 0.00 25685 S 699.65 0.00 0.00<br />

25431 S 1,680.46 0.00 0.00 25690 S 414.54 0.00 0.00<br />

25440 S 1,886.27 0.00 0.00 25695 S 671.00 0.00 0.00<br />

25441 S 5,586.60 3,419.71 1,252.81 25800 S 1,886.27 0.00 0.00<br />

25442 S 5,586.60 3,419.71 1,252.81 25805 S 1,161.13 0.00 0.00<br />

25443 S 1,305.83 0.00 0.00 25810 S 1,925.21 0.00 0.00<br />

25444 S 1,305.83 0.00 0.00 25820 S 1,122.20 0.00 0.00<br />

25445 S 1,305.83 0.00 0.00 25825 S 1,925.21 0.00 0.00<br />

25446 S 5,711.02 3,544.13 1,377.24 25830 S 1,925.21 0.00 0.00<br />

25447 S 1,021.78 0.00 0.00 25907 S 631.79 0.00 0.00<br />

25449 S 1,021.78 0.00 0.00 25922 S 631.79 0.00 0.00<br />

25450 S 1,068.49 0.00 0.00 25929 S 524.21 0.00 0.00<br />

25455 S 1,068.49 0.00 0.00 25931 S 807.04 0.00 0.00<br />

25490 S 1,068.49 0.00 0.00 26010 S 52.34 0.00 0.00<br />

25491 S 1,068.49 0.00 0.00 26011 S 382.38 0.00 0.00<br />

25492 S 1,068.49 0.00 0.00 26020 S 507.38 0.00 0.00<br />

25500 S 59.20 0.00 0.00 26025 S 456.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 507.38 0.00 0.00 26392 S 746.99 0.00 0.00<br />

26034 S 507.38 0.00 0.00 26410 S 536.02 0.00 0.00<br />

26035 S 615.52 0.00 0.00 26412 S 746.99 0.00 0.00<br />

26040 S 800.70 0.00 0.00 26415 S 800.70 0.00 0.00<br />

26045 S 746.99 0.00 0.00 26416 S 746.99 0.00 0.00<br />

26055 S 507.38 0.00 0.00 26418 S 589.73 0.00 0.00<br />

26060 S 507.38 0.00 0.00 26420 S 800.70 0.00 0.00<br />

26070 S 507.38 0.00 0.00 26426 S 746.99 0.00 0.00<br />

26075 S 589.73 0.00 0.00 26428 S 746.99 0.00 0.00<br />

26080 S 589.73 0.00 0.00 26432 S 536.02 0.00 0.00<br />

26100 S 507.38 0.00 0.00 26433 S 536.02 0.00 0.00<br />

26105 S 456.80 0.00 0.00 26434 S 746.99 0.00 0.00<br />

26110 S 456.80 0.00 0.00 26437 S 536.02 0.00 0.00<br />

26115 S 604.28 0.00 0.00 26440 S 536.02 0.00 0.00<br />

26116 S 604.28 0.00 0.00 26442 S 746.99 0.00 0.00<br />

26117 S 632.93 0.00 0.00 26445 S 536.02 0.00 0.00<br />

26121 S 800.70 0.00 0.00 26449 S 746.99 0.00 0.00<br />

26123 S 800.70 0.00 0.00 26450 S 536.02 0.00 0.00<br />

26125 S 589.73 0.00 0.00 26455 S 536.02 0.00 0.00<br />

26130 S 536.02 0.00 0.00 26460 S 536.02 0.00 0.00<br />

26135 S 800.70 0.00 0.00 26471 S 507.38 0.00 0.00<br />

26140 S 507.38 0.00 0.00 26474 S 507.38 0.00 0.00<br />

26145 S 536.02 0.00 0.00 26476 S 456.80 0.00 0.00<br />

26160 S 536.02 0.00 0.00 26477 S 456.80 0.00 0.00<br />

26170 S 536.02 0.00 0.00 26478 S 456.80 0.00 0.00<br />

26180 S 536.02 0.00 0.00 26479 S 456.80 0.00 0.00<br />

26185 S 589.73 0.00 0.00 26480 S 746.99 0.00 0.00<br />

26200 S 507.38 0.00 0.00 26483 S 746.99 0.00 0.00<br />

26205 S 746.99 0.00 0.00 26485 S 718.34 0.00 0.00<br />

26210 S 507.38 0.00 0.00 26489 S 746.99 0.00 0.00<br />

26215 S 536.02 0.00 0.00 26490 S 746.99 0.00 0.00<br />

26230 S 752.17 0.00 0.00 26492 S 746.99 0.00 0.00<br />

26235 S 536.02 0.00 0.00 26494 S 746.99 0.00 0.00<br />

26236 S 536.02 0.00 0.00 26496 S 746.99 0.00 0.00<br />

26250 S 536.02 0.00 0.00 26497 S 746.99 0.00 0.00<br />

26255 S 746.99 0.00 0.00 26498 S 800.70 0.00 0.00<br />

26260 S 536.02 0.00 0.00 26499 S 746.99 0.00 0.00<br />

26261 S 536.02 0.00 0.00 26500 S 589.73 0.00 0.00<br />

26262 S 507.38 0.00 0.00 26502 S 800.70 0.00 0.00<br />

26320 S 494.13 0.00 0.00 26508 S 536.02 0.00 0.00<br />

26340 S 227.79 0.00 0.00 26510 S 746.99 0.00 0.00<br />

26350 S 667.76 0.00 0.00 26516 S 667.76 0.00 0.00<br />

26352 S 800.70 0.00 0.00 26517 S 746.99 0.00 0.00<br />

26356 S 800.70 0.00 0.00 26518 S 746.99 0.00 0.00<br />

26357 S 800.70 0.00 0.00 26520 S 536.02 0.00 0.00<br />

26358 S 800.70 0.00 0.00 26525 S 536.02 0.00 0.00<br />

26370 S 800.70 0.00 0.00 26530 S 929.14 0.00 0.00<br />

26372 S 800.70 0.00 0.00 26531 S 1,430.25 0.00 0.00<br />

26373 S 746.99 0.00 0.00 26535 S 1,021.78 0.00 0.00<br />

26390 S 800.70 0.00 0.00 26536 S 1,305.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 589.73 0.00 0.00 26775 S 158.26 0.00 0.00<br />

26541 S 964.06 0.00 0.00 26776 S 671.00 0.00 0.00<br />

26542 S 589.73 0.00 0.00 26785 S 671.00 0.00 0.00<br />

26545 S 800.70 0.00 0.00 26820 S 839.63 0.00 0.00<br />

26546 S 800.70 0.00 0.00 26841 S 800.70 0.00 0.00<br />

26548 S 800.70 0.00 0.00 26842 S 800.70 0.00 0.00<br />

26550 S 718.34 0.00 0.00 26843 S 746.99 0.00 0.00<br />

26555 S 746.99 0.00 0.00 26844 S 746.99 0.00 0.00<br />

26560 S 507.38 0.00 0.00 26850 S 800.70 0.00 0.00<br />

26561 S 746.99 0.00 0.00 26852 S 800.70 0.00 0.00<br />

26562 S 800.70 0.00 0.00 26860 S 746.99 0.00 0.00<br />

26565 S 839.63 0.00 0.00 26861 S 718.34 0.00 0.00<br />

26567 S 839.63 0.00 0.00 26862 S 800.70 0.00 0.00<br />

26568 S 746.99 0.00 0.00 26863 S 746.99 0.00 0.00<br />

26580 S 628.66 0.00 0.00 26910 S 746.99 0.00 0.00<br />

26587 S 628.66 0.00 0.00 26951 S 507.38 0.00 0.00<br />

26590 S 628.66 0.00 0.00 26952 S 589.73 0.00 0.00<br />

26591 S 746.99 0.00 0.00 26990 S 552.56 0.00 0.00<br />

26593 S 536.02 0.00 0.00 26991 S 552.56 0.00 0.00<br />

26596 S 507.38 0.00 0.00 27000 S 603.14 0.00 0.00<br />

26600 S 59.20 0.00 0.00 27001 S 781.86 0.00 0.00<br />

26605 S 75.97 0.00 0.00 27003 S 781.86 0.00 0.00<br />

26607 S 414.54 0.00 0.00 27033 S 1,068.49 0.00 0.00<br />

26608 S 753.36 0.00 0.00 27035 S 1,122.20 0.00 0.00<br />

26615 S 1,076.12 0.00 0.00 27040 S 302.00 0.00 0.00<br />

26641 S 59.20 0.00 0.00 27041 S 340.27 0.00 0.00<br />

26645 S 160.27 0.00 0.00 27047 S 604.28 0.00 0.00<br />

26650 S 671.00 0.00 0.00 27048 S 632.93 0.00 0.00<br />

26665 S 1,076.12 0.00 0.00 27049 S 632.93 0.00 0.00<br />

26670 S 59.20 0.00 0.00 27050 S 631.79 0.00 0.00<br />

26675 S 160.27 0.00 0.00 27052 S 631.79 0.00 0.00<br />

26676 S 671.00 0.00 0.00 27060 S 724.43 0.00 0.00<br />

26685 S 699.65 0.00 0.00 27062 S 724.43 0.00 0.00<br />

26686 S 1,387.44 0.00 0.00 27065 S 724.43 0.00 0.00<br />

26700 S 59.20 0.00 0.00 27066 S 874.51 0.00 0.00<br />

26705 S 75.97 0.00 0.00 27067 S 874.51 0.00 0.00<br />

26706 S 414.54 0.00 0.00 27080 S 753.21 0.00 0.00<br />

26715 S 753.36 0.00 0.00 27086 S 302.00 0.00 0.00<br />

26720 S 59.20 0.00 0.00 27087 S 631.79 0.00 0.00<br />

26725 S 59.20 0.00 0.00 27097 S 781.86 0.00 0.00<br />

26727 S 916.72 0.00 0.00 27098 S 781.86 0.00 0.00<br />

26735 S 753.36 0.00 0.00 27100 S 1,122.20 0.00 0.00<br />

26740 S 59.20 0.00 0.00 27105 S 1,122.20 0.00 0.00<br />

26742 S 75.97 0.00 0.00 27110 S 1,122.20 0.00 0.00<br />

26746 S 792.30 0.00 0.00 27111 S 1,122.20 0.00 0.00<br />

26750 S 59.20 0.00 0.00 27193 S 75.97 0.00 0.00<br />

26755 S 59.20 0.00 0.00 27194 S 488.02 0.00 0.00<br />

26756 S 671.00 0.00 0.00 27200 S 59.20 0.00 0.00<br />

26765 S 753.36 0.00 0.00 27202 S 993.76 0.00 0.00<br />

26770 S 59.20 0.00 0.00 27220 S 59.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 75.97 0.00 0.00 27397 S 1,068.49 0.00 0.00<br />

27238 S 160.27 0.00 0.00 27400 S 1,068.49 0.00 0.00<br />

27246 S 160.27 0.00 0.00 27403 S 835.56 0.00 0.00<br />

27250 S 75.97 0.00 0.00 27405 S 1,122.20 0.00 0.00<br />

27252 S 488.02 0.00 0.00 27407 S 1,886.27 0.00 0.00<br />

27256 S 59.20 0.00 0.00 27409 S 1,122.20 0.00 0.00<br />

27257 S 516.67 0.00 0.00 27416 S 1,680.46 0.00 0.00<br />

27265 S 75.97 0.00 0.00 27418 S 1,068.49 0.00 0.00<br />

27266 S 488.02 0.00 0.00 27420 S 1,068.49 0.00 0.00<br />

27267 S 59.20 0.00 0.00 27422 S 1,285.56 0.00 0.00<br />

27275 S 488.02 0.00 0.00 27424 S 1,068.49 0.00 0.00<br />

27301 S 587.44 0.00 0.00 27425 S 998.93 0.00 0.00<br />

27305 S 603.14 0.00 0.00 27427 S 1,068.49 0.00 0.00<br />

27306 S 631.79 0.00 0.00 27428 S 1,886.27 0.00 0.00<br />

27307 S 631.79 0.00 0.00 27429 S 1,886.27 0.00 0.00<br />

27310 S 835.56 0.00 0.00 27430 S 1,122.20 0.00 0.00<br />

27323 S 302.00 0.00 0.00 27435 S 1,122.20 0.00 0.00<br />

27324 S 553.71 0.00 0.00 27437 S 982.84 0.00 0.00<br />

27325 S 542.56 0.00 0.00 27438 S 1,305.83 0.00 0.00<br />

27326 S 542.56 0.00 0.00 27440 S 1,401.74 0.00 0.00<br />

27327 S 604.28 0.00 0.00 27441 S 1,021.78 0.00 0.00<br />

27328 S 632.93 0.00 0.00 27442 S 1,021.78 0.00 0.00<br />

27329 S 686.64 0.00 0.00 27443 S 1,021.78 0.00 0.00<br />

27330 S 835.56 0.00 0.00 27446 S 10,025.63 6,022.94 2,020.25<br />

27331 S 835.56 0.00 0.00 27496 S 724.43 0.00 0.00<br />

27332 S 835.56 0.00 0.00 27497 S 631.79 0.00 0.00<br />

27333 S 835.56 0.00 0.00 27498 S 631.79 0.00 0.00<br />

27334 S 835.56 0.00 0.00 27499 S 631.79 0.00 0.00<br />

27335 S 835.56 0.00 0.00 27500 S 160.27 0.00 0.00<br />

27340 S 631.79 0.00 0.00 27501 S 75.97 0.00 0.00<br />

27345 S 685.49 0.00 0.00 27502 S 414.54 0.00 0.00<br />

27347 S 685.49 0.00 0.00 27503 S 75.97 0.00 0.00<br />

27350 S 835.56 0.00 0.00 27508 S 75.97 0.00 0.00<br />

27355 S 781.86 0.00 0.00 27509 S 699.65 0.00 0.00<br />

27356 S 835.56 0.00 0.00 27510 S 160.27 0.00 0.00<br />

27357 S 874.51 0.00 0.00 27516 S 75.97 0.00 0.00<br />

27358 S 874.51 0.00 0.00 27517 S 75.97 0.00 0.00<br />

27360 S 874.51 0.00 0.00 27520 S 75.97 0.00 0.00<br />

27372 S 850.00 0.00 0.00 27530 S 75.97 0.00 0.00<br />

27380 S 552.56 0.00 0.00 27532 S 414.54 0.00 0.00<br />

27381 S 631.79 0.00 0.00 27538 S 75.97 0.00 0.00<br />

27385 S 631.79 0.00 0.00 27550 S 75.97 0.00 0.00<br />

27386 S 631.79 0.00 0.00 27552 S 437.45 0.00 0.00<br />

27390 S 552.56 0.00 0.00 27560 S 75.97 0.00 0.00<br />

27391 S 603.14 0.00 0.00 27562 S 437.45 0.00 0.00<br />

27392 S 631.79 0.00 0.00 27566 S 993.76 0.00 0.00<br />

27393 S 753.21 0.00 0.00 27570 S 437.45 0.00 0.00<br />

27394 S 781.86 0.00 0.00 27594 S 631.79 0.00 0.00<br />

27395 S 1,068.49 0.00 0.00 27600 S 631.79 0.00 0.00<br />

27396 S 781.86 0.00 0.00 27601 S 631.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 631.79 0.00 0.00 27730 S 753.21 0.00 0.00<br />

27603 S 558.80 0.00 0.00 27732 S 753.21 0.00 0.00<br />

27604 S 603.14 0.00 0.00 27734 S 753.21 0.00 0.00<br />

27605 S 549.60 0.00 0.00 27740 S 753.21 0.00 0.00<br />

27606 S 552.56 0.00 0.00 27742 S 1,039.85 0.00 0.00<br />

27607 S 603.14 0.00 0.00 27745 S 1,832.57 0.00 0.00<br />

27610 S 753.21 0.00 0.00 27750 S 75.97 0.00 0.00<br />

27612 S 781.86 0.00 0.00 27752 S 414.54 0.00 0.00<br />

27613 S 124.16 0.00 0.00 27756 S 699.65 0.00 0.00<br />

27614 S 604.28 0.00 0.00 27758 S 1,076.12 0.00 0.00<br />

27615 S 781.86 0.00 0.00 27759 S 1,441.14 0.00 0.00<br />

27618 S 494.13 0.00 0.00 27760 S 75.97 0.00 0.00<br />

27619 S 632.93 0.00 0.00 27762 S 414.54 0.00 0.00<br />

27620 S 835.56 0.00 0.00 27766 S 1,022.40 0.00 0.00<br />

27625 S 835.56 0.00 0.00 27767 S 59.20 0.00 0.00<br />

27626 S 835.56 0.00 0.00 27768 S 59.20 0.00 0.00<br />

27630 S 631.79 0.00 0.00 27769 S 1,588.28 0.00 0.00<br />

27635 S 781.86 0.00 0.00 27780 S 75.97 0.00 0.00<br />

27637 S 781.86 0.00 0.00 27781 S 414.54 0.00 0.00<br />

27638 S 781.86 0.00 0.00 27784 S 1,022.40 0.00 0.00<br />

27640 S 1,039.85 0.00 0.00 27786 S 75.97 0.00 0.00<br />

27641 S 753.21 0.00 0.00 27788 S 75.97 0.00 0.00<br />

27647 S 1,068.49 0.00 0.00 27792 S 1,022.40 0.00 0.00<br />

27650 S 1,068.49 0.00 0.00 27808 S 75.97 0.00 0.00<br />

27652 S 1,832.57 0.00 0.00 27810 S 160.27 0.00 0.00<br />

27654 S 1,068.49 0.00 0.00 27814 S 1,022.40 0.00 0.00<br />

27656 S 603.14 0.00 0.00 27816 S 75.97 0.00 0.00<br />

27658 S 552.56 0.00 0.00 27818 S 160.27 0.00 0.00<br />

27659 S 603.14 0.00 0.00 27822 S 1,022.40 0.00 0.00<br />

27664 S 603.14 0.00 0.00 27823 S 1,387.44 0.00 0.00<br />

27665 S 753.21 0.00 0.00 27824 S 75.97 0.00 0.00<br />

27675 S 603.14 0.00 0.00 27825 S 414.54 0.00 0.00<br />

27676 S 781.86 0.00 0.00 27826 S 1,022.40 0.00 0.00<br />

27680 S 781.86 0.00 0.00 27827 S 1,387.44 0.00 0.00<br />

27681 S 753.21 0.00 0.00 27828 S 1,441.14 0.00 0.00<br />

27685 S 781.86 0.00 0.00 27829 S 993.76 0.00 0.00<br />

27686 S 781.86 0.00 0.00 27830 S 75.97 0.00 0.00<br />

27687 S 781.86 0.00 0.00 27831 S 414.54 0.00 0.00<br />

27690 S 1,122.20 0.00 0.00 27832 S 993.76 0.00 0.00<br />

27691 S 1,122.20 0.00 0.00 27840 S 160.27 0.00 0.00<br />

27692 S 1,068.49 0.00 0.00 27842 S 437.45 0.00 0.00<br />

27695 S 753.21 0.00 0.00 27846 S 1,022.40 0.00 0.00<br />

27696 S 753.21 0.00 0.00 27848 S 1,022.40 0.00 0.00<br />

27698 S 753.21 0.00 0.00 27860 S 437.45 0.00 0.00<br />

27700 S 1,021.78 0.00 0.00 27870 S 1,886.27 0.00 0.00<br />

27704 S 603.14 0.00 0.00 27871 S 1,886.27 0.00 0.00<br />

27705 S 1,039.85 0.00 0.00 27884 S 631.79 0.00 0.00<br />

27707 S 603.14 0.00 0.00 27889 S 781.86 0.00 0.00<br />

27709 S 753.21 0.00 0.00 27892 S 631.79 0.00 0.00<br />

27726 S 942.78 0.00 0.00 27893 S 631.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 631.79 0.00 0.00 28153 S 628.82 0.00 0.00<br />

28001 S 121.18 0.00 0.00 28160 S 628.82 0.00 0.00<br />

28002 S 631.79 0.00 0.00 28171 S 628.82 0.00 0.00<br />

28003 S 631.79 0.00 0.00 28173 S 628.82 0.00 0.00<br />

28005 S 628.82 0.00 0.00 28175 S 628.82 0.00 0.00<br />

28008 S 628.82 0.00 0.00 28190 S 125.15 0.00 0.00<br />

28010 S 89.06 0.00 0.00 28192 S 494.13 0.00 0.00<br />

28011 S 628.82 0.00 0.00 28193 S 340.27 0.00 0.00<br />

28020 S 600.17 0.00 0.00 28200 S 628.82 0.00 0.00<br />

28022 S 600.17 0.00 0.00 28202 S 628.82 0.00 0.00<br />

28024 S 600.17 0.00 0.00 28208 S 628.82 0.00 0.00<br />

28035 S 624.91 0.00 0.00 28210 S 1,104.40 0.00 0.00<br />

28043 S 604.28 0.00 0.00 28220 S 193.03 0.00 0.00<br />

28045 S 628.82 0.00 0.00 28222 S 549.60 0.00 0.00<br />

28046 S 628.82 0.00 0.00 28225 S 549.60 0.00 0.00<br />

28050 S 600.17 0.00 0.00 28226 S 549.60 0.00 0.00<br />

28052 S 600.17 0.00 0.00 28230 S 189.38 0.00 0.00<br />

28054 S 600.17 0.00 0.00 28232 S 181.10 0.00 0.00<br />

28055 S 624.91 0.00 0.00 28234 S 600.17 0.00 0.00<br />

28060 S 600.17 0.00 0.00 28238 S 1,104.40 0.00 0.00<br />

28062 S 628.82 0.00 0.00 28240 S 600.17 0.00 0.00<br />

28070 S 628.82 0.00 0.00 28250 S 628.82 0.00 0.00<br />

28072 S 628.82 0.00 0.00 28260 S 628.82 0.00 0.00<br />

28080 S 628.82 0.00 0.00 28261 S 628.82 0.00 0.00<br />

28086 S 600.17 0.00 0.00 28262 S 682.52 0.00 0.00<br />

28088 S 600.17 0.00 0.00 28264 S 1,025.18 0.00 0.00<br />

28090 S 628.82 0.00 0.00 28270 S 628.82 0.00 0.00<br />

28092 S 628.82 0.00 0.00 28272 S 174.81 0.00 0.00<br />

28100 S 600.17 0.00 0.00 28280 S 600.17 0.00 0.00<br />

28102 S 1,104.40 0.00 0.00 28285 S 628.82 0.00 0.00<br />

28103 S 1,104.40 0.00 0.00 28286 S 682.52 0.00 0.00<br />

28104 S 600.17 0.00 0.00 28288 S 628.82 0.00 0.00<br />

28106 S 1,104.40 0.00 0.00 28289 S 628.82 0.00 0.00<br />

28107 S 1,104.40 0.00 0.00 28290 S 775.10 0.00 0.00<br />

28108 S 600.17 0.00 0.00 28292 S 775.10 0.00 0.00<br />

28110 S 628.82 0.00 0.00 28293 S 803.75 0.00 0.00<br />

28111 S 628.82 0.00 0.00 28294 S 803.75 0.00 0.00<br />

28112 S 628.82 0.00 0.00 28296 S 803.75 0.00 0.00<br />

28113 S 628.82 0.00 0.00 28297 S 803.75 0.00 0.00<br />

28114 S 628.82 0.00 0.00 28298 S 803.75 0.00 0.00<br />

28116 S 628.82 0.00 0.00 28299 S 896.39 0.00 0.00<br />

28118 S 682.52 0.00 0.00 28300 S 1,075.76 0.00 0.00<br />

28119 S 682.52 0.00 0.00 28302 S 600.17 0.00 0.00<br />

28120 S 845.89 0.00 0.00 28304 S 1,075.76 0.00 0.00<br />

28122 S 628.82 0.00 0.00 28305 S 1,104.40 0.00 0.00<br />

28124 S 204.94 0.00 0.00 28306 S 682.52 0.00 0.00<br />

28126 S 628.82 0.00 0.00 28307 S 682.52 0.00 0.00<br />

28130 S 628.82 0.00 0.00 28308 S 600.17 0.00 0.00<br />

28140 S 628.82 0.00 0.00 28309 S 1,158.11 0.00 0.00<br />

28150 S 628.82 0.00 0.00 28310 S 628.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 628.82 0.00 0.00 28636 S 699.65 0.00 0.00<br />

28313 S 600.17 0.00 0.00 28645 S 699.65 0.00 0.00<br />

28315 S 682.52 0.00 0.00 28660 S 42.38 0.00 0.00<br />

28320 S 1,158.11 0.00 0.00 28665 S 437.45 0.00 0.00<br />

28322 S 1,158.11 0.00 0.00 28666 S 699.65 0.00 0.00<br />

28340 S 682.52 0.00 0.00 28675 S 699.65 0.00 0.00<br />

28341 S 682.52 0.00 0.00 28705 S 1,158.11 0.00 0.00<br />

28344 S 682.52 0.00 0.00 28715 S 1,886.27 0.00 0.00<br />

28345 S 682.52 0.00 0.00 28725 S 1,158.11 0.00 0.00<br />

28400 S 75.97 0.00 0.00 28730 S 1,158.11 0.00 0.00<br />

28405 S 414.54 0.00 0.00 28735 S 1,158.11 0.00 0.00<br />

28406 S 671.00 0.00 0.00 28737 S 1,197.04 0.00 0.00<br />

28415 S 1,387.44 0.00 0.00 28740 S 1,158.11 0.00 0.00<br />

28420 S 1,076.12 0.00 0.00 28750 S 1,158.11 0.00 0.00<br />

28430 S 59.20 0.00 0.00 28755 S 682.52 0.00 0.00<br />

28435 S 75.97 0.00 0.00 28760 S 1,158.11 0.00 0.00<br />

28436 S 671.00 0.00 0.00 28810 S 600.17 0.00 0.00<br />

28445 S 1,022.40 0.00 0.00 28820 S 600.17 0.00 0.00<br />

28446 S 1,752.28 0.00 0.00 28825 S 600.17 0.00 0.00<br />

28450 S 59.20 0.00 0.00 28890 S 158.59 0.00 0.00<br />

28455 S 59.20 0.00 0.00 29000 S 40.18 0.00 0.00<br />

28456 S 671.00 0.00 0.00 29010 S 90.06 0.00 0.00<br />

28465 S 1,022.40 0.00 0.00 29015 S 90.06 0.00 0.00<br />

28470 S 59.20 0.00 0.00 29020 S 40.18 0.00 0.00<br />

28475 S 59.20 0.00 0.00 29025 S 40.18 0.00 0.00<br />

28476 S 671.00 0.00 0.00 29035 S 90.06 0.00 0.00<br />

28485 S 1,076.12 0.00 0.00 29040 S 40.18 0.00 0.00<br />

28490 S 59.20 0.00 0.00 29044 S 90.06 0.00 0.00<br />

28495 S 59.20 0.00 0.00 29046 S 90.06 0.00 0.00<br />

28496 S 671.00 0.00 0.00 29049 S 36.42 0.00 0.00<br />

28505 S 699.65 0.00 0.00 29055 S 90.06 0.00 0.00<br />

28510 S 53.31 0.00 0.00 29058 S 40.18 0.00 0.00<br />

28515 S 59.20 0.00 0.00 29065 S 42.71 0.00 0.00<br />

28525 S 699.65 0.00 0.00 29075 S 41.05 0.00 0.00<br />

28530 S 51.32 0.00 0.00 29085 S 40.18 0.00 0.00<br />

28531 S 699.65 0.00 0.00 29086 S 34.43 0.00 0.00<br />

28540 S 59.20 0.00 0.00 29105 S 37.08 0.00 0.00<br />

28545 S 620.43 0.00 0.00 29125 S 32.11 0.00 0.00<br />

28546 S 671.00 0.00 0.00 29126 S 34.10 0.00 0.00<br />

28555 S 993.76 0.00 0.00 29130 S 14.57 0.00 0.00<br />

28570 S 76.81 0.00 0.00 29131 S 21.19 0.00 0.00<br />

28575 S 414.54 0.00 0.00 29200 S 20.53 0.00 0.00<br />

28576 S 699.65 0.00 0.00 29220 S 22.18 0.00 0.00<br />

28585 S 699.65 0.00 0.00 29240 S 23.18 0.00 0.00<br />

28600 S 59.20 0.00 0.00 29260 S 22.18 0.00 0.00<br />

28605 S 75.97 0.00 0.00 29280 S 22.52 0.00 0.00<br />

28606 S 671.00 0.00 0.00 29305 S 90.06 0.00 0.00<br />

28615 S 1,022.40 0.00 0.00 29325 S 90.06 0.00 0.00<br />

28630 S 59.20 0.00 0.00 29345 S 55.95 0.00 0.00<br />

28635 S 437.45 0.00 0.00 29355 S 54.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 68.21 0.00 0.00 29847 S 1,140.04 0.00 0.00<br />

29365 S 52.98 0.00 0.00 29848 S 1,144.24 0.00 0.00<br />

29405 S 39.40 0.00 0.00 29850 S 826.92 0.00 0.00<br />

29425 S 40.06 0.00 0.00 29851 S 1,193.75 0.00 0.00<br />

29435 S 50.66 0.00 0.00 29855 S 1,193.75 0.00 0.00<br />

29440 S 21.52 0.00 0.00 29856 S 1,193.75 0.00 0.00<br />

29445 S 53.31 0.00 0.00 29860 S 1,193.75 0.00 0.00<br />

29450 S 40.18 0.00 0.00 29861 S 1,193.75 0.00 0.00<br />

29505 S 35.76 0.00 0.00 29862 S 1,511.07 0.00 0.00<br />

29515 S 30.46 0.00 0.00 29863 S 1,193.75 0.00 0.00<br />

29520 S 21.85 0.00 0.00 29866 S 1,823.55 0.00 0.00<br />

29530 S 22.18 0.00 0.00 29870 S 773.21 0.00 0.00<br />

29540 S 16.55 0.00 0.00 29871 S 773.21 0.00 0.00<br />

29550 S 16.88 0.00 0.00 29873 S 773.21 0.00 0.00<br />

29580 S 22.85 0.00 0.00 29874 S 773.21 0.00 0.00<br />

29590 S 18.54 0.00 0.00 29875 S 826.92 0.00 0.00<br />

29700 S 30.79 0.00 0.00 29876 S 826.92 0.00 0.00<br />

29705 S 26.15 0.00 0.00 29877 S 826.92 0.00 0.00<br />

29710 S 46.02 0.00 0.00 29879 S 773.21 0.00 0.00<br />

29715 S 40.18 0.00 0.00 29880 S 826.92 0.00 0.00<br />

29720 S 38.41 0.00 0.00 29881 S 826.92 0.00 0.00<br />

29730 S 25.16 0.00 0.00 29882 S 773.21 0.00 0.00<br />

29740 S 34.43 0.00 0.00 29883 S 773.21 0.00 0.00<br />

29750 S 36.09 0.00 0.00 29884 S 773.21 0.00 0.00<br />

29800 S 773.21 0.00 0.00 29885 S 1,140.04 0.00 0.00<br />

29804 S 773.21 0.00 0.00 29886 S 773.21 0.00 0.00<br />

29805 S 773.21 0.00 0.00 29887 S 773.21 0.00 0.00<br />

29806 S 1,140.04 0.00 0.00 29888 S 1,140.04 0.00 0.00<br />

29807 S 1,140.04 0.00 0.00 29889 S 1,140.04 0.00 0.00<br />

29819 S 1,140.04 0.00 0.00 29891 S 1,140.04 0.00 0.00<br />

29820 S 1,140.04 0.00 0.00 29892 S 1,140.04 0.00 0.00<br />

29821 S 1,140.04 0.00 0.00 29893 S 962.50 0.00 0.00<br />

29822 S 773.21 0.00 0.00 29894 S 773.21 0.00 0.00<br />

29823 S 1,140.04 0.00 0.00 29895 S 773.21 0.00 0.00<br />

29824 S 865.86 0.00 0.00 29897 S 773.21 0.00 0.00<br />

29825 S 1,140.04 0.00 0.00 29898 S 773.21 0.00 0.00<br />

29826 S 1,140.04 0.00 0.00 29899 S 1,140.04 0.00 0.00<br />

29827 S 1,232.68 0.00 0.00 29900 S 773.21 0.00 0.00<br />

29828 S 1,823.55 0.00 0.00 29901 S 773.21 0.00 0.00<br />

29830 S 773.21 0.00 0.00 29902 S 773.21 0.00 0.00<br />

29834 S 773.21 0.00 0.00 29904 S 1,089.90 0.00 0.00<br />

29835 S 773.21 0.00 0.00 29905 S 1,089.90 0.00 0.00<br />

29836 S 773.21 0.00 0.00 29906 S 1,089.90 0.00 0.00<br />

29837 S 773.21 0.00 0.00 29907 S 1,823.55 0.00 0.00<br />

29838 S 773.21 0.00 0.00 30000 S 122.53 0.00 0.00<br />

29840 S 773.21 0.00 0.00 30020 S 122.53 0.00 0.00<br />

29843 S 773.21 0.00 0.00 30100 S 79.46 0.00 0.00<br />

29844 S 773.21 0.00 0.00 30110 S 122.84 0.00 0.00<br />

29845 S 773.21 0.00 0.00 30115 S 519.01 0.00 0.00<br />

29846 S 773.21 0.00 0.00 30117 S 547.66 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 686.89 0.00 0.00 31080 S 1,057.74 0.00 0.00<br />

30120 S 468.44 0.00 0.00 31081 S 1,057.74 0.00 0.00<br />

30124 S 279.12 0.00 0.00 31084 S 1,057.74 0.00 0.00<br />

30125 S 975.38 0.00 0.00 31085 S 1,057.74 0.00 0.00<br />

30130 S 547.66 0.00 0.00 31086 S 1,057.74 0.00 0.00<br />

30140 S 658.24 0.00 0.00 31087 S 1,057.74 0.00 0.00<br />

30150 S 1,004.03 0.00 0.00 31090 S 1,096.68 0.00 0.00<br />

30160 S 1,057.74 0.00 0.00 31200 S 975.38 0.00 0.00<br />

30200 S 62.58 0.00 0.00 31201 S 1,096.68 0.00 0.00<br />

30210 S 79.46 0.00 0.00 31205 S 1,004.03 0.00 0.00<br />

30220 S 347.30 0.00 0.00 31231 S 66.99 0.00 0.00<br />

30300 S 23.94 0.00 0.00 31233 S 72.15 0.00 0.00<br />

30310 S 468.44 0.00 0.00 31235 S 490.22 0.00 0.00<br />

30320 S 519.01 0.00 0.00 31237 S 540.79 0.00 0.00<br />

30400 S 1,057.74 0.00 0.00 31238 S 490.22 0.00 0.00<br />

30410 S 1,096.68 0.00 0.00 31239 S 715.57 0.00 0.00<br />

30420 S 1,096.68 0.00 0.00 31240 S 540.79 0.00 0.00<br />

30430 S 686.89 0.00 0.00 31254 S 661.86 0.00 0.00<br />

30435 S 1,096.68 0.00 0.00 31255 S 754.50 0.00 0.00<br />

30450 S 1,221.11 0.00 0.00 31256 S 661.86 0.00 0.00<br />

30460 S 1,221.11 0.00 0.00 31267 S 661.86 0.00 0.00<br />

30462 S 1,375.06 0.00 0.00 31276 S 661.86 0.00 0.00<br />

30465 S 1,375.06 0.00 0.00 31287 S 661.86 0.00 0.00<br />

30520 S 740.60 0.00 0.00 31288 S 661.86 0.00 0.00<br />

30540 S 1,096.68 0.00 0.00 31300 S 779.54 0.00 0.00<br />

30545 S 1,096.68 0.00 0.00 31320 S 975.38 0.00 0.00<br />

30560 S 128.72 0.00 0.00 31400 S 975.38 0.00 0.00<br />

30580 S 1,057.74 0.00 0.00 31420 S 975.38 0.00 0.00<br />

30600 S 1,057.74 0.00 0.00 31500 S 89.60 0.00 0.00<br />

30620 S 1,221.11 0.00 0.00 31502 S 51.52 0.00 0.00<br />

30630 S 903.96 0.00 0.00 31505 S 30.44 0.00 0.00<br />

30801 S 288.60 0.00 0.00 31510 S 540.79 0.00 0.00<br />

30802 S 288.60 0.00 0.00 31511 S 72.15 0.00 0.00<br />

30901 S 41.16 0.00 0.00 31512 S 540.79 0.00 0.00<br />

30903 S 53.02 0.00 0.00 31513 S 72.15 0.00 0.00<br />

30905 S 53.02 0.00 0.00 31515 S 490.22 0.00 0.00<br />

30906 S 53.02 0.00 0.00 31520 S 66.99 0.00 0.00<br />

30915 S 706.52 0.00 0.00 31525 S 490.22 0.00 0.00<br />

30920 S 735.17 0.00 0.00 31526 S 633.22 0.00 0.00<br />

30930 S 601.36 0.00 0.00 31527 S 582.64 0.00 0.00<br />

31000 S 102.31 0.00 0.00 31528 S 540.79 0.00 0.00<br />

31002 S 279.12 0.00 0.00 31529 S 540.79 0.00 0.00<br />

31020 S 658.24 0.00 0.00 31530 S 633.22 0.00 0.00<br />

31030 S 1,004.03 0.00 0.00 31531 S 661.86 0.00 0.00<br />

31032 S 1,057.74 0.00 0.00 31535 S 633.22 0.00 0.00<br />

31040 S 917.27 0.00 0.00 31536 S 661.86 0.00 0.00<br />

31050 S 975.38 0.00 0.00 31540 S 661.86 0.00 0.00<br />

31051 S 1,057.74 0.00 0.00 31541 S 715.57 0.00 0.00<br />

31070 S 658.24 0.00 0.00 31545 S 715.57 0.00 0.00<br />

31075 S 1,057.74 0.00 0.00 31546 S 715.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 754.50 0.00 0.00 32405 S 326.50 0.00 0.00<br />

31561 S 754.50 0.00 0.00 32420 S 198.54 0.00 0.00<br />

31570 S 540.79 0.00 0.00 32421 S 198.54 0.00 0.00<br />

31571 S 633.22 0.00 0.00 32422 S 197.65 0.00 0.00<br />

31575 S 57.61 0.00 0.00 32550 S 1,106.65 0.00 0.00<br />

31576 S 633.22 0.00 0.00 32960 S 197.65 0.00 0.00<br />

31577 S 187.05 0.00 0.00 32998 S 1,722.99 0.00 0.00<br />

31578 S 633.22 0.00 0.00 33010 S 198.54 0.00 0.00<br />

31579 S 102.64 0.00 0.00 33011 S 198.54 0.00 0.00<br />

31580 S 1,096.68 0.00 0.00 33206 S 6,369.78 3,790.00 1,210.23<br />

31582 S 1,096.68 0.00 0.00 33207 S 6,369.78 3,790.00 1,210.23<br />

31588 S 1,096.68 0.00 0.00 33208 S 7,900.34 4,603.49 1,306.64<br />

31590 S 1,096.68 0.00 0.00 33210 S 1,870.51 0.00 0.00<br />

31595 S 975.38 0.00 0.00 33211 S 1,870.51 0.00 0.00<br />

31603 S 288.60 0.00 0.00 33212 S 5,002.55 2,849.74 696.93<br />

31605 S 279.12 0.00 0.00 33213 S 5,774.02 3,235.06 696.10<br />

31611 S 686.89 0.00 0.00 33214 S 7,900.34 4,603.49 1,306.64<br />

31612 S 607.67 0.00 0.00 33215 S 819.87 0.00 0.00<br />

31613 S 658.24 0.00 0.00 33216 S 1,870.51 0.00 0.00<br />

31614 S 975.38 0.00 0.00 33217 S 1,870.51 0.00 0.00<br />

31615 S 288.60 0.00 0.00 33218 S 819.87 0.00 0.00<br />

31622 S 338.00 0.00 0.00 33220 S 819.87 0.00 0.00<br />

31623 S 388.57 0.00 0.00 33222 S 495.57 0.00 0.00<br />

31624 S 388.57 0.00 0.00 33223 S 495.57 0.00 0.00<br />

31625 S 388.57 0.00 0.00 33224 S 7,457.18 4,464.59 1,472.01<br />

31628 S 388.57 0.00 0.00 33225 S 7,457.18 4,464.59 1,472.01<br />

31629 S 388.57 0.00 0.00 33226 S 819.87 0.00 0.00<br />

31630 S 665.85 0.00 0.00 33233 S 609.55 0.00 0.00<br />

31631 S 665.85 0.00 0.00 33234 S 819.87 0.00 0.00<br />

31632 S 377.91 0.00 0.00 33235 S 819.87 0.00 0.00<br />

31633 S 377.91 0.00 0.00 33240 S 18,588.85 9,936.50 1,284.15<br />

31635 S 388.57 0.00 0.00 33241 S 819.87 0.00 0.00<br />

31636 S 665.85 0.00 0.00 33249 S 24,808.23 13,288.32 1,768.40<br />

31637 S 338.00 0.00 0.00 33282 S 3,922.34 2,348.14 773.95<br />

31638 S 665.85 0.00 0.00 33284 S 305.93 0.00 0.00<br />

31640 S 665.85 0.00 0.00 34490 S 1,493.65 0.00 0.00<br />

31641 S 665.85 0.00 0.00 35188 S 1,028.79 0.00 0.00<br />

31643 S 388.57 0.00 0.00 35207 S 1,028.79 0.00 0.00<br />

31645 S 338.00 0.00 0.00 35473 S 1,791.81 0.00 0.00<br />

31646 S 338.00 0.00 0.00 35476 S 1,791.81 0.00 0.00<br />

31656 S 338.00 0.00 0.00 35492 S 3,344.23 0.00 0.00<br />

31717 S 187.05 0.00 0.00 35761 S 1,075.80 0.00 0.00<br />

31720 S 28.64 0.00 0.00 35875 S 1,346.12 0.00 0.00<br />

31730 S 187.05 0.00 0.00 35876 S 1,346.12 0.00 0.00<br />

31750 S 1,096.68 0.00 0.00 36002 S 85.92 0.00 0.00<br />

31755 S 975.38 0.00 0.00 36260 S 779.37 0.00 0.00<br />

31820 S 468.44 0.00 0.00 36261 S 609.55 0.00 0.00<br />

31825 S 658.24 0.00 0.00 36262 S 558.97 0.00 0.00<br />

31830 S 658.24 0.00 0.00 36420 S 8.10 0.00 0.00<br />

32400 S 326.50 0.00 0.00 36425 S 8.10 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 31.12 0.00 0.00 36800 S 839.00 0.00 0.00<br />

36440 S 124.29 0.00 0.00 36810 S 839.00 0.00 0.00<br />

36450 S 124.29 0.00 0.00 36815 S 839.00 0.00 0.00<br />

36455 S 124.29 0.00 0.00 36818 S 975.09 0.00 0.00<br />

36468 S 30.68 0.00 0.00 36819 S 975.09 0.00 0.00<br />

36469 S 30.68 0.00 0.00 36820 S 975.09 0.00 0.00<br />

36470 S 30.68 0.00 0.00 36821 S 975.09 0.00 0.00<br />

36471 S 30.68 0.00 0.00 36825 S 1,028.79 0.00 0.00<br />

36475 S 1,410.60 0.00 0.00 36830 S 1,028.79 0.00 0.00<br />

36476 S 1,106.20 0.00 0.00 36831 S 1,346.12 0.00 0.00<br />

36478 S 1,106.20 0.00 0.00 36832 S 1,028.79 0.00 0.00<br />

36479 S 1,106.20 0.00 0.00 36833 S 1,028.79 0.00 0.00<br />

36511 S 426.12 0.00 0.00 36834 S 975.09 0.00 0.00<br />

36512 S 426.12 0.00 0.00 36835 S 892.71 0.00 0.00<br />

36513 S 426.12 0.00 0.00 36860 S 102.46 0.00 0.00<br />

36514 S 426.12 0.00 0.00 36861 S 839.00 0.00 0.00<br />

36515 S 1,140.72 0.00 0.00 36870 S 1,467.28 0.00 0.00<br />

36516 S 1,140.72 0.00 0.00 37184 S 1,493.65 0.00 0.00<br />

36522 S 1,140.72 0.00 0.00 37185 S 1,493.65 0.00 0.00<br />

36555 S 354.05 0.00 0.00 37186 S 1,493.65 0.00 0.00<br />

36556 S 354.05 0.00 0.00 37187 S 1,493.65 0.00 0.00<br />

36557 S 661.21 0.00 0.00 37188 S 1,493.65 0.00 0.00<br />

36558 S 661.21 0.00 0.00 37200 S 1,102.22 0.00 0.00<br />

36560 S 779.37 0.00 0.00 37203 S 1,102.22 0.00 0.00<br />

36561 S 779.37 0.00 0.00 37500 S 1,039.57 0.00 0.00<br />

36563 S 779.37 0.00 0.00 37607 S 735.17 0.00 0.00<br />

36565 S 779.37 0.00 0.00 37609 S 494.13 0.00 0.00<br />

36566 S 779.37 0.00 0.00 37650 S 706.52 0.00 0.00<br />

36568 S 354.05 0.00 0.00 37700 S 706.52 0.00 0.00<br />

36569 S 354.05 0.00 0.00 37718 S 735.17 0.00 0.00<br />

36570 S 689.85 0.00 0.00 37722 S 1,039.57 0.00 0.00<br />

36571 S 689.85 0.00 0.00 37735 S 1,039.57 0.00 0.00<br />

36575 S 284.75 0.00 0.00 37760 S 735.17 0.00 0.00<br />

36576 S 404.62 0.00 0.00 37765 S 1,013.81 0.00 0.00<br />

36578 S 661.21 0.00 0.00 37766 S 1,013.81 0.00 0.00<br />

36580 S 354.05 0.00 0.00 37780 S 735.17 0.00 0.00<br />

36581 S 661.21 0.00 0.00 37785 S 735.17 0.00 0.00<br />

36582 S 779.37 0.00 0.00 37790 S 887.13 0.00 0.00<br />

36583 S 779.37 0.00 0.00 38205 S 426.12 0.00 0.00<br />

36584 S 354.05 0.00 0.00 38206 S 426.12 0.00 0.00<br />

36585 S 689.85 0.00 0.00 38220 S 97.68 0.00 0.00<br />

36589 S 234.18 0.00 0.00 38221 S 102.31 0.00 0.00<br />

36590 S 354.05 0.00 0.00 38230 S 1,140.72 0.00 0.00<br />

36593 S 23.51 0.00 0.00 38241 S 1,140.72 0.00 0.00<br />

36595 S 923.18 0.00 0.00 38242 S 426.12 0.00 0.00<br />

36596 S 410.00 0.00 0.00 38300 S 382.38 0.00 0.00<br />

36597 S 410.00 0.00 0.00 38305 S 558.80 0.00 0.00<br />

36598 S 75.82 0.00 0.00 38308 S 638.50 0.00 0.00<br />

36640 S 700.15 0.00 0.00 38500 S 638.50 0.00 0.00<br />

36680 S 53.07 0.00 0.00 38505 S 244.29 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 638.50 0.00 0.00 41005 S 128.72 0.00 0.00<br />

38520 S 638.50 0.00 0.00 41006 S 607.67 0.00 0.00<br />

38525 S 638.50 0.00 0.00 41007 S 468.44 0.00 0.00<br />

38530 S 638.50 0.00 0.00 41008 S 468.44 0.00 0.00<br />

38542 S 1,074.18 0.00 0.00 41009 S 128.72 0.00 0.00<br />

38550 S 667.15 0.00 0.00 41010 S 288.60 0.00 0.00<br />

38555 S 720.85 0.00 0.00 41015 S 128.72 0.00 0.00<br />

38570 S 1,457.50 0.00 0.00 41016 S 288.60 0.00 0.00<br />

38571 S 1,894.72 0.00 0.00 41017 S 288.60 0.00 0.00<br />

38572 S 1,457.50 0.00 0.00 41018 S 288.60 0.00 0.00<br />

38700 S 877.76 0.00 0.00 41019 S 917.27 0.00 0.00<br />

38740 S 1,074.18 0.00 0.00 41100 S 86.41 0.00 0.00<br />

38745 S 1,156.53 0.00 0.00 41105 S 85.42 0.00 0.00<br />

38760 S 638.50 0.00 0.00 41108 S 79.13 0.00 0.00<br />

40490 S 65.22 0.00 0.00 41110 S 114.56 0.00 0.00<br />

40500 S 519.01 0.00 0.00 41112 S 519.01 0.00 0.00<br />

40510 S 658.24 0.00 0.00 41113 S 519.01 0.00 0.00<br />

40520 S 519.01 0.00 0.00 41114 S 658.24 0.00 0.00<br />

40525 S 658.24 0.00 0.00 41115 S 133.43 0.00 0.00<br />

40527 S 658.24 0.00 0.00 41116 S 468.44 0.00 0.00<br />

40530 S 658.24 0.00 0.00 41120 S 779.54 0.00 0.00<br />

40650 S 347.30 0.00 0.00 41250 S 88.04 0.00 0.00<br />

40652 S 347.30 0.00 0.00 41251 S 128.72 0.00 0.00<br />

40654 S 347.30 0.00 0.00 41252 S 339.17 0.00 0.00<br />

40700 S 1,221.11 0.00 0.00 41500 S 607.67 0.00 0.00<br />

40701 S 1,221.11 0.00 0.00 41510 S 468.44 0.00 0.00<br />

40702 S 1,551.54 0.00 0.00 41520 S 339.17 0.00 0.00<br />

40720 S 1,221.11 0.00 0.00 41530 S 638.79 0.00 0.00<br />

40761 S 1,004.03 0.00 0.00 41800 S 65.77 0.00 0.00<br />

40800 S 52.34 0.00 0.00 41805 S 142.37 0.00 0.00<br />

40801 S 339.17 0.00 0.00 41806 S 175.48 0.00 0.00<br />

40804 S 23.94 0.00 0.00 41820 S 279.12 0.00 0.00<br />

40805 S 161.91 0.00 0.00 41821 S 279.12 0.00 0.00<br />

40806 S 74.50 0.00 0.00 41822 S 145.35 0.00 0.00<br />

40808 S 110.58 0.00 0.00 41823 S 211.90 0.00 0.00<br />

40810 S 114.56 0.00 0.00 41825 S 116.54 0.00 0.00<br />

40812 S 143.69 0.00 0.00 41826 S 146.68 0.00 0.00<br />

40814 S 519.01 0.00 0.00 41827 S 658.24 0.00 0.00<br />

40816 S 658.24 0.00 0.00 41828 S 132.44 0.00 0.00<br />

40818 S 128.72 0.00 0.00 41830 S 188.06 0.00 0.00<br />

40819 S 288.60 0.00 0.00 41850 S 638.79 0.00 0.00<br />

40820 S 165.21 0.00 0.00 41870 S 917.27 0.00 0.00<br />

40830 S 122.53 0.00 0.00 41872 S 188.06 0.00 0.00<br />

40831 S 288.60 0.00 0.00 41874 S 181.43 0.00 0.00<br />

40840 S 658.24 0.00 0.00 42000 S 128.72 0.00 0.00<br />

40842 S 686.89 0.00 0.00 42100 S 73.50 0.00 0.00<br />

40843 S 686.89 0.00 0.00 42104 S 109.26 0.00 0.00<br />

40844 S 1,096.68 0.00 0.00 42106 S 137.08 0.00 0.00<br />

40845 S 1,096.68 0.00 0.00 42107 S 658.24 0.00 0.00<br />

41000 S 82.12 0.00 0.00 42120 S 1,057.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 339.17 0.00 0.00 42809 S 23.94 0.00 0.00<br />

42145 S 779.54 0.00 0.00 42810 S 686.89 0.00 0.00<br />

42160 S 129.79 0.00 0.00 42815 S 1,096.68 0.00 0.00<br />

42180 S 128.72 0.00 0.00 42820 S 686.89 0.00 0.00<br />

42182 S 975.38 0.00 0.00 42821 S 779.54 0.00 0.00<br />

42200 S 1,096.68 0.00 0.00 42825 S 740.60 0.00 0.00<br />

42205 S 1,096.68 0.00 0.00 42826 S 740.60 0.00 0.00<br />

42210 S 1,096.68 0.00 0.00 42830 S 740.60 0.00 0.00<br />

42215 S 1,221.11 0.00 0.00 42831 S 740.60 0.00 0.00<br />

42220 S 1,096.68 0.00 0.00 42835 S 740.60 0.00 0.00<br />

42226 S 1,096.68 0.00 0.00 42836 S 740.60 0.00 0.00<br />

42235 S 640.31 0.00 0.00 42860 S 686.89 0.00 0.00<br />

42260 S 740.60 0.00 0.00 42870 S 686.89 0.00 0.00<br />

42280 S 71.51 0.00 0.00 42890 S 1,221.11 0.00 0.00<br />

42281 S 638.79 0.00 0.00 42892 S 1,221.11 0.00 0.00<br />

42300 S 468.44 0.00 0.00 42900 S 288.60 0.00 0.00<br />

42305 S 519.01 0.00 0.00 42950 S 658.24 0.00 0.00<br />

42310 S 128.72 0.00 0.00 42955 S 658.24 0.00 0.00<br />

42320 S 128.72 0.00 0.00 42960 S 53.02 0.00 0.00<br />

42330 S 110.58 0.00 0.00 42962 S 975.38 0.00 0.00<br />

42335 S 183.43 0.00 0.00 42970 S 41.16 0.00 0.00<br />

42340 S 519.01 0.00 0.00 42972 S 547.66 0.00 0.00<br />

42400 S 62.25 0.00 0.00 43030 S 638.79 0.00 0.00<br />

42405 S 519.01 0.00 0.00 43200 S 309.34 0.00 0.00<br />

42408 S 547.66 0.00 0.00 43201 S 309.34 0.00 0.00<br />

42409 S 547.66 0.00 0.00 43202 S 309.34 0.00 0.00<br />

42410 S 1,004.03 0.00 0.00 43204 S 309.34 0.00 0.00<br />

42415 S 1,221.11 0.00 0.00 43205 S 309.34 0.00 0.00<br />

42420 S 1,221.11 0.00 0.00 43215 S 309.34 0.00 0.00<br />

42425 S 1,221.11 0.00 0.00 43216 S 309.34 0.00 0.00<br />

42440 S 1,004.03 0.00 0.00 43217 S 309.34 0.00 0.00<br />

42450 S 658.24 0.00 0.00 43219 S 625.18 0.00 0.00<br />

42500 S 686.89 0.00 0.00 43220 S 309.34 0.00 0.00<br />

42505 S 1,057.74 0.00 0.00 43226 S 309.34 0.00 0.00<br />

42507 S 1,004.03 0.00 0.00 43227 S 359.92 0.00 0.00<br />

42508 S 1,057.74 0.00 0.00 43228 S 669.78 0.00 0.00<br />

42509 S 1,057.74 0.00 0.00 43231 S 359.92 0.00 0.00<br />

42510 S 1,057.74 0.00 0.00 43232 S 359.92 0.00 0.00<br />

42600 S 468.44 0.00 0.00 43234 S 309.34 0.00 0.00<br />

42650 S 40.72 0.00 0.00 43235 S 309.34 0.00 0.00<br />

42660 S 47.68 0.00 0.00 43236 S 359.92 0.00 0.00<br />

42665 S 903.96 0.00 0.00 43237 S 359.92 0.00 0.00<br />

42700 S 128.72 0.00 0.00 43238 S 359.92 0.00 0.00<br />

42720 S 468.44 0.00 0.00 43239 S 359.92 0.00 0.00<br />

42725 S 975.38 0.00 0.00 43240 S 359.92 0.00 0.00<br />

42800 S 78.80 0.00 0.00 43241 S 359.92 0.00 0.00<br />

42802 S 468.44 0.00 0.00 43242 S 359.92 0.00 0.00<br />

42804 S 468.44 0.00 0.00 43243 S 359.92 0.00 0.00<br />

42806 S 658.24 0.00 0.00 43244 S 359.92 0.00 0.00<br />

42808 S 519.01 0.00 0.00 43245 S 359.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 359.92 0.00 0.00 44378 S 376.96 0.00 0.00<br />

43247 S 359.92 0.00 0.00 44379 S 1,075.44 0.00 0.00<br />

43248 S 359.92 0.00 0.00 44380 S 326.38 0.00 0.00<br />

43249 S 359.92 0.00 0.00 44382 S 326.38 0.00 0.00<br />

43250 S 359.92 0.00 0.00 44383 S 1,075.44 0.00 0.00<br />

43251 S 359.92 0.00 0.00 44385 S 315.56 0.00 0.00<br />

43255 S 359.92 0.00 0.00 44386 S 315.56 0.00 0.00<br />

43256 S 704.40 0.00 0.00 44388 S 315.56 0.00 0.00<br />

43257 S 698.43 0.00 0.00 44389 S 315.56 0.00 0.00<br />

43258 S 388.56 0.00 0.00 44390 S 315.56 0.00 0.00<br />

43259 S 388.56 0.00 0.00 44391 S 315.56 0.00 0.00<br />

43260 S 605.93 0.00 0.00 44392 S 315.56 0.00 0.00<br />

43261 S 605.93 0.00 0.00 44393 S 315.56 0.00 0.00<br />

43262 S 605.93 0.00 0.00 44394 S 315.56 0.00 0.00<br />

43263 S 605.93 0.00 0.00 44397 S 625.18 0.00 0.00<br />

43264 S 605.93 0.00 0.00 44500 S 170.29 0.00 0.00<br />

43265 S 605.93 0.00 0.00 45000 S 365.95 0.00 0.00<br />

43267 S 605.93 0.00 0.00 45005 S 425.90 0.00 0.00<br />

43268 S 675.76 0.00 0.00 45020 S 425.90 0.00 0.00<br />

43269 S 675.76 0.00 0.00 45100 S 578.62 0.00 0.00<br />

43271 S 605.93 0.00 0.00 45108 S 629.20 0.00 0.00<br />

43272 S 605.93 0.00 0.00 45150 S 629.20 0.00 0.00<br />

43273 S 812.62 0.00 0.00 45160 S 629.20 0.00 0.00<br />

43450 S 270.53 0.00 0.00 45170 S 629.20 0.00 0.00<br />

43453 S 270.53 0.00 0.00 45190 S 1,028.88 0.00 0.00<br />

43456 S 271.61 0.00 0.00 45300 S 60.92 0.00 0.00<br />

43458 S 310.42 0.00 0.00 45303 S 338.38 0.00 0.00<br />

43600 S 309.34 0.00 0.00 45305 S 318.23 0.00 0.00<br />

43653 S 1,457.50 0.00 0.00 45307 S 587.80 0.00 0.00<br />

43760 S 150.03 0.00 0.00 45308 S 318.23 0.00 0.00<br />

43761 S 309.34 0.00 0.00 45309 S 318.23 0.00 0.00<br />

43870 S 309.34 0.00 0.00 45315 S 318.23 0.00 0.00<br />

43886 S 780.54 0.00 0.00 45317 S 318.23 0.00 0.00<br />

43887 S 164.17 0.00 0.00 45320 S 587.80 0.00 0.00<br />

43888 S 780.54 0.00 0.00 45321 S 587.80 0.00 0.00<br />

44100 S 309.34 0.00 0.00 45327 S 625.18 0.00 0.00<br />

44312 S 539.31 0.00 0.00 45330 S 80.45 0.00 0.00<br />

44340 S 618.53 0.00 0.00 45331 S 237.92 0.00 0.00<br />

44360 S 376.96 0.00 0.00 45332 S 237.92 0.00 0.00<br />

44361 S 376.96 0.00 0.00 45333 S 318.23 0.00 0.00<br />

44363 S 376.96 0.00 0.00 45334 S 318.23 0.00 0.00<br />

44364 S 376.96 0.00 0.00 45335 S 237.92 0.00 0.00<br />

44365 S 376.96 0.00 0.00 45337 S 237.92 0.00 0.00<br />

44366 S 376.96 0.00 0.00 45338 S 318.23 0.00 0.00<br />

44369 S 376.96 0.00 0.00 45339 S 318.23 0.00 0.00<br />

44370 S 1,075.44 0.00 0.00 45340 S 318.23 0.00 0.00<br />

44372 S 376.96 0.00 0.00 45341 S 318.23 0.00 0.00<br />

44373 S 376.96 0.00 0.00 45342 S 318.23 0.00 0.00<br />

44376 S 376.96 0.00 0.00 45345 S 625.18 0.00 0.00<br />

44377 S 376.96 0.00 0.00 45355 S 315.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 366.14 0.00 0.00 46505 S 452.56 0.00 0.00<br />

45379 S 366.14 0.00 0.00 46600 S 23.94 0.00 0.00<br />

45380 S 366.14 0.00 0.00 46604 S 338.38 0.00 0.00<br />

45381 S 366.14 0.00 0.00 46606 S 127.14 0.00 0.00<br />

45382 S 366.14 0.00 0.00 46608 S 318.23 0.00 0.00<br />

45383 S 366.14 0.00 0.00 46610 S 587.80 0.00 0.00<br />

45384 S 366.14 0.00 0.00 46611 S 318.23 0.00 0.00<br />

45385 S 366.14 0.00 0.00 46612 S 587.80 0.00 0.00<br />

45386 S 366.14 0.00 0.00 46614 S 66.88 0.00 0.00<br />

45387 S 625.18 0.00 0.00 46615 S 638.37 0.00 0.00<br />

45391 S 366.14 0.00 0.00 46700 S 657.85 0.00 0.00<br />

45392 S 366.14 0.00 0.00 46706 S 724.09 0.00 0.00<br />

45500 S 629.20 0.00 0.00 46750 S 803.31 0.00 0.00<br />

45505 S 774.67 0.00 0.00 46753 S 657.85 0.00 0.00<br />

45520 S 30.68 0.00 0.00 46754 S 629.20 0.00 0.00<br />

45560 S 774.67 0.00 0.00 46760 S 774.67 0.00 0.00<br />

45900 S 248.09 0.00 0.00 46761 S 803.31 0.00 0.00<br />

45905 S 578.62 0.00 0.00 46762 S 1,020.38 0.00 0.00<br />

45910 S 578.62 0.00 0.00 46900 S 101.11 0.00 0.00<br />

45915 S 365.95 0.00 0.00 46910 S 120.85 0.00 0.00<br />

45990 S 569.25 0.00 0.00 46916 S 56.21 0.00 0.00<br />

46020 S 657.85 0.00 0.00 46917 S 524.34 0.00 0.00<br />

46030 S 248.09 0.00 0.00 46922 S 524.34 0.00 0.00<br />

46040 S 657.85 0.00 0.00 46924 S 524.34 0.00 0.00<br />

46045 S 629.20 0.00 0.00 46930 S 117.21 0.00 0.00<br />

46050 S 365.95 0.00 0.00 46937 S 629.20 0.00 0.00<br />

46060 S 629.20 0.00 0.00 46938 S 774.67 0.00 0.00<br />

46070 S 452.56 0.00 0.00 46940 S 86.74 0.00 0.00<br />

46080 S 657.85 0.00 0.00 46942 S 84.43 0.00 0.00<br />

46083 S 69.27 0.00 0.00 46945 S 143.69 0.00 0.00<br />

46200 S 629.20 0.00 0.00 46946 S 375.32 0.00 0.00<br />

46210 S 629.20 0.00 0.00 46947 S 1,020.38 0.00 0.00<br />

46211 S 629.20 0.00 0.00 47000 S 326.50 0.00 0.00<br />

46220 S 578.62 0.00 0.00 47382 S 1,722.99 0.00 0.00<br />

46221 S 113.90 0.00 0.00 47510 S 763.04 0.00 0.00<br />

46230 S 578.62 0.00 0.00 47511 S 1,121.02 0.00 0.00<br />

46250 S 657.85 0.00 0.00 47525 S 438.04 0.00 0.00<br />

46255 S 657.85 0.00 0.00 47530 S 438.04 0.00 0.00<br />

46257 S 657.85 0.00 0.00 47552 S 763.04 0.00 0.00<br />

46258 S 657.85 0.00 0.00 47553 S 791.68 0.00 0.00<br />

46260 S 657.85 0.00 0.00 47554 S 791.68 0.00 0.00<br />

46261 S 711.55 0.00 0.00 47555 S 791.68 0.00 0.00<br />

46262 S 711.55 0.00 0.00 47556 S 1,121.02 0.00 0.00<br />

46270 S 657.85 0.00 0.00 47560 S 930.20 0.00 0.00<br />

46275 S 657.85 0.00 0.00 47561 S 930.20 0.00 0.00<br />

46280 S 711.55 0.00 0.00 47562 S 1,716.41 0.00 0.00<br />

46285 S 578.62 0.00 0.00 47563 S 1,716.41 0.00 0.00<br />

46288 S 711.55 0.00 0.00 47564 S 1,716.41 0.00 0.00<br />

46320 S 77.15 0.00 0.00 47630 S 791.68 0.00 0.00<br />

46500 S 106.28 0.00 0.00 48102 S 326.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 198.54 0.00 0.00 49590 S 814.86 0.00 0.00<br />

49081 S 198.54 0.00 0.00 49600 S 868.57 0.00 0.00<br />

49180 S 326.50 0.00 0.00 49650 S 1,140.17 0.00 0.00<br />

49250 S 715.69 0.00 0.00 49651 S 1,303.54 0.00 0.00<br />

49320 S 930.20 0.00 0.00 49652 S 1,403.88 0.00 0.00<br />

49321 S 983.91 0.00 0.00 49653 S 1,403.88 0.00 0.00<br />

49322 S 983.91 0.00 0.00 49654 S 1,403.88 0.00 0.00<br />

49324 S 1,403.88 0.00 0.00 49655 S 1,403.88 0.00 0.00<br />

49325 S 1,403.88 0.00 0.00 49656 S 1,403.88 0.00 0.00<br />

49326 S 1,403.88 0.00 0.00 49657 S 1,403.88 0.00 0.00<br />

49402 S 633.34 0.00 0.00 50200 S 326.50 0.00 0.00<br />

49419 S 759.77 0.00 0.00 50382 S 948.07 0.00 0.00<br />

49420 S 702.36 0.00 0.00 50384 S 696.34 0.00 0.00<br />

49421 S 702.36 0.00 0.00 50385 S 696.34 0.00 0.00<br />

49422 S 558.97 0.00 0.00 50386 S 267.17 0.00 0.00<br />

49423 S 578.00 0.00 0.00 50387 S 578.00 0.00 0.00<br />

49426 S 633.34 0.00 0.00 50389 S 267.17 0.00 0.00<br />

49429 S 819.87 0.00 0.00 50390 S 326.50 0.00 0.00<br />

49440 S 320.60 0.00 0.00 50391 S 38.67 0.00 0.00<br />

49441 S 320.60 0.00 0.00 50392 S 497.21 0.00 0.00<br />

49446 S 320.60 0.00 0.00 50393 S 623.07 0.00 0.00<br />

49450 S 170.29 0.00 0.00 50395 S 497.21 0.00 0.00<br />

49451 S 170.29 0.00 0.00 50396 S 93.49 0.00 0.00<br />

49452 S 170.29 0.00 0.00 50398 S 438.04 0.00 0.00<br />

49460 S 170.29 0.00 0.00 50551 S 282.62 0.00 0.00<br />

49495 S 868.57 0.00 0.00 50553 S 623.07 0.00 0.00<br />

49496 S 868.57 0.00 0.00 50555 S 282.62 0.00 0.00<br />

49500 S 868.57 0.00 0.00 50557 S 623.07 0.00 0.00<br />

49501 S 1,185.89 0.00 0.00 50561 S 623.07 0.00 0.00<br />

49505 S 868.57 0.00 0.00 50562 S 267.17 0.00 0.00<br />

49507 S 1,185.89 0.00 0.00 50570 S 267.17 0.00 0.00<br />

49520 S 1,031.93 0.00 0.00 50572 S 267.17 0.00 0.00<br />

49521 S 1,185.89 0.00 0.00 50574 S 267.17 0.00 0.00<br />

49525 S 868.57 0.00 0.00 50575 S 1,328.93 0.00 0.00<br />

49540 S 786.21 0.00 0.00 50576 S 696.34 0.00 0.00<br />

49550 S 907.51 0.00 0.00 50580 S 696.34 0.00 0.00<br />

49553 S 1,185.89 0.00 0.00 50590 S 1,552.50 0.00 0.00<br />

49555 S 907.51 0.00 0.00 50592 S 1,722.99 0.00 0.00<br />

49557 S 1,185.89 0.00 0.00 50686 S 38.67 0.00 0.00<br />

49560 S 868.57 0.00 0.00 50688 S 438.04 0.00 0.00<br />

49561 S 1,185.89 0.00 0.00 50947 S 1,457.50 0.00 0.00<br />

49565 S 868.57 0.00 0.00 50948 S 1,457.50 0.00 0.00<br />

49566 S 1,185.89 0.00 0.00 50951 S 282.62 0.00 0.00<br />

49568 S 1,031.93 0.00 0.00 50953 S 282.62 0.00 0.00<br />

49570 S 868.57 0.00 0.00 50955 S 623.07 0.00 0.00<br />

49572 S 1,185.89 0.00 0.00 50957 S 623.07 0.00 0.00<br />

49580 S 868.57 0.00 0.00 50961 S 623.07 0.00 0.00<br />

49582 S 1,185.89 0.00 0.00 50970 S 282.62 0.00 0.00<br />

49585 S 868.57 0.00 0.00 50972 S 282.62 0.00 0.00<br />

49587 S 1,185.89 0.00 0.00 50974 S 497.21 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 497.21 0.00 0.00 52275 S 673.66 0.00 0.00<br />

50980 S 623.07 0.00 0.00 52276 S 702.30 0.00 0.00<br />

51020 S 756.01 0.00 0.00 52277 S 673.66 0.00 0.00<br />

51030 S 756.01 0.00 0.00 52281 S 547.78 0.00 0.00<br />

51040 S 756.01 0.00 0.00 52282 S 1,263.76 0.00 0.00<br />

51045 S 312.27 0.00 0.00 52283 S 673.66 0.00 0.00<br />

51050 S 756.01 0.00 0.00 52285 S 547.78 0.00 0.00<br />

51065 S 756.01 0.00 0.00 52290 S 547.78 0.00 0.00<br />

51080 S 508.21 0.00 0.00 52300 S 673.66 0.00 0.00<br />

51100 S 29.47 0.00 0.00 52301 S 702.30 0.00 0.00<br />

51101 S 38.67 0.00 0.00 52305 S 673.66 0.00 0.00<br />

51102 S 520.20 0.00 0.00 52310 S 526.85 0.00 0.00<br />

51500 S 868.57 0.00 0.00 52315 S 673.66 0.00 0.00<br />

51520 S 756.01 0.00 0.00 52317 S 623.07 0.00 0.00<br />

51700 S 50.32 0.00 0.00 52318 S 673.66 0.00 0.00<br />

51701 S 23.94 0.00 0.00 52320 S 794.94 0.00 0.00<br />

51702 S 23.94 0.00 0.00 52325 S 756.01 0.00 0.00<br />

51703 S 38.67 0.00 0.00 52327 S 864.09 0.00 0.00<br />

51705 S 69.27 0.00 0.00 52330 S 673.66 0.00 0.00<br />

51710 S 438.04 0.00 0.00 52332 S 673.66 0.00 0.00<br />

51715 S 795.36 0.00 0.00 52334 S 702.30 0.00 0.00<br />

51720 S 55.62 0.00 0.00 52341 S 702.30 0.00 0.00<br />

51725 TC S 106.86 0.00 0.00 52342 S 702.30 0.00 0.00<br />

51726 TC S 147.18 0.00 0.00 52343 S 702.30 0.00 0.00<br />

51736 TC S 20.20 0.00 0.00 52344 S 702.30 0.00 0.00<br />

51741 TC S 23.51 0.00 0.00 52345 S 702.30 0.00 0.00<br />

51772 TC S 93.49 0.00 0.00 52346 S 702.30 0.00 0.00<br />

51784 TC S 38.67 0.00 0.00 52351 S 702.30 0.00 0.00<br />

51785 TC S 64.59 0.00 0.00 52352 S 756.01 0.00 0.00<br />

51792 TC S 38.67 0.00 0.00 52353 S 946.44 0.00 0.00<br />

51795 TC S 69.27 0.00 0.00 52354 S 756.01 0.00 0.00<br />

51797 TC S 69.27 0.00 0.00 52355 S 756.01 0.00 0.00<br />

51798 S 17.21 0.00 0.00 52400 S 702.30 0.00 0.00<br />

51880 S 623.07 0.00 0.00 52402 S 702.30 0.00 0.00<br />

51992 S 1,179.12 0.00 0.00 52450 S 702.30 0.00 0.00<br />

52000 S 282.62 0.00 0.00 52500 S 702.30 0.00 0.00<br />

52001 S 526.85 0.00 0.00 52601 S 946.44 0.00 0.00<br />

52005 S 547.78 0.00 0.00 52630 S 864.09 0.00 0.00<br />

52007 S 673.66 0.00 0.00 52640 S 673.66 0.00 0.00<br />

52010 S 312.27 0.00 0.00 52647 S 1,447.96 0.00 0.00<br />

52204 S 547.78 0.00 0.00 52648 S 1,447.96 0.00 0.00<br />

52214 S 673.66 0.00 0.00 52700 S 673.66 0.00 0.00<br />

52224 S 673.66 0.00 0.00 53000 S 517.03 0.00 0.00<br />

52234 S 673.66 0.00 0.00 53010 S 517.03 0.00 0.00<br />

52235 S 702.30 0.00 0.00 53020 S 517.03 0.00 0.00<br />

52240 S 702.30 0.00 0.00 53025 S 735.97 0.00 0.00<br />

52250 S 756.01 0.00 0.00 53040 S 567.61 0.00 0.00<br />

52260 S 547.78 0.00 0.00 53060 S 67.22 0.00 0.00<br />

52265 S 267.17 0.00 0.00 53080 S 596.25 0.00 0.00<br />

52270 S 547.78 0.00 0.00 53085 S 735.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 517.03 0.00 0.00 54060 S 524.34 0.00 0.00<br />

53210 S 888.00 0.00 0.00 54065 S 524.34 0.00 0.00<br />

53215 S 688.89 0.00 0.00 54100 S 443.56 0.00 0.00<br />

53220 S 766.70 0.00 0.00 54105 S 553.71 0.00 0.00<br />

53230 S 766.70 0.00 0.00 54110 S 858.49 0.00 0.00<br />

53235 S 596.25 0.00 0.00 54111 S 858.49 0.00 0.00<br />

53240 S 766.70 0.00 0.00 54112 S 858.49 0.00 0.00<br />

53250 S 567.61 0.00 0.00 54115 S 508.21 0.00 0.00<br />

53260 S 567.61 0.00 0.00 54120 S 858.49 0.00 0.00<br />

53265 S 567.61 0.00 0.00 54150 S 572.13 0.00 0.00<br />

53270 S 567.61 0.00 0.00 54160 S 622.72 0.00 0.00<br />

53275 S 567.61 0.00 0.00 54161 S 622.72 0.00 0.00<br />

53400 S 795.36 0.00 0.00 54162 S 622.72 0.00 0.00<br />

53405 S 766.70 0.00 0.00 54163 S 622.72 0.00 0.00<br />

53410 S 766.70 0.00 0.00 54164 S 622.72 0.00 0.00<br />

53420 S 795.36 0.00 0.00 54200 S 65.22 0.00 0.00<br />

53425 S 766.70 0.00 0.00 54205 S 940.84 0.00 0.00<br />

53430 S 766.70 0.00 0.00 54220 S 93.49 0.00 0.00<br />

53431 S 766.70 0.00 0.00 54231 S 61.25 0.00 0.00<br />

53440 S 4,416.53 2,682.36 948.19 54235 S 43.38 0.00 0.00<br />

53442 S 716.13 0.00 0.00 54240 TC S 30.79 0.00 0.00<br />

53444 S 4,416.53 2,682.36 948.19 54250 TC S 10.92 0.00 0.00<br />

53445 S 7,418.64 4,224.87 1,031.10 54300 S 887.13 0.00 0.00<br />

53446 S 716.13 0.00 0.00 54304 S 887.13 0.00 0.00<br />

53447 S 7,418.64 4,224.87 1,031.10 54308 S 887.13 0.00 0.00<br />

53449 S 716.13 0.00 0.00 54312 S 887.13 0.00 0.00<br />

53450 S 716.13 0.00 0.00 54316 S 887.13 0.00 0.00<br />

53460 S 517.03 0.00 0.00 54318 S 887.13 0.00 0.00<br />

53502 S 567.61 0.00 0.00 54322 S 887.13 0.00 0.00<br />

53505 S 766.70 0.00 0.00 54324 S 887.13 0.00 0.00<br />

53510 S 567.61 0.00 0.00 54326 S 887.13 0.00 0.00<br />

53515 S 766.70 0.00 0.00 54328 S 887.13 0.00 0.00<br />

53520 S 766.70 0.00 0.00 54340 S 887.13 0.00 0.00<br />

53600 S 38.74 0.00 0.00 54344 S 887.13 0.00 0.00<br />

53601 S 38.67 0.00 0.00 54348 S 887.13 0.00 0.00<br />

53605 S 547.78 0.00 0.00 54352 S 887.13 0.00 0.00<br />

53620 S 59.60 0.00 0.00 54360 S 887.13 0.00 0.00<br />

53621 S 62.58 0.00 0.00 54380 S 887.13 0.00 0.00<br />

53660 S 38.67 0.00 0.00 54385 S 887.13 0.00 0.00<br />

53661 S 38.67 0.00 0.00 54400 S 4,445.18 2,711.01 976.84<br />

53665 S 517.03 0.00 0.00 54401 S 7,497.87 4,304.09 1,110.32<br />

53850 S 1,697.34 0.00 0.00 54405 S 7,497.87 4,304.09 1,110.32<br />

53852 S 1,697.34 0.00 0.00 54406 S 887.13 0.00 0.00<br />

54000 S 567.61 0.00 0.00 54408 S 887.13 0.00 0.00<br />

54001 S 567.61 0.00 0.00 54410 S 7,497.87 4,304.09 1,110.32<br />

54015 S 641.15 0.00 0.00 54415 S 887.13 0.00 0.00<br />

54050 S 30.68 0.00 0.00 54416 S 7,497.87 4,304.09 1,110.32<br />

54055 S 62.58 0.00 0.00 54420 S 940.84 0.00 0.00<br />

54056 S 30.68 0.00 0.00 54435 S 940.84 0.00 0.00<br />

54057 S 524.34 0.00 0.00 54440 S 940.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 147.18 0.00 0.00 55706 S 427.87 0.00 0.00<br />

54500 S 399.47 0.00 0.00 55720 S 623.07 0.00 0.00<br />

54505 S 572.13 0.00 0.00 55725 S 673.66 0.00 0.00<br />

54512 S 622.72 0.00 0.00 55860 S 742.33 0.00 0.00<br />

54520 S 651.36 0.00 0.00 55870 S 75.49 0.00 0.00<br />

54522 S 651.36 0.00 0.00 55873 S 5,873.61 0.00 0.00<br />

54530 S 868.57 0.00 0.00 55875 S 1,263.76 0.00 0.00<br />

54550 S 868.57 0.00 0.00 55876 S 69.20 0.00 0.00<br />

54560 S 846.19 0.00 0.00 55920 S 867.45 0.00 0.00<br />

54600 S 705.07 0.00 0.00 56405 S 40.39 0.00 0.00<br />

54620 S 651.36 0.00 0.00 56420 S 52.72 0.00 0.00<br />

54640 S 868.57 0.00 0.00 56440 S 566.14 0.00 0.00<br />

54660 S 622.72 0.00 0.00 56441 S 515.56 0.00 0.00<br />

54670 S 651.36 0.00 0.00 56442 S 515.56 0.00 0.00<br />

54680 S 651.36 0.00 0.00 56501 S 55.62 0.00 0.00<br />

54690 S 1,457.50 0.00 0.00 56515 S 603.57 0.00 0.00<br />

54692 S 2,590.84 0.00 0.00 56605 S 32.11 0.00 0.00<br />

54700 S 622.72 0.00 0.00 56606 S 13.25 0.00 0.00<br />

54800 S 139.77 0.00 0.00 56620 S 687.43 0.00 0.00<br />

54830 S 651.36 0.00 0.00 56625 S 811.85 0.00 0.00<br />

54840 S 705.07 0.00 0.00 56700 S 515.56 0.00 0.00<br />

54860 S 651.36 0.00 0.00 56740 S 594.78 0.00 0.00<br />

54861 S 705.07 0.00 0.00 56800 S 594.78 0.00 0.00<br />

54865 S 572.13 0.00 0.00 56805 S 733.04 0.00 0.00<br />

54900 S 705.07 0.00 0.00 56810 S 687.43 0.00 0.00<br />

54901 S 705.07 0.00 0.00 56820 S 41.05 0.00 0.00<br />

55000 S 63.57 0.00 0.00 56821 S 52.72 0.00 0.00<br />

55040 S 814.86 0.00 0.00 57000 S 515.56 0.00 0.00<br />

55041 S 907.51 0.00 0.00 57010 S 566.14 0.00 0.00<br />

55060 S 705.07 0.00 0.00 57020 S 296.91 0.00 0.00<br />

55100 S 382.38 0.00 0.00 57022 S 466.69 0.00 0.00<br />

55110 S 622.72 0.00 0.00 57023 S 508.21 0.00 0.00<br />

55120 S 622.72 0.00 0.00 57061 S 51.32 0.00 0.00<br />

55150 S 572.13 0.00 0.00 57065 S 515.56 0.00 0.00<br />

55175 S 572.13 0.00 0.00 57100 S 32.78 0.00 0.00<br />

55180 S 622.72 0.00 0.00 57105 S 566.14 0.00 0.00<br />

55200 S 622.72 0.00 0.00 57130 S 566.14 0.00 0.00<br />

55250 S 622.72 0.00 0.00 57135 S 566.14 0.00 0.00<br />

55400 S 572.13 0.00 0.00 57150 S 23.84 0.00 0.00<br />

55450 S 204.61 0.00 0.00 57155 S 296.91 0.00 0.00<br />

55500 S 651.36 0.00 0.00 57160 S 34.43 0.00 0.00<br />

55520 S 705.07 0.00 0.00 57170 S 5.65 0.00 0.00<br />

55530 S 705.07 0.00 0.00 57180 S 106.05 0.00 0.00<br />

55535 S 868.57 0.00 0.00 57200 S 515.56 0.00 0.00<br />

55540 S 907.51 0.00 0.00 57210 S 566.14 0.00 0.00<br />

55550 S 1,457.50 0.00 0.00 57220 S 1,038.22 0.00 0.00<br />

55600 S 846.19 0.00 0.00 57230 S 852.47 0.00 0.00<br />

55680 S 572.13 0.00 0.00 57240 S 945.12 0.00 0.00<br />

55700 S 368.71 0.00 0.00 57250 S 945.12 0.00 0.00<br />

55705 S 368.71 0.00 0.00 57260 S 945.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,255.29 0.00 0.00 58555 S 557.03 0.00 0.00<br />

57267 S 1,069.54 0.00 0.00 58558 S 636.26 0.00 0.00<br />

57268 S 852.47 0.00 0.00 58559 S 607.62 0.00 0.00<br />

57287 S 1,248.42 0.00 0.00 58560 S 907.21 0.00 0.00<br />

57288 S 1,130.87 0.00 0.00 58561 S 907.21 0.00 0.00<br />

57289 S 945.12 0.00 0.00 58562 S 636.26 0.00 0.00<br />

57291 S 945.12 0.00 0.00 58563 S 1,278.24 0.00 0.00<br />

57300 S 852.47 0.00 0.00 58565 S 1,409.26 0.00 0.00<br />

57320 S 1,248.42 0.00 0.00 58600 S 1,248.42 0.00 0.00<br />

57400 S 566.14 0.00 0.00 58615 S 733.04 0.00 0.00<br />

57410 S 566.14 0.00 0.00 58660 S 1,179.12 0.00 0.00<br />

57415 S 566.14 0.00 0.00 58661 S 1,179.12 0.00 0.00<br />

57420 S 42.38 0.00 0.00 58662 S 1,179.12 0.00 0.00<br />

57421 S 55.29 0.00 0.00 58670 S 1,086.47 0.00 0.00<br />

57452 S 40.06 0.00 0.00 58671 S 1,086.47 0.00 0.00<br />

57454 S 49.00 0.00 0.00 58672 S 1,179.12 0.00 0.00<br />

57455 S 51.98 0.00 0.00 58673 S 1,179.12 0.00 0.00<br />

57456 S 50.32 0.00 0.00 58800 S 594.78 0.00 0.00<br />

57460 S 154.62 0.00 0.00 58805 S 1,248.42 0.00 0.00<br />

57461 S 164.22 0.00 0.00 58820 S 852.47 0.00 0.00<br />

57500 S 70.85 0.00 0.00 58900 S 594.78 0.00 0.00<br />

57505 S 45.03 0.00 0.00 58970 S 165.67 0.00 0.00<br />

57510 S 45.69 0.00 0.00 58974 S 165.67 0.00 0.00<br />

57511 S 52.72 0.00 0.00 58976 S 165.67 0.00 0.00<br />

57513 S 566.14 0.00 0.00 59000 S 60.59 0.00 0.00<br />

57520 S 566.14 0.00 0.00 59001 S 227.43 0.00 0.00<br />

57522 S 566.14 0.00 0.00 59012 S 111.21 0.00 0.00<br />

57530 S 852.47 0.00 0.00 59015 S 49.00 0.00 0.00<br />

57550 S 852.47 0.00 0.00 59020 TC S 25.82 0.00 0.00<br />

57556 S 1,130.87 0.00 0.00 59025 TC S 13.58 0.00 0.00<br />

57558 S 594.78 0.00 0.00 59070 S 111.21 0.00 0.00<br />

57700 S 515.56 0.00 0.00 59072 S 111.21 0.00 0.00<br />

57720 S 594.78 0.00 0.00 59076 S 111.21 0.00 0.00<br />

57800 S 24.17 0.00 0.00 59100 S 1,248.42 0.00 0.00<br />

58100 S 39.73 0.00 0.00 59150 S 1,716.41 0.00 0.00<br />

58120 S 566.14 0.00 0.00 59151 S 1,716.41 0.00 0.00<br />

58145 S 945.12 0.00 0.00 59160 S 594.78 0.00 0.00<br />

58301 S 37.08 0.00 0.00 59200 S 33.11 0.00 0.00<br />

58321 S 34.76 0.00 0.00 59300 S 71.51 0.00 0.00<br />

58322 S 35.76 0.00 0.00 59320 S 515.56 0.00 0.00<br />

58323 S 8.28 0.00 0.00 59412 S 733.04 0.00 0.00<br />

58345 S 733.04 0.00 0.00 59414 S 733.04 0.00 0.00<br />

58346 S 566.14 0.00 0.00 59812 S 687.43 0.00 0.00<br />

58350 S 852.47 0.00 0.00 59820 S 687.43 0.00 0.00<br />

58353 S 1,069.54 0.00 0.00 59821 S 687.43 0.00 0.00<br />

58356 S 1,619.92 0.00 0.00 59840 S 687.43 0.00 0.00<br />

58545 S 1,301.24 0.00 0.00 59841 S 687.43 0.00 0.00<br />

58546 S 1,457.50 0.00 0.00 59866 S 111.21 0.00 0.00<br />

58550 S 1,894.72 0.00 0.00 59870 S 687.43 0.00 0.00<br />

58552 S 1,716.41 0.00 0.00 59871 S 687.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 288.60 0.00 0.00 62367 S 15.89 0.00 0.00<br />

60100 S 45.36 0.00 0.00 62368 S 20.20 0.00 0.00<br />

60200 S 1,074.18 0.00 0.00 63600 S 542.56 0.00 0.00<br />

60280 S 1,156.53 0.00 0.00 63610 S 491.97 0.00 0.00<br />

60281 S 1,156.53 0.00 0.00 63615 S 685.87 0.00 0.00<br />

60300 S 59.60 0.00 0.00 63650 S 2,920.30 1,810.87 701.46<br />

61000 S 265.74 0.00 0.00 63655 S 4,277.52 2,727.78 1,178.05<br />

61001 S 265.74 0.00 0.00 63660 S 512.86 0.00 0.00<br />

61020 S 215.15 0.00 0.00 63685 S 12,983.26 6,922.79 862.33<br />

61026 S 215.15 0.00 0.00 63688 S 696.42 0.00 0.00<br />

61050 S 215.15 0.00 0.00 63744 S 1,007.13 0.00 0.00<br />

61055 S 215.15 0.00 0.00 63746 S 465.88 0.00 0.00<br />

61070 S 167.42 0.00 0.00 64400 S 50.99 0.00 0.00<br />

61215 S 1,007.13 0.00 0.00 64402 S 48.01 0.00 0.00<br />

61330 S 1,551.54 0.00 0.00 64405 S 40.72 0.00 0.00<br />

61334 S 1,551.54 0.00 0.00 64408 S 50.66 0.00 0.00<br />

61790 S 571.20 0.00 0.00 64410 S 281.91 0.00 0.00<br />

61791 S 423.77 0.00 0.00 64412 S 74.50 0.00 0.00<br />

61880 S 727.63 0.00 0.00 64413 S 47.68 0.00 0.00<br />

61885 S 10,470.78 5,609.10 747.42 64415 S 129.83 0.00 0.00<br />

61886 S 15,635.43 8,240.78 846.13 64416 S 265.74 0.00 0.00<br />

61888 S 696.42 0.00 0.00 64417 S 129.83 0.00 0.00<br />

62194 S 281.91 0.00 0.00 64418 S 66.88 0.00 0.00<br />

62225 S 438.04 0.00 0.00 64420 S 129.83 0.00 0.00<br />

62230 S 978.48 0.00 0.00 64421 S 281.91 0.00 0.00<br />

62252 TC S 44.37 0.00 0.00 64425 S 46.35 0.00 0.00<br />

62263 S 281.91 0.00 0.00 64430 S 195.08 0.00 0.00<br />

62264 S 415.29 0.00 0.00 64435 S 69.86 0.00 0.00<br />

62267 S 165.73 0.00 0.00 64445 S 61.91 0.00 0.00<br />

62268 S 215.15 0.00 0.00 64446 S 532.51 0.00 0.00<br />

62269 S 326.50 0.00 0.00 64447 S 135.24 0.00 0.00<br />

62270 S 129.83 0.00 0.00 64448 S 135.24 0.00 0.00<br />

62272 S 129.83 0.00 0.00 64449 S 265.74 0.00 0.00<br />

62273 S 216.66 0.00 0.00 64450 S 41.38 0.00 0.00<br />

62280 S 281.91 0.00 0.00 64455 S 17.21 0.00 0.00<br />

62281 S 281.91 0.00 0.00 64470 S 281.91 0.00 0.00<br />

62282 S 281.91 0.00 0.00 64472 S 216.66 0.00 0.00<br />

62287 S 1,265.51 0.00 0.00 64475 S 281.91 0.00 0.00<br />

62292 S 265.74 0.00 0.00 64476 S 195.12 0.00 0.00<br />

62294 S 215.15 0.00 0.00 64479 S 281.91 0.00 0.00<br />

62310 S 281.91 0.00 0.00 64480 S 216.66 0.00 0.00<br />

62311 S 281.91 0.00 0.00 64483 S 281.91 0.00 0.00<br />

62318 S 281.91 0.00 0.00 64484 S 216.66 0.00 0.00<br />

62319 S 281.91 0.00 0.00 64505 S 37.75 0.00 0.00<br />

62350 S 978.48 0.00 0.00 64508 S 80.12 0.00 0.00<br />

62355 S 465.88 0.00 0.00 64510 S 281.91 0.00 0.00<br />

62360 S 978.48 0.00 0.00 64517 S 195.08 0.00 0.00<br />

62361 S 10,044.21 5,436.57 828.94 64520 S 281.91 0.00 0.00<br />

62362 S 10,044.21 5,436.57 828.94 64530 S 281.91 0.00 0.00<br />

62365 S 865.83 0.00 0.00 64553 S 2,869.71 1,760.29 650.88<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,222.52 2,113.10 1,003.69 64746 S 542.56 0.00 0.00<br />

64560 S 3,222.52 2,113.10 1,003.69 64761 S 685.87 0.00 0.00<br />

64561 S 2,948.94 1,839.52 730.10 64763 S 685.87 0.00 0.00<br />

64565 S 3,222.52 2,113.10 1,003.69 64766 S 1,332.42 0.00 0.00<br />

64573 S 5,020.20 2,973.98 927.76 64771 S 542.56 0.00 0.00<br />

64575 S 3,837.53 2,287.79 738.06 64772 S 542.56 0.00 0.00<br />

64577 S 3,837.53 2,287.79 738.06 64774 S 542.56 0.00 0.00<br />

64580 S 3,837.53 2,287.79 738.06 64776 S 571.20 0.00 0.00<br />

64581 S 3,916.76 2,367.02 817.29 64778 S 542.56 0.00 0.00<br />

64585 S 512.86 0.00 0.00 64782 S 571.20 0.00 0.00<br />

64590 S 10,470.78 5,609.10 747.42 64783 S 542.56 0.00 0.00<br />

64595 S 696.42 0.00 0.00 64784 S 571.20 0.00 0.00<br />

64600 S 415.29 0.00 0.00 64786 S 894.47 0.00 0.00<br />

64605 S 415.29 0.00 0.00 64787 S 542.56 0.00 0.00<br />

64610 S 415.29 0.00 0.00 64788 S 571.20 0.00 0.00<br />

64612 S 60.59 0.00 0.00 64790 S 571.20 0.00 0.00<br />

64613 S 58.61 0.00 0.00 64792 S 894.47 0.00 0.00<br />

64614 S 66.88 0.00 0.00 64795 S 542.56 0.00 0.00<br />

64620 S 281.91 0.00 0.00 64802 S 542.56 0.00 0.00<br />

64622 S 415.29 0.00 0.00 64820 S 685.87 0.00 0.00<br />

64623 S 281.91 0.00 0.00 64821 S 800.70 0.00 0.00<br />

64626 S 415.29 0.00 0.00 64822 S 1,037.45 0.00 0.00<br />

64627 S 195.12 0.00 0.00 64823 S 1,037.45 0.00 0.00<br />

64630 S 290.38 0.00 0.00 64831 S 948.18 0.00 0.00<br />

64632 S 31.45 0.00 0.00 64832 S 815.25 0.00 0.00<br />

64640 S 93.70 0.00 0.00 64834 S 865.83 0.00 0.00<br />

64650 S 31.45 0.00 0.00 64835 S 894.47 0.00 0.00<br />

64653 S 34.10 0.00 0.00 64836 S 894.47 0.00 0.00<br />

64680 S 441.24 0.00 0.00 64837 S 815.25 0.00 0.00<br />

64681 S 465.88 0.00 0.00 64840 S 865.83 0.00 0.00<br />

64702 S 491.97 0.00 0.00 64856 S 865.83 0.00 0.00<br />

64704 S 491.97 0.00 0.00 64857 S 865.83 0.00 0.00<br />

64708 S 542.56 0.00 0.00 64858 S 865.83 0.00 0.00<br />

64712 S 542.56 0.00 0.00 64859 S 815.25 0.00 0.00<br />

64713 S 542.56 0.00 0.00 64861 S 894.47 0.00 0.00<br />

64714 S 542.56 0.00 0.00 64862 S 894.47 0.00 0.00<br />

64716 S 571.20 0.00 0.00 64864 S 894.47 0.00 0.00<br />

64718 S 542.56 0.00 0.00 64865 S 948.18 0.00 0.00<br />

64719 S 542.56 0.00 0.00 64870 S 948.18 0.00 0.00<br />

64721 S 542.56 0.00 0.00 64872 S 865.83 0.00 0.00<br />

64722 S 491.97 0.00 0.00 64874 S 894.47 0.00 0.00<br />

64726 S 491.97 0.00 0.00 64876 S 894.47 0.00 0.00<br />

64727 S 491.97 0.00 0.00 64885 S 865.83 0.00 0.00<br />

64732 S 542.56 0.00 0.00 64886 S 865.83 0.00 0.00<br />

64734 S 542.56 0.00 0.00 64890 S 865.83 0.00 0.00<br />

64736 S 542.56 0.00 0.00 64891 S 865.83 0.00 0.00<br />

64738 S 542.56 0.00 0.00 64892 S 865.83 0.00 0.00<br />

64740 S 542.56 0.00 0.00 64893 S 865.83 0.00 0.00<br />

64742 S 542.56 0.00 0.00 64895 S 894.47 0.00 0.00<br />

64744 S 542.56 0.00 0.00 64896 S 894.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 894.47 0.00 0.00 65770 S 5,263.67 0.00 0.00<br />

64898 S 894.47 0.00 0.00 65772 S 592.12 0.00 0.00<br />

64901 S 865.83 0.00 0.00 65775 S 592.12 0.00 0.00<br />

64902 S 865.83 0.00 0.00 65780 S 1,024.29 0.00 0.00<br />

64905 S 865.83 0.00 0.00 65781 S 1,024.29 0.00 0.00<br />

64907 S 815.25 0.00 0.00 65782 S 1,024.29 0.00 0.00<br />

64910 S 1,332.42 0.00 0.00 65800 S 459.19 0.00 0.00<br />

65091 S 941.83 0.00 0.00 65805 S 459.19 0.00 0.00<br />

65093 S 941.83 0.00 0.00 65810 S 670.98 0.00 0.00<br />

65101 S 941.83 0.00 0.00 65815 S 642.32 0.00 0.00<br />

65103 S 941.83 0.00 0.00 65820 S 235.58 0.00 0.00<br />

65105 S 995.54 0.00 0.00 65850 S 724.68 0.00 0.00<br />

65110 S 1,034.48 0.00 0.00 65855 S 125.15 0.00 0.00<br />

65112 S 1,158.90 0.00 0.00 65860 S 116.88 0.00 0.00<br />

65114 S 1,158.90 0.00 0.00 65865 S 459.19 0.00 0.00<br />

65125 S 964.49 0.00 0.00 65870 S 724.68 0.00 0.00<br />

65130 S 710.50 0.00 0.00 65875 S 724.68 0.00 0.00<br />

65135 S 681.86 0.00 0.00 65880 S 592.12 0.00 0.00<br />

65140 S 941.83 0.00 0.00 65900 S 631.06 0.00 0.00<br />

65150 S 681.86 0.00 0.00 65920 S 888.05 0.00 0.00<br />

65155 S 941.83 0.00 0.00 65930 S 763.62 0.00 0.00<br />

65175 S 506.86 0.00 0.00 66020 S 459.19 0.00 0.00<br />

65205 S 19.54 0.00 0.00 66030 S 235.58 0.00 0.00<br />

65210 S 24.83 0.00 0.00 66130 S 888.05 0.00 0.00<br />

65220 S 34.60 0.00 0.00 66150 S 724.68 0.00 0.00<br />

65222 S 27.15 0.00 0.00 66155 S 724.68 0.00 0.00<br />

65235 S 509.77 0.00 0.00 66160 S 642.32 0.00 0.00<br />

65260 S 336.23 0.00 0.00 66165 S 724.68 0.00 0.00<br />

65265 S 695.61 0.00 0.00 66170 S 724.68 0.00 0.00<br />

65270 S 557.43 0.00 0.00 66172 S 724.68 0.00 0.00<br />

65272 S 642.32 0.00 0.00 66180 S 1,079.62 0.00 0.00<br />

65275 S 724.68 0.00 0.00 66185 S 958.34 0.00 0.00<br />

65280 S 695.61 0.00 0.00 66220 S 935.51 0.00 0.00<br />

65285 S 989.21 0.00 0.00 66225 S 1,040.69 0.00 0.00<br />

65286 S 173.06 0.00 0.00 66250 S 509.77 0.00 0.00<br />

65290 S 685.04 0.00 0.00 66500 S 235.58 0.00 0.00<br />

65400 S 459.19 0.00 0.00 66505 S 235.58 0.00 0.00<br />

65410 S 509.77 0.00 0.00 66600 S 670.98 0.00 0.00<br />

65420 S 509.77 0.00 0.00 66605 S 670.98 0.00 0.00<br />

65426 S 763.62 0.00 0.00 66625 S 477.07 0.00 0.00<br />

65430 S 34.60 0.00 0.00 66630 S 670.98 0.00 0.00<br />

65435 S 30.13 0.00 0.00 66635 S 670.98 0.00 0.00<br />

65436 S 130.78 0.00 0.00 66680 S 670.98 0.00 0.00<br />

65450 S 79.84 0.00 0.00 66682 S 642.32 0.00 0.00<br />

65600 S 154.29 0.00 0.00 66700 S 509.77 0.00 0.00<br />

65710 S 1,148.71 0.00 0.00 66710 S 509.77 0.00 0.00<br />

65730 S 1,148.71 0.00 0.00 66711 S 509.77 0.00 0.00<br />

65750 S 1,148.71 0.00 0.00 66720 S 509.77 0.00 0.00<br />

65755 S 1,148.71 0.00 0.00 66740 S 642.32 0.00 0.00<br />

65756 S 1,406.75 0.00 0.00 66761 S 174.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 177.14 0.00 0.00 67228 S 195.08 0.00 0.00<br />

66770 S 195.08 0.00 0.00 67229 S 195.08 0.00 0.00<br />

66820 S 173.06 0.00 0.00 67250 S 586.08 0.00 0.00<br />

66821 S 237.39 0.00 0.00 67255 S 641.90 0.00 0.00<br />

66825 S 724.68 0.00 0.00 67311 S 685.04 0.00 0.00<br />

66830 S 253.45 0.00 0.00 67312 S 738.75 0.00 0.00<br />

66840 S 544.82 0.00 0.00 67314 S 738.75 0.00 0.00<br />

66850 S 1,025.77 0.00 0.00 67316 S 738.75 0.00 0.00<br />

66852 S 862.41 0.00 0.00 67318 S 738.75 0.00 0.00<br />

66920 S 862.41 0.00 0.00 67320 S 738.75 0.00 0.00<br />

66930 S 901.35 0.00 0.00 67331 S 738.75 0.00 0.00<br />

66940 S 583.77 0.00 0.00 67332 S 738.75 0.00 0.00<br />

66982 S 885.59 0.00 0.00 67334 S 738.75 0.00 0.00<br />

66983 S 885.59 0.00 0.00 67335 S 738.75 0.00 0.00<br />

66984 S 885.59 0.00 0.00 67340 S 738.75 0.00 0.00<br />

66985 S 819.80 0.00 0.00 67343 S 902.11 0.00 0.00<br />

66986 S 819.80 0.00 0.00 67345 S 77.15 0.00 0.00<br />

67005 S 695.61 0.00 0.00 67346 S 417.27 0.00 0.00<br />

67010 S 695.61 0.00 0.00 67400 S 586.08 0.00 0.00<br />

67015 S 856.28 0.00 0.00 67405 S 764.22 0.00 0.00<br />

67025 S 562.68 0.00 0.00 67412 S 678.72 0.00 0.00<br />

67027 S 989.21 0.00 0.00 67413 S 803.15 0.00 0.00<br />

67028 S 77.81 0.00 0.00 67414 S 1,427.14 0.00 0.00<br />

67030 S 562.68 0.00 0.00 67415 S 506.86 0.00 0.00<br />

67031 S 237.39 0.00 0.00 67420 S 1,034.48 0.00 0.00<br />

67036 S 989.21 0.00 0.00 67430 S 1,034.48 0.00 0.00<br />

67039 S 1,152.58 0.00 0.00 67440 S 1,034.48 0.00 0.00<br />

67040 S 1,152.58 0.00 0.00 67445 S 1,034.48 0.00 0.00<br />

67041 S 1,414.48 0.00 0.00 67450 S 1,034.48 0.00 0.00<br />

67042 S 1,414.48 0.00 0.00 67500 S 79.84 0.00 0.00<br />

67043 S 1,414.48 0.00 0.00 67505 S 24.83 0.00 0.00<br />

67101 S 215.93 0.00 0.00 67515 S 25.16 0.00 0.00<br />

67105 S 195.08 0.00 0.00 67550 S 995.54 0.00 0.00<br />

67107 S 1,028.15 0.00 0.00 67560 S 681.86 0.00 0.00<br />

67108 S 1,152.58 0.00 0.00 67570 S 995.54 0.00 0.00<br />

67110 S 313.87 0.00 0.00 67700 S 116.81 0.00 0.00<br />

67112 S 1,152.58 0.00 0.00 67710 S 136.41 0.00 0.00<br />

67113 S 1,414.48 0.00 0.00 67715 S 506.86 0.00 0.00<br />

67115 S 613.25 0.00 0.00 67800 S 49.00 0.00 0.00<br />

67120 S 613.25 0.00 0.00 67801 S 59.27 0.00 0.00<br />

67121 S 613.25 0.00 0.00 67805 S 76.81 0.00 0.00<br />

67141 S 216.17 0.00 0.00 67808 S 557.43 0.00 0.00<br />

67145 S 184.42 0.00 0.00 67810 S 116.81 0.00 0.00<br />

67208 S 196.67 0.00 0.00 67820 S 16.22 0.00 0.00<br />

67210 S 195.08 0.00 0.00 67825 S 49.99 0.00 0.00<br />

67218 S 734.55 0.00 0.00 67830 S 342.22 0.00 0.00<br />

67220 S 215.93 0.00 0.00 67835 S 557.43 0.00 0.00<br />

67221 S 110.91 0.00 0.00 67840 S 143.03 0.00 0.00<br />

67225 S 7.62 0.00 0.00 67850 S 113.57 0.00 0.00<br />

67227 S 562.68 0.00 0.00 67875 S 285.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 538.42 0.00 0.00 68440 S 48.67 0.00 0.00<br />

67882 S 586.08 0.00 0.00 68500 S 710.50 0.00 0.00<br />

67900 S 764.22 0.00 0.00 68505 S 710.50 0.00 0.00<br />

67901 S 678.72 0.00 0.00 68510 S 506.86 0.00 0.00<br />

67902 S 803.15 0.00 0.00 68520 S 710.50 0.00 0.00<br />

67903 S 639.78 0.00 0.00 68525 S 506.86 0.00 0.00<br />

67904 S 639.78 0.00 0.00 68530 S 116.81 0.00 0.00<br />

67906 S 678.72 0.00 0.00 68540 S 586.08 0.00 0.00<br />

67908 S 639.78 0.00 0.00 68550 S 710.50 0.00 0.00<br />

67909 S 639.78 0.00 0.00 68700 S 557.43 0.00 0.00<br />

67911 S 586.08 0.00 0.00 68705 S 110.91 0.00 0.00<br />

67912 S 586.08 0.00 0.00 68720 S 764.22 0.00 0.00<br />

67914 S 586.08 0.00 0.00 68745 S 764.22 0.00 0.00<br />

67915 S 158.26 0.00 0.00 68750 S 764.22 0.00 0.00<br />

67916 S 639.78 0.00 0.00 68760 S 94.36 0.00 0.00<br />

67917 S 639.78 0.00 0.00 68761 S 65.22 0.00 0.00<br />

67921 S 586.08 0.00 0.00 68770 S 764.22 0.00 0.00<br />

67922 S 153.96 0.00 0.00 68801 S 34.60 0.00 0.00<br />

67923 S 639.78 0.00 0.00 68810 S 98.94 0.00 0.00<br />

67924 S 639.78 0.00 0.00 68811 S 557.43 0.00 0.00<br />

67930 S 158.26 0.00 0.00 68815 S 557.43 0.00 0.00<br />

67935 S 557.43 0.00 0.00 68816 S 715.63 0.00 0.00<br />

67938 S 79.84 0.00 0.00 68840 S 51.32 0.00 0.00<br />

67950 S 557.43 0.00 0.00 69000 S 52.34 0.00 0.00<br />

67961 S 586.08 0.00 0.00 69005 S 99.00 0.00 0.00<br />

67966 S 586.08 0.00 0.00 69020 S 52.34 0.00 0.00<br />

67971 S 586.08 0.00 0.00 69100 S 59.60 0.00 0.00<br />

67973 S 710.50 0.00 0.00 69105 S 84.43 0.00 0.00<br />

67974 S 586.08 0.00 0.00 69110 S 443.56 0.00 0.00<br />

67975 S 586.08 0.00 0.00 69120 S 658.24 0.00 0.00<br />

68020 S 43.38 0.00 0.00 69140 S 658.24 0.00 0.00<br />

68040 S 21.52 0.00 0.00 69145 S 494.13 0.00 0.00<br />

68100 S 86.08 0.00 0.00 69150 S 347.30 0.00 0.00<br />

68110 S 110.91 0.00 0.00 69200 S 23.94 0.00 0.00<br />

68115 S 557.43 0.00 0.00 69205 S 553.71 0.00 0.00<br />

68130 S 509.77 0.00 0.00 69210 S 19.54 0.00 0.00<br />

68135 S 55.62 0.00 0.00 69220 S 30.68 0.00 0.00<br />

68200 S 15.89 0.00 0.00 69222 S 129.13 0.00 0.00<br />

68320 S 764.22 0.00 0.00 69300 S 686.89 0.00 0.00<br />

68325 S 764.22 0.00 0.00 69310 S 1,004.03 0.00 0.00<br />

68326 S 639.78 0.00 0.00 69320 S 1,221.11 0.00 0.00<br />

68328 S 764.22 0.00 0.00 69400 S 86.74 0.00 0.00<br />

68330 S 724.68 0.00 0.00 69401 S 45.69 0.00 0.00<br />

68335 S 764.22 0.00 0.00 69405 S 119.85 0.00 0.00<br />

68340 S 639.78 0.00 0.00 69420 S 107.61 0.00 0.00<br />

68360 S 642.32 0.00 0.00 69421 S 547.66 0.00 0.00<br />

68362 S 642.32 0.00 0.00 69424 S 75.49 0.00 0.00<br />

68371 S 509.77 0.00 0.00 69433 S 107.28 0.00 0.00<br />

68400 S 116.81 0.00 0.00 69436 S 547.66 0.00 0.00<br />

68420 S 166.20 0.00 0.00 69440 S 686.89 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 924.81 0.00 0.00 69840 S 1,096.68 0.00 0.00<br />

69501 S 1,221.11 0.00 0.00 69905 S 1,221.11 0.00 0.00<br />

69502 S 903.96 0.00 0.00 69910 S 1,221.11 0.00 0.00<br />

69505 S 1,221.11 0.00 0.00 69915 S 1,221.11 0.00 0.00<br />

69511 S 1,221.11 0.00 0.00 69930 S 22,075.92 11,853.27 1,630.63<br />

69530 S 1,221.11 0.00 0.00 70030 TC A 16.88 0.00 0.00<br />

69540 S 126.14 0.00 0.00 70100 TC A 18.54 0.00 0.00<br />

69550 S 1,096.68 0.00 0.00 70110 TC A 22.85 0.00 0.00<br />

69552 S 1,221.11 0.00 0.00 70120 TC A 20.53 0.00 0.00<br />

69601 S 1,221.11 0.00 0.00 70130 TC A 25.08 0.00 0.00<br />

69602 S 1,221.11 0.00 0.00 70134 TC A 25.16 0.00 0.00<br />

69603 S 1,221.11 0.00 0.00 70140 TC A 17.21 0.00 0.00<br />

69604 S 1,221.11 0.00 0.00 70150 TC A 25.08 0.00 0.00<br />

69605 S 1,221.11 0.00 0.00 70160 TC A 20.20 0.00 0.00<br />

69610 S 168.86 0.00 0.00 70190 TC A 21.19 0.00 0.00<br />

69620 S 658.24 0.00 0.00 70200 TC A 25.08 0.00 0.00<br />

69631 S 1,096.68 0.00 0.00 70210 TC A 17.88 0.00 0.00<br />

69632 S 1,096.68 0.00 0.00 70220 TC A 22.52 0.00 0.00<br />

69633 S 1,096.68 0.00 0.00 70240 TC A 16.88 0.00 0.00<br />

69635 S 1,221.11 0.00 0.00 70250 TC A 20.53 0.00 0.00<br />

69636 S 1,221.11 0.00 0.00 70260 TC A 26.15 0.00 0.00<br />

69637 S 1,221.11 0.00 0.00 70300 TC A 7.28 0.00 0.00<br />

69641 S 1,221.11 0.00 0.00 70310 TC A 17.99 0.00 0.00<br />

69642 S 1,221.11 0.00 0.00 70320 TC A 17.99 0.00 0.00<br />

69643 S 1,221.11 0.00 0.00 70328 TC A 17.88 0.00 0.00<br />

69644 S 1,221.11 0.00 0.00 70330 TC A 25.08 0.00 0.00<br />

69645 S 1,221.11 0.00 0.00 70336 TC A 195.22 0.00 0.00<br />

69646 S 1,221.11 0.00 0.00 70350 TC A 9.93 0.00 0.00<br />

69650 S 903.96 0.00 0.00 70355 TC A 10.26 0.00 0.00<br />

69660 S 1,096.68 0.00 0.00 70360 TC A 15.89 0.00 0.00<br />

69661 S 1,096.68 0.00 0.00 70370 TC A 46.67 0.00 0.00<br />

69662 S 1,096.68 0.00 0.00 70371 TC A 46.67 0.00 0.00<br />

69666 S 1,057.74 0.00 0.00 70380 TC A 24.17 0.00 0.00<br />

69667 S 1,057.74 0.00 0.00 70450 TC A 109.03 0.00 0.00<br />

69670 S 1,004.03 0.00 0.00 70460 TC A 172.65 0.00 0.00<br />

69676 S 1,004.03 0.00 0.00 70470 TC A 191.25 0.00 0.00<br />

69700 S 1,004.03 0.00 0.00 70480 TC A 109.03 0.00 0.00<br />

69711 S 924.81 0.00 0.00 70481 TC A 172.65 0.00 0.00<br />

69714 S 5,864.99 3,698.10 1,531.21 70482 TC A 191.25 0.00 0.00<br />

69715 S 5,864.99 3,698.10 1,531.21 70486 TC A 109.03 0.00 0.00<br />

69717 S 5,864.99 3,698.10 1,531.21 70487 TC A 172.65 0.00 0.00<br />

69718 S 5,864.99 3,698.10 1,531.21 70488 TC A 191.25 0.00 0.00<br />

69720 S 1,096.68 0.00 0.00 70490 TC A 109.03 0.00 0.00<br />

69740 S 1,096.68 0.00 0.00 70491 TC A 172.65 0.00 0.00<br />

69745 S 1,096.68 0.00 0.00 70492 TC A 191.25 0.00 0.00<br />

69801 S 1,096.68 0.00 0.00 70496 TC A 197.36 0.00 0.00<br />

69802 S 1,221.11 0.00 0.00 70498 TC A 197.36 0.00 0.00<br />

69805 S 1,221.11 0.00 0.00 70540 TC A 195.22 0.00 0.00<br />

69806 S 1,221.11 0.00 0.00 70542 TC A 239.74 0.00 0.00<br />

69820 S 1,096.68 0.00 0.00 70543 TC A 302.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 195.22 0.00 0.00 72120 TC A 31.78 0.00 0.00<br />

70545 TC A 239.74 0.00 0.00 72125 TC A 109.03 0.00 0.00<br />

70546 TC A 302.15 0.00 0.00 72126 TC A 172.65 0.00 0.00<br />

70547 TC A 195.22 0.00 0.00 72127 TC A 191.25 0.00 0.00<br />

70548 TC A 239.74 0.00 0.00 72128 TC A 109.03 0.00 0.00<br />

70549 TC A 302.15 0.00 0.00 72129 TC A 172.65 0.00 0.00<br />

70551 TC A 195.22 0.00 0.00 72130 TC A 191.25 0.00 0.00<br />

70552 TC A 239.74 0.00 0.00 72131 TC A 109.03 0.00 0.00<br />

70553 TC A 302.15 0.00 0.00 72132 TC A 172.65 0.00 0.00<br />

70554 TC A 195.22 0.00 0.00 72133 TC A 191.25 0.00 0.00<br />

70555 TC A 195.22 0.00 0.00 72141 TC A 195.22 0.00 0.00<br />

70557 TC A 195.22 0.00 0.00 72142 TC A 239.74 0.00 0.00<br />

70558 TC A 239.74 0.00 0.00 72146 TC A 195.22 0.00 0.00<br />

70559 TC A 302.15 0.00 0.00 72147 TC A 239.74 0.00 0.00<br />

71010 TC A 12.92 0.00 0.00 72148 TC A 195.22 0.00 0.00<br />

71015 TC A 16.55 0.00 0.00 72149 TC A 239.74 0.00 0.00<br />

71020 TC A 17.55 0.00 0.00 72156 TC A 302.15 0.00 0.00<br />

71021 TC A 21.19 0.00 0.00 72157 TC A 302.15 0.00 0.00<br />

71022 TC A 25.08 0.00 0.00 72158 TC A 302.15 0.00 0.00<br />

71023 TC A 41.05 0.00 0.00 72170 TC A 14.90 0.00 0.00<br />

71030 TC A 25.08 0.00 0.00 72190 TC A 25.08 0.00 0.00<br />

71034 TC A 46.67 0.00 0.00 72191 TC A 197.36 0.00 0.00<br />

71035 TC A 21.85 0.00 0.00 72192 TC A 109.03 0.00 0.00<br />

71100 TC A 18.21 0.00 0.00 72193 TC A 172.65 0.00 0.00<br />

71101 TC A 22.18 0.00 0.00 72194 TC A 191.25 0.00 0.00<br />

71110 TC A 23.18 0.00 0.00 72195 TC A 195.22 0.00 0.00<br />

71111 TC A 30.79 0.00 0.00 72196 TC A 239.74 0.00 0.00<br />

71120 TC A 19.20 0.00 0.00 72197 TC A 302.15 0.00 0.00<br />

71130 TC A 22.52 0.00 0.00 72200 TC A 17.55 0.00 0.00<br />

71250 TC A 109.03 0.00 0.00 72202 TC A 21.52 0.00 0.00<br />

71260 TC A 172.65 0.00 0.00 72220 TC A 17.55 0.00 0.00<br />

71270 TC A 191.25 0.00 0.00 73000 TC A 16.55 0.00 0.00<br />

71275 TC A 197.36 0.00 0.00 73010 TC A 16.88 0.00 0.00<br />

71550 TC A 195.22 0.00 0.00 73020 TC A 13.58 0.00 0.00<br />

71551 TC A 239.74 0.00 0.00 73030 TC A 17.21 0.00 0.00<br />

71552 TC A 302.15 0.00 0.00 73050 TC A 21.52 0.00 0.00<br />

72010 TC A 41.75 0.00 0.00 73060 TC A 17.21 0.00 0.00<br />

72020 TC A 13.58 0.00 0.00 73070 TC A 16.55 0.00 0.00<br />

72040 TC A 21.85 0.00 0.00 73080 TC A 21.85 0.00 0.00<br />

72050 TC A 31.12 0.00 0.00 73090 TC A 16.55 0.00 0.00<br />

72052 TC A 41.75 0.00 0.00 73092 TC A 17.21 0.00 0.00<br />

72069 TC A 20.53 0.00 0.00 73100 TC A 17.21 0.00 0.00<br />

72070 TC A 19.20 0.00 0.00 73110 TC A 21.85 0.00 0.00<br />

72072 TC A 23.18 0.00 0.00 73120 TC A 16.22 0.00 0.00<br />

72074 TC A 25.08 0.00 0.00 73130 TC A 19.20 0.00 0.00<br />

72080 TC A 20.53 0.00 0.00 73140 TC A 18.87 0.00 0.00<br />

72090 TC A 27.48 0.00 0.00 73200 TC A 109.03 0.00 0.00<br />

72100 TC A 23.51 0.00 0.00 73201 TC A 172.65 0.00 0.00<br />

72110 TC A 32.78 0.00 0.00 73202 TC A 191.25 0.00 0.00<br />

72114 TC A 41.75 0.00 0.00 73206 TC A 197.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 195.22 0.00 0.00 74246 TC A 49.27 0.00 0.00<br />

73219 TC A 239.74 0.00 0.00 74247 TC A 49.27 0.00 0.00<br />

73220 TC A 302.15 0.00 0.00 74249 TC A 80.11 0.00 0.00<br />

73221 TC A 195.22 0.00 0.00 74250 TC A 49.27 0.00 0.00<br />

73222 TC A 239.74 0.00 0.00 74251 TC A 80.11 0.00 0.00<br />

73223 TC A 302.15 0.00 0.00 74260 TC A 49.27 0.00 0.00<br />

73500 TC A 14.24 0.00 0.00 74270 TC A 49.27 0.00 0.00<br />

73510 TC A 21.85 0.00 0.00 74280 TC A 80.11 0.00 0.00<br />

73520 TC A 22.52 0.00 0.00 74283 TC A 49.27 0.00 0.00<br />

73540 TC A 22.52 0.00 0.00 74290 TC A 42.04 0.00 0.00<br />

73550 TC A 16.55 0.00 0.00 74291 TC A 40.39 0.00 0.00<br />

73560 TC A 16.88 0.00 0.00 74400 TC A 73.17 0.00 0.00<br />

73562 TC A 20.86 0.00 0.00 74410 TC A 78.14 0.00 0.00<br />

73564 TC A 24.17 0.00 0.00 74415 TC A 93.37 0.00 0.00<br />

73565 TC A 18.21 0.00 0.00 74420 TC A 97.59 0.00 0.00<br />

73590 TC A 15.89 0.00 0.00 74710 TC A 21.85 0.00 0.00<br />

73592 TC A 17.21 0.00 0.00 74775 TC A 97.59 0.00 0.00<br />

73600 TC A 16.22 0.00 0.00 75557 TC A 195.22 0.00 0.00<br />

73610 TC A 19.20 0.00 0.00 75559 TC A 195.22 0.00 0.00<br />

73620 TC A 15.56 0.00 0.00 75561 TC A 302.15 0.00 0.00<br />

73630 TC A 18.87 0.00 0.00 75563 TC A 302.15 0.00 0.00<br />

73650 TC A 15.89 0.00 0.00 76010 TC A 16.22 0.00 0.00<br />

73660 TC A 17.88 0.00 0.00 76098 TC A 9.93 0.00 0.00<br />

73700 TC A 109.03 0.00 0.00 76100 TC A 41.75 0.00 0.00<br />

73701 TC A 172.65 0.00 0.00 76101 TC A 111.90 0.00 0.00<br />

73702 TC A 191.25 0.00 0.00 76102 TC A 111.90 0.00 0.00<br />

73706 TC A 197.36 0.00 0.00 76120 TC A 46.67 0.00 0.00<br />

73718 TC A 195.22 0.00 0.00 76150 A 16.22 0.00 0.00<br />

73719 TC A 239.74 0.00 0.00 76380 TC A 58.90 0.00 0.00<br />

73720 TC A 302.15 0.00 0.00 76496 TC A 46.67 0.00 0.00<br />

73721 TC A 195.22 0.00 0.00 76497 TC A 58.90 0.00 0.00<br />

73722 TC A 239.74 0.00 0.00 76498 TC A 195.22 0.00 0.00<br />

73723 TC A 302.15 0.00 0.00 76499 TC A 25.08 0.00 0.00<br />

74000 TC A 14.24 0.00 0.00 76506 TC A 35.06 0.00 0.00<br />

74010 TC A 22.18 0.00 0.00 76510 TC A 59.60 0.00 0.00<br />

74020 TC A 22.52 0.00 0.00 76511 TC A 41.71 0.00 0.00<br />

74022 TC A 27.48 0.00 0.00 76512 TC A 35.43 0.00 0.00<br />

74150 TC A 109.03 0.00 0.00 76513 TC A 43.05 0.00 0.00<br />

74160 TC A 172.65 0.00 0.00 76514 TC A 2.98 0.00 0.00<br />

74170 TC A 191.25 0.00 0.00 76516 TC A 33.77 0.00 0.00<br />

74175 TC A 197.36 0.00 0.00 76519 TC A 37.75 0.00 0.00<br />

74181 TC A 195.22 0.00 0.00 76529 TC A 32.78 0.00 0.00<br />

74182 TC A 239.74 0.00 0.00 76536 TC A 54.84 0.00 0.00<br />

74183 TC A 302.15 0.00 0.00 76604 TC A 35.06 0.00 0.00<br />

74210 TC A 49.27 0.00 0.00 76645 TC A 35.06 0.00 0.00<br />

74220 TC A 49.27 0.00 0.00 76700 TC A 54.84 0.00 0.00<br />

74230 TC A 49.27 0.00 0.00 76705 TC A 54.84 0.00 0.00<br />

74240 TC A 49.27 0.00 0.00 76770 TC A 54.84 0.00 0.00<br />

74241 TC A 49.27 0.00 0.00 76775 TC A 54.84 0.00 0.00<br />

74245 TC A 80.11 0.00 0.00 76776 TC A 54.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 54.84 0.00 0.00 77290 TC A 143.42 0.00 0.00<br />

76801 TC A 54.84 0.00 0.00 77295 TC A 375.79 0.00 0.00<br />

76802 TC A 26.15 0.00 0.00 77299 TC A 64.34 0.00 0.00<br />

76805 TC A 54.84 0.00 0.00 77300 TC A 34.76 0.00 0.00<br />

76810 TC A 41.38 0.00 0.00 77301 TC A 500.82 0.00 0.00<br />

76811 TC A 85.92 0.00 0.00 77305 TC A 31.78 0.00 0.00<br />

76812 TC A 35.06 0.00 0.00 77310 TC A 41.38 0.00 0.00<br />

76813 TC A 35.06 0.00 0.00 77315 TC A 60.26 0.00 0.00<br />

76814 TC A 27.82 0.00 0.00 77321 TC A 62.58 0.00 0.00<br />

76815 TC A 35.06 0.00 0.00 77326 TC A 64.34 0.00 0.00<br />

76816 TC A 35.06 0.00 0.00 77327 TC A 116.88 0.00 0.00<br />

76817 TC A 35.06 0.00 0.00 77328 TC A 143.42 0.00 0.00<br />

76818 TC A 54.84 0.00 0.00 77331 TC A 16.55 0.00 0.00<br />

76819 TC A 47.35 0.00 0.00 77332 TC A 44.37 0.00 0.00<br />

76820 TC A 23.51 0.00 0.00 77333 TC A 21.52 0.00 0.00<br />

76821 TC A 53.09 0.00 0.00 77334 TC A 83.11 0.00 0.00<br />

76825 TC A 110.58 0.00 0.00 77336 A 52.32 0.00 0.00<br />

76826 TC A 65.88 0.00 0.00 77370 A 64.34 0.00 0.00<br />

76827 TC A 35.06 0.00 0.00 77371 A 4,286.23 0.00 0.00<br />

76828 TC A 20.86 0.00 0.00 77399 TC A 64.34 0.00 0.00<br />

76830 TC A 54.84 0.00 0.00 77401 A 26.15 0.00 0.00<br />

76831 TC A 73.83 0.00 0.00 77402 A 52.66 0.00 0.00<br />

76856 TC A 54.84 0.00 0.00 77403 A 52.66 0.00 0.00<br />

76857 TC A 35.06 0.00 0.00 77404 A 52.66 0.00 0.00<br />

76870 TC A 54.84 0.00 0.00 77406 A 85.29 0.00 0.00<br />

76872 TC A 54.84 0.00 0.00 77407 A 52.66 0.00 0.00<br />

76873 TC A 54.84 0.00 0.00 77408 A 52.66 0.00 0.00<br />

76880 TC A 54.84 0.00 0.00 77409 A 52.66 0.00 0.00<br />

76885 TC A 35.06 0.00 0.00 77411 A 85.29 0.00 0.00<br />

76886 TC A 35.06 0.00 0.00 77412 A 85.29 0.00 0.00<br />

76936 TC A 53.09 0.00 0.00 77413 A 85.29 0.00 0.00<br />

76970 TC A 35.06 0.00 0.00 77414 A 85.29 0.00 0.00<br />

76977 TC A 8.94 0.00 0.00 77416 A 85.29 0.00 0.00<br />

76999 TC A 35.06 0.00 0.00 77418 A 230.44 0.00 0.00<br />

77071 A 20.53 0.00 0.00 77422 A 85.29 0.00 0.00<br />

77072 TC A 11.92 0.00 0.00 77423 A 85.29 0.00 0.00<br />

77073 TC A 20.20 0.00 0.00 77470 TC A 122.51 0.00 0.00<br />

77074 TC A 39.73 0.00 0.00 77520 A 394.53 0.00 0.00<br />

77075 TC A 41.75 0.00 0.00 77522 A 394.53 0.00 0.00<br />

77076 TC A 41.75 0.00 0.00 77523 A 471.48 0.00 0.00<br />

77077 TC A 22.52 0.00 0.00 77525 A 471.48 0.00 0.00<br />

77078 TC A 40.34 0.00 0.00 77600 TC A 209.33 0.00 0.00<br />

77079 TC A 41.38 0.00 0.00 77605 TC A 209.33 0.00 0.00<br />

77080 TC A 40.34 0.00 0.00 77610 TC A 209.33 0.00 0.00<br />

77081 TC A 16.22 0.00 0.00 77615 TC A 209.33 0.00 0.00<br />

77082 TC A 17.55 0.00 0.00 77620 TC A 209.33 0.00 0.00<br />

77083 TC A 13.91 0.00 0.00 77750 TC A 81.44 0.00 0.00<br />

77084 TC A 195.22 0.00 0.00 77761 TC A 143.36 0.00 0.00<br />

77280 TC A 64.34 0.00 0.00 77762 TC A 169.85 0.00 0.00<br />

77285 TC A 143.42 0.00 0.00 77763 TC A 218.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 155.28 0.00 0.00 78262 TC A 136.37 0.00 0.00<br />

77777 TC A 170.51 0.00 0.00 78264 TC A 136.37 0.00 0.00<br />

77778 TC A 227.13 0.00 0.00 78270 TC A 59.60 0.00 0.00<br />

77785 TC A 100.98 0.00 0.00 78271 TC A 60.59 0.00 0.00<br />

77786 TC A 354.93 0.00 0.00 78272 TC A 66.55 0.00 0.00<br />

77787 TC A 411.28 0.00 0.00 78278 TC A 136.37 0.00 0.00<br />

77789 TC A 42.38 0.00 0.00 78282 TC A 136.37 0.00 0.00<br />

77799 TC A 241.56 0.00 0.00 78290 TC A 136.37 0.00 0.00<br />

78000 TC A 51.98 0.00 0.00 78291 TC A 136.37 0.00 0.00<br />

78001 TC A 65.88 0.00 0.00 78299 TC A 136.37 0.00 0.00<br />

78003 TC A 52.32 0.00 0.00 78300 TC A 118.86 0.00 0.00<br />

78006 TC A 124.47 0.00 0.00 78305 TC A 137.86 0.00 0.00<br />

78007 TC A 92.05 0.00 0.00 78306 TC A 137.86 0.00 0.00<br />

78010 TC A 76.48 0.00 0.00 78315 TC A 137.86 0.00 0.00<br />

78011 TC A 76.48 0.00 0.00 78320 TC A 137.86 0.00 0.00<br />

78015 TC A 148.66 0.00 0.00 78399 TC A 137.86 0.00 0.00<br />

78016 TC A 167.80 0.00 0.00 78414 TC A 175.23 0.00 0.00<br />

78018 TC A 167.80 0.00 0.00 78428 TC A 134.42 0.00 0.00<br />

78070 TC A 114.23 0.00 0.00 78445 TC A 104.85 0.00 0.00<br />

78075 TC A 323.48 0.00 0.00 78456 TC A 104.85 0.00 0.00<br />

78099 TC A 76.48 0.00 0.00 78457 TC A 104.85 0.00 0.00<br />

78102 TC A 115.55 0.00 0.00 78458 TC A 104.85 0.00 0.00<br />

78103 TC A 147.29 0.00 0.00 78459 TC A 648.89 0.00 0.00<br />

78104 TC A 147.29 0.00 0.00 78460 TC A 125.81 0.00 0.00<br />

78110 TC A 58.61 0.00 0.00 78461 TC A 126.81 0.00 0.00<br />

78111 TC A 74.17 0.00 0.00 78464 TC A 186.07 0.00 0.00<br />

78120 TC A 64.89 0.00 0.00 78465 TC A 352.28 0.00 0.00<br />

78121 TC A 76.81 0.00 0.00 78466 TC A 124.82 0.00 0.00<br />

78122 TC A 91.05 0.00 0.00 78468 TC A 159.59 0.00 0.00<br />

78130 TC A 105.62 0.00 0.00 78469 TC A 175.23 0.00 0.00<br />

78135 TC A 224.47 0.00 0.00 78472 TC A 175.23 0.00 0.00<br />

78140 TC A 99.66 0.00 0.00 78473 TC A 175.23 0.00 0.00<br />

78185 TC A 147.29 0.00 0.00 78481 TC A 151.30 0.00 0.00<br />

78190 TC A 92.42 0.00 0.00 78483 TC A 175.23 0.00 0.00<br />

78191 TC A 92.42 0.00 0.00 78491 TC A 648.89 0.00 0.00<br />

78195 TC A 147.29 0.00 0.00 78492 TC A 648.89 0.00 0.00<br />

78199 TC A 147.29 0.00 0.00 78494 TC A 175.23 0.00 0.00<br />

78201 TC A 131.11 0.00 0.00 78499 TC A 175.23 0.00 0.00<br />

78202 TC A 154.23 0.00 0.00 78580 TC A 118.72 0.00 0.00<br />

78205 TC A 154.23 0.00 0.00 78584 TC A 91.71 0.00 0.00<br />

78206 TC A 154.23 0.00 0.00 78585 TC A 182.16 0.00 0.00<br />

78215 TC A 138.73 0.00 0.00 78586 TC A 118.72 0.00 0.00<br />

78216 TC A 94.03 0.00 0.00 78587 TC A 118.72 0.00 0.00<br />

78220 TC A 102.64 0.00 0.00 78588 TC A 182.16 0.00 0.00<br />

78223 TC A 154.23 0.00 0.00 78591 TC A 118.72 0.00 0.00<br />

78230 TC A 116.54 0.00 0.00 78593 TC A 118.72 0.00 0.00<br />

78231 TC A 91.71 0.00 0.00 78594 TC A 118.72 0.00 0.00<br />

78232 TC A 95.68 0.00 0.00 78596 TC A 182.16 0.00 0.00<br />

78258 TC A 136.37 0.00 0.00 78599 TC A 118.72 0.00 0.00<br />

78261 TC A 136.37 0.00 0.00 78600 TC A 104.62 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 37460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 104.62 0.00 0.00<br />

78605 TC A 104.62 0.00 0.00<br />

78606 TC A 235.07 0.00 0.00<br />

78607 TC A 258.25 0.00 0.00<br />

78608 TC A 581.61 0.00 0.00<br />

78610 TC A 139.39 0.00 0.00<br />

78630 TC A 248.32 0.00 0.00<br />

78635 TC A 228.78 0.00 0.00<br />

78645 TC A 104.62 0.00 0.00<br />

78647 TC A 253.29 0.00 0.00<br />

78650 TC A 245.34 0.00 0.00<br />

78660 TC A 104.62 0.00 0.00<br />

78699 TC A 104.62 0.00 0.00<br />

78700 TC A 128.80 0.00 0.00<br />

78701 TC A 156.94 0.00 0.00<br />

78707 TC A 163.89 0.00 0.00<br />

78708 TC A 112.24 0.00 0.00<br />

78709 TC A 184.54 0.00 0.00<br />

78710 TC A 173.16 0.00 0.00<br />

78725 TC A 69.20 0.00 0.00<br />

78730 TC A 58.61 0.00 0.00<br />

78740 TC A 152.97 0.00 0.00<br />

78761 TC A 146.01 0.00 0.00<br />

78799 TC A 184.54 0.00 0.00<br />

78800 TC A 129.13 0.00 0.00<br />

78801 TC A 177.14 0.00 0.00<br />

78802 TC A 240.04 0.00 0.00<br />

78803 TC A 257.26 0.00 0.00<br />

78804 TC A 448.96 0.00 0.00<br />

78805 TC A 126.14 0.00 0.00<br />

78806 TC A 252.29 0.00 0.00<br />

78807 TC A 257.59 0.00 0.00<br />

78811 TC A 581.61 0.00 0.00<br />

78812 TC A 581.61 0.00 0.00<br />

78813 TC A 581.61 0.00 0.00<br />

78814 TC A 581.61 0.00 0.00<br />

78815 TC A 581.61 0.00 0.00<br />

78816 TC A 581.61 0.00 0.00<br />

78999 TC A 65.88 0.00 0.00<br />

79005 TC A 52.98 0.00 0.00<br />

79101 TC A 57.94 0.00 0.00<br />

79200 TC A 62.58 0.00 0.00<br />

79300 TC A 120.74 0.00 0.00<br />

79403 TC A 89.73 0.00 0.00<br />

79440 TC A 50.66 0.00 0.00<br />

79445 TC A 120.74 0.00 0.00<br />

79999 TC A 120.74 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,119.53 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,437.72 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.26 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,485.59 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,485.59 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 214.54 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 214.54 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 108.33 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 228.96 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 68.83 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 616.31 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,405.39 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,100.07 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,100.07 0.00 0.00<br />

C8900 A 238.19 0.00 0.00 0123T S 879.73 0.00 0.00<br />

C8901 A 193.97 0.00 0.00 0124T S 171.95 0.00 0.00<br />

C8902 A 300.21 0.00 0.00 0144T TC A 58.52 0.00 0.00<br />

C8903 A 238.19 0.00 0.00 0145T TC A 157.54 0.00 0.00<br />

C8904 A 193.97 0.00 0.00 0146T TC A 157.54 0.00 0.00<br />

C8905 A 300.21 0.00 0.00 0147T TC A 157.54 0.00 0.00<br />

C8906 A 238.19 0.00 0.00 0148T TC A 157.54 0.00 0.00<br />

C8907 A 193.97 0.00 0.00 0149T TC A 157.54 0.00 0.00<br />

C8908 A 300.21 0.00 0.00 0150T TC A 157.54 0.00 0.00<br />

C8909 A 238.19 0.00 0.00 0151T TC A 58.52 0.00 0.00<br />

C8910 A 193.97 0.00 0.00 0170T S 1,142.72 0.00 0.00<br />

C8911 A 300.21 0.00 0.00 0176T S 1,349.29 0.00 0.00<br />

C8912 A 238.19 0.00 0.00 0177T S 1,349.29 0.00 0.00<br />

C8913 A 193.97 0.00 0.00 0182T A 975.27 0.00 0.00<br />

C8914 A 300.21 0.00 0.00 0186T S 821.96 0.00 0.00<br />

C8918 A 238.19 0.00 0.00 0190T S 821.96 0.00 0.00<br />

C8919 A 193.97 0.00 0.00 0191T S 879.73 0.00 0.00<br />

C8920 A 300.21 0.00 0.00 0192T S 1,507.68 0.00 0.00<br />

C9716 S 1,142.72 0.00 0.00 10021 S 52.73 0.00 0.00<br />

C9724 S 934.30 0.00 0.00 10022 S 164.66 0.00 0.00<br />

C9725 S 215.45 0.00 0.00 10040 S 30.48 0.00 0.00<br />

C9726 S 790.96 0.00 0.00 10060 S 46.38 0.00 0.00<br />

C9727 S 277.32 0.00 0.00 10061 S 52.01 0.00 0.00<br />

C9728 S 497.61 0.00 0.00 10080 S 52.01 0.00 0.00<br />

G0104 S 79.94 0.00 0.00 10081 S 119.74 0.00 0.00<br />

G0105 S 345.49 0.00 0.00 10120 S 65.13 0.00 0.00<br />

G0121 S 345.49 0.00 0.00 10121 S 490.96 0.00 0.00<br />

G0127 S 11.18 0.00 0.00 10140 S 69.08 0.00 0.00<br />

G0130 TC A 18.42 0.00 0.00 10160 S 52.01 0.00 0.00<br />

G0173 A 2,119.53 0.00 0.00 10180 S 555.20 0.00 0.00<br />

G0186 S 214.54 0.00 0.00 11000 S 22.37 0.00 0.00<br />

G0247 S 20.39 0.00 0.00 11001 S 7.57 0.00 0.00<br />

G0251 A 530.76 0.00 0.00 11010 S 194.24 0.00 0.00<br />

G0260 S 280.10 0.00 0.00 11011 S 194.24 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 194.24 0.00 0.00 11601 S 107.24 0.00 0.00<br />

11040 S 20.39 0.00 0.00 11602 S 118.10 0.00 0.00<br />

11041 S 22.70 0.00 0.00 11603 S 125.33 0.00 0.00<br />

11042 S 123.34 0.00 0.00 11604 S 338.08 0.00 0.00<br />

11043 S 123.34 0.00 0.00 11606 S 490.96 0.00 0.00<br />

11044 S 321.17 0.00 0.00 11620 S 91.46 0.00 0.00<br />

11055 S 24.02 0.00 0.00 11621 S 108.56 0.00 0.00<br />

11056 S 26.31 0.00 0.00 11622 S 120.73 0.00 0.00<br />

11057 S 30.48 0.00 0.00 11623 S 129.94 0.00 0.00<br />

11100 S 55.85 0.00 0.00 11624 S 490.96 0.00 0.00<br />

11101 S 13.16 0.00 0.00 11626 S 600.40 0.00 0.00<br />

11200 S 30.48 0.00 0.00 11640 S 96.72 0.00 0.00<br />

11201 S 5.26 0.00 0.00 11641 S 114.15 0.00 0.00<br />

11300 S 30.48 0.00 0.00 11642 S 127.31 0.00 0.00<br />

11301 S 30.48 0.00 0.00 11643 S 137.18 0.00 0.00<br />

11302 S 30.48 0.00 0.00 11644 S 490.96 0.00 0.00<br />

11303 S 55.85 0.00 0.00 11646 S 600.40 0.00 0.00<br />

11305 S 30.48 0.00 0.00 11719 S 11.18 0.00 0.00<br />

11306 S 30.48 0.00 0.00 11720 S 13.82 0.00 0.00<br />

11307 S 30.48 0.00 0.00 11721 S 16.77 0.00 0.00<br />

11308 S 30.48 0.00 0.00 11730 S 30.48 0.00 0.00<br />

11310 S 30.48 0.00 0.00 11732 S 16.77 0.00 0.00<br />

11311 S 30.48 0.00 0.00 11740 S 15.40 0.00 0.00<br />

11312 S 30.48 0.00 0.00 11750 S 88.82 0.00 0.00<br />

11313 S 30.48 0.00 0.00 11752 S 123.36 0.00 0.00<br />

11400 S 62.83 0.00 0.00 11755 S 61.51 0.00 0.00<br />

11401 S 70.72 0.00 0.00 11760 S 126.69 0.00 0.00<br />

11402 S 77.64 0.00 0.00 11762 S 113.16 0.00 0.00<br />

11403 S 82.90 0.00 0.00 11765 S 30.48 0.00 0.00<br />

11404 S 440.71 0.00 0.00 11770 S 628.87 0.00 0.00<br />

11406 S 490.96 0.00 0.00 11771 S 628.87 0.00 0.00<br />

11420 S 58.89 0.00 0.00 11772 S 628.87 0.00 0.00<br />

11421 S 71.38 0.00 0.00 11900 S 27.96 0.00 0.00<br />

11422 S 77.97 0.00 0.00 11901 S 30.48 0.00 0.00<br />

11423 S 86.85 0.00 0.00 11920 S 88.49 0.00 0.00<br />

11424 S 490.96 0.00 0.00 11921 S 97.38 0.00 0.00<br />

11426 S 600.40 0.00 0.00 11922 S 31.58 0.00 0.00<br />

11440 S 67.44 0.00 0.00 11950 S 32.24 0.00 0.00<br />

11441 S 77.97 0.00 0.00 11951 S 40.13 0.00 0.00<br />

11442 S 85.86 0.00 0.00 11952 S 48.31 0.00 0.00<br />

11443 S 95.07 0.00 0.00 11954 S 48.31 0.00 0.00<br />

11444 S 300.06 0.00 0.00 11960 S 586.10 0.00 0.00<br />

11446 S 600.40 0.00 0.00 11970 S 1,061.62 0.00 0.00<br />

11450 S 600.40 0.00 0.00 11971 S 550.15 0.00 0.00<br />

11451 S 600.40 0.00 0.00 11976 S 58.89 0.00 0.00<br />

11462 S 600.40 0.00 0.00 11980 S 23.79 0.00 0.00<br />

11463 S 600.40 0.00 0.00 11981 S 23.79 0.00 0.00<br />

11470 S 600.40 0.00 0.00 11982 S 23.79 0.00 0.00<br />

11471 S 600.40 0.00 0.00 11983 S 23.79 0.00 0.00<br />

11600 S 88.49 0.00 0.00 12001 S 48.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 48.31 0.00 0.00 14021 S 520.85 0.00 0.00<br />

12004 S 48.31 0.00 0.00 14040 S 492.39 0.00 0.00<br />

12005 S 64.73 0.00 0.00 14041 S 520.85 0.00 0.00<br />

12006 S 64.73 0.00 0.00 14060 S 520.85 0.00 0.00<br />

12007 S 64.73 0.00 0.00 14061 S 520.85 0.00 0.00<br />

12011 S 48.31 0.00 0.00 14300 S 667.92 0.00 0.00<br />

12013 S 48.31 0.00 0.00 14350 S 614.55 0.00 0.00<br />

12014 S 48.31 0.00 0.00 15002 S 225.32 0.00 0.00<br />

12015 S 48.31 0.00 0.00 15003 S 225.32 0.00 0.00<br />

12016 S 64.73 0.00 0.00 15004 S 225.32 0.00 0.00<br />

12017 S 64.73 0.00 0.00 15005 S 225.32 0.00 0.00<br />

12018 S 64.73 0.00 0.00 15040 S 103.92 0.00 0.00<br />

12020 S 122.13 0.00 0.00 15050 S 225.32 0.00 0.00<br />

12021 S 103.92 0.00 0.00 15100 S 586.10 0.00 0.00<br />

12031 S 48.31 0.00 0.00 15101 S 614.55 0.00 0.00<br />

12032 S 126.69 0.00 0.00 15110 S 279.89 0.00 0.00<br />

12034 S 64.73 0.00 0.00 15111 S 229.64 0.00 0.00<br />

12035 S 64.73 0.00 0.00 15115 S 279.89 0.00 0.00<br />

12036 S 103.92 0.00 0.00 15116 S 229.64 0.00 0.00<br />

12037 S 207.11 0.00 0.00 15120 S 586.10 0.00 0.00<br />

12041 S 48.31 0.00 0.00 15121 S 614.55 0.00 0.00<br />

12042 S 48.31 0.00 0.00 15130 S 492.39 0.00 0.00<br />

12044 S 64.73 0.00 0.00 15131 S 442.13 0.00 0.00<br />

12045 S 103.92 0.00 0.00 15135 S 492.39 0.00 0.00<br />

12046 S 103.92 0.00 0.00 15136 S 442.13 0.00 0.00<br />

12047 S 207.11 0.00 0.00 15150 S 279.89 0.00 0.00<br />

12051 S 48.31 0.00 0.00 15151 S 229.64 0.00 0.00<br />

12052 S 48.31 0.00 0.00 15152 S 229.64 0.00 0.00<br />

12053 S 48.31 0.00 0.00 15155 S 279.89 0.00 0.00<br />

12054 S 64.73 0.00 0.00 15156 S 229.64 0.00 0.00<br />

12055 S 103.92 0.00 0.00 15157 S 229.64 0.00 0.00<br />

12056 S 103.92 0.00 0.00 15170 S 126.69 0.00 0.00<br />

12057 S 207.11 0.00 0.00 15171 S 126.69 0.00 0.00<br />

13100 S 225.32 0.00 0.00 15175 S 163.11 0.00 0.00<br />

13101 S 225.32 0.00 0.00 15176 S 163.11 0.00 0.00<br />

13102 S 122.13 0.00 0.00 15200 S 520.85 0.00 0.00<br />

13120 S 103.92 0.00 0.00 15201 S 437.82 0.00 0.00<br />

13121 S 103.92 0.00 0.00 15220 S 492.39 0.00 0.00<br />

13122 S 103.92 0.00 0.00 15221 S 225.32 0.00 0.00<br />

13131 S 103.92 0.00 0.00 15240 S 520.85 0.00 0.00<br />

13132 S 103.92 0.00 0.00 15241 S 225.32 0.00 0.00<br />

13133 S 103.92 0.00 0.00 15260 S 492.39 0.00 0.00<br />

13150 S 225.32 0.00 0.00 15261 S 437.82 0.00 0.00<br />

13151 S 225.32 0.00 0.00 15300 S 225.32 0.00 0.00<br />

13152 S 225.32 0.00 0.00 15301 S 225.32 0.00 0.00<br />

13153 S 103.92 0.00 0.00 15320 S 225.32 0.00 0.00<br />

13160 S 586.10 0.00 0.00 15321 S 225.32 0.00 0.00<br />

14000 S 492.39 0.00 0.00 15330 S 225.32 0.00 0.00<br />

14001 S 520.85 0.00 0.00 15331 S 225.32 0.00 0.00<br />

14020 S 520.85 0.00 0.00 15335 S 225.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 225.32 0.00 0.00 15826 S 614.55 0.00 0.00<br />

15340 S 126.69 0.00 0.00 15828 S 614.55 0.00 0.00<br />

15341 S 126.69 0.00 0.00 15829 S 706.60 0.00 0.00<br />

15360 S 126.69 0.00 0.00 15830 S 628.87 0.00 0.00<br />

15361 S 126.69 0.00 0.00 15832 S 628.87 0.00 0.00<br />

15365 S 126.69 0.00 0.00 15833 S 628.87 0.00 0.00<br />

15366 S 126.69 0.00 0.00 15834 S 628.87 0.00 0.00<br />

15400 S 225.32 0.00 0.00 15835 S 545.83 0.00 0.00<br />

15401 S 225.32 0.00 0.00 15836 S 519.42 0.00 0.00<br />

15420 S 225.32 0.00 0.00 15837 S 585.26 0.00 0.00<br />

15421 S 225.32 0.00 0.00 15838 S 585.26 0.00 0.00<br />

15430 S 225.32 0.00 0.00 15839 S 519.42 0.00 0.00<br />

15431 S 225.32 0.00 0.00 15840 S 667.92 0.00 0.00<br />

15570 S 614.55 0.00 0.00 15841 S 667.92 0.00 0.00<br />

15572 S 614.55 0.00 0.00 15842 S 775.52 0.00 0.00<br />

15574 S 614.55 0.00 0.00 15845 S 667.92 0.00 0.00<br />

15576 S 614.55 0.00 0.00 15847 S 628.87 0.00 0.00<br />

15600 S 614.55 0.00 0.00 15850 S 100.46 0.00 0.00<br />

15610 S 614.55 0.00 0.00 15851 S 45.72 0.00 0.00<br />

15620 S 667.92 0.00 0.00 15852 S 23.79 0.00 0.00<br />

15630 S 614.55 0.00 0.00 15860 S 23.79 0.00 0.00<br />

15650 S 706.60 0.00 0.00 15876 S 614.55 0.00 0.00<br />

15731 S 614.55 0.00 0.00 15877 S 614.55 0.00 0.00<br />

15732 S 614.55 0.00 0.00 15878 S 614.55 0.00 0.00<br />

15734 S 614.55 0.00 0.00 15879 S 614.55 0.00 0.00<br />

15736 S 614.55 0.00 0.00 15920 S 194.24 0.00 0.00<br />

15738 S 614.55 0.00 0.00 15922 S 667.92 0.00 0.00<br />

15740 S 492.39 0.00 0.00 15931 S 628.87 0.00 0.00<br />

15750 S 586.10 0.00 0.00 15933 S 628.87 0.00 0.00<br />

15760 S 586.10 0.00 0.00 15934 S 614.55 0.00 0.00<br />

15770 S 614.55 0.00 0.00 15935 S 667.92 0.00 0.00<br />

15775 S 167.92 0.00 0.00 15936 S 574.21 0.00 0.00<br />

15776 S 167.92 0.00 0.00 15937 S 667.92 0.00 0.00<br />

15780 S 374.36 0.00 0.00 15940 S 628.87 0.00 0.00<br />

15781 S 164.78 0.00 0.00 15941 S 628.87 0.00 0.00<br />

15782 S 164.78 0.00 0.00 15944 S 614.55 0.00 0.00<br />

15783 S 100.46 0.00 0.00 15945 S 667.92 0.00 0.00<br />

15786 S 30.48 0.00 0.00 15946 S 667.92 0.00 0.00<br />

15787 S 27.64 0.00 0.00 15950 S 628.87 0.00 0.00<br />

15788 S 30.48 0.00 0.00 15951 S 682.22 0.00 0.00<br />

15789 S 55.85 0.00 0.00 15952 S 520.85 0.00 0.00<br />

15792 S 55.85 0.00 0.00 15953 S 574.21 0.00 0.00<br />

15793 S 30.48 0.00 0.00 15956 S 520.85 0.00 0.00<br />

15819 S 126.69 0.00 0.00 15958 S 574.21 0.00 0.00<br />

15820 S 614.55 0.00 0.00 16000 S 24.67 0.00 0.00<br />

15821 S 614.55 0.00 0.00 16020 S 37.51 0.00 0.00<br />

15822 S 614.55 0.00 0.00 16025 S 57.76 0.00 0.00<br />

15823 S 706.60 0.00 0.00 16030 S 72.32 0.00 0.00<br />

15824 S 614.55 0.00 0.00 16035 S 55.85 0.00 0.00<br />

15825 S 614.55 0.00 0.00 17000 S 30.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.62 0.00 0.00 19300 S 675.64 0.00 0.00<br />

17004 S 79.61 0.00 0.00 19301 S 622.28 0.00 0.00<br />

17106 S 100.46 0.00 0.00 19302 S 1,188.48 0.00 0.00<br />

17107 S 100.46 0.00 0.00 19303 S 898.17 0.00 0.00<br />

17108 S 100.46 0.00 0.00 19304 S 898.17 0.00 0.00<br />

17110 S 30.48 0.00 0.00 19316 S 898.17 0.00 0.00<br />

17111 S 55.85 0.00 0.00 19318 S 1,026.17 0.00 0.00<br />

17250 S 42.11 0.00 0.00 19324 S 1,026.17 0.00 0.00<br />

17260 S 45.07 0.00 0.00 19325 S 1,702.02 0.00 0.00<br />

17261 S 55.85 0.00 0.00 19328 S 766.10 0.00 0.00<br />

17262 S 55.85 0.00 0.00 19330 S 766.10 0.00 0.00<br />

17263 S 55.85 0.00 0.00 19340 S 944.34 0.00 0.00<br />

17264 S 55.85 0.00 0.00 19342 S 1,333.37 0.00 0.00<br />

17266 S 100.46 0.00 0.00 19350 S 675.64 0.00 0.00<br />

17270 S 55.85 0.00 0.00 19355 S 898.17 0.00 0.00<br />

17271 S 55.85 0.00 0.00 19357 S 1,425.42 0.00 0.00<br />

17272 S 55.85 0.00 0.00 19366 S 936.86 0.00 0.00<br />

17273 S 100.46 0.00 0.00 19370 S 898.17 0.00 0.00<br />

17274 S 100.46 0.00 0.00 19371 S 898.17 0.00 0.00<br />

17276 S 100.46 0.00 0.00 19380 S 1,064.86 0.00 0.00<br />

17280 S 55.85 0.00 0.00 19396 S 1,236.02 0.00 0.00<br />

17281 S 83.23 0.00 0.00 20000 S 52.01 0.00 0.00<br />

17282 S 95.07 0.00 0.00 20005 S 599.26 0.00 0.00<br />

17283 S 100.46 0.00 0.00 20103 S 588.11 0.00 0.00<br />

17284 S 100.46 0.00 0.00 20150 S 1,669.66 0.00 0.00<br />

17286 S 100.46 0.00 0.00 20200 S 490.96 0.00 0.00<br />

17311 S 165.84 0.00 0.00 20205 S 519.42 0.00 0.00<br />

17312 S 165.84 0.00 0.00 20206 S 242.72 0.00 0.00<br />

17313 S 165.84 0.00 0.00 20220 S 263.83 0.00 0.00<br />

17314 S 165.84 0.00 0.00 20225 S 478.72 0.00 0.00<br />

17315 S 37.51 0.00 0.00 20240 S 600.40 0.00 0.00<br />

17340 S 13.49 0.00 0.00 20245 S 628.87 0.00 0.00<br />

17360 S 30.48 0.00 0.00 20250 S 627.73 0.00 0.00<br />

17380 S 30.48 0.00 0.00 20251 S 627.73 0.00 0.00<br />

19000 S 63.49 0.00 0.00 20500 S 51.98 0.00 0.00<br />

19001 S 8.56 0.00 0.00 20520 S 87.51 0.00 0.00<br />

19020 S 555.20 0.00 0.00 20525 S 628.87 0.00 0.00<br />

19100 S 189.06 0.00 0.00 20526 S 28.29 0.00 0.00<br />

19101 S 593.81 0.00 0.00 20550 S 21.38 0.00 0.00<br />

19102 S 242.72 0.00 0.00 20551 S 21.05 0.00 0.00<br />

19103 S 424.82 0.00 0.00 20552 S 20.39 0.00 0.00<br />

19105 S 1,236.02 0.00 0.00 20553 S 22.70 0.00 0.00<br />

19110 S 593.81 0.00 0.00 20555 S 1,100.07 0.00 0.00<br />

19112 S 622.28 0.00 0.00 20600 S 21.71 0.00 0.00<br />

19120 S 622.28 0.00 0.00 20605 S 24.34 0.00 0.00<br />

19125 S 622.28 0.00 0.00 20610 S 34.21 0.00 0.00<br />

19126 S 622.28 0.00 0.00 20612 S 23.03 0.00 0.00<br />

19296 S 1,702.02 0.00 0.00 20615 S 96.39 0.00 0.00<br />

19297 S 1,702.02 0.00 0.00 20650 S 627.73 0.00 0.00<br />

19298 S 1,702.02 0.00 0.00 20662 S 801.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 801.85 0.00 0.00 21085 S 241.46 0.00 0.00<br />

20665 S 23.79 0.00 0.00 21086 S 525.68 0.00 0.00<br />

20670 S 440.71 0.00 0.00 21087 S 526.35 0.00 0.00<br />

20680 S 628.87 0.00 0.00 21088 S 1,541.57 0.00 0.00<br />

20690 S 748.37 0.00 0.00 21100 S 969.12 0.00 0.00<br />

20692 S 776.84 0.00 0.00 21110 S 277.32 0.00 0.00<br />

20693 S 627.73 0.00 0.00 21120 S 898.15 0.00 0.00<br />

20694 S 549.01 0.00 0.00 21121 S 898.15 0.00 0.00<br />

20696 S 1,100.07 0.00 0.00 21122 S 898.15 0.00 0.00<br />

20697 S 731.60 0.00 0.00 21123 S 898.15 0.00 0.00<br />

20822 S 1,030.78 0.00 0.00 21125 S 898.15 0.00 0.00<br />

20900 S 776.84 0.00 0.00 21127 S 1,366.23 0.00 0.00<br />

20902 S 830.19 0.00 0.00 21137 S 911.37 0.00 0.00<br />

20910 S 614.55 0.00 0.00 21138 S 1,541.57 0.00 0.00<br />

20912 S 614.55 0.00 0.00 21139 S 1,541.57 0.00 0.00<br />

20920 S 574.21 0.00 0.00 21150 S 1,541.57 0.00 0.00<br />

20922 S 520.85 0.00 0.00 21181 S 898.15 0.00 0.00<br />

20924 S 830.19 0.00 0.00 21198 S 1,541.57 0.00 0.00<br />

20926 S 361.71 0.00 0.00 21199 S 1,541.57 0.00 0.00<br />

20950 S 52.01 0.00 0.00 21206 S 1,089.63 0.00 0.00<br />

20972 S 1,741.02 0.00 0.00 21208 S 1,213.26 0.00 0.00<br />

20973 S 1,741.02 0.00 0.00 21209 S 1,089.63 0.00 0.00<br />

20979 S 21.38 0.00 0.00 21210 S 1,213.26 0.00 0.00<br />

20982 S 1,669.66 0.00 0.00 21215 S 1,213.26 0.00 0.00<br />

21010 S 654.01 0.00 0.00 21230 S 1,213.26 0.00 0.00<br />

21015 S 544.14 0.00 0.00 21235 S 898.15 0.00 0.00<br />

21025 S 969.12 0.00 0.00 21240 S 1,050.94 0.00 0.00<br />

21026 S 969.12 0.00 0.00 21242 S 1,089.63 0.00 0.00<br />

21029 S 969.12 0.00 0.00 21243 S 1,089.63 0.00 0.00<br />

21030 S 228.63 0.00 0.00 21244 S 1,213.26 0.00 0.00<br />

21031 S 189.15 0.00 0.00 21245 S 1,213.26 0.00 0.00<br />

21032 S 192.77 0.00 0.00 21246 S 1,213.26 0.00 0.00<br />

21034 S 997.58 0.00 0.00 21248 S 1,213.26 0.00 0.00<br />

21040 S 654.01 0.00 0.00 21249 S 1,213.26 0.00 0.00<br />

21044 S 969.12 0.00 0.00 21260 S 1,541.57 0.00 0.00<br />

21046 S 969.12 0.00 0.00 21267 S 1,213.26 0.00 0.00<br />

21047 S 969.12 0.00 0.00 21270 S 1,089.63 0.00 0.00<br />

21048 S 1,541.57 0.00 0.00 21275 S 1,213.26 0.00 0.00<br />

21050 S 997.58 0.00 0.00 21280 S 1,089.63 0.00 0.00<br />

21060 S 969.12 0.00 0.00 21282 S 636.19 0.00 0.00<br />

21070 S 997.58 0.00 0.00 21295 S 286.75 0.00 0.00<br />

21073 S 177.64 0.00 0.00 21296 S 603.76 0.00 0.00<br />

21076 S 308.24 0.00 0.00 21310 S 87.47 0.00 0.00<br />

21077 S 745.10 0.00 0.00 21315 S 384.37 0.00 0.00<br />

21079 S 533.58 0.00 0.00 21320 S 515.67 0.00 0.00<br />

21080 S 611.87 0.00 0.00 21325 S 735.84 0.00 0.00<br />

21081 S 563.84 0.00 0.00 21330 S 774.53 0.00 0.00<br />

21082 S 536.54 0.00 0.00 21335 S 898.15 0.00 0.00<br />

21083 S 528.64 0.00 0.00 21336 S 748.51 0.00 0.00<br />

21084 S 608.25 0.00 0.00 21337 S 515.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 735.84 0.00 0.00 22310 S 159.24 0.00 0.00<br />

21339 S 774.53 0.00 0.00 22315 S 411.88 0.00 0.00<br />

21340 S 1,050.94 0.00 0.00 22505 S 484.88 0.00 0.00<br />

21345 S 898.15 0.00 0.00 22520 S 1,145.48 0.00 0.00<br />

21355 S 997.58 0.00 0.00 22521 S 1,145.48 0.00 0.00<br />

21356 S 682.48 0.00 0.00 22522 S 1,145.48 0.00 0.00<br />

21360 S 911.37 0.00 0.00 22523 S 3,187.98 0.00 0.00<br />

21390 S 1,541.57 0.00 0.00 22524 S 3,187.98 0.00 0.00<br />

21400 S 336.99 0.00 0.00 22525 S 3,187.98 0.00 0.00<br />

21401 S 544.14 0.00 0.00 22900 S 682.22 0.00 0.00<br />

21406 S 1,541.57 0.00 0.00 23000 S 490.96 0.00 0.00<br />

21407 S 1,541.57 0.00 0.00 23020 S 1,033.16 0.00 0.00<br />

21421 S 735.84 0.00 0.00 23030 S 504.95 0.00 0.00<br />

21440 S 309.89 0.00 0.00 23031 S 583.66 0.00 0.00<br />

21445 S 735.84 0.00 0.00 23035 S 627.73 0.00 0.00<br />

21450 S 127.89 0.00 0.00 23040 S 776.84 0.00 0.00<br />

21451 S 345.07 0.00 0.00 23044 S 830.19 0.00 0.00<br />

21452 S 515.67 0.00 0.00 23065 S 92.77 0.00 0.00<br />

21453 S 997.58 0.00 0.00 23066 S 600.40 0.00 0.00<br />

21454 S 774.53 0.00 0.00 23075 S 490.96 0.00 0.00<br />

21461 S 1,050.94 0.00 0.00 23076 S 600.40 0.00 0.00<br />

21462 S 1,089.63 0.00 0.00 23077 S 628.87 0.00 0.00<br />

21465 S 1,050.94 0.00 0.00 23100 S 599.26 0.00 0.00<br />

21480 S 87.47 0.00 0.00 23101 S 992.51 0.00 0.00<br />

21485 S 515.67 0.00 0.00 23105 S 830.19 0.00 0.00<br />

21490 S 997.58 0.00 0.00 23106 S 830.19 0.00 0.00<br />

21495 S 634.68 0.00 0.00 23107 S 830.19 0.00 0.00<br />

21497 S 515.67 0.00 0.00 23120 S 868.88 0.00 0.00<br />

21501 S 555.20 0.00 0.00 23125 S 868.88 0.00 0.00<br />

21502 S 599.26 0.00 0.00 23130 S 1,153.67 0.00 0.00<br />

21550 S 585.26 0.00 0.00 23140 S 681.08 0.00 0.00<br />

21555 S 600.40 0.00 0.00 23145 S 868.88 0.00 0.00<br />

21556 S 600.40 0.00 0.00 23146 S 868.88 0.00 0.00<br />

21557 S 804.13 0.00 0.00 23150 S 830.19 0.00 0.00<br />

21600 S 748.37 0.00 0.00 23155 S 868.88 0.00 0.00<br />

21610 S 748.37 0.00 0.00 23156 S 868.88 0.00 0.00<br />

21685 S 277.32 0.00 0.00 23170 S 748.37 0.00 0.00<br />

21700 S 599.26 0.00 0.00 23172 S 748.37 0.00 0.00<br />

21720 S 627.73 0.00 0.00 23174 S 748.37 0.00 0.00<br />

21725 S 65.34 0.00 0.00 23180 S 830.19 0.00 0.00<br />

21800 S 75.49 0.00 0.00 23182 S 830.19 0.00 0.00<br />

21805 S 666.69 0.00 0.00 23184 S 830.19 0.00 0.00<br />

21820 S 75.49 0.00 0.00 23190 S 830.19 0.00 0.00<br />

21920 S 134.22 0.00 0.00 23195 S 868.88 0.00 0.00<br />

21925 S 600.40 0.00 0.00 23330 S 300.06 0.00 0.00<br />

21930 S 600.40 0.00 0.00 23331 S 550.15 0.00 0.00<br />

21935 S 628.87 0.00 0.00 23395 S 1,153.67 0.00 0.00<br />

22102 S 1,789.44 0.00 0.00 23397 S 2,036.46 0.00 0.00<br />

22103 S 1,789.44 0.00 0.00 23400 S 992.51 0.00 0.00<br />

22305 S 75.49 0.00 0.00 23405 S 748.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 748.37 0.00 0.00 23931 S 555.20 0.00 0.00<br />

23410 S 1,153.67 0.00 0.00 23935 S 599.26 0.00 0.00<br />

23412 S 1,277.30 0.00 0.00 24000 S 830.19 0.00 0.00<br />

23415 S 1,153.67 0.00 0.00 24006 S 830.19 0.00 0.00<br />

23420 S 1,277.30 0.00 0.00 24065 S 128.62 0.00 0.00<br />

23430 S 1,114.99 0.00 0.00 24066 S 490.96 0.00 0.00<br />

23440 S 1,114.99 0.00 0.00 24075 S 490.96 0.00 0.00<br />

23450 S 1,912.84 0.00 0.00 24076 S 600.40 0.00 0.00<br />

23455 S 2,036.46 0.00 0.00 24077 S 628.87 0.00 0.00<br />

23460 S 1,912.84 0.00 0.00 24100 S 549.01 0.00 0.00<br />

23462 S 1,277.30 0.00 0.00 24101 S 830.19 0.00 0.00<br />

23465 S 1,912.84 0.00 0.00 24102 S 830.19 0.00 0.00<br />

23466 S 1,277.30 0.00 0.00 24105 S 627.73 0.00 0.00<br />

23480 S 1,114.99 0.00 0.00 24110 S 599.26 0.00 0.00<br />

23485 S 2,036.46 0.00 0.00 24115 S 776.84 0.00 0.00<br />

23490 S 1,061.62 0.00 0.00 24116 S 776.84 0.00 0.00<br />

23491 S 1,820.79 0.00 0.00 24120 S 627.73 0.00 0.00<br />

23500 S 75.49 0.00 0.00 24125 S 776.84 0.00 0.00<br />

23505 S 411.88 0.00 0.00 24126 S 776.84 0.00 0.00<br />

23515 S 1,378.52 0.00 0.00 24130 S 776.84 0.00 0.00<br />

23520 S 159.24 0.00 0.00 24134 S 748.37 0.00 0.00<br />

23525 S 159.24 0.00 0.00 24136 S 748.37 0.00 0.00<br />

23530 S 1,015.83 0.00 0.00 24138 S 748.37 0.00 0.00<br />

23532 S 748.51 0.00 0.00 24140 S 776.84 0.00 0.00<br />

23540 S 75.49 0.00 0.00 24145 S 776.84 0.00 0.00<br />

23545 S 159.24 0.00 0.00 24147 S 748.37 0.00 0.00<br />

23550 S 1,015.83 0.00 0.00 24149 S 1,100.07 0.00 0.00<br />

23552 S 1,069.20 0.00 0.00 24152 S 1,669.66 0.00 0.00<br />

23570 S 75.49 0.00 0.00 24153 S 3,187.98 0.00 0.00<br />

23575 S 159.24 0.00 0.00 24155 S 1,061.62 0.00 0.00<br />

23585 S 1,378.52 0.00 0.00 24160 S 748.37 0.00 0.00<br />

23600 S 58.82 0.00 0.00 24164 S 776.84 0.00 0.00<br />

23605 S 411.88 0.00 0.00 24200 S 94.08 0.00 0.00<br />

23615 S 1,431.88 0.00 0.00 24201 S 490.96 0.00 0.00<br />

23616 S 1,431.88 0.00 0.00 24300 S 573.10 0.00 0.00<br />

23620 S 58.82 0.00 0.00 24301 S 830.19 0.00 0.00<br />

23625 S 411.88 0.00 0.00 24305 S 830.19 0.00 0.00<br />

23630 S 1,470.57 0.00 0.00 24310 S 627.73 0.00 0.00<br />

23650 S 75.49 0.00 0.00 24320 S 1,061.62 0.00 0.00<br />

23655 S 434.63 0.00 0.00 24330 S 1,820.79 0.00 0.00<br />

23660 S 1,015.83 0.00 0.00 24331 S 1,061.62 0.00 0.00<br />

23665 S 159.24 0.00 0.00 24332 S 801.85 0.00 0.00<br />

23670 S 1,378.52 0.00 0.00 24340 S 1,061.62 0.00 0.00<br />

23675 S 75.49 0.00 0.00 24341 S 1,061.62 0.00 0.00<br />

23680 S 1,015.83 0.00 0.00 24342 S 1,061.62 0.00 0.00<br />

23700 S 434.63 0.00 0.00 24343 S 1,100.07 0.00 0.00<br />

23800 S 1,874.15 0.00 0.00 24344 S 3,187.98 0.00 0.00<br />

23802 S 1,277.30 0.00 0.00 24345 S 748.37 0.00 0.00<br />

23921 S 437.82 0.00 0.00 24346 S 1,669.66 0.00 0.00<br />

23930 S 504.95 0.00 0.00 24357 S 1,100.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,100.07 0.00 0.00 24925 S 627.73 0.00 0.00<br />

24359 S 1,100.07 0.00 0.00 25000 S 627.73 0.00 0.00<br />

24360 S 1,015.21 0.00 0.00 25001 S 801.85 0.00 0.00<br />

24361 S 5,550.69 3,397.73 1,244.76 25020 S 627.73 0.00 0.00<br />

24362 S 1,297.43 0.00 0.00 25023 S 776.84 0.00 0.00<br />

24363 S 5,674.32 3,521.35 1,368.39 25024 S 776.84 0.00 0.00<br />

24365 S 1,015.21 0.00 0.00 25025 S 776.84 0.00 0.00<br />

24366 S 5,550.69 3,397.73 1,244.76 25028 S 549.01 0.00 0.00<br />

24400 S 830.19 0.00 0.00 25031 S 599.26 0.00 0.00<br />

24410 S 830.19 0.00 0.00 25035 S 599.26 0.00 0.00<br />

24420 S 1,061.62 0.00 0.00 25040 S 868.88 0.00 0.00<br />

24430 S 1,820.79 0.00 0.00 25065 S 130.59 0.00 0.00<br />

24435 S 1,874.15 0.00 0.00 25066 S 600.40 0.00 0.00<br />

24470 S 1,061.62 0.00 0.00 25075 S 490.96 0.00 0.00<br />

24495 S 748.37 0.00 0.00 25076 S 628.87 0.00 0.00<br />

24498 S 1,820.79 0.00 0.00 25077 S 628.87 0.00 0.00<br />

24500 S 75.49 0.00 0.00 25085 S 627.73 0.00 0.00<br />

24505 S 75.49 0.00 0.00 25100 S 599.26 0.00 0.00<br />

24515 S 1,431.88 0.00 0.00 25101 S 776.84 0.00 0.00<br />

24516 S 1,431.88 0.00 0.00 25105 S 830.19 0.00 0.00<br />

24530 S 75.49 0.00 0.00 25107 S 776.84 0.00 0.00<br />

24535 S 159.24 0.00 0.00 25109 S 801.85 0.00 0.00<br />

24538 S 666.69 0.00 0.00 25110 S 627.73 0.00 0.00<br />

24545 S 1,431.88 0.00 0.00 25111 S 627.73 0.00 0.00<br />

24546 S 1,470.57 0.00 0.00 25112 S 681.08 0.00 0.00<br />

24560 S 75.49 0.00 0.00 25115 S 681.08 0.00 0.00<br />

24565 S 75.49 0.00 0.00 25116 S 681.08 0.00 0.00<br />

24566 S 666.69 0.00 0.00 25118 S 748.37 0.00 0.00<br />

24575 S 1,378.52 0.00 0.00 25119 S 776.84 0.00 0.00<br />

24576 S 75.49 0.00 0.00 25120 S 776.84 0.00 0.00<br />

24577 S 159.24 0.00 0.00 25125 S 776.84 0.00 0.00<br />

24579 S 1,378.52 0.00 0.00 25126 S 776.84 0.00 0.00<br />

24582 S 666.69 0.00 0.00 25130 S 776.84 0.00 0.00<br />

24586 S 1,431.88 0.00 0.00 25135 S 776.84 0.00 0.00<br />

24587 S 1,470.57 0.00 0.00 25136 S 776.84 0.00 0.00<br />

24600 S 75.49 0.00 0.00 25145 S 748.37 0.00 0.00<br />

24605 S 484.88 0.00 0.00 25150 S 748.37 0.00 0.00<br />

24615 S 1,378.52 0.00 0.00 25151 S 748.37 0.00 0.00<br />

24620 S 411.88 0.00 0.00 25210 S 776.84 0.00 0.00<br />

24635 S 1,378.52 0.00 0.00 25215 S 830.19 0.00 0.00<br />

24640 S 50.99 0.00 0.00 25230 S 830.19 0.00 0.00<br />

24650 S 58.82 0.00 0.00 25240 S 830.19 0.00 0.00<br />

24655 S 159.24 0.00 0.00 25248 S 599.26 0.00 0.00<br />

24665 S 1,069.20 0.00 0.00 25250 S 698.12 0.00 0.00<br />

24666 S 1,431.88 0.00 0.00 25251 S 698.12 0.00 0.00<br />

24670 S 75.49 0.00 0.00 25259 S 731.60 0.00 0.00<br />

24675 S 75.49 0.00 0.00 25260 S 830.19 0.00 0.00<br />

24685 S 1,015.83 0.00 0.00 25263 S 748.37 0.00 0.00<br />

24800 S 1,114.99 0.00 0.00 25265 S 776.84 0.00 0.00<br />

24802 S 1,153.67 0.00 0.00 25270 S 830.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 776.84 0.00 0.00 25505 S 159.24 0.00 0.00<br />

25274 S 830.19 0.00 0.00 25515 S 1,015.83 0.00 0.00<br />

25275 S 830.19 0.00 0.00 25520 S 159.24 0.00 0.00<br />

25280 S 830.19 0.00 0.00 25525 S 1,069.20 0.00 0.00<br />

25290 S 776.84 0.00 0.00 25526 S 1,107.88 0.00 0.00<br />

25295 S 627.73 0.00 0.00 25530 S 58.82 0.00 0.00<br />

25300 S 776.84 0.00 0.00 25535 S 75.49 0.00 0.00<br />

25301 S 776.84 0.00 0.00 25545 S 1,015.83 0.00 0.00<br />

25310 S 1,061.62 0.00 0.00 25560 S 58.82 0.00 0.00<br />

25312 S 1,114.99 0.00 0.00 25565 S 159.24 0.00 0.00<br />

25315 S 1,061.62 0.00 0.00 25574 S 1,378.52 0.00 0.00<br />

25316 S 1,820.79 0.00 0.00 25575 S 1,378.52 0.00 0.00<br />

25320 S 1,061.62 0.00 0.00 25600 S 58.82 0.00 0.00<br />

25332 S 1,015.21 0.00 0.00 25605 S 159.24 0.00 0.00<br />

25335 S 1,061.62 0.00 0.00 25606 S 695.16 0.00 0.00<br />

25337 S 1,153.67 0.00 0.00 25607 S 1,470.57 0.00 0.00<br />

25350 S 1,820.79 0.00 0.00 25608 S 1,470.57 0.00 0.00<br />

25355 S 1,061.62 0.00 0.00 25609 S 1,470.57 0.00 0.00<br />

25360 S 776.84 0.00 0.00 25622 S 58.82 0.00 0.00<br />

25365 S 776.84 0.00 0.00 25624 S 159.24 0.00 0.00<br />

25370 S 1,061.62 0.00 0.00 25628 S 1,015.83 0.00 0.00<br />

25375 S 1,114.99 0.00 0.00 25630 S 58.82 0.00 0.00<br />

25390 S 776.84 0.00 0.00 25635 S 159.24 0.00 0.00<br />

25391 S 1,114.99 0.00 0.00 25645 S 1,015.83 0.00 0.00<br />

25392 S 776.84 0.00 0.00 25650 S 58.82 0.00 0.00<br />

25393 S 1,114.99 0.00 0.00 25651 S 936.72 0.00 0.00<br />

25394 S 1,669.66 0.00 0.00 25652 S 1,578.07 0.00 0.00<br />

25400 S 1,061.62 0.00 0.00 25660 S 75.49 0.00 0.00<br />

25405 S 1,874.15 0.00 0.00 25670 S 695.16 0.00 0.00<br />

25415 S 1,820.79 0.00 0.00 25671 S 616.44 0.00 0.00<br />

25420 S 1,874.15 0.00 0.00 25675 S 75.49 0.00 0.00<br />

25425 S 1,061.62 0.00 0.00 25676 S 666.69 0.00 0.00<br />

25426 S 1,114.99 0.00 0.00 25680 S 75.49 0.00 0.00<br />

25430 S 1,669.66 0.00 0.00 25685 S 695.16 0.00 0.00<br />

25431 S 1,669.66 0.00 0.00 25690 S 411.88 0.00 0.00<br />

25440 S 1,874.15 0.00 0.00 25695 S 666.69 0.00 0.00<br />

25441 S 5,550.69 3,397.73 1,244.76 25800 S 1,874.15 0.00 0.00<br />

25442 S 5,550.69 3,397.73 1,244.76 25805 S 1,153.67 0.00 0.00<br />

25443 S 1,297.43 0.00 0.00 25810 S 1,912.84 0.00 0.00<br />

25444 S 1,297.43 0.00 0.00 25820 S 1,114.99 0.00 0.00<br />

25445 S 1,297.43 0.00 0.00 25825 S 1,912.84 0.00 0.00<br />

25446 S 5,674.32 3,521.35 1,368.39 25830 S 1,912.84 0.00 0.00<br />

25447 S 1,015.21 0.00 0.00 25907 S 627.73 0.00 0.00<br />

25449 S 1,015.21 0.00 0.00 25922 S 627.73 0.00 0.00<br />

25450 S 1,061.62 0.00 0.00 25929 S 520.85 0.00 0.00<br />

25455 S 1,061.62 0.00 0.00 25931 S 801.85 0.00 0.00<br />

25490 S 1,061.62 0.00 0.00 26010 S 52.01 0.00 0.00<br />

25491 S 1,061.62 0.00 0.00 26011 S 379.93 0.00 0.00<br />

25492 S 1,061.62 0.00 0.00 26020 S 504.12 0.00 0.00<br />

25500 S 58.82 0.00 0.00 26025 S 453.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 504.12 0.00 0.00 26392 S 742.18 0.00 0.00<br />

26034 S 504.12 0.00 0.00 26410 S 532.58 0.00 0.00<br />

26035 S 611.56 0.00 0.00 26412 S 742.18 0.00 0.00<br />

26040 S 795.55 0.00 0.00 26415 S 795.55 0.00 0.00<br />

26045 S 742.18 0.00 0.00 26416 S 742.18 0.00 0.00<br />

26055 S 504.12 0.00 0.00 26418 S 585.94 0.00 0.00<br />

26060 S 504.12 0.00 0.00 26420 S 795.55 0.00 0.00<br />

26070 S 504.12 0.00 0.00 26426 S 742.18 0.00 0.00<br />

26075 S 585.94 0.00 0.00 26428 S 742.18 0.00 0.00<br />

26080 S 585.94 0.00 0.00 26432 S 532.58 0.00 0.00<br />

26100 S 504.12 0.00 0.00 26433 S 532.58 0.00 0.00<br />

26105 S 453.86 0.00 0.00 26434 S 742.18 0.00 0.00<br />

26110 S 453.86 0.00 0.00 26437 S 532.58 0.00 0.00<br />

26115 S 600.40 0.00 0.00 26440 S 532.58 0.00 0.00<br />

26116 S 600.40 0.00 0.00 26442 S 742.18 0.00 0.00<br />

26117 S 628.87 0.00 0.00 26445 S 532.58 0.00 0.00<br />

26121 S 795.55 0.00 0.00 26449 S 742.18 0.00 0.00<br />

26123 S 795.55 0.00 0.00 26450 S 532.58 0.00 0.00<br />

26125 S 585.94 0.00 0.00 26455 S 532.58 0.00 0.00<br />

26130 S 532.58 0.00 0.00 26460 S 532.58 0.00 0.00<br />

26135 S 795.55 0.00 0.00 26471 S 504.12 0.00 0.00<br />

26140 S 504.12 0.00 0.00 26474 S 504.12 0.00 0.00<br />

26145 S 532.58 0.00 0.00 26476 S 453.86 0.00 0.00<br />

26160 S 532.58 0.00 0.00 26477 S 453.86 0.00 0.00<br />

26170 S 532.58 0.00 0.00 26478 S 453.86 0.00 0.00<br />

26180 S 532.58 0.00 0.00 26479 S 453.86 0.00 0.00<br />

26185 S 585.94 0.00 0.00 26480 S 742.18 0.00 0.00<br />

26200 S 504.12 0.00 0.00 26483 S 742.18 0.00 0.00<br />

26205 S 742.18 0.00 0.00 26485 S 713.73 0.00 0.00<br />

26210 S 504.12 0.00 0.00 26489 S 742.18 0.00 0.00<br />

26215 S 532.58 0.00 0.00 26490 S 742.18 0.00 0.00<br />

26230 S 747.34 0.00 0.00 26492 S 742.18 0.00 0.00<br />

26235 S 532.58 0.00 0.00 26494 S 742.18 0.00 0.00<br />

26236 S 532.58 0.00 0.00 26496 S 742.18 0.00 0.00<br />

26250 S 532.58 0.00 0.00 26497 S 742.18 0.00 0.00<br />

26255 S 742.18 0.00 0.00 26498 S 795.55 0.00 0.00<br />

26260 S 532.58 0.00 0.00 26499 S 742.18 0.00 0.00<br />

26261 S 532.58 0.00 0.00 26500 S 585.94 0.00 0.00<br />

26262 S 504.12 0.00 0.00 26502 S 795.55 0.00 0.00<br />

26320 S 490.96 0.00 0.00 26508 S 532.58 0.00 0.00<br />

26340 S 226.33 0.00 0.00 26510 S 742.18 0.00 0.00<br />

26350 S 663.47 0.00 0.00 26516 S 663.47 0.00 0.00<br />

26352 S 795.55 0.00 0.00 26517 S 742.18 0.00 0.00<br />

26356 S 795.55 0.00 0.00 26518 S 742.18 0.00 0.00<br />

26357 S 795.55 0.00 0.00 26520 S 532.58 0.00 0.00<br />

26358 S 795.55 0.00 0.00 26525 S 532.58 0.00 0.00<br />

26370 S 795.55 0.00 0.00 26530 S 923.16 0.00 0.00<br />

26372 S 795.55 0.00 0.00 26531 S 1,421.06 0.00 0.00<br />

26373 S 742.18 0.00 0.00 26535 S 1,015.21 0.00 0.00<br />

26390 S 795.55 0.00 0.00 26536 S 1,297.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 585.94 0.00 0.00 26775 S 157.25 0.00 0.00<br />

26541 S 957.86 0.00 0.00 26776 S 666.69 0.00 0.00<br />

26542 S 585.94 0.00 0.00 26785 S 666.69 0.00 0.00<br />

26545 S 795.55 0.00 0.00 26820 S 834.23 0.00 0.00<br />

26546 S 795.55 0.00 0.00 26841 S 795.55 0.00 0.00<br />

26548 S 795.55 0.00 0.00 26842 S 795.55 0.00 0.00<br />

26550 S 713.73 0.00 0.00 26843 S 742.18 0.00 0.00<br />

26555 S 742.18 0.00 0.00 26844 S 742.18 0.00 0.00<br />

26560 S 504.12 0.00 0.00 26850 S 795.55 0.00 0.00<br />

26561 S 742.18 0.00 0.00 26852 S 795.55 0.00 0.00<br />

26562 S 795.55 0.00 0.00 26860 S 742.18 0.00 0.00<br />

26565 S 834.23 0.00 0.00 26861 S 713.73 0.00 0.00<br />

26567 S 834.23 0.00 0.00 26862 S 795.55 0.00 0.00<br />

26568 S 742.18 0.00 0.00 26863 S 742.18 0.00 0.00<br />

26580 S 624.62 0.00 0.00 26910 S 742.18 0.00 0.00<br />

26587 S 624.62 0.00 0.00 26951 S 504.12 0.00 0.00<br />

26590 S 624.62 0.00 0.00 26952 S 585.94 0.00 0.00<br />

26591 S 742.18 0.00 0.00 26990 S 549.01 0.00 0.00<br />

26593 S 532.58 0.00 0.00 26991 S 549.01 0.00 0.00<br />

26596 S 504.12 0.00 0.00 27000 S 599.26 0.00 0.00<br />

26600 S 58.82 0.00 0.00 27001 S 776.84 0.00 0.00<br />

26605 S 75.49 0.00 0.00 27003 S 776.84 0.00 0.00<br />

26607 S 411.88 0.00 0.00 27033 S 1,061.62 0.00 0.00<br />

26608 S 748.51 0.00 0.00 27035 S 1,114.99 0.00 0.00<br />

26615 S 1,069.20 0.00 0.00 27040 S 300.06 0.00 0.00<br />

26641 S 58.82 0.00 0.00 27041 S 338.08 0.00 0.00<br />

26645 S 159.24 0.00 0.00 27047 S 600.40 0.00 0.00<br />

26650 S 666.69 0.00 0.00 27048 S 628.87 0.00 0.00<br />

26665 S 1,069.20 0.00 0.00 27049 S 628.87 0.00 0.00<br />

26670 S 58.82 0.00 0.00 27050 S 627.73 0.00 0.00<br />

26675 S 159.24 0.00 0.00 27052 S 627.73 0.00 0.00<br />

26676 S 666.69 0.00 0.00 27060 S 719.77 0.00 0.00<br />

26685 S 695.16 0.00 0.00 27062 S 719.77 0.00 0.00<br />

26686 S 1,378.52 0.00 0.00 27065 S 719.77 0.00 0.00<br />

26700 S 58.82 0.00 0.00 27066 S 868.88 0.00 0.00<br />

26705 S 75.49 0.00 0.00 27067 S 868.88 0.00 0.00<br />

26706 S 411.88 0.00 0.00 27080 S 748.37 0.00 0.00<br />

26715 S 748.51 0.00 0.00 27086 S 300.06 0.00 0.00<br />

26720 S 58.82 0.00 0.00 27087 S 627.73 0.00 0.00<br />

26725 S 58.82 0.00 0.00 27097 S 776.84 0.00 0.00<br />

26727 S 910.83 0.00 0.00 27098 S 776.84 0.00 0.00<br />

26735 S 748.51 0.00 0.00 27100 S 1,114.99 0.00 0.00<br />

26740 S 58.82 0.00 0.00 27105 S 1,114.99 0.00 0.00<br />

26742 S 75.49 0.00 0.00 27110 S 1,114.99 0.00 0.00<br />

26746 S 787.21 0.00 0.00 27111 S 1,114.99 0.00 0.00<br />

26750 S 58.82 0.00 0.00 27193 S 75.49 0.00 0.00<br />

26755 S 58.82 0.00 0.00 27194 S 484.88 0.00 0.00<br />

26756 S 666.69 0.00 0.00 27200 S 58.82 0.00 0.00<br />

26765 S 748.51 0.00 0.00 27202 S 987.38 0.00 0.00<br />

26770 S 58.82 0.00 0.00 27220 S 58.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 75.49 0.00 0.00 27397 S 1,061.62 0.00 0.00<br />

27238 S 159.24 0.00 0.00 27400 S 1,061.62 0.00 0.00<br />

27246 S 159.24 0.00 0.00 27403 S 830.19 0.00 0.00<br />

27250 S 75.49 0.00 0.00 27405 S 1,114.99 0.00 0.00<br />

27252 S 484.88 0.00 0.00 27407 S 1,874.15 0.00 0.00<br />

27256 S 58.82 0.00 0.00 27409 S 1,114.99 0.00 0.00<br />

27257 S 513.35 0.00 0.00 27416 S 1,669.66 0.00 0.00<br />

27265 S 75.49 0.00 0.00 27418 S 1,061.62 0.00 0.00<br />

27266 S 484.88 0.00 0.00 27420 S 1,061.62 0.00 0.00<br />

27267 S 58.82 0.00 0.00 27422 S 1,277.30 0.00 0.00<br />

27275 S 484.88 0.00 0.00 27424 S 1,061.62 0.00 0.00<br />

27301 S 583.66 0.00 0.00 27425 S 992.51 0.00 0.00<br />

27305 S 599.26 0.00 0.00 27427 S 1,061.62 0.00 0.00<br />

27306 S 627.73 0.00 0.00 27428 S 1,874.15 0.00 0.00<br />

27307 S 627.73 0.00 0.00 27429 S 1,874.15 0.00 0.00<br />

27310 S 830.19 0.00 0.00 27430 S 1,114.99 0.00 0.00<br />

27323 S 300.06 0.00 0.00 27435 S 1,114.99 0.00 0.00<br />

27324 S 550.15 0.00 0.00 27437 S 976.52 0.00 0.00<br />

27325 S 539.07 0.00 0.00 27438 S 1,297.43 0.00 0.00<br />

27326 S 539.07 0.00 0.00 27440 S 1,392.73 0.00 0.00<br />

27327 S 600.40 0.00 0.00 27441 S 1,015.21 0.00 0.00<br />

27328 S 628.87 0.00 0.00 27442 S 1,015.21 0.00 0.00<br />

27329 S 682.22 0.00 0.00 27443 S 1,015.21 0.00 0.00<br />

27330 S 830.19 0.00 0.00 27446 S 9,961.20 5,984.23 2,007.27<br />

27331 S 830.19 0.00 0.00 27496 S 719.77 0.00 0.00<br />

27332 S 830.19 0.00 0.00 27497 S 627.73 0.00 0.00<br />

27333 S 830.19 0.00 0.00 27498 S 627.73 0.00 0.00<br />

27334 S 830.19 0.00 0.00 27499 S 627.73 0.00 0.00<br />

27335 S 830.19 0.00 0.00 27500 S 159.24 0.00 0.00<br />

27340 S 627.73 0.00 0.00 27501 S 75.49 0.00 0.00<br />

27345 S 681.08 0.00 0.00 27502 S 411.88 0.00 0.00<br />

27347 S 681.08 0.00 0.00 27503 S 75.49 0.00 0.00<br />

27350 S 830.19 0.00 0.00 27508 S 75.49 0.00 0.00<br />

27355 S 776.84 0.00 0.00 27509 S 695.16 0.00 0.00<br />

27356 S 830.19 0.00 0.00 27510 S 159.24 0.00 0.00<br />

27357 S 868.88 0.00 0.00 27516 S 75.49 0.00 0.00<br />

27358 S 868.88 0.00 0.00 27517 S 75.49 0.00 0.00<br />

27360 S 868.88 0.00 0.00 27520 S 75.49 0.00 0.00<br />

27372 S 844.54 0.00 0.00 27530 S 75.49 0.00 0.00<br />

27380 S 549.01 0.00 0.00 27532 S 411.88 0.00 0.00<br />

27381 S 627.73 0.00 0.00 27538 S 75.49 0.00 0.00<br />

27385 S 627.73 0.00 0.00 27550 S 75.49 0.00 0.00<br />

27386 S 627.73 0.00 0.00 27552 S 434.63 0.00 0.00<br />

27390 S 549.01 0.00 0.00 27560 S 75.49 0.00 0.00<br />

27391 S 599.26 0.00 0.00 27562 S 434.63 0.00 0.00<br />

27392 S 627.73 0.00 0.00 27566 S 987.38 0.00 0.00<br />

27393 S 748.37 0.00 0.00 27570 S 434.63 0.00 0.00<br />

27394 S 776.84 0.00 0.00 27594 S 627.73 0.00 0.00<br />

27395 S 1,061.62 0.00 0.00 27600 S 627.73 0.00 0.00<br />

27396 S 776.84 0.00 0.00 27601 S 627.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 627.73 0.00 0.00 27730 S 748.37 0.00 0.00<br />

27603 S 555.20 0.00 0.00 27732 S 748.37 0.00 0.00<br />

27604 S 599.26 0.00 0.00 27734 S 748.37 0.00 0.00<br />

27605 S 546.07 0.00 0.00 27740 S 748.37 0.00 0.00<br />

27606 S 549.01 0.00 0.00 27742 S 1,033.16 0.00 0.00<br />

27607 S 599.26 0.00 0.00 27745 S 1,820.79 0.00 0.00<br />

27610 S 748.37 0.00 0.00 27750 S 75.49 0.00 0.00<br />

27612 S 776.84 0.00 0.00 27752 S 411.88 0.00 0.00<br />

27613 S 123.36 0.00 0.00 27756 S 695.16 0.00 0.00<br />

27614 S 600.40 0.00 0.00 27758 S 1,069.20 0.00 0.00<br />

27615 S 776.84 0.00 0.00 27759 S 1,431.88 0.00 0.00<br />

27618 S 490.96 0.00 0.00 27760 S 75.49 0.00 0.00<br />

27619 S 628.87 0.00 0.00 27762 S 411.88 0.00 0.00<br />

27620 S 830.19 0.00 0.00 27766 S 1,015.83 0.00 0.00<br />

27625 S 830.19 0.00 0.00 27767 S 58.82 0.00 0.00<br />

27626 S 830.19 0.00 0.00 27768 S 58.82 0.00 0.00<br />

27630 S 627.73 0.00 0.00 27769 S 1,578.07 0.00 0.00<br />

27635 S 776.84 0.00 0.00 27780 S 75.49 0.00 0.00<br />

27637 S 776.84 0.00 0.00 27781 S 411.88 0.00 0.00<br />

27638 S 776.84 0.00 0.00 27784 S 1,015.83 0.00 0.00<br />

27640 S 1,033.16 0.00 0.00 27786 S 75.49 0.00 0.00<br />

27641 S 748.37 0.00 0.00 27788 S 75.49 0.00 0.00<br />

27647 S 1,061.62 0.00 0.00 27792 S 1,015.83 0.00 0.00<br />

27650 S 1,061.62 0.00 0.00 27808 S 75.49 0.00 0.00<br />

27652 S 1,820.79 0.00 0.00 27810 S 159.24 0.00 0.00<br />

27654 S 1,061.62 0.00 0.00 27814 S 1,015.83 0.00 0.00<br />

27656 S 599.26 0.00 0.00 27816 S 75.49 0.00 0.00<br />

27658 S 549.01 0.00 0.00 27818 S 159.24 0.00 0.00<br />

27659 S 599.26 0.00 0.00 27822 S 1,015.83 0.00 0.00<br />

27664 S 599.26 0.00 0.00 27823 S 1,378.52 0.00 0.00<br />

27665 S 748.37 0.00 0.00 27824 S 75.49 0.00 0.00<br />

27675 S 599.26 0.00 0.00 27825 S 411.88 0.00 0.00<br />

27676 S 776.84 0.00 0.00 27826 S 1,015.83 0.00 0.00<br />

27680 S 776.84 0.00 0.00 27827 S 1,378.52 0.00 0.00<br />

27681 S 748.37 0.00 0.00 27828 S 1,431.88 0.00 0.00<br />

27685 S 776.84 0.00 0.00 27829 S 987.38 0.00 0.00<br />

27686 S 776.84 0.00 0.00 27830 S 75.49 0.00 0.00<br />

27687 S 776.84 0.00 0.00 27831 S 411.88 0.00 0.00<br />

27690 S 1,114.99 0.00 0.00 27832 S 987.38 0.00 0.00<br />

27691 S 1,114.99 0.00 0.00 27840 S 159.24 0.00 0.00<br />

27692 S 1,061.62 0.00 0.00 27842 S 434.63 0.00 0.00<br />

27695 S 748.37 0.00 0.00 27846 S 1,015.83 0.00 0.00<br />

27696 S 748.37 0.00 0.00 27848 S 1,015.83 0.00 0.00<br />

27698 S 748.37 0.00 0.00 27860 S 434.63 0.00 0.00<br />

27700 S 1,015.21 0.00 0.00 27870 S 1,874.15 0.00 0.00<br />

27704 S 599.26 0.00 0.00 27871 S 1,874.15 0.00 0.00<br />

27705 S 1,033.16 0.00 0.00 27884 S 627.73 0.00 0.00<br />

27707 S 599.26 0.00 0.00 27889 S 776.84 0.00 0.00<br />

27709 S 748.37 0.00 0.00 27892 S 627.73 0.00 0.00<br />

27726 S 936.72 0.00 0.00 27893 S 627.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 627.73 0.00 0.00 28153 S 624.78 0.00 0.00<br />

28001 S 120.40 0.00 0.00 28160 S 624.78 0.00 0.00<br />

28002 S 627.73 0.00 0.00 28171 S 624.78 0.00 0.00<br />

28003 S 627.73 0.00 0.00 28173 S 624.78 0.00 0.00<br />

28005 S 624.78 0.00 0.00 28175 S 624.78 0.00 0.00<br />

28008 S 624.78 0.00 0.00 28190 S 124.35 0.00 0.00<br />

28010 S 88.49 0.00 0.00 28192 S 490.96 0.00 0.00<br />

28011 S 624.78 0.00 0.00 28193 S 338.08 0.00 0.00<br />

28020 S 596.31 0.00 0.00 28200 S 624.78 0.00 0.00<br />

28022 S 596.31 0.00 0.00 28202 S 624.78 0.00 0.00<br />

28024 S 596.31 0.00 0.00 28208 S 624.78 0.00 0.00<br />

28035 S 620.89 0.00 0.00 28210 S 1,097.30 0.00 0.00<br />

28043 S 600.40 0.00 0.00 28220 S 191.79 0.00 0.00<br />

28045 S 624.78 0.00 0.00 28222 S 546.07 0.00 0.00<br />

28046 S 624.78 0.00 0.00 28225 S 546.07 0.00 0.00<br />

28050 S 596.31 0.00 0.00 28226 S 546.07 0.00 0.00<br />

28052 S 596.31 0.00 0.00 28230 S 188.17 0.00 0.00<br />

28054 S 596.31 0.00 0.00 28232 S 179.94 0.00 0.00<br />

28055 S 620.89 0.00 0.00 28234 S 596.31 0.00 0.00<br />

28060 S 596.31 0.00 0.00 28238 S 1,097.30 0.00 0.00<br />

28062 S 624.78 0.00 0.00 28240 S 596.31 0.00 0.00<br />

28070 S 624.78 0.00 0.00 28250 S 624.78 0.00 0.00<br />

28072 S 624.78 0.00 0.00 28260 S 624.78 0.00 0.00<br />

28080 S 624.78 0.00 0.00 28261 S 624.78 0.00 0.00<br />

28086 S 596.31 0.00 0.00 28262 S 678.14 0.00 0.00<br />

28088 S 596.31 0.00 0.00 28264 S 1,018.59 0.00 0.00<br />

28090 S 624.78 0.00 0.00 28270 S 624.78 0.00 0.00<br />

28092 S 624.78 0.00 0.00 28272 S 173.69 0.00 0.00<br />

28100 S 596.31 0.00 0.00 28280 S 596.31 0.00 0.00<br />

28102 S 1,097.30 0.00 0.00 28285 S 624.78 0.00 0.00<br />

28103 S 1,097.30 0.00 0.00 28286 S 678.14 0.00 0.00<br />

28104 S 596.31 0.00 0.00 28288 S 624.78 0.00 0.00<br />

28106 S 1,097.30 0.00 0.00 28289 S 624.78 0.00 0.00<br />

28107 S 1,097.30 0.00 0.00 28290 S 770.12 0.00 0.00<br />

28108 S 596.31 0.00 0.00 28292 S 770.12 0.00 0.00<br />

28110 S 624.78 0.00 0.00 28293 S 798.58 0.00 0.00<br />

28111 S 624.78 0.00 0.00 28294 S 798.58 0.00 0.00<br />

28112 S 624.78 0.00 0.00 28296 S 798.58 0.00 0.00<br />

28113 S 624.78 0.00 0.00 28297 S 798.58 0.00 0.00<br />

28114 S 624.78 0.00 0.00 28298 S 798.58 0.00 0.00<br />

28116 S 624.78 0.00 0.00 28299 S 890.63 0.00 0.00<br />

28118 S 678.14 0.00 0.00 28300 S 1,068.84 0.00 0.00<br />

28119 S 678.14 0.00 0.00 28302 S 596.31 0.00 0.00<br />

28120 S 840.45 0.00 0.00 28304 S 1,068.84 0.00 0.00<br />

28122 S 624.78 0.00 0.00 28305 S 1,097.30 0.00 0.00<br />

28124 S 203.63 0.00 0.00 28306 S 678.14 0.00 0.00<br />

28126 S 624.78 0.00 0.00 28307 S 678.14 0.00 0.00<br />

28130 S 624.78 0.00 0.00 28308 S 596.31 0.00 0.00<br />

28140 S 624.78 0.00 0.00 28309 S 1,150.67 0.00 0.00<br />

28150 S 624.78 0.00 0.00 28310 S 624.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 624.78 0.00 0.00 28636 S 695.16 0.00 0.00<br />

28313 S 596.31 0.00 0.00 28645 S 695.16 0.00 0.00<br />

28315 S 678.14 0.00 0.00 28660 S 42.11 0.00 0.00<br />

28320 S 1,150.67 0.00 0.00 28665 S 434.63 0.00 0.00<br />

28322 S 1,150.67 0.00 0.00 28666 S 695.16 0.00 0.00<br />

28340 S 678.14 0.00 0.00 28675 S 695.16 0.00 0.00<br />

28341 S 678.14 0.00 0.00 28705 S 1,150.67 0.00 0.00<br />

28344 S 678.14 0.00 0.00 28715 S 1,874.15 0.00 0.00<br />

28345 S 678.14 0.00 0.00 28725 S 1,150.67 0.00 0.00<br />

28400 S 75.49 0.00 0.00 28730 S 1,150.67 0.00 0.00<br />

28405 S 411.88 0.00 0.00 28735 S 1,150.67 0.00 0.00<br />

28406 S 666.69 0.00 0.00 28737 S 1,189.35 0.00 0.00<br />

28415 S 1,378.52 0.00 0.00 28740 S 1,150.67 0.00 0.00<br />

28420 S 1,069.20 0.00 0.00 28750 S 1,150.67 0.00 0.00<br />

28430 S 58.82 0.00 0.00 28755 S 678.14 0.00 0.00<br />

28435 S 75.49 0.00 0.00 28760 S 1,150.67 0.00 0.00<br />

28436 S 666.69 0.00 0.00 28810 S 596.31 0.00 0.00<br />

28445 S 1,015.83 0.00 0.00 28820 S 596.31 0.00 0.00<br />

28446 S 1,741.02 0.00 0.00 28825 S 596.31 0.00 0.00<br />

28450 S 58.82 0.00 0.00 28890 S 157.57 0.00 0.00<br />

28455 S 58.82 0.00 0.00 29000 S 39.92 0.00 0.00<br />

28456 S 666.69 0.00 0.00 29010 S 89.48 0.00 0.00<br />

28465 S 1,015.83 0.00 0.00 29015 S 89.48 0.00 0.00<br />

28470 S 58.82 0.00 0.00 29020 S 39.92 0.00 0.00<br />

28475 S 58.82 0.00 0.00 29025 S 39.92 0.00 0.00<br />

28476 S 666.69 0.00 0.00 29035 S 89.48 0.00 0.00<br />

28485 S 1,069.20 0.00 0.00 29040 S 39.92 0.00 0.00<br />

28490 S 58.82 0.00 0.00 29044 S 89.48 0.00 0.00<br />

28495 S 58.82 0.00 0.00 29046 S 89.48 0.00 0.00<br />

28496 S 666.69 0.00 0.00 29049 S 36.18 0.00 0.00<br />

28505 S 695.16 0.00 0.00 29055 S 89.48 0.00 0.00<br />

28510 S 52.97 0.00 0.00 29058 S 39.92 0.00 0.00<br />

28515 S 58.82 0.00 0.00 29065 S 42.44 0.00 0.00<br />

28525 S 695.16 0.00 0.00 29075 S 40.79 0.00 0.00<br />

28530 S 50.99 0.00 0.00 29085 S 39.92 0.00 0.00<br />

28531 S 695.16 0.00 0.00 29086 S 34.21 0.00 0.00<br />

28540 S 58.82 0.00 0.00 29105 S 36.84 0.00 0.00<br />

28545 S 616.44 0.00 0.00 29125 S 31.91 0.00 0.00<br />

28546 S 666.69 0.00 0.00 29126 S 33.88 0.00 0.00<br />

28555 S 987.38 0.00 0.00 29130 S 14.48 0.00 0.00<br />

28570 S 76.32 0.00 0.00 29131 S 21.05 0.00 0.00<br />

28575 S 411.88 0.00 0.00 29200 S 20.39 0.00 0.00<br />

28576 S 695.16 0.00 0.00 29220 S 22.04 0.00 0.00<br />

28585 S 695.16 0.00 0.00 29240 S 23.03 0.00 0.00<br />

28600 S 58.82 0.00 0.00 29260 S 22.04 0.00 0.00<br />

28605 S 75.49 0.00 0.00 29280 S 22.37 0.00 0.00<br />

28606 S 666.69 0.00 0.00 29305 S 89.48 0.00 0.00<br />

28615 S 1,015.83 0.00 0.00 29325 S 89.48 0.00 0.00<br />

28630 S 58.82 0.00 0.00 29345 S 55.59 0.00 0.00<br />

28635 S 434.63 0.00 0.00 29355 S 54.61 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 67.77 0.00 0.00 29847 S 1,132.71 0.00 0.00<br />

29365 S 52.64 0.00 0.00 29848 S 1,136.89 0.00 0.00<br />

29405 S 39.15 0.00 0.00 29850 S 821.60 0.00 0.00<br />

29425 S 39.80 0.00 0.00 29851 S 1,186.08 0.00 0.00<br />

29435 S 50.33 0.00 0.00 29855 S 1,186.08 0.00 0.00<br />

29440 S 21.38 0.00 0.00 29856 S 1,186.08 0.00 0.00<br />

29445 S 52.97 0.00 0.00 29860 S 1,186.08 0.00 0.00<br />

29450 S 39.92 0.00 0.00 29861 S 1,186.08 0.00 0.00<br />

29505 S 35.53 0.00 0.00 29862 S 1,501.36 0.00 0.00<br />

29515 S 30.26 0.00 0.00 29863 S 1,186.08 0.00 0.00<br />

29520 S 21.71 0.00 0.00 29866 S 1,811.83 0.00 0.00<br />

29530 S 22.04 0.00 0.00 29870 S 768.24 0.00 0.00<br />

29540 S 16.45 0.00 0.00 29871 S 768.24 0.00 0.00<br />

29550 S 16.77 0.00 0.00 29873 S 768.24 0.00 0.00<br />

29580 S 22.70 0.00 0.00 29874 S 768.24 0.00 0.00<br />

29590 S 18.42 0.00 0.00 29875 S 821.60 0.00 0.00<br />

29700 S 30.59 0.00 0.00 29876 S 821.60 0.00 0.00<br />

29705 S 25.99 0.00 0.00 29877 S 821.60 0.00 0.00<br />

29710 S 45.72 0.00 0.00 29879 S 768.24 0.00 0.00<br />

29715 S 39.92 0.00 0.00 29880 S 821.60 0.00 0.00<br />

29720 S 38.16 0.00 0.00 29881 S 821.60 0.00 0.00<br />

29730 S 25.00 0.00 0.00 29882 S 768.24 0.00 0.00<br />

29740 S 34.21 0.00 0.00 29883 S 768.24 0.00 0.00<br />

29750 S 35.85 0.00 0.00 29884 S 768.24 0.00 0.00<br />

29800 S 768.24 0.00 0.00 29885 S 1,132.71 0.00 0.00<br />

29804 S 768.24 0.00 0.00 29886 S 768.24 0.00 0.00<br />

29805 S 768.24 0.00 0.00 29887 S 768.24 0.00 0.00<br />

29806 S 1,132.71 0.00 0.00 29888 S 1,132.71 0.00 0.00<br />

29807 S 1,132.71 0.00 0.00 29889 S 1,132.71 0.00 0.00<br />

29819 S 1,132.71 0.00 0.00 29891 S 1,132.71 0.00 0.00<br />

29820 S 1,132.71 0.00 0.00 29892 S 1,132.71 0.00 0.00<br />

29821 S 1,132.71 0.00 0.00 29893 S 956.32 0.00 0.00<br />

29822 S 768.24 0.00 0.00 29894 S 768.24 0.00 0.00<br />

29823 S 1,132.71 0.00 0.00 29895 S 768.24 0.00 0.00<br />

29824 S 860.29 0.00 0.00 29897 S 768.24 0.00 0.00<br />

29825 S 1,132.71 0.00 0.00 29898 S 768.24 0.00 0.00<br />

29826 S 1,132.71 0.00 0.00 29899 S 1,132.71 0.00 0.00<br />

29827 S 1,224.76 0.00 0.00 29900 S 768.24 0.00 0.00<br />

29828 S 1,811.83 0.00 0.00 29901 S 768.24 0.00 0.00<br />

29830 S 768.24 0.00 0.00 29902 S 768.24 0.00 0.00<br />

29834 S 768.24 0.00 0.00 29904 S 1,082.89 0.00 0.00<br />

29835 S 768.24 0.00 0.00 29905 S 1,082.89 0.00 0.00<br />

29836 S 768.24 0.00 0.00 29906 S 1,082.89 0.00 0.00<br />

29837 S 768.24 0.00 0.00 29907 S 1,811.83 0.00 0.00<br />

29838 S 768.24 0.00 0.00 30000 S 121.75 0.00 0.00<br />

29840 S 768.24 0.00 0.00 30020 S 121.75 0.00 0.00<br />

29843 S 768.24 0.00 0.00 30100 S 78.95 0.00 0.00<br />

29844 S 768.24 0.00 0.00 30110 S 122.05 0.00 0.00<br />

29845 S 768.24 0.00 0.00 30115 S 515.67 0.00 0.00<br />

29846 S 768.24 0.00 0.00 30117 S 544.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 682.48 0.00 0.00 31080 S 1,050.94 0.00 0.00<br />

30120 S 465.43 0.00 0.00 31081 S 1,050.94 0.00 0.00<br />

30124 S 277.32 0.00 0.00 31084 S 1,050.94 0.00 0.00<br />

30125 S 969.12 0.00 0.00 31085 S 1,050.94 0.00 0.00<br />

30130 S 544.14 0.00 0.00 31086 S 1,050.94 0.00 0.00<br />

30140 S 654.01 0.00 0.00 31087 S 1,050.94 0.00 0.00<br />

30150 S 997.58 0.00 0.00 31090 S 1,089.63 0.00 0.00<br />

30160 S 1,050.94 0.00 0.00 31200 S 969.12 0.00 0.00<br />

30200 S 62.18 0.00 0.00 31201 S 1,089.63 0.00 0.00<br />

30210 S 78.95 0.00 0.00 31205 S 997.58 0.00 0.00<br />

30220 S 345.07 0.00 0.00 31231 S 66.56 0.00 0.00<br />

30300 S 23.79 0.00 0.00 31233 S 71.69 0.00 0.00<br />

30310 S 465.43 0.00 0.00 31235 S 487.07 0.00 0.00<br />

30320 S 515.67 0.00 0.00 31237 S 537.32 0.00 0.00<br />

30400 S 1,050.94 0.00 0.00 31238 S 487.07 0.00 0.00<br />

30410 S 1,089.63 0.00 0.00 31239 S 710.97 0.00 0.00<br />

30420 S 1,089.63 0.00 0.00 31240 S 537.32 0.00 0.00<br />

30430 S 682.48 0.00 0.00 31254 S 657.61 0.00 0.00<br />

30435 S 1,089.63 0.00 0.00 31255 S 749.65 0.00 0.00<br />

30450 S 1,213.26 0.00 0.00 31256 S 657.61 0.00 0.00<br />

30460 S 1,213.26 0.00 0.00 31267 S 657.61 0.00 0.00<br />

30462 S 1,366.23 0.00 0.00 31276 S 657.61 0.00 0.00<br />

30465 S 1,366.23 0.00 0.00 31287 S 657.61 0.00 0.00<br />

30520 S 735.84 0.00 0.00 31288 S 657.61 0.00 0.00<br />

30540 S 1,089.63 0.00 0.00 31300 S 774.53 0.00 0.00<br />

30545 S 1,089.63 0.00 0.00 31320 S 969.12 0.00 0.00<br />

30560 S 127.89 0.00 0.00 31400 S 969.12 0.00 0.00<br />

30580 S 1,050.94 0.00 0.00 31420 S 969.12 0.00 0.00<br />

30600 S 1,050.94 0.00 0.00 31500 S 89.02 0.00 0.00<br />

30620 S 1,213.26 0.00 0.00 31502 S 51.19 0.00 0.00<br />

30630 S 898.15 0.00 0.00 31505 S 30.25 0.00 0.00<br />

30801 S 286.75 0.00 0.00 31510 S 537.32 0.00 0.00<br />

30802 S 286.75 0.00 0.00 31511 S 71.69 0.00 0.00<br />

30901 S 40.90 0.00 0.00 31512 S 537.32 0.00 0.00<br />

30903 S 52.68 0.00 0.00 31513 S 71.69 0.00 0.00<br />

30905 S 52.68 0.00 0.00 31515 S 487.07 0.00 0.00<br />

30906 S 52.68 0.00 0.00 31520 S 66.56 0.00 0.00<br />

30915 S 701.98 0.00 0.00 31525 S 487.07 0.00 0.00<br />

30920 S 730.45 0.00 0.00 31526 S 629.15 0.00 0.00<br />

30930 S 597.50 0.00 0.00 31527 S 578.89 0.00 0.00<br />

31000 S 101.65 0.00 0.00 31528 S 537.32 0.00 0.00<br />

31002 S 277.32 0.00 0.00 31529 S 537.32 0.00 0.00<br />

31020 S 654.01 0.00 0.00 31530 S 629.15 0.00 0.00<br />

31030 S 997.58 0.00 0.00 31531 S 657.61 0.00 0.00<br />

31032 S 1,050.94 0.00 0.00 31535 S 629.15 0.00 0.00<br />

31040 S 911.37 0.00 0.00 31536 S 657.61 0.00 0.00<br />

31050 S 969.12 0.00 0.00 31540 S 657.61 0.00 0.00<br />

31051 S 1,050.94 0.00 0.00 31541 S 710.97 0.00 0.00<br />

31070 S 654.01 0.00 0.00 31545 S 710.97 0.00 0.00<br />

31075 S 1,050.94 0.00 0.00 31546 S 710.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 749.65 0.00 0.00 32405 S 324.40 0.00 0.00<br />

31561 S 749.65 0.00 0.00 32420 S 197.26 0.00 0.00<br />

31570 S 537.32 0.00 0.00 32421 S 197.26 0.00 0.00<br />

31571 S 629.15 0.00 0.00 32422 S 196.38 0.00 0.00<br />

31575 S 57.24 0.00 0.00 32550 S 1,099.54 0.00 0.00<br />

31576 S 629.15 0.00 0.00 32960 S 196.38 0.00 0.00<br />

31577 S 185.85 0.00 0.00 32998 S 1,711.92 0.00 0.00<br />

31578 S 629.15 0.00 0.00 33010 S 197.26 0.00 0.00<br />

31579 S 101.98 0.00 0.00 33011 S 197.26 0.00 0.00<br />

31580 S 1,089.63 0.00 0.00 33206 S 6,328.84 3,765.64 1,202.45<br />

31582 S 1,089.63 0.00 0.00 33207 S 6,328.84 3,765.64 1,202.45<br />

31588 S 1,089.63 0.00 0.00 33208 S 7,849.56 4,573.90 1,298.25<br />

31590 S 1,089.63 0.00 0.00 33210 S 1,858.49 0.00 0.00<br />

31595 S 969.12 0.00 0.00 33211 S 1,858.49 0.00 0.00<br />

31603 S 286.75 0.00 0.00 33212 S 4,970.40 2,831.42 692.45<br />

31605 S 277.32 0.00 0.00 33213 S 5,736.91 3,214.27 691.63<br />

31611 S 682.48 0.00 0.00 33214 S 7,849.56 4,573.90 1,298.25<br />

31612 S 603.76 0.00 0.00 33215 S 814.60 0.00 0.00<br />

31613 S 654.01 0.00 0.00 33216 S 1,858.49 0.00 0.00<br />

31614 S 969.12 0.00 0.00 33217 S 1,858.49 0.00 0.00<br />

31615 S 286.75 0.00 0.00 33218 S 814.60 0.00 0.00<br />

31622 S 335.83 0.00 0.00 33220 S 814.60 0.00 0.00<br />

31623 S 386.07 0.00 0.00 33222 S 492.39 0.00 0.00<br />

31624 S 386.07 0.00 0.00 33223 S 492.39 0.00 0.00<br />

31625 S 386.07 0.00 0.00 33224 S 7,409.25 4,435.90 1,462.55<br />

31628 S 386.07 0.00 0.00 33225 S 7,409.25 4,435.90 1,462.55<br />

31629 S 386.07 0.00 0.00 33226 S 814.60 0.00 0.00<br />

31630 S 661.57 0.00 0.00 33233 S 605.63 0.00 0.00<br />

31631 S 661.57 0.00 0.00 33234 S 814.60 0.00 0.00<br />

31632 S 375.48 0.00 0.00 33235 S 814.60 0.00 0.00<br />

31633 S 375.48 0.00 0.00 33240 S 18,469.38 9,872.63 1,275.90<br />

31635 S 386.07 0.00 0.00 33241 S 814.60 0.00 0.00<br />

31636 S 661.57 0.00 0.00 33249 S 24,648.79 13,202.91 1,757.03<br />

31637 S 335.83 0.00 0.00 33282 S 3,897.13 2,333.05 768.97<br />

31638 S 661.57 0.00 0.00 33284 S 303.97 0.00 0.00<br />

31640 S 661.57 0.00 0.00 34490 S 1,484.05 0.00 0.00<br />

31641 S 661.57 0.00 0.00 35188 S 1,022.18 0.00 0.00<br />

31643 S 386.07 0.00 0.00 35207 S 1,022.18 0.00 0.00<br />

31645 S 335.83 0.00 0.00 35473 S 1,780.29 0.00 0.00<br />

31646 S 335.83 0.00 0.00 35476 S 1,780.29 0.00 0.00<br />

31656 S 335.83 0.00 0.00 35492 S 3,322.73 0.00 0.00<br />

31717 S 185.85 0.00 0.00 35761 S 1,068.88 0.00 0.00<br />

31720 S 28.46 0.00 0.00 35875 S 1,337.47 0.00 0.00<br />

31730 S 185.85 0.00 0.00 35876 S 1,337.47 0.00 0.00<br />

31750 S 1,089.63 0.00 0.00 36002 S 85.36 0.00 0.00<br />

31755 S 969.12 0.00 0.00 36260 S 774.36 0.00 0.00<br />

31820 S 465.43 0.00 0.00 36261 S 605.63 0.00 0.00<br />

31825 S 654.01 0.00 0.00 36262 S 555.38 0.00 0.00<br />

31830 S 654.01 0.00 0.00 36420 S 8.04 0.00 0.00<br />

32400 S 324.40 0.00 0.00 36425 S 8.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 30.92 0.00 0.00 36800 S 833.60 0.00 0.00<br />

36440 S 123.49 0.00 0.00 36810 S 833.60 0.00 0.00<br />

36450 S 123.49 0.00 0.00 36815 S 833.60 0.00 0.00<br />

36455 S 123.49 0.00 0.00 36818 S 968.82 0.00 0.00<br />

36468 S 30.48 0.00 0.00 36819 S 968.82 0.00 0.00<br />

36469 S 30.48 0.00 0.00 36820 S 968.82 0.00 0.00<br />

36470 S 30.48 0.00 0.00 36821 S 968.82 0.00 0.00<br />

36471 S 30.48 0.00 0.00 36825 S 1,022.18 0.00 0.00<br />

36475 S 1,401.53 0.00 0.00 36830 S 1,022.18 0.00 0.00<br />

36476 S 1,099.09 0.00 0.00 36831 S 1,337.47 0.00 0.00<br />

36478 S 1,099.09 0.00 0.00 36832 S 1,022.18 0.00 0.00<br />

36479 S 1,099.09 0.00 0.00 36833 S 1,022.18 0.00 0.00<br />

36511 S 423.38 0.00 0.00 36834 S 968.82 0.00 0.00<br />

36512 S 423.38 0.00 0.00 36835 S 886.97 0.00 0.00<br />

36513 S 423.38 0.00 0.00 36860 S 101.80 0.00 0.00<br />

36514 S 423.38 0.00 0.00 36861 S 833.60 0.00 0.00<br />

36515 S 1,133.38 0.00 0.00 36870 S 1,457.85 0.00 0.00<br />

36516 S 1,133.38 0.00 0.00 37184 S 1,484.05 0.00 0.00<br />

36522 S 1,133.38 0.00 0.00 37185 S 1,484.05 0.00 0.00<br />

36555 S 351.77 0.00 0.00 37186 S 1,484.05 0.00 0.00<br />

36556 S 351.77 0.00 0.00 37187 S 1,484.05 0.00 0.00<br />

36557 S 656.96 0.00 0.00 37188 S 1,484.05 0.00 0.00<br />

36558 S 656.96 0.00 0.00 37200 S 1,095.14 0.00 0.00<br />

36560 S 774.36 0.00 0.00 37203 S 1,095.14 0.00 0.00<br />

36561 S 774.36 0.00 0.00 37500 S 1,032.89 0.00 0.00<br />

36563 S 774.36 0.00 0.00 37607 S 730.45 0.00 0.00<br />

36565 S 774.36 0.00 0.00 37609 S 490.96 0.00 0.00<br />

36566 S 774.36 0.00 0.00 37650 S 701.98 0.00 0.00<br />

36568 S 351.77 0.00 0.00 37700 S 701.98 0.00 0.00<br />

36569 S 351.77 0.00 0.00 37718 S 730.45 0.00 0.00<br />

36570 S 685.42 0.00 0.00 37722 S 1,032.89 0.00 0.00<br />

36571 S 685.42 0.00 0.00 37735 S 1,032.89 0.00 0.00<br />

36575 S 282.92 0.00 0.00 37760 S 730.45 0.00 0.00<br />

36576 S 402.02 0.00 0.00 37765 S 1,007.30 0.00 0.00<br />

36578 S 656.96 0.00 0.00 37766 S 1,007.30 0.00 0.00<br />

36580 S 351.77 0.00 0.00 37780 S 730.45 0.00 0.00<br />

36581 S 656.96 0.00 0.00 37785 S 730.45 0.00 0.00<br />

36582 S 774.36 0.00 0.00 37790 S 881.43 0.00 0.00<br />

36583 S 774.36 0.00 0.00 38205 S 423.38 0.00 0.00<br />

36584 S 351.77 0.00 0.00 38206 S 423.38 0.00 0.00<br />

36585 S 685.42 0.00 0.00 38220 S 97.05 0.00 0.00<br />

36589 S 232.68 0.00 0.00 38221 S 101.65 0.00 0.00<br />

36590 S 351.77 0.00 0.00 38230 S 1,133.38 0.00 0.00<br />

36593 S 23.36 0.00 0.00 38241 S 1,133.38 0.00 0.00<br />

36595 S 917.24 0.00 0.00 38242 S 423.38 0.00 0.00<br />

36596 S 407.36 0.00 0.00 38300 S 379.93 0.00 0.00<br />

36597 S 407.36 0.00 0.00 38305 S 555.20 0.00 0.00<br />

36598 S 75.33 0.00 0.00 38308 S 634.39 0.00 0.00<br />

36640 S 695.65 0.00 0.00 38500 S 634.39 0.00 0.00<br />

36680 S 52.73 0.00 0.00 38505 S 242.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 634.39 0.00 0.00 41005 S 127.89 0.00 0.00<br />

38520 S 634.39 0.00 0.00 41006 S 603.76 0.00 0.00<br />

38525 S 634.39 0.00 0.00 41007 S 465.43 0.00 0.00<br />

38530 S 634.39 0.00 0.00 41008 S 465.43 0.00 0.00<br />

38542 S 1,067.28 0.00 0.00 41009 S 127.89 0.00 0.00<br />

38550 S 662.86 0.00 0.00 41010 S 286.75 0.00 0.00<br />

38555 S 716.22 0.00 0.00 41015 S 127.89 0.00 0.00<br />

38570 S 1,448.13 0.00 0.00 41016 S 286.75 0.00 0.00<br />

38571 S 1,882.54 0.00 0.00 41017 S 286.75 0.00 0.00<br />

38572 S 1,448.13 0.00 0.00 41018 S 286.75 0.00 0.00<br />

38700 S 872.12 0.00 0.00 41019 S 911.37 0.00 0.00<br />

38740 S 1,067.28 0.00 0.00 41100 S 85.86 0.00 0.00<br />

38745 S 1,149.10 0.00 0.00 41105 S 84.87 0.00 0.00<br />

38760 S 634.39 0.00 0.00 41108 S 78.62 0.00 0.00<br />

40490 S 64.80 0.00 0.00 41110 S 113.82 0.00 0.00<br />

40500 S 515.67 0.00 0.00 41112 S 515.67 0.00 0.00<br />

40510 S 654.01 0.00 0.00 41113 S 515.67 0.00 0.00<br />

40520 S 515.67 0.00 0.00 41114 S 654.01 0.00 0.00<br />

40525 S 654.01 0.00 0.00 41115 S 132.57 0.00 0.00<br />

40527 S 654.01 0.00 0.00 41116 S 465.43 0.00 0.00<br />

40530 S 654.01 0.00 0.00 41120 S 774.53 0.00 0.00<br />

40650 S 345.07 0.00 0.00 41250 S 87.47 0.00 0.00<br />

40652 S 345.07 0.00 0.00 41251 S 127.89 0.00 0.00<br />

40654 S 345.07 0.00 0.00 41252 S 336.99 0.00 0.00<br />

40700 S 1,213.26 0.00 0.00 41500 S 603.76 0.00 0.00<br />

40701 S 1,213.26 0.00 0.00 41510 S 465.43 0.00 0.00<br />

40702 S 1,541.57 0.00 0.00 41520 S 336.99 0.00 0.00<br />

40720 S 1,213.26 0.00 0.00 41530 S 634.68 0.00 0.00<br />

40761 S 997.58 0.00 0.00 41800 S 65.34 0.00 0.00<br />

40800 S 52.01 0.00 0.00 41805 S 141.46 0.00 0.00<br />

40801 S 336.99 0.00 0.00 41806 S 174.35 0.00 0.00<br />

40804 S 23.79 0.00 0.00 41820 S 277.32 0.00 0.00<br />

40805 S 160.87 0.00 0.00 41821 S 277.32 0.00 0.00<br />

40806 S 74.02 0.00 0.00 41822 S 144.41 0.00 0.00<br />

40808 S 109.87 0.00 0.00 41823 S 210.54 0.00 0.00<br />

40810 S 113.82 0.00 0.00 41825 S 115.79 0.00 0.00<br />

40812 S 142.77 0.00 0.00 41826 S 145.74 0.00 0.00<br />

40814 S 515.67 0.00 0.00 41827 S 654.01 0.00 0.00<br />

40816 S 654.01 0.00 0.00 41828 S 131.59 0.00 0.00<br />

40818 S 127.89 0.00 0.00 41830 S 186.85 0.00 0.00<br />

40819 S 286.75 0.00 0.00 41850 S 634.68 0.00 0.00<br />

40820 S 164.15 0.00 0.00 41870 S 911.37 0.00 0.00<br />

40830 S 121.75 0.00 0.00 41872 S 186.85 0.00 0.00<br />

40831 S 286.75 0.00 0.00 41874 S 180.27 0.00 0.00<br />

40840 S 654.01 0.00 0.00 42000 S 127.89 0.00 0.00<br />

40842 S 682.48 0.00 0.00 42100 S 73.03 0.00 0.00<br />

40843 S 682.48 0.00 0.00 42104 S 108.56 0.00 0.00<br />

40844 S 1,089.63 0.00 0.00 42106 S 136.19 0.00 0.00<br />

40845 S 1,089.63 0.00 0.00 42107 S 654.01 0.00 0.00<br />

41000 S 81.59 0.00 0.00 42120 S 1,050.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 336.99 0.00 0.00 42809 S 23.79 0.00 0.00<br />

42145 S 774.53 0.00 0.00 42810 S 682.48 0.00 0.00<br />

42160 S 128.95 0.00 0.00 42815 S 1,089.63 0.00 0.00<br />

42180 S 127.89 0.00 0.00 42820 S 682.48 0.00 0.00<br />

42182 S 969.12 0.00 0.00 42821 S 774.53 0.00 0.00<br />

42200 S 1,089.63 0.00 0.00 42825 S 735.84 0.00 0.00<br />

42205 S 1,089.63 0.00 0.00 42826 S 735.84 0.00 0.00<br />

42210 S 1,089.63 0.00 0.00 42830 S 735.84 0.00 0.00<br />

42215 S 1,213.26 0.00 0.00 42831 S 735.84 0.00 0.00<br />

42220 S 1,089.63 0.00 0.00 42835 S 735.84 0.00 0.00<br />

42226 S 1,089.63 0.00 0.00 42836 S 735.84 0.00 0.00<br />

42235 S 636.19 0.00 0.00 42860 S 682.48 0.00 0.00<br />

42260 S 735.84 0.00 0.00 42870 S 682.48 0.00 0.00<br />

42280 S 71.05 0.00 0.00 42890 S 1,213.26 0.00 0.00<br />

42281 S 634.68 0.00 0.00 42892 S 1,213.26 0.00 0.00<br />

42300 S 465.43 0.00 0.00 42900 S 286.75 0.00 0.00<br />

42305 S 515.67 0.00 0.00 42950 S 654.01 0.00 0.00<br />

42310 S 127.89 0.00 0.00 42955 S 654.01 0.00 0.00<br />

42320 S 127.89 0.00 0.00 42960 S 52.68 0.00 0.00<br />

42330 S 109.87 0.00 0.00 42962 S 969.12 0.00 0.00<br />

42335 S 182.25 0.00 0.00 42970 S 40.90 0.00 0.00<br />

42340 S 515.67 0.00 0.00 42972 S 544.14 0.00 0.00<br />

42400 S 61.85 0.00 0.00 43030 S 634.68 0.00 0.00<br />

42405 S 515.67 0.00 0.00 43200 S 307.35 0.00 0.00<br />

42408 S 544.14 0.00 0.00 43201 S 307.35 0.00 0.00<br />

42409 S 544.14 0.00 0.00 43202 S 307.35 0.00 0.00<br />

42410 S 997.58 0.00 0.00 43204 S 307.35 0.00 0.00<br />

42415 S 1,213.26 0.00 0.00 43205 S 307.35 0.00 0.00<br />

42420 S 1,213.26 0.00 0.00 43215 S 307.35 0.00 0.00<br />

42425 S 1,213.26 0.00 0.00 43216 S 307.35 0.00 0.00<br />

42440 S 997.58 0.00 0.00 43217 S 307.35 0.00 0.00<br />

42450 S 654.01 0.00 0.00 43219 S 621.16 0.00 0.00<br />

42500 S 682.48 0.00 0.00 43220 S 307.35 0.00 0.00<br />

42505 S 1,050.94 0.00 0.00 43226 S 307.35 0.00 0.00<br />

42507 S 997.58 0.00 0.00 43227 S 357.61 0.00 0.00<br />

42508 S 1,050.94 0.00 0.00 43228 S 665.48 0.00 0.00<br />

42509 S 1,050.94 0.00 0.00 43231 S 357.61 0.00 0.00<br />

42510 S 1,050.94 0.00 0.00 43232 S 357.61 0.00 0.00<br />

42600 S 465.43 0.00 0.00 43234 S 307.35 0.00 0.00<br />

42650 S 40.46 0.00 0.00 43235 S 307.35 0.00 0.00<br />

42660 S 47.37 0.00 0.00 43236 S 357.61 0.00 0.00<br />

42665 S 898.15 0.00 0.00 43237 S 357.61 0.00 0.00<br />

42700 S 127.89 0.00 0.00 43238 S 357.61 0.00 0.00<br />

42720 S 465.43 0.00 0.00 43239 S 357.61 0.00 0.00<br />

42725 S 969.12 0.00 0.00 43240 S 357.61 0.00 0.00<br />

42800 S 78.29 0.00 0.00 43241 S 357.61 0.00 0.00<br />

42802 S 465.43 0.00 0.00 43242 S 357.61 0.00 0.00<br />

42804 S 465.43 0.00 0.00 43243 S 357.61 0.00 0.00<br />

42806 S 654.01 0.00 0.00 43244 S 357.61 0.00 0.00<br />

42808 S 515.67 0.00 0.00 43245 S 357.61 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 357.61 0.00 0.00 44378 S 374.54 0.00 0.00<br />

43247 S 357.61 0.00 0.00 44379 S 1,068.53 0.00 0.00<br />

43248 S 357.61 0.00 0.00 44380 S 324.28 0.00 0.00<br />

43249 S 357.61 0.00 0.00 44382 S 324.28 0.00 0.00<br />

43250 S 357.61 0.00 0.00 44383 S 1,068.53 0.00 0.00<br />

43251 S 357.61 0.00 0.00 44385 S 313.53 0.00 0.00<br />

43255 S 357.61 0.00 0.00 44386 S 313.53 0.00 0.00<br />

43256 S 699.87 0.00 0.00 44388 S 313.53 0.00 0.00<br />

43257 S 693.94 0.00 0.00 44389 S 313.53 0.00 0.00<br />

43258 S 386.06 0.00 0.00 44390 S 313.53 0.00 0.00<br />

43259 S 386.06 0.00 0.00 44391 S 313.53 0.00 0.00<br />

43260 S 602.03 0.00 0.00 44392 S 313.53 0.00 0.00<br />

43261 S 602.03 0.00 0.00 44393 S 313.53 0.00 0.00<br />

43262 S 602.03 0.00 0.00 44394 S 313.53 0.00 0.00<br />

43263 S 602.03 0.00 0.00 44397 S 621.16 0.00 0.00<br />

43264 S 602.03 0.00 0.00 44500 S 169.19 0.00 0.00<br />

43265 S 602.03 0.00 0.00 45000 S 363.60 0.00 0.00<br />

43267 S 602.03 0.00 0.00 45005 S 423.16 0.00 0.00<br />

43268 S 671.42 0.00 0.00 45020 S 423.16 0.00 0.00<br />

43269 S 671.42 0.00 0.00 45100 S 574.91 0.00 0.00<br />

43271 S 602.03 0.00 0.00 45108 S 625.15 0.00 0.00<br />

43272 S 602.03 0.00 0.00 45150 S 625.15 0.00 0.00<br />

43273 S 807.40 0.00 0.00 45160 S 625.15 0.00 0.00<br />

43450 S 268.80 0.00 0.00 45170 S 625.15 0.00 0.00<br />

43453 S 268.80 0.00 0.00 45190 S 1,022.26 0.00 0.00<br />

43456 S 269.86 0.00 0.00 45300 S 60.53 0.00 0.00<br />

43458 S 308.43 0.00 0.00 45303 S 336.21 0.00 0.00<br />

43600 S 307.35 0.00 0.00 45305 S 316.19 0.00 0.00<br />

43653 S 1,448.13 0.00 0.00 45307 S 584.02 0.00 0.00<br />

43760 S 149.06 0.00 0.00 45308 S 316.19 0.00 0.00<br />

43761 S 307.35 0.00 0.00 45309 S 316.19 0.00 0.00<br />

43870 S 307.35 0.00 0.00 45315 S 316.19 0.00 0.00<br />

43886 S 775.52 0.00 0.00 45317 S 316.19 0.00 0.00<br />

43887 S 163.11 0.00 0.00 45320 S 584.02 0.00 0.00<br />

43888 S 775.52 0.00 0.00 45321 S 584.02 0.00 0.00<br />

44100 S 307.35 0.00 0.00 45327 S 621.16 0.00 0.00<br />

44312 S 535.84 0.00 0.00 45330 S 79.94 0.00 0.00<br />

44340 S 614.55 0.00 0.00 45331 S 236.39 0.00 0.00<br />

44360 S 374.54 0.00 0.00 45332 S 236.39 0.00 0.00<br />

44361 S 374.54 0.00 0.00 45333 S 316.19 0.00 0.00<br />

44363 S 374.54 0.00 0.00 45334 S 316.19 0.00 0.00<br />

44364 S 374.54 0.00 0.00 45335 S 236.39 0.00 0.00<br />

44365 S 374.54 0.00 0.00 45337 S 236.39 0.00 0.00<br />

44366 S 374.54 0.00 0.00 45338 S 316.19 0.00 0.00<br />

44369 S 374.54 0.00 0.00 45339 S 316.19 0.00 0.00<br />

44370 S 1,068.53 0.00 0.00 45340 S 316.19 0.00 0.00<br />

44372 S 374.54 0.00 0.00 45341 S 316.19 0.00 0.00<br />

44373 S 374.54 0.00 0.00 45342 S 316.19 0.00 0.00<br />

44376 S 374.54 0.00 0.00 45345 S 621.16 0.00 0.00<br />

44377 S 374.54 0.00 0.00 45355 S 313.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 363.79 0.00 0.00 46505 S 449.65 0.00 0.00<br />

45379 S 363.79 0.00 0.00 46600 S 23.79 0.00 0.00<br />

45380 S 363.79 0.00 0.00 46604 S 336.21 0.00 0.00<br />

45381 S 363.79 0.00 0.00 46606 S 126.33 0.00 0.00<br />

45382 S 363.79 0.00 0.00 46608 S 316.19 0.00 0.00<br />

45383 S 363.79 0.00 0.00 46610 S 584.02 0.00 0.00<br />

45384 S 363.79 0.00 0.00 46611 S 316.19 0.00 0.00<br />

45385 S 363.79 0.00 0.00 46612 S 584.02 0.00 0.00<br />

45386 S 363.79 0.00 0.00 46614 S 66.45 0.00 0.00<br />

45387 S 621.16 0.00 0.00 46615 S 634.27 0.00 0.00<br />

45391 S 363.79 0.00 0.00 46700 S 653.62 0.00 0.00<br />

45392 S 363.79 0.00 0.00 46706 S 719.44 0.00 0.00<br />

45500 S 625.15 0.00 0.00 46750 S 798.15 0.00 0.00<br />

45505 S 769.69 0.00 0.00 46753 S 653.62 0.00 0.00<br />

45520 S 30.48 0.00 0.00 46754 S 625.15 0.00 0.00<br />

45560 S 769.69 0.00 0.00 46760 S 769.69 0.00 0.00<br />

45900 S 246.50 0.00 0.00 46761 S 798.15 0.00 0.00<br />

45905 S 574.91 0.00 0.00 46762 S 1,013.83 0.00 0.00<br />

45910 S 574.91 0.00 0.00 46900 S 100.46 0.00 0.00<br />

45915 S 363.60 0.00 0.00 46910 S 120.07 0.00 0.00<br />

45990 S 565.59 0.00 0.00 46916 S 55.85 0.00 0.00<br />

46020 S 653.62 0.00 0.00 46917 S 520.97 0.00 0.00<br />

46030 S 246.50 0.00 0.00 46922 S 520.97 0.00 0.00<br />

46040 S 653.62 0.00 0.00 46924 S 520.97 0.00 0.00<br />

46045 S 625.15 0.00 0.00 46930 S 116.46 0.00 0.00<br />

46050 S 363.60 0.00 0.00 46937 S 625.15 0.00 0.00<br />

46060 S 625.15 0.00 0.00 46938 S 769.69 0.00 0.00<br />

46070 S 449.65 0.00 0.00 46940 S 86.18 0.00 0.00<br />

46080 S 653.62 0.00 0.00 46942 S 83.89 0.00 0.00<br />

46083 S 68.83 0.00 0.00 46945 S 142.77 0.00 0.00<br />

46200 S 625.15 0.00 0.00 46946 S 372.90 0.00 0.00<br />

46210 S 625.15 0.00 0.00 46947 S 1,013.83 0.00 0.00<br />

46211 S 625.15 0.00 0.00 47000 S 324.40 0.00 0.00<br />

46220 S 574.91 0.00 0.00 47382 S 1,711.92 0.00 0.00<br />

46221 S 113.16 0.00 0.00 47510 S 758.14 0.00 0.00<br />

46230 S 574.91 0.00 0.00 47511 S 1,113.82 0.00 0.00<br />

46250 S 653.62 0.00 0.00 47525 S 435.23 0.00 0.00<br />

46255 S 653.62 0.00 0.00 47530 S 435.23 0.00 0.00<br />

46257 S 653.62 0.00 0.00 47552 S 758.14 0.00 0.00<br />

46258 S 653.62 0.00 0.00 47553 S 786.60 0.00 0.00<br />

46260 S 653.62 0.00 0.00 47554 S 786.60 0.00 0.00<br />

46261 S 706.98 0.00 0.00 47555 S 786.60 0.00 0.00<br />

46262 S 706.98 0.00 0.00 47556 S 1,113.82 0.00 0.00<br />

46270 S 653.62 0.00 0.00 47560 S 924.22 0.00 0.00<br />

46275 S 653.62 0.00 0.00 47561 S 924.22 0.00 0.00<br />

46280 S 706.98 0.00 0.00 47562 S 1,705.38 0.00 0.00<br />

46285 S 574.91 0.00 0.00 47563 S 1,705.38 0.00 0.00<br />

46288 S 706.98 0.00 0.00 47564 S 1,705.38 0.00 0.00<br />

46320 S 76.65 0.00 0.00 47630 S 786.60 0.00 0.00<br />

46500 S 105.59 0.00 0.00 48102 S 324.40 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 197.26 0.00 0.00 49590 S 809.63 0.00 0.00<br />

49081 S 197.26 0.00 0.00 49600 S 862.98 0.00 0.00<br />

49180 S 324.40 0.00 0.00 49650 S 1,132.85 0.00 0.00<br />

49250 S 711.09 0.00 0.00 49651 S 1,295.16 0.00 0.00<br />

49320 S 924.22 0.00 0.00 49652 S 1,394.86 0.00 0.00<br />

49321 S 977.59 0.00 0.00 49653 S 1,394.86 0.00 0.00<br />

49322 S 977.59 0.00 0.00 49654 S 1,394.86 0.00 0.00<br />

49324 S 1,394.86 0.00 0.00 49655 S 1,394.86 0.00 0.00<br />

49325 S 1,394.86 0.00 0.00 49656 S 1,394.86 0.00 0.00<br />

49326 S 1,394.86 0.00 0.00 49657 S 1,394.86 0.00 0.00<br />

49402 S 629.27 0.00 0.00 50200 S 324.40 0.00 0.00<br />

49419 S 754.89 0.00 0.00 50382 S 941.98 0.00 0.00<br />

49420 S 697.85 0.00 0.00 50384 S 691.86 0.00 0.00<br />

49421 S 697.85 0.00 0.00 50385 S 691.86 0.00 0.00<br />

49422 S 555.38 0.00 0.00 50386 S 265.45 0.00 0.00<br />

49423 S 574.29 0.00 0.00 50387 S 574.29 0.00 0.00<br />

49426 S 629.27 0.00 0.00 50389 S 265.45 0.00 0.00<br />

49429 S 814.60 0.00 0.00 50390 S 324.40 0.00 0.00<br />

49440 S 318.54 0.00 0.00 50391 S 38.42 0.00 0.00<br />

49441 S 318.54 0.00 0.00 50392 S 494.01 0.00 0.00<br />

49446 S 318.54 0.00 0.00 50393 S 619.07 0.00 0.00<br />

49450 S 169.19 0.00 0.00 50395 S 494.01 0.00 0.00<br />

49451 S 169.19 0.00 0.00 50396 S 92.89 0.00 0.00<br />

49452 S 169.19 0.00 0.00 50398 S 435.23 0.00 0.00<br />

49460 S 169.19 0.00 0.00 50551 S 280.81 0.00 0.00<br />

49495 S 862.98 0.00 0.00 50553 S 619.07 0.00 0.00<br />

49496 S 862.98 0.00 0.00 50555 S 280.81 0.00 0.00<br />

49500 S 862.98 0.00 0.00 50557 S 619.07 0.00 0.00<br />

49501 S 1,178.27 0.00 0.00 50561 S 619.07 0.00 0.00<br />

49505 S 862.98 0.00 0.00 50562 S 265.45 0.00 0.00<br />

49507 S 1,178.27 0.00 0.00 50570 S 265.45 0.00 0.00<br />

49520 S 1,025.30 0.00 0.00 50572 S 265.45 0.00 0.00<br />

49521 S 1,178.27 0.00 0.00 50574 S 265.45 0.00 0.00<br />

49525 S 862.98 0.00 0.00 50575 S 1,320.39 0.00 0.00<br />

49540 S 781.16 0.00 0.00 50576 S 691.86 0.00 0.00<br />

49550 S 901.67 0.00 0.00 50580 S 691.86 0.00 0.00<br />

49553 S 1,178.27 0.00 0.00 50590 S 1,542.53 0.00 0.00<br />

49555 S 901.67 0.00 0.00 50592 S 1,711.92 0.00 0.00<br />

49557 S 1,178.27 0.00 0.00 50686 S 38.42 0.00 0.00<br />

49560 S 862.98 0.00 0.00 50688 S 435.23 0.00 0.00<br />

49561 S 1,178.27 0.00 0.00 50947 S 1,448.13 0.00 0.00<br />

49565 S 862.98 0.00 0.00 50948 S 1,448.13 0.00 0.00<br />

49566 S 1,178.27 0.00 0.00 50951 S 280.81 0.00 0.00<br />

49568 S 1,025.30 0.00 0.00 50953 S 280.81 0.00 0.00<br />

49570 S 862.98 0.00 0.00 50955 S 619.07 0.00 0.00<br />

49572 S 1,178.27 0.00 0.00 50957 S 619.07 0.00 0.00<br />

49580 S 862.98 0.00 0.00 50961 S 619.07 0.00 0.00<br />

49582 S 1,178.27 0.00 0.00 50970 S 280.81 0.00 0.00<br />

49585 S 862.98 0.00 0.00 50972 S 280.81 0.00 0.00<br />

49587 S 1,178.27 0.00 0.00 50974 S 494.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 494.01 0.00 0.00 52275 S 669.33 0.00 0.00<br />

50980 S 619.07 0.00 0.00 52276 S 697.78 0.00 0.00<br />

51020 S 751.15 0.00 0.00 52277 S 669.33 0.00 0.00<br />

51030 S 751.15 0.00 0.00 52281 S 544.26 0.00 0.00<br />

51040 S 751.15 0.00 0.00 52282 S 1,255.64 0.00 0.00<br />

51045 S 310.26 0.00 0.00 52283 S 669.33 0.00 0.00<br />

51050 S 751.15 0.00 0.00 52285 S 544.26 0.00 0.00<br />

51065 S 751.15 0.00 0.00 52290 S 544.26 0.00 0.00<br />

51080 S 504.95 0.00 0.00 52300 S 669.33 0.00 0.00<br />

51100 S 29.28 0.00 0.00 52301 S 697.78 0.00 0.00<br />

51101 S 38.42 0.00 0.00 52305 S 669.33 0.00 0.00<br />

51102 S 516.86 0.00 0.00 52310 S 523.46 0.00 0.00<br />

51500 S 862.98 0.00 0.00 52315 S 669.33 0.00 0.00<br />

51520 S 751.15 0.00 0.00 52317 S 619.07 0.00 0.00<br />

51700 S 50.00 0.00 0.00 52318 S 669.33 0.00 0.00<br />

51701 S 23.79 0.00 0.00 52320 S 789.83 0.00 0.00<br />

51702 S 23.79 0.00 0.00 52325 S 751.15 0.00 0.00<br />

51703 S 38.42 0.00 0.00 52327 S 858.53 0.00 0.00<br />

51705 S 68.83 0.00 0.00 52330 S 669.33 0.00 0.00<br />

51710 S 435.23 0.00 0.00 52332 S 669.33 0.00 0.00<br />

51715 S 790.24 0.00 0.00 52334 S 697.78 0.00 0.00<br />

51720 S 55.26 0.00 0.00 52341 S 697.78 0.00 0.00<br />

51725 TC S 106.17 0.00 0.00 52342 S 697.78 0.00 0.00<br />

51726 TC S 146.24 0.00 0.00 52343 S 697.78 0.00 0.00<br />

51736 TC S 20.07 0.00 0.00 52344 S 697.78 0.00 0.00<br />

51741 TC S 23.36 0.00 0.00 52345 S 697.78 0.00 0.00<br />

51772 TC S 92.89 0.00 0.00 52346 S 697.78 0.00 0.00<br />

51784 TC S 38.42 0.00 0.00 52351 S 697.78 0.00 0.00<br />

51785 TC S 64.18 0.00 0.00 52352 S 751.15 0.00 0.00<br />

51792 TC S 38.42 0.00 0.00 52353 S 940.36 0.00 0.00<br />

51795 TC S 68.83 0.00 0.00 52354 S 751.15 0.00 0.00<br />

51797 TC S 68.83 0.00 0.00 52355 S 751.15 0.00 0.00<br />

51798 S 17.10 0.00 0.00 52400 S 697.78 0.00 0.00<br />

51880 S 619.07 0.00 0.00 52402 S 697.78 0.00 0.00<br />

51992 S 1,171.54 0.00 0.00 52450 S 697.78 0.00 0.00<br />

52000 S 280.81 0.00 0.00 52500 S 697.78 0.00 0.00<br />

52001 S 523.46 0.00 0.00 52601 S 940.36 0.00 0.00<br />

52005 S 544.26 0.00 0.00 52630 S 858.53 0.00 0.00<br />

52007 S 669.33 0.00 0.00 52640 S 669.33 0.00 0.00<br />

52010 S 310.26 0.00 0.00 52647 S 1,438.66 0.00 0.00<br />

52204 S 544.26 0.00 0.00 52648 S 1,438.66 0.00 0.00<br />

52214 S 669.33 0.00 0.00 52700 S 669.33 0.00 0.00<br />

52224 S 669.33 0.00 0.00 53000 S 513.70 0.00 0.00<br />

52234 S 669.33 0.00 0.00 53010 S 513.70 0.00 0.00<br />

52235 S 697.78 0.00 0.00 53020 S 513.70 0.00 0.00<br />

52240 S 697.78 0.00 0.00 53025 S 731.24 0.00 0.00<br />

52250 S 751.15 0.00 0.00 53040 S 563.96 0.00 0.00<br />

52260 S 544.26 0.00 0.00 53060 S 66.78 0.00 0.00<br />

52265 S 265.45 0.00 0.00 53080 S 592.42 0.00 0.00<br />

52270 S 544.26 0.00 0.00 53085 S 731.24 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 513.70 0.00 0.00 54060 S 520.97 0.00 0.00<br />

53210 S 882.29 0.00 0.00 54065 S 520.97 0.00 0.00<br />

53215 S 684.47 0.00 0.00 54100 S 440.71 0.00 0.00<br />

53220 S 761.78 0.00 0.00 54105 S 550.15 0.00 0.00<br />

53230 S 761.78 0.00 0.00 54110 S 852.97 0.00 0.00<br />

53235 S 592.42 0.00 0.00 54111 S 852.97 0.00 0.00<br />

53240 S 761.78 0.00 0.00 54112 S 852.97 0.00 0.00<br />

53250 S 563.96 0.00 0.00 54115 S 504.95 0.00 0.00<br />

53260 S 563.96 0.00 0.00 54120 S 852.97 0.00 0.00<br />

53265 S 563.96 0.00 0.00 54150 S 568.46 0.00 0.00<br />

53270 S 563.96 0.00 0.00 54160 S 618.71 0.00 0.00<br />

53275 S 563.96 0.00 0.00 54161 S 618.71 0.00 0.00<br />

53400 S 790.24 0.00 0.00 54162 S 618.71 0.00 0.00<br />

53405 S 761.78 0.00 0.00 54163 S 618.71 0.00 0.00<br />

53410 S 761.78 0.00 0.00 54164 S 618.71 0.00 0.00<br />

53420 S 790.24 0.00 0.00 54200 S 64.80 0.00 0.00<br />

53425 S 761.78 0.00 0.00 54205 S 934.79 0.00 0.00<br />

53430 S 761.78 0.00 0.00 54220 S 92.89 0.00 0.00<br />

53431 S 761.78 0.00 0.00 54231 S 60.86 0.00 0.00<br />

53440 S 4,388.14 2,665.12 942.10 54235 S 43.10 0.00 0.00<br />

53442 S 711.53 0.00 0.00 54240 TC S 30.59 0.00 0.00<br />

53444 S 4,388.14 2,665.12 942.10 54250 TC S 10.85 0.00 0.00<br />

53445 S 7,370.96 4,197.71 1,024.47 54300 S 881.43 0.00 0.00<br />

53446 S 711.53 0.00 0.00 54304 S 881.43 0.00 0.00<br />

53447 S 7,370.96 4,197.71 1,024.47 54308 S 881.43 0.00 0.00<br />

53449 S 711.53 0.00 0.00 54312 S 881.43 0.00 0.00<br />

53450 S 711.53 0.00 0.00 54316 S 881.43 0.00 0.00<br />

53460 S 513.70 0.00 0.00 54318 S 881.43 0.00 0.00<br />

53502 S 563.96 0.00 0.00 54322 S 881.43 0.00 0.00<br />

53505 S 761.78 0.00 0.00 54324 S 881.43 0.00 0.00<br />

53510 S 563.96 0.00 0.00 54326 S 881.43 0.00 0.00<br />

53515 S 761.78 0.00 0.00 54328 S 881.43 0.00 0.00<br />

53520 S 761.78 0.00 0.00 54340 S 881.43 0.00 0.00<br />

53600 S 38.49 0.00 0.00 54344 S 881.43 0.00 0.00<br />

53601 S 38.42 0.00 0.00 54348 S 881.43 0.00 0.00<br />

53605 S 544.26 0.00 0.00 54352 S 881.43 0.00 0.00<br />

53620 S 59.21 0.00 0.00 54360 S 881.43 0.00 0.00<br />

53621 S 62.18 0.00 0.00 54380 S 881.43 0.00 0.00<br />

53660 S 38.42 0.00 0.00 54385 S 881.43 0.00 0.00<br />

53661 S 38.42 0.00 0.00 54400 S 4,416.61 2,693.59 970.57<br />

53665 S 513.70 0.00 0.00 54401 S 7,449.68 4,276.43 1,103.18<br />

53850 S 1,686.43 0.00 0.00 54405 S 7,449.68 4,276.43 1,103.18<br />

53852 S 1,686.43 0.00 0.00 54406 S 881.43 0.00 0.00<br />

54000 S 563.96 0.00 0.00 54408 S 881.43 0.00 0.00<br />

54001 S 563.96 0.00 0.00 54410 S 7,449.68 4,276.43 1,103.18<br />

54015 S 637.03 0.00 0.00 54415 S 881.43 0.00 0.00<br />

54050 S 30.48 0.00 0.00 54416 S 7,449.68 4,276.43 1,103.18<br />

54055 S 62.18 0.00 0.00 54420 S 934.79 0.00 0.00<br />

54056 S 30.48 0.00 0.00 54435 S 934.79 0.00 0.00<br />

54057 S 520.97 0.00 0.00 54440 S 934.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 146.24 0.00 0.00 55706 S 425.12 0.00 0.00<br />

54500 S 396.90 0.00 0.00 55720 S 619.07 0.00 0.00<br />

54505 S 568.46 0.00 0.00 55725 S 669.33 0.00 0.00<br />

54512 S 618.71 0.00 0.00 55860 S 737.56 0.00 0.00<br />

54520 S 647.17 0.00 0.00 55870 S 75.00 0.00 0.00<br />

54522 S 647.17 0.00 0.00 55873 S 5,835.86 0.00 0.00<br />

54530 S 862.98 0.00 0.00 55875 S 1,255.64 0.00 0.00<br />

54550 S 862.98 0.00 0.00 55876 S 68.75 0.00 0.00<br />

54560 S 840.76 0.00 0.00 55920 S 861.88 0.00 0.00<br />

54600 S 700.54 0.00 0.00 56405 S 40.13 0.00 0.00<br />

54620 S 647.17 0.00 0.00 56420 S 52.38 0.00 0.00<br />

54640 S 862.98 0.00 0.00 56440 S 562.50 0.00 0.00<br />

54660 S 618.71 0.00 0.00 56441 S 512.24 0.00 0.00<br />

54670 S 647.17 0.00 0.00 56442 S 512.24 0.00 0.00<br />

54680 S 647.17 0.00 0.00 56501 S 55.26 0.00 0.00<br />

54690 S 1,448.13 0.00 0.00 56515 S 599.69 0.00 0.00<br />

54692 S 2,574.19 0.00 0.00 56605 S 31.91 0.00 0.00<br />

54700 S 618.71 0.00 0.00 56606 S 13.16 0.00 0.00<br />

54800 S 138.88 0.00 0.00 56620 S 683.01 0.00 0.00<br />

54830 S 647.17 0.00 0.00 56625 S 806.63 0.00 0.00<br />

54840 S 700.54 0.00 0.00 56700 S 512.24 0.00 0.00<br />

54860 S 647.17 0.00 0.00 56740 S 590.96 0.00 0.00<br />

54861 S 700.54 0.00 0.00 56800 S 590.96 0.00 0.00<br />

54865 S 568.46 0.00 0.00 56805 S 728.33 0.00 0.00<br />

54900 S 700.54 0.00 0.00 56810 S 683.01 0.00 0.00<br />

54901 S 700.54 0.00 0.00 56820 S 40.79 0.00 0.00<br />

55000 S 63.16 0.00 0.00 56821 S 52.38 0.00 0.00<br />

55040 S 809.63 0.00 0.00 57000 S 512.24 0.00 0.00<br />

55041 S 901.67 0.00 0.00 57010 S 562.50 0.00 0.00<br />

55060 S 700.54 0.00 0.00 57020 S 295.00 0.00 0.00<br />

55100 S 379.93 0.00 0.00 57022 S 463.69 0.00 0.00<br />

55110 S 618.71 0.00 0.00 57023 S 504.95 0.00 0.00<br />

55120 S 618.71 0.00 0.00 57061 S 50.99 0.00 0.00<br />

55150 S 568.46 0.00 0.00 57065 S 512.24 0.00 0.00<br />

55175 S 568.46 0.00 0.00 57100 S 32.57 0.00 0.00<br />

55180 S 618.71 0.00 0.00 57105 S 562.50 0.00 0.00<br />

55200 S 618.71 0.00 0.00 57130 S 562.50 0.00 0.00<br />

55250 S 618.71 0.00 0.00 57135 S 562.50 0.00 0.00<br />

55400 S 568.46 0.00 0.00 57150 S 23.69 0.00 0.00<br />

55450 S 203.30 0.00 0.00 57155 S 295.00 0.00 0.00<br />

55500 S 647.17 0.00 0.00 57160 S 34.21 0.00 0.00<br />

55520 S 700.54 0.00 0.00 57170 S 5.61 0.00 0.00<br />

55530 S 700.54 0.00 0.00 57180 S 105.37 0.00 0.00<br />

55535 S 862.98 0.00 0.00 57200 S 512.24 0.00 0.00<br />

55540 S 901.67 0.00 0.00 57210 S 562.50 0.00 0.00<br />

55550 S 1,448.13 0.00 0.00 57220 S 1,031.55 0.00 0.00<br />

55600 S 840.76 0.00 0.00 57230 S 846.99 0.00 0.00<br />

55680 S 568.46 0.00 0.00 57240 S 939.04 0.00 0.00<br />

55700 S 366.34 0.00 0.00 57250 S 939.04 0.00 0.00<br />

55705 S 366.34 0.00 0.00 57260 S 939.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,247.22 0.00 0.00 58555 S 553.45 0.00 0.00<br />

57267 S 1,062.67 0.00 0.00 58558 S 632.17 0.00 0.00<br />

57268 S 846.99 0.00 0.00 58559 S 603.71 0.00 0.00<br />

57287 S 1,240.40 0.00 0.00 58560 S 901.38 0.00 0.00<br />

57288 S 1,123.60 0.00 0.00 58561 S 901.38 0.00 0.00<br />

57289 S 939.04 0.00 0.00 58562 S 632.17 0.00 0.00<br />

57291 S 939.04 0.00 0.00 58563 S 1,270.03 0.00 0.00<br />

57300 S 846.99 0.00 0.00 58565 S 1,400.20 0.00 0.00<br />

57320 S 1,240.40 0.00 0.00 58600 S 1,240.40 0.00 0.00<br />

57400 S 562.50 0.00 0.00 58615 S 728.33 0.00 0.00<br />

57410 S 562.50 0.00 0.00 58660 S 1,171.54 0.00 0.00<br />

57415 S 562.50 0.00 0.00 58661 S 1,171.54 0.00 0.00<br />

57420 S 42.11 0.00 0.00 58662 S 1,171.54 0.00 0.00<br />

57421 S 54.94 0.00 0.00 58670 S 1,079.49 0.00 0.00<br />

57452 S 39.80 0.00 0.00 58671 S 1,079.49 0.00 0.00<br />

57454 S 48.69 0.00 0.00 58672 S 1,171.54 0.00 0.00<br />

57455 S 51.64 0.00 0.00 58673 S 1,171.54 0.00 0.00<br />

57456 S 50.00 0.00 0.00 58800 S 590.96 0.00 0.00<br />

57460 S 153.63 0.00 0.00 58805 S 1,240.40 0.00 0.00<br />

57461 S 163.17 0.00 0.00 58820 S 846.99 0.00 0.00<br />

57500 S 70.40 0.00 0.00 58900 S 590.96 0.00 0.00<br />

57505 S 44.74 0.00 0.00 58970 S 164.61 0.00 0.00<br />

57510 S 45.40 0.00 0.00 58974 S 164.61 0.00 0.00<br />

57511 S 52.38 0.00 0.00 58976 S 164.61 0.00 0.00<br />

57513 S 562.50 0.00 0.00 59000 S 60.20 0.00 0.00<br />

57520 S 562.50 0.00 0.00 59001 S 225.96 0.00 0.00<br />

57522 S 562.50 0.00 0.00 59012 S 110.49 0.00 0.00<br />

57530 S 846.99 0.00 0.00 59015 S 48.69 0.00 0.00<br />

57550 S 846.99 0.00 0.00 59020 TC S 25.66 0.00 0.00<br />

57556 S 1,123.60 0.00 0.00 59025 TC S 13.49 0.00 0.00<br />

57558 S 590.96 0.00 0.00 59070 S 110.49 0.00 0.00<br />

57700 S 512.24 0.00 0.00 59072 S 110.49 0.00 0.00<br />

57720 S 590.96 0.00 0.00 59076 S 110.49 0.00 0.00<br />

57800 S 24.02 0.00 0.00 59100 S 1,240.40 0.00 0.00<br />

58100 S 39.48 0.00 0.00 59150 S 1,705.38 0.00 0.00<br />

58120 S 562.50 0.00 0.00 59151 S 1,705.38 0.00 0.00<br />

58145 S 939.04 0.00 0.00 59160 S 590.96 0.00 0.00<br />

58301 S 36.84 0.00 0.00 59200 S 32.90 0.00 0.00<br />

58321 S 34.54 0.00 0.00 59300 S 71.05 0.00 0.00<br />

58322 S 35.53 0.00 0.00 59320 S 512.24 0.00 0.00<br />

58323 S 8.23 0.00 0.00 59412 S 728.33 0.00 0.00<br />

58345 S 728.33 0.00 0.00 59414 S 728.33 0.00 0.00<br />

58346 S 562.50 0.00 0.00 59812 S 683.01 0.00 0.00<br />

58350 S 846.99 0.00 0.00 59820 S 683.01 0.00 0.00<br />

58353 S 1,062.67 0.00 0.00 59821 S 683.01 0.00 0.00<br />

58356 S 1,609.51 0.00 0.00 59840 S 683.01 0.00 0.00<br />

58545 S 1,292.87 0.00 0.00 59841 S 683.01 0.00 0.00<br />

58546 S 1,448.13 0.00 0.00 59866 S 110.49 0.00 0.00<br />

58550 S 1,882.54 0.00 0.00 59870 S 683.01 0.00 0.00<br />

58552 S 1,705.38 0.00 0.00 59871 S 683.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 286.75 0.00 0.00 62367 S 15.79 0.00 0.00<br />

60100 S 45.07 0.00 0.00 62368 S 20.07 0.00 0.00<br />

60200 S 1,067.28 0.00 0.00 63600 S 539.07 0.00 0.00<br />

60280 S 1,149.10 0.00 0.00 63610 S 488.81 0.00 0.00<br />

60281 S 1,149.10 0.00 0.00 63615 S 681.47 0.00 0.00<br />

60300 S 59.21 0.00 0.00 63650 S 2,901.53 1,799.24 696.95<br />

61000 S 264.03 0.00 0.00 63655 S 4,250.03 2,710.25 1,170.48<br />

61001 S 264.03 0.00 0.00 63660 S 509.56 0.00 0.00<br />

61020 S 213.77 0.00 0.00 63685 S 12,899.82 6,878.30 856.79<br />

61026 S 213.77 0.00 0.00 63688 S 691.95 0.00 0.00<br />

61050 S 213.77 0.00 0.00 63744 S 1,000.66 0.00 0.00<br />

61055 S 213.77 0.00 0.00 63746 S 462.88 0.00 0.00<br />

61070 S 166.34 0.00 0.00 64400 S 50.66 0.00 0.00<br />

61215 S 1,000.66 0.00 0.00 64402 S 47.70 0.00 0.00<br />

61330 S 1,541.57 0.00 0.00 64405 S 40.46 0.00 0.00<br />

61334 S 1,541.57 0.00 0.00 64408 S 50.33 0.00 0.00<br />

61790 S 567.53 0.00 0.00 64410 S 280.10 0.00 0.00<br />

61791 S 421.04 0.00 0.00 64412 S 74.02 0.00 0.00<br />

61880 S 722.96 0.00 0.00 64413 S 47.37 0.00 0.00<br />

61885 S 10,403.49 5,573.05 742.61 64415 S 129.00 0.00 0.00<br />

61886 S 15,534.94 8,187.81 840.69 64416 S 264.03 0.00 0.00<br />

61888 S 691.95 0.00 0.00 64417 S 129.00 0.00 0.00<br />

62194 S 280.10 0.00 0.00 64418 S 66.45 0.00 0.00<br />

62225 S 435.23 0.00 0.00 64420 S 129.00 0.00 0.00<br />

62230 S 972.19 0.00 0.00 64421 S 280.10 0.00 0.00<br />

62252 TC S 44.08 0.00 0.00 64425 S 46.05 0.00 0.00<br />

62263 S 280.10 0.00 0.00 64430 S 193.83 0.00 0.00<br />

62264 S 412.62 0.00 0.00 64435 S 69.41 0.00 0.00<br />

62267 S 164.66 0.00 0.00 64445 S 61.51 0.00 0.00<br />

62268 S 213.77 0.00 0.00 64446 S 529.09 0.00 0.00<br />

62269 S 324.40 0.00 0.00 64447 S 134.37 0.00 0.00<br />

62270 S 129.00 0.00 0.00 64448 S 134.37 0.00 0.00<br />

62272 S 129.00 0.00 0.00 64449 S 264.03 0.00 0.00<br />

62273 S 215.26 0.00 0.00 64450 S 41.12 0.00 0.00<br />

62280 S 280.10 0.00 0.00 64455 S 17.10 0.00 0.00<br />

62281 S 280.10 0.00 0.00 64470 S 280.10 0.00 0.00<br />

62282 S 280.10 0.00 0.00 64472 S 215.26 0.00 0.00<br />

62287 S 1,257.38 0.00 0.00 64475 S 280.10 0.00 0.00<br />

62292 S 264.03 0.00 0.00 64476 S 193.87 0.00 0.00<br />

62294 S 213.77 0.00 0.00 64479 S 280.10 0.00 0.00<br />

62310 S 280.10 0.00 0.00 64480 S 215.26 0.00 0.00<br />

62311 S 280.10 0.00 0.00 64483 S 280.10 0.00 0.00<br />

62318 S 280.10 0.00 0.00 64484 S 215.26 0.00 0.00<br />

62319 S 280.10 0.00 0.00 64505 S 37.51 0.00 0.00<br />

62350 S 972.19 0.00 0.00 64508 S 79.61 0.00 0.00<br />

62355 S 462.88 0.00 0.00 64510 S 280.10 0.00 0.00<br />

62360 S 972.19 0.00 0.00 64517 S 193.83 0.00 0.00<br />

62361 S 9,979.65 5,401.63 823.62 64520 S 280.10 0.00 0.00<br />

62362 S 9,979.65 5,401.63 823.62 64530 S 280.10 0.00 0.00<br />

62365 S 860.27 0.00 0.00 64553 S 2,851.27 1,748.98 646.70<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,201.81 2,099.52 997.24 64746 S 539.07 0.00 0.00<br />

64560 S 3,201.81 2,099.52 997.24 64761 S 681.47 0.00 0.00<br />

64561 S 2,929.98 1,827.69 725.41 64763 S 681.47 0.00 0.00<br />

64565 S 3,201.81 2,099.52 997.24 64766 S 1,323.86 0.00 0.00<br />

64573 S 4,987.94 2,954.87 921.80 64771 S 539.07 0.00 0.00<br />

64575 S 3,812.87 2,273.09 733.32 64772 S 539.07 0.00 0.00<br />

64577 S 3,812.87 2,273.09 733.32 64774 S 539.07 0.00 0.00<br />

64580 S 3,812.87 2,273.09 733.32 64776 S 567.53 0.00 0.00<br />

64581 S 3,891.58 2,351.80 812.03 64778 S 539.07 0.00 0.00<br />

64585 S 509.56 0.00 0.00 64782 S 567.53 0.00 0.00<br />

64590 S 10,403.49 5,573.05 742.61 64783 S 539.07 0.00 0.00<br />

64595 S 691.95 0.00 0.00 64784 S 567.53 0.00 0.00<br />

64600 S 412.62 0.00 0.00 64786 S 888.72 0.00 0.00<br />

64605 S 412.62 0.00 0.00 64787 S 539.07 0.00 0.00<br />

64610 S 412.62 0.00 0.00 64788 S 567.53 0.00 0.00<br />

64612 S 60.20 0.00 0.00 64790 S 567.53 0.00 0.00<br />

64613 S 58.23 0.00 0.00 64792 S 888.72 0.00 0.00<br />

64614 S 66.45 0.00 0.00 64795 S 539.07 0.00 0.00<br />

64620 S 280.10 0.00 0.00 64802 S 539.07 0.00 0.00<br />

64622 S 412.62 0.00 0.00 64820 S 681.47 0.00 0.00<br />

64623 S 280.10 0.00 0.00 64821 S 795.55 0.00 0.00<br />

64626 S 412.62 0.00 0.00 64822 S 1,030.78 0.00 0.00<br />

64627 S 193.87 0.00 0.00 64823 S 1,030.78 0.00 0.00<br />

64630 S 288.52 0.00 0.00 64831 S 942.09 0.00 0.00<br />

64632 S 31.25 0.00 0.00 64832 S 810.01 0.00 0.00<br />

64640 S 93.10 0.00 0.00 64834 S 860.27 0.00 0.00<br />

64650 S 31.25 0.00 0.00 64835 S 888.72 0.00 0.00<br />

64653 S 33.88 0.00 0.00 64836 S 888.72 0.00 0.00<br />

64680 S 438.40 0.00 0.00 64837 S 810.01 0.00 0.00<br />

64681 S 462.88 0.00 0.00 64840 S 860.27 0.00 0.00<br />

64702 S 488.81 0.00 0.00 64856 S 860.27 0.00 0.00<br />

64704 S 488.81 0.00 0.00 64857 S 860.27 0.00 0.00<br />

64708 S 539.07 0.00 0.00 64858 S 860.27 0.00 0.00<br />

64712 S 539.07 0.00 0.00 64859 S 810.01 0.00 0.00<br />

64713 S 539.07 0.00 0.00 64861 S 888.72 0.00 0.00<br />

64714 S 539.07 0.00 0.00 64862 S 888.72 0.00 0.00<br />

64716 S 567.53 0.00 0.00 64864 S 888.72 0.00 0.00<br />

64718 S 539.07 0.00 0.00 64865 S 942.09 0.00 0.00<br />

64719 S 539.07 0.00 0.00 64870 S 942.09 0.00 0.00<br />

64721 S 539.07 0.00 0.00 64872 S 860.27 0.00 0.00<br />

64722 S 488.81 0.00 0.00 64874 S 888.72 0.00 0.00<br />

64726 S 488.81 0.00 0.00 64876 S 888.72 0.00 0.00<br />

64727 S 488.81 0.00 0.00 64885 S 860.27 0.00 0.00<br />

64732 S 539.07 0.00 0.00 64886 S 860.27 0.00 0.00<br />

64734 S 539.07 0.00 0.00 64890 S 860.27 0.00 0.00<br />

64736 S 539.07 0.00 0.00 64891 S 860.27 0.00 0.00<br />

64738 S 539.07 0.00 0.00 64892 S 860.27 0.00 0.00<br />

64740 S 539.07 0.00 0.00 64893 S 860.27 0.00 0.00<br />

64742 S 539.07 0.00 0.00 64895 S 888.72 0.00 0.00<br />

64744 S 539.07 0.00 0.00 64896 S 888.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 888.72 0.00 0.00 65770 S 5,229.84 0.00 0.00<br />

64898 S 888.72 0.00 0.00 65772 S 588.31 0.00 0.00<br />

64901 S 860.27 0.00 0.00 65775 S 588.31 0.00 0.00<br />

64902 S 860.27 0.00 0.00 65780 S 1,017.70 0.00 0.00<br />

64905 S 860.27 0.00 0.00 65781 S 1,017.70 0.00 0.00<br />

64907 S 810.01 0.00 0.00 65782 S 1,017.70 0.00 0.00<br />

64910 S 1,323.86 0.00 0.00 65800 S 456.24 0.00 0.00<br />

65091 S 935.78 0.00 0.00 65805 S 456.24 0.00 0.00<br />

65093 S 935.78 0.00 0.00 65810 S 666.66 0.00 0.00<br />

65101 S 935.78 0.00 0.00 65815 S 638.20 0.00 0.00<br />

65103 S 935.78 0.00 0.00 65820 S 234.06 0.00 0.00<br />

65105 S 989.15 0.00 0.00 65850 S 720.02 0.00 0.00<br />

65110 S 1,027.83 0.00 0.00 65855 S 124.35 0.00 0.00<br />

65112 S 1,151.45 0.00 0.00 65860 S 116.13 0.00 0.00<br />

65114 S 1,151.45 0.00 0.00 65865 S 456.24 0.00 0.00<br />

65125 S 958.29 0.00 0.00 65870 S 720.02 0.00 0.00<br />

65130 S 705.94 0.00 0.00 65875 S 720.02 0.00 0.00<br />

65135 S 677.48 0.00 0.00 65880 S 588.31 0.00 0.00<br />

65140 S 935.78 0.00 0.00 65900 S 627.00 0.00 0.00<br />

65150 S 677.48 0.00 0.00 65920 S 882.34 0.00 0.00<br />

65155 S 935.78 0.00 0.00 65930 S 758.71 0.00 0.00<br />

65175 S 503.60 0.00 0.00 66020 S 456.24 0.00 0.00<br />

65205 S 19.41 0.00 0.00 66030 S 234.06 0.00 0.00<br />

65210 S 24.67 0.00 0.00 66130 S 882.34 0.00 0.00<br />

65220 S 34.38 0.00 0.00 66150 S 720.02 0.00 0.00<br />

65222 S 26.97 0.00 0.00 66155 S 720.02 0.00 0.00<br />

65235 S 506.49 0.00 0.00 66160 S 638.20 0.00 0.00<br />

65260 S 334.07 0.00 0.00 66165 S 720.02 0.00 0.00<br />

65265 S 691.13 0.00 0.00 66170 S 720.02 0.00 0.00<br />

65270 S 553.85 0.00 0.00 66172 S 720.02 0.00 0.00<br />

65272 S 638.20 0.00 0.00 66180 S 1,072.68 0.00 0.00<br />

65275 S 720.02 0.00 0.00 66185 S 952.18 0.00 0.00<br />

65280 S 691.13 0.00 0.00 66220 S 929.49 0.00 0.00<br />

65285 S 982.85 0.00 0.00 66225 S 1,034.00 0.00 0.00<br />

65286 S 171.95 0.00 0.00 66250 S 506.49 0.00 0.00<br />

65290 S 680.64 0.00 0.00 66500 S 234.06 0.00 0.00<br />

65400 S 456.24 0.00 0.00 66505 S 234.06 0.00 0.00<br />

65410 S 506.49 0.00 0.00 66600 S 666.66 0.00 0.00<br />

65420 S 506.49 0.00 0.00 66605 S 666.66 0.00 0.00<br />

65426 S 758.71 0.00 0.00 66625 S 474.00 0.00 0.00<br />

65430 S 34.38 0.00 0.00 66630 S 666.66 0.00 0.00<br />

65435 S 29.94 0.00 0.00 66635 S 666.66 0.00 0.00<br />

65436 S 129.94 0.00 0.00 66680 S 666.66 0.00 0.00<br />

65450 S 79.33 0.00 0.00 66682 S 638.20 0.00 0.00<br />

65600 S 153.30 0.00 0.00 66700 S 506.49 0.00 0.00<br />

65710 S 1,141.33 0.00 0.00 66710 S 506.49 0.00 0.00<br />

65730 S 1,141.33 0.00 0.00 66711 S 506.49 0.00 0.00<br />

65750 S 1,141.33 0.00 0.00 66720 S 506.49 0.00 0.00<br />

65755 S 1,141.33 0.00 0.00 66740 S 638.20 0.00 0.00<br />

65756 S 1,397.71 0.00 0.00 66761 S 173.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 176.00 0.00 0.00 67228 S 193.82 0.00 0.00<br />

66770 S 193.82 0.00 0.00 67229 S 193.82 0.00 0.00<br />

66820 S 171.95 0.00 0.00 67250 S 582.31 0.00 0.00<br />

66821 S 235.87 0.00 0.00 67255 S 637.78 0.00 0.00<br />

66825 S 720.02 0.00 0.00 67311 S 680.64 0.00 0.00<br />

66830 S 251.82 0.00 0.00 67312 S 734.00 0.00 0.00<br />

66840 S 541.32 0.00 0.00 67314 S 734.00 0.00 0.00<br />

66850 S 1,019.18 0.00 0.00 67316 S 734.00 0.00 0.00<br />

66852 S 856.86 0.00 0.00 67318 S 734.00 0.00 0.00<br />

66920 S 856.86 0.00 0.00 67320 S 734.00 0.00 0.00<br />

66930 S 895.55 0.00 0.00 67331 S 734.00 0.00 0.00<br />

66940 S 580.01 0.00 0.00 67332 S 734.00 0.00 0.00<br />

66982 S 879.90 0.00 0.00 67334 S 734.00 0.00 0.00<br />

66983 S 879.90 0.00 0.00 67335 S 734.00 0.00 0.00<br />

66984 S 879.90 0.00 0.00 67340 S 734.00 0.00 0.00<br />

66985 S 814.53 0.00 0.00 67343 S 896.31 0.00 0.00<br />

66986 S 814.53 0.00 0.00 67345 S 76.65 0.00 0.00<br />

67005 S 691.13 0.00 0.00 67346 S 414.59 0.00 0.00<br />

67010 S 691.13 0.00 0.00 67400 S 582.31 0.00 0.00<br />

67015 S 850.78 0.00 0.00 67405 S 759.31 0.00 0.00<br />

67025 S 559.06 0.00 0.00 67412 S 674.36 0.00 0.00<br />

67027 S 982.85 0.00 0.00 67413 S 797.99 0.00 0.00<br />

67028 S 77.31 0.00 0.00 67414 S 1,417.97 0.00 0.00<br />

67030 S 559.06 0.00 0.00 67415 S 503.60 0.00 0.00<br />

67031 S 235.87 0.00 0.00 67420 S 1,027.83 0.00 0.00<br />

67036 S 982.85 0.00 0.00 67430 S 1,027.83 0.00 0.00<br />

67039 S 1,145.17 0.00 0.00 67440 S 1,027.83 0.00 0.00<br />

67040 S 1,145.17 0.00 0.00 67445 S 1,027.83 0.00 0.00<br />

67041 S 1,405.39 0.00 0.00 67450 S 1,027.83 0.00 0.00<br />

67042 S 1,405.39 0.00 0.00 67500 S 79.33 0.00 0.00<br />

67043 S 1,405.39 0.00 0.00 67505 S 24.67 0.00 0.00<br />

67101 S 214.54 0.00 0.00 67515 S 25.00 0.00 0.00<br />

67105 S 193.82 0.00 0.00 67550 S 989.15 0.00 0.00<br />

67107 S 1,021.54 0.00 0.00 67560 S 677.48 0.00 0.00<br />

67108 S 1,145.17 0.00 0.00 67570 S 989.15 0.00 0.00<br />

67110 S 311.86 0.00 0.00 67700 S 116.06 0.00 0.00<br />

67112 S 1,145.17 0.00 0.00 67710 S 135.53 0.00 0.00<br />

67113 S 1,405.39 0.00 0.00 67715 S 503.60 0.00 0.00<br />

67115 S 609.31 0.00 0.00 67800 S 48.69 0.00 0.00<br />

67120 S 609.31 0.00 0.00 67801 S 58.89 0.00 0.00<br />

67121 S 609.31 0.00 0.00 67805 S 76.32 0.00 0.00<br />

67141 S 214.78 0.00 0.00 67808 S 553.85 0.00 0.00<br />

67145 S 183.23 0.00 0.00 67810 S 116.06 0.00 0.00<br />

67208 S 195.41 0.00 0.00 67820 S 16.12 0.00 0.00<br />

67210 S 193.82 0.00 0.00 67825 S 49.67 0.00 0.00<br />

67218 S 729.83 0.00 0.00 67830 S 340.02 0.00 0.00<br />

67220 S 214.54 0.00 0.00 67835 S 553.85 0.00 0.00<br />

67221 S 110.20 0.00 0.00 67840 S 142.11 0.00 0.00<br />

67225 S 7.57 0.00 0.00 67850 S 112.84 0.00 0.00<br />

67227 S 559.06 0.00 0.00 67875 S 283.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 534.96 0.00 0.00 68440 S 48.36 0.00 0.00<br />

67882 S 582.31 0.00 0.00 68500 S 705.94 0.00 0.00<br />

67900 S 759.31 0.00 0.00 68505 S 705.94 0.00 0.00<br />

67901 S 674.36 0.00 0.00 68510 S 503.60 0.00 0.00<br />

67902 S 797.99 0.00 0.00 68520 S 705.94 0.00 0.00<br />

67903 S 635.67 0.00 0.00 68525 S 503.60 0.00 0.00<br />

67904 S 635.67 0.00 0.00 68530 S 116.06 0.00 0.00<br />

67906 S 674.36 0.00 0.00 68540 S 582.31 0.00 0.00<br />

67908 S 635.67 0.00 0.00 68550 S 705.94 0.00 0.00<br />

67909 S 635.67 0.00 0.00 68700 S 553.85 0.00 0.00<br />

67911 S 582.31 0.00 0.00 68705 S 110.20 0.00 0.00<br />

67912 S 582.31 0.00 0.00 68720 S 759.31 0.00 0.00<br />

67914 S 582.31 0.00 0.00 68745 S 759.31 0.00 0.00<br />

67915 S 157.25 0.00 0.00 68750 S 759.31 0.00 0.00<br />

67916 S 635.67 0.00 0.00 68760 S 93.75 0.00 0.00<br />

67917 S 635.67 0.00 0.00 68761 S 64.80 0.00 0.00<br />

67921 S 582.31 0.00 0.00 68770 S 759.31 0.00 0.00<br />

67922 S 152.97 0.00 0.00 68801 S 34.38 0.00 0.00<br />

67923 S 635.67 0.00 0.00 68810 S 98.31 0.00 0.00<br />

67924 S 635.67 0.00 0.00 68811 S 553.85 0.00 0.00<br />

67930 S 157.25 0.00 0.00 68815 S 553.85 0.00 0.00<br />

67935 S 553.85 0.00 0.00 68816 S 711.03 0.00 0.00<br />

67938 S 79.33 0.00 0.00 68840 S 50.99 0.00 0.00<br />

67950 S 553.85 0.00 0.00 69000 S 52.01 0.00 0.00<br />

67961 S 582.31 0.00 0.00 69005 S 98.36 0.00 0.00<br />

67966 S 582.31 0.00 0.00 69020 S 52.01 0.00 0.00<br />

67971 S 582.31 0.00 0.00 69100 S 59.21 0.00 0.00<br />

67973 S 705.94 0.00 0.00 69105 S 83.89 0.00 0.00<br />

67974 S 582.31 0.00 0.00 69110 S 440.71 0.00 0.00<br />

67975 S 582.31 0.00 0.00 69120 S 654.01 0.00 0.00<br />

68020 S 43.10 0.00 0.00 69140 S 654.01 0.00 0.00<br />

68040 S 21.38 0.00 0.00 69145 S 490.96 0.00 0.00<br />

68100 S 85.53 0.00 0.00 69150 S 345.07 0.00 0.00<br />

68110 S 110.20 0.00 0.00 69200 S 23.79 0.00 0.00<br />

68115 S 553.85 0.00 0.00 69205 S 550.15 0.00 0.00<br />

68130 S 506.49 0.00 0.00 69210 S 19.41 0.00 0.00<br />

68135 S 55.26 0.00 0.00 69220 S 30.48 0.00 0.00<br />

68200 S 15.79 0.00 0.00 69222 S 128.30 0.00 0.00<br />

68320 S 759.31 0.00 0.00 69300 S 682.48 0.00 0.00<br />

68325 S 759.31 0.00 0.00 69310 S 997.58 0.00 0.00<br />

68326 S 635.67 0.00 0.00 69320 S 1,213.26 0.00 0.00<br />

68328 S 759.31 0.00 0.00 69400 S 86.18 0.00 0.00<br />

68330 S 720.02 0.00 0.00 69401 S 45.40 0.00 0.00<br />

68335 S 759.31 0.00 0.00 69405 S 119.08 0.00 0.00<br />

68340 S 635.67 0.00 0.00 69420 S 106.92 0.00 0.00<br />

68360 S 638.20 0.00 0.00 69421 S 544.14 0.00 0.00<br />

68362 S 638.20 0.00 0.00 69424 S 75.00 0.00 0.00<br />

68371 S 506.49 0.00 0.00 69433 S 106.59 0.00 0.00<br />

68400 S 116.06 0.00 0.00 69436 S 544.14 0.00 0.00<br />

68420 S 165.14 0.00 0.00 69440 S 682.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 918.87 0.00 0.00 69840 S 1,089.63 0.00 0.00<br />

69501 S 1,213.26 0.00 0.00 69905 S 1,213.26 0.00 0.00<br />

69502 S 898.15 0.00 0.00 69910 S 1,213.26 0.00 0.00<br />

69505 S 1,213.26 0.00 0.00 69915 S 1,213.26 0.00 0.00<br />

69511 S 1,213.26 0.00 0.00 69930 S 21,934.03 11,777.09 1,620.15<br />

69530 S 1,213.26 0.00 0.00 70030 TC A 16.77 0.00 0.00<br />

69540 S 125.33 0.00 0.00 70100 TC A 18.42 0.00 0.00<br />

69550 S 1,089.63 0.00 0.00 70110 TC A 22.70 0.00 0.00<br />

69552 S 1,213.26 0.00 0.00 70120 TC A 20.39 0.00 0.00<br />

69601 S 1,213.26 0.00 0.00 70130 TC A 24.92 0.00 0.00<br />

69602 S 1,213.26 0.00 0.00 70134 TC A 25.00 0.00 0.00<br />

69603 S 1,213.26 0.00 0.00 70140 TC A 17.10 0.00 0.00<br />

69604 S 1,213.26 0.00 0.00 70150 TC A 24.92 0.00 0.00<br />

69605 S 1,213.26 0.00 0.00 70160 TC A 20.07 0.00 0.00<br />

69610 S 167.77 0.00 0.00 70190 TC A 21.05 0.00 0.00<br />

69620 S 654.01 0.00 0.00 70200 TC A 24.92 0.00 0.00<br />

69631 S 1,089.63 0.00 0.00 70210 TC A 17.77 0.00 0.00<br />

69632 S 1,089.63 0.00 0.00 70220 TC A 22.37 0.00 0.00<br />

69633 S 1,089.63 0.00 0.00 70240 TC A 16.77 0.00 0.00<br />

69635 S 1,213.26 0.00 0.00 70250 TC A 20.39 0.00 0.00<br />

69636 S 1,213.26 0.00 0.00 70260 TC A 25.99 0.00 0.00<br />

69637 S 1,213.26 0.00 0.00 70300 TC A 7.23 0.00 0.00<br />

69641 S 1,213.26 0.00 0.00 70310 TC A 17.88 0.00 0.00<br />

69642 S 1,213.26 0.00 0.00 70320 TC A 17.88 0.00 0.00<br />

69643 S 1,213.26 0.00 0.00 70328 TC A 17.77 0.00 0.00<br />

69644 S 1,213.26 0.00 0.00 70330 TC A 24.92 0.00 0.00<br />

69645 S 1,213.26 0.00 0.00 70336 TC A 193.97 0.00 0.00<br />

69646 S 1,213.26 0.00 0.00 70350 TC A 9.87 0.00 0.00<br />

69650 S 898.15 0.00 0.00 70355 TC A 10.20 0.00 0.00<br />

69660 S 1,089.63 0.00 0.00 70360 TC A 15.79 0.00 0.00<br />

69661 S 1,089.63 0.00 0.00 70370 TC A 46.37 0.00 0.00<br />

69662 S 1,089.63 0.00 0.00 70371 TC A 46.37 0.00 0.00<br />

69666 S 1,050.94 0.00 0.00 70380 TC A 24.02 0.00 0.00<br />

69667 S 1,050.94 0.00 0.00 70450 TC A 108.33 0.00 0.00<br />

69670 S 997.58 0.00 0.00 70460 TC A 171.54 0.00 0.00<br />

69676 S 997.58 0.00 0.00 70470 TC A 190.02 0.00 0.00<br />

69700 S 997.58 0.00 0.00 70480 TC A 108.33 0.00 0.00<br />

69711 S 918.87 0.00 0.00 70481 TC A 171.54 0.00 0.00<br />

69714 S 5,827.30 3,674.33 1,521.36 70482 TC A 190.02 0.00 0.00<br />

69715 S 5,827.30 3,674.33 1,521.36 70486 TC A 108.33 0.00 0.00<br />

69717 S 5,827.30 3,674.33 1,521.36 70487 TC A 171.54 0.00 0.00<br />

69718 S 5,827.30 3,674.33 1,521.36 70488 TC A 190.02 0.00 0.00<br />

69720 S 1,089.63 0.00 0.00 70490 TC A 108.33 0.00 0.00<br />

69740 S 1,089.63 0.00 0.00 70491 TC A 171.54 0.00 0.00<br />

69745 S 1,089.63 0.00 0.00 70492 TC A 190.02 0.00 0.00<br />

69801 S 1,089.63 0.00 0.00 70496 TC A 196.09 0.00 0.00<br />

69802 S 1,213.26 0.00 0.00 70498 TC A 196.09 0.00 0.00<br />

69805 S 1,213.26 0.00 0.00 70540 TC A 193.97 0.00 0.00<br />

69806 S 1,213.26 0.00 0.00 70542 TC A 238.19 0.00 0.00<br />

69820 S 1,089.63 0.00 0.00 70543 TC A 300.21 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 193.97 0.00 0.00 72120 TC A 31.58 0.00 0.00<br />

70545 TC A 238.19 0.00 0.00 72125 TC A 108.33 0.00 0.00<br />

70546 TC A 300.21 0.00 0.00 72126 TC A 171.54 0.00 0.00<br />

70547 TC A 193.97 0.00 0.00 72127 TC A 190.02 0.00 0.00<br />

70548 TC A 238.19 0.00 0.00 72128 TC A 108.33 0.00 0.00<br />

70549 TC A 300.21 0.00 0.00 72129 TC A 171.54 0.00 0.00<br />

70551 TC A 193.97 0.00 0.00 72130 TC A 190.02 0.00 0.00<br />

70552 TC A 238.19 0.00 0.00 72131 TC A 108.33 0.00 0.00<br />

70553 TC A 300.21 0.00 0.00 72132 TC A 171.54 0.00 0.00<br />

70554 TC A 193.97 0.00 0.00 72133 TC A 190.02 0.00 0.00<br />

70555 TC A 193.97 0.00 0.00 72141 TC A 193.97 0.00 0.00<br />

70557 TC A 193.97 0.00 0.00 72142 TC A 238.19 0.00 0.00<br />

70558 TC A 238.19 0.00 0.00 72146 TC A 193.97 0.00 0.00<br />

70559 TC A 300.21 0.00 0.00 72147 TC A 238.19 0.00 0.00<br />

71010 TC A 12.83 0.00 0.00 72148 TC A 193.97 0.00 0.00<br />

71015 TC A 16.45 0.00 0.00 72149 TC A 238.19 0.00 0.00<br />

71020 TC A 17.44 0.00 0.00 72156 TC A 300.21 0.00 0.00<br />

71021 TC A 21.05 0.00 0.00 72157 TC A 300.21 0.00 0.00<br />

71022 TC A 24.92 0.00 0.00 72158 TC A 300.21 0.00 0.00<br />

71023 TC A 40.79 0.00 0.00 72170 TC A 14.80 0.00 0.00<br />

71030 TC A 24.92 0.00 0.00 72190 TC A 24.92 0.00 0.00<br />

71034 TC A 46.37 0.00 0.00 72191 TC A 196.09 0.00 0.00<br />

71035 TC A 21.71 0.00 0.00 72192 TC A 108.33 0.00 0.00<br />

71100 TC A 18.10 0.00 0.00 72193 TC A 171.54 0.00 0.00<br />

71101 TC A 22.04 0.00 0.00 72194 TC A 190.02 0.00 0.00<br />

71110 TC A 23.03 0.00 0.00 72195 TC A 193.97 0.00 0.00<br />

71111 TC A 30.59 0.00 0.00 72196 TC A 238.19 0.00 0.00<br />

71120 TC A 19.08 0.00 0.00 72197 TC A 300.21 0.00 0.00<br />

71130 TC A 22.37 0.00 0.00 72200 TC A 17.44 0.00 0.00<br />

71250 TC A 108.33 0.00 0.00 72202 TC A 21.38 0.00 0.00<br />

71260 TC A 171.54 0.00 0.00 72220 TC A 17.44 0.00 0.00<br />

71270 TC A 190.02 0.00 0.00 73000 TC A 16.45 0.00 0.00<br />

71275 TC A 196.09 0.00 0.00 73010 TC A 16.77 0.00 0.00<br />

71550 TC A 193.97 0.00 0.00 73020 TC A 13.49 0.00 0.00<br />

71551 TC A 238.19 0.00 0.00 73030 TC A 17.10 0.00 0.00<br />

71552 TC A 300.21 0.00 0.00 73050 TC A 21.38 0.00 0.00<br />

72010 TC A 41.48 0.00 0.00 73060 TC A 17.10 0.00 0.00<br />

72020 TC A 13.49 0.00 0.00 73070 TC A 16.45 0.00 0.00<br />

72040 TC A 21.71 0.00 0.00 73080 TC A 21.71 0.00 0.00<br />

72050 TC A 30.92 0.00 0.00 73090 TC A 16.45 0.00 0.00<br />

72052 TC A 41.48 0.00 0.00 73092 TC A 17.10 0.00 0.00<br />

72069 TC A 20.39 0.00 0.00 73100 TC A 17.10 0.00 0.00<br />

72070 TC A 19.08 0.00 0.00 73110 TC A 21.71 0.00 0.00<br />

72072 TC A 23.03 0.00 0.00 73120 TC A 16.12 0.00 0.00<br />

72074 TC A 24.92 0.00 0.00 73130 TC A 19.08 0.00 0.00<br />

72080 TC A 20.39 0.00 0.00 73140 TC A 18.75 0.00 0.00<br />

72090 TC A 27.31 0.00 0.00 73200 TC A 108.33 0.00 0.00<br />

72100 TC A 23.36 0.00 0.00 73201 TC A 171.54 0.00 0.00<br />

72110 TC A 32.57 0.00 0.00 73202 TC A 190.02 0.00 0.00<br />

72114 TC A 41.48 0.00 0.00 73206 TC A 196.09 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 193.97 0.00 0.00 74246 TC A 48.95 0.00 0.00<br />

73219 TC A 238.19 0.00 0.00 74247 TC A 48.95 0.00 0.00<br />

73220 TC A 300.21 0.00 0.00 74249 TC A 79.60 0.00 0.00<br />

73221 TC A 193.97 0.00 0.00 74250 TC A 48.95 0.00 0.00<br />

73222 TC A 238.19 0.00 0.00 74251 TC A 79.60 0.00 0.00<br />

73223 TC A 300.21 0.00 0.00 74260 TC A 48.95 0.00 0.00<br />

73500 TC A 14.15 0.00 0.00 74270 TC A 48.95 0.00 0.00<br />

73510 TC A 21.71 0.00 0.00 74280 TC A 79.60 0.00 0.00<br />

73520 TC A 22.37 0.00 0.00 74283 TC A 48.95 0.00 0.00<br />

73540 TC A 22.37 0.00 0.00 74290 TC A 41.77 0.00 0.00<br />

73550 TC A 16.45 0.00 0.00 74291 TC A 40.13 0.00 0.00<br />

73560 TC A 16.77 0.00 0.00 74400 TC A 72.70 0.00 0.00<br />

73562 TC A 20.72 0.00 0.00 74410 TC A 77.64 0.00 0.00<br />

73564 TC A 24.02 0.00 0.00 74415 TC A 92.77 0.00 0.00<br />

73565 TC A 18.10 0.00 0.00 74420 TC A 96.97 0.00 0.00<br />

73590 TC A 15.79 0.00 0.00 74710 TC A 21.71 0.00 0.00<br />

73592 TC A 17.10 0.00 0.00 74775 TC A 96.97 0.00 0.00<br />

73600 TC A 16.12 0.00 0.00 75557 TC A 193.97 0.00 0.00<br />

73610 TC A 19.08 0.00 0.00 75559 TC A 193.97 0.00 0.00<br />

73620 TC A 15.46 0.00 0.00 75561 TC A 300.21 0.00 0.00<br />

73630 TC A 18.75 0.00 0.00 75563 TC A 300.21 0.00 0.00<br />

73650 TC A 15.79 0.00 0.00 76010 TC A 16.12 0.00 0.00<br />

73660 TC A 17.77 0.00 0.00 76098 TC A 9.87 0.00 0.00<br />

73700 TC A 108.33 0.00 0.00 76100 TC A 41.48 0.00 0.00<br />

73701 TC A 171.54 0.00 0.00 76101 TC A 111.18 0.00 0.00<br />

73702 TC A 190.02 0.00 0.00 76102 TC A 111.18 0.00 0.00<br />

73706 TC A 196.09 0.00 0.00 76120 TC A 46.37 0.00 0.00<br />

73718 TC A 193.97 0.00 0.00 76150 A 16.12 0.00 0.00<br />

73719 TC A 238.19 0.00 0.00 76380 TC A 58.52 0.00 0.00<br />

73720 TC A 300.21 0.00 0.00 76496 TC A 46.37 0.00 0.00<br />

73721 TC A 193.97 0.00 0.00 76497 TC A 58.52 0.00 0.00<br />

73722 TC A 238.19 0.00 0.00 76498 TC A 193.97 0.00 0.00<br />

73723 TC A 300.21 0.00 0.00 76499 TC A 24.92 0.00 0.00<br />

74000 TC A 14.15 0.00 0.00 76506 TC A 34.83 0.00 0.00<br />

74010 TC A 22.04 0.00 0.00 76510 TC A 59.21 0.00 0.00<br />

74020 TC A 22.37 0.00 0.00 76511 TC A 41.45 0.00 0.00<br />

74022 TC A 27.31 0.00 0.00 76512 TC A 35.20 0.00 0.00<br />

74150 TC A 108.33 0.00 0.00 76513 TC A 42.77 0.00 0.00<br />

74160 TC A 171.54 0.00 0.00 76514 TC A 2.96 0.00 0.00<br />

74170 TC A 190.02 0.00 0.00 76516 TC A 33.56 0.00 0.00<br />

74175 TC A 196.09 0.00 0.00 76519 TC A 37.51 0.00 0.00<br />

74181 TC A 193.97 0.00 0.00 76529 TC A 32.57 0.00 0.00<br />

74182 TC A 238.19 0.00 0.00 76536 TC A 54.49 0.00 0.00<br />

74183 TC A 300.21 0.00 0.00 76604 TC A 34.83 0.00 0.00<br />

74210 TC A 48.95 0.00 0.00 76645 TC A 34.83 0.00 0.00<br />

74220 TC A 48.95 0.00 0.00 76700 TC A 54.49 0.00 0.00<br />

74230 TC A 48.95 0.00 0.00 76705 TC A 54.49 0.00 0.00<br />

74240 TC A 48.95 0.00 0.00 76770 TC A 54.49 0.00 0.00<br />

74241 TC A 48.95 0.00 0.00 76775 TC A 54.49 0.00 0.00<br />

74245 TC A 79.60 0.00 0.00 76776 TC A 54.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 54.49 0.00 0.00 77290 TC A 142.50 0.00 0.00<br />

76801 TC A 54.49 0.00 0.00 77295 TC A 373.38 0.00 0.00<br />

76802 TC A 25.99 0.00 0.00 77299 TC A 63.93 0.00 0.00<br />

76805 TC A 54.49 0.00 0.00 77300 TC A 34.54 0.00 0.00<br />

76810 TC A 41.12 0.00 0.00 77301 TC A 497.61 0.00 0.00<br />

76811 TC A 85.36 0.00 0.00 77305 TC A 31.58 0.00 0.00<br />

76812 TC A 34.83 0.00 0.00 77310 TC A 41.12 0.00 0.00<br />

76813 TC A 34.83 0.00 0.00 77315 TC A 59.87 0.00 0.00<br />

76814 TC A 27.64 0.00 0.00 77321 TC A 62.18 0.00 0.00<br />

76815 TC A 34.83 0.00 0.00 77326 TC A 63.93 0.00 0.00<br />

76816 TC A 34.83 0.00 0.00 77327 TC A 116.13 0.00 0.00<br />

76817 TC A 34.83 0.00 0.00 77328 TC A 142.50 0.00 0.00<br />

76818 TC A 54.49 0.00 0.00 77331 TC A 16.45 0.00 0.00<br />

76819 TC A 47.05 0.00 0.00 77332 TC A 44.08 0.00 0.00<br />

76820 TC A 23.36 0.00 0.00 77333 TC A 21.38 0.00 0.00<br />

76821 TC A 52.75 0.00 0.00 77334 TC A 82.57 0.00 0.00<br />

76825 TC A 109.87 0.00 0.00 77336 A 51.98 0.00 0.00<br />

76826 TC A 65.46 0.00 0.00 77370 A 63.93 0.00 0.00<br />

76827 TC A 34.83 0.00 0.00 77371 A 4,258.69 0.00 0.00<br />

76828 TC A 20.72 0.00 0.00 77399 TC A 63.93 0.00 0.00<br />

76830 TC A 54.49 0.00 0.00 77401 A 25.99 0.00 0.00<br />

76831 TC A 73.36 0.00 0.00 77402 A 52.32 0.00 0.00<br />

76856 TC A 54.49 0.00 0.00 77403 A 52.32 0.00 0.00<br />

76857 TC A 34.83 0.00 0.00 77404 A 52.32 0.00 0.00<br />

76870 TC A 54.49 0.00 0.00 77406 A 84.74 0.00 0.00<br />

76872 TC A 54.49 0.00 0.00 77407 A 52.32 0.00 0.00<br />

76873 TC A 54.49 0.00 0.00 77408 A 52.32 0.00 0.00<br />

76880 TC A 54.49 0.00 0.00 77409 A 52.32 0.00 0.00<br />

76885 TC A 34.83 0.00 0.00 77411 A 84.74 0.00 0.00<br />

76886 TC A 34.83 0.00 0.00 77412 A 84.74 0.00 0.00<br />

76936 TC A 52.75 0.00 0.00 77413 A 84.74 0.00 0.00<br />

76970 TC A 34.83 0.00 0.00 77414 A 84.74 0.00 0.00<br />

76977 TC A 8.88 0.00 0.00 77416 A 84.74 0.00 0.00<br />

76999 TC A 34.83 0.00 0.00 77418 A 228.96 0.00 0.00<br />

77071 A 20.39 0.00 0.00 77422 A 84.74 0.00 0.00<br />

77072 TC A 11.84 0.00 0.00 77423 A 84.74 0.00 0.00<br />

77073 TC A 20.07 0.00 0.00 77470 TC A 121.72 0.00 0.00<br />

77074 TC A 39.48 0.00 0.00 77520 A 391.99 0.00 0.00<br />

77075 TC A 41.48 0.00 0.00 77522 A 391.99 0.00 0.00<br />

77076 TC A 41.48 0.00 0.00 77523 A 468.45 0.00 0.00<br />

77077 TC A 22.37 0.00 0.00 77525 A 468.45 0.00 0.00<br />

77078 TC A 40.08 0.00 0.00 77600 TC A 207.99 0.00 0.00<br />

77079 TC A 41.12 0.00 0.00 77605 TC A 207.99 0.00 0.00<br />

77080 TC A 40.08 0.00 0.00 77610 TC A 207.99 0.00 0.00<br />

77081 TC A 16.12 0.00 0.00 77615 TC A 207.99 0.00 0.00<br />

77082 TC A 17.44 0.00 0.00 77620 TC A 207.99 0.00 0.00<br />

77083 TC A 13.82 0.00 0.00 77750 TC A 80.92 0.00 0.00<br />

77084 TC A 193.97 0.00 0.00 77761 TC A 142.44 0.00 0.00<br />

77280 TC A 63.93 0.00 0.00 77762 TC A 168.76 0.00 0.00<br />

77285 TC A 142.50 0.00 0.00 77763 TC A 217.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 154.28 0.00 0.00 78262 TC A 135.49 0.00 0.00<br />

77777 TC A 169.41 0.00 0.00 78264 TC A 135.49 0.00 0.00<br />

77778 TC A 225.67 0.00 0.00 78270 TC A 59.21 0.00 0.00<br />

77785 TC A 100.33 0.00 0.00 78271 TC A 60.20 0.00 0.00<br />

77786 TC A 352.65 0.00 0.00 78272 TC A 66.12 0.00 0.00<br />

77787 TC A 408.64 0.00 0.00 78278 TC A 135.49 0.00 0.00<br />

77789 TC A 42.11 0.00 0.00 78282 TC A 135.49 0.00 0.00<br />

77799 TC A 240.01 0.00 0.00 78290 TC A 135.49 0.00 0.00<br />

78000 TC A 51.64 0.00 0.00 78291 TC A 135.49 0.00 0.00<br />

78001 TC A 65.45 0.00 0.00 78299 TC A 135.49 0.00 0.00<br />

78003 TC A 51.98 0.00 0.00 78300 TC A 118.10 0.00 0.00<br />

78006 TC A 123.67 0.00 0.00 78305 TC A 136.97 0.00 0.00<br />

78007 TC A 91.46 0.00 0.00 78306 TC A 136.97 0.00 0.00<br />

78010 TC A 75.99 0.00 0.00 78315 TC A 136.97 0.00 0.00<br />

78011 TC A 75.99 0.00 0.00 78320 TC A 136.97 0.00 0.00<br />

78015 TC A 147.71 0.00 0.00 78399 TC A 136.97 0.00 0.00<br />

78016 TC A 166.72 0.00 0.00 78414 TC A 174.10 0.00 0.00<br />

78018 TC A 166.72 0.00 0.00 78428 TC A 133.56 0.00 0.00<br />

78070 TC A 113.49 0.00 0.00 78445 TC A 104.18 0.00 0.00<br />

78075 TC A 321.40 0.00 0.00 78456 TC A 104.18 0.00 0.00<br />

78099 TC A 75.99 0.00 0.00 78457 TC A 104.18 0.00 0.00<br />

78102 TC A 114.81 0.00 0.00 78458 TC A 104.18 0.00 0.00<br />

78103 TC A 146.35 0.00 0.00 78459 TC A 644.72 0.00 0.00<br />

78104 TC A 146.35 0.00 0.00 78460 TC A 125.00 0.00 0.00<br />

78110 TC A 58.23 0.00 0.00 78461 TC A 126.00 0.00 0.00<br />

78111 TC A 73.69 0.00 0.00 78464 TC A 184.87 0.00 0.00<br />

78120 TC A 64.48 0.00 0.00 78465 TC A 350.02 0.00 0.00<br />

78121 TC A 76.32 0.00 0.00 78466 TC A 124.02 0.00 0.00<br />

78122 TC A 90.46 0.00 0.00 78468 TC A 158.56 0.00 0.00<br />

78130 TC A 104.94 0.00 0.00 78469 TC A 174.10 0.00 0.00<br />

78135 TC A 223.03 0.00 0.00 78472 TC A 174.10 0.00 0.00<br />

78140 TC A 99.02 0.00 0.00 78473 TC A 174.10 0.00 0.00<br />

78185 TC A 146.35 0.00 0.00 78481 TC A 150.33 0.00 0.00<br />

78190 TC A 91.83 0.00 0.00 78483 TC A 174.10 0.00 0.00<br />

78191 TC A 91.83 0.00 0.00 78491 TC A 644.72 0.00 0.00<br />

78195 TC A 146.35 0.00 0.00 78492 TC A 644.72 0.00 0.00<br />

78199 TC A 146.35 0.00 0.00 78494 TC A 174.10 0.00 0.00<br />

78201 TC A 130.27 0.00 0.00 78499 TC A 174.10 0.00 0.00<br />

78202 TC A 153.24 0.00 0.00 78580 TC A 117.95 0.00 0.00<br />

78205 TC A 153.24 0.00 0.00 78584 TC A 91.12 0.00 0.00<br />

78206 TC A 153.24 0.00 0.00 78585 TC A 180.99 0.00 0.00<br />

78215 TC A 137.84 0.00 0.00 78586 TC A 117.95 0.00 0.00<br />

78216 TC A 93.43 0.00 0.00 78587 TC A 117.95 0.00 0.00<br />

78220 TC A 101.98 0.00 0.00 78588 TC A 180.99 0.00 0.00<br />

78223 TC A 153.24 0.00 0.00 78591 TC A 117.95 0.00 0.00<br />

78230 TC A 115.79 0.00 0.00 78593 TC A 117.95 0.00 0.00<br />

78231 TC A 91.12 0.00 0.00 78594 TC A 117.95 0.00 0.00<br />

78232 TC A 95.07 0.00 0.00 78596 TC A 180.99 0.00 0.00<br />

78258 TC A 135.49 0.00 0.00 78599 TC A 117.95 0.00 0.00<br />

78261 TC A 135.49 0.00 0.00 78600 TC A 103.95 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 37860 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 103.95 0.00 0.00<br />

78605 TC A 103.95 0.00 0.00<br />

78606 TC A 233.56 0.00 0.00<br />

78607 TC A 256.59 0.00 0.00<br />

78608 TC A 577.87 0.00 0.00<br />

78610 TC A 138.49 0.00 0.00<br />

78630 TC A 246.72 0.00 0.00<br />

78635 TC A 227.31 0.00 0.00<br />

78645 TC A 103.95 0.00 0.00<br />

78647 TC A 251.66 0.00 0.00<br />

78650 TC A 243.76 0.00 0.00<br />

78660 TC A 103.95 0.00 0.00<br />

78699 TC A 103.95 0.00 0.00<br />

78700 TC A 127.97 0.00 0.00<br />

78701 TC A 155.93 0.00 0.00<br />

78707 TC A 162.84 0.00 0.00<br />

78708 TC A 111.52 0.00 0.00<br />

78709 TC A 183.35 0.00 0.00<br />

78710 TC A 172.05 0.00 0.00<br />

78725 TC A 68.75 0.00 0.00<br />

78730 TC A 58.23 0.00 0.00<br />

78740 TC A 151.98 0.00 0.00<br />

78761 TC A 145.07 0.00 0.00<br />

78799 TC A 183.35 0.00 0.00<br />

78800 TC A 128.30 0.00 0.00<br />

78801 TC A 176.00 0.00 0.00<br />

78802 TC A 238.50 0.00 0.00<br />

78803 TC A 255.61 0.00 0.00<br />

78804 TC A 446.07 0.00 0.00<br />

78805 TC A 125.33 0.00 0.00<br />

78806 TC A 250.67 0.00 0.00<br />

78807 TC A 255.94 0.00 0.00<br />

78811 TC A 577.87 0.00 0.00<br />

78812 TC A 577.87 0.00 0.00<br />

78813 TC A 577.87 0.00 0.00<br />

78814 TC A 577.87 0.00 0.00<br />

78815 TC A 577.87 0.00 0.00<br />

78816 TC A 577.87 0.00 0.00<br />

78999 TC A 65.45 0.00 0.00<br />

79005 TC A 52.64 0.00 0.00<br />

79101 TC A 57.57 0.00 0.00<br />

79200 TC A 62.18 0.00 0.00<br />

79300 TC A 119.96 0.00 0.00<br />

79403 TC A 89.15 0.00 0.00<br />

79440 TC A 50.33 0.00 0.00<br />

79445 TC A 119.96 0.00 0.00<br />

79999 TC A 119.96 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,308.69 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,566.03 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.73 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,618.17 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,618.17 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 233.69 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 233.69 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 118.00 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 249.39 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 74.97 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 671.31 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,530.81 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,198.25 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,198.25 0.00 0.00<br />

C8900 A 259.45 0.00 0.00 0123T S 958.24 0.00 0.00<br />

C8901 A 211.28 0.00 0.00 0124T S 187.29 0.00 0.00<br />

C8902 A 327.00 0.00 0.00 0144T TC A 63.74 0.00 0.00<br />

C8903 A 259.45 0.00 0.00 0145T TC A 171.60 0.00 0.00<br />

C8904 A 211.28 0.00 0.00 0146T TC A 171.60 0.00 0.00<br />

C8905 A 327.00 0.00 0.00 0147T TC A 171.60 0.00 0.00<br />

C8906 A 259.45 0.00 0.00 0148T TC A 171.60 0.00 0.00<br />

C8907 A 211.28 0.00 0.00 0149T TC A 171.60 0.00 0.00<br />

C8908 A 327.00 0.00 0.00 0150T TC A 171.60 0.00 0.00<br />

C8909 A 259.45 0.00 0.00 0151T TC A 63.74 0.00 0.00<br />

C8910 A 211.28 0.00 0.00 0170T S 1,244.70 0.00 0.00<br />

C8911 A 327.00 0.00 0.00 0176T S 1,469.70 0.00 0.00<br />

C8912 A 259.45 0.00 0.00 0177T S 1,469.70 0.00 0.00<br />

C8913 A 211.28 0.00 0.00 0182T A 1,062.31 0.00 0.00<br />

C8914 A 327.00 0.00 0.00 0186T S 895.31 0.00 0.00<br />

C8918 A 259.45 0.00 0.00 0190T S 895.31 0.00 0.00<br />

C8919 A 211.28 0.00 0.00 0191T S 958.24 0.00 0.00<br />

C8920 A 327.00 0.00 0.00 0192T S 1,642.24 0.00 0.00<br />

C9716 S 1,244.70 0.00 0.00 10021 S 57.43 0.00 0.00<br />

C9724 S 1,017.68 0.00 0.00 10022 S 179.36 0.00 0.00<br />

C9725 S 234.67 0.00 0.00 10040 S 33.20 0.00 0.00<br />

C9726 S 861.55 0.00 0.00 10060 S 50.52 0.00 0.00<br />

C9727 S 302.07 0.00 0.00 10061 S 56.65 0.00 0.00<br />

C9728 S 542.01 0.00 0.00 10080 S 56.65 0.00 0.00<br />

G0104 S 87.07 0.00 0.00 10081 S 130.43 0.00 0.00<br />

G0105 S 376.32 0.00 0.00 10120 S 70.95 0.00 0.00<br />

G0121 S 376.32 0.00 0.00 10121 S 534.77 0.00 0.00<br />

G0127 S 12.18 0.00 0.00 10140 S 75.25 0.00 0.00<br />

G0130 TC A 20.07 0.00 0.00 10160 S 56.65 0.00 0.00<br />

G0173 A 2,308.69 0.00 0.00 10180 S 604.75 0.00 0.00<br />

G0186 S 233.69 0.00 0.00 11000 S 24.37 0.00 0.00<br />

G0247 S 22.21 0.00 0.00 11001 S 8.25 0.00 0.00<br />

G0251 A 578.13 0.00 0.00 11010 S 211.58 0.00 0.00<br />

G0260 S 305.09 0.00 0.00 11011 S 211.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 211.58 0.00 0.00 11601 S 116.82 0.00 0.00<br />

11040 S 22.21 0.00 0.00 11602 S 128.64 0.00 0.00<br />

11041 S 24.73 0.00 0.00 11603 S 136.52 0.00 0.00<br />

11042 S 134.35 0.00 0.00 11604 S 368.25 0.00 0.00<br />

11043 S 134.35 0.00 0.00 11606 S 534.77 0.00 0.00<br />

11044 S 349.83 0.00 0.00 11620 S 99.62 0.00 0.00<br />

11055 S 26.16 0.00 0.00 11621 S 118.25 0.00 0.00<br />

11056 S 28.66 0.00 0.00 11622 S 131.50 0.00 0.00<br />

11057 S 33.20 0.00 0.00 11623 S 141.53 0.00 0.00<br />

11100 S 60.83 0.00 0.00 11624 S 534.77 0.00 0.00<br />

11101 S 14.34 0.00 0.00 11626 S 653.98 0.00 0.00<br />

11200 S 33.20 0.00 0.00 11640 S 105.35 0.00 0.00<br />

11201 S 5.73 0.00 0.00 11641 S 124.34 0.00 0.00<br />

11300 S 33.20 0.00 0.00 11642 S 138.67 0.00 0.00<br />

11301 S 33.20 0.00 0.00 11643 S 149.42 0.00 0.00<br />

11302 S 33.20 0.00 0.00 11644 S 534.77 0.00 0.00<br />

11303 S 60.83 0.00 0.00 11646 S 653.98 0.00 0.00<br />

11305 S 33.20 0.00 0.00 11719 S 12.18 0.00 0.00<br />

11306 S 33.20 0.00 0.00 11720 S 15.05 0.00 0.00<br />

11307 S 33.20 0.00 0.00 11721 S 18.27 0.00 0.00<br />

11308 S 33.20 0.00 0.00 11730 S 33.20 0.00 0.00<br />

11310 S 33.20 0.00 0.00 11732 S 18.27 0.00 0.00<br />

11311 S 33.20 0.00 0.00 11740 S 16.77 0.00 0.00<br />

11312 S 33.20 0.00 0.00 11750 S 96.75 0.00 0.00<br />

11313 S 33.20 0.00 0.00 11752 S 134.37 0.00 0.00<br />

11400 S 68.44 0.00 0.00 11755 S 67.00 0.00 0.00<br />

11401 S 77.04 0.00 0.00 11760 S 138.00 0.00 0.00<br />

11402 S 84.57 0.00 0.00 11762 S 123.26 0.00 0.00<br />

11403 S 90.30 0.00 0.00 11765 S 33.20 0.00 0.00<br />

11404 S 480.04 0.00 0.00 11770 S 684.99 0.00 0.00<br />

11406 S 534.77 0.00 0.00 11771 S 684.99 0.00 0.00<br />

11420 S 64.14 0.00 0.00 11772 S 684.99 0.00 0.00<br />

11421 S 77.75 0.00 0.00 11900 S 30.46 0.00 0.00<br />

11422 S 84.92 0.00 0.00 11901 S 33.20 0.00 0.00<br />

11423 S 94.60 0.00 0.00 11920 S 96.39 0.00 0.00<br />

11424 S 534.77 0.00 0.00 11921 S 106.07 0.00 0.00<br />

11426 S 653.98 0.00 0.00 11922 S 34.39 0.00 0.00<br />

11440 S 73.46 0.00 0.00 11950 S 35.12 0.00 0.00<br />

11441 S 84.92 0.00 0.00 11951 S 43.71 0.00 0.00<br />

11442 S 93.52 0.00 0.00 11952 S 52.63 0.00 0.00<br />

11443 S 103.55 0.00 0.00 11954 S 52.63 0.00 0.00<br />

11444 S 326.84 0.00 0.00 11960 S 638.40 0.00 0.00<br />

11446 S 653.98 0.00 0.00 11970 S 1,156.36 0.00 0.00<br />

11450 S 653.98 0.00 0.00 11971 S 599.25 0.00 0.00<br />

11451 S 653.98 0.00 0.00 11976 S 64.14 0.00 0.00<br />

11462 S 653.98 0.00 0.00 11980 S 25.91 0.00 0.00<br />

11463 S 653.98 0.00 0.00 11981 S 25.91 0.00 0.00<br />

11470 S 653.98 0.00 0.00 11982 S 25.91 0.00 0.00<br />

11471 S 653.98 0.00 0.00 11983 S 25.91 0.00 0.00<br />

11600 S 96.39 0.00 0.00 12001 S 52.63 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 52.63 0.00 0.00 14021 S 567.33 0.00 0.00<br />

12004 S 52.63 0.00 0.00 14040 S 536.33 0.00 0.00<br />

12005 S 70.51 0.00 0.00 14041 S 567.33 0.00 0.00<br />

12006 S 70.51 0.00 0.00 14060 S 567.33 0.00 0.00<br />

12007 S 70.51 0.00 0.00 14061 S 567.33 0.00 0.00<br />

12011 S 52.63 0.00 0.00 14300 S 727.53 0.00 0.00<br />

12013 S 52.63 0.00 0.00 14350 S 669.40 0.00 0.00<br />

12014 S 52.63 0.00 0.00 15002 S 245.42 0.00 0.00<br />

12015 S 52.63 0.00 0.00 15003 S 245.42 0.00 0.00<br />

12016 S 70.51 0.00 0.00 15004 S 245.42 0.00 0.00<br />

12017 S 70.51 0.00 0.00 15005 S 245.42 0.00 0.00<br />

12018 S 70.51 0.00 0.00 15040 S 113.19 0.00 0.00<br />

12020 S 133.03 0.00 0.00 15050 S 245.42 0.00 0.00<br />

12021 S 113.19 0.00 0.00 15100 S 638.40 0.00 0.00<br />

12031 S 52.63 0.00 0.00 15101 S 669.40 0.00 0.00<br />

12032 S 138.00 0.00 0.00 15110 S 304.87 0.00 0.00<br />

12034 S 70.51 0.00 0.00 15111 S 250.13 0.00 0.00<br />

12035 S 70.51 0.00 0.00 15115 S 304.87 0.00 0.00<br />

12036 S 113.19 0.00 0.00 15116 S 250.13 0.00 0.00<br />

12037 S 225.59 0.00 0.00 15120 S 638.40 0.00 0.00<br />

12041 S 52.63 0.00 0.00 15121 S 669.40 0.00 0.00<br />

12042 S 52.63 0.00 0.00 15130 S 536.33 0.00 0.00<br />

12044 S 70.51 0.00 0.00 15131 S 481.59 0.00 0.00<br />

12045 S 113.19 0.00 0.00 15135 S 536.33 0.00 0.00<br />

12046 S 113.19 0.00 0.00 15136 S 481.59 0.00 0.00<br />

12047 S 225.59 0.00 0.00 15150 S 304.87 0.00 0.00<br />

12051 S 52.63 0.00 0.00 15151 S 250.13 0.00 0.00<br />

12052 S 52.63 0.00 0.00 15152 S 250.13 0.00 0.00<br />

12053 S 52.63 0.00 0.00 15155 S 304.87 0.00 0.00<br />

12054 S 70.51 0.00 0.00 15156 S 250.13 0.00 0.00<br />

12055 S 113.19 0.00 0.00 15157 S 250.13 0.00 0.00<br />

12056 S 113.19 0.00 0.00 15170 S 138.00 0.00 0.00<br />

12057 S 225.59 0.00 0.00 15171 S 138.00 0.00 0.00<br />

13100 S 245.42 0.00 0.00 15175 S 177.67 0.00 0.00<br />

13101 S 245.42 0.00 0.00 15176 S 177.67 0.00 0.00<br />

13102 S 133.03 0.00 0.00 15200 S 567.33 0.00 0.00<br />

13120 S 113.19 0.00 0.00 15201 S 476.89 0.00 0.00<br />

13121 S 113.19 0.00 0.00 15220 S 536.33 0.00 0.00<br />

13122 S 113.19 0.00 0.00 15221 S 245.42 0.00 0.00<br />

13131 S 113.19 0.00 0.00 15240 S 567.33 0.00 0.00<br />

13132 S 113.19 0.00 0.00 15241 S 245.42 0.00 0.00<br />

13133 S 113.19 0.00 0.00 15260 S 536.33 0.00 0.00<br />

13150 S 245.42 0.00 0.00 15261 S 476.89 0.00 0.00<br />

13151 S 245.42 0.00 0.00 15300 S 245.42 0.00 0.00<br />

13152 S 245.42 0.00 0.00 15301 S 245.42 0.00 0.00<br />

13153 S 113.19 0.00 0.00 15320 S 245.42 0.00 0.00<br />

13160 S 638.40 0.00 0.00 15321 S 245.42 0.00 0.00<br />

14000 S 536.33 0.00 0.00 15330 S 245.42 0.00 0.00<br />

14001 S 567.33 0.00 0.00 15331 S 245.42 0.00 0.00<br />

14020 S 567.33 0.00 0.00 15335 S 245.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 245.42 0.00 0.00 15826 S 669.40 0.00 0.00<br />

15340 S 138.00 0.00 0.00 15828 S 669.40 0.00 0.00<br />

15341 S 138.00 0.00 0.00 15829 S 769.66 0.00 0.00<br />

15360 S 138.00 0.00 0.00 15830 S 684.99 0.00 0.00<br />

15361 S 138.00 0.00 0.00 15832 S 684.99 0.00 0.00<br />

15365 S 138.00 0.00 0.00 15833 S 684.99 0.00 0.00<br />

15366 S 138.00 0.00 0.00 15834 S 684.99 0.00 0.00<br />

15400 S 245.42 0.00 0.00 15835 S 594.54 0.00 0.00<br />

15401 S 245.42 0.00 0.00 15836 S 565.78 0.00 0.00<br />

15420 S 245.42 0.00 0.00 15837 S 637.49 0.00 0.00<br />

15421 S 245.42 0.00 0.00 15838 S 637.49 0.00 0.00<br />

15430 S 245.42 0.00 0.00 15839 S 565.78 0.00 0.00<br />

15431 S 245.42 0.00 0.00 15840 S 727.53 0.00 0.00<br />

15570 S 669.40 0.00 0.00 15841 S 727.53 0.00 0.00<br />

15572 S 669.40 0.00 0.00 15842 S 844.73 0.00 0.00<br />

15574 S 669.40 0.00 0.00 15845 S 727.53 0.00 0.00<br />

15576 S 669.40 0.00 0.00 15847 S 684.99 0.00 0.00<br />

15600 S 669.40 0.00 0.00 15850 S 109.42 0.00 0.00<br />

15610 S 669.40 0.00 0.00 15851 S 49.80 0.00 0.00<br />

15620 S 727.53 0.00 0.00 15852 S 25.91 0.00 0.00<br />

15630 S 669.40 0.00 0.00 15860 S 25.91 0.00 0.00<br />

15650 S 769.66 0.00 0.00 15876 S 669.40 0.00 0.00<br />

15731 S 669.40 0.00 0.00 15877 S 669.40 0.00 0.00<br />

15732 S 669.40 0.00 0.00 15878 S 669.40 0.00 0.00<br />

15734 S 669.40 0.00 0.00 15879 S 669.40 0.00 0.00<br />

15736 S 669.40 0.00 0.00 15920 S 211.58 0.00 0.00<br />

15738 S 669.40 0.00 0.00 15922 S 727.53 0.00 0.00<br />

15740 S 536.33 0.00 0.00 15931 S 684.99 0.00 0.00<br />

15750 S 638.40 0.00 0.00 15933 S 684.99 0.00 0.00<br />

15760 S 638.40 0.00 0.00 15934 S 669.40 0.00 0.00<br />

15770 S 669.40 0.00 0.00 15935 S 727.53 0.00 0.00<br />

15775 S 182.90 0.00 0.00 15936 S 625.46 0.00 0.00<br />

15776 S 182.90 0.00 0.00 15937 S 727.53 0.00 0.00<br />

15780 S 407.77 0.00 0.00 15940 S 684.99 0.00 0.00<br />

15781 S 179.49 0.00 0.00 15941 S 684.99 0.00 0.00<br />

15782 S 179.49 0.00 0.00 15944 S 669.40 0.00 0.00<br />

15783 S 109.42 0.00 0.00 15945 S 727.53 0.00 0.00<br />

15786 S 33.20 0.00 0.00 15946 S 727.53 0.00 0.00<br />

15787 S 30.10 0.00 0.00 15950 S 684.99 0.00 0.00<br />

15788 S 33.20 0.00 0.00 15951 S 743.11 0.00 0.00<br />

15789 S 60.83 0.00 0.00 15952 S 567.33 0.00 0.00<br />

15792 S 60.83 0.00 0.00 15953 S 625.46 0.00 0.00<br />

15793 S 33.20 0.00 0.00 15956 S 567.33 0.00 0.00<br />

15819 S 138.00 0.00 0.00 15958 S 625.46 0.00 0.00<br />

15820 S 669.40 0.00 0.00 16000 S 26.87 0.00 0.00<br />

15821 S 669.40 0.00 0.00 16020 S 40.85 0.00 0.00<br />

15822 S 669.40 0.00 0.00 16025 S 62.92 0.00 0.00<br />

15823 S 769.66 0.00 0.00 16030 S 78.77 0.00 0.00<br />

15824 S 669.40 0.00 0.00 16035 S 60.83 0.00 0.00<br />

15825 S 669.40 0.00 0.00 17000 S 33.20 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.94 0.00 0.00 19300 S 735.94 0.00 0.00<br />

17004 S 86.71 0.00 0.00 19301 S 677.82 0.00 0.00<br />

17106 S 109.42 0.00 0.00 19302 S 1,294.55 0.00 0.00<br />

17107 S 109.42 0.00 0.00 19303 S 978.33 0.00 0.00<br />

17108 S 109.42 0.00 0.00 19304 S 978.33 0.00 0.00<br />

17110 S 33.20 0.00 0.00 19316 S 978.33 0.00 0.00<br />

17111 S 60.83 0.00 0.00 19318 S 1,117.75 0.00 0.00<br />

17250 S 45.87 0.00 0.00 19324 S 1,117.75 0.00 0.00<br />

17260 S 49.09 0.00 0.00 19325 S 1,853.92 0.00 0.00<br />

17261 S 60.83 0.00 0.00 19328 S 834.47 0.00 0.00<br />

17262 S 60.83 0.00 0.00 19330 S 834.47 0.00 0.00<br />

17263 S 60.83 0.00 0.00 19340 S 1,028.62 0.00 0.00<br />

17264 S 60.83 0.00 0.00 19342 S 1,452.37 0.00 0.00<br />

17266 S 109.42 0.00 0.00 19350 S 735.94 0.00 0.00<br />

17270 S 60.83 0.00 0.00 19355 S 978.33 0.00 0.00<br />

17271 S 60.83 0.00 0.00 19357 S 1,552.63 0.00 0.00<br />

17272 S 60.83 0.00 0.00 19366 S 1,020.47 0.00 0.00<br />

17273 S 109.42 0.00 0.00 19370 S 978.33 0.00 0.00<br />

17274 S 109.42 0.00 0.00 19371 S 978.33 0.00 0.00<br />

17276 S 109.42 0.00 0.00 19380 S 1,159.89 0.00 0.00<br />

17280 S 60.83 0.00 0.00 19396 S 1,346.33 0.00 0.00<br />

17281 S 90.66 0.00 0.00 20000 S 56.65 0.00 0.00<br />

17282 S 103.55 0.00 0.00 20005 S 652.74 0.00 0.00<br />

17283 S 109.42 0.00 0.00 20103 S 640.60 0.00 0.00<br />

17284 S 109.42 0.00 0.00 20150 S 1,818.67 0.00 0.00<br />

17286 S 109.42 0.00 0.00 20200 S 534.77 0.00 0.00<br />

17311 S 180.64 0.00 0.00 20205 S 565.78 0.00 0.00<br />

17312 S 180.64 0.00 0.00 20206 S 264.38 0.00 0.00<br />

17313 S 180.64 0.00 0.00 20220 S 287.38 0.00 0.00<br />

17314 S 180.64 0.00 0.00 20225 S 521.45 0.00 0.00<br />

17315 S 40.85 0.00 0.00 20240 S 653.98 0.00 0.00<br />

17340 S 14.69 0.00 0.00 20245 S 684.99 0.00 0.00<br />

17360 S 33.20 0.00 0.00 20250 S 683.75 0.00 0.00<br />

17380 S 33.20 0.00 0.00 20251 S 683.75 0.00 0.00<br />

19000 S 69.16 0.00 0.00 20500 S 56.62 0.00 0.00<br />

19001 S 9.32 0.00 0.00 20520 S 95.32 0.00 0.00<br />

19020 S 604.75 0.00 0.00 20525 S 684.99 0.00 0.00<br />

19100 S 205.93 0.00 0.00 20526 S 30.82 0.00 0.00<br />

19101 S 646.81 0.00 0.00 20550 S 23.29 0.00 0.00<br />

19102 S 264.38 0.00 0.00 20551 S 22.93 0.00 0.00<br />

19103 S 462.73 0.00 0.00 20552 S 22.21 0.00 0.00<br />

19105 S 1,346.33 0.00 0.00 20553 S 24.73 0.00 0.00<br />

19110 S 646.81 0.00 0.00 20555 S 1,198.25 0.00 0.00<br />

19112 S 677.82 0.00 0.00 20600 S 23.65 0.00 0.00<br />

19120 S 677.82 0.00 0.00 20605 S 26.52 0.00 0.00<br />

19125 S 677.82 0.00 0.00 20610 S 37.27 0.00 0.00<br />

19126 S 677.82 0.00 0.00 20612 S 25.09 0.00 0.00<br />

19296 S 1,853.92 0.00 0.00 20615 S 104.99 0.00 0.00<br />

19297 S 1,853.92 0.00 0.00 20650 S 683.75 0.00 0.00<br />

19298 S 1,853.92 0.00 0.00 20662 S 873.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 873.42 0.00 0.00 21085 S 263.01 0.00 0.00<br />

20665 S 25.91 0.00 0.00 21086 S 572.59 0.00 0.00<br />

20670 S 480.04 0.00 0.00 21087 S 573.32 0.00 0.00<br />

20680 S 684.99 0.00 0.00 21088 S 1,679.14 0.00 0.00<br />

20690 S 815.16 0.00 0.00 21100 S 1,055.60 0.00 0.00<br />

20692 S 846.16 0.00 0.00 21110 S 302.07 0.00 0.00<br />

20693 S 683.75 0.00 0.00 21120 S 978.31 0.00 0.00<br />

20694 S 598.01 0.00 0.00 21121 S 978.31 0.00 0.00<br />

20696 S 1,198.25 0.00 0.00 21122 S 978.31 0.00 0.00<br />

20697 S 796.89 0.00 0.00 21123 S 978.31 0.00 0.00<br />

20822 S 1,122.77 0.00 0.00 21125 S 978.31 0.00 0.00<br />

20900 S 846.16 0.00 0.00 21127 S 1,488.15 0.00 0.00<br />

20902 S 904.28 0.00 0.00 21137 S 992.71 0.00 0.00<br />

20910 S 669.40 0.00 0.00 21138 S 1,679.14 0.00 0.00<br />

20912 S 669.40 0.00 0.00 21139 S 1,679.14 0.00 0.00<br />

20920 S 625.46 0.00 0.00 21150 S 1,679.14 0.00 0.00<br />

20922 S 567.33 0.00 0.00 21181 S 978.31 0.00 0.00<br />

20924 S 904.28 0.00 0.00 21198 S 1,679.14 0.00 0.00<br />

20926 S 393.99 0.00 0.00 21199 S 1,679.14 0.00 0.00<br />

20950 S 56.65 0.00 0.00 21206 S 1,186.87 0.00 0.00<br />

20972 S 1,896.39 0.00 0.00 21208 S 1,321.53 0.00 0.00<br />

20973 S 1,896.39 0.00 0.00 21209 S 1,186.87 0.00 0.00<br />

20979 S 23.29 0.00 0.00 21210 S 1,321.53 0.00 0.00<br />

20982 S 1,818.67 0.00 0.00 21215 S 1,321.53 0.00 0.00<br />

21010 S 712.38 0.00 0.00 21230 S 1,321.53 0.00 0.00<br />

21015 S 592.70 0.00 0.00 21235 S 978.31 0.00 0.00<br />

21025 S 1,055.60 0.00 0.00 21240 S 1,144.73 0.00 0.00<br />

21026 S 1,055.60 0.00 0.00 21242 S 1,186.87 0.00 0.00<br />

21029 S 1,055.60 0.00 0.00 21243 S 1,186.87 0.00 0.00<br />

21030 S 249.03 0.00 0.00 21244 S 1,321.53 0.00 0.00<br />

21031 S 206.03 0.00 0.00 21245 S 1,321.53 0.00 0.00<br />

21032 S 209.98 0.00 0.00 21246 S 1,321.53 0.00 0.00<br />

21034 S 1,086.61 0.00 0.00 21248 S 1,321.53 0.00 0.00<br />

21040 S 712.38 0.00 0.00 21249 S 1,321.53 0.00 0.00<br />

21044 S 1,055.60 0.00 0.00 21260 S 1,679.14 0.00 0.00<br />

21046 S 1,055.60 0.00 0.00 21267 S 1,321.53 0.00 0.00<br />

21047 S 1,055.60 0.00 0.00 21270 S 1,186.87 0.00 0.00<br />

21048 S 1,679.14 0.00 0.00 21275 S 1,321.53 0.00 0.00<br />

21050 S 1,086.61 0.00 0.00 21280 S 1,186.87 0.00 0.00<br />

21060 S 1,055.60 0.00 0.00 21282 S 692.97 0.00 0.00<br />

21070 S 1,086.61 0.00 0.00 21295 S 312.34 0.00 0.00<br />

21073 S 193.49 0.00 0.00 21296 S 657.65 0.00 0.00<br />

21076 S 335.74 0.00 0.00 21310 S 95.28 0.00 0.00<br />

21077 S 811.60 0.00 0.00 21315 S 418.67 0.00 0.00<br />

21079 S 581.20 0.00 0.00 21320 S 561.70 0.00 0.00<br />

21080 S 666.48 0.00 0.00 21325 S 801.51 0.00 0.00<br />

21081 S 614.16 0.00 0.00 21330 S 843.65 0.00 0.00<br />

21082 S 584.43 0.00 0.00 21335 S 978.31 0.00 0.00<br />

21083 S 575.82 0.00 0.00 21336 S 815.32 0.00 0.00<br />

21084 S 662.54 0.00 0.00 21337 S 561.70 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 801.51 0.00 0.00 22310 S 173.46 0.00 0.00<br />

21339 S 843.65 0.00 0.00 22315 S 448.63 0.00 0.00<br />

21340 S 1,144.73 0.00 0.00 22505 S 528.15 0.00 0.00<br />

21345 S 978.31 0.00 0.00 22520 S 1,247.71 0.00 0.00<br />

21355 S 1,086.61 0.00 0.00 22521 S 1,247.71 0.00 0.00<br />

21356 S 743.39 0.00 0.00 22522 S 1,247.71 0.00 0.00<br />

21360 S 992.71 0.00 0.00 22523 S 3,472.49 0.00 0.00<br />

21390 S 1,679.14 0.00 0.00 22524 S 3,472.49 0.00 0.00<br />

21400 S 367.07 0.00 0.00 22525 S 3,472.49 0.00 0.00<br />

21401 S 592.70 0.00 0.00 22900 S 743.11 0.00 0.00<br />

21406 S 1,679.14 0.00 0.00 23000 S 534.77 0.00 0.00<br />

21407 S 1,679.14 0.00 0.00 23020 S 1,125.37 0.00 0.00<br />

21421 S 801.51 0.00 0.00 23030 S 550.01 0.00 0.00<br />

21440 S 337.54 0.00 0.00 23031 S 635.75 0.00 0.00<br />

21445 S 801.51 0.00 0.00 23035 S 683.75 0.00 0.00<br />

21450 S 139.31 0.00 0.00 23040 S 846.16 0.00 0.00<br />

21451 S 375.86 0.00 0.00 23044 S 904.28 0.00 0.00<br />

21452 S 561.70 0.00 0.00 23065 S 101.05 0.00 0.00<br />

21453 S 1,086.61 0.00 0.00 23066 S 653.98 0.00 0.00<br />

21454 S 843.65 0.00 0.00 23075 S 534.77 0.00 0.00<br />

21461 S 1,144.73 0.00 0.00 23076 S 653.98 0.00 0.00<br />

21462 S 1,186.87 0.00 0.00 23077 S 684.99 0.00 0.00<br />

21465 S 1,144.73 0.00 0.00 23100 S 652.74 0.00 0.00<br />

21480 S 95.28 0.00 0.00 23101 S 1,081.09 0.00 0.00<br />

21485 S 561.70 0.00 0.00 23105 S 904.28 0.00 0.00<br />

21490 S 1,086.61 0.00 0.00 23106 S 904.28 0.00 0.00<br />

21495 S 691.33 0.00 0.00 23107 S 904.28 0.00 0.00<br />

21497 S 561.70 0.00 0.00 23120 S 946.43 0.00 0.00<br />

21501 S 604.75 0.00 0.00 23125 S 946.43 0.00 0.00<br />

21502 S 652.74 0.00 0.00 23130 S 1,256.63 0.00 0.00<br />

21550 S 637.49 0.00 0.00 23140 S 741.87 0.00 0.00<br />

21555 S 653.98 0.00 0.00 23145 S 946.43 0.00 0.00<br />

21556 S 653.98 0.00 0.00 23146 S 946.43 0.00 0.00<br />

21557 S 875.90 0.00 0.00 23150 S 904.28 0.00 0.00<br />

21600 S 815.16 0.00 0.00 23155 S 946.43 0.00 0.00<br />

21610 S 815.16 0.00 0.00 23156 S 946.43 0.00 0.00<br />

21685 S 302.07 0.00 0.00 23170 S 815.16 0.00 0.00<br />

21700 S 652.74 0.00 0.00 23172 S 815.16 0.00 0.00<br />

21720 S 683.75 0.00 0.00 23174 S 815.16 0.00 0.00<br />

21725 S 71.17 0.00 0.00 23180 S 904.28 0.00 0.00<br />

21800 S 82.22 0.00 0.00 23182 S 904.28 0.00 0.00<br />

21805 S 726.19 0.00 0.00 23184 S 904.28 0.00 0.00<br />

21820 S 82.22 0.00 0.00 23190 S 904.28 0.00 0.00<br />

21920 S 146.19 0.00 0.00 23195 S 946.43 0.00 0.00<br />

21925 S 653.98 0.00 0.00 23330 S 326.84 0.00 0.00<br />

21930 S 653.98 0.00 0.00 23331 S 599.25 0.00 0.00<br />

21935 S 684.99 0.00 0.00 23395 S 1,256.63 0.00 0.00<br />

22102 S 1,949.14 0.00 0.00 23397 S 2,218.21 0.00 0.00<br />

22103 S 1,949.14 0.00 0.00 23400 S 1,081.09 0.00 0.00<br />

22305 S 82.22 0.00 0.00 23405 S 815.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 815.16 0.00 0.00 23931 S 604.75 0.00 0.00<br />

23410 S 1,256.63 0.00 0.00 23935 S 652.74 0.00 0.00<br />

23412 S 1,391.29 0.00 0.00 24000 S 904.28 0.00 0.00<br />

23415 S 1,256.63 0.00 0.00 24006 S 904.28 0.00 0.00<br />

23420 S 1,391.29 0.00 0.00 24065 S 140.10 0.00 0.00<br />

23430 S 1,214.49 0.00 0.00 24066 S 534.77 0.00 0.00<br />

23440 S 1,214.49 0.00 0.00 24075 S 534.77 0.00 0.00<br />

23450 S 2,083.55 0.00 0.00 24076 S 653.98 0.00 0.00<br />

23455 S 2,218.21 0.00 0.00 24077 S 684.99 0.00 0.00<br />

23460 S 2,083.55 0.00 0.00 24100 S 598.01 0.00 0.00<br />

23462 S 1,391.29 0.00 0.00 24101 S 904.28 0.00 0.00<br />

23465 S 2,083.55 0.00 0.00 24102 S 904.28 0.00 0.00<br />

23466 S 1,391.29 0.00 0.00 24105 S 683.75 0.00 0.00<br />

23480 S 1,214.49 0.00 0.00 24110 S 652.74 0.00 0.00<br />

23485 S 2,218.21 0.00 0.00 24115 S 846.16 0.00 0.00<br />

23490 S 1,156.36 0.00 0.00 24116 S 846.16 0.00 0.00<br />

23491 S 1,983.28 0.00 0.00 24120 S 683.75 0.00 0.00<br />

23500 S 82.22 0.00 0.00 24125 S 846.16 0.00 0.00<br />

23505 S 448.63 0.00 0.00 24126 S 846.16 0.00 0.00<br />

23515 S 1,501.55 0.00 0.00 24130 S 846.16 0.00 0.00<br />

23520 S 173.46 0.00 0.00 24134 S 815.16 0.00 0.00<br />

23525 S 173.46 0.00 0.00 24136 S 815.16 0.00 0.00<br />

23530 S 1,106.49 0.00 0.00 24138 S 815.16 0.00 0.00<br />

23532 S 815.32 0.00 0.00 24140 S 846.16 0.00 0.00<br />

23540 S 82.22 0.00 0.00 24145 S 846.16 0.00 0.00<br />

23545 S 173.46 0.00 0.00 24147 S 815.16 0.00 0.00<br />

23550 S 1,106.49 0.00 0.00 24149 S 1,198.25 0.00 0.00<br />

23552 S 1,164.62 0.00 0.00 24152 S 1,818.67 0.00 0.00<br />

23570 S 82.22 0.00 0.00 24153 S 3,472.49 0.00 0.00<br />

23575 S 173.46 0.00 0.00 24155 S 1,156.36 0.00 0.00<br />

23585 S 1,501.55 0.00 0.00 24160 S 815.16 0.00 0.00<br />

23600 S 64.07 0.00 0.00 24164 S 846.16 0.00 0.00<br />

23605 S 448.63 0.00 0.00 24200 S 102.48 0.00 0.00<br />

23615 S 1,559.67 0.00 0.00 24201 S 534.77 0.00 0.00<br />

23616 S 1,559.67 0.00 0.00 24300 S 624.25 0.00 0.00<br />

23620 S 64.07 0.00 0.00 24301 S 904.28 0.00 0.00<br />

23625 S 448.63 0.00 0.00 24305 S 904.28 0.00 0.00<br />

23630 S 1,601.81 0.00 0.00 24310 S 683.75 0.00 0.00<br />

23650 S 82.22 0.00 0.00 24320 S 1,156.36 0.00 0.00<br />

23655 S 473.42 0.00 0.00 24330 S 1,983.28 0.00 0.00<br />

23660 S 1,106.49 0.00 0.00 24331 S 1,156.36 0.00 0.00<br />

23665 S 173.46 0.00 0.00 24332 S 873.42 0.00 0.00<br />

23670 S 1,501.55 0.00 0.00 24340 S 1,156.36 0.00 0.00<br />

23675 S 82.22 0.00 0.00 24341 S 1,156.36 0.00 0.00<br />

23680 S 1,106.49 0.00 0.00 24342 S 1,156.36 0.00 0.00<br />

23700 S 473.42 0.00 0.00 24343 S 1,198.25 0.00 0.00<br />

23800 S 2,041.40 0.00 0.00 24344 S 3,472.49 0.00 0.00<br />

23802 S 1,391.29 0.00 0.00 24345 S 815.16 0.00 0.00<br />

23921 S 476.89 0.00 0.00 24346 S 1,818.67 0.00 0.00<br />

23930 S 550.01 0.00 0.00 24357 S 1,198.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,198.25 0.00 0.00 24925 S 683.75 0.00 0.00<br />

24359 S 1,198.25 0.00 0.00 25000 S 683.75 0.00 0.00<br />

24360 S 1,105.82 0.00 0.00 25001 S 873.42 0.00 0.00<br />

24361 S 6,046.06 3,700.96 1,355.85 25020 S 683.75 0.00 0.00<br />

24362 S 1,413.22 0.00 0.00 25023 S 846.16 0.00 0.00<br />

24363 S 6,180.72 3,835.62 1,490.51 25024 S 846.16 0.00 0.00<br />

24365 S 1,105.82 0.00 0.00 25025 S 846.16 0.00 0.00<br />

24366 S 6,046.06 3,700.96 1,355.85 25028 S 598.01 0.00 0.00<br />

24400 S 904.28 0.00 0.00 25031 S 652.74 0.00 0.00<br />

24410 S 904.28 0.00 0.00 25035 S 652.74 0.00 0.00<br />

24420 S 1,156.36 0.00 0.00 25040 S 946.43 0.00 0.00<br />

24430 S 1,983.28 0.00 0.00 25065 S 142.25 0.00 0.00<br />

24435 S 2,041.40 0.00 0.00 25066 S 653.98 0.00 0.00<br />

24470 S 1,156.36 0.00 0.00 25075 S 534.77 0.00 0.00<br />

24495 S 815.16 0.00 0.00 25076 S 684.99 0.00 0.00<br />

24498 S 1,983.28 0.00 0.00 25077 S 684.99 0.00 0.00<br />

24500 S 82.22 0.00 0.00 25085 S 683.75 0.00 0.00<br />

24505 S 82.22 0.00 0.00 25100 S 652.74 0.00 0.00<br />

24515 S 1,559.67 0.00 0.00 25101 S 846.16 0.00 0.00<br />

24516 S 1,559.67 0.00 0.00 25105 S 904.28 0.00 0.00<br />

24530 S 82.22 0.00 0.00 25107 S 846.16 0.00 0.00<br />

24535 S 173.46 0.00 0.00 25109 S 873.42 0.00 0.00<br />

24538 S 726.19 0.00 0.00 25110 S 683.75 0.00 0.00<br />

24545 S 1,559.67 0.00 0.00 25111 S 683.75 0.00 0.00<br />

24546 S 1,601.81 0.00 0.00 25112 S 741.87 0.00 0.00<br />

24560 S 82.22 0.00 0.00 25115 S 741.87 0.00 0.00<br />

24565 S 82.22 0.00 0.00 25116 S 741.87 0.00 0.00<br />

24566 S 726.19 0.00 0.00 25118 S 815.16 0.00 0.00<br />

24575 S 1,501.55 0.00 0.00 25119 S 846.16 0.00 0.00<br />

24576 S 82.22 0.00 0.00 25120 S 846.16 0.00 0.00<br />

24577 S 173.46 0.00 0.00 25125 S 846.16 0.00 0.00<br />

24579 S 1,501.55 0.00 0.00 25126 S 846.16 0.00 0.00<br />

24582 S 726.19 0.00 0.00 25130 S 846.16 0.00 0.00<br />

24586 S 1,559.67 0.00 0.00 25135 S 846.16 0.00 0.00<br />

24587 S 1,601.81 0.00 0.00 25136 S 846.16 0.00 0.00<br />

24600 S 82.22 0.00 0.00 25145 S 815.16 0.00 0.00<br />

24605 S 528.15 0.00 0.00 25150 S 815.16 0.00 0.00<br />

24615 S 1,501.55 0.00 0.00 25151 S 815.16 0.00 0.00<br />

24620 S 448.63 0.00 0.00 25210 S 846.16 0.00 0.00<br />

24635 S 1,501.55 0.00 0.00 25215 S 904.28 0.00 0.00<br />

24640 S 55.54 0.00 0.00 25230 S 904.28 0.00 0.00<br />

24650 S 64.07 0.00 0.00 25240 S 904.28 0.00 0.00<br />

24655 S 173.46 0.00 0.00 25248 S 652.74 0.00 0.00<br />

24665 S 1,164.62 0.00 0.00 25250 S 760.42 0.00 0.00<br />

24666 S 1,559.67 0.00 0.00 25251 S 760.42 0.00 0.00<br />

24670 S 82.22 0.00 0.00 25259 S 796.89 0.00 0.00<br />

24675 S 82.22 0.00 0.00 25260 S 904.28 0.00 0.00<br />

24685 S 1,106.49 0.00 0.00 25263 S 815.16 0.00 0.00<br />

24800 S 1,214.49 0.00 0.00 25265 S 846.16 0.00 0.00<br />

24802 S 1,256.63 0.00 0.00 25270 S 904.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 846.16 0.00 0.00 25505 S 173.46 0.00 0.00<br />

25274 S 904.28 0.00 0.00 25515 S 1,106.49 0.00 0.00<br />

25275 S 904.28 0.00 0.00 25520 S 173.46 0.00 0.00<br />

25280 S 904.28 0.00 0.00 25525 S 1,164.62 0.00 0.00<br />

25290 S 846.16 0.00 0.00 25526 S 1,206.75 0.00 0.00<br />

25295 S 683.75 0.00 0.00 25530 S 64.07 0.00 0.00<br />

25300 S 846.16 0.00 0.00 25535 S 82.22 0.00 0.00<br />

25301 S 846.16 0.00 0.00 25545 S 1,106.49 0.00 0.00<br />

25310 S 1,156.36 0.00 0.00 25560 S 64.07 0.00 0.00<br />

25312 S 1,214.49 0.00 0.00 25565 S 173.46 0.00 0.00<br />

25315 S 1,156.36 0.00 0.00 25574 S 1,501.55 0.00 0.00<br />

25316 S 1,983.28 0.00 0.00 25575 S 1,501.55 0.00 0.00<br />

25320 S 1,156.36 0.00 0.00 25600 S 64.07 0.00 0.00<br />

25332 S 1,105.82 0.00 0.00 25605 S 173.46 0.00 0.00<br />

25335 S 1,156.36 0.00 0.00 25606 S 757.20 0.00 0.00<br />

25337 S 1,256.63 0.00 0.00 25607 S 1,601.81 0.00 0.00<br />

25350 S 1,983.28 0.00 0.00 25608 S 1,601.81 0.00 0.00<br />

25355 S 1,156.36 0.00 0.00 25609 S 1,601.81 0.00 0.00<br />

25360 S 846.16 0.00 0.00 25622 S 64.07 0.00 0.00<br />

25365 S 846.16 0.00 0.00 25624 S 173.46 0.00 0.00<br />

25370 S 1,156.36 0.00 0.00 25628 S 1,106.49 0.00 0.00<br />

25375 S 1,214.49 0.00 0.00 25630 S 64.07 0.00 0.00<br />

25390 S 846.16 0.00 0.00 25635 S 173.46 0.00 0.00<br />

25391 S 1,214.49 0.00 0.00 25645 S 1,106.49 0.00 0.00<br />

25392 S 846.16 0.00 0.00 25650 S 64.07 0.00 0.00<br />

25393 S 1,214.49 0.00 0.00 25651 S 1,020.31 0.00 0.00<br />

25394 S 1,818.67 0.00 0.00 25652 S 1,718.90 0.00 0.00<br />

25400 S 1,156.36 0.00 0.00 25660 S 82.22 0.00 0.00<br />

25405 S 2,041.40 0.00 0.00 25670 S 757.20 0.00 0.00<br />

25415 S 1,983.28 0.00 0.00 25671 S 671.46 0.00 0.00<br />

25420 S 2,041.40 0.00 0.00 25675 S 82.22 0.00 0.00<br />

25425 S 1,156.36 0.00 0.00 25676 S 726.19 0.00 0.00<br />

25426 S 1,214.49 0.00 0.00 25680 S 82.22 0.00 0.00<br />

25430 S 1,818.67 0.00 0.00 25685 S 757.20 0.00 0.00<br />

25431 S 1,818.67 0.00 0.00 25690 S 448.63 0.00 0.00<br />

25440 S 2,041.40 0.00 0.00 25695 S 726.19 0.00 0.00<br />

25441 S 6,046.06 3,700.96 1,355.85 25800 S 2,041.40 0.00 0.00<br />

25442 S 6,046.06 3,700.96 1,355.85 25805 S 1,256.63 0.00 0.00<br />

25443 S 1,413.22 0.00 0.00 25810 S 2,083.55 0.00 0.00<br />

25444 S 1,413.22 0.00 0.00 25820 S 1,214.49 0.00 0.00<br />

25445 S 1,413.22 0.00 0.00 25825 S 2,083.55 0.00 0.00<br />

25446 S 6,180.72 3,835.62 1,490.51 25830 S 2,083.55 0.00 0.00<br />

25447 S 1,105.82 0.00 0.00 25907 S 683.75 0.00 0.00<br />

25449 S 1,105.82 0.00 0.00 25922 S 683.75 0.00 0.00<br />

25450 S 1,156.36 0.00 0.00 25929 S 567.33 0.00 0.00<br />

25455 S 1,156.36 0.00 0.00 25931 S 873.42 0.00 0.00<br />

25490 S 1,156.36 0.00 0.00 26010 S 56.65 0.00 0.00<br />

25491 S 1,156.36 0.00 0.00 26011 S 413.83 0.00 0.00<br />

25492 S 1,156.36 0.00 0.00 26020 S 549.11 0.00 0.00<br />

25500 S 64.07 0.00 0.00 26025 S 494.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 549.11 0.00 0.00 26392 S 808.42 0.00 0.00<br />

26034 S 549.11 0.00 0.00 26410 S 580.10 0.00 0.00<br />

26035 S 666.14 0.00 0.00 26412 S 808.42 0.00 0.00<br />

26040 S 866.55 0.00 0.00 26415 S 866.55 0.00 0.00<br />

26045 S 808.42 0.00 0.00 26416 S 808.42 0.00 0.00<br />

26055 S 549.11 0.00 0.00 26418 S 638.23 0.00 0.00<br />

26060 S 549.11 0.00 0.00 26420 S 866.55 0.00 0.00<br />

26070 S 549.11 0.00 0.00 26426 S 808.42 0.00 0.00<br />

26075 S 638.23 0.00 0.00 26428 S 808.42 0.00 0.00<br />

26080 S 638.23 0.00 0.00 26432 S 580.10 0.00 0.00<br />

26100 S 549.11 0.00 0.00 26433 S 580.10 0.00 0.00<br />

26105 S 494.37 0.00 0.00 26434 S 808.42 0.00 0.00<br />

26110 S 494.37 0.00 0.00 26437 S 580.10 0.00 0.00<br />

26115 S 653.98 0.00 0.00 26440 S 580.10 0.00 0.00<br />

26116 S 653.98 0.00 0.00 26442 S 808.42 0.00 0.00<br />

26117 S 684.99 0.00 0.00 26445 S 580.10 0.00 0.00<br />

26121 S 866.55 0.00 0.00 26449 S 808.42 0.00 0.00<br />

26123 S 866.55 0.00 0.00 26450 S 580.10 0.00 0.00<br />

26125 S 638.23 0.00 0.00 26455 S 580.10 0.00 0.00<br />

26130 S 580.10 0.00 0.00 26460 S 580.10 0.00 0.00<br />

26135 S 866.55 0.00 0.00 26471 S 549.11 0.00 0.00<br />

26140 S 549.11 0.00 0.00 26474 S 549.11 0.00 0.00<br />

26145 S 580.10 0.00 0.00 26476 S 494.37 0.00 0.00<br />

26160 S 580.10 0.00 0.00 26477 S 494.37 0.00 0.00<br />

26170 S 580.10 0.00 0.00 26478 S 494.37 0.00 0.00<br />

26180 S 580.10 0.00 0.00 26479 S 494.37 0.00 0.00<br />

26185 S 638.23 0.00 0.00 26480 S 808.42 0.00 0.00<br />

26200 S 549.11 0.00 0.00 26483 S 808.42 0.00 0.00<br />

26205 S 808.42 0.00 0.00 26485 S 777.42 0.00 0.00<br />

26210 S 549.11 0.00 0.00 26489 S 808.42 0.00 0.00<br />

26215 S 580.10 0.00 0.00 26490 S 808.42 0.00 0.00<br />

26230 S 814.03 0.00 0.00 26492 S 808.42 0.00 0.00<br />

26235 S 580.10 0.00 0.00 26494 S 808.42 0.00 0.00<br />

26236 S 580.10 0.00 0.00 26496 S 808.42 0.00 0.00<br />

26250 S 580.10 0.00 0.00 26497 S 808.42 0.00 0.00<br />

26255 S 808.42 0.00 0.00 26498 S 866.55 0.00 0.00<br />

26260 S 580.10 0.00 0.00 26499 S 808.42 0.00 0.00<br />

26261 S 580.10 0.00 0.00 26500 S 638.23 0.00 0.00<br />

26262 S 549.11 0.00 0.00 26502 S 866.55 0.00 0.00<br />

26320 S 534.77 0.00 0.00 26508 S 580.10 0.00 0.00<br />

26340 S 246.53 0.00 0.00 26510 S 808.42 0.00 0.00<br />

26350 S 722.68 0.00 0.00 26516 S 722.68 0.00 0.00<br />

26352 S 866.55 0.00 0.00 26517 S 808.42 0.00 0.00<br />

26356 S 866.55 0.00 0.00 26518 S 808.42 0.00 0.00<br />

26357 S 866.55 0.00 0.00 26520 S 580.10 0.00 0.00<br />

26358 S 866.55 0.00 0.00 26525 S 580.10 0.00 0.00<br />

26370 S 866.55 0.00 0.00 26530 S 1,005.55 0.00 0.00<br />

26372 S 866.55 0.00 0.00 26531 S 1,547.88 0.00 0.00<br />

26373 S 808.42 0.00 0.00 26535 S 1,105.82 0.00 0.00<br />

26390 S 866.55 0.00 0.00 26536 S 1,413.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 638.23 0.00 0.00 26775 S 171.28 0.00 0.00<br />

26541 S 1,043.34 0.00 0.00 26776 S 726.19 0.00 0.00<br />

26542 S 638.23 0.00 0.00 26785 S 726.19 0.00 0.00<br />

26545 S 866.55 0.00 0.00 26820 S 908.68 0.00 0.00<br />

26546 S 866.55 0.00 0.00 26841 S 866.55 0.00 0.00<br />

26548 S 866.55 0.00 0.00 26842 S 866.55 0.00 0.00<br />

26550 S 777.42 0.00 0.00 26843 S 808.42 0.00 0.00<br />

26555 S 808.42 0.00 0.00 26844 S 808.42 0.00 0.00<br />

26560 S 549.11 0.00 0.00 26850 S 866.55 0.00 0.00<br />

26561 S 808.42 0.00 0.00 26852 S 866.55 0.00 0.00<br />

26562 S 866.55 0.00 0.00 26860 S 808.42 0.00 0.00<br />

26565 S 908.68 0.00 0.00 26861 S 777.42 0.00 0.00<br />

26567 S 908.68 0.00 0.00 26862 S 866.55 0.00 0.00<br />

26568 S 808.42 0.00 0.00 26863 S 808.42 0.00 0.00<br />

26580 S 680.37 0.00 0.00 26910 S 808.42 0.00 0.00<br />

26587 S 680.37 0.00 0.00 26951 S 549.11 0.00 0.00<br />

26590 S 680.37 0.00 0.00 26952 S 638.23 0.00 0.00<br />

26591 S 808.42 0.00 0.00 26990 S 598.01 0.00 0.00<br />

26593 S 580.10 0.00 0.00 26991 S 598.01 0.00 0.00<br />

26596 S 549.11 0.00 0.00 27000 S 652.74 0.00 0.00<br />

26600 S 64.07 0.00 0.00 27001 S 846.16 0.00 0.00<br />

26605 S 82.22 0.00 0.00 27003 S 846.16 0.00 0.00<br />

26607 S 448.63 0.00 0.00 27033 S 1,156.36 0.00 0.00<br />

26608 S 815.32 0.00 0.00 27035 S 1,214.49 0.00 0.00<br />

26615 S 1,164.62 0.00 0.00 27040 S 326.84 0.00 0.00<br />

26641 S 64.07 0.00 0.00 27041 S 368.25 0.00 0.00<br />

26645 S 173.46 0.00 0.00 27047 S 653.98 0.00 0.00<br />

26650 S 726.19 0.00 0.00 27048 S 684.99 0.00 0.00<br />

26665 S 1,164.62 0.00 0.00 27049 S 684.99 0.00 0.00<br />

26670 S 64.07 0.00 0.00 27050 S 683.75 0.00 0.00<br />

26675 S 173.46 0.00 0.00 27052 S 683.75 0.00 0.00<br />

26676 S 726.19 0.00 0.00 27060 S 784.01 0.00 0.00<br />

26685 S 757.20 0.00 0.00 27062 S 784.01 0.00 0.00<br />

26686 S 1,501.55 0.00 0.00 27065 S 784.01 0.00 0.00<br />

26700 S 64.07 0.00 0.00 27066 S 946.43 0.00 0.00<br />

26705 S 82.22 0.00 0.00 27067 S 946.43 0.00 0.00<br />

26706 S 448.63 0.00 0.00 27080 S 815.16 0.00 0.00<br />

26715 S 815.32 0.00 0.00 27086 S 326.84 0.00 0.00<br />

26720 S 64.07 0.00 0.00 27087 S 683.75 0.00 0.00<br />

26725 S 64.07 0.00 0.00 27097 S 846.16 0.00 0.00<br />

26727 S 992.12 0.00 0.00 27098 S 846.16 0.00 0.00<br />

26735 S 815.32 0.00 0.00 27100 S 1,214.49 0.00 0.00<br />

26740 S 64.07 0.00 0.00 27105 S 1,214.49 0.00 0.00<br />

26742 S 82.22 0.00 0.00 27110 S 1,214.49 0.00 0.00<br />

26746 S 857.46 0.00 0.00 27111 S 1,214.49 0.00 0.00<br />

26750 S 64.07 0.00 0.00 27193 S 82.22 0.00 0.00<br />

26755 S 64.07 0.00 0.00 27194 S 528.15 0.00 0.00<br />

26756 S 726.19 0.00 0.00 27200 S 64.07 0.00 0.00<br />

26765 S 815.32 0.00 0.00 27202 S 1,075.49 0.00 0.00<br />

26770 S 64.07 0.00 0.00 27220 S 64.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 82.22 0.00 0.00 27397 S 1,156.36 0.00 0.00<br />

27238 S 173.46 0.00 0.00 27400 S 1,156.36 0.00 0.00<br />

27246 S 173.46 0.00 0.00 27403 S 904.28 0.00 0.00<br />

27250 S 82.22 0.00 0.00 27405 S 1,214.49 0.00 0.00<br />

27252 S 528.15 0.00 0.00 27407 S 2,041.40 0.00 0.00<br />

27256 S 64.07 0.00 0.00 27409 S 1,214.49 0.00 0.00<br />

27257 S 559.16 0.00 0.00 27416 S 1,818.67 0.00 0.00<br />

27265 S 82.22 0.00 0.00 27418 S 1,156.36 0.00 0.00<br />

27266 S 528.15 0.00 0.00 27420 S 1,156.36 0.00 0.00<br />

27267 S 64.07 0.00 0.00 27422 S 1,391.29 0.00 0.00<br />

27275 S 528.15 0.00 0.00 27424 S 1,156.36 0.00 0.00<br />

27301 S 635.75 0.00 0.00 27425 S 1,081.09 0.00 0.00<br />

27305 S 652.74 0.00 0.00 27427 S 1,156.36 0.00 0.00<br />

27306 S 683.75 0.00 0.00 27428 S 2,041.40 0.00 0.00<br />

27307 S 683.75 0.00 0.00 27429 S 2,041.40 0.00 0.00<br />

27310 S 904.28 0.00 0.00 27430 S 1,214.49 0.00 0.00<br />

27323 S 326.84 0.00 0.00 27435 S 1,214.49 0.00 0.00<br />

27324 S 599.25 0.00 0.00 27437 S 1,063.67 0.00 0.00<br />

27325 S 587.18 0.00 0.00 27438 S 1,413.22 0.00 0.00<br />

27326 S 587.18 0.00 0.00 27440 S 1,517.02 0.00 0.00<br />

27327 S 653.98 0.00 0.00 27441 S 1,105.82 0.00 0.00<br />

27328 S 684.99 0.00 0.00 27442 S 1,105.82 0.00 0.00<br />

27329 S 743.11 0.00 0.00 27443 S 1,105.82 0.00 0.00<br />

27330 S 904.28 0.00 0.00 27446 S 10,850.18 6,518.29 2,186.41<br />

27331 S 904.28 0.00 0.00 27496 S 784.01 0.00 0.00<br />

27332 S 904.28 0.00 0.00 27497 S 683.75 0.00 0.00<br />

27333 S 904.28 0.00 0.00 27498 S 683.75 0.00 0.00<br />

27334 S 904.28 0.00 0.00 27499 S 683.75 0.00 0.00<br />

27335 S 904.28 0.00 0.00 27500 S 173.46 0.00 0.00<br />

27340 S 683.75 0.00 0.00 27501 S 82.22 0.00 0.00<br />

27345 S 741.87 0.00 0.00 27502 S 448.63 0.00 0.00<br />

27347 S 741.87 0.00 0.00 27503 S 82.22 0.00 0.00<br />

27350 S 904.28 0.00 0.00 27508 S 82.22 0.00 0.00<br />

27355 S 846.16 0.00 0.00 27509 S 757.20 0.00 0.00<br />

27356 S 904.28 0.00 0.00 27510 S 173.46 0.00 0.00<br />

27357 S 946.43 0.00 0.00 27516 S 82.22 0.00 0.00<br />

27358 S 946.43 0.00 0.00 27517 S 82.22 0.00 0.00<br />

27360 S 946.43 0.00 0.00 27520 S 82.22 0.00 0.00<br />

27372 S 919.91 0.00 0.00 27530 S 82.22 0.00 0.00<br />

27380 S 598.01 0.00 0.00 27532 S 448.63 0.00 0.00<br />

27381 S 683.75 0.00 0.00 27538 S 82.22 0.00 0.00<br />

27385 S 683.75 0.00 0.00 27550 S 82.22 0.00 0.00<br />

27386 S 683.75 0.00 0.00 27552 S 473.42 0.00 0.00<br />

27390 S 598.01 0.00 0.00 27560 S 82.22 0.00 0.00<br />

27391 S 652.74 0.00 0.00 27562 S 473.42 0.00 0.00<br />

27392 S 683.75 0.00 0.00 27566 S 1,075.49 0.00 0.00<br />

27393 S 815.16 0.00 0.00 27570 S 473.42 0.00 0.00<br />

27394 S 846.16 0.00 0.00 27594 S 683.75 0.00 0.00<br />

27395 S 1,156.36 0.00 0.00 27600 S 683.75 0.00 0.00<br />

27396 S 846.16 0.00 0.00 27601 S 683.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 683.75 0.00 0.00 27730 S 815.16 0.00 0.00<br />

27603 S 604.75 0.00 0.00 27732 S 815.16 0.00 0.00<br />

27604 S 652.74 0.00 0.00 27734 S 815.16 0.00 0.00<br />

27605 S 594.80 0.00 0.00 27740 S 815.16 0.00 0.00<br />

27606 S 598.01 0.00 0.00 27742 S 1,125.37 0.00 0.00<br />

27607 S 652.74 0.00 0.00 27745 S 1,983.28 0.00 0.00<br />

27610 S 815.16 0.00 0.00 27750 S 82.22 0.00 0.00<br />

27612 S 846.16 0.00 0.00 27752 S 448.63 0.00 0.00<br />

27613 S 134.37 0.00 0.00 27756 S 757.20 0.00 0.00<br />

27614 S 653.98 0.00 0.00 27758 S 1,164.62 0.00 0.00<br />

27615 S 846.16 0.00 0.00 27759 S 1,559.67 0.00 0.00<br />

27618 S 534.77 0.00 0.00 27760 S 82.22 0.00 0.00<br />

27619 S 684.99 0.00 0.00 27762 S 448.63 0.00 0.00<br />

27620 S 904.28 0.00 0.00 27766 S 1,106.49 0.00 0.00<br />

27625 S 904.28 0.00 0.00 27767 S 64.07 0.00 0.00<br />

27626 S 904.28 0.00 0.00 27768 S 64.07 0.00 0.00<br />

27630 S 683.75 0.00 0.00 27769 S 1,718.90 0.00 0.00<br />

27635 S 846.16 0.00 0.00 27780 S 82.22 0.00 0.00<br />

27637 S 846.16 0.00 0.00 27781 S 448.63 0.00 0.00<br />

27638 S 846.16 0.00 0.00 27784 S 1,106.49 0.00 0.00<br />

27640 S 1,125.37 0.00 0.00 27786 S 82.22 0.00 0.00<br />

27641 S 815.16 0.00 0.00 27788 S 82.22 0.00 0.00<br />

27647 S 1,156.36 0.00 0.00 27792 S 1,106.49 0.00 0.00<br />

27650 S 1,156.36 0.00 0.00 27808 S 82.22 0.00 0.00<br />

27652 S 1,983.28 0.00 0.00 27810 S 173.46 0.00 0.00<br />

27654 S 1,156.36 0.00 0.00 27814 S 1,106.49 0.00 0.00<br />

27656 S 652.74 0.00 0.00 27816 S 82.22 0.00 0.00<br />

27658 S 598.01 0.00 0.00 27818 S 173.46 0.00 0.00<br />

27659 S 652.74 0.00 0.00 27822 S 1,106.49 0.00 0.00<br />

27664 S 652.74 0.00 0.00 27823 S 1,501.55 0.00 0.00<br />

27665 S 815.16 0.00 0.00 27824 S 82.22 0.00 0.00<br />

27675 S 652.74 0.00 0.00 27825 S 448.63 0.00 0.00<br />

27676 S 846.16 0.00 0.00 27826 S 1,106.49 0.00 0.00<br />

27680 S 846.16 0.00 0.00 27827 S 1,501.55 0.00 0.00<br />

27681 S 815.16 0.00 0.00 27828 S 1,559.67 0.00 0.00<br />

27685 S 846.16 0.00 0.00 27829 S 1,075.49 0.00 0.00<br />

27686 S 846.16 0.00 0.00 27830 S 82.22 0.00 0.00<br />

27687 S 846.16 0.00 0.00 27831 S 448.63 0.00 0.00<br />

27690 S 1,214.49 0.00 0.00 27832 S 1,075.49 0.00 0.00<br />

27691 S 1,214.49 0.00 0.00 27840 S 173.46 0.00 0.00<br />

27692 S 1,156.36 0.00 0.00 27842 S 473.42 0.00 0.00<br />

27695 S 815.16 0.00 0.00 27846 S 1,106.49 0.00 0.00<br />

27696 S 815.16 0.00 0.00 27848 S 1,106.49 0.00 0.00<br />

27698 S 815.16 0.00 0.00 27860 S 473.42 0.00 0.00<br />

27700 S 1,105.82 0.00 0.00 27870 S 2,041.40 0.00 0.00<br />

27704 S 652.74 0.00 0.00 27871 S 2,041.40 0.00 0.00<br />

27705 S 1,125.37 0.00 0.00 27884 S 683.75 0.00 0.00<br />

27707 S 652.74 0.00 0.00 27889 S 846.16 0.00 0.00<br />

27709 S 815.16 0.00 0.00 27892 S 683.75 0.00 0.00<br />

27726 S 1,020.31 0.00 0.00 27893 S 683.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 683.75 0.00 0.00 28153 S 680.54 0.00 0.00<br />

28001 S 131.14 0.00 0.00 28160 S 680.54 0.00 0.00<br />

28002 S 683.75 0.00 0.00 28171 S 680.54 0.00 0.00<br />

28003 S 683.75 0.00 0.00 28173 S 680.54 0.00 0.00<br />

28005 S 680.54 0.00 0.00 28175 S 680.54 0.00 0.00<br />

28008 S 680.54 0.00 0.00 28190 S 135.44 0.00 0.00<br />

28010 S 96.39 0.00 0.00 28192 S 534.77 0.00 0.00<br />

28011 S 680.54 0.00 0.00 28193 S 368.25 0.00 0.00<br />

28020 S 649.53 0.00 0.00 28200 S 680.54 0.00 0.00<br />

28022 S 649.53 0.00 0.00 28202 S 680.54 0.00 0.00<br />

28024 S 649.53 0.00 0.00 28208 S 680.54 0.00 0.00<br />

28035 S 676.31 0.00 0.00 28210 S 1,195.23 0.00 0.00<br />

28043 S 653.98 0.00 0.00 28220 S 208.90 0.00 0.00<br />

28045 S 680.54 0.00 0.00 28222 S 594.80 0.00 0.00<br />

28046 S 680.54 0.00 0.00 28225 S 594.80 0.00 0.00<br />

28050 S 649.53 0.00 0.00 28226 S 594.80 0.00 0.00<br />

28052 S 649.53 0.00 0.00 28230 S 204.96 0.00 0.00<br />

28054 S 649.53 0.00 0.00 28232 S 196.00 0.00 0.00<br />

28055 S 676.31 0.00 0.00 28234 S 649.53 0.00 0.00<br />

28060 S 649.53 0.00 0.00 28238 S 1,195.23 0.00 0.00<br />

28062 S 680.54 0.00 0.00 28240 S 649.53 0.00 0.00<br />

28070 S 680.54 0.00 0.00 28250 S 680.54 0.00 0.00<br />

28072 S 680.54 0.00 0.00 28260 S 680.54 0.00 0.00<br />

28080 S 680.54 0.00 0.00 28261 S 680.54 0.00 0.00<br />

28086 S 649.53 0.00 0.00 28262 S 738.66 0.00 0.00<br />

28088 S 649.53 0.00 0.00 28264 S 1,109.49 0.00 0.00<br />

28090 S 680.54 0.00 0.00 28270 S 680.54 0.00 0.00<br />

28092 S 680.54 0.00 0.00 28272 S 189.19 0.00 0.00<br />

28100 S 649.53 0.00 0.00 28280 S 649.53 0.00 0.00<br />

28102 S 1,195.23 0.00 0.00 28285 S 680.54 0.00 0.00<br />

28103 S 1,195.23 0.00 0.00 28286 S 738.66 0.00 0.00<br />

28104 S 649.53 0.00 0.00 28288 S 680.54 0.00 0.00<br />

28106 S 1,195.23 0.00 0.00 28289 S 680.54 0.00 0.00<br />

28107 S 1,195.23 0.00 0.00 28290 S 838.85 0.00 0.00<br />

28108 S 649.53 0.00 0.00 28292 S 838.85 0.00 0.00<br />

28110 S 680.54 0.00 0.00 28293 S 869.85 0.00 0.00<br />

28111 S 680.54 0.00 0.00 28294 S 869.85 0.00 0.00<br />

28112 S 680.54 0.00 0.00 28296 S 869.85 0.00 0.00<br />

28113 S 680.54 0.00 0.00 28297 S 869.85 0.00 0.00<br />

28114 S 680.54 0.00 0.00 28298 S 869.85 0.00 0.00<br />

28116 S 680.54 0.00 0.00 28299 S 970.11 0.00 0.00<br />

28118 S 738.66 0.00 0.00 28300 S 1,164.23 0.00 0.00<br />

28119 S 738.66 0.00 0.00 28302 S 649.53 0.00 0.00<br />

28120 S 915.46 0.00 0.00 28304 S 1,164.23 0.00 0.00<br />

28122 S 680.54 0.00 0.00 28305 S 1,195.23 0.00 0.00<br />

28124 S 221.80 0.00 0.00 28306 S 738.66 0.00 0.00<br />

28126 S 680.54 0.00 0.00 28307 S 738.66 0.00 0.00<br />

28130 S 680.54 0.00 0.00 28308 S 649.53 0.00 0.00<br />

28140 S 680.54 0.00 0.00 28309 S 1,253.36 0.00 0.00<br />

28150 S 680.54 0.00 0.00 28310 S 680.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 680.54 0.00 0.00 28636 S 757.20 0.00 0.00<br />

28313 S 649.53 0.00 0.00 28645 S 757.20 0.00 0.00<br />

28315 S 738.66 0.00 0.00 28660 S 45.87 0.00 0.00<br />

28320 S 1,253.36 0.00 0.00 28665 S 473.42 0.00 0.00<br />

28322 S 1,253.36 0.00 0.00 28666 S 757.20 0.00 0.00<br />

28340 S 738.66 0.00 0.00 28675 S 757.20 0.00 0.00<br />

28341 S 738.66 0.00 0.00 28705 S 1,253.36 0.00 0.00<br />

28344 S 738.66 0.00 0.00 28715 S 2,041.40 0.00 0.00<br />

28345 S 738.66 0.00 0.00 28725 S 1,253.36 0.00 0.00<br />

28400 S 82.22 0.00 0.00 28730 S 1,253.36 0.00 0.00<br />

28405 S 448.63 0.00 0.00 28735 S 1,253.36 0.00 0.00<br />

28406 S 726.19 0.00 0.00 28737 S 1,295.49 0.00 0.00<br />

28415 S 1,501.55 0.00 0.00 28740 S 1,253.36 0.00 0.00<br />

28420 S 1,164.62 0.00 0.00 28750 S 1,253.36 0.00 0.00<br />

28430 S 64.07 0.00 0.00 28755 S 738.66 0.00 0.00<br />

28435 S 82.22 0.00 0.00 28760 S 1,253.36 0.00 0.00<br />

28436 S 726.19 0.00 0.00 28810 S 649.53 0.00 0.00<br />

28445 S 1,106.49 0.00 0.00 28820 S 649.53 0.00 0.00<br />

28446 S 1,896.39 0.00 0.00 28825 S 649.53 0.00 0.00<br />

28450 S 64.07 0.00 0.00 28890 S 171.64 0.00 0.00<br />

28455 S 64.07 0.00 0.00 29000 S 43.49 0.00 0.00<br />

28456 S 726.19 0.00 0.00 29010 S 97.46 0.00 0.00<br />

28465 S 1,106.49 0.00 0.00 29015 S 97.46 0.00 0.00<br />

28470 S 64.07 0.00 0.00 29020 S 43.49 0.00 0.00<br />

28475 S 64.07 0.00 0.00 29025 S 43.49 0.00 0.00<br />

28476 S 726.19 0.00 0.00 29035 S 97.46 0.00 0.00<br />

28485 S 1,164.62 0.00 0.00 29040 S 43.49 0.00 0.00<br />

28490 S 64.07 0.00 0.00 29044 S 97.46 0.00 0.00<br />

28495 S 64.07 0.00 0.00 29046 S 97.46 0.00 0.00<br />

28496 S 726.19 0.00 0.00 29049 S 39.41 0.00 0.00<br />

28505 S 757.20 0.00 0.00 29055 S 97.46 0.00 0.00<br />

28510 S 57.69 0.00 0.00 29058 S 43.49 0.00 0.00<br />

28515 S 64.07 0.00 0.00 29065 S 46.23 0.00 0.00<br />

28525 S 757.20 0.00 0.00 29075 S 44.43 0.00 0.00<br />

28530 S 55.54 0.00 0.00 29085 S 43.49 0.00 0.00<br />

28531 S 757.20 0.00 0.00 29086 S 37.27 0.00 0.00<br />

28540 S 64.07 0.00 0.00 29105 S 40.13 0.00 0.00<br />

28545 S 671.46 0.00 0.00 29125 S 34.75 0.00 0.00<br />

28546 S 726.19 0.00 0.00 29126 S 36.91 0.00 0.00<br />

28555 S 1,075.49 0.00 0.00 29130 S 15.77 0.00 0.00<br />

28570 S 83.13 0.00 0.00 29131 S 22.93 0.00 0.00<br />

28575 S 448.63 0.00 0.00 29200 S 22.21 0.00 0.00<br />

28576 S 757.20 0.00 0.00 29220 S 24.00 0.00 0.00<br />

28585 S 757.20 0.00 0.00 29240 S 25.09 0.00 0.00<br />

28600 S 64.07 0.00 0.00 29260 S 24.00 0.00 0.00<br />

28605 S 82.22 0.00 0.00 29280 S 24.37 0.00 0.00<br />

28606 S 726.19 0.00 0.00 29305 S 97.46 0.00 0.00<br />

28615 S 1,106.49 0.00 0.00 29325 S 97.46 0.00 0.00<br />

28630 S 64.07 0.00 0.00 29345 S 60.55 0.00 0.00<br />

28635 S 473.42 0.00 0.00 29355 S 59.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 73.82 0.00 0.00 29847 S 1,233.80 0.00 0.00<br />

29365 S 57.33 0.00 0.00 29848 S 1,238.35 0.00 0.00<br />

29405 S 42.64 0.00 0.00 29850 S 894.92 0.00 0.00<br />

29425 S 43.36 0.00 0.00 29851 S 1,291.93 0.00 0.00<br />

29435 S 54.82 0.00 0.00 29855 S 1,291.93 0.00 0.00<br />

29440 S 23.29 0.00 0.00 29856 S 1,291.93 0.00 0.00<br />

29445 S 57.69 0.00 0.00 29860 S 1,291.93 0.00 0.00<br />

29450 S 43.49 0.00 0.00 29861 S 1,291.93 0.00 0.00<br />

29505 S 38.70 0.00 0.00 29862 S 1,635.35 0.00 0.00<br />

29515 S 32.96 0.00 0.00 29863 S 1,291.93 0.00 0.00<br />

29520 S 23.65 0.00 0.00 29866 S 1,973.53 0.00 0.00<br />

29530 S 24.00 0.00 0.00 29870 S 836.81 0.00 0.00<br />

29540 S 17.91 0.00 0.00 29871 S 836.81 0.00 0.00<br />

29550 S 18.27 0.00 0.00 29873 S 836.81 0.00 0.00<br />

29580 S 24.73 0.00 0.00 29874 S 836.81 0.00 0.00<br />

29590 S 20.07 0.00 0.00 29875 S 894.92 0.00 0.00<br />

29700 S 33.32 0.00 0.00 29876 S 894.92 0.00 0.00<br />

29705 S 28.30 0.00 0.00 29877 S 894.92 0.00 0.00<br />

29710 S 49.80 0.00 0.00 29879 S 836.81 0.00 0.00<br />

29715 S 43.49 0.00 0.00 29880 S 894.92 0.00 0.00<br />

29720 S 41.57 0.00 0.00 29881 S 894.92 0.00 0.00<br />

29730 S 27.23 0.00 0.00 29882 S 836.81 0.00 0.00<br />

29740 S 37.27 0.00 0.00 29883 S 836.81 0.00 0.00<br />

29750 S 39.05 0.00 0.00 29884 S 836.81 0.00 0.00<br />

29800 S 836.81 0.00 0.00 29885 S 1,233.80 0.00 0.00<br />

29804 S 836.81 0.00 0.00 29886 S 836.81 0.00 0.00<br />

29805 S 836.81 0.00 0.00 29887 S 836.81 0.00 0.00<br />

29806 S 1,233.80 0.00 0.00 29888 S 1,233.80 0.00 0.00<br />

29807 S 1,233.80 0.00 0.00 29889 S 1,233.80 0.00 0.00<br />

29819 S 1,233.80 0.00 0.00 29891 S 1,233.80 0.00 0.00<br />

29820 S 1,233.80 0.00 0.00 29892 S 1,233.80 0.00 0.00<br />

29821 S 1,233.80 0.00 0.00 29893 S 1,041.66 0.00 0.00<br />

29822 S 836.81 0.00 0.00 29894 S 836.81 0.00 0.00<br />

29823 S 1,233.80 0.00 0.00 29895 S 836.81 0.00 0.00<br />

29824 S 937.07 0.00 0.00 29897 S 836.81 0.00 0.00<br />

29825 S 1,233.80 0.00 0.00 29898 S 836.81 0.00 0.00<br />

29826 S 1,233.80 0.00 0.00 29899 S 1,233.80 0.00 0.00<br />

29827 S 1,334.06 0.00 0.00 29900 S 836.81 0.00 0.00<br />

29828 S 1,973.53 0.00 0.00 29901 S 836.81 0.00 0.00<br />

29830 S 836.81 0.00 0.00 29902 S 836.81 0.00 0.00<br />

29834 S 836.81 0.00 0.00 29904 S 1,179.53 0.00 0.00<br />

29835 S 836.81 0.00 0.00 29905 S 1,179.53 0.00 0.00<br />

29836 S 836.81 0.00 0.00 29906 S 1,179.53 0.00 0.00<br />

29837 S 836.81 0.00 0.00 29907 S 1,973.53 0.00 0.00<br />

29838 S 836.81 0.00 0.00 30000 S 132.61 0.00 0.00<br />

29840 S 836.81 0.00 0.00 30020 S 132.61 0.00 0.00<br />

29843 S 836.81 0.00 0.00 30100 S 86.00 0.00 0.00<br />

29844 S 836.81 0.00 0.00 30110 S 132.94 0.00 0.00<br />

29845 S 836.81 0.00 0.00 30115 S 561.70 0.00 0.00<br />

29846 S 836.81 0.00 0.00 30117 S 592.70 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 743.39 0.00 0.00 31080 S 1,144.73 0.00 0.00<br />

30120 S 506.96 0.00 0.00 31081 S 1,144.73 0.00 0.00<br />

30124 S 302.07 0.00 0.00 31084 S 1,144.73 0.00 0.00<br />

30125 S 1,055.60 0.00 0.00 31085 S 1,144.73 0.00 0.00<br />

30130 S 592.70 0.00 0.00 31086 S 1,144.73 0.00 0.00<br />

30140 S 712.38 0.00 0.00 31087 S 1,144.73 0.00 0.00<br />

30150 S 1,086.61 0.00 0.00 31090 S 1,186.87 0.00 0.00<br />

30160 S 1,144.73 0.00 0.00 31200 S 1,055.60 0.00 0.00<br />

30200 S 67.73 0.00 0.00 31201 S 1,186.87 0.00 0.00<br />

30210 S 86.00 0.00 0.00 31205 S 1,086.61 0.00 0.00<br />

30220 S 375.86 0.00 0.00 31231 S 72.50 0.00 0.00<br />

30300 S 25.91 0.00 0.00 31233 S 78.09 0.00 0.00<br />

30310 S 506.96 0.00 0.00 31235 S 530.54 0.00 0.00<br />

30320 S 561.70 0.00 0.00 31237 S 585.27 0.00 0.00<br />

30400 S 1,144.73 0.00 0.00 31238 S 530.54 0.00 0.00<br />

30410 S 1,186.87 0.00 0.00 31239 S 774.42 0.00 0.00<br />

30420 S 1,186.87 0.00 0.00 31240 S 585.27 0.00 0.00<br />

30430 S 743.39 0.00 0.00 31254 S 716.29 0.00 0.00<br />

30435 S 1,186.87 0.00 0.00 31255 S 816.56 0.00 0.00<br />

30450 S 1,321.53 0.00 0.00 31256 S 716.29 0.00 0.00<br />

30460 S 1,321.53 0.00 0.00 31267 S 716.29 0.00 0.00<br />

30462 S 1,488.15 0.00 0.00 31276 S 716.29 0.00 0.00<br />

30465 S 1,488.15 0.00 0.00 31287 S 716.29 0.00 0.00<br />

30520 S 801.51 0.00 0.00 31288 S 716.29 0.00 0.00<br />

30540 S 1,186.87 0.00 0.00 31300 S 843.65 0.00 0.00<br />

30545 S 1,186.87 0.00 0.00 31320 S 1,055.60 0.00 0.00<br />

30560 S 139.31 0.00 0.00 31400 S 1,055.60 0.00 0.00<br />

30580 S 1,144.73 0.00 0.00 31420 S 1,055.60 0.00 0.00<br />

30600 S 1,144.73 0.00 0.00 31500 S 96.97 0.00 0.00<br />

30620 S 1,321.53 0.00 0.00 31502 S 55.76 0.00 0.00<br />

30630 S 978.31 0.00 0.00 31505 S 32.94 0.00 0.00<br />

30801 S 312.34 0.00 0.00 31510 S 585.27 0.00 0.00<br />

30802 S 312.34 0.00 0.00 31511 S 78.09 0.00 0.00<br />

30901 S 44.55 0.00 0.00 31512 S 585.27 0.00 0.00<br />

30903 S 57.38 0.00 0.00 31513 S 78.09 0.00 0.00<br />

30905 S 57.38 0.00 0.00 31515 S 530.54 0.00 0.00<br />

30906 S 57.38 0.00 0.00 31520 S 72.50 0.00 0.00<br />

30915 S 764.63 0.00 0.00 31525 S 530.54 0.00 0.00<br />

30920 S 795.63 0.00 0.00 31526 S 685.30 0.00 0.00<br />

30930 S 650.82 0.00 0.00 31527 S 630.55 0.00 0.00<br />

31000 S 110.73 0.00 0.00 31528 S 585.27 0.00 0.00<br />

31002 S 302.07 0.00 0.00 31529 S 585.27 0.00 0.00<br />

31020 S 712.38 0.00 0.00 31530 S 685.30 0.00 0.00<br />

31030 S 1,086.61 0.00 0.00 31531 S 716.29 0.00 0.00<br />

31032 S 1,144.73 0.00 0.00 31535 S 685.30 0.00 0.00<br />

31040 S 992.71 0.00 0.00 31536 S 716.29 0.00 0.00<br />

31050 S 1,055.60 0.00 0.00 31540 S 716.29 0.00 0.00<br />

31051 S 1,144.73 0.00 0.00 31541 S 774.42 0.00 0.00<br />

31070 S 712.38 0.00 0.00 31545 S 774.42 0.00 0.00<br />

31075 S 1,144.73 0.00 0.00 31546 S 774.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 816.56 0.00 0.00 32405 S 353.35 0.00 0.00<br />

31561 S 816.56 0.00 0.00 32420 S 214.86 0.00 0.00<br />

31570 S 585.27 0.00 0.00 32421 S 214.86 0.00 0.00<br />

31571 S 685.30 0.00 0.00 32422 S 213.91 0.00 0.00<br />

31575 S 62.35 0.00 0.00 32550 S 1,197.66 0.00 0.00<br />

31576 S 685.30 0.00 0.00 32960 S 213.91 0.00 0.00<br />

31577 S 202.44 0.00 0.00 32998 S 1,864.70 0.00 0.00<br />

31578 S 685.30 0.00 0.00 33010 S 214.86 0.00 0.00<br />

31579 S 111.08 0.00 0.00 33011 S 214.86 0.00 0.00<br />

31580 S 1,186.87 0.00 0.00 33206 S 6,893.66 4,101.70 1,309.76<br />

31582 S 1,186.87 0.00 0.00 33207 S 6,893.66 4,101.70 1,309.76<br />

31588 S 1,186.87 0.00 0.00 33208 S 8,550.09 4,982.09 1,414.11<br />

31590 S 1,186.87 0.00 0.00 33210 S 2,024.35 0.00 0.00<br />

31595 S 1,055.60 0.00 0.00 33211 S 2,024.35 0.00 0.00<br />

31603 S 312.34 0.00 0.00 33212 S 5,413.98 3,084.11 754.25<br />

31605 S 302.07 0.00 0.00 33213 S 6,248.90 3,501.12 753.35<br />

31611 S 743.39 0.00 0.00 33214 S 8,550.09 4,982.09 1,414.11<br />

31612 S 657.65 0.00 0.00 33215 S 887.29 0.00 0.00<br />

31613 S 712.38 0.00 0.00 33216 S 2,024.35 0.00 0.00<br />

31614 S 1,055.60 0.00 0.00 33217 S 2,024.35 0.00 0.00<br />

31615 S 312.34 0.00 0.00 33218 S 887.29 0.00 0.00<br />

31622 S 365.80 0.00 0.00 33220 S 887.29 0.00 0.00<br />

31623 S 420.53 0.00 0.00 33222 S 536.33 0.00 0.00<br />

31624 S 420.53 0.00 0.00 33223 S 536.33 0.00 0.00<br />

31625 S 420.53 0.00 0.00 33224 S 8,070.49 4,831.78 1,593.08<br />

31628 S 420.53 0.00 0.00 33225 S 8,070.49 4,831.78 1,593.08<br />

31629 S 420.53 0.00 0.00 33226 S 887.29 0.00 0.00<br />

31630 S 720.62 0.00 0.00 33233 S 659.68 0.00 0.00<br />

31631 S 720.62 0.00 0.00 33234 S 887.29 0.00 0.00<br />

31632 S 408.99 0.00 0.00 33235 S 887.29 0.00 0.00<br />

31633 S 408.99 0.00 0.00 33240 S 20,117.67 10,753.71 1,389.77<br />

31635 S 420.53 0.00 0.00 33241 S 887.29 0.00 0.00<br />

31636 S 720.62 0.00 0.00 33249 S 26,848.56 14,381.20 1,913.84<br />

31637 S 365.80 0.00 0.00 33282 S 4,244.93 2,541.26 837.60<br />

31638 S 720.62 0.00 0.00 33284 S 331.09 0.00 0.00<br />

31640 S 720.62 0.00 0.00 34490 S 1,616.49 0.00 0.00<br />

31641 S 720.62 0.00 0.00 35188 S 1,113.41 0.00 0.00<br />

31643 S 420.53 0.00 0.00 35207 S 1,113.41 0.00 0.00<br />

31645 S 365.80 0.00 0.00 35473 S 1,939.17 0.00 0.00<br />

31646 S 365.80 0.00 0.00 35476 S 1,939.17 0.00 0.00<br />

31656 S 365.80 0.00 0.00 35492 S 3,619.27 0.00 0.00<br />

31717 S 202.44 0.00 0.00 35761 S 1,164.27 0.00 0.00<br />

31720 S 31.00 0.00 0.00 35875 S 1,456.83 0.00 0.00<br />

31730 S 202.44 0.00 0.00 35876 S 1,456.83 0.00 0.00<br />

31750 S 1,186.87 0.00 0.00 36002 S 92.98 0.00 0.00<br />

31755 S 1,055.60 0.00 0.00 36260 S 843.47 0.00 0.00<br />

31820 S 506.96 0.00 0.00 36261 S 659.68 0.00 0.00<br />

31825 S 712.38 0.00 0.00 36262 S 604.94 0.00 0.00<br />

31830 S 712.38 0.00 0.00 36420 S 8.76 0.00 0.00<br />

32400 S 353.35 0.00 0.00 36425 S 8.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 33.68 0.00 0.00 36800 S 908.00 0.00 0.00<br />

36440 S 134.51 0.00 0.00 36810 S 908.00 0.00 0.00<br />

36450 S 134.51 0.00 0.00 36815 S 908.00 0.00 0.00<br />

36455 S 134.51 0.00 0.00 36818 S 1,055.29 0.00 0.00<br />

36468 S 33.20 0.00 0.00 36819 S 1,055.29 0.00 0.00<br />

36469 S 33.20 0.00 0.00 36820 S 1,055.29 0.00 0.00<br />

36470 S 33.20 0.00 0.00 36821 S 1,055.29 0.00 0.00<br />

36471 S 33.20 0.00 0.00 36825 S 1,113.41 0.00 0.00<br />

36475 S 1,526.61 0.00 0.00 36830 S 1,113.41 0.00 0.00<br />

36476 S 1,197.18 0.00 0.00 36831 S 1,456.83 0.00 0.00<br />

36478 S 1,197.18 0.00 0.00 36832 S 1,113.41 0.00 0.00<br />

36479 S 1,197.18 0.00 0.00 36833 S 1,113.41 0.00 0.00<br />

36511 S 461.16 0.00 0.00 36834 S 1,055.29 0.00 0.00<br />

36512 S 461.16 0.00 0.00 36835 S 966.13 0.00 0.00<br />

36513 S 461.16 0.00 0.00 36860 S 110.88 0.00 0.00<br />

36514 S 461.16 0.00 0.00 36861 S 908.00 0.00 0.00<br />

36515 S 1,234.53 0.00 0.00 36870 S 1,587.95 0.00 0.00<br />

36516 S 1,234.53 0.00 0.00 37184 S 1,616.49 0.00 0.00<br />

36522 S 1,234.53 0.00 0.00 37185 S 1,616.49 0.00 0.00<br />

36555 S 383.16 0.00 0.00 37186 S 1,616.49 0.00 0.00<br />

36556 S 383.16 0.00 0.00 37187 S 1,616.49 0.00 0.00<br />

36557 S 715.59 0.00 0.00 37188 S 1,616.49 0.00 0.00<br />

36558 S 715.59 0.00 0.00 37200 S 1,192.88 0.00 0.00<br />

36560 S 843.47 0.00 0.00 37203 S 1,192.88 0.00 0.00<br />

36561 S 843.47 0.00 0.00 37500 S 1,125.07 0.00 0.00<br />

36563 S 843.47 0.00 0.00 37607 S 795.63 0.00 0.00<br />

36565 S 843.47 0.00 0.00 37609 S 534.77 0.00 0.00<br />

36566 S 843.47 0.00 0.00 37650 S 764.63 0.00 0.00<br />

36568 S 383.16 0.00 0.00 37700 S 764.63 0.00 0.00<br />

36569 S 383.16 0.00 0.00 37718 S 795.63 0.00 0.00<br />

36570 S 746.59 0.00 0.00 37722 S 1,125.07 0.00 0.00<br />

36571 S 746.59 0.00 0.00 37735 S 1,125.07 0.00 0.00<br />

36575 S 308.17 0.00 0.00 37760 S 795.63 0.00 0.00<br />

36576 S 437.90 0.00 0.00 37765 S 1,097.19 0.00 0.00<br />

36578 S 715.59 0.00 0.00 37766 S 1,097.19 0.00 0.00<br />

36580 S 383.16 0.00 0.00 37780 S 795.63 0.00 0.00<br />

36581 S 715.59 0.00 0.00 37785 S 795.63 0.00 0.00<br />

36582 S 843.47 0.00 0.00 37790 S 960.09 0.00 0.00<br />

36583 S 843.47 0.00 0.00 38205 S 461.16 0.00 0.00<br />

36584 S 383.16 0.00 0.00 38206 S 461.16 0.00 0.00<br />

36585 S 746.59 0.00 0.00 38220 S 105.71 0.00 0.00<br />

36589 S 253.44 0.00 0.00 38221 S 110.73 0.00 0.00<br />

36590 S 383.16 0.00 0.00 38230 S 1,234.53 0.00 0.00<br />

36593 S 25.44 0.00 0.00 38241 S 1,234.53 0.00 0.00<br />

36595 S 999.10 0.00 0.00 38242 S 461.16 0.00 0.00<br />

36596 S 443.72 0.00 0.00 38300 S 413.83 0.00 0.00<br />

36597 S 443.72 0.00 0.00 38305 S 604.75 0.00 0.00<br />

36598 S 82.05 0.00 0.00 38308 S 691.01 0.00 0.00<br />

36640 S 757.73 0.00 0.00 38500 S 691.01 0.00 0.00<br />

36680 S 57.43 0.00 0.00 38505 S 264.38 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 691.01 0.00 0.00 41005 S 139.31 0.00 0.00<br />

38520 S 691.01 0.00 0.00 41006 S 657.65 0.00 0.00<br />

38525 S 691.01 0.00 0.00 41007 S 506.96 0.00 0.00<br />

38530 S 691.01 0.00 0.00 41008 S 506.96 0.00 0.00<br />

38542 S 1,162.52 0.00 0.00 41009 S 139.31 0.00 0.00<br />

38550 S 722.02 0.00 0.00 41010 S 312.34 0.00 0.00<br />

38555 S 780.14 0.00 0.00 41015 S 139.31 0.00 0.00<br />

38570 S 1,577.37 0.00 0.00 41016 S 312.34 0.00 0.00<br />

38571 S 2,050.54 0.00 0.00 41017 S 312.34 0.00 0.00<br />

38572 S 1,577.37 0.00 0.00 41018 S 312.34 0.00 0.00<br />

38700 S 949.95 0.00 0.00 41019 S 992.71 0.00 0.00<br />

38740 S 1,162.52 0.00 0.00 41100 S 93.52 0.00 0.00<br />

38745 S 1,251.65 0.00 0.00 41105 S 92.45 0.00 0.00<br />

38760 S 691.01 0.00 0.00 41108 S 85.64 0.00 0.00<br />

40490 S 70.59 0.00 0.00 41110 S 123.98 0.00 0.00<br />

40500 S 561.70 0.00 0.00 41112 S 561.70 0.00 0.00<br />

40510 S 712.38 0.00 0.00 41113 S 561.70 0.00 0.00<br />

40520 S 561.70 0.00 0.00 41114 S 712.38 0.00 0.00<br />

40525 S 712.38 0.00 0.00 41115 S 144.41 0.00 0.00<br />

40527 S 712.38 0.00 0.00 41116 S 506.96 0.00 0.00<br />

40530 S 712.38 0.00 0.00 41120 S 843.65 0.00 0.00<br />

40650 S 375.86 0.00 0.00 41250 S 95.28 0.00 0.00<br />

40652 S 375.86 0.00 0.00 41251 S 139.31 0.00 0.00<br />

40654 S 375.86 0.00 0.00 41252 S 367.07 0.00 0.00<br />

40700 S 1,321.53 0.00 0.00 41500 S 657.65 0.00 0.00<br />

40701 S 1,321.53 0.00 0.00 41510 S 506.96 0.00 0.00<br />

40702 S 1,679.14 0.00 0.00 41520 S 367.07 0.00 0.00<br />

40720 S 1,321.53 0.00 0.00 41530 S 691.33 0.00 0.00<br />

40761 S 1,086.61 0.00 0.00 41800 S 71.17 0.00 0.00<br />

40800 S 56.65 0.00 0.00 41805 S 154.08 0.00 0.00<br />

40801 S 367.07 0.00 0.00 41806 S 189.91 0.00 0.00<br />

40804 S 25.91 0.00 0.00 41820 S 302.07 0.00 0.00<br />

40805 S 175.22 0.00 0.00 41821 S 302.07 0.00 0.00<br />

40806 S 80.62 0.00 0.00 41822 S 157.30 0.00 0.00<br />

40808 S 119.68 0.00 0.00 41823 S 229.33 0.00 0.00<br />

40810 S 123.98 0.00 0.00 41825 S 126.12 0.00 0.00<br />

40812 S 155.51 0.00 0.00 41826 S 158.74 0.00 0.00<br />

40814 S 561.70 0.00 0.00 41827 S 712.38 0.00 0.00<br />

40816 S 712.38 0.00 0.00 41828 S 143.33 0.00 0.00<br />

40818 S 139.31 0.00 0.00 41830 S 203.53 0.00 0.00<br />

40819 S 312.34 0.00 0.00 41850 S 691.33 0.00 0.00<br />

40820 S 178.80 0.00 0.00 41870 S 992.71 0.00 0.00<br />

40830 S 132.61 0.00 0.00 41872 S 203.53 0.00 0.00<br />

40831 S 312.34 0.00 0.00 41874 S 196.36 0.00 0.00<br />

40840 S 712.38 0.00 0.00 42000 S 139.31 0.00 0.00<br />

40842 S 743.39 0.00 0.00 42100 S 79.55 0.00 0.00<br />

40843 S 743.39 0.00 0.00 42104 S 118.25 0.00 0.00<br />

40844 S 1,186.87 0.00 0.00 42106 S 148.35 0.00 0.00<br />

40845 S 1,186.87 0.00 0.00 42107 S 712.38 0.00 0.00<br />

41000 S 88.87 0.00 0.00 42120 S 1,144.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 367.07 0.00 0.00 42809 S 25.91 0.00 0.00<br />

42145 S 843.65 0.00 0.00 42810 S 743.39 0.00 0.00<br />

42160 S 140.46 0.00 0.00 42815 S 1,186.87 0.00 0.00<br />

42180 S 139.31 0.00 0.00 42820 S 743.39 0.00 0.00<br />

42182 S 1,055.60 0.00 0.00 42821 S 843.65 0.00 0.00<br />

42200 S 1,186.87 0.00 0.00 42825 S 801.51 0.00 0.00<br />

42205 S 1,186.87 0.00 0.00 42826 S 801.51 0.00 0.00<br />

42210 S 1,186.87 0.00 0.00 42830 S 801.51 0.00 0.00<br />

42215 S 1,321.53 0.00 0.00 42831 S 801.51 0.00 0.00<br />

42220 S 1,186.87 0.00 0.00 42835 S 801.51 0.00 0.00<br />

42226 S 1,186.87 0.00 0.00 42836 S 801.51 0.00 0.00<br />

42235 S 692.97 0.00 0.00 42860 S 743.39 0.00 0.00<br />

42260 S 801.51 0.00 0.00 42870 S 743.39 0.00 0.00<br />

42280 S 77.39 0.00 0.00 42890 S 1,321.53 0.00 0.00<br />

42281 S 691.33 0.00 0.00 42892 S 1,321.53 0.00 0.00<br />

42300 S 506.96 0.00 0.00 42900 S 312.34 0.00 0.00<br />

42305 S 561.70 0.00 0.00 42950 S 712.38 0.00 0.00<br />

42310 S 139.31 0.00 0.00 42955 S 712.38 0.00 0.00<br />

42320 S 139.31 0.00 0.00 42960 S 57.38 0.00 0.00<br />

42330 S 119.68 0.00 0.00 42962 S 1,055.60 0.00 0.00<br />

42335 S 198.51 0.00 0.00 42970 S 44.55 0.00 0.00<br />

42340 S 561.70 0.00 0.00 42972 S 592.70 0.00 0.00<br />

42400 S 67.37 0.00 0.00 43030 S 691.33 0.00 0.00<br />

42405 S 561.70 0.00 0.00 43200 S 334.78 0.00 0.00<br />

42408 S 592.70 0.00 0.00 43201 S 334.78 0.00 0.00<br />

42409 S 592.70 0.00 0.00 43202 S 334.78 0.00 0.00<br />

42410 S 1,086.61 0.00 0.00 43204 S 334.78 0.00 0.00<br />

42415 S 1,321.53 0.00 0.00 43205 S 334.78 0.00 0.00<br />

42420 S 1,321.53 0.00 0.00 43215 S 334.78 0.00 0.00<br />

42425 S 1,321.53 0.00 0.00 43216 S 334.78 0.00 0.00<br />

42440 S 1,086.61 0.00 0.00 43217 S 334.78 0.00 0.00<br />

42450 S 712.38 0.00 0.00 43219 S 676.59 0.00 0.00<br />

42500 S 743.39 0.00 0.00 43220 S 334.78 0.00 0.00<br />

42505 S 1,144.73 0.00 0.00 43226 S 334.78 0.00 0.00<br />

42507 S 1,086.61 0.00 0.00 43227 S 389.52 0.00 0.00<br />

42508 S 1,144.73 0.00 0.00 43228 S 724.87 0.00 0.00<br />

42509 S 1,144.73 0.00 0.00 43231 S 389.52 0.00 0.00<br />

42510 S 1,144.73 0.00 0.00 43232 S 389.52 0.00 0.00<br />

42600 S 506.96 0.00 0.00 43234 S 334.78 0.00 0.00<br />

42650 S 44.07 0.00 0.00 43235 S 334.78 0.00 0.00<br />

42660 S 51.60 0.00 0.00 43236 S 389.52 0.00 0.00<br />

42665 S 978.31 0.00 0.00 43237 S 389.52 0.00 0.00<br />

42700 S 139.31 0.00 0.00 43238 S 389.52 0.00 0.00<br />

42720 S 506.96 0.00 0.00 43239 S 389.52 0.00 0.00<br />

42725 S 1,055.60 0.00 0.00 43240 S 389.52 0.00 0.00<br />

42800 S 85.28 0.00 0.00 43241 S 389.52 0.00 0.00<br />

42802 S 506.96 0.00 0.00 43242 S 389.52 0.00 0.00<br />

42804 S 506.96 0.00 0.00 43243 S 389.52 0.00 0.00<br />

42806 S 712.38 0.00 0.00 43244 S 389.52 0.00 0.00<br />

42808 S 561.70 0.00 0.00 43245 S 389.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 389.52 0.00 0.00 44378 S 407.96 0.00 0.00<br />

43247 S 389.52 0.00 0.00 44379 S 1,163.89 0.00 0.00<br />

43248 S 389.52 0.00 0.00 44380 S 353.22 0.00 0.00<br />

43249 S 389.52 0.00 0.00 44382 S 353.22 0.00 0.00<br />

43250 S 389.52 0.00 0.00 44383 S 1,163.89 0.00 0.00<br />

43251 S 389.52 0.00 0.00 44385 S 341.52 0.00 0.00<br />

43255 S 389.52 0.00 0.00 44386 S 341.52 0.00 0.00<br />

43256 S 762.33 0.00 0.00 44388 S 341.52 0.00 0.00<br />

43257 S 755.87 0.00 0.00 44389 S 341.52 0.00 0.00<br />

43258 S 420.52 0.00 0.00 44390 S 341.52 0.00 0.00<br />

43259 S 420.52 0.00 0.00 44391 S 341.52 0.00 0.00<br />

43260 S 655.76 0.00 0.00 44392 S 341.52 0.00 0.00<br />

43261 S 655.76 0.00 0.00 44393 S 341.52 0.00 0.00<br />

43262 S 655.76 0.00 0.00 44394 S 341.52 0.00 0.00<br />

43263 S 655.76 0.00 0.00 44397 S 676.59 0.00 0.00<br />

43264 S 655.76 0.00 0.00 44500 S 184.29 0.00 0.00<br />

43265 S 655.76 0.00 0.00 45000 S 396.05 0.00 0.00<br />

43267 S 655.76 0.00 0.00 45005 S 460.92 0.00 0.00<br />

43268 S 731.34 0.00 0.00 45020 S 460.92 0.00 0.00<br />

43269 S 731.34 0.00 0.00 45100 S 626.21 0.00 0.00<br />

43271 S 655.76 0.00 0.00 45108 S 680.94 0.00 0.00<br />

43272 S 655.76 0.00 0.00 45150 S 680.94 0.00 0.00<br />

43273 S 879.46 0.00 0.00 45160 S 680.94 0.00 0.00<br />

43450 S 292.78 0.00 0.00 45170 S 680.94 0.00 0.00<br />

43453 S 292.78 0.00 0.00 45190 S 1,113.49 0.00 0.00<br />

43456 S 293.95 0.00 0.00 45300 S 65.93 0.00 0.00<br />

43458 S 335.95 0.00 0.00 45303 S 366.21 0.00 0.00<br />

43600 S 334.78 0.00 0.00 45305 S 344.41 0.00 0.00<br />

43653 S 1,577.37 0.00 0.00 45307 S 636.14 0.00 0.00<br />

43760 S 162.37 0.00 0.00 45308 S 344.41 0.00 0.00<br />

43761 S 334.78 0.00 0.00 45309 S 344.41 0.00 0.00<br />

43870 S 334.78 0.00 0.00 45315 S 344.41 0.00 0.00<br />

43886 S 844.73 0.00 0.00 45317 S 344.41 0.00 0.00<br />

43887 S 177.67 0.00 0.00 45320 S 636.14 0.00 0.00<br />

43888 S 844.73 0.00 0.00 45321 S 636.14 0.00 0.00<br />

44100 S 334.78 0.00 0.00 45327 S 676.59 0.00 0.00<br />

44312 S 583.66 0.00 0.00 45330 S 87.07 0.00 0.00<br />

44340 S 669.40 0.00 0.00 45331 S 257.49 0.00 0.00<br />

44360 S 407.96 0.00 0.00 45332 S 257.49 0.00 0.00<br />

44361 S 407.96 0.00 0.00 45333 S 344.41 0.00 0.00<br />

44363 S 407.96 0.00 0.00 45334 S 344.41 0.00 0.00<br />

44364 S 407.96 0.00 0.00 45335 S 257.49 0.00 0.00<br />

44365 S 407.96 0.00 0.00 45337 S 257.49 0.00 0.00<br />

44366 S 407.96 0.00 0.00 45338 S 344.41 0.00 0.00<br />

44369 S 407.96 0.00 0.00 45339 S 344.41 0.00 0.00<br />

44370 S 1,163.89 0.00 0.00 45340 S 344.41 0.00 0.00<br />

44372 S 407.96 0.00 0.00 45341 S 344.41 0.00 0.00<br />

44373 S 407.96 0.00 0.00 45342 S 344.41 0.00 0.00<br />

44376 S 407.96 0.00 0.00 45345 S 676.59 0.00 0.00<br />

44377 S 407.96 0.00 0.00 45355 S 341.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 396.26 0.00 0.00 46505 S 489.78 0.00 0.00<br />

45379 S 396.26 0.00 0.00 46600 S 25.91 0.00 0.00<br />

45380 S 396.26 0.00 0.00 46604 S 366.21 0.00 0.00<br />

45381 S 396.26 0.00 0.00 46606 S 137.60 0.00 0.00<br />

45382 S 396.26 0.00 0.00 46608 S 344.41 0.00 0.00<br />

45383 S 396.26 0.00 0.00 46610 S 636.14 0.00 0.00<br />

45384 S 396.26 0.00 0.00 46611 S 344.41 0.00 0.00<br />

45385 S 396.26 0.00 0.00 46612 S 636.14 0.00 0.00<br />

45386 S 396.26 0.00 0.00 46614 S 72.38 0.00 0.00<br />

45387 S 676.59 0.00 0.00 46615 S 690.87 0.00 0.00<br />

45391 S 396.26 0.00 0.00 46700 S 711.95 0.00 0.00<br />

45392 S 396.26 0.00 0.00 46706 S 783.64 0.00 0.00<br />

45500 S 680.94 0.00 0.00 46750 S 869.38 0.00 0.00<br />

45505 S 838.38 0.00 0.00 46753 S 711.95 0.00 0.00<br />

45520 S 33.20 0.00 0.00 46754 S 680.94 0.00 0.00<br />

45560 S 838.38 0.00 0.00 46760 S 838.38 0.00 0.00<br />

45900 S 268.49 0.00 0.00 46761 S 869.38 0.00 0.00<br />

45905 S 626.21 0.00 0.00 46762 S 1,104.31 0.00 0.00<br />

45910 S 626.21 0.00 0.00 46900 S 109.42 0.00 0.00<br />

45915 S 396.05 0.00 0.00 46910 S 130.78 0.00 0.00<br />

45990 S 616.07 0.00 0.00 46916 S 60.83 0.00 0.00<br />

46020 S 711.95 0.00 0.00 46917 S 567.47 0.00 0.00<br />

46030 S 268.49 0.00 0.00 46922 S 567.47 0.00 0.00<br />

46040 S 711.95 0.00 0.00 46924 S 567.47 0.00 0.00<br />

46045 S 680.94 0.00 0.00 46930 S 126.85 0.00 0.00<br />

46050 S 396.05 0.00 0.00 46937 S 680.94 0.00 0.00<br />

46060 S 680.94 0.00 0.00 46938 S 838.38 0.00 0.00<br />

46070 S 489.78 0.00 0.00 46940 S 93.88 0.00 0.00<br />

46080 S 711.95 0.00 0.00 46942 S 91.37 0.00 0.00<br />

46083 S 74.97 0.00 0.00 46945 S 155.51 0.00 0.00<br />

46200 S 680.94 0.00 0.00 46946 S 406.18 0.00 0.00<br />

46210 S 680.94 0.00 0.00 46947 S 1,104.31 0.00 0.00<br />

46211 S 680.94 0.00 0.00 47000 S 353.35 0.00 0.00<br />

46220 S 626.21 0.00 0.00 47382 S 1,864.70 0.00 0.00<br />

46221 S 123.26 0.00 0.00 47510 S 825.80 0.00 0.00<br />

46230 S 626.21 0.00 0.00 47511 S 1,213.22 0.00 0.00<br />

46250 S 711.95 0.00 0.00 47525 S 474.07 0.00 0.00<br />

46255 S 711.95 0.00 0.00 47530 S 474.07 0.00 0.00<br />

46257 S 711.95 0.00 0.00 47552 S 825.80 0.00 0.00<br />

46258 S 711.95 0.00 0.00 47553 S 856.79 0.00 0.00<br />

46260 S 711.95 0.00 0.00 47554 S 856.79 0.00 0.00<br />

46261 S 770.07 0.00 0.00 47555 S 856.79 0.00 0.00<br />

46262 S 770.07 0.00 0.00 47556 S 1,213.22 0.00 0.00<br />

46270 S 711.95 0.00 0.00 47560 S 1,006.70 0.00 0.00<br />

46275 S 711.95 0.00 0.00 47561 S 1,006.70 0.00 0.00<br />

46280 S 770.07 0.00 0.00 47562 S 1,857.58 0.00 0.00<br />

46285 S 626.21 0.00 0.00 47563 S 1,857.58 0.00 0.00<br />

46288 S 770.07 0.00 0.00 47564 S 1,857.58 0.00 0.00<br />

46320 S 83.49 0.00 0.00 47630 S 856.79 0.00 0.00<br />

46500 S 115.02 0.00 0.00 48102 S 353.35 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 214.86 0.00 0.00 49590 S 881.88 0.00 0.00<br />

49081 S 214.86 0.00 0.00 49600 S 940.00 0.00 0.00<br />

49180 S 353.35 0.00 0.00 49650 S 1,233.95 0.00 0.00<br />

49250 S 774.55 0.00 0.00 49651 S 1,410.75 0.00 0.00<br />

49320 S 1,006.70 0.00 0.00 49652 S 1,519.34 0.00 0.00<br />

49321 S 1,064.83 0.00 0.00 49653 S 1,519.34 0.00 0.00<br />

49322 S 1,064.83 0.00 0.00 49654 S 1,519.34 0.00 0.00<br />

49324 S 1,519.34 0.00 0.00 49655 S 1,519.34 0.00 0.00<br />

49325 S 1,519.34 0.00 0.00 49656 S 1,519.34 0.00 0.00<br />

49326 S 1,519.34 0.00 0.00 49657 S 1,519.34 0.00 0.00<br />

49402 S 685.43 0.00 0.00 50200 S 353.35 0.00 0.00<br />

49419 S 822.26 0.00 0.00 50382 S 1,026.05 0.00 0.00<br />

49420 S 760.13 0.00 0.00 50384 S 753.61 0.00 0.00<br />

49421 S 760.13 0.00 0.00 50385 S 753.61 0.00 0.00<br />

49422 S 604.94 0.00 0.00 50386 S 289.14 0.00 0.00<br />

49423 S 625.54 0.00 0.00 50387 S 625.54 0.00 0.00<br />

49426 S 685.43 0.00 0.00 50389 S 289.14 0.00 0.00<br />

49429 S 887.29 0.00 0.00 50390 S 353.35 0.00 0.00<br />

49440 S 346.97 0.00 0.00 50391 S 41.85 0.00 0.00<br />

49441 S 346.97 0.00 0.00 50392 S 538.10 0.00 0.00<br />

49446 S 346.97 0.00 0.00 50393 S 674.32 0.00 0.00<br />

49450 S 184.29 0.00 0.00 50395 S 538.10 0.00 0.00<br />

49451 S 184.29 0.00 0.00 50396 S 101.18 0.00 0.00<br />

49452 S 184.29 0.00 0.00 50398 S 474.07 0.00 0.00<br />

49460 S 184.29 0.00 0.00 50551 S 305.87 0.00 0.00<br />

49495 S 940.00 0.00 0.00 50553 S 674.32 0.00 0.00<br />

49496 S 940.00 0.00 0.00 50555 S 305.87 0.00 0.00<br />

49500 S 940.00 0.00 0.00 50557 S 674.32 0.00 0.00<br />

49501 S 1,283.42 0.00 0.00 50561 S 674.32 0.00 0.00<br />

49505 S 940.00 0.00 0.00 50562 S 289.14 0.00 0.00<br />

49507 S 1,283.42 0.00 0.00 50570 S 289.14 0.00 0.00<br />

49520 S 1,116.80 0.00 0.00 50572 S 289.14 0.00 0.00<br />

49521 S 1,283.42 0.00 0.00 50574 S 289.14 0.00 0.00<br />

49525 S 940.00 0.00 0.00 50575 S 1,438.23 0.00 0.00<br />

49540 S 850.87 0.00 0.00 50576 S 753.61 0.00 0.00<br />

49550 S 982.14 0.00 0.00 50580 S 753.61 0.00 0.00<br />

49553 S 1,283.42 0.00 0.00 50590 S 1,680.19 0.00 0.00<br />

49555 S 982.14 0.00 0.00 50592 S 1,864.70 0.00 0.00<br />

49557 S 1,283.42 0.00 0.00 50686 S 41.85 0.00 0.00<br />

49560 S 940.00 0.00 0.00 50688 S 474.07 0.00 0.00<br />

49561 S 1,283.42 0.00 0.00 50947 S 1,577.37 0.00 0.00<br />

49565 S 940.00 0.00 0.00 50948 S 1,577.37 0.00 0.00<br />

49566 S 1,283.42 0.00 0.00 50951 S 305.87 0.00 0.00<br />

49568 S 1,116.80 0.00 0.00 50953 S 305.87 0.00 0.00<br />

49570 S 940.00 0.00 0.00 50955 S 674.32 0.00 0.00<br />

49572 S 1,283.42 0.00 0.00 50957 S 674.32 0.00 0.00<br />

49580 S 940.00 0.00 0.00 50961 S 674.32 0.00 0.00<br />

49582 S 1,283.42 0.00 0.00 50970 S 305.87 0.00 0.00<br />

49585 S 940.00 0.00 0.00 50972 S 305.87 0.00 0.00<br />

49587 S 1,283.42 0.00 0.00 50974 S 538.10 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 538.10 0.00 0.00 52275 S 729.06 0.00 0.00<br />

50980 S 674.32 0.00 0.00 52276 S 760.06 0.00 0.00<br />

51020 S 818.19 0.00 0.00 52277 S 729.06 0.00 0.00<br />

51030 S 818.19 0.00 0.00 52281 S 592.83 0.00 0.00<br />

51040 S 818.19 0.00 0.00 52282 S 1,367.70 0.00 0.00<br />

51045 S 337.95 0.00 0.00 52283 S 729.06 0.00 0.00<br />

51050 S 818.19 0.00 0.00 52285 S 592.83 0.00 0.00<br />

51065 S 818.19 0.00 0.00 52290 S 592.83 0.00 0.00<br />

51080 S 550.01 0.00 0.00 52300 S 729.06 0.00 0.00<br />

51100 S 31.89 0.00 0.00 52301 S 760.06 0.00 0.00<br />

51101 S 41.85 0.00 0.00 52305 S 729.06 0.00 0.00<br />

51102 S 562.99 0.00 0.00 52310 S 570.18 0.00 0.00<br />

51500 S 940.00 0.00 0.00 52315 S 729.06 0.00 0.00<br />

51520 S 818.19 0.00 0.00 52317 S 674.32 0.00 0.00<br />

51700 S 54.46 0.00 0.00 52318 S 729.06 0.00 0.00<br />

51701 S 25.91 0.00 0.00 52320 S 860.32 0.00 0.00<br />

51702 S 25.91 0.00 0.00 52325 S 818.19 0.00 0.00<br />

51703 S 41.85 0.00 0.00 52327 S 935.15 0.00 0.00<br />

51705 S 74.97 0.00 0.00 52330 S 729.06 0.00 0.00<br />

51710 S 474.07 0.00 0.00 52332 S 729.06 0.00 0.00<br />

51715 S 860.77 0.00 0.00 52334 S 760.06 0.00 0.00<br />

51720 S 60.20 0.00 0.00 52341 S 760.06 0.00 0.00<br />

51725 TC S 115.64 0.00 0.00 52342 S 760.06 0.00 0.00<br />

51726 TC S 159.29 0.00 0.00 52343 S 760.06 0.00 0.00<br />

51736 TC S 21.86 0.00 0.00 52344 S 760.06 0.00 0.00<br />

51741 TC S 25.44 0.00 0.00 52345 S 760.06 0.00 0.00<br />

51772 TC S 101.18 0.00 0.00 52346 S 760.06 0.00 0.00<br />

51784 TC S 41.85 0.00 0.00 52351 S 760.06 0.00 0.00<br />

51785 TC S 69.90 0.00 0.00 52352 S 818.19 0.00 0.00<br />

51792 TC S 41.85 0.00 0.00 52353 S 1,024.28 0.00 0.00<br />

51795 TC S 74.97 0.00 0.00 52354 S 818.19 0.00 0.00<br />

51797 TC S 74.97 0.00 0.00 52355 S 818.19 0.00 0.00<br />

51798 S 18.63 0.00 0.00 52400 S 760.06 0.00 0.00<br />

51880 S 674.32 0.00 0.00 52402 S 760.06 0.00 0.00<br />

51992 S 1,276.09 0.00 0.00 52450 S 760.06 0.00 0.00<br />

52000 S 305.87 0.00 0.00 52500 S 760.06 0.00 0.00<br />

52001 S 570.18 0.00 0.00 52601 S 1,024.28 0.00 0.00<br />

52005 S 592.83 0.00 0.00 52630 S 935.15 0.00 0.00<br />

52007 S 729.06 0.00 0.00 52640 S 729.06 0.00 0.00<br />

52010 S 337.95 0.00 0.00 52647 S 1,567.05 0.00 0.00<br />

52204 S 592.83 0.00 0.00 52648 S 1,567.05 0.00 0.00<br />

52214 S 729.06 0.00 0.00 52700 S 729.06 0.00 0.00<br />

52224 S 729.06 0.00 0.00 53000 S 559.55 0.00 0.00<br />

52234 S 729.06 0.00 0.00 53010 S 559.55 0.00 0.00<br />

52235 S 760.06 0.00 0.00 53020 S 559.55 0.00 0.00<br />

52240 S 760.06 0.00 0.00 53025 S 796.50 0.00 0.00<br />

52250 S 818.19 0.00 0.00 53040 S 614.29 0.00 0.00<br />

52260 S 592.83 0.00 0.00 53060 S 72.74 0.00 0.00<br />

52265 S 289.14 0.00 0.00 53080 S 645.29 0.00 0.00<br />

52270 S 592.83 0.00 0.00 53085 S 796.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 559.55 0.00 0.00 54060 S 567.47 0.00 0.00<br />

53210 S 961.03 0.00 0.00 54065 S 567.47 0.00 0.00<br />

53215 S 745.55 0.00 0.00 54100 S 480.04 0.00 0.00<br />

53220 S 829.76 0.00 0.00 54105 S 599.25 0.00 0.00<br />

53230 S 829.76 0.00 0.00 54110 S 929.09 0.00 0.00<br />

53235 S 645.29 0.00 0.00 54111 S 929.09 0.00 0.00<br />

53240 S 829.76 0.00 0.00 54112 S 929.09 0.00 0.00<br />

53250 S 614.29 0.00 0.00 54115 S 550.01 0.00 0.00<br />

53260 S 614.29 0.00 0.00 54120 S 929.09 0.00 0.00<br />

53265 S 614.29 0.00 0.00 54150 S 619.19 0.00 0.00<br />

53270 S 614.29 0.00 0.00 54160 S 673.93 0.00 0.00<br />

53275 S 614.29 0.00 0.00 54161 S 673.93 0.00 0.00<br />

53400 S 860.77 0.00 0.00 54162 S 673.93 0.00 0.00<br />

53405 S 829.76 0.00 0.00 54163 S 673.93 0.00 0.00<br />

53410 S 829.76 0.00 0.00 54164 S 673.93 0.00 0.00<br />

53420 S 860.77 0.00 0.00 54200 S 70.59 0.00 0.00<br />

53425 S 829.76 0.00 0.00 54205 S 1,018.22 0.00 0.00<br />

53430 S 829.76 0.00 0.00 54220 S 101.18 0.00 0.00<br />

53431 S 829.76 0.00 0.00 54231 S 66.29 0.00 0.00<br />

53440 S 4,779.76 2,902.97 1,026.18 54235 S 46.94 0.00 0.00<br />

53442 S 775.03 0.00 0.00 54240 TC S 33.32 0.00 0.00<br />

53444 S 4,779.76 2,902.97 1,026.18 54250 TC S 11.82 0.00 0.00<br />

53445 S 8,028.78 4,572.34 1,115.90 54300 S 960.09 0.00 0.00<br />

53446 S 775.03 0.00 0.00 54304 S 960.09 0.00 0.00<br />

53447 S 8,028.78 4,572.34 1,115.90 54308 S 960.09 0.00 0.00<br />

53449 S 775.03 0.00 0.00 54312 S 960.09 0.00 0.00<br />

53450 S 775.03 0.00 0.00 54316 S 960.09 0.00 0.00<br />

53460 S 559.55 0.00 0.00 54318 S 960.09 0.00 0.00<br />

53502 S 614.29 0.00 0.00 54322 S 960.09 0.00 0.00<br />

53505 S 829.76 0.00 0.00 54324 S 960.09 0.00 0.00<br />

53510 S 614.29 0.00 0.00 54326 S 960.09 0.00 0.00<br />

53515 S 829.76 0.00 0.00 54328 S 960.09 0.00 0.00<br />

53520 S 829.76 0.00 0.00 54340 S 960.09 0.00 0.00<br />

53600 S 41.93 0.00 0.00 54344 S 960.09 0.00 0.00<br />

53601 S 41.85 0.00 0.00 54348 S 960.09 0.00 0.00<br />

53605 S 592.83 0.00 0.00 54352 S 960.09 0.00 0.00<br />

53620 S 64.50 0.00 0.00 54360 S 960.09 0.00 0.00<br />

53621 S 67.73 0.00 0.00 54380 S 960.09 0.00 0.00<br />

53660 S 41.85 0.00 0.00 54385 S 960.09 0.00 0.00<br />

53661 S 41.85 0.00 0.00 54400 S 4,810.77 2,933.97 1,057.18<br />

53665 S 559.55 0.00 0.00 54401 S 8,114.52 4,658.07 1,201.64<br />

53850 S 1,836.93 0.00 0.00 54405 S 8,114.52 4,658.07 1,201.64<br />

53852 S 1,836.93 0.00 0.00 54406 S 960.09 0.00 0.00<br />

54000 S 614.29 0.00 0.00 54408 S 960.09 0.00 0.00<br />

54001 S 614.29 0.00 0.00 54410 S 8,114.52 4,658.07 1,201.64<br />

54015 S 693.88 0.00 0.00 54415 S 960.09 0.00 0.00<br />

54050 S 33.20 0.00 0.00 54416 S 8,114.52 4,658.07 1,201.64<br />

54055 S 67.73 0.00 0.00 54420 S 1,018.22 0.00 0.00<br />

54056 S 33.20 0.00 0.00 54435 S 1,018.22 0.00 0.00<br />

54057 S 567.47 0.00 0.00 54440 S 1,018.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 159.29 0.00 0.00 55706 S 463.06 0.00 0.00<br />

54500 S 432.32 0.00 0.00 55720 S 674.32 0.00 0.00<br />

54505 S 619.19 0.00 0.00 55725 S 729.06 0.00 0.00<br />

54512 S 673.93 0.00 0.00 55860 S 803.38 0.00 0.00<br />

54520 S 704.93 0.00 0.00 55870 S 81.70 0.00 0.00<br />

54522 S 704.93 0.00 0.00 55873 S 6,356.68 0.00 0.00<br />

54530 S 940.00 0.00 0.00 55875 S 1,367.70 0.00 0.00<br />

54550 S 940.00 0.00 0.00 55876 S 74.89 0.00 0.00<br />

54560 S 915.79 0.00 0.00 55920 S 938.80 0.00 0.00<br />

54600 S 763.06 0.00 0.00 56405 S 43.71 0.00 0.00<br />

54620 S 704.93 0.00 0.00 56420 S 57.06 0.00 0.00<br />

54640 S 940.00 0.00 0.00 56440 S 612.70 0.00 0.00<br />

54660 S 673.93 0.00 0.00 56441 S 557.96 0.00 0.00<br />

54670 S 704.93 0.00 0.00 56442 S 557.96 0.00 0.00<br />

54680 S 704.93 0.00 0.00 56501 S 60.20 0.00 0.00<br />

54690 S 1,577.37 0.00 0.00 56515 S 653.21 0.00 0.00<br />

54692 S 2,803.93 0.00 0.00 56605 S 34.75 0.00 0.00<br />

54700 S 673.93 0.00 0.00 56606 S 14.34 0.00 0.00<br />

54800 S 151.27 0.00 0.00 56620 S 743.96 0.00 0.00<br />

54830 S 704.93 0.00 0.00 56625 S 878.62 0.00 0.00<br />

54840 S 763.06 0.00 0.00 56700 S 557.96 0.00 0.00<br />

54860 S 704.93 0.00 0.00 56740 S 643.70 0.00 0.00<br />

54861 S 763.06 0.00 0.00 56800 S 643.70 0.00 0.00<br />

54865 S 619.19 0.00 0.00 56805 S 793.33 0.00 0.00<br />

54900 S 763.06 0.00 0.00 56810 S 743.96 0.00 0.00<br />

54901 S 763.06 0.00 0.00 56820 S 44.43 0.00 0.00<br />

55000 S 68.80 0.00 0.00 56821 S 57.06 0.00 0.00<br />

55040 S 881.88 0.00 0.00 57000 S 557.96 0.00 0.00<br />

55041 S 982.14 0.00 0.00 57010 S 612.70 0.00 0.00<br />

55060 S 763.06 0.00 0.00 57020 S 321.33 0.00 0.00<br />

55100 S 413.83 0.00 0.00 57022 S 505.08 0.00 0.00<br />

55110 S 673.93 0.00 0.00 57023 S 550.01 0.00 0.00<br />

55120 S 673.93 0.00 0.00 57061 S 55.54 0.00 0.00<br />

55150 S 619.19 0.00 0.00 57065 S 557.96 0.00 0.00<br />

55175 S 619.19 0.00 0.00 57100 S 35.48 0.00 0.00<br />

55180 S 673.93 0.00 0.00 57105 S 612.70 0.00 0.00<br />

55200 S 673.93 0.00 0.00 57130 S 612.70 0.00 0.00<br />

55250 S 673.93 0.00 0.00 57135 S 612.70 0.00 0.00<br />

55400 S 619.19 0.00 0.00 57150 S 25.80 0.00 0.00<br />

55450 S 221.44 0.00 0.00 57155 S 321.33 0.00 0.00<br />

55500 S 704.93 0.00 0.00 57160 S 37.27 0.00 0.00<br />

55520 S 763.06 0.00 0.00 57170 S 6.11 0.00 0.00<br />

55530 S 763.06 0.00 0.00 57180 S 114.77 0.00 0.00<br />

55535 S 940.00 0.00 0.00 57200 S 557.96 0.00 0.00<br />

55540 S 982.14 0.00 0.00 57210 S 612.70 0.00 0.00<br />

55550 S 1,577.37 0.00 0.00 57220 S 1,123.61 0.00 0.00<br />

55600 S 915.79 0.00 0.00 57230 S 922.58 0.00 0.00<br />

55680 S 619.19 0.00 0.00 57240 S 1,022.85 0.00 0.00<br />

55700 S 399.04 0.00 0.00 57250 S 1,022.85 0.00 0.00<br />

55705 S 399.04 0.00 0.00 57260 S 1,022.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,358.53 0.00 0.00 58555 S 602.85 0.00 0.00<br />

57267 S 1,157.51 0.00 0.00 58558 S 688.58 0.00 0.00<br />

57268 S 922.58 0.00 0.00 58559 S 657.59 0.00 0.00<br />

57287 S 1,351.10 0.00 0.00 58560 S 981.83 0.00 0.00<br />

57288 S 1,223.87 0.00 0.00 58561 S 981.83 0.00 0.00<br />

57289 S 1,022.85 0.00 0.00 58562 S 688.58 0.00 0.00<br />

57291 S 1,022.85 0.00 0.00 58563 S 1,383.37 0.00 0.00<br />

57300 S 922.58 0.00 0.00 58565 S 1,525.16 0.00 0.00<br />

57320 S 1,351.10 0.00 0.00 58600 S 1,351.10 0.00 0.00<br />

57400 S 612.70 0.00 0.00 58615 S 793.33 0.00 0.00<br />

57410 S 612.70 0.00 0.00 58660 S 1,276.09 0.00 0.00<br />

57415 S 612.70 0.00 0.00 58661 S 1,276.09 0.00 0.00<br />

57420 S 45.87 0.00 0.00 58662 S 1,276.09 0.00 0.00<br />

57421 S 59.84 0.00 0.00 58670 S 1,175.83 0.00 0.00<br />

57452 S 43.36 0.00 0.00 58671 S 1,175.83 0.00 0.00<br />

57454 S 53.03 0.00 0.00 58672 S 1,276.09 0.00 0.00<br />

57455 S 56.25 0.00 0.00 58673 S 1,276.09 0.00 0.00<br />

57456 S 54.46 0.00 0.00 58800 S 643.70 0.00 0.00<br />

57460 S 167.34 0.00 0.00 58805 S 1,351.10 0.00 0.00<br />

57461 S 177.73 0.00 0.00 58820 S 922.58 0.00 0.00<br />

57500 S 76.68 0.00 0.00 58900 S 643.70 0.00 0.00<br />

57505 S 48.73 0.00 0.00 58970 S 179.30 0.00 0.00<br />

57510 S 49.45 0.00 0.00 58974 S 179.30 0.00 0.00<br />

57511 S 57.06 0.00 0.00 58976 S 179.30 0.00 0.00<br />

57513 S 612.70 0.00 0.00 59000 S 65.57 0.00 0.00<br />

57520 S 612.70 0.00 0.00 59001 S 246.13 0.00 0.00<br />

57522 S 612.70 0.00 0.00 59012 S 120.35 0.00 0.00<br />

57530 S 922.58 0.00 0.00 59015 S 53.03 0.00 0.00<br />

57550 S 922.58 0.00 0.00 59020 TC S 27.95 0.00 0.00<br />

57556 S 1,223.87 0.00 0.00 59025 TC S 14.69 0.00 0.00<br />

57558 S 643.70 0.00 0.00 59070 S 120.35 0.00 0.00<br />

57700 S 557.96 0.00 0.00 59072 S 120.35 0.00 0.00<br />

57720 S 643.70 0.00 0.00 59076 S 120.35 0.00 0.00<br />

57800 S 26.16 0.00 0.00 59100 S 1,351.10 0.00 0.00<br />

58100 S 43.00 0.00 0.00 59150 S 1,857.58 0.00 0.00<br />

58120 S 612.70 0.00 0.00 59151 S 1,857.58 0.00 0.00<br />

58145 S 1,022.85 0.00 0.00 59160 S 643.70 0.00 0.00<br />

58301 S 40.13 0.00 0.00 59200 S 35.84 0.00 0.00<br />

58321 S 37.62 0.00 0.00 59300 S 77.39 0.00 0.00<br />

58322 S 38.70 0.00 0.00 59320 S 557.96 0.00 0.00<br />

58323 S 8.96 0.00 0.00 59412 S 793.33 0.00 0.00<br />

58345 S 793.33 0.00 0.00 59414 S 793.33 0.00 0.00<br />

58346 S 612.70 0.00 0.00 59812 S 743.96 0.00 0.00<br />

58350 S 922.58 0.00 0.00 59820 S 743.96 0.00 0.00<br />

58353 S 1,157.51 0.00 0.00 59821 S 743.96 0.00 0.00<br />

58356 S 1,753.15 0.00 0.00 59840 S 743.96 0.00 0.00<br />

58545 S 1,408.26 0.00 0.00 59841 S 743.96 0.00 0.00<br />

58546 S 1,577.37 0.00 0.00 59866 S 120.35 0.00 0.00<br />

58550 S 2,050.54 0.00 0.00 59870 S 743.96 0.00 0.00<br />

58552 S 1,857.58 0.00 0.00 59871 S 743.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 312.34 0.00 0.00 62367 S 17.20 0.00 0.00<br />

60100 S 49.09 0.00 0.00 62368 S 21.86 0.00 0.00<br />

60200 S 1,162.52 0.00 0.00 63600 S 587.18 0.00 0.00<br />

60280 S 1,251.65 0.00 0.00 63610 S 532.44 0.00 0.00<br />

60281 S 1,251.65 0.00 0.00 63615 S 742.28 0.00 0.00<br />

60300 S 64.50 0.00 0.00 63650 S 3,160.47 1,959.81 759.15<br />

61000 S 287.60 0.00 0.00 63655 S 4,629.32 2,952.13 1,274.94<br />

61001 S 287.60 0.00 0.00 63660 S 555.04 0.00 0.00<br />

61020 S 232.85 0.00 0.00 63685 S 14,051.06 7,492.15 933.25<br />

61026 S 232.85 0.00 0.00 63688 S 753.70 0.00 0.00<br />

61050 S 232.85 0.00 0.00 63744 S 1,089.96 0.00 0.00<br />

61055 S 232.85 0.00 0.00 63746 S 504.19 0.00 0.00<br />

61070 S 181.18 0.00 0.00 64400 S 55.18 0.00 0.00<br />

61215 S 1,089.96 0.00 0.00 64402 S 51.96 0.00 0.00<br />

61330 S 1,679.14 0.00 0.00 64405 S 44.07 0.00 0.00<br />

61334 S 1,679.14 0.00 0.00 64408 S 54.82 0.00 0.00<br />

61790 S 618.18 0.00 0.00 64410 S 305.09 0.00 0.00<br />

61791 S 458.62 0.00 0.00 64412 S 80.62 0.00 0.00<br />

61880 S 787.48 0.00 0.00 64413 S 51.60 0.00 0.00<br />

61885 S 11,331.94 6,070.41 808.89 64415 S 140.51 0.00 0.00<br />

61886 S 16,921.35 8,918.53 915.72 64416 S 287.60 0.00 0.00<br />

61888 S 753.70 0.00 0.00 64417 S 140.51 0.00 0.00<br />

62194 S 305.09 0.00 0.00 64418 S 72.38 0.00 0.00<br />

62225 S 474.07 0.00 0.00 64420 S 140.51 0.00 0.00<br />

62230 S 1,058.95 0.00 0.00 64421 S 305.09 0.00 0.00<br />

62252 TC S 48.02 0.00 0.00 64425 S 50.16 0.00 0.00<br />

62263 S 305.09 0.00 0.00 64430 S 211.13 0.00 0.00<br />

62264 S 449.45 0.00 0.00 64435 S 75.61 0.00 0.00<br />

62267 S 179.36 0.00 0.00 64445 S 67.00 0.00 0.00<br />

62268 S 232.85 0.00 0.00 64446 S 576.31 0.00 0.00<br />

62269 S 353.35 0.00 0.00 64447 S 146.36 0.00 0.00<br />

62270 S 140.51 0.00 0.00 64448 S 146.36 0.00 0.00<br />

62272 S 140.51 0.00 0.00 64449 S 287.60 0.00 0.00<br />

62273 S 234.48 0.00 0.00 64450 S 44.79 0.00 0.00<br />

62280 S 305.09 0.00 0.00 64455 S 18.63 0.00 0.00<br />

62281 S 305.09 0.00 0.00 64470 S 305.09 0.00 0.00<br />

62282 S 305.09 0.00 0.00 64472 S 234.48 0.00 0.00<br />

62287 S 1,369.59 0.00 0.00 64475 S 305.09 0.00 0.00<br />

62292 S 287.60 0.00 0.00 64476 S 211.17 0.00 0.00<br />

62294 S 232.85 0.00 0.00 64479 S 305.09 0.00 0.00<br />

62310 S 305.09 0.00 0.00 64480 S 234.48 0.00 0.00<br />

62311 S 305.09 0.00 0.00 64483 S 305.09 0.00 0.00<br />

62318 S 305.09 0.00 0.00 64484 S 234.48 0.00 0.00<br />

62319 S 305.09 0.00 0.00 64505 S 40.85 0.00 0.00<br />

62350 S 1,058.95 0.00 0.00 64508 S 86.71 0.00 0.00<br />

62355 S 504.19 0.00 0.00 64510 S 305.09 0.00 0.00<br />

62360 S 1,058.95 0.00 0.00 64517 S 211.13 0.00 0.00<br />

62361 S 10,870.28 5,883.70 897.12 64520 S 305.09 0.00 0.00<br />

62362 S 10,870.28 5,883.70 897.12 64530 S 305.09 0.00 0.00<br />

62365 S 937.04 0.00 0.00 64553 S 3,105.73 1,905.07 704.41<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,487.55 2,286.89 1,086.23 64746 S 587.18 0.00 0.00<br />

64560 S 3,487.55 2,286.89 1,086.23 64761 S 742.28 0.00 0.00<br />

64561 S 3,191.47 1,990.81 790.15 64763 S 742.28 0.00 0.00<br />

64565 S 3,487.55 2,286.89 1,086.23 64766 S 1,442.01 0.00 0.00<br />

64573 S 5,433.08 3,218.57 1,004.06 64771 S 587.18 0.00 0.00<br />

64575 S 4,153.15 2,475.95 798.76 64772 S 587.18 0.00 0.00<br />

64577 S 4,153.15 2,475.95 798.76 64774 S 587.18 0.00 0.00<br />

64580 S 4,153.15 2,475.95 798.76 64776 S 618.18 0.00 0.00<br />

64581 S 4,238.89 2,561.69 884.50 64778 S 587.18 0.00 0.00<br />

64585 S 555.04 0.00 0.00 64782 S 618.18 0.00 0.00<br />

64590 S 11,331.94 6,070.41 808.89 64783 S 587.18 0.00 0.00<br />

64595 S 753.70 0.00 0.00 64784 S 618.18 0.00 0.00<br />

64600 S 449.45 0.00 0.00 64786 S 968.04 0.00 0.00<br />

64605 S 449.45 0.00 0.00 64787 S 587.18 0.00 0.00<br />

64610 S 449.45 0.00 0.00 64788 S 618.18 0.00 0.00<br />

64612 S 65.57 0.00 0.00 64790 S 618.18 0.00 0.00<br />

64613 S 63.43 0.00 0.00 64792 S 968.04 0.00 0.00<br />

64614 S 72.38 0.00 0.00 64795 S 587.18 0.00 0.00<br />

64620 S 305.09 0.00 0.00 64802 S 587.18 0.00 0.00<br />

64622 S 449.45 0.00 0.00 64820 S 742.28 0.00 0.00<br />

64623 S 305.09 0.00 0.00 64821 S 866.55 0.00 0.00<br />

64626 S 449.45 0.00 0.00 64822 S 1,122.77 0.00 0.00<br />

64627 S 211.17 0.00 0.00 64823 S 1,122.77 0.00 0.00<br />

64630 S 314.26 0.00 0.00 64831 S 1,026.17 0.00 0.00<br />

64632 S 34.04 0.00 0.00 64832 S 882.30 0.00 0.00<br />

64640 S 101.41 0.00 0.00 64834 S 937.04 0.00 0.00<br />

64650 S 34.04 0.00 0.00 64835 S 968.04 0.00 0.00<br />

64653 S 36.91 0.00 0.00 64836 S 968.04 0.00 0.00<br />

64680 S 477.53 0.00 0.00 64837 S 882.30 0.00 0.00<br />

64681 S 504.19 0.00 0.00 64840 S 937.04 0.00 0.00<br />

64702 S 532.44 0.00 0.00 64856 S 937.04 0.00 0.00<br />

64704 S 532.44 0.00 0.00 64857 S 937.04 0.00 0.00<br />

64708 S 587.18 0.00 0.00 64858 S 937.04 0.00 0.00<br />

64712 S 587.18 0.00 0.00 64859 S 882.30 0.00 0.00<br />

64713 S 587.18 0.00 0.00 64861 S 968.04 0.00 0.00<br />

64714 S 587.18 0.00 0.00 64862 S 968.04 0.00 0.00<br />

64716 S 618.18 0.00 0.00 64864 S 968.04 0.00 0.00<br />

64718 S 587.18 0.00 0.00 64865 S 1,026.17 0.00 0.00<br />

64719 S 587.18 0.00 0.00 64870 S 1,026.17 0.00 0.00<br />

64721 S 587.18 0.00 0.00 64872 S 937.04 0.00 0.00<br />

64722 S 532.44 0.00 0.00 64874 S 968.04 0.00 0.00<br />

64726 S 532.44 0.00 0.00 64876 S 968.04 0.00 0.00<br />

64727 S 532.44 0.00 0.00 64885 S 937.04 0.00 0.00<br />

64732 S 587.18 0.00 0.00 64886 S 937.04 0.00 0.00<br />

64734 S 587.18 0.00 0.00 64890 S 937.04 0.00 0.00<br />

64736 S 587.18 0.00 0.00 64891 S 937.04 0.00 0.00<br />

64738 S 587.18 0.00 0.00 64892 S 937.04 0.00 0.00<br />

64740 S 587.18 0.00 0.00 64893 S 937.04 0.00 0.00<br />

64742 S 587.18 0.00 0.00 64895 S 968.04 0.00 0.00<br />

64744 S 587.18 0.00 0.00 64896 S 968.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 968.04 0.00 0.00 65770 S 5,696.57 0.00 0.00<br />

64898 S 968.04 0.00 0.00 65772 S 640.82 0.00 0.00<br />

64901 S 937.04 0.00 0.00 65775 S 640.82 0.00 0.00<br />

64902 S 937.04 0.00 0.00 65780 S 1,108.53 0.00 0.00<br />

64905 S 937.04 0.00 0.00 65781 S 1,108.53 0.00 0.00<br />

64907 S 882.30 0.00 0.00 65782 S 1,108.53 0.00 0.00<br />

64910 S 1,442.01 0.00 0.00 65800 S 496.96 0.00 0.00<br />

65091 S 1,019.29 0.00 0.00 65805 S 496.96 0.00 0.00<br />

65093 S 1,019.29 0.00 0.00 65810 S 726.16 0.00 0.00<br />

65101 S 1,019.29 0.00 0.00 65815 S 695.15 0.00 0.00<br />

65103 S 1,019.29 0.00 0.00 65820 S 254.95 0.00 0.00<br />

65105 S 1,077.42 0.00 0.00 65850 S 784.28 0.00 0.00<br />

65110 S 1,119.56 0.00 0.00 65855 S 135.44 0.00 0.00<br />

65112 S 1,254.21 0.00 0.00 65860 S 126.49 0.00 0.00<br />

65114 S 1,254.21 0.00 0.00 65865 S 496.96 0.00 0.00<br />

65125 S 1,043.81 0.00 0.00 65870 S 784.28 0.00 0.00<br />

65130 S 768.94 0.00 0.00 65875 S 784.28 0.00 0.00<br />

65135 S 737.94 0.00 0.00 65880 S 640.82 0.00 0.00<br />

65140 S 1,019.29 0.00 0.00 65900 S 682.96 0.00 0.00<br />

65150 S 737.94 0.00 0.00 65920 S 961.08 0.00 0.00<br />

65155 S 1,019.29 0.00 0.00 65930 S 826.42 0.00 0.00<br />

65175 S 548.54 0.00 0.00 66020 S 496.96 0.00 0.00<br />

65205 S 21.14 0.00 0.00 66030 S 254.95 0.00 0.00<br />

65210 S 26.87 0.00 0.00 66130 S 961.08 0.00 0.00<br />

65220 S 37.45 0.00 0.00 66150 S 784.28 0.00 0.00<br />

65222 S 29.38 0.00 0.00 66155 S 784.28 0.00 0.00<br />

65235 S 551.69 0.00 0.00 66160 S 695.15 0.00 0.00<br />

65260 S 363.88 0.00 0.00 66165 S 784.28 0.00 0.00<br />

65265 S 752.81 0.00 0.00 66170 S 784.28 0.00 0.00<br />

65270 S 603.27 0.00 0.00 66172 S 784.28 0.00 0.00<br />

65272 S 695.15 0.00 0.00 66180 S 1,168.42 0.00 0.00<br />

65275 S 784.28 0.00 0.00 66185 S 1,037.15 0.00 0.00<br />

65280 S 752.81 0.00 0.00 66220 S 1,012.45 0.00 0.00<br />

65285 S 1,070.57 0.00 0.00 66225 S 1,126.28 0.00 0.00<br />

65286 S 187.29 0.00 0.00 66250 S 551.69 0.00 0.00<br />

65290 S 741.38 0.00 0.00 66500 S 254.95 0.00 0.00<br />

65400 S 496.96 0.00 0.00 66505 S 254.95 0.00 0.00<br />

65410 S 551.69 0.00 0.00 66600 S 726.16 0.00 0.00<br />

65420 S 551.69 0.00 0.00 66605 S 726.16 0.00 0.00<br />

65426 S 826.42 0.00 0.00 66625 S 516.30 0.00 0.00<br />

65430 S 37.45 0.00 0.00 66630 S 726.16 0.00 0.00<br />

65435 S 32.61 0.00 0.00 66635 S 726.16 0.00 0.00<br />

65436 S 141.53 0.00 0.00 66680 S 726.16 0.00 0.00<br />

65450 S 86.40 0.00 0.00 66682 S 695.15 0.00 0.00<br />

65600 S 166.98 0.00 0.00 66700 S 551.69 0.00 0.00<br />

65710 S 1,243.19 0.00 0.00 66710 S 551.69 0.00 0.00<br />

65730 S 1,243.19 0.00 0.00 66711 S 551.69 0.00 0.00<br />

65750 S 1,243.19 0.00 0.00 66720 S 551.69 0.00 0.00<br />

65755 S 1,243.19 0.00 0.00 66740 S 695.15 0.00 0.00<br />

65756 S 1,522.45 0.00 0.00 66761 S 188.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 191.71 0.00 0.00 67228 S 211.12 0.00 0.00<br />

66770 S 211.12 0.00 0.00 67229 S 211.12 0.00 0.00<br />

66820 S 187.29 0.00 0.00 67250 S 634.28 0.00 0.00<br />

66821 S 256.92 0.00 0.00 67255 S 694.69 0.00 0.00<br />

66825 S 784.28 0.00 0.00 67311 S 741.38 0.00 0.00<br />

66830 S 274.30 0.00 0.00 67312 S 799.51 0.00 0.00<br />

66840 S 589.63 0.00 0.00 67314 S 799.51 0.00 0.00<br />

66850 S 1,110.14 0.00 0.00 67316 S 799.51 0.00 0.00<br />

66852 S 933.33 0.00 0.00 67318 S 799.51 0.00 0.00<br />

66920 S 933.33 0.00 0.00 67320 S 799.51 0.00 0.00<br />

66930 S 975.48 0.00 0.00 67331 S 799.51 0.00 0.00<br />

66940 S 631.78 0.00 0.00 67332 S 799.51 0.00 0.00<br />

66982 S 958.43 0.00 0.00 67334 S 799.51 0.00 0.00<br />

66983 S 958.43 0.00 0.00 67335 S 799.51 0.00 0.00<br />

66984 S 958.43 0.00 0.00 67340 S 799.51 0.00 0.00<br />

66985 S 887.23 0.00 0.00 67343 S 976.30 0.00 0.00<br />

66986 S 887.23 0.00 0.00 67345 S 83.49 0.00 0.00<br />

67005 S 752.81 0.00 0.00 67346 S 451.59 0.00 0.00<br />

67010 S 752.81 0.00 0.00 67400 S 634.28 0.00 0.00<br />

67015 S 926.71 0.00 0.00 67405 S 827.07 0.00 0.00<br />

67025 S 608.96 0.00 0.00 67412 S 734.54 0.00 0.00<br />

67027 S 1,070.57 0.00 0.00 67413 S 869.20 0.00 0.00<br />

67028 S 84.21 0.00 0.00 67414 S 1,544.51 0.00 0.00<br />

67030 S 608.96 0.00 0.00 67415 S 548.54 0.00 0.00<br />

67031 S 256.92 0.00 0.00 67420 S 1,119.56 0.00 0.00<br />

67036 S 1,070.57 0.00 0.00 67430 S 1,119.56 0.00 0.00<br />

67039 S 1,247.37 0.00 0.00 67440 S 1,119.56 0.00 0.00<br />

67040 S 1,247.37 0.00 0.00 67445 S 1,119.56 0.00 0.00<br />

67041 S 1,530.81 0.00 0.00 67450 S 1,119.56 0.00 0.00<br />

67042 S 1,530.81 0.00 0.00 67500 S 86.40 0.00 0.00<br />

67043 S 1,530.81 0.00 0.00 67505 S 26.87 0.00 0.00<br />

67101 S 233.69 0.00 0.00 67515 S 27.23 0.00 0.00<br />

67105 S 211.12 0.00 0.00 67550 S 1,077.42 0.00 0.00<br />

67107 S 1,112.71 0.00 0.00 67560 S 737.94 0.00 0.00<br />

67108 S 1,247.37 0.00 0.00 67570 S 1,077.42 0.00 0.00<br />

67110 S 339.69 0.00 0.00 67700 S 126.41 0.00 0.00<br />

67112 S 1,247.37 0.00 0.00 67710 S 147.62 0.00 0.00<br />

67113 S 1,530.81 0.00 0.00 67715 S 548.54 0.00 0.00<br />

67115 S 663.69 0.00 0.00 67800 S 53.03 0.00 0.00<br />

67120 S 663.69 0.00 0.00 67801 S 64.14 0.00 0.00<br />

67121 S 663.69 0.00 0.00 67805 S 83.13 0.00 0.00<br />

67141 S 233.95 0.00 0.00 67808 S 603.27 0.00 0.00<br />

67145 S 199.58 0.00 0.00 67810 S 126.41 0.00 0.00<br />

67208 S 212.85 0.00 0.00 67820 S 17.56 0.00 0.00<br />

67210 S 211.12 0.00 0.00 67825 S 54.11 0.00 0.00<br />

67218 S 794.96 0.00 0.00 67830 S 370.37 0.00 0.00<br />

67220 S 233.69 0.00 0.00 67835 S 603.27 0.00 0.00<br />

67221 S 120.03 0.00 0.00 67840 S 154.80 0.00 0.00<br />

67225 S 8.25 0.00 0.00 67850 S 122.91 0.00 0.00<br />

67227 S 608.96 0.00 0.00 67875 S 308.66 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 582.70 0.00 0.00 68440 S 52.68 0.00 0.00<br />

67882 S 634.28 0.00 0.00 68500 S 768.94 0.00 0.00<br />

67900 S 827.07 0.00 0.00 68505 S 768.94 0.00 0.00<br />

67901 S 734.54 0.00 0.00 68510 S 548.54 0.00 0.00<br />

67902 S 869.20 0.00 0.00 68520 S 768.94 0.00 0.00<br />

67903 S 692.40 0.00 0.00 68525 S 548.54 0.00 0.00<br />

67904 S 692.40 0.00 0.00 68530 S 126.41 0.00 0.00<br />

67906 S 734.54 0.00 0.00 68540 S 634.28 0.00 0.00<br />

67908 S 692.40 0.00 0.00 68550 S 768.94 0.00 0.00<br />

67909 S 692.40 0.00 0.00 68700 S 603.27 0.00 0.00<br />

67911 S 634.28 0.00 0.00 68705 S 120.03 0.00 0.00<br />

67912 S 634.28 0.00 0.00 68720 S 827.07 0.00 0.00<br />

67914 S 634.28 0.00 0.00 68745 S 827.07 0.00 0.00<br />

67915 S 171.28 0.00 0.00 68750 S 827.07 0.00 0.00<br />

67916 S 692.40 0.00 0.00 68760 S 102.12 0.00 0.00<br />

67917 S 692.40 0.00 0.00 68761 S 70.59 0.00 0.00<br />

67921 S 634.28 0.00 0.00 68770 S 827.07 0.00 0.00<br />

67922 S 166.62 0.00 0.00 68801 S 37.45 0.00 0.00<br />

67923 S 692.40 0.00 0.00 68810 S 107.08 0.00 0.00<br />

67924 S 692.40 0.00 0.00 68811 S 603.27 0.00 0.00<br />

67930 S 171.28 0.00 0.00 68815 S 603.27 0.00 0.00<br />

67935 S 603.27 0.00 0.00 68816 S 774.48 0.00 0.00<br />

67938 S 86.40 0.00 0.00 68840 S 55.54 0.00 0.00<br />

67950 S 603.27 0.00 0.00 69000 S 56.65 0.00 0.00<br />

67961 S 634.28 0.00 0.00 69005 S 107.14 0.00 0.00<br />

67966 S 634.28 0.00 0.00 69020 S 56.65 0.00 0.00<br />

67971 S 634.28 0.00 0.00 69100 S 64.50 0.00 0.00<br />

67973 S 768.94 0.00 0.00 69105 S 91.37 0.00 0.00<br />

67974 S 634.28 0.00 0.00 69110 S 480.04 0.00 0.00<br />

67975 S 634.28 0.00 0.00 69120 S 712.38 0.00 0.00<br />

68020 S 46.94 0.00 0.00 69140 S 712.38 0.00 0.00<br />

68040 S 23.29 0.00 0.00 69145 S 534.77 0.00 0.00<br />

68100 S 93.16 0.00 0.00 69150 S 375.86 0.00 0.00<br />

68110 S 120.03 0.00 0.00 69200 S 25.91 0.00 0.00<br />

68115 S 603.27 0.00 0.00 69205 S 599.25 0.00 0.00<br />

68130 S 551.69 0.00 0.00 69210 S 21.14 0.00 0.00<br />

68135 S 60.20 0.00 0.00 69220 S 33.20 0.00 0.00<br />

68200 S 17.20 0.00 0.00 69222 S 139.75 0.00 0.00<br />

68320 S 827.07 0.00 0.00 69300 S 743.39 0.00 0.00<br />

68325 S 827.07 0.00 0.00 69310 S 1,086.61 0.00 0.00<br />

68326 S 692.40 0.00 0.00 69320 S 1,321.53 0.00 0.00<br />

68328 S 827.07 0.00 0.00 69400 S 93.88 0.00 0.00<br />

68330 S 784.28 0.00 0.00 69401 S 49.45 0.00 0.00<br />

68335 S 827.07 0.00 0.00 69405 S 129.71 0.00 0.00<br />

68340 S 692.40 0.00 0.00 69420 S 116.46 0.00 0.00<br />

68360 S 695.15 0.00 0.00 69421 S 592.70 0.00 0.00<br />

68362 S 695.15 0.00 0.00 69424 S 81.70 0.00 0.00<br />

68371 S 551.69 0.00 0.00 69433 S 116.10 0.00 0.00<br />

68400 S 126.41 0.00 0.00 69436 S 592.70 0.00 0.00<br />

68420 S 179.87 0.00 0.00 69440 S 743.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 1,000.87 0.00 0.00 69840 S 1,186.87 0.00 0.00<br />

69501 S 1,321.53 0.00 0.00 69905 S 1,321.53 0.00 0.00<br />

69502 S 978.31 0.00 0.00 69910 S 1,321.53 0.00 0.00<br />

69505 S 1,321.53 0.00 0.00 69915 S 1,321.53 0.00 0.00<br />

69511 S 1,321.53 0.00 0.00 69930 S 23,891.53 12,828.13 1,764.74<br />

69530 S 1,321.53 0.00 0.00 70030 TC A 18.27 0.00 0.00<br />

69540 S 136.52 0.00 0.00 70100 TC A 20.07 0.00 0.00<br />

69550 S 1,186.87 0.00 0.00 70110 TC A 24.73 0.00 0.00<br />

69552 S 1,321.53 0.00 0.00 70120 TC A 22.21 0.00 0.00<br />

69601 S 1,321.53 0.00 0.00 70130 TC A 27.14 0.00 0.00<br />

69602 S 1,321.53 0.00 0.00 70134 TC A 27.23 0.00 0.00<br />

69603 S 1,321.53 0.00 0.00 70140 TC A 18.63 0.00 0.00<br />

69604 S 1,321.53 0.00 0.00 70150 TC A 27.14 0.00 0.00<br />

69605 S 1,321.53 0.00 0.00 70160 TC A 21.86 0.00 0.00<br />

69610 S 182.74 0.00 0.00 70190 TC A 22.93 0.00 0.00<br />

69620 S 712.38 0.00 0.00 70200 TC A 27.14 0.00 0.00<br />

69631 S 1,186.87 0.00 0.00 70210 TC A 19.35 0.00 0.00<br />

69632 S 1,186.87 0.00 0.00 70220 TC A 24.37 0.00 0.00<br />

69633 S 1,186.87 0.00 0.00 70240 TC A 18.27 0.00 0.00<br />

69635 S 1,321.53 0.00 0.00 70250 TC A 22.21 0.00 0.00<br />

69636 S 1,321.53 0.00 0.00 70260 TC A 28.30 0.00 0.00<br />

69637 S 1,321.53 0.00 0.00 70300 TC A 7.88 0.00 0.00<br />

69641 S 1,321.53 0.00 0.00 70310 TC A 19.47 0.00 0.00<br />

69642 S 1,321.53 0.00 0.00 70320 TC A 19.47 0.00 0.00<br />

69643 S 1,321.53 0.00 0.00 70328 TC A 19.35 0.00 0.00<br />

69644 S 1,321.53 0.00 0.00 70330 TC A 27.14 0.00 0.00<br />

69645 S 1,321.53 0.00 0.00 70336 TC A 211.28 0.00 0.00<br />

69646 S 1,321.53 0.00 0.00 70350 TC A 10.75 0.00 0.00<br />

69650 S 978.31 0.00 0.00 70355 TC A 11.11 0.00 0.00<br />

69660 S 1,186.87 0.00 0.00 70360 TC A 17.20 0.00 0.00<br />

69661 S 1,186.87 0.00 0.00 70370 TC A 50.51 0.00 0.00<br />

69662 S 1,186.87 0.00 0.00 70371 TC A 50.51 0.00 0.00<br />

69666 S 1,144.73 0.00 0.00 70380 TC A 26.16 0.00 0.00<br />

69667 S 1,144.73 0.00 0.00 70450 TC A 118.00 0.00 0.00<br />

69670 S 1,086.61 0.00 0.00 70460 TC A 186.85 0.00 0.00<br />

69676 S 1,086.61 0.00 0.00 70470 TC A 206.98 0.00 0.00<br />

69700 S 1,086.61 0.00 0.00 70480 TC A 118.00 0.00 0.00<br />

69711 S 1,000.87 0.00 0.00 70481 TC A 186.85 0.00 0.00<br />

69714 S 6,347.35 4,002.25 1,657.14 70482 TC A 206.98 0.00 0.00<br />

69715 S 6,347.35 4,002.25 1,657.14 70486 TC A 118.00 0.00 0.00<br />

69717 S 6,347.35 4,002.25 1,657.14 70487 TC A 186.85 0.00 0.00<br />

69718 S 6,347.35 4,002.25 1,657.14 70488 TC A 206.98 0.00 0.00<br />

69720 S 1,186.87 0.00 0.00 70490 TC A 118.00 0.00 0.00<br />

69740 S 1,186.87 0.00 0.00 70491 TC A 186.85 0.00 0.00<br />

69745 S 1,186.87 0.00 0.00 70492 TC A 206.98 0.00 0.00<br />

69801 S 1,186.87 0.00 0.00 70496 TC A 213.59 0.00 0.00<br />

69802 S 1,321.53 0.00 0.00 70498 TC A 213.59 0.00 0.00<br />

69805 S 1,321.53 0.00 0.00 70540 TC A 211.28 0.00 0.00<br />

69806 S 1,321.53 0.00 0.00 70542 TC A 259.45 0.00 0.00<br />

69820 S 1,186.87 0.00 0.00 70543 TC A 327.00 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 211.28 0.00 0.00 72120 TC A 34.39 0.00 0.00<br />

70545 TC A 259.45 0.00 0.00 72125 TC A 118.00 0.00 0.00<br />

70546 TC A 327.00 0.00 0.00 72126 TC A 186.85 0.00 0.00<br />

70547 TC A 211.28 0.00 0.00 72127 TC A 206.98 0.00 0.00<br />

70548 TC A 259.45 0.00 0.00 72128 TC A 118.00 0.00 0.00<br />

70549 TC A 327.00 0.00 0.00 72129 TC A 186.85 0.00 0.00<br />

70551 TC A 211.28 0.00 0.00 72130 TC A 206.98 0.00 0.00<br />

70552 TC A 259.45 0.00 0.00 72131 TC A 118.00 0.00 0.00<br />

70553 TC A 327.00 0.00 0.00 72132 TC A 186.85 0.00 0.00<br />

70554 TC A 211.28 0.00 0.00 72133 TC A 206.98 0.00 0.00<br />

70555 TC A 211.28 0.00 0.00 72141 TC A 211.28 0.00 0.00<br />

70557 TC A 211.28 0.00 0.00 72142 TC A 259.45 0.00 0.00<br />

70558 TC A 259.45 0.00 0.00 72146 TC A 211.28 0.00 0.00<br />

70559 TC A 327.00 0.00 0.00 72147 TC A 259.45 0.00 0.00<br />

71010 TC A 13.98 0.00 0.00 72148 TC A 211.28 0.00 0.00<br />

71015 TC A 17.91 0.00 0.00 72149 TC A 259.45 0.00 0.00<br />

71020 TC A 19.00 0.00 0.00 72156 TC A 327.00 0.00 0.00<br />

71021 TC A 22.93 0.00 0.00 72157 TC A 327.00 0.00 0.00<br />

71022 TC A 27.14 0.00 0.00 72158 TC A 327.00 0.00 0.00<br />

71023 TC A 44.43 0.00 0.00 72170 TC A 16.12 0.00 0.00<br />

71030 TC A 27.14 0.00 0.00 72190 TC A 27.14 0.00 0.00<br />

71034 TC A 50.51 0.00 0.00 72191 TC A 213.59 0.00 0.00<br />

71035 TC A 23.65 0.00 0.00 72192 TC A 118.00 0.00 0.00<br />

71100 TC A 19.71 0.00 0.00 72193 TC A 186.85 0.00 0.00<br />

71101 TC A 24.00 0.00 0.00 72194 TC A 206.98 0.00 0.00<br />

71110 TC A 25.09 0.00 0.00 72195 TC A 211.28 0.00 0.00<br />

71111 TC A 33.32 0.00 0.00 72196 TC A 259.45 0.00 0.00<br />

71120 TC A 20.78 0.00 0.00 72197 TC A 327.00 0.00 0.00<br />

71130 TC A 24.37 0.00 0.00 72200 TC A 19.00 0.00 0.00<br />

71250 TC A 118.00 0.00 0.00 72202 TC A 23.29 0.00 0.00<br />

71260 TC A 186.85 0.00 0.00 72220 TC A 19.00 0.00 0.00<br />

71270 TC A 206.98 0.00 0.00 73000 TC A 17.91 0.00 0.00<br />

71275 TC A 213.59 0.00 0.00 73010 TC A 18.27 0.00 0.00<br />

71550 TC A 211.28 0.00 0.00 73020 TC A 14.69 0.00 0.00<br />

71551 TC A 259.45 0.00 0.00 73030 TC A 18.63 0.00 0.00<br />

71552 TC A 327.00 0.00 0.00 73050 TC A 23.29 0.00 0.00<br />

72010 TC A 45.18 0.00 0.00 73060 TC A 18.63 0.00 0.00<br />

72020 TC A 14.69 0.00 0.00 73070 TC A 17.91 0.00 0.00<br />

72040 TC A 23.65 0.00 0.00 73080 TC A 23.65 0.00 0.00<br />

72050 TC A 33.68 0.00 0.00 73090 TC A 17.91 0.00 0.00<br />

72052 TC A 45.18 0.00 0.00 73092 TC A 18.63 0.00 0.00<br />

72069 TC A 22.21 0.00 0.00 73100 TC A 18.63 0.00 0.00<br />

72070 TC A 20.78 0.00 0.00 73110 TC A 23.65 0.00 0.00<br />

72072 TC A 25.09 0.00 0.00 73120 TC A 17.56 0.00 0.00<br />

72074 TC A 27.14 0.00 0.00 73130 TC A 20.78 0.00 0.00<br />

72080 TC A 22.21 0.00 0.00 73140 TC A 20.43 0.00 0.00<br />

72090 TC A 29.75 0.00 0.00 73200 TC A 118.00 0.00 0.00<br />

72100 TC A 25.44 0.00 0.00 73201 TC A 186.85 0.00 0.00<br />

72110 TC A 35.48 0.00 0.00 73202 TC A 206.98 0.00 0.00<br />

72114 TC A 45.18 0.00 0.00 73206 TC A 213.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 211.28 0.00 0.00 74246 TC A 53.32 0.00 0.00<br />

73219 TC A 259.45 0.00 0.00 74247 TC A 53.32 0.00 0.00<br />

73220 TC A 327.00 0.00 0.00 74249 TC A 86.70 0.00 0.00<br />

73221 TC A 211.28 0.00 0.00 74250 TC A 53.32 0.00 0.00<br />

73222 TC A 259.45 0.00 0.00 74251 TC A 86.70 0.00 0.00<br />

73223 TC A 327.00 0.00 0.00 74260 TC A 53.32 0.00 0.00<br />

73500 TC A 15.41 0.00 0.00 74270 TC A 53.32 0.00 0.00<br />

73510 TC A 23.65 0.00 0.00 74280 TC A 86.70 0.00 0.00<br />

73520 TC A 24.37 0.00 0.00 74283 TC A 53.32 0.00 0.00<br />

73540 TC A 24.37 0.00 0.00 74290 TC A 45.50 0.00 0.00<br />

73550 TC A 17.91 0.00 0.00 74291 TC A 43.71 0.00 0.00<br />

73560 TC A 18.27 0.00 0.00 74400 TC A 79.19 0.00 0.00<br />

73562 TC A 22.57 0.00 0.00 74410 TC A 84.57 0.00 0.00<br />

73564 TC A 26.16 0.00 0.00 74415 TC A 101.05 0.00 0.00<br />

73565 TC A 19.71 0.00 0.00 74420 TC A 105.62 0.00 0.00<br />

73590 TC A 17.20 0.00 0.00 74710 TC A 23.65 0.00 0.00<br />

73592 TC A 18.63 0.00 0.00 74775 TC A 105.62 0.00 0.00<br />

73600 TC A 17.56 0.00 0.00 75557 TC A 211.28 0.00 0.00<br />

73610 TC A 20.78 0.00 0.00 75559 TC A 211.28 0.00 0.00<br />

73620 TC A 16.84 0.00 0.00 75561 TC A 327.00 0.00 0.00<br />

73630 TC A 20.43 0.00 0.00 75563 TC A 327.00 0.00 0.00<br />

73650 TC A 17.20 0.00 0.00 76010 TC A 17.56 0.00 0.00<br />

73660 TC A 19.35 0.00 0.00 76098 TC A 10.75 0.00 0.00<br />

73700 TC A 118.00 0.00 0.00 76100 TC A 45.18 0.00 0.00<br />

73701 TC A 186.85 0.00 0.00 76101 TC A 121.11 0.00 0.00<br />

73702 TC A 206.98 0.00 0.00 76102 TC A 121.11 0.00 0.00<br />

73706 TC A 213.59 0.00 0.00 76120 TC A 50.51 0.00 0.00<br />

73718 TC A 211.28 0.00 0.00 76150 A 17.56 0.00 0.00<br />

73719 TC A 259.45 0.00 0.00 76380 TC A 63.74 0.00 0.00<br />

73720 TC A 327.00 0.00 0.00 76496 TC A 50.51 0.00 0.00<br />

73721 TC A 211.28 0.00 0.00 76497 TC A 63.74 0.00 0.00<br />

73722 TC A 259.45 0.00 0.00 76498 TC A 211.28 0.00 0.00<br />

73723 TC A 327.00 0.00 0.00 76499 TC A 27.14 0.00 0.00<br />

74000 TC A 15.41 0.00 0.00 76506 TC A 37.94 0.00 0.00<br />

74010 TC A 24.00 0.00 0.00 76510 TC A 64.50 0.00 0.00<br />

74020 TC A 24.37 0.00 0.00 76511 TC A 45.14 0.00 0.00<br />

74022 TC A 29.75 0.00 0.00 76512 TC A 38.34 0.00 0.00<br />

74150 TC A 118.00 0.00 0.00 76513 TC A 46.59 0.00 0.00<br />

74160 TC A 186.85 0.00 0.00 76514 TC A 3.23 0.00 0.00<br />

74170 TC A 206.98 0.00 0.00 76516 TC A 36.55 0.00 0.00<br />

74175 TC A 213.59 0.00 0.00 76519 TC A 40.85 0.00 0.00<br />

74181 TC A 211.28 0.00 0.00 76529 TC A 35.48 0.00 0.00<br />

74182 TC A 259.45 0.00 0.00 76536 TC A 59.35 0.00 0.00<br />

74183 TC A 327.00 0.00 0.00 76604 TC A 37.94 0.00 0.00<br />

74210 TC A 53.32 0.00 0.00 76645 TC A 37.94 0.00 0.00<br />

74220 TC A 53.32 0.00 0.00 76700 TC A 59.35 0.00 0.00<br />

74230 TC A 53.32 0.00 0.00 76705 TC A 59.35 0.00 0.00<br />

74240 TC A 53.32 0.00 0.00 76770 TC A 59.35 0.00 0.00<br />

74241 TC A 53.32 0.00 0.00 76775 TC A 59.35 0.00 0.00<br />

74245 TC A 86.70 0.00 0.00 76776 TC A 59.35 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 59.35 0.00 0.00 77290 TC A 155.21 0.00 0.00<br />

76801 TC A 59.35 0.00 0.00 77295 TC A 406.70 0.00 0.00<br />

76802 TC A 28.30 0.00 0.00 77299 TC A 69.63 0.00 0.00<br />

76805 TC A 59.35 0.00 0.00 77300 TC A 37.62 0.00 0.00<br />

76810 TC A 44.79 0.00 0.00 77301 TC A 542.01 0.00 0.00<br />

76811 TC A 92.98 0.00 0.00 77305 TC A 34.39 0.00 0.00<br />

76812 TC A 37.94 0.00 0.00 77310 TC A 44.79 0.00 0.00<br />

76813 TC A 37.94 0.00 0.00 77315 TC A 65.21 0.00 0.00<br />

76814 TC A 30.10 0.00 0.00 77321 TC A 67.73 0.00 0.00<br />

76815 TC A 37.94 0.00 0.00 77326 TC A 69.63 0.00 0.00<br />

76816 TC A 37.94 0.00 0.00 77327 TC A 126.49 0.00 0.00<br />

76817 TC A 37.94 0.00 0.00 77328 TC A 155.21 0.00 0.00<br />

76818 TC A 59.35 0.00 0.00 77331 TC A 17.91 0.00 0.00<br />

76819 TC A 51.24 0.00 0.00 77332 TC A 48.02 0.00 0.00<br />

76820 TC A 25.44 0.00 0.00 77333 TC A 23.29 0.00 0.00<br />

76821 TC A 57.45 0.00 0.00 77334 TC A 89.94 0.00 0.00<br />

76825 TC A 119.68 0.00 0.00 77336 A 56.62 0.00 0.00<br />

76826 TC A 71.30 0.00 0.00 77370 A 69.63 0.00 0.00<br />

76827 TC A 37.94 0.00 0.00 77371 A 4,638.75 0.00 0.00<br />

76828 TC A 22.57 0.00 0.00 77399 TC A 69.63 0.00 0.00<br />

76830 TC A 59.35 0.00 0.00 77401 A 28.30 0.00 0.00<br />

76831 TC A 79.91 0.00 0.00 77402 A 56.99 0.00 0.00<br />

76856 TC A 59.35 0.00 0.00 77403 A 56.99 0.00 0.00<br />

76857 TC A 37.94 0.00 0.00 77404 A 56.99 0.00 0.00<br />

76870 TC A 59.35 0.00 0.00 77406 A 92.31 0.00 0.00<br />

76872 TC A 59.35 0.00 0.00 77407 A 56.99 0.00 0.00<br />

76873 TC A 59.35 0.00 0.00 77408 A 56.99 0.00 0.00<br />

76880 TC A 59.35 0.00 0.00 77409 A 56.99 0.00 0.00<br />

76885 TC A 37.94 0.00 0.00 77411 A 92.31 0.00 0.00<br />

76886 TC A 37.94 0.00 0.00 77412 A 92.31 0.00 0.00<br />

76936 TC A 57.45 0.00 0.00 77413 A 92.31 0.00 0.00<br />

76970 TC A 37.94 0.00 0.00 77414 A 92.31 0.00 0.00<br />

76977 TC A 9.68 0.00 0.00 77416 A 92.31 0.00 0.00<br />

76999 TC A 37.94 0.00 0.00 77418 A 249.39 0.00 0.00<br />

77071 A 22.21 0.00 0.00 77422 A 92.31 0.00 0.00<br />

77072 TC A 12.90 0.00 0.00 77423 A 92.31 0.00 0.00<br />

77073 TC A 21.86 0.00 0.00 77470 TC A 132.58 0.00 0.00<br />

77074 TC A 43.00 0.00 0.00 77520 A 426.98 0.00 0.00<br />

77075 TC A 45.18 0.00 0.00 77522 A 426.98 0.00 0.00<br />

77076 TC A 45.18 0.00 0.00 77523 A 510.25 0.00 0.00<br />

77077 TC A 24.37 0.00 0.00 77525 A 510.25 0.00 0.00<br />

77078 TC A 43.65 0.00 0.00 77600 TC A 226.55 0.00 0.00<br />

77079 TC A 44.79 0.00 0.00 77605 TC A 226.55 0.00 0.00<br />

77080 TC A 43.65 0.00 0.00 77610 TC A 226.55 0.00 0.00<br />

77081 TC A 17.56 0.00 0.00 77615 TC A 226.55 0.00 0.00<br />

77082 TC A 19.00 0.00 0.00 77620 TC A 226.55 0.00 0.00<br />

77083 TC A 15.05 0.00 0.00 77750 TC A 88.14 0.00 0.00<br />

77084 TC A 211.28 0.00 0.00 77761 TC A 155.15 0.00 0.00<br />

77280 TC A 69.63 0.00 0.00 77762 TC A 183.82 0.00 0.00<br />

77285 TC A 155.21 0.00 0.00 77763 TC A 236.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 168.05 0.00 0.00 78262 TC A 147.58 0.00 0.00<br />

77777 TC A 184.53 0.00 0.00 78264 TC A 147.58 0.00 0.00<br />

77778 TC A 245.81 0.00 0.00 78270 TC A 64.50 0.00 0.00<br />

77785 TC A 109.29 0.00 0.00 78271 TC A 65.57 0.00 0.00<br />

77786 TC A 384.12 0.00 0.00 78272 TC A 72.02 0.00 0.00<br />

77787 TC A 445.11 0.00 0.00 78278 TC A 147.58 0.00 0.00<br />

77789 TC A 45.87 0.00 0.00 78282 TC A 147.58 0.00 0.00<br />

77799 TC A 261.43 0.00 0.00 78290 TC A 147.58 0.00 0.00<br />

78000 TC A 56.25 0.00 0.00 78291 TC A 147.58 0.00 0.00<br />

78001 TC A 71.29 0.00 0.00 78299 TC A 147.58 0.00 0.00<br />

78003 TC A 56.62 0.00 0.00 78300 TC A 128.64 0.00 0.00<br />

78006 TC A 134.71 0.00 0.00 78305 TC A 149.19 0.00 0.00<br />

78007 TC A 99.62 0.00 0.00 78306 TC A 149.19 0.00 0.00<br />

78010 TC A 82.77 0.00 0.00 78315 TC A 149.19 0.00 0.00<br />

78011 TC A 82.77 0.00 0.00 78320 TC A 149.19 0.00 0.00<br />

78015 TC A 160.89 0.00 0.00 78399 TC A 149.19 0.00 0.00<br />

78016 TC A 181.60 0.00 0.00 78414 TC A 189.64 0.00 0.00<br />

78018 TC A 181.60 0.00 0.00 78428 TC A 145.48 0.00 0.00<br />

78070 TC A 123.62 0.00 0.00 78445 TC A 113.48 0.00 0.00<br />

78075 TC A 350.08 0.00 0.00 78456 TC A 113.48 0.00 0.00<br />

78099 TC A 82.77 0.00 0.00 78457 TC A 113.48 0.00 0.00<br />

78102 TC A 125.05 0.00 0.00 78458 TC A 113.48 0.00 0.00<br />

78103 TC A 159.41 0.00 0.00 78459 TC A 702.26 0.00 0.00<br />

78104 TC A 159.41 0.00 0.00 78460 TC A 136.16 0.00 0.00<br />

78110 TC A 63.43 0.00 0.00 78461 TC A 137.24 0.00 0.00<br />

78111 TC A 80.26 0.00 0.00 78464 TC A 201.37 0.00 0.00<br />

78120 TC A 70.23 0.00 0.00 78465 TC A 381.26 0.00 0.00<br />

78121 TC A 83.13 0.00 0.00 78466 TC A 135.09 0.00 0.00<br />

78122 TC A 98.54 0.00 0.00 78468 TC A 172.71 0.00 0.00<br />

78130 TC A 114.30 0.00 0.00 78469 TC A 189.64 0.00 0.00<br />

78135 TC A 242.93 0.00 0.00 78472 TC A 189.64 0.00 0.00<br />

78140 TC A 107.85 0.00 0.00 78473 TC A 189.64 0.00 0.00<br />

78185 TC A 159.41 0.00 0.00 78481 TC A 163.75 0.00 0.00<br />

78190 TC A 100.03 0.00 0.00 78483 TC A 189.64 0.00 0.00<br />

78191 TC A 100.03 0.00 0.00 78491 TC A 702.26 0.00 0.00<br />

78195 TC A 159.41 0.00 0.00 78492 TC A 702.26 0.00 0.00<br />

78199 TC A 159.41 0.00 0.00 78494 TC A 189.64 0.00 0.00<br />

78201 TC A 141.89 0.00 0.00 78499 TC A 189.64 0.00 0.00<br />

78202 TC A 166.92 0.00 0.00 78580 TC A 128.48 0.00 0.00<br />

78205 TC A 166.92 0.00 0.00 78584 TC A 99.25 0.00 0.00<br />

78206 TC A 166.92 0.00 0.00 78585 TC A 197.14 0.00 0.00<br />

78215 TC A 150.14 0.00 0.00 78586 TC A 128.48 0.00 0.00<br />

78216 TC A 101.76 0.00 0.00 78587 TC A 128.48 0.00 0.00<br />

78220 TC A 111.08 0.00 0.00 78588 TC A 197.14 0.00 0.00<br />

78223 TC A 166.92 0.00 0.00 78591 TC A 128.48 0.00 0.00<br />

78230 TC A 126.12 0.00 0.00 78593 TC A 128.48 0.00 0.00<br />

78231 TC A 99.25 0.00 0.00 78594 TC A 128.48 0.00 0.00<br />

78232 TC A 103.55 0.00 0.00 78596 TC A 197.14 0.00 0.00<br />

78258 TC A 147.58 0.00 0.00 78599 TC A 128.48 0.00 0.00<br />

78261 TC A 147.58 0.00 0.00 78600 TC A 113.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 38940 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 113.23 0.00 0.00<br />

78605 TC A 113.23 0.00 0.00<br />

78606 TC A 254.41 0.00 0.00<br />

78607 TC A 279.49 0.00 0.00<br />

78608 TC A 629.44 0.00 0.00<br />

78610 TC A 150.85 0.00 0.00<br />

78630 TC A 268.74 0.00 0.00<br />

78635 TC A 247.60 0.00 0.00<br />

78645 TC A 113.23 0.00 0.00<br />

78647 TC A 274.12 0.00 0.00<br />

78650 TC A 265.51 0.00 0.00<br />

78660 TC A 113.23 0.00 0.00<br />

78699 TC A 113.23 0.00 0.00<br />

78700 TC A 139.39 0.00 0.00<br />

78701 TC A 169.85 0.00 0.00<br />

78707 TC A 177.37 0.00 0.00<br />

78708 TC A 121.48 0.00 0.00<br />

78709 TC A 199.71 0.00 0.00<br />

78710 TC A 187.40 0.00 0.00<br />

78725 TC A 74.89 0.00 0.00<br />

78730 TC A 63.43 0.00 0.00<br />

78740 TC A 165.55 0.00 0.00<br />

78761 TC A 158.02 0.00 0.00<br />

78799 TC A 199.71 0.00 0.00<br />

78800 TC A 139.75 0.00 0.00<br />

78801 TC A 191.71 0.00 0.00<br />

78802 TC A 259.78 0.00 0.00<br />

78803 TC A 278.42 0.00 0.00<br />

78804 TC A 485.88 0.00 0.00<br />

78805 TC A 136.52 0.00 0.00<br />

78806 TC A 273.04 0.00 0.00<br />

78807 TC A 278.78 0.00 0.00<br />

78811 TC A 629.44 0.00 0.00<br />

78812 TC A 629.44 0.00 0.00<br />

78813 TC A 629.44 0.00 0.00<br />

78814 TC A 629.44 0.00 0.00<br />

78815 TC A 629.44 0.00 0.00<br />

78816 TC A 629.44 0.00 0.00<br />

78999 TC A 71.29 0.00 0.00<br />

79005 TC A 57.33 0.00 0.00<br />

79101 TC A 62.71 0.00 0.00<br />

79200 TC A 67.73 0.00 0.00<br />

79300 TC A 130.67 0.00 0.00<br />

79403 TC A 97.10 0.00 0.00<br />

79440 TC A 54.82 0.00 0.00<br />

79445 TC A 130.67 0.00 0.00<br />

79999 TC A 130.67 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,204.81 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,495.57 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.47 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,545.37 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,545.37 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 223.18 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 223.18 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 112.69 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 238.17 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 71.60 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 641.10 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,461.94 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,144.34 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,144.34 0.00 0.00<br />

C8900 A 247.78 0.00 0.00 0123T S 915.13 0.00 0.00<br />

C8901 A 201.77 0.00 0.00 0124T S 178.87 0.00 0.00<br />

C8902 A 312.29 0.00 0.00 0144T TC A 60.88 0.00 0.00<br />

C8903 A 247.78 0.00 0.00 0145T TC A 163.88 0.00 0.00<br />

C8904 A 201.77 0.00 0.00 0146T TC A 163.88 0.00 0.00<br />

C8905 A 312.29 0.00 0.00 0147T TC A 163.88 0.00 0.00<br />

C8906 A 247.78 0.00 0.00 0148T TC A 163.88 0.00 0.00<br />

C8907 A 201.77 0.00 0.00 0149T TC A 163.88 0.00 0.00<br />

C8908 A 312.29 0.00 0.00 0150T TC A 163.88 0.00 0.00<br />

C8909 A 247.78 0.00 0.00 0151T TC A 60.88 0.00 0.00<br />

C8910 A 201.77 0.00 0.00 0170T S 1,188.69 0.00 0.00<br />

C8911 A 312.29 0.00 0.00 0176T S 1,403.58 0.00 0.00<br />

C8912 A 247.78 0.00 0.00 0177T S 1,403.58 0.00 0.00<br />

C8913 A 201.77 0.00 0.00 0182T A 1,014.51 0.00 0.00<br />

C8914 A 312.29 0.00 0.00 0186T S 855.03 0.00 0.00<br />

C8918 A 247.78 0.00 0.00 0190T S 855.03 0.00 0.00<br />

C8919 A 201.77 0.00 0.00 0191T S 915.13 0.00 0.00<br />

C8920 A 312.29 0.00 0.00 0192T S 1,568.35 0.00 0.00<br />

C9716 S 1,188.69 0.00 0.00 10021 S 54.85 0.00 0.00<br />

C9724 S 971.89 0.00 0.00 10022 S 171.29 0.00 0.00<br />

C9725 S 224.12 0.00 0.00 10040 S 31.71 0.00 0.00<br />

C9726 S 822.79 0.00 0.00 10060 S 48.25 0.00 0.00<br />

C9727 S 288.48 0.00 0.00 10061 S 54.10 0.00 0.00<br />

C9728 S 517.63 0.00 0.00 10080 S 54.10 0.00 0.00<br />

G0104 S 83.15 0.00 0.00 10081 S 124.56 0.00 0.00<br />

G0105 S 359.39 0.00 0.00 10120 S 67.75 0.00 0.00<br />

G0121 S 359.39 0.00 0.00 10121 S 510.71 0.00 0.00<br />

G0127 S 11.63 0.00 0.00 10140 S 71.86 0.00 0.00<br />

G0130 TC A 19.17 0.00 0.00 10160 S 54.10 0.00 0.00<br />

G0173 A 2,204.81 0.00 0.00 10180 S 577.54 0.00 0.00<br />

G0186 S 223.18 0.00 0.00 11000 S 23.27 0.00 0.00<br />

G0247 S 21.22 0.00 0.00 11001 S 7.88 0.00 0.00<br />

G0251 A 552.12 0.00 0.00 11010 S 202.06 0.00 0.00<br />

G0260 S 291.37 0.00 0.00 11011 S 202.06 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 202.06 0.00 0.00 11601 S 111.56 0.00 0.00<br />

11040 S 21.22 0.00 0.00 11602 S 122.85 0.00 0.00<br />

11041 S 23.62 0.00 0.00 11603 S 130.37 0.00 0.00<br />

11042 S 128.31 0.00 0.00 11604 S 351.68 0.00 0.00<br />

11043 S 128.31 0.00 0.00 11606 S 510.71 0.00 0.00<br />

11044 S 334.09 0.00 0.00 11620 S 95.14 0.00 0.00<br />

11055 S 24.98 0.00 0.00 11621 S 112.93 0.00 0.00<br />

11056 S 27.37 0.00 0.00 11622 S 125.58 0.00 0.00<br />

11057 S 31.71 0.00 0.00 11623 S 135.17 0.00 0.00<br />

11100 S 58.10 0.00 0.00 11624 S 510.71 0.00 0.00<br />

11101 S 13.69 0.00 0.00 11626 S 624.56 0.00 0.00<br />

11200 S 31.71 0.00 0.00 11640 S 100.61 0.00 0.00<br />

11201 S 5.47 0.00 0.00 11641 S 118.74 0.00 0.00<br />

11300 S 31.71 0.00 0.00 11642 S 132.43 0.00 0.00<br />

11301 S 31.71 0.00 0.00 11643 S 142.70 0.00 0.00<br />

11302 S 31.71 0.00 0.00 11644 S 510.71 0.00 0.00<br />

11303 S 58.10 0.00 0.00 11646 S 624.56 0.00 0.00<br />

11305 S 31.71 0.00 0.00 11719 S 11.63 0.00 0.00<br />

11306 S 31.71 0.00 0.00 11720 S 14.37 0.00 0.00<br />

11307 S 31.71 0.00 0.00 11721 S 17.45 0.00 0.00<br />

11308 S 31.71 0.00 0.00 11730 S 31.71 0.00 0.00<br />

11310 S 31.71 0.00 0.00 11732 S 17.45 0.00 0.00<br />

11311 S 31.71 0.00 0.00 11740 S 16.02 0.00 0.00<br />

11312 S 31.71 0.00 0.00 11750 S 92.39 0.00 0.00<br />

11313 S 31.71 0.00 0.00 11752 S 128.33 0.00 0.00<br />

11400 S 65.36 0.00 0.00 11755 S 63.99 0.00 0.00<br />

11401 S 73.57 0.00 0.00 11760 S 131.79 0.00 0.00<br />

11402 S 80.76 0.00 0.00 11762 S 117.72 0.00 0.00<br />

11403 S 86.24 0.00 0.00 11765 S 31.71 0.00 0.00<br />

11404 S 458.44 0.00 0.00 11770 S 654.17 0.00 0.00<br />

11406 S 510.71 0.00 0.00 11771 S 654.17 0.00 0.00<br />

11420 S 61.25 0.00 0.00 11772 S 654.17 0.00 0.00<br />

11421 S 74.25 0.00 0.00 11900 S 29.09 0.00 0.00<br />

11422 S 81.10 0.00 0.00 11901 S 31.71 0.00 0.00<br />

11423 S 90.34 0.00 0.00 11920 S 92.05 0.00 0.00<br />

11424 S 510.71 0.00 0.00 11921 S 101.29 0.00 0.00<br />

11426 S 624.56 0.00 0.00 11922 S 32.85 0.00 0.00<br />

11440 S 70.15 0.00 0.00 11950 S 33.54 0.00 0.00<br />

11441 S 81.10 0.00 0.00 11951 S 41.75 0.00 0.00<br />

11442 S 89.31 0.00 0.00 11952 S 50.26 0.00 0.00<br />

11443 S 98.89 0.00 0.00 11954 S 50.26 0.00 0.00<br />

11444 S 312.14 0.00 0.00 11960 S 609.68 0.00 0.00<br />

11446 S 624.56 0.00 0.00 11970 S 1,104.34 0.00 0.00<br />

11450 S 624.56 0.00 0.00 11971 S 572.29 0.00 0.00<br />

11451 S 624.56 0.00 0.00 11976 S 61.25 0.00 0.00<br />

11462 S 624.56 0.00 0.00 11980 S 24.74 0.00 0.00<br />

11463 S 624.56 0.00 0.00 11981 S 24.74 0.00 0.00<br />

11470 S 624.56 0.00 0.00 11982 S 24.74 0.00 0.00<br />

11471 S 624.56 0.00 0.00 11983 S 24.74 0.00 0.00<br />

11600 S 92.05 0.00 0.00 12001 S 50.26 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 50.26 0.00 0.00 14021 S 541.80 0.00 0.00<br />

12004 S 50.26 0.00 0.00 14040 S 512.20 0.00 0.00<br />

12005 S 67.34 0.00 0.00 14041 S 541.80 0.00 0.00<br />

12006 S 67.34 0.00 0.00 14060 S 541.80 0.00 0.00<br />

12007 S 67.34 0.00 0.00 14061 S 541.80 0.00 0.00<br />

12011 S 50.26 0.00 0.00 14300 S 694.80 0.00 0.00<br />

12013 S 50.26 0.00 0.00 14350 S 639.28 0.00 0.00<br />

12014 S 50.26 0.00 0.00 15002 S 234.38 0.00 0.00<br />

12015 S 50.26 0.00 0.00 15003 S 234.38 0.00 0.00<br />

12016 S 67.34 0.00 0.00 15004 S 234.38 0.00 0.00<br />

12017 S 67.34 0.00 0.00 15005 S 234.38 0.00 0.00<br />

12018 S 67.34 0.00 0.00 15040 S 108.10 0.00 0.00<br />

12020 S 127.04 0.00 0.00 15050 S 234.38 0.00 0.00<br />

12021 S 108.10 0.00 0.00 15100 S 609.68 0.00 0.00<br />

12031 S 50.26 0.00 0.00 15101 S 639.28 0.00 0.00<br />

12032 S 131.79 0.00 0.00 15110 S 291.15 0.00 0.00<br />

12034 S 67.34 0.00 0.00 15111 S 238.88 0.00 0.00<br />

12035 S 67.34 0.00 0.00 15115 S 291.15 0.00 0.00<br />

12036 S 108.10 0.00 0.00 15116 S 238.88 0.00 0.00<br />

12037 S 215.44 0.00 0.00 15120 S 609.68 0.00 0.00<br />

12041 S 50.26 0.00 0.00 15121 S 639.28 0.00 0.00<br />

12042 S 50.26 0.00 0.00 15130 S 512.20 0.00 0.00<br />

12044 S 67.34 0.00 0.00 15131 S 459.92 0.00 0.00<br />

12045 S 108.10 0.00 0.00 15135 S 512.20 0.00 0.00<br />

12046 S 108.10 0.00 0.00 15136 S 459.92 0.00 0.00<br />

12047 S 215.44 0.00 0.00 15150 S 291.15 0.00 0.00<br />

12051 S 50.26 0.00 0.00 15151 S 238.88 0.00 0.00<br />

12052 S 50.26 0.00 0.00 15152 S 238.88 0.00 0.00<br />

12053 S 50.26 0.00 0.00 15155 S 291.15 0.00 0.00<br />

12054 S 67.34 0.00 0.00 15156 S 238.88 0.00 0.00<br />

12055 S 108.10 0.00 0.00 15157 S 238.88 0.00 0.00<br />

12056 S 108.10 0.00 0.00 15170 S 131.79 0.00 0.00<br />

12057 S 215.44 0.00 0.00 15171 S 131.79 0.00 0.00<br />

13100 S 234.38 0.00 0.00 15175 S 169.67 0.00 0.00<br />

13101 S 234.38 0.00 0.00 15176 S 169.67 0.00 0.00<br />

13102 S 127.04 0.00 0.00 15200 S 541.80 0.00 0.00<br />

13120 S 108.10 0.00 0.00 15201 S 455.43 0.00 0.00<br />

13121 S 108.10 0.00 0.00 15220 S 512.20 0.00 0.00<br />

13122 S 108.10 0.00 0.00 15221 S 234.38 0.00 0.00<br />

13131 S 108.10 0.00 0.00 15240 S 541.80 0.00 0.00<br />

13132 S 108.10 0.00 0.00 15241 S 234.38 0.00 0.00<br />

13133 S 108.10 0.00 0.00 15260 S 512.20 0.00 0.00<br />

13150 S 234.38 0.00 0.00 15261 S 455.43 0.00 0.00<br />

13151 S 234.38 0.00 0.00 15300 S 234.38 0.00 0.00<br />

13152 S 234.38 0.00 0.00 15301 S 234.38 0.00 0.00<br />

13153 S 108.10 0.00 0.00 15320 S 234.38 0.00 0.00<br />

13160 S 609.68 0.00 0.00 15321 S 234.38 0.00 0.00<br />

14000 S 512.20 0.00 0.00 15330 S 234.38 0.00 0.00<br />

14001 S 541.80 0.00 0.00 15331 S 234.38 0.00 0.00<br />

14020 S 541.80 0.00 0.00 15335 S 234.38 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 234.38 0.00 0.00 15826 S 639.28 0.00 0.00<br />

15340 S 131.79 0.00 0.00 15828 S 639.28 0.00 0.00<br />

15341 S 131.79 0.00 0.00 15829 S 735.04 0.00 0.00<br />

15360 S 131.79 0.00 0.00 15830 S 654.17 0.00 0.00<br />

15361 S 131.79 0.00 0.00 15832 S 654.17 0.00 0.00<br />

15365 S 131.79 0.00 0.00 15833 S 654.17 0.00 0.00<br />

15366 S 131.79 0.00 0.00 15834 S 654.17 0.00 0.00<br />

15400 S 234.38 0.00 0.00 15835 S 567.79 0.00 0.00<br />

15401 S 234.38 0.00 0.00 15836 S 540.32 0.00 0.00<br />

15420 S 234.38 0.00 0.00 15837 S 608.81 0.00 0.00<br />

15421 S 234.38 0.00 0.00 15838 S 608.81 0.00 0.00<br />

15430 S 234.38 0.00 0.00 15839 S 540.32 0.00 0.00<br />

15431 S 234.38 0.00 0.00 15840 S 694.80 0.00 0.00<br />

15570 S 639.28 0.00 0.00 15841 S 694.80 0.00 0.00<br />

15572 S 639.28 0.00 0.00 15842 S 806.73 0.00 0.00<br />

15574 S 639.28 0.00 0.00 15845 S 694.80 0.00 0.00<br />

15576 S 639.28 0.00 0.00 15847 S 654.17 0.00 0.00<br />

15600 S 639.28 0.00 0.00 15850 S 104.50 0.00 0.00<br />

15610 S 639.28 0.00 0.00 15851 S 47.56 0.00 0.00<br />

15620 S 694.80 0.00 0.00 15852 S 24.74 0.00 0.00<br />

15630 S 639.28 0.00 0.00 15860 S 24.74 0.00 0.00<br />

15650 S 735.04 0.00 0.00 15876 S 639.28 0.00 0.00<br />

15731 S 639.28 0.00 0.00 15877 S 639.28 0.00 0.00<br />

15732 S 639.28 0.00 0.00 15878 S 639.28 0.00 0.00<br />

15734 S 639.28 0.00 0.00 15879 S 639.28 0.00 0.00<br />

15736 S 639.28 0.00 0.00 15920 S 202.06 0.00 0.00<br />

15738 S 639.28 0.00 0.00 15922 S 694.80 0.00 0.00<br />

15740 S 512.20 0.00 0.00 15931 S 654.17 0.00 0.00<br />

15750 S 609.68 0.00 0.00 15933 S 654.17 0.00 0.00<br />

15760 S 609.68 0.00 0.00 15934 S 639.28 0.00 0.00<br />

15770 S 639.28 0.00 0.00 15935 S 694.80 0.00 0.00<br />

15775 S 174.67 0.00 0.00 15936 S 597.32 0.00 0.00<br />

15776 S 174.67 0.00 0.00 15937 S 694.80 0.00 0.00<br />

15780 S 389.43 0.00 0.00 15940 S 654.17 0.00 0.00<br />

15781 S 171.41 0.00 0.00 15941 S 654.17 0.00 0.00<br />

15782 S 171.41 0.00 0.00 15944 S 639.28 0.00 0.00<br />

15783 S 104.50 0.00 0.00 15945 S 694.80 0.00 0.00<br />

15786 S 31.71 0.00 0.00 15946 S 694.80 0.00 0.00<br />

15787 S 28.75 0.00 0.00 15950 S 654.17 0.00 0.00<br />

15788 S 31.71 0.00 0.00 15951 S 709.67 0.00 0.00<br />

15789 S 58.10 0.00 0.00 15952 S 541.80 0.00 0.00<br />

15792 S 58.10 0.00 0.00 15953 S 597.32 0.00 0.00<br />

15793 S 31.71 0.00 0.00 15956 S 541.80 0.00 0.00<br />

15819 S 131.79 0.00 0.00 15958 S 597.32 0.00 0.00<br />

15820 S 639.28 0.00 0.00 16000 S 25.67 0.00 0.00<br />

15821 S 639.28 0.00 0.00 16020 S 39.01 0.00 0.00<br />

15822 S 639.28 0.00 0.00 16025 S 60.09 0.00 0.00<br />

15823 S 735.04 0.00 0.00 16030 S 75.23 0.00 0.00<br />

15824 S 639.28 0.00 0.00 16035 S 58.10 0.00 0.00<br />

15825 S 639.28 0.00 0.00 17000 S 31.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.77 0.00 0.00 19300 S 702.82 0.00 0.00<br />

17004 S 82.81 0.00 0.00 19301 S 647.32 0.00 0.00<br />

17106 S 104.50 0.00 0.00 19302 S 1,236.31 0.00 0.00<br />

17107 S 104.50 0.00 0.00 19303 S 934.31 0.00 0.00<br />

17108 S 104.50 0.00 0.00 19304 S 934.31 0.00 0.00<br />

17110 S 31.71 0.00 0.00 19316 S 934.31 0.00 0.00<br />

17111 S 58.10 0.00 0.00 19318 S 1,067.46 0.00 0.00<br />

17250 S 43.81 0.00 0.00 19324 S 1,067.46 0.00 0.00<br />

17260 S 46.88 0.00 0.00 19325 S 1,770.51 0.00 0.00<br />

17261 S 58.10 0.00 0.00 19328 S 796.93 0.00 0.00<br />

17262 S 58.10 0.00 0.00 19330 S 796.93 0.00 0.00<br />

17263 S 58.10 0.00 0.00 19340 S 982.34 0.00 0.00<br />

17264 S 58.10 0.00 0.00 19342 S 1,387.02 0.00 0.00<br />

17266 S 104.50 0.00 0.00 19350 S 702.82 0.00 0.00<br />

17270 S 58.10 0.00 0.00 19355 S 934.31 0.00 0.00<br />

17271 S 58.10 0.00 0.00 19357 S 1,482.78 0.00 0.00<br />

17272 S 58.10 0.00 0.00 19366 S 974.56 0.00 0.00<br />

17273 S 104.50 0.00 0.00 19370 S 934.31 0.00 0.00<br />

17274 S 104.50 0.00 0.00 19371 S 934.31 0.00 0.00<br />

17276 S 104.50 0.00 0.00 19380 S 1,107.71 0.00 0.00<br />

17280 S 58.10 0.00 0.00 19396 S 1,285.76 0.00 0.00<br />

17281 S 86.58 0.00 0.00 20000 S 54.10 0.00 0.00<br />

17282 S 98.89 0.00 0.00 20005 S 623.37 0.00 0.00<br />

17283 S 104.50 0.00 0.00 20103 S 611.78 0.00 0.00<br />

17284 S 104.50 0.00 0.00 20150 S 1,736.84 0.00 0.00<br />

17286 S 104.50 0.00 0.00 20200 S 510.71 0.00 0.00<br />

17311 S 172.51 0.00 0.00 20205 S 540.32 0.00 0.00<br />

17312 S 172.51 0.00 0.00 20206 S 252.49 0.00 0.00<br />

17313 S 172.51 0.00 0.00 20220 S 274.45 0.00 0.00<br />

17314 S 172.51 0.00 0.00 20225 S 497.99 0.00 0.00<br />

17315 S 39.01 0.00 0.00 20240 S 624.56 0.00 0.00<br />

17340 S 14.03 0.00 0.00 20245 S 654.17 0.00 0.00<br />

17360 S 31.71 0.00 0.00 20250 S 652.98 0.00 0.00<br />

17380 S 31.71 0.00 0.00 20251 S 652.98 0.00 0.00<br />

19000 S 66.05 0.00 0.00 20500 S 54.07 0.00 0.00<br />

19001 S 8.90 0.00 0.00 20520 S 91.03 0.00 0.00<br />

19020 S 577.54 0.00 0.00 20525 S 654.17 0.00 0.00<br />

19100 S 196.67 0.00 0.00 20526 S 29.43 0.00 0.00<br />

19101 S 617.71 0.00 0.00 20550 S 22.24 0.00 0.00<br />

19102 S 252.49 0.00 0.00 20551 S 21.90 0.00 0.00<br />

19103 S 441.91 0.00 0.00 20552 S 21.22 0.00 0.00<br />

19105 S 1,285.76 0.00 0.00 20553 S 23.62 0.00 0.00<br />

19110 S 617.71 0.00 0.00 20555 S 1,144.34 0.00 0.00<br />

19112 S 647.32 0.00 0.00 20600 S 22.58 0.00 0.00<br />

19120 S 647.32 0.00 0.00 20605 S 25.32 0.00 0.00<br />

19125 S 647.32 0.00 0.00 20610 S 35.59 0.00 0.00<br />

19126 S 647.32 0.00 0.00 20612 S 23.96 0.00 0.00<br />

19296 S 1,770.51 0.00 0.00 20615 S 100.27 0.00 0.00<br />

19297 S 1,770.51 0.00 0.00 20650 S 652.98 0.00 0.00<br />

19298 S 1,770.51 0.00 0.00 20662 S 834.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 834.12 0.00 0.00 21085 S 251.18 0.00 0.00<br />

20665 S 24.74 0.00 0.00 21086 S 546.83 0.00 0.00<br />

20670 S 458.44 0.00 0.00 21087 S 547.52 0.00 0.00<br />

20680 S 654.17 0.00 0.00 21088 S 1,603.60 0.00 0.00<br />

20690 S 778.48 0.00 0.00 21100 S 1,008.11 0.00 0.00<br />

20692 S 808.09 0.00 0.00 21110 S 288.48 0.00 0.00<br />

20693 S 652.98 0.00 0.00 21120 S 934.29 0.00 0.00<br />

20694 S 571.10 0.00 0.00 21121 S 934.29 0.00 0.00<br />

20696 S 1,144.34 0.00 0.00 21122 S 934.29 0.00 0.00<br />

20697 S 761.03 0.00 0.00 21123 S 934.29 0.00 0.00<br />

20822 S 1,072.26 0.00 0.00 21125 S 934.29 0.00 0.00<br />

20900 S 808.09 0.00 0.00 21127 S 1,421.20 0.00 0.00<br />

20902 S 863.60 0.00 0.00 21137 S 948.04 0.00 0.00<br />

20910 S 639.28 0.00 0.00 21138 S 1,603.60 0.00 0.00<br />

20912 S 639.28 0.00 0.00 21139 S 1,603.60 0.00 0.00<br />

20920 S 597.32 0.00 0.00 21150 S 1,603.60 0.00 0.00<br />

20922 S 541.80 0.00 0.00 21181 S 934.29 0.00 0.00<br />

20924 S 863.60 0.00 0.00 21198 S 1,603.60 0.00 0.00<br />

20926 S 376.27 0.00 0.00 21199 S 1,603.60 0.00 0.00<br />

20950 S 54.10 0.00 0.00 21206 S 1,133.47 0.00 0.00<br />

20972 S 1,811.07 0.00 0.00 21208 S 1,262.07 0.00 0.00<br />

20973 S 1,811.07 0.00 0.00 21209 S 1,133.47 0.00 0.00<br />

20979 S 22.24 0.00 0.00 21210 S 1,262.07 0.00 0.00<br />

20982 S 1,736.84 0.00 0.00 21215 S 1,262.07 0.00 0.00<br />

21010 S 680.33 0.00 0.00 21230 S 1,262.07 0.00 0.00<br />

21015 S 566.04 0.00 0.00 21235 S 934.29 0.00 0.00<br />

21025 S 1,008.11 0.00 0.00 21240 S 1,093.23 0.00 0.00<br />

21026 S 1,008.11 0.00 0.00 21242 S 1,133.47 0.00 0.00<br />

21029 S 1,008.11 0.00 0.00 21243 S 1,133.47 0.00 0.00<br />

21030 S 237.83 0.00 0.00 21244 S 1,262.07 0.00 0.00<br />

21031 S 196.76 0.00 0.00 21245 S 1,262.07 0.00 0.00<br />

21032 S 200.53 0.00 0.00 21246 S 1,262.07 0.00 0.00<br />

21034 S 1,037.72 0.00 0.00 21248 S 1,262.07 0.00 0.00<br />

21040 S 680.33 0.00 0.00 21249 S 1,262.07 0.00 0.00<br />

21044 S 1,008.11 0.00 0.00 21260 S 1,603.60 0.00 0.00<br />

21046 S 1,008.11 0.00 0.00 21267 S 1,262.07 0.00 0.00<br />

21047 S 1,008.11 0.00 0.00 21270 S 1,133.47 0.00 0.00<br />

21048 S 1,603.60 0.00 0.00 21275 S 1,262.07 0.00 0.00<br />

21050 S 1,037.72 0.00 0.00 21280 S 1,133.47 0.00 0.00<br />

21060 S 1,008.11 0.00 0.00 21282 S 661.79 0.00 0.00<br />

21070 S 1,037.72 0.00 0.00 21295 S 298.28 0.00 0.00<br />

21073 S 184.79 0.00 0.00 21296 S 628.06 0.00 0.00<br />

21076 S 320.64 0.00 0.00 21310 S 90.99 0.00 0.00<br />

21077 S 775.08 0.00 0.00 21315 S 399.83 0.00 0.00<br />

21079 S 555.05 0.00 0.00 21320 S 536.42 0.00 0.00<br />

21080 S 636.49 0.00 0.00 21325 S 765.44 0.00 0.00<br />

21081 S 586.53 0.00 0.00 21330 S 805.69 0.00 0.00<br />

21082 S 558.13 0.00 0.00 21335 S 934.29 0.00 0.00<br />

21083 S 549.91 0.00 0.00 21336 S 778.63 0.00 0.00<br />

21084 S 632.73 0.00 0.00 21337 S 536.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 765.44 0.00 0.00 22310 S 165.65 0.00 0.00<br />

21339 S 805.69 0.00 0.00 22315 S 428.45 0.00 0.00<br />

21340 S 1,093.23 0.00 0.00 22505 S 504.39 0.00 0.00<br />

21345 S 934.29 0.00 0.00 22520 S 1,191.57 0.00 0.00<br />

21355 S 1,037.72 0.00 0.00 22521 S 1,191.57 0.00 0.00<br />

21356 S 709.94 0.00 0.00 22522 S 1,191.57 0.00 0.00<br />

21360 S 948.04 0.00 0.00 22523 S 3,316.26 0.00 0.00<br />

21390 S 1,603.60 0.00 0.00 22524 S 3,316.26 0.00 0.00<br />

21400 S 350.55 0.00 0.00 22525 S 3,316.26 0.00 0.00<br />

21401 S 566.04 0.00 0.00 22900 S 709.67 0.00 0.00<br />

21406 S 1,603.60 0.00 0.00 23000 S 510.71 0.00 0.00<br />

21407 S 1,603.60 0.00 0.00 23020 S 1,074.73 0.00 0.00<br />

21421 S 765.44 0.00 0.00 23030 S 525.27 0.00 0.00<br />

21440 S 322.35 0.00 0.00 23031 S 607.15 0.00 0.00<br />

21445 S 765.44 0.00 0.00 23035 S 652.98 0.00 0.00<br />

21450 S 133.04 0.00 0.00 23040 S 808.09 0.00 0.00<br />

21451 S 358.95 0.00 0.00 23044 S 863.60 0.00 0.00<br />

21452 S 536.42 0.00 0.00 23065 S 96.50 0.00 0.00<br />

21453 S 1,037.72 0.00 0.00 23066 S 624.56 0.00 0.00<br />

21454 S 805.69 0.00 0.00 23075 S 510.71 0.00 0.00<br />

21461 S 1,093.23 0.00 0.00 23076 S 624.56 0.00 0.00<br />

21462 S 1,133.47 0.00 0.00 23077 S 654.17 0.00 0.00<br />

21465 S 1,093.23 0.00 0.00 23100 S 623.37 0.00 0.00<br />

21480 S 90.99 0.00 0.00 23101 S 1,032.45 0.00 0.00<br />

21485 S 536.42 0.00 0.00 23105 S 863.60 0.00 0.00<br />

21490 S 1,037.72 0.00 0.00 23106 S 863.60 0.00 0.00<br />

21495 S 660.22 0.00 0.00 23107 S 863.60 0.00 0.00<br />

21497 S 536.42 0.00 0.00 23120 S 903.85 0.00 0.00<br />

21501 S 577.54 0.00 0.00 23125 S 903.85 0.00 0.00<br />

21502 S 623.37 0.00 0.00 23130 S 1,200.09 0.00 0.00<br />

21550 S 608.81 0.00 0.00 23140 S 708.49 0.00 0.00<br />

21555 S 624.56 0.00 0.00 23145 S 903.85 0.00 0.00<br />

21556 S 624.56 0.00 0.00 23146 S 903.85 0.00 0.00<br />

21557 S 836.49 0.00 0.00 23150 S 863.60 0.00 0.00<br />

21600 S 778.48 0.00 0.00 23155 S 903.85 0.00 0.00<br />

21610 S 778.48 0.00 0.00 23156 S 903.85 0.00 0.00<br />

21685 S 288.48 0.00 0.00 23170 S 778.48 0.00 0.00<br />

21700 S 623.37 0.00 0.00 23172 S 778.48 0.00 0.00<br />

21720 S 652.98 0.00 0.00 23174 S 778.48 0.00 0.00<br />

21725 S 67.97 0.00 0.00 23180 S 863.60 0.00 0.00<br />

21800 S 78.52 0.00 0.00 23182 S 863.60 0.00 0.00<br />

21805 S 693.52 0.00 0.00 23184 S 863.60 0.00 0.00<br />

21820 S 78.52 0.00 0.00 23190 S 863.60 0.00 0.00<br />

21920 S 139.62 0.00 0.00 23195 S 903.85 0.00 0.00<br />

21925 S 624.56 0.00 0.00 23330 S 312.14 0.00 0.00<br />

21930 S 624.56 0.00 0.00 23331 S 572.29 0.00 0.00<br />

21935 S 654.17 0.00 0.00 23395 S 1,200.09 0.00 0.00<br />

22102 S 1,861.44 0.00 0.00 23397 S 2,118.40 0.00 0.00<br />

22103 S 1,861.44 0.00 0.00 23400 S 1,032.45 0.00 0.00<br />

22305 S 78.52 0.00 0.00 23405 S 778.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 778.48 0.00 0.00 23931 S 577.54 0.00 0.00<br />

23410 S 1,200.09 0.00 0.00 23935 S 623.37 0.00 0.00<br />

23412 S 1,328.69 0.00 0.00 24000 S 863.60 0.00 0.00<br />

23415 S 1,200.09 0.00 0.00 24006 S 863.60 0.00 0.00<br />

23420 S 1,328.69 0.00 0.00 24065 S 133.80 0.00 0.00<br />

23430 S 1,159.85 0.00 0.00 24066 S 510.71 0.00 0.00<br />

23440 S 1,159.85 0.00 0.00 24075 S 510.71 0.00 0.00<br />

23450 S 1,989.80 0.00 0.00 24076 S 624.56 0.00 0.00<br />

23455 S 2,118.40 0.00 0.00 24077 S 654.17 0.00 0.00<br />

23460 S 1,989.80 0.00 0.00 24100 S 571.10 0.00 0.00<br />

23462 S 1,328.69 0.00 0.00 24101 S 863.60 0.00 0.00<br />

23465 S 1,989.80 0.00 0.00 24102 S 863.60 0.00 0.00<br />

23466 S 1,328.69 0.00 0.00 24105 S 652.98 0.00 0.00<br />

23480 S 1,159.85 0.00 0.00 24110 S 623.37 0.00 0.00<br />

23485 S 2,118.40 0.00 0.00 24115 S 808.09 0.00 0.00<br />

23490 S 1,104.34 0.00 0.00 24116 S 808.09 0.00 0.00<br />

23491 S 1,894.05 0.00 0.00 24120 S 652.98 0.00 0.00<br />

23500 S 78.52 0.00 0.00 24125 S 808.09 0.00 0.00<br />

23505 S 428.45 0.00 0.00 24126 S 808.09 0.00 0.00<br />

23515 S 1,433.99 0.00 0.00 24130 S 808.09 0.00 0.00<br />

23520 S 165.65 0.00 0.00 24134 S 778.48 0.00 0.00<br />

23525 S 165.65 0.00 0.00 24136 S 778.48 0.00 0.00<br />

23530 S 1,056.71 0.00 0.00 24138 S 778.48 0.00 0.00<br />

23532 S 778.63 0.00 0.00 24140 S 808.09 0.00 0.00<br />

23540 S 78.52 0.00 0.00 24145 S 808.09 0.00 0.00<br />

23545 S 165.65 0.00 0.00 24147 S 778.48 0.00 0.00<br />

23550 S 1,056.71 0.00 0.00 24149 S 1,144.34 0.00 0.00<br />

23552 S 1,112.22 0.00 0.00 24152 S 1,736.84 0.00 0.00<br />

23570 S 78.52 0.00 0.00 24153 S 3,316.26 0.00 0.00<br />

23575 S 165.65 0.00 0.00 24155 S 1,104.34 0.00 0.00<br />

23585 S 1,433.99 0.00 0.00 24160 S 778.48 0.00 0.00<br />

23600 S 61.19 0.00 0.00 24164 S 808.09 0.00 0.00<br />

23605 S 428.45 0.00 0.00 24200 S 97.87 0.00 0.00<br />

23615 S 1,489.49 0.00 0.00 24201 S 510.71 0.00 0.00<br />

23616 S 1,489.49 0.00 0.00 24300 S 596.16 0.00 0.00<br />

23620 S 61.19 0.00 0.00 24301 S 863.60 0.00 0.00<br />

23625 S 428.45 0.00 0.00 24305 S 863.60 0.00 0.00<br />

23630 S 1,529.74 0.00 0.00 24310 S 652.98 0.00 0.00<br />

23650 S 78.52 0.00 0.00 24320 S 1,104.34 0.00 0.00<br />

23655 S 452.12 0.00 0.00 24330 S 1,894.05 0.00 0.00<br />

23660 S 1,056.71 0.00 0.00 24331 S 1,104.34 0.00 0.00<br />

23665 S 165.65 0.00 0.00 24332 S 834.12 0.00 0.00<br />

23670 S 1,433.99 0.00 0.00 24340 S 1,104.34 0.00 0.00<br />

23675 S 78.52 0.00 0.00 24341 S 1,104.34 0.00 0.00<br />

23680 S 1,056.71 0.00 0.00 24342 S 1,104.34 0.00 0.00<br />

23700 S 452.12 0.00 0.00 24343 S 1,144.34 0.00 0.00<br />

23800 S 1,949.56 0.00 0.00 24344 S 3,316.26 0.00 0.00<br />

23802 S 1,328.69 0.00 0.00 24345 S 778.48 0.00 0.00<br />

23921 S 455.43 0.00 0.00 24346 S 1,736.84 0.00 0.00<br />

23930 S 525.27 0.00 0.00 24357 S 1,144.34 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,144.34 0.00 0.00 24925 S 652.98 0.00 0.00<br />

24359 S 1,144.34 0.00 0.00 25000 S 652.98 0.00 0.00<br />

24360 S 1,056.06 0.00 0.00 25001 S 834.12 0.00 0.00<br />

24361 S 5,774.04 3,534.44 1,294.85 25020 S 652.98 0.00 0.00<br />

24362 S 1,349.64 0.00 0.00 25023 S 808.09 0.00 0.00<br />

24363 S 5,902.64 3,663.04 1,423.45 25024 S 808.09 0.00 0.00<br />

24365 S 1,056.06 0.00 0.00 25025 S 808.09 0.00 0.00<br />

24366 S 5,774.04 3,534.44 1,294.85 25028 S 571.10 0.00 0.00<br />

24400 S 863.60 0.00 0.00 25031 S 623.37 0.00 0.00<br />

24410 S 863.60 0.00 0.00 25035 S 623.37 0.00 0.00<br />

24420 S 1,104.34 0.00 0.00 25040 S 903.85 0.00 0.00<br />

24430 S 1,894.05 0.00 0.00 25065 S 135.85 0.00 0.00<br />

24435 S 1,949.56 0.00 0.00 25066 S 624.56 0.00 0.00<br />

24470 S 1,104.34 0.00 0.00 25075 S 510.71 0.00 0.00<br />

24495 S 778.48 0.00 0.00 25076 S 654.17 0.00 0.00<br />

24498 S 1,894.05 0.00 0.00 25077 S 654.17 0.00 0.00<br />

24500 S 78.52 0.00 0.00 25085 S 652.98 0.00 0.00<br />

24505 S 78.52 0.00 0.00 25100 S 623.37 0.00 0.00<br />

24515 S 1,489.49 0.00 0.00 25101 S 808.09 0.00 0.00<br />

24516 S 1,489.49 0.00 0.00 25105 S 863.60 0.00 0.00<br />

24530 S 78.52 0.00 0.00 25107 S 808.09 0.00 0.00<br />

24535 S 165.65 0.00 0.00 25109 S 834.12 0.00 0.00<br />

24538 S 693.52 0.00 0.00 25110 S 652.98 0.00 0.00<br />

24545 S 1,489.49 0.00 0.00 25111 S 652.98 0.00 0.00<br />

24546 S 1,529.74 0.00 0.00 25112 S 708.49 0.00 0.00<br />

24560 S 78.52 0.00 0.00 25115 S 708.49 0.00 0.00<br />

24565 S 78.52 0.00 0.00 25116 S 708.49 0.00 0.00<br />

24566 S 693.52 0.00 0.00 25118 S 778.48 0.00 0.00<br />

24575 S 1,433.99 0.00 0.00 25119 S 808.09 0.00 0.00<br />

24576 S 78.52 0.00 0.00 25120 S 808.09 0.00 0.00<br />

24577 S 165.65 0.00 0.00 25125 S 808.09 0.00 0.00<br />

24579 S 1,433.99 0.00 0.00 25126 S 808.09 0.00 0.00<br />

24582 S 693.52 0.00 0.00 25130 S 808.09 0.00 0.00<br />

24586 S 1,489.49 0.00 0.00 25135 S 808.09 0.00 0.00<br />

24587 S 1,529.74 0.00 0.00 25136 S 808.09 0.00 0.00<br />

24600 S 78.52 0.00 0.00 25145 S 778.48 0.00 0.00<br />

24605 S 504.39 0.00 0.00 25150 S 778.48 0.00 0.00<br />

24615 S 1,433.99 0.00 0.00 25151 S 778.48 0.00 0.00<br />

24620 S 428.45 0.00 0.00 25210 S 808.09 0.00 0.00<br />

24635 S 1,433.99 0.00 0.00 25215 S 863.60 0.00 0.00<br />

24640 S 53.04 0.00 0.00 25230 S 863.60 0.00 0.00<br />

24650 S 61.19 0.00 0.00 25240 S 863.60 0.00 0.00<br />

24655 S 165.65 0.00 0.00 25248 S 623.37 0.00 0.00<br />

24665 S 1,112.22 0.00 0.00 25250 S 726.21 0.00 0.00<br />

24666 S 1,489.49 0.00 0.00 25251 S 726.21 0.00 0.00<br />

24670 S 78.52 0.00 0.00 25259 S 761.03 0.00 0.00<br />

24675 S 78.52 0.00 0.00 25260 S 863.60 0.00 0.00<br />

24685 S 1,056.71 0.00 0.00 25263 S 778.48 0.00 0.00<br />

24800 S 1,159.85 0.00 0.00 25265 S 808.09 0.00 0.00<br />

24802 S 1,200.09 0.00 0.00 25270 S 863.60 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 808.09 0.00 0.00 25505 S 165.65 0.00 0.00<br />

25274 S 863.60 0.00 0.00 25515 S 1,056.71 0.00 0.00<br />

25275 S 863.60 0.00 0.00 25520 S 165.65 0.00 0.00<br />

25280 S 863.60 0.00 0.00 25525 S 1,112.22 0.00 0.00<br />

25290 S 808.09 0.00 0.00 25526 S 1,152.46 0.00 0.00<br />

25295 S 652.98 0.00 0.00 25530 S 61.19 0.00 0.00<br />

25300 S 808.09 0.00 0.00 25535 S 78.52 0.00 0.00<br />

25301 S 808.09 0.00 0.00 25545 S 1,056.71 0.00 0.00<br />

25310 S 1,104.34 0.00 0.00 25560 S 61.19 0.00 0.00<br />

25312 S 1,159.85 0.00 0.00 25565 S 165.65 0.00 0.00<br />

25315 S 1,104.34 0.00 0.00 25574 S 1,433.99 0.00 0.00<br />

25316 S 1,894.05 0.00 0.00 25575 S 1,433.99 0.00 0.00<br />

25320 S 1,104.34 0.00 0.00 25600 S 61.19 0.00 0.00<br />

25332 S 1,056.06 0.00 0.00 25605 S 165.65 0.00 0.00<br />

25335 S 1,104.34 0.00 0.00 25606 S 723.13 0.00 0.00<br />

25337 S 1,200.09 0.00 0.00 25607 S 1,529.74 0.00 0.00<br />

25350 S 1,894.05 0.00 0.00 25608 S 1,529.74 0.00 0.00<br />

25355 S 1,104.34 0.00 0.00 25609 S 1,529.74 0.00 0.00<br />

25360 S 808.09 0.00 0.00 25622 S 61.19 0.00 0.00<br />

25365 S 808.09 0.00 0.00 25624 S 165.65 0.00 0.00<br />

25370 S 1,104.34 0.00 0.00 25628 S 1,056.71 0.00 0.00<br />

25375 S 1,159.85 0.00 0.00 25630 S 61.19 0.00 0.00<br />

25390 S 808.09 0.00 0.00 25635 S 165.65 0.00 0.00<br />

25391 S 1,159.85 0.00 0.00 25645 S 1,056.71 0.00 0.00<br />

25392 S 808.09 0.00 0.00 25650 S 61.19 0.00 0.00<br />

25393 S 1,159.85 0.00 0.00 25651 S 974.41 0.00 0.00<br />

25394 S 1,736.84 0.00 0.00 25652 S 1,641.57 0.00 0.00<br />

25400 S 1,104.34 0.00 0.00 25660 S 78.52 0.00 0.00<br />

25405 S 1,949.56 0.00 0.00 25670 S 723.13 0.00 0.00<br />

25415 S 1,894.05 0.00 0.00 25671 S 641.25 0.00 0.00<br />

25420 S 1,949.56 0.00 0.00 25675 S 78.52 0.00 0.00<br />

25425 S 1,104.34 0.00 0.00 25676 S 693.52 0.00 0.00<br />

25426 S 1,159.85 0.00 0.00 25680 S 78.52 0.00 0.00<br />

25430 S 1,736.84 0.00 0.00 25685 S 723.13 0.00 0.00<br />

25431 S 1,736.84 0.00 0.00 25690 S 428.45 0.00 0.00<br />

25440 S 1,949.56 0.00 0.00 25695 S 693.52 0.00 0.00<br />

25441 S 5,774.04 3,534.44 1,294.85 25800 S 1,949.56 0.00 0.00<br />

25442 S 5,774.04 3,534.44 1,294.85 25805 S 1,200.09 0.00 0.00<br />

25443 S 1,349.64 0.00 0.00 25810 S 1,989.80 0.00 0.00<br />

25444 S 1,349.64 0.00 0.00 25820 S 1,159.85 0.00 0.00<br />

25445 S 1,349.64 0.00 0.00 25825 S 1,989.80 0.00 0.00<br />

25446 S 5,902.64 3,663.04 1,423.45 25830 S 1,989.80 0.00 0.00<br />

25447 S 1,056.06 0.00 0.00 25907 S 652.98 0.00 0.00<br />

25449 S 1,056.06 0.00 0.00 25922 S 652.98 0.00 0.00<br />

25450 S 1,104.34 0.00 0.00 25929 S 541.80 0.00 0.00<br />

25455 S 1,104.34 0.00 0.00 25931 S 834.12 0.00 0.00<br />

25490 S 1,104.34 0.00 0.00 26010 S 54.10 0.00 0.00<br />

25491 S 1,104.34 0.00 0.00 26011 S 395.21 0.00 0.00<br />

25492 S 1,104.34 0.00 0.00 26020 S 524.40 0.00 0.00<br />

25500 S 61.19 0.00 0.00 26025 S 472.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 524.40 0.00 0.00 26392 S 772.05 0.00 0.00<br />

26034 S 524.40 0.00 0.00 26410 S 554.00 0.00 0.00<br />

26035 S 636.17 0.00 0.00 26412 S 772.05 0.00 0.00<br />

26040 S 827.56 0.00 0.00 26415 S 827.56 0.00 0.00<br />

26045 S 772.05 0.00 0.00 26416 S 772.05 0.00 0.00<br />

26055 S 524.40 0.00 0.00 26418 S 609.52 0.00 0.00<br />

26060 S 524.40 0.00 0.00 26420 S 827.56 0.00 0.00<br />

26070 S 524.40 0.00 0.00 26426 S 772.05 0.00 0.00<br />

26075 S 609.52 0.00 0.00 26428 S 772.05 0.00 0.00<br />

26080 S 609.52 0.00 0.00 26432 S 554.00 0.00 0.00<br />

26100 S 524.40 0.00 0.00 26433 S 554.00 0.00 0.00<br />

26105 S 472.12 0.00 0.00 26434 S 772.05 0.00 0.00<br />

26110 S 472.12 0.00 0.00 26437 S 554.00 0.00 0.00<br />

26115 S 624.56 0.00 0.00 26440 S 554.00 0.00 0.00<br />

26116 S 624.56 0.00 0.00 26442 S 772.05 0.00 0.00<br />

26117 S 654.17 0.00 0.00 26445 S 554.00 0.00 0.00<br />

26121 S 827.56 0.00 0.00 26449 S 772.05 0.00 0.00<br />

26123 S 827.56 0.00 0.00 26450 S 554.00 0.00 0.00<br />

26125 S 609.52 0.00 0.00 26455 S 554.00 0.00 0.00<br />

26130 S 554.00 0.00 0.00 26460 S 554.00 0.00 0.00<br />

26135 S 827.56 0.00 0.00 26471 S 524.40 0.00 0.00<br />

26140 S 524.40 0.00 0.00 26474 S 524.40 0.00 0.00<br />

26145 S 554.00 0.00 0.00 26476 S 472.12 0.00 0.00<br />

26160 S 554.00 0.00 0.00 26477 S 472.12 0.00 0.00<br />

26170 S 554.00 0.00 0.00 26478 S 472.12 0.00 0.00<br />

26180 S 554.00 0.00 0.00 26479 S 472.12 0.00 0.00<br />

26185 S 609.52 0.00 0.00 26480 S 772.05 0.00 0.00<br />

26200 S 524.40 0.00 0.00 26483 S 772.05 0.00 0.00<br />

26205 S 772.05 0.00 0.00 26485 S 742.45 0.00 0.00<br />

26210 S 524.40 0.00 0.00 26489 S 772.05 0.00 0.00<br />

26215 S 554.00 0.00 0.00 26490 S 772.05 0.00 0.00<br />

26230 S 777.41 0.00 0.00 26492 S 772.05 0.00 0.00<br />

26235 S 554.00 0.00 0.00 26494 S 772.05 0.00 0.00<br />

26236 S 554.00 0.00 0.00 26496 S 772.05 0.00 0.00<br />

26250 S 554.00 0.00 0.00 26497 S 772.05 0.00 0.00<br />

26255 S 772.05 0.00 0.00 26498 S 827.56 0.00 0.00<br />

26260 S 554.00 0.00 0.00 26499 S 772.05 0.00 0.00<br />

26261 S 554.00 0.00 0.00 26500 S 609.52 0.00 0.00<br />

26262 S 524.40 0.00 0.00 26502 S 827.56 0.00 0.00<br />

26320 S 510.71 0.00 0.00 26508 S 554.00 0.00 0.00<br />

26340 S 235.44 0.00 0.00 26510 S 772.05 0.00 0.00<br />

26350 S 690.17 0.00 0.00 26516 S 690.17 0.00 0.00<br />

26352 S 827.56 0.00 0.00 26517 S 772.05 0.00 0.00<br />

26356 S 827.56 0.00 0.00 26518 S 772.05 0.00 0.00<br />

26357 S 827.56 0.00 0.00 26520 S 554.00 0.00 0.00<br />

26358 S 827.56 0.00 0.00 26525 S 554.00 0.00 0.00<br />

26370 S 827.56 0.00 0.00 26530 S 960.31 0.00 0.00<br />

26372 S 827.56 0.00 0.00 26531 S 1,478.24 0.00 0.00<br />

26373 S 772.05 0.00 0.00 26535 S 1,056.06 0.00 0.00<br />

26390 S 827.56 0.00 0.00 26536 S 1,349.64 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 609.52 0.00 0.00 26775 S 163.57 0.00 0.00<br />

26541 S 996.40 0.00 0.00 26776 S 693.52 0.00 0.00<br />

26542 S 609.52 0.00 0.00 26785 S 693.52 0.00 0.00<br />

26545 S 827.56 0.00 0.00 26820 S 867.80 0.00 0.00<br />

26546 S 827.56 0.00 0.00 26841 S 827.56 0.00 0.00<br />

26548 S 827.56 0.00 0.00 26842 S 827.56 0.00 0.00<br />

26550 S 742.45 0.00 0.00 26843 S 772.05 0.00 0.00<br />

26555 S 772.05 0.00 0.00 26844 S 772.05 0.00 0.00<br />

26560 S 524.40 0.00 0.00 26850 S 827.56 0.00 0.00<br />

26561 S 772.05 0.00 0.00 26852 S 827.56 0.00 0.00<br />

26562 S 827.56 0.00 0.00 26860 S 772.05 0.00 0.00<br />

26565 S 867.80 0.00 0.00 26861 S 742.45 0.00 0.00<br />

26567 S 867.80 0.00 0.00 26862 S 827.56 0.00 0.00<br />

26568 S 772.05 0.00 0.00 26863 S 772.05 0.00 0.00<br />

26580 S 649.76 0.00 0.00 26910 S 772.05 0.00 0.00<br />

26587 S 649.76 0.00 0.00 26951 S 524.40 0.00 0.00<br />

26590 S 649.76 0.00 0.00 26952 S 609.52 0.00 0.00<br />

26591 S 772.05 0.00 0.00 26990 S 571.10 0.00 0.00<br />

26593 S 554.00 0.00 0.00 26991 S 571.10 0.00 0.00<br />

26596 S 524.40 0.00 0.00 27000 S 623.37 0.00 0.00<br />

26600 S 61.19 0.00 0.00 27001 S 808.09 0.00 0.00<br />

26605 S 78.52 0.00 0.00 27003 S 808.09 0.00 0.00<br />

26607 S 428.45 0.00 0.00 27033 S 1,104.34 0.00 0.00<br />

26608 S 778.63 0.00 0.00 27035 S 1,159.85 0.00 0.00<br />

26615 S 1,112.22 0.00 0.00 27040 S 312.14 0.00 0.00<br />

26641 S 61.19 0.00 0.00 27041 S 351.68 0.00 0.00<br />

26645 S 165.65 0.00 0.00 27047 S 624.56 0.00 0.00<br />

26650 S 693.52 0.00 0.00 27048 S 654.17 0.00 0.00<br />

26665 S 1,112.22 0.00 0.00 27049 S 654.17 0.00 0.00<br />

26670 S 61.19 0.00 0.00 27050 S 652.98 0.00 0.00<br />

26675 S 165.65 0.00 0.00 27052 S 652.98 0.00 0.00<br />

26676 S 693.52 0.00 0.00 27060 S 748.74 0.00 0.00<br />

26685 S 723.13 0.00 0.00 27062 S 748.74 0.00 0.00<br />

26686 S 1,433.99 0.00 0.00 27065 S 748.74 0.00 0.00<br />

26700 S 61.19 0.00 0.00 27066 S 903.85 0.00 0.00<br />

26705 S 78.52 0.00 0.00 27067 S 903.85 0.00 0.00<br />

26706 S 428.45 0.00 0.00 27080 S 778.48 0.00 0.00<br />

26715 S 778.63 0.00 0.00 27086 S 312.14 0.00 0.00<br />

26720 S 61.19 0.00 0.00 27087 S 652.98 0.00 0.00<br />

26725 S 61.19 0.00 0.00 27097 S 808.09 0.00 0.00<br />

26727 S 947.48 0.00 0.00 27098 S 808.09 0.00 0.00<br />

26735 S 778.63 0.00 0.00 27100 S 1,159.85 0.00 0.00<br />

26740 S 61.19 0.00 0.00 27105 S 1,159.85 0.00 0.00<br />

26742 S 78.52 0.00 0.00 27110 S 1,159.85 0.00 0.00<br />

26746 S 818.88 0.00 0.00 27111 S 1,159.85 0.00 0.00<br />

26750 S 61.19 0.00 0.00 27193 S 78.52 0.00 0.00<br />

26755 S 61.19 0.00 0.00 27194 S 504.39 0.00 0.00<br />

26756 S 693.52 0.00 0.00 27200 S 61.19 0.00 0.00<br />

26765 S 778.63 0.00 0.00 27202 S 1,027.10 0.00 0.00<br />

26770 S 61.19 0.00 0.00 27220 S 61.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 78.52 0.00 0.00 27397 S 1,104.34 0.00 0.00<br />

27238 S 165.65 0.00 0.00 27400 S 1,104.34 0.00 0.00<br />

27246 S 165.65 0.00 0.00 27403 S 863.60 0.00 0.00<br />

27250 S 78.52 0.00 0.00 27405 S 1,159.85 0.00 0.00<br />

27252 S 504.39 0.00 0.00 27407 S 1,949.56 0.00 0.00<br />

27256 S 61.19 0.00 0.00 27409 S 1,159.85 0.00 0.00<br />

27257 S 534.00 0.00 0.00 27416 S 1,736.84 0.00 0.00<br />

27265 S 78.52 0.00 0.00 27418 S 1,104.34 0.00 0.00<br />

27266 S 504.39 0.00 0.00 27420 S 1,104.34 0.00 0.00<br />

27267 S 61.19 0.00 0.00 27422 S 1,328.69 0.00 0.00<br />

27275 S 504.39 0.00 0.00 27424 S 1,104.34 0.00 0.00<br />

27301 S 607.15 0.00 0.00 27425 S 1,032.45 0.00 0.00<br />

27305 S 623.37 0.00 0.00 27427 S 1,104.34 0.00 0.00<br />

27306 S 652.98 0.00 0.00 27428 S 1,949.56 0.00 0.00<br />

27307 S 652.98 0.00 0.00 27429 S 1,949.56 0.00 0.00<br />

27310 S 863.60 0.00 0.00 27430 S 1,159.85 0.00 0.00<br />

27323 S 312.14 0.00 0.00 27435 S 1,159.85 0.00 0.00<br />

27324 S 572.29 0.00 0.00 27437 S 1,015.81 0.00 0.00<br />

27325 S 560.76 0.00 0.00 27438 S 1,349.64 0.00 0.00<br />

27326 S 560.76 0.00 0.00 27440 S 1,448.77 0.00 0.00<br />

27327 S 624.56 0.00 0.00 27441 S 1,056.06 0.00 0.00<br />

27328 S 654.17 0.00 0.00 27442 S 1,056.06 0.00 0.00<br />

27329 S 709.67 0.00 0.00 27443 S 1,056.06 0.00 0.00<br />

27330 S 863.60 0.00 0.00 27446 S 10,362.01 6,225.02 2,088.03<br />

27331 S 863.60 0.00 0.00 27496 S 748.74 0.00 0.00<br />

27332 S 863.60 0.00 0.00 27497 S 652.98 0.00 0.00<br />

27333 S 863.60 0.00 0.00 27498 S 652.98 0.00 0.00<br />

27334 S 863.60 0.00 0.00 27499 S 652.98 0.00 0.00<br />

27335 S 863.60 0.00 0.00 27500 S 165.65 0.00 0.00<br />

27340 S 652.98 0.00 0.00 27501 S 78.52 0.00 0.00<br />

27345 S 708.49 0.00 0.00 27502 S 428.45 0.00 0.00<br />

27347 S 708.49 0.00 0.00 27503 S 78.52 0.00 0.00<br />

27350 S 863.60 0.00 0.00 27508 S 78.52 0.00 0.00<br />

27355 S 808.09 0.00 0.00 27509 S 723.13 0.00 0.00<br />

27356 S 863.60 0.00 0.00 27510 S 165.65 0.00 0.00<br />

27357 S 903.85 0.00 0.00 27516 S 78.52 0.00 0.00<br />

27358 S 903.85 0.00 0.00 27517 S 78.52 0.00 0.00<br />

27360 S 903.85 0.00 0.00 27520 S 78.52 0.00 0.00<br />

27372 S 878.52 0.00 0.00 27530 S 78.52 0.00 0.00<br />

27380 S 571.10 0.00 0.00 27532 S 428.45 0.00 0.00<br />

27381 S 652.98 0.00 0.00 27538 S 78.52 0.00 0.00<br />

27385 S 652.98 0.00 0.00 27550 S 78.52 0.00 0.00<br />

27386 S 652.98 0.00 0.00 27552 S 452.12 0.00 0.00<br />

27390 S 571.10 0.00 0.00 27560 S 78.52 0.00 0.00<br />

27391 S 623.37 0.00 0.00 27562 S 452.12 0.00 0.00<br />

27392 S 652.98 0.00 0.00 27566 S 1,027.10 0.00 0.00<br />

27393 S 778.48 0.00 0.00 27570 S 452.12 0.00 0.00<br />

27394 S 808.09 0.00 0.00 27594 S 652.98 0.00 0.00<br />

27395 S 1,104.34 0.00 0.00 27600 S 652.98 0.00 0.00<br />

27396 S 808.09 0.00 0.00 27601 S 652.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 652.98 0.00 0.00 27730 S 778.48 0.00 0.00<br />

27603 S 577.54 0.00 0.00 27732 S 778.48 0.00 0.00<br />

27604 S 623.37 0.00 0.00 27734 S 778.48 0.00 0.00<br />

27605 S 568.04 0.00 0.00 27740 S 778.48 0.00 0.00<br />

27606 S 571.10 0.00 0.00 27742 S 1,074.73 0.00 0.00<br />

27607 S 623.37 0.00 0.00 27745 S 1,894.05 0.00 0.00<br />

27610 S 778.48 0.00 0.00 27750 S 78.52 0.00 0.00<br />

27612 S 808.09 0.00 0.00 27752 S 428.45 0.00 0.00<br />

27613 S 128.33 0.00 0.00 27756 S 723.13 0.00 0.00<br />

27614 S 624.56 0.00 0.00 27758 S 1,112.22 0.00 0.00<br />

27615 S 808.09 0.00 0.00 27759 S 1,489.49 0.00 0.00<br />

27618 S 510.71 0.00 0.00 27760 S 78.52 0.00 0.00<br />

27619 S 654.17 0.00 0.00 27762 S 428.45 0.00 0.00<br />

27620 S 863.60 0.00 0.00 27766 S 1,056.71 0.00 0.00<br />

27625 S 863.60 0.00 0.00 27767 S 61.19 0.00 0.00<br />

27626 S 863.60 0.00 0.00 27768 S 61.19 0.00 0.00<br />

27630 S 652.98 0.00 0.00 27769 S 1,641.57 0.00 0.00<br />

27635 S 808.09 0.00 0.00 27780 S 78.52 0.00 0.00<br />

27637 S 808.09 0.00 0.00 27781 S 428.45 0.00 0.00<br />

27638 S 808.09 0.00 0.00 27784 S 1,056.71 0.00 0.00<br />

27640 S 1,074.73 0.00 0.00 27786 S 78.52 0.00 0.00<br />

27641 S 778.48 0.00 0.00 27788 S 78.52 0.00 0.00<br />

27647 S 1,104.34 0.00 0.00 27792 S 1,056.71 0.00 0.00<br />

27650 S 1,104.34 0.00 0.00 27808 S 78.52 0.00 0.00<br />

27652 S 1,894.05 0.00 0.00 27810 S 165.65 0.00 0.00<br />

27654 S 1,104.34 0.00 0.00 27814 S 1,056.71 0.00 0.00<br />

27656 S 623.37 0.00 0.00 27816 S 78.52 0.00 0.00<br />

27658 S 571.10 0.00 0.00 27818 S 165.65 0.00 0.00<br />

27659 S 623.37 0.00 0.00 27822 S 1,056.71 0.00 0.00<br />

27664 S 623.37 0.00 0.00 27823 S 1,433.99 0.00 0.00<br />

27665 S 778.48 0.00 0.00 27824 S 78.52 0.00 0.00<br />

27675 S 623.37 0.00 0.00 27825 S 428.45 0.00 0.00<br />

27676 S 808.09 0.00 0.00 27826 S 1,056.71 0.00 0.00<br />

27680 S 808.09 0.00 0.00 27827 S 1,433.99 0.00 0.00<br />

27681 S 778.48 0.00 0.00 27828 S 1,489.49 0.00 0.00<br />

27685 S 808.09 0.00 0.00 27829 S 1,027.10 0.00 0.00<br />

27686 S 808.09 0.00 0.00 27830 S 78.52 0.00 0.00<br />

27687 S 808.09 0.00 0.00 27831 S 428.45 0.00 0.00<br />

27690 S 1,159.85 0.00 0.00 27832 S 1,027.10 0.00 0.00<br />

27691 S 1,159.85 0.00 0.00 27840 S 165.65 0.00 0.00<br />

27692 S 1,104.34 0.00 0.00 27842 S 452.12 0.00 0.00<br />

27695 S 778.48 0.00 0.00 27846 S 1,056.71 0.00 0.00<br />

27696 S 778.48 0.00 0.00 27848 S 1,056.71 0.00 0.00<br />

27698 S 778.48 0.00 0.00 27860 S 452.12 0.00 0.00<br />

27700 S 1,056.06 0.00 0.00 27870 S 1,949.56 0.00 0.00<br />

27704 S 623.37 0.00 0.00 27871 S 1,949.56 0.00 0.00<br />

27705 S 1,074.73 0.00 0.00 27884 S 652.98 0.00 0.00<br />

27707 S 623.37 0.00 0.00 27889 S 808.09 0.00 0.00<br />

27709 S 778.48 0.00 0.00 27892 S 652.98 0.00 0.00<br />

27726 S 974.41 0.00 0.00 27893 S 652.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 652.98 0.00 0.00 28153 S 649.92 0.00 0.00<br />

28001 S 125.24 0.00 0.00 28160 S 649.92 0.00 0.00<br />

28002 S 652.98 0.00 0.00 28171 S 649.92 0.00 0.00<br />

28003 S 652.98 0.00 0.00 28173 S 649.92 0.00 0.00<br />

28005 S 649.92 0.00 0.00 28175 S 649.92 0.00 0.00<br />

28008 S 649.92 0.00 0.00 28190 S 129.35 0.00 0.00<br />

28010 S 92.05 0.00 0.00 28192 S 510.71 0.00 0.00<br />

28011 S 649.92 0.00 0.00 28193 S 351.68 0.00 0.00<br />

28020 S 620.31 0.00 0.00 28200 S 649.92 0.00 0.00<br />

28022 S 620.31 0.00 0.00 28202 S 649.92 0.00 0.00<br />

28024 S 620.31 0.00 0.00 28208 S 649.92 0.00 0.00<br />

28035 S 645.88 0.00 0.00 28210 S 1,141.45 0.00 0.00<br />

28043 S 624.56 0.00 0.00 28220 S 199.50 0.00 0.00<br />

28045 S 649.92 0.00 0.00 28222 S 568.04 0.00 0.00<br />

28046 S 649.92 0.00 0.00 28225 S 568.04 0.00 0.00<br />

28050 S 620.31 0.00 0.00 28226 S 568.04 0.00 0.00<br />

28052 S 620.31 0.00 0.00 28230 S 195.74 0.00 0.00<br />

28054 S 620.31 0.00 0.00 28232 S 187.18 0.00 0.00<br />

28055 S 645.88 0.00 0.00 28234 S 620.31 0.00 0.00<br />

28060 S 620.31 0.00 0.00 28238 S 1,141.45 0.00 0.00<br />

28062 S 649.92 0.00 0.00 28240 S 620.31 0.00 0.00<br />

28070 S 649.92 0.00 0.00 28250 S 649.92 0.00 0.00<br />

28072 S 649.92 0.00 0.00 28260 S 649.92 0.00 0.00<br />

28080 S 649.92 0.00 0.00 28261 S 649.92 0.00 0.00<br />

28086 S 620.31 0.00 0.00 28262 S 705.42 0.00 0.00<br />

28088 S 620.31 0.00 0.00 28264 S 1,059.57 0.00 0.00<br />

28090 S 649.92 0.00 0.00 28270 S 649.92 0.00 0.00<br />

28092 S 649.92 0.00 0.00 28272 S 180.68 0.00 0.00<br />

28100 S 620.31 0.00 0.00 28280 S 620.31 0.00 0.00<br />

28102 S 1,141.45 0.00 0.00 28285 S 649.92 0.00 0.00<br />

28103 S 1,141.45 0.00 0.00 28286 S 705.42 0.00 0.00<br />

28104 S 620.31 0.00 0.00 28288 S 649.92 0.00 0.00<br />

28106 S 1,141.45 0.00 0.00 28289 S 649.92 0.00 0.00<br />

28107 S 1,141.45 0.00 0.00 28290 S 801.11 0.00 0.00<br />

28108 S 620.31 0.00 0.00 28292 S 801.11 0.00 0.00<br />

28110 S 649.92 0.00 0.00 28293 S 830.71 0.00 0.00<br />

28111 S 649.92 0.00 0.00 28294 S 830.71 0.00 0.00<br />

28112 S 649.92 0.00 0.00 28296 S 830.71 0.00 0.00<br />

28113 S 649.92 0.00 0.00 28297 S 830.71 0.00 0.00<br />

28114 S 649.92 0.00 0.00 28298 S 830.71 0.00 0.00<br />

28116 S 649.92 0.00 0.00 28299 S 926.47 0.00 0.00<br />

28118 S 705.42 0.00 0.00 28300 S 1,111.85 0.00 0.00<br />

28119 S 705.42 0.00 0.00 28302 S 620.31 0.00 0.00<br />

28120 S 874.27 0.00 0.00 28304 S 1,111.85 0.00 0.00<br />

28122 S 649.92 0.00 0.00 28305 S 1,141.45 0.00 0.00<br />

28124 S 211.82 0.00 0.00 28306 S 705.42 0.00 0.00<br />

28126 S 649.92 0.00 0.00 28307 S 705.42 0.00 0.00<br />

28130 S 649.92 0.00 0.00 28308 S 620.31 0.00 0.00<br />

28140 S 649.92 0.00 0.00 28309 S 1,196.97 0.00 0.00<br />

28150 S 649.92 0.00 0.00 28310 S 649.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 649.92 0.00 0.00 28636 S 723.13 0.00 0.00<br />

28313 S 620.31 0.00 0.00 28645 S 723.13 0.00 0.00<br />

28315 S 705.42 0.00 0.00 28660 S 43.81 0.00 0.00<br />

28320 S 1,196.97 0.00 0.00 28665 S 452.12 0.00 0.00<br />

28322 S 1,196.97 0.00 0.00 28666 S 723.13 0.00 0.00<br />

28340 S 705.42 0.00 0.00 28675 S 723.13 0.00 0.00<br />

28341 S 705.42 0.00 0.00 28705 S 1,196.97 0.00 0.00<br />

28344 S 705.42 0.00 0.00 28715 S 1,949.56 0.00 0.00<br />

28345 S 705.42 0.00 0.00 28725 S 1,196.97 0.00 0.00<br />

28400 S 78.52 0.00 0.00 28730 S 1,196.97 0.00 0.00<br />

28405 S 428.45 0.00 0.00 28735 S 1,196.97 0.00 0.00<br />

28406 S 693.52 0.00 0.00 28737 S 1,237.21 0.00 0.00<br />

28415 S 1,433.99 0.00 0.00 28740 S 1,196.97 0.00 0.00<br />

28420 S 1,112.22 0.00 0.00 28750 S 1,196.97 0.00 0.00<br />

28430 S 61.19 0.00 0.00 28755 S 705.42 0.00 0.00<br />

28435 S 78.52 0.00 0.00 28760 S 1,196.97 0.00 0.00<br />

28436 S 693.52 0.00 0.00 28810 S 620.31 0.00 0.00<br />

28445 S 1,056.71 0.00 0.00 28820 S 620.31 0.00 0.00<br />

28446 S 1,811.07 0.00 0.00 28825 S 620.31 0.00 0.00<br />

28450 S 61.19 0.00 0.00 28890 S 163.91 0.00 0.00<br />

28455 S 61.19 0.00 0.00 29000 S 41.53 0.00 0.00<br />

28456 S 693.52 0.00 0.00 29010 S 93.08 0.00 0.00<br />

28465 S 1,056.71 0.00 0.00 29015 S 93.08 0.00 0.00<br />

28470 S 61.19 0.00 0.00 29020 S 41.53 0.00 0.00<br />

28475 S 61.19 0.00 0.00 29025 S 41.53 0.00 0.00<br />

28476 S 693.52 0.00 0.00 29035 S 93.08 0.00 0.00<br />

28485 S 1,112.22 0.00 0.00 29040 S 41.53 0.00 0.00<br />

28490 S 61.19 0.00 0.00 29044 S 93.08 0.00 0.00<br />

28495 S 61.19 0.00 0.00 29046 S 93.08 0.00 0.00<br />

28496 S 693.52 0.00 0.00 29049 S 37.64 0.00 0.00<br />

28505 S 723.13 0.00 0.00 29055 S 93.08 0.00 0.00<br />

28510 S 55.10 0.00 0.00 29058 S 41.53 0.00 0.00<br />

28515 S 61.19 0.00 0.00 29065 S 44.15 0.00 0.00<br />

28525 S 723.13 0.00 0.00 29075 S 42.43 0.00 0.00<br />

28530 S 53.04 0.00 0.00 29085 S 41.53 0.00 0.00<br />

28531 S 723.13 0.00 0.00 29086 S 35.59 0.00 0.00<br />

28540 S 61.19 0.00 0.00 29105 S 38.32 0.00 0.00<br />

28545 S 641.25 0.00 0.00 29125 S 33.19 0.00 0.00<br />

28546 S 693.52 0.00 0.00 29126 S 35.25 0.00 0.00<br />

28555 S 1,027.10 0.00 0.00 29130 S 15.06 0.00 0.00<br />

28570 S 79.39 0.00 0.00 29131 S 21.90 0.00 0.00<br />

28575 S 428.45 0.00 0.00 29200 S 21.22 0.00 0.00<br />

28576 S 723.13 0.00 0.00 29220 S 22.92 0.00 0.00<br />

28585 S 723.13 0.00 0.00 29240 S 23.96 0.00 0.00<br />

28600 S 61.19 0.00 0.00 29260 S 22.92 0.00 0.00<br />

28605 S 78.52 0.00 0.00 29280 S 23.27 0.00 0.00<br />

28606 S 693.52 0.00 0.00 29305 S 93.08 0.00 0.00<br />

28615 S 1,056.71 0.00 0.00 29325 S 93.08 0.00 0.00<br />

28630 S 61.19 0.00 0.00 29345 S 57.83 0.00 0.00<br />

28635 S 452.12 0.00 0.00 29355 S 56.80 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 70.50 0.00 0.00 29847 S 1,178.29 0.00 0.00<br />

29365 S 54.76 0.00 0.00 29848 S 1,182.63 0.00 0.00<br />

29405 S 40.72 0.00 0.00 29850 S 854.66 0.00 0.00<br />

29425 S 41.41 0.00 0.00 29851 S 1,233.80 0.00 0.00<br />

29435 S 52.35 0.00 0.00 29855 S 1,233.80 0.00 0.00<br />

29440 S 22.24 0.00 0.00 29856 S 1,233.80 0.00 0.00<br />

29445 S 55.10 0.00 0.00 29860 S 1,233.80 0.00 0.00<br />

29450 S 41.53 0.00 0.00 29861 S 1,233.80 0.00 0.00<br />

29505 S 36.96 0.00 0.00 29862 S 1,561.77 0.00 0.00<br />

29515 S 31.48 0.00 0.00 29863 S 1,233.80 0.00 0.00<br />

29520 S 22.58 0.00 0.00 29866 S 1,884.73 0.00 0.00<br />

29530 S 22.92 0.00 0.00 29870 S 799.16 0.00 0.00<br />

29540 S 17.11 0.00 0.00 29871 S 799.16 0.00 0.00<br />

29550 S 17.45 0.00 0.00 29873 S 799.16 0.00 0.00<br />

29580 S 23.62 0.00 0.00 29874 S 799.16 0.00 0.00<br />

29590 S 19.17 0.00 0.00 29875 S 854.66 0.00 0.00<br />

29700 S 31.82 0.00 0.00 29876 S 854.66 0.00 0.00<br />

29705 S 27.03 0.00 0.00 29877 S 854.66 0.00 0.00<br />

29710 S 47.56 0.00 0.00 29879 S 799.16 0.00 0.00<br />

29715 S 41.53 0.00 0.00 29880 S 854.66 0.00 0.00<br />

29720 S 39.70 0.00 0.00 29881 S 854.66 0.00 0.00<br />

29730 S 26.01 0.00 0.00 29882 S 799.16 0.00 0.00<br />

29740 S 35.59 0.00 0.00 29883 S 799.16 0.00 0.00<br />

29750 S 37.30 0.00 0.00 29884 S 799.16 0.00 0.00<br />

29800 S 799.16 0.00 0.00 29885 S 1,178.29 0.00 0.00<br />

29804 S 799.16 0.00 0.00 29886 S 799.16 0.00 0.00<br />

29805 S 799.16 0.00 0.00 29887 S 799.16 0.00 0.00<br />

29806 S 1,178.29 0.00 0.00 29888 S 1,178.29 0.00 0.00<br />

29807 S 1,178.29 0.00 0.00 29889 S 1,178.29 0.00 0.00<br />

29819 S 1,178.29 0.00 0.00 29891 S 1,178.29 0.00 0.00<br />

29820 S 1,178.29 0.00 0.00 29892 S 1,178.29 0.00 0.00<br />

29821 S 1,178.29 0.00 0.00 29893 S 994.80 0.00 0.00<br />

29822 S 799.16 0.00 0.00 29894 S 799.16 0.00 0.00<br />

29823 S 1,178.29 0.00 0.00 29895 S 799.16 0.00 0.00<br />

29824 S 894.91 0.00 0.00 29897 S 799.16 0.00 0.00<br />

29825 S 1,178.29 0.00 0.00 29898 S 799.16 0.00 0.00<br />

29826 S 1,178.29 0.00 0.00 29899 S 1,178.29 0.00 0.00<br />

29827 S 1,274.04 0.00 0.00 29900 S 799.16 0.00 0.00<br />

29828 S 1,884.73 0.00 0.00 29901 S 799.16 0.00 0.00<br />

29830 S 799.16 0.00 0.00 29902 S 799.16 0.00 0.00<br />

29834 S 799.16 0.00 0.00 29904 S 1,126.46 0.00 0.00<br />

29835 S 799.16 0.00 0.00 29905 S 1,126.46 0.00 0.00<br />

29836 S 799.16 0.00 0.00 29906 S 1,126.46 0.00 0.00<br />

29837 S 799.16 0.00 0.00 29907 S 1,884.73 0.00 0.00<br />

29838 S 799.16 0.00 0.00 30000 S 126.65 0.00 0.00<br />

29840 S 799.16 0.00 0.00 30020 S 126.65 0.00 0.00<br />

29843 S 799.16 0.00 0.00 30100 S 82.13 0.00 0.00<br />

29844 S 799.16 0.00 0.00 30110 S 126.96 0.00 0.00<br />

29845 S 799.16 0.00 0.00 30115 S 536.42 0.00 0.00<br />

29846 S 799.16 0.00 0.00 30117 S 566.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 709.94 0.00 0.00 31080 S 1,093.23 0.00 0.00<br />

30120 S 484.15 0.00 0.00 31081 S 1,093.23 0.00 0.00<br />

30124 S 288.48 0.00 0.00 31084 S 1,093.23 0.00 0.00<br />

30125 S 1,008.11 0.00 0.00 31085 S 1,093.23 0.00 0.00<br />

30130 S 566.04 0.00 0.00 31086 S 1,093.23 0.00 0.00<br />

30140 S 680.33 0.00 0.00 31087 S 1,093.23 0.00 0.00<br />

30150 S 1,037.72 0.00 0.00 31090 S 1,133.47 0.00 0.00<br />

30160 S 1,093.23 0.00 0.00 31200 S 1,008.11 0.00 0.00<br />

30200 S 64.68 0.00 0.00 31201 S 1,133.47 0.00 0.00<br />

30210 S 82.13 0.00 0.00 31205 S 1,037.72 0.00 0.00<br />

30220 S 358.95 0.00 0.00 31231 S 69.23 0.00 0.00<br />

30300 S 24.74 0.00 0.00 31233 S 74.58 0.00 0.00<br />

30310 S 484.15 0.00 0.00 31235 S 506.67 0.00 0.00<br />

30320 S 536.42 0.00 0.00 31237 S 558.94 0.00 0.00<br />

30400 S 1,093.23 0.00 0.00 31238 S 506.67 0.00 0.00<br />

30410 S 1,133.47 0.00 0.00 31239 S 739.58 0.00 0.00<br />

30420 S 1,133.47 0.00 0.00 31240 S 558.94 0.00 0.00<br />

30430 S 709.94 0.00 0.00 31254 S 684.07 0.00 0.00<br />

30435 S 1,133.47 0.00 0.00 31255 S 779.82 0.00 0.00<br />

30450 S 1,262.07 0.00 0.00 31256 S 684.07 0.00 0.00<br />

30460 S 1,262.07 0.00 0.00 31267 S 684.07 0.00 0.00<br />

30462 S 1,421.20 0.00 0.00 31276 S 684.07 0.00 0.00<br />

30465 S 1,421.20 0.00 0.00 31287 S 684.07 0.00 0.00<br />

30520 S 765.44 0.00 0.00 31288 S 684.07 0.00 0.00<br />

30540 S 1,133.47 0.00 0.00 31300 S 805.69 0.00 0.00<br />

30545 S 1,133.47 0.00 0.00 31320 S 1,008.11 0.00 0.00<br />

30560 S 133.04 0.00 0.00 31400 S 1,008.11 0.00 0.00<br />

30580 S 1,093.23 0.00 0.00 31420 S 1,008.11 0.00 0.00<br />

30600 S 1,093.23 0.00 0.00 31500 S 92.60 0.00 0.00<br />

30620 S 1,262.07 0.00 0.00 31502 S 53.25 0.00 0.00<br />

30630 S 934.29 0.00 0.00 31505 S 31.46 0.00 0.00<br />

30801 S 298.28 0.00 0.00 31510 S 558.94 0.00 0.00<br />

30802 S 298.28 0.00 0.00 31511 S 74.58 0.00 0.00<br />

30901 S 42.54 0.00 0.00 31512 S 558.94 0.00 0.00<br />

30903 S 54.80 0.00 0.00 31513 S 74.58 0.00 0.00<br />

30905 S 54.80 0.00 0.00 31515 S 506.67 0.00 0.00<br />

30906 S 54.80 0.00 0.00 31520 S 69.23 0.00 0.00<br />

30915 S 730.22 0.00 0.00 31525 S 506.67 0.00 0.00<br />

30920 S 759.84 0.00 0.00 31526 S 654.46 0.00 0.00<br />

30930 S 621.54 0.00 0.00 31527 S 602.18 0.00 0.00<br />

31000 S 105.74 0.00 0.00 31528 S 558.94 0.00 0.00<br />

31002 S 288.48 0.00 0.00 31529 S 558.94 0.00 0.00<br />

31020 S 680.33 0.00 0.00 31530 S 654.46 0.00 0.00<br />

31030 S 1,037.72 0.00 0.00 31531 S 684.07 0.00 0.00<br />

31032 S 1,093.23 0.00 0.00 31535 S 654.46 0.00 0.00<br />

31040 S 948.04 0.00 0.00 31536 S 684.07 0.00 0.00<br />

31050 S 1,008.11 0.00 0.00 31540 S 684.07 0.00 0.00<br />

31051 S 1,093.23 0.00 0.00 31541 S 739.58 0.00 0.00<br />

31070 S 680.33 0.00 0.00 31545 S 739.58 0.00 0.00<br />

31075 S 1,093.23 0.00 0.00 31546 S 739.58 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 779.82 0.00 0.00 32405 S 337.45 0.00 0.00<br />

31561 S 779.82 0.00 0.00 32420 S 205.20 0.00 0.00<br />

31570 S 558.94 0.00 0.00 32421 S 205.20 0.00 0.00<br />

31571 S 654.46 0.00 0.00 32422 S 204.29 0.00 0.00<br />

31575 S 59.55 0.00 0.00 32550 S 1,143.78 0.00 0.00<br />

31576 S 654.46 0.00 0.00 32960 S 204.29 0.00 0.00<br />

31577 S 193.33 0.00 0.00 32998 S 1,780.80 0.00 0.00<br />

31578 S 654.46 0.00 0.00 33010 S 205.20 0.00 0.00<br />

31579 S 106.09 0.00 0.00 33011 S 205.20 0.00 0.00<br />

31580 S 1,133.47 0.00 0.00 33206 S 6,583.50 3,917.16 1,250.83<br />

31582 S 1,133.47 0.00 0.00 33207 S 6,583.50 3,917.16 1,250.83<br />

31588 S 1,133.47 0.00 0.00 33208 S 8,165.40 4,757.94 1,350.48<br />

31590 S 1,133.47 0.00 0.00 33210 S 1,933.27 0.00 0.00<br />

31595 S 1,008.11 0.00 0.00 33211 S 1,933.27 0.00 0.00<br />

31603 S 298.28 0.00 0.00 33212 S 5,170.39 2,945.35 720.31<br />

31605 S 288.48 0.00 0.00 33213 S 5,967.74 3,343.60 719.46<br />

31611 S 709.94 0.00 0.00 33214 S 8,165.40 4,757.94 1,350.48<br />

31612 S 628.06 0.00 0.00 33215 S 847.37 0.00 0.00<br />

31613 S 680.33 0.00 0.00 33216 S 1,933.27 0.00 0.00<br />

31614 S 1,008.11 0.00 0.00 33217 S 1,933.27 0.00 0.00<br />

31615 S 298.28 0.00 0.00 33218 S 847.37 0.00 0.00<br />

31622 S 349.34 0.00 0.00 33220 S 847.37 0.00 0.00<br />

31623 S 401.61 0.00 0.00 33222 S 512.20 0.00 0.00<br />

31624 S 401.61 0.00 0.00 33223 S 512.20 0.00 0.00<br />

31625 S 401.61 0.00 0.00 33224 S 7,707.38 4,614.38 1,521.40<br />

31628 S 401.61 0.00 0.00 33225 S 7,707.38 4,614.38 1,521.40<br />

31629 S 401.61 0.00 0.00 33226 S 847.37 0.00 0.00<br />

31630 S 688.19 0.00 0.00 33233 S 630.00 0.00 0.00<br />

31631 S 688.19 0.00 0.00 33234 S 847.37 0.00 0.00<br />

31632 S 390.59 0.00 0.00 33235 S 847.37 0.00 0.00<br />

31633 S 390.59 0.00 0.00 33240 S 19,212.53 10,269.88 1,327.24<br />

31635 S 401.61 0.00 0.00 33241 S 847.37 0.00 0.00<br />

31636 S 688.19 0.00 0.00 33249 S 25,640.58 13,734.16 1,827.73<br />

31637 S 349.34 0.00 0.00 33282 S 4,053.94 2,426.93 799.91<br />

31638 S 688.19 0.00 0.00 33284 S 316.20 0.00 0.00<br />

31640 S 688.19 0.00 0.00 34490 S 1,543.76 0.00 0.00<br />

31641 S 688.19 0.00 0.00 35188 S 1,063.31 0.00 0.00<br />

31643 S 401.61 0.00 0.00 35207 S 1,063.31 0.00 0.00<br />

31645 S 349.34 0.00 0.00 35473 S 1,851.92 0.00 0.00<br />

31646 S 349.34 0.00 0.00 35476 S 1,851.92 0.00 0.00<br />

31656 S 349.34 0.00 0.00 35492 S 3,456.43 0.00 0.00<br />

31717 S 193.33 0.00 0.00 35761 S 1,111.89 0.00 0.00<br />

31720 S 29.60 0.00 0.00 35875 S 1,391.28 0.00 0.00<br />

31730 S 193.33 0.00 0.00 35876 S 1,391.28 0.00 0.00<br />

31750 S 1,133.47 0.00 0.00 36002 S 88.80 0.00 0.00<br />

31755 S 1,008.11 0.00 0.00 36260 S 805.52 0.00 0.00<br />

31820 S 484.15 0.00 0.00 36261 S 630.00 0.00 0.00<br />

31825 S 680.33 0.00 0.00 36262 S 577.72 0.00 0.00<br />

31830 S 680.33 0.00 0.00 36420 S 8.37 0.00 0.00<br />

32400 S 337.45 0.00 0.00 36425 S 8.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.16 0.00 0.00 36800 S 867.15 0.00 0.00<br />

36440 S 128.46 0.00 0.00 36810 S 867.15 0.00 0.00<br />

36450 S 128.46 0.00 0.00 36815 S 867.15 0.00 0.00<br />

36455 S 128.46 0.00 0.00 36818 S 1,007.81 0.00 0.00<br />

36468 S 31.71 0.00 0.00 36819 S 1,007.81 0.00 0.00<br />

36469 S 31.71 0.00 0.00 36820 S 1,007.81 0.00 0.00<br />

36470 S 31.71 0.00 0.00 36821 S 1,007.81 0.00 0.00<br />

36471 S 31.71 0.00 0.00 36825 S 1,063.31 0.00 0.00<br />

36475 S 1,457.93 0.00 0.00 36830 S 1,063.31 0.00 0.00<br />

36476 S 1,143.31 0.00 0.00 36831 S 1,391.28 0.00 0.00<br />

36478 S 1,143.31 0.00 0.00 36832 S 1,063.31 0.00 0.00<br />

36479 S 1,143.31 0.00 0.00 36833 S 1,063.31 0.00 0.00<br />

36511 S 440.41 0.00 0.00 36834 S 1,007.81 0.00 0.00<br />

36512 S 440.41 0.00 0.00 36835 S 922.66 0.00 0.00<br />

36513 S 440.41 0.00 0.00 36860 S 105.90 0.00 0.00<br />

36514 S 440.41 0.00 0.00 36861 S 867.15 0.00 0.00<br />

36515 S 1,178.99 0.00 0.00 36870 S 1,516.50 0.00 0.00<br />

36516 S 1,178.99 0.00 0.00 37184 S 1,543.76 0.00 0.00<br />

36522 S 1,178.99 0.00 0.00 37185 S 1,543.76 0.00 0.00<br />

36555 S 365.92 0.00 0.00 37186 S 1,543.76 0.00 0.00<br />

36556 S 365.92 0.00 0.00 37187 S 1,543.76 0.00 0.00<br />

36557 S 683.39 0.00 0.00 37188 S 1,543.76 0.00 0.00<br />

36558 S 683.39 0.00 0.00 37200 S 1,139.21 0.00 0.00<br />

36560 S 805.52 0.00 0.00 37203 S 1,139.21 0.00 0.00<br />

36561 S 805.52 0.00 0.00 37500 S 1,074.45 0.00 0.00<br />

36563 S 805.52 0.00 0.00 37607 S 759.84 0.00 0.00<br />

36565 S 805.52 0.00 0.00 37609 S 510.71 0.00 0.00<br />

36566 S 805.52 0.00 0.00 37650 S 730.22 0.00 0.00<br />

36568 S 365.92 0.00 0.00 37700 S 730.22 0.00 0.00<br />

36569 S 365.92 0.00 0.00 37718 S 759.84 0.00 0.00<br />

36570 S 712.99 0.00 0.00 37722 S 1,074.45 0.00 0.00<br />

36571 S 712.99 0.00 0.00 37735 S 1,074.45 0.00 0.00<br />

36575 S 294.31 0.00 0.00 37760 S 759.84 0.00 0.00<br />

36576 S 418.19 0.00 0.00 37765 S 1,047.83 0.00 0.00<br />

36578 S 683.39 0.00 0.00 37766 S 1,047.83 0.00 0.00<br />

36580 S 365.92 0.00 0.00 37780 S 759.84 0.00 0.00<br />

36581 S 683.39 0.00 0.00 37785 S 759.84 0.00 0.00<br />

36582 S 805.52 0.00 0.00 37790 S 916.89 0.00 0.00<br />

36583 S 805.52 0.00 0.00 38205 S 440.41 0.00 0.00<br />

36584 S 365.92 0.00 0.00 38206 S 440.41 0.00 0.00<br />

36585 S 712.99 0.00 0.00 38220 S 100.95 0.00 0.00<br />

36589 S 242.04 0.00 0.00 38221 S 105.74 0.00 0.00<br />

36590 S 365.92 0.00 0.00 38230 S 1,178.99 0.00 0.00<br />

36593 S 24.30 0.00 0.00 38241 S 1,178.99 0.00 0.00<br />

36595 S 954.15 0.00 0.00 38242 S 440.41 0.00 0.00<br />

36596 S 423.75 0.00 0.00 38300 S 395.21 0.00 0.00<br />

36597 S 423.75 0.00 0.00 38305 S 577.54 0.00 0.00<br />

36598 S 78.36 0.00 0.00 38308 S 659.92 0.00 0.00<br />

36640 S 723.64 0.00 0.00 38500 S 659.92 0.00 0.00<br />

36680 S 54.85 0.00 0.00 38505 S 252.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 659.92 0.00 0.00 41005 S 133.04 0.00 0.00<br />

38520 S 659.92 0.00 0.00 41006 S 628.06 0.00 0.00<br />

38525 S 659.92 0.00 0.00 41007 S 484.15 0.00 0.00<br />

38530 S 659.92 0.00 0.00 41008 S 484.15 0.00 0.00<br />

38542 S 1,110.22 0.00 0.00 41009 S 133.04 0.00 0.00<br />

38550 S 689.53 0.00 0.00 41010 S 298.28 0.00 0.00<br />

38555 S 745.04 0.00 0.00 41015 S 133.04 0.00 0.00<br />

38570 S 1,506.40 0.00 0.00 41016 S 298.28 0.00 0.00<br />

38571 S 1,958.29 0.00 0.00 41017 S 298.28 0.00 0.00<br />

38572 S 1,506.40 0.00 0.00 41018 S 298.28 0.00 0.00<br />

38700 S 907.21 0.00 0.00 41019 S 948.04 0.00 0.00<br />

38740 S 1,110.22 0.00 0.00 41100 S 89.31 0.00 0.00<br />

38745 S 1,195.34 0.00 0.00 41105 S 88.29 0.00 0.00<br />

38760 S 659.92 0.00 0.00 41108 S 81.79 0.00 0.00<br />

40490 S 67.41 0.00 0.00 41110 S 118.40 0.00 0.00<br />

40500 S 536.42 0.00 0.00 41112 S 536.42 0.00 0.00<br />

40510 S 680.33 0.00 0.00 41113 S 536.42 0.00 0.00<br />

40520 S 536.42 0.00 0.00 41114 S 680.33 0.00 0.00<br />

40525 S 680.33 0.00 0.00 41115 S 137.91 0.00 0.00<br />

40527 S 680.33 0.00 0.00 41116 S 484.15 0.00 0.00<br />

40530 S 680.33 0.00 0.00 41120 S 805.69 0.00 0.00<br />

40650 S 358.95 0.00 0.00 41250 S 90.99 0.00 0.00<br />

40652 S 358.95 0.00 0.00 41251 S 133.04 0.00 0.00<br />

40654 S 358.95 0.00 0.00 41252 S 350.55 0.00 0.00<br />

40700 S 1,262.07 0.00 0.00 41500 S 628.06 0.00 0.00<br />

40701 S 1,262.07 0.00 0.00 41510 S 484.15 0.00 0.00<br />

40702 S 1,603.60 0.00 0.00 41520 S 350.55 0.00 0.00<br />

40720 S 1,262.07 0.00 0.00 41530 S 660.22 0.00 0.00<br />

40761 S 1,037.72 0.00 0.00 41800 S 67.97 0.00 0.00<br />

40800 S 54.10 0.00 0.00 41805 S 147.15 0.00 0.00<br />

40801 S 350.55 0.00 0.00 41806 S 181.36 0.00 0.00<br />

40804 S 24.74 0.00 0.00 41820 S 288.48 0.00 0.00<br />

40805 S 167.34 0.00 0.00 41821 S 288.48 0.00 0.00<br />

40806 S 77.00 0.00 0.00 41822 S 150.22 0.00 0.00<br />

40808 S 114.29 0.00 0.00 41823 S 219.01 0.00 0.00<br />

40810 S 118.40 0.00 0.00 41825 S 120.45 0.00 0.00<br />

40812 S 148.52 0.00 0.00 41826 S 151.60 0.00 0.00<br />

40814 S 536.42 0.00 0.00 41827 S 680.33 0.00 0.00<br />

40816 S 680.33 0.00 0.00 41828 S 136.88 0.00 0.00<br />

40818 S 133.04 0.00 0.00 41830 S 194.37 0.00 0.00<br />

40819 S 298.28 0.00 0.00 41850 S 660.22 0.00 0.00<br />

40820 S 170.76 0.00 0.00 41870 S 948.04 0.00 0.00<br />

40830 S 126.65 0.00 0.00 41872 S 194.37 0.00 0.00<br />

40831 S 298.28 0.00 0.00 41874 S 187.52 0.00 0.00<br />

40840 S 680.33 0.00 0.00 42000 S 133.04 0.00 0.00<br />

40842 S 709.94 0.00 0.00 42100 S 75.97 0.00 0.00<br />

40843 S 709.94 0.00 0.00 42104 S 112.93 0.00 0.00<br />

40844 S 1,133.47 0.00 0.00 42106 S 141.67 0.00 0.00<br />

40845 S 1,133.47 0.00 0.00 42107 S 680.33 0.00 0.00<br />

41000 S 84.87 0.00 0.00 42120 S 1,093.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 350.55 0.00 0.00 42809 S 24.74 0.00 0.00<br />

42145 S 805.69 0.00 0.00 42810 S 709.94 0.00 0.00<br />

42160 S 134.14 0.00 0.00 42815 S 1,133.47 0.00 0.00<br />

42180 S 133.04 0.00 0.00 42820 S 709.94 0.00 0.00<br />

42182 S 1,008.11 0.00 0.00 42821 S 805.69 0.00 0.00<br />

42200 S 1,133.47 0.00 0.00 42825 S 765.44 0.00 0.00<br />

42205 S 1,133.47 0.00 0.00 42826 S 765.44 0.00 0.00<br />

42210 S 1,133.47 0.00 0.00 42830 S 765.44 0.00 0.00<br />

42215 S 1,262.07 0.00 0.00 42831 S 765.44 0.00 0.00<br />

42220 S 1,133.47 0.00 0.00 42835 S 765.44 0.00 0.00<br />

42226 S 1,133.47 0.00 0.00 42836 S 765.44 0.00 0.00<br />

42235 S 661.79 0.00 0.00 42860 S 709.94 0.00 0.00<br />

42260 S 765.44 0.00 0.00 42870 S 709.94 0.00 0.00<br />

42280 S 73.91 0.00 0.00 42890 S 1,262.07 0.00 0.00<br />

42281 S 660.22 0.00 0.00 42892 S 1,262.07 0.00 0.00<br />

42300 S 484.15 0.00 0.00 42900 S 298.28 0.00 0.00<br />

42305 S 536.42 0.00 0.00 42950 S 680.33 0.00 0.00<br />

42310 S 133.04 0.00 0.00 42955 S 680.33 0.00 0.00<br />

42320 S 133.04 0.00 0.00 42960 S 54.80 0.00 0.00<br />

42330 S 114.29 0.00 0.00 42962 S 1,008.11 0.00 0.00<br />

42335 S 189.58 0.00 0.00 42970 S 42.54 0.00 0.00<br />

42340 S 536.42 0.00 0.00 42972 S 566.04 0.00 0.00<br />

42400 S 64.34 0.00 0.00 43030 S 660.22 0.00 0.00<br />

42405 S 536.42 0.00 0.00 43200 S 319.72 0.00 0.00<br />

42408 S 566.04 0.00 0.00 43201 S 319.72 0.00 0.00<br />

42409 S 566.04 0.00 0.00 43202 S 319.72 0.00 0.00<br />

42410 S 1,037.72 0.00 0.00 43204 S 319.72 0.00 0.00<br />

42415 S 1,262.07 0.00 0.00 43205 S 319.72 0.00 0.00<br />

42420 S 1,262.07 0.00 0.00 43215 S 319.72 0.00 0.00<br />

42425 S 1,262.07 0.00 0.00 43216 S 319.72 0.00 0.00<br />

42440 S 1,037.72 0.00 0.00 43217 S 319.72 0.00 0.00<br />

42450 S 680.33 0.00 0.00 43219 S 646.15 0.00 0.00<br />

42500 S 709.94 0.00 0.00 43220 S 319.72 0.00 0.00<br />

42505 S 1,093.23 0.00 0.00 43226 S 319.72 0.00 0.00<br />

42507 S 1,037.72 0.00 0.00 43227 S 372.00 0.00 0.00<br />

42508 S 1,093.23 0.00 0.00 43228 S 692.25 0.00 0.00<br />

42509 S 1,093.23 0.00 0.00 43231 S 372.00 0.00 0.00<br />

42510 S 1,093.23 0.00 0.00 43232 S 372.00 0.00 0.00<br />

42600 S 484.15 0.00 0.00 43234 S 319.72 0.00 0.00<br />

42650 S 42.09 0.00 0.00 43235 S 319.72 0.00 0.00<br />

42660 S 49.28 0.00 0.00 43236 S 372.00 0.00 0.00<br />

42665 S 934.29 0.00 0.00 43237 S 372.00 0.00 0.00<br />

42700 S 133.04 0.00 0.00 43238 S 372.00 0.00 0.00<br />

42720 S 484.15 0.00 0.00 43239 S 372.00 0.00 0.00<br />

42725 S 1,008.11 0.00 0.00 43240 S 372.00 0.00 0.00<br />

42800 S 81.44 0.00 0.00 43241 S 372.00 0.00 0.00<br />

42802 S 484.15 0.00 0.00 43242 S 372.00 0.00 0.00<br />

42804 S 484.15 0.00 0.00 43243 S 372.00 0.00 0.00<br />

42806 S 680.33 0.00 0.00 43244 S 372.00 0.00 0.00<br />

42808 S 536.42 0.00 0.00 43245 S 372.00 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 372.00 0.00 0.00 44378 S 389.61 0.00 0.00<br />

43247 S 372.00 0.00 0.00 44379 S 1,111.52 0.00 0.00<br />

43248 S 372.00 0.00 0.00 44380 S 337.33 0.00 0.00<br />

43249 S 372.00 0.00 0.00 44382 S 337.33 0.00 0.00<br />

43250 S 372.00 0.00 0.00 44383 S 1,111.52 0.00 0.00<br />

43251 S 372.00 0.00 0.00 44385 S 326.15 0.00 0.00<br />

43255 S 372.00 0.00 0.00 44386 S 326.15 0.00 0.00<br />

43256 S 728.03 0.00 0.00 44388 S 326.15 0.00 0.00<br />

43257 S 721.87 0.00 0.00 44389 S 326.15 0.00 0.00<br />

43258 S 401.60 0.00 0.00 44390 S 326.15 0.00 0.00<br />

43259 S 401.60 0.00 0.00 44391 S 326.15 0.00 0.00<br />

43260 S 626.26 0.00 0.00 44392 S 326.15 0.00 0.00<br />

43261 S 626.26 0.00 0.00 44393 S 326.15 0.00 0.00<br />

43262 S 626.26 0.00 0.00 44394 S 326.15 0.00 0.00<br />

43263 S 626.26 0.00 0.00 44397 S 646.15 0.00 0.00<br />

43264 S 626.26 0.00 0.00 44500 S 176.00 0.00 0.00<br />

43265 S 626.26 0.00 0.00 45000 S 378.23 0.00 0.00<br />

43267 S 626.26 0.00 0.00 45005 S 440.19 0.00 0.00<br />

43268 S 698.43 0.00 0.00 45020 S 440.19 0.00 0.00<br />

43269 S 698.43 0.00 0.00 45100 S 598.04 0.00 0.00<br />

43271 S 626.26 0.00 0.00 45108 S 650.31 0.00 0.00<br />

43272 S 626.26 0.00 0.00 45150 S 650.31 0.00 0.00<br />

43273 S 839.89 0.00 0.00 45160 S 650.31 0.00 0.00<br />

43450 S 279.61 0.00 0.00 45170 S 650.31 0.00 0.00<br />

43453 S 279.61 0.00 0.00 45190 S 1,063.40 0.00 0.00<br />

43456 S 280.72 0.00 0.00 45300 S 62.96 0.00 0.00<br />

43458 S 320.84 0.00 0.00 45303 S 349.74 0.00 0.00<br />

43600 S 319.72 0.00 0.00 45305 S 328.91 0.00 0.00<br />

43653 S 1,506.40 0.00 0.00 45307 S 607.52 0.00 0.00<br />

43760 S 155.06 0.00 0.00 45308 S 328.91 0.00 0.00<br />

43761 S 319.72 0.00 0.00 45309 S 328.91 0.00 0.00<br />

43870 S 319.72 0.00 0.00 45315 S 328.91 0.00 0.00<br />

43886 S 806.73 0.00 0.00 45317 S 328.91 0.00 0.00<br />

43887 S 169.67 0.00 0.00 45320 S 607.52 0.00 0.00<br />

43888 S 806.73 0.00 0.00 45321 S 607.52 0.00 0.00<br />

44100 S 319.72 0.00 0.00 45327 S 646.15 0.00 0.00<br />

44312 S 557.40 0.00 0.00 45330 S 83.15 0.00 0.00<br />

44340 S 639.28 0.00 0.00 45331 S 245.90 0.00 0.00<br />

44360 S 389.61 0.00 0.00 45332 S 245.90 0.00 0.00<br />

44361 S 389.61 0.00 0.00 45333 S 328.91 0.00 0.00<br />

44363 S 389.61 0.00 0.00 45334 S 328.91 0.00 0.00<br />

44364 S 389.61 0.00 0.00 45335 S 245.90 0.00 0.00<br />

44365 S 389.61 0.00 0.00 45337 S 245.90 0.00 0.00<br />

44366 S 389.61 0.00 0.00 45338 S 328.91 0.00 0.00<br />

44369 S 389.61 0.00 0.00 45339 S 328.91 0.00 0.00<br />

44370 S 1,111.52 0.00 0.00 45340 S 328.91 0.00 0.00<br />

44372 S 389.61 0.00 0.00 45341 S 328.91 0.00 0.00<br />

44373 S 389.61 0.00 0.00 45342 S 328.91 0.00 0.00<br />

44376 S 389.61 0.00 0.00 45345 S 646.15 0.00 0.00<br />

44377 S 389.61 0.00 0.00 45355 S 326.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 378.43 0.00 0.00 46505 S 467.74 0.00 0.00<br />

45379 S 378.43 0.00 0.00 46600 S 24.74 0.00 0.00<br />

45380 S 378.43 0.00 0.00 46604 S 349.74 0.00 0.00<br />

45381 S 378.43 0.00 0.00 46606 S 131.41 0.00 0.00<br />

45382 S 378.43 0.00 0.00 46608 S 328.91 0.00 0.00<br />

45383 S 378.43 0.00 0.00 46610 S 607.52 0.00 0.00<br />

45384 S 378.43 0.00 0.00 46611 S 328.91 0.00 0.00<br />

45385 S 378.43 0.00 0.00 46612 S 607.52 0.00 0.00<br />

45386 S 378.43 0.00 0.00 46614 S 69.12 0.00 0.00<br />

45387 S 646.15 0.00 0.00 46615 S 659.79 0.00 0.00<br />

45391 S 378.43 0.00 0.00 46700 S 679.92 0.00 0.00<br />

45392 S 378.43 0.00 0.00 46706 S 748.38 0.00 0.00<br />

45500 S 650.31 0.00 0.00 46750 S 830.27 0.00 0.00<br />

45505 S 800.66 0.00 0.00 46753 S 679.92 0.00 0.00<br />

45520 S 31.71 0.00 0.00 46754 S 650.31 0.00 0.00<br />

45560 S 800.66 0.00 0.00 46760 S 800.66 0.00 0.00<br />

45900 S 256.41 0.00 0.00 46761 S 830.27 0.00 0.00<br />

45905 S 598.04 0.00 0.00 46762 S 1,054.62 0.00 0.00<br />

45910 S 598.04 0.00 0.00 46900 S 104.50 0.00 0.00<br />

45915 S 378.23 0.00 0.00 46910 S 124.90 0.00 0.00<br />

45990 S 588.35 0.00 0.00 46916 S 58.10 0.00 0.00<br />

46020 S 679.92 0.00 0.00 46917 S 541.94 0.00 0.00<br />

46030 S 256.41 0.00 0.00 46922 S 541.94 0.00 0.00<br />

46040 S 679.92 0.00 0.00 46924 S 541.94 0.00 0.00<br />

46045 S 650.31 0.00 0.00 46930 S 121.14 0.00 0.00<br />

46050 S 378.23 0.00 0.00 46937 S 650.31 0.00 0.00<br />

46060 S 650.31 0.00 0.00 46938 S 800.66 0.00 0.00<br />

46070 S 467.74 0.00 0.00 46940 S 89.65 0.00 0.00<br />

46080 S 679.92 0.00 0.00 46942 S 87.26 0.00 0.00<br />

46083 S 71.60 0.00 0.00 46945 S 148.52 0.00 0.00<br />

46200 S 650.31 0.00 0.00 46946 S 387.91 0.00 0.00<br />

46210 S 650.31 0.00 0.00 46947 S 1,054.62 0.00 0.00<br />

46211 S 650.31 0.00 0.00 47000 S 337.45 0.00 0.00<br />

46220 S 598.04 0.00 0.00 47382 S 1,780.80 0.00 0.00<br />

46221 S 117.72 0.00 0.00 47510 S 788.64 0.00 0.00<br />

46230 S 598.04 0.00 0.00 47511 S 1,158.64 0.00 0.00<br />

46250 S 679.92 0.00 0.00 47525 S 452.74 0.00 0.00<br />

46255 S 679.92 0.00 0.00 47530 S 452.74 0.00 0.00<br />

46257 S 679.92 0.00 0.00 47552 S 788.64 0.00 0.00<br />

46258 S 679.92 0.00 0.00 47553 S 818.25 0.00 0.00<br />

46260 S 679.92 0.00 0.00 47554 S 818.25 0.00 0.00<br />

46261 S 735.42 0.00 0.00 47555 S 818.25 0.00 0.00<br />

46262 S 735.42 0.00 0.00 47556 S 1,158.64 0.00 0.00<br />

46270 S 679.92 0.00 0.00 47560 S 961.41 0.00 0.00<br />

46275 S 679.92 0.00 0.00 47561 S 961.41 0.00 0.00<br />

46280 S 735.42 0.00 0.00 47562 S 1,774.00 0.00 0.00<br />

46285 S 598.04 0.00 0.00 47563 S 1,774.00 0.00 0.00<br />

46288 S 735.42 0.00 0.00 47564 S 1,774.00 0.00 0.00<br />

46320 S 79.74 0.00 0.00 47630 S 818.25 0.00 0.00<br />

46500 S 109.84 0.00 0.00 48102 S 337.45 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 205.20 0.00 0.00 49590 S 842.20 0.00 0.00<br />

49081 S 205.20 0.00 0.00 49600 S 897.71 0.00 0.00<br />

49180 S 337.45 0.00 0.00 49650 S 1,178.43 0.00 0.00<br />

49250 S 739.70 0.00 0.00 49651 S 1,347.28 0.00 0.00<br />

49320 S 961.41 0.00 0.00 49652 S 1,450.98 0.00 0.00<br />

49321 S 1,016.92 0.00 0.00 49653 S 1,450.98 0.00 0.00<br />

49322 S 1,016.92 0.00 0.00 49654 S 1,450.98 0.00 0.00<br />

49324 S 1,450.98 0.00 0.00 49655 S 1,450.98 0.00 0.00<br />

49325 S 1,450.98 0.00 0.00 49656 S 1,450.98 0.00 0.00<br />

49326 S 1,450.98 0.00 0.00 49657 S 1,450.98 0.00 0.00<br />

49402 S 654.59 0.00 0.00 50200 S 337.45 0.00 0.00<br />

49419 S 785.26 0.00 0.00 50382 S 979.88 0.00 0.00<br />

49420 S 725.93 0.00 0.00 50384 S 719.70 0.00 0.00<br />

49421 S 725.93 0.00 0.00 50385 S 719.70 0.00 0.00<br />

49422 S 577.72 0.00 0.00 50386 S 276.13 0.00 0.00<br />

49423 S 597.39 0.00 0.00 50387 S 597.39 0.00 0.00<br />

49426 S 654.59 0.00 0.00 50389 S 276.13 0.00 0.00<br />

49429 S 847.37 0.00 0.00 50390 S 337.45 0.00 0.00<br />

49440 S 331.36 0.00 0.00 50391 S 39.96 0.00 0.00<br />

49441 S 331.36 0.00 0.00 50392 S 513.89 0.00 0.00<br />

49446 S 331.36 0.00 0.00 50393 S 643.98 0.00 0.00<br />

49450 S 176.00 0.00 0.00 50395 S 513.89 0.00 0.00<br />

49451 S 176.00 0.00 0.00 50396 S 96.63 0.00 0.00<br />

49452 S 176.00 0.00 0.00 50398 S 452.74 0.00 0.00<br />

49460 S 176.00 0.00 0.00 50551 S 292.11 0.00 0.00<br />

49495 S 897.71 0.00 0.00 50553 S 643.98 0.00 0.00<br />

49496 S 897.71 0.00 0.00 50555 S 292.11 0.00 0.00<br />

49500 S 897.71 0.00 0.00 50557 S 643.98 0.00 0.00<br />

49501 S 1,225.68 0.00 0.00 50561 S 643.98 0.00 0.00<br />

49505 S 897.71 0.00 0.00 50562 S 276.13 0.00 0.00<br />

49507 S 1,225.68 0.00 0.00 50570 S 276.13 0.00 0.00<br />

49520 S 1,066.56 0.00 0.00 50572 S 276.13 0.00 0.00<br />

49521 S 1,225.68 0.00 0.00 50574 S 276.13 0.00 0.00<br />

49525 S 897.71 0.00 0.00 50575 S 1,373.52 0.00 0.00<br />

49540 S 812.59 0.00 0.00 50576 S 719.70 0.00 0.00<br />

49550 S 937.96 0.00 0.00 50580 S 719.70 0.00 0.00<br />

49553 S 1,225.68 0.00 0.00 50590 S 1,604.59 0.00 0.00<br />

49555 S 937.96 0.00 0.00 50592 S 1,780.80 0.00 0.00<br />

49557 S 1,225.68 0.00 0.00 50686 S 39.96 0.00 0.00<br />

49560 S 897.71 0.00 0.00 50688 S 452.74 0.00 0.00<br />

49561 S 1,225.68 0.00 0.00 50947 S 1,506.40 0.00 0.00<br />

49565 S 897.71 0.00 0.00 50948 S 1,506.40 0.00 0.00<br />

49566 S 1,225.68 0.00 0.00 50951 S 292.11 0.00 0.00<br />

49568 S 1,066.56 0.00 0.00 50953 S 292.11 0.00 0.00<br />

49570 S 897.71 0.00 0.00 50955 S 643.98 0.00 0.00<br />

49572 S 1,225.68 0.00 0.00 50957 S 643.98 0.00 0.00<br />

49580 S 897.71 0.00 0.00 50961 S 643.98 0.00 0.00<br />

49582 S 1,225.68 0.00 0.00 50970 S 292.11 0.00 0.00<br />

49585 S 897.71 0.00 0.00 50972 S 292.11 0.00 0.00<br />

49587 S 1,225.68 0.00 0.00 50974 S 513.89 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 513.89 0.00 0.00 52275 S 696.26 0.00 0.00<br />

50980 S 643.98 0.00 0.00 52276 S 725.86 0.00 0.00<br />

51020 S 781.37 0.00 0.00 52277 S 696.26 0.00 0.00<br />

51030 S 781.37 0.00 0.00 52281 S 566.16 0.00 0.00<br />

51040 S 781.37 0.00 0.00 52282 S 1,306.17 0.00 0.00<br />

51045 S 322.74 0.00 0.00 52283 S 696.26 0.00 0.00<br />

51050 S 781.37 0.00 0.00 52285 S 566.16 0.00 0.00<br />

51065 S 781.37 0.00 0.00 52290 S 566.16 0.00 0.00<br />

51080 S 525.27 0.00 0.00 52300 S 696.26 0.00 0.00<br />

51100 S 30.46 0.00 0.00 52301 S 725.86 0.00 0.00<br />

51101 S 39.96 0.00 0.00 52305 S 696.26 0.00 0.00<br />

51102 S 537.66 0.00 0.00 52310 S 544.53 0.00 0.00<br />

51500 S 897.71 0.00 0.00 52315 S 696.26 0.00 0.00<br />

51520 S 781.37 0.00 0.00 52317 S 643.98 0.00 0.00<br />

51700 S 52.01 0.00 0.00 52318 S 696.26 0.00 0.00<br />

51701 S 24.74 0.00 0.00 52320 S 821.61 0.00 0.00<br />

51702 S 24.74 0.00 0.00 52325 S 781.37 0.00 0.00<br />

51703 S 39.96 0.00 0.00 52327 S 893.08 0.00 0.00<br />

51705 S 71.60 0.00 0.00 52330 S 696.26 0.00 0.00<br />

51710 S 452.74 0.00 0.00 52332 S 696.26 0.00 0.00<br />

51715 S 822.04 0.00 0.00 52334 S 725.86 0.00 0.00<br />

51720 S 57.49 0.00 0.00 52341 S 725.86 0.00 0.00<br />

51725 TC S 110.44 0.00 0.00 52342 S 725.86 0.00 0.00<br />

51726 TC S 152.12 0.00 0.00 52343 S 725.86 0.00 0.00<br />

51736 TC S 20.87 0.00 0.00 52344 S 725.86 0.00 0.00<br />

51741 TC S 24.30 0.00 0.00 52345 S 725.86 0.00 0.00<br />

51772 TC S 96.63 0.00 0.00 52346 S 725.86 0.00 0.00<br />

51784 TC S 39.96 0.00 0.00 52351 S 725.86 0.00 0.00<br />

51785 TC S 66.76 0.00 0.00 52352 S 781.37 0.00 0.00<br />

51792 TC S 39.96 0.00 0.00 52353 S 978.19 0.00 0.00<br />

51795 TC S 71.60 0.00 0.00 52354 S 781.37 0.00 0.00<br />

51797 TC S 71.60 0.00 0.00 52355 S 781.37 0.00 0.00<br />

51798 S 17.79 0.00 0.00 52400 S 725.86 0.00 0.00<br />

51880 S 643.98 0.00 0.00 52402 S 725.86 0.00 0.00<br />

51992 S 1,218.68 0.00 0.00 52450 S 725.86 0.00 0.00<br />

52000 S 292.11 0.00 0.00 52500 S 725.86 0.00 0.00<br />

52001 S 544.53 0.00 0.00 52601 S 978.19 0.00 0.00<br />

52005 S 566.16 0.00 0.00 52630 S 893.08 0.00 0.00<br />

52007 S 696.26 0.00 0.00 52640 S 696.26 0.00 0.00<br />

52010 S 322.74 0.00 0.00 52647 S 1,496.54 0.00 0.00<br />

52204 S 566.16 0.00 0.00 52648 S 1,496.54 0.00 0.00<br />

52214 S 696.26 0.00 0.00 52700 S 696.26 0.00 0.00<br />

52224 S 696.26 0.00 0.00 53000 S 534.37 0.00 0.00<br />

52234 S 696.26 0.00 0.00 53010 S 534.37 0.00 0.00<br />

52235 S 725.86 0.00 0.00 53020 S 534.37 0.00 0.00<br />

52240 S 725.86 0.00 0.00 53025 S 760.66 0.00 0.00<br />

52250 S 781.37 0.00 0.00 53040 S 586.65 0.00 0.00<br />

52260 S 566.16 0.00 0.00 53060 S 69.47 0.00 0.00<br />

52265 S 276.13 0.00 0.00 53080 S 616.26 0.00 0.00<br />

52270 S 566.16 0.00 0.00 53085 S 760.66 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 534.37 0.00 0.00 54060 S 541.94 0.00 0.00<br />

53210 S 917.79 0.00 0.00 54065 S 541.94 0.00 0.00<br />

53215 S 712.01 0.00 0.00 54100 S 458.44 0.00 0.00<br />

53220 S 792.43 0.00 0.00 54105 S 572.29 0.00 0.00<br />

53230 S 792.43 0.00 0.00 54110 S 887.29 0.00 0.00<br />

53235 S 616.26 0.00 0.00 54111 S 887.29 0.00 0.00<br />

53240 S 792.43 0.00 0.00 54112 S 887.29 0.00 0.00<br />

53250 S 586.65 0.00 0.00 54115 S 525.27 0.00 0.00<br />

53260 S 586.65 0.00 0.00 54120 S 887.29 0.00 0.00<br />

53265 S 586.65 0.00 0.00 54150 S 591.33 0.00 0.00<br />

53270 S 586.65 0.00 0.00 54160 S 643.61 0.00 0.00<br />

53275 S 586.65 0.00 0.00 54161 S 643.61 0.00 0.00<br />

53400 S 822.04 0.00 0.00 54162 S 643.61 0.00 0.00<br />

53405 S 792.43 0.00 0.00 54163 S 643.61 0.00 0.00<br />

53410 S 792.43 0.00 0.00 54164 S 643.61 0.00 0.00<br />

53420 S 822.04 0.00 0.00 54200 S 67.41 0.00 0.00<br />

53425 S 792.43 0.00 0.00 54205 S 972.41 0.00 0.00<br />

53430 S 792.43 0.00 0.00 54220 S 96.63 0.00 0.00<br />

53431 S 792.43 0.00 0.00 54231 S 63.30 0.00 0.00<br />

53440 S 4,564.71 2,772.36 980.01 54235 S 44.83 0.00 0.00<br />

53442 S 740.16 0.00 0.00 54240 TC S 31.82 0.00 0.00<br />

53444 S 4,564.71 2,772.36 980.01 54250 TC S 11.29 0.00 0.00<br />

53445 S 7,667.55 4,366.61 1,065.69 54300 S 916.89 0.00 0.00<br />

53446 S 740.16 0.00 0.00 54304 S 916.89 0.00 0.00<br />

53447 S 7,667.55 4,366.61 1,065.69 54308 S 916.89 0.00 0.00<br />

53449 S 740.16 0.00 0.00 54312 S 916.89 0.00 0.00<br />

53450 S 740.16 0.00 0.00 54316 S 916.89 0.00 0.00<br />

53460 S 534.37 0.00 0.00 54318 S 916.89 0.00 0.00<br />

53502 S 586.65 0.00 0.00 54322 S 916.89 0.00 0.00<br />

53505 S 792.43 0.00 0.00 54324 S 916.89 0.00 0.00<br />

53510 S 586.65 0.00 0.00 54326 S 916.89 0.00 0.00<br />

53515 S 792.43 0.00 0.00 54328 S 916.89 0.00 0.00<br />

53520 S 792.43 0.00 0.00 54340 S 916.89 0.00 0.00<br />

53600 S 40.04 0.00 0.00 54344 S 916.89 0.00 0.00<br />

53601 S 39.96 0.00 0.00 54348 S 916.89 0.00 0.00<br />

53605 S 566.16 0.00 0.00 54352 S 916.89 0.00 0.00<br />

53620 S 61.60 0.00 0.00 54360 S 916.89 0.00 0.00<br />

53621 S 64.68 0.00 0.00 54380 S 916.89 0.00 0.00<br />

53660 S 39.96 0.00 0.00 54385 S 916.89 0.00 0.00<br />

53661 S 39.96 0.00 0.00 54400 S 4,594.32 2,801.97 1,009.62<br />

53665 S 534.37 0.00 0.00 54401 S 7,749.43 4,448.50 1,147.57<br />

53850 S 1,754.28 0.00 0.00 54405 S 7,749.43 4,448.50 1,147.57<br />

53852 S 1,754.28 0.00 0.00 54406 S 916.89 0.00 0.00<br />

54000 S 586.65 0.00 0.00 54408 S 916.89 0.00 0.00<br />

54001 S 586.65 0.00 0.00 54410 S 7,749.43 4,448.50 1,147.57<br />

54015 S 662.66 0.00 0.00 54415 S 916.89 0.00 0.00<br />

54050 S 31.71 0.00 0.00 54416 S 7,749.43 4,448.50 1,147.57<br />

54055 S 64.68 0.00 0.00 54420 S 972.41 0.00 0.00<br />

54056 S 31.71 0.00 0.00 54435 S 972.41 0.00 0.00<br />

54057 S 541.94 0.00 0.00 54440 S 972.41 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 152.12 0.00 0.00 55706 S 442.23 0.00 0.00<br />

54500 S 412.87 0.00 0.00 55720 S 643.98 0.00 0.00<br />

54505 S 591.33 0.00 0.00 55725 S 696.26 0.00 0.00<br />

54512 S 643.61 0.00 0.00 55860 S 767.24 0.00 0.00<br />

54520 S 673.21 0.00 0.00 55870 S 78.02 0.00 0.00<br />

54522 S 673.21 0.00 0.00 55873 S 6,070.68 0.00 0.00<br />

54530 S 897.71 0.00 0.00 55875 S 1,306.17 0.00 0.00<br />

54550 S 897.71 0.00 0.00 55876 S 71.52 0.00 0.00<br />

54560 S 874.58 0.00 0.00 55920 S 896.56 0.00 0.00<br />

54600 S 728.73 0.00 0.00 56405 S 41.75 0.00 0.00<br />

54620 S 673.21 0.00 0.00 56420 S 54.49 0.00 0.00<br />

54640 S 897.71 0.00 0.00 56440 S 585.13 0.00 0.00<br />

54660 S 643.61 0.00 0.00 56441 S 532.86 0.00 0.00<br />

54670 S 673.21 0.00 0.00 56442 S 532.86 0.00 0.00<br />

54680 S 673.21 0.00 0.00 56501 S 57.49 0.00 0.00<br />

54690 S 1,506.40 0.00 0.00 56515 S 623.82 0.00 0.00<br />

54692 S 2,677.77 0.00 0.00 56605 S 33.19 0.00 0.00<br />

54700 S 643.61 0.00 0.00 56606 S 13.69 0.00 0.00<br />

54800 S 144.46 0.00 0.00 56620 S 710.49 0.00 0.00<br />

54830 S 673.21 0.00 0.00 56625 S 839.09 0.00 0.00<br />

54840 S 728.73 0.00 0.00 56700 S 532.86 0.00 0.00<br />

54860 S 673.21 0.00 0.00 56740 S 614.74 0.00 0.00<br />

54861 S 728.73 0.00 0.00 56800 S 614.74 0.00 0.00<br />

54865 S 591.33 0.00 0.00 56805 S 757.64 0.00 0.00<br />

54900 S 728.73 0.00 0.00 56810 S 710.49 0.00 0.00<br />

54901 S 728.73 0.00 0.00 56820 S 42.43 0.00 0.00<br />

55000 S 65.70 0.00 0.00 56821 S 54.49 0.00 0.00<br />

55040 S 842.20 0.00 0.00 57000 S 532.86 0.00 0.00<br />

55041 S 937.96 0.00 0.00 57010 S 585.13 0.00 0.00<br />

55060 S 728.73 0.00 0.00 57020 S 306.87 0.00 0.00<br />

55100 S 395.21 0.00 0.00 57022 S 482.35 0.00 0.00<br />

55110 S 643.61 0.00 0.00 57023 S 525.27 0.00 0.00<br />

55120 S 643.61 0.00 0.00 57061 S 53.04 0.00 0.00<br />

55150 S 591.33 0.00 0.00 57065 S 532.86 0.00 0.00<br />

55175 S 591.33 0.00 0.00 57100 S 33.88 0.00 0.00<br />

55180 S 643.61 0.00 0.00 57105 S 585.13 0.00 0.00<br />

55200 S 643.61 0.00 0.00 57130 S 585.13 0.00 0.00<br />

55250 S 643.61 0.00 0.00 57135 S 585.13 0.00 0.00<br />

55400 S 591.33 0.00 0.00 57150 S 24.64 0.00 0.00<br />

55450 S 211.48 0.00 0.00 57155 S 306.87 0.00 0.00<br />

55500 S 673.21 0.00 0.00 57160 S 35.59 0.00 0.00<br />

55520 S 728.73 0.00 0.00 57170 S 5.84 0.00 0.00<br />

55530 S 728.73 0.00 0.00 57180 S 109.61 0.00 0.00<br />

55535 S 897.71 0.00 0.00 57200 S 532.86 0.00 0.00<br />

55540 S 937.96 0.00 0.00 57210 S 585.13 0.00 0.00<br />

55550 S 1,506.40 0.00 0.00 57220 S 1,073.05 0.00 0.00<br />

55600 S 874.58 0.00 0.00 57230 S 881.07 0.00 0.00<br />

55680 S 591.33 0.00 0.00 57240 S 976.83 0.00 0.00<br />

55700 S 381.09 0.00 0.00 57250 S 976.83 0.00 0.00<br />

55705 S 381.09 0.00 0.00 57260 S 976.83 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,297.41 0.00 0.00 58555 S 575.72 0.00 0.00<br />

57267 S 1,105.43 0.00 0.00 58558 S 657.60 0.00 0.00<br />

57268 S 881.07 0.00 0.00 58559 S 628.00 0.00 0.00<br />

57287 S 1,290.31 0.00 0.00 58560 S 937.65 0.00 0.00<br />

57288 S 1,168.81 0.00 0.00 58561 S 937.65 0.00 0.00<br />

57289 S 976.83 0.00 0.00 58562 S 657.60 0.00 0.00<br />

57291 S 976.83 0.00 0.00 58563 S 1,321.13 0.00 0.00<br />

57300 S 881.07 0.00 0.00 58565 S 1,456.54 0.00 0.00<br />

57320 S 1,290.31 0.00 0.00 58600 S 1,290.31 0.00 0.00<br />

57400 S 585.13 0.00 0.00 58615 S 757.64 0.00 0.00<br />

57410 S 585.13 0.00 0.00 58660 S 1,218.68 0.00 0.00<br />

57415 S 585.13 0.00 0.00 58661 S 1,218.68 0.00 0.00<br />

57420 S 43.81 0.00 0.00 58662 S 1,218.68 0.00 0.00<br />

57421 S 57.15 0.00 0.00 58670 S 1,122.92 0.00 0.00<br />

57452 S 41.41 0.00 0.00 58671 S 1,122.92 0.00 0.00<br />

57454 S 50.65 0.00 0.00 58672 S 1,218.68 0.00 0.00<br />

57455 S 53.72 0.00 0.00 58673 S 1,218.68 0.00 0.00<br />

57456 S 52.01 0.00 0.00 58800 S 614.74 0.00 0.00<br />

57460 S 159.81 0.00 0.00 58805 S 1,290.31 0.00 0.00<br />

57461 S 169.73 0.00 0.00 58820 S 881.07 0.00 0.00<br />

57500 S 73.23 0.00 0.00 58900 S 614.74 0.00 0.00<br />

57505 S 46.54 0.00 0.00 58970 S 171.23 0.00 0.00<br />

57510 S 47.22 0.00 0.00 58974 S 171.23 0.00 0.00<br />

57511 S 54.49 0.00 0.00 58976 S 171.23 0.00 0.00<br />

57513 S 585.13 0.00 0.00 59000 S 62.62 0.00 0.00<br />

57520 S 585.13 0.00 0.00 59001 S 235.06 0.00 0.00<br />

57522 S 585.13 0.00 0.00 59012 S 114.94 0.00 0.00<br />

57530 S 881.07 0.00 0.00 59015 S 50.65 0.00 0.00<br />

57550 S 881.07 0.00 0.00 59020 TC S 26.69 0.00 0.00<br />

57556 S 1,168.81 0.00 0.00 59025 TC S 14.03 0.00 0.00<br />

57558 S 614.74 0.00 0.00 59070 S 114.94 0.00 0.00<br />

57700 S 532.86 0.00 0.00 59072 S 114.94 0.00 0.00<br />

57720 S 614.74 0.00 0.00 59076 S 114.94 0.00 0.00<br />

57800 S 24.98 0.00 0.00 59100 S 1,290.31 0.00 0.00<br />

58100 S 41.06 0.00 0.00 59150 S 1,774.00 0.00 0.00<br />

58120 S 585.13 0.00 0.00 59151 S 1,774.00 0.00 0.00<br />

58145 S 976.83 0.00 0.00 59160 S 614.74 0.00 0.00<br />

58301 S 38.32 0.00 0.00 59200 S 34.22 0.00 0.00<br />

58321 S 35.93 0.00 0.00 59300 S 73.91 0.00 0.00<br />

58322 S 36.96 0.00 0.00 59320 S 532.86 0.00 0.00<br />

58323 S 8.56 0.00 0.00 59412 S 757.64 0.00 0.00<br />

58345 S 757.64 0.00 0.00 59414 S 757.64 0.00 0.00<br />

58346 S 585.13 0.00 0.00 59812 S 710.49 0.00 0.00<br />

58350 S 881.07 0.00 0.00 59820 S 710.49 0.00 0.00<br />

58353 S 1,105.43 0.00 0.00 59821 S 710.49 0.00 0.00<br />

58356 S 1,674.27 0.00 0.00 59840 S 710.49 0.00 0.00<br />

58545 S 1,344.90 0.00 0.00 59841 S 710.49 0.00 0.00<br />

58546 S 1,506.40 0.00 0.00 59866 S 114.94 0.00 0.00<br />

58550 S 1,958.29 0.00 0.00 59870 S 710.49 0.00 0.00<br />

58552 S 1,774.00 0.00 0.00 59871 S 710.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 298.28 0.00 0.00 62367 S 16.42 0.00 0.00<br />

60100 S 46.88 0.00 0.00 62368 S 20.87 0.00 0.00<br />

60200 S 1,110.22 0.00 0.00 63600 S 560.76 0.00 0.00<br />

60280 S 1,195.34 0.00 0.00 63610 S 508.48 0.00 0.00<br />

60281 S 1,195.34 0.00 0.00 63615 S 708.89 0.00 0.00<br />

60300 S 61.60 0.00 0.00 63650 S 3,018.28 1,871.63 725.00<br />

61000 S 274.66 0.00 0.00 63655 S 4,421.04 2,819.30 1,217.58<br />

61001 S 274.66 0.00 0.00 63660 S 530.07 0.00 0.00<br />

61020 S 222.37 0.00 0.00 63685 S 13,418.87 7,155.06 891.26<br />

61026 S 222.37 0.00 0.00 63688 S 719.79 0.00 0.00<br />

61050 S 222.37 0.00 0.00 63744 S 1,040.92 0.00 0.00<br />

61055 S 222.37 0.00 0.00 63746 S 481.51 0.00 0.00<br />

61070 S 173.03 0.00 0.00 64400 S 52.70 0.00 0.00<br />

61215 S 1,040.92 0.00 0.00 64402 S 49.62 0.00 0.00<br />

61330 S 1,603.60 0.00 0.00 64405 S 42.09 0.00 0.00<br />

61334 S 1,603.60 0.00 0.00 64408 S 52.35 0.00 0.00<br />

61790 S 590.36 0.00 0.00 64410 S 291.37 0.00 0.00<br />

61791 S 437.99 0.00 0.00 64412 S 77.00 0.00 0.00<br />

61880 S 752.05 0.00 0.00 64413 S 49.28 0.00 0.00<br />

61885 S 10,822.09 5,797.29 772.49 64415 S 134.19 0.00 0.00<br />

61886 S 16,160.02 8,517.26 874.52 64416 S 274.66 0.00 0.00<br />

61888 S 719.79 0.00 0.00 64417 S 134.19 0.00 0.00<br />

62194 S 291.37 0.00 0.00 64418 S 69.12 0.00 0.00<br />

62225 S 452.74 0.00 0.00 64420 S 134.19 0.00 0.00<br />

62230 S 1,011.31 0.00 0.00 64421 S 291.37 0.00 0.00<br />

62252 TC S 45.86 0.00 0.00 64425 S 47.90 0.00 0.00<br />

62263 S 291.37 0.00 0.00 64430 S 201.63 0.00 0.00<br />

62264 S 429.23 0.00 0.00 64435 S 72.20 0.00 0.00<br />

62267 S 171.29 0.00 0.00 64445 S 63.99 0.00 0.00<br />

62268 S 222.37 0.00 0.00 64446 S 550.38 0.00 0.00<br />

62269 S 337.45 0.00 0.00 64447 S 139.78 0.00 0.00<br />

62270 S 134.19 0.00 0.00 64448 S 139.78 0.00 0.00<br />

62272 S 134.19 0.00 0.00 64449 S 274.66 0.00 0.00<br />

62273 S 223.93 0.00 0.00 64450 S 42.77 0.00 0.00<br />

62280 S 291.37 0.00 0.00 64455 S 17.79 0.00 0.00<br />

62281 S 291.37 0.00 0.00 64470 S 291.37 0.00 0.00<br />

62282 S 291.37 0.00 0.00 64472 S 223.93 0.00 0.00<br />

62287 S 1,307.97 0.00 0.00 64475 S 291.37 0.00 0.00<br />

62292 S 274.66 0.00 0.00 64476 S 201.67 0.00 0.00<br />

62294 S 222.37 0.00 0.00 64479 S 291.37 0.00 0.00<br />

62310 S 291.37 0.00 0.00 64480 S 223.93 0.00 0.00<br />

62311 S 291.37 0.00 0.00 64483 S 291.37 0.00 0.00<br />

62318 S 291.37 0.00 0.00 64484 S 223.93 0.00 0.00<br />

62319 S 291.37 0.00 0.00 64505 S 39.01 0.00 0.00<br />

62350 S 1,011.31 0.00 0.00 64508 S 82.81 0.00 0.00<br />

62355 S 481.51 0.00 0.00 64510 S 291.37 0.00 0.00<br />

62360 S 1,011.31 0.00 0.00 64517 S 201.63 0.00 0.00<br />

62361 S 10,381.20 5,618.97 856.76 64520 S 291.37 0.00 0.00<br />

62362 S 10,381.20 5,618.97 856.76 64530 S 291.37 0.00 0.00<br />

62365 S 894.88 0.00 0.00 64553 S 2,966.00 1,819.35 672.72<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,330.64 2,184.00 1,037.36 64746 S 560.76 0.00 0.00<br />

64560 S 3,330.64 2,184.00 1,037.36 64761 S 708.89 0.00 0.00<br />

64561 S 3,047.88 1,901.23 754.60 64763 S 708.89 0.00 0.00<br />

64565 S 3,330.64 2,184.00 1,037.36 64766 S 1,377.13 0.00 0.00<br />

64573 S 5,188.64 3,073.76 958.89 64771 S 560.76 0.00 0.00<br />

64575 S 3,966.29 2,364.55 762.83 64772 S 560.76 0.00 0.00<br />

64577 S 3,966.29 2,364.55 762.83 64774 S 560.76 0.00 0.00<br />

64580 S 3,966.29 2,364.55 762.83 64776 S 590.36 0.00 0.00<br />

64581 S 4,048.17 2,446.43 844.71 64778 S 560.76 0.00 0.00<br />

64585 S 530.07 0.00 0.00 64782 S 590.36 0.00 0.00<br />

64590 S 10,822.09 5,797.29 772.49 64783 S 560.76 0.00 0.00<br />

64595 S 719.79 0.00 0.00 64784 S 590.36 0.00 0.00<br />

64600 S 429.23 0.00 0.00 64786 S 924.48 0.00 0.00<br />

64605 S 429.23 0.00 0.00 64787 S 560.76 0.00 0.00<br />

64610 S 429.23 0.00 0.00 64788 S 590.36 0.00 0.00<br />

64612 S 62.62 0.00 0.00 64790 S 590.36 0.00 0.00<br />

64613 S 60.57 0.00 0.00 64792 S 924.48 0.00 0.00<br />

64614 S 69.12 0.00 0.00 64795 S 560.76 0.00 0.00<br />

64620 S 291.37 0.00 0.00 64802 S 560.76 0.00 0.00<br />

64622 S 429.23 0.00 0.00 64820 S 708.89 0.00 0.00<br />

64623 S 291.37 0.00 0.00 64821 S 827.56 0.00 0.00<br />

64626 S 429.23 0.00 0.00 64822 S 1,072.26 0.00 0.00<br />

64627 S 201.67 0.00 0.00 64823 S 1,072.26 0.00 0.00<br />

64630 S 300.12 0.00 0.00 64831 S 980.00 0.00 0.00<br />

64632 S 32.51 0.00 0.00 64832 S 842.60 0.00 0.00<br />

64640 S 96.84 0.00 0.00 64834 S 894.88 0.00 0.00<br />

64650 S 32.51 0.00 0.00 64835 S 924.48 0.00 0.00<br />

64653 S 35.25 0.00 0.00 64836 S 924.48 0.00 0.00<br />

64680 S 456.04 0.00 0.00 64837 S 842.60 0.00 0.00<br />

64681 S 481.51 0.00 0.00 64840 S 894.88 0.00 0.00<br />

64702 S 508.48 0.00 0.00 64856 S 894.88 0.00 0.00<br />

64704 S 508.48 0.00 0.00 64857 S 894.88 0.00 0.00<br />

64708 S 560.76 0.00 0.00 64858 S 894.88 0.00 0.00<br />

64712 S 560.76 0.00 0.00 64859 S 842.60 0.00 0.00<br />

64713 S 560.76 0.00 0.00 64861 S 924.48 0.00 0.00<br />

64714 S 560.76 0.00 0.00 64862 S 924.48 0.00 0.00<br />

64716 S 590.36 0.00 0.00 64864 S 924.48 0.00 0.00<br />

64718 S 560.76 0.00 0.00 64865 S 980.00 0.00 0.00<br />

64719 S 560.76 0.00 0.00 64870 S 980.00 0.00 0.00<br />

64721 S 560.76 0.00 0.00 64872 S 894.88 0.00 0.00<br />

64722 S 508.48 0.00 0.00 64874 S 924.48 0.00 0.00<br />

64726 S 508.48 0.00 0.00 64876 S 924.48 0.00 0.00<br />

64727 S 508.48 0.00 0.00 64885 S 894.88 0.00 0.00<br />

64732 S 560.76 0.00 0.00 64886 S 894.88 0.00 0.00<br />

64734 S 560.76 0.00 0.00 64890 S 894.88 0.00 0.00<br />

64736 S 560.76 0.00 0.00 64891 S 894.88 0.00 0.00<br />

64738 S 560.76 0.00 0.00 64892 S 894.88 0.00 0.00<br />

64740 S 560.76 0.00 0.00 64893 S 894.88 0.00 0.00<br />

64742 S 560.76 0.00 0.00 64895 S 924.48 0.00 0.00<br />

64744 S 560.76 0.00 0.00 64896 S 924.48 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 924.48 0.00 0.00 65770 S 5,440.27 0.00 0.00<br />

64898 S 924.48 0.00 0.00 65772 S 611.99 0.00 0.00<br />

64901 S 894.88 0.00 0.00 65775 S 611.99 0.00 0.00<br />

64902 S 894.88 0.00 0.00 65780 S 1,058.65 0.00 0.00<br />

64905 S 894.88 0.00 0.00 65781 S 1,058.65 0.00 0.00<br />

64907 S 842.60 0.00 0.00 65782 S 1,058.65 0.00 0.00<br />

64910 S 1,377.13 0.00 0.00 65800 S 474.60 0.00 0.00<br />

65091 S 973.43 0.00 0.00 65805 S 474.60 0.00 0.00<br />

65093 S 973.43 0.00 0.00 65810 S 693.49 0.00 0.00<br />

65101 S 973.43 0.00 0.00 65815 S 663.88 0.00 0.00<br />

65103 S 973.43 0.00 0.00 65820 S 243.48 0.00 0.00<br />

65105 S 1,028.95 0.00 0.00 65850 S 748.99 0.00 0.00<br />

65110 S 1,069.18 0.00 0.00 65855 S 129.35 0.00 0.00<br />

65112 S 1,197.78 0.00 0.00 65860 S 120.80 0.00 0.00<br />

65114 S 1,197.78 0.00 0.00 65865 S 474.60 0.00 0.00<br />

65125 S 996.85 0.00 0.00 65870 S 748.99 0.00 0.00<br />

65130 S 734.34 0.00 0.00 65875 S 748.99 0.00 0.00<br />

65135 S 704.74 0.00 0.00 65880 S 611.99 0.00 0.00<br />

65140 S 973.43 0.00 0.00 65900 S 652.23 0.00 0.00<br />

65150 S 704.74 0.00 0.00 65920 S 917.84 0.00 0.00<br />

65155 S 973.43 0.00 0.00 65930 S 789.24 0.00 0.00<br />

65175 S 523.86 0.00 0.00 66020 S 474.60 0.00 0.00<br />

65205 S 20.19 0.00 0.00 66030 S 243.48 0.00 0.00<br />

65210 S 25.67 0.00 0.00 66130 S 917.84 0.00 0.00<br />

65220 S 35.76 0.00 0.00 66150 S 748.99 0.00 0.00<br />

65222 S 28.06 0.00 0.00 66155 S 748.99 0.00 0.00<br />

65235 S 526.87 0.00 0.00 66160 S 663.88 0.00 0.00<br />

65260 S 347.51 0.00 0.00 66165 S 748.99 0.00 0.00<br />

65265 S 718.94 0.00 0.00 66170 S 748.99 0.00 0.00<br />

65270 S 576.13 0.00 0.00 66172 S 748.99 0.00 0.00<br />

65272 S 663.88 0.00 0.00 66180 S 1,115.85 0.00 0.00<br />

65275 S 748.99 0.00 0.00 66185 S 990.49 0.00 0.00<br />

65280 S 718.94 0.00 0.00 66220 S 966.89 0.00 0.00<br />

65285 S 1,022.40 0.00 0.00 66225 S 1,075.61 0.00 0.00<br />

65286 S 178.87 0.00 0.00 66250 S 526.87 0.00 0.00<br />

65290 S 708.02 0.00 0.00 66500 S 243.48 0.00 0.00<br />

65400 S 474.60 0.00 0.00 66505 S 243.48 0.00 0.00<br />

65410 S 526.87 0.00 0.00 66600 S 693.49 0.00 0.00<br />

65420 S 526.87 0.00 0.00 66605 S 693.49 0.00 0.00<br />

65426 S 789.24 0.00 0.00 66625 S 493.07 0.00 0.00<br />

65430 S 35.76 0.00 0.00 66630 S 693.49 0.00 0.00<br />

65435 S 31.14 0.00 0.00 66635 S 693.49 0.00 0.00<br />

65436 S 135.17 0.00 0.00 66680 S 693.49 0.00 0.00<br />

65450 S 82.52 0.00 0.00 66682 S 663.88 0.00 0.00<br />

65600 S 159.46 0.00 0.00 66700 S 526.87 0.00 0.00<br />

65710 S 1,187.25 0.00 0.00 66710 S 526.87 0.00 0.00<br />

65730 S 1,187.25 0.00 0.00 66711 S 526.87 0.00 0.00<br />

65750 S 1,187.25 0.00 0.00 66720 S 526.87 0.00 0.00<br />

65755 S 1,187.25 0.00 0.00 66740 S 663.88 0.00 0.00<br />

65756 S 1,453.95 0.00 0.00 66761 S 180.00 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 183.08 0.00 0.00 67228 S 201.62 0.00 0.00<br />

66770 S 201.62 0.00 0.00 67229 S 201.62 0.00 0.00<br />

66820 S 178.87 0.00 0.00 67250 S 605.74 0.00 0.00<br />

66821 S 245.36 0.00 0.00 67255 S 663.44 0.00 0.00<br />

66825 S 748.99 0.00 0.00 67311 S 708.02 0.00 0.00<br />

66830 S 261.95 0.00 0.00 67312 S 763.54 0.00 0.00<br />

66840 S 563.10 0.00 0.00 67314 S 763.54 0.00 0.00<br />

66850 S 1,060.19 0.00 0.00 67316 S 763.54 0.00 0.00<br />

66852 S 891.34 0.00 0.00 67318 S 763.54 0.00 0.00<br />

66920 S 891.34 0.00 0.00 67320 S 763.54 0.00 0.00<br />

66930 S 931.59 0.00 0.00 67331 S 763.54 0.00 0.00<br />

66940 S 603.35 0.00 0.00 67332 S 763.54 0.00 0.00<br />

66982 S 915.31 0.00 0.00 67334 S 763.54 0.00 0.00<br />

66983 S 915.31 0.00 0.00 67335 S 763.54 0.00 0.00<br />

66984 S 915.31 0.00 0.00 67340 S 763.54 0.00 0.00<br />

66985 S 847.31 0.00 0.00 67343 S 932.38 0.00 0.00<br />

66986 S 847.31 0.00 0.00 67345 S 79.74 0.00 0.00<br />

67005 S 718.94 0.00 0.00 67346 S 431.27 0.00 0.00<br />

67010 S 718.94 0.00 0.00 67400 S 605.74 0.00 0.00<br />

67015 S 885.01 0.00 0.00 67405 S 789.86 0.00 0.00<br />

67025 S 581.56 0.00 0.00 67412 S 701.50 0.00 0.00<br />

67027 S 1,022.40 0.00 0.00 67413 S 830.10 0.00 0.00<br />

67028 S 80.42 0.00 0.00 67414 S 1,475.02 0.00 0.00<br />

67030 S 581.56 0.00 0.00 67415 S 523.86 0.00 0.00<br />

67031 S 245.36 0.00 0.00 67420 S 1,069.18 0.00 0.00<br />

67036 S 1,022.40 0.00 0.00 67430 S 1,069.18 0.00 0.00<br />

67039 S 1,191.25 0.00 0.00 67440 S 1,069.18 0.00 0.00<br />

67040 S 1,191.25 0.00 0.00 67445 S 1,069.18 0.00 0.00<br />

67041 S 1,461.94 0.00 0.00 67450 S 1,069.18 0.00 0.00<br />

67042 S 1,461.94 0.00 0.00 67500 S 82.52 0.00 0.00<br />

67043 S 1,461.94 0.00 0.00 67505 S 25.67 0.00 0.00<br />

67101 S 223.18 0.00 0.00 67515 S 26.01 0.00 0.00<br />

67105 S 201.62 0.00 0.00 67550 S 1,028.95 0.00 0.00<br />

67107 S 1,062.65 0.00 0.00 67560 S 704.74 0.00 0.00<br />

67108 S 1,191.25 0.00 0.00 67570 S 1,028.95 0.00 0.00<br />

67110 S 324.40 0.00 0.00 67700 S 120.73 0.00 0.00<br />

67112 S 1,191.25 0.00 0.00 67710 S 140.98 0.00 0.00<br />

67113 S 1,461.94 0.00 0.00 67715 S 523.86 0.00 0.00<br />

67115 S 633.83 0.00 0.00 67800 S 50.65 0.00 0.00<br />

67120 S 633.83 0.00 0.00 67801 S 61.25 0.00 0.00<br />

67121 S 633.83 0.00 0.00 67805 S 79.39 0.00 0.00<br />

67141 S 223.42 0.00 0.00 67808 S 576.13 0.00 0.00<br />

67145 S 190.60 0.00 0.00 67810 S 120.73 0.00 0.00<br />

67208 S 203.27 0.00 0.00 67820 S 16.77 0.00 0.00<br />

67210 S 201.62 0.00 0.00 67825 S 51.67 0.00 0.00<br />

67218 S 759.19 0.00 0.00 67830 S 353.70 0.00 0.00<br />

67220 S 223.18 0.00 0.00 67835 S 576.13 0.00 0.00<br />

67221 S 114.63 0.00 0.00 67840 S 147.83 0.00 0.00<br />

67225 S 7.88 0.00 0.00 67850 S 117.38 0.00 0.00<br />

67227 S 581.56 0.00 0.00 67875 S 294.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 556.48 0.00 0.00 68440 S 50.31 0.00 0.00<br />

67882 S 605.74 0.00 0.00 68500 S 734.34 0.00 0.00<br />

67900 S 789.86 0.00 0.00 68505 S 734.34 0.00 0.00<br />

67901 S 701.50 0.00 0.00 68510 S 523.86 0.00 0.00<br />

67902 S 830.10 0.00 0.00 68520 S 734.34 0.00 0.00<br />

67903 S 661.25 0.00 0.00 68525 S 523.86 0.00 0.00<br />

67904 S 661.25 0.00 0.00 68530 S 120.73 0.00 0.00<br />

67906 S 701.50 0.00 0.00 68540 S 605.74 0.00 0.00<br />

67908 S 661.25 0.00 0.00 68550 S 734.34 0.00 0.00<br />

67909 S 661.25 0.00 0.00 68700 S 576.13 0.00 0.00<br />

67911 S 605.74 0.00 0.00 68705 S 114.63 0.00 0.00<br />

67912 S 605.74 0.00 0.00 68720 S 789.86 0.00 0.00<br />

67914 S 605.74 0.00 0.00 68745 S 789.86 0.00 0.00<br />

67915 S 163.57 0.00 0.00 68750 S 789.86 0.00 0.00<br />

67916 S 661.25 0.00 0.00 68760 S 97.53 0.00 0.00<br />

67917 S 661.25 0.00 0.00 68761 S 67.41 0.00 0.00<br />

67921 S 605.74 0.00 0.00 68770 S 789.86 0.00 0.00<br />

67922 S 159.12 0.00 0.00 68801 S 35.76 0.00 0.00<br />

67923 S 661.25 0.00 0.00 68810 S 102.26 0.00 0.00<br />

67924 S 661.25 0.00 0.00 68811 S 576.13 0.00 0.00<br />

67930 S 163.57 0.00 0.00 68815 S 576.13 0.00 0.00<br />

67935 S 576.13 0.00 0.00 68816 S 739.64 0.00 0.00<br />

67938 S 82.52 0.00 0.00 68840 S 53.04 0.00 0.00<br />

67950 S 576.13 0.00 0.00 69000 S 54.10 0.00 0.00<br />

67961 S 605.74 0.00 0.00 69005 S 102.32 0.00 0.00<br />

67966 S 605.74 0.00 0.00 69020 S 54.10 0.00 0.00<br />

67971 S 605.74 0.00 0.00 69100 S 61.60 0.00 0.00<br />

67973 S 734.34 0.00 0.00 69105 S 87.26 0.00 0.00<br />

67974 S 605.74 0.00 0.00 69110 S 458.44 0.00 0.00<br />

67975 S 605.74 0.00 0.00 69120 S 680.33 0.00 0.00<br />

68020 S 44.83 0.00 0.00 69140 S 680.33 0.00 0.00<br />

68040 S 22.24 0.00 0.00 69145 S 510.71 0.00 0.00<br />

68100 S 88.97 0.00 0.00 69150 S 358.95 0.00 0.00<br />

68110 S 114.63 0.00 0.00 69200 S 24.74 0.00 0.00<br />

68115 S 576.13 0.00 0.00 69205 S 572.29 0.00 0.00<br />

68130 S 526.87 0.00 0.00 69210 S 20.19 0.00 0.00<br />

68135 S 57.49 0.00 0.00 69220 S 31.71 0.00 0.00<br />

68200 S 16.42 0.00 0.00 69222 S 133.46 0.00 0.00<br />

68320 S 789.86 0.00 0.00 69300 S 709.94 0.00 0.00<br />

68325 S 789.86 0.00 0.00 69310 S 1,037.72 0.00 0.00<br />

68326 S 661.25 0.00 0.00 69320 S 1,262.07 0.00 0.00<br />

68328 S 789.86 0.00 0.00 69400 S 89.65 0.00 0.00<br />

68330 S 748.99 0.00 0.00 69401 S 47.22 0.00 0.00<br />

68335 S 789.86 0.00 0.00 69405 S 123.88 0.00 0.00<br />

68340 S 661.25 0.00 0.00 69420 S 111.22 0.00 0.00<br />

68360 S 663.88 0.00 0.00 69421 S 566.04 0.00 0.00<br />

68362 S 663.88 0.00 0.00 69424 S 78.02 0.00 0.00<br />

68371 S 526.87 0.00 0.00 69433 S 110.88 0.00 0.00<br />

68400 S 120.73 0.00 0.00 69436 S 566.04 0.00 0.00<br />

68420 S 171.78 0.00 0.00 69440 S 709.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 955.84 0.00 0.00 69840 S 1,133.47 0.00 0.00<br />

69501 S 1,262.07 0.00 0.00 69905 S 1,262.07 0.00 0.00<br />

69502 S 934.29 0.00 0.00 69910 S 1,262.07 0.00 0.00<br />

69505 S 1,262.07 0.00 0.00 69915 S 1,262.07 0.00 0.00<br />

69511 S 1,262.07 0.00 0.00 69930 S 22,816.59 12,250.96 1,685.34<br />

69530 S 1,262.07 0.00 0.00 70030 TC A 17.45 0.00 0.00<br />

69540 S 130.37 0.00 0.00 70100 TC A 19.17 0.00 0.00<br />

69550 S 1,133.47 0.00 0.00 70110 TC A 23.62 0.00 0.00<br />

69552 S 1,262.07 0.00 0.00 70120 TC A 21.22 0.00 0.00<br />

69601 S 1,262.07 0.00 0.00 70130 TC A 25.92 0.00 0.00<br />

69602 S 1,262.07 0.00 0.00 70134 TC A 26.01 0.00 0.00<br />

69603 S 1,262.07 0.00 0.00 70140 TC A 17.79 0.00 0.00<br />

69604 S 1,262.07 0.00 0.00 70150 TC A 25.92 0.00 0.00<br />

69605 S 1,262.07 0.00 0.00 70160 TC A 20.87 0.00 0.00<br />

69610 S 174.52 0.00 0.00 70190 TC A 21.90 0.00 0.00<br />

69620 S 680.33 0.00 0.00 70200 TC A 25.92 0.00 0.00<br />

69631 S 1,133.47 0.00 0.00 70210 TC A 18.48 0.00 0.00<br />

69632 S 1,133.47 0.00 0.00 70220 TC A 23.27 0.00 0.00<br />

69633 S 1,133.47 0.00 0.00 70240 TC A 17.45 0.00 0.00<br />

69635 S 1,262.07 0.00 0.00 70250 TC A 21.22 0.00 0.00<br />

69636 S 1,262.07 0.00 0.00 70260 TC A 27.03 0.00 0.00<br />

69637 S 1,262.07 0.00 0.00 70300 TC A 7.52 0.00 0.00<br />

69641 S 1,262.07 0.00 0.00 70310 TC A 18.60 0.00 0.00<br />

69642 S 1,262.07 0.00 0.00 70320 TC A 18.60 0.00 0.00<br />

69643 S 1,262.07 0.00 0.00 70328 TC A 18.48 0.00 0.00<br />

69644 S 1,262.07 0.00 0.00 70330 TC A 25.92 0.00 0.00<br />

69645 S 1,262.07 0.00 0.00 70336 TC A 201.77 0.00 0.00<br />

69646 S 1,262.07 0.00 0.00 70350 TC A 10.27 0.00 0.00<br />

69650 S 934.29 0.00 0.00 70355 TC A 10.61 0.00 0.00<br />

69660 S 1,133.47 0.00 0.00 70360 TC A 16.42 0.00 0.00<br />

69661 S 1,133.47 0.00 0.00 70370 TC A 48.24 0.00 0.00<br />

69662 S 1,133.47 0.00 0.00 70371 TC A 48.24 0.00 0.00<br />

69666 S 1,093.23 0.00 0.00 70380 TC A 24.98 0.00 0.00<br />

69667 S 1,093.23 0.00 0.00 70450 TC A 112.69 0.00 0.00<br />

69670 S 1,037.72 0.00 0.00 70460 TC A 178.44 0.00 0.00<br />

69676 S 1,037.72 0.00 0.00 70470 TC A 197.66 0.00 0.00<br />

69700 S 1,037.72 0.00 0.00 70480 TC A 112.69 0.00 0.00<br />

69711 S 955.84 0.00 0.00 70481 TC A 178.44 0.00 0.00<br />

69714 S 6,061.77 3,822.17 1,582.58 70482 TC A 197.66 0.00 0.00<br />

69715 S 6,061.77 3,822.17 1,582.58 70486 TC A 112.69 0.00 0.00<br />

69717 S 6,061.77 3,822.17 1,582.58 70487 TC A 178.44 0.00 0.00<br />

69718 S 6,061.77 3,822.17 1,582.58 70488 TC A 197.66 0.00 0.00<br />

69720 S 1,133.47 0.00 0.00 70490 TC A 112.69 0.00 0.00<br />

69740 S 1,133.47 0.00 0.00 70491 TC A 178.44 0.00 0.00<br />

69745 S 1,133.47 0.00 0.00 70492 TC A 197.66 0.00 0.00<br />

69801 S 1,133.47 0.00 0.00 70496 TC A 203.98 0.00 0.00<br />

69802 S 1,262.07 0.00 0.00 70498 TC A 203.98 0.00 0.00<br />

69805 S 1,262.07 0.00 0.00 70540 TC A 201.77 0.00 0.00<br />

69806 S 1,262.07 0.00 0.00 70542 TC A 247.78 0.00 0.00<br />

69820 S 1,133.47 0.00 0.00 70543 TC A 312.29 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 201.77 0.00 0.00 72120 TC A 32.85 0.00 0.00<br />

70545 TC A 247.78 0.00 0.00 72125 TC A 112.69 0.00 0.00<br />

70546 TC A 312.29 0.00 0.00 72126 TC A 178.44 0.00 0.00<br />

70547 TC A 201.77 0.00 0.00 72127 TC A 197.66 0.00 0.00<br />

70548 TC A 247.78 0.00 0.00 72128 TC A 112.69 0.00 0.00<br />

70549 TC A 312.29 0.00 0.00 72129 TC A 178.44 0.00 0.00<br />

70551 TC A 201.77 0.00 0.00 72130 TC A 197.66 0.00 0.00<br />

70552 TC A 247.78 0.00 0.00 72131 TC A 112.69 0.00 0.00<br />

70553 TC A 312.29 0.00 0.00 72132 TC A 178.44 0.00 0.00<br />

70554 TC A 201.77 0.00 0.00 72133 TC A 197.66 0.00 0.00<br />

70555 TC A 201.77 0.00 0.00 72141 TC A 201.77 0.00 0.00<br />

70557 TC A 201.77 0.00 0.00 72142 TC A 247.78 0.00 0.00<br />

70558 TC A 247.78 0.00 0.00 72146 TC A 201.77 0.00 0.00<br />

70559 TC A 312.29 0.00 0.00 72147 TC A 247.78 0.00 0.00<br />

71010 TC A 13.35 0.00 0.00 72148 TC A 201.77 0.00 0.00<br />

71015 TC A 17.11 0.00 0.00 72149 TC A 247.78 0.00 0.00<br />

71020 TC A 18.14 0.00 0.00 72156 TC A 312.29 0.00 0.00<br />

71021 TC A 21.90 0.00 0.00 72157 TC A 312.29 0.00 0.00<br />

71022 TC A 25.92 0.00 0.00 72158 TC A 312.29 0.00 0.00<br />

71023 TC A 42.43 0.00 0.00 72170 TC A 15.40 0.00 0.00<br />

71030 TC A 25.92 0.00 0.00 72190 TC A 25.92 0.00 0.00<br />

71034 TC A 48.24 0.00 0.00 72191 TC A 203.98 0.00 0.00<br />

71035 TC A 22.58 0.00 0.00 72192 TC A 112.69 0.00 0.00<br />

71100 TC A 18.82 0.00 0.00 72193 TC A 178.44 0.00 0.00<br />

71101 TC A 22.92 0.00 0.00 72194 TC A 197.66 0.00 0.00<br />

71110 TC A 23.96 0.00 0.00 72195 TC A 201.77 0.00 0.00<br />

71111 TC A 31.82 0.00 0.00 72196 TC A 247.78 0.00 0.00<br />

71120 TC A 19.85 0.00 0.00 72197 TC A 312.29 0.00 0.00<br />

71130 TC A 23.27 0.00 0.00 72200 TC A 18.14 0.00 0.00<br />

71250 TC A 112.69 0.00 0.00 72202 TC A 22.24 0.00 0.00<br />

71260 TC A 178.44 0.00 0.00 72220 TC A 18.14 0.00 0.00<br />

71270 TC A 197.66 0.00 0.00 73000 TC A 17.11 0.00 0.00<br />

71275 TC A 203.98 0.00 0.00 73010 TC A 17.45 0.00 0.00<br />

71550 TC A 201.77 0.00 0.00 73020 TC A 14.03 0.00 0.00<br />

71551 TC A 247.78 0.00 0.00 73030 TC A 17.79 0.00 0.00<br />

71552 TC A 312.29 0.00 0.00 73050 TC A 22.24 0.00 0.00<br />

72010 TC A 43.15 0.00 0.00 73060 TC A 17.79 0.00 0.00<br />

72020 TC A 14.03 0.00 0.00 73070 TC A 17.11 0.00 0.00<br />

72040 TC A 22.58 0.00 0.00 73080 TC A 22.58 0.00 0.00<br />

72050 TC A 32.16 0.00 0.00 73090 TC A 17.11 0.00 0.00<br />

72052 TC A 43.15 0.00 0.00 73092 TC A 17.79 0.00 0.00<br />

72069 TC A 21.22 0.00 0.00 73100 TC A 17.79 0.00 0.00<br />

72070 TC A 19.85 0.00 0.00 73110 TC A 22.58 0.00 0.00<br />

72072 TC A 23.96 0.00 0.00 73120 TC A 16.77 0.00 0.00<br />

72074 TC A 25.92 0.00 0.00 73130 TC A 19.85 0.00 0.00<br />

72080 TC A 21.22 0.00 0.00 73140 TC A 19.51 0.00 0.00<br />

72090 TC A 28.41 0.00 0.00 73200 TC A 112.69 0.00 0.00<br />

72100 TC A 24.30 0.00 0.00 73201 TC A 178.44 0.00 0.00<br />

72110 TC A 33.88 0.00 0.00 73202 TC A 197.66 0.00 0.00<br />

72114 TC A 43.15 0.00 0.00 73206 TC A 203.98 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 201.77 0.00 0.00 74246 TC A 50.92 0.00 0.00<br />

73219 TC A 247.78 0.00 0.00 74247 TC A 50.92 0.00 0.00<br />

73220 TC A 312.29 0.00 0.00 74249 TC A 82.80 0.00 0.00<br />

73221 TC A 201.77 0.00 0.00 74250 TC A 50.92 0.00 0.00<br />

73222 TC A 247.78 0.00 0.00 74251 TC A 82.80 0.00 0.00<br />

73223 TC A 312.29 0.00 0.00 74260 TC A 50.92 0.00 0.00<br />

73500 TC A 14.72 0.00 0.00 74270 TC A 50.92 0.00 0.00<br />

73510 TC A 22.58 0.00 0.00 74280 TC A 82.80 0.00 0.00<br />

73520 TC A 23.27 0.00 0.00 74283 TC A 50.92 0.00 0.00<br />

73540 TC A 23.27 0.00 0.00 74290 TC A 43.46 0.00 0.00<br />

73550 TC A 17.11 0.00 0.00 74291 TC A 41.75 0.00 0.00<br />

73560 TC A 17.45 0.00 0.00 74400 TC A 75.63 0.00 0.00<br />

73562 TC A 21.56 0.00 0.00 74410 TC A 80.76 0.00 0.00<br />

73564 TC A 24.98 0.00 0.00 74415 TC A 96.50 0.00 0.00<br />

73565 TC A 18.82 0.00 0.00 74420 TC A 100.87 0.00 0.00<br />

73590 TC A 16.42 0.00 0.00 74710 TC A 22.58 0.00 0.00<br />

73592 TC A 17.79 0.00 0.00 74775 TC A 100.87 0.00 0.00<br />

73600 TC A 16.77 0.00 0.00 75557 TC A 201.77 0.00 0.00<br />

73610 TC A 19.85 0.00 0.00 75559 TC A 201.77 0.00 0.00<br />

73620 TC A 16.08 0.00 0.00 75561 TC A 312.29 0.00 0.00<br />

73630 TC A 19.51 0.00 0.00 75563 TC A 312.29 0.00 0.00<br />

73650 TC A 16.42 0.00 0.00 76010 TC A 16.77 0.00 0.00<br />

73660 TC A 18.48 0.00 0.00 76098 TC A 10.27 0.00 0.00<br />

73700 TC A 112.69 0.00 0.00 76100 TC A 43.15 0.00 0.00<br />

73701 TC A 178.44 0.00 0.00 76101 TC A 115.66 0.00 0.00<br />

73702 TC A 197.66 0.00 0.00 76102 TC A 115.66 0.00 0.00<br />

73706 TC A 203.98 0.00 0.00 76120 TC A 48.24 0.00 0.00<br />

73718 TC A 201.77 0.00 0.00 76150 A 16.77 0.00 0.00<br />

73719 TC A 247.78 0.00 0.00 76380 TC A 60.88 0.00 0.00<br />

73720 TC A 312.29 0.00 0.00 76496 TC A 48.24 0.00 0.00<br />

73721 TC A 201.77 0.00 0.00 76497 TC A 60.88 0.00 0.00<br />

73722 TC A 247.78 0.00 0.00 76498 TC A 201.77 0.00 0.00<br />

73723 TC A 312.29 0.00 0.00 76499 TC A 25.92 0.00 0.00<br />

74000 TC A 14.72 0.00 0.00 76506 TC A 36.23 0.00 0.00<br />

74010 TC A 22.92 0.00 0.00 76510 TC A 61.60 0.00 0.00<br />

74020 TC A 23.27 0.00 0.00 76511 TC A 43.11 0.00 0.00<br />

74022 TC A 28.41 0.00 0.00 76512 TC A 36.61 0.00 0.00<br />

74150 TC A 112.69 0.00 0.00 76513 TC A 44.49 0.00 0.00<br />

74160 TC A 178.44 0.00 0.00 76514 TC A 3.08 0.00 0.00<br />

74170 TC A 197.66 0.00 0.00 76516 TC A 34.91 0.00 0.00<br />

74175 TC A 203.98 0.00 0.00 76519 TC A 39.01 0.00 0.00<br />

74181 TC A 201.77 0.00 0.00 76529 TC A 33.88 0.00 0.00<br />

74182 TC A 247.78 0.00 0.00 76536 TC A 56.68 0.00 0.00<br />

74183 TC A 312.29 0.00 0.00 76604 TC A 36.23 0.00 0.00<br />

74210 TC A 50.92 0.00 0.00 76645 TC A 36.23 0.00 0.00<br />

74220 TC A 50.92 0.00 0.00 76700 TC A 56.68 0.00 0.00<br />

74230 TC A 50.92 0.00 0.00 76705 TC A 56.68 0.00 0.00<br />

74240 TC A 50.92 0.00 0.00 76770 TC A 56.68 0.00 0.00<br />

74241 TC A 50.92 0.00 0.00 76775 TC A 56.68 0.00 0.00<br />

74245 TC A 82.80 0.00 0.00 76776 TC A 56.68 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 56.68 0.00 0.00 77290 TC A 148.23 0.00 0.00<br />

76801 TC A 56.68 0.00 0.00 77295 TC A 388.40 0.00 0.00<br />

76802 TC A 27.03 0.00 0.00 77299 TC A 66.50 0.00 0.00<br />

76805 TC A 56.68 0.00 0.00 77300 TC A 35.93 0.00 0.00<br />

76810 TC A 42.77 0.00 0.00 77301 TC A 517.63 0.00 0.00<br />

76811 TC A 88.80 0.00 0.00 77305 TC A 32.85 0.00 0.00<br />

76812 TC A 36.23 0.00 0.00 77310 TC A 42.77 0.00 0.00<br />

76813 TC A 36.23 0.00 0.00 77315 TC A 62.28 0.00 0.00<br />

76814 TC A 28.75 0.00 0.00 77321 TC A 64.68 0.00 0.00<br />

76815 TC A 36.23 0.00 0.00 77326 TC A 66.50 0.00 0.00<br />

76816 TC A 36.23 0.00 0.00 77327 TC A 120.80 0.00 0.00<br />

76817 TC A 36.23 0.00 0.00 77328 TC A 148.23 0.00 0.00<br />

76818 TC A 56.68 0.00 0.00 77331 TC A 17.11 0.00 0.00<br />

76819 TC A 48.94 0.00 0.00 77332 TC A 45.86 0.00 0.00<br />

76820 TC A 24.30 0.00 0.00 77333 TC A 22.24 0.00 0.00<br />

76821 TC A 54.87 0.00 0.00 77334 TC A 85.89 0.00 0.00<br />

76825 TC A 114.29 0.00 0.00 77336 A 54.07 0.00 0.00<br />

76826 TC A 68.10 0.00 0.00 77370 A 66.50 0.00 0.00<br />

76827 TC A 36.23 0.00 0.00 77371 A 4,430.04 0.00 0.00<br />

76828 TC A 21.56 0.00 0.00 77399 TC A 66.50 0.00 0.00<br />

76830 TC A 56.68 0.00 0.00 77401 A 27.03 0.00 0.00<br />

76831 TC A 76.31 0.00 0.00 77402 A 54.42 0.00 0.00<br />

76856 TC A 56.68 0.00 0.00 77403 A 54.42 0.00 0.00<br />

76857 TC A 36.23 0.00 0.00 77404 A 54.42 0.00 0.00<br />

76870 TC A 56.68 0.00 0.00 77406 A 88.15 0.00 0.00<br />

76872 TC A 56.68 0.00 0.00 77407 A 54.42 0.00 0.00<br />

76873 TC A 56.68 0.00 0.00 77408 A 54.42 0.00 0.00<br />

76880 TC A 56.68 0.00 0.00 77409 A 54.42 0.00 0.00<br />

76885 TC A 36.23 0.00 0.00 77411 A 88.15 0.00 0.00<br />

76886 TC A 36.23 0.00 0.00 77412 A 88.15 0.00 0.00<br />

76936 TC A 54.87 0.00 0.00 77413 A 88.15 0.00 0.00<br />

76970 TC A 36.23 0.00 0.00 77414 A 88.15 0.00 0.00<br />

76977 TC A 9.24 0.00 0.00 77416 A 88.15 0.00 0.00<br />

76999 TC A 36.23 0.00 0.00 77418 A 238.17 0.00 0.00<br />

77071 A 21.22 0.00 0.00 77422 A 88.15 0.00 0.00<br />

77072 TC A 12.32 0.00 0.00 77423 A 88.15 0.00 0.00<br />

77073 TC A 20.87 0.00 0.00 77470 TC A 126.62 0.00 0.00<br />

77074 TC A 41.06 0.00 0.00 77520 A 407.77 0.00 0.00<br />

77075 TC A 43.15 0.00 0.00 77522 A 407.77 0.00 0.00<br />

77076 TC A 43.15 0.00 0.00 77523 A 487.29 0.00 0.00<br />

77077 TC A 23.27 0.00 0.00 77525 A 487.29 0.00 0.00<br />

77078 TC A 41.69 0.00 0.00 77600 TC A 216.35 0.00 0.00<br />

77079 TC A 42.77 0.00 0.00 77605 TC A 216.35 0.00 0.00<br />

77080 TC A 41.69 0.00 0.00 77610 TC A 216.35 0.00 0.00<br />

77081 TC A 16.77 0.00 0.00 77615 TC A 216.35 0.00 0.00<br />

77082 TC A 18.14 0.00 0.00 77620 TC A 216.35 0.00 0.00<br />

77083 TC A 14.37 0.00 0.00 77750 TC A 84.18 0.00 0.00<br />

77084 TC A 201.77 0.00 0.00 77761 TC A 148.17 0.00 0.00<br />

77280 TC A 66.50 0.00 0.00 77762 TC A 175.55 0.00 0.00<br />

77285 TC A 148.23 0.00 0.00 77763 TC A 226.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 160.49 0.00 0.00 78262 TC A 140.94 0.00 0.00<br />

77777 TC A 176.23 0.00 0.00 78264 TC A 140.94 0.00 0.00<br />

77778 TC A 234.75 0.00 0.00 78270 TC A 61.60 0.00 0.00<br />

77785 TC A 104.37 0.00 0.00 78271 TC A 62.62 0.00 0.00<br />

77786 TC A 366.83 0.00 0.00 78272 TC A 68.78 0.00 0.00<br />

77787 TC A 425.08 0.00 0.00 78278 TC A 140.94 0.00 0.00<br />

77789 TC A 43.81 0.00 0.00 78282 TC A 140.94 0.00 0.00<br />

77799 TC A 249.67 0.00 0.00 78290 TC A 140.94 0.00 0.00<br />

78000 TC A 53.72 0.00 0.00 78291 TC A 140.94 0.00 0.00<br />

78001 TC A 68.09 0.00 0.00 78299 TC A 140.94 0.00 0.00<br />

78003 TC A 54.07 0.00 0.00 78300 TC A 122.85 0.00 0.00<br />

78006 TC A 128.65 0.00 0.00 78305 TC A 142.48 0.00 0.00<br />

78007 TC A 95.14 0.00 0.00 78306 TC A 142.48 0.00 0.00<br />

78010 TC A 79.04 0.00 0.00 78315 TC A 142.48 0.00 0.00<br />

78011 TC A 79.04 0.00 0.00 78320 TC A 142.48 0.00 0.00<br />

78015 TC A 153.65 0.00 0.00 78399 TC A 142.48 0.00 0.00<br />

78016 TC A 173.43 0.00 0.00 78414 TC A 181.11 0.00 0.00<br />

78018 TC A 173.43 0.00 0.00 78428 TC A 138.93 0.00 0.00<br />

78070 TC A 118.06 0.00 0.00 78445 TC A 108.37 0.00 0.00<br />

78075 TC A 334.33 0.00 0.00 78456 TC A 108.37 0.00 0.00<br />

78099 TC A 79.04 0.00 0.00 78457 TC A 108.37 0.00 0.00<br />

78102 TC A 119.43 0.00 0.00 78458 TC A 108.37 0.00 0.00<br />

78103 TC A 152.23 0.00 0.00 78459 TC A 670.66 0.00 0.00<br />

78104 TC A 152.23 0.00 0.00 78460 TC A 130.03 0.00 0.00<br />

78110 TC A 60.57 0.00 0.00 78461 TC A 131.07 0.00 0.00<br />

78111 TC A 76.65 0.00 0.00 78464 TC A 192.31 0.00 0.00<br />

78120 TC A 67.07 0.00 0.00 78465 TC A 364.10 0.00 0.00<br />

78121 TC A 79.39 0.00 0.00 78466 TC A 129.01 0.00 0.00<br />

78122 TC A 94.10 0.00 0.00 78468 TC A 164.94 0.00 0.00<br />

78130 TC A 109.16 0.00 0.00 78469 TC A 181.11 0.00 0.00<br />

78135 TC A 232.00 0.00 0.00 78472 TC A 181.11 0.00 0.00<br />

78140 TC A 103.00 0.00 0.00 78473 TC A 181.11 0.00 0.00<br />

78185 TC A 152.23 0.00 0.00 78481 TC A 156.38 0.00 0.00<br />

78190 TC A 95.53 0.00 0.00 78483 TC A 181.11 0.00 0.00<br />

78191 TC A 95.53 0.00 0.00 78491 TC A 670.66 0.00 0.00<br />

78195 TC A 152.23 0.00 0.00 78492 TC A 670.66 0.00 0.00<br />

78199 TC A 152.23 0.00 0.00 78494 TC A 181.11 0.00 0.00<br />

78201 TC A 135.51 0.00 0.00 78499 TC A 181.11 0.00 0.00<br />

78202 TC A 159.41 0.00 0.00 78580 TC A 122.70 0.00 0.00<br />

78205 TC A 159.41 0.00 0.00 78584 TC A 94.79 0.00 0.00<br />

78206 TC A 159.41 0.00 0.00 78585 TC A 188.27 0.00 0.00<br />

78215 TC A 143.38 0.00 0.00 78586 TC A 122.70 0.00 0.00<br />

78216 TC A 97.19 0.00 0.00 78587 TC A 122.70 0.00 0.00<br />

78220 TC A 106.09 0.00 0.00 78588 TC A 188.27 0.00 0.00<br />

78223 TC A 159.41 0.00 0.00 78591 TC A 122.70 0.00 0.00<br />

78230 TC A 120.45 0.00 0.00 78593 TC A 122.70 0.00 0.00<br />

78231 TC A 94.79 0.00 0.00 78594 TC A 122.70 0.00 0.00<br />

78232 TC A 98.89 0.00 0.00 78596 TC A 188.27 0.00 0.00<br />

78258 TC A 140.94 0.00 0.00 78599 TC A 122.70 0.00 0.00<br />

78261 TC A 140.94 0.00 0.00 78600 TC A 108.13 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 39460 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 108.13 0.00 0.00<br />

78605 TC A 108.13 0.00 0.00<br />

78606 TC A 242.96 0.00 0.00<br />

78607 TC A 266.92 0.00 0.00<br />

78608 TC A 601.12 0.00 0.00<br />

78610 TC A 144.07 0.00 0.00<br />

78630 TC A 256.65 0.00 0.00<br />

78635 TC A 236.46 0.00 0.00<br />

78645 TC A 108.13 0.00 0.00<br />

78647 TC A 261.78 0.00 0.00<br />

78650 TC A 253.57 0.00 0.00<br />

78660 TC A 108.13 0.00 0.00<br />

78699 TC A 108.13 0.00 0.00<br />

78700 TC A 133.12 0.00 0.00<br />

78701 TC A 162.21 0.00 0.00<br />

78707 TC A 169.39 0.00 0.00<br />

78708 TC A 116.01 0.00 0.00<br />

78709 TC A 190.73 0.00 0.00<br />

78710 TC A 178.97 0.00 0.00<br />

78725 TC A 71.52 0.00 0.00<br />

78730 TC A 60.57 0.00 0.00<br />

78740 TC A 158.10 0.00 0.00<br />

78761 TC A 150.91 0.00 0.00<br />

78799 TC A 190.73 0.00 0.00<br />

78800 TC A 133.46 0.00 0.00<br />

78801 TC A 183.08 0.00 0.00<br />

78802 TC A 248.09 0.00 0.00<br />

78803 TC A 265.89 0.00 0.00<br />

78804 TC A 464.02 0.00 0.00<br />

78805 TC A 130.37 0.00 0.00<br />

78806 TC A 260.76 0.00 0.00<br />

78807 TC A 266.23 0.00 0.00<br />

78811 TC A 601.12 0.00 0.00<br />

78812 TC A 601.12 0.00 0.00<br />

78813 TC A 601.12 0.00 0.00<br />

78814 TC A 601.12 0.00 0.00<br />

78815 TC A 601.12 0.00 0.00<br />

78816 TC A 601.12 0.00 0.00<br />

78999 TC A 68.09 0.00 0.00<br />

79005 TC A 54.76 0.00 0.00<br />

79101 TC A 59.89 0.00 0.00<br />

79200 TC A 64.68 0.00 0.00<br />

79300 TC A 124.79 0.00 0.00<br />

79403 TC A 92.74 0.00 0.00<br />

79440 TC A 52.35 0.00 0.00<br />

79445 TC A 124.79 0.00 0.00<br />

79999 TC A 124.79 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,232.81 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,514.57 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.54 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,564.99 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,564.99 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 226.01 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 226.01 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 114.12 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 241.19 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 72.51 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 649.25 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,480.51 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,158.87 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,158.87 0.00 0.00<br />

C8900 A 250.93 0.00 0.00 0123T S 926.75 0.00 0.00<br />

C8901 A 204.33 0.00 0.00 0124T S 181.14 0.00 0.00<br />

C8902 A 316.25 0.00 0.00 0144T TC A 61.65 0.00 0.00<br />

C8903 A 250.93 0.00 0.00 0145T TC A 165.96 0.00 0.00<br />

C8904 A 204.33 0.00 0.00 0146T TC A 165.96 0.00 0.00<br />

C8905 A 316.25 0.00 0.00 0147T TC A 165.96 0.00 0.00<br />

C8906 A 250.93 0.00 0.00 0148T TC A 165.96 0.00 0.00<br />

C8907 A 204.33 0.00 0.00 0149T TC A 165.96 0.00 0.00<br />

C8908 A 316.25 0.00 0.00 0150T TC A 165.96 0.00 0.00<br />

C8909 A 250.93 0.00 0.00 0151T TC A 61.65 0.00 0.00<br />

C8910 A 204.33 0.00 0.00 0170T S 1,203.79 0.00 0.00<br />

C8911 A 316.25 0.00 0.00 0176T S 1,421.40 0.00 0.00<br />

C8912 A 250.93 0.00 0.00 0177T S 1,421.40 0.00 0.00<br />

C8913 A 204.33 0.00 0.00 0182T A 1,027.40 0.00 0.00<br />

C8914 A 316.25 0.00 0.00 0186T S 865.89 0.00 0.00<br />

C8918 A 250.93 0.00 0.00 0190T S 865.89 0.00 0.00<br />

C8919 A 204.33 0.00 0.00 0191T S 926.75 0.00 0.00<br />

C8920 A 316.25 0.00 0.00 0192T S 1,588.27 0.00 0.00<br />

C9716 S 1,203.79 0.00 0.00 10021 S 55.55 0.00 0.00<br />

C9724 S 984.24 0.00 0.00 10022 S 173.46 0.00 0.00<br />

C9725 S 226.96 0.00 0.00 10040 S 32.11 0.00 0.00<br />

C9726 S 833.24 0.00 0.00 10060 S 48.86 0.00 0.00<br />

C9727 S 292.15 0.00 0.00 10061 S 54.79 0.00 0.00<br />

C9728 S 524.20 0.00 0.00 10080 S 54.79 0.00 0.00<br />

G0104 S 84.21 0.00 0.00 10081 S 126.14 0.00 0.00<br />

G0105 S 363.95 0.00 0.00 10120 S 68.61 0.00 0.00<br />

G0121 S 363.95 0.00 0.00 10121 S 517.20 0.00 0.00<br />

G0127 S 11.78 0.00 0.00 10140 S 72.77 0.00 0.00<br />

G0130 TC A 19.41 0.00 0.00 10160 S 54.79 0.00 0.00<br />

G0173 A 2,232.81 0.00 0.00 10180 S 584.88 0.00 0.00<br />

G0186 S 226.01 0.00 0.00 11000 S 23.57 0.00 0.00<br />

G0247 S 21.48 0.00 0.00 11001 S 7.98 0.00 0.00<br />

G0251 A 559.13 0.00 0.00 11010 S 204.62 0.00 0.00<br />

G0260 S 295.07 0.00 0.00 11011 S 204.62 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 204.62 0.00 0.00 11601 S 112.98 0.00 0.00<br />

11040 S 21.48 0.00 0.00 11602 S 124.41 0.00 0.00<br />

11041 S 23.92 0.00 0.00 11603 S 132.03 0.00 0.00<br />

11042 S 129.94 0.00 0.00 11604 S 356.15 0.00 0.00<br />

11043 S 129.94 0.00 0.00 11606 S 517.20 0.00 0.00<br />

11044 S 338.33 0.00 0.00 11620 S 96.34 0.00 0.00<br />

11055 S 25.30 0.00 0.00 11621 S 114.36 0.00 0.00<br />

11056 S 27.72 0.00 0.00 11622 S 127.18 0.00 0.00<br />

11057 S 32.11 0.00 0.00 11623 S 136.88 0.00 0.00<br />

11100 S 58.83 0.00 0.00 11624 S 517.20 0.00 0.00<br />

11101 S 13.87 0.00 0.00 11626 S 632.49 0.00 0.00<br />

11200 S 32.11 0.00 0.00 11640 S 101.89 0.00 0.00<br />

11201 S 5.54 0.00 0.00 11641 S 120.25 0.00 0.00<br />

11300 S 32.11 0.00 0.00 11642 S 134.12 0.00 0.00<br />

11301 S 32.11 0.00 0.00 11643 S 144.51 0.00 0.00<br />

11302 S 32.11 0.00 0.00 11644 S 517.20 0.00 0.00<br />

11303 S 58.83 0.00 0.00 11646 S 632.49 0.00 0.00<br />

11305 S 32.11 0.00 0.00 11719 S 11.78 0.00 0.00<br />

11306 S 32.11 0.00 0.00 11720 S 14.56 0.00 0.00<br />

11307 S 32.11 0.00 0.00 11721 S 17.67 0.00 0.00<br />

11308 S 32.11 0.00 0.00 11730 S 32.11 0.00 0.00<br />

11310 S 32.11 0.00 0.00 11732 S 17.67 0.00 0.00<br />

11311 S 32.11 0.00 0.00 11740 S 16.22 0.00 0.00<br />

11312 S 32.11 0.00 0.00 11750 S 93.57 0.00 0.00<br />

11313 S 32.11 0.00 0.00 11752 S 129.95 0.00 0.00<br />

11400 S 66.19 0.00 0.00 11755 S 64.80 0.00 0.00<br />

11401 S 74.50 0.00 0.00 11760 S 133.46 0.00 0.00<br />

11402 S 81.79 0.00 0.00 11762 S 119.21 0.00 0.00<br />

11403 S 87.33 0.00 0.00 11765 S 32.11 0.00 0.00<br />

11404 S 464.26 0.00 0.00 11770 S 662.48 0.00 0.00<br />

11406 S 517.20 0.00 0.00 11771 S 662.48 0.00 0.00<br />

11420 S 62.03 0.00 0.00 11772 S 662.48 0.00 0.00<br />

11421 S 75.20 0.00 0.00 11900 S 29.46 0.00 0.00<br />

11422 S 82.13 0.00 0.00 11901 S 32.11 0.00 0.00<br />

11423 S 91.49 0.00 0.00 11920 S 93.22 0.00 0.00<br />

11424 S 517.20 0.00 0.00 11921 S 102.58 0.00 0.00<br />

11426 S 632.49 0.00 0.00 11922 S 33.26 0.00 0.00<br />

11440 S 71.05 0.00 0.00 11950 S 33.97 0.00 0.00<br />

11441 S 82.13 0.00 0.00 11951 S 42.28 0.00 0.00<br />

11442 S 90.44 0.00 0.00 11952 S 50.90 0.00 0.00<br />

11443 S 100.15 0.00 0.00 11954 S 50.90 0.00 0.00<br />

11444 S 316.10 0.00 0.00 11960 S 617.42 0.00 0.00<br />

11446 S 632.49 0.00 0.00 11970 S 1,118.36 0.00 0.00<br />

11450 S 632.49 0.00 0.00 11971 S 579.56 0.00 0.00<br />

11451 S 632.49 0.00 0.00 11976 S 62.03 0.00 0.00<br />

11462 S 632.49 0.00 0.00 11980 S 25.06 0.00 0.00<br />

11463 S 632.49 0.00 0.00 11981 S 25.06 0.00 0.00<br />

11470 S 632.49 0.00 0.00 11982 S 25.06 0.00 0.00<br />

11471 S 632.49 0.00 0.00 11983 S 25.06 0.00 0.00<br />

11600 S 93.22 0.00 0.00 12001 S 50.90 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 50.90 0.00 0.00 14021 S 548.68 0.00 0.00<br />

12004 S 50.90 0.00 0.00 14040 S 518.71 0.00 0.00<br />

12005 S 68.19 0.00 0.00 14041 S 548.68 0.00 0.00<br />

12006 S 68.19 0.00 0.00 14060 S 548.68 0.00 0.00<br />

12007 S 68.19 0.00 0.00 14061 S 548.68 0.00 0.00<br />

12011 S 50.90 0.00 0.00 14300 S 703.62 0.00 0.00<br />

12013 S 50.90 0.00 0.00 14350 S 647.40 0.00 0.00<br />

12014 S 50.90 0.00 0.00 15002 S 237.36 0.00 0.00<br />

12015 S 50.90 0.00 0.00 15003 S 237.36 0.00 0.00<br />

12016 S 68.19 0.00 0.00 15004 S 237.36 0.00 0.00<br />

12017 S 68.19 0.00 0.00 15005 S 237.36 0.00 0.00<br />

12018 S 68.19 0.00 0.00 15040 S 109.47 0.00 0.00<br />

12020 S 128.66 0.00 0.00 15050 S 237.36 0.00 0.00<br />

12021 S 109.47 0.00 0.00 15100 S 617.42 0.00 0.00<br />

12031 S 50.90 0.00 0.00 15101 S 647.40 0.00 0.00<br />

12032 S 133.46 0.00 0.00 15110 S 294.85 0.00 0.00<br />

12034 S 68.19 0.00 0.00 15111 S 241.91 0.00 0.00<br />

12035 S 68.19 0.00 0.00 15115 S 294.85 0.00 0.00<br />

12036 S 109.47 0.00 0.00 15116 S 241.91 0.00 0.00<br />

12037 S 218.18 0.00 0.00 15120 S 617.42 0.00 0.00<br />

12041 S 50.90 0.00 0.00 15121 S 647.40 0.00 0.00<br />

12042 S 50.90 0.00 0.00 15130 S 518.71 0.00 0.00<br />

12044 S 68.19 0.00 0.00 15131 S 465.76 0.00 0.00<br />

12045 S 109.47 0.00 0.00 15135 S 518.71 0.00 0.00<br />

12046 S 109.47 0.00 0.00 15136 S 465.76 0.00 0.00<br />

12047 S 218.18 0.00 0.00 15150 S 294.85 0.00 0.00<br />

12051 S 50.90 0.00 0.00 15151 S 241.91 0.00 0.00<br />

12052 S 50.90 0.00 0.00 15152 S 241.91 0.00 0.00<br />

12053 S 50.90 0.00 0.00 15155 S 294.85 0.00 0.00<br />

12054 S 68.19 0.00 0.00 15156 S 241.91 0.00 0.00<br />

12055 S 109.47 0.00 0.00 15157 S 241.91 0.00 0.00<br />

12056 S 109.47 0.00 0.00 15170 S 133.46 0.00 0.00<br />

12057 S 218.18 0.00 0.00 15171 S 133.46 0.00 0.00<br />

13100 S 237.36 0.00 0.00 15175 S 171.83 0.00 0.00<br />

13101 S 237.36 0.00 0.00 15176 S 171.83 0.00 0.00<br />

13102 S 128.66 0.00 0.00 15200 S 548.68 0.00 0.00<br />

13120 S 109.47 0.00 0.00 15201 S 461.22 0.00 0.00<br />

13121 S 109.47 0.00 0.00 15220 S 518.71 0.00 0.00<br />

13122 S 109.47 0.00 0.00 15221 S 237.36 0.00 0.00<br />

13131 S 109.47 0.00 0.00 15240 S 548.68 0.00 0.00<br />

13132 S 109.47 0.00 0.00 15241 S 237.36 0.00 0.00<br />

13133 S 109.47 0.00 0.00 15260 S 518.71 0.00 0.00<br />

13150 S 237.36 0.00 0.00 15261 S 461.22 0.00 0.00<br />

13151 S 237.36 0.00 0.00 15300 S 237.36 0.00 0.00<br />

13152 S 237.36 0.00 0.00 15301 S 237.36 0.00 0.00<br />

13153 S 109.47 0.00 0.00 15320 S 237.36 0.00 0.00<br />

13160 S 617.42 0.00 0.00 15321 S 237.36 0.00 0.00<br />

14000 S 518.71 0.00 0.00 15330 S 237.36 0.00 0.00<br />

14001 S 548.68 0.00 0.00 15331 S 237.36 0.00 0.00<br />

14020 S 548.68 0.00 0.00 15335 S 237.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 237.36 0.00 0.00 15826 S 647.40 0.00 0.00<br />

15340 S 133.46 0.00 0.00 15828 S 647.40 0.00 0.00<br />

15341 S 133.46 0.00 0.00 15829 S 744.37 0.00 0.00<br />

15360 S 133.46 0.00 0.00 15830 S 662.48 0.00 0.00<br />

15361 S 133.46 0.00 0.00 15832 S 662.48 0.00 0.00<br />

15365 S 133.46 0.00 0.00 15833 S 662.48 0.00 0.00<br />

15366 S 133.46 0.00 0.00 15834 S 662.48 0.00 0.00<br />

15400 S 237.36 0.00 0.00 15835 S 575.00 0.00 0.00<br />

15401 S 237.36 0.00 0.00 15836 S 547.18 0.00 0.00<br />

15420 S 237.36 0.00 0.00 15837 S 616.54 0.00 0.00<br />

15421 S 237.36 0.00 0.00 15838 S 616.54 0.00 0.00<br />

15430 S 237.36 0.00 0.00 15839 S 547.18 0.00 0.00<br />

15431 S 237.36 0.00 0.00 15840 S 703.62 0.00 0.00<br />

15570 S 647.40 0.00 0.00 15841 S 703.62 0.00 0.00<br />

15572 S 647.40 0.00 0.00 15842 S 816.97 0.00 0.00<br />

15574 S 647.40 0.00 0.00 15845 S 703.62 0.00 0.00<br />

15576 S 647.40 0.00 0.00 15847 S 662.48 0.00 0.00<br />

15600 S 647.40 0.00 0.00 15850 S 105.83 0.00 0.00<br />

15610 S 647.40 0.00 0.00 15851 S 48.17 0.00 0.00<br />

15620 S 703.62 0.00 0.00 15852 S 25.06 0.00 0.00<br />

15630 S 647.40 0.00 0.00 15860 S 25.06 0.00 0.00<br />

15650 S 744.37 0.00 0.00 15876 S 647.40 0.00 0.00<br />

15731 S 647.40 0.00 0.00 15877 S 647.40 0.00 0.00<br />

15732 S 647.40 0.00 0.00 15878 S 647.40 0.00 0.00<br />

15734 S 647.40 0.00 0.00 15879 S 647.40 0.00 0.00<br />

15736 S 647.40 0.00 0.00 15920 S 204.62 0.00 0.00<br />

15738 S 647.40 0.00 0.00 15922 S 703.62 0.00 0.00<br />

15740 S 518.71 0.00 0.00 15931 S 662.48 0.00 0.00<br />

15750 S 617.42 0.00 0.00 15933 S 662.48 0.00 0.00<br />

15760 S 617.42 0.00 0.00 15934 S 647.40 0.00 0.00<br />

15770 S 647.40 0.00 0.00 15935 S 703.62 0.00 0.00<br />

15775 S 176.89 0.00 0.00 15936 S 604.90 0.00 0.00<br />

15776 S 176.89 0.00 0.00 15937 S 703.62 0.00 0.00<br />

15780 S 394.37 0.00 0.00 15940 S 662.48 0.00 0.00<br />

15781 S 173.59 0.00 0.00 15941 S 662.48 0.00 0.00<br />

15782 S 173.59 0.00 0.00 15944 S 647.40 0.00 0.00<br />

15783 S 105.83 0.00 0.00 15945 S 703.62 0.00 0.00<br />

15786 S 32.11 0.00 0.00 15946 S 703.62 0.00 0.00<br />

15787 S 29.11 0.00 0.00 15950 S 662.48 0.00 0.00<br />

15788 S 32.11 0.00 0.00 15951 S 718.69 0.00 0.00<br />

15789 S 58.83 0.00 0.00 15952 S 548.68 0.00 0.00<br />

15792 S 58.83 0.00 0.00 15953 S 604.90 0.00 0.00<br />

15793 S 32.11 0.00 0.00 15956 S 548.68 0.00 0.00<br />

15819 S 133.46 0.00 0.00 15958 S 604.90 0.00 0.00<br />

15820 S 647.40 0.00 0.00 16000 S 25.99 0.00 0.00<br />

15821 S 647.40 0.00 0.00 16020 S 39.51 0.00 0.00<br />

15822 S 647.40 0.00 0.00 16025 S 60.85 0.00 0.00<br />

15823 S 744.37 0.00 0.00 16030 S 76.19 0.00 0.00<br />

15824 S 647.40 0.00 0.00 16035 S 58.83 0.00 0.00<br />

15825 S 647.40 0.00 0.00 17000 S 32.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.81 0.00 0.00 19300 S 711.75 0.00 0.00<br />

17004 S 83.86 0.00 0.00 19301 S 655.54 0.00 0.00<br />

17106 S 105.83 0.00 0.00 19302 S 1,252.01 0.00 0.00<br />

17107 S 105.83 0.00 0.00 19303 S 946.18 0.00 0.00<br />

17108 S 105.83 0.00 0.00 19304 S 946.18 0.00 0.00<br />

17110 S 32.11 0.00 0.00 19316 S 946.18 0.00 0.00<br />

17111 S 58.83 0.00 0.00 19318 S 1,081.01 0.00 0.00<br />

17250 S 44.36 0.00 0.00 19324 S 1,081.01 0.00 0.00<br />

17260 S 47.48 0.00 0.00 19325 S 1,792.99 0.00 0.00<br />

17261 S 58.83 0.00 0.00 19328 S 807.05 0.00 0.00<br />

17262 S 58.83 0.00 0.00 19330 S 807.05 0.00 0.00<br />

17263 S 58.83 0.00 0.00 19340 S 994.82 0.00 0.00<br />

17264 S 58.83 0.00 0.00 19342 S 1,404.64 0.00 0.00<br />

17266 S 105.83 0.00 0.00 19350 S 711.75 0.00 0.00<br />

17270 S 58.83 0.00 0.00 19355 S 946.18 0.00 0.00<br />

17271 S 58.83 0.00 0.00 19357 S 1,501.61 0.00 0.00<br />

17272 S 58.83 0.00 0.00 19366 S 986.94 0.00 0.00<br />

17273 S 105.83 0.00 0.00 19370 S 946.18 0.00 0.00<br />

17274 S 105.83 0.00 0.00 19371 S 946.18 0.00 0.00<br />

17276 S 105.83 0.00 0.00 19380 S 1,121.77 0.00 0.00<br />

17280 S 58.83 0.00 0.00 19396 S 1,302.09 0.00 0.00<br />

17281 S 87.68 0.00 0.00 20000 S 54.79 0.00 0.00<br />

17282 S 100.15 0.00 0.00 20005 S 631.29 0.00 0.00<br />

17283 S 105.83 0.00 0.00 20103 S 619.55 0.00 0.00<br />

17284 S 105.83 0.00 0.00 20150 S 1,758.90 0.00 0.00<br />

17286 S 105.83 0.00 0.00 20200 S 517.20 0.00 0.00<br />

17311 S 174.70 0.00 0.00 20205 S 547.18 0.00 0.00<br />

17312 S 174.70 0.00 0.00 20206 S 255.69 0.00 0.00<br />

17313 S 174.70 0.00 0.00 20220 S 277.94 0.00 0.00<br />

17314 S 174.70 0.00 0.00 20225 S 504.31 0.00 0.00<br />

17315 S 39.51 0.00 0.00 20240 S 632.49 0.00 0.00<br />

17340 S 14.21 0.00 0.00 20245 S 662.48 0.00 0.00<br />

17360 S 32.11 0.00 0.00 20250 S 661.28 0.00 0.00<br />

17380 S 32.11 0.00 0.00 20251 S 661.28 0.00 0.00<br />

19000 S 66.88 0.00 0.00 20500 S 54.76 0.00 0.00<br />

19001 S 9.01 0.00 0.00 20520 S 92.18 0.00 0.00<br />

19020 S 584.88 0.00 0.00 20525 S 662.48 0.00 0.00<br />

19100 S 199.16 0.00 0.00 20526 S 29.81 0.00 0.00<br />

19101 S 625.55 0.00 0.00 20550 S 22.52 0.00 0.00<br />

19102 S 255.69 0.00 0.00 20551 S 22.18 0.00 0.00<br />

19103 S 447.53 0.00 0.00 20552 S 21.48 0.00 0.00<br />

19105 S 1,302.09 0.00 0.00 20553 S 23.92 0.00 0.00<br />

19110 S 625.55 0.00 0.00 20555 S 1,158.87 0.00 0.00<br />

19112 S 655.54 0.00 0.00 20600 S 22.87 0.00 0.00<br />

19120 S 655.54 0.00 0.00 20605 S 25.65 0.00 0.00<br />

19125 S 655.54 0.00 0.00 20610 S 36.04 0.00 0.00<br />

19126 S 655.54 0.00 0.00 20612 S 24.26 0.00 0.00<br />

19296 S 1,792.99 0.00 0.00 20615 S 101.54 0.00 0.00<br />

19297 S 1,792.99 0.00 0.00 20650 S 661.28 0.00 0.00<br />

19298 S 1,792.99 0.00 0.00 20662 S 844.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 844.71 0.00 0.00 21085 S 254.37 0.00 0.00<br />

20665 S 25.06 0.00 0.00 21086 S 553.78 0.00 0.00<br />

20670 S 464.26 0.00 0.00 21087 S 554.48 0.00 0.00<br />

20680 S 662.48 0.00 0.00 21088 S 1,623.96 0.00 0.00<br />

20690 S 788.37 0.00 0.00 21100 S 1,020.91 0.00 0.00<br />

20692 S 818.36 0.00 0.00 21110 S 292.15 0.00 0.00<br />

20693 S 661.28 0.00 0.00 21120 S 946.16 0.00 0.00<br />

20694 S 578.35 0.00 0.00 21121 S 946.16 0.00 0.00<br />

20696 S 1,158.87 0.00 0.00 21122 S 946.16 0.00 0.00<br />

20697 S 770.70 0.00 0.00 21123 S 946.16 0.00 0.00<br />

20822 S 1,085.88 0.00 0.00 21125 S 946.16 0.00 0.00<br />

20900 S 818.36 0.00 0.00 21127 S 1,439.25 0.00 0.00<br />

20902 S 874.57 0.00 0.00 21137 S 960.08 0.00 0.00<br />

20910 S 647.40 0.00 0.00 21138 S 1,623.96 0.00 0.00<br />

20912 S 647.40 0.00 0.00 21139 S 1,623.96 0.00 0.00<br />

20920 S 604.90 0.00 0.00 21150 S 1,623.96 0.00 0.00<br />

20922 S 548.68 0.00 0.00 21181 S 946.16 0.00 0.00<br />

20924 S 874.57 0.00 0.00 21198 S 1,623.96 0.00 0.00<br />

20926 S 381.04 0.00 0.00 21199 S 1,623.96 0.00 0.00<br />

20950 S 54.79 0.00 0.00 21206 S 1,147.87 0.00 0.00<br />

20972 S 1,834.07 0.00 0.00 21208 S 1,278.10 0.00 0.00<br />

20973 S 1,834.07 0.00 0.00 21209 S 1,147.87 0.00 0.00<br />

20979 S 22.52 0.00 0.00 21210 S 1,278.10 0.00 0.00<br />

20982 S 1,758.90 0.00 0.00 21215 S 1,278.10 0.00 0.00<br />

21010 S 688.97 0.00 0.00 21230 S 1,278.10 0.00 0.00<br />

21015 S 573.22 0.00 0.00 21235 S 946.16 0.00 0.00<br />

21025 S 1,020.91 0.00 0.00 21240 S 1,107.11 0.00 0.00<br />

21026 S 1,020.91 0.00 0.00 21242 S 1,147.87 0.00 0.00<br />

21029 S 1,020.91 0.00 0.00 21243 S 1,147.87 0.00 0.00<br />

21030 S 240.85 0.00 0.00 21244 S 1,278.10 0.00 0.00<br />

21031 S 199.26 0.00 0.00 21245 S 1,278.10 0.00 0.00<br />

21032 S 203.08 0.00 0.00 21246 S 1,278.10 0.00 0.00<br />

21034 S 1,050.90 0.00 0.00 21248 S 1,278.10 0.00 0.00<br />

21040 S 688.97 0.00 0.00 21249 S 1,278.10 0.00 0.00<br />

21044 S 1,020.91 0.00 0.00 21260 S 1,623.96 0.00 0.00<br />

21046 S 1,020.91 0.00 0.00 21267 S 1,278.10 0.00 0.00<br />

21047 S 1,020.91 0.00 0.00 21270 S 1,147.87 0.00 0.00<br />

21048 S 1,623.96 0.00 0.00 21275 S 1,278.10 0.00 0.00<br />

21050 S 1,050.90 0.00 0.00 21280 S 1,147.87 0.00 0.00<br />

21060 S 1,020.91 0.00 0.00 21282 S 670.19 0.00 0.00<br />

21070 S 1,050.90 0.00 0.00 21295 S 302.07 0.00 0.00<br />

21073 S 187.14 0.00 0.00 21296 S 636.03 0.00 0.00<br />

21076 S 324.71 0.00 0.00 21310 S 92.15 0.00 0.00<br />

21077 S 784.93 0.00 0.00 21315 S 404.91 0.00 0.00<br />

21079 S 562.10 0.00 0.00 21320 S 543.24 0.00 0.00<br />

21080 S 644.58 0.00 0.00 21325 S 775.17 0.00 0.00<br />

21081 S 593.98 0.00 0.00 21330 S 815.92 0.00 0.00<br />

21082 S 565.22 0.00 0.00 21335 S 946.16 0.00 0.00<br />

21083 S 556.90 0.00 0.00 21336 S 788.52 0.00 0.00<br />

21084 S 640.76 0.00 0.00 21337 S 543.24 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 775.17 0.00 0.00 22310 S 167.75 0.00 0.00<br />

21339 S 815.92 0.00 0.00 22315 S 433.89 0.00 0.00<br />

21340 S 1,107.11 0.00 0.00 22505 S 510.80 0.00 0.00<br />

21345 S 946.16 0.00 0.00 22520 S 1,206.70 0.00 0.00<br />

21355 S 1,050.90 0.00 0.00 22521 S 1,206.70 0.00 0.00<br />

21356 S 718.96 0.00 0.00 22522 S 1,206.70 0.00 0.00<br />

21360 S 960.08 0.00 0.00 22523 S 3,358.37 0.00 0.00<br />

21390 S 1,623.96 0.00 0.00 22524 S 3,358.37 0.00 0.00<br />

21400 S 355.01 0.00 0.00 22525 S 3,358.37 0.00 0.00<br />

21401 S 573.22 0.00 0.00 22900 S 718.69 0.00 0.00<br />

21406 S 1,623.96 0.00 0.00 23000 S 517.20 0.00 0.00<br />

21407 S 1,623.96 0.00 0.00 23020 S 1,088.38 0.00 0.00<br />

21421 S 775.17 0.00 0.00 23030 S 531.94 0.00 0.00<br />

21440 S 326.45 0.00 0.00 23031 S 614.86 0.00 0.00<br />

21445 S 775.17 0.00 0.00 23035 S 661.28 0.00 0.00<br />

21450 S 134.73 0.00 0.00 23040 S 818.36 0.00 0.00<br />

21451 S 363.51 0.00 0.00 23044 S 874.57 0.00 0.00<br />

21452 S 543.24 0.00 0.00 23065 S 97.73 0.00 0.00<br />

21453 S 1,050.90 0.00 0.00 23066 S 632.49 0.00 0.00<br />

21454 S 815.92 0.00 0.00 23075 S 517.20 0.00 0.00<br />

21461 S 1,107.11 0.00 0.00 23076 S 632.49 0.00 0.00<br />

21462 S 1,147.87 0.00 0.00 23077 S 662.48 0.00 0.00<br />

21465 S 1,107.11 0.00 0.00 23100 S 631.29 0.00 0.00<br />

21480 S 92.15 0.00 0.00 23101 S 1,045.56 0.00 0.00<br />

21485 S 543.24 0.00 0.00 23105 S 874.57 0.00 0.00<br />

21490 S 1,050.90 0.00 0.00 23106 S 874.57 0.00 0.00<br />

21495 S 668.61 0.00 0.00 23107 S 874.57 0.00 0.00<br />

21497 S 543.24 0.00 0.00 23120 S 915.32 0.00 0.00<br />

21501 S 584.88 0.00 0.00 23125 S 915.32 0.00 0.00<br />

21502 S 631.29 0.00 0.00 23130 S 1,215.33 0.00 0.00<br />

21550 S 616.54 0.00 0.00 23140 S 717.49 0.00 0.00<br />

21555 S 632.49 0.00 0.00 23145 S 915.32 0.00 0.00<br />

21556 S 632.49 0.00 0.00 23146 S 915.32 0.00 0.00<br />

21557 S 847.11 0.00 0.00 23150 S 874.57 0.00 0.00<br />

21600 S 788.37 0.00 0.00 23155 S 915.32 0.00 0.00<br />

21610 S 788.37 0.00 0.00 23156 S 915.32 0.00 0.00<br />

21685 S 292.15 0.00 0.00 23170 S 788.37 0.00 0.00<br />

21700 S 631.29 0.00 0.00 23172 S 788.37 0.00 0.00<br />

21720 S 661.28 0.00 0.00 23174 S 788.37 0.00 0.00<br />

21725 S 68.84 0.00 0.00 23180 S 874.57 0.00 0.00<br />

21800 S 79.52 0.00 0.00 23182 S 874.57 0.00 0.00<br />

21805 S 702.32 0.00 0.00 23184 S 874.57 0.00 0.00<br />

21820 S 79.52 0.00 0.00 23190 S 874.57 0.00 0.00<br />

21920 S 141.39 0.00 0.00 23195 S 915.32 0.00 0.00<br />

21925 S 632.49 0.00 0.00 23330 S 316.10 0.00 0.00<br />

21930 S 632.49 0.00 0.00 23331 S 579.56 0.00 0.00<br />

21935 S 662.48 0.00 0.00 23395 S 1,215.33 0.00 0.00<br />

22102 S 1,885.08 0.00 0.00 23397 S 2,145.31 0.00 0.00<br />

22103 S 1,885.08 0.00 0.00 23400 S 1,045.56 0.00 0.00<br />

22305 S 79.52 0.00 0.00 23405 S 788.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 788.37 0.00 0.00 23931 S 584.88 0.00 0.00<br />

23410 S 1,215.33 0.00 0.00 23935 S 631.29 0.00 0.00<br />

23412 S 1,345.56 0.00 0.00 24000 S 874.57 0.00 0.00<br />

23415 S 1,215.33 0.00 0.00 24006 S 874.57 0.00 0.00<br />

23420 S 1,345.56 0.00 0.00 24065 S 135.50 0.00 0.00<br />

23430 S 1,174.58 0.00 0.00 24066 S 517.20 0.00 0.00<br />

23440 S 1,174.58 0.00 0.00 24075 S 517.20 0.00 0.00<br />

23450 S 2,015.08 0.00 0.00 24076 S 632.49 0.00 0.00<br />

23455 S 2,145.31 0.00 0.00 24077 S 662.48 0.00 0.00<br />

23460 S 2,015.08 0.00 0.00 24100 S 578.35 0.00 0.00<br />

23462 S 1,345.56 0.00 0.00 24101 S 874.57 0.00 0.00<br />

23465 S 2,015.08 0.00 0.00 24102 S 874.57 0.00 0.00<br />

23466 S 1,345.56 0.00 0.00 24105 S 661.28 0.00 0.00<br />

23480 S 1,174.58 0.00 0.00 24110 S 631.29 0.00 0.00<br />

23485 S 2,145.31 0.00 0.00 24115 S 818.36 0.00 0.00<br />

23490 S 1,118.36 0.00 0.00 24116 S 818.36 0.00 0.00<br />

23491 S 1,918.11 0.00 0.00 24120 S 661.28 0.00 0.00<br />

23500 S 79.52 0.00 0.00 24125 S 818.36 0.00 0.00<br />

23505 S 433.89 0.00 0.00 24126 S 818.36 0.00 0.00<br />

23515 S 1,452.20 0.00 0.00 24130 S 818.36 0.00 0.00<br />

23520 S 167.75 0.00 0.00 24134 S 788.37 0.00 0.00<br />

23525 S 167.75 0.00 0.00 24136 S 788.37 0.00 0.00<br />

23530 S 1,070.13 0.00 0.00 24138 S 788.37 0.00 0.00<br />

23532 S 788.52 0.00 0.00 24140 S 818.36 0.00 0.00<br />

23540 S 79.52 0.00 0.00 24145 S 818.36 0.00 0.00<br />

23545 S 167.75 0.00 0.00 24147 S 788.37 0.00 0.00<br />

23550 S 1,070.13 0.00 0.00 24149 S 1,158.87 0.00 0.00<br />

23552 S 1,126.35 0.00 0.00 24152 S 1,758.90 0.00 0.00<br />

23570 S 79.52 0.00 0.00 24153 S 3,358.37 0.00 0.00<br />

23575 S 167.75 0.00 0.00 24155 S 1,118.36 0.00 0.00<br />

23585 S 1,452.20 0.00 0.00 24160 S 788.37 0.00 0.00<br />

23600 S 61.97 0.00 0.00 24164 S 818.36 0.00 0.00<br />

23605 S 433.89 0.00 0.00 24200 S 99.11 0.00 0.00<br />

23615 S 1,508.41 0.00 0.00 24201 S 517.20 0.00 0.00<br />

23616 S 1,508.41 0.00 0.00 24300 S 603.73 0.00 0.00<br />

23620 S 61.97 0.00 0.00 24301 S 874.57 0.00 0.00<br />

23625 S 433.89 0.00 0.00 24305 S 874.57 0.00 0.00<br />

23630 S 1,549.17 0.00 0.00 24310 S 661.28 0.00 0.00<br />

23650 S 79.52 0.00 0.00 24320 S 1,118.36 0.00 0.00<br />

23655 S 457.86 0.00 0.00 24330 S 1,918.11 0.00 0.00<br />

23660 S 1,070.13 0.00 0.00 24331 S 1,118.36 0.00 0.00<br />

23665 S 167.75 0.00 0.00 24332 S 844.71 0.00 0.00<br />

23670 S 1,452.20 0.00 0.00 24340 S 1,118.36 0.00 0.00<br />

23675 S 79.52 0.00 0.00 24341 S 1,118.36 0.00 0.00<br />

23680 S 1,070.13 0.00 0.00 24342 S 1,118.36 0.00 0.00<br />

23700 S 457.86 0.00 0.00 24343 S 1,158.87 0.00 0.00<br />

23800 S 1,974.32 0.00 0.00 24344 S 3,358.37 0.00 0.00<br />

23802 S 1,345.56 0.00 0.00 24345 S 788.37 0.00 0.00<br />

23921 S 461.22 0.00 0.00 24346 S 1,758.90 0.00 0.00<br />

23930 S 531.94 0.00 0.00 24357 S 1,158.87 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,158.87 0.00 0.00 24925 S 661.28 0.00 0.00<br />

24359 S 1,158.87 0.00 0.00 25000 S 661.28 0.00 0.00<br />

24360 S 1,069.47 0.00 0.00 25001 S 844.71 0.00 0.00<br />

24361 S 5,847.37 3,579.33 1,311.29 25020 S 661.28 0.00 0.00<br />

24362 S 1,366.78 0.00 0.00 25023 S 818.36 0.00 0.00<br />

24363 S 5,977.60 3,709.56 1,441.52 25024 S 818.36 0.00 0.00<br />

24365 S 1,069.47 0.00 0.00 25025 S 818.36 0.00 0.00<br />

24366 S 5,847.37 3,579.33 1,311.29 25028 S 578.35 0.00 0.00<br />

24400 S 874.57 0.00 0.00 25031 S 631.29 0.00 0.00<br />

24410 S 874.57 0.00 0.00 25035 S 631.29 0.00 0.00<br />

24420 S 1,118.36 0.00 0.00 25040 S 915.32 0.00 0.00<br />

24430 S 1,918.11 0.00 0.00 25065 S 137.57 0.00 0.00<br />

24435 S 1,974.32 0.00 0.00 25066 S 632.49 0.00 0.00<br />

24470 S 1,118.36 0.00 0.00 25075 S 517.20 0.00 0.00<br />

24495 S 788.37 0.00 0.00 25076 S 662.48 0.00 0.00<br />

24498 S 1,918.11 0.00 0.00 25077 S 662.48 0.00 0.00<br />

24500 S 79.52 0.00 0.00 25085 S 661.28 0.00 0.00<br />

24505 S 79.52 0.00 0.00 25100 S 631.29 0.00 0.00<br />

24515 S 1,508.41 0.00 0.00 25101 S 818.36 0.00 0.00<br />

24516 S 1,508.41 0.00 0.00 25105 S 874.57 0.00 0.00<br />

24530 S 79.52 0.00 0.00 25107 S 818.36 0.00 0.00<br />

24535 S 167.75 0.00 0.00 25109 S 844.71 0.00 0.00<br />

24538 S 702.32 0.00 0.00 25110 S 661.28 0.00 0.00<br />

24545 S 1,508.41 0.00 0.00 25111 S 661.28 0.00 0.00<br />

24546 S 1,549.17 0.00 0.00 25112 S 717.49 0.00 0.00<br />

24560 S 79.52 0.00 0.00 25115 S 717.49 0.00 0.00<br />

24565 S 79.52 0.00 0.00 25116 S 717.49 0.00 0.00<br />

24566 S 702.32 0.00 0.00 25118 S 788.37 0.00 0.00<br />

24575 S 1,452.20 0.00 0.00 25119 S 818.36 0.00 0.00<br />

24576 S 79.52 0.00 0.00 25120 S 818.36 0.00 0.00<br />

24577 S 167.75 0.00 0.00 25125 S 818.36 0.00 0.00<br />

24579 S 1,452.20 0.00 0.00 25126 S 818.36 0.00 0.00<br />

24582 S 702.32 0.00 0.00 25130 S 818.36 0.00 0.00<br />

24586 S 1,508.41 0.00 0.00 25135 S 818.36 0.00 0.00<br />

24587 S 1,549.17 0.00 0.00 25136 S 818.36 0.00 0.00<br />

24600 S 79.52 0.00 0.00 25145 S 788.37 0.00 0.00<br />

24605 S 510.80 0.00 0.00 25150 S 788.37 0.00 0.00<br />

24615 S 1,452.20 0.00 0.00 25151 S 788.37 0.00 0.00<br />

24620 S 433.89 0.00 0.00 25210 S 818.36 0.00 0.00<br />

24635 S 1,452.20 0.00 0.00 25215 S 874.57 0.00 0.00<br />

24640 S 53.71 0.00 0.00 25230 S 874.57 0.00 0.00<br />

24650 S 61.97 0.00 0.00 25240 S 874.57 0.00 0.00<br />

24655 S 167.75 0.00 0.00 25248 S 631.29 0.00 0.00<br />

24665 S 1,126.35 0.00 0.00 25250 S 735.43 0.00 0.00<br />

24666 S 1,508.41 0.00 0.00 25251 S 735.43 0.00 0.00<br />

24670 S 79.52 0.00 0.00 25259 S 770.70 0.00 0.00<br />

24675 S 79.52 0.00 0.00 25260 S 874.57 0.00 0.00<br />

24685 S 1,070.13 0.00 0.00 25263 S 788.37 0.00 0.00<br />

24800 S 1,174.58 0.00 0.00 25265 S 818.36 0.00 0.00<br />

24802 S 1,215.33 0.00 0.00 25270 S 874.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 818.36 0.00 0.00 25505 S 167.75 0.00 0.00<br />

25274 S 874.57 0.00 0.00 25515 S 1,070.13 0.00 0.00<br />

25275 S 874.57 0.00 0.00 25520 S 167.75 0.00 0.00<br />

25280 S 874.57 0.00 0.00 25525 S 1,126.35 0.00 0.00<br />

25290 S 818.36 0.00 0.00 25526 S 1,167.10 0.00 0.00<br />

25295 S 661.28 0.00 0.00 25530 S 61.97 0.00 0.00<br />

25300 S 818.36 0.00 0.00 25535 S 79.52 0.00 0.00<br />

25301 S 818.36 0.00 0.00 25545 S 1,070.13 0.00 0.00<br />

25310 S 1,118.36 0.00 0.00 25560 S 61.97 0.00 0.00<br />

25312 S 1,174.58 0.00 0.00 25565 S 167.75 0.00 0.00<br />

25315 S 1,118.36 0.00 0.00 25574 S 1,452.20 0.00 0.00<br />

25316 S 1,918.11 0.00 0.00 25575 S 1,452.20 0.00 0.00<br />

25320 S 1,118.36 0.00 0.00 25600 S 61.97 0.00 0.00<br />

25332 S 1,069.47 0.00 0.00 25605 S 167.75 0.00 0.00<br />

25335 S 1,118.36 0.00 0.00 25606 S 732.31 0.00 0.00<br />

25337 S 1,215.33 0.00 0.00 25607 S 1,549.17 0.00 0.00<br />

25350 S 1,918.11 0.00 0.00 25608 S 1,549.17 0.00 0.00<br />

25355 S 1,118.36 0.00 0.00 25609 S 1,549.17 0.00 0.00<br />

25360 S 818.36 0.00 0.00 25622 S 61.97 0.00 0.00<br />

25365 S 818.36 0.00 0.00 25624 S 167.75 0.00 0.00<br />

25370 S 1,118.36 0.00 0.00 25628 S 1,070.13 0.00 0.00<br />

25375 S 1,174.58 0.00 0.00 25630 S 61.97 0.00 0.00<br />

25390 S 818.36 0.00 0.00 25635 S 167.75 0.00 0.00<br />

25391 S 1,174.58 0.00 0.00 25645 S 1,070.13 0.00 0.00<br />

25392 S 818.36 0.00 0.00 25650 S 61.97 0.00 0.00<br />

25393 S 1,174.58 0.00 0.00 25651 S 986.78 0.00 0.00<br />

25394 S 1,758.90 0.00 0.00 25652 S 1,662.41 0.00 0.00<br />

25400 S 1,118.36 0.00 0.00 25660 S 79.52 0.00 0.00<br />

25405 S 1,974.32 0.00 0.00 25670 S 732.31 0.00 0.00<br />

25415 S 1,918.11 0.00 0.00 25671 S 649.39 0.00 0.00<br />

25420 S 1,974.32 0.00 0.00 25675 S 79.52 0.00 0.00<br />

25425 S 1,118.36 0.00 0.00 25676 S 702.32 0.00 0.00<br />

25426 S 1,174.58 0.00 0.00 25680 S 79.52 0.00 0.00<br />

25430 S 1,758.90 0.00 0.00 25685 S 732.31 0.00 0.00<br />

25431 S 1,758.90 0.00 0.00 25690 S 433.89 0.00 0.00<br />

25440 S 1,974.32 0.00 0.00 25695 S 702.32 0.00 0.00<br />

25441 S 5,847.37 3,579.33 1,311.29 25800 S 1,974.32 0.00 0.00<br />

25442 S 5,847.37 3,579.33 1,311.29 25805 S 1,215.33 0.00 0.00<br />

25443 S 1,366.78 0.00 0.00 25810 S 2,015.08 0.00 0.00<br />

25444 S 1,366.78 0.00 0.00 25820 S 1,174.58 0.00 0.00<br />

25445 S 1,366.78 0.00 0.00 25825 S 2,015.08 0.00 0.00<br />

25446 S 5,977.60 3,709.56 1,441.52 25830 S 2,015.08 0.00 0.00<br />

25447 S 1,069.47 0.00 0.00 25907 S 661.28 0.00 0.00<br />

25449 S 1,069.47 0.00 0.00 25922 S 661.28 0.00 0.00<br />

25450 S 1,118.36 0.00 0.00 25929 S 548.68 0.00 0.00<br />

25455 S 1,118.36 0.00 0.00 25931 S 844.71 0.00 0.00<br />

25490 S 1,118.36 0.00 0.00 26010 S 54.79 0.00 0.00<br />

25491 S 1,118.36 0.00 0.00 26011 S 400.23 0.00 0.00<br />

25492 S 1,118.36 0.00 0.00 26020 S 531.06 0.00 0.00<br />

25500 S 61.97 0.00 0.00 26025 S 478.12 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 531.06 0.00 0.00 26392 S 781.85 0.00 0.00<br />

26034 S 531.06 0.00 0.00 26410 S 561.04 0.00 0.00<br />

26035 S 644.25 0.00 0.00 26412 S 781.85 0.00 0.00<br />

26040 S 838.07 0.00 0.00 26415 S 838.07 0.00 0.00<br />

26045 S 781.85 0.00 0.00 26416 S 781.85 0.00 0.00<br />

26055 S 531.06 0.00 0.00 26418 S 617.26 0.00 0.00<br />

26060 S 531.06 0.00 0.00 26420 S 838.07 0.00 0.00<br />

26070 S 531.06 0.00 0.00 26426 S 781.85 0.00 0.00<br />

26075 S 617.26 0.00 0.00 26428 S 781.85 0.00 0.00<br />

26080 S 617.26 0.00 0.00 26432 S 561.04 0.00 0.00<br />

26100 S 531.06 0.00 0.00 26433 S 561.04 0.00 0.00<br />

26105 S 478.12 0.00 0.00 26434 S 781.85 0.00 0.00<br />

26110 S 478.12 0.00 0.00 26437 S 561.04 0.00 0.00<br />

26115 S 632.49 0.00 0.00 26440 S 561.04 0.00 0.00<br />

26116 S 632.49 0.00 0.00 26442 S 781.85 0.00 0.00<br />

26117 S 662.48 0.00 0.00 26445 S 561.04 0.00 0.00<br />

26121 S 838.07 0.00 0.00 26449 S 781.85 0.00 0.00<br />

26123 S 838.07 0.00 0.00 26450 S 561.04 0.00 0.00<br />

26125 S 617.26 0.00 0.00 26455 S 561.04 0.00 0.00<br />

26130 S 561.04 0.00 0.00 26460 S 561.04 0.00 0.00<br />

26135 S 838.07 0.00 0.00 26471 S 531.06 0.00 0.00<br />

26140 S 531.06 0.00 0.00 26474 S 531.06 0.00 0.00<br />

26145 S 561.04 0.00 0.00 26476 S 478.12 0.00 0.00<br />

26160 S 561.04 0.00 0.00 26477 S 478.12 0.00 0.00<br />

26170 S 561.04 0.00 0.00 26478 S 478.12 0.00 0.00<br />

26180 S 561.04 0.00 0.00 26479 S 478.12 0.00 0.00<br />

26185 S 617.26 0.00 0.00 26480 S 781.85 0.00 0.00<br />

26200 S 531.06 0.00 0.00 26483 S 781.85 0.00 0.00<br />

26205 S 781.85 0.00 0.00 26485 S 751.87 0.00 0.00<br />

26210 S 531.06 0.00 0.00 26489 S 781.85 0.00 0.00<br />

26215 S 561.04 0.00 0.00 26490 S 781.85 0.00 0.00<br />

26230 S 787.28 0.00 0.00 26492 S 781.85 0.00 0.00<br />

26235 S 561.04 0.00 0.00 26494 S 781.85 0.00 0.00<br />

26236 S 561.04 0.00 0.00 26496 S 781.85 0.00 0.00<br />

26250 S 561.04 0.00 0.00 26497 S 781.85 0.00 0.00<br />

26255 S 781.85 0.00 0.00 26498 S 838.07 0.00 0.00<br />

26260 S 561.04 0.00 0.00 26499 S 781.85 0.00 0.00<br />

26261 S 561.04 0.00 0.00 26500 S 617.26 0.00 0.00<br />

26262 S 531.06 0.00 0.00 26502 S 838.07 0.00 0.00<br />

26320 S 517.20 0.00 0.00 26508 S 561.04 0.00 0.00<br />

26340 S 238.43 0.00 0.00 26510 S 781.85 0.00 0.00<br />

26350 S 698.93 0.00 0.00 26516 S 698.93 0.00 0.00<br />

26352 S 838.07 0.00 0.00 26517 S 781.85 0.00 0.00<br />

26356 S 838.07 0.00 0.00 26518 S 781.85 0.00 0.00<br />

26357 S 838.07 0.00 0.00 26520 S 561.04 0.00 0.00<br />

26358 S 838.07 0.00 0.00 26525 S 561.04 0.00 0.00<br />

26370 S 838.07 0.00 0.00 26530 S 972.51 0.00 0.00<br />

26372 S 838.07 0.00 0.00 26531 S 1,497.01 0.00 0.00<br />

26373 S 781.85 0.00 0.00 26535 S 1,069.47 0.00 0.00<br />

26390 S 838.07 0.00 0.00 26536 S 1,366.78 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 617.26 0.00 0.00 26775 S 165.65 0.00 0.00<br />

26541 S 1,009.06 0.00 0.00 26776 S 702.32 0.00 0.00<br />

26542 S 617.26 0.00 0.00 26785 S 702.32 0.00 0.00<br />

26545 S 838.07 0.00 0.00 26820 S 878.82 0.00 0.00<br />

26546 S 838.07 0.00 0.00 26841 S 838.07 0.00 0.00<br />

26548 S 838.07 0.00 0.00 26842 S 838.07 0.00 0.00<br />

26550 S 751.87 0.00 0.00 26843 S 781.85 0.00 0.00<br />

26555 S 781.85 0.00 0.00 26844 S 781.85 0.00 0.00<br />

26560 S 531.06 0.00 0.00 26850 S 838.07 0.00 0.00<br />

26561 S 781.85 0.00 0.00 26852 S 838.07 0.00 0.00<br />

26562 S 838.07 0.00 0.00 26860 S 781.85 0.00 0.00<br />

26565 S 878.82 0.00 0.00 26861 S 751.87 0.00 0.00<br />

26567 S 878.82 0.00 0.00 26862 S 838.07 0.00 0.00<br />

26568 S 781.85 0.00 0.00 26863 S 781.85 0.00 0.00<br />

26580 S 658.01 0.00 0.00 26910 S 781.85 0.00 0.00<br />

26587 S 658.01 0.00 0.00 26951 S 531.06 0.00 0.00<br />

26590 S 658.01 0.00 0.00 26952 S 617.26 0.00 0.00<br />

26591 S 781.85 0.00 0.00 26990 S 578.35 0.00 0.00<br />

26593 S 561.04 0.00 0.00 26991 S 578.35 0.00 0.00<br />

26596 S 531.06 0.00 0.00 27000 S 631.29 0.00 0.00<br />

26600 S 61.97 0.00 0.00 27001 S 818.36 0.00 0.00<br />

26605 S 79.52 0.00 0.00 27003 S 818.36 0.00 0.00<br />

26607 S 433.89 0.00 0.00 27033 S 1,118.36 0.00 0.00<br />

26608 S 788.52 0.00 0.00 27035 S 1,174.58 0.00 0.00<br />

26615 S 1,126.35 0.00 0.00 27040 S 316.10 0.00 0.00<br />

26641 S 61.97 0.00 0.00 27041 S 356.15 0.00 0.00<br />

26645 S 167.75 0.00 0.00 27047 S 632.49 0.00 0.00<br />

26650 S 702.32 0.00 0.00 27048 S 662.48 0.00 0.00<br />

26665 S 1,126.35 0.00 0.00 27049 S 662.48 0.00 0.00<br />

26670 S 61.97 0.00 0.00 27050 S 661.28 0.00 0.00<br />

26675 S 167.75 0.00 0.00 27052 S 661.28 0.00 0.00<br />

26676 S 702.32 0.00 0.00 27060 S 758.25 0.00 0.00<br />

26685 S 732.31 0.00 0.00 27062 S 758.25 0.00 0.00<br />

26686 S 1,452.20 0.00 0.00 27065 S 758.25 0.00 0.00<br />

26700 S 61.97 0.00 0.00 27066 S 915.32 0.00 0.00<br />

26705 S 79.52 0.00 0.00 27067 S 915.32 0.00 0.00<br />

26706 S 433.89 0.00 0.00 27080 S 788.37 0.00 0.00<br />

26715 S 788.52 0.00 0.00 27086 S 316.10 0.00 0.00<br />

26720 S 61.97 0.00 0.00 27087 S 661.28 0.00 0.00<br />

26725 S 61.97 0.00 0.00 27097 S 818.36 0.00 0.00<br />

26727 S 959.51 0.00 0.00 27098 S 818.36 0.00 0.00<br />

26735 S 788.52 0.00 0.00 27100 S 1,174.58 0.00 0.00<br />

26740 S 61.97 0.00 0.00 27105 S 1,174.58 0.00 0.00<br />

26742 S 79.52 0.00 0.00 27110 S 1,174.58 0.00 0.00<br />

26746 S 829.28 0.00 0.00 27111 S 1,174.58 0.00 0.00<br />

26750 S 61.97 0.00 0.00 27193 S 79.52 0.00 0.00<br />

26755 S 61.97 0.00 0.00 27194 S 510.80 0.00 0.00<br />

26756 S 702.32 0.00 0.00 27200 S 61.97 0.00 0.00<br />

26765 S 788.52 0.00 0.00 27202 S 1,040.15 0.00 0.00<br />

26770 S 61.97 0.00 0.00 27220 S 61.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 79.52 0.00 0.00 27397 S 1,118.36 0.00 0.00<br />

27238 S 167.75 0.00 0.00 27400 S 1,118.36 0.00 0.00<br />

27246 S 167.75 0.00 0.00 27403 S 874.57 0.00 0.00<br />

27250 S 79.52 0.00 0.00 27405 S 1,174.58 0.00 0.00<br />

27252 S 510.80 0.00 0.00 27407 S 1,974.32 0.00 0.00<br />

27256 S 61.97 0.00 0.00 27409 S 1,174.58 0.00 0.00<br />

27257 S 540.79 0.00 0.00 27416 S 1,758.90 0.00 0.00<br />

27265 S 79.52 0.00 0.00 27418 S 1,118.36 0.00 0.00<br />

27266 S 510.80 0.00 0.00 27420 S 1,118.36 0.00 0.00<br />

27267 S 61.97 0.00 0.00 27422 S 1,345.56 0.00 0.00<br />

27275 S 510.80 0.00 0.00 27424 S 1,118.36 0.00 0.00<br />

27301 S 614.86 0.00 0.00 27425 S 1,045.56 0.00 0.00<br />

27305 S 631.29 0.00 0.00 27427 S 1,118.36 0.00 0.00<br />

27306 S 661.28 0.00 0.00 27428 S 1,974.32 0.00 0.00<br />

27307 S 661.28 0.00 0.00 27429 S 1,974.32 0.00 0.00<br />

27310 S 874.57 0.00 0.00 27430 S 1,174.58 0.00 0.00<br />

27323 S 316.10 0.00 0.00 27435 S 1,174.58 0.00 0.00<br />

27324 S 579.56 0.00 0.00 27437 S 1,028.71 0.00 0.00<br />

27325 S 567.88 0.00 0.00 27438 S 1,366.78 0.00 0.00<br />

27326 S 567.88 0.00 0.00 27440 S 1,467.17 0.00 0.00<br />

27327 S 632.49 0.00 0.00 27441 S 1,069.47 0.00 0.00<br />

27328 S 662.48 0.00 0.00 27442 S 1,069.47 0.00 0.00<br />

27329 S 718.69 0.00 0.00 27443 S 1,069.47 0.00 0.00<br />

27330 S 874.57 0.00 0.00 27446 S 10,493.61 6,304.08 2,114.55<br />

27331 S 874.57 0.00 0.00 27496 S 758.25 0.00 0.00<br />

27332 S 874.57 0.00 0.00 27497 S 661.28 0.00 0.00<br />

27333 S 874.57 0.00 0.00 27498 S 661.28 0.00 0.00<br />

27334 S 874.57 0.00 0.00 27499 S 661.28 0.00 0.00<br />

27335 S 874.57 0.00 0.00 27500 S 167.75 0.00 0.00<br />

27340 S 661.28 0.00 0.00 27501 S 79.52 0.00 0.00<br />

27345 S 717.49 0.00 0.00 27502 S 433.89 0.00 0.00<br />

27347 S 717.49 0.00 0.00 27503 S 79.52 0.00 0.00<br />

27350 S 874.57 0.00 0.00 27508 S 79.52 0.00 0.00<br />

27355 S 818.36 0.00 0.00 27509 S 732.31 0.00 0.00<br />

27356 S 874.57 0.00 0.00 27510 S 167.75 0.00 0.00<br />

27357 S 915.32 0.00 0.00 27516 S 79.52 0.00 0.00<br />

27358 S 915.32 0.00 0.00 27517 S 79.52 0.00 0.00<br />

27360 S 915.32 0.00 0.00 27520 S 79.52 0.00 0.00<br />

27372 S 889.68 0.00 0.00 27530 S 79.52 0.00 0.00<br />

27380 S 578.35 0.00 0.00 27532 S 433.89 0.00 0.00<br />

27381 S 661.28 0.00 0.00 27538 S 79.52 0.00 0.00<br />

27385 S 661.28 0.00 0.00 27550 S 79.52 0.00 0.00<br />

27386 S 661.28 0.00 0.00 27552 S 457.86 0.00 0.00<br />

27390 S 578.35 0.00 0.00 27560 S 79.52 0.00 0.00<br />

27391 S 631.29 0.00 0.00 27562 S 457.86 0.00 0.00<br />

27392 S 661.28 0.00 0.00 27566 S 1,040.15 0.00 0.00<br />

27393 S 788.37 0.00 0.00 27570 S 457.86 0.00 0.00<br />

27394 S 818.36 0.00 0.00 27594 S 661.28 0.00 0.00<br />

27395 S 1,118.36 0.00 0.00 27600 S 661.28 0.00 0.00<br />

27396 S 818.36 0.00 0.00 27601 S 661.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 661.28 0.00 0.00 27730 S 788.37 0.00 0.00<br />

27603 S 584.88 0.00 0.00 27732 S 788.37 0.00 0.00<br />

27604 S 631.29 0.00 0.00 27734 S 788.37 0.00 0.00<br />

27605 S 575.25 0.00 0.00 27740 S 788.37 0.00 0.00<br />

27606 S 578.35 0.00 0.00 27742 S 1,088.38 0.00 0.00<br />

27607 S 631.29 0.00 0.00 27745 S 1,918.11 0.00 0.00<br />

27610 S 788.37 0.00 0.00 27750 S 79.52 0.00 0.00<br />

27612 S 818.36 0.00 0.00 27752 S 433.89 0.00 0.00<br />

27613 S 129.95 0.00 0.00 27756 S 732.31 0.00 0.00<br />

27614 S 632.49 0.00 0.00 27758 S 1,126.35 0.00 0.00<br />

27615 S 818.36 0.00 0.00 27759 S 1,508.41 0.00 0.00<br />

27618 S 517.20 0.00 0.00 27760 S 79.52 0.00 0.00<br />

27619 S 662.48 0.00 0.00 27762 S 433.89 0.00 0.00<br />

27620 S 874.57 0.00 0.00 27766 S 1,070.13 0.00 0.00<br />

27625 S 874.57 0.00 0.00 27767 S 61.97 0.00 0.00<br />

27626 S 874.57 0.00 0.00 27768 S 61.97 0.00 0.00<br />

27630 S 661.28 0.00 0.00 27769 S 1,662.41 0.00 0.00<br />

27635 S 818.36 0.00 0.00 27780 S 79.52 0.00 0.00<br />

27637 S 818.36 0.00 0.00 27781 S 433.89 0.00 0.00<br />

27638 S 818.36 0.00 0.00 27784 S 1,070.13 0.00 0.00<br />

27640 S 1,088.38 0.00 0.00 27786 S 79.52 0.00 0.00<br />

27641 S 788.37 0.00 0.00 27788 S 79.52 0.00 0.00<br />

27647 S 1,118.36 0.00 0.00 27792 S 1,070.13 0.00 0.00<br />

27650 S 1,118.36 0.00 0.00 27808 S 79.52 0.00 0.00<br />

27652 S 1,918.11 0.00 0.00 27810 S 167.75 0.00 0.00<br />

27654 S 1,118.36 0.00 0.00 27814 S 1,070.13 0.00 0.00<br />

27656 S 631.29 0.00 0.00 27816 S 79.52 0.00 0.00<br />

27658 S 578.35 0.00 0.00 27818 S 167.75 0.00 0.00<br />

27659 S 631.29 0.00 0.00 27822 S 1,070.13 0.00 0.00<br />

27664 S 631.29 0.00 0.00 27823 S 1,452.20 0.00 0.00<br />

27665 S 788.37 0.00 0.00 27824 S 79.52 0.00 0.00<br />

27675 S 631.29 0.00 0.00 27825 S 433.89 0.00 0.00<br />

27676 S 818.36 0.00 0.00 27826 S 1,070.13 0.00 0.00<br />

27680 S 818.36 0.00 0.00 27827 S 1,452.20 0.00 0.00<br />

27681 S 788.37 0.00 0.00 27828 S 1,508.41 0.00 0.00<br />

27685 S 818.36 0.00 0.00 27829 S 1,040.15 0.00 0.00<br />

27686 S 818.36 0.00 0.00 27830 S 79.52 0.00 0.00<br />

27687 S 818.36 0.00 0.00 27831 S 433.89 0.00 0.00<br />

27690 S 1,174.58 0.00 0.00 27832 S 1,040.15 0.00 0.00<br />

27691 S 1,174.58 0.00 0.00 27840 S 167.75 0.00 0.00<br />

27692 S 1,118.36 0.00 0.00 27842 S 457.86 0.00 0.00<br />

27695 S 788.37 0.00 0.00 27846 S 1,070.13 0.00 0.00<br />

27696 S 788.37 0.00 0.00 27848 S 1,070.13 0.00 0.00<br />

27698 S 788.37 0.00 0.00 27860 S 457.86 0.00 0.00<br />

27700 S 1,069.47 0.00 0.00 27870 S 1,974.32 0.00 0.00<br />

27704 S 631.29 0.00 0.00 27871 S 1,974.32 0.00 0.00<br />

27705 S 1,088.38 0.00 0.00 27884 S 661.28 0.00 0.00<br />

27707 S 631.29 0.00 0.00 27889 S 818.36 0.00 0.00<br />

27709 S 788.37 0.00 0.00 27892 S 661.28 0.00 0.00<br />

27726 S 986.78 0.00 0.00 27893 S 661.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 661.28 0.00 0.00 28153 S 658.17 0.00 0.00<br />

28001 S 126.83 0.00 0.00 28160 S 658.17 0.00 0.00<br />

28002 S 661.28 0.00 0.00 28171 S 658.17 0.00 0.00<br />

28003 S 661.28 0.00 0.00 28173 S 658.17 0.00 0.00<br />

28005 S 658.17 0.00 0.00 28175 S 658.17 0.00 0.00<br />

28008 S 658.17 0.00 0.00 28190 S 130.99 0.00 0.00<br />

28010 S 93.22 0.00 0.00 28192 S 517.20 0.00 0.00<br />

28011 S 658.17 0.00 0.00 28193 S 356.15 0.00 0.00<br />

28020 S 628.18 0.00 0.00 28200 S 658.17 0.00 0.00<br />

28022 S 628.18 0.00 0.00 28202 S 658.17 0.00 0.00<br />

28024 S 628.18 0.00 0.00 28208 S 658.17 0.00 0.00<br />

28035 S 654.08 0.00 0.00 28210 S 1,155.95 0.00 0.00<br />

28043 S 632.49 0.00 0.00 28220 S 202.04 0.00 0.00<br />

28045 S 658.17 0.00 0.00 28222 S 575.25 0.00 0.00<br />

28046 S 658.17 0.00 0.00 28225 S 575.25 0.00 0.00<br />

28050 S 628.18 0.00 0.00 28226 S 575.25 0.00 0.00<br />

28052 S 628.18 0.00 0.00 28230 S 198.22 0.00 0.00<br />

28054 S 628.18 0.00 0.00 28232 S 189.56 0.00 0.00<br />

28055 S 654.08 0.00 0.00 28234 S 628.18 0.00 0.00<br />

28060 S 628.18 0.00 0.00 28238 S 1,155.95 0.00 0.00<br />

28062 S 658.17 0.00 0.00 28240 S 628.18 0.00 0.00<br />

28070 S 658.17 0.00 0.00 28250 S 658.17 0.00 0.00<br />

28072 S 658.17 0.00 0.00 28260 S 658.17 0.00 0.00<br />

28080 S 658.17 0.00 0.00 28261 S 658.17 0.00 0.00<br />

28086 S 628.18 0.00 0.00 28262 S 714.38 0.00 0.00<br />

28088 S 628.18 0.00 0.00 28264 S 1,073.03 0.00 0.00<br />

28090 S 658.17 0.00 0.00 28270 S 658.17 0.00 0.00<br />

28092 S 658.17 0.00 0.00 28272 S 182.97 0.00 0.00<br />

28100 S 628.18 0.00 0.00 28280 S 628.18 0.00 0.00<br />

28102 S 1,155.95 0.00 0.00 28285 S 658.17 0.00 0.00<br />

28103 S 1,155.95 0.00 0.00 28286 S 714.38 0.00 0.00<br />

28104 S 628.18 0.00 0.00 28288 S 658.17 0.00 0.00<br />

28106 S 1,155.95 0.00 0.00 28289 S 658.17 0.00 0.00<br />

28107 S 1,155.95 0.00 0.00 28290 S 811.28 0.00 0.00<br />

28108 S 628.18 0.00 0.00 28292 S 811.28 0.00 0.00<br />

28110 S 658.17 0.00 0.00 28293 S 841.26 0.00 0.00<br />

28111 S 658.17 0.00 0.00 28294 S 841.26 0.00 0.00<br />

28112 S 658.17 0.00 0.00 28296 S 841.26 0.00 0.00<br />

28113 S 658.17 0.00 0.00 28297 S 841.26 0.00 0.00<br />

28114 S 658.17 0.00 0.00 28298 S 841.26 0.00 0.00<br />

28116 S 658.17 0.00 0.00 28299 S 938.23 0.00 0.00<br />

28118 S 714.38 0.00 0.00 28300 S 1,125.97 0.00 0.00<br />

28119 S 714.38 0.00 0.00 28302 S 628.18 0.00 0.00<br />

28120 S 885.38 0.00 0.00 28304 S 1,125.97 0.00 0.00<br />

28122 S 658.17 0.00 0.00 28305 S 1,155.95 0.00 0.00<br />

28124 S 214.51 0.00 0.00 28306 S 714.38 0.00 0.00<br />

28126 S 658.17 0.00 0.00 28307 S 714.38 0.00 0.00<br />

28130 S 658.17 0.00 0.00 28308 S 628.18 0.00 0.00<br />

28140 S 658.17 0.00 0.00 28309 S 1,212.17 0.00 0.00<br />

28150 S 658.17 0.00 0.00 28310 S 658.17 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 658.17 0.00 0.00 28636 S 732.31 0.00 0.00<br />

28313 S 628.18 0.00 0.00 28645 S 732.31 0.00 0.00<br />

28315 S 714.38 0.00 0.00 28660 S 44.36 0.00 0.00<br />

28320 S 1,212.17 0.00 0.00 28665 S 457.86 0.00 0.00<br />

28322 S 1,212.17 0.00 0.00 28666 S 732.31 0.00 0.00<br />

28340 S 714.38 0.00 0.00 28675 S 732.31 0.00 0.00<br />

28341 S 714.38 0.00 0.00 28705 S 1,212.17 0.00 0.00<br />

28344 S 714.38 0.00 0.00 28715 S 1,974.32 0.00 0.00<br />

28345 S 714.38 0.00 0.00 28725 S 1,212.17 0.00 0.00<br />

28400 S 79.52 0.00 0.00 28730 S 1,212.17 0.00 0.00<br />

28405 S 433.89 0.00 0.00 28735 S 1,212.17 0.00 0.00<br />

28406 S 702.32 0.00 0.00 28737 S 1,252.92 0.00 0.00<br />

28415 S 1,452.20 0.00 0.00 28740 S 1,212.17 0.00 0.00<br />

28420 S 1,126.35 0.00 0.00 28750 S 1,212.17 0.00 0.00<br />

28430 S 61.97 0.00 0.00 28755 S 714.38 0.00 0.00<br />

28435 S 79.52 0.00 0.00 28760 S 1,212.17 0.00 0.00<br />

28436 S 702.32 0.00 0.00 28810 S 628.18 0.00 0.00<br />

28445 S 1,070.13 0.00 0.00 28820 S 628.18 0.00 0.00<br />

28446 S 1,834.07 0.00 0.00 28825 S 628.18 0.00 0.00<br />

28450 S 61.97 0.00 0.00 28890 S 166.00 0.00 0.00<br />

28455 S 61.97 0.00 0.00 29000 S 42.06 0.00 0.00<br />

28456 S 702.32 0.00 0.00 29010 S 94.26 0.00 0.00<br />

28465 S 1,070.13 0.00 0.00 29015 S 94.26 0.00 0.00<br />

28470 S 61.97 0.00 0.00 29020 S 42.06 0.00 0.00<br />

28475 S 61.97 0.00 0.00 29025 S 42.06 0.00 0.00<br />

28476 S 702.32 0.00 0.00 29035 S 94.26 0.00 0.00<br />

28485 S 1,126.35 0.00 0.00 29040 S 42.06 0.00 0.00<br />

28490 S 61.97 0.00 0.00 29044 S 94.26 0.00 0.00<br />

28495 S 61.97 0.00 0.00 29046 S 94.26 0.00 0.00<br />

28496 S 702.32 0.00 0.00 29049 S 38.12 0.00 0.00<br />

28505 S 732.31 0.00 0.00 29055 S 94.26 0.00 0.00<br />

28510 S 55.80 0.00 0.00 29058 S 42.06 0.00 0.00<br />

28515 S 61.97 0.00 0.00 29065 S 44.71 0.00 0.00<br />

28525 S 732.31 0.00 0.00 29075 S 42.97 0.00 0.00<br />

28530 S 53.71 0.00 0.00 29085 S 42.06 0.00 0.00<br />

28531 S 732.31 0.00 0.00 29086 S 36.04 0.00 0.00<br />

28540 S 61.97 0.00 0.00 29105 S 38.81 0.00 0.00<br />

28545 S 649.39 0.00 0.00 29125 S 33.61 0.00 0.00<br />

28546 S 702.32 0.00 0.00 29126 S 35.70 0.00 0.00<br />

28555 S 1,040.15 0.00 0.00 29130 S 15.25 0.00 0.00<br />

28570 S 80.39 0.00 0.00 29131 S 22.18 0.00 0.00<br />

28575 S 433.89 0.00 0.00 29200 S 21.48 0.00 0.00<br />

28576 S 732.31 0.00 0.00 29220 S 23.21 0.00 0.00<br />

28585 S 732.31 0.00 0.00 29240 S 24.26 0.00 0.00<br />

28600 S 61.97 0.00 0.00 29260 S 23.21 0.00 0.00<br />

28605 S 79.52 0.00 0.00 29280 S 23.57 0.00 0.00<br />

28606 S 702.32 0.00 0.00 29305 S 94.26 0.00 0.00<br />

28615 S 1,070.13 0.00 0.00 29325 S 94.26 0.00 0.00<br />

28630 S 61.97 0.00 0.00 29345 S 58.56 0.00 0.00<br />

28635 S 457.86 0.00 0.00 29355 S 57.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 71.39 0.00 0.00 29847 S 1,193.25 0.00 0.00<br />

29365 S 55.45 0.00 0.00 29848 S 1,197.65 0.00 0.00<br />

29405 S 41.24 0.00 0.00 29850 S 865.51 0.00 0.00<br />

29425 S 41.93 0.00 0.00 29851 S 1,249.47 0.00 0.00<br />

29435 S 53.02 0.00 0.00 29855 S 1,249.47 0.00 0.00<br />

29440 S 22.52 0.00 0.00 29856 S 1,249.47 0.00 0.00<br />

29445 S 55.80 0.00 0.00 29860 S 1,249.47 0.00 0.00<br />

29450 S 42.06 0.00 0.00 29861 S 1,249.47 0.00 0.00<br />

29505 S 37.43 0.00 0.00 29862 S 1,581.61 0.00 0.00<br />

29515 S 31.88 0.00 0.00 29863 S 1,249.47 0.00 0.00<br />

29520 S 22.87 0.00 0.00 29866 S 1,908.67 0.00 0.00<br />

29530 S 23.21 0.00 0.00 29870 S 809.30 0.00 0.00<br />

29540 S 17.32 0.00 0.00 29871 S 809.30 0.00 0.00<br />

29550 S 17.67 0.00 0.00 29873 S 809.30 0.00 0.00<br />

29580 S 23.92 0.00 0.00 29874 S 809.30 0.00 0.00<br />

29590 S 19.41 0.00 0.00 29875 S 865.51 0.00 0.00<br />

29700 S 32.23 0.00 0.00 29876 S 865.51 0.00 0.00<br />

29705 S 27.37 0.00 0.00 29877 S 865.51 0.00 0.00<br />

29710 S 48.17 0.00 0.00 29879 S 809.30 0.00 0.00<br />

29715 S 42.06 0.00 0.00 29880 S 865.51 0.00 0.00<br />

29720 S 40.20 0.00 0.00 29881 S 865.51 0.00 0.00<br />

29730 S 26.34 0.00 0.00 29882 S 809.30 0.00 0.00<br />

29740 S 36.04 0.00 0.00 29883 S 809.30 0.00 0.00<br />

29750 S 37.77 0.00 0.00 29884 S 809.30 0.00 0.00<br />

29800 S 809.30 0.00 0.00 29885 S 1,193.25 0.00 0.00<br />

29804 S 809.30 0.00 0.00 29886 S 809.30 0.00 0.00<br />

29805 S 809.30 0.00 0.00 29887 S 809.30 0.00 0.00<br />

29806 S 1,193.25 0.00 0.00 29888 S 1,193.25 0.00 0.00<br />

29807 S 1,193.25 0.00 0.00 29889 S 1,193.25 0.00 0.00<br />

29819 S 1,193.25 0.00 0.00 29891 S 1,193.25 0.00 0.00<br />

29820 S 1,193.25 0.00 0.00 29892 S 1,193.25 0.00 0.00<br />

29821 S 1,193.25 0.00 0.00 29893 S 1,007.43 0.00 0.00<br />

29822 S 809.30 0.00 0.00 29894 S 809.30 0.00 0.00<br />

29823 S 1,193.25 0.00 0.00 29895 S 809.30 0.00 0.00<br />

29824 S 906.27 0.00 0.00 29897 S 809.30 0.00 0.00<br />

29825 S 1,193.25 0.00 0.00 29898 S 809.30 0.00 0.00<br />

29826 S 1,193.25 0.00 0.00 29899 S 1,193.25 0.00 0.00<br />

29827 S 1,290.22 0.00 0.00 29900 S 809.30 0.00 0.00<br />

29828 S 1,908.67 0.00 0.00 29901 S 809.30 0.00 0.00<br />

29830 S 809.30 0.00 0.00 29902 S 809.30 0.00 0.00<br />

29834 S 809.30 0.00 0.00 29904 S 1,140.77 0.00 0.00<br />

29835 S 809.30 0.00 0.00 29905 S 1,140.77 0.00 0.00<br />

29836 S 809.30 0.00 0.00 29906 S 1,140.77 0.00 0.00<br />

29837 S 809.30 0.00 0.00 29907 S 1,908.67 0.00 0.00<br />

29838 S 809.30 0.00 0.00 30000 S 128.25 0.00 0.00<br />

29840 S 809.30 0.00 0.00 30020 S 128.25 0.00 0.00<br />

29843 S 809.30 0.00 0.00 30100 S 83.17 0.00 0.00<br />

29844 S 809.30 0.00 0.00 30110 S 128.57 0.00 0.00<br />

29845 S 809.30 0.00 0.00 30115 S 543.24 0.00 0.00<br />

29846 S 809.30 0.00 0.00 30117 S 573.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 718.96 0.00 0.00 31080 S 1,107.11 0.00 0.00<br />

30120 S 490.30 0.00 0.00 31081 S 1,107.11 0.00 0.00<br />

30124 S 292.15 0.00 0.00 31084 S 1,107.11 0.00 0.00<br />

30125 S 1,020.91 0.00 0.00 31085 S 1,107.11 0.00 0.00<br />

30130 S 573.22 0.00 0.00 31086 S 1,107.11 0.00 0.00<br />

30140 S 688.97 0.00 0.00 31087 S 1,107.11 0.00 0.00<br />

30150 S 1,050.90 0.00 0.00 31090 S 1,147.87 0.00 0.00<br />

30160 S 1,107.11 0.00 0.00 31200 S 1,020.91 0.00 0.00<br />

30200 S 65.50 0.00 0.00 31201 S 1,147.87 0.00 0.00<br />

30210 S 83.17 0.00 0.00 31205 S 1,050.90 0.00 0.00<br />

30220 S 363.51 0.00 0.00 31231 S 70.11 0.00 0.00<br />

30300 S 25.06 0.00 0.00 31233 S 75.52 0.00 0.00<br />

30310 S 490.30 0.00 0.00 31235 S 513.10 0.00 0.00<br />

30320 S 543.24 0.00 0.00 31237 S 566.04 0.00 0.00<br />

30400 S 1,107.11 0.00 0.00 31238 S 513.10 0.00 0.00<br />

30410 S 1,147.87 0.00 0.00 31239 S 748.97 0.00 0.00<br />

30420 S 1,147.87 0.00 0.00 31240 S 566.04 0.00 0.00<br />

30430 S 718.96 0.00 0.00 31254 S 692.75 0.00 0.00<br />

30435 S 1,147.87 0.00 0.00 31255 S 789.72 0.00 0.00<br />

30450 S 1,278.10 0.00 0.00 31256 S 692.75 0.00 0.00<br />

30460 S 1,278.10 0.00 0.00 31267 S 692.75 0.00 0.00<br />

30462 S 1,439.25 0.00 0.00 31276 S 692.75 0.00 0.00<br />

30465 S 1,439.25 0.00 0.00 31287 S 692.75 0.00 0.00<br />

30520 S 775.17 0.00 0.00 31288 S 692.75 0.00 0.00<br />

30540 S 1,147.87 0.00 0.00 31300 S 815.92 0.00 0.00<br />

30545 S 1,147.87 0.00 0.00 31320 S 1,020.91 0.00 0.00<br />

30560 S 134.73 0.00 0.00 31400 S 1,020.91 0.00 0.00<br />

30580 S 1,107.11 0.00 0.00 31420 S 1,020.91 0.00 0.00<br />

30600 S 1,107.11 0.00 0.00 31500 S 93.78 0.00 0.00<br />

30620 S 1,278.10 0.00 0.00 31502 S 53.92 0.00 0.00<br />

30630 S 946.16 0.00 0.00 31505 S 31.86 0.00 0.00<br />

30801 S 302.07 0.00 0.00 31510 S 566.04 0.00 0.00<br />

30802 S 302.07 0.00 0.00 31511 S 75.52 0.00 0.00<br />

30901 S 43.08 0.00 0.00 31512 S 566.04 0.00 0.00<br />

30903 S 55.50 0.00 0.00 31513 S 75.52 0.00 0.00<br />

30905 S 55.50 0.00 0.00 31515 S 513.10 0.00 0.00<br />

30906 S 55.50 0.00 0.00 31520 S 70.11 0.00 0.00<br />

30915 S 739.50 0.00 0.00 31525 S 513.10 0.00 0.00<br />

30920 S 769.49 0.00 0.00 31526 S 662.78 0.00 0.00<br />

30930 S 629.43 0.00 0.00 31527 S 609.83 0.00 0.00<br />

31000 S 107.09 0.00 0.00 31528 S 566.04 0.00 0.00<br />

31002 S 292.15 0.00 0.00 31529 S 566.04 0.00 0.00<br />

31020 S 688.97 0.00 0.00 31530 S 662.78 0.00 0.00<br />

31030 S 1,050.90 0.00 0.00 31531 S 692.75 0.00 0.00<br />

31032 S 1,107.11 0.00 0.00 31535 S 662.78 0.00 0.00<br />

31040 S 960.08 0.00 0.00 31536 S 692.75 0.00 0.00<br />

31050 S 1,020.91 0.00 0.00 31540 S 692.75 0.00 0.00<br />

31051 S 1,107.11 0.00 0.00 31541 S 748.97 0.00 0.00<br />

31070 S 688.97 0.00 0.00 31545 S 748.97 0.00 0.00<br />

31075 S 1,107.11 0.00 0.00 31546 S 748.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 789.72 0.00 0.00 32405 S 341.74 0.00 0.00<br />

31561 S 789.72 0.00 0.00 32420 S 207.80 0.00 0.00<br />

31570 S 566.04 0.00 0.00 32421 S 207.80 0.00 0.00<br />

31571 S 662.78 0.00 0.00 32422 S 206.88 0.00 0.00<br />

31575 S 60.30 0.00 0.00 32550 S 1,158.30 0.00 0.00<br />

31576 S 662.78 0.00 0.00 32960 S 206.88 0.00 0.00<br />

31577 S 195.78 0.00 0.00 32998 S 1,803.42 0.00 0.00<br />

31578 S 662.78 0.00 0.00 33010 S 207.80 0.00 0.00<br />

31579 S 107.43 0.00 0.00 33011 S 207.80 0.00 0.00<br />

31580 S 1,147.87 0.00 0.00 33206 S 6,667.11 3,966.91 1,266.72<br />

31582 S 1,147.87 0.00 0.00 33207 S 6,667.11 3,966.91 1,266.72<br />

31588 S 1,147.87 0.00 0.00 33208 S 8,269.10 4,818.36 1,367.64<br />

31590 S 1,147.87 0.00 0.00 33210 S 1,957.82 0.00 0.00<br />

31595 S 1,020.91 0.00 0.00 33211 S 1,957.82 0.00 0.00<br />

31603 S 302.07 0.00 0.00 33212 S 5,236.06 2,982.76 729.46<br />

31605 S 292.15 0.00 0.00 33213 S 6,043.54 3,386.06 728.59<br />

31611 S 718.96 0.00 0.00 33214 S 8,269.10 4,818.36 1,367.64<br />

31612 S 636.03 0.00 0.00 33215 S 858.14 0.00 0.00<br />

31613 S 688.97 0.00 0.00 33216 S 1,957.82 0.00 0.00<br />

31614 S 1,020.91 0.00 0.00 33217 S 1,957.82 0.00 0.00<br />

31615 S 302.07 0.00 0.00 33218 S 858.14 0.00 0.00<br />

31622 S 353.78 0.00 0.00 33220 S 858.14 0.00 0.00<br />

31623 S 406.71 0.00 0.00 33222 S 518.71 0.00 0.00<br />

31624 S 406.71 0.00 0.00 33223 S 518.71 0.00 0.00<br />

31625 S 406.71 0.00 0.00 33224 S 7,805.26 4,672.99 1,540.72<br />

31628 S 406.71 0.00 0.00 33225 S 7,805.26 4,672.99 1,540.72<br />

31629 S 406.71 0.00 0.00 33226 S 858.14 0.00 0.00<br />

31630 S 696.93 0.00 0.00 33233 S 638.00 0.00 0.00<br />

31631 S 696.93 0.00 0.00 33234 S 858.14 0.00 0.00<br />

31632 S 395.55 0.00 0.00 33235 S 858.14 0.00 0.00<br />

31633 S 395.55 0.00 0.00 33240 S 19,456.53 10,400.31 1,344.09<br />

31635 S 406.71 0.00 0.00 33241 S 858.14 0.00 0.00<br />

31636 S 696.93 0.00 0.00 33249 S 25,966.22 13,908.58 1,850.94<br />

31637 S 353.78 0.00 0.00 33282 S 4,105.42 2,457.75 810.07<br />

31638 S 696.93 0.00 0.00 33284 S 320.21 0.00 0.00<br />

31640 S 696.93 0.00 0.00 34490 S 1,563.37 0.00 0.00<br />

31641 S 696.93 0.00 0.00 35188 S 1,076.81 0.00 0.00<br />

31643 S 406.71 0.00 0.00 35207 S 1,076.81 0.00 0.00<br />

31645 S 353.78 0.00 0.00 35473 S 1,875.44 0.00 0.00<br />

31646 S 353.78 0.00 0.00 35476 S 1,875.44 0.00 0.00<br />

31656 S 353.78 0.00 0.00 35492 S 3,500.33 0.00 0.00<br />

31717 S 195.78 0.00 0.00 35761 S 1,126.01 0.00 0.00<br />

31720 S 29.98 0.00 0.00 35875 S 1,408.95 0.00 0.00<br />

31730 S 195.78 0.00 0.00 35876 S 1,408.95 0.00 0.00<br />

31750 S 1,147.87 0.00 0.00 36002 S 89.93 0.00 0.00<br />

31755 S 1,020.91 0.00 0.00 36260 S 815.75 0.00 0.00<br />

31820 S 490.30 0.00 0.00 36261 S 638.00 0.00 0.00<br />

31825 S 688.97 0.00 0.00 36262 S 585.06 0.00 0.00<br />

31830 S 688.97 0.00 0.00 36420 S 8.47 0.00 0.00<br />

32400 S 341.74 0.00 0.00 36425 S 8.47 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.57 0.00 0.00 36800 S 878.16 0.00 0.00<br />

36440 S 130.09 0.00 0.00 36810 S 878.16 0.00 0.00<br />

36450 S 130.09 0.00 0.00 36815 S 878.16 0.00 0.00<br />

36455 S 130.09 0.00 0.00 36818 S 1,020.61 0.00 0.00<br />

36468 S 32.11 0.00 0.00 36819 S 1,020.61 0.00 0.00<br />

36469 S 32.11 0.00 0.00 36820 S 1,020.61 0.00 0.00<br />

36470 S 32.11 0.00 0.00 36821 S 1,020.61 0.00 0.00<br />

36471 S 32.11 0.00 0.00 36825 S 1,076.81 0.00 0.00<br />

36475 S 1,476.44 0.00 0.00 36830 S 1,076.81 0.00 0.00<br />

36476 S 1,157.83 0.00 0.00 36831 S 1,408.95 0.00 0.00<br />

36478 S 1,157.83 0.00 0.00 36832 S 1,076.81 0.00 0.00<br />

36479 S 1,157.83 0.00 0.00 36833 S 1,076.81 0.00 0.00<br />

36511 S 446.01 0.00 0.00 36834 S 1,020.61 0.00 0.00<br />

36512 S 446.01 0.00 0.00 36835 S 934.38 0.00 0.00<br />

36513 S 446.01 0.00 0.00 36860 S 107.24 0.00 0.00<br />

36514 S 446.01 0.00 0.00 36861 S 878.16 0.00 0.00<br />

36515 S 1,193.96 0.00 0.00 36870 S 1,535.76 0.00 0.00<br />

36516 S 1,193.96 0.00 0.00 37184 S 1,563.37 0.00 0.00<br />

36522 S 1,193.96 0.00 0.00 37185 S 1,563.37 0.00 0.00<br />

36555 S 370.57 0.00 0.00 37186 S 1,563.37 0.00 0.00<br />

36556 S 370.57 0.00 0.00 37187 S 1,563.37 0.00 0.00<br />

36557 S 692.07 0.00 0.00 37188 S 1,563.37 0.00 0.00<br />

36558 S 692.07 0.00 0.00 37200 S 1,153.67 0.00 0.00<br />

36560 S 815.75 0.00 0.00 37203 S 1,153.67 0.00 0.00<br />

36561 S 815.75 0.00 0.00 37500 S 1,088.10 0.00 0.00<br />

36563 S 815.75 0.00 0.00 37607 S 769.49 0.00 0.00<br />

36565 S 815.75 0.00 0.00 37609 S 517.20 0.00 0.00<br />

36566 S 815.75 0.00 0.00 37650 S 739.50 0.00 0.00<br />

36568 S 370.57 0.00 0.00 37700 S 739.50 0.00 0.00<br />

36569 S 370.57 0.00 0.00 37718 S 769.49 0.00 0.00<br />

36570 S 722.05 0.00 0.00 37722 S 1,088.10 0.00 0.00<br />

36571 S 722.05 0.00 0.00 37735 S 1,088.10 0.00 0.00<br />

36575 S 298.05 0.00 0.00 37760 S 769.49 0.00 0.00<br />

36576 S 423.50 0.00 0.00 37765 S 1,061.13 0.00 0.00<br />

36578 S 692.07 0.00 0.00 37766 S 1,061.13 0.00 0.00<br />

36580 S 370.57 0.00 0.00 37780 S 769.49 0.00 0.00<br />

36581 S 692.07 0.00 0.00 37785 S 769.49 0.00 0.00<br />

36582 S 815.75 0.00 0.00 37790 S 928.54 0.00 0.00<br />

36583 S 815.75 0.00 0.00 38205 S 446.01 0.00 0.00<br />

36584 S 370.57 0.00 0.00 38206 S 446.01 0.00 0.00<br />

36585 S 722.05 0.00 0.00 38220 S 102.23 0.00 0.00<br />

36589 S 245.11 0.00 0.00 38221 S 107.09 0.00 0.00<br />

36590 S 370.57 0.00 0.00 38230 S 1,193.96 0.00 0.00<br />

36593 S 24.61 0.00 0.00 38241 S 1,193.96 0.00 0.00<br />

36595 S 966.27 0.00 0.00 38242 S 446.01 0.00 0.00<br />

36596 S 429.13 0.00 0.00 38300 S 400.23 0.00 0.00<br />

36597 S 429.13 0.00 0.00 38305 S 584.88 0.00 0.00<br />

36598 S 79.36 0.00 0.00 38308 S 668.30 0.00 0.00<br />

36640 S 732.83 0.00 0.00 38500 S 668.30 0.00 0.00<br />

36680 S 55.55 0.00 0.00 38505 S 255.69 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 668.30 0.00 0.00 41005 S 134.73 0.00 0.00<br />

38520 S 668.30 0.00 0.00 41006 S 636.03 0.00 0.00<br />

38525 S 668.30 0.00 0.00 41007 S 490.30 0.00 0.00<br />

38530 S 668.30 0.00 0.00 41008 S 490.30 0.00 0.00<br />

38542 S 1,124.32 0.00 0.00 41009 S 134.73 0.00 0.00<br />

38550 S 698.29 0.00 0.00 41010 S 302.07 0.00 0.00<br />

38555 S 754.50 0.00 0.00 41015 S 134.73 0.00 0.00<br />

38570 S 1,525.53 0.00 0.00 41016 S 302.07 0.00 0.00<br />

38571 S 1,983.16 0.00 0.00 41017 S 302.07 0.00 0.00<br />

38572 S 1,525.53 0.00 0.00 41018 S 302.07 0.00 0.00<br />

38700 S 918.74 0.00 0.00 41019 S 960.08 0.00 0.00<br />

38740 S 1,124.32 0.00 0.00 41100 S 90.44 0.00 0.00<br />

38745 S 1,210.52 0.00 0.00 41105 S 89.41 0.00 0.00<br />

38760 S 668.30 0.00 0.00 41108 S 82.83 0.00 0.00<br />

40490 S 68.27 0.00 0.00 41110 S 119.90 0.00 0.00<br />

40500 S 543.24 0.00 0.00 41112 S 543.24 0.00 0.00<br />

40510 S 688.97 0.00 0.00 41113 S 543.24 0.00 0.00<br />

40520 S 543.24 0.00 0.00 41114 S 688.97 0.00 0.00<br />

40525 S 688.97 0.00 0.00 41115 S 139.66 0.00 0.00<br />

40527 S 688.97 0.00 0.00 41116 S 490.30 0.00 0.00<br />

40530 S 688.97 0.00 0.00 41120 S 815.92 0.00 0.00<br />

40650 S 363.51 0.00 0.00 41250 S 92.15 0.00 0.00<br />

40652 S 363.51 0.00 0.00 41251 S 134.73 0.00 0.00<br />

40654 S 363.51 0.00 0.00 41252 S 355.01 0.00 0.00<br />

40700 S 1,278.10 0.00 0.00 41500 S 636.03 0.00 0.00<br />

40701 S 1,278.10 0.00 0.00 41510 S 490.30 0.00 0.00<br />

40702 S 1,623.96 0.00 0.00 41520 S 355.01 0.00 0.00<br />

40720 S 1,278.10 0.00 0.00 41530 S 668.61 0.00 0.00<br />

40761 S 1,050.90 0.00 0.00 41800 S 68.84 0.00 0.00<br />

40800 S 54.79 0.00 0.00 41805 S 149.02 0.00 0.00<br />

40801 S 355.01 0.00 0.00 41806 S 183.67 0.00 0.00<br />

40804 S 25.06 0.00 0.00 41820 S 292.15 0.00 0.00<br />

40805 S 169.47 0.00 0.00 41821 S 292.15 0.00 0.00<br />

40806 S 77.97 0.00 0.00 41822 S 152.13 0.00 0.00<br />

40808 S 115.74 0.00 0.00 41823 S 221.79 0.00 0.00<br />

40810 S 119.90 0.00 0.00 41825 S 121.98 0.00 0.00<br />

40812 S 150.40 0.00 0.00 41826 S 153.52 0.00 0.00<br />

40814 S 543.24 0.00 0.00 41827 S 688.97 0.00 0.00<br />

40816 S 688.97 0.00 0.00 41828 S 138.62 0.00 0.00<br />

40818 S 134.73 0.00 0.00 41830 S 196.84 0.00 0.00<br />

40819 S 302.07 0.00 0.00 41850 S 668.61 0.00 0.00<br />

40820 S 172.92 0.00 0.00 41870 S 960.08 0.00 0.00<br />

40830 S 128.25 0.00 0.00 41872 S 196.84 0.00 0.00<br />

40831 S 302.07 0.00 0.00 41874 S 189.90 0.00 0.00<br />

40840 S 688.97 0.00 0.00 42000 S 134.73 0.00 0.00<br />

40842 S 718.96 0.00 0.00 42100 S 76.94 0.00 0.00<br />

40843 S 718.96 0.00 0.00 42104 S 114.36 0.00 0.00<br />

40844 S 1,147.87 0.00 0.00 42106 S 143.47 0.00 0.00<br />

40845 S 1,147.87 0.00 0.00 42107 S 688.97 0.00 0.00<br />

41000 S 85.95 0.00 0.00 42120 S 1,107.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 355.01 0.00 0.00 42809 S 25.06 0.00 0.00<br />

42145 S 815.92 0.00 0.00 42810 S 718.96 0.00 0.00<br />

42160 S 135.84 0.00 0.00 42815 S 1,147.87 0.00 0.00<br />

42180 S 134.73 0.00 0.00 42820 S 718.96 0.00 0.00<br />

42182 S 1,020.91 0.00 0.00 42821 S 815.92 0.00 0.00<br />

42200 S 1,147.87 0.00 0.00 42825 S 775.17 0.00 0.00<br />

42205 S 1,147.87 0.00 0.00 42826 S 775.17 0.00 0.00<br />

42210 S 1,147.87 0.00 0.00 42830 S 775.17 0.00 0.00<br />

42215 S 1,278.10 0.00 0.00 42831 S 775.17 0.00 0.00<br />

42220 S 1,147.87 0.00 0.00 42835 S 775.17 0.00 0.00<br />

42226 S 1,147.87 0.00 0.00 42836 S 775.17 0.00 0.00<br />

42235 S 670.19 0.00 0.00 42860 S 718.96 0.00 0.00<br />

42260 S 775.17 0.00 0.00 42870 S 718.96 0.00 0.00<br />

42280 S 74.85 0.00 0.00 42890 S 1,278.10 0.00 0.00<br />

42281 S 668.61 0.00 0.00 42892 S 1,278.10 0.00 0.00<br />

42300 S 490.30 0.00 0.00 42900 S 302.07 0.00 0.00<br />

42305 S 543.24 0.00 0.00 42950 S 688.97 0.00 0.00<br />

42310 S 134.73 0.00 0.00 42955 S 688.97 0.00 0.00<br />

42320 S 134.73 0.00 0.00 42960 S 55.50 0.00 0.00<br />

42330 S 115.74 0.00 0.00 42962 S 1,020.91 0.00 0.00<br />

42335 S 191.99 0.00 0.00 42970 S 43.08 0.00 0.00<br />

42340 S 543.24 0.00 0.00 42972 S 573.22 0.00 0.00<br />

42400 S 65.16 0.00 0.00 43030 S 668.61 0.00 0.00<br />

42405 S 543.24 0.00 0.00 43200 S 323.78 0.00 0.00<br />

42408 S 573.22 0.00 0.00 43201 S 323.78 0.00 0.00<br />

42409 S 573.22 0.00 0.00 43202 S 323.78 0.00 0.00<br />

42410 S 1,050.90 0.00 0.00 43204 S 323.78 0.00 0.00<br />

42415 S 1,278.10 0.00 0.00 43205 S 323.78 0.00 0.00<br />

42420 S 1,278.10 0.00 0.00 43215 S 323.78 0.00 0.00<br />

42425 S 1,278.10 0.00 0.00 43216 S 323.78 0.00 0.00<br />

42440 S 1,050.90 0.00 0.00 43217 S 323.78 0.00 0.00<br />

42450 S 688.97 0.00 0.00 43219 S 654.36 0.00 0.00<br />

42500 S 718.96 0.00 0.00 43220 S 323.78 0.00 0.00<br />

42505 S 1,107.11 0.00 0.00 43226 S 323.78 0.00 0.00<br />

42507 S 1,050.90 0.00 0.00 43227 S 376.72 0.00 0.00<br />

42508 S 1,107.11 0.00 0.00 43228 S 701.05 0.00 0.00<br />

42509 S 1,107.11 0.00 0.00 43231 S 376.72 0.00 0.00<br />

42510 S 1,107.11 0.00 0.00 43232 S 376.72 0.00 0.00<br />

42600 S 490.30 0.00 0.00 43234 S 323.78 0.00 0.00<br />

42650 S 42.62 0.00 0.00 43235 S 323.78 0.00 0.00<br />

42660 S 49.91 0.00 0.00 43236 S 376.72 0.00 0.00<br />

42665 S 946.16 0.00 0.00 43237 S 376.72 0.00 0.00<br />

42700 S 134.73 0.00 0.00 43238 S 376.72 0.00 0.00<br />

42720 S 490.30 0.00 0.00 43239 S 376.72 0.00 0.00<br />

42725 S 1,020.91 0.00 0.00 43240 S 376.72 0.00 0.00<br />

42800 S 82.48 0.00 0.00 43241 S 376.72 0.00 0.00<br />

42802 S 490.30 0.00 0.00 43242 S 376.72 0.00 0.00<br />

42804 S 490.30 0.00 0.00 43243 S 376.72 0.00 0.00<br />

42806 S 688.97 0.00 0.00 43244 S 376.72 0.00 0.00<br />

42808 S 543.24 0.00 0.00 43245 S 376.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 376.72 0.00 0.00 44378 S 394.55 0.00 0.00<br />

43247 S 376.72 0.00 0.00 44379 S 1,125.64 0.00 0.00<br />

43248 S 376.72 0.00 0.00 44380 S 341.61 0.00 0.00<br />

43249 S 376.72 0.00 0.00 44382 S 341.61 0.00 0.00<br />

43250 S 376.72 0.00 0.00 44383 S 1,125.64 0.00 0.00<br />

43251 S 376.72 0.00 0.00 44385 S 330.29 0.00 0.00<br />

43255 S 376.72 0.00 0.00 44386 S 330.29 0.00 0.00<br />

43256 S 737.28 0.00 0.00 44388 S 330.29 0.00 0.00<br />

43257 S 731.03 0.00 0.00 44389 S 330.29 0.00 0.00<br />

43258 S 406.70 0.00 0.00 44390 S 330.29 0.00 0.00<br />

43259 S 406.70 0.00 0.00 44391 S 330.29 0.00 0.00<br />

43260 S 634.21 0.00 0.00 44392 S 330.29 0.00 0.00<br />

43261 S 634.21 0.00 0.00 44393 S 330.29 0.00 0.00<br />

43262 S 634.21 0.00 0.00 44394 S 330.29 0.00 0.00<br />

43263 S 634.21 0.00 0.00 44397 S 654.36 0.00 0.00<br />

43264 S 634.21 0.00 0.00 44500 S 178.24 0.00 0.00<br />

43265 S 634.21 0.00 0.00 45000 S 383.03 0.00 0.00<br />

43267 S 634.21 0.00 0.00 45005 S 445.78 0.00 0.00<br />

43268 S 707.30 0.00 0.00 45020 S 445.78 0.00 0.00<br />

43269 S 707.30 0.00 0.00 45100 S 605.63 0.00 0.00<br />

43271 S 634.21 0.00 0.00 45108 S 658.57 0.00 0.00<br />

43272 S 634.21 0.00 0.00 45150 S 658.57 0.00 0.00<br />

43273 S 850.55 0.00 0.00 45160 S 658.57 0.00 0.00<br />

43450 S 283.16 0.00 0.00 45170 S 658.57 0.00 0.00<br />

43453 S 283.16 0.00 0.00 45190 S 1,076.90 0.00 0.00<br />

43456 S 284.29 0.00 0.00 45300 S 63.76 0.00 0.00<br />

43458 S 324.91 0.00 0.00 45303 S 354.18 0.00 0.00<br />

43600 S 323.78 0.00 0.00 45305 S 333.09 0.00 0.00<br />

43653 S 1,525.53 0.00 0.00 45307 S 615.23 0.00 0.00<br />

43760 S 157.03 0.00 0.00 45308 S 333.09 0.00 0.00<br />

43761 S 323.78 0.00 0.00 45309 S 333.09 0.00 0.00<br />

43870 S 323.78 0.00 0.00 45315 S 333.09 0.00 0.00<br />

43886 S 816.97 0.00 0.00 45317 S 333.09 0.00 0.00<br />

43887 S 171.83 0.00 0.00 45320 S 615.23 0.00 0.00<br />

43888 S 816.97 0.00 0.00 45321 S 615.23 0.00 0.00<br />

44100 S 323.78 0.00 0.00 45327 S 654.36 0.00 0.00<br />

44312 S 564.48 0.00 0.00 45330 S 84.21 0.00 0.00<br />

44340 S 647.40 0.00 0.00 45331 S 249.02 0.00 0.00<br />

44360 S 394.55 0.00 0.00 45332 S 249.02 0.00 0.00<br />

44361 S 394.55 0.00 0.00 45333 S 333.09 0.00 0.00<br />

44363 S 394.55 0.00 0.00 45334 S 333.09 0.00 0.00<br />

44364 S 394.55 0.00 0.00 45335 S 249.02 0.00 0.00<br />

44365 S 394.55 0.00 0.00 45337 S 249.02 0.00 0.00<br />

44366 S 394.55 0.00 0.00 45338 S 333.09 0.00 0.00<br />

44369 S 394.55 0.00 0.00 45339 S 333.09 0.00 0.00<br />

44370 S 1,125.64 0.00 0.00 45340 S 333.09 0.00 0.00<br />

44372 S 394.55 0.00 0.00 45341 S 333.09 0.00 0.00<br />

44373 S 394.55 0.00 0.00 45342 S 333.09 0.00 0.00<br />

44376 S 394.55 0.00 0.00 45345 S 654.36 0.00 0.00<br />

44377 S 394.55 0.00 0.00 45355 S 330.29 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 383.24 0.00 0.00 46505 S 473.68 0.00 0.00<br />

45379 S 383.24 0.00 0.00 46600 S 25.06 0.00 0.00<br />

45380 S 383.24 0.00 0.00 46604 S 354.18 0.00 0.00<br />

45381 S 383.24 0.00 0.00 46606 S 133.08 0.00 0.00<br />

45382 S 383.24 0.00 0.00 46608 S 333.09 0.00 0.00<br />

45383 S 383.24 0.00 0.00 46610 S 615.23 0.00 0.00<br />

45384 S 383.24 0.00 0.00 46611 S 333.09 0.00 0.00<br />

45385 S 383.24 0.00 0.00 46612 S 615.23 0.00 0.00<br />

45386 S 383.24 0.00 0.00 46614 S 70.00 0.00 0.00<br />

45387 S 654.36 0.00 0.00 46615 S 668.17 0.00 0.00<br />

45391 S 383.24 0.00 0.00 46700 S 688.55 0.00 0.00<br />

45392 S 383.24 0.00 0.00 46706 S 757.89 0.00 0.00<br />

45500 S 658.57 0.00 0.00 46750 S 840.81 0.00 0.00<br />

45505 S 810.83 0.00 0.00 46753 S 688.55 0.00 0.00<br />

45520 S 32.11 0.00 0.00 46754 S 658.57 0.00 0.00<br />

45560 S 810.83 0.00 0.00 46760 S 810.83 0.00 0.00<br />

45900 S 259.67 0.00 0.00 46761 S 840.81 0.00 0.00<br />

45905 S 605.63 0.00 0.00 46762 S 1,068.01 0.00 0.00<br />

45910 S 605.63 0.00 0.00 46900 S 105.83 0.00 0.00<br />

45915 S 383.03 0.00 0.00 46910 S 126.49 0.00 0.00<br />

45990 S 595.82 0.00 0.00 46916 S 58.83 0.00 0.00<br />

46020 S 688.55 0.00 0.00 46917 S 548.82 0.00 0.00<br />

46030 S 259.67 0.00 0.00 46922 S 548.82 0.00 0.00<br />

46040 S 688.55 0.00 0.00 46924 S 548.82 0.00 0.00<br />

46045 S 658.57 0.00 0.00 46930 S 122.68 0.00 0.00<br />

46050 S 383.03 0.00 0.00 46937 S 658.57 0.00 0.00<br />

46060 S 658.57 0.00 0.00 46938 S 810.83 0.00 0.00<br />

46070 S 473.68 0.00 0.00 46940 S 90.79 0.00 0.00<br />

46080 S 688.55 0.00 0.00 46942 S 88.37 0.00 0.00<br />

46083 S 72.51 0.00 0.00 46945 S 150.40 0.00 0.00<br />

46200 S 658.57 0.00 0.00 46946 S 392.83 0.00 0.00<br />

46210 S 658.57 0.00 0.00 46947 S 1,068.01 0.00 0.00<br />

46211 S 658.57 0.00 0.00 47000 S 341.74 0.00 0.00<br />

46220 S 605.63 0.00 0.00 47382 S 1,803.42 0.00 0.00<br />

46221 S 119.21 0.00 0.00 47510 S 798.66 0.00 0.00<br />

46230 S 605.63 0.00 0.00 47511 S 1,173.35 0.00 0.00<br />

46250 S 688.55 0.00 0.00 47525 S 458.49 0.00 0.00<br />

46255 S 688.55 0.00 0.00 47530 S 458.49 0.00 0.00<br />

46257 S 688.55 0.00 0.00 47552 S 798.66 0.00 0.00<br />

46258 S 688.55 0.00 0.00 47553 S 828.64 0.00 0.00<br />

46260 S 688.55 0.00 0.00 47554 S 828.64 0.00 0.00<br />

46261 S 744.76 0.00 0.00 47555 S 828.64 0.00 0.00<br />

46262 S 744.76 0.00 0.00 47556 S 1,173.35 0.00 0.00<br />

46270 S 688.55 0.00 0.00 47560 S 973.62 0.00 0.00<br />

46275 S 688.55 0.00 0.00 47561 S 973.62 0.00 0.00<br />

46280 S 744.76 0.00 0.00 47562 S 1,796.53 0.00 0.00<br />

46285 S 605.63 0.00 0.00 47563 S 1,796.53 0.00 0.00<br />

46288 S 744.76 0.00 0.00 47564 S 1,796.53 0.00 0.00<br />

46320 S 80.75 0.00 0.00 47630 S 828.64 0.00 0.00<br />

46500 S 111.24 0.00 0.00 48102 S 341.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 207.80 0.00 0.00 49590 S 852.90 0.00 0.00<br />

49081 S 207.80 0.00 0.00 49600 S 909.11 0.00 0.00<br />

49180 S 341.74 0.00 0.00 49650 S 1,193.39 0.00 0.00<br />

49250 S 749.10 0.00 0.00 49651 S 1,364.39 0.00 0.00<br />

49320 S 973.62 0.00 0.00 49652 S 1,469.41 0.00 0.00<br />

49321 S 1,029.84 0.00 0.00 49653 S 1,469.41 0.00 0.00<br />

49322 S 1,029.84 0.00 0.00 49654 S 1,469.41 0.00 0.00<br />

49324 S 1,469.41 0.00 0.00 49655 S 1,469.41 0.00 0.00<br />

49325 S 1,469.41 0.00 0.00 49656 S 1,469.41 0.00 0.00<br />

49326 S 1,469.41 0.00 0.00 49657 S 1,469.41 0.00 0.00<br />

49402 S 662.90 0.00 0.00 50200 S 341.74 0.00 0.00<br />

49419 S 795.24 0.00 0.00 50382 S 992.33 0.00 0.00<br />

49420 S 735.15 0.00 0.00 50384 S 728.84 0.00 0.00<br />

49421 S 735.15 0.00 0.00 50385 S 728.84 0.00 0.00<br />

49422 S 585.06 0.00 0.00 50386 S 279.64 0.00 0.00<br />

49423 S 604.98 0.00 0.00 50387 S 604.98 0.00 0.00<br />

49426 S 662.90 0.00 0.00 50389 S 279.64 0.00 0.00<br />

49429 S 858.14 0.00 0.00 50390 S 341.74 0.00 0.00<br />

49440 S 335.57 0.00 0.00 50391 S 40.47 0.00 0.00<br />

49441 S 335.57 0.00 0.00 50392 S 520.42 0.00 0.00<br />

49446 S 335.57 0.00 0.00 50393 S 652.16 0.00 0.00<br />

49450 S 178.24 0.00 0.00 50395 S 520.42 0.00 0.00<br />

49451 S 178.24 0.00 0.00 50396 S 97.85 0.00 0.00<br />

49452 S 178.24 0.00 0.00 50398 S 458.49 0.00 0.00<br />

49460 S 178.24 0.00 0.00 50551 S 295.82 0.00 0.00<br />

49495 S 909.11 0.00 0.00 50553 S 652.16 0.00 0.00<br />

49496 S 909.11 0.00 0.00 50555 S 295.82 0.00 0.00<br />

49500 S 909.11 0.00 0.00 50557 S 652.16 0.00 0.00<br />

49501 S 1,241.25 0.00 0.00 50561 S 652.16 0.00 0.00<br />

49505 S 909.11 0.00 0.00 50562 S 279.64 0.00 0.00<br />

49507 S 1,241.25 0.00 0.00 50570 S 279.64 0.00 0.00<br />

49520 S 1,080.10 0.00 0.00 50572 S 279.64 0.00 0.00<br />

49521 S 1,241.25 0.00 0.00 50574 S 279.64 0.00 0.00<br />

49525 S 909.11 0.00 0.00 50575 S 1,390.96 0.00 0.00<br />

49540 S 822.91 0.00 0.00 50576 S 728.84 0.00 0.00<br />

49550 S 949.87 0.00 0.00 50580 S 728.84 0.00 0.00<br />

49553 S 1,241.25 0.00 0.00 50590 S 1,624.97 0.00 0.00<br />

49555 S 949.87 0.00 0.00 50592 S 1,803.42 0.00 0.00<br />

49557 S 1,241.25 0.00 0.00 50686 S 40.47 0.00 0.00<br />

49560 S 909.11 0.00 0.00 50688 S 458.49 0.00 0.00<br />

49561 S 1,241.25 0.00 0.00 50947 S 1,525.53 0.00 0.00<br />

49565 S 909.11 0.00 0.00 50948 S 1,525.53 0.00 0.00<br />

49566 S 1,241.25 0.00 0.00 50951 S 295.82 0.00 0.00<br />

49568 S 1,080.10 0.00 0.00 50953 S 295.82 0.00 0.00<br />

49570 S 909.11 0.00 0.00 50955 S 652.16 0.00 0.00<br />

49572 S 1,241.25 0.00 0.00 50957 S 652.16 0.00 0.00<br />

49580 S 909.11 0.00 0.00 50961 S 652.16 0.00 0.00<br />

49582 S 1,241.25 0.00 0.00 50970 S 295.82 0.00 0.00<br />

49585 S 909.11 0.00 0.00 50972 S 295.82 0.00 0.00<br />

49587 S 1,241.25 0.00 0.00 50974 S 520.42 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 520.42 0.00 0.00 52275 S 705.10 0.00 0.00<br />

50980 S 652.16 0.00 0.00 52276 S 735.08 0.00 0.00<br />

51020 S 791.30 0.00 0.00 52277 S 705.10 0.00 0.00<br />

51030 S 791.30 0.00 0.00 52281 S 573.35 0.00 0.00<br />

51040 S 791.30 0.00 0.00 52282 S 1,322.75 0.00 0.00<br />

51045 S 326.84 0.00 0.00 52283 S 705.10 0.00 0.00<br />

51050 S 791.30 0.00 0.00 52285 S 573.35 0.00 0.00<br />

51065 S 791.30 0.00 0.00 52290 S 573.35 0.00 0.00<br />

51080 S 531.94 0.00 0.00 52300 S 705.10 0.00 0.00<br />

51100 S 30.84 0.00 0.00 52301 S 735.08 0.00 0.00<br />

51101 S 40.47 0.00 0.00 52305 S 705.10 0.00 0.00<br />

51102 S 544.48 0.00 0.00 52310 S 551.44 0.00 0.00<br />

51500 S 909.11 0.00 0.00 52315 S 705.10 0.00 0.00<br />

51520 S 791.30 0.00 0.00 52317 S 652.16 0.00 0.00<br />

51700 S 52.67 0.00 0.00 52318 S 705.10 0.00 0.00<br />

51701 S 25.06 0.00 0.00 52320 S 832.05 0.00 0.00<br />

51702 S 25.06 0.00 0.00 52325 S 791.30 0.00 0.00<br />

51703 S 40.47 0.00 0.00 52327 S 904.42 0.00 0.00<br />

51705 S 72.51 0.00 0.00 52330 S 705.10 0.00 0.00<br />

51710 S 458.49 0.00 0.00 52332 S 705.10 0.00 0.00<br />

51715 S 832.48 0.00 0.00 52334 S 735.08 0.00 0.00<br />

51720 S 58.22 0.00 0.00 52341 S 735.08 0.00 0.00<br />

51725 TC S 111.84 0.00 0.00 52342 S 735.08 0.00 0.00<br />

51726 TC S 154.05 0.00 0.00 52343 S 735.08 0.00 0.00<br />

51736 TC S 21.14 0.00 0.00 52344 S 735.08 0.00 0.00<br />

51741 TC S 24.61 0.00 0.00 52345 S 735.08 0.00 0.00<br />

51772 TC S 97.85 0.00 0.00 52346 S 735.08 0.00 0.00<br />

51784 TC S 40.47 0.00 0.00 52351 S 735.08 0.00 0.00<br />

51785 TC S 67.61 0.00 0.00 52352 S 791.30 0.00 0.00<br />

51792 TC S 40.47 0.00 0.00 52353 S 990.62 0.00 0.00<br />

51795 TC S 72.51 0.00 0.00 52354 S 791.30 0.00 0.00<br />

51797 TC S 72.51 0.00 0.00 52355 S 791.30 0.00 0.00<br />

51798 S 18.02 0.00 0.00 52400 S 735.08 0.00 0.00<br />

51880 S 652.16 0.00 0.00 52402 S 735.08 0.00 0.00<br />

51992 S 1,234.15 0.00 0.00 52450 S 735.08 0.00 0.00<br />

52000 S 295.82 0.00 0.00 52500 S 735.08 0.00 0.00<br />

52001 S 551.44 0.00 0.00 52601 S 990.62 0.00 0.00<br />

52005 S 573.35 0.00 0.00 52630 S 904.42 0.00 0.00<br />

52007 S 705.10 0.00 0.00 52640 S 705.10 0.00 0.00<br />

52010 S 326.84 0.00 0.00 52647 S 1,515.55 0.00 0.00<br />

52204 S 573.35 0.00 0.00 52648 S 1,515.55 0.00 0.00<br />

52214 S 705.10 0.00 0.00 52700 S 705.10 0.00 0.00<br />

52224 S 705.10 0.00 0.00 53000 S 541.16 0.00 0.00<br />

52234 S 705.10 0.00 0.00 53010 S 541.16 0.00 0.00<br />

52235 S 735.08 0.00 0.00 53020 S 541.16 0.00 0.00<br />

52240 S 735.08 0.00 0.00 53025 S 770.32 0.00 0.00<br />

52250 S 791.30 0.00 0.00 53040 S 594.10 0.00 0.00<br />

52260 S 573.35 0.00 0.00 53060 S 70.35 0.00 0.00<br />

52265 S 279.64 0.00 0.00 53080 S 624.08 0.00 0.00<br />

52270 S 573.35 0.00 0.00 53085 S 770.32 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 541.16 0.00 0.00 54060 S 548.82 0.00 0.00<br />

53210 S 929.45 0.00 0.00 54065 S 548.82 0.00 0.00<br />

53215 S 721.05 0.00 0.00 54100 S 464.26 0.00 0.00<br />

53220 S 802.49 0.00 0.00 54105 S 579.56 0.00 0.00<br />

53230 S 802.49 0.00 0.00 54110 S 898.56 0.00 0.00<br />

53235 S 624.08 0.00 0.00 54111 S 898.56 0.00 0.00<br />

53240 S 802.49 0.00 0.00 54112 S 898.56 0.00 0.00<br />

53250 S 594.10 0.00 0.00 54115 S 531.94 0.00 0.00<br />

53260 S 594.10 0.00 0.00 54120 S 898.56 0.00 0.00<br />

53265 S 594.10 0.00 0.00 54150 S 598.84 0.00 0.00<br />

53270 S 594.10 0.00 0.00 54160 S 651.78 0.00 0.00<br />

53275 S 594.10 0.00 0.00 54161 S 651.78 0.00 0.00<br />

53400 S 832.48 0.00 0.00 54162 S 651.78 0.00 0.00<br />

53405 S 802.49 0.00 0.00 54163 S 651.78 0.00 0.00<br />

53410 S 802.49 0.00 0.00 54164 S 651.78 0.00 0.00<br />

53420 S 832.48 0.00 0.00 54200 S 68.27 0.00 0.00<br />

53425 S 802.49 0.00 0.00 54205 S 984.76 0.00 0.00<br />

53430 S 802.49 0.00 0.00 54220 S 97.85 0.00 0.00<br />

53431 S 802.49 0.00 0.00 54231 S 64.11 0.00 0.00<br />

53440 S 4,622.68 2,807.57 992.45 54235 S 45.40 0.00 0.00<br />

53442 S 749.56 0.00 0.00 54240 TC S 32.23 0.00 0.00<br />

53444 S 4,622.68 2,807.57 992.45 54250 TC S 11.43 0.00 0.00<br />

53445 S 7,764.93 4,422.07 1,079.23 54300 S 928.54 0.00 0.00<br />

53446 S 749.56 0.00 0.00 54304 S 928.54 0.00 0.00<br />

53447 S 7,764.93 4,422.07 1,079.23 54308 S 928.54 0.00 0.00<br />

53449 S 749.56 0.00 0.00 54312 S 928.54 0.00 0.00<br />

53450 S 749.56 0.00 0.00 54316 S 928.54 0.00 0.00<br />

53460 S 541.16 0.00 0.00 54318 S 928.54 0.00 0.00<br />

53502 S 594.10 0.00 0.00 54322 S 928.54 0.00 0.00<br />

53505 S 802.49 0.00 0.00 54324 S 928.54 0.00 0.00<br />

53510 S 594.10 0.00 0.00 54326 S 928.54 0.00 0.00<br />

53515 S 802.49 0.00 0.00 54328 S 928.54 0.00 0.00<br />

53520 S 802.49 0.00 0.00 54340 S 928.54 0.00 0.00<br />

53600 S 40.55 0.00 0.00 54344 S 928.54 0.00 0.00<br />

53601 S 40.47 0.00 0.00 54348 S 928.54 0.00 0.00<br />

53605 S 573.35 0.00 0.00 54352 S 928.54 0.00 0.00<br />

53620 S 62.38 0.00 0.00 54360 S 928.54 0.00 0.00<br />

53621 S 65.50 0.00 0.00 54380 S 928.54 0.00 0.00<br />

53660 S 40.47 0.00 0.00 54385 S 928.54 0.00 0.00<br />

53661 S 40.47 0.00 0.00 54400 S 4,652.67 2,837.55 1,022.44<br />

53665 S 541.16 0.00 0.00 54401 S 7,847.85 4,504.99 1,162.15<br />

53850 S 1,776.56 0.00 0.00 54405 S 7,847.85 4,504.99 1,162.15<br />

53852 S 1,776.56 0.00 0.00 54406 S 928.54 0.00 0.00<br />

54000 S 594.10 0.00 0.00 54408 S 928.54 0.00 0.00<br />

54001 S 594.10 0.00 0.00 54410 S 7,847.85 4,504.99 1,162.15<br />

54015 S 671.08 0.00 0.00 54415 S 928.54 0.00 0.00<br />

54050 S 32.11 0.00 0.00 54416 S 7,847.85 4,504.99 1,162.15<br />

54055 S 65.50 0.00 0.00 54420 S 984.76 0.00 0.00<br />

54056 S 32.11 0.00 0.00 54435 S 984.76 0.00 0.00<br />

54057 S 548.82 0.00 0.00 54440 S 984.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 154.05 0.00 0.00 55706 S 447.84 0.00 0.00<br />

54500 S 418.11 0.00 0.00 55720 S 652.16 0.00 0.00<br />

54505 S 598.84 0.00 0.00 55725 S 705.10 0.00 0.00<br />

54512 S 651.78 0.00 0.00 55860 S 776.98 0.00 0.00<br />

54520 S 681.76 0.00 0.00 55870 S 79.01 0.00 0.00<br />

54522 S 681.76 0.00 0.00 55873 S 6,147.78 0.00 0.00<br />

54530 S 909.11 0.00 0.00 55875 S 1,322.75 0.00 0.00<br />

54550 S 909.11 0.00 0.00 55876 S 72.43 0.00 0.00<br />

54560 S 885.69 0.00 0.00 55920 S 907.95 0.00 0.00<br />

54600 S 737.98 0.00 0.00 56405 S 42.28 0.00 0.00<br />

54620 S 681.76 0.00 0.00 56420 S 55.18 0.00 0.00<br />

54640 S 909.11 0.00 0.00 56440 S 592.57 0.00 0.00<br />

54660 S 651.78 0.00 0.00 56441 S 539.62 0.00 0.00<br />

54670 S 681.76 0.00 0.00 56442 S 539.62 0.00 0.00<br />

54680 S 681.76 0.00 0.00 56501 S 58.22 0.00 0.00<br />

54690 S 1,525.53 0.00 0.00 56515 S 631.74 0.00 0.00<br />

54692 S 2,711.78 0.00 0.00 56605 S 33.61 0.00 0.00<br />

54700 S 651.78 0.00 0.00 56606 S 13.87 0.00 0.00<br />

54800 S 146.30 0.00 0.00 56620 S 719.51 0.00 0.00<br />

54830 S 681.76 0.00 0.00 56625 S 849.75 0.00 0.00<br />

54840 S 737.98 0.00 0.00 56700 S 539.62 0.00 0.00<br />

54860 S 681.76 0.00 0.00 56740 S 622.54 0.00 0.00<br />

54861 S 737.98 0.00 0.00 56800 S 622.54 0.00 0.00<br />

54865 S 598.84 0.00 0.00 56805 S 767.26 0.00 0.00<br />

54900 S 737.98 0.00 0.00 56810 S 719.51 0.00 0.00<br />

54901 S 737.98 0.00 0.00 56820 S 42.97 0.00 0.00<br />

55000 S 66.54 0.00 0.00 56821 S 55.18 0.00 0.00<br />

55040 S 852.90 0.00 0.00 57000 S 539.62 0.00 0.00<br />

55041 S 949.87 0.00 0.00 57010 S 592.57 0.00 0.00<br />

55060 S 737.98 0.00 0.00 57020 S 310.77 0.00 0.00<br />

55100 S 400.23 0.00 0.00 57022 S 488.48 0.00 0.00<br />

55110 S 651.78 0.00 0.00 57023 S 531.94 0.00 0.00<br />

55120 S 651.78 0.00 0.00 57061 S 53.71 0.00 0.00<br />

55150 S 598.84 0.00 0.00 57065 S 539.62 0.00 0.00<br />

55175 S 598.84 0.00 0.00 57100 S 34.31 0.00 0.00<br />

55180 S 651.78 0.00 0.00 57105 S 592.57 0.00 0.00<br />

55200 S 651.78 0.00 0.00 57130 S 592.57 0.00 0.00<br />

55250 S 651.78 0.00 0.00 57135 S 592.57 0.00 0.00<br />

55400 S 598.84 0.00 0.00 57150 S 24.95 0.00 0.00<br />

55450 S 214.16 0.00 0.00 57155 S 310.77 0.00 0.00<br />

55500 S 681.76 0.00 0.00 57160 S 36.04 0.00 0.00<br />

55520 S 737.98 0.00 0.00 57170 S 5.91 0.00 0.00<br />

55530 S 737.98 0.00 0.00 57180 S 111.00 0.00 0.00<br />

55535 S 909.11 0.00 0.00 57200 S 539.62 0.00 0.00<br />

55540 S 949.87 0.00 0.00 57210 S 592.57 0.00 0.00<br />

55550 S 1,525.53 0.00 0.00 57220 S 1,086.68 0.00 0.00<br />

55600 S 885.69 0.00 0.00 57230 S 892.26 0.00 0.00<br />

55680 S 598.84 0.00 0.00 57240 S 989.23 0.00 0.00<br />

55700 S 385.93 0.00 0.00 57250 S 989.23 0.00 0.00<br />

55705 S 385.93 0.00 0.00 57260 S 989.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,313.89 0.00 0.00 58555 S 583.03 0.00 0.00<br />

57267 S 1,119.47 0.00 0.00 58558 S 665.96 0.00 0.00<br />

57268 S 892.26 0.00 0.00 58559 S 635.98 0.00 0.00<br />

57287 S 1,306.70 0.00 0.00 58560 S 949.56 0.00 0.00<br />

57288 S 1,183.65 0.00 0.00 58561 S 949.56 0.00 0.00<br />

57289 S 989.23 0.00 0.00 58562 S 665.96 0.00 0.00<br />

57291 S 989.23 0.00 0.00 58563 S 1,337.91 0.00 0.00<br />

57300 S 892.26 0.00 0.00 58565 S 1,475.04 0.00 0.00<br />

57320 S 1,306.70 0.00 0.00 58600 S 1,306.70 0.00 0.00<br />

57400 S 592.57 0.00 0.00 58615 S 767.26 0.00 0.00<br />

57410 S 592.57 0.00 0.00 58660 S 1,234.15 0.00 0.00<br />

57415 S 592.57 0.00 0.00 58661 S 1,234.15 0.00 0.00<br />

57420 S 44.36 0.00 0.00 58662 S 1,234.15 0.00 0.00<br />

57421 S 57.87 0.00 0.00 58670 S 1,137.19 0.00 0.00<br />

57452 S 41.93 0.00 0.00 58671 S 1,137.19 0.00 0.00<br />

57454 S 51.29 0.00 0.00 58672 S 1,234.15 0.00 0.00<br />

57455 S 54.40 0.00 0.00 58673 S 1,234.15 0.00 0.00<br />

57456 S 52.67 0.00 0.00 58800 S 622.54 0.00 0.00<br />

57460 S 161.84 0.00 0.00 58805 S 1,306.70 0.00 0.00<br />

57461 S 171.89 0.00 0.00 58820 S 892.26 0.00 0.00<br />

57500 S 74.16 0.00 0.00 58900 S 622.54 0.00 0.00<br />

57505 S 47.13 0.00 0.00 58970 S 173.40 0.00 0.00<br />

57510 S 47.82 0.00 0.00 58974 S 173.40 0.00 0.00<br />

57511 S 55.18 0.00 0.00 58976 S 173.40 0.00 0.00<br />

57513 S 592.57 0.00 0.00 59000 S 63.42 0.00 0.00<br />

57520 S 592.57 0.00 0.00 59001 S 238.04 0.00 0.00<br />

57522 S 592.57 0.00 0.00 59012 S 116.40 0.00 0.00<br />

57530 S 892.26 0.00 0.00 59015 S 51.29 0.00 0.00<br />

57550 S 892.26 0.00 0.00 59020 TC S 27.03 0.00 0.00<br />

57556 S 1,183.65 0.00 0.00 59025 TC S 14.21 0.00 0.00<br />

57558 S 622.54 0.00 0.00 59070 S 116.40 0.00 0.00<br />

57700 S 539.62 0.00 0.00 59072 S 116.40 0.00 0.00<br />

57720 S 622.54 0.00 0.00 59076 S 116.40 0.00 0.00<br />

57800 S 25.30 0.00 0.00 59100 S 1,306.70 0.00 0.00<br />

58100 S 41.59 0.00 0.00 59150 S 1,796.53 0.00 0.00<br />

58120 S 592.57 0.00 0.00 59151 S 1,796.53 0.00 0.00<br />

58145 S 989.23 0.00 0.00 59160 S 622.54 0.00 0.00<br />

58301 S 38.81 0.00 0.00 59200 S 34.66 0.00 0.00<br />

58321 S 36.39 0.00 0.00 59300 S 74.85 0.00 0.00<br />

58322 S 37.43 0.00 0.00 59320 S 539.62 0.00 0.00<br />

58323 S 8.67 0.00 0.00 59412 S 767.26 0.00 0.00<br />

58345 S 767.26 0.00 0.00 59414 S 767.26 0.00 0.00<br />

58346 S 592.57 0.00 0.00 59812 S 719.51 0.00 0.00<br />

58350 S 892.26 0.00 0.00 59820 S 719.51 0.00 0.00<br />

58353 S 1,119.47 0.00 0.00 59821 S 719.51 0.00 0.00<br />

58356 S 1,695.54 0.00 0.00 59840 S 719.51 0.00 0.00<br />

58545 S 1,361.98 0.00 0.00 59841 S 719.51 0.00 0.00<br />

58546 S 1,525.53 0.00 0.00 59866 S 116.40 0.00 0.00<br />

58550 S 1,983.16 0.00 0.00 59870 S 719.51 0.00 0.00<br />

58552 S 1,796.53 0.00 0.00 59871 S 719.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 302.07 0.00 0.00 62367 S 16.63 0.00 0.00<br />

60100 S 47.48 0.00 0.00 62368 S 21.14 0.00 0.00<br />

60200 S 1,124.32 0.00 0.00 63600 S 567.88 0.00 0.00<br />

60280 S 1,210.52 0.00 0.00 63610 S 514.94 0.00 0.00<br />

60281 S 1,210.52 0.00 0.00 63615 S 717.89 0.00 0.00<br />

60300 S 62.38 0.00 0.00 63650 S 3,056.61 1,895.40 734.20<br />

61000 S 278.15 0.00 0.00 63655 S 4,477.19 2,855.11 1,233.04<br />

61001 S 278.15 0.00 0.00 63660 S 536.80 0.00 0.00<br />

61020 S 225.19 0.00 0.00 63685 S 13,589.29 7,245.93 902.58<br />

61026 S 225.19 0.00 0.00 63688 S 728.93 0.00 0.00<br />

61050 S 225.19 0.00 0.00 63744 S 1,054.14 0.00 0.00<br />

61055 S 225.19 0.00 0.00 63746 S 487.62 0.00 0.00<br />

61070 S 175.23 0.00 0.00 64400 S 53.37 0.00 0.00<br />

61215 S 1,054.14 0.00 0.00 64402 S 50.25 0.00 0.00<br />

61330 S 1,623.96 0.00 0.00 64405 S 42.62 0.00 0.00<br />

61334 S 1,623.96 0.00 0.00 64408 S 53.02 0.00 0.00<br />

61790 S 597.86 0.00 0.00 64410 S 295.07 0.00 0.00<br />

61791 S 443.55 0.00 0.00 64412 S 77.97 0.00 0.00<br />

61880 S 761.60 0.00 0.00 64413 S 49.91 0.00 0.00<br />

61885 S 10,959.53 5,870.92 782.30 64415 S 135.89 0.00 0.00<br />

61886 S 16,365.25 8,625.44 885.63 64416 S 278.15 0.00 0.00<br />

61888 S 728.93 0.00 0.00 64417 S 135.89 0.00 0.00<br />

62194 S 295.07 0.00 0.00 64418 S 70.00 0.00 0.00<br />

62225 S 458.49 0.00 0.00 64420 S 135.89 0.00 0.00<br />

62230 S 1,024.15 0.00 0.00 64421 S 295.07 0.00 0.00<br />

62252 TC S 46.44 0.00 0.00 64425 S 48.51 0.00 0.00<br />

62263 S 295.07 0.00 0.00 64430 S 204.19 0.00 0.00<br />

62264 S 434.68 0.00 0.00 64435 S 73.12 0.00 0.00<br />

62267 S 173.46 0.00 0.00 64445 S 64.80 0.00 0.00<br />

62268 S 225.19 0.00 0.00 64446 S 557.37 0.00 0.00<br />

62269 S 341.74 0.00 0.00 64447 S 141.55 0.00 0.00<br />

62270 S 135.89 0.00 0.00 64448 S 141.55 0.00 0.00<br />

62272 S 135.89 0.00 0.00 64449 S 278.15 0.00 0.00<br />

62273 S 226.77 0.00 0.00 64450 S 43.32 0.00 0.00<br />

62280 S 295.07 0.00 0.00 64455 S 18.02 0.00 0.00<br />

62281 S 295.07 0.00 0.00 64470 S 295.07 0.00 0.00<br />

62282 S 295.07 0.00 0.00 64472 S 226.77 0.00 0.00<br />

62287 S 1,324.58 0.00 0.00 64475 S 295.07 0.00 0.00<br />

62292 S 278.15 0.00 0.00 64476 S 204.23 0.00 0.00<br />

62294 S 225.19 0.00 0.00 64479 S 295.07 0.00 0.00<br />

62310 S 295.07 0.00 0.00 64480 S 226.77 0.00 0.00<br />

62311 S 295.07 0.00 0.00 64483 S 295.07 0.00 0.00<br />

62318 S 295.07 0.00 0.00 64484 S 226.77 0.00 0.00<br />

62319 S 295.07 0.00 0.00 64505 S 39.51 0.00 0.00<br />

62350 S 1,024.15 0.00 0.00 64508 S 83.86 0.00 0.00<br />

62355 S 487.62 0.00 0.00 64510 S 295.07 0.00 0.00<br />

62360 S 1,024.15 0.00 0.00 64517 S 204.19 0.00 0.00<br />

62361 S 10,513.04 5,690.34 867.64 64520 S 295.07 0.00 0.00<br />

62362 S 10,513.04 5,690.34 867.64 64530 S 295.07 0.00 0.00<br />

62365 S 906.24 0.00 0.00 64553 S 3,003.67 1,842.46 681.26<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,372.94 2,211.73 1,050.54 64746 S 567.88 0.00 0.00<br />

64560 S 3,372.94 2,211.73 1,050.54 64761 S 717.89 0.00 0.00<br />

64561 S 3,086.59 1,925.38 764.18 64763 S 717.89 0.00 0.00<br />

64565 S 3,372.94 2,211.73 1,050.54 64766 S 1,394.62 0.00 0.00<br />

64573 S 5,254.53 3,112.80 971.06 64771 S 567.88 0.00 0.00<br />

64575 S 4,016.66 2,394.58 772.51 64772 S 567.88 0.00 0.00<br />

64577 S 4,016.66 2,394.58 772.51 64774 S 567.88 0.00 0.00<br />

64580 S 4,016.66 2,394.58 772.51 64776 S 597.86 0.00 0.00<br />

64581 S 4,099.58 2,477.50 855.44 64778 S 567.88 0.00 0.00<br />

64585 S 536.80 0.00 0.00 64782 S 597.86 0.00 0.00<br />

64590 S 10,959.53 5,870.92 782.30 64783 S 567.88 0.00 0.00<br />

64595 S 728.93 0.00 0.00 64784 S 597.86 0.00 0.00<br />

64600 S 434.68 0.00 0.00 64786 S 936.22 0.00 0.00<br />

64605 S 434.68 0.00 0.00 64787 S 567.88 0.00 0.00<br />

64610 S 434.68 0.00 0.00 64788 S 597.86 0.00 0.00<br />

64612 S 63.42 0.00 0.00 64790 S 597.86 0.00 0.00<br />

64613 S 61.34 0.00 0.00 64792 S 936.22 0.00 0.00<br />

64614 S 70.00 0.00 0.00 64795 S 567.88 0.00 0.00<br />

64620 S 295.07 0.00 0.00 64802 S 567.88 0.00 0.00<br />

64622 S 434.68 0.00 0.00 64820 S 717.89 0.00 0.00<br />

64623 S 295.07 0.00 0.00 64821 S 838.07 0.00 0.00<br />

64626 S 434.68 0.00 0.00 64822 S 1,085.88 0.00 0.00<br />

64627 S 204.23 0.00 0.00 64823 S 1,085.88 0.00 0.00<br />

64630 S 303.94 0.00 0.00 64831 S 992.44 0.00 0.00<br />

64632 S 32.92 0.00 0.00 64832 S 853.30 0.00 0.00<br />

64640 S 98.07 0.00 0.00 64834 S 906.24 0.00 0.00<br />

64650 S 32.92 0.00 0.00 64835 S 936.22 0.00 0.00<br />

64653 S 35.70 0.00 0.00 64836 S 936.22 0.00 0.00<br />

64680 S 461.83 0.00 0.00 64837 S 853.30 0.00 0.00<br />

64681 S 487.62 0.00 0.00 64840 S 906.24 0.00 0.00<br />

64702 S 514.94 0.00 0.00 64856 S 906.24 0.00 0.00<br />

64704 S 514.94 0.00 0.00 64857 S 906.24 0.00 0.00<br />

64708 S 567.88 0.00 0.00 64858 S 906.24 0.00 0.00<br />

64712 S 567.88 0.00 0.00 64859 S 853.30 0.00 0.00<br />

64713 S 567.88 0.00 0.00 64861 S 936.22 0.00 0.00<br />

64714 S 567.88 0.00 0.00 64862 S 936.22 0.00 0.00<br />

64716 S 597.86 0.00 0.00 64864 S 936.22 0.00 0.00<br />

64718 S 567.88 0.00 0.00 64865 S 992.44 0.00 0.00<br />

64719 S 567.88 0.00 0.00 64870 S 992.44 0.00 0.00<br />

64721 S 567.88 0.00 0.00 64872 S 906.24 0.00 0.00<br />

64722 S 514.94 0.00 0.00 64874 S 936.22 0.00 0.00<br />

64726 S 514.94 0.00 0.00 64876 S 936.22 0.00 0.00<br />

64727 S 514.94 0.00 0.00 64885 S 906.24 0.00 0.00<br />

64732 S 567.88 0.00 0.00 64886 S 906.24 0.00 0.00<br />

64734 S 567.88 0.00 0.00 64890 S 906.24 0.00 0.00<br />

64736 S 567.88 0.00 0.00 64891 S 906.24 0.00 0.00<br />

64738 S 567.88 0.00 0.00 64892 S 906.24 0.00 0.00<br />

64740 S 567.88 0.00 0.00 64893 S 906.24 0.00 0.00<br />

64742 S 567.88 0.00 0.00 64895 S 936.22 0.00 0.00<br />

64744 S 567.88 0.00 0.00 64896 S 936.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 936.22 0.00 0.00 65770 S 5,509.36 0.00 0.00<br />

64898 S 936.22 0.00 0.00 65772 S 619.76 0.00 0.00<br />

64901 S 906.24 0.00 0.00 65775 S 619.76 0.00 0.00<br />

64902 S 906.24 0.00 0.00 65780 S 1,072.10 0.00 0.00<br />

64905 S 906.24 0.00 0.00 65781 S 1,072.10 0.00 0.00<br />

64907 S 853.30 0.00 0.00 65782 S 1,072.10 0.00 0.00<br />

64910 S 1,394.62 0.00 0.00 65800 S 480.63 0.00 0.00<br />

65091 S 985.79 0.00 0.00 65805 S 480.63 0.00 0.00<br />

65093 S 985.79 0.00 0.00 65810 S 702.29 0.00 0.00<br />

65101 S 985.79 0.00 0.00 65815 S 672.31 0.00 0.00<br />

65103 S 985.79 0.00 0.00 65820 S 246.57 0.00 0.00<br />

65105 S 1,042.01 0.00 0.00 65850 S 758.50 0.00 0.00<br />

65110 S 1,082.76 0.00 0.00 65855 S 130.99 0.00 0.00<br />

65112 S 1,213.00 0.00 0.00 65860 S 122.34 0.00 0.00<br />

65114 S 1,213.00 0.00 0.00 65865 S 480.63 0.00 0.00<br />

65125 S 1,009.51 0.00 0.00 65870 S 758.50 0.00 0.00<br />

65130 S 743.67 0.00 0.00 65875 S 758.50 0.00 0.00<br />

65135 S 713.69 0.00 0.00 65880 S 619.76 0.00 0.00<br />

65140 S 985.79 0.00 0.00 65900 S 660.52 0.00 0.00<br />

65150 S 713.69 0.00 0.00 65920 S 929.50 0.00 0.00<br />

65155 S 985.79 0.00 0.00 65930 S 799.26 0.00 0.00<br />

65175 S 530.51 0.00 0.00 66020 S 480.63 0.00 0.00<br />

65205 S 20.45 0.00 0.00 66030 S 246.57 0.00 0.00<br />

65210 S 25.99 0.00 0.00 66130 S 929.50 0.00 0.00<br />

65220 S 36.21 0.00 0.00 66150 S 758.50 0.00 0.00<br />

65222 S 28.41 0.00 0.00 66155 S 758.50 0.00 0.00<br />

65235 S 533.56 0.00 0.00 66160 S 672.31 0.00 0.00<br />

65260 S 351.92 0.00 0.00 66165 S 758.50 0.00 0.00<br />

65265 S 728.07 0.00 0.00 66170 S 758.50 0.00 0.00<br />

65270 S 583.45 0.00 0.00 66172 S 758.50 0.00 0.00<br />

65272 S 672.31 0.00 0.00 66180 S 1,130.02 0.00 0.00<br />

65275 S 758.50 0.00 0.00 66185 S 1,003.07 0.00 0.00<br />

65280 S 728.07 0.00 0.00 66220 S 979.17 0.00 0.00<br />

65285 S 1,035.38 0.00 0.00 66225 S 1,089.27 0.00 0.00<br />

65286 S 181.14 0.00 0.00 66250 S 533.56 0.00 0.00<br />

65290 S 717.02 0.00 0.00 66500 S 246.57 0.00 0.00<br />

65400 S 480.63 0.00 0.00 66505 S 246.57 0.00 0.00<br />

65410 S 533.56 0.00 0.00 66600 S 702.29 0.00 0.00<br />

65420 S 533.56 0.00 0.00 66605 S 702.29 0.00 0.00<br />

65426 S 799.26 0.00 0.00 66625 S 499.33 0.00 0.00<br />

65430 S 36.21 0.00 0.00 66630 S 702.29 0.00 0.00<br />

65435 S 31.54 0.00 0.00 66635 S 702.29 0.00 0.00<br />

65436 S 136.88 0.00 0.00 66680 S 702.29 0.00 0.00<br />

65450 S 83.57 0.00 0.00 66682 S 672.31 0.00 0.00<br />

65600 S 161.49 0.00 0.00 66700 S 533.56 0.00 0.00<br />

65710 S 1,202.33 0.00 0.00 66710 S 533.56 0.00 0.00<br />

65730 S 1,202.33 0.00 0.00 66711 S 533.56 0.00 0.00<br />

65750 S 1,202.33 0.00 0.00 66720 S 533.56 0.00 0.00<br />

65755 S 1,202.33 0.00 0.00 66740 S 672.31 0.00 0.00<br />

65756 S 1,472.42 0.00 0.00 66761 S 182.28 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 185.41 0.00 0.00 67228 S 204.18 0.00 0.00<br />

66770 S 204.18 0.00 0.00 67229 S 204.18 0.00 0.00<br />

66820 S 181.14 0.00 0.00 67250 S 613.44 0.00 0.00<br />

66821 S 248.48 0.00 0.00 67255 S 671.86 0.00 0.00<br />

66825 S 758.50 0.00 0.00 67311 S 717.02 0.00 0.00<br />

66830 S 265.28 0.00 0.00 67312 S 773.23 0.00 0.00<br />

66840 S 570.25 0.00 0.00 67314 S 773.23 0.00 0.00<br />

66850 S 1,073.65 0.00 0.00 67316 S 773.23 0.00 0.00<br />

66852 S 902.66 0.00 0.00 67318 S 773.23 0.00 0.00<br />

66920 S 902.66 0.00 0.00 67320 S 773.23 0.00 0.00<br />

66930 S 943.42 0.00 0.00 67331 S 773.23 0.00 0.00<br />

66940 S 611.01 0.00 0.00 67332 S 773.23 0.00 0.00<br />

66982 S 926.93 0.00 0.00 67334 S 773.23 0.00 0.00<br />

66983 S 926.93 0.00 0.00 67335 S 773.23 0.00 0.00<br />

66984 S 926.93 0.00 0.00 67340 S 773.23 0.00 0.00<br />

66985 S 858.07 0.00 0.00 67343 S 944.22 0.00 0.00<br />

66986 S 858.07 0.00 0.00 67345 S 80.75 0.00 0.00<br />

67005 S 728.07 0.00 0.00 67346 S 436.74 0.00 0.00<br />

67010 S 728.07 0.00 0.00 67400 S 613.44 0.00 0.00<br />

67015 S 896.25 0.00 0.00 67405 S 799.89 0.00 0.00<br />

67025 S 588.94 0.00 0.00 67412 S 710.40 0.00 0.00<br />

67027 S 1,035.38 0.00 0.00 67413 S 840.64 0.00 0.00<br />

67028 S 81.44 0.00 0.00 67414 S 1,493.76 0.00 0.00<br />

67030 S 588.94 0.00 0.00 67415 S 530.51 0.00 0.00<br />

67031 S 248.48 0.00 0.00 67420 S 1,082.76 0.00 0.00<br />

67036 S 1,035.38 0.00 0.00 67430 S 1,082.76 0.00 0.00<br />

67039 S 1,206.38 0.00 0.00 67440 S 1,082.76 0.00 0.00<br />

67040 S 1,206.38 0.00 0.00 67445 S 1,082.76 0.00 0.00<br />

67041 S 1,480.51 0.00 0.00 67450 S 1,082.76 0.00 0.00<br />

67042 S 1,480.51 0.00 0.00 67500 S 83.57 0.00 0.00<br />

67043 S 1,480.51 0.00 0.00 67505 S 25.99 0.00 0.00<br />

67101 S 226.01 0.00 0.00 67515 S 26.34 0.00 0.00<br />

67105 S 204.18 0.00 0.00 67550 S 1,042.01 0.00 0.00<br />

67107 S 1,076.14 0.00 0.00 67560 S 713.69 0.00 0.00<br />

67108 S 1,206.38 0.00 0.00 67570 S 1,042.01 0.00 0.00<br />

67110 S 328.52 0.00 0.00 67700 S 122.26 0.00 0.00<br />

67112 S 1,206.38 0.00 0.00 67710 S 142.77 0.00 0.00<br />

67113 S 1,480.51 0.00 0.00 67715 S 530.51 0.00 0.00<br />

67115 S 641.88 0.00 0.00 67800 S 51.29 0.00 0.00<br />

67120 S 641.88 0.00 0.00 67801 S 62.03 0.00 0.00<br />

67121 S 641.88 0.00 0.00 67805 S 80.39 0.00 0.00<br />

67141 S 226.26 0.00 0.00 67808 S 583.45 0.00 0.00<br />

67145 S 193.03 0.00 0.00 67810 S 122.26 0.00 0.00<br />

67208 S 205.85 0.00 0.00 67820 S 16.98 0.00 0.00<br />

67210 S 204.18 0.00 0.00 67825 S 52.33 0.00 0.00<br />

67218 S 768.83 0.00 0.00 67830 S 358.20 0.00 0.00<br />

67220 S 226.01 0.00 0.00 67835 S 583.45 0.00 0.00<br />

67221 S 116.09 0.00 0.00 67840 S 149.71 0.00 0.00<br />

67225 S 7.98 0.00 0.00 67850 S 118.87 0.00 0.00<br />

67227 S 588.94 0.00 0.00 67875 S 298.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 563.55 0.00 0.00 68440 S 50.94 0.00 0.00<br />

67882 S 613.44 0.00 0.00 68500 S 743.67 0.00 0.00<br />

67900 S 799.89 0.00 0.00 68505 S 743.67 0.00 0.00<br />

67901 S 710.40 0.00 0.00 68510 S 530.51 0.00 0.00<br />

67902 S 840.64 0.00 0.00 68520 S 743.67 0.00 0.00<br />

67903 S 669.65 0.00 0.00 68525 S 530.51 0.00 0.00<br />

67904 S 669.65 0.00 0.00 68530 S 122.26 0.00 0.00<br />

67906 S 710.40 0.00 0.00 68540 S 613.44 0.00 0.00<br />

67908 S 669.65 0.00 0.00 68550 S 743.67 0.00 0.00<br />

67909 S 669.65 0.00 0.00 68700 S 583.45 0.00 0.00<br />

67911 S 613.44 0.00 0.00 68705 S 116.09 0.00 0.00<br />

67912 S 613.44 0.00 0.00 68720 S 799.89 0.00 0.00<br />

67914 S 613.44 0.00 0.00 68745 S 799.89 0.00 0.00<br />

67915 S 165.65 0.00 0.00 68750 S 799.89 0.00 0.00<br />

67916 S 669.65 0.00 0.00 68760 S 98.77 0.00 0.00<br />

67917 S 669.65 0.00 0.00 68761 S 68.27 0.00 0.00<br />

67921 S 613.44 0.00 0.00 68770 S 799.89 0.00 0.00<br />

67922 S 161.14 0.00 0.00 68801 S 36.21 0.00 0.00<br />

67923 S 669.65 0.00 0.00 68810 S 103.56 0.00 0.00<br />

67924 S 669.65 0.00 0.00 68811 S 583.45 0.00 0.00<br />

67930 S 165.65 0.00 0.00 68815 S 583.45 0.00 0.00<br />

67935 S 583.45 0.00 0.00 68816 S 749.03 0.00 0.00<br />

67938 S 83.57 0.00 0.00 68840 S 53.71 0.00 0.00<br />

67950 S 583.45 0.00 0.00 69000 S 54.79 0.00 0.00<br />

67961 S 613.44 0.00 0.00 69005 S 103.62 0.00 0.00<br />

67966 S 613.44 0.00 0.00 69020 S 54.79 0.00 0.00<br />

67971 S 613.44 0.00 0.00 69100 S 62.38 0.00 0.00<br />

67973 S 743.67 0.00 0.00 69105 S 88.37 0.00 0.00<br />

67974 S 613.44 0.00 0.00 69110 S 464.26 0.00 0.00<br />

67975 S 613.44 0.00 0.00 69120 S 688.97 0.00 0.00<br />

68020 S 45.40 0.00 0.00 69140 S 688.97 0.00 0.00<br />

68040 S 22.52 0.00 0.00 69145 S 517.20 0.00 0.00<br />

68100 S 90.10 0.00 0.00 69150 S 363.51 0.00 0.00<br />

68110 S 116.09 0.00 0.00 69200 S 25.06 0.00 0.00<br />

68115 S 583.45 0.00 0.00 69205 S 579.56 0.00 0.00<br />

68130 S 533.56 0.00 0.00 69210 S 20.45 0.00 0.00<br />

68135 S 58.22 0.00 0.00 69220 S 32.11 0.00 0.00<br />

68200 S 16.63 0.00 0.00 69222 S 135.15 0.00 0.00<br />

68320 S 799.89 0.00 0.00 69300 S 718.96 0.00 0.00<br />

68325 S 799.89 0.00 0.00 69310 S 1,050.90 0.00 0.00<br />

68326 S 669.65 0.00 0.00 69320 S 1,278.10 0.00 0.00<br />

68328 S 799.89 0.00 0.00 69400 S 90.79 0.00 0.00<br />

68330 S 758.50 0.00 0.00 69401 S 47.82 0.00 0.00<br />

68335 S 799.89 0.00 0.00 69405 S 125.45 0.00 0.00<br />

68340 S 669.65 0.00 0.00 69420 S 112.63 0.00 0.00<br />

68360 S 672.31 0.00 0.00 69421 S 573.22 0.00 0.00<br />

68362 S 672.31 0.00 0.00 69424 S 79.01 0.00 0.00<br />

68371 S 533.56 0.00 0.00 69433 S 112.28 0.00 0.00<br />

68400 S 122.26 0.00 0.00 69436 S 573.22 0.00 0.00<br />

68420 S 173.96 0.00 0.00 69440 S 718.96 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 967.98 0.00 0.00 69840 S 1,147.87 0.00 0.00<br />

69501 S 1,278.10 0.00 0.00 69905 S 1,278.10 0.00 0.00<br />

69502 S 946.16 0.00 0.00 69910 S 1,278.10 0.00 0.00<br />

69505 S 1,278.10 0.00 0.00 69915 S 1,278.10 0.00 0.00<br />

69511 S 1,278.10 0.00 0.00 69930 S 23,106.37 12,406.55 1,706.75<br />

69530 S 1,278.10 0.00 0.00 70030 TC A 17.67 0.00 0.00<br />

69540 S 132.03 0.00 0.00 70100 TC A 19.41 0.00 0.00<br />

69550 S 1,147.87 0.00 0.00 70110 TC A 23.92 0.00 0.00<br />

69552 S 1,278.10 0.00 0.00 70120 TC A 21.48 0.00 0.00<br />

69601 S 1,278.10 0.00 0.00 70130 TC A 26.25 0.00 0.00<br />

69602 S 1,278.10 0.00 0.00 70134 TC A 26.34 0.00 0.00<br />

69603 S 1,278.10 0.00 0.00 70140 TC A 18.02 0.00 0.00<br />

69604 S 1,278.10 0.00 0.00 70150 TC A 26.25 0.00 0.00<br />

69605 S 1,278.10 0.00 0.00 70160 TC A 21.14 0.00 0.00<br />

69610 S 176.74 0.00 0.00 70190 TC A 22.18 0.00 0.00<br />

69620 S 688.97 0.00 0.00 70200 TC A 26.25 0.00 0.00<br />

69631 S 1,147.87 0.00 0.00 70210 TC A 18.72 0.00 0.00<br />

69632 S 1,147.87 0.00 0.00 70220 TC A 23.57 0.00 0.00<br />

69633 S 1,147.87 0.00 0.00 70240 TC A 17.67 0.00 0.00<br />

69635 S 1,278.10 0.00 0.00 70250 TC A 21.48 0.00 0.00<br />

69636 S 1,278.10 0.00 0.00 70260 TC A 27.37 0.00 0.00<br />

69637 S 1,278.10 0.00 0.00 70300 TC A 7.62 0.00 0.00<br />

69641 S 1,278.10 0.00 0.00 70310 TC A 18.83 0.00 0.00<br />

69642 S 1,278.10 0.00 0.00 70320 TC A 18.83 0.00 0.00<br />

69643 S 1,278.10 0.00 0.00 70328 TC A 18.72 0.00 0.00<br />

69644 S 1,278.10 0.00 0.00 70330 TC A 26.25 0.00 0.00<br />

69645 S 1,278.10 0.00 0.00 70336 TC A 204.33 0.00 0.00<br />

69646 S 1,278.10 0.00 0.00 70350 TC A 10.40 0.00 0.00<br />

69650 S 946.16 0.00 0.00 70355 TC A 10.74 0.00 0.00<br />

69660 S 1,147.87 0.00 0.00 70360 TC A 16.63 0.00 0.00<br />

69661 S 1,147.87 0.00 0.00 70370 TC A 48.85 0.00 0.00<br />

69662 S 1,147.87 0.00 0.00 70371 TC A 48.85 0.00 0.00<br />

69666 S 1,107.11 0.00 0.00 70380 TC A 25.30 0.00 0.00<br />

69667 S 1,107.11 0.00 0.00 70450 TC A 114.12 0.00 0.00<br />

69670 S 1,050.90 0.00 0.00 70460 TC A 180.71 0.00 0.00<br />

69676 S 1,050.90 0.00 0.00 70470 TC A 200.17 0.00 0.00<br />

69700 S 1,050.90 0.00 0.00 70480 TC A 114.12 0.00 0.00<br />

69711 S 967.98 0.00 0.00 70481 TC A 180.71 0.00 0.00<br />

69714 S 6,138.76 3,870.72 1,602.68 70482 TC A 200.17 0.00 0.00<br />

69715 S 6,138.76 3,870.72 1,602.68 70486 TC A 114.12 0.00 0.00<br />

69717 S 6,138.76 3,870.72 1,602.68 70487 TC A 180.71 0.00 0.00<br />

69718 S 6,138.76 3,870.72 1,602.68 70488 TC A 200.17 0.00 0.00<br />

69720 S 1,147.87 0.00 0.00 70490 TC A 114.12 0.00 0.00<br />

69740 S 1,147.87 0.00 0.00 70491 TC A 180.71 0.00 0.00<br />

69745 S 1,147.87 0.00 0.00 70492 TC A 200.17 0.00 0.00<br />

69801 S 1,147.87 0.00 0.00 70496 TC A 206.57 0.00 0.00<br />

69802 S 1,278.10 0.00 0.00 70498 TC A 206.57 0.00 0.00<br />

69805 S 1,278.10 0.00 0.00 70540 TC A 204.33 0.00 0.00<br />

69806 S 1,278.10 0.00 0.00 70542 TC A 250.93 0.00 0.00<br />

69820 S 1,147.87 0.00 0.00 70543 TC A 316.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 204.33 0.00 0.00 72120 TC A 33.26 0.00 0.00<br />

70545 TC A 250.93 0.00 0.00 72125 TC A 114.12 0.00 0.00<br />

70546 TC A 316.25 0.00 0.00 72126 TC A 180.71 0.00 0.00<br />

70547 TC A 204.33 0.00 0.00 72127 TC A 200.17 0.00 0.00<br />

70548 TC A 250.93 0.00 0.00 72128 TC A 114.12 0.00 0.00<br />

70549 TC A 316.25 0.00 0.00 72129 TC A 180.71 0.00 0.00<br />

70551 TC A 204.33 0.00 0.00 72130 TC A 200.17 0.00 0.00<br />

70552 TC A 250.93 0.00 0.00 72131 TC A 114.12 0.00 0.00<br />

70553 TC A 316.25 0.00 0.00 72132 TC A 180.71 0.00 0.00<br />

70554 TC A 204.33 0.00 0.00 72133 TC A 200.17 0.00 0.00<br />

70555 TC A 204.33 0.00 0.00 72141 TC A 204.33 0.00 0.00<br />

70557 TC A 204.33 0.00 0.00 72142 TC A 250.93 0.00 0.00<br />

70558 TC A 250.93 0.00 0.00 72146 TC A 204.33 0.00 0.00<br />

70559 TC A 316.25 0.00 0.00 72147 TC A 250.93 0.00 0.00<br />

71010 TC A 13.52 0.00 0.00 72148 TC A 204.33 0.00 0.00<br />

71015 TC A 17.32 0.00 0.00 72149 TC A 250.93 0.00 0.00<br />

71020 TC A 18.37 0.00 0.00 72156 TC A 316.25 0.00 0.00<br />

71021 TC A 22.18 0.00 0.00 72157 TC A 316.25 0.00 0.00<br />

71022 TC A 26.25 0.00 0.00 72158 TC A 316.25 0.00 0.00<br />

71023 TC A 42.97 0.00 0.00 72170 TC A 15.59 0.00 0.00<br />

71030 TC A 26.25 0.00 0.00 72190 TC A 26.25 0.00 0.00<br />

71034 TC A 48.85 0.00 0.00 72191 TC A 206.57 0.00 0.00<br />

71035 TC A 22.87 0.00 0.00 72192 TC A 114.12 0.00 0.00<br />

71100 TC A 19.06 0.00 0.00 72193 TC A 180.71 0.00 0.00<br />

71101 TC A 23.21 0.00 0.00 72194 TC A 200.17 0.00 0.00<br />

71110 TC A 24.26 0.00 0.00 72195 TC A 204.33 0.00 0.00<br />

71111 TC A 32.23 0.00 0.00 72196 TC A 250.93 0.00 0.00<br />

71120 TC A 20.10 0.00 0.00 72197 TC A 316.25 0.00 0.00<br />

71130 TC A 23.57 0.00 0.00 72200 TC A 18.37 0.00 0.00<br />

71250 TC A 114.12 0.00 0.00 72202 TC A 22.52 0.00 0.00<br />

71260 TC A 180.71 0.00 0.00 72220 TC A 18.37 0.00 0.00<br />

71270 TC A 200.17 0.00 0.00 73000 TC A 17.32 0.00 0.00<br />

71275 TC A 206.57 0.00 0.00 73010 TC A 17.67 0.00 0.00<br />

71550 TC A 204.33 0.00 0.00 73020 TC A 14.21 0.00 0.00<br />

71551 TC A 250.93 0.00 0.00 73030 TC A 18.02 0.00 0.00<br />

71552 TC A 316.25 0.00 0.00 73050 TC A 22.52 0.00 0.00<br />

72010 TC A 43.70 0.00 0.00 73060 TC A 18.02 0.00 0.00<br />

72020 TC A 14.21 0.00 0.00 73070 TC A 17.32 0.00 0.00<br />

72040 TC A 22.87 0.00 0.00 73080 TC A 22.87 0.00 0.00<br />

72050 TC A 32.57 0.00 0.00 73090 TC A 17.32 0.00 0.00<br />

72052 TC A 43.70 0.00 0.00 73092 TC A 18.02 0.00 0.00<br />

72069 TC A 21.48 0.00 0.00 73100 TC A 18.02 0.00 0.00<br />

72070 TC A 20.10 0.00 0.00 73110 TC A 22.87 0.00 0.00<br />

72072 TC A 24.26 0.00 0.00 73120 TC A 16.98 0.00 0.00<br />

72074 TC A 26.25 0.00 0.00 73130 TC A 20.10 0.00 0.00<br />

72080 TC A 21.48 0.00 0.00 73140 TC A 19.76 0.00 0.00<br />

72090 TC A 28.77 0.00 0.00 73200 TC A 114.12 0.00 0.00<br />

72100 TC A 24.61 0.00 0.00 73201 TC A 180.71 0.00 0.00<br />

72110 TC A 34.31 0.00 0.00 73202 TC A 200.17 0.00 0.00<br />

72114 TC A 43.70 0.00 0.00 73206 TC A 206.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 204.33 0.00 0.00 74246 TC A 51.57 0.00 0.00<br />

73219 TC A 250.93 0.00 0.00 74247 TC A 51.57 0.00 0.00<br />

73220 TC A 316.25 0.00 0.00 74249 TC A 83.85 0.00 0.00<br />

73221 TC A 204.33 0.00 0.00 74250 TC A 51.57 0.00 0.00<br />

73222 TC A 250.93 0.00 0.00 74251 TC A 83.85 0.00 0.00<br />

73223 TC A 316.25 0.00 0.00 74260 TC A 51.57 0.00 0.00<br />

73500 TC A 14.90 0.00 0.00 74270 TC A 51.57 0.00 0.00<br />

73510 TC A 22.87 0.00 0.00 74280 TC A 83.85 0.00 0.00<br />

73520 TC A 23.57 0.00 0.00 74283 TC A 51.57 0.00 0.00<br />

73540 TC A 23.57 0.00 0.00 74290 TC A 44.01 0.00 0.00<br />

73550 TC A 17.32 0.00 0.00 74291 TC A 42.28 0.00 0.00<br />

73560 TC A 17.67 0.00 0.00 74400 TC A 76.59 0.00 0.00<br />

73562 TC A 21.83 0.00 0.00 74410 TC A 81.79 0.00 0.00<br />

73564 TC A 25.30 0.00 0.00 74415 TC A 97.73 0.00 0.00<br />

73565 TC A 19.06 0.00 0.00 74420 TC A 102.15 0.00 0.00<br />

73590 TC A 16.63 0.00 0.00 74710 TC A 22.87 0.00 0.00<br />

73592 TC A 18.02 0.00 0.00 74775 TC A 102.15 0.00 0.00<br />

73600 TC A 16.98 0.00 0.00 75557 TC A 204.33 0.00 0.00<br />

73610 TC A 20.10 0.00 0.00 75559 TC A 204.33 0.00 0.00<br />

73620 TC A 16.29 0.00 0.00 75561 TC A 316.25 0.00 0.00<br />

73630 TC A 19.76 0.00 0.00 75563 TC A 316.25 0.00 0.00<br />

73650 TC A 16.63 0.00 0.00 76010 TC A 16.98 0.00 0.00<br />

73660 TC A 18.72 0.00 0.00 76098 TC A 10.40 0.00 0.00<br />

73700 TC A 114.12 0.00 0.00 76100 TC A 43.70 0.00 0.00<br />

73701 TC A 180.71 0.00 0.00 76101 TC A 117.13 0.00 0.00<br />

73702 TC A 200.17 0.00 0.00 76102 TC A 117.13 0.00 0.00<br />

73706 TC A 206.57 0.00 0.00 76120 TC A 48.85 0.00 0.00<br />

73718 TC A 204.33 0.00 0.00 76150 A 16.98 0.00 0.00<br />

73719 TC A 250.93 0.00 0.00 76380 TC A 61.65 0.00 0.00<br />

73720 TC A 316.25 0.00 0.00 76496 TC A 48.85 0.00 0.00<br />

73721 TC A 204.33 0.00 0.00 76497 TC A 61.65 0.00 0.00<br />

73722 TC A 250.93 0.00 0.00 76498 TC A 204.33 0.00 0.00<br />

73723 TC A 316.25 0.00 0.00 76499 TC A 26.25 0.00 0.00<br />

74000 TC A 14.90 0.00 0.00 76506 TC A 36.69 0.00 0.00<br />

74010 TC A 23.21 0.00 0.00 76510 TC A 62.38 0.00 0.00<br />

74020 TC A 23.57 0.00 0.00 76511 TC A 43.66 0.00 0.00<br />

74022 TC A 28.77 0.00 0.00 76512 TC A 37.08 0.00 0.00<br />

74150 TC A 114.12 0.00 0.00 76513 TC A 45.05 0.00 0.00<br />

74160 TC A 180.71 0.00 0.00 76514 TC A 3.12 0.00 0.00<br />

74170 TC A 200.17 0.00 0.00 76516 TC A 35.35 0.00 0.00<br />

74175 TC A 206.57 0.00 0.00 76519 TC A 39.51 0.00 0.00<br />

74181 TC A 204.33 0.00 0.00 76529 TC A 34.31 0.00 0.00<br />

74182 TC A 250.93 0.00 0.00 76536 TC A 57.40 0.00 0.00<br />

74183 TC A 316.25 0.00 0.00 76604 TC A 36.69 0.00 0.00<br />

74210 TC A 51.57 0.00 0.00 76645 TC A 36.69 0.00 0.00<br />

74220 TC A 51.57 0.00 0.00 76700 TC A 57.40 0.00 0.00<br />

74230 TC A 51.57 0.00 0.00 76705 TC A 57.40 0.00 0.00<br />

74240 TC A 51.57 0.00 0.00 76770 TC A 57.40 0.00 0.00<br />

74241 TC A 51.57 0.00 0.00 76775 TC A 57.40 0.00 0.00<br />

74245 TC A 83.85 0.00 0.00 76776 TC A 57.40 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 57.40 0.00 0.00 77290 TC A 150.11 0.00 0.00<br />

76801 TC A 57.40 0.00 0.00 77295 TC A 393.33 0.00 0.00<br />

76802 TC A 27.37 0.00 0.00 77299 TC A 67.35 0.00 0.00<br />

76805 TC A 57.40 0.00 0.00 77300 TC A 36.39 0.00 0.00<br />

76810 TC A 43.32 0.00 0.00 77301 TC A 524.20 0.00 0.00<br />

76811 TC A 89.93 0.00 0.00 77305 TC A 33.26 0.00 0.00<br />

76812 TC A 36.69 0.00 0.00 77310 TC A 43.32 0.00 0.00<br />

76813 TC A 36.69 0.00 0.00 77315 TC A 63.07 0.00 0.00<br />

76814 TC A 29.11 0.00 0.00 77321 TC A 65.50 0.00 0.00<br />

76815 TC A 36.69 0.00 0.00 77326 TC A 67.35 0.00 0.00<br />

76816 TC A 36.69 0.00 0.00 77327 TC A 122.34 0.00 0.00<br />

76817 TC A 36.69 0.00 0.00 77328 TC A 150.11 0.00 0.00<br />

76818 TC A 57.40 0.00 0.00 77331 TC A 17.32 0.00 0.00<br />

76819 TC A 49.56 0.00 0.00 77332 TC A 46.44 0.00 0.00<br />

76820 TC A 24.61 0.00 0.00 77333 TC A 22.52 0.00 0.00<br />

76821 TC A 55.57 0.00 0.00 77334 TC A 86.99 0.00 0.00<br />

76825 TC A 115.74 0.00 0.00 77336 A 54.76 0.00 0.00<br />

76826 TC A 68.96 0.00 0.00 77370 A 67.35 0.00 0.00<br />

76827 TC A 36.69 0.00 0.00 77371 A 4,486.30 0.00 0.00<br />

76828 TC A 21.83 0.00 0.00 77399 TC A 67.35 0.00 0.00<br />

76830 TC A 57.40 0.00 0.00 77401 A 27.37 0.00 0.00<br />

76831 TC A 77.28 0.00 0.00 77402 A 55.11 0.00 0.00<br />

76856 TC A 57.40 0.00 0.00 77403 A 55.11 0.00 0.00<br />

76857 TC A 36.69 0.00 0.00 77404 A 55.11 0.00 0.00<br />

76870 TC A 57.40 0.00 0.00 77406 A 89.27 0.00 0.00<br />

76872 TC A 57.40 0.00 0.00 77407 A 55.11 0.00 0.00<br />

76873 TC A 57.40 0.00 0.00 77408 A 55.11 0.00 0.00<br />

76880 TC A 57.40 0.00 0.00 77409 A 55.11 0.00 0.00<br />

76885 TC A 36.69 0.00 0.00 77411 A 89.27 0.00 0.00<br />

76886 TC A 36.69 0.00 0.00 77412 A 89.27 0.00 0.00<br />

76936 TC A 55.57 0.00 0.00 77413 A 89.27 0.00 0.00<br />

76970 TC A 36.69 0.00 0.00 77414 A 89.27 0.00 0.00<br />

76977 TC A 9.36 0.00 0.00 77416 A 89.27 0.00 0.00<br />

76999 TC A 36.69 0.00 0.00 77418 A 241.19 0.00 0.00<br />

77071 A 21.48 0.00 0.00 77422 A 89.27 0.00 0.00<br />

77072 TC A 12.47 0.00 0.00 77423 A 89.27 0.00 0.00<br />

77073 TC A 21.14 0.00 0.00 77470 TC A 128.23 0.00 0.00<br />

77074 TC A 41.59 0.00 0.00 77520 A 412.94 0.00 0.00<br />

77075 TC A 43.70 0.00 0.00 77522 A 412.94 0.00 0.00<br />

77076 TC A 43.70 0.00 0.00 77523 A 493.48 0.00 0.00<br />

77077 TC A 23.57 0.00 0.00 77525 A 493.48 0.00 0.00<br />

77078 TC A 42.22 0.00 0.00 77600 TC A 219.10 0.00 0.00<br />

77079 TC A 43.32 0.00 0.00 77605 TC A 219.10 0.00 0.00<br />

77080 TC A 42.22 0.00 0.00 77610 TC A 219.10 0.00 0.00<br />

77081 TC A 16.98 0.00 0.00 77615 TC A 219.10 0.00 0.00<br />

77082 TC A 18.37 0.00 0.00 77620 TC A 219.10 0.00 0.00<br />

77083 TC A 14.56 0.00 0.00 77750 TC A 85.25 0.00 0.00<br />

77084 TC A 204.33 0.00 0.00 77761 TC A 150.06 0.00 0.00<br />

77280 TC A 67.35 0.00 0.00 77762 TC A 177.78 0.00 0.00<br />

77285 TC A 150.11 0.00 0.00 77763 TC A 229.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 162.53 0.00 0.00 78262 TC A 142.73 0.00 0.00<br />

77777 TC A 178.47 0.00 0.00 78264 TC A 142.73 0.00 0.00<br />

77778 TC A 237.73 0.00 0.00 78270 TC A 62.38 0.00 0.00<br />

77785 TC A 105.69 0.00 0.00 78271 TC A 63.42 0.00 0.00<br />

77786 TC A 371.49 0.00 0.00 78272 TC A 69.65 0.00 0.00<br />

77787 TC A 430.48 0.00 0.00 78278 TC A 142.73 0.00 0.00<br />

77789 TC A 44.36 0.00 0.00 78282 TC A 142.73 0.00 0.00<br />

77799 TC A 252.84 0.00 0.00 78290 TC A 142.73 0.00 0.00<br />

78000 TC A 54.40 0.00 0.00 78291 TC A 142.73 0.00 0.00<br />

78001 TC A 68.95 0.00 0.00 78299 TC A 142.73 0.00 0.00<br />

78003 TC A 54.76 0.00 0.00 78300 TC A 124.41 0.00 0.00<br />

78006 TC A 130.28 0.00 0.00 78305 TC A 144.29 0.00 0.00<br />

78007 TC A 96.34 0.00 0.00 78306 TC A 144.29 0.00 0.00<br />

78010 TC A 80.05 0.00 0.00 78315 TC A 144.29 0.00 0.00<br />

78011 TC A 80.05 0.00 0.00 78320 TC A 144.29 0.00 0.00<br />

78015 TC A 155.60 0.00 0.00 78399 TC A 144.29 0.00 0.00<br />

78016 TC A 175.63 0.00 0.00 78414 TC A 183.41 0.00 0.00<br />

78018 TC A 175.63 0.00 0.00 78428 TC A 140.70 0.00 0.00<br />

78070 TC A 119.56 0.00 0.00 78445 TC A 109.75 0.00 0.00<br />

78075 TC A 338.57 0.00 0.00 78456 TC A 109.75 0.00 0.00<br />

78099 TC A 80.05 0.00 0.00 78457 TC A 109.75 0.00 0.00<br />

78102 TC A 120.94 0.00 0.00 78458 TC A 109.75 0.00 0.00<br />

78103 TC A 154.17 0.00 0.00 78459 TC A 679.18 0.00 0.00<br />

78104 TC A 154.17 0.00 0.00 78460 TC A 131.68 0.00 0.00<br />

78110 TC A 61.34 0.00 0.00 78461 TC A 132.73 0.00 0.00<br />

78111 TC A 77.63 0.00 0.00 78464 TC A 194.75 0.00 0.00<br />

78120 TC A 67.92 0.00 0.00 78465 TC A 368.73 0.00 0.00<br />

78121 TC A 80.39 0.00 0.00 78466 TC A 130.65 0.00 0.00<br />

78122 TC A 95.30 0.00 0.00 78468 TC A 167.03 0.00 0.00<br />

78130 TC A 110.55 0.00 0.00 78469 TC A 183.41 0.00 0.00<br />

78135 TC A 234.95 0.00 0.00 78472 TC A 183.41 0.00 0.00<br />

78140 TC A 104.31 0.00 0.00 78473 TC A 183.41 0.00 0.00<br />

78185 TC A 154.17 0.00 0.00 78481 TC A 158.37 0.00 0.00<br />

78190 TC A 96.74 0.00 0.00 78483 TC A 183.41 0.00 0.00<br />

78191 TC A 96.74 0.00 0.00 78491 TC A 679.18 0.00 0.00<br />

78195 TC A 154.17 0.00 0.00 78492 TC A 679.18 0.00 0.00<br />

78199 TC A 154.17 0.00 0.00 78494 TC A 183.41 0.00 0.00<br />

78201 TC A 137.23 0.00 0.00 78499 TC A 183.41 0.00 0.00<br />

78202 TC A 161.43 0.00 0.00 78580 TC A 124.26 0.00 0.00<br />

78205 TC A 161.43 0.00 0.00 78584 TC A 95.99 0.00 0.00<br />

78206 TC A 161.43 0.00 0.00 78585 TC A 190.66 0.00 0.00<br />

78215 TC A 145.20 0.00 0.00 78586 TC A 124.26 0.00 0.00<br />

78216 TC A 98.42 0.00 0.00 78587 TC A 124.26 0.00 0.00<br />

78220 TC A 107.43 0.00 0.00 78588 TC A 190.66 0.00 0.00<br />

78223 TC A 161.43 0.00 0.00 78591 TC A 124.26 0.00 0.00<br />

78230 TC A 121.98 0.00 0.00 78593 TC A 124.26 0.00 0.00<br />

78231 TC A 95.99 0.00 0.00 78594 TC A 124.26 0.00 0.00<br />

78232 TC A 100.15 0.00 0.00 78596 TC A 190.66 0.00 0.00<br />

78258 TC A 142.73 0.00 0.00 78599 TC A 124.26 0.00 0.00<br />

78261 TC A 142.73 0.00 0.00 78600 TC A 109.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 42680 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 109.51 0.00 0.00<br />

78605 TC A 109.51 0.00 0.00<br />

78606 TC A 246.04 0.00 0.00<br />

78607 TC A 270.31 0.00 0.00<br />

78608 TC A 608.76 0.00 0.00<br />

78610 TC A 145.90 0.00 0.00<br />

78630 TC A 259.91 0.00 0.00<br />

78635 TC A 239.46 0.00 0.00<br />

78645 TC A 109.51 0.00 0.00<br />

78647 TC A 265.11 0.00 0.00<br />

78650 TC A 256.79 0.00 0.00<br />

78660 TC A 109.51 0.00 0.00<br />

78699 TC A 109.51 0.00 0.00<br />

78700 TC A 134.81 0.00 0.00<br />

78701 TC A 164.27 0.00 0.00<br />

78707 TC A 171.54 0.00 0.00<br />

78708 TC A 117.48 0.00 0.00<br />

78709 TC A 193.15 0.00 0.00<br />

78710 TC A 181.25 0.00 0.00<br />

78725 TC A 72.43 0.00 0.00<br />

78730 TC A 61.34 0.00 0.00<br />

78740 TC A 160.11 0.00 0.00<br />

78761 TC A 152.82 0.00 0.00<br />

78799 TC A 193.15 0.00 0.00<br />

78800 TC A 135.15 0.00 0.00<br />

78801 TC A 185.41 0.00 0.00<br />

78802 TC A 251.24 0.00 0.00<br />

78803 TC A 269.27 0.00 0.00<br />

78804 TC A 469.91 0.00 0.00<br />

78805 TC A 132.03 0.00 0.00<br />

78806 TC A 264.07 0.00 0.00<br />

78807 TC A 269.61 0.00 0.00<br />

78811 TC A 608.76 0.00 0.00<br />

78812 TC A 608.76 0.00 0.00<br />

78813 TC A 608.76 0.00 0.00<br />

78814 TC A 608.76 0.00 0.00<br />

78815 TC A 608.76 0.00 0.00<br />

78816 TC A 608.76 0.00 0.00<br />

78999 TC A 68.95 0.00 0.00<br />

79005 TC A 55.45 0.00 0.00<br />

79101 TC A 60.65 0.00 0.00<br />

79200 TC A 65.50 0.00 0.00<br />

79300 TC A 126.37 0.00 0.00<br />

79403 TC A 93.91 0.00 0.00<br />

79440 TC A 53.02 0.00 0.00<br />

79445 TC A 126.37 0.00 0.00<br />

79999 TC A 126.37 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,203.42 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,494.63 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.47 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,544.39 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,544.39 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 223.04 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 223.04 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 112.62 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 238.02 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 71.55 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 640.70 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,461.02 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,143.61 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,143.61 0.00 0.00<br />

C8900 A 247.62 0.00 0.00 0123T S 914.55 0.00 0.00<br />

C8901 A 201.64 0.00 0.00 0124T S 178.75 0.00 0.00<br />

C8902 A 312.09 0.00 0.00 0144T TC A 60.84 0.00 0.00<br />

C8903 A 247.62 0.00 0.00 0145T TC A 163.77 0.00 0.00<br />

C8904 A 201.64 0.00 0.00 0146T TC A 163.77 0.00 0.00<br />

C8905 A 312.09 0.00 0.00 0147T TC A 163.77 0.00 0.00<br />

C8906 A 247.62 0.00 0.00 0148T TC A 163.77 0.00 0.00<br />

C8907 A 201.64 0.00 0.00 0149T TC A 163.77 0.00 0.00<br />

C8908 A 312.09 0.00 0.00 0150T TC A 163.77 0.00 0.00<br />

C8909 A 247.62 0.00 0.00 0151T TC A 60.84 0.00 0.00<br />

C8910 A 201.64 0.00 0.00 0170T S 1,187.94 0.00 0.00<br />

C8911 A 312.09 0.00 0.00 0176T S 1,402.69 0.00 0.00<br />

C8912 A 247.62 0.00 0.00 0177T S 1,402.69 0.00 0.00<br />

C8913 A 201.64 0.00 0.00 0182T A 1,013.87 0.00 0.00<br />

C8914 A 312.09 0.00 0.00 0186T S 854.49 0.00 0.00<br />

C8918 A 247.62 0.00 0.00 0190T S 854.49 0.00 0.00<br />

C8919 A 201.64 0.00 0.00 0191T S 914.55 0.00 0.00<br />

C8920 A 312.09 0.00 0.00 0192T S 1,567.36 0.00 0.00<br />

C9716 S 1,187.94 0.00 0.00 10021 S 54.82 0.00 0.00<br />

C9724 S 971.28 0.00 0.00 10022 S 171.18 0.00 0.00<br />

C9725 S 223.97 0.00 0.00 10040 S 31.69 0.00 0.00<br />

C9726 S 822.27 0.00 0.00 10060 S 48.22 0.00 0.00<br />

C9727 S 288.30 0.00 0.00 10061 S 54.07 0.00 0.00<br />

C9728 S 517.30 0.00 0.00 10080 S 54.07 0.00 0.00<br />

G0104 S 83.10 0.00 0.00 10081 S 124.48 0.00 0.00<br />

G0105 S 359.16 0.00 0.00 10120 S 67.71 0.00 0.00<br />

G0121 S 359.16 0.00 0.00 10121 S 510.39 0.00 0.00<br />

G0127 S 11.62 0.00 0.00 10140 S 71.82 0.00 0.00<br />

G0130 TC A 19.15 0.00 0.00 10160 S 54.07 0.00 0.00<br />

G0173 A 2,203.42 0.00 0.00 10180 S 577.18 0.00 0.00<br />

G0186 S 223.04 0.00 0.00 11000 S 23.26 0.00 0.00<br />

G0247 S 21.20 0.00 0.00 11001 S 7.87 0.00 0.00<br />

G0251 A 551.77 0.00 0.00 11010 S 201.93 0.00 0.00<br />

G0260 S 291.18 0.00 0.00 11011 S 201.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 201.93 0.00 0.00 11601 S 111.49 0.00 0.00<br />

11040 S 21.20 0.00 0.00 11602 S 122.77 0.00 0.00<br />

11041 S 23.60 0.00 0.00 11603 S 130.29 0.00 0.00<br />

11042 S 128.23 0.00 0.00 11604 S 351.46 0.00 0.00<br />

11043 S 128.23 0.00 0.00 11606 S 510.39 0.00 0.00<br />

11044 S 333.88 0.00 0.00 11620 S 95.08 0.00 0.00<br />

11055 S 24.97 0.00 0.00 11621 S 112.85 0.00 0.00<br />

11056 S 27.36 0.00 0.00 11622 S 125.50 0.00 0.00<br />

11057 S 31.69 0.00 0.00 11623 S 135.08 0.00 0.00<br />

11100 S 58.06 0.00 0.00 11624 S 510.39 0.00 0.00<br />

11101 S 13.68 0.00 0.00 11626 S 624.16 0.00 0.00<br />

11200 S 31.69 0.00 0.00 11640 S 100.55 0.00 0.00<br />

11201 S 5.47 0.00 0.00 11641 S 118.67 0.00 0.00<br />

11300 S 31.69 0.00 0.00 11642 S 132.35 0.00 0.00<br />

11301 S 31.69 0.00 0.00 11643 S 142.61 0.00 0.00<br />

11302 S 31.69 0.00 0.00 11644 S 510.39 0.00 0.00<br />

11303 S 58.06 0.00 0.00 11646 S 624.16 0.00 0.00<br />

11305 S 31.69 0.00 0.00 11719 S 11.62 0.00 0.00<br />

11306 S 31.69 0.00 0.00 11720 S 14.37 0.00 0.00<br />

11307 S 31.69 0.00 0.00 11721 S 17.44 0.00 0.00<br />

11308 S 31.69 0.00 0.00 11730 S 31.69 0.00 0.00<br />

11310 S 31.69 0.00 0.00 11732 S 17.44 0.00 0.00<br />

11311 S 31.69 0.00 0.00 11740 S 16.01 0.00 0.00<br />

11312 S 31.69 0.00 0.00 11750 S 92.34 0.00 0.00<br />

11313 S 31.69 0.00 0.00 11752 S 128.24 0.00 0.00<br />

11400 S 65.32 0.00 0.00 11755 S 63.95 0.00 0.00<br />

11401 S 73.52 0.00 0.00 11760 S 131.70 0.00 0.00<br />

11402 S 80.71 0.00 0.00 11762 S 117.64 0.00 0.00<br />

11403 S 86.18 0.00 0.00 11765 S 31.69 0.00 0.00<br />

11404 S 458.15 0.00 0.00 11770 S 653.76 0.00 0.00<br />

11406 S 510.39 0.00 0.00 11771 S 653.76 0.00 0.00<br />

11420 S 61.22 0.00 0.00 11772 S 653.76 0.00 0.00<br />

11421 S 74.21 0.00 0.00 11900 S 29.07 0.00 0.00<br />

11422 S 81.05 0.00 0.00 11901 S 31.69 0.00 0.00<br />

11423 S 90.29 0.00 0.00 11920 S 91.99 0.00 0.00<br />

11424 S 510.39 0.00 0.00 11921 S 101.23 0.00 0.00<br />

11426 S 624.16 0.00 0.00 11922 S 32.83 0.00 0.00<br />

11440 S 70.11 0.00 0.00 11950 S 33.52 0.00 0.00<br />

11441 S 81.05 0.00 0.00 11951 S 41.72 0.00 0.00<br />

11442 S 89.25 0.00 0.00 11952 S 50.23 0.00 0.00<br />

11443 S 98.83 0.00 0.00 11954 S 50.23 0.00 0.00<br />

11444 S 311.94 0.00 0.00 11960 S 609.29 0.00 0.00<br />

11446 S 624.16 0.00 0.00 11970 S 1,103.64 0.00 0.00<br />

11450 S 624.16 0.00 0.00 11971 S 571.93 0.00 0.00<br />

11451 S 624.16 0.00 0.00 11976 S 61.22 0.00 0.00<br />

11462 S 624.16 0.00 0.00 11980 S 24.73 0.00 0.00<br />

11463 S 624.16 0.00 0.00 11981 S 24.73 0.00 0.00<br />

11470 S 624.16 0.00 0.00 11982 S 24.73 0.00 0.00<br />

11471 S 624.16 0.00 0.00 11983 S 24.73 0.00 0.00<br />

11600 S 91.99 0.00 0.00 12001 S 50.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 50.23 0.00 0.00 14021 S 541.46 0.00 0.00<br />

12004 S 50.23 0.00 0.00 14040 S 511.88 0.00 0.00<br />

12005 S 67.29 0.00 0.00 14041 S 541.46 0.00 0.00<br />

12006 S 67.29 0.00 0.00 14060 S 541.46 0.00 0.00<br />

12007 S 67.29 0.00 0.00 14061 S 541.46 0.00 0.00<br />

12011 S 50.23 0.00 0.00 14300 S 694.36 0.00 0.00<br />

12013 S 50.23 0.00 0.00 14350 S 638.88 0.00 0.00<br />

12014 S 50.23 0.00 0.00 15002 S 234.23 0.00 0.00<br />

12015 S 50.23 0.00 0.00 15003 S 234.23 0.00 0.00<br />

12016 S 67.29 0.00 0.00 15004 S 234.23 0.00 0.00<br />

12017 S 67.29 0.00 0.00 15005 S 234.23 0.00 0.00<br />

12018 S 67.29 0.00 0.00 15040 S 108.03 0.00 0.00<br />

12020 S 126.96 0.00 0.00 15050 S 234.23 0.00 0.00<br />

12021 S 108.03 0.00 0.00 15100 S 609.29 0.00 0.00<br />

12031 S 50.23 0.00 0.00 15101 S 638.88 0.00 0.00<br />

12032 S 131.70 0.00 0.00 15110 S 290.96 0.00 0.00<br />

12034 S 67.29 0.00 0.00 15111 S 238.73 0.00 0.00<br />

12035 S 67.29 0.00 0.00 15115 S 290.96 0.00 0.00<br />

12036 S 108.03 0.00 0.00 15116 S 238.73 0.00 0.00<br />

12037 S 215.31 0.00 0.00 15120 S 609.29 0.00 0.00<br />

12041 S 50.23 0.00 0.00 15121 S 638.88 0.00 0.00<br />

12042 S 50.23 0.00 0.00 15130 S 511.88 0.00 0.00<br />

12044 S 67.29 0.00 0.00 15131 S 459.63 0.00 0.00<br />

12045 S 108.03 0.00 0.00 15135 S 511.88 0.00 0.00<br />

12046 S 108.03 0.00 0.00 15136 S 459.63 0.00 0.00<br />

12047 S 215.31 0.00 0.00 15150 S 290.96 0.00 0.00<br />

12051 S 50.23 0.00 0.00 15151 S 238.73 0.00 0.00<br />

12052 S 50.23 0.00 0.00 15152 S 238.73 0.00 0.00<br />

12053 S 50.23 0.00 0.00 15155 S 290.96 0.00 0.00<br />

12054 S 67.29 0.00 0.00 15156 S 238.73 0.00 0.00<br />

12055 S 108.03 0.00 0.00 15157 S 238.73 0.00 0.00<br />

12056 S 108.03 0.00 0.00 15170 S 131.70 0.00 0.00<br />

12057 S 215.31 0.00 0.00 15171 S 131.70 0.00 0.00<br />

13100 S 234.23 0.00 0.00 15175 S 169.57 0.00 0.00<br />

13101 S 234.23 0.00 0.00 15176 S 169.57 0.00 0.00<br />

13102 S 126.96 0.00 0.00 15200 S 541.46 0.00 0.00<br />

13120 S 108.03 0.00 0.00 15201 S 455.15 0.00 0.00<br />

13121 S 108.03 0.00 0.00 15220 S 511.88 0.00 0.00<br />

13122 S 108.03 0.00 0.00 15221 S 234.23 0.00 0.00<br />

13131 S 108.03 0.00 0.00 15240 S 541.46 0.00 0.00<br />

13132 S 108.03 0.00 0.00 15241 S 234.23 0.00 0.00<br />

13133 S 108.03 0.00 0.00 15260 S 511.88 0.00 0.00<br />

13150 S 234.23 0.00 0.00 15261 S 455.15 0.00 0.00<br />

13151 S 234.23 0.00 0.00 15300 S 234.23 0.00 0.00<br />

13152 S 234.23 0.00 0.00 15301 S 234.23 0.00 0.00<br />

13153 S 108.03 0.00 0.00 15320 S 234.23 0.00 0.00<br />

13160 S 609.29 0.00 0.00 15321 S 234.23 0.00 0.00<br />

14000 S 511.88 0.00 0.00 15330 S 234.23 0.00 0.00<br />

14001 S 541.46 0.00 0.00 15331 S 234.23 0.00 0.00<br />

14020 S 541.46 0.00 0.00 15335 S 234.23 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 234.23 0.00 0.00 15826 S 638.88 0.00 0.00<br />

15340 S 131.70 0.00 0.00 15828 S 638.88 0.00 0.00<br />

15341 S 131.70 0.00 0.00 15829 S 734.57 0.00 0.00<br />

15360 S 131.70 0.00 0.00 15830 S 653.76 0.00 0.00<br />

15361 S 131.70 0.00 0.00 15832 S 653.76 0.00 0.00<br />

15365 S 131.70 0.00 0.00 15833 S 653.76 0.00 0.00<br />

15366 S 131.70 0.00 0.00 15834 S 653.76 0.00 0.00<br />

15400 S 234.23 0.00 0.00 15835 S 567.43 0.00 0.00<br />

15401 S 234.23 0.00 0.00 15836 S 539.98 0.00 0.00<br />

15420 S 234.23 0.00 0.00 15837 S 608.42 0.00 0.00<br />

15421 S 234.23 0.00 0.00 15838 S 608.42 0.00 0.00<br />

15430 S 234.23 0.00 0.00 15839 S 539.98 0.00 0.00<br />

15431 S 234.23 0.00 0.00 15840 S 694.36 0.00 0.00<br />

15570 S 638.88 0.00 0.00 15841 S 694.36 0.00 0.00<br />

15572 S 638.88 0.00 0.00 15842 S 806.22 0.00 0.00<br />

15574 S 638.88 0.00 0.00 15845 S 694.36 0.00 0.00<br />

15576 S 638.88 0.00 0.00 15847 S 653.76 0.00 0.00<br />

15600 S 638.88 0.00 0.00 15850 S 104.43 0.00 0.00<br />

15610 S 638.88 0.00 0.00 15851 S 47.53 0.00 0.00<br />

15620 S 694.36 0.00 0.00 15852 S 24.73 0.00 0.00<br />

15630 S 638.88 0.00 0.00 15860 S 24.73 0.00 0.00<br />

15650 S 734.57 0.00 0.00 15876 S 638.88 0.00 0.00<br />

15731 S 638.88 0.00 0.00 15877 S 638.88 0.00 0.00<br />

15732 S 638.88 0.00 0.00 15878 S 638.88 0.00 0.00<br />

15734 S 638.88 0.00 0.00 15879 S 638.88 0.00 0.00<br />

15736 S 638.88 0.00 0.00 15920 S 201.93 0.00 0.00<br />

15738 S 638.88 0.00 0.00 15922 S 694.36 0.00 0.00<br />

15740 S 511.88 0.00 0.00 15931 S 653.76 0.00 0.00<br />

15750 S 609.29 0.00 0.00 15933 S 653.76 0.00 0.00<br />

15760 S 609.29 0.00 0.00 15934 S 638.88 0.00 0.00<br />

15770 S 638.88 0.00 0.00 15935 S 694.36 0.00 0.00<br />

15775 S 174.56 0.00 0.00 15936 S 596.94 0.00 0.00<br />

15776 S 174.56 0.00 0.00 15937 S 694.36 0.00 0.00<br />

15780 S 389.18 0.00 0.00 15940 S 653.76 0.00 0.00<br />

15781 S 171.30 0.00 0.00 15941 S 653.76 0.00 0.00<br />

15782 S 171.30 0.00 0.00 15944 S 638.88 0.00 0.00<br />

15783 S 104.43 0.00 0.00 15945 S 694.36 0.00 0.00<br />

15786 S 31.69 0.00 0.00 15946 S 694.36 0.00 0.00<br />

15787 S 28.73 0.00 0.00 15950 S 653.76 0.00 0.00<br />

15788 S 31.69 0.00 0.00 15951 S 709.23 0.00 0.00<br />

15789 S 58.06 0.00 0.00 15952 S 541.46 0.00 0.00<br />

15792 S 58.06 0.00 0.00 15953 S 596.94 0.00 0.00<br />

15793 S 31.69 0.00 0.00 15956 S 541.46 0.00 0.00<br />

15819 S 131.70 0.00 0.00 15958 S 596.94 0.00 0.00<br />

15820 S 638.88 0.00 0.00 16000 S 25.65 0.00 0.00<br />

15821 S 638.88 0.00 0.00 16020 S 38.99 0.00 0.00<br />

15822 S 638.88 0.00 0.00 16025 S 60.05 0.00 0.00<br />

15823 S 734.57 0.00 0.00 16030 S 75.18 0.00 0.00<br />

15824 S 638.88 0.00 0.00 16035 S 58.06 0.00 0.00<br />

15825 S 638.88 0.00 0.00 17000 S 31.69 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.76 0.00 0.00 19300 S 702.38 0.00 0.00<br />

17004 S 82.76 0.00 0.00 19301 S 646.91 0.00 0.00<br />

17106 S 104.43 0.00 0.00 19302 S 1,235.52 0.00 0.00<br />

17107 S 104.43 0.00 0.00 19303 S 933.72 0.00 0.00<br />

17108 S 104.43 0.00 0.00 19304 S 933.72 0.00 0.00<br />

17110 S 31.69 0.00 0.00 19316 S 933.72 0.00 0.00<br />

17111 S 58.06 0.00 0.00 19318 S 1,066.78 0.00 0.00<br />

17250 S 43.78 0.00 0.00 19324 S 1,066.78 0.00 0.00<br />

17260 S 46.85 0.00 0.00 19325 S 1,769.39 0.00 0.00<br />

17261 S 58.06 0.00 0.00 19328 S 796.42 0.00 0.00<br />

17262 S 58.06 0.00 0.00 19330 S 796.42 0.00 0.00<br />

17263 S 58.06 0.00 0.00 19340 S 981.72 0.00 0.00<br />

17264 S 58.06 0.00 0.00 19342 S 1,386.15 0.00 0.00<br />

17266 S 104.43 0.00 0.00 19350 S 702.38 0.00 0.00<br />

17270 S 58.06 0.00 0.00 19355 S 933.72 0.00 0.00<br />

17271 S 58.06 0.00 0.00 19357 S 1,481.84 0.00 0.00<br />

17272 S 58.06 0.00 0.00 19366 S 973.94 0.00 0.00<br />

17273 S 104.43 0.00 0.00 19370 S 933.72 0.00 0.00<br />

17274 S 104.43 0.00 0.00 19371 S 933.72 0.00 0.00<br />

17276 S 104.43 0.00 0.00 19380 S 1,107.00 0.00 0.00<br />

17280 S 58.06 0.00 0.00 19396 S 1,284.94 0.00 0.00<br />

17281 S 86.52 0.00 0.00 20000 S 54.07 0.00 0.00<br />

17282 S 98.83 0.00 0.00 20005 S 622.98 0.00 0.00<br />

17283 S 104.43 0.00 0.00 20103 S 611.39 0.00 0.00<br />

17284 S 104.43 0.00 0.00 20150 S 1,735.75 0.00 0.00<br />

17286 S 104.43 0.00 0.00 20200 S 510.39 0.00 0.00<br />

17311 S 172.40 0.00 0.00 20205 S 539.98 0.00 0.00<br />

17312 S 172.40 0.00 0.00 20206 S 252.33 0.00 0.00<br />

17313 S 172.40 0.00 0.00 20220 S 274.28 0.00 0.00<br />

17314 S 172.40 0.00 0.00 20225 S 497.67 0.00 0.00<br />

17315 S 38.99 0.00 0.00 20240 S 624.16 0.00 0.00<br />

17340 S 14.02 0.00 0.00 20245 S 653.76 0.00 0.00<br />

17360 S 31.69 0.00 0.00 20250 S 652.57 0.00 0.00<br />

17380 S 31.69 0.00 0.00 20251 S 652.57 0.00 0.00<br />

19000 S 66.00 0.00 0.00 20500 S 54.04 0.00 0.00<br />

19001 S 8.89 0.00 0.00 20520 S 90.97 0.00 0.00<br />

19020 S 577.18 0.00 0.00 20525 S 653.76 0.00 0.00<br />

19100 S 196.54 0.00 0.00 20526 S 29.41 0.00 0.00<br />

19101 S 617.32 0.00 0.00 20550 S 22.23 0.00 0.00<br />

19102 S 252.33 0.00 0.00 20551 S 21.88 0.00 0.00<br />

19103 S 441.63 0.00 0.00 20552 S 21.20 0.00 0.00<br />

19105 S 1,284.94 0.00 0.00 20553 S 23.60 0.00 0.00<br />

19110 S 617.32 0.00 0.00 20555 S 1,143.61 0.00 0.00<br />

19112 S 646.91 0.00 0.00 20600 S 22.57 0.00 0.00<br />

19120 S 646.91 0.00 0.00 20605 S 25.31 0.00 0.00<br />

19125 S 646.91 0.00 0.00 20610 S 35.57 0.00 0.00<br />

19126 S 646.91 0.00 0.00 20612 S 23.94 0.00 0.00<br />

19296 S 1,769.39 0.00 0.00 20615 S 100.21 0.00 0.00<br />

19297 S 1,769.39 0.00 0.00 20650 S 652.57 0.00 0.00<br />

19298 S 1,769.39 0.00 0.00 20662 S 833.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 833.59 0.00 0.00 21085 S 251.02 0.00 0.00<br />

20665 S 24.73 0.00 0.00 21086 S 546.49 0.00 0.00<br />

20670 S 458.15 0.00 0.00 21087 S 547.18 0.00 0.00<br />

20680 S 653.76 0.00 0.00 21088 S 1,602.58 0.00 0.00<br />

20690 S 777.99 0.00 0.00 21100 S 1,007.47 0.00 0.00<br />

20692 S 807.58 0.00 0.00 21110 S 288.30 0.00 0.00<br />

20693 S 652.57 0.00 0.00 21120 S 933.70 0.00 0.00<br />

20694 S 570.74 0.00 0.00 21121 S 933.70 0.00 0.00<br />

20696 S 1,143.61 0.00 0.00 21122 S 933.70 0.00 0.00<br />

20697 S 760.55 0.00 0.00 21123 S 933.70 0.00 0.00<br />

20822 S 1,071.58 0.00 0.00 21125 S 933.70 0.00 0.00<br />

20900 S 807.58 0.00 0.00 21127 S 1,420.30 0.00 0.00<br />

20902 S 863.05 0.00 0.00 21137 S 947.44 0.00 0.00<br />

20910 S 638.88 0.00 0.00 21138 S 1,602.58 0.00 0.00<br />

20912 S 638.88 0.00 0.00 21139 S 1,602.58 0.00 0.00<br />

20920 S 596.94 0.00 0.00 21150 S 1,602.58 0.00 0.00<br />

20922 S 541.46 0.00 0.00 21181 S 933.70 0.00 0.00<br />

20924 S 863.05 0.00 0.00 21198 S 1,602.58 0.00 0.00<br />

20926 S 376.03 0.00 0.00 21199 S 1,602.58 0.00 0.00<br />

20950 S 54.07 0.00 0.00 21206 S 1,132.76 0.00 0.00<br />

20972 S 1,809.92 0.00 0.00 21208 S 1,261.28 0.00 0.00<br />

20973 S 1,809.92 0.00 0.00 21209 S 1,132.76 0.00 0.00<br />

20979 S 22.23 0.00 0.00 21210 S 1,261.28 0.00 0.00<br />

20982 S 1,735.75 0.00 0.00 21215 S 1,261.28 0.00 0.00<br />

21010 S 679.90 0.00 0.00 21230 S 1,261.28 0.00 0.00<br />

21015 S 565.68 0.00 0.00 21235 S 933.70 0.00 0.00<br />

21025 S 1,007.47 0.00 0.00 21240 S 1,092.54 0.00 0.00<br />

21026 S 1,007.47 0.00 0.00 21242 S 1,132.76 0.00 0.00<br />

21029 S 1,007.47 0.00 0.00 21243 S 1,132.76 0.00 0.00<br />

21030 S 237.68 0.00 0.00 21244 S 1,261.28 0.00 0.00<br />

21031 S 196.64 0.00 0.00 21245 S 1,261.28 0.00 0.00<br />

21032 S 200.40 0.00 0.00 21246 S 1,261.28 0.00 0.00<br />

21034 S 1,037.07 0.00 0.00 21248 S 1,261.28 0.00 0.00<br />

21040 S 679.90 0.00 0.00 21249 S 1,261.28 0.00 0.00<br />

21044 S 1,007.47 0.00 0.00 21260 S 1,602.58 0.00 0.00<br />

21046 S 1,007.47 0.00 0.00 21267 S 1,261.28 0.00 0.00<br />

21047 S 1,007.47 0.00 0.00 21270 S 1,132.76 0.00 0.00<br />

21048 S 1,602.58 0.00 0.00 21275 S 1,261.28 0.00 0.00<br />

21050 S 1,037.07 0.00 0.00 21280 S 1,132.76 0.00 0.00<br />

21060 S 1,007.47 0.00 0.00 21282 S 661.37 0.00 0.00<br />

21070 S 1,037.07 0.00 0.00 21295 S 298.10 0.00 0.00<br />

21073 S 184.67 0.00 0.00 21296 S 627.66 0.00 0.00<br />

21076 S 320.43 0.00 0.00 21310 S 90.93 0.00 0.00<br />

21077 S 774.59 0.00 0.00 21315 S 399.58 0.00 0.00<br />

21079 S 554.70 0.00 0.00 21320 S 536.08 0.00 0.00<br />

21080 S 636.09 0.00 0.00 21325 S 764.96 0.00 0.00<br />

21081 S 586.16 0.00 0.00 21330 S 805.18 0.00 0.00<br />

21082 S 557.78 0.00 0.00 21335 S 933.70 0.00 0.00<br />

21083 S 549.57 0.00 0.00 21336 S 778.14 0.00 0.00<br />

21084 S 632.33 0.00 0.00 21337 S 536.08 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 764.96 0.00 0.00 22310 S 165.55 0.00 0.00<br />

21339 S 805.18 0.00 0.00 22315 S 428.18 0.00 0.00<br />

21340 S 1,092.54 0.00 0.00 22505 S 504.07 0.00 0.00<br />

21345 S 933.70 0.00 0.00 22520 S 1,190.82 0.00 0.00<br />

21355 S 1,037.07 0.00 0.00 22521 S 1,190.82 0.00 0.00<br />

21356 S 709.49 0.00 0.00 22522 S 1,190.82 0.00 0.00<br />

21360 S 947.44 0.00 0.00 22523 S 3,314.16 0.00 0.00<br />

21390 S 1,602.58 0.00 0.00 22524 S 3,314.16 0.00 0.00<br />

21400 S 350.33 0.00 0.00 22525 S 3,314.16 0.00 0.00<br />

21401 S 565.68 0.00 0.00 22900 S 709.23 0.00 0.00<br />

21406 S 1,602.58 0.00 0.00 23000 S 510.39 0.00 0.00<br />

21407 S 1,602.58 0.00 0.00 23020 S 1,074.05 0.00 0.00<br />

21421 S 764.96 0.00 0.00 23030 S 524.93 0.00 0.00<br />

21440 S 322.15 0.00 0.00 23031 S 606.76 0.00 0.00<br />

21445 S 764.96 0.00 0.00 23035 S 652.57 0.00 0.00<br />

21450 S 132.96 0.00 0.00 23040 S 807.58 0.00 0.00<br />

21451 S 358.72 0.00 0.00 23044 S 863.05 0.00 0.00<br />

21452 S 536.08 0.00 0.00 23065 S 96.44 0.00 0.00<br />

21453 S 1,037.07 0.00 0.00 23066 S 624.16 0.00 0.00<br />

21454 S 805.18 0.00 0.00 23075 S 510.39 0.00 0.00<br />

21461 S 1,092.54 0.00 0.00 23076 S 624.16 0.00 0.00<br />

21462 S 1,132.76 0.00 0.00 23077 S 653.76 0.00 0.00<br />

21465 S 1,092.54 0.00 0.00 23100 S 622.98 0.00 0.00<br />

21480 S 90.93 0.00 0.00 23101 S 1,031.79 0.00 0.00<br />

21485 S 536.08 0.00 0.00 23105 S 863.05 0.00 0.00<br />

21490 S 1,037.07 0.00 0.00 23106 S 863.05 0.00 0.00<br />

21495 S 659.80 0.00 0.00 23107 S 863.05 0.00 0.00<br />

21497 S 536.08 0.00 0.00 23120 S 903.27 0.00 0.00<br />

21501 S 577.18 0.00 0.00 23125 S 903.27 0.00 0.00<br />

21502 S 622.98 0.00 0.00 23130 S 1,199.33 0.00 0.00<br />

21550 S 608.42 0.00 0.00 23140 S 708.04 0.00 0.00<br />

21555 S 624.16 0.00 0.00 23145 S 903.27 0.00 0.00<br />

21556 S 624.16 0.00 0.00 23146 S 903.27 0.00 0.00<br />

21557 S 835.96 0.00 0.00 23150 S 863.05 0.00 0.00<br />

21600 S 777.99 0.00 0.00 23155 S 903.27 0.00 0.00<br />

21610 S 777.99 0.00 0.00 23156 S 903.27 0.00 0.00<br />

21685 S 288.30 0.00 0.00 23170 S 777.99 0.00 0.00<br />

21700 S 622.98 0.00 0.00 23172 S 777.99 0.00 0.00<br />

21720 S 652.57 0.00 0.00 23174 S 777.99 0.00 0.00<br />

21725 S 67.93 0.00 0.00 23180 S 863.05 0.00 0.00<br />

21800 S 78.47 0.00 0.00 23182 S 863.05 0.00 0.00<br />

21805 S 693.08 0.00 0.00 23184 S 863.05 0.00 0.00<br />

21820 S 78.47 0.00 0.00 23190 S 863.05 0.00 0.00<br />

21920 S 139.53 0.00 0.00 23195 S 903.27 0.00 0.00<br />

21925 S 624.16 0.00 0.00 23330 S 311.94 0.00 0.00<br />

21930 S 624.16 0.00 0.00 23331 S 571.93 0.00 0.00<br />

21935 S 653.76 0.00 0.00 23395 S 1,199.33 0.00 0.00<br />

22102 S 1,860.26 0.00 0.00 23397 S 2,117.07 0.00 0.00<br />

22103 S 1,860.26 0.00 0.00 23400 S 1,031.79 0.00 0.00<br />

22305 S 78.47 0.00 0.00 23405 S 777.99 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 777.99 0.00 0.00 23931 S 577.18 0.00 0.00<br />

23410 S 1,199.33 0.00 0.00 23935 S 622.98 0.00 0.00<br />

23412 S 1,327.85 0.00 0.00 24000 S 863.05 0.00 0.00<br />

23415 S 1,199.33 0.00 0.00 24006 S 863.05 0.00 0.00<br />

23420 S 1,327.85 0.00 0.00 24065 S 133.72 0.00 0.00<br />

23430 S 1,159.12 0.00 0.00 24066 S 510.39 0.00 0.00<br />

23440 S 1,159.12 0.00 0.00 24075 S 510.39 0.00 0.00<br />

23450 S 1,988.55 0.00 0.00 24076 S 624.16 0.00 0.00<br />

23455 S 2,117.07 0.00 0.00 24077 S 653.76 0.00 0.00<br />

23460 S 1,988.55 0.00 0.00 24100 S 570.74 0.00 0.00<br />

23462 S 1,327.85 0.00 0.00 24101 S 863.05 0.00 0.00<br />

23465 S 1,988.55 0.00 0.00 24102 S 863.05 0.00 0.00<br />

23466 S 1,327.85 0.00 0.00 24105 S 652.57 0.00 0.00<br />

23480 S 1,159.12 0.00 0.00 24110 S 622.98 0.00 0.00<br />

23485 S 2,117.07 0.00 0.00 24115 S 807.58 0.00 0.00<br />

23490 S 1,103.64 0.00 0.00 24116 S 807.58 0.00 0.00<br />

23491 S 1,892.85 0.00 0.00 24120 S 652.57 0.00 0.00<br />

23500 S 78.47 0.00 0.00 24125 S 807.58 0.00 0.00<br />

23505 S 428.18 0.00 0.00 24126 S 807.58 0.00 0.00<br />

23515 S 1,433.08 0.00 0.00 24130 S 807.58 0.00 0.00<br />

23520 S 165.55 0.00 0.00 24134 S 777.99 0.00 0.00<br />

23525 S 165.55 0.00 0.00 24136 S 777.99 0.00 0.00<br />

23530 S 1,056.04 0.00 0.00 24138 S 777.99 0.00 0.00<br />

23532 S 778.14 0.00 0.00 24140 S 807.58 0.00 0.00<br />

23540 S 78.47 0.00 0.00 24145 S 807.58 0.00 0.00<br />

23545 S 165.55 0.00 0.00 24147 S 777.99 0.00 0.00<br />

23550 S 1,056.04 0.00 0.00 24149 S 1,143.61 0.00 0.00<br />

23552 S 1,111.52 0.00 0.00 24152 S 1,735.75 0.00 0.00<br />

23570 S 78.47 0.00 0.00 24153 S 3,314.16 0.00 0.00<br />

23575 S 165.55 0.00 0.00 24155 S 1,103.64 0.00 0.00<br />

23585 S 1,433.08 0.00 0.00 24160 S 777.99 0.00 0.00<br />

23600 S 61.15 0.00 0.00 24164 S 807.58 0.00 0.00<br />

23605 S 428.18 0.00 0.00 24200 S 97.81 0.00 0.00<br />

23615 S 1,488.55 0.00 0.00 24201 S 510.39 0.00 0.00<br />

23616 S 1,488.55 0.00 0.00 24300 S 595.78 0.00 0.00<br />

23620 S 61.15 0.00 0.00 24301 S 863.05 0.00 0.00<br />

23625 S 428.18 0.00 0.00 24305 S 863.05 0.00 0.00<br />

23630 S 1,528.77 0.00 0.00 24310 S 652.57 0.00 0.00<br />

23650 S 78.47 0.00 0.00 24320 S 1,103.64 0.00 0.00<br />

23655 S 451.84 0.00 0.00 24330 S 1,892.85 0.00 0.00<br />

23660 S 1,056.04 0.00 0.00 24331 S 1,103.64 0.00 0.00<br />

23665 S 165.55 0.00 0.00 24332 S 833.59 0.00 0.00<br />

23670 S 1,433.08 0.00 0.00 24340 S 1,103.64 0.00 0.00<br />

23675 S 78.47 0.00 0.00 24341 S 1,103.64 0.00 0.00<br />

23680 S 1,056.04 0.00 0.00 24342 S 1,103.64 0.00 0.00<br />

23700 S 451.84 0.00 0.00 24343 S 1,143.61 0.00 0.00<br />

23800 S 1,948.32 0.00 0.00 24344 S 3,314.16 0.00 0.00<br />

23802 S 1,327.85 0.00 0.00 24345 S 777.99 0.00 0.00<br />

23921 S 455.15 0.00 0.00 24346 S 1,735.75 0.00 0.00<br />

23930 S 524.93 0.00 0.00 24357 S 1,143.61 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,143.61 0.00 0.00 24925 S 652.57 0.00 0.00<br />

24359 S 1,143.61 0.00 0.00 25000 S 652.57 0.00 0.00<br />

24360 S 1,055.39 0.00 0.00 25001 S 833.59 0.00 0.00<br />

24361 S 5,770.38 3,532.21 1,294.03 25020 S 652.57 0.00 0.00<br />

24362 S 1,348.79 0.00 0.00 25023 S 807.58 0.00 0.00<br />

24363 S 5,898.90 3,660.73 1,422.55 25024 S 807.58 0.00 0.00<br />

24365 S 1,055.39 0.00 0.00 25025 S 807.58 0.00 0.00<br />

24366 S 5,770.38 3,532.21 1,294.03 25028 S 570.74 0.00 0.00<br />

24400 S 863.05 0.00 0.00 25031 S 622.98 0.00 0.00<br />

24410 S 863.05 0.00 0.00 25035 S 622.98 0.00 0.00<br />

24420 S 1,103.64 0.00 0.00 25040 S 903.27 0.00 0.00<br />

24430 S 1,892.85 0.00 0.00 25065 S 135.76 0.00 0.00<br />

24435 S 1,948.32 0.00 0.00 25066 S 624.16 0.00 0.00<br />

24470 S 1,103.64 0.00 0.00 25075 S 510.39 0.00 0.00<br />

24495 S 777.99 0.00 0.00 25076 S 653.76 0.00 0.00<br />

24498 S 1,892.85 0.00 0.00 25077 S 653.76 0.00 0.00<br />

24500 S 78.47 0.00 0.00 25085 S 652.57 0.00 0.00<br />

24505 S 78.47 0.00 0.00 25100 S 622.98 0.00 0.00<br />

24515 S 1,488.55 0.00 0.00 25101 S 807.58 0.00 0.00<br />

24516 S 1,488.55 0.00 0.00 25105 S 863.05 0.00 0.00<br />

24530 S 78.47 0.00 0.00 25107 S 807.58 0.00 0.00<br />

24535 S 165.55 0.00 0.00 25109 S 833.59 0.00 0.00<br />

24538 S 693.08 0.00 0.00 25110 S 652.57 0.00 0.00<br />

24545 S 1,488.55 0.00 0.00 25111 S 652.57 0.00 0.00<br />

24546 S 1,528.77 0.00 0.00 25112 S 708.04 0.00 0.00<br />

24560 S 78.47 0.00 0.00 25115 S 708.04 0.00 0.00<br />

24565 S 78.47 0.00 0.00 25116 S 708.04 0.00 0.00<br />

24566 S 693.08 0.00 0.00 25118 S 777.99 0.00 0.00<br />

24575 S 1,433.08 0.00 0.00 25119 S 807.58 0.00 0.00<br />

24576 S 78.47 0.00 0.00 25120 S 807.58 0.00 0.00<br />

24577 S 165.55 0.00 0.00 25125 S 807.58 0.00 0.00<br />

24579 S 1,433.08 0.00 0.00 25126 S 807.58 0.00 0.00<br />

24582 S 693.08 0.00 0.00 25130 S 807.58 0.00 0.00<br />

24586 S 1,488.55 0.00 0.00 25135 S 807.58 0.00 0.00<br />

24587 S 1,528.77 0.00 0.00 25136 S 807.58 0.00 0.00<br />

24600 S 78.47 0.00 0.00 25145 S 777.99 0.00 0.00<br />

24605 S 504.07 0.00 0.00 25150 S 777.99 0.00 0.00<br />

24615 S 1,433.08 0.00 0.00 25151 S 777.99 0.00 0.00<br />

24620 S 428.18 0.00 0.00 25210 S 807.58 0.00 0.00<br />

24635 S 1,433.08 0.00 0.00 25215 S 863.05 0.00 0.00<br />

24640 S 53.00 0.00 0.00 25230 S 863.05 0.00 0.00<br />

24650 S 61.15 0.00 0.00 25240 S 863.05 0.00 0.00<br />

24655 S 165.55 0.00 0.00 25248 S 622.98 0.00 0.00<br />

24665 S 1,111.52 0.00 0.00 25250 S 725.75 0.00 0.00<br />

24666 S 1,488.55 0.00 0.00 25251 S 725.75 0.00 0.00<br />

24670 S 78.47 0.00 0.00 25259 S 760.55 0.00 0.00<br />

24675 S 78.47 0.00 0.00 25260 S 863.05 0.00 0.00<br />

24685 S 1,056.04 0.00 0.00 25263 S 777.99 0.00 0.00<br />

24800 S 1,159.12 0.00 0.00 25265 S 807.58 0.00 0.00<br />

24802 S 1,199.33 0.00 0.00 25270 S 863.05 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 807.58 0.00 0.00 25505 S 165.55 0.00 0.00<br />

25274 S 863.05 0.00 0.00 25515 S 1,056.04 0.00 0.00<br />

25275 S 863.05 0.00 0.00 25520 S 165.55 0.00 0.00<br />

25280 S 863.05 0.00 0.00 25525 S 1,111.52 0.00 0.00<br />

25290 S 807.58 0.00 0.00 25526 S 1,151.73 0.00 0.00<br />

25295 S 652.57 0.00 0.00 25530 S 61.15 0.00 0.00<br />

25300 S 807.58 0.00 0.00 25535 S 78.47 0.00 0.00<br />

25301 S 807.58 0.00 0.00 25545 S 1,056.04 0.00 0.00<br />

25310 S 1,103.64 0.00 0.00 25560 S 61.15 0.00 0.00<br />

25312 S 1,159.12 0.00 0.00 25565 S 165.55 0.00 0.00<br />

25315 S 1,103.64 0.00 0.00 25574 S 1,433.08 0.00 0.00<br />

25316 S 1,892.85 0.00 0.00 25575 S 1,433.08 0.00 0.00<br />

25320 S 1,103.64 0.00 0.00 25600 S 61.15 0.00 0.00<br />

25332 S 1,055.39 0.00 0.00 25605 S 165.55 0.00 0.00<br />

25335 S 1,103.64 0.00 0.00 25606 S 722.67 0.00 0.00<br />

25337 S 1,199.33 0.00 0.00 25607 S 1,528.77 0.00 0.00<br />

25350 S 1,892.85 0.00 0.00 25608 S 1,528.77 0.00 0.00<br />

25355 S 1,103.64 0.00 0.00 25609 S 1,528.77 0.00 0.00<br />

25360 S 807.58 0.00 0.00 25622 S 61.15 0.00 0.00<br />

25365 S 807.58 0.00 0.00 25624 S 165.55 0.00 0.00<br />

25370 S 1,103.64 0.00 0.00 25628 S 1,056.04 0.00 0.00<br />

25375 S 1,159.12 0.00 0.00 25630 S 61.15 0.00 0.00<br />

25390 S 807.58 0.00 0.00 25635 S 165.55 0.00 0.00<br />

25391 S 1,159.12 0.00 0.00 25645 S 1,056.04 0.00 0.00<br />

25392 S 807.58 0.00 0.00 25650 S 61.15 0.00 0.00<br />

25393 S 1,159.12 0.00 0.00 25651 S 973.79 0.00 0.00<br />

25394 S 1,735.75 0.00 0.00 25652 S 1,640.53 0.00 0.00<br />

25400 S 1,103.64 0.00 0.00 25660 S 78.47 0.00 0.00<br />

25405 S 1,948.32 0.00 0.00 25670 S 722.67 0.00 0.00<br />

25415 S 1,892.85 0.00 0.00 25671 S 640.84 0.00 0.00<br />

25420 S 1,948.32 0.00 0.00 25675 S 78.47 0.00 0.00<br />

25425 S 1,103.64 0.00 0.00 25676 S 693.08 0.00 0.00<br />

25426 S 1,159.12 0.00 0.00 25680 S 78.47 0.00 0.00<br />

25430 S 1,735.75 0.00 0.00 25685 S 722.67 0.00 0.00<br />

25431 S 1,735.75 0.00 0.00 25690 S 428.18 0.00 0.00<br />

25440 S 1,948.32 0.00 0.00 25695 S 693.08 0.00 0.00<br />

25441 S 5,770.38 3,532.21 1,294.03 25800 S 1,948.32 0.00 0.00<br />

25442 S 5,770.38 3,532.21 1,294.03 25805 S 1,199.33 0.00 0.00<br />

25443 S 1,348.79 0.00 0.00 25810 S 1,988.55 0.00 0.00<br />

25444 S 1,348.79 0.00 0.00 25820 S 1,159.12 0.00 0.00<br />

25445 S 1,348.79 0.00 0.00 25825 S 1,988.55 0.00 0.00<br />

25446 S 5,898.90 3,660.73 1,422.55 25830 S 1,988.55 0.00 0.00<br />

25447 S 1,055.39 0.00 0.00 25907 S 652.57 0.00 0.00<br />

25449 S 1,055.39 0.00 0.00 25922 S 652.57 0.00 0.00<br />

25450 S 1,103.64 0.00 0.00 25929 S 541.46 0.00 0.00<br />

25455 S 1,103.64 0.00 0.00 25931 S 833.59 0.00 0.00<br />

25490 S 1,103.64 0.00 0.00 26010 S 54.07 0.00 0.00<br />

25491 S 1,103.64 0.00 0.00 26011 S 394.96 0.00 0.00<br />

25492 S 1,103.64 0.00 0.00 26020 S 524.07 0.00 0.00<br />

25500 S 61.15 0.00 0.00 26025 S 471.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 524.07 0.00 0.00 26392 S 771.56 0.00 0.00<br />

26034 S 524.07 0.00 0.00 26410 S 553.65 0.00 0.00<br />

26035 S 635.77 0.00 0.00 26412 S 771.56 0.00 0.00<br />

26040 S 827.04 0.00 0.00 26415 S 827.04 0.00 0.00<br />

26045 S 771.56 0.00 0.00 26416 S 771.56 0.00 0.00<br />

26055 S 524.07 0.00 0.00 26418 S 609.13 0.00 0.00<br />

26060 S 524.07 0.00 0.00 26420 S 827.04 0.00 0.00<br />

26070 S 524.07 0.00 0.00 26426 S 771.56 0.00 0.00<br />

26075 S 609.13 0.00 0.00 26428 S 771.56 0.00 0.00<br />

26080 S 609.13 0.00 0.00 26432 S 553.65 0.00 0.00<br />

26100 S 524.07 0.00 0.00 26433 S 553.65 0.00 0.00<br />

26105 S 471.82 0.00 0.00 26434 S 771.56 0.00 0.00<br />

26110 S 471.82 0.00 0.00 26437 S 553.65 0.00 0.00<br />

26115 S 624.16 0.00 0.00 26440 S 553.65 0.00 0.00<br />

26116 S 624.16 0.00 0.00 26442 S 771.56 0.00 0.00<br />

26117 S 653.76 0.00 0.00 26445 S 553.65 0.00 0.00<br />

26121 S 827.04 0.00 0.00 26449 S 771.56 0.00 0.00<br />

26123 S 827.04 0.00 0.00 26450 S 553.65 0.00 0.00<br />

26125 S 609.13 0.00 0.00 26455 S 553.65 0.00 0.00<br />

26130 S 553.65 0.00 0.00 26460 S 553.65 0.00 0.00<br />

26135 S 827.04 0.00 0.00 26471 S 524.07 0.00 0.00<br />

26140 S 524.07 0.00 0.00 26474 S 524.07 0.00 0.00<br />

26145 S 553.65 0.00 0.00 26476 S 471.82 0.00 0.00<br />

26160 S 553.65 0.00 0.00 26477 S 471.82 0.00 0.00<br />

26170 S 553.65 0.00 0.00 26478 S 471.82 0.00 0.00<br />

26180 S 553.65 0.00 0.00 26479 S 471.82 0.00 0.00<br />

26185 S 609.13 0.00 0.00 26480 S 771.56 0.00 0.00<br />

26200 S 524.07 0.00 0.00 26483 S 771.56 0.00 0.00<br />

26205 S 771.56 0.00 0.00 26485 S 741.98 0.00 0.00<br />

26210 S 524.07 0.00 0.00 26489 S 771.56 0.00 0.00<br />

26215 S 553.65 0.00 0.00 26490 S 771.56 0.00 0.00<br />

26230 S 776.92 0.00 0.00 26492 S 771.56 0.00 0.00<br />

26235 S 553.65 0.00 0.00 26494 S 771.56 0.00 0.00<br />

26236 S 553.65 0.00 0.00 26496 S 771.56 0.00 0.00<br />

26250 S 553.65 0.00 0.00 26497 S 771.56 0.00 0.00<br />

26255 S 771.56 0.00 0.00 26498 S 827.04 0.00 0.00<br />

26260 S 553.65 0.00 0.00 26499 S 771.56 0.00 0.00<br />

26261 S 553.65 0.00 0.00 26500 S 609.13 0.00 0.00<br />

26262 S 524.07 0.00 0.00 26502 S 827.04 0.00 0.00<br />

26320 S 510.39 0.00 0.00 26508 S 553.65 0.00 0.00<br />

26340 S 235.29 0.00 0.00 26510 S 771.56 0.00 0.00<br />

26350 S 689.73 0.00 0.00 26516 S 689.73 0.00 0.00<br />

26352 S 827.04 0.00 0.00 26517 S 771.56 0.00 0.00<br />

26356 S 827.04 0.00 0.00 26518 S 771.56 0.00 0.00<br />

26357 S 827.04 0.00 0.00 26520 S 553.65 0.00 0.00<br />

26358 S 827.04 0.00 0.00 26525 S 553.65 0.00 0.00<br />

26370 S 827.04 0.00 0.00 26530 S 959.70 0.00 0.00<br />

26372 S 827.04 0.00 0.00 26531 S 1,477.31 0.00 0.00<br />

26373 S 771.56 0.00 0.00 26535 S 1,055.39 0.00 0.00<br />

26390 S 827.04 0.00 0.00 26536 S 1,348.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 609.13 0.00 0.00 26775 S 163.47 0.00 0.00<br />

26541 S 995.77 0.00 0.00 26776 S 693.08 0.00 0.00<br />

26542 S 609.13 0.00 0.00 26785 S 693.08 0.00 0.00<br />

26545 S 827.04 0.00 0.00 26820 S 867.25 0.00 0.00<br />

26546 S 827.04 0.00 0.00 26841 S 827.04 0.00 0.00<br />

26548 S 827.04 0.00 0.00 26842 S 827.04 0.00 0.00<br />

26550 S 741.98 0.00 0.00 26843 S 771.56 0.00 0.00<br />

26555 S 771.56 0.00 0.00 26844 S 771.56 0.00 0.00<br />

26560 S 524.07 0.00 0.00 26850 S 827.04 0.00 0.00<br />

26561 S 771.56 0.00 0.00 26852 S 827.04 0.00 0.00<br />

26562 S 827.04 0.00 0.00 26860 S 771.56 0.00 0.00<br />

26565 S 867.25 0.00 0.00 26861 S 741.98 0.00 0.00<br />

26567 S 867.25 0.00 0.00 26862 S 827.04 0.00 0.00<br />

26568 S 771.56 0.00 0.00 26863 S 771.56 0.00 0.00<br />

26580 S 649.35 0.00 0.00 26910 S 771.56 0.00 0.00<br />

26587 S 649.35 0.00 0.00 26951 S 524.07 0.00 0.00<br />

26590 S 649.35 0.00 0.00 26952 S 609.13 0.00 0.00<br />

26591 S 771.56 0.00 0.00 26990 S 570.74 0.00 0.00<br />

26593 S 553.65 0.00 0.00 26991 S 570.74 0.00 0.00<br />

26596 S 524.07 0.00 0.00 27000 S 622.98 0.00 0.00<br />

26600 S 61.15 0.00 0.00 27001 S 807.58 0.00 0.00<br />

26605 S 78.47 0.00 0.00 27003 S 807.58 0.00 0.00<br />

26607 S 428.18 0.00 0.00 27033 S 1,103.64 0.00 0.00<br />

26608 S 778.14 0.00 0.00 27035 S 1,159.12 0.00 0.00<br />

26615 S 1,111.52 0.00 0.00 27040 S 311.94 0.00 0.00<br />

26641 S 61.15 0.00 0.00 27041 S 351.46 0.00 0.00<br />

26645 S 165.55 0.00 0.00 27047 S 624.16 0.00 0.00<br />

26650 S 693.08 0.00 0.00 27048 S 653.76 0.00 0.00<br />

26665 S 1,111.52 0.00 0.00 27049 S 653.76 0.00 0.00<br />

26670 S 61.15 0.00 0.00 27050 S 652.57 0.00 0.00<br />

26675 S 165.55 0.00 0.00 27052 S 652.57 0.00 0.00<br />

26676 S 693.08 0.00 0.00 27060 S 748.26 0.00 0.00<br />

26685 S 722.67 0.00 0.00 27062 S 748.26 0.00 0.00<br />

26686 S 1,433.08 0.00 0.00 27065 S 748.26 0.00 0.00<br />

26700 S 61.15 0.00 0.00 27066 S 903.27 0.00 0.00<br />

26705 S 78.47 0.00 0.00 27067 S 903.27 0.00 0.00<br />

26706 S 428.18 0.00 0.00 27080 S 777.99 0.00 0.00<br />

26715 S 778.14 0.00 0.00 27086 S 311.94 0.00 0.00<br />

26720 S 61.15 0.00 0.00 27087 S 652.57 0.00 0.00<br />

26725 S 61.15 0.00 0.00 27097 S 807.58 0.00 0.00<br />

26727 S 946.88 0.00 0.00 27098 S 807.58 0.00 0.00<br />

26735 S 778.14 0.00 0.00 27100 S 1,159.12 0.00 0.00<br />

26740 S 61.15 0.00 0.00 27105 S 1,159.12 0.00 0.00<br />

26742 S 78.47 0.00 0.00 27110 S 1,159.12 0.00 0.00<br />

26746 S 818.36 0.00 0.00 27111 S 1,159.12 0.00 0.00<br />

26750 S 61.15 0.00 0.00 27193 S 78.47 0.00 0.00<br />

26755 S 61.15 0.00 0.00 27194 S 504.07 0.00 0.00<br />

26756 S 693.08 0.00 0.00 27200 S 61.15 0.00 0.00<br />

26765 S 778.14 0.00 0.00 27202 S 1,026.45 0.00 0.00<br />

26770 S 61.15 0.00 0.00 27220 S 61.15 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 78.47 0.00 0.00 27397 S 1,103.64 0.00 0.00<br />

27238 S 165.55 0.00 0.00 27400 S 1,103.64 0.00 0.00<br />

27246 S 165.55 0.00 0.00 27403 S 863.05 0.00 0.00<br />

27250 S 78.47 0.00 0.00 27405 S 1,159.12 0.00 0.00<br />

27252 S 504.07 0.00 0.00 27407 S 1,948.32 0.00 0.00<br />

27256 S 61.15 0.00 0.00 27409 S 1,159.12 0.00 0.00<br />

27257 S 533.67 0.00 0.00 27416 S 1,735.75 0.00 0.00<br />

27265 S 78.47 0.00 0.00 27418 S 1,103.64 0.00 0.00<br />

27266 S 504.07 0.00 0.00 27420 S 1,103.64 0.00 0.00<br />

27267 S 61.15 0.00 0.00 27422 S 1,327.85 0.00 0.00<br />

27275 S 504.07 0.00 0.00 27424 S 1,103.64 0.00 0.00<br />

27301 S 606.76 0.00 0.00 27425 S 1,031.79 0.00 0.00<br />

27305 S 622.98 0.00 0.00 27427 S 1,103.64 0.00 0.00<br />

27306 S 652.57 0.00 0.00 27428 S 1,948.32 0.00 0.00<br />

27307 S 652.57 0.00 0.00 27429 S 1,948.32 0.00 0.00<br />

27310 S 863.05 0.00 0.00 27430 S 1,159.12 0.00 0.00<br />

27323 S 311.94 0.00 0.00 27435 S 1,159.12 0.00 0.00<br />

27324 S 571.93 0.00 0.00 27437 S 1,015.17 0.00 0.00<br />

27325 S 560.41 0.00 0.00 27438 S 1,348.79 0.00 0.00<br />

27326 S 560.41 0.00 0.00 27440 S 1,447.85 0.00 0.00<br />

27327 S 624.16 0.00 0.00 27441 S 1,055.39 0.00 0.00<br />

27328 S 653.76 0.00 0.00 27442 S 1,055.39 0.00 0.00<br />

27329 S 709.23 0.00 0.00 27443 S 1,055.39 0.00 0.00<br />

27330 S 863.05 0.00 0.00 27446 S 10,355.45 6,221.08 2,086.71<br />

27331 S 863.05 0.00 0.00 27496 S 748.26 0.00 0.00<br />

27332 S 863.05 0.00 0.00 27497 S 652.57 0.00 0.00<br />

27333 S 863.05 0.00 0.00 27498 S 652.57 0.00 0.00<br />

27334 S 863.05 0.00 0.00 27499 S 652.57 0.00 0.00<br />

27335 S 863.05 0.00 0.00 27500 S 165.55 0.00 0.00<br />

27340 S 652.57 0.00 0.00 27501 S 78.47 0.00 0.00<br />

27345 S 708.04 0.00 0.00 27502 S 428.18 0.00 0.00<br />

27347 S 708.04 0.00 0.00 27503 S 78.47 0.00 0.00<br />

27350 S 863.05 0.00 0.00 27508 S 78.47 0.00 0.00<br />

27355 S 807.58 0.00 0.00 27509 S 722.67 0.00 0.00<br />

27356 S 863.05 0.00 0.00 27510 S 165.55 0.00 0.00<br />

27357 S 903.27 0.00 0.00 27516 S 78.47 0.00 0.00<br />

27358 S 903.27 0.00 0.00 27517 S 78.47 0.00 0.00<br />

27360 S 903.27 0.00 0.00 27520 S 78.47 0.00 0.00<br />

27372 S 877.97 0.00 0.00 27530 S 78.47 0.00 0.00<br />

27380 S 570.74 0.00 0.00 27532 S 428.18 0.00 0.00<br />

27381 S 652.57 0.00 0.00 27538 S 78.47 0.00 0.00<br />

27385 S 652.57 0.00 0.00 27550 S 78.47 0.00 0.00<br />

27386 S 652.57 0.00 0.00 27552 S 451.84 0.00 0.00<br />

27390 S 570.74 0.00 0.00 27560 S 78.47 0.00 0.00<br />

27391 S 622.98 0.00 0.00 27562 S 451.84 0.00 0.00<br />

27392 S 652.57 0.00 0.00 27566 S 1,026.45 0.00 0.00<br />

27393 S 777.99 0.00 0.00 27570 S 451.84 0.00 0.00<br />

27394 S 807.58 0.00 0.00 27594 S 652.57 0.00 0.00<br />

27395 S 1,103.64 0.00 0.00 27600 S 652.57 0.00 0.00<br />

27396 S 807.58 0.00 0.00 27601 S 652.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 652.57 0.00 0.00 27730 S 777.99 0.00 0.00<br />

27603 S 577.18 0.00 0.00 27732 S 777.99 0.00 0.00<br />

27604 S 622.98 0.00 0.00 27734 S 777.99 0.00 0.00<br />

27605 S 567.68 0.00 0.00 27740 S 777.99 0.00 0.00<br />

27606 S 570.74 0.00 0.00 27742 S 1,074.05 0.00 0.00<br />

27607 S 622.98 0.00 0.00 27745 S 1,892.85 0.00 0.00<br />

27610 S 777.99 0.00 0.00 27750 S 78.47 0.00 0.00<br />

27612 S 807.58 0.00 0.00 27752 S 428.18 0.00 0.00<br />

27613 S 128.24 0.00 0.00 27756 S 722.67 0.00 0.00<br />

27614 S 624.16 0.00 0.00 27758 S 1,111.52 0.00 0.00<br />

27615 S 807.58 0.00 0.00 27759 S 1,488.55 0.00 0.00<br />

27618 S 510.39 0.00 0.00 27760 S 78.47 0.00 0.00<br />

27619 S 653.76 0.00 0.00 27762 S 428.18 0.00 0.00<br />

27620 S 863.05 0.00 0.00 27766 S 1,056.04 0.00 0.00<br />

27625 S 863.05 0.00 0.00 27767 S 61.15 0.00 0.00<br />

27626 S 863.05 0.00 0.00 27768 S 61.15 0.00 0.00<br />

27630 S 652.57 0.00 0.00 27769 S 1,640.53 0.00 0.00<br />

27635 S 807.58 0.00 0.00 27780 S 78.47 0.00 0.00<br />

27637 S 807.58 0.00 0.00 27781 S 428.18 0.00 0.00<br />

27638 S 807.58 0.00 0.00 27784 S 1,056.04 0.00 0.00<br />

27640 S 1,074.05 0.00 0.00 27786 S 78.47 0.00 0.00<br />

27641 S 777.99 0.00 0.00 27788 S 78.47 0.00 0.00<br />

27647 S 1,103.64 0.00 0.00 27792 S 1,056.04 0.00 0.00<br />

27650 S 1,103.64 0.00 0.00 27808 S 78.47 0.00 0.00<br />

27652 S 1,892.85 0.00 0.00 27810 S 165.55 0.00 0.00<br />

27654 S 1,103.64 0.00 0.00 27814 S 1,056.04 0.00 0.00<br />

27656 S 622.98 0.00 0.00 27816 S 78.47 0.00 0.00<br />

27658 S 570.74 0.00 0.00 27818 S 165.55 0.00 0.00<br />

27659 S 622.98 0.00 0.00 27822 S 1,056.04 0.00 0.00<br />

27664 S 622.98 0.00 0.00 27823 S 1,433.08 0.00 0.00<br />

27665 S 777.99 0.00 0.00 27824 S 78.47 0.00 0.00<br />

27675 S 622.98 0.00 0.00 27825 S 428.18 0.00 0.00<br />

27676 S 807.58 0.00 0.00 27826 S 1,056.04 0.00 0.00<br />

27680 S 807.58 0.00 0.00 27827 S 1,433.08 0.00 0.00<br />

27681 S 777.99 0.00 0.00 27828 S 1,488.55 0.00 0.00<br />

27685 S 807.58 0.00 0.00 27829 S 1,026.45 0.00 0.00<br />

27686 S 807.58 0.00 0.00 27830 S 78.47 0.00 0.00<br />

27687 S 807.58 0.00 0.00 27831 S 428.18 0.00 0.00<br />

27690 S 1,159.12 0.00 0.00 27832 S 1,026.45 0.00 0.00<br />

27691 S 1,159.12 0.00 0.00 27840 S 165.55 0.00 0.00<br />

27692 S 1,103.64 0.00 0.00 27842 S 451.84 0.00 0.00<br />

27695 S 777.99 0.00 0.00 27846 S 1,056.04 0.00 0.00<br />

27696 S 777.99 0.00 0.00 27848 S 1,056.04 0.00 0.00<br />

27698 S 777.99 0.00 0.00 27860 S 451.84 0.00 0.00<br />

27700 S 1,055.39 0.00 0.00 27870 S 1,948.32 0.00 0.00<br />

27704 S 622.98 0.00 0.00 27871 S 1,948.32 0.00 0.00<br />

27705 S 1,074.05 0.00 0.00 27884 S 652.57 0.00 0.00<br />

27707 S 622.98 0.00 0.00 27889 S 807.58 0.00 0.00<br />

27709 S 777.99 0.00 0.00 27892 S 652.57 0.00 0.00<br />

27726 S 973.79 0.00 0.00 27893 S 652.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 652.57 0.00 0.00 28153 S 649.51 0.00 0.00<br />

28001 S 125.16 0.00 0.00 28160 S 649.51 0.00 0.00<br />

28002 S 652.57 0.00 0.00 28171 S 649.51 0.00 0.00<br />

28003 S 652.57 0.00 0.00 28173 S 649.51 0.00 0.00<br />

28005 S 649.51 0.00 0.00 28175 S 649.51 0.00 0.00<br />

28008 S 649.51 0.00 0.00 28190 S 129.27 0.00 0.00<br />

28010 S 91.99 0.00 0.00 28192 S 510.39 0.00 0.00<br />

28011 S 649.51 0.00 0.00 28193 S 351.46 0.00 0.00<br />

28020 S 619.91 0.00 0.00 28200 S 649.51 0.00 0.00<br />

28022 S 619.91 0.00 0.00 28202 S 649.51 0.00 0.00<br />

28024 S 619.91 0.00 0.00 28208 S 649.51 0.00 0.00<br />

28035 S 645.47 0.00 0.00 28210 S 1,140.73 0.00 0.00<br />

28043 S 624.16 0.00 0.00 28220 S 199.38 0.00 0.00<br />

28045 S 649.51 0.00 0.00 28222 S 567.68 0.00 0.00<br />

28046 S 649.51 0.00 0.00 28225 S 567.68 0.00 0.00<br />

28050 S 619.91 0.00 0.00 28226 S 567.68 0.00 0.00<br />

28052 S 619.91 0.00 0.00 28230 S 195.61 0.00 0.00<br />

28054 S 619.91 0.00 0.00 28232 S 187.06 0.00 0.00<br />

28055 S 645.47 0.00 0.00 28234 S 619.91 0.00 0.00<br />

28060 S 619.91 0.00 0.00 28238 S 1,140.73 0.00 0.00<br />

28062 S 649.51 0.00 0.00 28240 S 619.91 0.00 0.00<br />

28070 S 649.51 0.00 0.00 28250 S 649.51 0.00 0.00<br />

28072 S 649.51 0.00 0.00 28260 S 649.51 0.00 0.00<br />

28080 S 649.51 0.00 0.00 28261 S 649.51 0.00 0.00<br />

28086 S 619.91 0.00 0.00 28262 S 704.98 0.00 0.00<br />

28088 S 619.91 0.00 0.00 28264 S 1,058.90 0.00 0.00<br />

28090 S 649.51 0.00 0.00 28270 S 649.51 0.00 0.00<br />

28092 S 649.51 0.00 0.00 28272 S 180.57 0.00 0.00<br />

28100 S 619.91 0.00 0.00 28280 S 619.91 0.00 0.00<br />

28102 S 1,140.73 0.00 0.00 28285 S 649.51 0.00 0.00<br />

28103 S 1,140.73 0.00 0.00 28286 S 704.98 0.00 0.00<br />

28104 S 619.91 0.00 0.00 28288 S 649.51 0.00 0.00<br />

28106 S 1,140.73 0.00 0.00 28289 S 649.51 0.00 0.00<br />

28107 S 1,140.73 0.00 0.00 28290 S 800.60 0.00 0.00<br />

28108 S 619.91 0.00 0.00 28292 S 800.60 0.00 0.00<br />

28110 S 649.51 0.00 0.00 28293 S 830.19 0.00 0.00<br />

28111 S 649.51 0.00 0.00 28294 S 830.19 0.00 0.00<br />

28112 S 649.51 0.00 0.00 28296 S 830.19 0.00 0.00<br />

28113 S 649.51 0.00 0.00 28297 S 830.19 0.00 0.00<br />

28114 S 649.51 0.00 0.00 28298 S 830.19 0.00 0.00<br />

28116 S 649.51 0.00 0.00 28299 S 925.88 0.00 0.00<br />

28118 S 704.98 0.00 0.00 28300 S 1,111.15 0.00 0.00<br />

28119 S 704.98 0.00 0.00 28302 S 619.91 0.00 0.00<br />

28120 S 873.72 0.00 0.00 28304 S 1,111.15 0.00 0.00<br />

28122 S 649.51 0.00 0.00 28305 S 1,140.73 0.00 0.00<br />

28124 S 211.69 0.00 0.00 28306 S 704.98 0.00 0.00<br />

28126 S 649.51 0.00 0.00 28307 S 704.98 0.00 0.00<br />

28130 S 649.51 0.00 0.00 28308 S 619.91 0.00 0.00<br />

28140 S 649.51 0.00 0.00 28309 S 1,196.21 0.00 0.00<br />

28150 S 649.51 0.00 0.00 28310 S 649.51 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 649.51 0.00 0.00 28636 S 722.67 0.00 0.00<br />

28313 S 619.91 0.00 0.00 28645 S 722.67 0.00 0.00<br />

28315 S 704.98 0.00 0.00 28660 S 43.78 0.00 0.00<br />

28320 S 1,196.21 0.00 0.00 28665 S 451.84 0.00 0.00<br />

28322 S 1,196.21 0.00 0.00 28666 S 722.67 0.00 0.00<br />

28340 S 704.98 0.00 0.00 28675 S 722.67 0.00 0.00<br />

28341 S 704.98 0.00 0.00 28705 S 1,196.21 0.00 0.00<br />

28344 S 704.98 0.00 0.00 28715 S 1,948.32 0.00 0.00<br />

28345 S 704.98 0.00 0.00 28725 S 1,196.21 0.00 0.00<br />

28400 S 78.47 0.00 0.00 28730 S 1,196.21 0.00 0.00<br />

28405 S 428.18 0.00 0.00 28735 S 1,196.21 0.00 0.00<br />

28406 S 693.08 0.00 0.00 28737 S 1,236.42 0.00 0.00<br />

28415 S 1,433.08 0.00 0.00 28740 S 1,196.21 0.00 0.00<br />

28420 S 1,111.52 0.00 0.00 28750 S 1,196.21 0.00 0.00<br />

28430 S 61.15 0.00 0.00 28755 S 704.98 0.00 0.00<br />

28435 S 78.47 0.00 0.00 28760 S 1,196.21 0.00 0.00<br />

28436 S 693.08 0.00 0.00 28810 S 619.91 0.00 0.00<br />

28445 S 1,056.04 0.00 0.00 28820 S 619.91 0.00 0.00<br />

28446 S 1,809.92 0.00 0.00 28825 S 619.91 0.00 0.00<br />

28450 S 61.15 0.00 0.00 28890 S 163.81 0.00 0.00<br />

28455 S 61.15 0.00 0.00 29000 S 41.50 0.00 0.00<br />

28456 S 693.08 0.00 0.00 29010 S 93.02 0.00 0.00<br />

28465 S 1,056.04 0.00 0.00 29015 S 93.02 0.00 0.00<br />

28470 S 61.15 0.00 0.00 29020 S 41.50 0.00 0.00<br />

28475 S 61.15 0.00 0.00 29025 S 41.50 0.00 0.00<br />

28476 S 693.08 0.00 0.00 29035 S 93.02 0.00 0.00<br />

28485 S 1,111.52 0.00 0.00 29040 S 41.50 0.00 0.00<br />

28490 S 61.15 0.00 0.00 29044 S 93.02 0.00 0.00<br />

28495 S 61.15 0.00 0.00 29046 S 93.02 0.00 0.00<br />

28496 S 693.08 0.00 0.00 29049 S 37.62 0.00 0.00<br />

28505 S 722.67 0.00 0.00 29055 S 93.02 0.00 0.00<br />

28510 S 55.06 0.00 0.00 29058 S 41.50 0.00 0.00<br />

28515 S 61.15 0.00 0.00 29065 S 44.12 0.00 0.00<br />

28525 S 722.67 0.00 0.00 29075 S 42.40 0.00 0.00<br />

28530 S 53.00 0.00 0.00 29085 S 41.50 0.00 0.00<br />

28531 S 722.67 0.00 0.00 29086 S 35.57 0.00 0.00<br />

28540 S 61.15 0.00 0.00 29105 S 38.30 0.00 0.00<br />

28545 S 640.84 0.00 0.00 29125 S 33.17 0.00 0.00<br />

28546 S 693.08 0.00 0.00 29126 S 35.23 0.00 0.00<br />

28555 S 1,026.45 0.00 0.00 29130 S 15.05 0.00 0.00<br />

28570 S 79.34 0.00 0.00 29131 S 21.88 0.00 0.00<br />

28575 S 428.18 0.00 0.00 29200 S 21.20 0.00 0.00<br />

28576 S 722.67 0.00 0.00 29220 S 22.91 0.00 0.00<br />

28585 S 722.67 0.00 0.00 29240 S 23.94 0.00 0.00<br />

28600 S 61.15 0.00 0.00 29260 S 22.91 0.00 0.00<br />

28605 S 78.47 0.00 0.00 29280 S 23.26 0.00 0.00<br />

28606 S 693.08 0.00 0.00 29305 S 93.02 0.00 0.00<br />

28615 S 1,056.04 0.00 0.00 29325 S 93.02 0.00 0.00<br />

28630 S 61.15 0.00 0.00 29345 S 57.79 0.00 0.00<br />

28635 S 451.84 0.00 0.00 29355 S 56.77 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 70.45 0.00 0.00 29847 S 1,177.54 0.00 0.00<br />

29365 S 54.72 0.00 0.00 29848 S 1,181.88 0.00 0.00<br />

29405 S 40.70 0.00 0.00 29850 S 854.12 0.00 0.00<br />

29425 S 41.38 0.00 0.00 29851 S 1,233.02 0.00 0.00<br />

29435 S 52.32 0.00 0.00 29855 S 1,233.02 0.00 0.00<br />

29440 S 22.23 0.00 0.00 29856 S 1,233.02 0.00 0.00<br />

29445 S 55.06 0.00 0.00 29860 S 1,233.02 0.00 0.00<br />

29450 S 41.50 0.00 0.00 29861 S 1,233.02 0.00 0.00<br />

29505 S 36.93 0.00 0.00 29862 S 1,560.78 0.00 0.00<br />

29515 S 31.46 0.00 0.00 29863 S 1,233.02 0.00 0.00<br />

29520 S 22.57 0.00 0.00 29866 S 1,883.54 0.00 0.00<br />

29530 S 22.91 0.00 0.00 29870 S 798.65 0.00 0.00<br />

29540 S 17.10 0.00 0.00 29871 S 798.65 0.00 0.00<br />

29550 S 17.44 0.00 0.00 29873 S 798.65 0.00 0.00<br />

29580 S 23.60 0.00 0.00 29874 S 798.65 0.00 0.00<br />

29590 S 19.15 0.00 0.00 29875 S 854.12 0.00 0.00<br />

29700 S 31.80 0.00 0.00 29876 S 854.12 0.00 0.00<br />

29705 S 27.01 0.00 0.00 29877 S 854.12 0.00 0.00<br />

29710 S 47.53 0.00 0.00 29879 S 798.65 0.00 0.00<br />

29715 S 41.50 0.00 0.00 29880 S 854.12 0.00 0.00<br />

29720 S 39.67 0.00 0.00 29881 S 854.12 0.00 0.00<br />

29730 S 25.99 0.00 0.00 29882 S 798.65 0.00 0.00<br />

29740 S 35.57 0.00 0.00 29883 S 798.65 0.00 0.00<br />

29750 S 37.27 0.00 0.00 29884 S 798.65 0.00 0.00<br />

29800 S 798.65 0.00 0.00 29885 S 1,177.54 0.00 0.00<br />

29804 S 798.65 0.00 0.00 29886 S 798.65 0.00 0.00<br />

29805 S 798.65 0.00 0.00 29887 S 798.65 0.00 0.00<br />

29806 S 1,177.54 0.00 0.00 29888 S 1,177.54 0.00 0.00<br />

29807 S 1,177.54 0.00 0.00 29889 S 1,177.54 0.00 0.00<br />

29819 S 1,177.54 0.00 0.00 29891 S 1,177.54 0.00 0.00<br />

29820 S 1,177.54 0.00 0.00 29892 S 1,177.54 0.00 0.00<br />

29821 S 1,177.54 0.00 0.00 29893 S 994.17 0.00 0.00<br />

29822 S 798.65 0.00 0.00 29894 S 798.65 0.00 0.00<br />

29823 S 1,177.54 0.00 0.00 29895 S 798.65 0.00 0.00<br />

29824 S 894.34 0.00 0.00 29897 S 798.65 0.00 0.00<br />

29825 S 1,177.54 0.00 0.00 29898 S 798.65 0.00 0.00<br />

29826 S 1,177.54 0.00 0.00 29899 S 1,177.54 0.00 0.00<br />

29827 S 1,273.23 0.00 0.00 29900 S 798.65 0.00 0.00<br />

29828 S 1,883.54 0.00 0.00 29901 S 798.65 0.00 0.00<br />

29830 S 798.65 0.00 0.00 29902 S 798.65 0.00 0.00<br />

29834 S 798.65 0.00 0.00 29904 S 1,125.75 0.00 0.00<br />

29835 S 798.65 0.00 0.00 29905 S 1,125.75 0.00 0.00<br />

29836 S 798.65 0.00 0.00 29906 S 1,125.75 0.00 0.00<br />

29837 S 798.65 0.00 0.00 29907 S 1,883.54 0.00 0.00<br />

29838 S 798.65 0.00 0.00 30000 S 126.57 0.00 0.00<br />

29840 S 798.65 0.00 0.00 30020 S 126.57 0.00 0.00<br />

29843 S 798.65 0.00 0.00 30100 S 82.08 0.00 0.00<br />

29844 S 798.65 0.00 0.00 30110 S 126.88 0.00 0.00<br />

29845 S 798.65 0.00 0.00 30115 S 536.08 0.00 0.00<br />

29846 S 798.65 0.00 0.00 30117 S 565.68 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 709.49 0.00 0.00 31080 S 1,092.54 0.00 0.00<br />

30120 S 483.85 0.00 0.00 31081 S 1,092.54 0.00 0.00<br />

30124 S 288.30 0.00 0.00 31084 S 1,092.54 0.00 0.00<br />

30125 S 1,007.47 0.00 0.00 31085 S 1,092.54 0.00 0.00<br />

30130 S 565.68 0.00 0.00 31086 S 1,092.54 0.00 0.00<br />

30140 S 679.90 0.00 0.00 31087 S 1,092.54 0.00 0.00<br />

30150 S 1,037.07 0.00 0.00 31090 S 1,132.76 0.00 0.00<br />

30160 S 1,092.54 0.00 0.00 31200 S 1,007.47 0.00 0.00<br />

30200 S 64.64 0.00 0.00 31201 S 1,132.76 0.00 0.00<br />

30210 S 82.08 0.00 0.00 31205 S 1,037.07 0.00 0.00<br />

30220 S 358.72 0.00 0.00 31231 S 69.19 0.00 0.00<br />

30300 S 24.73 0.00 0.00 31233 S 74.53 0.00 0.00<br />

30310 S 483.85 0.00 0.00 31235 S 506.35 0.00 0.00<br />

30320 S 536.08 0.00 0.00 31237 S 558.58 0.00 0.00<br />

30400 S 1,092.54 0.00 0.00 31238 S 506.35 0.00 0.00<br />

30410 S 1,132.76 0.00 0.00 31239 S 739.11 0.00 0.00<br />

30420 S 1,132.76 0.00 0.00 31240 S 558.58 0.00 0.00<br />

30430 S 709.49 0.00 0.00 31254 S 683.63 0.00 0.00<br />

30435 S 1,132.76 0.00 0.00 31255 S 779.33 0.00 0.00<br />

30450 S 1,261.28 0.00 0.00 31256 S 683.63 0.00 0.00<br />

30460 S 1,261.28 0.00 0.00 31267 S 683.63 0.00 0.00<br />

30462 S 1,420.30 0.00 0.00 31276 S 683.63 0.00 0.00<br />

30465 S 1,420.30 0.00 0.00 31287 S 683.63 0.00 0.00<br />

30520 S 764.96 0.00 0.00 31288 S 683.63 0.00 0.00<br />

30540 S 1,132.76 0.00 0.00 31300 S 805.18 0.00 0.00<br />

30545 S 1,132.76 0.00 0.00 31320 S 1,007.47 0.00 0.00<br />

30560 S 132.96 0.00 0.00 31400 S 1,007.47 0.00 0.00<br />

30580 S 1,092.54 0.00 0.00 31420 S 1,007.47 0.00 0.00<br />

30600 S 1,092.54 0.00 0.00 31500 S 92.54 0.00 0.00<br />

30620 S 1,261.28 0.00 0.00 31502 S 53.21 0.00 0.00<br />

30630 S 933.70 0.00 0.00 31505 S 31.44 0.00 0.00<br />

30801 S 298.10 0.00 0.00 31510 S 558.58 0.00 0.00<br />

30802 S 298.10 0.00 0.00 31511 S 74.53 0.00 0.00<br />

30901 S 42.52 0.00 0.00 31512 S 558.58 0.00 0.00<br />

30903 S 54.77 0.00 0.00 31513 S 74.53 0.00 0.00<br />

30905 S 54.77 0.00 0.00 31515 S 506.35 0.00 0.00<br />

30906 S 54.77 0.00 0.00 31520 S 69.19 0.00 0.00<br />

30915 S 729.76 0.00 0.00 31525 S 506.35 0.00 0.00<br />

30920 S 759.36 0.00 0.00 31526 S 654.05 0.00 0.00<br />

30930 S 621.15 0.00 0.00 31527 S 601.80 0.00 0.00<br />

31000 S 105.68 0.00 0.00 31528 S 558.58 0.00 0.00<br />

31002 S 288.30 0.00 0.00 31529 S 558.58 0.00 0.00<br />

31020 S 679.90 0.00 0.00 31530 S 654.05 0.00 0.00<br />

31030 S 1,037.07 0.00 0.00 31531 S 683.63 0.00 0.00<br />

31032 S 1,092.54 0.00 0.00 31535 S 654.05 0.00 0.00<br />

31040 S 947.44 0.00 0.00 31536 S 683.63 0.00 0.00<br />

31050 S 1,007.47 0.00 0.00 31540 S 683.63 0.00 0.00<br />

31051 S 1,092.54 0.00 0.00 31541 S 739.11 0.00 0.00<br />

31070 S 679.90 0.00 0.00 31545 S 739.11 0.00 0.00<br />

31075 S 1,092.54 0.00 0.00 31546 S 739.11 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 779.33 0.00 0.00 32405 S 337.24 0.00 0.00<br />

31561 S 779.33 0.00 0.00 32420 S 205.07 0.00 0.00<br />

31570 S 558.58 0.00 0.00 32421 S 205.07 0.00 0.00<br />

31571 S 654.05 0.00 0.00 32422 S 204.16 0.00 0.00<br />

31575 S 59.51 0.00 0.00 32550 S 1,143.06 0.00 0.00<br />

31576 S 654.05 0.00 0.00 32960 S 204.16 0.00 0.00<br />

31577 S 193.21 0.00 0.00 32998 S 1,779.68 0.00 0.00<br />

31578 S 654.05 0.00 0.00 33010 S 205.07 0.00 0.00<br />

31579 S 106.02 0.00 0.00 33011 S 205.07 0.00 0.00<br />

31580 S 1,132.76 0.00 0.00 33206 S 6,579.33 3,914.68 1,250.04<br />

31582 S 1,132.76 0.00 0.00 33207 S 6,579.33 3,914.68 1,250.04<br />

31588 S 1,132.76 0.00 0.00 33208 S 8,160.24 4,754.93 1,349.63<br />

31590 S 1,132.76 0.00 0.00 33210 S 1,932.04 0.00 0.00<br />

31595 S 1,007.47 0.00 0.00 33211 S 1,932.04 0.00 0.00<br />

31603 S 298.10 0.00 0.00 33212 S 5,167.12 2,943.49 719.85<br />

31605 S 288.30 0.00 0.00 33213 S 5,963.97 3,341.49 719.00<br />

31611 S 709.49 0.00 0.00 33214 S 8,160.24 4,754.93 1,349.63<br />

31612 S 627.66 0.00 0.00 33215 S 846.84 0.00 0.00<br />

31613 S 679.90 0.00 0.00 33216 S 1,932.04 0.00 0.00<br />

31614 S 1,007.47 0.00 0.00 33217 S 1,932.04 0.00 0.00<br />

31615 S 298.10 0.00 0.00 33218 S 846.84 0.00 0.00<br />

31622 S 349.12 0.00 0.00 33220 S 846.84 0.00 0.00<br />

31623 S 401.35 0.00 0.00 33222 S 511.88 0.00 0.00<br />

31624 S 401.35 0.00 0.00 33223 S 511.88 0.00 0.00<br />

31625 S 401.35 0.00 0.00 33224 S 7,702.50 4,611.47 1,520.44<br />

31628 S 401.35 0.00 0.00 33225 S 7,702.50 4,611.47 1,520.44<br />

31629 S 401.35 0.00 0.00 33226 S 846.84 0.00 0.00<br />

31630 S 687.76 0.00 0.00 33233 S 629.60 0.00 0.00<br />

31631 S 687.76 0.00 0.00 33234 S 846.84 0.00 0.00<br />

31632 S 390.35 0.00 0.00 33235 S 846.84 0.00 0.00<br />

31633 S 390.35 0.00 0.00 33240 S 19,200.38 10,263.38 1,326.40<br />

31635 S 401.35 0.00 0.00 33241 S 846.84 0.00 0.00<br />

31636 S 687.76 0.00 0.00 33249 S 25,624.37 13,725.47 1,826.57<br />

31637 S 349.12 0.00 0.00 33282 S 4,051.37 2,425.39 799.41<br />

31638 S 687.76 0.00 0.00 33284 S 316.00 0.00 0.00<br />

31640 S 687.76 0.00 0.00 34490 S 1,542.79 0.00 0.00<br />

31641 S 687.76 0.00 0.00 35188 S 1,062.64 0.00 0.00<br />

31643 S 401.35 0.00 0.00 35207 S 1,062.64 0.00 0.00<br />

31645 S 349.12 0.00 0.00 35473 S 1,850.75 0.00 0.00<br />

31646 S 349.12 0.00 0.00 35476 S 1,850.75 0.00 0.00<br />

31656 S 349.12 0.00 0.00 35492 S 3,454.25 0.00 0.00<br />

31717 S 193.21 0.00 0.00 35761 S 1,111.19 0.00 0.00<br />

31720 S 29.58 0.00 0.00 35875 S 1,390.40 0.00 0.00<br />

31730 S 193.21 0.00 0.00 35876 S 1,390.40 0.00 0.00<br />

31750 S 1,132.76 0.00 0.00 36002 S 88.74 0.00 0.00<br />

31755 S 1,007.47 0.00 0.00 36260 S 805.01 0.00 0.00<br />

31820 S 483.85 0.00 0.00 36261 S 629.60 0.00 0.00<br />

31825 S 679.90 0.00 0.00 36262 S 577.36 0.00 0.00<br />

31830 S 679.90 0.00 0.00 36420 S 8.36 0.00 0.00<br />

32400 S 337.24 0.00 0.00 36425 S 8.36 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 32.14 0.00 0.00 36800 S 866.60 0.00 0.00<br />

36440 S 128.38 0.00 0.00 36810 S 866.60 0.00 0.00<br />

36450 S 128.38 0.00 0.00 36815 S 866.60 0.00 0.00<br />

36455 S 128.38 0.00 0.00 36818 S 1,007.17 0.00 0.00<br />

36468 S 31.69 0.00 0.00 36819 S 1,007.17 0.00 0.00<br />

36469 S 31.69 0.00 0.00 36820 S 1,007.17 0.00 0.00<br />

36470 S 31.69 0.00 0.00 36821 S 1,007.17 0.00 0.00<br />

36471 S 31.69 0.00 0.00 36825 S 1,062.64 0.00 0.00<br />

36475 S 1,457.00 0.00 0.00 36830 S 1,062.64 0.00 0.00<br />

36476 S 1,142.59 0.00 0.00 36831 S 1,390.40 0.00 0.00<br />

36478 S 1,142.59 0.00 0.00 36832 S 1,062.64 0.00 0.00<br />

36479 S 1,142.59 0.00 0.00 36833 S 1,062.64 0.00 0.00<br />

36511 S 440.14 0.00 0.00 36834 S 1,007.17 0.00 0.00<br />

36512 S 440.14 0.00 0.00 36835 S 922.08 0.00 0.00<br />

36513 S 440.14 0.00 0.00 36860 S 105.83 0.00 0.00<br />

36514 S 440.14 0.00 0.00 36861 S 866.60 0.00 0.00<br />

36515 S 1,178.24 0.00 0.00 36870 S 1,515.55 0.00 0.00<br />

36516 S 1,178.24 0.00 0.00 37184 S 1,542.79 0.00 0.00<br />

36522 S 1,178.24 0.00 0.00 37185 S 1,542.79 0.00 0.00<br />

36555 S 365.69 0.00 0.00 37186 S 1,542.79 0.00 0.00<br />

36556 S 365.69 0.00 0.00 37187 S 1,542.79 0.00 0.00<br />

36557 S 682.96 0.00 0.00 37188 S 1,542.79 0.00 0.00<br />

36558 S 682.96 0.00 0.00 37200 S 1,138.48 0.00 0.00<br />

36560 S 805.01 0.00 0.00 37203 S 1,138.48 0.00 0.00<br />

36561 S 805.01 0.00 0.00 37500 S 1,073.77 0.00 0.00<br />

36563 S 805.01 0.00 0.00 37607 S 759.36 0.00 0.00<br />

36565 S 805.01 0.00 0.00 37609 S 510.39 0.00 0.00<br />

36566 S 805.01 0.00 0.00 37650 S 729.76 0.00 0.00<br />

36568 S 365.69 0.00 0.00 37700 S 729.76 0.00 0.00<br />

36569 S 365.69 0.00 0.00 37718 S 759.36 0.00 0.00<br />

36570 S 712.54 0.00 0.00 37722 S 1,073.77 0.00 0.00<br />

36571 S 712.54 0.00 0.00 37735 S 1,073.77 0.00 0.00<br />

36575 S 294.12 0.00 0.00 37760 S 759.36 0.00 0.00<br />

36576 S 417.93 0.00 0.00 37765 S 1,047.16 0.00 0.00<br />

36578 S 682.96 0.00 0.00 37766 S 1,047.16 0.00 0.00<br />

36580 S 365.69 0.00 0.00 37780 S 759.36 0.00 0.00<br />

36581 S 682.96 0.00 0.00 37785 S 759.36 0.00 0.00<br />

36582 S 805.01 0.00 0.00 37790 S 916.31 0.00 0.00<br />

36583 S 805.01 0.00 0.00 38205 S 440.14 0.00 0.00<br />

36584 S 365.69 0.00 0.00 38206 S 440.14 0.00 0.00<br />

36585 S 712.54 0.00 0.00 38220 S 100.89 0.00 0.00<br />

36589 S 241.89 0.00 0.00 38221 S 105.68 0.00 0.00<br />

36590 S 365.69 0.00 0.00 38230 S 1,178.24 0.00 0.00<br />

36593 S 24.28 0.00 0.00 38241 S 1,178.24 0.00 0.00<br />

36595 S 953.55 0.00 0.00 38242 S 440.14 0.00 0.00<br />

36596 S 423.49 0.00 0.00 38300 S 394.96 0.00 0.00<br />

36597 S 423.49 0.00 0.00 38305 S 577.18 0.00 0.00<br />

36598 S 78.31 0.00 0.00 38308 S 659.50 0.00 0.00<br />

36640 S 723.18 0.00 0.00 38500 S 659.50 0.00 0.00<br />

36680 S 54.82 0.00 0.00 38505 S 252.33 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 659.50 0.00 0.00 41005 S 132.96 0.00 0.00<br />

38520 S 659.50 0.00 0.00 41006 S 627.66 0.00 0.00<br />

38525 S 659.50 0.00 0.00 41007 S 483.85 0.00 0.00<br />

38530 S 659.50 0.00 0.00 41008 S 483.85 0.00 0.00<br />

38542 S 1,109.52 0.00 0.00 41009 S 132.96 0.00 0.00<br />

38550 S 689.09 0.00 0.00 41010 S 298.10 0.00 0.00<br />

38555 S 744.56 0.00 0.00 41015 S 132.96 0.00 0.00<br />

38570 S 1,505.45 0.00 0.00 41016 S 298.10 0.00 0.00<br />

38571 S 1,957.05 0.00 0.00 41017 S 298.10 0.00 0.00<br />

38572 S 1,505.45 0.00 0.00 41018 S 298.10 0.00 0.00<br />

38700 S 906.64 0.00 0.00 41019 S 947.44 0.00 0.00<br />

38740 S 1,109.52 0.00 0.00 41100 S 89.25 0.00 0.00<br />

38745 S 1,194.58 0.00 0.00 41105 S 88.23 0.00 0.00<br />

38760 S 659.50 0.00 0.00 41108 S 81.73 0.00 0.00<br />

40490 S 67.37 0.00 0.00 41110 S 118.33 0.00 0.00<br />

40500 S 536.08 0.00 0.00 41112 S 536.08 0.00 0.00<br />

40510 S 679.90 0.00 0.00 41113 S 536.08 0.00 0.00<br />

40520 S 536.08 0.00 0.00 41114 S 679.90 0.00 0.00<br />

40525 S 679.90 0.00 0.00 41115 S 137.82 0.00 0.00<br />

40527 S 679.90 0.00 0.00 41116 S 483.85 0.00 0.00<br />

40530 S 679.90 0.00 0.00 41120 S 805.18 0.00 0.00<br />

40650 S 358.72 0.00 0.00 41250 S 90.93 0.00 0.00<br />

40652 S 358.72 0.00 0.00 41251 S 132.96 0.00 0.00<br />

40654 S 358.72 0.00 0.00 41252 S 350.33 0.00 0.00<br />

40700 S 1,261.28 0.00 0.00 41500 S 627.66 0.00 0.00<br />

40701 S 1,261.28 0.00 0.00 41510 S 483.85 0.00 0.00<br />

40702 S 1,602.58 0.00 0.00 41520 S 350.33 0.00 0.00<br />

40720 S 1,261.28 0.00 0.00 41530 S 659.80 0.00 0.00<br />

40761 S 1,037.07 0.00 0.00 41800 S 67.93 0.00 0.00<br />

40800 S 54.07 0.00 0.00 41805 S 147.06 0.00 0.00<br />

40801 S 350.33 0.00 0.00 41806 S 181.25 0.00 0.00<br />

40804 S 24.73 0.00 0.00 41820 S 288.30 0.00 0.00<br />

40805 S 167.23 0.00 0.00 41821 S 288.30 0.00 0.00<br />

40806 S 76.95 0.00 0.00 41822 S 150.13 0.00 0.00<br />

40808 S 114.22 0.00 0.00 41823 S 218.87 0.00 0.00<br />

40810 S 118.33 0.00 0.00 41825 S 120.37 0.00 0.00<br />

40812 S 148.42 0.00 0.00 41826 S 151.50 0.00 0.00<br />

40814 S 536.08 0.00 0.00 41827 S 679.90 0.00 0.00<br />

40816 S 679.90 0.00 0.00 41828 S 136.80 0.00 0.00<br />

40818 S 132.96 0.00 0.00 41830 S 194.25 0.00 0.00<br />

40819 S 298.10 0.00 0.00 41850 S 659.80 0.00 0.00<br />

40820 S 170.65 0.00 0.00 41870 S 947.44 0.00 0.00<br />

40830 S 126.57 0.00 0.00 41872 S 194.25 0.00 0.00<br />

40831 S 298.10 0.00 0.00 41874 S 187.40 0.00 0.00<br />

40840 S 679.90 0.00 0.00 42000 S 132.96 0.00 0.00<br />

40842 S 709.49 0.00 0.00 42100 S 75.92 0.00 0.00<br />

40843 S 709.49 0.00 0.00 42104 S 112.85 0.00 0.00<br />

40844 S 1,132.76 0.00 0.00 42106 S 141.59 0.00 0.00<br />

40845 S 1,132.76 0.00 0.00 42107 S 679.90 0.00 0.00<br />

41000 S 84.82 0.00 0.00 42120 S 1,092.54 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 350.33 0.00 0.00 42809 S 24.73 0.00 0.00<br />

42145 S 805.18 0.00 0.00 42810 S 709.49 0.00 0.00<br />

42160 S 134.06 0.00 0.00 42815 S 1,132.76 0.00 0.00<br />

42180 S 132.96 0.00 0.00 42820 S 709.49 0.00 0.00<br />

42182 S 1,007.47 0.00 0.00 42821 S 805.18 0.00 0.00<br />

42200 S 1,132.76 0.00 0.00 42825 S 764.96 0.00 0.00<br />

42205 S 1,132.76 0.00 0.00 42826 S 764.96 0.00 0.00<br />

42210 S 1,132.76 0.00 0.00 42830 S 764.96 0.00 0.00<br />

42215 S 1,261.28 0.00 0.00 42831 S 764.96 0.00 0.00<br />

42220 S 1,132.76 0.00 0.00 42835 S 764.96 0.00 0.00<br />

42226 S 1,132.76 0.00 0.00 42836 S 764.96 0.00 0.00<br />

42235 S 661.37 0.00 0.00 42860 S 709.49 0.00 0.00<br />

42260 S 764.96 0.00 0.00 42870 S 709.49 0.00 0.00<br />

42280 S 73.86 0.00 0.00 42890 S 1,261.28 0.00 0.00<br />

42281 S 659.80 0.00 0.00 42892 S 1,261.28 0.00 0.00<br />

42300 S 483.85 0.00 0.00 42900 S 298.10 0.00 0.00<br />

42305 S 536.08 0.00 0.00 42950 S 679.90 0.00 0.00<br />

42310 S 132.96 0.00 0.00 42955 S 679.90 0.00 0.00<br />

42320 S 132.96 0.00 0.00 42960 S 54.77 0.00 0.00<br />

42330 S 114.22 0.00 0.00 42962 S 1,007.47 0.00 0.00<br />

42335 S 189.46 0.00 0.00 42970 S 42.52 0.00 0.00<br />

42340 S 536.08 0.00 0.00 42972 S 565.68 0.00 0.00<br />

42400 S 64.30 0.00 0.00 43030 S 659.80 0.00 0.00<br />

42405 S 536.08 0.00 0.00 43200 S 319.51 0.00 0.00<br />

42408 S 565.68 0.00 0.00 43201 S 319.51 0.00 0.00<br />

42409 S 565.68 0.00 0.00 43202 S 319.51 0.00 0.00<br />

42410 S 1,037.07 0.00 0.00 43204 S 319.51 0.00 0.00<br />

42415 S 1,261.28 0.00 0.00 43205 S 319.51 0.00 0.00<br />

42420 S 1,261.28 0.00 0.00 43215 S 319.51 0.00 0.00<br />

42425 S 1,261.28 0.00 0.00 43216 S 319.51 0.00 0.00<br />

42440 S 1,037.07 0.00 0.00 43217 S 319.51 0.00 0.00<br />

42450 S 679.90 0.00 0.00 43219 S 645.74 0.00 0.00<br />

42500 S 709.49 0.00 0.00 43220 S 319.51 0.00 0.00<br />

42505 S 1,092.54 0.00 0.00 43226 S 319.51 0.00 0.00<br />

42507 S 1,037.07 0.00 0.00 43227 S 371.76 0.00 0.00<br />

42508 S 1,092.54 0.00 0.00 43228 S 691.82 0.00 0.00<br />

42509 S 1,092.54 0.00 0.00 43231 S 371.76 0.00 0.00<br />

42510 S 1,092.54 0.00 0.00 43232 S 371.76 0.00 0.00<br />

42600 S 483.85 0.00 0.00 43234 S 319.51 0.00 0.00<br />

42650 S 42.06 0.00 0.00 43235 S 319.51 0.00 0.00<br />

42660 S 49.25 0.00 0.00 43236 S 371.76 0.00 0.00<br />

42665 S 933.70 0.00 0.00 43237 S 371.76 0.00 0.00<br />

42700 S 132.96 0.00 0.00 43238 S 371.76 0.00 0.00<br />

42720 S 483.85 0.00 0.00 43239 S 371.76 0.00 0.00<br />

42725 S 1,007.47 0.00 0.00 43240 S 371.76 0.00 0.00<br />

42800 S 81.39 0.00 0.00 43241 S 371.76 0.00 0.00<br />

42802 S 483.85 0.00 0.00 43242 S 371.76 0.00 0.00<br />

42804 S 483.85 0.00 0.00 43243 S 371.76 0.00 0.00<br />

42806 S 679.90 0.00 0.00 43244 S 371.76 0.00 0.00<br />

42808 S 536.08 0.00 0.00 43245 S 371.76 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 371.76 0.00 0.00 44378 S 389.36 0.00 0.00<br />

43247 S 371.76 0.00 0.00 44379 S 1,110.82 0.00 0.00<br />

43248 S 371.76 0.00 0.00 44380 S 337.11 0.00 0.00<br />

43249 S 371.76 0.00 0.00 44382 S 337.11 0.00 0.00<br />

43250 S 371.76 0.00 0.00 44383 S 1,110.82 0.00 0.00<br />

43251 S 371.76 0.00 0.00 44385 S 325.94 0.00 0.00<br />

43255 S 371.76 0.00 0.00 44386 S 325.94 0.00 0.00<br />

43256 S 727.57 0.00 0.00 44388 S 325.94 0.00 0.00<br />

43257 S 721.41 0.00 0.00 44389 S 325.94 0.00 0.00<br />

43258 S 401.34 0.00 0.00 44390 S 325.94 0.00 0.00<br />

43259 S 401.34 0.00 0.00 44391 S 325.94 0.00 0.00<br />

43260 S 625.86 0.00 0.00 44392 S 325.94 0.00 0.00<br />

43261 S 625.86 0.00 0.00 44393 S 325.94 0.00 0.00<br />

43262 S 625.86 0.00 0.00 44394 S 325.94 0.00 0.00<br />

43263 S 625.86 0.00 0.00 44397 S 645.74 0.00 0.00<br />

43264 S 625.86 0.00 0.00 44500 S 175.89 0.00 0.00<br />

43265 S 625.86 0.00 0.00 45000 S 377.99 0.00 0.00<br />

43267 S 625.86 0.00 0.00 45005 S 439.91 0.00 0.00<br />

43268 S 697.99 0.00 0.00 45020 S 439.91 0.00 0.00<br />

43269 S 697.99 0.00 0.00 45100 S 597.66 0.00 0.00<br />

43271 S 625.86 0.00 0.00 45108 S 649.90 0.00 0.00<br />

43272 S 625.86 0.00 0.00 45150 S 649.90 0.00 0.00<br />

43273 S 839.36 0.00 0.00 45160 S 649.90 0.00 0.00<br />

43450 S 279.43 0.00 0.00 45170 S 649.90 0.00 0.00<br />

43453 S 279.43 0.00 0.00 45190 S 1,062.72 0.00 0.00<br />

43456 S 280.54 0.00 0.00 45300 S 62.92 0.00 0.00<br />

43458 S 320.63 0.00 0.00 45303 S 349.52 0.00 0.00<br />

43600 S 319.51 0.00 0.00 45305 S 328.70 0.00 0.00<br />

43653 S 1,505.45 0.00 0.00 45307 S 607.13 0.00 0.00<br />

43760 S 154.96 0.00 0.00 45308 S 328.70 0.00 0.00<br />

43761 S 319.51 0.00 0.00 45309 S 328.70 0.00 0.00<br />

43870 S 319.51 0.00 0.00 45315 S 328.70 0.00 0.00<br />

43886 S 806.22 0.00 0.00 45317 S 328.70 0.00 0.00<br />

43887 S 169.57 0.00 0.00 45320 S 607.13 0.00 0.00<br />

43888 S 806.22 0.00 0.00 45321 S 607.13 0.00 0.00<br />

44100 S 319.51 0.00 0.00 45327 S 645.74 0.00 0.00<br />

44312 S 557.05 0.00 0.00 45330 S 83.10 0.00 0.00<br />

44340 S 638.88 0.00 0.00 45331 S 245.74 0.00 0.00<br />

44360 S 389.36 0.00 0.00 45332 S 245.74 0.00 0.00<br />

44361 S 389.36 0.00 0.00 45333 S 328.70 0.00 0.00<br />

44363 S 389.36 0.00 0.00 45334 S 328.70 0.00 0.00<br />

44364 S 389.36 0.00 0.00 45335 S 245.74 0.00 0.00<br />

44365 S 389.36 0.00 0.00 45337 S 245.74 0.00 0.00<br />

44366 S 389.36 0.00 0.00 45338 S 328.70 0.00 0.00<br />

44369 S 389.36 0.00 0.00 45339 S 328.70 0.00 0.00<br />

44370 S 1,110.82 0.00 0.00 45340 S 328.70 0.00 0.00<br />

44372 S 389.36 0.00 0.00 45341 S 328.70 0.00 0.00<br />

44373 S 389.36 0.00 0.00 45342 S 328.70 0.00 0.00<br />

44376 S 389.36 0.00 0.00 45345 S 645.74 0.00 0.00<br />

44377 S 389.36 0.00 0.00 45355 S 325.94 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 378.19 0.00 0.00 46505 S 467.44 0.00 0.00<br />

45379 S 378.19 0.00 0.00 46600 S 24.73 0.00 0.00<br />

45380 S 378.19 0.00 0.00 46604 S 349.52 0.00 0.00<br />

45381 S 378.19 0.00 0.00 46606 S 131.33 0.00 0.00<br />

45382 S 378.19 0.00 0.00 46608 S 328.70 0.00 0.00<br />

45383 S 378.19 0.00 0.00 46610 S 607.13 0.00 0.00<br />

45384 S 378.19 0.00 0.00 46611 S 328.70 0.00 0.00<br />

45385 S 378.19 0.00 0.00 46612 S 607.13 0.00 0.00<br />

45386 S 378.19 0.00 0.00 46614 S 69.08 0.00 0.00<br />

45387 S 645.74 0.00 0.00 46615 S 659.37 0.00 0.00<br />

45391 S 378.19 0.00 0.00 46700 S 679.49 0.00 0.00<br />

45392 S 378.19 0.00 0.00 46706 S 747.91 0.00 0.00<br />

45500 S 649.90 0.00 0.00 46750 S 829.74 0.00 0.00<br />

45505 S 800.16 0.00 0.00 46753 S 679.49 0.00 0.00<br />

45520 S 31.69 0.00 0.00 46754 S 649.90 0.00 0.00<br />

45560 S 800.16 0.00 0.00 46760 S 800.16 0.00 0.00<br />

45900 S 256.25 0.00 0.00 46761 S 829.74 0.00 0.00<br />

45905 S 597.66 0.00 0.00 46762 S 1,053.95 0.00 0.00<br />

45910 S 597.66 0.00 0.00 46900 S 104.43 0.00 0.00<br />

45915 S 377.99 0.00 0.00 46910 S 124.82 0.00 0.00<br />

45990 S 587.98 0.00 0.00 46916 S 58.06 0.00 0.00<br />

46020 S 679.49 0.00 0.00 46917 S 541.59 0.00 0.00<br />

46030 S 256.25 0.00 0.00 46922 S 541.59 0.00 0.00<br />

46040 S 679.49 0.00 0.00 46924 S 541.59 0.00 0.00<br />

46045 S 649.90 0.00 0.00 46930 S 121.07 0.00 0.00<br />

46050 S 377.99 0.00 0.00 46937 S 649.90 0.00 0.00<br />

46060 S 649.90 0.00 0.00 46938 S 800.16 0.00 0.00<br />

46070 S 467.44 0.00 0.00 46940 S 89.60 0.00 0.00<br />

46080 S 679.49 0.00 0.00 46942 S 87.21 0.00 0.00<br />

46083 S 71.55 0.00 0.00 46945 S 148.42 0.00 0.00<br />

46200 S 649.90 0.00 0.00 46946 S 387.66 0.00 0.00<br />

46210 S 649.90 0.00 0.00 46947 S 1,053.95 0.00 0.00<br />

46211 S 649.90 0.00 0.00 47000 S 337.24 0.00 0.00<br />

46220 S 597.66 0.00 0.00 47382 S 1,779.68 0.00 0.00<br />

46221 S 117.64 0.00 0.00 47510 S 788.14 0.00 0.00<br />

46230 S 597.66 0.00 0.00 47511 S 1,157.90 0.00 0.00<br />

46250 S 679.49 0.00 0.00 47525 S 452.45 0.00 0.00<br />

46255 S 679.49 0.00 0.00 47530 S 452.45 0.00 0.00<br />

46257 S 679.49 0.00 0.00 47552 S 788.14 0.00 0.00<br />

46258 S 679.49 0.00 0.00 47553 S 817.73 0.00 0.00<br />

46260 S 679.49 0.00 0.00 47554 S 817.73 0.00 0.00<br />

46261 S 734.96 0.00 0.00 47555 S 817.73 0.00 0.00<br />

46262 S 734.96 0.00 0.00 47556 S 1,157.90 0.00 0.00<br />

46270 S 679.49 0.00 0.00 47560 S 960.80 0.00 0.00<br />

46275 S 679.49 0.00 0.00 47561 S 960.80 0.00 0.00<br />

46280 S 734.96 0.00 0.00 47562 S 1,772.88 0.00 0.00<br />

46285 S 597.66 0.00 0.00 47563 S 1,772.88 0.00 0.00<br />

46288 S 734.96 0.00 0.00 47564 S 1,772.88 0.00 0.00<br />

46320 S 79.69 0.00 0.00 47630 S 817.73 0.00 0.00<br />

46500 S 109.77 0.00 0.00 48102 S 337.24 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 205.07 0.00 0.00 49590 S 841.67 0.00 0.00<br />

49081 S 205.07 0.00 0.00 49600 S 897.14 0.00 0.00<br />

49180 S 337.24 0.00 0.00 49650 S 1,177.68 0.00 0.00<br />

49250 S 739.24 0.00 0.00 49651 S 1,346.43 0.00 0.00<br />

49320 S 960.80 0.00 0.00 49652 S 1,450.06 0.00 0.00<br />

49321 S 1,016.28 0.00 0.00 49653 S 1,450.06 0.00 0.00<br />

49322 S 1,016.28 0.00 0.00 49654 S 1,450.06 0.00 0.00<br />

49324 S 1,450.06 0.00 0.00 49655 S 1,450.06 0.00 0.00<br />

49325 S 1,450.06 0.00 0.00 49656 S 1,450.06 0.00 0.00<br />

49326 S 1,450.06 0.00 0.00 49657 S 1,450.06 0.00 0.00<br />

49402 S 654.17 0.00 0.00 50200 S 337.24 0.00 0.00<br />

49419 S 784.77 0.00 0.00 50382 S 979.26 0.00 0.00<br />

49420 S 725.47 0.00 0.00 50384 S 719.25 0.00 0.00<br />

49421 S 725.47 0.00 0.00 50385 S 719.25 0.00 0.00<br />

49422 S 577.36 0.00 0.00 50386 S 275.95 0.00 0.00<br />

49423 S 597.02 0.00 0.00 50387 S 597.02 0.00 0.00<br />

49426 S 654.17 0.00 0.00 50389 S 275.95 0.00 0.00<br />

49429 S 846.84 0.00 0.00 50390 S 337.24 0.00 0.00<br />

49440 S 331.15 0.00 0.00 50391 S 39.94 0.00 0.00<br />

49441 S 331.15 0.00 0.00 50392 S 513.56 0.00 0.00<br />

49446 S 331.15 0.00 0.00 50393 S 643.57 0.00 0.00<br />

49450 S 175.89 0.00 0.00 50395 S 513.56 0.00 0.00<br />

49451 S 175.89 0.00 0.00 50396 S 96.56 0.00 0.00<br />

49452 S 175.89 0.00 0.00 50398 S 452.45 0.00 0.00<br />

49460 S 175.89 0.00 0.00 50551 S 291.92 0.00 0.00<br />

49495 S 897.14 0.00 0.00 50553 S 643.57 0.00 0.00<br />

49496 S 897.14 0.00 0.00 50555 S 291.92 0.00 0.00<br />

49500 S 897.14 0.00 0.00 50557 S 643.57 0.00 0.00<br />

49501 S 1,224.90 0.00 0.00 50561 S 643.57 0.00 0.00<br />

49505 S 897.14 0.00 0.00 50562 S 275.95 0.00 0.00<br />

49507 S 1,224.90 0.00 0.00 50570 S 275.95 0.00 0.00<br />

49520 S 1,065.88 0.00 0.00 50572 S 275.95 0.00 0.00<br />

49521 S 1,224.90 0.00 0.00 50574 S 275.95 0.00 0.00<br />

49525 S 897.14 0.00 0.00 50575 S 1,372.65 0.00 0.00<br />

49540 S 812.08 0.00 0.00 50576 S 719.25 0.00 0.00<br />

49550 S 937.36 0.00 0.00 50580 S 719.25 0.00 0.00<br />

49553 S 1,224.90 0.00 0.00 50590 S 1,603.58 0.00 0.00<br />

49555 S 937.36 0.00 0.00 50592 S 1,779.68 0.00 0.00<br />

49557 S 1,224.90 0.00 0.00 50686 S 39.94 0.00 0.00<br />

49560 S 897.14 0.00 0.00 50688 S 452.45 0.00 0.00<br />

49561 S 1,224.90 0.00 0.00 50947 S 1,505.45 0.00 0.00<br />

49565 S 897.14 0.00 0.00 50948 S 1,505.45 0.00 0.00<br />

49566 S 1,224.90 0.00 0.00 50951 S 291.92 0.00 0.00<br />

49568 S 1,065.88 0.00 0.00 50953 S 291.92 0.00 0.00<br />

49570 S 897.14 0.00 0.00 50955 S 643.57 0.00 0.00<br />

49572 S 1,224.90 0.00 0.00 50957 S 643.57 0.00 0.00<br />

49580 S 897.14 0.00 0.00 50961 S 643.57 0.00 0.00<br />

49582 S 1,224.90 0.00 0.00 50970 S 291.92 0.00 0.00<br />

49585 S 897.14 0.00 0.00 50972 S 291.92 0.00 0.00<br />

49587 S 1,224.90 0.00 0.00 50974 S 513.56 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 513.56 0.00 0.00 52275 S 695.82 0.00 0.00<br />

50980 S 643.57 0.00 0.00 52276 S 725.40 0.00 0.00<br />

51020 S 780.88 0.00 0.00 52277 S 695.82 0.00 0.00<br />

51030 S 780.88 0.00 0.00 52281 S 565.80 0.00 0.00<br />

51040 S 780.88 0.00 0.00 52282 S 1,305.34 0.00 0.00<br />

51045 S 322.54 0.00 0.00 52283 S 695.82 0.00 0.00<br />

51050 S 780.88 0.00 0.00 52285 S 565.80 0.00 0.00<br />

51065 S 780.88 0.00 0.00 52290 S 565.80 0.00 0.00<br />

51080 S 524.93 0.00 0.00 52300 S 695.82 0.00 0.00<br />

51100 S 30.44 0.00 0.00 52301 S 725.40 0.00 0.00<br />

51101 S 39.94 0.00 0.00 52305 S 695.82 0.00 0.00<br />

51102 S 537.32 0.00 0.00 52310 S 544.18 0.00 0.00<br />

51500 S 897.14 0.00 0.00 52315 S 695.82 0.00 0.00<br />

51520 S 780.88 0.00 0.00 52317 S 643.57 0.00 0.00<br />

51700 S 51.98 0.00 0.00 52318 S 695.82 0.00 0.00<br />

51701 S 24.73 0.00 0.00 52320 S 821.09 0.00 0.00<br />

51702 S 24.73 0.00 0.00 52325 S 780.88 0.00 0.00<br />

51703 S 39.94 0.00 0.00 52327 S 892.51 0.00 0.00<br />

51705 S 71.55 0.00 0.00 52330 S 695.82 0.00 0.00<br />

51710 S 452.45 0.00 0.00 52332 S 695.82 0.00 0.00<br />

51715 S 821.52 0.00 0.00 52334 S 725.40 0.00 0.00<br />

51720 S 57.45 0.00 0.00 52341 S 725.40 0.00 0.00<br />

51725 TC S 110.37 0.00 0.00 52342 S 725.40 0.00 0.00<br />

51726 TC S 152.02 0.00 0.00 52343 S 725.40 0.00 0.00<br />

51736 TC S 20.86 0.00 0.00 52344 S 725.40 0.00 0.00<br />

51741 TC S 24.28 0.00 0.00 52345 S 725.40 0.00 0.00<br />

51772 TC S 96.56 0.00 0.00 52346 S 725.40 0.00 0.00<br />

51784 TC S 39.94 0.00 0.00 52351 S 725.40 0.00 0.00<br />

51785 TC S 66.72 0.00 0.00 52352 S 780.88 0.00 0.00<br />

51792 TC S 39.94 0.00 0.00 52353 S 977.58 0.00 0.00<br />

51795 TC S 71.55 0.00 0.00 52354 S 780.88 0.00 0.00<br />

51797 TC S 71.55 0.00 0.00 52355 S 780.88 0.00 0.00<br />

51798 S 17.78 0.00 0.00 52400 S 725.40 0.00 0.00<br />

51880 S 643.57 0.00 0.00 52402 S 725.40 0.00 0.00<br />

51992 S 1,217.91 0.00 0.00 52450 S 725.40 0.00 0.00<br />

52000 S 291.92 0.00 0.00 52500 S 725.40 0.00 0.00<br />

52001 S 544.18 0.00 0.00 52601 S 977.58 0.00 0.00<br />

52005 S 565.80 0.00 0.00 52630 S 892.51 0.00 0.00<br />

52007 S 695.82 0.00 0.00 52640 S 695.82 0.00 0.00<br />

52010 S 322.54 0.00 0.00 52647 S 1,495.60 0.00 0.00<br />

52204 S 565.80 0.00 0.00 52648 S 1,495.60 0.00 0.00<br />

52214 S 695.82 0.00 0.00 52700 S 695.82 0.00 0.00<br />

52224 S 695.82 0.00 0.00 53000 S 534.04 0.00 0.00<br />

52234 S 695.82 0.00 0.00 53010 S 534.04 0.00 0.00<br />

52235 S 725.40 0.00 0.00 53020 S 534.04 0.00 0.00<br />

52240 S 725.40 0.00 0.00 53025 S 760.18 0.00 0.00<br />

52250 S 780.88 0.00 0.00 53040 S 586.28 0.00 0.00<br />

52260 S 565.80 0.00 0.00 53060 S 69.43 0.00 0.00<br />

52265 S 275.95 0.00 0.00 53080 S 615.87 0.00 0.00<br />

52270 S 565.80 0.00 0.00 53085 S 760.18 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 534.04 0.00 0.00 54060 S 541.59 0.00 0.00<br />

53210 S 917.21 0.00 0.00 54065 S 541.59 0.00 0.00<br />

53215 S 711.56 0.00 0.00 54100 S 458.15 0.00 0.00<br />

53220 S 791.93 0.00 0.00 54105 S 571.93 0.00 0.00<br />

53230 S 791.93 0.00 0.00 54110 S 886.73 0.00 0.00<br />

53235 S 615.87 0.00 0.00 54111 S 886.73 0.00 0.00<br />

53240 S 791.93 0.00 0.00 54112 S 886.73 0.00 0.00<br />

53250 S 586.28 0.00 0.00 54115 S 524.93 0.00 0.00<br />

53260 S 586.28 0.00 0.00 54120 S 886.73 0.00 0.00<br />

53265 S 586.28 0.00 0.00 54150 S 590.96 0.00 0.00<br />

53270 S 586.28 0.00 0.00 54160 S 643.20 0.00 0.00<br />

53275 S 586.28 0.00 0.00 54161 S 643.20 0.00 0.00<br />

53400 S 821.52 0.00 0.00 54162 S 643.20 0.00 0.00<br />

53405 S 791.93 0.00 0.00 54163 S 643.20 0.00 0.00<br />

53410 S 791.93 0.00 0.00 54164 S 643.20 0.00 0.00<br />

53420 S 821.52 0.00 0.00 54200 S 67.37 0.00 0.00<br />

53425 S 791.93 0.00 0.00 54205 S 971.79 0.00 0.00<br />

53430 S 791.93 0.00 0.00 54220 S 96.56 0.00 0.00<br />

53431 S 791.93 0.00 0.00 54231 S 63.26 0.00 0.00<br />

53440 S 4,561.82 2,770.60 979.39 54235 S 44.80 0.00 0.00<br />

53442 S 739.69 0.00 0.00 54240 TC S 31.80 0.00 0.00<br />

53444 S 4,561.82 2,770.60 979.39 54250 TC S 11.28 0.00 0.00<br />

53445 S 7,662.70 4,363.85 1,065.02 54300 S 916.31 0.00 0.00<br />

53446 S 739.69 0.00 0.00 54304 S 916.31 0.00 0.00<br />

53447 S 7,662.70 4,363.85 1,065.02 54308 S 916.31 0.00 0.00<br />

53449 S 739.69 0.00 0.00 54312 S 916.31 0.00 0.00<br />

53450 S 739.69 0.00 0.00 54316 S 916.31 0.00 0.00<br />

53460 S 534.04 0.00 0.00 54318 S 916.31 0.00 0.00<br />

53502 S 586.28 0.00 0.00 54322 S 916.31 0.00 0.00<br />

53505 S 791.93 0.00 0.00 54324 S 916.31 0.00 0.00<br />

53510 S 586.28 0.00 0.00 54326 S 916.31 0.00 0.00<br />

53515 S 791.93 0.00 0.00 54328 S 916.31 0.00 0.00<br />

53520 S 791.93 0.00 0.00 54340 S 916.31 0.00 0.00<br />

53600 S 40.01 0.00 0.00 54344 S 916.31 0.00 0.00<br />

53601 S 39.94 0.00 0.00 54348 S 916.31 0.00 0.00<br />

53605 S 565.80 0.00 0.00 54352 S 916.31 0.00 0.00<br />

53620 S 61.56 0.00 0.00 54360 S 916.31 0.00 0.00<br />

53621 S 64.64 0.00 0.00 54380 S 916.31 0.00 0.00<br />

53660 S 39.94 0.00 0.00 54385 S 916.31 0.00 0.00<br />

53661 S 39.94 0.00 0.00 54400 S 4,591.41 2,800.20 1,008.98<br />

53665 S 534.04 0.00 0.00 54401 S 7,744.53 4,445.68 1,146.85<br />

53850 S 1,753.17 0.00 0.00 54405 S 7,744.53 4,445.68 1,146.85<br />

53852 S 1,753.17 0.00 0.00 54406 S 916.31 0.00 0.00<br />

54000 S 586.28 0.00 0.00 54408 S 916.31 0.00 0.00<br />

54001 S 586.28 0.00 0.00 54410 S 7,744.53 4,445.68 1,146.85<br />

54015 S 662.24 0.00 0.00 54415 S 916.31 0.00 0.00<br />

54050 S 31.69 0.00 0.00 54416 S 7,744.53 4,445.68 1,146.85<br />

54055 S 64.64 0.00 0.00 54420 S 971.79 0.00 0.00<br />

54056 S 31.69 0.00 0.00 54435 S 971.79 0.00 0.00<br />

54057 S 541.59 0.00 0.00 54440 S 971.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 152.02 0.00 0.00 55706 S 441.95 0.00 0.00<br />

54500 S 412.61 0.00 0.00 55720 S 643.57 0.00 0.00<br />

54505 S 590.96 0.00 0.00 55725 S 695.82 0.00 0.00<br />

54512 S 643.20 0.00 0.00 55860 S 766.75 0.00 0.00<br />

54520 S 672.79 0.00 0.00 55870 S 77.97 0.00 0.00<br />

54522 S 672.79 0.00 0.00 55873 S 6,066.84 0.00 0.00<br />

54530 S 897.14 0.00 0.00 55875 S 1,305.34 0.00 0.00<br />

54550 S 897.14 0.00 0.00 55876 S 71.48 0.00 0.00<br />

54560 S 874.03 0.00 0.00 55920 S 895.99 0.00 0.00<br />

54600 S 728.27 0.00 0.00 56405 S 41.72 0.00 0.00<br />

54620 S 672.79 0.00 0.00 56420 S 54.46 0.00 0.00<br />

54640 S 897.14 0.00 0.00 56440 S 584.76 0.00 0.00<br />

54660 S 643.20 0.00 0.00 56441 S 532.52 0.00 0.00<br />

54670 S 672.79 0.00 0.00 56442 S 532.52 0.00 0.00<br />

54680 S 672.79 0.00 0.00 56501 S 57.45 0.00 0.00<br />

54690 S 1,505.45 0.00 0.00 56515 S 623.42 0.00 0.00<br />

54692 S 2,676.08 0.00 0.00 56605 S 33.17 0.00 0.00<br />

54700 S 643.20 0.00 0.00 56606 S 13.68 0.00 0.00<br />

54800 S 144.37 0.00 0.00 56620 S 710.04 0.00 0.00<br />

54830 S 672.79 0.00 0.00 56625 S 838.56 0.00 0.00<br />

54840 S 728.27 0.00 0.00 56700 S 532.52 0.00 0.00<br />

54860 S 672.79 0.00 0.00 56740 S 614.35 0.00 0.00<br />

54861 S 728.27 0.00 0.00 56800 S 614.35 0.00 0.00<br />

54865 S 590.96 0.00 0.00 56805 S 757.16 0.00 0.00<br />

54900 S 728.27 0.00 0.00 56810 S 710.04 0.00 0.00<br />

54901 S 728.27 0.00 0.00 56820 S 42.40 0.00 0.00<br />

55000 S 65.66 0.00 0.00 56821 S 54.46 0.00 0.00<br />

55040 S 841.67 0.00 0.00 57000 S 532.52 0.00 0.00<br />

55041 S 937.36 0.00 0.00 57010 S 584.76 0.00 0.00<br />

55060 S 728.27 0.00 0.00 57020 S 306.68 0.00 0.00<br />

55100 S 394.96 0.00 0.00 57022 S 482.05 0.00 0.00<br />

55110 S 643.20 0.00 0.00 57023 S 524.93 0.00 0.00<br />

55120 S 643.20 0.00 0.00 57061 S 53.00 0.00 0.00<br />

55150 S 590.96 0.00 0.00 57065 S 532.52 0.00 0.00<br />

55175 S 590.96 0.00 0.00 57100 S 33.86 0.00 0.00<br />

55180 S 643.20 0.00 0.00 57105 S 584.76 0.00 0.00<br />

55200 S 643.20 0.00 0.00 57130 S 584.76 0.00 0.00<br />

55250 S 643.20 0.00 0.00 57135 S 584.76 0.00 0.00<br />

55400 S 590.96 0.00 0.00 57150 S 24.62 0.00 0.00<br />

55450 S 211.34 0.00 0.00 57155 S 306.68 0.00 0.00<br />

55500 S 672.79 0.00 0.00 57160 S 35.57 0.00 0.00<br />

55520 S 728.27 0.00 0.00 57170 S 5.83 0.00 0.00<br />

55530 S 728.27 0.00 0.00 57180 S 109.54 0.00 0.00<br />

55535 S 897.14 0.00 0.00 57200 S 532.52 0.00 0.00<br />

55540 S 937.36 0.00 0.00 57210 S 584.76 0.00 0.00<br />

55550 S 1,505.45 0.00 0.00 57220 S 1,072.38 0.00 0.00<br />

55600 S 874.03 0.00 0.00 57230 S 880.52 0.00 0.00<br />

55680 S 590.96 0.00 0.00 57240 S 976.21 0.00 0.00<br />

55700 S 380.84 0.00 0.00 57250 S 976.21 0.00 0.00<br />

55705 S 380.84 0.00 0.00 57260 S 976.21 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,296.59 0.00 0.00 58555 S 575.36 0.00 0.00<br />

57267 S 1,104.73 0.00 0.00 58558 S 657.19 0.00 0.00<br />

57268 S 880.52 0.00 0.00 58559 S 627.60 0.00 0.00<br />

57287 S 1,289.50 0.00 0.00 58560 S 937.06 0.00 0.00<br />

57288 S 1,168.07 0.00 0.00 58561 S 937.06 0.00 0.00<br />

57289 S 976.21 0.00 0.00 58562 S 657.19 0.00 0.00<br />

57291 S 976.21 0.00 0.00 58563 S 1,320.29 0.00 0.00<br />

57300 S 880.52 0.00 0.00 58565 S 1,455.62 0.00 0.00<br />

57320 S 1,289.50 0.00 0.00 58600 S 1,289.50 0.00 0.00<br />

57400 S 584.76 0.00 0.00 58615 S 757.16 0.00 0.00<br />

57410 S 584.76 0.00 0.00 58660 S 1,217.91 0.00 0.00<br />

57415 S 584.76 0.00 0.00 58661 S 1,217.91 0.00 0.00<br />

57420 S 43.78 0.00 0.00 58662 S 1,217.91 0.00 0.00<br />

57421 S 57.11 0.00 0.00 58670 S 1,122.21 0.00 0.00<br />

57452 S 41.38 0.00 0.00 58671 S 1,122.21 0.00 0.00<br />

57454 S 50.61 0.00 0.00 58672 S 1,217.91 0.00 0.00<br />

57455 S 53.69 0.00 0.00 58673 S 1,217.91 0.00 0.00<br />

57456 S 51.98 0.00 0.00 58800 S 614.35 0.00 0.00<br />

57460 S 159.71 0.00 0.00 58805 S 1,289.50 0.00 0.00<br />

57461 S 169.62 0.00 0.00 58820 S 880.52 0.00 0.00<br />

57500 S 73.18 0.00 0.00 58900 S 614.35 0.00 0.00<br />

57505 S 46.51 0.00 0.00 58970 S 171.12 0.00 0.00<br />

57510 S 47.19 0.00 0.00 58974 S 171.12 0.00 0.00<br />

57511 S 54.46 0.00 0.00 58976 S 171.12 0.00 0.00<br />

57513 S 584.76 0.00 0.00 59000 S 62.58 0.00 0.00<br />

57520 S 584.76 0.00 0.00 59001 S 234.91 0.00 0.00<br />

57522 S 584.76 0.00 0.00 59012 S 114.86 0.00 0.00<br />

57530 S 880.52 0.00 0.00 59015 S 50.61 0.00 0.00<br />

57550 S 880.52 0.00 0.00 59020 TC S 26.67 0.00 0.00<br />

57556 S 1,168.07 0.00 0.00 59025 TC S 14.02 0.00 0.00<br />

57558 S 614.35 0.00 0.00 59070 S 114.86 0.00 0.00<br />

57700 S 532.52 0.00 0.00 59072 S 114.86 0.00 0.00<br />

57720 S 614.35 0.00 0.00 59076 S 114.86 0.00 0.00<br />

57800 S 24.97 0.00 0.00 59100 S 1,289.50 0.00 0.00<br />

58100 S 41.04 0.00 0.00 59150 S 1,772.88 0.00 0.00<br />

58120 S 584.76 0.00 0.00 59151 S 1,772.88 0.00 0.00<br />

58145 S 976.21 0.00 0.00 59160 S 614.35 0.00 0.00<br />

58301 S 38.30 0.00 0.00 59200 S 34.20 0.00 0.00<br />

58321 S 35.91 0.00 0.00 59300 S 73.86 0.00 0.00<br />

58322 S 36.93 0.00 0.00 59320 S 532.52 0.00 0.00<br />

58323 S 8.55 0.00 0.00 59412 S 757.16 0.00 0.00<br />

58345 S 757.16 0.00 0.00 59414 S 757.16 0.00 0.00<br />

58346 S 584.76 0.00 0.00 59812 S 710.04 0.00 0.00<br />

58350 S 880.52 0.00 0.00 59820 S 710.04 0.00 0.00<br />

58353 S 1,104.73 0.00 0.00 59821 S 710.04 0.00 0.00<br />

58356 S 1,673.21 0.00 0.00 59840 S 710.04 0.00 0.00<br />

58545 S 1,344.05 0.00 0.00 59841 S 710.04 0.00 0.00<br />

58546 S 1,505.45 0.00 0.00 59866 S 114.86 0.00 0.00<br />

58550 S 1,957.05 0.00 0.00 59870 S 710.04 0.00 0.00<br />

58552 S 1,772.88 0.00 0.00 59871 S 710.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 298.10 0.00 0.00 62367 S 16.41 0.00 0.00<br />

60100 S 46.85 0.00 0.00 62368 S 20.86 0.00 0.00<br />

60200 S 1,109.52 0.00 0.00 63600 S 560.41 0.00 0.00<br />

60280 S 1,194.58 0.00 0.00 63610 S 508.16 0.00 0.00<br />

60281 S 1,194.58 0.00 0.00 63615 S 708.44 0.00 0.00<br />

60300 S 61.56 0.00 0.00 63650 S 3,016.37 1,870.45 724.54<br />

61000 S 274.48 0.00 0.00 63655 S 4,418.24 2,817.52 1,216.81<br />

61001 S 274.48 0.00 0.00 63660 S 529.73 0.00 0.00<br />

61020 S 222.23 0.00 0.00 63685 S 13,410.38 7,150.54 890.70<br />

61026 S 222.23 0.00 0.00 63688 S 719.33 0.00 0.00<br />

61050 S 222.23 0.00 0.00 63744 S 1,040.26 0.00 0.00<br />

61055 S 222.23 0.00 0.00 63746 S 481.20 0.00 0.00<br />

61070 S 172.92 0.00 0.00 64400 S 52.66 0.00 0.00<br />

61215 S 1,040.26 0.00 0.00 64402 S 49.59 0.00 0.00<br />

61330 S 1,602.58 0.00 0.00 64405 S 42.06 0.00 0.00<br />

61334 S 1,602.58 0.00 0.00 64408 S 52.32 0.00 0.00<br />

61790 S 589.99 0.00 0.00 64410 S 291.18 0.00 0.00<br />

61791 S 437.71 0.00 0.00 64412 S 76.95 0.00 0.00<br />

61880 S 751.57 0.00 0.00 64413 S 49.25 0.00 0.00<br />

61885 S 10,815.25 5,793.63 772.01 64415 S 134.10 0.00 0.00<br />

61886 S 16,149.80 8,511.88 873.97 64416 S 274.48 0.00 0.00<br />

61888 S 719.33 0.00 0.00 64417 S 134.10 0.00 0.00<br />

62194 S 291.18 0.00 0.00 64418 S 69.08 0.00 0.00<br />

62225 S 452.45 0.00 0.00 64420 S 134.10 0.00 0.00<br />

62230 S 1,010.67 0.00 0.00 64421 S 291.18 0.00 0.00<br />

62252 TC S 45.83 0.00 0.00 64425 S 47.87 0.00 0.00<br />

62263 S 291.18 0.00 0.00 64430 S 201.50 0.00 0.00<br />

62264 S 428.96 0.00 0.00 64435 S 72.16 0.00 0.00<br />

62267 S 171.18 0.00 0.00 64445 S 63.95 0.00 0.00<br />

62268 S 222.23 0.00 0.00 64446 S 550.03 0.00 0.00<br />

62269 S 337.24 0.00 0.00 64447 S 139.69 0.00 0.00<br />

62270 S 134.10 0.00 0.00 64448 S 139.69 0.00 0.00<br />

62272 S 134.10 0.00 0.00 64449 S 274.48 0.00 0.00<br />

62273 S 223.78 0.00 0.00 64450 S 42.74 0.00 0.00<br />

62280 S 291.18 0.00 0.00 64455 S 17.78 0.00 0.00<br />

62281 S 291.18 0.00 0.00 64470 S 291.18 0.00 0.00<br />

62282 S 291.18 0.00 0.00 64472 S 223.78 0.00 0.00<br />

62287 S 1,307.14 0.00 0.00 64475 S 291.18 0.00 0.00<br />

62292 S 274.48 0.00 0.00 64476 S 201.54 0.00 0.00<br />

62294 S 222.23 0.00 0.00 64479 S 291.18 0.00 0.00<br />

62310 S 291.18 0.00 0.00 64480 S 223.78 0.00 0.00<br />

62311 S 291.18 0.00 0.00 64483 S 291.18 0.00 0.00<br />

62318 S 291.18 0.00 0.00 64484 S 223.78 0.00 0.00<br />

62319 S 291.18 0.00 0.00 64505 S 38.99 0.00 0.00<br />

62350 S 1,010.67 0.00 0.00 64508 S 82.76 0.00 0.00<br />

62355 S 481.20 0.00 0.00 64510 S 291.18 0.00 0.00<br />

62360 S 1,010.67 0.00 0.00 64517 S 201.50 0.00 0.00<br />

62361 S 10,374.64 5,615.42 856.22 64520 S 291.18 0.00 0.00<br />

62362 S 10,374.64 5,615.42 856.22 64530 S 291.18 0.00 0.00<br />

62365 S 894.31 0.00 0.00 64553 S 2,964.12 1,818.20 672.29<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,328.53 2,182.61 1,036.70 64746 S 560.41 0.00 0.00<br />

64560 S 3,328.53 2,182.61 1,036.70 64761 S 708.44 0.00 0.00<br />

64561 S 3,045.95 1,900.03 754.12 64763 S 708.44 0.00 0.00<br />

64565 S 3,328.53 2,182.61 1,036.70 64766 S 1,376.26 0.00 0.00<br />

64573 S 5,185.35 3,071.82 958.28 64771 S 560.41 0.00 0.00<br />

64575 S 3,963.78 2,363.06 762.34 64772 S 560.41 0.00 0.00<br />

64577 S 3,963.78 2,363.06 762.34 64774 S 560.41 0.00 0.00<br />

64580 S 3,963.78 2,363.06 762.34 64776 S 589.99 0.00 0.00<br />

64581 S 4,045.61 2,444.89 844.17 64778 S 560.41 0.00 0.00<br />

64585 S 529.73 0.00 0.00 64782 S 589.99 0.00 0.00<br />

64590 S 10,815.25 5,793.63 772.01 64783 S 560.41 0.00 0.00<br />

64595 S 719.33 0.00 0.00 64784 S 589.99 0.00 0.00<br />

64600 S 428.96 0.00 0.00 64786 S 923.90 0.00 0.00<br />

64605 S 428.96 0.00 0.00 64787 S 560.41 0.00 0.00<br />

64610 S 428.96 0.00 0.00 64788 S 589.99 0.00 0.00<br />

64612 S 62.58 0.00 0.00 64790 S 589.99 0.00 0.00<br />

64613 S 60.53 0.00 0.00 64792 S 923.90 0.00 0.00<br />

64614 S 69.08 0.00 0.00 64795 S 560.41 0.00 0.00<br />

64620 S 291.18 0.00 0.00 64802 S 560.41 0.00 0.00<br />

64622 S 428.96 0.00 0.00 64820 S 708.44 0.00 0.00<br />

64623 S 291.18 0.00 0.00 64821 S 827.04 0.00 0.00<br />

64626 S 428.96 0.00 0.00 64822 S 1,071.58 0.00 0.00<br />

64627 S 201.54 0.00 0.00 64823 S 1,071.58 0.00 0.00<br />

64630 S 299.93 0.00 0.00 64831 S 979.38 0.00 0.00<br />

64632 S 32.49 0.00 0.00 64832 S 842.07 0.00 0.00<br />

64640 S 96.78 0.00 0.00 64834 S 894.31 0.00 0.00<br />

64650 S 32.49 0.00 0.00 64835 S 923.90 0.00 0.00<br />

64653 S 35.23 0.00 0.00 64836 S 923.90 0.00 0.00<br />

64680 S 455.75 0.00 0.00 64837 S 842.07 0.00 0.00<br />

64681 S 481.20 0.00 0.00 64840 S 894.31 0.00 0.00<br />

64702 S 508.16 0.00 0.00 64856 S 894.31 0.00 0.00<br />

64704 S 508.16 0.00 0.00 64857 S 894.31 0.00 0.00<br />

64708 S 560.41 0.00 0.00 64858 S 894.31 0.00 0.00<br />

64712 S 560.41 0.00 0.00 64859 S 842.07 0.00 0.00<br />

64713 S 560.41 0.00 0.00 64861 S 923.90 0.00 0.00<br />

64714 S 560.41 0.00 0.00 64862 S 923.90 0.00 0.00<br />

64716 S 589.99 0.00 0.00 64864 S 923.90 0.00 0.00<br />

64718 S 560.41 0.00 0.00 64865 S 979.38 0.00 0.00<br />

64719 S 560.41 0.00 0.00 64870 S 979.38 0.00 0.00<br />

64721 S 560.41 0.00 0.00 64872 S 894.31 0.00 0.00<br />

64722 S 508.16 0.00 0.00 64874 S 923.90 0.00 0.00<br />

64726 S 508.16 0.00 0.00 64876 S 923.90 0.00 0.00<br />

64727 S 508.16 0.00 0.00 64885 S 894.31 0.00 0.00<br />

64732 S 560.41 0.00 0.00 64886 S 894.31 0.00 0.00<br />

64734 S 560.41 0.00 0.00 64890 S 894.31 0.00 0.00<br />

64736 S 560.41 0.00 0.00 64891 S 894.31 0.00 0.00<br />

64738 S 560.41 0.00 0.00 64892 S 894.31 0.00 0.00<br />

64740 S 560.41 0.00 0.00 64893 S 894.31 0.00 0.00<br />

64742 S 560.41 0.00 0.00 64895 S 923.90 0.00 0.00<br />

64744 S 560.41 0.00 0.00 64896 S 923.90 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 923.90 0.00 0.00 65770 S 5,436.83 0.00 0.00<br />

64898 S 923.90 0.00 0.00 65772 S 611.60 0.00 0.00<br />

64901 S 894.31 0.00 0.00 65775 S 611.60 0.00 0.00<br />

64902 S 894.31 0.00 0.00 65780 S 1,057.98 0.00 0.00<br />

64905 S 894.31 0.00 0.00 65781 S 1,057.98 0.00 0.00<br />

64907 S 842.07 0.00 0.00 65782 S 1,057.98 0.00 0.00<br />

64910 S 1,376.26 0.00 0.00 65800 S 474.30 0.00 0.00<br />

65091 S 972.82 0.00 0.00 65805 S 474.30 0.00 0.00<br />

65093 S 972.82 0.00 0.00 65810 S 693.05 0.00 0.00<br />

65101 S 972.82 0.00 0.00 65815 S 663.46 0.00 0.00<br />

65103 S 972.82 0.00 0.00 65820 S 243.33 0.00 0.00<br />

65105 S 1,028.29 0.00 0.00 65850 S 748.52 0.00 0.00<br />

65110 S 1,068.51 0.00 0.00 65855 S 129.27 0.00 0.00<br />

65112 S 1,197.03 0.00 0.00 65860 S 120.72 0.00 0.00<br />

65114 S 1,197.03 0.00 0.00 65865 S 474.30 0.00 0.00<br />

65125 S 996.22 0.00 0.00 65870 S 748.52 0.00 0.00<br />

65130 S 733.88 0.00 0.00 65875 S 748.52 0.00 0.00<br />

65135 S 704.29 0.00 0.00 65880 S 611.60 0.00 0.00<br />

65140 S 972.82 0.00 0.00 65900 S 651.82 0.00 0.00<br />

65150 S 704.29 0.00 0.00 65920 S 917.26 0.00 0.00<br />

65155 S 972.82 0.00 0.00 65930 S 788.74 0.00 0.00<br />

65175 S 523.53 0.00 0.00 66020 S 474.30 0.00 0.00<br />

65205 S 20.18 0.00 0.00 66030 S 243.33 0.00 0.00<br />

65210 S 25.65 0.00 0.00 66130 S 917.26 0.00 0.00<br />

65220 S 35.74 0.00 0.00 66150 S 748.52 0.00 0.00<br />

65222 S 28.04 0.00 0.00 66155 S 748.52 0.00 0.00<br />

65235 S 526.54 0.00 0.00 66160 S 663.46 0.00 0.00<br />

65260 S 347.29 0.00 0.00 66165 S 748.52 0.00 0.00<br />

65265 S 718.49 0.00 0.00 66170 S 748.52 0.00 0.00<br />

65270 S 575.77 0.00 0.00 66172 S 748.52 0.00 0.00<br />

65272 S 663.46 0.00 0.00 66180 S 1,115.14 0.00 0.00<br />

65275 S 748.52 0.00 0.00 66185 S 989.86 0.00 0.00<br />

65280 S 718.49 0.00 0.00 66220 S 966.28 0.00 0.00<br />

65285 S 1,021.75 0.00 0.00 66225 S 1,074.93 0.00 0.00<br />

65286 S 178.75 0.00 0.00 66250 S 526.54 0.00 0.00<br />

65290 S 707.58 0.00 0.00 66500 S 243.33 0.00 0.00<br />

65400 S 474.30 0.00 0.00 66505 S 243.33 0.00 0.00<br />

65410 S 526.54 0.00 0.00 66600 S 693.05 0.00 0.00<br />

65420 S 526.54 0.00 0.00 66605 S 693.05 0.00 0.00<br />

65426 S 788.74 0.00 0.00 66625 S 492.76 0.00 0.00<br />

65430 S 35.74 0.00 0.00 66630 S 693.05 0.00 0.00<br />

65435 S 31.12 0.00 0.00 66635 S 693.05 0.00 0.00<br />

65436 S 135.08 0.00 0.00 66680 S 693.05 0.00 0.00<br />

65450 S 82.46 0.00 0.00 66682 S 663.46 0.00 0.00<br />

65600 S 159.36 0.00 0.00 66700 S 526.54 0.00 0.00<br />

65710 S 1,186.50 0.00 0.00 66710 S 526.54 0.00 0.00<br />

65730 S 1,186.50 0.00 0.00 66711 S 526.54 0.00 0.00<br />

65750 S 1,186.50 0.00 0.00 66720 S 526.54 0.00 0.00<br />

65755 S 1,186.50 0.00 0.00 66740 S 663.46 0.00 0.00<br />

65756 S 1,453.03 0.00 0.00 66761 S 179.88 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 182.96 0.00 0.00 67228 S 201.49 0.00 0.00<br />

66770 S 201.49 0.00 0.00 67229 S 201.49 0.00 0.00<br />

66820 S 178.75 0.00 0.00 67250 S 605.36 0.00 0.00<br />

66821 S 245.20 0.00 0.00 67255 S 663.02 0.00 0.00<br />

66825 S 748.52 0.00 0.00 67311 S 707.58 0.00 0.00<br />

66830 S 261.79 0.00 0.00 67312 S 763.05 0.00 0.00<br />

66840 S 562.75 0.00 0.00 67314 S 763.05 0.00 0.00<br />

66850 S 1,059.52 0.00 0.00 67316 S 763.05 0.00 0.00<br />

66852 S 890.78 0.00 0.00 67318 S 763.05 0.00 0.00<br />

66920 S 890.78 0.00 0.00 67320 S 763.05 0.00 0.00<br />

66930 S 931.00 0.00 0.00 67331 S 763.05 0.00 0.00<br />

66940 S 602.97 0.00 0.00 67332 S 763.05 0.00 0.00<br />

66982 S 914.73 0.00 0.00 67334 S 763.05 0.00 0.00<br />

66983 S 914.73 0.00 0.00 67335 S 763.05 0.00 0.00<br />

66984 S 914.73 0.00 0.00 67340 S 763.05 0.00 0.00<br />

66985 S 846.77 0.00 0.00 67343 S 931.79 0.00 0.00<br />

66986 S 846.77 0.00 0.00 67345 S 79.69 0.00 0.00<br />

67005 S 718.49 0.00 0.00 67346 S 430.99 0.00 0.00<br />

67010 S 718.49 0.00 0.00 67400 S 605.36 0.00 0.00<br />

67015 S 884.45 0.00 0.00 67405 S 789.36 0.00 0.00<br />

67025 S 581.19 0.00 0.00 67412 S 701.05 0.00 0.00<br />

67027 S 1,021.75 0.00 0.00 67413 S 829.57 0.00 0.00<br />

67028 S 80.37 0.00 0.00 67414 S 1,474.09 0.00 0.00<br />

67030 S 581.19 0.00 0.00 67415 S 523.53 0.00 0.00<br />

67031 S 245.20 0.00 0.00 67420 S 1,068.51 0.00 0.00<br />

67036 S 1,021.75 0.00 0.00 67430 S 1,068.51 0.00 0.00<br />

67039 S 1,190.49 0.00 0.00 67440 S 1,068.51 0.00 0.00<br />

67040 S 1,190.49 0.00 0.00 67445 S 1,068.51 0.00 0.00<br />

67041 S 1,461.02 0.00 0.00 67450 S 1,068.51 0.00 0.00<br />

67042 S 1,461.02 0.00 0.00 67500 S 82.46 0.00 0.00<br />

67043 S 1,461.02 0.00 0.00 67505 S 25.65 0.00 0.00<br />

67101 S 223.04 0.00 0.00 67515 S 25.99 0.00 0.00<br />

67105 S 201.49 0.00 0.00 67550 S 1,028.29 0.00 0.00<br />

67107 S 1,061.97 0.00 0.00 67560 S 704.29 0.00 0.00<br />

67108 S 1,190.49 0.00 0.00 67570 S 1,028.29 0.00 0.00<br />

67110 S 324.20 0.00 0.00 67700 S 120.65 0.00 0.00<br />

67112 S 1,190.49 0.00 0.00 67710 S 140.89 0.00 0.00<br />

67113 S 1,461.02 0.00 0.00 67715 S 523.53 0.00 0.00<br />

67115 S 633.43 0.00 0.00 67800 S 50.61 0.00 0.00<br />

67120 S 633.43 0.00 0.00 67801 S 61.22 0.00 0.00<br />

67121 S 633.43 0.00 0.00 67805 S 79.34 0.00 0.00<br />

67141 S 223.28 0.00 0.00 67808 S 575.77 0.00 0.00<br />

67145 S 190.48 0.00 0.00 67810 S 120.65 0.00 0.00<br />

67208 S 203.14 0.00 0.00 67820 S 16.75 0.00 0.00<br />

67210 S 201.49 0.00 0.00 67825 S 51.64 0.00 0.00<br />

67218 S 758.71 0.00 0.00 67830 S 353.48 0.00 0.00<br />

67220 S 223.04 0.00 0.00 67835 S 575.77 0.00 0.00<br />

67221 S 114.56 0.00 0.00 67840 S 147.74 0.00 0.00<br />

67225 S 7.87 0.00 0.00 67850 S 117.30 0.00 0.00<br />

67227 S 581.19 0.00 0.00 67875 S 294.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 556.13 0.00 0.00 68440 S 50.27 0.00 0.00<br />

67882 S 605.36 0.00 0.00 68500 S 733.88 0.00 0.00<br />

67900 S 789.36 0.00 0.00 68505 S 733.88 0.00 0.00<br />

67901 S 701.05 0.00 0.00 68510 S 523.53 0.00 0.00<br />

67902 S 829.57 0.00 0.00 68520 S 733.88 0.00 0.00<br />

67903 S 660.83 0.00 0.00 68525 S 523.53 0.00 0.00<br />

67904 S 660.83 0.00 0.00 68530 S 120.65 0.00 0.00<br />

67906 S 701.05 0.00 0.00 68540 S 605.36 0.00 0.00<br />

67908 S 660.83 0.00 0.00 68550 S 733.88 0.00 0.00<br />

67909 S 660.83 0.00 0.00 68700 S 575.77 0.00 0.00<br />

67911 S 605.36 0.00 0.00 68705 S 114.56 0.00 0.00<br />

67912 S 605.36 0.00 0.00 68720 S 789.36 0.00 0.00<br />

67914 S 605.36 0.00 0.00 68745 S 789.36 0.00 0.00<br />

67915 S 163.47 0.00 0.00 68750 S 789.36 0.00 0.00<br />

67916 S 660.83 0.00 0.00 68760 S 97.47 0.00 0.00<br />

67917 S 660.83 0.00 0.00 68761 S 67.37 0.00 0.00<br />

67921 S 605.36 0.00 0.00 68770 S 789.36 0.00 0.00<br />

67922 S 159.02 0.00 0.00 68801 S 35.74 0.00 0.00<br />

67923 S 660.83 0.00 0.00 68810 S 102.20 0.00 0.00<br />

67924 S 660.83 0.00 0.00 68811 S 575.77 0.00 0.00<br />

67930 S 163.47 0.00 0.00 68815 S 575.77 0.00 0.00<br />

67935 S 575.77 0.00 0.00 68816 S 739.17 0.00 0.00<br />

67938 S 82.46 0.00 0.00 68840 S 53.00 0.00 0.00<br />

67950 S 575.77 0.00 0.00 69000 S 54.07 0.00 0.00<br />

67961 S 605.36 0.00 0.00 69005 S 102.25 0.00 0.00<br />

67966 S 605.36 0.00 0.00 69020 S 54.07 0.00 0.00<br />

67971 S 605.36 0.00 0.00 69100 S 61.56 0.00 0.00<br />

67973 S 733.88 0.00 0.00 69105 S 87.21 0.00 0.00<br />

67974 S 605.36 0.00 0.00 69110 S 458.15 0.00 0.00<br />

67975 S 605.36 0.00 0.00 69120 S 679.90 0.00 0.00<br />

68020 S 44.80 0.00 0.00 69140 S 679.90 0.00 0.00<br />

68040 S 22.23 0.00 0.00 69145 S 510.39 0.00 0.00<br />

68100 S 88.91 0.00 0.00 69150 S 358.72 0.00 0.00<br />

68110 S 114.56 0.00 0.00 69200 S 24.73 0.00 0.00<br />

68115 S 575.77 0.00 0.00 69205 S 571.93 0.00 0.00<br />

68130 S 526.54 0.00 0.00 69210 S 20.18 0.00 0.00<br />

68135 S 57.45 0.00 0.00 69220 S 31.69 0.00 0.00<br />

68200 S 16.41 0.00 0.00 69222 S 133.37 0.00 0.00<br />

68320 S 789.36 0.00 0.00 69300 S 709.49 0.00 0.00<br />

68325 S 789.36 0.00 0.00 69310 S 1,037.07 0.00 0.00<br />

68326 S 660.83 0.00 0.00 69320 S 1,261.28 0.00 0.00<br />

68328 S 789.36 0.00 0.00 69400 S 89.60 0.00 0.00<br />

68330 S 748.52 0.00 0.00 69401 S 47.19 0.00 0.00<br />

68335 S 789.36 0.00 0.00 69405 S 123.80 0.00 0.00<br />

68340 S 660.83 0.00 0.00 69420 S 111.15 0.00 0.00<br />

68360 S 663.46 0.00 0.00 69421 S 565.68 0.00 0.00<br />

68362 S 663.46 0.00 0.00 69424 S 77.97 0.00 0.00<br />

68371 S 526.54 0.00 0.00 69433 S 110.81 0.00 0.00<br />

68400 S 120.65 0.00 0.00 69436 S 565.68 0.00 0.00<br />

68420 S 171.67 0.00 0.00 69440 S 709.49 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 955.24 0.00 0.00 69840 S 1,132.76 0.00 0.00<br />

69501 S 1,261.28 0.00 0.00 69905 S 1,261.28 0.00 0.00<br />

69502 S 933.70 0.00 0.00 69910 S 1,261.28 0.00 0.00<br />

69505 S 1,261.28 0.00 0.00 69915 S 1,261.28 0.00 0.00<br />

69511 S 1,261.28 0.00 0.00 69930 S 22,802.16 12,243.22 1,684.28<br />

69530 S 1,261.28 0.00 0.00 70030 TC A 17.44 0.00 0.00<br />

69540 S 130.29 0.00 0.00 70100 TC A 19.15 0.00 0.00<br />

69550 S 1,132.76 0.00 0.00 70110 TC A 23.60 0.00 0.00<br />

69552 S 1,261.28 0.00 0.00 70120 TC A 21.20 0.00 0.00<br />

69601 S 1,261.28 0.00 0.00 70130 TC A 25.90 0.00 0.00<br />

69602 S 1,261.28 0.00 0.00 70134 TC A 25.99 0.00 0.00<br />

69603 S 1,261.28 0.00 0.00 70140 TC A 17.78 0.00 0.00<br />

69604 S 1,261.28 0.00 0.00 70150 TC A 25.90 0.00 0.00<br />

69605 S 1,261.28 0.00 0.00 70160 TC A 20.86 0.00 0.00<br />

69610 S 174.41 0.00 0.00 70190 TC A 21.88 0.00 0.00<br />

69620 S 679.90 0.00 0.00 70200 TC A 25.90 0.00 0.00<br />

69631 S 1,132.76 0.00 0.00 70210 TC A 18.47 0.00 0.00<br />

69632 S 1,132.76 0.00 0.00 70220 TC A 23.26 0.00 0.00<br />

69633 S 1,132.76 0.00 0.00 70240 TC A 17.44 0.00 0.00<br />

69635 S 1,261.28 0.00 0.00 70250 TC A 21.20 0.00 0.00<br />

69636 S 1,261.28 0.00 0.00 70260 TC A 27.01 0.00 0.00<br />

69637 S 1,261.28 0.00 0.00 70300 TC A 7.52 0.00 0.00<br />

69641 S 1,261.28 0.00 0.00 70310 TC A 18.58 0.00 0.00<br />

69642 S 1,261.28 0.00 0.00 70320 TC A 18.58 0.00 0.00<br />

69643 S 1,261.28 0.00 0.00 70328 TC A 18.47 0.00 0.00<br />

69644 S 1,261.28 0.00 0.00 70330 TC A 25.90 0.00 0.00<br />

69645 S 1,261.28 0.00 0.00 70336 TC A 201.64 0.00 0.00<br />

69646 S 1,261.28 0.00 0.00 70350 TC A 10.26 0.00 0.00<br />

69650 S 933.70 0.00 0.00 70355 TC A 10.60 0.00 0.00<br />

69660 S 1,132.76 0.00 0.00 70360 TC A 16.41 0.00 0.00<br />

69661 S 1,132.76 0.00 0.00 70370 TC A 48.21 0.00 0.00<br />

69662 S 1,132.76 0.00 0.00 70371 TC A 48.21 0.00 0.00<br />

69666 S 1,092.54 0.00 0.00 70380 TC A 24.97 0.00 0.00<br />

69667 S 1,092.54 0.00 0.00 70450 TC A 112.62 0.00 0.00<br />

69670 S 1,037.07 0.00 0.00 70460 TC A 178.33 0.00 0.00<br />

69676 S 1,037.07 0.00 0.00 70470 TC A 197.54 0.00 0.00<br />

69700 S 1,037.07 0.00 0.00 70480 TC A 112.62 0.00 0.00<br />

69711 S 955.24 0.00 0.00 70481 TC A 178.33 0.00 0.00<br />

69714 S 6,057.94 3,819.76 1,581.58 70482 TC A 197.54 0.00 0.00<br />

69715 S 6,057.94 3,819.76 1,581.58 70486 TC A 112.62 0.00 0.00<br />

69717 S 6,057.94 3,819.76 1,581.58 70487 TC A 178.33 0.00 0.00<br />

69718 S 6,057.94 3,819.76 1,581.58 70488 TC A 197.54 0.00 0.00<br />

69720 S 1,132.76 0.00 0.00 70490 TC A 112.62 0.00 0.00<br />

69740 S 1,132.76 0.00 0.00 70491 TC A 178.33 0.00 0.00<br />

69745 S 1,132.76 0.00 0.00 70492 TC A 197.54 0.00 0.00<br />

69801 S 1,132.76 0.00 0.00 70496 TC A 203.85 0.00 0.00<br />

69802 S 1,261.28 0.00 0.00 70498 TC A 203.85 0.00 0.00<br />

69805 S 1,261.28 0.00 0.00 70540 TC A 201.64 0.00 0.00<br />

69806 S 1,261.28 0.00 0.00 70542 TC A 247.62 0.00 0.00<br />

69820 S 1,132.76 0.00 0.00 70543 TC A 312.09 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 201.64 0.00 0.00 72120 TC A 32.83 0.00 0.00<br />

70545 TC A 247.62 0.00 0.00 72125 TC A 112.62 0.00 0.00<br />

70546 TC A 312.09 0.00 0.00 72126 TC A 178.33 0.00 0.00<br />

70547 TC A 201.64 0.00 0.00 72127 TC A 197.54 0.00 0.00<br />

70548 TC A 247.62 0.00 0.00 72128 TC A 112.62 0.00 0.00<br />

70549 TC A 312.09 0.00 0.00 72129 TC A 178.33 0.00 0.00<br />

70551 TC A 201.64 0.00 0.00 72130 TC A 197.54 0.00 0.00<br />

70552 TC A 247.62 0.00 0.00 72131 TC A 112.62 0.00 0.00<br />

70553 TC A 312.09 0.00 0.00 72132 TC A 178.33 0.00 0.00<br />

70554 TC A 201.64 0.00 0.00 72133 TC A 197.54 0.00 0.00<br />

70555 TC A 201.64 0.00 0.00 72141 TC A 201.64 0.00 0.00<br />

70557 TC A 201.64 0.00 0.00 72142 TC A 247.62 0.00 0.00<br />

70558 TC A 247.62 0.00 0.00 72146 TC A 201.64 0.00 0.00<br />

70559 TC A 312.09 0.00 0.00 72147 TC A 247.62 0.00 0.00<br />

71010 TC A 13.34 0.00 0.00 72148 TC A 201.64 0.00 0.00<br />

71015 TC A 17.10 0.00 0.00 72149 TC A 247.62 0.00 0.00<br />

71020 TC A 18.13 0.00 0.00 72156 TC A 312.09 0.00 0.00<br />

71021 TC A 21.88 0.00 0.00 72157 TC A 312.09 0.00 0.00<br />

71022 TC A 25.90 0.00 0.00 72158 TC A 312.09 0.00 0.00<br />

71023 TC A 42.40 0.00 0.00 72170 TC A 15.39 0.00 0.00<br />

71030 TC A 25.90 0.00 0.00 72190 TC A 25.90 0.00 0.00<br />

71034 TC A 48.21 0.00 0.00 72191 TC A 203.85 0.00 0.00<br />

71035 TC A 22.57 0.00 0.00 72192 TC A 112.62 0.00 0.00<br />

71100 TC A 18.81 0.00 0.00 72193 TC A 178.33 0.00 0.00<br />

71101 TC A 22.91 0.00 0.00 72194 TC A 197.54 0.00 0.00<br />

71110 TC A 23.94 0.00 0.00 72195 TC A 201.64 0.00 0.00<br />

71111 TC A 31.80 0.00 0.00 72196 TC A 247.62 0.00 0.00<br />

71120 TC A 19.84 0.00 0.00 72197 TC A 312.09 0.00 0.00<br />

71130 TC A 23.26 0.00 0.00 72200 TC A 18.13 0.00 0.00<br />

71250 TC A 112.62 0.00 0.00 72202 TC A 22.23 0.00 0.00<br />

71260 TC A 178.33 0.00 0.00 72220 TC A 18.13 0.00 0.00<br />

71270 TC A 197.54 0.00 0.00 73000 TC A 17.10 0.00 0.00<br />

71275 TC A 203.85 0.00 0.00 73010 TC A 17.44 0.00 0.00<br />

71550 TC A 201.64 0.00 0.00 73020 TC A 14.02 0.00 0.00<br />

71551 TC A 247.62 0.00 0.00 73030 TC A 17.78 0.00 0.00<br />

71552 TC A 312.09 0.00 0.00 73050 TC A 22.23 0.00 0.00<br />

72010 TC A 43.12 0.00 0.00 73060 TC A 17.78 0.00 0.00<br />

72020 TC A 14.02 0.00 0.00 73070 TC A 17.10 0.00 0.00<br />

72040 TC A 22.57 0.00 0.00 73080 TC A 22.57 0.00 0.00<br />

72050 TC A 32.14 0.00 0.00 73090 TC A 17.10 0.00 0.00<br />

72052 TC A 43.12 0.00 0.00 73092 TC A 17.78 0.00 0.00<br />

72069 TC A 21.20 0.00 0.00 73100 TC A 17.78 0.00 0.00<br />

72070 TC A 19.84 0.00 0.00 73110 TC A 22.57 0.00 0.00<br />

72072 TC A 23.94 0.00 0.00 73120 TC A 16.75 0.00 0.00<br />

72074 TC A 25.90 0.00 0.00 73130 TC A 19.84 0.00 0.00<br />

72080 TC A 21.20 0.00 0.00 73140 TC A 19.49 0.00 0.00<br />

72090 TC A 28.39 0.00 0.00 73200 TC A 112.62 0.00 0.00<br />

72100 TC A 24.28 0.00 0.00 73201 TC A 178.33 0.00 0.00<br />

72110 TC A 33.86 0.00 0.00 73202 TC A 197.54 0.00 0.00<br />

72114 TC A 43.12 0.00 0.00 73206 TC A 203.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 201.64 0.00 0.00 74246 TC A 50.89 0.00 0.00<br />

73219 TC A 247.62 0.00 0.00 74247 TC A 50.89 0.00 0.00<br />

73220 TC A 312.09 0.00 0.00 74249 TC A 82.75 0.00 0.00<br />

73221 TC A 201.64 0.00 0.00 74250 TC A 50.89 0.00 0.00<br />

73222 TC A 247.62 0.00 0.00 74251 TC A 82.75 0.00 0.00<br />

73223 TC A 312.09 0.00 0.00 74260 TC A 50.89 0.00 0.00<br />

73500 TC A 14.71 0.00 0.00 74270 TC A 50.89 0.00 0.00<br />

73510 TC A 22.57 0.00 0.00 74280 TC A 82.75 0.00 0.00<br />

73520 TC A 23.26 0.00 0.00 74283 TC A 50.89 0.00 0.00<br />

73540 TC A 23.26 0.00 0.00 74290 TC A 43.43 0.00 0.00<br />

73550 TC A 17.10 0.00 0.00 74291 TC A 41.72 0.00 0.00<br />

73560 TC A 17.44 0.00 0.00 74400 TC A 75.58 0.00 0.00<br />

73562 TC A 21.54 0.00 0.00 74410 TC A 80.71 0.00 0.00<br />

73564 TC A 24.97 0.00 0.00 74415 TC A 96.44 0.00 0.00<br />

73565 TC A 18.81 0.00 0.00 74420 TC A 100.80 0.00 0.00<br />

73590 TC A 16.41 0.00 0.00 74710 TC A 22.57 0.00 0.00<br />

73592 TC A 17.78 0.00 0.00 74775 TC A 100.80 0.00 0.00<br />

73600 TC A 16.75 0.00 0.00 75557 TC A 201.64 0.00 0.00<br />

73610 TC A 19.84 0.00 0.00 75559 TC A 201.64 0.00 0.00<br />

73620 TC A 16.07 0.00 0.00 75561 TC A 312.09 0.00 0.00<br />

73630 TC A 19.49 0.00 0.00 75563 TC A 312.09 0.00 0.00<br />

73650 TC A 16.41 0.00 0.00 76010 TC A 16.75 0.00 0.00<br />

73660 TC A 18.47 0.00 0.00 76098 TC A 10.26 0.00 0.00<br />

73700 TC A 112.62 0.00 0.00 76100 TC A 43.12 0.00 0.00<br />

73701 TC A 178.33 0.00 0.00 76101 TC A 115.59 0.00 0.00<br />

73702 TC A 197.54 0.00 0.00 76102 TC A 115.59 0.00 0.00<br />

73706 TC A 203.85 0.00 0.00 76120 TC A 48.21 0.00 0.00<br />

73718 TC A 201.64 0.00 0.00 76150 A 16.75 0.00 0.00<br />

73719 TC A 247.62 0.00 0.00 76380 TC A 60.84 0.00 0.00<br />

73720 TC A 312.09 0.00 0.00 76496 TC A 48.21 0.00 0.00<br />

73721 TC A 201.64 0.00 0.00 76497 TC A 60.84 0.00 0.00<br />

73722 TC A 247.62 0.00 0.00 76498 TC A 201.64 0.00 0.00<br />

73723 TC A 312.09 0.00 0.00 76499 TC A 25.90 0.00 0.00<br />

74000 TC A 14.71 0.00 0.00 76506 TC A 36.21 0.00 0.00<br />

74010 TC A 22.91 0.00 0.00 76510 TC A 61.56 0.00 0.00<br />

74020 TC A 23.26 0.00 0.00 76511 TC A 43.09 0.00 0.00<br />

74022 TC A 28.39 0.00 0.00 76512 TC A 36.59 0.00 0.00<br />

74150 TC A 112.62 0.00 0.00 76513 TC A 44.46 0.00 0.00<br />

74160 TC A 178.33 0.00 0.00 76514 TC A 3.08 0.00 0.00<br />

74170 TC A 197.54 0.00 0.00 76516 TC A 34.88 0.00 0.00<br />

74175 TC A 203.85 0.00 0.00 76519 TC A 38.99 0.00 0.00<br />

74181 TC A 201.64 0.00 0.00 76529 TC A 33.86 0.00 0.00<br />

74182 TC A 247.62 0.00 0.00 76536 TC A 56.65 0.00 0.00<br />

74183 TC A 312.09 0.00 0.00 76604 TC A 36.21 0.00 0.00<br />

74210 TC A 50.89 0.00 0.00 76645 TC A 36.21 0.00 0.00<br />

74220 TC A 50.89 0.00 0.00 76700 TC A 56.65 0.00 0.00<br />

74230 TC A 50.89 0.00 0.00 76705 TC A 56.65 0.00 0.00<br />

74240 TC A 50.89 0.00 0.00 76770 TC A 56.65 0.00 0.00<br />

74241 TC A 50.89 0.00 0.00 76775 TC A 56.65 0.00 0.00<br />

74245 TC A 82.75 0.00 0.00 76776 TC A 56.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 56.65 0.00 0.00 77290 TC A 148.14 0.00 0.00<br />

76801 TC A 56.65 0.00 0.00 77295 TC A 388.16 0.00 0.00<br />

76802 TC A 27.01 0.00 0.00 77299 TC A 66.46 0.00 0.00<br />

76805 TC A 56.65 0.00 0.00 77300 TC A 35.91 0.00 0.00<br />

76810 TC A 42.74 0.00 0.00 77301 TC A 517.30 0.00 0.00<br />

76811 TC A 88.74 0.00 0.00 77305 TC A 32.83 0.00 0.00<br />

76812 TC A 36.21 0.00 0.00 77310 TC A 42.74 0.00 0.00<br />

76813 TC A 36.21 0.00 0.00 77315 TC A 62.24 0.00 0.00<br />

76814 TC A 28.73 0.00 0.00 77321 TC A 64.64 0.00 0.00<br />

76815 TC A 36.21 0.00 0.00 77326 TC A 66.46 0.00 0.00<br />

76816 TC A 36.21 0.00 0.00 77327 TC A 120.72 0.00 0.00<br />

76817 TC A 36.21 0.00 0.00 77328 TC A 148.14 0.00 0.00<br />

76818 TC A 56.65 0.00 0.00 77331 TC A 17.10 0.00 0.00<br />

76819 TC A 48.91 0.00 0.00 77332 TC A 45.83 0.00 0.00<br />

76820 TC A 24.28 0.00 0.00 77333 TC A 22.23 0.00 0.00<br />

76821 TC A 54.83 0.00 0.00 77334 TC A 85.84 0.00 0.00<br />

76825 TC A 114.22 0.00 0.00 77336 A 54.04 0.00 0.00<br />

76826 TC A 68.05 0.00 0.00 77370 A 66.46 0.00 0.00<br />

76827 TC A 36.21 0.00 0.00 77371 A 4,427.24 0.00 0.00<br />

76828 TC A 21.54 0.00 0.00 77399 TC A 66.46 0.00 0.00<br />

76830 TC A 56.65 0.00 0.00 77401 A 27.01 0.00 0.00<br />

76831 TC A 76.26 0.00 0.00 77402 A 54.39 0.00 0.00<br />

76856 TC A 56.65 0.00 0.00 77403 A 54.39 0.00 0.00<br />

76857 TC A 36.21 0.00 0.00 77404 A 54.39 0.00 0.00<br />

76870 TC A 56.65 0.00 0.00 77406 A 88.10 0.00 0.00<br />

76872 TC A 56.65 0.00 0.00 77407 A 54.39 0.00 0.00<br />

76873 TC A 56.65 0.00 0.00 77408 A 54.39 0.00 0.00<br />

76880 TC A 56.65 0.00 0.00 77409 A 54.39 0.00 0.00<br />

76885 TC A 36.21 0.00 0.00 77411 A 88.10 0.00 0.00<br />

76886 TC A 36.21 0.00 0.00 77412 A 88.10 0.00 0.00<br />

76936 TC A 54.83 0.00 0.00 77413 A 88.10 0.00 0.00<br />

76970 TC A 36.21 0.00 0.00 77414 A 88.10 0.00 0.00<br />

76977 TC A 9.24 0.00 0.00 77416 A 88.10 0.00 0.00<br />

76999 TC A 36.21 0.00 0.00 77418 A 238.02 0.00 0.00<br />

77071 A 21.20 0.00 0.00 77422 A 88.10 0.00 0.00<br />

77072 TC A 12.31 0.00 0.00 77423 A 88.10 0.00 0.00<br />

77073 TC A 20.86 0.00 0.00 77470 TC A 126.54 0.00 0.00<br />

77074 TC A 41.04 0.00 0.00 77520 A 407.51 0.00 0.00<br />

77075 TC A 43.12 0.00 0.00 77522 A 407.51 0.00 0.00<br />

77076 TC A 43.12 0.00 0.00 77523 A 486.99 0.00 0.00<br />

77077 TC A 23.26 0.00 0.00 77525 A 486.99 0.00 0.00<br />

77078 TC A 41.66 0.00 0.00 77600 TC A 216.22 0.00 0.00<br />

77079 TC A 42.74 0.00 0.00 77605 TC A 216.22 0.00 0.00<br />

77080 TC A 41.66 0.00 0.00 77610 TC A 216.22 0.00 0.00<br />

77081 TC A 16.75 0.00 0.00 77615 TC A 216.22 0.00 0.00<br />

77082 TC A 18.13 0.00 0.00 77620 TC A 216.22 0.00 0.00<br />

77083 TC A 14.37 0.00 0.00 77750 TC A 84.12 0.00 0.00<br />

77084 TC A 201.64 0.00 0.00 77761 TC A 148.08 0.00 0.00<br />

77280 TC A 66.46 0.00 0.00 77762 TC A 175.44 0.00 0.00<br />

77285 TC A 148.14 0.00 0.00 77763 TC A 226.05 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 160.39 0.00 0.00 78262 TC A 140.86 0.00 0.00<br />

77777 TC A 176.12 0.00 0.00 78264 TC A 140.86 0.00 0.00<br />

77778 TC A 234.60 0.00 0.00 78270 TC A 61.56 0.00 0.00<br />

77785 TC A 104.30 0.00 0.00 78271 TC A 62.58 0.00 0.00<br />

77786 TC A 366.60 0.00 0.00 78272 TC A 68.74 0.00 0.00<br />

77787 TC A 424.81 0.00 0.00 78278 TC A 140.86 0.00 0.00<br />

77789 TC A 43.78 0.00 0.00 78282 TC A 140.86 0.00 0.00<br />

77799 TC A 249.51 0.00 0.00 78290 TC A 140.86 0.00 0.00<br />

78000 TC A 53.69 0.00 0.00 78291 TC A 140.86 0.00 0.00<br />

78001 TC A 68.04 0.00 0.00 78299 TC A 140.86 0.00 0.00<br />

78003 TC A 54.04 0.00 0.00 78300 TC A 122.77 0.00 0.00<br />

78006 TC A 128.57 0.00 0.00 78305 TC A 142.39 0.00 0.00<br />

78007 TC A 95.08 0.00 0.00 78306 TC A 142.39 0.00 0.00<br />

78010 TC A 78.99 0.00 0.00 78315 TC A 142.39 0.00 0.00<br />

78011 TC A 78.99 0.00 0.00 78320 TC A 142.39 0.00 0.00<br />

78015 TC A 153.55 0.00 0.00 78399 TC A 142.39 0.00 0.00<br />

78016 TC A 173.32 0.00 0.00 78414 TC A 180.99 0.00 0.00<br />

78018 TC A 173.32 0.00 0.00 78428 TC A 138.84 0.00 0.00<br />

78070 TC A 117.98 0.00 0.00 78445 TC A 108.30 0.00 0.00<br />

78075 TC A 334.12 0.00 0.00 78456 TC A 108.30 0.00 0.00<br />

78099 TC A 78.99 0.00 0.00 78457 TC A 108.30 0.00 0.00<br />

78102 TC A 119.35 0.00 0.00 78458 TC A 108.30 0.00 0.00<br />

78103 TC A 152.14 0.00 0.00 78459 TC A 670.24 0.00 0.00<br />

78104 TC A 152.14 0.00 0.00 78460 TC A 129.95 0.00 0.00<br />

78110 TC A 60.53 0.00 0.00 78461 TC A 130.98 0.00 0.00<br />

78111 TC A 76.61 0.00 0.00 78464 TC A 192.19 0.00 0.00<br />

78120 TC A 67.03 0.00 0.00 78465 TC A 363.87 0.00 0.00<br />

78121 TC A 79.34 0.00 0.00 78466 TC A 128.93 0.00 0.00<br />

78122 TC A 94.04 0.00 0.00 78468 TC A 164.84 0.00 0.00<br />

78130 TC A 109.09 0.00 0.00 78469 TC A 180.99 0.00 0.00<br />

78135 TC A 231.85 0.00 0.00 78472 TC A 180.99 0.00 0.00<br />

78140 TC A 102.94 0.00 0.00 78473 TC A 180.99 0.00 0.00<br />

78185 TC A 152.14 0.00 0.00 78481 TC A 156.28 0.00 0.00<br />

78190 TC A 95.46 0.00 0.00 78483 TC A 180.99 0.00 0.00<br />

78191 TC A 95.46 0.00 0.00 78491 TC A 670.24 0.00 0.00<br />

78195 TC A 152.14 0.00 0.00 78492 TC A 670.24 0.00 0.00<br />

78199 TC A 152.14 0.00 0.00 78494 TC A 180.99 0.00 0.00<br />

78201 TC A 135.42 0.00 0.00 78499 TC A 180.99 0.00 0.00<br />

78202 TC A 159.31 0.00 0.00 78580 TC A 122.62 0.00 0.00<br />

78205 TC A 159.31 0.00 0.00 78584 TC A 94.73 0.00 0.00<br />

78206 TC A 159.31 0.00 0.00 78585 TC A 188.15 0.00 0.00<br />

78215 TC A 143.29 0.00 0.00 78586 TC A 122.62 0.00 0.00<br />

78216 TC A 97.12 0.00 0.00 78587 TC A 122.62 0.00 0.00<br />

78220 TC A 106.02 0.00 0.00 78588 TC A 188.15 0.00 0.00<br />

78223 TC A 159.31 0.00 0.00 78591 TC A 122.62 0.00 0.00<br />

78230 TC A 120.37 0.00 0.00 78593 TC A 122.62 0.00 0.00<br />

78231 TC A 94.73 0.00 0.00 78594 TC A 122.62 0.00 0.00<br />

78232 TC A 98.83 0.00 0.00 78596 TC A 188.15 0.00 0.00<br />

78258 TC A 140.86 0.00 0.00 78599 TC A 122.62 0.00 0.00<br />

78261 TC A 140.86 0.00 0.00 78600 TC A 108.07 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 45220 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 108.07 0.00 0.00<br />

78605 TC A 108.07 0.00 0.00<br />

78606 TC A 242.81 0.00 0.00<br />

78607 TC A 266.75 0.00 0.00<br />

78608 TC A 600.74 0.00 0.00<br />

78610 TC A 143.97 0.00 0.00<br />

78630 TC A 256.49 0.00 0.00<br />

78635 TC A 236.31 0.00 0.00<br />

78645 TC A 108.07 0.00 0.00<br />

78647 TC A 261.62 0.00 0.00<br />

78650 TC A 253.41 0.00 0.00<br />

78660 TC A 108.07 0.00 0.00<br />

78699 TC A 108.07 0.00 0.00<br />

78700 TC A 133.03 0.00 0.00<br />

78701 TC A 162.10 0.00 0.00<br />

78707 TC A 169.28 0.00 0.00<br />

78708 TC A 115.94 0.00 0.00<br />

78709 TC A 190.61 0.00 0.00<br />

78710 TC A 178.86 0.00 0.00<br />

78725 TC A 71.48 0.00 0.00<br />

78730 TC A 60.53 0.00 0.00<br />

78740 TC A 158.00 0.00 0.00<br />

78761 TC A 150.81 0.00 0.00<br />

78799 TC A 190.61 0.00 0.00<br />

78800 TC A 133.37 0.00 0.00<br />

78801 TC A 182.96 0.00 0.00<br />

78802 TC A 247.94 0.00 0.00<br />

78803 TC A 265.72 0.00 0.00<br />

78804 TC A 463.73 0.00 0.00<br />

78805 TC A 130.29 0.00 0.00<br />

78806 TC A 260.59 0.00 0.00<br />

78807 TC A 266.06 0.00 0.00<br />

78811 TC A 600.74 0.00 0.00<br />

78812 TC A 600.74 0.00 0.00<br />

78813 TC A 600.74 0.00 0.00<br />

78814 TC A 600.74 0.00 0.00<br />

78815 TC A 600.74 0.00 0.00<br />

78816 TC A 600.74 0.00 0.00<br />

78999 TC A 68.04 0.00 0.00<br />

79005 TC A 54.72 0.00 0.00<br />

79101 TC A 59.85 0.00 0.00<br />

79200 TC A 64.64 0.00 0.00<br />

79300 TC A 124.71 0.00 0.00<br />

79403 TC A 92.68 0.00 0.00<br />

79440 TC A 52.32 0.00 0.00<br />

79445 TC A 124.71 0.00 0.00<br />

79999 TC A 124.71 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,190.40 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,485.80 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.44 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,535.27 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,535.27 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 221.72 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 221.72 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 111.95 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 236.61 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 71.13 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 636.91 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,452.39 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,136.86 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,136.86 0.00 0.00<br />

C8900 A 246.16 0.00 0.00 0123T S 909.15 0.00 0.00<br />

C8901 A 200.45 0.00 0.00 0124T S 177.70 0.00 0.00<br />

C8902 A 310.25 0.00 0.00 0144T TC A 60.48 0.00 0.00<br />

C8903 A 246.16 0.00 0.00 0145T TC A 162.81 0.00 0.00<br />

C8904 A 200.45 0.00 0.00 0146T TC A 162.81 0.00 0.00<br />

C8905 A 310.25 0.00 0.00 0147T TC A 162.81 0.00 0.00<br />

C8906 A 246.16 0.00 0.00 0148T TC A 162.81 0.00 0.00<br />

C8907 A 200.45 0.00 0.00 0149T TC A 162.81 0.00 0.00<br />

C8908 A 310.25 0.00 0.00 0150T TC A 162.81 0.00 0.00<br />

C8909 A 246.16 0.00 0.00 0151T TC A 60.48 0.00 0.00<br />

C8910 A 200.45 0.00 0.00 0170T S 1,180.93 0.00 0.00<br />

C8911 A 310.25 0.00 0.00 0176T S 1,394.41 0.00 0.00<br />

C8912 A 246.16 0.00 0.00 0177T S 1,394.41 0.00 0.00<br />

C8913 A 200.45 0.00 0.00 0182T A 1,007.88 0.00 0.00<br />

C8914 A 310.25 0.00 0.00 0186T S 849.44 0.00 0.00<br />

C8918 A 246.16 0.00 0.00 0190T S 849.44 0.00 0.00<br />

C8919 A 200.45 0.00 0.00 0191T S 909.15 0.00 0.00<br />

C8920 A 310.25 0.00 0.00 0192T S 1,558.10 0.00 0.00<br />

C9716 S 1,180.93 0.00 0.00 10021 S 54.49 0.00 0.00<br />

C9724 S 965.54 0.00 0.00 10022 S 170.17 0.00 0.00<br />

C9725 S 222.65 0.00 0.00 10040 S 31.50 0.00 0.00<br />

C9726 S 817.41 0.00 0.00 10060 S 47.93 0.00 0.00<br />

C9727 S 286.60 0.00 0.00 10061 S 53.75 0.00 0.00<br />

C9728 S 514.24 0.00 0.00 10080 S 53.75 0.00 0.00<br />

G0104 S 82.61 0.00 0.00 10081 S 123.74 0.00 0.00<br />

G0105 S 357.04 0.00 0.00 10120 S 67.31 0.00 0.00<br />

G0121 S 357.04 0.00 0.00 10121 S 507.37 0.00 0.00<br />

G0127 S 11.56 0.00 0.00 10140 S 71.39 0.00 0.00<br />

G0130 TC A 19.04 0.00 0.00 10160 S 53.75 0.00 0.00<br />

G0173 A 2,190.40 0.00 0.00 10180 S 573.77 0.00 0.00<br />

G0186 S 221.72 0.00 0.00 11000 S 23.12 0.00 0.00<br />

G0247 S 21.08 0.00 0.00 11001 S 7.82 0.00 0.00<br />

G0251 A 548.51 0.00 0.00 11010 S 200.74 0.00 0.00<br />

G0260 S 289.46 0.00 0.00 11011 S 200.74 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 200.74 0.00 0.00 11601 S 110.83 0.00 0.00<br />

11040 S 21.08 0.00 0.00 11602 S 122.05 0.00 0.00<br />

11041 S 23.46 0.00 0.00 11603 S 129.52 0.00 0.00<br />

11042 S 127.47 0.00 0.00 11604 S 349.38 0.00 0.00<br />

11043 S 127.47 0.00 0.00 11606 S 507.37 0.00 0.00<br />

11044 S 331.91 0.00 0.00 11620 S 94.51 0.00 0.00<br />

11055 S 24.82 0.00 0.00 11621 S 112.19 0.00 0.00<br />

11056 S 27.19 0.00 0.00 11622 S 124.76 0.00 0.00<br />

11057 S 31.50 0.00 0.00 11623 S 134.28 0.00 0.00<br />

11100 S 57.72 0.00 0.00 11624 S 507.37 0.00 0.00<br />

11101 S 13.60 0.00 0.00 11626 S 620.48 0.00 0.00<br />

11200 S 31.50 0.00 0.00 11640 S 99.95 0.00 0.00<br />

11201 S 5.44 0.00 0.00 11641 S 117.97 0.00 0.00<br />

11300 S 31.50 0.00 0.00 11642 S 131.57 0.00 0.00<br />

11301 S 31.50 0.00 0.00 11643 S 141.77 0.00 0.00<br />

11302 S 31.50 0.00 0.00 11644 S 507.37 0.00 0.00<br />

11303 S 57.72 0.00 0.00 11646 S 620.48 0.00 0.00<br />

11305 S 31.50 0.00 0.00 11719 S 11.56 0.00 0.00<br />

11306 S 31.50 0.00 0.00 11720 S 14.28 0.00 0.00<br />

11307 S 31.50 0.00 0.00 11721 S 17.33 0.00 0.00<br />

11308 S 31.50 0.00 0.00 11730 S 31.50 0.00 0.00<br />

11310 S 31.50 0.00 0.00 11732 S 17.33 0.00 0.00<br />

11311 S 31.50 0.00 0.00 11740 S 15.91 0.00 0.00<br />

11312 S 31.50 0.00 0.00 11750 S 91.79 0.00 0.00<br />

11313 S 31.50 0.00 0.00 11752 S 127.49 0.00 0.00<br />

11400 S 64.94 0.00 0.00 11755 S 63.57 0.00 0.00<br />

11401 S 73.09 0.00 0.00 11760 S 130.93 0.00 0.00<br />

11402 S 80.23 0.00 0.00 11762 S 116.95 0.00 0.00<br />

11403 S 85.67 0.00 0.00 11765 S 31.50 0.00 0.00<br />

11404 S 455.45 0.00 0.00 11770 S 649.89 0.00 0.00<br />

11406 S 507.37 0.00 0.00 11771 S 649.89 0.00 0.00<br />

11420 S 60.85 0.00 0.00 11772 S 649.89 0.00 0.00<br />

11421 S 73.77 0.00 0.00 11900 S 28.90 0.00 0.00<br />

11422 S 80.57 0.00 0.00 11901 S 31.50 0.00 0.00<br />

11423 S 89.75 0.00 0.00 11920 S 91.45 0.00 0.00<br />

11424 S 507.37 0.00 0.00 11921 S 100.63 0.00 0.00<br />

11426 S 620.48 0.00 0.00 11922 S 32.63 0.00 0.00<br />

11440 S 69.70 0.00 0.00 11950 S 33.32 0.00 0.00<br />

11441 S 80.57 0.00 0.00 11951 S 41.47 0.00 0.00<br />

11442 S 88.73 0.00 0.00 11952 S 49.93 0.00 0.00<br />

11443 S 98.25 0.00 0.00 11954 S 49.93 0.00 0.00<br />

11444 S 310.10 0.00 0.00 11960 S 605.70 0.00 0.00<br />

11446 S 620.48 0.00 0.00 11970 S 1,097.12 0.00 0.00<br />

11450 S 620.48 0.00 0.00 11971 S 568.55 0.00 0.00<br />

11451 S 620.48 0.00 0.00 11976 S 60.85 0.00 0.00<br />

11462 S 620.48 0.00 0.00 11980 S 24.58 0.00 0.00<br />

11463 S 620.48 0.00 0.00 11981 S 24.58 0.00 0.00<br />

11470 S 620.48 0.00 0.00 11982 S 24.58 0.00 0.00<br />

11471 S 620.48 0.00 0.00 11983 S 24.58 0.00 0.00<br />

11600 S 91.45 0.00 0.00 12001 S 49.93 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 49.93 0.00 0.00 14021 S 538.26 0.00 0.00<br />

12004 S 49.93 0.00 0.00 14040 S 508.85 0.00 0.00<br />

12005 S 66.90 0.00 0.00 14041 S 538.26 0.00 0.00<br />

12006 S 66.90 0.00 0.00 14060 S 538.26 0.00 0.00<br />

12007 S 66.90 0.00 0.00 14061 S 538.26 0.00 0.00<br />

12011 S 49.93 0.00 0.00 14300 S 690.26 0.00 0.00<br />

12013 S 49.93 0.00 0.00 14350 S 635.11 0.00 0.00<br />

12014 S 49.93 0.00 0.00 15002 S 232.85 0.00 0.00<br />

12015 S 49.93 0.00 0.00 15003 S 232.85 0.00 0.00<br />

12016 S 66.90 0.00 0.00 15004 S 232.85 0.00 0.00<br />

12017 S 66.90 0.00 0.00 15005 S 232.85 0.00 0.00<br />

12018 S 66.90 0.00 0.00 15040 S 107.39 0.00 0.00<br />

12020 S 126.21 0.00 0.00 15050 S 232.85 0.00 0.00<br />

12021 S 107.39 0.00 0.00 15100 S 605.70 0.00 0.00<br />

12031 S 49.93 0.00 0.00 15101 S 635.11 0.00 0.00<br />

12032 S 130.93 0.00 0.00 15110 S 289.25 0.00 0.00<br />

12034 S 66.90 0.00 0.00 15111 S 237.32 0.00 0.00<br />

12035 S 66.90 0.00 0.00 15115 S 289.25 0.00 0.00<br />

12036 S 107.39 0.00 0.00 15116 S 237.32 0.00 0.00<br />

12037 S 214.04 0.00 0.00 15120 S 605.70 0.00 0.00<br />

12041 S 49.93 0.00 0.00 15121 S 635.11 0.00 0.00<br />

12042 S 49.93 0.00 0.00 15130 S 508.85 0.00 0.00<br />

12044 S 66.90 0.00 0.00 15131 S 456.92 0.00 0.00<br />

12045 S 107.39 0.00 0.00 15135 S 508.85 0.00 0.00<br />

12046 S 107.39 0.00 0.00 15136 S 456.92 0.00 0.00<br />

12047 S 214.04 0.00 0.00 15150 S 289.25 0.00 0.00<br />

12051 S 49.93 0.00 0.00 15151 S 237.32 0.00 0.00<br />

12052 S 49.93 0.00 0.00 15152 S 237.32 0.00 0.00<br />

12053 S 49.93 0.00 0.00 15155 S 289.25 0.00 0.00<br />

12054 S 66.90 0.00 0.00 15156 S 237.32 0.00 0.00<br />

12055 S 107.39 0.00 0.00 15157 S 237.32 0.00 0.00<br />

12056 S 107.39 0.00 0.00 15170 S 130.93 0.00 0.00<br />

12057 S 214.04 0.00 0.00 15171 S 130.93 0.00 0.00<br />

13100 S 232.85 0.00 0.00 15175 S 168.57 0.00 0.00<br />

13101 S 232.85 0.00 0.00 15176 S 168.57 0.00 0.00<br />

13102 S 126.21 0.00 0.00 15200 S 538.26 0.00 0.00<br />

13120 S 107.39 0.00 0.00 15201 S 452.46 0.00 0.00<br />

13121 S 107.39 0.00 0.00 15220 S 508.85 0.00 0.00<br />

13122 S 107.39 0.00 0.00 15221 S 232.85 0.00 0.00<br />

13131 S 107.39 0.00 0.00 15240 S 538.26 0.00 0.00<br />

13132 S 107.39 0.00 0.00 15241 S 232.85 0.00 0.00<br />

13133 S 107.39 0.00 0.00 15260 S 508.85 0.00 0.00<br />

13150 S 232.85 0.00 0.00 15261 S 452.46 0.00 0.00<br />

13151 S 232.85 0.00 0.00 15300 S 232.85 0.00 0.00<br />

13152 S 232.85 0.00 0.00 15301 S 232.85 0.00 0.00<br />

13153 S 107.39 0.00 0.00 15320 S 232.85 0.00 0.00<br />

13160 S 605.70 0.00 0.00 15321 S 232.85 0.00 0.00<br />

14000 S 508.85 0.00 0.00 15330 S 232.85 0.00 0.00<br />

14001 S 538.26 0.00 0.00 15331 S 232.85 0.00 0.00<br />

14020 S 538.26 0.00 0.00 15335 S 232.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 232.85 0.00 0.00 15826 S 635.11 0.00 0.00<br />

15340 S 130.93 0.00 0.00 15828 S 635.11 0.00 0.00<br />

15341 S 130.93 0.00 0.00 15829 S 730.23 0.00 0.00<br />

15360 S 130.93 0.00 0.00 15830 S 649.89 0.00 0.00<br />

15361 S 130.93 0.00 0.00 15832 S 649.89 0.00 0.00<br />

15365 S 130.93 0.00 0.00 15833 S 649.89 0.00 0.00<br />

15366 S 130.93 0.00 0.00 15834 S 649.89 0.00 0.00<br />

15400 S 232.85 0.00 0.00 15835 S 564.08 0.00 0.00<br />

15401 S 232.85 0.00 0.00 15836 S 536.79 0.00 0.00<br />

15420 S 232.85 0.00 0.00 15837 S 604.83 0.00 0.00<br />

15421 S 232.85 0.00 0.00 15838 S 604.83 0.00 0.00<br />

15430 S 232.85 0.00 0.00 15839 S 536.79 0.00 0.00<br />

15431 S 232.85 0.00 0.00 15840 S 690.26 0.00 0.00<br />

15570 S 635.11 0.00 0.00 15841 S 690.26 0.00 0.00<br />

15572 S 635.11 0.00 0.00 15842 S 801.46 0.00 0.00<br />

15574 S 635.11 0.00 0.00 15845 S 690.26 0.00 0.00<br />

15576 S 635.11 0.00 0.00 15847 S 649.89 0.00 0.00<br />

15600 S 635.11 0.00 0.00 15850 S 103.82 0.00 0.00<br />

15610 S 635.11 0.00 0.00 15851 S 47.25 0.00 0.00<br />

15620 S 690.26 0.00 0.00 15852 S 24.58 0.00 0.00<br />

15630 S 635.11 0.00 0.00 15860 S 24.58 0.00 0.00<br />

15650 S 730.23 0.00 0.00 15876 S 635.11 0.00 0.00<br />

15731 S 635.11 0.00 0.00 15877 S 635.11 0.00 0.00<br />

15732 S 635.11 0.00 0.00 15878 S 635.11 0.00 0.00<br />

15734 S 635.11 0.00 0.00 15879 S 635.11 0.00 0.00<br />

15736 S 635.11 0.00 0.00 15920 S 200.74 0.00 0.00<br />

15738 S 635.11 0.00 0.00 15922 S 690.26 0.00 0.00<br />

15740 S 508.85 0.00 0.00 15931 S 649.89 0.00 0.00<br />

15750 S 605.70 0.00 0.00 15933 S 649.89 0.00 0.00<br />

15760 S 605.70 0.00 0.00 15934 S 635.11 0.00 0.00<br />

15770 S 635.11 0.00 0.00 15935 S 690.26 0.00 0.00<br />

15775 S 173.53 0.00 0.00 15936 S 593.41 0.00 0.00<br />

15776 S 173.53 0.00 0.00 15937 S 690.26 0.00 0.00<br />

15780 S 386.88 0.00 0.00 15940 S 649.89 0.00 0.00<br />

15781 S 170.29 0.00 0.00 15941 S 649.89 0.00 0.00<br />

15782 S 170.29 0.00 0.00 15944 S 635.11 0.00 0.00<br />

15783 S 103.82 0.00 0.00 15945 S 690.26 0.00 0.00<br />

15786 S 31.50 0.00 0.00 15946 S 690.26 0.00 0.00<br />

15787 S 28.56 0.00 0.00 15950 S 649.89 0.00 0.00<br />

15788 S 31.50 0.00 0.00 15951 S 705.04 0.00 0.00<br />

15789 S 57.72 0.00 0.00 15952 S 538.26 0.00 0.00<br />

15792 S 57.72 0.00 0.00 15953 S 593.41 0.00 0.00<br />

15793 S 31.50 0.00 0.00 15956 S 538.26 0.00 0.00<br />

15819 S 130.93 0.00 0.00 15958 S 593.41 0.00 0.00<br />

15820 S 635.11 0.00 0.00 16000 S 25.50 0.00 0.00<br />

15821 S 635.11 0.00 0.00 16020 S 38.76 0.00 0.00<br />

15822 S 635.11 0.00 0.00 16025 S 59.69 0.00 0.00<br />

15823 S 730.23 0.00 0.00 16030 S 74.74 0.00 0.00<br />

15824 S 635.11 0.00 0.00 16035 S 57.72 0.00 0.00<br />

15825 S 635.11 0.00 0.00 17000 S 31.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.74 0.00 0.00 19300 S 698.23 0.00 0.00<br />

17004 S 82.27 0.00 0.00 19301 S 643.09 0.00 0.00<br />

17106 S 103.82 0.00 0.00 19302 S 1,228.23 0.00 0.00<br />

17107 S 103.82 0.00 0.00 19303 S 928.21 0.00 0.00<br />

17108 S 103.82 0.00 0.00 19304 S 928.21 0.00 0.00<br />

17110 S 31.50 0.00 0.00 19316 S 928.21 0.00 0.00<br />

17111 S 57.72 0.00 0.00 19318 S 1,060.48 0.00 0.00<br />

17250 S 43.52 0.00 0.00 19324 S 1,060.48 0.00 0.00<br />

17260 S 46.57 0.00 0.00 19325 S 1,758.94 0.00 0.00<br />

17261 S 57.72 0.00 0.00 19328 S 791.72 0.00 0.00<br />

17262 S 57.72 0.00 0.00 19330 S 791.72 0.00 0.00<br />

17263 S 57.72 0.00 0.00 19340 S 975.92 0.00 0.00<br />

17264 S 57.72 0.00 0.00 19342 S 1,377.96 0.00 0.00<br />

17266 S 103.82 0.00 0.00 19350 S 698.23 0.00 0.00<br />

17270 S 57.72 0.00 0.00 19355 S 928.21 0.00 0.00<br />

17271 S 57.72 0.00 0.00 19357 S 1,473.09 0.00 0.00<br />

17272 S 57.72 0.00 0.00 19366 S 968.19 0.00 0.00<br />

17273 S 103.82 0.00 0.00 19370 S 928.21 0.00 0.00<br />

17274 S 103.82 0.00 0.00 19371 S 928.21 0.00 0.00<br />

17276 S 103.82 0.00 0.00 19380 S 1,100.47 0.00 0.00<br />

17280 S 57.72 0.00 0.00 19396 S 1,277.35 0.00 0.00<br />

17281 S 86.01 0.00 0.00 20000 S 53.75 0.00 0.00<br />

17282 S 98.25 0.00 0.00 20005 S 619.30 0.00 0.00<br />

17283 S 103.82 0.00 0.00 20103 S 607.78 0.00 0.00<br />

17284 S 103.82 0.00 0.00 20150 S 1,725.50 0.00 0.00<br />

17286 S 103.82 0.00 0.00 20200 S 507.37 0.00 0.00<br />

17311 S 171.38 0.00 0.00 20205 S 536.79 0.00 0.00<br />

17312 S 171.38 0.00 0.00 20206 S 250.84 0.00 0.00<br />

17313 S 171.38 0.00 0.00 20220 S 272.66 0.00 0.00<br />

17314 S 171.38 0.00 0.00 20225 S 494.73 0.00 0.00<br />

17315 S 38.76 0.00 0.00 20240 S 620.48 0.00 0.00<br />

17340 S 13.94 0.00 0.00 20245 S 649.89 0.00 0.00<br />

17360 S 31.50 0.00 0.00 20250 S 648.72 0.00 0.00<br />

17380 S 31.50 0.00 0.00 20251 S 648.72 0.00 0.00<br />

19000 S 65.61 0.00 0.00 20500 S 53.72 0.00 0.00<br />

19001 S 8.84 0.00 0.00 20520 S 90.43 0.00 0.00<br />

19020 S 573.77 0.00 0.00 20525 S 649.89 0.00 0.00<br />

19100 S 195.38 0.00 0.00 20526 S 29.24 0.00 0.00<br />

19101 S 613.67 0.00 0.00 20550 S 22.09 0.00 0.00<br />

19102 S 250.84 0.00 0.00 20551 S 21.76 0.00 0.00<br />

19103 S 439.03 0.00 0.00 20552 S 21.08 0.00 0.00<br />

19105 S 1,277.35 0.00 0.00 20553 S 23.46 0.00 0.00<br />

19110 S 613.67 0.00 0.00 20555 S 1,136.86 0.00 0.00<br />

19112 S 643.09 0.00 0.00 20600 S 22.43 0.00 0.00<br />

19120 S 643.09 0.00 0.00 20605 S 25.16 0.00 0.00<br />

19125 S 643.09 0.00 0.00 20610 S 35.36 0.00 0.00<br />

19126 S 643.09 0.00 0.00 20612 S 23.80 0.00 0.00<br />

19296 S 1,758.94 0.00 0.00 20615 S 99.61 0.00 0.00<br />

19297 S 1,758.94 0.00 0.00 20650 S 648.72 0.00 0.00<br />

19298 S 1,758.94 0.00 0.00 20662 S 828.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 828.67 0.00 0.00 21085 S 249.53 0.00 0.00<br />

20665 S 24.58 0.00 0.00 21086 S 543.26 0.00 0.00<br />

20670 S 455.45 0.00 0.00 21087 S 543.95 0.00 0.00<br />

20680 S 649.89 0.00 0.00 21088 S 1,593.12 0.00 0.00<br />

20690 S 773.39 0.00 0.00 21100 S 1,001.52 0.00 0.00<br />

20692 S 802.81 0.00 0.00 21110 S 286.60 0.00 0.00<br />

20693 S 648.72 0.00 0.00 21120 S 928.19 0.00 0.00<br />

20694 S 567.37 0.00 0.00 21121 S 928.19 0.00 0.00<br />

20696 S 1,136.86 0.00 0.00 21122 S 928.19 0.00 0.00<br />

20697 S 756.06 0.00 0.00 21123 S 928.19 0.00 0.00<br />

20822 S 1,065.25 0.00 0.00 21125 S 928.19 0.00 0.00<br />

20900 S 802.81 0.00 0.00 21127 S 1,411.91 0.00 0.00<br />

20902 S 857.95 0.00 0.00 21137 S 941.85 0.00 0.00<br />

20910 S 635.11 0.00 0.00 21138 S 1,593.12 0.00 0.00<br />

20912 S 635.11 0.00 0.00 21139 S 1,593.12 0.00 0.00<br />

20920 S 593.41 0.00 0.00 21150 S 1,593.12 0.00 0.00<br />

20922 S 538.26 0.00 0.00 21181 S 928.19 0.00 0.00<br />

20924 S 857.95 0.00 0.00 21198 S 1,593.12 0.00 0.00<br />

20926 S 373.81 0.00 0.00 21199 S 1,593.12 0.00 0.00<br />

20950 S 53.75 0.00 0.00 21206 S 1,126.07 0.00 0.00<br />

20972 S 1,799.23 0.00 0.00 21208 S 1,253.83 0.00 0.00<br />

20973 S 1,799.23 0.00 0.00 21209 S 1,126.07 0.00 0.00<br />

20979 S 22.09 0.00 0.00 21210 S 1,253.83 0.00 0.00<br />

20982 S 1,725.50 0.00 0.00 21215 S 1,253.83 0.00 0.00<br />

21010 S 675.88 0.00 0.00 21230 S 1,253.83 0.00 0.00<br />

21015 S 562.34 0.00 0.00 21235 S 928.19 0.00 0.00<br />

21025 S 1,001.52 0.00 0.00 21240 S 1,086.08 0.00 0.00<br />

21026 S 1,001.52 0.00 0.00 21242 S 1,126.07 0.00 0.00<br />

21029 S 1,001.52 0.00 0.00 21243 S 1,126.07 0.00 0.00<br />

21030 S 236.27 0.00 0.00 21244 S 1,253.83 0.00 0.00<br />

21031 S 195.48 0.00 0.00 21245 S 1,253.83 0.00 0.00<br />

21032 S 199.22 0.00 0.00 21246 S 1,253.83 0.00 0.00<br />

21034 S 1,030.94 0.00 0.00 21248 S 1,253.83 0.00 0.00<br />

21040 S 675.88 0.00 0.00 21249 S 1,253.83 0.00 0.00<br />

21044 S 1,001.52 0.00 0.00 21260 S 1,593.12 0.00 0.00<br />

21046 S 1,001.52 0.00 0.00 21267 S 1,253.83 0.00 0.00<br />

21047 S 1,001.52 0.00 0.00 21270 S 1,126.07 0.00 0.00<br />

21048 S 1,593.12 0.00 0.00 21275 S 1,253.83 0.00 0.00<br />

21050 S 1,030.94 0.00 0.00 21280 S 1,126.07 0.00 0.00<br />

21060 S 1,001.52 0.00 0.00 21282 S 657.46 0.00 0.00<br />

21070 S 1,030.94 0.00 0.00 21295 S 296.33 0.00 0.00<br />

21073 S 183.58 0.00 0.00 21296 S 623.95 0.00 0.00<br />

21076 S 318.54 0.00 0.00 21310 S 90.40 0.00 0.00<br />

21077 S 770.02 0.00 0.00 21315 S 397.22 0.00 0.00<br />

21079 S 551.42 0.00 0.00 21320 S 532.92 0.00 0.00<br />

21080 S 632.33 0.00 0.00 21325 S 760.44 0.00 0.00<br />

21081 S 582.70 0.00 0.00 21330 S 800.43 0.00 0.00<br />

21082 S 554.48 0.00 0.00 21335 S 928.19 0.00 0.00<br />

21083 S 546.32 0.00 0.00 21336 S 773.54 0.00 0.00<br />

21084 S 628.59 0.00 0.00 21337 S 532.92 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 760.44 0.00 0.00 22310 S 164.57 0.00 0.00<br />

21339 S 800.43 0.00 0.00 22315 S 425.65 0.00 0.00<br />

21340 S 1,086.08 0.00 0.00 22505 S 501.10 0.00 0.00<br />

21345 S 928.19 0.00 0.00 22520 S 1,183.78 0.00 0.00<br />

21355 S 1,030.94 0.00 0.00 22521 S 1,183.78 0.00 0.00<br />

21356 S 705.30 0.00 0.00 22522 S 1,183.78 0.00 0.00<br />

21360 S 941.85 0.00 0.00 22523 S 3,294.58 0.00 0.00<br />

21390 S 1,593.12 0.00 0.00 22524 S 3,294.58 0.00 0.00<br />

21400 S 348.26 0.00 0.00 22525 S 3,294.58 0.00 0.00<br />

21401 S 562.34 0.00 0.00 22900 S 705.04 0.00 0.00<br />

21406 S 1,593.12 0.00 0.00 23000 S 507.37 0.00 0.00<br />

21407 S 1,593.12 0.00 0.00 23020 S 1,067.71 0.00 0.00<br />

21421 S 760.44 0.00 0.00 23030 S 521.83 0.00 0.00<br />

21440 S 320.25 0.00 0.00 23031 S 603.18 0.00 0.00<br />

21445 S 760.44 0.00 0.00 23035 S 648.72 0.00 0.00<br />

21450 S 132.17 0.00 0.00 23040 S 802.81 0.00 0.00<br />

21451 S 356.60 0.00 0.00 23044 S 857.95 0.00 0.00<br />

21452 S 532.92 0.00 0.00 23065 S 95.87 0.00 0.00<br />

21453 S 1,030.94 0.00 0.00 23066 S 620.48 0.00 0.00<br />

21454 S 800.43 0.00 0.00 23075 S 507.37 0.00 0.00<br />

21461 S 1,086.08 0.00 0.00 23076 S 620.48 0.00 0.00<br />

21462 S 1,126.07 0.00 0.00 23077 S 649.89 0.00 0.00<br />

21465 S 1,086.08 0.00 0.00 23100 S 619.30 0.00 0.00<br />

21480 S 90.40 0.00 0.00 23101 S 1,025.70 0.00 0.00<br />

21485 S 532.92 0.00 0.00 23105 S 857.95 0.00 0.00<br />

21490 S 1,030.94 0.00 0.00 23106 S 857.95 0.00 0.00<br />

21495 S 655.91 0.00 0.00 23107 S 857.95 0.00 0.00<br />

21497 S 532.92 0.00 0.00 23120 S 897.94 0.00 0.00<br />

21501 S 573.77 0.00 0.00 23125 S 897.94 0.00 0.00<br />

21502 S 619.30 0.00 0.00 23130 S 1,192.25 0.00 0.00<br />

21550 S 604.83 0.00 0.00 23140 S 703.86 0.00 0.00<br />

21555 S 620.48 0.00 0.00 23145 S 897.94 0.00 0.00<br />

21556 S 620.48 0.00 0.00 23146 S 897.94 0.00 0.00<br />

21557 S 831.02 0.00 0.00 23150 S 857.95 0.00 0.00<br />

21600 S 773.39 0.00 0.00 23155 S 897.94 0.00 0.00<br />

21610 S 773.39 0.00 0.00 23156 S 897.94 0.00 0.00<br />

21685 S 286.60 0.00 0.00 23170 S 773.39 0.00 0.00<br />

21700 S 619.30 0.00 0.00 23172 S 773.39 0.00 0.00<br />

21720 S 648.72 0.00 0.00 23174 S 773.39 0.00 0.00<br />

21725 S 67.53 0.00 0.00 23180 S 857.95 0.00 0.00<br />

21800 S 78.01 0.00 0.00 23182 S 857.95 0.00 0.00<br />

21805 S 688.98 0.00 0.00 23184 S 857.95 0.00 0.00<br />

21820 S 78.01 0.00 0.00 23190 S 857.95 0.00 0.00<br />

21920 S 138.70 0.00 0.00 23195 S 897.94 0.00 0.00<br />

21925 S 620.48 0.00 0.00 23330 S 310.10 0.00 0.00<br />

21930 S 620.48 0.00 0.00 23331 S 568.55 0.00 0.00<br />

21935 S 649.89 0.00 0.00 23395 S 1,192.25 0.00 0.00<br />

22102 S 1,849.28 0.00 0.00 23397 S 2,104.56 0.00 0.00<br />

22103 S 1,849.28 0.00 0.00 23400 S 1,025.70 0.00 0.00<br />

22305 S 78.01 0.00 0.00 23405 S 773.39 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 773.39 0.00 0.00 23931 S 573.77 0.00 0.00<br />

23410 S 1,192.25 0.00 0.00 23935 S 619.30 0.00 0.00<br />

23412 S 1,320.01 0.00 0.00 24000 S 857.95 0.00 0.00<br />

23415 S 1,192.25 0.00 0.00 24006 S 857.95 0.00 0.00<br />

23420 S 1,320.01 0.00 0.00 24065 S 132.93 0.00 0.00<br />

23430 S 1,152.27 0.00 0.00 24066 S 507.37 0.00 0.00<br />

23440 S 1,152.27 0.00 0.00 24075 S 507.37 0.00 0.00<br />

23450 S 1,976.80 0.00 0.00 24076 S 620.48 0.00 0.00<br />

23455 S 2,104.56 0.00 0.00 24077 S 649.89 0.00 0.00<br />

23460 S 1,976.80 0.00 0.00 24100 S 567.37 0.00 0.00<br />

23462 S 1,320.01 0.00 0.00 24101 S 857.95 0.00 0.00<br />

23465 S 1,976.80 0.00 0.00 24102 S 857.95 0.00 0.00<br />

23466 S 1,320.01 0.00 0.00 24105 S 648.72 0.00 0.00<br />

23480 S 1,152.27 0.00 0.00 24110 S 619.30 0.00 0.00<br />

23485 S 2,104.56 0.00 0.00 24115 S 802.81 0.00 0.00<br />

23490 S 1,097.12 0.00 0.00 24116 S 802.81 0.00 0.00<br />

23491 S 1,881.67 0.00 0.00 24120 S 648.72 0.00 0.00<br />

23500 S 78.01 0.00 0.00 24125 S 802.81 0.00 0.00<br />

23505 S 425.65 0.00 0.00 24126 S 802.81 0.00 0.00<br />

23515 S 1,424.62 0.00 0.00 24130 S 802.81 0.00 0.00<br />

23520 S 164.57 0.00 0.00 24134 S 773.39 0.00 0.00<br />

23525 S 164.57 0.00 0.00 24136 S 773.39 0.00 0.00<br />

23530 S 1,049.80 0.00 0.00 24138 S 773.39 0.00 0.00<br />

23532 S 773.54 0.00 0.00 24140 S 802.81 0.00 0.00<br />

23540 S 78.01 0.00 0.00 24145 S 802.81 0.00 0.00<br />

23545 S 164.57 0.00 0.00 24147 S 773.39 0.00 0.00<br />

23550 S 1,049.80 0.00 0.00 24149 S 1,136.86 0.00 0.00<br />

23552 S 1,104.95 0.00 0.00 24152 S 1,725.50 0.00 0.00<br />

23570 S 78.01 0.00 0.00 24153 S 3,294.58 0.00 0.00<br />

23575 S 164.57 0.00 0.00 24155 S 1,097.12 0.00 0.00<br />

23585 S 1,424.62 0.00 0.00 24160 S 773.39 0.00 0.00<br />

23600 S 60.79 0.00 0.00 24164 S 802.81 0.00 0.00<br />

23605 S 425.65 0.00 0.00 24200 S 97.23 0.00 0.00<br />

23615 S 1,479.76 0.00 0.00 24201 S 507.37 0.00 0.00<br />

23616 S 1,479.76 0.00 0.00 24300 S 592.26 0.00 0.00<br />

23620 S 60.79 0.00 0.00 24301 S 857.95 0.00 0.00<br />

23625 S 425.65 0.00 0.00 24305 S 857.95 0.00 0.00<br />

23630 S 1,519.74 0.00 0.00 24310 S 648.72 0.00 0.00<br />

23650 S 78.01 0.00 0.00 24320 S 1,097.12 0.00 0.00<br />

23655 S 449.17 0.00 0.00 24330 S 1,881.67 0.00 0.00<br />

23660 S 1,049.80 0.00 0.00 24331 S 1,097.12 0.00 0.00<br />

23665 S 164.57 0.00 0.00 24332 S 828.67 0.00 0.00<br />

23670 S 1,424.62 0.00 0.00 24340 S 1,097.12 0.00 0.00<br />

23675 S 78.01 0.00 0.00 24341 S 1,097.12 0.00 0.00<br />

23680 S 1,049.80 0.00 0.00 24342 S 1,097.12 0.00 0.00<br />

23700 S 449.17 0.00 0.00 24343 S 1,136.86 0.00 0.00<br />

23800 S 1,936.82 0.00 0.00 24344 S 3,294.58 0.00 0.00<br />

23802 S 1,320.01 0.00 0.00 24345 S 773.39 0.00 0.00<br />

23921 S 452.46 0.00 0.00 24346 S 1,725.50 0.00 0.00<br />

23930 S 521.83 0.00 0.00 24357 S 1,136.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,136.86 0.00 0.00 24925 S 648.72 0.00 0.00<br />

24359 S 1,136.86 0.00 0.00 25000 S 648.72 0.00 0.00<br />

24360 S 1,049.16 0.00 0.00 25001 S 828.67 0.00 0.00<br />

24361 S 5,736.31 3,511.35 1,286.39 25020 S 648.72 0.00 0.00<br />

24362 S 1,340.82 0.00 0.00 25023 S 802.81 0.00 0.00<br />

24363 S 5,864.07 3,639.11 1,414.15 25024 S 802.81 0.00 0.00<br />

24365 S 1,049.16 0.00 0.00 25025 S 802.81 0.00 0.00<br />

24366 S 5,736.31 3,511.35 1,286.39 25028 S 567.37 0.00 0.00<br />

24400 S 857.95 0.00 0.00 25031 S 619.30 0.00 0.00<br />

24410 S 857.95 0.00 0.00 25035 S 619.30 0.00 0.00<br />

24420 S 1,097.12 0.00 0.00 25040 S 897.94 0.00 0.00<br />

24430 S 1,881.67 0.00 0.00 25065 S 134.96 0.00 0.00<br />

24435 S 1,936.82 0.00 0.00 25066 S 620.48 0.00 0.00<br />

24470 S 1,097.12 0.00 0.00 25075 S 507.37 0.00 0.00<br />

24495 S 773.39 0.00 0.00 25076 S 649.89 0.00 0.00<br />

24498 S 1,881.67 0.00 0.00 25077 S 649.89 0.00 0.00<br />

24500 S 78.01 0.00 0.00 25085 S 648.72 0.00 0.00<br />

24505 S 78.01 0.00 0.00 25100 S 619.30 0.00 0.00<br />

24515 S 1,479.76 0.00 0.00 25101 S 802.81 0.00 0.00<br />

24516 S 1,479.76 0.00 0.00 25105 S 857.95 0.00 0.00<br />

24530 S 78.01 0.00 0.00 25107 S 802.81 0.00 0.00<br />

24535 S 164.57 0.00 0.00 25109 S 828.67 0.00 0.00<br />

24538 S 688.98 0.00 0.00 25110 S 648.72 0.00 0.00<br />

24545 S 1,479.76 0.00 0.00 25111 S 648.72 0.00 0.00<br />

24546 S 1,519.74 0.00 0.00 25112 S 703.86 0.00 0.00<br />

24560 S 78.01 0.00 0.00 25115 S 703.86 0.00 0.00<br />

24565 S 78.01 0.00 0.00 25116 S 703.86 0.00 0.00<br />

24566 S 688.98 0.00 0.00 25118 S 773.39 0.00 0.00<br />

24575 S 1,424.62 0.00 0.00 25119 S 802.81 0.00 0.00<br />

24576 S 78.01 0.00 0.00 25120 S 802.81 0.00 0.00<br />

24577 S 164.57 0.00 0.00 25125 S 802.81 0.00 0.00<br />

24579 S 1,424.62 0.00 0.00 25126 S 802.81 0.00 0.00<br />

24582 S 688.98 0.00 0.00 25130 S 802.81 0.00 0.00<br />

24586 S 1,479.76 0.00 0.00 25135 S 802.81 0.00 0.00<br />

24587 S 1,519.74 0.00 0.00 25136 S 802.81 0.00 0.00<br />

24600 S 78.01 0.00 0.00 25145 S 773.39 0.00 0.00<br />

24605 S 501.10 0.00 0.00 25150 S 773.39 0.00 0.00<br />

24615 S 1,424.62 0.00 0.00 25151 S 773.39 0.00 0.00<br />

24620 S 425.65 0.00 0.00 25210 S 802.81 0.00 0.00<br />

24635 S 1,424.62 0.00 0.00 25215 S 857.95 0.00 0.00<br />

24640 S 52.69 0.00 0.00 25230 S 857.95 0.00 0.00<br />

24650 S 60.79 0.00 0.00 25240 S 857.95 0.00 0.00<br />

24655 S 164.57 0.00 0.00 25248 S 619.30 0.00 0.00<br />

24665 S 1,104.95 0.00 0.00 25250 S 721.47 0.00 0.00<br />

24666 S 1,479.76 0.00 0.00 25251 S 721.47 0.00 0.00<br />

24670 S 78.01 0.00 0.00 25259 S 756.06 0.00 0.00<br />

24675 S 78.01 0.00 0.00 25260 S 857.95 0.00 0.00<br />

24685 S 1,049.80 0.00 0.00 25263 S 773.39 0.00 0.00<br />

24800 S 1,152.27 0.00 0.00 25265 S 802.81 0.00 0.00<br />

24802 S 1,192.25 0.00 0.00 25270 S 857.95 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 802.81 0.00 0.00 25505 S 164.57 0.00 0.00<br />

25274 S 857.95 0.00 0.00 25515 S 1,049.80 0.00 0.00<br />

25275 S 857.95 0.00 0.00 25520 S 164.57 0.00 0.00<br />

25280 S 857.95 0.00 0.00 25525 S 1,104.95 0.00 0.00<br />

25290 S 802.81 0.00 0.00 25526 S 1,144.93 0.00 0.00<br />

25295 S 648.72 0.00 0.00 25530 S 60.79 0.00 0.00<br />

25300 S 802.81 0.00 0.00 25535 S 78.01 0.00 0.00<br />

25301 S 802.81 0.00 0.00 25545 S 1,049.80 0.00 0.00<br />

25310 S 1,097.12 0.00 0.00 25560 S 60.79 0.00 0.00<br />

25312 S 1,152.27 0.00 0.00 25565 S 164.57 0.00 0.00<br />

25315 S 1,097.12 0.00 0.00 25574 S 1,424.62 0.00 0.00<br />

25316 S 1,881.67 0.00 0.00 25575 S 1,424.62 0.00 0.00<br />

25320 S 1,097.12 0.00 0.00 25600 S 60.79 0.00 0.00<br />

25332 S 1,049.16 0.00 0.00 25605 S 164.57 0.00 0.00<br />

25335 S 1,097.12 0.00 0.00 25606 S 718.40 0.00 0.00<br />

25337 S 1,192.25 0.00 0.00 25607 S 1,519.74 0.00 0.00<br />

25350 S 1,881.67 0.00 0.00 25608 S 1,519.74 0.00 0.00<br />

25355 S 1,097.12 0.00 0.00 25609 S 1,519.74 0.00 0.00<br />

25360 S 802.81 0.00 0.00 25622 S 60.79 0.00 0.00<br />

25365 S 802.81 0.00 0.00 25624 S 164.57 0.00 0.00<br />

25370 S 1,097.12 0.00 0.00 25628 S 1,049.80 0.00 0.00<br />

25375 S 1,152.27 0.00 0.00 25630 S 60.79 0.00 0.00<br />

25390 S 802.81 0.00 0.00 25635 S 164.57 0.00 0.00<br />

25391 S 1,152.27 0.00 0.00 25645 S 1,049.80 0.00 0.00<br />

25392 S 802.81 0.00 0.00 25650 S 60.79 0.00 0.00<br />

25393 S 1,152.27 0.00 0.00 25651 S 968.04 0.00 0.00<br />

25394 S 1,725.50 0.00 0.00 25652 S 1,630.84 0.00 0.00<br />

25400 S 1,097.12 0.00 0.00 25660 S 78.01 0.00 0.00<br />

25405 S 1,936.82 0.00 0.00 25670 S 718.40 0.00 0.00<br />

25415 S 1,881.67 0.00 0.00 25671 S 637.06 0.00 0.00<br />

25420 S 1,936.82 0.00 0.00 25675 S 78.01 0.00 0.00<br />

25425 S 1,097.12 0.00 0.00 25676 S 688.98 0.00 0.00<br />

25426 S 1,152.27 0.00 0.00 25680 S 78.01 0.00 0.00<br />

25430 S 1,725.50 0.00 0.00 25685 S 718.40 0.00 0.00<br />

25431 S 1,725.50 0.00 0.00 25690 S 425.65 0.00 0.00<br />

25440 S 1,936.82 0.00 0.00 25695 S 688.98 0.00 0.00<br />

25441 S 5,736.31 3,511.35 1,286.39 25800 S 1,936.82 0.00 0.00<br />

25442 S 5,736.31 3,511.35 1,286.39 25805 S 1,192.25 0.00 0.00<br />

25443 S 1,340.82 0.00 0.00 25810 S 1,976.80 0.00 0.00<br />

25444 S 1,340.82 0.00 0.00 25820 S 1,152.27 0.00 0.00<br />

25445 S 1,340.82 0.00 0.00 25825 S 1,976.80 0.00 0.00<br />

25446 S 5,864.07 3,639.11 1,414.15 25830 S 1,976.80 0.00 0.00<br />

25447 S 1,049.16 0.00 0.00 25907 S 648.72 0.00 0.00<br />

25449 S 1,049.16 0.00 0.00 25922 S 648.72 0.00 0.00<br />

25450 S 1,097.12 0.00 0.00 25929 S 538.26 0.00 0.00<br />

25455 S 1,097.12 0.00 0.00 25931 S 828.67 0.00 0.00<br />

25490 S 1,097.12 0.00 0.00 26010 S 53.75 0.00 0.00<br />

25491 S 1,097.12 0.00 0.00 26011 S 392.63 0.00 0.00<br />

25492 S 1,097.12 0.00 0.00 26020 S 520.98 0.00 0.00<br />

25500 S 60.79 0.00 0.00 26025 S 469.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 520.98 0.00 0.00 26392 S 767.00 0.00 0.00<br />

26034 S 520.98 0.00 0.00 26410 S 550.38 0.00 0.00<br />

26035 S 632.01 0.00 0.00 26412 S 767.00 0.00 0.00<br />

26040 S 822.15 0.00 0.00 26415 S 822.15 0.00 0.00<br />

26045 S 767.00 0.00 0.00 26416 S 767.00 0.00 0.00<br />

26055 S 520.98 0.00 0.00 26418 S 605.54 0.00 0.00<br />

26060 S 520.98 0.00 0.00 26420 S 822.15 0.00 0.00<br />

26070 S 520.98 0.00 0.00 26426 S 767.00 0.00 0.00<br />

26075 S 605.54 0.00 0.00 26428 S 767.00 0.00 0.00<br />

26080 S 605.54 0.00 0.00 26432 S 550.38 0.00 0.00<br />

26100 S 520.98 0.00 0.00 26433 S 550.38 0.00 0.00<br />

26105 S 469.04 0.00 0.00 26434 S 767.00 0.00 0.00<br />

26110 S 469.04 0.00 0.00 26437 S 550.38 0.00 0.00<br />

26115 S 620.48 0.00 0.00 26440 S 550.38 0.00 0.00<br />

26116 S 620.48 0.00 0.00 26442 S 767.00 0.00 0.00<br />

26117 S 649.89 0.00 0.00 26445 S 550.38 0.00 0.00<br />

26121 S 822.15 0.00 0.00 26449 S 767.00 0.00 0.00<br />

26123 S 822.15 0.00 0.00 26450 S 550.38 0.00 0.00<br />

26125 S 605.54 0.00 0.00 26455 S 550.38 0.00 0.00<br />

26130 S 550.38 0.00 0.00 26460 S 550.38 0.00 0.00<br />

26135 S 822.15 0.00 0.00 26471 S 520.98 0.00 0.00<br />

26140 S 520.98 0.00 0.00 26474 S 520.98 0.00 0.00<br />

26145 S 550.38 0.00 0.00 26476 S 469.04 0.00 0.00<br />

26160 S 550.38 0.00 0.00 26477 S 469.04 0.00 0.00<br />

26170 S 550.38 0.00 0.00 26478 S 469.04 0.00 0.00<br />

26180 S 550.38 0.00 0.00 26479 S 469.04 0.00 0.00<br />

26185 S 605.54 0.00 0.00 26480 S 767.00 0.00 0.00<br />

26200 S 520.98 0.00 0.00 26483 S 767.00 0.00 0.00<br />

26205 S 767.00 0.00 0.00 26485 S 737.59 0.00 0.00<br />

26210 S 520.98 0.00 0.00 26489 S 767.00 0.00 0.00<br />

26215 S 550.38 0.00 0.00 26490 S 767.00 0.00 0.00<br />

26230 S 772.33 0.00 0.00 26492 S 767.00 0.00 0.00<br />

26235 S 550.38 0.00 0.00 26494 S 767.00 0.00 0.00<br />

26236 S 550.38 0.00 0.00 26496 S 767.00 0.00 0.00<br />

26250 S 550.38 0.00 0.00 26497 S 767.00 0.00 0.00<br />

26255 S 767.00 0.00 0.00 26498 S 822.15 0.00 0.00<br />

26260 S 550.38 0.00 0.00 26499 S 767.00 0.00 0.00<br />

26261 S 550.38 0.00 0.00 26500 S 605.54 0.00 0.00<br />

26262 S 520.98 0.00 0.00 26502 S 822.15 0.00 0.00<br />

26320 S 507.37 0.00 0.00 26508 S 550.38 0.00 0.00<br />

26340 S 233.90 0.00 0.00 26510 S 767.00 0.00 0.00<br />

26350 S 685.66 0.00 0.00 26516 S 685.66 0.00 0.00<br />

26352 S 822.15 0.00 0.00 26517 S 767.00 0.00 0.00<br />

26356 S 822.15 0.00 0.00 26518 S 767.00 0.00 0.00<br />

26357 S 822.15 0.00 0.00 26520 S 550.38 0.00 0.00<br />

26358 S 822.15 0.00 0.00 26525 S 550.38 0.00 0.00<br />

26370 S 822.15 0.00 0.00 26530 S 954.03 0.00 0.00<br />

26372 S 822.15 0.00 0.00 26531 S 1,468.58 0.00 0.00<br />

26373 S 767.00 0.00 0.00 26535 S 1,049.16 0.00 0.00<br />

26390 S 822.15 0.00 0.00 26536 S 1,340.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 605.54 0.00 0.00 26775 S 162.50 0.00 0.00<br />

26541 S 989.89 0.00 0.00 26776 S 688.98 0.00 0.00<br />

26542 S 605.54 0.00 0.00 26785 S 688.98 0.00 0.00<br />

26545 S 822.15 0.00 0.00 26820 S 862.13 0.00 0.00<br />

26546 S 822.15 0.00 0.00 26841 S 822.15 0.00 0.00<br />

26548 S 822.15 0.00 0.00 26842 S 822.15 0.00 0.00<br />

26550 S 737.59 0.00 0.00 26843 S 767.00 0.00 0.00<br />

26555 S 767.00 0.00 0.00 26844 S 767.00 0.00 0.00<br />

26560 S 520.98 0.00 0.00 26850 S 822.15 0.00 0.00<br />

26561 S 767.00 0.00 0.00 26852 S 822.15 0.00 0.00<br />

26562 S 822.15 0.00 0.00 26860 S 767.00 0.00 0.00<br />

26565 S 862.13 0.00 0.00 26861 S 737.59 0.00 0.00<br />

26567 S 862.13 0.00 0.00 26862 S 822.15 0.00 0.00<br />

26568 S 767.00 0.00 0.00 26863 S 767.00 0.00 0.00<br />

26580 S 645.51 0.00 0.00 26910 S 767.00 0.00 0.00<br />

26587 S 645.51 0.00 0.00 26951 S 520.98 0.00 0.00<br />

26590 S 645.51 0.00 0.00 26952 S 605.54 0.00 0.00<br />

26591 S 767.00 0.00 0.00 26990 S 567.37 0.00 0.00<br />

26593 S 550.38 0.00 0.00 26991 S 567.37 0.00 0.00<br />

26596 S 520.98 0.00 0.00 27000 S 619.30 0.00 0.00<br />

26600 S 60.79 0.00 0.00 27001 S 802.81 0.00 0.00<br />

26605 S 78.01 0.00 0.00 27003 S 802.81 0.00 0.00<br />

26607 S 425.65 0.00 0.00 27033 S 1,097.12 0.00 0.00<br />

26608 S 773.54 0.00 0.00 27035 S 1,152.27 0.00 0.00<br />

26615 S 1,104.95 0.00 0.00 27040 S 310.10 0.00 0.00<br />

26641 S 60.79 0.00 0.00 27041 S 349.38 0.00 0.00<br />

26645 S 164.57 0.00 0.00 27047 S 620.48 0.00 0.00<br />

26650 S 688.98 0.00 0.00 27048 S 649.89 0.00 0.00<br />

26665 S 1,104.95 0.00 0.00 27049 S 649.89 0.00 0.00<br />

26670 S 60.79 0.00 0.00 27050 S 648.72 0.00 0.00<br />

26675 S 164.57 0.00 0.00 27052 S 648.72 0.00 0.00<br />

26676 S 688.98 0.00 0.00 27060 S 743.84 0.00 0.00<br />

26685 S 718.40 0.00 0.00 27062 S 743.84 0.00 0.00<br />

26686 S 1,424.62 0.00 0.00 27065 S 743.84 0.00 0.00<br />

26700 S 60.79 0.00 0.00 27066 S 897.94 0.00 0.00<br />

26705 S 78.01 0.00 0.00 27067 S 897.94 0.00 0.00<br />

26706 S 425.65 0.00 0.00 27080 S 773.39 0.00 0.00<br />

26715 S 773.54 0.00 0.00 27086 S 310.10 0.00 0.00<br />

26720 S 60.79 0.00 0.00 27087 S 648.72 0.00 0.00<br />

26725 S 60.79 0.00 0.00 27097 S 802.81 0.00 0.00<br />

26727 S 941.29 0.00 0.00 27098 S 802.81 0.00 0.00<br />

26735 S 773.54 0.00 0.00 27100 S 1,152.27 0.00 0.00<br />

26740 S 60.79 0.00 0.00 27105 S 1,152.27 0.00 0.00<br />

26742 S 78.01 0.00 0.00 27110 S 1,152.27 0.00 0.00<br />

26746 S 813.53 0.00 0.00 27111 S 1,152.27 0.00 0.00<br />

26750 S 60.79 0.00 0.00 27193 S 78.01 0.00 0.00<br />

26755 S 60.79 0.00 0.00 27194 S 501.10 0.00 0.00<br />

26756 S 688.98 0.00 0.00 27200 S 60.79 0.00 0.00<br />

26765 S 773.54 0.00 0.00 27202 S 1,020.39 0.00 0.00<br />

26770 S 60.79 0.00 0.00 27220 S 60.79 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 78.01 0.00 0.00 27397 S 1,097.12 0.00 0.00<br />

27238 S 164.57 0.00 0.00 27400 S 1,097.12 0.00 0.00<br />

27246 S 164.57 0.00 0.00 27403 S 857.95 0.00 0.00<br />

27250 S 78.01 0.00 0.00 27405 S 1,152.27 0.00 0.00<br />

27252 S 501.10 0.00 0.00 27407 S 1,936.82 0.00 0.00<br />

27256 S 60.79 0.00 0.00 27409 S 1,152.27 0.00 0.00<br />

27257 S 530.51 0.00 0.00 27416 S 1,725.50 0.00 0.00<br />

27265 S 78.01 0.00 0.00 27418 S 1,097.12 0.00 0.00<br />

27266 S 501.10 0.00 0.00 27420 S 1,097.12 0.00 0.00<br />

27267 S 60.79 0.00 0.00 27422 S 1,320.01 0.00 0.00<br />

27275 S 501.10 0.00 0.00 27424 S 1,097.12 0.00 0.00<br />

27301 S 603.18 0.00 0.00 27425 S 1,025.70 0.00 0.00<br />

27305 S 619.30 0.00 0.00 27427 S 1,097.12 0.00 0.00<br />

27306 S 648.72 0.00 0.00 27428 S 1,936.82 0.00 0.00<br />

27307 S 648.72 0.00 0.00 27429 S 1,936.82 0.00 0.00<br />

27310 S 857.95 0.00 0.00 27430 S 1,152.27 0.00 0.00<br />

27323 S 310.10 0.00 0.00 27435 S 1,152.27 0.00 0.00<br />

27324 S 568.55 0.00 0.00 27437 S 1,009.18 0.00 0.00<br />

27325 S 557.10 0.00 0.00 27438 S 1,340.82 0.00 0.00<br />

27326 S 557.10 0.00 0.00 27440 S 1,439.30 0.00 0.00<br />

27327 S 620.48 0.00 0.00 27441 S 1,049.16 0.00 0.00<br />

27328 S 649.89 0.00 0.00 27442 S 1,049.16 0.00 0.00<br />

27329 S 705.04 0.00 0.00 27443 S 1,049.16 0.00 0.00<br />

27330 S 857.95 0.00 0.00 27446 S 10,294.29 6,184.34 2,074.39<br />

27331 S 857.95 0.00 0.00 27496 S 743.84 0.00 0.00<br />

27332 S 857.95 0.00 0.00 27497 S 648.72 0.00 0.00<br />

27333 S 857.95 0.00 0.00 27498 S 648.72 0.00 0.00<br />

27334 S 857.95 0.00 0.00 27499 S 648.72 0.00 0.00<br />

27335 S 857.95 0.00 0.00 27500 S 164.57 0.00 0.00<br />

27340 S 648.72 0.00 0.00 27501 S 78.01 0.00 0.00<br />

27345 S 703.86 0.00 0.00 27502 S 425.65 0.00 0.00<br />

27347 S 703.86 0.00 0.00 27503 S 78.01 0.00 0.00<br />

27350 S 857.95 0.00 0.00 27508 S 78.01 0.00 0.00<br />

27355 S 802.81 0.00 0.00 27509 S 718.40 0.00 0.00<br />

27356 S 857.95 0.00 0.00 27510 S 164.57 0.00 0.00<br />

27357 S 897.94 0.00 0.00 27516 S 78.01 0.00 0.00<br />

27358 S 897.94 0.00 0.00 27517 S 78.01 0.00 0.00<br />

27360 S 897.94 0.00 0.00 27520 S 78.01 0.00 0.00<br />

27372 S 872.78 0.00 0.00 27530 S 78.01 0.00 0.00<br />

27380 S 567.37 0.00 0.00 27532 S 425.65 0.00 0.00<br />

27381 S 648.72 0.00 0.00 27538 S 78.01 0.00 0.00<br />

27385 S 648.72 0.00 0.00 27550 S 78.01 0.00 0.00<br />

27386 S 648.72 0.00 0.00 27552 S 449.17 0.00 0.00<br />

27390 S 567.37 0.00 0.00 27560 S 78.01 0.00 0.00<br />

27391 S 619.30 0.00 0.00 27562 S 449.17 0.00 0.00<br />

27392 S 648.72 0.00 0.00 27566 S 1,020.39 0.00 0.00<br />

27393 S 773.39 0.00 0.00 27570 S 449.17 0.00 0.00<br />

27394 S 802.81 0.00 0.00 27594 S 648.72 0.00 0.00<br />

27395 S 1,097.12 0.00 0.00 27600 S 648.72 0.00 0.00<br />

27396 S 802.81 0.00 0.00 27601 S 648.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 648.72 0.00 0.00 27730 S 773.39 0.00 0.00<br />

27603 S 573.77 0.00 0.00 27732 S 773.39 0.00 0.00<br />

27604 S 619.30 0.00 0.00 27734 S 773.39 0.00 0.00<br />

27605 S 564.33 0.00 0.00 27740 S 773.39 0.00 0.00<br />

27606 S 567.37 0.00 0.00 27742 S 1,067.71 0.00 0.00<br />

27607 S 619.30 0.00 0.00 27745 S 1,881.67 0.00 0.00<br />

27610 S 773.39 0.00 0.00 27750 S 78.01 0.00 0.00<br />

27612 S 802.81 0.00 0.00 27752 S 425.65 0.00 0.00<br />

27613 S 127.49 0.00 0.00 27756 S 718.40 0.00 0.00<br />

27614 S 620.48 0.00 0.00 27758 S 1,104.95 0.00 0.00<br />

27615 S 802.81 0.00 0.00 27759 S 1,479.76 0.00 0.00<br />

27618 S 507.37 0.00 0.00 27760 S 78.01 0.00 0.00<br />

27619 S 649.89 0.00 0.00 27762 S 425.65 0.00 0.00<br />

27620 S 857.95 0.00 0.00 27766 S 1,049.80 0.00 0.00<br />

27625 S 857.95 0.00 0.00 27767 S 60.79 0.00 0.00<br />

27626 S 857.95 0.00 0.00 27768 S 60.79 0.00 0.00<br />

27630 S 648.72 0.00 0.00 27769 S 1,630.84 0.00 0.00<br />

27635 S 802.81 0.00 0.00 27780 S 78.01 0.00 0.00<br />

27637 S 802.81 0.00 0.00 27781 S 425.65 0.00 0.00<br />

27638 S 802.81 0.00 0.00 27784 S 1,049.80 0.00 0.00<br />

27640 S 1,067.71 0.00 0.00 27786 S 78.01 0.00 0.00<br />

27641 S 773.39 0.00 0.00 27788 S 78.01 0.00 0.00<br />

27647 S 1,097.12 0.00 0.00 27792 S 1,049.80 0.00 0.00<br />

27650 S 1,097.12 0.00 0.00 27808 S 78.01 0.00 0.00<br />

27652 S 1,881.67 0.00 0.00 27810 S 164.57 0.00 0.00<br />

27654 S 1,097.12 0.00 0.00 27814 S 1,049.80 0.00 0.00<br />

27656 S 619.30 0.00 0.00 27816 S 78.01 0.00 0.00<br />

27658 S 567.37 0.00 0.00 27818 S 164.57 0.00 0.00<br />

27659 S 619.30 0.00 0.00 27822 S 1,049.80 0.00 0.00<br />

27664 S 619.30 0.00 0.00 27823 S 1,424.62 0.00 0.00<br />

27665 S 773.39 0.00 0.00 27824 S 78.01 0.00 0.00<br />

27675 S 619.30 0.00 0.00 27825 S 425.65 0.00 0.00<br />

27676 S 802.81 0.00 0.00 27826 S 1,049.80 0.00 0.00<br />

27680 S 802.81 0.00 0.00 27827 S 1,424.62 0.00 0.00<br />

27681 S 773.39 0.00 0.00 27828 S 1,479.76 0.00 0.00<br />

27685 S 802.81 0.00 0.00 27829 S 1,020.39 0.00 0.00<br />

27686 S 802.81 0.00 0.00 27830 S 78.01 0.00 0.00<br />

27687 S 802.81 0.00 0.00 27831 S 425.65 0.00 0.00<br />

27690 S 1,152.27 0.00 0.00 27832 S 1,020.39 0.00 0.00<br />

27691 S 1,152.27 0.00 0.00 27840 S 164.57 0.00 0.00<br />

27692 S 1,097.12 0.00 0.00 27842 S 449.17 0.00 0.00<br />

27695 S 773.39 0.00 0.00 27846 S 1,049.80 0.00 0.00<br />

27696 S 773.39 0.00 0.00 27848 S 1,049.80 0.00 0.00<br />

27698 S 773.39 0.00 0.00 27860 S 449.17 0.00 0.00<br />

27700 S 1,049.16 0.00 0.00 27870 S 1,936.82 0.00 0.00<br />

27704 S 619.30 0.00 0.00 27871 S 1,936.82 0.00 0.00<br />

27705 S 1,067.71 0.00 0.00 27884 S 648.72 0.00 0.00<br />

27707 S 619.30 0.00 0.00 27889 S 802.81 0.00 0.00<br />

27709 S 773.39 0.00 0.00 27892 S 648.72 0.00 0.00<br />

27726 S 968.04 0.00 0.00 27893 S 648.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 648.72 0.00 0.00 28153 S 645.67 0.00 0.00<br />

28001 S 124.42 0.00 0.00 28160 S 645.67 0.00 0.00<br />

28002 S 648.72 0.00 0.00 28171 S 645.67 0.00 0.00<br />

28003 S 648.72 0.00 0.00 28173 S 645.67 0.00 0.00<br />

28005 S 645.67 0.00 0.00 28175 S 645.67 0.00 0.00<br />

28008 S 645.67 0.00 0.00 28190 S 128.50 0.00 0.00<br />

28010 S 91.45 0.00 0.00 28192 S 507.37 0.00 0.00<br />

28011 S 645.67 0.00 0.00 28193 S 349.38 0.00 0.00<br />

28020 S 616.25 0.00 0.00 28200 S 645.67 0.00 0.00<br />

28022 S 616.25 0.00 0.00 28202 S 645.67 0.00 0.00<br />

28024 S 616.25 0.00 0.00 28208 S 645.67 0.00 0.00<br />

28035 S 641.66 0.00 0.00 28210 S 1,133.99 0.00 0.00<br />

28043 S 620.48 0.00 0.00 28220 S 198.20 0.00 0.00<br />

28045 S 645.67 0.00 0.00 28222 S 564.33 0.00 0.00<br />

28046 S 645.67 0.00 0.00 28225 S 564.33 0.00 0.00<br />

28050 S 616.25 0.00 0.00 28226 S 564.33 0.00 0.00<br />

28052 S 616.25 0.00 0.00 28230 S 194.46 0.00 0.00<br />

28054 S 616.25 0.00 0.00 28232 S 185.96 0.00 0.00<br />

28055 S 641.66 0.00 0.00 28234 S 616.25 0.00 0.00<br />

28060 S 616.25 0.00 0.00 28238 S 1,133.99 0.00 0.00<br />

28062 S 645.67 0.00 0.00 28240 S 616.25 0.00 0.00<br />

28070 S 645.67 0.00 0.00 28250 S 645.67 0.00 0.00<br />

28072 S 645.67 0.00 0.00 28260 S 645.67 0.00 0.00<br />

28080 S 645.67 0.00 0.00 28261 S 645.67 0.00 0.00<br />

28086 S 616.25 0.00 0.00 28262 S 700.81 0.00 0.00<br />

28088 S 616.25 0.00 0.00 28264 S 1,052.65 0.00 0.00<br />

28090 S 645.67 0.00 0.00 28270 S 645.67 0.00 0.00<br />

28092 S 645.67 0.00 0.00 28272 S 179.50 0.00 0.00<br />

28100 S 616.25 0.00 0.00 28280 S 616.25 0.00 0.00<br />

28102 S 1,133.99 0.00 0.00 28285 S 645.67 0.00 0.00<br />

28103 S 1,133.99 0.00 0.00 28286 S 700.81 0.00 0.00<br />

28104 S 616.25 0.00 0.00 28288 S 645.67 0.00 0.00<br />

28106 S 1,133.99 0.00 0.00 28289 S 645.67 0.00 0.00<br />

28107 S 1,133.99 0.00 0.00 28290 S 795.87 0.00 0.00<br />

28108 S 616.25 0.00 0.00 28292 S 795.87 0.00 0.00<br />

28110 S 645.67 0.00 0.00 28293 S 825.28 0.00 0.00<br />

28111 S 645.67 0.00 0.00 28294 S 825.28 0.00 0.00<br />

28112 S 645.67 0.00 0.00 28296 S 825.28 0.00 0.00<br />

28113 S 645.67 0.00 0.00 28297 S 825.28 0.00 0.00<br />

28114 S 645.67 0.00 0.00 28298 S 825.28 0.00 0.00<br />

28116 S 645.67 0.00 0.00 28299 S 920.41 0.00 0.00<br />

28118 S 700.81 0.00 0.00 28300 S 1,104.59 0.00 0.00<br />

28119 S 700.81 0.00 0.00 28302 S 616.25 0.00 0.00<br />

28120 S 868.56 0.00 0.00 28304 S 1,104.59 0.00 0.00<br />

28122 S 645.67 0.00 0.00 28305 S 1,133.99 0.00 0.00<br />

28124 S 210.44 0.00 0.00 28306 S 700.81 0.00 0.00<br />

28126 S 645.67 0.00 0.00 28307 S 700.81 0.00 0.00<br />

28130 S 645.67 0.00 0.00 28308 S 616.25 0.00 0.00<br />

28140 S 645.67 0.00 0.00 28309 S 1,189.15 0.00 0.00<br />

28150 S 645.67 0.00 0.00 28310 S 645.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 645.67 0.00 0.00 28636 S 718.40 0.00 0.00<br />

28313 S 616.25 0.00 0.00 28645 S 718.40 0.00 0.00<br />

28315 S 700.81 0.00 0.00 28660 S 43.52 0.00 0.00<br />

28320 S 1,189.15 0.00 0.00 28665 S 449.17 0.00 0.00<br />

28322 S 1,189.15 0.00 0.00 28666 S 718.40 0.00 0.00<br />

28340 S 700.81 0.00 0.00 28675 S 718.40 0.00 0.00<br />

28341 S 700.81 0.00 0.00 28705 S 1,189.15 0.00 0.00<br />

28344 S 700.81 0.00 0.00 28715 S 1,936.82 0.00 0.00<br />

28345 S 700.81 0.00 0.00 28725 S 1,189.15 0.00 0.00<br />

28400 S 78.01 0.00 0.00 28730 S 1,189.15 0.00 0.00<br />

28405 S 425.65 0.00 0.00 28735 S 1,189.15 0.00 0.00<br />

28406 S 688.98 0.00 0.00 28737 S 1,229.12 0.00 0.00<br />

28415 S 1,424.62 0.00 0.00 28740 S 1,189.15 0.00 0.00<br />

28420 S 1,104.95 0.00 0.00 28750 S 1,189.15 0.00 0.00<br />

28430 S 60.79 0.00 0.00 28755 S 700.81 0.00 0.00<br />

28435 S 78.01 0.00 0.00 28760 S 1,189.15 0.00 0.00<br />

28436 S 688.98 0.00 0.00 28810 S 616.25 0.00 0.00<br />

28445 S 1,049.80 0.00 0.00 28820 S 616.25 0.00 0.00<br />

28446 S 1,799.23 0.00 0.00 28825 S 616.25 0.00 0.00<br />

28450 S 60.79 0.00 0.00 28890 S 162.84 0.00 0.00<br />

28455 S 60.79 0.00 0.00 29000 S 41.26 0.00 0.00<br />

28456 S 688.98 0.00 0.00 29010 S 92.47 0.00 0.00<br />

28465 S 1,049.80 0.00 0.00 29015 S 92.47 0.00 0.00<br />

28470 S 60.79 0.00 0.00 29020 S 41.26 0.00 0.00<br />

28475 S 60.79 0.00 0.00 29025 S 41.26 0.00 0.00<br />

28476 S 688.98 0.00 0.00 29035 S 92.47 0.00 0.00<br />

28485 S 1,104.95 0.00 0.00 29040 S 41.26 0.00 0.00<br />

28490 S 60.79 0.00 0.00 29044 S 92.47 0.00 0.00<br />

28495 S 60.79 0.00 0.00 29046 S 92.47 0.00 0.00<br />

28496 S 688.98 0.00 0.00 29049 S 37.39 0.00 0.00<br />

28505 S 718.40 0.00 0.00 29055 S 92.47 0.00 0.00<br />

28510 S 54.74 0.00 0.00 29058 S 41.26 0.00 0.00<br />

28515 S 60.79 0.00 0.00 29065 S 43.86 0.00 0.00<br />

28525 S 718.40 0.00 0.00 29075 S 42.15 0.00 0.00<br />

28530 S 52.69 0.00 0.00 29085 S 41.26 0.00 0.00<br />

28531 S 718.40 0.00 0.00 29086 S 35.36 0.00 0.00<br />

28540 S 60.79 0.00 0.00 29105 S 38.07 0.00 0.00<br />

28545 S 637.06 0.00 0.00 29125 S 32.97 0.00 0.00<br />

28546 S 688.98 0.00 0.00 29126 S 35.02 0.00 0.00<br />

28555 S 1,020.39 0.00 0.00 29130 S 14.96 0.00 0.00<br />

28570 S 78.87 0.00 0.00 29131 S 21.76 0.00 0.00<br />

28575 S 425.65 0.00 0.00 29200 S 21.08 0.00 0.00<br />

28576 S 718.40 0.00 0.00 29220 S 22.77 0.00 0.00<br />

28585 S 718.40 0.00 0.00 29240 S 23.80 0.00 0.00<br />

28600 S 60.79 0.00 0.00 29260 S 22.77 0.00 0.00<br />

28605 S 78.01 0.00 0.00 29280 S 23.12 0.00 0.00<br />

28606 S 688.98 0.00 0.00 29305 S 92.47 0.00 0.00<br />

28615 S 1,049.80 0.00 0.00 29325 S 92.47 0.00 0.00<br />

28630 S 60.79 0.00 0.00 29345 S 57.45 0.00 0.00<br />

28635 S 449.17 0.00 0.00 29355 S 56.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 70.04 0.00 0.00 29847 S 1,170.59 0.00 0.00<br />

29365 S 54.40 0.00 0.00 29848 S 1,174.90 0.00 0.00<br />

29405 S 40.46 0.00 0.00 29850 S 849.08 0.00 0.00<br />

29425 S 41.14 0.00 0.00 29851 S 1,225.74 0.00 0.00<br />

29435 S 52.01 0.00 0.00 29855 S 1,225.74 0.00 0.00<br />

29440 S 22.09 0.00 0.00 29856 S 1,225.74 0.00 0.00<br />

29445 S 54.74 0.00 0.00 29860 S 1,225.74 0.00 0.00<br />

29450 S 41.26 0.00 0.00 29861 S 1,225.74 0.00 0.00<br />

29505 S 36.71 0.00 0.00 29862 S 1,551.57 0.00 0.00<br />

29515 S 31.28 0.00 0.00 29863 S 1,225.74 0.00 0.00<br />

29520 S 22.43 0.00 0.00 29866 S 1,872.42 0.00 0.00<br />

29530 S 22.77 0.00 0.00 29870 S 793.93 0.00 0.00<br />

29540 S 17.00 0.00 0.00 29871 S 793.93 0.00 0.00<br />

29550 S 17.33 0.00 0.00 29873 S 793.93 0.00 0.00<br />

29580 S 23.46 0.00 0.00 29874 S 793.93 0.00 0.00<br />

29590 S 19.04 0.00 0.00 29875 S 849.08 0.00 0.00<br />

29700 S 31.61 0.00 0.00 29876 S 849.08 0.00 0.00<br />

29705 S 26.85 0.00 0.00 29877 S 849.08 0.00 0.00<br />

29710 S 47.25 0.00 0.00 29879 S 793.93 0.00 0.00<br />

29715 S 41.26 0.00 0.00 29880 S 849.08 0.00 0.00<br />

29720 S 39.44 0.00 0.00 29881 S 849.08 0.00 0.00<br />

29730 S 25.84 0.00 0.00 29882 S 793.93 0.00 0.00<br />

29740 S 35.36 0.00 0.00 29883 S 793.93 0.00 0.00<br />

29750 S 37.05 0.00 0.00 29884 S 793.93 0.00 0.00<br />

29800 S 793.93 0.00 0.00 29885 S 1,170.59 0.00 0.00<br />

29804 S 793.93 0.00 0.00 29886 S 793.93 0.00 0.00<br />

29805 S 793.93 0.00 0.00 29887 S 793.93 0.00 0.00<br />

29806 S 1,170.59 0.00 0.00 29888 S 1,170.59 0.00 0.00<br />

29807 S 1,170.59 0.00 0.00 29889 S 1,170.59 0.00 0.00<br />

29819 S 1,170.59 0.00 0.00 29891 S 1,170.59 0.00 0.00<br />

29820 S 1,170.59 0.00 0.00 29892 S 1,170.59 0.00 0.00<br />

29821 S 1,170.59 0.00 0.00 29893 S 988.30 0.00 0.00<br />

29822 S 793.93 0.00 0.00 29894 S 793.93 0.00 0.00<br />

29823 S 1,170.59 0.00 0.00 29895 S 793.93 0.00 0.00<br />

29824 S 889.06 0.00 0.00 29897 S 793.93 0.00 0.00<br />

29825 S 1,170.59 0.00 0.00 29898 S 793.93 0.00 0.00<br />

29826 S 1,170.59 0.00 0.00 29899 S 1,170.59 0.00 0.00<br />

29827 S 1,265.71 0.00 0.00 29900 S 793.93 0.00 0.00<br />

29828 S 1,872.42 0.00 0.00 29901 S 793.93 0.00 0.00<br />

29830 S 793.93 0.00 0.00 29902 S 793.93 0.00 0.00<br />

29834 S 793.93 0.00 0.00 29904 S 1,119.10 0.00 0.00<br />

29835 S 793.93 0.00 0.00 29905 S 1,119.10 0.00 0.00<br />

29836 S 793.93 0.00 0.00 29906 S 1,119.10 0.00 0.00<br />

29837 S 793.93 0.00 0.00 29907 S 1,872.42 0.00 0.00<br />

29838 S 793.93 0.00 0.00 30000 S 125.82 0.00 0.00<br />

29840 S 793.93 0.00 0.00 30020 S 125.82 0.00 0.00<br />

29843 S 793.93 0.00 0.00 30100 S 81.59 0.00 0.00<br />

29844 S 793.93 0.00 0.00 30110 S 126.13 0.00 0.00<br />

29845 S 793.93 0.00 0.00 30115 S 532.92 0.00 0.00<br />

29846 S 793.93 0.00 0.00 30117 S 562.34 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 705.30 0.00 0.00 31080 S 1,086.08 0.00 0.00<br />

30120 S 480.99 0.00 0.00 31081 S 1,086.08 0.00 0.00<br />

30124 S 286.60 0.00 0.00 31084 S 1,086.08 0.00 0.00<br />

30125 S 1,001.52 0.00 0.00 31085 S 1,086.08 0.00 0.00<br />

30130 S 562.34 0.00 0.00 31086 S 1,086.08 0.00 0.00<br />

30140 S 675.88 0.00 0.00 31087 S 1,086.08 0.00 0.00<br />

30150 S 1,030.94 0.00 0.00 31090 S 1,126.07 0.00 0.00<br />

30160 S 1,086.08 0.00 0.00 31200 S 1,001.52 0.00 0.00<br />

30200 S 64.26 0.00 0.00 31201 S 1,126.07 0.00 0.00<br />

30210 S 81.59 0.00 0.00 31205 S 1,030.94 0.00 0.00<br />

30220 S 356.60 0.00 0.00 31231 S 68.78 0.00 0.00<br />

30300 S 24.58 0.00 0.00 31233 S 74.09 0.00 0.00<br />

30310 S 480.99 0.00 0.00 31235 S 503.36 0.00 0.00<br />

30320 S 532.92 0.00 0.00 31237 S 555.29 0.00 0.00<br />

30400 S 1,086.08 0.00 0.00 31238 S 503.36 0.00 0.00<br />

30410 S 1,126.07 0.00 0.00 31239 S 734.75 0.00 0.00<br />

30420 S 1,126.07 0.00 0.00 31240 S 555.29 0.00 0.00<br />

30430 S 705.30 0.00 0.00 31254 S 679.60 0.00 0.00<br />

30435 S 1,126.07 0.00 0.00 31255 S 774.72 0.00 0.00<br />

30450 S 1,253.83 0.00 0.00 31256 S 679.60 0.00 0.00<br />

30460 S 1,253.83 0.00 0.00 31267 S 679.60 0.00 0.00<br />

30462 S 1,411.91 0.00 0.00 31276 S 679.60 0.00 0.00<br />

30465 S 1,411.91 0.00 0.00 31287 S 679.60 0.00 0.00<br />

30520 S 760.44 0.00 0.00 31288 S 679.60 0.00 0.00<br />

30540 S 1,126.07 0.00 0.00 31300 S 800.43 0.00 0.00<br />

30545 S 1,126.07 0.00 0.00 31320 S 1,001.52 0.00 0.00<br />

30560 S 132.17 0.00 0.00 31400 S 1,001.52 0.00 0.00<br />

30580 S 1,086.08 0.00 0.00 31420 S 1,001.52 0.00 0.00<br />

30600 S 1,086.08 0.00 0.00 31500 S 92.00 0.00 0.00<br />

30620 S 1,253.83 0.00 0.00 31502 S 52.90 0.00 0.00<br />

30630 S 928.19 0.00 0.00 31505 S 31.26 0.00 0.00<br />

30801 S 296.33 0.00 0.00 31510 S 555.29 0.00 0.00<br />

30802 S 296.33 0.00 0.00 31511 S 74.09 0.00 0.00<br />

30901 S 42.27 0.00 0.00 31512 S 555.29 0.00 0.00<br />

30903 S 54.44 0.00 0.00 31513 S 74.09 0.00 0.00<br />

30905 S 54.44 0.00 0.00 31515 S 503.36 0.00 0.00<br />

30906 S 54.44 0.00 0.00 31520 S 68.78 0.00 0.00<br />

30915 S 725.45 0.00 0.00 31525 S 503.36 0.00 0.00<br />

30920 S 754.87 0.00 0.00 31526 S 650.19 0.00 0.00<br />

30930 S 617.48 0.00 0.00 31527 S 598.25 0.00 0.00<br />

31000 S 105.05 0.00 0.00 31528 S 555.29 0.00 0.00<br />

31002 S 286.60 0.00 0.00 31529 S 555.29 0.00 0.00<br />

31020 S 675.88 0.00 0.00 31530 S 650.19 0.00 0.00<br />

31030 S 1,030.94 0.00 0.00 31531 S 679.60 0.00 0.00<br />

31032 S 1,086.08 0.00 0.00 31535 S 650.19 0.00 0.00<br />

31040 S 941.85 0.00 0.00 31536 S 679.60 0.00 0.00<br />

31050 S 1,001.52 0.00 0.00 31540 S 679.60 0.00 0.00<br />

31051 S 1,086.08 0.00 0.00 31541 S 734.75 0.00 0.00<br />

31070 S 675.88 0.00 0.00 31545 S 734.75 0.00 0.00<br />

31075 S 1,086.08 0.00 0.00 31546 S 734.75 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 774.72 0.00 0.00 32405 S 335.25 0.00 0.00<br />

31561 S 774.72 0.00 0.00 32420 S 203.86 0.00 0.00<br />

31570 S 555.29 0.00 0.00 32421 S 203.86 0.00 0.00<br />

31571 S 650.19 0.00 0.00 32422 S 202.95 0.00 0.00<br />

31575 S 59.16 0.00 0.00 32550 S 1,136.30 0.00 0.00<br />

31576 S 650.19 0.00 0.00 32960 S 202.95 0.00 0.00<br />

31577 S 192.06 0.00 0.00 32998 S 1,769.17 0.00 0.00<br />

31578 S 650.19 0.00 0.00 33010 S 203.86 0.00 0.00<br />

31579 S 105.39 0.00 0.00 33011 S 203.86 0.00 0.00<br />

31580 S 1,126.07 0.00 0.00 33206 S 6,540.48 3,891.56 1,242.66<br />

31582 S 1,126.07 0.00 0.00 33207 S 6,540.48 3,891.56 1,242.66<br />

31588 S 1,126.07 0.00 0.00 33208 S 8,112.04 4,726.85 1,341.66<br />

31590 S 1,126.07 0.00 0.00 33210 S 1,920.63 0.00 0.00<br />

31595 S 1,001.52 0.00 0.00 33211 S 1,920.63 0.00 0.00<br />

31603 S 296.33 0.00 0.00 33212 S 5,136.60 2,926.10 715.60<br />

31605 S 286.60 0.00 0.00 33213 S 5,928.75 3,321.75 714.75<br />

31611 S 705.30 0.00 0.00 33214 S 8,112.04 4,726.85 1,341.66<br />

31612 S 623.95 0.00 0.00 33215 S 841.84 0.00 0.00<br />

31613 S 675.88 0.00 0.00 33216 S 1,920.63 0.00 0.00<br />

31614 S 1,001.52 0.00 0.00 33217 S 1,920.63 0.00 0.00<br />

31615 S 296.33 0.00 0.00 33218 S 841.84 0.00 0.00<br />

31622 S 347.06 0.00 0.00 33220 S 841.84 0.00 0.00<br />

31623 S 398.98 0.00 0.00 33222 S 508.85 0.00 0.00<br />

31624 S 398.98 0.00 0.00 33223 S 508.85 0.00 0.00<br />

31625 S 398.98 0.00 0.00 33224 S 7,657.01 4,584.23 1,511.46<br />

31628 S 398.98 0.00 0.00 33225 S 7,657.01 4,584.23 1,511.46<br />

31629 S 398.98 0.00 0.00 33226 S 841.84 0.00 0.00<br />

31630 S 683.70 0.00 0.00 33233 S 625.89 0.00 0.00<br />

31631 S 683.70 0.00 0.00 33234 S 841.84 0.00 0.00<br />

31632 S 388.04 0.00 0.00 33235 S 841.84 0.00 0.00<br />

31633 S 388.04 0.00 0.00 33240 S 19,086.98 10,202.77 1,318.57<br />

31635 S 398.98 0.00 0.00 33241 S 841.84 0.00 0.00<br />

31636 S 683.70 0.00 0.00 33249 S 25,473.03 13,644.41 1,815.79<br />

31637 S 347.06 0.00 0.00 33282 S 4,027.45 2,411.07 794.69<br />

31638 S 683.70 0.00 0.00 33284 S 314.13 0.00 0.00<br />

31640 S 683.70 0.00 0.00 34490 S 1,533.68 0.00 0.00<br />

31641 S 683.70 0.00 0.00 35188 S 1,056.36 0.00 0.00<br />

31643 S 398.98 0.00 0.00 35207 S 1,056.36 0.00 0.00<br />

31645 S 347.06 0.00 0.00 35473 S 1,839.82 0.00 0.00<br />

31646 S 347.06 0.00 0.00 35476 S 1,839.82 0.00 0.00<br />

31656 S 347.06 0.00 0.00 35492 S 3,433.84 0.00 0.00<br />

31717 S 192.06 0.00 0.00 35761 S 1,104.62 0.00 0.00<br />

31720 S 29.41 0.00 0.00 35875 S 1,382.19 0.00 0.00<br />

31730 S 192.06 0.00 0.00 35876 S 1,382.19 0.00 0.00<br />

31750 S 1,126.07 0.00 0.00 36002 S 88.22 0.00 0.00<br />

31755 S 1,001.52 0.00 0.00 36260 S 800.26 0.00 0.00<br />

31820 S 480.99 0.00 0.00 36261 S 625.89 0.00 0.00<br />

31825 S 675.88 0.00 0.00 36262 S 573.95 0.00 0.00<br />

31830 S 675.88 0.00 0.00 36420 S 8.31 0.00 0.00<br />

32400 S 335.25 0.00 0.00 36425 S 8.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 31.95 0.00 0.00 36800 S 861.48 0.00 0.00<br />

36440 S 127.62 0.00 0.00 36810 S 861.48 0.00 0.00<br />

36450 S 127.62 0.00 0.00 36815 S 861.48 0.00 0.00<br />

36455 S 127.62 0.00 0.00 36818 S 1,001.22 0.00 0.00<br />

36468 S 31.50 0.00 0.00 36819 S 1,001.22 0.00 0.00<br />

36469 S 31.50 0.00 0.00 36820 S 1,001.22 0.00 0.00<br />

36470 S 31.50 0.00 0.00 36821 S 1,001.22 0.00 0.00<br />

36471 S 31.50 0.00 0.00 36825 S 1,056.36 0.00 0.00<br />

36475 S 1,448.40 0.00 0.00 36830 S 1,056.36 0.00 0.00<br />

36476 S 1,135.84 0.00 0.00 36831 S 1,382.19 0.00 0.00<br />

36478 S 1,135.84 0.00 0.00 36832 S 1,056.36 0.00 0.00<br />

36479 S 1,135.84 0.00 0.00 36833 S 1,056.36 0.00 0.00<br />

36511 S 437.54 0.00 0.00 36834 S 1,001.22 0.00 0.00<br />

36512 S 437.54 0.00 0.00 36835 S 916.63 0.00 0.00<br />

36513 S 437.54 0.00 0.00 36860 S 105.20 0.00 0.00<br />

36514 S 437.54 0.00 0.00 36861 S 861.48 0.00 0.00<br />

36515 S 1,171.28 0.00 0.00 36870 S 1,506.60 0.00 0.00<br />

36516 S 1,171.28 0.00 0.00 37184 S 1,533.68 0.00 0.00<br />

36522 S 1,171.28 0.00 0.00 37185 S 1,533.68 0.00 0.00<br />

36555 S 363.53 0.00 0.00 37186 S 1,533.68 0.00 0.00<br />

36556 S 363.53 0.00 0.00 37187 S 1,533.68 0.00 0.00<br />

36557 S 678.93 0.00 0.00 37188 S 1,533.68 0.00 0.00<br />

36558 S 678.93 0.00 0.00 37200 S 1,131.76 0.00 0.00<br />

36560 S 800.26 0.00 0.00 37203 S 1,131.76 0.00 0.00<br />

36561 S 800.26 0.00 0.00 37500 S 1,067.43 0.00 0.00<br />

36563 S 800.26 0.00 0.00 37607 S 754.87 0.00 0.00<br />

36565 S 800.26 0.00 0.00 37609 S 507.37 0.00 0.00<br />

36566 S 800.26 0.00 0.00 37650 S 725.45 0.00 0.00<br />

36568 S 363.53 0.00 0.00 37700 S 725.45 0.00 0.00<br />

36569 S 363.53 0.00 0.00 37718 S 754.87 0.00 0.00<br />

36570 S 708.34 0.00 0.00 37722 S 1,067.43 0.00 0.00<br />

36571 S 708.34 0.00 0.00 37735 S 1,067.43 0.00 0.00<br />

36575 S 292.39 0.00 0.00 37760 S 754.87 0.00 0.00<br />

36576 S 415.46 0.00 0.00 37765 S 1,040.98 0.00 0.00<br />

36578 S 678.93 0.00 0.00 37766 S 1,040.98 0.00 0.00<br />

36580 S 363.53 0.00 0.00 37780 S 754.87 0.00 0.00<br />

36581 S 678.93 0.00 0.00 37785 S 754.87 0.00 0.00<br />

36582 S 800.26 0.00 0.00 37790 S 910.90 0.00 0.00<br />

36583 S 800.26 0.00 0.00 38205 S 437.54 0.00 0.00<br />

36584 S 363.53 0.00 0.00 38206 S 437.54 0.00 0.00<br />

36585 S 708.34 0.00 0.00 38220 S 100.29 0.00 0.00<br />

36589 S 240.46 0.00 0.00 38221 S 105.05 0.00 0.00<br />

36590 S 363.53 0.00 0.00 38230 S 1,171.28 0.00 0.00<br />

36593 S 24.14 0.00 0.00 38241 S 1,171.28 0.00 0.00<br />

36595 S 947.92 0.00 0.00 38242 S 437.54 0.00 0.00<br />

36596 S 420.98 0.00 0.00 38300 S 392.63 0.00 0.00<br />

36597 S 420.98 0.00 0.00 38305 S 573.77 0.00 0.00<br />

36598 S 77.85 0.00 0.00 38308 S 655.61 0.00 0.00<br />

36640 S 718.91 0.00 0.00 38500 S 655.61 0.00 0.00<br />

36680 S 54.49 0.00 0.00 38505 S 250.84 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 655.61 0.00 0.00 41005 S 132.17 0.00 0.00<br />

38520 S 655.61 0.00 0.00 41006 S 623.95 0.00 0.00<br />

38525 S 655.61 0.00 0.00 41007 S 480.99 0.00 0.00<br />

38530 S 655.61 0.00 0.00 41008 S 480.99 0.00 0.00<br />

38542 S 1,102.96 0.00 0.00 41009 S 132.17 0.00 0.00<br />

38550 S 685.03 0.00 0.00 41010 S 296.33 0.00 0.00<br />

38555 S 740.17 0.00 0.00 41015 S 132.17 0.00 0.00<br />

38570 S 1,496.56 0.00 0.00 41016 S 296.33 0.00 0.00<br />

38571 S 1,945.49 0.00 0.00 41017 S 296.33 0.00 0.00<br />

38572 S 1,496.56 0.00 0.00 41018 S 296.33 0.00 0.00<br />

38700 S 901.29 0.00 0.00 41019 S 941.85 0.00 0.00<br />

38740 S 1,102.96 0.00 0.00 41100 S 88.73 0.00 0.00<br />

38745 S 1,187.53 0.00 0.00 41105 S 87.71 0.00 0.00<br />

38760 S 655.61 0.00 0.00 41108 S 81.25 0.00 0.00<br />

40490 S 66.97 0.00 0.00 41110 S 117.63 0.00 0.00<br />

40500 S 532.92 0.00 0.00 41112 S 532.92 0.00 0.00<br />

40510 S 675.88 0.00 0.00 41113 S 532.92 0.00 0.00<br />

40520 S 532.92 0.00 0.00 41114 S 675.88 0.00 0.00<br />

40525 S 675.88 0.00 0.00 41115 S 137.01 0.00 0.00<br />

40527 S 675.88 0.00 0.00 41116 S 480.99 0.00 0.00<br />

40530 S 675.88 0.00 0.00 41120 S 800.43 0.00 0.00<br />

40650 S 356.60 0.00 0.00 41250 S 90.40 0.00 0.00<br />

40652 S 356.60 0.00 0.00 41251 S 132.17 0.00 0.00<br />

40654 S 356.60 0.00 0.00 41252 S 348.26 0.00 0.00<br />

40700 S 1,253.83 0.00 0.00 41500 S 623.95 0.00 0.00<br />

40701 S 1,253.83 0.00 0.00 41510 S 480.99 0.00 0.00<br />

40702 S 1,593.12 0.00 0.00 41520 S 348.26 0.00 0.00<br />

40720 S 1,253.83 0.00 0.00 41530 S 655.91 0.00 0.00<br />

40761 S 1,030.94 0.00 0.00 41800 S 67.53 0.00 0.00<br />

40800 S 53.75 0.00 0.00 41805 S 146.19 0.00 0.00<br />

40801 S 348.26 0.00 0.00 41806 S 180.18 0.00 0.00<br />

40804 S 24.58 0.00 0.00 41820 S 286.60 0.00 0.00<br />

40805 S 166.25 0.00 0.00 41821 S 286.60 0.00 0.00<br />

40806 S 76.49 0.00 0.00 41822 S 149.24 0.00 0.00<br />

40808 S 113.55 0.00 0.00 41823 S 217.58 0.00 0.00<br />

40810 S 117.63 0.00 0.00 41825 S 119.66 0.00 0.00<br />

40812 S 147.55 0.00 0.00 41826 S 150.61 0.00 0.00<br />

40814 S 532.92 0.00 0.00 41827 S 675.88 0.00 0.00<br />

40816 S 675.88 0.00 0.00 41828 S 135.99 0.00 0.00<br />

40818 S 132.17 0.00 0.00 41830 S 193.10 0.00 0.00<br />

40819 S 296.33 0.00 0.00 41850 S 655.91 0.00 0.00<br />

40820 S 169.64 0.00 0.00 41870 S 941.85 0.00 0.00<br />

40830 S 125.82 0.00 0.00 41872 S 193.10 0.00 0.00<br />

40831 S 296.33 0.00 0.00 41874 S 186.30 0.00 0.00<br />

40840 S 675.88 0.00 0.00 42000 S 132.17 0.00 0.00<br />

40842 S 705.30 0.00 0.00 42100 S 75.47 0.00 0.00<br />

40843 S 705.30 0.00 0.00 42104 S 112.19 0.00 0.00<br />

40844 S 1,126.07 0.00 0.00 42106 S 140.75 0.00 0.00<br />

40845 S 1,126.07 0.00 0.00 42107 S 675.88 0.00 0.00<br />

41000 S 84.32 0.00 0.00 42120 S 1,086.08 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 348.26 0.00 0.00 42809 S 24.58 0.00 0.00<br />

42145 S 800.43 0.00 0.00 42810 S 705.30 0.00 0.00<br />

42160 S 133.26 0.00 0.00 42815 S 1,126.07 0.00 0.00<br />

42180 S 132.17 0.00 0.00 42820 S 705.30 0.00 0.00<br />

42182 S 1,001.52 0.00 0.00 42821 S 800.43 0.00 0.00<br />

42200 S 1,126.07 0.00 0.00 42825 S 760.44 0.00 0.00<br />

42205 S 1,126.07 0.00 0.00 42826 S 760.44 0.00 0.00<br />

42210 S 1,126.07 0.00 0.00 42830 S 760.44 0.00 0.00<br />

42215 S 1,253.83 0.00 0.00 42831 S 760.44 0.00 0.00<br />

42220 S 1,126.07 0.00 0.00 42835 S 760.44 0.00 0.00<br />

42226 S 1,126.07 0.00 0.00 42836 S 760.44 0.00 0.00<br />

42235 S 657.46 0.00 0.00 42860 S 705.30 0.00 0.00<br />

42260 S 760.44 0.00 0.00 42870 S 705.30 0.00 0.00<br />

42280 S 73.43 0.00 0.00 42890 S 1,253.83 0.00 0.00<br />

42281 S 655.91 0.00 0.00 42892 S 1,253.83 0.00 0.00<br />

42300 S 480.99 0.00 0.00 42900 S 296.33 0.00 0.00<br />

42305 S 532.92 0.00 0.00 42950 S 675.88 0.00 0.00<br />

42310 S 132.17 0.00 0.00 42955 S 675.88 0.00 0.00<br />

42320 S 132.17 0.00 0.00 42960 S 54.44 0.00 0.00<br />

42330 S 113.55 0.00 0.00 42962 S 1,001.52 0.00 0.00<br />

42335 S 188.34 0.00 0.00 42970 S 42.27 0.00 0.00<br />

42340 S 532.92 0.00 0.00 42972 S 562.34 0.00 0.00<br />

42400 S 63.92 0.00 0.00 43030 S 655.91 0.00 0.00<br />

42405 S 532.92 0.00 0.00 43200 S 317.63 0.00 0.00<br />

42408 S 562.34 0.00 0.00 43201 S 317.63 0.00 0.00<br />

42409 S 562.34 0.00 0.00 43202 S 317.63 0.00 0.00<br />

42410 S 1,030.94 0.00 0.00 43204 S 317.63 0.00 0.00<br />

42415 S 1,253.83 0.00 0.00 43205 S 317.63 0.00 0.00<br />

42420 S 1,253.83 0.00 0.00 43215 S 317.63 0.00 0.00<br />

42425 S 1,253.83 0.00 0.00 43216 S 317.63 0.00 0.00<br />

42440 S 1,030.94 0.00 0.00 43217 S 317.63 0.00 0.00<br />

42450 S 675.88 0.00 0.00 43219 S 641.93 0.00 0.00<br />

42500 S 705.30 0.00 0.00 43220 S 317.63 0.00 0.00<br />

42505 S 1,086.08 0.00 0.00 43226 S 317.63 0.00 0.00<br />

42507 S 1,030.94 0.00 0.00 43227 S 369.57 0.00 0.00<br />

42508 S 1,086.08 0.00 0.00 43228 S 687.73 0.00 0.00<br />

42509 S 1,086.08 0.00 0.00 43231 S 369.57 0.00 0.00<br />

42510 S 1,086.08 0.00 0.00 43232 S 369.57 0.00 0.00<br />

42600 S 480.99 0.00 0.00 43234 S 317.63 0.00 0.00<br />

42650 S 41.81 0.00 0.00 43235 S 317.63 0.00 0.00<br />

42660 S 48.96 0.00 0.00 43236 S 369.57 0.00 0.00<br />

42665 S 928.19 0.00 0.00 43237 S 369.57 0.00 0.00<br />

42700 S 132.17 0.00 0.00 43238 S 369.57 0.00 0.00<br />

42720 S 480.99 0.00 0.00 43239 S 369.57 0.00 0.00<br />

42725 S 1,001.52 0.00 0.00 43240 S 369.57 0.00 0.00<br />

42800 S 80.91 0.00 0.00 43241 S 369.57 0.00 0.00<br />

42802 S 480.99 0.00 0.00 43242 S 369.57 0.00 0.00<br />

42804 S 480.99 0.00 0.00 43243 S 369.57 0.00 0.00<br />

42806 S 675.88 0.00 0.00 43244 S 369.57 0.00 0.00<br />

42808 S 532.92 0.00 0.00 43245 S 369.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 369.57 0.00 0.00 44378 S 387.06 0.00 0.00<br />

43247 S 369.57 0.00 0.00 44379 S 1,104.26 0.00 0.00<br />

43248 S 369.57 0.00 0.00 44380 S 335.12 0.00 0.00<br />

43249 S 369.57 0.00 0.00 44382 S 335.12 0.00 0.00<br />

43250 S 369.57 0.00 0.00 44383 S 1,104.26 0.00 0.00<br />

43251 S 369.57 0.00 0.00 44385 S 324.02 0.00 0.00<br />

43255 S 369.57 0.00 0.00 44386 S 324.02 0.00 0.00<br />

43256 S 723.28 0.00 0.00 44388 S 324.02 0.00 0.00<br />

43257 S 717.15 0.00 0.00 44389 S 324.02 0.00 0.00<br />

43258 S 398.97 0.00 0.00 44390 S 324.02 0.00 0.00<br />

43259 S 398.97 0.00 0.00 44391 S 324.02 0.00 0.00<br />

43260 S 622.16 0.00 0.00 44392 S 324.02 0.00 0.00<br />

43261 S 622.16 0.00 0.00 44393 S 324.02 0.00 0.00<br />

43262 S 622.16 0.00 0.00 44394 S 324.02 0.00 0.00<br />

43263 S 622.16 0.00 0.00 44397 S 641.93 0.00 0.00<br />

43264 S 622.16 0.00 0.00 44500 S 174.85 0.00 0.00<br />

43265 S 622.16 0.00 0.00 45000 S 375.76 0.00 0.00<br />

43267 S 622.16 0.00 0.00 45005 S 437.31 0.00 0.00<br />

43268 S 693.87 0.00 0.00 45020 S 437.31 0.00 0.00<br />

43269 S 693.87 0.00 0.00 45100 S 594.13 0.00 0.00<br />

43271 S 622.16 0.00 0.00 45108 S 646.06 0.00 0.00<br />

43272 S 622.16 0.00 0.00 45150 S 646.06 0.00 0.00<br />

43273 S 834.40 0.00 0.00 45160 S 646.06 0.00 0.00<br />

43450 S 277.78 0.00 0.00 45170 S 646.06 0.00 0.00<br />

43453 S 277.78 0.00 0.00 45190 S 1,056.45 0.00 0.00<br />

43456 S 278.89 0.00 0.00 45300 S 62.55 0.00 0.00<br />

43458 S 318.74 0.00 0.00 45303 S 347.45 0.00 0.00<br />

43600 S 317.63 0.00 0.00 45305 S 326.76 0.00 0.00<br />

43653 S 1,496.56 0.00 0.00 45307 S 603.55 0.00 0.00<br />

43760 S 154.05 0.00 0.00 45308 S 326.76 0.00 0.00<br />

43761 S 317.63 0.00 0.00 45309 S 326.76 0.00 0.00<br />

43870 S 317.63 0.00 0.00 45315 S 326.76 0.00 0.00<br />

43886 S 801.46 0.00 0.00 45317 S 326.76 0.00 0.00<br />

43887 S 168.57 0.00 0.00 45320 S 603.55 0.00 0.00<br />

43888 S 801.46 0.00 0.00 45321 S 603.55 0.00 0.00<br />

44100 S 317.63 0.00 0.00 45327 S 641.93 0.00 0.00<br />

44312 S 553.76 0.00 0.00 45330 S 82.61 0.00 0.00<br />

44340 S 635.11 0.00 0.00 45331 S 244.29 0.00 0.00<br />

44360 S 387.06 0.00 0.00 45332 S 244.29 0.00 0.00<br />

44361 S 387.06 0.00 0.00 45333 S 326.76 0.00 0.00<br />

44363 S 387.06 0.00 0.00 45334 S 326.76 0.00 0.00<br />

44364 S 387.06 0.00 0.00 45335 S 244.29 0.00 0.00<br />

44365 S 387.06 0.00 0.00 45337 S 244.29 0.00 0.00<br />

44366 S 387.06 0.00 0.00 45338 S 326.76 0.00 0.00<br />

44369 S 387.06 0.00 0.00 45339 S 326.76 0.00 0.00<br />

44370 S 1,104.26 0.00 0.00 45340 S 326.76 0.00 0.00<br />

44372 S 387.06 0.00 0.00 45341 S 326.76 0.00 0.00<br />

44373 S 387.06 0.00 0.00 45342 S 326.76 0.00 0.00<br />

44376 S 387.06 0.00 0.00 45345 S 641.93 0.00 0.00<br />

44377 S 387.06 0.00 0.00 45355 S 324.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 375.96 0.00 0.00 46505 S 464.68 0.00 0.00<br />

45379 S 375.96 0.00 0.00 46600 S 24.58 0.00 0.00<br />

45380 S 375.96 0.00 0.00 46604 S 347.45 0.00 0.00<br />

45381 S 375.96 0.00 0.00 46606 S 130.55 0.00 0.00<br />

45382 S 375.96 0.00 0.00 46608 S 326.76 0.00 0.00<br />

45383 S 375.96 0.00 0.00 46610 S 603.55 0.00 0.00<br />

45384 S 375.96 0.00 0.00 46611 S 326.76 0.00 0.00<br />

45385 S 375.96 0.00 0.00 46612 S 603.55 0.00 0.00<br />

45386 S 375.96 0.00 0.00 46614 S 68.67 0.00 0.00<br />

45387 S 641.93 0.00 0.00 46615 S 655.47 0.00 0.00<br />

45391 S 375.96 0.00 0.00 46700 S 675.48 0.00 0.00<br />

45392 S 375.96 0.00 0.00 46706 S 743.49 0.00 0.00<br />

45500 S 646.06 0.00 0.00 46750 S 824.84 0.00 0.00<br />

45505 S 795.43 0.00 0.00 46753 S 675.48 0.00 0.00<br />

45520 S 31.50 0.00 0.00 46754 S 646.06 0.00 0.00<br />

45560 S 795.43 0.00 0.00 46760 S 795.43 0.00 0.00<br />

45900 S 254.74 0.00 0.00 46761 S 824.84 0.00 0.00<br />

45905 S 594.13 0.00 0.00 46762 S 1,047.73 0.00 0.00<br />

45910 S 594.13 0.00 0.00 46900 S 103.82 0.00 0.00<br />

45915 S 375.76 0.00 0.00 46910 S 124.08 0.00 0.00<br />

45990 S 584.51 0.00 0.00 46916 S 57.72 0.00 0.00<br />

46020 S 675.48 0.00 0.00 46917 S 538.39 0.00 0.00<br />

46030 S 254.74 0.00 0.00 46922 S 538.39 0.00 0.00<br />

46040 S 675.48 0.00 0.00 46924 S 538.39 0.00 0.00<br />

46045 S 646.06 0.00 0.00 46930 S 120.35 0.00 0.00<br />

46050 S 375.76 0.00 0.00 46937 S 646.06 0.00 0.00<br />

46060 S 646.06 0.00 0.00 46938 S 795.43 0.00 0.00<br />

46070 S 464.68 0.00 0.00 46940 S 89.07 0.00 0.00<br />

46080 S 675.48 0.00 0.00 46942 S 86.69 0.00 0.00<br />

46083 S 71.13 0.00 0.00 46945 S 147.55 0.00 0.00<br />

46200 S 646.06 0.00 0.00 46946 S 385.37 0.00 0.00<br />

46210 S 646.06 0.00 0.00 46947 S 1,047.73 0.00 0.00<br />

46211 S 646.06 0.00 0.00 47000 S 335.25 0.00 0.00<br />

46220 S 594.13 0.00 0.00 47382 S 1,769.17 0.00 0.00<br />

46221 S 116.95 0.00 0.00 47510 S 783.49 0.00 0.00<br />

46230 S 594.13 0.00 0.00 47511 S 1,151.07 0.00 0.00<br />

46250 S 675.48 0.00 0.00 47525 S 449.78 0.00 0.00<br />

46255 S 675.48 0.00 0.00 47530 S 449.78 0.00 0.00<br />

46257 S 675.48 0.00 0.00 47552 S 783.49 0.00 0.00<br />

46258 S 675.48 0.00 0.00 47553 S 812.90 0.00 0.00<br />

46260 S 675.48 0.00 0.00 47554 S 812.90 0.00 0.00<br />

46261 S 730.62 0.00 0.00 47555 S 812.90 0.00 0.00<br />

46262 S 730.62 0.00 0.00 47556 S 1,151.07 0.00 0.00<br />

46270 S 675.48 0.00 0.00 47560 S 955.13 0.00 0.00<br />

46275 S 675.48 0.00 0.00 47561 S 955.13 0.00 0.00<br />

46280 S 730.62 0.00 0.00 47562 S 1,762.41 0.00 0.00<br />

46285 S 594.13 0.00 0.00 47563 S 1,762.41 0.00 0.00<br />

46288 S 730.62 0.00 0.00 47564 S 1,762.41 0.00 0.00<br />

46320 S 79.22 0.00 0.00 47630 S 812.90 0.00 0.00<br />

46500 S 109.12 0.00 0.00 48102 S 335.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 203.86 0.00 0.00 49590 S 836.70 0.00 0.00<br />

49081 S 203.86 0.00 0.00 49600 S 891.84 0.00 0.00<br />

49180 S 335.25 0.00 0.00 49650 S 1,170.73 0.00 0.00<br />

49250 S 734.87 0.00 0.00 49651 S 1,338.47 0.00 0.00<br />

49320 S 955.13 0.00 0.00 49652 S 1,441.50 0.00 0.00<br />

49321 S 1,010.28 0.00 0.00 49653 S 1,441.50 0.00 0.00<br />

49322 S 1,010.28 0.00 0.00 49654 S 1,441.50 0.00 0.00<br />

49324 S 1,441.50 0.00 0.00 49655 S 1,441.50 0.00 0.00<br />

49325 S 1,441.50 0.00 0.00 49656 S 1,441.50 0.00 0.00<br />

49326 S 1,441.50 0.00 0.00 49657 S 1,441.50 0.00 0.00<br />

49402 S 650.31 0.00 0.00 50200 S 335.25 0.00 0.00<br />

49419 S 780.13 0.00 0.00 50382 S 973.48 0.00 0.00<br />

49420 S 721.18 0.00 0.00 50384 S 715.00 0.00 0.00<br />

49421 S 721.18 0.00 0.00 50385 S 715.00 0.00 0.00<br />

49422 S 573.95 0.00 0.00 50386 S 274.32 0.00 0.00<br />

49423 S 593.49 0.00 0.00 50387 S 593.49 0.00 0.00<br />

49426 S 650.31 0.00 0.00 50389 S 274.32 0.00 0.00<br />

49429 S 841.84 0.00 0.00 50390 S 335.25 0.00 0.00<br />

49440 S 329.19 0.00 0.00 50391 S 39.70 0.00 0.00<br />

49441 S 329.19 0.00 0.00 50392 S 510.53 0.00 0.00<br />

49446 S 329.19 0.00 0.00 50393 S 639.77 0.00 0.00<br />

49450 S 174.85 0.00 0.00 50395 S 510.53 0.00 0.00<br />

49451 S 174.85 0.00 0.00 50396 S 95.99 0.00 0.00<br />

49452 S 174.85 0.00 0.00 50398 S 449.78 0.00 0.00<br />

49460 S 174.85 0.00 0.00 50551 S 290.20 0.00 0.00<br />

49495 S 891.84 0.00 0.00 50553 S 639.77 0.00 0.00<br />

49496 S 891.84 0.00 0.00 50555 S 290.20 0.00 0.00<br />

49500 S 891.84 0.00 0.00 50557 S 639.77 0.00 0.00<br />

49501 S 1,217.67 0.00 0.00 50561 S 639.77 0.00 0.00<br />

49505 S 891.84 0.00 0.00 50562 S 274.32 0.00 0.00<br />

49507 S 1,217.67 0.00 0.00 50570 S 274.32 0.00 0.00<br />

49520 S 1,059.59 0.00 0.00 50572 S 274.32 0.00 0.00<br />

49521 S 1,217.67 0.00 0.00 50574 S 274.32 0.00 0.00<br />

49525 S 891.84 0.00 0.00 50575 S 1,364.55 0.00 0.00<br />

49540 S 807.28 0.00 0.00 50576 S 715.00 0.00 0.00<br />

49550 S 931.83 0.00 0.00 50580 S 715.00 0.00 0.00<br />

49553 S 1,217.67 0.00 0.00 50590 S 1,594.11 0.00 0.00<br />

49555 S 931.83 0.00 0.00 50592 S 1,769.17 0.00 0.00<br />

49557 S 1,217.67 0.00 0.00 50686 S 39.70 0.00 0.00<br />

49560 S 891.84 0.00 0.00 50688 S 449.78 0.00 0.00<br />

49561 S 1,217.67 0.00 0.00 50947 S 1,496.56 0.00 0.00<br />

49565 S 891.84 0.00 0.00 50948 S 1,496.56 0.00 0.00<br />

49566 S 1,217.67 0.00 0.00 50951 S 290.20 0.00 0.00<br />

49568 S 1,059.59 0.00 0.00 50953 S 290.20 0.00 0.00<br />

49570 S 891.84 0.00 0.00 50955 S 639.77 0.00 0.00<br />

49572 S 1,217.67 0.00 0.00 50957 S 639.77 0.00 0.00<br />

49580 S 891.84 0.00 0.00 50961 S 639.77 0.00 0.00<br />

49582 S 1,217.67 0.00 0.00 50970 S 290.20 0.00 0.00<br />

49585 S 891.84 0.00 0.00 50972 S 290.20 0.00 0.00<br />

49587 S 1,217.67 0.00 0.00 50974 S 510.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 510.53 0.00 0.00 52275 S 691.71 0.00 0.00<br />

50980 S 639.77 0.00 0.00 52276 S 721.12 0.00 0.00<br />

51020 S 776.27 0.00 0.00 52277 S 691.71 0.00 0.00<br />

51030 S 776.27 0.00 0.00 52281 S 562.46 0.00 0.00<br />

51040 S 776.27 0.00 0.00 52282 S 1,297.63 0.00 0.00<br />

51045 S 320.63 0.00 0.00 52283 S 691.71 0.00 0.00<br />

51050 S 776.27 0.00 0.00 52285 S 562.46 0.00 0.00<br />

51065 S 776.27 0.00 0.00 52290 S 562.46 0.00 0.00<br />

51080 S 521.83 0.00 0.00 52300 S 691.71 0.00 0.00<br />

51100 S 30.26 0.00 0.00 52301 S 721.12 0.00 0.00<br />

51101 S 39.70 0.00 0.00 52305 S 691.71 0.00 0.00<br />

51102 S 534.14 0.00 0.00 52310 S 540.97 0.00 0.00<br />

51500 S 891.84 0.00 0.00 52315 S 691.71 0.00 0.00<br />

51520 S 776.27 0.00 0.00 52317 S 639.77 0.00 0.00<br />

51700 S 51.67 0.00 0.00 52318 S 691.71 0.00 0.00<br />

51701 S 24.58 0.00 0.00 52320 S 816.24 0.00 0.00<br />

51702 S 24.58 0.00 0.00 52325 S 776.27 0.00 0.00<br />

51703 S 39.70 0.00 0.00 52327 S 887.24 0.00 0.00<br />

51705 S 71.13 0.00 0.00 52330 S 691.71 0.00 0.00<br />

51710 S 449.78 0.00 0.00 52332 S 691.71 0.00 0.00<br />

51715 S 816.67 0.00 0.00 52334 S 721.12 0.00 0.00<br />

51720 S 57.11 0.00 0.00 52341 S 721.12 0.00 0.00<br />

51725 TC S 109.72 0.00 0.00 52342 S 721.12 0.00 0.00<br />

51726 TC S 151.13 0.00 0.00 52343 S 721.12 0.00 0.00<br />

51736 TC S 20.74 0.00 0.00 52344 S 721.12 0.00 0.00<br />

51741 TC S 24.14 0.00 0.00 52345 S 721.12 0.00 0.00<br />

51772 TC S 95.99 0.00 0.00 52346 S 721.12 0.00 0.00<br />

51784 TC S 39.70 0.00 0.00 52351 S 721.12 0.00 0.00<br />

51785 TC S 66.32 0.00 0.00 52352 S 776.27 0.00 0.00<br />

51792 TC S 39.70 0.00 0.00 52353 S 971.80 0.00 0.00<br />

51795 TC S 71.13 0.00 0.00 52354 S 776.27 0.00 0.00<br />

51797 TC S 71.13 0.00 0.00 52355 S 776.27 0.00 0.00<br />

51798 S 17.67 0.00 0.00 52400 S 721.12 0.00 0.00<br />

51880 S 639.77 0.00 0.00 52402 S 721.12 0.00 0.00<br />

51992 S 1,210.71 0.00 0.00 52450 S 721.12 0.00 0.00<br />

52000 S 290.20 0.00 0.00 52500 S 721.12 0.00 0.00<br />

52001 S 540.97 0.00 0.00 52601 S 971.80 0.00 0.00<br />

52005 S 562.46 0.00 0.00 52630 S 887.24 0.00 0.00<br />

52007 S 691.71 0.00 0.00 52640 S 691.71 0.00 0.00<br />

52010 S 320.63 0.00 0.00 52647 S 1,486.76 0.00 0.00<br />

52204 S 562.46 0.00 0.00 52648 S 1,486.76 0.00 0.00<br />

52214 S 691.71 0.00 0.00 52700 S 691.71 0.00 0.00<br />

52224 S 691.71 0.00 0.00 53000 S 530.88 0.00 0.00<br />

52234 S 691.71 0.00 0.00 53010 S 530.88 0.00 0.00<br />

52235 S 721.12 0.00 0.00 53020 S 530.88 0.00 0.00<br />

52240 S 721.12 0.00 0.00 53025 S 755.69 0.00 0.00<br />

52250 S 776.27 0.00 0.00 53040 S 582.82 0.00 0.00<br />

52260 S 562.46 0.00 0.00 53060 S 69.02 0.00 0.00<br />

52265 S 274.32 0.00 0.00 53080 S 612.23 0.00 0.00<br />

52270 S 562.46 0.00 0.00 53085 S 755.69 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 530.88 0.00 0.00 54060 S 538.39 0.00 0.00<br />

53210 S 911.80 0.00 0.00 54065 S 538.39 0.00 0.00<br />

53215 S 707.36 0.00 0.00 54100 S 455.45 0.00 0.00<br />

53220 S 787.25 0.00 0.00 54105 S 568.55 0.00 0.00<br />

53230 S 787.25 0.00 0.00 54110 S 881.49 0.00 0.00<br />

53235 S 612.23 0.00 0.00 54111 S 881.49 0.00 0.00<br />

53240 S 787.25 0.00 0.00 54112 S 881.49 0.00 0.00<br />

53250 S 582.82 0.00 0.00 54115 S 521.83 0.00 0.00<br />

53260 S 582.82 0.00 0.00 54120 S 881.49 0.00 0.00<br />

53265 S 582.82 0.00 0.00 54150 S 587.47 0.00 0.00<br />

53270 S 582.82 0.00 0.00 54160 S 639.40 0.00 0.00<br />

53275 S 582.82 0.00 0.00 54161 S 639.40 0.00 0.00<br />

53400 S 816.67 0.00 0.00 54162 S 639.40 0.00 0.00<br />

53405 S 787.25 0.00 0.00 54163 S 639.40 0.00 0.00<br />

53410 S 787.25 0.00 0.00 54164 S 639.40 0.00 0.00<br />

53420 S 816.67 0.00 0.00 54200 S 66.97 0.00 0.00<br />

53425 S 787.25 0.00 0.00 54205 S 966.05 0.00 0.00<br />

53430 S 787.25 0.00 0.00 54220 S 95.99 0.00 0.00<br />

53431 S 787.25 0.00 0.00 54231 S 62.89 0.00 0.00<br />

53440 S 4,534.88 2,754.24 973.60 54235 S 44.54 0.00 0.00<br />

53442 S 735.32 0.00 0.00 54240 TC S 31.61 0.00 0.00<br />

53444 S 4,534.88 2,754.24 973.60 54250 TC S 11.22 0.00 0.00<br />

53445 S 7,617.44 4,338.08 1,058.73 54300 S 910.90 0.00 0.00<br />

53446 S 735.32 0.00 0.00 54304 S 910.90 0.00 0.00<br />

53447 S 7,617.44 4,338.08 1,058.73 54308 S 910.90 0.00 0.00<br />

53449 S 735.32 0.00 0.00 54312 S 910.90 0.00 0.00<br />

53450 S 735.32 0.00 0.00 54316 S 910.90 0.00 0.00<br />

53460 S 530.88 0.00 0.00 54318 S 910.90 0.00 0.00<br />

53502 S 582.82 0.00 0.00 54322 S 910.90 0.00 0.00<br />

53505 S 787.25 0.00 0.00 54324 S 910.90 0.00 0.00<br />

53510 S 582.82 0.00 0.00 54326 S 910.90 0.00 0.00<br />

53515 S 787.25 0.00 0.00 54328 S 910.90 0.00 0.00<br />

53520 S 787.25 0.00 0.00 54340 S 910.90 0.00 0.00<br />

53600 S 39.78 0.00 0.00 54344 S 910.90 0.00 0.00<br />

53601 S 39.70 0.00 0.00 54348 S 910.90 0.00 0.00<br />

53605 S 562.46 0.00 0.00 54352 S 910.90 0.00 0.00<br />

53620 S 61.19 0.00 0.00 54360 S 910.90 0.00 0.00<br />

53621 S 64.26 0.00 0.00 54380 S 910.90 0.00 0.00<br />

53660 S 39.70 0.00 0.00 54385 S 910.90 0.00 0.00<br />

53661 S 39.70 0.00 0.00 54400 S 4,564.30 2,783.66 1,003.02<br />

53665 S 530.88 0.00 0.00 54401 S 7,698.79 4,419.43 1,140.07<br />

53850 S 1,742.82 0.00 0.00 54405 S 7,698.79 4,419.43 1,140.07<br />

53852 S 1,742.82 0.00 0.00 54406 S 910.90 0.00 0.00<br />

54000 S 582.82 0.00 0.00 54408 S 910.90 0.00 0.00<br />

54001 S 582.82 0.00 0.00 54410 S 7,698.79 4,419.43 1,140.07<br />

54015 S 658.33 0.00 0.00 54415 S 910.90 0.00 0.00<br />

54050 S 31.50 0.00 0.00 54416 S 7,698.79 4,419.43 1,140.07<br />

54055 S 64.26 0.00 0.00 54420 S 966.05 0.00 0.00<br />

54056 S 31.50 0.00 0.00 54435 S 966.05 0.00 0.00<br />

54057 S 538.39 0.00 0.00 54440 S 966.05 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 151.13 0.00 0.00 55706 S 439.34 0.00 0.00<br />

54500 S 410.17 0.00 0.00 55720 S 639.77 0.00 0.00<br />

54505 S 587.47 0.00 0.00 55725 S 691.71 0.00 0.00<br />

54512 S 639.40 0.00 0.00 55860 S 762.22 0.00 0.00<br />

54520 S 668.81 0.00 0.00 55870 S 77.51 0.00 0.00<br />

54522 S 668.81 0.00 0.00 55873 S 6,031.01 0.00 0.00<br />

54530 S 891.84 0.00 0.00 55875 S 1,297.63 0.00 0.00<br />

54550 S 891.84 0.00 0.00 55876 S 71.05 0.00 0.00<br />

54560 S 868.87 0.00 0.00 55920 S 890.70 0.00 0.00<br />

54600 S 723.96 0.00 0.00 56405 S 41.47 0.00 0.00<br />

54620 S 668.81 0.00 0.00 56420 S 54.13 0.00 0.00<br />

54640 S 891.84 0.00 0.00 56440 S 581.31 0.00 0.00<br />

54660 S 639.40 0.00 0.00 56441 S 529.37 0.00 0.00<br />

54670 S 668.81 0.00 0.00 56442 S 529.37 0.00 0.00<br />

54680 S 668.81 0.00 0.00 56501 S 57.11 0.00 0.00<br />

54690 S 1,496.56 0.00 0.00 56515 S 619.74 0.00 0.00<br />

54692 S 2,660.27 0.00 0.00 56605 S 32.97 0.00 0.00<br />

54700 S 639.40 0.00 0.00 56606 S 13.60 0.00 0.00<br />

54800 S 143.52 0.00 0.00 56620 S 705.85 0.00 0.00<br />

54830 S 668.81 0.00 0.00 56625 S 833.61 0.00 0.00<br />

54840 S 723.96 0.00 0.00 56700 S 529.37 0.00 0.00<br />

54860 S 668.81 0.00 0.00 56740 S 610.72 0.00 0.00<br />

54861 S 723.96 0.00 0.00 56800 S 610.72 0.00 0.00<br />

54865 S 587.47 0.00 0.00 56805 S 752.68 0.00 0.00<br />

54900 S 723.96 0.00 0.00 56810 S 705.85 0.00 0.00<br />

54901 S 723.96 0.00 0.00 56820 S 42.15 0.00 0.00<br />

55000 S 65.28 0.00 0.00 56821 S 54.13 0.00 0.00<br />

55040 S 836.70 0.00 0.00 57000 S 529.37 0.00 0.00<br />

55041 S 931.83 0.00 0.00 57010 S 581.31 0.00 0.00<br />

55060 S 723.96 0.00 0.00 57020 S 304.87 0.00 0.00<br />

55100 S 392.63 0.00 0.00 57022 S 479.20 0.00 0.00<br />

55110 S 639.40 0.00 0.00 57023 S 521.83 0.00 0.00<br />

55120 S 639.40 0.00 0.00 57061 S 52.69 0.00 0.00<br />

55150 S 587.47 0.00 0.00 57065 S 529.37 0.00 0.00<br />

55175 S 587.47 0.00 0.00 57100 S 33.66 0.00 0.00<br />

55180 S 639.40 0.00 0.00 57105 S 581.31 0.00 0.00<br />

55200 S 639.40 0.00 0.00 57130 S 581.31 0.00 0.00<br />

55250 S 639.40 0.00 0.00 57135 S 581.31 0.00 0.00<br />

55400 S 587.47 0.00 0.00 57150 S 24.48 0.00 0.00<br />

55450 S 210.10 0.00 0.00 57155 S 304.87 0.00 0.00<br />

55500 S 668.81 0.00 0.00 57160 S 35.36 0.00 0.00<br />

55520 S 723.96 0.00 0.00 57170 S 5.80 0.00 0.00<br />

55530 S 723.96 0.00 0.00 57180 S 108.89 0.00 0.00<br />

55535 S 891.84 0.00 0.00 57200 S 529.37 0.00 0.00<br />

55540 S 931.83 0.00 0.00 57210 S 581.31 0.00 0.00<br />

55550 S 1,496.56 0.00 0.00 57220 S 1,066.04 0.00 0.00<br />

55600 S 868.87 0.00 0.00 57230 S 875.32 0.00 0.00<br />

55680 S 587.47 0.00 0.00 57240 S 970.44 0.00 0.00<br />

55700 S 378.60 0.00 0.00 57250 S 970.44 0.00 0.00<br />

55705 S 378.60 0.00 0.00 57260 S 970.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,288.93 0.00 0.00 58555 S 571.96 0.00 0.00<br />

57267 S 1,098.20 0.00 0.00 58558 S 653.31 0.00 0.00<br />

57268 S 875.32 0.00 0.00 58559 S 623.90 0.00 0.00<br />

57287 S 1,281.88 0.00 0.00 58560 S 931.52 0.00 0.00<br />

57288 S 1,161.17 0.00 0.00 58561 S 931.52 0.00 0.00<br />

57289 S 970.44 0.00 0.00 58562 S 653.31 0.00 0.00<br />

57291 S 970.44 0.00 0.00 58563 S 1,312.50 0.00 0.00<br />

57300 S 875.32 0.00 0.00 58565 S 1,447.02 0.00 0.00<br />

57320 S 1,281.88 0.00 0.00 58600 S 1,281.88 0.00 0.00<br />

57400 S 581.31 0.00 0.00 58615 S 752.68 0.00 0.00<br />

57410 S 581.31 0.00 0.00 58660 S 1,210.71 0.00 0.00<br />

57415 S 581.31 0.00 0.00 58661 S 1,210.71 0.00 0.00<br />

57420 S 43.52 0.00 0.00 58662 S 1,210.71 0.00 0.00<br />

57421 S 56.77 0.00 0.00 58670 S 1,115.59 0.00 0.00<br />

57452 S 41.14 0.00 0.00 58671 S 1,115.59 0.00 0.00<br />

57454 S 50.32 0.00 0.00 58672 S 1,210.71 0.00 0.00<br />

57455 S 53.37 0.00 0.00 58673 S 1,210.71 0.00 0.00<br />

57456 S 51.67 0.00 0.00 58800 S 610.72 0.00 0.00<br />

57460 S 158.76 0.00 0.00 58805 S 1,281.88 0.00 0.00<br />

57461 S 168.62 0.00 0.00 58820 S 875.32 0.00 0.00<br />

57500 S 72.75 0.00 0.00 58900 S 610.72 0.00 0.00<br />

57505 S 46.23 0.00 0.00 58970 S 170.11 0.00 0.00<br />

57510 S 46.91 0.00 0.00 58974 S 170.11 0.00 0.00<br />

57511 S 54.13 0.00 0.00 58976 S 170.11 0.00 0.00<br />

57513 S 581.31 0.00 0.00 59000 S 62.21 0.00 0.00<br />

57520 S 581.31 0.00 0.00 59001 S 233.52 0.00 0.00<br />

57522 S 581.31 0.00 0.00 59012 S 114.19 0.00 0.00<br />

57530 S 875.32 0.00 0.00 59015 S 50.32 0.00 0.00<br />

57550 S 875.32 0.00 0.00 59020 TC S 26.52 0.00 0.00<br />

57556 S 1,161.17 0.00 0.00 59025 TC S 13.94 0.00 0.00<br />

57558 S 610.72 0.00 0.00 59070 S 114.19 0.00 0.00<br />

57700 S 529.37 0.00 0.00 59072 S 114.19 0.00 0.00<br />

57720 S 610.72 0.00 0.00 59076 S 114.19 0.00 0.00<br />

57800 S 24.82 0.00 0.00 59100 S 1,281.88 0.00 0.00<br />

58100 S 40.80 0.00 0.00 59150 S 1,762.41 0.00 0.00<br />

58120 S 581.31 0.00 0.00 59151 S 1,762.41 0.00 0.00<br />

58145 S 970.44 0.00 0.00 59160 S 610.72 0.00 0.00<br />

58301 S 38.07 0.00 0.00 59200 S 34.00 0.00 0.00<br />

58321 S 35.70 0.00 0.00 59300 S 73.43 0.00 0.00<br />

58322 S 36.71 0.00 0.00 59320 S 529.37 0.00 0.00<br />

58323 S 8.50 0.00 0.00 59412 S 752.68 0.00 0.00<br />

58345 S 752.68 0.00 0.00 59414 S 752.68 0.00 0.00<br />

58346 S 581.31 0.00 0.00 59812 S 705.85 0.00 0.00<br />

58350 S 875.32 0.00 0.00 59820 S 705.85 0.00 0.00<br />

58353 S 1,098.20 0.00 0.00 59821 S 705.85 0.00 0.00<br />

58356 S 1,663.33 0.00 0.00 59840 S 705.85 0.00 0.00<br />

58545 S 1,336.11 0.00 0.00 59841 S 705.85 0.00 0.00<br />

58546 S 1,496.56 0.00 0.00 59866 S 114.19 0.00 0.00<br />

58550 S 1,945.49 0.00 0.00 59870 S 705.85 0.00 0.00<br />

58552 S 1,762.41 0.00 0.00 59871 S 705.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 296.33 0.00 0.00 62367 S 16.32 0.00 0.00<br />

60100 S 46.57 0.00 0.00 62368 S 20.74 0.00 0.00<br />

60200 S 1,102.96 0.00 0.00 63600 S 557.10 0.00 0.00<br />

60280 S 1,187.53 0.00 0.00 63610 S 505.16 0.00 0.00<br />

60281 S 1,187.53 0.00 0.00 63615 S 704.25 0.00 0.00<br />

60300 S 61.19 0.00 0.00 63650 S 2,998.55 1,859.40 720.26<br />

61000 S 272.86 0.00 0.00 63655 S 4,392.15 2,800.88 1,209.62<br />

61001 S 272.86 0.00 0.00 63660 S 526.60 0.00 0.00<br />

61020 S 220.92 0.00 0.00 63685 S 13,331.18 7,108.31 885.44<br />

61026 S 220.92 0.00 0.00 63688 S 715.08 0.00 0.00<br />

61050 S 220.92 0.00 0.00 63744 S 1,034.12 0.00 0.00<br />

61055 S 220.92 0.00 0.00 63746 S 478.36 0.00 0.00<br />

61070 S 171.90 0.00 0.00 64400 S 52.35 0.00 0.00<br />

61215 S 1,034.12 0.00 0.00 64402 S 49.30 0.00 0.00<br />

61330 S 1,593.12 0.00 0.00 64405 S 41.81 0.00 0.00<br />

61334 S 1,593.12 0.00 0.00 64408 S 52.01 0.00 0.00<br />

61790 S 586.50 0.00 0.00 64410 S 289.46 0.00 0.00<br />

61791 S 435.12 0.00 0.00 64412 S 76.49 0.00 0.00<br />

61880 S 747.13 0.00 0.00 64413 S 48.96 0.00 0.00<br />

61885 S 10,751.37 5,759.41 767.45 64415 S 133.31 0.00 0.00<br />

61886 S 16,054.42 8,461.61 868.80 64416 S 272.86 0.00 0.00<br />

61888 S 715.08 0.00 0.00 64417 S 133.31 0.00 0.00<br />

62194 S 289.46 0.00 0.00 64418 S 68.67 0.00 0.00<br />

62225 S 449.78 0.00 0.00 64420 S 133.31 0.00 0.00<br />

62230 S 1,004.70 0.00 0.00 64421 S 289.46 0.00 0.00<br />

62252 TC S 45.56 0.00 0.00 64425 S 47.59 0.00 0.00<br />

62263 S 289.46 0.00 0.00 64430 S 200.31 0.00 0.00<br />

62264 S 426.42 0.00 0.00 64435 S 71.73 0.00 0.00<br />

62267 S 170.17 0.00 0.00 64445 S 63.57 0.00 0.00<br />

62268 S 220.92 0.00 0.00 64446 S 546.78 0.00 0.00<br />

62269 S 335.25 0.00 0.00 64447 S 138.86 0.00 0.00<br />

62270 S 133.31 0.00 0.00 64448 S 138.86 0.00 0.00<br />

62272 S 133.31 0.00 0.00 64449 S 272.86 0.00 0.00<br />

62273 S 222.46 0.00 0.00 64450 S 42.49 0.00 0.00<br />

62280 S 289.46 0.00 0.00 64455 S 17.67 0.00 0.00<br />

62281 S 289.46 0.00 0.00 64470 S 289.46 0.00 0.00<br />

62282 S 289.46 0.00 0.00 64472 S 222.46 0.00 0.00<br />

62287 S 1,299.42 0.00 0.00 64475 S 289.46 0.00 0.00<br />

62292 S 272.86 0.00 0.00 64476 S 200.35 0.00 0.00<br />

62294 S 220.92 0.00 0.00 64479 S 289.46 0.00 0.00<br />

62310 S 289.46 0.00 0.00 64480 S 222.46 0.00 0.00<br />

62311 S 289.46 0.00 0.00 64483 S 289.46 0.00 0.00<br />

62318 S 289.46 0.00 0.00 64484 S 222.46 0.00 0.00<br />

62319 S 289.46 0.00 0.00 64505 S 38.76 0.00 0.00<br />

62350 S 1,004.70 0.00 0.00 64508 S 82.27 0.00 0.00<br />

62355 S 478.36 0.00 0.00 64510 S 289.46 0.00 0.00<br />

62360 S 1,004.70 0.00 0.00 64517 S 200.31 0.00 0.00<br />

62361 S 10,313.36 5,582.26 851.16 64520 S 289.46 0.00 0.00<br />

62362 S 10,313.36 5,582.26 851.16 64530 S 289.46 0.00 0.00<br />

62365 S 889.03 0.00 0.00 64553 S 2,946.61 1,807.46 668.32<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,308.87 2,169.72 1,030.58 64746 S 557.10 0.00 0.00<br />

64560 S 3,308.87 2,169.72 1,030.58 64761 S 704.25 0.00 0.00<br />

64561 S 3,027.96 1,888.81 749.67 64763 S 704.25 0.00 0.00<br />

64565 S 3,308.87 2,169.72 1,030.58 64766 S 1,368.13 0.00 0.00<br />

64573 S 5,154.73 3,053.68 952.62 64771 S 557.10 0.00 0.00<br />

64575 S 3,940.37 2,349.10 757.84 64772 S 557.10 0.00 0.00<br />

64577 S 3,940.37 2,349.10 757.84 64774 S 557.10 0.00 0.00<br />

64580 S 3,940.37 2,349.10 757.84 64776 S 586.50 0.00 0.00<br />

64581 S 4,021.72 2,430.45 839.19 64778 S 557.10 0.00 0.00<br />

64585 S 526.60 0.00 0.00 64782 S 586.50 0.00 0.00<br />

64590 S 10,751.37 5,759.41 767.45 64783 S 557.10 0.00 0.00<br />

64595 S 715.08 0.00 0.00 64784 S 586.50 0.00 0.00<br />

64600 S 426.42 0.00 0.00 64786 S 918.44 0.00 0.00<br />

64605 S 426.42 0.00 0.00 64787 S 557.10 0.00 0.00<br />

64610 S 426.42 0.00 0.00 64788 S 586.50 0.00 0.00<br />

64612 S 62.21 0.00 0.00 64790 S 586.50 0.00 0.00<br />

64613 S 60.18 0.00 0.00 64792 S 918.44 0.00 0.00<br />

64614 S 68.67 0.00 0.00 64795 S 557.10 0.00 0.00<br />

64620 S 289.46 0.00 0.00 64802 S 557.10 0.00 0.00<br />

64622 S 426.42 0.00 0.00 64820 S 704.25 0.00 0.00<br />

64623 S 289.46 0.00 0.00 64821 S 822.15 0.00 0.00<br />

64626 S 426.42 0.00 0.00 64822 S 1,065.25 0.00 0.00<br />

64627 S 200.35 0.00 0.00 64823 S 1,065.25 0.00 0.00<br />

64630 S 298.16 0.00 0.00 64831 S 973.59 0.00 0.00<br />

64632 S 32.29 0.00 0.00 64832 S 837.09 0.00 0.00<br />

64640 S 96.21 0.00 0.00 64834 S 889.03 0.00 0.00<br />

64650 S 32.29 0.00 0.00 64835 S 918.44 0.00 0.00<br />

64653 S 35.02 0.00 0.00 64836 S 918.44 0.00 0.00<br />

64680 S 453.06 0.00 0.00 64837 S 837.09 0.00 0.00<br />

64681 S 478.36 0.00 0.00 64840 S 889.03 0.00 0.00<br />

64702 S 505.16 0.00 0.00 64856 S 889.03 0.00 0.00<br />

64704 S 505.16 0.00 0.00 64857 S 889.03 0.00 0.00<br />

64708 S 557.10 0.00 0.00 64858 S 889.03 0.00 0.00<br />

64712 S 557.10 0.00 0.00 64859 S 837.09 0.00 0.00<br />

64713 S 557.10 0.00 0.00 64861 S 918.44 0.00 0.00<br />

64714 S 557.10 0.00 0.00 64862 S 918.44 0.00 0.00<br />

64716 S 586.50 0.00 0.00 64864 S 918.44 0.00 0.00<br />

64718 S 557.10 0.00 0.00 64865 S 973.59 0.00 0.00<br />

64719 S 557.10 0.00 0.00 64870 S 973.59 0.00 0.00<br />

64721 S 557.10 0.00 0.00 64872 S 889.03 0.00 0.00<br />

64722 S 505.16 0.00 0.00 64874 S 918.44 0.00 0.00<br />

64726 S 505.16 0.00 0.00 64876 S 918.44 0.00 0.00<br />

64727 S 505.16 0.00 0.00 64885 S 889.03 0.00 0.00<br />

64732 S 557.10 0.00 0.00 64886 S 889.03 0.00 0.00<br />

64734 S 557.10 0.00 0.00 64890 S 889.03 0.00 0.00<br />

64736 S 557.10 0.00 0.00 64891 S 889.03 0.00 0.00<br />

64738 S 557.10 0.00 0.00 64892 S 889.03 0.00 0.00<br />

64740 S 557.10 0.00 0.00 64893 S 889.03 0.00 0.00<br />

64742 S 557.10 0.00 0.00 64895 S 918.44 0.00 0.00<br />

64744 S 557.10 0.00 0.00 64896 S 918.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 918.44 0.00 0.00 65770 S 5,404.72 0.00 0.00<br />

64898 S 918.44 0.00 0.00 65772 S 607.99 0.00 0.00<br />

64901 S 889.03 0.00 0.00 65775 S 607.99 0.00 0.00<br />

64902 S 889.03 0.00 0.00 65780 S 1,051.73 0.00 0.00<br />

64905 S 889.03 0.00 0.00 65781 S 1,051.73 0.00 0.00<br />

64907 S 837.09 0.00 0.00 65782 S 1,051.73 0.00 0.00<br />

64910 S 1,368.13 0.00 0.00 65800 S 471.50 0.00 0.00<br />

65091 S 967.07 0.00 0.00 65805 S 471.50 0.00 0.00<br />

65093 S 967.07 0.00 0.00 65810 S 688.96 0.00 0.00<br />

65101 S 967.07 0.00 0.00 65815 S 659.54 0.00 0.00<br />

65103 S 967.07 0.00 0.00 65820 S 241.89 0.00 0.00<br />

65105 S 1,022.22 0.00 0.00 65850 S 744.10 0.00 0.00<br />

65110 S 1,062.20 0.00 0.00 65855 S 128.50 0.00 0.00<br />

65112 S 1,189.96 0.00 0.00 65860 S 120.01 0.00 0.00<br />

65114 S 1,189.96 0.00 0.00 65865 S 471.50 0.00 0.00<br />

65125 S 990.33 0.00 0.00 65870 S 744.10 0.00 0.00<br />

65130 S 729.54 0.00 0.00 65875 S 744.10 0.00 0.00<br />

65135 S 700.14 0.00 0.00 65880 S 607.99 0.00 0.00<br />

65140 S 967.07 0.00 0.00 65900 S 647.97 0.00 0.00<br />

65150 S 700.14 0.00 0.00 65920 S 911.84 0.00 0.00<br />

65155 S 967.07 0.00 0.00 65930 S 784.08 0.00 0.00<br />

65175 S 520.44 0.00 0.00 66020 S 471.50 0.00 0.00<br />

65205 S 20.06 0.00 0.00 66030 S 241.89 0.00 0.00<br />

65210 S 25.50 0.00 0.00 66130 S 911.84 0.00 0.00<br />

65220 S 35.53 0.00 0.00 66150 S 744.10 0.00 0.00<br />

65222 S 27.87 0.00 0.00 66155 S 744.10 0.00 0.00<br />

65235 S 523.43 0.00 0.00 66160 S 659.54 0.00 0.00<br />

65260 S 345.24 0.00 0.00 66165 S 744.10 0.00 0.00<br />

65265 S 714.25 0.00 0.00 66170 S 744.10 0.00 0.00<br />

65270 S 572.37 0.00 0.00 66172 S 744.10 0.00 0.00<br />

65272 S 659.54 0.00 0.00 66180 S 1,108.55 0.00 0.00<br />

65275 S 744.10 0.00 0.00 66185 S 984.02 0.00 0.00<br />

65280 S 714.25 0.00 0.00 66220 S 960.58 0.00 0.00<br />

65285 S 1,015.72 0.00 0.00 66225 S 1,068.58 0.00 0.00<br />

65286 S 177.70 0.00 0.00 66250 S 523.43 0.00 0.00<br />

65290 S 703.40 0.00 0.00 66500 S 241.89 0.00 0.00<br />

65400 S 471.50 0.00 0.00 66505 S 241.89 0.00 0.00<br />

65410 S 523.43 0.00 0.00 66600 S 688.96 0.00 0.00<br />

65420 S 523.43 0.00 0.00 66605 S 688.96 0.00 0.00<br />

65426 S 784.08 0.00 0.00 66625 S 489.85 0.00 0.00<br />

65430 S 35.53 0.00 0.00 66630 S 688.96 0.00 0.00<br />

65435 S 30.94 0.00 0.00 66635 S 688.96 0.00 0.00<br />

65436 S 134.28 0.00 0.00 66680 S 688.96 0.00 0.00<br />

65450 S 81.98 0.00 0.00 66682 S 659.54 0.00 0.00<br />

65600 S 158.42 0.00 0.00 66700 S 523.43 0.00 0.00<br />

65710 S 1,179.49 0.00 0.00 66710 S 523.43 0.00 0.00<br />

65730 S 1,179.49 0.00 0.00 66711 S 523.43 0.00 0.00<br />

65750 S 1,179.49 0.00 0.00 66720 S 523.43 0.00 0.00<br />

65755 S 1,179.49 0.00 0.00 66740 S 659.54 0.00 0.00<br />

65756 S 1,444.45 0.00 0.00 66761 S 178.82 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 181.88 0.00 0.00 67228 S 200.30 0.00 0.00<br />

66770 S 200.30 0.00 0.00 67229 S 200.30 0.00 0.00<br />

66820 S 177.70 0.00 0.00 67250 S 601.78 0.00 0.00<br />

66821 S 243.76 0.00 0.00 67255 S 659.10 0.00 0.00<br />

66825 S 744.10 0.00 0.00 67311 S 703.40 0.00 0.00<br />

66830 S 260.24 0.00 0.00 67312 S 758.55 0.00 0.00<br />

66840 S 559.42 0.00 0.00 67314 S 758.55 0.00 0.00<br />

66850 S 1,053.26 0.00 0.00 67316 S 758.55 0.00 0.00<br />

66852 S 885.52 0.00 0.00 67318 S 758.55 0.00 0.00<br />

66920 S 885.52 0.00 0.00 67320 S 758.55 0.00 0.00<br />

66930 S 925.50 0.00 0.00 67331 S 758.55 0.00 0.00<br />

66940 S 599.41 0.00 0.00 67332 S 758.55 0.00 0.00<br />

66982 S 909.33 0.00 0.00 67334 S 758.55 0.00 0.00<br />

66983 S 909.33 0.00 0.00 67335 S 758.55 0.00 0.00<br />

66984 S 909.33 0.00 0.00 67340 S 758.55 0.00 0.00<br />

66985 S 841.77 0.00 0.00 67343 S 926.28 0.00 0.00<br />

66986 S 841.77 0.00 0.00 67345 S 79.22 0.00 0.00<br />

67005 S 714.25 0.00 0.00 67346 S 428.45 0.00 0.00<br />

67010 S 714.25 0.00 0.00 67400 S 601.78 0.00 0.00<br />

67015 S 879.23 0.00 0.00 67405 S 784.70 0.00 0.00<br />

67025 S 577.76 0.00 0.00 67412 S 696.91 0.00 0.00<br />

67027 S 1,015.72 0.00 0.00 67413 S 824.67 0.00 0.00<br />

67028 S 79.89 0.00 0.00 67414 S 1,465.38 0.00 0.00<br />

67030 S 577.76 0.00 0.00 67415 S 520.44 0.00 0.00<br />

67031 S 243.76 0.00 0.00 67420 S 1,062.20 0.00 0.00<br />

67036 S 1,015.72 0.00 0.00 67430 S 1,062.20 0.00 0.00<br />

67039 S 1,183.46 0.00 0.00 67440 S 1,062.20 0.00 0.00<br />

67040 S 1,183.46 0.00 0.00 67445 S 1,062.20 0.00 0.00<br />

67041 S 1,452.39 0.00 0.00 67450 S 1,062.20 0.00 0.00<br />

67042 S 1,452.39 0.00 0.00 67500 S 81.98 0.00 0.00<br />

67043 S 1,452.39 0.00 0.00 67505 S 25.50 0.00 0.00<br />

67101 S 221.72 0.00 0.00 67515 S 25.84 0.00 0.00<br />

67105 S 200.30 0.00 0.00 67550 S 1,022.22 0.00 0.00<br />

67107 S 1,055.70 0.00 0.00 67560 S 700.14 0.00 0.00<br />

67108 S 1,183.46 0.00 0.00 67570 S 1,022.22 0.00 0.00<br />

67110 S 322.28 0.00 0.00 67700 S 119.94 0.00 0.00<br />

67112 S 1,183.46 0.00 0.00 67710 S 140.06 0.00 0.00<br />

67113 S 1,452.39 0.00 0.00 67715 S 520.44 0.00 0.00<br />

67115 S 629.69 0.00 0.00 67800 S 50.32 0.00 0.00<br />

67120 S 629.69 0.00 0.00 67801 S 60.85 0.00 0.00<br />

67121 S 629.69 0.00 0.00 67805 S 78.87 0.00 0.00<br />

67141 S 221.96 0.00 0.00 67808 S 572.37 0.00 0.00<br />

67145 S 189.36 0.00 0.00 67810 S 119.94 0.00 0.00<br />

67208 S 201.94 0.00 0.00 67820 S 16.66 0.00 0.00<br />

67210 S 200.30 0.00 0.00 67825 S 51.33 0.00 0.00<br />

67218 S 754.23 0.00 0.00 67830 S 351.39 0.00 0.00<br />

67220 S 221.72 0.00 0.00 67835 S 572.37 0.00 0.00<br />

67221 S 113.88 0.00 0.00 67840 S 146.87 0.00 0.00<br />

67225 S 7.82 0.00 0.00 67850 S 116.61 0.00 0.00<br />

67227 S 577.76 0.00 0.00 67875 S 292.85 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 552.84 0.00 0.00 68440 S 49.98 0.00 0.00<br />

67882 S 601.78 0.00 0.00 68500 S 729.54 0.00 0.00<br />

67900 S 784.70 0.00 0.00 68505 S 729.54 0.00 0.00<br />

67901 S 696.91 0.00 0.00 68510 S 520.44 0.00 0.00<br />

67902 S 824.67 0.00 0.00 68520 S 729.54 0.00 0.00<br />

67903 S 656.93 0.00 0.00 68525 S 520.44 0.00 0.00<br />

67904 S 656.93 0.00 0.00 68530 S 119.94 0.00 0.00<br />

67906 S 696.91 0.00 0.00 68540 S 601.78 0.00 0.00<br />

67908 S 656.93 0.00 0.00 68550 S 729.54 0.00 0.00<br />

67909 S 656.93 0.00 0.00 68700 S 572.37 0.00 0.00<br />

67911 S 601.78 0.00 0.00 68705 S 113.88 0.00 0.00<br />

67912 S 601.78 0.00 0.00 68720 S 784.70 0.00 0.00<br />

67914 S 601.78 0.00 0.00 68745 S 784.70 0.00 0.00<br />

67915 S 162.50 0.00 0.00 68750 S 784.70 0.00 0.00<br />

67916 S 656.93 0.00 0.00 68760 S 96.89 0.00 0.00<br />

67917 S 656.93 0.00 0.00 68761 S 66.97 0.00 0.00<br />

67921 S 601.78 0.00 0.00 68770 S 784.70 0.00 0.00<br />

67922 S 158.08 0.00 0.00 68801 S 35.53 0.00 0.00<br />

67923 S 656.93 0.00 0.00 68810 S 101.59 0.00 0.00<br />

67924 S 656.93 0.00 0.00 68811 S 572.37 0.00 0.00<br />

67930 S 162.50 0.00 0.00 68815 S 572.37 0.00 0.00<br />

67935 S 572.37 0.00 0.00 68816 S 734.80 0.00 0.00<br />

67938 S 81.98 0.00 0.00 68840 S 52.69 0.00 0.00<br />

67950 S 572.37 0.00 0.00 69000 S 53.75 0.00 0.00<br />

67961 S 601.78 0.00 0.00 69005 S 101.65 0.00 0.00<br />

67966 S 601.78 0.00 0.00 69020 S 53.75 0.00 0.00<br />

67971 S 601.78 0.00 0.00 69100 S 61.19 0.00 0.00<br />

67973 S 729.54 0.00 0.00 69105 S 86.69 0.00 0.00<br />

67974 S 601.78 0.00 0.00 69110 S 455.45 0.00 0.00<br />

67975 S 601.78 0.00 0.00 69120 S 675.88 0.00 0.00<br />

68020 S 44.54 0.00 0.00 69140 S 675.88 0.00 0.00<br />

68040 S 22.09 0.00 0.00 69145 S 507.37 0.00 0.00<br />

68100 S 88.39 0.00 0.00 69150 S 356.60 0.00 0.00<br />

68110 S 113.88 0.00 0.00 69200 S 24.58 0.00 0.00<br />

68115 S 572.37 0.00 0.00 69205 S 568.55 0.00 0.00<br />

68130 S 523.43 0.00 0.00 69210 S 20.06 0.00 0.00<br />

68135 S 57.11 0.00 0.00 69220 S 31.50 0.00 0.00<br />

68200 S 16.32 0.00 0.00 69222 S 132.59 0.00 0.00<br />

68320 S 784.70 0.00 0.00 69300 S 705.30 0.00 0.00<br />

68325 S 784.70 0.00 0.00 69310 S 1,030.94 0.00 0.00<br />

68326 S 656.93 0.00 0.00 69320 S 1,253.83 0.00 0.00<br />

68328 S 784.70 0.00 0.00 69400 S 89.07 0.00 0.00<br />

68330 S 744.10 0.00 0.00 69401 S 46.91 0.00 0.00<br />

68335 S 784.70 0.00 0.00 69405 S 123.07 0.00 0.00<br />

68340 S 656.93 0.00 0.00 69420 S 110.49 0.00 0.00<br />

68360 S 659.54 0.00 0.00 69421 S 562.34 0.00 0.00<br />

68362 S 659.54 0.00 0.00 69424 S 77.51 0.00 0.00<br />

68371 S 523.43 0.00 0.00 69433 S 110.15 0.00 0.00<br />

68400 S 119.94 0.00 0.00 69436 S 562.34 0.00 0.00<br />

68420 S 170.66 0.00 0.00 69440 S 705.30 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 949.59 0.00 0.00 69840 S 1,126.07 0.00 0.00<br />

69501 S 1,253.83 0.00 0.00 69905 S 1,253.83 0.00 0.00<br />

69502 S 928.19 0.00 0.00 69910 S 1,253.83 0.00 0.00<br />

69505 S 1,253.83 0.00 0.00 69915 S 1,253.83 0.00 0.00<br />

69511 S 1,253.83 0.00 0.00 69930 S 22,667.49 12,170.91 1,674.33<br />

69530 S 1,253.83 0.00 0.00 70030 TC A 17.33 0.00 0.00<br />

69540 S 129.52 0.00 0.00 70100 TC A 19.04 0.00 0.00<br />

69550 S 1,126.07 0.00 0.00 70110 TC A 23.46 0.00 0.00<br />

69552 S 1,253.83 0.00 0.00 70120 TC A 21.08 0.00 0.00<br />

69601 S 1,253.83 0.00 0.00 70130 TC A 25.75 0.00 0.00<br />

69602 S 1,253.83 0.00 0.00 70134 TC A 25.84 0.00 0.00<br />

69603 S 1,253.83 0.00 0.00 70140 TC A 17.67 0.00 0.00<br />

69604 S 1,253.83 0.00 0.00 70150 TC A 25.75 0.00 0.00<br />

69605 S 1,253.83 0.00 0.00 70160 TC A 20.74 0.00 0.00<br />

69610 S 173.38 0.00 0.00 70190 TC A 21.76 0.00 0.00<br />

69620 S 675.88 0.00 0.00 70200 TC A 25.75 0.00 0.00<br />

69631 S 1,126.07 0.00 0.00 70210 TC A 18.36 0.00 0.00<br />

69632 S 1,126.07 0.00 0.00 70220 TC A 23.12 0.00 0.00<br />

69633 S 1,126.07 0.00 0.00 70240 TC A 17.33 0.00 0.00<br />

69635 S 1,253.83 0.00 0.00 70250 TC A 21.08 0.00 0.00<br />

69636 S 1,253.83 0.00 0.00 70260 TC A 26.85 0.00 0.00<br />

69637 S 1,253.83 0.00 0.00 70300 TC A 7.47 0.00 0.00<br />

69641 S 1,253.83 0.00 0.00 70310 TC A 18.47 0.00 0.00<br />

69642 S 1,253.83 0.00 0.00 70320 TC A 18.47 0.00 0.00<br />

69643 S 1,253.83 0.00 0.00 70328 TC A 18.36 0.00 0.00<br />

69644 S 1,253.83 0.00 0.00 70330 TC A 25.75 0.00 0.00<br />

69645 S 1,253.83 0.00 0.00 70336 TC A 200.45 0.00 0.00<br />

69646 S 1,253.83 0.00 0.00 70350 TC A 10.20 0.00 0.00<br />

69650 S 928.19 0.00 0.00 70355 TC A 10.54 0.00 0.00<br />

69660 S 1,126.07 0.00 0.00 70360 TC A 16.32 0.00 0.00<br />

69661 S 1,126.07 0.00 0.00 70370 TC A 47.92 0.00 0.00<br />

69662 S 1,126.07 0.00 0.00 70371 TC A 47.92 0.00 0.00<br />

69666 S 1,086.08 0.00 0.00 70380 TC A 24.82 0.00 0.00<br />

69667 S 1,086.08 0.00 0.00 70450 TC A 111.95 0.00 0.00<br />

69670 S 1,030.94 0.00 0.00 70460 TC A 177.27 0.00 0.00<br />

69676 S 1,030.94 0.00 0.00 70470 TC A 196.37 0.00 0.00<br />

69700 S 1,030.94 0.00 0.00 70480 TC A 111.95 0.00 0.00<br />

69711 S 949.59 0.00 0.00 70481 TC A 177.27 0.00 0.00<br />

69714 S 6,022.16 3,797.20 1,572.24 70482 TC A 196.37 0.00 0.00<br />

69715 S 6,022.16 3,797.20 1,572.24 70486 TC A 111.95 0.00 0.00<br />

69717 S 6,022.16 3,797.20 1,572.24 70487 TC A 177.27 0.00 0.00<br />

69718 S 6,022.16 3,797.20 1,572.24 70488 TC A 196.37 0.00 0.00<br />

69720 S 1,126.07 0.00 0.00 70490 TC A 111.95 0.00 0.00<br />

69740 S 1,126.07 0.00 0.00 70491 TC A 177.27 0.00 0.00<br />

69745 S 1,126.07 0.00 0.00 70492 TC A 196.37 0.00 0.00<br />

69801 S 1,126.07 0.00 0.00 70496 TC A 202.65 0.00 0.00<br />

69802 S 1,253.83 0.00 0.00 70498 TC A 202.65 0.00 0.00<br />

69805 S 1,253.83 0.00 0.00 70540 TC A 200.45 0.00 0.00<br />

69806 S 1,253.83 0.00 0.00 70542 TC A 246.16 0.00 0.00<br />

69820 S 1,126.07 0.00 0.00 70543 TC A 310.25 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 200.45 0.00 0.00 72120 TC A 32.63 0.00 0.00<br />

70545 TC A 246.16 0.00 0.00 72125 TC A 111.95 0.00 0.00<br />

70546 TC A 310.25 0.00 0.00 72126 TC A 177.27 0.00 0.00<br />

70547 TC A 200.45 0.00 0.00 72127 TC A 196.37 0.00 0.00<br />

70548 TC A 246.16 0.00 0.00 72128 TC A 111.95 0.00 0.00<br />

70549 TC A 310.25 0.00 0.00 72129 TC A 177.27 0.00 0.00<br />

70551 TC A 200.45 0.00 0.00 72130 TC A 196.37 0.00 0.00<br />

70552 TC A 246.16 0.00 0.00 72131 TC A 111.95 0.00 0.00<br />

70553 TC A 310.25 0.00 0.00 72132 TC A 177.27 0.00 0.00<br />

70554 TC A 200.45 0.00 0.00 72133 TC A 196.37 0.00 0.00<br />

70555 TC A 200.45 0.00 0.00 72141 TC A 200.45 0.00 0.00<br />

70557 TC A 200.45 0.00 0.00 72142 TC A 246.16 0.00 0.00<br />

70558 TC A 246.16 0.00 0.00 72146 TC A 200.45 0.00 0.00<br />

70559 TC A 310.25 0.00 0.00 72147 TC A 246.16 0.00 0.00<br />

71010 TC A 13.26 0.00 0.00 72148 TC A 200.45 0.00 0.00<br />

71015 TC A 17.00 0.00 0.00 72149 TC A 246.16 0.00 0.00<br />

71020 TC A 18.02 0.00 0.00 72156 TC A 310.25 0.00 0.00<br />

71021 TC A 21.76 0.00 0.00 72157 TC A 310.25 0.00 0.00<br />

71022 TC A 25.75 0.00 0.00 72158 TC A 310.25 0.00 0.00<br />

71023 TC A 42.15 0.00 0.00 72170 TC A 15.30 0.00 0.00<br />

71030 TC A 25.75 0.00 0.00 72190 TC A 25.75 0.00 0.00<br />

71034 TC A 47.92 0.00 0.00 72191 TC A 202.65 0.00 0.00<br />

71035 TC A 22.43 0.00 0.00 72192 TC A 111.95 0.00 0.00<br />

71100 TC A 18.70 0.00 0.00 72193 TC A 177.27 0.00 0.00<br />

71101 TC A 22.77 0.00 0.00 72194 TC A 196.37 0.00 0.00<br />

71110 TC A 23.80 0.00 0.00 72195 TC A 200.45 0.00 0.00<br />

71111 TC A 31.61 0.00 0.00 72196 TC A 246.16 0.00 0.00<br />

71120 TC A 19.72 0.00 0.00 72197 TC A 310.25 0.00 0.00<br />

71130 TC A 23.12 0.00 0.00 72200 TC A 18.02 0.00 0.00<br />

71250 TC A 111.95 0.00 0.00 72202 TC A 22.09 0.00 0.00<br />

71260 TC A 177.27 0.00 0.00 72220 TC A 18.02 0.00 0.00<br />

71270 TC A 196.37 0.00 0.00 73000 TC A 17.00 0.00 0.00<br />

71275 TC A 202.65 0.00 0.00 73010 TC A 17.33 0.00 0.00<br />

71550 TC A 200.45 0.00 0.00 73020 TC A 13.94 0.00 0.00<br />

71551 TC A 246.16 0.00 0.00 73030 TC A 17.67 0.00 0.00<br />

71552 TC A 310.25 0.00 0.00 73050 TC A 22.09 0.00 0.00<br />

72010 TC A 42.87 0.00 0.00 73060 TC A 17.67 0.00 0.00<br />

72020 TC A 13.94 0.00 0.00 73070 TC A 17.00 0.00 0.00<br />

72040 TC A 22.43 0.00 0.00 73080 TC A 22.43 0.00 0.00<br />

72050 TC A 31.95 0.00 0.00 73090 TC A 17.00 0.00 0.00<br />

72052 TC A 42.87 0.00 0.00 73092 TC A 17.67 0.00 0.00<br />

72069 TC A 21.08 0.00 0.00 73100 TC A 17.67 0.00 0.00<br />

72070 TC A 19.72 0.00 0.00 73110 TC A 22.43 0.00 0.00<br />

72072 TC A 23.80 0.00 0.00 73120 TC A 16.66 0.00 0.00<br />

72074 TC A 25.75 0.00 0.00 73130 TC A 19.72 0.00 0.00<br />

72080 TC A 21.08 0.00 0.00 73140 TC A 19.38 0.00 0.00<br />

72090 TC A 28.22 0.00 0.00 73200 TC A 111.95 0.00 0.00<br />

72100 TC A 24.14 0.00 0.00 73201 TC A 177.27 0.00 0.00<br />

72110 TC A 33.66 0.00 0.00 73202 TC A 196.37 0.00 0.00<br />

72114 TC A 42.87 0.00 0.00 73206 TC A 202.65 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 200.45 0.00 0.00 74246 TC A 50.59 0.00 0.00<br />

73219 TC A 246.16 0.00 0.00 74247 TC A 50.59 0.00 0.00<br />

73220 TC A 310.25 0.00 0.00 74249 TC A 82.26 0.00 0.00<br />

73221 TC A 200.45 0.00 0.00 74250 TC A 50.59 0.00 0.00<br />

73222 TC A 246.16 0.00 0.00 74251 TC A 82.26 0.00 0.00<br />

73223 TC A 310.25 0.00 0.00 74260 TC A 50.59 0.00 0.00<br />

73500 TC A 14.62 0.00 0.00 74270 TC A 50.59 0.00 0.00<br />

73510 TC A 22.43 0.00 0.00 74280 TC A 82.26 0.00 0.00<br />

73520 TC A 23.12 0.00 0.00 74283 TC A 50.59 0.00 0.00<br />

73540 TC A 23.12 0.00 0.00 74290 TC A 43.17 0.00 0.00<br />

73550 TC A 17.00 0.00 0.00 74291 TC A 41.47 0.00 0.00<br />

73560 TC A 17.33 0.00 0.00 74400 TC A 75.13 0.00 0.00<br />

73562 TC A 21.42 0.00 0.00 74410 TC A 80.23 0.00 0.00<br />

73564 TC A 24.82 0.00 0.00 74415 TC A 95.87 0.00 0.00<br />

73565 TC A 18.70 0.00 0.00 74420 TC A 100.21 0.00 0.00<br />

73590 TC A 16.32 0.00 0.00 74710 TC A 22.43 0.00 0.00<br />

73592 TC A 17.67 0.00 0.00 74775 TC A 100.21 0.00 0.00<br />

73600 TC A 16.66 0.00 0.00 75557 TC A 200.45 0.00 0.00<br />

73610 TC A 19.72 0.00 0.00 75559 TC A 200.45 0.00 0.00<br />

73620 TC A 15.98 0.00 0.00 75561 TC A 310.25 0.00 0.00<br />

73630 TC A 19.38 0.00 0.00 75563 TC A 310.25 0.00 0.00<br />

73650 TC A 16.32 0.00 0.00 76010 TC A 16.66 0.00 0.00<br />

73660 TC A 18.36 0.00 0.00 76098 TC A 10.20 0.00 0.00<br />

73700 TC A 111.95 0.00 0.00 76100 TC A 42.87 0.00 0.00<br />

73701 TC A 177.27 0.00 0.00 76101 TC A 114.90 0.00 0.00<br />

73702 TC A 196.37 0.00 0.00 76102 TC A 114.90 0.00 0.00<br />

73706 TC A 202.65 0.00 0.00 76120 TC A 47.92 0.00 0.00<br />

73718 TC A 200.45 0.00 0.00 76150 A 16.66 0.00 0.00<br />

73719 TC A 246.16 0.00 0.00 76380 TC A 60.48 0.00 0.00<br />

73720 TC A 310.25 0.00 0.00 76496 TC A 47.92 0.00 0.00<br />

73721 TC A 200.45 0.00 0.00 76497 TC A 60.48 0.00 0.00<br />

73722 TC A 246.16 0.00 0.00 76498 TC A 200.45 0.00 0.00<br />

73723 TC A 310.25 0.00 0.00 76499 TC A 25.75 0.00 0.00<br />

74000 TC A 14.62 0.00 0.00 76506 TC A 36.00 0.00 0.00<br />

74010 TC A 22.77 0.00 0.00 76510 TC A 61.19 0.00 0.00<br />

74020 TC A 23.12 0.00 0.00 76511 TC A 42.83 0.00 0.00<br />

74022 TC A 28.22 0.00 0.00 76512 TC A 36.37 0.00 0.00<br />

74150 TC A 111.95 0.00 0.00 76513 TC A 44.20 0.00 0.00<br />

74160 TC A 177.27 0.00 0.00 76514 TC A 3.06 0.00 0.00<br />

74170 TC A 196.37 0.00 0.00 76516 TC A 34.68 0.00 0.00<br />

74175 TC A 202.65 0.00 0.00 76519 TC A 38.76 0.00 0.00<br />

74181 TC A 200.45 0.00 0.00 76529 TC A 33.66 0.00 0.00<br />

74182 TC A 246.16 0.00 0.00 76536 TC A 56.31 0.00 0.00<br />

74183 TC A 310.25 0.00 0.00 76604 TC A 36.00 0.00 0.00<br />

74210 TC A 50.59 0.00 0.00 76645 TC A 36.00 0.00 0.00<br />

74220 TC A 50.59 0.00 0.00 76700 TC A 56.31 0.00 0.00<br />

74230 TC A 50.59 0.00 0.00 76705 TC A 56.31 0.00 0.00<br />

74240 TC A 50.59 0.00 0.00 76770 TC A 56.31 0.00 0.00<br />

74241 TC A 50.59 0.00 0.00 76775 TC A 56.31 0.00 0.00<br />

74245 TC A 82.26 0.00 0.00 76776 TC A 56.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 56.31 0.00 0.00 77290 TC A 147.26 0.00 0.00<br />

76801 TC A 56.31 0.00 0.00 77295 TC A 385.86 0.00 0.00<br />

76802 TC A 26.85 0.00 0.00 77299 TC A 66.07 0.00 0.00<br />

76805 TC A 56.31 0.00 0.00 77300 TC A 35.70 0.00 0.00<br />

76810 TC A 42.49 0.00 0.00 77301 TC A 514.24 0.00 0.00<br />

76811 TC A 88.22 0.00 0.00 77305 TC A 32.63 0.00 0.00<br />

76812 TC A 36.00 0.00 0.00 77310 TC A 42.49 0.00 0.00<br />

76813 TC A 36.00 0.00 0.00 77315 TC A 61.87 0.00 0.00<br />

76814 TC A 28.56 0.00 0.00 77321 TC A 64.26 0.00 0.00<br />

76815 TC A 36.00 0.00 0.00 77326 TC A 66.07 0.00 0.00<br />

76816 TC A 36.00 0.00 0.00 77327 TC A 120.01 0.00 0.00<br />

76817 TC A 36.00 0.00 0.00 77328 TC A 147.26 0.00 0.00<br />

76818 TC A 56.31 0.00 0.00 77331 TC A 17.00 0.00 0.00<br />

76819 TC A 48.62 0.00 0.00 77332 TC A 45.56 0.00 0.00<br />

76820 TC A 24.14 0.00 0.00 77333 TC A 22.09 0.00 0.00<br />

76821 TC A 54.51 0.00 0.00 77334 TC A 85.33 0.00 0.00<br />

76825 TC A 113.55 0.00 0.00 77336 A 53.72 0.00 0.00<br />

76826 TC A 67.65 0.00 0.00 77370 A 66.07 0.00 0.00<br />

76827 TC A 36.00 0.00 0.00 77371 A 4,401.09 0.00 0.00<br />

76828 TC A 21.42 0.00 0.00 77399 TC A 66.07 0.00 0.00<br />

76830 TC A 56.31 0.00 0.00 77401 A 26.85 0.00 0.00<br />

76831 TC A 75.81 0.00 0.00 77402 A 54.07 0.00 0.00<br />

76856 TC A 56.31 0.00 0.00 77403 A 54.07 0.00 0.00<br />

76857 TC A 36.00 0.00 0.00 77404 A 54.07 0.00 0.00<br />

76870 TC A 56.31 0.00 0.00 77406 A 87.58 0.00 0.00<br />

76872 TC A 56.31 0.00 0.00 77407 A 54.07 0.00 0.00<br />

76873 TC A 56.31 0.00 0.00 77408 A 54.07 0.00 0.00<br />

76880 TC A 56.31 0.00 0.00 77409 A 54.07 0.00 0.00<br />

76885 TC A 36.00 0.00 0.00 77411 A 87.58 0.00 0.00<br />

76886 TC A 36.00 0.00 0.00 77412 A 87.58 0.00 0.00<br />

76936 TC A 54.51 0.00 0.00 77413 A 87.58 0.00 0.00<br />

76970 TC A 36.00 0.00 0.00 77414 A 87.58 0.00 0.00<br />

76977 TC A 9.18 0.00 0.00 77416 A 87.58 0.00 0.00<br />

76999 TC A 36.00 0.00 0.00 77418 A 236.61 0.00 0.00<br />

77071 A 21.08 0.00 0.00 77422 A 87.58 0.00 0.00<br />

77072 TC A 12.23 0.00 0.00 77423 A 87.58 0.00 0.00<br />

77073 TC A 20.74 0.00 0.00 77470 TC A 125.79 0.00 0.00<br />

77074 TC A 40.80 0.00 0.00 77520 A 405.10 0.00 0.00<br />

77075 TC A 42.87 0.00 0.00 77522 A 405.10 0.00 0.00<br />

77076 TC A 42.87 0.00 0.00 77523 A 484.11 0.00 0.00<br />

77077 TC A 23.12 0.00 0.00 77525 A 484.11 0.00 0.00<br />

77078 TC A 41.42 0.00 0.00 77600 TC A 214.94 0.00 0.00<br />

77079 TC A 42.49 0.00 0.00 77605 TC A 214.94 0.00 0.00<br />

77080 TC A 41.42 0.00 0.00 77610 TC A 214.94 0.00 0.00<br />

77081 TC A 16.66 0.00 0.00 77615 TC A 214.94 0.00 0.00<br />

77082 TC A 18.02 0.00 0.00 77620 TC A 214.94 0.00 0.00<br />

77083 TC A 14.28 0.00 0.00 77750 TC A 83.63 0.00 0.00<br />

77084 TC A 200.45 0.00 0.00 77761 TC A 147.21 0.00 0.00<br />

77280 TC A 66.07 0.00 0.00 77762 TC A 174.40 0.00 0.00<br />

77285 TC A 147.26 0.00 0.00 77763 TC A 224.72 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 159.44 0.00 0.00 78262 TC A 140.02 0.00 0.00<br />

77777 TC A 175.08 0.00 0.00 78264 TC A 140.02 0.00 0.00<br />

77778 TC A 233.22 0.00 0.00 78270 TC A 61.19 0.00 0.00<br />

77785 TC A 103.69 0.00 0.00 78271 TC A 62.21 0.00 0.00<br />

77786 TC A 364.44 0.00 0.00 78272 TC A 68.33 0.00 0.00<br />

77787 TC A 422.30 0.00 0.00 78278 TC A 140.02 0.00 0.00<br />

77789 TC A 43.52 0.00 0.00 78282 TC A 140.02 0.00 0.00<br />

77799 TC A 248.04 0.00 0.00 78290 TC A 140.02 0.00 0.00<br />

78000 TC A 53.37 0.00 0.00 78291 TC A 140.02 0.00 0.00<br />

78001 TC A 67.64 0.00 0.00 78299 TC A 140.02 0.00 0.00<br />

78003 TC A 53.72 0.00 0.00 78300 TC A 122.05 0.00 0.00<br />

78006 TC A 127.81 0.00 0.00 78305 TC A 141.55 0.00 0.00<br />

78007 TC A 94.51 0.00 0.00 78306 TC A 141.55 0.00 0.00<br />

78010 TC A 78.53 0.00 0.00 78315 TC A 141.55 0.00 0.00<br />

78011 TC A 78.53 0.00 0.00 78320 TC A 141.55 0.00 0.00<br />

78015 TC A 152.64 0.00 0.00 78399 TC A 141.55 0.00 0.00<br />

78016 TC A 172.30 0.00 0.00 78414 TC A 179.92 0.00 0.00<br />

78018 TC A 172.30 0.00 0.00 78428 TC A 138.02 0.00 0.00<br />

78070 TC A 117.29 0.00 0.00 78445 TC A 107.66 0.00 0.00<br />

78075 TC A 332.14 0.00 0.00 78456 TC A 107.66 0.00 0.00<br />

78099 TC A 78.53 0.00 0.00 78457 TC A 107.66 0.00 0.00<br />

78102 TC A 118.65 0.00 0.00 78458 TC A 107.66 0.00 0.00<br />

78103 TC A 151.24 0.00 0.00 78459 TC A 666.28 0.00 0.00<br />

78104 TC A 151.24 0.00 0.00 78460 TC A 129.18 0.00 0.00<br />

78110 TC A 60.18 0.00 0.00 78461 TC A 130.21 0.00 0.00<br />

78111 TC A 76.15 0.00 0.00 78464 TC A 191.06 0.00 0.00<br />

78120 TC A 66.63 0.00 0.00 78465 TC A 361.72 0.00 0.00<br />

78121 TC A 78.87 0.00 0.00 78466 TC A 128.17 0.00 0.00<br />

78122 TC A 93.49 0.00 0.00 78468 TC A 163.86 0.00 0.00<br />

78130 TC A 108.45 0.00 0.00 78469 TC A 179.92 0.00 0.00<br />

78135 TC A 230.48 0.00 0.00 78472 TC A 179.92 0.00 0.00<br />

78140 TC A 102.33 0.00 0.00 78473 TC A 179.92 0.00 0.00<br />

78185 TC A 151.24 0.00 0.00 78481 TC A 155.36 0.00 0.00<br />

78190 TC A 94.90 0.00 0.00 78483 TC A 179.92 0.00 0.00<br />

78191 TC A 94.90 0.00 0.00 78491 TC A 666.28 0.00 0.00<br />

78195 TC A 151.24 0.00 0.00 78492 TC A 666.28 0.00 0.00<br />

78199 TC A 151.24 0.00 0.00 78494 TC A 179.92 0.00 0.00<br />

78201 TC A 134.62 0.00 0.00 78499 TC A 179.92 0.00 0.00<br />

78202 TC A 158.37 0.00 0.00 78580 TC A 121.90 0.00 0.00<br />

78205 TC A 158.37 0.00 0.00 78584 TC A 94.17 0.00 0.00<br />

78206 TC A 158.37 0.00 0.00 78585 TC A 187.04 0.00 0.00<br />

78215 TC A 142.45 0.00 0.00 78586 TC A 121.90 0.00 0.00<br />

78216 TC A 96.55 0.00 0.00 78587 TC A 121.90 0.00 0.00<br />

78220 TC A 105.39 0.00 0.00 78588 TC A 187.04 0.00 0.00<br />

78223 TC A 158.37 0.00 0.00 78591 TC A 121.90 0.00 0.00<br />

78230 TC A 119.66 0.00 0.00 78593 TC A 121.90 0.00 0.00<br />

78231 TC A 94.17 0.00 0.00 78594 TC A 121.90 0.00 0.00<br />

78232 TC A 98.25 0.00 0.00 78596 TC A 187.04 0.00 0.00<br />

78258 TC A 140.02 0.00 0.00 78599 TC A 121.90 0.00 0.00<br />

78261 TC A 140.02 0.00 0.00 78600 TC A 107.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 45300 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 107.43 0.00 0.00<br />

78605 TC A 107.43 0.00 0.00<br />

78606 TC A 241.37 0.00 0.00<br />

78607 TC A 265.17 0.00 0.00<br />

78608 TC A 597.19 0.00 0.00<br />

78610 TC A 143.12 0.00 0.00<br />

78630 TC A 254.97 0.00 0.00<br />

78635 TC A 234.91 0.00 0.00<br />

78645 TC A 107.43 0.00 0.00<br />

78647 TC A 260.07 0.00 0.00<br />

78650 TC A 251.91 0.00 0.00<br />

78660 TC A 107.43 0.00 0.00<br />

78699 TC A 107.43 0.00 0.00<br />

78700 TC A 132.25 0.00 0.00<br />

78701 TC A 161.15 0.00 0.00<br />

78707 TC A 168.28 0.00 0.00<br />

78708 TC A 115.25 0.00 0.00<br />

78709 TC A 189.48 0.00 0.00<br />

78710 TC A 177.80 0.00 0.00<br />

78725 TC A 71.05 0.00 0.00<br />

78730 TC A 60.18 0.00 0.00<br />

78740 TC A 157.07 0.00 0.00<br />

78761 TC A 149.92 0.00 0.00<br />

78799 TC A 189.48 0.00 0.00<br />

78800 TC A 132.59 0.00 0.00<br />

78801 TC A 181.88 0.00 0.00<br />

78802 TC A 246.47 0.00 0.00<br />

78803 TC A 264.15 0.00 0.00<br />

78804 TC A 460.99 0.00 0.00<br />

78805 TC A 129.52 0.00 0.00<br />

78806 TC A 259.05 0.00 0.00<br />

78807 TC A 264.49 0.00 0.00<br />

78811 TC A 597.19 0.00 0.00<br />

78812 TC A 597.19 0.00 0.00<br />

78813 TC A 597.19 0.00 0.00<br />

78814 TC A 597.19 0.00 0.00<br />

78815 TC A 597.19 0.00 0.00<br />

78816 TC A 597.19 0.00 0.00<br />

78999 TC A 67.64 0.00 0.00<br />

79005 TC A 54.40 0.00 0.00<br />

79101 TC A 59.50 0.00 0.00<br />

79200 TC A 64.26 0.00 0.00<br />

79300 TC A 123.97 0.00 0.00<br />

79403 TC A 92.13 0.00 0.00<br />

79440 TC A 52.01 0.00 0.00<br />

79445 TC A 123.97 0.00 0.00<br />

79999 TC A 123.97 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 1<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

A9527 C 0.00 0.00 0.00 G0339 A 2,295.56 0.00 0.00<br />

C1716 C 0.00 0.00 0.00 G0340 A 1,557.13 0.00 0.00<br />

C1717 C 0.00 0.00 0.00 G0364 S 5.70 0.00 0.00<br />

C1719 C 0.00 0.00 0.00 G0392 S 1,608.97 0.00 0.00<br />

C2616 C 0.00 0.00 0.00 G0393 S 1,608.97 0.00 0.00<br />

C2634 C 0.00 0.00 0.00 Q1003 A 50.00 0.00 0.00<br />

C2635 C 0.00 0.00 0.00 V2785 C 0.00 0.00 0.00<br />

C2636 C 0.00 0.00 0.00 0016T S 232.36 0.00 0.00<br />

C2638 C 0.00 0.00 0.00 0017T S 232.36 0.00 0.00<br />

C2639 C 0.00 0.00 0.00 0067T TC A 117.33 0.00 0.00<br />

C2640 C 0.00 0.00 0.00 0073T A 247.97 0.00 0.00<br />

C2641 C 0.00 0.00 0.00 0084T S 74.54 0.00 0.00<br />

C2642 C 0.00 0.00 0.00 0099T S 667.49 0.00 0.00<br />

C2643 C 0.00 0.00 0.00 0100T S 1,522.11 0.00 0.00<br />

C2698 C 0.00 0.00 0.00 0101T S 1,191.44 0.00 0.00<br />

C2699 C 0.00 0.00 0.00 0102T S 1,191.44 0.00 0.00<br />

C8900 A 257.98 0.00 0.00 0123T S 952.79 0.00 0.00<br />

C8901 A 210.08 0.00 0.00 0124T S 186.23 0.00 0.00<br />

C8902 A 325.14 0.00 0.00 0144T TC A 63.38 0.00 0.00<br />

C8903 A 257.98 0.00 0.00 0145T TC A 170.62 0.00 0.00<br />

C8904 A 210.08 0.00 0.00 0146T TC A 170.62 0.00 0.00<br />

C8905 A 325.14 0.00 0.00 0147T TC A 170.62 0.00 0.00<br />

C8906 A 257.98 0.00 0.00 0148T TC A 170.62 0.00 0.00<br />

C8907 A 210.08 0.00 0.00 0149T TC A 170.62 0.00 0.00<br />

C8908 A 325.14 0.00 0.00 0150T TC A 170.62 0.00 0.00<br />

C8909 A 257.98 0.00 0.00 0151T TC A 63.38 0.00 0.00<br />

C8910 A 210.08 0.00 0.00 0170T S 1,237.62 0.00 0.00<br />

C8911 A 325.14 0.00 0.00 0176T S 1,461.35 0.00 0.00<br />

C8912 A 257.98 0.00 0.00 0177T S 1,461.35 0.00 0.00<br />

C8913 A 210.08 0.00 0.00 0182T A 1,056.27 0.00 0.00<br />

C8914 A 325.14 0.00 0.00 0186T S 890.22 0.00 0.00<br />

C8918 A 257.98 0.00 0.00 0190T S 890.22 0.00 0.00<br />

C8919 A 210.08 0.00 0.00 0191T S 952.79 0.00 0.00<br />

C8920 A 325.14 0.00 0.00 0192T S 1,632.90 0.00 0.00<br />

C9716 S 1,237.62 0.00 0.00 10021 S 57.11 0.00 0.00<br />

C9724 S 1,011.89 0.00 0.00 10022 S 178.34 0.00 0.00<br />

C9725 S 233.34 0.00 0.00 10040 S 33.01 0.00 0.00<br />

C9726 S 856.65 0.00 0.00 10060 S 50.23 0.00 0.00<br />

C9727 S 300.36 0.00 0.00 10061 S 56.33 0.00 0.00<br />

C9728 S 538.93 0.00 0.00 10080 S 56.33 0.00 0.00<br />

G0104 S 86.58 0.00 0.00 10081 S 129.68 0.00 0.00<br />

G0105 S 374.18 0.00 0.00 10120 S 70.54 0.00 0.00<br />

G0121 S 374.18 0.00 0.00 10121 S 531.73 0.00 0.00<br />

G0127 S 12.11 0.00 0.00 10140 S 74.82 0.00 0.00<br />

G0130 TC A 19.95 0.00 0.00 10160 S 56.33 0.00 0.00<br />

G0173 A 2,295.56 0.00 0.00 10180 S 601.31 0.00 0.00<br />

G0186 S 232.36 0.00 0.00 11000 S 24.23 0.00 0.00<br />

G0247 S 22.09 0.00 0.00 11001 S 8.20 0.00 0.00<br />

G0251 A 574.84 0.00 0.00 11010 S 210.37 0.00 0.00<br />

G0260 S 303.36 0.00 0.00 11011 S 210.37 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 2<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

11012 S 210.37 0.00 0.00 11601 S 116.15 0.00 0.00<br />

11040 S 22.09 0.00 0.00 11602 S 127.91 0.00 0.00<br />

11041 S 24.59 0.00 0.00 11603 S 135.74 0.00 0.00<br />

11042 S 133.59 0.00 0.00 11604 S 366.16 0.00 0.00<br />

11043 S 133.59 0.00 0.00 11606 S 531.73 0.00 0.00<br />

11044 S 347.84 0.00 0.00 11620 S 99.05 0.00 0.00<br />

11055 S 26.01 0.00 0.00 11621 S 117.57 0.00 0.00<br />

11056 S 28.50 0.00 0.00 11622 S 130.75 0.00 0.00<br />

11057 S 33.01 0.00 0.00 11623 S 140.73 0.00 0.00<br />

11100 S 60.49 0.00 0.00 11624 S 531.73 0.00 0.00<br />

11101 S 14.25 0.00 0.00 11626 S 650.26 0.00 0.00<br />

11200 S 33.01 0.00 0.00 11640 S 104.75 0.00 0.00<br />

11201 S 5.70 0.00 0.00 11641 S 123.63 0.00 0.00<br />

11300 S 33.01 0.00 0.00 11642 S 137.88 0.00 0.00<br />

11301 S 33.01 0.00 0.00 11643 S 148.57 0.00 0.00<br />

11302 S 33.01 0.00 0.00 11644 S 531.73 0.00 0.00<br />

11303 S 60.49 0.00 0.00 11646 S 650.26 0.00 0.00<br />

11305 S 33.01 0.00 0.00 11719 S 12.11 0.00 0.00<br />

11306 S 33.01 0.00 0.00 11720 S 14.97 0.00 0.00<br />

11307 S 33.01 0.00 0.00 11721 S 18.17 0.00 0.00<br />

11308 S 33.01 0.00 0.00 11730 S 33.01 0.00 0.00<br />

11310 S 33.01 0.00 0.00 11732 S 18.17 0.00 0.00<br />

11311 S 33.01 0.00 0.00 11740 S 16.67 0.00 0.00<br />

11312 S 33.01 0.00 0.00 11750 S 96.20 0.00 0.00<br />

11313 S 33.01 0.00 0.00 11752 S 133.61 0.00 0.00<br />

11400 S 68.05 0.00 0.00 11755 S 66.62 0.00 0.00<br />

11401 S 76.60 0.00 0.00 11760 S 137.21 0.00 0.00<br />

11402 S 84.09 0.00 0.00 11762 S 122.56 0.00 0.00<br />

11403 S 89.79 0.00 0.00 11765 S 33.01 0.00 0.00<br />

11404 S 477.31 0.00 0.00 11770 S 681.09 0.00 0.00<br />

11406 S 531.73 0.00 0.00 11771 S 681.09 0.00 0.00<br />

11420 S 63.78 0.00 0.00 11772 S 681.09 0.00 0.00<br />

11421 S 77.31 0.00 0.00 11900 S 30.29 0.00 0.00<br />

11422 S 84.44 0.00 0.00 11901 S 33.01 0.00 0.00<br />

11423 S 94.06 0.00 0.00 11920 S 95.84 0.00 0.00<br />

11424 S 531.73 0.00 0.00 11921 S 105.46 0.00 0.00<br />

11426 S 650.26 0.00 0.00 11922 S 34.20 0.00 0.00<br />

11440 S 73.04 0.00 0.00 11950 S 34.92 0.00 0.00<br />

11441 S 84.44 0.00 0.00 11951 S 43.47 0.00 0.00<br />

11442 S 92.99 0.00 0.00 11952 S 52.33 0.00 0.00<br />

11443 S 102.96 0.00 0.00 11954 S 52.33 0.00 0.00<br />

11444 S 324.98 0.00 0.00 11960 S 634.77 0.00 0.00<br />

11446 S 650.26 0.00 0.00 11970 S 1,149.79 0.00 0.00<br />

11450 S 650.26 0.00 0.00 11971 S 595.84 0.00 0.00<br />

11451 S 650.26 0.00 0.00 11976 S 63.78 0.00 0.00<br />

11462 S 650.26 0.00 0.00 11980 S 25.76 0.00 0.00<br />

11463 S 650.26 0.00 0.00 11981 S 25.76 0.00 0.00<br />

11470 S 650.26 0.00 0.00 11982 S 25.76 0.00 0.00<br />

11471 S 650.26 0.00 0.00 11983 S 25.76 0.00 0.00<br />

11600 S 95.84 0.00 0.00 12001 S 52.33 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 3<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

12002 S 52.33 0.00 0.00 14021 S 564.10 0.00 0.00<br />

12004 S 52.33 0.00 0.00 14040 S 533.28 0.00 0.00<br />

12005 S 70.11 0.00 0.00 14041 S 564.10 0.00 0.00<br />

12006 S 70.11 0.00 0.00 14060 S 564.10 0.00 0.00<br />

12007 S 70.11 0.00 0.00 14061 S 564.10 0.00 0.00<br />

12011 S 52.33 0.00 0.00 14300 S 723.39 0.00 0.00<br />

12013 S 52.33 0.00 0.00 14350 S 665.59 0.00 0.00<br />

12014 S 52.33 0.00 0.00 15002 S 244.03 0.00 0.00<br />

12015 S 52.33 0.00 0.00 15003 S 244.03 0.00 0.00<br />

12016 S 70.11 0.00 0.00 15004 S 244.03 0.00 0.00<br />

12017 S 70.11 0.00 0.00 15005 S 244.03 0.00 0.00<br />

12018 S 70.11 0.00 0.00 15040 S 112.55 0.00 0.00<br />

12020 S 132.27 0.00 0.00 15050 S 244.03 0.00 0.00<br />

12021 S 112.55 0.00 0.00 15100 S 634.77 0.00 0.00<br />

12031 S 52.33 0.00 0.00 15101 S 665.59 0.00 0.00<br />

12032 S 137.21 0.00 0.00 15110 S 303.13 0.00 0.00<br />

12034 S 70.11 0.00 0.00 15111 S 248.71 0.00 0.00<br />

12035 S 70.11 0.00 0.00 15115 S 303.13 0.00 0.00<br />

12036 S 112.55 0.00 0.00 15116 S 248.71 0.00 0.00<br />

12037 S 224.31 0.00 0.00 15120 S 634.77 0.00 0.00<br />

12041 S 52.33 0.00 0.00 15121 S 665.59 0.00 0.00<br />

12042 S 52.33 0.00 0.00 15130 S 533.28 0.00 0.00<br />

12044 S 70.11 0.00 0.00 15131 S 478.85 0.00 0.00<br />

12045 S 112.55 0.00 0.00 15135 S 533.28 0.00 0.00<br />

12046 S 112.55 0.00 0.00 15136 S 478.85 0.00 0.00<br />

12047 S 224.31 0.00 0.00 15150 S 303.13 0.00 0.00<br />

12051 S 52.33 0.00 0.00 15151 S 248.71 0.00 0.00<br />

12052 S 52.33 0.00 0.00 15152 S 248.71 0.00 0.00<br />

12053 S 52.33 0.00 0.00 15155 S 303.13 0.00 0.00<br />

12054 S 70.11 0.00 0.00 15156 S 248.71 0.00 0.00<br />

12055 S 112.55 0.00 0.00 15157 S 248.71 0.00 0.00<br />

12056 S 112.55 0.00 0.00 15170 S 137.21 0.00 0.00<br />

12057 S 224.31 0.00 0.00 15171 S 137.21 0.00 0.00<br />

13100 S 244.03 0.00 0.00 15175 S 176.66 0.00 0.00<br />

13101 S 244.03 0.00 0.00 15176 S 176.66 0.00 0.00<br />

13102 S 132.27 0.00 0.00 15200 S 564.10 0.00 0.00<br />

13120 S 112.55 0.00 0.00 15201 S 474.18 0.00 0.00<br />

13121 S 112.55 0.00 0.00 15220 S 533.28 0.00 0.00<br />

13122 S 112.55 0.00 0.00 15221 S 244.03 0.00 0.00<br />

13131 S 112.55 0.00 0.00 15240 S 564.10 0.00 0.00<br />

13132 S 112.55 0.00 0.00 15241 S 244.03 0.00 0.00<br />

13133 S 112.55 0.00 0.00 15260 S 533.28 0.00 0.00<br />

13150 S 244.03 0.00 0.00 15261 S 474.18 0.00 0.00<br />

13151 S 244.03 0.00 0.00 15300 S 244.03 0.00 0.00<br />

13152 S 244.03 0.00 0.00 15301 S 244.03 0.00 0.00<br />

13153 S 112.55 0.00 0.00 15320 S 244.03 0.00 0.00<br />

13160 S 634.77 0.00 0.00 15321 S 244.03 0.00 0.00<br />

14000 S 533.28 0.00 0.00 15330 S 244.03 0.00 0.00<br />

14001 S 564.10 0.00 0.00 15331 S 244.03 0.00 0.00<br />

14020 S 564.10 0.00 0.00 15335 S 244.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 4<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

15336 S 244.03 0.00 0.00 15826 S 665.59 0.00 0.00<br />

15340 S 137.21 0.00 0.00 15828 S 665.59 0.00 0.00<br />

15341 S 137.21 0.00 0.00 15829 S 765.29 0.00 0.00<br />

15360 S 137.21 0.00 0.00 15830 S 681.09 0.00 0.00<br />

15361 S 137.21 0.00 0.00 15832 S 681.09 0.00 0.00<br />

15365 S 137.21 0.00 0.00 15833 S 681.09 0.00 0.00<br />

15366 S 137.21 0.00 0.00 15834 S 681.09 0.00 0.00<br />

15400 S 244.03 0.00 0.00 15835 S 591.16 0.00 0.00<br />

15401 S 244.03 0.00 0.00 15836 S 562.56 0.00 0.00<br />

15420 S 244.03 0.00 0.00 15837 S 633.86 0.00 0.00<br />

15421 S 244.03 0.00 0.00 15838 S 633.86 0.00 0.00<br />

15430 S 244.03 0.00 0.00 15839 S 562.56 0.00 0.00<br />

15431 S 244.03 0.00 0.00 15840 S 723.39 0.00 0.00<br />

15570 S 665.59 0.00 0.00 15841 S 723.39 0.00 0.00<br />

15572 S 665.59 0.00 0.00 15842 S 839.93 0.00 0.00<br />

15574 S 665.59 0.00 0.00 15845 S 723.39 0.00 0.00<br />

15576 S 665.59 0.00 0.00 15847 S 681.09 0.00 0.00<br />

15600 S 665.59 0.00 0.00 15850 S 108.80 0.00 0.00<br />

15610 S 665.59 0.00 0.00 15851 S 49.52 0.00 0.00<br />

15620 S 723.39 0.00 0.00 15852 S 25.76 0.00 0.00<br />

15630 S 665.59 0.00 0.00 15860 S 25.76 0.00 0.00<br />

15650 S 765.29 0.00 0.00 15876 S 665.59 0.00 0.00<br />

15731 S 665.59 0.00 0.00 15877 S 665.59 0.00 0.00<br />

15732 S 665.59 0.00 0.00 15878 S 665.59 0.00 0.00<br />

15734 S 665.59 0.00 0.00 15879 S 665.59 0.00 0.00<br />

15736 S 665.59 0.00 0.00 15920 S 210.37 0.00 0.00<br />

15738 S 665.59 0.00 0.00 15922 S 723.39 0.00 0.00<br />

15740 S 533.28 0.00 0.00 15931 S 681.09 0.00 0.00<br />

15750 S 634.77 0.00 0.00 15933 S 681.09 0.00 0.00<br />

15760 S 634.77 0.00 0.00 15934 S 665.59 0.00 0.00<br />

15770 S 665.59 0.00 0.00 15935 S 723.39 0.00 0.00<br />

15775 S 181.86 0.00 0.00 15936 S 621.90 0.00 0.00<br />

15776 S 181.86 0.00 0.00 15937 S 723.39 0.00 0.00<br />

15780 S 405.45 0.00 0.00 15940 S 681.09 0.00 0.00<br />

15781 S 178.46 0.00 0.00 15941 S 681.09 0.00 0.00<br />

15782 S 178.46 0.00 0.00 15944 S 665.59 0.00 0.00<br />

15783 S 108.80 0.00 0.00 15945 S 723.39 0.00 0.00<br />

15786 S 33.01 0.00 0.00 15946 S 723.39 0.00 0.00<br />

15787 S 29.93 0.00 0.00 15950 S 681.09 0.00 0.00<br />

15788 S 33.01 0.00 0.00 15951 S 738.88 0.00 0.00<br />

15789 S 60.49 0.00 0.00 15952 S 564.10 0.00 0.00<br />

15792 S 60.49 0.00 0.00 15953 S 621.90 0.00 0.00<br />

15793 S 33.01 0.00 0.00 15956 S 564.10 0.00 0.00<br />

15819 S 137.21 0.00 0.00 15958 S 621.90 0.00 0.00<br />

15820 S 665.59 0.00 0.00 16000 S 26.72 0.00 0.00<br />

15821 S 665.59 0.00 0.00 16020 S 40.62 0.00 0.00<br />

15822 S 665.59 0.00 0.00 16025 S 62.56 0.00 0.00<br />

15823 S 765.29 0.00 0.00 16030 S 78.33 0.00 0.00<br />

15824 S 665.59 0.00 0.00 16035 S 60.49 0.00 0.00<br />

15825 S 665.59 0.00 0.00 17000 S 33.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 5<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

17003 S 3.92 0.00 0.00 19300 S 731.75 0.00 0.00<br />

17004 S 86.22 0.00 0.00 19301 S 673.96 0.00 0.00<br />

17106 S 108.80 0.00 0.00 19302 S 1,287.19 0.00 0.00<br />

17107 S 108.80 0.00 0.00 19303 S 972.77 0.00 0.00<br />

17108 S 108.80 0.00 0.00 19304 S 972.77 0.00 0.00<br />

17110 S 33.01 0.00 0.00 19316 S 972.77 0.00 0.00<br />

17111 S 60.49 0.00 0.00 19318 S 1,111.39 0.00 0.00<br />

17250 S 45.61 0.00 0.00 19324 S 1,111.39 0.00 0.00<br />

17260 S 48.81 0.00 0.00 19325 S 1,843.38 0.00 0.00<br />

17261 S 60.49 0.00 0.00 19328 S 829.72 0.00 0.00<br />

17262 S 60.49 0.00 0.00 19330 S 829.72 0.00 0.00<br />

17263 S 60.49 0.00 0.00 19340 S 1,022.77 0.00 0.00<br />

17264 S 60.49 0.00 0.00 19342 S 1,444.11 0.00 0.00<br />

17266 S 108.80 0.00 0.00 19350 S 731.75 0.00 0.00<br />

17270 S 60.49 0.00 0.00 19355 S 972.77 0.00 0.00<br />

17271 S 60.49 0.00 0.00 19357 S 1,543.80 0.00 0.00<br />

17272 S 60.49 0.00 0.00 19366 S 1,014.67 0.00 0.00<br />

17273 S 108.80 0.00 0.00 19370 S 972.77 0.00 0.00<br />

17274 S 108.80 0.00 0.00 19371 S 972.77 0.00 0.00<br />

17276 S 108.80 0.00 0.00 19380 S 1,153.30 0.00 0.00<br />

17280 S 60.49 0.00 0.00 19396 S 1,338.68 0.00 0.00<br />

17281 S 90.14 0.00 0.00 20000 S 56.33 0.00 0.00<br />

17282 S 102.96 0.00 0.00 20005 S 649.03 0.00 0.00<br />

17283 S 108.80 0.00 0.00 20103 S 636.96 0.00 0.00<br />

17284 S 108.80 0.00 0.00 20150 S 1,808.33 0.00 0.00<br />

17286 S 108.80 0.00 0.00 20200 S 531.73 0.00 0.00<br />

17311 S 179.61 0.00 0.00 20205 S 562.56 0.00 0.00<br />

17312 S 179.61 0.00 0.00 20206 S 262.88 0.00 0.00<br />

17313 S 179.61 0.00 0.00 20220 S 285.75 0.00 0.00<br />

17314 S 179.61 0.00 0.00 20225 S 518.48 0.00 0.00<br />

17315 S 40.62 0.00 0.00 20240 S 650.26 0.00 0.00<br />

17340 S 14.61 0.00 0.00 20245 S 681.09 0.00 0.00<br />

17360 S 33.01 0.00 0.00 20250 S 679.86 0.00 0.00<br />

17380 S 33.01 0.00 0.00 20251 S 679.86 0.00 0.00<br />

19000 S 68.76 0.00 0.00 20500 S 56.30 0.00 0.00<br />

19001 S 9.27 0.00 0.00 20520 S 94.77 0.00 0.00<br />

19020 S 601.31 0.00 0.00 20525 S 681.09 0.00 0.00<br />

19100 S 204.76 0.00 0.00 20526 S 30.64 0.00 0.00<br />

19101 S 643.13 0.00 0.00 20550 S 23.16 0.00 0.00<br />

19102 S 262.88 0.00 0.00 20551 S 22.80 0.00 0.00<br />

19103 S 460.10 0.00 0.00 20552 S 22.09 0.00 0.00<br />

19105 S 1,338.68 0.00 0.00 20553 S 24.59 0.00 0.00<br />

19110 S 643.13 0.00 0.00 20555 S 1,191.44 0.00 0.00<br />

19112 S 673.96 0.00 0.00 20600 S 23.51 0.00 0.00<br />

19120 S 673.96 0.00 0.00 20605 S 26.37 0.00 0.00<br />

19125 S 673.96 0.00 0.00 20610 S 37.05 0.00 0.00<br />

19126 S 673.96 0.00 0.00 20612 S 24.94 0.00 0.00<br />

19296 S 1,843.38 0.00 0.00 20615 S 104.40 0.00 0.00<br />

19297 S 1,843.38 0.00 0.00 20650 S 679.86 0.00 0.00<br />

19298 S 1,843.38 0.00 0.00 20662 S 868.45 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 6<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

20663 S 868.45 0.00 0.00 21085 S 261.51 0.00 0.00<br />

20665 S 25.76 0.00 0.00 21086 S 569.34 0.00 0.00<br />

20670 S 477.31 0.00 0.00 21087 S 570.06 0.00 0.00<br />

20680 S 681.09 0.00 0.00 21088 S 1,669.59 0.00 0.00<br />

20690 S 810.52 0.00 0.00 21100 S 1,049.60 0.00 0.00<br />

20692 S 841.35 0.00 0.00 21110 S 300.36 0.00 0.00<br />

20693 S 679.86 0.00 0.00 21120 S 972.75 0.00 0.00<br />

20694 S 594.61 0.00 0.00 21121 S 972.75 0.00 0.00<br />

20696 S 1,191.44 0.00 0.00 21122 S 972.75 0.00 0.00<br />

20697 S 792.35 0.00 0.00 21123 S 972.75 0.00 0.00<br />

20822 S 1,116.39 0.00 0.00 21125 S 972.75 0.00 0.00<br />

20900 S 841.35 0.00 0.00 21127 S 1,479.69 0.00 0.00<br />

20902 S 899.14 0.00 0.00 21137 S 987.06 0.00 0.00<br />

20910 S 665.59 0.00 0.00 21138 S 1,669.59 0.00 0.00<br />

20912 S 665.59 0.00 0.00 21139 S 1,669.59 0.00 0.00<br />

20920 S 621.90 0.00 0.00 21150 S 1,669.59 0.00 0.00<br />

20922 S 564.10 0.00 0.00 21181 S 972.75 0.00 0.00<br />

20924 S 899.14 0.00 0.00 21198 S 1,669.59 0.00 0.00<br />

20926 S 391.75 0.00 0.00 21199 S 1,669.59 0.00 0.00<br />

20950 S 56.33 0.00 0.00 21206 S 1,180.13 0.00 0.00<br />

20972 S 1,885.61 0.00 0.00 21208 S 1,314.02 0.00 0.00<br />

20973 S 1,885.61 0.00 0.00 21209 S 1,180.13 0.00 0.00<br />

20979 S 23.16 0.00 0.00 21210 S 1,314.02 0.00 0.00<br />

20982 S 1,808.33 0.00 0.00 21215 S 1,314.02 0.00 0.00<br />

21010 S 708.33 0.00 0.00 21230 S 1,314.02 0.00 0.00<br />

21015 S 589.33 0.00 0.00 21235 S 972.75 0.00 0.00<br />

21025 S 1,049.60 0.00 0.00 21240 S 1,138.22 0.00 0.00<br />

21026 S 1,049.60 0.00 0.00 21242 S 1,180.13 0.00 0.00<br />

21029 S 1,049.60 0.00 0.00 21243 S 1,180.13 0.00 0.00<br />

21030 S 247.61 0.00 0.00 21244 S 1,314.02 0.00 0.00<br />

21031 S 204.86 0.00 0.00 21245 S 1,314.02 0.00 0.00<br />

21032 S 208.78 0.00 0.00 21246 S 1,314.02 0.00 0.00<br />

21034 S 1,080.43 0.00 0.00 21248 S 1,314.02 0.00 0.00<br />

21040 S 708.33 0.00 0.00 21249 S 1,314.02 0.00 0.00<br />

21044 S 1,049.60 0.00 0.00 21260 S 1,669.59 0.00 0.00<br />

21046 S 1,049.60 0.00 0.00 21267 S 1,314.02 0.00 0.00<br />

21047 S 1,049.60 0.00 0.00 21270 S 1,180.13 0.00 0.00<br />

21048 S 1,669.59 0.00 0.00 21275 S 1,314.02 0.00 0.00<br />

21050 S 1,080.43 0.00 0.00 21280 S 1,180.13 0.00 0.00<br />

21060 S 1,049.60 0.00 0.00 21282 S 689.03 0.00 0.00<br />

21070 S 1,080.43 0.00 0.00 21295 S 310.56 0.00 0.00<br />

21073 S 192.39 0.00 0.00 21296 S 653.91 0.00 0.00<br />

21076 S 333.83 0.00 0.00 21310 S 94.73 0.00 0.00<br />

21077 S 806.98 0.00 0.00 21315 S 416.29 0.00 0.00<br />

21079 S 577.89 0.00 0.00 21320 S 558.50 0.00 0.00<br />

21080 S 662.69 0.00 0.00 21325 S 796.95 0.00 0.00<br />

21081 S 610.67 0.00 0.00 21330 S 838.85 0.00 0.00<br />

21082 S 581.10 0.00 0.00 21335 S 972.75 0.00 0.00<br />

21083 S 572.55 0.00 0.00 21336 S 810.68 0.00 0.00<br />

21084 S 658.77 0.00 0.00 21337 S 558.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 7<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

21338 S 796.95 0.00 0.00 22310 S 172.47 0.00 0.00<br />

21339 S 838.85 0.00 0.00 22315 S 446.08 0.00 0.00<br />

21340 S 1,138.22 0.00 0.00 22505 S 525.15 0.00 0.00<br />

21345 S 972.75 0.00 0.00 22520 S 1,240.61 0.00 0.00<br />

21355 S 1,080.43 0.00 0.00 22521 S 1,240.61 0.00 0.00<br />

21356 S 739.16 0.00 0.00 22522 S 1,240.61 0.00 0.00<br />

21360 S 987.06 0.00 0.00 22523 S 3,452.74 0.00 0.00<br />

21390 S 1,669.59 0.00 0.00 22524 S 3,452.74 0.00 0.00<br />

21400 S 364.98 0.00 0.00 22525 S 3,452.74 0.00 0.00<br />

21401 S 589.33 0.00 0.00 22900 S 738.88 0.00 0.00<br />

21406 S 1,669.59 0.00 0.00 23000 S 531.73 0.00 0.00<br />

21407 S 1,669.59 0.00 0.00 23020 S 1,118.97 0.00 0.00<br />

21421 S 796.95 0.00 0.00 23030 S 546.88 0.00 0.00<br />

21440 S 335.62 0.00 0.00 23031 S 632.14 0.00 0.00<br />

21445 S 796.95 0.00 0.00 23035 S 679.86 0.00 0.00<br />

21450 S 138.52 0.00 0.00 23040 S 841.35 0.00 0.00<br />

21451 S 373.72 0.00 0.00 23044 S 899.14 0.00 0.00<br />

21452 S 558.50 0.00 0.00 23065 S 100.47 0.00 0.00<br />

21453 S 1,080.43 0.00 0.00 23066 S 650.26 0.00 0.00<br />

21454 S 838.85 0.00 0.00 23075 S 531.73 0.00 0.00<br />

21461 S 1,138.22 0.00 0.00 23076 S 650.26 0.00 0.00<br />

21462 S 1,180.13 0.00 0.00 23077 S 681.09 0.00 0.00<br />

21465 S 1,138.22 0.00 0.00 23100 S 649.03 0.00 0.00<br />

21480 S 94.73 0.00 0.00 23101 S 1,074.94 0.00 0.00<br />

21485 S 558.50 0.00 0.00 23105 S 899.14 0.00 0.00<br />

21490 S 1,080.43 0.00 0.00 23106 S 899.14 0.00 0.00<br />

21495 S 687.40 0.00 0.00 23107 S 899.14 0.00 0.00<br />

21497 S 558.50 0.00 0.00 23120 S 941.05 0.00 0.00<br />

21501 S 601.31 0.00 0.00 23125 S 941.05 0.00 0.00<br />

21502 S 649.03 0.00 0.00 23130 S 1,249.48 0.00 0.00<br />

21550 S 633.86 0.00 0.00 23140 S 737.65 0.00 0.00<br />

21555 S 650.26 0.00 0.00 23145 S 941.05 0.00 0.00<br />

21556 S 650.26 0.00 0.00 23146 S 941.05 0.00 0.00<br />

21557 S 870.92 0.00 0.00 23150 S 899.14 0.00 0.00<br />

21600 S 810.52 0.00 0.00 23155 S 941.05 0.00 0.00<br />

21610 S 810.52 0.00 0.00 23156 S 941.05 0.00 0.00<br />

21685 S 300.36 0.00 0.00 23170 S 810.52 0.00 0.00<br />

21700 S 649.03 0.00 0.00 23172 S 810.52 0.00 0.00<br />

21720 S 679.86 0.00 0.00 23174 S 810.52 0.00 0.00<br />

21725 S 70.77 0.00 0.00 23180 S 899.14 0.00 0.00<br />

21800 S 81.75 0.00 0.00 23182 S 899.14 0.00 0.00<br />

21805 S 722.06 0.00 0.00 23184 S 899.14 0.00 0.00<br />

21820 S 81.75 0.00 0.00 23190 S 899.14 0.00 0.00<br />

21920 S 145.36 0.00 0.00 23195 S 941.05 0.00 0.00<br />

21925 S 650.26 0.00 0.00 23330 S 324.98 0.00 0.00<br />

21930 S 650.26 0.00 0.00 23331 S 595.84 0.00 0.00<br />

21935 S 681.09 0.00 0.00 23395 S 1,249.48 0.00 0.00<br />

22102 S 1,938.05 0.00 0.00 23397 S 2,205.59 0.00 0.00<br />

22103 S 1,938.05 0.00 0.00 23400 S 1,074.94 0.00 0.00<br />

22305 S 81.75 0.00 0.00 23405 S 810.52 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 8<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

23406 S 810.52 0.00 0.00 23931 S 601.31 0.00 0.00<br />

23410 S 1,249.48 0.00 0.00 23935 S 649.03 0.00 0.00<br />

23412 S 1,383.38 0.00 0.00 24000 S 899.14 0.00 0.00<br />

23415 S 1,249.48 0.00 0.00 24006 S 899.14 0.00 0.00<br />

23420 S 1,383.38 0.00 0.00 24065 S 139.31 0.00 0.00<br />

23430 S 1,207.59 0.00 0.00 24066 S 531.73 0.00 0.00<br />

23440 S 1,207.59 0.00 0.00 24075 S 531.73 0.00 0.00<br />

23450 S 2,071.70 0.00 0.00 24076 S 650.26 0.00 0.00<br />

23455 S 2,205.59 0.00 0.00 24077 S 681.09 0.00 0.00<br />

23460 S 2,071.70 0.00 0.00 24100 S 594.61 0.00 0.00<br />

23462 S 1,383.38 0.00 0.00 24101 S 899.14 0.00 0.00<br />

23465 S 2,071.70 0.00 0.00 24102 S 899.14 0.00 0.00<br />

23466 S 1,383.38 0.00 0.00 24105 S 679.86 0.00 0.00<br />

23480 S 1,207.59 0.00 0.00 24110 S 649.03 0.00 0.00<br />

23485 S 2,205.59 0.00 0.00 24115 S 841.35 0.00 0.00<br />

23490 S 1,149.79 0.00 0.00 24116 S 841.35 0.00 0.00<br />

23491 S 1,972.01 0.00 0.00 24120 S 679.86 0.00 0.00<br />

23500 S 81.75 0.00 0.00 24125 S 841.35 0.00 0.00<br />

23505 S 446.08 0.00 0.00 24126 S 841.35 0.00 0.00<br />

23515 S 1,493.01 0.00 0.00 24130 S 841.35 0.00 0.00<br />

23520 S 172.47 0.00 0.00 24134 S 810.52 0.00 0.00<br />

23525 S 172.47 0.00 0.00 24136 S 810.52 0.00 0.00<br />

23530 S 1,100.20 0.00 0.00 24138 S 810.52 0.00 0.00<br />

23532 S 810.68 0.00 0.00 24140 S 841.35 0.00 0.00<br />

23540 S 81.75 0.00 0.00 24145 S 841.35 0.00 0.00<br />

23545 S 172.47 0.00 0.00 24147 S 810.52 0.00 0.00<br />

23550 S 1,100.20 0.00 0.00 24149 S 1,191.44 0.00 0.00<br />

23552 S 1,158.00 0.00 0.00 24152 S 1,808.33 0.00 0.00<br />

23570 S 81.75 0.00 0.00 24153 S 3,452.74 0.00 0.00<br />

23575 S 172.47 0.00 0.00 24155 S 1,149.79 0.00 0.00<br />

23585 S 1,493.01 0.00 0.00 24160 S 810.52 0.00 0.00<br />

23600 S 63.71 0.00 0.00 24164 S 841.35 0.00 0.00<br />

23605 S 446.08 0.00 0.00 24200 S 101.90 0.00 0.00<br />

23615 S 1,550.80 0.00 0.00 24201 S 531.73 0.00 0.00<br />

23616 S 1,550.80 0.00 0.00 24300 S 620.70 0.00 0.00<br />

23620 S 63.71 0.00 0.00 24301 S 899.14 0.00 0.00<br />

23625 S 446.08 0.00 0.00 24305 S 899.14 0.00 0.00<br />

23630 S 1,592.70 0.00 0.00 24310 S 679.86 0.00 0.00<br />

23650 S 81.75 0.00 0.00 24320 S 1,149.79 0.00 0.00<br />

23655 S 470.73 0.00 0.00 24330 S 1,972.01 0.00 0.00<br />

23660 S 1,100.20 0.00 0.00 24331 S 1,149.79 0.00 0.00<br />

23665 S 172.47 0.00 0.00 24332 S 868.45 0.00 0.00<br />

23670 S 1,493.01 0.00 0.00 24340 S 1,149.79 0.00 0.00<br />

23675 S 81.75 0.00 0.00 24341 S 1,149.79 0.00 0.00<br />

23680 S 1,100.20 0.00 0.00 24342 S 1,149.79 0.00 0.00<br />

23700 S 470.73 0.00 0.00 24343 S 1,191.44 0.00 0.00<br />

23800 S 2,029.79 0.00 0.00 24344 S 3,452.74 0.00 0.00<br />

23802 S 1,383.38 0.00 0.00 24345 S 810.52 0.00 0.00<br />

23921 S 474.18 0.00 0.00 24346 S 1,808.33 0.00 0.00<br />

23930 S 546.88 0.00 0.00 24357 S 1,191.44 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 9<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

24358 S 1,191.44 0.00 0.00 24925 S 679.86 0.00 0.00<br />

24359 S 1,191.44 0.00 0.00 25000 S 679.86 0.00 0.00<br />

24360 S 1,099.53 0.00 0.00 25001 S 868.45 0.00 0.00<br />

24361 S 6,011.68 3,679.91 1,348.14 25020 S 679.86 0.00 0.00<br />

24362 S 1,405.19 0.00 0.00 25023 S 841.35 0.00 0.00<br />

24363 S 6,145.57 3,813.80 1,482.03 25024 S 841.35 0.00 0.00<br />

24365 S 1,099.53 0.00 0.00 25025 S 841.35 0.00 0.00<br />

24366 S 6,011.68 3,679.91 1,348.14 25028 S 594.61 0.00 0.00<br />

24400 S 899.14 0.00 0.00 25031 S 649.03 0.00 0.00<br />

24410 S 899.14 0.00 0.00 25035 S 649.03 0.00 0.00<br />

24420 S 1,149.79 0.00 0.00 25040 S 941.05 0.00 0.00<br />

24430 S 1,972.01 0.00 0.00 25065 S 141.44 0.00 0.00<br />

24435 S 2,029.79 0.00 0.00 25066 S 650.26 0.00 0.00<br />

24470 S 1,149.79 0.00 0.00 25075 S 531.73 0.00 0.00<br />

24495 S 810.52 0.00 0.00 25076 S 681.09 0.00 0.00<br />

24498 S 1,972.01 0.00 0.00 25077 S 681.09 0.00 0.00<br />

24500 S 81.75 0.00 0.00 25085 S 679.86 0.00 0.00<br />

24505 S 81.75 0.00 0.00 25100 S 649.03 0.00 0.00<br />

24515 S 1,550.80 0.00 0.00 25101 S 841.35 0.00 0.00<br />

24516 S 1,550.80 0.00 0.00 25105 S 899.14 0.00 0.00<br />

24530 S 81.75 0.00 0.00 25107 S 841.35 0.00 0.00<br />

24535 S 172.47 0.00 0.00 25109 S 868.45 0.00 0.00<br />

24538 S 722.06 0.00 0.00 25110 S 679.86 0.00 0.00<br />

24545 S 1,550.80 0.00 0.00 25111 S 679.86 0.00 0.00<br />

24546 S 1,592.70 0.00 0.00 25112 S 737.65 0.00 0.00<br />

24560 S 81.75 0.00 0.00 25115 S 737.65 0.00 0.00<br />

24565 S 81.75 0.00 0.00 25116 S 737.65 0.00 0.00<br />

24566 S 722.06 0.00 0.00 25118 S 810.52 0.00 0.00<br />

24575 S 1,493.01 0.00 0.00 25119 S 841.35 0.00 0.00<br />

24576 S 81.75 0.00 0.00 25120 S 841.35 0.00 0.00<br />

24577 S 172.47 0.00 0.00 25125 S 841.35 0.00 0.00<br />

24579 S 1,493.01 0.00 0.00 25126 S 841.35 0.00 0.00<br />

24582 S 722.06 0.00 0.00 25130 S 841.35 0.00 0.00<br />

24586 S 1,550.80 0.00 0.00 25135 S 841.35 0.00 0.00<br />

24587 S 1,592.70 0.00 0.00 25136 S 841.35 0.00 0.00<br />

24600 S 81.75 0.00 0.00 25145 S 810.52 0.00 0.00<br />

24605 S 525.15 0.00 0.00 25150 S 810.52 0.00 0.00<br />

24615 S 1,493.01 0.00 0.00 25151 S 810.52 0.00 0.00<br />

24620 S 446.08 0.00 0.00 25210 S 841.35 0.00 0.00<br />

24635 S 1,493.01 0.00 0.00 25215 S 899.14 0.00 0.00<br />

24640 S 55.22 0.00 0.00 25230 S 899.14 0.00 0.00<br />

24650 S 63.71 0.00 0.00 25240 S 899.14 0.00 0.00<br />

24655 S 172.47 0.00 0.00 25248 S 649.03 0.00 0.00<br />

24665 S 1,158.00 0.00 0.00 25250 S 756.10 0.00 0.00<br />

24666 S 1,550.80 0.00 0.00 25251 S 756.10 0.00 0.00<br />

24670 S 81.75 0.00 0.00 25259 S 792.35 0.00 0.00<br />

24675 S 81.75 0.00 0.00 25260 S 899.14 0.00 0.00<br />

24685 S 1,100.20 0.00 0.00 25263 S 810.52 0.00 0.00<br />

24800 S 1,207.59 0.00 0.00 25265 S 841.35 0.00 0.00<br />

24802 S 1,249.48 0.00 0.00 25270 S 899.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 10<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

25272 S 841.35 0.00 0.00 25505 S 172.47 0.00 0.00<br />

25274 S 899.14 0.00 0.00 25515 S 1,100.20 0.00 0.00<br />

25275 S 899.14 0.00 0.00 25520 S 172.47 0.00 0.00<br />

25280 S 899.14 0.00 0.00 25525 S 1,158.00 0.00 0.00<br />

25290 S 841.35 0.00 0.00 25526 S 1,199.89 0.00 0.00<br />

25295 S 679.86 0.00 0.00 25530 S 63.71 0.00 0.00<br />

25300 S 841.35 0.00 0.00 25535 S 81.75 0.00 0.00<br />

25301 S 841.35 0.00 0.00 25545 S 1,100.20 0.00 0.00<br />

25310 S 1,149.79 0.00 0.00 25560 S 63.71 0.00 0.00<br />

25312 S 1,207.59 0.00 0.00 25565 S 172.47 0.00 0.00<br />

25315 S 1,149.79 0.00 0.00 25574 S 1,493.01 0.00 0.00<br />

25316 S 1,972.01 0.00 0.00 25575 S 1,493.01 0.00 0.00<br />

25320 S 1,149.79 0.00 0.00 25600 S 63.71 0.00 0.00<br />

25332 S 1,099.53 0.00 0.00 25605 S 172.47 0.00 0.00<br />

25335 S 1,149.79 0.00 0.00 25606 S 752.89 0.00 0.00<br />

25337 S 1,249.48 0.00 0.00 25607 S 1,592.70 0.00 0.00<br />

25350 S 1,972.01 0.00 0.00 25608 S 1,592.70 0.00 0.00<br />

25355 S 1,149.79 0.00 0.00 25609 S 1,592.70 0.00 0.00<br />

25360 S 841.35 0.00 0.00 25622 S 63.71 0.00 0.00<br />

25365 S 841.35 0.00 0.00 25624 S 172.47 0.00 0.00<br />

25370 S 1,149.79 0.00 0.00 25628 S 1,100.20 0.00 0.00<br />

25375 S 1,207.59 0.00 0.00 25630 S 63.71 0.00 0.00<br />

25390 S 841.35 0.00 0.00 25635 S 172.47 0.00 0.00<br />

25391 S 1,207.59 0.00 0.00 25645 S 1,100.20 0.00 0.00<br />

25392 S 841.35 0.00 0.00 25650 S 63.71 0.00 0.00<br />

25393 S 1,207.59 0.00 0.00 25651 S 1,014.51 0.00 0.00<br />

25394 S 1,808.33 0.00 0.00 25652 S 1,709.13 0.00 0.00<br />

25400 S 1,149.79 0.00 0.00 25660 S 81.75 0.00 0.00<br />

25405 S 2,029.79 0.00 0.00 25670 S 752.89 0.00 0.00<br />

25415 S 1,972.01 0.00 0.00 25671 S 667.64 0.00 0.00<br />

25420 S 2,029.79 0.00 0.00 25675 S 81.75 0.00 0.00<br />

25425 S 1,149.79 0.00 0.00 25676 S 722.06 0.00 0.00<br />

25426 S 1,207.59 0.00 0.00 25680 S 81.75 0.00 0.00<br />

25430 S 1,808.33 0.00 0.00 25685 S 752.89 0.00 0.00<br />

25431 S 1,808.33 0.00 0.00 25690 S 446.08 0.00 0.00<br />

25440 S 2,029.79 0.00 0.00 25695 S 722.06 0.00 0.00<br />

25441 S 6,011.68 3,679.91 1,348.14 25800 S 2,029.79 0.00 0.00<br />

25442 S 6,011.68 3,679.91 1,348.14 25805 S 1,249.48 0.00 0.00<br />

25443 S 1,405.19 0.00 0.00 25810 S 2,071.70 0.00 0.00<br />

25444 S 1,405.19 0.00 0.00 25820 S 1,207.59 0.00 0.00<br />

25445 S 1,405.19 0.00 0.00 25825 S 2,071.70 0.00 0.00<br />

25446 S 6,145.57 3,813.80 1,482.03 25830 S 2,071.70 0.00 0.00<br />

25447 S 1,099.53 0.00 0.00 25907 S 679.86 0.00 0.00<br />

25449 S 1,099.53 0.00 0.00 25922 S 679.86 0.00 0.00<br />

25450 S 1,149.79 0.00 0.00 25929 S 564.10 0.00 0.00<br />

25455 S 1,149.79 0.00 0.00 25931 S 868.45 0.00 0.00<br />

25490 S 1,149.79 0.00 0.00 26010 S 56.33 0.00 0.00<br />

25491 S 1,149.79 0.00 0.00 26011 S 411.48 0.00 0.00<br />

25492 S 1,149.79 0.00 0.00 26020 S 545.98 0.00 0.00<br />

25500 S 63.71 0.00 0.00 26025 S 491.55 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 11<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26030 S 545.98 0.00 0.00 26392 S 803.82 0.00 0.00<br />

26034 S 545.98 0.00 0.00 26410 S 576.81 0.00 0.00<br />

26035 S 662.35 0.00 0.00 26412 S 803.82 0.00 0.00<br />

26040 S 861.62 0.00 0.00 26415 S 861.62 0.00 0.00<br />

26045 S 803.82 0.00 0.00 26416 S 803.82 0.00 0.00<br />

26055 S 545.98 0.00 0.00 26418 S 634.60 0.00 0.00<br />

26060 S 545.98 0.00 0.00 26420 S 861.62 0.00 0.00<br />

26070 S 545.98 0.00 0.00 26426 S 803.82 0.00 0.00<br />

26075 S 634.60 0.00 0.00 26428 S 803.82 0.00 0.00<br />

26080 S 634.60 0.00 0.00 26432 S 576.81 0.00 0.00<br />

26100 S 545.98 0.00 0.00 26433 S 576.81 0.00 0.00<br />

26105 S 491.55 0.00 0.00 26434 S 803.82 0.00 0.00<br />

26110 S 491.55 0.00 0.00 26437 S 576.81 0.00 0.00<br />

26115 S 650.26 0.00 0.00 26440 S 576.81 0.00 0.00<br />

26116 S 650.26 0.00 0.00 26442 S 803.82 0.00 0.00<br />

26117 S 681.09 0.00 0.00 26445 S 576.81 0.00 0.00<br />

26121 S 861.62 0.00 0.00 26449 S 803.82 0.00 0.00<br />

26123 S 861.62 0.00 0.00 26450 S 576.81 0.00 0.00<br />

26125 S 634.60 0.00 0.00 26455 S 576.81 0.00 0.00<br />

26130 S 576.81 0.00 0.00 26460 S 576.81 0.00 0.00<br />

26135 S 861.62 0.00 0.00 26471 S 545.98 0.00 0.00<br />

26140 S 545.98 0.00 0.00 26474 S 545.98 0.00 0.00<br />

26145 S 576.81 0.00 0.00 26476 S 491.55 0.00 0.00<br />

26160 S 576.81 0.00 0.00 26477 S 491.55 0.00 0.00<br />

26170 S 576.81 0.00 0.00 26478 S 491.55 0.00 0.00<br />

26180 S 576.81 0.00 0.00 26479 S 491.55 0.00 0.00<br />

26185 S 634.60 0.00 0.00 26480 S 803.82 0.00 0.00<br />

26200 S 545.98 0.00 0.00 26483 S 803.82 0.00 0.00<br />

26205 S 803.82 0.00 0.00 26485 S 773.00 0.00 0.00<br />

26210 S 545.98 0.00 0.00 26489 S 803.82 0.00 0.00<br />

26215 S 576.81 0.00 0.00 26490 S 803.82 0.00 0.00<br />

26230 S 809.40 0.00 0.00 26492 S 803.82 0.00 0.00<br />

26235 S 576.81 0.00 0.00 26494 S 803.82 0.00 0.00<br />

26236 S 576.81 0.00 0.00 26496 S 803.82 0.00 0.00<br />

26250 S 576.81 0.00 0.00 26497 S 803.82 0.00 0.00<br />

26255 S 803.82 0.00 0.00 26498 S 861.62 0.00 0.00<br />

26260 S 576.81 0.00 0.00 26499 S 803.82 0.00 0.00<br />

26261 S 576.81 0.00 0.00 26500 S 634.60 0.00 0.00<br />

26262 S 545.98 0.00 0.00 26502 S 861.62 0.00 0.00<br />

26320 S 531.73 0.00 0.00 26508 S 576.81 0.00 0.00<br />

26340 S 245.13 0.00 0.00 26510 S 803.82 0.00 0.00<br />

26350 S 718.57 0.00 0.00 26516 S 718.57 0.00 0.00<br />

26352 S 861.62 0.00 0.00 26517 S 803.82 0.00 0.00<br />

26356 S 861.62 0.00 0.00 26518 S 803.82 0.00 0.00<br />

26357 S 861.62 0.00 0.00 26520 S 576.81 0.00 0.00<br />

26358 S 861.62 0.00 0.00 26525 S 576.81 0.00 0.00<br />

26370 S 861.62 0.00 0.00 26530 S 999.83 0.00 0.00<br />

26372 S 861.62 0.00 0.00 26531 S 1,539.08 0.00 0.00<br />

26373 S 803.82 0.00 0.00 26535 S 1,099.53 0.00 0.00<br />

26390 S 861.62 0.00 0.00 26536 S 1,405.19 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 12<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

26540 S 634.60 0.00 0.00 26775 S 170.31 0.00 0.00<br />

26541 S 1,037.41 0.00 0.00 26776 S 722.06 0.00 0.00<br />

26542 S 634.60 0.00 0.00 26785 S 722.06 0.00 0.00<br />

26545 S 861.62 0.00 0.00 26820 S 903.52 0.00 0.00<br />

26546 S 861.62 0.00 0.00 26841 S 861.62 0.00 0.00<br />

26548 S 861.62 0.00 0.00 26842 S 861.62 0.00 0.00<br />

26550 S 773.00 0.00 0.00 26843 S 803.82 0.00 0.00<br />

26555 S 803.82 0.00 0.00 26844 S 803.82 0.00 0.00<br />

26560 S 545.98 0.00 0.00 26850 S 861.62 0.00 0.00<br />

26561 S 803.82 0.00 0.00 26852 S 861.62 0.00 0.00<br />

26562 S 861.62 0.00 0.00 26860 S 803.82 0.00 0.00<br />

26565 S 903.52 0.00 0.00 26861 S 773.00 0.00 0.00<br />

26567 S 903.52 0.00 0.00 26862 S 861.62 0.00 0.00<br />

26568 S 803.82 0.00 0.00 26863 S 803.82 0.00 0.00<br />

26580 S 676.50 0.00 0.00 26910 S 803.82 0.00 0.00<br />

26587 S 676.50 0.00 0.00 26951 S 545.98 0.00 0.00<br />

26590 S 676.50 0.00 0.00 26952 S 634.60 0.00 0.00<br />

26591 S 803.82 0.00 0.00 26990 S 594.61 0.00 0.00<br />

26593 S 576.81 0.00 0.00 26991 S 594.61 0.00 0.00<br />

26596 S 545.98 0.00 0.00 27000 S 649.03 0.00 0.00<br />

26600 S 63.71 0.00 0.00 27001 S 841.35 0.00 0.00<br />

26605 S 81.75 0.00 0.00 27003 S 841.35 0.00 0.00<br />

26607 S 446.08 0.00 0.00 27033 S 1,149.79 0.00 0.00<br />

26608 S 810.68 0.00 0.00 27035 S 1,207.59 0.00 0.00<br />

26615 S 1,158.00 0.00 0.00 27040 S 324.98 0.00 0.00<br />

26641 S 63.71 0.00 0.00 27041 S 366.16 0.00 0.00<br />

26645 S 172.47 0.00 0.00 27047 S 650.26 0.00 0.00<br />

26650 S 722.06 0.00 0.00 27048 S 681.09 0.00 0.00<br />

26665 S 1,158.00 0.00 0.00 27049 S 681.09 0.00 0.00<br />

26670 S 63.71 0.00 0.00 27050 S 679.86 0.00 0.00<br />

26675 S 172.47 0.00 0.00 27052 S 679.86 0.00 0.00<br />

26676 S 722.06 0.00 0.00 27060 S 779.55 0.00 0.00<br />

26685 S 752.89 0.00 0.00 27062 S 779.55 0.00 0.00<br />

26686 S 1,493.01 0.00 0.00 27065 S 779.55 0.00 0.00<br />

26700 S 63.71 0.00 0.00 27066 S 941.05 0.00 0.00<br />

26705 S 81.75 0.00 0.00 27067 S 941.05 0.00 0.00<br />

26706 S 446.08 0.00 0.00 27080 S 810.52 0.00 0.00<br />

26715 S 810.68 0.00 0.00 27086 S 324.98 0.00 0.00<br />

26720 S 63.71 0.00 0.00 27087 S 679.86 0.00 0.00<br />

26725 S 63.71 0.00 0.00 27097 S 841.35 0.00 0.00<br />

26727 S 986.48 0.00 0.00 27098 S 841.35 0.00 0.00<br />

26735 S 810.68 0.00 0.00 27100 S 1,207.59 0.00 0.00<br />

26740 S 63.71 0.00 0.00 27105 S 1,207.59 0.00 0.00<br />

26742 S 81.75 0.00 0.00 27110 S 1,207.59 0.00 0.00<br />

26746 S 852.58 0.00 0.00 27111 S 1,207.59 0.00 0.00<br />

26750 S 63.71 0.00 0.00 27193 S 81.75 0.00 0.00<br />

26755 S 63.71 0.00 0.00 27194 S 525.15 0.00 0.00<br />

26756 S 722.06 0.00 0.00 27200 S 63.71 0.00 0.00<br />

26765 S 810.68 0.00 0.00 27202 S 1,069.38 0.00 0.00<br />

26770 S 63.71 0.00 0.00 27220 S 63.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 13<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27230 S 81.75 0.00 0.00 27397 S 1,149.79 0.00 0.00<br />

27238 S 172.47 0.00 0.00 27400 S 1,149.79 0.00 0.00<br />

27246 S 172.47 0.00 0.00 27403 S 899.14 0.00 0.00<br />

27250 S 81.75 0.00 0.00 27405 S 1,207.59 0.00 0.00<br />

27252 S 525.15 0.00 0.00 27407 S 2,029.79 0.00 0.00<br />

27256 S 63.71 0.00 0.00 27409 S 1,207.59 0.00 0.00<br />

27257 S 555.98 0.00 0.00 27416 S 1,808.33 0.00 0.00<br />

27265 S 81.75 0.00 0.00 27418 S 1,149.79 0.00 0.00<br />

27266 S 525.15 0.00 0.00 27420 S 1,149.79 0.00 0.00<br />

27267 S 63.71 0.00 0.00 27422 S 1,383.38 0.00 0.00<br />

27275 S 525.15 0.00 0.00 27424 S 1,149.79 0.00 0.00<br />

27301 S 632.14 0.00 0.00 27425 S 1,074.94 0.00 0.00<br />

27305 S 649.03 0.00 0.00 27427 S 1,149.79 0.00 0.00<br />

27306 S 679.86 0.00 0.00 27428 S 2,029.79 0.00 0.00<br />

27307 S 679.86 0.00 0.00 27429 S 2,029.79 0.00 0.00<br />

27310 S 899.14 0.00 0.00 27430 S 1,207.59 0.00 0.00<br />

27323 S 324.98 0.00 0.00 27435 S 1,207.59 0.00 0.00<br />

27324 S 595.84 0.00 0.00 27437 S 1,057.62 0.00 0.00<br />

27325 S 583.84 0.00 0.00 27438 S 1,405.19 0.00 0.00<br />

27326 S 583.84 0.00 0.00 27440 S 1,508.40 0.00 0.00<br />

27327 S 650.26 0.00 0.00 27441 S 1,099.53 0.00 0.00<br />

27328 S 681.09 0.00 0.00 27442 S 1,099.53 0.00 0.00<br />

27329 S 738.88 0.00 0.00 27443 S 1,099.53 0.00 0.00<br />

27330 S 899.14 0.00 0.00 27446 S 10,788.48 6,481.22 2,173.97<br />

27331 S 899.14 0.00 0.00 27496 S 779.55 0.00 0.00<br />

27332 S 899.14 0.00 0.00 27497 S 679.86 0.00 0.00<br />

27333 S 899.14 0.00 0.00 27498 S 679.86 0.00 0.00<br />

27334 S 899.14 0.00 0.00 27499 S 679.86 0.00 0.00<br />

27335 S 899.14 0.00 0.00 27500 S 172.47 0.00 0.00<br />

27340 S 679.86 0.00 0.00 27501 S 81.75 0.00 0.00<br />

27345 S 737.65 0.00 0.00 27502 S 446.08 0.00 0.00<br />

27347 S 737.65 0.00 0.00 27503 S 81.75 0.00 0.00<br />

27350 S 899.14 0.00 0.00 27508 S 81.75 0.00 0.00<br />

27355 S 841.35 0.00 0.00 27509 S 752.89 0.00 0.00<br />

27356 S 899.14 0.00 0.00 27510 S 172.47 0.00 0.00<br />

27357 S 941.05 0.00 0.00 27516 S 81.75 0.00 0.00<br />

27358 S 941.05 0.00 0.00 27517 S 81.75 0.00 0.00<br />

27360 S 941.05 0.00 0.00 27520 S 81.75 0.00 0.00<br />

27372 S 914.68 0.00 0.00 27530 S 81.75 0.00 0.00<br />

27380 S 594.61 0.00 0.00 27532 S 446.08 0.00 0.00<br />

27381 S 679.86 0.00 0.00 27538 S 81.75 0.00 0.00<br />

27385 S 679.86 0.00 0.00 27550 S 81.75 0.00 0.00<br />

27386 S 679.86 0.00 0.00 27552 S 470.73 0.00 0.00<br />

27390 S 594.61 0.00 0.00 27560 S 81.75 0.00 0.00<br />

27391 S 649.03 0.00 0.00 27562 S 470.73 0.00 0.00<br />

27392 S 679.86 0.00 0.00 27566 S 1,069.38 0.00 0.00<br />

27393 S 810.52 0.00 0.00 27570 S 470.73 0.00 0.00<br />

27394 S 841.35 0.00 0.00 27594 S 679.86 0.00 0.00<br />

27395 S 1,149.79 0.00 0.00 27600 S 679.86 0.00 0.00<br />

27396 S 841.35 0.00 0.00 27601 S 679.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 14<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27602 S 679.86 0.00 0.00 27730 S 810.52 0.00 0.00<br />

27603 S 601.31 0.00 0.00 27732 S 810.52 0.00 0.00<br />

27604 S 649.03 0.00 0.00 27734 S 810.52 0.00 0.00<br />

27605 S 591.42 0.00 0.00 27740 S 810.52 0.00 0.00<br />

27606 S 594.61 0.00 0.00 27742 S 1,118.97 0.00 0.00<br />

27607 S 649.03 0.00 0.00 27745 S 1,972.01 0.00 0.00<br />

27610 S 810.52 0.00 0.00 27750 S 81.75 0.00 0.00<br />

27612 S 841.35 0.00 0.00 27752 S 446.08 0.00 0.00<br />

27613 S 133.61 0.00 0.00 27756 S 752.89 0.00 0.00<br />

27614 S 650.26 0.00 0.00 27758 S 1,158.00 0.00 0.00<br />

27615 S 841.35 0.00 0.00 27759 S 1,550.80 0.00 0.00<br />

27618 S 531.73 0.00 0.00 27760 S 81.75 0.00 0.00<br />

27619 S 681.09 0.00 0.00 27762 S 446.08 0.00 0.00<br />

27620 S 899.14 0.00 0.00 27766 S 1,100.20 0.00 0.00<br />

27625 S 899.14 0.00 0.00 27767 S 63.71 0.00 0.00<br />

27626 S 899.14 0.00 0.00 27768 S 63.71 0.00 0.00<br />

27630 S 679.86 0.00 0.00 27769 S 1,709.13 0.00 0.00<br />

27635 S 841.35 0.00 0.00 27780 S 81.75 0.00 0.00<br />

27637 S 841.35 0.00 0.00 27781 S 446.08 0.00 0.00<br />

27638 S 841.35 0.00 0.00 27784 S 1,100.20 0.00 0.00<br />

27640 S 1,118.97 0.00 0.00 27786 S 81.75 0.00 0.00<br />

27641 S 810.52 0.00 0.00 27788 S 81.75 0.00 0.00<br />

27647 S 1,149.79 0.00 0.00 27792 S 1,100.20 0.00 0.00<br />

27650 S 1,149.79 0.00 0.00 27808 S 81.75 0.00 0.00<br />

27652 S 1,972.01 0.00 0.00 27810 S 172.47 0.00 0.00<br />

27654 S 1,149.79 0.00 0.00 27814 S 1,100.20 0.00 0.00<br />

27656 S 649.03 0.00 0.00 27816 S 81.75 0.00 0.00<br />

27658 S 594.61 0.00 0.00 27818 S 172.47 0.00 0.00<br />

27659 S 649.03 0.00 0.00 27822 S 1,100.20 0.00 0.00<br />

27664 S 649.03 0.00 0.00 27823 S 1,493.01 0.00 0.00<br />

27665 S 810.52 0.00 0.00 27824 S 81.75 0.00 0.00<br />

27675 S 649.03 0.00 0.00 27825 S 446.08 0.00 0.00<br />

27676 S 841.35 0.00 0.00 27826 S 1,100.20 0.00 0.00<br />

27680 S 841.35 0.00 0.00 27827 S 1,493.01 0.00 0.00<br />

27681 S 810.52 0.00 0.00 27828 S 1,550.80 0.00 0.00<br />

27685 S 841.35 0.00 0.00 27829 S 1,069.38 0.00 0.00<br />

27686 S 841.35 0.00 0.00 27830 S 81.75 0.00 0.00<br />

27687 S 841.35 0.00 0.00 27831 S 446.08 0.00 0.00<br />

27690 S 1,207.59 0.00 0.00 27832 S 1,069.38 0.00 0.00<br />

27691 S 1,207.59 0.00 0.00 27840 S 172.47 0.00 0.00<br />

27692 S 1,149.79 0.00 0.00 27842 S 470.73 0.00 0.00<br />

27695 S 810.52 0.00 0.00 27846 S 1,100.20 0.00 0.00<br />

27696 S 810.52 0.00 0.00 27848 S 1,100.20 0.00 0.00<br />

27698 S 810.52 0.00 0.00 27860 S 470.73 0.00 0.00<br />

27700 S 1,099.53 0.00 0.00 27870 S 2,029.79 0.00 0.00<br />

27704 S 649.03 0.00 0.00 27871 S 2,029.79 0.00 0.00<br />

27705 S 1,118.97 0.00 0.00 27884 S 679.86 0.00 0.00<br />

27707 S 649.03 0.00 0.00 27889 S 841.35 0.00 0.00<br />

27709 S 810.52 0.00 0.00 27892 S 679.86 0.00 0.00<br />

27726 S 1,014.51 0.00 0.00 27893 S 679.86 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 15<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

27894 S 679.86 0.00 0.00 28153 S 676.67 0.00 0.00<br />

28001 S 130.40 0.00 0.00 28160 S 676.67 0.00 0.00<br />

28002 S 679.86 0.00 0.00 28171 S 676.67 0.00 0.00<br />

28003 S 679.86 0.00 0.00 28173 S 676.67 0.00 0.00<br />

28005 S 676.67 0.00 0.00 28175 S 676.67 0.00 0.00<br />

28008 S 676.67 0.00 0.00 28190 S 134.67 0.00 0.00<br />

28010 S 95.84 0.00 0.00 28192 S 531.73 0.00 0.00<br />

28011 S 676.67 0.00 0.00 28193 S 366.16 0.00 0.00<br />

28020 S 645.84 0.00 0.00 28200 S 676.67 0.00 0.00<br />

28022 S 645.84 0.00 0.00 28202 S 676.67 0.00 0.00<br />

28024 S 645.84 0.00 0.00 28208 S 676.67 0.00 0.00<br />

28035 S 672.46 0.00 0.00 28210 S 1,188.43 0.00 0.00<br />

28043 S 650.26 0.00 0.00 28220 S 207.72 0.00 0.00<br />

28045 S 676.67 0.00 0.00 28222 S 591.42 0.00 0.00<br />

28046 S 676.67 0.00 0.00 28225 S 591.42 0.00 0.00<br />

28050 S 645.84 0.00 0.00 28226 S 591.42 0.00 0.00<br />

28052 S 645.84 0.00 0.00 28230 S 203.79 0.00 0.00<br />

28054 S 645.84 0.00 0.00 28232 S 194.88 0.00 0.00<br />

28055 S 672.46 0.00 0.00 28234 S 645.84 0.00 0.00<br />

28060 S 645.84 0.00 0.00 28238 S 1,188.43 0.00 0.00<br />

28062 S 676.67 0.00 0.00 28240 S 645.84 0.00 0.00<br />

28070 S 676.67 0.00 0.00 28250 S 676.67 0.00 0.00<br />

28072 S 676.67 0.00 0.00 28260 S 676.67 0.00 0.00<br />

28080 S 676.67 0.00 0.00 28261 S 676.67 0.00 0.00<br />

28086 S 645.84 0.00 0.00 28262 S 734.46 0.00 0.00<br />

28088 S 645.84 0.00 0.00 28264 S 1,103.18 0.00 0.00<br />

28090 S 676.67 0.00 0.00 28270 S 676.67 0.00 0.00<br />

28092 S 676.67 0.00 0.00 28272 S 188.12 0.00 0.00<br />

28100 S 645.84 0.00 0.00 28280 S 645.84 0.00 0.00<br />

28102 S 1,188.43 0.00 0.00 28285 S 676.67 0.00 0.00<br />

28103 S 1,188.43 0.00 0.00 28286 S 734.46 0.00 0.00<br />

28104 S 645.84 0.00 0.00 28288 S 676.67 0.00 0.00<br />

28106 S 1,188.43 0.00 0.00 28289 S 676.67 0.00 0.00<br />

28107 S 1,188.43 0.00 0.00 28290 S 834.08 0.00 0.00<br />

28108 S 645.84 0.00 0.00 28292 S 834.08 0.00 0.00<br />

28110 S 676.67 0.00 0.00 28293 S 864.90 0.00 0.00<br />

28111 S 676.67 0.00 0.00 28294 S 864.90 0.00 0.00<br />

28112 S 676.67 0.00 0.00 28296 S 864.90 0.00 0.00<br />

28113 S 676.67 0.00 0.00 28297 S 864.90 0.00 0.00<br />

28114 S 676.67 0.00 0.00 28298 S 864.90 0.00 0.00<br />

28116 S 676.67 0.00 0.00 28299 S 964.60 0.00 0.00<br />

28118 S 734.46 0.00 0.00 28300 S 1,157.61 0.00 0.00<br />

28119 S 734.46 0.00 0.00 28302 S 645.84 0.00 0.00<br />

28120 S 910.25 0.00 0.00 28304 S 1,157.61 0.00 0.00<br />

28122 S 676.67 0.00 0.00 28305 S 1,188.43 0.00 0.00<br />

28124 S 220.54 0.00 0.00 28306 S 734.46 0.00 0.00<br />

28126 S 676.67 0.00 0.00 28307 S 734.46 0.00 0.00<br />

28130 S 676.67 0.00 0.00 28308 S 645.84 0.00 0.00<br />

28140 S 676.67 0.00 0.00 28309 S 1,246.23 0.00 0.00<br />

28150 S 676.67 0.00 0.00 28310 S 676.67 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 16<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

28312 S 676.67 0.00 0.00 28636 S 752.89 0.00 0.00<br />

28313 S 645.84 0.00 0.00 28645 S 752.89 0.00 0.00<br />

28315 S 734.46 0.00 0.00 28660 S 45.61 0.00 0.00<br />

28320 S 1,246.23 0.00 0.00 28665 S 470.73 0.00 0.00<br />

28322 S 1,246.23 0.00 0.00 28666 S 752.89 0.00 0.00<br />

28340 S 734.46 0.00 0.00 28675 S 752.89 0.00 0.00<br />

28341 S 734.46 0.00 0.00 28705 S 1,246.23 0.00 0.00<br />

28344 S 734.46 0.00 0.00 28715 S 2,029.79 0.00 0.00<br />

28345 S 734.46 0.00 0.00 28725 S 1,246.23 0.00 0.00<br />

28400 S 81.75 0.00 0.00 28730 S 1,246.23 0.00 0.00<br />

28405 S 446.08 0.00 0.00 28735 S 1,246.23 0.00 0.00<br />

28406 S 722.06 0.00 0.00 28737 S 1,288.13 0.00 0.00<br />

28415 S 1,493.01 0.00 0.00 28740 S 1,246.23 0.00 0.00<br />

28420 S 1,158.00 0.00 0.00 28750 S 1,246.23 0.00 0.00<br />

28430 S 63.71 0.00 0.00 28755 S 734.46 0.00 0.00<br />

28435 S 81.75 0.00 0.00 28760 S 1,246.23 0.00 0.00<br />

28436 S 722.06 0.00 0.00 28810 S 645.84 0.00 0.00<br />

28445 S 1,100.20 0.00 0.00 28820 S 645.84 0.00 0.00<br />

28446 S 1,885.61 0.00 0.00 28825 S 645.84 0.00 0.00<br />

28450 S 63.71 0.00 0.00 28890 S 170.66 0.00 0.00<br />

28455 S 63.71 0.00 0.00 29000 S 43.24 0.00 0.00<br />

28456 S 722.06 0.00 0.00 29010 S 96.91 0.00 0.00<br />

28465 S 1,100.20 0.00 0.00 29015 S 96.91 0.00 0.00<br />

28470 S 63.71 0.00 0.00 29020 S 43.24 0.00 0.00<br />

28475 S 63.71 0.00 0.00 29025 S 43.24 0.00 0.00<br />

28476 S 722.06 0.00 0.00 29035 S 96.91 0.00 0.00<br />

28485 S 1,158.00 0.00 0.00 29040 S 43.24 0.00 0.00<br />

28490 S 63.71 0.00 0.00 29044 S 96.91 0.00 0.00<br />

28495 S 63.71 0.00 0.00 29046 S 96.91 0.00 0.00<br />

28496 S 722.06 0.00 0.00 29049 S 39.19 0.00 0.00<br />

28505 S 752.89 0.00 0.00 29055 S 96.91 0.00 0.00<br />

28510 S 57.36 0.00 0.00 29058 S 43.24 0.00 0.00<br />

28515 S 63.71 0.00 0.00 29065 S 45.96 0.00 0.00<br />

28525 S 752.89 0.00 0.00 29075 S 44.18 0.00 0.00<br />

28530 S 55.22 0.00 0.00 29085 S 43.24 0.00 0.00<br />

28531 S 752.89 0.00 0.00 29086 S 37.05 0.00 0.00<br />

28540 S 63.71 0.00 0.00 29105 S 39.90 0.00 0.00<br />

28545 S 667.64 0.00 0.00 29125 S 34.55 0.00 0.00<br />

28546 S 722.06 0.00 0.00 29126 S 36.70 0.00 0.00<br />

28555 S 1,069.38 0.00 0.00 29130 S 15.68 0.00 0.00<br />

28570 S 82.65 0.00 0.00 29131 S 22.80 0.00 0.00<br />

28575 S 446.08 0.00 0.00 29200 S 22.09 0.00 0.00<br />

28576 S 752.89 0.00 0.00 29220 S 23.87 0.00 0.00<br />

28585 S 752.89 0.00 0.00 29240 S 24.94 0.00 0.00<br />

28600 S 63.71 0.00 0.00 29260 S 23.87 0.00 0.00<br />

28605 S 81.75 0.00 0.00 29280 S 24.23 0.00 0.00<br />

28606 S 722.06 0.00 0.00 29305 S 96.91 0.00 0.00<br />

28615 S 1,100.20 0.00 0.00 29325 S 96.91 0.00 0.00<br />

28630 S 63.71 0.00 0.00 29345 S 60.21 0.00 0.00<br />

28635 S 470.73 0.00 0.00 29355 S 59.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 17<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

29358 S 73.40 0.00 0.00 29847 S 1,226.78 0.00 0.00<br />

29365 S 57.01 0.00 0.00 29848 S 1,231.31 0.00 0.00<br />

29405 S 42.40 0.00 0.00 29850 S 889.84 0.00 0.00<br />

29425 S 43.11 0.00 0.00 29851 S 1,284.58 0.00 0.00<br />

29435 S 54.51 0.00 0.00 29855 S 1,284.58 0.00 0.00<br />

29440 S 23.16 0.00 0.00 29856 S 1,284.58 0.00 0.00<br />

29445 S 57.36 0.00 0.00 29860 S 1,284.58 0.00 0.00<br />

29450 S 43.24 0.00 0.00 29861 S 1,284.58 0.00 0.00<br />

29505 S 38.48 0.00 0.00 29862 S 1,626.05 0.00 0.00<br />

29515 S 32.78 0.00 0.00 29863 S 1,284.58 0.00 0.00<br />

29520 S 23.51 0.00 0.00 29866 S 1,962.30 0.00 0.00<br />

29530 S 23.87 0.00 0.00 29870 S 832.05 0.00 0.00<br />

29540 S 17.81 0.00 0.00 29871 S 832.05 0.00 0.00<br />

29550 S 18.17 0.00 0.00 29873 S 832.05 0.00 0.00<br />

29580 S 24.59 0.00 0.00 29874 S 832.05 0.00 0.00<br />

29590 S 19.95 0.00 0.00 29875 S 889.84 0.00 0.00<br />

29700 S 33.13 0.00 0.00 29876 S 889.84 0.00 0.00<br />

29705 S 28.14 0.00 0.00 29877 S 889.84 0.00 0.00<br />

29710 S 49.52 0.00 0.00 29879 S 832.05 0.00 0.00<br />

29715 S 43.24 0.00 0.00 29880 S 889.84 0.00 0.00<br />

29720 S 41.33 0.00 0.00 29881 S 889.84 0.00 0.00<br />

29730 S 27.08 0.00 0.00 29882 S 832.05 0.00 0.00<br />

29740 S 37.05 0.00 0.00 29883 S 832.05 0.00 0.00<br />

29750 S 38.83 0.00 0.00 29884 S 832.05 0.00 0.00<br />

29800 S 832.05 0.00 0.00 29885 S 1,226.78 0.00 0.00<br />

29804 S 832.05 0.00 0.00 29886 S 832.05 0.00 0.00<br />

29805 S 832.05 0.00 0.00 29887 S 832.05 0.00 0.00<br />

29806 S 1,226.78 0.00 0.00 29888 S 1,226.78 0.00 0.00<br />

29807 S 1,226.78 0.00 0.00 29889 S 1,226.78 0.00 0.00<br />

29819 S 1,226.78 0.00 0.00 29891 S 1,226.78 0.00 0.00<br />

29820 S 1,226.78 0.00 0.00 29892 S 1,226.78 0.00 0.00<br />

29821 S 1,226.78 0.00 0.00 29893 S 1,035.74 0.00 0.00<br />

29822 S 832.05 0.00 0.00 29894 S 832.05 0.00 0.00<br />

29823 S 1,226.78 0.00 0.00 29895 S 832.05 0.00 0.00<br />

29824 S 931.74 0.00 0.00 29897 S 832.05 0.00 0.00<br />

29825 S 1,226.78 0.00 0.00 29898 S 832.05 0.00 0.00<br />

29826 S 1,226.78 0.00 0.00 29899 S 1,226.78 0.00 0.00<br />

29827 S 1,326.48 0.00 0.00 29900 S 832.05 0.00 0.00<br />

29828 S 1,962.30 0.00 0.00 29901 S 832.05 0.00 0.00<br />

29830 S 832.05 0.00 0.00 29902 S 832.05 0.00 0.00<br />

29834 S 832.05 0.00 0.00 29904 S 1,172.82 0.00 0.00<br />

29835 S 832.05 0.00 0.00 29905 S 1,172.82 0.00 0.00<br />

29836 S 832.05 0.00 0.00 29906 S 1,172.82 0.00 0.00<br />

29837 S 832.05 0.00 0.00 29907 S 1,962.30 0.00 0.00<br />

29838 S 832.05 0.00 0.00 30000 S 131.86 0.00 0.00<br />

29840 S 832.05 0.00 0.00 30020 S 131.86 0.00 0.00<br />

29843 S 832.05 0.00 0.00 30100 S 85.51 0.00 0.00<br />

29844 S 832.05 0.00 0.00 30110 S 132.18 0.00 0.00<br />

29845 S 832.05 0.00 0.00 30115 S 558.50 0.00 0.00<br />

29846 S 832.05 0.00 0.00 30117 S 589.33 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 18<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

30118 S 739.16 0.00 0.00 31080 S 1,138.22 0.00 0.00<br />

30120 S 504.08 0.00 0.00 31081 S 1,138.22 0.00 0.00<br />

30124 S 300.36 0.00 0.00 31084 S 1,138.22 0.00 0.00<br />

30125 S 1,049.60 0.00 0.00 31085 S 1,138.22 0.00 0.00<br />

30130 S 589.33 0.00 0.00 31086 S 1,138.22 0.00 0.00<br />

30140 S 708.33 0.00 0.00 31087 S 1,138.22 0.00 0.00<br />

30150 S 1,080.43 0.00 0.00 31090 S 1,180.13 0.00 0.00<br />

30160 S 1,138.22 0.00 0.00 31200 S 1,049.60 0.00 0.00<br />

30200 S 67.34 0.00 0.00 31201 S 1,180.13 0.00 0.00<br />

30210 S 85.51 0.00 0.00 31205 S 1,080.43 0.00 0.00<br />

30220 S 373.72 0.00 0.00 31231 S 72.08 0.00 0.00<br />

30300 S 25.76 0.00 0.00 31233 S 77.65 0.00 0.00<br />

30310 S 504.08 0.00 0.00 31235 S 527.52 0.00 0.00<br />

30320 S 558.50 0.00 0.00 31237 S 581.94 0.00 0.00<br />

30400 S 1,138.22 0.00 0.00 31238 S 527.52 0.00 0.00<br />

30410 S 1,180.13 0.00 0.00 31239 S 770.02 0.00 0.00<br />

30420 S 1,180.13 0.00 0.00 31240 S 581.94 0.00 0.00<br />

30430 S 739.16 0.00 0.00 31254 S 712.22 0.00 0.00<br />

30435 S 1,180.13 0.00 0.00 31255 S 811.91 0.00 0.00<br />

30450 S 1,314.02 0.00 0.00 31256 S 712.22 0.00 0.00<br />

30460 S 1,314.02 0.00 0.00 31267 S 712.22 0.00 0.00<br />

30462 S 1,479.69 0.00 0.00 31276 S 712.22 0.00 0.00<br />

30465 S 1,479.69 0.00 0.00 31287 S 712.22 0.00 0.00<br />

30520 S 796.95 0.00 0.00 31288 S 712.22 0.00 0.00<br />

30540 S 1,180.13 0.00 0.00 31300 S 838.85 0.00 0.00<br />

30545 S 1,180.13 0.00 0.00 31320 S 1,049.60 0.00 0.00<br />

30560 S 138.52 0.00 0.00 31400 S 1,049.60 0.00 0.00<br />

30580 S 1,138.22 0.00 0.00 31420 S 1,049.60 0.00 0.00<br />

30600 S 1,138.22 0.00 0.00 31500 S 96.41 0.00 0.00<br />

30620 S 1,314.02 0.00 0.00 31502 S 55.44 0.00 0.00<br />

30630 S 972.75 0.00 0.00 31505 S 32.76 0.00 0.00<br />

30801 S 310.56 0.00 0.00 31510 S 581.94 0.00 0.00<br />

30802 S 310.56 0.00 0.00 31511 S 77.65 0.00 0.00<br />

30901 S 44.30 0.00 0.00 31512 S 581.94 0.00 0.00<br />

30903 S 57.06 0.00 0.00 31513 S 77.65 0.00 0.00<br />

30905 S 57.06 0.00 0.00 31515 S 527.52 0.00 0.00<br />

30906 S 57.06 0.00 0.00 31520 S 72.08 0.00 0.00<br />

30915 S 760.28 0.00 0.00 31525 S 527.52 0.00 0.00<br />

30920 S 791.11 0.00 0.00 31526 S 681.40 0.00 0.00<br />

30930 S 647.12 0.00 0.00 31527 S 626.97 0.00 0.00<br />

31000 S 110.10 0.00 0.00 31528 S 581.94 0.00 0.00<br />

31002 S 300.36 0.00 0.00 31529 S 581.94 0.00 0.00<br />

31020 S 708.33 0.00 0.00 31530 S 681.40 0.00 0.00<br />

31030 S 1,080.43 0.00 0.00 31531 S 712.22 0.00 0.00<br />

31032 S 1,138.22 0.00 0.00 31535 S 681.40 0.00 0.00<br />

31040 S 987.06 0.00 0.00 31536 S 712.22 0.00 0.00<br />

31050 S 1,049.60 0.00 0.00 31540 S 712.22 0.00 0.00<br />

31051 S 1,138.22 0.00 0.00 31541 S 770.02 0.00 0.00<br />

31070 S 708.33 0.00 0.00 31545 S 770.02 0.00 0.00<br />

31075 S 1,138.22 0.00 0.00 31546 S 770.02 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 19<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

31560 S 811.91 0.00 0.00 32405 S 351.34 0.00 0.00<br />

31561 S 811.91 0.00 0.00 32420 S 213.64 0.00 0.00<br />

31570 S 581.94 0.00 0.00 32421 S 213.64 0.00 0.00<br />

31571 S 681.40 0.00 0.00 32422 S 212.69 0.00 0.00<br />

31575 S 62.00 0.00 0.00 32550 S 1,190.85 0.00 0.00<br />

31576 S 681.40 0.00 0.00 32960 S 212.69 0.00 0.00<br />

31577 S 201.28 0.00 0.00 32998 S 1,854.10 0.00 0.00<br />

31578 S 681.40 0.00 0.00 33010 S 213.64 0.00 0.00<br />

31579 S 110.45 0.00 0.00 33011 S 213.64 0.00 0.00<br />

31580 S 1,180.13 0.00 0.00 33206 S 6,854.45 4,078.38 1,302.31<br />

31582 S 1,180.13 0.00 0.00 33207 S 6,854.45 4,078.38 1,302.31<br />

31588 S 1,180.13 0.00 0.00 33208 S 8,501.47 4,953.76 1,406.07<br />

31590 S 1,180.13 0.00 0.00 33210 S 2,012.83 0.00 0.00<br />

31595 S 1,049.60 0.00 0.00 33211 S 2,012.83 0.00 0.00<br />

31603 S 310.56 0.00 0.00 33212 S 5,383.19 3,066.57 749.96<br />

31605 S 300.36 0.00 0.00 33213 S 6,213.36 3,481.21 749.07<br />

31611 S 739.16 0.00 0.00 33214 S 8,501.47 4,953.76 1,406.07<br />

31612 S 653.91 0.00 0.00 33215 S 882.25 0.00 0.00<br />

31613 S 708.33 0.00 0.00 33216 S 2,012.83 0.00 0.00<br />

31614 S 1,049.60 0.00 0.00 33217 S 2,012.83 0.00 0.00<br />

31615 S 310.56 0.00 0.00 33218 S 882.25 0.00 0.00<br />

31622 S 363.72 0.00 0.00 33220 S 882.25 0.00 0.00<br />

31623 S 418.14 0.00 0.00 33222 S 533.28 0.00 0.00<br />

31624 S 418.14 0.00 0.00 33223 S 533.28 0.00 0.00<br />

31625 S 418.14 0.00 0.00 33224 S 8,024.59 4,804.30 1,584.02<br />

31628 S 418.14 0.00 0.00 33225 S 8,024.59 4,804.30 1,584.02<br />

31629 S 418.14 0.00 0.00 33226 S 882.25 0.00 0.00<br />

31630 S 716.52 0.00 0.00 33233 S 655.93 0.00 0.00<br />

31631 S 716.52 0.00 0.00 33234 S 882.25 0.00 0.00<br />

31632 S 406.67 0.00 0.00 33235 S 882.25 0.00 0.00<br />

31633 S 406.67 0.00 0.00 33240 S 20,003.26 10,692.56 1,381.86<br />

31635 S 418.14 0.00 0.00 33241 S 882.25 0.00 0.00<br />

31636 S 716.52 0.00 0.00 33249 S 26,695.88 14,299.42 1,902.95<br />

31637 S 363.72 0.00 0.00 33282 S 4,220.79 2,526.81 832.84<br />

31638 S 716.52 0.00 0.00 33284 S 329.21 0.00 0.00<br />

31640 S 716.52 0.00 0.00 34490 S 1,607.30 0.00 0.00<br />

31641 S 716.52 0.00 0.00 35188 S 1,107.07 0.00 0.00<br />

31643 S 418.14 0.00 0.00 35207 S 1,107.07 0.00 0.00<br />

31645 S 363.72 0.00 0.00 35473 S 1,928.14 0.00 0.00<br />

31646 S 363.72 0.00 0.00 35476 S 1,928.14 0.00 0.00<br />

31656 S 363.72 0.00 0.00 35492 S 3,598.69 0.00 0.00<br />

31717 S 201.28 0.00 0.00 35761 S 1,157.65 0.00 0.00<br />

31720 S 30.82 0.00 0.00 35875 S 1,448.54 0.00 0.00<br />

31730 S 201.28 0.00 0.00 35876 S 1,448.54 0.00 0.00<br />

31750 S 1,180.13 0.00 0.00 36002 S 92.45 0.00 0.00<br />

31755 S 1,049.60 0.00 0.00 36260 S 838.67 0.00 0.00<br />

31820 S 504.08 0.00 0.00 36261 S 655.93 0.00 0.00<br />

31825 S 708.33 0.00 0.00 36262 S 601.50 0.00 0.00<br />

31830 S 708.33 0.00 0.00 36420 S 8.71 0.00 0.00<br />

32400 S 351.34 0.00 0.00 36425 S 8.71 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 20<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

36430 S 33.49 0.00 0.00 36800 S 902.84 0.00 0.00<br />

36440 S 133.75 0.00 0.00 36810 S 902.84 0.00 0.00<br />

36450 S 133.75 0.00 0.00 36815 S 902.84 0.00 0.00<br />

36455 S 133.75 0.00 0.00 36818 S 1,049.28 0.00 0.00<br />

36468 S 33.01 0.00 0.00 36819 S 1,049.28 0.00 0.00<br />

36469 S 33.01 0.00 0.00 36820 S 1,049.28 0.00 0.00<br />

36470 S 33.01 0.00 0.00 36821 S 1,049.28 0.00 0.00<br />

36471 S 33.01 0.00 0.00 36825 S 1,107.07 0.00 0.00<br />

36475 S 1,517.93 0.00 0.00 36830 S 1,107.07 0.00 0.00<br />

36476 S 1,190.37 0.00 0.00 36831 S 1,448.54 0.00 0.00<br />

36478 S 1,190.37 0.00 0.00 36832 S 1,107.07 0.00 0.00<br />

36479 S 1,190.37 0.00 0.00 36833 S 1,107.07 0.00 0.00<br />

36511 S 458.54 0.00 0.00 36834 S 1,049.28 0.00 0.00<br />

36512 S 458.54 0.00 0.00 36835 S 960.63 0.00 0.00<br />

36513 S 458.54 0.00 0.00 36860 S 110.25 0.00 0.00<br />

36514 S 458.54 0.00 0.00 36861 S 902.84 0.00 0.00<br />

36515 S 1,227.51 0.00 0.00 36870 S 1,578.92 0.00 0.00<br />

36516 S 1,227.51 0.00 0.00 37184 S 1,607.30 0.00 0.00<br />

36522 S 1,227.51 0.00 0.00 37185 S 1,607.30 0.00 0.00<br />

36555 S 380.98 0.00 0.00 37186 S 1,607.30 0.00 0.00<br />

36556 S 380.98 0.00 0.00 37187 S 1,607.30 0.00 0.00<br />

36557 S 711.52 0.00 0.00 37188 S 1,607.30 0.00 0.00<br />

36558 S 711.52 0.00 0.00 37200 S 1,186.09 0.00 0.00<br />

36560 S 838.67 0.00 0.00 37203 S 1,186.09 0.00 0.00<br />

36561 S 838.67 0.00 0.00 37500 S 1,118.67 0.00 0.00<br />

36563 S 838.67 0.00 0.00 37607 S 791.11 0.00 0.00<br />

36565 S 838.67 0.00 0.00 37609 S 531.73 0.00 0.00<br />

36566 S 838.67 0.00 0.00 37650 S 760.28 0.00 0.00<br />

36568 S 380.98 0.00 0.00 37700 S 760.28 0.00 0.00<br />

36569 S 380.98 0.00 0.00 37718 S 791.11 0.00 0.00<br />

36570 S 742.34 0.00 0.00 37722 S 1,118.67 0.00 0.00<br />

36571 S 742.34 0.00 0.00 37735 S 1,118.67 0.00 0.00<br />

36575 S 306.42 0.00 0.00 37760 S 791.11 0.00 0.00<br />

36576 S 435.40 0.00 0.00 37765 S 1,090.95 0.00 0.00<br />

36578 S 711.52 0.00 0.00 37766 S 1,090.95 0.00 0.00<br />

36580 S 380.98 0.00 0.00 37780 S 791.11 0.00 0.00<br />

36581 S 711.52 0.00 0.00 37785 S 791.11 0.00 0.00<br />

36582 S 838.67 0.00 0.00 37790 S 954.63 0.00 0.00<br />

36583 S 838.67 0.00 0.00 38205 S 458.54 0.00 0.00<br />

36584 S 380.98 0.00 0.00 38206 S 458.54 0.00 0.00<br />

36585 S 742.34 0.00 0.00 38220 S 105.11 0.00 0.00<br />

36589 S 252.00 0.00 0.00 38221 S 110.10 0.00 0.00<br />

36590 S 380.98 0.00 0.00 38230 S 1,227.51 0.00 0.00<br />

36593 S 25.30 0.00 0.00 38241 S 1,227.51 0.00 0.00<br />

36595 S 993.42 0.00 0.00 38242 S 458.54 0.00 0.00<br />

36596 S 441.19 0.00 0.00 38300 S 411.48 0.00 0.00<br />

36597 S 441.19 0.00 0.00 38305 S 601.31 0.00 0.00<br />

36598 S 81.59 0.00 0.00 38308 S 687.08 0.00 0.00<br />

36640 S 753.42 0.00 0.00 38500 S 687.08 0.00 0.00<br />

36680 S 57.11 0.00 0.00 38505 S 262.88 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 21<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

38510 S 687.08 0.00 0.00 41005 S 138.52 0.00 0.00<br />

38520 S 687.08 0.00 0.00 41006 S 653.91 0.00 0.00<br />

38525 S 687.08 0.00 0.00 41007 S 504.08 0.00 0.00<br />

38530 S 687.08 0.00 0.00 41008 S 504.08 0.00 0.00<br />

38542 S 1,155.91 0.00 0.00 41009 S 138.52 0.00 0.00<br />

38550 S 717.91 0.00 0.00 41010 S 310.56 0.00 0.00<br />

38555 S 775.70 0.00 0.00 41015 S 138.52 0.00 0.00<br />

38570 S 1,568.40 0.00 0.00 41016 S 310.56 0.00 0.00<br />

38571 S 2,038.88 0.00 0.00 41017 S 310.56 0.00 0.00<br />

38572 S 1,568.40 0.00 0.00 41018 S 310.56 0.00 0.00<br />

38700 S 944.55 0.00 0.00 41019 S 987.06 0.00 0.00<br />

38740 S 1,155.91 0.00 0.00 41100 S 92.99 0.00 0.00<br />

38745 S 1,244.53 0.00 0.00 41105 S 91.92 0.00 0.00<br />

38760 S 687.08 0.00 0.00 41108 S 85.15 0.00 0.00<br />

40490 S 70.19 0.00 0.00 41110 S 123.27 0.00 0.00<br />

40500 S 558.50 0.00 0.00 41112 S 558.50 0.00 0.00<br />

40510 S 708.33 0.00 0.00 41113 S 558.50 0.00 0.00<br />

40520 S 558.50 0.00 0.00 41114 S 708.33 0.00 0.00<br />

40525 S 708.33 0.00 0.00 41115 S 143.58 0.00 0.00<br />

40527 S 708.33 0.00 0.00 41116 S 504.08 0.00 0.00<br />

40530 S 708.33 0.00 0.00 41120 S 838.85 0.00 0.00<br />

40650 S 373.72 0.00 0.00 41250 S 94.73 0.00 0.00<br />

40652 S 373.72 0.00 0.00 41251 S 138.52 0.00 0.00<br />

40654 S 373.72 0.00 0.00 41252 S 364.98 0.00 0.00<br />

40700 S 1,314.02 0.00 0.00 41500 S 653.91 0.00 0.00<br />

40701 S 1,314.02 0.00 0.00 41510 S 504.08 0.00 0.00<br />

40702 S 1,669.59 0.00 0.00 41520 S 364.98 0.00 0.00<br />

40720 S 1,314.02 0.00 0.00 41530 S 687.40 0.00 0.00<br />

40761 S 1,080.43 0.00 0.00 41800 S 70.77 0.00 0.00<br />

40800 S 56.33 0.00 0.00 41805 S 153.21 0.00 0.00<br />

40801 S 364.98 0.00 0.00 41806 S 188.83 0.00 0.00<br />

40804 S 25.76 0.00 0.00 41820 S 300.36 0.00 0.00<br />

40805 S 174.23 0.00 0.00 41821 S 300.36 0.00 0.00<br />

40806 S 80.16 0.00 0.00 41822 S 156.41 0.00 0.00<br />

40808 S 119.00 0.00 0.00 41823 S 228.03 0.00 0.00<br />

40810 S 123.27 0.00 0.00 41825 S 125.41 0.00 0.00<br />

40812 S 154.63 0.00 0.00 41826 S 157.84 0.00 0.00<br />

40814 S 558.50 0.00 0.00 41827 S 708.33 0.00 0.00<br />

40816 S 708.33 0.00 0.00 41828 S 142.52 0.00 0.00<br />

40818 S 138.52 0.00 0.00 41830 S 202.37 0.00 0.00<br />

40819 S 310.56 0.00 0.00 41850 S 687.40 0.00 0.00<br />

40820 S 177.78 0.00 0.00 41870 S 987.06 0.00 0.00<br />

40830 S 131.86 0.00 0.00 41872 S 202.37 0.00 0.00<br />

40831 S 310.56 0.00 0.00 41874 S 195.24 0.00 0.00<br />

40840 S 708.33 0.00 0.00 42000 S 138.52 0.00 0.00<br />

40842 S 739.16 0.00 0.00 42100 S 79.10 0.00 0.00<br />

40843 S 739.16 0.00 0.00 42104 S 117.57 0.00 0.00<br />

40844 S 1,180.13 0.00 0.00 42106 S 147.51 0.00 0.00<br />

40845 S 1,180.13 0.00 0.00 42107 S 708.33 0.00 0.00<br />

41000 S 88.36 0.00 0.00 42120 S 1,138.22 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 22<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

42140 S 364.98 0.00 0.00 42809 S 25.76 0.00 0.00<br />

42145 S 838.85 0.00 0.00 42810 S 739.16 0.00 0.00<br />

42160 S 139.66 0.00 0.00 42815 S 1,180.13 0.00 0.00<br />

42180 S 138.52 0.00 0.00 42820 S 739.16 0.00 0.00<br />

42182 S 1,049.60 0.00 0.00 42821 S 838.85 0.00 0.00<br />

42200 S 1,180.13 0.00 0.00 42825 S 796.95 0.00 0.00<br />

42205 S 1,180.13 0.00 0.00 42826 S 796.95 0.00 0.00<br />

42210 S 1,180.13 0.00 0.00 42830 S 796.95 0.00 0.00<br />

42215 S 1,314.02 0.00 0.00 42831 S 796.95 0.00 0.00<br />

42220 S 1,180.13 0.00 0.00 42835 S 796.95 0.00 0.00<br />

42226 S 1,180.13 0.00 0.00 42836 S 796.95 0.00 0.00<br />

42235 S 689.03 0.00 0.00 42860 S 739.16 0.00 0.00<br />

42260 S 796.95 0.00 0.00 42870 S 739.16 0.00 0.00<br />

42280 S 76.95 0.00 0.00 42890 S 1,314.02 0.00 0.00<br />

42281 S 687.40 0.00 0.00 42892 S 1,314.02 0.00 0.00<br />

42300 S 504.08 0.00 0.00 42900 S 310.56 0.00 0.00<br />

42305 S 558.50 0.00 0.00 42950 S 708.33 0.00 0.00<br />

42310 S 138.52 0.00 0.00 42955 S 708.33 0.00 0.00<br />

42320 S 138.52 0.00 0.00 42960 S 57.06 0.00 0.00<br />

42330 S 119.00 0.00 0.00 42962 S 1,049.60 0.00 0.00<br />

42335 S 197.38 0.00 0.00 42970 S 44.30 0.00 0.00<br />

42340 S 558.50 0.00 0.00 42972 S 589.33 0.00 0.00<br />

42400 S 66.99 0.00 0.00 43030 S 687.40 0.00 0.00<br />

42405 S 558.50 0.00 0.00 43200 S 332.88 0.00 0.00<br />

42408 S 589.33 0.00 0.00 43201 S 332.88 0.00 0.00<br />

42409 S 589.33 0.00 0.00 43202 S 332.88 0.00 0.00<br />

42410 S 1,080.43 0.00 0.00 43204 S 332.88 0.00 0.00<br />

42415 S 1,314.02 0.00 0.00 43205 S 332.88 0.00 0.00<br />

42420 S 1,314.02 0.00 0.00 43215 S 332.88 0.00 0.00<br />

42425 S 1,314.02 0.00 0.00 43216 S 332.88 0.00 0.00<br />

42440 S 1,080.43 0.00 0.00 43217 S 332.88 0.00 0.00<br />

42450 S 708.33 0.00 0.00 43219 S 672.75 0.00 0.00<br />

42500 S 739.16 0.00 0.00 43220 S 332.88 0.00 0.00<br />

42505 S 1,138.22 0.00 0.00 43226 S 332.88 0.00 0.00<br />

42507 S 1,080.43 0.00 0.00 43227 S 387.31 0.00 0.00<br />

42508 S 1,138.22 0.00 0.00 43228 S 720.75 0.00 0.00<br />

42509 S 1,138.22 0.00 0.00 43231 S 387.31 0.00 0.00<br />

42510 S 1,138.22 0.00 0.00 43232 S 387.31 0.00 0.00<br />

42600 S 504.08 0.00 0.00 43234 S 332.88 0.00 0.00<br />

42650 S 43.82 0.00 0.00 43235 S 332.88 0.00 0.00<br />

42660 S 51.31 0.00 0.00 43236 S 387.31 0.00 0.00<br />

42665 S 972.75 0.00 0.00 43237 S 387.31 0.00 0.00<br />

42700 S 138.52 0.00 0.00 43238 S 387.31 0.00 0.00<br />

42720 S 504.08 0.00 0.00 43239 S 387.31 0.00 0.00<br />

42725 S 1,049.60 0.00 0.00 43240 S 387.31 0.00 0.00<br />

42800 S 84.80 0.00 0.00 43241 S 387.31 0.00 0.00<br />

42802 S 504.08 0.00 0.00 43242 S 387.31 0.00 0.00<br />

42804 S 504.08 0.00 0.00 43243 S 387.31 0.00 0.00<br />

42806 S 708.33 0.00 0.00 43244 S 387.31 0.00 0.00<br />

42808 S 558.50 0.00 0.00 43245 S 387.31 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 23<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

43246 S 387.31 0.00 0.00 44378 S 405.64 0.00 0.00<br />

43247 S 387.31 0.00 0.00 44379 S 1,157.27 0.00 0.00<br />

43248 S 387.31 0.00 0.00 44380 S 351.21 0.00 0.00<br />

43249 S 387.31 0.00 0.00 44382 S 351.21 0.00 0.00<br />

43250 S 387.31 0.00 0.00 44383 S 1,157.27 0.00 0.00<br />

43251 S 387.31 0.00 0.00 44385 S 339.57 0.00 0.00<br />

43255 S 387.31 0.00 0.00 44386 S 339.57 0.00 0.00<br />

43256 S 758.00 0.00 0.00 44388 S 339.57 0.00 0.00<br />

43257 S 751.58 0.00 0.00 44389 S 339.57 0.00 0.00<br />

43258 S 418.13 0.00 0.00 44390 S 339.57 0.00 0.00<br />

43259 S 418.13 0.00 0.00 44391 S 339.57 0.00 0.00<br />

43260 S 652.03 0.00 0.00 44392 S 339.57 0.00 0.00<br />

43261 S 652.03 0.00 0.00 44393 S 339.57 0.00 0.00<br />

43262 S 652.03 0.00 0.00 44394 S 339.57 0.00 0.00<br />

43263 S 652.03 0.00 0.00 44397 S 672.75 0.00 0.00<br />

43264 S 652.03 0.00 0.00 44500 S 183.25 0.00 0.00<br />

43265 S 652.03 0.00 0.00 45000 S 393.80 0.00 0.00<br />

43267 S 652.03 0.00 0.00 45005 S 458.30 0.00 0.00<br />

43268 S 727.18 0.00 0.00 45020 S 458.30 0.00 0.00<br />

43269 S 727.18 0.00 0.00 45100 S 622.65 0.00 0.00<br />

43271 S 652.03 0.00 0.00 45108 S 677.07 0.00 0.00<br />

43272 S 652.03 0.00 0.00 45150 S 677.07 0.00 0.00<br />

43273 S 874.45 0.00 0.00 45160 S 677.07 0.00 0.00<br />

43450 S 291.12 0.00 0.00 45170 S 677.07 0.00 0.00<br />

43453 S 291.12 0.00 0.00 45190 S 1,107.16 0.00 0.00<br />

43456 S 292.28 0.00 0.00 45300 S 65.55 0.00 0.00<br />

43458 S 334.04 0.00 0.00 45303 S 364.13 0.00 0.00<br />

43600 S 332.88 0.00 0.00 45305 S 342.45 0.00 0.00<br />

43653 S 1,568.40 0.00 0.00 45307 S 632.52 0.00 0.00<br />

43760 S 161.44 0.00 0.00 45308 S 342.45 0.00 0.00<br />

43761 S 332.88 0.00 0.00 45309 S 342.45 0.00 0.00<br />

43870 S 332.88 0.00 0.00 45315 S 342.45 0.00 0.00<br />

43886 S 839.93 0.00 0.00 45317 S 342.45 0.00 0.00<br />

43887 S 176.66 0.00 0.00 45320 S 632.52 0.00 0.00<br />

43888 S 839.93 0.00 0.00 45321 S 632.52 0.00 0.00<br />

44100 S 332.88 0.00 0.00 45327 S 672.75 0.00 0.00<br />

44312 S 580.34 0.00 0.00 45330 S 86.58 0.00 0.00<br />

44340 S 665.59 0.00 0.00 45331 S 256.02 0.00 0.00<br />

44360 S 405.64 0.00 0.00 45332 S 256.02 0.00 0.00<br />

44361 S 405.64 0.00 0.00 45333 S 342.45 0.00 0.00<br />

44363 S 405.64 0.00 0.00 45334 S 342.45 0.00 0.00<br />

44364 S 405.64 0.00 0.00 45335 S 256.02 0.00 0.00<br />

44365 S 405.64 0.00 0.00 45337 S 256.02 0.00 0.00<br />

44366 S 405.64 0.00 0.00 45338 S 342.45 0.00 0.00<br />

44369 S 405.64 0.00 0.00 45339 S 342.45 0.00 0.00<br />

44370 S 1,157.27 0.00 0.00 45340 S 342.45 0.00 0.00<br />

44372 S 405.64 0.00 0.00 45341 S 342.45 0.00 0.00<br />

44373 S 405.64 0.00 0.00 45342 S 342.45 0.00 0.00<br />

44376 S 405.64 0.00 0.00 45345 S 672.75 0.00 0.00<br />

44377 S 405.64 0.00 0.00 45355 S 339.57 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 24<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

45378 S 394.00 0.00 0.00 46505 S 486.99 0.00 0.00<br />

45379 S 394.00 0.00 0.00 46600 S 25.76 0.00 0.00<br />

45380 S 394.00 0.00 0.00 46604 S 364.13 0.00 0.00<br />

45381 S 394.00 0.00 0.00 46606 S 136.82 0.00 0.00<br />

45382 S 394.00 0.00 0.00 46608 S 342.45 0.00 0.00<br />

45383 S 394.00 0.00 0.00 46610 S 632.52 0.00 0.00<br />

45384 S 394.00 0.00 0.00 46611 S 342.45 0.00 0.00<br />

45385 S 394.00 0.00 0.00 46612 S 632.52 0.00 0.00<br />

45386 S 394.00 0.00 0.00 46614 S 71.96 0.00 0.00<br />

45387 S 672.75 0.00 0.00 46615 S 686.94 0.00 0.00<br />

45391 S 394.00 0.00 0.00 46700 S 707.90 0.00 0.00<br />

45392 S 394.00 0.00 0.00 46706 S 779.19 0.00 0.00<br />

45500 S 677.07 0.00 0.00 46750 S 864.44 0.00 0.00<br />

45505 S 833.62 0.00 0.00 46753 S 707.90 0.00 0.00<br />

45520 S 33.01 0.00 0.00 46754 S 677.07 0.00 0.00<br />

45560 S 833.62 0.00 0.00 46760 S 833.62 0.00 0.00<br />

45900 S 266.97 0.00 0.00 46761 S 864.44 0.00 0.00<br />

45905 S 622.65 0.00 0.00 46762 S 1,098.02 0.00 0.00<br />

45910 S 622.65 0.00 0.00 46900 S 108.80 0.00 0.00<br />

45915 S 393.80 0.00 0.00 46910 S 130.04 0.00 0.00<br />

45990 S 612.57 0.00 0.00 46916 S 60.49 0.00 0.00<br />

46020 S 707.90 0.00 0.00 46917 S 564.24 0.00 0.00<br />

46030 S 266.97 0.00 0.00 46922 S 564.24 0.00 0.00<br />

46040 S 707.90 0.00 0.00 46924 S 564.24 0.00 0.00<br />

46045 S 677.07 0.00 0.00 46930 S 126.13 0.00 0.00<br />

46050 S 393.80 0.00 0.00 46937 S 677.07 0.00 0.00<br />

46060 S 677.07 0.00 0.00 46938 S 833.62 0.00 0.00<br />

46070 S 486.99 0.00 0.00 46940 S 93.34 0.00 0.00<br />

46080 S 707.90 0.00 0.00 46942 S 90.85 0.00 0.00<br />

46083 S 74.54 0.00 0.00 46945 S 154.63 0.00 0.00<br />

46200 S 677.07 0.00 0.00 46946 S 403.87 0.00 0.00<br />

46210 S 677.07 0.00 0.00 46947 S 1,098.02 0.00 0.00<br />

46211 S 677.07 0.00 0.00 47000 S 351.34 0.00 0.00<br />

46220 S 622.65 0.00 0.00 47382 S 1,854.10 0.00 0.00<br />

46221 S 122.56 0.00 0.00 47510 S 821.10 0.00 0.00<br />

46230 S 622.65 0.00 0.00 47511 S 1,206.32 0.00 0.00<br />

46250 S 707.90 0.00 0.00 47525 S 471.37 0.00 0.00<br />

46255 S 707.90 0.00 0.00 47530 S 471.37 0.00 0.00<br />

46257 S 707.90 0.00 0.00 47552 S 821.10 0.00 0.00<br />

46258 S 707.90 0.00 0.00 47553 S 851.92 0.00 0.00<br />

46260 S 707.90 0.00 0.00 47554 S 851.92 0.00 0.00<br />

46261 S 765.69 0.00 0.00 47555 S 851.92 0.00 0.00<br />

46262 S 765.69 0.00 0.00 47556 S 1,206.32 0.00 0.00<br />

46270 S 707.90 0.00 0.00 47560 S 1,000.98 0.00 0.00<br />

46275 S 707.90 0.00 0.00 47561 S 1,000.98 0.00 0.00<br />

46280 S 765.69 0.00 0.00 47562 S 1,847.01 0.00 0.00<br />

46285 S 622.65 0.00 0.00 47563 S 1,847.01 0.00 0.00<br />

46288 S 765.69 0.00 0.00 47564 S 1,847.01 0.00 0.00<br />

46320 S 83.02 0.00 0.00 47630 S 851.92 0.00 0.00<br />

46500 S 114.36 0.00 0.00 48102 S 351.34 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 25<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

49080 S 213.64 0.00 0.00 49590 S 876.87 0.00 0.00<br />

49081 S 213.64 0.00 0.00 49600 S 934.65 0.00 0.00<br />

49180 S 351.34 0.00 0.00 49650 S 1,226.93 0.00 0.00<br />

49250 S 770.15 0.00 0.00 49651 S 1,402.73 0.00 0.00<br />

49320 S 1,000.98 0.00 0.00 49652 S 1,510.70 0.00 0.00<br />

49321 S 1,058.78 0.00 0.00 49653 S 1,510.70 0.00 0.00<br />

49322 S 1,058.78 0.00 0.00 49654 S 1,510.70 0.00 0.00<br />

49324 S 1,510.70 0.00 0.00 49655 S 1,510.70 0.00 0.00<br />

49325 S 1,510.70 0.00 0.00 49656 S 1,510.70 0.00 0.00<br />

49326 S 1,510.70 0.00 0.00 49657 S 1,510.70 0.00 0.00<br />

49402 S 681.53 0.00 0.00 50200 S 351.34 0.00 0.00<br />

49419 S 817.58 0.00 0.00 50382 S 1,020.21 0.00 0.00<br />

49420 S 755.80 0.00 0.00 50384 S 749.32 0.00 0.00<br />

49421 S 755.80 0.00 0.00 50385 S 749.32 0.00 0.00<br />

49422 S 601.50 0.00 0.00 50386 S 287.49 0.00 0.00<br />

49423 S 621.98 0.00 0.00 50387 S 621.98 0.00 0.00<br />

49426 S 681.53 0.00 0.00 50389 S 287.49 0.00 0.00<br />

49429 S 882.25 0.00 0.00 50390 S 351.34 0.00 0.00<br />

49440 S 345.00 0.00 0.00 50391 S 41.61 0.00 0.00<br />

49441 S 345.00 0.00 0.00 50392 S 535.04 0.00 0.00<br />

49446 S 345.00 0.00 0.00 50393 S 670.48 0.00 0.00<br />

49450 S 183.25 0.00 0.00 50395 S 535.04 0.00 0.00<br />

49451 S 183.25 0.00 0.00 50396 S 100.60 0.00 0.00<br />

49452 S 183.25 0.00 0.00 50398 S 471.37 0.00 0.00<br />

49460 S 183.25 0.00 0.00 50551 S 304.13 0.00 0.00<br />

49495 S 934.65 0.00 0.00 50553 S 670.48 0.00 0.00<br />

49496 S 934.65 0.00 0.00 50555 S 304.13 0.00 0.00<br />

49500 S 934.65 0.00 0.00 50557 S 670.48 0.00 0.00<br />

49501 S 1,276.12 0.00 0.00 50561 S 670.48 0.00 0.00<br />

49505 S 934.65 0.00 0.00 50562 S 287.49 0.00 0.00<br />

49507 S 1,276.12 0.00 0.00 50570 S 287.49 0.00 0.00<br />

49520 S 1,110.45 0.00 0.00 50572 S 287.49 0.00 0.00<br />

49521 S 1,276.12 0.00 0.00 50574 S 287.49 0.00 0.00<br />

49525 S 934.65 0.00 0.00 50575 S 1,430.05 0.00 0.00<br />

49540 S 846.03 0.00 0.00 50576 S 749.32 0.00 0.00<br />

49550 S 976.56 0.00 0.00 50580 S 749.32 0.00 0.00<br />

49553 S 1,276.12 0.00 0.00 50590 S 1,670.63 0.00 0.00<br />

49555 S 976.56 0.00 0.00 50592 S 1,854.10 0.00 0.00<br />

49557 S 1,276.12 0.00 0.00 50686 S 41.61 0.00 0.00<br />

49560 S 934.65 0.00 0.00 50688 S 471.37 0.00 0.00<br />

49561 S 1,276.12 0.00 0.00 50947 S 1,568.40 0.00 0.00<br />

49565 S 934.65 0.00 0.00 50948 S 1,568.40 0.00 0.00<br />

49566 S 1,276.12 0.00 0.00 50951 S 304.13 0.00 0.00<br />

49568 S 1,110.45 0.00 0.00 50953 S 304.13 0.00 0.00<br />

49570 S 934.65 0.00 0.00 50955 S 670.48 0.00 0.00<br />

49572 S 1,276.12 0.00 0.00 50957 S 670.48 0.00 0.00<br />

49580 S 934.65 0.00 0.00 50961 S 670.48 0.00 0.00<br />

49582 S 1,276.12 0.00 0.00 50970 S 304.13 0.00 0.00<br />

49585 S 934.65 0.00 0.00 50972 S 304.13 0.00 0.00<br />

49587 S 1,276.12 0.00 0.00 50974 S 535.04 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 26<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

50976 S 535.04 0.00 0.00 52275 S 724.91 0.00 0.00<br />

50980 S 670.48 0.00 0.00 52276 S 755.73 0.00 0.00<br />

51020 S 813.53 0.00 0.00 52277 S 724.91 0.00 0.00<br />

51030 S 813.53 0.00 0.00 52281 S 589.46 0.00 0.00<br />

51040 S 813.53 0.00 0.00 52282 S 1,359.92 0.00 0.00<br />

51045 S 336.03 0.00 0.00 52283 S 724.91 0.00 0.00<br />

51050 S 813.53 0.00 0.00 52285 S 589.46 0.00 0.00<br />

51065 S 813.53 0.00 0.00 52290 S 589.46 0.00 0.00<br />

51080 S 546.88 0.00 0.00 52300 S 724.91 0.00 0.00<br />

51100 S 31.71 0.00 0.00 52301 S 755.73 0.00 0.00<br />

51101 S 41.61 0.00 0.00 52305 S 724.91 0.00 0.00<br />

51102 S 559.78 0.00 0.00 52310 S 566.94 0.00 0.00<br />

51500 S 934.65 0.00 0.00 52315 S 724.91 0.00 0.00<br />

51520 S 813.53 0.00 0.00 52317 S 670.48 0.00 0.00<br />

51700 S 54.15 0.00 0.00 52318 S 724.91 0.00 0.00<br />

51701 S 25.76 0.00 0.00 52320 S 855.43 0.00 0.00<br />

51702 S 25.76 0.00 0.00 52325 S 813.53 0.00 0.00<br />

51703 S 41.61 0.00 0.00 52327 S 929.83 0.00 0.00<br />

51705 S 74.54 0.00 0.00 52330 S 724.91 0.00 0.00<br />

51710 S 471.37 0.00 0.00 52332 S 724.91 0.00 0.00<br />

51715 S 855.87 0.00 0.00 52334 S 755.73 0.00 0.00<br />

51720 S 59.85 0.00 0.00 52341 S 755.73 0.00 0.00<br />

51725 TC S 114.99 0.00 0.00 52342 S 755.73 0.00 0.00<br />

51726 TC S 158.38 0.00 0.00 52343 S 755.73 0.00 0.00<br />

51736 TC S 21.73 0.00 0.00 52344 S 755.73 0.00 0.00<br />

51741 TC S 25.30 0.00 0.00 52345 S 755.73 0.00 0.00<br />

51772 TC S 100.60 0.00 0.00 52346 S 755.73 0.00 0.00<br />

51784 TC S 41.61 0.00 0.00 52351 S 755.73 0.00 0.00<br />

51785 TC S 69.51 0.00 0.00 52352 S 813.53 0.00 0.00<br />

51792 TC S 41.61 0.00 0.00 52353 S 1,018.45 0.00 0.00<br />

51795 TC S 74.54 0.00 0.00 52354 S 813.53 0.00 0.00<br />

51797 TC S 74.54 0.00 0.00 52355 S 813.53 0.00 0.00<br />

51798 S 18.52 0.00 0.00 52400 S 755.73 0.00 0.00<br />

51880 S 670.48 0.00 0.00 52402 S 755.73 0.00 0.00<br />

51992 S 1,268.83 0.00 0.00 52450 S 755.73 0.00 0.00<br />

52000 S 304.13 0.00 0.00 52500 S 755.73 0.00 0.00<br />

52001 S 566.94 0.00 0.00 52601 S 1,018.45 0.00 0.00<br />

52005 S 589.46 0.00 0.00 52630 S 929.83 0.00 0.00<br />

52007 S 724.91 0.00 0.00 52640 S 724.91 0.00 0.00<br />

52010 S 336.03 0.00 0.00 52647 S 1,558.14 0.00 0.00<br />

52204 S 589.46 0.00 0.00 52648 S 1,558.14 0.00 0.00<br />

52214 S 724.91 0.00 0.00 52700 S 724.91 0.00 0.00<br />

52224 S 724.91 0.00 0.00 53000 S 556.37 0.00 0.00<br />

52234 S 724.91 0.00 0.00 53010 S 556.37 0.00 0.00<br />

52235 S 755.73 0.00 0.00 53020 S 556.37 0.00 0.00<br />

52240 S 755.73 0.00 0.00 53025 S 791.97 0.00 0.00<br />

52250 S 813.53 0.00 0.00 53040 S 610.80 0.00 0.00<br />

52260 S 589.46 0.00 0.00 53060 S 72.33 0.00 0.00<br />

52265 S 287.49 0.00 0.00 53080 S 641.62 0.00 0.00<br />

52270 S 589.46 0.00 0.00 53085 S 791.97 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 27<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

53200 S 556.37 0.00 0.00 54060 S 564.24 0.00 0.00<br />

53210 S 955.57 0.00 0.00 54065 S 564.24 0.00 0.00<br />

53215 S 741.31 0.00 0.00 54100 S 477.31 0.00 0.00<br />

53220 S 825.04 0.00 0.00 54105 S 595.84 0.00 0.00<br />

53230 S 825.04 0.00 0.00 54110 S 923.81 0.00 0.00<br />

53235 S 641.62 0.00 0.00 54111 S 923.81 0.00 0.00<br />

53240 S 825.04 0.00 0.00 54112 S 923.81 0.00 0.00<br />

53250 S 610.80 0.00 0.00 54115 S 546.88 0.00 0.00<br />

53260 S 610.80 0.00 0.00 54120 S 923.81 0.00 0.00<br />

53265 S 610.80 0.00 0.00 54150 S 615.67 0.00 0.00<br />

53270 S 610.80 0.00 0.00 54160 S 670.10 0.00 0.00<br />

53275 S 610.80 0.00 0.00 54161 S 670.10 0.00 0.00<br />

53400 S 855.87 0.00 0.00 54162 S 670.10 0.00 0.00<br />

53405 S 825.04 0.00 0.00 54163 S 670.10 0.00 0.00<br />

53410 S 825.04 0.00 0.00 54164 S 670.10 0.00 0.00<br />

53420 S 855.87 0.00 0.00 54200 S 70.19 0.00 0.00<br />

53425 S 825.04 0.00 0.00 54205 S 1,012.43 0.00 0.00<br />

53430 S 825.04 0.00 0.00 54220 S 100.60 0.00 0.00<br />

53431 S 825.04 0.00 0.00 54231 S 65.91 0.00 0.00<br />

53440 S 4,752.58 2,886.46 1,020.34 54235 S 46.68 0.00 0.00<br />

53442 S 770.62 0.00 0.00 54240 TC S 33.13 0.00 0.00<br />

53444 S 4,752.58 2,886.46 1,020.34 54250 TC S 11.76 0.00 0.00<br />

53445 S 7,983.12 4,546.33 1,109.55 54300 S 954.63 0.00 0.00<br />

53446 S 770.62 0.00 0.00 54304 S 954.63 0.00 0.00<br />

53447 S 7,983.12 4,546.33 1,109.55 54308 S 954.63 0.00 0.00<br />

53449 S 770.62 0.00 0.00 54312 S 954.63 0.00 0.00<br />

53450 S 770.62 0.00 0.00 54316 S 954.63 0.00 0.00<br />

53460 S 556.37 0.00 0.00 54318 S 954.63 0.00 0.00<br />

53502 S 610.80 0.00 0.00 54322 S 954.63 0.00 0.00<br />

53505 S 825.04 0.00 0.00 54324 S 954.63 0.00 0.00<br />

53510 S 610.80 0.00 0.00 54326 S 954.63 0.00 0.00<br />

53515 S 825.04 0.00 0.00 54328 S 954.63 0.00 0.00<br />

53520 S 825.04 0.00 0.00 54340 S 954.63 0.00 0.00<br />

53600 S 41.69 0.00 0.00 54344 S 954.63 0.00 0.00<br />

53601 S 41.61 0.00 0.00 54348 S 954.63 0.00 0.00<br />

53605 S 589.46 0.00 0.00 54352 S 954.63 0.00 0.00<br />

53620 S 64.13 0.00 0.00 54360 S 954.63 0.00 0.00<br />

53621 S 67.34 0.00 0.00 54380 S 954.63 0.00 0.00<br />

53660 S 41.61 0.00 0.00 54385 S 954.63 0.00 0.00<br />

53661 S 41.61 0.00 0.00 54400 S 4,783.41 2,917.29 1,051.17<br />

53665 S 556.37 0.00 0.00 54401 S 8,068.37 4,631.58 1,194.80<br />

53850 S 1,826.49 0.00 0.00 54405 S 8,068.37 4,631.58 1,194.80<br />

53852 S 1,826.49 0.00 0.00 54406 S 954.63 0.00 0.00<br />

54000 S 610.80 0.00 0.00 54408 S 954.63 0.00 0.00<br />

54001 S 610.80 0.00 0.00 54410 S 8,068.37 4,631.58 1,194.80<br />

54015 S 689.93 0.00 0.00 54415 S 954.63 0.00 0.00<br />

54050 S 33.01 0.00 0.00 54416 S 8,068.37 4,631.58 1,194.80<br />

54055 S 67.34 0.00 0.00 54420 S 1,012.43 0.00 0.00<br />

54056 S 33.01 0.00 0.00 54435 S 1,012.43 0.00 0.00<br />

54057 S 564.24 0.00 0.00 54440 S 1,012.43 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 28<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

54450 S 158.38 0.00 0.00 55706 S 460.43 0.00 0.00<br />

54500 S 429.86 0.00 0.00 55720 S 670.48 0.00 0.00<br />

54505 S 615.67 0.00 0.00 55725 S 724.91 0.00 0.00<br />

54512 S 670.10 0.00 0.00 55860 S 798.82 0.00 0.00<br />

54520 S 700.92 0.00 0.00 55870 S 81.23 0.00 0.00<br />

54522 S 700.92 0.00 0.00 55873 S 6,320.53 0.00 0.00<br />

54530 S 934.65 0.00 0.00 55875 S 1,359.92 0.00 0.00<br />

54550 S 934.65 0.00 0.00 55876 S 74.46 0.00 0.00<br />

54560 S 910.58 0.00 0.00 55920 S 933.46 0.00 0.00<br />

54600 S 758.72 0.00 0.00 56405 S 43.47 0.00 0.00<br />

54620 S 700.92 0.00 0.00 56420 S 56.73 0.00 0.00<br />

54640 S 934.65 0.00 0.00 56440 S 609.22 0.00 0.00<br />

54660 S 670.10 0.00 0.00 56441 S 554.79 0.00 0.00<br />

54670 S 700.92 0.00 0.00 56442 S 554.79 0.00 0.00<br />

54680 S 700.92 0.00 0.00 56501 S 59.85 0.00 0.00<br />

54690 S 1,568.40 0.00 0.00 56515 S 649.49 0.00 0.00<br />

54692 S 2,787.98 0.00 0.00 56605 S 34.55 0.00 0.00<br />

54700 S 670.10 0.00 0.00 56606 S 14.25 0.00 0.00<br />

54800 S 150.41 0.00 0.00 56620 S 739.73 0.00 0.00<br />

54830 S 700.92 0.00 0.00 56625 S 873.62 0.00 0.00<br />

54840 S 758.72 0.00 0.00 56700 S 554.79 0.00 0.00<br />

54860 S 700.92 0.00 0.00 56740 S 640.04 0.00 0.00<br />

54861 S 758.72 0.00 0.00 56800 S 640.04 0.00 0.00<br />

54865 S 615.67 0.00 0.00 56805 S 788.82 0.00 0.00<br />

54900 S 758.72 0.00 0.00 56810 S 739.73 0.00 0.00<br />

54901 S 758.72 0.00 0.00 56820 S 44.18 0.00 0.00<br />

55000 S 68.41 0.00 0.00 56821 S 56.73 0.00 0.00<br />

55040 S 876.87 0.00 0.00 57000 S 554.79 0.00 0.00<br />

55041 S 976.56 0.00 0.00 57010 S 609.22 0.00 0.00<br />

55060 S 758.72 0.00 0.00 57020 S 319.50 0.00 0.00<br />

55100 S 411.48 0.00 0.00 57022 S 502.20 0.00 0.00<br />

55110 S 670.10 0.00 0.00 57023 S 546.88 0.00 0.00<br />

55120 S 670.10 0.00 0.00 57061 S 55.22 0.00 0.00<br />

55150 S 615.67 0.00 0.00 57065 S 554.79 0.00 0.00<br />

55175 S 615.67 0.00 0.00 57100 S 35.28 0.00 0.00<br />

55180 S 670.10 0.00 0.00 57105 S 609.22 0.00 0.00<br />

55200 S 670.10 0.00 0.00 57130 S 609.22 0.00 0.00<br />

55250 S 670.10 0.00 0.00 57135 S 609.22 0.00 0.00<br />

55400 S 615.67 0.00 0.00 57150 S 25.65 0.00 0.00<br />

55450 S 220.18 0.00 0.00 57155 S 319.50 0.00 0.00<br />

55500 S 700.92 0.00 0.00 57160 S 37.05 0.00 0.00<br />

55520 S 758.72 0.00 0.00 57170 S 6.08 0.00 0.00<br />

55530 S 758.72 0.00 0.00 57180 S 114.12 0.00 0.00<br />

55535 S 934.65 0.00 0.00 57200 S 554.79 0.00 0.00<br />

55540 S 976.56 0.00 0.00 57210 S 609.22 0.00 0.00<br />

55550 S 1,568.40 0.00 0.00 57220 S 1,117.22 0.00 0.00<br />

55600 S 910.58 0.00 0.00 57230 S 917.34 0.00 0.00<br />

55680 S 615.67 0.00 0.00 57240 S 1,017.03 0.00 0.00<br />

55700 S 396.77 0.00 0.00 57250 S 1,017.03 0.00 0.00<br />

55705 S 396.77 0.00 0.00 57260 S 1,017.03 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 29<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

57265 S 1,350.81 0.00 0.00 58555 S 599.42 0.00 0.00<br />

57267 S 1,150.92 0.00 0.00 58558 S 684.67 0.00 0.00<br />

57268 S 917.34 0.00 0.00 58559 S 653.85 0.00 0.00<br />

57287 S 1,343.42 0.00 0.00 58560 S 976.24 0.00 0.00<br />

57288 S 1,216.91 0.00 0.00 58561 S 976.24 0.00 0.00<br />

57289 S 1,017.03 0.00 0.00 58562 S 684.67 0.00 0.00<br />

57291 S 1,017.03 0.00 0.00 58563 S 1,375.50 0.00 0.00<br />

57300 S 917.34 0.00 0.00 58565 S 1,516.49 0.00 0.00<br />

57320 S 1,343.42 0.00 0.00 58600 S 1,343.42 0.00 0.00<br />

57400 S 609.22 0.00 0.00 58615 S 788.82 0.00 0.00<br />

57410 S 609.22 0.00 0.00 58660 S 1,268.83 0.00 0.00<br />

57415 S 609.22 0.00 0.00 58661 S 1,268.83 0.00 0.00<br />

57420 S 45.61 0.00 0.00 58662 S 1,268.83 0.00 0.00<br />

57421 S 59.50 0.00 0.00 58670 S 1,169.14 0.00 0.00<br />

57452 S 43.11 0.00 0.00 58671 S 1,169.14 0.00 0.00<br />

57454 S 52.73 0.00 0.00 58672 S 1,268.83 0.00 0.00<br />

57455 S 55.93 0.00 0.00 58673 S 1,268.83 0.00 0.00<br />

57456 S 54.15 0.00 0.00 58800 S 640.04 0.00 0.00<br />

57460 S 166.38 0.00 0.00 58805 S 1,343.42 0.00 0.00<br />

57461 S 176.72 0.00 0.00 58820 S 917.34 0.00 0.00<br />

57500 S 76.24 0.00 0.00 58900 S 640.04 0.00 0.00<br />

57505 S 48.45 0.00 0.00 58970 S 178.28 0.00 0.00<br />

57510 S 49.17 0.00 0.00 58974 S 178.28 0.00 0.00<br />

57511 S 56.73 0.00 0.00 58976 S 178.28 0.00 0.00<br />

57513 S 609.22 0.00 0.00 59000 S 65.20 0.00 0.00<br />

57520 S 609.22 0.00 0.00 59001 S 244.73 0.00 0.00<br />

57522 S 609.22 0.00 0.00 59012 S 119.67 0.00 0.00<br />

57530 S 917.34 0.00 0.00 59015 S 52.73 0.00 0.00<br />

57550 S 917.34 0.00 0.00 59020 TC S 27.79 0.00 0.00<br />

57556 S 1,216.91 0.00 0.00 59025 TC S 14.61 0.00 0.00<br />

57558 S 640.04 0.00 0.00 59070 S 119.67 0.00 0.00<br />

57700 S 554.79 0.00 0.00 59072 S 119.67 0.00 0.00<br />

57720 S 640.04 0.00 0.00 59076 S 119.67 0.00 0.00<br />

57800 S 26.01 0.00 0.00 59100 S 1,343.42 0.00 0.00<br />

58100 S 42.75 0.00 0.00 59150 S 1,847.01 0.00 0.00<br />

58120 S 609.22 0.00 0.00 59151 S 1,847.01 0.00 0.00<br />

58145 S 1,017.03 0.00 0.00 59160 S 640.04 0.00 0.00<br />

58301 S 39.90 0.00 0.00 59200 S 35.63 0.00 0.00<br />

58321 S 37.41 0.00 0.00 59300 S 76.95 0.00 0.00<br />

58322 S 38.48 0.00 0.00 59320 S 554.79 0.00 0.00<br />

58323 S 8.91 0.00 0.00 59412 S 788.82 0.00 0.00<br />

58345 S 788.82 0.00 0.00 59414 S 788.82 0.00 0.00<br />

58346 S 609.22 0.00 0.00 59812 S 739.73 0.00 0.00<br />

58350 S 917.34 0.00 0.00 59820 S 739.73 0.00 0.00<br />

58353 S 1,150.92 0.00 0.00 59821 S 739.73 0.00 0.00<br />

58356 S 1,743.18 0.00 0.00 59840 S 739.73 0.00 0.00<br />

58545 S 1,400.25 0.00 0.00 59841 S 739.73 0.00 0.00<br />

58546 S 1,568.40 0.00 0.00 59866 S 119.67 0.00 0.00<br />

58550 S 2,038.88 0.00 0.00 59870 S 739.73 0.00 0.00<br />

58552 S 1,847.01 0.00 0.00 59871 S 739.73 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 30<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

60000 S 310.56 0.00 0.00 62367 S 17.10 0.00 0.00<br />

60100 S 48.81 0.00 0.00 62368 S 21.73 0.00 0.00<br />

60200 S 1,155.91 0.00 0.00 63600 S 583.84 0.00 0.00<br />

60280 S 1,244.53 0.00 0.00 63610 S 529.41 0.00 0.00<br />

60281 S 1,244.53 0.00 0.00 63615 S 738.06 0.00 0.00<br />

60300 S 64.13 0.00 0.00 63650 S 3,142.50 1,948.66 754.84<br />

61000 S 285.96 0.00 0.00 63655 S 4,603.00 2,935.34 1,267.69<br />

61001 S 285.96 0.00 0.00 63660 S 551.88 0.00 0.00<br />

61020 S 231.52 0.00 0.00 63685 S 13,971.15 7,449.54 927.95<br />

61026 S 231.52 0.00 0.00 63688 S 749.41 0.00 0.00<br />

61050 S 231.52 0.00 0.00 63744 S 1,083.76 0.00 0.00<br />

61055 S 231.52 0.00 0.00 63746 S 501.32 0.00 0.00<br />

61070 S 180.15 0.00 0.00 64400 S 54.87 0.00 0.00<br />

61215 S 1,083.76 0.00 0.00 64402 S 51.66 0.00 0.00<br />

61330 S 1,669.59 0.00 0.00 64405 S 43.82 0.00 0.00<br />

61334 S 1,669.59 0.00 0.00 64408 S 54.51 0.00 0.00<br />

61790 S 614.66 0.00 0.00 64410 S 303.36 0.00 0.00<br />

61791 S 456.01 0.00 0.00 64412 S 80.16 0.00 0.00<br />

61880 S 783.00 0.00 0.00 64413 S 51.31 0.00 0.00<br />

61885 S 11,267.50 6,035.89 804.29 64415 S 139.71 0.00 0.00<br />

61886 S 16,825.12 8,867.81 910.51 64416 S 285.96 0.00 0.00<br />

61888 S 749.41 0.00 0.00 64417 S 139.71 0.00 0.00<br />

62194 S 303.36 0.00 0.00 64418 S 71.96 0.00 0.00<br />

62225 S 471.37 0.00 0.00 64420 S 139.71 0.00 0.00<br />

62230 S 1,052.93 0.00 0.00 64421 S 303.36 0.00 0.00<br />

62252 TC S 47.74 0.00 0.00 64425 S 49.88 0.00 0.00<br />

62263 S 303.36 0.00 0.00 64430 S 209.93 0.00 0.00<br />

62264 S 446.89 0.00 0.00 64435 S 75.18 0.00 0.00<br />

62267 S 178.34 0.00 0.00 64445 S 66.62 0.00 0.00<br />

62268 S 231.52 0.00 0.00 64446 S 573.03 0.00 0.00<br />

62269 S 351.34 0.00 0.00 64447 S 145.53 0.00 0.00<br />

62270 S 139.71 0.00 0.00 64448 S 145.53 0.00 0.00<br />

62272 S 139.71 0.00 0.00 64449 S 285.96 0.00 0.00<br />

62273 S 233.14 0.00 0.00 64450 S 44.53 0.00 0.00<br />

62280 S 303.36 0.00 0.00 64455 S 18.52 0.00 0.00<br />

62281 S 303.36 0.00 0.00 64470 S 303.36 0.00 0.00<br />

62282 S 303.36 0.00 0.00 64472 S 233.14 0.00 0.00<br />

62287 S 1,361.80 0.00 0.00 64475 S 303.36 0.00 0.00<br />

62292 S 285.96 0.00 0.00 64476 S 209.97 0.00 0.00<br />

62294 S 231.52 0.00 0.00 64479 S 303.36 0.00 0.00<br />

62310 S 303.36 0.00 0.00 64480 S 233.14 0.00 0.00<br />

62311 S 303.36 0.00 0.00 64483 S 303.36 0.00 0.00<br />

62318 S 303.36 0.00 0.00 64484 S 233.14 0.00 0.00<br />

62319 S 303.36 0.00 0.00 64505 S 40.62 0.00 0.00<br />

62350 S 1,052.93 0.00 0.00 64508 S 86.22 0.00 0.00<br />

62355 S 501.32 0.00 0.00 64510 S 303.36 0.00 0.00<br />

62360 S 1,052.93 0.00 0.00 64517 S 209.93 0.00 0.00<br />

62361 S 10,808.46 5,850.24 892.02 64520 S 303.36 0.00 0.00<br />

62362 S 10,808.46 5,850.24 892.02 64530 S 303.36 0.00 0.00<br />

62365 S 931.71 0.00 0.00 64553 S 3,088.07 1,894.23 700.41<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 31<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64555 S 3,467.72 2,273.88 1,080.06 64746 S 583.84 0.00 0.00<br />

64560 S 3,467.72 2,273.88 1,080.06 64761 S 738.06 0.00 0.00<br />

64561 S 3,173.32 1,979.48 785.66 64763 S 738.06 0.00 0.00<br />

64565 S 3,467.72 2,273.88 1,080.06 64766 S 1,433.81 0.00 0.00<br />

64573 S 5,402.19 3,200.27 998.35 64771 S 583.84 0.00 0.00<br />

64575 S 4,129.53 2,461.87 794.22 64772 S 583.84 0.00 0.00<br />

64577 S 4,129.53 2,461.87 794.22 64774 S 583.84 0.00 0.00<br />

64580 S 4,129.53 2,461.87 794.22 64776 S 614.66 0.00 0.00<br />

64581 S 4,214.78 2,547.12 879.47 64778 S 583.84 0.00 0.00<br />

64585 S 551.88 0.00 0.00 64782 S 614.66 0.00 0.00<br />

64590 S 11,267.50 6,035.89 804.29 64783 S 583.84 0.00 0.00<br />

64595 S 749.41 0.00 0.00 64784 S 614.66 0.00 0.00<br />

64600 S 446.89 0.00 0.00 64786 S 962.53 0.00 0.00<br />

64605 S 446.89 0.00 0.00 64787 S 583.84 0.00 0.00<br />

64610 S 446.89 0.00 0.00 64788 S 614.66 0.00 0.00<br />

64612 S 65.20 0.00 0.00 64790 S 614.66 0.00 0.00<br />

64613 S 63.06 0.00 0.00 64792 S 962.53 0.00 0.00<br />

64614 S 71.96 0.00 0.00 64795 S 583.84 0.00 0.00<br />

64620 S 303.36 0.00 0.00 64802 S 583.84 0.00 0.00<br />

64622 S 446.89 0.00 0.00 64820 S 738.06 0.00 0.00<br />

64623 S 303.36 0.00 0.00 64821 S 861.62 0.00 0.00<br />

64626 S 446.89 0.00 0.00 64822 S 1,116.39 0.00 0.00<br />

64627 S 209.97 0.00 0.00 64823 S 1,116.39 0.00 0.00<br />

64630 S 312.48 0.00 0.00 64831 S 1,020.33 0.00 0.00<br />

64632 S 33.84 0.00 0.00 64832 S 877.28 0.00 0.00<br />

64640 S 100.83 0.00 0.00 64834 S 931.71 0.00 0.00<br />

64650 S 33.84 0.00 0.00 64835 S 962.53 0.00 0.00<br />

64653 S 36.70 0.00 0.00 64836 S 962.53 0.00 0.00<br />

64680 S 474.81 0.00 0.00 64837 S 877.28 0.00 0.00<br />

64681 S 501.32 0.00 0.00 64840 S 931.71 0.00 0.00<br />

64702 S 529.41 0.00 0.00 64856 S 931.71 0.00 0.00<br />

64704 S 529.41 0.00 0.00 64857 S 931.71 0.00 0.00<br />

64708 S 583.84 0.00 0.00 64858 S 931.71 0.00 0.00<br />

64712 S 583.84 0.00 0.00 64859 S 877.28 0.00 0.00<br />

64713 S 583.84 0.00 0.00 64861 S 962.53 0.00 0.00<br />

64714 S 583.84 0.00 0.00 64862 S 962.53 0.00 0.00<br />

64716 S 614.66 0.00 0.00 64864 S 962.53 0.00 0.00<br />

64718 S 583.84 0.00 0.00 64865 S 1,020.33 0.00 0.00<br />

64719 S 583.84 0.00 0.00 64870 S 1,020.33 0.00 0.00<br />

64721 S 583.84 0.00 0.00 64872 S 931.71 0.00 0.00<br />

64722 S 529.41 0.00 0.00 64874 S 962.53 0.00 0.00<br />

64726 S 529.41 0.00 0.00 64876 S 962.53 0.00 0.00<br />

64727 S 529.41 0.00 0.00 64885 S 931.71 0.00 0.00<br />

64732 S 583.84 0.00 0.00 64886 S 931.71 0.00 0.00<br />

64734 S 583.84 0.00 0.00 64890 S 931.71 0.00 0.00<br />

64736 S 583.84 0.00 0.00 64891 S 931.71 0.00 0.00<br />

64738 S 583.84 0.00 0.00 64892 S 931.71 0.00 0.00<br />

64740 S 583.84 0.00 0.00 64893 S 931.71 0.00 0.00<br />

64742 S 583.84 0.00 0.00 64895 S 962.53 0.00 0.00<br />

64744 S 583.84 0.00 0.00 64896 S 962.53 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 32<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

64897 S 962.53 0.00 0.00 65770 S 5,664.17 0.00 0.00<br />

64898 S 962.53 0.00 0.00 65772 S 637.17 0.00 0.00<br />

64901 S 931.71 0.00 0.00 65775 S 637.17 0.00 0.00<br />

64902 S 931.71 0.00 0.00 65780 S 1,102.22 0.00 0.00<br />

64905 S 931.71 0.00 0.00 65781 S 1,102.22 0.00 0.00<br />

64907 S 877.28 0.00 0.00 65782 S 1,102.22 0.00 0.00<br />

64910 S 1,433.81 0.00 0.00 65800 S 494.13 0.00 0.00<br />

65091 S 1,013.49 0.00 0.00 65805 S 494.13 0.00 0.00<br />

65093 S 1,013.49 0.00 0.00 65810 S 722.03 0.00 0.00<br />

65101 S 1,013.49 0.00 0.00 65815 S 691.20 0.00 0.00<br />

65103 S 1,013.49 0.00 0.00 65820 S 253.50 0.00 0.00<br />

65105 S 1,071.29 0.00 0.00 65850 S 779.82 0.00 0.00<br />

65110 S 1,113.19 0.00 0.00 65855 S 134.67 0.00 0.00<br />

65112 S 1,247.08 0.00 0.00 65860 S 125.77 0.00 0.00<br />

65114 S 1,247.08 0.00 0.00 65865 S 494.13 0.00 0.00<br />

65125 S 1,037.87 0.00 0.00 65870 S 779.82 0.00 0.00<br />

65130 S 764.57 0.00 0.00 65875 S 779.82 0.00 0.00<br />

65135 S 733.75 0.00 0.00 65880 S 637.17 0.00 0.00<br />

65140 S 1,013.49 0.00 0.00 65900 S 679.08 0.00 0.00<br />

65150 S 733.75 0.00 0.00 65920 S 955.62 0.00 0.00<br />

65155 S 1,013.49 0.00 0.00 65930 S 821.72 0.00 0.00<br />

65175 S 545.42 0.00 0.00 66020 S 494.13 0.00 0.00<br />

65205 S 21.02 0.00 0.00 66030 S 253.50 0.00 0.00<br />

65210 S 26.72 0.00 0.00 66130 S 955.62 0.00 0.00<br />

65220 S 37.23 0.00 0.00 66150 S 779.82 0.00 0.00<br />

65222 S 29.21 0.00 0.00 66155 S 779.82 0.00 0.00<br />

65235 S 548.55 0.00 0.00 66160 S 691.20 0.00 0.00<br />

65260 S 361.81 0.00 0.00 66165 S 779.82 0.00 0.00<br />

65265 S 748.53 0.00 0.00 66170 S 779.82 0.00 0.00<br />

65270 S 599.84 0.00 0.00 66172 S 779.82 0.00 0.00<br />

65272 S 691.20 0.00 0.00 66180 S 1,161.77 0.00 0.00<br />

65275 S 779.82 0.00 0.00 66185 S 1,031.26 0.00 0.00<br />

65280 S 748.53 0.00 0.00 66220 S 1,006.69 0.00 0.00<br />

65285 S 1,064.48 0.00 0.00 66225 S 1,119.88 0.00 0.00<br />

65286 S 186.23 0.00 0.00 66250 S 548.55 0.00 0.00<br />

65290 S 737.16 0.00 0.00 66500 S 253.50 0.00 0.00<br />

65400 S 494.13 0.00 0.00 66505 S 253.50 0.00 0.00<br />

65410 S 548.55 0.00 0.00 66600 S 722.03 0.00 0.00<br />

65420 S 548.55 0.00 0.00 66605 S 722.03 0.00 0.00<br />

65426 S 821.72 0.00 0.00 66625 S 513.37 0.00 0.00<br />

65430 S 37.23 0.00 0.00 66630 S 722.03 0.00 0.00<br />

65435 S 32.42 0.00 0.00 66635 S 722.03 0.00 0.00<br />

65436 S 140.73 0.00 0.00 66680 S 722.03 0.00 0.00<br />

65450 S 85.91 0.00 0.00 66682 S 691.20 0.00 0.00<br />

65600 S 166.03 0.00 0.00 66700 S 548.55 0.00 0.00<br />

65710 S 1,236.12 0.00 0.00 66710 S 548.55 0.00 0.00<br />

65730 S 1,236.12 0.00 0.00 66711 S 548.55 0.00 0.00<br />

65750 S 1,236.12 0.00 0.00 66720 S 548.55 0.00 0.00<br />

65755 S 1,236.12 0.00 0.00 66740 S 691.20 0.00 0.00<br />

65756 S 1,513.79 0.00 0.00 66761 S 187.41 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 33<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

66762 S 190.62 0.00 0.00 67228 S 209.92 0.00 0.00<br />

66770 S 209.92 0.00 0.00 67229 S 209.92 0.00 0.00<br />

66820 S 186.23 0.00 0.00 67250 S 630.67 0.00 0.00<br />

66821 S 255.46 0.00 0.00 67255 S 690.74 0.00 0.00<br />

66825 S 779.82 0.00 0.00 67311 S 737.16 0.00 0.00<br />

66830 S 272.74 0.00 0.00 67312 S 794.96 0.00 0.00<br />

66840 S 586.28 0.00 0.00 67314 S 794.96 0.00 0.00<br />

66850 S 1,103.82 0.00 0.00 67316 S 794.96 0.00 0.00<br />

66852 S 928.03 0.00 0.00 67318 S 794.96 0.00 0.00<br />

66920 S 928.03 0.00 0.00 67320 S 794.96 0.00 0.00<br />

66930 S 969.93 0.00 0.00 67331 S 794.96 0.00 0.00<br />

66940 S 628.18 0.00 0.00 67332 S 794.96 0.00 0.00<br />

66982 S 952.98 0.00 0.00 67334 S 794.96 0.00 0.00<br />

66983 S 952.98 0.00 0.00 67335 S 794.96 0.00 0.00<br />

66984 S 952.98 0.00 0.00 67340 S 794.96 0.00 0.00<br />

66985 S 882.18 0.00 0.00 67343 S 970.75 0.00 0.00<br />

66986 S 882.18 0.00 0.00 67345 S 83.02 0.00 0.00<br />

67005 S 748.53 0.00 0.00 67346 S 449.02 0.00 0.00<br />

67010 S 748.53 0.00 0.00 67400 S 630.67 0.00 0.00<br />

67015 S 921.44 0.00 0.00 67405 S 822.37 0.00 0.00<br />

67025 S 605.49 0.00 0.00 67412 S 730.37 0.00 0.00<br />

67027 S 1,064.48 0.00 0.00 67413 S 864.26 0.00 0.00<br />

67028 S 83.73 0.00 0.00 67414 S 1,535.73 0.00 0.00<br />

67030 S 605.49 0.00 0.00 67415 S 545.42 0.00 0.00<br />

67031 S 255.46 0.00 0.00 67420 S 1,113.19 0.00 0.00<br />

67036 S 1,064.48 0.00 0.00 67430 S 1,113.19 0.00 0.00<br />

67039 S 1,240.28 0.00 0.00 67440 S 1,113.19 0.00 0.00<br />

67040 S 1,240.28 0.00 0.00 67445 S 1,113.19 0.00 0.00<br />

67041 S 1,522.11 0.00 0.00 67450 S 1,113.19 0.00 0.00<br />

67042 S 1,522.11 0.00 0.00 67500 S 85.91 0.00 0.00<br />

67043 S 1,522.11 0.00 0.00 67505 S 26.72 0.00 0.00<br />

67101 S 232.36 0.00 0.00 67515 S 27.08 0.00 0.00<br />

67105 S 209.92 0.00 0.00 67550 S 1,071.29 0.00 0.00<br />

67107 S 1,106.38 0.00 0.00 67560 S 733.75 0.00 0.00<br />

67108 S 1,240.28 0.00 0.00 67570 S 1,071.29 0.00 0.00<br />

67110 S 337.76 0.00 0.00 67700 S 125.69 0.00 0.00<br />

67112 S 1,240.28 0.00 0.00 67710 S 146.78 0.00 0.00<br />

67113 S 1,522.11 0.00 0.00 67715 S 545.42 0.00 0.00<br />

67115 S 659.91 0.00 0.00 67800 S 52.73 0.00 0.00<br />

67120 S 659.91 0.00 0.00 67801 S 63.78 0.00 0.00<br />

67121 S 659.91 0.00 0.00 67805 S 82.65 0.00 0.00<br />

67141 S 232.62 0.00 0.00 67808 S 599.84 0.00 0.00<br />

67145 S 198.45 0.00 0.00 67810 S 125.69 0.00 0.00<br />

67208 S 211.64 0.00 0.00 67820 S 17.46 0.00 0.00<br />

67210 S 209.92 0.00 0.00 67825 S 53.80 0.00 0.00<br />

67218 S 790.44 0.00 0.00 67830 S 368.26 0.00 0.00<br />

67220 S 232.36 0.00 0.00 67835 S 599.84 0.00 0.00<br />

67221 S 119.35 0.00 0.00 67840 S 153.92 0.00 0.00<br />

67225 S 8.20 0.00 0.00 67850 S 122.21 0.00 0.00<br />

67227 S 605.49 0.00 0.00 67875 S 306.91 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 34<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

67880 S 579.38 0.00 0.00 68440 S 52.38 0.00 0.00<br />

67882 S 630.67 0.00 0.00 68500 S 764.57 0.00 0.00<br />

67900 S 822.37 0.00 0.00 68505 S 764.57 0.00 0.00<br />

67901 S 730.37 0.00 0.00 68510 S 545.42 0.00 0.00<br />

67902 S 864.26 0.00 0.00 68520 S 764.57 0.00 0.00<br />

67903 S 688.46 0.00 0.00 68525 S 545.42 0.00 0.00<br />

67904 S 688.46 0.00 0.00 68530 S 125.69 0.00 0.00<br />

67906 S 730.37 0.00 0.00 68540 S 630.67 0.00 0.00<br />

67908 S 688.46 0.00 0.00 68550 S 764.57 0.00 0.00<br />

67909 S 688.46 0.00 0.00 68700 S 599.84 0.00 0.00<br />

67911 S 630.67 0.00 0.00 68705 S 119.35 0.00 0.00<br />

67912 S 630.67 0.00 0.00 68720 S 822.37 0.00 0.00<br />

67914 S 630.67 0.00 0.00 68745 S 822.37 0.00 0.00<br />

67915 S 170.31 0.00 0.00 68750 S 822.37 0.00 0.00<br />

67916 S 688.46 0.00 0.00 68760 S 101.54 0.00 0.00<br />

67917 S 688.46 0.00 0.00 68761 S 70.19 0.00 0.00<br />

67921 S 630.67 0.00 0.00 68770 S 822.37 0.00 0.00<br />

67922 S 165.67 0.00 0.00 68801 S 37.23 0.00 0.00<br />

67923 S 688.46 0.00 0.00 68810 S 106.47 0.00 0.00<br />

67924 S 688.46 0.00 0.00 68811 S 599.84 0.00 0.00<br />

67930 S 170.31 0.00 0.00 68815 S 599.84 0.00 0.00<br />

67935 S 599.84 0.00 0.00 68816 S 770.08 0.00 0.00<br />

67938 S 85.91 0.00 0.00 68840 S 55.22 0.00 0.00<br />

67950 S 599.84 0.00 0.00 69000 S 56.33 0.00 0.00<br />

67961 S 630.67 0.00 0.00 69005 S 106.53 0.00 0.00<br />

67966 S 630.67 0.00 0.00 69020 S 56.33 0.00 0.00<br />

67971 S 630.67 0.00 0.00 69100 S 64.13 0.00 0.00<br />

67973 S 764.57 0.00 0.00 69105 S 90.85 0.00 0.00<br />

67974 S 630.67 0.00 0.00 69110 S 477.31 0.00 0.00<br />

67975 S 630.67 0.00 0.00 69120 S 708.33 0.00 0.00<br />

68020 S 46.68 0.00 0.00 69140 S 708.33 0.00 0.00<br />

68040 S 23.16 0.00 0.00 69145 S 531.73 0.00 0.00<br />

68100 S 92.63 0.00 0.00 69150 S 373.72 0.00 0.00<br />

68110 S 119.35 0.00 0.00 69200 S 25.76 0.00 0.00<br />

68115 S 599.84 0.00 0.00 69205 S 595.84 0.00 0.00<br />

68130 S 548.55 0.00 0.00 69210 S 21.02 0.00 0.00<br />

68135 S 59.85 0.00 0.00 69220 S 33.01 0.00 0.00<br />

68200 S 17.10 0.00 0.00 69222 S 138.95 0.00 0.00<br />

68320 S 822.37 0.00 0.00 69300 S 739.16 0.00 0.00<br />

68325 S 822.37 0.00 0.00 69310 S 1,080.43 0.00 0.00<br />

68326 S 688.46 0.00 0.00 69320 S 1,314.02 0.00 0.00<br />

68328 S 822.37 0.00 0.00 69400 S 93.34 0.00 0.00<br />

68330 S 779.82 0.00 0.00 69401 S 49.17 0.00 0.00<br />

68335 S 822.37 0.00 0.00 69405 S 128.97 0.00 0.00<br />

68340 S 688.46 0.00 0.00 69420 S 115.80 0.00 0.00<br />

68360 S 691.20 0.00 0.00 69421 S 589.33 0.00 0.00<br />

68362 S 691.20 0.00 0.00 69424 S 81.23 0.00 0.00<br />

68371 S 548.55 0.00 0.00 69433 S 115.44 0.00 0.00<br />

68400 S 125.69 0.00 0.00 69436 S 589.33 0.00 0.00<br />

68420 S 178.85 0.00 0.00 69440 S 739.16 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 35<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

69450 S 995.18 0.00 0.00 69840 S 1,180.13 0.00 0.00<br />

69501 S 1,314.02 0.00 0.00 69905 S 1,314.02 0.00 0.00<br />

69502 S 972.75 0.00 0.00 69910 S 1,314.02 0.00 0.00<br />

69505 S 1,314.02 0.00 0.00 69915 S 1,314.02 0.00 0.00<br />

69511 S 1,314.02 0.00 0.00 69930 S 23,755.66 12,755.18 1,754.71<br />

69530 S 1,314.02 0.00 0.00 70030 TC A 18.17 0.00 0.00<br />

69540 S 135.74 0.00 0.00 70100 TC A 19.95 0.00 0.00<br />

69550 S 1,180.13 0.00 0.00 70110 TC A 24.59 0.00 0.00<br />

69552 S 1,314.02 0.00 0.00 70120 TC A 22.09 0.00 0.00<br />

69601 S 1,314.02 0.00 0.00 70130 TC A 26.99 0.00 0.00<br />

69602 S 1,314.02 0.00 0.00 70134 TC A 27.08 0.00 0.00<br />

69603 S 1,314.02 0.00 0.00 70140 TC A 18.52 0.00 0.00<br />

69604 S 1,314.02 0.00 0.00 70150 TC A 26.99 0.00 0.00<br />

69605 S 1,314.02 0.00 0.00 70160 TC A 21.73 0.00 0.00<br />

69610 S 181.71 0.00 0.00 70190 TC A 22.80 0.00 0.00<br />

69620 S 708.33 0.00 0.00 70200 TC A 26.99 0.00 0.00<br />

69631 S 1,180.13 0.00 0.00 70210 TC A 19.24 0.00 0.00<br />

69632 S 1,180.13 0.00 0.00 70220 TC A 24.23 0.00 0.00<br />

69633 S 1,180.13 0.00 0.00 70240 TC A 18.17 0.00 0.00<br />

69635 S 1,314.02 0.00 0.00 70250 TC A 22.09 0.00 0.00<br />

69636 S 1,314.02 0.00 0.00 70260 TC A 28.14 0.00 0.00<br />

69637 S 1,314.02 0.00 0.00 70300 TC A 7.83 0.00 0.00<br />

69641 S 1,314.02 0.00 0.00 70310 TC A 19.36 0.00 0.00<br />

69642 S 1,314.02 0.00 0.00 70320 TC A 19.36 0.00 0.00<br />

69643 S 1,314.02 0.00 0.00 70328 TC A 19.24 0.00 0.00<br />

69644 S 1,314.02 0.00 0.00 70330 TC A 26.99 0.00 0.00<br />

69645 S 1,314.02 0.00 0.00 70336 TC A 210.08 0.00 0.00<br />

69646 S 1,314.02 0.00 0.00 70350 TC A 10.69 0.00 0.00<br />

69650 S 972.75 0.00 0.00 70355 TC A 11.04 0.00 0.00<br />

69660 S 1,180.13 0.00 0.00 70360 TC A 17.10 0.00 0.00<br />

69661 S 1,180.13 0.00 0.00 70370 TC A 50.22 0.00 0.00<br />

69662 S 1,180.13 0.00 0.00 70371 TC A 50.22 0.00 0.00<br />

69666 S 1,138.22 0.00 0.00 70380 TC A 26.01 0.00 0.00<br />

69667 S 1,138.22 0.00 0.00 70450 TC A 117.33 0.00 0.00<br />

69670 S 1,080.43 0.00 0.00 70460 TC A 185.78 0.00 0.00<br />

69676 S 1,080.43 0.00 0.00 70470 TC A 205.80 0.00 0.00<br />

69700 S 1,080.43 0.00 0.00 70480 TC A 117.33 0.00 0.00<br />

69711 S 995.18 0.00 0.00 70481 TC A 185.78 0.00 0.00<br />

69714 S 6,311.26 3,979.48 1,647.71 70482 TC A 205.80 0.00 0.00<br />

69715 S 6,311.26 3,979.48 1,647.71 70486 TC A 117.33 0.00 0.00<br />

69717 S 6,311.26 3,979.48 1,647.71 70487 TC A 185.78 0.00 0.00<br />

69718 S 6,311.26 3,979.48 1,647.71 70488 TC A 205.80 0.00 0.00<br />

69720 S 1,180.13 0.00 0.00 70490 TC A 117.33 0.00 0.00<br />

69740 S 1,180.13 0.00 0.00 70491 TC A 185.78 0.00 0.00<br />

69745 S 1,180.13 0.00 0.00 70492 TC A 205.80 0.00 0.00<br />

69801 S 1,180.13 0.00 0.00 70496 TC A 212.38 0.00 0.00<br />

69802 S 1,314.02 0.00 0.00 70498 TC A 212.38 0.00 0.00<br />

69805 S 1,314.02 0.00 0.00 70540 TC A 210.08 0.00 0.00<br />

69806 S 1,314.02 0.00 0.00 70542 TC A 257.98 0.00 0.00<br />

69820 S 1,180.13 0.00 0.00 70543 TC A 325.14 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 36<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

70544 TC A 210.08 0.00 0.00 72120 TC A 34.20 0.00 0.00<br />

70545 TC A 257.98 0.00 0.00 72125 TC A 117.33 0.00 0.00<br />

70546 TC A 325.14 0.00 0.00 72126 TC A 185.78 0.00 0.00<br />

70547 TC A 210.08 0.00 0.00 72127 TC A 205.80 0.00 0.00<br />

70548 TC A 257.98 0.00 0.00 72128 TC A 117.33 0.00 0.00<br />

70549 TC A 325.14 0.00 0.00 72129 TC A 185.78 0.00 0.00<br />

70551 TC A 210.08 0.00 0.00 72130 TC A 205.80 0.00 0.00<br />

70552 TC A 257.98 0.00 0.00 72131 TC A 117.33 0.00 0.00<br />

70553 TC A 325.14 0.00 0.00 72132 TC A 185.78 0.00 0.00<br />

70554 TC A 210.08 0.00 0.00 72133 TC A 205.80 0.00 0.00<br />

70555 TC A 210.08 0.00 0.00 72141 TC A 210.08 0.00 0.00<br />

70557 TC A 210.08 0.00 0.00 72142 TC A 257.98 0.00 0.00<br />

70558 TC A 257.98 0.00 0.00 72146 TC A 210.08 0.00 0.00<br />

70559 TC A 325.14 0.00 0.00 72147 TC A 257.98 0.00 0.00<br />

71010 TC A 13.90 0.00 0.00 72148 TC A 210.08 0.00 0.00<br />

71015 TC A 17.81 0.00 0.00 72149 TC A 257.98 0.00 0.00<br />

71020 TC A 18.89 0.00 0.00 72156 TC A 325.14 0.00 0.00<br />

71021 TC A 22.80 0.00 0.00 72157 TC A 325.14 0.00 0.00<br />

71022 TC A 26.99 0.00 0.00 72158 TC A 325.14 0.00 0.00<br />

71023 TC A 44.18 0.00 0.00 72170 TC A 16.03 0.00 0.00<br />

71030 TC A 26.99 0.00 0.00 72190 TC A 26.99 0.00 0.00<br />

71034 TC A 50.22 0.00 0.00 72191 TC A 212.38 0.00 0.00<br />

71035 TC A 23.51 0.00 0.00 72192 TC A 117.33 0.00 0.00<br />

71100 TC A 19.60 0.00 0.00 72193 TC A 185.78 0.00 0.00<br />

71101 TC A 23.87 0.00 0.00 72194 TC A 205.80 0.00 0.00<br />

71110 TC A 24.94 0.00 0.00 72195 TC A 210.08 0.00 0.00<br />

71111 TC A 33.13 0.00 0.00 72196 TC A 257.98 0.00 0.00<br />

71120 TC A 20.67 0.00 0.00 72197 TC A 325.14 0.00 0.00<br />

71130 TC A 24.23 0.00 0.00 72200 TC A 18.89 0.00 0.00<br />

71250 TC A 117.33 0.00 0.00 72202 TC A 23.16 0.00 0.00<br />

71260 TC A 185.78 0.00 0.00 72220 TC A 18.89 0.00 0.00<br />

71270 TC A 205.80 0.00 0.00 73000 TC A 17.81 0.00 0.00<br />

71275 TC A 212.38 0.00 0.00 73010 TC A 18.17 0.00 0.00<br />

71550 TC A 210.08 0.00 0.00 73020 TC A 14.61 0.00 0.00<br />

71551 TC A 257.98 0.00 0.00 73030 TC A 18.52 0.00 0.00<br />

71552 TC A 325.14 0.00 0.00 73050 TC A 23.16 0.00 0.00<br />

72010 TC A 44.93 0.00 0.00 73060 TC A 18.52 0.00 0.00<br />

72020 TC A 14.61 0.00 0.00 73070 TC A 17.81 0.00 0.00<br />

72040 TC A 23.51 0.00 0.00 73080 TC A 23.51 0.00 0.00<br />

72050 TC A 33.49 0.00 0.00 73090 TC A 17.81 0.00 0.00<br />

72052 TC A 44.93 0.00 0.00 73092 TC A 18.52 0.00 0.00<br />

72069 TC A 22.09 0.00 0.00 73100 TC A 18.52 0.00 0.00<br />

72070 TC A 20.67 0.00 0.00 73110 TC A 23.51 0.00 0.00<br />

72072 TC A 24.94 0.00 0.00 73120 TC A 17.46 0.00 0.00<br />

72074 TC A 26.99 0.00 0.00 73130 TC A 20.67 0.00 0.00<br />

72080 TC A 22.09 0.00 0.00 73140 TC A 20.31 0.00 0.00<br />

72090 TC A 29.58 0.00 0.00 73200 TC A 117.33 0.00 0.00<br />

72100 TC A 25.30 0.00 0.00 73201 TC A 185.78 0.00 0.00<br />

72110 TC A 35.28 0.00 0.00 73202 TC A 205.80 0.00 0.00<br />

72114 TC A 44.93 0.00 0.00 73206 TC A 212.38 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 37<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

73218 TC A 210.08 0.00 0.00 74246 TC A 53.02 0.00 0.00<br />

73219 TC A 257.98 0.00 0.00 74247 TC A 53.02 0.00 0.00<br />

73220 TC A 325.14 0.00 0.00 74249 TC A 86.21 0.00 0.00<br />

73221 TC A 210.08 0.00 0.00 74250 TC A 53.02 0.00 0.00<br />

73222 TC A 257.98 0.00 0.00 74251 TC A 86.21 0.00 0.00<br />

73223 TC A 325.14 0.00 0.00 74260 TC A 53.02 0.00 0.00<br />

73500 TC A 15.32 0.00 0.00 74270 TC A 53.02 0.00 0.00<br />

73510 TC A 23.51 0.00 0.00 74280 TC A 86.21 0.00 0.00<br />

73520 TC A 24.23 0.00 0.00 74283 TC A 53.02 0.00 0.00<br />

73540 TC A 24.23 0.00 0.00 74290 TC A 45.24 0.00 0.00<br />

73550 TC A 17.81 0.00 0.00 74291 TC A 43.47 0.00 0.00<br />

73560 TC A 18.17 0.00 0.00 74400 TC A 78.74 0.00 0.00<br />

73562 TC A 22.44 0.00 0.00 74410 TC A 84.09 0.00 0.00<br />

73564 TC A 26.01 0.00 0.00 74415 TC A 100.47 0.00 0.00<br />

73565 TC A 19.60 0.00 0.00 74420 TC A 105.02 0.00 0.00<br />

73590 TC A 17.10 0.00 0.00 74710 TC A 23.51 0.00 0.00<br />

73592 TC A 18.52 0.00 0.00 74775 TC A 105.02 0.00 0.00<br />

73600 TC A 17.46 0.00 0.00 75557 TC A 210.08 0.00 0.00<br />

73610 TC A 20.67 0.00 0.00 75559 TC A 210.08 0.00 0.00<br />

73620 TC A 16.74 0.00 0.00 75561 TC A 325.14 0.00 0.00<br />

73630 TC A 20.31 0.00 0.00 75563 TC A 325.14 0.00 0.00<br />

73650 TC A 17.10 0.00 0.00 76010 TC A 17.46 0.00 0.00<br />

73660 TC A 19.24 0.00 0.00 76098 TC A 10.69 0.00 0.00<br />

73700 TC A 117.33 0.00 0.00 76100 TC A 44.93 0.00 0.00<br />

73701 TC A 185.78 0.00 0.00 76101 TC A 120.42 0.00 0.00<br />

73702 TC A 205.80 0.00 0.00 76102 TC A 120.42 0.00 0.00<br />

73706 TC A 212.38 0.00 0.00 76120 TC A 50.22 0.00 0.00<br />

73718 TC A 210.08 0.00 0.00 76150 A 17.46 0.00 0.00<br />

73719 TC A 257.98 0.00 0.00 76380 TC A 63.38 0.00 0.00<br />

73720 TC A 325.14 0.00 0.00 76496 TC A 50.22 0.00 0.00<br />

73721 TC A 210.08 0.00 0.00 76497 TC A 63.38 0.00 0.00<br />

73722 TC A 257.98 0.00 0.00 76498 TC A 210.08 0.00 0.00<br />

73723 TC A 325.14 0.00 0.00 76499 TC A 26.99 0.00 0.00<br />

74000 TC A 15.32 0.00 0.00 76506 TC A 37.73 0.00 0.00<br />

74010 TC A 23.87 0.00 0.00 76510 TC A 64.13 0.00 0.00<br />

74020 TC A 24.23 0.00 0.00 76511 TC A 44.89 0.00 0.00<br />

74022 TC A 29.58 0.00 0.00 76512 TC A 38.12 0.00 0.00<br />

74150 TC A 117.33 0.00 0.00 76513 TC A 46.32 0.00 0.00<br />

74160 TC A 185.78 0.00 0.00 76514 TC A 3.21 0.00 0.00<br />

74170 TC A 205.80 0.00 0.00 76516 TC A 36.34 0.00 0.00<br />

74175 TC A 212.38 0.00 0.00 76519 TC A 40.62 0.00 0.00<br />

74181 TC A 210.08 0.00 0.00 76529 TC A 35.28 0.00 0.00<br />

74182 TC A 257.98 0.00 0.00 76536 TC A 59.01 0.00 0.00<br />

74183 TC A 325.14 0.00 0.00 76604 TC A 37.73 0.00 0.00<br />

74210 TC A 53.02 0.00 0.00 76645 TC A 37.73 0.00 0.00<br />

74220 TC A 53.02 0.00 0.00 76700 TC A 59.01 0.00 0.00<br />

74230 TC A 53.02 0.00 0.00 76705 TC A 59.01 0.00 0.00<br />

74240 TC A 53.02 0.00 0.00 76770 TC A 59.01 0.00 0.00<br />

74241 TC A 53.02 0.00 0.00 76775 TC A 59.01 0.00 0.00<br />

74245 TC A 86.21 0.00 0.00 76776 TC A 59.01 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 38<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

76800 TC A 59.01 0.00 0.00 77290 TC A 154.33 0.00 0.00<br />

76801 TC A 59.01 0.00 0.00 77295 TC A 404.39 0.00 0.00<br />

76802 TC A 28.14 0.00 0.00 77299 TC A 69.24 0.00 0.00<br />

76805 TC A 59.01 0.00 0.00 77300 TC A 37.41 0.00 0.00<br />

76810 TC A 44.53 0.00 0.00 77301 TC A 538.93 0.00 0.00<br />

76811 TC A 92.45 0.00 0.00 77305 TC A 34.20 0.00 0.00<br />

76812 TC A 37.73 0.00 0.00 77310 TC A 44.53 0.00 0.00<br />

76813 TC A 37.73 0.00 0.00 77315 TC A 64.84 0.00 0.00<br />

76814 TC A 29.93 0.00 0.00 77321 TC A 67.34 0.00 0.00<br />

76815 TC A 37.73 0.00 0.00 77326 TC A 69.24 0.00 0.00<br />

76816 TC A 37.73 0.00 0.00 77327 TC A 125.77 0.00 0.00<br />

76817 TC A 37.73 0.00 0.00 77328 TC A 154.33 0.00 0.00<br />

76818 TC A 59.01 0.00 0.00 77331 TC A 17.81 0.00 0.00<br />

76819 TC A 50.95 0.00 0.00 77332 TC A 47.74 0.00 0.00<br />

76820 TC A 25.30 0.00 0.00 77333 TC A 23.16 0.00 0.00<br />

76821 TC A 57.13 0.00 0.00 77334 TC A 89.43 0.00 0.00<br />

76825 TC A 119.00 0.00 0.00 77336 A 56.30 0.00 0.00<br />

76826 TC A 70.90 0.00 0.00 77370 A 69.24 0.00 0.00<br />

76827 TC A 37.73 0.00 0.00 77371 A 4,612.37 0.00 0.00<br />

76828 TC A 22.44 0.00 0.00 77399 TC A 69.24 0.00 0.00<br />

76830 TC A 59.01 0.00 0.00 77401 A 28.14 0.00 0.00<br />

76831 TC A 79.45 0.00 0.00 77402 A 56.66 0.00 0.00<br />

76856 TC A 59.01 0.00 0.00 77403 A 56.66 0.00 0.00<br />

76857 TC A 37.73 0.00 0.00 77404 A 56.66 0.00 0.00<br />

76870 TC A 59.01 0.00 0.00 77406 A 91.78 0.00 0.00<br />

76872 TC A 59.01 0.00 0.00 77407 A 56.66 0.00 0.00<br />

76873 TC A 59.01 0.00 0.00 77408 A 56.66 0.00 0.00<br />

76880 TC A 59.01 0.00 0.00 77409 A 56.66 0.00 0.00<br />

76885 TC A 37.73 0.00 0.00 77411 A 91.78 0.00 0.00<br />

76886 TC A 37.73 0.00 0.00 77412 A 91.78 0.00 0.00<br />

76936 TC A 57.13 0.00 0.00 77413 A 91.78 0.00 0.00<br />

76970 TC A 37.73 0.00 0.00 77414 A 91.78 0.00 0.00<br />

76977 TC A 9.62 0.00 0.00 77416 A 91.78 0.00 0.00<br />

76999 TC A 37.73 0.00 0.00 77418 A 247.97 0.00 0.00<br />

77071 A 22.09 0.00 0.00 77422 A 91.78 0.00 0.00<br />

77072 TC A 12.82 0.00 0.00 77423 A 91.78 0.00 0.00<br />

77073 TC A 21.73 0.00 0.00 77470 TC A 131.83 0.00 0.00<br />

77074 TC A 42.75 0.00 0.00 77520 A 424.55 0.00 0.00<br />

77075 TC A 44.93 0.00 0.00 77522 A 424.55 0.00 0.00<br />

77076 TC A 44.93 0.00 0.00 77523 A 507.35 0.00 0.00<br />

77077 TC A 24.23 0.00 0.00 77525 A 507.35 0.00 0.00<br />

77078 TC A 43.41 0.00 0.00 77600 TC A 225.26 0.00 0.00<br />

77079 TC A 44.53 0.00 0.00 77605 TC A 225.26 0.00 0.00<br />

77080 TC A 43.41 0.00 0.00 77610 TC A 225.26 0.00 0.00<br />

77081 TC A 17.46 0.00 0.00 77615 TC A 225.26 0.00 0.00<br />

77082 TC A 18.89 0.00 0.00 77620 TC A 225.26 0.00 0.00<br />

77083 TC A 14.97 0.00 0.00 77750 TC A 87.64 0.00 0.00<br />

77084 TC A 210.08 0.00 0.00 77761 TC A 154.27 0.00 0.00<br />

77280 TC A 69.24 0.00 0.00 77762 TC A 182.77 0.00 0.00<br />

77285 TC A 154.33 0.00 0.00 77763 TC A 235.50 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 39<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

77776 TC A 167.09 0.00 0.00 78262 TC A 146.75 0.00 0.00<br />

77777 TC A 183.48 0.00 0.00 78264 TC A 146.75 0.00 0.00<br />

77778 TC A 244.41 0.00 0.00 78270 TC A 64.13 0.00 0.00<br />

77785 TC A 108.66 0.00 0.00 78271 TC A 65.20 0.00 0.00<br />

77786 TC A 381.93 0.00 0.00 78272 TC A 71.61 0.00 0.00<br />

77787 TC A 442.58 0.00 0.00 78278 TC A 146.75 0.00 0.00<br />

77789 TC A 45.61 0.00 0.00 78282 TC A 146.75 0.00 0.00<br />

77799 TC A 259.94 0.00 0.00 78290 TC A 146.75 0.00 0.00<br />

78000 TC A 55.93 0.00 0.00 78291 TC A 146.75 0.00 0.00<br />

78001 TC A 70.89 0.00 0.00 78299 TC A 146.75 0.00 0.00<br />

78003 TC A 56.30 0.00 0.00 78300 TC A 127.91 0.00 0.00<br />

78006 TC A 133.94 0.00 0.00 78305 TC A 148.35 0.00 0.00<br />

78007 TC A 99.05 0.00 0.00 78306 TC A 148.35 0.00 0.00<br />

78010 TC A 82.30 0.00 0.00 78315 TC A 148.35 0.00 0.00<br />

78011 TC A 82.30 0.00 0.00 78320 TC A 148.35 0.00 0.00<br />

78015 TC A 159.97 0.00 0.00 78399 TC A 148.35 0.00 0.00<br />

78016 TC A 180.57 0.00 0.00 78414 TC A 188.56 0.00 0.00<br />

78018 TC A 180.57 0.00 0.00 78428 TC A 144.65 0.00 0.00<br />

78070 TC A 122.92 0.00 0.00 78445 TC A 112.83 0.00 0.00<br />

78075 TC A 348.09 0.00 0.00 78456 TC A 112.83 0.00 0.00<br />

78099 TC A 82.30 0.00 0.00 78457 TC A 112.83 0.00 0.00<br />

78102 TC A 124.34 0.00 0.00 78458 TC A 112.83 0.00 0.00<br />

78103 TC A 158.50 0.00 0.00 78459 TC A 698.26 0.00 0.00<br />

78104 TC A 158.50 0.00 0.00 78460 TC A 135.38 0.00 0.00<br />

78110 TC A 63.06 0.00 0.00 78461 TC A 136.46 0.00 0.00<br />

78111 TC A 79.81 0.00 0.00 78464 TC A 200.23 0.00 0.00<br />

78120 TC A 69.83 0.00 0.00 78465 TC A 379.09 0.00 0.00<br />

78121 TC A 82.65 0.00 0.00 78466 TC A 134.32 0.00 0.00<br />

78122 TC A 97.97 0.00 0.00 78468 TC A 171.73 0.00 0.00<br />

78130 TC A 113.65 0.00 0.00 78469 TC A 188.56 0.00 0.00<br />

78135 TC A 241.55 0.00 0.00 78472 TC A 188.56 0.00 0.00<br />

78140 TC A 107.24 0.00 0.00 78473 TC A 188.56 0.00 0.00<br />

78185 TC A 158.50 0.00 0.00 78481 TC A 162.82 0.00 0.00<br />

78190 TC A 99.46 0.00 0.00 78483 TC A 188.56 0.00 0.00<br />

78191 TC A 99.46 0.00 0.00 78491 TC A 698.26 0.00 0.00<br />

78195 TC A 158.50 0.00 0.00 78492 TC A 698.26 0.00 0.00<br />

78199 TC A 158.50 0.00 0.00 78494 TC A 188.56 0.00 0.00<br />

78201 TC A 141.08 0.00 0.00 78499 TC A 188.56 0.00 0.00<br />

78202 TC A 165.97 0.00 0.00 78580 TC A 127.75 0.00 0.00<br />

78205 TC A 165.97 0.00 0.00 78584 TC A 98.69 0.00 0.00<br />

78206 TC A 165.97 0.00 0.00 78585 TC A 196.02 0.00 0.00<br />

78215 TC A 149.28 0.00 0.00 78586 TC A 127.75 0.00 0.00<br />

78216 TC A 101.19 0.00 0.00 78587 TC A 127.75 0.00 0.00<br />

78220 TC A 110.45 0.00 0.00 78588 TC A 196.02 0.00 0.00<br />

78223 TC A 165.97 0.00 0.00 78591 TC A 127.75 0.00 0.00<br />

78230 TC A 125.41 0.00 0.00 78593 TC A 127.75 0.00 0.00<br />

78231 TC A 98.69 0.00 0.00 78594 TC A 127.75 0.00 0.00<br />

78232 TC A 102.96 0.00 0.00 78596 TC A 196.02 0.00 0.00<br />

78258 TC A 146.75 0.00 0.00 78599 TC A 127.75 0.00 0.00<br />

78261 TC A 146.75 0.00 0.00 78600 TC A 112.59 0.00 0.00<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

1H99RPPS5 FIRST COAST SERVICE OPTIONS JAN. 15, <strong>2009</strong><br />

<strong>ASC</strong> FEE SCHEDULE DISCLOSURE PAGE 40<br />

CBSA: 48424 EFFECTIVE DATE: 01/01/<strong>2009</strong><br />

0 PROC FC MOD FB MOD PROC FC MOD FB MOD<br />

HCPCS MOD IND AMOUNT AMOUNT AMOUNT HCPCS MOD IND AMOUNT AMOUNT AMOUNT<br />

----- --- ---- --------- --------- --------- ----- --- ---- --------- --------- ---------<br />

78601 TC A 112.59 0.00 0.00<br />

78605 TC A 112.59 0.00 0.00<br />

78606 TC A 252.96 0.00 0.00<br />

78607 TC A 277.90 0.00 0.00<br />

78608 TC A 625.86 0.00 0.00<br />

78610 TC A 150.00 0.00 0.00<br />

78630 TC A 267.21 0.00 0.00<br />

78635 TC A 246.19 0.00 0.00<br />

78645 TC A 112.59 0.00 0.00<br />

78647 TC A 272.56 0.00 0.00<br />

78650 TC A 264.00 0.00 0.00<br />

78660 TC A 112.59 0.00 0.00<br />

78699 TC A 112.59 0.00 0.00<br />

78700 TC A 138.60 0.00 0.00<br />

78701 TC A 168.88 0.00 0.00<br />

78707 TC A 176.36 0.00 0.00<br />

78708 TC A 120.78 0.00 0.00<br />

78709 TC A 198.58 0.00 0.00<br />

78710 TC A 186.34 0.00 0.00<br />

78725 TC A 74.46 0.00 0.00<br />

78730 TC A 63.06 0.00 0.00<br />

78740 TC A 164.61 0.00 0.00<br />

78761 TC A 157.12 0.00 0.00<br />

78799 TC A 198.58 0.00 0.00<br />

78800 TC A 138.95 0.00 0.00<br />

78801 TC A 190.62 0.00 0.00<br />

78802 TC A 258.30 0.00 0.00<br />

78803 TC A 276.84 0.00 0.00<br />

78804 TC A 483.12 0.00 0.00<br />

78805 TC A 135.74 0.00 0.00<br />

78806 TC A 271.49 0.00 0.00<br />

78807 TC A 277.19 0.00 0.00<br />

78811 TC A 625.86 0.00 0.00<br />

78812 TC A 625.86 0.00 0.00<br />

78813 TC A 625.86 0.00 0.00<br />

78814 TC A 625.86 0.00 0.00<br />

78815 TC A 625.86 0.00 0.00<br />

78816 TC A 625.86 0.00 0.00<br />

78999 TC A 70.89 0.00 0.00<br />

79005 TC A 57.01 0.00 0.00<br />

79101 TC A 62.35 0.00 0.00<br />

79200 TC A 67.34 0.00 0.00<br />

79300 TC A 129.92 0.00 0.00<br />

79403 TC A 96.55 0.00 0.00<br />

79440 TC A 54.51 0.00 0.00<br />

79445 TC A 129.92 0.00 0.00<br />

79999 TC A 129.92 0.00 0.00<br />

** END OF REPORT **<br />

0 PROCEDURE INDICATORS: S = SURGICAL PROCEDURE, A = ANCILLARY SERVICE, C = CARRIER PRICED.<br />

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2008 BY THE AMERICAN MEDICAL ASSOCIATION.

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